DAR File No. 27549

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-63

Medicaid Policy for Pharmacy Reimbursement

NOTICE OF PROPOSED RULE

DAR File No.: 27549
Filed: 11/16/2004, 04:44
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking eliminates the exemption of select therapeutic drug classes from review by the Utah College of Pharmacy's Drug Regimen Review Center (DRRC) in the monthly Drug Utilization Review (DUR) of Medicaid client's who use the most prescriptions. With the elimination of the drug class exemptions, all prescriptions will be subject to a complete DUR review for adverse drug events. Eliminating adverse drug events results in increased safety to patients and subsequent savings to the Department.

Summary of the rule or change:

Exemptions from the seven-prescription threshold for review have been eliminated. Subsection R414-63-2(2) states that clients whose total number of prescriptions exceeds seven prescriptions per month are subject to clinical review by the Division of Health Care Financing. Subsection R414-63-2(3) states that prescribers may be subject to peer review in regard to a patient's prescription drug profile when opportunities exist to decrease duplicative prescribing, waste, perceived abuse of the pharmacy benefit, or the likelihood of a level one adverse drug event between one or more drugs for any given patient drug profile. Subsection R414-63-2(4) states that the prescriber shall have ultimate say in what is prescribed.

State statutory or constitutional authorization for this rule:

Title 26, Chapter 18

Anticipated cost or savings to:

the state budget:

An additional $150,000 will be used to contract with the University of Utah College of Pharmacy to fund an additional 100 hours each month of drug utilization peer review with Medicaid drug prescribers. Anticipated savings will be approximately $2,500,000.

local governments:

No local governments are affected by this rulemaking because no local governments pay prescribers of Medicaid drugs.

other persons:

There is no way to calculate the aggregate costs and savings to prescribers of Medicaid drugs. However, the time required to participate in the peer review should be more than offset by more effective drug utilization savings.

Compliance costs for affected persons:

There is no way to calculate the cost or savings to each individual prescriber of Medicaid drugs. However, the time required to participate in each peer review should be more than offset by more effective drug utilization savings.

Comments by the department head on the fiscal impact the rule may have on businesses:

This rule change is expected to increase patient safety by detecting potential adverse drug interactions as well as save tax dollars by eliminating duplicate and unnecessary prescriptions. Minimal impact on prescribing physicians is predicted. Scott L. Williams MD

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Direct questions regarding this rule to:

Ross Martin at the above address, by phone at 801-538-6592, by FAX at 801-538-6099, or by Internet E-mail at rmartin@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

01/14/2005

This rule may become effective on:

01/15/2005

Authorized by:

Scott D. Williams, Executive Director

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-63. Medicaid Policy for Pharmacy Reimbursement.

R414-63-1. Introduction and Authority.

(1) The Medicaid Policy for reimbursement of dispensing fees for pharmacy providers was achieved through negotiations with representatives of the pharmacy industry.

(2) This rule is authorized under Chapter 26-18.

R414-63-2. Pharmacy Reimbursement.

(1) For each prescription filled for a Medicaid recipient the Department may reimburse the pharmacy provider for:[ up to seven (7) non-exempt prescriptions in any calendar month. The limit on prescriptions will not take effect until the assessment required in section (4) of this rule is completed. A single prescription that is filled multiple times in the month is one prescription. The pharmacy provider shall be reimbursed:]

(a) the average wholesale price for the medication minus 15%; and

(b) a dispensing fee in the amount of $3.90 for urban providers and $4.40 for rural providers.

[(2) The limitation on the number of prescriptions does not apply to pregnant women or children under age 21.

