Reimbursement : Amounts

Covered Outpatient Drug Reimbursement: Professional Dispensing Fees

Per 42 C.F.R. § 447.502, the professional dispensing fee is designed to reflect professional services and costs associated with delivering a covered outpatient drug to a ForwardHealth member. BadgerCare Plus, Medicaid, SeniorCare, ADAP, and WCDP reimburse the same professional dispensing fee reimbursement rates, based on a dispensing provider's annual prescription volume for all prescriptions dispensed, for services provided. These fees include the following:

• Professional dispensing fee (Services covered under the professional dispensing fee include record keeping, patient profile preparation, prospective DUR, and counseling.)
• A compound drug add-on of $7.79

Additionally, BadgerCare Plus, Medicaid, and SeniorCare reimburse a repackaging allowance of $0.015 per unit billed to the professional dispensing fee for oral drugs in a solid form that are not considered unit dose.

Professional Dispensing Fee Reimbursement Rates

A professional dispensing fee is usually paid once per member, per service, per month, per provider, depending on the prescriber's prescription.

The following table lists the professional dispensing fee reimbursement rates that include overall annual prescription volume and associated professional dispensing fees:

Professional Dispensing Fee Surveys

ForwardHealth periodically conducts mandatory professional dispensing fee surveys as part of an ongoing process to ensure up-to-date professional dispensing fee reimbursement rates that accurately reflect the costs associated with dispensing covered outpatient drugs to ForwardHealth members.

Prescription Volume Attestation

Providers are required to attest to their overall annual prescription volume on a yearly basis. The annual attestation process is mandatory for all providers and organizations that dispense covered outpatient drugs. ForwardHealth uses providers' self-reported annual prescription volumes to assign professional dispensing fee reimbursement rates. If providers do not self-report annual prescription volume, ForwardHealth will automatically assign the lowest professional dispensing fee reimbursement rate. Providers are subject to audit at ForwardHealth's discretion.

Newly Enrolled Providers

ForwardHealth assigns the lowest professional dispensing fee reimbursement rate of $10.51 to newly enrolled providers that:

• Enroll in ForwardHealth from December 1 of the previous year to November 30 of the current year. For example, if a provider enrolls in ForwardHealth during the month of December 2020 they are not eligible to participate in the attestation survey sent January 2021. They would be eligible to participate in the attestation survey the following year in January 2022.
• Have not completed a prescription volume attestation survey.
• Have not billed ForwardHealth for a covered outpatient drug.

Out-of-State Providers and In-State Emergency Providers

ForwardHealth assigns a professional dispensing fee reimbursement rate of $10.51 to out-of-state providers and in-state emergency providers.

Change of Ownership

If a pharmacy location experiences a change of ownership during the year, the location is considered a new location and is assigned a professional dispensing fee reimbursement rate of $10.51, regardless of the previous dispensing fee.

The following events are considered a change of ownership and require the completion of a new provider enrollment application:

• Change from one type of business structure to another type of business structure.
• Change of name and tax identification number associated with the provider's submitted enrollment application.
• Change (addition or removal) of names identified as owners of the provider.

FQHCs

FQHCs are not required to attest to their annual prescription volume and are automatically assigned a provider-specific professional dispensing fee reimbursement rate.

Tribal FQHCs

Tribal FQHCs receive an interim professional dispensing fee reimbursement rate of $24.92, which is reconciled to approved federal encounter rates.

Non-Tribal FQHCs

Non-tribal FQHCs, also known as community health centers, receive an interim professional dispensing fee of $24.92 for SeniorCare members. For non-SeniorCare members, non-tribal FQHCs do not receive an interim professional dispensing fee because the professional dispensing fee is incorporated into the approved rate process.

Multiple Locations

Providers who have multiple locations are required to attest for each location individually.

Disputes

There will be no dispute process for providers who do not agree with their rate assignment because the assignment is based on the prescription volume they have reported.

Compound Drug Add-on

A claim submitted for a compound drug for BadgerCare Plus, Medicaid, and SeniorCare will be reimbursed at the provider's assigned professional dispensing fee reimbursement rate plus a compound add-on of $7.79.

Repackaged Drugs and Repackaging Allowances

The repackaging allowance is limited to oral drugs in a solid form that are not considered unit dose. However, the professional dispensing fee may be allowed for unit dose drugs.

Pharmacy providers can obtain a repackaging allowance for oral drugs in a solid form that are repackaged by the pharmacy by entering the appropriate value in the Special Packaging Indicator field. If this field is present on a pharmacy claim when the drug is defined as unit dose, the repackaging allowance will not be reimbursed. Providers will receive an EOB code for repackaged drugs and repackaging allowances.

The repackaging allowance only applies to drugs dispensed in whole units, such as capsules and tablets. The repackaging allowance is not allowed for liquids and creams.

Repackaged manufacturers' products are not covered by BadgerCare Plus, Medicaid, or SeniorCare.