Missouri Regulations
Department of Social Services/MO HealthNet Division
Code of State Regulations 2021-10-31
PUBLICATION DATE: 10/31/2021
ACTION DATE: 10/15/2021
EFFECTIVE DATE: 11/30/2021
PUBLICATION TYPE: Centralized Repository
REGISTER SOURCE: Vol. 46, No. 20, Missouri Register 2021-10-15 pp.1879-1880
PUBLICATION DATE: 10/15/2021
ACTION DATE: 10/15/2021
EFFECTIVE DATE: 11/30/2021
PUBLICATION TYPE: Register
REGISTER SOURCE: Vol. 46, No. 11, Missouri Register 2021-06-01 pp.904-905
PUBLICATION DATE: 06/01/2021
ACTION DATE: 04/26/2021
EFFECTIVE DATE: 07/01/2021
EXPIRATION DATE: 02/24/2022
PUBLICATION TYPE: Register
REGISTER SOURCE: Vol. 46, No. 11, Missouri Register 2021-06-01 p.944
PUBLICATION DATE: 06/01/2021
ACTION DATE: 04/26/2021
COMMENT DEADLINE: 07/01/2021
PUBLICATION TYPE: Register
REGISTER SOURCE: Office of the Secretary of State 2021-05-07
PUBLICATION DATE: 05/07/2021
ACTION DATE: 04/26/2021
EFFECTIVE DATE: 07/01/2021
EXPIRATION DATE: 02/24/2022
PUBLICATION TYPE: Agency

Title 13-DEPARTMENT OF SOCIAL SERVICES

Division 70-MO HealthNet Division

Chapter 20-Pharmacy Program

ORDER OF RULEMAKING

By the authority vested in the Department of Social Services, MO HealthNet Division, under sections 208.153, 208.201, and 660.017, RSMo 2016, and section 208.152, RSMo Supp. 2021, the division amends a rule as follows:

13 CSR 70-20.070 is amended.

A notice of proposed rulemaking containing the text of the proposed amendment was published in the Missouri Register on June 1, 2021 (46 MoReg 944). Those sections with changes are reprinted here. This proposed amendment becomes effective thirty (30) days after publication in the Code of State Regulations.

SUMMARY OF COMMENTS: The Department of Social Services, MO HealthNet Division (MHD), received two (2) comments on the proposed amendment.

COMMENT #1: George Oestreich, a Clinical Pharmacist with G.L.O. and Associates, commented that the rule should define what the agency considers "general public" as exclusive of all third-party payers.

RESPONSE AND EXPLANATION OF CHANGE: The MHD has amended subsection (3)(D) to move the definition of usual and cus-tomary (U&C) into a new paragraph (3)(D)1., and to include a definition for "general public" in a new paragraph (3)(D)2.

COMMENT #2: George Oestreich, a Clinical Pharmacist with G.L.O. and Associates, commented that the listing of potential patient services that may reflect a difference in the usual and customary price are unclear and the timeframe is undefined.

RESPONSE AND EXPLANATION OF CHANGE: The MHD has amended paragraph (3)(D)1. to identify that the timeframe to be used for this definition is the date services are provided.

COMMENT #3: George Oestreich, a Clinical Pharmacist with G.L.O. and Associates, asked how the agency defines "other programs."

RESPONSE AND EXPLANATION OF CHANGE: The MHD has amended paragraph (3)(D)1. to clarify "other programs."

13 CSR 70-20.070 Drug Reimbursement Methodology

(3) Effective December 16, 2018, reimbursement for covered drugs will be determined by applying the following hierarchy method:

(D) The usual and customary (U&C) charge submitted by the provider if it is lower than the chosen price (NADAC, MAC, or WAC).

1. U&C is defined as the provider's charge to the general public that reflects all discounts or programs such as, but not limited to, discount programs, membership programs, price matching programs, or any other program offered by the provider to initiate a reduced price for product costs available to the general public, a special population, or an inclusive category of customers, on the date of service.

2. General public is defined as those patients that pay for their prescriptions and the prescription is not processed by a third-party which includes both governmental and non-governmental payers.