CHAPTER 10
PHARMACEUTICAL SERVICES
Section 1. Authority.
This Chapter is promulgated by the Department of Health pursuant to the Wyoming Medical Assistance and Services Act at Wyoming Statutes §§ 42-4-101 through -121.
Section 2. Purpose and Applicability.
(a) This Chapter has been adopted to establish the standards and procedures for the provision of and payment for pharmaceutical services under Medicaid. It shall apply to all pharmaceutical services provided on or after the effective date of this rule.
(b) The Department may issue manuals and bulletins to interpret the provisions of this Chapter. Such manuals and bulletins shall be consistent with and reflect the policies contained in this Chapter. The provisions contained in manuals or bulletins shall be subordinate to the provisions of this Chapter.
Section 3. Definitions. Except as otherwise specified in Chapter 1 of the Wyoming Medicaid Rules or as defined in this section, the terminology used in this chapter is the standard terminology and has the standard meaning used in healthcare, Medicaid, and Medicare.
(a) "AB Rated." An "AB rated" generic drug product is one that the FDA has determined to be bioequivalent to a branded drug. A generic drug is considered bioequivalent to a branded drug if it contains the same active pharmaceutical ingredient as the branded drug and there is no significant difference in the formulation, quality, and effectiveness of the two (2) drugs.
(b) "Average wholesale price (AWP)." A national average of list prices charged by wholesalers to pharmacies.
(c) "Board of Pharmacy." The Wyoming State Board of Pharmacy, its agent, designee or successor.
(d) "Brand name." The proprietary or trade name selected by the manufacturer, given to a drug, and placed upon a drug, its container, label, or wrapping at the time of packaging.
(e) "Compound Drug." A drug prepared by a pharmacist who mixes or adjusts drug ingredients to customize a medication to meet a patient's individual needs.
(f) "Device." Any article or healthcare product intended for use in the diagnosis of disease or other condition or for use in the care, treatment, or prevention of disease that does not achieve any of its primary intended purposes by chemical action or by being metabolized.
(g) "Drug Efficacy Study Implementation (DESI) drugs." Drugs determined by the United States Food and Drug Administration (FDA) to be less than effective. This definition applies to all drugs that are similar, related, or identical to these drugs pursuant to FDA designation. Compound formulations which contain a DESI drug are considered to be DESI compounds/DESI drugs.
(h) "Drug Utilization Review (DUR) requirements." The Drug Utilization Review Requirements as set forth in Chapter 9 of the Board of Pharmacy Rules and 42 C.F.R. Part 456. A DUR program shall include prospective drug review, retrospective drug use review, and an educational program.
(i) "Federal Upper Limit (FUL)." The maximum amount the federal government (Centers for Medicare and Medicaid Services) will pay for multiple source drugs.
(j) "Food and Drug Administration (FDA)." The Food and Drug Administration of the United States of America, its agent, designee, or successor.
(k) "Local Trade Area." The geographic area surrounding the client's residence, including portions of states other than Wyoming, commonly used by other persons in the same area to obtain pharmaceutical services.
(l) "Gross Amount Due (GAD)." The sum of the submitted product component cost and the dispensing fee submitted by the pharmacy on a prescription claim.
(m) "Ingredient Cost Submitted." The product cost submitted by the pharmacy on a prescription claim.
(n) "Maintenance drug." A covered prescription drug prescribed for a chronic condition (i.e., diabetes, arthritis, high blood pressure, or heart conditions).
(o) "Multiple source drug." A drug marketed or sold by two (2) or more manufacturers or labelers or a drug marketed or sold by the same manufacturer or labeler under two (2) or more different proprietary names.
(p) "National Average Drug Acquisition Cost (NADAC)." A drug price point that is calculated based on average pharmacy acquisition cost of a particular drug.
(q) "National drug code (NDC)." The code number determined for and assigned to a drug by the FDA.
(r) "One month supply." The quantity of drugs sufficient to last up to thirty-four (34) days.
(s) "Pharmaceutical service." Drugs, devices or medical supplies that are covered services, as defined in this Chapter.
(t) "Pharmacist." A person licensed to practice pharmacy by the Wyoming State Board of Pharmacy or a similar board or agency in another state.
