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      RS 46:460.36     


§460.36. Pharmacy reimbursement by managed care organizations

            A. Words and terms used in this Section shall have the following meanings:

            (1) "Department" means the Louisiana Department of Health.

            (2) "Legacy Medicaid rate" means the lesser of one of the following:

            (a) The published Medicaid fee-for-service reimbursement rate for the combination of the ingredient cost and dispensing fee in use for the current approved Medicaid state plan in effect on the date of service.

            (b) The usual and customary charge. This charge shall be the price the provider most frequently charges the general public for the same drug unless otherwise defined in the current approved Medicaid state plan in effect on the date of service.

            (c) The pharmacy's submitted charge.

            (3) "Local pharmacy" means any pharmacy, domiciled in at least one Louisiana parish that meets both of the following criteria:

            (a) Contracts with the managed care organization or the managed care organization's contractor in its own name or through a pharmacy services administration organization and not under the authority of a group purchasing organization.

            (b) Has fewer than ten retail outlets under its corporate umbrella.

            B. A managed care organization may negotiate the ingredient cost reimbursement in its contracts with providers.

            C. Any contract between the department and a managed care organization that includes provisions for pharmacy reimbursement shall provide for a reimbursement dispute process for local pharmacies.

            (1) Such reimbursement dispute process shall, at a minimum, include the following elements:

            (a) Final review authority shall be retained by the department or by a party agreed upon by the department, the Louisiana Association of Health Plans, and the Louisiana Independent Pharmacies Association.

            (b) If the dispute results in a finding that reimbursement was unreasonable, the managed care organization shall be required to provide the pharmacy an increased reimbursement and shall update its maximum allowable cost list to reflect the increase.

            (c) The department shall define reasonableness in relation to the contractual rate paid by the department to the managed care organization to manage pharmacy services in the medical assistance program.

            (2) The department shall not amend any contract between itself and a managed care organization in order to comply with the requirements of this Subsection unless such amendment shall not increase the actuarially sound rate paid to the managed care organization as of March 1, 2015.

            D. After June 15, 2016, no managed care organization shall pay a local pharmacy a per-prescription reimbursement at a rate less than the legacy Medicaid rate unless its contract with the department provides for a reimbursement dispute process as described in Subsection C of this Section.

            E. The full cost of implementing and performing the provisions of this Section shall be the responsibility of the Louisiana Department of Health through a reallocation of existing budget resources of the department and not through additional appropriations.

            Acts 2015, No. 399, §2.

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