Pharmacy provider reimbursement rates should be consistent with efficiency, economy, and quality of care while assuring sufficient beneficiary access, in accordance with section 1902(a)(30)(A) of the Act. As states revise their reimbursement for the ingredient cost of a drug to stay within the FUL, they should also consider whether their current dispensing fee continues to provide adequate reimbursement for the cost of dispensing a prescription to a Medicaid beneficiary, as well as the need to submit a SPA. If a state determines that any change to reimbursement rates are needed, they are responsible for submitting a SPA demonstrating compliance with applicable requirements in the final rule with comment.
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Date
Sub Topic
FAQ ID
94751
FAQ Page
FAQ Question
Since the FULs are effective April 1, 2016, but States have 4 quarters to revise and submit a SPA it seems to imply that ingredient cost reimbursement changes and PDF changes do not need to occur simultaneously. Is this correct, or do they need to occur at the same time as part of the SPA? For example, could a State start utilizing new AMP-based FULs on April 1, 2016, but not change their PDF until April 1, 2017?