New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-W - Former Division of Human Services
Chapter He-W 500 - MEDICAL ASSISTANCE
Part He-W 570 - PHARMACEUTICAL SERVICES
Section He-W 570.14 - Payment for Drugs
Universal Citation: NH Admin Rules He-W 570.14
Current through Register No. 40, October 3, 2024
(a) Payment for drugs shall be:
(1) Made for products whose manufacturer has
a signed rebate agreement with the USDHHS, or for single or innovator
multiple-source products exempt from such agreements, pursuant to
Section
4401 of
P.L.
101-508, OBRA '90;
(2) Reimbursed at the lesser of the
following:
a. The AAC using NADAC files when
available, plus the dispensing fee;
b. The WAC, when a NADAC is not available,
plus the dispensing fee;
c. The
usual and customary charge to the general public;
d. The NHMAC plus the dispensing fee;
or
e. The FUL plus the dispensing
fee; and
(3) Subject to
the following conditions and restrictions:
a.
The payment for multiple source drugs, listed as having a FUL by the USDHHS,
shall be reimbursed at a rate which does not exceed the FUL plus the dispensing
fee, except as determined by the CMS of the USDHHS;
b. The payment for multiple source drugs,
listed as having a NHMAC by the department, shall be reimbursed at a rate which
does not exceed the maximum allowable cost plus the dispensing fee;
c. The NHMAC and FUL shall not apply when a
licensed practitioner certifies on the face of the prescription in his or her
own handwriting, pursuant to
He-W
570.09, that a specific brand of drug, which is a
NHMAC or FUL drug, is medically necessary for a particular recipient;
d. The payment for any refill prescriptions
for the same recipient for solid oral maintenance drugs within a time period
that does not allow for usage of 75% of the supply of the drug shall be only
for the cost of the drug unless the reason for the exception is documented on
the prescription or the licensed practitioner's order; and
e. The payment for compound drugs and sterile
preparations for parenteral use shall be at the rate established by the
department in accordance with
RSA 161:4, VI(a)
.
(b) For a unit dose drug:
(1) The unit dose form of tablets and
capsules shall be reimbursable only for medicaid recipients residing in nursing
facilities and other facilities licensed under RSA 151;
(2) Unused portions of unit dose drugs shall
be returned by the licensed facility in (b) (1) above to the pharmacy provider
when allowed in accordance with 21 CFR 1306 or applicable state law;
(3) Unit dose credit shall be submitted by
the pharmacy provider to the department, within 90 days of such
return;
(4) The original claim
shall be voided by the pharmacy provider and a new claim submitted for the
actual amount used;
(5) A pharmacy
provider shall use the manufacturer's unit dose package or his or her own unit
dose package which meets the requirements of US pharmacopoeia dispensing
information (USPDI) unit dose packages; and
(6) Claims for unit dose packages shall be
submitted only at the end of any monthly period.
(c) The pharmacy provider shall submit drug claims for payment to the PBM.
(d) The pharmacy provider shall submit medical supply and equipment claims with NDCs for payment to the PBM.
(e) The pharmacy provider shall submit medical supply and equipment claims with HCPCS codes for payment to the department's fiscal agent.
(f) The pharmacy provider shall make available to the department the following documents for utilization and review purposes:
(1) All prescriptions for both
medicaid recipients and non-medicaid recipients filled during the time period
specified by the department, with all identifying information blocked out;
(2) All price lists that were in
effect for such time period; and
(3) Invoices showing the actual acquisition
cost of the drugs and supplies.
#7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02
New. #7805, eff 12-21-02; ss by #9831, eff 12-21-10
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