212.212
(DME) Specialized
Rehabilitative Equipment, Two (2) Years of Age and Older
Arkansas Medicaid covers specialized rehabilitative equipment
for Medicaid-eligible beneficiaries two (2) years of age and older.
Some items of specialized equipment require prior authorization
from DHS or its designated vendor. View or print form DMS-679A and instructions
for completion. View or print contact information for how to submit the
request.
212.213
(DME)
Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Two (2)
Years of Age and Older
Arkansas Medicaid covers specialized wheelchairs and wheelchair
seating systems for individuals two (2) years of age and older.
Some items of specialized equipment require prior authorization
from DHS or its designated vendor. View or print form DMS-679 and instructions
for completion. View or print contact information for how to submit the
request.
217.000
Federal Public Health Service's 340B Drug Pricing Program
All covered entities that participate in the Federal Public
Health Service's 340B Drug Pricing Program that carve Arkansas Medicaid into
the 340B program are required to bill Arkansas Medicaid using their 340B Actual
Invoice Price for drugs.
A. Covered
entities that bill Arkansas Medicaid for physician administered drugs,
including specialty drugs, are required to bill Arkansas Medicaid using their
340B Actual Invoice Price.
B.
Pharmacies are required to bill Arkansas Medicaid using their 340B Actual
Invoice Price for Covered Legend and non-legend drugs, including specialty
drugs, purchased through the Federal Public Health Service's 340B Drug Pricing
Program. The 340B covered entity pharmacies that carve Medicaid into the 340B
Drug Pricing Program will be reimbursed the lesser of the 340B Actual Invoice
Price or the 340B ceiling price [provided or calculated by Average Manufacturer
Price (AMP) minus Unit Rebate Amount (URA)] plus the established professional
dispensing fee, minus the beneficiary's copayment. The 340B actual invoice
price for each drug reimbursement covered under this program must be submitted
to the Department prior to any claims being processed. The 340B pharmacies will
identify on claim submission using the National Council for Prescription Drug
Programs (NCPDP) indicator for drugs purchased through the 340B program. Drugs
purchased outside the 340B program shall be submitted without the NCPDP 340B
claim indicator and will be reimbursed using the lesser of methodology plus the
established professional dispensing fee minus the beneficiary's copayment. All
applicable federal and state supplemental rebates will be applied to claims
submitted without the NCPDP 340B claim indicator. The State will not recognize
340B contract pharmacies. The 340B contract pharmacies are required to carve
Medicaid claims out of the 340B Drug Pricing Program. Claims exceeding the 340B
ceiling price as published or calculated by Average Manufacturer Price (AMP)
minus Unit Rebate Amount (URA) will be subject to audit and may reject at point
of sale.
Pharmacy providers who submit NCPDP claims to the Arkansas
Medicaid Program on or after January 1, 2012, will be required to send value
07, 08, or 13 in the Basis of Cost Determination field (423-DN). The 340B
providers have contractual agreements with federally qualified 340B entities,
enabling special purchase of medication at federal bid pricing. These
medications are reserved for only beneficiaries meeting the federal definition
of 340B patients. Claims for prescriptions filled with medications purchased
through the 340B program will carry the 08 value (340B Pricing) in the Basis of
Cost Determination Field. Claims submitted with usual and customary pricing
will carry the 07 value (Usual and Customary Pricing) in this field. Claims for
prescriptions filled with non-340B purchased medication AND given a special
price will carry the 13 value (Special Pricing) in this field.
251.000
Method of
Reimbursement
A. Payment for ingredient
cost for covered outpatient legend and non-legend drugs for all pharmacy and
medication types that are not otherwise identified within this section shall be
based upon the lesser of methodology.
Lesser of Methodology:
1.
Brand Drugs
a. The usual and customary charge to the
public or submitted ingredient cost;
b. The National Average Drug Acquisition Cost
(NADAC), as defined in B, plus the established professional dispensing
fee;
c. The ACA Federal Upper Limit
(FUL) plus the established professional dispensing fee;
OR
d. The calculated
State Actual Acquisition Cost (SAAC), as defined in C, plus the established
professional dispensing fee.
