Medicaid Generic Dispensing Fee Change Today!
February 1, 2012
Dear Member:If your pharmacy department has an outpatient pharmacy serving Illinois Medicaid patients you need to read this. As of today, February 1, 2012 the reimbursement formula for Medicaid prescriptions has changed! The new formula is provided below and it is important to make sure that your outpatient pharmacy has received this information to insure proper billing and to reduce rejected claims.
The new reimbursement formula is:
Effective February 1, 2012, for legend (prescription) drugs, the Department shall pay the lower of:
a) the pharmacy's usual and customary prevailing charge to the general public; or
b) the Department's maximum price plus the established dispensing fee of $6.35 for generic drugs and $3.40 for brand name drugs. If the generic dispensing rate during the quarter ending June 30, 2014 is not 2% higher than the generic dispensing rate during the quarter ending December 31, 2011, then effective January 1, 2015 the dispensing fee shall be $4.60 for generic drugs and $3.40 for brand name drugs.
b) the Department's maximum price plus the established dispensing fee of $6.35 for generic drugs and $3.40 for brand name drugs. If the generic dispensing rate during the quarter ending June 30, 2014 is not 2% higher than the generic dispensing rate during the quarter ending December 31, 2011, then effective January 1, 2015 the dispensing fee shall be $4.60 for generic drugs and $3.40 for brand name drugs.
1) For generic drugs, the Department's maximum price is calculated as the lowest of:
A) Wholesale Acquisition Cost (WAC) plus 1 percent; or
B) the Federal upper limit as established under section 1927(e)(4) of the Social Security Act (42 USC 1396r-8(e)(4)); or
C) the State upper limit; or
D) the average wholesale price for drugs based upon the actual market wholesale price.
B) the Federal upper limit as established under section 1927(e)(4) of the Social Security Act (42 USC 1396r-8(e)(4)); or
C) the State upper limit; or
D) the average wholesale price for drugs based upon the actual market wholesale price.
2) For brand name drugs, the Department's maximum price is calculated as the lowest of:
A) WAC plus 1 percent; or
B) the State upper limit; or
C) the average wholesale price for drugs based upon the actual market wholesale price.
B) the State upper limit; or
C) the average wholesale price for drugs based upon the actual market wholesale price.
If you bill electronically, the changes are already in place.
Please pass this critical information on to the appropriate individuals within your facility in order to maximize your Medicaid reimbursement!
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