The NACDS, NCPA, and the Washington State Pharmacy Association (WSPA) have teamed up to file a joint legal brief in support of CMS’ rejection of a Washington State pharmacy reimbursement plan.
The organizations argue that the state has refused to increase its cost-based professional dispensing fees (PDFs) to community pharmacies providing care and services to Medicaid patients. The fees cover pharmacies’ costs of dispensing, as well as ingredient-cost reimbursement for drugs. Currently, according to the brief, Washington only offers reimbursements ranging between $4.24 and $5.25. According to an independent cost-of-dispensing study commissioned by the Coalition for Community Pharmacy Action in 2015, the average cost to dispense per prescription in Washington in 2013 was $11.65.
The state alleges that it does not need to consider the pharmacy’s actual costs when determining dispensing fees, but the parties issuing the brief suggest that the state is “intentionally misreading the requirements of the federal rule and using inapplicable payment data from private insurance plans that do not track actual costs." CMS disagrees with this stance.
Many states have adopted cost-based PDFs ranging between $10 and $12. Washington State’s neighbors, according to the brief, have agreed to cost-based PDFs that are substantially higher than Washington’s. For example, Idaho reimburses $11.51 to $15.11, Montana reimburses $11 to $15, and Oregon reimburses $9.68 to $14.01.
Currently, Washington State rejects the price comparison to those states. The brief argues that since the prices are derived from a “neighbor state survey” of pharmacy costs, the data satisfies the CMS Rule’s requirement for “reliability data.”
“Washington is convinced that CMS does not understand its own rule, and Washington apparently also believes that all the other states adopted cost-based PDFs because they are similarly deluded about the CMS rule,” the brief notes.
The CMS rules went into effect in 2016, but CMS is arguing that reimbursements should be retroactively implemented to April 2017. If approved, Washington State would be required to increase their PDFs and reimburse pharmacies dispensing to Medicaid patients through that date.