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FAQs about DMAP pharmacy pricing and reimbursement
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Q. What is the Oregon Maximum Allowable Cost?
A. The Oregon Maximum Allowable Cost (MAC), or the maximum amount that the Division of Medical Assistance Programs (DMAP) will reimburse for prescribed drugs, is determined by DMAP’s claims processing company. First Health Services 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. Click here for the current OMAC
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Q. How do I research specific MACs?
A. Follow these steps:
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Complete this form and send it to:
Rebate/MAC Department
Fax: 804-217-7911, or
E-mail: Rebate@FHSC.com
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Q. How often does DMAP update the Average Wholesale Price (AWP) of covered medications?
A. DMAP updates the price files from First DataBank weekly.
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Q. What is the lag time between when the update is released from First DataBank and the time it is entered into DMAP’s computer system?
A. First Health Services loads the file from FDB every Thursday. There is no lag time uploading that information into the Point of Sale (POS) system.
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Q. Do the AWP updates apply retroactively?
A. The drug file is updated with the dates and prices that are given to DMAP from First DataBank. 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.
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Q What is the Plan Drug List (PDL), also known as Practitioner-Managed Prescription Drug Plan (PMPDP)?
A. Click here for an overview of the PMPDP Plan Drug List.
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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.
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Q. When is the next Pharmacy and Therapeutics (P&T) Committee meeting?
A. DMAP does not have a Pharmacy and Therapeutics (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.
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Q. Does DMAP/OHP cover [a particular] drug?
A. These rules apply to patients in the fee-for-service (open-card) program only. For patients enrolled in OHP managed care plans, refer to the reimbursement policies of the individual’s plan.
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Q. How do I get a drug on the PDL?
A. 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.
Steps of the process:
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DMAP reviews the HRC recommendations and the cost of each of the drugs in the classes and determines which drugs will be listed on the PDL.
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Q. When will my new or OTC drug be covered by DMAP?
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These rules apply to patients in the fee-for-service (open-card) program only. For patients enrolled in Medicaid managed care plans, refer to the reimbursement policies of the individual’s plan.
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If a drug is administered by a physician, identified by J-code, HCPCS, coverage is dictated by the Medical Surgical Rules.
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NDC codes must be added to the First DataBank drug file and then loaded to the First Health PBM claim processing system. Upon market release, there may be a one week delay to be added to First DataBank and another week for loading to the PBM.
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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.
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Drugs must be distributed by a company participating in the Medicaid rebate program. See Medicaid Rebate List.
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Drugs must be used for a covered Oregon Health Plan diagnosis. See the Prioritized List. Some drugs that are used exclusively for not covered diagnoses are excluded from coverage (e.g. acne drugs).
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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.
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Coverage is also listed in ePocrates, a free formulary hosting service. This is updated approximately weekly.
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DMAP does have a voluntary (not enforced) Plan Drug List (Practitioner-Managed Prescription Drug Plan).
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Q. How does DMAP reimburse pharmacies for drugs?
A. The rules and procedures for DMAP claim submissions are in the Pharmacy rulebook and supplemental information online. The following rules apply to OHP clients who receive services on a fee-for-service (open-card) basis only. For patients enrolled in Medicaid managed care plans, refer to the reimbursement policies of the individual’s plan.
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Drugs must be distributed by a company participating in the Medicaid rebate program. See Medicaid Rebate List.
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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:
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Usual and Customary (U/C or billed amount),
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State Maximum Allowable Cost (SMAC),
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Federal Upper Limit (FUL) or
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Average Wholesale Price (AWP)-15% as reported by First DataBank and specific to NDC billed.
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A $3.50 dispensing fee is also paid. Patient co-pays are deducted from reimbursement.
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Q. How does DMAP reimburse pharmacies for compound drugs?
A. 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.
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Q. How does DMAP reimburse pharmacies for drugs dispensed to residents in long-term care facilities?
A. If an OHP client is 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 NH List (at the bottom of the Web page under the Miscellaneous heading).
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Q. How does DMAP reimburse pharmacies for mental health drugs?
A. Mental health drugs are “carved-out” of the all OHP managed care contracts. This means that for all Oregon Health Plan (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.
Click here for fee-for-service drug billing reimbursement and coverage rules.
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