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State Maximum Allowable Cost (SMAC) Implementation

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.

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State Maximum Allowable Cost (SMAC) Implementation

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

  2. DHCF Pharmacy ProgramHighlights • Point of Sale (POS) claims processing system • DC Medicaid fee-for-service program for eligible beneficiaries

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

  4. POS Pharmacy Claims Current Price Structure

  5. 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.

  6. 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

  7. 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

  8. POS Pharmacy Claims Rule Change Price Structure

  9. Sample Claims Pharmacy submits claim A • Submit Ingred $2.00 • DC Discount • AWP $2.00 -10% = $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

  10. Sample Claims Pharmacy submits claim A • Submit Ingred $2.00 • DC Discount • AWP $2.00 -10% = $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

  11. 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:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Email DC SMAC Drug Pricing Inquiry to dcrph@acs-inc.com Or fax to 202-906-8399 ATTN: PBM Dept 03/2010

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