Department of Health and Family Services
(Medicaid Drug Coverage and Reimbursement)
The state of Wisconsin covers legend and non-legend drugs and drug products and reimburses pharmacies for services provided to low-income persons under the authority of Title XIX of the Federal Social Security Act and sections 49.43 to 49.47 and 49.688, Wisconsin Statutes. The Wisconsin Department of Health and Family Services administers this program, which is called Medical Assistance or Medicaid.
Federal statutes and regulations require a state plan that indicates Medicaid covered services and limits to coverage.
A state plan is in effect that indicates coverage of drugs and drug products for medically needy and categorically needy Medicaid recipients and reimbursement policy for pharmacy services. Pursuant to final provisions of the state budget act, the Department is proposing to make changes in the provisions contained in the state plan that apply to pharmacy reimbursement policies.
Change in Payment Methods
Pharmacies are currently reimbursed for brand name drugs at a rate of Average Wholesale Price (AWP) minus 13%, and a dispensing fee of $4.38 for brand or generic drugs. Based on the Governor's budget vetoes and the provisions of 2005 Act 25
, the 2005-2007 state biennial budget act, the Department will reimburse pharmacies for brand name drugs at a rate of AWP minus 16% and a dispensing fee of $3.88 for brand or generic drugs. The Department is proposing modifications to the state Medicaid plan effective August 16, 2005 to reflect provisions of the budget bill, and is implementing the change on the earliest possible date not before August 16, 2005.
The change in AWP reimbursement is projected to decrease expenditures $3,921,300 GPR in state fiscal year 2006 and $6,020,000 GPR in state fiscal year 2007. The change in the dispensing fee is projected to decrease expenditures $1,319,800 GPR in state fiscal year 2006 and $1,880,500 all funds in state fiscal year 2007.
Copies of Proposed Changes and Proposed Payment Rates
When the proposed state plan changes have been drafted, copies may be obtained free of charge by calling or writing as follows:
James J. Vavra, Director
Bureau of Fee-for-Service Health Care Benefits
Division of Health Care Financing
P.O. Box 309
Madison, WI 53701-0309
Written comments are welcome. Written comments on the proposed changes may be sent by FAX, e-mail, or regular mail to the Division of Health Care Financing. The FAX number is (608) 266-1096.
The e-mail address is firstname.lastname@example.org
. Regular mail can be sent to the above address. All written comments will be reviewed and considered. The written comments will be available for public review between the hours of 7:45 a.m. and 4:30 p.m. daily in Room 350 of the State Office Building, 1 West Wilson Street, Madison, Wisconsin.
Copies of the legislative enactment directing the change and conforming state plan change will be made available for review at the main office of any county department of social services or human services. Revisions may be made in the proposed changed methodology based on comments received.