HF 1722

1st Engrossment - 85th Legislature (2007 - 2008) Posted on 12/15/2009 12:00am

A bill for an act
relating to human services; changing the pharmacy dispensing fee; amending
Minnesota Statutes 2006, section 256B.0625, subdivision 13e.

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

Section 1.

Minnesota Statutes 2006, 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. new text begin Effective July 1, 2007, new text end the pharmacy dispensing fee shall be
$3.65 new text begin for single-source drugs and $12.92 for multiple-source generic drugs new text end , 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.
new text begin An inflation adjustment shall be made annually to the dispensing fee for multiple-source
generic prescriptions based on the CPI-all items for urban consumers. new text end Actual acquisition
cost includes quantity and other special discounts except time and cash discounts. The
actual acquisition cost of a drug shall be estimated by the commissioner, at average
wholesale price minus 12 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 new text begin generic new text end drug may be set by the commissioner and it shall
be comparable to, but no deleted text begin higher than, the maximum amount paid by other third-party
payors in this state who have maximum allowable cost programs deleted text end new text begin lower than the price of
the drug available to retail pharmacies for purchase from prescription drug wholesalers new text end .
Establishment of the amount of payment for drugs shall not be subject to the requirements
of the Administrative Procedure Act.

new text begin (b) Effective for fee-for-service pharmacy services rendered on or after July 1, 2007,
the commissioner may, within the limits of available appropriation, increase dispensing
fees to pharmacists and pharmacies deemed by the commissioner to be critical access
pharmacy providers. Reimbursement to a critical access pharmacy provider may be
increased by not more than 50 percent above the dispensing fee that would otherwise be
paid to the provider. In determining which pharmacists and pharmacies shall be deemed
critical access pharmacy providers, the commissioner shall review:
new text end

new text begin (1) the utilization rate in the service area in which the pharmacist or pharmacy
operates for pharmacy services to patients covered by medical assistance, general
assistance medical care, or MinnesotaCare as their primary source of coverage;
new text end

new text begin (2) the level of services provided by the pharmacist or pharmacy to patients covered
by medical assistance, general assistance medical care, or MinnesotaCare as their primary
source of coverage; and
new text end

new text begin (3) whether the level of services provided by the pharmacist or pharmacy is critical
to maintaining adequate levels of patient access within the service area.
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 deleted text begin actual acquisition cost of deleted text end new text begin federal upper limit set for new text end 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.