2023 New York Laws › ELD - Elder › Article 2 - Programs for the Elderly › Title 3 - Program for Elderly Pharmaceutical Insurance Coverage › 250 - Reimbursement to Participating Provider Pharmacies.

§  250.  Reimbursement  to  participating  provider pharmacies. 1. The
amount  of  reimbursement  which  shall  be  paid  by  the  state  to  a
participating  provider pharmacy for any covered drug filled or refilled
for any eligible program participant  shall  be  equal  to  the  allowed
amount  defined  as  follows,  minus  the  point  of  sale co-payment as
required by sections two hundred forty-seven and two hundred forty-eight
of this title:
(a) Multiple source covered drugs. Except for brand  name  drugs  that
are  required  by the prescriber to be dispensed as written, the allowed
amount for a multiple source covered drug shall equal the lower of:
(1) The pharmacy's usual and customary charge to the  general  public,
taking  into consideration any quantity and promotional discounts to the
general public at the time of purchase, or
(2) The upper limit, if any, set  by  the  centers  for  medicare  and
medicaid services for such multiple source drug, or
(3) Average wholesale price discounted by twenty-five percent, or
(4)   The   maximum   allowable  cost,  if  any,  established  by  the
commissioner of health pursuant to paragraph (e) of subdivision nine  of
section three hundred sixty-seven-a of the social services law.
Plus  a  dispensing fee for drugs reimbursed pursuant to subparagraphs
two, three, and four of this paragraph, as defined in paragraph  (c)  of
this subdivision.
(b)  Other  covered  drugs.  The  allowed  amount for brand name drugs
required by the prescriber to be dispensed as written  and  for  covered
drugs  other  than multiple source drugs shall be determined by applying
the lower of:
(1) Average wholesale price discounted by sixteen and twenty-five  one
hundredths percent, plus a dispensing fee as defined in paragraph (c) of
this subdivision, or
(2)  The  pharmacy's usual and customary charge to the general public,
taking into consideration any quantity and promotional discounts to  the
general public at the time of purchase.
(c)  As  required  by  paragraphs  (a)  and (b) of this subdivision, a
dispensing fee of four dollars fifty cents will apply to  generic  drugs
and  a  dispensing  fee of three dollars fifty cents will apply to brand
name drugs.
2. For purposes of determining the amount of reimbursement which shall
be paid to a participating provider pharmacy, the commissioner of health
shall determine or cause to be determined, through a statistically valid
survey, the quantities of each covered drug that participating  provider
pharmacies  buy  most  frequently.  Using the result of this survey, the
contractor shall update every thirty days the list of average  wholesale
prices  upon  which  such  reimbursement  is determined using nationally
recognized and most recently revised sources. Such price revisions shall
be  made  available  to  all  participating  provider  pharmacies.   The
pharmacist  shall be reimbursed based on the price in effect at the time
the covered drug is dispensed.
3. (a) Notwithstanding any inconsistent provision of law, the  program
for  elderly  pharmaceutical  insurance  coverage  shall  reimburse  for
covered drugs which are  dispensed  under  the  program  by  a  provider
pharmacy  only  pursuant  to the terms of a rebate agreement between the
program and the manufacturer (as  defined  under  section  1927  of  the
federal  social  security act) of such covered drugs; provided, however,
that:
(1) any agreement between the program and a manufacturer entered  into
before  August  first,  nineteen  hundred ninety-one, shall be deemed to
have been entered into on April first, nineteen hundred ninety-one;  and
provided  further,  that  if  a  manufacturer  has  not  entered into an

