WSR 04-01-089

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed December 16, 2003, 9:43 a.m. ]


Date Adopted: December 9, 2003.

Purpose: This amendment is a change recommended by the DSHS payment review program steering committee. The new language will help control pharmacy costs.

Citation of Existing Rules Affected by this Order: Amending WAC 388-530-1300.

Statutory Authority for Adoption: RCW 74.08.090 and 74.09.520.

Adopted under notice filed as WSR 03-20-075 on September 29, 2003.

Changes Other than Editing from Proposed to Adopted Version: As a result of comments received, the words "medically necessary" were inserted into the following text: WAC 388-530-1300(4) "MAA reimburses a pharmacy for the least costly dosage form of a drug within the same route of administration, unless the prescriber has designated a medically necessary specific dosage form."

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.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.

December 9, 2003

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3309.2
AMENDATORY SECTION(Amending WSR 02-17-023, filed 8/9/02, effective 9/9/02)

WAC 388-530-1300   General reimbursement methodology.   (1) The medical assistance administration's (MAA) total reimbursement for a prescription drug must not exceed the lowest of:

(a) Estimated acquisition cost (EAC) plus a dispensing fee;

(b) Maximum allowable cost (MAC) plus a dispensing fee;

(c) Federal Upper Limit (FUL) plus a dispensing fee;

(d) Actual acquisition cost (AAC) plus a dispensing fee for drugs purchased under section 340 B of the Public Health Service (PHS) Act and dispensed to medical assistance clients;

(e) Automated maximum allowable cost (AMAC) plus a dispensing fee;

(f) Certified average wholesale price (CAWP) plus a dispensing fee; or

(g) The provider's usual and customary charge to the non-Medicaid population.

(2) MAA selects the sources for pricing information used to set EAC and MAC. These sources may include pharmaceutical wholesalers.

(3) MAA may solicit assistance from pharmacy providers, pharmacy benefit managers (PBM), other government agencies, actuaries, and/or other consultants when establishing EAC and/or MAC.

(4) MAA reimburses a pharmacy for the least costly dosage form of a drug within the same route of administration, unless the prescriber has designated a medically necessary specific dosage form.

(5) If the pharmacy provider offers a discount, rebate, promotion or other incentive which directly relates to the reduction of the price of a prescription to the individual non-Medicaid customer, the provider must similarly reduce its charge to MAA for the prescription.

(((5))) (6) If a pharmacy gives a product free to the general public, the pharmacy must not submit a claim to MAA when giving the free product to a medical assistance client.

[Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, 388-530-1300, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-029, 388-530-1300, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, 388-530-1300, filed 10/9/96, effective 11/9/96.]