PURPOSE: This rule establishes the basis and the method for pricing all drug claims in Missouri under the Title XIX Medicaid program. The purchase of a computer-generated tape, with weekly updates, will make it possible to utilize the computer for review purposes, which greatly increases the speed with which claims can be paid.

1. (1) The MO HealthNet Division will obtain, by contract with a reputable medical publishing company, a weekly computer-generated tape which will provide the information needed to price all fee-for-service Medicaid drug claims. The tape will contain National Drug Code (NDC), drug name, drug strength, dosage form, package size, the prices set by direct-selling manufacturers (direct prices), Wholesaler Acquisition Cost (WAC), federal Health and Human Services upper limits for specified multiple source drugs (FUL), and National Average Drug Acquisition Cost (NADAC). A multiple source drug is defined as a drug marketed or sold by two (2) or more manufacturers or labelers, or a drug marketed or sold by the same manufacturer or labeler under two (2) or more different proprietary names or both under a proprietary name and without that name.
2. (2) The MO HealthNet Division will add the Missouri Maximum Allowable Cost (MMAC) limits, for multiple source drugs as defined, to the data shown on the tape described in section (1) of this rule.

3. (3) Reimbursement for covered drugs dispensed between April 1, 2017, and December 15, 2018, will be determined by applying the following hierarchy method:

   1. (A) Federal Upper Limit (FUL) price; if there is no FUL;
   2. (B) Missouri Maximum Allowed Cost (MAC); if no FUL or MAC;
   3. (C) Wholesale Acquisition Cost (WAC) minus three and one-tenth percent (3.1%); or
   4. (D) The usual and customary (U&C) charge submitted by the provider if it is lower than the chosen price (FUL, MAC, or WAC).

4. (4) Effective December 16, 2018, reimbursement for covered drugs will be determined by applying the following hierarchy method:

   1. (A) National Average Drug Acquisition Cost (NADAC); if there is no NADAC;
   2. (B) Missouri Maximum Allowed Cost (MAC); if no NADAC or MAC;
   3. (C) Wholesale Acquisition Cost (WAC); or
   4. (D) The usual and customary (U&C) charge submitted by the provider if it is lower than the chosen price (NADAC, MAC, or WAC).

5. (5) Between April 1, 2017, and December 15, 2018, reimbursement for covered drugs for 340B providers as defined by the Public Health Service Veterans Health Care Act of 1992 who carve-in for Medicaid will be determined by applying the following method:

   1. (A) Wholesale Acquisition Cost (WAC) minus forty-nine percent (49%); or
   2. (B) The usual and customary (U&C) charge submitted by the provider if it is lower.

6. (6) Effective December 16, 2018, reimbursement for covered drugs for 340B providers as defined by the Public Health Service Veterans Health Care Act of 1992 who carve-in for Medicaid will be determined by applying the following method:

   1. (A) Wholesale Acquisition Cost (WAC) minus twenty-five percent (25%); or
   2. (B) The usual and customary (U&C) charge submitted by the provider if it is lower.
7. (7) The professional dispensing fee will be calculated according to 13 CSR 70-20.060.

AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016, and section 208.152, RSMo Supp. 2018.* This rule was previously filed as 13 CSR 40-81.150. Original rule filed April 23, 1979, effective Aug. 11, 1979. Emergency amendment filed Sept. 9, 1981, effective Oct. 1, 1981, expired Dec. 10, 1981. Amended: Filed Sept. 9, 1981, effective Dec. 11, 1981. Emergency amendment filed Oct. 19, 1987, effective Oct. 29, 1987, expired Feb. 25, 1988. Amended: Filed Dec. 1, 1987, effective Feb. 11, 1988. Emergency amendment filed March 29, 1988, effective April 8, 1988, expired Aug. 5, 1988. Amended: Filed May 3, 1988, effective July 28, 1988. Emergency amendment filed Dec. 21, 1990, effective March 17, 1991, expired April 30, 1991. Emergency amendment filed March 6, 1991, effective March 17, 1991, expired July 14, 1991. Emergency amendment filed Sept. 4, 1991, effective Sept. 17, 1991, expired Jan. 14, 1992. Amended: Filed Sept. 4, 1991, effective Jan. 13, 1992. Amended: Filed Dec. 5, 2000, effective June 30, 2001. Amended: Filed July 19, 2018, effective March 30, 2019.

*Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2015, 2018; 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.