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(2011-11-24 01:40:14)
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Related article: The system will deny brand drugs when a generic is available and the DAW code = 1 (Physician request) with edit 22 (M/I DAW code) and the message �PA required � Brand Medically Necessary�. ACS will ensure that the only valid DAW codes will be 0, 1, and 5: 0 - default, no product selection 1 - Physician request 5 - Brand used as generic DATE RX WRITTEN AND DATE OF SERVICE The system will enforce the following rules regarding the amount of time allowed between Date RX Written and Date of Service: If DEA = 2 (CII) � 5 (CV), then 30 days If DEA = 0, then 120 days Edit only applies to original prescriptions PRICING The following reimbursement structure is used by the MADAP program: 1) Legend Drugs Payment is lesser of: U/C -or- Allowable Cost + Dispensing Fee Allowable Cost lesser of: 1. IDC, 2. EAC (lesser of): WAC+8%� Direct+8%� � AWP - 12%, 3. FUL 2) Medical Supplies (Needles and Syringes) Payment is lesser of: U/C -or- Allowable Cost + Dispensing Fee Allowable Cost: AWP 3) DAW 1 Claims Payment is lesser of: U/C -or- Allowable Cost + Dispensing Fee Allowable Cost: EAC (lesser of): � Lorazepam Without Prescription WAC+8% -or- Direct+8% -or- AWP � 12% 4) OTC Drugs (Insulin) Payment is lesser of: U/C -or- Allowable Cost + 50% -or- Allowable Cost + Dispensing Fee Allowable Cost: AWP COPAYS ACS will ensure that MADAP claims do not have copays Dispensing Fee Brand Products = $3.69 Generic Products = $4.69 Partial fills = ? + ? dispensing fee. Drug Coverage All medications on MADAP's formulary are covered and that list is below for reference. Generic Brand name Anti-Ret Group Restrict* HRSA code Drug CD AppDT abacavir Ziagen 1 Anti-retroviral NRTI N d04376 49 2/1/1999 abacavir-lamivudine Epzicom 2 Anti-retroviral NRTI N d05354 118 8/1/2004 abacavir-zidovudine-lamivudine Trizivir 3 Anti-retroviral NRTI N d04727
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