Current through Vol. 42, No. 1, September 16, 2024
(a)
Reimbursement. Reimbursement for pharmacy claims is based on the
sum of the ingredient cost plus a professional dispensing fee for brand and
generic drugs dispensed by a retail community pharmacy or for a member residing
in a long term care facility.
(b)
Ingredient Cost. Ingredient
cost is determined by one of the following methods:
(1)
Maximum Allowable Cost. The
State Maximum Allowable Cost (SMAC) is established for certain products which
have a Food and Drug Administration (FDA) approved generic equivalent. The SMAC
will be calculated using prices from pharmaceutical wholesalers who supply
these products to pharmacy providers in Oklahoma. Pharmacies may challenge a
specific product's SMAC price by providing information from their wholesaler(s)
to certify a net cost higher than the calculated SMAC price and that there is
not another product available to them which is generically equivalent to the
higher priced product.
(2)
Actual Acquisition Cost. The Actual Acquisition Cost (AAC) means
the cost of a particular drug product to the pharmacy based on a review of
invoices or the Wholesale Acquisition Cost (WAC), whichever is lower. The
National Average Drug Acquisition Cost (NADAC) is based on a review of invoices
and published by Centers for Medicare and Medicaid Services (CMS) and will be
used in the determination of AAC.
(3)
Specialty Pharmaceutical Allowable
Cost. Reimbursement for specialty drugs not typically dispensed by a
retail community pharmacy and dispensed primarily by delivery, including
clotting factor for hemophilia, shall be set as a Specialty Pharmaceutical
Allowable Cost (SPAC). The Medicare Part B allowed charge, WAC, and NADAC when
available, will be considered in setting the SPAC rate. For the purpose of this
section, a drug may be classified as a specialty drug when it has one or more
of the following characteristics:
(A) Covered
by Medicare Part B;
(B) "5i drug" -
Injected, infused, instilled, inhaled, or implanted;
(C) Cost greater than $1,000.00 per
claim;
(D) Licensed by the FDA
under a Biological License Application;
(E) Special storage, shipping, or handling
requirements;
(F) Available only
through a limited distribution network; and/or
(G) Does not have a NADAC price from
CMS.
(4)
Exceptions. Some exceptions apply to the above ingredient cost
methods:
(A) Physician administered drugs
shall be priced based on a formula equivalent to the Medicare Part B allowed
charge. If a price equivalent to the Medicare Part B allowed charge cannot be
determined, a purchase invoice may be supplied by the provider and will be
considered in setting the reimbursement.
(B) I/T/U pharmacies shall be reimbursed at
the OMB encounter rate as a per member per facility per day fee regardless of
the number of prescriptions filled on that day. I/T/U pharmacies should not
split prescriptions into quantities less than a one month supply for
maintenance medications. For this purpose a maintenance medication is one that
the member uses consistently month to month.
(C) Pharmacies other than I/T/U facilities
that acquire drugs via the Federal Supply Schedule (FSS) or at nominal price
outside the 340B program or FSS shall notify OHCA and submit claims at their
actual invoice price plus a professional dispensing fee.
(c)
Professional dispensing
fee. The professional dispensing fee for prescribed medication is
established by review of surveys. A recommendation is made by the State Plan
Amendment Rate Committee and presented to the Oklahoma Health Care Authority
Board for their approval. There may be more than one level or type of
dispensing fee if approved by the OHCA Board and CMS. A contracted pharmacy
agrees to participate in any survey conducted by the OHCA with regard to
dispensing fees. The pharmacy shall furnish all necessary information to
determine the cost of dispensing drug products. Failure to participate may
result in administrative sanctions by the OHCA which may include but are not
limited to a reduction in the dispensing fee.
(d)
Reimbursement for prescription
claims. Prescription claims will be reimbursed using the lower of the
following calculation methods:
(1) the lower
of Actual Acquisition Cost (AAC), State Maximum Allowable Cost (SMAC), or
Specialty Pharmaceutical Allowable Cost (SPAC) plus a professional dispensing
fee, or
(2) usual and customary
charge to the general public. The pharmacy is responsible to determine its
usual and customary charge to the general public and submit it to OHCA on each
pharmacy claim. The OHCA may conduct periodic reviews within its audit
guidelines to verify the pharmacy's usual and customary charge to the general
public and the pharmacy agrees to make available to the OHCA's reviewers
prescription and pricing records deemed necessary by the reviewers. The OHCA
defines general public as the patient group accounting for the largest number
of non-SoonerCare prescriptions from the individual pharmacy, but does not
include patients who purchase or receive their prescriptions through other
third-party payers. If a pharmacy offers discount prices to a portion of its
customers (i.e. -10% discount to senior citizens), these lower prices would be
excluded from the usual and customary calculations unless the patients
receiving the favorable prices represent more than 50% of the pharmacy's
prescription volume. The usual and customary charge will be a single price
which includes both the product price and the dispensing fee. For routine usual
and customary reviews, the pharmacy may provide prescription records for
non-SoonerCare customers in a manner which does not identify the customer by
name so long as the customer's identity may be determined later if a subsequent
audit is initiated. The OHCA will provide the pharmacy notice of its intent to
conduct a review of usual and customary charges at least ten days in advance of
its planned date of review.
(e)
Payment of Claims. In order
for an eligible provider to be paid for filling a prescription drug, the
pharmacy must complete all of the following:
(1) have an existing provider agreement with
OHCA,
(2) submit the claim in a
format acceptable to OHCA,
(3) have
a prior authorization before filling the prescription, if a prior authorization
is necessary,
(4) have a proper
brand name certification for the drug, if necessary, and
(5) include the usual and customary charges
to the general public as well as the actual acquisition cost and professional
dispensing fee.
(f)
Claims. Prescription reimbursement may be made only for
individuals who are eligible for coverage at the time a prescription is filled.
Member eligibility information may be accessed by swiping a SoonerCare
identification card through a commercial card swipe machine which is connected
to the eligibility database or via the Point of Sale (POS) system when a
prescription claim is submitted for payment. Persons who do not contract with
commercial vendors can use the Member Eligibility Verification System (EVS) at
no additional cost.
