CMS releases Medicaid proposed rule

NCPA May 26, 2023

CMS released a Medicaid proposed rule. The proposed rule clarifies and establishes requirements for State fee--for-service (FFS) pharmacy reimbursement, including that both ingredient cost reimbursement and professional dispensing fee reimbursement under Medicaid fee for service must be based on pharmacy-established cost data, and that market-based research (such as third-party payments accepted by pharmacies) will not qualify as supporting data. CMS is also proposing that managed care plans structure contracts with PBMs to be transparent about spread pricing. CMS proposes to require PBMs report the cost of the covered outpatient drug and dispensing separately from any other fees charged to the plan by the PBM. CMS also seeks to implement a “Medicaid Drug Price Verification Survey” through which certain manufacturers of high-cost drugs would be required to submit detailed pricing and other data to CMS. Stay tuned for further details.