Washington faces Rx reimbursement challenge

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NACDS, NCPA, WSPA brief questions state's recent changes

OLYMPIA, Wash. — The National Association of Chain Drug Stores, National Community Pharmacists Association and Washington State Pharmacy Association (WSPA) are challenging changes to Medicaid pharmacy reimbursement in Washington state.

NACDS said Thursday that it teamed with NCPA and WSPA in filing a legal brief last week for a case involving the changes, which the associations described as major. They claim Washington is violating federal and state laws requiring the state to reimburse community pharmacies for the actual cost of dispensing medications, possibly hindering access to care for Medicaid patients.

At issue is a Washington State Health Care Authority rule (WSR 17-07-001) that changes how the state reimburses pharmacies for drugs dispensed to Medicaid patients. The rule called for a new cost-based methodology for reimbursement to be implemented consistent with a federal rule by the U.S. Department of Health and Human Services’ Centers for Medicare & Medicaid Services (CMS).

NACDS, NCPA and WSPA contend, however, that the Washington State Health Care Authority violated state and federal law by not properly considering pharmacies’ costs in setting their professional dispensing fee, resulted in underpayment for the cost to dispense. They noted that because this new cost-based payment methodology doesn’t include any profit margin, pharmacies are forced to pay for part of every prescription dispensed to Medicaid patients or stop providing them care.

“The CMS rule specifically requires states to implement new professional dispensing fees that cover pharmacies’ costs of dispensing effective April 1, 2017,” stated the Oct. 17 legal brief filed with the Superior Court of the State of Washington in Thurston County. “Therefore, the court should order that the state must, retroactive to April 1, 2017, establish and pay new professional dispensing fees that properly reflect pharmacies’ costs of dispensing medications and providing related services to Medicaid patients.”

On April 1, Washington state changed prescription reimbursements without adjusting the professional dispensing fee to comply with the law, according to NACDS, NCPA and WSPA. They argue that pharmacies continuing to care for Medicaid patients despite the below-cost reimbursement should have professional dispensing fees corrected since the change.

In March, NACDS, WSPA and NCPA filed suit against Washington to stop what they called a “substantively and procedurally flawed” rule that would pay community pharmacies below the actual cost to dispense Medicaid scripts. They claimed the rule could threaten access to medications needed to ensure patient health and, in turn, lead to more costly forms of care resulting from untreated conditions.

CMS is now reviewing Washington state’s professional dispensing fee, NACDS, WSPA and NCPA reported. The groups added that new documents obtained from the state indicates that CMS has been questioning the adequacy of the state’s dispensing fees since they were first proposed last year.


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