Medicaid Covered Outpatient Prescription Drug Reimbursement Information by State

Quarter Ending September 2018*

View cost sharing and copayment information.

State Ingredient Cost Dispensing Fee State Maximum Allowance Cost (MAC)

Alabama

Ingredient cost is:

  • Actual acquisition cost (AAC) or if not available wholesaler acquisition cost (WAC), or Usual and Customary (U&C);
  • Average sale price (ASP) plus 6% (blood clotting factors)

Professional dispensing fee is $10.64

Yes

Alaska

Ingredient cost is:

  • National Averaged Drug Acquisition Cost (NADAC)
  • Gross Amount due
  • U&C
  • Submitted Ingredient Cost
  • WAC plus 1%
  • Federal upper limit (FUL)

Professional dispensing fee is:

  • $21.28 (pharmacy not located on the road system);
  • $13.36 (pharmacy located on the road system);
  • $16.58 (mediset pharmacy);
  • $10.76 (out-of-state pharmacy)

Yes

Arizona

Ingredient cost is:

  • Average wholesale price (AWP) minus 15%;
  • Federally Qualified Health Centers (FQHCs) and FQHC Look-alikes at the lesser of billed charges or the 340B ceiling price

Dispensing fee is:

  • $2.00 (Fee for Service (FFS) only);
  • $8.75 (FQHCs and FQHC Look-alikes)

No

Arkansas

Ingredient cost is lower of:

  • NADAC; or
  • state AAC; or
  • FUL

Professional dispensing fee is:

  • $9.00 for brand and non-preferred brands;
  • $10.50 for preferred brand and generics

Yes

California

Ingredient cost is:

Approved but not implemented – Implementation date is scheduled no later than quarter 2 of 2018 with retro- billing back to April 1, 2017

The “drug’s ingredient cost” means the lowest of:

  • NADAC;
  • or when no NADAC is available, the WAC plus 0%; or
  • FUL; or
  • The Maximum Allowable Ingredient Cost (MAIC).

Approved but not implemented - Implementation date is scheduled no later than quarter 2 of 2018 with retro-billing back to April 1st, 2017

Professional dispensing fee is:

  • $13.20 for claims less than 90,000
  • $10.05 for claims 90,000 or more

Yes

Colorado

Ingredient cost for all drugs for retail pharmacies, rural, mail order, specialty, government, institutional and long term care pharmacies shall be based upon the lower of:

  • The U&C charge to the public

    or
  • The allowed ingredient cost.

The allowed ingredient cost is the lesser of AAC or submitted ingredient cost. If AAC is not available the allowed ingredient cost is the lesser of WAC or the submitted drug ingredient cost.

The professional dispensing fees for all pharmacies except government and rural pharmacies shall be tiered based upon annual total prescription volume. The dispensing fees shall be tiered at:

  • Less than 60,000 total prescriptions filled per year = $13.40
  • Between 60,000 and 90,000 total prescriptions filled per year = $11.49
  • Between 90,000 and 110,000 total prescriptions filled per year = $10.25
  • Greater than 110,000 total prescriptions filled per year = $9.31

Professional dispensing fee is $14.41 (rural pharmacies); no dispensing fee (government pharmacies)

No

Connecticut

Ingredient cost is lowest of:

  • NADAC
  • FUL or
  • (WAC) plus zero (0) percent

Professional dispensing fee is $10.75

Yes

Delaware

Ingredient cost is NADAC

Professional dispensing fee is $10.00

Yes

District of Columbia

Ingredient cost is:

  • Brand Name Drugs: the lesser of the pharmacies’ U&C, AAC, or WAC.
  • Multiple Source Drugs: the lesser of FUL, NADAC, WAC, the pharmacy’s U&C, or the District Maximum Allowable Cost (DMAC).
  • 340B purchased drugs, Federal Supply Schedule (FSS), nominal price: AAC

Professional dispensing fee is $11.15

Yes

Florida

Ingredient cost is lower of:

  • NADAC,
  • WAC plus 0%
  • SMAC,
  • provider’s U&C

Professional dispensing fee is $10.24

Yes

Georgia

Reimbursement for legend and non-legend drugs shall not exceed the lowest of:

  • The Georgia Maximum Allowable Cost (GMAC),
  • The Georgia Estimated Actual Acquisition Cost (GEAC),
  • FUL,
  • The usual and customary charge or the submitted ingredient cost

The Select Specialty Pharmacy Rate (SSPR)

