CMS creates fairer pharmacy reimbursement

As WVPA reported February 17, the Center for Medicare and Medicaid Services (CMS) has issued directives to states addressing key areas of Medicaid drug reimbursement beginning in 2017.  The CMS final rule is designed to ensure that pharmacy reimbursement is aligned with acquisition costs of drugs and that states pay an appropriate professional dispensing fee.  Highlights of the final rule include:

Creates an exception to the FUL calculation, which allows for the use of a higher multiplier than 175% to calculate the FUL based on acquisition costs for certain multiple source drugs.

Establishes actual acquisition costs (ACC) as the basis by which states should determine their ingredient cost reimbursement so payments are based on a more accurate estimate of the prices available in the marketplace, while still ensuring sufficient beneficiary access.

Implements the use of the term professional dispensing fee to ensure that the dispensing fee paid to pharmacies reflect the cost of the pharmacist’s professional services and cost to dispense the drug product to a Medicaid beneficiary.

Clarifies that states are required to evaluate the sufficiency of both the ingredient cost reimbursement and the professional dispensing fee reimbursement when proposing changes to either of these components.

Requires states to specify in the Medicaid state plan that reimbursement methodology to pharmacies that purchase drugs through the Federal Supply Schedule and the 340B Drug Pricing Program is consistent with overall AAC requirements.