DAR File No. 28356

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-63

Medicaid Policy for Pharmacy Reimbursement

NOTICE OF PROPOSED RULE

DAR File No.: 28356
Filed: 11/15/2005, 05:38
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking is necessary to repeal Rule R414-63 and consolidate current Medicaid pharmacy rules into one rule.

Summary of the rule or change:

This rule is repealed in its entirety. However, Rule R414-60 will incorporate this repealed rule's provisions, add pharmacy coverage, and implement Medicare Part D coverage changes. (DAR NOTE: The repeal and reenactment of Rule R414-60 is under DAR No. 28357 in this issue.)

State statutory or constitutional authorization for this rule:

Section 26-18-3 and the Social Security Act 1935(a)

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget associated with this rulemaking because this rule is being repealed and consolidated into Rule R414-60.

local governments:

There is no impact to local governments as a result of this rulemaking because this rule is being repealed and consolidated into Rule R414-60.

other persons:

There is no impact to other persons as a result of this rulemaking because this rule is being repealed and consolidated into Rule R414-60.

Compliance costs for affected persons:

There are no compliance costs because this rule is being repealed and consolidated into Rule R414-60.

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

No costs are anticipated for business as a result of this rule. David N. Sundwall MD, Executive Director

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:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@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:

01/03/2006

This rule may become effective on:

01/04/2006

Authorized by:

David N. Sundwall, 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:

(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) 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

January 26, 2005

26-18]

ADDITIONAL INFORMATION

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For questions regarding the content or application of this rule, please contact Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@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.