Professional Dispensing fee is $10.63 for pharmacies

Yes

Hawaii

Ingredient cost is WAC

Dispensing fee is $5.00

Yes

Idaho

Ingredient cost is:

  • AAC, or where there is no AAC reimbursement is WAC

Professional dispensing fees:

  • Less than 39,999 claims a year = $15.11
  • Between 40,000 and 69,999 claims per year = $12.35
  • 70,000 or more claims per year = $11.51

Yes

Illinois

Ingredient cost is:

  • WAC plus 1% (multiple source legend);
  • WAC plus 1% (single source legend);
  • WAC plus 25% (over-the-counter drugs);
  • AAC for implantable contraceptive devices purchased under the 340B Drug Pricing Program via FQHC or rural health centers

Dispensing fee is:

  • $5.50 (multiple source);
  • $2.40 (single source); $12.00 for both single source and multiple source drugs purchased through the 340B Drug Pricing Program

Yes

Indiana

Ingredient cost is lower of:

  • NADAC;
  • State MAC;
  • The FUL; or
  • WAC

Professional dispensing fee is $10.48

Yes

Iowa

Ingredient cost is:

  • AAC as determined from surveys or where there is no AAC reimbursement is WAC

Professional dispensing fee is $10.07

Yes

Kansas

Ingredient cost is the lower of:

  • NADAC,
  • WAC,
  • FUL,
  • SMAC,
  • Submitted Ingredient Cost, or
  • The U&C

Professional dispensing fee is $10.50

Yes

Kentucky

Ingredient cost for:

Legend, non-legend, specialty drugs, and long-term care is the lower of:

  • NADAC,
  • WAC plus 0%,
  • The FUL,
  • The State MAC, or
  • U&C.
  • ASP plus 6% is included in the lower of logic for clotting factor and physician administered drugs

340B purchased drugs, FSS, nominal price:

  • AAC

Professional dispensing fee is $10.64

Yes

Louisiana

Ingredient cost is:

  • AAC of the drug dispensed, or
  • WAC

Professional dispensing fee is:

  • $10.41, the State provider fee will be reimbursed separately

Yes

Maine

Ingredient cost is lower of:

Generic Drugs

  • NADAC,
  • FUL,
  • WAC,
  • The State MAC,
  • The Submitted Ingredient Cost dispensing fee,
  • U&C,
  • GAD, or
  • AWP – 16.67%

Brand-name Drugs

  • NADAC,
  • WAC,
  • The State MAC,
  • The Submitted Ingredient Cost dispensing fee,
  • U&C,
  • GAD, or
  • AWP – 16%

Specialty Pharmacy Providers -

  • NADAC,
  • FUL,
  • WAC,
  • The State MAC,
  • The Submitted Ingredient Cost dispensing fee,
  • U&C,
  • GAD, or
  • AWP – 16.67%

Professional dispensing fee is $11.89

Yes

Maryland

Ingredient cost is lower of:

  • NADAC,
  • WAC plus 0%,
  • FUL,
  • State AAC,
  • U&C

Professional dispensing fee is:

  • $10.49

Yes

Massachusetts

Ingredient cost is lowest of:

  • FUL
  • WAC
  • NADAC
  • U&C

340B drugs is the AAC of the drug

Non - 340B Clotting factor is lowest of:

  • NADAC
  • WAC
  • ASP + 6%
  • U&C

340B Clotting Factor is Ceiling Price

Professional Dispensing fee is:

  • $10.02
  • $10.02 for non-340B Clotting Factor
  • $10.02 plus 2.75 cents per unit for 340B Clotting Factor

Yes

Michigan

Ingredient cost is:

  • NADAC
  • WAC
  • MAC
  • U&C

Professional dispensing fee is:

  • $20.02 for specialty drugs
  • $10.80 for drugs preferred on PDL
  • $10.64 for drugs not on PDL
  • $9.00 for drugs on PDL but non-preferred

Yes

Minnesota

Ingredient cost is:

  • WAC plus 2%;
  • WAC plus 4% (independently owned pharmacies located in a small rural or isolated rural location);
  • WAC minus 40% (340B billed drugs)

Dispensing fee is:

  • $3.65 (plus $0.30 for legend unit dose drugs);
  • Dispensing fee for over-the-counter drugs in a nursing facility through the use of an automated dispensing system is $1.31 when the amount dispensed is less than the amount contained in the manufacturer’s original packaging.

