Pharmacy Reimbursement Allowance

PURPOSE: This rule establishes a Pharmacy Federal Reimbursement Allowance and the methodologies to determine the formula for the amount of allowance each pharmacy is required to pay for the privilege of providing outpatient prescription drugs. (1) Pharmacy Reimbursement Allowance (PRA). PRA shall be assessed as described in this section. (A) Definitions. 1. Department—Department of Social Services. 2. Director—Director of Department of Social Services. 3. Division—MO HealthNet Division. 4. Gross retail prescription receipts—For ease of administration for the department as well as the industry, this shall be an annual amount. The basis of tax in any fiscal year will be the gross prescription sales of the last calendar year prior to the previous fiscal year. (B) Each pharmacy engaging in the business of providing outpatient prescription drugs in Missouri to the general public shall pay a PRA. 1. The PRA owed for existing pharmacies shall be calculated by multiplying the pharmacy’s total gross retail prescription receipts by the tax rate determined by the department. Subject to the limitations established in section 338.520, RSMo, such said tax rate shall be uniform and shall not exceed five percent (5%). 2. The PRA shall be divided by and collected over the number of months for which the PRA is effective. 3. The initial PRA owed by a newly licensed pharmacy shall be calculated by estimating the total prescription sales and multiplying the estimate by the rate determined by the department, as described in paragraph (1)(B)1. 4. If a pharmacy ceases to provide outpatient prescription drugs to the general public, the pharmacy is not required to pay the PRA during the time it did not provide outpatient prescription drugs. 5. If the pharmacy reopens, it shall resume paying the PRA. It shall owe the same PRA as it did prior to closing, if the PRA has not changed per paragraph (1)(B)1. (C) Each pharmacy shall submit an affidavit to the department with the following information: 1. Pharmacy name; 2. Contact; 3. Telephone number; 4. Address; 5. Federal tax ID number; 6. MO HealthNet pharmacy number (if applicable); 7. Pharmacy sales (total); 8. MO HealthNet pharmacy sales; 9. Number of paid MO HealthNet prescriptions; and 10. Gross receipts attributable to prescription drugs that are delivered directly to the patient via common carrier, by mail, or a courier service. (D) The department shall prepare a confirmation schedule of the information provided by each pharmacy and the amount of PRA that is due from the pharmacy. (E) Each pharmacy shall review the information prepared by the department and the amount of PRA calculated by the department to verify that the information is correct. 1. If the information supplied by the department is incorrect, the facility within thirty (30) calendar days of receiving the confirmation schedule must notify the division and explain the correction. 2. If the division does not receive corrected information within thirty (30) calendar days, it will be assumed to be correct, unless the pharmacy files a protest in accordance with subsection (2)(D) of this regulation. (2) Payment of the PRA. (A) Offset. 1. Each pharmacy may request that its PRA offset against any MO HealthNet payment due to that pharmacy. A. A statement authorizing the offset must be on file with the division before any offset may be made relative to the PRA by the pharmacy. B. Assessments shall be allocated and deducted over the applicable service period. C. Any balance due after the offset shall be remitted to the director of the Department of Revenue and be deposited in the state treasury to the credit of the Pharmacy Reimbursement Allowance Fund. D. If the remittance is not received before the next MO HealthNet payment cycle, the division shall offset the balance due from that check. (B) Check. 1. If no offset has been authorized by the pharmacy, the division will begin collecting the pharmacy reimbursement allowance on the first day of each month for the preceding months. 2. The PRA shall be remitted by the pharmacy to the department. The remittance shall be made payable to the director of the Department of Revenue and be deposited in the state treasury to the credit of the Pharmacy Reimbursement Allowance Fund. (C) Failure to comply with this request for information or failure to pay the PRA. 1. If a pharmacy fails to comply with a request for information from the MO HealthNet Division or fails to pay its PRA within thirty (30) days of notice, the PRA shall be delinquent. 