Section 418.101003a. Reimbursement for dispensed medications.

a. (1) Prescription medication shall be reimbursed at the average wholesale price (AWP) minus 10%, as determined by Red Book or Medi-Span referenced in R 418.10107, plus a dispense fee. All of the following apply:

(a)   The dispense fee for a brand name drug shall be $3.50 and shall be billed with WC700-

B.

(b)   The dispense fee for a generic drug shall be $5.50 and shall be billed with WC700-G.

(c)   Reimbursement for repackaged pharmaceuticals shall be at a maximum reimbursement

of AWP minus 10% based upon the original manufacturer’s NDC number, as published by Red Book or Medi-Span, plus a dispensing fee of $3.50 for brand name and $5.50 for generic.

(d)   All pharmaceutical bills submitted for repackaged products shall include the original manufacturer or distributer stock package national drug code or NDC number.

(e)    When an original manufacturer’s NDC number is not available in either Red Book or Medi-Span and a pharmaceutical is billed using an unlisted or “not otherwise specified code,” the payer shall select the most closely related NDC number to use for reimbursement of the pharmaceutical.

(2) Over-the-counter drugs (OTC's), dispensed by a provider other than a pharmacy, shall be dispensed in 10-day quantities and shall be reimbursed at the average wholesale price, as determined by Red Book or Medi-Span or $2.50, whichever is greater.

History: 2008 AACS; 2010 AACS; 2012 AACS; 2014 AACS.