Yes

Mississippi

Ingredient cost is lesser of:

  • NADAC, or
  • WAC plus 0% no NADAC is available, or
  • A rate set by the Division of Medicaid’s rate-setting vendor when no NADAC or WAC are available, or
  • The provider’s usual and customary charge.

Professional dispensing fee is $11.29

No

Missouri

Ingredient cost is lower of:

  • AWP minus 10.43%, or
  • WAC plus 10%

Dispensing fee is $4.09

Yes

Montana

Ingredient cost is lower of:

  • AAC,
  • Submitted Ingredient Cost,
  • WAC, or
  • FUL

Professional dispensing fee is:

  • $10.67 for pharmacies with annual prescription volume > 70,000
  • $12.61 for pharmacies with annual prescription volume 40,000 – 69,999
  • $14.55 for pharmacies with annual prescription volume 0 – 39,999

Yes

Nebraska

Ingredient cost is the lower of:

  • NADAC,
  • FUL,
  • MAC, or
  • U&C.

If NADAC pricing is not available:

  • WAC plus 0% will be included in the lower of logic (legend, non-legend, specialty drugs, long- term care);
  • ASP plus 6% and when ASP is unavailable, WAC plus 6.8% or manual pricing at actual acquisition cost (physician administered drugs);
  • AAC (340B purchased drugs, FSS, nominal price); the lesser of NADAC, WAC plus 0%, ASP plus 6%, FUL (clotting factor).

Professional dispensing fee is $10.02

Yes

Nevada

Ingredient cost is the lower of:

  • NADAC,
  • FUL,
  • SMAC, or
  • U&C

Professional Dispensing Fee is $10.17

Yes

New Hampshire

Ingredient cost is lower of:

  • NADAC
  • WAC +0%
  • SMAC
  • FUL
  • U&C

Professional dispensing fee is:

  • $10.47

Yes

New Jersey

Ingredient cost is:

  • NADAC,
  • WAC minus 2%,
  • SWP minus 19%,

Professional dispensing fee is:

  • $10.92

Yes

New Mexico

Ingredient cost is lower of:

  • FUL
  • NADAC
  • WAC Plus 6%
  • Ingredient Cost
  • U & C

Professional Dispensing fee is $10.30

Yes

New York

Ingredient cost is:

  • NADAC
  • WAC less 3.3% (brand)
  • WAC less 17.5% (generic)
  • FUL
  • SMAC
  • U&C

Professional dispensing fee is $10.08

Yes

North Carolina

Ingredient cost is the lower of:

  • NADAC,
  • MAC, or
  • U&C.

If NADAC pricing is not available:

  • WAC plus 0% will be included in the lower of logic (legend, non-legend, specialty drugs, long- term care);
  • ASP plus 6% or if ASP is unavailable, AWP minus 10% (physician administered drugs);
  • WAC plus 6% (physician administered contraceptive drugs);
  • AAC (340B purchased drugs, FSS, nominal price);
  • The lower of NADAC, MAC or U&C (clotting factor)

Tiered professional dispensing fee:

  • $13.00 when 85% or more of claims per quarter are for generic or preferred brand drugs
  • $7.88 when less than 85% of claims per quarter are for generic or preferred brand drugs and
  • $3.98 for non-preferred brand drugs.
  • Clotting factor: HTC $0.04 per unit and non-HTC $0.025 per unit

Yes

North Dakota

Ingredient cost for legend, non-legend, specialty drugs, long-term care, physician administered drugs, clotting factor is the lower of:

  • NADAC,
  • WAC,
  • MAC,
  • U&C

The lower of logic also includes:

  • AAC (340B, 340B physician administered drugs, FSS, Nominal Price);
  • 340B contract pharmacies not covered;
  • Invoice pricing (investigational drugs).

Professional dispensing fee is $12.46; plus $0.15 per pill (pill splitting)

Yes

Ohio

Ingredient cost is lower of:

  • NADAC PDF or;
  • U&C

If NADAC is not available, AAC is the lesser of:

  • WAC (WAC plus 0%);
  • SMAC;
  • Provider’s U&C
  • Drugs purchased by 340B covered entities through the federal 340B program will be paid at ingredient cost 340B AAC
  • Drugs purchased by 340B CE’s outside of the federal 340B program = AAC

FSS – paid at AAC

NP- paid at AAC

Specialty drugs – AAC

Clotting Factor will be the lesser of:

  • Payment limit shown in Medicare Part B pricing file, minus the furnishing fee
  • Provider’s U&C

Provider Administered Drugs (other than VCF vaccines):

