Pharmaceutical Benefits Under State Medical Assistance Programs, 1989

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 assist 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 development, 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 in 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 beginning 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 recognized 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 specialized 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 education), 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 physician. 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 practitioners 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 in 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 programs 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 copayments 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.~rovis ions 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 prevailing 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 reported 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 in 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 to 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.

Fiied 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.

Formulq: 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 in 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 is 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 therapeutic 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.

P r 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 in 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 in the costs of practice and in 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 in 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 ion : 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 injury, 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 HI0 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. Kier, 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 Medicaid 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 singe 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 Medicaid 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 m r 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 authoii 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 being easily 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 c la i l ing 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 in the NPRM. This requirement Is a safeguard that assures that the physician can select the drug that is medically necessaty and best s u b d 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 their 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 compdiion for a certain period of time during which they may charge prices high enough, presumably, 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 in this final rule pertain only to the Medicaid program. They do not apply t o hospitals 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 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 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~tina 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 - w o ~ 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 in 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 to 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 ~roviders 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 to 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 iwel 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 wth 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~tive~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 q e o ~ r a ~ h i 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 chains t o small independent single-owner outlets. Yet because retaii pharmaceutical markets appear to be largely local in nature, retaii pharmacies operate in 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, w h o l e s a l e d i s t r i b u t o r s a n d manufacturers, also may qualify as smail entities under the RFA, but are mora iikeiy to participate in 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 competitive basis for ~harmaceutical services with selected pnarmacias to wn:ch recipients may go for o r ~ g s r r ~ l n o ~ t inc~rr ing 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 in 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 to 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 to 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 fii 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 th ree al ternat ive presented. 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

~ h u s , 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-PRINCIPLES 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 A d (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 multi~le 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 in 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 the (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,

'Limitations 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~llMlTAllONS 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 Health Care Financing

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 in 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 D a ~ 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


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


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


Chlorthalidone


Clindamycin Hydrochloride

75 mg Capsule i 50 mg Capsule


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'


Librium

Diuril

Diabinese

Hygroton

Cleocin

Paraflex Parafon Forte DSC

Atromid-S

Catapress

Tranxene

Tegopen, Cloxapen, etc.


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 I00 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


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


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


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


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


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


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


Ibuprofen


Tofranil lmipramine Hydrochloride


Addendum A (cant.) PAYMENT FOR SERVICES

GENERIC NAME GENERIC UPPER LlMITbJNIT Source'


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


Meclizine Hydrochloride

12.5 mg Oral Tablet 25 mg Oral Tablet

Meclofenamate Sodium


Mefenamic Acid

" 250 mg Capsule

Megestrol Acetate


Meperidine Hydrochloride


Meprobamate


Mestranol; Norethindrone

0.05 mg; I mg Tablet, Oral21 Tablet, Oral-28

Metaproterenol Sulfate


Methocarbamol


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


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


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'


Aquatensen, Enduron, etc.

Aldomet

Ritalin

Reglan

Flagyl

Loniten

Neggram

Vasocon

Macrodantin

Mycostatin


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 Gginal 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


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


Promethazine Hydrochloride

6.25 mgl5 ml Syrup 480 ml

Propantheline Bromide

15 mg Tablet

Propoxyphene Hydrochloride

65 mg Capsule

Propranolol Hydrochloride


GENERIC UPPER UMIT/UNIT Source'


Azolid; Butazolidin, etc.

Phenergan VC

Dilantin

Metimyd, Predsulfair

Mysoline

Benemid

Pronestyl, etc.

Compazine

Phenergan Plain

Pro-Banthine

Darvon

lnderal



lnderal

GENERIC NAME GENERIC UPPER LIMITAJNIT Source'

Propranolol Hydrochloride

40 mg Tablet 60 mg Tablet 80 mg Tablet 90 mg Tablet

Quinidine Sulfate


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


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


Tolbutamide

500 mg Tablet

Trazodone Hydrochloride


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'


Mellaril

Navane

Tolinase

Orinase

Desyrel

Aristocort, Kenalog

Addendum A Icont.) PAYMENT FOR SERVICES 04-89

GENERIC NAME

Trifluoperazine Hydrochloride


Trihexyphenidyl Hydrochloride


Trimethoprim


Valproate Sodium

Syrup: Oral 250 mg Base15 ml

Valproic Acid

250 mg Capsule

Verapamil Hydrochloride


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 jn ia 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 :' rida !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 xth Carolina ~ r t h Dakota i io 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~yland 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 =Limit 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




(7) Some, But Not All Rx's

(8) 3 Refill Limit


(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. MEDICAID RECIP IENTS BY MAINTENANCE ASSISTANCE STATUS AN0 BY REGION AND STATE: F I S C A L YEAR 1988

BOSTON: REGION I CONNECTICUT

2/ MAINE 11 MASSACHUSETTS

NEW HAMPSHIRE RHOOE I S L A N D VERMONT

NEW YORK: REGION 2/ NEW JERSEY

NEW YORK 3/ PUERTO R ICO

V I R G I N ISLANDS

PHILADELPHIA: REGION 111 DELAWARE D I S T R I C T OF COLUMBIA .~ - -

YLAND

ATLANTA: REGION I V 2/ ALABAMA

FLORf OA GEORGIA KENTUCKY M I S S I S S I P P I NORTH CAROLINA SOUTH CAROLINA

CHICAGO: REGION V I L L I N O I S I N D I A N A MICHIGAN MINNESOTA OHIO- WISCONSIN

DALLAS: REGION V I ARKANSAS LOUIS IANA NEW MEXICO OKLAHOMA TEXAS

KANSAS C I T Y : REGION V I I 2/ IOWA 2/ KANSAS

MISSOURI NEBRASKA

DENVER: REGION V I I I COLORADO

2/ MONTANA 2/ NORTH OAKOTA

SOUTI4 DAKOTA - - - . . . - 2/ UTAH

WYOMING

SAN FRANCISCO: REGION I X CALIFORNIA H A W A I I NEVADA

808.424 26.691 27,669

OREGON 122.076 WASHINGTON 403.272 332.199

I/ MASSACHUSETTS B L I N D R E C I P I E N T AN0 EXPENOITURE OATA ARE ESTIMATED.

2/ MEOSTAT STATES' R E C I P I E N T AND EXPENDITURE OATA. - 8 sunrrrTfs STATES' DATA ARE ESTIMATED.

SEATTLE: REGION X ALASKA IDAHO

JUNE 2 3 . 1989 T A B L E 1. M E D I C A I D R E C I P I E N T S BY MAINTENANCE ASSISTANCE STATUS AN0 BY REGION AND

(CONT) STATE: F I S C A L YEAR 1988 OPTIONAL MAINTENANCE

M E D I C A L L Y CATEGORICALLY ASSISTANCE BEGZPY--bYQ--81AIE---- ---NEEQY-- ----YEEQI---- SIBIYS-UNYNQb!b - A L L J U R I S D I C T I O N S 3,604,619 8 9 , 5 3 1 44.818

BOSTON: REGION I CONNECTICUT M A I N E MASSACHUSETTS NEW HAMPSHIRE RHOOE I S L A N D VERMONT

NEW YORK: REGION I1 1,192.479 NEW JERSEY 4 , 6 5 2 NEW YORK 567.298 PUERTO R I C O 613.257 V I R G I N I S L A N D S 7,262

P H I L A D E L P H I A : REGION I11 263.866 DELAWARE 0 - . -. . - D I S T R I C T O F COLUMBIA MARYLAND PENNSYLVANIA V I R G I N I A WEST V I R G I N I A

ATLANTA: REGION I V ALABAMA F L O R I D A GEORGIA KENTUCKY M I S S I S S I P P I NORTH CAROLINA SOUTH CAROLINA TENNESSEE

CHICAGO: REQION V I L L I N O I S I N D I A N A -

M I C H I G A N MINNESOTA O H I O WISCONSIN

DALLAS: REGION V I ARKANSAS LOUISIANA NEY MEXICO OKLAHOMA TEXAS

KANSAS C I T Y : REGION IOWA

V I I

KANSAS M I S S O U R I NEBRASKA

DENVER: REGION V I I I COLORADO MONTANA NORTH DAKOTA SOUTH OAKOTA UTAH WYOMING

SAN FRANCISCO: REGION I X 901.339 C A L I F O R N I A 881.000 H A W A I I 20.339 NEVADA 0

J U N E 23, 1989 T A B L E 2. M E D I C A I D R E C I P I E N T S BY B A S I S OF E L I G I B I L I T Y AND BY REGION A N 0 S T A T E :

