Sec. 10.09.03.07. Payment Procedures

A. The provider shall produce records to verify any charge to the Program upon request.

B. The provider shall bill all appropriate insurance carriers before requesting payment from the Department.

C. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.

D. The provider shall submit a request for payment on a form designated by the Department.

E. The Department may return to the provider all invoices not properly completed.

F. The pharmacy provider shall charge the Program the provider’s usual and customary charge to the general public for similar prescriptions.

G. The physician or osteopath shall charge the Program his actual acquisition cost for the drugs dispensed.

H. Determination of Allowable Cost.

(1) For covered legend drugs and nonlegend drugs, allowable cost shall be:

(a) The NADAC; or

(b) When the NADAC is unavailable, the lowest of the:

(i) WAC plus 0 percent;

(ii) FUL; and

(iii) SAAC.

(2) For covered legend brand name drugs for which the prescriber files an official report of an adverse event or product problem regarding a generic drug with the Program or the United States Food and Drug Administration, or when the Department requires the brand name drugs to be dispensed, the allowable cost shall be:

(a) The NADAC of the branded product; or

(b) When the NADAC of the branded product is unavailable, the lower of the:

(i) WAC plus 0 percent; or

(ii) SAAC.

(3) For condoms dispensed by pharmacy providers, the allowable cost shall be as described in §H(1) of this regulation.

(4) For covered over-the-counter products, and covered medical supplies, the allowable cost shall be as described in §H(1) of this regulation.

(5) For covered specialty drugs not dispensed by a retail community pharmacy but dispensed primarily through the mail, the allowable cost shall be:

(a) The NADAC; or

(b) When the NADAC is unavailable, the lowest of the:

(i) WAC plus 0 percent;

(ii) FUL; or

(iii) SAAC.

(6) Except when purchased at the 340B price by a provider, the allowable cost for covered clotting factors shall be the lower of the:

(a) WAC plus 0 percent; or

(b) AAC plus 8 percent.

(7) For 340B covered entities or FQHCs that fill Program participant prescriptions with drugs purchased at the prices authorized under Section 340B of the Public Health Service Act, the allowable cost shall be the provider’s AAC.

(8) For facilities that fill Medicaid participant prescriptions with drugs purchased through the FSS, the allowable cost shall be the provider’s AAC.

(9) For facilities that fill Medicaid participant prescriptions with drugs purchased at nominal price, outside of 340B and FSS, the allowable cost shall be the provider’s AAC.

I. Payment for Covered Services to a Pharmacy.

(1) Payment for covered legend and nonlegend drugs, over-the-counter products, and covered medical supplies is the lower of:

(a) The provider's charge according to §F of this regulation, less any applicable co-payment according to Regulation .05C(5) of this chapter; or

(b) The amount that is:

(i) The allowable cost of the item in §H(1) of this regulation;

(ii) Plus the applicable professional dispensing fee indicated in §I(10) or (11) of this regulation; and

(iii) Less any applicable copayment according to Regulation .05C(5) of this chapter.

(2) Payment for covered legend brand name drugs as indicated in §H(2) of this regulation shall be the lower of:

(a) The provider’s charge according to §F of this regulation, less any applicable copayment according to Regulation .05C(5) of this chapter; or

(b) The total of:

(i) The allowable cost of the item in §H(2) of this regulation;

(ii) Plus the applicable professional dispensing fee indicated in §I(10) or (11) of this regulation; and

(iii) Less any applicable copayment according to Regulation .05C(5) of this chapter.

(3) Payment for condoms will be the lower of the:

(a) The provider's charge according to §F of this regulation; or

(b) Allowable cost according to §H(3) of this regulation.

(4) Copayment is not required for condom orders.

(5) Payment for covered specialty drugs not dispensed by a retail community pharmacy but dispensed primarily through the mail shall be the lower of the:

(a) Provider charge according to §F of this regulation, less any applicable copayment according to Regulation .05C(5) of this chapter; or

(b) The total of:

(i) The allowable cost of the item in §H(5) of this regulation;

(ii) Plus the applicable professional dispensing fee indicated in §I(11) of this regulation; and

(iii) Less any applicable copayment according to Regulation .05C(5) of this chapter.

(6) Payment for clotting factor shall be lower of the:

(a) Provider charge according to §F of this regulation, less any applicable copayment according to Regulation .05C(5) of this chapter; or

(b) Amount that is:

(i) The allowable cost of the item in §H(6) of this regulation;

(ii) Plus the applicable professional dispensing fee indicated in §I(11) of this regulation; and

(iii) Less any applicable copayment according to Regulation .05C(5) of this chapter.

(7) Payment for providers that fill Medicaid participant prescriptions with drugs purchased at the prices authorized under Section 340B of the Public Health Service Act shall be the total of:

(a) The allowable cost of the item in §H(7) of this regulation;

(b) Plus the applicable professional dispensing fee indicated in §I(12) of this regulation; and

(c) Less any applicable copayment according to Regulation .05C(5) of this chapter.

(8) Payment for facilities that fill Medicaid participant prescriptions with drugs purchased through the FSS shall be the total of:

(a) The allowable cost of item in §H(8) this regulation;

(b) Plus the applicable professional dispensing fee indicated in §I(10) or (11) of this regulation; and

(c) Less any applicable copayment according to Regulation .05C(5) of this chapter.

(9) Payment for facilities that fill Medicaid participant prescriptions with drugs purchased at nominal price, outside of 340B and FSS, shall be the total of:

(a) The allowable cost of item in §H(9) this regulation;

(b) Plus the applicable professional dispensing fee indicated in §I(10) or (11) of this regulation; and

(c) Less any applicable copayment according to Regulation .05C(5) of this chapter.

(10) The professional dispensing fee for covered services rendered on or after April 1, 2017 to a pharmacy for participants residing in nursing facilities shall be $11.49.

(11) The professional dispensing fee for covered services rendered on or after April 1, 2017 to a pharmacy for individuals other than residents in nursing facilities shall be $10.49.

(12) The professional dispensing fee for covered services rendered on or after April 1, 2017 to a pharmacy for medication purchased at the prices authorized under Section 340B of the Public Health Services Act shall be $12.12.

(13) The Department may pay a pharmacy using an approved unit dose system on the basis of a monthly dispensing fee per nursing home resident. The value of the fee may not be higher than the pharmacy’s usual and customary charge to non-Medicaid patients for similar services.

J. Payment for Covered Services to a Physician or Osteopath.

(1) Except as provided in §J(2) of this regulation, the Program shall reimburse a physician or osteopath for covered drugs dispensed at the lower of:

(a) The physician's or osteopath's actual acquisition cost, less any applicable copayment according to Regulation .05C(5) of this chapter; or

(b) The allowable cost of the item in §H of this regulation, less any applicable copayment according to Regulation .05C(5) of this chapter.

(2) The Program shall reimburse a physician or osteopath for covered drugs dispensed to Medicaid participants on the same basis as reimbursement to a registered pharmacist if:

(a) The physician or osteopath dispenses the covered drugs on a regular basis in the physician's or osteopath’s office;

(b) The physician's or osteopath’s office is not located within a 10-mile radius of a Medicaid participating pharmacy; and

(c) The Program, after consultation with the Board of Pharmacy, has verified that the physician or osteopath is dispensing drugs in accordance with accepted pharmacy standards.

K. In order to determine whether the current professional dispensing fee is appropriate, the Department will periodically conduct surveys to determine the actual costs involved in filling a prescription in the State.