2711 CLAIMS REIMBURSEMENT REQUIREMENTS FOR NURSING HOME PHARMACY PROVIDERS

2711.1 Effective January 1, 2006, pharmacy claims for a nursing home pharmacy provider shall be reimbursed at the lower of the following:

1. (a) The allowable cost, established pursuant to the methodology described in this chapter, as appropriate, plus a dispensing fee of four dollars and fifty cents ($4.50) per non-IV (intravenous) prescription; or seven dollars and twenty-five cents ($7.25) per IV prescription; or seventeen dollars and twenty-five cents ($17.25) for cassette, Total Parental Nutrition (TPN) or container-related prescriptions; or
2. (b) The pharmacy's usual and customary charge for non-Medicaid residents.

2711.2 The allowable cost for drugs purchased by a nursing home pharmacy provider who is also a federally approved 340-B (Public Health Service) provider for Medicaid shall not exceed the actual acquisition cost for each 340-B purchased drug. Pharmacy claims for 340-B providers shall be excluded from any manufacturer's rebate.

2711.3 An additional supply of medications may be dispensed for use by a nursing facility resident during a short-term medically approved trip away from the facility during holidays or family trips.

2711.4 Prescribed drugs for purposes of nursing home pharmacy reimbursement shall not include OTC medications, syringes for diabetic preparations, geriatric vitamin formulations, or senna extract single dose preparations except when required for diagnostic radiological procedures performed under the supervision of a physician.

SOURCE: Notice of Final Rulemaking published at 59 DCR 2298, 2308 (March 23, 2012).