AAC FAQs
State Maximum Allowable Cost (MAC)
Frequently Asked Questions
- What is a State Maximum Allowable Cost (MAC)?
- How was the State MAC list developed?
- When will the State MAC list begin to be used?
- Will the State MAC list be updated?
- Whom may I contact with questions regarding this initiative?
- What is the process to follow if I would like the Department to review a current State MAC Price?
- Is the Dispensing Fee changing based on the changes in the State MAC?
- Where are the Colorado Medicaid Rules for Pharmaceutical Reimbursement located?
- What Training is Available to Providers for Billing Questions?
- Can a Pharmacy charge a Medicaid client for the cost of the drug?
- How does the Pharmacy know what the payment is based on?
- Where can we get the WAC prices that the Department will be using for the methodology?
- Will the average acquisition cost identified be related to the CMS acquisition cost survey process?
- Will there be any need for the pharmacy to change the pricing information submitted to CO Medicaid?
- Is Synagis dispensed by a specialty pharmacy still covered under the pharmacy benefit?
- When will the first AAC price list be released?
- How will this methodology affect compound claims?
What is a State Maximum Allowable Cost (MAC)?
The adjusted Average Acquisition Cost (AAC) of generic code numbers (GCN) available in the marketplace.
How was the State MAC list developed?
The temporary vendor hired by the Department uses the following guidelines when developing and maintaining State MAC price list:
- A minimum of two readily available manufactures in the United States
- An Orange Book (bio-equivalency) rating of “A”
- The most popular / practical package sizes are used in the review process
- Multiple wholesaler pricing, availability and proprietary pricing software programs are utilized in determining State MAC limits
- State MAC limits are continually reviewed for additions, deletions, increases, decreases and FUL comparison.
When will the State MAC list begin to be used?
The Department currently has a State MAC program in place. The State MAC list will greatly increase in September 2011 when the new list is implemented.
Will the State MAC list be updated?
The Department recognizes that changes in pharmaceutical prices and product availability occur on a regular basis. The Department will obtain and review data to ensure that State MAC rates reflect current pharmaceutical market conditions. To respond to changes in the pharmaceutical market that may impact the price and/or availability of drug products, adjustments to the State MAC list will be updated regularly. Providers should check the website for the most current list.
Whom may I contact with questions regarding this change?
The Department encourages providers to review the reference materials available on the website to determine if answers are provided. If providers still have questions, comments, and input regarding the State MAC program or to request general information regarding the State MAC, contact Colorado.SMAC@hcpf.state.co.us.
Providers are encouraged to contact ACS PA Helpdesk at 800-365-4944 for Clinical and PA questions and contact Provider Services at 800-237-0044 for Payment and Reimbursement questions.
What is the process to follow if I would like the Department to review a current State MAC Price?
Pharmacy providers should use the Colorado State Maximum Allowable Cost (MAC) Request for Medicaid Reimbursement Review form to report to the Department issues or concerns with purchasing drugs at or below the established State MAC rate. The form can be sent via email to Colorado.SMAC@hcpf.state.co.us or faxed to (303) 866-3590 attention Pharmacy.
Is the Dispensing Fee changing based on the changes in the State MAC?
The Department is in process of procuring a vendor who will complete a survey to determine the cost of dispensing prescriptions in Colorado.
Where are the Colorado Medicaid Rules for Pharmaceutical Reimbursement located?
The rules for Colorado Medicaid Pharmaceuticals are located at 10 CCR 2505-10 8.800 MEDICAL ASSISTANCE - SECTION 8.800.12 or click here to view online
What Training is Available to Providers for Billing Questions?
Training information is available in the Provider Bulletin. If providers have questions regarding billing process, the Department highly encourages providers to attend training.
Can a Pharmacy charge a Medicaid client for the cost of the drug?
If the client is eligible for Medicaid benefits, the client may have a co-pay. Other than the co-pay, pharmacies cannot charge Medicaid clients for the cost of any medication received.
How does the Pharmacy know what the payment is based on?
The pharmacy can review the State MAC list available on the website to search for an NDC to see if it has a State MAC price. If there is no price available, the payment would be based on Wholesale Acquisition Cost (WAC).
Where can we get the WAC prices that the department will be using for the methodology?
Pharmacies have access to this information through their current vendor and should continue the process that is currently used with that vendor to inquire about a WAC price.
Will the average acquisition cost identified be related to the CMS acquisition cost survey process?
CMS is in process of providing an Average Acquisition Cost (AAC) list. Once the CMS AAC list is available, the department may use the information in determining the average acquisition price used for Colorado.
Will there be any need for the pharmacy to change the pricing information submitted to CO Medicaid?
No. the pharmacy will continue to submit the claim as is done today. all calculations for reimbursement are completed when the claim reaches the state system.
Is Synagis dispensed by a specialty pharmacy still covered under the pharmacy benefit?
Yes. The reimbursement methodology change does not affect the way any Synagis will be billed.
When will the first AAC price list be released?
The price list will be posted on the website prior to the implementation of the new pricing methodology.
How will this methodology affect compound claims?
It will not. The pharmacy should continue to submit the compound claim as is done today. All calculations for reimbursement are completed when the claim reaches the state system.
All Compound Claims are paid one dispensing fee and ingredients are paid based on each line item billed. This will not change.