PHARMACEUTICAL BENEFITS

UNDER
STATE MEDICAL ASSISTANCE
PROGRAMS
SEPTEMBER 1985
1
NATIONAL PHARMACEUTICAL COUNCIL. INC
QULSrq T L z ~ u ~ L 4 z x a u 4
Dear Reader:
This twentieth annual edition of the compilation, Pharmaceutical Benefits Under St at e
Medical Assistance Proqrams, was prepared by t he National Pharmaceutical Council, lnc.
to assist in your evaluation of Medicaid program characteristics. NPC recognizes
Medicaid as an important health care component and, therefore, t he significance of care
made available to Title XIX patients. The Council shares the view held by public health
officials t hat public assistance patients should receive the same quality medical care a s
do other patients in the community.
We hope that the information contained in this compilation continues to assist you in the
development, implementation and operation of responsive and financially viable
pharmaceutical programs.
, Sincerely,
President
National Pharmaceutical Council, Inc.
1894 PRESTON WHITE DRIVE. RESTON. VIRGINIA 22091 703~620-6390
PHARMACEUTICAL BENEFITS
UNDER
STATE MEDICAL ASSISTANCE
PROGRAMS
SEPTEMBER 1985
Compiled by NATIONAL PHARMACEUTICAL
COUNCIL, INC.
1894 Preston White Drive. Reston. Virginia 2209 1
TABLE OF CONTENTS
Introduction
Pharmaceutical Benefits Under State Medical Assistance Programs
Health and Human Services Regional Administration
State Medicaid Drug Program Administrators
Glossary of Medicaid Terms
Acronyms
Tables
1. Medicaid Statistics:
Current Data
a. Medicaid Drug Reimbursement
b. Drug Recipients and Vendor Payments, 1984
Trends
c. Medicaid Drug Reimbursement, 1984 versus 1985
d. Vendor Payments for Prescribed Drugs (1979 to 1984)
e. Recipients of Prescribed Drugs (1979 to 1984)
f. Average Expenditures per Recipient for Prescribed
Drugs (1979 to 1984)
g. Percentage of Medicaid Expenditures Allocated to
Prescription Medication (1981 to 1984)
h. Ranking of States Based on Medicaid Drug Expenditures
i. Ranking of States Based on Average Drug Expenditure
per Recipient
U.S. Totals by type of service
j.
Medical Assistance Program Benefits (Title XIX)
Total U.S. Vendor Payments by Type of Sewice. I98311984
k. National Title XIX Payments by Type of Service
I. National Medicaid Expenditure and Receipt Data
m. 1984 National Health Care Expenditures-Where
They Came From
n. 1984 National Health Care Expenditures-Where
They Went
o. Federal Medical Assistance Percentage ("FMAP")
2. Maximum Allowable Cost Information:
a. List of Federal MAC Drugs
3. Expanded Drug Coverage for the Elderly:
a. Programs Characteristics for States with
Elderly Drug Coverage Programs
iii
NPC-I
4. State Demographic and Economic Characteristics, 1984:
a. State Population. Unemployment, Income,
and Age Characteristics
5. Miscellaneous:
a. Pharmacies and Pharmacists
b. Key Provisions of State Drug Product Selection Laws
Medical Assistance Drug Programs
(Alphabetically by State andlor Territory)
NPC
NATIONAL PHARMACEUTICAL COUNCIL, INC.
The National Pharmaceutical Council, lnc, 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 twenty-eight 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, phar-
macists, manufacturers, professional associations, colleges of pharmacy, medical schools, government
offices and consumers concerning key aspects of health care. NPC services include providing informa-
tion 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 (CFR42),
supplemented by material contained in HCFA publication, "Analysis of State Medicaid Program
Characteristics, 1984" published March, 1985.
"' Acknowledgements -
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.
NPC
PHARMACEUTICAL BENEFITS
UNDER STATE MEDICAL ASSISTANCE PROGRAMS
(Provided under Title XIX of the Social Security Amendments)
This compilation of data on State Medical Assistance Programs (Title XIX) has been prepared to
present a generai overview of the characteristics of state programs together with detailed information on
the pharmaceutical benefits provided.
The following information is provided for each state:
1. Recipient groups eligible for benefits
2. Amount expended for drugs per recipient category
3. Characteristics of the State Drug Program
4. Restrictions or limitations on drugs
5, Medicaid or public health officials
6. Pharmacy and medical consultants to the state programs
7. Pharmacy and medical advisory committees
8. State medical and pharmaceutical association executives
9. 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 Puerto Rico, Guam, Virgin Islands 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, except that Arizona operates a
program as an alternative to Medicaid under a waiver of some basic Medicaid requirements. Federal
funding has also been provided for a Medicaid program in American Samoa.
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 pay-
ments," i.e., direct payments by a state to doctors, nurses, and health care institutions, rather than
to the welfare recipient himself. Although federal sharing in vendor payments created an administra-
tive framework for a welfare medical program, federal funding was so small that only a few states par-
ticipated. 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 pro-
grams. 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, pius Guam. District of Columbia, Puerto Rico, Samoa,
NPC 1985
Northern Mariana Islands and the Virgin Islands) disiinctly 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 eiigible for Medicaid and to reimburse providers of those services in certain
ways. Reimbursement levels for many sewices 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 primariiy 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 legislature 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 evaluat-
ing the Medicaid program. The law further requires the states to establish medical care advisory com-
mittees to advise the Medicaid agency director about health and medical services. This committee
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 aiiowed 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 determi-nations 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 states elected to have federai determination and those 30 states expended 74.4 percent of total
Medicaid expenditures in 1983. Six states elected to extend Medicaid to all recipients of SSI but maintain
eligibility determination on a state level. Those six states expended only 3.0 percent of total Medicaid
expenditures in 1983. Fourteen states elected the 209(b) option, consisting of 22.6 percent of total
Medicaid expenditures.
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 431.50jb)). 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 and accounted for
60.3% of total Medicaid expenditures in 1983. Six states have chosen local administration and those
six states accounted for 39.7 percent of total Medicaid expenditures in 1983. What 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
NPC 1985
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 umbreila 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 SSliSSP programs, individuals who automatically become eligible for Medicaid.
This separation could create a span of control problems for the Medicaid agencies. Five states have
designated the health depanment, 22 states have designated the welfare department, 20 states have
designated an umbrella agency, and three states have designated other agencies to administer the
Medicaid program. The "other" agencies included the office of the Governor in Alabama and an
independent agencylcommission in Georgia and Mississippi.
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 seven major categories as follows:
I. Professional Services-treatments provided by physicians, optometrists, dentists, etc.
I!. Nursing Care Services-types of care provided by nurses in hospitals, patient's homes, clinics,
nurse-midwife services, etc.
Ill. Nursing Home Services-types of care available in nursing homes, such as skilled, intermediate, or
general nursing care.
IV. Hospital and Clinic Services-services provided at a hospital, clinic, or other type of medical
treatment center (does not include nursing homes).
V. Drugs, Supplies, and Equipment-includes prescribed drugs and any supplies or equipment needed
to aid in the treatment of a medical problem.
VI. Special Services and Therapy-includes screening, diagnostic, and preventive services as well as
therapy for physical, occupational, or communication disorders.
VII. 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).
~lll.0ther-any services provided which facilitate medical treatment that are not covered by any of the
above categories.
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. lnpatieni 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.)
NPC
The six additional mandatory services added since 1965 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. Rura! Health Clinic Services
11. 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.
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 iegard to where they
receive their care, including an option to obtain their care through organizations that provide servlces or
arrange for their ava~lability on a prepayment basis, such as health maintenance organizations.
MEDICAID ELIGIBILITY
Medicaid ; s the primary source of health care coverage for the poor in America. Through it, medical
services 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 needy" persons. 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.
NPC 1985
MEDICAID SERVICE
(Mandatory Services Indicated by Capital Letters)
I. Professional Services
PHYSICIAN SERVICES
Chiropractors' Services
Podiatrists' Services
Optometrists' Services
Other Practitioners' Services
Dental Services (for persons 21 years of age and older)
II. Nursing Care Services
HOME HEALTH CARE SERVICES (for persons 21 years of age or older)
Personal Care Services
Private Duty Nursing
NURSEMIDWIFE SERVICES
Adult Day Treatment Services
Ill. Nursing Home Services
SKILLED NURSING FACILITY SERVICES (for persons 21 years of age or older)
Intermediate 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
Vl. Special Services and Therapy
INDEPENDENT LABORATORY & XRAY 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 Institutions (for persons age 65 or older)
Care in Mental Institutions-Intermediate Care Facility Services (for persons age 65 or older)
Care in Mental Institutions-Skilled Nursing Facility (for persons age 65 or older)
Vlll. Othei
TRANSPORTATION TO & FROM MEDICAL SERVICES
Enrollment in Medicare-Part B, Title XVIII, Supplemental Medical lnsurance
Enrollment in Medicare-Part A, Title XVIII, Hospital lnsurance Benefits
6
NPC 1985
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 "categorically needy" or "medically 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 andlor local funds must be used to support the medical
expenses of these individuals i f 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
lnpatient Hospital Services
Inpatient 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):
The facility must be licensed or formally aproved as a hospital by an officially designated authority
for state standard-setting;
0 The facility must meet the requirements for participation in Medicaid;
0 The care and treatment of inpatients must be under the direction of a physician or dentist; and
e The facility must have in effect an approved utilization review plan, applicable to all Medicaid patients,
uniess 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:
e Tine services must be provided under the direction of a physician or dentist;
0 The facility must be licensed or formally approved as a hospital by an officiaily designated authority
for state standardsetling; and
0 The facility must meet the requirements for participation in Medicare
States are free to specify other limits on outpatient hospital services and 40 states have chosen to do
so.
NPC
Twenty-two states, accouniing for 54.6% of total Medicaid expenditures for outpatient hospital sewices,
place other limits on outpatient hospital services. Examples of "other limits" include: (1) emergency
room services are not provided between 5:00 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 Health Cllnic Services
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. Parttime 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 XRay Sewices
Other laboratory and X-ray services are professional and technical laboratory and radiological ser-
vices. As specified in 42 CFR 440.30 (ac), 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 Xray 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:
0 Pr0vided.b~ 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 recertification of need for inpatient care, individuals written plan of care, etc.
Early and Pe~jadic Scmening, 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 441.56). These services include:
e Health and development history screening
NPC
0 Unclothed physical examination
e Developmental assessment
0 lmmunizations which are appropriate for age and health history
a Assessment of nutritional status
0 Vision testing
0 Hearing testing
0 Laboratory procedures appropriate for age and population groups
0 Dental services furnished by direct ieferral to a dentist for diagnosis and treatment for children three
years of age and over
0 Treatment for defects for vision and hearing, including eyeglasses and hearing aids; and
0 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 regula-
tions 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 physicien
or prescribed by a physician; laboratory examination; medically approved methods, procedures, phar-
maceutical supplies and devices to prevent conception; natural family planning methods, diagnosis
and treatment for infertility: and voluntary sterilization. In addition, states may 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 specificaily excluded from family planning
services and states are prohibited from considering any abortion as being a family planning service.
Voiuntary sterilizations must be inciuded among the range of family planning services offered by a
state. Federal regulations require that the individual to be sterilized voluntarily gives informed wrinen
consent and that the individual must be at least 21 years of age at the time consent is obtained and
must be mentally competent.
Physkians' Sewices
Physicians' sewices are covered whether provided in the office, the patient's home, a hospital, a skil!ed
, c m or nursing facility, or elsewhere. Physicians' services must be within the scope of practice oi medi :
osteopathy as defined by state law and by or under the personal supervision of an individual ilcensed
under state law to practice medicine or osteopathy.
Heme Health Sewices
Home health services are piovided to a recipient at his piace of residence which does not i nci ~de
a hospital, skilled nursifig 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 written plan of care that is reviewed by the physician every 60 days. Home heaith
services include three mandatory services (part-time nursing, home health aide, and medicai supp!ies
and equipment) and one optional service (physical therapy, occupational therapy, and speech p&hoIog:i
and audiology services) (42 CFil 440.70). These services are defined as follows:
NPC 1985
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 written orders from
the patient's physician, documents the care and services provided, and has had orientation to
acceptable clinical and administrative recordkeeping from a health department nurse;
e Home Health Aide-home health aide service that is provided by a home health agency;
0 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 nurse-midwife
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
skates offer direct reimbursement to nurse-midwives as one of the payment options. Nursemidwives
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 OF'TIONAL 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 440.150(ab)).
This optional service is provided by all 50 states
Services for Individuals Age 21 end 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 furlher specify certification of need, active treatment, and individual plans of care.
Prescribed Drugs
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
10
NPC 1985
or other licensed practitioner of the healing arts within the scope of their professional practice as defined
and limited by federal and state iaw (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. 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" imposed on prescribed drug services are tha! 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 impair-
ment 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 at 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 ser-
vices, supervised by a registered nurse, and not a member of the recipient's family (42 CFR 440.1 70(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 statss had been approved for Section 21 76
waivers.
Private duty nursing services refer to nursing services for recipients who require more individual and
continuois 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 liensed 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 siructure of the oral cavity; and
o Gisease, 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 sen'ices 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
NPC 1985
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 malfuncticn; 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 10(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 ser-
vice 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 supe~i sed 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 iliness, 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 440.130(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
health 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 440.1 30(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 li-censed practitioner of the healing arts within the scope of
his oractice under state law.
MEDICALLY NEEDY COVERAGE AND LIMITATIONS
A state plan must specify that, as a minimum, categorically needy recipients are provided the man-
datory 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;
12
NPC 1985
Ambulatory services to individuais under age 18 and individuais entitied to institutional services;
Home health services to individuals entitied 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
nurse-midwives are authorized to practice under state law or regulations);
The services contained in any seven of the sections in 42 CFR 440.10 through 42 CFP 440.165.
The state can, in addition, p'rovide 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 noninstitutionai
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 97248, 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);
0 Pregnancy-related services (or, at state option, any service provided to pregnant women);
0 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 enrollees (or, at state option, services provided to
both categorically needy HMO enroiiees (or, at state option, services provided to both categorically
needy and medically needy HMO enrollees).
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 nonemergency 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 accessibility
to alternative sources of care.
Medicaid Management Information System
The Social Security Amendments of 1972 authorized 90 percent federal matching to states tor 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.
NPC 1985
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, sur-
veillance 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-two states have certified MMlSs and operate a mechanized claims processing and information
retrieval system.
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 28 states, by states themselves in 19 states, and by a combination of fiscal agentktate
in three states.
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 othewise qualify for the cash assistance programs i f 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 clientele and part to do with reimbursement rates for both Medicare and Medicaid
falling behind those offered by private insurance cariers. Over 25 percent of the nation's private practice
physicians refuse to treat Medicaid patients, and participation among key specialists such as OBGYNs is
even lower.2 In the nation's highly urbanized areas in which the majority of Medicaid recipients live, low
officebased 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 Schoen. Health and the War on Poverty, A Ten Year Appraisal; Brookings Institution, 1978.
Mitchell and Cromwell, "Large Medicaid Practices and Medicaid Mills," Journal of the American
Medical Association, November 1950.
NPC 1985
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 iate 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 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 97-35). 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 2174) 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 quaiified 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.
The final legislative step thus far 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 adaptated
the new Medicare PPS concept to their own hospital reimbursement ~yst em. ~
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 service reimbursement policies are included in this report. These services represent
over 90 percent of all Medicaid expenditures nationwide for fiscal year 1984.
Clinkscaie, Robert, "Impact of Medicare's Prospective Payment System (PPS) on State Medicaid
Programs,'' Proceedings, First National DRG Conference, Atlantic City, N.J., 1983.
NPC 1985
NURSING HOME RElMBURSEMENT
Expenditures for nursing home services is the largest and most rapidly growing component of national
Medicaid outlays. From fiscal year 1982 through fiscal year 1984, Medicaid expenditures for nursing
homes increased by approximately 9.4 percent; from $12.9 billion to $14.8 billion in fiscal year 1984.
ICFMR 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 combina-
tion 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 REMBURSEMENT
Inpatient hospital services are the second largest component of Medicaid expenditures nationwide.
accounting for $10 billion or 29.5 percent of Medicaid outlays in fiscal year 1984. 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 sys-
tems have tended toward facility-specific budget review, rate of increase control and forms of prospec-
tive 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 encompass 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 third largest component of Medicaid expenditures. In
fiscal year 1984, physician services accounted for $2.2 billion, or 6.5 percent of Medicaid expenditures
nationwide. States have broad discretion within general federal guidelines regarding Medicaid reim-
bursement 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 Onibus 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 "adequate 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 "rea-
sonable." In some states, the 75th percentile is determined on the basis of physicians' charges in the
same specialty andlor substate region; in others, states use charge data from all physicians regardless
of specialty or substate region. Finally, since 1976 an "economic index" has been a2plied to limit the rate
16
NPC
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 percentiie of pervailing to the point where they have in reality converted to a
fee schedule.
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 freestanding clinic services. Three states
reported adherence to Medicare principies. There were 41 states using alternate methods (these 41
states represented 99 percent of total Medicaid clinic services expenditures).
PRESCRIPTION DRUG REIMBURSEMENT
Prescription drug reimbursement conforms to the maximum allowable cost (MAC) system in effect
since 1976. This has led to considerable uniformity in drug-specific payments across states; however,
states vary in retail pharmacy dispensing fees, recipient copayments, limitations on use, over-the-counter
exclusions and formulary status for legend drugs. For example, retail pharmacy dispensing fees (per
prescription) range from a low of $2.50 to a high of $4.05. Of the 48 states sponsoring a drug program, 26
charge no copayments; the remainder charge copayments to recipients ranging from $SO to $3.00, most
having copayments of $50 to $1 .OOper prescription. A few states made up and downward adjustments
to drug copayment levels. Eleven states limit number of new prescriptions per month. Nineteen states
use a formulary (limited or restricted drug list). Twenty-six states establish state MACs in addition to the
federal MAC list. See chart, detailing state reimbursement characteristics.
VENDOR DRUG PROGRAM PROVISIONS
1. Freedom of Choice. Section 1902 (a) (23) Social Security Act, Reg. 42 CFR 431.51
Any individual eligible ior Medicaid may obtain the services available under the state Medicaid pian
from any institution, agency, pharmacy, person or organization which provides such services or
arranges for their availability on a prepayment basis, and is qualified to perform such services.
It is not required that an institution allow a recipient a choice of drug provider if the institution
(e.g., hospital or nursing home) customarily includes pharmaceuticals as part of its total package of
services.
Section 2175 Freedom of Choice Waivers. Section 21 75 attempts to increase the importance oi price
considerations in the decision about when, where, and how to utilize health care services. Each of
the waivers focuses on a different part of the health care decision making process and allows a state
to:
implement a primary care case mangement system focusing on primary care physicians;
Allow a locality to act as central broker in assisting Medicaid recipients in selecting among
competing health plans;
Spitz, Bruce. State Guide to Medicaid Cost Containment, National Governors' Association and
Intergovernmental health Policy Project, September 1981
NPC 1985
Share with recipients, through the provision of additional services, savings resulting from
recipients' use of more costeffective medical care; and
Restrain recipients to receiving services (other than in emergency situations) from only efficient
and cost effective providers.
The waivers can be granted for a period of up to two years, and a state may request a continuation.
2. Drug Reimbursement. Title 45 PUBLIC WELFARE, Subtitle A Department of Health and Human
Services, Part 19-Limitations on Payment or Reimbursement for Drugs
Regulation Sec. 19.1. Purposes
(a) This establishes Department of Health and Human Services procedures for determining drug
costs and, where applicable, dispensing fees which the Department will use for the purpose of
determining:
(1) Reimbursement to providers and health maintenance organizations under the Medicare
program;
(2) Reimbursement to states under state administered health, welfare, and social service
programs; and
(3) Allowable costs under projects for health services.
(b) Policies and procedures, which will be consistent with the policies and procedures set forth in this
Part, will be published in the HHS Procurement Regulations, Title 41, Chapter 3, Code of Federal
Regulations, governing the direct purchase of drugs by the Department and the purchase or
supply of drugs by contractors of the Department.
(c) This Part does not establish procedures for fixing the actual amount of reimbursement to which
providers will be entitled for dispensing drugs. Rather, it establishes procedures for setting a
limit on what the individual program regulations and policies might otherwise provide. If the
authorizing legislation for a particular program, or the program regulation or policies adopted
or issued under that legislation, provides for a lower rate of reimbursement than this regulation
permits, then the program reimbursement rate, being lower, will necessarily control the actual
payment.
Regulation Sec. 19.3. Cost Li mi tati ~n.~
(a) The amount which the Department will recognize for reimbursement or payment purposes for
any drug used in the programs or activities described in Sec. 19.1 shall not exceed the lowest
of:
(1) The maximum allowable cost (MAC) of the drug, if any, established in accordance with Sec.
19.5 plus a reasonable dispensing fee;
(2) The acquisition cost of the drug plus a reasonable dispensing fee; or
(3) The provider's usual and customary charge to the public for the drug; provided that: the
MAC established for any drug shall not apply to a brand of that drug prescribed for a patient
which the prescriber has certified in his own handwriting is medically necessary for that
patient; and provided further, that: where compensation for drug dispensing is included in
some other amount payable to the provider by the reimbursing or paying program agency,
a separate dispensing fee will not be recognized.
(b) Each program agency shall estimate the acquisition cost of each drug for which it reimburses or
pays a provider. Such estimate should be consistent with any drug price information furnished
the program agency by the Department.
Federal Register, Vol. 40, 32283, July 31, 1975
Federal Register, Vol. 40, 32283, July 31, 1975 and corrected in Federal Register, Vol. 40, 36342,
August 20, 1975
NPC 1985
Sec. 250.3 (b)(2)(H)-Reasonable Charges
For each multiple source drug designated by the Pharmaceutical Reimbursement Board and
published in the Federal Register cost will be iimited to the lower of:
a. the maximum allowable cost (MAC) established by the Board for such drug and published in the
Federal Register, or
b. the estimated acquisition cost (EAC as defined in the regulations).
Limitation to the maximum allowable cost established by the Board 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.
The form and procedure for the certification shall be prescribed by the state. An example of an
acceptable certification would be a notation "brand necessary". A procedure for checking a box on
a form will not constitute an acceptable certification.
For all prescribed drugs the upper limits for which payment is made shall be based on the lower
of the cost of the drug plus a dispensing fee or the provider's usual and customary charge to the
general public.
3. Pharmaceutical Reimbursement Board (PUB)
Pharmaceutical Reimbursement Section
Health Care Financing Administration
Department of Health and Human Services
Establishment of pharmaceutical reimbursement board.
(a) There is established in the Health Care Financing Administration a Pharmaceutical
Reimbursement Board consisting of six full time employees of the Department, representing the
principal offices and agencies concerned with developing and implementing cost determina-
tions under this part. The Director, Office of Pharmaceutical Reimbursement, shall serve as the
Chairman.
(b) The Board may make use of outside consultants to advise it on any technical or complex issues
during its consideration of a proposed MAC.
(Outline of procedures only-detail omitted)
(a) Identification of drugs to which MAC may be applied
(b) Review by the Food and Drug Administration
(c) Initial determination of lowest unit price
(d) Proposed MAC
(e) Notice of Comment
(f) Public Hearing(gConduct of hearing
(h) Proposed final determination
(i) Administrator's concurrence
(j) Publication-(Federal Register notice)
A list of Federally MAC'd drugs appears on page **, Table IIA
4. Estimated Acquisition Cost (EAC)
Estimated Acquisition Cost (EAC) applies to all drug products not reimbursable as a maximum
allowable cost (MAC) drug product as established by the HHSPharmaceutical Reimbursement Board.
The development of EAC price levels is the responsibility of each state.
HHS will periodicaliy provide each state with product cost data as a guideline to assist in establishing
the estimated acquisition costs for that particular state.
NPC 1935
Medicaid-Formula for Determhing EAC for Drugs
70th Percentile "bench mark
HHS Action Transmittal. HCFAAT77113 (LIMB), December 13, 1977. Subject: "Title Xi X, Social
Security Act: Limitation on Payment or Reimbursement for Drugs: Estimated Acquisition Cost (EAC)."
The intent of the final Medicaid regulations on drug reimbursement is to have each state's
estimated acquisition cost as close as feasible to the price generally and currently paid by
the provider. The states are, therefore, expected to set their ingredient cost levels as close
as possible to actual acquisition cost. The Department's analysis of price data over several
months indicates that a specific percentile listing-the 70th-might appropriately be used as a
bench mark in determining the degree to which the ingredient cost levels established by states,
approach actual acquisition cost. Any state which is found to be reimbursing at a level above
the 70th percentile could be expected to provide evidence to indicate that its reimbursement
levels are closer to the providers' AAC than the Federal data.
Tne text of the transmittal also states:
"Each program administrator should evaluate the state's method of setting EAC limits for the drug
program to assure that drug reimbursement limits are as close as feasible to Actual Acquisition
Cost."
5. Formularies in Medicaid Programs
Under existing federal policy, the use of a formulary or limited drug list in a Title XIX program is
optional. The policy states, "the basic objective is to enable doctors and pharmacists throughout the
state to join in a mutually beneficial selection of high quality drugs of recognized therapeutic value,
produced by reputable manufacturers and broad enough to cover virtually any situation" (Medicaid
Assistance Manual SRSMSA196 1971).
A drug formulary or list of pharmaceutical products is either open (unrestricted) or closed (restricted).
Each state's Medicaid program determines its own formulary status. An open formulary is a list of
virtually all prescription drugs approved by the FDA and allows the prescriber to choose the most
medically appropriate drug to treat each patient. A closed formulary is a limited list of drugs for which
reimbursement will be granted under the state Medicaid program. No drug that is not contained in
the list is covered without prior approval by the state. Thus, prescribers are administratively limited
in their choice of drugs in treating Medicaid patients.
6. Implementation of Formulary Guidelines
Formulary regulations were codified in Sec. 250.30 (b) (2) (iv) of Title 45, Chapter il, of Code of
Federal Regulations as set forth below:
"Drugs. (iv) The use of a formulary is optional, as are provisions for use of generic drugs. Where
either is employed, there must be standards for quality, safety and effectiveness under the
supervision of professional personnel."
In carrying out the above regulation, state agencies should consider the following guidelines:
0 Any medication included in a formulary shall meet such acceptable standards for drugs as
required under the Federal Food, Drug, and Cosmetic Act, as amended, and the applicable
requirements of official compendia with respect to identity, strength, safety, quality, purity, and
effectiveness.
0 State agencies should adopt procedures which will ensure the greatest economy consistent wiln
acceptable standards of identity, strength, safety, quality, purity, and effectiveness.
Any formulary developed for a state's Medicaid Drug Program should not become so rigid
that the prescriber's privilege for requesting items outside the formulary in justified sittations
is made impossible. The formulary should have due regard for the professional prerogatives of
practitioners. It should not place undue restrictions upon the physician insofar as his prescribing
practices are concerned.
The state's formulary committee should be composed of practicing physiciins, pharmacologists,
20
NPC 1985
pharmacists, and other professional personnel operating within specific procedures established
by the state. It should be charged with the responsibility of revising the formulary when required
at specified intervais.
0 A principal purpose of the formulary should be to identify the drugs approved for reimbursement
under the program. However, it should permit authorization for the reimbursement of nonlisted
items upon professional justification.
Each item should have an assigned code number (preferably, from the FDA National Drug Code
Directory.) That code number should lend itself to automatic or electronic data processing for t i e
purpose of handling administrative functions with greater efficiency and speed, and at reduced
cost.'
XI. Health and Human Services Department, Health Care Financing Administration-An Overview
The Health Care Financing Administration (HCFA) was established in early 1977 to bring into one
agency the major federal health care financing programs and their associated quality assurance activity
HCFA is responsible for the federal administration of health financing and quality assurance programs.
HCFA's mission is to:
Ensure the effective administration of its program in order to promote the timely delivery of
appropriate, quality health care to its beneficiaries;
0 Make certain that beneficiaries are aware of the services for which they are eligible, that these
services are accessible to them and are provided in the most effective manner, and;
0 Ensure that its policies and actions promote efficiency and quality within the total health delivery
system which services all Americans.
This mission is carried out by ten regional offices, each of which is responsible for the administration
of HCFA programs in a given geographic area. The basic functions of a regional office are to: monitor
the performance of Medicare contractors, Medicaid state agencies, state survey agencies, and PSROs;
interpret Federal health policies and regulations to these organizations; monitor the expenditure oi
Federal funds: oversee the operation of quality control programs, and assure effective communication
between HCFA, its providers and its beneficiaries.
(Reference-Medical Assistance Manual SRS-MSA-196-1971)
Because of the direct relationship between formulary development, maximum allowable cost procedures
and the substitution of generic drugs, a table has been inciuded which outlines the provisions of state
laws permitting drug substitution by pharmacists, See Table #VIB.
REGION #I Connecticut, Maine,
Massachusetts, New
Hampshire, Rhode
Island, Vermont
REGIONAL ADMlNlSTRATiVE OFFICE
Health and Human Services
Health Care Financing Administration
REGION #2 New Jersey, New York,
Puerto Rico, Virgin
Islands
REGION #3 Delaware, District of
Columbia, Maryland,
Pennsylvania,
Virginia, West Virginia
REGION #4 Alabama, Florida,
Georgia, Kentucky,
Mississippi, North
Carolina, South
Carolina, Tennessee
REGION #5 Illinois, Indiana,
Michigan, Minnesota,
Ohio, Wisconsin
REGION #6 Arkansas, Louisiana,
New Mexico, Oklahoma,
Texas
REGION #7 Iowa, Kansas,
Missouri, Nebraska
REGION #8 Colorado, Montana,
South Dakota, North
Dakota. Utah, Wyoming
REGION #9 Arizona, California,
Guam, Hawaii, Nevada,
American Samoa
REGION #10 Alaska, Idaho,
Oregon, Washington
John F. Kennedy Federal Bldg.
Government Center, Room 1309
Boston, Massachusetts 02203
Room 3800
26 Federal Plaza
New York, New York 10278
3535 Market Street
HCFA Region Ill
Philadelphia, Pennsylvania 19101
101 Marietta Tower
Suite 701
Atlanta, Georgia 30323
175 West Jackson Boulevard
Suite A835
Chicago, Illinois 60604
1200 Main Tower Building
Room 2400
Dallas, Texas 75202
New Federal Office Building
601 East 12th Street, Rm. 235
Kansas City, Missouri 64106
1961 Stout Street
Federal Office Building, Rm. 628
Denver, Colorado 80294
100 Van Ness Avenue, 14th Floor
San Francisco, California 94102
2901 Third Avenue, MS. 407
Seattle, Washington 98121
NPC
OFFICE OF THE INSPECTOR GENERAL
REGIONAL OFFICE CONTACT
Region
Region /-Boston
Office of Health Financing lntegrity
Room 1305-JFK Building
Government Center
Boston, Massachusetts 02203
6171223-6881
(FTS) 223-6881
Region 11-New York
Office of Health Financing lntegrity
Room 38-1 00
Federal Off ice Building
26 Federal Plaza
New York, New York 10278
2121264-5295
(FTS) 264-5292
Region Ill-Phildeiphia
Office of Health Financing lntegrity
Room 10460 (P.O. Box 13618
3535 Market Street
Philadelphia, Pennsylvania 1910
21 51596-0607
(FTS) 596-0607
Region I V Atlanta
Office of Health Financing integrity
Suite 1403
101 Marietta Tower
Atlanta, Georgia 30323
4041221 -41 08
(FTS) 242-41 08
Region V Chicago
Office of Health Financing lntegrity
Suite A935
175 West Jackson Boulevard
Chicago, Illinois 60604
31 21353-9867
(FTS) 353-9867
States
Connecticut
Maine
Massachusetts
New Hampshire
Rhode Island
Utnadt'
New Jersey
New York
Puerto Rico
Virgin Islands
Delaware
District of Columbia
Maryland
Pennsylvania
Virginia
West Virginia
Alabama
Florida
Georgia
Kentucky
Mississippi
North Carolina
South Carolina
Tennessee
Illinois
Indiana
Michigan
Minnesota
Ohio
Wisconsin
NPC
Region VI Dallas
Office of Health Financing lntegrity
Room 4E6
1100 Commerce Street
Dallas, Texas 75242
21 41767-6371
(FTS) 729-6371
Region VI I Kansas City
Office of Health Financing lntegrity
P.O. Box 26248
1 100 Main Street
Kansas City, Missouri 64196
81 61374-3697
(FTS) 758-3697
Region Vl l l Denver
Office of Health Financing lntegrity
Room 11 85, 13th Floor
Federal Office Building
1961 Stout Street
Denver, Colorado 80294
3031844-2491
(FTS) 564-2491
Region IX San Francisco
Office of Health Financing lntegrity
50 United Nations Plaza
Room 365 .
San Francisco, California 941 02
4151556-3132
(FTS) 556-3132
Region X Seattle
Office of Health Financing lntegrity
Mail Stop 408
2901 Third Avenue
Seattle, Washington 98121
2061442-0577
(FTS) 399-0577
Arkansas
Louisiana
New Mexico
Oklahoma
Texas
Iowa
Kansas
Missouri
Nebraska
Colorado
Montana
North Dakota
South Dakota
Wyoming
Utah
Arizona
California
Guam
Hawaii
Samoa
Alaska
Idaho
Oregon
Washington
NPC
ALABAMA
Sam T. Hardin, P.D.
Associate Director
Pharmaceutical Program
Alabama Medicaid Agency
2500 Fairlane Drive
Montgomery, Alabama 36130
(205) 277-271 0
ALASKA
Bob Ogden
Chief of Medical Assistance
Division of Medical Assistance
4041 "5" Street
Juneau, Alaska 99503
(907) 561 -2171
ARIZONA
STATE
MEDICAID
DRUG PROGRAM ADMINISTRATOR
Dr. Don Schaller
Director
Arizona Department of Health Services
124 West Thomas
Suite 301
Phoenix, Arizona 85013
ARKANSAS
Mark Crossley
Pharmacist Consultant
Arkansas Social Services
P.O. Box 1437
Little Rock, Arkansas 72203
(501) 371 -5361
CALIFORNIA
Milton Kuschnereit, Pharm.
Senior Consulting Pharmacist
Medi-Cal Benefits Branch
California Health and
Welfare Services
714 P. Street, Room 1640
Sacramento, California 95814
(916) 324-2477
COLORADO
Myrle A. Myers, R.Ph., M.S.
Mgr., Pharmacy and Ambulatory
Care Services Section
Division of Medical Assistance
Colorado Department of Social
Services
1575 Sherman Street, Room 101 0
Denver, Colorado 80203
(303) 866-5372
CONNECTICUT
Meyer Rosenkrantz, R.Ph.
Pharmacist Consultant
Department of Income Maintenance
11 0 Bartholomew Avenue
Hartford, Connecticut 06106
(203) 566-8007
DELAWARE
Ruth Fischer
Administrator, Medical Services
Division of Economic Services, DHSS
P.O. Box 906
New Castle, Delaware 19720
(302) 421 -61 39
DISTRICT OF COLUMBIA
James F. Harris, R.Ph.
Pharmacy Consultant
Office of Health Care Financing
Department of Human Services
1331 H Street, NW
Washington, D.C. 20005
(202) 727-0753
FLORIDA
Jerry F. Weils
Pharmacist Consultant
Medicaid Office of Program Development
Dept. of Health and Rehabilitative Serv.
131 7 Winewood Boulevard, 5-6. R-243
Tallahassee, Florida 32301
(904) 488-9990
NPC
GEORGIA
Frances Lipscomb. R.Ph.
Progam Management Officer
Pharmacy Service
2 M.L. King Jr. Drive, S.E.
James Floyd Memorial Building
West Tower. P.O. Box 38440
Atlanta, Georgia 30334
(404) 656-4044
HAWAII
Omel L. Turk
Pharmacist Consultant
Public Welfare Division
Dept. of Social Services & Housing
P.O. Box 339
Honolulu, Hawaii 96809-0339
(808) 548-891 7
IDAHO
Dianne B. Onnen, R.Ph.. M.P.A.
Pharmacy Consultant
Dept. of Health and Welfare
Statehouse
Boise, Idaho 83720
(208) 334-4323
ILLINOIS
Ron Gottrich
Pharmacy Program Supervisor
Medical Assistance Program
Illinois Dept. of Public Aid,
2nd Floor
931 East Washington Street
Springfield, Illinois 62708
(21 7) 782-0563
INDIANA
Marc Shirley
Pharmacy Consultant
lndiana State Dept, of Public Welfare
100 North Senate Avenue Room 702
Indianapolis, Indiana 46204
(317) 232-4312
Ronald J. Mahrenholz, R.Ph.. MS.
Manager, Operations Section
Bureau of Medical Services
Dept. of Human Services
Hoover State Office Building, 5th Floor
Des Moines, Iowa 50319
(51 5) 281 -61 99
KANSAS
Gene Hotchkiss, R.Ph.
Pharmacist Consultant
Dept. of Social & Rehabilitation Sew
State Office Building
Topeka, Kansas 6661 2
(91 3) 296-3981
KENTUCKY
Ms. Gene A. Thomas, R.Ph.
Division of Medical Assistance
Bureau of Social Insurance
275 East Main Street, 3rd Floor
Frankfort, Kentucky 40621
(502) 564-4321
LOUISIANA
Merrell Patin
Pharmacist Consultant
Dept. of Health & Human Resources
P.O. Box 44065
Baton Rouge, Louisiana 70808
(504) 342-9320
MAINE
Michael P. O'Donnell, R.Ph.
Pharmacy Consultant
Br. Med. Sew. Section 11
Dept. of Human Services
Statehouse
Augusta. Maine 04333
(207) 289-2674
NPC
MARYLAND MISSOURI
Joseph Fine, R.Ph.
Section Manager for Pharmacy
Operations
Medicai Assist. Operations Admin
300 West Preston Street
Baltimore, Maryland 21201
(301) 383-2658
MASSACHUSETTS
Robert Karlyn. B.S., R.Ph.
Department of Public Welfare
600 Washington Street, Room 746
Boston, Massachusetts 021 11
(617) 727-1391
MICHIGAN
Robert Levin, D.D.S., Director
Bureau of Health Sewices Review
Medical Service Administration
Department of Social Services
P.O. Box 30037
Lansing, Michigan 48909
(617) 373-7720
MINNESOTA
John T. Bush, R.Ph.
Pharmacist Consultant
Professional Services Section
Dept. Public Welfare, Medical Assist.
444 Lafayette Road, P.O. Box 43170
St. Paul, Minnesota 55101
(612) 296-2363
MISSISSIPPI
James T. Steele. R.Ph.
Pharmacist
Mississippi Medicaid Commission
P.O. Box 16786
4785 1-55 North
Jackson. Mississippi 39236
(601) 981 -4507 Ext. 145
Susan McCann, Ph.D.
Pharmaceutical Consultant,
Medical Services Division
Department of Sociai Services
227 Metro Drive, P.O. Box 6500
Jefferson City, Missouri 65102
(31 4) 751 -3277
MONTANA
Randal P. Bowsher
Pharmacy Consultant, Admin. Officer
Dept. Social & Rehabilitation Services
P.O. Box 421 0
Helena, Montana 59604
4061444-4540
NEBRASKA
Tom R. Doian, R.Ph.
Pharmaceutical Consultant
Medical Services Div.
Dept. of Social Services
301 Centennial Mall South, 5th Floo~
P.O. Box 95026
Lincoln, Nebraska 68509
(402) 471 -3121
NEVADA
Steven P. Bradford, Pharm.D.
Pharmaceutical Consultant
Nevada Medicaid Off ice
Dept. Human Resources
State Capitol Complex
251 Jeanell Drive
Carson City, Nevada 89710
(702) 885-4869
NEW HAMPSHIRE
Clifford A. Zilch, R.Ph.
Chief, Bureau of Medicai Claims Review
Dept. of Health and Welfare
Hazen Drive
Concord, New Hampshire 03301
(603) 271 -4359
OKLAHOMA
sanford Luger, R.Ph.
chief, Bureau of Pharmacy Services
Div. of Medical Assistance & Heaith
Services
324 East State Street, CN-712
Trenton, New Jersey 08625
(609) 292-3756
Nick Army, R.Ph.
Drug Program Administrator
Medical Assistance
gept. of Human Services
pERA Bldg., Room 524
Santa Fe, New Mexico
(505) 827-4315
NEW YORK
Gerald F. Nelligan, R.Ph.
