Public Notices

public_notices Wisconsin Administrative Register No. 669, 9/30/2011

Public Notices

Department of Health Services

(Medicaid Drug 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 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 legal action against First DataBank regarding the validity of the Average Wholesale Price (AWP) benchmark, the Department of Health Services is proposing to make changes in the provisions contained in the state plan that apply to pharmacy reimbursement.

Change in Payment Methods

Federal law requires Medicaid programs to reimburse pharmacy providers at their estimated acquisition cost for pharmacy products. For brand name drugs and generic drugs without a State Maximum Allowed Cost (SMAC) rate, Wisconsin Medicaid has used a discount to AWP to estimate pharmacy acquisition cost.

As a result of a lawsuit settlement, AWP will no longer be reported to the State by its vendor First DataBank after September 28, 2011. The Department will implement Wholesale Acquisition Cost (WAC) as the pricing benchmark for brand name drugs and generic drugs without a SMAC rate. Dispensing fee amounts paid to pharmacies are not affected by the change from AWP to WAC. The Department will continue to reimburse pharmacies for the drug ingredient cost plus a dispensing fee.

Effective October 1, 2011, the Department will reimburse pharmacies for brand name drugs at a rate of WAC + 2%; the Department will reimburse pharmacies for generic drugs without a SMAC rate at a rate of WAC – 3.8%. For drugs without a WAC rate reported by the manufacturer or SMAC rate established, the Department will establish an Expanded Maximum Allowed Cost (EMAC) rate.

In most circumstances, for drugs with multiple rates on file, e.g., WAC and EMAC or WAC and SMAC, the Department will reimburse the pharmacy at the lower of the rates on file.

The change from AWP to WAC reimbursement is projected to decrease expenditures $3.06 million GPR in state fiscal year 2012.

Copies of Proposed Changes:

A copy of the proposed Medicaid program changes may be obtained free of charge by calling or writing as follows:

Regular Mail

James Vavra
Division of Health Care Access and Accountability
Wisconsin Department of Health Services
P. O. Box 309
Madison, WI 53701-0309

Phone

James Vavra
[phone]

FAX

[phone]
Attn: James Vavra

E-Mail

[e-mail]

Written Comments:

Written comments are welcome. Written comments on the changes may be sent by FAX, e-mail, or regular mail to the Division of Health Care Access and Accountability. The FAX number is [phone]. The e-mail address is [e-mail]. Regular mail can be sent to the above address.

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.