Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 5 - PHARMACIES › Section 317:30-5-78 - Reimbursement

Current through Vol. 41, No. 20, July 1, 2024
(a)
Reimbursement.
Reimbursement for pharmacy claims is based on the
				  sum of the ingredient cost plus a professional dispensing fee for brand and
				  generic drugs dispensed by a retail community pharmacy or for a member residing
				  in a long term care facility.
(b)
Ingredient cost.
Ingredient cost is determined by one of the
				  following methods:
(1)
Maximum
				  Allowable Cost.
The State Maximum Allowable Cost (SMAC) is established
				  for certain products which have a Food and Drug Administration (FDA) approved
				  generic equivalent. The SMAC will be calculated using prices from
				  pharmaceutical wholesalers who supply these products to pharmacy providers in
				  Oklahoma. Pharmacies may challenge a specific product's SMAC price by providing
				  information from their wholesaler(s) to certify a net cost higher than the
				  calculated SMAC price and that there is not another product available to them
				  which is generically equivalent to the higher priced product.
(2)
Actual Acquisition Cost.
The
				  Actual Acquisition Cost (AAC) means the cost of a particular drug product to
				  the pharmacy based on a review of invoices or the Wholesale Acquisition Cost
				  (WAC), whichever is lower. The National Average Drug Acquisition Cost (NADAC)
				  is based on a review of invoices and published by Centers for Medicare and
				  Medicaid Services (CMS) and will be used in the determination of AAC.
(3)
Specialty Pharmaceutical Allowable
				  Cost.
Reimbursement for specialty drugs not typically dispensed by a
				  retail community pharmacy and dispensed primarily by delivery, including
				  clotting factor for hemophilia, shall be set as a Specialty Pharmaceutical
				  Allowable Cost (SPAC). The Medicare Part B allowed charge, defined as Average
				  Sales Price (ASP) plus 6%, WAC, and NADAC when available, will be considered in
				  setting the SPAC rate. For the purpose of this section, a drug may be
				  classified as a specialty drug when it has one or more of the following
				  characteristics:
(A) Covered by Medicare Part
				  B;
(B) "5i drug" - Injected,
				  infused, instilled, inhaled, or implanted;
(C) Cost greater than $1,000.00 per
				  claim;
(D) Licensed by the FDA
				  under a Biological License Application;
(E) Special storage, shipping, or handling
				  requirements;
(F) Available only
				  through a limited distribution network; and/or
(G) Does not have a NADAC price from
				  CMS.
(4)
Exceptions.
(A) Physician
				  administered drugs shall be priced based on a formula equivalent to the
				  Medicare Part B allowed charge, defined as ASP plus 6%. If a price equivalent
				  to the Medicare Part B allowed charge cannot be determined, a purchase invoice
				  may be supplied by the provider and will be considered in setting the
				  reimbursement.
(B) I/T/U pharmacies
				  shall be reimbursed at the OMB encounter rate as a per member per facility per
				  day fee regardless of the number of prescriptions filled on that day. I/T/U
				  pharmacies should not split prescriptions into quantities less than a one month
				  supply for maintenance medications. For this purpose a maintenance medication
				  is one that the member uses consistently month to month.
(C) Pharmacies other than I/T/U facilities
				  that acquire drugs via the Federal Supply Schedule (FSS) or at nominal price
				  outside the 340B program or FSS shall notify OHCA and submit claims at their
				  actual invoice price plus a professional dispensing fee.