Associate Social Services
Medical Assistance Specialist
~mbulatory Standards Unit
40 North Pearl Street
Albany, New York 12243
(518) 474-9261
NORTH CAROLINA
C. B. Ridout, R.Ph.
pharmacist Consultant
Division of Medical Assistance
Qept. of Human Resources
Kirby Building' 1985 Umstead Drive
~aleigh, North Carolina 27603
(919) 733-2833
NORTH DAKOTA
chuck Gress, R.Ph.
~dministrator of Pharmacy Services
Department of Human Services
State Capitol Building
Bismarck, North Dakota 58505
(701) 224-4023
Robert P. Reid, R.Ph.
pharmacist Consultant
Howard Stansberry
Pharmacy Program Administrator
Dept. of Human Services
P.O. Box 53034
Oklahoma City, Oklahoma 73125
(405) 521 -3804
OREGON
Charles N. Mortensen. R.Ph.
Pharmacist Consultant
Adult and Family Services Division
Dept. of Human Resources
203 Public Service Building
Salem, Oregon 9731 0
87504-2348
(503) 378-2263
PENNSYLVANIA
Joseph E. Concino, R.Ph.
Bureau of Policy and Program Development
Department of Public Welfare, Room 510
Health and Welfare Building
Harrisburg, Pennsylvania 17120
(717) 787-1 170
RHODE ISLAND
John A. Pagliarini, R.Ph.
Assistant Administrator
Department of Social & Rehabilitative Services
600 New London Avenue
Cranston, Rhode Island 02920
(401) 464-2183
SOUTH CAROLINA
James Assey
Medicaid Program Consultant
Department of Health & Human Financ
P. 0. Box 8206
Columbia, South Carolina 29202-8206
(803) 758-2320
SOUTH DAKOTA
Donald Mahannah, Fi.Ph.
Pharmacist Consultant
Department of Social Services
Medical Services
700 North Illinois
Pierre, South Dakota 57501
NPC
Bureau of Medicaid Policy
Department of Human Services
30 East Broad Street-31st Floor
Columbus, Ohio 43215
(61 4) 466-6420
TENNESSEE
Ronald E. Graham, Pharm.D.
Director of Pharmacy Serivces
Tennessee Department of Public
Health and Environment
729 Church Street
Nashville, Tennessee 37219-5406
(61 5) 741 -01 92
TEXAS
W. Blount Earner, R.Ph., D.Ph.
Program Specialist, Vendor Drugs
Texas Department of Human Resources
Mail Code 541-W, P.O. Box 2960
Austin, Texas 78769
(512) 450-3202
UTAH
RaeDell Ashley, R.Ph.
Manager, Program Operations and
Medical Determinations
Health Care Financing
Utah Department of Health
150 W. North Temple, P.O. Box 2500
Salt Lake City, Utah 841 10
(801) 533-6648
VERMONT
Robert Edson, R.Ph.
Pharmacy Consultant
Medicaid Division
Department of Social Welfare
103 South Main Street
Waterbury, Vermont 05676
(802) 241 -2880
VIRGINIA
Mary Ann Johnson, R.Ph.
Pharmacist Consultant
Medical Assistance Program
State Department of Health
109 Governor Street, VMAP
Richmond, Virginia 23219
(804) 786-3820
WASHINGTON
William P. Pace, R.Ph.
Pharmacist Consultant
Office Medical Dir.
Mail Stop HB-41
Olympia, Washington 98504
(206) 753-0524
WEST VIRGINIA
Bernard Schlact. R.Ph.
Pharmacy Coordinator
Division of Medical Care
West Virginia Department of Welfare
1900 Washington Street, East
Charleston, West Virginia 348-8990
WISCONSIN
Michael Boushon
Pharmacist Consultant
Wisconsin Dept. of Health
and Social Service
P.O. Box 309
Madison, Wisconsin 53701
(608) 266-0722
PUERTO RlCO
Emilia Hoyos Rucabado, M.S.
Pharmacist Consultant
Department of Health
Bldg. A, Call Box 70184
San Juan, Puerto Rico 00936
767-6060 x 2232
NPC 1985
GLOSSARY OF MEDICAID TERMS
0 Capitation (fee): Fee the agency pays periodically to a contractor for each recipient enrolled under
a contract for the provision of medical services under the State plan, whether or not the recipient
receives the services during the period covered by the fee.
a Categorically Needy. Under Medicaid, categorically needy cases are aged, blind, or disabled
individuais or families and children who are otherwise eligible for Medicaid and who meet financial
eligibility requirements for AFDC, SSI, or an optional state supplement.
0 Copayment: Copayments are a type of cost-sharing under Medicaid whereby insured or covered
persons pay a specified fiat amount per unit of seivice or unit of time, and the insurer pays the rest
of the cost.
a 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: Metnod 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).
e Customaw Charge: The charge a physician or supplier usually bills his patients for furnishing a
particular service or supply is called the customary charge.
a Diagnosis Related Groups: Tnese groupings are used for incorporating severity of illness measure-
ments into the process for prospective payment determination for inpatient hospital sewices.
e Early and Periodic Screening, Diagnosis, and Treatment (EPSDT): The EPSDT program covers
screening and diagnostic services to determine physicial 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.
0 Expenditures: Under Medicaid, "expenditures" refers to an amount paid out by a state agency for
the covered medical expenses of eligible participants.
a 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 individtials freely to determine the number or spacing of their children.
a Fiscal Agent: A fiscal agent (fiscal intermediary) is a contractor that processes or pays vendor
claims on behalf of the Medicaid agency.
a Health Maintenance Organizations (HMO's): A health care plan that deliveries comprehensive,
coordinated health care services to voluntarily enrolled members on a prepaid basis.
HMO Model Types:
Group Practice or Closed Panel-An HMO that contracts with a medical group, partnership,
or corporation composed of health professionals licensed to practice medicine or osteopathy
as well as other health professionals necessary for the provision of health services. In a group
practice arrangement, all physicians are usually located in one facility and are compensated on
a capitation basis.
Individual Practice Association (IPA) or Foundation Model-An HMO that contracts with
a partnership, corporation, or association whose major objective is to enter into contractual
arrangements with health professionals for the delivery of health service. Unlike the group
practice arrangement, the ~ ~ ~ ' o r ~ a n i r a t i o n provides services in a variety of locations, allowing
physicians to work directly from their own offices and permitting the HMO members to retain the
mode of delivery to which he may be accustomed. Physicians are usually compensated by the
IPG. on a fee-for-service arrangemeni.
30
NPC
Staff HMO-An HMO that delivers services through physicians who are on the staff of the HMO,
i.e., are paid directiy by the HMO and not through a physician organization or legal entity.
Home Health Agency: A home health agency is a public agency or private organization which is
primarily engaged in providing skilled nursing sewlces and other therapeutic services in the patient's
home, and which meets certain conditions designed to ensure the health and safety of the individuais
who are furnished these services.
0 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:
parttime 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.
0 lnpatient 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 services,
diagnostic and therapeutic services, and medical or surgical services.
0 Intermediate Care Facility: An intermediate care facility is an institution furnishing healthrelated care
and services to individuals who do not require the degree of care provided by hospitals or skilled
nursing facilities as defined under Title XiX (Medicaid) of the Social Security Act.
0 Laboratory and Radiological Services: Laboratory and radiological services are professional and
technical laboratory and radiologicai services ordered by a iicensed practitioner and provided in
an office or similar facility (other than a hospital outpatient department or clinic) or by a qualified
laboratory.
0 Medically Needy: Under Medicaid, medicaily 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.
0 Other Practitioners' Services: Other practitioners' services are health care services of iicensed
practitioners other than physicians and dentists.
0 Outpatient Hospital Services: Outpatient hospital services are services furnished to outpatients by
a participating hospital for diagnosis or treatment of an illness or injury
0 Prescribed Drugs: Prescribed drugs are drugs dispensed by a licensed pharmacist on the prescrip-
tion 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.
0 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 of: 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 biil 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.
0 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 enrollees. 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.
e 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.
NPC 1985
0 Rural Health Clinic: A rural health clinic is an outpatient faciiity 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.
0 Skilled Nursing Facility (SNF): A skilled nursing facility is an institution which has in effect a trans-
fer agreement with one or more participating hospitals, and is primarily engaged in providing to in-
patients skilled nursing care and restorative care services, and meets specific regulatory certification
requirements.
0 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.
0 SpendDown: Under the Medicaid program, spenddown 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.
0 State Buyln: State buyin is the term given to the process by which a state may provide
Supplementary Medical Insurance coverage for its needy eligible persons through an agreement
with the Federal government under which the state pays the premiums for them.
0 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.
0 Supplemental Security income (SSI): SSI is a program of income support for lowincome aged,
blind, and disabled persons established by Title XVI of the Social Security Act.
0 Third-Party Liabllity: Under Medicaid, thirdparty 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.
0 hndor: A medical vendor is an institution, agency, organization, or individual practitioner which
provides health or medical services.
NPC
ACRONYMS
AABD
AB
AFDC
APTD
CFR
CPR
DHHS
DRGs
EPSDT
FY
HCFA
HMO
ICF
MAC
MMlS
MQC
NMCUES
NP
OAA
OASDl
OBR A
ORD
OT
OTC
PA
PT
RHC
SNF
SSA
SSI
SSP
TDOC
TEFRAA
UCR
Aid to Aged, Blind, and Disabled
Aid to the Blind
Aid to Families with Dependent Children
Aid to the Permanently and Totally Disabled
Code of Federal Regulations
Customary Prevailing, and Reasonable (charges)
Department of Health and Human Services
Diagnostic Related Groupings
Early and Periodic Screening, Diagnostic and Treatment
Fiscal Year
Health Care Financing Administration
Health Maintenance Organization
Intermediate Care Facility
Maximum Allowable Cost
Medicaid Management Information System
Medicaid Quality Control
National Medicare Care Utilization and Expenditures Survey
Nurse Practitioner
Old Age Assistance
Old Age, Survivors, and Disablity Insurance
Omnibus Reconciliation Act 1981
Office of Research and Demonstrations
Occupational Therapy
Overthecounter (drugs)
Physician's Assistant
Physical Therapy
Rural Health Clinic
Skilled Nursing Facility
Social Security Administration
Supplemental Security Income
State Supplemental Payments
Total Days of Care
Tax Equity and Fiscal Responsibility Act
Usual, Customary and Reasonable (charges)
I(ED1CAIO DRUG REIWURSMMT Tabl e I A
Page Two
...................... ~ i s c a l year 1985 ------------------- .---.------------ Fi scal Year 1984 -------------------
I ngr edi ent Fonnu- #State Medicaid Average Average Number o f
Dispensing Copay- Reimburse- Formu- l a r y St at e MAC'd Drug Ingred. Cost Pr escr i pt i on Pr escr i pt i ons
St at e Fee ment ment Basi s l a r y Status MAC Drugs Expenditures Per Claim Pri ce* Processed*
Massachusetts 3.25 AWP/EAC No B yes (4) 58,298,292 12.02 NA
Michigan .O . O AAC Yes C c 10.40 10.8 8.285
Minnesota 4.30 AWP-10% Yes C No 35,655,862 6.80 11.13 3,534,814
Mi ssi ssi ppi c . .O EAC Yes C 12.01 3,340,389
Mi ssouri 2.50 .50-2.0 AMP/EAC Yes C c ,662.55
Montana 2.00-3.75 .50 AWPIEAC No B NO 5,074,659 7.14 10.64 442,069
Nebraska 3.25-4.69 EAC No B Yes 220 11.325.229 9.56 11.74 1,021,640
Nevada 3.78 1.00 AWP-5% No B No 2.941.202 12.69 212,183
New Hampshire 2.85 .75 EAC No B No 4,928,443 N A N A
W
m New Jersey 3.53-3.87 AMP-016% No B No 67,421,822 7.43 10.54
6,905,548
New Mexico 3.65 AWPIEAC No B Yes 168 9,427,783 9.14 12.79 789,822
New York 2.60 EAC Yes , C No 202.701.752 9.04 11.64 17,928,987
Nort h Carol i na 3.36 .50 AWPIEAC No A No 39,622,195 9.83 12.86 3,316,160
Nort h Dakota 3. 5 EAC NO B B 7.72 11.5 14.023
Ohio 2. 0 AMP-7 Yes C c
Oklahoma 3.55 Max. AWPIEAC Yes C Yes 75 16.535.307 11.88 15.29 1,097,560
regon 3. AWPIEAC No B B , 41, 03
Pennsy vani a . 5 .5 AWPIE C No B B .72 13,815,483
Rhode I sl and 3.25 AWPIEAC No B Yes 10 11.216.084 11.21 1 ,002,061
South Carol i na 3.40 .50 AMP-7.5% No B No 22.041.244 9.52 12.05 1,737,968
South Dakota 3.2 1. 0 AWP Yes C c 2.1 284.396
Tennessee 3.36 AAC Yes C Yes 180 53,582,671 9.11 12.36 4,304.448
Table I A
Page Three
Fi scal year 1985 ...................... ----------------- Fi scal year 1984 -------------------
I ngredi ent Formu- #State Wi c a i d Average Average Number of
Dispensing Copay- Reimburse- Formu- l a r y State M a d Drug Ingred. Cost Pr escr i pt i on Prescri pt i ons
State Fee ment meni Basis l a r y Status MAC Drugs Expenditures Per Claim Pri ce* Processed*
Texas 3.72-4.05 AWPIEAC NO A No 94.794.375 12.35 15.78 6,579,073
Utah 3.25 EAC No B No 5,489,059 5.57 8.82 638.293
Vermont 2.50 1.00 AMP No A Yes 155 5,142.532
Vi r gi ni a 3.40 SO-1.00 AUPIEAC No 8 Yes 138 7.53 9.88 3,670,206
Washington 3.00-3.70 89XAUP Yes C Yes 142 25,946,074 7.60 10.89 2,631,639
est i r gl ni a . . - . UP es C c 8.80 895,271
Wisconsin 3.61 .50 AWPIEAC No B Yes 145 46,871,019 6.49 10.41 2,438.506
w Ry m~ n g No Vendor Drug Program
Legend :
(1) Col l ect i on by pharmacy i s opt i onal
( 2)
Plus $0.50 i ncent i ve fee f o r di spensi ng generi c product
(3) State funded r eci pi ent s onl y
(4) Most mu1 t i - sour ce drugs
( 5)
Wholesaler cost pl us a percentage
* Approximate number
A - No drug l i s t - a l l legend drugs reimbursed
B - No drug l i s t - but cer t ai n cat agori es excluded from reimbursement
C - Rest r i ct ed drug l i s t
I nf or nat i on i n t h i s t abl e was obtai ned from an
NPC survey o f St at e Medicaid Departments
DRUG RECIPIEHTS M D VENDOR PAVNEWTS
Table IB
Page One
Average Vendor Average Drug % o f Medi cai d
Tot al Tot al Vendor Expenditure Drug orug Expendi ture $ A1l ocat ed
St at e Reci pi ent s Medical Payrnents Per Reci pi ent Reci pi ent s Payrnents Per Reci pi ent t o Drugs
A1abama 315.666 $366,328,236 $1,160 226.256 135,266,930 $156 9.6%
Al aska 24,068 65,612,614 2.726
p ~ ~ p ~
Arizona
Arkansas - 5. 668 1.689 155.131 33.166.977 214 10.22
Cal i f or ni a 3.395.080 3,472,708,099 1.023 2.172200 205.707.914 95 5.9%
Colorado 1 . 26 0, 9.
S ,616. 7 5.
Connecti cut 220.090 591. 48631 2,460 157,029 159 4.6%
Delaware 47.253 67.988.932 1.439 31.038 98 4.52
D.C. c 5 3 3 9 . 09 5.
Fl or i da 572.127 7 9 0, 6.263 1.29 178 10.
Georgia 421,124 602,508,978 1,431 386.758 68.365.809 177 11.4%
Hawaii 95,413 131,736.032 1.381 71.049 6.428.885 90 4.9%
Idaho 3 , 1 ,543. 93 3.
I l l i n o i s 1.6X299.209 1.328 782.353 125 5.91
Indi ana 271,956 642.012.489 2,361 206.532 44.034.163 213 6.9%
~owa 200.564 316,511.0 5
0 20.978.23 142 6.
Kansas 2 6 .5 106.755 117.3o5.55-
Kentucky 4 9 9,3 86, .9
Loui si ana 3 8 2 . 3 6 7 6 8 2 . 2 4 6 . 4 4 9 1.784 289,689 212 9.0%
Maine 121,843 215,249,151 1 1, 67 159 6 7
7 3 1 , 5 2 5 234.441 32,967,163 141 6.7%
Mas~achuset t s r n 3 ~ 9 3 i ~ m 2.413 3lsT6r;578;Tg8,292 154 4 .r
Michigan 1,-155,165 r.574,044,207 1.363 764.048 86.822.120 114 5.5%
DRUG RECIPIENTS M D VENDOR PAYMENTS
Table I 8
Page Two
Average Vendor Average Drug I o f Medicaid
Tot al Tot al Vendor Expendi ture Drug Drug Expendi ture $ Al l ocat ed
St at e Reci pi ent s Medical Paynents Per Reci pi ent Reci pi ent s Paynents Per Recipient t o Drugs
Minnesota 341.174 1947,316,494 $2.777 221,465 $35,655,862 $161 3.8%
Mi ssi ssi ppi 302,437 307.469284 1.017 241,805 38.883.529 161 12.7%
Mi ssouri 356.753 502,254.322 1.550 248,371 29.577.082 119 5.9%
Montana 46.516 92356.743 1,998 30.178 5,074,659 168 5.5%
Nebraska 86.432 151.740.691 1,756 63,473 178 7.5%
Nevada 7,435 % , 9412 .5
New Hampshire 39,433 108,815.390 2.760 27.512 4,928.443 179 4.5%
New Jersey 596,937 1,082.154.989 1.813 484.755 67,421822 139 6.2%
New Mexico 83.026 1,550 59.873 9.427.783 157 7.3%
New York 2,205.138 6,795,024,224 3.081 1,477.239 202.701.752 137 3.0%
-
Nort h Carol i na 340.499 605,732,042 1,779 236.926 39,622.195 167 6.5%
North Dakota 33.705 97,338,011 2,888 21.240 4,704,007 221 4.8%
Ohio 1,014.647 1,613,303,363 1,590 744.524 142,454,356 191 8.8%
hl ahoma 252,450 403223,436 1.597 117.296 16,535.307 141 4.l Z
Oregon 139.413 221,900.783 1,592 97,454 14,803.643 152 6.7%
Pennsy vania 1,059. , 8 ,022. 2 99.095.892 13 5.91
Rhode l sl and 4. 34. 06, 02 2 11,216,084 134 4.8%-
South Carol i na 231,394 287,729,166 1,243 164,329 22,041,244 134 7.7%
South Dakota 32.552 89,732,636 2.757 19,444 3,474,613 179 3.9%
ennessee 345. 02 4 ,169, 9 53,582,671 21 9.9%
Texas 715.278 1.920 568,155 94,794.375 167 6.9%
Utah 69,353 1.620 47.008 5,489.059 117 4.9%
ennont
0 ,142,532 134 5.8%
DRUG RECIPIENTS AND VENWR PAYMENTS
Table IB
Page Three
Average Vendor Average Drug % o f Medi cai d
Tot al Tot al Vendor Expenditure Drug Drug Expenditure $ Al l ocat ed
St at e Reci pi ent s Medical Paynents Per Reci pi ent Reci pi ent s Paynents Per Reci pi ent t o Drugs
Vi r gi ni a 301,448 1494,225,868 $1,640 221.394 $36,050.372 $163 7.3%
Washington 301.254 501,478,983 1,665 214.123 25.946.074 121 5.2%
West 0 Vi r gi ni a 85, 3 2 0, 8.449.268 .3%
Wisconsin 9 ,328 931,685.9 4 9 46,871,019 14 5.0%
Wyoming . 9 9
United States 20.251.575 $34.135.788.352 $1.781 14.004.571 $1.979.822.741 $150 6.32
Excludes Puerto Rico and Vi r gi n I sl and
Tabl e I C
Page One
I ngr edi ent I of
Reinbursenent Formul ary St at e St at e WAC'd
Dispensing Fee Copayaent Basi s Formulary St at us WAC Drugs
St at e 1985 1984 . 1985 1984 1985 1984 1985 1W 1985 1985 1984 1985
Alabama $3.25 $2.75 .50-3.00 .50-3.00 EAC EM: Yes Yes C No No
Al aska No Vendor Drug Program
Anzona AHCCCS capi t at i on Plan
Arkansas 3.8 8 E AC NO NO B Yes Yes o
Ca i f o r n i a .O 3. 1 1 Yes Yes C Yes Yes
Colorado 0 3. .50 C Yes Yes 1
Connecti cut $3.11[21 $3.11(21 - - MPlEAC AWPIEAC NO No B No No
B B NO NO
ax. $3.95 3.95 50 50 AWP E AC N~ N~ B N~ N~
Fl or i da $3.33 $3.33 - - AWPIEAC EAC No No 8 NO No
Georgia $3.61 13.61 - - , AWP E AC Yes Yes C Yes Yes 19
Hawaii .90 0 Yes Yes c NO NO
Idaho $2.50-3.50 $2.50-3.50 - - AWPIEAC EAC No No B No No
f l l i n o i s 13.46 13.30 - - AAC AM: Yes Yes C Yes Yes 5009
Indi ana $3.00 $2.50 - - AWP-3% EAC NO NO B NO NO
Iowa 3. 8 . 8 1.00 0 NO NO B Yes Yes 2 -
Kansas . .
q Yes NO c Yes NO 1
Kentucky $3.25 $3.25 - AWPIEAC EAC Yes No C Yes Yes 133*
Loui si ana $3.67 $3.67 - - EAC EAC No Yes B Yes Yes 392*
Maine $3.20 $3.20 .50 .50 AWP-5% EAC NO Yes B No No
Mary and 3.
0 Yes NO
Table 1 C
Page Two
I ngr edi ent I of
Reimburse~nent Formulary St at e St at e MAC'd
Di spensi ng Fee Lopayment Basi s Fomul ar y St at us MAC Drugs
St at e 1985 1984 ' 1985 1984 1985 1984 1985 1984 1985 1985 1984 1985
Massachusetts $3.25 $3.09 - - AUPIEAC AUPIEAC NO Yes B Yes Yes ( 4)
Mi chi gan $3.00 $2.75 .50 .50 AAC AUPlAAC Yes Yes C Yes Yes 64
Minnesota $4.30 $1.30-5.00 - - AMP-102 EAC Yes Yes C NO NO
Mi ssi ssi ppi $3.33 $3.33 1.00 - EAC EAC
Yes Yes C Yes Yes 500*
Mi ssouri 2. 0 . O
0 C Yes Yes 60
Montana $2.00-3.75 $2.00-3.75 .50 - AUPlEAC EAC
NO NO B NO NO
Nebraska . - . 9 .28-3.69 - - EAC EAC
NO ye6 B Yes Yes 220
Nevada $3.78 $3.78 1.00 1.00 AUP-52 EAC No No B No No
New Hampshire $2.85 $2.85 .75 1.00 EAC EAC
NO NO B NO No
New Jersey $3.53-3.87 $3.16-3.38 - - AUP-016% EAC
NO NO B NO NO
New Mexico $3.65 $3.65 - - AWPIEAC EAC
No Yes B Yes Yes
( 4)
New York $2.60 $2.60 - - EAC EAC
Yes Yes C No No
Nort h Carol i na $3.36 $3.36 .50 .50 AUPIEAC AUPIEAC No No A NO No
Nort h Dakota $3.75 $3.75 - - EAC AMP
No No B NO NO
Ohio $2.60 $2.60 - - AUP-7% EAC
Yes Yes C
Yes No 4 0
Oklahoma 03.55 $3.55 - - AWPIEAC EAC
yes yes C Yes NO 75
Oregon $3.57 $3.40 - - AWP/EAC EAC
No NO B Yes Yes 292
.--
~ennsyi vani a $2.75 $2.75 5 AWPIE C Y No No
khode i sl and $3.25 8 3 . r - - AWPIEAC AUP/EAC NO No B Yes Yes 10
South Carol i na $3.40 $3.03 .SO .50 AMP-7% EAC
No Yes 6 NO NO
Table I C
Page Three
Dispensing Fee
I ngredi ent I of
Reimbursement Formulary St at e State MAC'd
Copayinent Basis Formulary Status MAC Drugs
State 1985 1984 1985 1984 1985 1984 1985 1984 1985 1985 1984 1985
South Dakota $3.25 $3.25 1.00 1.00 AMP EAC Yes No C No No
Tennessee $3.25 $3.25 - - AAC AAC Yes Yes C Yes Yes 180
--- -
Texas $3.72-4.05 $3.45-3.80 - - AWPIEAC AWPIEAC No No A No No
Utah $3.25 $3.25 - - E AC EAC No Yes B No No
Vermont $2.50 12.50 1.00 1.00 AWP AMP NO NO A Yes No 155
Vi r gi ni a $3.40 $2.85 .50-1.00 .SO-1.00 AWPIEAC EAC No No 8
Yes Yes 138
Washington $3.00-3.70 $3.00-3.70 - - 89%AWP EAC yes Yes C Yes Yes 142
West Vi r gi ni a $2.75 $2.75 .50-1.00 .50-1.00 AMP AWP Yes Yes C No No
Uisconsin $3.61 $3.50 .50 - AUPIEAC EAC No Yes B
Yes Yes 145
Wyomi ng No Vendor Drug Program
Legend :
( 1) Col l ect i on by pharmacy i s opt i onal A - No drug l i s t - a l l legend drugs reimbursed
( 2)
Plus $0.50 i ncent i ve fee f or di spensi ng generi c product B - NO drug l i s t - but cer t ai n cat egori es excluded from
(3) State funded r eci pi ent onl y reimbursement
( 4) Most mul t i source drugs C - Rest r i ct ed drug l i s t
(5) Wholesaler cost pl us a percentage
Approximate number Informati on i n t h i s t abl e mas obtai ned from an NPC
Survey o f St at e Medicaid Departments.
NPC
VENDOR PAYMENTS FOR PRESCRIBED DRUGS
Table 13
Page One
(Amounts in Thousands)
State 1979 1980 1981 1982 1983 1984
U.S. Total $1 , I 79,985 $1,323,011 $1,530,329 $1,599,143 $1,770,834 81,979,822'
Alabama 21,422 19,984 24,243 28,269 31 $1 6 35,266
Arkansas 19,000 21,455 23,165 21,085 28,219 33,166
California 157,014 172,487 207,591 231,590 213,168 205,707
Colorado 9,712 10,823 12,128 14,319 14,896 16,616
Connecticut 14,155 15,393 17,970 17,394 21,265 24,948
Delaware 1,845 2,046 2,301 2,468 2,706 3,049
D.C. 4,935 5,732 6,124 6,717 7,180 8,113
Florida 33,240 38,150 45,743 48.794 60,670 76,184
Georgia 37.000 45,888 54,597 47,706 60,935 68,365
Hawaii 5,122 4,958 4,824 5,204 6,324 6,428
Idaho 2,316 2.222 2,337 2,452 2,463 2,543
Illinois
78,932 92,142 99,015 91,880 96,506 98,044
Indiana 22,184 26,530 30,933 36,483 39,459 44,034
Iowa 13,240 13,916 15,315 16,052 19,031 20,978
Kansas 11,078 13,249 14,460 15,687 15,975 17,305
Kentucky 13.629 14,922 16,615 15,665 19,505 27,996
Louisiana 39,396 45,205 46,037 52,280 57,026 61,313
Maine 8,284 8,213 9,634 10,357 12,403 13,459
Maryland 13,929 16,264 19,342 22,280 28,570 32.967
Massachusetts 32,278 34,651 47,559 49,794 52.752 58,298
Michigan 59,436 69,755 74,525 71,581 77,561 86,822
Minnesota 20,647 23,012 27,447 29,352 30,746 35,655
Mississippi 21,816 26,855 27,157 28.457 36,973 38,883
Missouri 21,107 25,516 31,395 23,011 25,569 29,577
Montana 2,497 2,880 3,521 4,172 3,965 5,074
Nebraska 6,942 7,765 8,888 9,570 10,636 11,325
Nevada 1,393 1,702 2,258 2,412 2,663 2,941
New Hampshire 3,059 3,365 3,726 3,391 4,241 4,928
New Jersey 36,699 42,945 48,369 54,399 61 ,I 25 67,421
New Mexico 4,442 5,294 6,141 6.81 7 7,569 9.427
New York 98,561 120,137 122.648 142,259 173,095 202,701
North Carolina 29,131 32,401 34,598 31,488 35,460 39,622
North Dakota 2,571 2,697 3,310 3,442 4,002 4,704
NPC 1985
Table ID
Page Two
(Amounts in Thousands)
State 1979 1980 1981 1982 1983 1984
Ohio 46,104 47,953 92,147 96,681 1 17,695 142,454
Oklahoma 7,586 8,621 12,013 12,399 14,775 16,535
Oregon 7,933 8,769 10,215 1 1.408 14,552 14,803
Pennsylvania 70,950 60.315 64,524 75,911 87,571 99,095
Rhode Island 6,962 8,087 9,061 9,760 9,997 11,216
South Carolina 14.371 17,963 21,759 16,866 18,410 22,041
South Dakota 1,720 1,920 2,177 2,934 3, 128 3,474
Tennessee 34,740 40,974 44,003 48,241 47,686 53,582
Texas 58,874 64,227 74,124 76,120 83.933 94,794
Utah 3.783 3,796 4,484 3,622 4,618 5,489
Vermont 3,026 3,468 3,891 3,829 4,151 5,142
Virginia 20,519 23,950 27,121 29.862 31,067 36,050
Washington 15.1 76 17,485 19,380 19,661 21,968 25,946
West Virginia 9,550 10.833 10,868 8.400 591 4 8,449
Wisconsin 31,618 36,103 40,646 36,623 41,125 46,871
~~ ~ ~
Source: HCFA 2082 reports, compiled by State Medicaid program officials. Although the reports have
been reviewed and edited by HCFA, they may still contain some reporting errors. Despite these potential
shortcomings the 2082 HCFA data represent the most accurate figures available on utilization of state
Medicaid services.
'These totals do not include the Virgin Islands and Puerto Rico.
NPC
/
! 985
d R E a P m n s PREs cRmED m u G s
/' Table IE
Page One
State 1979 1980 1981 1982 1983 1984
US . Total bd3,277,148 13,720,161 14,248,165 13,668,131 13,678,801 14,001,571"
Alabama 237,383 222,525 223,538 222,109 222,713 226,256
Arkansas 169,073 173,089 171,781 151,711 151,260 155,131
California 2,248,819 2,266,520 2,363,220 2,397,000 2,225,500 2,172,200
Colorado 118,377 95,762 97,582 99,346 103,453 105,519
Connecticut 148,579 150,451 154,473 143,675 153,729 157,029
Delaware 32,369 34,608 34,535 33,743 31,940 31,038
D.C. 78,308 78,328 69,970 69,056 68,338 65,009
Florida 327,873 374,670 408,923 389,534 414,406 429,016
Georgia 307,794 320,550 352,118 330,380 312,218 386,758
Hawaii 80,456 77,845 74,968 75,634 75,458 71,049
Idaho 28,998 29,547 28,995 27,114 27,954 27,249
Illinois 757,237 802,882 835,781 803,391 797,800 782,353
Indiana 167,971 182,400 197,846 21 2,071 203,447 206,532
Iowa 130,370 133,215 140,865 128,389 140,110 !48,00!
Kansas 108,671 108,671 107,550 106,097 104,280 106,755
Kentucky 250,531 252,682 263,380 225,493 251,935 31 1,656
Louisiana 287,731 285,349 300,236 276,307 283,027 289,689
Maine 104,871 61,377 94,328 84,469 84,577 84,396
Maryland 206,257 21 7,405 229,561 226,722 232,522 234,441
Massachusetts 474,396 485,712 488,026 437,710 367,084 378:065
Michigan 659,088 729,394 720,848 742,825 774,896 764,048
Minnesota 190,714 199,721 207,958 206,300 209,514 221,465
Mississippi ~ 226,600 253,466 258,641 232,154 233,956 241,805
Missouri 228,957 240,026 262,935 228,673 237,290 243,371
Montana 26,3f 7 28.612 30,464 32,810 27,715 30,7 78
Nebraska 52,329 53,277 55,403 57,267 60,097 63,473
Nevada 15,622 17,048 19,486 19,116 18,951 18,313
New Hampshire 30,166 30,790 30,304 29,233 29,092 27,512
New Jersey 51 7,656 528,209 525,434 507,658 493,234 484;75.5
New Mexico 59.505 60,702 62,966 60,507 58,324 59,873
New York 1,360,974 1,317,262 1,401,768 1,471,856 1,384,943 : ,477,239
--
North Carolina 281,090 270,169 268,799 237,621 244,187 236,926
North Dakota 20,193 21,973 21,542 20,138 20,575 21,240
Ohio 521,361 520,579 606,702 612.386 670,421 744,524
NPC 1985
Table I€
Page Two
State 1979 1980 1981 1982 1983 1984
Oklahoma 11 1,479 108,366 118,131 104,673 107,971 1 17,296
Oregon 131,111 158,819 111,912 102,258 111,156 97,454
Pennsyivania 680,961 786,013 763,219 590,176 802,731 724,858
Rhode island 84,172 86,418 85,782 83,946 75,751 83,407
South Carolina 173,894 183,569 191,196 168,535 162,074 164,329
South Dakota 18,837 18,723 19,024 19,923 19,812 19,444
Tennessee 257,295 265,135 272,418 271,519 248,128 254,591
Texas 524,494 542,051 565,757 533.520 533,595 568.1 55
Utah 40,839 40,053 45,485 38.688 43,721 47,008
Vermont 35,568 38,851 40,273 38,593 37.905 38,446
Virginia 215,644 236,481 243.71 1 225,290 219,970 221,394
Washingtcn 198,704 208,767 209,566 174,821 185,225 214,123
West Virginia 79,572 105,027 144,221 1 12,497 98,779 115.838
Wiscons~n 267,942 307,072 325,544 305,197 317,137 329.964
Source: HCFA 2082 reports, compiled by State Medicaid program officials. Although the reports have
been reviewed and edited by HCFA, they may still contain some reporting errors. Despite these potential
shortcomings the 2082 HCFA data represent the most accurate figures available on utilization of state
Medicaid services.
'These figures do not include the Virgin Islands and Puerto Rico
NPC
AVERAGE EXPENDITURE PER RECIPIENT FOR PRESCRIBED DRUGS
Table IF
Page One
State 1979 1980 1981 1982 1983 1984
U.S. Average $88.87 $96.43 $1 07.41 $1 17.00 $129.00 $i 50.W
Alabama 90.24 89.80 108.45 127.27 142.00 156.00
Arkansas 112.38 123.90 134.85 138.98 187.00 214.00
California 69.82 76.10 87.84 96.62 96.00 95.00
Colorado 82.04 113.02 124.29 144.13 144.00 157.00
Connecticut 95.27 102.31 1 16.33 121 .06 138.00 159.00
Delaware 56.99 59.1 1 64.76 73.13 85.00 98.00
D.C. 63.03 73.18 87.53 97.27 105.00 125.00
Florida 101.38 101.82 111.86 125.26 146.00 178.00
Georgia 120.21 143.15 155.05 144.40 195.00 . 177.00
Hawaii 63.66 63.69 64.35 68.80 84.00 90.00
Idaho 79.85 75.21 80.60 90.45 88.00 93.00
Illinois 104.24 114.76 1 18.47 114.37 121 .OO 125.00
Indiana 132.07 145.45 156.35 172.03 194.00 213.00
Iowa 101 56 104.46 .1 08.72 125.03 136.00 142.00
Kansas 101.94 121.92 134.45 147.85 153.00 162.00
Kentucky 54.40 59.06 63.08 69.47 77.00 90.00
Louisiana 136.92 158.42 153.34 189.21 201 .OO 212.00
Maine 78.99 133.81 102.14 122.62 147.00 159.00
Maryland 67.53 74.81 84.26 98.27 123.00 141 .OO
Massachusetts 68.04 71 34 97.45 1 13.76 144.00 154.00
Michigan 90.18 95.63 103.39 96.36 100.00 11 4.00
Minnesota 108.26 1 15.22 131.99 142.28 147.00 161.00
Mississippi 96.27 105.95 105.00 122.58 158.00 161 .OO
Missouri $92.19 $106.31 $1 19.40 $1 00.63 $1 08.00 119.00
Montana . 94.90 100.67 115.58 127.16 143.00 168.00
Nebraska 132.67 145.76 160.43 167.11 177.00 178.00
Nevada 89.16 99.85 1 15.88 126.18 141.00 161.00
New Hampshire 101.39 109.28 122.95 116.00 146.00 179.00
New Jersey 70.90 81.30 92.06 107.16 124.00 139.00
New Mexico 74.66 87.21 97.53 11 2.66 130.00 157.00
New York 72.42 91.20 87.50 96.65 125.00 137.00
North Carolina 103.64 119.93 128.71 132.51 145.00 167.00
North Dakota 127.34 122.72 153.63 170.94 195.00 221 .OO
Ohio 88.43 90.38 151.88 157.88 176.00 191 .OO
Oklahoma 68.05 79.55 101.69 11 8.46 137.00 141 .OO
Oregon 60.96 55.21 91.28 111.56 131 .OO 152.00
NPC
Table IF
Page Two
State 1979 1980 1981 1982 1983 1984
Pennsylvania 104.19 76.74 84.54 128.62 109.00 137.00
Rhode Island 82.72 93.59 105.63 116.26 132.00 134.00
South Carolina 82.64 97.85 1 13.79 100.07 1 14.00 134.00
South Dakota 91.32 102.54 114.46 147.28 158.00 179.00
Tennessee 138.91 154.54 161.53 177.67 192.00 210.00
Texas 1 10.34 1 18.49 131.02 142.67 157.00 167.00
Utah 92.62 94.76 98.57 93.63 106.00 11 7.00
Vermont 85.08 89.27 96.61 99.23 1 10.00 134.00
Virginia 95.15 101.28 111.28 132.55 141.00 163.00
Washington 76.37 83.76 92.48 1 12.46 1 19.00 121 .OO
West Virginia $1 20.01 $103.14 $75.35 $74.67 $60.00 73.00
Wisconsin 1 18.00 11 7.57 124.86 120.00 130.00 142.00
Source: HCFA 2082 reports, compiled by State Medicaid program officials. Although the reports have
been reviewed and edited by HCFA, they may still contain some reporting errors. Despite these potential
shortcomings the 2082 HCFA data represent the most accurate figures available on utilization of state
Medicaid services.
*These figures do not include the Virgin Islands and Puerto Rico.