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: R E G I O N I CONNECTICUT M A T N E

VERMONT

P H I L A D E L P H I A : REGION I11 DELAWARE D I S T R I C T O F COLUMBIA MARYLAND P E N N S Y L V A N I A V I R G I N I A WEST V I R G I N I A

ATLANTA: R E G I O N I V ALABAMA F L O R I D A GEORGIA KENTUCKY M I S S I S S I P P I NORTH C A R O L I N A ~ -

SOUTH CAROLINA TENNESSEE

CHICAGO: REGION V I L L I N O I S I N D I A N A M I C H I G A N MINNESOTA O H I O W I S C O N S I N

D A L L A S : R E G I O N V I ARKANSAS L O U I S I A N A NEW M E X I C O OKLAHOMA TEXAS

KANSAS C I T Y : REGION V I I IOWA KANSAS M I S S O U R I NEBRASKA

DENVER: REGION V I I I COLORADO MONTANA NORTH DAKOTA SOUTH DAKOTA UTAH WYOMING

SAN FRANCISCO: REGION I X C A L I F O R N I A H A W A I I NEVADA

S E A T T L E : REGION X ALASKA T n A U n - - . . . . - OREGON WASHINGTON

- -

JUNE 2 3 . 1989

TABLE 2 . M E D I C A I D R E C I P I E N T S BY B A S I S OF ELIGIBILITY AND BY REGION AN0 STATE: ( C ~ ~ ~ ) F I S C A L YEAR 1 9 8 8

AFOC OTHER B A S I S O F C H I L D R E N AFOC T I T L E X I X E L I G

RMIQN--~NP--SI&IE---- UNDER-21 A D U L I S R E C I P E E N I S -UN_YNPYN_ -- ALL J U R I S D I C T I O N S 10,037.347 5.603.317 1,343,460 44,960

BOSTON: R E G I O N I CONNECTICUT M A I N E MASSACHUSETTS NEW HAMPSHIRE RHOOE I S L A N D VERMONT

NEW YORK: REGION I1 NEW JERSEY NEW YORK PUERTO R I C O V I R G I N I S L A N D S

PHILADELPHIA: REGION 1 x 1 1.028.137 FLAWA ARE 18.377 .- DISTRICT OF COLUMBIA 44,273 MARYLAND 163,823 PENNSYLVANIA 596.215 V I R G I N I A 122.222 WEST V I R G I N I A 93.227

ATLANTA: R E G I O N I V ALABAMA F L O R I D A GEORGIA KENTUCKY M I S S I S S I P P I NORTH CAROLINA SOUTH C A R O L I N A TENNESSEE

CHICAGO: R E G I O N V I L L I N O I S I N D I A N A MICHIGAN MINNESOTA O H I O W I S C O N S I N

DALLAS: R E G I O N V I ARKANSAS L O U I S I A N A NEW M E X I C O OKLAHOMA TEXAS

KANSAS C I T Y : REGION IOWA KANSAS

V I I 358,757 88,071



S E A T T L E : R E G I O N X ALASKA I D A H O OREGON WASHINGTON

JUNE 23. 1989

ABLE 3. M E D I C A I D R E C I P I E N T S BY T Y P E O F S E R V I C E A N 0 BY REOION AND STATE: F I S C A L YEAR 1988


NEW YORK: REGION 11 NEW JERSEY NEW YORK PUERTO R I C O V I R G I N I S L A N D S

P H I L A D E L P H I A : REGION 111 DELAWARE D I S T R I C T O F COLUMBIA MARYLAND PENNSYLVANIA V I R G I N I A WEST V I W I N I A

ATLANTA: REGION 1'4' ALABAMA F L O R I D A GEORGIA KENTUCKY M I S S I S S I P P I NORTH CAROLINA SOUTH CAROLINA TENNESSEE

on10 WISCONSIN

DALLAS: REOION V I ARKANSAS L O U I S I A N A NEW MEXICO OKLAHOMA TEXAS


DENVER : COLC

NOR' SOUTH I --. UTAH WYDWING


SEATTLE: REGION X ALASKA I D A H O OREGON WASHINGTON

T A B L E 3. M E D I C A I D R E C I P I E N T S BY T Y P E OF S E R V I C E AN0 BY REGION A N 0 STATE: (CONT) F I S C A L YEAR 1988

IYIESMEPLBIS--cbBE--E&GZCIILES MENTALLY A L L P H Y S I C I A N DENTAL

-BEEIQY--bYQ--SIbIE---- BEIbBDED PIHEC! SSRYIEES S S B Y I C E ~ A L L J U R I S D I C T I O N S 145,408 865.589 15.265.198 5 . 0 7 1 . 9 5 0



P H I L A D E L P H I A : REGION 111 DELAWARE D I S T R I C T OF COLUMBIA MARYLAND PENNSYLVANIA V I R G I N I A WEST V I R G I N I A


CHICAGO: REGION V I L L I N O I S I N D I A N A M I C H I G A N MINNESOTA O H I O W I S C O N S I N


KANSAS C I T Y : REGION V I I I O U A

DENVER: REGION V I I I COLORADO MONTANA NORTH OAKOTA SOUTH OAKOTA UTAH WYOMING


S E A T T L E : REOIDN X ALASKA - -

I D A H O OREGON WASHINGTON

JUNE 23, 1989 T A B L E 3. M E D I C A I D R E C I P I E N T S BY T Y P E O F S E R V I C E AN0 BY REGION A N 0 S T A T E :

(CONT) F I S C A L YEAR 1988

OUTPATIENT YPSPII64

10,532,976

C L I N I C SEBYIGES

2,256.420

L A B A --X_=R&Y_-

7,679,294

BOSTON: REGION I CONNECTICUT M A I N E MASSACHUSETTS NEW HAMPSHIRE RHODE I S L A N D VERMONT

NEW YORK: REGION I1 NEW JERSEY NEW YORK PUERTO R I C O

P H I L A D E L P H I A : REGION I11 DELAWARE D I S T R I C T O F COLUMBIA MARYLAND PENNSYLVANIA V I R G I N I A WEST V I R G I N I A

ATLANTA: R E G I O N I V ALABAMA F L O R I D A GEORGIA KENTUCKY M I S S I S S I P P I NORTH C A R O L I N A SOUTH C A R O L I N A TENNESSEE

CHICAGO: R E G I O N V I L L I N O I S I N D I A N A M I C H I G A N MINNESOTA O H I O W I S C O N S I N

D A L L A S : REGION V I ARKANSAS . .. .~ ~ -

L O U I S I A N A NEW MEXICO OKLAHOMA TEXAS

KANSAS C I T Y : R E G I O N V I I I O W A KANSAS M I S S O U R I NEBRASKA

DENVER: REGION V I I I COLORADO MONTANA . . - . . . . . . . . . NORTH DAKOTA SOUTH DAKOTA UTAH WYOMING


SEATTLE: R E G I O N X ALASKA TnAYn - - . . . . - OREGON WASHINGTON

TABLE 3. M E D I C A I D R E C I P I E N (CONT) F I S C A L YEAR 1988

TS BY T Y P E OF S E R V I C E AND BY REG JUNE 23, 1989

; I O N AND S T A T E :

EARLY A N 0 F A M I L Y P E R I O D I C HOME PRESCRIBED

HEALTH - - - - - - - ---------- DRUGS 569,097 16,323,372

BOSTON: R E G I O N I CONNECTICUT . . . . - . . - MASSACHUSETTS NEW HAMPSHIRE RHODE I S L A N D

NEW YORK: R E G I O N I1 N F W JERSEY

v n w . !TO R I C O

I S L A N D S

A: REGION 111 YARE R I C T O F COLUMBIA

0 V A N I 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 C A R O L I N A SOUTH C A R O L I N A TENNESSEE

CHICAOO: R E G I O N V I L L I N O I S I N D I A N A M I C H I G A N . MINNESOTA O H I O W I S C O N S I N

D A L L A S : R E G I O N V I ARKANSAS L O U I S I A N A NEW M E X I C O OKLAHOMA TEXAS

KANSAS C I T Y : REGION V I I IOWA K ~ N S A S M I S S O U R I YEBRASKA

DENVER: R E G I O N V I I I COLORADO MONTANA NORTH DAKOTA SOUTH DAKOTA UTAH WYOMING


S E A T T L E : R E G I O N X I ALASKA

I I D A H O

I OREGON

: WASHINGTON

JUNE 23. 1989 T A B L E 3. M E D I C A I D R E C I P I E N T S BY T Y P E O F S E R V I C E AND B Y REGION AND S T A T E :

