SMD: Implementation of the Covered Outpatient Drug Final Regulation Provisions Regarding Reimbursement for Covered Outpatient Drugs in the Medicaid Program

Today the Centers for Medicare & Medicaid Services (CMS) issued a letter to states providing guidance to the states concerning implementation of the Covered Outpatient Drug final rule with comment (CMS-2345-FC) (81 FR 5170) published on February 1, 2016, concerning final regulations pertaining to reimbursement for covered outpatient drugs in the Medicaid program. It outlines the key changes that states need to address when determining their reimbursement methodologies, including the revised requirement in 42 CFR §447.512(b) for states to reimburse at an aggregate upper limit based on actual acquisition cost (AAC) plus a professional dispensing fee established by the agency; the implementation of the Affordable Care Act federal upper limit (FUL); and requirements for the 340B entities, 340B contract pharmacies, Indian Health Service (IHS), Tribal, and Urban Indian Organization (I/T/U) pharmacies.

The letter is available online on Medicaid.gov at https://www.medicaid.gov/federal-policy-guidance/federal-policy-guidance.html.