59G-4.251: Florida Medicaid Prescribed Drugs Reimbursement Methodology
PURPOSE AND EFFECT: The purpose of this rule is to state the reimbursement methodology for prescribed drug claims in the Florida Medicaid program.
SUMMARY: The purpose of this rule is to state the reimbursement methodology for prescribed drug claims in the Florida Medicaid program, per statutory change.
SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS: Approximately 3,300 retail pharmacy providers of Medicaid prescription services are affected by this rule, and no individual Medicaid recipients are affected. Implementation of this rule will reduce the dispensing fee paid to all retail providers of Florida Medicaid prescription services from $4.23 to $3.73 per prescription. The total reduction in fees paid will be approximately $6.39 million annually. No transactional costs will be incurred pertaining to requirements of this rule. Some of these retail pharmacies may qualify as small businesses as defined by Section 288.703, F.S., however the number is not known. The dispensing fee change is the same for all Medicaid retail pharmacy providers.
Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.
SPECIFIC AUTHORITY: 409.919 FS.
LAW IMPLEMENTED: 409.906(20), 409.908(14), 409.912(39)(a) FS.
A HEARING WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:
DATE AND TIME: June 3, 2009, 10:00 a.m.
PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room D, Tallahassee, FL 32308
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Marie Donnelly, (850)487-4441
THE FULL TEXT OF THE PROPOSED RULE IS:
59G-4.251 Florida Medicaid Prescribed Drugs Reimbursement Methodology.
(1) Reimbursement for prescribed drug claims is made in accordance with the provisions of Title 42, Code of Federal Regulations Sections 447.512-.516. Reimbursement for covered drugs dispensed by a licensed pharmacy, approved as a Medicaid provider, or an enrolled dispensing physician filling his own prescriptions, shall not exceed the lower of:
(a) The estimated acquisition cost, defined as the lower of:
1. Average Wholesale Price (AWP) minus 16.4%, or Wholesaler Acquisition Cost (WAC) plus 4.75%, plus a dispensing fee of $3.73 $4.23;
2. The Federal Upper Limit (FUL) established by the Centers for Medicare and Medicaid Services, plus a dispensing fee of $3.73 $4.23; or
(b) The State Maximum Allowable Cost (SMAC), plus a dispensing fee of $3.73 $4.23; or
(c) The provider’s Usual and Customary (U&C) charge, inclusive of dispensing fee.
(2) For drugs purchased by qualified entities under Section 340B of the Public Health Service Act: Covered entities and Federally Qualified Health Centers or their contracted agents that fill Medicaid patient prescriptions with drugs purchased at prices authorized under Section 340B of the Public Health Service Act must bill Medicaid for reimbursement at the actual acquisition cost plus a dispensing fee of $7.50 for these drugs.
Rulemaking Specific Authority 409.919 FS. Law Implemented 409.906(20), 409.908, 409.912(39)(a) FS. History–New 1-28-09, Amended_________.