Amendment of Payment Methodology for Pharmaceutical Services [42 Pa.B. 1002]
[Saturday, February 18, 2012]The Department of Public Welfare (Department) is announcing its intent to amend the provisions of the Commonwealth's Medicaid State Plan and current Medical Assistance (MA) pharmaceutical services regulations in 55 Pa. Code §§ 1121.55 and 1121.56 (relating to method of payment; and drug cost determination).
On July 1, 2011, the General Assembly enacted the act of June 30, 2011 (P. L. 89, No. 22) (Act 22), which amended the Public Welfare Code (code) (62 P. S. §§ 101—1503). Act 22 added several provisions to the code, including section 403.1 (62 P. S. § 403.1). Section 403.1(a)(4), (c) and (d) of the code authorizes the Department to promulgate final-omitted regulations under section 204(1)(iv) of the Commonwealth Documents Law (CDL)1 to establish or revise provider payment rates or fee schedules, reimbursement models or payment methodologies for particular services. In addition, to ensure that the Department's expenditures for State Fiscal Year (FY) 2011-2012 do not exceed the aggregate amount appropriated by the General Assembly, section 403.1 of the code expressly exempts these regulations from the Regulatory Review Act (71 P. S. §§ 745.1—745.12), section 205 of the CDL (45 P. S. § 1205) and section 204(b) of the Commonwealth Attorneys Act (71 P. S. § 732-204(b)).
Under section 403.1 of the code, the Department intends to submit a State Plan Amendment and promulgate final-omitted regulations amending 55 Pa. Code §§ 1121.55 and 1121.56 to revise the method of payment and the determination of drug cost as follows:
• Set the dispensing fee paid to pharmacies at $2 for prescriptions for compensable, noncompounded legend and nonlegend drugs, and $3 for compensable compounded prescriptions.
• Set the dispensing fee paid to pharmacies for prescriptions for compensable legend and nonlegend drugs for MA recipients with a pharmacy benefit resource which is a primary third party payer to MA at $0.50 to cover the pharmacy's cost to transmit the claim to the MA program for secondary payment.
• Revise the establishment of estimated acquisition cost (EAC) as follows:
◦ For brand name drugs, establish EAC as the lower of the lowest wholesale acquisition cost (WAC) listed for the drug in available Nationally recognized pricing services, plus 3.2%, or the lowest average wholesale price (AWP) listed for the drug in available Nationally recognized pricing services, minus 14%.
◦ For generic drugs, establish EAC as the lower of the lowest WAC listed for the drug in available Nationally recognized pricing services, minus 5%, or the lowest AWP listed for the drug in available Nationally recognized pricing services, minus 25%.
In addition, the Department intends to make technical changes including:
• Amendments to the list of noncompensable services and items to reflect and clarify payment for pharmaceutical services that have been in effect but have not yet been codified in Department regulations.
• Clarification that the definition of ''usual and customary charge'' includes discount generic drug savings and discount programs.
The Department intends to implement these changes effective April 1, 2012. These changes will help to ensure that expenditures for FY 2011-2012 for assistance programs administered by the Department do not exceed the aggregate amount appropriated for the programs by the General Appropriations Act of 2011.
Fiscal Impact
The FY 2011-2012 fiscal impact, as a result of amending the pharmaceutical services regulations is a savings of $3.365 million ($1.512 million in State funds and $1.853 million in Federal funds).
Public Comment
Interested persons are invited to submit written comments regarding this notice to the Department of Public Welfare, Office of Medical Assistance Programs, c/o Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120. Comments received within 15 days will be reviewed and considered in the development of the State Plan Amendment and regulations.
Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
GARY D. ALEXANDER,
SecretaryFiscal Note: 14-NOT-742. No fiscal impact; (8) recommends adoption.
[Pa.B. Doc. No. 12-300. Filed for public inspection February 17, 2012, 9:00 a.m.] _______
1 The act of July 31, 1968 (P. L. 769, No. 240) (45 P. S. § 1204(1)(iv)). Section 204(1)(iv) of the CDL authorizes an agency to omit or modify notice of proposed rulemaking when a regulation relates to Commonwealth grants or benefits. The MA Program is a Commonwealth grant program through which eligible recipients receive coverage of certain health care benefits, including pharmaceuticals.
