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.
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). 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.
DMAS is specifically soliciting input from stakeholders, providers and beneficiaries, on the potential impact of the proposed reimbursement adjustments to pharmacy services. Comments or inquiries may be submitted, in writing, within 30 days of this notice publication to Ms. Proffitt and such comments are available for review at the same address. Comments may also be submitted, in writing, on the Town Hall public comment forum attached to this notice.
This notice is available for public review on the Regulatory Town Hall (www.townhall.com), on the General Notices page, found at: https://townhall.virginia.gov/L/generalnotice.cfm
DMAS is making these changes in its methods and standards for setting payment rates for services in order to comply with the legislative mandates set forth in the 2016 Acts of Assembly, Chapter 780, Item 306.
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 September 1, 2016:
A. Reimbursement for covered legend and non-legend drugs shall be the lowest of subdivisions 1 through 4 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) + 0%.
- The Federal Upper Limit (FUL).
- The provider's usual and customary (U&C) charge to the public, as identified by the claim charge.
B. 340B covered entities and Federally Qualified Health Centers (FQHCs) that fill Medicaid member prescriptions with drugs purchased at the prices authorized under Section 340B of the Public Health Services Act shall bill Medicaid their actual acquisition cost. DMAS shall not accept claims from "contracted pharmacy entities" for drugs purchased through a 340B program. Facilities purchasing drugs through the Federal Supply Scheduled or drug pricing program under 38 U.S.C. 1826, 42 U.S.C. 1396-8, other than the 340B drug pricing program shall bill Medicaid their actual acquisition cost.
C. Payment for pharmacy services will be as described above; however, payment for covered outpatient 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. The professional dispensing fee shall be determined by a cost of dispensing survey conducted at least every five (5) years.
D. There is no expected annual increase or decrease in expenditures. The change is expected to be budget-neutral.