(u) "Pharmacy Therapeutics (P&T) Committee." An advisory committee that shall review evidence based research and provide recommendations to the Department as to the clinical effectiveness of a service or medication within a therapeutic drug class.
(v) "Preferred Drug List (PDL)." A list of preferred pharmaceutical substances for selected pharmacologic or therapeutic classes that is maintained by the Department, is designed to maximize clinical and economic outcomes, and is incorporated herein by reference.
(w) "Prescription drug." A drug that is:
(i) Prescribed by a practitioner acting within the scope of his practice; and
(ii) Dispensed by a provider pursuant to a written prescription that is recorded and maintained in the provider's records.
(x) "Wholesale Acquisition Cost (WAC)." The list price paid by a wholesaler, distributor and other direct accounts for drugs purchased from the wholesaler's supplier not including discounts or rebates.
(y) "Wholesaler." An individual or entity that furnishes drugs, medical supplies, or both, to pharmacies or pharmacists.
Section 4. Provider Participation.
(a) Compliance with Chapter 3. An individual or entity that wishes to receive Medicaid funds for pharmaceutical services furnished to a client shall meet the requirements of Chapter 3 of the Wyoming Medicaid Rules.
(b) Eligible pharmaceutical services providers include non-excluded
(i) Pharmacies;
(ii) Pharmacists; and
(iii) Physicians who practice in a local trade area where pharmacy services are not available from a pharmacy or pharmacist and are enrolled as a Medicaid pharmacy services provider. Except as otherwise specified in this Chapter, such a physician shall meet the standards and follow the procedures established for a pharmacist provider.
Section 5. Provider Records.
(a) Compliance with Chapter 3. A provider of pharmaceutical services shall comply with the record-keeping requirements of Chapter 3 of the Wyoming Medicaid Rules.
(b) Additional requirements. In addition to the requirements of Chapter 3, providers of pharmaceutical services shall retain records that include:
(i) Invoices for drugs;
(A) Pharmacies shall be able to supply all drug invoices in the format requested by the Department. This format may include, but is not limited to, paper, electronic, or a format generated and sent by wholesaler.
(ii) Prescriptions;
(A) All prescriptions shall be reduced to writing. Prescriptions for brand name drugs with multi-source generics that are not considered preferred brand name drugs by the Department shall contain the certification "medically necessary," shall be received and on file within thirty days after the oral prescription, and shall meet the requirements of Section 9 of this Chapter;
(iii) A signature log in the form specified by the Department;
(iv) Client account records; and
(v) Copies of claim forms.
Section 6. Verification of Client Data. A provider of pharmaceutical services shall comply with the verification of client data requirements of Chapter 3 of the Wyoming Medicaid Rules.
Section 7. DUR Requirements. A provider of pharmaceutical services shall comply with the Drug Utilization Review (DUR) requirements of 42 C.F.R. Part 456 and Chapter 9 of the Board of Pharmacy Rules.
Section 8. Covered Services.
(a) Prescription drugs. Prescription drugs are covered in the quantity prescribed by a practitioner, subject to the dispensing limitations of Section 9 and the exclusions of Section 11.
(b) Refill of prescription. In addition to the criteria specified in subsection (a), a refill of a prescription shall:
(i) Be authorized by the practitioner who originally prescribed the drug;
(ii) Conform to State and Federal laws governing prescription refills; and
(iii) Be within one (1) year of the date of the original prescription.
(c) Brand name drugs. Non-preferred brand name drugs with multi-source generics shall be certified in writing by the prescribing practitioner as medically necessary.
(d) Compound drugs. Compound drugs shall be paid per line item if each ingredient is a prescription or Over-the-Counter (OTC) drug covered pursuant to subsections (a) and (e) and is not classified by the FDA as a Drug Efficacy Study Implementation (DESI) drug. One (1) dispensing fee is paid per compound prescription.
(e) OTC drugs and medical supplies. Select OTC drugs and medical supplies are covered pharmacy services if they:
(i) Are dispensed to a client who is not a resident of a nursing facility, not admitted as an inpatient or outpatient in a hospital, and not occupying a swing bed;
(ii) Are prescribed by a practitioner;
(iii) Are rebatable OTC drugs;
(iv) Have been assigned a National Drug Code (NDC) number; and
(v) Are medically necessary.
