80.09-1
Reimbursement Rates
MaineCare reimbursement for drugs covered under this
Section will only be made for drugs of any manufacturer that has entered into
and complies with a rebate agreement, except as noted in Section
80.09, and specific
reporting requirements as defined by Title XIX of the Social Security
Act Section 1927 described in OBRA 90 as amended.
A.
Reimbursement for Retail Pharmacy
Providers
1.
Generic
Drugs
The reimbursement rate for covered generic drugs shall be
the lowest of the following:
a. The
usual and customary charge; or
b.
The Average Wholesale Price minus sixteen point six seven percent (16.67%) plus
eleven dollars and eighty-nine cents ($11.89) dispensing fee except as
otherwise noted below; or
c The
Federal Upper Limit (FUL) unless the Department meets the FUL in aggregate;
or
d. The Maine maximum allowable
cost plus eleven dollars and eighty-nine cents ($11.89) dispensing fee except
as otherwise noted below; or
e. The
Wholesale Acquisition Cost (WAC) plus eleven dollars and eighty-nine cents
($11.89) dispensing fee; or
f. The
Submitted Ingredient Cost plus eleven dollars and eighty-nine cents ($11.89)
dispensing fee; or
g. Gross Amount
Due (GAD); or
h. National Average
Drug Acquisition Cost (NADAC) plus eleven dollars and eighty-nine cents
($11.89) dispensing fee.
2.
Brand-name Drugs
The reimbursement rate for covered brand-name drugs
shall be the lowest of the following:
a. The usual and customary charge; or
b. The Average Wholesale Price
minus sixteen percent (16%) plus eleven dollars and eighty-nine cents ($11.89)
dispensing fee except as otherwise noted below; or
c. The Maine maximum allowable cost plus
eleven dollars and eighty-nine cents ($11.89) dispensing fee except as
otherwise noted below; or
d. The
Wholesale Acquisition Cost (WAC) plus eleven dollars and eighty-nine cents
($11.89) dispensing fee; or
e. The
Submitted Ingredient Cost plus eleven dollars and eighty-nine cents ($11.89)
dispensing fee; or
f. Gross Amount
Due (GAD); or
g. National Average
Drug Acquisition Cost (NADAC) plus eleven dollars and eighty-nine cents
($11.89) dispensing fee.
3.
Rural Dispensing Fee
Adjustment
The Department will pay a supplemental dispensing fee for
prescriptions provided to members residing in rural areas in an attempt to
assure continuing access to prescription services for these members. The rural
dispensing fee will range from 55¢ to 65¢ per prescription dispensed
to rural members, and will change on a quarterly basis to reflect the prior
quarter's number of prescriptions filled. The Department will distribute the
rural dispensing fee adjustment retrospectively on a quarterly basis. The
Department will calculate the quarterly adjustment for each pharmacy by taking
that quarter's total allotment ($500,000 per quarter) and dividing the total
allotment for the quarter by the number of prescriptions filled for rural
members in the quarter.
The Department will then group these by pharmacy and
distribute in the quarter following. Pharmacies will be notified on a quarterly
basis on the Department's designated website the amount of the adjustment for
the quarter.
Rural members will be defined using a standard and
federally recognized definition of rural using Metropolitan Statistical Area
(MSA) designations. The Department will determine MSA/Non-MSA designation based
on the zip code of the member's residence.
B.
Reimbursement for Specialty Pharmacy
Providers
The reimbursement rate for Specialty Pharmacy Providers
shall be the lowest of the following:
1. The usual and customary charge;
or
2. The Average Wholesale Price
minus sixteen point six seven (16.67%) plus eleven dollars and eighty-nine
cents ($11.89) dispensing fee except as otherwise noted below; or
3. The Federal Upper Limit (FUL) unless the
Department meets the FUL in aggregate or the Maine maximum allowable cost plus
eleven dollars and eighty-nine cents ($11.89) dispensing fee except as
otherwise noted below.
4. The Maine
maximum allowable cost plus eleven dollars and eighty-nine cents ($11.89)
dispensing fee except as otherwise noted below; or
5. The Wholesale Acquisition Cost (WAC) plus
eleven dollars and eighty-nine cents ($11.89) dispensing fee; or
6. The Submitted Ingredient Cost plus eleven
dollars and eighty-nine cents ($11.89) dispensing fee; or
7. Gross Amount Due (GAD); or
8. National Average Drug Acquisition Cost
(NADAC) plus eleven dollars and eighty-nine cents ($11.89) dispensing
fee.
