Subsection 144-104-2.11 - REIMBURSEMENTThe Department will reimburse participating pharmacies only for drugs that are covered drugs as set forth above.
The DEL Benefit is the payor of last resort. If the participant has another prescription drug coverage plan, that plan must be billed first.
A. The Department may establish the Maine Maximum Allowable Cost (MMAC) for covered drugs, considering the following factors:1. Multiple manufacturers;2. Broad wholesale price span;3. Availability of drugs to retailers at the selected cost;4. High volume of utilization; and5. Bioequivalence or interchangability.B. For retail pharmacies the amount of reimbursement will be the lowest of the following: 1. For Generic Drugs a. The usual and customary charge; orb. The Maine Maximum Allowable Cost plus a $2.35 professional fee; orc. The Average Wholesale Price minus 14% plus a $2.35 professional fee; ord. The State Upper Limit (250% of Average Manufacturer's Cost for multi-source generic drugs) plus a $2.35 professional fee.2. For Brand-Name Drugs a. The usual and customary charge; orb. The Average Wholesale Price minus 15% plus a $2.35 professional fee.C. For mail order pharmacies, the amount of reimbursement will be the lowest of the following: 1. For Generic Drugs a. The usual and customary charge; orb. The Average Wholesale Price minus 60% plus $1.00 professional fee except as otherwise noted below, orc. The Maine Maximum Allowable Cost plus $1.00 professional fee.2. For Brand-Name Drugs a. The usual and customary charge; orb. The Average Wholesale Price minus 20% plus $1.00 professional fee. C.M.R. 10, 144, ch. 104, § 144-104-2, subsec. 144-104-2.11