Page 2864

Article 5. Payment Rates; Prescription Drugs and Medical Supplies; Durable Medical Equipment; Transportation; Laboratory Services. Rule 7 AAC 145.400. Covered outpatient drug payment rates and home infusion therapy drug rates 7 AAC 145.410. Dispensing fee 7 AAC 145.420. Durable medical equipment, supplies, prosthetics, orthotics, and respiratory therapy payment rates 7 AAC 145.421. Prosthetics and orthotics payment rates 7 AAC 145.425. Home infusion therapy payment rates 7 AAC 145.440. Transportation and accommodation services payment rates 7 AAC 145.460. Laboratory services payment 7 AAC 145.400. Covered outpatient drug payment rates and home infusion therapy drug rates. (a) In addition to complying with the requirements of 7 AAC 105.220, and before submitting a claim for payment from the department, a pharmacy provider shall bill any third-party prescription drug plan in which the recipient is enrolled and that is in effect on the date of service. After the pharmacy provider receives notification from the third-party prescription drug plan of the amount, if any, that the third-party prescription drug plan will pay, the pharmacy provider may submit a claim for payment from the department for the remaining cost of service. The department will pay the pharmacy provider the lesser of the difference between the payment by the third-party prescription drug plan and the department-calculated allowable payment, minus any recipient cost-sharing amounts imposed under AS 47.07.042 by the department or the remaining patient liability amount, minus any recipient cost-sharing amounts imposed under AS 47.07.042 by the department. The department will consider the payment to be payment in full. (b) For a prescription of a covered outpatient drug as described in 7 AAC 120.110(b), the department will pay the provider for reasonable and necessary postage or freight shipping, not to exceed $16, incurred in the delivery of the prescription from the dispensing pharmacy to the recipient if pharmacy services are not available in the recipient’s community. If multiple prescriptions for covered outpatient drugs are shipped in a single package, the postage or freight shipping costs must be divided by the number of prescriptions for covered outpatient drugs shipped and the partial postage amount is to be billed on each prescription claim. (c) The department may establish a state maximum allowable cost for a covered outpatient drug described in 7 AAC 120.110(b). The state maximum allowable cost will be established by reviewing pricing sources, including the wholesale acquisition cost, purchase invoices, or direct price for the covered outpatient drug as identified in the First Data Bank National Drug Data File (NDDF) Plus, taking into consideration the cost of the most frequently dispensed drugs. (d) The department will maintain on its website, or on the website of the department’s designated contractor, a current listing of covered outpatient drugs and their corresponding state