(A) The Department shall, from time to time, designate OTC drugs and medical supplies as covered services based on their therapeutic value, clinical consultation with practitioners, and applicable Centers for Medicare and Medicaid Services (CMS) guidelines. The Department shall disseminate current lists of covered OTC drugs and medical supplies to providers through manuals, bulletins, facsimiles, designated websites, or other appropriate means.
Section 9. Dispensing Limitations.
(a) Generic drugs. Practitioners shall prescribe generic drugs except in the following circumstances:
(i) When a brand name drug is medically necessary and the appropriate prior authorization criteria has been met,
(ii) When there is not an AB rated generic available, or
(iii) When the brand name drug is listed on the Department's preferred drug list as preferred instead of the generic.
(b) Quantities dispensed.
(i) Maintenance drugs.
(A) Minimum quantities. Except as provided in subparagraph (C), maintenance drugs shall be dispensed in a quantity sufficient for at least a one (1) month supply.
(B) Maximum quantities. Maintenance drugs shall not be dispensed in an amount which exceeds a ninety (90) day supply.
(C) Less than a one (1) month supply of a maintenance drug may be dispensed to allow a client to be stabilized on a new or adjusted maintenance drug.
(ii) Oral contraceptives. The maximum quantity of oral contraceptive which may be dispensed is a ninety (90) day supply.
(iii) All other drugs. The maximum quantity dispensed for all other conditions shall be a one (1) month supply unless the Department has designated a minimum days supply for a specific drug that exceeds a one month supply.
(c) Days supply. A prescription's day supply must equal the quantity of drug dispensed divided by the daily dose prescribed. A prescription claim will be subject to subsequent recovery if:
(i) The days supply submitted is not supported by the dosing directions as prescribed, or
(ii) The dosing directions are given as "take as directed" and the pharmacist has not taken appropriate action to obtain and document on the prescription the actual dosing directions given by the practitioner.
(iii) Extra Doses. The Department does not pre-emptively pay for extra doses in the anticipation of lost or wasted medication.
(d) Tamper resistant prescription pads. Prescriptions written for Medicaid clients shall be written on tamper resistant prescription pads per Section 7002(b) of the U.S. Troop Readiness, Veterans' Care, Katrina Recovery and Iraq Accountability Appropriations Act of 2007. The law requires that all written, non-electronic prescriptions for Medicaid outpatient drugs shall be executed on tamper resistant pads in order for them to be reimbursable by the federal government. In addition to all current Wyoming Board of Pharmacy requirements for tamper resistant prescription forms, all prescriptions paid for by Wyoming Medicaid shall meet the following requirements to help ensure against tampering:
(i) Written or computer printed prescriptions shall contain all of the following characteristics:
(A) One (1) or more industry recognized features designed to prevent unauthorized copying of a completed or blank prescription or prescription form. In order to meet this requirement, all written or computer printed prescriptions shall contain some type of "void" or "illegal" pantograph that appears if the prescription is copied.
(B) One (1) or more industry recognized features designed to prevent the erasure or modifications of information written on the prescription by the prescriber. This requirement applies only to prescriptions written for controlled substances. In order to meet this requirement, all written or computer printed prescriptions shall contain:
(I) Quantity check-off boxes plus numeric form of quantity values or alpha and numeric forms of quantity values, and
(II) Refill indicator (circle or check number of refills or "NR") plus numeric form of refill values or alpha and numeric forms of refill values.
(C) One (1) or more industry recognized features designed to prevent the use of counterfeit prescription forms. In order to meet this requirement, all written or computer printed prescriptions shall contain security features and descriptions listed on the front and back of the prescription blank.
(ii) In addition to the guidance outlined above, the tamper resistant requirement does not apply when a prescription is communicated by the prescriber to the pharmacy electronically, verbally, or by fax; when a managed care entity pays for the prescription; or, in most situations, when drugs are provided in designated institutional and clinical settings. The guidance also allows emergency fills with a non-compliant written prescription as long as the prescriber provides a verbal, faxed, electronic, or compliant written prescription within seventy-two (72) hours.
