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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsNovember 2016

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Regulatory Flexibility Act Form

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1927 of the Social Security Act, Payment for Covered Outpatient Drugs
42 CFR §447.512, Drugs: Aggregate upper limits of payment
42 CFR §447.201, State plan requirements
42 CFR §447.205, Public notice of changes in Statewide methods and standards for setting payment rates
In accordance with the federal public notice requirements established at Section 1902(a)(13)(A) of the Social Security Act and 42 CFR 447.205 and the state public notice requirements of Title 29, Chapter 101 of the Delaware Code, Delaware Health and Social Services (DHSS)/Division of Medicaid and Medical Assistance (DMMA) gives public notice and provides an open comment period for thirty (30) days to allow all stakeholders an opportunity to provide input to the methods and standards governing payment methodology for pharmaceutical services. Comments must be received by 4:30 p.m. on December 1, 2016.
National Average Drug Acquisition Cost (NADAC), or if a NADAC is not available the Average Wholesale Price (AWP) minus 19%,
The professional dispensing fee rate is ten dollars ($10.00). There is one-time professional fee per thirty (30)-day period unless the class of drugs is routinely prescribed for a limited number of days.
Federal Upper Limit (FUL) - The FUL is a federally defined price and constitutes the upper limit of reimbursement where a DMAC limit does not exist.
Non-Traditional Pharmacy - long term care and specialty pharmacies.
Traditional Pharmacy - retail independent and retail chain pharmacies.
The Actual Acquisition Cost (AAC) for Drug Reimbursement is derived using the methodology in the table below.
Exceptions of the reimbursement of FUL and DMAC can be made if a physician certifies in their own handwriting that a specific brand is medically necessary. The medical necessity must be documented on a FDA Med-Watch form based on the client experiencing an adverse reaction.
Other Exceptions will be made if documentation provided demonstrates that the product can only be obtained at a higher rate.
Last Updated: December 31 1969 19:00:00.
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