Subsection 144-101-II-80.09 - REIMBURSEMENT80.09-1Reimbursement RatesMaineCare reimbursement for drugs covered under this Section will only be made for drugs of any manufacturer that has entered into and complies with a rebate agreement, except as noted in Section 80.09, and specific reporting requirements as defined by Title XIX of the Social Security Act Section 1927 described in OBRA 90 as amended.
A.Reimbursement for Retail Pharmacy Providers1.Generic DrugsThe reimbursement rate for covered generic drugs shall be the lowest of the following:
a. The usual and customary charge; orb. The Average Wholesale Price minus sixteen point six seven percent (16.67%) plus eleven dollars and eighty-nine cents ($11.89) dispensing fee except as otherwise noted below; orc The Federal Upper Limit (FUL) unless the Department meets the FUL in aggregate; ord. The Maine maximum allowable cost plus eleven dollars and eighty-nine cents ($11.89) dispensing fee except as otherwise noted below; ore. The Wholesale Acquisition Cost (WAC) plus eleven dollars and eighty-nine cents ($11.89) dispensing fee; orf. The Submitted Ingredient Cost plus eleven dollars and eighty-nine cents ($11.89) dispensing fee; org. Gross Amount Due (GAD); orh. National Average Drug Acquisition Cost (NADAC) plus eleven dollars and eighty-nine cents ($11.89) dispensing fee.2.Brand-name Drugs The reimbursement rate for covered brand-name drugs shall be the lowest of the following:
a. The usual and customary charge; or b. The Average Wholesale Price minus sixteen percent (16%) plus eleven dollars and eighty-nine cents ($11.89) dispensing fee except as otherwise noted below; orc. The Maine maximum allowable cost plus eleven dollars and eighty-nine cents ($11.89) dispensing fee except as otherwise noted below; ord. The Wholesale Acquisition Cost (WAC) plus eleven dollars and eighty-nine cents ($11.89) dispensing fee; ore. The Submitted Ingredient Cost plus eleven dollars and eighty-nine cents ($11.89) dispensing fee; orf. Gross Amount Due (GAD); org. National Average Drug Acquisition Cost (NADAC) plus eleven dollars and eighty-nine cents ($11.89) dispensing fee.3.Rural Dispensing Fee AdjustmentThe Department will pay a supplemental dispensing fee for prescriptions provided to members residing in rural areas in an attempt to assure continuing access to prescription services for these members. The rural dispensing fee will range from 55¢ to 65¢ per prescription dispensed to rural members, and will change on a quarterly basis to reflect the prior quarter's number of prescriptions filled. The Department will distribute the rural dispensing fee adjustment retrospectively on a quarterly basis. The Department will calculate the quarterly adjustment for each pharmacy by taking that quarter's total allotment ($500,000 per quarter) and dividing the total allotment for the quarter by the number of prescriptions filled for rural members in the quarter.
The Department will then group these by pharmacy and distribute in the quarter following. Pharmacies will be notified on a quarterly basis on the Department's designated website the amount of the adjustment for the quarter.
Rural members will be defined using a standard and federally recognized definition of rural using Metropolitan Statistical Area (MSA) designations. The Department will determine MSA/Non-MSA designation based on the zip code of the member's residence.