(CONT) F I S C A L YEAR 1988 RURAL HEALTH

-cLlNIE 140.380

S E R V I C E YNKNPYN

36


NEW YORK: REGION NEW JERSEY NEW YORK PUERTO R I C O V I R G I N I S L A N D S

P H I L A D E L P H I A : REGION 111 DELAWARE D I S T R I C T O F COLUMBIA MARYLAND PENNSYLVANIA V I R G I N I A WEST V I R G I N I A

A T L A N T A : REGION I V ALABAMA F L O R I D A GEORGIA KENTUCKY M I S S I S S I P P I NORTH CAROLINA SOUTH C A R O L I N A TENNESSEE

on10 W I S C O N S I N

D A L L A S : REGION V I ARKANSAS L O U I S I A N A NEW MEXICO OKLAHOMA TEXAS




S E A T T L E : REGION X ALASKA I D A H O OREGON WASHINGTON

i- JUNE 23, 1989

TABLE 4. CATEGORICALLY NEEDY M E D I C A I D RECIPIENTS WHO R E C E I V E CASH PAYMENTS BY B A S I S OF E L I G I B I L I T Y AND B Y R E G I O N A N 0 S T A T E : F I S C A L YEAR 1988

AGE 65 n m - w m 1,561,247

BOSTON: REGION I CONNECTICUT M A I N E MASSACHUSETTS NEW HAMPSHIRE AW~DE ISLAND VERMONT

YORK: REGION I1 NEW JERSEY NEW YORK PUERTO R I C O V I R G I N I S L A N D S

NEW

~HILAOELPHIA: REGION I11 DELAWARE D I S T R I C T OF COLUMBIA

ATLANTA: REGION I V ALABAMA F L O R I D A GEORGIA KENTUCKY M I S S I S S I P P I NORTH C A R O L I N A SOUTH C A R O L I N A TENNESSEE

CHICAGO: R E G I O N V I L L I N O I S I N D I A N A M I C H I Q A N MINNESOTA O H I O WISCONSIN


DENVER: REGION V I I I COLORADO M n Y T A L I A . .-.. .7...-

NORTH OAKOTA SOUTH OAKOTA UTAH WYOMING



- - ~~ ~ ~

~ - .--- ~~ -

JUNE 23. 1989 T A B L E 4. CATEGORICALLY NEEDY M E D I C A I D R E C I P I E N T S WHO R E C E I V E CASH PAYMENTS

(CONT) BY B A S I S OF E L I G I B I L I T Y AND BY REGION AN0 STATE: F I S C A L YEAR 1988

AFOC B A S I S O F AFOC E L I G

---6QULIS UYKNQVY 4 . 0 7 7 . 2 7 2 162

-BSP IQN- -4NP- -S I4 IE - - - - A L L J U R I S D I C T I O N S


NEW YORK: REGION I1 N W JERSEY N W YORK W E R T O R I C O V I R G I N I S L A N D S

P H I L A D E L P H I A : REGION 111 DELAWARE D I S T R I C T O F COLUMBIA MARYLAND PENNSYLVANIA V I R Q I N I A WEST V I R G I N I A

ATLANTA: REGION I V ALABAMA F L O R I D A GEORGIA , . -. . - -

M I S S I S S I P P I NORTH CAROLINA SOUTH CAROLINA TENNESSEE

CHICAGO: REGION V I L L I N O I S I N D I A N A M I C H I G A N MINNESOTA O H I O WISCONSIN

DALLAS: REGION V I ARKANSAS i O U I S I A N A NEW MEXICO OKLAHOMA TEXAS



20; o o i 11.221 14,934 2 7 . 0 3 2



JUNE 23. 1989

TABLE 5 . CATEGORICALLY NEEDY M E D I C A I D R E C I P I E N T S WHO 00 NOT R E C E I V E CASH PAYMENTS BY B A S I S OF E L I G I B I L I T Y A N 0 BY REGION AND S T A T E : F I S C A L YEAR 1988

BOSTON: R E G I O N I CONNECTICUT M A I N E MASSACHUSETTS NEW HAMPSHIRE RHODE I S L A N D VERMONT

*NEW YORK: R E G I O N I1 NEW JERSEY NEW YORK PUERTO R I C O V I R G I N I S L A N D S


ATLANTA: R E G I O N I V ALABAMA F L O R I D A GEORGIA KENTUCKY M I S S I S S I P P I NORTH C A R O L I N A SOUTH C A R O L I N A TENNESSEE

CHICAGO: R E G I O N V I L L I N O I S I N D I A N A M I C H I G A N MINNESOTA O H I O WISCONSIN

DALLAS: REGION V I ARKANSAS L O U I S I A N A NEW M E X I C O OKLAHOMA TEXAS

KANSAS C I T Y : REGION V I I IOWA . KANSAS M I S S O U R I NEBRASKA



JUNE 23. 1989

\BLE 5 . CATEGORICALLY NEEDY M E D I C A I D R E C I P I E N T S WHO DO NOT R E C E I V E CASH PAYMENTS (CONT) B Y B A S I S O F E L I G I B I L I T Y AND BY REGION AN0 STATE: F I S C A L YEAR 1988

B A S I S O F E L I G

Y M K Y W Y 20

OTHER T I T L E X I X REGIPIENIS

446.176

AFDC A Q Y L I S 683.223

IOSTON: REGION I CONNECTICUT M A I N E MASSACHUSETTS MEW HAMPSHIRE .. RHDDE ISLAND VERMONT

YEW YORK: REGION 11 NEW JERSEY NEW YORK PUERTO R I C O V I R G I N I S L A N D S

P H I L A D E L P H I A : REGION 1x1 DELAWARE D I S T R I C T O F COLUMBIA MARYLANO PENNSYLVANIA V I R G I N I A WEST V I R G I N I A


DALLAS: REGION V I ARKANSAS LOUISIANA NEW MEXICO OKLAHOMA TEXAS

KANSAS C I T Y : REGION V I I IOWA KANSAS N I S S O U R I NEBRASKA



SEATTLE: REGION X ALASKA I D A H O OREGON

JUNE 23, 1989 T A B L E 6. M E D I C A L L Y NEEDY M E D I C A I D R E C I P I E N T S WHO DO NOT R E C E I V E CASH PAYMENTS

BY B A S I S OF E L I G I B I L I T Y AND BY REGION AND STATE: F I S C A L YEAR 1 9 8 8

T O T A L REGElEN-IS

3,604,619


NEW YORK: REGION I1 NEW JERSEY YEW YORK PUERTO R I C O V I R G I N I S L A N D S

P H I L A D E L P H I A : REGION I11 DELAWARE D I S T R I C T OF COLUMBIA MARYLAND PENNSYLVANIA VIRGINIA WEST V I R G I N I A

ATLANTA: R E G I O N I V ALABAMA F L O R I D A GEORQIA KENTUCKY M I S S I S S I P P I NORTH CAROLINA SOUTH CAROLINA TENNESSEE

CHICAGO: REGION V I L L I N O I S TNDIANA - . . - - . . . . . . M I C H I G A N MINNESOTA O H I O WISCONSIN

DALLAS: REGION V I ARKANSAS

OKLAHOMA TEXAS




J U N E 23. 1989 .ABLE 6 . M E D I C A L L Y NEEDY M E D I C A I D R E C I P I E N T S WHO DO NOT R E C E I V E CASH PAYMENTS (CONT) BY B A S I S OF E L I G I B I L l T Y AND BY REGION A N 0 S T A T E : 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 C H I L D R E N YMDEB-21

