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, 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.
Some exceptions apply to the above ingredient cost
				  methods:
(A) Physician administered drugs
				  shall be priced based on a formula equivalent to the Medicare Part B allowed
				  charge. 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.