NPC
PERCENTAGE OF MEDlCAlD EXPENDITURES
ALLOCATED TO PRESCRIPTION MEDICATION
State
U.S. Total
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 Carolma
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Table IG
7983
5.5%
8.6%
-
-
9.0%
6.0%
5.8%
4.3%
4.4%
3.7%
8.9%
10.1%
4.5%
3.9%
7.2%
6.6%
6.1%
6.3%
4.7%
8.5%
6.0%
6.4%
3.9%
5.5%
3.5%
12.3%
5.5%
4.6%
7.3%
3.6%
4.6%
6.2%
7.4%
2.8%
6.3%
4.8%
8.0%
4.0%
6.4%
5.1%
4.5%
6.6%
4.0%
9.4%
6.4%
4.0%
5.2%
6.4%
5.1%
NPC
West Virginia
Wisconsin
Wyoming
NPC
RANKING OF STATES BASED ON
MEDICAID DRUG EXPENDITURES
Percent
1983 Vendor 1984 Vendor 1983 1 984 Increase
State Drug Payments Drug Payments Ranking Ranking (Dee)
California $213,168,000 $205,708,000 1 1 (3.5%)
New York 173,095,000 202,701,000 2 2 17.1
Ohio 117,695,000 142,454,000 3 3 21 .O
Pennsylvania 87,571,000 99,096,000 5 4 13.2
Illinois 96,506,000 98,045,000 4 5 (1.6)
Texas 83,933,000 94,794,000 6 6 12.9
Michigan 77,561.000 86,822,000 7 7 11.9
Florida 60,670,000 76,184,000 9 8 25.6
Georgia 60,935,000 68,366,000 10 9 12.8
New Jersey 61,125,000 67,422,000 8 10 10.3
Louisiana 57,026,000 61,314.000 11 1 1 7.5
Massachusetts 52,752,000 58,298,000 12 12 10.5
Tennessee 47,686,000 53,583,000 13 13 12.4
Wisconsin 41,125,000 46,871.000 14 14 14.0
Indiana 39,459,000 44,034,000 15 15 11.6
North Carolina 35,460,000 39,622,000 17 16 11.7
Mississippi 36,973,000 38,884,000 16 17 5.2
Virginia 31,067,000 36,050,000 19 18 16.0
Minnesota 30,746,000 35,656,000 20 19 16.0
Alabama 31 5 1 6,000 35,267,000 18 20 11.5
Arkansas 28,219,000 33,167,000 22 21 7.5
Maryland 28,570,000 32,967,000 21 22 15.4
Missouri 25,569,000 29,577,000 23 23 15.7
Kentucky 19,505,000 27,996,000 26 24 44.5
Washington 21,968,000 25,946,000 24 25 18.1
Connecticut 21,265,000 24,949,000 25 26 17.3
South Carolina 18,410,000 22,041.000 28 27 19.6
Iowa 19,031,000 20,978,000 27 28 10.2
Kansas 15,975,000 17,306,000 29 29 8.3
Colorado 14,896,000 16.61 7,000 30 30 11.6
Oklahoma 14,775,000 16,535.000 31 3 1 11.9
Oregon 14,522,000 14,804,000 32 32 1.9
Maine 12,403,000 13,460,000 33 33 8.5
Nebraska 10.636.000 11,325,000 34 34 10.4
Rhode Island 9,997,000 11,216,000 35 35 12.2
New Mexico 7,569,000 9,428,000 36 36 24.6
West Virginia 5,914,000 8,449,000 39 37 42.9
D.C. 7,180.000 8,: 13,000 37 38 (1.9)
Hawaii 6,324,000 6,429,000 38 39 1.7
Utah 4.61 8,000 5,489,000 40 40 18.9
Vermont 4,151,000 5,143,000 42 41 23.9
Montana 3,965,000 5,075,000 44 42 28.0
NPC 1985
New Hampshire 4,214,000 4,928,000 41 43 16.9
North Dakota 4,002.000 4,704,000 43 44 15.6
South Dakota 3,128,000 3,475,000 45 45 11.1
Delaware 2,706,000 3.049.000 46 46 12 7
Nevada 2,663,000 2,941,000 47 47 10.4
Idaho 2,463,000 2,544,000 48 48 3.3
Alaska
- -
Arizona - -
Wyoming - -
U.S. T O ~ I s i , n 0 , ~ 3 4 , m SI , WQ, S~~, OOO 11.8%
NPC
State
Table li
RANKING OF STATES BASED ON
AVERAGE DRUG EXPENDITURE PER RECIPIENT
Avg. Drug Avg. Drug
Expenditure Expanditure 1983 1984
Per Recipient Per Recipient Ranking Ranking
North Dakota $195 $21 8 2 1
Louisiana 201 21 4 1 2
Arkansas 187 214 6 3
Indiana 194 213 4 4
Tennessee 192 211 5 5
Ohio 176 191 8 6
Nebraska 177 185 7 7
South Dakota 158 179 9 8
New Hampshire 146 179 16 9
Georgia 195 177 3 10
Florida 146 176 15 11
Montana 143 168 20 12
Texas 157 167 11 13
North Carolina 145 167 17 14
Virginia 141 163 23 15
Kansas 153 162 12 16
Mississippi 158 161 10 17
Minnesota 147 161 14 18
Nevada 141 161 22 19
Maine 147 160 13 20
Connecticut 138 159 24 21
New Mexico 130 158 29 22
Colorado 144 157 18 23
Alabama 142 156 21 24
Massachusetts 144 154 19 25
Oregon 131 152 28 26
Iowa 136 142 26 27
Wisconsin 130 142 30 28
Oklahoma 137 141 25 29
Maryland 123 141 33 30
New Jersey 124 139 32 31
Rhode Island 132 137 27 32
New York 125 137 31 33
Pennsylvania 109 137 38 34
South Carolina 114 134 36 35
Vermont 110 134 37 36
Illinois 121 125 34 37
Washington 119 121 35 38
Missouri 1 08 119 39 39
Utah 106 117 40 40
Michigan 1 00 114 42 41
D.C. 105 112 41 42
Delaware 85 98 45 43
NPC 1985
California 96 95 43 44
Idaho 88 93 44 45
Hawaii 84 91 46 46
Kentucky 77 90 47 47
West Virginia 60 73 48 48
Alaska
Arizona
Wyoming
NPC
MEDICAL ASSISTANCE PROGRAM BENEFITS (TITLE XIX)
TOTAL UNITED STATES VENDOR PAYMENTS BY TYPE OF SERVICE
Hospital Inpatient
Intermediate Care Facility
Skilled Nursing Facility
Physicians
Drugs
Hospital Outpatient
Dental
Home Health Care
Clinic
Other Practitioners
LabiX-ray
Family Planning
Other Care
Totals $32,204,730,553
Table IJ
--- FY 1984---
Excludes Puerto Rico and Virgin Islands
National Title XIX Payments
By Type of Service
T a b l e IK
4.8%
Drugs
5.8%
Physicians
6.5%
Skilled
Nursing
Facility
14.2:
Hospital Inpatient
! 29.5%
Intermediate cari
Facility
29.5%
M 1978
All Other
Hospital Outpati
Drugs
5.93
Physicians
8.8%
Skilled Nursing
Facility
Intermediate
Care Facility
24.2%
All Other includes: Dental, Home Health Care, Lab/X-ray,
Family Planning, Other Practitioners, Other care.
Nat i onal Medicaid Expendi t ure and Reci pi ent Data
T a b l e I L
AFDC Mu111
Distribution of we ndi r ur t r
by ~lipibility Class, PI 1984
~dis'id Expenditures
PI1970 - niss4
Source : OAIHCFAID~HS
T a b l e I M
1981 NATIONAL HEALTH CARE EXPENDITURES:
$387 Billion
Where They Came From
Public Private O
Source: Health Care Financing Administration. DHHS.
T a b l e IN
1954 NATIONAL WEALTH CARE EXPENDITURES:
$357 Billion
Where They Went
NPC 1985
Table 10
FEDERAL MEDICAL ASSISTANCE PERCENTAGE ("FMAP")
Payment for Care and Sewlces
The federal government pays a percentage-a 50% minimum-of the expenditure each state incurs in
providing Medicaid care and services. The federal government's share is referred to as "FMAP" (federal
medical assistance percentage). The percentage (FMAP) for each state is computed according to a
formula based on the state's per capita income.
Effective October 1, 1985-September 30, 1987
State Percent State Percent
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
NorthCarolina
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 federal Medicaid law (Sections 1903(a)(l), 1903(g), and 1905(b)) requires federal payments to
states, on the basis of a federal medical assistance percentage, for part of their expenditures for services
provided under their approved Medicaid Plans. Under the FMAP formula in Section 1905(b) of the law.
if a state's per capita income equals the national average per capita income, the federal share is 50%. If
a state's per capita income is below the national average, the federal share is increased, but not beyond
83%.
Source: CCH Medicare and Medicaid Guide January, 1985.
S e p t e mb e r 1985
LIST OF FEDEM HAC 0RUS
T a b l e I I A
EFFECTIVE DATE
Acetaminnpnen */Codeine. 300mg/30mg Tabs.
Acetaminophen wi'codeine, 300mg/60mg Tabs.
Amoxicill iit, 250mg Capsules
h o x i c i l l i n. 500mg Capsules
Ampicillin. 250mg Capsales
Ampicillin, 500mg Capsules
Ampicillin Oral suspension, 125mg/Sml lco"l
Ampicillin Oral suspension, 2fOmg/5ml ;oo *i
$0.0780 per Tab.
0.1158 per Tab.
0.2108 per Capsule
0.3942 per Capsule
0.0422 per Capsule
0.1103 per Capsule
0.0114 per ml
0.0205 per ml
Chlordiazepoxide HCI, 5 mg Capsules
Chlordiazepoxide HCI, lCmg Capsules
Cblordiazepaxide HCI. 25 mg Capsules
0.0140 per Capsule.
0.0211 per Capsule
0.0438 per Capsule
Diphenoxylate HCI wi t h Atropine Sul f at e,
2.5mrr/O.O25ma Tablets 0.0491 per Tablet
0.1030 per Capsule
0.1328 per Capsule
0.1869 per Capsule
0.3382 per Capsule
~ ~
~oxepi n. HCI, l h g Capsules
Doxepin HCI. 25mg Capsules
Doxepin HCI, 50mg Capsules
Doxepin HCI, 100 mg Capsules
Erythromycin St er at e. 250mg Tablets 0.0697 per Tablet
Elutethimide, 500mq Tablets 0.0432 per Tablet
0.0279 per Tablet
0.0384 per Tablet
0.0152 per Tablet
0.0194 per Tablet
Hydralazine HCI. 25mg Tablets
Hydralazine HCI. 50mg Tablets
Hydrochlorothiazide. 25mg Tablets
Hydrochlorothiazide, SOmg Tablets
Neprobama t e. 200mg Tablets
Meprobamate. 40Cmg Tabl et s
Methocarbamol . 500mg Tablets
Methocarbamol . 7501119 Tablets
0.0108 per Tablet
0.0117 per Tablet
0.0496 per Tablet
0.0640 per Tablet
Peni ci l l i n E. Potassium, 400mg Tablets
Peni ci l l i n YK Oral Susp.. 125mg/5m1
Peni ci l l i n YK Oral Susp., 250ng/5m1
Peni ci l l i n YX, 250mg Tablets
Peni ci l l i n YK, 5Ohg Tabl et s
Po t a s s i u ~ Chloride, Oral Liquid 101
Probenecid. 0 . 5 9 Tablets
Procainanide HCI. 25hg Capsules
Procainamide HCI, 3751119 Capsules
Procainamide HCI. 500mg Capsules
Propantheline Br, 15mg Tablets
Propoxyphene HCI, 65mg Capsules
Propoxyphene HCI with APC, 65mg Cap.
0.0237 per Tablet
0.0109 per iul
0.0160 per 11
0.0417 per Tablet
0.0649 per Tablet
0.0030 per ml
0.0644 Tablet
0.0383 per Capsule
0.0505 Capsule
0.0585 per Capsule
0.0235 per Tablet
0.0317 per Capsule
0.0330 per Capsule
qui ni di ne Sul f at e, 20Dnrg Tablets 0.0688 per Tablet
0.0273 per Tablet
Tet racycl i ne H t E . 25Cmg Capsules
Tet racycl i ne HCI, 500rng Capsules
Tet racycl i ne HCI, 125mg/5al Syrup
0.0250 per Capsule
0.0394 per Capsule
0.0104 per ni
UPMDEO ORUS COVEMGE mR ME ELDERLY
Tabl e I l l A
Since the enactment , , f ~ r d i c a r c i n 1965, t her e have been var i ous proposal s i n Congress to extend benef i t s t o i ncl ude out pat i ent pr escr i pt i on drugs. r he
basi c r at i onal e f or t he i ncj usi on of pr escr i pt i on medi ci nes gener al l y r est s on t hr ee poi nt s: 1) persons over 65 years o f age use, on t he average. 2.5 ti mes
t he number o f pr escr i pt i ons used by younger groups; 2) Persons over 65 gener al l y l i v e on f i xed incomes; and 3) t her e i s r e l a t i v e l y l i t t l e pr i vat e pr escr i p-
t i o n drug i nsurance avai l abl e f o r t h i s group. The f i scal d i f f i c u l t i e s t hat surround Medicare have precl uded the addi t i on o f t h i s benef i t .
However, heal t h pl anners and l e g i r l a t o r r a t t he st at e l evel have pmposed st at e-f i nanced programs f or t h e i r el der l y ci t i zens, and i n sme cases i ndi gent
non-Medicaid el i gi bl es. At Present f i ve st at es. New Jersey. Maine, Maryland, Delaware. I l l i n o i s , and Pennsylvania have implemented programs t o f i nanc i al l y
as s i s t e l i g i b l e el der l y i n def r ayi ng pr escr i pt i on drug expenses. Rhode I sl and and Connecti cut passed l e g i s l a t i o n i n 1985 and are i n the process of
i mpl ementi ng s i mi l ar programs.
STATE YEAR ELl Gt8ILl TY PROGRAM FISCAL IMPACT POPULATION CCMPARATIVE MEDICAID DATA
ENACTED CRITERIA CHARACTERISTICS OVER AGE 65
Cost Per Tot al Drug Drug Net
Orugs # of Year Recip- Recip- Expend. St at e Cost
Age Means Test Copay Covered Rx Fee Funding Reci pi ent s ( Mi l l i ons) i ent s i ent r ( Mi l l i ons ) ( Mi l l i o n r l
NEW JERSEY 1977 65+ $13.250 r $2.00 Al l Rx. $3.53 t o 213 GF 258,441 $64.8 942,000 596,937 484.755 167.4 $33.7 (501)
Pharmaceutical $16.250 c l ns ul i n $3.87 113
Assi stance t o Aged Test Mat ' l r (Medi cai d) Lot t er y
MAINE 2977 62+ $ 6,200 c 12.00 Host Rx. $3.20 General 10,500 1 1.6 152,000 121.843 84,396 113.5 $ 4.0 (30%)
1 7.400 c heart . BP. (Medi cai d) Fund (1984)
l URYWl 0 1979 None Ranges from $1.00 A11 Rx 13.45 General 13.100 1 4.5 447.000 324.071 234.441 132.9 $16.5 (501)
Pharmacy 1 5.600 r t o +Medicaid (Medi cai d) Fund Avg monthl y
Assi stance 111.000 OTC' r enrol l ment
Program Fami l y o f FY 1985
D W # E * 1982 65+ 1 6.730 s 114 of Rx Drugs. OuPont 8.100 $ 0.9 67.000 47.253 31.038 1 3.0 $ 1.5 (50%)
Pharmacy $ 9.575 c ACC up Fowul ar y t de Nemurs ( enr ol l ed) (Est.)
Assi st an~e t o $100 I ns ul i n 6 Founda- 1984
Program per y r Qui ni ne t i o n
PEUNSVLYAWIA 1984 65t $12.000 s $4.00 Al l Rx. $2.75 Lot t er y 400,000 $70 1.646.000 1,059.725 724.858 $99.1 $43.6 (441)
Pharm. Asrt . $15.000 c 30 day (Medi cai d) Funds + 484 (FY '85
Cont ract f or suppl y o r pr oj ect ed
El der l y (PACE) 100 doses $110)
ILLINOIS 1985 65+ $12.000 No Cardi ovar- $3.30 General 7.000 NA 1.320.000 1257,954 782,353 $98.0 149.0 (502)
household cul ar druos Fund l oot ent i al
RHDOE ISLAM0 *" 1985 65+ $ 9.000 s 401 of Rx 602 o f net General 138.000 104.489 83.407 $11.2 1 4.7 (42%)
$12.000 c cost ( speci f i c cost ( i n c l Fund
cat egor i es) i ngreds)
COWWECTICUT *** 1985 407.000 220,090 157.029 124.9 $12.5 (50%)
Not a vendor drug program. Al l Rx's dispensed thr; El emr i al Heal t h Cl i ni c. Yi l mi ngton, OE
"
Passed l egi sl at ur e 1985 -- Program shal l begi n t he pr ovi si on of benef i t s no sooner than 1 Oct 1985 and t er mi nat e benef i t s no l a t e r than 30 June 1981
**' Passed t he l egi sl at ur e 1985 -- Task force w i l l devel op recamendat i ons f or t wl e l e n t i n g t he program by 1 0ece.ber 1985. Program scheduled t o t ake
ef f ect 1 Jul y 1986
STATE
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
KentucQ
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Plexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
mode Island
South Carolina
South Dakota
Tennessee
Texas
Stah
Vermont
Virginia
Washington
West Virginia
ise eon sin
Wyoming
T a b l e I i l A
STATE POPULATION AND DEMOGiL9PXICS 27-Sep-85
State % of
Population State
as a % of Per Capita Unem- Population Population
Population total U.S. Personal ployment 65 and 65 and
prov. est. Population Income Rate
United States 234,439,000
Over Over
NPC
PHARMACIES & PHARMACISTS
Table VA
Page One
PHARMACIES PHARMA-
Nursing All C l STS
State Community Chain Hospital Clinic Home Others* Total
GRAND TOTALS: 39,589 16,721 5,380 1,592 790 2,593 66,665 161,522
Alabama 797 330 128 44 10 44 1,353 2,826
Alaska 58 28 21 0 3 1 111 323
Arizona 243 268 71 46 3 80 71 1 2,386
Arkansas 584 116 82 7 4 15 808 1,376
California 3,446 1,242 519 176 5 215 5,603 13,484
Colorado 453 151 52 27 1 83 767 2,573
Connecticut 587 169 1 4 0 0 761 2,078
Delaware 49 71 16 2 4 0 142 429
D.C. 89 77 5 2 2 5 180 396
Florida 1,566 1,054 268 116 347 223 3,574 6,021
Georgia 1,234 558 182 49 26 78 2,127 4,685
Hawaii 75 36 15 11 0 1 138 290
Idaho 1 89 43 40 7 3 25 307 697
Illinois 2.231 670 200 80 19 89 3,289 6,666
Indiana 694 590 127 21 10 33 1,475 4,720
Iowa 542 203 27 45 7 22 846 2,212
Kansas 515 138 147 18 1 32 851 1,516
Kentucky 724 272 113 28 12 27 1,176 2,769
Louisiana 839 380 160 31 4 42 1,456 3,381
Maine 156 119 4 1 1 0 281 497
Maryland . 451 389 62 13 3 27 945 3.651
Massachusetls 947 398 21 8 0 1 1,375 5,625
Michigan 1,540 493 21 9 54 10 101 2,417 6,315
Minnesota 679 192 152 39 5 53 1,120 3,247
Mississippi 680 1 64 119 31 56 5 1,055 1,800
Missouri 888 360 121 49 5 45 1,468 3,737
Montana 166 47 63 8 4 5 293 707
Nebraska 386 80 102 15 4 16 603 1,578
Nevada 88 71 19 4 0 24 206 508
New Hampshire 119 78 35 1 8 1 242 626
New Jersey 1,337 435 89 13 9 10 1,893 6,709
New Mexico 187 83 41 49 2 105 467 866
New York 3,227 840 31 9 56 70 168 4,680 13,549
NPC
Tabie VA
Page Two
PHARMACIES PHARMA-
Nursing All CISTS
State Community Chain Hospital Clinic Home Others' Total
North Carolina 964 650 131 25 13 56 1,839 2,582
NoFth Dakota 156 18 54 14 2 3 247 696
Ohio 1,490 1,998 77 45 11 142 2,809 8.057
Oklahoma 746 232 53 32 0 57 1,120 2,087
Oregon 446 126 59 20 5 11 667 1,917
Pennsylvania 2,114 918 271 27 66 31 3,427 8,660
Puerto Rico 1,076 86 50 9 0 19 1,240 887
Rhode island 135 82 17 2 1 2 239 699
South Carolina 476 365 61 27 5 32 966 2,526
South Dakota 179 18 60 20 7 9 293 460
Tennessee 94 1 393 166 42 7 54 1,603 2,910
Texas 2,304 1,303 307 111 2 382 4,409 8,588
Utah 224 87 34 9 3 63 420 1,014
Vermont 96 39 18 1 1 1 i 56 267
-
Virginia 594 546 119 40 6 48 1,353 3,066
Virgin Islands 0 0 0 0 0 0 0 20
Washington 642 269 126 33 6 40 1,116 3,426
West Virginia 332 169 86 21 2 14 624 1,343
Wisconsin 816 208 122 56 15 39 1,256 2,994
Wyoming 88 22 29 2 0 14 155 415
Pacific Islands 0 0 0 0 0 0 0 6
APOIFPO, Foreign 4 1 0 1 0 0 5 665
* Includes 1,158 Department Stores and 702 Grocery Stores
Source: Business Mailersilnc. March 1985. Official List of the NABP and NCPDP
I PC CWPI LATI OI
KEY PROVISIONS OF STATE DRUG PRQWCT
Permissive How t o Phamacy
Formulary 2-Line Rx , or Prevent Record
Format Mandatory Subst i t ut i on Required
SELECTI OI W S
Ta b l e V B
Page One
Cost Label
Savings Pat i ent Speci f i c- L i a b i l i t y
Pass-on Consent at i ons Di scl ai mer
~~ ~ ~ ~ - p ~ ~
Alabama None Yes P A Yes B NO Yes No
Alaska None No P E(1) No 6 yes No No
Arizona None Yes P A Yes B yes Yes No
Arkansas Negative No P B(1) No B Yes Yes Yes
Cal i f or ni a Negative No P 8(1) No B Yes Yes Y ~ S
Colorado None No P B Yes A Yes Yes yes
Connecticut None No P B Yes A Yes Yes Yes
-
Delaware Pos i t i v el l ) Yes P A Yes A Yes Yes No
D.C. Posi t i ve No P B Yes B Yes Yes yes
Fl or i da Negative(2) No M B Yes A Y ~ S No Yes
Georgia None Y ~ S P A Yes C Yes No No
Hawai i Posi t i ve( l 1 No M B Yes B Yes Yes Yes
Idaho None Yes P A Yes A Yes Yes No
I l l i n o i s Posi t i ve No P B[Z) Yes B yes No yes
Indi ana None Yes P A Yes B yes Yes No
Iowa None NO P B Yes A yes No No
Kansas None Yes (opt.) P A/ B NO B No No No
Kentucky Negative(1) No M B yes B No Yes Yes
Louisiana None No P B Yes A Yes No No
Maine None No P B E ) No D Yes Yes NO
Maryland Posi t i ve No P B Yes B Yes Yes yes
Ta bl e V B
Page Three
Permissive How t o Pharmacy Cost Label
Formulary Z-Line Rx o r Prevent Record Savings Pat i ent Speci f i c- L i a b i l i t y
Fomat Mandatory Subst i t ut i on Required Pass-on Consent at i ons Di scl ai mer
Texas None yes P A Yes B ' Yes Yes Yes
Utah Posi t i ve( 1) No P B(1) Yes A Yes Yes Yes
Vermont Posi t i ve No M B No D Yes Yes NO
Vi r gi ni a Posi t i ve Yes P
p Yes es Yes
Washington Posi t i ve( 1) Yes M A Yes 6 No Yes Yes
west Vi r gi ni a Negative Yes (opt.) M A/ B Yes A Yes Yes Yes
Wisconsin Posi t i ve 1 No P
p Yes es Yes
Wyoming None Yes P A yes B No Yes Yes
*Some of t he i nf ormat i on i n t h i s char t i s based upon NPC st af f i nt er pr et at i ons o f st at e st at ut es and regul at i ons.
Legend:
i .' ?f%%+DA Therapeutic Equivalency L i s t
( 2 ) Each pharmacy i s t o develop DPS L i s t
( 3) Each pharmacy i s t o l i s t conunonly used generics from st at e developed formul ary
Permissive o r Mandatory Languaqe:
P = Permissive; M = Mandatory
( 1) unless i n the pharmacist' s professi onal judgement
Prevention of Subst i t ul i on:
]A) Prescri ber' s si gnature on appropri at e l i n e o f 2- l i ne pr escr i pt i on
( b) Prescri ber expressl y i ndi cat es do not DPS i n some manner
1. Allows use o f prepri nt ed "do not sub'' check-box
2. Box must be checked t o prevent DPS
Cost Savinrts Pass-On:
A be passed on t o consumer
Bj Drus dispensed must be l ess exoensive than drug prescri bed
( c) No cost savings pass-on requirement mentioned -
(D) No more than usual and customary charge f or prescri bed drug
Pat i ent Consent: (Yes) i ncl udes st at es where consent i s requi red and those which requi red t he pat i ent t o
be not i f i edl i nf or med o f subst i t ut i on.
Oklahoma: 0.8. (1961) si mpl y st at es t hat i t i s unlawful f or a pharmacist t o subst i t ut e wi t hout the
aut hor i t y o f the pr escr i ber o r purchaser.
Researched and compiled by t he Nati onal Pharmaceutical Council. Inc. i n conj uncti on wi t h Jesse E. Stewart, ph.~.,
Associate Professor of Pharmacy Admi ni strati on, College o f Pharmacy. The Uni ver si t y of I l l i n o i s a t Chicago.
NPC
AL ABAMA
MEDI CAL ASSI STANCE D R U G PROGRAM ( TI TLE XI X)
Al a b a ma - ?
1985
I. BENEFiTS PROVIDED AND GROUPS ELiGlBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other-
O M AB APT0 AFDC OAA AB PPTD AFOC Children 21 (SFO!
Prescribed
Drugs X X X X
inpatient
Hospital Care X X X X
Outpatlent
Hospital Care X X X X
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician
Dental
Other Benefits: Optometric services; home health care; early, periodic, screening, diagnosis and treatmenl; family planning; !ranspotta!icn.
'SF0 - Slate Funds Only
"'Dental Services EPSDT - under 21 years old
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending September 30. 1984
. . . . . TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aoed . . . . . . . . . . . .
1984 1983
Expended Pecipiezt
-
Recipient
-
Expended
- -
$35,266,939 225,256'" $31,616,230 222,713""
Blind . . . . . . . . . . . . . . . . . . . . . . 321,253 1.084 294,667
1,462
Di s a b l e d . . . . . . . . . . . . . . . . . . . . . 12,459,958 51,365 10,758,949 48,922
. . . . . . . . . . . . Children-Families wiDep Children 1,305,488 38,016 1,203,069 58,761
Adults-Farniiies wlDep Children . . . : . . . . . . . . 2,358,341 58,725 2,184,940 38.183
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . $4,768,386
Aged . . . . . . . . . . . . . . . . . . . . . . 4,016,798
Blind . . . . . . . . . . . . . . . . . . . . . . 5,652
Disabled . . . . . . . . . . . . . . . . . . . . . 531,761
Children-Families wiDep Children . . . . . . . . . . . . 58,320
Adults-Families wiDep Children . . . . . . . . . . . . 114,661
Other Title XIX Recipients . . . . . . . . . . . . . . . 40,594
. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL $0
Aged . . . . . . . . . . . . . . . . . . . . . . 0
Blind . . . . . . . . . . . . . . . . . . . . . . 0
Disabied . . . . . . . . . . . . . . . . . . . . . 0
Children-Families wIDep Children . . . . . . . . . . . . 0
Adults-Families wiDep Children . . . . . . . . . . . . 0
Other Title XIX Recipients . . . . . . . . . . . . . . . 0
'Vnduplicated Total - HHS report HCFA - 2082
69
Ill. Administration
Alabama Medicaid Agency
IV. Provisions Reiating 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.
0. Formuiary: Alabama Drug Code Index, which specifies those drugs that may be dispensed on
prescription only. Contact person for approving formulary additions: Sam T. Hardin, P.D. (see p.
4)
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Normal prescriptions are limited to a maximum 34-day supply with
a maximum of 5 refills. The 34-day limitation does not apply to long-term maintenance
medication. The quantities (units) of drugs prescribed by a physician SHALL NOT be
arbitrarily changed by a pharmacy except by authorization of the physician. The pharmacist
should contact the prescribing physician for authorization to reduce the quantity of a non-
maintenance medication prescription to the 34-day supply limitation where appropriate.
Authorization to reduce 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 must be written for at least a minimum thirty (30) day supply.
2. Refills: When authorized by prescriber, a maximum of five (5) refills within a six month period.
(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
au!horized under the program based upon and shall not exceed the lowest of:
0 The Maximum Allowable Cost (MAC) of the drug plus a dispensing fee
0 The Estimated Acquisition Cost (EAC) of the drug plus a dispensing fee, or
0 The provider's usual and customary charge to the public for the drug.
Professional Fee
0 2.4Retail pharmacies $3.00
0 Institutional pharmacies (hospital
pharmacies with outpatient
prescription services and skilled
nursing facilities pharmacies)
@ Government pharmacies (county, state,
or federai pharmacies) 1.65
Dispensing Physicians 1.05
E. Variable Co-Payment for Prescription Drugs. Medicaid patients are required to pay and phar-
macies are required to collect the maximim designated variable co-pay amount for each prescrip-
tion filled and each refill.
EXEMPTIONS: No co-payment amount is to be collected by the pharmacy or paid by the
recipient on the following:
e Family planning drugs or supplies.
Drilgs dispensed to a Medicaid recipient under 18 years of age
NPC
0 Drugs dispensed to Medicaid eligible pregnant women.
0 Drugs dispensed to Medicaid recipients residing in a long-term care facility (nursing home)
CO-PAYMENT (Effective October 1, 1984) Retail Pharmacies
$.01-$7.00
7.01 -$22.00
22.01-$47.00
47.01 or more
V. Miscellaneous Remarks:
1. Fiscal Intermediary:
Alacaid (E.D.S.F.)
P.O. Box 3367
Montgomery. Alabama 36109
(205) 834-3330
1-800-392-5741
Officials, Consultants and Committees
1. Officials-Alabama Medicaid Agency
Faye S. Baggiano
Commissioner
Clayton H. Schmidt, M.D., Chief
Professional Services Div.
p ' a m T. Hardin, P.D.,
Assoc~ate D~rector
Pharmaceutical Program
2. Title XIX Medical Care Advisory Committee:
Permanent Ex Officio Members
State Health Officer-
Commissioner-State DPS-
Alabama Medicaid Agency
2500 Fairlane Drive
Montgomery, Alabama 36130
(205) 277-2710
Ira L. Myers, M.D.
State Public Health Department
434 Monroe Street
Montogomery, Alabama 361 30
Appointment Ends July 19, 1987
The Medlcal Association of the State of Alabama
Dr. Leon Frazier, Commissioner
State Department of Pensions
and Security
64 North Union Street
Montgomery, Alabama 36130
(205) 261 -31 90
Glen D. Bedsole, M.D.
303 S. Ripley Street
Montgomery, Alabama 36104
NPC
Alabama Hospital Association
Mr. Frank Perryman
Sylacauga Hospital and Nursing Home
Sylacauga, Alabama 35151
Alabama Optometric Association
Craig McNamara, O.D.
5723 Carmichael Parkway
Montgomery, Alabama 361 17
American Association of Medical Assistants
Ms. Nancy Q.Gil1, CMA-A
3005 Hood Road, S. W.
Huntsville, Alabama 35805
Medical Group Management Association of Alabama
Mr. William Stewart
Department of Medicine
6th Floor MEB
University Station
Birmingham, Alabama 35294
Appointment Ends July 19, 1986
The Medical Association of the State of Alabama
Roy T. Hager, M.D.
2055 Normandie Drive
Montgomery, Alabama 36198
Alabama Pharmaceutical Association
Mr. Jim Scruggs
61 1 Moore Street
Marion, Alabama 36756
Alabama State Nurses Association
Mrs. Bonnie Griffith, R.N.
P. 0. Box 175
Dadeville, Alabama 36853
Dr. Raymond T. Handy
Director, Adult Education
Tuskegee Institute
Carnegie Hall 3rd Floor
Tuskegee Institute, Alabama 35088
Consumer Representative
Mrs. Julie Trant
P. 0. Box 6406
Dothan, Alabama 36302
NPC
Alebarna Chapter of Academy of Pediatrics
Dr. Stan Brasfield
P. 0. Box 1007
Demopolis Alabama 36732
Medicaid Recipient Representative
Mrs. Lula Gladback
12 Astor Drive
Sunshine Village
Montgomery, Alabama 36109
Medicaid Recipient Representative
Mrs. Lee Raye Pearson
256-0 Lynwood Montgomery, Alabama 36105
Consumer Representative
Mr. William Glover, Director
Area Agency on Aging
Southeast Alabama Regional Planning
and Development Commission
P. 0. Box 1406
Dothan, Alabama 36301
Montgomery Area Council on Aging
Ms. Ellen Dempsey
1949 Walnut Street
Montgomery, Alabama 36106
Consumer Representative
Mr. Charles G. Spradling, Jr.
P. 0. Box 11 765
Birmingham, Alabama 35202
3. Executive Officers of State Medical and Pharmaceutical Societies:
Medical Association Pharmaceutical Association
Lon Conner
Executive Director
Medical Association of Alabama
19 South Jackson Street
P. 0. BOX 1900-C
Montgomery, Alabama 36104
2051263-6441
Jon Barganier
Executive Director
Alabama Pharmaceutical
Association
340 Dexter Avenue
Montgomery. Alabama 361 04
2051262-0027
Osteopathic Association
Kenneth D. McLeod, D.O.
Secretary
Alabama Osteopathic Association
151 1 N. McKenzie Street
Foley, Alabama 36535
2051943-1 584
Nursing Home Association
Mr. Fred Draper
Executive Vice-president
Alabama Nursing Home Association
4140 Carmichael Road
Montgomery, Alabama 36106
2051271 -6214
4. State Board of Pharmacy
Hospital Association
Dr. Tommy R. McDougal
President
Alabama Hospital Association
East Station
P. 0. Box 17059
Montgomery, Alabama 361 93
20512724781
James W. McLane,
Secretary
231 2 City Federal Building
Birmingham, Alabama 35203
2051252-8976
NPC
AL ASKA
MEDI CAL ASSI STANCE D R U G PROGRAM ( TI TLE XI X)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB A?TD AFDC OAA AB APT0 AFDC Children 21 (SF01
Prescribed
Druos
Inpatient
Hospital Care X X X X X
Outpatient
Hospital Care X X X X X
Laboratory &
X-ray Service X X X X X
Skilled Nursing
Home Services X X X X X
Physician
Services X X X X X
Dental
Other Benelits: Intermediate Care Facilities; transpoilation; home health care; early and periodic screening, diagnosis and trealment for eligibles
under 21; family planning; inlermediate care for the mentally retarded; inpatient psychiatric care; optometrist services; eyeglasses; speech and
hearing services; mental health clinic.
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
1984 1983
Expended Recipient
- -
Expended Recipient
- -
TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . .
Children-Families wlDep Children . . . . .
Adults-Families wIDep Children . . . . .
CATEGORICALLY NEEDY NON-CASH TOTAL .
Aged . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . .
Children-Families wlDep Children . . . . .
Aduits-Families wlDep Children . . . . .
. . . . . . . . Other Tiile XIX Recipients
. . . . . . . MEDICALLY NEEDY TOTAL
Aged . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . .
Children-Families wlDep Children . . . . .
Adults-Famiiies w1Dep Children . . . . .
. . . . . . . . Other Title XIX Recipients
Alaska's Medicaid program does not include
drugs, except family planning drugs and
drugs dispensed to inpatients of hospitals and
nursing homes. (See page 2.)
YJndupIicated Total - HHS report HCFA - 2082
Ill. Administration:
There is no state Title XIX vendor drug program. The Alaska Medical Assistance programs including
Medicaid and General Relief-Medical are administered by the Division of Medical Assistance of the
Alaska Department of Health and Social Services. This Division also administers general relief -
medical assistance and catastrophic illness assistance programs.
IV. Provisions Relating to Prescribed Drugs:
Although drugs are not covered under Medicaid in Alaska, prescriptions are paid from the General
Relief-Medical budget for Medicaid recipients who have no other resource for obtaining prescribed
medications.
Officials, Consultants and Committees
1. Health and Social Services Deparlment Officials:
Robert Pugh, M.S.W.
Commissioner
Rod Betit
Director
Bob Ogden
Chief of Medical Assistance
Division of Medical Assistance
2. Alaska Medical Care Advisory Committee:
Sister Barbara Haase
Chairman
9071225-51 71
Department of Health and
Social Services
Pouch H-01
Juneau, Alaska 9981 1
9071465-3355
Division of Medical Assistance
Pouch H-07
Division of Public Assistance
Division of Medical Assistance
4041 B Street
Anchorage, Alaska 99503
9071561-2171
Administrator
Ketchikan General Hospital
31 00 Tongass Avenue
Ketchikan, Alaska 99901
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: C. State Board of Pharmacy
Martha MacDermaid
Executive Director .
Alaska State Medical Association
4107 Laurel Street, Suite 1
Anchorage 99504
Phone: 9071562-2662
0. Pharmaceutical Association:
Margaret Loden
Secretary
3222 Anella Avenue
Fairbanks, Alaska 99701
9071479-6793
Frank Zoppo
Secretary-Treasurer
Alaska Pharmaceutical Association
Box 10-1 185
Anchorage 9951 0
NPC
Arizona-!
! 985
ARIZONA
MEDICAL ASSISTANCE DRUG PROGRAM UNDER TiTLE XIX
Arizona Heaith Care Cost Containment System
(AHCCCS pronounced "ACCESS")
AHCCCS Features:
Arizona set the scene for an experimental health-care program when in 1981 the state and HCFA
deveioped an aiternative health-care program for the indigent.
The Arizona Health Care Cost Containment System (AHCCCS) was born in a speciai session of
the legislature in November 1981, after 10 years of debate. The plan utilizes statelfederal money with
supposedly fewer complications tinan the Medicaid programs in place in the other states.
AHCCCS was begun in October 1982 as a three-year experiment for the state's 220,000 indigents.
Under this program, hospitals, physicians and other medical-care suppliers treat patients on a prepaid
basis. The providers offer bids to the state to treat a certain number of patients for a fixed amount of
money each year. Bids are based on what individual providers have determined are average fees for
various services.
Administration:
Arizona Heaith Care Containment System (AHCCCS), Arizona Department of Health Services.
General Information:
The Arizona Health Care Cost Containment System (AHCCCS), developed in Senate Biii i0G1,
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 leveis of
quality health care services are provided to eligible persons in a dignified fashion. The goai 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:
0 Primary Care Physicians Acting as Gatekeepers
0 Prepaid Capitated Financing
0 Competitive Bidding Process
0 Cost Sharing
0 Limitations on Freedom-of-Choice
0 Capitation of the State by the Federai Government
Primary Care'Physicians Acting as Gatekeepers:
The AHCCCS legislation ~rovi des 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 ail 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 medicai 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 ailows 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 seMces to be
delivered in a given county. Providers may bid on a prepaid capitated basis for oniy those services tnsy
normally provide. For exampie, a group of physicians may choose to bid oniy for physician services for
a particular area; hospitais may do the same; and so on. The law aliows for expansion and contraction
of bids to achieve the best possible system. in the event there are insufficient bids for a given area, ine
legisiation permits capped fee-for-service arrangements. it is intended, however, that capped fee-for-
NPC Arizona-2
1985
service will be authorized as a last resort oniy.
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 mag-
nitude has never been attempted in any other state. Arizona DHS believes that competitive bidding for
health care service contracts, as opposed to conventional negotiation processes, will provide accessable
cost-effective delivery of health care without sacrificing quality performance.
The Department of Health Services issues an invitation to qualified providers of health services, at
leas: on a biennial basis, to bid to provide services to AHCCCS members in each county. Qualified
providers may bid to offer the iull range of AHCCCS services, or any allowable partial grouping of
services, in one or more counties.
Cost Sharing:
The fourth major device for containing costs in the AHCCCS model is a provision for cost sharing
by users. A statewide co-payment schedule was developed for this purpose, and the medically needy
participate in coinsurance cost 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
utiiizaiion by members for truly needed health care.
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 pians 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-service 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
actuariai principles, and will represent no more than 95 percent of the estimated cost of services delivered
in Arizona under conventionai 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 pians 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 modei. 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 pians 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-service arrangements will be
authorized as a last resort only and when there are insufficient bids for a given area.
NPC
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 Administrator:
The AHCCCS contract Administrator 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.
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 bebefits to a defined population at a capitation rate.
Administrator Organized Health Systems
The Administrator Organized Health Systems serve as back-up to the full benefit capitated plans,
assuring that there are no service area gaps in the state and that there is at least one alternative choice
in those areas covered by a Contracting Health Plan.
The Administrator Organized Plans must:
e Be prepared to function as the routine health care delivery systems in any area of the State not
adequately covered by Contracting Health Plans.
e Serve as the mechanism for assuring emergency and urgent care for the "emergent members" of
AHCCCS.
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 Administrator Organized Health Systems with a residual
budget.
The Organizational Role of the Arizona Department of Health Services:
The Department of Health Services has been charged with the general implementation and monitor-
ing of the AHCCCS program. A Division has been created within the Department (Arizona Health Care
Cost Containment System Division) to fulfill that responsibility.
The Department develops the Rules and Regulations; conducts the Administrator bidding process.
and provider bidding processes in conjunction with the Administrator; 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.