897.730

BOSTON: REGION I CONNECTICUT M A I N E MASSACHUSETTS NEW HAMPSHIRE R ~ O D E I S L A N D VERMONT


P H I L A D E L P H I A : REGION 111 DELAWARE D I S T R I C T O F COLUMBIA -

MARYLAND PENNSYLVANIA V I R G I N I A WEST V I R G I N I A



DALLAS: REGION V I ARKANSAS L O U I S I A N A N W M E X I C O OKLAHOMA TEXAS

KANSAS C I T Y : REGION V I I IOWA KANSAS V I S S O U R I NEBRASKA




T A B L E 7. M E D I C A I D M E D I C A L VENDOR PAYMENTS BY AND BY REGION AND S T A T E : F I S C A L YEI

J U N E 23. 1 9 8 9 MAINTENANCE A S S I S T A N C E STATUS OF R E C I P I E N T

BOSTON: R E G I O N I CONNECTICUT

2/ M A I N E I 1 MASSACHUSETTS -,


NEW YORK: REGION I1 21 NEW JERSEY

P H I L A D E L P H I A : REGION I11 DELAWARE DISTRICT OF COLUMBIA MARYLAND PENNSYLVANIA V I R G I N I A WEST V I R G I N I A

ATLANTA: R E G I O N I V 2/ ALABAMA

F L O R I D A GEORGIA KENTUCKY M I S S I S S I P P I NORTH C A R O L I N A SOUTH C A R O L I N A TENNESSEE

CHICAGO: R E G I O N V I L L I N O I S I N D I A N A M I C H I G A N MINNESOTA O H I O W I S C O N S I N


KANSAS C I T Y : REGION 2 / IOWA

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: REGION V I I I COLORADO

2/ MONTANA 2/ NORTH DAKOTA

SOUTH DAKOTA 2 / UTAH

WYOMING

SAN FRANCISCO: REGION I X 5,475,379,568 3,187,617,565 C A L I F O R N I A 5,226,773,277 3.052.745.740 H A W A I I 154,967,251 78,537,760 NEVADA 9 4 , 6 3 9 . 0 6 0 56.334.065

SEATTLE: REGION 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 T A B L E 7. M E D I C A I D M E D I C A L VENDOR PAYMENTS BY MAINTENANCE A S S I S T A N C E STATUS OF R E C I P I E N T

(cONT) AND BY REGION AN0 S T A T E : F I S C A L YEAR 1988 i O P T I O N A L

M E D I C A L L Y CATEGORICALLY NEEDY --- ----------- ----YEEPZ----

13,068,364,127 123,562.827

MAINTENANCE A S S I S T A N C E

S I A I U S - Y I K I P Y I 52,664.824

BOSTON: REGION I CONNECTICUT M A I N E MASSACHUSETTS NEW HAMPSHIRE RHOOE I S L A N D



ATLANTA: REGION I V ALABAMA F L O R I D A GEOROIA KENTUCKY M I S S I S S I P P I NORTH CAROLINA SOUTH CAROLINA TENNESSEE

O H I O W I S C O N S I N




S A N FRANCISCO: REGION I X C A L I F O R N I A H A W A I I NEVADA


T A B L E 8. M E D I C A I D M E D I C A L \ A N 0 BY REGION AN0

JUNE 23. 1989 'ENDOR PAYMENTS BY BASIS OF ELIGIBILITY OF RECIPIENT S T A T E : F I S C A L YEAR 1988

TOTAL AGE 65 PERMANENTLY A N 0 tAYVENI5 6ND--PLDER BCENQNESS IPIdLLI-PISdBhEP

48.710.157.836 17.135.323.201 343,756,610 18.260.087.009




ATLANTA: REGION I V ALABAMA F L O R I D A GEOROIA KENTUCKY M I S S I S S I P P I NORTH CAROLINA SOUTH C A R O L I N A TENNESSEE

O H I O WISCONSIN

DALLAS: REGION V I ARKANSAS L O U I S I A N A NEW MEXICO OKLAHOMA TEXAS

KANSAS C I T Y : REGION V I I IOWA KANSAS M I S S O U R I

SOUTH DAKOTA UTAH WYOMING



r !

JUNE 2 3 , 1989 G I B I L I T Y O F R E C I P I E N T j r m L E 8. MEOICAID MEDICAL VENDOR PAYMENTS BY BASIS OF ELI

(cONT) A N 0 BY REGION AN0 STATE: F I S C A L YEAR 1988

AFOC C H I L D R E N AFDC



D u T I A D F L P H I A : REGION 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 - - - . . - . . . . - - - . - - . . - D I S T R I C T OF COLUMBIA 47,161,206 42;080; 1 5 4 MARYLAND 1 3 9 . 5 8 6 . 8 4 9 103,037,611 PENNSYLVANIA 3 8 8 , 0 9 0 , 6 6 6 246,863,607 V I R G I N I A WEST V I R G I N I A


CHICAGO: REGION V I L L I N O I S I N D I A N A MICHIGAN MINNESOTA O H I O WISCONSIN

DALLAS: REGION VI ARKANSAS LOUISIANA NEW MEXICO OKLAHOMA TEXAS



SAN FRANCISCO: REGION IX 707.787.895 1.000.478.615

SEATTLE: REGION X ALASKA TnAHO - -. . . . - OREGON WASHINGTON

JUNE 23. 1989 TABLE 9 . MEDICAID MEDICAL VENDOR PAYMENTS BY TYPE OF SERVICE AND BY REGION AND STATE:


BOSTON: REGION I CONNECTICUT M A I N E

VERMONT

NEW YORK: REGION I1 NEW JERSEY NFW v n w . . - - . - . . . . PUERTO R I C O V I R G I N I S L A N D S

P H I L A D E L P H I A : R E G I O N I11 DELAWARE ~- D I S T R I C T O F COLUMBIA MARYLAND PENNSYLVANIA V I R G I N I A WEST V I R G I N I A

ATLANTA: REGION I V ALABAMA F L O R I D A GEORGIA KENTUCKY M I S S I S S I P P I NORTH C A R O L I N A SOUTH C A R O L I N A TENNESSEE


DALLAS: REGION V I .ARKANSAS L O U I S I A N A NEW MEXICO OKLAHOMA TEXAS

NEBRASKA




J U N E 23, 1989 T A B L E 9. M E D I C A I D M E D I C A L VENDOR PAYMENTS B Y T Y P E O F S E R V I C E AND BY REGION A N 0 S T A T E :


A L L

BOSTON: REGION I CONNECTICUT M A I N E MASSACHUSETTS NEW HAMPSHIRE RHQDE ISLAND VERMONT




O H I O WISCONSIN

OKLAHOMA

KANSAS C I T Y : REGION V I I IOWA KANSAS M I S S O U R I

DENVER: REGION V I I I COLORADO MONTANA NORTH DAKOTA


SEATTLE: REGION X ALASKA IOAHO OREGON WASHINGTON

JUNE 23, 1 9 8 9 2 TABLE 9. M E D I C A I D M E D I C A L VENDOR PAYMENTS BY T Y P E OF S E R V I C E AN0 BY REGION AN0 S T A T E :


OTnER O U T P A T I E N T C L I N I C e s n c I r m m hgsr114~ SEBYICES-

284.235.721 2.413.028.723 1.105.212.592

BOSTON: REGION I CONNECTICUT M A I N E MASSACHUSETTS NEW HAMPSHIRE 6 0 0 ~ I S L A N D VERMONT

NEW YORK: R E G I O N I1 NEW JERSEY NEW YORK PUERTO R I C O

~HILAOELPHIA: REGION I11 DELAWARE D I S T R I C T O F COLUMBIA MARYLAND PENNSYLVANIA V I R G I N I A WEST V I R O I N I A

ATLANTA: REGION I V ALABAMA F L O R I D A OEOROIA KENTUCKY M I S S I S S I P P I NORTH C A R O L I N A SOUTH C A R O L I N A TENNESSEE

O H I O W I S C O N S I N

DALLAS: REGION V I ARKANSAS L O U I S I A N A NEW M E X I C O OKLAHOMA TEXAS



SAN FRANCISCO: REGION I X - - - ~

C A L I F O R N I A H A W A I I NEVADA

S E A T T L E : R E G I O N X ALASKA

JUNE 23. 1989 BY TYPE OF S E R V I C E AND BY REGION AND S T A T E : T A B L E 9 . M E D I C A I D M E D I C A L VENDOR PAYMENTS

