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SF 14

as introduced - 91st Legislature, 2020 2nd Special Session (2020 - 2020) Posted on 07/14/2020 07:51am

KEY: stricken = removed, old language.
underscored = added, new language.

Current Version - as introduced

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A bill for an act
relating to health care; modifying certain reimbursement provisions for direct
injectable drugs for certain conditions under medical assistance; amending
Minnesota Statutes 2019 Supplement, section 256B.0625, subdivision 13e.

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

Section 1.

Minnesota Statutes 2019 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 ingredient costs of the drugs plus the professional dispensing fee; or the
usual and customary price charged to the public. The usual and customary price means the
lowest price charged by the provider to a patient who pays for the prescription by cash,
check, or charge account and includes prices the pharmacy charges to a patient enrolled in
a prescription savings club or prescription discount club administered by the pharmacy or
pharmacy chain. The amount of payment basis must be reduced to reflect all discount
amounts applied to the charge by any third-party 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 professional dispensing fee shall be
$10.48 for prescriptions filled with legend drugs meeting the definition of "covered outpatient
drugs" according to United States Code, title 42, section 1396r-8(k)(2). The dispensing fee
for intravenous solutions that must be compounded by the pharmacist shall be $10.48 per
bag. The professional dispensing fee for prescriptions filled with over-the-counter drugs
meeting the definition of covered outpatient drugs shall be $10.48 for dispensed quantities
equal to or greater than the number of units contained in the manufacturer's original package.
The professional dispensing fee shall be prorated based on the percentage of the package
dispensed when the pharmacy dispenses a quantity less than the number of units contained
in the manufacturer's original package. The pharmacy dispensing fee for prescribed
over-the-counter drugs not meeting the definition of covered outpatient drugs shall be $3.65
for quantities equal to or greater than the number of units contained in the manufacturer's
original package and shall be prorated based on the percentage of the package dispensed
when the pharmacy dispenses a quantity less than the number of units contained in the
manufacturer's original package. The National Average Drug Acquisition Cost (NADAC)
shall be used to determine the ingredient cost of a drug. For drugs for which a NADAC is
not reported, the commissioner shall estimate the ingredient cost at the wholesale acquisition
cost minus two percent. The ingredient cost of a drug for a provider participating in the
federal 340B Drug Pricing Program shall be either the 340B Drug Pricing Program ceiling
price established by the Health Resources and Services Administration or NADAC,
whichever is lower. Wholesale acquisition cost is defined as the manufacturer's list price
for a drug or biological to wholesalers or direct purchasers in the United States, not including
prompt pay or other discounts, rebates, or reductions in price, for the most recent month for
which information is available, as reported in wholesale price guides or other publications
of drug or biological pricing data. The maximum allowable cost of a multisource drug may
be set by the commissioner and it shall be comparable to the actual acquisition cost of the
drug product and no higher than the NADAC of the generic product. Establishment of the
amount of payment for drugs shall not be subject to the requirements of the Administrative
Procedure Act.

(b) Pharmacies dispensing prescriptions to residents of long-term care facilities using
an automated drug distribution system meeting the requirements of section 151.58, or a
packaging system meeting the packaging standards set forth in Minnesota Rules, part
6800.2700, that govern the return of unused drugs to the pharmacy for reuse, may employ
retrospective billing for prescription drugs dispensed to long-term care facility residents. A
retrospectively billing pharmacy must submit a claim only for the quantity of medication
used by the enrolled recipient during the defined billing period. A retrospectively billing
pharmacy must use a billing period not less than one calendar month or 30 days.

(c) A pharmacy provider using packaging that meets the standards set forth in Minnesota
Rules, part 6800.2700, is required to credit the department for the actual acquisition cost
of all unused drugs that are eligible for reuse, unless the pharmacy is using retrospective
billing. The commissioner may permit the drug clozapine to be dispensed in a quantity that
is less than a 30-day supply.

