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2.2.1.2 Drugs/Biologicals
Physician-administered drugs/biologicals are reimbursed under the Texas Medicaid Program as access-based fees under the physician fee schedule in accordance with 1 TAC §355.8085. Physicians and certain other practitioners are reimbursed for physician-administered drugs/biologicals at the lesser of their usual and customary or billed charges and the Medicaid fee established by the HHSC. The Medicaid fee is an estimate of the provider's acquisition cost for the specific drug/biological. An invoice must be submitted when it is in the provider's possession. Submission of an invoice will document that the provider is billing the lesser of the usual and customary charge or the access-based fee.
The following guidelines are effective for dates of service on and after October 1, 2006, with respect to fee decisions for physician-administered drugs/biologicals:
• Vaccines and infusion drugs furnished through an item of implanted DME are based on the lesser of documented provider acquisition/invoice cost (if available) or 89.5 percent of the average wholesale price (AWP).
•Certain, specific drugs studied by the Office of Inspector General (OIG)/General Accounting Office (GAO) are based on the lesser of documented provider acquisition/invoice cost (if available) or the recommended percentages of AWP resulting from those studies (Table 1 in §20 of Chapter 17 of the Medicare Claims Processing Manual, Pub. 100-04).
•The remaining drugs/biologicals not listed in two previous bullets above that are covered by Medicare are based on the lesser of documented provider acquisition/invoice cost (if available) or 106 percent of average sales price (ASP).
•Those remaining drugs/biologicals not listed in the first two bullets above that are not covered by Medicare are based on the lesser of documented provider acquisition/invoice cost or one of the following:
•89.5 percent of AWP if the drug/biological is considered a new drug/biological (i.e., approved for marketing by the Food and Drug Administration within 12 months of implementation as a benefit of the Texas Medicaid Program); or
•85.0 percent of AWP if the drug/biological does not meet the definition of a new drug (above).
HHSC reserves the option to use other data sources to determine Medicaid fees for drugs/biologicals when AWP or ASP calculations are determined to be unreasonable or insufficient.
Prescriptions are covered under the Texas Medicaid Vendor Drug Program (VDP). The reimbursement methodology for pharmacy services is located at 1 TAC §§355.8541-355.8551.
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