(iii) Audits of pharmacies may be performed by the Department to ensure that the above requirements are being followed.
Section 10. Relationship to Other Programs.
(a) This Chapter does not limit the services available to clients under age twenty-one (21) pursuant to Chapter 6 of the Wyoming Medicaid Rules.
(b) This Chapter does not affect services available pursuant to Chapter 29 of the Wyoming Medicaid Rules.
Section 11. Excluded Services. The following prescription drugs are excluded:
(a) Anorexiants, except Amphetamines and derivatives which are prescribed for narcolepsy and hyperkinetic conditions;
(b) Fertility drugs;
(c) Weight gain agents, including androgenic or anabolic steroid agents when used for weight gain;
(d) Cosmetic agents such as Retin-A, provided to clients age twenty-one (21) years or over;
(e) OTC drugs and medical supplies, except as designated in Section 8(e) of this Chapter;
(f) DESI drugs;
(g) Drugs supplied by a manufacturer that has not entered into and does not have in effect a rebate agreement which meets the requirements of 42 U.S.C. § 1396r-8, including any amendments or updates, except as otherwise specified by that Section; and
(h) Any services and supplies included in the per diem which are furnished to a resident of a nursing home, an individual admitted as an inpatient or an outpatient in a hospital, or an individual in a swing bed.
(i) Any drug, supply or service not designated as a covered service under this Chapter.
Section 12. Pharmacy and Therapeutics (P&T) Committee.
(a) Pharmacy Services shall have a P&T Committee to meet the DUR requirements designated in Section 7 of this Chapter. The P&T Committee shall be made up as follows:
(i) At least one third (1/3), but not more than fifty-one percent (51%) physicians;
(ii) At least one third (1/3), but not more than fifty-one (51%) pharmacists; and
(iii) At least one physician's assistant or nurse practitioner.
(b) The responsibilities of the P&T Committee include:
(i) Prospective Drug Utilization Review, including determination of prior authorization criteria in accordance with Section 13 of this Chapter;
(ii) Retrospective Drug Utilization Review including periodic review of client profiles and claims data in order to identify patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care among physicians, pharmacists, or clients, or associated with specific drugs or groups of drugs;
(iii) Provider education programs to include written or live dissemination of information in group or individual settings;
(iv) Review of literature and providing recommendations to Medicaid Pharmacy Services for the purpose of creating the Preferred Drug List in accordance with Section 15 of this chapter;
(v) Providing recommendations and feedback to Medicaid Pharmacy Services regarding pharmacy policy in general; and
(vi) Other duties as requested by the Department.
Section 13. Prior Authorization.
(a) Procedures. A provider seeking reimbursement for services which require prior authorization shall request prior authorization pursuant to the procedures and in the format specified by the Department and disseminated to providers through manuals or bulletins.
(i) Criteria for review. Prior authorization shall be granted if the proposed services:
(A) Are covered services;
(B) Are consistent with the client's diagnosis;
(C) Are medically necessary;
(D) Are cost-effective;
(E) Meet the criteria established by the rules of the Department; and
(F) Are not reimbursable by any third party payer.
(ii) Denial of prior authorization. The Department shall provide written notice of the denial of prior authorization to the provider and the client.
(A) If a request for prior authorization is denied, the provider may submit a revised request for prior authorization or additional documentation, as necessary, for the Department to reconsider the matter; or
(B) The provider or client may request reconsideration of the denial of prior authorization pursuant to Chapter 4 of the Wyoming Medicaid Rules. If a timely request for reconsideration is made, the services shall be furnished for up to sixty (60) days while the Department reconsiders the denial. The Department shall provide a written notice of its decision on reconsideration.
(C) The denial of prior authorization precludes Medicaid reimbursement for the services in question, except to the extent services are furnished pending reconsideration pursuant to subsection (B).
(iii) Failure to timely request prior authorization. The failure to obtain prior authorization before providing services requiring authorization precludes Medicaid reimbursement for such services.
