59G-4.251: Florida Medicaid Prescribed Drugs Reimbursement Methodology
PURPOSE AND EFFECT: The purpose of this rule is to update the reimbursement methodology for prescribed drug claims in the Medicaid program.
SUBJECT AREA TO BE ADDRESSED: Florida Medicaid Prescribed Drugs Reimbursement Methodology.
SPECIFIC AUTHORITY: 409.919 FS.
LAW IMPLEMENTED: 409.906(20), 409.908, 409.912(39)(a) FS.
A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:
DATE AND TIME: Friday, March 13, 2008, 10:00 a.m.
PLACE: Agency for Health Care Administration Headquarters, 2727 Mahan Drive, Building 3, Conference Room D, Tallahassee, Florida
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Marie Donnelly, Bureau of Medicaid Prescribed Drug Services, 2727 Mahan Drive, Mail Stop 38, Tallahassee, Florida 32308-5407; (850)487-4441
THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT 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.
Specific Authority 409.919 FS. Law Implemented 409.906(20), 409.908, 409.912(39)(a) FS. History–New 1-28-09, Amended _________.