September 1989

Dear Reader:
This twenty-fourth annual edition of the compilation, Pharmaceutical Benefits Under State
Medical Assistance Programs, was prepared by the National Pharmaceutical Council to as-
sist in your evaluation of Medicaid program characteristics. NPC recognizes Medicaid as
an important health care component and believes that public assistance patients should
receive the same quality of care as other patients in the community.
We hope that you find the information contained in this compilation useful in the develop-
ment, implementation and operation of pharmaceutical programs that are responsive to the
needs of Title XIX recipients.
Sincerely,
Mark R. Knowles &
President
PHARMACEUTICAL
BENEFITS
UNDER
STATE MEDICAL ASSISTANCE
PROGRAMS
SEPTEMBER 1989
Compiled by
NATIONAL PHARMACEUTICAL COUNCIL, INC.
1894 Preston White Drive, Reston VA 22091
TABLE OF CONTENTS
Page
...
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Introduction 111
Pharmaceutical Benefits Under State Medical Assistance Programs . . . . . . . . . . . . . . . . . . . . . . 1
Impact of Catastrophic Coverage on State Medicaid Programs . . . . . . . . . . . . . . . . . . . . . . . . 23
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Glossary of Medicaid Terms 25
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acronyms 31
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Regional Administrative Offices 32
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State Medicaid Drug Program Administrators 33
Stateofficials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
. . . . . . . . . . . . . . . . . . Federal Register42CFR Parts413. 430. 447and45CFR Pans 1 & 19 51
. . . . . . . . . . . . . . . . . . . . State Medicaid Manual Pan 6 - Payment for Services (Upper Limits) 62
Tables (Program Characteristics and Statistics)
1 . Medicaid Statistics:
A . Title XIX Medical Assistance U.S. Totals by Type of Service . . . . . . . . . . . . . . . 84
. . . . . . . . . . . . . . . . . . . . . . . . . . . B . Medicaid Recipients and Vendor Payments 86
. . . . . . . . . . . . . . . . . . . . . C . Vendor Payments for Prescribed Drugs (1 983-1 988) 87
D . Recipients of Prescribed Drugs (1983 - 1988) . . . . . . . . . . . . . . . . . . . . . . . . . 88
E . Ranking of States Based on Medicaid Drug Expenditures . . . . . . . . . . . . . . . . . 89
. . . . . . . . . F Average Expenditures per Recipient for Prescribed Drugs (1983 1988) 90
G . Percentage of Medicaid Expenditures Allocated to Prescription
. . . . . . . . . . . . . . . . . . . . . . . . . . Medication (1984 . 1988)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . H Medicaid Drug Reimbursement Chan 92
. . . . . . . . . . . . . . . . . . . . .
I . Summary of Medicaid Limitations . Pharmaceuticals 95
. . . . . . . . . . . . . . . . . . . . . . . . . . .
J . Caveats for using HCFA 2082 Data Tables 97
K.
Medicaid Recipients by Type of Service, Region & State . . . . . . . . . . . . . . . . . . 98
L.
Medicaid Medical Vendor Payments by Type of Service,
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Region & State
M. Federal Medical Assistance Percentage ("FMAP) . . . . . . . . . . . . . . . . . . . . . . . 132
2.
State Demographic and Economic Characteristics, 1987:
A. State Population, Unemployment, Income, and Age Characteristics . . . . . . . . . . 133
3. Miscellaneous:
A.
Pharmacies and Pharmacists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
. . . . . . . . . . . . . . . . . . . .
B. Key Provisions of State Drug Product Selection Laws 135
4.
Expanded Drug Coverage for the Elderly:
A.
Programs Characteristics for States with Elderly Drug
. . . . . . . . . . . . . . . . . . . . . . . Coverage Programs
Medical Assistance Drug Programs
(Alphabetically by State)
Richard W. Fowler, R.Ph
Vice President, Health Programs
National Pharmaceutical Council
Editor
The National Pharmaceutical Council, Inc. is dedicated to the enhancement of the quality and
integrity of pharmaceutical services in research, development, manufacturing, and dispensing of
prescription medications and other pharmaceutical products.
The National Pharmaceutical Council, Inc. was founded in 1953 by companies engaged primarily
in the discovery, development, production, and marketing of innovative prescription medicines.
Today, our thirty member companies continue their commitment to major programs of
pharmaceutical research and maintain exacting quality control standards.
Toward this end, NPC undertakes educational activities and provides services to physicians,
pharmacists, manufacturers, professional associations, colleges of pharmacy, medical schools,
government offices and consumers concerning key aspects of health care. NPC services include
providing information on the quality and cost-effectiveness of pharmaceutical products, the
economics of drug programs, and the notable contributions of research oriented pharmaceutical
manufacturers.
Methodology
The statistics and characteristics of each state Medicaid program were obtained from an NPC
survey of state Medicaid program administrators and pharmacy consultants. Other statistics were
reported by the HCFA Medicaid Statistics Branch, Department of Commerce, and state
pharmaceutical association executives.
The narrative and descriptive material was condensed from the Code of Federal Regulations
(CFR-42), supplemented by material contained in HCFA publication No. 03249, "Analysis of State
Medicaid Program Characteristics, 1986 published August, 1987.
NPC acknowledges the cooperation and assistance of the many
state Medicaid program officials and their staffs, state
pharmaceutical associations, Health Care Financing Administration
personnel, and others i n supplying data for this compilation.
iii
PHARMACEUTICAL BENEFITS
UNDER STATE MEDICAL ASSISTANCE PROGRAMS
This compilation of data on State Medical Assistance Programs (Title XIX) has been prepared to present a
general over~iew of the characteristics of state programs together with detailed information on the
pharmaceutical benefits provided. The data collection effon covers all states with medicaid programs.
The following information is provided for each state:
Recipient groups eligible for benefits
Amount expended for drugs per recipient category
Characteristics of the State Drug Program
Restrictions or limitations on drugs
Medicaid or public health officials
Pharmacy and medical consultants to the state programs
Pharmacy and medical advisory committees
State medical and pharmaceutical association executives
State boards of pharmacy
Medicaid (Title XIX of the federal Social Security Act) is a program of medical assistance, funded by the
federal government and the states, for impoverished individuals who are aged, blind or disabled, or members
of families with dependent children. The states and territories of Puerto Rico, Guam, Virgin Islands, American
Samoa, and Northern Mariana Islands each operate Medicaid programs according to state or territorial rules
and criteria that vary widely within a broad framework of federal guidelines. Arizona has an experimental
program marked by organized health plans and capitation.
The original Social Security Act, which was enacted in 1935, made no direct provision for medical assistance.
However, it did establish a system of "categorical" public assistance that allowed the federal government to
share with states the cost of providing maintenance payments to the needy aged and blind, and to needy
families with dependent children. This assistance, which was subsequently extended to the permanently and
totally disabled, could include the cost of some medical care in monthly assistance payments to recipients.
In 1950, public assistance under the Act was broadened to include federal sharing in "vendor payments,"
i.e., direct payments by a state to doctors, nurses, and health care institutions, rather than to the welfare
recipient. Although federal sharing in vendor payments created an administrative framework for a welfare
medical program, federal funding was so small that only a few states participated. Subsequent amendments
to the Act made more federal funds available so that, by 1965, all of the states provided medical vendor
payments in their federally aided categorical assistance programs. Many states also offered an allowance
for some items of medical care in welfare payments to categorical assistance recipients.
Despite these expanded federal and state efforts, the need for medical assistance became so great that
most states could finance only a few services. To help satisfy this need, Title XIX or "Medicaid" was enacted
in the Social Security Amendments of 1965, providing grants to states for medical assistance programs be-
ginning January 1, 1966. By January 1, 1967, more than half of the states had Medicaid programs, and by
1970, all of the states except Alaska (which later implemented one) and Arizona (which implemented an
alternative to Medicaid in 1982) had programs. As a result, the federal financial participation in medical care
that had been available through the categorical public assistance programs was ended because of the
availability of federal Medicaid funds and the administrative advantages of offering medical care exclusively
through Medicaid.
The program operates on the basis of a state and federal division of responsibilities. The federal
government establishes regulations, guidelines and policy interpretations which describe the broad outline
within which states can tailor their individual programs. States assume control and direction of operations.
As a result there are 56 (50 states, plus Guam, District of Columbia, Puerto Rico, Samoa, Northern Mariana
Islands and the Virgin Islands) distinctly different programs in operation. Funding is shared between the two
bodies, with the federal government matching state health care provider reimbursements of an authorized
rate between 50% and 83% depending on the states per capita income. Federal law governs certain
aspects of Medicaid, and requires that all persons who qualify for Aid to Families with Dependent Children
(AFDC) and most persons who qualify for Supplemental Security Income (SSI) receive Medicaid coverage.
The Federal Government requires states to provide a basic set of services to people eligible for Medicaid
and to reimburse providers of those services in certain ways. Reimbursement levels for many services are
subject to federally established ceilings and, in some instances, floors.
The states' control over eligibility, for example, is substantial, because states establish eligibility for AFDC
which establishes eligibility for Medicaid. (The same does not hold true for SSI recipients, whose eligibility
is determined primarily by Federal criteria.) Furthermore, states may voluntarily extend Medicaid coverage
to additional groups of people and expand the range of services covered. States also have considerable
freedom in choosing reimbursement methods for physicians and other health care providers. Title XIX of the
1965 Social Security Amendments provide the legislative basis for Medicaid. Medicaid should not be
confused with Medicare, which was also established by the Social Security Amendments of 1965. Medicare
is a federally administered medical insurance program for the elderly, which is administered by the Social
Security Administration (SSA).
ADMINISTRATION
Administration of the state Medicaid program is vested in single state agencies. Within each agency, state
plans must designate a medical assistance unit responsible for developing, analyzing, and evaluating the
Medicaid program. The law further requires the states to establish medical care advisory committees to
advise the Medicaid agency director about health and medical services. These committees must include
board certified physicians and other representatives of the health professions, members of consumer groups,
and the director of either the state public welfare or the public health department (whichever department
does not run the Medicaid agency). Activities for administering the state Medicaid program include:
program administration, Medicaid Management Information System (MMIS), claims processing activity, state
administration, and waivers.
Eligibility Determination and Program Administration
States are allowed three options for administering coverage of SSI recipients (42 CFR 431.10(c)):
States electing to extend Medicaid to all SSI recipients can enter into an agreement with the Social
Security Administration under Section 1634 of the Act for determinations of Medicaid eligibility;
States electing to extend Medicaid eligibility to recipients of SSI can maintain eligibility determinations
on a state level; or
States electing the 209(b) option (where recipients of cash assistance under SSI are not automatically
eligible for Medicaid) can require cash assistance recipients to make a separate application for
Medicaid.
Thirty-one states elected to have federal determination. Five states elected to extend Medicaid to all
recipients of SSI but maintain eligibility determination on a state level. Fourteen states elected the 209(b)
option.
A state plan must be in operation statewide through a system of local offices under equitable standards for
assistance and administration that are mandatory throughout the state (42 CFR 431.50(b). However, the
state may choose to administer the program on the state level or by political subdivision of the state.
Forty-four states have chosen to administer the Medicaid program on a state level. Six states have chosen
local (county) administration. This means is that in those states whose program is locally administered, the
state plan is mandatory on each of the political subdivisions. The local administrations do not have the
authority to change or disapprove any administrative decision of the state Medicaid agency with respect to
the application of policies, rules, and regulations issued by the Medicaid agency.
A state plan must specify a single state agency, established or designated, to administer or supervise the
administration of the plan (42 CFR 431.10(b)). Generally, the administering agency has been the state
health agency, welfare agency, or an umbrella agency. A possible effect of the administering agency being
the health department is that the welfare department has control over the intake of eligibles in the AFDC and
SSI/SSP programs, individuals who automatically become eligible for Medicaid. This separation could create
a span of control problems for the Medicaid agencies. Three states have designated the health department,
21 states have designated the welfare department, 22 states have designated an umbrella agency, and four
states have designated other agencies to administer the Medicaid program. The "other" agencies included
the office of the Governor in Alabama and an independent agency/commission in Georgia and Mississippi,
and the State Health and Human Services Finance Commission in South Carolina.
SERVICE COVERAGE
The original Title XIX legislation listed fifteen types of medical care for which federal funding would be
received. The last one was very general in nature specifying that "any other medical care, and any other
type of remedial care recognized under state law" was eligible for federal support. By 1970, 21 types of
medical care were specified and by 1979, over 30 medical services were listed as acceptable Medicaid
services.
Medicaid services can be grouped into eight major categories as follows:
1.
11.
111.
IV.
v.
VI.
VII.
VIII.
Professional Services - treatments provided by physicians, optometrists, dentists, etc.
Nursing Care Services - types of care provided by nurses in hospitals, patient's homes, clinics,
nurse-midwife services, etc.
Nursing Home Services - types of care available in nursing homes, such as skilled, intermediate, or
general nursing care.
Hospital and Clinic Services - services provided at a hospital, clinic, or other type of medical
treatment center (does not include nursing homes).
Drugs, Supplies, and Equipment - includes prescribed drugs and any supplies or equipment needed
to aid in the treatment of a medical problem.
Special Services and Therapy - includes screening, diagnostic, and preventive services as well as
therapy for physical, occupational, or communication disorders.
Institutional Care - care provided to individuals during their stay at mental institutions or tuberculosis
hospitals (includes any institutional stay other than that at regular hospitals or nursing homes).
Other - any services provided which facilitate medical treatment that are not covered by any of the
above categories.
3
MANDATORY SERVICES
In order to participate in Medicaid, there are certain basic services that must be offered in a state's Medicaid
program. There were five of these mandatory services specified in the original legislation of 1965. These
services were:
1. Inpatient hospital services
2. Outpatient hospital services
3. Physician services
4. Independent laboratory and X-ray services
5. Skilled nursing home services. (This service had to be provided only to eligible persons
twenty-one years of age or older.)
The six additional mandatory services added since 1985 are listed below:
6. Early and periodic screening, diagnostic, and treatment program
7. Family planning services and supplies
8. Home health care services
9. Patient transportation
10. Rural Health Clinic Services
I I Nurse-midwife services
OPTIONAL SERVICES
In addition to these required programs, the participating states may elect to offer additional services. Some
of these services are defined in the Medicaid rules and regulations. Others have been defined through
federal acceptance of a particular service in a state's plan. A state may include any type of care recog-
nized under state law and authorized by the Secretary of the Department of Health and Human Services.
A list of the Medicaid mandatory and defined optional services is provided beginning on page 5.
REGULATIONS PERTAINING TO MEDICAID SERVICES
Federal regulations require that the amount and/or duration of each type of medical and remedial care and
services furnished under a state's Medicaid plan must be specified in the state plan, and that these types
of care and services must be sufficient in amount, duration, or scope to 'reasonably achieve" their purpose.
Each plan must include a description of the methods that will be used to assure that the medical and
remedial care and services are of high quality, and a description of the standards established by the state
to assure high quality care. The regulations also require that fee structures be developed which will result
in participation of a sufficient number of providers of services in the program so that eligible persons can
receive the medical care and services included in the plan at least to the extent that these are available to
the general population. The law further requires that services provided under the plan be available
throughout the state. Recipients are to have freedom of choice with regard to where they receive their care,
including an option to obtain their care through organizations that provide services or arrange for their
availability on a prepayment basis, such as health maintenance organizations.
MEDICAID ELIGIBILITY
Medicaid is the primary source of health care coverage for the poor in America. Through it, medical sewices
are provided primarily to those people who are eligible to receive cash payments under one of the existing
welfare programs established by the Social Security Act. Basically these eligible persons fall into two
categories - those whose eligibility for Medicaid services is mandated at the federal level and those whose
eligibility is determined by the individual state. These categories are described in the sections below.
Mandatory Coverage
Every state, in order to receive Title XIX funding, must provide Medicaid benefits to certain groups of
'categorically needyversons. In order to be considered "categorically needy' for Medicaid purposes, an
individual must be receiving financial assistance (maintenance payments), or be eligible for financial
assistance, under Title XVI, Supplemental Security Income for the Aged, Blind, and Disabled (SSI).
The two largest of these "categorically needy' groups are persons already receiving maintenance payments
through the Aid to Families with Dependent Children program or through the Supplemental Security Income
program. Other groups that are categorically needy and thus automatically eligible for Medicaid are
recipients of mandatory state supplements and persons' affected by increases in Social Security payments.
MEDICAID SERVICE
(Mandatory Services Indicated by Capital Letters)
PHYSICIAN SERVICES
Chiropractors' Services
Podiatrists' Services
Optometrists' Services
Other Practitioners' Services
Dental Services (for persons 21 years of age and older)
11. Nursing Care Services
HOME HEALTH CARE SERVICES (for persons 21 years of age or older)
Personal Care Services
Private Duty Nursing
NURSE-MIDWIFE SERVICES
Adult Day Treatment Services
111. Nursing Home Services
SKILLED NURSING FACILITY SERVICES (for persons 21 years of age or older)
lntermediate Care Facility Services
Skilled Nursing Facility Services (for persons under 21 years of age)
IV. Hospital and Clinic Services
INPATIENT HOSPITAL SERVICES
OUTPATIENT HOSPITAL SERVICES
RURAL HEALTH CLINIC SERVICES
Clinic Services
Emergency Hospital Services
V. Drugs, Supplies and Equipment
Prescribed Drugs
Dentures
Eyeglasses (for persons 21 years of age and older)
Hearing Aids (for persons 21 years of age and older)
Prosthetic Devices
VI. Special Services and Therapy
INDEPENDENT LABORATORY & X-RAY SERVICES
EARLY & PERIODIC SCREENING, DIAGNOSIS & TREATMENT (EPSDT) OF CHILDREN (under
21 years of age)
FAMILY PLANNING SERVICES
Diagnostic Services (for persons 21 years of age and older)
Screening Services (for persons 21 years of age and older)
Preventive Services
Physical Therapy
Occupational Therapy
Occupational Therapy
Treatment for Speech, Hearing and Language Disorders
VII. Institutional Care
Inpatient Psychiatric Services (for persons under 22 years of age)
Care in Tuberculosis lnstitutions (for persons age 65 or older)
Care in Mental Institutions - lntermediate Care Facility Services (for persons age 65 or 01der)Care
in Mental lnstitutions - Skilled Nursing Facility (for persons age 65 or older)
VIII. Other
TRANSPORTATION TO & FROM MEDICAL SERVICES
Enrollment in Medicare - Part B, Title XVIII, Supplemental Medical InsuranceEnrollrnent in
Medicare - Part A, Title XVIII, Hospital Insurance Benefits
In addition to the services listed as being mandatory or optional, Title XIX specifies that 'any other medical
care, and any type of remedial care recognized under state law, specified by the Secretary of the Department
of Health and Human Services," is acceptable as a Medicaid service and thus eligible for federal support.
Optional Coverage
In addition to the groups that must be covered by the state's Medicaid programs, there are other groups
that are kategorically needy" or Vnedically needy" who may be included in Medicaid at the Option of each
state. That is, the participating states are not required to offer services to these people unless they elect to
do so.
General Eligibility Requirements
In addition to designating that certain groups of people must be covered by a state's Medicaid plan and
defining other groups that may be covered at the discretion of the state, the federal government specifies
certain general requirements that must be met for Medicaid eligibility. This does not mean that a state
cannot provide coverage for those persons included in the Medicaid plan that do not meet these specified
requirements. Rather, federal matching funds will not be made available to cover the claims for services
provided to these individuals. State and/or local funds must be used to support the medical expenses of
these individuals if the state elects to include them in its Medicaid plan. A Medicaid agency that chooses
to cover an optional group must provide Medicaid to all eligible individuals in that group.
CHARACTERISTICS OF BENEFITS PROVIDED
Inpatient Hospital Services
lnpatient hospital services refer to services that are ordinarily furnished in a hospital for the care and
treatment of an inpatient. The facility is one maintained primarily for the care and treatment of patients with
disorders other than tuberculosis or mental diseases.There are several general federal limitations on inpatient
hospital services which are applicable to all states with Medicaid programs (42 CFR 440.10):
O
The facility must be licensed or formally approved as a hospital by an officially designated
authority for state standard-setting;
The facility must meet the requirements for participation in Medicaid;
"
The care and treatment of inpatients must be under the direction of a physician or dentist; and
The facility must have in effect an approved utilization review plan, applicable to all Medicaid
patients, unless a waiver has been granted by the Secretary.
In addition to the federal limitations, each state may impose further limitations on inpatient hospital services.
Outpatient Hospital Services
Outpatient hospital services refer to preventive, diagnostic, therapeutic, rehabilitative, or palliative services
provided to an outpatient. There are three federal limitations that are imposed on these services:
The services must be provided under the direction of a physician or dentist;
The facility must be licensed or formally approved as a hospital by an officially designated
authority for state standard-setting; and
O
The facility must meet the requirements for participation in Medicare.
States are free to specify other limits on outpatient hospital services and 42 states have chosen to do so.
Examples of "other IimitsVnclude: (1) emergency room services are not provided between 8:00 a.m. and
4:00 p.m. in Vermont except for trauma and (2) outpatient services are limited to a maximum of $100 per
fiscal year in Florida.
Rural Heaith Clinic Sewices
Rural health clinic (RHC) services became a mandatory service for the categorically needy in July 1978.
Each RHC is required to have a nurse practitioner (NP) or physician's assistant (PA) on its staff. Therefore,
a clinic can only be certified if the state permits the delivery of primary care by an NP or PA. Services in
certified clinics must be provided and furnished by a physician or by a PA, NP, nurse-midwife, or other spec-
ialized nurse practitioner. Services and supplies are furnished as an incident to professional services.
Part-time or intermittent visiting nurse care and related medical supplies are provided given that the clinic is
located in a Health Manpower Shortage Area, the services are furnished by nurses employer by the clinic,
and the services are furnished under a written plan of treatment to a homebound recipient.
Other Laboratory and X-Ray Services
Other laboratory and X-ray services are professional and technical laboratory and radiological services. As
specified in 42 CFR 440.30 (a-c), federal requirements for Medicaid mandate that these services be:
Ordered and provided by or under the direction of a physician or other licensed practitioner of
the healing arts within the scope of his practice as defined by state law or ordered and billed
by a physician but provided by an independent laboratory;
Provided in an office or similar facility other than a hospital outpatient department or clinic; and
Provided by a laboratory that meets the requirements for participation in Medicare.
In addition, the states can place limitations on "other laboratory and X-ray services."
Skilled Nursing Facility Services
Skilled nursing facility (SNF) services are provided to individuals age 21 or older and do not include services
in institutions for tuberculosis or mental diseases (42 CFR 440,40(a)). These services must be needed on
a daily basis and provided in an inpatient facility. Federal regulations require that the services be:
"
Provided by a facility or distinct part of a facility that is certified to meet the requirements for
participation. These requirements include provider agreements, facility certification, and facility
standards; and
"
Ordered by and under the direction of a physician
These services include services provided by any facility located on an Indian reservation and certified by
the Secretary of Health and Human Services. Further, the requirements concerning control of the utilization
of Medicaid services impact upon skilled nursing facility services on such areas as certification and re-
certification of need for inpatient care, individuals written plan of care, etc.
Early and Periodic Screening, Diagnosis and Treatment
Early and periodic screening, diagnosis and treatment (EPSDT) refers to screening and diagnostic services
to determine physical or mental defects in recipients under age 21 and health care, treatment and other
measures to correct or ameliorate any defects and chronic conditions discovered (42 CFR 440.40(b)). There
are certain basic screening and treatment services that each state must provide as minimum (42 CFR
441 S6). These services include:
Health and development history screening
Unclothed physical examination
Developmental assessment
Immunizations which are appropriate for age and health history
Assessment of nutritional status
Vision testing
Hearing testing
Laboratory procedures appropriate for age and population groups
Dental services furnished by direct referral to a dentist for diagnosis and treatment for children
three years of age and over
Treatment for defects for vision and hearing, including eyeglasses and hearing aids; and
Dental care needed for relief of pain and infections, restoration of teeth and maintenance of
dental health
The state Medicaid agency may provide for any other medical or remedial care specified as a Medicaid
service even if the agency does not otherwise provide for these services to other recipients or provides for
them in a lesser amount, duration or scope.
Family Planning Services
Family planning services and supplies are allowable for individuals of child bearing age as a means of
enabling individuals to freely determine the number and spacing of their children. Although there are no
federal regulations defining what family planning services a state can provide, provisional regulations are
written which defined family planning services to be: consultation (including counseling and patient educa-
tion), examination, and treatment, furnished by or under the supervision of a physician or prescribed by a
physician; laboratory examination; medically approved methods, procedures, pharmaceutical supplies and
devices to prevent conception; natural family planning methods, diagnosis and treatment for infertility; and
voluntary sterilization. In addition, states niay provide any medically approved means other than abortion,
for family planning purposes, if furnished by or under supervision of a physician or if prescribed by a phy-
sician. Abortions are specifically excluded from family planning services and states are prohibited from
considering any abortion as being a family planning service.
Voluntary sterilizations must be included among the range of family planning services offered by a state.
Federal regulations require that the individual to be sterilized voluntarily gives informed written consent and
that the individual must be at least 21 years of age at the time consent is obtained and must be mentally
competent.
Physicians' Services
Physicians' services are covered whether provided in the office, the patient's home, a hospital, a skilled
nursing facility, or elsewhere. Physicians' services must be within the scope of practice of medicine or
osteopathy as defined by state law and by or under the personal supervision of an individual licensed under
state law to practice medicine or osteopathy.
Home Health Services
Home health services are provided to a recipient at his place of residence which does not include a hospital,
skilled nursing facility, or intermediate care facility (ICF) except for home health services in an ICF that are
not required to be provided by the facility. Services provided must be on physicians' orders as part of a
wrinen plan of care that is reviewed by the physician every 60 days. Home health services include three
mandatory services (part-time nursing, home health aide, and medical supplies and equipment) and one
optional service (physical therapy, occupational therapy, and speech pathology and audiology sewices) (42
CFR 440.70). These services are defined as follows:
Part-time nursing - nursing service that is provided on a part-time or intermittent basis by a home
health agency. If there is no home health agency in the area, services may be provided by a
registered nurse who is currently licensed to practice in the state, receives wrinen orders from
the patient's physician, documents the care and services provided, and has had orientation to
acceptable clinical and administrative record-keeping from a health department nurse;
Home Health Aide - home health aide service that is provided by a home health agency;
Medical Supplies and Equipment - Medical supplies, equipment and appliances that are suitable
for use in the home; and
Physical Therapy (PT), Occupational Therapy (OT), and Speech Pathology and Audiology
Services - PT, OT, and speech and hearing services provided by a home health agency or by
a facility licensed by the state to provide medical rehabilitation services.
Home health services are provided to categorically needy recipients age 21 and over and to those under
21 only if the state plan provides SNF services for them.
Nurse-Midwife Services
The Omnibus Reconciliation Act of 1980 mandates that payment must be made for nursemidwife services
to categorically needy recipients (42 CFR 440.165). The effective date of this legislation was July 16, 1982,
or, if state legislation was needed in order to conform, the first day of the first calendar quarter beginning
after the close of the first regular session of the state legislature that began after May 17, 1982.
These provisions require states to provide coverage for nurse-midwife services to the extent that the
nurse-midwife is authorized to practice under state law or regulation. The statute also requires that states
offer direct reimbursement to nurse-midwives as one of the payment options. Nurse-midwives must be
registered nurses who are either certified by an organization recognized by the secretary or have completed
a program of study and clinical experience that has been approved by the secretary. Nurse-midwife services
are those concerned with management of the care of mothers and newborns throughout the maternity cycle.
LIMITATIONS ON OPTIONAL SERVICES
Intermediate care facility (ICF) services, other than in an institution for tuberculosis or mental diseases, refers
to services provided in a facility that fully meets the requirements for a state license to provide on a regular
basis, health-related services to individuals who do not require hospital or SNF care but whose mental or
physical condition requires services that are above the level of room and board and can be made available
only through institutional facilities. The facility must meet all the requirements to be certified for Medicaid (42
CFR 440.1 50(a-b)).
This optional service is provided by all 50 states.
Services for Individuals Age 21 and Under
States may elect to provide two types of services for individuals age 21 and under: (1) skilled nursing
facility services and (2) inpatient psychiatric services. "Skilled nursing facility services for individuals under
age 21" (42 CFR 440.170(d)) are defined to be those services as specified previously that are provided to
recipients under 21 years of age.
Inpatient psychiatric services for individuals under age 21 refer to services that are provided under the
direction of a physician and are provided in an accredited facility or program (42 CFR 440.160). Federal
regulations further specify certification of need, active treatment, and individual plans of care.
Prescribed D ~ g s
Prescribed drugs are simple or compound substances or mixture of substances prescribed for the cure,
mitigation, or prevention of disease, or for health maintenance that are prescribed by a physician or other
licensed practitioner of the healing arts within the scope of their professional practice as defined and limited
by federal and state law (42 CFR 440.120). The drugs must be dispensed by licensed authorized practit-
ioners on a written prescription that is recorded and maintained in the pharmacist's or practitioner's records.
Two states, Alaska and Wyoming, do not provide prescribed drugs as a separate service to Medicaid
recipients. Alaska passed legislation authorizing a one-year pilot project for prescription drugs under
Medicaid (S.B. 255, effective 1 July 1988.) States place limits on prescription quantities in three different
ways: number of prescriptions that can be filled in a certain time period, number of prescriptions that can
be refilled in a certain time period, and quantity of each prescription.
States further limit prescribed drugs by restricting the quantity of medication for a single prescription. Some
of the "other limits"mposed on prescribed drug services are that brand name drug services must be
documented as medically necessary, refills must be filled by the same pharmacy as the original prescription
and flu and pneumococcal vaccines are covered only for persons age 65 and over.
Other Optional Services and Equipment
Clinic services are preventive, diagnostic, therapeutic, rehabilitative or palliative items or services provided
to an outpatient, by or under the direction of a physician or dentist, by a facility that is not part of a hospital
but is organized and operated to provide medical care to outpatients (42 CFR 440.90).
Emergency hospital services refer to services that are necessary to prevent death or serious impairment of
the health of a recipient and because of the threat to life or health necessitates the use of the most
accessible hospital available that is equipped to furnish the services (42 CFR 440.170(e)). The services will
be provided that such a hospital even if it does not meet the conditions for participation under Medicaid or
the definition of inpatient or outpatient hospital services.
Personal care services in a recipient's home refer to services prescribed by a physician in accordance with
the recipient's plan of treatment and provided by an individual who is qualified to provide the services,
supervised by a registered nurse, and not a member of the recipient's family (42 CFR 440.170(f)). It should
be noted that states which are granted a waiver under Section 2176 for home and community-based services
(that an individual needs to avoid institutionalization) are given the latitude to define personal care services
differently. As of April 1, 1984, 42 states had been approved for Section 2176 waivers.
Private duty nursing services refer to nursing services for recipients who require more individual and
continuous care than is available from a visiting nurse or routinely provided by the nursing staff of the
hospital or SNF (42 CFR 440.80). These services must be provided by a registered nurse or a licensed
practical nurse under the direction of the recipient's physician. The services must be provided in the
recipient's home, in a hospital, or in a SNF.
Optometrists are included in the 42 CFR 440.60 category of "medical or other remedial care provided by
licensed practitioners.' They are licensed practitioners and provide medical, remedial care, or services other
than physicians' services, within the scope of practice as defined under the state law.
Dental services (42 CFR 440.100) refer to diagnostic, preventive, or corrective procedures provided by or
under the supervision of a dentist. The services include treatment of:
The teeth and associated structure of the oral cavity; and
Disease, injury, or impairment that may affect the oral or general health of the recipient.
A dentist is defined to be an individual licensed to practice dentistry or oral surgery.
Podiatrists' services are one of the services included under 42 CFR 440.60, "medical or other remedial care
provided by licensed practitioners.These services include any medical or remedial care provided by a
podiatrist licensed and within the scope of practice as defined under state law.
Chiropractors' services are included under 42 CFR 440.60 "medical or other remedial care provided by
licensed practitioners.' Chiropractors' services are defined to include only services that consist of treatment
by means of manual manipulation of the spine that the chiropractor is legally authorized by the state to
perform. In addition to being licensed by the state, the chiropractor must also meet the standard issued by
the Secretary of HHS. These standards include age, education, and licensure standards.
Prosthetic devices are defined by 42 CFR 440.120(c) to mean replacement, corrective, or supportive devices
prescribed by a physician or other licensed practitioner of the healing arts within the scope of practice as
defined by state law. The devices must:
"
Artificially replace a missing portion of the body;
Prevent or correct physical deformity or malfunction; or
Support a weak or deformed portion of the body.
Physical therapy according to 42 CFR 440.110(a) refers to services prescribed by a physician and provided
to a recipient by or under the direction of a qualified physical therapist. To be a qualified physical therapist
an individual must be licensed by the state, where applicable, and be a graduate of a program of physical
therapy approved by both the Council on Medical Education of the American Medical Association and the
American Physical Therapy Association or its equivalent. Physical therapy includes any necessary supplies
and equipment.
Occupational therapy (42 CFR 440.1 lO(b)) refers to services prescribed by a physician and provided to a
recipient by or under the direction of a qualified occupational therapist. A qualified occupational therapist
is an individual who is either registered by the American Occupational Therapy Association or who is a
graduate of an approved occupational therapy program (by the Council on Medical Education of the
American Medical Association) and engaged in the supplemental clinical experience required by the American
Occupational Therapy Association. Occupational therapy services include any necessary supplies and
equipment.
Services for individuals with speech, hearing and language disorders are provided as an optional service
in 33 states. These services are diagnostic, screening, preventive, or corrective services provided by or
under the direction of a speech pathologist or audiologist for which a patient is referred by a physician (42
CFR 440.1 10(c)). It includes any necessary supplies and equipment. A speech pathologist or audiologist
is an individual who has a certificate of clinical competence from the American Speech and Hearing
Association, has completed the equivalent educational requirements and work experience necessary for the
certificate, or has completed the academic program and is acquiring supervised work experience to qualify
for the certificate.
Diagnostic services (42 CFR 440.130(a)) include medical procedures or supplies recommended by a
physician, or other licensed practitioner of the healing arts, within the scope of his practice under state law.
The services must enable the practitioner to identify the existence, nature or extent of illness, injury, or other
health deviation i n a recipient.
Screening services (42 CFR 440.130(b)) refer to the use of standardized tests given under medical direction
in the mass examination of a designated population to detect the existence of one or more particular
diseases.
Preventive services (42 CFR 440.1 30(c)) are those that prevent disease, disability, and other health conditions
or their progression; services that prolong life; and services that promote physical and mental heaith and
efficiency. Preventive services must be provided by a physician or other licensed practitioner of the healing
arts within the scope of practice under state law.
Rehabilitative services (42 CFR 440.130(d)) are medical or remedial services for reduction of physical or
mental disability and restoration of a recipient to his best possible functional level. The services must be
recommended by a physician or other licensed practitioner of the healing arts within the scope of his practice
under state law.
MEDICALLY NEEDY COVERAGE AND LIMITATIONS
A state plan must specify that, as a minimum, categorically needy recipients are provided the mandatory
services. Additionally, if a state plan includes the medically needy, it must provide, as a minimum, the
following services (42 CFR 440.220):
"
Prenatal care and delivery services for pregnant women;
Ambulatory services to individuals under age 18 and individuals entitled to institutional services;
"
Home health services to individuals entitled to SNF services; and
If the state plan includes services either in institutions for mental diseases or in ICF-MRs, it must
offer either of the following to each of the medically needy group: the services contained in 42
CFR sections 440.10 through 440.50 and 440.165 (to the extent that nurse-midwives are
authorized to practice under state law or regulations); and the services contained in any seven
of the sections in 42 CFR 440.10 through 42 CFR 440.165.
The state can, in addition, provide any other services to the medically needy without being bound by
requirements pertaining to a minimum number of services or a mix of institutional and non-institutional
services. Furthermore, a state may offer one set of services for a certain medically needy group without
being required to offer them to all the medically needy groups.
COST SHARING
States are permitted to require certain recipients to share some of the costs of Medicaid by imposing upon
them such payments as enrollment fees, premiums, deductibles, coinsurance, copayments, or similar cost
sharing charges (42 CFR 447.50). For states that impose cost sharing payments, the regulations specify the
standards and conditions under which states may impose cost sharing, set forth minimum amounts and the
methods for determining maximum amounts, and describe limitations on availability that relate to cost sharing
requirements. With the passage of the Social Security Amendments of 1972, states were empowered to
impose "nominal" cost sharing requirements on optional Medicaid services for cash assistance recipients, and
on any services for the medically needy. Section 131 of the Tax Equity and Fiscal Responsibility Act (TEFRA)
of 1982 introduced major changes to Medicaid cost sharing requirements. States may now impose a nominal
deductible, coinsurance, copayment, or similar charge upon both categorically needy and medically needy
for any service offered under the state plan. Public Law 97-248, TEFRA, has been in effect since October
1982 and it prohibits imposition of cost sharing on the following:
Services furnished to individuals under 18 years of age (or up to 21 at state option);
Pregnancy-related services (or, at state option, any service provided to pregnant women):
Services provided to certain institutionalized individuals, who are required to spend all of their
income for medical care except for a personal needs allowance;
" Emergency services;
"
Family planning services and supplies; and
"
Services furnished to categorically needy HMO enrolles (or, at state option, services provided
to both categorically needy HMO enrolles (or, at state option, services provided to both
categorically needy and medically needy HMO enrolles).
In addition, no more than one type of charge can be imposed on any service.
While emergency services are excluded from cost sharing, states may apply for waivers of nominal amounts
for non-emergency services furnished in hospital emergency rooms. Such a waiver allows states to impose
a copayment amount up to twice the current maximum for such services. Approval of a waiver request by
HCFA is based partly on the state's assurance that recipients will have access to alternative sources of care.
Medicaid Management Information System
The Social Security Amendments of 1972 authorized 90 percent federal matching to states for the costs of
design, development, and installation or improvement of mechanized claims processing and information
retrieval systems, and 75 percent for the costs of operating such systems, if the system is approved by the
Administrator.
The MMlS is a general systems design that can be tailored by state Medicaid agencies to their own particular
needs so long as the system meets federally required minimum performance standards. The conceptual
design includes six subsystems: recipient, provider, claims processing, reference file, surveillance and
utilization review, and management and administration reporting. The first four subsystems work together
with the overall objective of processing and paying each eligible provider for every valid claim. The other
two subsystems consolidate and organize data necessary for managing and controlling the Medicaid
program.
Forty-four states have certified MMlSs and operate a mechanized claims processing and information retrieval
system. (1 988)
Medicaid Claims Processing Activity
States handle the processing of Medicaid claims in different ways. There is variability in who handles the
claims for each service type. Claims processing activities for prescription drugs are handled by fiscal agents
in 30 states, by states themselves in 16 states, and by a combination of fiscal agentlstate in four states.
(1 988)
Medicaid Quality Control
Each state agency must operate a Medicaid Quality Control (MQC) system designed to reduce erroneous
expenditures by monitoring eligibility determinations, third-party liability activities, and claims processing (42
CFR 431.800(a)).
MEDICAID PRINCIPLES OF REIMBURSEMENT
From the inception of Medicare and Medicaid in 1965, there were two fundamental axioms related to provider
reimbursement. The first was that reimbursement be based upon reasonable cost or reasonable charges;
basically the same philosophy used by private insurance carriers. This, it was reasoned, would ensure equity
of reimbursement and adequate participation on the part of hospitals and physicians to ensure recipient
access to quality mainstream medicine; i.e., traditional, private, fee-for-service care, just as that enjoyed by
privately insured citizens. The second axiom was freedom of choice; meaning that Medicare and Medicaid
recipients would be free to choose from among many providers of care on the basis of convenience and
satisfaction. The 1972 Social Security Amendments liberalized eligibility for Medicaid to include SSI recipients
(cash assistance to poor elderly, blind, and disabled) and; at state option, certain optionally categorically
needy groups and certain medically needy people who would otherwise qualify for the cash assistance pro-
grams if it were not for moderately excessive income or resources. These policy decisions set the stage for
explosive growth in Medicaid expenditures throughout the remainder of the seventies. Up through fiscal year
1981, Medicaid experienced double-digit annual growth rates, with hospitals and nursing homes representing
three-quarters of total national expenditures.
Although Medicaid has been unquestionably successful in improving access by the poor to health services
generally (Davis and Schoen, 1978), it has been much less successful in ensuring access to mainstream
medical care.' As gatekeepers to the rest of the health care system, private physicians did not respond to
the program as its architects had assumed. Part of this has to do with the welfare stigma of Medicaid clien-
tele and part to do with reimbursement rates for both Medicare and Medicaid falling behind those offered
by private insurance carriers. Over 25 percent of the nation's private practice physicians refuse to treat
Medicaid patients, and participation among key specialists such as OB-GYNS is even lower.2 in the nation's
highly urbanized areas in which the majority of Medicaid recipients live, low office-based physician
participation rates drive large numbers of Medicaid recipients to costly hospital-based settings for routine
primary care; hence, higher costs per recipient.
'
Davis and Shoen, Health and the War on Poveny, A Ten Year Appraisal; Brookings Institution,
1978.
Mitchell and Cromwell, "Large Medicaid Practices and Medicaid Mills," Journal of the American
Medical Association, November 1980.
Quite inadvertently, the architects of the Medicaid program designed built-in reimbursement incentives that
would undermine its overall goal, access by the poor to quality mainstream medicine at reasonable costs.
In the late seventies through 1980 states tried, with varying levels of success, to contain costs of the program
through the use of more stringent eligibility requirements, imposition of service cutbacks and limitations,
tighter administrative Controls, and postponement of increases in physician and pharmacy reimbursement.
Although numbers of recipients declined, the cost per recipient continued to rise sharply. It became obvious
to HCFA that something had to be done about Medicaid cost-based provider reimbursement incentives for
hospitals and nursing homes which had no real incentive to contain rising costs. Since the unit of payment
was per diem, there was even an incentive to maximize utilization so long as the Medicaid revenue played
a useful role in the overall financial health of hospitals and nursing homes. Further, Medicaid eligibility rules
led physicians to institutionalize patients so they would be eligible for needed services. The first significant
legislative step to redress provider incentives came in 1980 with the Omnibus Reconciliation Act of 1980 (PL
96-499). The Act replaced Section 249(a) of the 1972 Social Security Amendments requiring Medicare-based
retrospective cost reimbursement principles for nursing homes. States were freed to reimburse nursing
homes on the basis of "reasonable and adequate to the costs which must be incurred by efficiently and
economically operated facilities." Many states moved swiftly to implement prospective reimbursement
methodologies to curb inflation in nursing home costs.
The second significant step in reforming Medicaid provider reimbursement came with passage of the
Omnibus Reconciliation Act of 1981 (PL 9735). Among other things, the Act, implemented by federal
regulations on September 30, 1981, granted significant new flexibility to the states in setting provider
reimbursement policies for hospitals (Section 2173) and physicians (Section 21 74) by relaxing the constraints
which tied payments to Medicare retrospective cost reimbursement principles. States quickly began to adopt
alternate payment methods tailored to their own unique needs. The Act gave states waiver authority to
restrict freedom of choice (section 2175) and to eliminate the institutional bias towards institutional long-term
care through home and community-based care (Section 2176). The Act also gave the states new flexibility
to enter into prepaid service arrangements with non-federally qualified HMOs and to impose certain copay-
ments on service use by Medicaid recipients.
The third significant piece of legislation affecting Medicaid provider reimbursement policies is the Tax Equity
and Fiscal Responsibility Act of 1982. TEFRA actually rescinded some of the flexibility given to the states
through OBRA 81 by removing the authority given to the Secretary of DHHS to grant waivers for capitation
and prepayment systems to other than federally qualified HMOs and restricted the imposition of nominal
copayments by exempting from any copayment certain recipient types and services. The TEFRA contained
two other important provisions related to Medicaid reimbursement. The first was a requirement that the
Secretary of DHHS recommend a system of prospective reimbursement for the Medicare program which
might apply to the Medicaid inpatient reimbursement setting. The second was an expansion of Section 223
limitations on hospital charges from routine hospital costs per day to the cost per case, including ancillary
costs. Special adjustments are to be made for hospitals which have a disproportionate load of low income
or Medicare patients, and for psychiatric hospitals. Non-SMSA hospitals with less than 50 beds will be
excluded from the limitations.
Another step to reform Medicaid provider reimbursement is the Social Security Act Amendments of 1983.
This Act mandates a three-year phase-in of a case rate prospective reimbursement system for Medicare
that could also be adopted by state Medicaid agencies. The Medicare Prospective Payment System (PPS)
is based on a prospectively determined rate for each patient according to age, sex and diagnostically-related
grouping (DRG). To date, several state Medicaid programs have adapted the new Medicare PPS concept
to their own hospital reimbursement system?
-
Clinkscale, Robert, "Impact of Medicare's Prospective Payment System (PPS) on State Medicaid
Programs," Proceedings, First Nat~onal DRG Conference, Atlantic City, NJ, 1983.
Further changes to promote economy and to generate savings in the Medicaid programs will result from
implementing section 2314 of the Deficit Reduction Act of 1984 and sections 91 10 and 9509 of the
Consolidated Omnibus Budget Reconcilation Act of 1985 (Pub. L. 99-272), enacted on April 7, 1986. These
changes affect reimbursing providers for patient-care related capital costs by limiting the valuation of assets
acquired as the result of changes in ownership occuring on or after July 18, 1984.
A recent legislative provision intends to clarify the flexibility granted State Medicaid payment systems for
inpatient services. Section 9433 of OBRA 1984 (Pub. L. 99-509), provides that nothing in Title XIX of the
Social Security Act shall be construed as authorizing the Secretary to limit the amount of payment
adjustments that may be under a Medicaid plan with respect to hospitals that serve a disproportionate
number of low-income patients with special needs. This provision is intended to aid only hospitals meeting
the States' definition of a hospital that serves a disproportionate number of such patients. States are now
not limited in the amount of a payment adjustment (e.g., an add-on or a percent increase over a base
payment amount) that may be granted to eligible hospitals for fiscal relief for specific costs incurred in
providing care to these recipients.
Other changes to the Medicaid program will result from recently passed legislation entitled Wedicare
Catastrophic Coverage Act of 1988. ~r ovi si ons relating to the medicaid program include Title Ill, Section
301, requiring medicaid buyers of premiums and cost-sharing for indigent medicare beneficiaries; Section
302, coverage and payments for pregnant women and infants with incomes below the poverty level and
Section 303, protection of income and resources of couples for maintenance of community spouse.
In summary, the above discussion represents a historical perspective or context in which to consider how
states altered their Medicaid provider reimbursement policies in recent years.
Only nursing home, inpatient hospital, physician, outpatient hospital, free-standing clinics and prescription
drug sewice reimbursement policies are included in this report. These services represent about 90.9 percent
of all Medicaid expenditures for fiscal year 1988.
NURSING HOME REIMBURSEMENT
Expenditures for nursing home services is the largest and most rapidly growing component of national
Medicaid outlays. From fiscal year 1982 through fiscal year 1988, Medicaid expenditures for nursing homes
increased from $12.9 billion to $20.2 billion. ICF-MR nursing expenditures continue to rise at a much higher
rate than for SNF and ICF homes. Most state Medicaid programs have departed from Medicare principles
of reimbursement in favor of various forms of prospective reimbursement where rates and rate increases are
negotiated or determined by formulas prior to each new fiscal year. The prospective methods are generally
either facility specific negotiated rates or class rates based on type of facility, size, and location. Some states
use a combination of methods.
Other recent initiatives to contain nursing home Medicaid expenditures include restrictions in licensed bed
capacity, more stringent patient assessment protocols for entry into homes, and emphasis on home and
community-based care settings as an alternative to expensive institutional care.
INPATIENT HOSPITAL SERVICES REIMBURSEMENT
Inpatient hospital services are the second largest component of Medicaid expenditures nationwide, accounting
for $13.5 billion or 27.6 percent of Medicaid outlays in fiscal year 1988. Prior to the Omnibus Budget
Reconciliation Act of 1981, states were generally compelled to use Medicare reasonable cost-based
reimbursement principles unless authorized by DHHS to adopt an alternative method.
post-OBRA Environment
BY early 1984, only 17 states (17 percent of national inpatient expenditures) still used the Medicare
retrospective cost-based method. The other 33 states (83 percent of total inpatient expenditures) had moved
to adopt either an alternative plan or an experimental system of inpatient reimbursement. States using
experimental systems based on diagnostic-related groupings (DRGs) are New Jersey, Pennsylvania, Michigan,
Ohio, Vermont, and Washington. Most of the other states using alternative systems have tended toward
facility-specific budget review, rate of increase control and forms of prospective rate-setting. Among those
states that had departed from Medicare principles by early 1982, only two had extended the method to
private payers (Massachusetts and Rhode Island). The systems in Maryland, New Jersey, and New York en-
compass all payers. The dates for states using alternative methods represent the year in which the method
was approved by DHHS and implemented. By early 1982 the method may have undergone modifications
since its original approval. As a result of OBRA 81, many other states are expected to abandon inpatient
Medicare reimbursement principles.
Between March Of 1983 and March of 1984, the states of Alaska, Arkansas, District of Columbia, Georgia,
Minnesota, Nevada, Oklahoma, Oregon, Tennessee, and Utah altered their Medicare-based inpatient
reimbursement systems to some form of prospective payment.
PHYSICIAN SERVICES REIMBURSEMENT
Expenditures for physician services are the fourth largest component of Medicaid expenditures. In fiscal
year 1988, physician services accounted for $2.9 billion, or 6.0 percent of Medicaid expenditures nationwide.
States have broad discretion within general federal guidelines regarding Medicaid reimbursement to
physicians. Unlike Medicare, which uses the statutorily mandated customary, prevailing and reasonable
(CPR) charge methodology, state Medicaid programs can use either the CPR method or a fee schedule
approach; whichever is the lower. The Omnibus Budget Reconciliation Act of 1981 freed states from the
CPR-based upper limit. States are now free to set physician Medicaid reimbursement payments at their
discretion so long as they are Qdequate and reasonable. "The CPR method used by Medicare limits
reimbursement to the lowest of the following: a physician's actual charge, the physician's median charge
in a recent prior period (customary), or the 75th percentile of charges in that same period (prevailing). Any
prevailing charges at or under the 75th percentile criterion are considered "reasonable.' In some states, the
75th percentile is determined on the basis of physicians' charges in the same specialty and/or sub-state
region; in others, states use charge data from all physicians regardless of specialty or sub-state region.
Finally, since 1976 an %conomic index" has been applied to limit the rate of increases in Medicare prevailing
rates. Technically, Medicaid regulations refer to a "usual, customary and reasonable" (UCR) method. Other
than confusion over definitions, the UCR method and the CPR methods are the same.4 Within this
framework, state Medicaid programs set physician reimbursement rates using the Medicaid method or a fee
schedule, whichever is the lower. Some states have delayed in updating physician charge profiles, use
artificially low economic indices, or simply elect to reimburse at below Medicare's 75th percentile of pre-
vailing to the point where they have in reality converted to a fee schedule.
Spitz, Bruce, State Guide to Medicaid Cost Containment, National Governors' Association and
Intergovernmental Health Policy Project, September 1981.
18
OUTPATIENT HOSPITAL, CLINIC
Outpatient hospital services refer to emergency rooms and hospital-based ambulatory care clinics. Clinics"
refer to free-standing physician-supervised ambulatory care settings; this excludes rural health clinics. Federal
regulations specify only that Medicaid payments for outpatient hospital services cannot exceed charges to
Medicare. Below this ceiling, rates can be altered downward to reflect local conditions and preferences.
There is flexibility to differentiate rates among emergency room care, specialized outpatient services, and
primary care services. As with inpatient care, the trend has been for more and more states to abandon
Medicare principles to reimburse outpatient hospital services in favor of alternate methods. Five states repor-
ted no coverage for free-standing clinic services. Three states reported adherence to Medicare principles.
There were 41 states using alternate methods (these 41 states represented 99 percent of total Medicaid clinic
services expenditures).
PRESCRIPTION DRUG REIMBURSEMENT
(Existing System)
Federal Medicaid regulations dictate the method for reimbursing prescription drugs. Reimbursement is
made on a retrospective, fee-for-service basis with payments limited to the lower of the pharmacy's usual
and customary charge or the cost of the drug product plus an established dispensing fee to cover the
pharmacy's overhead and profit. (Some states have experimented with enrolling Medicaid eligibles in Health
Maintenance Organizations under capitated payment contracts.) In 1976, utilizing the authority to set an
upper limit for services available under Medicaid programs as provided under Section 1902(a)(30)(A) of the
Social Security Act, the Health Care Financing Administration (HCFA), HHS implemented drug reimbursement
rules at 45 CFR Pan 19 pertaining to upper payment limits for Medicaid and other programs. Specifically,
these regulations provided that the amount the Department recognized for drug reimbursement or payment
purposes was not to exceed the lowest of:
the maximum allowable cost (MAC) of the drug, as established by HCFA's pharmaceutical
reimbursement board for certain multi-source drugs (generic drugs), plus a reasonable
dispensing fee;
the estimated acquisition cost (EAC) of the drug (the price generally and currently paid by
providers for a particular drug in the package size most frequently purchased by providers), as
determined by the program agency, plus a reasonable dispensing fee; or
the providers' usual and customary charge to the public for the drug;
"
the regulations provided that the MAC would not apply if the prescriber has certified in his or
her own handwriting that a certain brand of that drug is medically necessary for the patient.
The regulations at 45 CFR Part 19 also established within HCFA a pharmaceutical reimbursement board
(PRB). The PRB identified multiple-source drugs for which significant amounts of federal funds were
expended and was responsible for establishing the MAC for those drugs. The PRB set the MAC at the
lowest unit price for which the drug is widely and consistently available. In addition to limiting the level of
payment for multiple-source drugs, the MAC program tended to promote substitution of lower cost drug
products for brand name drugs.
During its decade of implementation, a number of problems and concerns were voiced about the MAC
program by the pharmacies and the pharmaceutical industry. Specific concerns included:
quality of multi-source drugs;
the interpretation 'widely and consistently available-s related to the process used by the PRB
in setting MAC limits;
"
the adequacy of drug reimbursement; and
problems and administering the MAC and EAC programs
In 1983, a departmental task force was established to review the Department's drug reimbursement
regulations at 45 CFR Part 19. Subsequent to the Department's review process, an NPRM notice of
proposed rule making was published on August 19, 1986. The NPRM (51 FR 29560) proposed to remove
the Department's rule at 45 CFR Part 19 that limited drug reimbursement under certain federal programs
including Medicaid. The Department proposed three alternative approaches to the current Medicaid rules
(42 CFR 447.331 through 447.334) regarding upper limits for drug reimbursement and invited public comment
on all three suggestions, as well as suggestions for alternatives which would improve any of the three
recommendations. The three recommendations included:
Pharmacists Incentive Program (PhlP)
"
revisions to the current MAC programs
Competitive lncentive Program(CIP)
Discussions outlining these proposals appear in the following pages under Federal Register Vol. 52 No.
147, Friday, July 31, 1987.
FINAL RULE ON MEDICAID PRESCRIPTION DRUG REIMBURSEMENT
On Friday, July 31, 1987, the Health Care Financing Administration (HCFA), HHS, published a notice of the
final rule for limits on payments for drugs in the Medicaid program. The regulations adopted in the rule
become effective on October 29, 1987 (52 FR 28648).
Provisions of the final regulations.
In this final rule, HCFA has attempted to (1) respond to public comments on the NPRM (51 FR 2956); (2)
provide maximum flexibility to the states in their administration of the Medicaid program; (3) provide
responsible but not burdensome federal oversight of the Medicaid program; and (4) take advantage of
savings in the marketplace for multiple source drugs.
To accomplish this, HCFA is adopting a federal upper limit standard for certain multiple-source drugs based
upon application of a specific formula. The upper limit for other drugs is similar in that it retains the EAC
as the upper limit standard that state agencies must meet. However, this standard is applied on an
aggregate basis rather than on a prescription specific basis. State agencies are therefore encouraged to
exercise maximum flexibility in establishing their own payment methodologies. (See Federal Reqister, Vol.
52, No. 147, Friday, July 31, 1987, p 28648.)
Multiple-source Drugs:
A multiple-source drug is a drug marketed or sold by two more manufacturers or labelers, or a drug
marketed or sold by the same manufacturer or labeler under two or more different proprietary names or
both under a proprietary name and without such a name.
A specific upper limit for a multiple-source drug may be established if the following requirements are met:
1. All of the formulations of the drug approved by the Food and Drug Administration (FDA) have
been evaluated as therapeutically equivalent in their current edition of the publication, Approved
Drug Products with Therapeutically Equivalent Evaluations, and
2. At least three suppliers list the drug (which is classified by the FDA as Category A in its
publication) in the current editions of published compendia of cost information for drugs available
for sale nationally.
The upper limit for a multiple-source drug for which a specific limit has been established does not apply if
a physician certifies in his or her own handwriting that a specific brand is "medically necessary' for a
particular recipient. The handwritten phrase 'brand necessarv."medicallv necessarv.' or 'brand medically
necessarv' must amear on the face of the prescription. The rule specifically states that a check-off box
on a prescription form is not acceptable, but it does not address the use of two-line prescription forms.
The formula to be used in calculating the aggregate upper limit of payment for certain multiple-source drugs
will be 150% of the least costly therapeutic equivalent that can be purchased by pharmacists in quantities
of 100 tablets or capsules (or if the drug is not commonly available in quantities of 100, the package size
commonly listed), or in the case of liquids the commonly listed size, plus a reasonable dispensing fee.
Other Drugs:
A drug described as 'other drug" is (1) a brand name drug certified as medically necessary by the physician,
(2) a multiple-source drug not subject to the 150% formula; or (3) single-source drugs. Payments for these
drugs must not exceed, in the aggregate, payment levels determined by applying the lower of:
Estimated Acquisition Cost (EAC) plus reasonable dispensing fees or
O
the provider's usual and customary charges to the general public.
States may continue to use their existing EAC program, or adopt another method, as long as their aggregate
expenditures do not exceed what would have been paid under EAC principles.
Conclusion:
The Health Care Financing Administration (HCFA) publishes a list of those multiple-source drugs to which
the upper limit payment formula will apply (see page 62). Revisions to the list will be provided through
Medicaid program issuances 'State Medicaid Manual - Part 6 Payment for Sewices" on a periodic basis. Any
price revisions will be included in these issuances.
The states are required in the rule to submit a state plan that describes their payment methodology for
prescribed drugs. The rule does not prescribe a preferred payment method as long as the state's aggregate
spending in each category is equal to or below the upper limit requirements. States are also required to
submit assurances to HCFA that the requirements are met.
This new rule does not prescribe a preferred payment method for the states, but gives states the flexibility
to determine how they will pay for prescription drugs under Medicaid. As long as the state's aggregate
spending is at or below the amount derived from the formula, the state is free to maintain its current payment
program or adopt other methods. States can alter payment rates for individual drugs, balancing payment
increases for certain products with payment decreases for other drugs so that in the aggregate, the program
does not exceed the established limit. With the establishment of upper limit payment maximums, some states
may alter their current payment methodologies to comply with the established limitations. State programs
will vary, depending upon whether or not state maximum allowable cost programs cover the same drugs
listed by HCFA. States with established MAC programs may remain unaffected if their MAC rates are already
low, or they may have to make certain adjustments in their MAC levels to meet the federal aaareaate
expenditure limits. States without MAC programs may develop a new payment methodology to increase the
use of lower cost generic drug products in order to keep within the upper payment limits, or may simply
adopt HCFA's formula for listed drug products.
Medicaid Smndinq Rose i n 1988. States Cover More Women and Children
Medicaid spending rose in 1988 as states took advantage of a new federal law and expanded eligibility for
poor women and their children. Half the states expanded coverage of poor pregnant women, infants, and
children; more are expected to follow suit in 1988-1989. The Omnibus Budget Reconciliation Act of 1986
allowed states to cover those groups if they are in families with income below the federal poverty line. The
1987 growth rate is about the same as in the previous two years, says the Intergovernmental Health Policy
Project (IHPP), but exceeds the 7.5 percent growth rate from 1981 to 1984. States also continued to respond
to the impact of AlDS on Medicaid budgets; all but six covered the costs of AZT: three (CA, IL, WI) offer
higher payments to providers who care for AlDS patients. New Jersey and New Mexico have Medicaid
waivers to provide home and community-based care to AlDS victims; five states plan to seek waivers in 1988.
Ten states offer case management to such groups as the chronically mentally ill and developmentally
disabled, substance abusers, and emotionally disturbed children; eight offer hospice care. The 1989 state
legislative sessions provided additional changes to the Medicaid programs as states attempt to deal with the
priority issues of AIDS, long term care, and indigent care.
IMPACT OF CATASTROPHIC COVERAGE
ON STATE MEDICAID PROGRAMS
Studies done by the Office of Management and Budget and the Congressional Budget Office have analyzed the costs
of catastrophic coverage to the Federal government and the Medicare beneficiaries. The additional costs to a state
Medicaid program are intended to be Offset by program savings, on the basis of an "average" state.
While the catastrophic care bill was intended to be self-funding, a large expenditure for the elderly and disabled has
been shifted to the States.
The impact of the new catastrophic coverage varies widely from one State to another due to demographics and
variations in the Medicaid programs.
Some of the important variables include:
1. Elderly as a percent of total population --the U.S. average is 12.2 percent, varying by state from a low
of 8.2 percent in Utah to a high of 17.8 percent in Florida.
2. Percent of elderly and disabled who are eligible for both Medicare and Medicaid. The U. S. average
is about 81 percent of the Medicaid recipients over 65 and 37 percent of disabled recipients.
3. Percent of elderly living below the poverty level -- a Census Bureau Study using 1979 data showed a
range from 8.3 percent in Connecticut to 34.3 percent in Mississippi. The data were adjusted to 1986
using a recent study by the Census Bureau published in Current Population Reports.
4. State Medicaid eligibility in relation to the Federal poverty level -- the states which are the most
conservative are the hardest hit by the new law. Some liberal states already include eligibles up to or
exceeding the poverty level in their program, and will realize an immediate savings.
Saving Wth Existing Eligibles
Savings can be calculated resulting from changes in Part A coverage, Part B coverage (including the cap on
expenditures), and the drug program, for the existing Medicaid eligibles.
Enhanced Part A benefits -- beneficiaries will now pay Only one in-hospital deductible per year, and will be
allowed as many days of inpatient care as needed without coinsurance. Skilled nursing home coverage has
been extended and hospice care is now included.
A new Part B payment limitation -- beneficiaries pay a deductible of $75 per year and a 20 perceni
copayment on each approved Medicare charge. Beginning January 1, 1990, when the deductible anc
copayments reach $1,370 -- Medicare will pay 100 percent of allowed charges for Part 6 expenses.
A new prescription drug benefit -- beginning January 1, 1990, Medicare will help pay for some intravenous
drugs and drugs used in immunosuppressive therapy. In 1991, this is extended to all prescription drugs.
Additional Costs Due t o Added Eligibles
States will be required to "buy-in" to Medicare for their dual eligibles and pay premiums, deductibles and coinsurance
for all Medicare beneficiaries up to the Federal poverty level.
Dual eligibles are persons eligible for both Medicare and Medicaid. Under those conditions, Medicaid is the payer
1
of last resort. The HCFA 2082 report, submitted annually by each state, shows state expenditures for dual eligibles.
I
The state pays the deductibles and copays which would normally be paid by the Medicare beneficialy. Studies have
1
shown that Medicare pays about 90 percent of Part A coverage and approximately 67 percent of Part B coverage.
1
It is important for a state to buy-in to Medicare for their dual eligibles and to get crossover claims properly identified
and processed.
I
i
Baldwin E. Kloer
Eli Lilly and Company
April 26, 1989 (Revised)
IMPACT ON MEDICAID
Although Medicare and Medicaid are separate programs, current law permits states to "buy into' the Medicare Program
for eligible beneficiaries. The Catastrophic Act will require states to phase in a Medicare buy-in for the elderly and
disabled poor based on (1) the percentage of incomes at or below the Federal poverty level ($5770 for an individual
in 1988) and (2) resources at or below twice the Supplemental Security Income program standard for 1988, $3800.
The buy-in requirements will be phased in according to the following schedule (percentage figures refer to Federal
poverty level): 1989 - 85%; 1990 - 90%; 1991 - 95%; 1992 - 100%. Pregnant women and infants up to one year old
with incomes at 100% of the poverty level for a family of three, $9690 for 1988, must also be covered by 1990, an
interim step will provide coverage for those at 75% of the level in 1989.
In 1991, the prescription drug benefit must also be offered to Medicaid-eligible beneficiaries now covered by Medicare,
subject the deductible and the coinsurance. However, states will be required to phase in payment of premiums,
deductibles, and coinsurance for those whose incomes are at or below the poverty level and whose resources are
at or below $3800. Alternatively, states will have to provide the same drug coverage as is offered to Medicaid
recipients. The phase-in will be according to the same schedule as the general buy-in requirement.
Robert Greenberg, J.D.
American Journal of Hospital Pharmacy
December 1988
GLOSSARY OF MEDICAID TERMS
Actual acquisition cost: The pharmacist's net payment made to purchase a drug product, after taking into
account such items as purchasing allowances, discounts, rebates and the like.
Average Wholesale Price (AWP): The composite wholesale prices charged on a specific commodity that is
assigned by the drug manufacturer and is listed in either the Red or Blue Books.
Capitation (fee): A per-member, monthly payment to a provider that covers contracted services, and is paid
in advance of this delivery. In essence, a provider agrees to provide specified services to HMO members
for this fixed, predetermined payment for a specified length of time (usually a year), regardless of how many
times the member uses the service. The rate can be fixed for all members, e.g., $10 per month, or it can
be adjusted for the age and sex of the member, based on actuarial projections of medical utilization.
Categorically Needy: Under Medicaid, categorically needy cases are aged, blind, or disabled individuals or
families and children who are otherwise eligible for Medicaid and who meet financial eligibility requirements
for AFDC, SSI, or an optional state supplement.
Coinsurance: A cost-sharing requirement under a health insurance policy which provides that the insured
will assume a portion or percentage of the costs of covered services.
Copayment: Copayments are a type of cost-sharing under Medicaid whereby insured or covered persons
pay a specified flat amount per unit of service or unit of time, and the insurer pays the rest of the cost.
Covered Services: Covered services are the specific services and supplies for which Medicaid will provide
reimbursement. Covered services under the Medicaid program consist of a combination of mandatory and
optional services within each state.
Customary, Prevailing, and Reasonable Charges: Method of reimbursement used under Medicare which limits
payment to the lowest of the following: a physician's actual charge, the physician's median charge in a
recent prior period (customary), or the 75th percentile of charges in that same time period (prevailing).
Customary Charge: The charge a physician or supplier usually bills his patients for furnishing a particular
service or supply is called the customary charge.
Deductible: A set dollar amount that a person must pay before insurance coverage for medical expenses
can begin.
Diagnosis Related Groups (DRGs): A classification system for hospital inpatients that groups patients
according to principal diagnosis, presence of a surgical procedure, age, presence or absence of significant
comorbidities or complications, and other relevant criteria. Originally developed at Yale University for use in
hospital utilization review, the DRG system is now used by the federal government for hospital payment under
Medicare. The set now in use, developed using 1979 data, includes 470 DRGs.
D N ~ Utilization: The prescribing, dispensing, administering and ingestion or use of pharmaceutical products.
Drug Utilization Review: Used by Medicaid and other health plans to monitor the frequency and usage of
prescriptions. Typically, a DUR committee examines the number of prescriptions per member per month and
the average cost per prescription. The utilization and costs of pharmaceuticals are reviewed by the
comminee for each physician, physician group, medical specialty, retail pharmacy, employee group, and
member.
Early and Periodic Screening, Diagnosis, and Treatment (EPSDTj: The EPSDT program covers screening
and diagnostic services to determine physical or mental defects in recipients under age 21, and health care,
treatment, and other measures to correct or ameliorate any defects and chronic conditions discovered.
Estimated Acquisition Cost (EAC): Estimated acquisition cost based on price information supplied at regular
intervals by the DHHS. This information will show estimated costs to groups of providers classified by dollar
volume of drug sales.
Expenditures: Under Medicaid, "expenditures" refers to an amount paid out by a state agency for the
covered medical expenses of eligible participants.
Family Planning Services: Family planning services are any medically approved means, including diagnosis,
treatment, drugs, supplies and devices, and related counseling which are furnished or prescribed by or under
the supervision of a physician for individuals of childbearing age for purposes of enabling such individuals
freely to determine the number or spacing of their children.
Federally Qualified HMOs: HMOs that meet certain federally stipulated provisions aimed at protecting
consumers: e.g., providing a broad range of basic health services, assuring financial solvency, and
monitoring the quality of care. HMOs must apply to the federal government for qualification. The process
is administered by the Office of Prepaid Health Care of the Health Care Financing Administration (HGFA),
Department of Health and Human Services (DHHS).
Fee for Sewice: A system of payment for health care whereby a fee is rendered for each sewice delivered.
This traditional method contrasts with that used in the prepaid sector, where services are covered by a fixed
payment made in advance that is independent of the number of services rendered.
Fiscal Agent: A fiscal agent is a contractor that processes or pays vendor claims on behalf of the Medicaid
agency.
Fiscal Intermediary: The agent (Blue Cross or an insurance company, for example) that has contracted with
providers of service to process claims for reimbursement under health care coverage. In addition to handling
financial matters, it may perform other functions such as providing consultative services or sewing as a center
for communicating with providers and making audits of providers' records.
Fiscal Year: Any twelve month period for which annual accounts are kept. The Federal Government's fiscal
year extends from October 1 to the following September 30.
Fi i ed Fee: An established 'Yee" schedule for pharmacy services allowed by certain government and private
third-party programs in lieu of cost-of-doing business markups.
Formul q: A list of selected pharmaceuticals and their appropriate dosages felt to be the most useful and
cost effective for patient care. Organizations often develop a formulary under the aegis of a pharmacy and
therapeutics (P&T) committee. In HMOs, physicians are often required to prescribe from the formulary.
Gatekeeper: The primary care HMO physician who must authorize all medical services, e.g., hospitalizations,
diagnostic workups, and specialty referrals, as a condition of their being covered by the HMO. For instance,
a patient is not covered for a visit to a specialist without prior approval of the generalist.
Generic Substitution: Substituting a generic version of a branded off-patent pharmaceutical for the branded
product when the latter is prescribed. Some HMOs and Medicaid programs mandate generic substitution.
Mandatory generic substitution within the Medicare program is currently being debated in Congress.
Health Maintenance Organizations (HMO's): In broad terms, an HMO is a form of health insurance. An HMO
provides health care services for members who prepay a premium that generally covers a specified range
of both inpatient and ambulatory care. Providers share the risk of the cost of care with the HMO.
Prescription drugs may be included either as part of the basic benefit package or as an option. Traditionally,
there have been four main types or models of HMOs, classified according to the financial and organizational
arrangements between the HMO and its physicians.
HMO - Model Types:
Group Practice or Closed Panel -The HMO contracts with a group of physicians, which is paid a set
amount per patient to provide a specified range of services. The group of physicians determines the
compensation of each individual physician, often sharing profits. The practice may be located in a hospital
setting or clinic. Like staff model HMOs, the medical facility usually contains a pharmacy, but in some cases
the HMO contracts for pharmacy services.
Staff HMO - An HMO that hires its physicians individually and pays them a Salary to practice i n the
HMO facility or clinic. Because physicians in this model and group model HMOs traditionally have had few,
if any, fee-for-service patients of their own, both models are often referred to as closed-panel HMOs. The
physicians are subject to the policies of the HMO management. The HMO facility often contains a pharmacy,
but in some cases the HMO will contract for pharmacy services. As in all the models, the affiliated pharmacy
may be paid either a fee for service or a capitation.
Network - A Network Model HMO is essentially an IPA of group practices rather than individual
physicians. Each of the contracted group practices sees HMO patients as well as fee-for-se~ice patients
in its group offices.
Home Health Services: Home health services are services and items furnished to an individual who i s under
the care of a physician by a home health agency, or by others under arrangements made by such agency.
The services are furnished under a plan established and periodically reviewed by a physician. The services
are provided on a visiting basis in an individual's home and include: part-time Or intermittent skilled nursing
care; physical, occupational, or speech therapy; medical social services, medical supplies and appliances
(other than drugs and biologicals); home health aide services, and services of interns and residents.
Home Health Agency: A home health agency is a public agency or private organization which is primarily
engaged in providing skilled nursing services and other therapeutic services in the patient's home, and which
meets certain conditions designed to ensure the health and safety of the individuals who are furnished these
services.
Hybrid Model HMO: An HMO that combines attributes of more than one of the four principal HMO models
and hence is not classifiable in any one of the four categories.
There are exceptions to these definitions. For instance, a group model HMO may allow its physicians to see
a number of fee-for-semjce patients. As competition increases in the health care marketplace, hMOs are
varying their traditional organizational and financial arrangements on a large scale. A knowledge of the four
basic models, however, facilitates a basic understanding of the organization of the industry.
Indemnity Benefit: The patient or consumer pays directly for the services or products and is reimbursed by
a third pany.
Ind'~idua1 Practice Association (IPA): An IPA contracts with individual physicians who see HMO members
as well as their own patients, in their own private offices. It is the ability of IPA physicians to see both HMO
and private patients in their own offices that principally differentiates an IPA from a group or staff HMO.
Physicians in an IPA are paid either on a capitation or a modified fee-for-service basis. An IPA HMO may
also contract with chain or independent pharmacies to dispense prescriptions to members.
Inpatient Hospital Services: lnpatient hospital services are items and services furnished to an inpatient of
a hospital by the hospital, including bed and board, nursing and related sen/ices, diagnostic and therapeu-
tic services, and medical or surgical services.
Intermediate Care Facility: An intermediate care facility is an institution furnishing health-related care and
services to individuals who do not require the degree of care provided by hospitals or skilled nursing facii-
ities as defined under Title XIX (Medicaid) of the Social Security Act.
Laboratory and Radiological Services: Laboratory and radiological ?.elvices are Professional and technical
laboratory and radiological services ordered by a licensed practitioner and provided in an office or similar
facility (other than a hospital outpatient department or clinic) or by a qualified laboratory.
Legend Drug: A drug product that cannot be dispensed legally without a prescription.
Managed Care: A relatively new term coined originally to refer to the prepaid health care sector, e.g., HMOs
and CMPs, where care is provided under a fixed budget and costs are therein capable of being Wanaged:
Increasingly, the term is being used by many analysts to include PPOS and even forms of indemnity
insurance Coverage that incorporate preadmission certification and other utilization controls.
Maximum Allowable Cost, or 'Reasonable Cost Range': A maximum cost is fixed for which the pharmacist
can be reimbursed for selected products, as identified in a 'formulary."
Medicaid: A government health program, established by Title XIX of the Social Securlty Act, for people with
low incomes. Each state administers its own program. Medicaid is funded by both the state and federal
governments.
Medicaid Management Information System: Federally developed set of guidelines for computer system
design to achieve national standardization of Medicaid claims processing, payment, review and reporting for
all medical health care claims.
Medically Needy: Under Medicaid, medically needy cases are aged, blind, or disabled individuals or families
and children who are otherwise eligible for Medicaid, and whose income resources are above the limits for
eligibility as categorically needy (AFDC or SSI) but are within limits set under the Medicaid state plan.
Medicare: A federal health insurance program, established by Title XVlll of the Social Security Act, for elderly
and disabled. It is funded principally by FICA payroll deductions and somewhat by general revenues. It is
administered by the Health Care Financing Administration (HCFA), Department of Health and Human Services
(DHHS) of the federal government. It has a program to enable the elderly to enroll in HMOs.
Other Practitioners' Services: Other practitioners' services are health care services of licensed practitioners
other than physicians and dentists.
Outpatient Hospital Services: Outpatient hospital services are services furnished to outpatients by a
participating hospital for diagnosis or treatment of an illness or injury.
Peer Review A review by members of the profession "peers' regarding the quality of care provided a patient,
including documentation of care (medical audit), diagnostic steps used, conclusions reached, therapy given,
appropriateness of utilization (utilization review), and reasonableness of charges claimed.
Peer Review Organization (PRO): An organization which contracts with the federal government to conduct
utilization review for the Medicare program. PROS are intended to prevent overutilization of hospital services
and to assure the quality of care provided to Medicare beneficiaries.
Prepaid Group Practice Plans: Organized medical groups of essentially full-time physicians in appropriate
specialties, as well as other professional and subprofessional personnel, who, for regular compensation,
undertake to provide comprehensive care to an enrolled population for premium payments that are made in
advance by the consumer and/or their employers.
Preferred Provider Organization (PPO): Typically, a group of hospitals, physicians and/or pharmacists that
contracts on a discounted fee-for-sewice basis with employers, insurance carriers, or a third-party
administrator to provide services to subscribers. Provider charges are usually 10% to 20% below usual fees.
There is substantial variation in organizational and financial arrangements amount PPOs. PPOs are often
formed as a competitive response to HMOs. There are exceptions to this definition of PPOs, just as there
are to that for HMOs. For example, some PPOs are now emerging that require providers to share in the
financial risk, and others are employing the gatekeeper concept.
Pr e s c n i D ~ g s : Prescribed drugs are drugs dispensed by a licensed pharmacist on the prescription of
a practitioner licensed by law to administer such drugs, and drugs dispensed by a licensed practitioner to
his own patients. This item does not include a practitioner's drug charges that are not separable from his
other charges, or drugs covered by a hospital's bill.