(iv) Effect of prior authorization. Granting prior authorization shall constitute approval for the provider to receive Medicaid reimbursement for the approved services to be furnished, subject to the other requirements of this and the other Medicaid rules of the Department and post payment review. Prior authorization is not a guarantee of the client's eligibility or a guarantee of Medicaid payment.
(b) Services that require prior authorization.
(i) This and other rules of the Department specify services that require prior authorization. Notice of services requiring prior authorization can be found in manuals, bulletins, faxes, and designated websites published by the Department.
(ii) Designation of additional services. The Department may designate additional services that require prior authorization pursuant to this paragraph.
(A) Request for designation. The Department, the P&T Committee, a provider, a client, an organization of providers or clients, or any other person, may request that the Department consider designating a service as requiring prior authorization. Except when requested by the Department, such a request shall be delivered to the Department in the form and manner specified by the Department.
(B) Referral to the P&T Committee. Any request for designation received by or made by the Department shall be referred to the P&T Committee.
(C) Review by P&T Committee. The P&T Committee may review a referral received from the Department to designate a service as requiring prior authorization. In reviewing any such referral, the P&T Committee may consider the:
(I) Clinical efficacy of the service as demonstrated by:
(1.) peer-reviewed clinical literature;
(2.) nationally recognized practice standards; and
(3.) the consensus of the members of the P&T Committee;
(II) Cost effectiveness of the service;
(III) Potential for over-utilization of the services;
(IV) The availability of lower cost alternatives; and
(V) Comments received from interested parties for services which are under consideration for designation as requiring prior authorization.
(D) Recommendation to the Department. The P&T Committee shall make a recommendation to the Department about whether it should designate a service as requiring prior authorization. Such recommendation shall include the criteria to be used in determining whether to prescribe such services.
(E) Consideration of recommendation. The Department may consider the recommendation of the P&T Committee in determining whether to designate services as requiring prior authorization. The Department may also consider information from CMS and other sources of clinical information which it deems relevant to the determination. The Department shall not be bound by the recommendation of the P&T Committee, but the Department shall not designate a service as requiring prior authorization until it has received the P&T Committee's recommendation.
(iii) Notice of services which require prior authorization.
(A) The Department shall, from time to time, disseminate a current list of services which require prior authorization to providers through manuals, bulletins, facsimiles, designated websites, or other appropriate means.
(B) If additional services are designated pursuant to this section, the Department shall disseminate notice of the additional services which require prior authorization to providers through manuals, bulletins, facsimiles, designated websites, or other appropriate means.
Section 14. Copayment. There is no copayment requirement for services provided under this chapter pursuant to Wyoming Medicaid Rule Chapter 26.
Section 15. Preferred Drug List.
(a) A service may be placed on the Preferred Drug List if the service:
(i) Is a covered service;
(ii) Is cost-effective; and
(iii) Has been reviewed by the P&T Committee.
(b) Services that require listing on the Preferred Drug List.
(i) Review by the Pharmacy and Therapeutics (P&T) Committee. The P&T Committee shall review services of the same therapeutic class in order to determine if one (1) or more services are more clinically effective than others in the same class, or if all services in the class are determined to be clinically equivalent. In reviewing therapeutic classes, the P&T Committee shall consider the clinical efficacy of the services as determined by consensus of the P&T Committee utilizing:
(A) Evidence-based research reports;
(B) Peer-reviewed clinical literature; and
(C) Nationally recognized practice standards.
(ii) In order to solicit comments, the P&T Committee may provide notice to interested parties of services which are under consideration for designation on the Preferred Drug List and the criteria applied to such services.
(iii) Recommendation to the Department. The P&T Committee shall make a recommendation to the Department about whether one (1) or more services are more clinically safe or effective than others in the same therapeutic class.
(iv) Consideration of recommendation. The Department may consider the recommendation of the P&T Committee in determining whether to assign services to the Preferred Drug List. The Department may also consider information from CMS and other sources of clinical information which it deems relevant to the determination. The Department shall not be bound by the recommendations of the P&T Committee, but the Department shall not assign services to the Preferred Drug List until it has received and considered the P&T Committee's recommendation.
(c) Once the Department has chosen services for the Preferred Drug List for a therapeutic class, the Department will refer all non-preferred services to the P&T Committee for recommendations on prior authorization, and the criteria to be used for those services.
