SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Date of Adoption: December 7, 2000.
Purpose: To update and clarify MAA's prescription drug program reimbursement methodology to reflect current department practice. New sections codify current policy for the drug rebate program, for payment methodology for federal upper limit (FUL), for drugs purchased under the Public Health Service (PHS) Act, and for compliance packaging. The amended sections reflect clearly written and updated policy that is consistent with federal regulations and agency goals.
Citation of Existing Rules Affected by this Order: Amending WAC 388-530-1300, 388-530-1350, 388-530-1400, 388-530-1450, 388-530-1500, 388-530-1550, 388-530-1600, 388-530-1650, and 388-530-1700.
Statutory Authority for Adoption: RCW 74.08.090, 74.04.050.
Adopted under notice filed as WSR 00-17-056 on August 9, 2000.
Changes Other than Editing from Proposed to Adopted Version: (Text additions are indicated by underlining and deletions are
(1) ...MAA may make exceptions based on medical necessity and
on a case-by-case basis... (2) MAA may negotiate separate, additional discounts with
manufacturers to facilitate formulary management.
(6) MAA pays EAC for a drug with an established MAC when the EAC for the particular drug is lower than the MAC price. (This was proposed as part of (5); now numbered as (6). Proposed (6) renumbered as (7)).
(1) Drugs purchased under section 340B of the Public Health
Service (PHS) Act
and can be dispensed only by PHS-qualified
health facilities to medical assistance clients. These
medications must be billed using the actual acquisition cost
(AAC) of the drug plus the appropriate dispensing fee.
(2)(a) MAA allows only the lowest cost for each
ingredient whether EAC, MAC, or amount billed.
formulary covered or prior authorized-drug
ingredient billed separately; and...
(1) The medical assistance administration (MAA) reimburses
for covered drugs, and supplies, and devices provided dispensed
or administered by nonpharmacy providers under specified
conditions. MAA does not reimburse providers for the cost of
vaccines obtained from the state department of health; MAA does
pay a fee for administering the vaccine. (First sentence of
proposed (1) now used as an introduction; last sentence of this
proposed section renumbered as new (3)) (2) (1) MAA reimburses actual acquisition cost (AAC) to a
physician or ARNP for a covered drug (oral, topical or
injectable) prepared or packaged for individual use and provided
or administered to a client during an office visit. When the
cost of the drug provided or administered to the patient client
exceeds the established fee, the physician or ARNP may submit to
MAA a photocopy of the invoice for the actual drug cost. The
invoice must show the name of the drug, the manufacturer, drug
strength, quantity, and cost.
(3) MAA does not reimburse providers for the cost of vaccines obtained through the state department of health; MAA does pay a fee for administering the vaccine.
(3) (4) MAA reimburses family planning clinics: their AAC
for birth control pills and contraceptive supplies distributed to
clients. MAA may request an invoice for the actual cost of the
drug. If an invoice is requested, the invoice must show the name
of the drug, manufacturer, drug strength, and cost.
(a) For oral contraceptives, the lesser of the family planning clinic's certified full fee or MAA's maximum allowable fee per cycle of birth control pills. The certified full fee is the clinic's acquisition cost for each cycle of birth control pills, as reported annually by the clinic to DOH;
(b) For contraceptive supplies and devices, the clinic's actual acquisition cost or MAA's maximum allowable fee, whichever is specified by MAA; and
(c) For other drugs, supplies, and devices, according to MAA's established fee schedules.
(5) MAA may request family planning clinics and other nonpharmacy providers to submit an invoice for the actual cost of the drug, supply, or device billed. If an invoice is requested, the invoice must show the name of the drug, supply, or device, the drug or product manufacturer, drug strength, and quantity or product description and quantity and cost.
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 4, Amended 9, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 4, Amended 9, 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 4, Amended 9, Repealed 0. Effective Date of Rule: Thirty-one days after filing.
December 7, 2000
Marie Myerchin-Redifer, Manager
Rules and Policies Assistance Unit
Reviser's note: The material contained in this filing exceeded the page-count limitations of WAC 1-21-040 for appearance in this issue of the Register. It will appear in the 01-02 issue of the Register.