Prospective Payment Assessment Commission (ProPAC): A 15 member commission, appointed by the
Director of the Office of Technology Assessment, which makes recommendations to the Secretaty of Health
and Human Services on various aspects of the diagnosis related group system of Medicare reimbursement.
it will advise the Secretary on the appropriate annual percentage change in DRG payment rates and on the
need for changes in the DRG classification system, (e.g., new DRGs, modifications to existing DRGs) and
in the weighing of individual DRGs.
Prospectke Financing: Financing for health care services based on prices or budgets determined prior to
the delivery of service. Payments can be per unit of service, per member, or per time period. In all its forms
prospective financing differs from cost-based reimbursement, under which a provider is paid for costs
incurred.
Rate Setting: A form of financing under which hospitals or nursing homes are paid prices which are
prospectively determined, generally by a state agency. Prospectively determined prices may be paid by all
payers for all covered services, as in all payer systems, or by only some payers. The unit of payment can
be service, patient, or time period. (See "Prospective Financing")
Rational D N ~ Therapy: Prescribing the right drug for the right patient, at the right time, in the right amounts,
and with due consideration of relative costs.
Reasonable Charge: In processing claims for Supplementary Medical lnsurance benefits, carriers use HCFA
guidelines to establish the reasonable charge for services rendered. The reasonable charge is the lowest
oi: the actual charge billed by the physician or supplier; the charge the physician or supplier customarily
bills his patients for the same services, and the prevailing charge which most physicians or suppliers i n that
locality bill for the same service. Increases in the physicians' prevailing charge levels are recognized only
to the extent justified by an index reflecting changes i n the costs of practice and i n general earnings.
Reasonable Cost: In processing claims for Health lnsurance benefits, intermediaries use HCFA guidelines
to determine the reasonable cost incurred by the individual providers in furnishing covered services to
enrolles. The reasonable cost is based on the actual cost of providing such services, including direct and
indirect costs of providers, and excluding any costs which are unnecessary in the efficient delivery of services
covered by the insurance program.
Recipient: A recipient of Medicaid is an individual who has been determined to be eligible for Medicaid and
who has used medical services covered under Medicaid.
Restrictive Formulary: A list of the drug products that are available to physicians for use in treating their
patients within an institution or health care financing system. Restrictive formularies are used by some
hospitals and certain state Medicaid programs to limit prescribing and reimbursement to only certain
products.
Rural Health Clinic: A rural health clinic is an outpatient facility which is primarily engaged in furnishing
physicians' and other medical and health services, which meets certain other requirements designed to
ensure the health and safety of the individuals served by the clinic. The clinic must be located i n an area
that is not an urbanized area as defined by the Bureau of the Census and that is designated by the
Secretary of DHHS either as an area with a shortage of personal health services, or as a health manpower
shortage area, and has filed an agreement with the Secretary not to charge any individual or other person
for items or services for which such individual is entitled to have payment made by Medicare, except for the
amount of any deductible or coinsurance amount applicable.
Skilled Nursing Facilily (SNF): A skilled nursing facility is an institution which has in effect a transfer
agreement with one or more participating hospitals, and is primarily engaged in providing to inpatients skilled
nursing care and restorative care services, and meets specific regulatory certification requirements.
Skilled Nursing Facility Services: SNF services are all services furnished to inpatients of, and billed for by,
a formally certified skilled nursing facility that meets standards required by the Secretary of DHHS.
Spend-Down: Under the Medicaid program, spend-down refers to a method by which an individual
establishes Medicaid eligibility by reducing gross income through incurring medical expenses until net income
(after medical expenses) meets Medicaid financial requirements.
State Buy-In: State buy-in is the term given to the process by which a state may provide Supplementary
Medical lnsurance coverage for its needy eligible persons through an agreement with the Federal government
under which the state pays the premiums for them.
State Plan: The Medicaid State Plan is a comprehensive written commitment by a Medicaid agency to
administer or supervise the administration of a Medicaid program in accordance with Federal requirements.
Supplemental Security Income (SSI): SSI is a program of income support for low-income aged, blind, and
disabled persons established by Title XVI of the Social Security Act.
Therapeutic Subst i i on: A practice entailing a pharmacist's dispensing a drug felt to be therapeutically
equivalent to the drug prescribed by a physician without obtaining permission from the prescribing physician.
Generally, the P&T committee of an HMO will formally approve the therapeutic substitutions that it feels are
permissible, and only those so designated can be made by the pharmacist dispensing for the HMO.
Third-Party Liability: Under Medicaid, third-party liability exists if there is any entity (including other
government programs or insurance) which is or may be liable to pay all or part of the medical cost or in-
jury, disease, or disability of an applicant or recipient of Medicaid.
Usual. Customary and Reasonable Charges: Method of reimbursement used under Medicaid by which State
Medicaid programs set reimbursements rates using the Medicare method or a fee schedule, whichever is
lower.
Wnhhold: The portion of the monthly capitation payment to physicians withheld by the HMO until the end
of the year or other time period to create an incentive for efficient care. The withhold is 'at risk": if the
physician exceeds utilization norms, he does not receive it. It serves as a financial incentive for lower
utilization. The withhold can cover all services or be specific to hospital care, laboratory usage, or specialty
referrals.
Vendor: A medical vendor is an institution, agency, organization, or individual practitioner which provides
health or medical services.
Vendor Payments: In welfare programs, direct payments are made by the state to such providers as
physicians, pharmacists and health care institutions rather than to the welfare recipient himself.
ACRONYMS
AABD
AB
AFDC
APTD
ARF
CFR
COBRA
CPR
CPT
DEFRA
DHHS
DRGs
EPSDT
FFP
FY
HCFA
HI 0
HMO
ICF
ICF-MR
MAC
MMlS
MQC
NMCUES
NP
OAA
OACT
OASDl
OBRA
ORD
OT
OTC
PCF
PA
PT
RHC
SNF
SS A
SSI
SSP
TEFRA
TDOC
UCR
Aid to Aged, Blind, and Disabled
Aid to the Blind
Aid to Families with Dependent Children
Aid to the Permanently and Totally Disabled
Area Resource File
Code of Federal Regulations
Consolidated Omnibus Reconciliation Act of 1985
Customary Prevailing, and Reasonable (charges)
Current Procedural Terminology
Deficit Reduction Act of 1984
Department of Health and Human Services
Diagnostic Related Groupings
Early and Periodic Screening, Diagnostic and Treatment
Federal Financial Participation
Fiscal Year
Health Care Financing Administration
Health Insuring Organizations
Health Maintenance Organization
lntermediate Care Facility
lntermediate Care Facility for the Mentally Retarded
Maximum Allowable Cost
Medicaid Management Information System
Medicaid Quality Control
National Medicare Care Utilization and Expenditure Survey
Nurse Practitioner
Old Age Assistance
Office of the Actuary
Old Age, Survivors, and Disability Insurance
Omnibus Reconciliation Act - 1981
Office of Research and Demonstrations
Occupational Therapy
Over-the-counter (drugs)
Program Characteristics File
Physician's Assistant
Physical Therapy
Rural Health Clinic
Skilled Nursing Facility
Social Security Administration
Supplemental Security Income
State supplemental Payments
Tax Equity and Fiscal Responsibility Act
Total Days of Care
Usual, Customary and Reasonable (charges)
REGIONAL ADMINISTRATIVE OFFICES
Region I
Region II
Region Ill
Region N
Region V
Region VI
Region VII
Region Vlll
Region K
Region X
Heath and Human Services
Heaith Care Financing Administration
John F. Kennedy Federal Bldg.
Government Center, Room 1309
Boston, Massachusetts 02203
61 71565-1 188
Room 381 1
26 Federal Plaza
New York, New York 10278
21 21264-4488
3535 Market Street
P. 0. Box 7760
Philadelphia, Pennsylvania 191 01
21 51596-0324
101 Marietta Tower
Suite 701
Atlanta, Georgia 30323
4041331 -2329
105 West Adams Street
15th Floor
Chicago, Illinois 60603-6201
31 21886-6432
1200 Main Tower Building, Room 2000
Dallas, Texas 75202
21 41767-6427
New Federal Office Building
601 East 12th Street, Room 235
Kansas City, Missouri 64106
81 61426-5233
1961 Stout Street
Federal Office Building, Room 576
Denver, Colorado 80294
3031844-21 11
75 Hawthorne Street, 4th & 5th Floors
San Francisco, California 94105
41 51995-61 46
2201 6th Avenue, Mail Stop RX-40
Seattle, Washington 98121
2061442-0425
Connecticut, Maine,
Massachusetts, New
Hampshire, Rhode Island,
Vermont
New Jersey, New York,
Puerto Rico, Virgin Islands
Delaware, District of
Columbia, Maryland,
Virginia, West Virginia
Pennsylvania
Alabama, Florida, Georgia,
Kentucky, Mississippi, North
Carolina, South Carolina,
Tennessee
Illinois, Indiana, Michigan,
Minnesota, Ohio, Wisconsin
Arkansas, Louisiana, New
Mexico, Oklahoma, Texas
Iowa, Kansas, Missouri,
Nebraska
Colorado, Montana, South
Dakota, North Dakota, Utah,
Wyoming
Arizona, California, Hawaii,
Nevada, and Pacific Islands
Alaska, Idaho, Oregon,
Washington
STATE
MEDICAID
DRUG PROGRAM ADMINISTRATORS
ALABAMA
Larry A. Tatum, R.Ph.
Associate Director
pharmaceutical Programs
Alabama Medicaid Agency
2500 Fairlane Drive
Montgomery, AL 36130
2051277-271 0
ARIZONA
George Carlson, R.N., C.P.M.
Medicaid Pharmacy Coordinator
Arizona Health Care Containment System
801 E. Jefferson Street
Phoenix, AZ 85034
60212343655
CALIFORNIA
Milton Kushnereit, Pharm.D.
Senior Consulting Pharmacist
Medi-Cal Benefits Branch
California Healthwelfare Services
714 P Street, Room 1640
Sacramento, CA 9581 4
I
91 61324-2477
CONNECTICUT
Meyer Rosenkrantz, P.D.
Pharmacist Consultant
Connecticut Dept. of Income Maintenance
11 0 Bartholomew Avenue
Hartford, CT 06106
2031566-8007
DISTRICT OF COLUMBIA
James F. Harris, R.Ph.
Pharmacy Consultant
DC Department of Human Services
1331 H Street, N. W.
Suite 500
Washington, DC 20005
2021727.0753
ALASKA
Eric S. Hansen
Chief, Medical Assistance
Alaska Div. of Medical Assistance, DHSS
4433 Business Park Boulevard
Building M
Anchorage, AK 99503
9071561-2171
ARKANSAS
Thelma Underwood
Pharmacist Consultant
Arkansas Social Services Division
P. 0. BOX 1437
Little Rock, AR 72203
501 1682-8364
COLORADO
Stanley G. Callas, R.Ph.
Manager
PharmacylAmbulatory Care Services Section
CO Div. of Medical Assistance
Colorado Dept. of Social Services
1575 Sherman Street
Denver, CO 80203
3031866-5508
DELAWARE
Ruth S. Fischer
Administrator, Medical Services
Delaware Dept. of Health & Human Services
P. 0. Box 906
New Castle, DE 19720
3021421 -61 39
FLORIDA
Jerry F. Wells
Pharmacist Consultant
Medicaid Office
FL Department of Health & Human Services
1317 Winewood Blvd.
Building 6, Room 243
Tallahassee, FL 32301
9041487-4441
GEORGIA
Frances Lipscomb, R.Ph.
Program Management Officer
Georgia Dept. of Medical Assistance
2 Martin Luther Dr., S. E.
James Floyd Memorial Bldg.
West Tower, P. 0. Box 38440
Atlanta, GA 30334
40416564044
IDAHO
Mary K. Wheatley, R.Ph.
Pharmacy Services Specialist
Idaho Dept. of Health & Welfare
450 W. State Street
Boise, ID 83720
20813345795
INDIANA
Marc Shirley
Pharmacy Consultant
Indiana State Dept. of Public Welfare
100 N. Senate Ave., Room 702
Indianapolis, IN 46204
31 71232-4343
KANSAS
E. Eugene Stephens, R.Ph.
Mgr. Pharmacy Services Program
Kansas Division of Medical Programs
Docking State Office Building, #6825
Topeka, KS 66612
91 31296-3981
LOUISIANA
Carolyn Maggio
Medical Assistance Program
Louisiana Dept. of HealthIHuman Resources
P. 0. Box 94065
Baton Rouge, LA 70804
5041342-3891
MARYLAND
Leone W. Marks, R.Ph.
Staff Specialist for Pharmacy Services
Maryland Health Systems Financing Admin.
300 West Preston Street
Baltimore, MD 21201
301 1225-1459
HAWAII
Omel L. Turk
Pharmacist Consultant
Public Welfare Division
HI Dept. of Social Services & Housing
P. 0. Box 339
Honolulu, HI 9681 6-0339
8081546-8917
ILLINOIS
Ronald W. Gonrich, R.Ph.
Manager, Drug Section
Div. of Food, Drugs, Dairies
Illinois Dept. of Public Health
628 East Adams St. 4th FI.
Springfield, IL 62761
21 71782-7532
IOWA
Ronald J. Mahrenholz, R.Ph.
Manager, Operations Section
Bureau of Medical Services
Iowa Dept. of Human Services
Hoover State Office Bldg.
5th Floor
Des Moines, IA 50319
51 51281 -61 99
KENTUCKY
Gene A. Thomas, R.Ph.
Dept. for Medicaid Services
Kentucky Bureau of Social Insurance
275 E. Main St. 3-E CHR Bldg.
Frankfort, KY 40621
5021564-4321
MAINE
Michael P. O'Donnell, R.Ph.
Pharmacy Consultant
Br. Medical Svces. Station I I
Maine Dept. of Human Services
Statehouse
Augusta, ME 04333
2071289-2674
MASSACHUSElTS
Arnold H. Shapiro
Massachusetts Department of Public Welfare
600 Washington St.
Boston, MA 021 11
61 71348-521 7
MICHIGAN
Sandy Kramer, R.Ph.
pharmacy Program Specialist
Medical Service Administration
Michigan Dept. of Social Services
921 West Holmes
Lansing, MI 48910
51 71335-51 27
MISSISSIPPI
James T. Steele, R.Ph.
Pharmacist
Mississippi Div. of Medicaid
Suite 801, Robert E. Lee Building
239 North Lamar Street
Jackson, MS 39201 -1 31 1
6011359-6135
MONTANA
Karl E. Banschbach
Administrative Officer
Montana Department of SocialIRehab. Services
P. 0. Box 421 0
Helena, MT 59604
4061444-4540
NEVADA
Steven P. Bradford, Pharm.D.
Pharmaceutical Consultant
Nevada Medicaid Office
Dept. of Human Resources
State Capitol Complex, 2527 N. Carson St.
Carson City, NV 8971 0
7021885-4869
NEW JERSEY
Sanford Luger, R.Ph.
Chief Consultant
New Jersey Div. of Medical Assist.lHealth Ser.
7 Quakerbridge Plaza, CN 712
Trenton, NJ 08625
609f588-2724
NEW YORK
Michael A. Felzano
Medical Review Analyst IV
New York Dept. of Social Services
40 North Pearl Street
Albany, NY I2243
51 81473-5602
MINNESOTA
John T. Bush, R.Ph.
Pharmacist Consultant
Minnesota Medical Assistance Program
Health Services Policy, 6th Floor
44 Lafayette Rd.
St. Paul, MN 55155
61 21296-2363
MISSOURI
Susan McCann, Ph.D.
Pharmaceutical Consultant
Medical Services Division
Missouri Dept, of Social Services
227 Metro Drive, P.O. 6500
Jefferson City, MO 65102
3141751 3277
NEBRASKA
Daniel W. Snodgrass, R.Ph.
Pharmaceutical Consultant
Medical Services Division
Nebraska Department of Social Services
301 Centennial Mall South
5th Floor, P.O. 95026
Lincoln, NE 68509
4021471 -9379
NEW HAMPSHIRE
Edward J. Pierce, R.Ph.
Office of Medical Service
New Hampshire Div. of Human Services
6 Hazen Drive
Concord, NH 03301
6031271 4393
NEW MEXICO
Robert Stevens
Drug Program Administrator
Medical Assistance Programs
New Mexico Dept. of Human Services
PERA Bldg., Rm. 524
P.O. Box 2348
Santa Fe, NM 87504-2348
50518274315
NORTH CAROUNA
C. Benny Ridout, R.Ph.
Pharmacist Consultant
Div. of Medical Assistance
North Carolina Dept. of Human Resources
Kirby Bldg, 1985 Urnstead Dr.
Raleigh, NC 27603
91 91733-2833
NORTH DAKOTA
Patricia A. Kramer, R.Ph.
Administrator, Pharmacy Services
Medical Services Division
North Dakota Dept. of Human Services
State Capitol Bldg., Judicial Wing
Bismarck, ND 58505
701 1224-4023
OKLAHOMA
Howard Stansberry
Program Administrator, Medical Sew. Div.
Oklahoma Department of Human Services
P.O. Box 25352, 4001 N. Lincoln Blvd.
Oklahoma City, OK 73125
4051557-2539
PENNSYLVANIA
Joseph E. Concino, P.D.
PA Division of Outpatient Programs
Section of Pharmacy & Ancillary Services
P. 0. Box 8043
Harrisburg, PA 171 05
71 71782-61 42
SOUM CAROLINA
James M. Assey
Medicaid Program Consultant
SC HealthIHuman Services Finance Comrnision
P.O. Box 8206
Columbia, SC 29202-8206
8031253-61 38
TENNESSEE
(vacant)
Director of Pharmacy Services
Tennessee Dept. of Public HealthIEnvironrnent
729 Church Street
Nashville, TN 37214
61 51741 -021 3
UTAH
RaeDell Ashley, R.Ph.
Manager, Policy and Planning
Health Care Financing
Utah Dept. of Health
288 N. 1460 West
Salt Lake City, UT 841 16-0580
8011538-6495
OHIO
Robert P. Reid, R.Ph.
Pharmacist Consultant
Bureau of Medicaid Policy
Ohio Dept. of Human Services
30 E. Broad St., 31st FI.
Columbus, OH 43215
61 41466-6420
OREGON
James E. Peters, Ph.D., R.Ph.
Medicaid Pharmacy Prog. Mgr.
Health Services Section
Oregon Dept. of Human Resources
203 Public Service Bldg.
Salem, OR 97310
5031378-5581
RHODE ISLAND
John A. Pagliarini, R.Ph.
Chief of Pharmacy
Rhode Island Dept. of Human Services
600 New London Avenue
Cranston, RI 02920
4011464-21 84
SOUM DAKOTA
Donald Mahannah, P.D.
Pharmacist Consultant
South Dakota Dept. of Social Services
Medical Services
700 Governor Drive
Pierre, SD 57501
6051773-3495
TEXAS
Robert S. Nash, R.Ph.
Program Specialist, Vendor Drugs
Texas Dept. of Human Services
P. 0. Box 2960, Mail Code 541-W
Austin, TX 78769
5121450-31 98
VERMONT
Robert Thomas
Quality Assurance Specialist
Medicaid Division
Vermont Dept. of Social Welfare
103 S. Main Street
Waterbury, VT 05676
8021241 -2744
VIRGINIA
Mary Ann Johnson, R.Ph.
Pharmacist Consultant
Medical Assistance Program
Virginia State Department of Health
Suite 1300, 600 E. Broad Street
Richmond, VA 23218
8041786-3820
WEST VIRGINIA
Ann Bond Smith, R.Ph.
Pharmacy Coordinator
Division of Medical Care
West Vjrginia Department of Welfare
1900 Washington Street, East
Charleston, WV 25305
3041348-8990
WASHINGTON
William P. Pace, R.Ph.
Pharmacist Consultant
Washington State Div. of Medical Assistance
Mail Stop Hb-41
Olympia, WA 98504-0095
2061753-0524
WISCONSIN
Michael Boushon, R.Ph.
Pharmacist Consultant
Wisc. Dept. HealthJSoc. Svce.
1 W. Wilson Street
P.O. Box 309
Madison, WI 53701
6081266-0722
WYOMING
Fred Lund
Pharmaceutical Consultant
Division of Health & Medical Services
117 Hathaway Building, Room 454
Cheyenne, WY 82002
STATE OFFICIALS
ALABAMA
Governor
Honorable Guy Hunt
Governor of Alabama
11 South Union Street
Montgomery, AL 36130
2051261 -71 00
Governor's DC Office
Ms. Judith Pittman
2021624-5820
Single State Agency Director
Ms. Carol A. Herrmann
Commissioner
Alabama Medicaid Agency
2500 Fairlane Drive
Montgomery, AL 361 10
2051277-271 0
R4edica.d Director
Ms. Carol Herrmann
(see above)
ALASKA
Governor
Honorable Steve Cowper
Governor of Alaska
P. 0. Box A
Juneau, AK 9981 1-0101
9071465-3500
Governor's DC Office
Mr. John Katz
2021624-5858
Single State Agency Director
Ms. Myra M. Munson
Commissioner
AK Dept. of Health & Social Services
P. 0. Box H
Juneau, AK 9981 1-0601
9071465-3030
Medicaid Director
Ms. Kim Busch
Director
Div. of Medical Assistance
Dept. of Health & Social Services
P. 0. Box H-07
Juneau, AK 9981 1-0601
9071465-3355
ARIZONA
Governor
Honorable Rose Mofford
Governor of Arizona
State House
1700 W. Washington
Phoenix, AZ 85007
60215434331
Single state Agency Director
Leonard J. Kirschner, M.D., MPH
Director Arizona Health Care Cost Containment
System (AHCCCS)
801 East Jefferson Street
Phoenix, AZ 85034
6021234.3655 ext. 4053
Medicaid Director
Leonard J. Kirschner, M.D., MPH
(see above)
ARKANSAS
Governor
Honorable Bill Clinton
Governor of Arkansas
State Capitol Building
Little Rock, AR 72201
501 1682-2345
Single state Agency Director
Mr. Walt Patterson
Director
Arkansas Dept. of Human Services
P. 0. Box 1437, 7th and Main Streets
Little Rock, AR 72203
501 1682-8650
Medicaid Director
Mr. Ray Hanley, Director
Office of Medical Services
Arkansas Dept. of Human Services
P. 0. Box 1437, Slot 1100
Little Rock, AR 72203-1437
5011682-8292
CAUFORNIA
Governor
Honorable George Deukmejian
Governor of California
state Capitol
First Floor
Sacramento, CA 9581 4
91 61445-0282
Governo<s DC Office
Mr. Robert J. Moore
2021347-6894
Single State Agency Director
Kenneth W. Ki er, M.D., MPH
Director Dept. of Health Sewices
71 4 P Street, Room 1253
Sacramento, CA 9581 4
91 61445-1 248
Medicaid Director
Mr. John Rodriquez
Deputy Director
Medical Care Semkes
Dept. of Health Services
714 P Street, Room 1253
Sacramento, CA 95814
91 61322-5824
COLORADO
Governor
Honorable Roy Romer
Governor of Colorado
State Capitol, Room 136
Denver, CO 80203
3031866-2471
Single state Agency Director
Ms. Irene M. lbarra
Executive Director
Colorado Dept. of Social Services
1575 Sherman Street, 8th Floor
Denver, CO 80203-1 71 4
3031866-5800
Medicaid Director
Mr. Gary Toerber
Director
Bureau of Medical Services
Dept. of Social Services
1575 Sherman Street, 6th Floor
Denver, CO 80203-1714
3031866-5901
CONNECTICUT
Governor
Honorable William A. O'Neill
Governor of Connecticut
State Capitol
Hartford, CT 06106
2031566-4840
Governor's DC Ofice
Ms. Ann L. Sullivan
2021347-4535
Single State Agency Director
Ms. Lorraine Aronson
Commissioner
Dept. of Income Maintenance
110 Bartholomew Avenue
Hartford, CT 06106
2031566-2008
Medicaid Director
Ms. Linda Schofield
Director
Medical Care Administration
Dept. of Income Maintenance
1 10 Bartholomew Avenue
Hartford, CT 06106
2031566-2934
DELAWARE
Governor
Honorable Michael N. Castle
Governor of Delaware
Legislative Hall
Dover, DE 19901
3021736-41 01
Governor's DC Office
Mr. Goodrich H. Stokes
2021624-7724
Single State Agency Director
Mr. Thomas P. Eichler
Secretary
DE Dept. of Health 8 Social Services
1901 North DuPont Highway
New Castle, DE 19720
3021421 -6705
Medicaid Director
Ms. Ruth S. Fischer
Medicaid Director
Dept. of Health & Social Services
Delaware State Hospital
New Castle, DE 19720
3021421 -61 39
WASHINGTON, D.C.
Mwr
Honorable Marion Barry, Jr.
Mayor, District of Columbia
District Building, Suite 520
1350 Pennsylvania Avenue, N.W.
Washington, D. C. 20004
2021727-631 9
Single State Agency Director
Mr. Peter G. Parham
Director
Dept. of Human Services
801 North Capitol Street, Room 700
Washington, D. C. 20002
2021727-031 0
Medicaid Director
Ms. Lee Partridge
Chief, Office of Health Care Financing
D.C. Dept. of Human Services
1331 H Street, N.W., Suite 500
Washington, D. C. 20005
2021727-0735
FLORIDA
Governor
Honorable Bob Martinez
Governor of Florida
State Capitol
Tallahassee, FL 32399
9041488-2272
Governor's DC Office
Ms. Lynda Davis
2OU624-5885
Single Smte Agency Director
Mr. Gregory L. Coler
Secretary
FL Dept. of Health &
Rehabilitative Sewices
131 7 Winewood Boulevard
Building 2, Room 432
Tallahassee, FL 32399-0700
9041488-7721
Medicaid Director
Mr. Gary J. Clarke
Asst. Secretary for Medicaid
Dept. of Health & Rehab. Services
131 7 Winewood Boulevard
Building 6, Room 233
Tallahassee, FL 32399-0700
9041488-3560
GEORGIA
Governor
Honorable Joe Frank Harris
Governor of Georgia
State Capitol
Atlanta, GA 30334
4041656-1 776
Governor's DC Office
Ms. Jan Finn
2021624-5437
Single State Agency Director
Mr. Aaron J. Johnson
Commissioner
GA Dept. of Medical Assistance
2 Martin Luther King, Jr., Drive, SE
1220-C West Tower
Atlanta, GA 30334
4041656-4479
Medicaid Director
Mr. Aaron J. Johnson
(see above)
HAWAII
Governor
Honorable John D. Waihee, Ill
Governor of Hawaii
State Capitol
Honolulu, HI 96813
8081548-5420
Governor's DC Office
Ms. Janice C. Lipsen
20U785-0550
Single State Agency Director
Ms. Winona E. Rubin
Director
HI Department of Social Services
P. 0. Box 339
Honolulu, HI 96809
8081548-6260
Medicaid Director
Mr. Earl Motooka
Administrator
Health Care Administration Division
Dept. of Social Services & Housing
P. 0. Box 339
Honolulu, HI 96809
8081548-6584
IDAHO
Governor
Honorable Cecil D. Andrus
Governor of Idaho
State Capitol
Boise, ID 83720
208/334-2100
single State Agency Director
Mr. Richard P. Donovan
Director
ID Dept. of Health & Welfare
State House
Boise, ID 83720
2081334-5500
Medicaid Director
Mrs. Jean Schoonover
Chief, Bureau of Medical Assistance
Dept. of Health &Welfare
450 West State Street
Statehouse Mail
Boise, ID 83720
2081334-5794
ILLINOIS
Governor
Honorable James R. Thompson
Governor of Illinois
State Capitol
Springfield, IL 62706
21 71782-6830
Governor's DC Office
Mr. Douglas Richardson
2021624-7760
Single State Agency Director
Ms. Susan S. Suter
Director
IL Dept. of Public Aid
Jesse B. Harris Bldg. II, 3rd Floor
I00 S. Grand Avenue, East
Springfield, IL 62762
21 71782-671 6
Medicaid Director
Mr. Tim Claborn
Administrator
Division of Medical Programs
IL Dept, of Public Aid
201 South Grand Avenue, East
Springfield, IL 62743-0001
21 71782-2570
INDIANA
Governor
Honorable Evan Bayh
Governor of Indiana
State Capitol, Room 206
Indianapolis, IN 46204
3 1 71232-4567
Governor's DC Office
Mr. Tom Koutsoumpas
202l785-2615
Single State Agency Director
Ms. Suzanne L. Magnate
Commissioner
IN Dept. of Public Welfare
State Office Building
100 N. Senate Avenue, Room 701
Indianapolis, IN 46204
31 71232-4705
Medicaid Director
Gary Kyzr-Sheeley, Ph.D.
Director, Medicaid Division
IN State Dept of Public Welfare
State Office Bldg, Room 702
Indianapolis, IN 46204
31 71232-4333
IOWA
Governor
Honorable Terry Branstad
Governor of Iowa
State Capitol
Des Moines, IA 50319
51 51281 -521 1
Governor's DC Office
Mr. Philip C. Smith
2021624-5442
Single State Agency Director
Mr. Charles M. Palmer
Director
IA Dept. of Human Services
Hoover State Office Bldg.
5th Floor
Des Moines, IA 5031 9
51 51281 -5452
Medicaid Director
Mr. Donald Herman
Chief, Bureau of Medical Services
Dept, of Human Sewices
Hoover State Office Bldg, 5th Floor
Des Moines, IA 50319
51 51281 -8794
KANSAS
Governor
Honorable John Michael Hayden
Governor of Kansas
State Capitol Building
Topeka, KS 66612
91 31296-3232
Governor's DC Office
Ms. Jennifer S. Stradinger
2021785-6966
Single State Agency Director
Mr. Winston Barton
Secretary
KS Dept. of Social &
Rehabilitation Services
Docking State Office Building
6th Floor
Topeka, KS 66612
91 312963271
Medicaid Director
Ms. L. Kathryn Klassen, R.N., MS.
Director
Medical Services Division
Dept. of Social & Rehab. Services
~ 6 c k i n ~ State Office Building
Room 628-S
Topeka, KS 66612
91 312963981
KENTUCKY
Governor
Honorable Wallace G. Wilkinson
Governor of Kentucky
State Capitol
Frankfort, KY 40601
5021564-261 1
Governor's DC Office
Ms. Linda Breathin
2021624-7741
Single State Agency Director
Mr. Roy Butler
Commissioner
Dept. of Medicaid Services
275 East Main Street
Frankfort, KY 40621
5021564-4321
Medicaid Director
Mr. Roy Butler
(see above)
LOUISIANA
Governor
Honorable Buddy Roemer
Governor of Louisiana
State Capitol, P. 0. Box 94004
Baton Rouge, LA 70804
5041342-7015
Governor's DC Office
Mr. James A. Burns
2021624-81 95
Single State Agency Director
Mr. David L. Ramsey
Secretary
Dept. of Health & Hospitals
P. 0. Box 3776
Baton Rouge, LA 70821
5041342-671 I
Medicaid Director
Ms. Carolyn Maggio
Director
Bureau of Health Service Finance
P. 0. Box 91 030
Baton Rouge, LA 70821 -9030
5041342-3891
MAINE
Governor
Honorable John R. McKernan, Jr.
Governor of Maine
State House, Station 1
Augusta, ME 04333
2071289-3531
Governor's DC Office
Mr. Donald R. Larrabee
2021638-5865
Single State Agency Director
Mr. Rollin lves
Commissioner
ME Dept. of Human Services
221 State Street
State House, Station 11
Augusta, ME 04333
2071289-2736
Medicaid Director
Ms. Elaine Fuller
Director
Bureau of Medical Services
Dept. of Human Services
State House, Station 11
Augusta, ME 04333
20712892674
MARYLAND
Governor
Honorable William Donald Schaefer
Governor of Maryland
State House
~nnapolis, MD 21 401
3011974-3901
Governor's Dc Office
Ms. Monica Healy
20216382215
Single State Agency Director
Ms. Adele Wiback, R.N., MS.
Secretary
MD Dept. of Health & Mental Hygiene
Herbert R. O'Connor Bldg.
201 West Preston Street
Baltimore, MD 21201
3011225-6500
Medicaid Director
Mr. Nelson Sabatini
Deputy Secretary
Health Care Policy, Finance & Regul.
Dept. of Health & Mental Hygiene
201 West Preston Street, Rm. 525
Baltimore, MD 21201
301 1225-6535
MASSACHUSETTS
Governor
Honorable Michael S. Dukakis
Governor of Massachusetts
Executive Office, State House
Boston, MA 02133
61 71727-91 73
Governor's DC Office
Mr. Mark Gearan
2021624-771 3
Single State Agency Director
Ms. Carmen S. Canino-Siegrist
Commissioner
Dept. of Public Welfare
180 Tremont Street
Boston, MA 021 11
61 71574-0200
Medicaid Director
Mr. Bruce M. Bullen
Associate Commissioner for Medical Pay
Dept. of Public Welfare
180 Tremont Street, 13th Floor
Boston, MA 021 11
61 71574-0205
MICHIGAN
Governor
Honorable James J. Blanchard
Governor of Michigan
State Capitol
Lansing, MI 48909
51 71373-3423
Governor's DC Office
Mr. E. Douglas Frost
2021624-5840
Single State Agency Director
Mr. C. Patrick Babcock
Director
MI Dept. of Social Services
P. 0. Box 30037
Lansing, MI 48909
5171373-2000
Medicaid Director
Mr. Kevin Seitz
Director, Medical Services Admin.
Dept. of Social Services
P. 0. Box 30037
Lansing, MI 48910
51 71334-7262
MINNESOTA
Governor
Honorable Rudy Perpich
Governor of Minnesota
State Capitol
St. Paul, MN 55155
61 21296.3391
Governor's DC Office
Ms. Barbara Rohde
2021624-5308
Single State Agency Director
Ms. Sandra Gardebring
Commissioner
MN Dept. of Human Services
444 Lafayette Road, 2nd Floor
St. Paul, MN 55155-3815
61 2/296-2701
Medicaid Director
Mr. Robert Baird
Director
Health Care Programs Division
ments Dept. of Human Services
444 Lafayette Road, 6th Floor
St. Paul, MN 55155-3848
61 21296.2766
MISSISSIPPI
Governor
Honorabie Ray Mabus
Governor of Mississippi
State Capitol
Jackson, MS 39205
601/3593150
Governor3 DC Office
Mr. William Simpson
202/452-1003
Single State Agency Director
J. Clinton Smith, M.D.
Director, Div. of Medicaid
Office of the Governor
Robert E. Lee Building
239 North Lamar Street, Room 801
Jackson, MS 39201 -1 31 1
601 1359-6050
Medim-d Director
J. Clinton Smlh, M.D.
(see above)
MISSOURI
Governor
Honorable John Ashcroft
Governor of Missouri
State Capitol
P. 0. Box 720
Jefferson City, MO 651 02
31 41751 3222
Governor's DC Office
Ms. Marise Stewart
2021624-7720
Single State Agency Director
Mr. Gary Stangler
Director
MO Dept. of Social Services
P. 0. Box 1527
Jefferson City, MO 65102
31 41751 -481 5
Medicaid Director
Ms. Donna Checkett
Director
Division of Medical Services
Dept. of Social Services
P. 0. Box 6500
Jefferson City, MO 65102
31 41751 -6529
MONTANA
Governor
Honorable Stan Stephens
Governor of Montana
State Capitol
Helena, MT 59620
406144431 1 1
Single Srate Agency Director
Ms. Julia Robinson
Director
MT Dept. of Social &
Rehabilitation Services
P. 0. Box 421 0
11 I Sanders
Helena, MT 59604
4061444-5622
Medi cai d Director
Mr. John Donwen
Acting Administrator
Economic Assistance Division
Dept. of Social & Rehab. Services
P. 0. Box 421 0
Helena, MT 59604
4061444-4540
NEBRASKA
Governor
Honorabie Kay A. Orr
Governor of Nebraska
P. 0. Box 94848
Lincoln, NE 68509
402/471-2244
Single Slate Agency Director
Kermit R. McMurry, Ph.D.
Director
NE Dept. of Social Services
301 Centennial Mall South
5th Floor
Lincoln, NE 68509
4021471-3121
Medicaid Director
Mr. Robert Seiffert
Administrator
Medical Services Division
Dept. of Social Services
5th Floor
301 Centennial Mail South
Lincoln, NE 68509
4021471 -9330
Governor
Honorable Robert J. Miiier
Governor of Nevada
state CapLol
Carson City, NV 89710
7021885-5670
&nernofs DC Olfice
Mr. R. Leo Penne
202/624-5405
si nge State Agency Director
Mr. Jerry Griepentrog
Director
NV Dept, of Human Resources
Kinkead sldg. - Capitol Complex
505 East King Street, Rm. 600
Carson City, NV 89710
70218854730
Medi c ai d Director
Ms. April Heff
Deputy Administrator
NV Medicaid, Welfare Division
Dept. of Human Resources
2527 North Canon Street
Carson City, NV 8971 0
702/885-4378
NEW HAMPSHIRE
Gwemor
Honorable Judd Gregg
Governor of New Hampshire
State House
Concord, NH 03301
6031271-2121
Single W e Agency Director
Ms. M. Mary Mongan
Commissioner
NH Dept. of Health & Human Services
6 Hazen Drive
Concord, NH 03301 -6521
6031271 -4331
Medicaid Director
Mr. Philip Soule', Sr.
Administrator
Office of Medical Sewices
NH Div. of Human Services
Dept. of Health & Human Services
6 Hazen Drive
Concord, NH 03301 -6521
6031271 -4353
NEW JERSEY
Governor
Honorable Thomas H. Kean
Governor of New Jersey
State House CN-001
Trenton, NJ 08625
6091292-6000
Governofs DC Office
Ms. Alice Tetelman
2021638-0631
Single State Agency Director
Drew Aitman, Ph.D.
Commissioner
NJ Dept. of Human Sewices
Capitol Place One CN-700
222 South Warren Street
Trehton, NJ 08625
6091292-371 7
Medicaid Director
Mr. Saul M. Kilstein
Director
Div. of Medical Assistance & Health Services
Dept. of Human Sewices
CN-712, 7 Quakerbridge Plaza
Trenton, NJ 08625
6091588-2602
NEW MWCO
Governor
Honorable Garrey Carruthers
Governor of New Mexico
State Capitol
Santa Fe, NM 87503
Single State Agency Director
Mr. Alex Valdez
Cabinet Secretary
Human Services Dept.
P. 0. Box 2348
PERA Building, Room 301
Santa Fe, NM 87504-2348
5051827-4072
Medicaid Director
Vacant
Contact: Mr. Larry Martinez
Chief, Program Support Bureau
Dept. of Human Services
P. 0. Box 2348
Santa Fe, NM 87504-2348
5051827-431 5
NEW YORK
Governor
Honorable Mario Cuomo
Governor of New York
Executive Chamber
State Capitol
Albany, NY 12224
51 81474-751 6
Garemor's DC Office
Mr. Brad Johnson
2021638-1311
Single State Agency Director
Mr. Cesar A. Perales
Commissioner
NY State Dept. of Social Services
Ten Eyck Office Building
40 North Pearl Street
Albany, NY 12243
51 81474-9475
Medicaid Director
Ms. JoAnn A. Costantino
Dep. Comm., Div. of Medical Assistance
State Dept. of Social Services
Ten Eyck Office Building
40 North Pearl Street
Albany, NY 12243-0001
51 81474-9123
NORTH CAROLINA
Governor
Honorable James G. Marlin
Governor of North Carolina
State Capitol
Raleigh, NC 27603
9191733-581 1
G mr n d s DC Office
Ms. Karen Robert
2021624-5630
Single State Agency Director
Mr. David Flaherty
Secretary, Dept. of Human Resources
325 N. Salisbuly Street
Raleigh, NC 27611
91 9/73-4534
Medicaid Director
Ms. Barbara Matula
Director, Div. of Medical Assistance
Dept. of Human Resources
1985 Umstead Drive
Raleigh, NC 27603
91 91733-2060
NORTH DAKOTA
Governor
Honorable George Sinner
Governor of North Dakota
State Capitol, Ground Floor
Bismarck, ND 58505
701 1224.2200
Single State Agency Director
Mr. John Graham
Executive Director
ND Dept. of Human Services
State Capitol, Judicial Wing
600 East Boulevard
Bismarck, ND 58505
7011224-231 0
Medicaid Director
Mr. Richard Myatt
Director, Medical Services
ND Dept. of Human Services
State Capitol, Judicial Wing
600 East Boulevard
Bismarck, ND 58505-0251
701 /2242321
OHIO
Governor
Honorable Richard F. Celeste
Governor of the State of Ohio
77 South High Street
30th Floor
Columbus, OH 43266-0601
61 414664555
Governor's DC Office
Mr. Gary Falle
20216245844
Single State Agency Director
Ms. Patricia K. Barry
Director, OH Dept. of Human Services
30 East Broad Street
32nd Floor
Columbus, OH 43266-0423
6141466-6282
A4edica.d Director
Paul Offner, Deputy Director
Benefits Administration
Medicaid Administration
Dept. of Human Services
30 East Broad Street, 31st Floor
Columbus, OH 43266-0423
6141466-31 96
OKLAHOMA
Governor
Honorable Henty Bellmon
Governor of Oklahoma
212 State Capitol
Oklahoma City, OK 73105
4051521 -2342
Single State Agency Director
Mr. Phil Watson
Director
OK Dept. of Human Services
p. 0. Box 25352
Oklahoma City, OK 73125
40515213646
Medicaid Director
Mr. Charles Brodt
Assistant Director
Division of Medical Services
Dept, of Human Services
P. 0. Box 25352
Oklahoma City, OK 73125
405/557-2539
OREGON
Governor
Honorable Neil Goldschmidt
Governor of Oregon
State Capitol
Salem, OR 9731 0
50313784344
Single State Agency Director
Mr. Kevin Concannon
Director
Dept. of Human Resources
318 Public Service Building
Salem, OR 9731 0
50313783034
Medicaid Director
Ms. Jean I. Thorne
Assistant Administrator
Adult & Family Services Division
Dept, of Human Resources
203 Public Service Building
Salem, OR 97310
5031378-2263
PENNSYLVANIA
Governor
Honorable Robert P. Casey
Governor of Pennsylvania
225 Main Capitol Building
Harrisburg, PA 171 20
71 71787-2500
Governor's DC Office
Mr. Philip Jehle
2021624-7828
Single State Agency Director
Mr. John White
Secretary
Dept. of Public Welfare, Room 333
Health & Welfare Building
Harrisburg, PA 17120
717/7874600
Medicaid Director
Ms. Eileen M. Schoen
Deputy Secretary
Medical Assistance Programs
Room 515
Dept. of Public Welfare
Health & Welfare Building
Harrisburg, PA 171 20
71 71787-1 870
RHODE ISLAND
Governor
Honorable Edward D. DiPrete
Governor of Rhode Island
State House
Providence, RI 02903
4011277-2080
Single State Agency Director
Ms. Nancy V. Bordeleau
Director
RI Dept. of Human Services
Aime J. Forand Building
600 New London Avenue
Cranston, RI 02920
4011464-2121
Medicaid Director
Mr. Anthony Barile
Associate Director
Division of Medical Services
Dept. of Human Services
Aime J. Forand Building
600 New London Avenue
Cranston, RI 02920
4011464-3575
SOUTH CAROUNA
Governor
Honorable Carroll A. Campbell, Jr.
Governor of South Carolina
P. 0. Box 11369
Columbia, SC 2921 1
8031734-981 8
Governor's DC Office
Ms. Nikki McNamee
2021624-7784
Single Stare Agency Director
Eugene A. Laurent, Ph.D.
Executive Director
SC State Health & Human Services
Finance commission
P. 0. Box 8206
Columbia, SC 29202-8206
803125361 00
Medicaid Director
Ms. Gwendolyn G. Power
Deputy Executive DirectoriPrograms
Health & Human Services
Finance Commission
P. 0. Box 8206
Columbia, SC 29202-8206
8031253-61 00
SOUTH DAKOTA
Governor
Honorable George S. Mickelson
Governor of South Dakota
500 East Capitol
Pierre, SD 57501
6051773-321 2
Governor's DC Office
Mr. Thomas Kindness
2021429-6060
Single State Agency Director
Mr. James W. Ellenbecker
Secretary
SD Dept. of Social Services
Kneip Building, 700 Governor's Drive
Pierre, SD 57501 -2291
6051773-31 65
Medicaid Director
Mr. Ervin Schumacher
Program Administrator, Medical Services
Dept. of Social Services
Kneip Building, 700 Governor's Drive
Pierre, SD 57501-2291
6051773-3495
TENNESSEE
Governor
Honorable Ned McWherter
Governor of Tennessee
State Capitol
Nashville, TN 37219
61 51741 -2001
Single State Agency Director
Mr. J. W. Luna
Commissioner
TN Dept. of Health & Environment
344 Cordell Hull Building
Nashville, TN 3721 9
61 51741 -31 11
Medicaid Director
Mr. Manny Martins
Assistant Commissioner & Director
Bureau of Medicaid
Dept. of Health & Environment
729 Church Street
Nashville, TN 3721 9
61 51741 -021 3
TEXAS
Governor
Honorable William Clements, Jr.
Governor of Texas
State Capitol
Austin, TX 7871 1
51 21463-2000
Governor's DC Office
Mr. Henry Gandy
2021488-3927
Single State Agency Director
Mr. Ron Lindsay
Commissioner
Dept, of Human Services
P. 0. Box 149030
Austin, TX 78714-9030
5121450-301 1
Medicaid Director
Dr. Donald Kelley
Deputy Commissioner
Health Care Services
Dept. of Human Services
P. 0. Box 149030
Austin, TX 78714-9030
51 21450-3050
Goyemor
Honorable Norman H. Bangerter
Governor of Utah
state Capitol
Salt Lake City, UT 841 14
8Ol/538-lOOO
overn nor's DC Offce
Ms. Deborah Turner
Single State Agency Director
Suzanne Dandoy, M.D., MPH
Executive Director
Utah Dept. of Health
P, 0. Box 16700
Salt Lake City, UT 841 16-0700
8011538-61 11
Medicaid Director
Mr. Rod Betit
Director
Division of Health Care Financing
UT Dept. of Health
P. 0. Box 16580
Salt Lake City, UT 841 16-0580
8011538-61 51
VERMONT
Governor
Honorable Madeleine M. Kunin
Governor of Vermont
Pavilion Office Building
Montpelier, VT 05602
8021828-3333
Single Slate Agency Director
Ms. Gretchen B. Morse
Secretary
VT Agency of Human Services
103 South Main Street
Waterbury, W 05676
8021241 -2220
Medicaid Director
Mr. Elmo A. Sassorossi
Director
Division of Medicaid
Dept. of Social Welfare
Vl Agency of Human Services
103 South Main Street
Waterbury, Vl 05676
8021241 -2880
VIRGINIA
Governor
Honorable Gerald L. Baliles
Governor of Virginia
State Capitol
Richmond, VA 2321 9
8041786-221 1
Governor's DC Ofice
Mr. Stewart Gamage
202l783-1769
Single State Agency Director
Ms. Eva S. Teig
Secretary
Health & Human Resources
P. 0. BOX 1475
Richmond, VA 23212
8041786-7765
Medicaid Director
Mr. Bruce Kozlowski
Director
VA Dept. of Medical Assistance Services
600 East Broad Street, Room 1300
Richmond, VA 2321 9
8041786-7933
WASHINGTON
Governor
Honorable Booth Gardner
Governor of Washington
Legislative Building
Olympia, WA 98504
2061753-6780
Single State Agency Director
Mr. Dick Thompson
Secretaty
WA Dept. of Social & Health Services
12th & Franklin, Mail Stop 08-44
Olympia, WA 98504
2061753-3395
Medicaid Director
Mr. Ron Kero
Director
Division of Medical Assistance
Gept. of Social & Health Services
12th & Franklin, Mail Stop HB-41
Olympia, WA 98504
2061753-1 777
WEST VIRGINIA
Governor
Honorable Gaston Caperton
Governor of West Virginia
State Capitol
Charleston, WV 25305
3041340-1 600
Single State Agency Director
Mr. Nicholas R. DeMarco
Interim Bureau Administrator
Bureau of Medical Services
WV Dept. of Human Services
1900 Washington Street, East
Charleston, WV 25305
3041348-8990
Medicaid Director
Ms. Helen Condry
Director
Division of Medical Care
WV Dept. of Human Services
1900 Washington Street, East
Charleston, WV 25305
3041348-8990
WlSCONSlN
Governor
Honorable Tommy G. Thompson
Governor of Wisconsin
State Capitol
Madison, WI 53702
6081266-1 212
Governor's DC Office
Mr. David Beightol
202/624-5870
Single State Agency Director
Ms. Patricia Goodrich
Secretary
WI Dept. of Health & Social Services
1 West Wilson Street
Room 650
P. 0. BOX 7850
Madison, WI 53707
6081266-3681
Medicaid Director
Ms. Christine Nye
Director, Bureau of Health Care Financing
Division of Health
WI Dept. of Health & Social Services
P. 0. Box 309
Madison, WI 53701
6081266-2522
WYOMING
Governor
Honorable Mike Sullivan
Governor of Wyoming
State Capitol
Cheyenne, WY 82002
3071777-7434
Single State Agency Director
R. Larry Meuli, M.D.
Administrator
WY Dept. of Health Services
2300 Capitol Avenue
Hathaway Building, 4th Floor
Cheyenne, WY 82002
3071777-71 21
Medicaid Director
Mr. Kenneth C. Kamis
Director
Medical Assistance Services
Dept. of Health & Social Services
Hathaway Building, 4th Floor
Cheyenne, WY 82002
3071777-7531
Department of Health and Human
SSMC~S
~ ~ a l t h Care Financing Administration
42 CFR Pats 413, 430, and 447
45 CFR Pats 1 and 19
[ B E w - w
Medicare and Medicaid Programs;
timits on Payments for Drugs;
AGENCY: Health Care Financing
Administration (HCFA), HHS.
ACTION: Final rule.
s U M W . This rule eliminates current
Departmental procedures for setting
limits on payments for drugs supplied
under certain Federal health programs;
and revises Medicaid rules concerning
the methodology for determining upper
limits for drug reimbursement. This rule
enables the Federai and State
governments to take advantage of
savings that are currently available in
the marketplace for multiple source
drugs. It aiso maintains State flexibility
in the administration of the Medicaid
program.
EFECME D A E The reguiations are
eflective October 29, 1987. State
aaencies have 90 days from the
~ -
publication date of this regulation until
the effective date in which to submit a
State plan amendment and the required
attachment.
FOR FURTHER INFORMATION
CONTACT: Anthony Lovecchio, (301)
5944010.
SUPPLEMENTARY INFORMATION:
L Background
A. Existing System
In 1976, the Department implemented
drug reimbursement rules at 45 CFR
Part 19 under the authority of statutes
pertaining to upper payment limits for
Medicaid and other programs. The
aut hoi i to set an upper payment limit
for sewices available under the
Medicaid program is provided under
section 1902(a)(30)(A) of the Social
Secui i Act.
The Department rules are intended to
ensure that the Federai government acts
as a prudent buyer of drugs under
certain Federal health programs. The
Set limits on payments for drugs
supplied under Medicaid and other
Programs. M the Federal programs
imolved, these rules have the greatest
impact on the Medicaid program.
Specifically, these regulations provide
that -the amount the Department
recognizes for drug reimbursement or
payment purposes will not exceed the
lowest of-
0 The maximum allowable cost (MAC)
of the drug, as estabiished by HCFA's
Pharmaceutical Reimbursement Board
for certain mukiple source drugs
(generic drugs), plus a reasonable
dispensing fee;
O The estimated acquisition cost (EAC)
of the drug (the price generally and
currently paid by providers for a
drug in the package size most
frequently purchased by providers), as
determined by the program agency,
plus a reasonable dispensing fee; or
0 The provider's usual and customary
charge to the pubiic for the drug.
The regulations provide that the MAC
wiil not apply if the prescriber has
certified in his own handwriting that a
specific brand of that drug is medically
necessary for the patient. The
regulations at 45 CFR Part 19 aiso
establish within HCFA a Pharmaceutical
Reimbursement Board (PRB). The PRB
identifies multiple source drugs for
which significant amounts of Federai
funds are or may be expended and is
responsible for estabiishing the MAC for
those drugs. The process by which a
MAC is established includes PRB
consultation with the Food and Drug
Administration (FDA), opportuniw for
pubiic comment on a proposed notice
of the MAC limit published in the
Federal Register, a pubiic hearing, and
publication of the final MAC
determination in the Federai Register.
The PRB sets the MAC at the lowest
unit price at which the drug is widely
and consistently available. In addition to
limiting the level of payment for multiple
source drugs, the MAC program tends
to promote substitution of lower cost
(generic) drug products for brand-name
drugs, since the latter are frequently
available only at prices higher than the
MAC limits.
Similar to the Department reguiations
(45 CFR Part 19) that set limits to
Federal payments for drugs are the
Medicaid regulations at 42 CFR 447.331
through 447.334. The regulations at
50447.331 through 447.334 limit the
amounts that State Medicaid agencies
may ciaim for Federai matching
purposes under the Medicaid program.
These limits are the same as those
specified in 45 CFR Part 19. Thus. the
Medicaid agency must ciaim no more
for each drug than the lowest of -
0 The MAC of the drug, as established
by the HCFA PRB for certain mukiple
source drugs, plus a reasonable
dispensing fee;
O The EAC of the drug (that is, the
Medicaid State agency's best estimate
of the price generaity paid by providers)
plus a reasonable dispensing fee; or
The provider's usual and customary
charge to the pubiic for the drug.
The Medicaid reguiations also provide
that the MAC will not apply if the
prescriber has certified in his own
handwriting that a celtain brand of that
drug is medically necessary for the
patient.
B. Problems and Concerns
in 1983, a Departmental Task Force
was established to review the
Department's drug reimbursement
regulations at 45 CFR Part 19. Specific
concerns presented to the Task Force
included-
The quality of muhipie source drugs;
0 The interpretation of Widely and
consistently available' as related to the
process used by the PRB in setting
MAC iimits;
The adequacy of drug reimbursement;
and
O Problems in administering the MAC
and EAC programs (for example, the
short time that the Medicaid agencies
have to implement MAC limits once they
become effective, and the lack of a
mechanism for raising the MAC limits
quickly when necessary due to changes
in the market).
We agree that the process of approving
a MAC for a specific drug is lengthy.
This has been of concern parlicularly
since the passage of the Drug Price
Competition and Patent Term Extension
Act of 1984 (Pub. L. 98417). This law
streamlines the FDA approval process
for certain drugs. The resuit of this law
is that therapeutically equivalent
(generic) drugs wiil be coming into the
marketplace more quickly than in the
past. As evidenced by the current MAC
program, we are interested in
encouraging the use of therapeutically
equivaient drugs. We would like to
adopt a Medicaid drug policy that would
allow us promptly to adjust payment
upper limits to reflect the availability of
new drug equivalents as they enter the
marketplace. Bssed on the concerns
addressed above and the Deparlment's
desire to take advantage of savings that
are currently available in the
marketplace for mukipie source drugs,
we published a Notice of Proposed
Ruiemaking (NPRM) on August 19,1986
(51 FR 29560). The NPRM announced
proposed revisions to our procedures
for estabiishing upper limits for drug
payments and provided a Wday public
comment period. On September 18,
1986, we published a second notice in
the Federal Register (51 FR 33086)
announcing an extension of the
comment period, the availability of new
data to anyone wishing to perform an
independent review and analysis, and
clarifications to the proposal.
I!. Provisions of the Propmed
Regulations
We proposed to remove the
Departmental ruies at 45 CFR Part 19
that limit drug reimbursement under
certain Federai health programs
including Medicaid, Medicare. Public
HeaRh Service (for example, Indian
Health Services), and other
Departmental grantees. We proposed
the removal of these ruies because they
have little impact upon programs other
than Medicaid and because similar rules
exist in the Medicaid regulations. In the
NPRM, we noted that to the extent that
specific iimits are useful for those other
programs, other authorities exist for
applying the limits. We aiso proposed
three akernative approaches to the
current Medicaid rules (42 CFR 447.331
through 447.334) regarding upper iimits
far drug reimbursement and invited
public comment on all three as well as
suggestionsfor alternatives which would
improve any of the three, inciuding
possible combinations of options. The
three approaches were intended to
enable the Medioaid program to take
advantage of the savings available in
the marketplace for therapeutically
equivalent multiple source drugs. We
proposed that all three approaches
wouid be subjectto'physician override'.
This means that the upper limits
established for multiple source drugs
wouid not apply if the prescribing
physician certifies that a brand name
drug is medically necessary.
We stated that under the finai rule,
which wouid adopt one of these
a~~roaches. State aclencies wouid be
required for purp&es of Federai
financial participation (FFP) to adhere to
the upper iimits set by the adopted
approach. However, in accordance with
State flexibility in the administration of
the Medicaid program, a State agency
wouid be permitted to utilize an
alternative drug reimbursement system
if aggregate payments under that
system would not exceed the upper
limits set by the adopted approach.
Specifically, the maximum amount of
State drug expenditures that would
qualify for FFP could not exceed, in the
aggregate, the upper limit of payment
for certain drugs described in listings
established by HCFA under the
approech adopted under the final rule.
The three approaches are discussed
below and include the Pharmacists'
Incentive Program, a proposed revision
of the existing MAC program, and the
Competitive incentive program.
A. Pharmacists' Incentive Program (PhlP)
As proposed, PhlP wouid have
replaced the current Federai MAC
program for multiple source drugs.
Other drugs would continue to be paid
the EAC or the provider's usual and
customary charge to the general public,
whichever is lower.
We proposed to base PhlP on a
specific formula that would establish
payment levels above which Federai
financial participation (FFP) wouid not
be recognized. A PhlP limii wouid be
estabiished only for those muitiple
source drugs for which: (1) Ali of the
formuiations of the drug approved by
FDA have been evaiuated as
therapeutically equivalent; and (2) at
least three suppliers adverlise the drug
(which has been classified by the FDA
as category "A' in the FDA's therapeutic
equivalence evaluations publication) in
either the Red Book or Blue Book,
whichever we wouid choose to use. We
proposed that the PhlP limA be set at
150 percent of the lowest priced
multiple source drug advertised in the
Red Book or Blue b o k , whichever is
lower. Thus, the pharmacist couid be
reimbursed the ingredient costs of a
drug at 150 percent of the lowest priced
multiple source drug plus the
State-established dispensing fee. in
order to ensure that the PhlP upper
limits for muitiple source drugs wouid
be reasonable for extremely low cost
and high cost drugs, we proposed to
set minimum and maximum markups.
We proposed a minimum markup of
$1.50 over the cost of the least costlv
advertised drug product and a
maximum markup of $4.00 over the cost
of the ieast costly adverlised drug
product. While PhlP would reimburse
drug ingredients at a rate that is slightly
above the lowest cost at which they
may be obtained, it would have the
advantages of bei ng easi l y
administrable (once drug prices are
obtained), easily updated for new drug
prices, and likely to produce substantial
savings for the Medicaid program.
B. Revisions to the MAC Program
We alternatively proposed to apply
MAC limits to drugs purchased under
the Medicaid program using a revised
process. Under that process, we
proposed to eliminate the PRB and to
streamline the procedures for
establishing MAC limits for selected
multiple source drugs. Mher drugs
would continue to be paid for at the
EAC plus a dispensing fee, or the
provider's usual and customary charge
to the general public, whichever is
lower.
$
We proposed that the MAC program be
$
operated directly by HCFA rather than a
under a special board. We aiso
i
proposed to continue to use much of
the current process for establishing MAC
iimits. We would continue to publish the
proposed MAC limits in the Federai
Register; utilize a comment period: and
attar considering all of the comments,
publish the finai notice in the Federai
Register. However, the process would
be shortened by not conducting a
public hearing before the PRB and
eliminating the requirement for specific
PRB consultation with FDA for each
drug.
We proposed three new requirements
that we wouid consider before
establishing a MAC limit. The first
requirement wouid be that ail of the
formuiations of the drug approved by
the FDA have been evaiuated as
therapeutically equivaient. The second
requirement would be that at least three
sumliers advertise the drua (which has
be& classified by the FD' & category
'A' in the FDA's therapeutic equivalence
evaluations Dubiicationl in theked Book
or Blue Bodk. Finally, we specified that
we wouid expect to reduce total State
and Federal Medicaid expenditures by
at least $50,000 annuelk for any drug
for which a MAC limit is to be
established.
We specified in the proposed
regulations that we would survey drug
wholesalers for assurances that they: (1)
Are carrying the muitiple source
products at or beiow the proposed MAC
iimits; or (2) would carry the products in
the event that limits are estabiished. We
also stated that, initially, we would
conduct surveys to determine the prices
at which the multiple souroe drugs that
meet the MAC criteria are widely and
consistentiy available.
in order to provide some flexibility in
the MAC iimits, we proposed to waive
specific MAC iimits in a State upon the
State Medioaid agency's request and
demonstration that the volume of the
drug in that State is too low to justify
administering the limit or that there are
availabili problems in that State for
that particular product under the MAC
limit. We also proposed to suspend or
raise temporarily a MAC iimit if the
product becomes unavailable at or
beiow the iimit.
C. Competitive Incentive Program (CIP)
As proposed, CIP wouid have replaced
the current MAC and EAC programs.
Under CiP, the starting point for
establishing an upper limit for
,imbursement for all drugs would be
the price that the pharmacy charges
p&ate retail customers for that drug, at
that time, and in that quantity. Because
~p payment wouid be based on the
pharmacist's retail charge, Medicaid
would participate in the retail
pharmaceutical market in a way similar
to that of a pharmacy's non-Medicaid
customer or third party payor. CIP
would depend upon the competitive
market place to regulate prices.
Under CIP, we proposed to appiy a
mandatory discount to the pharmacist's
retail charge and a screen of charges to
protect the Medicaid program from
excessive oharges. The mandatoiy
discount on leading brand name drugs
would be greater than the discount
applied to other drugs. Thus, an
incentive would be created for the
pharmacist to use non-brand multiple
source drugs (generics).
We proposed that the mandatory
discount on leading brand name and
multiple source drugs would appiy only
to certain drugs. These wouid be drugs
for which: (1) All of the tormuiations of
the drug approved by the FDA have
been evaluated as therapeutically
equivalent; and (2) at least three
suppliers adveltise the drug (which has
been olassified bv the FDA as catesow
- .
'A' in the FDA's therapeutic equivalence
evaluations publication) in the Red Book
or Blue Book.
In the notice published on September
18, 1986, we clarified the proposal and
proposed further alternatives relating to
the screen of oharges under CIP.
Ill. Discussion of Comments
We received approximately 123 tirnely
items of correspondence in response to
the proposed notice. The mmmenlers
represented trade associations,
manufacturers, State pharmacy
associations, State agencies and drug
stores. In general, comments were
negative to portions of all three
proposals. For example, regarding the
CIP proposal, 35 of the 39 State
agencies responding indicated that CiP
wouid be costk from an administrative
viewpoint. Regirding PhiP, some State
agencies questioned the use of the Red
~ i o k and Blue Book, stating that
average wholesale prices listed in these
publications are often overstated. With
respect to the MAC proposal,
commenten indicated that the MAC rate
hefting process would remain a time
consuming and burdensome process.
Atler review of all comments and further
deliberation within the Depaltment, we
decided that prescribing a preferred
payment method would be unnecessary
and counterproductive. Instead, we
decided that encouragement of State
flexibility is the most important aspect of
reform in terms of avoiding disruption
and bringing drug payments into
conformance with the flexibility we allow
States for other Medicaid services, in
addition to this general conclusion, each
option had significant weaknesses.
We have decided to eliminate the PhlP,
CIP and MAC revisions as proposed.
We decided to eliminate the MAC
requirements because of the
commenters and our concerns that the
MAC rate setting process is too lengthy
and time consuming. We determined
that MAC wouid not achieve timely
budget savings, simplified program
administration, or increased State
flexibility in the design and operation of
drug payment systems.
We did not implement CIP as
discussed in the NPRM due to the
consensus expressed bv many State
agencies regarding administrative costs
and implementation problems. However,
in the context of State flexibilitv, we are
allowing State agencies to use the CIP
concept of competitive pricing should
the State select this option.
For the purpose of determining an
aggregate limit to ,State spending (but
not as a payment method for individual
prescriptions), we are adopting that part
of PhlP that relates to the formula
concept for setting upper limits for
mukiple source drugs because it is the
least burdensome administratively for
HCFA and the State agencies, responds
to changes in drug pricing so that
Medicaid program payments will reflect
savings achievable from lower price
multiple source drugs, and is readily
updated. Furthermore, by setting an
aggregate iimit for multiple source
drugs, we believe that we can provide
more than adequate flexibility to States
to use payment standards that reflect
the prices and avaiiabiiity of particular
drugs. Additionaiiy, as we stated in the
NPRM, based on a study of the 60
entities that would be iisted initially, we
can be assured of an adequate supply
of the product at or below the iimit We
note that this list of 60 entities includes
those drugs for which a current MAC
iimit has been established.
A summary of the comments and our
responses to them follows.
A. State Flexibiiity
Comment: The predominant themes
expressed by the commenters were: The
proposed rules were unnecessarily
intrusive; the Medicaid State agancies
should be allowed to design and
develop their own payment systems, in
order to respond to Stateapecitic
marketplace economics; and, Federal
regulations should be kept to a
minimum. Commenters were concerned
that unnecessary Federal regulation
would restrict price competition and
stifle State innovation in the area of
payment policies and practices. Further.
commenters were concerned that the
proposais would limit the ability of State
agencies to monnor timely changes in
drug availability, costs and usage
patterns, as well as the ability to react to
these changes. The commenters
indicated that these issues are problems
experienced by State agencies under
the current regulations and expressed
the desire to avoid continued Federal
intrusion into existing programs that
have proven to be cost-effective and
innovative.
Response: Although it was not readily
apparent judged by the tenor of the
comments, we had intended to provide
State Medicaid agencies with increased
flexibility through the proposed rule. We
proposed to establish an upper limit
standard that would permit a State
agency to design and operate, or
maintain the current operation of, its
own payment system. The responsibility
of the State agency would be to make a
finding that the maximum amount of
State drug expendhures that would
quality tor FFP could not exceed, in the
aggregate, the upper limit payment level
established by HCFA under the final
rule. This approach would allow State
agencies to maintain control over their
pharmaceuticalreimbursementprograms
while providing the Federal government
needed oversight and control of
expenditures. In order to claity our
intent, we are revising the language we
had proposed.
Comment: Several commenters argued
that HCFA could save $324 million in
combined State and Federal
expenditures tor prescription drugs
between 1986 and 1990 as the resuit of
patents expiring on several drugs, and
that no regulatory action was, therefore.
necessary to achieve our savings
objectives.
Response: As discussed in section
V.E.3. of this preamble, implementing
the 150 percent aggregate limit on iisted
drugs is estimated to save
approximately $270 million over the next
f i e years, taking into account drugs
coming off patent and allowing for
physician certification of brand named
products as being medically necessary.
We doubt whether States and HCFA
wouid be assured of realizing those
savings, or the savings that commenters
estimate, without the kind of limits we
are implementing in this rule. We
believe that these limits will not operate
to constrain dispensing or pricing
behavior and it is both appropriate and
necessary to establish upper payment
limits in order to ensure that program
payments reflect the savings available
from lower cost therapeutically
equivalent drugs.
8. Stafe Plans
Comment: Many commenters thought
that if a State agency wished to use an
alternative payment system to the one
that would be established as the upper
limit standard, the agency would have
to secure a program waiver under the
provisions of section 1915 of the Act.
The perception was that this process
was very rigorous and entailed
considerable State effolts for justifying
the waiver.
Response: R was our intent that,
regardless of whether a State agency
follows the approach established by
HCFA or uses an alternative drug
payment system, a State agency would
not be required to obtain a program
waiver. The NPRM proposed a process
under which a State agency would be
free to establish any payment system it
wouid choose (except when freedom of
choice or provider contracting is
involved which would then require a
waiver). The State agency must describe
the methodology in its State plan which
is subject to the usual State plan
approval process.
Because the proposed language
regarding the State plan approval
process caused some confusion, we are
revising it to make clear that drug
payment methodologies must conform
to all State plan requirements as must
any other sewice. Under this final rule,
we are cl ai l i ng that all State agencies
are required to: (1) Describe
compreh&ively the agenhs payment
methodology for prescription drugs in its
State plan; (2) make two findings, one
for therapeutically equivalent muitipie
source drugs and one for all other
drugs, through mathematical
- . -
computation, analysis and comparison
to determine that the payment ieveis
under its payment methodology will not
exceed the payment levels that wouid
result from the application of the system
promulgated by HCFA as the upper
iimit; (3) make an assurance to us that
it has made such findings; and (4)
maintain and make available to HCFA.
upon request documentation to support
the finding.
The agency's assurance wili serve as
the basis for the approval of the State
plan. The agency findings will be
monitored through State assessments
and other evaluations or auditing
~rocedures to review the State
documentation underlying the assurance
without the need for specialized annual
reporting by the States. Consistent with
other aspects of the Medicaid program,
if HCFA finds a problem with a State's
assurance. HCFA can request the State
to provide data to support its assurance
and, if aDpropriate. HCFA wiil disallow
FFP or consider whether the State ought
to be subject to the statute's compliance
procedures.
C. Implementation of PhlP or CIP
Comment: Many commenters expressed
confusion or raised questions about the
absence of operational details for PhiP
and CIP. States were particularly
concerned about the significant changes
that would occur in current operations
(for example, data collection,
Droorammina modifications. Davment
, - - . . .
screens, monitoring price changes) and
accompanying costs, to implement PhlP
~ . .
or CiP.
Response: We deliberately did not
include specific technical details in the
NPRM because the objective of the
proposals was to establish a
methodology for setting a standard for
Medicaid upper payment limits for
purposes of FFP. We did not intend to
set forth or describe the intricate details
of a particular payment system.
Nonetheless, we did set forth a sufficient
amount of technical detail to allow
commenters to identify potential
problems and solutions, and we took
these into account in reaching the final
decision. We do not intend to impose
unnecessary or expensive operational
requirements on States. Rather, it was
our intent to permit State agencies to
exercise maximum flexibility in designing
a payment system subject only to the
maximum payment ievels established by
this regulation.
D. Aveilabilify and Ouaiity of Drugs
Comment: Several commenters wrote
requeJting that we demonstrate that the
availability and quality of drugs would
not be adversely affected under the
proposed Medicaid drug reform
alternatives.
Response: it is our belief that the
application of the 150 percent upper
limR standard that we are adopting for
certain multiple source drugs wiil yield
a payment level that will be great
enough to assure widespread availability
of drug products.
Furthermore, because we are
implementing aggregate upper limit
standards on the State's Medicaid
payments (expenditures) for drugs, a
State will have the ability to make
payment at levels above the specific
standard for certain drugs, provid;d that
the agency makes the payment at levels
below the specific standard for other
drug products. This added State
flexibility will virtually guarantee
widespread availability of all affected
drugs provided that the State agency
can determine that in the aggregate for
those drugs, the State achieved savings
equal to or greater than the HCFA
upper limit standard.
In reference to the quality of those
muRiple source drugs to which we will
apply the 150 percent markup, we
believe that the FDA assurance that all
of the formulations it has approved have
been evaluated as therapeutically
equivalent in the most current edition of
their publication 'Approved Drug
Products with Therapeutio Equivalence
Evaiuations'is adequate.
E. Additional Compendia
Comment: One commenter requested
inclusion of its publication, which is a
national compendium of drug cost
information, among the publications that
will be used in determining the upper
iimit payment for multiple source drugs.
Response: We agree with the
commenter that publications other than
the Red Book and Blue Book, which
were the onlv sources we Drooosed to
. .
use, can be used. Thus, we are revising
the regulations. The final rules will state
that h determining the upper limit
payment levels for multipie source
drugs, we wili select from ail available
national compendia of drug cost
information that reflect drug prices and
availability on a national level. As we
publish these upper limits in State
Medicaid program issuances, we will
identify the source of our drug price
information. We periodioally will publish
these upper limits in our Medicaid
Manual to assure comprehensive
knowledge of upper limits for multiple
source drugs and to reduce the need
for State agencies to do Independent
research and computation,
F. Dispensing Fees
Comment: Several commenters
suggested that either we delete tfie
requirement in current regulations for
State surveys of dispensing fee costs or
require State agencies to update these
fees in s periodic manner.
Response: In the interest of State
flexibility and to avoid imposing
unnecessary Federal procedural
requirements as to how State agencies
establish such fees, we are deleting the
current requirement at 8447,333
regarding dispensing fees. State
agencies will still be required to
determine reasonable dispensing fees
or, if dispensing fees are not paid
separarely, to impute an amount
equivalent to a reasonable dispensing
fee, In order to include those amounts
in the calculations and comparisons
they make to meet the upper limit
standard for FFP. We expect that most
States will continue their present ~~
activities to establish a reasonable
dispensing fee level and will document
the$e and any new activities in their
State plan. Such activities could include:
(1) Audits and sulveys of pharmacy
omrational costs: (2) com~ilation of
- 7 -
. . ,
data regarding professional salaries and
fees: and. (3) analysis of compiled data
regarding pharmacy overhead costs,
profits, etc.
G. Use of 'Smad Cards' and 'Vouchers'
Comment: Several commenters
suggested that HCFA adopt the use of
a 'smart card' or 'voucher' payment
system for payment of prescription drug
claims. These commenters 1nd.ca1ed mat
these systems would save significant
amounts of expenditures.
Response: As we noted in the preamble
to the NPRM, the use of a voucher or
bank draft payment (smart card) system
by State agencies was not one of the
issues addressed in the proposal to . .
establish upper payment limits. The
methodology of determining an upper
limit for prescription drug payments was
the subject of the NPRM, not the claims
payment process. The use of a voucher
or 'smart card' claims payment system
is something which State agencies may
do at present. If State agencies
determine that such a system to process
claims is workable, efficient and more
cost-effective than their current system.
and that system meets Medicaid
program requirements, then, indeed, we
encourage the individual agencies to
adopt such a claims payment system.
H. Physician's Override
Comment: Several commenters
recommended that we delete the
physician override requirement while
one State agency recommended that we
strengthen the requirement.
Response: We are retaining the
physician override requirement as
Proposed i n the NPRM. This
requirement Is a safeguard that assures
that the physician can select the drug
that is medically necessaty and best
s ubd for his or her patient. This means
. ~-
.>,~
.-
that the upper limits established for
specific (listed) multiple source drugs
will not apply if the prescribing
physician certifies that a brand name
drug is medically necessary. These
payments will not be Included in the
calculation for compliance with the
upper limit for multiple source drugs.
Instead, In these instances, the upper
limit for all other (non-listed) drugs will
appiy As under current regulations, a
State agency may choose to elaborate
and be more stringent regarding this
standard if it chooses.
I. Acceptable Upper Limit Assurance
Comment: Several State agencies asked
for guidance in making annual findings
regarding the upper limit determinations
and in deciding what constitutes an
adequate assurance regarding the upper
limit determinations when proposing
State plan amendments.
Response: We are requiring in the final
rule two findings. We are requiring an
annual finding relating specifically to the
multiple source drugs which HCFA will
identify through Medicaid program
issuances. We also are requiring a
separate triennial flnding relating to the
categofy of "other drugs'.
The finding for the listed multiple source
drugs wili confirm that the agency's
payment rates for these drugs do not
exceed the aggregate payment levels
determined by applying the upper limit
formula plus a dispensing fee. The
flnding for the category of 'other drugs'
wili confirm that a State agency's
aggregate expenditures for these drugs
under thei r chosen payment
methodology, will not exceed aggregate
payment under the EAC criteria that are
retained for this rule. (Under this rule,
the EAC criteria are applied as an upper
limit on an aggregate basis rather than
on a prescription by prescription basis.)
The findings for both the listed multiple
source drugs or 'other drugs" can be
supported by any documented
acceptable method of sampling,
imputation and statistical analysis that
the State agency uses in making Its
determination. The State agency wili
then make an assurance to HCFA that it
has made the required findings. That
assurance to HCFA will constitute a
presumption of validity of the findings
and will selve as the basis for approval
of the State plan
J. Phase-In Upper Limit Standard for
Multiple Source Drugs
Comment: One State agency
recommended that the upper limit
standard for multiple source drugs
consist of between 15-20 specific limits
established at W day intervals. The
agency is concerned about having
sufficient lead-time for wholesalers and
pharmacies to adjust inventories to
comply with the upper limit standard.
Response: We believe that we are
providing an adequate period of time for
these adjustments to occur. These
regulations are effective October 29,
1987. This allows State agencies 90
days from the date of publication to the
effective date of these final regulations
in which to submit their plan
amendment and required attachment.
K. Impact Analysis
Comment: Several commenters criticized
us for not providing sufficient detaii in
our impact analysis to permit a
comparison of the relative effects of the
three alternatives presented in the
NPRM. In particular, one commenter
stated that we failed to support our
contentions that all three proposals
would reduce Visruptions'of drugs to
retail outlets and achieve substantial
savings through encouraging the use of
low cost generic substitutions.
Response: As we explain in section V.
of this preamble, the combination of
having to analyze an extremely complex
industry with very little data makes it
difficult to formulate a comprehensive
empirically grounded Impact analysis.
Based on the information available to us
at the time of the NPRM, we did not
expect any of the three proposals
offered in the NPRM to have an annual
effect on the economy of $100 million or
more. Thus, we were not required under
Executive Order 12291 to propose an
impact analysis. Yet, because we were
concerned, at the time the NPRM was
published, that one or more of the
proposals might have an annual effect
of $100 million or more, and because
we expected our proposals to generate
considerable public debate, we
voluntarily prepared an analysis that met
the criteria of the Executive Order.
