Note: This bulletin replaces Changes to Pharmacy Professional Dispensing Fee and 340B Long-Acting Reversible Contraception published Jan. 4, 2023.
The Department of Health and Human Services, Division of Health Benefits, has begun implementing changes pursuant to a Medicaid State Plan Amendment for Professional Dispensing Fee (PDF) and 340B Long-Acting Reversible Contraception (LARC). These changes were approved by the Centers for Medicare & Medicaid Services (CMS) on Jan. 25, 2023, with an effective date of Dec. 1, 2022.
The amendment revises the pharmacy reimbursement methodology for PDFs as follows:
- Establishes the PDF at a flat fee of $10.24 per prescription, as determined by the Cost of Dispensing Study conducted on behalf of the North Carolina Department of Health and Human Services, Division of Health Benefits
- Removes the rule allowing only one PDF per drug, per member, per pharmacy, per month
- Permits PDF payment on emergency dispensations (including the one emergency fill allowed through the lock-in program per year)
- Allows the OMB (Office of Management and Budget) encounter rate to pay for medication-assisted therapy (MAT) for tribal option beneficiaries
This amendment also changes the reimbursement methodology for LARC acquired through the 340B program and utilized in the PADP. For LARCs acquired and dispensed under the 340B program, reimbursement will be paid at the lesser of actual acquisition cost submitted plus 6% or 340B ceiling price plus 6%.
These new reimbursements will be applicable to all active NC Medicaid Providers.
Contact
NCTracks Call Center: 800-688-6696