Florida Administrative Code
59 - AGENCY FOR HEALTH CARE ADMINISTRATION
59G - Medicaid
Chapter 59G-4 - MEDICAID POLICY
Section 59G-4.251 - Prescribed Drugs Reimbursement Methodology
Current through Reg. 50, No. 187; September 24, 2024
(1) This rule applies to all prescribed drug service providers enrolled in the Florida Medicaid program that provide services under the fee-for-service delivery system in accordance with Rule 59G-4.250, Florida Administrative Code (F.A.C.).
(2) Definitions.
(3) Reimbursement Methodology.
(4) Florida Medicaid utilizes the actual purchased drug price plus a PDF in the reimbursement methodology for drugs acquired via the Federal Supply Schedule.
(5) Florida Medicaid utilizes the actual purchased drug price plus a PDF in the reimbursement methodology for drugs acquired via nominal price.
(6) Florida Medicaid reimburses for drugs purchased under the 340B program at the actual purchased drug price, which cannot exceed the 340B ceiling price, plus a dispensing fee of $10.24. This provision only applies to covered entities, Indian Health Services, tribal organizations, urban Indian pharmacies and federally qualified health centers that dispense drugs purchased at prices authorized under section 340B of the Public Health Services Act.
(7) Florida Medicaid reimburses for clotting factor to the vendor(s) awarded the state's hemophilia contract(s) at the negotiated price.
(8) Florida Medicaid reimburses for prescribed drugs administered by a licensed practitioner in an office setting at 106 percent of ASP, as provided by CMS quarterly in the format of drug pricing files, available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html; or, when no ASP rate is available, at WAC.
(9) Florida Medicaid reimburses for prescribed drugs purchased under the 340B program administered in an outpatient facility at an amount not to exceed the 340B ceiling price.
(10) Florida Medicaid does not reimburse for investigational or experimental drugs.
(11) The rule is in effect for five years from its effective date.
Rulemaking Authority 409.919 FS. Law Implemented 409.906, 409.908, 409.912 FS.
New 1-28-09, Amended 8-23-09, 5-20-12, 6-2-16, 3-29-18, 12-20-21.