Comment: One commenter claimed that
in our impact analysis, we failed to
evaluate the effects of our proposals on
the research and development of new
drugs.
Response: it is far from clear to us what
impact our proposals would have on the
research and development of new
drugs. These proposals are attempts on
our part to take advantage of the
competiiive forces at work in the
marketplace. Companies that develop
new drugs are provided protection
under patent from compdi i on for a
certain period of time during which they
may charge prices high enough,
presumabl y, t o recover their
development costs associated with the
drug in question or to subsidize the
research and development costs of
other drugs. Once the patent expires.
however, other pharmaceutical firms
may copy the drug, and once approved
by the FDA, they may market the same
drug and set their own price. Our
proposals were designed to take
advantage of this competition among
drugs that are no longer under patent
and not intended to prevent the
development of new drugs. We were
merely seeking to participate in the
market as prudent buyers.
L. Application to Medicare
Comment: One commenter specifically
requested clarification that the
alternative selected by the Department
for the final rule would not apply to the
Medicare program and that hospitals
and hospital-based skilled nursing
facilities would be exempt under
Medicare.
Response: As we stated in the NPRM,
we are deleting the referenoes to the
MAC program contained in the Medicare
regulations concerning allowable costs
for drugs. (in the NPRM, we noted that
we would delete 5405.433. However.
that regulation has since been
redesignated and is now located at
g413.110. Thus, in this final rule, we are
deleting g413.110.) The upper limits for
drugs contained i n this final rule pertain
only to the Medicaid program. They do
not appl y t o hospi t al s and
hospital-based skilled nursing facilities
under Medicare.
N. Provisions of the Final Regulations
in this final rule, we have attempted to:
(1) Respond to the public comments on
the NPRM; (2) provide maximum
flexibility t o the States in their
administration of the Medicaid program;
(3) provide responsible, but not
burdensome Federal oversight of the
Medicaid program; and, (4) take
advantaae of savings resulting from the
availabiky of less costly, but safe and
effective, generic drug substitutes.
To accomplish this, we are drawing
from various aspects of the proposals.
The Federal upper limit standard we are
ado~t i na for certain multiple source
~. -
drugs Is based on the appijcation of a
soecific formula similar to that described
in the NPRM. The upper limit for other
drugs is similar to that in the NPRM In
that it retains the EAC limits as the
upper limit standard that State agencies
must meet, However, this standard is
applied on an aggregate rather than on
a prescription specific basis.
We want to emphasize that as a result
of our adopting aggregate iimits as the
upper limit standards, State agencies
are encouraged to exercise maximum
State flexibilitv in estabiishina their own
payment me~hodologies. i e do not
intend that our adoption of the formula
approach to set iimits for multiple
source drugs be construed as an
indicator of the Federally preferred
payment system. The use of the formula
approach is primarily due to the
straight-forward application and
administrative ease in setting upper
limits. We encourage State agencies to
establish any program that wiil
substitute lower-priced alternatives for
drugs. We hope that the State agencies
wiii be innovative in these programs and
find ways to assure the availability at
reasonable prices of multiple-source
druas. One wav thev could do this
-
wo~l o oe to encourage reta;l pharmacy
panicipat an .n tnc Med caio program oy
permining them to retain profits from tha
sale of listed drugs to Medicaid
recipients. Other alternative payment
systems could include, for example,
contracting on a oompetitive basis for
pharmaceutical sewices with selected
pharmacies to which recipients may go
for drugs without incurring a copayment
or a system which entails charge
screens andlor mandatory discounts.
Additionally, State agencies may initiate
or retain already existing so-called
"mini-MAC" programs, which they have
established on specific drugs either at
levels lower than those established
under the current Federal MAC limits or
an drugs not now covered by MAC
limits. This system of aggregate upper
iimits wiil allow State agencies to alter
payment rates for specific listed drugs
without first having to obtain permission
from HCFA. The agencies then will be
able to respond rapidly to sudden price
fluctuations, which may threaten the
supply of specific drugs on the HCFA
lid without having to pursue a
cumbersome approval process. A final
advantage of the aggregate limit
methodology is the ease of
administration at the Federal level and
the lack of administrative burden on
State programs.
A. Multiple Source Drugs
The Federai upper limit standard that
we have adopted for certain multiple
source drugs is based on an aggregate
payment amount equal to an amount
that includes the ingredient cost of the
druo calculated accordino to the formula
described below and -a reasonable
dispensing fee. HCFA wiii determine to
which drugs the formula wiil be applied.
The listing of these drugs end any
revisions to the list will be provided to
State agencies through Medicaid
program issuances on a timely, periodic
basis (possibly semi-annually). The
effedive date of the new prices will be
subsequent to the issuance of the
listing. As did the NPRM, the final rule
wiil specify that the drugs to which this
formula will be applied must have been
evaluated as therapeutically equivalent
by the FDA. Similar to the NPRM, the
final rule will specify that at least three
suppliers list the drug i n a national
compendium. The NPRM stated that
three suppliers would advertise the drug
in the Red Book or Blue Book.
The formula to be used in calculating
the upper limit of payment for certain
multiple source drugs will be 150
percent of the least costly therapeutic
equivalent that can be purchased by
pharmacists in quantities of 100 tablets
or capsules (or if the drug is not
commonly available in quantities of 100,
the package size commonly listed), or in
the case of liquids, the commonly listed
size. As we stated in the NPRM, we
chose the markup of 150 percent in
order to meet the following two
objectives: (1) That the markup be high
enough to assure that pharmacists can
normally obtain and stock an equivalent
produd without losing money on
acquisition costs of incurring the
expense of departure from normal
purchasing channels, and (2) that the
markup not be so high as to cost the
Medicaid program unnecessary money.
in other words, the 150 percent is
intended to balance the interests of both
pharmacists and the government in
achieving efficiency, economy and
quality of care as specified in section
1902(a)(30) of the Ad.
In the NPRM, we stated that we would
use the Red Book or Blue Book to
determine the least costly therapeutic
equivalent that can be purchased by
pharmacists. In this final rule, however,
we are deleting the reference to these
specific sources and are specifying that
we will publish and use the list of ail
current edlions (or updates) of
acceptable published drug compendia
available for sale nationally. Although
State agencies wiil need t o calculate or
impute a dispensing fee (if they do not
pay for the dispensing fee separately) in
order to determine % they meet the
upper iimit standard for certain multiple
source drugs, we are deieting the
current 5447.3'33 that recommends how
agencies are to establish the dispensing
fee.
As originally proposed under ail
options, this final rule will provide that il
a physician certifies that a brand name
drug is medically necessary, the upper
limit for payment based on the formula
will not apply. The upper iimit for
payment of 'other drugs' (discussed in
section 1V.B ) wiil apply. in the future,
the formula approach to setting an
upper iimit will be evaluated. We are
aware of several State agencies now in
the process of negotiating competitive
bids for discounts or rebates from drug
manufacturers and suppliers. Other
agencies are considering selective
contractina with ~rovi ders or pharmacies
-
(preferred provider organizations).
Additionally, the interaction of
competitive pricing and creative
marketing may cause dynamics in the
market that would necessitate a revision
of our policy. Thus, we will monitor the
implementation of this policy, as well as
the various payment systems used by
State agencies and the dynamics of the
marketplace, in order to make timely
revisions t o the policy for Medicaid
upper limits for drug payments.
6. Other Drugs
In this final ruie, we specify that the
agency payment for certified brand
name drugs and drugs other than
muitiple source drugs for which a
specific limit has been established must
not exceed, in the aggregate, the level
of payment calculated by applying the
lower of (1) the EAC plus a dispensing
fee; or (2) the provider's usual and
customary charges to the general
public.
Under these rules, the Federai
requirement for States to use the EAC
method of payment will be eliminated.
However, because the rule merely
establishes an upper limit concept and
does not describe the specific
methodology for payment, State
agencies may continue their practice of
estabiishina EACs for the inaredient
" -
costs and adding to it a dispensing fee.
Such practices will be acceptabie, as
will a system of establishing
chargelpayment screens based on
Statewide or regionai customary and
usual prices.
The State's findings in regard to
whether the Statewide aggregate upper
limit test is met must demonstrate that
aggregate payments do not exceed
payment as calculated under the EAC
principles.
C. State Plan Requirements, Findings
and Assurances
We are revising the proposed language
concerning State agency assurances
regarding drug payment systems. We
are clarifying that all agencies.
regardless of the payment system used,
wiil be required, in accordance with
§447.333(b)(1) of this finai rule, to make
two separate and distinct findings that
expenditures for listed multiple source
drugs on the one hand, and for all other
drugs on the other, under their payment
methodology wiil not exceed the upper
iimits established by HCFA. All State
agencies will be required to maintain
the supporting documentation and to
provide HCFA with an assurance that
they have made the required findings.
We note that we also have changed
the requirements for findings and
assurances to differ with regard to each
drug category. We will require an
annual finding for multiple source drugs
and a triennial finding for all other
drugs. The findings for multiple source
drugs will be required at least annually
because the State agencies efforts will
be directed primarily at comparing State
payments, in the aggregate, to the
maximum ingredient costs published by
HCFA.
However, for all other drugs, State
agencies wiil first have to determine the
estimated acquisition costs before
making comparisons on the aggregate
basis. it is because of the various
activities States will need to pursue in
order to make the findings for ail other
drugs that we are requiring that this be
done at least every three years. We
anticipate that the trienniai findings and
assurances for all other drugs will
lessen the administrativeireporting
burdens on State agencies and maintain
a i wel of accountability for purposes of
FFP.
Apart from the initial plan submission,
and s.bseq,ent eswrsnces an aeoncy.
which has determmed that n 8 adopt'ng
a new methodology or making
. .
s.gn'ficant cnangcs .n .ts paymenr rates
or to 11s existing system. be reqdred
to probloe rlCFA wt h tne req-is le Stale
amendments and the assurance
that it has made the necessary findings.
D. Other Changes
As proposed, this finai ruie will remove
the Departmental rules at 45 CFR Part
19 that limit drug reimbursement under
certain Federal health programs. These
ruies have little impact upon programs
other than Medicaid, and the Medicaid
regulations concerning upper limits for
drug payments are being revised under
this final rule. We also are deleting
cross references to 45 CFR Part 19
contained in 42 CFR 430.0(b)(Z)(ii) and
45 CFR 1.2, and the reference to MAC
iimits in 42 CFR 413.110.
V. Regulatoty Impact Statement
A. introduction
Exec~ti ve~Order (E.O.) 12291 requires
us to prepare and publish a finai
regulatory impact analysis for any finai
regulation that meets one of the E.O.
criteria for a "major rule": that is, that
would be likely to result in: An annual
effect on the the economy of $100
million or more; a major increase in
costs or prices for consumers, individual
industries, Federal, State, or local
government agencies, or qeo~r a~hi c
regions; or significant advers; .&tikcis on
competition, employment, investment,
productivity, innovation, or on the abi i i i
of United States-based enterprises to
compete with foreign-based enterprises
in domestic or export markets.
The local character of retail
pharmaceutical markets, the large
number of parties that participate in
those markets, the variety of products
sold, the numerous distribution channels
through which these products flow, and
a general lack of data adequately
describing these various aspects of the
market ail make it extremely difficult for
us to determine how and to what
degree this final rule will affect market
participants. For these reasons, we
cannot say with any degree of certainfy
whether this ruie will meat or exceed the
Executive Order's criteria for a major
rule. However, because of its
controversial nature, we are providing a
regulatory impact analysis.
In addition, we generally prepare a final
regulatory flexibility analysis that is
consistent with the Regulatory Flexibility
Act (RFA) (5 U.S.C. 601 through 612),
unless the Secretary CeRifies that a final
regulation wiil not have a significant
economic impact on a substantial
number of smaii entities. Although the
most direct effect of this rule will be on
States, States are not smail entities
under the RFA. The economic size of
Medicaid participating retail pharmacies
range from large national corporate
chai ns t o smal l i ndependent
single-owner outlets. Yet because retaii
pharmaceutical markets appear to be
largely local in nature, retaii pharmacies
operate i n these markets as smaii
entities. For Durooses of the RFA.
~~,
therefore, we cbnsider pharmacies to be
smaii entities. Other entities that may be
affected by this finai ruie, for example,
whol es al e d i s t r i b u t o r s and
manufacturers, also may qualify as smail
entities under the RFA, but are mora
iikeiy to participate i n regionai or
national markets, and thus, are more
likely to take on the characteristics of
large firms. For this reason, plus the fact
that this rule is not explicitly directed at
these other entiiies or expected to affect
them directly, we are not considering
them as small entities for purposes of
this rule.
B. Objectives
Through promulgation of this final rule,
we hope to achieve several objectives
we view as essential for providing
acceptable care to Medicaid recipients
and for increasing the efficiency with
which pharmaceutical products and
services are delivered to recipients.
These objectives are to:
o ~stabiish simple, administrable
methods of applying iwo separate and
distinct upper limits on State Medicaid
expenditures: one for certain
therapeutically equivalent multiple
source drugs, and one for ail other
drugs.
0 Promote wider and more efficient
distribution of pharmaceutical products
and services, and avoid potential
disruptions in the supply of drug
products that appear to be a major
drawback of the present method of
reimbursing retail
~harmacists under the MAC Program.
Conserve scarce Federal and State
resources through encouraging the more
judicious purchasing of pharmaceuticals
on behalf of Medicaid recipients, thus
achieving some budget savings, while
preserving or enhancing current levels
of service.
in pursuing these objectives, we also
wish to give State agencies the
incentive to encourage prudent
purchasing practices on the part of retail
pharmacists and foster price competition
among wholesale suppliers and
manufacturers of multiple source drugs.
C. Impact on State Agencies
The aggregate payment limit on HCFA
listed drugs as well as the general limit
on sole-source and non-listed multiple
source drugs, afford State agencies
wide latitude in developing their own
payment schemes to suit local
conditions and unusual circumstances
that may arise from time to time. For
example, State agencies may retain
already existing so called 'mini-MAC'
programs, which they have established
on specific drugs either at levels lower
than those established under the
Federal MAC limits or on drugs not now
covered by MAC limits. Also, under the
aggregate limits. State agencies are free
to experiment with alternative payment
systems, for example, letting contracts
on a competi ti ve basi s f or
~harmaceutical services with selected
pnarmacias to wn:ch recipients may go
for o r ~ g s r r ~ l n o ~ t i nc~rri ng a copaymenl.
or sb stems .dent'cai or s m!ar to PnP or
CIP: This system wiil aiso allow States
to alter payment rates for specific iisted
drugs without first having to obtain
permission from HCFA. States then wiil
be able to respond rapidly to sudden
price fluctuations which may threaten
the supply of specific drugs on the
HCFA list without having to pursue a
cumbersome approval process. A final
advantage of the aggregate limit
methodology is ease of administration at
the Federal level and the lack of
administrative burden on State
programs.
D. Small Entities Affected
The drug industry is highly complex
and multi-layered, with a variety of
manufacturing, distribution, and retail
sales arrangements that not only differ
according to geographic location, but
aiso vary by product. Further, under the
Medicaid program, the immediate payor
(that is, the State) is distinct from the
purchaser (usually the recipient) or the
orderer (the physician), both of whom
are key decision makers for each
specific purchase of drugs. These rules
wili directly affect only the State, and
even then, these rules do not control the
option available to the State, but
establish limits on the extent that we wili
share in the State's overall expenditures
for covered drugs. It is each State's
actions, taken in some measure in
response to these upper limits, that will
in turn affect other parties.
As a resutt, it is difficult for us to clearly
identify the entities affected by these
regulations, and nearly impossible to fix
the magnitude of any impact. At best,
we can only identify broad categories of
small entities that may be affected in
some fashion by this ruie, such as retail
drug outlets and pharmacists, wholesale
drug distributors, and manufacturers.
Through requiring States to establish
programs to make payments which
refled the availability of lower cost
alternatives when three or more
therapeutically equivalent generic
alternatives are available, this ruie wiil
affect the behavior of retail pharmacists
who receive Medicaid payments. As a
result of the response of pharmacists to
State programs, we expect there to be
effects on drug manufacturers and
wholesale distributors. Also, it is
conceivable that this rule might make
physicians more aware of the availability
of low cost generic drugs that could be
substituted for higher cost leading brand
drugs, and thus produce changes in
physician prescribing practices.
Furthermore, by making payments more
prudent, we hope to affect Medicaid
recipients positively by improving the
States' and Federal government's
financial ability to provide for needed
services.
E. Expected impact of Limits Placed on
Listed Drugs
I. increased State Flexibility
As described in section IV of this
preamble and in §§447.332(a) and
447.331 of the rule, HCFA will prescribe
aggregate upper limits on certain
t h e r a p e u t i c a l l y e q u i v a l e n t
multiple-souroe drugs we determine to
be readily available, and on sole source
and other multiple-source drugs. The
limit for readily available drugs is to be
based on 150 percent of the lowest
known price for each drug on the list.
The limit for sole source and other
multiple-source drugs will be based on
the amounts paid by other payors.
Since we are setting separate aggregate
limits on what we are calling 'iisted
drugs' and on 'other drugs', States wiil
be free to make payments for individual
drugs on any reasonable basis as long
as total payments for each group of
drugs do not exceed the aggregate limit
on that group. This approach should
help avoid disruptions in the supply of
listed drugs in circumstances i n which
acquisition costs may exceed the listed
price used in establishing the HCFA
limits.
State agencies should determine,
independent of the 150 percent formula,
appropriate payment levels for the iisted
multiple-source drugs. We would not
expect a State agency to adopt direothl
the upper limit methodology as a
payment method be does not gear
payments to markups appropriate to the
actual costs of acquiring and dispensing
these drugs. Under these final
regulations, State agencies will be able
t o make higher payments for some
listed drugs as long as they pay at rates
lower than those listed for other drugs
on the list. By providing this measure of
flexibility, we expect that State agencies
will be able to ensure that iisted drugs
will be generally available t o recipients.
As a counterpart to allowing State
agencies the freedom to set their own
minimum price floor on drugs in order
to cover pharmacists' ingredient costs,
they also have the authority to set an
upper limit on the mark-up of specific
drugs on the HCFA list. Since we are
not placing maximum payment limits on
individual drugs, drugs with high
compendia prices could generate
extremely high payment levels. Unless
an agency's payment methodology
ensured otherwise, a Medicaid agency
could end up paying inappropriately
high rates for some drugs while still
being in compliance with the aggregate
upper limit Nevertheless, we believe
States may establish maximum payment
limits in order to offset the minimum
payment ieveis necessaly to ensure
reasonable compensation for very low
priced drugs.
Similarly. State agencies may employ
essentially the same approach in
meeting the limits for all other drugs.
That is, the same principsl of balancing
payment increases for some drugs with
decreases for other drugs also applies
in determining whether aggregate
payments exceed the limit. For reasons
of economy, availability, or therapeutic
efficacy, a State agency may Want to
raise or lower the amount it pays for
certain drugs in efforts to influence the
supply of specific drugs. Under the
aggregate limit methodology any
change in payments above or below the
lower of the EAC or customary charges
for specific drugs must be balanced
with a corresponding reduction or
increase in payments for other drugs
within the all 'othef drug payment
category.
2. Possible Effects on Wholesale
Distributors and Manufacturers
in the previous section, we discussed
the possible effects of building into our
rates for ingredients a profit margin for
pharmacists. We expressed the hope
that States would recognize the
advantage of providing pharmacists with
an incentive to participate in the
Medicaid program and to stimulate
pharmacists to engage in prudent
purchasing practices and the
substitution of lower cost therapeutically
equivalent products. In addition to
these effects, we believe that our
method of calculating the aggregate
upper limit on payment to States may
have consequences for other sectors of
the industw: In Dalticuiar on wholesalers
, .
and manufacturers. Although these
entities may not fi i the definition of small
entities as discussed section V.A. of this
preamble, nevertheless the manner in
which this initiative affects these entities
may have an Impact on pharmacies and
on our ability to manage the program.
By using the lowest compendia Price
for a drug as the benchmark for our
listed drug rates, the low price supplier
may be encouraged to raise its
pubiished price to a point just beiow the
next higher price. Other drug
wholesalers and manufacturers may
tend to lower their published prices so
the range of published prices would
begin to narrow and cluster around the
low end of the price scale We would
expect to see such pricing pafierns
develop only for those drugs which had
sizable poltions of their total sales
among Medicaid recipients. However,
we suspect that price competition would
be carried on in the form of discounts,
promotional campaigns and other
incentives aimed at the retail
pharmacists.
Such tactics would work to the
advantage of both retail druggists and
wholesalers. Retail pharmacists would
gain by being able to purchase drugs at
prices beiow the HCFA list rice, while
khoiesaiers could gradually push the
benchmark price upwards without
loosing sales. Although, historically, it
has been the large retail outlets that
have benefited the most from wholesale
discount practices, if adopted by a
substantial number of State agencies,
our policy of using pubiished prices as
a basis for determining payment levels
may cause wholesalers to invent new
ways of offering discounts to the smaller
independent retail outlets, thereby
expanding the practice of discounting to
those outlets and enabling them to have
access to less expensive sources of
pharmaceuticals. The drawback is that
neither State programs nor the Federal
Medicaid program will benefit from such
reductions in wholesale prices.
3. Savings
Based on current State spending for
prescription drugs, and the potential for
savings to be gained from drugs
currently under patent losing their
protection, we estimated savings to the
Federal government over the next five
fiscal years from implementing an
aggregate upper limit on readily
available multiple source drugs to be
$270 million. (This assumes that the
aggregate limits an listed multiple
source drugs would be appiied to
payments for at least 60 drugs which we
identified for purposes of applying the
proposed PhlP limits in the NPRM.) Our
savings estimates also incorporate a
factor to account for physicians
exercising their privilege of specifying a
particular brand in accordance with
5447.331 (c). The following table shows
the Federal savings by fiscal year (FY),
and assumes that actual implementation
of the provisions at the Stale level will
begin April, 1988.
These savings estimates are at the
limits presented in this rule and
represent only the Federal ponion, and
whiie we generally calculate the States
share of any savings to be about 82
percent of the Federal share (assuming
the average FFP rate to be 55 percent),
State savings or additional Federai
savings will largely depend on the plans
State Medicaid agencies adopt in
response to the Federal upper limit
F. Alternafives Considered
In the NPRM, we proposed three
alternative payment schemes for
reimbursing pharmacy costs of
providing drugs and pharmacy services
to Medicaid recipients. Two of the
proposals, the PhlP and reformed MAC
program, were efforts to strengthen our
policies on payments for readily
available generic drugs, whiie the third
proposal, CIP, was designed as an all
inclusive payment scheme that would
cover both muitipia and single source
drugs.
in evaluating the three alternatives, we
considered comments and the
avaiiabiliq of resources to implement
the proposed alternatives. it became
clear almost immediately, that of the
t hr ee al t er nat i ve present ed.
implementation of CIP wouid be the
most problematic. Several obstacles
proved insurmountable. These were:
9 The added cost of implementing CIP
for multiple source drugs appeared to
be considerable. Based on comments
received and our own research, the
administrative costs were estimated to
be about $7 million to implement CIP
nationally.
0 We could not determine the impact of
CIP because of the iaok of reliable data
on retail drug charges.
CIP could not be im~lemented
quickly.
Our reasons for rejecting the reformed
version of the MAC program had to do
largely with our conclusion that even
with the reforms we were proposing, the
program wouid stilt prove to be too
cumbersome to enable us to respond to
the rapidly changing drug market
~hus, by a process of elimination, the
Federal upper limit for selected
therapeutically equivalent multiple
source drugs is based on an aggregate
payment amount equal to the ingredient
cost of the drug calculated according to
the 150 percent markup formula plus
the dispensing fee established by the
State agency. The upper limit for all
other drugs is an aggregate upper iimit
that does not exceed the iimit as
calculated under the EAC principles.
G. Conclusions
We recognize that we have presented
a somewhat limited discussion of the
potential effects this rule may have on
States and other entities. As we have
pointed out, there are many reasons for
our inability to present a more thorough
analysis. The complex market structures
that operate at national, regional and
local levels, the proprietary and highly
competitive nature of these markets, and
the combined effects of different
participants (States, pharmacies.
physicians, recipients, distributors,
manufacturers) interacting with one
another create analytical problems that
are beyond our capacity to analyze. The
flexibility provided the States means that
a variety of payment systems or
methods will be used subject to the
established payment standards noted in
this final rule. We cannot predict with
any certainty what decisions the States
will make over time, particularly as they
experiment with new and improved
payment methods.
We do, however, recognize that the
establishment of the two upper limits
described in section lV of this preamble
represents only a partial solution to the
problems of drug availability, increased
efficiency in the allocation of resources,
retail pharmacists satisfaction with
payment levels, and the provision of
adequate pharmacy sewices to
Medicaid recipients. Each State agency
will evolve its own payment
methodology and solutions to local
probiems. Each State agency wili have
to identify and decide on the trade-offs
it wishes to make with the
understanding that some of the side
effects of a particular payment method
may be counter productive with respect
to achieving stated objectives.
VI. Papemork Requirements
Section 447.333 of this rule contains
information collection requirements. The
public is not required to comply with the
information collection requirements until
the Executive Office of Management and
Budget approves these requirements
under section 3507 of the Paperwork
Reduction Act (44 U.S.C. 3507). A notice
wili be published in the Federal Register
when approval is obtained. Comments
on the information collection
requirements should be sent directly to
Allison Herron, Office of information and
Regulatory Affairs, Office of
Management and Budget, Room 3208,
New Executive Office Building,
Washington, DC 20503
Lkl of Subjects
42 CFR Part 413
Health facilities, Kidney diseases,
Medicare, Reporting and recordkeeping
requirements.
42 CFR Part 430
Grant programs-health, Medicaid.
42 CFR Part 447
Accounting, Administrative practice and
procedure. Grant programs-health,
Health facilities, Health professions,
Medicaid. Reporting and recordkeeping
requirements, Rural areas.
45 CFR Part 1
Organization and functions.
45 CFR Part 19
Administrative practice and procedure,
Drugs, Health care, Health maintenance
organizations, Medicare
42 CFR Chapter IV is amended as set
forth below:
1. 42 CFR Part 413 is amended as set
forth below:
PART 413- PRI NCI PLES OF
R E A S O N A B L E C O S T
REIMBURSEMENT: PAYMENT FOR
A. The authority citation continues to
read as follows:
Authority: Secs. 1102, 1122 1814(b),
1815. 1833(a), 1861 (v). 1871, 1881. and
1886 of the Social Security Act as
amended (42 U.S.C. 1302, 1320a-1,
1395f(b), 13958, 13951(a), 1395x(v),
1395hh,1395rr, and 1 3 9 5 ~ ) .
B. The table of contents for Subpart F is
amended by removing 5413.110.
§ 413.1 10 [Removedl
C. Section 413,110 is removed.
11. 42 CFR 430.0 is amended as set
forth below:
PART 430GRAFCTS TO STATES FOR
MEDICAL ASSISTANCE PROGRAMS
1. The authority for Part 430 continues
to read as follows:
(Sec. 1102 of the Social Security Act (42
U.S.C. 1302))
430.0 [AMENDED]
2. In ~430.0(b)(2)(1iJ, the reference to
"Pa 11BLimitations on Pavment or
Reimbursement for Drugs' is removed.
111.42 CFR Part 447 is amended as set
J
forth below:
A. The authority for Pan 447 continues
to read as foliows:
Authority: Sec. 1102 of the Social
Security Ad (42 U.S.C. 1302) unless
otherwise noted.
B. The table of contents is amended by
adding a new S447.301 and by revising
the entries for 8S47.331 through
447.333 as follows:
PART 447-PAYMEMS FOR SERVICES
. I * * *
Subpart DPayment Memods for Other
institutional and NoninsthmonalServices
Sec.
447.301 Definitions.
t * * . *
447.331 Drugs: Aggregate upper limits
of payment.
447.332 Umer limitsfor mul ti ~l e source
. .
drugs.
447.333 State plan requirements,
findings and assurances.
. * * * *
C. Section 447.301 is added to Subpart
D to read as follows:
For the purposes of this subpart- 'Brand
name" means any registered trade name
commonly used to identity a drug.
"Estimated acquisition cosr means the
agency's best estimate of the price
generally and currently paid by
providers for a drug marketed or sold
by a particular manufacturer or iabeler
in the package size of drug most
frequently purchased by providers.
"Multiple source drug' means a drug
marketed or sold by two or more
manufacturers or iabelen or a drug
marketed or sold by the same
manufacturer or iabeier under two or
more different proprietary names or both
under a proprietaly name and without
such a name.
D. Section 447.331 is revised to read as
f0liows:
8 447.331 DNP: Aggregate upper
limits of payment
(a) Multiple source drugs. Except for
brand name drugs that are certified in
accordance with paragraph (c) of this
section, the agency payment for multipie
source drugs must not exceed, the
amount that would result from the
-. -
application of the specific limits
established i n accordance with
5447,332. ii a specific limit has not been
established under 5447.332, then the
rule for 'other drugs' set forth in
paragraph (b) applies.
(b) Other drugs. The agency payments
for brand name drugs certified in
acoordance with paragraph (c) of this
section and drugs other than multiple
source drugs for which a specific limit
has been established under 8447.332
must not exceed in the aggregate.
payment levels that the agency has
determined by applying the lower of
t he
(1) Estimated acquisition costs plus
reasonable dispensing fees established
by the agency; or
(2) Providers' usual and customary
charges to the general public.
(c) Cdfication of brand name drugs.
(1) The upper limit for payments
mukiple source drugs for which a
specifio limit has been established
under 5447.332 doas not apply if a
physician certaies in his or her own
handwriting that a specific brand is
medically neoessaty for a particular
recipient.
(2) The agency must decide what
certification form and procedure are
used.
(3) A checkoff box on a form is not
acceptable but a notation like 'brand
necessary' is allowable.
(4) The agency may allow providers to
keep the certification forms U the forms
will be available for inspection by the
agency or HHS.
E. Section 447.332 is revised as
follows:
s 447.332 Upper limb for rnulSple
source drugs.
(a1 Establishment and issuance of a
. .
listing.
(1) HCFA will establish listings that
identify and set upper limits for multiple
source drugs that meet the following
requirements:
( i ) All of the formulations of the drug
approved by the Food and Drug
Administration (FDA) have been
evaluated as therapeutically equivalent
in the most current edition of their
publication, Approved Drug Products
with Therapeutic Equivalence Evaluations
(including supplements or in successor
publications).
(ii) At least three suppliers list the drug
(which has been classified by the FDA
as categoy 'A" in Rs publication.
Approved Drug Products with
Therapeutic Equivalence Evaluations,
including supplements or in successor
publications) based on all listings
contained in current editions (or
updates) of published compendia of
cost information for drugs available for
sale nationally.
(2) HCFA publishes the iist of multiple
source drugs for which upper limits
have been established and any
revisions to the iist in Medicaid program
instructions.
(3) HCFA will identify the sources used
in compiling these lists.
(b) Specific upper limits. The agency's
payments for muitiple source drugs
identified and iisted in accordance with
paragraph (a) of this. section must not
exceed, in the aggregate, payment
levels determined by applying for each
drug entity a reasonable dispensing fee
established by the agency plus an
amount established by HCFA that is
equal to 150 percent of the pubiished
price for the ieast costly therapeutic
equivalent (using all available national
compendia) that can be purchased by
pharmacists in quantities of 100 tablets
or capsules (or, if the drug is not
commonly available in quantities of 100,
the package sizg commonly listed) or, in
the case of liquids, the commonly listed
size.
F. Section 447.333 is revised as
follows:
% 447.333 State plan requirements,
findings and assurances.
(a1 State olan. The State dan musi
. .
describe comprehensively the agency's
payment methodology for prescription
(b) indi dings and assurances. Upon
proposing significant State plan changes
in paymentsfor prescription drugs, and
at ieast annually for multiple source
drugs and triennially for all other drugs,
the agenw must make the following
- .
findings and assurances:
(1) Findings. The agency must make the
following separate and distinct findings:
( i ) in the aggregate, its Medicaid
expenditures for multiple source drugs,
identified and iisted in accordance with
5447.332(a) of this subpart, are in
accordance with the upper limits
specified in §447.332(b) of this subpart;
and
(ii) in the aggregate, its Medicaid
expenditures for all other drugs are in
accordance with 8447.331 of this
subpart.
(2) kssurances. The agency must make
assurances satisfactory to HCFA that the
requirements set forth In S0447.331 and
447.332 concerning upper limits and in
paragraph (b)(l) of this section
concerning agency findings are met.
(0) Recordkeeping. The agency must
maintain and make available to HCFA,
upon request, data, mathematical or
statistical computations, comparisons,
and any other pertinent records to
support its findings and assurances.
SUBTITLE ADEPAFiTh4ENT OF HEALTH
AND HUMAN SEMCES; GENERAL
ADMIN6TFWON
iV. 45 CFR Subtitle A is amended as set
forth below:
A. The table of contents for Subtitie A
is amended by removing "Palt 19,
' Li mi t at i ons on Payment or
Reimbursement for Drugs".
PART 1 - HHS's REGULATIONS
6. The authority citation for Part 1
continues to read as follows:
(5 U.S.C. 301)
5 1.2 [Amendedl
C. In 51.2 of Subpart A, the last bullet
point antiiled 'Miscellaneous' is
amended by removing the reference to
Part 19.
PART l ~l l Ml TAl l ONS ON PAYMENT
OR REIMBURSEMENT FOR DRUGS
IREMOVEDI
D. Subtitle A is amended by removing
Part 19, 'Limitations on Payment or
Reimbursement for Drugs'.
(Catalog of Federal Domestic Ass;stance
Program No 13 714, Meoical Assistance
Program: 13.773. MedicareHos~itai
- .
I n s u r a n c e ; 1 3 . 7 7 ' 4 ,
Medicare-Supplementary Medical
insurance)
Dated: June 15, 1987
William L Roper,
Administrator, Health Care Financing
Administration
Approved: June 16, 1987.
058 R. Bowen,
Secretaty.
[FR Doc. 87-17384 Filed 7-3087; 8:45
am1
BILLING CODE 412Mll-M
STATE MEDICAID
Part 6 -- Payment
MANUAL Department of Health and Human
Services
for Services Heal th Care Fi nanci ng
Administration
TmmitLal No. 12 Daie: April 1989
REVISED MATERIAL REVISED PAGES REPLACED PAGES
Addendum A A1 -A22 (22 pp.) A1 -A20 (20 pp.)
CHANGED IMPLEMENTING INSTRUCTIONS - EFFECTIVE DATE: June I , 1989
Addendum A. - This issuance revises Addendum A to the State Medicaid Manual S6305 in order to
reflect the update of drug ingredient prices utilized by States to establish upper limits for prescription
drugs.
As you will note, this periodic update of the listing of therapeutically equivalent mukiple-source
prescription drugs includes oral-contraceptive products that meet the definitions set forth in 42 CFR
447.331 ff. Although these products are now subject to the aggregate upper limits as specified in the
regulations, we believe it appropriate to reiterate that where a state determines that for various policy
reasons, that it is preferable to make payments for the brand-name products, they are free to do so as
long as the excess payments are offset through payments for other multiple-source drugs in such a
manner that the aggregate upper-limit test would still be met. Additionally, the same rules regarding
physician certification of brand-name medically necessary apply to these products added to the listing
of multiple source drugs.
NOTE: Brackets have not been used since Addendum A is being entirely replaced
SPECIFIC UPPER LIMITS FOR MULTIPLE SOURCE AND "OTHER DRUGS"
In 1976, the Department of Health and Human Services (HHS) implemented drug reimbursement rules at 45 CFR
Part 19 under the authority of statutes pertaining to upper payment limits for Medicaid and other programs. The
authority to set an upper payment limit for services available under the Medicaid program is provided under
81902(a)(30)(A) of the Social Security Act.
HHS rules are intended to ensure that the Federal Government acts as a prudent buyer of drugs under Federal
health programs. The rules set limits on payments for drugs supplied under Medicaid and other programs. Of the
Federal programs involved, these rules have the greatest impact on the Medicaid program.
In 1983, an HHS Task Force was established to review the Department's drug reimbursement regulations at 45 CFR
Part 19. Specific concerns presented to the Task Force coupled with the Department's desire to take advantage
of savings that are currently available in the marketplace for multiple source drugs, resulted in a revision of the
regulations to change the procedures for drug payments. The final regulation was published on July 31, 1987 (52
Fed. Reg. 28648).
6305.1 Upper Limits Requirements
A. Multiple Source Drugs
I. Definition
A multiple source drug is a drug marketed or sold by two or more manufacturers or labelers, or a drug marketed
or sold by the same manufacturer or labeler under two or more different proprietary names or both under a
proprietary name and without such a name.
2. Establishment of Limits
Under the authority of a1902(a)(30)(A) and the regulations in 42 CFR 447.332, HCFA establishes a specific upper
limit for a multiple source drug if the following requirements are met:
All of the formulations of the drug approved by the Food and Drug Administration (FDA) have been
evaluated as therapeutically equivalent in the current edition of the publication, Approved Drug Products
with Therapeutic Equivalence Evaluations (including supplements or in successor publications); and
At least three suppliers list the drug (which has been classified by the FDA as category "A" in its
publication, Approved Drug Products with Therapeutic Equivalence Evaluations (including supplements
or in successor publications) in the current editions (or updates) of published compendia of cost
information for drugs available for sale nationally (e.g., Red Book, Blue Book, Medispan).
3. Awwlication of Limits
Payments for multiple source drugs identified and listed in the accompanying addendum must not exceed, in the
aggregate, payment levels determined by applying to each drug entity a reasonable dispensing fee, established by
the State, plus an amount based on the limit per unit set forth in the accompanying addendum, which HCFA has
determined to be equal to 150 percent of the published price in any of the above compendia for the least costly
therapeutic equivalent that can be purchased by pharmacists in quantities of 100 tablets or capsules, (or, if the drug
is not commonly available in quantities of 100, the package size commonly listed or, in the case of liquids, the
commonly listed size).
The upper limit for multiple source drugs for which a specific limit has been established does not apply if a
physician certifies in his or her own handwritina that a specific brand is "medicallv necessarv" for a particular
recipient. The handwritten phrase 'brand necessary" or "brand medically necessary" must appear on the face of
the prescription. A dual line prescription form does not satisfy the certification requirement. A checkoff box on a
form is not acceptable, but, again, a notation like "brand necessary" is allowable. For telephone prescriptions,
decide what certification form and procedures should be used. Providers may be allowed to keep the certification
forms if the forms will be available for inspection by their agency or HHS.
B. 'Other Drugs'
A drug described as an "other drug" is a brand name drug certified as medically necessary by a physician
or a drug other than a multiple source drug. (See s6305.1.A.) Payments for these drugs must not exceed,
in the aggregate, payment levels determined by applying the lower of the:
Estimated acquisition costs, plus reasonable dispensing fees, or
The provider's usual and customary charges to the general public.
Estimated acquisition costs mean the agency's best estimate of the price generally, and currently, paid
by providers for a drug marketed or sold by a particular manufacturer or labeler in the package size most
frequently purchased by providers.
6305.2 State Plan And Procedural Requirements -
k State Plan
As required by 42 CFR 447.333(a) the State plan must describe comprehensively, your payment
methodology for prescription drugs.
B. Findings
As required by 42 CFR 447.333(b), upon proposing significant State plan changes in payments for
prescription drugs, and at least annually for multiple source drugs and triennially for all other drugs, you
must make the following separate and distinct findings, which may not be aggregated for these purposes.
The findings can be supported by any documented, acceptable method of sampling, imputation and
statistical analysis used to make the determinations:
In the aggregate, Medicaid expenditures for multiple source drugs, identified and listed in accordance
with e6305.1.A., Multiple Source Drugs, are in accordance with the upper limit requirements, established
by that section, and
"
In the aggregate, Medicaid expenditures for all 'other drugs" are in accordance with the respective
requirements noted in ~6305.1.B.
C. Assurances
Regulations in 42 CFR 447.333(b)(2) require that, upon proposing significant State plan changes in
payments for prescription drugs, and at least annually for multiple source drugs and triennially for other
drugs, you must make assurances satisfactory to HCFA that the requirements in s and ~6305.2 are met.
The acceptance of satisfactory assurances is the basis of approval of a State plan.
D. Recordkeeping
As required by 42 CFR 447.333(c), you must maintain and make available to HCFA, upon request, data,
mathematical or statistical computations, comparisons and any other pertinent records to support your
findings and assurances.
E. Upper Limits and Federal Financial Participation (FFP)
In your assurance letter indicate that you pay no more than the upper limits described in ~6305.1, in
accordance with 42 CFR 447.304(a), since as required by 42 CFR 447.304(c) FFP is unavailable for
payments for services that exceed the upper limits.
6305.3 Upper Limit Drug Price List Update for Multiple Source Drugs
We have developed a price listing of multiple source drugs to which the formula in ~6305.1 applies. The listing of
these drugs and any revision to the list will be provided through Medicaid program issuances on a periodic basis
(possibly, semi-annually). The effective date of the new prices will be subsequent to the issuance of each new
listing and will be included i n the issuance. The listing is presented as an addendum.
04-89 PAYMENT FOR SERVICES Addendum A
Addendum A. -- The following listing of multiple source drugs meets the criteria set forth in 42 CFR 447.332. The
listing was developed by applying the 150 percent formula to the lowest price listed (in package sizes of 100 units,
unless otherwise noted) in any of the published compendia of cost information of drugs. Where a double asterisk
(**) appears the result of the application of the 150 percent formula yields a Federal financial participation (FFP)
limit that exceeds the commonly known brand name listed price. (You may want to consider making downward
adjustments in these instances and apply the excess amount to other drug payments.) The regulations at
447.333(b) set forth the aggregate upper limit test that must be met for FFP purposes. This listing is based on data
published in the December 1988 Red Book microfiche, a December 1988 First Data Banks analysis (Blue Book),
and the 1st quarter 1989 Generic Buying and Reimbursement Guide of Medi-Span and a December 1988 Medispan
analysis. All upper limts are expressed in a per unit basis, e.g., tablet, capsule.
The effective date of this list is June 1. 1989.
GENERIC NAME
Acetaminophen; Butalbial;
Caffeine 325 mg; 50 mg; 40 mg
Tablet
Acetaminophen; Codeine
300 mg; 15 mg Tablet (#2)
300 mg; 30 mg Tablet (#3)
300 mg; 60 mg Tablet (#4)
120 mg/5 ml; 12 mgl5 ml Elixir,
Oral 480 ml
Acetaminophen; Hydrocodone Bitartrate
500 mg; 5 mg Tablet
Acetaminophen; Oxycodone Hydrochloride
325 mg; 5 mg Tablet
Acetic Acid Glacial; Hydrocortisone
2%; 1%
SoluntionlDrops, Otic
10 ml.
Acetaminophen; Propoxyphene Hydrochloride
GENERIC UPPER
UMITIUNIT Source'
650 mg; 65 mg Tablet
Acetaminophen; Propoxyphene Napsylate
325 mg; 50 mg Tablet
650 mg; 100 mg Tablet
'B = Blue Book M = Medispan
COMMONLY KNOWN
BRAND NAME(S)
Fioricet
Tylenol w/Codeine
Vicodin, Lortab 5, etc.
Percocet
Vosol HC,
Orlex HC
Acetasol HC
Dolene AP-65
Wygesic
Da~ocet-N 100
Propacet
R = Red Book
Addendum A (cant.) PAYMENT FOR SERVICES 04-89
GENERIC NAME
Acetazolamide
250 mg Tablet
Allopurinol
100 mg Tablet
300 mg Tablet
Amantidine Hydrochloride
100 mg Capsule
Aminophylline
Solution Oral 105 mg15 ml
240 ml
Amitriptyline. Hydrochloride;
Chlordiazepoxide
12.5 mg; 5 mg
25 mg; 10 mg
Amoxicillin
250 mg Capsule
500 mg Capsule 50's
125 mgl5 ml 80 ml PwdIRecon.
125 mg15 ml 100 ml PwdIRecon.
125 mu5 ml 150 ml PwdIRecon.
250 mg/5 ml 80 ml PwdIRecon.
250 mu5 ml 100 ml PwdIRecon.
250 mg/5 ml 150 ml PwdIRecon.
AmpicillinIAmpicillin Trihydrate
250 mg Capsule
500 mg Capsule
125 mg15 ml 100 ml PwdIRecon.
125 mg15 ml 200 ml PwdIRecon.
250 mg15 ml 100 ml Pwd/Recon.
250 mu5 ml 200 ml PwdlRecon.
Aspirin; Butalbital; Caffeine
325 mg; 50 mg; 40 mg Tablet
Aspirin; Caffeine; Orphenadrine Citrate
385 mg; 30 mg; 25 mg Tablet
770 mg; 60 mg; 50 mg Tablet
GENERIC UPPER
UMrrRlNlT Source'
COMMONLY KNOWN
BRAND NAMEIS)
Diamox
Zyloprim
Lopurin
Symmetrel
Aminophyllin
Limbitrol
Polymox, Larotid,
Amoxil,
Trimox
Ulimax
Wymox, etc.
Amcill, Omnipen,
Polycillin,
Principen, etc.
Fiorinal
Lanorinal
Norgesic
Norgesic Forte
Addendum A (cont.) PAYMENT FOR SERVICES
GENERIC UPPER
UMITIUNIT Source*
04-89
COMMONLY KNOWN
BRAND NAME61
GENERIC NAME
Aspirin; Caffeine; Propoxyphene
Hydrochloride Da ~ o n Compound 65, etc.
389 mg; 32.4 mg; 65 mg Capsule
Aspirin; Carisoprodol
325 mg; 200 mg Tablet Soma Compound
Aspirin, Oxycodone Hydrochloride;
Oxycodone Terephthalate
Percodan
Codoxy
325 mg; 4.5 mg; 0.38 mg Tablet
Aspirin, Meprobamate Equagesic
325 mg; 200 mg Tablet
Atropine Sulfate; Diphenoxylate
Hydrochloride Lomotil, Colonaid,
Lomonate (liq. only) 0.025 mg15 ml; 2.5 mgl5 ml Oral
Soluntion 60 ml
0.025 mg; 2.5 mg Tablet
Bacitracin Zinc; Neomycin Sulfate
Polymyxin B Sulfate 400 unitslgm;
Neosporin, etc.
Neo-Polycin
eq 3.5 mg Basefgm
Ointment; Opthalmic
3.5 gm
Baclofen
10 mg Tablet
20 mg Tablet
Lioresal
Lioresal DS
Benztropine Mesylate Cogentin
0.5 mg Tablet
1 mg Tablet
2 rng Tablet
Valisone Betamethasone Valerate
0.1 % base Cream
15 gm
45 gm
0.1% base Lotion 60 ml
0.1% base Ointment
15 gm
45 gm
Addendum A (cant.) PAYMENT FOR SERVICES 04-89
GENERIC NAME
Bethanechol Chloride
25 mg Tablet
Bromodiphenhydramine Hydrochloride;
Codeine Phosphate 12.5 mgl5 ml; 10mg15 ml
Syrup, Oral 480 ml
Butabarbital Sodium
30 mg/5 ml Elixir 480 ml
15 mg Tablet 1000's
30 mg Tablet 1000's
Caffeine; Ergotamine Tartrate
100 mg; 1 mg Tablet
Carbarnazepine
200 mg Tablet
100 mg Tablet, Chewable
Carisoprodol
350 mg Tablet
Cephalexin
250 mg Capsule
500 mg Capsule
125 mg Base15 ml PwdIRecon.
100 mi
200 ml
250 mg base15 ml PwdlRecon.
100 mi
200 ml
Cephradine
250 mg Capsule
500 mg Capsule
Chloramphenicol
Ointment; Pothalmic 1%
3.5 gm
Solutionldrops; Opthalmic 0.5%
GENERIC UPPER COMMONLY KNOWN
UMlTlUNlT Source' BRAND NAME61
Urecholine
Bromanyl, Ambenyl,
Butisol Sodium
Cafergot
Ercatab
Wigraine
Tegretol
Soma,
Rela
Keflex
Velosef, Anspor
Chlorofair,
Chloromycetin
Addendum A (c0nt.l
PAYMENT FOR SERVICES
GENERIC NAME
Chlordiazepoxide Hydrochloride
5 mg Capsule
10 mg Capsule
25 mg Capsule
chlorothiazide
500 mg Tablet
chlorpropamide
100 mg Tablet
250 mg Tablet
Chlorthalidone
25 mg Tablet
50 mg Tablet
Clindamycin Hydrochloride
75 mg Capsule
i 50 mg Capsule
250 mg Tablet
500 mg Tablet
Clofibrate
500 mg Capsule
Clonidine Hydrochloride
0.1 mg Tablet
0.2 mg Tablet
0.3 mg Tablet
Clorazepate Dipotassium
3.75 mg Tablet
7.5 mg Tablet
15 mg Tablet
Cloxacillin Sodium
250 mg Capsule
500 mg Capsule
125 mg/5 ml 100 ml Pwd/Oral
Suspension
GENERIC UPPER
UMiT/UNiT Source'
COMMONLY KNOWN
BRAND NAME61
Librium
Diuril
Diabinese
Hygroton
Cleocin
Paraflex
Parafon Forte DSC
Atromid-S
Catapress
Tranxene
Tegopen, Cloxapen, etc.
Addendum A (cant.) PAYMENT FOR SERVICES 04-89
GENERIC NAME
Codeine Phosphate; Phenylephrine
Hydrochloride; Promethazine Hydrochloride
10 mg/5 ml; 5 mg/5 ml; 6.25 mg/5 ml
Syrup 480 ml
Codeine Phosphate; Promethazine
Hydrochloride 10 mg/5 ml; 6.25 mg15 ml
Syrup 480 ml
Codeine Phosphate; Pseudoephedrine
Hydrochloride; Triprolidine
Hydrochloride 10 mgl5 ml;
30 mg15 ml; 1.25 mg/5 ml
Syrup 480 ml
Cyproheptadine Hydrochloride
4 mg Tablets
2 mgl5 ml Syrup 480 ml
Desipramine Hydrochloride
10 mg Tablet
25 mg Tablet
50 mg Tablet
75 mg Tablet
I 00 mg Tablet
150 mg Tablet
Dexamethasone; Neomycin Sulfate;
Polymyxin B Sulfate 0.1%; 0.12%; EQ
3.5 mg Basehg; 10,000 unitslgrn
Ointment; Opthalmic
3.5 gm
0.1%; EQ 3.5 mg base ml; 10,0OO/ml
Suspension/Drops; Opthalmic
5 ml
Dexamethasone Sodium Phosphate;
Neomycin Sulfate EQ 0.1%
Phosphate; EQ 3.5% Base/ ml
Solution/Drops Opthalmic
5 ml
Dextromethorphan Hydrobromide; Promethazine
Hydrochloride 15 mgl5 ml; 6.25 mgl5 ml
Syrup 480 ml
GENERIC UPPER
UMITNNIT source'
M
M
M
M
M
B
R
M
M
M
B
M
M
B
M
COMMONLY KNOWN
BRAND NAME(S1
Phenergan VC
with
Codeine
Phenergan wlcodeine
Periactin
Norpramin
Maxitrol, Dexasporin
Dexacidin, Maxitrol
Neodecadron
Phenergan
w1Dextromethorphan
Addendum A (cont.)
PAYMENT FOR SERVICES
04-89
GENERIC NAME
Diazepam
2 mg Tablet
5 mg Tablet
10 mg Tablet
Dicloxiciliin Sodium
250 rng Capsule
500 mg Capsule
Dicyclornine Hydrochloride
10 mg Capsule
20 mg Tablet
Diethylproprion Hydrochloride
25 mg Tablet
Diphenhydramine Hydrochloride
25 mg Capsule
50 mg Capsule
12.5 mg/5 ml. Elixir, 480 rnl
Disopyramide Phosphate
I 00 mg Capsule
I 50 mg Capsule
Doxepin Hydrochloride
10 rng Capsule
25 Mg Capsule
50 rng Capsule
75 mg Capsule
100 mg Capsule
10 rnglml Oral Concentrate 120 rnl
Doxycycline Hyclate
100 mg Capsule, 50's
100 rng Tablet, 50's
Ergocalciferol
50,000 IU Capsule
Ergoloid Mesylates
1 rng Tablet; Oral
1 rng Tablet; Sublingual
GENERIC UPPER COMMONLY KNOWN
UMWNIT Source' BRAND NAMElS)
Valium
B
B
B
Pathocil, Dynapen, etC.
Bentyl
Tenuate, Tepanil, etc.
Benadryl
Norpace
Adapin, Sinequan, etc.
Vibrarnycin, Vibra-Tabs,
etc.
Deltalin, Drisdol, etC.
Hydergine
Addendum A (cant.) PAYMENT FOR SERVICES 04-89
GENERIC W E
Erythromycin
250 mg Enteric Coated Tablets
Ointment; Opthalmic 5 mglgm
3.5 gm
Solution; Topical 2%, 60 ml
Ewhromycin Estolate
125 mg/5 ml Oral Suspension 480 rnl
250 mg15 rnl Oral Suspension 480 rnl
Erythromycin Ethylsuccinate
200 mg/5 ml Oral Suspension 480 rnl
400 mg/5 rnl Oral Suspension 480 rnl
400 mg Tablet
Erythromycin Ethysuccinate;
Sulfisoxazole Acetyl EQ 200 mg
Base15 ml; 600 mg Base15 ml
Erythromycin Stearate
250 mg Tablet
500 mg Tablet
Ethinyl Estradiol; Norethindrone
0.035 mg; 0.5 mg
Tablet, Oral-21
Tablet, Oral-28
Ethinyl Estradiol: Norethindrone
0.035 mg; 1 mg
Tablet, Oral-21
Tablet, Oral-28
Fenoprofen Calcium
200 mg Capsule
300 rng Capsule
600 mg Capsule
GENERIC UPPER COMMONLY KNOWN
LIMlTluNrr Source' BRAND NAMEfS)
E-Mycin, ERY-TAB,
Robimycin
B
Ilotycin, etc.
M
M Elyderm, etc.
E.E.S., Pediamycin, etc.
Pedizole
B
B
B
Erythrocin
B
B
Ortho-Novum,
Norethin
B
B
Ortho-Novurn,
Norethin
B
B
Nalfon, Nalfon 200
B
M
M
Addendum A (cont.) PAYMENT FOR SERVICES 04-89
GENERIC NAME
Fluocinolone Acetonide
Cream; Topical 0.01%
15 gm
60 gm
Ointment; Topical 0.025%
15 gm
60 mg
Solution; Topical 0.01 %
20 ml
60 ml
Fluocinonide
Cream; Topical 0.05%
15 gm
30 mg
60 mg
Flurazepam Hydrochloride
15 mg Capsules
30 mg Capsules
Folic Acid
1 mg Tablet (1 000's)
Furosemide
20 mg Tablet
40 mg Tablet
80 mg Tablet
Gentamicin Suifate
Cream; Topical EQ 1 mg Baselmg
15 gm~
Ointment; Opthalmic EQ 3 mg Baselgm
3.5 gm
Ointment; Topical EQ 1 mg Baselgm
15 gm
Solution/Drops; Ophthalmic EQ
3 mg Baselml
5 ml
Gramicidin; Neomycin Sulfate;
Polymyxin B Sulfate
SolutionIDrops; Ophthalmic 0.025 mg/ml;
EQ 1.75 mg Baselmi; 10,000 unitslml
GENERIC UPPER COMMONLY KNOWN
UMITRlNIT Source' BRAND NAME61
Fluocet, Synalar, etc.
Fluonid, etc.
Fluotrex, etc.
Lidex, Vasoderm, etc.
Dalmane
Folvite
Lasix
M Garamycin, etc.
Gentacidin, etc.
M
M
Neosporin
Addendum A (cont.) PAYMENT FOR SERVICES 04-89
GENERIC NAME
Haloperidol
0.5 mg Tablet
1 mg Tablet
2 mg Tablet
5 rng Tablet
10 mg Tablet
20 mg Tablet
Haloperidol Lactate
2 mglml Oral Concentrate 120 rnl
Homatropine Methylbromide; Hydocodone
Bitartrate 1.5 mgl5 rnl; 5 mg/5 ml
Oral Syrup 480 rnl
Hydralazine Hydrochloride
10 mg Tablet
25 mg Tablet
50 mg Tablet
100 mg Tablet
Hydralazine Hydrochloride;
Hydrochlorothiazide
25 mg; 25 rng Capsule
50 mg; 50 mg Capsule
100 mg; 50 mg Capsule
Hydrochlorothiazide
25 mg Tablet
50 mg Tablet
100 mg Tablet
Hydrochlorothiazide; Methyldopa
15 mg: 250 mg Tablet
25 mg; 250 mg Tablet
30 mg; 50 mg Tablet
50 mg; 500 rng Tablet
Hydrochlorothiazide; Propranolol
Hydrochloride
25 mg; 40 rng Tablet
25 mg; 80 mg Tablet
Hydrochlorothiazide; Spironolactone
25 rng; 25 rng Tablet
GENERIC UPPER
UMITNNIT Source.
COMMONLY KNOWN
BRAND NAME(SI
Haldol
Haldol
Hycodan, etc.
Apresazide
Hydrodiuril, Esidrix,
etc.
Aldoril 15, 25, D30, D50
Inderide - 40125;
lnderide - 80125
Addendum A Icont.) PAYMENT FOR SERVICES 04-89
GENERIC NAME
GENERIC UPPER COMMONLY KNOWN
UMF/UNF Source' BRAND NAMElS)
Hydrochorothazide, Triamterene
Dyazide
25 mg; 50 mg Capsule
50 mg; 75 mg Tablet
B
M Maxzide
Hydrocortisone
Cream, Topical 1 %
20 gm
30 gm
Lotion; Topical 1 %
120 ml
Ointment; Topical
1% 20 gm
30 mg
2.5% 20 gm
Cetacort, Dermacort, etc
Cortril, Pentcort, etc.
Hydrocortisone; Neomycin Sulfate;
Polymyxin B Sulfate 1%; EQ 3.5 mg Baselml;
l0,OOOlml Cortisporin, etc.
Solution/Drops; Otic
10 ml
Suspension; Otic
10 ml
Cortisporin
Otocort, etc.
Hydroxyzine Hydrochloride Atarax
10 mg Tablet
25 mg Tablet
50 mg Tablet
10 mg/5 ml Oral Syrup 480 ml
Hydroxyzine Pamoate Vistaril
Motrin, Rufin
25 mg Capsule
50 mg Capsule
Ibuprofen
400 mg Tablet
600 mg Tablet
800 mg Tablet
Tofranil lmipramine Hydrochloride
25 mg Tablet
50 mg Tablet
Addendum A (cant.) PAYMENT FOR SERVICES
GENERIC NAME
GENERIC UPPER
LlMITbJNIT Source'
COMMONLY KNOWN
BRAND NAMEIS)
lndomethacin
25 mg Capsule
50 mg Capsule
75 mg Capsule, Controlled Release
lsoetharine Hydrochloride
1% solution; Inhalation
10 ml .3285
lsoniazid
300 mg Tablet
lsosorbide Dinitrate
5 mg Tablet; Oral
10 mg Tablet; Oral
20 mg Tablet; Oral
30 mg Tablet; Oral
40 mg Tablet; Oral
2.5 mg Tablet; Sublingual
5 mg Tablet; Sublingual
10 mg Tablet; Sublingual
Lactulose
10 mg/ 15 ml Syrup; Oral 480 ml
Lindane
Lotion; Topical 1 %
60 ml
480 ml
Shampoo; Topical 1 %
60 ml
480 rnl
Lithium Carbonate
300 mg Capsule
300 mg Tablet
Lithium Citrate
300 mg/5 ml 480 rnl
Lorazepam
0.5 mg Tablet
1 rng Tablet
2 mg Tablet
lndocin
lndocin SR
Bronkosol
INH, etc.
lsordil
Chronulac
Kwell, Scabene
Scabene, Kwell
Eskalith. Lithonate
Eskalith
Cibalith-S, etc.
Ativan
Addendum A kont.) PAYMENT FOR SERVICES 04-89
GENERIC NAME
Loxapine Succinate
5 mg Capsule
10 mg Capsule
25 mg Capsule
50 mg Capsule
Maprotiline Hydrochloride
25 mg Tablet
50 mg Tablet
75 mg Tablet
Meclizine Hydrochloride
12.5 mg Oral Tablet
25 mg Oral Tablet
Meclofenamate Sodium
50 mg Capsule
100 mg Capsule
Mefenamic Acid
" 250 mg Capsule
Megestrol Acetate
20 mg Tablet
40 mg Tablet
Meperidine Hydrochloride
50 mg Tablet
100 mg Tablet
Meprobamate
200 mg Tablet
400 mg Tablet
Mestranol; Norethindrone
0.05 mg; I mg
Tablet, Oral21
Tablet, Oral-28
Metaproterenol Sulfate
10 mg Tablet
20 mg Tablet
Methocarbamol
500 mg Tablet
750 mg Tablet
GENERIC UPPER
COMMONLY KNOWN
UMlT/UNlT Source' BRAND NAMEIS)
Loxitane
M
B
B
B
Ludiomil
Antivert
Meclornen
Ponstel
Megace
Demerol
Miltown, Equanil
Norethin 1/50 M-21
Norethin 1/50 M-28
Alupent
Robaxin
Addendum A Ic0nt.l PAYMENT FOR SERVICES 04-89
GENERIC NAME
Methyclothiazide
2.5 mg Tablet
5 mg Tablet
Methyldopa
125 mg Tablet
250 mg Tablet
500 mg Tablet
Methylphenidate Hydrochloride
5 mg Tablet
10 mg Tablet
20 mg Tablet
20 rng Tablet, Controlled Release
Metoclopramide Hydrochloride
5 mg Tablet
10 rng Tablet
Metronidazole
250 mg Tablet
500 mg Tablet
Minoxidil
10 mg Tablet
Nalidixic Acid
250 mg Tablet
500 mg Tablet
1 gm Tablet
Naphazoline Hydrochloride
SolutionJDrops; Ophthalmic 0.1%
15 ml
Nitrofurantoin, Macrocrystalline
50 mg Capsule
100 rng Capsule
Nystatin
Suspension, Oral
lo0,OoO Unitd5 ml
60 mi
GENERIC UPPER
LlMIT/UNlT Source'
COMMONLY KNOWN
BRAND NAME61
Aquatensen, Enduron,
etc.
Aldomet
Ritalin
Reglan
Flagyl
Loniten
Neggram
Vasocon
Macrodantin
Mycostatin
Addendum A (cant.)
PAYMENT FOR SERVICES
04-89
GENERIC NAME
Nystatin
Cream:Topical
i00,000 Unitstgrn
15 gm
30 gm
Ointment; Topical
GENERIC UPPER COMMONLY KNOWN
LlMIT/UNIT Source' BRAND NAME61
Mycostatin
Nilstat, etc.
Tablet Ggi nal
100,000 Units 15's ,1680 R
30's .I 474 R
Nystatin; Triarncinolone Acetonide
100,000 Unitslgrn; 0.1%
Cream; Topical
15 gm
30 gm
60 gm
Ointment; Topical
15 gm
30 grn
60 gm
Oxtriphylline
20 mg Enteric Coated Tablet
Oxybutynin Chloride
5 mg Tablet
Pencillin V Potassium
125 mg/5 rnl 100 rnl PwdiRecon.
125 mg/5 rnl 200 mi PwdiRecon.
250 rngl5 ml 100 rnl PwdtRecon.
250 mg/5 rnl 200 rnl PwdiRecon.
250 mg Tablet
500 rng Tablet
Phendimetrazine Tartrate
35 mg Tablet, 1000's
Phentermine Hydrochloride
30 mg Capsule
Mycolog II, etc.
M
M
M
Mycolog II, etc.
M
Choledyl
Ditropan
B Pen-Vee K, V-cillin K,
R
R
R
R
B
Plegine, etc.
R
Fastin, etc.
M
Addendum A (cant.) PAYMENT FOR SERVICES 04-89
GENERIC NAME
Phenylbutazone
100 mg Tablet
100 mg Capsule
Phenylephrine Hydrochloride;
Promethazine Hydrochloride
5 mgI5 ml; 6.25 mgl5 ml
Syrup, Oral 480 ml
Phenytoin Sodium
100 mg Capsule Extended Release
Prednisolone Acetate; Sulfacetamide Sodium
0.5%; 10% Suspension/Drops; Ophthalmic
5 ml
Primidone
250 mg Tablet
Probenecid
500 mg Tablet
procainamide Hydrochloride
250 mg Capsule
375 mg Capsule
500 mg Capsule
250 mg Tablet, Controlled Release
500 mg Tablet, Controlled Release
750 mg Tablet, Controlled Release
Prochlorperazine Maleate
5 mg Tablet
10 mg Tablet
25 mg Tablet
Promethazine Hydrochloride
6.25 mgl5 ml Syrup 480 ml
Propantheline Bromide
15 mg Tablet
Propoxyphene Hydrochloride
65 mg Capsule
Propranolol Hydrochloride
10 mg Tablet
20 mg Tablet
GENERIC UPPER
UMIT/UNIT Source'
COMMONLY KNOWN
BRAND NAMEIS)
Azolid; Butazolidin, etc.
Phenergan VC
Dilantin
Metimyd, Predsulfair
Mysoline
Benemid
Pronestyl, etc.
Compazine
Phenergan Plain
Pro-Banthine
Darvon
lnderal
Addendum A (cont.) PAYMENT FOR SERVICES 04-89
COMMONLY KNOWN
BRAND NAME61
lnderal
GENERIC NAME GENERIC UPPER
LIMITAJNIT Source'
Propranolol Hydrochloride
40 mg Tablet
60 mg Tablet
80 mg Tablet
90 mg Tablet
Quinidine Sulfate
200 mg Tablet
300 mg Tablet
Selenium Sulfide
Lotion/Shampoo; Topical 2.5%
120 ml
Spironolactone
25 mg Tablet
Sulfacetamide Sodium
Ointment, Ophthalmic 10%
3.5 gm
Solution/Drops, Ophthalmic 10%
15 ml
Sulfamethoxazole
500 mg Tablet
Sulfamethoxazole; Trimethoprim
200 mg/5 ml; 40 mg/5 ml
Oral Suspension 480 ml
400 mg; 80 mg Tablet
800 mg; 160 mg DS Tablet
Sulfisoxazole
500 mg Tablet
Temazepam
15 mg Capsule
30 mg Capsule
Tetracycline Hydrochloride
125 rngl5 rnl Syrup 480 ml
250 mg Capsule
500 mg Capsule
Theophylline
Cin-Quin, Quinora, etc.
Selsun, etc.
Aldactone
Sulfair, etc
Bleph-10, etc.
Gantanol
Bactrim Septra, etc.
Gantrisin
RestOril
Achromycin, Sumycin, etc.
Elixophyllin, Lanophyllin
Theolixir, Elixomin, etc.
80 mg115 ml Elixir 480 ml
Addendum A (cant.)
PAYMENT FOR SERVICES
GENERIC NAME
Thioridazine Hydrochloride
10 mg Tablet
15 mg Tablet
25 mg Tablet
50 mg Tablet
100 mg Tablet
150 mg Tablet
200 mg Tablet
30 mglml Oral Concentrate 120 ml
100 mg/ml Oral Concentrate 120 ml
Thiothixene Hydrochloride
1 mg Capsule
2 mg Capsule
5 mg Capsule
10 mg Capsule
Tolazamide
100 mg Tablet
250 mg Tablet
500 mg Tablet
Tolbutamide
500 mg Tablet
Trazodone Hydrochloride
50 mg Tablet
100 mg Tablet
Triamcinolone Acetonide
Cream, Topical
0.025% I 5 gm
80 gm
0.1% 15 gm
80 gm
Ointment, Topical
0.1% 15 gm
80 gm
Lotion, Topical
.025% 60 ml
.I% 15 ml
60 ml
GENERIC UPPER
UMiT/UNIT Source'
COMMONLY KNOWN
BRAND NAMEIS)
Mellaril
Navane
Tolinase
Orinase
Desyrel
Aristocort, Kenalog
Addendum A Icont.)
PAYMENT FOR SERVICES
04-89
GENERIC NAME
Trifluoperazine Hydrochloride
2 mg Tablet
5 mg Tablet
10 mg Tablet
Trihexyphenidyl Hydrochloride
2 mg Tablet
5 mg Tablet
Trimethoprim
100 mg Tablet
200 mg Tablet
Valproate Sodium
Syrup: Oral
250 mg Base15 ml
Valproic Acid
250 mg Capsule
Verapamil Hydrochloride
80 mg Tablet
120 mg Tablet
GENERIC UPPER COMMONLY KNOWN
UMITRlNrr Source' BRAND NAME61
Stelazine
Artane
Proloprim, Trimpex
Trimpex 200, etc.
Depakene
Depakene
Calan, Isoptin, etc.
NPC - 1989
MEDICAL ASSISTANCE PROGRAM BENEFITS (TITLE XIX)
TOTAL UNITED STATES VENDOR PAYMENTS BY WPE OF SERVICE
Intermediate Care Facility
Hospital Inpatient
Skilled Nursing
Facility
Pharmaceuticals
Physicians
Hospital Outpatient
Home Health Care
Clinic
Dental
LabK-ray
Family Planning
Other Practitioners
Other Care
TOTALS
% Total
28.7
28.1
13.2
6.6
5.9
4.9
3.8
2.1
1.2
1 .o
0.5
0.6
3.0
% Total
30.5
27.6
13.0
6.7
6.0
4.9
4.1
2.2
1.1
1 .I
0.4
0.5
3.2
Above figures include Puerto Rico and the Virgin Islands.
Other care includes: early and periodic screening, rural health clinic services and miscellaneous other care.
NOTE: The totals used on this chart are detailed on pages 98-131, obtained from the HCFA 2082 report
dated June 1989.
-
NPC-I 989
MEDICAL ASSISTANCE PROGFWM BENEFITS (TITLE XIX)
TOTAL U. S. VENDOR PAYMENTS BY TYPE OF SERVICE
1988
Other care includes early & periodic screening, rural health clinic services and miscellaneous other care.
85
MEDICAID RECIPIENTS AND VENDOR PAYMENTS - 1988
Total
State Recipients
Alabama 305,302
Alaska 32,892
Arkansas 226,733
California 3,674,940
Colorado 179,587
Connecticut 212,881
Delaware 37,150
District of Columbia 96.705
Florida
Georgia
Hawaii
ldaho
Illinois
lndiana
lowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusens
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New York
New Jersey
New Mexico
North Dakota
North Carolina
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Dakota
South Carolina
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
United States
Total Vendor
Medical
Payments
Average
Expenditure States
Per Recipient By Ranking
Mississippi
West Virginia
California
Alabama
Michigan
Wyoming
Kentucky
Montana
Hawaii
South Carolina
Oregon
Illinois
Louisiana
Missouri
Texas
Tennessee
Arkansas
Florida
Kansas
Georgia
New Mexico
Pennsylvania
lowa
Ohio
Washington
Utah
Nebraska
Vermont
Virginia
North Carolina
Oklahoma
Wisconsin
Colorado
Nevada
Maryland
ldaho
Delaware
Maine
Alaska
South Dakota
New Jersey
Minnesota
Rhode Island
lndiana
North Dakota
Massachusetts
District of Colun
Connecticut
New York
New Hampshire
Average
Expenditure
Per Recipient
C - 1989
4TE
Total
bama
ska
ansas
iifornia
lorado
nnecticut
aware
rida
orgia
uaii
h0
lois
iana
fa
isas
itucky
~isiana
ine
ryland
ssachusetts
:higan
lnesota
isissippi
souri
ntana
braska
irada
N Hampshire
N Jersey
N Mexico
N York
rth Carolina
rth Dakota
io
lahoma
:gon
insylvania
3de island
~ t h Carolina
~ t h Dakota
messee
:as
lh
'mont
j ni a
shington
st Virginia
;consin
RECIPIENTS OF PRESCRIBED DRUGS
Jrce: HCFA 2082 reports, compiled by state Medicaid program officials. Although the reports have been reviewed and
ted by HCFA, they do not guarantee the accuracy of the data. (See caveats p. 97) Despite these caveats, the 2082
a represents the most accurate figures available On the utilization of state Medicaid services.
AVERAGE EXPENDITURE PER RECIPIENT FOR PRESCRIBED DRUGS
ATE
Average
ibama
!ska
ransas
lifornia
,lorado
nnecticut
laware
:'
ri da
!orgia
iwaii
ih0
iois
iiana
va
.nsas
ntuckyi
uisiana
aine
aryland
assachusetts
chigan
nnesota
ssissippi
ssouri
mtana
?braska
wada
?w Hampshirei
?W Jerseyi
?w Mexico
?w Yorki
xt h Carolina
~ r t h Dakota
i i o
dahoma
'egon
mnsylvania
lode Island
~ u t h Carolina
~ u t h Dakota
mnessee
lxas
:ah
3rmont
rginia
ashington
'est Virginia
'isconsin
Iurce: HCFA 2082 reports, compiled by state Medicaid program officials. Although the reports have been reviewed
i d edited by HCFA, they do not guarantee the accuracy of the data. (See caveats p. 97) Despite these caveats, the
182 data represents the most accurate figures available on the utilization of state Medicaid sewices.
' Jurisdictions reporting some or all nursing home prescription expenditures in per diem nursing home rate
90
NPC - 1989
STATE
US Total
Alabama
Alaska
Arkansas
California
Colorado
Connecticut
Delaware
DC
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
PERCENTAGE OF MEDICAID EXPENDITURES
ALLOCATED TO PRESCRIPTION MEDICATION
NPC - 1989
MEDICAID DRUG REIMBURSEMENT REPORT
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Ma~yl and
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Dispensing
Fees
$3.75
3.45-1 1.46
2.50
4.01
4.05
3.78
3.55 (1)
3.65
4.25
4.23
4.26
4.14
4.00
3.47
3.00
3.78 (1)
2.79-5.26
3.25
3.51
3.55
3.70
3.88
3.65
4.20
3.75
3.00
2.00-4.00
2.84-5.05
3.95
2.85-3.00
3.73-4.07
3.65
2.60
4.24
3.75
3.23
3.55
3.52-3.83
2.75
3.40
4.05
4.25
4.21
(3)
3.65
2.75
3.40
3.1 5-4.20
2.75
3.72
4.16
Ingredient
Reimbursement Formulam
Copayment Basis Formulary
$ .50 - 3.00 WAC+9.2% Yes
AWP-5% No
AHCCCS - Arizona Health Care Cost Containment System
AWP
EAC
EAC (4)
AWP-8%
AAC
AWP-10%
WAC+7%
AWP-10%
AWP-10.5%
AWPIEAC
AWP-10%
AWP3%
AWP
EAC
EAC
AWP-10.5%
EAC
EAC
WAC+lO%
AAC (5)
AWP-10%
EAC
AWPIEAC
AWP-10%
(6)
(7)
AWP
EAC (9)
AWP-10.5%
EAC
AWPIEAC
AWPIEAC
EAC (1 0)
AAC
EAC
EAC
EACIAWP
AWP-9.5%
AWP-I 0.5%
AWP-7%
EAC (8)
AWP-12%
AWPIEAC
EAC
EAC
EACIAWP
EAC
EAC
yes
Yes
Yes
No
No
NO
NO
Yes
Yes
NO
Yes
NO
No
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
Yes
No
Yes
No
No
Yes
Yes
No
No
No
No
Yes
Yes
No
No
No
No
Yes
Yes
No
No
Status
C
B
C
C
C
B
B
B
B
C
C
B
C
B
B
C
C
B
B
B
B
C
C
C
C
A
B
B
B
B
B
C
A
B
C
C
B
B
B
B
B
C
B
B
B
B
C
C
B
B
State
MAC
(12)
Yes
Yes
Yes
NO
NO
NO
NO
Yes
NO
No
Yes
NO
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
NO
Yes
Yes
NO
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
See legend page 94
NPC - 1989
LEGEND:
Connecticut, Iowa: Plus incentive fee for dispensing a lower cost product
California: Collection by pharmacy is optional
Texas: Amount paid pharmacy equals (EAC + $3.26) divided by 0.945
Colorado: AWP or direct cost of wholesaler cost plus 18%
Michigan: AAC with AWP minus 10% screens
Nebraska: WAC plus 12.52% or AWP minus 8.71%, whichever is less
Nevada: EAC or AWP minus 10%
Texas: EAC equals lower of AWP minus 10.49% or WAC plus 12% or direct price or federal
upper limit
New Jersey: Lowest of AWP, AWP - 6% (under $25), and WAC + 25%
Ohio: EAC equals a combination of AWP minus 7%, direct price, AWP for scheduled II, 65th
percentile MAC'd drugs
Most multisource products
State MAC'S are in addition to Federal Upper Limits (FUL) list
Wyoming: MMlS data not available until FY 89
A = No drug list - all legend drugs reimbursed
B = No drug list - but certain categories are excluded from reimbursement
C = Restricted drug list
NOTE: The dispensing fees, copayments, ingredient reimbursement, formulary and MAC data
are current to August 1989.
The vendor payment, average Rx price, and prescriptions processed data are close
approximations based upon the 1988 fiscal year.
