The DHS determines maximum reimbursement rates for all covered pharmaceutical drugs and OTC items. Maximum reimbursement rates may be adjusted to reflect market rates, reimbursement limits, or limits on the availability of federal funding as specified in federal law (42 CFR 447.331).
Some covered legend drugs are reimbursed at either the drug's AWP minus 14 percent plus a dispensing fee, or the provider's usual and customary charge, whichever is less. Other legend drugs are reimbursed at either the drug's price on the Maximum Allowed Cost List pharmacy data table plus a dispensing fee or the provider's usual and customary charge, whichever is less.
The AWP reimbursement for brand name legend drugs is AWP minus 14 percent.
Under Wisconsin's State Medicaid Plan approved by the U.S. Department of Health and Human Services, Wisconsin Medicaid and WCDP may assign MACs to establish an upper limit for payment of brand or generic versions of the same drug (federal legend or OTC drugs), regardless of manufacturer. MAC rates are set by using best estimates of prices currently in the marketplace in comparison to AWP as stated in the approved Wisconsin State Plan.
Providers will receive an informational EOB on pharmacy non-compound and compound claims that are reimbursed at the MAC rate.
State law limits what pharmacies may charge SeniorCare members for covered drugs. SeniorCare payment rates are based on the BadgerCare Plus payment rate, plus the applicable dispensing fee. Regardless of the member's level of participation, pharmacies should always submit their usual and customary charge.
SeniorCare's payment rate for brand name drugs is the AWP of an NDC minus 14 percent plus the applicable dispensing fee.