N.Y. Elder Law § 250: Reimbursement to participating provider pharmacies

§ 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 upper limit, if any, set by the centers for medicare and

medicaid services for such multiple source drug, or

(3) Average wholesale price discounted by twenty-five percent, or

(4) The maximum allowable cost, if any, established by the

commissioner of health pursuant to paragraph (e) of subdivision nine of

section three hundred sixty-seven-a of the social services law.

Plus a dispensing fee for drugs reimbursed pursuant to subparagraphs

two, three, and four of this paragraph, as defined in paragraph (c) of

this subdivision.

(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 sixteen and twenty-five one

hundredths 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.

(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 commissioner of health

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 commissioner 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.

(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 commissioner of

health 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 commissioner of health 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.

6. The EPIC program shall be the payor of last resort for individuals

qualified in both the EPIC program and title XVIII of the federal social

security act (Medicare).