Current through December 21, 2024
(a) Reimbursement
Limits. Except as specified in subsection (b) of this section, the Medicaid
allowable payment for pharmaceutical services shall be of the calculation below
with the lowest reimbursement:
(i) The
National Average Drug Acquisition Cost (NADAC) of the ingredient(s) plus the
dispensing fee specified in subsection (d);
(ii) When no NADAC is available, Medicaid
shall substitute Wholesale Acquisition Cost (WAC) + 0% plus the dispensing fee
specified in subsection (d);
(iii)
When neither NADAC nor WAC are available, Medicaid shall substitute Average
Wholesale Price (AWP) - 11% plus the dispensing fee specified in subsection
(d);
(iv) The Federal Upper Limit
(FUL) plus the dispensing fee specified in subsection (d);
(v) The Department set maximum allowable cost
for specified drugs or drug categories plus the dispensing fee specified in
subsection (d);
(vi) The ingredient
cost submitted by the pharmacy on the claim plus the dispensing fee specified
in subsection (d);
(vii) The gross
amount due; or
(viii) The
provider's usual and customary charge.
(b) Covered entities purchasing drugs under
Section 340B of the Public Health Service Act. Entities that purchase products
under Section 340B of the Public Health Service Act shall request, in writing
to use these drugs for Wyoming Medicaid clients. 340B entities who are granted
such an arrangement shall bill Medicaid no more than their actual acquisition
cost (AAC) for the drug and shall be reimbursed no more than the AAC plus the
dispensing fee specified in subsection (d). 340B entities that fill Wyoming
Medicaid client prescriptions with drugs not purchased under Section 340B of
the Public Health Service Act will be reimbursed in accordance with subsection
(a).
(c) Pharmacies which are
operating as contract pharmacies in the 340B program shall not utilize drugs
purchased under Section 340B of the Public Health Service Act for Wyoming
Medicaid clients.
(d) Dispensing
fee. Except as specified below, the dispensing fee shall be the lower of the
provider's usual and customary dispensing fee or the dispensing fee specified
in (i) or (ii) below. The dispensing fee shall be adjusted as specified in
subsection (f).
(i) Physicians. The
dispensing fee for physicians who perform pharmacy services shall be two
dollars ($2.00) per prescription.
(ii) Pharmacies. The dispensing fee for
pharmacies shall be ten dollars and sixty-five cents ($10.65) per prescription
or compound.
(e)
Adjustment of dispensing fee. The dispensing fee shall be adjusted pursuant to
subsection (f) when necessary to:
(i) Enlist
enough providers so that pharmaceutical services are available to clients to
the extent that those services are available to the general population;
and
(ii) Ensure that payments are
consistent with efficiency, economy, and quality of care.
(f) Method of adjusting dispensing fee. The
dispensing fee shall be adjusted as follows:
(i) The Department shall conduct a usual and
customary survey which may include a review of other insurance payers in-state,
and Medicaid pharmacy programs in surrounding areas.
(ii) Using the data collected pursuant to
subsection (i), the Department may redetermine the fee.
(iii) The Department may use an appropriate
indicator of pharmacy costs to adjust the dispensing fee.
(iv) The Department shall notify providers of
any adjustment in the dispensing fee through manuals, bulletins, facsimiles,
designated websites, or other appropriate means.
(g) Prescription splitting. If a provider
does not have sufficient supplies of a drug to fill a prescription completely,
the provider may fill the prescription to the extent possible and claim a
dispensing fee. When the balance of the prescription is dispensed, the provider
may not seek an additional dispensing fee.
(h) Proof of delivery.
(i) A Provider shall keep a dated log that
maintains a record of when a client or client's representative picks up, or
takes delivery of, every prescription paid for by the Department. All
signatures shall be original at the time each prescription is dispensed;
electronic or other methods of reproducing past signatures are not acceptable.
The signature log can be either manual or electronic and should comply with all
Health Insurance Portability and Accountability Act (HIPAA), State, and Federal
regulations.
(ii) Prescriptions
that are mailed to clients shall be recorded in a dated log that shall contain
the prescription number, date of fill, client's name and address that the
prescription is mailed to as well as the name of the person mailing or
delivering the mail to the mail carrier. If a single prescription to be mailed
has a dollar amount paid by the Department exceeding five hundred dollars
($500.00), a receipt that indicates that the prescription was mailed shall be
obtained and attached to the log.
(iii) The above requirements also apply to
clients living in nursing or institutional facilities.