B.Reimbursement for Specialty Pharmacy Providers The reimbursement rate for Specialty Pharmacy Providers shall be the lowest of the following:
1. The usual and customary charge; or2. The Average Wholesale Price minus sixteen point six seven (16.67%) plus eleven dollars and eighty-nine cents ($11.89) dispensing fee except as otherwise noted below; or3. The Federal Upper Limit (FUL) unless the Department meets the FUL in aggregate or the Maine maximum allowable cost plus eleven dollars and eighty-nine cents ($11.89) dispensing fee except as otherwise noted below.4. The Maine maximum allowable cost plus eleven dollars and eighty-nine cents ($11.89) dispensing fee except as otherwise noted below; or5. The Wholesale Acquisition Cost (WAC) plus eleven dollars and eighty-nine cents ($11.89) dispensing fee; or6. The Submitted Ingredient Cost plus eleven dollars and eighty-nine cents ($11.89) dispensing fee; or7. Gross Amount Due (GAD); or8. National Average Drug Acquisition Cost (NADAC) plus eleven dollars and eighty-nine cents ($11.89) dispensing fee.C.Reimbursement for Mail Order Pharmacy Providers1.Generic Drugs The reimbursement rate for covered generic drugs obtained through mail order pharmacy providers shall be the lowest of the following:
a. The usual and customary charge; orb. The Average Wholesale Price minus sixty percent (60%) plus a two-dollar and fifty cent ($2.50) dispensing fee except as otherwise noted below; orc. The Federal Upper Limit (FUL) unless the Department meets the FUL in aggregate or the Maine maximum allowable cost plus a two-dollar and fifty cent ($2.50) dispensing fee except as otherwise noted below.2.Brand Name Drugs The reimbursement rate for covered brand name drugs obtained through mail order pharmacy providers shall be the lowest of the following:
a. The usual and customary charge; orb. The Average Wholesale Price minus twenty percent (20%) plus a two-dollar and fifty cent ($2.50) dispensing fee except as otherwise noted below; orD.Reimbursement for 340B Drugs Providers or entities who purchase drugs under the 340B policy, must sign a memorandum of understanding (MOU) with the state. When the state and the entity reach an agreement on the billing process, reporting process, specific covered drugs, and pricing standards this MOU must be individualized to include the term of these components.
For entities and providers that are eligible to enroll in the 340B program, see the listing on http://www.hrsa.gov/opa/introduction.htm. All providers and entities must comply with federal and HRSA 340B rules and regulations.
E. Effective October 1, 2009 the reimbursement rate for the Seasonal Flu Vaccine and/or Allowable Immunizations as allowed by 32 MRSA §13831, shall be the Federal Upper Limit or the Maine maximum allowable cost plus five dollars ($5.00) dispensing fee except as otherwise noted.F. The Department's reimbursement rate will be reduced by any applicable member co-payment.G. In accordance with Chapter I, of the MaineCare Benefits Manual, it is the responsibility of the provider to seek payment from every other source. It is the responsibility of the provider to verify a member's eligibility for MaineCare prior to providing services by requesting the individual to present his or her MaineCare ID card on each occasion that a service is provided and verifying this information as described in Chapter I of the MBM.H If the provider is aware that a member's eligibility is due to expire within one (1) month of the date of service, reimbursement will only be made for up to a one (1) month's supply.I.Maine Maximum Allowable Cost (MMAC). The establishment of a MMAC is subject, but not limited, to the following considerations:1. Multiple active rebatable manufacturers;2. Multiple covered non-drug products available through the pharmacy POS3. Broad wholesale acquisition, average manufacturer price, actual acquisition cost and wholesaler price spans;4. Availability of drugs to retailers, specialty stores and mail order providers at the selected cost;5. High volume of MaineCare member utilization; and6. Bioequivalence or interchangeability. The Department will periodically notify pharmacies of updates to the list of drugs affected by FUL or MMAC pricing. This information will also be available on the OMS website.
J.Reimbursement for Drugs More Expensive Than MAC or MMAC AllowancesA prescriber who requests a drug more expensive than an equivalent MAC or MMAC limited generic drug must get prior authorization for the requested product before reimbursement will be permitted. Prescribers and providers will be notified of the drugs requiring prior authorization and this list, and any updates, will be posted on the Department's designated website.
K.Reimbursement for Compounded Drugs for Retail Pharmacy Providers Reimbursement for compounded drugs is determined by subtracting the co-payment described in Section 80.08, from the sum of the dispensing fee and the ingredient cost. The ingredient cost is the sum of the cost of the defined ingredients contained in the compounded drug. The provider must list the NDC for each active and inactive ingredient and the corresponding quantity used for each ingredient. Ingredients that are identified as DESI (less than effective) may not be included in the reimbursement for the compounded drug. Only electronic claims will be accepted.
1. Dispensing fees for compound drugs are as follows:a. Eleven dollars and eighty-nine cents ($11.89) except for filling insulin syringes as provided under 1(b). b Twelve dollars and fifty cents ($12.50) for filling insulin syringes per fourteen (14) day supply. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-80, subsec. 144-101-II-80.09