Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 145 - Medicaid Payment Rates › Article 5 - Payment Rates; Prescription Drugs and Medical Supplies; Durable Medical Equipment; Transportation; Laboratory Services › 7 AAC 145.400 - Covered outpatient drug payment rates and home infusion therapy drug rates

Current through May 31, 2024
(a) In
				  addition to complying with the requirements of
				  7 AAC 105.220, and before submitting a claim for payment
				  from the department, a pharmacy provider shall bill any third-party
				  prescription drug plan in which the recipient is enrolled and that is in effect
				  on the date of service. After the pharmacy provider receives notification from
				  the third-party prescription drug plan of the amount, if any, that the
				  third-party prescription drug plan will pay, the pharmacy provider may submit a
				  claim for payment from the department for the remaining cost of service. The
				  department will pay the pharmacy provider the lesser of the difference between
				  the payment by the third-party prescription drug plan and the
				  department-calculated allowable payment, minus any recipient cost-sharing
				  amounts imposed under
				  AS
				  47.07.042 by the department or the remaining
				  patient liability amount, minus any recipient cost-sharing amounts imposed
				  under
				  AS
				  47.07.042 by the department. The department
				  will consider the payment to be payment in full.
(b) For a prescription of a covered
				  outpatient drug as described in
				  7 AAC 120.110(b), the department will pay
				  the provider for reasonable and necessary postage or freight shipping, not to
				  exceed $16, incurred in the delivery of the prescription from the dispensing
				  pharmacy to the recipient if pharmacy services are not available in the
				  recipient's community. If multiple prescriptions for covered outpatient drugs
				  are shipped in a single package, the postage or freight shipping costs must be
				  divided by the number of prescriptions for covered outpatient drugs shipped and
				  the partial postage amount is to be billed on each prescription claim.
(c) The department may establish a
				  state maximum allowable cost for a covered outpatient drug described in
				  7 AAC 120.110(b). The state maximum
				  allowable cost will be established by reviewing pricing sources, including the
				  wholesale acquisition cost, purchase invoices, or direct price for the covered
				  outpatient drug as identified in the First Data Bank
National Drug Data
				  File (NDDF) Plus
, taking into consideration the cost of the most
				  frequently dispensed drugs.
(d)
				  The department will maintain on its website, or on the website of the
				  department's designated contractor, a current listing of covered outpatient
				  drugs and their corresponding state maximum allowable costs.
(e) The payment for covered outpatient drugs
				  described in
				  7 AAC 120.110(b) is the lowest of the
				  following:
(1) the submitted covered
				  outpatient drug cost plus the dispensing fee set under
				  7 AAC 145.410;
(2) the federal upper limit established by
				  CMS plus the dispensing fee;
(3)
				  the estimated acquisition cost of the covered outpatient drug plus the
				  dispensing fee;
(4) the state
				  maximum allowable cost plus the dispensing fee.