WSR 03-20-075



(Medical Assistance Administration)

[ Filed September 29, 2003, 2:47 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 03-11-086.

Title of Rule: Chapter 388-530 WAC, Pharmacy services, amending WAC 388-530-1300 General reimbursement methodology.

Purpose: This amendment is a change recommended by the DSHS Payment Review Program Steering Committee. The new language will help control pharmacy costs.

Statutory Authority for Adoption: RCW 74.08.090 and 74.09.520.

Statute Being Implemented: RCW 74.09.120, 74.09.200, and 74.09.520.

Summary: The proposed amendment adds the following new subsection (4) to pharmacy services WAC 388-530-1300 General reimbursement methodology: "(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 specific dosage form."

Name of Agency Personnel Responsible for Drafting: Myra S. Davis, MAA, Rules and Publications, P.O. Box 45533, Olympia, WA 98504, (360) 725-1306; Implementation and Enforcement: Ayuni Wimpee, Operations Manager, Rates Analysis Section, P.O. Box 45510, Olympia, WA, (360) 725-1835.

Name of Proponent: Department of Social and Health Services, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: This rule responds to a recommendation of the DSHS Payment Review Committee. The rule will require providers to dispense the least costly form of a drug.

Proposal Changes the Following Existing Rules: See Summary above.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rule and determined that it does not create more than minor costs to small business.

RCW 34.05.328 applies to this rule adoption. MAA has analyzed the proposed rules and concludes that the rules meet the definition of a "significant legislative rule." MAA has prepared an evaluation of probable costs and benefits, which may be obtained by contacting the person at the address listed above.

Hearing Location: Blake Office Park (behind Goodyear Courtesy Tire), 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on November 4, 2003, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact DSHS Rules Coordinator by October 31, 2003, phone (360) 664-6094, TTY (360) 664-6178, e-mail

Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, mail to P.O. Box 45850, Olympia, WA 98504-5850, deliver to 4500 10th Avenue S.E., Lacey, WA, fax (360) 664-6185, e-mail, by 5:00 p.m. on November 4, 2003.

Date of Intended Adoption: Not sooner than November 5, 2003.

September 29, 2003

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

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 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.]

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