Maryland Medicaid pharmacy reimbursement: what the federal file shows — and what it leaves out
An audit of generic-drug reimbursement in Maryland Medicaid, using the program's own federal reporting (Maryland Medicaid fee-for-service vs managed care (HealthChoice MCOs 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
1. Maryland's federal filings omit roughly the entire dispensing fee from managed-care pharmacy payments. The fee-for-service rows are consistent with the state's $10.67 professional fee (Maryland Medicaid FFS professional dispensing fee ($10.67)); the managed-care rows sit near ingredient cost alone. Over the latest four quarters that is roughly $82 million the national file does not show. The file alone cannot say whether that money is paid but unreported — as dispensing pharmacists confirmed in Oklahoma— or genuinely not paid. What is known for Maryland is in the Verification note below.
2. Reported ingredient reimbursement leaves nothing above the national-average acquisition cost. Managed-care rows sit $1.62 per prescription above the NADAC benchmark, versus $10.86under fee-for-service (fee included). Whatever dispensing fee is actually paid becomes the pharmacy's entire gross margin — and any pharmacy whose invoice runs above the national average starts the fill underwater.
Background
Maryland's HealthChoice program covers most Medicaid members through MCOs whose PBMs set pharmacy reimbursement, beside a fee-for-service program paying acquisition cost plus a $10.67 professional dispensing fee. Maryland's legislature has studied MCO pharmacy payment twice — reports in 2018 and 2023 — and both times found managed-care dispensing fees well below the fee-for-service level.
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 (Maryland 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, 61% were reimbursed below even the national-average cost — a $392K shortfall before counting any labor.
| Drug | NADAC / unit | Paid / unit | Rx | Qtr shortfall |
|---|---|---|---|---|
| norelgestromin and ethinyl estradiol | $36.15 | $18.31 | 1,880 | −$205,143.15 |
| BREYNA | $23.16 | $12.07 | 1,406 | −$200,857.68 |
| BREYNA | $19.95 | $9.61 | 982 | −$125,944.43 |
| Cetirizine Hydrochloride | $0.1385 | $0.0568 | 7,674 | −$98,401.65 |
| XULANE | $36.82 | $17.79 | 763 | −$88,608.94 |
| ALBUTEROL SULFATE | $2.13 | $1.53 | 15,126 | −$68,719.93 |
| ZAFEMY | $32.38 | $16.06 | 658 | −$60,466.01 |
| OXYCODONE HYDROCHLORIDE | $0.1649 | $0.1085 | 7,989 | −$39,083.78 |
ⓘ How this was built
- CMS State Drug Utilization Data (Maryland 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, Maryland 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 $10.67 from Maryland Medicaid FFS professional dispensing fee ($10.67).
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.
Verification. Maryland's own legislative studies (the 2018 PBM report and the 2023 Joint Chairmen's Report on MCO pharmacy claims, Maryland Department of Health) found that all HealthChoice MCOs paid significantly lower professional dispensing fees than the fee-for-service program. For Maryland, the filings may therefore reflect genuinely lower payment rather than only missing reporting.
Reproduce it. Every number on this page is emitted by one script, public in our repository: drugdashboards/reports/state_report.py. Generated 2026-08-31.
A DrugDashboards report · the 50-state fee survey · site-wide methodology · informational only — not legal, clinical, or purchasing advice.