SECTION IX MARYLAND AIDS DRUG ASSISTANCE PROGRAM (MADAP) SPECIFICS

Generic Mandatory

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): · 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

Brand Products = $3.69

Generic Products = $4.69

Partial fills = ½ + ½ dispensing fee.

All medications on MADAP's formulary are covered and that list is below for reference.