053-9 Wyo. Code R. § 9-6

Current through April 27, 2019

Section 9-6 - Fees for Pharmacy Items

Pharmaceuticals must be billed with a National Drug Code (NDC). See Chapter 10, and Chapter 9, Section 1 for additional guidelines.

(a) Pharmaceuticals shall be reimbursed at the lower of:

• (i) Average Wholesale Price (AWP) minus 10% plus a $5.00 dispensing fee; or

• (ii) The provider's usual and customary charge. In no case shall any provider bill for charges greater than those charged to the general public for like services. The Division reserves the right to review such charges and reimburse at the usual and customary rate if a discrepancy is found.

(b) Reimbursement shall be decreased by $2.50 per prescription if a paper claim is submitted unless:

• (i) The provider has received prior approval from the Division to submit a claim on paper.

• (ii) Electronic billing is unavailable at the time of service making it unreasonable to submit the claim through the online process.

(c) Over the counter items that do not have a valid NDC number shall be considered supplies and shall not be paid with an added dispensing fee. See Chapter 9, Section 4 for additional guidelines.

(d) If the pharmaceutical is a repackaged drug, as determined by the NDC for the product dispensed, reimbursement shall be calculated per Section 6(a) using the AWP of the lowest cost therapeutic equivalent product.

(e) If a pharmaceutical intended for outpatient use is dispensed through the office of a medical care provider, reimbursement will be calculated per Section 6(a) - (d), equivalent to the reimbursement provided to a retail pharmacy.

053-9 Wyo. Code R. § 9-6

Amended, Eff. 12/12/2017.

Amended, Eff. 5/23/2018.