It is the Departiment's obligation to contract with a private Administrator who will assume respon-
sibility for the day-to-day operation of the program.
The Operational Role of the AHCCCS Administrator:
Organizationally, the Administrator will assume responsibility for the every day operations of the
program, subject to the general supervision of the Department.
NPC Arizona-4
j "5
u:,-,,~~,
The AHCCCS Administrator wili have overall responsibility for the following activity areas: V a i 7
Ma. z-
Promotion of AHCCCS
0 Procurement of Contract Providers
e Provider Management
0 Provider, Member, and Public Relations
0 Program Operations
AHCCCS became effective December 1, 1981. Services commenced October 1, 1982 and expire
September 30. 1985. Funding for first year operation stated to be $105.4 million. Services include:
Inpatient, outpatient, laboratory, x-ray, prescription drugs, medical supplies, prosthetic devices, emer-
gency dental care including extractions and dentures, treatment of eye conditions and EPSDT.
The McAuto Systems Group, Inc. of New York was designated AHCCCS administrator, however
a contract dispute resulted in the state taking over administration of the plan on March 16, 1984.
By June 1984, the AHCCCS program was costing $215 million and serving about 189,000 indigents.
The AHCCCS budget request for 1985-86 was expected to reach $276 million. One controversial
development in 1984 was the approval by the AHCCCS program and the Arizona Board of Pharmacy of a
proposal by the Walgreen Company and the state's largest health care provider to set up mail-order drug
distribution for indigent patients. Walgreen held a contract to administer pharmacy services to 61,000
patients at that time. The mail-order distribution was requested by Arizona Physiciansllndependent
Practice Association.
Though AHCCCS is a three-year experiment which was to end in October 1985, Governor Bruce
Babbitt is prepared to ask the federal government for permission to extend funding for the program for
an additional two years.
Official, Consultants and Committees
1. Health Services Department Officials:
Donald F. Schaller, M.D,
Director
Arizona Health Care Cost Containment
System
124 West Thomas, Suite 301
Phoenix, Arizona 85013
2. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: C. Osteopathic Association:
Bruce E. Robinson
Executive Vice President ,
Arizona Medical Association, Inc.
810 West Bethany Home Road
Phoenix 85013
Phone: 6021246-8901
B. Pharmaceutical Association:
Warren J. Ellison, R.Ph.
Executive Director
Arizona Pharmaceuticai Association
2202 North 7 Street
Phoenix 85006
Phone: 6021258-8121
Mr. S. N. Schultz
Executive Director
Arizona Osteopathic Medical Association
5057 E. Thomas Road
Phoenix 8501 8
6021840-0460
D. State Board of Pharmacy
Executive Director
Arizonia Board of Pharmacy
1645 North Jefferson Street
Phoenix, Arizona 85009
6021255-51 25
NPC
ARKANSAS
MEDI CAL ASSI STANCE D R U G PROGRAM ( TI TLE XI X)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other"
O M AB APT0 AFDC O M AB APTD AFDC Children 21 fSFDI
Prescribed
Oruos X X X X X X X X X
inpatient
Hospital Care X X X X X X X X X
~ospi t al 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
Denial
Services X X X X X X X X X
"SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Pdyment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
Expended Recipient Expended Recipient
- - -
TOTAL . . . . . . . . . . . . . . . . . . . . . $33,166,977 155,131" $28,218,714 151,260
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $26,151,084 125,344 21,375,519 122,711
Aged . . . . . . . . . . . . . . . . . . . . . . 11,124,351 36,129 5,582,801 35,772
Biind . . . . . . . . . . . . . . . . . . . . . . 340,685 1,194 300,143 1,225
Di s a b l e d . . . . . . . . . . . . . . . . . . . . . 11,057,771 32,510 9,019,490 30,380
Children-Families wlDep Children . . . . . . . . . . . . 1,395,067 34,690 1,218,723 34,304
Adults-Fzmilies ~ 1 0 e p Children . . . . . . . . . . . . 2,233,210 21.130 1,854,362 20,719
CATEGORiCALLY NEEDY NDN-CASH TOTAL
A . . . . . . . . . . . . -
Blind . . . . . . . . . . . . . . . . . . . . . . 22,596 60 19.068 59
Disabled . . . . . . . . . . . . . . . . . . . . . 1,065,412 2,376 973,090 2,524
Children-Families wIDep Children . . . . . . . . . . . . 3,241 160 3,428 140
Aduits-Families wlDeo Children . . . . . . . . . . . . 8.435 131 6.204 108
Other Title XIX flecipients . . . . . . . . . . . . . . . 61;010 1,402 52;914 1.231
MEDICALLY NEEDY TOTAL
Aged . . . . . . .
Bi nd . . . . . . . . . . . . . . . . . . . . . . 902 7 1,424 6
Disabled . . . . . . . . . . . . . . . . . . . . . 325,110 1.544 250,650 1,555
Childreii-Families wlDeo Children . . . . . . . . . . . . 113.431 3,181 87.575 2.536 ~ ~
Adults-Families wlDep children
Other Title XIX Recipients . .
"Unduplicated Total - HHS report HCFA - 2082
NPC
ili. Administration:
By the Division of Social Services, of the Department of Human Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions (diseases, drug categories, etc.):
All legend drugs are covered with the following exceptions: investigational drugs, I.V. solu-
tions, amphetamines, anti-obesity agents, irrigating solutions, vaccines, and routine immunizing
agents.
0-T-Cs: Pursuant to a prescription the following OTC items are covered: insulin, insulin needles
and syringes, analgesics, antacids, calcium lactate, contraceptive foams and jellies, dicalcium
phosphate, ferrous fumarate, ferrous gluconate, ferrous sulfate, ferrous cholinate, meclizine HC1,
pediatric vitamin drops for children up to three years of age, laxatives and stool softners, nicotinic
acid and schedule V narcotics. All other non-legend items are excluded.
B. Formulary: None
C. 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. Doilar Limits: None
4. Monthly Limit: Four prescriptions per month per recipient.
D. Prescription Charge Formula:
Legend drugs-estimated acquisition cost plus $3.87 professional fee. Total charge may not
exceed provider's prevailing charge to the self-paying public, or any other third-party prescription
drug program.
V. Miscellaneous Remarks:
The Arkansas MAC program exists for 20 multi-source drugs. (effective 1 July 1984)
Fiscai intermediary:
Aritansas Blue Cross-Blue Shieid, Inc.
7th and Gaines Streets
Little Rock, Arkansas 72203
Officials, Consultants and Committees
1. Ray Scott, Director
Department of Human Services
Social Services Division:
Commissioner
Vacant
Mauda Russell, Director
Office of Management Services
Arkansas Dept. of Human Services
Division of Social Services
P. 0. Box 1437
Little Rock, Arkansas 72203
501 1371 -1 806
Sam Lamey. Director
Office of Financial Management
NPC
Gordon Page
Office of Program Operations
Kenny Whitlock, Director
Office of Medicai Services
Vacant, Director
Office of Long Term Care
Ivan H. Smith, Director
Office of Legal Services
Al Sliger, Administrator
Medical Assistance Section
Mark Crossley, P.D.
Pharmacy Consultant
501 I371 -5361
2. Social Services Consultants:
Physicians (Part-time):
W. H. O'Neal, M.D.
Harold Betton, M.D
Guy Ferris. M.D
Thomas D.Honeycutt, M.D
3. Medical Care Advisory Committee
Asa Crow
Jack Burge
C.C. Long
James Webel
Baptist Medical Center
Medical Education
Department
9600 West 12th
Little Rock, Arkansas 72205
1505 West 1 1 th
Little Rock, Arkansas 72202
621 3 Lee
Little Rock, Arkansas 72205
4124 West 11th
Little Rock, Arkansas 72204
Morriss Henry
Walter O'Neal
Charles Wilkins
4. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medicai Society:
C. C. Long, M.D.
Executive Vice-president
Arkansas Medical Society
P. 0 . Box 1208
Fort Smith, Arkansas 72902
Phone: 501 1782-821 8
NPC
8. Pharmaceutical Association:
Norman Canterbury, P.D.
Executive Vice President
Arkansas Pharmacists Association
81 8 Garland Avenue
Little Rock, Arkansas 72201
Phone: 5011372-5250
C. Osteopathic Medical Association:
Bob E. Jones
Executive Director
Arkansas Osteopathic Medical Association
502 West 16th Street
Hope, Arkansas 71801
5011777-8839
5. State Board of Pharmacy
Lester Hosto
Executive Director
P.O. Box 55356
Little Rock, Arkansas 72225
501 1661 -2833
NPC
CALI FORNI A
MEDI CAL ASSI STANCE D R U G PROGRAM ( TI TLE XIX)
I. BENEFITS PROViDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MI)
(SSilSSP) Chiidren 21
Prescribed
Drugs X X X
Inpatient
Hospital Care X X X
Outpatient
Hospital Care X X X
Laboratory &
X-rav Service
Skilled Nursing
Home Services X X X
-
Physician
Services X X X
Dental
Services X X X
li. EXPENDiTURES FOR DRUGS. Fiscal year ending June 30, 1985
M 1984
Expended
-
Recipient
-
Expended
-
TOTAL . . . . . . . . . . . . . . . . . . . . . $205,707,921 2,172,200" $213,167,811
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $165,965,510 1,725000 173,386,305
Aged . . . . . . . . . . . . . . . . . . . . . . 37,366,125 230,280 40,489,841
Blind . . . . . . . . . . . . . . . . . . . . . . 3,833,063 16.300 3,918,064
Disabled . . . . . . . . . . . . . . . . . . . . . 80,009,900 317,320 80,145.731
Children-Families wiDep Children . . . . . . . . . . . . 20,608,211 679,400 21,327,988
Adults-Families wIDep Children . . . . . . . . . . . . 24,148,209 481,700 27,504.679
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . $2,620,458 64,680 $2,208,170
Aged . . . . . . . . . . . . . . . . . . . . . . 934,927 7,380 836,433
Blind . . . . . . . . . . . . . . . . . . . . . . 26,196 140 15,552
Disabled . . . . . . . . . . . . . . . . . . . . . 559,278 3,280 533,732
. . . . . . . . . . . . . Children-Families wlDep Children
471,658 28,440 365,721
Adults-Families wlDep Children . . . . . . . . . . . . 628,397 25,440 456.730
Other Title XIX Recipients . . . . . . . . . . . . . . . 0 0 0
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families wIOep Children . . . . . . . . . . . .
. . . . . . . . . . . . Adults-Families w1Dep Children
Other Title XIX Recipients . . . . . . . . . . . . . . .
FY 1983
Recipient
-
2,225,500
1,793,460
253,240
17,060
327.800
660.560
534,800
61,400
11,440
160
6,000
'"Undupiicated Total - HHS report HCFA - 2082
NPC
Ill. Administration:
By the Health and Welfare Agency with direct supervision by the Department of Health Services.
Payment of bilis by the state is processed through a fiscal intermediary, Computer Sciences
Corporation
Under the generat direction of tine 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 UtilizationiCost Controls and
the development, implementation, and interpretation of policies and regulations concerning the full
scope of pharmaceutical benefits.
IV. Provisions Relating to Prescribed Drugs:
A. General Limitations and Exclusions (diseases, drug categories, etc.):
Formulary CNS stimulants*, i.e., amphetamines and methylphenidate, are only available for
epilepsy or Minimal Brain Dysfunction in individuals between 6 and 16 years of age. Contact
laxative suppositories 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 lumepilepsy or Minimal Brain Dysfunction in individuals between 6
and 16 years of age. Contact laxative suppositories 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).
Formulary Diazepam* restricted to use in cerebral palsy, athetoid states, and spinal cord
degeneration. Nutritional supplements or replacements only for therapeutic use to prevent
serious disability or death in patients with medically diagnosed conditions that preclude the full
use of regular food-stuffs.
Formulary Baclofen* restricted to use in spasticity resulting from multiple sclerosis or spinal cord
injury.
Formulary Carbonacillin' restricted to pseudomonas aerugenosa urinary tract infections.
Formulary CImetidine* restricted to use in treatment of duodenal ulcer, Zollinger-Ellison
syndrome, systemic mastocytosis, and multiple endocrine adenomas.
Formulary Dantrolene* restricted to use in spasticity resulting from cerebral palsy, spastic hemys-
legia, multiple sclerosis, and spinal cord injury.
Formulary Erythromycin-Sulfkoxayol* restricted to use in acute otitis media.
Formulary Fenoprofen, Ibuprofen, Naproxen, TolmatIn* restricted to use for arthritis.
Formulary Nalodixic Acid* restricted to urinary tract infections resistant to sulfonamides or in
patients sensitive to sulfonamides.
Formulary Trumethoprim-Sulfamethoxayolz* restricted to genitourinary tract infections.
Excluded from coverage are multivitamins for persons over five years of age and most OTC
household remedies.
9. 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. Many
brand names listed alphabetically as cross-index references. The patient's physician or phar-
macist 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:
'other uses require prior authorization.
Computer Sciences Corporation
P.O. Box 15000
Sacramento, CA 95813
Ann: Distribution
(Please remit $3.25 per manual, including updates, by check or money order payable to "State
of California")
For formulary information contact:
M. Kuschnereit, Pharm.
714 P Street, #I640
Sacramento, CA 95814
91 61324-2477
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: This is flexible, but quantities should be consistent with the medi-
cal needs of the patient and may not exceed a 100-day supply except under certain cir-
cumstances. Many high volume andlor chronically used oral dosage forms of drugs are
subject to minimum quantity or maximum frequency of billing controls.
2. Refills: A prescription refill can be dispensed after authorization by prescriber. Exception
is allowed for refill of a reasonable quantity when prescriber is unavailable (pursuant to
California law). Fee is prorated so that total fee (for authorized 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 postpayment controls. These controls include those
mentioned in item 1 supported by onsite 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 MAC type price
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.
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 Maximum Allowble cost (MAC) plus $4.05 professional fee.
3. State Maximum Allowable Ingredient Cost (MAIC) plus $4.05 professional fee.
4. Pharmacy's usual price to general public.
\I. Miscellaneous Remarks:
Drug Price List Updating
Drug prices used to determine reimbursement are updated the 1st day of each even month for price
change notices which are effective on or before that date. Price notices are received by Computer
Sciences Corporation, P.O. Box 15000, Sacramento, California 95813.
87
Medicai Therapeutics and Drug Advisory Committee
Reacting to the lead responsibility of the Drug Policy Unit in the Benefits Branch, the Medical
Therapeutics and Drug Advisory Committee 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 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 ingredient Cost Program
State MACs are established on over 150 multisource 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.
Officials, Consultants and Committees
1. Health and Welfare Agency
A. Health and Welfare Agency Officials:
David Swoap
Secretary
B. Depattment of Health Services:
Kenneth Kizer
Director
Stan Cubanski
Chief Deputy ~i rect or
Linda Martland
Deputy Director
Sue Staats
Chief
California Health and
Welfare Agency
1600 9th Street
Suite 460
Sacramento, California
Department of Health
Services
714 "P" Street
Sacramento 95814
Department of Health Services
714 " P Street
Sacramento 9581 4
Medical Care Services
714 " P Street
Sacramento 95814
Medi-Cal Policy
Division
714 "P" Street
Sacramento 95814
Jerome Hansen
Chief
Benefits Branch
714 "P" Street
Sacramento 95814
NPC
James Parks
Chief
(916) 445-1995
Medical Services Section
714 "P" Street, Room 1640
Sacramento 95814
Milton Kuschnereit, Pharm.
Sr. Pharmaceutical Program
Consultant
(916) 324-2477
C. Advisory Committee to California Department of Health Services:
1. Medical Therapeutics and Drug Advisory Committee:
James Parks
Coordinator
David Fung, Pharm
Chairman
California Department of
Health Services
714 "P" Street
Sacramento 9581 4
460 Pollasky Avenue
Clovis 9361 2
D. Officers of Computer Sciences Corporation (the Fiscal Intermediary):
Carl Hagenau Computer Sciences Corp,
President of P.O. Box 15000
Governmental Services 2000 Evergreen Street
Sacramento 9581 3
Glenn Spaulding, Pharm.
Manager of Pharmacy
Relations
2. Executive Officers of State Medical and Pharmaceutical
A. Medical Association: B. Pharmaceutical Association:
Willis W. Babb
Executive Director
California Medical Assn
44 Gough Street
San Francisco 941 03
' . Phone: 4151863-5522
Robert C. Johnson
Executive Vice President
California Pharmacists' Association
1112 I Street
Sacramento 95814
Phone: 9161444-781 1
C. Osteopathic Physicians & Surgeons of California:
Matthew L. Weyuker
Executive Director, OPSC
921 -1 I t h Street, Suite
Sacramento 9581 4
Phone: 9161447-2004
3. State Board of Pharmacy
Lorie Garris Rice
Executive Officer
1020 "N" Street
Sacramento, California 5814-5784
91 61445-501 4
Colorado- 1
1985
COL ORADO
MEDI CAL ASSI STANCE D R U G PROGRAM ( TI TLE XI X)
I. BENEFITS PROVIDED AN0 GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other*
OAA AB APT0 AFDC DAA A0 APTD AFDC Children 21 ( S W
Prescribed
Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatient
Hosoitai Care X X X X
Laboratoiy &
X-rav Service
Skilled Nursino
Hame service; X X X X
Physician
Services X X X X
Dental
Services X
'SFD - State Funds Only
"Dental Services EPSDT - under 21 years old
11. EXPENDITURES FOR DRUGS. Pavment to Pharmacists by fiscal year endino June 30. 1984
TOTAL . . . . . . . . . . . . . . . . . . . . .
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
A d . . . . . . . . . . . . . . . . . . . . . .
i d . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families wlDep Children . . . . . . . . . . . .
Adults-Families WDep Children . . . . . . . . . . . .
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Chiidren-Families wlOep Children . . . . . . . . . . . .
Adulls-Families wIDep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Msabkd . . . . . . . . . . . . . . . . . . . . .
Children-Families wlDep Children . . . . . . . . . . . .
Adults-Families wlDep Children . . . . . . . . . . . .
Other Title XiX Recipien!~ . . . . . . . . . . . . . . .
1984
Expended
-
Recipient
-
$16,616,730 105,919'
$13,652,477 93.021
7,966,083 25,115
26,753 133
2,926,770 9,163
898.710 34,621
1,834,161 24,389
$2,964,253 21,586
1,343,666 5,267
7,167 44
1,257,076 5,452
57.791 3,992
134,107 4,021
164,446 3.052
$0 0
0 0
0 0
0 0
0 0
0 0
0 0
1983
Expended
-
Recipient
-
$14,895,527 103,453
12,454,097 92,692
7,135,252 25,450
23,810 143
2,633,758 9,242
894,360 33,979
1,766,917 24.288
$2,441,430 19,594
1,201,455 5,443
3.436 44
944,605 4.784
43,859 3,174
99,895 3.462
148,180 2.848
$0 0
0 0
0 0
0 0
0 0
0 0
0 0
"Undupiicated Tatai - HHS report HCFA - 2082
NPC
Ill. Administration:
Eligibility is determined by 63 County Departments of Social Services, and the drug program is
administered by the Colorado Department of Social Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions (diseases, drug categories, etc.):
Restricted Drug Categories:
1. Prescription-legend drugs not listed in the "ColoRx Drug Formulary".
2. Certain over the counter drugs provided under prior authorization.
3. Payment for restricted drugs authorized only in accordance with non-emergency or emer-
gency 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 I1 - Generic drugs are identified as having a Maximum Allowable Price, iisted with
price information which is updated periodically.
Section 111- EAC Price List. High volume drugs reimbursed at greater than 100's size or
direct manufacturer's price.
C. Prescribing or Dispensing Limitations:
1 . Terminology: The Department encourages appropriate consideration of cost in prescribing
and dispensing by the selection of the less expensive trade name or generic product when,
in the practitioner'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.
Exceptfons 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 profes-
sional 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. Doilar Limits: None.
91
NPC
D. Basis for Reimbursement
1. Benefit drugs shall be reimbursed at the lesser of the Medicaid allowable reimbursement
charge, or the provider's reimbursement.
2. The Medicaid allowable reimbursement charge is the sum of the ingredient cost of the drug
dispensed and the provider's dispensing fee.
3. Dispensingfee: $3.40 (effective date 7180)
4. The dispensing fee is a pre-determined amount paid to a provider for dispensing a prescrip-
tion. 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 retaii pharmacies shall be based upon the average cost
of filling a prescription as determined by the cost survey.
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 M.A.C. or the high volume E.A.C., whichever
is less.
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 M.A.C., or the high volume E.A.C., whichever is
less.
a. Maximum Allowable Cost (M.A.C.)
The state M.A.C. is the maximum ingredient cost allowed by the Department for certain
multiple-source drugs. The establishment of a M.A.C. 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 M.A.C. limits for multiple source drugs are announced, they will be
adopted if they are less than state M.A.C.'s or if no state M.A.C.'s exist.
Section I! of the ColoRx shall identify the generic drugs subject to M.A.C.
The ingredient cost of any drug subject to M.A.C. shall be limited to M.A.C. or wholesale
price as determined by the Department, which is less. Exceptions which will allow
reimbursement greater than M.A.C. 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 invoived, or any similar situation
exists.
NPC
If a recipient requests a brand name for a prescription which is subject to M.A.C., then
helshe may pay the ingredient cost difference between the M.A.C. and brand name
drug. The recipient must sign the prescription stating that helshe is wiliing to pay the
difference in ingredient cost to the pharmacy. The pharmacy will be paid M.A.C. plus a
dispensing fee or reimbursement charges whichever is lower.
b. High volume Estimated Acquisition Cost (E.A.C.)
Reimbursement for singie source drugs or certain multiple source drugs which are most
frequently prescribed will be based upon average wholesale prices or direct manufac-
turers' 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 acquistion
cost list includes but is not limited to:
1. Single source manufacturers
2. High volume Medicaid recipient utilization
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, M.A.C., and high
colurne E.A.C., will be the basis for setting the prices in the drug pricing file.
The Department will determine the average wholesale price whlch 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 closes! 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 whoiesale piicing
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 suplements, 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 ihe
same as in 3 above.
Special Note:
The Maximum Allowable Cost shall be determined by the Division of Medicai Assistance, based
upon professional determination of a quality product available at the least expense possible.
Recommendations from the CoioRx Drug Formulary Advisory Committee of the Medicai Advisory
Council is considered in determining the MAC.
V. Miscellaneous Remarks:
Lock-In Review Procedures:
The State Department receives computer processed printouts designed to discover overutilization 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 Committee's recommendations.
Case-workers are also contacted and informed of the overutilization 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. . .,r&
Prescription Data:
Total Rxs . . . 1,534,958
Average Rx Cost. . . $1 1.27
fiscal
Denver. CO 80272
Officials, Consultants and Committees
1. Social Services Department Officials:
George A. Goldstein, Ph.D
Executive Director
Cecilia Holmes
Assistant Director
George E. Kawamura
Associate Director for Programs
Andrea Baugher
Office of Intergovernment Affairs
Willis H. LaVance
Associate Director for
Administration
Gary Angerhofer
Director. Bureau of Medical
Assistance
Bonnie Orkow
Director, Program Operations
Myrle A. Myers, R.Ph., M.S.
Manager, Pharmacy and Ambulatory
Care Services Section
Division of Medical Assistance
3031866-5372
Colorado Department of
Social Services
1575 Sherman Street
Denver. Colorado 80203
James C. Syner, M.D.
Medical Consuitant
Division of Medical Assistance
NPC
Marjorie Jones, Acting Chief
Hospital Services Section
Division of Medical Assistance
Mary Ann Seddon
Surveillance and Utilization
Review Section
Wes Letz
Fiscal Agent Monitoring
Dean Woodward
Manager, Appeals
Janell Townsend
Dan Milne
Manager, Cost Containment &
Fiscal Agent Monitoring
Richard Allen
Manager, Long Term Care
2. Social Services Department Consultant:
Marvin J. Lubeck. M.D
Ophthalmology
3. Medical Advisory Committees:
A. Medical Assistance and Services Ad
Walter Ballard, D.D.S.
141 6 Constitution
Pueblo, Colorado 81001
Stephen Gill, D.P.M.
Denver Foot Clinic, P.C.
3193 South Broadway
Englewood, Colorado 801 10
Elmer Houtsma
2316 West Davis Circle
Littleton. Colorado 80120
Kenneth R. Huey
Longmont United Hospital
P. 0. Box 1659
1950 Mountain View Avenue
Longmont, Colorado 80501
Charles A. Rademacher, D.O.
1060 Orchard Avenue
Grand Junction, Colorado 81501
Members
3865 Cherry Creek
North Drive
Denver 8021 0
visory Council:
Donald Schiff M.D.
600 Front Range Road
Littleton, Colorado 80120
Anthony J. Makowski Ill, M.D.
3005 East 16th Avenue, Suite 150
Denver, Colorado 80206
Kaye Grounds
Rehabilitation and Visiting
Nurse Association
1500 1 1 th Avenue
Greeley, Colorado 80631
Hanna Evans, M.D.
Clinical Psychologist
Common Course
60 Kearney Street
Denver, Colorado 80220
Victoria McLane Gow
31 Friendship Lane
Colorado Springs, Colorado 80904
NPC
John A. Thomas, O.D.
3405 Wright Street
Wheatridge, Colorado 80033
Janet Washburn
1260 South Reed, #4
Lakewood, Colorado 80226
Bernard Tessler
370 South Franklin Street
Denver. Colorado 80209
EX OFFlClO MEMBERS:
George A. Goldstein, Ph.D
Executive Director
Colorado Department of
Social Services
1575 Sherman Street
Denver, Colorado 80203
B. ColoRx Drug Formulary Advisory Committee:
Richard A. Haynes, R.Ph.,
Chairman
130 Pearl Street, #I805
Denver, Colorado 80203
Lillian Bird, R.Ph.
2420 - 71st Street
Greeley, Colorado
Franklin L. Connell, R.Ph.
P.O. Box 189
Del Norte, Colorado 81 132
Gerri Sorrnani. R.Ph.
Musick Drug
309 East Fontanero SJreet
.Colorado Springs, Colorado
80907
Don Asher
2770 W. 5th Avenue
Denver, Colorado 80204
Jerry D. Harvey, H.Ph.
2201 San Juan Avenue
LaJunta, Colorado 81050
William A. Hoover
Englewood Pharmacy
3601 South Clarkson
Englewood, Colorado 801 10
Mary Ernestine Kotthoff-Burrell,
R.N.
11313 San Juan Range Road
Littleton, Colorado 80127
Tom Vernon
Executive Director
Colorado Department of
Colorado Department of
Social Services
Duane H. Lambert, R.Ph.
1700 Vine Street
Denver, Colorado 80206
Roger R. Pearce, P.Ph.,
Pharmacy Division
King Soopers
80631 P.O. Box 5567 (65 Tejon Street)
Denver, Colorado 80221
Robert W. Piepho, Ph.D., F.C.P.
Professor and Assciate Dean
Division of Clinical Programs
University of Colorado Medical
Center
4200 East Ninth Street-Box C-238
Denver, Colorado 80262
Miles Schuman, R.Ph.
Professional Pharmacy
1920 High Street
Denver, Colorado 80218
Thomas Perry, M.D.
5440 W. 25th Avenue
Edgewater, Colorado 80214
NPC Colorado-8
1985
4. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: C. Society of Osteopathic Medicine:
R.G. Jerry Bowman
Executive Vice-president
Colorado Medical Society
6825 E. Tennessee, Bldg. 2,
Suite 500
Denver, Colorado 80224
Phone: 303/321-8590
Ms. Kathleen Brennanor
Executive Director
Colorado Society of Osteopathic
Medicine
4701 E. 9th Avenue, Room 304
Denver. Colorado 80220
8. Pharmaceutical Association: D. State Board of Pharmacy
Arthur C. Hassen, Jr.
Executive Director
Colorado Pharmacal Association
171 1 Pennsylvania Street,
Suite 108
Denver, Colorado 80203
Phone: 3031861-0328
David L. Simmons, Administrator
1525 Sherman Street, Room 128
Denver, Colorado 80203
3031866-2526
NPC
CONNECTI CUT
MEDI CAL ASSI STANCE D R U G P R OGR A M ( TI TLE XXIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other*
O M A0 APT0 AFDC O M AB APTD AFDC Children 21 ( % ! I )
Prescribed
Drugs X X X X X X X X X X
Inpatient
Hosp~tal Care X X X X X X X X X X
Outpatlent
Hosp~tal 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
Phvzicim
,
Services X X X X X X X X X X
Dental
Swi ces X X X X X X X X X X
'SF0 - State Funds Only
I 1 EXPENDITURES FOR DRUGS. PaVment to Pharmacists by fiscal year endinp June 30. 1984
. . . . . . . . . . . . . . . . . . . . . TOTAL
. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Di sbl ed . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families wiDep Children
. . . . . . . . . . . . Adults-Families wiDep Children
. . . . . . . . CATEGORICALLY NEEDY NON-CASH TOTAL
AQed . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families wiOep Children . . . . . . . . . . . .
. . . . . . . . . . . . Aduits-Families wiDep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabied . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families wiDep Children
. . . . . . . . . . . . Adults-Families wiDep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
1984
Expended
-
Recipient
-
$24,948,974 157,029"
1983
Expended
-
Recipient
-
$21,265,077 153,729
YJnduplicated Total - HHS report HCFA - 2082
NPC
Ill. Administration:
Directed by the State Welfare Department through seven district offices and one town delegated this
special authority.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions (diseases, drug categories, etc.):
1. Will not pay for experimental drugs, anti-obesity drugs, drugs available free from the
Department of Health Services. DESl drugs.
2. Prior authorization required for: non-legend drugs not listed on Connecticut Drug List;
Amphetamines except when used for narcolepsy and hyperkenesis; vitamins except prena-
tal, 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 influenze or pneumovax vaccine, irrigating solutions, diabetic and
diagnostic testing material and I.V. solutions or sets.
B. Formulary: OTC Drugs Only
C. Prescribing or Dispensing Limitations:
1. Physicians are encouraged to prescribe drugs generically, when possible
2. Quant~ty of Medication: Maximum quantity: 30-day supply or 120 tablets or capsules or 1
Ib. 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 5 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.
Fees: Convalescent and nursing homes -cost plus $2.59
"Walk-In" patients - cost plus $3.11
The Department will pay an incentive professional dispensing fee of one dollar per prescription,
in addition to any other dispensing fee, for substituting a generically equivalent drug product.
Officials, Consultants and Committees
1. lncome Maintenance Officials:
Stephen B. Heintz
Commissioner
Thomas Kilcoyne
Deputy Commissioner
Department of Income Maintenance
110 Bartholomew Avenue
Hartford, Connecticut 06106
2031566-41 20
Mary Nakashian
Deputy Commissioner
Sally Bowles
Director
Medical Care Administration
Dennis Bothamley
Chief, Institutional Care
Medical Care Administration
Harry Kiernan, D.D.S,
Dental Consultant
Meyer Rosenkrantz, R.Ph
Pharmacist Consultant
2031566-8007
2. Income Maintenance Consultants (Part-time):
Waldo Maltin, M.D.
Arthur V. McDowell, Sr.. M.D
Francis Naples, D.D.S.
Edmund Ziegler, M.D.
H. Kallman, D.P.M.
0 . B. Hill, OD.
3. Title XIX Advisory Committees:
A. Pharmacy Advisory Committee:
State Pharmacy Commission
Dr. James O'Brien
Mike Williams
Connecticut State Medical
Society
Dr. Elliott R. Mayo
Connecticut Pharmaceutical
Assoc.
William Summa
Edward C. Liska
lncome Maintenance
Depaflment
Meyer Rosenkrantz
Pharmacist
4. Fiscal Agent
Electronic Data Systems Corp
Farmington, CT
5. Average Rx Prices FY 1984 $10.26
6. Executive.Officers of State Medical and Pharmaceutical Societies:
A. Medical Society:
T. B. Norbeck
Executive Director
Conn. State Medical Assoc.
160 St. Ronan Street
New Haven, CT 0651 1
Phone: 2031865-0587
C. Society of Osteopathic Medicine:
Norman S. Roome, D.O., Secretary
Connecticut Osteopathic Medical Society
Summit Farm
Joy Road RFD
Woodstock, CT 06774
B. Pharmaceutical Association: D. State Board of Pharmacy
Daniel C. Leone, P.D. Edward c. Liska, Executive Secretary
Executive Director State office Building
Connecticut Pharmaceutical Association Hartford, CT 06106
943 Silas Deane Highway 2031566-391 7
Wethersfield, CT 06109
Phone: 2031563.461 9
NPC
seicount3 1
DELAWARE
MEDI CAL ASSI STANCE D R U G P ROGRA M ( TI TLE XI X)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other"
OM AB APTD AFDC O M AB APTD AFOC Children 21 (SFG)
Prescribed
inpatient
Hosoital 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
Services X X X X
Dental
'SF0 - State Funds Only
II. MPENDiTURES FOR DRUGS. Payment to Pharmacists by fiscal year ending September 30. 1984
1984 1983 . .
Expended
-
Recipient
-
Expended
-
Recipient
-
TOTAL . . . . . . . . . . . . . . . . . . . . . $3,049,313 31,038" $2,706,325 31,940
CATEGORICALLY NEEDY CASH TOTAL . . ,
A . . . . . . . . . . . . . . .
0
Blind . . . . . . . . . . . . . . . . . . . . . . 22,389 70 13.312 73
Disabled . . . . . . . . . . . . . . . . . . . . . 92601 1 3,114 760,132 3,205
Children-Families wiDep Children . . . . . . . . . . . . 447,946 13,857 427,925 14,260
Adults-Families wiDep Children . . . . . . . . . . . . 601,542 8,736 574,656 8,990
CATEGORICALLY NEEDY NON-CASH TOTAL
Aaed . . . . . . . . . . . . . .
- ~ -
Blind . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0
Disabled . . . . . . . . . . . . . . . . . . . . . 30,068 110 25,732 113
Children-Families wi0ep Children . . . . . . . . . . . . 19,828 658 17,683 677
Adults-Families w/Dep Children . . . . . . . . . . . . 22,715 497 20,257 512
Other Title XIX Recipients . . . . . . . . . . . . . . . 63,068 1,823 57.348 1,876
MEDICALLY NEEDY TOTAL
Aaed . . . . . . .
.
Blind . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0
Disabled . . . . . . . . . . . . . . . . . . . . . 0 0 0 0
Children-Families wmep Children . . . . . . . . . . . . 0 0 0 0
Adults-Families wiOep Children . . . . . . . . . . . . 0 0 0 0
Other Title XIX Recipients . . . . . . . . . . . . . . . 0 0 0 0
TJnduplicated Total - HHS report HCFA - 2082
NPC
Ill. Administration:
By Division of Economic Services, Department of Health and Social Services, through 3 county offices
of the state agency.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions:
Only legend item drugs (except for insulin) can be prescribed. Vitamins (except pediatric
vitamins), antacids, etc. can not be prescribed unless they are legend items. OTC items cannot
be prescribed. Anorectics are excluded, (except for pediatric hyperactivity and certain sleep
disorders, when certified by the physician).
B. Formulary: None.
C. Prescribing or Dispensing Limitations:
1. Quantity: None. Department requests physician to prescribe reasonable amounts.
2. Refills: Prescription blank has space for physician to authorize renewals.
3. Dollar Limits: None.
D. Prescription Charge Formula:
Payment is based on the actual acquisition cost or maximum allowable cost (MAC) to the
pharmacy or MAC, plus a $3.40 dispensing fee, or the usual and customary cost to the general
public, whichever is lower.
E. Total number of Rx claims in fiscal year 1984-276,636
IV. Fiscal Intermediary
The Computer Company
#1 Pike Creek Center, Suite 402, Wing 2
Wilmington, DE 19808
Officials, Consultants and Committees
1. Health and Social Services Department Officials:
Thomas Eichler
Secretary
Charles Hayward
Director
Department of Health and
Social Services
Delaware State Hospital
New Castle, Delaware 19720
3021421 -61 39
Division of Economic Services
P. 0 . Box 906
New Castle 19720
Ruth Fischer
Administrator
Medical Assistance Services
Dr. James Salva
Medical Consultant
201 8 Naamans Road, Suite 1 B
Wilmington 19810
Pharmacist Consultant
%fsn
NPC
2. Medical Advisory Committee Members:
Mark Abrarns
Delaware Pharmaceutical Assn
2501 Northgate Road
Wilrnington, DE 19810
Anne Shane Bader
Delaware Medical Society
1925 Lovering Avenue
Wilrnington, DE 19806
Dale Bunting
Division of Mental Health
Director, Social Services
Delaware State Hospital
New Castle. DE 19720
Bonita DePree
Medicaid Recipient-N.C. County
1200 Lancaster Avenue
Wilrnington, DE 19805
Carol Guaz-Mandelberg
Delaware Health Council
1925 Lovering Avenue
Delaware State Hospital
Carol Katz
Sussex County Home Services
CHEER Program
64 Sussex Drive
Lewes, DE 19958
David Levitsky, M.D.
Delaware Medical Society
11 0 Christiana Medical Center
Newark, DE 19702
Brenda Sims
Delaware Review Organization
1601 Concord Pike
Suite 92-1 00
Whi ngton, DE
Martin Moss, O.D.
Consultant-Vision Care Program
702 North Union Street
Wilmington, DE 19805
Patricia Purceli, M.D.
Delaware Medical Society
1508 Pennsylvania Avenue
Wilmington, DE 19806
Paris Carpenter
Medicaid Recipient
Sussex County
RD 1, Box 209
Lincoln, DE 19960
Donald B. Cowan, DDS
Division of Public Health
Bureau of Specialized Health Services
Jesse Cooper Building
Dover, DE 19901
William Duffy
Association of Delaware Hospitals
Riverside Hospital
P. 0 . Box 845
Wiirnington, DE
Elizabeth Henry
Division of Aging
CT Building, Del. State Hospital
New Castle, DE 19720
David Howard, M.D.
Delaware Chapter American
Academy of Pediatricians
P. 0 . Box 107
Ocean View, DE 19970
Bob Trernain
Blue CrossIBlue Shield, Inc
1 Brandywine Gateway
Wilrnington. DE 19899
Allen Levine, O.D.
Delaware Optometric Society
41 9 North Market Street
Wilmington, DE 19803
Charles Moiloy
The Computer Company
#1 Pike Creek Center
Suite 402, Wing 2
Wilrnington, DE 19805
Mabel C. Nowland
Visiting Nurse Association
2713 Lancaster Avenue
Wilrnington, DE 19805
Olga Ramirez
Consumer-Public Task Force
1225 Mayfield Road -
Wiimington, DE 19803
103
NPC District of Col umbi a- !
1 9 8 5
DI STRI CT OF COL UMBI A
MEDI CAL ASSI STANCE D R U G PROGRAM ( TI TLE XI X)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
O M AB APT0 AFDC O M AB APT0 AFDC Children 21 (SFO)
Prescribed
o w 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
Sewices X X X X X X X X X
Dental
'SF0 - State Funds Only
11. EXPENDITURES FOR DRUGS. Pavment to Pharmacists bv fiscal vear endino Seotember 30. 1984
1984
Expended
-
Recipient
-
T O T A L . . . . . . . . . . . . . . . . . . . . . $8,113,136 65,009"
CATEGORiCALLY NEEDY CASH TOTAL . . . . . . . . . . 6,541,254 54,431
Aged . . . . . . . . . . . . . . . . . . . . . . 1,134.234 3,613
Blind . . . . . . . . . . . . . . . . . . . . . . 14,723 53
Disabled . . . . . . . . . . . . . . . . . . . . . 2,498,626 7,162
Children-Families wlDep Children . . . . . . . . . . . . 993,806 25,218
Adults-Families wIDep Children . . . . . . . . . . . . 1,896,168 18,375
CATEGORICALLY ~ E E DY NON-CASH TOTAL . . . . . . . . 892,448
A d . . . . . . . . . . . . . . . . . . . . . . 404,666
Blind . . . . . . . . . . . . . . . . . . . . . . . 0
Disabled . . . . . . . . . . . . . . . . . . . . . 288,388
Chiidren-Families w1Dep Children . . . . . . . . . . . . 32,878
Adults-Families wlDep Children . . . . . . . . . . . . 62.983
Other Title XIX Recipients . . . . . . . . . . . . . . . 103,531
. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL 683,127
A ~ e d . . . . . . . . . . . . . . . . . . . . . . 231,593
B i d . . . . . . . . . . . . . . . . . . . . . . 132
Disabled . . . . . . . . . . . . . . . . . . . . 206,747
. . . . . . . . . . . . Chiidren-Families w1Dep Children 81,405
. . . . . . . . . . . . Adults-Families wiDep Children 157,597
Other Title XIX Recipients . . . . . . . . . . . . . . . 5,650
1983
Expended
-
Recipient
-
$7,180,151 68,338
5,774,148 58,010
1,030,505 3,824
12,858 54
2,028,715 7,064
951,752 27,511
1,750,323 19.557
318,361 2,853
109,578 758
3 0
151,545 815
19,371 639
37,005 640
862 1
1,087,642 7,475
491,803 1,630
Vndupl i cat ed Tota - HHS report HCFA - 2082
District of Columbia-2
1985
Ill. Administration:
The D.C. Department of Human Services (DHS), Office of Health Care Financing.
iV. Provisions Relating to Prescribed Drugs'
A. General Exclusions: All legend drugs are covered except those drugs that are listed by FDA
as ineffective. Pursuant to a prescription the following non-legend items are covered: oral
analgesics, oral antacids, insulin, insulin needles and syringes, contraceptive foams and jellies,
ferrous sulfate, prenatal vitamin formulations, geriatric vitamin formulations for recipients 65 years
of age and over, and multivitamin formulations for children 7 years of age and under. All other
rron-legend items are excluded.
