Procella HelpdeskDAW
The Dispense as Written (DAW) rules allow you to specify multiple processing conditions for multi-source drug claims when a generic equivalent drug exists. All of the supported NCPDP DAW codes have the same options.
The Dispense as Written edit only applies to the following:
Non-Compound Drug. Compound claims are bypassed/excluded.
Brand Multi-Source drugs
Therapeutic Equivalence Evaluation (TEE) code begins with an A.
Brand Class = Brand, Multi-Source
Multi-Source Code = O (letter O)
There are various processing options that can be set based on the DAW code submitted in the claim, the processing options can be handled differently for POS and DMR claims.
The Dispense as Written Codes available include the following as defined by NCPDP:
Code | Description |
|---|---|
0 | No Product Selection Indicated - This is the field default value that is appropriately used for prescriptions for single source brand, co-branded/co-licensed, or generic products. For a multi-source branded product with available generic(s), DAW 0 is not appropriate, and may result in a reject. |
1 | Substitution Not Allowed by Prescriber – This value is used when the prescriber indicates, in a manner specified by prevailing law, that the product is Medically Necessary to be Dispensed As Written. DAW 1 is based on prescriber instruction and not product classification. |
2 | Substitution Allowed-Patient Requested Product Dispensed -This value is used when the prescriber has indicated, in a manner specified by prevailing law, that generic substitution is permitted and the patient requests the brand product. This situation can occur when the prescriber writes the prescription using either the brand or generic name and the product is available from multiple sources. |
3 | Substitution Allowed-Pharmacist Selected Product Dispensed -This value is used when the prescriber has indicated, in a manner specified by prevailing law, that generic substitution is permitted and the pharmacist determines that the brand product should be dispensed. This can occur when the prescriber writes the prescription using either the brand or generic name and the product is available from multiple sources. |
4 | Substitution Allowed-Generic Drug Not in Stock -This value is used when the prescriber has indicated, in a manner specified by prevailing law, that generic substitution is permitted and the brand product is dispensed since a currently marketed generic is not stocked in the pharmacy. This situation exists due to the buying habits of the pharmacist, not because of the unavailability of the generic product in the marketplace. |
5 | Substitution Allowed-Brand Drug Dispensed as a Generic -This value is used when the prescriber has indicated, in a manner specified by prevailing law, that generic substitution is permitted and the pharmacist is utilizing the brand product as the generic entity. |
6 | Override -This value is used by various claims processors in very specific instances as defined by that claims’ processor and/or its client(s). |
7 | Substitution Not Allowed-Brand Drug Mandated by Law -This value is used when the prescriber has indicated, in a manner specified by prevailing law, that generic substitution is permitted but prevailing law or regulation prohibits the substitution of a brand product even though generic versions of the product may be available in the marketplace. |
8 | Substitution Allowed-Generic Drug Not Available in Marketplace -This value is used when the prescriber has indicated, in a manner specified by prevailing law, that generic substitution is permitted and the brand product is dispensed since the generic is not currently manufactured, distributed, or is temporarily unavailable. |
9 | Substitution Allowed By Prescriber but Plan Requests Brand - Patient's Plan Requested Brand Product To Be Dispensed - This value is used when the prescriber has indicated, in a manner specified by prevailing law, that generic substitution is permitted, but the plan's formulary requests the brand product. This situation can occur when the prescriber writes the prescription using either the brand or generic name and the product is available from multiple sources. |
DAW Penalty Options
The options available for DAW processing are:
- Price as Generic: This prices the multi source brand drug using the generic pricing information. This is common for a DAW of 5, where the pharmacy is using the brand as its generic.
- Calculate Difference: This calculates the price difference between the brand and the generic, assessing the penalty to the member.
- Set a Penalty: This option enables a penalty of a fixed dollar amount and/or a percentage amount of the brand cost be assessed as the penalty.
- Member Pays: This option indicates that the Member pays for the claim.
- Reject Claim: If the DAW code encounters this option, the claim will be rejected. Many use this for a DAW of 0, ensuring the pharmacy submits the reason why a multi source brand is being submitted. The standard message is NCPDP reject code 22 - M/I Dispense as Written (DAW)/Product Selection Code.
