COMMONWEALTH OF VIRGINIA
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Notice of Intent to Change the Reimbursement Methodology for Pharmacy Services
Notice is hereby given that the Department of Medical Assistance Services (DMAS) intends to change the reimbursement methodology for pharmacy services pursuant to the Department’s authority under Title XIX of the Social Security Act. This notice is intended to satisfy the requirements of 42 C.F.R. § 447.205 and of § 1902(a)(13) of the Social Security Act, 42 U.S.C. § 1396a(a)(13). The changes contained in this public notice are occurring in response to the 2015 Acts of the Assembly, Item 301 QQ.
In order to comply with a new requirements in a final federal rule entitled “Medicaid Program; Covered Outpatient Drugs” that was published in the Federal Register on February 1, 2016, DMAS proposes the following new payment methodology for pharmacy services effective July 1, 2016:
A. Reimbursement for covered legend and non-legend drugs shall be the lowest of subdivisions 1 through 3 of this section:
The National Average Drug Acquisition Cost (NADAC) of the drug.
In cases where no NADAC is available, DMAS will reimburse at Wholesale Acquisition Cost (WAC).
The provider's usual and customary (U&C) charge to the public, as identified by the claim charge.
B. The Public Health Services (PHS) Act Section 340B covered entities and federally qualified health centers, or their contracted agents, that fill Medicaid members' prescriptions with drugs purchased at the prices authorized under Section 340B must bill Medicaid for the actual acquisition cost.
C. Payment for pharmacy services will be as described above; however, payment for legend and non-legend drugs will include the allowed cost of the drug plus only one professional dispensing fee per month for each specific drug. Exceptions to the monthly dispensing fees shall be allowed for drugs determined by the department to have unique dispensing requirements. The professional dispensing fee for all drugs is $10.65.
D. There is no expected annual increase or decrease in expenditures. The change is expected to be budget-neutral.
A copy of this notice is available for public review from Donna Proffitt, Manager, Pharmacy Services, Division of Health Care Services, DMAS, 600 Broad Street, Suite 1300, Richmond, VA 23219. Comments or inquiries may be submitted, in writing, within 30 days of this notice publication to Ms. Proffitt at Donna.Proffitt@dmas.virginia.gov and such comments are available for review at the same address.