State Maximum Allowable Cost (SMAC) Implementation Updates and Changes to DC Point-of-Sale Pricing Structure

DHCF Pharmacy Program Highlights Point of Sale (POS) claims processing system DC Medicaid fee-for-service program for eligible beneficiaries

SMAC Objectives Review current pricing structure Review national database pricing definitions Overview of new pricing structure Pharmacy Provider pricing inquiry form

POS Pharmacy Claims Current Price Structure Lesser Usual & Customary Charges (Price from Pharmacy Claim) OR Than DC Discount Price (AWP-10%) + Dispensing fee ($4.50) OR Logic Federal Upper Limit Price + Dispensing fee ($4.50)

First Data Bank (FDB) Pricing Definitions DHCF uses Blue Book AWP Unit Price displayed as AWP in ACS Point-of- Sale (POS) system FDB has announced that it will stop publishing the Blue Book AWP field for all drugs no later than September 26, 2011.

First Data Bank (FDB) Pricing Definitions DHCF uses Federal Financing Participation Upper Limit Price (FUL) displayed as FMAC in ACS Point-of-Sale (POS) system

First Data Bank (FDB) Pricing Definitions DHCF uses Wholesale Acquisition Cost (WAC) displayed as both WNP (package price) and WNU (unit price) in ACS Point-of-Sale (POS) system

POS Pharmacy Claims Rule Change Price Structure New Usual & Customary Charges (Price from Pharmacy Claim) OR Lesser DC Discount Price (AWP-10%) + Dispensing fee ($4.50) OR Than Federal Upper Limit Price + Dispensing fee ($4.50) OR Logic State Maximum Allowable Cost + Dispensing fee ($4.50)

Sample Claims Pharmacy submits claim A Submit Ingred $2.00 DC Discount – AWP $ % = $1.80 FUL $1.50 SMAC $1.25 Pharmacy submit claim B Submit Ingred $1.00 DC Discount – AWP $200-10% = $1.80 FUL $1.50 SMAC $1.25

Sample Claims Pharmacy submits claim A Submit Ingred $2.00 DC Discount – AWP $ % = $1.80 FUL $1.50 SMAC $1.25 POS system will price claim with SMAC Pharmacy submit claim B Submit Ingred $1.00 DC Discount – AWP $200-10% = $1.80 FUL $1.50 SMAC $1.25 POS system will price claim with Submit Ingred

DC SMAC Pricing Inquiry Form Claim Information DOS: _______________RX #: _______________________ Pharmacy Information Pharmacy NPI Number_______________________Pharmacy Medicaid ID________________ Pharmacy Printed Name______________________Store Name_________________________ Pharmacist Signature________________________Store Address_______________________ Store Phone Number________________________Store Address_______________________ Store Fax Number__________________________Store City, Zip_______________________ Comments:_________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ DC SMAC Drug Pricing Inquiry to Or fax to ATTN: PBM Dept 03/2010 GCNNDC CodeManufacturerDrug Name Package Size Dosage Form Wholesaler Lowest Price Attainable Date of Price Search SMAC Reimbursement Amount