Pharmacy Supplying Fee and Inhalation Drug Dispensing Fee (Rev. 754, 01-03-06)

by  Jared Staheli
July 9th, 2015

Section 303(e) (2) of the MMA implements a supplying fee for immunosuppressive drugs, oral anti-cancer chemotherapeutic drugs, and oral anti-emetic drugs used as part of an anti-cancer chemotherapeutic regimen. Effective January 1, 2005, Medicare paid a separately billable supplying fee of $24.00 to a pharmacy, dialysis facility in the State of Washington or any hospital outpatient department not subject to the OPPS for each supplied prescription of the above-mentioned drugs. In addition, Medicare also paid a separately billable supplying fee of $50.00 for the initial supplied prescription of the immunosuppressive drugs during the first month following the patient’s transplant.

Effective January 1, 2006, we are changing the supplying fee when multiple prescriptions are supplied in a 30-day period. Medicare will pay $24 for the first prescription of the above-mentioned drugs supplied by a pharmacy in a 30-day period, and will pay $16 for each subsequent prescription, after the first one, supplied in that 30-day period. A pharmacy will be limited to one $24 fee per 30-day period even if the pharmacy supplies more than one category of the abovementioned drugs (for example, an oral-anticancer drug and an oral anti-emetic drug) to a beneficiary. If two different pharmacies supply the above-mentioned drugs to a beneficiary during a 30-day period, each pharmacy will be eligible for one $24 supplying fee for the first prescription supplied during that 30-day period, and a supplying fee of $16 for each subsequent prescription supplied in that 30- day period. For a refill prescription, Medicare will allow payment of a $24 supplying fee to a particular supplier up to seven days before the end of the 30-day period for which the last $24 supplying fee was paid to that supplier; however, each supplier will be limited to twelve $24 supplying fees per beneficiary per year. Medicare will pay a supplying fee for each prescription, including prescriptions for different strengths of the same drug supplied on the same day (for example, a prescription for 100 mg tablets and 5 mg Tablets). These changes do not alter the one-time $50 supplying fee for the first immunosuppressive prescription after a transplant.

We are also changing the dispensing fee for inhalation drugs furnished through durable medical equipment. Effective January 1, 2006, Medicare will pay an initial dispensing fee of $57 to a pharmacy for the initial 30-day period of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during that time and regardless of the number of pharmacies used by a beneficiary during that time. This initial 30-day dispensing fee is a one-time fee applicable only to beneficiaries who are using inhalation drugs for the first time as a Medicare beneficiary. Except in those circumstances where an initial 30-day dispensing fee is applicable, Medicare will pay a dispensing fee of $33 to a pharmacy/supplier for each 30-day supply of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during the 30 day period. Medicare will pay a dispensing fee of $66 to a pharmacy/supplier for each 90-day period of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during the 90 days. Only one 30-day dispensing fee will be payable per 30-day period, and only one 90-day dispensing fee will be payable per 90- day period, regardless of the numbers of suppliers used during the respective periods. A 30-day and 90-day supplying fee cannot be paid for drug supplied for the same month. For a refill prescription, Medicare will allow payment of the dispensing fee no sooner than 7 days before the end of usage for the current 30-day or 90-day period for which a dispensing fee was previously paid. Each inhalation drug supplier will be allowed no more than 12 months of dispensing fees per beneficiary per year. Medicare will not pay separately for compounding drugs. This cost is in the dispensing fees.

Supply fees and dispensing fees must be billed on the same claim as the drug.

HCPCS Codes and Fees:

GO369, G0370, G0371, G0374 – not recognized by Medicare as of 1/1/06.

Q0510 – First immunosuppressive prescription after a transplant, $50.00 fee

Q0511 – Pharmacy supplying fee for immunosuppressive, oral-anti-cancer, and oral antiemetic drugs, first prescription in a one month period. Each pharmacy may receive this fee once in a 30-day period. Fee is $24.00.

Q0512 – Pharmacy supplying fee for immunosuppressive, oral anti-cancer, and oral antiemetic drugs – each subsequent prescription in a 30-day period. Fee is $16.00.

Q0513 – Pharmacy dispensing fee for inhalation drug(s); per 30-days.

Effective 1/1/06, Medicare will pay a dispensing fee of $33.00 to a pharmacy for a 30- day period of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during that time and regardless of the number of pharmacies used by a beneficiary during that period. Payment will be made on the first claim received.

Q0514 – Pharmacy dispensing fee for inhalation drugs(s); per 90-days.

Effective 1/1/06, Medicare will pay a dispensing fee of $66.00 to a pharmacy for a 90- day period of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during that time and regardless of the number of pharmacies used by a beneficiary during that period. Payment will be made on the first claim received.

G0333- Pharmacy dispensing fee for initial inhalation drug(s); initial 30 day supply to a beneficiary.

Effective January 1, 2006, Medicare will pay an initial dispensing fee of $57.00 to a pharmacy for the initial 30-day period of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during that time and regardless of the number of pharmacies used by a beneficiary during that time. This initial 30-day dispensing fee is a one-time fee applicable only to beneficiaries who are using inhalation drugs for the first time as a Medicare beneficiary.

Based on the code descriptions above, a supplying fee and a dispensing fee is not appropriate for one drug. The supplying fee is for immunosuppressives, oral anti-cancer drugs and oral anti-emetic drugs. The dispensing fee is for inhalation drugs only. A supplier cannot be paid for more than one of the following -- an initial dispensing fee (G0333), a 30-day dispensing fee (Q0513), or a 90-day dispensing fee (Q0514) – for a beneficiary for the same period.

References:

Pharmacy Supplying Fee and Inhalation Drug Dispensing Fee (Rev. 754, 01-03-06). (2015, July 9). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/pharmacy-supplying-fee-and-inhalation-drug-dispensing-fee-rev-754-01-03-06-27128.html

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