8. Formulary: None.
C. Prescribing or Dispensing Limitations:
1. Refills: In general, amounts dispensed are to be limited to quantities sufficient to treat an
episode of illness. Maintenance drugs such as thyroid, digitalis, etc. may be dispensed i n
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.
4. Formulary: No
D. Prescription Charge Formula:
The lesser of:
-Maximum allowable charge (MAC) or
-Estimated Acquisition Cost (EAC) plus $3.95 fee
-The provider's usual charge to the public.
E. Compounded Prescriptions:
-Lesser of EAC of all ingredients plus $4.70.
-The provider's usual charge to the public.
F. Co-payment:
$0.50 co-pay by recipient. Does not apply to recipients under 21 years of age, prescriptions
for family planning, nursing home patients, or pregnancy related.
V. Miscellaneous Remarks:
Fiscal Intermediary
The Computer Company (TCC)
401 New York Avenue, N.E.
Washington, D.C. 20002
Officials, Consultants and Committees
1. Department of Human Services Officials:
David E. Rivers
Director
Department of Human Services
801 North Capitol Street, N.E.
Washington, D.C. 20002
Andrew D. McBride. M.D., M.P.H. 1875 Connecticut Ave., N.W,
Commissioner of Public Health
Room 825
Washington, D. C. 20009
106
NPC District of Coiumbia-3
1985
Lee Partridge
Chief, Office of Health
Care Financing
1331 H Street, N.W., Room 500
Washington, D. C. 20005
James Harris, R.Ph.
Pharmacist Consultant
Office of Health Care Financing
2. Executive Officers of District Medical and Pharmaceutical Societies:
A. Medical Society: C. Osteopathic Association:
Francisco P. Ferraraccio
Executive Secretary
Medical Society of the
District of Columbia
2007 Eye Street, N.W.
Washington, D. C. 20006
Phone: 2021223-2230
Harry Handiesman, O.D.
Secretary
Osteopathic Assn. of D.C
2804 Ellicott, N.W.
Washington, D. C. 20008
Phone: 2021362-2250
0. Pharmaceutical Association: D. Board of Pharmacy
Roscoe Deveoux Carlyle McAdams
Acting Executive Director Secretary
D.C. Pharmaceutical Association 614 H Street. Room 923
6400 Georgia Ave., N.W., Suite 6 Washington, D. C. 20001
Washington, D. C. 20012 2021727-7468
Phone: 2021829-1 51 5
NPC
FLORI DA
MEDI CAL ASSI STANCE D R U G P ROGRA M ( TI TLE XI X)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other*
O M AB APT0 AFDC OAA AB APTD AFOC Children 21 (SFo)
Prescribed
Drugs X X X X
Inpatient
Hospital Care X X X X
~ospi t al Care X X X X
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X
Physician
Services X X X X
Dental
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
T OT AL . . . . . . . . . . . . . . . . . . . . .
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . , . . . ,
Adults-Families w/Dep Children . . . . . . . . . . . .
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
B h d . . . . . . . . . . . . . . . . , . . , . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Oep 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 . . . . . . . , . . , , , . .
1984
Expended Recipient
- -
Expended
-
$76,184,224 429,016" $60,679,046
Not available
Not available
1983
Recipient
-
""Undupiicated Total - HHS repoii HCFA - 2082
NPC
Ill. Administration:
By the Department of Health and Rehabilitative Services. Claims processing and payment by
contract with fiscal agent.
IV. Provisions Relating to Prescribed Drugs:
A. Limitations and Exclusions
1. Vitamins and phosphate binders only for dialysis patients.
2. Protheses; appliances; devices; and personal care items;
3. Non-legend drugs (except for prescribed insulin and buffered and enteric coated aspirin
when prescribed as an anti-inflammatory agent only).
4. Anorexiants unless the drug is prescribed for an indication other than obesity (i.e. narcolepsy,
hyperkinesis);
5. Topical acne preparations and selenium sulfide preparations;
6. Oral vitamins with exception of fluorinated pediatric vitamins prescribed for pediatric patients;
7. Digestants, except when prescribed for hepatic or pancreatic diseases;
8. Laxatives and Lactulose preparations, except when prescribed as a chelating agent;
9. Oral contraceptives unless prescribed for indications other than birth control;
10. Nursing home floor stock drugs.
8. Formulary: None.
C. Prescribing or Dispensing Limitations:
1. Prescribed drugs covered up to $22 per recipient per month ($150 i f the recipient is in a
nursing home), limited to legend drugs within program limits plus insulin. Greater expendi-
tures require prior authorization by the program.
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 suppres-
sant items are not covered, nor are drugs that are prescribed for other than their approved
indications.
D. Prescription Charge Formula:
Fee-effective July 1, 1980
Lower of: (1) MAC plus $3.33
(2) EAC plus $3.33
(3) Usual and Customary
V. Miscellaneous Remarks:
A. Some High Volume EACs set at large package size
B. Provisions for medically necessary considerations
C. Maximum Allowable Ingredient Cost (MAIC)
1. Federal MAC drug list
NPC
D. Claims Processol
EDS Federal Corporation
Pharmacy Services
P.O. Box 9030
Tallahassee. Florida 32314
Officials, Consultants and Committees
1. Department of Health and Rehabilitative Services Officials:
David Pingree
Secretary
Richard T. Lutz
Deputy Assistant Secretary
for Medicaid
9041488-3560
Rod Presnell, R.Ph.
Pharmacist Consultant
Medicaid Office of Program
Development
Jerry Wells R.Ph.
Pharmacist Consultant
Medicaid Office of Program
Development
9041488-9990
2. Consultants to Medical Services Program: (Part- time)
Donald 0. Alford, M.D.
Gene L. Davidson, M.D.
Larry C. Deeb, M.D.
Irving J. Fleet. D.D.S.
Charles F. James, M.D.
Fred Lindsey, M.D.
Richard Lamb. D.D.S.
Ms. Janet Shelfer
Armanda M. Sittig, M.D.
J. Orson Smith, M.D.
James A. Stephens, O.D.
Sam Tatum, D.D.S.
3. Medicaid Advisory Council:
Mrs. Maggie Bennett
720 West Myrtle Street
Lakeland 33801
*Consumer
Ms. Patricia Bryant
Post Office box 2104
Miami 33143
*Consumer
Department of Health and
Rehabilitative Services
1323 Winewood Boulevard
Tallahassee, Florida 32301
131 7 Winewood Boulevard
Building 6, Room 233
Tallahassee 32301
131 7 Winewood Boulevard
Building 6, Room 237
Tallahassee 32301
1317 Winewood Boulevard
Building 6, Room 237
Tallahassee 32301
Medicaid Office
131 7 Winewood Boulevard
Tallahassee 32301
George Browning, R.Ph.
1281 South Hickory Street
Melbourne 32901
*Florida Pharmacy Association
Mrs. Susie Mae Bums
4205 Maxwell Boulevard South
Tallahassee 32301
'Consumer
NPC
Commissioner Pat Glass
Manatee County
Post Office Box 1000
Bradenton 33506
*State Association of County
Commissioners of Florida, Inc.
Mr. Arthur Harris
Florida Manor
830 West Michigan
Orlando 32804
'Florida Health Care Association
Mrs. Gaylia Howard
Route 1, Box 31
O'Brien 32071
'Consumer
Chris C. Scures, D.D.S.
2122 East Robinson Street
Orlando 32803
'Florida Dental Association
Mr. Leon Zucker
Vice President
Finance, Public Health Trust
Jackson Memorial Hospital
161 1 Northwest 12 Avenue
Miami 33136
*Florida Hospital Association
4. Florida MAC Advisory Committee:
George Browning, R.Ph.
Retail Pharmacy for Nursing
Homes 3730 Thornwood Drive
1281 Hickory Street
Melbourne 32901
Lew Becks
Nursing Home Pharmacy
5607 Hammock Lane
Lauderhill 33319
Virginia Haggerty, R.N.
Commission Post Office Box 6985
Orlando 32803
'Florida Nurses Association
Mr. William Hobson
610 South "K" Street
Lake Worth 33460
'Consumer
Donald G. Nikolaus. M.D.
Mease Hospital and Clinic
Dunedin 33528
'Florida Medical Association
Mr. Fatah Wallizada
3656 St. Johns Avenue
Jacksonville 32205
'Consumer
Mr. Richard T. Lutz
Deputy Assistant Secretary
for Medicaid
131 7 Winewood Boulevard
Building 6. Room 233
Tallahassee 32301
'Department of Health and
Rehabilitation Services'
Dick Kaplan
Pharmacy Manager
Tampa 33618
Jim Powers, R.Ph. .
Secretary, Florida
Pharmacy Association
61 0 North Adams
Tallahassee 32301
NPC
Lawrence DuBow
Wholesaler
Lawrence Pharmaceuticals
Post Office Box 5386
Jacksonville 32207
Michael Zagorac, R.Ph.
Pharmacy Manager
C/O Jack Eckard Corporation
Post Office Box 4689
Clearwater 33518
DHRS Medicaid Representatives:
Dick Grant, R.Ph.
Department of HRS (PDHERx)
131 7 Winewood Boulevard
Tallahassee 32301
Mark Sullivan, R.Ph.
Pharmacist
1330 Miccosukee Road
Tallahassee 32303
Jerry Wells, R.Ph.
Department of HRS (PDDE)
1309 Winewood Boulevard
Tallahassee 32301
5. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: B. Pharmaceutical Association:
W. Harold Parham
Executive Vice-president
Florida Medical Association. Inc
Post Office Box 241 1
Jacksonville 32203
Phone: 9041356-1571
James B. Powers
Executive Director
Florida Pharmacy Association
610 North Adams Street
Tallahassee 32301
Phone: 9041222-2400
C. Osteopathic Medical Association: D. State Board of Pharmacy
Mervin E. Meck, D.O.
C. Rod Presnell
Secretary-Treasurer, Executive Director Executive D~rector
Florida Osteopathic Medical Association
130 North Monroe Street
161 N. Causeway. Suite 1
Tallahassee, Florida 32301
New Smyrna Beach 32070 9041488-7546
Phone: 904/427-3489
NPC
GEORGI A
MEDI CAL ASSI STANCE D R U G PROGRAM ( TI TLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
O M AB APT0 AFDC O M AB APTD AFOC Children 21 ( S W
Prescribed
Drum X X X X
lnoatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X
Laboratory &
X-rav Service X X X X
Skilled Nursing
Home Se~i ces X X X X
Phvsician
Dental
Sewices X X X X
'SF0 - State Funds Only
Ii. EXPENDITURES FOR DRUGS. hvrnent to Pharmacists bv fiscal vear ending June 30. 1984
. . . . . . . . . . . . . . . . . . . . . TOTAL
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
. . . . . . . . . . . . Adults-Families wl h o Children
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
A~ e d . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families w/Oep Chiidren
. . . . . . . . . . . . Aduits-Families w/Oep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
. . . . . . . . . . . . . . MEDICALLY NEEOY TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Chiidren-Families w/Oep Chiidren
. . . . . . . . . . . . Adults-Families w/ hp Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
1984
Expended Recipient
- -
$66,365,609 386.758"'
Not avaliable
Not available
1983
Expended
-
Recipient
-
"Undupiicated Total - HHS report HCFA - 2082
NPC
Ill. Administration:
By the Department of Medical Assistance.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Drugs not on the drug list
B. Formulary: The Controlled Medical Assistance Drug List. For information contact:
Mrs. Earline D. Jordan
2 M.L. King, Jr. Drive S.E.
Floyd Building - West Tower
P.O. Box 38440
Atlanta, GA 30334
4041656-4044
C. Prescribing or Dispensing Limitations:
I
I
1. Quantity of Medication: Physicians are encouraged to prescribe a 30 day supply. Six
I
prescriptions per month per recipient except by prior authorization.
3. Refills: According to state and federal law.
4. Dollar Limits: None.
I
D. Prescription Charge Formula: Lower of, average wholesale price (AWP) plus fee of $3.61, or
MAC plus fee, or usual and customary.
, .
V. Miscellaneous Remarks:
Average Rx price during FY 1984 $1 1.86
State MAC List = Federal MAC Plus 19 Additional Drugs
Officials, Consultants and Committees
1. Department of Medical Assistance Officials:
Aaron Johnson
Commissioner
Russ Toal
Deputy Commissioner
Jacqueline Foster, Director
Program Mangement
(Mrs.) Earline P. Jordan, R.Ph
InstitutionalIAncillary Services
(Mrs.) Frances Lipscomb. R.Ph
Program Mangernent Officer
Pharmacy Service
4041656-4037
Department of Medical
Assistance
James Floyd Memorial Bldg
(Twin Towers)
P.O. Box 38440
Atlanta. Georgia 30334
4041656479
w 4
2. Title XIX (Medicaid) Medical Assistance Advisory Committees:
Representatives from each of the following groups:
Medical Association of Georgia
Georgia Pharmaceutical Assn.
Atlanta Medical Association
Georgia Health Care Assn.
Georgia Hospital Associat~on
Georgia Dental Assn.
Georgia Osteopathic Medical Assn.
3. Executive Off~cers of State Medical and Pharmaceutical Societies:
A. Medical Association: C. Osteopathic Medical Assn.:
J.M. Moffatt
Executive Director
Medical Association of Georgia
938 Peachtree Street. N. E.
Atlanta 30309
Phone: 4041876-7535
Ms. Cathy M. Garris
Executive Director
GA Osteopathic Medical Assn.
2157 ldlewood Road
Tucker 30084
B. Pharmaceutical Association: D. State Board of Pharmacy
Larry L. Braden
William C. Miller, Jr.
Executive Director Secretary
Georgia Pharmaceutical Association
166 Pryor Street, S. W.
2520 Carroll Avenue
Atlanta. GA 30303
Atlanta 30341 404656-391 2
Phone: 4041451-1336
NPC
GU A M
MEDI CAL ASSI STANCE DRUG PROGRAM ( TI TLE XI X)
I BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categoc~cally Needy Med~cally Needy (MN) Other'
O M AB APT0 AFOC O M AB APT0 AFDC Ch~ldren 21 (SF@
Prescribed
Drugs X X X X X X X X
Inpallen1
Hospltal Care X X X X X X X X
Outpatlent
Hospltal Care X X X X X X X X
Laboratow &
X-ray Se&e X X X X X X X X
Skilled Nurs~ng
Home Sewlces X X X X X X X X
Physician
Services X X X X X X X X
Dental
Services X X X X X X X X
'SF0 - State Funds Only
Other Benefit: Transportation; prostheses
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year.
1984 1983
Expended
-
Recipient
-
Expended
-
Recipient
-
TOTAL . . . . . . . . . . . . . . . . . . . . .
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families w/Dep Children
. . . . . . . . . . . . Adulk-Families w/Dep Children
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families w1Dep Children
. . . . . . . . . . . . Adults-Families wiDep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . Blind
Disabled . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families w/Dep Children
Adults-Families w10ep Children . . . .
Other Title XIX Recipients . . . . . . .
NO Data
Available
Wnduplicated Total - HHS report HCFA - 2082
NPC
ill. Administration:
By the Department of Public Health and Social Services.
IV. Provisions Relating to Prescribed Drugs:
Prescribed drugs are provided to needy persons eligible for services under Title XIX. Providers
include the Guam Memorial Hospital pharmacy as well as other privately operated pharmacies.
Dispensing fee-AWP plus $2.75
V. Officials, Consultants and Committees
A. Public Health and Social Services Department Officials:
Dennis G. Rodriguez
Director
Department of Public Health
and Social Services
Government of Guam
Post Office Box 281 6
Agana. Guam 9691 0
8. Executive Officer of Pharmaceutical Association:
Orencia L. Concepcion
Guam Pharmaceutical Association
626 Western Boulevard
Jonestown
Tamuning, Guam 96911
C. Guam Medical Society:
Pieter Huitema. M.D.
President
P. 0. Box 8718
Tamuning, Guam 9691 1
NPC
HAWAI I
MEDI CAL ASSI STANCE DRUG PROGRAM ( TI TLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
O M AB APTD AFDC O M AB APTD AFDC Children 21 (SFO)
Prescribed
Drugs X X X X X X X X X
X
Inpatient
Hospital Care X X X X X X X X X
X
Outpatient
Hospital Care X X X X X X X X X X
Laboratory &
X-ray Service X X X X X X ' X X X
X
Skilled Nursing
Home Services X X X X X X X X X
X
Physician
Services X X X X
X X X X X X
Dental
Services
X X X X X X X X X X
'SF0 - State Funds Only
II.
EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30,1984
1984 1983
Expended
-
Recipient
-
Expended
-
Recipient
-
TOTAL . . . . . . . . . . . . . . . . . . . . . $6,428,885 71,049" $6,324,334
75,458
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $5,352,071 60,635 5,015,691 65.259
Aged . . . . . . . . . . . . . . . . . . . . . . 832,520 4.093 749.985 3.974
Blind . . . . . . . . . . . . . . . . . . . . . . 54.318 91 12,305 75
Disabled . . . . . . . . . . . . . . . . . . . . . 1.130.762 3.874 998.053
3.692
Children-Families w/Dep Children . . . . . . . . . . . . 1,540,056 33.438 1,547,805 34.616
Adults-Families w/Dep Children . . . . . . . . . . . . 1.794.415 19.139 1,707,543 22,902
CATEGORICALLY NEEDY NON-CASH TOTAL . . .
A ~ e d . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . 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 wDep Children
Other Title XIX Recipients . . . . . . . . . . . . . .
"Unduplicated Total - HHS report HCFA - 2082
NPC Hawaii-2
1985
Ill. Administration:
By the State Department of Social Services and Housing through its Public Welfare Division and four
county branch offices.
IV. Provisions Relating to Prescribed Drugs
A. Exclusions: Investigational new drugs, and drugs classified as ineffective or possibly effective
by the FDA.
B. Formulary: Hawaii State Medicaid Drug Formulary
C. Co-payment: No
D. Prescription Charge Formula: Estimated Acquisitions Cost (EAC) plus dispensing fee $3.22 (eff.
July 1, 1985).
E. Program pays for no more than the larger of: 30 days supply or 100 doses.
V. Fiscal Intermediary
Hawaii Medical Service Association
Medicaid Program Section
P.O. Box 860
Honolulu, Hawaii 96808
Officials, Consultants and Committees
1. Social Services and Housing Department Officials:
Franklin Y. K. Sunn Department of Social Services
Director and Housing
P. 0. Box 339
Honolulu, Hawaii 96816
Richard K. Paglinawan
Deputy Director
Earl S. Motooka
Medical Care Administrator
Omel L. Turk, R.Ph. Public Welfare Division
Pharmaceutical Consultant (part-time) (same address as above)
8081548-891 7
2. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
Jonathan Won
Executive Director
Hawaii Medical Association
320 Ward Avenue
Honolulu 9681 4
Phone: 8081536-7702
C. Hawaii Assn. of Osteopathic Physicians
and Surgeons:
Ronald Kienitz, D.O.
Secretarynreasurer
P. 0. Box M
Kameohe, HI 96744
B. Pharmaceutical Assn.: D. State Board of Pharmacy:
Dominic A. Solimando, Jr.
President
Hawaii Pharmaceutical Assn.
P. 0 . Box 1198
Honolulu 96807
Phone: 8081433-5394
Noe Noe Tom, Executive Secretary
P. 0. Box 3469
Honolulu, HI 96801
80818590
NPC
I DAHO
MEDI CAL ASSI STANCE DRUG PROGRAM ( TI TLE XIX)
I. BENEFITS PROVIDED AN0 GROUPS ELIGIBLE
Type ol Benelit Categorically Needy Medically Needy (MN) Other.
OAA AB APT0 AFDC OAA AB APTD AFDC Children 21 (SFo)
Prescribed
Drugs X X X X
Inpatient
Hospital Care X X X X
Out~alienl
Hospital Care X X X X
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Sefflces X X X X
Phvsician
. . ., ..--
Services X X X X
Dental
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Pdyment to Pharmacisls by f i ml year ending June 30, 1984
1984 1983
Expended
-
Recipient
-
Expended
-
Recipient
-
T O T A L . . . . . . . . . . . . . . . . . . . . . $2,453,822 27,249" $2,462,560 27,954
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $1.149.983 19.198
Aged . . . . . . . . . . . . . . . . . . . . . . 186,733 930
Blind . . . . . . . . . . . . . . . . . . . . . . 1.339 16
Disabled . . . . . . . . . . . . . . . . . . . . . 283.633 1.526
Children-Families w/Dep Children . . . . . . . . . . . . 299.241 10.634
Adults-Families w/p?p Children . . . . . . . . . . . . 378.484 6,092
CATEGORICALLY NEEDY NON-CASH TOTAL, . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . Blind
. . . . . . . . . . . . . . . . . . . . . Disabled
. . . . . . . . . . . Children Families w10ep Children
. . . . . . . . . . . . Adults Families w/Oep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
MEDICALLY NEEDY TOTAL . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . .
Aged
. . . . . . . . . . . . . . . . . . . . . . Blind
. . . . . . . . . . . . . . . . . . . . . Disabled
. . . . . . . . . . . . Children-Families w/Oep Children
. . . . . . . . . . . . Adults-Families w/ Bp Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
"Unduplicated Total - HHS report HCFA - 2082
NPC
Ill. Administration:
By the State Department of Health and Welfare through seven regional offices, each serving five or
more of the state's 44 counties.
IV. Provisions Relating to Prescribed Drugs:
A. Exclusions: Amphetamine and related medication, plus certain therapeutic vitamins.
B. Drug formulary: None
C. Prescribing or dispensing limitations: Prescription drugs are limited to 530.00 per month per
recipient. (34 day supply with limited exceptions)
D. Prescription charge formula:
Lower of MAC or EAC plus a variable dispensing fee $2.50-3.50, (unit dose $4.15) accord-
ing to location, size and Rx volume of the provider, or the provider's usual and customary
price to the general public.
V. Miscellaneous Information
Copayment: none
Average prescription price during FY 1983: 59.50
Fiscal intermediary
EDS Federal Corporation
P.O. Box 1168
Boise, ldaho 83701
Otflclals, Consultants and Committees
1. Health and Welfare Department:
Rose Bowman
Director
Depattment of Health and Welfare
Statehouse
Boise, ldaho 83720
20813344334,
William J. Whiteman, D.Ph.
Bureau of Medical Assistance
Dianne 8. Onnen, R.Ph., M.P.A.
Supervisor
Medicaid Policy Section
20813344323
2. Medical Care Advisory Committee:
Richard D. Adams, Director
Health District Ill
P. 0. Box 489
Caldwell, ID 83605
459-0744
J. Stephen Anderson
Regional Services Manager. Region V
Department of Health and Welfare
P. 0 . Box 1509
Twin Falls, ID 83301
734-4000
Committee: Ruby Crosby, R.N.
St. Benedict's Hospital
Jerome, ID 83338
324-4301
Arlene Davidson
ldaho Office on Aging
Statehouse
Boise, ID 83720
334-3220
NPC
Howard Barton
ldaho Commission for the Blind
Statehouse
Boise, ID 83720
334-3220
Laura Barton, R.N.
Home Health Services
Central District Health Department
1455 North Orchard
Boise, ID 83706
375-521 1
The Honorable Pamela I. Bengson
Idaho House of Representatives
2704 Raindrop Drive
Boise. ID 83706
345-61 68
Brent Brocksome
Chartham Management
2465 Overland Road.
Boise, ID 83705
343-701 3
Robert Campbell
St. Benedict's Hospital
Jerome, ID 83338
324-4301
Raiph W. Carpenter, Administrator
Division of Health
Department of Health and Welfare
Statehouse
Boise. ID 83720
334-4283
Susan Sutich
P. 0. Box 601
Boise, ID 83701
336-6837
John Watts, Executive Director
ldaho State Council on Developmental
Disabilities
Statehouse
Boise, ID 83720
334-4408
Dr. Rodney Heater
827 Center Avenue
Payette, ID 83664
642-4434
J. Charles Holden
ldaho Association of Counties
P. 0. Box 1623
Boise. ID 83701
345-91 26
Dr. John S. Kriz
ldaho State Dental Association
8424 Fairview Avenue
Boise. ID 83704
376-7740
Randy Robinson, Esq.
ldaho Legal Aid Services. Inc
Suite A P. 0 . Box 973
Lewiston, ID 83501
743-1 556
Dale Shirk, Exec. Vice President
ldaho Health Care Association
P. 0 . Box 2623
Boise, ID 83701
343-9735
Don Sower. Executive Director
ldaho Medical Association
407 West Bannock
Boise, ID 83702
344-7888
Marilyn Loenins Sword
ldaho Mental Health Association
1617 Holden
Boise, ID 83706
344-8585
Rosemary Wells
ldaho State Pharmaceutical Assoc.
1365 North Orchard, Room 103
Boise, ID 83706
NPC Idaho-4
1985
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: 6. Pharmaceutical Association:
Donald W. Sower
Executive Director
ldaho Medical Association
407 W. Bannock
P. 0. Box 2668
Boise 83701
Phone: 2081344-7888
C. Osteopathic Medical Assn.:
Harry E. Kale, D.O.
Secretary-Treasurer
ldaho Osteopathic Medical Assn.
522 West Main Street
Grangeville 83530
2081988-1 133
Rosemary Wells
Executive Director
ldaho State Pharmaceutical
Association
1365 North Orchard Street, Room 103
Boise 83706
Phone: 2081376-2273
D. State Board of Pharmacy:
- %??&- x %k e Director
700 West State Street
Boise, ID 83720
2081334-2356
NPC
ILLINOIS
MEDI CAL ASSI STANCE D R U G PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
O M AB APT0 AFOC O M AB APT0 AFOC Children 21 (SFo)
Prescrtbed
nn~"< 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
~aboratory &
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
Denlal
Services X X X X X X X X X X
'SF0 - Stale Funds Only
11. MPENOITURES FOR DRUGS. kiyment to Pharmacists by fiscal year ending September 30. 1984
TOTAL
Expended
-
. . . . . . . . . . . $98,044,838
. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families wlDep Children
. . . . . . . . . . . . Adulls-Families wIOep Children
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families wlDep Children
. . . . . . . . . . . . Adults-Families wIOep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
. . . . . . . . . . . . . . MEDICALLY NEEOY TOTAL
Aged . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Ch~ldren-Famiiiw w/Dep Children
. . . . . . . . . . . . Adults-Families wlDepChildren
. . . . . . . . . . . . . . . Other Title XIX Recipients
1984
Recipient
-
"Unduolicated Total - HHS reDolt HCFA - 2082
Ill. Administration:
Illinois Department of Public Aid
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Biologicals and drugs available from State Department of Health or other
agencies, anorectics, desi-ineffectives, cough syrups, general multivitamins, topical acne preps.
B. Formulary: Pharmacies are encouraged to stock and dispense non-proprietary drugs of recog-
nized 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 prac-
titioner to obtain his permission to dispense the generic product which does not exceed the
maximum allowable price.
For formulary information contact:
Ms. Dawn Gottrich
P.O. Box 4037
Springfield, Illinois 62708
(21 7)782-0506
C. Prescribing or Dispensing Limitations:
1. "The pharmacy shall dispense non-proprietary products of quality. Maximum reimbursement
to the pharmacy will be based on the price of a non-proprietary item of recognized quality."
2. Quantity: One prescription per patient per drug per month
3. Refills: A prescription may be refilled only if the prescribing practitioner 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.
4. Dollar Limits: None.
D. Prescription Charge Formula: Lowest of 1) usual and customary, 2) Actual Acquisition Cost (AAC)
plus fee, or 3) Department's MAC plus fee. Professional fee was increased to 3.46 on 9/1/85.
V. Miscellaneous Information:
State MAC: Yes
Approximately 5M) drugs
Copayment-none
Average prescription price during FY 1984-$8.29
Fiscal Intermediary-none'
Offlclals, Consultants and Commlttees
1. Public Aid Department Officials:
Gregory L. Coler
Director
Thomas J. Walsh
Administrator
Medical Assistance Program
Louis J. Bosco
Chief
Off ice of Personnel Management
and Labor
Department of Public Aid
316 South 2nd Street
Springfield 62762
628 East Adams
Springfield 62763
316 South 2nd Street
Springfield 62762
NPC
John Muller
Deputy Administrator
Medical Assistance Program
628 East Adam
Springfield 62763
Norman L. Ryan
21 6 East Monroe
General Services Administrator Springfield 62762
Mary Ann Langston
Administrator
Policy and Planning
Curt Fleming. Chief
Bureau of Research & Analysis
Beverly Knous. Chief
Bureau of Information Systems
Dawn Gottrich, Supervisor
Drug Program
Ron Gottrich
Pharmacist Consultant
21 71702-5385
316 South 2nd Street
Springfield 62762
21 6 East Monroe
Springfield 62705
100 South Grand Avenue East
Springfield 62705
628 East Adams
Springfield 62763
628 East Adams
Springfield 62763
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 speciality fields.
Frederick B. White
Chairman
723 North 2nd Street
Chillicothe, Illinois 61 523
B. Committee on Drugs and Therapeutics:
A Committee on Drugs and Therapeutics, a standing committee appointed by the lllinois State
Medical Society, serves in an advisory capacity to the Department of Public Aid on drug policy
and the Drug Manual.
Vincent A. Costano. Jr.. M.D
Chairman
Amin N. Daghestani. M.D.
Dorothy Hubler. M.D.
Martin J. Kaplan, M.D
7531 South Stony Island
Chicago, Illinois 60649
64 Old Orchard, Suite 205
Skokie 60077
Casey Medical Center
Casey, Illinois 62420
11 60 Park Avenue West
Highland Park 60035
Robert Reeder, M.D
970 N. 5th Avenue
St. Charles 601 74
NPC
Arthur Marks. M.D.
Allan L. Lorincz, M.D.
Consultants:
A. Samuel Enloe, R.Ph
Joan E. Cummings, M.D
Harold L. Jensen, M.D.
Arthur R. Peterson, M.D
Dawn Gottrich
101 E. Center
Fairfield 62837
5841 S. Maryland, Box 409
Chicago, 11 60637
251 W. First Drive
Decatur 62521
Hines V.A. Hospital
Hines, 11 60141
3235 Vollmer Road
Flossmoor 60422
2740 West Foster
Chicago, 11 60625
628 East Adams
Springfield, 11 62763
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.
George Karpman, R.Ph.
901 N. First
Springfield 62702
Bernie Evers, R.Ph.
Evers Pharmacy
417 West Main
Collinsville 62234
Don Gronewold, R.Ph.
Don's Pharmacy
100 South Main Street
Washington 61571
Rose Mancuso, R.Ph.
1610 Arden Place
Joliet 60435
Ron Stevens, R.Ph.
Union Prescription Center
646 Summit
Caseyville 62232
Robert Mandelbaum, R.Ph
Manager 3rd Party
Walgreed Company
200 Wilmot Road
Deerfield 60015
Sam Enloe, R.Ph., Chairman
Enloe's Southtowne Pharmacy
251 West First Drive
Decatur 62521
Tom Gulick, R.Ph.
Gulick Pharmacy. Inc.
912 North Vermilion
Danville 61 832
Sherwood Thomas. R.Ph.
Touhy Pharmacy
71 73 North Clark Street
Chicago 60626
Jeffrey Veal, R.Ph.
340 East 67th Place
Chicago 6061 9
Harry Staub, R.Ph.
Cabrini Pharmacy
949 N. Larrabee
Chicago 60610
Kenneth L. Gimmy, R.Ph.
Rx Gimmy's Drug Store, Inc.
97 South 9th, Rosewood Heights
East Alton, 11 62232
NPC
Jerry Handler. R.Ph. Bill Ghodes, R.Ph.
481 1 West Madison 7 Buttonwood Court
Chicago, 11 60644 lndianhead Park, 11 60525
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society B. Pharmaceutical Association:
Alexander R. Lerner Alan L. Granat
Executive Administrator Executive Director
Illinois State Medical Society Illinois Pharmaceutical
20 N. Michigan Ave. Suite 7002 Association
Chicago, 11 60602 222 W. Adams Street. Suite 546
Phone: 312i782-1654 Chicago 60606
Phone: 31 21236-1 135
C. Osteopathic Medical Association: D. State Board of Pharmacy
Mr. George C. Andrews Gary L. Clayton, Director
Executive Director
Department of Reg. and Ed.,
Illinois Association of Osteopathic Pharmacy Section
Physicians and Surgeons. Inc. 320 West Washington Street
900 East Center Street
Springfield. IL 62786
Onawa 61350 21 71785-0800
81 5/43-5576
4. State Board of Pharmacy
Gary L. Clayton, Director
Department of Reg. and Ed., Pharmacy Section
320 West Washington Street
Springfield, 11 62786
21 7/785-0800
I NDI ANA
MEDI CAL ASSI STANCE D R U G PROGRAM ( TI TLE XI X)
I. BENEFITS PROVIOEO AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other*
OAA AB APTD AFDC O M AB APTD AFDC Children 21 (SFO)
Prescribed
Drugs X X X X
Inpatient
Hospital Care X X X X
outpatient
Hnsnihl Care X X X X
Laboratory &
X-rav Service
Skilled Nursing
Home Services X X X X
Physician
Sewices X X X X
npntal
Services X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Payment to Phar ~ci St S by fiscal year ending June 30, 1984
TOTAL
1984 1983
Expended Recipient Expended Recipient
- - - -
$44,034,165 206,532" $39,459,209 203.447
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $18,990.471 156,613 $18,071,549 160.720
Aged . . . . . . . . . . . . . . . . . . . . . . 3,466,598 7.222 3,283,885 7,677
Blind . . . . . . . . . . . . . . . . . . . . . . 225,995 583 208,232 597
Disabled . . . . . . . . . . . . . . . . . . . . 6,403,677 12,039 5,671,751 11.993
Children-Families w/Dep Children . . . . . . . . . . . . 2,889.439 82.323 2,767,085 84,057
Adults-Families w/Dep Children . . . . . . . . . . . . 6,004.761 54,446 6,140,598 56.833
CATEGORICALLY mEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . Blind
. . . . . . . . . . . . . . . . . . . . . Disabled
. . . . . . . . . . . . Children-Families w/Oep Children
. . . . . . . . . . . . Adults-Families w/Dep Children
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Bi nd . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . .
Children-Families wIOeo Children ~ ~~
. . . . . . . . . . . . Adults-Families wIDep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
'"Unduplicated Total - HHS report HCFA - 2082
NPC
Ill. Administration:
The lndiana State Department of Public Welfare.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: (Most OTC drugs are covered) No legend or non-legend anorexics or anti-
smoking aids.
6. Formulary: None
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: None.
2. Refills: Allowed as authorized by physician.
3. Dollar Limits: None.
4. One dispensing fee paid per legend drug order per recipient per month in nursing home
setting.
D. Prescription Charge Formula:
1. The lowest of the:
a. MAC plus the dispensing fee of $3.00.
b. EAC (Estimated Acquisition Cost) plus the dispensing fee of $3.00. (EAC is 3% less than
AWP reported by Drug Topics Red Book)
c. Pharmacy's usual and customary charge to the general public.
V. Miscellanous Information:
Fiscal Intermediary:
EDS Federal Corp
120 W. Market Street
Indianapolis, lndiana 46204
Officials, Consultants and Committees
1. Welfare Department Officials:
Donald L. Elinzinger
Administrator
James H. Cook
Assistant Administrator-
Administration
Mrs. Tara Lenn French
Assistant Administrator-
Medicaid
Department of Public Welfare
100 N. Senate Avenue
Room 701
Indianapolis, lndiana 46204
William Harding
Director
Division of Administrative
Services
NPC
Mrs. Mary Kapur
Assistant Administrator
Local Operations Division
Marc Shirley, P.D.
Pharmacy Consultant
31 71232-431 2
2. Advisory Committee for Medical Assistance (Medicaid)
Mary Ludwig, M.D.
674 Sugar Tree Road
Crawfordsville, IA 47933
Lawrence E. Allen, M.D.
2009 Brown Street
Anderson, IA 4601 4
Mr. Sandy Quarles
P. 0 . Bc..506
Kokorno, IA 46901
Mr. George S. Row. Ill
121 West Ripley Street
Osgood, lA 47037
Robert C. Shirey, D.D.S
7216 Madison Avenue
Indianapolis, IA 46227
31 71786-7643
Mr. Robert Spaulding
Department of Mental Health
5 lndiana Square
Indianapolis, IA 46204
Albert 6. Stroud, O.D.
6326 Rucker Road Suite C
Indianapolis. IA 46220
Mr. Newell J. Hall, V.P.
Director. Professional Services
Hook Drug, Inc.
2800 Enterprise Street
Indianapolis. IA 46226
3171353-1451
Mr. John Huber. Adm.
Sycamore Village Health
2905 West Sycamore Road
Kokorno, IA 46901
Mr. Edward W. James
3150 West 19th Place
Gary, IA 46402
21 91949-7858
Citizenry of lndiana
Medical Association
Statewide Taxpayer
Agricultural lnterests
State Dental Association
Ex-Officio Represents
Mental Health Commissioner
Ootometric Association
Pharmaceutical lnterests
lndiana Health Care Assoc
Labor lnterests
NPC
Mr. George H. James, Adm.
Jackson County Hospital
200 South Walnut Street
Seymour. IA 47274
8121522-01 12
Mrs. Belle Kasting
1724 Parkview Drive
Bedfore. IA 47421
Albert F. Kull, D.O.
203 South Ironwood Drive
P. 0 . Box 6172
South Bend, IA 4661 5
21 91282-2481
Mrs. Frances Safford
Director. Division of Health Facilities
State Board of Health
1330 West Michigan
Indianapolis. IA 46202
31 71633-8496
Mrs. Jo Haynes Brooks, R.N.
Associate Professor, Nursing
Purdue University School of Nursing
West Lafayette. IA 47907
Ms. Joyce Burton, L.P.N
21 Rigney Road
Terre Haute, IA 47802
Mr. Joseph M. Douglass. Jr.
P. 0. Box 276
Angola. IA 46703
Hon. William Dunba~
Hon. Jeffrey K. Espich
BOX i 58
Uniondale, IA 46791
Mrs. Hazel Gromer
717 N.W. 2nd Street
Washington, IA 47501
Mr. Ray Fox
Fox & Fox lnsurance Co.
3656 North Washington Boulevard
Indianapolis. IA 46205
J. K. Wincklebach. D.P.M.
8144 Madison Avenue
Indianapolis, IA 46227
Indiana Hospital Association
Citizenly of Indiana
Association of Osteopathic
Physicians & Surgeons
Ex-Officio - Represents Health
State Nurses' Association
Licensed Practical Nurses' Assoc.
