Which term describes the maximum price per tablet that an insurer or PBM will pay for a given product?

Which term describes the maximum price per tablet that an insurer or PBM will pay for a given product?

• A. WAC
• B. ASP
• C. FUL
• D. MAC

Answer: (D)

The concept being tested is how payers control per‑unit drug reimbursement. The term for the maximum price a payer, such as an insurer or PBM, will reimburse for a single tablet of a given product is the maximum allowable cost, or MAC. MAC sets a per-unit ceiling to curb costs when multiple manufacturers offer the same drug. When a pharmacy submits a claim, the payer uses the MAC list to determine reimbursement up to that fixed per‑unit amount; any amount above the MAC may be covered by other sources, discounts, or patient cost sharing depending on specifics. For context, WAC is the manufacturer's list price to wholesalers, not what payers reimburse; ASP is the average sales price used to set certain Medicare Part B reimbursements; and FUL is the Federal Upper Limit used under Medicaid for multisource drugs. Among these, MAC best describes the maximum per‑tablet reimbursement by a payer.

The concept being tested is how payers control per‑unit drug reimbursement. The term for the maximum price a payer, such as an insurer or PBM, will reimburse for a single tablet of a given product is the maximum allowable cost, or MAC. MAC sets a per-unit ceiling to curb costs when multiple manufacturers offer the same drug. When a pharmacy submits a claim, the payer uses the MAC list to determine reimbursement up to that fixed per‑unit amount; any amount above the MAC may be covered by other sources, discounts, or patient cost sharing depending on specifics.

For context, WAC is the manufacturer's list price to wholesalers, not what payers reimburse; ASP is the average sales price used to set certain Medicare Part B reimbursements; and FUL is the Federal Upper Limit used under Medicaid for multisource drugs. Among these, MAC best describes the maximum per‑tablet reimbursement by a payer.