5.6 Maximum Pricing Policy

General Policy Description

PharmaCare sets a maximum price it will reimburse for drugs under the Drug Price Regulation. This maximum price is applied during PharmaNet claims adjudication. The maximum pricing policy also applies to some non-drug products.

Policy Details

PharmaCare reimburses drugs and some non-drug products eligible for PharmaCare coverage up to a maximum price based on

  • The sum of the manufacturer list price and 8% of that price for most drugs
  • The sum of the manufacturer list price and 5% or less for drugs subject to the High-Cost Drugs Policy

The level of PharmaCare reimbursement may be further limited when the product is subject to the Reference Drug Program (RDP), the Low Cost Alternative Program, a price established in an agreement entered into under the Pharmaceutical Services Act, or another PharmaCare pricing program or policy.

PharmaCare reimburses the lesser of the costs adjudicated under all pricing programs and policies applicable to a particular product.

Procedures

When entering a claim in PharmaNet, ensure that the unit of measure used for the dispensed quantity matches that used in PharmaNet. PharmaNet divides the product cost by the dispensed quantity and compares the result to the PharmaCare pricing rules for the product. Using the correct unit of measure ensures accurate adjudication of claims in PharmaNet.

Refer to the PharmaCare Formulary Search and the Correct Quantities list to determine the unit of measure used for a product’s PharmaCare pricing.

Tools and Resources

For information on current PharmaCare reimbursement of specific products, use the online PharmaCare Formulary Search.