Ohio Admin. Code 5160-9-10 - Ohio average acquisition cost (OAAC) appeal and managed care pharmacy dispensing fee modification request

(A) Ohio average acquisition cost (OAAC) appeal.

(1) OAAC is the average acquisition cost of a product calculated based on surveys submitted by pharmacy providers enrolled with the Ohio department of medicaid (ODM).

(a) The OAAC rate does not account for off-invoice adjustments between pharmacy providers and wholesalers or manufacturers and is reflective of the market conditions specific to enrolled Ohio pharmacy providers.

(b) The OAAC rate is recalculated utilizing surveys issued to pharmacy providers semiannually, in April and October.

(c) Rates are updated weekly based on published pricing and market fluctuations.

(2) Pharmacy providers initiate OAAC rate inquiries by submitting the OAAC rate review form "Ohio average acquisition cost program request for medicaid reimbursement review." This form along with copies of purchase records for the national drug code (NDC) are submitted to pharmacy pricing and audit consultant (PPAC). This information is found at https://medicaid.ohio.gov/stakehiolders-and-partners/phm .

(a) PPAC staff evaluate and recommend whether an OAAC rate adjustment is warranted.

(b) All OAAC rate adjustments are sent by PPAC to ODM for final approval within two business days.

(c) ODM approved OAAC rate changes are provided to the single pharmacy benefit manager (SPBM) for adjustment and are backdated to cover dispensing dates included in the rate inquiry.

(3) If an OAAC rate adjustment is not recommended by PPAC, a pharmacy provider may appeal directly to ODM using the ODM 10293 form "Ohio average acquisition cost (OAAC) rate appeal." A pharmacy provider must submit an OAAC appeal form to ODM within thirty calendar days from the date of dispensing.

(a) ODM is responsible for the following:

(i) Reviewing the ODM 10293 form along with any supporting documentation submitted by the pharmacy provider and any other relevant information available to ODM.

(ii) Notifying the pharmacy provider of the final rate adjustment appeal decision using the ODM 10293 form.

(iii) Notifying PPAC of the final rate adjustment appeal decision. If approved, rate changes are provided to the SPBM for adjustment and are backdated to cover dispensing dates included in the rate appeal.

(b) ODM's decision is final and there are no state fair hearing rights or additional appeal rights for the OAAC appeal process.

(B) Managed care pharmacy dispensing fee modification request.

(1) Pharmacy providers may request a modification of their managed care dispensing fee using the ODM 10292 form "Managed care pharmacy dispensing fee modification."

(a) Existing pharmacy providers may request a modification to their dispensing fee at any time.

(b) New pharmacy providers may request a modification to their dispensing fee when there is at least one month of accumulated claims data.

(2) Dispensing fee modification requests received on or before the fifteenth of the month are effective on the first day of the following month. Modification requests received after the fifteenth of the month are effective on the first day of the month after the next month.

(3) ODM reviews the ODM 10292 form and calculates the dispensing fee modification. Calculation scoring is available in the SPBM managed care pharmacy reference guide on ODM's pharmacy website.

(4) ODM communicates the calculated dispensing fee modification to the pharmacy provider.

(5) If warranted, all managed care pharmacy dispensing fee modifications are prospective.

(6) ODM's decision is final and there are no state fair hearing rights or additional appeal rights for the dispensing fee modification process.

Notes

Ohio Admin. Code 5160-9-10

Effective: 7/1/2024
Five Year Review (FYR) Dates: 07/01/2029
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.751, 5164.7511, 5164.7515, 5164.752, 5164.753, 5167.123