Pennsylvania Medical Bill Reviewer Training Program

1. Pennsylvania Medical Bill Reviewer Training Program Unit 3: Pharmacy and Supplies Module 1: Pharmacy Guidelines

2. Hi! In this module, you will learn about pharmacy guidelines. Then, you will learn how other types of pharmacy services are reimbursed. Overview • Pharmacy Reimbursements • Supplies

3. Key pharmacy charges as billed with NDC codes and number of units. In the system, units have been broken down to number of tablets, ounces, or milliliters prescribed. Inpatient prescription drugs are reimbursed under the applicable Medicare reimbursement x 113%. Pharmacy Guidelines

4. Prescriptions require a few pieces of information that you can locate on a pharmacy bill. The required information is: Prescription Reimbursement • NDC number • Number of units • Billed Charge • Date of Service

5. Drugs dispensed by a pharmacy are limited to 110% of the AWP (Average Wholesale Price). • If the NDC code is not found, payment will be the lesser of the following: • U & C value at 110% • Billed charge Pharmacy Guidelines

6. Supplies and/or materials normally necessary to perform a service are not separately reimbursable. • These include supplies such as: • Cotton balls • Band-Aids • Applied meds/ointments Drugs and Supplies Supplies and materials provided above and beyond items usually included with the service may be separately reimbursed at Average Wholesale Price (AWP) x 110%.

7. Reimbursement for most DME, home infusion therapy, and supplies related to the infusion equipment, is paid at the Medicare Part B Fee Schedule reimbursement for the equipment or therapy multiplied by 113%. Key as billed. Durable Medical Equipment - DME Supplies not covered by fee schedule and not bundled in the office visit are paid at 80% of billed charge, if documentation demonstrates the need for the supplies.

8. Pharmacy Reimbursement Guidelines Summary Reimbursement of Supplies That’s All, Folks!!!