Section 405 IAC 5-24-4 - Reimbursement for legend drugsAuthority: IC 12-15-1-10; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 4.
(a) The office shall reimburse pharmacy providers for covered legend drugs at the lowest of the following, as applicable:(1) The National Average Drug Acquisition Cost (NADAC) of the drug as published by the Centers for Medicare and Medicaid Services (CMS) pursuant to 42 U.S.C. 1396r-8(f), as of the date of dispensing, plus any applicable Medicaid professional dispensing fee.(2) The state maximum allowable cost (MAC) of the drug as determined by the office as of the date of dispensing, plus any applicable Medicaid professional dispensing fee.(3) The federal upper limit (FUL) of the drug as determined by CMS pursuant to 42 CFR 447.514, as of the date of dispensing, plus any applicable Medicaid professional dispensing fee.(4) The wholesale acquisition cost (WAC) of the drug according to the office's drug database file contracted from a nationally recognized source such as Medi-Span or First DataBank, adjusted by a percentage as determined by the office through analysis of the dispensing cost survey or other methodology approved by CMS, as of the date of dispensing, plus any applicable Medicaid professional dispensing fee. The purpose of the percentage is to ensure that the applicable WAC rate sufficiently reflects the actual acquisition cost of the provider. The WAC shall only be considered if there is no applicable NADAC, FUL, or state MAC rate.(5) The provider's submitted charge, representing the provider's usual and customary charge for the drug, as of the date of dispensing.(b) The state MAC is equal to the average actual acquisition cost per drug adjusted by a multiplier of at least 1.0. The actual acquisition cost will be determined using pharmacy invoices and other information that the office determines is necessary. The purpose of the multiplier is to ensure that the applicable state MAC rate is sufficient to allow reasonable access by providers to the drug at or below the established state MAC rate.(c) OMPP will review state MAC rates on an ongoing basis and adjust the rates as necessary to: (1) reflect prevailing market conditions; and(2) ensure reasonable access by providers to drugs at or below the applicable state MAC rate.(d) Pharmacies and providers that are enrolled in Medicaid are required, as a condition of participation, to make available and submit to the office acquisition cost information, product availability information, or other information deemed necessary by the office for the efficient operation of the pharmacy benefit in the format requested by the office. Providers will:(1) not be reimbursed for this information; and(2) submit information to the office or its designee within thirty (30) days following a request for such information unless the office or its designee grants an extension upon written request of the pharmacy or provider.Office ofthe Secretary of Family and Social Services; 405 IAC 5-24-4; filed Jul 25, 1997, 4:00p.m.: 20 IR 3345; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Aug 29, 2001, 9:50 a.m.: 25 IR 60 [NOTE: On October 9, 2001, the Marion Superior Court issued an Order in Cause No. 49D05-0109-CP-1480, enjoining the Family and Social Services Administration from implementing LSA Document #01-22(F), published at 25 IR 60.]; filed Apr 30, 2002, 10:59 a.m.: 25 IR 2727; errata filed Aug 22, 2002, 3:11 p.m.: 26 IR 35; filed Nov 23, 2005, 11:30 a.m.: 29 IR 1212; readopted filed Sep 19, 2007, 12:16p.m.: 20071010-IR-405070311RFA; filed Jan 23, 2008,1:42p.m.: 20080220-IR-405070547FRA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFAFiled 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRAErrata filed 11/1/2016, 9:36 a.m.: 20161109-IR-405160493ACAFiled 3/2/2017, 3:39 p.m.: 20170329-IR-405160530FRAFiled 4/29/2019, 10:35 p.m.: 20190529-IR-405180482FRAReadopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA