PURPOSE: This rule establishes, via regulation, the Department of Social Services, Division of Medical Services’ upper limits on reimbursement for selected multiple source drugs, in response to the implementation of new federal guidelines.

1. (1) The federal Health Care Financing Administration has established policy that federal matching funds will be provided for certain multiple source drugs, at the appropriate match rate, of an amount not to exceed specified upper limits of reimbursement. The specific upper limits of reimbursement are communicated to state Medicaid agencies periodically, with effective dates designated.
2. (2) As specified in 13 CSR 70-20.070, reimbursement for multiple source drugs shall be made in an amount not to exceed the federal upper limit, unless prior authorization is obtained by the prescribing physician. Prior authorization must be obtained by telephone or by mailing a completed Drug Prior Authorization Form to the Division of Medical Services to allow reimbursement at the trade name price. The Medicaid Pharmacy Manual and updating bulletins shall provide the detailed listing of the specific drug products that shall not be reimbursed in an amount that exceeds the federal upper limit.

AUTHORITY: sections 208.153, RSMo Supp. 1991 and 208.201, RSMo Supp. 1987.* Emergency rule filed Oct. 19, 1987, effective Oct. 29, 1987, expired Feb. 25, 1988. Emergency amendment filed Oct. 29, 1987, effective Nov. 8, 1987, expired March 6, 1988. Original rule filed Dec. 1, 1987, effective Feb. 11, 1988. Emergency amendment filed June 21, 1988, effective July 1, 1988, expired Oct. 28, 1988. Amended: Filed Aug. 16, 1988, effective Oct. 29, 1988. Emergency amendment filed May 12, 1989, effective June 1, 1989, expired Sept. 23, 1989. Amended: Filed May 12, 1989, effective Aug. 11, 1989. Amended: Filed Nov. 15, 1989, effective Feb. 1, 1990. Amended: Filed April 18, 1990, effective June 30, 1990. Emergency amendment filed Aug. 20, 1990, effective Sept. 1, 1990, expired Dec. 30, 1990. Amended: Filed Sept. 5, 1990, effective Feb. 14, 1991. Emergency amendment filed Dec. 20, 1990, effective Dec. 31, 1990, expired April 29, 1991. Emergency amendment filed March 21, 1991, effective March 31, 1991, expired July 28, 1991. Amended: Filed April 2, 1991, effective Oct. 31, 1991. Emergency amendment filed Dec. 4, 1992, effective Dec. 15, 1992, expired April 13, 1993. Emergency rescission and emergency rule filed April 2, 1993, effective April 13, 1993, expired Aug. 10, 1993. Amended: Filed Aug. 27, 1993, effective May 9, 1994. *Original authority: 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991 and 208.201, RSMo 1987.