State regulators in Michigan are working on draft rules to address drug repackaging in work comp. Several weeks ago, I wrote a post on the 6 core tenets of any strong statutory/regulatory action in this area. Let's see how Michigan's newly proposed rules stack up.
1) The rule doesn't ban physician dispensing. There are legitimate reasons a
doctor may need to dispense medications to a patient and the rule allows for
those limited circumstances.
Michigan = check.
2) The rule focuses on the financial
remuneration tied to physician dispensing and fixes such fees at the Average
Wholesale Price (AWP) of the medication plus a reasonable dispensing fee.
Michigan = check. (AWP - 10% + $3.50 for brands and AWP - 10% + $5.50 for generics)
3) The rule clearly specifies the source for
the AWP (Medi-Span, Redbook, etc.). Many states are silent to the AWP source and this creates
a lot of noise in the system.
Michigan = check. (Redbook)
4) The rule specifies that fees are
determined by "a) the NDC for the underlying drug product from the original
manufacturer, or b) the therapeutic equivalent drug product from the original
manufacturer/labeler NDC." This leaves no room for physicians or other agents
to create new NDC codes as a result of repackaging.
Michigan = check.
5) If the underlying
NDC isn't known or isn't shared, discretion rests with the payer to determine
the most appropriate NDC code. There is a dispute resolution process outlined
if the provider disagrees.
Michigan = unclear. The Michigan rules stipulate that if a pharmaceutical bill is submitted for more than $35 using an unlisted or "not otherwise specified" code, then the bill must be accompanied by an invoice. Not sure I follow, but at least they're thinking about it.
6) Perhaps most importantly, this is a
regulatory change, not a statutory change. This won't be possible in all states, but where
it is, it's the way to go.
Michigan = check.
A great start for Michigan. Well done.
Michael
On Twitter @PRIUM1
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