§ 250. Reimbursement to participating provider pharmacies. 1. The
amount of reimbursement which shall be paid by the state to a
participating provider pharmacy for any covered drug filled or refilled
for any eligible program participant shall be equal to the allowed
amount defined as follows, minus the point of sale co-payment as
required by sections two hundred forty-seven and two hundred forty-eight
of this title:
* (a) Multiple source covered drugs. Except for brand name drugs that
are required by the prescriber to be dispensed as written, the allowed
amount for a multiple source covered drug shall equal the lower of:
(1) The pharmacy's usual and customary charge to the general public,
taking into consideration any quantity and promotional discounts to the
general public at the time of purchase, or
(2) The sum of the upper limit set by the centers for medicare and
medicaid services for such multiple source drug, or average wholesale
price discounted by sixteen and one-half percent when no upper limit has
been established by the centers for Medicare and Medicaid services for
such multiple source drug, plus a dispensing fee as defined in paragraph
(c) of this subdivision.
* NB Amended Ch. 58/2004 Part A 䅍, language juxtaposed per Ch.
642/2004 䅇
* (b) Other covered drugs. The allowed amount for brand name drugs
required by the prescriber to be dispensed as written and for covered
drugs other than multiple source drugs shall be determined by applying
the lower of:
(1) Average wholesale price discounted by twelve and seventy-five
hundredths of one percent, plus a dispensing fee as defined in paragraph
(c) of this subdivision, or
(2) The pharmacy's usual and customary charge to the general public,
taking into consideration any quantity and promotional discounts to the
general public at the time of purchase.
* NB Amended Ch. 58/2004 Part A 䅍, language juxtaposed per Ch.
642/2004 䅇
(c) As required by paragraphs (a) and (b) of this subdivision, a
dispensing fee of four dollars fifty cents will apply to generic drugs
and a dispensing fee of three dollars fifty cents will apply to brand
name drugs.
2. For purposes of determining the amount of reimbursement which shall
be paid to a participating provider pharmacy, the panel shall determine
or cause to be determined, through a statistically valid survey, the
quantities of each covered drug that participating provider pharmacies
buy most frequently. Using the result of this survey, the contractor
shall update every thirty days the list of average wholesale prices upon
which such reimbursement is determined using nationally recognized and
most recently revised sources. Such price revisions shall be made
available to all participating provider pharmacies. The pharmacist shall
be reimbursed based on the price in effect at the time the covered drug
is dispensed.
3. (a) Notwithstanding any inconsistent provision of law, the program
for elderly pharmaceutical insurance coverage shall reimburse for
covered drugs which are dispensed under the program by a provider
pharmacy only pursuant to the terms of a rebate agreement between the
program and the manufacturer (as defined under section 1927 of the
federal social security act) of such covered drugs; provided, however,
that:
(1) any agreement between the program and a manufacturer entered into
before August first, nineteen hundred ninety-one, shall be deemed to
have been entered into on April first, nineteen hundred ninety-one; and
provided further, that if a manufacturer has not entered into an
agreement with the department before August first, nineteen hundred
ninety-one, such agreement shall not be effective until April first,
nineteen hundred ninety-two, unless such agreement provides that rebates
will be retroactively calculated as if the agreement had been in effect
on April first, nineteen hundred ninety-one; and
(2) the program may reimburse for any covered drugs pursuant to
subdivisions one and two of this section, for which a rebate agreement
does not exist and which are determined by the elderly pharmaceutical
insurance coverage panel to be essential to the health of persons
participating in the program; and likely to provide effective therapy or
diagnosis for a disease not adequately treated or diagnosed by any other
covered drug; and which are recommended for reimbursement by the panel
and approved by the commissioner of health.
(b) The rebate agreement between such manufacturer and the program for
elderly pharmaceutical insurance coverage shall utilize for covered
drugs the identical formula used to determine the rebate for federal
financial participation for drugs, pursuant to section 1927(c) of the
federal social security act, to determine the amount of the rebate
pursuant to this subdivision.
(c) The amount of rebate pursuant to paragraph (b) of this subdivision
shall be calculated by multiplying the required rebate formulas by the
total number of units of each dosage form and strength dispensed. The
rebate agreement shall also provide for periodic payment of the rebate,
provision of information to the program, audits, verification of data,
damages to the program for any delay or non-production of necessary data
by the manufacturer and for the confidentiality of information.
(d) The program in providing utilization data to a manufacturer (as
provided for under section 1927 (b) of the federal social security act)
shall provide such data by zip code, if requested, for the top three
hundred most commonly used drugs by volume covered under a rebate
agreement.
(e) Any funds collected pursuant to any rebate agreements entered into
with a manufacturer pursuant to this subdivision, shall be deposited
into the elderly pharmaceutical insurance coverage program premium
account.
4. Notwithstanding any other provision of law, entities which offer
insurance coverage for provision of and/or reimbursement for
pharmaceutical expenses, including but not limited to, entities
licensed/certified pursuant to article thirty-two, forty-two,
forty-three or forty-four of the insurance law (employees welfare funds)
or article forty-four of the public health law, shall participate in a
benefit recovery program with the elderly pharmaceutical insurance
coverage (EPIC) program which includes, but is not limited to, a
semi-annual match of EPIC's file of enrollees against the entity's file
of insured to identify individuals enrolled in both plans with claims
paid within the twenty-four months preceding the date the entity
receives the match request information from EPIC. Such entity shall
indicate if pharmaceutical coverage is available from the entity for the
insured persons, list the copayment or other payment obligations of the
insured persons applicable to the pharmaceutical coverage, and (after
receiving necessary claim information from EPIC) list the amounts which
the entity would have paid for the pharmaceutical claims for those
identified individuals and the entity shall reimburse EPIC for
pharmaceutical expenses paid by EPIC that are covered under the contract
between the entity and its insured in only those instances where the
entity has not already made payment of the claim. Reimbursement of the
net amount payable (after rebates and discounts) that would have been
paid under the coverage issued by the entity will be made by the entity
to EPIC within sixty days of receipt from EPIC of the standard data in
electronic format necessary for the entity to adjudicate the claim and
if the standard data is provided to the entity by EPIC in paper format
payment by the entity shall be made within one hundred eighty days.
After completing at least one match process with EPIC in electronic
format, an entity shall be entitled to elect a monthly or bi-monthly
match process rather than a semi-annual match process.
5. Notwithstanding any other provision of law, the panel shall
maximize the coordination of benefits for persons enrolled under Title
XVIII of the federal social security act (medicare) and enrolled under
this title in order to facilitate medicare payment of claims. The panel
may select an independent contractor, through a request-for-proposal
process, to implement a centralized coordination of benefits system
under this subdivision for individuals qualified in both the elderly
pharmaceutical insurance coverage (EPIC) program and medicare programs
who receive medications or other covered products from a pharmacy
provider currently enrolled in the elderly pharmaceutical insurance
coverage (EPIC) program.
Last modified: November 19, 2006