(d) If a pharmacy dispenses a multisource drug, the ingredient cost shall be the NADAC
of the generic product or the maximum allowable cost established by the commissioner
unless prior authorization for the brand name product has been granted according to the
criteria established by the Drug Formulary Committee as required by subdivision 13f,
paragraph (a), and the prescriber has indicated "dispense as written" on the prescription in
a manner consistent with section 151.21, subdivision 2.

(e) 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, 106 percent of the average sales price as determined by the United States
Department of Health and Human Services pursuant to title XVIII, section 1847a of the
federal Social Security Act, the specialty pharmacy rate, or the maximum allowable cost
set by the commissioner. If new text beginthe new text endaverage sales price is unavailable, the amount of payment
must benew text begin thenew text end lower of the usual and customary cost submitted by the provider, the wholesale
acquisition cost, the specialty pharmacy rate, or the maximum allowable cost set by the
commissioner. The commissioner shall discount the payment rate for drugs obtained through
the federal 340B Drug Pricing Program by 28.6 percent. new text beginWith the exception of paragraph
(f),
new text endthe payment for drugs administered in an outpatient setting shall be made to the
administering facility or practitioner. A retail or specialty pharmacy dispensing a drug for
administration in an outpatient setting is not eligible for direct reimbursement.

new text begin (f) Notwithstanding paragraph (e), payment for injectable drugs used to treat substance
use disorder administered by a practitioner or pharmacist in an outpatient setting shall be
made either to the administering facility, the practitioner, the administering pharmacy or
pharmacist, or directly to the dispensing pharmacy. The practitioner, administering facility,
or administering pharmacy or pharmacist shall submit the claim for the drug if they purchase
the drug directly from a wholesale distributor licensed under section 151.47 or from a
manufacturer licensed under section 151.252. The dispensing pharmacy shall submit the
claim if the pharmacy dispenses the drug pursuant to a prescription issued by the practitioner
and delivers the filled prescription to the practitioner for subsequent administration. Payment
shall be made according to this section. The administering practitioner and pharmacy shall
ensure that claims are not duplicated. A pharmacy shall not dispense a
practitioner-administered injectable drug described in this paragraph directly to an enrollee.
new text end

deleted text begin (f)deleted text endnew text begin (g)new text end The commissioner may establish maximum allowable cost rates for specialty
pharmacy products that are lower than the ingredient cost formulas 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, antihemophilic factor products, 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 maximum allowable cost
reimbursement. 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 maximum allowable cost
to prevent access to care issues.

deleted text begin (g)deleted text endnew text begin (h)new text end Home infusion therapy services provided by home infusion therapy pharmacies
must be paid at rates according to subdivision 8d.

deleted text begin (h)deleted text endnew text begin (i)new text end The commissioner shall contract with a vendor to conduct a cost of dispensing
survey for all pharmacies that are physically located in the state of Minnesota that dispense
outpatient drugs under medical assistance. The commissioner shall ensure that the vendor
has prior experience in conducting cost of dispensing surveys. Each pharmacy enrolled with
the department to dispense outpatient prescription drugs to fee-for-service members must
respond to the cost of dispensing survey. The commissioner may sanction a pharmacy under
section 256B.064 for failure to respond. The commissioner shall require the vendor to
measure a single statewide cost of dispensing for all responding pharmacies to measure the
mean, mean weighted by total prescription volume, mean weighted by medical assistance
prescription volume, median, median weighted by total prescription volume, and median
weighted by total medical assistance prescription volume. The commissioner shall post a
copy of the final cost of dispensing survey report on the department's website. The initial
survey must be completed no later than January 1, 2021, and repeated every three years.
The commissioner shall provide a summary of the results of each cost of dispensing survey
and provide recommendations for any changes to the dispensing fee to the chairs and ranking
members of the legislative committees with jurisdiction over medical assistance pharmacy
reimbursement.

deleted text begin (i)deleted text endnew text begin (j)new text end The commissioner shall increase the ingredient cost reimbursement calculated in
paragraphs (a) and deleted text begin(f)deleted text endnew text begin (g)new text end by 1.8 percent for prescription and nonprescription drugs subject
to the wholesale drug distributor tax under section 295.52.