Mich. Admin. Code R. 418.101003a - Reimbursement for dispensed medications
Rule 1003a.
(1)
Prescription medication must be reimbursed at the average wholesale price (AWP)
minus 10%, as determined by Red Book or Medi-Span, adopted by reference in
R 418.10107, plus a dispense fee.
All of the following apply to reimbursements: The dispense fee for a brand name
drug is $3.50. The dispense fee for a generic drug is $5.50.
(c) Reimbursement for repackaged
pharmaceuticals is at a maximum reimbursement of AWP minus 10% based on the
original manufacturer's NDC number, as determined by Red Book or Medi-Span,
adopted by reference in
R 418.10107, plus a dispensing fee
of $3.50 for brand name and $5.50 for generic.
(d) All pharmaceutical bills submitted for repackaged products
must include the original manufacturer or distributer stock package national
drug code or NDC number.
(e) When
an original manufacturer's NDC number is not available in either Red Book or
Medi-Span, as adopted by reference in
R 418.10107, and a pharmaceutical
is billed using an unlisted or not otherwise specified code, the payer shall
select the most closely related NDC number to use for reimbursement of the
pharmaceutical.
(2)
Over-the-counter drugs (OTC's), dispensed by a provider other than a pharmacy,
must be dispensed in 10-day quantities and be reimbursed at the average
wholesale price, as determined by Red Book or Medi-Span, adopted by reference
in R 418.10107, or $2.50, whichever is
greater.
(3) All commercially
manufactured topical medications that do not meet the definition of custom
compound dispensed by a pharmacy or a provider, must not exceed a 30-day
supply. Regardless of dispensing party, reimbursement is a maximum of the
acquisition cost, plus a single dispense fee. The single dispense fee is $8.50.
A provider shall only be reimbursed 1 dispense fee per topical medication in a
10-day period.
Notes
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