WSR 10-24-021

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medicaid Purchasing Administration)

[ Filed November 19, 2010, 1:30 p.m. , effective December 20, 2010 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: This revision is necessary to update and clarify wording under subsection (3) of this section, specifically the word "percentage" should be "maximum allowable cost."

The rule change clarifies that the department may set "estimated acquisition cost (EAC)" payment rates for certain specified drugs or drug categories, at a maximum cost, rather than as a percentage discount off the reference price. This will allow the department to avoid excessive programming costs associated with setting unique percentage rates on specified drugs. The new wording does not change the prerogative of the department to pay lower EAC rates when appropriate.

Citation of Existing Rules Affected by this Order: Amending WAC 388-530-8000.

Statutory Authority for Adoption: RCW 74.04.050 and 74.08.090.

Adopted under notice filed as WSR 10-19-133 on September 22, 2010.

A final cost-benefit analysis is available by contacting Myra Davis, P.O. Box 45510, Olympia, WA 98504-5510, phone (360) 725-1847, fax (360) 586-9727, e-mail davisms@dshs.wa.gov.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.

Date Adopted: November 19, 2010.

Susan N. Dreyfus

Secretary

4235.1
AMENDATORY SECTION(Amending WSR 07-20-049, filed 9/26/07, effective 11/1/07)

WAC 388-530-8000   Reimbursement method--Estimated acquisition cost (EAC).   (1) The department determines estimated acquisition cost (EAC) using:

(a) Acquisition cost data made available to the department; or

(b) Information provided by any of the following:

(i) Audit agencies, federal or state;

(ii) Other state health care purchasing agencies;

(iii) Pharmacy benefit managers;

(iv) Individual pharmacy providers participating in the department's programs;

(v) Centers for Medicare and Medicaid Services (CMS);

(vi) Other third party payers;

(vii) Drug file data bases; and/or

(viii) Actuaries or other consultants.

(2) The department implements EAC by applying a percentage adjustment to available reference pricing from national sources such as wholesale acquisition cost (((WAC))), average wholesale price (AWP), average sale price (ASP), and average manufacturer price (AMP).

(3) The department may set EAC for specified drugs or drug categories at a ((percentage)) maximum allowable cost other than that determined in subsection (1)(a) of this section when the department considers it necessary. The factors the department considers in setting a rate for a class of drugs under this subsection include, but are not limited to:

(a) Product acquisition cost;

(b) The department's documented clinical concerns; and

(c) The department's budget limits.

(4) The department bases EAC drug reimbursement on the actual package size dispensed.

(5) The department uses ((the)) EAC as the department's reimbursement for a drug when ((the)) EAC is the lowest of the rates calculated under the methods listed in WAC 388-530-7000, or when the conditions of WAC 388-530-7300 are met.

[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 07-20-049, 388-530-8000, filed 9/26/07, effective 11/1/07.]

Washington State Code Reviser's Office