CMS has approved the State Department of Health’s Medicaid State Plan Amendment for cost-based reimbursement plus a $10.00 professional dispensing fee retroactive to April 1, 2017 for the Medicaid fee-for-service program. The new professional dispensing fee is $10.00 per prescription or written order by a practitioner and does not apply to over-the-counter products that do not meet the definition of a covered outpatient drug per section 1927K of the Social Security Act. The following are changes to product reimbursement in the Medicaid fee-for-service program:

• Generic Drugs: The lower of NADAC or WAC-17.5% if no NADAC exists; or the Federal Upper Limit (FUL); or State Maximum Acquisition Cost (SMAC); or the dispensing pharmacy’s usual and customary price charged to the general public.
• Brand Name Drugs: The lower of NADAC or WAC-3 & 3/10% if no NADAC exists; or the dispensing pharmacy’s usual and customary price charged to the general public.

The state will initiate the reimbursement changes in two phases. In the near future, the State intends to give pharmacies two weeks’ notice that the new rate will be initiated on all Medicaid fee-for-service claims. After the successful roll out of the claims processing with the new rates, the State will begin a retroactive adjustment of past claims. The adjustment will be spread out over a period of time.

For more information, please contact NACDS’ Ben Pearlman at 617-515-2603.