- Bypass: This option may be used when you do not want any additional action taken on a particular DAW code. If a DAW code has no definition or setup, no action is taken. The use for a BYPASS is when there are multi source brands that should not have any DAW penalty assessed.
Calculate Difference
This document primarily focuses on the following processing options
- Price as Generic
- Calculate Difference
Price as Generic
- When the processing option is selected as Price Claim as Generic. We use the Generic MS price rules instead of using Brand MS price rules. This applies to both Ingredient and dispensing fee calculations.
Note: The system calculates the original price (using Brand MS price) and also the DAW drug price (using Generic MS price). If the Brand MS price is less than the Generic MS price, then the Brand MS price will be used as the final price.
Example
| Drug | Quantity | Unit Price | AWP | DAW Code |
50458058801 Brand MS | 30 | $15.866400 | $475.99 | 5 - Substitution Allowed - Brand Drug Dispensed as a Generic |
| Brand MS | Generic MS | |
| Ingredient Cost Rule | AWP - 35% | AWP - 87% |
| Dispensing Fee | $2.00 | $3.00 |
Original Price Calculation (System will use Brand MS rules) :
IC = $309.39
DF = $2.00
DAW Drug Price is calculated When the DAW rules are applied. The new price is calculated because the Processing option is set to 'Price Claim as Generic', this overwrites the original price calculated.
IC = $61.88
DF = $3.00
This will be the final price used. In the claim history screen, you can see the PBM brand class is Brand MS but the priced brand class is Generic MS
Note: The percentage sales tax will be calculated based on the DAW Drug price
Calculate Difference
There are multiple options that can be set when processing options is Calculate Difference
- The difference type can be - Generic or based on the Basis of Cost. The Difference type determines how the DAW drug cost should be calculated.
- Calculate Dispensing Fee - When this option is enabled, the Dispensing fee will be calculated. It will be used in calculating the difference (penalty)
- Exclude Penalty from Accumulation - This option when enabled, the calculated penalty will NOT be included in Member's Accumulation. If unchecked, the penalty will be included in the Accums.
Calculate Difference / Difference Type: Generic
- Calculate Original drug pricing (based on Brand MS)
- Calculate DAW drug pricing (Using the same Ingredient cost/DF rule, calculate the Daw drug pricing based on Generic MS. Use Default if the Generic MS is not available)
- If DAW Drug Pricing (Generic MS) > Original Drug Pricing (Brand MS), then NO Penalty
- If DAW Drug Pricing (Generic MS) < Original Drug Pricing (Brand MS), then Calculate Penalty
Example 1
DAW Setup
| Processing Option | Difference Type | Primary Brand Class | Calculate Dispensing Fee | Exclude Penalty from Accumulation |
| Calculate Difference | Generic | Generic MS | True/Yes | True/Yes |
The penalty is the difference between the Original (Brand MS Price) and DAW Drug Cost (Generic MS Price)
The differences will be calculated separately.
Please note, that the Dispensing Fee will be included in the penalty calculation ONLY when Calculate Dispense Fee option is checked in the edit.
When the Calculate Dispensing Fee is checked, the System calculates the Generic Dispensing Fee. If the claim has Percentage sales tax (GE) and Percentage sales tax (JE), the generic DF is used when calculating the percentage sales tax amount.
| Drug | Submitted Sales Tax Percentage (483-HE) | Submitted Sales Tax Basis (484-JE) | Quantity | Unit Price | AWP |
50458058801 Brand MS Drug | 2.25% | 03 | 30 | $15.866400 | $475.99 |
Rules
| Brand MS | Generic MS | |
| Ingredient Cost Rule | AWP - 35% | AWP - 87% |
| Dispensing Fee Rule | Default + $2.00 | Default + $3.00 |
Brand MS Pricing
| Ingredient Cost | Dispensing Fee | Sales Tax |
| $309.39 | $2.00 | $7.01 |
DAW Drug Cost / Generic MS Pricing
| Ingredient Cost | Dispensing Fee | Sales Tax |
| $61.88 | $3.00 | $1.46 |
Penalty
DAW IC is less than the Original IC. So penalty will be calculated.
