Prescription Drugs: Provider Reimbursement

Medicaid pharmacies are reimbursed based on Actual Acquisition Costs (AAC) except where noted. Medicaid may require providers to supply documentation of their AACs under the Medicaid Pharmacy Claims Submission Manual available at: https://idaho.fhsc.com/downloads/providers/IDRx_Pharmacy_Claims_Submission_Manual.pdf. Reimbursement is restricted to drugs supplied from labelers participating in the CMS Medicaid Drug Rebate Program. (7-1-26) 01. Pharmacy Reimbursement. Prescriptions not filled according to dispensing procedures will be subject to nonpayment or recoupment. The following protocol is required for reimbursement. (7-1-26) a. Reimbursement is limited to the lowest of the following: (7-1-26) i. AAC based on results of the periodic state cost survey under this rule, plus professional dispensing IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 215 Page 65 fee. In cases where no AAC is available, reimbursement will be the Wholesale Acquisition Cost (WAC). WAC is the price, for a given calendar quarter, paid by a wholesaler for the drugs purchased from the wholesaler’s supplier. The wholesaler’s supplier is typically the manufacturer of the drug as published by a recognized compendium of drug pricing for the same calendar quarter; (7-1-26) ii. State Maximum Allowable Cost (SMAC), as established by the Department, plus professional dispensing fee; (7-1-26) iii. Federal Upper Limit (FUL), as established by CMS, plus professional dispensing fee; or (7-1-26) iv. The provider’s usual and customary charge to the general public. (7-1-26) b. The Department will utilize periodic state cost surveys to obtain the most accurate pharmacy drug AACs in establishing a pharmacy reimbursement fee schedule. Pharmacies participating in the Medicaid Pharmacy Program are required to participate in these periodic state cost surveys by disclosing the costs of all drugs. A pharmacy that is non-responsive to the periodic state cost surveys can be disenrolled as a Medicaid provider by the Department. (7-1-26) c. Provider Administered Drugs. (7-1-26) i. Reimbursement to providers that are not 340B-covered entities for medications administered to participants by providers will be: (7-1-26) (1) Ninety percent (90%) of the published Medicare Average Sales Price plus six percent (6%) rate (ASP+6% rate). (7-1-26) (2) If the ASP+6% rate is not available, payment will be at the WAC. (7-1-26) (3) If the ASP and WAC are not available, an invoice from the manufacturer or wholesaler is required, reimbursement will be at cost plus ten percent (10%). Radiopharmaceuticals will be paid additionally for the cost of shipping. (7-1-26) ii. Reimbursement to 340B covered entities for medications administered to participants by providers will be the actual 340B drug AAC, not to exceed the 340B ceiling price. (7-1-26) d. Clotting Factors. (7-1-26) i. Reimbursement to specialty pharmacies will be at a state-based price equivalent to the published Medicare ASP+6% rate, plus professional dispensing fee. (7-1-26) ii. Reimbursement to Hemophilia Treatment Centers will be the 340B AAC, not to exceed the 340B ceiling price. (7-1-26) e. Professional Dispensing Fee is a tier-based amount paid on a pharmacy claim, over and above the ingredient cost, to compensate the provider for the pharmacist's professional services related to dispensing a prescription to a participant, including: (7-1-26) i. Verifying a participant’s coverage; (7-1-26) ii. Performing drug use reviews and preferred drug list review activities; (7-1-26) iii. Measuring or mixing the covered outpatient drug; (7-1-26) iv. Filling the container; (7-1-26) v. Participant counseling; (7-1-26) IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 215 Page 66 vi. Physically providing the completed prescription to the participant; (7-1-26) vii. Special packaging; and (7-1-26) viii. Overhead associated with maintaining the facility and equipment necessary to operate the dispensing entity. (7-1-26) f. Only one (1) professional dispensing fee per month is allowed for the dispensing of each maintenance drug to any participant as an outpatient or a resident in a care facility except: (7-1-26) i. Multiple dispensing of topical and injectable medication when dispensed in manufacturer's original package sizes, unless evidence exists, as determined by the Department, that the quantity dispensed does not relate to the prescriber's order; (7-1-26) ii. Multiple dispensing of oral liquid maintenance medication if a reasonable