Section 471-16-015 - PAYMENT FOR PHARMACY SERVICES015.01PROFESSIONAL DISPENSING FEES.015.01(A)DISPENSING FEE, The fee-for-service professional dispensing fee will be assigned to each claim payment based on the lesser of methodology described below.015.01(B)DISPENSING PHYSICIANS. The Department assigns a professional dispensing fee to a dispensing physician only when there is no pharmacy within a 25-mile radius of the physician's place of practice.015.02REIMBURSEMENT METHODOLOGY. Payment levels for ail drugs will not exceed, in the aggregate, upper levels of reimbursement established by federal law. 015.02(A)BRAND NECESSARY CERTIFICATION OF DRUGS. The Federal Upper Limit or State Maximum Allowable Cost limitations will not apply in any case where the prescribing physician certifies a specific brand is medically necessary. In these cases, the usual and customary charge or National Average Drug Acquisition Cost will be the maximum allowable cost. The prescriber must certify that a brand name is medically necessary.015.03PRICING INSTRUCTIONS. Pharmacists will not, under any circumstances, submit charges to the Department which exceed the pharmacy's usual and customary charge.015.03(A)PRICING.Any loss leader, shelf, sale, cash only, coupon certificate, or newspaper and brochure ad prices which are in effect on the date the prescription is dispensed will be considered the pharmacy's usual and customary charge to the general public.015.03(B)PRICE MATCHING. When a pharmacy lowers its usual and customary price for a prescription, all claims submitted to Nebraska Medicaid for the same drug and quantity dispensed during that business day will also be billed at the lowered price. 015.04PAYMENT METHODOLOGY.015.04(A)LEGEND DRUGS, NON-LEGEND DRUGS, AND COMPOUNDED PRESCRIPTIONS. The Nebraska Medicaid Drug Program is required to reimburse ingredient cost for covered outpatient legend and non-legend drugs at the lowest of: (i) The usual and customary charge to the public:(ii) The National Average Drug Acquisition Cost, plus the established professional dispensing fee:(iii) The Affordable Care Act Federal Upper Limit plus the established professional dispensing fee; or (iv) The calculated State Maximum Allowable Cost, plus the established professional dispensing fee. 015.04(B)BACKUP INGREDIENT COST BENCHMARK. If the National Average Drug Acquisition Cost is not available, the allowed ingredient cost will be the lesser of Wholesale Acquisition Cost + 0%, State Maximum Allowable Cost, or the Affordable Care Act Federal Upper Limit plus the established professional dispensing fee.015.04(C)SPECIALTY DRUGS. Specialty drugs will be reimbursed at National Average Drug Acquisition Cost, if National Average Drug Acquisition Cost is not available, then the Backup Ingredient Cost Benchmark will apply.015.04(D)DRUG PRICING PROGRAM. Covered legend and non-legend drugs, including specialty drugs, purchased through the Federal Public Health Service's 340B Drug Pricing Program by covered entities which carve Medicaid into the 340B Drug Pricing Program will be reimbursed at the 340B actual Acquisition cost, but no more than the 340B ceiling price plus the established professional dispensing fee. A 340B contract pharmacy under contract with a 340B covered entity described in section 1927 (a)(5)(B) of the Act is not covered.015.04(E)FEDERAL SUPPLY SCHEDULE. Facilities purchasing drugs through the Federal Supply Schedule will be reimbursed at no more than their actual Acquisition cost plus the established professional dispensing fee.015.04(F)CLOTTING FACTOR.(i) Pharmacies dispensing Antihemophilic Factor products will be reimbursed at the lesser of methodology plus the established professional dispensing fee. If National Average Drug Acquisition Cost is not available, the lesser of methodology for the allowed ingredient cost will be the Wholesale Acquisition Cost + 0%. the Average Sales Price + 6%, or the Affordable Care Act Federal Upper Limit; and(ii) Pharmacies dispensing Antihemophilic Factor products purchased through the Federal Public Health Service's 340B Drug Pricing Program by pharmacies which carve Medicaid into the 340B Drug Pricing Program will be reimbursed at the 340B actual acquisition cost, but no more than the 340B ceiling price plus the established professional dispensing fee.015.04(G)DRUGS PURCHASED AT NOMINAL PRICE. Facilities purchasing drugs at Nominal Price, outside of Federal Public Health Service's 340B Drug Pricing Program or Federal Supply Schedule, will be reimbursed by their actual Acquisition cost plus the established professional dispensing fees.015.04(H)INVESTIGATIONAL DRUGS. Excluded from coverage.015.04(I)TRIBAL RATES. Tribal pharmacies will be paid the federal encounter rate. 015.04(J)CERTIFIED LONG-TERM CARE. Pharmacies providing covered outpatient prescription services for Certified Long-Term Care beneficiaries will be reimbursed for ingredient cost using the lesser of methodology plus the established professional dispensing fee.015.04(K)UNIT DOSE PRESCRIPTIONS. The Department defines unit dose in this chapter. Unit dose providers are allowed one professional dispensing fee per recipient and drug per month. 015.04(L)SALES TAX. The State of Nebraska is tax exempt: therefore, providers do not charge sales tax on claims to the Department.015.04(M)THIRD PARTY LIABILITY. The pharmacy provider will bill any third party resource for claims before billing Medicaid. All third party resources available to Medicaid clients must be utilized for all or part of their medical costs before Medicaid. Third party resources are any individual, entity, or program which is, or may be, liable to pay all or part of the cost of any medical services furnished to a client.471 Neb. Admin. Code, ch. 16, § 015
Adopted effective 12/26/2021