METHOD ESTABLISHED FOR DETERMINING PRESCRIPTION REIMBURSEMENT

924.1 Pharmacy claims for a community or retail pharmacy provider shall be reimbursed at the lower of the following:

(a) The allowable cost, established pursuant to section 922 or 923, as appropriate, plus a dispensing fee of four dollars and fifty cents (\$4.50) per prescription; or

(b) The pharmacy's usual and customary charge to the general public.

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

(a) The allowable cost, established pursuant to section 922, 923 or 924.3, 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, TPN (total parenteral nutrition) or container-related prescriptions; or

(b) The pharmacy's usual and customary charge for non-Medicaid residents.

924.3 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.

924.4 Effective January 1, 2006, drugs covered by Medicare for persons who are dually eligible for Medicare and Medicaid shall be billed to Medicare under the Medicare Prescription Drug Benefit -Part D. The Medicaid program shall continue to provide coverage to persons who are dually eligible for the following excluded or otherwise restricted drug or restricted classes of drugs to the same extent that it provides coverage to all Medicaid recipients:

(a) Select agents when used for weight gain: Megesterol

(b) Select prescription vitamins and mineral products except prenatal vitamins and fluoride: Folic Acid, Vitamin B12

(c) Select non-prescription drugs: analgesics, antacids, diabetic therapy, bowel diagnostic preparation kits

(d) All barbiturates

(e) All benzodiazepines

924.5 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.

924.6 Prescribed drugs for purposes of nursing homes pharmacy reimbursement shall not include over-the-counter 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: As amended by Final Rulemaking published at 35 DCR 4011, 4013 (May 27, 1988);

as amended by Final Rulemaking published at 44 DCR 3121 (May 30, 1997); and by Final Rulemaking published at 44 DCR 6639 (November 7, 1997); as amended by Final Rulemaking published at 44 DCR 6639 (October 3, 2003); as amended by Final Rulemaking published at 53 DCR 2401 (March 31, 2006).