Public Notices

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Department of Health Services

Maximum Allowable Cost for Drugs with More than One Manufacturer

The State of Wisconsin reimburses pharmacies for services provided to low-income persons under the authority of Title XIX of the Federal Social Security Act and sections 49.43 to 49.47, Wisconsin Statutes. The Wisconsin Department of Health Services (DHS) administers this program, which is called Medical Assistance or Medicaid. In addition, the state of Wisconsin reimburses pharmacies for services provided under the authority of chapters 49.471, 49.665, and 49.688, Wisconsin Statutes.

Under the Wisconsin State Medicaid Plan as approved by the U.S. Department of Health and Human Services, DHS establishes maximum allowable fees for all covered pharmaceutical items provided to Wisconsin Medicaid recipients. The Plan further specifies that DHS will provide public notice in advance of the effective date of any significant change in maximum allowable fees. Federal regulations at 42 CFR §§ 447.512 – 447.518 establish certain aggregate upper limits in State Medicaid expenditures for drugs. This notice is to announce new maximum allowable costs for drugs with more than one manufacturer.

Maximum Allowable Cost (MAC)

When multiple generic equivalent drugs become available, the Department establishes the MAC, (an upper limit for payment of brand or generic version of the same drug for federal and over-the-counter products), regardless of the manufacturer. The Department uses marketplace research or best estimate of prices currently and generally paid for those drugs.

Drug costs will be calculated based on the package size from which the prescription was dispensed, as indicated by the NDC. The only exceptions are for those drugs for which quantity minimums are specified by federal regulations and for drugs listed on the Wisconsin MAC list.

Effective for dates of service on and after April 1, 2010, DHS is proposing to establish new MACs in accordance with the approved Wisconsin State Plan, including MACs for drugs that have not previously had a MAC established. The MACs are published by DHS and are available in the data table section of the Pharmacy page, located in the Provider area of the ForwardHealth Portal at www.forwardhealth.wi.gov.

This proposal is estimated to reduce WI Medicaid expenditures by $25 million, all funds, in SFY10.

Copies of Proposed Changes

A copy of the proposed change is available for review at the main office of any county department of social services or human services.

A copy of the proposed changes may also be obtained free of charge by calling or writing as follows:

Regular Mail:

James Vavra

Division of Health Care Access and Accountability

P.O. Box 309

Madison, 53701-0309

Phone:

James Vavra

[phone]

FAX:

[phone]

Attention: James Vavra

E-Mail:

[e-mail]

Written Comments

Written comments are welcome. Written comments on the changes may be sent by FAX, e-mail, or regular mail to the Division of Health Care Access and Accountability. The FAX number is [phone]. The e-mail address is [e-mail]. Regular mail can be sent to the above address.

The written comments will be available for public review between the hours of 7:45 a.m. and 4:30 p.m. daily in Room 350 of the State Office Building, 1 West Wilson Street, Madison, Wisconsin.