2. For any delinquent PRA, the department may— A. Proceed to enforce the state’s lien of the property of the pharmacy; B. Cancel or refuse to issue, extend, or reinstate the MO HealthNet provider agreement; or C. Seek denial, suspension, or revocation of license granted under Chapter 338, RSMo. 3. The new owner, as a result of a change in ownership, shall have his/her PRA paid by the same method the previous owner elected. (D) Each pharmacy, upon receiving written notice of the final determination of its PRA, may file a protest with the director of the department setting forth the grounds on which the protest is based, within thirty (30) days from the date of receipt of written notice from the department. The director of the department shall reconsider the determination and, if the pharmacy so requested, grant the pharmacy a hearing to be held within forty-five (45) days after the protest was filed, unless extended by agreement between the pharmacy and the director. The director shall issue a final decision within forty-five (45) days of the completion of the hearing. After a final decision by the director, a pharmacy’s appeal of the director’s final decision shall be to the Administrative Hearing Commission in accordance with section 208.156, RSMo, and section 621.055, RSMo. (E) PRA Rates. 1. The PRA tax rate will be a uniform effective rate of one and twenty hundredths percent (1.20%) with an aggregate annual adjustment, by the MO HealthNet Division, not to exceed five hundredths percent (.05%) based on the pharmacy’s total prescription volume. 2. Beginning January 1, 2019, the PRA tax rate will be a uniform effective rate of one and forty-three hundredths percent (1.43%) with an aggregate quarterly adjustment, by the MO HealthNet Division, not to exceed one and five-tenths percent (1.5%) based on the pharmacy’s total prescription volume. 3. Beginning July 1, 2022, the PRA tax rate will be a uniform effective rate of thirty-seven hundredths percent (0.37%) with an aggregate quarterly adjustment, by the MO HealthNet Division, not to exceed one and five-tenths percent (1.5%) based on the pharmacy’s total prescription volume. 4. Beginning July 1, 2023, the PRA tax rate will be a uniform effective rate of fifty-two hundredths percent (0.52%) with an aggregate quarterly adjustment, by the MO HealthNet Division, not to exceed one and five-tenths percent (1.5%) based on the pharmacy’s total prescription volume. 5. Beginning January 1, 2024, the PRA tax rate will be a uniform effective rate of forty-nine hundredths percent (0.49%) with an aggregate quarterly adjustment, by the MO HealthNet Division, not to exceed one and five-tenths percent (1.5%) based on the pharmacy’s total prescription volume. 6. Beginning July 1, 2025, the PRA tax rate will be a uniform effective rate of two percent (2%) with an aggregate quarterly adjustment, by the MO HealthNet Division, not to exceed two percent (2%) based on the pharmacy’s total prescription volume. 7. The maximum rate shall be five percent (5%). AUTHORITY: sections 208.201, 338.505, and 660.017, RSMo 2016.* Emergency rule filed June 20, 2002, effective July 1, 2002, expired Feb. 27, 2003. Original rule filed July 15, 2002, effective Feb. 28, 2003. Amended: Filed Feb. 3, 2003, effective Aug. 30, 2003. Amended: Filed Nov. 3, 2003, effective April 30, 2004. Emergency amendment filed Sept. 12, 2008, effective Sept. 22, 2008, expired March 20, 2009. Amended: Filed Sept. 12, 2008, effective April 30, 2009. Amended: Filed July 1, 2009, effective Jan. 30, 2010. Emergency amendment filed Dec. 1, 2009, effective Jan. 1, 2010, expired June 29, 2010. Amended: Filed Dec. 1, 2009, effective June 30, 2010. Emergency amendment filed June 17, 2010, effective July 1, 2010, expired Dec. 27, 2010. Amended: Filed April 26, 2019, effective Nov. 30, 2019. Amended: Filed March 2, 2023, effective Oct. 30, 2023. Amended: Filed Feb. 21, 2024, effective Aug. 30, 2024. Emergency amendment filed June 23, 2025, effective July 8, 2025, expired Feb. 26, 2026. Amended: Filed June 23, 2025, effective Jan. 30, 2026. *Original authority: 208.201, RSMo 1987, amended 2007; 338.505, RSMo 2002; and 660.017, RSMo 1993, amended 1995.