NPC - 1989
SUMMARY OF MEDICAID LIMITATIONS
- PHARMACEUTICALS
Alabama
Alaska
Arizona'
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Fbc Limit
No
No
Yes (6)
No
No
No
No
No
Yes
Yes (6)
No
No
No
No (10)
No
No
No
No
No
No
NO
No
NO
Yes (4)
Yes (5)
No
No
Yes (5)
NO
NO
NO
Yes
Yes (6)
NO
NO
Yes (3)
No
NO
NO
Yes (4)
NO
Yes (9)
Yes (3)
No
NO
NO
NO
NO
NO
NO
Refill Limit
Yes (1)
No
No
Yes
No
Yes (6)
No
Yes (3)
No
No
No
No
No
No
No
NO
Yes (1)
Yes (1)
Yes (I)
Yes (2)
NO
Yes (1)
Yes (5)
Yes (1)
NO
No
NO
No
Yes (1)
Yes (1)
Yes
Yes (1)
No
Yes (1)
Yes
NO
NO
Yes (I)
Yes (1)
NO
NO
Yes (1)
Yes (1)
No
Yes (1)
NO
NO (2)
Yes (1)
Yes
Yes (I)
Quan. Limit = L i mi t OTC Status
NO NO D
Yes (1 2) No D
No
Yes
Yes
Yes
No
Yes (12)
NO
Yes (12)
Yes
Yes (1 2)
Yes
NO
NO
No
Yes (1 2)
Yes
NO
Yes
Yes
Yes
Yes (1 3)
Yes
No
Yes
Yes (7)
Yes (12)
Yes (1 2)
Yes (14)
No
No
No
No
Yes
Yes (12)
Yes (13)
Yes
Yes (12)
Yes (13)
No
Yes (12)
Yes (1 5)
Yes (12)
Yes
NO
Yes (12)
Yes (12)
Yes (12)
No
No C
No B
No C
No C
No C
No C
No C
No C
No C
No C
No C
No B
No C
No C
No C
No C
No C
No C
No C
No C
No C
No C
No C
No C
No B
No C
No B
No C
No C
No C
No D
No C
No C
NO D
No C
No B
No B
No C
No C
No C
No C
No C
No C
NO B
No C
No C
No C
No C
See next page for key deilniLions
' AHCCCS Capitation Plan
KEY
(1) 5 Refill Limit
(2) 2 Refill Limit
(3) 3 Rx's Per Month
(4) 4 Rx's Per Month
(5) 5 Rx's Per Month
(6) 6 Rx's Per Month
(7) Some, But Not All Rx's
(8) 3 Refill Limit
(9) 7 Rx's Per Month
(10) In Long Term Care Facility Only
(2 Dispensing Fees/Drug/RecipienffMonth)
(1 1) Up To One Year
(12) 30 Days Supply or 100 Units
(1 3) 100 Days Supply
(1 4) 60 Days or 100 Units
(1 5) 180 Days Supply
OTC Status
A - All OTC's Reimbursed
B - Most OTC's Reimbursed
C - Few OTC's Reimbursed
D - None
CAVEATS FOR BASIC N 88 HCFA 2082 DATA TABLES
February 3, 1989
The data in the anached tables are based on information reported to the Health Care Financing
Administration (HCFA) for federal fiscal years ending September 30 on the Form HCFA 2082. Statistical
Report on Medical Care: Eliaibles, Recipients, Payments, and Services. HCFA provides the data in
these tables as a public service. HCFA does not guarantee the accuracy of the data, which were
obtained from State Medicaid Agencies.
When using the data keep the following caveat in mind:
o
Counts of recipients and eligibles stratified by Maintenance Assistance Status (MAS) and
Basis of Eligibility (BOE) generally count each person only once -- based on the person's
MASIBOE as of his first appearance on the Medicaid rolls during the federal fiscal year
covered by the report.
Note, however, that some States report duplicated counts of recipients in the MASIBOE
stratification cells. That is, they report an individual in as many stratification cells as the
individual had different MASIBOE statuses during the year. In such cases, the sum of
all MASIBOE cells will be greater than the Total Recipients" number.
o
Expenditure data include payments for all claims adjudicated or paid during the fiscal
year covered by the report. Note that this is not the same as summing payments for
services that were rendered during the report period.
o
Some States fail to submit the HCFA 2082 for a particular year. When this happens,
HCFA estimates the current year's HCFA 2082 data for missing States based upon prior
year's submissions and information the State entered on HCFA 64 (the form States use
to claim reimbursement for Federal matching funds for Medicaid).
HCFA 2082s submitted by States frequently contain obvious errors in one or more cells
in the form. For cells obviously in error, HCFA estimates values that appear to be more
reasonable.
e
Certain States submitted a revised HCFA 2082 that may have amended some data
originally reported. States which submitted amended data are indicated.
Questions about these tables or other Medicaid data should be directed to Tony Parker at 3011966-
791 7 or FTS 646-791 7.
JUNE 23. 1989
F
TABLE 1.
MEDI CAI D RECI PI ENTS BY MAINTENANCE ASSI STANCE STATUS AN0 BY REGION AND
STATE: FI SCAL YEAR 1988
BOSTON: REGI ON I
CONNECTICUT
2/ MAI NE
11 MASSACHUSETTS
NEW HAMPSHIRE
RHOOE I SLAND
VERMONT
NEW YORK: REGI ON
2/ NEW JERSEY
NEW YORK
3/ PUERTO RI CO
VI RGI N I SLANDS
PHI LADELPHI A: REGION 111
DELAWARE
DI STRI CT OF COLUMBIA .~ - -
YLAND
ATLANTA: REGI ON I V
2/ ALABAMA
FLORf OA
GEORGIA
KENTUCKY
MI S S I S S I P P I
NORTH CAROLINA
SOUTH CAROLINA
CHICAGO: REGI ON V
I L L I N O I S
I NDI ANA
MI CHI GAN
MINNESOTA
OHI O-
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
LOUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS CI TY: REGION V I I
2/ IOWA
2/ KANSAS
MI SSOURI
NEBRASKA
DENVER: REGION V I I I
COLORADO
2/ MONTANA
2/ NORTH OAKOTA
SOUTI4 DAKOTA
- - - . . . -
2/ UTAH
WYOMING
SAN FRANCISCO: REGION I X
CALI FORNI A
HAWAI I
NEVADA
808.424
26.691
27,669
OREGON
122.076
WASHINGTON
403.272 332.199
I/
MASSACHUSETTS BL I ND RECI PI ENT AN0 EXPENOI TURE OATA ARE ESTI MATED.
2/
MEOSTAT STATES'
RECI PI ENT AND EXPENDI TURE OATA.
- 8 sunrrrTfs STATES' DATA ARE ESTI MATED.
SEATTLE: REGION X
ALASKA
I DAHO
JUNE 2 3 . 1989
TABLE 1. MEDI CAI D RECI PI ENTS BY MAI NTENANCE ASSISTANCE STATUS AN0 BY REGI ON AND
(CONT) STATE: F I SCAL YEAR 1988
OPTI ONAL MAI NTENANCE
MEDI CALLY CATEGORICALLY ASSI STANCE
BEGZPY--bYQ--81AIE---- ---NEEQY-- ----YEEQI---- SIBIYS-UNYNQb!b
- A L L J URI SDI CTI ONS 3,604,619 8 9 , 5 3 1 44.818
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHOOE I S L A ND
VERMONT
NEW YORK: REGI ON I1 1,192.479
NEW JERSEY 4 , 6 5 2
NEW YORK 567.298
PUERTO RI CO 613.257
V I RGI N I SLANDS 7,262
PHI LADELPHI A: REGI ON I11 263.866
DELAWARE 0 - . -. . -
DI ST RI CT OF COLUMBI A
MARYLAND
PENNSYLVANI A
V I R GI N I A
WEST V I R GI N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
MI S S I S S I P P I
NORTH CAROLINA
SOUTH CAROLI NA
TENNESSEE
CHI CAGO: REQI ON V
I L L I N O I S
I NDI ANA -
MI CHI GAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
LOUISIANA
NEY MEXI CO
OKLAHOMA
TEXAS
KANSAS CI T Y : REGI ON
IOWA
V I I
KANSAS
MI SSOURI
NEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH DAKOTA
SOUTH OAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X 901.339
CALI FORNI A 881.000
HAWAI I 20.339
NEVADA 0
J UNE 23, 1989
TABL E 2. MEDI CAI D RECI PI ENTS BY B A S I S OF E L I G I B I L I T Y AND BY REGI ON AN0 STATE:
F I S C A L YEAR 1988
PERMANENTLY AND
IBIBbCI-PISBBLEQ
3,401,136
166.6-
26.862
19.696
88.148
6.093
19.761
*,* , ~ : ~
7.188
.,&
TOTAL AGE 65
BOSTON: REGI ON I
CONNECTI CUT
MA T N E
VERMONT
PHI L ADEL PHI A: REGI ON I11
DELAWARE
D I S T R I C T OF COLUMBI A
MARYLAND
PENNSYLVANI A
V I R G I N I A
WEST V I R G I N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA ~ -
SOUTH CAROLINA
TENNESSEE
CHI CAGO: REGI ON V
I L L I N O I S
I NDI A NA
MI CHI GAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS C I T Y : REGI ON V I I
I OWA
KANSAS
MI SSOURI
NEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH DAKOTA
SOUTH DAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CAL I FORNI A
H A WA I I
NEVADA
SEATTLE: REGI ON X
ALASKA
T n A U n
- - . . . . -
OREGON
WASHINGTON
-
-
JUNE 2 3 . 1989
TABLE 2.
MEDI CAI D RECI PI ENTS BY B A S I S OF ELIGIBILITY AND BY REGI ON AN0 STATE:
( C ~ ~ ~ ) F I S C A L YEAR 1 9 8 8
AFOC OTHER BASI S OF
CHI LDREN AFOC T I T L E X I X E L I G
RMIQN--~NP--SI&IE---- UNDER- 21 ADUL I S RECI PEENI S -UN_YNPYN_
--
ALL J URI SDI CT I ONS 10,037.347 5.603.317 1,343,460 44,960
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHOOE I S L A ND
VERMONT
NEW YORK: REGI ON I1
NEW JERSEY
NEW YORK
PUERTO RI CO
V I R GI N I SL ANDS
PHILADELPHIA: REGI ON 1 x 1 1.028.137
FLAWA ARE 18.377
.-
DISTRICT OF COLUMBIA 44,273
MARYLAND 163,823
PENNSYLVANI A 596.215
V I R G I N I A 122.222
WEST V I R G I N I A 93.227
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLINA
SOUTH CAROLI NA
TENNESSEE
CHI CAGO: REGI ON V
I L L I N O I S
I NDI A NA
MICHIGAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS C I T Y : REGI ON
I OWA
KANSAS
V I I 358,757
88,071
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH DAKOTA
SOUTH DAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CAL I FORNI A
H A WA I I
NEVADA
SEATTLE: REGI ON X
ALASKA
I DAHO
OREGON
WASHINGTON
JUNE 23. 1989
ABLE 3.
MEDI CAI D RECI PI ENTS BY TYPE OF SERVI CE AN0 BY REOI ON AND STATE:
F I S C A L YEAR 1988
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHOOE I SL AND
VERMONT
NEW YORK: REGI ON 11
NEW JERSEY
NEW YORK
PUERTO RI CO
V I RGI N I SLANDS
PHI LADELPHI A: REGI ON 111
DELAWARE
DI S T RI CT OF COLUMBI A
MARYLAND
PENNSYLVANI A
V I R GI N I A
WEST V I W I N I A
ATLANTA: REGI ON 1'4'
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
on10
WI SCONSI N
DALLAS: REOI ON V I
ARKANSAS
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS CI T Y : REGI ON V I I
I OWA
KANSAS
MI SSOURI
NEBRASKA
DENVER :
COLC
NOR'
SOUTH I --.
UTAH
WYDWING
SAN FRANCI SCO: REGI ON I X
CALI FORNI A
HAWAI I
NEVADA
SEATTLE: REGI ON X
ALASKA
I DAHO
OREGON
WASHI NGTON
TABL E 3. MEDI CAI D RECI PI ENT S BY TYPE OF SERVI CE AN0 BY REGI ON AN0 STATE:
(CONT) F I S C A L YEAR 1988
IYIESMEPLBIS--cbBE--E&GZCIILES
MENTALLY A L L PHYSI CI AN DENTAL
-BEEIQY--bYQ--SIbIE---- BEIbBDED PIHEC! SSRYIEES SSBYI CE~
A L L J URI SDI CT I ONS 145,408 865.589 15.265.198 5. 071. 950
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHOOE I S L A ND
VERMONT
NEW YORK: REGI ON I1
NEW JERSEY
NEW YORK
PUERTO RI CO
V I RGI N I SL ANDS
PHI LADELPHI A: REGI ON 111
DELAWARE
D I S T R I C T OF COLUMBI A
MARYLAND
PENNSYLVANI A
V I R G I N I A
WEST V I R G I N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLINA
SOUTH CAROLI NA
TENNESSEE
CHI CAGO: REGI ON V
I L L I N O I S
I NDI A NA
MI CHI GAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS C I T Y : REGI ON V I I
I O U A
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH OAKOTA
SOUTH OAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGION I X
CAL I FORNI A
H A WA I I
NEVADA
SEATTLE: REOI DN X
ALASKA - -
I DAHO
OREGON
WASHINGTON
JUNE 23, 1989
TABLE 3. MEDI CAI D RECI PI ENTS BY TYPE OF SERVI CE AN0 BY REGI ON AN0 STATE:
(CONT) F I S C A L YEAR 1988
OUTPATI ENT
YPSPI I 64
10,532,976
C L I N I C
SEBYIGES
2,256.420
L A B A
--X_=R&Y_-
7,679,294
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHODE I S L A N D
VERMONT
NEW YORK: REGI ON I1
NEW JERSEY
NEW YORK
PUERTO RI CO
PHI L ADEL PHI A: REGI ON I11
DELAWARE
D I S T R I C T OF COLUMBI A
MARYLAND
PENNSYLVANI A
V I R GI N I A
WEST V I R G I N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
CHI CAGO: REGI ON V
I L L I N O I S
I NDI ANA
MI CHI GAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS . .. .~ ~ -
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS C I T Y : REGI ON V I I
I OWA
KANSAS
MI SSOURI
NEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
. . - . . . . . . . . .
NORTH DAKOTA
SOUTH DAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CAL I FORNI A
HAWAI I
NEVADA
SEATTLE: REGI ON X
ALASKA
TnAYn
- - . . . . -
OREGON
WASHINGTON
TABLE 3. MEDI CAI D RECI PI EN
(CONT) F I S C A L YEAR 1988
TS BY TYPE OF SERVI CE AND BY REG
JUNE 23, 1989
; I ON AND STATE:
EARLY AN0
F AMI L Y PERI ODI C HOME PRESCRI BED
HEALTH
- - - - - - - ---------- DRUGS
569,097 16,323,372
BOSTON: REGI ON I
CONNECTI CUT
. . . . - . . -
MASSACHUSETTS
NEW HAMPSHI RE
RHODE I S L A ND
NEW YORK: REGI ON I1
NF W JERSEY
v n w
.
!TO RI CO
I SL ANDS
A: REGI ON 111
YARE
R I C T OF COLUMBI A
0
VANI A
V I R O I N I A
WEST V I R G I N I A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
CHI CAOO: REGI ON V
I L L I N O I S
I NDI A NA
MI CHI GAN .
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS C I T Y : REGI ON V I I
I OWA
K ~ NS A S
MI SSOURI
YEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH DAKOTA
SOUTH DAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CAL I FORNI A
H A WA I I
NEVADA
SEATTLE: REGI ON X
I ALASKA
I I DAHO
I
OREGON
:
WASHINGTON
JUNE 23. 1989
TABLE 3. MEDI CAI D RECI PI ENTS BY TYPE O F SERVI CE AND BY REGI ON AND STATE:
(CONT) F I S C A L YEAR 1988
RURAL
HEALTH
-cLl NI E
140.380
SERVI CE
YNKNPYN
36
BOSTON: REGI ON I
CONNECTI CUT
MA I NE
MASSACHUSETTS
NEW HAMPSHI RE
RHOOE I S L A ND
VERMONT
NEW YORK: REGI ON
NEW JERSEY
NEW YORK
PUERTO RI CO
V I RGI N I SL ANDS
PHI L ADEL PHI A: REGI ON 111
DELAWARE
DI S T RI CT OF COLUMBI A
MARYLAND
PENNSYLVANI A
V I R G I N I A
WEST V I R G I N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
on10
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS C I T Y : REGI ON V I I
I OWA
KANSAS
MI SSOURI
NEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH OAKOTA
SOUTH OAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CAL I FORNI A
HAWAI I
NEVADA
SEATTLE: REGI ON X
ALASKA
I DAHO
OREGON
WASHINGTON
i-
JUNE 23, 1989
TABLE 4.
CATEGORI CALLY NEEDY MEDI CAI D RECI PI ENTS WHO RECEI VE CASH PAYMENTS
BY B A S I S OF E L I G I B I L I T Y AND BY REGI ON AN0 STATE: F I S C A L YEAR 1988
AGE 65
n m - w m
1,561,247
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
AW~DE ISLAND
VERMONT
YORK: REGI ON I1
NEW JERSEY
NEW YORK
PUERTO RI CO
V I RGI N I SL ANDS
NEW
~HILAOELPHIA: REGI ON I11
DELAWARE
DI S T RI CT OF COLUMBI A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
CHI CAGO: REGI ON V
I L L I N O I S
I NDI A NA
MI CHI QAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
DENVER: REGI ON V I I I
COLORADO
MnYTALI A
. .-.. .7...-
NORTH OAKOTA
SOUTH OAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CAL I FORNI A
HA WA I I
NEVADA
SEATTLE: REGI ON X
ALASKA
I DAHO
OREGON
WASHINGTON
- - ~~
~ ~ ~ - .--- ~~ -
JUNE 23. 1989
TABLE 4. CATEGORI CALLY NEEDY MEDI CAI D RECI PI ENTS WHO RECEI VE CASH PAYMENTS
(CONT) BY B A S I S OF E L I G I B I L I T Y AND BY REGI ON AN0 STATE: F I S C A L YEAR 1988
AFOC B A S I S OF
AFOC E L I G
---6QULIS UYKNQVY
4 . 0 7 7 . 2 7 2 162
- BSPI QN- - 4NP- - SI 4I E- - - -
A L L J URI SDI CTI ONS
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHODE I S L A ND
VERMONT
NEW YORK: REGI ON I1
N W JERSEY
N W YORK
WE RT O RI CO
V I R GI N I SL ANDS
PHI L ADEL PHI A: REGI ON 111
DELAWARE
DI S T RI CT OF COLUMBI A
MARYLAND
PENNSYLVANI A
V I R QI N I A
WEST V I R GI N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
, . -. . - -
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
CHI CAGO: REGI ON V
I L L I N O I S
I NDI ANA
MI CHI GAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
i OU I S I A N A
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS CI T Y : REGI ON V I I
I OWA
KANSAS
MI SSOURI
NEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH DAKOTA
SOUTH DAKOTA
UTAH
WYOMING
20; o o i
11.221
14,934
2 7 . 0 3 2
SAN FRANCI SCO: REGI ON I X
CALI FORNI A
HA WA I I
NEVADA
SEATTLE: REGI ON X
ALASKA
I DAHO
OREGON
WASHINGTON
JUNE 23. 1989
TABLE 5.
CATEGORI CALLY NEEDY MEDI CAI D RECI PI ENTS WHO 00 NOT RECEI VE CASH PAYMENTS
BY B A S I S OF E L I G I B I L I T Y AN0 BY REGI ON AND STATE: F I S C A L YEAR 1988
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHODE I S L A ND
VERMONT
*NEW YORK: REGI ON I1
NEW JERSEY
NEW YORK
PUERTO RI CO
V I RGI N I SL ANDS
PHI LADELPHI A: REGI ON I11
DELAWARE
DI S T RI CT OF COLUMBI A
MARYLAND
PENNSYLVANI A
V I R GI N I A
WEST V I R G I N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
CHI CAGO: REGI ON V
I L L I N O I S
I NDI A NA
MI CHI GAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS CI T Y : REGI ON V I I
I OWA .
KANSAS
MI SSOURI
NEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH OAKOTA
SOUTH OAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CAL I FORNI A
HAWAI I
NEVADA
JUNE 23. 1989
\BLE 5.
CATEGORI CALLY NEEDY MEDI CAI D RECI PI ENTS WHO DO NOT RECEI VE CASH PAYMENTS
(CONT)
BY B A S I S OF E L I G I B I L I T Y AND BY REGI ON AN0 STATE:
F I S CA L YEAR 1988
B A S I S OF
E L I G
YMKYWY
20
OTHER
T I T L E X I X
REGIPIENIS
446.176
AFDC
AQYLI S
683.223
IOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
MEW HAMPSHI RE
..
RHDDE ISLAND
VERMONT
YEW YORK: REGI ON 11
NEW JERSEY
NEW YORK
PUERTO RI CO
V I RGI N I SL ANDS
PHI LADELPHI A: REGI ON 1x1
DELAWARE
DI S T RI CT OF COLUMBI A
MARYLANO
PENNSYLVANI A
V I R GI N I A
WEST V I R GI N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
DALLAS: REGI ON V I
ARKANSAS
LOUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS CI T Y : REGI ON V I I
IOWA
KANSAS
NI SSOURI
NEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH DAKOTA
SOUTH DAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CALI FORNI A
HAWAI I
NEVADA
SEATTLE: REGI ON X
ALASKA
I DAHO
OREGON
JUNE 23, 1989
TABL E 6. MEDI CALLY NEEDY MEDI CAI D RECI PI ENT S WHO DO NOT RECEI VE CASH PAYMENTS
BY B A S I S OF E L I G I B I L I T Y AND BY REGI ON AND STATE: F I S C A L YEAR 1 9 8 8
TOTAL
REGEl EN-IS
3,604,619
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHOOE I S L A ND
VERMONT
NEW YORK: REGI ON I1
NEW JERSEY
YEW YORK
PUERTO RI CO
V I R GI N I SL ANDS
PHI L ADEL PHI A: REGI ON I11
DELAWARE
DI S T RI CT OF COLUMBI A
MARYLAND
PENNSYLVANI A
VI RGI NI A
WEST V I R GI N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORQI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
CHI CAGO: REGI ON V
I L L I N O I S
TNDI ANA
- . . - - . . . . . .
MI CHI GAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
OKLAHOMA
TEXAS
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH DAKOTA
SOUTH DAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGION I X
CAL I FORNI A
HAWAI I
NEVADA
SEATTLE: REGI ON X
ALASKA
I DAHO
OREGON
WASHINGTON
JUNE 23. 1989
. ABLE 6. MEDI CALLY NEEDY MEDI CAI D RECI PI ENTS WHO DO NOT RECEI VE CASH PAYMENTS
(CONT)
BY B A S I S OF E L I G I B I L l T Y AND BY REGI ON AN0 STATE: F I S C A L YEAR 1988
B A S I S OF
E L I G
UNKNQUN
0
AFOC OTHER
T I T L E X I X
REGPIENIS
885,567
AFOC CHI LDREN
YMDEB-21
897.730
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
R~ODE I S L A ND
VERMONT
NEW YORK: REGI ON 11
NEW JERSEY
NEW YORK
PUERTO RI CO
V I RGI N I SL ANDS
PHI L ADEL PHI A: REGI ON 111
DELAWARE
DI S T RI CT OF COLUMBI A
-
MARYLAND
PENNSYLVANI A
V I R GI N I A
WEST V I R GI N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
CHI CAGO: REGI ON V
I L L I N O I S
I NDI ANA
MI CHI GAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
L OUI SI ANA
N W MEXI CO
OKLAHOMA
TEXAS
KANSAS CI T Y : REGI ON V I I
I OWA
KANSAS
VI SSOURI
NEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH OAKOTA
SOUTH OAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CAL I FORNI A
HA WA I I
NEVADA
SEATTLE: REGI ON X
ALASKA
I DAHO
OREGON
WASHINGTON
TABLE 7. MEDI CAI D MEDI CAL VENDOR PAYMENTS BY
AND BY REGI ON AND STATE: F I S CA L YEI
JUNE 23. 1 9 8 9
MAI NTENANCE ASSI STANCE STATUS OF RECI PI ENT
BOSTON: REGI ON I
CONNECTI CUT
2/ MAI NE
I 1 MASSACHUSETTS
-,
NEW HAMPSHIRE
RHOOE I S L A ND
VERMONT
NEW YORK: REGI ON I1
21 NEW JERSEY
PHI L ADEL PHI A: REGI ON I11
DELAWARE
DISTRICT OF COLUMBIA
MARYLAND
PENNSYLVANI A
V I R GI N I A
WEST V I R G I N I A
ATLANTA: REGI ON I V
2/ ALABAMA
FLORI DA
GEORGI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
CHICAGO: REGI ON V
I L L I N O I S
I NDI A NA
MI CHI GAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS C I T Y : REGI ON
2/ I OWA
V I I 1,724.107.743
472,237,173
3 3 7 . 9 9 7 . 3 3 1
6 8 6 . 4 6 8 . 6 9 7
227,404,542
DENVER: REGI ON V I I I
COLORADO
2/ MONTANA
2/ NORTH DAKOTA
SOUTH DAKOTA
2/ UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X 5,475,379,568 3,187,617,565
CAL I FORNI A 5,226,773,277 3.052.745.740
HAWAI I 154,967,251 78,537,760
NEVADA 9 4 , 6 3 9 . 0 6 0 56.334.065
SEATTLE: REGI ON X 1,401,541,311 716.894.116
ALASKA 94.867.649 64.698.388
- . -
TDAHD 123.089.041 29.273.470 93:816.671
JUNE 23. 1989
TABLE 7. MEDI CAI D MEDI CAL VENDOR PAYMENTS BY MAI NTENANCE ASSI STANCE STATUS OF RE CI P I E NT
(cONT) AND BY REGI ON AN0 STATE: F I S CA L YEAR 1988
i
OPTI ONAL
MEDI CALLY CATEGORI CALLY
NEEDY ---
----------- ----YEEPZ----
13,068,364,127 123,562.827
MAI NTENANCE
ASSI STANCE
SI AI US- YI KI PYI
52,664.824
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHOOE I S L A ND
NEW YORK: REGI ON
NEW JERSEY
NEW YORK
PUERTO RI CO
V I R GI N I SL ANDS
PHI L ADEL PHI A: REGI ON 111
DELAWARE
D I S T R I C T OF COLUMBI A
MARYLAND
PENNSYLVANI A
V I R G I N I A
WEST V I R GI N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEOROI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS C I T Y : REGI ON V I I
I OWA
KANSAS
MI SSOURI
NEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH DAKOTA
SOUTH DAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CAL I FORNI A
HA WA I I
NEVADA
SEATTLE: REGI ON X
ALASKA
I DAHO
OREGON
WASHINGTON
TABLE 8. MEDI CAI D MEDI CAL \
AN0 BY REGI ON AN0
JUNE 23. 1989
'ENDOR PAYMENTS BY BASIS OF ELI GI BI LI TY OF RECIPIENT
STATE: F I S C A L YEAR 1988
TOTAL AGE 65 PERMANENTLY AN0
tAYVENI5 6ND--PLDER BCENQNESS IPIdLLI-PISdBhEP
48.710.157.836 17.135.323.201 343,756,610 18.260.087.009
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHOOE I S L A ND
VERMONT
NEW YORK: REGI ON I1
NEW JERSEY
NEW YORK
PUERTO RI CO
V I RGI N I SL ANDS
PHI LADELPHI A: REGI ON I11
DELAWARE
D I S T R I C T OF COLUMBI A
MARYLAND
PENNSYLVANI A
V I R G I N I A
WEST V I R G I N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEOROI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS C I T Y : REGI ON V I I
I OWA
KANSAS
MI SSOURI
SOUTH DAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CAL I FORNI A
H A WA I I
NEVADA
SEATTLE: REGI ON X
ALASKA
I DAHO
OREGON
WASHINGTON
r
!
JUNE 2 3 , 1989
G I B I L I T Y OF RECI PI ENT j
r mL E 8. MEOICAID MEDICAL VENDOR PAYMENTS BY BASIS OF ELI
(cONT) AN0 BY REGI ON AN0 STATE: F I SCAL YEAR 1988
AFOC
CHI LDREN AFDC
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHOOE I S L A ND
VERMONT
NEW YORK: REGI ON I1
NEW JERSEY
NEW YORK
PUERTO RI CO
V I RGI N I SL ANDS
Du TI ADFL PHI A: REGI ON I11 6 7 6 . 4 6 0 . 2 8 9 5 4 1 . 4 1 6 . 8 5 8
. . . - -. . - -- -
- -
nFI AWARF 11:018:0~8 9 1877 988
- - - . . - . . . . -
- - . - - . . -
DI S T RI CT OF COLUMBI A 47,161,206 42;080; 1 5 4
MARYLAND
1 3 9 . 5 8 6 . 8 4 9 103,037,611
PENNSYLVANI A
3 8 8 , 0 9 0 , 6 6 6 246,863,607
V I R GI N I A
WEST V I R GI N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
CHI CAGO: REGI ON V
I L L I N O I S
I NDI ANA
MICHIGAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON VI
ARKANSAS
LOUISIANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS CI T Y : REGI ON V I I
I OWA
KANSAS
MI SSOURI
NEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH OAKOTA
SOUTH OAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON IX 707.787.895 1.000.478.615
SEATTLE: REGI ON X
ALASKA
TnAHO
- -. . . . -
OREGON
WASHINGTON
JUNE 23. 1989
TABLE 9 . MEDICAID MEDICAL VENDOR PAYMENTS BY TYPE OF SERVICE AND BY REGION AND STATE:
F I S C A L YEAR 1988
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
VERMONT
NEW YORK: REGI ON I1
NEW JERSEY
NFW v n w
. . - - . - . . . .
PUERTO RI CO
V I RGI N I SL ANDS
PHI L ADEL PHI A: REGI ON I11
DELAWARE ~-
DI S T RI CT OF COLUMBI A
MARYLAND
PENNSYLVANI A
V I R GI N I A
WEST V I R GI N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
CHI CAGO: REGI ON V
I L L I N O I S
I NDI A NA
MI CHI GAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
.ARKANSAS
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
NEBRASKA
SOUTH DAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CAL I FORNI A
HAWAI I
NEVADA
SEATTLE: REGI ON X
ALASKA
I DAHO
OREGON
WASHINGTON
JUNE 23, 1989
TABLE 9. MEDI CAI D MEDI CAL VENDOR PAYMENTS BY T YPE OF SERVI CE AND BY REGI ON AN0 STATE:
(CONT) F I S C A L YEAR 1988
A L L
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHQDE ISLAND
VERMONT
NEW YORK: REGI ON I1
NEW JERSEY
NEW YORK
PUERTO RI CO
V I RGI N I SL ANDS
PHI LADELPHI A: REGI ON I11
DELAWARE
DI S T RI CT OF COLUMBI A
MARYLAND
PENNSYLVANI A
V I R GI N I A
WEST V I R GI N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
OHI O
WI SCONSI N
OKLAHOMA
KANSAS CI T Y : REGI ON V I I
I OWA
KANSAS
MI SSOURI
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH DAKOTA
SAN FRANCI SCO: REGI ON I X
CALI FORNI A
HAWAI I
NEVADA
SEATTLE: REGI ON X
ALASKA
IOAHO
OREGON
WASHINGTON
JUNE 23, 1 9 8 9
2
TABLE 9.
MEDI CAI D MEDI CAL VENDOR PAYMENTS BY TYPE OF SERVI CE AN0 BY REGI ON AN0 STATE:
(CONT) F I S C A L YEAR 1988
OTnER OUTPATI ENT C L I N I C
e s n c I r mm hgsr 114~ SEBYICES-
284.235.721 2.413.028.723 1.105.212.592
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
6 0 0 ~ I S L A ND
VERMONT
NEW YORK: REGI ON I1
NEW JERSEY
NEW YORK
PUERTO RI CO
~HILAOELPHIA: REGI ON I11
DELAWARE
D I S T R I C T OF COLUMBI A
MARYLAND
PENNSYLVANI A
V I R G I N I A
WEST V I R O I N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
OEOROI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS C I T Y : REGI ON V I I
I OWA
KANSAS
MI SSOURI
NEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH OAKOTA
SOUTH OAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X - - - ~
CAL I FORNI A
H A WA I I
NEVADA
SEATTLE: REGI ON X
ALASKA
JUNE 23. 1989
BY TYPE OF SERVI CE AND BY REGI ON AND STATE: TABLE 9 . MEDI CAI D MEDI CAL VENDOR PAYMENTS
(CONT) F I S C A L YEAR 1 9 8 8
HOME PRESCRI BED
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHODE I S L A ND
VERMONT
NEW YORK: REGI ON 11
NEW JERSEY
PHI L ADEL PHI A: REGI ON I11
DELAWARE
DI S T RI CT OF COLUMBI A
MARYLAND
PENNSYLVANI A
V I RGI NI A
WEST V I R GI N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLINA
SOUTH CAROLI NA
TENNESSEE
CHI CAGO: REGI ON V
I L L I N O I S
I NDI ANA - - -
MI CHI GAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REOI ON V I
ARKANSAS
LOUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS C I T Y : REGI ON V I I
TOWA
KANSAS
MI SSOURI
NEBRASKA
DENVER: REOI ON V I I I ~ ~ -
COLORADO
MONTANA
NORTH DAKOTA
SOUTH DAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CALI FORNI A
HAWAI I
NEVADA
SEATTLE: REOI ON X
ALASKA
I DAHO
OREGON
WASHINGTON
JUNE 23, 1989
TABLE 9. MEDI CAI D MEDI CAL VENDOR PAYMENTS BY TYPE OF SERVI CE AN0 BY REGI ON AN0 STATE:
(CONT) F I S C A L YEAR 1 9 8 8
RURAL
HEALTH SERVI CE
YNENQYN
41.811
OTHER
28BE-
1.431.007.209
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHDDE I S L A ND
VERMONT
NEW YORK: REGI ON I1
NEW JERSEY
NEW YORK
PUERTO RI CO
V I RGI N I SL ANDS
PHI L ADEL PHI A: REGI ON I11
DELAWARE
DISTRICT OF COLUMBIA
MARYLAND
. . . . . . . - . . . . -
PENNSYLVANI A
V I R GI N I A
WEST V I R G I N I A
ATLANTA: REGI ON I V
ALABAMA
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
CHI CAGO: REGI ON V
I L L I N O I S
I NDI ANA
MI CHI GAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS C I T Y : REGI ON V I I
I OWA
KANSAS
MI SSOURI
NEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH DAKOTA
SOUTH DAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CAL I FORNI A
HAWAI I
NEVADA
JUNE 23. 1589
TABL E 10. MEDI CAI D MEDI CAL VENDOR PAYMENTS FOR CATEGORI CALLY NEEDY RECI PI ENT S WHO
RECEI VE CASH PAYMENTS BY B A S I S OF E L I G I B I L I T Y AN0 BY REGI ON AND STATE: -
FTSCAL YEAR 1988 . -. .-
TOTAL AGE 65 PERMANENTLY AND
REQIQY--BN-P_-SIAIE-_---- PAIBEYIS AND--PLPEB BC61PN-ESS I PI AhLLPI SbBhEP
A L L J URI SDI CTI ONS 24.583.768.754 4.183.887.631 234,587,080 11,132,951.532
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEU HAMPSHI RE
RHODE I S L A ND
VERMONT
NEW YORK: REGI ON I1
NEW JERSEY
NEW YORK
PUERTO RI CO
V I RGI N I SL ANDS
PHI L ADEL PHI A: REGI ON 111
DELAWARE
D I S T R I C T OF COLUMBI A
MARYLAND
PENNSYLVANI A
V I R G I N I A
WEST V I R GI N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
CHI CAGO: REGI ON V
I L L I N O I S
I NDI ANA
MI CHI GAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS ....... ~
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS C I T Y : REGI ON V I I
I OWA
KANSAS
. . . . . . - . . -
MI SSOURI
NEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH DAKOTA
SOUTH DAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CAL I FORNI A
HA WA I I
NEVADA
SEATTLE: REGI ON X
ALASKA
I DAHO
OREGON
WASHINGTON
- - . . - - - , - -
TABLE 10. MEDI CAI D MEDI CAL VENDOR PAYMENTS FOR CATEGORI CALLY NEEDY RECI PI ENTS WHO
(CONT) RECEI VE CASH PAYMENTS BY B A S I S OF E L I G I B I L I T Y AND BY REGI ON AND STATE:
F I S CA L YEAR 1988
AFDC BASI S OF
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHODE I SL AND
VERMONT
NEW YORK: REGI ON I1
NEW JERSEY
NEU YORK
PUERTO RI CO
V I RGI N I SLANDS
PHI LADELPHI A: REGI ON I11
DELAWARE - ..
OI STl
MI
PI
VI RG:
WEST
.. .. ~-
RI CT OF COLUMBI A
WYLANO
SNNSYLVANI A
I N I A
V I RGI NI A
ATLANTA: REGION I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
MI S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
CHI CAGO: REGI ON V
I L L I N O I S
I NDI ANA
MI CHI GAN .- -~
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
LOUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS CI T Y : REGI ON V I I
IOWA
KANSAS
MI SSOURI
NEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH DAKOTA
SOUTH DAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CALI FORNI A
HAWAI I
NEVADA
SEATTLE: REGI ON X
ALASKA
I DAHO
OREGON
WASHINGTON
JUNE 23, 1989
TABLE 11. MEDI CAI D MEDI CAL VENDOR PAYMENTS FOR CATEGORI CALLY NEEDY RECI PI ENT S WHO DO NOT
RECEI VE CASH PAYMENTS BY B A S I S OF E L I G I B I L I T Y AN0 BY REGI ON AN0 STATE:
FISCAL YEAR 1 9 8 8
PERMANENTLY AND
BCEIPIESS IPIBLCI-PES6BCEP
61.906.847 3,198,237.608
TOTAL
PAIMENlS
10,881.797.304
BOSTON: REGI ON I
CONNECTI CUT
MATNF
, ,. . - . - -
MASSACHUSETTS
NEW HAMPSHI RE
RHODE I S L A ND
VERMONT
NEW YORK: REGI ON I1
NEW JERSEY
NEW YORK
PUERTO RI CO
V I RGI N I SL ANDS
PHI L ADEL PHI A: REGI ON 111
DELAWARE
DI S T RI CT OF COLUMBI A
MARYLAND
PENNSYLVANI A
V I R GI N I A
WEST V I R GI N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
CHI CAGO: REGI ON V
I L L I N O I S
I NDI ANA
MI CHI GAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS C I T Y : REGI ON V I I
I OWA
KANSAS
MI SSOURI
NEBRASKA
REGI ON V I I I
IRADO
SOUTH DAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CALI FORNI A
HAWAI I
NEVADA
SEATTLE: REGI ON X
ALASKA
I DAHO
OREGON
WASHINGTON
TABLE 11. MEDI CAI D MEDI CAL VENDOR PAYMENTS FOR CATEGORI CALL
(CONT) RECEI VE CASH PAYMENTS BY B A S I S OF E L I G I B I L I T Y AN0
F I S CA L YEAR 1988
JUNE 23. 1989
Y NEEDY RECI PI ENT S WHO DO NOT
BY REGI ON AN0 STATE:
B A S I S OF
E L I G
UN_K_N_O_YN-
11.266
AFOC
CHI LDREN AFOC
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHODE I S L A ND
VERMONT
PHI LADELPHI A: REGI ON I11 83.590.552 43,428,388
t x l ~ AWARE 1.148.316 1 .123.719
- - - . . - . . - -.-- .
DI S T RI CT OF COLUMBI A 137; 279 219.454
MARYLAND
1,504,430 781.238
PENNSYLVANI A
72.765.282 17.441.635
V I R GI N I A
4,316,305 17,809.053
WEST V I R GI N I A
3 . 7 1 8 . 9 4 0 6 , 0 5 3 , 2 8 9
ATL .ANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
CHI CAGO: REGI ON V
I L L I N O I S
I NDI ANA
MI CHI GAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS CI T Y : REGI ON
I OWA
KANSAS
V I I 24,623,840
5.448.553
4.766.256
9.321.488
4,987,543
. . . . . . - . .-
MI SSOURI
NEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH OAKOTA
SOUTH OAKOTA
UTAH
WYOMING
S I N FRANCI SCO: REG1
CAL I FORNI A
HA WA I I
NEVADA
SEATTLE: REGI ON X
ALASKA
I DAHO
OREGON
I
WASHINGTON
I
JUNE 23, 1 9 8 9
r ABL E 12. MEDI CAI D MEDI CAL VENDOR PAYMENTS FOR MEDI CALLY NEEDY RECI PI ENTS
BY BASI S OF E L I G I B I L I T Y AN0 BY REGION AN0 STATE: F I SCAL YEAR 1 9 8 8
TOTAL ACE 66 PERMANENTLY AN0
- -
REOI QY- - AYD- - SI AI E- - - - - P4YMEYI S
AL L J URI SDI CTI ONS 13,068,364,127
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHOOE I SL AND
VERMONT
NEW YORK: REGI ON I1
NEW JERSEY
NEW YORK
PUERTO RI CO
VI RGI N I SLANDS
PHI LADELPHI A: REGI ON 111
DELAWARE
DI ST RI CT OF COLUMBI A
MARYLAND
PENNSYLVANI A
VI RGI NI A
WEST VI RGI NI A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
MI S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
CHICAGO: REGI ON V
I L L I N O I S
I NDI ANA
MI CHI GAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
LOUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS CI T Y: REGI ON V I I
IOWA
KANSAS
MI SSOURI
NEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH DAKOTA
SOUTH DAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CALI FORNI A
HAWAI I
NEVADA
SEATTLE: REGI ON X
ALASKA
I DAHO
OREGON
WASHINGTON
JUNE 2 3 , 1989
TABLE 12. MEDI CAI D MEDI CAL VENDOR PAYWENTS FOR MEDI CALLY NEEDY RECI PI ENTS
(CONT) BY B A S I S OF E L I G I B I L I T Y AND BY REGI ON AN0 STATE: F I SCAL YEAR 1988
AFDC
CHI LDREN
YNPER-21
7 0 4 , 8 6 7 , 2 3 5
OTHER
T I T L E X I X
B A S I S OF
E L I G
YY' 6YQI Y
0
AFOC
NEW HAMPSHI RE
RHOOE I SL AND
VERMONT
NEW YORK: REGI ON I1
NEW JERSEY
NEW YORK
PUERTO RI CO
V I R GI N I SLANDS
PHI L ADEL PHI A: REGI ON 111
DELAWARE
DI S T RI CT OF COLUMBI A
MARYLAND
PENNSYLVANI A
V I R GI N I A
WEST V I R GI N I A
ATLANTA: REGI ON I V
ALABAMA
TENNESSEE
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS CI T Y : REGI ON V I I
I OWA
KANSAS
MI SSOURI
NEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH OAKOTA
SOUTH OAKOTA
UTAH
WYOMING
S I N FRANCI SCO: REGI ON I X
CALI FORNI A
HA WA I I
I NEVADA
SEATTLE: REQI ON X
ALASKA
I DAHO
OREGON
WASHINGTON
JUNE 23. 1989
E L I G I B I L I T Y
PERMANENTLY AND
IQI4LLY-PI588LEQ +
2,017 4
.*,
TABLE 13. OPTI ONAL CATEGORI CALLY NEEDY MEDI CAI D RECI PI ENTS BY BASI S OF
AN0 BY REGI ON AN0 STATE: F I S CA L YEAR 1988
TOTAL AGE 65
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHOOE I SL AND
VERMONT
NEW YORK: REGI ON I1
NEW JERSEY
NEW YORK
PUERTO RI CO
V I RGI N I SLANDS
PHI L ADEL PHI A: REGI ON I11
DELAWARE -
DI S T RI CT OF COLUMBI A 1 , 1 2 2
MARYLAND 7.805
PENNSYLVANI A 7.277
V I R GI N I A 873
WEST V I RGI NI A 4.088
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
MI S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
CHI CAGO: REGI ON V
I L L I N O I S
I NDI ANA
MI CHI GAN
MINNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS C I T Y : REGI ON V I I
I OWA
KANSAS
MI SSOURI
NEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH OAKOTA
SOUTH OAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CALI FORNI A
HA WA I I
NEVADA
SEATTLE: REGI ON X
ALASKA
IDAHO
OREGON
WASHINGTON
JUNE 23, 1989
BASI S OF E L I G I B I L I T Y TABLE 13. OPTI ONAL CATEGORI CALLY NEEDY MEDI CAI D RECI PI ENTS BY
(CONT) AN0 BY REGI ON AN0 STATE: F I S C A L YEAR 1988
AFOC
CHI LDREN
UNDER21
27, 666
B A S I S OF
E L I G
YNKYQYIN
0
AFOC
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHOOE I S L A ND
VERMONT
NEW YORK: REGI ON
NEW JERSEY
NEW YORK
PUERTO RI CO
V I RGI N I SL ANDS
PHI LADELPHI A: REGI ON I11
DELAWARE
DI S T RI CT OF COLUMBI A
MARYLAND
PENNSYLVANI A
V I R GI N I A
YEST V I R GI N I A
ATLANTA: REGI ON I V
ALABAMA
FLORI DA
GEORGI A
KENTUCKY
MI S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
OHI O
WI SCONSI N
OKLAHOMA
TEXAS
KANSAS CI T Y : REGI ON V I I
I OWA
KANSAS
MI SSOURI
NEBRASKA
DENVER:
COL
MONTANA
NORTH DAKOTA
SOUTH DAKOTA
REGI ON V I I I
.ORAOO
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CAL I FORNI A
HAWAI I
NEVADA
SEATTLE: REGI ON X
ALASKA
I DAHO
OREGON
WASHINGTON
JUNE 23, 1989
TABL E 14. MEDI CAI D MEDI CAL VENDOR PAYMENTS FOR OPTI ONAL CATEGORI CALLY NEEDY RECI PI ENTS
BY B A S I S OF E L I G I B I L I T Y AND BY REGI ON AND STATE: F I S C A L YEAR 1988
TOTAL
PAI MENTS
1 2 3 , 5 6 2 , 8 2 7
AGE 65
b N P - A b E B
5.617.209
PERMANENTLY AN0
BCI MPI ESS I QI b h L Y - QI S b B L E P
185.946 8,416,722
BOSTON: REGI ON I
CONNECTI CUT
MAI NE
MASSACHUSETTS
NEW HAMPSHI RE
RHOOE I SL AND
VERMONT
NEW YORK: REGI ON 11
NEW JERSEY
NEW YORK
PUERTO RI CO
V I R GI N I SLANDS
PHI L ADEL PHI A: REGI ON I11
DELAWARE
DI S T RI CT OF COLUMBI A
MARYLAND
PENNSYLVANI A
V I R GI N I A
WEST V I R GI N I A
KENTUCKY
M I S S I S S I P P I
NORTH CAROLI NA
SOUTH CAROLI NA
TENNESSEE
CHI CAGO: REGI ON V
I L L I N O I S
I NDI ANA
MI CHI GAN
MI NNESOTA
OHI O
WI SCONSI N
DALLAS: REGI ON V I
ARKANSAS
L OUI SI ANA
NEW MEXI CO
OKLAHOMA
TEXAS
KANSAS CI T Y: REGI ON V I I
I OWA
KANSAS
. . . . .- . .-
MI SSOURI
NEBRASKA
DENVER: REGI ON V I I I
COLORADO
MONTANA
NORTH DAKOTA
SOUTH DAKOTA
UTAH
WYOMING
SAN FRANCI SCO: REGI ON I X
CALI FORNI A
HAWAI I
NEVADA
SEATTLE: REGI ON X
ALASKA
I DAHO
DREGON
WASHINGTON
NPC - 1989
FEDERAL MEDICAL ASSISTANCE PERCENTAGE (FMAP)
The federal government pays states for part of their expenditures under Medicaid for providing services
and for administration of their medicaid programs. The following FMAP table is used to determine the
amount of federal matching in state medical expenditures. The state provides separately for federal
matching of administrative costs.
Service Expenditures
Effective October 1, 1989 - September 30, 1990
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
DC
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Percent State Percent
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
The above percentage (FMAP) is based upon the state's per capita income; if a state's per capita income
is equal to the national average, the federal share is 50%. If a state's per capita income is below the
national average, the federal share is increased to a maximum of 83%.
Cost sharing for administrative expenditures vary with the services, i.e., 75% for training, 90% for
designing, developing or installing mechanized claims processing and information retrieval, etc. (Federal
Medicaid Law (Section 1903(a)(2) et seg.)
Source: CCH Medicare and Medicaid Guide 1989 (14,905)
132
STATE
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D. C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
United States
STATE POPULATION AND DEMOGRAPHICS, 1987-88
Population
prw. est.
4,066,000
540,000
3,372,000
2,379,000
27,255,000
3,284,000
3,199,000
638,000
629,000
11,803,000
6,161,000
1,068,000
1,002,000
11,569,000
5,510,000
2,841,000
2,466,000
3,732,000
4,513,000
1 ,I 77,000
4,493,000
5,846,000
9,180,000
4,226,000
2,633,000
5,081,000
81 7,000
1,597,000
974,000
1,038,000
7,650,000
1,488,000
17,798,000
6,366,000
677,000
10,762,000
3,309,000
2,705,000
1 1,903,000
979,000
3,397,000
709,000
4,822,000
16,825,000
1,675,000
544,000
5,826,000
4,487,000
1,912,000
4,792,000
506,000
242,221,000
State
Population
asa%of
total U.S.
Population
1.7%
0.2%
1.4%
1 .O%
1 1.2%
1.3%
1.3%
0.3%
0.3%
4.8%
2.5%
0.4%
0.4%
4.8%
2.3%
1.2%
1 .O%
1.5%
1.9%
0.5%
1.8%
2.4%
3.8%
1.7%
1.1%
2.1 %
0.3%
0.7%
0.4%
0.4%
3.1%
0.6%
7.3%
2.6%
0.3%
4.4%
1.4%
1.1%
4.9%
0.4%
1.4%
0.3%
2.0%
6.9%
0.7%
0.2%
2.4%
1.8%
0.8%
2.0%
0.2%
Income
$1 1,947
$1 8,321
$14,310
$1 1,538
$17,841
$1 5,594
$21,197
$16,510
$20,057
$15,584
$1 4,320
$1 5,677
$1 1,875
$1 6,421
$1 3,935
$14,230
$15.143
$1 1,997
$1 1,482
$13,971
$18,174
$1 9,053
$1 5,428
$1 5,906
$1 0,302
$14,663
$1 2,291
$1 4,297
$16,396
$17,895
$20,321
$1 1,861
$18,017
$13,322
$1 2,961
$14,605
$12,558
$1 4,Ol 8
$1 5,208
$1 6,640
$12,036
$12,550
$12,878
$13,888
$1 1,386
$14,299
$16,516
$1 5,642
$1 0,992
$1 4,723
$1 2,706
$1 4,755
133
Per Capita Unem-
Personal ployment
Rate
Population
65 and
Over
505,000
19,000
430,000
348,000
2,944,000
305,000
429,000
75,000
77,000
2,140,000
623,000
109,000
1 15,000
1,405,000
670,000
421,000
336,000
457,000
481,000
159,000
486,000
800,000
1,058,000
534,000
31 8,000
703,000
101,000
220,000
106,000
121,000
994,000
150,000
2,309,000
754,000
90,000
1,346,000
41 8,000
373,000
1,764,000
145,000
367,000
100,000
602,000
1,627,000
138,000
65,000
623,000
536,000
264,000
633,000
44,000
29,837,000
%of
State
Population
65 and
Over
12.4%
3.5%
12.8%
14.6%
10.8%
9.3%
13.4%
11.8%
12.2%
18.1%
10.1%
10.2%
11.5%
12.1%
12.2%
14.8%
13.6%
12.2%
10.7%
13.5%
10.8%
13.7%
11.5%
12.6%
12.1%
13.8%
12.4%
13.8%
10.9%
11.7%
13.0%
10.1%
13.0%
11.8%
13.3%
12.5%
12.6%
13.8%
14.8%
14.8%
: 0.8%
14.1%
12.5%
9.7%
8.2%
11.9%
10.7%
11.9%
13.8%
13.2%
8.7%
PHARMACIES AND
PHARMACIES
STATE Community Chain Hospital Clinic
PHARMACISTS
PHARMACISTS
Nursing Ail
Home others' Total
TOTALS:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
Nolth Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
34,944
782
49
224
547
2,980
380
467
35
69
1,317
968
84
179
1,771
560
504
445
651
732
loa
446
749
1,346
6354
670
890
159
359
74
112
1.277
154
3,203
844
153
1,168
710
356
1,818
916
113
469
162
777
2,099
205
89
586
607
262
768
82
NCPDP-NABP List, Business Mailenilnc., 1989
' Includes 1,098 Depattment Stores and 859 Grocery Stores
134
F-
NPC - 1989
KEY PROVISIONS OF STATE DRUG PRODUCT SELECTION LAWS
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Formulary
None
None
Negative
Negative
Negative
None
None
Positive (1)
Positive
Negative (2)
None
Positive (1)
None
Positive
None
Negative
None
Negative (1)
None
None
Positive
Positive
None
None
None
Negative
None
Positive
Positive (1)
Positive (1)
Positive
Positive (1)
Positive
None
None
Positive (2)
(See legend)
None
Positive (3)
Negative
None
None
Positive
None
Positive (1)
Positive
Positive
Positive (1)
Negative
Positive (1)
None
2-Line Rx
Format
Yes
NO
Yes
No
No
No
NO
Yes
NO
No
No
NO
Yes
NO
Yes
NO
Yes (optional)
No
No
No
NO
NO
No
No
Yes
Yes
No
No
No
NO
Yes
NO
No
Yes (optional)
Yes
NO
NO
No
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
No
No
Yes
135
Permissive
or
Mandatory
P
P
P
P
P
P
P
P
P
M
P
M
P
P~
P
P
P
M
P
P
P
M
P
P
M
P
P
P
P
P
M
P
M
P
P
P
P
M
M
P
P
P
P
P
M
P
M
M (1)
P
P A
See legend page 737
NPC - 1989
KEY PROVISIONS OF STATE DRUG PRODUCT SELECTION LAWS
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Pharmacy
Record
Required
Yes
No
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
No
Yes
No
No
Yes
NO
NO
Yes
Yes
NO
NO
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Cost
Savings
Pass-On
B
B
B
B
B
A
A
A
B
A
C
B
A
B
B
A
B
B
A
D
B
B
A
A
B
B
A
A
B
B
A
A
B
B
B
A
B
B
A
C
C
A
B
A
D
B
B
A
B
B
Patient
Consent
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
Yes
Yes
No
Yes
No
No
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Label
Specifications
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
No
Yes
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Liability
Disclaimer
No
NO
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
NO
Yes
No
No
NO
Yes
No
No
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
NO
Yes
Yes
Yes
Yes
Yes
Yes
NO
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
See legend page 137
LEGEND:
Formulary: (1) uses FDA Therapeutic Equivalency List
(2)
each pharmacy is to develop DPS List
(3)
each pharmacy is to list commonly used generics from state- developed
formulary
Permissive or Mandatory Language:
P = Permissive (R.Ph. "May")
M = Mandatory (R.Ph. 'Shall")
(1) Unless in the pharmacist's judgment ......
Prevention of Substitution:
(A)
prescriber's signature on appropriate line of 2-line prescription form
(8)
prescriber expressly indicates 'do not substituteqn some manner
(1)
allows use of preprinted 'do not sub" check-box
(2)
box must be checked to prevent DPS
(3)
prescriber must write 'brand medically necessary"
Cost Savings Pass-on:
Oklahoma:
full savings must be passed on to consumer
drug dispensed must be less expensive than drug prescribed
no cost savings pass-on requirement mentioned
no more than usual and customary charge for prescribed drug
includes states where consent is required and those which require the patient
to be notifiedlinformed of the substitution
The law (1961) simply states that it is unlawful for a pharmacist to substitute
without the authority of the prescriber or purchaser
Researched and compiled by the National Pharmaceutical Council, Reston, Va
137
NPC - 1989 E X P A N D E D D R U G C O V E R A G E
This manual primarily focuses on prescription drug benefits under Medicaid, Title XIX of the Social Security Act, for
persons with low incomes and dependant children. In response to a growing need for prescription drug coverage to
the elderly, who consume considerably more drugs than the average American, state health planners and legislators
in nine states have developed state-funded programs for their elderly citizens. Each of these programs differ somewhat
and their characteristics are listed below.
Year
Enacted:
New Jersey Maine
1977 1977
Mawland Delaware'
1979 1982
Eligibility
Criteria:
Age 65+ 62+
None 65+
Means test $13,650 s $7,000 s $6,700 s to $8,150 s
$16,750 C $9,000 c $13,000 $1 1,500 C
under age 65 Fam. of 10
w/SS disability
Program
Characteristics:
COP~Y $2.00 $2.00 $1 .OO 10% AAC4
Rxs covered All legend Rx, Most Rx, heart, All Rx + Rx drugs, formulary
insulin test materials BP, COPD, diabetes Medicaid OTCs + insulin/quinine
No DESl list drugs antiarthritic
Rx fee
to Pharmacy $3.63 to 3.973 $3.39
Fiscal Impact:
Funding 56.9% General fund General fund General fund The Nemours
43.1 % Casino Revenue Foundation
Fund
# recipients 246,693
Cost per yearz $108.6
16,659 12,000 (enrolled) 1988
$6.9 $1.65
Pop. over age 65: 994,000 159,000 486,000 75,000
Comp. Medicaid
Rx Data 1988:
Tot. Recipients 533,076 11 9,483 319,929 37,150
Rx Recipients 436,269 91,089 221,219 26,193
Rx Expend.' $1 05.0 $22.9 $46.9 $4.6
Net State Cost2 $52.5 (50%) $7.2 (33%) $23.5 (50%) $2.1 (48%)
~ o t a vendor drug program. All W s dispensed through Nemours Memorial Health Clinic, Wilrnington, DE
Millions
F 0 R T H E E L D E R L Y
Note: Congress passed and President Reagan signed the Catastrophic Care Act of 1988. Section 202 of that act will
provide for coverage of catastrophic expenses for prescription drugs beginning in 1991.
pennsvhmnia m Rhode Island Connecticut New Yolk
1984 1985 1985 1986 1987
less than $1 4,000 $12,000 s less than $9,000-1 5,000 s
$12,000 s household $15,000 c $13,300 s $1 2,000-20,000 c
$15,000 m $16,000 c (low-moderate
over 16 & disabled 18-64 income)
disabled Title II & XVI
No 40% of cost $4.00
All Rx, 30- Cardiovascular Rx, Rx (specific All 'State" All Rx
day ~ U P P ~ antiarthritic, categories) Rx
or 100 units insulin insulin
No DESl or Exp. needles & syr. needles & syr.
$2.75= $3.60 60% net cost $3.553 $2.75
(incl. ingreds.) ($.50 generic to
incentive fee) $3.00
Lottery General fund General fund General fund General fund
funds
Medicaid
Actual Acquisition Cost
Vermont passed PAA legislation in 1989. Effective July, 1990.
NPC - 1989
ALABAMA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
_*
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE -
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Children<21 ISFO)
Prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services X"
'SF0 - State Funds Only
"Dental Services EPSDT - under 21 years old.
I!. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
1987
Expended Recipient
$44,701,304 227.794
38,714,959 21 1,421
15,531,235 54,562
385,189 1,404
18,367,101 60,732
1,784,103 58,974
2,647,331 36,781
5,986,345 22,049
5,041,026 12,677
4,559 15
730,000 1,705
62,494 2,495
105,717 3,847
42,549 1,490
0 0
0 0
0 0
0 0
0 0
0 0
0 0
I988
Expended :Recipient
$48.1 07,554 226,602
41,139,722 205,178
15,898,208 51,730
41 8,016 1,395
20,437,432 63,094
1,763,461 55,561
2,617,605 34,259
6,972,832 29,092
5,753,387 13,269
2,514 16
817,130 1,833
138,888 5,837
204,168 6,335
56,745 1,907
0 0
0 0
0 0
0 0
0 0
0 0
0 0
HHS report HCFA - 2082
Alabama - 2
111. Administration:
Alabama Medicaid Agency
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Vitamins, food supplements, and anti-obesity, cough and cold preparations,
certain drug products classified by FDA as less than effective.
6. Formulary: Alabama Medicaid Formulary, which specifies those drugs that may be dispensed on
prescription only. Contact person for approving formulary additions: , Non-formulary products are
available via a prior authorization procedure.
C. Prescribing or Dispensing Limitations:
I. Quantity of Medication: Normal prescriptions are limited to a maximum of 5 refills. The
quantities (units) of drugs prescribed by a physician SHALL NOT be arbitrarily changed by
a pharmacy except by authorization of the physician. Authorization to alter the units of a
prescription must be noted on the prescription form by the pharmacist. Prescriptions for Title
XIX nursing home patients who are on long-range therapy or maintenance drugs should be
written for at least a minimum thirty (30) day supply.
2. Refills: When authorized by prescriber, a prescription may be refilled a maximum of five (5)
times. (subject to DSIUR). All prescriptions should be refilled only in quantities
commensurate with dosage schedule and refill instructions.
D. Prescription Charge Formula: Medicaid pays for prescribed legend and non-legend drugs authorized
under the program based upon and shall not exceed the lowest of:
The Maximum Allowable Cost (MAC) of the drug plus a dispensing fee.
"
The Estimated Acquisition Cost (EAC) of the drug plus a dispensing fee, or
The provider's usual and customary charge to the public for the drug.
Professional Fee:
Retail pharmacies: $3.75
E. Variable Co-Payment for Prescription Drugs. Medicaid patients are required to pay and pharmacies
are reauired to collect the maximum designated variable co-pay amount for each prescription filled
and each refill.
MEMPTIONS: No co-payment amount is to be collected by the pharmacy or paid by the recipient
on the following:
=
Family planning drugs or supplies.
Drugs dispensed to a Medicaid recipient under 18 years of age.
Drugs dispensed to Medicaid eligible pregnant women.
Drugs dispensed to Medicaid recipients residing in a long-term care facility (nursing home).
NPC - 1989
Co-payment (Effective November I , 1988) Retail Pharmacies:
Drua lnaredient Cost
$00.00 - $ 6.25
Copav Amount for Collection
$0.50
21.26 - 46.25
46.26 or more
V. Miscellaneous Remarks:
1. Fiscal Intermediary:
E.D.S.
P.O. Box 7600
Montgomery, AL 361 07
(205) 834-3330
1-800-392-5741
Price adjustments to:
First Data Bank
11 1 1 Bayhill Drive
San Bruno, CA 94066
Officials, Consultants and Committees
1. Officials - Alabama Medicaid Agency:
Carol A. Herrmann
Commissioner
James F. Mracek, M.D.
Professional Sewices Div.
Larry A. Tatum, R.Ph., Associate Director
Pharmaceutical Programs
2. Title XIX Medical Care Advisory Committee:
Alabama Medicaid Agency
2500 Fairlane Drive
Montgomery, AL 36130
2051277-271 0
Alabama Medicaid Agency
2500 Fairlane Drive
Montgomery, AL 36130
2051277-271 0
Earl Fox, M.D. Andrew P. Hornsby, Jr. Ms. Jean Yarbrough
State Health Officer Commissioner American Assn. Med. Assist.
State Public Health Dept.
Department of Human Rt. 1 Box 355
434 Monroe Street, Room 381 Resources Enterprise, AL 36330
Montgomery, AL 36130 64 N. Union Street
2051261 -5052
Montgomery, AL 36130
2051261 -31 90
F
-
NPC - 1989
Alabama - 4
Frank Perryman Craig McNamara, O.D.
AL Hospital Association AL Optometric Association
Sylacauga Hospital/Nursing Home 5723 Carmichael Parkway
Sylacauga, AL 351 51 Montgomery, AL 361 17
William Stewart Roy T. Hager, M.D.
Med. Grp. Managemt. Assn. of AL Med. Assn. of AL
Dept. of Medicine 2055 Normandie Drive
6th FI. MEB, University Station Montgomery, AL 36198
Birmingham, AL 35294
Ms. Elizabeth Norris
AL State Nurses Association
360 N. Hull
Montgomery, AL 361 97
Sandra Hullett, M.D.
Health Services Director
P. 0. BOX 71 1
Eutaw, AL 35462
Dr. Joe Sharp Diane Betts
AL Chapter of Acad. of Pediatrics Medicaid Recipient Rep.
P.O. Box 1001 122 Pegler Street
Troy, AL 36081 Prattville, AL 36067
Mike Woodall, Director Mrs. Euthel Garrett Hill
Central AL Aging Consortium 6209 20th Avenue
81 8 S. Perry Langdale, AL 36854
Montgomery, AL 361 04
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
Lon Conner
Executive Director
Medical Association of AL
19 South Jackson Street
P. 0. Box 1900-C
Montgomery, AL 361 97
2051263-6441
D. State Board of Pharmacy:
James W. McLane
Secretarv
Pharmaceutical Association: C.
Sharon Taylor
Acting Executive Director
AL Pharmaceutical Assn.
340 Dexter Avenue
Montgomery, AL 36104
2051262-0027
Nursing Home Association: F.
Sen. William H. Drinkard
Executive Vice-president
1 perimeter Park South, Suite 425 AL Nursing Home Association
US. 280 at 1-495 4140 Carmichael Road
Birmingham, AL 35243 Montgomery, AL 36106
2051967-01 30 2051271 -621 4
Jim Scruggs
AL Pharmaceutical Assn.
61 1 Moore Street
Marion, AL 36756
Dr. A. Z. Holloway
Consumer Representative
3086 ~ o s a Parks Avenue
Montgomery, AL 36105
Mrs. Gwendolyn Tallie
Medicaid Recipient Rep.
460 Caroline Street
Montgomery, AL 36104
Charles G. Sprading, Jr.
Consumer Representative
P.0. BOX 11 765
Birmingham, AL 35202
Osteopathic Association
Kenneth D. McLeod, D.O.
Secretary
AL Osteopathic Association
151 1 N. McKenzie Street
Foley, AL 36535'
2051943-1 584
Hospital Association:
Dr. Tommy R. McDougal
President
AL Hospital Association
East Station, P.O. Box 17059
Montgomery, AL 36193
2051272-8781
NPC - 1989
1
Alaska - 1
ALASKA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XD()
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services X
*SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families wIDep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
Alaska's Medicaid program was amended by
the passage of legislation (H.B.70) in 1989,
which added prescribed medicines to the list
of optional services, effective July I , 1989.
HHS report HCFA - 2082
NPC - 1989 Alaska - :
111. Administration: Health and Social Services Department
IV. Provisions Relating to Prescribed Drugs:
A. Ingredient Reimbursement Basis: AWP minus 5%.
B. State Maximum Allowable Cost List parallels federal FMAC list. Override requires "Brand Medicall\
Necessary.'
C. No formulary.
Certain classes of prescriptions are restricted, i.e., amphetamines (except for narcolepsy and hyperactivity)
DESI; infertility drugs.
D. Formulary information and additions should be addressed to:
Mr. Eric Hansen
Chief, Medical Assistance
DHSS
4433 Business Park Blvd.
Anchorage, AK 99503
9071561 -21 71
E. Pharmacy Fee: Variable $3.45 - $1 1.46, effective February 1, 1989.
G. Quantities limited to 30-day supply.
H. No OTC drugs reimbursed
Officials, Consultants and Committees
1. Health and Social Services Department Officials:
Myra M. Munson, Commissioner
9071465-3030
Kimberly B. Busch, Director
9071465-3355
Eric S. Hansen, Chief, Medical Assistance
9071561 -21 71
Department of Health and Social Services
Pouch H-01
Juneau, AK 9981 1
Division of Medical Assistance, DHSS
Pouch H-07
Juneau, AK 9981 1
4433 Business Park Blvd., Bldg. M
Anchorage, AK 99503
2.
William F. Davnie, R.Ph., Medicaid Pharm. Cons. 13121 Biscayne Circle
9071345-0644 Anchorage, AK 9951 6
3. Alaska Medical Care Advisory Committee:
John White. DDS, Chairman
9071543-2926
P. 0. Box 757
Bethel, AK 99559
NPC - 1989
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: B. Pharmaceutical Association: C. State Board of Pharmacy:
Raymond G. Schalow Ruth Alton Christy Nielsen
Executive Director President-elect Secretary
AK State Medical Assn. AK Pharmaceutical Association P. 0. Box D-LIC
2401 East 42nd Avenue Box 10-1 185 Juneau, AK 9981 1
Anchorage, AK 99508 Anchorage, AK 99510 9071465-2541
9071562-2662 90713456428
Arizona - 1
ARIZONA
MEDICAL ASSISTANCE DRUG PROGRAM UNDER TITLE XIX
Arizona Health Care Cost Containment System
(AHCCCS - pronounced "ACCESS)
EXPENDITURES FOR DRUGS
-
1987 1988
Expended Recipient Expended Recipient
TOTAL 96,280
CATEGORICALLY NEEDY CASH TOTAL 90,435
Aged 6,627
Blind 385
Disabled 18,679
Children -Families w/Dep. Children 44,556
~dul t s -Families w/Dep. Children 20,270
CATEGORICALLY NEEDY NON-CASH TOTAL 7,490
Aged 72
Blind 9
Disabled 400
Children -Families w/Dep. Children 5,567
Adults -Families w/Dep. Children 1,445
Other Title XIX Recipients 0
OPTIONAL CATEGORICALLY NEEDY 1,476
Aged 0
Blind 0
Disabled 0
Children -Families w/Dep. Children
51 3
Adults -Families w/Dep. Children 967
Other Title XIX Recipients 0
HHS report HCFA - 2082
AHCCCS Features:
The Arizona Health Care Cost-Containment System (AHCCCS) is an experimental Medicaid program. Begun in October
1982, it serves as a new model for providing medical services to the indigent. Typically, Medicaid programs have
incorporated the traditional hallmarks of the US health care system: namely, independent providers and fee-for-service
reimbursement. In contrast, the AHCCCS model is marked by organized health plans and capitation.
In traditional Medicaid programs, the states assume responsibility for contracting with individual pharmacies and
reimbursing them. In the AHCCCS model however, the state contracts instead with pre-paid health plans, HMOs and
HMO-like entities. These plans are paid on a capitation basis and are responsible for providing all of the sewices
covered by the program. Thus, the delivery of pharmacy services is the responsibility of each prepaid plan.'
Administration:
Arizona Health Care Containment System (AHCCCS).
'
McGhan et al, American Pharmacy, vol. N526, no. 11, November 1986.
147
NPC - 1989
Arizona - 2
General Information:
The Arizona Health Care Cost Containment System (AHCCCS), developed in Senate Bill 1001, was passed by the
Legislature and signed by the Governor in November, 1981. It contains six major mechanisms for restraining health
care costs while, at the same time, ensuring that appropriate levels of quality health care services are provided to
eligible persons in a dignified fashion. The goal of these six items is to contribute to the establishment of a health care
financing system that is less expensive than conventional fee-for-service systems. The six mechanisms are:
o
Primary Care Physicians Acting as Gatekeepers
o Prepaid Capitated Financing
Competitive Bidding Process
o Cost Sharing
Limitations on Freedom-of-Choice
O Capitation of the State by the Federal Government
Primaty Care Physicians Acting as Gatekeepers:
The AHCCCS legislation provides that all members must be under the care and supervision of a primary care physician
who will assume the role of case manager. A statewide network of primary care physicians, acting as case managers,
will thereby be established to perform a gatekeeping function for the system. Because all care must be approved by
the primary care physicians, the primary care network will eliminate self-referrals to specialists and diminish excessive
use of emergency rooms--both of which have contributed substantially to high medical costs.
Prepaid Capitated Financing:
It is the intent of the AHCCCS legislation that providers offer all necessary services to groups of members for a fixed
price, for a definite period of time. The law allows for the creation of consortia to facilitate the establishment of a
statewide bidding process. Services are provided on a county-by-county basis, and bids encourage that goal. It is
not necessary, however, for a single bidder to bid for all services to be delivered in a given county. Providers may
bid on a prepaid capitated basis for only those services they normally provide. For example, a group of physicians
may choose to bid only for physician services for a particular area; hospitals may do the same; and so on. The law
allows for expansion and contraction of bids to achieve the best possible system. In the event thers are insufficient
bids for a given area, the legislation permits capped fee-for-service arrangements. It is intended, however, that capped
fee-for-service will be authorized as a last resort only.
In essence, AHCCCS providers represent forms of prepaid health plans (PHPs), health maintenance organizations
(HMOs), and other types of organized health delivery systems. As such, they charge a fixed fee per individual enrolled
(i.e., a capitation rate) and assume responsibility for providing a broad array of health care services to members.
Competitive Bidding Process:
The statewide competitive aspect of the bid process for selecting providers and offering the prepaid capitated services
is the most unique feature of the AHCCCS model. A provider competition of this magnitude has never been attempted
in any other state. The AHCCCS administration believes competitive bidding forhealth care service contracts, as
opposed to conventional negotiation processes, will provide accessible cost-effective delivery of health care without
sacrificing quality performance.
The AI-ICCCS administration issues an invitation to qualified providers of health services, at least on a biennial basis,
to bid to provide services to AHCCCS members in each County. Qualified providers may bid to offer the full range
of AHCCCS services, or any allowable partial grouping of services, in one or more counties.
Arizona - 3
cost Sharing:
The fourth major device for containing costs in the AHCCCS model is a provision for cost sharing by users.
A
gatewide co-payment schedule was developed for this purpose, and the medically needy participate in coinsurance
sharing. It i s expected that the imposition of nominal co-payments will ensure optimal effectiveness i n the area
of service utilization. The Department co-payment schedule accomplishes three objectives: curtailment of
over-utilizatiOn; enhancement Of patient dignity; and service utilization by members for truly needed health care, There
is no co-payment for drugs and medication, prenatal care including all obstetrical visits, members in long care facilities
and for visits scheduled by the primary care physician or practitioner, and not at the request of the member.
Limitations of Freedom-of-Choice:
The fifth major item for containing costs is a restriction on provideriphysician selection by AHCCCS members. Unlike
conventional delivery models, Arizona does not rely on fee-for-service arrangements. The goal is to have the state
completely blanketed with prepaid capitated arrangements. Members are linked to selected or assigned plans for
definite durations of time. Freedom-of-choice is permitted to the extent practicable for members to select the particular
group with which t o enroll, as well as the primary care physician within the selected group. Capped fee-for-sewice
health service contracts is used as a last resort, and only in areas not covered by prepaid capitated plans.
Capitation of the State by the Federal Government:
The State of Arizona will itself be capitated by the Federal Government and therefore will be at financial risk for
containing health care costs. Capitation rates will be established according to sound actuarial principles, and will
represent no more than 95 percent of the estimated cost of services delivered in Arizona under conventional
fee-for-service arrangements. Capitation provides a key incentive for the state to monitor health care costs on a careful
and continuous basis.
IMPLEMENTATION OF AHCCCS
AHCCCS is based on plans that have been tested, in part, on smaller scales in different areas of the country. By
combining a number of key mechanisms on a statewide basis, AHCCCS represents a novel health care model. The
purpose of this section is to present a discussion of how the key concepts embodied in the AHCCCS legislation will
be implemented and rendered operational.
Provider Participation:
Providers may participate in AHCCCS in three different ways. First, they may enter the competitive bidding process
with prepaid capitated plans as either full or partial benefit providers.
The second mode of participation is on a capped fee-for-service basis. Here, providers agree to accept capped fee
payments as payments in full. Capped fee-for-sewice arrangements will be authorized as a last resort only and when
there are insufficient bids for a given area.
Finally, the third means of participation concerns the provision of emergency medical services by non-AHCCCS
providers. No formal contract is required for this mode of participation, and reimbursement will be allowed almost
exclusively for emergency services.
Functions of the AHCCCS Administration:
The AHCCCS Administration contracts with full benefit capitated providers to serve AHCCCS members; and create a
number of organized health systems through a network of contracts with providers, as necessary to complement the
capitated system.
NPC - 1983
Contracting Health Plans
Under the Contracting Health Plan arrangement, plans are defined in terms of explicit groups of providers organized
into consortia or more formal entities. These consortia, or formal entities, are /capable of providing the full range of
AHCCCS benefits within a defined service area for all AHCCCS members who elect to join the plans, up to a
predetermined capacity. This is the dominant mode of operation within AHCCCS--with two or more competing plans
wherever possible.
The Contracting Health Plans are delivery systems, not simply insurance plans, but they need not be Health
Maintenance Organizations by any legal or conventional definition of the term. The AHCCCS legislation provides for
the creation of provider consortia for the purpose of participation In the program. The Contracting Health Plan may
be a loosely organized system, but it must be capable of providing the full range of AHCCCS benefits to a defined
population at a capitation rate.
Administration Organized Health Systems
The Administration Organized Health Systems serve as back-up to the full benefit capitated plans, assuring there are
no service area gaps in the state and there is at least one alternative choice in those areas covered by a Contracting
Health Plan. The Administration Organized Plans must:
Be prepared to function as the routine health care delivery systems in any area of the State not adequately
covered by Contracting Health Plans.
Serve as the mechanism for assuring emergency and urgent care for the "emergent members" of AHCCCS
o
Serve as back-up systems in the event of a failure of a Contracting Health Plan, or a state decision to terminate
a contract.
Operate within a fixed budget, regardless of the number of members enrolled. The Contracting Health Plans
will draw funds out of the total AHCCCS budget in direct proportion to the number of AHCCCS members they
serve, leaving the Administration Organized Health Systems with a residual budget.
The Organizationai Role of the AHCCCS Administration:
The AHCCCS Administration has been charged with the general implementation and monitoring of the AHCCCS
program.
The AHCCCS Administration develops the Rules and Regulations; computes provider bidding processes; awards the
contracts; provides technical assistance to providers for the purpose of forming consortia to contract with AHCCCS;
and monitors the overall operation of the program.
The Operational Role of the AHCCCS Administration
Organizationaily, the AHCCCS Administration will assume responsibility for the every day operations of the program.
