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.

PUBLISHER’S NOTE: The publication of the full text of the material that the adopting agency has incorporated by reference in this rule would be unduly cumbersome or expensive. Therefore, the full text of that material will be made available to any interested person at both the Office of the Secretary of State and the office of the adopting agency, pursuant to section 536.031.4, RSMo. Such material will be provided at the cost established by state law.

1. (1) The Division of Medical Services 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 Average Wholesale Price (AWP), the prices set by direct-selling manufacturers (direct prices), Wholesaler Acquisition Cost (WAC), and federal Health and Human Services upper limits for specified multiple source drugs. 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 Division of Medical Services 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 will be made at the lower of the—

   1. (A) Usual and customary charge as billed by the provider; or

   2. (B) Price(s) included on the Drug Pricing File which is derived from one (1) or more of the following:

      1. 1. The AWP as furnished by the state’s

contracted agent, less ten and forty-three hundredths percent (10.43%);

1. 2. The MMAC as determined by the

state agency for selected multiple source drugs;

1. 3. Applicable federal upper limits as

found at www.dss.state.mo.us/dms; or

1. 4. The WAC as furnished by the state’s

contracted agent, plus ten percent (10%).

AUTHORITY: sections 208.152, 208.153, and 208.201, RSMo 2000.* 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. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993; 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991; and 208.201, RSMo 1987.