Pharmacy Owners: Register today to Participate in the Medi-Cal NADAC Reimbursement Webinar

Medi-Cal has implemented a new drug reimbursement cost methodology that was mandated by the federal Center for Medicare and Medicaid Services (CMS) in 2016. This implementation began February 23 rd , 2019. 

In 2015, the Federal Center for Medicare and Medicaid Services (CMS) issued the Covered Outpatient Drugs Final Rule CMS 2345-FC , which among other things, directed states to implement either a NADAC-based payment methodology for their Medicaid program, or, to perform a state-specific acquisition cost study. Additionally, states were to determine a true professional dispensing fee for pharmacies.  

California’s Department of Healthcare Services (DHCS) used Mercer to perform a state-specific study for both the drug acquisition cost and professional dispensing fee. For the drug cost reimbursement, DHCS received approval from CMS to reimburse at the National Average Drug Acquisition Cost (NADAC), and Wholesale Acquisition Cost (WAC) + 0% as a backup benchmark when a NADAC price is not available. NADAC pricing information can be found here and is updated weekly by CMS.

For the professional dispensing fee, they received approval for a two tier fee. The fee for pharmacies who dispense more than 90,000 prescriptions per year would receive an increase from the existing $7.50 to $10.05, and pharmacies that dispense fewer than 90,000 would see roughly a 50% increase in the dispensing fee to $13.20. 

Since the implementation of the new methodology, CPhA has heard from pharmacies regarding significant reductions in reimbursements involving high-cost specialty drugs. The Mercer study concluded that there was not enough data submitted by pharmacies to support a carve-out of specialty drugs. Per the report, Mercer sent out surveys to 5,644 pharmacies, of which 2,562 pharmacies provided responses. Of the 2,562 responses received, only three (3) included cost information related to specialty medications. This was insufficient to substantiate a specialty drug carve out.

CPhA has been in communication with owners and DHCS on how to address this devastating cut to specialty pharmacy within Medi-Cal. On Tuesday, March 19, at 7 PM , CPhA will provide a free Members-Only webinar to review the status of reimbursement change and report on strategies being used with DHCS. This webinar will be free of charge for members, but prior registration is required.

If you are already a member, register for the free webinar here

If you are not a member, please click here to sign up for membership, or call 916-779-1400. Once your membership is processed you will be able to register for the webinar .

If you have any questions, please contact CPhA Government Relations and External Affairs Manager, Danny Martinez at dmartinez@cpha.com .