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 AND LEGISLATIVE RATIFICATION:
The Agency has determined that this will not have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule. A SERC has not been prepared by the agency.
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.
RULEMAKING AUTHORITY: 409.919 FS.
LAW IMPLEMENTED: 409.906(20), 409.908, 409.912 FS.
A HEARING WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:
DATE AND TIME: Thursday, March 1, 2012, 10:00 a.m.
PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Bldg. 3, Conference Room B, Tallahassee, FL 32301
Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 48 hours before the workshop/meeting by contacting: Marie Donnelly at Marie.Donnelly@ahca.myflorida.com. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Marie Donnelly at Marie.Donnelly@ahca.myflorida.com
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, by or an enrolled dispensing physician filling his own prescriptions, or by a medical professional administering injectable medications, 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 1.5 4.75%, plus a dispensing fee of $3.73;
2. The Federal Upper Limit (FUL) established by the Centers for Medicare and Medicaid Services, plus a dispensing fee of $3.73; or
(b) The State Maximum Allowable Cost (SMAC), plus a dispensing fee of $3.73; 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 Authority 409.919 FS. Law Implemented 409.906(20), 409.908, 409.912 (37)(a) FS. History–New 1-28-09, Amended 8-23-09,__________.