HF 3266

as introduced - 86th Legislature (2009 - 2010) Posted on 03/01/2010 09:47am

A bill for an act
relating to health; adjusting pharmacy reimbursement rates; amending Minnesota
Statutes 2009 Supplement, section 256B.0625, subdivision 13e.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

Minnesota Statutes 2009 Supplement, section 256B.0625, subdivision 13e,
is amended to read:

Subd. 13e.

Payment rates.

(a) The basis for determining the amount of payment
shall be the lower of the actual acquisition costs of the drugs plus a fixed dispensing fee;
the maximum allowable cost set by the federal government or by the commissioner plus
the fixed dispensing fee; or the usual and customary price charged to the public. The
amount of payment basis must be reduced to reflect all discount amounts applied to the
charge by any provider/insurer agreement or contract for submitted charges to medical
assistance programs. The net submitted charge may not be greater than the patient liability
for the service. The pharmacy dispensing fee shall be $3.65, except that the dispensing fee
for intravenous solutions which must be compounded by the pharmacist shall be $8 per
bag, $14 per bag for cancer chemotherapy products, and $30 per bag for total parenteral
nutritional products dispensed in one liter quantities, or $44 per bag for total parenteral
nutritional products dispensed in quantities greater than one liter. Actual acquisition cost
includes quantity and other special discounts except time and cash discounts. Effective
July 1, 2009, the actual acquisition cost of a drug shall be estimated by the commissioner,
at average wholesale price minus 15 percent. The actual acquisition cost of antihemophilic
factor drugs shall be estimated at the average wholesale price minus 30 percent. The
maximum allowable cost of a multisource drug may be set by the commissioner and it
shall be comparable to, but no higher than, the maximum amount paid by other third-party
payors in this state who have maximum allowable cost programs. Establishment of the
amount of payment for drugs shall not be subject to the requirements of the Administrative
Procedure Act.

new text begin (b) Notwithstanding paragraph (a), the drug products named in the lawsuit styled
as New England Carpenters Health Benefits Fund v. First Data Bank, Inc., Civil Action
No. 05-11148-PBS (D. Mass. 2007), are reimbursed at the average wholesale price
minus 11.46 percent or the equivalent wholesale acquisition cost plus 6.25 percent,
whichever formula reimburses pharmacies at the equivalent reimbursement rate that was
in effect prior to the settlement agreement in this lawsuit. If there is a dispute regarding
reimbursement, the pharmacy shall contact the Department of Human Services to adjust
the reimbursement rate. If the dispute is not resolved between the pharmacy and the
Department of Human Services, either party may bring the dispute on reimbursement to
the drug formulary committee for a decision on reimbursement. The decision of the drug
formulary committee is binding upon both parties. The Department of Human Services
shall publish a list of the drugs affected by the settlement agreement on its Web site.
new text end

deleted text begin (b) deleted text end new text begin (c) new text end An additional dispensing fee of $.30 may be added to the dispensing fee paid
to pharmacists for legend drug prescriptions dispensed to residents of long-term care
facilities when a unit dose blister card system, approved by the department, is used. Under
this type of dispensing system, the pharmacist must dispense a 30-day supply of drug.
The National Drug Code (NDC) from the drug container used to fill the blister card must
be identified on the claim to the department. The unit dose blister card containing the
drug must meet the packaging standards set forth in Minnesota Rules, part 6800.2700,
that govern the return of unused drugs to the pharmacy for reuse. The pharmacy provider
will be required to credit the department for the actual acquisition cost of all unused
drugs that are eligible for reuse. Over-the-counter medications must be dispensed in the
manufacturer's unopened package. The commissioner may permit the drug clozapine to be
dispensed in a quantity that is less than a 30-day supply.

deleted text begin (c) deleted text end new text begin (d) new text end Whenever a generically equivalent product is available, payment shall be on
the basis of the actual acquisition cost of the generic drug, or on the maximum allowable
cost established by the commissioner.

deleted text begin (d) deleted text end new text begin (e) new text end The basis for determining the amount of payment for drugs administered in
an outpatient setting shall be the lower of the usual and customary cost submitted by the
provider or the amount established for Medicare by the United States Department of
Health and Human Services pursuant to title XVIII, section 1847a of the federal Social
Security Act.

deleted text begin (e) deleted text end new text begin (f) new text end The commissioner may negotiate lower reimbursement rates for specialty
pharmacy products than the rates specified in paragraph (a). The commissioner may
require individuals enrolled in the health care programs administered by the department
to obtain specialty pharmacy products from providers with whom the commissioner has
negotiated lower reimbursement rates. Specialty pharmacy products are defined as those
used by a small number of recipients or recipients with complex and chronic diseases
that require expensive and challenging drug regimens. Examples of these conditions
include, but are not limited to: multiple sclerosis, HIV/AIDS, transplantation, hepatitis
C, growth hormone deficiency, Crohn's Disease, rheumatoid arthritis, and certain forms
of cancer. Specialty pharmaceutical products include injectable and infusion therapies,
biotechnology drugs, high-cost therapies, and therapies that require complex care. The
commissioner shall consult with the formulary committee to develop a list of specialty
pharmacy products subject to this paragraph. In consulting with the formulary committee
in developing this list, the commissioner shall take into consideration the population
served by specialty pharmacy products, the current delivery system and standard of care in
the state, and access to care issues. The commissioner shall have the discretion to adjust
the reimbursement rate to prevent access to care issues.