(i) As new drugs in a therapeutic class are introduced, the Department may change or update prior authorization criteria to include the new services until the P&T Committee can make recommendations to the Department in regard to the services.
(ii) In the event the Department changes the preferred service for a therapeutic class, the Department may ask the P&T Committee to review and update the prior authorization criteria based upon changes to the non-preferred services.
(d) The Department may make changes to the Preferred Drug List for a therapeutic class based upon recommendations from the P&T Committee or changes in pricing.
(e) Notice of services on the Preferred Drug List. If additional services are designated pursuant to this section, the Department shall disseminate notice of the additional services on the Preferred Drug List to providers through bulletins, manuals, or a designated website.
(f) Procedure for requesting other service coverage. A provider seeking reimbursement for services not listed as the Preferred Drug in its therapeutic class may request prior authorization pursuant to the procedures as defined in Section 13.
Section 16. Medicaid Allowable Payment.
(a) Reimbursement Limits. Except as specified in subsection (b) of this section, the Medicaid allowable payment for pharmaceutical services shall be of the calculation below with the lowest reimbursement:
(i) The National Average Drug Acquisition Cost (NADAC) of the ingredient(s) plus the dispensing fee specified in subsection (d);
(ii) When no NADAC is available, Medicaid shall substitute Wholesale Acquisition Cost (WAC) + 0% plus the dispensing fee specified in subsection (d);
(iii) When neither NADAC nor WAC are available, Medicaid shall substitute Average Wholesale Price (AWP) - 11% plus the dispensing fee specified in subsection (d);
(iv) The Federal Upper Limit (FUL) plus the dispensing fee specified in subsection (d);
(v) The Department set maximum allowable cost for specified drugs or drug categories plus the dispensing fee specified in subsection (d);
(vi) The ingredient cost submitted by the pharmacy on the claim plus the dispensing fee specified in subsection (d);
(vii) The gross amount due; or
(viii) The provider's usual and customary charge.
(b) Covered entities purchasing drugs under Section 340B of the Public Health Service Act. Entities that purchase products under Section 340B of the Public Health Service Act shall request, in writing to use these drugs for Wyoming Medicaid clients. 340B entities who are granted such an arrangement shall bill Medicaid no more than their actual acquisition cost (AAC) for the drug and shall be reimbursed no more than the AAC plus the dispensing fee specified in subsection (d). 340B entities that fill Wyoming Medicaid client prescriptions with drugs not purchased under Section 340B of the Public Health Service Act will be reimbursed in accordance with subsection (a).
(c) Pharmacies which are operating as contract pharmacies in the 340B program shall not utilize drugs purchased under Section 340B of the Public Health Service Act for Wyoming Medicaid clients.
(d) Dispensing fee. Except as specified below, the dispensing fee shall be the lower of the provider's usual and customary dispensing fee or the dispensing fee specified in (i) or (ii) below. The dispensing fee shall be adjusted as specified in subsection (f).
(i) Physicians. The dispensing fee for physicians who perform pharmacy services shall be two dollars ($2.00) per prescription.
(ii) Pharmacies. The dispensing fee for pharmacies shall be ten dollars and sixty-five cents ($10.65) per prescription or compound.
(e) Adjustment of dispensing fee. The dispensing fee shall be adjusted pursuant to subsection (f) when necessary to:
(i) Enlist enough providers so that pharmaceutical services are available to clients to the extent that those services are available to the general population; and
(ii) Ensure that payments are consistent with efficiency, economy, and quality of care.
(f) Method of adjusting dispensing fee. The dispensing fee shall be adjusted as follows:
(i) The Department shall conduct a usual and customary survey which may include a review of other insurance payers in-state, and Medicaid pharmacy programs in surrounding areas.
(ii) Using the data collected pursuant to subsection (i), the Department may redetermine the fee.
(iii) The Department may use an appropriate indicator of pharmacy costs to adjust the dispensing fee.
(iv) The Department shall notify providers of any adjustment in the dispensing fee through manuals, bulletins, facsimiles, designated websites, or other appropriate means.
