PDFWAC 182-530-8100
Reimbursement—Maximum allowable cost (MAC).
(1) The medicaid agency establishes a maximum allowable cost (MAC) for covered outpatient drugs.
(2) The agency determines the MAC for covered outpatient drugs:
(a) When specific regional and local drug acquisition cost data is available, the agency:
(i) Identifies what products are available from wholesalers for each drug being considered for MAC pricing;
(ii) Determines pharmacy providers' approximate acquisition costs for these products; and
(iii) Establishes the MAC at a level which gives pharmacists access to at least one product from a manufacturer with a qualified rebate agreement (see WAC 182-530-7500(4)).
(b) When specific regional and local drug acquisition cost data is not available, the agency may estimate acquisition cost based on national pricing sources.
(3) The MAC established for covered outpatient drugs does not apply if the written prescription identifies that a specific brand is medically necessary for a particular client. In such cases, the actual acquisition cost (AAC) for the particular brand applies, provided authorization is obtained from the agency as specified under WAC 182-530-3000.
(4) Except as provided in subsection (3) of this section, the agency reimburses providers for covered outpatient drugs at the lowest of the rates calculated under the methods listed in WAC 182-530-7000.
(5) The MAC established for covered outpatient drugs may vary by package size, including those identified as unit dose national drug codes (NDCs) by the manufacturer or manufacturers of the drug.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-08-061, § 182-530-8100, filed 3/29/24, effective 5/1/24; WSR 17-07-001, § 182-530-8100, filed 3/1/17, effective 4/1/17; WSR 16-01-046, § 182-530-8100, filed 12/9/15, effective 1/9/16. WSR 11-14-075, recodified as § 182-530-8100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-8100, filed 9/26/07, effective 11/1/07.]