The AHCCCS Administration will have overall responsibility for the following activity areas:
Promotion of AHCCCS
Procurement of Contract Providers
Provider Management
Provider, Member, and Public Relations
Program Operations
Arizona - 5
AHCCCS became effective December 1, 1981, and services commenced October 1, 1982. Services include: Inpatient,
outpatient, laboratory, x-ray, prescription drugs, medical supplies, prosthetic devices, emergency dental care including
extractions and dentures, treatment of eye conditions and EPSDT.
~hough AHCCCS was a three-year experiment which was to end in October 1985, the federal government continues
to extend funding for the program. In 1988, AHCCCS received a five year extension from the federal government.
Medical Plans and Administrators
Arizona Physicians, IPA - 602/274-6102 University Famli-Care
4041 N. Central Bldg. B 1650 East Fort Lowell Blvd., Suite 208
phoenix, AZ 8501 2 Tucson, AZ 8571 9
Med. Dir. - Peter Thomas, MD Med. Dir. - Barbara Warren, M.D.
Administrator - Mary Warren Administrator - Mark Williams
Comprehenske AHCCCS Plan - 60217793366
1325 North Beaver, Suite 101
Flagstaff, AZ 86001
Med. Dir. - William Finney, MD
Administrator - Carla Conway
FHP of NE Arizona - W5374375
PO Box 425
Show Low, AZ 85901
Med. Dir. - Ken Jackson, MD
Administrator - Jim Burns
No. Arizona FHP - W634-2216
PO Box 276
Cottonwood, AZ 86326
Med. Dir. - Henry Kaldenbaugh, MD
Administrator - Jim Burns
Pinal General - 602/868-5841
PO Box 789
Florence, AZ 85232
Med. Dir. - Paul Kaiser, D.O.
Administrator - Mary Fields
Gila Medical Services - 602/4734441
Claypool Medical Center
315 N. Broad Street
Claypool, AZ 85532
Med. Dir. - Charles Bejarano, MD
Administrator - Art Bejarand
Phoenk Health Plan - 60212528970
1301 South Seventh Avenue
Phoenix, AZ 85003
Med. Dir. - Rodney Armstead, M.D.
Administrator - Craig Keffelor
Doctor's Health Plan, PC - 602/428-7801
PO Box 249
Safford, AZ 85548
Med. Dir. - Jack Bennett, MD
Administrator - Jim Burns
Mercy Care Plan - M)2/263-7100
77 E. Thomas Road, Suite 150
Phoenix, AZ 85012
Med. Dir. - Michael Grossman, M.D.
Administrator - Kathy Byrne
No. Arizona FHP - 602J445-0482
11 55 lronspring Plaza
Prescott, AZ 86301
Med. Dir. - Glen Overley, M.D.
Administrator - Jim Burns
Pima Health Plan - 602/573-0042
150 W. Congress, Room 304A
Tucson, AZ 85701-1305
Med. Dir. - Samual Goldfein, M.D
Administrator - Paul Axinn
Maricopa County Health Plan602/267-5900
2601 East Roosevelt
Phoenix, AZ 85008
Med. Dir. - Leonard Tamsky, M.D.
Assoc. Med. Dirs. - Gary Yates, M.D./Ann Young, M.D.
Administrator - Foster Northrup
SHSIMedical Care Systems
P. 0. Box 238
Springerville, AZ 85938
Med. Dir. - Fred Hosler, M.D.
Administrator - Rick Shrake
NPC - 1989
Officials, Consultants and Committees
I. AHCCCS Officials:
Dr. Len Kirschner
Director
David A. Lowenberg
Deputy Director
Arizona Health Care Cost Containment Sys.
801 E. Jefferson
Phoenix, AZ 85034
6021234-3655
2.
Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
Chic Older
Executive Vice President
Arizona Medical Association, Inc.
810 West Bethany Home Road
Phoenix, AZ 85013
6021246-8901
C. Osteopathic Association:
Mr. Ted Podleski
Executive Director
Arizona Osteopathic Medical Assn.
5057 E. Thomas Road
Phoenix, AZ 85018
6021840-0460
B. Pharmaceutical Association:
Daniel Boesen
Executive Director
Arizona Pharmaceutical Assoc.
2202 North 7th Street
Phoenix, AZ 85006-1 604
6021258-81 21
D. State Board of Pharmacy
L. A. Lloyd
Executive Director
Arizona Board of Pharmacy
5060 North 19th Ave. - Suite 101
Phoenix, AZ 85015
602/255-5125
Arkansas - 1
ARKANSAS
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
1. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC Children<21
prescribed Drugs X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X
Laboratoly &
x-ray Sewice X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X
Physician Sewices X X X X X X X X X
Dental Sewices X X X X X X X X X
*SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
1987
Expended Recipient
$43,240,168 167,760
$33,762,289 131,877
12,374,761 31,706
408,536 1,184
16,048,209 37,155
2,035,499 39,287
2,895,283 22,545
$8,216,046 19,886
6,910,070 14,249
12,565 21
i,070,780 1,776
65,291 1,262
89,883 1,485
67,455 1,093
$1,261,992 15,497
93,409 499
443 3
168,428 684
198,137 4,096
415,871 3,780
285,701 6,435
. I988
Exwnded Recipient
$40,982,879 174,287
31,739,588 130,954
10,962,996 29,570
382,231 1,124
16,062,991 38,740
1,824,273 39,378
2,507,094 22,142
7,739,667 20,063
6,453,677 14,846
9,313 18
1,097,824 1,832
49,665 1,012
79,380 1,354
49,805 1,001
1 .I 74.925 14.976
HHS report HCFA - 2082
NPC - 1989
Arkansas - 2
Ill. Administration:
By the Division of Economic and Medical Services, of the Department of Human Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions (diseases, drug categories, etc.):
Experimental of investigational drugs Anorectic agents
Food Supplements of infant formula DESl drugs
Vaccines and routine immunizing agents Sedative-hypnotics
Fertility drugs Irrigating solutions
.<at
OTCs: Pursuant to a prescription, the following OTC items are covered: insulin, insulin needles and syringes, : ! $
analgesics, antacids, family planning supplies and certain multiple source laxatives, antihistamines,
:a
decongestants and iron products. 3
,..:
+?
Formula~y: Yes .,-
Prescribing or Dispensing Limitations:
1. Quantity of Medication: 33 day supply.
2. Refills: 5 refills within 6 months are allowed, if authorized by prescriber.
3. Dollar Limits: None
4. Monthly Limit: Four prescriptions per month per recipient.
Prescription Charge Formula:
Legend drugs - lower of the EAC plus $4.01 professional fee or HCFNstate upper limit plus $4.01
dispensing fee. Total charge may not exceed provider's charge to the self-paying public.
V. Miscellaneous Remarks:
The Arkansas generic upper limit program exists for 34 multi-source drugs,
Fiscal intermediary:
1. Walt Patterson, Director
Department of Human Services
EDS Federal
PO Box 2501
Little Rock, AR 72203
5011664-6608
Officials. Consultants and Committees
Arkansas Dept. of Human Services
Division of Economic & Medical Sew.
P. 0. Box 1437, Slot 326
Little Rock, Arkansas 72203
501 1682-8650
Arkansas - 3
Kenny Whitlock, Deputy Director Division of Economic & Medical Services
~ a y Hanley, Asst. Deputy Dir. Office of Medical Services
Rebecca Meredih, Asst. Deputy Dir. General Accounting
judy Kerr, Administrator Program Planning & Development
Thelma Undetwood, P.D.
501/862-8363
Pharmacy Consultant
Office of Medical Services
AR Dept of Human Services
PO Box 1437, Slot 1 1 03
Little Rock, AR 72203
Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society:
Kenneth L. LaMastus, CAE
Executive Vice-president
Arkansas Medical Society
10 Corporate Hill Dr., P.O. Box 5776
Little Rock, AR 7221 5
5011224-8967
C. Osteopathic Medical Association:
Bob E. Jones
Executive Director
Arkansas Osteopathic Medical Association
101 Windwood Drive
Beebe, AR 72012
5011882-5433
B. Pharmaceutical Association:
Norman Canterbury, P.D.
Executive Vice President
Arkansas Pharmacists Association
417 South Victory
Little Rock, AR 72201
501/372-5250
D. State Board of Pharmacy:
Lester Hosto, P.D.
Executive Director
P. 0. Box 55356
Li i l e Rock, AR 72225
501/661-2833
California - 2
111. Administration:
the Health and Welfare Agency with direct supervision by the Department of Health Services. Payment of bills by
the state is processed through a fiscal intermediary, Electronic Data Systems,
Under the general direction of the Department of Health Services' Medi-Cal Policy Division, the Drug Policy Unit of the
Benefits Branch monitors the full scope and quality of pharmaceutical benefits covered under the provisions of the
california Medical Assistance Program. This unit, additionally, has the prime responsibility for both the evaluation and
formulation of Utilization/Cost Controls and the development, implementation, and interpretation of policies and
concerning the full scope of pharmaceutical benefits.
IV. Provisions Relating to Prescribed Drugs:
A. Examples of General Limitations and Exclusions (diseases, drug categories, etc.):
Formulary CNS stimulants', i.e., amphetamines and methylphenidate, are only available for epilepsy or
attention deficit disorder in individuals between 6 and 16 years of age.
Formulary Diazepam' restricted to use in cerebral palsy, athetoid states, and spinal cord degeneration.
Formulary Baclofen' restricted to use in spasticity resulting from multiple sclerosis or spiml cord injury,
Formulary Carbenicillinl restricted to pseudomonas aeruginosa urinary tract infections.
Formulary Cirnetidine and Famatodine' restricted to use in treatment of duodenal ulcer, Zollinger-Ellison
syndrome, systemic mastocytosis, and multiple endocrine adenomas.
Formulary Dantrolenel restricted to use in spasticity resulting from cerebral palsy, spastic hemiplegia, multiple
sclerosis, and spinal cord injury.
Formulary ErythromycinSulfisoxazolel restricted to use in acute otitis media.
Formulary Fenoprofen, Ibuprofen, Naproxen, Piroxicarn. Salsalate, Sulindac, Tolrnetin' restricted to use for
arthritis.
Formulary Nalidkic Acid' restricted to urinary tract and prostatic infections.
Formulary TrirnethoprirnSulfarnethoxazole' restricted to urinary tract and prostatic infections, otitis media,
shigellosis, pneumocystitis carinii pneumonitis.
Formulary Cefaclor Capsules' restricted to treatment of lower respiratory tract infections in persons age 50
and over.
Formulary lsotretinoin Capsules' restricted to treatment of severe recalcitrant cystic acne.
Formulary Acylovir Capsules1 restricted to herpes genitalis or for immunocomprornised patients.
Formulary Zidovudine' restricted to use in the management of certain adult patients with symptomatic HIV
infection (AIDS and advanced ARC) who have a history of cytologically confirmed pneumocystis carinii
pneumonia or an absolute CD4 (Tr helperlinducer) lymphocyte count of less than 200/mm in the peripheral
blood before therapy is begun.
Formulary Codeine Combinations' payment to a pharmacy for ASA or APAP with codeine 15 mg. limited to
a maximum dispensing quantity of 60 tablets or capsules and a meximum of 3 claims for the same beneficiary
in any 75-day period. Payment to a pharmacy for ASA or APAP with codeine 30 mg. limited to a maximum
dispensing quantity of 45 tablets or capsules and a maximum of 3 claims for the same beneficiary in any
75-day period. Payment to a pharmacy for a claim that exceeds a maximum is limited only to cost for the
quantity dispensed, up to the maximum dispensing quantity. No professional fee paid. Exceptions require
prior authorization. One grain codeine combination tablets2 are covered, subject to prior authorizatioc.
Other uses require prior authorization
NPC - 1989
Excluded from coverage are multivitamins for persons over five years of age and most OTC household
remedies. Contact laxative suppositoriesz can be used only for specific diagnosis (paraplegia or
quadriplegia, multiple sclerosis, poliomyelitis, ganglionic blockade processes occurring in the spinal nerve
pathways or affecting the lumbo-sacral autonomic nervous system pathways related to bowel motility).
Nutritional supplements2 or replacements may be covered, subject to prior authorization, if used as a
therapeutic regimen to prevent serious disability or death in patients with medically diagnosed conditions that
preclude the full use of regular foodstuffs.
B. Formulary: A semi-restrictive formulary system is used. Over 450 drugs (approximately 1,500 separate codes
for differing strengths and dosage forms) listed generically in formulary. The patient's physician or pharmacist
may request authorization from the local Medi-Cal consultant for approval of unlisted drugs or for listed drugs
which are restricted to specific use(s).
Medi-Cal Drug Formulary may be obtained by ordering the Pharmacy Provider Manual from:
Electronic Data Systems
P. 0. Box 13029
Sacramento, CA 9581 3-4029
(Please remit $5.00 per manual, including updates, by check or money order payable to "State of California")
For formulary and drug program information contact:
M. Kuschnereit, Pharm.
714 P Street, #I640
Sacramento, CA 9581 4
91 61324-2477
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: This is flexible, but quantities should be consistent with the medical needs of
the patient and may not exceed a 100-day supply except under certain circumstances. Many formulary
maintenance drugs are subject to minimum quantity or maximum frequency of billing controls.
2. Refills: A prescription refill can be dispensed as authorized by prescriber. Exception is allowed for
refill of a reasonable quantity when prescriber is unavailable (pursuant t o California law). Fee is pro-
rated so that total fee (for partial quantity and balance of the prescription after prescriber is contacted)
does not exceed fee for same prescription when refilled as routine service.
3. Number of prescriptions: Number of prescriptions for formulary drugs not limited but over-utilization
is limited by prepayment and post-payment controls. These controls include those mentioned in item
1 above supported by on-site audit of provider files.
4. Prior Authorization: Approval may be obtained from a Medi-Cal consultant for covered non-formulary
items or services (including special circumstance override of multiple source drug reimbursement
ceilings or minimum quantitylfrequency of billing limitations). Statewide mail and toll free telephone
requests are accepted in the San Francisco and Los Angeles Medi-Cal Field Offices. Requests must
include adequate information and justification. Authorization may only be granted for the lowest cost
item or service that meets the patient's medical needs.
Non-formulary items
California - 4
5. Pharmacist, to the extent permitted by law, is required to dispense lowest cost brand of a multiple
source item in stock meeting medical needs of the patient.
6. Beneficiary or Prescriber Prior Authorization: On a case by case basis, the Department of Health
Services restricts, through the requirements of prior authorization, the availability of designated
prescription drugs to certain beneficiaries or prescribers found by the Department to be abusing those
benefits.
7. Dollar Limits: None,
D. Prescription Charge Formula: Reimbursement is based on the lowest of:
1. Estimated Acquisition Cost (EAC) plus $4.05 professional fee.
2. Federal Allowable cost (FAC) plus $4.05 professional fee.
3. State Maximum Allowable lngredient Cost (MAIC) plus $4.05 professional fee.
4. Pharmacy's usual price to general public.
V. Miscellaneous Remarks:
Drug Price List Updating: Drug prices used to determine reimbursement are updated the first day of each month
for price change notices which are effective on or before that date. Price notices are received by Electronic Data
Systems, P. 0. Box 13029, Sacramento, California 95813-4929.
Copayment: with certain exceptions, recipients are obligated to copay $1.00 per prescription. Copay may be
collected and retained or waived by the pharmacy. Pharmacy reimbursement is not reduced by the copayment.
Pharmacy may not deny a prescription to an individual due to that individual's inability to copay.
Medical Therapeutics and Drug Advisory Committee: reacting to the lead responsibility of the Medical Services
Section in the Benefits Branch, the Medical Therapeutics and Drug Advisory Committee, composed of physicians
and pharmacists from the private sector, compares the cost, efficacy, misuse potential, essential need, and safety
of drugs and makes recommendations as to additions to or deletions from the formulary.
Hospital Discharge Medications
1. The quantities furnished as discharge medications are limited to not more than a 10-day supply.
2. The charges are incorporated in the hospital's claims for inpatient services.
Cancer and DESl Drugs: Any antineoplastic drug approved by FDA for the treatment of cancer is available through
the Formulary. Most DESl drugs rated less-than- effective by FDA are not.
Maximum Allowable lngredient Cost Program: State MACs are established on over 155 multi-source items. List
is periodically revised and price limits changed to reflect current market conditions.
Estimated Acquisition Cost (EAC): Direct prices for certain high volume brands, bulk package size prices for certain
high volume drugs, and, "average wholesale prices" for standard packages on rest.
Drug Utilization Review (DUR): project is being conducted to test costibenefit of this process. Completion date,
June 30, 1991.
Federal Allowable Cost (FAC): Implemented as issued and updated by Health Care Financing Administration.
Reimbursement limit is temporarily discontinued when an item is not available at or below the FAC.
NPC - 1989
Officials, Consultants and Committees
1. Health and Welfare Agency:
A.
Health and Welfare Agency Officials:
Clifford L. Allenby
Secretary
B. Department of Health Services:
Kenneth W. Kizer, M.D.
Director
Stanley Cubanski
Chief Deputy Director
John Rodriguez
Deputy Director
Virgil J. Toney
Chief
Thomas J. Elkin
Chief
Richard lniquez
Chief
California Health and Welfare Agency
1600 9th Street
Suite 460
Sacramento, CA 9581 4
Department of Health Services
714 "P" Street, P. 0. Box 942732
Sacramento, CA 92434-7320
Department of Health Services
Medical Care Services
Medi-Cal Policy Division
Benefits Branch
Medical Services Section
Room 1640
(91 6) 445-1 995
C. Advisory Committee to California Department of Health Services:
1. Medical Therapeutics and Drug Advisory Committee:
Richard lniquez
Coordinator
California Department of Health Services
71 4 " P Street, Room 1640
P. 0. BOX 942732
Sacramento, CA 92434-7320
David K. Fung, Pharm. 460 Pollasky Avenue
Chairman Clovis, CA 93612
D.
Officers of Electronic Data Systems (the Fiscal Intermediary):
California -
John G. Crysler Electronic Data Systems
Executive Program Director 3215 Prospect Park Drive
EDS-Medi-Cal Rancho Cordova, CA 95670
91 61636.1 000
California - 6
Medical Association:
B. Pharmaceutical Association:
Robert H. Elsner
Executive VPICEO
California Medical Assn.
221 Main Street
San Francisco, CA 94120-7690
41 51541 -0900
Osteopathic Physicians &
Surgeons of California:
Matthew L. Weyuker
Executive Director, OPSC
101 0-1 1 th Street, Suite 220
Sacramento,CA 95814
91 61447-2004
Robert C. Johnson
Executive Vice President
California Pharmacists' Assn.
11 12 l Street, Ste.300
Sacramento, CA 95814-2865
91 61444-781 I
(fax) 9161443-1915
D. State Board of Pharmacy:
Lorie Garris Rice
Executive Officer
1020 N Street, Room 448
Sacramento, CA 9581 4-5784
91 61445-501 4
NPC - 1989
COLORADO
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Colorado - 1
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Childrenc21 (SFOI
Prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Sewices X X X X
v>
*SF0 - State Funds Only
:*
2
LC
II. EXPENDITURES FOR DRUGS. ?
1987 1988
Ex~ended Recipient Emended Recipient ,:i
3.
TOTAL
~~,
$22,444,856 11 0.31 9 $28,269,316 117,136 p
<."
CATEGORICALLY NEEDY CASH TOTAL .sz
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
HHS repon HCFA - 2082
Colorado - 2
Eligibility is determined by 63 County Departments of Social Services, and the drug program is administered
by the Colorado Department of Social Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions (diseases, drug categories, etc.):
Restricted Drug Categories:
1. Prescription-legend drugs not listed in the "ColoRx Drug Formulary."
2. Certain over the counter drugs provided under prior authorization.
3. Payment for restricted drugs authorized only in accordance with non-emergency or emergency
procedures as set forth in the Department's Manual Regulations, Volume VIII, Section 8.800.
4. OTC items are not included; exceptions are: insulin, aspirin under certain conditions, with refill
limitations as stated in Manual Regulations, Volume VIII, Section 8.800.
B. Formulary: ColoRx Drug Formulary
Only those drugs presently assigned drug numbers in the Formulary are a benefit. (Refer to Manual
Regulation Section 8.800 for provisions whereby drugs not listed in the ColoRx Drug Formulary may
be allowed as a benefit.)
Controlled Drug Formulary:
Section I - Alphabetical drug index in brand name order; if no brand name assigned, the generic
name is listed.
Section II -Generic drugs identified as having a Maximum Allowable Price, listed with price information
which is updated periodically.
Section Ill - EAC Price List. High volume drugs reimbursed at greater than 100's size or direct
manufacturer's price.
C. Prescribing or Dispensing Limitations:
I. Terminology: The Department encourages appropriate consideration of cost in prescribing and
dispensina bv the selection of the less expensive trade name or generic product when, in the
pr&tition&s~professional judgment, the 'use of such a product-is compatible with the best
interests of the patient.
The ColoRx Drug Formulary will not be used by clinic and hospital pharmacies for drug pricing
- only for drug code number information, Acquisition cost must be used for unit pricing.
2. Quantity of Medication: New prescriptions for chronic or acute conditions, at the discretion
of the physician. However, reasonable amounts for more than a 30-day supply for chronic
conditions are recommended. Maximum supply is 100 days.
NPC - 1989
-
Exceptions to the above are:
a.
Shelf package size oral liquid medications, in pint size only, or smaller package size
>'
when not packaged in pint size.
b. Shelf package size oral tablet and capsule medications in quantities of 100 only or
smaller when not available in package size of 100.
c. Prescriptions for less than minimum amounts will be denied reimbursement of the
professional fee unless the physician notified the State Department in writing of the
medical need for amounts less than a 30-day supply. Medical consultation will determine
the decision.
3. Dollar Limits: None.
D. Basis for Reimbursement:
1. Benefit drugs shall be reimbursed at the lesser of the Medicaid allowable reimbursement
charge, or the provider's usual and customary charge or whatever is accepted from any third
party, discounts, rebates, etc.
2. The Medicaid allowable reimbursement charge is the sum of the ingredient cost of the drug
dispensed and the provider's dispensing fee.
3. Dispensing fee: $3.78 as of July 1, 1986. The patient copayment is $1.00.
4. The dispensing fee is a pre-determined amount paid to a provider for dispensing a prescription.
It is established and periodically adjusted within appropriated funds based upon the results
. . .
of a cost survey which is designed to measure actual costs of filling prescriptions.
5. The pharmacy dispensing fee for retail pharmacies shall be based upon the average cost of
filling a prescription as determined by the cost survey subject to appropriated funds.
6. Institutional pharmacies shall receive a dispensing fee equal to one-half the retail pharmacy
fee.
7. Governmental pharmacies shall receive no fee.
8. Dispensing physicians shall not receive a dispensing fee unless their offices or sites of practice
are located more than 25 miles from the nearest participating pharmacy. In the latter case,
a fee equal to one-half the retail pharmacy fee will be paid.
E. lngredient Cost:
1. lngredient cost for retail pharmacies (estimated acquisition cost) is the price of the drug actually
dispensed as defined in (c) below or the MAC or the high volume EAC, whichever is less.
Colorado - 4
2. Benefit drugs dispensed in unit of use (unit dose) packaging will be reimbursed based upon
the bulk package size of 100 or pints or if not available in those sizes, the most common size
which most closely matches the standard sizes defined above.
3. The ingredient cost for institutional and government pharmacies is defined as the actual Cost
of acquisition for the drug dispensed or the MAC, or the high volume EAC, whichever is less.
a. Maximum Allowable Cost (MAC)
The state MAC is the maximum ingredient cost allowed by the Department for certain
multiple-source drugs. The establishment of a MAC is subject, but not limited to, the
following considerations:
(1) multiple manufacturers;
(2) broad wholesale price span;
(3)
availability of drugs to retailers at the selected cost;
(4)
high volume of Medicaid recipient utilization;
(5) bioequivalence or interchangeability.
When federal MAC limits for multiple source drugs are announced, they will be adopted
if they are less than state MAC's or if no state MAC's exist.
Section II of the ColoRx shall identlfy the generic drugs subject to MAC
The ingredient cost of any drug subject to MAC shall be limited to MAC or wholesale
price as determined by the Department, which is less. Exceptions which will allow
reimbursement greater than MAC for a drug entity are obtained through the prior
authorization mechanism. An exception will be granted if the patient's response to the
generic drug is not therapeutic, an allergic reaction is involved, or any similar situation
exists.
If a recipient requests a brand name for a prescription which is subject to MAC, then
helshe may pay the ingredient cost difference between the MAC and brand name drug.
The recipient must sign the prescription stating that helshe is willing to pay the
difference in ingredient cost to the pharmacy. The pharmacy will be paid MAC plus a
dispensing fee or reimbursement charges whichever is lower.
b. High volume Estimated Acquisition Cost (EAC)
Reimbursement for single source drugs or certain multiple source drugs which are most
frequently prescribed will be based upon average wholesale prices or direct
manufacturers' prices for package sizes containing quantities greater than 100 dosage
units or less if not available in 100's. Basis for inclusion in the high volume estimated
acquisition cost list includes but is not limited to:
(1) Single source manufacturers;
(2)
High volume Medicaid recipient uutilization;
NPC - 1989
(3)
Interchangeability problems with multiple source drugs;
(4)
Package sizes in excess of 100;
These drugs will be identified in Section Ill of the ColoRx.
c. Drug Pricing
The Department will maintain a drug pricing file which will be updated at least monthly.
The average wholesale price of a drug as determined by the Department, MAC, and high
volume EAC, will be the basis for setting the prices in the drug pricing file.
The Department will determine the average wholesale price which will be placed in the
drug pricing file as follows:
(1)
The average wholesale price as it appears in the Red Book, its supplements,
and Medi-Span will be the first source. However, if there is a difference between
the two published average wholesale prices, then the Department will set the price
as the published amount which is the closest to the lowest average price charged
by two drug wholesalers doing business in Colorado.
(2)
If there is a price change which does not appear immediately in the Red Book,
its supplements or in Medi-Span, then the Department will set the average
wholesale price by averaging the wholesale prices of three drug wholesalers doing
business in Colorado, until the price is published in the Red Book, its
supplements, or in Medi-Span.
(3)
If the prices or changes do not appear in the publications or the wholesalers'
records, then the distributors' or manufacturers' prices will be adjusted to the
wholesale pricing level and used in the drug pricing file as the price of the drug.
If the difference between the pharmacist's invoice purchase price and the average
wholesale price which appears in the Red Book, its supplements, or Medi-Span exceeds
18%, then the Department may adopt a lower price after a survey is conducted to
determine the validity of the published prices. The price from the distributor or
manufacturer will be adjusted the same as in 3 above.
Special Note:
The Maximum Allowable Cost shall be determined by the Division of Medical Assistance, based upon
professional determination of a quality product available at the least expense possible.
Recommendations from the ColoRx Drug Formula/y Advisory Committee of the Medical Advisory Council
is considered in. determining the MAC.
T
NPC - 1989
Colorado - 6
V. Miscellaneous Remarks:
Lock-In Review Procedures:
The State Department receives computer processed printouts designed to discover over-utilization of drugs
prescribed by physicians, dispensed by vendors, and received by eligible recipients.
A Lock-In Review Committee composed of two physicians, one consumer, and three pharmacists meets monthly
to review the printouts and make recommendations to the State regarding corrective action. In most cases, the
attending physician is notified of the Cornminee's recommendations. Case-workers are also contacted and
informed of the over-utilization review on abuse with a request to contact the recipient and explain lock-in and help
the recipient choose a physician and pharmacy. Recipient and the family are locked in for a year. A review of
the case is then made to determine if the recipient and family should remain locked in.
Fiscal Intermediary:
Blue CrossIBlue Shield
700 Broadway
Denver, CO 80237
Officials, Consultants and Committees
I. Social Services Department Officials:
Irene M. Ibarra. Executive Director Colorado Department of Social Sewices
P.O. Box I81000
Denver, Colorado 80218-0899
Mark L'kvan, Deputy Director
Garry A. Toerber, Ph.D., Director Bureau of Medical Assistance
David West, Director Program Services
Donna Bishop, Director Program Support
Stanley G. Callas, R.Ph., Manager
3031866-5508
PharmacyIAmbulatory Care Svces. Sect.
Division of Medical Assistance
James C. Syner, M.D., Medical Consultant Division of Medical Assistance
Jordon Stevens, Manager
Mary Ann Seddon, Manager
Hospital Services Section
Division of Medical Assistance
Su~eillance/Utilization Review Sect
Marion McLain, Manager HMO Section
NPC - 1989
Colorado - 7
Alena Gratts, Manager
Dean Woodward, Manager
Janell Little, Manager
Richard Allen, Manager
Wes Letz, Manager
2. Social Services Department Consultant:
Marvin J. Lubeck, M.D.
Ophthalmology
3865 Cherry Creek
North Drive
Denver, CO 80210
3. Medical Advisory Committees:
A. Medical Assistance and Sewices Advisory Council:
Members:
John Thomas, OD
3405 Wright Street
Wheatridge, CO 80033
Jess Hayden, Jr., DMD
2465 S. Downing St., Ste. 108
Denver, CO 8021 0
Tony Makowski, M.D.
206 W. County Line Road
Middleton, CO
David Holz, DPM
51 61 E. Arapahoe #260
Littleton, CO 80122
Ex-Officio Members:
Irene Ubarra
Executive Director
CO Dept, of Social Services
71 7 17th Street
Denver, CO 80218
Ernestine Kotthoff-Burrell, RN
11313 San Juan Range Road
Littleton, CO 80127
Richard McCoy, Jr., R.Ph.
2852 Dexter
Denver, CO 80207
Jo Ann Welier
15580 E. 144th Avenue
Brighton, CO 80601
Florangel Mendez-Cottingham
1390 Logan Street #315
Denver, CO 80203
Thomas Vernon, M.D.
Executive Director
CO Department of Health
421 0 E. 1 1 th Avenue
Denver, CO 80220
Fiscal Agent Monitoring
Physician Services
Third Party Recovery & Liabilities
Long Term Care
Appeals
Donald Schiff, MD
4200 E. 9th Ave., BOX C230
Denver, CO 80262
Donna Rayer, RN
6060 East lliff
Denver, CO 80222
David Harmon, DO
1060 Orchard
Grand Junction, CO 81501
Ronald Ellis, MD
950 E. Haward, Suite 470
Denver, CO 80210
Recordinq Secretary:
Carole Allen
Bureau of Medical Services
PO Box 181000
Denver, CO 8021 8-0899
Colorado - 8
B. ColoRx Drug Formulary Advisory Committee:
Richard A. Haynes, R.Ph. Roger R. Pearce, R.Ph.
Chairman Pharmacy Div., King Soopers
130 Pearl Street, #I805 P.O. Box 5567, 65 Tejon St.
Denver, CO 80203 Denver, CO 80221
Don Asher
300 Hudson
Denver, CO 80204
Jerry D. Harvey, R.Ph.
2201 San Juan Avenue
La Junta, CO 81050
Steve Taylor, R.Ph. Roger Thompson, R.Ph.
1077 S. Federal Blvd. Prof. Pharmacy of Derby
Denver, CO 8021 9 6401 E. 72nd Avenue
Commerce City, CO 80822
Lillian Bird, R.Ph.
2420 71 st Street Duane Hess, R.Ph.
Greeley, CO 80631 5421 Manitou Road
Middleton. CO 80123
4. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society:
Harold F. F~ye
Executive Vice-president
Colorado Medical Society
P.O. Box 17550
Denver, CO 8021 7
3031779-5455
C. Society of Osteopathic Medicine:
Kathleen Brennan
Executive Director
CO Society of Osteopathic Medicine
50 S. Steele Street
Denver, CO 80209
3031322-1 752
Gerri Sormani, R.Ph.
Musick Drug
309 East Fontanero Steet
Colorado Springs, CO 80907
Duane H. Lambert, R.Ph.
131 5 South Clarkson
Denver, CO 80210
Thomas Perry, M.D.
5440 W. 25th Avenue
Edgewater, CO 80214
Gregory Tosiou
400 E. Colfax
Denver. CO 80203
B. Pharmaceutical Association:
S. Thomas Gray
Executive Director
CO Pharmaceutical Association
770 Grant Street, Ste. 244
Denver, CO 80203
303/861-0328
D. State Board of Pharmacy:
David L. (Mike) Simmons
Administrator
1525 Sherman St., Rm. 128
Denver, CO 80203-1751
3031866-2526
NPC - 1989
Connecticut - 1
CONNECTICUT
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Childrenc21
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X X
Laboratory &
X-ray Service
~ki l l kd Nursing
Home Services X X X X X X X X X X
Physician Services X X X X X X X X X X
Dental Services X X X X X X X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
HHS report HCFA - 2082
1987
Ex~ended Recipient
$37,603,536 152,137
$14,561,090 99,256
2,948,284 5,560
51,160 85
5,101,593 9,023
2,447,896 52,540
4,012,157 32,048
$6,912,734 15,863
4,360,108 7,298
15,955 28
2,006,796 3,358
120,517 1,755
240,027 1,406
169,331 2,018
$16,129,712 37,018
10,173,585 17,029
37,228 67
4,682,524 7,835
281,207 4,096
560,064 3,281
395,104 4,710
Connecticut - 2
111. Administration:
Directly by the State Weifare Department through seven district offices and one town delegated this special
authority.
IV. Provisions Relating to Prescribed Drugs:
A.
General Exclusions (diseases, drug categories, etc.):
1. Will not pay for experimental drugs, anti-obesity drugs, drugs available free from the Department of
Health Services, DESl drugs.
2. Prior authorization required for: non-legend drugs not listed on Connecticut Drug List; Amphetamines
except when used for narcolepsy and hyperkinesis: vitamins except prenatal, pediatric prior to 7th
birthday and fluoride prior to 14th birthday; nutritional supplements.
3. Nursing home patients: The department will not pay for drugs used in routine care and treatment
of patients normally covered in per diem rate except by prior authorization. Prior authorization
required for influenza or pneumovax vaccine, irrigating solutions, diabetic and diagnostic testing
material and I.V. solutions or sets.
B. Formulary: OTC Drugs Only
C. Prescribing or Dispensing Limitations:
1. Physicians are encouraged to prescribe drugs generically, when possible.
2. Quantity of Medication: Maximum quantity: 30-day supply or 120 tablets or capsules or 1 lb. powder.
For chronic conditions, prescription may cover 120 day supply but no more than 120 tablets or
capsules or 1 lb. powder. Oral Contraceptives: 3 months supply may be dispensed at one time.
3. Refills: 6 month refill limit except for oral contraceptives which have a 12 month limit. Controlled
substances have a 5 refill or 6 month limit.
4. Dollar Limits: None
D. Prescription Charge Formula: MAC, AWP as listed in Red Book or EAC price set by Department plus fee;
or usual and customary if lower. EAC = AWP minus 8%.
Fees: Convalescent and nursing homes - cost plus $3.03
Walk-In" patients - cost plus $3.55
The Department will pay an incentive professional dispensing fee of fifty cents per prescription, in addition
to any other dispensing fee, for substituting a generically equivalent drug product.
NPC - 1989
Connecticut - 3
Officials, Consultants and Committees
1. Income Maintenance Officials:
Lorraine M. Aronson
Commissioner
Sally Bowles, Deputy Commissioner
2031566-2759
Bradford Blancard, Deputy Commissioner
3021566-2759
Linda Schofield, Director, Medical Care Administration
2031566-2934
Bill Diamond, Chief, Medicaid Policy & Program Implementation
2031566-6650
Patricia Smith, M.D., Medical Director
2031566-6438
Margaret R. Lempitsky, Chief of Long Term Care
2031566-2049
Jan VanTassell, Manager, Alternate Care Unit
2031566-1905
David Parrella, Manager, Issues Analysis Una
2031566-1 330
Maureen Mohyde, Manager, Policy Unit
2031566-3761
Kathy Esposito, Manager, Operations Unit
2031566-2045
Julie Pollard, Manager, Medical Unit
2031566-3990
Department of Income Maintenance
11 0 Bartholomew Avenue
Hartford, Connecticut 061 06
2031566-2008
Meyer Rosenkrantz
11 0 Barthalomew Avenue
Hartford, CT 061 06
2031566-8007
Connecticut - 4
2. Fiscal Agent
Electronic Data Systems Corp
Farmington, CT
3. Income Maintenance Consultants
Fran Naples, D.D.S.
Kenneth Lambert, D.D.S.
Meyer Rosenkrantz, P.D.
Ned Zeigler, M.D.
Joseph Dushaine, M.D.
Income Maintenance Consultants (Part time)
William Pehl, O.D.
Padam Jain, M.D.
Elizabeth Geary, P.D.
4. Title XIX Advisory Committee
State Pharmacy Commission
Dr. James O'Brien
Michael Williams
CT State Medical Society
Dr. Elliott R. Mayo
CT Pharmaceutical Association
William Summa, P.D.
Edward C. Liska, P.D.
lncome Maintenance Dept.
Meyer Rosenkrantz, P.D., Pharmacist
5. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: B. Pharmaceutical Association
T. B. Norbeck
Executive Director
Conn. State Medical Association
160 St. Ronan Street
New Haven, CT 0651 1
Phone: 2031865-0587
Daniel C. Leone, P.D.
Executive Director
Connecticut Pharmaceutical Association
35 Cold Spring Rd., Ste. 125
Rocky Hill, CT 06067-3100
2031563-461 9
C. Society of Osteopathic Medicine: D. CT Commission of Pharmacy:
Hunter M. Addis, D.O.
Secretary
Connecticut Osteopathic Medical Society
225 Main Street
Manchester, CT 06040
Sharon Milton-Wilhelm
Board Administrator
State Office Building, Rm. 61-A
Hartford, CT 061 06
2031566.4832
NPC - 1989 Delaware - 1
DELAWARE
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other.
OAA AB APTD AFDC OAA AB APTD AFDC Children<21 (SFOI
Prescribed Drugs X X X X
inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services X X X X
'SF0 - State Funds Only
Ii. EXPENDITURES FOR DRUGS
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families wIDep. Children
~d u l t s -Families w1Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families wiDep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
1987
Expended Recipient
$4,486,023 27,064
$3,796,124 25,046
965,468 2,441
34,758 89
1,645,282 4,227
529,585 11,689
621,031 6,729
$689,899 3,654
51 1,299 1,064
326 1
68,791 21 5
27,656 862
44,100 738
37,727 793
$0 0
0 0
0 0
0 0
0 0
0 0
0 0
1988
Ex~ended Recipient
$4,622804 26.1 93
HHS report HCFA - 2082
F
NPC - 1989
Delaware - 2
111. Administration:
By Division of Economic Services, Department of Health and Social Services, through 3 county offices of
the state agency.
IV. Provisions Relating to Prescribed Drugs:
General Exclusions: Only legend item drugs (except for insulin) are reimbursable. Vitamins (except
pediatric vitamins), antacids, etc. can not be reimbursed unless they are legend items. OTC items
cannot be reimbursed. Anorectics are excluded, (except for pediatric hyperactivity and certain sleep
disorders, when certified by the physician). No drugs used solely for infertility.
Formulary: None.
Prescribing or Dispensing Limitations:
1. Quantity: None. Department requests physician to prescribe reasonable amounts
2. Refills: Prescription blank has space for physician to authorize renewals.
3. Dollar Limits: None.
Prescription Charge Formula:
Payment is based on the actual acquisition cost or maximum allowable cost (MAC) plus a $3.65
dispensing fee, or the usual and Customary cost to the general public, whichever is lower.
V. Fiscal Intermediary:
The Computer Company
Omega Professional Center
Bldg. J, Suite 25
Newark, DE 19713
Officials, Consultants and Committees
1. Health and Social Services Department Officials:
Thomas P. Eichler
Secretary
Phyllis T. Hazel
Director
Department of Health and Social Services
Delaware State Hospital
New Castle, DE 19720
3021421 -61 39
Division of Social Services
P. 0. Box 906
New Castle 19720
NPC - 1989
Ruth S. Fischer
Administrator
Medical Assistance Services
Dr. James B. Salva
Medical Consultant
Stephen G. Grant
Pharmacist C~f l s~l t af l t
2. Medical Advisory Committee Members:
Robert G. Kenrick, M.D.
Chairperson
A. I. duPont Institute
1600 Rockland Road
Wilmington, DE 19803
Rhoslyn J. Bishoff, M.D.
15 Park Drive
Dover, DE 199013799
Amos Burke, Director
Bureau of Health Planning & Resources Management
Robbins Building, Silver Lake Plaza
Silver Lake Boulevard
Dover, DE 19901
Richard Ellis
Director of Finance
Medical Center of Delaware
P. 0. Box 1668, 501 West 14th Street
Wilmington, DE 19899
Lyman Olsen, Director
Division of Public Health
Robbins Building, Silver Lake Plaza
Silver Lake Boulevard
Dover, DE 19901
Edward R. Sobel, D.O.
11 00 S. Broom Street
Wilmington, DE 19805
Anne Aldridge, M.D.
612 Ferry Cut Off
New Castle, DE 19720
Judith Brimer
209 McCallmont Road
New Castle, DE 19720
Sister Jeanne Cashman, O.S.U.
Ursuline Academy Convent
11 04 Pennsylvania Avenue
Wilmington, DE 19806
Neil McLaughlin, Director
Community Mental Health Center
Fernhook
14 Central Avenue
New Castle, DE 19720
David J. Richard
Executive Director
Delaware Assoc for Retarded Citizens, Inc.
240 N. James Street, 8-2
Tower Office Park
Wilmington, DE 19804
Norman Taub, M.D.
1802 West Cedar Avenue
Lewes, DE 19958
Daniel G. Thurman
The Milton & Hattie Kutz Home
704 River Road
Wilmington, DE 19809
3.
Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: B. Pharmaceutical Society:
Anne Shane Bader
Executive Director
Medical Society of DE
1925 Lovering Avenue
Wilmington, DE 19806
3021658-7596
Janice A. Gaska
Executive Director
DE Pharmaceutical Society
707 Philadelphia Pike
Wilmington, DE 19809-2599
3021762-6019
C. Osteopathic Society: D. State Board of Pharmacy:
Raymond H. Rickards, D.O. Martin Golden, Secretary
Executive Secretary 802 Silver Lake Boulevard
DE State Osteopathic Medical Society Silver Lake Plaza
1109 Nottingham Road - P.O. Box 845 Dover, DE 19901
Wilmington, DE 19899 3021736-4708
3021764-6120, ext. 295
NPC - 1989
District of Columbia - 1
DISTRICT OF COLUMBIA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs X X X X X X X X X
Inpatient
Hosoital Care
outpatient
Hospital Care X X X X X X X X X
Laborato~y &
X-ray Service
~ki l l kd Nursing
Home Services X X X X X X X X X
Phvsician Services X X X X X X X X X
~ e h a l Services X X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families wiDep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families wiDep. Children
~d u l t s -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families wiDep. Children
~d u l t s -Families wIDep. Children
Other Title XIX Recipients
1987
Expended Recipient
HHS report HCFA - 2082
1988
Expended Recipient
NPC - 1989 District of Columbia - 2
Ill. Administration:
The D.C. Department of Human Services (DHS), Office of Health Care Financing.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: All legend drugs are covered except those drugs that are listed by FDA as
ineffective. Pursuant to a prescription the following non-legend items are covered: oral analgesics,
oral antacids, insulin, insulin needles and syringes, contraceptive foams and jellies, ferrous sulfate,
prenatal vitamin formulations, geriatric vitamin formulations for recipients 65 years of age and over,
and multivitamin formulations for children 7 years of age and under. All other non-legend items are
excluded.
B. Formulary: None.
C. Prescribing or Dispensing Limitations:
1. Refills: In general, amounts dispensed are to be limited to quantities sufficient to treat an
episode of illness. Maintenance drugs such as thyroid, digitalis, etc. may be dispensed in
amounts up to a 30-day supply with 3 refills which must be dispensed within 4 months.
2. Antibiotic medications used in treatment of acute infections are not to be dispensed in excess
of a (10) day supply. Birth control tablets may be dispensed in 3-cycle units with a maximum
of 3 refills within one year.
3. Dollar Limits: There is no present dollar limitation. Physicians are requested to prescribe
reasonable amounts.
D. Prescription Charge Formula:
The lesser of: - Upper limit established by HCFA or the AWP - 10% plus a
dispensing fee of $4.25 or
- Usual and customary to the public
E. Compounded Prescriptions: - Allowable charges of all billable ingredients plus $5.10
- The provider's usual charge to the public.
F. Co-payment: $0.50 co-pay by recipient. Does not apply to recipients under 21 years of age,
prescriptions for family planning, nursing home patients, or pregnancy related.
V. Miscellaneous Remarks:
Fiscal Intermediary: The Computer Company FCC)
122 C Street, N. W.
Washington, D.C. 20001
Officials, Consultants and Committees
1. Department of Human Services Officials:
Peter Parham
Director
Reed Tuckson
Commissioner of Public Health
Lee Partridge
Chief, Office of Health Care Financing
James Harris, R.Ph.
Pharmacist Consultant
Office of Health Care Financing
202/727-0753
2. Executive Officers of District Medical and Pharmaceutical Societies:
Medical Society:
P. Douglas Torrence
Executive Director
Medical Society of D.C.
1707 L. Street, N. W., Suite 400
Washingon, D.C. 20036
2021466-1 800
Osteopathic Association:
Harry Handlesman, O.D.
Secretary
Osteopathic Association of D.C.
2804 Ellicon, N.W.
Washington, D.C. 20008
20213622250
Medico-Chirogical Society of D.C.
Jacqueline D. Savage
Executive Secretafy
P.O. Box 77013
Washington, D.C. 20013
2021347-47 70
District of Columbia - 3
Department of Human Services
801 North Capitol Street, N.E.
Washington, D.C. 20002
1660 L Street, N.W.
12th Floor
Washington, D. C. 20036
1331 H Street, N.W., Room 500
Washington, 5. C. 20005
B. Pharmaceutical Association:
John Smith
President
D.C. Pharmaceutical Assn.
6400 Georgia Ave., NW, Suite 6
Washington, D. C. 20012
2021629-1515
D. Board of Pharmacy:
Carlyle McAdams
Secretary
614 H Street - Room 923
Washington, D.C. 20001
2021727-7468
NPC - 1989
Florida - 1
FLORIDA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Children<21 (SFOI
prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X
Laboratoly &
X-ray Service X X X X
Skilled Nursing
Home Services X X X
Physician services X X X X
Dental Services X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS,
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w1Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
1987
Expended Recipient
$1 16,229,852 469.31 5
$93,814,378 391,047
36,603,054 73,695
965,183 2,586
5,282,505 101,452
5,071,394 136,302
5,892,241 11,012
20,950,413 64,724
17,688,499 33,276
9,205 14
2,308,352 4,284
341,125 12,858
378,063 9,129
225,166 5,163
$1,465,060 13,544
532,079 2,392
6,346 29
570,630 2,154
89,938 3,719
220,017 3,537
46,048 1,713
1988
Expended Recipient
$1 36,174,904 522,422
106,316,853 409,458
40,449,430 74,243
1,145,441 2,574
52,721,563 108,477
5,390,070 144,847
6'61 0,347 79,317
27,514,182 97,261
22,046,455 40,627
16,229 16
3,695,049 7,173
679,847 23,771
737,415 18,785
339,184 6,889
2,343,905 15,703
682,676 2,884
3,548 28
1,120,393 3,025
131,913 4,397
360,593 3,850
44,779 1,519
HHS report HCFA - 2082
NPC - 1989
Ill. Administration:
By the Department of Health and Rehabilitative Services. Claims processing and payment by Contract with
fiscal agent.
IV. Provisions Relating to Prescribed Drugs:
A. Limitations and Exclusions:
1. Vitamins and phosphate binders only for dialysis patients.
2. Protheses; appliances; devices; and personal care items;
3.
Non-legend drugs (except for prescribed insulin and buffered and enteric coated aspirin when
prescribed as an anti-inflammatory agent only).
4. Anorexiants unless the drug is prescribed for an indication other than obesity (i.e. narcolepsy,
hyperkinesis);
5. Topical acne preparations and selenium sulfide preparations;
6. Oral vitamins with exception of fluorinated pediatric vitamins prescribed for pediatric patients,
vitamins for dialysis patients, prenatal vitamins & hematinics for nursing home recipients;
7. Digestants, except when prescribed for hepatic or pancreatic diseases;
8. Laxatives and Lactulose preparations, except when prescribed as a chelating agent;
9. Nursing home floor stock drugs,
B. Formulary: None.
C. Prescribing or Dispensing Limitations:
1. Prescribed drugs covered up to $22 per recipient per month ($33 if the recipient is in a nursing
home), limited to legend drugs within program limits plus insulin. Greater expenditures require
prior authorization by the program. Prescription limits effective January 1, 1989: 6
prescriptions monthly for walk-in patients; 8 prescriptions per month for institutionalized
patients.
2. The recipient must present a monthly eligibility card to the provider and must then use the
same provider for the entire calendar month.
3. Maintenance medication should be dispensed and billed for at least a one-month supply.
4. Refills must be authorized by the prescriber and can be made for up to one year, except that
controlled substances can be refilled only in accordance with federal and state regulations.
5. Drugs with questionable efficacy, as rated by the FDA (DESI), are disallowed.
6. Investigational, experimental, blood derivative (e.g. for hemophilia), and appetite suppressant
items are not covered, nor are drugs that are prescribed for other than their approved
indications.
Florida - 3
D. Prescription Charge Formula:
Fee - effective March 11, 1986
Lower of: (1) GULP plus $4.23
(2) EAC plus $4.23 (EAC is wholesaler acquisition plus 7%)
(3) Usual and Customary
V. Miscellaneous Remarks:
A. Some High Volume EACs set at large package size
B. Provisions for medically necessary considerations
C. General Upper Limit Price (GULP)
1. Federal GULP drug list
2. Generic drugs are required to be dispensed if stocked by pharmacy and prescriber does not include
medically necessary" statement.
D. Claims Processor
EDS Federal Corporation
Pharmacy Services
P.O. Box 9030
Tallahassee, Florida 32314
Officials, Consultants and Cornrni-mees
1. Department of Health and Rehabilitative Services Officials:
Gregory Coler, Secretary
Gary Clarke, Deputy Assist. Secretary
for Medicaid
9041488-3560
Jerry Wells R.Ph., Pharmacist Consultant
Medicaid Office of Program Development
9041487-4441
2 Consultants to Medical Services Program: (Part-time)
Department of Health & Rehabilitative Services
1323 Winewood Boulevard
Tallahassee, FL 32399
131 7 Winewood Boulevard
Building 6, Room 233
Tallahassee, FL 32399-0700
131 7 Winewood Boulevard
Building 6, Room 243
Tallahassee, FL 32399-0700
Donald 0. Alford, M.D. Charles F. James, M.D. Armanda M. Sittig, M.D. Medicaid Office
Gene L. Davidson, M.D. Fred Lindsey, M.D. J. Orson Smith, M.D. 131 7 Winewood Blvd.
Larry C. Deeb, M.D. Richard Lamb, D. DS James A. Stephens, O.D. Tallahassee, FL
Irving J. Fleet, D.D.S. Janet Shelfer Sam Tatum, D.D.S 32301
NPC - 1989
3. Medicaid Advisory Council:
Florida - 4
Chairperson:
Stephen G. Reeder, R.Ph.
1314 N. Palafox
Pensacola, Florida 32501
9041438-6323
(Florida Pharmacy Association)
Ms. Bernice Jackson
Dir, Brevard Co. Social Services
2575 N. Courtney Parkway
Merrin Island, FL 32953
3051453-9513
(FL Assoc. of County Welfare Exec.)
Thomas P. Floyd, D.M.D.
400 Executive Center Drive, Suite 105
West Palm Beach, FL 33401
4071684-3331
(FL Dental Association)
Charles Fieldus, C.P.A.
Vice PresidentIFinance
Shands Teaching Hospital
Box J-327
Gainesville, FL 32610
9041371-7280
(FL Hospital Association)
4. Florida MAC Advisory Committee:
George Browning, R.Ph.
Retail Pharmacy for Nursing Homes
1281 Hickory Street
Melbourne, FL 32901
Lew Becks
Nursing Home Pharmacy
5607 Hammock Lane
Lauderhill, FL 3331 9
Lawrence DuBow
Wholesaler
Lawrence Pharmaceuticals
P.O. Box 5386
Jacksonville, FL 32207
Peggy Richardson
550 San Bernadino
North Ft. Myers, FL 33903
(Consumer - District 8)
Charles B. Mclntosh, M.D.
31 60 W. Edgewood Avenue
Jacksonville, FL 32209
9041765-5249
(FL Medical Association)
Vernon K. Yon
41 06 Arklow Drive
Tallahassee, FL 32308
9041488-8462
(Consumer - District 2)
Don Winstead
Asst. Secretary/Economic Services
Dept. of Health & Rehabilitative Sew.
1317 Winewood Blvd, Bldg. 6, Rm. 205
Tallahassee, FL 32301
(9041488-3271
Gary J. Clarke
Asst. Secretary for Medicaid
Dept. of Health & Rehabilitative Sew.
1317 Winwood Blvd, Bldg. 6, Rm. 205
Tallahassee, FL 32301
9041488-3560
Dick Kaplan
Pharmacy Manager
3730 Thornwood Drive
Tampa, FL 33618
Jim Powers, R.Ph.
Secretary
Florida Pharmacy Association
61 0 North Adams
Tallahassee, FL 32301
Mark Sullivan, R.Ph.
Pharmacist
1330 Miccosukee Road
Tallahassee, FL 32303
NPC - 1989
Florida - 5
DHRS Medicaid Representative:
Jerry Wells, R.Ph.
Department of HRS (PDDE)
1309 Winewood Boulevard
Tallahassee, FL 32399
5. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: B. Pharmaceutical Association:
Donald C. Jones
Executive Vice President
Florida Medical Association, Inc,
760 Riverside Avenue
Jacksonville, FL 32203
9041356-1 571
James B. Powers
Executive Vice President
Florida Pharmacy Association
610 North Adams Street
Tallahassee, FL 32301
9041222-2400
C. Osteopathic Medical Association: D. State Board of Pharmacy:
Steven 2. Winn
C. Rod Presnell
Secretary-Treasurer, Executive Director Executive Director
Florida Osteopathic Medical Association
130 North Monroe Street
2007 Apalachee Parkway
Tallahassee, FL 32399-0750
Tallahassee, FL 32301 9041488-7546
904878-7364
NPC - 1989
GEORGlA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Georgia - 1
Type of Benefit Categorically Needy Medically Needy (MN)" Other'
OAA AB APTD AFDC O M AB APTD AFDC"'Children<l8
Prescribed Drugs X X X X X X
Inpatient
Hospital Care X X X X X X
Outpatient
Hospital Care X X X X X X
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Sewices X X X X
Physician Services X X X X
Dental Services X X X X
'SF0 - State Funds Only
"Aged, Blind & Disabled (all services) effective April, 1990
"'Pregnant Women Only
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
1987
Expended Recipient
HHS report HCFA - 2082
NPC - 1989
Georgia - 2
ill. Administration:
By the Department of Medical Assistance.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: drugs not on the drug list.
B. Formulary: The Controlled Medical Assistance Drug List. For information contact:
(Vacant)
2 Martin Luther King, Jr. Drive S.E.
Floyd Building - west Tower
P.O. Box 38440
Atlanta, GA 30334
4041656-4044
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Physicians are encouraged to prescribe a 30 day supply. Six
prescriptions per month per recipient except by prior authorization.
2. Refills: According to state and federal law.
3. Dollar Limits: None.
D. Prescription Charge Formula: Lower of, average wholesale price (AWP) minus 10% plus fee of $4.26
or MAC plus fee, or usual and customary.
No copayment
V. Miscellaneous Remarks:
State MAC List = federal MAC plus 85 additional drugs
Officials, Consultants and Committees
1. Department of Medical Assistance Officials:
Aaron Johnson
Commissioner
Russ Toal
Deputy Commissioner
John W. Neal, Jr., Director
Program Management
Department of Medical Assistance
James Floyd Memorial Building
(Twin Towers) P.0, Box 38440
Atlanta, GA 30334
4041656-4479
Frances Lipscomb, R.Ph.
Program Management Officer
Pharmacy Service
4041656-4044
IPC - 1989
w
Georgia - 3
I. Title XIX (Medicaid) Medical Assistance Advisory Committees:
Representatives from each of the following groups:
Medical Association of Georgia
Atlanta Medical Association
Georgia Hospital Association
Georgia Osteopathic Medical Association
Georgia Pharmaceutical Association
Georgia Health Care Association
Georgia Dental Association
I. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: C. Osteopathic Medical Association:
Paul Shanor
Executive Director
Medical Association of Georgia
938 Peachtree Street, N. E.
Atlanta, GA 30309
4041876-7535
Cathy M. Garris
Executive Director
GA Osteopathic Medical Association
1847-A Peeler Road
Atlanta, GA 30338
4041399-6865
B. Pharmaceutical Association: D. State Board of Pharmacy:
Larry R. Braden
Executive Vice President
Georgia Pharmaceutical Association
20 Lenox Pointe, P.O. Box 95527
Atlanta, GA 30347
4041231 -5074
William G. Miller, Jr.
Joint Secretary
166 Pryor Street, S.W.
Atlanta, GA 30303
4041656-391 2
NPC - 1989 Hawaii - 1
HAWAII
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Ot hei
OAA AB APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X
Laboratory &
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X X
Physician Services X X X X X X X X X X
Dental Services X X X X X X X X X X
SF 0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Ti l e XIX Recipients
1987
Expended Recipient
1988
Emended Recipient
HHS report HCFA - 2082
Hawaii - 2
Administration:
By the State Department of Social Sewices and Housing through its Public Welfare Division and four County
branch offices.
I. Provisions Relating to Prescribed Drugs:
A.
Exclusions: Investigational new drugs, and drugs classified as ineffective or possibly effective by the
FDA.
B. Formulary: Drugs not listed in the Hawaii State Medicaid Drug Formulary require prior authorization.
C. Co-payment: No.
D.
Prescription Drugs: Payment for drugs listed i n the formulary is limited to the federally established
MAC price, or Estimated Acquisition Cost (EAC) plus dispensing fee $4.14 (effective July 1, 1989).
E.
Program pays for no more than the larger of: 30-day supply or 100 doses.
V. Fiscal Intermediary:
Hawaii Medical Service Association
Medicaid Program Section
P.O. Box 860
Honolulu, HI 96808
Officials, Consultants and CommiItees
1. Social Services and Housing Department Officials:
Winona Rubin. Director
Medical Care Administrator (vacant)
Department of Social Services and Housing
P.O. Box 339
Honolulu, HI 96809
8081548-6260
Ornel L. Turk, R.Ph., Pharmaceutical Consultant 8081548-891 7
NPC - 1989 Hawaii - 3
2. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: 8. Pharmaceutical Association:
Jonathan Won
Executive Director
Hawaii Medical Association
1380 S. Beretania Street
Honolulu, HI 96814
8081536.7702
Edmund Ehlke
Executive Director
Hawaii Pharmaceutical Association
P.O. Box 1198
Ho~OIUIU, HI 96807
8081547-4745
C. Osteopathic Medical Association: D. State Board of Pharmacy:
Alan R. Becker
SecretaryFreasurer
122 Oneawa Street
Kailua, HI 96734
Honolulu, HI 96815
Jerold Sakoda
Executive Secretary
P.O. Box 3469
Honolulu, HI 96801
8081548-3086
NPC - 1989
ldaho - 1
IDAHO
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC ChildreM21
Prescribed Drugs X X X X
Inpatient
Hospital Care
outpatient
Hospital Care X X X X
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician Sewices X X X X
Dental Sewices X
'SF0 - State Funds Only'
11. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
~dul t s -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
HHS report HCFA - 2082
1987 1988
Expended Recipient Expended Recipient
$2,920,363 28,020 $8,102,202 33,281
$1,519,289 18,915 2,603,370 19,429
247,635 958 477,585 893
1,876 17 5,725 17
462,722 1,889 872,558 1,662
366,202 10,367 491,530 11,037
440,852 5,684 755,971 5,820
$1,401,073 9,105 5,498,831 13,852
645,332 3,509 2,823,598 4,872
1,970 10 4,309 7
645,931 3,271 2,424,184 4,679
55,122 1,576 1 1 5,627 2,938
37,728 61 5 107,121 1,153
14,988 1 24 23,990 203
1988 data reflect major changes in the ldaho
Medicaid program, effective July I, 1987.
Nursing home patient utilization is now reported
in the vendor program. In addition, medications
which exceed the $30.00 per month per patient
limit are paid via county funds, but are now
reported in the total expenditure data. This
now provides a comprehensive pharmaceutical
benefit for Medicaid eligibles.
192
NPC - 1989
ldaho - 2
Ill. Administration:
By the State Department of Health and Welfare through seven regional offices, each serving five or more
of the state's 44 counties.
IV. Provisions Relating to Prescribed Drugs:
A.
Exclusions: Amphetamines, anorexic and related medication; non-legend medications except insulin
and insulin syringes; ovulation stimulants, DESl list in-effect; diet supplements; isotretinoin, nicotine
chewing gum; multivitamins, except for prenatal and pediatric fluoride-containing products; topicals;
minoxidil, benzoyl peroxide; clindamycin; erythromycin; meclomycin, tetracycline, tretinoin (except for
one indication).
B. Drug formulary: None
C. Prescribing or dispensing limitations: Prescription drugs are limited to a 34 day supply with limited
exceptions.
D. Prescription charge formula:
Lower of HCFA or EAC plus a variable dispensing fee $4.00, (unit dose $4.15) or the provider's
usual and customary price to the general public.
Miscellaneous Information:
Copayment - none
Fiscal intermediary:
1. Health and Welfare Department:
Richard Donovan, Director
Jean Schoonover, Chief
William J. Whiteman, D.Ph., Supervisor
EDS Federal Corporation
P.O. Box 23
Boise, ID 83707
Officials, Consultants and Committees
Mary K. Wheatley, R.Ph., Pharmacy
Services Specialist
2. Medical Care Advisory Committee:
Ruby Crosby, R.N.
St. Benedict's Hospital
Jerome, ID 83338
Arlene Davidson
ID Office on Aging
Statehouse
Boise, ID 83720
Department of Health and Welfare
Statehouse
Boise, ldaho 83720
2081334-5795
Bureau of Medical Assistance
Medicaid Policy Section
John Watts, Executive Dir.
ID Council on Develop. Disabil.
Statehouse
Boise, ID 83720
ldaho - 3
Howard Barton
ID Commission for the Blind
Statehouse
Boise, ID 83720
J. Charles Holden
ldaho Association of Counties
P. 0. Box 1623
Boise, ID 83701
Randy Robinson, Esq.
ID Legal Aid Services, Inc.
Suite A, P.O. Box 973
Lewiston, ID 83501
Jan Cox
Elmore Memorial Hospital
P.O. Drawer 'H'
Mt. Home, ID 83647
Ward Dickey, M.D.
125 E. ldaho #304
Boise, ID 83702
Dr. Rodney Heater
827 Center Avenue
Payette, ID 83664
Brian Lowry, D.D.S.
ID State Dental Assn.
9460 Franklin Road
Boise, ID 83704
Dick Schultz, Administrator
Division of Health
Dept. of Health and Welfare
Statehouse
Boise, ID 83720
Sharon Hubler
ID Mental health Assn.
715 S. Capitol Blvd. #401
Boise, ID 83702
Trudy Sheffield, R.N.
North ldaho Home Health
2170 Ironwood Center Drive
Coeur d'Alene, ID 83814
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
Donald W. Sower
Executive Director
ldaho Medical Association
305 West Jefferson, P.O. Box 2668
Boise, ID 83701
2081344-7888
C. Osteopathic Medical Association:
Harry E. Kale, D.O.
Secretary-Treasurer
ldaho Osteopathic Medical Association
522 West Main Street
Grangeville, ID 83530
2081983-1 133
Larry Benton
Idaho Health Care Association
P. 0. Box 2623
Boise, ID 83701
Beverly Carpentier
ID Pharmacists Association
31 20 Crescent Rim Drive #I 03
Boise, ID 83706
Huey R. Reed, Director
Central District Health
1455 N. Orchard
Boise. ID 83706
Don Sower, Executive Dir.
ID Medical Association
407 West Bannock
Boise, ID 83702
Mary Anne Saunders, Director
H & W - Region IV
1 105 S. Orchard
Boise, ID 83704
B. Pharmaceutical Association:
Jo An Condie
Executive Director
ldaho State Pharmaceutical Association
1365 N. Orchard Street, Room 103
Boise, ID 83706
2081376-2273
D. State Board of Pharmacy:
Richard K. Markuson
Executive Director
500 S. 10th Street, Suite 100
Boise, ID 83720-0001
2081334-2356
NPC - 1989
Illinois - 1
ILLINOIS
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other.
OAA AB APTD AFDC OAA AB APTD AFDC Childrenx21
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X X
Laboratory 8
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X X
Physician Services X X X X X X X X X X
Dental Services X X X X X X X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
1987
Expended ReciDient
1988
Expended RecipieM
HHS report HCFA - 2082
Illinois - 2
I. Administration:
Illinois Department of Public Aid
V. Provisions Relating to Prescribed Drugs:
A.
General Exclusions: Biologicals and drugs available from State Department of Health or other
agencies, anorectics, DESI-ineffectives (including identical, similar and related products), cough
syrups, general multivitamins, topical acne preps.
B.
Formulary: Pharmacies are encouraged to stock and dispense non-proprietary drugs of recognized
quality. If a drug is listed in the Drug Manual by generic name and the identical drug is prescribed
by trade name, the pharmacist may dispense the trade name product; however, payment will be
based on cost of the generic product. The pharmacist may so advise the practitioner to obtain his
permission to dispense the generic product which does not exceed the maximum allowable price.
Coverage is limited to items in the department's Drug Manual unless prior authorization is obtained
for exceptions.
For formulary information contact:
Ron Gottrich
P.O. Box 19117
Springfield, Illinois 62794-91 17
21 71782-7532
C. Prescribing or Dispensing Limitations:
1. The pharmacy shall dispense non-proprietary products of quality. Maximum reimbursement
to the pharmacy will be based on the price of a non-proprietary item of recognized quality.'
2. Quantity: A prescription may be refilled only if the prescribing practiiioner has so authorized
on the original prescription. A prescription may be refilled no more than twice and no later
than 3 months from the date of the original prescription. Maintenance Rx's may be refilled for
up to one year.
3. Dollar Limits: None.
D. Prescription Charge Formula: Lowest of I ) usual and customary, 2) Department's MAC plus fee.
Professional fee: $3.47.
V. Miscellaneous Information:
State MAC: Yes.
Approximately 3000 drugs
Copayment - none
Fiscal Intermediary - none
NPC - 1989 Illinois - 3
Officials, Consultants and Committees
1. Public Aid Department Officials:
Susan S. Suter
Director
Mary Ann Langston, Administrator
Norman L. Ryan
General Services Administrator
Sally Ferguson, Chief
Tim Claborn, Administrator
Medical Assistance Program
Ron Gottrich, R.Ph., Pharmacist Consultant
Maureen Mulhall, Chief
Bureau of Medical Practitioner Services
Department of Public Aid
100 S. Grand Avenue East
Springfield, IL 62704
21 71782-671 6
Policy and Planning
Bureau of Research & Analysis
201 S. Grand Avenue East
Springfield, IL 62762
3rd Floor
21 71782-7532
3rd Floor
2. Public Aid Department Advisory Committees:
A. The Department has a State Medical Advisory Committee, composed of physicians appointed by the Director
of Public Aid. The members of this Committee are from different areas of the State and are representative
of the different specialty fields.
Frederick B. White, M.D., Chairman 723 North 2nd Street
Chillicothe, IL 61523
B. Committee on Drugs and Therapeutics:
A Committee on Drugs and Therapeutics, a standing committee appointed by the Illinois State Medical
Society, serves in an advisory capacity to the Department of Public Aid on drug policy and the Drug
Manual.
Joseph B. Perez, M.D.
Chairman
Lawrence L. Hirsch, M.D.
Nicholas C. Bellios, M.D.
Marshall Blankenship, M.D.
5713 Strathmoor Drive, Ste. 2
Rockford, IL 61 107
81 51398-5456
1324 Coventry Lane
Northbrook, IL 60062
31 21578-3338
2504 Washington
Waukegan, IL 60085
3121249-3660
4647 W. 103rd Street
Oak Lawn, IL 60435
31 213373641
IPC - 1989
Theodore M. Kanellakes, M.D.
Armand Littman, M.D.
Allan L. Lorincz, M.D.
Patrick R. Staunton, M.D.
Phillip D. Boren, M.D.
61 81382-41 93
Joan E. Cummings, M.D.
31 2/343-7200
M. Anita Johnson, M.D.
31 21770-2000
Vincent A. Costanzo, Jr., M.D.
312/947-7310
Sam Enloe, Jr. R. Ph.
Kenneth E. Ryan
Director, Dept. of Economics
Ron Gottrich, R.Ph
IL Dept. of Public Health
Consultants:
229 N.Hammes Avenue
Joliet, IL 60435
81 51744-2300
9 Martha Lane
Evanston, IL 60201
31 21261 -6700
5841 S. Malyland, Box 409
Chicago, IL 60637
31 21702-6558
540 Linden
Oak Park, IL 60302
31 21696-5887
Doctor's Clinic
S. Plum Street
Cormi, IL 62821
Hines V.A. Hospital
Hines, 1L 60141
St. Maly of Nazareth
EENT Dept.
2233 W. Division
Chicago, IL 60622
7501 South Stony Island
Chicago, IL 60649
lPhA Representative:
261 W. First Drive
Decatur, IL 62521
IL State Medical Society
20 N. Michigan Avenue, Ste. 700
Chicago, IL 60602
31 2/782-1654
IDPH Representative
525 W. Jefferson
Springfield, IL 62761
21 71782-7532
-.
Illinois - 4
NPC - 1989 Illinois - 5
C. Drug Advisory Committee:
A State Drug Advisory Committee, appointed by the Director of the Department of Public Aid to advise on
general policies necessary to the operation of a statewide drug program for public assistance recipients.
Sam Enloe, R.Ph., Chairman George Karpman, R.Ph. Bernie Evers, R.Ph.
Enloe's Southtowne Pharmacy 901 N. First Evers Pharmacy
261 West First Drive Springfield, IL 62702 417 West Main
Decatur, IL 62521 Collinsville, lL 62234
Tom Gulick, R.Ph.
Gulick Pharmacy, Inc
912 North Vermilion
Danville, IL 61832
Rose Mancuso, R.Ph.
161 0 Arden Place
Joliet, IL 60435
Harry Staub, R.Ph.
Cabrini Pharmacy
949 N. Larrabee
Chicago, IL 60610
Jerry Handler, R.Ph.
481 1 West Madison
Chicago, IL 60644
Don Gronewold, R.Ph. Shewood Thomas, R.Ph.
Don's Pharmacy Touhy Pharmacy
100 South Main Street 7173 North Clark Street
Washington, IL 61571 Chicago, IL 60626
Ron Stephens, R.Ph. Jeffrey Veal, R.Ph.
83 West Lake Drive Watson's Malmart
Troy, IL 62294 6333 S. Green Street
Chicago, IL 60621
Kenneth L. Gimmy, R.Ph.
Gimrny's Drug Store, Inc
97 South 9th, Rosewood Heights
East Alton, iL 62232
Bill Ghodes, R.Ph.
7 Buttonwood Court
lndianhead Park, IL 60525
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: B.
Alexander R. Lerner
Executive Vice President
IL State Medical Society
20 N. Michigan Ave, Suite 700
Chicago, IL 60602-4890
31 21782-1 654
C. Osteopathic Medical Association: D.
Mr. George C. Andrews,
Executive Director
IL Association of Osteopathic
Physicians and Surgeons, Inc.
809 East Center Street
OnawaJL 61350
81 51434-5576
Pharmaceutical Association:
Edward Halstead, R.Ph.
Acting Executive Director
IL Pharmacists Association
223 W. Jackson, Suite 1000
Chicago, IL 60606-5307
31 21939-7300
State Board of Pharmacy:
Stephen F. Selcke
Director
Dept. of Professional Regulation
Pharmacy Section
320 West Washington Street
Springfield, IL 62786
21 71785-0800
NPC - 1989
Indiana - 1
I
INDIANA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE I
,
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Children<21 (SFOI
Prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatlent
Hospital Care X X X X
Laboratory &
X-ray Service
skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
1987
Expended Recipient
1988
Expended Recipient
$88,483,051 243,531
HS report HCFA - 2082
NPC - 1989
lndiana - 2
Ill. Administration:
The lndiana State Department of Public Welfare.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: (Most OTC drugs are covered) No legend or non-legend anorexics or
experimental, or DESl drugs.
B. Formulary: None.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: None.
2. Refills: Allowed as authorized by physician.
3. Dollar Limits: None.
4. Up to two dispensing fees paid per legend drug order per recipient per month in nursing home
setting.
D. Prescription Charge Formula:
1. The lowest of the:
a. MAC plus the dispensing fee of $3.00.
b. EAC (Estimated Acquisition Cost) plus the dispensing fee of $3.00. (EAC is 3% less than
AWP reported by Drug Topics Red Book)
c. Pharmacy's usual and customary charge to the general public.
V. Miscellaneous Information:
Fiscal Intermediary:
1. Welfare Department Officials:
Mrs. Suzanne L. Magnate
Administrator
(Vacant), Assistant Administrator
Medicaid
Mary Kapur, Assistant Administrator
Local Operations Division
Blue CrossIBlue Shield of IN
8350 Craig Street - Suite 250
Indianapolis, IN 46250
Officials, Consultants and Committees
Department of Public Welfare
100 N. Senate Avenue
Room 701
Indianapolis, IN 46204
31 71232.431 2
Marc Shirley, P.D., Pharmacy Consultant
Indiana - 3
Advisory Committee for Medical Assistance (Medicaid):
Sen. Virginia Blankenbaker Delano Bryant Richard L. Issacson, DPM
5019 N. Meridian St.
2028 Country Club Road 8424 Naab Rd., Ste. 2-L
Indianapolis, IN 46208 Indianapolis, IN 46234 Indianapolis, IN 46260
Jo Haynes Brooks, R.N., D.N.S.
Ray Fox Albert F. Kull, D.O.
Assoc. Professor, Nursing
Fox & Fox Insurance Co. 203 South Ironwood Drive
Purdue Univ. School of Nursing 101 E. 38th Street P. 0. Box 6172
West Lafayette, IN 47907 Indianapolis, IN 46205 South Bend, IN 46615
John Reed
Dir., Third Party Affairs
Hook-SupeRx., Inc.
2800 Enterprise St.
Indianapolis, IN 46226
Frank McAllister
4327 Valley Way Drive
Greenwood, IN 46142
Mr. Sandy Quarles
P. 0. Box 506
Kokomo, IN 46901
Joe D. Hunt, Director Mrs. Belle Kasting
Bur./Policy Development 1724 Parkview Drive
State Board of Health Bedford, IN 47421
1330 W. Michigan
Indianapolis, IN 46202
Barbara J. Miller Chris C. Paprocki, D.C.
P. 0. Box 277 420 North US. 31
Syracuse, IN 46567 Whieland, IN 46184
George S. Row, Ill Robert C. Shirey, D. DS
121 West Ripley Street 7216 Madison Avenue
Osgood, IN 47037 Indianapolis, IN 46227
Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: B. Pharmaceutical Association:
Richard R. King
Executive Director
lndiana State Medical Association
3935 N. Meridian Street
Indianapolis, IN 46208
31 71925-7545
David A. Clark
Executive Director
lndiana Pharmacists Association
156 E. Market Street, #900
Indianapolis, IN 46204
31 71634-4968
C. Osteopathic Medical Association: D. State Board of Pharmacy:
Stephan J. Noone
3520 Guion Road #i 06
Indianapolis, IN 46222
31 719263009
Mary Gaughan
Executive Director
lndiana Health Professions Bureau
One American Square Suite 1020
Indianapolis, IN 46282
31 71232-2960
NPC - 1989
IOWA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC' Childrew21
Prescribed Drugs X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X
Laboratory &
X-ray Service X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X
Physician Services X X X X X X X X X
Dental Services X X X X X X X X X
'SF0 - State Funds Only
+ Pregnant women
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adub -Families w/Dep. Children
Other Title XIX Recipients
I987
Expended Recipient
$33,7i7,984 174,376
$1 9,406,031 126,693
3,865,983 8,648
184,664 507
7,604,133 17,927
3,295,925 58,750
4,455,326 40,861
$1 2,094,059 38,461
9,198,832 16,722
50,127 79
1,467,174 2,266
276,304 5,757
61 8,215 6,048
12,094,059 7,589
$2,272,933 9,162
1,200,615 2,884
5,439 21
870,437 1,977
55,706 1,140
17,018 399
123,718 2,741
1988
Expended Recipient
38,298,744 171,584
22,513,728 121,759
4,800,750 9,332
215,669 509
9,780,252 19,693
3,354,071 55,270
4,362,986 36,955
12,314,606 38,741
9,448,469 16,322
42,414 64
1,222,873 1,896
321,114 6,197
766,361 6,738
51 3,375 7,524
3,465,116 11,059
1,876,507 3,729
6,947 19
1,328,870 2,452
60,446 1,108
18,166 429
174,180 3,322
HHS report HCFA - 2082
Iowa - 2
. Administration:
Central administration by the State Department of Human Services.
I. Provisions Relating to Prescribed Drugs:
A.
General Exclusions (diseases, drug categories, etc.): Most non-legend drugs, amphetamine products,
laxative drugs, and legend multiple vitamins require prior authorization.
lowa Medicaid OTC Coverage Rule
The lowa Department of Human Sewices adopted an administrative rule which permits coverage for
the following non-prescription drugs.
