District of Columbia Medicaid pharmacy reimbursement
An audit of generic-drug reimbursement in District of Columbia Medicaid, using the program's own federal reporting (DC Medicaid fee-for-service vs managed care (DC Healthy Families plans and their PBMs)). Findings only — every number traces to a public dataset and a published script, and the reader is welcome to check both.
The short version
Over the latest four quarters (through 2026 Q1), District of Columbia's managed-care filings show $5.36 per generic prescription above national-average acquisition cost — consistent with the dispensing fee being included in the reported totals — versus $9.60 under fee-for-service. The drug-level sections below show where reimbursement lands relative to acquisition cost regardless.
Background
The District of Columbia covers most Medicaid members through DC Healthy Families managed-care plans whose PBMs set pharmacy reimbursement; the small fee-for-service program — administered by a contracted pharmacy benefit administrator — pays acquisition cost plus an $11.15 professional dispensing fee. The District's managed-care filings clear the fee-included band at about half the published fee above acquisition cost.
Every state reports its Medicaid drug utilization to CMS, which publishes it as the State Drug Utilization Data (SDUD) — per drug, per quarter, fee-for-service and managed care separated. This report compares those reported payments against NADAC (CMS's national survey of pharmacy invoice prices) for every generic drug that can be matched.
Reported payment above ingredient cost, per generic prescription
ⓘ How this was built
- CMS State Drug Utilization Data (District of Columbia rows, FFSU vs MCOU)
- CMS NADAC quarterly per-NDC averages
- FDA NDC Directory (ANDA = generic)
For each quarter and payment system: (total amount reimbursed − units × quarterly NADAC) ÷ prescriptions, summed over every generic NDC with a NADAC price that quarter. Neither side of SDUD itemizes the dispensing fee — this residual is all that is measurable. Suppressed cells (fewer than 11 claims) are absent from the source data; brands are excluded because rebates make their gross prices uncomparable.
Pipeline and calculations built by Claude (Fable 5) from the public datasets above. Educational only — verify against primary sources before acting.
One limit stated plainly: no public dataset itemizes the fee on either side. The chart shows the reported residual above national-average ingredient cost — all that is measurable. A residual near the published fee is consistent with fee-included reporting; a residual near zero is consistent with ingredient-only reporting.
Reimbursed below the national-average cost
NADAC is an average — roughly half of pharmacies pay more than it for any given drug, and the fee absorbs the difference before becoming income. Among managed-care generic fills with $500+ of ingredient cost since 2025, 70% were reimbursed below even the national-average cost — a $296K shortfall before counting any labor.
| Drug | NADAC / unit | Paid / unit | Rx | Qtr shortfall |
|---|---|---|---|---|
| norelgestromin and ethinyl estradiol | $36.15 | $26.01 | 421 | −$25,449.43 |
| Cetirizine Hydrochloride | $0.1385 | $0.0453 | 1,399 | −$21,971.29 |
| CETIRIZINE HYDROCHLORIDE | $0.1385 | $0.0386 | 266 | −$4,542.85 |
| ZAFEMY | $32.38 | $28.31 | 104 | −$2,429.28 |
| Ibuprofen | $0.0409 | $0.0291 | 873 | −$2,030.34 |
| NALTREXONE HYDROCHLORIDE | $1.22 | $1.05 | 362 | −$1,783.38 |
| Ammonium Lactate | $0.0677 | $0.0472 | 208 | −$1,709.91 |
| Nicotine | $1.69 | $1.36 | 151 | −$1,352.32 |
ⓘ How this was built
- CMS State Drug Utilization Data (District of Columbia managed-care rows, latest quarter)
- CMS NADAC quarterly per-NDC averages
Managed-care generic NDCs with 100+ prescriptions in the quarter whose reported payment per unit is below the quarter's NADAC, ranked by total dollars below. 'Shortfall' compares against the national-average cost — an individual pharmacy's actual invoice may be higher or lower.
Pipeline and calculations built by Claude (Fable 5) from the public datasets above. Educational only — verify against primary sources before acting.
Methodology
Sources. CMS State Drug Utilization Data, District of Columbia rows at full grain (NDC × quarter × utilization type), from data.medicaid.gov; CMS NADAC weekly files and monthly archives, same portal; FDA NDC Directory application numbers (ANDA = generic) via openFDA; the state's professional dispensing fee of $11.15 from District of Columbia Medicaid FFS professional dispensing fee ($11.15).
Computation. Quarterly NADAC per NDC = the latest monthly average observation at or before the quarter's end (look-back capped at 6 months). Ingredient margin = total amount reimbursed − units × quarterly NADAC; per-prescription figures divide by prescription count. All sums are over generic NDCs (ANDA approvals) with a NADAC price in the quarter.
Exclusions. Brand drugs (statutory rebates make their gross prices incomparable); SDUD cells suppressed by CMS (fewer than 11 claims); NDCs without a NADAC price that quarter.
Reproduce it. Every number on this page is emitted by one script, public in our repository: drugdashboards/reports/state_report.py. Generated 2026-08-30.
A DrugDashboards report · the 50-state fee survey · site-wide methodology · informational only — not legal, clinical, or purchasing advice.