  • SMAC
  • Payment limit shown in the current Medicare Part B drug pricing file;
  • 107% of WAC
  • 85.6% of AWP

Professional dispensing fee is tiered:

Less than 49,999 prescriptions per year = $13.64 Between than 50,000 and 74,999 prescriptions per year = $10.80;

Between than 50,000 and 74,999 prescriptions per year = $9.51;

100,000 or more prescriptions per year = $8.30

Yes

Oklahoma

The ingredient cost for Brand Name Drugs is the lower of:

  • NADAC; or
  • WAC

The ingredient cost for Generic Drugs is the lower of:

  • State MAC,
  • NADAC, or
  • WAC

Professional dispensing fee is $10.55

Yes

Oregon

Ingredient cost is the lower of:

  • Oregon-specific AAC file,
  • NADAC,
  • WAC plus 0%, or
  • U&C.

Professional Dispensing Fee varies by claims volume;

  • less than 30,000 claims a year is $14.30;
  • between 30,000 and 69,999 claims per year is $11.91;
  • 70,000 or more claims per year is $9.80

No

Pennsylvania

Ingredient cost for brand drugs is the lower of:

  • Provider’s U&C to the general public,
  • NADAC or
  • In the absence of a NADAC, Wholesale Acquisition Cost (WAC) minus 3.3%

Ingredient cost for generic is the lower of:

  • Provider’s U&C to the general public,
  • NADAC or
  • In the absence of a NADAC, WAC minus 50.5%
  • FUL
  • State MAC

Professional dispensing fee is:

  • $10.00

Yes

Rhode Island

Ingredient cost is the lower of:

  • NADAC,
  • WAC plus 0%,
  • FUL,
  • SMAC,
  • FDB SWD minus 19%, or
  • U&C

Professional Dispensing Fee is:

  • $8.96;
  • $7.90 (Beneficiaries residing in a long-term care facility)

Yes

South Carolina

Ingredient cost is lower of:

  • AWP minus 16%, or
  • WAC plus 0.8%

Dispensing fee is:

  • $3.00 (independent pharmacy);
  • $3.00 (institutional pharmacies)

Yes

South Dakota

Ingredient cost is:

  • Consolidated Price (WAC multiplied by 1.2) for the drug less 13%;
  • If no WAC, then Direct Price multiplied by 1.2

Dispensing fee is $4.40 plus an additional $.80 for unit dose dispensing

Yes

Tennessee

Ingredient cost is:

  • FUL; or
  • AAAC, if there is no FUL or if the AAAC is lower than the FUL, or
  • NADAC, if there is no AAAC or if the NADAC is lower than the AAAC; or
  • WAC minus three percent for brand-name drugs or WAC minus six percent for generic drugs, if there is no AAAC or NADAC; or
  • U&C

Professional Dispensing fee is:

  • For ambulatory pharmacies the professional dispensing fee will be tiered based on annual prescription volume. The tiers are-
    • $10.09 for pharmacies with a prescription volume of less than 65,000 claims per year; and
    • $8.33 for pharmacies with a prescription volume of 65,000 or more claims per year.
  • long-term care pharmacies is set at $12.15
  • specialty pharmacies is set at $10.09
  • Blood Clotting Factors dispensing fee of $153.54

Reimbursement for compounded prescriptions

  • Level 1 (0-15 minutes) – $10.09
  • Level 2 (16-30 minutes) – $15.00
  • Level 3 (31 or more minutes) – $25.00

Yes

Texas

Ingredient costs of legend and nonlegend drugs:

  • Retail = NADAC
  • Long term care (LTC) = (NADAC minus 2.4%)
  • Specialty = (NADAC minus 1.7%)

If NADAC is not available for a specific drug:

  • Retail = (WAC minus 2%)
  • LTC = (WAC minus 3.4%)
  • Specialty = (WAC minus 8%)
  • 340B is based on state’s estimate of the 340 ceiling price

Professional Dispensing fee is:

  • ((Acquisition Cost + Fixed Component) divided by (1 – the percentage used to calculate the Variable Component)) - Acquisition Cost) + Delivery Incentive + Preferred Generic Incentive

Yes

Utah Ingredient cost is the lesser of:
  • Utah Estimated Acquisition Cost (UEAC),
  • FUL,
  • Utah Maximum Allowable Cost National Average Drug Acquisition Cost (NADAC), or
  • Submitted Ingredient Cost
Professional Dispensing fee is:
  • $9.99 (urban) located in Utah;
  • $10.15 (rural) located in Utah.
  • $9.99 for out of state pharmacies
  • $716.54 for hemophilia clotting factor dispensed by the contracted pharmacy and in accordance with the hemophilia disease management program
Yes

