WV Medicaid Pharmacy Pricing Methodology Changes Effective June 21, 2017

6/12/2017

​The West Virginia Medicaid Pharmacy Program will implement a change in pricing methodology as of Wednesday, June 21, 2017.
Prescription drugs will be reimbursed at the following rates:
Brand Name (single source) and Generic (multiple source) Drugs:
Reimbursement shall be at the lower of:
1. National Average Drug Acquisition Cost (NADAC) plus a dispensing fee of $10.49
(If no NADAC is available, then WAC plus a professional dispensing fee of $10.49)
2. The Federal Upper Limit (FUL) as supplied by CMS plus a professional dispensing fee of $10.49
3. The State Maximum Allowable Cost (SMAC) plus a professional dispensing fee of $10.49
4. The submitted ingredient cost plus a professional dispensing fee of $10.49
5. The provider’s usual and customary (U&C) charges to the general public, including any sale price which may be in effect on the date of dispensing

340B Purchased Drugs
Drugs purchased by covered entities described in Section 1927 (a)(5)(B)(340B) covered entity pharmacies) shall be reimbursed at the lower of:
1. Actual Acquisition Cost (AAC), which shall not exceed the 340B ceiling price, plus a professional dispensing fee of $10.49
2. The Federal Upper Limit (FUL) as supplied by CMS plus a professional dispensing fee of $10.49
3. The State Maximum Allowable Cost (SMAC) plus a professional dispensing fee of $10.49
4. The submitted ingredient cost plus a professional dispensing fee of $10.49
5. The provider’s usual and customary (U&C) charges to the general public, including any sale price which may be in effect on the date of dispensing

Specialty Drugs
Specialty drugs not dispensed by a retail community pharmacy and dispensed through the mail will be reimbursed at the lower of:
1.National Average Drug Acquisition Cost (NADAC) plus a dispensing fee of $10.49
(If no NADAC is available, then WAC plus a professional dispensing fee of $10.49)
2. The Federal Upper Limit (FUL) as supplied by CMS plus a professional dispensing fee of $10.49
3. The State Maximum Allowable Cost (SMAC) plus a professional dispensing fee of $10.49
4. The submitted ingredient cost plus a professional dispensing fee of $10.49
5. The provider’s usual and customary (U&C) charges to the general public,   
     including any sale price which may be in effect on the date of dispensing

Clotting Factors
Clotting Factors from specialty pharmacies, hemophilia treatments and Centers of Excellence will be reimbursed at:
1. NADAC plus a professional dispensing fee of $10.49
If NADAC is not available, then Wholesale Acquisition Cost (WAC) plus a professional dispensing fee of $10.49
**Clotting Factors must be billed through the Point of Sale system as of June 21, 2017. The J Codes for these factors will be closed on that date. **

The NADAC pricing file is available on the CMS website at: https://www.medicaid.gov/medicaid/prescription-drugs/pharmacy-pricing/index.html
Please note the date for transitioning the managed care population pharmacy benefits to the Fee for Service program is July 1, 2017.  (Further information may found in additional fax blasts regarding Pharmacy Benefit Transition.)
For questions or comments, please call the Bureau for Medical Services at 304-558-1700 or e-mail Vicki.M.Cunningham@wv.gov


Contact Information

For more information contact BMS at 3004-558-1700
350 Capitol Street | Room 251 | Charleston, WV 25301 | Phone: (304) 558-1700 | Contact Us | Site Map

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