Business & Industrial lnterests
State Senate
State Representative
Citizenry
lnsurance lnterests
State Podiatry Association
Charles Watkins, D C. Chiropractic Association
5117 East Washington Street
Indianapolis, IA 461219
3. Executive Officers of State Med~cal and Pharmaceutical Societ~es:
A. Medical Association: C. Osteopathic Medical Assoc.:
Donald F. Foy
Executive Director
lndiana State Medical Association
3936 North Meridian
lndianapolis 46208
Phone: 3171925-7545
Thomas D. Hanstrom
8900 Keystone Crossing
Suite 659
Indianapolis 46240
Phone: 31 71846-7616
8. Pharmaceutical Association: D. State Board of Pharmacy
David A. Clark
Executive Director
Indiana Pharmacists Association
156 E. Market Street, X900
indianapolis 46204
Phone: 31 71634-4968
William Keown, Executive Director
964 North Pennsylvania Avenue
Indianapolis, IA 46204
31 71232-2960
NPC
Ill. Administration:
Central administration by the State Department of Human Services
IV. 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 Services adopted an administrative rule which permits coverage for
the following non-prescription drugs.
Aspirin Tablets 325 mg, 650
Aspirin Tablets Enteric Coated 325 mg, 650
Aspirin Tablets Buffered 325
Acetaminphen Tablets 325 mg, 500
Acetaminophen Elixir 120 mgl5
Acetaminophen Solution 100 mgl
Ferrous Sulfate Tablets 300 mg, 325
Ferrous Sulfate Elixir 220 mgl5 ql Ferrous Sulfate Drops 75 mg10.6 ql Ferrous Gluconate Tablets
320 mg, 325
Ferrous Gluconate Elixir 300 mgl5
Ferrous Fumarate Tablets 300 mg, 325
B. Formulary: None.
C. Prescribing or Dispensing 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 current wholesale cost of the drug as
defined by the Deparlment of Social Services, plus a professional fee determined to be the 75th
percentile of usual and customary fees. Currently $3.78.
E. State MAC list contains 52 drugs
V. Miscellaneous Remarks:
FY 1984
Total number Rx 1,919.937
Average cosVRx for all categories $1 1.29
VI. Claims Processing Intermediary:
Systems Development Corporation
P.O. Box 10394
Des Moines, lowa 50306
Source: Statistics Section, Division of Management and Budget.
1. $1 .OOcopay (Federal Exclusions) fee: $3.78 fee effective July 1, 1984.
$0.50 incentive fee paid to pharmacy if $1.50 is saved per prescription by
the use of generics.
NPC
Officials, Consultants and Committees
1. Human Services Department Officials:
Michael V. Reagen, Ph.D.
Commissioner
Donald W. Herman
Chief
Bureau of Medical Services
Ronald J. Mahrenholz. R.Ph., M.S.
Manager
Operations Section
5151281-6199
2. Human Services Department Advisory Committees:
A. Title XIX Medical Assistance Council:
College of Medicine
Paul Seebohm. M.D
Associate Dean
College of Medicine
University Hospitals
lowa City 52240
House of Representatives
Rep. Andy McKean
Morley 5231 2
Rep. Edward G. Parker
R.R. 41. Box 128
Mingo 50168
lowa Dental Association
Edgar L. Smith, D.D.S.
2214 Forest
Des Moines 5031 1
Opticians Assoc. of lo'wa,
Inc.
Trish Smallenberger
550 11th Street. Suite 204
Des Moines 50309
lowa Assoc. of Retarded Citizens
Mary Etta Lane
1707 High Street
Des Moines 50309
Department of Human Services
Hoover State Office Building
Des Moines, lowa 5031 9
5151281 -8621
lowa Hospital Association Inc.
Donald Dunn
Suite R. 600 5th Avenue
Des Moines 50309
lowa Medical Society
Donald C. Young, M.D.
1301 10th Street. Suite 119
Des Moines 5031 6
lowa Nurses Association
Marilyn Russell (Mrs.)
Public Health Nursing Assoc.
Armory Building
East 1st & Des Moines Street
Des Moines 50309
Health Facilities Assoc. of
lowa
R. Buckrnan Brock
P. 0 . Box 677
2137 Sunset Road
Des Moines 50303
lowa Council of Health Care
Care Centers
Shirley Clark
2400 N.W. 86th Street. Suite 14
Des Moines 50322
lowa Senate
Senator Dale L. Tieden
Elkader 52043
NPC
lowa Assembly of Home
Health Agencies
Nancy Buitendorp
Box 418
Montezuma 501 71
lowa Society of Osteopathic
Physicians and Surgeons
Gary Hoff, D.O.
Des Moines 50313
lowa Optometric Association
Thomas E. Ward, O.D.
801 Grand Avenue
Des Moines 50309
lowa Osteopathic Hospital
Association
James Kingsbury
603 E. 12th Street
Des Moines 5(X716
lowa Pharmacists Assoc.
Thomas R. Temple
8515 Douglas, Suite 24
Des Moines 50322
lowa Pbdiatry Society
John C. Korn. D.P.M.
Davenport Bank Building
Davenport 52801
lowa State Dept. of Health
Commissioner
Lucas State Office Building
Des Moines 50319
lowa Assoc. of Homes for
the Aging
Bernard Bowman .
315 E. 5th, Suite 4
Des Moines 50309
8. Pharmaceutical Advisory Committee:
Mark Richards, Des Moines
Bill Robinson, Atlantic
Phil Weider, Des Moines
Dan Keckler, Eldridge
Dan Wiese. Davenport
Tom Taiber, Waverly
Ken Hampson. Ames
Senator Joe Brown
Montezuma 501 71
lowa Chiropractic Society
Robert Rasmussen, D.C.
3500 2nd Avenue
1440 East Grand, Suite 38
Public Representatives
Nancy M. Jones
RR #1
Ainsworth 52201
Dorothy J. Eide
701 5th Street. N. E
Oelwein 50662
Darlene M. Brown
4519 Grand
Des Moines 5031 2
lowa Psychological Assoc.
Craig 8. Rypma
2404 Forest Drive
Des Moines 50312
Community Mental Health Ctrs.
Assoc. of lowa
Holly Oppelt
101 W. Mississippi Dr., Suite 200
Muscatine 52761
Russ Wiesley, Creston
Duane Haberichter, Oskaloosa
Marion Reis. Sioux City
Roger Zobel, West Des Moines
Dick Hartig. Dubuque
Bev Bartos, lowa City
Keith Kouba, Anamosa
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3. Executive Officers of State Medical and Pharm~eutical Societies:
A. Medical Society:
Eldon Huston
Executive Vice-president
lowa Medical Society
1 OO1 Grand Avenue
West Des Moines 50265
Phone: 5151223-1401
8. Pharmacists Association:
Thomas R. Temple. R.Ph.. M.S.
Executive Director
lowa Pharmacists Association
8515 Douglas, Suite 24
Des Moines 50322
Phone: 5151270-0713
C. lowa Society of Osteopathic Physicians and Surgeons:
F. Walter Tomenga
Secretary-Treasurer
508 10th Street. Suite 300
Des Moines 50309
Phone: 51 51283-0002
D. State Board of Pharmacy Examiners
Norman C. Johnson, Executive Secretary
1209 East Court, Executive Hills West
Des Moines, lowa 50319
51 51281 -5944
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KANSAS
MEDI CAL ASSI STANCE DRUG PROGRAM (TITLE XI X)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type ol Benefit Categorically Needy Medically Needy (MN) Other'
O M AB APT0 AFDC OAA AB APTD AFDC Children 21 ( w
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
Other Benefits: Home Health Care: Clinic Services: Rehabilitative Services; Prostheseis; Preventive Services; Family Planning Services; Chiropractic
Services; Optometric Services; and Communily Based Alternative Services.
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
1984
Expended Recipient
- -
. . . . . . . . . . . . . . . . . . . . . TOTAL $1 7,305.550 106,755"
. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL
Not available
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 . . . . . . . . . . . .
. . . . . . . . . . . . Adulk-Families w/Oep Children
Other Title XiX Recipients . . . . . . . . . . . . . . .
1983
Expended Recipient
- -
$15,974,742 104,280
8,345,640 80.214
2,349.735 7.204
'VJndupiicated Total - HHS report HCFA - 2082
NPC
Ill. Administration:
State Department of Social and Rehabilitation Services.
IV. Provisions Relating to Prescribed Drugs:
A. Prescribed drugs. Covered are: (a) legend drugs in a formulary approved by the state Medicaid
agency, excluding drugs that the agency finds ineffective or possibly effective; and (b) seleted
nonlegend drugs, devices, and supplies when prescribed for diseases and conditions specified
in the state's Medicaid regulations.
0. Formulary: Restricted drug list.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Maximum of a 100-day supply. Minimum quantities of a 100-dose or
30-day supply should be prescribed and dispensed for maintenance drugs.
2. Refills: As authorized by the prescriber up to a one-year period from the date of issuance of
the prescription.
3. Dollar Limits: A prescription claim in excess of $75 is reviewed prior to payment.
D. Prescription Charge Formula: Variable fee per prescription established for each individual par-
ticipating pharmacy within the range of $2.46 to $4.67 for N-1984.
Pharmacies are reimbursed on the basis of product acquisition cost plus a professional fee. This
applies to all covered legend and non-legend drugs. 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" means the allowable price delermined by the agency for each
covered drug in accordance with state and federal regulations.
Effective May 1, 1983, a recipient co-pay charge of $1.00 was applied to each new and refill
prescription.
Officials, Consultants and Committees
1. Social and Rehabilitation Services Department Officials:
Dr. Robert C. Harder
Secretary
John Schneider, Commissioner
Income Maintenance and
Medical Services
Robin Smith, Director
Public Assistance Section
L. Kathryn Klassen, R.N.. M.S.
Director
Division of Medical Programs
Department of Social and
Rehabilitation Services
State Office Building
Topeka, Kansas 66612
Department of Administration
State Capitol
Topeka, Kansas 6661 2
Alden Shields. Budget Director
Department of Administration
NPC
Joyce Sugrue, A.N.
Coordinator of Medical Services
Elaine Hacker, M.D.
Utilization Review Administrator
Gene Hotchkiss, R.Ph.
Pharmacist Consultant
91 31296-3981
2. Governor's Medical Advisory Committee:
Daniel A. Shea, O.D.
2720 East 21st Street
Wichita, Kansas 67214
Fenton Williams, M.D.
15401 England Drive
Stanley, Kansas 66223
Stuart Averill, M.D.
Menninger Foundation
P.O. Box 829
Topeka, Kansas 66601
Joseph Hollowell, M.D.
Director of Health
Department of Health and
Environment
Topeka 66620
David Domann, R.Ph. M.S
FASCP
504 Commercial
Ben Rubin, M.D.
121 S. 17th Street
Kansas city. KS 661 02
James Reeves, DPM
930 Iowa-Suite 2
Lawrence. KS 66044
Mary Reyer
Topeka Resource Center
for Handicapped
1119 S.W. 10th
Topeka, KS 66604
Department Representatives
James Hawkins
Clinicare Family Health Services
510 Southwest Boulevard
Kansas City 661 03
Robert Anderson
Family Consulatation Services
560 North Exposition
Wichita Kansas 67205
Alice Fisher
226 Woodruff
Topeka
Robert E. Johnson, Committee Chairman
Administrator
Miama County Hospital
501 South Hospital Drive
bol o 66071
Betty Schultz
971 Manos Crest
Kansas City. KS 66101
E. Robert Sinnett, Ph.D,
21 7 Southwind Place
Manhattan, KS 66502
Tom Jones, D.D.J.
398 New Brotherhood Bldg.
Kansas City, KS
Verden Ellefson
Assoc. Director, Finance
Providence-St. Margaret
Health Center
Kansas City, KS 661 12
Dr. Robert C. Hardner
L. Kathryn Klassen, R.N., M.S
Elaine Hacker, M.D.
3. Executive Off~cers of State Medical and Pharmaceutical Societies:
A. Medical Society: C. Osteopathic Medical Association:
Jere Slaughter
Executive Director
Kansas Medical Society
1300 Topeka Boulevard
Topeka 66612
Phone: 9131235-2363
Mr. Harold Reihm
Executive Director
Kansas Assn. of Osteopathic Medicine
1325 S.W. Topeka Boulevard
Topeka 6661 2
Phone: 91 31234-5563
B. Pharmaceutical Association: D. State Board of Pharmacy
Kenneth W. Schafermeyer
Everett L. Willoughby
Executive Director Executive Secretary
Kansas Pharmaceutical Association
503 Kansas Avenue. Suite 328
1308 West 10th Street
P. 0 . Box 1007
Topeka 66604
Topeka. Kansas 66601
Phone: 91 31232-0439
91 312964066
NPC
KENTUCKY
MEDI CAL ASSI STANCE D R U G PROGRAM ( TI TLE XI X)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
O M AB APTD AFDC O M AB APTD AFOC Children 21 (SFO)
. ,
Prescribed
ON~ S X X x X x x x x x
Inpatient
Hospital Care X X X X X X X X X
Outpatient
Hos~i t al Care X X X X X X X X X
Laboratow &
X-ray service X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X
Physician
Services X X X X X X X X X
Dental
Services X X X X X X X X X
"SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30. 1984
1984 1983
Expended Recipient Expended
- - -
Recipienl
-
TOTAL . . . . . . . . . . . . . . . . . . . . . $27,996,238 31 1,656" $1 9,505,335 251,935
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $25,120,076 242,042 17.523.811 198,829
Aged . . . . . . . . . . . . . . . . . . . . . . 7,058,004 41,121 4,939.793 31,275
Blind . . . . . . . . . . . . . . . . . . . . . . 320,138 2,005 226.055 1.530
Disabled . . . . . . . . . . . . . . . . . . . . . 12,711,842 62.142 8.474.930 45,227
Children-Families wIDep Children . . . . . . . . . . . . 1.788.787 82,227 1.486.258 74,508
Adults-Families w1Dep Children . . . . . . . . . . . . 3,241,305 54,547 2,396,775 46.012
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . 240.091 5,298 236,368 5,437
Aged . . . . . . . . . . . . . . . . . . . . . . 85,882 501 95,055 497
. . . . . . . . . . . . . . . . . . . . . . Blind 1,217 5 1,436 8
Disabled . . . . . . . . . . . . . . . . . . . . . 57,087 262 55,463 243
Children-Families wlDep Children . . . . . . . . . . . . 33,357 2,677 30,255 2,399
Adults-Families wIDep Children . . . . . . . . . . . . 62,548 2.483 54,159 2.290
Other Title XIX Recipients . . . . . . . . . . . . . . . 0 0 0 0
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . 2,636,071 75.121 1,745,156 56.636
Aged . . . . . . . . . . . . . . . . . . . . . . 123.296 1,482 115,534 1,480
Blind . . . . . . . . . . . . . . . . . . . . . . 1,433 9 1,585 8
Disabled . . . . . . . . . . . . . . . . . . . . . 183,512 1,503 148,684 1.380
Children-Families wIDep Children . . . . . . . . . . . . 744.355 36,049 507,783 27.052
Adults-Families wIOep Children . . . . . . . . . . . . 1,550.733 34.633 946,488 25.421
Other Title XIX Recipienls . . . . . . . . . . . . . . . 32,742 1.445 25,032 1,295
Wnduplicated Total - HHS repoil HCFA - 2082
Ill. Administration:
By the Division for Medical Assistance within the Department for Social Insurance, within the
Cabinet for Human Resources.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions (diseases, drug categories, etc.):
The following are items which are not covered under the pharmacy benefits area of the program:
1. Most medical supply items such as bedpans, urinals, ice bags, etc. (Note: Insulin syringes
are covered.)
2. Medicine cabinet supplies and drug staples
3. Drugs available through other programs or agencies
4. Drugs not included on the Kentucky Medical Assistance Program Drug List (unless pre-
authorized 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 and enteric coated aspirin.
B. Formulary Yes. The list is revised in accordance with recommendations of the Formulary
Subcommittee and in accordance with available funds.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medications: None.
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.
2. The dispensing fee is $3.25.
3. Co-payment - none:
4. State MAC list contains 133 drugs
V. Miscellaneous Remarks:
Payment for drugs is limited to those pharmacies which affiliate themselves with the Medical
Assistance Program by completing the "Agreement of Participating Pharmacies."
Fiscal Intermediary:
Electronic Data Systems Corp
Dallas. Texas
Average Fix price during FY 1984 - $7.86
Officials, Consultants and Committees
1. Officials:
E. Austin, Jr.
Secretary
Jack F. Waddell
Commissioner
James B. Gooding, Director
Division of Medical Assistance
Cabinet for Human Resources
4th Floor, CHR Building
275 East Main Street
Frankfort, Kentucky 40621
Department for Social Insurance
3rd Floor, DHR Building
275 East Main Street
Frankfort 40621
(Miss) Gene A. Thomas, R.Ph.
Division of Medical Assistance
5021564-4321
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. (Chrmn) Robert N. McLeod, M.D.
Jefferson County 515 Mockingbird Drive
Health Department Somerset 42501
400 East Gray Street
Louisville 40202 Ms. Alice LeMaster
227 Douglas Avenue
Larry Spears, R.Ph. Frankfort 40601
C/O Grant County Drugs
Dry Ridge 41035 Ms. Wanda Humphreys
North Race Street.
William K. Rich, D.M.D. P.O. Box 257
129 Ridgelea Drive Glasgow 42141
Williamstown 41097
Ms. Oteria L. O'Rear
Ms. Elizabeth Moeller 835 Charles Avenue
Graham 42344 Lexington 40508
C.A. Nava, D.P.M.
Secretary
Kentucky State Board
of Podiatry
110 North Hubbard Lane
Louisville 40207
Nedra Divine
Administratrix
Dover Manor
112 Dover Drive
Georgetown 40324
Mr. Mark Whitaker
731 Jackson
Owensboro 42301
Ms. Doris Elrod
Kevil42053
Thomas W. Grant
Good Samaritan Hospital
310 South Limestone Street
Lexington 40503
NPC
Wayne Helderman, O.D.
20 Broadway
Mt. Sterling 40353
Frances Johnson
308 St. Johns Court, Apt. C
Frankfort 40601
Brenda Manns
Route I , Owenton Road
Frankfort 40601
Formulary Subcommittee
Samuel R. Scott, M.D.
Acting Chairman
1302 Richmond Road
Lexington 40506
James Sieg, Ph.D.
University of Kentucky
College of Pharmacy
Lexington 40506
J. Thomas Badgett, Ph.D. M.D.
Director, Ambulatory Pediatrics
University of Louisville
Health Sciences Center
Department of Pediatrics
Louisville 40292
Ms. Ellen Buchart, R.N.
Jefferson County Health
Department
400 East Gray Street
Louisville 40202
B. Pharmacy Technical Advisory Committee:
Dr. Condit Steil
Chairman
Trover Clinic
Madisonville 42431
Michael Sheets, R.Ph.
903 Lyndon Lane
Louisville 40222
Jack F. Waddell (ex officio)
Commissioner
Department for Social Insurance
CHR Building, 3rd Floor
Frankfort 40621
E. Austin, Jr. (ex officio)
Secretary
Cabinet for Human Resources
CHR Building, 4th Floor
Frankfort 40621
R. N. Smith
Smith's Pharmacy
Burkesville 4271 7
Stephen Jasper, M.D.
Family Practice Clinic
340 Bogle Street
Somerset 42501
Charles H. Jarboe. Ph.D.
Dept. of Pharmacolo~y~oxicology
School of Medicine
University of Louisville
Louisville 40292
Chester L. Parker. Phan.D.,R.Ph.
181 6 Darien Drive
Lexington, 40201
Chester L. Parker. Pharm.D.
1816 Darien Drive
Lexington 40201
James E. Garrett. R.Ph.
Pharmacare, Inc.
21 1 Geri Lane
Richmond 40475
Paul Ruwe, R.Ph.
1 1 Edna Lane
Ft. Wright 4101 1
David Hancock, R.Ph
401 Park Row
Bowling Green 42101
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
Robert Cox
Executive Vice President
Kentucky Medical Association
3532 Ephraim McDowell Drive
Louisville 40205
Phone: 50Z459-9790
B. Pharmaceutical Association:
Paul Davis. R.Ph.
Executive Director
Kentucky Pharmacists Association
P. 0. Box 715. 1228 U.S. Hwy. 1275
Frankfort 40602
Phone: 50Z227-2303
C. Osteopathic Medical Association:
Vacant
Executive Director
Kentucky Osteopathic Medical Association
208 Crossfied Drive
Versailles 40383
Phone: 6061873-8044
D. State Board of Pharmacy
Richard L. Ross
Executive Director
1228 US. 127 South
Frankfort 40601
5021564-3833
NPC
Louisiana
MEDI CAL ASSI STANCE DRUG PROGRAM ( TI TLE XI X)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other*
OAA AB APT0 AFDC O M AB APTD AFDC Children 21 (SFO)
Prescribed
Drugs X X X X X X X X X X
Inpatient
Hnsnital Care X X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X X
Laboratory &
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X X
Physician
Services X X X X X X X X X X
Dental
Services X X X X X X X X X X
'SF0 - State Funds Only
If. EXPENDITURES FOR DRUGS. Fayment to Pharmacists by fiscal year ending June 30, 1984
1983
Expended
-
Recipient
-
TOTAL .
1984
Expended Recipient
- -
$61,313,800 289.689"
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $48,982,322 61,869
Aged . . . . . . . . . . . . . . . . . . . . . . 25,030,357 1,310
Blind . . . . . . . . . . . . . . . . . . . . . . 419,683 43.505
Di s abl ed. . . . . . . . . . . . . . . . . . . . . 14,720,769 144,178
Children-Families w/Dep Children . . . . . . . . . . . . 8,270,866 4.357
. . . . . . . . . . . . Adults-Families w/Dep Children 540.647 28.333
. . . . . . . . CATEGORICALLY NEEDY NDN-CASH TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families wIDep Children
. . . . . . . . . . . . Adults-Families w/Dep Children
. . . . . . . . . . . . . . . Olher Title XIX Recipients
. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL
Aged
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families w/Dep Children
. . . . . . . . . . . . Adults-Families w/Dep Children
Other Title XIX Recipients . . . . . . . . . . . . . . .
"Unduplicated Total - HHS report HCFA - 2082
NPC
Ill. Administration:
Public assistance prosrams are administered by the State Office of Family Security. Department of
Health and Human Services.
IV. Provisions Relating to Prescribed Drugs:
A. Prescribed legend and non-legend drugs (OTC) are reimbursed; except experimental drugs,
anorexics and anti-anemia drugs, cough and cold preparations, vitamins, certain gastroin-
testinal drugs, and certain minor tranquilizers.
B. Prescribing or Dispensing Limitations:
1. Quantity of Medication: New prescription must be issued for drugs given on a continuing
basis, after 5 refills or after 6 months.
Maximum payment quantity for prescriptions shall be either one month's treatment or
100 unit doses.
2. Refills: Permitted as indicated by physician within 6 months and not to exceed 5 refills.
3. Dollar Limits: None.
4. Formulary: No.
C. Prescription Charge Formula:
1. The maximum payment for a prescription is estimated acquisition cost or MAC plus $3.67
dispensing fee.
D. Fiscal Intermediary:
The Computer Company
P.O. Box 4169
Baton Rouge, Louisiana 70821
E. Number of Rx claims processed in FY 1984-4,928,534
Average Rx price FY 1984-$12.32
Officials, Consultants and Committees
1. Health and Human Resources Administration Officials:
Sandra L. Robinson. M.D., M.P.H. Department of Health and Human
Secretary Resources
P. 0. Box 3776
Marjoria Stewart
Assistant Secretary
J. Christopher, Division Directol
Division of Medical Assistance
Carolyn Maggio (Mrs.)
Assistant Division Director
Medical Assistance Programs
5041342-3937
Office of Family Security
755 Riverside North
P.O. Box 44065
Baton Rouge, Louisiana 70804
Merrill A. Patin, R.Ph.
Pharmacist Consultant II
5041342-9320
NPC
Edward J. Daigle. R.Ph.
Pharmacist Consultant I
2. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: C. Osteopathic Association:
Dave L. Tarver
Executive Director
Louisiana State Medical Society
1700 Josephine Street
New Orleans 701 13
Phone: 5041561-1033
B. Pharmaceutical Association:
Peter Caldwell
Executive Vice President
Louisiana State Pharmacists Assn
2337 St. Claude Avenue
New Orleans 701 17
Phone: 50419447545
Charles S. Wyckoff, D.O.
Secretary-Treasurer
Louisiana Association of
Osteopathic Physicians
333 St. Charles Avenue - 412
New Orleans 70130
Phone: 5041588-9494
D. State Board of Pharmacy
Howard B. Bolton, Executive Dir.
5615 Corporate Boulevard, Ste. 8E
Baton Rouge 70808
5041925-6496
NPC
MAINE
MEDI CAL ASSI STANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AN0 GROUPS ELIGIBLE
Type of Benelit Categorically Needy Medically Needy (MN) Other*
O M AB APTD AFDC O M AB APTD AFDC Children 21 ( W
Prescribed
. . - - -. . - - -
Drugs X X X X X X X X X X
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
~a b o r a t o i &
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(1) X(1) X
'SF0 - State Funds Only (Catastrophic Illness Program in FY 83)
(1) Routine dental services; other categories eligible for non-routine dental service only.
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
TOTAL
1984
Expended
-
Recipient
-
. . . . . $13,459,553 84,396"
. . . . . . . . . . CATEGORiCALLY NEEDY CASH TOTAL
A g d . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Chiidren-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/Oep Children
Other Title XIX Recipients . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Chiidren-Families w/Dep Children . . . . . . . . . . . .
. . . . . . . . . . . . Aduits-Families w/Dep Children
Other Title XIX Recipients . . . . . . . . . . . . . . .
"Undupiicated Total - HHS repod HCFA - 2082
NPC
Ill. Administration:
State Department of Human Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions:
1. OTC drugs, except insulin and artificial tears.
2. Combination antibiotics.
3. Symptomatic remedies for common colds and coughs resulting from common colds.
4. All vitamins and vitamin preparations.
5. All amphetamines, straight or in combination, and all obesity control drugs. (Authorization
for amphetamines or methylphenidate in documented cases of narcolepsy or hyperkinesis
may be obtained upon request.)
6. lnjectables when oral medication is available for equally effective treatment.
Prior authorization may be obtained in the case of necessary exceptions.
B. Formulary: Open formulary, except for certain therapeutic categories.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Refills for chronic conditions can be for no less than a 30 day supply
unless the prescriber specifically directs otherwise.
3. Refills: A prescription can be refilled up to five times within six months if specifically ordered.
4. Dollar Limits: None.
D. Prescription Charge Formula: Usual and Customary. EAC plus a professional fee of $3.20 or MAC
plus a professional fee of $3.20. whichever is lower. (EAC for the top 150 drugs = AWP 5%
or direct prices, whichever applies.)
E. Copayment: $0.50
V. Miscellaneous:
Average Rx price during PI 1984-$10.49
Fiscal Intermediary: Good Health SystemslLow Cost Drug Program
P. 0. Box 508
Augusta, ME 04330
Officials, Consultants and Committees
1. Human Services Department Officials:
Michael R. Petit
Commissioner
Robert B. McKeagney, Jr.
Deputy Commissioner
Gordon A. Browne
Director
Bureau of Medical Services
Department of Human Services
State House
Augusta, Maine 043g3
Health and Medical Services
(address same as above)
Department of Human Services
State House
Augusta, Maine 04333
James H. Lewis
Assistant Bureau Director
Medicaid Operations
Bureau of Medical Services
Michael P. O'Donnell, R.Ph.
Pharmacist Consultant
2071289-2674
Margaret Ross
Director
Medicaid Surveillance and
Utilization Review
Medical Consultants:
Allen Elkins, M.D.
Psychiatric
D. K. McFadden, D.0,
Osteopathic
Donald Ellis, O.D.
Optometric
J.D. Reeder. D.C.
Chiropractic
2. Medical Assistance Advisory Committee:
A. Dewey Richards, M.D
Chairman
Dept. of Human Services
Bureau of Medical Services
Station XI 1
11 Gage Street
Bridgton 04009
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: C. Osteopathic Association:
Frank 0. Stred
Executive Director
Maine Medical Association
524 Western Avenue
Augusta 04330
Phone: 2071622-3374
Philip N. Johnson
Executive Director
Maine Osteopathic Association
303 State Street
Augusta 04330
Phone: 2071623-1 101
6. Pharmaceutical Association: D. State Board of Pharmacy
Irving 6. Faunce, Jr.
Executive Director
Maine Pharmacy Association
345 Water Street
P. 0. Box 488
Gardiner 04345
Phone: 2071582-1433
Richard 0. Campbell. Secretary
1 Northwood Road
Lewiston, Maine 04240
2071783-9769
NPC
MARYL AND
MEDI CAL ASSI STANCE DRUG PROGRAM ( TI TLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFOC OAA AB APTD AFDC Children 21 (SF@
Prescribed
Drugs X X X X
X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X X
Laboratory &
X-ray Service X X X X
X X X X X X
Skilled Nursing
Home Services X X X X
X X X X X X
- -
Physician
Services X X X X X X X X X X
Dental
Services X X X X
X X X X X X
^SF0 - Slate Funds Only
'Limited services available. Expanded services available to EPSDT eligibles.
II. MPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30. 1984
1984 1983
Expended
-
Recipient
-
Expended
-
Recipient
-
TOTAL . . . . . . . . . . . . . . . . . . . . . $32,967,163 234,441 "' $28,570,406 232,522"'
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . 24,118,862 197.802 $20,227.522 191,147
Aged . . . . . . . . . . . . . . . . . . . . . . 5,000.879 15,139 4,048.467 14,200
Blind . . . . . . . . . . . . . . . . . . . . . . 83,082 292
70.110 271
Disabled . . . . . . . . . . . . . . . . . . . . . 8,540,228 25,599 7,029,831 24.317
Children-Families w/Dep Children . . . . . . . . . . . . 4,212,994 98,078 3.458.693 92,196
Adults-Families wIDep Children . . . . . . . . . . . . 6,281,729 58.694 5,620,421 60,163
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . 0 0 0 0
1 Aged . . . . . . . . . . . . . . . . . . . . . 0 0 0 0
Blind . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0
Children-Families wlllep Children . . . . . . . . . . 0 0
0 0
Adults -Families w/Dep Children . . . . . . . . . . . . 0
0 0 0
Other Title XIX Recipients . . . . . . . . . . . . . . . 0 0 0 0
. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL
. . . . . . . . . . . . . . . . . . . . . . Aged
. . . . . . . . . . . . . . . . . . . . . . Blind
. . . . . . . . . . . . . . . . . . . . . Disabled
. . . . . . . . . . . . Children-Families wIDep Children
. . . . . . . . . . . . Adults-Families wIDep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
""Unduplicated Total - HHS report HCFA - 2082
NPC
Ill. Administration:
State Department of Health and Mental Hygiene.
IV. 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.
0. Coverage of non-legend drugs is limited to insulin, and Schedule V cough preparations, needles
and syringes, contraceptives other than condoms and specially formulated nutritional prepara-
tions when preauthorized by the program.
1. Quantity of Medication: The prescriber may order up to a 100-day supply of the medication
on a single prescription, except for birth control pills which are limited to a 6-cycle supply.
2. Refills:
a. Maximum number of refills authorized on a prescription is two. The original prescription
and its refills may not exceed a 100 day supply.
b. Refills may not be dispensed after 100 days of date of original prescription.
3. Dollar Limits: Prior authorization required from Medical Assistance Compliance
Administration when usual and customary charge exceeds $60 and prescribed amount is
more than a 34 day supply.
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..
5. Reimbursement:
a. Drug ingredient cost is calculated under one of the following procedures:
(1) Maximum Allowable Cost (MAC) - this list, which contained 44 price-controlled drugs in
fiscal year 1984, is continually updated to reflect deletions and additions made by the
Health Care Financing Administration of the Department of Health and Human Services.
(2) Interchangeable Drug Cost (IDC) effective June 1. 1985, the state of Maryland main-
tains 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 par-
ticular brand 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 June 1. 1985. there are 237 products representing 97 drug entities on the list.
(3) Usual Source and Quantity List for High Utilization Drugs effective June 1, 1985, the
state of Maryland maintains a list of products which are usually purchased directly from
manufacturers and/or in larger than minimum package size. Reimbursement for these
products is based on the less expensive source of supply or package size. As of June
1, 1984, 53 products representing 34 drug entities are included in this list.
(4) 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' d~rect prices.
b. Reimbursement will be the lower of:
-the usual and customary fee;
-the calculated ingredient cost plus $3.45 dispensing fee.
V. Miscellaneous:
Number of Rx claim processed in FY 1984 (July, 1983 June, 1984) 2,987,328
Average prescription price during FY 1983 $13.07
155
NPC
A copayment of $.50 applies only to state funded recipients of medical assistance. No copayment
for recipients in federal categories, or those receiving EPSDT and family planning related services.
Maryland Pharmacy Assistance Program
The Maryland Pharmacy Assistance Program, established by the Maryland General Assembly in
1978, is administered by the Assistant Secretary for Medical Care Programs 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, needles and
syringes, contraceptives except condoms and certain formulated nutritional preparations.
Eligibility for Pharmacy Assistance is based on the financial resources available to the family unit.
As a result of the passage of Senate Bill 124 by the 1982 General Assembly, the maximum allowable
fiscal year 1983 income levels were increased by 7.4%. This law also allows the Program to increase
its income levels each year by the annual Social Security cost-of living percentage increase, not to
exceed 8%. The resource standards for the Pharmacy Assistance Program are the same as those for
the Maryland Medical Assistance Program. The following chart shows the gross income and resource
standards effective during fiscal year 1985.
Gross hcome Resource
Family Size Standards Standards
1 $5,400 $2,500
2 6,000 2,600
3 6,500 2.700
4 7,100 2,8W
5 7.650 2.900
6 8,200 3,000
7 8.750 3.100
8 9,400 3,200
9 10,050 3,300
10 10,650 3,400
Each additional person + 600 + 100
In the fiscal year 1984. there was an average enrollment of 11,370 per month. The program paid
$3,494,592 for 234.845 prescriptions, an average of $14.88 per prescription. Providers are reimbursed
the lower of:
-usual and customary fee
-ingredient cost as calculated under Medical Assistance regulations plus a $3.45 dispensing fee
Recipients are responsible for a $1 .OO copayment for each prescription and each refill. The state
pays the remainder of total reimbursement.
Officials, Consultants and Committees
1. Health and Mental Hygeine Department Officials:
Adele Wilzack
Secretary
Douglas H. Morgan
Assistant Secretary for
Medical Care Programs
Kathleen B. Becker
Chief. Division of Specialized
Health Services
Department of Health and
Mental Hygiene
201 W. Preston Street
Baltimore, Maryland 21201
Medical Assistance Policy Admin.
300 W. Preston Street
Baltimore. Maryland 21201
Leone W. Marks, R.Ph.
- acy
&+.A- QL
Joseph Fine, P.D.
Section Manager, Pharmacy
Operations
301 1383-6893
George Lichter, P.D.
Manager, Pharmacy Operations
Administration
301B25-1745
Charles Sandler, R.Ph.
Pharmacy Consultant
301 1225-1 746
John W. Baker
Program Manager
301 1225-5392
2. Medicaid/Pharmacy Liaison Committee:
Chairman
David Banta, Executive Director
650 West Lombard Street
Baltimore, Maryland 21202
Stanton G. Ades, P.D.
P.O. Box 87
Stevenson. Maryland 21 153
Adolph Baer. P.D.
Fisher's Pharmacy
18935 Woodburn Road
Hagerstown, Maryland 21740
Samuel Lichter, P.D.
Randallstown, Maryland 21 133
Robert Martin, P.D.
Route 1, Box 75M
LaVale, Maryland 21 502
Ronald Sanford. P.D.
Dart Drugs
1336 Denbright Street
Baltimore, Maryland
Ronald Telak, P.D.
Maryland General Hospital
Pharmacy Department
827 Linden Avenue
Baltimore, Maryland 21201
Medical Assistance Operations
Administration
201 W. Preston Street
Baltimore, Maryland 21201
Medical Assistance Compliance
Administration
300 West Preston Street
Baltimore, Maryland 21201
Medical Assistance Compliance
Administration
300 W. Preston Street
Baltimore, Maryland 21201
Pharmacy Assistance Program
P. 0. Box 386
Baltimore, Maryland 21203
Martin Mintz, R.Ph.
Northern Pharmacy
6701 Harford Road
Baltimore, Maryland 21234
Dr. Frank Palumbo
University of Malyland School
of Pharmacy
636 West Lombard Street
Murray Polonsky, P.D.
Accredited Surgical Company
415 East Wayne Avenue
Silver Spring. Maryland 20901
4001 Carthage Road David Rombro, P.D
MacGillivray's Pharmacy
900 North Charles Street
Baltimore, Maryland 21201
Melvin Rubin, P.D.
Paradise Pharmacy
231 6 Sugarcone Road
Baltimore, Maryland 21209
21228 Angelo Voxakis, P.D.
Outpatient Pharmacy
University Hospital
22 South Greene St., Rm. 1101
Baltimore. Maryland 21201
NPC
Medical Assistance Staff Committee Members
Kathleen B. Becker
Joseph Fine, R.Ph.
Jeanne E. Fisher
Leone W. Marks, R.Ph.
Charles Sandler. R.Ph.
3. Medical Assistance Advisory Committee:
Douglas H. Morgan
Assistant Secretary
Medical Care Programs
201 W. Preston Street, Room 516
Baltimore. Maryland 21201
Lee Bernhardt, Director
Government Programs
Blue Cross/Blue Shield of Maryland
700 East Joppa Road
Baltimore. Maryland 21204
Millie Tyssowski
2500 Pickwick Road
Baltimore, Maryland 21207
William Hankins, Assistant Director
Bon Secours Hospital
2000 West Baltimore Street
Baltimore, Maryland 21223
Douglas H. Morgan
Assistant Secretary for
Medical Care Programs
201 West Preston Street. Room 516
Baltimore, Maryland 21201
Allen Bennett, P.D.
Park West Medical Center, Inc
3319 West Belvedere Avenue
Baltimore, Maryland 21215
Lee Bernhardt. Director
Government Programs
Blue Cross/Blue Shield of Maryland
700 East Joppa Road
Baltimore, Maryland 21204
Peter Borchardt, Executive Director
Del ma~a Foundation for Medical Care
108 North Harrison Street
Easton, Maryland 21601
Jack Bovaird, Assistant Director
Associated Catholic Charities
320 Cathedral Street
Baltimore. Maryland 21201
Dept. of Health and Mental Hygiene
Representative
Administrator. Blue CrosslBlue Shield
of Maryland
Acting Chairperson
Consumer Representative
Vice Chairperson. Maryland
Hospital Assoc. Representative
Dept. of Health and Mental
Hygiene Representative
Maryland Primary Care
Assoc. Representative
Administrator, Blue Cross1
Blue Shield of Maryland
Administrator, Utilization Control
Agent
Consumer Re~resentative
NPC
John Braxton, Jr., M.D.
4432 Park Heights Avenue
Baltimore, Maryland 21215
Mildred Bright
21 12 Jefferson Street
Baltimore, Maryland 21205
Mrs. Loretta Brown
2019 North Payson Street
Baltimore. Maryland 21217
Mrs. Eva Brown
Basilica Place
124 West Franklin Street
Baltimore, Maryland 21201
Richard Buck. Executive Director
Pickersgill Home
615 Chestnut Avenue
Baltimore, Maryland 21204
Darrell R. Cammack. Jr.. Administrator
Ivy Hall Nursing Home
19 Harrison Avenue
Baltimore, Maryland 21220
Mrs. Phyllis Colston
7850 Willing Court
Pasadena, Maryland 21 122
Jean Dockhorn
3603 Monterey Road
Baltimore, Maryland 21218
Ronald Harris
1423 Winston Avenue
Baltimore, Maryland 21239
Rosalyn Hurwitz-Hartman
Director. Nursing Home Advocacy
Project
Maryland Conference of Social Concern
1301 Park Avenue
Baltimore. Maryland 2121 7
Benjamin J. Kimbers. Jr.. D.D.S.
Madison Park Professional Building
932 West North Avenue
Baltimore, Maryland 21217
Harry F. Klinefelter, M.D. Physician,
550 North Broadway, Room 401
Baltimore. Maryland 21205
Maryland-6
1985
Monumental City Medical Society
Representative
Consumer Representative
Consumer Representative
Consumer Representative
Nursing Home Representatives
Nursing Home Representative
Consumer Representative
Consumer Representative
Consumer Representative
Consumer Representative
Maryland State Dental Association
Re~resentative
private practice
NPC
Joseph L. LaAsmar. Associate Executive
Director
Chesapeake Physicians, P.A.