(CONT) F I S C A L YEAR 1 9 8 8

HOME PRESCRIBED


NEW YORK: R E G I O N 11 NEW JERSEY

P H I L A D E L P H I A : REGION I11 DELAWARE D I S T R I C T OF COLUMBIA MARYLAND PENNSYLVANIA V I R G I N I A WEST V I R G I N I A


CHICAGO: REGION V I L L I N O I S I N D I A N A - - - M I C H I G A N MINNESOTA O H I O WISCONSIN

D A L L A S : REOION V I ARKANSAS L O U I S I A N A NEW MEXICO OKLAHOMA TEXAS

KANSAS C I T Y : R E G I O N V I I TOWA KANSAS M I S S O U R I NEBRASKA

DENVER: REOION V I I I ~ ~ -

COLORADO MONTANA NORTH DAKOTA SOUTH DAKOTA UTAH WYOMING


S E A T T L E : REOION X ALASKA I D A H O OREGON WASHINGTON

JUNE 23, 1989 T A B L E 9. M E D I C A I D M E D I C A L VENDOR PAYMENTS BY T Y P E OF S E R V I C E A N 0 BY REGION AN0 S T A T E :

(CONT) F I S C A L YEAR 1 9 8 8 RURAL HEALTH S E R V I C E

YNENQYN 41.811

OTHER 28BE-

1.431.007.209

BOSTON: R E G I O N I CONNECTICUT M A I N E MASSACHUSETTS NEW HAMPSHIRE RHDDE I S L A N D VERMONT


P H I L A D E L P H I A : REGION I11 DELAWARE DISTRICT OF COLUMBIA MARYLAND . . . . . . . - . . . . - PENNSYLVANIA V I R G I N I A WEST V I R G I N I A

ATLANTA: R E G I O N I V ALABAMA

NORTH C A R O L I N A SOUTH C A R O L I N A TENNESSEE


D A L L A S : REGION V I ARKANSAS L O U I S I A N A NEW M E X I C O OKLAHOMA TEXAS


DENVER: R E G I O N V I I I COLORADO MONTANA NORTH DAKOTA SOUTH DAKOTA UTAH WYOMING


JUNE 23. 1589 T A B L E 10. M E D I C A I D M E D I C A L VENDOR PAYMENTS FOR CATEGORICALLY NEEDY R E C I P I E N T S WHO

R E C E I V E CASH PAYMENTS BY B A S I S OF E L I G I B I L I T Y A N 0 BY R E G I O N AND S T A T E : - F T S C A L YEAR 1988 . -. .-

TOTAL AGE 65 PERMANENTLY AND REQIQY--BN-P_-SIAIE-_---- PAIBEYIS AND--PLPEB BC61PN-ESS IP IAhLLPISbBhEP

A L L J U R I S D I C T I O N S 24.583.768.754 4.183.887.631 234,587,080 11,132,951.532

BOSTON: REGION I CONNECTICUT M A I N E MASSACHUSETTS NEU HAMPSHIRE RHODE I S L A N D VERMONT





D A L L A S : REGION V I ARKANSAS ....... ~

L O U I S I A N A NEW MEXICO OKLAHOMA TEXAS

KANSAS C I T Y : REGION V I I IOWA KANSAS . . . . . . - . . - M I S S O U R I NEBRASKA




- - . . - - - , - - T A B L E 10. M E D I C A I D MEDICAL VENDOR PAYMENTS FOR CATEGORICALLY NEEDY R E C I P I E N T S WHO

(CONT) R E C E I V E CASH PAYMENTS BY B A S I S O F E L I G I B I L I T Y AND BY REGION AND STATE: F I S C A L YEAR 1988

AFDC B A S I S OF


NEW YORK: REGION I1 NEW JERSEY NEU YORK PUERTO R I C O V I R G I N I S L A N D S

P H I L A D E L P H I A : REGION I11 DELAWARE - .. O I S T l MI PI V IRG: WEST

.. .. ~- R I C T O F COLUMBIA

WYLANO SNNSYLVANIA

I N I A V I R G I N I A

ATLANTA: REGION IV ALABAMA F L O R I D A GEORGIA KENTUCKY M I S S I S S I P P I NORTH CAROLINA SOUTH CAROLINA TENNESSEE

CHICAGO: REGION V I L L I N O I S I N D I A N A M I C H I G A N .- -~

MINNESOTA O H I O WISCONSIN






J U N E 23, 1989 T A B L E 11. M E D I C A I D M E D I C A L VENDOR PAYMENTS FOR CATEGORICALLY NEEDY R E C I P I E N T S WHO DO NOT

R E C E I V E CASH PAYMENTS BY B A S I S OF E L I G I B I L I T Y AN0 BY R E G I O N A N 0 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: REGION I CONNECTICUT MATNF , ,. . - . - - MASSACHUSETTS NEW HAMPSHIRE RHODE I S L A N D VERMONT




CHICAGO: REGION V I L L I N O I S I N D I A N A MICHIGAN MINNESOTA O H I O WISCONSIN



REGION V I I I IRADO




T A B L E 11. M E D I C A I D M E D I C A L VENDOR PAYMENTS FOR CATEGORICALL (CONT) R E C E I V E CASH PAYMENTS BY B A S I S O F E L I G I B I L I T Y AN0


JUNE 23. 1989 Y NEEDY R E C I P I E N T S WHO DO NOT

BY R E G I O N A N 0 STATE:


UN_K_N_O_YN- 11.266

AFOC C H I L D R E N AFOC


P H I L A D E L P H I A : REGION I11 83.590.552 43,428,388 t x l ~ AWARE 1.148.316 1 .123.719 - - - . . - . . - -.-- . D I S T R I C T O F COLUMBIA 137; 279 219.454 MARYLAND 1,504,430 781.238 PENNSYLVANIA 72.765.282 17.441.635 V I R G I N I A 4,316,305 17,809.053 WEST V I R G I N I A 3 . 7 1 8 . 9 4 0 6 , 0 5 3 , 2 8 9

ATL .ANTA: REGION I V ALABAMA F L O R I D A GEORGIA KENTUCKY M I S S I S S I P P I NORTH CAROLINA SOUTH C A R O L I N A TENNESSEE



KANSAS C I T Y : REGION IOWA KANSAS

V I I 24,623,840 5.448.553 4.766.256 9.321.488 4,987,543

. . . . . . - . .- M I S S O U R I NEBRASKA


S I N FRANCISCO: REG1 C A L I F O R N I A H A W A I I NEVADA

SEATTLE: REGION X ALASKA I D A H O OREGON

I WASHINGTON

I

JUNE 23, 1 9 8 9 r A B L E 12. M E D I C A I D MEDICAL VENDOR PAYMENTS FOR MEDICALLY NEEDY R E C I P I E N T S

BY B A S I S OF E L I G I B I L I T Y AN0 BY REGION AN0 STATE: F I S C A L YEAR 1 9 8 8

TOTAL ACE 66 PERMANENTLY AN0 - -

REOIQY--AYD--SIAIE--- - - P4YMEYIS A L L J U R I S D I C T I O N S 13,068,364,127



P H I L A D E L P H I A : REGION 111 DELAWARE D I S T R I C T OF COLUMBIA MARYLAND PENNSYLVANIA VIRGINIA WEST V I R G I N I A

