§ 250 — Reimbursement to participating provider pharmacies

§ 250. Reimbursement to participating provider pharmacies. 1. The\namount of reimbursement which shall be paid by the state to a\nparticipating provider pharmacy for any covered drug filled or refilled\nfor any eligible program participant shall be equal to the allowed\namount defined as follows, minus the point of sale co-payment as\nrequired by sections two hundred forty-seven and two hundred forty-eight\nof this title:\n (a) Multiple source covered drugs. Except for brand name drugs that\nare required by the prescriber to be dispensed as written, the allowed\namount for a multiple source covered drug shall equal the lower of:\n (1) The pharmacy's usual and customary charge to the general public,\ntaking into consideration any quantity and promotional discounts to the\ngeneral public at the time of purchase, or\n (2) The upper limit, if any, set by the centers for medicare and\nmedicaid services for such multiple source drug, or\n (3) Average wholesale price discounted by twenty-five percent, or\n (4) The maximum allowable cost, if any, established by the\ncommissioner of health pursuant to paragraph (e) of subdivision nine of\nsection three hundred sixty-seven-a of the social services law.\n Plus a dispensing fee for drugs reimbursed pursuant to subparagraphs\ntwo, three, and four of this paragraph, as defined in paragraph (c) of\nthis subdivision.\n (b) Other covered drugs. The allowed amount for brand name drugs\nrequired by the prescriber to be dispensed as written and for covered\ndrugs other than multiple source drugs shall be determined by applying\nthe lower of:\n (1) Average wholesale price discounted by sixteen and twenty-five one\nhundredths percent, plus a dispensing fee as defined in paragraph (c) of\nthis subdivision, or\n (2) The pharmacy's usual and customary charge to the general public,\ntaking into consideration any quantity and promotional discounts to the\ngeneral public at the time of purchase.\n (c) As required by paragraphs (a) and (b) of this subdivision, a\ndispensing fee of four dollars fifty cents will apply to generic drugs\nand a dispensing fee of three dollars fifty cents will apply to brand\nname drugs.\n 2. For purposes of determining the amount of reimbursement which shall\nbe paid to a participating provider pharmacy, the commissioner of health\nshall determine or cause to be determined, through a statistically valid\nsurvey, the quantities of each covered drug that participating provider\npharmacies buy most frequently. Using the result of this survey, the\ncontractor shall update every thirty days the list of average wholesale\nprices upon which such reimbursement is determined using nationally\nrecognized and most recently revised sources. Such price revisions shall\nbe made available to all participating provider pharmacies. The\npharmacist shall be reimbursed based on the price in effect at the time\nthe covered drug is dispensed.\n 3. (a) Notwithstanding any inconsistent provision of law, the program\nfor elderly pharmaceutical insurance coverage shall reimburse for\ncovered drugs which are dispensed under the program by a provider\npharmacy only pursuant to the terms of a rebate agreement between the\nprogram and the manufacturer (as defined under section 1927 of the\nfederal social security act) of such covered drugs; provided, however,\nthat:\n (1) any agreement between the program and a manufacturer entered into\nbefore August first, nineteen hundred ninety-one, shall be deemed to\nhave been entered into on April first, nineteen hundred ninety-one; and\nprovided further, that if a manufacturer has not entered into an\nagreement with the department before August first, nineteen hundred\nninety-one, such agreement shall not be effective until April first,\nnineteen hundred ninety-two, unless such agreement provides that rebates\nwill be retroactively calculated as if the agreement had been in effect\non April first, nineteen hundred ninety-one; and\n (2) the program may reimburse for any covered drugs pursuant to\nsubdivisions one and two of this section, for which a rebate agreement\ndoes not exist and which are determined by the commissioner to be\nessential to the health of persons participating in the program; and\nlikely to provide effective therapy or diagnosis for a disease not\nadequately treated or diagnosed by any other covered drug.\n (b) The rebate agreement between such manufacturer and the program for\nelderly pharmaceutical insurance coverage shall utilize for covered\ndrugs the identical formula used to determine the rebate for federal\nfinancial participation for drugs, pursuant to section 1927(c) of the\nfederal social security act, to determine the amount of the rebate\npursuant to this subdivision.\n (c) The amount of rebate pursuant to paragraph (b) of this subdivision\nshall be calculated by multiplying the required rebate formulas by the\ntotal number of units of each dosage form and strength dispensed. The\nrebate agreement shall also provide for periodic payment of the rebate,\nprovision of information to the program, audits, verification of data,\ndamages to the program for any delay or non-production of necessary data\nby the manufacturer and for the confidentiality of information.\n (d) The program in providing utilization data to a manufacturer (as\nprovided for under section 1927 (b) of the federal social security act)\nshall provide such data by zip code, if requested, for the top three\nhundred most commonly used drugs by volume covered under a rebate\nagreement.\n (e) Any funds collected pursuant to any rebate agreements entered into\nwith a manufacturer pursuant to this subdivision, shall be deposited\ninto the elderly pharmaceutical insurance coverage program premium\naccount.\n 4. Notwithstanding any other provision of law, entities which offer\ninsurance coverage for provision of and/or reimbursement for\npharmaceutical expenses, including but not limited to, entities\nlicensed/certified pursuant to article thirty-two, forty-two,\nforty-three or forty-four of the insurance law (employees welfare funds)\nor article forty-four of the public health law, shall participate in a\nbenefit recovery program with the elderly pharmaceutical insurance\ncoverage (EPIC) program which includes, but is not limited to, a\nsemi-annual match of EPIC's file of enrollees against the entity's file\nof insured to identify individuals enrolled in both plans with claims\npaid within the twenty-four months preceding the date the entity\nreceives the match request information from EPIC. Such entity shall\nindicate if pharmaceutical coverage is available from the entity for the\ninsured persons, list the copayment or other payment obligations of the\ninsured persons applicable to the pharmaceutical coverage, and (after\nreceiving necessary claim information from EPIC) list the amounts which\nthe entity would have paid for the pharmaceutical claims for those\nidentified individuals and the entity shall reimburse EPIC for\npharmaceutical expenses paid by EPIC that are covered under the contract\nbetween the entity and its insured in only those instances where the\nentity has not already made payment of the claim. Reimbursement of the\nnet amount payable (after rebates and discounts) that would have been\npaid under the coverage issued by the entity will be made by the entity\nto EPIC within sixty days of receipt from EPIC of the standard data in\nelectronic format necessary for the entity to adjudicate the claim and\nif the standard data is provided to the entity by EPIC in paper format\npayment by the entity shall be made within one hundred eighty days.\nAfter completing at least one match process with EPIC in electronic\nformat, an entity shall be entitled to elect a monthly or bi-monthly\nmatch process rather than a semi-annual match process.\n 5. Notwithstanding any other provision of law, the commissioner of\nhealth shall maximize the coordination of benefits for persons enrolled\nunder Title XVIII of the federal social security act (medicare) and\nenrolled under this title in order to facilitate medicare payment of\nclaims. The commissioner of health may select an independent contractor,\nthrough a request-for-proposal process, to implement a centralized\ncoordination of benefits system under this subdivision for individuals\nqualified in both the elderly pharmaceutical insurance coverage (EPIC)\nprogram and medicare programs who receive medications or other covered\nproducts from a pharmacy provider currently enrolled in the elderly\npharmaceutical insurance coverage (EPIC) program.\n 6. The EPIC program shall be the payor of last resort for individuals\nqualified in both the EPIC program and title XVIII of the federal social\nsecurity act (Medicare).\n