Contract language is everything.
What is left in or out of a PBM contract can make major differences in the cost of your prescription benefit.
Example: Your PBM contract says you have a guarantee of AWP – 80 % for retail generics. Are zero balance claims included or excluded? How about Usual and Customary claims? What about repackaged NDC numbers? Depending on these answers, the actual calculation of the AWP discount for Retail Generics could vary wildly. Your PBM may miss the guarantee and owe you money or, with skillful math, can make the guarantee and owe you nothing.
What kind of definition do you have for a generic drug?
As with the “contract language is everything” answer, a poor or unclear definition of a generic drug means your PBM can “move” a drug from a generic to a brand classification or vice versa. That can affect whether the PBM owes you money.
AWP guarantees may or may not mean anything.
Let’s talk about AWP. (Average Wholesale Price or AIN’T WHAT’S PAID?) Theoretically, AWP does stand for AVERAGE WHOLESALE PRICE. Trouble is, there’s nothing average about it. It comes from one source (not multiple wholesalers.) It is NOT a set price for a drug or prescription and there are quite a few ways the AWP discount “guarantee” can be manipulated.