Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: PRESCRIPTION DRUGS › Section 16.03.09.665 - PRESCRIPTION DRUGS: PROVIDER REIMBURSEMENT

Current through August 31, 2023
With specific exceptions as set forth in Subsections
					 665.01 through
					 665.04 of this rule, Idaho
					 Medicaid pharmacy providers are reimbursed based on actual acquisition costs.
					 Idaho Medicaid may require providers to supply documentation of their
					 acquisition costs as described in the Medicaid Pharmacy Claims Submission
					 Manual available at:
https://idaho.fhsc.com/downloads/providers/IDRx_Pharmacy_Claims_Submission_Manual.pdf
.
					 Reimbursement is restricted to those drugs supplied from labelers that are
					 participating in the CMS Medicaid Drug Rebate Program. (3-17-22)
01.
Pharmacy Reimbursement
.
				  Prescriptions not filled in accordance with the provisions of Subsection
				  664.02 of these rules will be
				  subject to nonpayment or recoupment. The following protocol must be followed
				  for proper reimbursement. (3-17-22)
a. Filing
				  Claims. Pharmacies must file claims electronically with Department-approved
				  software or by submitting the appropriate claim form to the fiscal contractor.
				  Upon request, the contractor will provide pharmacies with a supply of claim
				  forms. The form must include information described in the pharmacy guidelines
				  issued by the Department. (3-17-22)
b. Billed Charges. A pharmacy's billed
				  charges are not to exceed the usual and customary charges defined as the lowest
				  charge by the provider to the general public for the same service including
				  advertised specials. (3-17-22)
c.
				  Reimbursement. Reimbursement to pharmacies is limited to the lowest of the
				  following: (3-17-22)
i. Actual Acquisition
				  Cost (AAC) based on results of the periodic state cost survey as defined in
				  this rule, plus the assigned professional dispensing fee. In cases where no AAC
				  is available, reimbursement will be the Wholesale Acquisition Cost (WAC). WAC
				  will mean the price, for a given calendar quarter, paid by a wholesaler for the
				  drugs purchased from the wholesaler's supplier. The wholesaler's supplier is
				  typically the manufacturer of the drug as published by a recognized compendium
				  of drug pricing for the same calendar quarter; (3-17-22)
ii. State Maximum Allowable Cost (SMAC), as
				  established by the Department, plus the assigned professional dispensing fee;
				  (3-17-22)
iii. Federal Upper Limit
				  (FUL), as established by the Centers for Medicare and Medicaid Services (CMS)
				  of the U.S. Department of Health and Human Services, plus the professional
				  dispensing fee assigned by the Department; or (3-17-22)
iv. The provider's usual and customary charge
				  to the general public. (3-17-22)
d. Periodic State Cost Surveys. The
				  Department will utilize periodic state cost surveys to obtain the most accurate
				  pharmacy drug acquisition costs in establishing a pharmacy reimbursement fee
				  schedule. Pharmacies participating in the Idaho Medicaid Pharmacy Program are
				  required to participate in these periodic state cost surveys by disclosing the
				  costs of all drugs. A pharmacy that is non-responsive to the periodic state
				  cost surveys can be disenrolled as a Medicaid provider by the Department.
				  (3-17-22)
e. Physician Administered
				  Drugs. (3-17-22)
i. Reimbursement to
				  providers that are not 340B covered entities for medications administered to
				  Medicaid participants by physicians or other qualified and licensed providers
				  will be ninety percent (90%) of the published Medicare Average Sales Price plus
				  six percent (6%) rate (ASP+6% rate). If the ASP+6% rate is not available,
				  payment will be at the Wholesale Acquisition Cost (WAC). (3-17-22)
ii. Reimbursement to 340B covered entities
				  for medications administered to Medicaid participants by physicians or other
				  qualified and licensed providers will be the actual 340B drug acquisition cost,
				  not to exceed the 340B ceiling price. (3-17-22)
f. Clotting Factors. (3-17-22)
i. Reimbursement to specialty pharmacies will
				  be at a state-based price equivalent to the published Medicare ASP+6% rate,
				  plus the assigned professional dispensing fee. (3-17-22)
ii. Reimbursement to Hemophilia Treatment
				  Centers will be the 340B actual acquisition cost, not to exceed the 340B
				  ceiling price. (3-17-22)
g. Professional Dispensing Fee. Professional
				  Dispensing Fee is defined as a tier-based amount paid on a pharmacy claim, over
				  and above the ingredient cost, to compensate the provider for the pharmacist's
				  professional services related to dispensing a prescription to a Medicaid
				  participant, including: (3-17-22)
i. Looking
				  up information about a participant's coverage on the computer;
				  (3-17-22)
ii. Performing drug use
				  reviews and preferred drug list review activities; (3-17-22)
iii. Measuring or mixing the covered
				  outpatient drug; (3-17-22)
iv.
				  Filling the container; (3-17-22)
v.
				  Participant counseling; (3-17-22)
vi. Physically providing the completed
				  prescription to the Medicaid participant; (3-17-22)
vii. Special packaging; and
				  (3-17-22)
viii. Overhead associated
				  with maintaining the facility and equipment necessary to operate the dispensing
				  entity. (3-17-22)
h.
				  Limitations on Payment of Professional Dispensing Fee. Only one (1)
				  professional dispensing fee per month will be allowed for the dispensing of
				  each maintenance drug to any participant as an outpatient or a resident in a
				  care facility except: (3-17-22)
i. Multiple
				  dispensing of topical and injectable medication when dispensed in
				  manufacturer's original package sizes, unless evidence exists, as determined by
				  the Department, that the quantity dispensed does not relate to the prescriber's
				  order; (3-17-22)
ii. Multiple
				  dispensing of oral liquid maintenance medication if a reasonable quantity, as
				  determined by the Department, is dispensed at each filling; (3-17-22)
iii. Multiple dispensing of tablets or
				  capsules if the quantity needed for a thirty-four (34) day supply is
				  excessively large or unduly expensive, in the judgment of the Department; or
				  (3-17-22)
iv. When the dose is
				  being titrated for maximum therapeutic response with a minimum of adverse
				  effects. (3-17-22)
i.
				  Tier-Based Professional Dispensing Fees. A professional dispensing fee for each
				  pharmacy provider will be established in accordance with this rule.
				  (3-17-22)
j. Claims Volume Survey
				  for Tier-Based Professional Dispensing Fees. The Department will survey
				  pharmacy providers to establish a professional dispensing fee for each
				  provider. The professional dispensing fees will be paid based on the provider's
				  total annual claims volume. The provider must return the claims volume survey
				  to the Department no later than May 31st each year. Pharmacy providers who do
				  not complete the annual claims volume survey will be assigned the lowest
				  professional dispensing fee starting on July 1st until the next annual survey
				  is completed. Based upon the annual claims volume of the enrolled pharmacy, the
				  professional dispensing fee is provided online at:
https://healthandwelfare.idaho.gov/providers/pharmacy-providers/idaho-medicaid-pharmacy-program
.
				  (3-17-22)
k. Remittance Advice.
				  Claims are processed by computer, and payments are made directly to the
				  pharmacy or its designated bank through electronic funds transfer. A remittance
				  advice with detailed information of each claim transaction will accompany each
				  payment made by the Department. (3-17-22)