agreement with the department  before  August  first,  nineteen  hundred
ninety-one,  such  agreement  shall  not be effective until April first,
nineteen hundred ninety-two, unless such agreement provides that rebates
will  be retroactively calculated as if the agreement had been in effect
on April first, nineteen hundred ninety-one; and
(2) the program may  reimburse  for  any  covered  drugs  pursuant  to
subdivisions  one  and two of this section, for which a rebate agreement
does not exist and which  are  determined  by  the  commissioner  to  be
essential  to  the  health  of persons participating in the program; and
likely to provide effective therapy  or  diagnosis  for  a  disease  not
adequately treated or diagnosed by any other covered drug.
(b) The rebate agreement between such manufacturer and the program for
elderly  pharmaceutical  insurance  coverage  shall  utilize for covered
drugs the identical formula used to determine  the  rebate  for  federal
financial  participation  for  drugs, pursuant to section 1927(c) of the
federal social security act, to  determine  the  amount  of  the  rebate
pursuant to this subdivision.
(c) The amount of rebate pursuant to paragraph (b) of this subdivision
shall  be  calculated by multiplying the required rebate formulas by the
total number of units of each dosage form and  strength  dispensed.  The
rebate  agreement shall also provide for periodic payment of the rebate,
provision of information to the program, audits, verification  of  data,
damages to the program for any delay or non-production of necessary data
by the manufacturer and for the confidentiality of information.
(d)  The  program  in providing utilization data to a manufacturer (as
provided for under section 1927 (b) of the federal social security  act)
shall  provide  such  data  by zip code, if requested, for the top three
hundred most commonly used  drugs  by  volume  covered  under  a  rebate
agreement.
(e) Any funds collected pursuant to any rebate agreements entered into
with  a  manufacturer  pursuant  to this subdivision, shall be deposited
into the  elderly  pharmaceutical  insurance  coverage  program  premium
account.
4.  Notwithstanding  any  other provision of law, entities which offer
insurance  coverage  for   provision   of   and/or   reimbursement   for
pharmaceutical   expenses,   including  but  not  limited  to,  entities
licensed/certified   pursuant   to   article   thirty-two,    forty-two,
forty-three or forty-four of the insurance law (employees welfare funds)
or  article  forty-four of the public health law, shall participate in a
benefit recovery  program  with  the  elderly  pharmaceutical  insurance
coverage  (EPIC)  program  which  includes,  but  is  not  limited to, a
semi-annual match of EPIC's file of enrollees against the entity's  file
of  insured  to  identify individuals enrolled in both plans with claims
paid within  the  twenty-four  months  preceding  the  date  the  entity
receives  the  match  request  information  from EPIC. Such entity shall
indicate if pharmaceutical coverage is available from the entity for the
insured persons, list the copayment or other payment obligations of  the
insured  persons  applicable  to the pharmaceutical coverage, and (after
receiving necessary claim information from EPIC) list the amounts  which
the  entity  would  have  paid  for  the pharmaceutical claims for those
identified  individuals  and  the  entity  shall  reimburse   EPIC   for
pharmaceutical expenses paid by EPIC that are covered under the contract
between  the  entity  and  its insured in only those instances where the
entity has not already made payment of the claim. Reimbursement  of  the
net  amount  payable  (after rebates and discounts) that would have been
paid under the coverage issued by the entity will be made by the  entity
to  EPIC  within sixty days of receipt from EPIC of the standard data in
electronic format necessary for the entity to adjudicate the  claim  and

if  the  standard data is provided to the entity by EPIC in paper format
payment by the entity shall be made  within  one  hundred  eighty  days.
After  completing  at  least  one  match process with EPIC in electronic
format,  an  entity  shall  be entitled to elect a monthly or bi-monthly
match process rather than a semi-annual match process.
5. Notwithstanding any other provision of  law,  the  commissioner  of
health  shall maximize the coordination of benefits for persons enrolled
under Title XVIII of the federal  social  security  act  (medicare)  and
enrolled  under  this  title  in order to facilitate medicare payment of
claims. The commissioner of health may select an independent contractor,
through a  request-for-proposal  process,  to  implement  a  centralized
coordination  of  benefits system under this subdivision for individuals
qualified in both the elderly pharmaceutical insurance  coverage  (EPIC)
program  and  medicare programs who receive medications or other covered
products from a pharmacy provider  currently  enrolled  in  the  elderly
pharmaceutical insurance coverage (EPIC) program.
6.  The EPIC program shall be the payor of last resort for individuals
qualified in both the EPIC program and title XVIII of the federal social
security act (Medicare).