Fla. Admin. Code Ann. R. 59G-4.251 - Prescribed Drugs Reimbursement Methodology
(1) This rule applies to all prescribed drug
service providers enrolled in the Florida Medicaid program that provide
services under the fee-for-service delivery system in accordance with Rule
59G-4.250, Florida
Administrative Code (F.A.C.).
(2)
Definitions.
(a) Actual Acquisition Cost for
Prescribed Drugs - (AAC) - The National Average Drug Acquisition Cost (NADAC)
will be used for the AAC, when available. If the NADAC is unavailable, the AAC
will be equal to the wholesaler acquisition cost.
(b) Average Sales Price - (ASP) - The average
sales price as reported by prescribed drug manufacturers to the Centers for
Medicare and Medicaid Services (CMS).
(c) State Maximum Allowable Cost - (SMAC) -
The maximum allowable unit cost established by the state; SMAC may be manually
set.
(d) Usual and Customary Charge
- (U&C Charge) - The average charge to all other customers in any quarter
for the same drug, quantity, and strength.
(e) Wholesaler Acquisition Cost - (WAC) - The
cost wholesalers pay for a prescribed drug.
(3) Reimbursement Methodology.
(a) Florida Medicaid reimburses for drugs
dispensed by an approved Florida Medicaid pharmacy provider, or a provider
enrolled as a dispensing practitioner, in an amount not to exceed the lesser
of:
1. The AAC plus a professional dispensing
fee (PDF) of $10.24.
2. The WAC
plus a PDF of $10.24.
3. The SMAC
plus a PDF of $10.24.
4. The
provider's U&C Charge.
(b) The above reimbursement methodology
applies to all of the following:
1. Covered
outpatient drugs dispensed by a retail community pharmacy.
2. Specialty drugs dispensed primarily
through the mail.
3. Drugs not
purchased pursuant to the 340B program by a covered entity, as defined in
section 340B(a)(4) of the federal Public Health Service Act.
4. Drugs dispensed in an institutional or
long-term care pharmacy, when not included as part of the floor stock contained
in the institution's cost report.
(4) Florida Medicaid utilizes the actual
purchased drug price plus a PDF in the reimbursement methodology for drugs
acquired via the Federal Supply Schedule.
(5) Florida Medicaid utilizes the actual
purchased drug price plus a PDF in the reimbursement methodology for drugs
acquired via nominal price.
(6)
Florida Medicaid reimburses for drugs purchased under the 340B program at the
actual purchased drug price, which cannot exceed the 340B ceiling price, plus a
dispensing fee of $10.24. This provision only applies to covered entities,
Indian Health Services, tribal organizations, urban Indian pharmacies and
federally qualified health centers that dispense drugs purchased at prices
authorized under section 340B of the Public Health Services Act.
(7) Florida Medicaid reimburses for clotting
factor to the vendor(s) awarded the state's hemophilia contract(s) at the
negotiated price.
(8) Florida
Medicaid reimburses for prescribed drugs administered by a licensed
practitioner in an office setting at 106 percent of ASP, as provided by CMS
quarterly in the format of drug pricing files, available at
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html;
or, when no ASP rate is available, at WAC.
(9) Florida Medicaid reimburses for
prescribed drugs purchased under the 340B program administered in an outpatient
facility at an amount not to exceed the 340B ceiling price.
(10) Florida Medicaid does not reimburse for
investigational or experimental drugs.
(11) The rule is in effect for five years
from its effective date.
Notes
Rulemaking Authority 409.919 FS. Law Implemented 409.906, 409.908, 409.912 FS.
New 1-28-09, Amended 8-23-09, 5-20-12, 6-2-16, 3-29-18, 12-20-21.
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