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, defined as Average
Sales Price (ASP) plus 6%, 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.
(A) Physician
administered drugs shall be priced based on a formula equivalent to the
Medicare Part B allowed charge, defined as ASP plus 6%. 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.
Added at 12 Ok Reg
751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
7-27-95; Amended at 12 Ok Reg 3638, eff 9-8-95 (emergency); Amended at 13 Ok
Reg 1645, eff 5-27-96; Amended at 16 Ok Reg 3446, eff 7-1-99
(emergency)1; Amended at 17 Ok Reg 719, eff 11-30-99
(emergency); Amended at 17 Ok Reg 1211, eff 5-11-00; Amended at 17 Ok Reg 2383,
eff 6-26-00; Amended at 19 Ok Reg 2136, eff 6-27-02; Amended at 25 Ok Reg 2662,
eff 7-25-08; Amended at 28 Ok Reg 266, eff 11-15-10 (emergency); Amended at 28
Ok Reg 1448, eff 6-25-11
1On October 15, 1999, the
District Court of Oklahoma County issued a Temporary Injunction Order
"prohibiting, barring, enjoining and restraining the Oklahoma Health Care
Authority from relying upon, maintaining, employing or using t[his] emergency
rule." [See Astrazeneca LP v. Oklahoma Health Care Authority, Case No.
CJ-99-5898, 10-15-99, Judge Bryan C. Dixon, District Court of Oklahoma County]
On 11-30-99, the emergency action was superseded by another emergency action,
which was later superseded by a permanent action on 5-11-00. On 10-10-00, the
case was dismissed with prejudice.