P.O. Box 9048
Baltimore, Maryland 21222
Eileen Leaman
27 Maple Avenue
Baltimore, Maryland 21228
Mrs. Felicia Martin
1007 McDonough Street
Baltimore, Maryland 21 205
Edward Matricardi, Program Director
HARBEL Community Mental Health Center
5807 Hariord Road
Baltimore, Maryland 21214
Helen B. McAllister, M.D.
61 00 Westchester Park Drive, X611
College Park, Maryland 20714
Maureen McCleary, Director
Bureau of Adult Health Services
Prince George's County Health Dept,
Cheverly. Maryland 20785
Mrs. Cecilia Moore
1328 North Mount Street
Baltimore. Maryland 21217
Gladys Moran Consumer Representative
618 North Castle Street
Baltimore. Maryland 21205
Ethel Pace
1707 Moreland Avenue
Baltimore. Maryland 21 21 6
Regina M. Phillips. R.N.
506 Moonflower Court
Millersville, Maryland 21 108
Melvin Rubin
2316 Sugarcone Road
Baltimore, Maryland 21209
Barbara Spence. DSW Director
Department of Social Work
Johns Hopkins Hospital
600 North Wolfe Street
Baltimore, Maryland 21205
Administrator, HMO
Consumer Representative
Consumer Representative
Administrator, Community Mental
Health Center
Health Officer, Prince George's
County
Maryland Assoc. of Home Health
Agencies Representative
Consumer Representative
Consumer Representative
Maryland Nurses Association
Representative
Maryland Pharmaceutical Association
Representative
Society of Hospital Social
Work Directors Representative
Mrs. Jackie J. Vickers Health Planning Council of
Director of Senior Programs Eastern Shore Representative
203 Belvedere Avenue
Cambridge, Maryland 21613
Gloria Washington, Department of Human Resources
Medical Assistance Division Representative
Income Maintenance Administration
300 West Preston Street
Baltimore, Maryland 21201
4. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Soc~ety:
Mr. John Sargeant
Executive Director
Medical and Chirurgical Faculty of Maryland
1121 Cathedral Street
Baltimore 21201
Phone: 3011539-0872
6. Pharmaceutical Association:
David A. Banta. R.Ph.
Executive Director
Maryland Pharmaceutical Association
650 W. Lombard Street
Baltimore 21201
Phone: 3011727-0746
C. Osteopathic Association:
Lawrence I. Silverberg. D.O.
Maryland Osteopathic Association
Route 32 at Route 144
West Friendship. Maryland 21794
3011442-2266
D. State Board of Pharmacy
Paul Friedman. Secretary
201 West Preston Street
Baltimore, Maryland 21201
301 1383-7245
NPC
MASSACHUSEl TS
MEDI CAL ASSI STANCE D R U G PROGRAM (TITLE XI X)
I. BENEFITS PROViDEO AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other*
O M AB APTD AFDC OAA A0 APTD AFDC Children 21 (SFO)
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
---
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
Other Benefits: Intermediate care facilities, clinics, mental health services, ambulance and other medically necessary transporlalion, special duly
nursing, adult day health, adult foster care, vision care services, kidney dialysis, family planning, centers for independent living, community health
center services.
'SF0 - Stale Funds Only eligibles.
11. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30. 1984
1984 1983
Expended
-
Recipient Expended
- -
Recipient
-
TOTAL . . . . . . . . . . . . . . . . . . . . . $58,298,292 378,065'' $52,752,436 367,084
. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL Not available
. . . . . . . . . . . . . . . . . . . . . . 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
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
. . . . . . . . . . . . Adults-Families w/Dep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
Wndupiicated Total - HHS report HCFA - 2082
Ill. Administration:
State Department of Public Welfare.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Immunizing biologicals available from DPH, legend vitamins not on Drug
List, 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: Yes. (Massachusetts list of interchangeable drugs for multisource drugs.)
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Not more than a 6-month supply may be prescribed.
2. Refills: Prescription may be refilled, as long as total authorization does not exceed a 6-
months' or Brefills supply from time of original prescription.
3. Dollar Limits: None.
D. Prescription Charge Formula:
1. Legend Drugs: $3.25 dispensing fee (effective 711 5/85).
2. Compounded prescriptions
a. Compounded prescriptions $4.09 dispensing fee.
b. Suppositories, tablet triturates, capsules $5.09 dispensing fee
3. 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.
4. Non-Legend Drugs: Not to exceed the lower of: (A) EAC plus dispensing fee. (6) Usual and
customary charge to pharmacy's retail customers.
V. Miscellaneous Remarks:
For A6 drugs, supplier bills State Commission for the Blind directly, which pays vendor pharmacy
through intermediary.
Fiscal Intermediary: 1983 Systems Development Corp
P.O. Box 9101
Somewille, Massachusens 02145
61 71625-01 20
Officials, Consultants and Commlttees
1. Welfare Department:
A. Officials
Charles Atkins
Commissioner
Carmen Canino
Acting Assistant Commissioner
Herbert B. Hechtman, M.D
Medical Director
Department of Public Welfare
600 Washington Street
Boston, Massachusens 021 11
Robert Karlyn, B.S., RPh.
Medicaid Pharmacy Program Consultant
61 71727-1 391
NPC
2. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: C. Osteopathic Society:
William B. Munier. M.D.
Executive Vice President
Massachusetts Medical Society
1440 Main Street
Watham 02254
Phone: 61 71893-4610
Mrs. Gladys M. Davis
Executive Secretary
Massachusetts Osteopathic Society Inc.
Box 147
Reading 01867
61 71944.5586
0. Pharmaceutical Association: D. State Board of Pharmacy
Ray Charpentier
Executive Director
Massachusetts State
Pharmaceutical Association
210 Lincoln Street
Boston 021 11
61 71423-7222
3. State Board of Pharmacy
Charles F. Monahan, Jr.
Executive Secretary
100 Cambridge Street. Room 1520
Boston. Massachusetts 02202
61 71727-3076
Charles F. Monahan, Jr.
Executive Secretary
100 Cambridge Street. Room 1520
Boston, Massachusetts 02202
61 717273076
61 7/944-5586
NPC
MI CHI GAN
MEDI CAL ASSI STANCE DRUG PROGRAM ( TI TLE XI X)
I. BENEFITS PROVIDED AN0 GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OM AB APTD AFDC O M AB APT0 AFOC Children 21 (SFOI
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
Outoatient
~ & a l Care X X X X X X X X X X
Laboratow &
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 (- Limited -) X (Limited)
Other Benefits: Transportation; Limited Vision & Hearing; Limited Medical Supplies & Equipment; Family Planning; Alcoholism & Drug Withdrawal;
Psychiatric Services. Special note: There are exclusions and limitations applicable to all services, and prior authorization i s required for some.
'SF0 -State Funds Only eligibles
11. EXPENDITURES FOR DRUGS. hvment to Pharmacists bv fiscal vear endina Seotember 30. 1984
Expended
-
Recipient
-
Expended
-
TOTAL . . . . . . . . . . . . . . . . . . . . . $86,822,1 20 764,1348" $77,560,984
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families.w/Oep Children
Adults-Families w1Dep Children . . . . . . . . . . . .
. . . . . . . . CATEGORICALLY NEEDY NON-CASH TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . Disabled
Children-Families w l h p Children . . . . . . . . . . . .
. . . . . . . . . . . . Adults-Families wlDep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families wlDep Children . . . . . . . . . . . .
. . . . . . . . . . . . Adults-Families w/Deo Children
Other Title XIX ~ecipients
Recipient
-
774,896
665,257
28,185
1.399
64,306
340.473
240.029
40,881
3,716
52
6,535
16,129
17.863
0
96.757
40,351
111
24.375
10,779
12,693
12.056
'"Unduplicated Total - HHS report HCFA - 2082
111. Administration:
Michigan Department of Social Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions and Restrictions:
Anorectics - Noncovered benefits; exception: prior authorization is given for certain diagnoses.
OTCs Noncovered benefit; exception: 1) insulin, 2) chronic renal disease drugs, 3) family
planning drugs, 4) medical supplies, and 5) reactivate supplies.
Analgesics - Selected products are noncovered benefits (i.e.. Darvocet-N. Ponstel, Talwin, Talwin
Compound).
Benzodiazepines - (used for anti-anxiety) - Chlordiazepoxide HCL and equivalents are the
only covered products (i.e., Antivan, Azene, Centrax. Serax. Tranzene, Valium, Verstran were
restricted).
Desi Drugs (Drug Efficacy Study Implementation) - Coverage of certain proposed less-than-
effective drugs is restricted base don federal regulation.
Hematinics, Antacids. Anti-Vertigo Drugs and Laxat~ves - Noncovered benefit; exception: certain
pediatric iron products.
Vitamins - Noncovered benefit; exceptions: 1) prenatal vitamins and 2) fluoride pedo-drops.
Cough and Cold Preparations - Noncovered benefits; exception: antihistamines.
Abused Drugs - Mequin, Parest, PBZ, Quaalude and Tripelenamine HCL (effective October 1,
1982). Doriden. Glutethimide and Placidyl (effective 4/01/83).
Potassium Replacements - Covered products are liquid potassium replacements and potassium
tablets and capsules with a maximum therapeutic price limit.
Sandimmune - Prior authorization required.
Drugs Withdrawn Because of Safety - Coverage restricted the date the program is notified.
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
Lansing, Michigan 48909
51 71373.0953
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, plus professional fee not to exceed $3.00 plus selected $0.50 copay
or
2. The M.A.C.' rate, plus professional fee not to exceed $3.00 plus selected $0.50 copay or
3. The provider's usual and customary charge to the general public.
'Maximum Allowable Costs
V. Miscellaneous Remarks:
Total Rx claims processed in FY 1984 10,888,285
Average Rx price during FY 1984 $10.40
Selected co-pay provision:
A $0.50 co-pay is assessed the patient when a branded drug product is dispensed. When
generic drugs are dispensed no co-pay is required.
Otflclala, Consultants and Comrnlttees
1. Social Services Department Officials:
Agnes M. Mansour, Ph.D.
Director
Kevin L. Seitz
Director
Dennis DuCap. Director
Office of Support Services
Vernon K. Smith, Ph.D.
Director. Bureau of Program
Pblicy
Keith F. Cole, Director
Bureau of Medicaid Operations
Robert Levin, D.D.S., Director
Bureau of Health Services Review
Richard Maharan. Director
Bureau of Medicaid Fiscal
Review
51 7,373-7720 @"
2. Social Services Department Advisory Committees:
A. State Medical Care Advisory Council:
Consumer Members
Ms. Ella Bragg
1541 1 Wabash
Detroit 48238
Mr. Samuel L. Davis
23555 Northwestern Hwy.
Southfield 48075
Mr. William Fairgrieve
300 North Washington Square
Suite 31 1
Lansing 48933
Michigan Department of Social
Services
P. 0. Box 30037
Lansing, Michigan 48909
Medical Services Administration
(same as above)
-Michigan Welfare Rights
Organization
-Michigan Association for
Emotionally Disturbed
Children
-Michigan League for Human
Services
NPC
Ms. Connie Marin
131 4 Ballard. Street
Lansing 48906
Mrs. Clarice Jones
2812 Woodruf, Apt. +3
Lansing 4891 2
Mrs. Janet Saxton
1309 Reo Road
Lansing 4891 0
Ms. Sharon Sebright
R #2,6657 U Avenue, West
Schoolcraft 49087
Mr. Paul N. Shaheen
320 West Ottawa
Lansing 48933
Ms. Jean Thompson
550 Collingwood
East Lansing 48823
Ms. Dorothy Walker
8721 East Jefferson Avenue
Detroit 48214
Provider Representatives
Mr. Reginald P. Ayala
Southwest Detroit Hospital
2401 20th Street
Detroit 4821 6
Mr. Dean Barker, R.Ph.
Smith Pharmacy
226 East Grand River
Lansing 48906
Ms. Sandra Billingslea
Michigan HMO Plans, Inc
7650 Second Avenue
Detroit 48202
Dorothy E. Carnegie, D.O.
Professor of Internal Medicine
College of Osteopathic Medicine
Michigan State University
East Lansing 48824
Lloyd Ganton
Arbor Manor Care Center
151 2nd Street
Spring Arbor 49283
-Cristo Rey Community Center
-American Association of
Retired Persons
-Consumer Member at Large
-Michigan Council on Maternal
and Child Health
-Citizens for Better Care
-United Auto Workers
Michigan Hospital Association
-Michigan Pharmacists Association
-Association of HMOs in Michigan
-Michigan Association of
Osteopathic Physicians
and Surgeons
-Health Care Association
of Michigan
Lilo Hoelzel-Seipp. R.N., Ph.D.
-Michigan Nurses Association
R.R. Y1 Holly Drive
T h o m~ ~ ~ n ~ i l l e 49683
Robert L. Leeser. M.D. -Michigan State Medical Society
210 North Oliver
Charlotte 48813
Richard F. Stilwill, D.D.S.
6020 North Hagadorn, Suite 4
East Lansing 48823
Grant Wiig, D.P.M.
305 North West Avenue
-Michigan Dental Association
-Michigan Association of
Podiatrists
Government Representatives
Mr. Dominic A. D'Annunzio
-Michigan Insurance Bureau
7419 Yorktown, Rt. #2
Lansing 4891 7
Mr. James P. Grannan
3001 West Big Beaver Road
Suite 700
Troy 48084
Ms. Judy Niles
930 West Holmes Road
Lansing 4891 0
Dr. Gloria R. Smith
P. 0 . Box 30035
Lansing 48909
Dr. Vernon K. Smith
P. 0. Box 30037
Lansing 48909
-Michigan Association of Health
Systems Agencies
-1ngham County Department of
Social Services
-Michigan Department of
Public Health
-Michigan Department of
Social Services
3. Executive Officers of State Medical, Pharmaceutical, and Osteopathic Associations:
A. Medical Society: C. Osteopathic Association:
Warren Tryloff
Executive Director
Michigan State Medical Society
120 West Saginaw
East Lansing 48823
Phone: 51 71337-1 351
B. Pharmaceutical Association:
Louis Sesti, R.Ph.
Executive Director
Michigan Pharmacists Association
815 N. Washington Avenue
Lansing 48906
Phone: 51 71484-1 466
D. A. DeShaw
Executive Director
Michigan Assoc. of Osteopathic
Physicians & Surgeons. Inc.
33100 Freedom Road
Farrnington 48024
Phone: 3131476-2800
D. State Board of Pharmacy:
Herman Fishman, Licensing Executive
North Ottawa Tower
61 1 West Ottawa Street, P.O. Box 30018
Lansing, Michigan 48909
NPC
MI NNESOTA
MEDI CAL ASSI STANCE D R U G PROGRAM ( TI TLE XI X)
I. BENEFITS PROVIDED AN0 GROUPS ELIGIBLE
Type of Benelit Categorically Needy Medically Needy (MN) Other*
OAA AB APT0 AFDC OAA AB APT0 AFDC Children 21 (SFo)
Prescribed
Drum X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X
Oulpatient
Hospital Care X X X X X X X X X
Laboratory &
X-rav Senrice X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X
physician
Services X X X X X X X X X
Dental
Services X X X X X X X X X
"SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Pavment to Pharmacists bv fiscal vear endino June 30. 1984
1984
Expended
-
Recipient
-
TOTAL . . . . . . . . . . . . . . . . . . . . . $35,655,862" 221.46s"
CATEGORICALLY NEEDY CASH TOTAL $15,611,255 148.286
Aged . . . . . . . . . . . . . . . . . . . . . . 3,278.777 9,032
Blind . . . . . . . . . . . . . . . . . . . . . . 117.802 345
Disabled . . . . . . . . . . . . . . . . . . . . . 6,128,761 14.978
Children-Families wlDep Children . . . . . . . . . . . . 2,122,283 70.092
Adults-Families w/Dep Children . . . . . . . . . . . . 3.963.632 53,839
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . 7,271.002 18,753
Aged . . . . . . . . . . . . . . . . . . . . . . 5,448.770 11,714
Blind . . . . . . . . . . . . . . . . . . . . . . 30.058 60
Disabled . . . . . . . . . . . . . . . . . . . . . 1,667,049 3.531
Children-Families w/Dep Children . . . . . . . . . . . . 42,942 1.756
Adults-Families w/Dep Children . . . . . . . . . . . . 80,358 1.664
Other Title XIX Recipients . . . . . . . . . . . . . . . 1,825 28
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . 12,773,605 51.555
Aged . . . . . . . . . . . . . . . . . . . . . . 8,926,414 21,958
Blind . . . . . . . . . . . . . . . . . . . . . . 34.694 94
Disabled . . . . . . . . . . . . . . .; . . . 2,814,329 6.729
Children-Families w/Dep Children . . . . . . . . .? . . . 118,329 4.228
Adults-Families w/Dep Children . . . . . . . . . . . . 320.995 4.426
Othe: Title XIX Recipients . . . . . . . . . . . . . . . 558,993 14,120
1983
Expended Recipient
- -
Ylnduplicated Total - HHS report HCFA - 2082
Ill. Administration:
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.
8. Formulary: Yes. (Restricted drug list.)
Thomas A. Kellenberger, Pharm.D.
Professional Services Section
Department of Public Welfare
444 Lafayette Road. P.O. Box 43170
St. Paul. Minnesota 55164
6121296-7850
C. Prescribing or Dispensing Limitations: 1. Refills are limited to 5 times or 6 months, whichever
comes first. Contraceptives may be filled to provide a 12-month supply.
D. Prescription Charge Formula: Reimbursement is based on the pharmacist's submitted charge or
the State Department of Public Welfare's maximum price, whichever is lower. Reimbursement
fee is $4.30 (effective July 1, 1985).
E. Ingredient reimbursement basis: AWP minus 10%.
Officials, Consultants and Committees
1. Welfare Department Officials:
Leonard Levine
Commissioner
61 21296-61 17
Robert C. Baird
Assistant Commissioner
Bureau of Income Maintenance
Thomas A. Gayiord, R.Ph.
Director
Health Care Programs
Thomas A. Kellenberger, Pharm.D
Director
Drug Utilization Review Program
John T. Bush, R.Ph.
Pharmacist Consultant
6121296-2363
2. Welfare Department Advisory Committees:
A. Professional Medical Advisory Committee:
Irving C. Bernstein. M.D.
101 1 Medical Arts Bldg.
Minneapolis 55402
Department of Public Welfare
Centennial Office Building
658 Cedar Street
St. Paul, Minnesota 55105
444 Lafayette Road
St. Paul 55164
Lyle Hay. M.D.
Route 1, Box 3028
Buffalo 5531 3
NPC
David Craig, M.D.
St. Paul Internist
590 Park Street, Suite 408
St. Paul 55103
Peter Fehr, M.D.
3931 Crystal Lake Blvd
Minneapolis 55422
Frank S. Babb, M.D.
St. Anthony Orthopaedic Clinic
1661 St. Anthony, Suite 200
St. Paul 55104
Kathleen Simo, M.D.
South Medical Clinic
Nicollet Avenue
Minneapolis 55408
Lyle French, M.D.
5620 West Bararian Path
Minneapolis 55432
Dorothy Bernstein. M.D.
101 1 Medical Arts Bldg.
Minneapolis 55404
Miland E. Knapp, M.D.
21020 Oak Lane
Excelsior 55331
John J. Reagan, M.D.
1431 Medical Arts Building
Minneapolis 55402
Henry Blissenbach, Pharm.D.
Merrill Chesler, M.D. 2119 Aztec
Physicians & Surgeons Bldg.
Mendota Heights 55120
63 S. 9th Street
Minneapolis 55402 Shirley Mink. Ph.D.
110 E. 18th Street
John McNeil, M.D. Minneapolis 55403
1224 Lowry Building
St. Paul 55102
8. Minnesota State Pharmaceutical Association Welfare Task Force:
Donald Gibson - Duluth
Michael E. O'Toole. R.Ph.
- Minneapolis
Roger Vadheim. R.Ph. -Tyler
(Chairman)
William F. Appel, R.Ph.
- Minneapolis
Kent F. Olson, R.Ph.
- Hopkins
Barry M. Krelitz. R.Ph. - Edina
Carl W. Oberg. R.Ph.
- Duluth
3. Executive.Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: C. Osteopathic Medical Society:
Douglas A. Shaw
Robert N. Sampson, D.O.
Chief Executive Officer Executive Director
Minnesota State MedicalAssociation
Minnesota Osteopathic Medical
2221 University Avenue, S.E. Society
Suite 400 Hoffman Clinic
Minneapolis 55414 Hoffman 56339
Phone: 61 21378-1 875
Phone: 61 21986-2038
NPC
0. Pharmaceutical Association: D. State Board of Pharmacy
Donald A. Dee. R.Ph. David Holmstrom, Secretary
Executive Director 717 Delaware Street, S.E., Room 351
Minnesota State Pharmaceutical Association Minneapolis, Minnesota 55414
Health Associations Center 61 21623-541 1
2221 University Avenue, S.E., Suite 326
Minneapolis 55414
Phone: 6121378-1414
4. State Board of Pharmacy:
David Holmstrorn. Secretary
717 Delaware Street. S.E., Room 351
Minneapolis, Minnesota 55414
6121623-541 1
NPC
MI SSI SSI PPI
MEDI CAL ASSI STANCE D R U G PROGRAM ( TI TLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of BeneM Catworically Needy Medically Needy (MN) Other*
OAA A8 APTD AFDC OAA AB APTD AFDC Children 21 lSFOl ~ ~
. .
Prescribed
Drugs X X X X
Hospital Care X X X X
Outpatient
Hospital Care X X X X
Laboratory &
X-rav Service X X X X
Skilled Nursing
Home Services X X X X
Phvsician
,- -
Serv~ces X X X X
Dental
Services X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Paymenl to Pharmacists by fiscal year ending June 30, 1984
1984 1983
Expended Recipient
- -
Expended Recipient
- -
TOTAL . . . . . . . . . . . . . . . . . . . . . $38,883,529 241.805** $34,623,626 230.248"
. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL $35,195,869
. . . . . . . . . . . . . . . . . . . . . . Aged 13.604.631
Blind . . . . . . . . . . . . . . . . . . . . . . 369,211
Di s abl ed. . . . . . . . . . . . . . . . . . . . . 14,788.923
. . . . . . . . . . . . Children-Families w1Dep Children 2,965.729
. . . . . . . . . . . . Adults-Families w1Dep Children 3,467,375
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . 4,935.787
Aged . . . . . . . . . . . . . . . . . . . . . . 3816.520
Blind 12.040
Disabled . . . . . . . . . . . . . . . . . . 714,343
. . . . . . . . . . . . Children-Families w/Dep Children 160.527
. . . . . . . . . . . . Adults-Families w/Dep Children 208,685
Other Title XIX Recipients 23,672
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . 0
Aged . . . . . . . . . . . . . . . . . . . . . . 0
Blind . . . . . . . . . . . . . . . . . . . . . . 0
Disabled . . . . . . . . . . . . . . . . . . . . . 0
Children-Families w/Dep Children . . . . . . . . . . . . 0
Adulk-Families wlDep Children . . . . . . . . . . . . 0
Other Tille XIX Recipients . . . . . . . . . . . . . . . 0
"Unduplicated Tota - HHS reporl HCFA - 2082
Ill. Administration:
Mississippi Medicaid Commission.
IV. Provisions Relating to Prescribed Drugs.
A. General Exclusions:
1. Reimbursement is limited to drugs listed in the formulary.
2. Exclusions are amphetamines, obesity control drugs, vitamins, cold and cough preparations,
certain peripheral vasodilators, and those drugs classified as mild tranquilizers.
8. Formulary: Restricted formulary. For formulary information contact:
James T. Steele
Mississippi Medicaid Commission
P.O. Box 16786
Jackson, Mississippi 39236
6011981 -4507, Ext. 145
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Prescription or refill quantities should not exceed the amount shown
in the maximum units column of the formulary. Prescriptions limited to four (4) per month per
recipient.
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.
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 Prolixin shall be an exception.
4. Dollar Limits: None.
D. Prescription Charge Formula:
1. Legend Drugs - reimbursement for all legend drug claims is based on the lower of:
a. MAClEAC (ingredient cost) determined for the drug in the quantity dispensed, plus $3.33
dispensing fee. Dispensing physicians receive a fee of $2.10.
b. The usual and customary retail charge.
c. Co-payment: $1.00.
2. Reimbursement for non-legend drugs are based on the lower of usual and customary charge
or the maximum over-the-counter price set for that item listed in formulary. Usual and
customary of a non-legend drug is to be the shelf price.
3. Compounded prescriptions for topical use are covered if at least one legend drug (in
therapeutic amounts) is included in the ingredients.
4. Compounded oral medications when all ingredients are covered separately under their own
drug codes in the formulary.
V. Miscellaneous Remarks:
Medicaid eligible persons received 3,340,389 prescriptions during Fiscal Year 1984. This
represents a decrease of 63,661 prescriptions or 01.9%from Fiscal Year 1983.
Average Rx price during PI 1983 - $12.01
Fiscal intermediary:
E.D.S. Federal
P. 0 . Box 31475
Jackson, MS 39206
Officials, Consultants and Committees
1. Office of the Governor. Division fo Medicaid (Bill Alain, Governor)
B.F. Simmons
Director
James T. Steele, R.Ph.
Pharmacist
Office of the Governor
Division of Medicaid
(P. 0. Box 16786)
4785 1-55 Frontage Road
Jackson, Mississippi 39236
2. Title XIX Technical Advisory Committee:
There are six (6) technical advisory committees. Each committee consists of individuals who are
health care professionals identified with the responsibility of the committee to which they are ap-
pointed.
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: B. Pharmaceutical Association:
Charles L. Mathews
Executive Secretary
MS State Medical Assoc
735 Riverside Drive
Jackson 39216
Phone: 60113545433
Phylliss M. Moret, R.Ph.
Executive Director
Mississippi Pharmacists Assoc
401 E. Capitol St., Suite 504
Jackson 39201
Phone: 601/944-0416
C. Osteopathic Medical Association: D. State Board of Pharmacy
Ronald Powell, D.O.
Secretaryrrreasurer
330 W. Broad Street
~ e s i Point, MS 39773
H.W. Holleman. Executive Director
Suite 107-F, C & 1 Plaza
2310 Highway 80 West
Jackson, MS 39204
6011354-6750
NPC
MI SSOURI
MEDI CAL ASSI STANCE D R U G PROGRAM (TITLE XI X)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
O M AB APT0 AFDC OM A8 APTD AFDC Children 21 WO)
Prescribed
Drugs X X X X X
inpatient
Hosoital Care
Hosp~tal Care X X X X X
Laboratory &
X-ray S e ~ ~ c e X X X X X
Sk~lled Nurslng
Home Services X X X X X
Phys~c~an
Serv~ces X X X X X
Dental
Se~l ces X X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30. 1984
TOTAL
19ffl 1983
Expended
-
Rec~pient
-
Expended Recipient
- -
. . . . . $29,577,083 248,371" $25,569,347 237,290
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . 12,649.514 170,551 11,W)5,615 163.919
Aged . . . . . . . . . . . . . . . . . . . . . . 4,500,173 19.960 4,634,232 23.334
Blind . . . . . . . . . . . . . . . . . . . . . . 262.911 1.053 258,122 1.209
Disabled . . . . . . . . . . . . . . . . . . . . . 2,930,762 10.475 2,719,315 11,090
Children-Families wIDep Children . . . . . . . . . . . . 1,925,546 . 81.358 1,640,793 75.878
Adults-Families w l k p Children . . . . . . . . . . . . 3,030,121 57,705 2,553,153 52,408
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . $16,927,569 77,820 13,763,732 73,371
Aoed . . . . : . . . . . . . . . . . . . . . . . 9,081,844 35,896 7,609,230 33.726
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w l k o Children . . . . . . . . . . . .
Adults-Families wIDep children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w l k p Children . . . . . . . . . . . .
Adults-Families w l k o Children . . . . . . . . . . . .
Other Title XIX ~eci pi i nt s
"Undupliraled Total - HHS report HCFA - 2082
NPC
Ill. Administration:
Division of Family Services of the State Department of Social Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Exclusions governed by Formulary.
8. 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. Missouri 65102
314/751-3277
State allows payment only for the drugs in the formulary.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Physician encouraged to prescribe 34-day or 100 doses supply but
may, at his own discretion, prescribe up to a maximum 90-day supply.
2. Refills: Federal regulations must be observed for all drugs on the formulary which are listed
in BNDD Schedules 2. 3, 4, and 5. All other prescriptions refilled should be in accordance
with the directions given by the prescribing physician.
3. Five Rx limitation per month per recipient. Certain drugs which are commonly prescribed for
long-term chronic medical conditions are exempt from limitation.
D. Prescription Charge Formula: The lowest of the following: Federal MAC. Missouri MAC, AWP, or
Direct plus $2.50 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
-Go-payment retained by pharmacist.
F. Drug Exception Process:
Certain nonsteroidal anti-inflammatory drugs covered on a prior authorization basis for recipients
with diagnosis of rheumatoid arthritis or juvenile rheumatoid arthritis who cannot tolerate aspirin.
V. Miscellaneous Remarks:
All prescriptions must be filled with drugs that meet USP standards. Participating pharmacies sign
a participation agreement with the State Department. All dispensing physicians participating in the
program are required to keep prescription files the same as pharmacies.
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 $2.50 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 (Average Wholesale Price), any drug that is not manufactured by Abbott. 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.
NPC
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.
The Federal Government has 19 drugs listed as MAC (Maximum Allowable Cost). Missouri has 41
drugs listed as MAC (Maximum Allowable Cost). These 60 drugs 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 Services 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, Missouri 65101
Number of drug claims processed in FY 1984 - 3,622,556
Average prescription price during FY 1984 - $8.77
Officials, Consultants and Committees
1. Social Services Department Officials:
Joseph J. O'Hara
Director
Susan Turner
Director,
Jane Y. Kruse
Director
David G. Foshage
Administrator
SurveillancelUtilization
Review Systems (SURS)
Susan McCann
Pharmacist Consultant
Everett Harris, D.O.,
Physician Consultant
Michael Wilson, D.O.,
Physician Consultant
Department of Social Services
Broadway State Office Building
P. 0. Box 1527
Jefferson City. Missouri 65103
Division of Family Services
P. 0. Box 88
Jefferson City, Missouri 65103
Division of Medical Services
308 East High Street
P. 0. Box 6500
Jefferson City 65102
2. Medical Advisory Committee to the State Division of Family Services:
Chairman
Lesiie F. Bond, M.D.
3400 North Kingshighway
St. Louis, Missouri 631 15
(31 4) 385-3600
Vice Chairman
B. David Hartwig, R.Ph.
Red Cross Pharmacy
52 Arrow Street
Marshall. Missouri 65340
(81 6) 886-5533
NPC
J.B. "Jet" Banks
1442 A North Grand
St. Louis, ~i ssouri
31 41533-1 900
Ms. Eddie Maw Binion
9463 Indian Meadow Drive 302
St. Louis, Missouri 63132
(314) 997-1 81 5. 421 -5322
James E. Canter, 13.0. D.
410 Northeast Street
California, Missouri 65018
(31 4) 796-31 11
Erma Cunningham
Executive Director
Missouri River Home Health Agency
219 East Dunklin
Jefferson City. Missouri 65101
31 416355643
Representative Russell Goward
4015 Fair Avenue
St. Louis, Missouri
31 41652-0200
Bob Griffith
Griffith Company
48 Doctors Park
Cape Girardeau, Missouri 63701
(31 4) 334-6003
Jonathan G. Hanson. D.D.S.
1407 Southwest Boulevard
Jefferson City, Missouri 65101
Doretta Henderson
1615 Mary Lou Williams Lane
Kansas City, Missouri 64106
8 16142 1-2075
Ex-Off icio Members:
Roben Hotchkiss, M.D.
Division of Health
63106 Broadway State Office Building
P. 0. Box 570
Jefferson City, Missouri 65102
Dennis L. Hunter, OD.
West Morgan
Marshall, Missouri 65340
(81 6) 886-551 7
Patrick Morton
Associate Hospital Director of
Financial Services
MU Hospital and Clinics
One Hospital Drive
Columbia, Missouri 65212
31 41882-291 2
Homer S. Spiers. Administrator
Resthaven Nursing Home
1500 West Truman Road
Independence, Missouri 64050
(81 6) 254-3500
631 15 John Vogt. MSW
805 East 41 st Street
Kansas City, Missouri 641 10
H. 8161531-5857; Of. 8161471-5930
Senator Harry Wiggins
7817 Terrace Street
Kansas City, Missouri 641 14
Starks Williams, M.D.
1734 East 63rd Street
Kansas City. Missouri 641 10
8161 H. 373-4831; Of. 361-6699
Norman McCann, President
Missouri Baptist Hospital
301 5 North Ballasl Road
St. Louis, Missouri 63131
3141432-1212
Joyne Leet
Executive Director
Primary Care Council of
Metropolitan St. Louis, Inc.
4900 Delmar Boulevard
St. Louis, Missouri 63108
3 1 4/36 1 -2330
Missouri 5
19H!i
3. Pharmacy Advisory Committee:
Chairman
B. David Hartwig, R.Ph
Red Cross Pharmacy
52 Arrow Street
Marshall 65340
8161886-5533
Bill Fitzpatrick. R.Ph.
Fitzpatrick Pharmacy
130 Manchester
Ballwin, Missouri 6301 1
(314) 394-6622, 576-1 300
Tom Gibson, R.Ph.
Waverly Pharmacy
Kelling and Broadway
Waverly 64096
(81 6) 493-2271
Eules Hively, R.Ph.
Teko Pharmacy
501 Teaco
Kennett, Missouri 63857
(31 4) 888-6673
Jack Littrell, R.Ph.
Blue Valley Pharmacy
581 1 Truman Road
Kansas City, Missouri 64126
(816) 483-4405,436-4700,373-0942
Max Maupin. R.Ph.
Hillcrest Pharmacy
Hillcrest Shopping Center
Rolla, Missouri 65401
(31 4) 364-3258
James S. Osborn, R.Ph.
Osborn Medical Tower Pharmacy
1443 North Robberson
Springfield 65802
(41 7) 866-4341
4. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: . C. Osteopathic Association:
Royal Cooper
Executive Secretary
Missouri State Medical Assoc.
1 13 Madison Street
P. 0. Box 1028
Jefferson City 65101
Phone: 3141636-5151
Edward Borman, J.D.
Executive Director
Missouri Assoc. of Osteopathic
Physicians and Surgeons
P. 0 . Box 748
Jefferson City 65102
Phone: 31 41634341 5
€3. Pharmaceutical Association: D. State Board of Pharmacy
J0hn.B. Zatti. R.Ph.
Chief Executive Officer
Missouri Pharmaceutical Assoc.
410 Madison Street
Jefferson City 65101
Phone: 3141636-7522
Kevin E. Kinkade, Executive Director
P.O. Box 625
Jefferson City, Missouri 65102
3141751 -2334
NPC
MONTANA
MEDI CAL ASSI STANCE D R U G PROGRAM ( TI TLE XM)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Olher*
O M AB APT0 AFDC OAA AB APT0 AFDC Children 21 (SFO)
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
Denlal
Services X X X X
X X X X X
'SF0 - Stale Funds Only
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
Expended Recipient Recipienl
- -
Expended
- -
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
A " P ~ . . . . . . . ., ..
.
Blind . . . . . . . . . . . . . . . . . . . . . . 13.204 73 13.508 68
Disabled 985.920 3.975 904.438 . . . . . . . . . . . . . . . . . . . . . 3.499
Children-Families w/Dep Children 252,740
9,615 215.449 . . . . . . . . . . . . 8,655
Adults-Families w/Oep Children 495.757
6,995 . . . . . . . . . . . . 387,585 6,033
Other 11,108 162 . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . .
CATEGORICALLY NEEDY NON-CASH TOTAL 1.866.599
Aged . . . . . . . . . . . . . . . . . . . . . . 1,208,898
Blind . . . . . . . . . . . . . . . . . . . . . . 4,805
Disabled . . . . . . . . . . . . . . . . . . 489.394
Children-Families w1Dep Children . . . . . . . . . 81,234
Adults-Families w/Dep Children . . . . . . . . . . . . 76.631
Other Title XIX Recipients . . . . . . . . . . . . . . . 5.636
. . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL 1,050,007
Aged . . . . . . . . . . . . . . . . . . . . 579.1 86
Blind . . . . . . . . . . . . . . . . . . . . . . 5.190
Disabled . . . . . . . . . . . . . . . . . . . 445,254
Children-Families w l k p Children . . . . . . . . . . . . 2,721
Adults-Families wlOep Children . . . . . . . . . . . . 15,857
Olher Title XIX Recipienls . . . . . . . . . . . . . . . 2,804
"Unduglicated Total - HHS report HCFA - 2082
ill. Administration:
State Department of Social and Rehabilitation Services
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Provided are all prescription drugs and those over-the-counter drugs in the
following classes: insulin, laxatives, antacids. Both types must be prescribed by a licensed
practitioner (physician, dentist, or podiatrist).
8. Formulary: None.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: None.
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 $3.75. Additional $0.75 per Rx allowed for unit dose systems.
E. Co-payment - $0.50 (Federal exemptions apply)
Offlclals, Consultants and Committees
1. Social and Rehabilitation Services Department Officials:
Dave Lewis
Director
Jack Ellery, Administrator
Economic Assistance Division
Lowell Uda, Chief
Medicaid Services Bureau
Department of Social and
Rehabilitation Services
P. 0. Box 4210
Helena. Montana 59604
John Larson, Chief
Medicaid Financing Bureau
Randal P. Bowsher
4061444-4540
2. Montana Medical Care Advisory Council:
James Conway
John Jacobson. M.D.
Lowell Uda
John Layne, M.D.
Calvin Bohleen
Gary Blewett
Charles Briggs
Jack Ellery
3. Social and Rehabilitation Services Economic Assistance Division:
Dale Haefer
Administrative Officer
Barbara Bartell
Administrative Officer
Karl Banschbach
Medical Care Specialist
Paul Miller
Medical Care Specialist
NPC
John Kall, D.D.S.
Dental Consultant
Joyce DeCunzo
Administrative Officer
John Patrick
Administrative Officer
Charles Williams
Administrative Officer
Randy Bowsher
Administrative Officer
Robert Olesen
Administrative Officer
Brian Camoure
Administrative Officer
4. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
G. Brian Zins
Executive Director
Montana Medical Association
2021 1 1 th Avenue. Suite 12
Helena 59601
Phone: 4061443-4000
6. Pharmaceutical Association:
Robert Likewise
Executive Director
Montana State Pharmaceutical Association
P.O. Box 4718
Helena 59604
Phone: 40614494843
C. Osteopathic Association:
Phillip L. Dean, D.O.
Secretary-Treasurer
Montana Osteopathic Association
Box 1299
Malta, Montana 59538
D. State Board of Pharmacy
warre;? Amole, Executive Director
510 1st Avenue. N.. Suite 100
Great Falls, Montana 59401
4061761 -5131
NEBRASKA
MEDI CAL ASSI STANCE D R U G PROGRAM ( TI TLE XI X)
I. BENEFITS PROVIDED AN0 GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
O M AB APT0 AFDC OAA AB APT0 AFDC Children 21 lSFOI
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
Hnsnital 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 Sewlces X X X X X X X X X X
Physician
Services X X X X X X X X X X
Dental
Services X X X X X X X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
Expended Recipient Expended Recipient
- - - -
. . . . . . . . . . . . . . . . . . . . . TOTAL $1 1,325,229 63,473'. $10,642,008 60,421
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $6,929.099 50,252 $6,381,812 47,738
Aoed . . . . . . . . . . . . . . . . . . . . . . 2,209,371 5.332 2847.696 5.169
0~~
Blind . . . . . . . . . . . . . . . . . . . . . . 37,753 124 40,636 142
Disabled . . . . . . . . . . . . . . . . . . . . . 2,553,456 6,229 2,329.579 6,155
. . . . . . . . . . . . Children-Families w/Dep Children 814.476 22,689 764,667 26,572
. . . . . . . . . . . . Adults-Families w/Oep Children 1.314.043 15.888 1,199.232 14.700
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . $163.290 3.705 $141,525 3.350
Aged . . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0
Blind 0 0 0 0
Disabled
0 0 0 0
Children-Families w/Dep Children . . . . . . . . . . . . 28,344 1,183 22,888 994
. . . . . . . . . . . . Adults-Families w/Oep Children 45,673 970 32.304 739
Other Title XIX Recipients . . . . . . . . . . . . . . . 89,280 1.552 86,333 1,617
MEDICALLY
Aged . .
