|
FAQs about DMAP pharmacy pricing and reimbursement
This page provides information about DMAP’s policies for fee-for-service pharmacy reimbursement. For patients enrolled in OHP managed care plans, refer to the reimbursement policies of the individual’s plan. The rules and procedures for DMAP claim submissions are in the Pharmacy rulebook and supplemental information.
_________________________________________________________________________________________
Q. What is the Oregon Maximum Allowable Cost (OMAC)?
A. The OMAC is the maximum amount that DMAP will reimburse for prescribed drugs. This amount is determined by DMAP’s Pharmacy Benefit Manager (PBM), the company that processes all fee-for-service pharmaceutical claims. The PBM also determines the maximum allowable cost on selected multiple-source drug designation when a bioequivalent drug product is available from at least two wholesalers serving the state of Oregon. You can access the current OMAC by GCN (PDF) or by NDC (zip file).
Back to top
Q. How do I research specific MACs?
A. To research or dispute a drug price, fill out the following form and fax it to the Oregon Pharmacy Call Center.
Back to top
Q. How often does DMAP update the Average Wholesale Price (AWP) of covered medications?
A. DMAP updates the price files from First DataBank weekly. The file is downloaded from FDB every Thursday. There is no lag time uploading that information into the Point of Sale (POS) system. All prices are effective to the date supplied by First DataBank.
However, if the drug manufacturer changed the price on the first of the month, DMAP changed the AWP on the 15th of the month, and the pharmacy submited the claim on the 4th of the month, the pharmacy may reverse the claim and re-bill DMAP, as long as all other rules and guidelines are followed.
Back to top
Q What is the Plan Drug List (PDL)? How do I get a drug on the PDL?
A. Click here for an overview of the PMPDP Plan Drug List. It is important to note that the list is not enforced. It is voluntary only. The Pocket Drug Guide, Epocrates, and OSU's educational lettering are the only methods used to promote the PDL.
Back to top
Q. When and where is the next Drug Use Review Board meeting and how can I get notified of future meetings?
A. Click here for DUR Board meeting notices. You can also sign up for e-notification of meetings posted to this page. Additional information is posted and archived here.
Back to top
Q. When is the next Pharmacy and Therapeutics (P&T) Committee meeting?
A. DMAP does not have a P&T committee. The Health Resources Commission (HRC) evaluates drugs for inclusion on the Plan Drug List (Practitioner-Managed Prescription Drug Plan). HRC meeting dates and agendas are posted to their Web site. Click here for more information about the PDL.
Back to top
Q. Does DMAP/OHP cover [a particular] drug?
A. If a drug is administered by a physician, identified by J-code, HCPCS, coverage is dictated by the Medical Surgical Rules. If a drug in dispensed by pharmacies using an NDC, it is covered by Pharmaceutical Rules.
- NDCs must be added to the First DataBank drug file and then loaded to the PBM claim processing system. Upon market release, there may be a one week delay to add new NDCs to First DataBank and another week for loading them to the PBM.
- Some OTC products do not have a valid NDC number assigned. A pharmacy will get a “non-matched NDC” error. Often these products are classed as nutritional supplements and not as drugs by the FDA. The product ID on the package could be a UPC or other identifying number, but it is not an NDC if it is not listed in First DataBank. DMAP cannot cover products that do not have a valid NDC listed in First DataBank. The pharmacy may have another product on shelf that has a valid NDC that DMAP does cover.
- Drugs must be distributed by a company participating in the Medicaid Drug Rebate Program. See Medicaid Rebate List.
- Drugs must NOT be on the DESI List.
- Some drugs that are used exclusively for not covered diagnoses are excluded from coverage (e.g. acne drugs).
- All drugs that require Prior Authorization are listed in the rulebook. Any changes to this rule follows a standard Oregon Administrative Rulemaking process. You can sign up for notification of proposed rules changes.
- Coverage is also listed in Epocrates, a free formulary hosting service. This is updated approximately weekly.
- Drugs must be used for a covered Oregon Health Plan diagnosis. See the Prioritized List.
- -AND-
- Drugs must be used in accord with Drug Use Review (DUR) Board recommended criteria for use.
- DMAP does have a voluntary (not enforced) Plan Drug List (Practitioner-Managed Prescription Drug Plan).