Aspirin Tablets 325 mg, 650 mg
Aspirin Tablets Enteric Coated 325 mg, 650 mg
Aspirin Tablets Buffered 325 mg
Acetaminphen Tablets 325 mg, 500 mg
Acetaminophen Elixir 120 mg/5 ml
Acetaminophen Solution 100 mg/ml
Ferrous Sulfate Tablets 300 mg, 325 mg
Ferrous Sulfate Elixir 220 mg15 ml
Ferrous Sulfate Drops 75 mg10.6 ml
Ferrous Gluconate Tablets 320 mg, 325 mg
Ferrous Gluconate Elixir 300 mg15 ml
Ferrous Fumarate Tablets 300 mg, 325 mg
B. Formulary: None.
C. Prescribing or Disperising Limitations:
1. Terminology: None.
2. Quantity of Medication: Prescriptions should be limited to a 30-day supply. Maintenance drugs
may be supplied in 90-day quantities.
3. Refills: Permitted.
4. Dollar Limits: None.
D. Prescription Charge Formula: Payment will be based on the pharmacist's usual, customary and
reasonable charge, but payment may not exceed the average wholesale price, plus a professional
fee determined to be the 75th percentile of usual and customafy fees. Currently 8.78.
E. State MAC list contains 35 drugs
NPC - 1989
V. Miscellaneous Remarks:
Co-payment: $1.00'
Incentive fee: $.SO2
VI. Claims Processing Intermediary:
Unisys Corporation
P.O. Box 10394
Des Moines, lowa 50306
Ofticials, Consultants and Committees
1. Human Services Department Officials:
Charles M. Palmer
Director
Donald W. Herman, Chief
Bureau of Medical Services
Ronald J. Mahrenholz, R.Ph., MS., Supervisor
Non-Institutional Services & Utilization Review Section
51 51281 -61 99
2. Human Services Department Advisory Committees:
A.
Title XIX Medical Assistance Council:
College of Medicine
Iowa Nurses Association
Charles M. Helms, MD, Ph.D. Mary Hosford
Associate Dean
100 Court Avenue 9 LL
College of Medicine Des Moines, IA 50309
University Hospitals
lowa City, IA 52240
Dept. of Hurhan Services
Hoover State Office Bldg.
Des Moines, lowa 50319
51 51281 -8621
House of Representat~es
Rep. Andy McKean
509 S. Oak
Anamosa, IA 52205
Rep. Mike Peters
1505 Glendale Bhd.
Sioux City, IA 51 105
$1 .OO co-pay (federal exclusions) fee: $3.78 fee effective July I , 1984.
$50 incentive fee paid to pharmacy if $1.50 is saved per prescription by the use of generics.
205
lowa - 4
lowa M e d i i Society
Donald C. Young, M.D.
1301 Pennsyvlania St.
Des Moines, IA 5031 6
Opticians Assn. of IA
Charles Ericson
P. 0. Box 3914
Des Moines, IA 50322
IA Assn. of Retarded Ciizens
Mary Ena Lane
71 5 E. Locust
Des Moines, IA 50309
lowa Senate
Sen. Linn Fuhrman
Box 87
Aurelia, IA 51005
Sen. Michael Gronstal
220 Bennett Avenue
Council Bluffs, IA 51501
IA Osteopath. Hospital Assn.
Darla Giese
603 E. 12th Street
Des Moines, IA 50307
IA State Dept. of Public Health
Ronald D. Eckoff, M.D.
Lucas State Office Bldg.
Des Moines, IA 50319
Public Representatives:
Dorothy J. Eide
RR 2, Box 74
Decorah, IA 52101
lowa Hospital Association
Donald Dunn
100 E. Grand Avenue
Des Moines, IA 50309
IA Health Care Association
Paul A. Romans
950 12th Street
Des Moines, IA 50309
IA Assn. for Home Care
Marilyn Russell
P. 0. Box 4985
Des Moines, IA 50306-4985
lowa Chiropractic Society
Robert Rasmussen, D.C.
3500 2nd Ave. Suite 1 1
Des Moines, IA 50309
IA Pharmacists Assn
Thomas R. Temple
851 5 Douglas, Ste 16
Des Moines, IA 50322
IA Assn. of Homes for the Aging
William Thayer
613 West North Street
Madrid, IA 50156
lowa Dental Assoc'lation
Dan Todd, D.D.S.
1454 30th Stret, Suite 2088
West Des Moines, IA 50265
IA Cncl. of Health Care Centers
Jennifer Tyler
303 Locust Street
Des Moines, IA 50309
IA Osteopathic Medical Assn.
Gregory L. Ga~i n, D.O.
1351 W. Central Park, Ste 1100
Davenport, IA 52804
IA Optometic Assn.
Russell R. Campbell
5721 Merle Hay Road
Johnston. IA 50131
IA Podiatry Society
John C. Korn, D.P.M.
207 Professional Arts Bldg.
Davenport, IA 52803
Community of Mental Health Centers of IA
William Cropp
1309 Center Street
Des Moines, IA 50309
IA Psychological Assn.
Don Kaesser, Ph.D.
2400 86th St., Ste 30
Des Moines, IA 50322
Nancy M. Jones
RR #I
Ainsworth. IA
B. Pharmaceutical Advisory Committee:
Mark Richards, Des Moines
Bill Robinson, Oakland
Leon Galehouse, Cedar Falls
Doug Fitzgerald, Des Moines
Ken Hampson, Ames
Bob Sack, Manchester
Owil Nelson
1534 Second Street
Boone, IA 50036
Russ Wiesley, Des Moines
Terry Jacobsen, Osceola
Marion Reis, Sioux City
Ray Buser, Cedar Rapids
David Persinger, West Des Moines
Mike Siefert, Des Moines
NPC - 1989
3. Executive Officers of State Medical and Pharmceutical Societies:
A. Medical Society: B. Pharmacists Association:
Eldon Huston
Executive Vice-president
lowa Medical Society
1001 Grand Avenue
West Des Moines, IA 50265
51 51223-1 401
Thomas R. Temple, R.Ph., MS.
Executive Vice President
lowa Pharmacists Association
8515 Douglas, Suite 16
Des Moines, IA 50322
51 51270-071 3
C. IA Osteopathic Medical Association: D. State Board of Pharmacy Examiners:
Norman Pawlewski
Executive Director
1 1 13 Locust STreet, Suite 28
Des Moines, IA 50309
51 51283-0002
Norman C. Johnson
Executive Secretary
1209 East Court, Executive Hills West
Des Moines, IA 5031 9-0075
51 51281 -5944
KANSAS
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
Kansas - 1
BENEFITS PROVIDED AND GROUPS ELIGIBLE
fpe of Benefii Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Children<2l
rescribed Drugs X X X X X X X X X X
patient
losoital Care
lutpatient
lospital Care X X X X X X X X X X
aboratory &
:-ray Service
;killed Nursing
iome Services X X X X X X X X X X
'hysician Services X X X X X X X X X X
)ental Services
................................................ KAN Be Healthy (EPSDT) ............. . . . . . . . . . . . . . . . . . . . . ....................
SF0 - State Funds Only
I. EXPENDITURES FOR DRUGS.
1987 1988
Expended Recioient Expended Recipient
rOTAL $ 2 0 , ~ ~ , 9 5 8 92,797 $23,278,380 114,165
2ATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
HHS report HCFA - 2082
NPC - 1989 Kansas - 2
Ill. Administration:
State Department of Social and Rehabilitation Services.
IV. Provisions Relating to Prescribed Drugs:
A. Prescribed drugs. Covered are: (a) legend drugs in a drug list approved by the state Medicaid
agency, excluding drugs that the agency finds ineffective or possibly effective; and (b) selected
nonlegend drugs, devices, and supplies when prescribed for diseases and conditions specified in
the state's Medicaid regulations.
B. Formulary: Restricted drug list.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Maximum of a 100-day supply. Minimum quantities of a 100-dose or
30-day supply should be prescribed and dispensed for maintenance drugs.
2. Refills: As authorized by the prescriber up to a one-year period from the date of issuance of
the prescription.
D. Prescription Charge Formula: Variable fee per prescription established for each individual
participating pharmacy within the range of $2.79 to $5.26.
Pharmacies are reimbursed on the basis of product acquisition cost plus a professional fee. This
applies to all covered legend drugs. Covered non-legend drugs are reimbursed at the lesser of usual
and customary selling price or allowable acquisition cost plus the assigned dispensing fee. The
professional fees are based upon each individual pharmacy's historical operating costs as determined
by analysis of data submitted by each pharmacy to the agency. Professional fee determination is
limited to the lowest of: (a) The 85th percentile of allocated costs per prescription for all pharmacies
filing a cost report plus a reasonable profit, or (b) usual and customary fee charges of each individual
pharmacy as determined. "Acquisition cost'rneans the allowable price determined by the agency
for each covered drug in accordance with state and federal regulations.
Ingredient reimbursement basis: a combination of AWP-EAC; direct prices for eight companies; lower
of SMAC, FUL or EAC on multisource; NDC specific AWP as EAC on others.
A recipient co-pay charge of $1.00 was applied to each new and refill prescription.
E. Fiscal agent:
EDS Federal Corporation
P.O. Box 4649
Topeka, KS 66604
91 31273-5700
Carolyn L. Counts
Director of Provider Services
ORicials. Consultants and Committees
Social and Rehabilitation Services Department Officials:
Winston Barton, Secretary
91 3,296-3981
L. Kathryn Klassen, R.N., MS.
Director
Division of Medical Programs
Elaine Hacker, M.D.
Utilization Review Administrator
E. Eugene Stephens, R.Ph.
Manager, Pharmacy Services Program
91 31296-3981
Governor's Medical Care Advisory Committee:
Dept. of SociaVRehab. Services
Docking State Office Building
915 SW Harrison
Topeka, KS 66612
Robert Anderson Stuart Averill, M.D.
Family Consultation Services Menninger Foundation
560 North Exposition
P. 0. Box 829
Wichita, KS 67203
Topeka, KS 66601
Div. of Medical Programs
Rm. 6285, Docking State Office Bldg.
Topeka, KS 66612
Virginia Tucker, MD
Juanita DeMott Roy
Healh and Environment
St. Francis Hospital
Landon State Office Building 1700 West 7th Street
900 SW Jackson Topeka, KS 66606
Topeka, KS 66612
Floyd Eaton, Admin. Mary Reyer
Countyside Health Center Topeka Res Ctr for Handicapped
3501 Seward
1119 SW loth
Topeka, KS 66616
Topeka, KS 66604
Betty Schultz Sandra Kelly
PO Box 15122
706 SW Tyler
Kansas City, KS 661 15 Topeka, KS 66603
James Reeves, DPM
930 Iowa - Suite 2
Lawrence, KS 66044
Winston Barton
Department Representatives
L. Kathryn Klassen, RN, MS
21 0
Kansas - 3
Roger Gausman
131 1 Wheatland
Hutchinson, KS 67501
Mitzi Richards
Homecare Inc.
2803 Claflin
Manhattan. KS 67501
Jeanette Dickes, RPh.
2003 Regency Parkway
Topeka, KS 66614
Fred E. Patrick, M.D.
904 Mulvane
Topeka, KS 66606
Elaine Hacker, MD
NPC - 1989 Kansas - 4
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: B. Pharmaceutical Association:
Jerry Slaughter
Executive Director
Kansas Medical Society
1300 Topeka Boulevard
Topeka, KS 66612
91 31235-2383
Robert R. Williams
Executive Director
KS Pharmaceutical Association
1308 West 10th Street
Topeka, KS 66604-1299
91 31232-0439
C. Osteopathic Medical Association: D. State Board of Pharmacy:
Harold Riehm
Executive Director
Kansas Assn. of Osteopathic Medicine
1260 S.W. Topeka Boulevard
Topeka, KS 66612
91 31234-5563
Thomas Hitchcock, R.Ph.
Executive Secretary
900 Jackson, Rm 513
Topeka, KS 6661 2-1 220
91 312964056
Kentucky - 1
KENTUCKY
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()
, BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X
Laboratory &
X-ray Service X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X
Physician Services X X X X X X X X X
Dental Services X X X X X X X X X
'SF0 - State Funds Only
11. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
~dul t s -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Ti l e XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
1987
Expended Recipient
1988
Expended Recipient
HHS report HCFA - 2082
NPC - 1989 Kentucky - 2
Ill. Administration:
By the Depanment for Medicaid Services, within the Cabinet for Human Resources,
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions (diseases, drug categories, etc.): The following are items which are not covered
under the pharmacy benefits area of the program:
1. Most medical supply items such as bedpans, urinals, ice bags, etc. (Note: Insulin syringes are
covered.)
2. Medicine cabinet supplies and drug staples
3. Drugs available through other programs or agencies
4. Drugs not included on the Kentucky Medical Assistance Program Drug List (unless
prsauthorized according to established guidelines and criteria).
5. Medications and supplies used or dispensed by physicians or dentists during home or office
calls.
6. Most non-legend (over-the-counter) drugs except those used to treat diabetes and iron
deficiency anemia, enteric coated aspirin, and buffered aspirin.
6. Formulary: Yes. The list is revised in accordance with recommendations of the Formulary
Subcommittee and in accordance with available funds.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medications: For designated classes of maintenance drugs, refills of the original
prescription and subsequent prescriptions for these drugs must be prescribed and dispensed
in quantities of not less than a thirty-day supply unless the prescriber requests an exception
to this policy.
2. Refills: No prescriptions may be refilled more than 5 times or more than 6 months after the
prescription is written.
3. Dollar Limits: None,
D. Prescription Charge -- Reimbursement Formula:
1. All covered outpatient pharmacy benefits provided to Kentucky Medical Assistance Program
recipients are to be billed to the Program at the usual charge to the general public for the
same product and service(s).
Reimbursement to the pharmacy consists of the lowest of: (1) the usual and customary
charge; (2) the MAC, if any, plus dispensing fee; or (3) the EAC plus dispensing fee.
(conr. on page 3)
Kentucky - 3
The most frequently purchased package size and the most frequent method of purchase (AWP
or direct), as reported by suppliers and wholesalers. When AWP is used. it is reduced by five
percent.
2.
The dispensing fee is $3.25.
3. Co-payment - none.
4.
State MAC list contains 268 drugs as of April 1, 1989.
1. Fiscal Intermediary:
Electronic Data Systems Corp
Dallas, Texas
Officials, Consultants and Cwnm.Wees
1. Officials:
Harry J. Cowherd, M.D.
Secretary
ROY Butler
Commissioner
Cabinet for Human Resources
4th Floor, CHR Builg'ing
275 East Main Street
Frankfort, KY 40621
5021564-4321
Department for Medicaid Services
3rd Flwr, DHR Building
275 East Main Street
Frankfort, KY 40621
Gene A. Thomas, RPh.
Department for Medicaid Services
50215643476
2. State Advisory Council on Medical Assistance: appointed by the Governor, is composed of members representing
pharmacy, hospitals, registered nurses, medical doctors, dentists, nursing homes, optometrists, podiatrists; meet
quarterly or more often.
A.
Advisory Council for Medical Assistance:
Ellen Buchart, R.N. (Chair) C.A. Nava, DPM, Secretary Gwen Click
Jefferson Cnty. Health Dept.
KY State Board of Pharmacy lwine Health Care
400 East Gray Street
11 0 North Hubbard Lane Wallace Dr. & Bertha Street
Louisville, KY 40202 Louisville, KY 40207 Iwine, KY 40336
Nellie Stewart
Louis B. Hollkamp Edward Schottland, Sr. VP
Rose Manor Nursing Home Visiting Nurse Association Kosair Children's Hospital
3056 Cleveland Road 101 West Chestnut Street PO Box 35070
Lexington, KY 40516 Louisville, KY 40202
Louisville, KY 40232
Katherine Stephens Gladys Trueax
649 Lakeshore Drive
333 East 4th Street, #B-4
Lexington, KY 40502
Frankfort, KY 40601
NPC - 1989 Kentucky - 4
Roy Butler
Dept. for Medicaid Sewices
CHR Building, 3rd FI.
Frankfort, KY 40621
William Rich, DMD
11 1 Humes Ridge Rd., Box 27
Williamstown, KY 41097
Loretta Lawson
727 South 44th Street
Louisville, KY 4021 1
Harly J. Cowherd, M.D.
Cabinet for Human Resources
CHR Building, 4th FI.
Frankfort, KY 40621
William Watkins, M.D.
401 Bogle Street
Somerset, KY 42501
Bernard Zakem, O.D.
4130 Taylor Boulevard
Louisville, KY 40215
Elizabeth Moeller
Graham, KY 42344
Formulary Subcommittee
Samuel Scott, M.D. (Chair)
1302 Richmond Road
Lexington, KY 40502
Jansen D. Diener, M.D.
1023 Sanibel Way
Suite A
LaGrange, KY 40031
Nancy Jo Matyunas, Pharm.D.
Clinical Instructor in Ped.
Adj. Instructor in Pharmacology
U of L School of Medicine
Louisville, KY 40292
R. N. Smith, R.Ph.
Smith's Pharmacy
Burkesville, KY 42717
Thomas S. Foster, Pharm.D.
Dept. of Pharmacy, Rm. C114B
Univ. of KY Medical Center
Lexington, KY 40536
Thomas Badgett, Ph.D., MD
Dept. of Pediatrics
Kosair Childrens Hospital
PO Box 35090
Louisville, KY 40232
B. Pharmacy Technical Advisory Committee:
Mike Leake
P. 0. Box 726
Danville, KY 40422
J. Michael Schutte, R.Ph.
13200 Urton Lane
Louisville, KY 40243
Tom Houchens, Chairman Paul Ruwe, R.Ph.
220 Chippewa 11 Edna Lane
London, KY 40741 Ft. Wright, KY 41011
Chester Parker, Pharm.D., R.Ph.
181 6 Darien Drive
Lexington, KY 40504
Bob Gray
2636 Windsor Avenue
Owensboro, KY 42301
Anna Robinson
Rt. 8, Box 74, Evergreen Rd.
Frankfort. KY 40601
Chester L. Parker, P.D., R.Ph.
181 6 Darien Drive
Lexington, KY 40504
Ellen Burchan, RN
Jefferson Co. Health Dept.
400 East Gray Street
Louisville. KY 40202
Clarence Sullivan, Ill, R.Ph.
3741 Forest Green Drive
Lexington, KY 40503
Robert L. Barnett, Jr.
Interim Executive Director
KY Pharmacists Association, Inc.
Frankfort, KY 40602
Kentucky - 5
Pharmacy Technical Advisory Committee Alternates:
Carl C. Sutherland, R.Ph.
R. N. Smith, R.Ph.
Director of Pharmacy
P. 0. Box 247
Fleming County Hospital
Burkesville, KY 4271 7
Flemingsburg, KY 41 041
Chester L. Parker, PharmD., R.Ph
181 6 Darien Drive
Lexington, KY 40504
I. Executive Officers of State Medical and Pharmaceutical
A. Medical Association:
Robert G. Cox
Executive Vice President
KY Medical Association
3532 Ephraim McDowell Drive
Louisville, KY 40205
502/459-9790
C. Osteopathic Medical Association:
Executive Director
KY Osteopathic Medical Association
208 Crossfied Drive
Versailles, KY 40383
6061873-8044
Steve Adams, R.Ph.
217 Lexington Street
Lancaster, KY 40444
Societies:
Pharmaceutical Association:
Robert Barnen
Interim Executive Director
KY Pharmacists Association
1228 U. S. Highway 127 S.
Frankfort, KY 40601
5021227-2303
State Board of Pharmacy:
Richard L. Ross
Executive Director
1228 U.S. 127 South
Frankfort, KY 40601
5021564-3833
NPC - 1989 Louisiana - 1
LOUISIANA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X X
Laboratory &
X-ray Service
ski l i d Nursing
Home Services X X X X X X X X X X
Physician Services X X X X X X X X X X
Dental Services X X X X X X X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Age4
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w1Dep. Children
Other Title XIX Recipients
1987 1988
Expended Recipient Ex~ended Recipient
$86,566,603 356,806 $84,955,349 320,004
HHS reporf HCFA - 2082
Louisiana - 2
. Administration:
Public assistance programs are administered by the Department of Health and Hospital.
1, Provisions Relating to Prescribed Drugs:
A. Restricted Formulary.
B. Prescribing or Dispensing Limitations:
I. Quantity of Medication: New prescription must be issued for drugs given on a continuing
basis, after 5 refills or after 6 months.
Maximum payment quantity for prescriptions shall be either one month's treatment or 100 unit
doses.
2. Refills: Permitted as indicated by physician within 6 months and not to exceed 5 refills
3. Dollar Limits: None.
4. Formulary: Yes.
C. Prescription Charge Formula:
1. The maximum payment for a prescription is estimated acquisition cost (EAC), UIC or MAC
whichever is lower plus $3.51 dispensing fee.
D. Fiscal Intermediary:
Unisys
P.O. Box 3396
Baton Rouge, LA 70821
Officials, Consultants and Committees
I. Department of Health and Hospital Administration Officials:
David L. Ramsey
Secretary
Department of Health and Hospital
755 Riverside North
Baton Rouge, LA 70804
504/342-3947
NPC - 1989
Louisiana - 3
Carolyn 0. Maggio, P. D., Director
Bureau of Health Services Financing
50413424891
M. J. Terrebonne, P. D., Pharmacist Consultant II
50413424956
2. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: 8. Pharmaceutical Association:
Dave L. Tamer
Executive Director
Louisiana State Medical Society
1700 Josephine Street
New Orleans, LA 701 13
5041561 -1 033
Linda Foreman
Executive Director
Louisiana State Pharmacists Association
2337 St. Claude Avenue
New Orleans, LA 701 17-8441
5041949-7545
C. Osteopathic Association: D. State Board of Pharmacy
Charles S. Wyckoff, D.O.
Secretary-Treasurer
LA Assn. of Osteopathic Physicians
333 St. Charles Avenue - 412
New Orleans, LA 70130
50415859494
Howard 8. Bolton
Executive Director
561 5 Corporate Boulevard, Suite 8E
Baton Rouge, LA 70808
5041925-6496
UPC - 1989
Maine - 1
MAINE
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care
Laboratory &
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X X
Physician Sewices X X X X X X X X X X
Dental Services X X X X X X X X+ X+ X
'SF0 - State Funds Only
'Routine dental services; other categories eligible for non-routine dental service only.
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
1987
Expended Recipient
$21,086.1 07 91,507
$1 3,621,049 70,679
3,321,969 7,929
67,875 199
6,807,262 13,881
1,146,677 28,388
2,277,266 20,682
$6,478,082 23,408
4,718,998 9,231
3,691 15
1,232,669 3, 164
279,655 7,464
243,069 3,853
0 0
$986,976 3,886
422,559 1,136
3,731 6
407,249 835
74,637 1,303
78,800 684
0 0
1988
Expended Recipient
22,994,787 91,089
13,649,448 62,886
3,191,707 6,679
65,655 172
7,211,996 13,565
1,118,164 24,868
2,061,926 17,602
8,195,831 24,558
5,883,374 9,877
5,442 13
1,542,019 2,986
231,262 5,312
383,144 3,568
150,590 2,792
1,131,171 484
525,548 975
5,528 6
452,184 703
66,156 1 ,I 52
81,755 652
0 0
HHS report HCFA - 2082
NPC - 1989
Maine - 2
Ill. Administration:
State Department of Human Services.
IV. Provisions relating to prescribed drugs:
A. General Exclusions:
1. OTC drugs, except insulin and artificial tears
2. Combination antibiotics
3. Symptomatic remedies for common colds and coughs resulting from common colds
4. All vitamins and vitamin preparations
5. All amphetamines, straight or in combination, and all obesity control drugs. (Authorization for
amphetamines or methylphenidate in documented cases of narcolepsy or hyperkinesis may
be obtained upon request.)
6. lnjectables when oral medication is available for equally effective treatment
Prior authorization may be obtained in the case of necessary exceptions
B. Formulary: open formulary, except for certain therapeutic categories.
C. Prescribing or dispensing limitations:
1. Quantity of medication: refills for chronic conditions can be for no less than a 30 day supply
unless the prescriber specifically directs otherwise.
2. Refills: a prescription can be refilled up to five times within six months if specifically ordered.
3. Dollar limits: none.
D. Prescription charge formula: usual and customary, EAC plus a professional fee of $3.55 or MAC plus
a professional fee of $3.35, whichever is lower. (EAC for the top 150 drugs = AWP minus 5% or
direct prices, whichever applies.)
V. Miscellaneous:
Fiscal intermediary:
Good Health SystemsiLow Cost Drug Program
P.O. Box 508
Augusta, ME 04330
Officials, Consultants and Committees
Human Services Department Officials:
H. Rollin Ives, Commissioner
2071289-2736
Department of Human Services
State House, Station 11
Augusta, ME 04333
Trish Riley, Associate Deputy Commissioner
HealthIMedical Services
Sarah Krevans, Acting Director
Bureau of Medical Services
Elaine Fuller, Deputy Director, Health Programs
Bureau of Medical Services
James H. Lewis, Assistant Bureau Director
Bureau of Medical Services
Michael P. O'Donnell, R.Ph., Pharmacist Consultant
2071289-2674
Margaret Ross, Director
Medicaid Surveil./Utilization Review
Medical Consultants:
Allen Elkins, M.D. - Psychiatric
D.K. McFadden, D.O. - Osteopathic
Medical Assistance Advisory Committee:
Donald Ellis, O.D. - Opt~fWtriC
J.D. Reeder, D.C. - Chiropractic
Executive Officers of State Medical and Pharmaceutical Societies:
A. Dewey Richards, M.D., Chair
11 Gage Street
Bridgton, ME 04009
A. Medical Association: B.
Frank 0. Stred
Executive Vice President
Maine Medical Association
P. 0. Box 190
Manchester, ME 04351
207/622-3374
C. Osteopathic Association: D.
David A. De Turk
Executive Director
Maine Osteopathic Association
303 State Street
Augusta, ME 04330
2071623-1 I 01
Pharmaceutical Association:
Stanley Stewart
Executive Director
Maine Pharmacy Association
P.0 Box 817
Bangor, ME 04401 -081 7
2071947-0885
State Board of Pharmacy:
Richard Labonte
President
Maine Commission of Pharmacy
Health Station No. 35
Augusta, ME 04333
2071783.9769
Maine - 3
NPC - 1989
Maryland - 1
MARYLAND
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC Childrenc21
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care
Laboratory &
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X X
Physician Services X X X X X X X X X X
Dental Services X X X X X X X X X X+
'SF0 - State Funds Only
+ Limited services available. Expanded services available to EPSDT eligibles.
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Ti l e XIX Recipients
1987
Expended Recipient
' $45,329,906 224,980
$31,642,088 186,066
6,999,284 15,647
108,023 283
13,921,020 28,832
4,210,884 90,358
6,402,877 50,946
$532,959 2,261
171,346 303
3,414 3
274,398 481
33,667 868
50,134 606
0 0
$13,151,102 36,453
9,824,188 17,683
5,126 10
2,216,105 4,063
355,047 7,567
560,765 4,399
189,871 2,731
1988
Emended Recipient
46,858,969 221.21 9
31,663,743 177,118
7,059,435 15,506
108,643 292
14,856,289 31,324
3,850,731 83,710
5,788,645 46,286
601,882 2,522
179,348 299
2,237 3
333,318 648
42,940 950
44,039 622
0 0
14,442,374 37,370
10,800,629 18,312
3,633 8
2,472,823 4,125
362,862 7,516
563,358 4,245
239,069 3,164
HHS report HCFA - 2082
Maryland - 2
Administration:
State Department of Health and Mental Hygiene.
Provisions Relating to Prescribed Drugs:
A.
General Exclusions: (a) experimental or investigational drugs; (b) food supplements or infant formulas; (c)
prescriptions and injections for central nervous system stimulants and anorectic agents used for weight
control; (d) 'less-than-effective' drugs under federal regulations; and (e) certain other items as specified in
the state's Medicaid plan.
B.
Coverage of non-legend drugs is limited to insulin, and Schedule V cough preparations, enteric coated
aspirin, contraceptives and hypodermic needles and syringes. Specially formulated nutritional preparations
are covered when preauthorized by the program.
1.
Quantity of Medication: The amount of medication to be dispensed on a prescription at one time
is limled to a less than 34-day supply except for specific maintenance drugs for chronic conditions,
where up to a 100-day supply may be dispensed at one time. Prescriptions are limited to an original
and two refills for which the total quantity may not exceed a 100-day supply, except for birth control
pills which are limited to a six-cycle supply, and oral sodium flouride preparations used to prevent
dental caries which are limited to a 120-day supply with two refills.
2. Refills:
a. The maximum number of refills authorized on a prescription is two. The original prescription
and its refills may not exceed a 100-day supply except for birth control pills and oral sodium
flouride preparations.
b. Refills may not be dispensed after 100 days of date of original prescription except for birth
control pills and oral sodium flouride preparations.
3. Dollar Limits: Prior authorization required from the Medical Assistance Compliance Administration
when the usual and customary charge exceeds $100 and the prescribed amount is more than a 34
day supply. Preauthorization is needed for any prescription with a usual and customaly charge
exceeding $400.
4. Formulary: The program has an open formulary. The program does not restrict prescribers in their
selection of drug products except for the exclusions stated in section 1V.A. The prescriber must
indicate on the prescription "brand necessary' or 'brand medically necessary" when a specific brand
of an interchangeable multiple source drug is desired.
5. Reimbursement:
a. Drug ingredient cost is calculated under one of the following procedures:
I. Interchangeable Drug Cost (IDC) - effective June 1, 1985, the state of Maryland maintains
a list of approved interchangeable multiple source drugs for which a maximum
reimbursement (the IDC) will be allowed unless the prescriber has indicated that a
specific brand is medically necessary and is to be dispensed. This IDC is based upon
the lowest cost at which an approved interchangeable product can be guaranteed
available throughout the state. As of February 15, 1989, there are 422 products
representing 168 drug entities on the list.
NPC - 1989
Maryland - 3
2. Usual Source and Quantity List for High Utilization Drugs - effective June 1, 1985, the
state of Maryland maintains a list of highly utilized products which are usually purchased
directly from manufacturers and/or in larger than minimum package size. Reimbursement
for these products is based on the least expensive source of supply or package size.
As of December 31, 1988, 11 6 products representing 57 drug entities are included in
this list.
3. Estimated Acquisition Cost (EAC) -for all other drugs, reimbursement levels are based
upon the price of standard size packages (a) available from wholesalers within the state,
or if not available from these wholesalers, (b) manufacturers' direct prices.
b. Reimbursement will be the lower of: (1) the usual and customary fee; (2) the calculated
ingredient cost plus $3.70 dispensing fee (eff. 7/1/87).
V. Miscellaneous:
Number of Rx claim processed in FY 1988 (July, 1987 - June, 1988) - 3.2 million
Average prescription price during FY 1988- $1 6.95
Effective November 15, 1988, a copayment of $1.25 applies to state funded recipients except for those
under 21 and for family planning services and a copayment of $.50 applies to recipients in federal
categories. This co-payment does not apply to family planning services or to recipients who are under 21,
pregnant, enrolled in HMO's or who are residents of long-term care facilities (nursing homes). Effective July
11, 1988, the Program covers condoms dispensed by a pharmacist when a recipient presenta a valid
Medical Assistance card. Only 12 condoms are dispensed at one time; natural condoms are not covered;
a prescription is not necessary; a co-payment is not charged.
Maryland Pharmacy Assistance Program
The Maryland Pharmacy Assistance Program, established by the Maryland General Assembly in 1978, is
administered by the Depuv Secretary for Health Care Policy, Finance and Regulations and supported
entirely by state funds. The purpose of this program is to help low-income families and individuals who are
not eligible for Medical Assistance pay for prescription drugs, Schedule V cough preparations, enteric coated
aspirin, needles and syringes, contraceptives, insulin and certain nutritional formulations.
In Fiscal Year 1988, there was an average enrollment of 16,659 per month. The program paid $6,905,420
for 370,065 prescriptions, an average of $18.66 per prescription. Providers are reimbursed the lower of:
(1) usual and customary fee; or (2) ingredient cost as calculated under Medical Assistance regulations plus
a $3.70 dispensing fee.
Recipients are responsible for a $1.00 copayment for each prescription and each refill. The state pays the
remainder of total reimbursement.
Officials, Consultants and Committees
Maryland - 4
Health and Mental Hygiene Department Officials:
Adele Wilzack
Secreta~y
Nelson J. Sabatini
Deputy Secretary
Healh Care Policy Finance & Regulation
Joseph M. Millstone
Director
Medical Care Policy Administration
Patricia C. Burkholder
Chief, Division of Acute Care
Medical Care Policy Administration
301 1225-1 455
Leone W. Marks, R.Ph., Staff Specialist
Pharmacy Services - 3011225-1 459
Department of HealthIMental Hygiene
201 W. Preston Street
Baltimore, MD 21201
201 W. Preston Street
Baltimore, MD 21201
300 W. Preston Street
Baltimore. MD 21201
300 W. Preston Street
Baltimore, MD 21201
Medical Care Policy Administration
300 West Preston Street
Balimore, MD 21201
Joseph Fine, P.D., Chief
Medical Care Operations Administration
Division of Invoice Processing - 3011225-5370
201 W. Preston Street
Baltimore, MD 21201
John W. Baker, Program Manager
Pharmacy Assistance Program
301 1225-5392
MedicaidIPharmacy Liaison Committee:
Mark Levi, R.Ph., Chairman
Medical Arts Pharmacy
816 Cathedral Street
Baltimore, MD 21201
Philip Marsiglia, R. Ph.
Cherry Hill Pharmacy Clinic
608 Cherry Hill Road
Baltimore, MD 21255
David Rombro, R.Ph.
MacGillivray's Pharmacy
900 N. Charles Street
Baltimore, MD 21201
Stanton G. Ades, R.Ph.
P. 0. Box 87
Stevenson, MD 21 153
PO Box 386
Baltimore, MD 21203
Adolph Baer, R.Ph. Roger G. Heer, R.Ph.
Fishers' Pharmacy Greater Baltimore Pharmacy
1835 Woodburn Road 6565 North Charles Street
Hagerstown, MD 21740 Baltimore, MD 21204
Martin Mintz, R.Ph. Frank Palumbo, Ph.D.
Northern Pharmacy U of MD, School of Pharmacy
6701 Harford Road 636 W. Lombard Street
Baltimore, MD 21201 Baltimore, MD 21201
Melvin Rubin, R.Ph. Samuel Lichter, R.Ph.
Paradise Pharmacy 4001 Carthage Road
231 6 Sugarcane Road Randallstown, MD 21 133
Baltimore, MD 21209
Madeline Feinberg, R.Ph. Robert Martin, Jr. R.Ph.
1901 Briggs Road 501 Center Street
Silver Spring, MD 20906 Cumberland, MD 21052
NPC - 1989
Maryland - 5
Murray Polonsky, R. Ph.
415 E. Wayne Avenue
Silver Spring, MD 20901
George Voxakis, R.Ph.
1628 Weyburn Road
Baltimore, MD 21237
Medical Assistance Staff Committee Members
Patricia C. Burkholder - Policy
Joseph L. Fine, R.Ph. - Operations
George Lichter, R.Ph. - compliance ~eone W. Marks, R.Ph. - Policy
Frank Tetkowski, R.Ph. - Compliance
3. Medi i Assistance Advisory Committee:
Chairman
Jack Bovaird, Asst. Dir.
Assoc. Catholic Charities
320 Cathedral Street
Baltimore, MD 21201
Rosemary Atkinson
MD Energy Asa. Program
11 14 N. Mount Street
Baltimore, MD 21217
Kathryn Cannan
West MD Health Plan Agency
153 Baltimore Street
Cumberland, MD 21502
Linda Clark, RN, Exec VP
Del ma~a Found. for Medical Care
341 B North Aurora St.
Easton, MD 21601
Jacqueline Fassett
Sinai Hosp. of Baltimore
Belvedere at Greenspring
Baltimore, MD 21215
William Hankins, Asst. Dir.
Bons Secours Hospital
2000 West Baltimore St.
Baltimore, MD 21223
Benjamin J. Kimbers, Jr., D.D.S.
Madison Park Prof. Bldg.
932 West North Avenue
Baltimore, MD 21217
David S. Klein
400 East Pratt St.
Suite 800
Baltimore, MD 21202
Caren Berry
41 1 N. Baltimore St.
Baltimore, MD 21201
John Braxton, Jr., M.D.
4432 Park Heights Avenue
Baltimore, MD 21215
Ray Brodie, Jr., M.D.
844 North Carey Street
Baltimore, MD 21217
Phyllis Colson Burley
2859 Woodbrooke Avenue
Baltimore, MD 21217
Dorothy Council
1100 N. Bolton St., #210
Baltimore, MD 21201
Jean Dockhorn
109-D Versailles Circle
Baltimore, MD 21204
Dorothy Egbert
104 West Third Street
Frederick, MD 21701
Deborah Lee Fritz, Ph.D.
3701 DuPont Avenue
Kensington, MD 20895
Clara Kimbro, R.N., Dr.Ph.
10470 Waterfowl Terrace
Columbia, MD 21044
Eileen Leaman
27 Maple Avenue
Baltimore, MD 21228
Kathleen W. Lopez
604 East 38th Street
Baltimore, MD 21218
Jacqueline Lynch
1610 E. Monument Street, #5
Baltimore, MD 21205
Phillip R. Marsiglia, R.Ph.
3910 Dance Mill Road
Phoenix, MD 21131
Edward Matricardi
Dir. Bur of Mental Health
105 West Chesapeake Avenue
Towson, MD 21 204
Helen McAllister, M.D.
Health Officer, PG County
Hospital Road
Cheverly, MD 20785
Diane Pedersen
Dir. Home CareIHospice
St. Agnes Hospital
900 Caton Avenue
Baltimore, MD 21229
Beverly Paul
Coor., Prov. Relations
Chesapeake Health Plan
81 4 Light Street
Baltimore, MD 21230
Michael Rashid
Director West Baltimore
Community Health Center
1501 Division Street
Baltimore, MD 21217
Paula McLellan
2301 Catcef Street
Annapolis, MD 21401
Ethel Pace
1707 Moreland Avenue
Baltimore, MD 21216
Michael J. Weinfeid
14600 Falling Leaf Way
Darnstown, MD 20878
Ex Offcio Members:
Harry Klinefelter, M.D.
550 N. Broadway, Rm. 401
Baltimore, MD 21205
Lawrence Payne, Director
Medical Care Compliance Admins.
300 W. Preston Street
Baltimore, MD 21201
Nelson Sabatini
Dep. Sec, for Health Policy, Finance,
and Regulation
5th Floor, 201 W. Preston Street
Baltimore, MD 21201
Denise Wheatley Rowe Donna Sewell
3817 West Rogers Avenue 610 ReSe~oi r Street
Baltimore, MD 21215 Baltimore, MD 21217
Kenneth Albrecht
Medicaid State Rep.
HCFA
US. HHS
3535 Market Street
Philadelphia, PA 191 01
Gloria Washington
Medical Assistance Division
Income Maintenance Administration
311 W. Saratoga St., 6th FI.
Baltimore, MD 21201
4. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: B. Pharmaceutical Association:
Angelo Troisi
Executive Director
Medical1 Chirurgical Faculty of MD
121 1 Cathedral Street
Baltimore, MD 21201
3011539-0072
Gregory J. Wood
Executive Director
MD Pharmacists Assn.
650 W. Lombard Street
Baltimore, MD 21201-1 572
3011727-0746
C. State Board of Pharmacy: D. Maryland Osteopathic Association
r
Maryland - 6
Roslyn Scheer
Executive Director
201 W. Preston Street
Baltimore, MD 21201
301 1225.591 0
Lawrence Silverberg, P.D.
President
Routes 32 & 144
West Friendship, MD 21794
301 1489-7272
Massachusetis - 1
MASSACHUSms
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X
Laboratory &
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X
Physician Services X X X X X X X X X X
Dental Services X X X X X X X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS
1987 1988
Expended Recipient Expended Reci~ient
TOTAL $89,829,373 393,742 $1 W,305,001 $397,302
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
HHS report HCFA - 2082
, Administration:
State Department of Public Welfare.
f. Provisions Relating to Prescribed Drugs:
A.
General Exclusions: Immunizing biologicals available from DPH, legend vitamins not on Drug Lia,
non-legend drugs not on Drug List. Restrictions on certain therapeutic classes. Legend cough and
cold medications excluded. Restrictions on propoxyphene containing products.
B. Formulary: No.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Not more than a Smonth supply may be prescribed.
2. Refills: Prescription may be refilled, as long as total authorization does not exceed a 6-months'
or 5-refills supply from time of original prescription.
3. Dollar Limits: None.
D. Prescription Charge Formula:
I. Legend Drugs: $3.88 dispensing fee.
2. Payment shall be for the lower of the usual and customary charge or MAC or MMAC or EAC
cost plus dispensing fee, or AWP plus dispensing fee.
3. Non-Legend Drugs: Not to exceed the lower of: (A) EAC plus dispensing fee. (8) Usual and
customary charge to pharmacy's retail customers.
V. Miscellaneous Remarks:
For AB drugs, supplier bills State Commission for the Blind directly, which pays vendor pharmacy through
intermediary.
Fiscal Intermediary: Unisys Corporation
P;O. Box 9101
Somerville, MA 02145
61 71625-01 20
Multisource: payment shall be for the lower of the usual and customary charge, or MMAC or FUL plus a
dispensing fee.
All other: payment shall be for the lower of the usual and customary charge, or EAC plus a dispensing
fee. EAC is defined as WAC plus 10%.
Massachusetts - 3
Ofkials, Consultants and Committees
I. Welfare Department:
Carmen CaninoSiegrist, Commissioner
Arnold H. Shapiro, R.Ph.
Pharmacy Program Manager
Department of Public Weifare
600 Washington Street
Boston, MA 021 1 1
2.
Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society:
William M. McDermott, M.D.
Executive Vice President
Massachusetts Medical Society
1440 Main Street
Waltham, MA 02254-91 18
61 71893461 0
C. Osteopathic Society:
Gladys M. Davis
Executive Secretary
MA Osteopathic Society Inc.
237 Main Street, Box 147
Reading, MA 01 867
61 71944-5586
Pharmaceutical Association:
Jeffrey J. Burgoyne
Executive Director
MA State Pharmaceutical Assn.
27 Cambridge St., P. 0. Box 160
Burlington, MA 01803
61 71272-7679
State Board of Pharmacy:
Harold R. Parlamian, R.Ph.
Executive Secretary
100 Cambridge Street
Room 1514
Boston, MA 02202-0001
61 71727-9954
-7-
Michigan - 1
MICHIGAN
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XD()
BENEFITS PROVIDED AND GROUPS ELIGIBLE
fpe of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Childrew21
rescribed Drugs X X X X X X X X X
patient
os~i t al Care
utpatient
ospital Care X X X X X X X X X
aboratory &
-ray Service X X X X X X X X X
killed Nursing
lome Services X X X X X X X X X
hysician Services X X X X X X X X X
lemal Services
----- Limited for all eligibles -----
S O - State Funds Only
. EXPENDITURES FOR DRUGS.
'OTAL
>ATEGORICALLY NEEDY CASH TOTAL
\ged
Hind
Iisabled
:hildren -Families wIDep. Children
idults -Families w/Dep. Children
>ATEGORICALLY NEEDY NON-CASH TOTAL
4ged
3lind
Iisabled
:hildren -Families wIDep. Children
4dults -Families w/Dep. Children
Ither Ti l e XIX Recipients
dEDICALLY NEEDY TOTAL
4ged
3lind
Iisabled
Zhildren -Families w/Dep. Children
4dults -Families wIDep. Children
3ther Title XIX Recipients
1987
Expended Recipient
$129,397,205 731,462
$92,659,151 61 2,743
11,157,068 27,128
595,141 1,551
39,768,200 84,946
13,222,779 293,946
27,915,963 214,609
$5,479,931 38,850
2,397,640 7,194
24,460 149
2,093,520 11,187
287,249 11,428
677,062 13,133
0 0
$31,258,123 11 9,636
19,219,103 41,572
44,326 117
8,561,501 19,417
41 2,735 12,525
1,223,305 13,478
1,797,153 35,759
1988
Expended Recipient
$1 39,447,906 731,246
98,444,518 61 1,507
11,934,663 26,456
654,982 1,569
43,741,047 87,985
14,132,484 293,258
27,981,372 21 1,504
6,269,752 38,522
2,887,791 7,427
32,876 151
2,341,362 10,625
308,991 11,389
698,732 12,821
0 0
34,733,636 11 9,071
21,446,975 42,297
53,259 120
9,727,108 20,174
403,046 11,741
1,254,890 1 2,838
1,848,358 35,222
i HS report HCFA - 2082
NPC - 1989 Michigan - 2
Ill. Administration:
Michigan Department of Social Services, Medical Services Administration
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions and Restrictions:
The Medical Services Administration has a closed drug formulary for pharmacies. The intent is to
maintain coverage of economical products for most drug classes. For example, selected over-the-
counter drugs are covered if ordered by prescription, and selected forms of potassium replacements
are covered. (Liquids and oral solids are covered, but not effervescent tablets and powder packets.)
Also, to utilize available funds, certain drugs are only covered generically (e.g., Acetaminophen with
Codeine, Chlorodiazepoxide, Cephalexin, etc.).
The Department believes that a closed drug formulary is preferable to the elimination of entire drug
classes for controlling Program costs. However, the Program does not cover cough/cold preparations
and multiple vitamins except prenatal vitamins and fluoride supplements.
B. Formulary: Yes. For information regarding the formulary contact:
Frank Loll, R.Ph.
Bureau of Health Services Review
Medical Services Administration
P. 0. Box 30007, 921 W. Holmes
Lansing, Michigan 48909
51 71335-5265
C. Prescribing or dispensing limitations: Prescribed quantities should be limited to an amount necessary
to keep the recipient supplied during the therapy regimen. In certain cases and conditions, more
than a month's supply will be appropriate. However, in no instance may more than 120 days supply
be dispensed per prescription.
D. Prescription Charge Formula: Reimbursement for legend drugs is limited to the Lower of:
1.
Actual acquisition cost (AWP minus 10% ceiling), plus professional fee not to exceed $3.65
minus selected $0.50 patient copay or
2.
The MAC rate, plus professional fee not to exceed $3.65 or
3. The provider's usual and customary charge to the general public.
NPC - 1989
Michigan - 3 I
Selected co-payment provision:
A $0.50 co-payment is assessed the patient when a branded drug product is dispensed. When generic
drugs that are MAC'd are dispensed no co-payment is required.
Ambulatory recipients age 21 and older are required to pay a $.50 co-payment for most legend drugs.
If the recipient is unable to pay a required copayment on the date of service, the pharmacy cannot refuse
to render the service. However, the pharmacy may bill the recipient for the co-payment amount, and helshe
is responsible for paying it. If the recipient fails to pay a co-payment, the pharmacy could, in the future,
refuse to serve the recipient as a Medicaid recipient.
Recipients are not required to make a co-payment if:
they are under age 21, or
they reside in a long-term care facility (nursing home, hospital long-term care facility, or
medical care facility
they are enrolled in the Physician Sponsor Plan, or Health Maintenance Organization (HMO)
or some Clinic Plans.
Drugs not requiring a co-payment include: pregnancy-related; over the counter drugs; insulin and syringes;
family planning; dietary formulas; reagents; and MAC drugs.
V. Miscellaneous Remarks:
Contractor for price updates: First Data Bank
11 11 Bayhill Drive
San Bruno, CA 94066
41 51588-5454
ORiciak, Consuitants and Committees
1. Social Services Department Officials:
Patrick Babcock, Ph.D., Director
Kevin L. Seitz, Director
Dennis DuCap, Director
Office of Support Services
MI Department of Social Sewices
P. 0. BOX 30037
Lansing, MI 48909
Medical Services Administration
921 W. Holmes Road
Lansing, MI 48910
Vernon K. Smith, Ph.D., Director
Bureau of Program Policy
NPC - 1989 Michigan - 4
Kenh F. Cole, Director
Bureau of Medicaid Operations
Robert Levin, D.D.S., Director
Bureau of Health Services Review
Sandy Kramer, Pharmacy Program Specialist
Acting Section Manager
Bureau of Program Policy
51 7/35-51 27
2. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: B. Pharmaceutical Association:
Bruce Ambrose
Executive Director
MI State Medical Society
120 West Saginaw
East Lansing, MI 48826-0950
51 71337-1 351
Larry D. Wagenknecht
Executive Director
MI Pharmacists Association
815 N. Washington Avenue
Lansing, MI 48906
51 71484-1 466
C. Osteopathic Association: D. State Board of Pharmacy:
D. A. DeShaw
Executive Director
MI Assoc. of Osteopathic
Physicians & Surgeons, Inc.
331 00 Freedom Road
Farmington, MI 48024
31 31476-2800
Cathy Seyka
Administrative Assistant
61 1 W. Ottawa, P. 0. Box 30018
Lansing, MI 48909
51 71373-0620
T-
Minnesota - 1
MINNESOTA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
1. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Ot hei
OAA A0 APTD AFDC OAA AB APTD AFDC Children<21 (SFO)
Prescribed Drugs X X X X X X X X X
Inpatient
Hospital Care
outpatient
Hospital Care
Laboratory &
X-ray Sewice
Skilled Nursing
Home Services X X X X X X X X X
Physician Services X X X X X X X X X
Dental Services X X X X X X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families wIDep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
HHS report HCFA - 2082
1987
Expended Recipient
1988
Expended Recipient
NPC - 1989 Minnesota - 2
Ill. Administration:
Minnesota Department of Public Welfare, Income Maintenance Division, Medical Assistance Program.
iV. Provisions Relating t o Prescribed Drugs:
A. General Exclusions: Certain non-legend, cosmetic, anorectic and nutritional items are not covered.
B. Formulary: Yes. (Restricted drug list.)
Rick Bruzek, Pharm.D.
Professional Services Section
Department of Human Services
444 Lafayette Road, P. 0. Box 43170
St. Paul, Minnesota 55164
61 21297-2529
C. Prescribing or Dispensing Limitations: Refills are limited to 5 times or 6 months, whichever comes
first. Contraceptives may be filled to provide a 3-month supply.
D. Prescription Charge Formula: Reimbursement is based on the pharmacist's submitted charge or the
State Department of Human Services' maximum price, whichever is lower. Reimbursement fee is
$4.20 (effective January 1, 1989).
E. Ingredient reimbursement basis: AWP minus 10%
Offcials. Consultants and Committees
1. Department of Human Services Officials:
Sandra Gardebring, Commissioner
Charles C. Schultz, Dep. Commissioner
Maria Gomez, Assistant Commissioner
Robert C. Baird, Deputy Assistant Commissioner
Health Care & Residential Programs
Rick Bruzek, Pharm.D., Director
Drug Utilization Review, Drug Formulary
Ronald Rogers, Pharmacy Policy, Consultant
Department of Human Services
Centennial Office Building
444 Lafayette Road
St. Paul, MN 55155
61 21296-2701
444 Lafayette Road
St. Paul, MN 55155
6121296-61 17
NPC - 1989
Minnesota - 3
Dept. of Human Services Committees:
Professional Medical Advisory Committee:
W. S. Akre, O.D.
David Craig, M.D.
Box 727
4300 W. River Parkway
New Ulm, MN 56073 Minneapolis, MN 55406
David A. Paulson, M.D.
Kathleen Simo, M.D.
Hennepin Faculty Associates
South Medical Clinic
825 S. 8th Street, Suite 350
431 0 Nicollet Avenue
Minneapolis, MN 55404 Minneapolis, MN 55408
Executive Officers of State Medical and Pharmaceutical Societies:
Medical Association: B.
Steven D. Caner
Chief Executive Officer
MN State Medical Association
2221 University Avenue, S.E., Suite 400
Minneapolis, MN 55414
61 21378-1 875
Osteopathic Medical Society: D.
Robert N. Sampson, D.O.
Executive Director
MN Osteopathic Medical Society
Hoffman Clinic
Hoffman, MN 56339
61 2/98&2038
Louis Furlong
905 White Bear Avenue
St. Paul, MN 55106
Karen Thorkelson, Ph.D.
4601 York Avenue South
Minneapolis, MN 55410
Pharmaceutical Association:
William E. Bond
Executive Director
Mn State Pharmaceutical Associatjon
2221 University Avenue, S.E., Suite 326
Minneapolis, MN 55414
6121378-1 414
State Board of Pharmacy:
David Holmstrom
Executive Director
2700 University Avenue W. Suite 107
St. Paul, MN 551 14-1079
612f642-0541
NPC - 1989
MISSISSIPPI
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Mississippi - 1
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Childrenc21
Prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services X X X X
SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Tltle XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
HHS report HCFA - 2082
1987
Expended Reci~ient
$46,493,654 265,842
21,759,030 166,409
6,448,670 22,757
190,624 838
9,266,184 32,812
3,263,855 77,331
2,589,697 326714
24,734,624 99,433
11,734,998 32,787
223,170 679
9,712,524 24,605
832,236 13,039
1,766,759 16,867
464,937 11,456
$0 0
0 0
0 0
0 0
0 0
0 0
0 0
' Mississippi reports drug expenditure of $49,913,962 for fiscal year ending June 30, 1988.
HCFA reports $47,266,631 in expenditures for the Federal fiscal year ending September 30, 1988.
NPC - 1989
Mississippi - 2
T!
Ill. Administration:
Division of Medicaid
IV. Provisions Relating to Prescribed Drugs.
A. General Exclusions:
1.
Reimbursement is limited to drugs listed in the formulary. Legend drugs and insulin and such
other lifesaving drugs as may be determined by the commission, but no over-the-counter drugs
except buffered aspirin, sodium salicylate, nicotinic acid, ferrous sulfate, kaolin, pectin,
belladonna alkaloids and powdered opium, aluminum and magnesium hydroxide, and basal
gel (for dialysis patients only). The commission shall not pay more for prescribed drugs than
the lower of ingredient cost plus a reasonable dispensing fee or the provider's usual and
customary charge to the general public. The ingredient cost shall not exceed the lower of the
maximum allowable cost (MAC) established by the Pharmaceutical Reimbursement Board and
published in the Federal Register or the estimated acquisition cost (EAC). As used in this
subsection, 'estimated acquisition costmeans the commission's best estimate of what price
providers generally are paying for a drug in the package size that providers buy most
frequently. Product selection shall be made in compliance with existing state law; however,
the commission may reimburse as if the prescription had been filled under the generic name.
The commission may provide otherwise in the case of specified drugs when the consensus
of competent medical advice is that trademarked drugs are substantially more ef ective. The
commission shall periodically survey pharmacy operations and consider the results of the
survey to set reasonable dispensing fees.
2. Exclusions are amphetamines, obesity control drugs, vitamins, cold and cough preparations,
certain peripheral vasodilators, and those drugs classified as mild tranquilizers.
B. Formulary: Restricted formulary. For formulary information contact:
James T. Steefe
Office of the Governor
Division of Medicaid
Suite 801, Robert E. Lee Building
239 North Lamar Street
Jackson, MS 39201 -131 1
601 1359-61 35
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Prescription or refill quantities should not exceed the amount shown
in the maximum units column of the formulary. Prescriptions limited to five (5) per month per
recipient (effective 7/1/89).
2. Refills: Prescription refills are limited to three (3), except for maintenance type prescriptions
with a limit of 5. Authorization is required in writing by the prescriber. There are no refill
restrictions on insulin, and no refills are allowed on telephoned prescriptions.
-
NPC - 1989
Mississippi - 3
3. Injections: The Medicaid program will not reimburse drug providers for injectable medications
except for insulin and injectable medications prescribed for residents of nursing homes, and
for those in private homes if the individual is receiving Home Health Services under an
approved plan of treatment. injectable Antipsychotic shall be an exception.
4. Dollar Limits: None.
D. Prescription Charge Formula:
1. Legend Drugs - reimbursement for all legend drug claims is based on the lower of:
a. MACIEAC (ingredient cost) determined for the drug in the quantity dispensed, plus $3.75
dispensing fee (effective 7/1/89). Dispensing physicians receive a fee of $2.63 (effective
7/1/89).
b. The usual and customary retail charge.
c. Go-payment: $1.00.
2. Reimbursement for non-legend drugs are based on the lower of usual and customary charge
or the maximum over-the-counter price set for that item listed in formulary. Usual and
customary of a non-legend drug is to be the shelf price.
3. Compounded prescriptions for topical use are covered if at least one legend drug (in
therapeutic amounts) is included in the ingredients.
4.
Compounded oral medications when all ingredients are covered separately under their own
drug codes in the formulary.
V. Miscellaneous Remarks:
Fiscal intermediary: Blue Cross/Blue Shield
P. 0. Box 23061
Jackson, MS 39225-3061
Officials, Consultants and Committees
1. Office of the Governor, Division of Medicaid (Ray Mabus, Governor)
J. Clinton Smith, M.D., M.P.H.
Director
James T. Steele, R.Ph., Pharmacist
Office of the Governor
Division of Medicaid
Suite 801, Robert E. Lee Bldg.
239 North Lamar Street
Jackson, MS 39201 -131 1
601\359-6059
Mississippi - 4
Title XIX Technical Advisory Committee:
There are six technical advisory committees. Each committee consists of individuals who are health care
professionals identified with the responsibility of the committee to which they are appointed.
!,
Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: B, Pharmaceutical Association:
Charles L. Mathews
Executive Director
MS State Medical Association
P. 0. Box 5229
Jackson, MS 39216
601 1354-5433
Phylliss M. Moret, RPh.
Executive Director
MS Pharmacists Association
341 Edgewood Terrace Drive
Jackson, MS 39206-6217
601/981-0416
C. Osteopathic Medical Association: D. State Board of Pharmacy:
Eric Dahl, D.O.
Secretary Treasurer
100 Village East Centre
Suite 8-4
Philadelphia, MS 39350
H.W. Holleman
Executive Director
Suite 1765, C & F Plaza
2310 Highway 80 West
Jackson, MS 39204-2391
601/354-6750
NPC - 1989
Missouri - 1
MISSOURI
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Chi l dr e~21
Prescribed Drugs X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X
-Laboratory &
X-ray Service X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X
Physician Services X X X X X X X X X
Dental Services X X X X X X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families wIDep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families wIDep. Children
Adults -Families w1Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families wIDep. Children
Other Tale XIX Recipients
1987
Expended Recipient
$46,483,890 271,220
$16,046,804 175,918
4,201,919 12,575
370,749 975
3,703,166 8,739
3,438,713 93,501
4,322,762 59,893
$30,437,086 95,302
15,797,548 42,026
55,513 122
13,895,928 38,814
305,128 7,949
352,725 5,289
30,242 1,102
$0 0
0 0
0 0
0 0
0 0
0 0
0 0
I988
Expended Recipient
$54,861,210 282,932
16,839,170 173,735
4,177,297 10,714
408,524 955
3,931,622 8,413
3,698,346 94,752
4,599,243 58,222
38,022,039 109,197
19,262,120 44,515
60,063 121
17,677,603 42,623
383,512 9,631
468,580 6,623
170,158 5,684
0 0
0 0
0 0
0 0
0 0
0 0
0 0
HHS report HCFA - 2082
JPC - 1989
II. Administration:
Division of Family Services of the
V.
Provisions Relating to Prescribed Drugs:
A. General Exclusions:
T
Missouri - 2
State Department of Social Services.
Exclusions governed by formulary
B. Formulary: Formulary lists 402 drugs by generic names or trade names. For information contact:
Susan McCann, P.D.
Pharmacy Consultant
P.O. Box 6500
Jefferson City, MO 65102-6500
31 41751-3277
State allows payment only for the drugs in the formulary
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Physician encouraged to prescribe 34-day or 100 doses supply but
may, at his own discretion, prescribe up to a maximum 90-day supply.
2. Refills: Federal regulations must be observed for all drugs on the formulary which are listed
in BNDD Schedules 2, 3, 4, and 5. All other prescriptions refilled should be in accordance
with the directions given by the prescribing physician.
3. Five Rx limitation per month per recipient. Certain drugs which are commonly prescribed for
long-term chronic medical conditions are exempt from limitation.
D. Prescription Charge Formula: The lowest of the following:Federal MAC, Missouri MAC, AWP, or Direct
plus $3.00 fee or usual and customary, whichever is lower,
E. Co-payment (variable) - $0.50 co-payment when acquisition is $10.00 or less
$1.00 co-payment when acquisition $10.01 to $25.00
$2.00 co-payment when acquisition cost is $25.01 or more
Co-payment retained by pharmacist.
F. Drug Exception Process:
Certain nonsteroidal anti-inflammatory drugs covered on a prior authorization basis for recipients with
diagnosis of rheumatoid arthritis or juvenile rheumatoid arthritis who cannot tolerate aspirin.
V. Miscellaneous Remarks:
All prescriptions must be filled with drugs that meet USP standards. Participating pharmacies sign a
participation agreement with the State Department. All dispensing physicians participating in the program
are required to keep prescription files the same as pharmacies.
NPC - 1989 Missouri - 3
Missouri formulary is a restricted formulary, restriction being that the State only pays for drugs listed on the
formulary, or drugs that are chemically equivalent to drugs listed. Any drug that is chemically equivalent
to a trade name drug listed as acceptable for reimbursement. And likewise any trade name drug that is
not listed, but is equivalent to a generic drug listed, is reimbursable under the drug program.
Method of reimbursement payment is based on acquisition cost plus a dispensing fee of $3.00 per
prescription filled. Acquisition may vary depending whether it is based on AWP, Direct Price and Federal
or Missouri MAC. The master drug file contains all acceptable drugs and their appropriate NDC (National
Drug Code) number.
AWP, any drug that is not manufactured by Abbon, Lederle, Merck Sharp & Dohme, Parke-Davis, Pfizer,
Roerig, Squibb, Upjohn and Wyeth, or is not a federal or Missouri MAC drug will be based on the AWP.
The majority of drugs listed are based on AWP. The method of pricing will be taken from the NDC number.
Any drug manufactured by Abbott, Lederle, Merck Sharp & Dohme, Parke-Davis, Pfizer, Roerig, Squibb.
Upjohn and Wyeth, acquisition cost will be based on the manufacturer's direct price.
Missouri has 59 drugs listed as MAC which have a maximum price that will be paid.
All pharmacists and physicians that participate in the Missouri Title XIX Medicaid Drug Vendor Program have
been issued a listing of all MAC drugs, a listing of the manufacturers that the Division of Family Services
limits price to direct price.
By following these guidelines the Division of Family Se~i ces feels that the pharmacist has a freedom of
choice of products and package sizes in which he or she may stock their inventory.
Fiscal intermediary: General American-Consultec
701 So. Country Club Drive
Jefferson City, MO 65101
Officials, Consultants and Committees
1. Social Services Department Officials:
Gary J. Stangler, Director
Donna Checken, Director
Director
Department of Social Services
Broadway State Office Building
P.O. Box 1527
Jefferson City, MO 65102
Division of Medical Services
308 East High Street
P.O. Box 6500
Jefferson City, MO 65102
Susan McCann, Pharmaceutical Consultant 31 41751 -3277
Everett Harris, D.O., Physician Consultant
Michael Wilson, D.O., Physician Consultant
2. Joint PharmacyIPhysician Subcommittee:
Joseph C. Blanton, M.D.
Douglass S. Weidner, D.P.M. Michael H. Ledbener, D.0
Ferguson Medical Group Phelps County Medical Center Dogwood Medical Center
1012 North Main
11 00 West Tenth, Ste 220 Route 1, Box 27C
Sikeston, MO 63801 Rolla, MO 65401 Osage Beach, MO 65065
31 41471 -0330
3141341-31 10 31 41348-0209
Missouri - 4
I
Fred E. Bodenhamer, OD.
124 East Dunklin St.
Jefferson City, MO 65101
31 41635-2020
Denzil J. Hawes-Davis, D.O.
1125 South Madison Street
Jefferson City, MO 65101
31 41635-7141
James E. Canter, D.0
706 East Smith
California, MO 6501 8
31 41751 -2929
Mark Kasten, M.D.
63 Doctors' Park
Cape Girardeau, MO 63701
31 41334-4765
I .
Medical Advisory Committee to the State Division of Family Se~i ces:
Under revision.
1. Pharmacy Advisoly Committee:
Blaine AlberLy, P.D.
D & H Drug
1001 West Broadway
Columbia, MO 65203
31 41442-61 05
Robert W. Piepho, Ph.D., F.C.P.
Dean & Professor
u of MO-KC Sch. of Pharmacy
Katz Pharmacy Bldg
5005 Rockhill Road
Kansas City, MO 641 10-2499
8 1 61276- 1 607
W. R. "Bill" Howell
1 1 103 Queensway Drive
St. Louis, MO 63146
3141872-8626
Gary W. Morrison, P.D.
Lincoln County Pharmacy
#8 Lincoln Center
Troy, MO 63379
31 41528-8241
Kermit Fendler, Pharm.D.
Chairman
10 West 74th Street
Kansas City, MO 641 14
91 31362-1229
Gordon Ireland, Pharm.D.
35 Chestnut Hill Lane
St. Louis, MO 63119
3141768-1 41 8
5. Executive Officers Of State Medical and Pharmaceutical Societies:
A. Medical Association:
Royal Cooper
Executive Secretary
Missouri State Medical Assn.
113 Madison Street, P.O. Box 1028
Jefferson City, MO 65102
31 41636-51 51
Cynthia Elliott, M.D.
91 I South Brentwood, Ste. 331
Clayton, MO 63105
3141727-6565
Donald R. Brown, P.D.
1031 West Riverside
Springfield, MO 65807
41 7/03 -7383
David R. flush, Pharm.D.
Dept. of Family Medicine
Truman Medical Center East
7900 Lee's Summit Road
Kansas City, MO 64139
81 613734475, X 2063
B. Pharmaceutical Association:
George Oestrich
Executive Director
MO Pharmaceutical Assn.
410 Madison Street
Jefferson City, MO 65101-3189
31 41636-7522
C. Osteopathic Association: D. State Board o f Pharmacy:
Bonnie Bowles
Executive Director
MO Assn. of Osteo. Physicians/Surgeons
1423 Randy Lane - P.O. Box 748
Jefferson City, MO 65102
31 41634341 5
Kevin E. Kinkade
Executive Director
P.O. Box 625
Jefferson City, MO 651 02
3 141751 -2334
NPC - 1989 Montana - 1
MONTANA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X
Outpatient
Hospital Care
Laboratoty &
X-ray Service X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X
Physician Services X X X X X X X X X
Dental Services X X X X X X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
I987
Expended Recipient
$7,837,338 38,674
$4,131,999 28,032
733,278 1,653
16,399 54
1,971,771 4,353
498,136 12,553
912,413 9,403
$1,884,547 6,587
876,199 1,698
4,500 10
813,816 1,592
47,777 1,193
86,123 1,144
56,130 950
$1,820,781 4,055
1,412,955 2,504
1,552 4
336,911 61 0
16,537 438
49,483 448
3.350 51
1988
Expended Recipient
58,530,665 50,673
4,633,799 28,820
71 2,052 1,639
19, 143 53
2,437,918 5,356
508,832 12,447
955,525 9,309
1,513,581 6,324
802,976 1,526
1,444 5
472,149 908
61,998 1,51 7
11 7,404 1,375
57,610 993
1,798,663 3,863
1,385,030 2,441
1,322 3
333,746 556
15,391 390
60,161 421
3,013 52
HHS report HCFA - 2082
II. Administration:
State Department of Social and Rehabilitation Services.
V. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Provided are all prescription drugs and those over-the-counter drugs in the
following classes: insulin, laxatives, antacids. Both types must be prescribed by a licensed
practitioner (physician, dentist, podiatrist, optometrist, physician assistant or nurse specialist).
B. Formula~y: None.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: effective 7/1/87, maximum 100 doses or 34 day supply, whichever is
greater.
2. Refills: As directed by licensed practitioner.
3. Dollar Limits: No limit.
4. For chronic conditions prescription must be a minimum of 100 units or one month's supply.
D.
Prescription Charge Formula: Drugs will be paid at the usual retail rate or estimated acquisition cost
or maximum allowable cost, plus a dispensing fee - whichever is lower. Dispensing fees range from
$2.00 to $4.00 (effective 7/1;89). ~dciitional $0.75 per Rx allowed for unit dose systems.
E.
Co-payment - $1.00 effective 7/1/87
Officials, Consultants and Committees
1 . Social and Rehabilitation Services Department Officials:
Julia E. Robinson, Director
John Donwen, Administrator
John L. Chappuis, Chief
Lowell Uda, Supervisor
Karl Banschbach, Administrative Officer
2. Montana Medical Care Advisoty Council:
Dept. of SocialIRehab. Services
P.O. BOX 4210
Helena, MT 59604
4041444-4540
Economic Assistance Div.
Medicaid Bureau
Medicaid Services Section
John Donwen, Administrator Erich Merdiner, Chief Donald Pezzini
Economic Assist. Div. Prog. Integrity Bureau Dept. of Health & Environmental Sciences
Dept. of Social/Rehabilitation Dept, of SociaP~ehabilitation Cogswell Bldg., Room C108
P. 0. Box 4210 P. 0. Box 421 0 Helena, MT 59620
Helena, MT 59604 Helena, MT 59604 4061444-4544
Montana - 3
Hugh Standley
4629 Chandler
Missoula, MT 59801
4061543-5245
Gwen Kloeber
State Workers' Comp. Ins. Fund
Dept. Labor & Industry
50 S. Last Chance Gulch
Helena, MT 59604
4061444-6485
Jeffrey H. Strickler, M.D. William E. Boharski
300 N. Montana Avenue P. 0. Box 2965
Helena, MT 59601 Kalispell, MT 59901
4061449-5563
Paul S. Donalson, M.D. William Peters, M.D.
405 Saddle Drive 300 N. Wilson, Suite 2004
Helena, MT 59601 Bozeman, MT 59715
4061587-9202
R. 0. Marks
2831 Ft. Misioula Road
Missoula, MT 59801
3. Social and Rehabilitation Services Economic Assistance Division:
Dee Capp Karl Banschbach Randall Bowser
Administrative Officer Administrative Officer Program Officer
Mary Dalton Paul Miller John Kall, DDS.
Administrative Officer Administrative Officer Dental Consultant
Joyce DeCunzo John Patrick Charles Williams
Administrative Officer Medicaid Supervisor Administrative Officer
Kelly Williams Pat Huber John Chappuis
Administrative Officer Administrative Officer Chief Medicaid Bureau
4. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: B.
G. Brian Zins
Executive Director
MT Medical Association
2021 I l t h Avenue, Suite 12
Helena, MT 59601
4061443-4000
C. Osteopathic Association: D.
Patrick Frankl, D.O.
Secretary-Treasurer
MT Osteopathic Association
Box 2004
Phillipsburg, MT 59858
Pharmaceutical Association:
Robert Likewise
Executive Director
MT State Pharmaceutical Assn.
P.O. Box 4718, 4376 Head Drive
Helena, MT 59604
4061449-3843
State Board of Pharmacy:
Warren Arnole
Executive Director
510 1st Avenue, N. Suite 100
Great Falls, MT 59401-2581
4061761 -51311444-5436
NPC - 1989
B
Nebraska - 1
NEBRASKA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Childrenc21
Prescribed Drugs X X X X X X X
Inpatient
Hospital Care X X X X X X X
Outpatient
Hospital Care X X X X X X X
Laboratory &
X-ray Sewice X X X X X X X
Skilled Nursing
Home Services X X X X X X X
Physician Services X X X X X X X
Dental Services X X X X X X X
'SF0 - State Funds Only
11. EXPENDITURES FOR DRUGS
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w1Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families wIDep. Children
Adults -Families wiDep. Children
Other Title XIX Recipients
1987
Expended Recipient
I988
Expended Recipient
HHS report MRS 11 5
NPC - 1989 Nebraska - 2
Ill. Administration:
State Department of Social Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Experimental drugs; weight control and appetite depressant drugs, except for
use in narcolepsy or hyperkinesis in children with granted prior approval; OTC drugs that are not
listed in the "Official Drug Guide" and have not been prescribed by a licensed practitioner; drugs that
are marketed without required FDA approval; drugs marketed that infringe on patent rights; prior
authorization is required for certain other items.
6. Formulary: None. The "Official Drug Guide" is a list of drugs together with identification members
for billing purposes. For Drug Guide Information, contact:
Daniel W. Snodgrass, R.Ph.
Nebraska Dept. of Social Services
P.O. Box 95026
Lincoln, NE 68509
4021471 -31 21
C. Prescribing or Dispensing Limitations:'
1. Quantity of Medication: Maintenance-type drugs limited to purchases of at least a 30-day
supply, unless an exception is specifically allowed. Cardiac glycosides, thyroid, vitamins and
Dilantin will be limited to purchases of not less than 100's.
The Department of Social Services further requires that any other maintenance drug or any
drug used in a chronic manner be prescribed and dispensed in a minimum of a one-month
supply.
(Note: Prescriptions which are written for quantities larger than a month's supply are not to
be reduced to a month's supply. The Nebraska Department of Social Services will consider
any form of prescription splitting as fraudulent.)
Exceptions to the Quantity Limitations:
a. When the prescribing physician first introduces a maintenance drug to a patient's course
of therapy, the physician is allowed to prescribe as his judgment dictates. Physicians
and Pharmacists must indicate on the claim form that this is the initial filling of the
medication.
Any subsequent dispensing of this maintenance drug must be prescribed and dispensed
in at least a month's supply or the required 100 doses.
'
Medical Services, Department of Social Services, State of Nebraska. Nebraska DSS Program
Manual, issued November 24, 1982, as amended.
Nebraska - 3
b. When the prescribing physician's professional judgment indicates that these quantities
of medication would not be in the patient's best medical interest, the physician may
prescribe as his judgment directs; but the claim form must clearly indicate that an
exception to the requirement is being made.
c. If, in the Pharmacist's professional judgment, an exception to the requirements must be
made, the Pharmacist also must clearly indicate this on the claim form.
d. Schedule II drugs are exceptions.
e. Original shelf packages: The Department of Social Services will accept certain original
shelf package sizes of medication.
An original shelf package of 16 fluid ounces, or less when not packaged in the
pint size, will be sufficient for our quantity limitations requirement for liquids, but
will not be sufficient, for the supplemental dispensing fee unless a's a full month's
supply.
Original shelf packages of 100 tablets or capsules of routinely prescribed drugs
will be acceptable as sufficient for fulfillment of our quantity limitations
requirement. The full month's supply must be prescribed and dispensed.
An original shelf package of 100 tablets or capsules, or less when not available
in the 100 size for seldom prescribed solid dosage drugs will be sufficient for our
quantity limitations requirement, but will not be sufficient for the supplemental
dispensing fee unless it is a full month's supply.
Ready-made ointments, creams, etc., when used in a chronic or maintenance
manner, may be dispensed in an original shelf package size provided it is the
original size closest to the needed amount of medication.
The determination of whether a claim violates our regulations or not, would, by
necessity, have to be made by the Department of Social Services professional
staff. Any claim deemed to be in violation or not an exception to our rulings, will
not be compensated with the dispensing fee.
Any disagreement with a determination may be arbitrated through the Nebraska
Pharmacists Association's Advisory Committee.
3. Refills: As authorized by the prescribing physician,
4. Dollar Limits: None.
D. Prescription Charge Formula:
1. Retail Pharmacies
NPC - 1989 Nebraska - 4
a. 'Assigned" dispensing fee.
A dispensing fee will be assigned by the Nebraska Department of Social Services, to each
individual pharmacy. The fee will be calculated from the information obtained through the
Department's Prescription Survey. Each Pharmacy will be notified of its dispensing fee.
b. maintenance Drug-Month Supply"
Supplemental fee.
In addition to the "assigned' dispensing fee for each retail pharmacy, there is a maintenance
drug-month supply supplemental fee of $1.00. This additional fee may be charged provided
that a maintenance drug or drug used in a chronic manner is dispensed in a quantity sufficient
to provide an entire month's therapy.
c. The department assigns a dispensing fee to a dispensing physician only when there is no
pharmacy within a 25 mile radius of the physician's place of practice.
Variable Pharmacy Fee for individual pharmacy determined from survey data submitted to state:
EAC, SMAC, MAC plus determined store fee: minimum $2.84 to maximum $5.05 or usual 2nd
customary, whichever is lower.
2. Determining drug or ingredient cost:
a. General Information
(1)
Federal UpDer Limit (FUL): Certain mukiple source drug products will have an
upper limit of reimbursement assigned by the Federal Government. This limit is
equal to 150 percent of the product's lowest price that is published in current
national compendia of drug cost information. Additionally, at least three suppliers
must list the product which has been classified by the Food and Drug
Administration as category A in its most recent publication of Approved Drug
Products with Therapeutic Equivalence Evaluations.
All pharmacies will be notified by the Nebraska Department of Social Services
as to which products the Medical Services Division have designated as FUL
products and what their respective FUL values are.
(2)
State Maximum Allowable Cost (SMAC): Certain drug products available from
mul ti ~l e manufacturers will have a state maximum allowable cost designated by
the Medical Se,rvices Division of the Nebraska Department of Social ~ e i c e s . he
SMAC value is the cost at which the drug is widely and consistently available to
pharmacy providers in Nebraska. The determination of which products are
designated SMAC products is the direct responsibility of the Medical Services
Division in conjunction with the Nebraska Pharmacists Association Medicaid
Advisory Committee. Any individual or organization may at any time request a
revision in a SMAC value directly from the Nebraska Department of Social
Services.
NPC - 1989
Nebraska - 5
..,.
. ~.
,<q
All pharmacists will be notified by the Nebraska Department of Social Services
as to which products have been designated as SMAC products and what their
respective SMAC values are.