quantity, as determined by the Department, is dispensed at each filling; (7-1-26) iii. Multiple dispensing of tablets or capsules if the quantity needed for a thirty-four (34) day supply is excessively large or unduly expensive, in the judgment of the Department; or (7-1-26) iv. When the dose is being titrated for maximum therapeutic response with a minimum of adverse effects. (7-1-26) g. The Department will survey providers to establish a professional dispensing fee for each provider. The professional dispensing fees will be paid based on the provider’s total annual claims volume. The provider must return the claims volume survey to the Department by May 31st each year. Providers who do not complete the survey will be assigned the lowest professional dispensing fee starting on July 1st until the next annual survey is completed. Based upon the annual claims volume of the enrolled pharmacy, the professional dispensing fee is provided online at: https://healthandwelfare.idaho.gov/providers/pharmacy-providers/idaho-medicaid-pharmacy-program. (7-1-26) 02. 340B-Covered Entity Reimbursement. (7-1-26) a. Participation as a 340B-Covered Entity. Medicaid will reimburse 340B covered entities under Section 340B of the Public Health Service Act, defined in 42 U.S.C. 256b(a)(4), when the provider meets the following requirements: (7-1-26) i. A 340B-covered entity submits its unique 340B identification number issued by the Health Resources and Services Administration (HRSA) and a copy of its completed HRSA 340B registration to Medicaid. (7-1-26) ii. A provider that elects to provide drugs to Medicaid participants through the 340B drug pricing program must use 340B-covered outpatient drugs for all dispensed or administered drugs, including those dispensed through the entity’s retail pharmacy or administered in an outpatient clinic. A 340B-covered entity must ensure that a contract pharmacy does not dispense drugs, or receive Medicaid reimbursement for drugs, acquired by the 340B- covered entity through the 340B drug pricing program. An entity that does not comply will be carved out of the 340B drug pricing program. (7-1-26) iii. A 340B-covered entity must provide Medicaid with thirty (30) days written notice of its intent to discontinue the provision of drugs acquired through the 340B drug pricing program to participants. (7-1-26) b. Drugs acquired through the 340B drug pricing program and dispensed by 340B contract pharmacies are not covered. (7-1-26) c. Reimbursement to 340B-covered entities is limited to their actual 340B drug AAC submitted, not to exceed the 340B ceiling price, plus professional dispensing fee. (7-1-26) 03. Reimbursement for Drugs Dispensed by Other Provider Types. (7-1-26) IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 221 Page 67 a. Drugs acquired through non-340B Indian Health Service, Tribal, or Urban Indian pharmacies will be reimbursed at the AAC to the entity, plus professional dispensing fee. (7-1-26) b. Drugs acquired via the Federal Supply Schedule (FSS) will be reimbursed at the FSS AAC, plus professional dispensing fee. (7-1-26) c. Drugs acquired at nominal price, defined as pricing that is outside of 340B regulations or FSS, will be reimbursed at the AAC, plus professional dispensing fee. (7-1-26) d. Specialty drugs not dispensed by retail community pharmacies and dispensed primarily through the mail will be reimbursed at the Idaho AAC, if such cost is available, plus professional dispensing fee. If the AAC is not available, drugs will be reimbursed at the lower of the WAC or SMAC as established by the Department, plus the assigned professional dispensing fee. (7-1-26) e. Drugs not distributed by a retail community pharmacy, such as drugs dispensed in a long-term care facility or dispensed to participants receiving swing-bed services, under these rules, will be reimbursed at the actual ingredient cost, plus professional dispensing fee. (7-1-26) 04. Limitations on Payment. (7-1-26) a. When the medication dispensed is for more than one (1) person, Medicaid will only pay for the amount prescribed for those covered by Medicaid. (7-1-26) b. Medicaid may conduct drug utilization reviews and impose limitations for participants whose drug utilization exceeds the standard participant profile or disease management guidelines determined by the Department. (7-1-26) 05. Cost Appeal Process. Cost appeals will be determined by the Department’s process provided online. (7-1-26) 216. – 219. (RESERVED) SUB AREA: FAMILY PLANNING (Sections 220-229) 220. (RESERVED)