Current through Register Vol. 35, No. 18, September 24, 2024
Pharmacy providers must submit claims for reimbursement on
the separate pharmacy claim form or its successor, see 8.302.2 NMAC and Section
17 of this rule.
A.
General
reimbursement methodology: The estimated ingredient cost will not exceed
the lowest of the estimated acquisition cost (EAC), the maximum allowable cost
(MAC), the actual acquisition cost of a 340B drug, or the federal upper limit
(FUL).
(1)
Estimated acquisition cost
(EAC). MAD determines EAC as follows:
(a) MAD establishes EAC, defined as MAD's
approximation of the net or actual acquisition costs of such drugs;
(b) the factors MAD considers in setting
rates for drugs under this subparagraph include:
(i) product cost, which may vary among
purchasing contracts;
(ii) clinical
concerns;
(iii) MAD's budget
limits;
(iv) the actual package
size dispensed; and
(v) payments by
other payers in New Mexico and other state MAD and medicare pricing
policies;
(c) MAD uses
the EAC as its reimbursement for a drug when the EAC, plus a dispensing fee
established by MAD, is the lowest of the rates calculated under the methods
listed in general reimbursement methodology;
(d) EAC is calculated using the current
published average wholesale price (AWP) of a drug less a percentage established
by MAD, the average manufacturer price (AMP) plus a percentage established by
MAD, or the wholesale acquisition cost (WAC) plus a percentage established by
HSD, and other pricing limits determined by other pricing information sources
selected by MAD; and
(e) MAD uses
the ingredient cost indicated in the ingredient cost field on the billing
transaction as the EAC when that indicated ingredient cost is lower than the
MAD EAC.
(2)
Maximum allowable cost (MAC) MAC methodology. MAD establishes a
MAC applicable for certain multiple-source drugs with FDA rated therapeutic
equivalents and for certain over-the-counter drugs and non-drug items on the
following basis:
(a) at least one A-rated
generic (as listed in the FDA orange book) is readily available to New Mexico
pharmacies;
(b) the MAC for the
brand name drug products and for all A-rated therapeutic equivalents shall be
determined by arraying costs for the A-rated therapeutic equivalent drugs
regardless of manufacturer, and selecting a reasonable price from the arrayed
list in a manner consistent with the state plan or any waiver approved by CMS
subjecting that price to cost factors and tests for reasonableness;
(c) when a state MAC price has not been
calculated by MAD, a baseline price calculated by a national supplier of drug
pricing information is used as the state MAC;
(d) MAC will not be applied if a specific
brand has been determined to be medically necessary, in which event the
reimbursement rate will be the lower of the EAC of the product dispensed plus
the dispensing fee or the provider's billed usual and customary charge;
and
(e) for over-the-counter drugs
and non-drug items, MAC may be established using the pricing sources in
Subsection B of this section.
(3)
Federal upper limit (FUL)
methodology:(a) MAD adopts the FUL
that is set by CMS or recommended by the federal department of
justice.
(b) MAD's maximum payment
for multiple-source drugs for which CMS has set FULs will not exceed, in the
aggregate, the prescribed upper limits plus the dispensing fees set by MAD
under the dispensing fee determination.
(c) MAD will not use the individual drug FUL
as MAD's reimbursement rate when the prescribing practitioner has certified
that a specific brand is medically necessary, in which event the reimbursement
rate will be the lower of the EAC of the product dispensed plus the dispensing
fee or the provider's usual and customary billed charge.
(4)
340B drug discount actual
acquisition cost:(a) The actual
ingredient cost for drugs purchased under Section 340B of the Public Health
Service Act,
42
USC 256 b, and dispensed to a MAP eligible
recipient must placed in the ingredient cost field and indicated on the billing
transaction as a 340B drug item.
(b) Drugs purchased under Section 340B of the
Public Health Service Act,
42
USC 256 b, and dispensed to a MAP eligible
recipient must be billed at the actual acquisition cost of the provider and
indicated on the billing transaction as a 340B drug item. If a MAP eligible
recipient with a prescription written at a 340B entity requests the item to be
dispensed by a 340B pharmacy under contract to the 340B entity then the
pharmacist must dispense 340B purchased items when filling the
prescription.
(5)
Usual and customary charge:(a)
The provider's billed charge must be its usual and customary charge for
services. Over-the-counter items must be billed with the over-the-counter price
as the usual and customary charge, unless it is labeled and dispensed as a
prescription.
(b) "Usual and
customary charge" refers to the amount that the individual provider charges the
general public in the majority of cases for a specific procedure or
service.
(c) Usual and customary
charges must reflect discounts given to a MAP recipient for certain reasons,
such as age or NF resident, when a MAP eligible recipient meets the standards
for the discount. MAD must be given the advantage of discounts received by the
general public, including promotions or items sold at cost to the general
public, if these are the prices usually and customarily charged to non-MAP
recipient.
(d) Providers cannot add
additional costs for their time, paperwork, or anticipated turnaround time for
payment.
(6)
Medicare reimbursement: Reimbursement may be limited to medicare
reimbursement limits where the total of the medicare-allowed amounts plus, if
applicable, a dispensing fee, is the lowest of EAC, MAC, FUL, usual and
customary charge or 340B drug discount amount as defined in this Section
Subsection A of this rule.
(7)
Practitioner administered drug items are reimbursed according to the MAD fee
schedule.
B.
Pricing information to set EAC and MAC: MAD selects the sources
for pricing information used to set EAC and MAC. These sources may include
pharmaceutical wholesalers, manufacturers, federal agencies, drug data
information clearinghouses and pharmacy invoices.
C.
Assistance in establishing EAC and
MAC: MAD may solicit assistance from pharmacy providers, pharmacy
benefit managers (PBMs), other government agencies, actuaries, or other
consultants when establishing EAC or MAC.
D.
Pharmacy price reductions: If
the pharmacy provider offers a discount, rebate, promotion or other incentive
that results in a reduction of the price of a prescription to the individual
non- MAP recipient, the provider must similarly reduce its charge to MAD for
the prescription.
E.
No
claims for free products: If a pharmacy gives a product free to the
general public, the pharmacy must not submit a claim to MAD when giving the
free product to a MAP eligible recipient.
F.
Solutions: Solutions, such as
saline for nebulizers, intravenous (IV) solutions without additives,
electrolyte and irrigation solutions, and diluents are considered medical
supply items for reimbursement purposes; see 8.310.2 NMAC.
G.
Non-drug items: Urine test
reagents, electrolyte replacement and nutritional products, equipment and
medical supplies, including syringes and alcohol swabs, are subject to
restrictions for medical supplies, see 8.310.2 NMAC.