2.
Generic Drugs
a. The usual and customary charge to the
public or submitted ingredient cost;
b. The National Average Drug Acquisition Cost
(NADAC), as defined in B, plus the established professional dispensing
fee;
c. The ACA Federal Upper Limit
(FUL) plus the established professional dispensing fee;
OR
d. The calculated
State Actual Acquisition Cost (SAAC), as defined in C, plus the established
professional dispensing fee.
3.
Backup Ingredient Cost
Benchmark
If NADAC is not available, the allowed ingredient cost, unless
otherwise defined, shall be the lesser of Wholesale Acquisition Cost (WAC) plus
zero percent (+0%), State Actual Acquisition Cost (SAAC) or ACA Federal Upper
Limit.
4.
Limited Access and Specialty Drugs
Limited Access Drugs, defined as drugs not available for
dispensing in all retail pharmacies based on price or separate agreements
between manufacturer and pharmacy, and Specialty Drugs, will be reimbursed at
the Lesser of Methodology plus the established professional dispensing fee. If
NADAC is not available, then the Backup Ingredient Cost Benchmark will apply,
which will use the lesser of Wholesale Acquisition Cost (WAC) plus zero percent
(+0%) or State Actual Acquisition Cost (SAAC).
5.
340B Drug Pricing
Program
a. Covered Legend and
non-legend drugs, including specialty drugs purchased through the Federal
Public Health Service's 340B Drug Pricing Program by pharmacies that carve
Medicaid into the 340B Drug Pricing Program, shall be reimbursed the lesser of
the 340B Actual Invoice Price or the 340B ceiling price [provided or calculated
by Average Manufacturer Price (AMP) minus Unit Rebate Amount (URA)] plus the
established professional dispensing fee. The 340B actual invoice price for each
drug reimbursement covered under this program must be submitted to the
Department prior to any claims being processed. Drugs acquired through the
federal 340B Drug Pricing Program and dispensed by 340B contract pharmacies are
not covered.
b. Physician
administered drugs, including specialty drugs, purchased through the 340B
Program, will be reimbursed the lesser of the 340B Actual Invoice Price or the
340B ceiling price [provided or calculated by Average Manufacturer Price (AMP)
minus Unit Rebate Amount (URA)]. The 340B actual invoice price for each drug
reimbursement covered under this program must be submitted to the Department
prior to any claims being processed. Physician administered drugs include
outpatient drugs and drugs used in connection with an inpatient or outpatient
service provided by a hospital. Covered entities must also identify all 340B
drug claims using the medical modifiers JG or TB. Medical drug claims from
covered 340B entities, without the modifiers JG or TB, will be considered
non-340B drug claims and will be subject to rebate invoicing.
6.
Federal Supply
Schedule (FSS) and FQHC
Facilities purchasing drugs, specialty drugs, and physician
administered drugs through the Federal Supply Schedule (FSS) or drug pricing
program under 38 U.S.C. 1826,
42 U.S.C.
256b, or 42 U.S.C. 1396-8, other than the
340B Drug Pricing Program, shall be reimbursed no more than the Federal Supply
Schedule price. The addition of the established professional dispensing fee for
pharmacies will apply, except in the cases of physician administered drugs.
Federally Qualified Health Centers (FQHC) that purchase drugs through the 340B
program, and carve in Medicaid, will be reimbursed by the encounter rate except
in the case of implantable contraceptive capsules, intrauterine devices, and
contraceptive injections in which case reimbursement will be no more than the
340B ceiling price. Federally Qualified Health Centers (FQHC) that do not
participate in the 340B program, or carve out Medicaid, will be reimbursed by
the encounter rate except in the case of implantable contraceptive capsules,
intrauterine devices, and contraceptive injections in which case reimbursement
will be at the actual acquisition cost.
