State Maximum Allowable Cost (SMAC) Implementation

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 ___________________
  ____