IC Penalty = $309.39 - $61.88 = $247.51
DF Penalty will not be calculated because the DAW DF is greater than Original DF
Sales Tax Difference = $5.55
Penalty = $253.06
Claim response (Assume the Member's Deductible is NOT MET)
| IC | DF | Sales Tax | Deductible | 134-UK Amount Attributed to Product Selection/Brand Drug | Patient Pay Amount | Net Amount Due |
| $309.39 | $2 | $7.01 | $65.34 | $253.06 | $318.4 | $0.00 |
Deductible Amount of $65.34 will be accumulated towards the member's deductible.
The Penalty of $253.06 will NOT be accumulated towards Member OOP as per the setup in the DAW edit.
Example 2
| Processing Option | Difference Type | Primary Brand Class | Calculate Dispensing Fee | Exclude Penalty from Accumulation |
| Calculate Difference | Generic | Generic MS | False/No | False/No |
The calculated penalty is the difference between the Brand MS Price and the Generic MS Price.
Please note in this case, the Dispensing Fee is not used when calculating the penalty.
| Drug | Submitted Sales Tax Percentage (483-HE) | Submitted Sales Tax Basis (484-JE) | Quantity | Unit Price | AWP |
50458058801 Brand MS Drug | 2.25% | 03 | 30 | $15.866400 | $475.99 |
Rules
| Brand MS | Generic MS | |
| Ingredient Cost Rule | AWP - 35% | AWP - 87% |
| Dispensing Fee Rule | Default + $2.00 | Default + $3.00 |
Brand MS Pricing
| Ingredient Cost | Dispensing Fee | Sales Tax |
| $309.39 | $2.00 | $7.01 |
DAW Drug Cost / Generic MS Pricing
| Ingredient Cost | Dispensing Fee | Sales Tax |
| $61.88 | - | $1.44 |
DAW DF is not calculated because of the Edit setup. Brand DF is used for generic and also when calculating Sales tax.
Percentage Sales Tax Amount Paid (559-AX) = (61.88 + 2.00) * 2.25% = $1.44
DAW IC is less than the Original IC. So penalty will be calculated.
IC Penalty = $309.39 - $61.88 = $247.51
Sales Tax Difference = $5.57
Penalty = $253.08
Claim response
Assume this is Straddle's Claim,
Remaining Deductible: $30 (Before this claim)
Copay Coinsurance rule: 40% CC
| IC | DF | Sales Tax | Deductible | Amount to Cost Share | Coinsurance | 134-UK Amount Attributed to Product Selection/Brand Drug | Patient Pay Amount | Net Amount Due |
| $309.39 | $2 | $7.01 | $30 | $65.32 - $30 = 35.32 | 14.13 | $253.08 | $297.21 | $21.19 |
Deductible of $30 is accumulated towards Member's deductible
Out Of Pocket of $297.21 is accumulated towards Member's OOP
Calculate Difference / Difference Type: Basis of Cost
- The penalty will be Original Drug Price - DAW Drug Price. The penalty will be calculated ONLY when the DAW drug price is less than the Original Drug price.
- To calculate the DAW Drug Pricing, Cost Basis/Alternative Cost Basis , Primary/Second brand class combinations will be used. IC / DF edit that was used to determine Original price will be used for DAW price as well.
- The flow works as explained below
Example
DAW Setup
| Processing Option | Difference Type | Primary Brand Class | Calculate Dispensing Fee | Exclude Penalty from Accumulation |
| Calculate Difference | Basis of Cost | Brand MS | True/Yes | True/Yes |
Original Drug Cost
| Ingredient Cost | Dispensing Fee |
| $154.21 | $3.47 |
DAW Drug Cost
There was no unit price available for edit.CostBasis ("HCFA FFP for unit does items) so System tries to calculate drug price with edit.AlternativeCostBasis and Primary Brand Class
| Ingredient Cost | Dispensing Fee |
| $20.23 | $3.47 |
Assuming there was no sales tax involved.
IC Penalty = $133.98
DF Penalty = 0
Penalty = $133.98
Claim Response
Assume Deductible is met, and 100% CC
| IC | DF | Sales Tax | Ded | 134-UK Amount Attributed to Product selection/Brand Drug | Coinsurance | Patient Pay | Net Amount Due |
| $154.21 | $3.47 | - | - | $133.98 | $23.70 | $157.68 | $0.00 |