Overview of the Virginia Medicaid Program

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  Pharmacy Program Initiatives Threshold, Mandatory Generic, Maximum Allowable Cost (MAC)Javier Menendez, RPh Pharmacy Manager Department of Medical Assistance Services


PDLThreshold/ PolyPharmacyProDUR EnhancementsPDLOTC Drug ListPharmacy ProgramsMACMandatory Generic


Threshold Program This program was required by the 2003 Appropriations Act, which directed the department to review recipients’ drug profiles after a threshold of nine prescriptions. The purpose of this program is to improve the health and safety of recipients and offer DMAS enhanced opportunities to improve quality by: Reducing potential and actual severe adverse reactions to drugs, Retrospectively monitoring high drug utilization by Medicaid recipients, Providing pharmacists with additional support for Drug Utilization Review, Enhancing continuity and coordination of care in the use of prescription drugs, and Identifying clinical abuse/misuse and fraud of prescriptions.


Threshold Program Two-Step Program Step-one: Coordination of Care Initiative Patients with multiple prescriptions from multiple medical providers dispensed from multiple pharmacy providers (Implemented October 1, 2004) Step-two: Threshold/Polypharmacy Program Retrospective review of all patients with greater than 9 prescriptions in 30 days (Implemented October 15, 2004)


Coordination of CareThis initiative would use the following criteria (for a 30 day period) to identify recipients with potential coordination of care issues: Prescriptions filled at ≥ 3 different pharmacies Prescriptions written by ≥ 3 different prescribers Received ≥ 6 prescriptions 1307 letters to prescribers involving 412 recipients To determine the impact of the initiative on prescription volume and prescription costs, the identified recipients will be compared after six months to a group of recipients with similar prescription utilization.


Threshold - First 10 days


Threshold - First 10 days generated 12 letters


PDLThreshold/ PolyPharmacyProDUR EnhancementsPDLOTC Drug ListPharmacy ProgramsMACMandatory Generic


BackgroundWhat is a Brand name drug? A brand name drug is an innovator drug that holds a patent to prevent other manufacturers from copying and is usually available from a single source or one manufacturer. What is a Generic drug? A generic drug is a copy of a brand name drug. It is the same medicine with the same active ingredients as the brand name drug, but usually made by another company at a less expensive cost. What is a Multi-source drug? Multi-Source drug is a drug that is made by both a brand name manufacturer and is also available from several generic manufacturers.


Mandatory Generic ProgramPrevious to September 1st 2004, this edit messaged the dispensing pharmacist to substitute with the generic, most commercial insurers have the same edit. 11.74% of total claims processed in calendar year 2003 were filled with multi-source brand name drugs Effective September 1st, 2004 , ALL multi-source prescriptions require a DAW of “1” (brand necessary) for claim to adjudicate for a brand name drug


2003 Results


2004 Results


PDLThreshold/ PolyPharmacyProDUR EnhancementsPDLOTC Drug ListPharmacy ProgramsMACMandatory Generic


NomenclatureMAC- Maximum allowable cost (also known as VMAC) FUL- Federal Upper limit (federal-MAC) AWP- Average Wholesale Price WAC- Wholesale Acquisition Cost U & C- Usual and Customary- Price charged to paying customers


Current VMACCurrent Virginia MAC based on Virginia Voluntary Formulary Pricing methodology = 75th percentile and 60th percentile for unit-dose drugs “Lower Of Logic” applied to determine the price paid(AWP-10.25%, FUL, MAC, Usual & Customary) Most claims use the FUL price, because current MAC is higher Great opportunity for improvement


Key MAC Program Notes30-60 days notice to pharmacy providers Pro-active work with VaPHA and select pharmacy providers in September to facilitate provider acceptance Easy Dispute Resolution Process (phone, fax, email) Easy access to MAC list through Mailing and Website Complete MAC list (800+ drugs) in easy to read and understand format IT coordination with Optima-FHSC-VAMMIS Reporting framework with DMAS policy department Projected utilization data on target for estimated budget savings


Dispute Resolution ProcessThe intent of the MAC (maximum allowable cost) program is to reimburse providers fairly based on accurate generic drug costs. If a provider discovers that the MAC price does not accurately reflect the drug cost, the provider should explore alternative manufacturers or wholesalers that more accurately reflect the MAC price. If there are no manufacturers or wholesalers that are at or below the established MAC price, the providers may request a review for resolution. The providers may call 1-866-312-8467, or fax the designated form to 1-866-312-8470 or e-mail disputeresolution@dmas.virginia.gov. with dispute resolution requests with the proper information; NDC, drug name, strength and dosage form, manufacturer, package size, wholesaler, lowest price found and search date. All the information will be researched and the appropriate action taken.   Providers will be notified of the receipt of their dispute resolution request within one business day. A resolution and notification to the provider will take place within three business days. The providers will either receive a notice stating that there has been confirmation of alternative manufacturers or wholesalers who have the product available at or below the MAC price, or the MAC price will be adjusted accordingly to reflect the collected data. The revised price will be effective from the date of the request. Providers may reverse and resubmit all affected claims made from the effective date forward. The MAC list will be updated monthly and can be found and downloaded from our website at www.dmas.virginia.gov.


MAC Pricing For GenericsAt least 41 other state Medicaid programs utilize MAC pricing for generics MAC pricing is used throughout commercial insurance market State Medicaid programs and private insurers vary in how aggressive they are in setting their MAC pricing The MAC that is set for each drug must be reviewed and updated periodically to ensure appropriate pricing DMAS estimates the net savings for its proposed MAC program to be $5.15 million (GF) in each of the 2004-2006 biennium

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Last Updated: 8th March 2018

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