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Specialty Drug Pricing and Reimbursement in Medicaid

Specialty pharmacies dispense prescription drugs that often require special handling or administration.† These specialty drugs are often expensive and are used to treat complex conditions, such as Hepatitis C, HIV, and certain cancers. States use Centers for Medicare & Medicaid Servicesís national average drug acquisition cost to set Medicaid pharmacy reimbursement amounts. However, this average does not include the cost of drugs sold at specialty pharmacies. Therefore, States that use the national average drug acquisition cost data to assist in setting Medicaid pharmacy reimbursement amounts may have difficulty determining Medicaid pharmacy reimbursement amounts for specialty drugs.† We will determine how State Medicaid agencies (States) define specialty drugs, how much States paid for specialty drugs, how States determine payment methodologies for specialty drugs, and the differences in reimbursement amounts for these drugs among the States.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
Nov-16 Centers for Medicare & Medicaid Services Specialty Drug Pricing and Reimbursement in Medicaid Office of Evaluation and Inspections OEI-00-00-00000 2019

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