ATLANTA: REGION I V ALABAMA FLORIDA GEORGIA KENTUCKY M I S S I S S I P P I NORTH CAROLINA SOUTH CAROLINA TENNESSEE

CHICAGO: REGION V I L L I N O I S I N D I A N A MICHIGAN MINNESOTA OHIO WISCONSIN





SEATTLE: REGION X ALASKA IDAHO OREGON WASHINGTON

JUNE 2 3 , 1989 T A B L E 12. M E D I C A I D MEDICAL VENDOR PAYWENTS FOR M E D I C A L L Y NEEDY R E C I P I E N T S

(CONT) BY B A S I S OF E L I G I B I L I T Y AND BY REGION A N 0 S T A T E : F I S C A L YEAR 1988

AFDC CHILDREN YNPER-21

7 0 4 , 8 6 7 , 2 3 5

OTHER T I T L E X I X


YY'6YQIY 0

AFOC




ATLANTA: REGION I V ALABAMA

TENNESSEE

O H I O WISCONSIN




S I N FRANCISCO: REGION I X C A L I F O R N I A H A W A I I

I NEVADA

SEATTLE: REQION X ALASKA I D A H O OREGON WASHINGTON

J U N E 23. 1989 E L I G I B I L I T Y

PERMANENTLY AND IQI4LLY-PI588LEQ +

2,017 4 .*,

T A B L E 13. O P T I O N A L CATEGORICALLY NEEDY M E D I C A I D R E C I P I E N T S BY B A S I S OF AN0 BY REGION A N 0 S T A T E : F I S C A L YEAR 1988

T O T A L AGE 65



P H I L A D E L P H I A : REGION I11 DELAWARE -

D I S T R I C T OF COLUMBIA 1 , 1 2 2 MARYLAND 7.805 PENNSYLVANIA 7.277 V I R G I N I A 873 WEST V I R G I N I A 4.088







S E A T T L E : REGION X ALASKA IDAHO OREGON WASHINGTON

JUNE 23, 1989 B A S I S OF E L I G I B I L I T Y T A B L E 13. O P T I O N A L CATEGORICALLY NEEDY M E D I C A I D R E C I P I E N T S BY

(CONT) AN0 BY REGION A N 0 S T A T E : F I S C A L YEAR 1988

AFOC C H I L D R E N U N D E R 2 1

27,666


YNKYQYIN 0

AFOC



P H I L A D E L P H I A : REGION I11 DELAWARE D I S T R I C T OF COLUMBIA MARYLAND PENNSYLVANIA V I R G I N I A YEST V I R G I N I A


O H I O WISCONSIN

OKLAHOMA TEXAS


DENVER: COL MONTANA NORTH DAKOTA SOUTH DAKOTA

REGION V I I I .ORAOO

UTAH WYOMING



JUNE 23, 1989 T A B L E 14. M E D I C A I D M E D I C A L VENDOR PAYMENTS FOR O P T I O N A L CATEGORICALLY NEEDY R E C I P I E N T S

BY B A S I S O F E L I G I B I L I T Y AND BY REGION AND S T A T E : F I S C A L YEAR 1988

TOTAL PAIMENTS

1 2 3 , 5 6 2 , 8 2 7

AGE 65 b N P - A b E B 5.617.209

PERMANENTLY AN0 B C I M P I E S S I Q I b h L Y - Q I S b B L E P

185.946 8,416,722




KENTUCKY M I S S I S S I P P I NORTH CAROLINA SOUTH CAROLINA TENNESSEE



KANSAS C I T Y : REGION V I I IOWA KANSAS . . . . .- . .- M I S S O U R I NEBRASKA



SEATTLE: REGION X ALASKA I D A H O 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


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.


NPC - 1989 Alaska - :

111. Administration: Health and Social Services Department


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


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


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 ~ d u l 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


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 is expected that the imposition of nominal co-payments will ensure optimal effectiveness in 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 to 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 - W 5 3 7 4 3 7 5 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


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



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


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





$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


NPC - 1989 Arkansas - 2

Ill. Administration:

By the Division of Economic and Medical Services, of the Department of Human Services.


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.


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


Norman Canterbury, P.D. Executive Vice President Arkansas Pharmacists Association 417 South Victory Little Rock, AR 72201 501/372-5250


Lester Hosto, P.D. Executive Director P. 0. Box 55356 Liile Rock, AR 72225 501/661-2833

California - 2


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.


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


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 to 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.


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


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


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)


Colorado - 1

Type of Benefit Categorically Needy Medically Needy (MN) Other' OAA AB APTD AFDC OAA AB APTD AFDC Childrenc21 (SFOI


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



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.



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.


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


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


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


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


S. Thomas Gray Executive Director CO Pharmaceutical Association 770 Grant Street, Ste. 244 Denver, CO 80203 303/861-0328


David L. (Mike) Simmons Administrator 1525 Sherman St., Rm. 128 Denver, CO 80203-1751 3031866-2526

NPC - 1989 Connecticut - 1 CONNECTICUT



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 ~k i 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


TOTAL



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


Directly by the State Weifare Department through seven district offices and one town delegated this special authority.



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


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


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


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)


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


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



$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


F

NPC - 1989 Delaware - 2


By Division of Economic Services, Department of Health and Social Services, through 3 county offices of the state agency.


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.


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.


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



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 ls~ l ta f 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


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



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 ~ k i l l k d 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



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




NPC - 1989 District of Columbia - 2


The D.C. Department of Human Services (DHS), Office of Health Care Financing.


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.


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.


Fiscal Intermediary: The Computer Company FCC) 122 C Street, N. W. Washington, D.C. 20001


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


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)


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


II. EXPENDITURES FOR DRUGS,

TOTAL

CATEGORICALLY NEEDY CASH TOTAL Aged Blind Disabled Children -Families w1Dep. Children Adults -Families w/Dep. Children




$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


$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


NPC - 1989


By the Department of Health and Rehabilitative Services. Claims processing and payment by Contract with fiscal agent.


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.


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


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


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


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()


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


TOTAL






NPC - 1989 Georgia - 2

ill. Administration:

By the Department of Medical Assistance.


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


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


State MAC List = federal MAC plus 85 additional drugs


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)


Type of Benefit Categorically Needy Medically Needy (MN) Othei 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

S F 0 - State Funds Only


TOTAL



MEDICALLY NEEDY TOTAL Aged Blind Disabled Children -Families w/Dep. Children Adults -Families w/Dep. Children Other Tile XIX Recipients


1988 Emended Recipient


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 in 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


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


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)


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 ~ d u l t s -Families w/Dep. Children




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 11 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


By the State Department of Health and Welfare through seven regional offices, each serving five or more of the state's 44 counties.


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


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



Donald W. Sower Executive Director ldaho Medical Association 305 West Jefferson, P.O. Box 2668 Boise, ID 83701 2081344-7888


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


Jo An Condie Executive Director ldaho State Pharmaceutical Association 1365 N. Orchard Street, Room 103 Boise, ID 83706 2081376-2273


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)


Type of Benefit Categorically Needy Medically Needy (MN) Other. OAA AB APTD AFDC OAA AB APTD AFDC Childrenx21


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



TOTAL




1987 Expended ReciDient

1988 Expended RecipieM


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


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.


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



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


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


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



TOTAL






$88,483,051 243,531

HS report HCFA - 2082

NPC - 1989 lndiana - 2


The lndiana State Department of Public Welfare.


A. General Exclusions: (Most OTC drugs are covered) No legend or non-legend anorexics or experimental, or DESl drugs.

B. Formulary: None.


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.


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:


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


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



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


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()


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


TOTAL



MEDICALLY NEEDY TOTAL Aged Blind Disabled Children -Families w/Dep. Children A d u b -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


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


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


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. G a ~ 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




NPC - 1989 Kansas - 2


State Department of Social and Rehabilitation Services.


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.


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


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


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



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



TOTAL


CATEGORICALLY NEEDY NON-CASH TOTAL Aged Blind Disabled Children -Families w/Dep. Children Adults -Families w/Dep. Children Other Tile XIX Recipients





NPC - 1989 Kentucky - 2


By the Depanment for Medicaid Services, within the Cabinet for Human Resources,


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.


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


Robert G. Cox Executive Vice President KY Medical Association 3532 Ephraim McDowell Drive Louisville, KY 40205 502/459-9790


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:


Robert Barnen Interim Executive Director KY Pharmacists Association 1228 U. S. Highway 127 S. Frankfort, KY 40601 5021227-2303


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)




Laboratory & X-ray Service sk i 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



TOTAL

CATEGORICALLY NEEDY CASH TOTAL Age4 Blind Disabled Children -Families w/Dep. Children Adults -Families w/Dep. Children


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


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


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


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)



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.


TOTAL





$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


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


NPC - 1989 Maine - 2


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


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


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 I01


Stanley Stewart Executive Director Maine Pharmacy Association P.0 Box 817 Bangor, ME 04401 -081 7 2071947-0885


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()


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.


