Mo. Code Regs. tit. 13 § 70-20.060

Current through Register Vol. 49, No. 23, December 2, 2024

Section 13 CSR 70-20.060 - Professional Dispensing Fee

PURPOSE: The purpose of this amendment is to update the amount of the professional dispensing fee reimbursable for the dispensing of MO HealthNet covered prescriptions by a pharmacy provider in line with the most recent cost of dispensing survey.

PURPOSE: The MO HealthNet Division establishes the amount of the fee reimbursable for the professional dispensing of each MO HealthNet covered prescription by a pharmacy provider.

(1) Between April 1, 2017 and January 31, 2021, a professional dispensing fee shall be added to the MO HealthNet maximum allowable payment for MO HealthNet reimbursable prescriptions filled or refilled by a pharmacy provider as follows:

(A) Out-of-state pharmacy providers receive a professional dispensing fee of nine dollars fifty-five cents ($9.55);

(B) In-state pharmacy providers receive a professional dispensing fee of fourteen dollars thirty-seven cents ($14.37);

(C) In-state pharmacy providers receive a preferred generic product incentive fee of five dollars zero cents ($5.00); and

(D) The professional dispensing fees as provided in this rule shall not be included in the computation of the MO HealthNet maximum allowable drug payment for participant cost-sharing purposes.

(2) Effective February 1, 2021, a professional dispensing fee shall be added to the MO HealthNet maximum allowable payment for MO HealthNet reimbursable prescriptions filled or refilled by a pharmacy provider as follows:

(A) Out-of-state pharmacy providers receive a professional dispensing fee of eight dollars and eighty-five cents ($8.85);

(B) In-state pharmacy providers receive a professional dispensing fee of twelve dollars and twenty-two cents ($12.22), plus an adjustment to account for the costs of the Missouri Pharmacy Reimbursement Allowance attributable to Medicaid-reimbursed prescriptions;

(C) The professional dispensing fee as provided in this rule shall not be added to prescriptions reimbursed at the usual and customary charge submitted by the provider; and

(D) The professional dispensing fees as provided in this rule shall not be included in the computation of the MO HealthNet maximum allowable drug payment for participant cost-sharing purposes.

(3) Effective April 1, 2017, all pharmacy providers supplying prescribed MO HealthNet covered drugs to participants in longterm care facilities shall receive an additional fifty cent (50¢) dispensing fee per claim provided they-

(A) Dispense medication in a drug distribution system(s) which meets minimum standards of container packaging (at least class B as defined in United States Pharmacopeia XXI);

(B) Certify to the MO HealthNet Division, on a form, and in the manner prescribed by the division, that they-

1. Provide this dispensing service to their long-term care facility resident patients;

2. Provide emergency services twenty-four (24) hours a day with seven (7) days a week availability; and

3. Have the ability and willingness to assist in accessing medications through the MO HealthNet Exception Process; and

(C) Indicate, as prescribed by the MO HealthNet Division, on each claim that the prescription was provided in packaging qualifying for the dispensing fee add-on to a participant in a long-term care facility.

(4) A professional dispensing fee shall be added to maintenance medications no more frequently than once every twenty-five (25) days. "Maintenance medications" are defined as drugs that have a common indication for treatment of a chronic disease, and the therapeutic duration is expected to exceed one year. This is determined by a First DataBank drug code maintenance indicator of "1."

13 CSR 70-20.060

AUTHORITY: sections 208.153 and 208.201, RSMo Supp. 2013.* Original rule filed Dec. 15, 1987, effective March 11, 1988. Amended: Filed Sept. 26, 2013, effective March 30, 2014.

Repealed by Missouri Register February 1, 2019/Volume 44, Number 3, effective 4/1/2019

Amended by Missouri Register June 1, 2021/Volume 46, Number 11, effective 7/31/2021

*Original authority: 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991, 2007, 2012 and 208.201, RSMo 1987, amended 2007.