7.
Clotting Factor
a. Pharmacies dispensing Antihemophilic
Factor products will be reimbursed at the lesser of methodology plus the
established professional dispensing fee. The lesser of methodology for the
allowed ingredient cost shall be the Wholesale Acquisition Cost (WAC) plus zero
percent (+0%) or State Actual Acquisition Cost (SAAC).
b. Pharmacies dispensing Antihemophilic
Factor products purchased through the Federal Public Health Service's 340B Drug
Pricing Program by pharmacies that carve Medicaid into the 340B Drug Pricing
Program shall be reimbursed at the lesser of the 340B actual invoice price or
the 340B ceiling price {provided or calculated by Average Manufacturer Price
(AMP) minus Unit Rebate Amount (URA)] plus the established professional
dispensing fee. The 340B actual invoice price for each drug reimbursement
covered under this program must be submitted to the Department prior to any
claims being processed.
8.
Drugs Purchased at Nominal
Price
Facilities purchasing drugs at Nominal Price (outside of 340B
or FSS) shall be reimbursed by their actual acquisition cost.
B. The National Average Drug
Acquisition Cost (NADAC) is a pricing benchmark published by CMS that
calculates ingredient average acquisition costs experienced by retail community
providers across the country. When Brand and Generic NADACs are available for
the same ingredient, reimbursement will be based on the Generic NADAC except in
the case of Preferred Brand Drugs. The allowed ingredient cost for Preferred
Brand Medications shall be reimbursed on the lesser of the Brand NADAC, WAC, or
SAAC.
C. State Actual Acquisition
Cost shall apply to certain drugs identified administratively, judicially, or
by a federal agency as having a published price exceeding the ingredient cost.
The calculated SAAC shall be obtained from actual acquisition costs from
multiple resources, if available. Depending on the variance, either the highest
acquisition cost, an average of the acquisition costs, or invoice price shall
be used in determining a SAAC. When Brand and Generic drugs are available for
the same ingredient, reimbursement will be based on the Generic State Actual
Acquisition Cost (SAAC). The SAAC was previously referred to as State Upper
Limit (SUL), Generic Upper Limit (GUL), Maximum Allowed Cost (MAC), and Cap
Upper Limit (CAP).
D.
Investigational drugs are excluded from coverage.
E. The Professional Dispensing Fee for
covered outpatient legend and non-legend drugs shall take into consideration
the State's Preferred Drug List status, for the drug being dispensed, and
equals the average professional dispensing fee in the aggregate:
1. Brand and Non-preferred Brand = Nine
Dollars ($9.00); or
2. Brand
Preferred and Generic Medication drug = Ten Dollars and Fifty Cents
($10.50).
Drug pricing files are updated weekly.
ATTACHMENT 4.19-B
Page 4a
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM STATE OF ARKANSAS
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES -
OTHER TYPES OF CARE
Revised: October 1, 2022
12. Prescribed drugs, dentures, and
prosthetic devices; and eyeglasses prescribed by a physician skilled in
diseases of the eye, or by an optometrist
a.
Prescribed Drugs
iv.
Limited
Access and Specialty Drugs
Limited Access Drugs are defined as drugs not available for
dispensing in all retail pharmacies based on price or separate agreements
between manufacturer and pharmacy. Limited Access Drugs and Specialty Drugs
will be reimbursed at the Lesser of Methodology plus the established
professional dispensing fee. If NADAC is not available, then the Backup
Ingredient Cost Benchmark will apply which will use the lesser of Wholesale
Acquisition Cost (WAC) plus zero percent (+0%) or State Actual Acquisition Cost
(SAAC).
v.
