In 2016, CMS published its Final Rule regarding Medicaid drug reimbursements for covered outpatient drugs. Under the Rule, each state Medicaid agency was required to adopt an actual acquisition cost (AAC) methodology for outpatient prescription drug reimbursement. To satisfy this requirement, California adopted CMS’s National Average Drug Acquisition Cost (NADAC) as the basis for AAC
New policy required by PBMs
During recent audits, several PBMs required pharmacies to have policies and procedures addressing CMS form 10147. Most pharmacies do not have written policies regarding CMS-10147 because it is not required by state or federal regulations or PBM manuals. Nevertheless, drafting a policy addressing when and how CMS-10147 is distributed is a good idea (especially considering
Greater risks under the False Claims Act
Last month, the U.S. Supreme Court extended the time in which a private party may bring a suit under the False Claims Act (FCA). The decision – United States ex rel. Hunt v. Cochise Consultancy – extended the statute of limitation to bring an FCA action up to 10 years from the date of the
Anticipating a CMS ruling on DIRs
In 2018, CMS proposed a Medicare rule that would eliminate retroactive DIR fees. One of the rationales for the rule was a colossal growth of DIRs between 2010 and 2017. During this period of time, DIRs grew by 45,000%.
As a result of this aggressive “performance enforcement” by PBMs, many pharmacies are reimbursed below cost
Discontinuation of the Moratorium on the Enrollment of Pharmacy Providers in Los Angeles County
Below is the announcement directly from the California Department of Health Care Services (DHCS):
The DHCS will not extend the moratorium on the enrollment of pharmacy providers in Los Angeles (LA) County after the moratorium expires on October 28, 2018. This bulletin provides information for pharmacy applicants in LA County applying for enrollment in the
California pharmacies experience a steep decline in Medicaid drug reimbursements
Last year, the California Department of Health Care Services (DHCS) announced changes in its drug reimbursement methodology by using the two-tier Professional Dispensing Fee and National Average Drug Acquisition Cost (NADAC) to calculate the new drug ingredient cost reimbursement. When NADAC does not exist, Wholesaler Acquisition Cost (WAC) + 0% would be used. (Related
Medi-Cal Pharmacy Dispensing Fee Will Increase
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