Current through Register Vol. 50, No. 9, September 20, 2024
A.
Brand Drugs. The department shall make payments for single source drugs (brand
drugs) based on the lower of:
1. national
average drug acquisition cost (NADAC) plus the professional dispensing fee:
a. if no NADAC is available, use the
wholesale acquisition cost (WAC) plus the professional dispensing fee;
or
b. Repealed.
2. the providers usual and customary charges
to the general public not to exceed the departments "maximum payment allowed."
a. For purposes of these provisions, the term
general public does not include any person whose prescriptions
are paid by third-party payors, including health insurers, governmental
entities, and Louisiana Medicaid.
i.-iii.
Repealed.
3.
Repealed.
B. Generic
Drugs. The department shall make payments for multiple source drugs (generic
drugs), other than drugs subject to "physician certifications", based on the
lower of:
1. NADAC plus the professional
dispensing fee:
a. if no NADAC is available,
use the WAC plus the professional dispensing fee; or
2. federal upper payment limits plus the
professional dispensing fee; or
a.
Repealed.
3. the
provider's usual and customary charges to the general public not to exceed the
department's "maximum payment allowed."
a.
For purposes of these provisions, the term general public does not include any
person whose prescriptions are paid by third-party payors, including health
insurers, governmental entities, and Louisiana Medicaid.
C. Federal Upper Payment Limits
for Multiple Source Drugs
1. Except for drugs
subject to "physician certification," the Medicaid Program shall utilize
listings established by the Centers for Medicare and Medicaid Services (CMS)
that identify and set upper limits for multiple source drugs that meet all of
the following requirements:
a. All of the
formulations of the drug approved by the Food and Drug Administration (FDA)
have been evaluated as therapeutically equivalent in the most current edition
of their publication, Approved Drug Products with Therapeutic Equivalence
Evaluations (including supplements or in successor publications).
b. At least three suppliers list the drug,
which has been classified by the FDA as category "A" in the aforementioned
publication based on listings contained in current editions (or updates) of
published compendia of cost information for drugs available for sale
nationally.
2. Medicaid
shall utilize the maximum acquisition cost established by CMS in determining
multiple source drug cost.
a. - c.
Repealed.
3. The
Medicaid Program shall provide pharmacists who participate in Medicaid
reimbursement with updated lists reflecting:
a. the multiple source drugs subject to
federal multiple source drug cost requirements;
b. the maximum reimbursement amount per unit;
and
c. the date such costs shall
become effective.
D. Physician Certifications
1. Limits on payments for multiple source
drugs shall not be applicable when the prescriber certifies that the brand name
drug is medically necessary for the care and treatment of a recipient in his
own handwriting or via an electronic prescription. Such certification shall be
written directly on the prescription, on a separate sheet which is dated and
attached to the prescription, or submitted electronically. A standard phrase
such as "brand necessary" indicating the medical necessity of the brand will be
acceptable.
2. - 2.c.
Repealed.
E. Fee for
Service 340B Purchased Drugs. The department shall make payments for
self-administered drugs that are purchased by a covered entity through the 340B
program at the actual acquisition cost which can be no more than the 340B
ceiling price plus the professional dispensing fee, unless the covered entity
has implemented the Medicaid carve-out option, in which case 340B drugs should
not be billed to or reimbursed by Medicaid. 340B contract pharmacies shall not
bill 340B stock to Medicaid. Fee-for-service outpatient hospital claims for
340B drugs shall use a cost to charge methodology on the interim cost report
and settled during final cost settlement. Federally qualified health center
(FQHC) and rural health clinic (RHC) claims for physician administered drugs
shall be included in the all-inclusive T1015 encounter rate.
F. Federal Supply Schedule Drugs. Drugs
acquired at federal supply schedule (FSS) and at a nominal price shall be
reimbursed at actual acquisition cost plus a professional dispensing
fee.
G. Indian Health Service
All-Inclusive Encounter Rate. Pharmacy services provided by the Indian Health
Service (IHS) shall be included in the encounter rate. No individual pharmacy
claims shall be reimbursed to IHS providers.
H. Mail Order, Long-Term Care and Specialty
Pharmacy. Drugs dispensed by mail order, long-term care and/or specialty
pharmacies (drugs not distributed by a retail community pharmacy) will be
reimbursed using the brand/generic drug reimbursement methodology.
1. - 2.b.iv. Repealed.
I. Physician-Administered Drugs.
Medicaid-covered physician-administered drugs shall be reimbursed according to
the Louisiana professional services fee schedule. Reimbursement shall be
determined utilizing the following methodology, and periodic updates to the
rates shall be made in accordance with the approved Louisiana Medicaid State
Plan provisions governing physician-administered drugs in a physician office
setting.
1. Average sales price (ASP) plus 6
percent, for drugs appearing on the Medicare file.
2. Reimbursement rates for drugs that do not
appear on the Medicare file shall be determined utilizing the following
alternative methods:
a. the wholesale
acquisition cost (WAC) of the drug, if available;
b. if there is no WAC available, the
reimbursement rate will be 100 percent of the providers current invoice for the
dosage administered.
J. Clotting Factor. Pharmacy claims for
clotting factor will be reimbursed using a state generated actual acquisition
cost (AAC) ingredient cost and a unit based professional dispensing fee
reimbursement methodology.
K.
Investigational or Experimental Drugs. Investigational or experimental drugs
shall not be reimbursed by Medicaid.
AUTHORITY
NOTE: Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
