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Minnesota Legislature

Office of the Revisor of Statutes

SF 2767

as introduced - 91st Legislature (2019 - 2020) Posted on 04/01/2019 03:49pm

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 2018, section 256B.0625, subdivision 13e.

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

Section 1.

Minnesota Statutes 2018, 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 or the maximum allowable cost 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 for legend prescription
drugs, 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.
The pharmacy dispensing fee for over-the-counter drugs shall be $3.65, except that the fee
shall be $1.31 for retrospectively billing pharmacies when billing for quantities less than
the number of units contained in the manufacturer's original package. 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 wholesale acquisition
cost plus four percent for independently owned pharmacies located in a designated rural
area within Minnesota, and at wholesale acquisition cost plus two percent for all other
pharmacies. A pharmacy is "independently owned" if it is one of four or fewer pharmacies
under the same ownership nationally. A "designated rural area" means an area defined as
a small rural area or isolated rural area according to the four-category classification of the
Rural Urban Commuting Area system developed for the United States Health Resources
and Services Administration. Effective January 1, 2014, the actual acquisition cost of a drug
acquired through the federal 340B Drug Pricing Program shall be estimated by the
commissioner at wholesale acquisition cost minus 40 percent. 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, 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.

(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) 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. 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) Whenever a maximum allowable cost has been set for a multisource drug, payment
shall be the lower of the usual and customary price charged to the public 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 average sales price is unavailable, the amount of payment must
be 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.
Effective January 1, 2014, the commissioner shall discount the payment rate for drugs
obtained through the federal 340B Drug Pricing Program by 20 percent. new text beginWith the exception
of paragraph (f),
new text end the 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.

(f) new text beginNotwithstanding paragraph (e), payment for nonscheduled injectable drugs used to
treat substance abuse administered by a practitioner in an outpatient setting shall be made
either to the administering facility or the practitioner, or directly to the dispensing pharmacy.
The practitioner or administering facility shall submit the claim for the drug, if the practitioner
purchases 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

new text begin (g) new text endThe 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, 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 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.

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.