Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-9 - Pharmacy Services
Section 5160-9-10 - Ohio average acquisition cost (OAAC) appeal and managed care pharmacy dispensing fee modification request
Universal Citation: OH Admin Code 5160-9-10
Current through all regulations passed and filed through September 16, 2024
(A) Ohio average acquisition cost (OAAC) appeal.
(1)
OAAC is the average acquisition cost of a product
calculated based on surveys submitted by pharmacy providers enrolled with the
Ohio department of medicaid (ODM).
(a)
The OAAC rate does not account for off-invoice
adjustments between pharmacy providers and wholesalers or manufacturers and is
reflective of the market conditions specific to enrolled Ohio pharmacy
providers.
(b)
The OAAC rate is recalculated utilizing surveys issued
to pharmacy providers semiannually, in April and October.
(c)
Rates are updated
weekly based on published pricing and market fluctuations.
(2)
Pharmacy providers initiate OAAC rate inquiries by
submitting the OAAC rate review form "Ohio average acquisition cost program
request for medicaid reimbursement review." This form along with copies of
purchase records for the national drug code (NDC) are submitted to pharmacy
pricing and audit consultant (PPAC). This information is found at
https://medicaid.ohio.gov/stakehiolders-and-partners/phm .
(a)
PPAC staff evaluate and recommend whether an OAAC rate
adjustment is warranted.
(b)
All OAAC rate adjustments are sent by PPAC to ODM for
final approval within two business days.
(c)
ODM approved OAAC
rate changes are provided to the single pharmacy benefit manager (SPBM) for
adjustment and are backdated to cover dispensing dates included in the rate
inquiry.
(3)
If an OAAC rate adjustment is not recommended by PPAC,
a pharmacy provider may appeal directly to ODM using the ODM 10293 form "Ohio
average acquisition cost (OAAC) rate appeal." A pharmacy provider must submit
an OAAC appeal form to ODM within thirty calendar days from the date of
dispensing.
(a)
ODM is responsible for the following:
(i)
Reviewing the ODM
10293 form along with any supporting documentation submitted by the pharmacy
provider and any other relevant information available to ODM.
(ii)
Notifying the
pharmacy provider of the final rate adjustment appeal decision using the ODM
10293 form.
(iii)
Notifying PPAC of the final rate adjustment appeal
decision. If approved, rate changes are provided to the SPBM for adjustment and
are backdated to cover dispensing dates included in the rate
appeal.
(b)
ODM's decision is final and there are no state fair
hearing rights or additional appeal rights for the OAAC appeal
process.
(B) Managed care pharmacy dispensing fee modification request.
(1)
Pharmacy
providers may request a modification of their managed care dispensing fee using
the ODM 10292 form "Managed care pharmacy dispensing fee modification."
(a)
Existing pharmacy
providers may request a modification to their dispensing fee at any
time.
(b)
New pharmacy providers may request a modification to
their dispensing fee when there is at least one month of accumulated claims
data.
(2)
Dispensing fee modification requests received on or
before the fifteenth of the month are effective on the first day of the
following month. Modification requests received after the fifteenth of the
month are effective on the first day of the month after the next
month.
(3)
ODM reviews the ODM 10292 form and calculates the
dispensing fee modification. Calculation scoring is available in the SPBM
managed care pharmacy reference guide on ODM's pharmacy
website.
(4)
ODM communicates the calculated dispensing fee
modification to the pharmacy provider.
(5)
If warranted, all
managed care pharmacy dispensing fee modifications are
prospective.
(6)
ODM's decision is final and there are no state fair
hearing rights or additional appeal rights for the dispensing fee modification
process.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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