TOTAL CATEGORICALLY NEEDY CASH TOTAL Aged Blind Disabled Children -Families w/Dep. Children Adults -Families w/Dep. Children




' $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


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.


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.


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


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. M e d i 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 D e l m a ~ 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~oir 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



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)



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



1987 1988 Expended Recipient Expended Reci~ient

TOTAL $89,829,373 393,742 $1 W,305,001 $397,302





, 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.


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.



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.


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 11


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


Jeffrey J. Burgoyne Executive Director MA State Pharmaceutical Assn. 27 Cambridge St., P. 0. Box 160 Burlington, MA 01803 61 71272-7679


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 ta l 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 Tile XIX Recipients

dEDICALLY NEEDY TOTAL 4ged 3lind Iisabled Zhildren -Families w/Dep. Children 4dults -Families wIDep. Children 3ther Title XIX Recipients


$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


$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

iHS report HCFA - 2082

NPC - 1989 Michigan - 2


Michigan Department of Social Services, Medical Services Administration


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.


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



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) Othei 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



TOTAL

CATEGORICALLY NEEDY CASH TOTAL Aged Blind Disabled Children -Families wIDep. Children Adults -Families w/Dep. Children






NPC - 1989 Minnesota - 2


Minnesota Department of Public Welfare, Income Maintenance Division, Medical Assistance Program.

iV. Provisions Relating to 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


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


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


William E. Bond Executive Director Mn State Pharmaceutical Associatjon 2221 University Avenue, S.E., Suite 326 Minneapolis, MN 55414 6121378-1 414


David Holmstrom Executive Director 2700 University Avenue W. Suite 107 St. Paul, MN 551 14-1079 612f642-0541

NPC - 1989 MISSISSIPPI



Mississippi - 1






TOTAL


CATEGORICALLY NEEDY NON-CASH TOTAL Aged Blind Disabled Children -Families w/Dep. Children Adults -Families w/Dep. Children Other Tltle XIX Recipients



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!


Division of Medicaid

IV. Provisions Relating to Prescribed Drugs.


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


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.



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.


Fiscal intermediary: Blue Cross/Blue Shield P. 0. Box 23061 Jackson, MS 39225-3061


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


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)


Type of Benefit Categorically Needy Medically Needy (MN) Other' OAA AB APTD AFDC OAA AB APTD AFDC C h i l d r e ~ 2 1


-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



TOTAL


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


$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


$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


JPC - 1989

II. Administration:

Division of Family Services of the



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


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.


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 S e ~ i c e s 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



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~ ices :

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:


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


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)



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



TOTAL





$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


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


II. Administration:

State Department of Social and Rehabilitation Services.


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.


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


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



G. Brian Zins Executive Director MT Medical Association 2021 I l t h Avenue, Suite 12 Helena, MT 59601 4061443-4000


Patrick Frankl, D.O. Secretary-Treasurer MT Osteopathic Association Box 2004 Phillipsburg, MT 59858


Robert Likewise Executive Director MT State Pharmaceutical Assn. P.O. Box 4718, 4376 Head Drive Helena, MT 59604 4061449-3843


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)



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


11. EXPENDITURES FOR DRUGS

TOTAL


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



HHS report MRS 11 5

NPC - 1989 Nebraska - 2




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,



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 multi~le 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.



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




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.



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


Thomas R. Dolan, R.Ph. Executive Director NE Pharmacists Association 5440 South Street, Ste. 1200 Lincoln, NE 68506 4021488-5002 or 8001742-0029


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)


Type of Benefit Categorically Needy Medically Needy (MN) Other' OAA A6 APTD AFDC OAA AB APTD AFDC Childrenc21


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



TOTAL





$4,751.062 21,764

$988 Expended Recipient

$5,045,498 23,195




State Welfare Division of the Department of Human Resources.


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.


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.)


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.


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


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



Larry Matheis Executive Director NV State Medical Assn 3660 Baker Lane Reno, NV 89509 7021825-6788


Jeffrey E. Brookman, D.O. Secretary-Treasurer NV Osteopathic Medical Assn 2300 South Rancho Rd. Las Vegas, NV 891 02 7021384-0414


Karen Peska Executive Director NV Pharmaceutical Assn, 3660 Baker Lane Reno, NV 89509-5413 7021826-3981


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)


~ 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



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



$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


$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


Office of Medical Services, Department of Health and Human Services


A. General Exclusions: Anorexiant (stimulants) except for treatment of narcolepsy and hyperkinetic children.

B. Formulary: None.


1. Quantity of Medication: Prescriptions limited to 100 day supply. 2. Dollar Limits: None.


$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



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:


Palmer P. Jones Executive Vice President NH Medical Society 4 Park Street Concord, NH 03301 -6389 6031224-1 909


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


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)


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





TOTAL



MEDICALLY NEEDY TOTAL Aged Blind Disabled Children -Famiiies w/Dep. Children Adults -Families w/Dep. Children Other Title XIX Recipients


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


Division of Medical Assistance and Health Services, Department of Health Services,


A. General Exclusions: Experimental drugs, anti-obesics and anorexiants.

B. Formulafy: None.


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,


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.


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


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)



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


Alvin N. Geser Executive Officer NJ Pharmaceutical Association 120 W. State Street Trenton, NJ 08608-1 102 6091394-5596


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)


Type of Benefit Categorically Needy Medically Needy (MN) Other' OAA AB APTD AFDC OAA AB APTD AFDC Childrew21


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



TOTAL


CATEGORICALLY NEEDY NON-CASH TOTAL Aged Blind Disabled Children -Families w/Dep. Children Adults -Families wIDep. Children Other Tile XIX Recipients



$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


$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


NPC - 1989 New Mexico - 2


Human Services Department (HSD)

IV. Provisions Relating to Prescribing Drugs:


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


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.


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%.


Fiscal Intermediary: EDS Federal Corporation 5801 Osuna N.E. Albuquerque, NM 87109


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


A. Medical Society:

Glenn R. Marshall, Executive Director NM Medical Society 303 San Mateo Blvd., NE Albuquerque, NM 871 08 5051266-7868


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


Dale Tinker, Executive Director NM Pharmaceutical Association 48000 Zuni, S.E. Albuquerque, NM 871 08-2830 5051265-8720


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)



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



TOTAL



MEDICALLY NEEDY TOTAL Aged Blind Disabled Children -Families wIDep. Children Adults -Families w/Dep. Children Other Title XIX Recipients

1987 Expended ReCi~ient


$394,893,872 1,529,889


NPC - 1989 New York - 2




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


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.



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


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.


Co-payment: None



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


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


Elizabeth Lasky, Executive Director Pharm. Society, State of NY Pine West Plaza IV Washington Avenue Extension Albany, NY 12205 51 81869-6595


Lawrence H. Mokhiber Executive Secretary Cultural Education Center Room 3035 Albany, NY 12230 51 81474-3848

NPC - 1989 NORTH CAROLINA



1 North Carolina - 1



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


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 le 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 Tile 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


NPC - 1989 North Carolina - 2


Division of Medical Assistance, Department of Human Resources.


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.


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


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


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 C i 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



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


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


A.H. Mebane, Ill Executive Director NC Pharmaceutical Assn. Box 151 Chapel Hill, NC 27514-0151 91 91967-2237


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)


Type of Benefit Categorically Needy OAA AB APTD AFDC





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 (MN) Other* OAA AB APTD AFDC Childrenc21

X X X X X


$7.51 6,587 27,651


$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




North Dakota Department of Human Services.



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


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.


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.


Co-payment - None


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


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


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



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


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)


Type of Benefit Categorically Needy Medically Needy (MN) Other' OAA AB APTD AFDC O M AB APTD AFDC Children<21


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



TOTAL


190,685CATEGORICALLY NEEDY NON-CASH TOTAL Aged Blind Disabled Children -Families w/Dep. Children Adults -Families w/Dep. Children Other Tile XIX Recipients

MEDICALLY NEEDY TOTAL Aged Blind Disabled Children -Families wiDep. Children Adults -Families w1Dep. Children Other Title XIX Recipients


$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


NPC - 1989 Ohio - 2


Ohio Department of Human Services


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.


