Date of Adoption: July 5, 2000.

Purpose: Updates and clarifies the process of reimbursing pharmacy providers for drugs or pharmaceutical supplies supplied to Medical Assistance Administration clients who have third-party insurance coverage, including clients who are eligible for both Medicare and medical assistance. Also to comply with the Governor's Executive Order 97-02 which mandates that all rules be reviewed for clarity, necessity, fairness, etc.

Citation of Existing Rules Affected by this Order: Amending WAC 388-530-1750.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.035.

Adopted under notice filed as WSR 00-11-106 on May 18, 2000.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 1, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0. Effective Date of Rule: Thirty-one days after filing.

July 5, 2000

Edith M. Rice, Chief

Office of Legal Affairs

(1) Except as specified under contract, ((MAA shall)) the medical assistance administration (MAA) does not reimburse providers for any drugs((/supplies)) or pharmaceutical supplies provided to clients who have pharmacy benefits under MAA-contracted managed care plans.      The managed care plan ((shall be)) is responsible for payment.

     (2) ((For the purposes of the section,)) The following definitions apply to this section:

     (a) "Closed pharmacy network" means an arrangement made by an insurer which restricts prescription coverage to an exclusive list of pharmacies.      This arrangement prohibits the coverage and/or payment of prescriptions provided by a pharmacy that is not included on the exclusive list.

     (b) "Private point-of-sale (POS) authorization system" means an insurer's system, other than the MAA POS system, which requires that coverage be verified by or submitted ((for authorization by)) to the insurer's agent for authorization at the time of service and at the time the prescription is filled.

     (3) ((MAA clients who have a third-party resource which is a managed care entity or other insurance requiring the use of "closed pharmacy networks" or "private point-of-sale authorization systems" shall not have prescription provider claims paid until the prescription provider submits an explanation of benefits from the private insurance which demonstrates that the prescription provider has complied with the terms of coverage.      If the private insurer has paid:)) This subsection applies to MAA clients who have a third-party resource that is a managed care entity other than an MAA-contracted plan, or have other insurance that requires the use of "closed pharmacy networks" or "private point-of-sale authorization." MAA will not pay pharmacies for prescription drug claims until the pharmacy provider submits an explanation of benefits from the private insurance that demonstrates that the pharmacy provider has complied with the terms of coverage.

     (a) If the private insurer pays a fee based on the incident of care, the ((prescription)) pharmacy provider ((shall)) must file a claim with ((the department)) MAA consistent with ((the department's)) MAA's billing requirements((; or)).

     (b) If the ((prescription)) private insurer pays the pharmacy provider a monthly capitation fee for all prescription costs related to the client, the ((prescription)) pharmacy provider ((may)) must submit a claim to ((the department)) MAA for the amount of the client co((-))payment, co((-))insurance, and/or deductible. ((The department shall)) MAA pays the provider the lesser of:

     (i) The ((lesser of the)) billed amount; or

     (ii) ((The department's)) MAA's maximum allowable fee for the prescription.

     (4) For clients eligible for both Medicare and ((Medicaid, providers shall)) medical assistance, MAA reimburses providers for:

     (a) ((Be reimbursed for drugs not covered by Medicare, but covered by MAA;)) An amount up to MAA's maximum allowable fee for drugs Medicare does not cover, but MAA does cover; or

     (b) ((Not be reimbursed for drugs covered by Medicare)) Deductible and/or coinsurance amounts up to Medicare's or MAA's maximum allowable fee, whichever is less, for drugs Medicare and MAA cover; or

     (c) Deductible and/or coinsurance amounts for clients under the qualified Medicare beneficiary (QMB) program for drugs Medicare does cover but MAA does not cover.

[Statutory Authority: RCW 74.08.090.      96-21-031, § 388-530-1750, filed 10/9/96, effective 11/9/96.]

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