(3) The following drug classes are exempt from the seven prescription limit in (1):

(a) A4A, hypotensive - vasodilator, example: minoxidil (Loniten);

(b) A4B, hypotensive - sympatholytic, example: guanethidine (Ismelin);

(c) A4C, hypotensives - ganglionic blockers, example: trimethaphan (Arfonad);

(d) A4D, hypotensives - ACE blocking type, example: captopril (Capoten);

(e) A4E, hypotensives - veratrum alkaloids, example: cryptenamine;

(f) A4F, hypotensives - angiotensin receptor antagonist, example: losartan (Cozaar);

(g) A4Y, hypotensives - miscellaneous, example: nitroprusside sodium (Nitropress);

(h) A9A, calcium channel blocking agents, example: nifedipine (Procardia);

(i) C4G, insulins;

(j) C4K, hypoglycemics - insulin-release stimulant type, example: tolbutamide (Orinase);

(k) C4L, hypoglycemics - biguanide type (non-sulfonylureas), example: metformin (Glucophage);

(l) C4M, hypoglycemics - alpha-glucosidase inhib. Type (N-S), example: miglitol (Glyset);

(m) M0E, antihemophilic factor VIII;

(n) M0F, antihemophilic factor IX;

(o) M4E, lipotropics (cholesterol lowering agents), example: pravastatin (Pravachol);

(p) R1M, loop diuretics, example: furosemide (Lasix);

(q) V1A, alkylating agents, example: chlorambucil (Leukeran);

(r) V1B, antimetabolites, example: methotrexate;

(s) V1C, vinca alkaloids, example: vinblastine (Velban);

(t) V1D, antibiotic antineoplastics, example: mitomycin (Mithracin);

(u) V1E, steroid antineoplastics, example: megestrol (Megace);

(v) V1F, antineoplastics, miscellaneous, example: tamoxifen (Nolvadex);

(w) W5B, HIV-specific, example: didanosine (Videx);

(x) W5C, HIV-specific - protease inhibitor; example: indinavir (Crixivan);

(y) Z2E, organ transplant immunosupressive agents, example: cyclosporine (Sandimmune);

(z) W1A, penicillins;

(aa) W1B, cephalosporins;

(bb) W1C, tetracyclines;

(cc) W1D, macrolides;

(dd) W1E, chloramphenicol and derivaties;

(ee) W1F, aminoglycosides;

(ff) W1G, antitubercular antibiotics;

(gg) W1J, vancomycin and derivaties;

(hh) W1K, lincosamides;

(ii) W1M, streptogramins;

(jj) W1N, polymyxin and derivatives;

(kk) W1O, oxazolidinones;

(ll) W1P, antileprotics;

(mm) W1Q, quinolones;

(nn) W1S, thienamycins;

(oo) W1W, cephalosporins - 1st generation;

(pp) W1X, cephalosporins - 2nd generation;

(qq) W1Y, cephalosproins - 3rd generation;

(rr) W2A, absorbable sulfonamides;

(ss) W2E, anti-mycobaterium agents;

(tt) W2F, nitrofuran derivatives; and

(uu) W2G, chemotherapeutics, antibacterial, misc.

(4) The Department may grant a medical exemption to the seven (7) prescription limit in (1), by:

(a) Conducting an assessment for the medical exemption with input from the recipient's prescribing physicians;

(b) Reimbursing for all medically necessary prescriptions pending agency action on the assessment;

(c) Granting the medical exemption if a preponderance of the evidence establishes that the recipient's medical needs cannot reasonably be met unless the Department agrees to pay for more than seven (7) prescriptions in any calendar month;

(d) Deferring to the decision of the prescribing physician, in the event of a disagreement between the Department and the prescribing physician on which prescriptions are medically necessary; and

(e) Setting reasonable conditions on the grant of a medical exemption to assure the most cost-effective method of meeting the medical need, such as the use of generics and other factors.](2) Clients whose prescription exceeds seven prescriptions per month may be subject to clinical review by the Division.

(3) Prescribers may be subject to peer review in regard to a patient's prescription drug profile when opportunities exist to decrease duplicative prescribing, waste, perceived abuse of the pharmacy benefit, or the likelihood of a level one adverse drug event between one or more drugs for any given patient drug profile.

(4) The prescriber shall have ultimate say in what is prescribed.

KEY: Medicaid, prescriptions

[2003]2005

26-18

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For questions regarding the content or application of this rule, please contact Ross Martin at the above address, by phone at 801-538-6592, by FAX at 801-538-6099, or by Internet E-mail at rmartin@utah.gov

For questions about the rulemaking process, please contact the Division of Administrative Rules (801-538-3764). Please Note: The Division of Administrative Rules is NOT able to answer questions about the content or application of these administrative rules.