(g) Prescription splitting. If a provider does not have sufficient supplies of a drug to fill a prescription completely, the provider may fill the prescription to the extent possible and claim a dispensing fee. When the balance of the prescription is dispensed, the provider may not seek an additional dispensing fee.
(h) Proof of delivery.
(i) A Provider shall keep a dated log that maintains a record of when a client or client's representative picks up, or takes delivery of, every prescription paid for by the Department. All signatures shall be original at the time each prescription is dispensed; electronic or other methods of reproducing past signatures are not acceptable. The signature log can be either manual or electronic and should comply with all Health Insurance Portability and Accountability Act (HIPAA), State, and Federal regulations.
(ii) Prescriptions that are mailed to clients shall be recorded in a dated log that shall contain the prescription number, date of fill, client's name and address that the prescription is mailed to as well as the name of the person mailing or delivering the mail to the mail carrier. If a single prescription to be mailed has a dollar amount paid by the Department exceeding five hundred dollars ($500.00), a receipt that indicates that the prescription was mailed shall be obtained and attached to the log.
(iii) The above requirements also apply to clients living in nursing or institutional facilities.
Section 17. Submission and Payment of Claims. Except as otherwise specified in this Chapter, submission and payment of claims shall be pursuant to the provisions of Chapter 3 of the Wyoming Medicaid Rules.
Section 18. Recovery of Overpayments. The Department may recover overpayments pursuant to Chapter 16 of the Wyoming Medicaid Rules.
Section 19. Audits. Audits are subject to the provisions of Chapter 16 of the Wyoming Medicaid Rules.
Section 20. Reconsideration. A provider may request reconsideration of the decision to recover overpayments pursuant to Chapter 16 of the Wyoming Medicaid Rules.
Section 21. Disposition of recovered funds. The Department shall dispose of recovered funds pursuant to the provisions of Chapter 16 of the Wyoming Medicaid Rules.
Section 22. Interpretation of Chapter.
(a) The order in which the provisions of this Chapter appear is not to be construed to mean that any one provision is more or less important than any other provision.
(b) The text of this Chapter shall control the titles of its various provisions.
Section 23. Superseding Effect. This Chapter supersedes all prior rules or policy statements issued by the Department, including manuals and bulletins, which are inconsistent with this Chapter.
Section 24. Severability. If any portion of these rules is found invalid or unenforceable, the remainder shall continue in full force and effect.
Section 25. Incorporation by Reference.
(a) For any code, standard, rule, or regulation incorporated by reference in these rules:
(i) The Department has determined that incorporation of the full text in these rules would be cumbersome or inefficient given the length or nature of the rules;
(ii) The incorporation by reference does not include any later amendments or editions of the incorporated matter beyond the applicable date identified in subsection (b) of this section; and
(iii) The incorporated code, standard, rule, or regulation is maintained at the Department and is available for public inspection and copying at cost at the same location.
(b) Each rule or regulation incorporated by reference in these rules is further identified as follows:
(i) Referenced in Sections 3 and 7 of this Chapter is Chapter 9 of the Board of Pharmacy Rules, incorporated as of the effective date of this Chapter and can be found at https://rules.wyo.gov/.
(ii) Referenced in Sections 3 and 7 of this Chapter is 42 C.F.R. Part 456, incorporated as of the effective date of this Chapter and can be found at https://ecfr.gov.
(iii) Referenced in Sections 3, 9, 12, and 15 of this Chapter is the Preferred Drug List, incorporated as of the effective date of this Chapter and can be found at www.wymedicaid.org.
(iv) Referenced in Section 9 of this Chapter is Section 7002(b) of the U.S. Troop Readiness, Veterans' Care, Katrina Recovery and Iraq Accountability Appropriations Act of 2007, incorporated as of the effective date of this Chapter and can be found at https://www.congress.gov.
(v) Referenced in Section 11 of this Chapter is 42 U.S.C. § 1396r-8, incorporated as of the effective date of this Chapter and can be found at https://www.gpo.gov.
(vi) Referenced in Section 16 of this Chapter is Section 340B of the Public Health Service Act, incorporated as of the effective date of this chapter and can be found at https://www.federalregister.gov.