Alabama Administrative Code
Title 560 - ALABAMA MEDICAID AGENCY
Chapter 560-X-16 - PHARMACEUTICAL SERVICES
Section 560-X-16-.06 - Reimbursement For Covered Drugs And Services
Current through Register Vol. 43, No. 02, November 27, 2024
(1) Medicaid pays for certain legend and non-legend drugs prescribed by practitioners legally licensed by the state of Alabama to prescribe the drugs authorized under the program and dispensed and/or administered by a licensed pharmacist or licensed authorized physician in accordance with state and federal laws as stated in Rule 560-X-16-.01.
(2) Blood clotting factor products. In addition to providing blood clotting factor, providers of the Alabama Medicaid Agency are required to provide, at the minimum, clinically appropriate items and services to their hemophilia patients as outlined in Rule No. 560-X-16-.31.
(3) The pharmacist shall submit claims in the units specified on the prescription by the prescribing physician up to a 34-day supply. A three-month supply is permitted for certain maintenance therapies. Payment for units greater than 34 days, unless otherwise permitted, may be recouped by Medicaid unless the pharmacist can provide documentation to support the units dispensed. Medications supplied in a dosage form that would prevent the dispensing of an exact 30 up to a 34-day supply for chronic medications, such as insulin, may require quantities that exceed the 34-day maximum and would not be subject to recoupment as long as the pharmacist can provide appropriate documentation.
(4) Dispensing Fees. A professional dispensing fee is set by the Agency. This fee is reviewed periodically, and when deemed appropriate by Medicaid, may be adjusted.
(5) Unless the designated amount of the original days' supply has been utilized or there is a documented consultation with the prescribing physician, only one dispensing fee is allowed for a 30 up to a 34-day supply of the same drug per month. For quantities up to a 34-day supply, the designated amount is 85% of the original days' supply for opioids (both agonists and partial agonists) and 75% for all other drugs. For quantities greater than a 34-day supply, the designated amount is 90% of the original days' supply.
(6) Medicaid may reimburse for professional services provided by licensed pharmacists. Professional services may include vaccine administration, medication maintenance therapy adherence and other clinical services as designated by the Agency.
Author: Kelli D. Littlejohn, R.Ph., Pharm. D., Director, Clinical Services and Support
Statutory Authority: State Plan, Attachments 3.1A, 4.18B; Title XIX, Social Security Act; 42 C.F.R. §§ 447.205, 447.331; Omnibus Budget Reconciliation Act of 1990 (Public Law 101-508); Veterans Health Care Act of 1992 (Public Law 102-585).