340B
Drug Pricing Program
a. Covered
Legend and non-legend drugs, including specialty drugs, purchased through the
Federal Public Health Service's 340B Drug Pricing Program (340B) by pharmacies
that carve Medicaid into the 340B Drug Pricing Program, shall be reimbursed the
lesser of the 340B actual invoice price or the 340B ceiling price [provided or
calculated by Average Manufacturer Price (AMP) minus Unit Rebate Amount (URA)]
plus the established professional dispensing fee. The 340B actual invoice price
for each drug reimbursement covered under this program must be submitted to the
Department prior to any claims being processed. Drugs acquired through the
federal 340B drug pricing program and dispensed by 340B contract pharmacies are
not covered.
b. Physician
administered drugs, including specialty drugs, purchased through the 340B
Program, will be reimbursed the lesser of the 340B actual invoice price or the
340B ceiling price [provided or calculated by Average Manufacturer Price (AMP)
minus Unit Rebate Amount (URA)]. The 340B actual invoice price for each drug
reimbursement covered under this program must be submitted to the Department
prior to any claims being processed.
vi.
Federal Supply Schedule (FSS)
and FQHC
Facilities purchasing drugs, specialty drugs, and physician
administered drugs through the Federal Supply Schedule (FSS) or drug pricing
program under 38 U.S.C. 1826,
42 U.S.C.
256b, or 42 U.S.C. 1396-8, other than the
340B Drug Pricing Program, shall be reimbursed no more than the Federal Supply
Schedule price. The addition of the established professional dispensing fee for
pharmacies will apply, except in the cases of physician administered drugs.
Federally Qualified Health Centers (FQHC) that purchase drugs through the 340B
program and carve in Medicaid will be reimbursed by the encounter rate, except
in the case of Implantable Contraceptive Capsules, Intrauterine Devices, and
Contraceptive Injections, in which case reimbursement will be no more than the
340B ceiling price. Federally Qualified Health Centers (FQHC) that do not
participate in the 340B program, or carve out Medicaid, will be reimbursed by
the encounter rate, except in the case of Implantable Contraceptive Capsules,
Intrauterine Devices, and Contraceptive Injections, in which case reimbursement
will be at the actual acquisition cost.
vii.
Clotting Factor
a. Pharmacies dispensing Antihemophilic
Factor products will be reimbursed at the lesser of methodology plus the
established professional dispensing fee. The lesser of methodology for the
allowed ingredient cost shall be the Wholesale Acquisition Cost
(WAC) plus zero percent (+0%) or State Actual Acquisition Cost
(SAAC).
b. Pharmacies dispensing
Antihemophilic Factor products purchased through the Federal Public Health
Service's 340B Drug Pricing Program (340B) by pharmacies that carve Medicaid
into the 340B Drug Pricing Program shall be reimbursed the lesser of
methodology for the allowed ingredient cost shall be the 340B actual invoice
price, Wholesale Acquisition Cost (WAC) plus zero percent (+0%) or State Actual
Acquisition Cost (SAAC). The 340B actual invoice price for each drug
reimbursement covered under this program must be submitted to the Department
prior to any claims being processed.
viii.
Drugs Purchased at Nominal
Price
Facilities purchasing drugs at Nominal Price (outside of 340B
or FSS) shall be reimbursed by their actual acquisition cost.
ix.
Physician Administered
Drugs
Reimbursement rates for Physician Administered Drugs are a "fee
schedule" as determined by the Medicare fee schedule. If the
Medicare rate is not available, then other published pricing
Average Wholesale Price (AWP) less five percent (-5%) shall be used to
determine reimbursement. Under the fee schedule methodology, reimbursement is
based on the lesser of the billed charge for each procedure or the maximum
allowable for each procedure.
B. State Upper Limit (SUL) shall apply to
certain drugs identified administratively, judicially, or by a federal agency
as having a published price exceeding the ingredient cost. The calculated SAAC
shall be obtained from actual acquisition costs from multiple resources, if
available. Depending on the variance, either the highest acquisition cost, an
average of the acquisition costs, or invoice price shall be used in determining
a SAAC. When Brand and Generic drugs are available for the same ingredient,
reimbursement will be based on the Generic State Actual Acquisition Cost
(SAAC).
