As many providers working in California know, the state had been steadily cutting the reimbursement rates for providers. So the DHCS’ announcement that it will start increasing pharmacy dispensing fees came as a surprise to many. The increase is due to a federal regulation promulgated by the Centers for Medicare and Medicaid Services (CMS) implementing provisions of the Affordable Care Act (the rule applies only to covered outpatient drugs).
As a result of the federal rule, the DHCS has contracted with Mercer to conduct an Actual Acquisition Cost and professional dispensing fee survey. Instead of the current methodology, the Medi-Cal will implement a two-tiered dispensing fee depending on a pharmacy’s total annual claim volume (under or over 90,000 claims). The National Average Drug Acquisition Cost (NADAC) will be used as the pricing benchmark for both brand and generic drug products. NADAC represents the national average invoice price derived from retail community pharmacies for drug products based on invoices from wholesalers and manufacturers. It does not reflect off-invoice discounts, rebates or price concessions.
When a NADAC price does not exist, Medi-Cal will use the Wholesaler Acquisition Cost (WAC) + 0% as the price benchmark. The reimbursement for outpatient drugs being billed under the 340B program will remain unchanged. 340B program billing will continue to require that drugs purchased under the 340B program be billed at actual purchase price.
What you need to do to receive higher rates:
If you meet the criteria to receive the higher dispensing fee, the pharmacy must submit an attestation to the DHCS. Starting January 2018, the DHCS will be sending instructions on whether you qualify for higher fees, how to prepare the attestation, where and how to file it. If you do not hear from the DHCS by February 2018, contact them directly for further information.