Archive: FAQs about DMAP pharmacy pricing and reimbursement prior to Jan. 1, 2011

This page provides information about DMAP’s policies for fee-for-service pharmacy reimbursement according to Oregon Maximum Allowable Cost (OMAC) rates effective prior to Jan. 1, 2011.

As of Jan. 1, 2011, DMAP reimburses according to Average Actual Acquisition Cost (AAAC) rates. For frequently asked questions about AAAC pharmacy reimbursement, go to DMAP's new prescription coverage FAQ.

• What is the Oregon Maximum Allowable Cost (OMAC)?
• How do I research specific MACs?
• How often does DMAP update the Average Wholesale Price of covered medications?

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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).

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.

• Click here for the current OMAC Dispute Resolution and Research Request form
• Fax it to the Oregon Pharmacy Call Center, Fax: 888-346-0178

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.

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 410-121-0146 (7) and 410-121-0160 (3) 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.

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