SECTION 355.8551. Professional Dispensing Fee

(a) The following words and terms, when used in this section, have the following meanings, unless the context clearly indicates otherwise.

(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 section.

(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 costs.

(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