Section He-W 570.14 - Payment for Drugs(a) Payment for drugs shall be: (1) Made for products whose manufacturer has a signed rebate agreement with the USDHHS, or for single or innovator multiple-source products exempt from such agreements, pursuant to Section 4401 of P.L. 101-508, OBRA '90;(2) Reimbursed at the lesser of the following: a. The AAC using NADAC files when available, plus the dispensing fee;b. The WAC, when a NADAC is not available, plus the dispensing fee;c. The usual and customary charge to the general public;d. The NHMAC plus the dispensing fee; ore. The FUL plus the dispensing fee; and(3) Subject to the following conditions and restrictions: a. The payment for multiple source drugs, listed as having a FUL by the USDHHS, shall be reimbursed at a rate which does not exceed the FUL plus the dispensing fee, except as determined by the CMS of the USDHHS;b. The payment for multiple source drugs, listed as having a NHMAC by the department, shall be reimbursed at a rate which does not exceed the maximum allowable cost plus the dispensing fee;c. The NHMAC and FUL shall not apply when a licensed practitioner certifies on the face of the prescription in his or her own handwriting, pursuant to He-W 570.09, that a specific brand of drug, which is a NHMAC or FUL drug, is medically necessary for a particular recipient;d. The payment for any refill prescriptions for the same recipient for solid oral maintenance drugs within a time period that does not allow for usage of 75% of the supply of the drug shall be only for the cost of the drug unless the reason for the exception is documented on the prescription or the licensed practitioner's order; ande. The payment for compound drugs and sterile preparations for parenteral use shall be at the rate established by the department in accordance with RSA 161:4, VI(a) .(b) For a unit dose drug: (1) The unit dose form of tablets and capsules shall be reimbursable only for medicaid recipients residing in nursing facilities and other facilities licensed under RSA 151;(2) Unused portions of unit dose drugs shall be returned by the licensed facility in (b) (1) above to the pharmacy provider when allowed in accordance with 21 CFR 1306 or applicable state law;(3) Unit dose credit shall be submitted by the pharmacy provider to the department, within 90 days of such return;(4) The original claim shall be voided by the pharmacy provider and a new claim submitted for the actual amount used;(5) A pharmacy provider shall use the manufacturer's unit dose package or his or her own unit dose package which meets the requirements of US pharmacopoeia dispensing information (USPDI) unit dose packages; and(6) Claims for unit dose packages shall be submitted only at the end of any monthly period.(c) The pharmacy provider shall submit drug claims for payment to the PBM.(d) The pharmacy provider shall submit medical supply and equipment claims with NDCs for payment to the PBM.(e) The pharmacy provider shall submit medical supply and equipment claims with HCPCS codes for payment to the department's fiscal agent.(f) The pharmacy provider shall make available to the department the following documents for utilization and review purposes: (1) All prescriptions for both medicaid recipients and non-medicaid recipients filled during the time period specified by the department, with all identifying information blocked out; (2) All price lists that were in effect for such time period; and(3) Invoices showing the actual acquisition cost of the drugs and supplies.N.H. Admin. Code § He-W 570.14
#7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02
New. #7805, eff 12-21-02; ss by #9831, eff 12-21-10
Amended by Volume XXXVII Number 15, Filed April 13, 2017, Proposed by #12140, Effective 4/1/2017, Expires 4/1/2027.Amended by Volume XXXVIII Number 23, Filed June 7, 2018, Proposed by #12529, Effective 5/22/2018, Expires 5/22/2028.