Source: http://townhall.virginia.gov/L/ViewXML.cfm?textid=12064
Timestamp: 2018-08-19 18:54:38
Document Index: 359879871

Matched Legal Cases: ['§ 340', '§ 340', '§ 1826', '§ 256', '§1396', '§ 340', '§ 340', '§ 340']

10/24/17 11:44 AM
A. Payment for covered outpatient legend and non-legend drugs dispensed by a retail community pharmacy will include the drug ingredient cost plus a $10.65 professional dispensing fee. The drug ingredient cost reimbursement shall be the lowest of:
1. The national average drug acquisition cost (NADAC) of the drug, the federal upper limit (FUL), or the provider's usual and customary (U&C) charge to the public, as identified by the claim charge; or
2. When no NADAC is available, DMAS shall reimburse at the lowest of the wholesale acquisition cost plus 0%, the FUL, or the provider's U&C charge to the public, as identified by the claim charge.
2. When no NADAC is available, DMAS shall reimburse at the lowest of the wholesale acquisition cost plus 0%; the FUL; or the provider's U&C charge to the public, as identified by the claim charge.
1. The national average drug acquisition cost (NADAC) of the drug; the federal upper limit (FUL); or the provider's usual and customary (U&C) charge to the public, as identified by the claim charge; or
D. Payment for clotting factor from specialty pharmacies, hemophilia treatment centers and Centers of Excellence will include the drug ingredient cost plus a $10.65 professional dispensing fee. The drug ingredient cost reimbursement shall be the lowest of:
1. The national average drug acquisition cost (NADAC) of the drug, or the provider's usual and customary (U&C) charge to the public, as identified by the claim charge; or
2. When no NADAC is available, DMAS shall reimburse at the lowest of the wholesale acquisition cost plus 0%, or the provider's U&C charge to the public, as identified by the claim charge.
E. Section 340B covered entities and federally qualified health centers (FQHCs) that fill Medicaid member prescriptions with drugs purchased at the prices authorized under § 340B of the Public Health Services Act will be reimbursed no more than the actual acquisition cost for the drug plus a $10.65 professional dispensing fee. Section 340B covered entities that fill Medicaid member prescriptions with drugs not purchased under § 340B of the Public Health Services Act will be reimbursed in accordance with subsection A of this section plus the $10.65 professional dispensing fee as described in subsection I of this section.
G. Facilities purchasing drugs through the federal supply schedule (FSS) or drug pricing program under 38 USC § 1826, 42 USC § 256b, or 42 USC §1396-8, other than the § 340B drug pricing program will be reimbursed no more than the actual acquisition cost for the drug plus a $10.65 professional dispensing fee.
H. Facilities purchasing drugs at nominal price (outside of § 340B or FSS) will be reimbursed no more than the actual acquisition cost for the drug plus a $10.65 professional dispensing fee. Nominal price as defined in 42 CFR 447.502 means that a price is less than 10% of the average manufacturer price (AMP) in the same quarter for which the AMP is computed.
I. Payment for pharmacy services will be as described in subsections A through H of this section; however, shall include the allowed cost of the drug plus only one professional dispensing fee, as defined at 42 CFR 447.502, per member per month for each specific drug. Exceptions to the monthly dispensing fees shall be allowed for drugs determined by the department to have unique dispensing requirements. The professional dispensing fee for all covered outpatient drugs shall be $10.65. The professional dispensing fee shall be determined by a cost of dispensing survey conducted at least every five years.
J. Physician administered drugs (PADs) submitted under the medical benefit will be reimbursed at 106% of the average sales price (ASP) as published by the Centers for Medicare and Medicaid Services (CMS). PADs without an ASP on the CMS reference file will be reimbursed at the provider's actual acquisition cost. Covered entities using drugs purchased at the prices authorized under § 340B of the Public Health Services Act for Medicaid members shall bill Medicaid their actual acquisition cost.