- See new drugs in PDL classes.
- Non-preferred drugs from the Plan Drug List are not restricted unless they meet criteria listed above (e.g., require PA, are for not-covered conditions, etc.).
Back to top
Q. How does DMAP reimburse pharmacies for drugs?
A. Federal Medicaid law requires that services and products provided to Medicaid clients are reimbursed at Estimated Acquisition Cost (EAC). Therefore, drugs dispensed by retail pharmacies are reimbursed at the lower of:
Usual and Customary (U/C or billed amount), State Maximum Allowable Cost (SMAC), Federal Upper Limit (FUL) or Average Wholesale Price (AWP)-15% as reported by First DataBank and specific to NDC billed.
A $3.50 dispensing fee is also paid. Patient co-pays are deducted from reimbursement.
For compound drugs:
Each component of a compound prescription, as defined in OAR 410-121-0140 (5), must be billed separately and is paid as above, but with a single $7.50 dispensing fee. Any reimbursement received from a third party for compounded prescriptions must be split and applied equally to each component.
For clients in a long-term care facility or community-based waiver facility and served by a qualified pharmacy:
The dispensing fee is $3.91 and reimbursement is the lower of U/C, SMAC, FUL or AWP-11%. Certain drugs are part of the facility capitation payments and not reimbursed via drug claim. See Nursing Home List.
For mental health drugs:
These drugs are “carved-out” of the all OHP managed care contracts. This means that for all OHP clients (those enrolled in managed care and those who? are not) mental health drugs are paid for on a fee-for-service basis.
For the purposes of the above payment policy, “mental health drugs” are defined in the managed care contracts as those drugs classified by First DataBank in the Standard Therapeutic Class equal to Class 07 (Ataractics, Tranquilizers), Class 11 (Psychostimulants, Antidepressants). In addition, lamotrigine and divalproate are also considered mental health drugs.
Back to top
Q. Who can DMAP reimburse for drugs?
A. DMAP only reimburses enrolled pharmacy providers (type 48) for drugs billed by NDC. Pharmacies can bill for drugs in the following formats:
- Point of Sale (electronic billing by a pharmacy)
- Paper (NCPDP Universal Claim Form 5.1 – Used for all pharmacy services except DME and home enteral/pareteral nutrition and IV services identified with a 5-digit HCPCS)
- Pharmacy Web Claim (through the Provider Web Portal at https://www.or-medicaid.gov)
DMAP currently does not reimburse DME providers (type 36) who bill DMAP for drugs using the professional claim format (CMS-1500 or 837P). Please refer to EPIV provider guidelines for services billed by a DME provider type.
If a drug is administered by a physician, identified by J-code, HCPCS, coverage is dictated by the Medical Surgical Rules. If a drug is dispensed by pharmacies using an NDC, it is covered by Pharmaceutical rules.
Back to top
Q. How does DMAP reimburse pharmacies for EPIV services?
A. Pharmacies can bill DMAP for oral nutritional supplements using the pharmacy claim format (Point of Sale or UCF 5.1) only when the supplement has a valid NDC. Prior authorization is required for all oral nutritional supplements.
- To request PA, complete the DMAP 3978 form and fax to the Oregon Pharmacy Call Center at 888-346-0178.
- Or, call the Oregon Pharmacy Call Center at 888-202-2126 with the diagnosis code and your NPI.
Nutritional formula administered by enteral tube is not available for billing through Point of Sale.
- Only enrolled DME providers (type 36 – Miscellaneous Medical Provider) can bill for these items using the professional claim format (CMS-1500 or 837P).
- For more information about billing for home enteral nutritional services, refer to OAR 410-148-0260 – Home Enteral Nutrition in the EPIV provider guidelines.
Back to top
Q. Where can I find the formulary list for OHP managed care plans?
A. You will need to contact the managed care plan. Some plans have their formularies available through Epocrates, where you can also find the Plan Drug List (listed as "Oregon Medicaid - open card"). Quick lists of plan addresses and telephone numbers are available at this link.
Back to top
Q. What are the copayment requirements for OHP clients?
A. Fee-for-service OHP Plus (BMH) and OHP with Limited Drug (BMD) clients have copayments. For more information, see the Frequently Asked Questions about Copayments. Clients in an OHP managed care plan are not required to pay copayments.
|