C.
Reimbursement for Mail Order Pharmacy Providers
1.
Generic Drugs
The reimbursement rate for covered generic drugs
obtained through mail order pharmacy providers shall be the lowest of the
following:
a. The usual and customary
charge; or
b. The Average Wholesale
Price minus sixty percent (60%) plus a two-dollar and fifty cent ($2.50)
dispensing fee except as otherwise noted below; or
c. The Federal Upper Limit (FUL) unless the
Department meets the FUL in aggregate or the Maine maximum allowable cost plus
a two-dollar and fifty cent ($2.50) dispensing fee except as otherwise noted
below.
2.
Brand
Name Drugs
The reimbursement rate for covered brand name drugs
obtained through mail order pharmacy providers shall be the lowest of the
following:
a. The usual and customary
charge; or
b. The Average Wholesale
Price minus twenty percent (20%) plus a two-dollar and fifty cent ($2.50)
dispensing fee except as otherwise noted below; or
D.
Reimbursement for 340B
Drugs
Providers or entities who purchase drugs under the 340B
policy, must sign a memorandum of understanding (MOU) with the state. When the
state and the entity reach an agreement on the billing process, reporting
process, specific covered drugs, and pricing standards this MOU must be
individualized to include the term of these components.
For entities and providers that are eligible to enroll
in the 340B program, see the listing on
http://www.hrsa.gov/opa/introduction.htm. All providers and entities must
comply with federal and HRSA 340B rules and regulations.
E. Effective October 1, 2009 the
reimbursement rate for the Seasonal Flu Vaccine and/or Allowable Immunizations
as allowed by
32 MRSA
§13831, shall be the Federal Upper Limit
or the Maine maximum allowable cost plus five dollars ($5.00) dispensing fee
except as otherwise noted.
F. The
Department's reimbursement rate will be reduced by any applicable member
co-payment.
G. In accordance with
Chapter I, of the MaineCare Benefits Manual, it is the
responsibility of the provider to seek payment from every other source. It is
the responsibility of the provider to verify a member's eligibility for
MaineCare prior to providing services by requesting the individual to present
his or her MaineCare ID card on each occasion that a service is provided and
verifying this information as described in Chapter I of the MBM.
H If the provider is aware that a member's
eligibility is due to expire within one (1) month of the date of service,
reimbursement will only be made for up to a one (1) month's supply.
I.
Maine Maximum Allowable Cost
(MMAC). The establishment of a MMAC is subject, but not limited, to the
following considerations:
1. Multiple active
rebatable manufacturers;
2.
Multiple covered non-drug products available through the pharmacy POS
3. Broad wholesale acquisition, average
manufacturer price, actual acquisition cost and wholesaler price
spans;
4. Availability of drugs to
retailers, specialty stores and mail order providers at the selected
cost;
5. High volume of MaineCare
member utilization; and
6.
Bioequivalence or interchangeability.
The Department will periodically notify pharmacies of
updates to the list of drugs affected by FUL or MMAC pricing. This information
will also be available on the OMS website.
J.
Reimbursement for Drugs More
Expensive Than MAC or MMAC Allowances
A prescriber who requests a drug more expensive than an
equivalent MAC or MMAC limited generic drug must get prior authorization for
the requested product before reimbursement will be permitted. Prescribers and
providers will be notified of the drugs requiring prior authorization and this
list, and any updates, will be posted on the Department's designated
website.
K.
Reimbursement for Compounded Drugs for Retail Pharmacy Providers
Reimbursement for compounded drugs is determined by
subtracting the co-payment described in Section
80.08, from the sum
of the dispensing fee and the ingredient cost. The ingredient cost is the sum
of the cost of the defined ingredients contained in the compounded drug. The
provider must list the NDC for each active and inactive ingredient and the
corresponding quantity used for each ingredient. Ingredients that are
identified as DESI (less than effective) may not be included in the
reimbursement for the compounded drug. Only electronic claims will be
accepted.
1. Dispensing fees for
compound drugs are as follows:
a. Eleven
dollars and eighty-nine cents ($11.89) except for filling insulin syringes as
provided under 1(b).
b Twelve
dollars and fifty cents ($12.50) for filling insulin syringes per fourteen (14)
day supply.
