Drug Reimbursement Methodology

PURPOSE: This rule establishes the basis and the method for pricing all drug claims in Missouri under the Title XIX Medicaid program. The purchase of a computer-generated tape, with weekly updates, will make it possible to utilize the computer for review purposes, which greatly increases the speed with which claims can be paid. (1) The MO HealthNet Division will obtain, by contract with a reputable medical publishing company, a weekly computergenerated tape which will provide the information needed to price all fee-for-service Medicaid drug claims. The tape will contain National Drug Code (NDC), drug name, drug strength, dosage form, package size, the prices set by direct-selling manufacturers (direct prices), Wholesaler Acquisition Cost (WAC), federal Health and Human Services upper limits for specified multiple source drugs (FUL), and National Average Drug Acquisition Cost (NADAC). A multiple source drug is defined as a drug marketed or sold by two (2) or more manufacturers or labelers, or a drug marketed or sold by the same manufacturer or labeler under two (2) or more different proprietary names or both under a proprietary name and without that name. (2) The MO HealthNet Division will add the Missouri Maximum Allowable Cost (MMAC) limits, for multiple source drugs as defined, to the data shown on the tape described in section (1) of this rule. (3) Effective December 16, 2018, reimbursement for covered drugs will be determined by applying the following hierarchy method: (A) National Average Drug Acquisition Cost (NADAC); if there is no NADAC; (B) Missouri Maximum Allowed Cost (MAC); if no NADAC or MAC; (C) Wholesale Acquisition Cost (WAC); or (D) The usual and customary (U&C) charge submitted by the provider if it is lower than the chosen price (NADAC, MAC, or WAC). 1. U&C is defined as the provider’s charge to the general public that reflects all discounts or programs such as, but not limited to, discount programs, membership programs, price matching programs, or any other program offered by the provider to initiate a reduced price for product costs available to the general public, a special population, or an inclusive category of customers, on the date of service. 2. General public is defined as those patients that pay for their prescriptions and the prescription is not processed by a third-party which includes both governmental and nongovernmental payers. (4) Reimbursement for covered drugs for 340B providers as defined in 42 U.S.C. 256b(a)(4) and 42 U.S.C. 1396r-8(a)(5)(B) who carve-in for Medicaid will be calculated according to 13 CSR 70-20.075. (5) The professional dispensing fee will be calculated according to 13 CSR 70-20.060. AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016, and section 208.152, RSMo Supp. 2021.* This rule was previously filed as 13 CSR 40-81.150. Original rule filed April 23, 1979, effective Aug. 11, 1979. Emergency amendment filed Sept. 9, 1981, effective Oct. 1, 1981, expired Dec. 10, 1981. Amended: Filed Sept. 9, 1981, effective Dec. 11, 1981. Emergency amendment filed Oct. 19, 1987, effective Oct. 29, 1987, expired Feb. 25, 1988. Amended: Filed Dec. 1, 1987, effective Feb. 11, 1988. Emergency amendment filed March 29, 1988, effective April 8, 1988, expired Aug. 5, 1988. Amended: Filed May 3, 1988, effective July 28, 1988. Emergency amendment filed Dec. 21, 1990, effective March 17, 1991, expired April 30, 1991. Emergency amendment filed March 6, 1991, effective March 17, 1991, expired July 14, 1991. Emergency amendment filed Sept. 4, 1991, effective Sept. 17, 1991, expired Jan. 14, 1992. Amended: Filed Sept. 4, 1991, effective Jan. 13, 1992. Amended: Filed Dec. 5, 2000, effective June 30, 2001. Amended: Filed July 19, 2018, effective March 30, 2019. Emergency amendment filed April 26, 2021, effective July 1, 2021, expired Feb. 24, 2022. Amended: Filed April 26, 2021, effective Nov. 30, 2021. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2015, 2018, 2021; 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.