5.7 Actual Acquisition Cost Policy

General Policy Description

For certain products, PharmaCare covers only the pharmacy’s actual cost of procuring the product.

Policy Details

For products subject to the Actual Acquisition Cost (AAC) policy, PharmaCare reimbursement will not exceed the provider’s AAC for the product up to a maximum price based on the manufacturer list price plus a 7% mark-up.

The product cost submitted in PharmaNet is to be reduced by any volume rebates or free goods received. Actual freight costs can be included in the AAC.

A discount paid or credited by a supplier for prompt payment of invoices is not included in the calculation of AAC. (The PharmaCare-recognized discount is usually no more than two per cent.)

When submitting claims, the Drug Cost field should contain only the AAC. Charges in excess of the AAC must be entered in the Drug Upcharge field so they do not adjudicate to PharmaCare.

PharmaCare will recover overpayments made as a result of claims submitted above the AAC.

Product costs submitted in excess of a PharmaCare maximum price will be adjudicated based on the applicable maximum price and any other applicable PharmaCare pricing policies.

Products subject to this policy include:

• Blood glucose test strips and continuous/flash glucose monitors—reimbursed at AAC up to the PharmaCare maximum price for the product plus a dispensing fee (up to the PharmaCare maximum dispensing fee)
• Cystic fibrosis vitamin and nutritional supplements—reimbursed at AAC up to the PharmaCare maximum price for the product plus a dispensing fee (up to the PharmaCare maximum dispensing fee)

Procedures

Entering claims under the AAC policy

Enter the AAC of the product in the PharmaNet Drug Cost field.

Enter any product cost in excess of the AAC in the Drug Upcharge field, not the Drug Cost field.

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 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 for PharmaCare Claim Submissions list to determine the unit of measure used for a product’s PharmaCare pricing.