Vermont

Ingredient cost will be reimbursed the lowest of:

  • NADAC + PDF;
  • WAC + 0% + PDF;
  • SMAC + PDF;
  • FUL + PDF;
  • AWP-19% + PDF;
  • Submitted Ingredient Cost + Submitted dispensing fee;
  • Provider’s U&C charges; or
  • Gross Amount Due  

Professional Dispensing fee is:

  • Retail community pharmacy, institutional or long term care pharmacy is $11.13.
  • Specialty drugs including but not limited to biologics and limited distribution drugs is $17.03.

Yes

Virginia

Ingredient cost for legend, non-legend, specialty drugs, long-term care is the lower of:

  • NADAC,
  • WAC,
  • FUL, or
  • U&C

Ingredient cost for other drugs:

  • Lower of NADAC, WAC, U&C (clotting factor);
  • AAC (340B, 340B physician administered drugs, FSS, Nominal Price);
  • ASP plus 6% (physician administered drugs)

Professional dispensing fee is $10.65

No

Washington

Ingredient cost is:

  • AWP minus 16% (single source drugs);
  • AWP minus 16% (multi-source drugs with four or fewer manufacturers/labelers);
  • AWP minus 50% (multi-source drugs with five or more manufacturers/labelers and no MAC or FUL);
  • ASP plus 6% (physician administered drugs)
Dispensing fee is $4.24 to $5.25 (based on 3- tiered pharmacy volume) Yes
West Virginia

Ingredient cost is the lower of:

  • NADAC;
  • If no NADAC, then WAC+0% ;
  • FU ;
  • SMAC;
  • Submitted ingredient cos;
  • Provider’s U&C

340B Purchased drugs:

Drugs purchased by CE’s reimbursed lower of AAC plus the PDF

Drugs purchased outside of 340B program by CEs will be reimbursed lower of:

  • NADAC;
  • No NADAC, then WAC plus 0%;
  • FUL;
  • SMAC
  • Submitted ingredient cost;
  • Provider’s U&C

FSS: AAC

NP: AAC

Specialty drugs & drugs not dispensed by a retail community pharmacy will be reimbursed the lower of:

  • NADAC;
  • No NADAC, then WAC plus 0%;
  • FUL;
  • SMAC
  • Submitted ingredient cost;
  • Provider’s U&C

Clotting Factor is reimbursed at WAC plus 0%.

.

Professional Dispensing fee is:

  • $10.49

Yes

Wisconsin

Ingredient cost is lower of:

  • NADAC
  • U&C
  • If NADAC is not available,
  • WAC
  • SMAC
  • Provider’s U&C;
  • 340B covered entity (including I/T/U) pharmacies will receive AAC ingredient cost (not to exceed the 340B ceiling price) plus PDF
  • Drugs purchased outside of 340B program by CE’s = AAC
  • Specialty drugs based on State SMAC

Lower of SMAC or

Provider’s U&C

  • FSS - reimbursed ingredient cost (AAC)
  • NP - reimbursed ingredient cost (AAC)

Professional Dispensing fee is based on annual prescription volume:

  • Less than 34,999 prescriptions per year $15.69;
  • $35,000 or more prescriptions per year is $ 10.51;
  • Non-tribal FQHC $24.92
  • $0.015 per unit (for repackaging);
  • $7.79 (compound drug fee);
  • $9.45 to $40.11 (pharmaceutical care dispensing fee)

Yes

Wyoming

Ingredient cost for legend, non-legend, specialty drugs, long term care pharmacies, and clotting factor is the lower of:

  • NADAC;
  • No NADAC WAC plus 0%
  • FUL;
  • SMAC;
  • Ingredient Cost submitted;
  • GAD;
  • Provider’s U&C

(Reimbursement for claims that pay GAD or U&C do not include the $10.65 PDF).

340B purchased products shall bill no more than AAC.

Drugs purchased outside of 340B program and dispensed by 340B contact pharmacies are not covered.

FSS = No more than the AAC for the cost of the drug.

Nominal Price = No more than AAC for the drug.

PADs submitted under the medical benefit will be reimbursed 100% of ASP. PADs without an ASP will be reimbursed at WAC plus 0%.

Professional dispensing fee is $10.65

Yes