Section 17-1739.1-11 - Payment for drugs and related supplies(a) The state medical assistance program shall determine reimbursement for the ingredient cost of prescription drugs using the following criteria: (1) Single source drugs shall not exceed the lower of:(A) The provider's invoice price;(B) The provider's usual and customary charge to the general public; or(C) The estimated acquisition cost (EAC).(2) Multiple source drugs shall not exceed the lower of: (A) The provider's invoice price;(B) The provider's usual and customary charge to the general public;(D) The federal upper limit (FUL) price; or(E) The state maximum allowable cost (SMAC).(3) The FUL price shall not apply if the practitioner: (A) Certifies in his or her own handwriting or by an electronic method compliant with national standard approved by the Centers for Medicare and Medicaid Services that a specific brand medication is medically necessary for a particular recipient. A check-off box is not acceptable but a notation of "brand medically necessary" or "do not substitute" is allowable; and(B) Obtains prior authorization for medical necessity from the state medical assistance program. In such cases, the payment shall be according to the methodology in this section.(4) The State medical assistance program requires that the lower cost equivalent drug product be dispensed if available in the marketplace and substitution is not prohibited by part VI of chapter 328, Hawaii Revised Statues, relating to drug product selection. The recipient may refuse lower cost drug products but must pay the entire cost of the higher price equivalent.(5) If a published WAC is unavailable for the medication and the provider does not submit documentation of the invoice price, then the medication and dispensing fee shall not be reimbursed.(b) The dispensing fee for prescription medications dispensed by a licensed pharmacy shall be: (1) $5.00 (five and no/100 dollars) per prescription.(2) The dispensing fee for any maintenance or chronic medication shall be extended only once per thirty (30) days without medical authorization from the medical assistance program. Other appropriate limits regarding the number of dispensing fees paid per interval of time shall be determined as necessary by the medical assistance program.(c) The Department may cover selected over-the-counter medications. (1) Reimbursement for over-the-counter medications shall be according to the methodology in subsection (a).(2) Reimbursement for over-the-counter drugs shall be limited to the over-the-counter drugs prescribed by a licensed practitioner and specifically designated by the medical assistance program. Over-the-counter drugs not specifically designated shall require prior authorization for medical necessity by the medical assistance program.(3) Under no circumstances shall the program pay more than the general public for the same prescription or item.(d) The following conditions shall apply to payment for drugs dispensed by physicians and dentists from the physicians' and dentists' offices: (1) Physicians and dentists dispensing medications from the physicians' and dentists' offices shall be reimbursed at the EAC plus $0.50 (fifty cents); and (2) If there is no pharmacy within five miles of the provider's office, special consideration for payment at the pharmacy rate may be made upon written request to the department's med-QUEST division administrator for approval.(e) Payment for prescribed drugs dispensed to outpatients and patients of long-term care facilities shall be made only upon the submission of an itemized claim by the dispensing provider (Form 204), hardcopy or electronic media claim or via point-of-sale.(f) Emergency calls by the pharmacist to the long-term care facility: (1) Shall be paid up to a maximum of four calls for each one hundred beds in the facility at the time services are rendered, at $25 (twenty-five and no/100 dollars) per emergency call. Any fraction of one hundred shall be prorated accordingly; and(2) Facilities with less than twenty-five beds at the time services are rendered may charge up to one full emergency call per month. (A) An emergency call shall be one that cannot be delayed, i.e. non-routine call to the patient of a facility by the pharmacist in a life-threatening situation.(B) All other services shall be handled during the pharmacist's routine visits whenever possible.(g) Payments for medical supplies shall be the lower of: (1) The rate set by the department;(2) Medicare's upper limit of payment; or(3) The EAC for a medical supply.Haw. Code R. § 17-1739.1-11
[Eff 10/26/01; am 05/10/03; am 05/05/05; am 04/12/13 ] (Auth: HRS § 346-59) (Imp: 42 C.F.R. §§447.331, 447.332, 447.333 )