1. (a) Except as provided under (b) of this section, and in accordance with the following, the department will pay a dispensing fee for a covered outpatient drug if the claim satisfies all coverage criteria under 7 AAC 120.110 - 7 AAC 120.140:

   1. (1) to a non-tribal pharmacy located on the road system, $11.80 to be paid not more than once every 22 days per pharmacy per covered outpatient drug;
   2. (2) to a non-tribal pharmacy not located on the road system, $22.17 to be paid not more than once every 22 days per pharmacy per covered outpatient drug;
   3. (3) to a tribal pharmacy, $26.81 to be paid not more than once every 22 days per pharmacy per covered outpatient drug;
   4. (4) to a non-tribal or tribal mediset pharmacy, $16.58 to be paid not more than once every 14 days per pharmacy per covered outpatient drug;
   5. (5) to an out-of-state pharmacy, $10.76 to be paid not more than once every 22 days per pharmacy per covered outpatient drug;
   6. (6) the dispensing fee for a compounded covered outpatient drug is the applicable fee listed in (1) - (5) of this subsection;
   7. (7) a claim submitted by a provider for the same covered outpatient drug for which a dispensing fee was paid within the last 14 or 22 days, as applicable under (1) - (6) of this subsection, will be paid without the dispensing fee listed in (1) - (6) of this subsection.
2. (b) The department will pay, under (a), (c), or (g) of this section, the lesser of the assigned dispensing fee or the submitted dispensing fee.
3. (c) Upon request by the department, a pharmacy shall produce business records and invoice information relevant to the cost of drugs and the cost of dispensing. If a pharmacy does not provide cost of drugs or dispensing fee data as requested by the department, the department may assign that pharmacy the dispensing fee of $3.45 and sanction the pharmacy as provided under 7 AAC 105.400 - 7 AAC 105.490.
4. (d) A pharmacy may not refuse to fill an interim prescription for a covered outpatient drug occurring before the end of the 14 or 22 days as applicable under (a)(1) - (5) of this section because an additional dispensing fee will not be paid.
5. (e) In addition to a dispensing fee under (a) - (c) of this section for a tobacco cessation covered outpatient drug, the department will pay for tobacco cessation medication therapy management that meets the requirements of 7 AAC 120.110(c) at the rate of $16, not more than once every 30 days.
6. (f) The department will pay for the administration of a vaccine product covered under 7 AAC 110.750 at the rate established in 7 AAC 145.275(2).
7. (g) A claim for a covered outpatient drug dispensed by a dispensing provider to a recipient for outpatient use will be reimbursed in accordance with 7 AAC 145.400 with no dispensing fee. A covered outpatient drug administered to an outpatient recipient by a physician, advanced practice registered nurse, or physician assistant, and billed using a covered code under the Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900, will be reimbursed at the estimated acquisition cost defined in 7 AAC 145.400(p) for the amount administered with no dispensing fee. For state fiscal year 2020, starting on the later of August 1, 2019 or after a 30 day notice to the providers, a covered outpatient drug administered to an outpatient recipient by a physician, advanced practice registered nurse, or physician assistant that is not enrolled in the Medicaid Management Information System (MMIS) as a provider type or provider specialty identified in 7 AAC 145.050(c), and who is identified as the rendering provider on the claim submitted to the MMIS billed using a covered CPT or HCPCS code will be reimbursed at 95 percent of the estimated acquisition cost defined in 7 AAC 145.400(p) with no dispensing fee.

8. (h) In this section,

   1. (1) "congregate living home" includes a long-term care facility, an assisted living home licensed under AS 47.32, a residential psychiatric treatment center, or other group home;
   2. (2) "mediset" means a quantity or unit dose of a prescription covered outpatient drug that the provider repackages into single-dose packing to help a recipient adhere to difficult dosing regimens;
   3. (3) "mediset pharmacy" means a pharmacy dispensing 75 percent or more of the total annual Medicaid prescriptions for covered outpatient drugs in prescriber-ordered medisets or unit doses to a recipient living in a congregate living home, a recipient of home and community-based waiver services, a recipient eligible for Medicaid under a category set out in 7 AAC 100.002(b) or (d) who is blind or disabled, a recipient who is an adult experiencing a serious mental illness as described in 7 AAC 135.055, or a recipient who is a child experiencing a severe emotional disturbance as described in 7 AAC 135.065;
   4. (4) "non-tribal pharmacy" means a pharmacy that does not meet the definition for "tribal health program" under 7 AAC 160.990(b);
   5. (5) "out-of-state pharmacy" means a pharmacy that is physically located in a state other than this state;
   6. (6) "pharmacy located on the road system" means a pharmacy that is located in this state and is connected to Anchorage by road;
   7. (7) "pharmacy not located on the road system" means a pharmacy that is located in this state and is not connected to Anchorage by road;
   8. (8) "tribal pharmacy" means a pharmacy that meets the definition for "tribal health program" under 7 AAC 160.990(b);
   9. (9) "unit dose" means a quantity of a covered outpatient drug that the provider repackages into single dosage packing.

(Eff. 2/1/2010, Register 193; am 1/1/2011, Register 196; am 9/7/2011, Register 199; am 1/4/2012, Register 201; am 5/18/2014, Register 210; am 6/16/2016, Register 218; am 7/1/2019, Register 231; am 4/24/2020, Register 234; am 1/10/2021, Register 237; am 8/16/2024, Register 251)

Authority: AS 47.05.010, AS 47.07.030, AS 47.07.040