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



Herbert E. Gillen Executive Director OH State Medical Assn. 1500 Lakeshore Drive Columbus, OH 43204 61 41486-2401


Jon F. Wills 53 W. 3rd Avenue Columbus, OH 43201 61 41299-21 07


Ernest "Ernie" Boyd Executive Director OH State Pharmaceutical Assn. 395 E. Broad Street, Suite 320 Columbus, OH 43215 6141464-1 874


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)




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



TOTAL



$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



NPC - 1989

-

Oklahoma - 2


Oklahoma Department of Human Services (DHS).


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.



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:


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


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()


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




TOTAL


CATEGORICALLY NEEDY NON-CASH TOTAL Aged Blind Disabled Children -Families w/Dep. Children Adults -Families w/Dep. Children Other Tile XIX Recipients



NPC - 1989 Oregon - 2


Adult and Family Services Division, Department of Human Resources.


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.


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.


4. Dispensing limits: none on dispensingslmonth or refills,


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:


Robert L. Demedde Executive Director OR Medical Association 5210 SW Corben Street Portland, OR 97201 5031226-1 555


Chuck Gress Executive Director OR State Pharmaceutical Assn. 1460 State Street Salem, OR 973014296 5031585-4887


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)



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



TOTAL


CATEGORICALLY NEEDY NON-CASH TOTAL Aged Blind Disabled Children -Families w/Dep. Children Adults -Families w1Dep. Children Other Title XIX Recipients



$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




Office of Medical Assistance, Department of Public Welfare.


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


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.


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:


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.


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


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


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


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)


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~ital 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 ~ e i l t a l Services X X X X X X X X X



TOTAL


CATEGORICALLY NEEDY NON-CASH TOTAL Aged Blind Disabled Children -Families wIDep. Children Adults -Families w/Dep. Children Other Title XIX Recipients



$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


$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


NPC - 1989 Rhode Island - 2


State Department Human Services.


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 I00 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


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.



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.


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:


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



Newell E. Warde, Ph.D. Executive Director RI Medical Society 106 Francis Street Providence, RI 02903 4011331 -3207


Reuben L. Alexander, D.O. Secretary Cranston General Hospital 1763 Broad Street Cranston, RI 02905


Denis R. Barton Executive Director RI Pharmaceutical Association 500 Prospect St. - Independence Square Pawtucket, RI 02860 4011725-41 41


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)


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



(I. EXPENDITURES FOR DRUGS.

TOTAL


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


$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


NPC - 1989 South Carolina - 2


State Healh and Human Services Finances Commission


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


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.


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.


4. Recipients are limited to three (3) prescriptions per month.


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 + 3 0 copay. = 3.80)


It is required that each recipient choose one pharmacy for a month.



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



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


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()


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


S F 0 - State Funds Only + - Renal Disease


TOTAL


CATEGORICALLY NEEDY NON-CASH TOTAL Aged Blind Disabled Children -Families wiDep. Children Adults -Families w/Dep. Children Other Title XIX Recipients





NPC - 1989 South Dakota - 2


State Department of Social Services, Office of Medical Services.


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.


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



Robert D. Johnson Chief Executive Officer SD State Medical Association 1323 Minnesota Avenue Sioux Falls, SD 571 05 6051336-1 965


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


Galen Jordre Secretary SD Pharmaceutical Association 222 East Capitol, Box 518 Pierre, SD 57501-051 8 6051224-2338


Galen Jordre Secretary Box 518 Pierre, SD 57501 -051 8 60512242338

NPC - 1989 Tennessee - I

TENNESSEE MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)


Type of Benefit Categorically Needy Medically Needy (MN) Other. OAA AB APTD AFDC OAA AB APTD AFDC Childrew21 (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


MEDICALLY NEEDY TOTAL Aged Blind

1 Disabled Children -Families w/Dep. Children / Adub -Families w D e p Children

i Other Tile XIX Recipients f



j HHS report HCFA - 2082

- -

NPC - 1989 Tennessee - 2


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


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.


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


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~sic ian '~ idd1e 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



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


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()


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


'SF0 State Funds Only " EPSDT Only


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


NPC - 1989 Texas - 2


Vendor drug program was implemented September 1, 1971

Texas Department of Human Services


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


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.


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


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



Robert G. Mickey Executive Vice President TX Medical Association 1801 N. Lamar Boulevard Austin, TX 78701 51 21477-6704


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 5lst 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


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()


Type of Benefit Categorically Needy Medically Needy (MN) Other* OAA AB APTD AFDC OAA AB APTD AFDC Childrem21 ISFO)


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



TOTAL



MEDICALLY NEEDY TOTAL Aged Blind Disabled Children -Families w/Dep. Children Adult - Families w/Dep. Children Other Title XIX Recipients



1988 E w n d e d Recipient

NPC - 1989 Utah - 2


Division of Health Care Financing, State Department of Health.


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.


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


I. Department of Health Officials:

Suzanne Dandoy, MD Executive Director

Rod L. Betit, Director

RaeDell Ashley, Manager, Policy Planning



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


Utah - 3

C. Neil Jensen Executive Director UT Pharmaceutical Association 1062 East 21s South, Suite 21 2 Sait Lake City, UT 84106 8011484-9141


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()


Type of Benefit Categorically Needy Medically Needy (MN) Other' OAA AB APTD AFDC OAA AB APTD AFDC Childrew21 (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


TOTAL


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


1987 1988 Expended Recipient Expended Reci~ient


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


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


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.


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


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)


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



TOTAL


CATEGORICALLY NEEDY NON-CASH TOTAL Aged Blind Disabled Children -Families w/Dep. Children Adults -Families wjDep. Children Other Title XIX Recipients



$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


$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


NPC - 1989 Virginia - 2


By the Department of Medical Assistance Services. Eligibility determination by the Department of Social Services.


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.


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.


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.


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


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


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



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


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)


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 ~ e h t a l 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.


TOTAL



MEDICALLY NEEDY TOTAL Aged Blind Disabled Children -Families wIDep. Children Adults -Families w1Dep. Children Other Tile XIX Recipients Optional Categorically Needy




NPC - 1989 I

Washington - 2


By Division of Medical Assistance, Department of Social and Health Services. The Central Authorization Unit (CAU) reviews the need for non-formulary 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.


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


1. Social and Health Services Department Officials:

Richard J. Thompson, Secretary Dept. of SociaVHealth Services 08-44 Olympia, WA 98504


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 ~ e d i c a l 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


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.



Thomas J. Curry Executive Director WA State Medical Association

2033 Sixth Avenue, Suite 900 Seattle, WA 98121 2061441 -9762


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


Raymond A. Olson Executive Director WA State Pharmacists Assn. 1420 Maple Avenue Suite 101 Renton, WA 9805531 96 2061228-71 71


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)


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



1987 1988 Ex~ended Recipient Expended Recipient

TOTAL



MEDICALLY NEEDY TOTAL Aged Blind Disabled Children -Families w/Dep. Children Adults -Families wlDep. Children Other Title XIX Recipients




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.


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.


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


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.


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 in 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.


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


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



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


Richard D. Stevens Executive Director WV Pharmacists Association 4004 MacCorkle Ave., SE, Suite 4 Charleston, WV 25304 304J925-7204


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)


Type of Benefit Categorically Needy Medically Needy (MN) Other. OAA AB APTD AFDC OAA AB APTD AFDC Childrenc21


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



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


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


The State Department of Health and Social Services.


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~arine hydrochloride.


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.



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.


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 copayment. (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


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)


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)


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


TOTAL


CATEGORICALLY NEEDY NON-CASH TOTAL Aged Blind Disabled Children - Families w/Dep. Children ~ d u l t s - 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



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.


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.


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


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:


Richard W. Johnson, Jr. Executive Director WY State Medical Society 1920 Evans, P.O. Drawer 4009 Cheyenne, WY 82003-4009 3071635-2424


Jonathan W. Singer, DO President WY Association of Osteopathic Physicians/Surgeons 1805 E. 19th Street, Suite 202 Cheyenne, WY 82001 30716354362


Richard Abood Executive Director WY Pharmaceutical Association 11 15 Custer Laramie, WY 82070 3071766-6126


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

Pharmaceutical Benefits Under State Medical Assistance Programs, 1989

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Transcript of Pharmaceutical Benefits Under State Medical Assistance Programs, 1989