(3)
Estimated Acquisition Cost (EAC): All drug products, including the FUL products,
will be assigned an estimated acquisition cost. The EAC of any product will be
the actual cost at which most Nebraska providers may obtain the product. The
Nebraska Department of Social Services will be responsible for assigning the EAC
values to all drugs. Any individual or organization may at any time request a
revision in an EAC value directly from the Nebraska Department of Social Services.
b. Cost Limitations
The Nebraska Medicaid Drug Program is required to reimburse product cost at the
lowest of:
(1)
Product cost (FUL, SMAC, or EAC) plus the appropriate dispensing fee($;
(2)
The pharmacy's usual and customary charge to the general public;
(3) The submitted charge; or
(4)
Payment levels for all drugs will not exceed, in the aggregrate, upper levels of
reimbursement established by federal code or regulation.
The FUL or SMAC limitations will not apply in any case where the prescribing physician
certifies that a specific brand is medically necessary. In these cases, the EAC will be
the maximum allowable cost.
4. Pricing Instruction (Drugs)
Under no circumstances, may charge exceed the usual and customary charge to the
general public.
a. Compounded Prescriptions and Legend Drugs
These drugs will be reimbursed at the lesser value of either:
1. Product Cost (FUL, SMAC or EAC) plus the appropriate dispensing fee@), or
2. The usual and customary charge to the general public.
b. Listed over-the-counter drugs
These items will be reimbursed at the lesser value of either:
I. Product Cost (FUL, SMAC or EAC) plus the appropriate dispensing fee@), or
Nebraska - 6
2. The usual and customary shelf mice to the general public.
Section 2500 - Products Requiring Prior Approval
Certain products require that approval be granted prior to their payment.
Physicians wishing to prescribe these products MUST obtain approval from:
The Medical Director (or designee)
Medical Services Division
Nebraska Department of Social Services
301 Centennial Mall South
Fifth Floor
Lincoln, Nebraska 68509
The Department of Social Services will notify the prescribing physician and the pharmacy of the recipient's choice,
whenever these requests are approved.
V. Miscellaneous:
Co-payment - None.
Officials, Consultants and Committees
1. Social Services Department Officials:
Kermit McMurry, Ph.D., Director
Robert Seiffert, Administrator
Ms. Kris Logsdon, Surveillanc.e/Utilization
Review Consultant
Christine Wright, M.D., Medical Director
Daniel W. Snodgrass, R.Ph., Pharmaceut. Consultant
4021471 -9379
Melvin Clothier, Admin. of Medical Programs
4021471 -9301
Max J. Ward, R.Ph., Pharmacist
4021471 -931 9
Department of Social Services
301 Centennial Mall S., 5th FI.
Lincoln, NE 68509
Division of Medical Services
Division of Medical Services
Division of Medical Services
Division of Medical Services
2. Social Services Department Medical Care Advisory Committee:
Warren Bosley, M.D. Tom Ferraro
181 1 West 2nd, Suite 360 Health America of Lincoln
Grand Island, NE 68801 17th & N Streets
Lincoln, NE
Div. of Payment and Data Services
Thomas Kiefer, D.D.S.
2602 J Street
Omaha, NE 68107
\PC - 1989
Nebraska - 7
Ray Schweiger Steve Lorenzen
Keith Mueller, Ph.D.
Assistant Administrator Director, Fed. Prog. Political Science Dept.
Lincoln General Hospital Blue CrosdBlue Shield of NE Univ. of Nebraska
2300 south 16th street Main P. 0. Station, Box 3248 Lincoln, NE 68588-0328
Lincoln, NE 68107 Omaha, NE 681 80
Tom Robinson
Capital Medical
500 North 66th St.
Lincoln, NE 68505
Evelyn Runyon Edmund Schneider, OD.
261 6 North 102nd Avenue Lincoln Vision Clinic
Omaha, NE 68134 810 North 48th Street
Lincoln, NE 68504
Julie Thelen, R.N.
Pat Snyder, Ex. Director Gregg Wright, M.D., Dir.
Director, Home & Comm. Nebraska Health Care Assoc. Department of Health
Health Agency
Suite 7, 3100 0 Street 301 Centennial Mall S, 3rd FI.
Grt. Plains Reg. Med. Ctr. Lincoln, NE 68510 Lincoln, NE 68509
P. 0. Box 11 67 North Plane, NE 691 03-1 167
Notices and memos are sent to: Kermit McMurry, Robert Seiffert, Me1 Clothier, Chris Wright, Nancy Staley, and
John Woody.
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
William Schellpeper
Executive Secretaiy
NE Medical Association
1512 First Tiers Bank Bldg.
Lincoln, NE 68508
40214744472
C. Osteopathic Physicians & Surgeons:
Arthur Weaver, D.O.
Secretary
NE Assn. of Osteopathic Physicians/Surgeons
8552 Cass Street
Omaha. NE 681 14
4021390-0900
B. Pharmaceutical Association:
Thomas R. Dolan, R.Ph.
Executive Director
NE Pharmacists Association
5440 South Street, Ste. 1200
Lincoln, NE 68506
4021488-5002 or 8001742-0029
D. State Board of Pharmacy:
Helen L. Meeks
Director
Bureau of Examining Boards
P.O. Box 95007
Lincoln, NE 68509-5007
4021471 -21 15
NPC - 1989 Nevada - 1
NEVADA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA A6 APTD AFDC OAA AB APTD AFDC Childrenc21
Prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X
Laboratory &
X-ray Sewice X X X X
Skilled Nursing
Home Services X X X X
Physician Sewices X X X X
Dental Sewices X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
1987
Expended Recipient
$4,751.062 21,764
$988
Expended Recipient
$5,045,498 23,195
HHS report HCFA - 2082
NPC - 1989
Nevada - 2
Ill. Administration:
State Welfare Division of the Department of Human Resources.
IV. Provisions Relating to Prescribed Drugs:
A. General: Pharmaceuticals
Covered: The Nevada Medicaid drug program will pay for the following prescribed pharmaceuticals:
1. Most legend pharmaceuticals
2. Insulin
3. Diabetic urine test tablets and test tapes.
4. Prenatal vitaminlmineral supplements, legend or non-legend, intended for prenatal care.
5. Family planning items such as diaphragms, oral contraceptives, foams and jellies.
Excluded:
Exceptions:
Nevada Medicaid will not pay for the following:
Anorectics used for obesity control.
Amphetamine combinations.
Fertility drugs (e.g. Clomid, Metrodin, Pergonal)
Yohimbine (e.g., Yocon)
Radiopaque agents (e.g., Telepaque, Hypaque, Barium Sulfate)
Radiographic adjuncts (e.g., Perchloracap).
Pharmaceuticals designed "ineffective," or "ess than effective' (including identical, related, or
similar drugs) by the FDA.
Pharmaceuticals considered "experimental" as to substance or diagnosis for which prescribed.
Nevada Medicaid will not pay for the following unless prior-authorized by the Medicaid Office on form
NMO-3, Payment Authorization Request (PAR):
Amphetamine (e.g., Dexedrine).
Aspirin (e.g., Zorprin, Easprin)
Amphetamine (e.g., Dexedrine).
Aspirin (e.g., Zorprin, Easprin).
Chorionic Gonadotropin (HCG).
Dipyridamole (e.g. Persantine)
Ergoloid mesylates (e.g., Hydergine).
Ethaverine (e.g., Ethatab).
Fluoride preparations.
Glucose blood test strips.
Growth hormone (Protopin).
Laxative (e.g., Chronulac, Golytely, Clysodrast).
Methylphenidate (e.g., Ritalin).
Nicotine preparation (e.g., Nicorette).
Nicotinic acid in oral or injectible form.
Non-legend pharmaceuticals.
Papaverine (e.g., Pavabid).
Pemoline (e.g., Cylert).
Quinine (e.g., Quinamm).
Transdermal patch systems (e.g., Nitrodisc, Nitro-Dur, Transderm-Nitro, Estraderm, Transderm-
Scop, Catapres-TTS).
Vitamins, vitaminlmineral combinations or hematinics.
NPC - 1989 Nevada - 3
23. Appliances, sundries and supplies.
24. Nutritional supplements or replacements.
25. Intravenous therapy.
26. Those vaccines not readily available free of charge
Formulary: None. (Certain Rx categories are excluded from reimbursement. See Section A above.)
Prescribing or Dispensing Limitations:
1. Prescriptions. Eligible Medicaid recipients may receive five out-patient prescriptions per month
plus those issued for EITHER prenatal OR family planning purposes. For special authorization
procedures, see 1203.3.
2. Refills. A refill is a prescription subject to the limitations in paragraph A above.
Prescription Charge Formula:
1. Reimbursement: Legend Drugs
Reimbursement for legend pharmaceuticals is the lowest of (1) specific upper limit (SUL) plus the
professional fee, (2) estimated acquisition cost (EAC) plus the professional fee, or (3) that pharmacy's
usual charge to the general public. The professional fee is currently $3.95 per prescription. (EAC
is defined as AWP minus 10%).
Fiscal intermediary: Blue Shield of Nevada
P.O. Box 10330
1. Human Resources Department Officials:
Jerry Griepentrog, Director
Reno, NV 89510
Officials, Consultants and Committees
Department of Human Resources
State Capital Complex
505 East King St. Room 600
Carson City, NV 8971 0
Linda Ryan, Administrator
State Welfare Division
NPC - 1989
Bill Engel, Chief
Medical Services
Jaime Wheeler, M.D., Medical Consultant
Nevada Medicaid Office
Steven P. Bradford, Pharm.D., Pharmaceutical Consultant
Nevada Medicaid Office
2. Advisory Committees of the Welfare Division:
Medical Care Advisory Group:
George Harvey, R.Ph.
Executive Comm.
Zeny Ocean, D.D.S., Chair.
Dental Comm.
Michael Fischer, M.D., Chair.
Physician C O ! ~ .
Drug Utilization Review:
. .
James Lamb, Chair. Jane Hirsch, Chair.
.:..
Hospital Comm. Long Term Care Comrn.
Sue Coons, Chair. George Harvey, R.Ph., Chair.
Consumer Recip. Comm. Pharmacy Comm.
Steven P. Bradford, PharmD
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
Larry Matheis
Executive Director
NV State Medical Assn
3660 Baker Lane
Reno, NV 89509
7021825-6788
C. Osteopathic Association:
Jeffrey E. Brookman, D.O.
Secretary-Treasurer
NV Osteopathic Medical Assn
2300 South Rancho Rd.
Las Vegas, NV 891 02
7021384-0414
B. Pharmaceutical Association:
Karen Peska
Executive Director
NV Pharmaceutical Assn,
3660 Baker Lane
Reno, NV 89509-5413
7021826-3981
D. State Board of Pharmacy:
Keith W. MacDonald, R.Ph.
Executive Secretary
1201 Terminal Way
Suite 21 2
Reno, NV 89502
7021322-0691
New Hampshire - 1
NEW HAMPSHIRE
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
~ y p e of Benefit Categorically Needy Medically Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC Childrenc21
prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X X
Laboratory &
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X X
physician Services X X X X X X X X X X
Dental Services X X X X X X X X X X
SF0 - State Funds Only
11. EXPENDITURES FOR DRUGS.
CATEGORICALLY NEEDY CASH TOTAL
Children -Families wIDep. Children
Adults -Families w1Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Children -Families wIDep. Children
Adults -Families wIDep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Children -Families wiDep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
HHS report HCFA - 2082
1987
Expended Recipient
$7,296,693 25,497
2,570,007 13,879
534,057 1,235
41,377 126
1,389,370 3,031
192,944 4,173
412,257 5,314
3,277,669 8,427
2,401,810 3,752
41,822 80
564,808 958
72,414 946
196,813 2,691
0 0
1,449,016 3,191
1,067,111 1,913
12,149 24
31 5,568 548
7,660 156
45,700 537
825 13
1988
Expended Recipient
$8,242,701 25,438
2,667,934 13,525
570,335 1,207
50,436 141
1,456,812 2,778
186,243 3,998
403,953 5,400
3,711,459 7,119
2,831,209 3,827
48,730 85
656,056 991
59,970 750
1 15,340 1,465
0 0
1,863,460 4,795
1,351,754 2,168
14,800 24
352,585 608
22,193 429
121,768 1,555
358 11
NPC - 1989
New Hampshire - 2
Ill. Administration:
Office of Medical Services, Department of Health and Human Services
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Anorexiant (stimulants) except for treatment of narcolepsy and hyperkinetic
children.
B. Formulary: None.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Prescriptions limited to 100 day supply.
2. Dollar Limits: None.
D. Prescription Charge Formula:
$2.85/$3.00 fee plus Estimated Acquisition Cost (EAC) or HCFA upper limit or Usual and Customary
Charge, whichever is less.
Maintenance medications are reimbursed by the above formula once every thirty days per recipient
per provider: any refills of maintenance medications within 30 days are reimbursed at cost only.
Co-payment: $0.50 generic, $1.00 brand name multisource, except nursing home patients, under
18 years, family planning and pregnancy prescriptions.
Officials, Consultants and Cornmiltees
1. Dept of Healh and Human Services Officials:
Mary Mongan, Commissioner
Philip Soule, Administrator
Roben W. Moore
Contract Administration
Edward J. Pierce, P.D., Pharmaceutical
Services Specialist
Department of Health and Human Services
Health and Human Services Building
6 Hazen Drive
Concord. NH 03301
6031271 -4353
Office of Medical Services
Division of Human Services
Office of Medical Services
Division of Human Services
Office of Medical Services
Division of Human Services
NPC - 1989 New Hampshire - 3
2. Medical Care Advisory Committee:
This committee consists of 30 members representing providers and consumers of health care, as well as the
various agencies interested in health care in the State.
3. Executive Officers of State Medical and Pharmaceutical Services:
A. Medical Society: B. Pharmaceutical Association:
Palmer P. Jones
Executive Vice President
NH Medical Society
4 Park Street
Concord, NH 03301 -6389
6031224-1 909
C. Osteopathic Association:
Edythe L. Craig, D.O.
Secretary-Treasurer
NH Osteopathic Assnociation
P.O. Box 421
Bradford, NH 03221
938-21 10
Maurice E. Goulet, P.D., M.S.
Executive Director
NH Pharmaceutical Association
44 S. Main Street
Pennacook, NU 03303
6031753-8759
D. State Board of Pharmacy:
Paul G. Boisseau
Secretary
Health & Human Service Building
6 Hazen Drive
Concord, NH 03301
6031271 -2350
NPC - 1989
NEW JERSEY
MEDICAL ASSISTANCE DRUG PROGRAM WTLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
New Jersey - 1
Type of Benefit Categorically Needy Medically Needy (MN) Other.
OAA AB APTD AFDC OAA AB APTD AFDC Childrene21
Prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
outpatient
Hospital Care
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
HHS report HCFA - 2082
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Famiiies w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
1987
Expended Recipient
893,872,997 446,071
1988
'Expended Recipient
$1 05,052,185 436,269
80,676,210 350,855
14,375,620 26,682
4441 33 91 5
36,942,110 60,954
13,429,223 172,093
15,485,124 90,201
22,406,225 72,237
14,860,110 29,037
32,726 76
4,402,941 6,668
1,432,808 20,566
1,092,998 9,408
638,642 6,482
231,712 2,649
4,904 11
0 0
18,392 45
205,463 2,547
2,953 46
0 0
Nursing home pharmaceuticals data not included in 2082 form. Unit dose fee plus consultation fee = $4,318,405.
Nursing home capitation = $5,416,306.
NPC - 1989 New Jersey - 2
Ill. Administration:
Division of Medical Assistance and Health Services, Department of Health Services,
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Experimental drugs, anti-obesics and anorexiants.
B. Formulafy: None.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: The quantity of medication prescribed should provide a sufficient
amount of medication necessary for the duration of the illness or an amount sufficient to cover
the interval between visits, but may not exceed a 60-day supply or 100 unit doses whichever
is greater.
Exceptions:
a. Oral contraceptives may be prescribed for up to a 3-month supply.
b. Vitamins and vitamin-mineral combinations may be dispensedfor up to a IOO-day supply.
2. Refills: Prescription refills will be limited to 5 times within a 6-month period if so indicated by
the prescriber on the original prescription.
Exceptions:
a. Oral contraceptives originally prescribed for a 3-month supply may be refilled 3 times
within one year.
b. Vitamins and vitamin-mineral combinations originally prescribed for 100 day supply may
be refilled 2 times within one year.
3. Dollar Limitations: None,
D. Prescription Charge Formula:
1. Payment for legend drugs, contraceptive diaphragms and reimbursable devices shall be based
upon 'Maximum Allowable Cost," or Average Wholesale Price minus 0 - 6%.
a. Maximum Allowable Cost is defined as:
(1)
The "Maximum Allowable CostYMAC) price published periodically by the Health
Care Finance Administration (HCFA) of the Federal Department of Health and
Human Services for listed multi-source drugs or established by the Division of
Medical Assistance and Health Services; or
New Jersey - 3
(2)
Subject to the limits of Section (b) below. The Estimated Acquisition Cost (EAC)
herein defined as lower of the Average Wholesale Price (AWP) listed for the most
frequently purchased package size (as defined by the Division of Medical
Assistance and Health Services) in current national price compendia or other
appropriate sources, and their supplements; price changes listed in the national
price compendia; or designated prices defined in Section 10:51-1.6. In the case
of unlisted or undesignated AWP "costs" or of typographical errors, the known
correct price will be used as maximum.
b. If the published MAC price as defined in (a)l. above is higher than the price which
would be paid under (a)2. above, then (a)l. above will apply.
2. Maximum cost for each eligible prescription claim not covered by section (a)l, above shall be
subject to the following fiscal conditions based upon six categories, as determined by the N.J.
Medicaid program based on the previous year's total prescription volume for each participating
pharmacy. The categories shall be reviewed annually and adjusted as appropriate.
a. To determine a provider's total prescription volume, which shall include all prescriptions
filled, both new and refills, for private patients, Medicaid, PAA, and other third party
recipients for the previous calendar year, each pharmacy provider shall submit in writing,
an annual report certifying its prescription volume. Failure to submit this report annually
will result in the provider being placed in the maximum discount category (category VI)
for the year of non-compliance, or until the required report is received.
Note: Those pharmacy providers who have been in business for less than one calendar
year will have their prescription volume projected for the entire year, to determine the
appropriate category.
b. Category I: Pharmacies whose total prescription volume in the preceding calendar year
was not more than 14,999 prescriptions.
(1)
Pharmacy providers in this categoty shall receive reimbursement for Medicaid
prescription claims for legend drugs at average wholesale price (AWP), as defined
in section 10:51-1.16a., as the maximum.
c. Category II: Pharmacies whose total prescription volume in the preceding calendar year
was at least 15,000 but not greater than 19,999 prescriptions.
(1)
Pharmacy providers in this category shall receive reimbursement for Medicaid
prescription claims for legend drugs at average wholesale price (AWP), as defined
in section 10:51-1 .I 6a, less two per cent, as the maximum.
d. Category Ill: Pharmacies whose total prescription volume in the preceding calendar year
was at least 20,000 but not greater than 29,999 prescriptions.
NPC - 1989
New Jersey - 4
(1)
Pharmacy providers in this category shall receive reimbursement for Medicaid
prescription claims for legend drugs at the average wholesale price (AWP), as
defined in section 10:51-1.16a, less three per cent, as the maximum.
e. Category IV: Pharmacies whose total prescription volume in the previous calendar year
was at least 30,000 but not greater than 39,999 prescriptions.
(1)
Pharmacy providers in this category shall receive reimbursement for Medicaid
prescription claims for legend drugs at average wholesale price (AWP), as defined
in section 10:51-1 . I 6a, less four per cent, as the maximum.
f. Category V: Pharmacies whose total prescription volume in the preceding calendar year
was at least 40,000 but not greater than 49,999 prescriptions.
(1)
Pharmacy providers in this category shall receive reimbursement for Medicaid
prescription claims for legend drugs at average wholesale price (AWP), as defined
in section 10:51-1.16a, less five per cent, as the maximum.
g.
Category VI: Pharmacies whose total prescription volume in the preceding calendar year
was 50,000 prescriptions or more.
(1)
Pharmacy providers in this category shall receive reimbursement for Medicaid
prescription claims for legend drugs at average wholesale price (AWP), as defined
in section 10:51-1.16a, less six per cent, as the maximum.
Notes:(l) If the published MAC price as defined in section 10:51-1.16(a)li is higher than
the price which would be paid under section 10:51-l.l6(a)lii, then section 10:51-
1.1 6(a)l ii, will apply.
(2)
The appropriate calculated discount will be automatically deducted (by Blue Cross
of New Jersey) from each eligible legend drug claim during the claim processing
procedures.
(3)
For prescription drugs costing more than $24.99 there will be no discount from
the average wholesale price (AWP).
Dispensing Fee
The dispensing and services fee ranges from $3.73 to a maximum of $4.07 depending upon the number
and types of services agreed to by the provider.
Service Fee
1. 24 hour emergency service availability
2. Patient Consultation
3. Impact Allowance
Increment
$0.11
$0.08
$0.15
NPC - 1989
New Jersey - 5
1
In completing the Pharmacy Provider Service Agreement the provider agrees to provide all services at no
additional charge to the Medicaid or PAA recipient. Under no circumstances are any additional
administrative charges allowed.
The Pharmacy Manual further states the following: The maximum charge to the New Jersey Health Services
Program for a legend drug may not exceed the lowest of the following:
a. Cost plus dispensing fee as outlined herein.
b. Usual and customary charges and/or posted or advertised charges.
c. Other third party prescription plan charges, when contracts or agreements to participate have been
entered into subsequent to the adoption of this regulation.
V. Miscellaneous Remarks:
Fiscal Intermediary: Blue Cross of New Jersey
33 Washington Street
Newark, NJ 07101
Co-payment: None
The Garden State Health Plan is as follows:
The New Jersey Medicaid program has implemented a State certified managed health care plan called the
Garden State Health Plan (GSHP). The Plan is a prepaid, primary care network model health plan whereby
all of the Medicaid eligible's health care is managed by a primary care physician.
The Garden State Health Plan is offered to Medicaid eligibles on a voluntary basis as an alternative to the
existing New Jersey Medicaid fee-for-service program. Physician case management is the key component
of the Plan whereby participating Medicaid physicians contract with the Plan to provide primary care and
to case manage all other health and medical services to Medicaid eligibles who enroll in the Plan.
The key goals of the Plan are:
1. To enhance the level of wellness of Medicaid eligibles;
2. To provide continuity of care and physician case management in the provision of total health care to
Medicaid eligibles;
3. To avoid inappropriate care and unnecessary utilization of health care services in inappropriate settings.
Medicaid approved physicians are offered the opportunity to participate in the Garden State Health Plan
and assume the role of physician case manager (PCM). The PCM is available to members on a 24 hour,
seven day a week basis, either directly or through coverage arrangements.
The Garden State Health Plan is currently implemented in 10 counties (Atlantic, Burlington, Camden, Essex,
Mercer, Middlesex, Morris, Passaic, Sussex, and Union Counties) and will eventually be phased-in
throughout the State.
NPC - 1989
Officials, Consultants and Committees
New Jersey - 6
I. Department of Human Resources Officials:
Drew Altman, Commissioner
Thomas M. Russo. Director
I. F. Erlichman, M.D., Medical Director
Sanford Luger, R.Ph., Chief
Pharmaceutical Sewices
2. Medical Assistance Advisory Council: (under revision)
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: B.
Vincent A. Maressa
Executive Director
Medical Society of NJ
2 Princess Road
Lawrenceville, NJ 08648
6091896-1 766
C. Osteopathic Physicianslsurgeons Association: D.
Eleanore Farley
Executive Director
NJ Assn. of Osteo. PhysiciansISurgeons
1212 Stuyvesant Avenue
Trenton, NJ 08618
6091393-81 14
Department of Human Sewices
Capitol Place 1
Trenton, NJ 08625
Div. of Med. Assist./Health Sew
CN712
7 Quakerbridge Plaza
Trenton, NJ 08625
Pharmaceutical Association:
Alvin N. Geser
Executive Officer
NJ Pharmaceutical Association
120 W. State Street
Trenton, NJ 08608-1 102
6091394-5596
State Board of Pharmacy:
H. Lee Gladstein, R.Ph.
Executive Director
11 00 Raymond Boulevard
Newark, NJ 07102
201 1648-2433
NPC - 1989
--
New Mexico - I
NEW MEXICO
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Chi l drew21
Prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X
Laboratoly &
X-ray Service X X X X
Skilled Nursing
Home Sewices X X X X
Physician Services X X X X
Dental Services X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families wIDep. Children
Other Ti l e XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
I987
Expended Recipient
$1 4,689,445 71,045
$12,508,125 64,337
2,295,036 6,834
1 19,843 357
6,498,967 14,709
1,333,066 26,712
2,261,213 15,725
$2,181,320 6,708
1,578,747 3,206
1,404 8
333,883 552
62,045 1,207
53,740 876
151,501 859
$0 0
0 0
0 0
0 0
0 0
0 0
0 0
1988
Expended Recipient
$1 8.01 5,021 77.265
15,104,123 67,100
2,714,437 6,942
147,306 360
7,950,964 15,427
1,617,847 27,922
2,673,569 16,449
2,882,390 9,283
2,139,147 3,772
2,516 8
470,511 764
146,735 2,880
78,390 1,117
45,091 742
0 0
0 0
0 0
0 0
0 0
0 0
0 0
HHS report HCFA - 2082
NPC - 1989
New Mexico - 2
Ill. Administration:
Human Services Department (HSD)
IV. Provisions Relating to Prescribing Drugs:
A. General Exclusions:
Drugs for treatment of tuberculosis, experimental and cosmetic drugs are not included.
Medications supplied by the New Mexico State Hospital to clients on convalescent leave from
hospital are not included.
Drugs and immunizations available from any other source are not included,
Legend multiple vitamins, tonic preparations and combinations thereof with minerals, hormones,
stimulants or other compounds which are available as separate entities for treatment of specific
conditions.
Hematinics except non-sustained release forms of Ferrous Sulfate, Ferrous Gluconate, Ferrous
Fumarate.
Amphetamines and combinations of amphetamines with other therapeutic agents;
amphetamine-like sympathomimetic compounds used for obesity control including any
combination of such compounds with other therapeutic agents.
Drugs classified by FDA as "Ineffective" or "Possibly Effective",
Hypnotic drugs.
OTC items with the following exceptions (the exceptions are covered by the program):
a. Insulin.
b. Antacids for active gastric and duodenal ulcers.
c.
Infant vitamin drops for children up to one year of age.
d. Salicylates and acetaminophen.
e. Non-sustained release forms of Ferrous Sulfate, Ferrous Gluconate, Ferrous Fumarate.
B. Formulary: Open formulary subject to above-stated limitations. For formulary information contact:
Robert Stevens
Medical Assistance Division
P.O. Box 2348
Santa Fe, NM 87504-2348
5051827-431 5
NPC - 1989
w
New Mexico - 3
C. Prescribing or Dispensing Limitations:
I. Quantity of Medication: 6 months supply maximum.
2. Refills: Payment will be made to a particular pharmacy only three times for the same drug for
the same client in any 90-day period.
D. Prescription Charge Formula:
I.
Prescriptions reimbursed at the lesser of the following:
a. Cost (MAC or EAC) dispensed plus fee ($3.65) or,
b. The usual and customary charge by the pharmacy to the general public,
EAC = AWP minus 10.5%.
V. Miscellaneous Remarks:
Fiscal Intermediary: EDS Federal Corporation
5801 Osuna N.E.
Albuquerque, NM 87109
Officials, Consultants and Committees
I. Human Services Department:
Alex Valdez, Secretary
Dennis Boyd, Dep. Secretary
Human Services Department
P.O. Box 2348
Santa Fe, NM 87504-2348
5051827431 5
Larry Martinez, Bureau Chief Program Support Division
Bruce Weydemeyer, Bureau Chief Medical Services Division
Robert Stevens, R.Ph., Drug Prog. Admin. Medical Assistance Division
2. Medical Advisory Committee Members:
Neal Johnson
Clinical Pharmacy
5121 Gibson Blvd. SE
Albuquerque, NM 87108
5051262-1 425
Chris Garcia Michael Kaufman, M. D.
Legal Aid Society of Albuq. P. 0. Box 5775
1020 Tijeras, NE Taos, NM 87571
Albuquerque, NM 87106 5051758-2224
5051243-7871
Bert Umland, M.D. John Foley, Executive Director Alicia Craft
Division of Family Practice NMARC Indigent Hospital Claims Admin.
UNM Medical Center 8210 La Mirada N E P.O. Box 1119
Albuquerque, NM 87131 Suite 500 Los Lunas, NM 87031
5051277-21 65
Albuquerque, NM 871 09
NPC - 1989 New Mexico - 4
Kathleen Brook, Ph.D.
4236 Winchester
Las Cruces, NM 88001
5051646-4905
Howard Shaver, Pres.
NM Hospital Association
P. 0. Box 36090
Albuquerque, NM 87176
5051889-3393
John S. Johnson, Ed.D.
AARP
P. 0. Box 457
Las Vegas, NM 87701
5051425-71 16
NM Primary Care Assn.
2340 Alamo, SE, Suite 304
Albuquerque, NM 871 06
5051242-0281
Herk Maldonado
DirJHealth Affairs Karen Wells, R.N., Ex. Dir.
NM Blue CrosslBlue Shield NM Assn. for Home Care
12800 Indian School Road, NE Route 9, Box 90M
Albuquerque, NM 871 12 Santa Fe, NM 87505
5051291 3526 5051988-1186
3. NMPHA Committee Third Party Payments:
Liaison Comminee for NM Pharmaceutical Association meets each month.
Robert Ghanas, R.Ph. Neil Johnson, R.Ph.
Durans Pharmacy Clinical Pharmacy
1815 Central, N.W. 5002 Gibson, S.E.
Albuquerque, NM 871 04 Albuquerque, NM 87108
Dale Tinker, Executive Director, NMPHA
4800 Zuni, S.E.
Albuquerque, NM 87108
4. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society:
Glenn R. Marshall, Executive Director
NM Medical Society
303 San Mateo Blvd., NE
Albuquerque, NM 871 08
5051266-7868
C. Osteopathic Medical Association:
Thomas P. Thompson, Executive Director
NM Osteopathic Medical Association
P. 0. Box 3096
Albuquerque, NM 871 10
5051884-0201
E. E. Vex" Rinerbush
Sandia Lab. Org 0133
P. 0. Box 5800
Albuquerque, NM 87105
5051844-9420
Linda Sechovec, Ex. Dir.
NM Health Care Assn.
1024 Eubank, NE, Suite D
Albuquerque, NM 871 12
5051296-0021
Carla Muth, R.N., Secretary
NM Health & Environment Dept.
Harold Runnels Bldg., 4th FI.
P. 0. Box 968
Santa Fe, NM 87504-0968
5051827-2613
Victor Castillo, R.Ph.
Victor's Pharmacy
1643 lsleta, S.W.
Albuquerque, NM 87105
Pharmaceutical Association:
Dale Tinker, Executive Director
NM Pharmaceutical Association
48000 Zuni, S.E.
Albuquerque, NM 871 08-2830
5051265-8720
State Board of Pharmacy:
James T. Daily
Acting Executive Director
4125 Carlisle N.E.
Albuquerque, NM 871 07
5051841 -631 1
NPC - 1989
q-
New York - 1
NEW YORK
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
outpatient
Hospital Care
Laboratory &
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X X
Physician Services X X X X X X X X X X
Dental Services X X X X X X X X X X
'SF0 - State Funds Only
11. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families wIDep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
1987
Expended ReCi~ient
1988
Expended Recipient
$394,893,872 1,529,889
HHS report HCFA - 2082
NPC - 1989 New York - 2
Ill. Administration:
State Department of Social Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: No restrictions except: (See V. Miscellaneous Remarks)
1. Prescribed vitamins and minerals not prescribed for medical necessity.
2. Amphetamines and other drugs whose sole clinical use is for reduction of weight.
3. Limited coverage of non-prescription drugs.
8. Formulary: Coverage of prescription drugs is limited to list of Medicaid reimbursable Prescription
drugs. For information contact:
Medicaid Reimbursement Drug Lists
Bureau of Standards Development
New York State Department of Health
Room 2074, Corning Tower
Albany, NY 12237
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Drugs and sickroom supplies shall be prescribed in sufficient quantity
consistent with the health needs of the patient and sound medical practice.
2. Refills: Refills cannot exceed 5, and the life of a prescription cannot exceed 6 months.
3. Dollar Limits: None.
D. Prescription Charge Formula:
1. Maximum Reimbursable Pricing Schedule is as follows:
a. Payment for multiple source drugs must not exceed the aggregate of the specified upper
limit set by the federal Health Care Financing Administration (HCFA), plus a dispensing
fee, for a particular drug; and
b. Payment for brand name drugs and other multiple source drugs not covered by clause
(a) will be the lower of: the estimated acquisition cost plus a dispensing fee; or
c. The provider's usual and customary price charged to the general public.
2. Dispensing Fee, $2.60
V. Miscellaneous Remarks:
The Medicaid drug list applies only to prescription and/or fiscal orders filled in community pharmacies.
\PC - 1989
New York - 3
Based on mandated payment criteria for prescription drugs, many non essential and high priced drug
products are excluded, e.g., those not essential to sustain life, relieve or prevent severe pain, or prevent
disease or continuing disability: sustained release medications; anti flatulence products; cough enzymes;
muscle relaxants; vitamins and vitaminlminerai preparations; and dermatologicals. Many combination drugs
and comfort products are also excluded.
Fiscal Intermediary:
Co-payment: None
Officials, Consultants and Committees
1. Social Services Department Officials:
Cesar A. Perales, Commissioner
51 81474-9130
Jo-Ann Constantino, Deputy Commissioner
Mary Alice Brankman, Director
51 81474-921 9
Michael A. Falzano, Medicaid Review Analyst IV (SUR)
2. Social Services Advisory Committees:
A. Medical Advisory Committee:
Ebun Adelona, R.N., Ph.D.
P. 0. BOX 1405, 92
Morningside #34
New York, NY 10027
Ruben P. Cowart, D.D.S.
Executive Director
Syracuse Community Health Center
819 South Saiina Street
Syracuse, NY 13202
Mary Lou Penengill
84 Westover Drive
Webster, NY 14580
David Axelrod, M.D.
Commissioner
NYS Dept. of Health
Empire State PI., Corning Tower
Albany, NY 12237
John L. S. Holloman
27-40 Ericsson Street
East Elmhurst, NY 11369
Hugh M. Morales, M.D., PC
Medical Director
Bronx Mental Health Center
Psychiatry & Neurology
121 1 Gerard Avenue
Bronx. NY 10452
Computer Sciences Corp. (CSG)
800 North Pearl Street
Albany, NY 12204
Dept. of Social Services
40 North Pearl Street
Albany, NY 12243
Division of Medical Assistance
Dept. of Social Services
40 North Pearl Street
Albany, NY 12243
Bur. of Ambulatory Services
Inpatient Care & Contracts
Ebie Brown
C/O Barss
53 Van Dorn Street
Saratoga Spring, NY 12866-1216
Beatrice Kresky, M.D., MPH, Chair.
Dept. of Ambulatory Care
Jamaica Hospital
Jamaica, NY 11418
Mrs. Gleniss Schonholz
Senior Vice President
Long Island Jewish Medical Ctr.
New Hyde Park, NY 11042
NPC - 1989
New York - 4
William O'Dwyer, M.D.
14 Loudon Parkway
Loudonville, NY 1221 1
Elena Padilla, Ph.D.
3 Washington Sq. Village
Apt. 15-0
New York, NY 10012
3. Pharmacy Advisory Committee 1988:
John P. Navarra (Chairman)
Town Drugs
1090 Amsterdam Avenue
New York, NY 10025
Mahmud AIam
Hina Drug Corp.
434 Rockaway Avenue
Brooklyn, NY 11212
James Marinos
2768 East 66th St.
Brooklyn, NY 11234
4. Public Health Department:
David Axelrod, M.D., Commissioner
51 81474-201 1
Hildamar Ortiz
1248 St. Nichols Avenue
New York, NY 10032
Robert H. Randles, M.D.
Medical Director
St. Peter's Hospital
315 S. Manning Blvd.
Albany, NY 12208
John Westerman, Jr.
Ace Drug Co.
22 Continental Drive
New Windsor, NY 12550
Kandyce J. Daley
Fays Drug Co., Inc.
7245 Henry Clay Blvd
Liverpool, NY 13088
Vincent Conte
Moby Drugs
226 Main Street
Farmingdale, NY 11 725
5. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society:
Donald F.Foy
Executive Vice President
Medical Society of the State of NY
420 Lakeville Road
Lake Success, NY 1 1042
51 61488-61 00
C. Osteopathic Society:
E. Wayne 'Harbinger, D.O.
Executive Director
NY State Osteopathic Medical Society, Inc.
87 South Lake Avenue
Albany, NY 12203
51 81663-8812
Walter Singer, Ph.D.
5 Barry Court
Loudonville, NY 1221 1
Thomas F. Golden, Jr.
Golden Drugs, Inc.
Park Plaza
Mechanicville, NY 121 18
Stephen L. Giroux
Middleport Family Health Center
81 Rochester Road, Box 188
Middleport, NY 14105
Neil Goldman
33-39 80th Street
Jackson Heights, NY 11 372
Department of Health
Corning Tower Building
Empire State Plaza
Albany, NY 12237
Pharmaceutical Association:
Elizabeth Lasky, Executive Director
Pharm. Society, State of NY
Pine West Plaza IV
Washington Avenue Extension
Albany, NY 12205
51 81869-6595
State Board of Pharmacy:
Lawrence H. Mokhiber
Executive Secretary
Cultural Education Center
Room 3035
Albany, NY 12230
51 81474-3848
NPC - 1989
NORTH CAROLINA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
1
North Carolina - 1
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Childrenc21
Prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X
Laboratory &
X-ray Sewice X X X X
Skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services X X X X
S F 0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
Ex~ended Recipient
TOTAL $65.51 1.242
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w1Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w1Dep. Children
Other Ti l e XIX Recipients
MEDICALLY NEEDY TOTAL $1 9,467,206
Aged 14,040,626
Blind 105,343
Disabled 3,971,547
Children -Families w/Dep. Children 41 7,538
Adults -Families w1Dep. Children 865,602
Other Ti l e XIX Recipients 66,550
SOBRA Expansion Coverage to Pregnant Women and Children below
100% Poverty (Optional Categorically Needy) effective 10187
Children
Pregnant Women
19871 988
Ex~ended Recipient
HHS report HCFA - 2082
NPC - 1989
North Carolina - 2
Ill. Administration:
Division of Medical Assistance, Department of Human Resources.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: No payment made for non-legend drugs, except insulin. Payment made for all
legend drugs. Non-legend vitamins are excluded.
B. Formulary: None.
C. Prescribing or Dispensing Limitations:
I. Quantity of Medication: None.
2. Number of Prescriptions:
a. Six per month per recipient
b. Prescription Limit Exemptions for Certain Recipients
The General Assembly has determined that exemptions to the six (6) prescription limit
per month may be authorized by the Department of Human Resources "where the life
of the patient would be threatened without additional care." Therefore, patients being
treated for the following illnesses should be excluded from the prescription limitation:
(1) End State Renal Diseases
(2)
Chemotherapy and Radiation Therapy for Malignancy
(3) Acute Sickle Cell Disease
(4) Hemophilia
(5) End State Lung Diseases
(6) Unstable Diabetes
(7)
Terminal Stage - any illness - life-threatening
3. Dollar Limits: None.
4. Generic Substitution: Pharmacists must substitute generically if they have a generically
equivalent product available in stock. The substituted product must be a lower cost product
than the one originally prescribed.
5. Lock-In: Each recipient is locked into one pharmacy of his choice for one month, except in
emergencies.
D. Prescription Charge Formula: The lowest price of MAC or AWP, plus $4.04 dispensing fee for each
different drug dispensed during a month, or AWP, plus lowest dispensing fee accepted from other
third party payers. The pharmacist filling the original prescription be reimbursed for refills
for the same drug within a calendar month. $0.50 co-payment/Rx (includes refills).
NPC - 1989
North Carolina . 3 a
V. Miscellaneous:
Fiscal Agent:
EDS Federal
P.O. Box 300001
Raleigh, NC 27622
Officials, Consultants and Committees
1.
Department of Human Resources Officials:
David T. Flaherty, Secretary
Barbara D. Matula, Director
Paul R. Perruui, Deputy Director
Ray J. DiNapoli, Medical Director
C. Benny Ridout, R.Ph., Pharmacist Consultant
Lillian J. Todd, R.N., Nurse Consultant
Betty King-Sutton, D.M.D., Dental Consultant
2. Department of Human Resources Advisory Comminees:
A. Pharmaceutical Association, Third Party Committee:
William H. Mast, Chair.
950 Meadow Lane
Henderson, NC 27536
David Hix
11 9 E. Main St.
Gibsonville, NC 27249
Jerry Kennedy
21 33 Canterbury Drive
Burlington, NC 27215
Samuel B. Peneway
1504 Tree Top Lane
Roc@ Mount, NC 27804
Susan Chiny Pitts
P. 0 . Box 1224
Glen Alpine, NC 28628
Depanment of Human Resources
Albermarle Building
325 N. Salisbury Street
Raleigh, NC 27611
Division of Medical Assistance
1985 Umstead Drive
Raleigh, NC 27603
Jerry D. Rhoades
Box 2
Southern Pines, NC 28387
A. G. Hartzema
James R. Hall
CB #7360, Beard Hall
C/O VIP Computer Systems
UNC School of Pharmacy P. 0. Box 3457
Chapel Hill, NC 27599-7360 Chapel Hill, NC 27599
Gary Bowman
1512 Peace Street
Henderson, NC 27536
Chris Dixon
27 O'Hara Drive
New Bern, NC 28560
C. B. (Benny) Rideout
Sox 88
Morrisville, NC 27560
Joe Minton
Colonial Pharmacy, Inc.
704 E. Main Street
Mwfreeshoro, NC 27855
North Carolina - 4
Catherine C. Simmons
Route 2, Box 282
Siler Ci i , NC 27344
Julian Upchurch, Advisor
5201 Pine Way
Durham, NC 27712
Mike J. Stegall Ed Vaughn
Glenwood Village Pharmacy Vaughn Independent Pharmacy
2921 Essex Circle 503 W. Main Street
Raleigh, NC 27608 Carrboro, NC 2751 0
B. Medical Society, Department of Human Resources Liaison Committee
John L. McCain, M.D.
Chairman
Wilson Clinic
Wilson, NC 27893
Hervy B. Kornegay, Sr., M.D.
238 Smith Chapel Road
Mt. Olive, NC 28365
Angus M. McBryde, Jr., M.D.
120 Providence Road
Charlotte, NC 28207
Charles R. Vernon, M.D.
7230 Wrightsville Avenue
Wilmington, NC 28403
M. Robert Cooper, M.D.
300 S. Hawthorne Road
WinstonSalem, NC 271 03
Thad B. Wester, M.D.
1001-101 Brighthurst Drive
Raleigh, NC 27605
George Johnson, Jr., M.D.
Vice-chairman
CB #7050 UNC Dept of Surgery
Chapel Hill, NC 27599
Consultants:
James D. Bernstein
Dept. of Human Resources
Health Resources Devl. Sect.
701 Barbour Drive
Raleigh, NC 27603
Donald T. Lucey, M.D.
2800 Blue Ridge Blvd.
St. 403
Raleigh, NC 27607
Jessica S. Saxe, M.D.
2216 Dilworth Dr, W.
Charlotte, NC 28203
Phillip E. Stover, M.D.
519 N. Bickett Blvd.
Louisburg, NC 27549
Thomas E. Castelloe, M.D
P. 0. Box 10707
Raleigh, NC 27605
W. Samuel Yancy, M.D.
306 S. Gregson Street
Durham, NC 27701
Hector H. Henry, II, M.D.
102 Lake Concord Road, N.E.
Concord, NC 28025
Campbell W. McMillan, M.D.
UNC, Dept. of Pediatrics
CB #7220
Chapel Hill, NC 27599
Jesse Goodman
Dept. of Human Resources
Governmental Liaison Sew.
325 N. Salisbury Street
Raleigh, NC 2761 I
John W. Watson
13 Forest Avenue
Tabor City, NC 28463
Robert G. Brame, M.D.
ECU School of Medicine
Dept. of OB/GYN
Greenville, NC 27834
Charles K. Scott, M.D.
530 W. Webb Avenue
Burlington, NC 27215
Charles R. Martin, M.D.
120 Memorial Drive
Jacksonville, NC 28540
Eugene H. Wade, M.D.
723 Edith Street
Burlington, NC 27215
Raphael J. Dinapoli, Jr. M.D.
1985 Umstead Drive
Raleigh, NC 27603
James S. Parsons, M.D.
704 W. Jones Street
Raleigh, NC 27603
Joseph A. Moylan, M.D.
Duke Medical Center
Box 3947
Durham, NC 27110
Barbara D. Matula
Division of Medical Assistance
1985 Umstead Drive
Raleigh, NC 27603
NPC - 1989
Mrs. John C. Faris (Aux.)
2720 Bitting Road
Winston-Salem, NC 271 04
Elizabeth P. Joyner
P. 0. Box 1390
New Bern, NC 28560
Lillian J. Todd, R.N.
Division of Medical Assistance
1985 Umstead Drive
Raleigh, NC 27603
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: B.
George E. Moore
Executive Director
NC Medical Society
222 North Person St., P.O. Box 27167
Raleigh, NC 2761 1-71 67
91 91833-3836
C. Osteopathic Association:
Guy T. Funk, D.O.
Secretary Treasurer
NC Osteopathic Society, Inc.
Box 667 Bermuda Road
Advance, NC 27006
zm
North Carolina - 5
Pam Silberman
P. 0. Box 27343
Raleigh, NC 27611
Pharmaceutical Association:
A.H. Mebane, Ill
Executive Director
NC Pharmaceutical Assn.
Box 151
Chapel Hill, NC 27514-0151
91 91967-2237
State Board of Pharmacy:
David R. Work
Executive Director
P.O. Box H
Carrboro, NC 2751 0-0747
91 91942-4454
NPC - 1989 North Dakota - 1
NORTH DAKOTA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XK)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy
OAA AB APTD AFDC
Prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Sewices X X X X
Physician Services X X X X
Dental Services X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families wiDep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families wiDep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
Medically Needy (MN) Other*
OAA AB APTD AFDC Childrenc21
X X X X X
I987
Expended Recipient
$7.51 6,587 27,651
1988
Expended Recipient
$7,797,307 29,284
3,756,880 16,700
1,882,679 2,481
10,545 20
1,489,618 2,758
371,476 6,937
502,562 4,504
329,166 3,060
51,648 61
0 0
73,221 160
74,286 1,283
90,908 756
39,108 820
3,694,857 9,261
2,820,286 5,140
3,504 1
679,127 1,234
67,309 986
75,146 870
49,485 1,020
HHS report HCFA - 2082
NPC - 1989
North Dakota - 2
111. Administration:
North Dakota Department of Human Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions:
1 . Anorectics
2.
High protein weight reduction supplements
3. Investigational drugs
4.
Drugs which have questionable therapeutic value
5.
Drugs which are not indicated for the diagnosis
6. DESl (Less-Than Effective) drugs
7.
OTCs - except antacids and oral analgesics
B. Formulary: None
C. Prescribing or Dispensing Limitations:
1 . Quantity of Medication: None.
2.
Refills: A prescription drug may be refilled up to 5 times or for 12 months after the date of
the original prescription, whichever occurs first, and provided that such refills have been
authorized by the physician.
3. Dollar Limits: None.
D. Prescription Charge Formula: Acquisition Cost plus $3.75 dispensing fee per prescription or usual
and customary retail charge, whichever is lower.
Acquisition Cost: EAC or MAC. EAC is North Dakota AWP.
V. Miscellaneous Remarks:
Co-payment - None
Officials, Consultants and Committees
I. Department of Human Services Officials:
John Graham, Executive Director
ND Dept. of Human Services
Capitol Building
Bismarck, ND 58505
LeRoy Bollinger, Administrator Research and Statistics
Richard Myatt, Director
Patricia A. Kramer, R.Ph., Administrator
701 1224-4023
Medical Services
Pharmacy Services
NPC - 1989 North Dakota - 3
2. Department of Human Sewices Advisory Committees:
Medical Care Advisory Committee:
Robert Wentz, M.D. Phyllis Bauer, Admin.
St. Health Officer Turtle Lake Hospital
St. Capitol Bldg. 220 5th Avenue
Bismarck, ND 58505 Turtle Lake, ND 58575
Allan Engen, Dir.
ND Health Care Assn.
513 E. Bismarck Avenue
Bismarck, ND 58501
Tonya Seggerman C. H. Peters, M.D.
215 Front Avenue 805 Griffin Street
Bismarck, ND 58501 Bismarck, ND 58501
Arne Springan, O.D.
41 1 North 4th Street
Bismarck, ND 58501
Tony Welder, R.Ph. Tom York. D.D.S.
Box 835 1102 S. Washington St.
Bismarck, ND 58502 Bismarck, ND 58501
Robert Thompson, Admin.
Missouri Slope Lutheran Home
2425 Hillview Avenue
Bismarck. ND 58501
Commission on Socio-Economic Affairs:
J.E. Adducci, M.D.
Box 2438
Williston, ND 58801
NE Byestol, MD, Chair
Dakota Clinic, Ltd.
Fargo, ND 58108
J.J. McLoed, Jr., M.D., Vice Chair.
Orthopaedic Clinic, P.D.
Grand Forks, ND 58201
C.S. Hamilton, Jr., MD
Fargo Clinic
Fargo, ND 58123
K.S. Helenbolt, M.D.
Blue Shield - ND
4510 13th Avenue, SW
Fargo, ND 58121
J.R. Herr, Jr., M.D.
121 3 15th Avenue West
Williston, ND 58801
F.M. Carter, M.D.
Grand Forks Clinic
Grand Forks, ND 58201
J. H. Coffey, M.D.
Fargo Clinic
Fargo, ND 58123
B.L. Dahl, M.D.
West Fargo Medical Center
West Fargo, ND 58078
D.L. Lamb, M.D.
#504 Professional Bldg.
Fargo, ND 58103
R.S. Larson, M.D.
Box A
Veiva, ND 58790
O.V. Lindelow, M.D.
Mid-Dakota Clinic
Bismarck, ND 58502
H.W. Evans, M.D.
Grand Forks Clinic
Grand Forks, ND 58201
M.D. Fiechtner, M.D.
Quain & Ramstad Clinic
Bismarck, ND 58202
W. J. Norberg, Jr., M.D.
Fargo, Clinic
Fargo, ND 58123
R.L. Odegard, M.D.
Medical Arts Clinic
Minot, ND 58701
N.B. Ordahl, M.D.
Box 1348
Dickenson ND 59601
D.M. Pfeifle, M.D.
Quain & Ramstad Clinic
Bismarck, ND 58502
R.F. Miller, M.D.
Medical Arts Bldg.
Bismarck, ND 58501
T.M. Polovitz, M.D.
Valley Medical Assn.
Grand Forks. ND 58201
R.F. Morgan, M.D.
316 N. 10th Street
Bismarck. ND 58501
NPC - 1989
North Dakota - 4
D.A. Rinn, M.D.
C.R. Thueson, M.D
UND Family Practice Ctr. Dakota Clinic, Ltd.
Minot, ND 58701 Fargo, ND 58108
Pharmacy Advisory Committee:
David Olig, Chair. Randy Skalsky Roy J. Ronholm
2701 1 3 h Avenue S.
1457 20th Street S. Box 1060
Fargo, ND 58103 Fargo, ND 58103 Jamestown, ND 58401
DuWayne Schlinenhard Tony Welder
Maw Tokach
3408 Par Street Box 835 #I Riverview Lane
Fargo, ND 58102 Bismarck, ND 58501 Jamestown, ND 58401
Jerry Hanson
Maw Malmberg (Ex. Off.)
1721 10th Street SW Box 1326
Minot, ND 58701 Fargo, ND 58107
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: 6. Pharmaceutical Association:
Vernon Wagner
Executive Vice President
North Dakota Medical Association
81 0 East Rosser Avenue, Box 1 1 98
Bismarck, ND 58502
701/223-9475
William J. Grosz
Executive SecretaryiTreasurer
ND Pharmaceutical Assn.
P.O. Box 5008, 405 E. Broadway
Bismarck, ND 58502-5008
701/258-9312
C. Osteopathic Association: D. State Board of Pharmacy:
James F. Klightlinger, D.O.
Secretary-Treasurer
ND State Osteopathic Association
Box 9
Elgin, ND 58533
William J. Grosz
Executive Secretavflreasurer
P.O. Box 1354
Bismarck, ND 58502-1354
7011258-1 535
NPC - 1989
Ohio - 1
OHIO
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC O M AB APTD AFDC Children<21
Prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Sewices X X X X
Physician Sewices X X X X
Dental Sewices X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
190,685CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Ti l e XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families wiDep. Children
Adults -Families w1Dep. Children
Other Title XIX Recipients
1987 1988
Expended Recipient Expended Recipient
$1 50,570,202 780,600 $1 52,609,139 757.81 8
94,238,763 608,980
10,556,077 21,215
477,640 985
43,115,756 78,210
13,372,864 31 7,885
26,716,426
58,370,376 148,838
36,231,512 58,876
200,365 346
18,061,151 27,130
940,926 20,514
1,471,120 14,214
1,465,302 27,758
0 0
0 0
0 0
0 0
0 0
0 0
0 0
HHS report HCFA - 2082
NPC - 1989
Ohio - 2
Ill. Administration:
Ohio Department of Human Services
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: For prescription legend and/or OTC drugs not listed in the formulary, pharmacist
should obtain authorization before filing claim for payment.
B. Formulary: Yes, approximately 3,000 drug products.
Contact Person: Robert P. Reid, R.Ph.
Bureau of Medicaid Policy
30 E. Broad Street, 31st Floor
Columbus, OH 43215
61 41466-6420
To promote economies in the drug program, practitioners are encouraged to prescribe by generic
name those drugs which consistently demonstrate therapeutic effectiveness and are produced by
pharmaceutical manufacturers with strict quality controls. In filling such generic prescriptions the
pharmacist is expected to dispense the least expensive drug available in his stock. The maximum
price allowed for such generics will be an amount calculated at the 65th percentile of those generics
readily available to Ohio pharmacy providers.
A drug code is listed in the Ohio Welfare Drug Formulary for each form of generic drug. Trade
names for some of these approximately 900 drug items are also contained in the formulary.
C. Prescribing or Dispensing Limitations:
I. Quantity of Medication:
a.
34-day supply or 100-dosage units (whichever is greater) for chronic maintenance
medications.
b. Amount designated in Ohio Medicaid drug formulary.
2. Refills: 11 for non-controlled drugs up to one year. 13 for birth control drugs up to one year.
Five for Scheduled Ill, IV, V drugs up to six months. None for Scheduled II drugs.
D. Prescription Reimbursement Formula:
1. Legend drugs and selected OTC products. Reimbursement based on the lowest of:
a. the provider's submitted charge, which should reflect his usual and customary charge
to the general public;
b. the Department's Estimated Acquisition Cost (EAC) (AWP minus 7% plus a dispensing
fee, or direct price if applicable, plus a dispensing fee; or
NPC - 1989 Ohio - 3
c. the federal- or state-established Maximum Allowable Cost (MAC), for specifically
designated generically equivalent drugs plus a dispensing fee.
2. Non-legend drugs - reimbursement is based on EAC plus a dispensing fee.
Dispensing Fee: $3.23 (effective 4/13/89)
ORicials Consultants and Committees
Welfare Department Officials:
Patricia Barry, Dir.
Roland Hairston, Assistant Dir.
Paul Offner, Deputy Dir.
Stanley D. Sells, Assistant Dep. Dir.
Kathi Glynn, Acting Deputy Dir.
Bureau of Medicaid Policy:
Kathi Glynn, Acting Bureau Chief
Robyn Colby, Senior Policy Analyst
Robert P. Reid, R.Ph., Pharmacist Consultant
Division of Medical Assistance:
John Boyle, Division Chief
Cecelia McGinniss, Bureau Chief
Philip J. Rogers, R.Ph., Pharmacy Consultant
Dept.of Human Services
30 East Broad Street, 32nd flr.
Columbus, OH 43215
Benefits Administration
Benefits Administration
Program Development
Department of Human Services
30 East Broad St., 31st Floor
Columbus, OH 43215
Department of Human Services
30 East Broad Street, 31st flr.
Columbus, OH 43215
61 41466-2365
Bureau of Medical Operations
Bureau of Medical Operations
NPC - 1989
Ohio - 4
2.
Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
Herbert E. Gillen
Executive Director
OH State Medical Assn.
1500 Lakeshore Drive
Columbus, OH 43204
61 41486-2401
C. Osteopathic Association:
Jon F. Wills
53 W. 3rd Avenue
Columbus, OH 43201
61 41299-21 07
B. Pharmaceutical Association:
Ernest "Ernie" Boyd
Executive Director
OH State Pharmaceutical Assn.
395 E. Broad Street, Suite 320
Columbus, OH 43215
6141464-1 874
D. State Board of Pharmacy:
Franklin 2. Wickham
Executive Director
77 S. High Street, 17th Floor
Columbus, OH 43266-0320
61 41466-41 43
NPC - 1989 Oklahoma - 1
OKLAHOMA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Childrenc21
Prescribed Drugs X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X
Laboratory &
X-ray Service
skilled Nursing
Home Services X X X X X X X X X
Physician Services X X X X X X X X X
Dental Services X X X X X X X X X
'SF0 - State Funds Only
11. EXPENDITURES FOR DRUGS
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
1987 1988
Expended Recipient Expended Recipient
$31,075,003 154,369 $34,096,431 158.472
CATEGORICALLY NEEDY NON-CASH TOTAL $7,724,937 28,364 9,297,038 30,516
Aged 6,136,292 16,994 7,096,047 15,636
Blind 3,991 15 5,475 19
Disabled 1,253,037 4,100 1,625,502 3,911
Children -Families w/Dep. Children 269,794 6,286 275,480 6,887
Adults -Families w/Dep. Children 47,417 648 99,226 1,083
Other Title XIX Recipients 14,406 457 195,308 3,811
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
HHS report HCFA - 2082
NPC - 1989
-
Oklahoma - 2
111. Administration:
Oklahoma Department of Human Services (DHS).
IV. Provisions Relating to Prescribed Drugs:
Formulary:
Yes - Oklahoma List of Covered Drugs
Contact: Howard Stansberry
Medical Services Division
Oklahoma City, OK 731 25
Provider Participation:
1. Pharmacy or Pharmacist:
Any pharmacy or pharmacist who has current license with the Oklahoma State Board of Pharmacy and
is free from any Pharmacy Board restrictions shall be entitled to be a participating provider under this
program.
2. Prescribing Practitioners:
Prescribing practitioners, authorized and licensed to practice the healing art as defined and limited by
Federal and state laws who choose to provide their own pharmaceuticals, may not be participating
providers at the present time.
3. Reimbursement Fee:
Estimated Acquisition Cost (EAC) plus maximum dispensing fee of $3.55 effective 11/1/81. In no event
shall charges to the Welfare Department exceed charges made to the general public for the same
prescription or item.
4. Categories of Drug Coverage (Revised 1/1/80)
Those drugs that are compensable under each category are specified individually by trade name;
otherwise by generic name only.
Antidiarrheals
Broncho-Dilators & Antiasthmatics
Opthalmic
Antibiotics (Oral & Injection)
Antibacterials (Oral & Injection)
Antineoplastics (Oral & Injection)
Birth Control
Antinauseants, AntivertigolAntiemetic
Insulin & Antidiabetics Drugs
Cardiovascular-Broad & Potassium Preparation
' 5. Prescription Limitations:
Antiparkinsonism
Antidepressants
Antiarthritics
Glaucoma Drugs
Otic
Antigout
Analgesics
Anticonvulsants
Antifungal
Specialized Preparations
Three prescriptions per monthirecipient, for outpatients. ICF-MR and nursing home recipients are
limited to 5 per month.
NPC - 1989
6. Quantities:
34-day supply.
Oklahoma - 3
7. Legend, Non-Legend and Generic Drugs:
Only legend drugs in the designated categories and insulin are covered in the program.
8. Refills:
Refills shall be provided only if authorized by the prescriber, no more than 1 year.
Officials, Consultants and Committees
1. Department of Human Services Officials:
Phil Watson, Director
Charles Brodt, Administrator
Medical Services Division
Howard Stansberry, Program Administrator
Medical Services Division
4051557-2539
Dept. of Human Services
Sequoyah Memorial Office Bldg.
P. 0. BOX 25352
Oklahoma City, OK 73125
Department of Human Services
P. 0. BOX 25352
Oklahoma City, OK 73125
Department of Human Services
P.O. BOX 25352
Oklahoma City, OK 73125
Ralph Hiett, R.Ph., Consultant
2. Advisory Committee on Medical Care for Public Assistance Recipients:
Robert Sukman, M.D., Chair. 3330 N.W. 56th #206
Oklahoma City, OK 73112
3. Executive Officers of State Medical, Pharmaceutical, and Osteopathic Societies:
A. Medical Association: B. Pharmaceutical Association:
David Bickham
Executive Director
Oklahoma State Medical Assn.
601 N. W. Expressway
Oklahoma City, OK 731 18
4051843-9571
John D. Donner
Executive Director
OK Pharmaceutical Association
Box 18731
Oklahoma City, OK 73154
4051528-3338
C. Osteopathic Association: D. State Board of Pharmacy:
Bob E. Jones
Executive Director
OK Osteopathic Association
4848 Lincoln Boulevard
Oklahoma City, OK 73105
4051528-4848
Bryan H, Potter
Executive Secretary
4545 N. Lincoln, Suite 112
Oklahoma City, OK 73105
4051521 -381 5
NPC - 1989
I
Oregon - 1
!
OREGON
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
O M AB APTD AFDC O M AB APTD AFDC Childrem21
Prescribed Drugs X X X X X X X
Inpatient
Hospital Care X X X X X X X
Outpatient
Hospital Care X X X X X X X
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services X X X X
'SF0 - State Funds Only
11. EXPENDITURES FOR DRUGS
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Ti l e XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Ti l e XIX Recipients
HHS report HCFA - 2082
NPC - 1989 Oregon - 2
Ill. Administration:
Adult and Family Services Division, Department of Human Resources.
IV. Provisions Relating to Prescribed Drugs:
A. Formulary: An open Yorrnuiary" except as noted below,
B. Non-Formulary: Prior approval from state reviewing physician must be obtained for minor tranquilizers
other then (generic) meprobamate or chlordiazepoxide, and amphetamines and amphetamine
derivatives, isotrenition, legend laxatives, pentamidine, ATT, Persantine, and certain non legend items.
C. Prescribing or Dispensing Limitations:
I. Quantity of Medication: Not to exceed 100 days supply, except topical preparations, sprays,
aerosol inhalers, and birth control tablets.
2. Refills - Schedule Ill, IV, or V drugs are limited to 5 refills.
3. Dollar Limits: None.
4. Dispensing limits: none on dispensingslmonth or refills,
D. Prescription Charge Formula:
Estimated acquisition cost (EAC) defined as the lesser of: (1) 89% AWP or direct price (9 selected
companies) (2) the Oregon MAC or HCFA upper limits for multiple source drugs or (3) the usual and
customary charge plus a dispensing fee of $3.52 or $3.83.
ORicials, Consukants and Committees
1. Kevin Concannon, Director
Freddye Webb-Petett, Administrator
Jean Thorne, Assistant Administrator
James E. Peters, Ph.D., R.Ph.
Medicaid Pharmacy Program Manager
2. Consultants to Health and Social Services Section:
Richard J. Cook, D.D.S. Donald Charlton, MD
Robinhood Prof. Bldg. 943 Liberty Street, SE
18603 Pacific Highway Salem, OR 97302
West Linn, OR 97068
Department of Human Resources
31 8 Public Services Building
Salem, OR 97310
5031378-2263
Adult and Family Services Div.
Health & Social Sew. Section
Edward Hendricks, MD, MPH, Dir.
203 Public Service Bldg.
Salem, OR 97310
NPC - 1989
a
Oregon - 3
Robert Staley, D.DS
William Henry, ND (Naturopath)
William R. Post. MD
1075 Hansen Avenue S.
1920 North Kilpatrick
203 Public Service Bldg.
Salem, OR 97302 Portland, OR 9721 7
Salem, OR 97310
3. Division Advisory Committees:
Governor's Advisory Committees on Medical Assistance:
Sadie R. Arrington, MD
Orin H. Bruton, MD
Route 3 Box 440-B
3404 12th St. SE
Hillsboro, OR 97124 Salem, OR 97302
Jean Furchner, Ph.D.
155 SW 88th Ave.
Portland, OR 97225
Minnie L. Jorgenson Glenn W. Kleen, DMD Mary Radtke Klein
3824 SW Lake Drive
1436 Ewald Ave. SE
3145 SW Evergreen Terrace
Pendleton, OR 97801 Salem, OR 97302 Portland, OR 97201
Dennis H. Marsh
Judge Earl C. Misener
1015 Cornell Avenue
410 H Avenue
Gladstone, OR 97027 La Grande, OR 97850
Larrie Patricia Noble, RN
Kenneth Patterson
1 1 750 SW 72nd
2210 Robinhood
Tigard, OR 97223
Corvallis, OR 97330
Dorothy M. Moon
4310 North Willis
Portland, OR 97203
Perry D. Quisenberry
850 Prospect Place, S.
Salem, OR 97302
Carie Strahorn, Brown Donna Clark
Sister Monica Heeran
6435 SW Parkhill Drive Maternallchild Health, HD Administrator
Portland, OR 97201
506 State Office Building Sacred Heart Hospital
1400 sw F R ~ Avenue
PO BOX 10905
Portland, OR 97201 Eugene, OR 97440
4. Executive Officers of State Medical and Pharmaceutical Associations:
A. Medical Association:
Robert L. Demedde
Executive Director
OR Medical Association
5210 SW Corben Street
Portland, OR 97201
5031226-1 555
B. Pharmaceutical Association:
Chuck Gress
Executive Director
OR State Pharmaceutical Assn.
1460 State Street
Salem, OR 973014296
5031585-4887
C. Osteopathic Association: D. State Board of Pharmacy:
Jeff Heatherington
Executive Director
Oregon Osteopathic Association
9221 SW Barbur, Suite 301
Portland, OR 97219
50312447592
Ruth Vandever
Executive Director
P.O. Box 231
State Office Bldg. Room 505
1400 SW 5th Avenue
Portland, OR 97207-0231
5031229-5849
NPC - 1989 Pennsylvania - 1
PENNSYLVANIA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X X
Laboratory &
X-ray Service
Skilled Nursing
Home Services X X X X X X X X X X
Physician Services X X X X X X X X X X
Dental Services X X X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w1Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
1987 1988
Expended Recipient Expended Recipient
$143,387,994 693,928 $1 57,192,136 679,852
11 3,061,666 548,906
21,318,166 41,337
483,505 1,011
55,135,936 100,999
14,679,275 264,498
21,444,764 146,835
44,021,589 158,849
29,641,992 50,921
4,571 16
9,472,769 15,909
1,445,997 37,311
1,648,933 20.1 59
1,807,327 36,768
0 0
0 0
0 0
0 0
0 0
0 0
0 0
HHS report HCFA - 2082
NPC - 1989
Pennsylvania - 2
Ill. Administration:
Office of Medical Assistance, Department of Public Welfare.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Payment will not be made to any pharmacy for the following services and items:
Methadone for any use.
Drugs for treatment of pulmonary tuberculosis. However, those tuberculosis drugs which are
prescribed for the prevention of meningococcal meningitis are compensable if the diagnosis
appears on the prescription.
Drugs and other items prescribed for obesity, appetite control, cessation of smoking or other
similar or related habit-altering tendencies. However, drugs which have been cleared for use
in the treatment of hyperkinesis in children and primary and secondary narcolepsy due to
structural damage of the brain are compensable if the physician indicates the diagnosis on
the the original prescription.
Non-legend drugs in the form of troches, lozenges, throat tablets, cough drops, chewing gum,
mouth washes and similar items.
Pharmaceutical services provided to a hospitalized person.
Single entity and multiple vitamins except for the following:
a. Single entity and multiple vitamin preparations with or without fluorides for children under
three (3) years of age.
b. A prescription drug product which contains a single entity vitamin combined with a
legend drug.
c. Vitamin D and its analogs.
d. Nicotinic acid and its amides.
e. Vitamin K and its analogs.
f. Folic Acid
g.
Single entity and multiple vitamin preparations when prescribed for prenatal use.
Drugs and devices classified as experimental by the FDA.
Drugs and devices not approved for use by the FDA.
Placebos.
Legend and non-legend soaps, cleansing agents, dentifrices, mouth washes, douche solutions,
ear wax removal agents, deodorants, liniments, antiseptics, emollients, and other personal care
and medicine chest items.
Legend and nonlegend agueous saline solutions for use other than for intravenous
administration.
Legend and non-legend water preparations such as distilled water, water for injection, and
identical, similar or related products.
Food supplements and substitutes.
Pennsylvania - 3
Compounded prescriptions when:
a. Compensable items are used in less than therapeutic quantities, or
b. Noncompensable items are compounded.
Non-legend drugs not listed in the Appendix to Chapter 1121
Drugs prescribed in conjunction with sex reassignment procedures or other noncompensable
surgical procedures.
The following items when prescribed for recipients in a skilled nursing and intermediate care
facillty services:
a. Intravenous solutions.
b. Noncompensable drugs and items as specified in this section.
c. The following non-legend drugs:
(0
(ii)
(iii)
(iv)
(v)
(vi)
(vii)
(viii)
Analgesics
Antacids
Antacids with simethicone
Cough and cold preparations
Contraceptives
Laxatives and stool softeners
Ophthalmic preparations
Diagnostic agents
d. Legend laxatives
Items prescribed or ordered by a prescriber who has been barred or suspended from
participation in the Medical Assistance Program. The Department will periodically send
pharmacies a list of the names of suspended, terminated or reinstated practitioners and the
dates of the various actions. Pharmacies are responsible for checking this list before filling
prescriptions.
Prescriptions or orders filled by a pharmacy other than the one to which a recipient has been
restricted. The Department will issue special medical services eligibility cards to resricted
recipients indicating the name of the pharmacy to which the recipient is restricted. Pharmacies
are responsible for checking the recipient's Medical Services Eligibility Card before filling the
prescription.
DESl Drugs and identical, similar or related products or combinations of these products.
Impregnated gauze and identical, similar or related products
A pharmaceutical service for which payments is available from another public agency or
another insurance or health program except for those drugs prescribed through the county
mental/mental retardation programs.
FDA-approved pharmaceutical products whose indicated use is not to treat or manage a
medical condition, illness or disorder.
8. Formulary: None
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: the quantity to be dispensed is as prescribed by the physician, not
to exceed a 34 day supply or 100 units, whichever is greater.
2. Refills: Prescriptions may be refilled, as long as total authorization does not exceed a 6
months' or Wefill supply from the time of original prescription.
NPC - 1989
Pennsylvania - 4
3.
Limitations on Dispensing Fees: payment to a pharmacy for prescriptions dispensed to a
recipient in either a skilled nursing facility, an intermediate care facility, or an intermediate care
facility for the mentally retarded are limited to one dispensing fee per drug dispensed within
a 30-day period. A 5-day grace period will be allowed to accommodate prescriptions filled and
delivered prior to the normal 30-day cycle. A 5-day grace period will be allowed to
accommodate prescriptions filled and delivered prior to the normal 30-day cycle. For the
purposes of this limitation, a drug is defined as an entity or dosage form which has the same
active ingredient in the same strength or the same combination of ingredients in the same
strengths. This limitation does not apply to:
a. Antibiotics
b. Anti-infectives
c. Schedule Ill analgesics
d. Topical and injectable preparations dispensed in the manufacturer's original package
size
e. Ophthalmic and otic preparations dispensed in the manufacturer's original package size
f. Compensable compounded prescriptions
g. Insulin
h. Schedule II drugs
i. Oral liquid anticonvulsants and oral liquid potassium supplements dispensed in the
manufacturer's original package size
j.
Legend cough and cold oral liquid preparations
4. Dollar limits: none
D. Drug Cost Determination:
1. Payment for compensable legend and non-legend drugs is based on on the current Estimated
Acquisition Cost (EAC) established by the Department, the State Maximum Allowable Cost
(MAC) established by the Department or the federal MAC established the Department of Health
and Human Services.
a. The EAC for compensable legend and non-iegend drugs is based on the package size
providers buy most frequently and is determined by taking the Average Wholesale Price
(AWP) for that drug as found in the Department's pricing service, except when one of
the following exists:
i. The AWP for that drug is not listed in the Department's pricing service.
ii. The drug is not widely and consistently available through Commonwealth
wholesalers.
b. The EAC for any legend or non-legend drug which is not listed in the Department's
pricing service or is not widely and consistently available through Commonwealth
wholesalers will be determined by taking one of the following:
i. The manufacturer's direct price for that drug based on the package size providers
buy most frequently.
ii. The lowest EAC for an identical or comparable product on the Department's drug
reference file in the absence of the manufacturer's direct price for that drug.
c. The Department's pricing service will be a pricing service which is both of the following:
NPC - 1989 Pennsylvania - 5
i. Currently under contract with the Department as selected by competitive bids
consistent with the Commonwealth procurement practices.
ii. A nationally recognized pricing guide which can supply the Department with the
necessary services needed to maintain the drug reference file under current
policies.
2. In cases where the EAC exceeds the state MAC or the federal MAC, the state MAC or federal
MAC will apply.
3. The EAC for individual drugs will be updated on a monthly basis as it appears in the pricing
service under contract with the Department or the direct price, whichever is applicable.
E. The State MAC Program:
1. The state MAC is determined by arraying the EACs of those generically equivalent drugs in
the same strengths and dosage forms, from high to low, whose products are listed in the
Department of Health Generic Drug Formulary. The state MAC is set at the EAC of the drug
that falls at the 70th percentile from the lowest EAC of all drugs in the particular group.
2. The state MAC for a Schedule IV anti-anxiety agent classified as a benzodiazepine or a
carbamate derivative is set at 110% of the lowest EAC of the generically equivalent drug listed
in the generic drug formulary.
3. The state MAC price will not apply if the words "Brand Medically Necessaryvr a similar phrase
is handwritten by the prescriber on the prescription blank.
4. The state MAC list may be updated every 6 months for the addition of drugs or for price
changes.
F. Prescription Charge Formula:
1. On May 16, 1981, Pennsylvania revised its payment methodology to pharmacies. This revised
payment methodology, which has been approved by the federal government as part of the
State's approved State Plan, recognizes a difference between a pharmacy's usual and
customary charge to the self-paying public and the pharmacy's usual and customary charge
to third party payors. The "self-paying publicVs defined as all persons whose costs for
prescribed drugs are not covered by a third party payor. "Third party payors'are defined as
~~ ~
public or private health insurance plans or programs which make payments to pharmacies on
behalf of eligible recipients or beneficiaries. As a result of this revised payment methodology,
pharmacies-are reimbursed an additional amount not to exceed 25 cents for each welfare
prescription that would ordinarily be paid on a usual and custornary basis. The amount of the
total payment will not exceed the cost of the drug plus the dispensing fee.
2. A licensed retail pharmacy's maximum reimbursement for all compensable legend and
nonlegend drugs shall be the cost of the drug plus a $2.75 disDensinq fee or the pharmacy's
usual and customary charge to third party payors, whichever is lower. For purposes of Medical
Assistance reimbursement, the usual and customary charge to third party payors may not
exceed 25 cents per prescription higher than the usual and customary charge to the self-
paying public. The cost of the drug shall be either the MAC, EAC, or AWP. Although payment
shall be made in accordance with this method of payment, the pharmacy is required to bill
the Department at its usual and custornary charge to the self-paying public.
NPC - 1989
Pennsylvania - 6
3.
For compound prescriptions, an additional fee of $1 .OO is allowed to a pharmacy, bringing the
total dispensing fee to $3.75. A compound prescription for the purposes of medical assistance
payment is one which is prepared at the time of dispensing and involves the weighing of at
least one solid ingredient which must be a compensable item or a legend drug in a therapeutic
amount.
4. The federal MAC program has been in effect since September I , 1978.
5.
The EAC program has been in effect since July I, 1984
6. The state MAC program has been in effect since March 15, 1987.
Copayment $0.50
On September I, 1984, Pennsylvania implemented a 50 cent copayment for each prescription, new or refill,
received by a recipient. The copayment will apply to those recipients who are federally exempt, under
21 years of age, pregnancy cases and long-term care patients, plus patients receiving drugs in the following
categories:
Antihypertensive agents
Cardiovascular preparations
Antiphychotic agents (excluding Schedule C-IV anti-anxiety agents
Antidiabetic agents
Anticonvulsants
Antineoplastic agents
Antiglaucoma agents
Antiparkinson agents
VI. Recipient Lock-In Program
A. Approximately 2,146 recipients were restricted to a pharmacy in calendar year 1988.
B. Approximately 1,905 recipients were restricted to other provider types in calendar year 1988.
VII. Miscellaneous
A. Fiscal Intermediary: The Computer Company.
3595 Vartan Way
Harrisburg, PA 171 10
The Computer Company's chief responsibility is clerical in nature and deals with claims processing
only, i.e., opening of mail, key punching claim information, microfilming, etc. All claims resolutions
and problems are handled by the department's in-house data facilities.
