Ala. Admin. Code r. 560-X-16-.06

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-16-.06 - Reimbursement For Covered Drugs And Services

(1) Medicaid pays for certain legend and non-legend drugs prescribed by practitioners legally licensed by the state of Alabama to prescribe the drugs authorized under the program and dispensed and/or administered by a licensed pharmacist or licensed authorized physician in accordance with state and federal laws as stated in Rule 560-X-16-.01.

(a) Notwithstanding specific reimbursement described in this section, payment for covered outpatient drugs (both brand and generic) dispensed by a:

1. Retail community pharmacy

2. Specialty pharmacy

3. Long-term care or institutional pharmacy (when not included as an inpatient stay)

4. 340B eligible entities (including 340B contract pharmacies) not listed on the U.S. Department of Health and Human Services Health Resources & Service Administration (HRSA) 340B Drug Pricing Program Database

5. Indian Health Service, Tribal and Urban Indian pharmacy

(b) Shall not exceed the lowest of:

1. Effective January 1, 2021. The Alabama Average Acquisition Cost (AAC) of the drug; when no AAC is available, the Wholesale Acquisition Cost (WAC)-4% for brand drugs and WAC + 0% for generic drugs, plus a professional dispensing fee of $10.64,

2. The Federal Upper Limit (FUL), plus a professional dispensing fee of $10.64, or

3. The provider's Usual and Customary (U&C) charge to the general public regardless of program fees.

(c) Payment for blood clotting factor products will be the Average Sales Price (ASP) + 6% plus a professional dispensing fee of $10.64.

(d) For eligible 340B entities listed on the U.S. Department of Health and Human Services Health Resources & Service Administration (HRSA) 340B Drug Pricing Program Database, payment shall not exceed the entity's actual acquisition cost for the drug, as charged by the manufacturer at a price consistent with the Veterans Health Care Act of 1992, plus a professional dispensing fee of $10.64.

(e) For facilities purchasing drugs through the Federal Supply Schedule (FSS), payment shall not exceed the entity's actual acquisition cost for the drug, plus a professional dispensing fee of $10.64.

(f) For facilities purchasing drugs at Nominal Price, payment shall not exceed the entity's actual acquisition cost for the drug, plus a professional dispensing fee of $10.64.

(g) Physician Administered Drugs (PADs) are reimbursed at a rate of ASP+ 6%. For PADs that do not have a published ASP, the reimbursement is calculated based on published compendia pricing such as Wholesale Acquisition Cost (WAC). For PADs administered by 340 entities, payment shall not exceed the entity's actual acquisition cost for the drug.

(h) Investigational drugs not approved by the FDA are not covered.

(2) Blood clotting factor products. In addition to providing blood clotting factor, providers of the Alabama Medicaid Agency are required to provide, at the minimum, clinically appropriate items and services to their hemophilia patients as outlined in Rule No. 560-X-16-.31.

(3) The pharmacist shall submit claims in the units specified on the prescription by the prescribing physician up to a 34-day supply. A three-month supply is permitted for certain maintenance therapies. Payment for units greater than 34 days, unless otherwise permitted, may be recouped by Medicaid unless the pharmacist can provide documentation to support the units dispensed. Medications supplied in a dosage form that would prevent the dispensing of an exact 30 up to a 34-day supply for chronic medications, such as insulin, may require quantities that exceed the 34-day maximum and would not be subject to recoupment as long as the pharmacist can provide appropriate documentation.

(4) Dispensing Fees. A professional dispensing fee is set by the Agency. This fee is reviewed periodically, and when deemed appropriate by Medicaid, may be adjusted.

(5) Unless the designated amount of the original days' supply has been utilized or there is a documented consultation with the prescribing physician, only one dispensing fee is allowed for a 30 up to a 34-day supply of the same drug per month. For quantities up to a 34-day supply, the designated amount is 85% of the original days' supply for opioids (both agonists and partial agonists) and 75% for all other drugs. For quantities greater than a 34-day supply, the designated amount is 90% of the original days' supply.

(6) Medicaid may reimburse for professional services provided by licensed pharmacists. Professional services may include vaccine administration, medication maintenance therapy adherence and other clinical services as designated by the Agency.

Ala. Admin. Code r. 560-X-16-.06

Rule effective October 1, 1982. Emergency rule: Effective October 29, 1987. Amended: Effective December 10, 1987; April 14, 1992. Amended: Filed October 7, 1993; effective November 12, 1993. Amended: Filed March 7, 1996; effective April 12, 1996. Amended: Filed January 6, 1998; effective February 10, 1998. Amended: Filed May 6, 1999; effective June 10, 1999. Amended: Filed May 10, 2002; effective June 14, 2002. Amended: Filed June 10, 2005; effective July 15, 2005. Amended: Filed November 9, 2007; effective December 14, 2007. Amended: Filed March 27, 2008; effective May 1, 2008. Amended: Filed January 11, 2010; effective February 15, 2010. Amended: Filed July 9, 2010; effective August 13, 2010. Amended: Filed January 25, 2011; effective March 1, 2011. Amended: Filed December 11, 2012; effective January 15, 2013. Amended: Filed August 13, 2013; effective September 17, 2013.

Amended by Alabama Administrative Monthly Volume XXXVI, Issue No. 02, November 30, 2017, eff. 12/28/2017.

Amended by Alabama Administrative Monthly Volume XXXVII, Issue No. 01, October 31, 2018, eff. 11/26/2018.

Amended by Alabama Administrative Monthly Volume XXXIX, Issue No. 01, October 30, 2020, eff. 12/14/2020.

Author: Kelli D. Littlejohn, R.Ph., Pharm. D., Director, Clinical Services and Support

Statutory Authority: State Plan, Attachments 3.1A, 4.18B; Title XIX, Social Security Act; 42 C.F.R. §§ 447.205, 447.331; Omnibus Budget Reconciliation Act of 1990 ( Public Law 101-508 ); Veterans Health Care Act of 1992 ( Public Law 102-585 ).