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Pharmacy Reimbursement

A new pharmacy reimbursement methodology for the Mississippi Division of Medicaid (DOM) impacts both fee-for-service and MississippiCAN pharmacy claims. This page covers the current pharmacy reimbursement timeline in addition to providing specific information regarding stakeholder meetings, pharmacy reimbursement methodology as found in the State Plan Amendment (SPA), specialty drug list, and the 340B program.

Reimbursement Timeline

On Feb. 1, 2016, the Centers for Medicare and Medicaid Services (CMS) published 42 CFR, Part 447: Medicaid Program Covered Outpatient Drugs with final comments (CMS-2345-FC). This rule addresses regulations that pertain to reimbursement for covered outpatient drugs in the Medicaid program (fee for service and MississippiCAN).

In compliance with the Final Rule issued by CMS, DOM submitted State Plan Amendment (SPA) 17-0002 Pharmacy Reimbursement to CMS on March 15, 2017. On June 1, 2017, DOM received a formal Request Additional Information (RAI) letter from CMS. DOM submitted an RAI response letter with revised SPA changes to CMS on June 27, 2017. On July 21, 2017, CMS approved the DOM SPA 17-0002 Pharmacy Reimbursement with an effective date of April 1, 2017.

Implementation of the CMS approved point of sale pharmacy reimbursement methodology for fee for service and MississippiCAN will begin on September 1, 2017.

Pharmacy Reimbursement Rate Setting Vendor

For questions about drug reimbursement for fee for service Medicaid beneficiaries, contact the Mercer Pharmacy Rate Setting call center.
Toll-free: 1-855-612-6863
Fax: 1-602-522-6499
Visit the Mercer website for more information.

Specialty Drug List

The Specialty Drug List is maintained by Mercer. For questions about the specialty list, please contact the Mercer Pharmacy Rate Setting call center at 1-855-612-6863.

340B Program

The 340B program is a Drug Pricing Program established by the Veterans Health Care Act of 1992, which is Section 340B of the Public Health Service Act (PHSA). Section 340B limits the cost of covered outpatient drugs to certain federal grantees, federally-qualified health center look-alikes, and qualified hospitals. These providers purchase, dispense and/or administer pharmaceuticals at significantly discounted prices. The significant discount applied to the cost of these drugs makes these drugs ineligible for the Medicaid drug rebate. State Medicaid programs are mandated to ensure that rebates are not claimed on these drugs thereby preventing duplicate discounts for these drugs.

Health Resources and Services Administration (HRSA) is specifically responsible for the enforcement of covered entity compliance with the duplicate discount prohibition. More information regarding eligibility and program logistics can be found on HRSA’s website.

For more information, visit the 340B Program webpage.

Reimbursement Archive