Pennsylvania - 7
Ofiicials, Consultants and Committees
I. Welfare Department Officials:
John F. White, Jr., Secretary
Eileen M. Schoen, Deputy Secretary
John Walter, Director
David S. Feinberg, Director
Richard H. Lee, Director
Elaine Crider, Director
2. Consultant Pharmacists:
Joseph E. Concino, P.D.
Medical Assistance Policy Specialist
Office of Medical Assistance Programs
71 71782-61 42
William M. Peifer, R.Ph.
Robert G. Dissinger, R.Ph.
S. Charles Modica, R.Ph.
John Ferrara, R.Ph.
Frank Cwynar, R.Ph.
3. Medical Assistance Advisory Committee:
Hosp. Assn. of PA
Joanne Coolen, Senior VP
Hospital Services
Hosp Assn. of PA
P.O. Box 608
Camp Hill, PA 1701 1
PA Health Care Assn.
I
Milton Jacobs, Exec. Dir.
1 Saunders House
i 100 Lancaster Avenue
1 Philadelphia, PA 191 51
t
PA Dental Assn.
H. William Gross, D.D.S.
141 4 Fairmont Street
Allentown, PA 18102
PA Dept. of Health
Jack B. Ogun, Dir.
Div. Drugs, Devices/Cosmetics
930 Health & Welfare Bldg.
Harrisburg, PA 17120
Dept. of Public Welfare
Health and Welfare Building
Harrisburg, PA 17120
Bureau of Quality Assurance
Bureau of Hospital &Outpatient Programs
Bur, of Reimbursement Methods
Bur., Special Medical Programs
Div. of Outpatient Programs
Section of Pharmacy &Ancillary Services
P. 0. Box 8043
Harrisburg, PA 171 05
Div. of Outpatient Programs
Div. of Outpatient Programs
Div. of Outpatient Operations
Div. of Provider Assessment
Department Public Welfare
25 North 32nd Street
Camp Hill, PA 1701 1
Div. of Provider Assessment
PA Medical Society
Walter M. Greissinger, M.D,
Central Medical Pavilion
1400 Center Avenue
Pittsburgh, PA 15219
PA Blue Shield
Robert Edmiston, MD, Ex.VP
Professional Affairs
PA Blue Shield
Camp Hill, PA 1701 1
NPC - 1989
w
Pennsylvania - 8
PA Forum for Primary Health Care
Hubert Gordon
Executive Director
101 7 Mumma Road
Worrnleysburg, PA 17043
PA Retailers Association
Donald Bell, R.Ph.
2503 Club House Drive
Wexford, PA 15090
PA Health Care Assn.
Michael D'Arcangelo
2400 Park Drive
Harrisburg, PA 171 10
Eagleville Hospital
Fred Carey
Chief Executive Officer
Eagleville, PA 19408
PA Assn. Non-Profit Homes
for the Aging
Christine Klejbuk
Director of Public Policy
P. 0. Box 698
Camp Hill, PA 1701 1
Hamilton Health Care
Sara N. Prioleau, D.M.D.
1094 Cardinal Drive
Harrisburg, PA 171 11
Harrisburg Concerned Citizens
Melvin F. Johnson
1627 Dr. Martin Luther King, Jr. Boulevard
Harrisburg, PA 17103
4.
Pharmacy Subcommittee to the Medical Assistance Advisoly Committee:
William L. Greene, R.Ph.
Chairman
780 West Macada
Bethleham, PA 18017
Fred D. Popolo, R.Ph.
6 Beacon Hill Drive
East Brunswick, NJ 0881 6
Michael J. Sheetz
PA Assn. of Med. Suppliers
C/O Harrisburg Healthcare
1223 N. Cameron, Box 2227
Harrisburg, PA 171 05
Richard L. Kunkle, R.Ph.
Weis Market, Inc.
P. 0. Box 471
Sunbuly, PA 17801
John A. Paone, R.Ph.
Wyman Pharmacy
524 East Ohio Street
Pittsburgh, PA 15212
Donald Schell, R.Ph.
129 Blacksmlh Road
Camp Hill, PA 1701 1
Benjamin Pulizzi, R.Ph.
Williamsport Orthopedic1
Prosthetic Co.
138 East 4th Street
Williamsport, PA 17701
Margaret Walwick, R.Ph.
29 Blyan Street
Havertown, PA 19083
Alma llery Medical Center
Wilfred Payne
7227 Hamilton Avenue
Pittsburgh, PA 15208
PA Assn Health Maint Org.
Ms. Andrea Schari
Executive Director
30 North 26th Street
Camp Hill, PA 1701 1
Maternal Care Coalition
Cynthia Holmes
51 34 Knox Street
Philadelphia, PA 19144
David Dalton, R.Ph.
Rite Aid Corporation
P.O. Box 3165
Harrisburg, PA 17105
Samuel D. Brog, RPh.
102 Buckley Drive
Philadelphia, PA 191 15
Janice Meikle, R.Ph.
Thrift Drug Company
61 5 Alpha Drive
Pittsburgh, PA 15238
NPC - 1989
Pennsylvania - 9
5. Executive Officers of State Medical and Pharmaceutical Associations:
A. Medical Society:
John F. Rineman
Executive Vice President
PA Medical Society
20 Erford Road
Lemoyne, PA 17043
71 71763-71 51
C. Osteopathic Medical Association:
Mario E.J. Lanni
Executive Director
PA Osteopathic Medical Assn.
1330 Eisenhower Boulevard
Harrisburg, PA 171 11
71 71939-931 8
E. State Board of Pharmacy:
Ida May Englehalt
Executive Secretary
P.O. Box 2649
Harrisburg, PA 171 05-2649
71 71783-1 357
B. Pharmaceutical Association:
Carmen A. DiCello, R.Ph.
Executive Director
PA Pharmaceutical Assn.
508 North Third Street
Harrisburg, PA 171 01 -1 199
71 71234-61 51
D. Podiatly Association:
Matthew M. Shook, Jr.
Executive Director
PA Podiatry Association
737 Poplar Church Road
Camp Hill, PA 1701 1
71 71763-7665
NPC - 1989
K
Rhode Island - 1
RHODE ISLAND
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA A6 APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs X X X X X X X X X
Inpatient
Hos~i t al Care
outpatient
Hospital Care
Laboratory &
X-ray Service
Skilled Nursing
Home Services X X X X X X X X X
Physician Services X X X X X X X X X
~ei l t al Services X X X X X X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families wIDep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
1987
Expended Recipient
$14,426,849 73,127
8,512,606 55,961
1,705,462 4,031
55,480 180
4,145,668 10,717
966,043 24,435
1,639,953 15,598
2,717,544 7,720
1,818,220 5,165
8,644 25
760,448 2,160
36,076 103
61,243 174
32,913 93
3,196,700 9,446
2,483,835 6,976
7,033 18
668,430 1,658
1 7,582 570
19,820 224
0 0
1988
Expended Recipient
$1 5,934,358 72,899
9,442,700 56,313
2,056,620 5,494
67,987 174
4,720,407 11,167
1,001,870 24,427
1,595,816 15,051
2,605,268 6,923
1,431,209 3,803
9,017 24
1,010,977 2,687
42,676 114
72,457 192
38,932 103
3,886,390 9,663
2,995,629 7,181
7,773 20
841,015 1,805
15,157 457
26,816 200
0 0
HHS report HCFA - 2082
NPC - 1989
Rhode Island - 2
Ill. Administration:
State Department Human Services.
IV. Provisions Relating to Prescribed Drugs:
General Exclusions:
OTC and certain medicine chest items and injectables:
Prior authorization is required for all injectables (excluding insulin and adrenalin), appetite
depressant drugs, central nervous system stimulants, expensive vitamins, hematinics and
lipotropic preparations (selling for over $1 0 per I 00 tabiets/capsules or pint), expensive and/or
new preparations.
Prescribed drugs requiring prior authorization may be refilled if requested by the attending physician
and approved by the Division of Medical Services.
Formulary: None
Prescribing or Dispensing Limitations:
1. Quantity of Medication: One month's supply of drugs.
2. Maintenance Medication: The attending physician may prescribe certain maintenance drugs
of 100 tablets, capsules or pint of liquid or a 30-days' supply of these drugs --whichever is
greater.
3. Refills: Refills to a maximum of five are allowed for specified drugs: anti-hypertensives,
diuretics, anti-convuisants, coronary vasodilators, tranquilizers, antidepressants, hormones,
antibiotics, etc.
Refills are not allowed for specified drugs, e.g., central nervous system stimulants, narcotics
(Schedule 11, Ill), Corticosteroids, appetite depressants and pentazocine.
4. Dollar Limits: None
Prescription Charge Formula:
1. Prescription Drugs Dispensed to Eligible Recipients Residing in Their Own Homes:
A Professional Fee for Service of $3.40 will be allowed for all prescriptions in addition to the
cost of the drug.
In accordance with federal regulation the upper limit for payment for prescribed drugs will be
based upon the amount allowed by the Medical Assistance Program or the usual and
customary charge to the general public, whichever is lower.
NPC - 1989
Rhode Island - 3
Payment for over-the-counter drugs (non-legend drugs) will be based upon the lower of either
the allowable cost of the drug plus 50 percent, the usual and customary charge to the general
public, or the allowable cost plus the Professional Fee for Service.
2. Prescription Drugs Dispensed to Recipients Residing in Skilled Nursing or Intermediate Care
Facilities:
A Special Professional Fee for Service of $2.85 will be allowed for these prescriptions in
addition to the cost of the drug to the pharmacist.
In accordance with federal regulation the upper limit for payment for prescribed drugs will be
based upon the amount allowed by the Medical Assistance Program or the usual and
customary charge to the general public, whichever is lower.
Payment for over-the-counter drugs (non-legend drugs) will be based upon the lower of either
the allowable cost of the drug plus 50 percent, the usual and customary charge to the general
public, or the allowable cost plus the Professional Fee for Service.
3.
The estimated acquisition cost for products manufactured by the following pharmaceutical
companies is the direct reimbursements:
Abbott-Ross Pfipharmics
Pfizer-Roerig Merck Sharp & Dohme
Parke-Davis & Co. Upjohn
Wyeth-Ayerst
Lederle
Squibb
Warner-Chilcott
4. The quantity of the drug dispensed on the original prescription would be determined on the
basis of a 30-day supply to the patient. A maximum of 5 refills in addition to the original
prescription will be allowed when so indicated by the physician.
5. The attending physician may prescribe certain maintenance drugs in quantities of 100 tablets,
capsules or equivalent, or a 30-days' supply of these -- whichever is greater.
The following classes of drugs are considered as maintenance drugs:
a. Anti-diabetic preparations
b. Anticonvulsants
c. Antihypertensives
d. Cardiovascular preparations, namely:
(1) Anti-anginal
(2)
Digitalis and the cardiac glycosides
e. Diuretics
f. Hormones, including thyroid preparations
g.
Vitamins, hematinics and lipotropic preparations for which the total charge to the Medical
Assistance Program does not exceed $1 0 per pint of liquid or 100 tablets or capsules.
Miscellaneous Remarks:
NPC - 1989 Rhode Island - 4
ORiciak, Consultants and Committees
1. Department of Human Sewices Officials
Nancy V. Bordeleau, Director
Anthony Barile, M.P.A., Associate Dir.
John A. Pagliarini, R.Ph., Chief of Pharmacy
Dept. of Human Sewices
600 New London Avenue
Cranston, RI 02920
Medical Sewices
2. Department of Human Sewices Advisory Committees:
Medical Assistance Committees:
(1)
Medical Advisory Committee on Pharmacy:
Joan Abar, D.O. Peter Mathieu, M.D. Anthony Solomon, R.Ph.
Joseph Navach, R.Ph. Walter Carnevale, R.Ph. Ira Wellins, R.Ph.
John DeFeo, Ph.D. John DePasquale, R.Ph. Louis Jeffrey, RPh.
Richard Yacino, R.Ph.
(2) Rhode Island Pharmaceutical Association:
E. Paul Larrat, RPh. President 4011725-41 41
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: B.
Newell E. Warde, Ph.D.
Executive Director
RI Medical Society
106 Francis Street
Providence, RI 02903
4011331 -3207
C. Osteopathic Association: D.
Reuben L. Alexander, D.O.
Secretary
Cranston General Hospital
1763 Broad Street
Cranston, RI 02905
Pharmaceutical Association:
Denis R. Barton
Executive Director
RI Pharmaceutical Association
500 Prospect St. - Independence Square
Pawtucket, RI 02860
4011725-41 41
State Board of Pharmacy:
Gilbert R. Dubuc
Secretary
State Board of Pharmacy
304 Cannon Building
75 Davis Avenue
Providence, RI 02908-5097
401 1277-2837
NPC - 1989
South Carolina - 1
J
SOUTH CAROLINA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XK)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Othei
OAA AB APTD AFDC OAA AB APTD AFDC Childrew21 ISFO)
Prescribed Drugs X X X X X
Inpatient
Hospital Care X X X X X
Outpatient
Hospital Care X X X X X
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Sewices X X X X
Physician Services X X X X
Dental Services X X X X
SF 0 - State Funds Only
(I. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w1Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families wIDep. Children
Other Title XIX Recipients
I987
Expended Recipient
$32385,360 187,520
$28,508,890 168,211
8,841,772 30,616
419,409 1,541
14,628,548 47,765
1,720,876 53,380
2,898,283 35,560
$3,831,936 22,233
2,681,176 7,713
7,809 20
745,341 1,970
181,013 6,160
181,991 5,535
34,603 863
$44,533 1,930
0 0
0 0
0 0
0 0
13,791 609
30,741 1,327
HHS report HCFA - 2082
NPC - 1989
South Carolina - 2
Ill. Administration:
State Healh and Human Services Finances Commission
IV. Provisions Relating to Prescribed Drugs:
A. Scope of Non-Formulaty Drug Program - Effective October 1, 1984, providers will be reimbursed for
most legend drugs and for certain non-legend (OTC) drugs within the three prescription limit.
Exclusions to this coverage are as follows:
Adult vitamins and vitamin combinations; (Prenatal vitamins for females, fluoride vitamins for
children and Rocaltrol for renal patients are covered.)
Amphetamines and obesity control drugs;
Experimental drugs;
Immunizing agents (Pneumovax is covered under Physicians' Services);
Drug Efficacy Study Implementation (DESI) Drugs. Drugs determined by the Food and Drug
Administration (FDA) to be ineffective are not reimbursable by Medicare or Medicaid.
Over-the-counter (OTC) drugs covered by the South Carolina Medicaid:
Acetaminophen, all strengths & forms
Actifed Syrup
Actifed Tablets
Aiternagel Liquid
Ascriptin AID tablets
Ascriptin Tablets
Aspirin, all forms (including enteric-coated)
Basaljel Capsules
Basaljel Extra Strength Suspension
Basaljet Suspension
Basaljel Swallow Tabs
Cama Inlay Tablets
Camalox Suspension
Camalox Tablets
Cerose DM Syrup
Contraceptive Condoms
Contraceptive Foams
Contraceptive Sponges
Contraceptive Vaginal Creams/Gelsl
JelliesISupp.
Debrisan Beads Unit 4gm 14s
Debrisan Beads Unit 4gm 7s
Dimenhydrinate Elixir
Dimenhydrinate Tablets 50mg
Dimetane Elixir
Dimetane Extentabs 12mg
Dimetane Extentabs 8mg
Dimetane Tabelts 4mg
Donnagel-PG Suspension
Gaviscon Liquid
Gaviscon Tablets
Gaviscon-2 Tablets
Gelusil II Liquid
Gelusil II Tablets
Gelusil Liquid
Gelusil Tablets
Hydrocortisone 0.5% CreamIOintment
Insulin, All Forms
Insulin Syringes
Maalox Plus Suspension
Maalox Plus Tablets
Maalox Suspension
Maalox Plus Suspension (Ext. Strength)
Maalox # I Tablets
Maalox #2 Tablets
Micatin Cream 2% 15gm
Micatin Cream 2% 30gm
Mylanta II Liquid
Mylanta II Tablets
Mylanta Liquid
Mylanta Tablets
Niacin Tablets 100mg
NPC - 1989
South Carolina - 3
Niacin Tablets 50mg
Novafed Liquid
Parepectolin Suspension
Phazyme Tablets (60mg only)
Riopan Chewable Tablets
Riopan Plus Suspension
Riopan Plus Tablets
Riopan Suspension
Riopan Tablets
Robiiussin AC Elixir
Robiiussin DAC Elixir
Tedral Elixir
Tedral Tablets
TiIralac Liquid
Tiiralac Tablets
B.
Formulary: certain drug categories are excluded.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: None (90day supply maximum)
In acute conditions, physician requested to limit supply to a minimum of ten (10) days. In
chronic conditions and for maintenance drugs, a minimum of a thirty (30) day supply where
appropriate, a ninety (90) day supply maximum is allowed and encouraged.
2 Refills:
The prescriber authorizes the number of refills.
3. Dollar Limits: None
4. Recipients are limited to three (3) prescriptions per month.
D. Prescription Charge Formula:
Medicaid reimbursement for pharmacy sewices will be based on the lower of: the South Carolina
Estimated Acquisition Cost (SCEAC): federal maximum allowable cost (MAC), AWP minus 9.594, or
the provider% submitted usual and customary charge.
Dispensing fee is $3.80 (3.30 + 30 copay. = 3.80)
Miscellaneous Remarks:
It is required that each recipient choose one pharmacy for a month.
NPC - 1989 South Carolina - 4
Officials, Consultants and Committees
1. Sooth Carolina State Health and Human Sewices Finance Commission
Eugene A. Laurent, Ph.D., Executive Director
8031253-61 00
Gwen Power, Deputy Executive Director
8031253-61 19
HealthIHuman Svces. Finance Commission
P.O. Box 8206
Columbia, SC 29202-8206
Office of Programs
P. 0. Box 8206
Columbia, SC 29202-8206
James M. Assey, R.Ph., Medicaid Program Consultant
8031253-61 38
Rosemary N. Boguski, R.Ph. Dept. Head
Dept. of Pharmaceutical & DME Services
8031253-61 79
2. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: 6. Pharmaceutical Association:
William F. Mahon
Executive Vice President
SC Medical Association
P. 0. Box 11188
Columbia, SC 2921 1
8031798-6207
Roben H. Burnside, Jr.
Executive Director
SC Pharmaceutical Association
1405 Calhoun Street, Suite 200
Columbia, SC 29201-2509
6031254-1 065
C. Osteopathic Association: D. State Board of Pharmacy:
L. Mark Adams, DO
Secretary-Treasurer
SC Osteopathic Association
P. 0. Box 30005
Charleston, SC 29407
C. Douglas Chavous
Executive Director
P.O. Box 11 927
1026 Surnter St, Rm. 209
Columbia, SC 2921 1-1 927
6031734-1 01 0
NPC - 1989
F
South Dakota - 1
SOUTH DAKOTA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
0.4.4 AB APTD AFDC O M AB APTD AFDC Children<2l (SFOI
Prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services X X X X
S F 0 - State Funds Only
+ - Renal Disease
11. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families wIDep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families wiDep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
1987
Expended Recipient
1988
Expended Recipient
HHS report HCFA - 2082
NPC - 1989
South Dakota - 2
Ill. Administration:
State Department of Social Services, Office of Medical Services.
IV. Provisions Relating to Prescribed Drugs:
A. Exclusions: The program is limited to legend prescription drugs as specified in the state's Medicaid
regulations, and to insulin.
B. Formulaly: Generic mandate deleted on Janualy 1, 1988. FUL prices plus 40 state MAC prices now
apply.
C. Prescribing or Dispensing Limitations:
1. Quantity: Maintenance drugs requiring more than one dose per day must be dispensed in
units of at least 100 or a 30 day supply, if more than 100 unit are required per month.
Maintenance prescriptions for family planning items must be dispensed in at least a 3 month
supply. (New family planning prescriptions can be in smaller units.)
2. Dollar limits: None.
D. Prescription charge formula: Payment is the lower of: (a) FUL, state MAC plus dispensing fee of
$4.25, (b) EAC plus dispensing fee of $4.25, or usual and customaly charge to the general public.
EAC = AWP minus 10.5%.
V. Miscellaneous
Administrative Rule, adopted July 1, 1983 states:
'Cost sharing for prescriptions is $1.00 for each prescription and $1.00 for each prescription refilled."
(Exemptions include patients under 18 years, residents of home or community-based services, services
related to pregnancy, residents of long term care facilities, family planning and emergency hospital services.)
Officials, Consukants and Committees
1. James Ellenbecker, Secretary Dept. of Social Services
700 Governors Drive
Pierre, SD 57501
NPC - 1989
South Dakota - 3
Ervin Schumacher, Program Administrator
Donald Mahannah, P.D., Pharmacist Consultant
6051773-3495
2. Medical Advisory Committee (MAC):
Lloyd Jones, Pharmacist
Paul I. Engelbrecht
Jones Drug Nursing Home Admin.
609 sixth Avenue
Tieszen Memorial Home
Aberdeen, SD 57401 437 State Street
Marion. SD 57043
Glenn W. Robeson, 0.D.
James D.M. Russell
Optometrist Hospital Admin.
34 3rd Street, SE
St. Mary's Hospital
Huron, SD 57350 Pierre, SD 57501
3.
Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
Robert D. Johnson
Chief Executive Officer
SD State Medical Association
1323 Minnesota Avenue
Sioux Falls, SD 571 05
6051336-1 965
C. Osteopathic Association:
David A. Lauer, D.O.
Secretary-Treasurer
SD Society of Osteopathic Physicians & Surgeons
C/O Massa-Berry Clinic
Sturgis, SD 57785
6051347-361 6
Medical Services
Medical Services
Michael Pekas, M.D.
Physician
2727 S. Kiwanis
Sioux Falls, SD 57105
Alvin A. Buechler, D.D.S.
Dentist
Box L
Genysburg, SD 57442
B. Pharmaceutical Association:
Galen Jordre
Secretary
SD Pharmaceutical Association
222 East Capitol, Box 518
Pierre, SD 57501-051 8
6051224-2338
D. State Board of Pharmacy:
Galen Jordre
Secretary
Box 518
Pierre, SD 57501 -051 8
60512242338
NPC - 1989 Tennessee - I
TENNESSEE
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other.
OAA AB APTD AFDC OAA AB APTD AFDC Chi l drew21 (SFO)
Prescribed Drugs X X X X
.. .. .. ..
Inpatient
Hospital Care X X X X
.. .. .. ..
Outpatient
Hospital Care X X X X
** .. .. ..
Laboratory &
X-ray Service X X X X
.. .. .. ..
Skilled Nursing
Home Services X X X X
.. .. .. ..
Physician Services X X X X
.. .. .. ..
Dental Services Covered only if EPSDT or under 21
and emergency health conditions
'SF0 - State Funds Only
"Caretaker over 21
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep.children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
1 Disabled
Children -Families w/Dep. Children
/ Adub -Families wDep Children
i Other Ti l e XIX Recipients
f
1987
Expended Recipient
1988
Expended Recipient
j
HHS report HCFA - 2082
- -
NPC - 1989
Tennessee - 2
Ill. Administration:
Tennessee Department of Health and Environment
IV, Provisions Relating to Prescribed Drugs:
A.
General Exclusions: cough and cold preparations, anoretic drugs (except for amphetamines and
derivatives for only specific indications of narcolepsy and the hyperkinetic child).
5. Formulary:
"Tennessee Medicaid Drug Formulary'; Restricted Formulary. For information contact:
Director of Pharmacy Services
729 Church Street
Nashville, TN 37219-5406
61 51741 -021 3
C. Prescribing or Dispensing Limitations:
1.
Terminology: May prescribe and dispense brand name drugs but encourage usage of generic
drugs for potential cost savings.
2. Quantity of Medication:
a. One month's supply.
b. Limit of 7 prescription and/or refills per month.
3. Refills: Covered only if specifically authorized by the prescribing physician On the original
prescription. Five refills within 6 months.
4. Dollar Limits: None.
5. MAC (Maximum Allowable Cost). 175 drugs in addition to federal MAC drugs. Approved
Manufacturer's List established based upon bioequivalence.
D.
Prescription Charge Formula: Estimated acquisition cost plus professional fee of $4.21 Im~iInum,
or usual and customary - whichever is lower.
Lesser of:
I. Estimated acquisition cost (AWP minus 7%) plus - fee, or
2. Maximum allowable cost - plus - fee, or
3. Usual and customary charge.
V. Miscellaneous
Fiscal Intermediary: The Virginia Computer Company
729 Church Street
Nashville, TN 37219
Officials, Consultants and Committees
1. Health Depanment:
A. Officials:
J. W. Luna, M.P.H., Commissioner TN Dept. of Health/Environment
344 Cordell Hull Building
Nashville, TN 37219
NPC - 1989
Manny Martin, Director Medicaid Administration
729 Church Street
Nashville, TN 3721 9-5406
Tennessee - 3
E. Conrad Shackleford M.D., Medical Director Div. of Medical Support, Bur. of Medicaid
W. Louis Moore, M.D., Deputy Medical Director
B. Medicaid Medical Care Advisory Committee:
Fifteen members appointed by the Governor for three-year terms (except initial appointments). One member
shall be the Commissioner of the Department of Human Services; seven members shall be representatives
of consumer groups and organizations (including Medicaid recipients, labor unions, HMO's, etc.); and seven
members shall be Medicaid providers (one physician from a rural area, one physician from an urban area,
one nurse, one dentist, one pharmacist, one nursing home administrator, and one hospital administrator).
Edward W. Reed, M.D. Chair. Robert Grunow Milton Beckman, D.Ph.
975 Thomas Street 15th FI. Citizens Plaza 120 East College Street
Memphis, TN 38107 Nashville, TN 37219 Murfreesboro, TN 37130
Nellie Stafford
626 Rowan Court
Nashville, TN 37207
Jere Hale, D.D.S.
300 Bryant Street
Smithville, TN 37166
Jim Moss
Jackson Madson Gen. Hosp
708 West Forest
Jackson, TN 38301
John Brown, Dir. Benefits
Northern Telecom, Inc.
200 Athens Way
Metro Center
Nashville, TN 37228
Marion Wheeler John Green
412 Greenwood 1015 Mitchell
Clinton, TN 37716 Cookeville, TN 38501
Joan Chastain
7420 Greenwood Road
Harrison, TN 37341
Helen Louise Stout
Royal Care
P. 0 . Box 1051
Cleveland, TN 3731 1
Becky lngle
11 00 Gateway Avenue
Chattanooga, TN 37402
Thomas L. Adams
91 9 Marengo Lane
Nashville, TN 37204
Gregory Swabe, M.D.
Route 1, Box 965
Rogersville, TN 37857
Betty Thompson
Family Nurse Clinic
Metro Health Dept.East Station
127 Delcrest Drive
Nashville, TN 37217
2. Medicaid Formulary Advisory Committee:
Nine members appointed by the Commissioner for three-year terms (initial terms will be staggered). Five members
will be pharmacists. Each pharmacist member will be selected from nominations submitted by the Tennessee
Pharmaceutical Association. Four members will be physicians. Each physician member will be selected from
/,
nominations submitted by the Tennessee Medical Association. Members should be familiar with the Medicaid
k
program - preferably enrolled providers.
I
Cornrnunily Pharmacist
Horton Jones, D.Ph.
P
Jones Pharmacy
14th and Buchanan St
Nashville, TN 37208
Clinical/lnstit. Pharm. Institutional Pharmacist
Terry Brimer, Pharm.D. Dianna C. Drake, D.Ph.
Dr.s' Hospital Pharmacy 11 00 Shadyland Drive
726 McFarland Avenue Knoxville, TN 37919
Morristown, TN 37813
NPC - 1989
x
Tennessee - 4
Community Pharmacist Institut. Pharmacist ~h~si ci an' ~i dd1e TN
Ray Marcrom, Pharm.D. Gary Cripps, Pharm.D. Stephen Schillig, M.D.
Marcrom's Pharmacy
100 West Church Street
Metro. Board of Hospitals
1277 McArthur Street Smithville, TN 37166 72 Hermitage Avenue
Manchester, TN 37355
Nashville, TN 3721 0
Physician West TN
Charles W. White, M.D.
14 Hospital Drive
Lexington, TN 38351
Physician East TN
Physician Middle TN
Carl T. Duer, M.D.
Edward R. Hills, M.D.
Route 9
191 6 Patterson, Suite 704
Crossville, TN 38555 Nashville, TN 37203
3.
Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: B. Pharmaceutical Association:
L. Hadley Williams
Executive Director
TN Medical Association
112 Louise Avenue
Nashville, TN 37203
61 51327-1 451
Tom C. Sharp, Jr.
Executive Director
TN Pharmaceutical Assoc.
226 Capitol Blvd., Suite 705
Nashville, TN 3721 9
61 512563023
C. Osteopathic Association: D. State Board of Pharmacy:
Paul Grayson Smith, Jr., D.O.
President
TN Osteopathic Medical Association
2401 North Ocoee Street
Cleveland, TN 3731 1
J. Floyd Ferrell, Jr.
Director
Volunteer Plaza Building
500 James Robertson Parkway
Nashville, TN 37219-5322
61 5/741-2718
NPC - 1989
Texas - I
TEXAS
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA A0 APTD AFDC OAA A0 APTD AFDC Childrenc21 LSFO)
Prescribed Drugs X X X X X X
Inpatient
Hospital Care X X X X X X
Outpatient
Hospital Care
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services X X X X
'SF0 State Funds Only
" EPSDT Only
II. EXPENDITURES FOR DRUGS.
TOTAL $123,297,069 765,858 $138,104,400 823,845
CATEGORICALLY NEEDY CASH TOTAL
$96,271,628 641,597 107,739,746 676,871
Aged
43,515,529 136,456 47,483,886 136,325
Blind
1,041,720 3,972 1,192,269 4,017
Disabled
27,172,951 96,128 31,164,065 101,339
Children -Families w/Dep. Children
1 1,326,717 267,764 13,062,096 ' 287,726
Adults -Families w/Dep. Children
13,214,711 137,277 14,837,430 147,464
CATEGORICALLY NEEDY NON-CASH TOTAL $26,443,296 1 1 0,458 29,471,934 128,907
Aged
22,030,991 52,704 24,056,758 53,813
Blind
11,008 29 9,937 27
Disabled
2,270,792 5,501 2,551,341 5,827
Children -Families w/Dep. Children
1,303,294 34,101 1,791,350 47,785
Adults -Families w/Dep. Children
752,608 16,890 968,763 20,079
Other Title XIX Recipients
74,603 1,233 93,785 1,376
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families wlDep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
HHS report HCFA - 2082
NPC - 1989
Texas - 2
Ill. Administration:
Vendor drug program was implemented September 1, 1971
Texas Department of Human Services
IV. Provisions Relating to Prescribed Drugs:
Pharmacy services under the vendor drug program include the dispensing of most legend drugs and certain
non-legend drugs to eligible recipients. Only pharmaceuticals which meet the FDA requirements, are
approved for marketing and are approved by the Texas Department of Human Services for use in the
vendor drug program, may be supplied.
Certain OTC drugs are covered on a prescription basis except as otherwise provided in the reimbursement
formula and vendor payment to hospitals, nursing homes and institutions.
A. General Exclusions (diseases, drug categories, etc.): Adult vitamins and adult vitamin combinations,
amphetamines and obesity control drugs, appliances, durable medical equipment (bedpans, etc. -
either rental or purchase), elastic stockings, experimental drugs, fertility agents, first aid supplies,
foods, food supplements or additives, immunizing agents, medical supplies, oxygen, supports and
suspensories, syringes, needles and trusses.
B. Formulary: None. However, the Texas Drug Code Index is utilized for product identification and
claims processing and contains those drugs which are covered under the program.
For information contact:
Martha McNeill, R.Ph. Robert S. Nash, R.Ph.
Product Enrollment Specialist Administrator, Pharmacy Quality Assurance
Texas Department of Human Services Texas Department of Human Services
P. 0. Box 149030 M.C. 320W P.O. Box 149030 M.C. 320W
Austin, TX 78714-9030 Austin, TX 7871 4-9030
512/4503181 5121450-3198
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Prescribed quantity cannot exceed a six month supply.
2. Refills: Five refills, but total amount may not exceed 6 months' supply.
D. Prescription Charge Formula:
1. For prescription legend medication:
$3.26 average dispensing expense (ADE) formula for payment: (EAC + 3.26) divided by 0.945
= amount paid + $.I0 delivery service.
2. Insulin and approved non-legend drugs on prescription:pharmacistS and dispensing physicians
will be reimbursed on the basis of usual charges to the general public or cost plus 50% of
cost, whichever is lower: 50% of cost not to exceed assigned variable dispensing fee.
NPC - 1989 Texas - 3
V. Miscellaneous Remarks:
The dispensing fee, which includes all costs of filling a prescription, was established by cost accounting
and service evaluation of the expenses involved in dispensing a prescription. Therefore, fees paid to
providers who do not experience all cost and service factors considered in arriving at the fee, may be less
than the maximum allowable fee.
Copayment - None.
ORicials, Consultants and Commmees
1. Department of Human Resources Officials:
Ron Lindsay, Commissioner
Vacant, Executive Deputy Commissioner
Mary Polk, Executive Assistant
Donald L. Kelley, M.D., Deputy Commissioner for
Health Care Services
Dr. Janice Caldwell, Deputy Commissioner
Services to Aged & Disabled
Vendor Drug Program:
Roben S. Nash, R.Ph., Administrator
Martha McNeill, Product Enrollment Specialist
Curtis F. Burch, R.Ph., Pharmacy Field Coordinator
2. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
Robert G. Mickey
Executive Vice President
TX Medical Association
1801 N. Lamar Boulevard
Austin, TX 78701
51 21477-6704
C. Osteopathic Association:
Tom Hanstrom
Executive Director
I
TX Osteopathic Medical Association
i
226 Bailey Avenue
I
Fort Worth, TX 76107
1
81 71336-0549
TX Dept. of Human Services
701 West 5l st St. - P. 0. Box 149030
Austin, TX 78714-9030
6. Pharmaceutical Association:
Luther R. Parker
Executive Director
TX Pharmaceutical Association
P.O. 14709 - 1624 E. Anderson Lane
Austin, TX 78761-4709
51 21836-8350
D. State Board of Pharmacy:
Fred S. Brinkley, Jr.
Executive DirectorISecretaly
8505 Cross Park Drive, Suite 11 0
Austin, TX 78754-4533
5121832-0661
NPC - 1989
Utah - 1
UTAH
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC Childrem21 ISFO)
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X X
Laboratory &
X-rav Service
skilled Nursing
Home Services X X X X X X X X X X
Physician Services X X X X X X X X X X
Dental Services X X X X X X X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adult - Families w/Dep. Children
Other Title XIX Recipients
HHS report HCFA - 2082
1987
Expended Recipient
1988
Ewnded Recipient
NPC - 1989 Utah - 2
Ill. Administration:
Division of Health Care Financing, State Department of Health.
IV. Provisions Relating to Prescribed Drugs:
General Exclusions: Vitamins, (except for expectant mothers and children to age 5), anorectics;
(except for amphetamines and derivatives only for specific indications of narcolepsy and the
hyperkinesis.) Reimbursable over the counter drugs are:
Acetaminophen All dosage forms
Acetone tests' (e.g., Acetest, Chemstrip-K, Ketostix)
Antacid liquid and tablets
Aspirin All dosage forms
Contraceptive creams, foams, tablets and sponges
DSS concentrate drops 5%
DSS caps liquid and syrup
Ferrous fumerate All dosage forms
Ferrous gluconate All dosage forms
Ferrous sulfate All dosage forms
Glucose blood tests' (e.g., Chemstrip, BG, Dextrostix, Visidex)
Glucose urine tests' (e.g., Clinitest, Clinistix, Diatrix, Tes Tape, Chemstrip G)
Insulin
Insulin syringes/needles/disposablesi
Kaolin wlpectin suspension (e.g., Kaopectate)
Lactobacillus acidophilus (e.g., Bacid, Lactinex)
Pedialyte liquid
Prophylactics male
Psyllium muciloid powder
Quinine 5gr
Nutrients (all nutrients require prior approval)
Formulary: open formulary (effective January 1, 1985).
Prescribing or Dispensing Limitations:
Quantity of Medication: In general, the quantity of medication shall be limited to a supply not to
exceed 30 days except for "sustainingVrugs, for which a 100-day supply is authorized. Limited OTC
products.
Prescription Charge Formula:
Lowest of EACIMAC Cost plus professional fee of $3.65, or usual and customary charges to the
private sector for legend and generic legend drugs. EAC is AWP minus 12%. OTC is AWP minus
12% plus $1.00 dispensing fee.
Not reimbursable for patients who are residents of nursing homes.
325
VPC - 1989
Officials, Consultants and Committees
I. Department of Health Officials:
Suzanne Dandoy, MD
Executive Director
Rod L. Betit, Director
RaeDell Ashley, Manager, Policy Planning
2.
Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
J. Leon Sorenson
Executive Director
UT State Medical Association
540 East 5th South
Salt Lake City, UT 841 02
Phone: 8011355-7477
Depanrnent of Health
288 N. 1460 West
Salt Lake City, UT 841 16
8011538-61 51
Div. of Health Care Financing
B. Pharmaceutical Association:
Utah - 3
C. Neil Jensen
Executive Director
UT Pharmaceutical Association
1062 East 21s South, Suite 21 2
Sait Lake City, UT 84106
8011484-9141
C. Osteopathic Association: D. State Board of Pharmacy:
Robert Moody, D.O.
President
2230 N. University Avenue
Provo, UT 84604
801/377,3413
David E. Robinson
Director
Division of Occupational &Prof. Licensing
160 East 300 S. - P.O. Box 45802
Salt Lake City, UT 84145-0802
8011530-6634
NPC - 1989 Vermont - 1
VERMONT
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Chi l drew21 (SFO]
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care
outpatient
Hospital Care
Laboratory &
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X X
Physician Services X X
Dental Services X X X X X X X X X X
3 F 0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep.children
Other Title XIX ~e c i ~i e n t s
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
1987 1988
Expended Recipient Expended Reci~ient
HHS report HCFA - 2082
Vermont - 2
I. Administration:
Agency of Human Services.
u'. Provisions Relating to Prescribed Drugs:
Program allows the weKare recipient to have free choice of physicians and pharmacists; lock-in provision
for mis-utilizers.
A.
General Exclusions: prior authorization is required for therapeutic vitamins, cathartics, antacids,
analgesics and fecal softenen.
B. Formulary: None, provided drug is included in Official Compendia.
The National Drug Code Directory is now being used as a drug manual for coding purposes. For
information or submissions contact:
Stan Lane
Health Department
60 Main Street
Burlington, VT 05401
8021663-7200
C. Prescribing or Dispensing Limitations:
1.
Quantity of Medication: Initial prescription should be sufficient to allow for the determination
of the patient's tolerance of the medication without creating unnecessary waste (expense) to
the program. This quantity could be up to a 60-day supply on all maintenance medication
prescriptions.
2. Refills: Up to 5 refills may be authorized by physician.
D.
Prescription Charge Formula: Pharmacies bill their usual and customary charge. Medicaid pays the
lower of:
1. Usual and customary
2.
EAC plus $2.75 fee (when ingredient cost exceeds $27.50 the fee becomes 10%).
3. the maximum allowable cost plus fee
E. Co-pay of $1.00 per dispensation required (excluding standard federal exemptions).
V. Miscellaneous
Fiscal Intermediary:
1. Agency of Human Services:
Gretchen Morse, Secretary
EDS Federal
P. 0. Box 1102
South Burlington, VT 05401
Oftidals, Consultants and Committees
Agency of Human Services
103 S. Main Street
Waterbury, VT 05678
8021241-2880
NPC - 1989
Vermont - 3
2. Social Welfare Department:
Elmo A. Sassorossi, Director
Director
Medicaid Division
Jeanne Richardson, Deputy Director
Charles Perry, Chief of Policy & Procedures
Robert Thomas, Quality Assurance Specialist
Robert Edson, R.Ph., Pharmacy Consultant
3. Medicaid Pharmacy Peer Review Committee:
Michael Scollins, M.D., Chairman
Medicaid Division
103 South Main Street
Waterbury, VT 05676
Medicaid Division
Dept. of Social Welfare
Medicaid Division
103 South Main Street
Waterbury, VT 05676
James Craddock, R.Ph.
Edgar Hyde, M.D.
James Lill, R.Ph.
John Low, R.Ph.
4. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: B. Pharmaceutical Association:
.
Karen Meyer
Executive Director
VT Medical Society
136 Main Street
Montpelier, VT 05602
802/223-7898
Neal Pease
Executive Director
VT Pharmacists Association
P. 0. Box 245
Richmond, VT 05477
8021434-3900
C. Osteopathic Association: D. State Board of Pharmacy:
John M. Peterson, D.O.
Janet Richard
Secretary-Treasurer Staff Assistant
VT St. Assn. Osteopathic PhysicianslSurgeons, Inc. Pavilion Office Building
28 School Street
Monpelier, VT 05602
Montpelier, VT 05602 80218282372
8021229-941 8
NPC - 1989
-
Virginia - 1
VIRGINIA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other.
OAA A8 APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs X X X X X X X X X
Inpatient
Hospital Care
outpatient
Hospital Care
Laboratory &
X-ray Service X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X
Physician Services X X X X X X X X X
Dental Services
All eligible recipients under age 21
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families wjDep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
I987
Expended Recipient
$55,496,164 232.1 73
$40,934,813 189,808
14,550,263 32,201
346,650 896
16,923,427 37,119
3,439,629 72,670
5,674,845 46,922
$1,817,028 16,241
688,828 1,304
9,681 22
395,910 644
122,460 2,914
299,568 5,547
300,580 5,810
$12,744,323 26,124
10,169,033 15,685
56,458 92
2,148,301 3,385
277,127 4,885
41,310 1,007
52,094 1,070
I988
Expended Recipient
$63,203,806 236,909
46,745,814 187,046
16,789,917 32,877
389,944 883
20,047,174 39,030
3,633,074 69,877
5,885,705 44,379
2,472,557 22,129
906,777 1,536
13,767 29
440,458 724
228,462 5,080
457,696 7,262
425,397 7,498
13,979,504 27,417
11,068,185 16,097
63,774 93
2,410,493 3,532
301,126 4,821
54,892 1,210
81,054 1,664
HHS report HCFA - 2082
NPC - 1989
Virginia - 2
Ill. Administration:
By the Department of Medical Assistance Services. Eligibility determination by the Department of Social
Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Non-legend drugs except family planning drugs and supplies, insulin, insulin
syringes and needles; and effective July 1, 1989, diabetic test strips for recipients under 21 years
of age. Anorectic drugs and designated DESl drugs; and effective July 1, 1989, transdermal delivery
systems.
B. Formulary: None.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Physicians requested to prescribe maintenance drugs in quantities
reflecting a 30-day supply, or 100 units or doses.
2. Refills: Physicians may authorize refills according to legal requirements.
D. Prescription Charge Formula:
State Reimbursement - Based upon the lower of MACIEAC plus fee if legend or usual and customary
charge minus applicable co-pay
Pharmacy fee, $3.40
$l.OO/Rx for all qualifying prescriptions.
(Exclusions, under 21, pregnancy related, and nursing home patients)
Unit-Dose: (Nursing Home Rxs)
1. All providers of unit-dose must be certified by Medicaid program - for computer purposes.
2. Unit-dose applies to tablets and capsules and oral liquid dosage forms. Each t a l a or
capsule or 10 ml oral liquids.
Packaging allowance $0.01 57/d0se
Plus an additional $O.Ol/metric quantity
Legend Drugs:
MACIEAC plus $3.40 fee or usual and customary charge.
Prescription Payment Limitation:
One dispensing fee per legend drug per month. Previously applicable to dispensing for services to
nursing home recipients; effective July 1, 1989, applicable to dispensing for services to
noninstitutionalized recipients.
NPC - 1989
Virginia - 3
Lower of cost plus markup (50%) or usual and customary charge.
State MAC drugs (OTC) = 15 (Nursing Home only)
V. Miscellaneous
State MAC Program - Yes, 82 drugs.
Fiscal Intermediary:
The Computer Company (TCC)
P.O. Box 6987
Richmond, VA 23230
Officials, Consukants and Committees
1.
Dept, of Medical Assistance Services Officials:
Bruce U. Kozlowski, Director
8041786-7933
Mary Ann Johnson, R.Ph., Pharmacist
8041786-3820
Malcolm 0. Perkins, Manager, Provider Relations
8041786-671 3
Dept. of Medical Assist. Services
Suite 1300
600 East Broad Street
Richmond, VA 23219
Div. of Health Services Review
Div. of Operations/Provider Svces.
2. Governor's Advisory Committee on Medicaid:
Medical Soc. of VA
BI. Cr.lBI. Sh. of VA
VA State Dental Assn.
Thomas J. Berenguer, M.D. Richardson Grinnan, M.D. Barry Shipman, DMD
Frank S. Royal, M.D. (Old
(Dental School)
Dominion Society)
Ralph L. Anderson, DDS
VA Hospital Assn
William M. Moss
VA Pharmaceutical Assn. Participants Advisory Council
Thomas E. Rayfield, R.Ph. Sharon P. Urofsky
VA Health Care Assn.
Robert G. Jackson Others:
Ms. Cherie Ashcroft Stanley C. Tucker, M.D. Winifred C. Roberson
Manikoth G. Kurup, M.D. Charles H. Crowder, Jr., M.D. William H. Sipe, M.D.
William S. Thornton, DPM
Ms. Jessie H. Key Winston M. Ueno, M.D.
Richard E. Merritt
NPC - 1989 Virginia - 4
Ex Officio:
Larry D. Jackson, Commissioner
Howard W. Cullum, Commissioner
C.M.G. Buttery, M.D., Commissioner
State Dept. of Social Services
State Dept. of Mental Health and Mental
Retardation
State Dept. of Health
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: B. Pharmaceutical Association:
James L. Moore
Executive Vice-president
Medical Society of VA
4205 Dover Road
Richmond, VA 23221
80413532721
Paul Galanti
Executive Director
VA Pharmaceutical Association
3119 West Clay Street
Richmond, VA 23230-4785
8041355-7941
C. Osteopathic Association: D. State Board of Pharmacy:
L. P. Chang, D.O.
Secretarylrreasurer
VA Osteopathic Medical Association
1225 Martha Curtis Drive, G-7
Alexandria, VA 22302
7031998-6760
J. B. Carson
Executive Director
1601 Rolling Hills Dr.
Richmond, VA 23229-5005
8041662-991 1
NPC - 1989
Washington - 1
WASHINGTON
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC Children<21+
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care
Outpatient
Hospital Care
Laboratory &
X-ray Service X X X X X X X X X X
Skilled Nursing X X X X X X X X X X
Home Services X X X X X X X X X X
Phvsician Services X X X X X X X X X X
~eht al Services X X X X X X X X X
'SF0 - State Funds Only
+ Limited to children in foster care, subsidized adoption, SNH, IFC, ICMR or inpatient psychiatric facility.
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families wIDep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families wIDep. Children
Adults -Families w1Dep. Children
Other Ti l e XIX Recipients
Optional Categorically Needy
1987
Expended Recipient
1988
Expended Recipient
HHS report HCFA - 2082
NPC - 1989
I
Washington - 2
Ill. Administration:
By Division of Medical Assistance, Department of Social and Health Services. The Central Authorization Unit
(CAU) reviews the need for non-formulary drugs.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Medicine chest drugs are not provided. Non-formulary drugs are provided in
an emergent life-endangering situation and/or medically mandatory.
B. Formulary: Includes approximately 2,900 listings by drug product name, quantity, dosage form and
strength. Formulary is revised 2 to 3 times annually.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: No maximums: minimum of 30 days supply for maintenance
medications.
2. Refills: No more than 2 refills in any 30-day period unless prescription and refills are in amount
of 100's.
3. Dollar Limits: State and Federal MAC where listed,
D. Prescription Charge Formula: The amount shall not exceed the usual and customary charge to the
public or the maximum allowed by the department.
The maximum charge to the department is to be estimated acquisition cost (EAC) (as determined
by the Division of Medical Assistance) plus a dispensing fee for service.
Effective 9/1/88:
$4.20 - Unit dose systems (Nursing Home Rxs)
$3.15 - Retail pharmacies, filling over 35,000 Rxs annually
$3.60 - Retail pharmacies, filling 15,000-35,000 Rxs annually
$4.20 - Retail pharmacies, filling 15,000 or less Rxs annually
V. Miscellaneous
Co-payment - None. State MAC - 338 drugs
Claims processing agent: Consultec, Inc.
P.O. Box 9245
Mail Stop HA-1 1
Olympia, WA 98504
Officials, Consultants and Committees
1.
Social and Health Services Department Officials:
Richard J. Thompson, Secretary Dept. of SociaVHealth Services
08-44
Olympia, WA 98504
NPC - 1989
Washington - 3
Ron W. Kero, Director
Jeffery J. Graham, M.D., Medical Dir.
William P. Pace, R.Ph., Pharmacist Consultant
2061753-0524
Division of Medical Assistance
HB-41
Olympia, WA 98504
Office of Med. Dir./Program Policy
HB-41
Olympia, WA 98504
Office of Medical & Program Policy
HB-41
Olympia, WA 98504
2. Social and Health Services Department Medical Consultants:
Full-time: Local Office
Joan Baumgartner, MD - State Office, Olympia
Wesley M. Brock, M.D. - State Office, Olympia
Michael D. McGee, MD - State Office, Olympia
James A. Moore, MD - State Office, Olympia
Part-time:
James B. Hutchinson, DDS (Dental) - State Office Olympia
Curtis C. Sapp, DDS (Orthodontia) - State Office Olympia
Jerrol R. Neupert, MD (Opthomalogy) - Seattle
3.
Department of Social and Heaith Services Title XIX Advisory Committee:
Members:
Andrade Man
Childrens Orthepedic Hosp.
4800 Sand Point Way, NE
Seattle, WA 98105
Craig Karpilow, M.D.
4608 S.W. Hill Street
Seattle, WA 98104
Sheldon Biback, MD
3216 NE 45th Place
Seattle, WA 981 05
Betty Thornton
Community Health Services
Group Health Cooperative
83 S. King, Suite 51 5
Seattle, WA 981 04
David W. Gitch, Chair
Harborview ~edi cal Center
325 9th Avenue
Seattle, WA 98104
Patricia Slagle
Box 497
Republic, WA 99166
Willie Cain
1814 East Aiton
Pasco, WA 99301
Ivy Alston
1700 E. Fir
Seattle, WA 98122
Rob Rolfs (Ex. Officio)
DSHS - Division of Health
Mail Stop ET-21
Olympia, WA 98504
William Hobson
1422 34th Avenue
Seattle, WA 98122
Lawrence Mast, D.D.S.
1126-112th NE
Bellevue, WA 98004
Pamela Bingen
(confirmation pending)
1028 Alder Street
Edmunds, WA 98106
NPC - 1989
Washington - 4
Ron W. Kero, Director
Division of Medical Assistance
HE41
Olympia, WA 98504
James A. Peterson, Assist. Dir.
Div. of Medical Assistance
HB-41
Olympia, WA 98504
DSHS Staff Members:
Debbie Meyer, Secretary
Div. of Medical Assistance
HB-41
Olympia, WA 98504
Tom Bedell, Acting Chief
Off. of Provider Services
HA-1 1
Olympia, WA 98504
'Responsible for approving new formulary additions.
4. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
Thomas J. Curry
Executive Director
WA State Medical Association
2033 Sixth Avenue, Suite 900
Seattle, WA 98121
2061441 -9762
C. Osteopathic Association:
Warren Lawless
Executive Director
WA Osteopathic Medical Association
P. 0. Box 16486
Seattle, WA 981 16-0486
2061937-5358
Steve Peterson, Acting Chief
Off. Analysis/Medical Review
HA-41
Olympia, WA 98504
Jeffery J Graham, MD'
Medical Director
Off. of Med.lProgram Policy
HB-41
Olympia, WA 98504
B. Pharmaceutical Association:
Raymond A. Olson
Executive Director
WA State Pharmacists Assn.
1420 Maple Avenue
Suite 101
Renton, WA 9805531 96
2061228-71 71
D. State Board of Pharmacy:
Donald H. Williams
Executive Secretary
WEA Building
319 E. 7th Avenue, FF-21
Olympia, WA 98504-3121
5061753-6834
-
NPC - 1989
West Virginia - 1
WEST VIRGINIA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Childrenx21
Prescribed Drugs X X X X X X X
Inpatient
Hospital Care X X X X X X X
outpatient
Hospital Care
Laboratory &
X-ray Service X X X X X X X
Skilled Nursing
Home Services X X X X X X X X
Physician Services X X X X X X X X
Dental Services X X X X X X X X
'SF0 - State Funds Only
11. EXPENDITURES FOR DRUGS.
1987 1988
Ex~ended Recipient Expended Recipient
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families wlDep. Children
Other Title XIX Recipients
HHS report HCFA - 2082
NPC - 1989 West Virginia - 2
Ill. Administration:
The Division of Medical Care, Department of Human Services, is the medical assistance unit responsible
for the administration of the Title XIX program. Eligibility for program benefits is determined by the local
Welfare offices for AFDC and medically needy individuals. Individuals eligible for SSI benefits are covered
for Medicaid as categorically needy, aged and disabled.
IV. Provisions Relating to Prescribed Drugs:
PROGRAM COVERAGE:
A. Ail covered drugs, whether legend or non-legend, must be prescribed by a physician or other
practitioner qualified under State law. Applicable State and Federal law governing dispensing of
drugs and biologists must be followed:
Drugs identified in the Medicaid Drug Formulaty, listed by product or therapeutic class, are covered
without prior authorization.
COVERED SERVICES:
1. Legend Drugs
Legend drugs including injectables are covered unless specifically excluded.
2. Non-Legend Drugs
The following non-legend drugs are covered:
(a) Family planning supplies
(b) insulin
(c)
Diabetic syringes, needles, and testing kits
(d)
ESRD vitaminivitamin mineral preparations, and other medications related to End Stage Renal
Disease services.
Exception:
Non-legend drug coverage does not apply for clients residing in long-term care facilities
(SNFIICF).
COVERAGE WITH PRIOR AUTHORIZATION
Consideration may be given on special drug needs of a client by the Medical Director on an individual basis
based on medical information supplied by the attending physician in the format specified by the State.
Specific items covered by prior authorization are:
1. Antibiotics and analgesics for chronic usage; i.e., over ten days.
2. Medical supplies and equipment. Medical Supplies; i.e., bandages, colostomy bags, underpads,
and other items required for home care, and covered by the Department based on a treatment plan
developed for the individual client.
NPC - 1989
West Virginia - 3
3.
Viiamin/vitamin mineral preparations for End-State Renal Disease patients and other medications
related to End-Stage Renal Disease services.
4. Life sustaining, critical, or necessary drugs not included in the formulary.
EMERGENCYCOVERAGE
If a physician determines that a particular drug is needed for his patient which is not included on the
formulary list, and is not excluded from program coverage, and that an emergency situations exists, he may
so indicate by writing "emergency" on the prescription above his signature. These prescriptions will be
covered up to a ten-day supply with no refill. Continuous therapy, if needed, will require prior authorization.
NON-COVERED SERVICES
The following drugs and drug products are not payable:
I.
Non-legend drugs except for those identified in IV. A.2.
2.
Legend drugs and drug products as follows:
(a)
Appetite depressants andlor drug products for weight control.
(b) Fecal softening agents; laxatives.
(c)
Food, food products-as labeled by F.D.A.(d)Experimental drugs; i.e., drugs under development,
in clinical testing, or other processes short of being fully approved by the F.D.A.
(e)
Oral vitamins, vitamin and mineral combinations, geriatric tonics.
(0
"Minor tranquilizers" identified by the Department.
(g)
Drugs determined by the F.D.A. of the Department of Health and Human Services to lack
substantial evidence of effectiveness published in the Federal Register, Volume 46, Number
210, dated Friday, October 30, 1981. Also, identical, related or similar drugs are included.
3. Exceptions:
The following exceptions are made:
(a)
Vitamins A, K, and D.
(b)
Vitaminfvitamin and mineral preparations for End-Stage Renal Disease patients, and other
medications related to End Stage Renal Disease services.
HANDICAPPED CHILDREN'S SERVICES PROGRAM
1. Pharmacy Services: Services are available for certain children under 21 years of age receiving
medical care within the Division of Handicapped Children's Services. These services are not limited
to children of families receiving public assistance grants.
2. Scope of Services: Prescriptions are limited to a one-month supply with maximum of five monthly
refills in any six-month period.
B. Formulary West Virginia Medicaid Drug Formulary List
NPC - 1989
For information contact:
West Virginia - 4
J.L. Mangus, M.D.
WV Department of Human Services
Division of Medical Care
1900 Washington Street, E.
Charleston, WV 25305
3041348-8990
C. Prescribing or Dispensing Limitations:
QUANTITY AND FREQUENCY
Covered legend and non-legend drugs are payable as prescribed by a licensed practitioner up to
a 30-day supply with a maximum of five refills.
Exception:
1. Antibiotics and analgesics are limited to a maximum of ten days with no refills. (See prior
authorization.)
2. Excluding phenobarbital, sedatives and hypnotics are limited to a maximum of 30 days with
no refills.
D. Prescription Charge Formula:
1. Maximum reimbursement for each drug claim processed will be based on the lowest of:
(a)
The maximum allowable cost (MAC) for each multiple-source drug as defined by the
Pharmaceutical Reimbursement Board and published in the Federal Register plus a
dispensing fee.
Exception: The MAC shall not apply in any case where a physician certifies i n his own
handwriting that in his medical judgement a specific brand is medically necessary for
a particular patient. A notation like "brand necessary" written by the physician on the
prescription above the physician's signature is an acceptable certification. A procedure
for checking a box on a form will not constitute an acceptable certification.
All such certified prescriptions must be maintained in the pharmacy files and made
available for inspection by the Department of Health and Human Services and the
Department of Welfare.
(b)
The estimated acquisition cost (EAC) for each multiple-source drug as defined by the
State plus a dispensing fee.
(c)
The acquisition cost or average wholesale price (AWP) for all other prescribed drugs
plus a dispensing fee.
(d)
The usual and customary price charged by the pharmacy to the general public including
any sale price which may be in effect on the date of service.
NPC - 1989
West Virginia - 5
APPLICATION OF DISPENSING FEE
A. For covered legend and non-legend drugs, a professional dispensing fee of $2.75 will. be
added to the Federally established MAC or State-established acquisition cost price of each
prescribed drug.
B.
For a compounded prescription, an additional $1.00 will be added to the dispensing fee. A
compound prescription is defined as any legend medicament requiring a combination of any
two or more substances to exclude normal reconstitution operations.
C. Unit dose drug delivery systems are reimbursed under the same provisions as other legend
drug services to Medicaid patients. Legend drugs are reimbursed on a 30-day basis
regardless of drug delivery system or how the pharmacist may choose to dispense.
CO-PAYMENT
A co-payment is required for each prescription filled on and after March 10, 1981, with the exception
of those items specifically excluded from the co-pay requirement. The recipient co-payment per
prescription will be deducted from the maximum allowable payment (prescription charge formula) to
determine the amount payable for each prescription billed to the programs.
The deduction will apply as follows:
I.
If the maximum allowable payment is under $10.99, the reduction will be $0.50 per prescription.
2.
If the maximum allowable payment is $11.00 or more, the reduction will be $1.00 per
prescription.
Excluded from the Co-Pay Requirement:
(a)
Family Planning Services and Supplies.
(b)
Prescriptions originating with the Early and Periodic Screening, Diagnosis and Treatment
Program (EPSDT).
V. Miscellaneous:
Claims processor: The Computer Company
Richmond, VA
1. Welfare Department Officials:
Reginia S. Lipscomb, Commissioner
Officials, Consukants and Committees
WV Department of Human Services
1900 Washington Street, East
Charleston, WY 25305
NPC - 1989
J. L. Mangus, M.D., Medical Director (part-time)
Helen M. Condry, Director
Ann Bond Smith, Pharmacy Coordinator
Division of Medical Care
Division of Medical Care
3041348-8990
2. Welfare Department Medical Services Advisory Council:
Medical Service Fund (MSF) Advisory Council Members
Regular Members:
Chair~erson
Joseoh V. Rice. DDS
1321' Quarrier st.
Charleston, WV 25301
3041343-9479
(Dentist Rep)
Jack E. Fruth, R.Ph.
Fruth Pharmacy
2501 Jackson Avenue
Pt. Pleasant, WV 25550
3041675-2303
(Pharmacist Rep)
Wilbur R. James
2240 Oakridge Drive
Charleston, WV 25305
(Consumer Rep)
Vice Chair.
Joseph W. Powell
President
WV Labor Fed. (AFL-CIO)
501 Broad Street
Charleston, WV 25301
3041344-3557
(Consumer Rep)
Mrs. Alice M. Couch
Administrator
Valley Haven Geriatric Ctr
RD 2, Box 44
Wellsburg, WV 26070
3041394-5322
(Nursing Home Rep)
Kenneth Fultz
President
Montgomery Gen. Hosp.
Washington & 6th Ave.
Montgomery, WV 25136
3041442-51 51
(Hospital Rep)
David K. Heydinger, MD
State Health Director
WV Dept. of Health
Capitol Complex-Bldg 3
1800 Washington St. East
Charleston, WV 25305
(Ex Officio Member)
Ms. Omeda Lucas
Route 1, Box 27
Lester, WV 25865
3041934-7248
(Consumer Rep)
Ms. Helen V. Stanley
214 N. Boulevard, West
Huntington, WV 25701
(Consumer Rep)
Alternate Members:
Thomas L. Carson, R.Ph. Jack R. McComas
College Drug Store, Inc. SecretarylTreasurer
Drawer 51 0 WV Labor Fed. (AFL-CIO)
Montgomery, WV 25136 501 Broad Street
3041949-5202 Charleston, WV 25301
(Pharmacist Alternate-Fruth) 3041344.3557
Consumer Alternate-Powell)
West Virginia - 7
Drug Formuby Committee
Pharmacy:
David P. Elliott
Asst. Prof. & Vice Chair.
WVU School of Pharmacy
31 10 MacCorkle Avenue, SE
Charleston, WV 25304
Tom Carson, R.Ph.
College Drug Store
Drawer 50
Montgomery, WV 25136
John W. Chambers, Ph.D.
Professor & Chairman
Dept. of Pharmacology
WV School/Osteopathic Med
400 North Lee Street
Lewisburg, WV 24901
Roger Shallis, R. Ph.
South Berkeley Pharmacy
Inwood, WV 25428
Medicine: Chairman:
Shirley Neitch, MD
Douglas Glover, MD, R.Ph.
Assoc. Prof. of Medicine
Dept. of OBIGYN
Chief, Section of Geriatrics
WV University Medical Ctr.
Marshall Univ. Sch. Medicine
Morgantown, WV 26506
Huntington, WV 25701
James T. Hughes, MD
Richard G. Starr, MD
Internist Internist
Jackson Medical Center
220 Professional Park
Ripley, WV 25271
Beckley, WV 25801
James H. Walker, M.D.
Ann Bond Smith, R.Ph.
Acting Medical Director
Division of Medical Care
Div. Handicapped Children's Sew.
Dept. of Human Services
Dept. of Human Services
C. Jean Cebula, R.N.
Laurie Tully, R.N.
Division of Medical Care
Handicapped Children's Sew.
Dept, of Human Services
Dept. of Human Services
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: B.
Merwyn G. Scholten
Executive Director
W State Medical Association
Box 41 06
Charleston, WV 25364
3041925-0342
C. Osteopathic Medicine: D.
Charlotte Ann Cales
5209 Washington Avenue, SE
Charleston, WV 25304-21 35
3041925-8264
Patrick M. Regan, R.Ph.
Rite Aid Pharmacy # I 634
8333 Court Avenue
Hamlin, WV 25523
John P. Hutton, MD
Clinical Director
Shawnee Hills Community
Mental Health Center
51 I Morris Street
Charleston, WV 25301
Patricia Jones
Rt. 1, Box 31 9-A
Charleston, WV 25312
J. L. Mangus, M.D., R.Ph.
Medical Director
Division of Medical
Dept, of Human Services
Joan Faris, R.N., M.S.N.
Office of Behavioral Health Services
Dept. of Health
Pharmaceutical Association:
Richard D. Stevens
Executive Director
WV Pharmacists Association
4004 MacCorkle Ave., SE, Suite 4
Charleston, WV 25304
304J925-7204
State Board of Pharmacy:
Dolores Prantil
Acting Office Administrator
150 Rockdale Road
Follansbee, WV 26037
3041527-1 270
NPC - 1989 Wisconsin - 1
WISCONSIN
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other.
OAA AB APTD AFDC OAA AB APTD AFDC Childrenc21
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X X
Laboratory &
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X X
Physician Services X X X X X X X X X X
Dental Services X X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families wIDep. Children
CA~EGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w1Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
1987
Expended Reci~ient
$66,232,967 281,675
$37,643,353 228,668
8,140,516 23,018
306,064 868
20,884,881 46,836
3,533,171 95,992
4,778,721 63,626
$25,959,037 97,538
18,200,002 35,542
14,873 33
5,086,247 9,039
61 9,470 26,468
894,851 23,317
1,143,594 4,496
$2,630,577 12,537
1,506,102 5,358
7,949 18
970,132 2,886
111,496 3,851
33,123 453
1,775 30
HHS repon HCFA - 2082
-
NPC - 1989
Wisconsin - 2
Ill. Administration:
The State Department of Health and Social Services.
IV. Provisions Relating to Prescribed Drugs:
General Exclusions:
1.
Legend laxatives and non-prenatal vitamins.
2.
All non-legend pharmaceuticals except Insulin, antacids and analgesics.
Formulary: No. Negative formulary includes (1) Alginic acid containing antacids; (2) propoxyphene
napsylate; (3) quinine sulfate; (4) progesterone for PMS; (5) chlordiazepoxidelamitriptyline combos;
(6) papa~ari ne hydrochloride.
Prescribing or Dispensing Limitations:
1. Quantity of Medication: Pharmacists may not dispense more than 34-day supply of a legend
drug. Certain exceptions for maintenance drugs (100 day supply).
2. Refills: Maximum of 11 refills during a 12-month period for non-scheduled medications.
3. Dollar Limits: None.
Prescription Charge Formula:
1. Traditional (non-unit dose) dispensing reimbursed at the lowest of: Estimated Acquisition Cost
(EAC) plus $3.72 professional fee; Maximum Allowable Cost (MAC) plus $3.72 professional fee;
or providers usual and customary. Maximum of two dispensing fees per month.
2. Unit Dose Dispensing - reimbursement at the lowest of: Estimated Acquisition Cost (EAC) plus
$5.73 professional fee; Maximum Allowable Cost (MAC) plus $5.73 professional fee; or providers
usual and customary.
Reimbursement limited to one unit dose professional fee per drug per month.
Miscellaneous Remarks:
A. Prior authorization required on the following drugs:
1. All anorectics 4. Cyclosporine
2. Cephulac 5. Total parenteral nutrition
3. Human Growth Hormone 6. Interferon
7. Enteral Nutrition
B. Co-payment: All legend and over-the-counter drugs except family planning drugs are subject to a
$.50 co-payment. Residents of Skilled Nursing Facilities (SNF) or Intermediate Care Facilities (ICF),
subsidized adoption recipients, children under age 18 and HMO enrollees are exempt from the co-
payment. (Co-payments limited to 10 per month)
NPC - 1989
C. State MAC Program - Yes. (163 entities and dosage forms)
D. Fiscal Intermediary:
EDS - Federal
6406 Bridge Road
Madison, WI 53713
Officials, Consunants and Committees
1. Health and Social Services Department Officials:
Patricia Goodrich, Secretary
George F. MacKenzie, Administrator
Christine Nye, Director
Alfred Dally, M.D., Physician Consultant
Michael Boushon, Pharmacy Practices Consultant
Wisconsin - 3
Dept. of HealthISocial Services
State Office Building
One West Wilson Street
Madison, Wl 53702
Division of Health
Bur. of Health Care Financing
(Medicaid)
2. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: 0. Pharmaceutical Association:
Thomas L. Adams
Secretary-General Manager
State Medical Society of WI
330 East Lakeside, Box 11 09
Madison, WI 53715
6081257-6781
Robert E. Henry, MS., P.D.
Executive Director
WI Pharmacists Assoc.
202 Price Place
Madison, WI 53705
6081238-551 5
C. Osteopathic Association: D. State Board of Pharmacy
Robert J. Finnegan
Executive Director
WI Assn. of Osteopathic PhysiciansiSurgeons
3451 5 Road E.
Oconomowoc, WI 53066
4141567-0520
Roberta Ward
Program Assistant
Box 8935
1400 East Washington Avenue
Madison, WI 53708
6081266-2811
NPC - 1989
Wyoming - 1
WYOMING
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AS APTD AFDC Children<21
Prescribed Drugs
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services
'SFO - State Funds Only
11. EXPENDITURES FOR DRUGS.
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
~dul t s -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children - Families w/Dep. Children
~dul t s - Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
Wyoming implemented a temporary Medicaid
Pharmaceutical Services Program, effective
August I, 1988, at the regular state administrative
match. A full MMIS, including the pharmacy
program, will be implemented on July I , 1989.
HCFA 2082 data will not be available for Federal
FY 1988.
HHS reporl HCFA - 2082
NPC - 1989
Wyoming - 2
Ill. Administration:
The Medicaid (Title XIX) Program is administered by the Medical Assistance Services Unit within the Division
of Health and Medical Services, Department of Health and Social Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Experimental drugs; anorexiants, except amphetamines and derivatives which are used
for narcolepsy and hyperkinetic states; fertility medication; products to stimulate hair growth; DESl drugs;
OTC drugs for in-home patients that are not listed in the Medicaid manual. Prior authorization is required
for AIDS medications, compounded drugs, home IV solutions, legend vitamins other than pediatric and
prenatal, nutritional supplements and post-transplant medications.
B. Formulary: Open with exceptions as listed above. The First Data Bank, National Drug Data File, provides
the fiscal agent with the Average Wholesale Unit Price and Date (Blue Book).
C. Prescribing or Dispensing Limitations: Each prescription shall be dispensed in the quantity ordered by a
physician, except as provided below:
Chronic conditions - prescriptions for chronic conditions for which a physician has not ordered a
specific quantity shall be dispensed in quantities of 100 or a minimum of one month's supply of
medication.
Acute Conditions - prescriptions for acute conditions for which a physician has not ordered a specific
quantity shall be dispensed in sufficient quantities to cover the period of time for which the condition
is being treated, except for injectable antibiotics, which may be dispensed in sufficient quantities to
cover a three-day period.
Schedule II drugs cannot be refilled.
0
Schedule Ill or IV drugs cannot be filled or refilled when the prescription is more than 6 months old.
Schedule Ill or IV drugs cannot be refilled more than 5 times.
Notwithstanding the above, prescriptions for all conditions may not be dispensed in quantities greater than
100 dosages or one month's supply, whichever is greater.
NO dollar limits.
Prescription splitting is prohibited. If a pharmacy does not have a sufficient supply of a product to fill a
prescription completely, it may only charge a dispensing fee when the initial amcunt of the product is
dispensed. The charge for the balance of the prescription must be for the cost of the product only.
D. Prescription Charge Formula: Payments for pharmacy services shall be the lowest of the following:
The average wholesale price (AWP) of the ingredient plus a dispensing fee;
The federally mandated maximum allowable cost (FMAC) plus a dispensing fee;
The pharmacy's usual and customary charge to the public, as indicated by the claim; or
The upper limit established by the Health Care Financing Administration (HCFA) for multiple source
drugs, except if "brand necessary" Or "medically necessary" is noted on the prescription by the
prescriber.
NPC - 1989
Wyoming - 3
E. Medicaid Dispensing Fee: The Medicaid dispensing fee for pharmacies is $4.16 or the customary markup
for the prescription filled, whichever is lower. The Medicaid dispensing fee for physicians dispensing
prescriptions is $2.00 per prescription.
Providers of nursing home 'unit dose" prescriptions are to bill the Medicaid program no more than once
a month per recipient and are allowed only one dispensing fee per prescription for chronic conditions, i.e.,
to be provided in quantities of 100 or a minimum-of one month's supply. The Medicaid maximum limits
(i.e., the greater of 100 doses or one month's supply) also apply except for Schedule II drugs.
V. Miscellaneous:
Copayment: A $1.00 charge per prescription is imposed on Medicaid recipients for pharmaceutical services.
The following recipients or products are exempt from the copayment:
o Foster care children
Eligible recipients under age 21
o
Patients residing in nursing homes
Family planning products
Products related to conditions of pregnancy
Primary Pharmacy: Recipients using pharmacy sewices will be restricted to receiving sewices from the
pharmacy filling the initial prescription for any one month of eligibility. The first pharmacy filling a
prescription for the month will retain that portion of the Medicaid Identification Card authorizing pharmacy
services. A Medicaid-enrolled pharmacy that is not the designated provider may provide and be paid for
sewices to these recipients only under the following circumstances:
-
In a real medical emergency where a delay in treatment may cause death or result in a lasting injury
or harm to the recipient.
When the primary pharmacy does not stock or is unable to obtain the drug or cannot fill the entire
prescription.
Claims Processing: Wyoming MedicaidIEDS
P. 0. Box 1245
Cheyenne, WY
3071778-2804
ORicials, Consultants and Committees
1. Health and Social Services Department Officials:
Ken Heinlein, (Interim) Director
3071777-7351
R. Larry Meuii, M.D., Administrator
3071777-71 21
Kenneth C. Kamis, Director
3071777-5399
Dept. of HealthISocial Services
11 7 Hathaway Building
Cheyenne, WY 82002-0710
Division of Health & Medical Sewices
Medical Assistance Services
Fred J. Lund, Program Consultant
3071777-6099
Prescription Drug Program
NPC - 1989
2 Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: B.
Richard W. Johnson, Jr.
Executive Director
WY State Medical Society
1920 Evans, P.O. Drawer 4009
Cheyenne, WY 82003-4009
3071635-2424
C. Osteopathic Association: D.
Jonathan W. Singer, DO
President
WY Association of Osteopathic Physicians/Surgeons
1805 E. 19th Street, Suite 202
Cheyenne, WY 82001
30716354362
Pharmaceutical Association:
Richard Abood
Executive Director
WY Pharmaceutical Association
11 15 Custer
Laramie, WY 82070
3071766-6126
State Board of Pharmacy:
Marilynn H. Mitchell
Executive Director
1720 S. Poplar St., Suite 5
Casper, WY 82501
3071234-0294
Wyoming - 4
NATIONAL PHARMACEUTICAL COUNCIL, INC.
Abbott Laboratories
North Chicago, IL 60064
Miles, Inc.
West Haven, CT 0651 6
Boehringer lngelheim Pharmaceuticals, lnc.
Ridgefield, CT 06877
Norwich Eaton Pharmaceuticals, Inc.
Norwich, NY 13815
Bristol-Myers US. Pharmaceutical Group
Evansville, IN 47721-0001
Parke-Davis
Morris Plains, NJ 07950
Burroughs Wellcome Co.
Research Triangle Park, NC 27709
Pfizer Inc.
New York, NY 10017
CIBA-GEIGY Corporation
Summit, NJ 07901
A.H. Robins Company
Richmond, VA 23220
DuPont Pharmaceuticals
Wilmington, DE 19898
Roche Laboratories
Nutley, NJ 07110
Glaxo Inc.
Research Triangle Park, NC 27709
Rorer Pharmaceuticals
Fort Washington, PA 19034
Hoechst-Roussel Pharmaceuticals Inc.
Somewille, NJ 08876
Sandoz Pharmaceuticals
East Hanover, NJ 07936
ICI Pharmaceutical Group
Wilmington, DE 19897
Schering Corporation
Kenilworth, NJ 07033
Johnson & Johnson
New Brunswick, NJ 08903
G. D. Searle & Co.
Skokie, IL 60680
Lederle Laboratories
Wayne, NJ 07470
Smith Kline & French Laboratories
Philadelphia, PA 19101
Eli Lilly and Company
Indianapolis, IN 46285
E.R. Squibb & Sons, Inc.
Princeton, NJ 08540
Marion Laboratories, Inc.
Kansas City, MO 641 14
Syntex Laboratories, Inc.
Palo Alto, CA 94304
Merck Sharp 8 Dohme
West Point, PA 19486
The Upjohn Company
Kalarnazoo, MI 49001
Merrell Dow Pharmaceuticals, InC.
Cincinnati, OH 45242
Winthrop Pharmaceuticals
New York, NY 10016
NPC MEMBER COMPANIES
Abbott Laboratories
Boehringer Ingelheim Pharmaceuticals, Inc.
Bristol-Myers US. Pharmaceutical Group
Burroughs Wellcome Co.
CIBA-GEIGY Corporation
DuPont Pharmaceuticals
Glaxo Inc.
Hoechst-Roussel Pharmaceuticals, Inc.
ICI Pharmaceuticals Group
Johnson & Johnson
Lederle Laboratories
Eli Lilly and Company
Marion Laboratories, Inc.
Merck Sharp & Dohme
Merrell Dow Pharmaceuticals Inc.
Miles, Inc.
Norwich Eaton Pharmaceuticals
Parke-Davis
F'fizer Inc.
AH. Robins Company
Roche Laboratories
Rorer Pharmaceuticals
Sandoz Pharmaceuticals
Schering Corporation
G.D. Searle & Company
Smith Kline & French Laboratories
E.R Squibb & Sons, Inc.
Syntex Laboratories, Inc.
The Upjohn Company
Winthrop Pharmaceuticals
National Pharmaceutical Council
1894 Preston White Drive Reston, Viginia 22091 703-620-6390

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