Transcript SMAC -Presentation March 10, 2010

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
Than
• Usual & Customary Charges (Price from Pharmacy Claim)
•
OR
• DC Discount Price (AWP-10%) + Dispensing fee ($4.50)
•
OR
• Federal Upper Limit Price + Dispensing fee ($4.50)
Logic
First Data Bank (FDB)
Pricing Definitions
DHCF uses Blue Book AWP Unit Price displayed as AWP in ACS Point-ofSale (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
• DC Discount Price (AWP-10%) + Dispensing fee ($4.50)
OR
Lesser •
Than
Logic
• Federal Upper Limit Price + Dispensing fee ($4.50)
•
OR
• State Maximum Allowable Cost + Dispensing fee ($4.50)
Sample Claims
Pharmacy submits claim A
• Submit Ingred $2.00
• DC Discount
Pharmacy submit claim B
• Submit Ingred $1.00
• DC Discount
– AWP $2.00 -10% = $1.80
– AWP $200-10% = $1.80
• FUL $1.50
• SMAC $1.25
• FUL $1.50
• SMAC $1.25
Sample Claims
Pharmacy submits claim A
• Submit Ingred $2.00
• DC Discount
Pharmacy submit claim B
• Submit Ingred $1.00
• DC Discount
– AWP $2.00 -10% = $1.80
– AWP $200-10% = $1.80
• FUL $1.50
• SMAC $1.25
• FUL $1.50
• SMAC $1.25
• POS system will price
claim with SMAC
• POS system will price
claim with Submit
Ingred
DC SMAC Pricing Inquiry Form
GCN
NDC Code
Manufacturer
Drug Name
Package
Size
Dosage
Form
Wholesaler
Lowest Price
Attainable
Date of Price
Search
SMAC
Reimbursement
Amount
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:_________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Email DC SMAC Drug Pricing Inquiry to [email protected]
Or fax to 202-906-8399 ATTN: PBM Dept
03/2010