|(a) The following words and terms, when used in this
section, have the following meanings, unless the context clearly indicates
(1) Acquisition Cost--As defined in §355.8541
of this division (relating to Legend and Nonlegend Medications).
(2) Delivery Incentive--An incentive for offering no-charge
prescription delivery to all Medicaid recipients, in accordance with
subsection (d) of this section.
(3) Professional Dispensing Fee--The portion of the
reimbursement paid to a pharmacy under §355.8541 of this division,
in accordance with 42 C.F.R., Subpart I and the Medicaid State Plan,
to provide a reasonable payment for the cost of dispensing a prescription
drug, including the pharmacist's professional services, and which
may include incentive amounts for providers that qualify under this
(4) Fixed Component--A component that provides the
base reimbursement to a pharmacy for the cost of dispensing a prescription;
it includes reimbursement for professional services costs and overhead
(5) Preferred Generic Incentive--An incentive to fill
a Medicaid prescription with a premium preferred generic drug for
which a drug manufacturer has agreed to pay a supplemental rebate.
(6) Variable Component--A component that is expressed
as a percentage of the acquisition cost, and provides an incentive
to a pharmacy to stock and dispense higher-cost drugs by covering
additional expenses incurred when providing those drugs.
(b) The Texas Health and Human Services Commission
(HHSC) reimburses contracted Medicaid pharmacy providers according
to the following formula: Professional Dispensing Fee = (((AC + Fixed
Component) divided by (1 - the percentage used to calculate the Variable
Component)) - AC) + Delivery Incentive + Preferred Generic Incentive.
(c) A delivery incentive is paid to approved providers
who certify in a form prescribed by HHSC that the delivery services
meet minimum conditions for payment of the incentive. These conditions
include: making deliveries to individuals rather than just to institutions,
such as nursing homes; offering no-charge prescription delivery to
all Medicaid recipients requesting delivery in the same manner as
to the general public; and publicly displaying the availability of
prescription delivery services at no charge. The delivery incentive
is to be paid on all Medicaid prescriptions filled for legend drugs.
This delivery incentive is not to be paid for over-the-counter drugs
that are prescribed as a benefit of this program.
(d) Preferred generic drugs are subject to the Preferred
Drug List requirements.
(e) The total professional dispensing fee will not
exceed $200 per prescription.
(f) Notwithstanding other provisions of this section,
HHSC may adjust the dispensing fee to address budgetary constraints
in accordance with the provisions of §355.201 of this division
(relating to Establishment and Adjustment of Reimbursement Rates by
the Health and Human Services Commission).
|Source Note: The provisions of this §355.8551 adopted to be effective October 5, 2003, 28 TexReg 8312; amended to be effective November 21, 2004, 29 TexReg 10503; amended to be effective September 1, 2007, 32 TexReg 5352; amended to be effective January 26, 2011, 36 TexReg 239; amended to be effective September 1, 2011, 36 TexReg 5345; amended to be effective May 15, 2016, 41 TexReg 3300; amended to be effective April 15, 2019, 44 TexReg 1837