(a) Reimbursement Limits. Except as specified in subsection (b) of this section, the Medicaid allowable payment for pharmaceutical services shall be of the calculation below with the lowest reimbursement: - (i) The National Average Drug Acquisition Cost (NADAC) of the ingredient(s) plus the dispensing fee specified in subsection (d);
- (ii) When no NADAC is available, Medicaid shall substitute Wholesale Acquisition Cost (WAC) + 0% plus the dispensing fee specified in subsection (d);
- (iii) When neither NADAC nor WAC are available, Medicaid shall substitute Average Wholesale Price (AWP) - 11% plus the dispensing fee specified in subsection (d);
- (iv) The Federal Upper Limit (FUL) plus the dispensing fee specified in subsection (d);
- (v) The Department set maximum allowable cost for specified drugs or drug categories plus the dispensing fee specified in subsection (d);
- (vi) The ingredient cost submitted by the pharmacy on the claim plus the dispensing fee specified in subsection (d);
- (vii) The gross amount due; or
- (viii) The provider's usual and customary charge.
(b) Covered entities purchasing drugs under Section 340B of the Public Health Service Act. Entities that purchase products under Section 340B of the Public Health Service Act shall request, in writing to use these drugs for Wyoming Medicaid clients. 340B entities who are granted such an arrangement shall bill Medicaid no more than their actual acquisition cost (AAC) for the drug and shall be reimbursed no more than the AAC plus the dispensing fee specified in subsection (d). 340B entities that fill Wyoming Medicaid client prescriptions with drugs not purchased under Section 340B of the Public Health Service Act will be reimbursed in accordance with subsection (a).
(c) Pharmacies which are operating as contract pharmacies in the 340B program shall not utilize drugs purchased under Section 340B of the Public Health Service Act for Wyoming Medicaid clients.
(d) Dispensing fee. Except as specified below, the dispensing fee shall be the lower of the provider's usual and customary dispensing fee or the dispensing fee specified in (i) or (ii) below. The dispensing fee shall be adjusted as specified in subsection (f). - (i) Physicians. The dispensing fee for physicians who perform pharmacy services shall be two dollars ($2.00) per prescription.
- (ii) Pharmacies. The dispensing fee for pharmacies shall be ten dollars and sixty-five cents ($10.65) per prescription or compound.
(e) Adjustment of dispensing fee. The dispensing fee shall be adjusted pursuant to subsection (f) when necessary to: - (i) Enlist enough providers so that pharmaceutical services are available to clients to the extent that those services are available to the general population; and
- (ii) Ensure that payments are consistent with efficiency, economy, and quality of care.
(f) Method of adjusting dispensing fee. The dispensing fee shall be adjusted as follows: - (i) The Department shall conduct a usual and customary survey which may include a review of other insurance payers in-state, and Medicaid pharmacy programs in surrounding areas.
- (ii) Using the data collected pursuant to subsection (i), the Department may redetermine the fee.
- (iii) The Department may use an appropriate indicator of pharmacy costs to adjust the dispensing fee.
- (iv) The Department shall notify providers of any adjustment in the dispensing fee through manuals, bulletins, facsimiles, designated websites, or other appropriate means.
(g) Prescription splitting. If a provider does not have sufficient supplies of a drug to fill a prescription completely, the provider may fill the prescription to the extent possible and claim a dispensing fee. When the balance of the prescription is dispensed, the provider may not seek an additional dispensing fee.
(h) Proof of delivery. - (i) A Provider shall keep a dated log that maintains a record of when a client or client's representative picks up, or takes delivery of, every prescription paid for by the Department. All signatures shall be original at the time each prescription is dispensed; electronic or other methods of reproducing past signatures are not acceptable. The signature log can be either manual or electronic and should comply with all Health Insurance Portability and Accountability Act (HIPAA), State, and Federal regulations.
- (ii) Prescriptions that are mailed to clients shall be recorded in a dated log that shall contain the prescription number, date of fill, client's name and address that the prescription is mailed to as well as the name of the person mailing or delivering the mail to the mail carrier. If a single prescription to be mailed has a dollar amount paid by the Department exceeding five hundred dollars ($500.00), a receipt that indicates that the prescription was mailed shall be obtained and attached to the log.
- (iii) The above requirements also apply to clients living in nursing or institutional facilities.
048-10 Wyo. Code R. § 10-16