Blind . .
Disabled
NEEDY
. . .
. . .
TOTAL . . . . . . . . . . . . . . $4232,579 9,498 4,118,451 9,338
. . . . . . . . . . . . . . . . . 3,564992 8,026 3.479.871 7.868
. . . . . . . . . . . . . . . . . 6,392 12 6,106 12
. . . . . . . . . . . . . . . . . 640,431
....... 1,181 61 1.394 1,194
Children-Families w/Dep Children . . . . . . . . . . . . 4,840 159 3.569 144
Adults-Families w/Dep Children . . . . . . . . . . . . 15,595 116 16.553 113
Other Title XIX Recipients . . . . . . . . . . . . . . . 329 4 958 7
*'Unduplicated Total - HHS report HCFA - 2082
NPC
111.Administration:
State Department of Social Services.
iV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Experimental drugs; weight control and appetite depressant drugs, except
for use in narcolepsy or hyperkineses 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.
8. Formulary: None. The "Official Drug Guide" is a list of drugs together with identification members
for billing purposes. For Drug Guide Information, contact:
Mr. Tom Dolan. R.Ph.
Nebraska Dept. of Social Services
P.O. Box 95026
Lincoln, Nebraska 68509
4021471 -3121
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.
b. When the prescribing physician's professional judgment indicates that these quantities
of medication wwi d 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.
* Medical Services, Department of Social Services. State of Nebraska. Nebraska DSS Program Manual
issued November 24. 1982. as amended.
(1) 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 it's a full month's supply.
(2) Original shelf packages of 100 tablets or capsules of ROUTINELY prescribed drugs
will NOT be acceptable as sufficient for fulfillment of our quantity limitations require-
ment. The full month's supply must be prescribed and dispensed.
(3) 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.
(4) Ready-made ointments, creams, etc., when used in a chronic or maintenance man-
ner, may be dispensed in an original shelf package size provided it is the original
size closest to the needed amount of medication.
(5) The determination of whether a claim violates our regulations or not, would, by
necessity, have to be made by the Department of Social Services professional staff.
Any claim deemed to be in violation or not an exception to our rulings, will not be
compensated with the dispensing fee.
Any disagreement with a determination may be arbitrated through the NEBRASKA
PHARMACISTS ASSOCIATION'S ADVISORY COMMITTEE.
3. Refills: As authorized by the prescribing physician.
4. Dollar Limits: None.
D. Prescription Charge Formula:
1. Retail Pharmacies
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 main-
tenance 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 month3 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 $3.25 to maximum $4.69.
or usual and customary, whichever is lower.
2. DETERMINING DRUG OR INGREDIENT COST
a. General Information
(1) Maximum Allowable Cost (M.A.C.)
Certain multiple source products will have a maximum allowable cost designated by
the Federal Pharmaceutical Reimbursement Board, Department of Health, Education,
and Welfare. The M.A.C. value will be Me lowest cost at whlch the drug is widely
and consistently available.
187
NPC
The determination of which products will be designated M.A.C. items will be the
direct responsibility of the Reimbursement Board. The Nebraska Department of
Social Services will NOT have authority to increase the M.A.C. of any product. Any
individual or organization may at any time request that a M.A.C. determination be
revised or withdrawn. All requests must be submitted directly to the Pharmaceutical
Reimbursement Board, DHHSIHCFA, 6401 Security Blvd.. Rm. 1-C-5 East Low Rise
Bldg., Baltimore. Maryland 21235.
All pharmacies will be notified by the Nebraska Department of Social Services as
to which items have been designated as M.A.C. products and what their respective
M.A.C. values are.
(2) State Maximum Allowable Cost (SMAC): NDSS designates a state maximum allow-
able cost (SMAC) for certain drug products available from multiple manufacturers.
The SMAC value is the cost at which the multiple-source drug is widely and con-
sistently available to pharmacy providers in Nebraska. The determination of which
products are designated SMAC items is the direct responsibility of the Division
of Medical Services in conjunction with the Nebraska Pharmacists Association's
Advisory Committee. Any individual or organization may request a revision in a
SMAC value directly from NDSS at any time.
(3) Estimated Acquisition Cost (EAC): All drug products, including the federally-
designated MAC and state-designated SMAC drugs, are assigned an estimated ac-
quisition cost (EAC) as required by 42 CFR 447.332 (a)
(4) The EAC of any product is the cost at which most prudent providers may obtain the
item. NDSS is 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
NDSS.
b. Cost Limitations
The Nebraska Medicaid Drug Program is required to reimburse product cost at the
LOWEST of:
(1) the M.A.C. or S.M.A.C. of the drug, i f one has been established, or,
(2) the E.A.C. for that drug,
The M.A.C. limitation will not apply when the prescribing physician certifies on a Form
MC-6 that a specific brand is medically necessary. In these cases, the E.A.C. will be
the maximum allowable cost.
The S.M.A.C. limitation may be overriden by contacting the medical director by phone
or mail.
4. PRICING INSTRUCTION (DRUGS)
UNDER NO CIRCUMSTANCES, MAY ANY 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 (M.A.C.. S.M.A.C. or E.A.C.) plus the appropriate dispensing fee(s), 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:
1. Product Cost (M.A.C., S.M.A.C. or E.A.C.) plus the appropriate dispensing fee(s), or
2. The usual and customary sheMprice to the general public
NPC
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
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.
Number of claims processed in FY 1984-1,021,640
Average prescription price during FY 1984-$11.74.
Officials, Consultants and Committees
1. Social Services Department Officials:
Gina C. Dunning
Director
Robert Seiffert
Administrator
Division of Medical Services
Ms. Kris Logsdon
Surveillance and Utilization
Review Consultant
Dr. Christine Wright. M.D.
Medical Consultant
Dr. Edward J. Smith, M.D.
Medical Director
Division of Medical Services
Tom R. Dolan. R.Ph.
Pharmaceutical Consultant
Division of Medical Services
4021471 -31 21
Max J. Ward, R.P.
Pharmacist
Division of Payment and Data Services
4021471 -3121, Ext. 315
Gary J. Cheloha, R.Ph.
Assistant to Administrator
Division of Medical Services
4021471 -31 21. Ext. 132
Department of Social Services
301 Centennial Mall South
5th Floor
Lincoln, Nebraska 68509
2. Social Services Department Medical Care Advisory Committee:
Evelyn Runyon
261 5 No. 102 Avenue
Omaha NE 68134
Warren Bosley, MD
181 1 West Znd, Suite 360
Grand Island. NE 68801
NPC
Edmund Schneider. O.D.
Lincoln Vision Clinic
810 North 48th Street
Lincoln 68504
Robert Marshall, Pharm.D.
Nebraska Pharmacists Assoc.
600 S. 12th Street
Lincoln 68508
Gregg Wright, MD, Director
Department of Health
301Centennial Mall South. 3rd FI.
Lincoln, NE 68509
Larry Rennecker
Senior Vice President
Bergan Mercy Hospital
7500 Mercy Road
Omaha, NE 68124
Faye Sorenson, RN
Director of Nursing Services
Jennie M. Melham Memorial Med. Ctr.
Broken Bow, NE 68822
Steve Lorenzen, Director
Federal Programs
Blue Cross-Blue Shield of NE
P.O. Box 3248
Main Post Office Station
Omaha, NE 68180
Diannae Kascht
1528 D Street
Lincoln, NE 68502
Jack Vetter, President
Vetter Health Services
12614 Sky Park Drive
Omaha, NE 68137
Thomas Kiefer. DDS
2602 J Street
Omaha, NE 68137
Peter R. Kongstvedt. MD
Executive Director
Health America of Lincoln
17th & N Streets
Lincoln, NE 68508
Keith Mueller, PhD
Political Science Department
University of Nebraska
Lincoln, NE 68588-0328
Pat Snyder, NHA, Administrator
Lancaster Manor
1145 South Street
Lincoln. NE 68502
Steve Petruconis, Vice President
St. Elizabeth Community Health Center
555 South 70th Street
Lincoln, NE 68510
Doris Gunn
2410 T Street
Lincoln, NE 68503
Shirley A. Munn-White
General Manager
Capitol Medical
271 1 0 Street
Lincoln, NE 68510
NPC
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
Kenneth Neff
Executive Secretary
Nebraska Medical Association
1902 First National Bank Bldg.
Lincoln 68508
Phone: 4021432-7585
6. Pharmaceutical Association:
Robert Marshall, Pharm.D.
Executive Director
Nebraska Pharmacists Association
600 S. 12th Street
Lincoln 68508
Phone: 4021475-4274
C. Osteopathic Physicians and Surgeons:
A. G. Zuspan. D.O.
Secretary
Nebraska Association Osteopathic
Physicians and Surgeons
121 0 13th Street
Aurora 68818
4121694-2525
4. State Board of Pharmacy
Laura J. Partsch. Director
P.O. Box 95007
Lincoln, NE 68509
402/471-2115
NPC
NEVADA
MEDI CAL ASSI STANCE DRUG PROGRAM ( TI TLE XI X)
I BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benel~t Categor~caliy Needy Medically Needy (MN) Other"
O M AB APT0 AFDC O M AB APT0 AFDC Ch~ldren 21 (SFO)
Prescribed
Drugs X X X X
lnnat~anl
... v- .. - ...
Hospital Care X X X X
Outpatient
Hospital Care X X X X
Laboratory &
X-ray S ~ N I C ~ X X X X
Skilled Nursing
Home Services X X X X
Phv~i ri an
'SF0 - State Funds Only
11. EXPENOiTURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
Expended
-
Recipient
-
Expended
-
Recipient
-
. . . . . . . . . . . . . . . . . . . . . TOTAL
. . . . . . . . . . CATEGORICALLY NEEOY CASH TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . Blind
Disabled
. . . . . . . . . . . . Chiidren-Families wloep Children
. . . . . . . . . . . . Adults-Families wIDep Chiidren
. . . . . . . . CATEGORICALLY QEEDY NON-CASH TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . Blind
. . . . . . . . . . . . . . . . . . . . . Disabled
. . . . . . . . . . . . Children-Families w l b p Children
. . . . . . . . . . . . Adults-Families w/Dep Chiidren
. . . . . . . . . . . . . . . Other Title XiX Recipients
. . . . . . . . . . . . . . MEDICALLY NEEOY TOTAL
. . . . . . . . . . . . . . . . . . . . . . Aged
. . . . . . . . . . . . . . . . . . . . . . Blind
Disabled . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families wIDep Chiidren
Aduits-Families wl b p Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
"'Undu~licated Total - HHS repolt HCFA - 2082
Ill. Administration:
State Welfare Division of the Department of Human Resources.
IV. Provisions Relating to Prescribed Drugs:
A. General: Pharmaceuticals
Covered. The Nevada Medicaid drug program will pay for the following prescribed pharmaceuticals:
1. Legend pharmaceuticals
2. Insulin
3. Diabetic urine test tablets and test tapes.
4. Prenatal vitamin/mineral supplements, legend or non-legend, intended for prenatal care.
5. Family planning items such as diaphragms, oral contraceptives, foams and jellies.
Excluded. Nevada Medicaid will not pay for the following:
1. Anorectics used for obesity control.
2. Amphetamine combinations.
3. Radiopaque agents (e.g.. Telepaque, Hypaque. Barium Sulfate).
4. Radiographic adjuncts (e.g., Perchloracap).
5. Pharmaceuticals designated "ineffective," or "less than effective" (including identical, related,
or similar drugs) by the FDA as to substance or diagnosis for which prescribed.
6. Pharmaceuticals considered "experimental" as to substance or diagnosis for which
prescribed.
Exceptions: Nevada Medicaid will not pay for the following unless prior-authorized by the
Medicaid Office on form NMO-3, Treatment Authorization Request (TAR):
1. Amphetamine (e.g., Dexedrine).
2. Aspirin (e.g.. Zorprin, Easprin)
3. Ergoloid mesylates (e.g., Hydergine).
4. Ethaverine (e.g., Ethatab).
5. Fluoride preparations.
6. Glucose blood test strips.
7. Methylphenidate (e.g.. Ritalin).
8. Nicotine preparations (e.g., Nicorette).
9. Nicotinic acid in oral or injectible form.
10. Nitroglycerin transdermal systems (e.g., Nitrodisc, Nitro-Dur. Transderm-Nitro.
11. Non-legend pharmaceuticals.
12. Papaverine (e.g., Pavabid).
13. Pemoline (e.g.. Cylert)
14. Quinine (e.g., Quinamm)
15. Vitamins, vitaminlmineral combinations or hematinics.
16. Appliances, sundries and supplies; see 1202.4.
17. Nutritional supplements or replacements; see 1202.5 and 1203.3.
18. Those vaccines not readily available free of charge.
B. Formulary: None. (Certain Rx categories are excluded from reimbursement. See Section B
above.)
C. Prescribing or Dispensing Limitations:
Limitations
1. Prescriptions. Eligible Medicaid recipients may receive three 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 of paragraph A above.
NPC
D. Prescription Charge Formula:
1. Reimbursement: Legend Drugs
Reimbursement for legend pharmaceuticals is the lowest of (1) maximum allowable cost
(MAC) 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 $3.78 per prescription. (EAC is defined as AWP minus 5%).
V. Miscellaneous Remarks:
Copayment by Recipient
Recipients are required to pay the pharmaceutical provider $1.00 copayment for each prescription
received:
A. Exemptions from the copayment requirement are the following:
1. Inpatients, except when receiving "take home" prescriptions on day of discharge.
2. Family planning prescriptions (oral contraceptives, diaphragms, foams and jellies).
3. Those ~ndividuals whose Medical Certificates ere printed "EXEMPT FROM CO-PAYMENT".
Miscellaneous:
Fiscal intermediary:
Blue Shield of Nevada
P.O. Box 10330
Reno, Nevada 89510
Number of claims processed PI 1984-212,183
Average prescription price during FY 1984-$12.69
Officials, Conaultants and Committees
1. Human Resources Department Officials:
Jerry Griepentrog
Director
Sharon Murphy, Administrator
State Welfare Division
Keith W. Macdonaid, R.Ph.
Chief, Medical Services
Jane Feldmen
Statistician Ill
James I. Laird, M.D.
Medical Consultant
Nevada Medicaid Off ice
Steven P. Bradford, Pharm.D,
Pharmaceutical Consultant
Nevada Medicaid Office
7021885-4869
Department of Human Resources
State Capital Complex
Carson City, Nevada 89710
NPC
2. Advisory Committees of the Welfare Division:
A. Medical Care Advisory Group:
Harry P. Massoth, D.D.S
-Chairman, Executive Committee
Tom Collier -Chairman. Hospital Committee
John Stutchman
-Chairman. Long Term Care
Committee
Michael Jones, M.D.
-Chairman, Physicians Committee
Harry P. Massoth. D.DS
-Chairman. Dental Committee
Vacant -Chairman, Consumer Recipient
Committee
Vacant -Chairman, Pharmacy Committee
6. Drug Utilization Review:
Steven P. Bradford, Pharm.D.
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
Richard C. Pugh
Executive Director
Nevada State Medical Association
3660 Baker Lane
Reno 89509
Phone: 7021825-6788
6. Pharmaceutical Association:
Robert C. Johnson
Executive Officer
Nevada Pharmaceutical Association
11 12 I Street
Sacramento. CA 95814
Phone: 9161444-781 1
C. Osteopathic Association:
Jeffrey E. Brookman, D.O.
Secretary-Treasurer
Nevada Osteopathic Medical Association
2300 South Rancho
Las Vegas 891 02
7021384-0414
4. State Board of Pharmacy
Elliott King. Secretary
1201 Terminal Way, Suite 212
Reno. Nevada 89502
7021322-0691
NPC New Hampshire-l
1985
N E W HAMPSHI RE
MEDI CAL ASSI STANCE D R U G PROGRAM (TITLE XI X)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other*
OAA AB APTD AFDC OAA AB APT0 AFDC Children 21 ISFO)
Prescribed
Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hosoital Care X X X X X X X X X X
Laboratorv &
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
I N. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
Expended
-
Recipient
-
Expended Recipient
- -
TOTAL . . . . . . . . . . . . . . . . . . . . . $4,928,443 27,512" $4,240,571 29,092
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
Aoed . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adulk-Families w/Dep Children . . . . . . . . . . . .
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families w/Dep Children
Adulk-Families w/Dep Children . . . . . . . . . . . .
. . . . . . . . . . . . . . . Other Title XIX Recipients
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families wl b p Children . . . . . . . . . . . .
Adults-Families w/Deo Children . . . . . . . . . . . .
Other Title XIX ~ecipients . . . . . . . . . . . . . . . 60 3
"Unduplicated Total - HHS repori HCFA - 2082
New Hampshire-2
1985
Ill. Administration:
Office of Medical Services, Department of Health and Welfare.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Anorexiant (stimulants) except for treatment of narcolepsy and hyperkinetic
children; and vitamins for patients over 7 years of age.
B. Formulary: None.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Prescriptions limited to 100 day supply; three prescriptions, including
refills for recipient per month.
2. Dollar Limits: None.
D. Prescription Charge Formula:
$2.85 fee plus Estimated Acquisition Cost (EAC) or Maximum Allowable Cost (MAC) 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: $0.75, except nursing home patients, under 18 years, family planning and preg-
nancy prescriptions.
Officials, Consultants and Committees
1. Health and Welfare Department Officials:
Mary Mongan
Acting Commissioner
Department of Health and
Welfare
Health and Welfare Building
Hazen Drive
Concord, New Hampshire 03301
6031271 -4353
Philip Soule
Administrator
Office of Medical Services
Division of Welfare
Clifford A. Zilch, P.D.
Chief, Bureau of Medical Claims
Review
Off ice of Medical Services
Division of Welfare
Edward J. Pierce, P.D.
Pharmaceutical Services Specialist
Office of Medical Services
Division of Welfare
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.
NPC New Hampshire-3
1985
3. Executive Officers of State Medical and Pharmaceutical Services:
A. Medical Society: B. Pharmaceutical Association:
Palmer P. Jones
Executive Officer
New Hampshire Medical
Society
4 Park Street
Concord 03301
Phone: 6031224-1 909
Maurice E. Goulet, P.D., M.S.
Executive Director
New Hampshire Pharmaceutical
Association
194 North Main Street
Concord 03301
Phone: 6031225-2231
C. Osteopathic Association: D. State Board of Pharmacy
William J. Kirmes. D.O.
Secretary-Treasurer
New Hampshire Osteopathic Assn.
13 North Street
Manchester 03104
6031623-6757
4. State Board of Pharmacy
Paul Boisseau, Secretary
Health and Welfare Building
Hazen Drive
Concord, New Hampshire 03301
6031271 -2350
Paul Boisseau, Secretary
Health and Welfare Building
Hazen Drive
Concord. New Hampshire 03301
6031271 -2350
NPC
I
New Jersey- 1
19%
N E W J ERSEY
MEDI CAL ASSI STANCE DRUG PROGRAM ( TI TLE XI X)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other*
D M AB APTD AFDC OAA AB APTD AFDC Children 21 iSFOl
Prescribed
Druos
Hospital Care X X X X
Outpallent
Hospila Care X X X X
Laboratory &
X-rav Service
Skilled Nursing
Home Services X X X X
Phvsician
Dental
Services X X X X
Other Benefits: Home Health Agency Services, Independent Clinic Services. Podiatrist, Chiropractor. Optomelrlst and Optical Appliances. Ambulance
and Invalid Coach, Medical Equipment and Prosthetic Devices.
'SF0 - State Funds Only (PAAD, Pharmaceutical Assistance to the Aged).
11. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending September 30. 1984
1984 1983
Expended
-
Recipient Expended
- -
Recipient
-
TOTAL . . . . . . . . . . . . . . . . . . . . . $67,421,822 484,755" $61,125,306 493,234
. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL $53,660,744 428,198 $48,869,000 437.859
Aged . . . . . . . . . . . . . . . . . . . . . . 9,008,458 27,818 8,010,000 27.287
Blind 251,791 892 225,000 857
Di sabl ed. . . . . . . . . . . . . . . . . . . . . 18,213,167 49,949 15,413.000 47,237
Children-Families wIOep Children . . . . . . . . . . . . 12.121.532 225.802 11,375,000 233,421
Adults-Families wpep Children . . . . . . . . . . . . 14,065,796 123,731 13,844.000 129,057
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . $13,761,078 65,731 12,255,000 64.982
Aged . . . . . . . . . . . . . . . . . . . . . . 10.008.465 24.996 9.020.000 24,487
Blind . . . . . . . . . . . . . . . . . . . . . . 12,803 47 11,000 41
i b l d . . . . . . . . . . . . . . . . . . . . . 1,890,677 4,505 1,648,000 4,271
Children-Families wiDep Children . . . . . . . . . . . . 877,715 19,645 777.000 19,946
. . . . . . . . . . . . Adults-Families w/Dep Children 338,915 7,797 320.000 8.145
. . . . . . . . . . . . . . . Other Title XIX Recipients 632,503 8,741 478.000 8.092
. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL $0 0 $0 0
A d . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0
Blind . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0
Disabled . . . . . . . . . . . . . . . . . . . . . 0 0 0 0
Children-Families w/Dep Children . . . . . . . . . . . . 0 0 0 0
. . . . . . . . . . . . Adults-Families w/Oep Children 0 0 0 0
. . . . . . . . . . . . . . . Other Title XIX Recipients 0 0 0 0
"*Undoplicaled Total - HHS report HCFA - 2082
New Jersey-2
1985
Ill. Administration:
Division of Medical Assistance and Health Services, Department of Health Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Experimental drugs, antiobesics and anorexiants.
B. Formulary: None.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: The quantity of medication prescribed should provide a sufficient
amount of medication necessary for the duration of the illness or an amount sufficient to
cover the interval between visits, but may not exceed a 60day 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 dispensed for up to a 100-day supply.
2. Refills: Prescription refills will be limited to 5 times within a 6-month period if so indicated by
the prescriber on the original prescription.
Exceptions:
a. Oral contraceptives originally prescribed for a 3-month supply may be refilled 3 times
within one year.
b. Vitamins and vitamin-mineral combinations originally prescribed for 100 day supply may
be refilled 2 times within one year.
3. Dollar Limitations: None.
D. Prescription Charge Formula:
1. Payment for legend drugs, contraceptive diaphragms and reimbursable devices shall be
based upon "Maximum Allowable Cost." or Average Wholesale Price minus 0-6%.
a. Maximum Allowable Cost is defined as:
(1) The "Maximum Allowable Cost" (MAC) price published by the Pharmaceutical
Reimbursement Board of the Department of Health and Human Services for listed
multi-source drugs or established by the Division of Medical Assistance and Health
Services; or
. (2) The Average Wholesale Price (AWP) listed for the most frequently purchased
package size (as defined by the N.J. Medicaid Program) in the current "Drug Topics
Red Book" (published by Medical Economics Co.. Oradell. New Jersey 07649). and
supplements; price changes listed by the same publisher in "Drug Topics Magazine"
or other appropriate sources; 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.
2. Maximum cost for each eligible prescription claim not covered by section 10:51-1.16(a)l
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
NPC
New Jersey-3
1985
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 category 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 10:51-1.16a. 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.
(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 10:51-1.16a. 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 cateogry 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: (1) 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 10:51-1.16(a)lii. then section 10:51-
1.16(a)lii, will apply.
(2) The appropriate calculated discount will be automtically 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).
New Jersey-4
1985
Dispensing Fee
The dispensing and services fee ranges from $3.53 to a maximum of $3.87 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
$0.1 1
$0.08
$0.1 5
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 stetes 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 andlor posted or advertised charges.
c. Other third party prescription plan charges, when contracts or agreements to participate have
been entered into subsequent to the adoption of this regulation.
V. Miscellaneous Remarks:
Fiscal Intermediary:
Blue Cross of New Jersey
33 Washington Street
Newark. New Jersey 07101
Number of Rx claims processed in FY 1984-6,905,548
Average Rx price during FY 1984-Retail: $10.54
Copayment: None
Medicaid Personal Physician Plan (MP Plan) Demonstration Project
The New Jersey Medicaid Program has implemented a four-year Statewide Competition Demonstration
Project, called the Medicaid Personal Physician Plan (MP Plan), which will provide medical care in a
manner different from the present Medicaid system. The Plan is classified as a Primary Care Network
or a health care delivery system whereby all of the Medicaid elibible's health care is obtained through,
but not necessarily from, a single primary care provider. It was developed under guidelines established
by the Health Care Financing Administration for funding which led to the inclusion of the following key
elements:
(1) a primary care physician who would be responsible for the provision of all primary care delivery,
referral, and ancillary services for non-institutional Medicaid eligibles;
(2) a capitation system of reimbursement, instead of fee-for-service, for a physician participating in
the Plan as a Physician Case Manager (PCM):
(3) a broker concept for marketing, enrollment, grievance system and quality asurance monitoring
and Plan reporting functions;
(4) the stimulation of competition among certain types of Medicaid providers by providing
strengthened alternatives to primary care in the hospital Emergency Room (ER) and Outpatient
Department setting (OPD).
The role of Physician Case Manager has potential to (1) discourage doctor shopping, self-referral, and
inappropriate and excessive utilization of Medicaid eligible services and (2) to effect better control over
almost 500 million dollars of New Jersey Medicaid's total expenditures annually without reducing quality
NPC
New Jersey-5
1985
or scope of care provided. This concept of the Physician Case Manager controlling costs has received
wide s u ~ ~ o r t throughout the country since this role negates the need for increased government regulation
and harsh budget caps
The MP Plan will be phased in throughout the State over a four-year period, or sooner if feasible. It
will be implemented first in Morris, Sussex and Warren counties. Participating providers may be in
solo practice; group practice; professional corporation or association; health maintenance organization
(HMO); independent, free-standing clinic; or in a hospital affiliated entity which allows for primary care
services and is not subject to DRG reimbursement principles.
The participation of physicians and Medicaid eligibles in the Demonstration Project is voluntary. A
physician may participate in the MP Plan and continue to participate in the current Medicaid Program
under the usual conditions.
Ofticlals, Consultants and Committees
1. Department of Human Resources Officials:
George J. Albanese Department of Human Services
Commissioner Division of Assistance and
Health Services
324 East State Street
P. 0. Box 2486
Trenton, New Jersey 08625
Thomas M. Russo
Director
I. F. Erlichman
Medical Director
Sanford Luger, R.Ph., Chief
Pharmaceutical Services
6091292-3756
Division of Medical Assistance
and Health Services
(same address as above)
2. Medical Assistance Advisory Council: (under revision)
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: C. Osteopathic Physicians & Surgeons Assn.:
Vincent A. Maressa Eleanore Farley
Executive Director Executive Director
Medical Society of New Jersey
New Jersey Assn. Osteopathic Physicians
2 Princess Road and Surgeons
Lawrenceville 08648 1212 Stuyvesant Avenue
Phone: 6091896-1 766 Trenton 08618
6091393-81 14
B. Pharmaceutical Association: D. State Board of Pharmacy
Alvin N. Geser Robert J. Terranova
Executive Off ~cer Executive Secretary
New Jersey Pharmaceutical Assn. 1 100 Raymond Boulevard
118 W. State Street Newark, New Jersey 07102
Trenton 08608 2011648-2433
Phone: 6091394-5596
NPC New Mexico-1
1985
N E W MEXI CO
MEDI CAL ASSI STANCE DRUG PROGRAM ( TI TLE XI X)
I BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benef~t Categorically Needy Med~cally Needy (MN) Other'
O M AB APTD AFDC O M A0 APTD AFOC Chlldren 21 (SFO)
Prescribed
Drugs X X X X X
Inpatlent
Hoso~tal Care X X X X X
Outpatlent
Hosp~tai Care X X X X X
Laboratory 8
X-ray Se~l c e X X X X X
Sk~lled Nurslng
Home Servlces X X X X X
Physlclan
Servlces X X X X X
Dental
Se~l ces X X X X X
Other Benefits: Private Duty Nursing. Home Health Services. Orthotic appliances and Prosthesis. Family Planning Services. Transporlatlon and
Mai nterme. Psychiatric and Psychological Services. Optometry. Podiatry.
'SF0 - Sfate Funds Only
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
Emended Reci~ient Emended Reci~ient
- - - -
TOTAL . . . . . . . . . . . . . . . . . . . . . $9,427,783 59,873" $7,569,254 58,324
. . . CATEGORICALLY NEEDY CASH TOTAL
Aged . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . .
Disabled
. . . . . Children-Families w/Dep Children
. . . . . Adults-Families w(0ep 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/ Rp Children
. . . . . . . . . . . . Adult-Families w/Dep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
$Not available
'"Unduplicated Total - HHS report HCFA - 2082
NPC
New Mexico-2
1985
Ill. Administration:
Department of Human Services.
IV. Provisions Relating to Prescribing Drugs:
A. General Exclusions:
1. Drugs for treatment of tuberculosis are not included.
2. Medications supplied by the New Mexico State Hospital to clients on convalescent leave
from hospital are not included.
3. Drugs and immunizations available from any other source are not included.
4. Legend multiple vitamins, tonic preparations and combinations thereof with minerals, hor-
mones, stimulants or other compounds which are available as separate entities for treatment
of specific conditions.
5. Hematinics except non-sustained release forms of Ferrous Sulfate, Ferrous Gluconate.
Ferrous Fumarate.
6. Amphetamines and combinations of amphetamines with other therapeutic agents;
amphetamine-like sympathomimetic compounds used for obesity control including any com-
bination of such compounds with other therapeutic agents.
7. Drugs classified by FDA as "Ineffective" or "Possibly Effective"
8. Hypnotic drugs.
9. 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:
Nick Army
Medical Assistance Bureau
P.O. Box 2348
Santa Fe, New Mexico 87504-2348
5051827-431 5
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: 6 months supply maximum
2. Refills: Payment will be made to a particular pharmacy only three times for the same drug
for the same client in any 90-day period.
D. Prescription Charge Formula:
1 . 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
V. Miscellaneous Remarks:
New Mexico-3
1985
Fiscal Intermedialy:
EDS Federal Corporation
4665 Indian School Road. N.E.. Suite A-1 14
Albuquerque. New Mexico 871 10
Number of Rx claims processed in FY 1984-789.822
Average Rx price during FY 1984-$12.79
Officials, Consultants and Committees
1. De~artment of Human Services:
Juan R. Vigil
Secretary
Jane Cotter
Director
Income Support Division
Bruce Weydemeyer
Acting Bureau Chief
Medical Assistance Bureau
Department of Human Services
P. 0. Box 2348
SantaFe, New Mexico 87503
5051827-4315
F. Richard Atkinson
Administrator
Medical Assistance Bureau
Nick Army, R.Ph.
Drug Program Administrator
Medical Assistance Bureau
2. ISD Policy Advisory Committee Members:
(pending)
3. NMPHA Committee Third Party Payments:
Liaison Committee for NM Pharmaceutical Association meets each month.
Robert Ghattas. R.Ph. Neil Johnon, R.Ph.
Durans Pharmacy Clinical Pharmacy
181 5 Central, N.W. 5002 Gibson, S.E.
Albuquerque 87104 Albuquerque 87108
5051247-41 41
Victor Castillo. R.Ph.
Robert Lee, R.Ph. Victor's Pharmacy
Lee's Pharmacy 1643 lsleta, S.W.
4403 4th Street. N.W.
Albuquerque 87105
Albuquerque 871 07
5051345-3533
Jack E. Hilligoss
Executive Director, NMPHA
4800 Zuni. S.E.
Albuquerque 871 08
4. Executive Officers of State Medical and Pharmaceutical Societies:
NPC
New Mexico-4
1985
A. Medical Society:
Ralph R. Marshall
Executive Director
New Mexico Medical Society
303 San Mateo Blvd., NE
Albuquerque 87108
Phone: 5051266-7868
B. Pharmaceutical Association:
Jack E. Hilligoss
Executive Director
New Mexico Pharmaceutical Association
4800 Zuni. S.E.
Albuquerque 87108
Phone: 5051265-8720
C. Osteopathic Medical Association:
Thomas P. Thompson
Executive Director
New Mexico Osteopathic Medical
Association
P.O. Box 3096
Albuquerque 871 10
Phone: 5051299-8900
D. State Board of Pharmacy
Olive Vaughn, Administrator
2340 Menaul. N.E. - Suite 216
Albuquerque. NM 87107
505/841-6311
NPC
New York-I
1985
N E W YORK
MEDI CAL ASSI STANCE D R U G PROGRAM ( TI TLE XIX)
I BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other"
O M AB APT0 AFDC OAA A8 APTD AFDC Children 21 (SF@
Prescribed
ONQS X X X X x X X x X X
inoatient
~ i s ~ i t a l Care X X X X X X X X X X
~ospi t al 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
Phwicim
".
Services X X X X X X X X X X
Dental
Services X X X X X X X X X X
Other Benefits: Prosthetic and Onhotic deviceslsupplies; eye services; podiatry services: family planning; EPSDT (CHAP); clinics; private duty
nursing in hospital selting; home care; transpollation; rehabilitation therapies
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Pavment to Pharmacists bv fiscal vear endina Se~tember 30. 1984
TOTAL . . . . . . . . . . . . . . . . . . . . .
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families.w/Dep Children . . . . . . . . . . . .
Adults-Families w/Dep Children . . . . . . . . . . . .
Other
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w1Dep Children . . . . . . . . . . . .
Adults-Families wIDep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
A ~ e d . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . .
Children-Families w/Deo Children . . ~ ~
Adults-Families w/Oep children
Other Title XIX Recipients . .
"'Unduplicated Total - HHS repon HCFA - 2082
209
NPC
New York-2
1985
Ill. Administration:
State Department of Social Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: No restrictions except: (See V. Miscellaneous Remarks)
1. Prescribed vitamins and minerals not prescribed for medical necessity.
2. Amphetamines and other drugs whose sole clinical use is for reduction of weight.
3. Limited coverage of non-prescription drugs.
B. Formulary: Coverage of prescription drugs is limited to list of Medicaid Reimbursable Prescription
Drugs. For information contact:
David G. Starks
Medicaid Reimbursement Drug Lists
Bureau of Standards Development
New York State Department of Health
Room 2074, Corning Tower
Albany, NY 12237
C. Prescribing or Dispensing Limitations:
1. Quadity of Medication: Drugs and sickroom supplies shall be prescribed in sufficient quantity
consistent with the health needs of the patient and sound medical practice.
2. Refills: Refills cannot exceed 5, and the life of a prescription cannot exceed 6 months.
3. Dollar Limits: None.
D. Prescription Charge Formula:
1. Maximum Reimbursable Pricing Schedule
Maximum reimbursement shall be based on the lowest of:
a. the maximum allowable cost (MAC) plus applicable dispensing fee; or
b. the estimated acquisition cost (EAC) established by the State, plus applicable dis-
pensing fee; or
c. the usual and customary price charged by the pharmacy provider to the general
public, including any sale price which may be in effect on the date of service.
2. Dispensing Fee, $2.60
V. Miscellaneous Remarks:
The Medicaid drug list applies only to prescription andlor fiscal orders filled in community phar-
macies.
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 vitaminlmineral preparations; and dermatologicals.
Many combination drugs and comfort products are also excluded.
Fiscal Intermediary:
McAuto Systems Group, Inc.
800 North Pearl Street
Albany, New York 12204
Copayment: None
Number Rx claims processed in FY 1984-17,928,987
New York-3
1985
Average Rx price during PI 1984-$11.64
O f clals, Consultants and Committees
1. Social Services Department Officials:
Cesar A. Perales
Commissioner
Mary Jo Bane
Executive Deputy Commissioner
Robert Osborne
Deputy Commissioner
Division of Medical Assistance
Mildred B. Shapiro
Associate Commissioner
Division of Medical Assistance
Richard T. Cody
Assistant Commissioner for
Eligibility
Division of Medical Assistance
Ralph Pogoda
Assistant Commissioner
Standards and Operations
Gerard F. Nelligan, R.Ph.
Associate Social Services
Medical Assistance Specialist
5181474-9261
Martin Roysher
Associate Commissioner
Program Analysis and Utilization
Review
2. Social Services Advisory Committees:
A.Medical Advisory Committee:
A. Medical Advisory Committee:
Ms. Beverly Hart
Child Development Associate
Comprehensive Interdisciplinary
Development Services
318 Madison
Elmira 14901
Charles Barr, D.D.S.
Director of Dentistry
Beth lsreal Medical Center
10 Nathan D. Perlman Place
New York 10003
Department of Social Services
40 North Fearl Street
Albany, New York 12243
5181474-9130
David Axelrod, M.D.
Commissioner
New York State Department of Health
Empire State Plaza
Tower Building
Albany 12237
Mr. Ebie Brown
115 Woodlawn Avenue. #2N
Saratoga Springs 12866
NPC
New York-4
1985
Beatrice Kresky. M.D., M.P.H., James G. Lione. M.D.
Chairman New York State Chairman
Department of Ambulatory Care. . . . Flushing Hospital and
Jamaica Hospital Medical Center
Jamaica 11418 4500 Parsons Boulevard
Flushing 11 355
Elena Padilla. Ph.D.
3 Washington Square Village
Apt. 15-0
New York 1001 2
Ms. Katherine Simmons
Executive Director
Visitin Nurse Association
of S 7 aten Island
400 Lake Avenue - Mariners Harbor
Staten Island 10303
Mr. Ebun Adelona
P.O. Box 1405
New York 10027
Arcy Degni. Secretary Treasurer
New York State Building and
Construction Trades Council
AFL-CIO
17 Jewett Place
Utica 13501
Mrs. Gleniss Schonholz
Administrator
Long Island Jewish Hillside
Medical Center
New Hyde Park 11042
3. Public Health Department:
David Axelrod, M.D.
Commissioner
5181474-201 1
Harold Rakov, Professor
26 Coleman Creek Road
Brockport 14420
Robert H. Randles, M.D.
Medical Director
St. Peter's Hosp~tal
315 South Manning Boulevard
Albany 12208
Ms. Isabel Appellaniz
Ridgewood Bushwick Senior
Citizen Council
319 Stanhope Street
Brooklyn 11237
Rufus Nichols. M.D.
736 Eastern Parkway
Brooklyn 11213
Ms. Marilyn Saviola
Apt 1 l - H
175 Willoughby Street
Brooklyn 11201
Department of Health
Tower Building
Empire State Plaza
Albany 12237
4. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society:
Edward Siegal
Executive Vice President
Medical Society of the State
of New York
420 Lakevllle Road
Lake Success 11042
Phone: 51 61488-61 00
NPC
New York-5
1985
B. Pharmaceutical Association:
Executive Director (vacant)
Pharmaceutical Society of the
State of New York
Pine West Plaza IV
Washington Avenue Extension
Albany. New York 12205
5181869-6595
C. Osteopathic Soc~ety:
8. C. Scharf, D.O.
Executive Director
New York State Osteopathic
Medical Society, Inc.
1973 Morris Gate
Seaford 11 783
5161826-2212
D. State Board of Pharmacy
Dr. Albert J. Sica, Executive Secretary
Cultural Education Center, Rm. 3035
Albany, New York 12230
5181474-3848
NPC
North Carolina-1
1985
NORTH CAROLI NA
MEDI CAL ASSI STANCE DRUG PROGRAM ( TI TLE XI X)
I BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) ot her
O M AB APT0 AFDC O M A8 APTD AFDC Children 21 (SFo)
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
7
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
Physlc~an
Servlces X X X X X X X X X
Dental
S e ~ ~ c e s X X X X X X X X X
'SF0 - State Funds Only
It. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30. 1984
1984 1983
Expended Recipient
- -
Expended
-
Recipient
-
TOTAL . . . . . . . . . . . . . . . . . . . . . $39,622,195 236,926.' $3Fb460 244,187'
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . 23,116,546 171.562 21.639 192.567
Aoed . . . . . . . . . . . . . . . . . . . . . . 7,308.543 20,424 7.222 32.384
Disabled . . . . . . . . . . . . .
. . . . Children-Families w/[)eo Children
Adults-~arnllies 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 . . . . . . . . . . . . . . 14,949.788 49,855 12.420 55.105
Aged . . . . . . . . . . . . . . . . . . . . . . 11,451,299 32.340 9,602 35,628
Blind . . . . . . . . . . . . . . . . . . . . . . 117.801 379 109 536
Disabled . . . . . . . . . . . . . . . . . . . 2,717,869 8,217 2.189 9,154
Children-Families w/Dep Children . . . . . . . . . . . . 129.262 3,642 117 3.971
Adults-Families w1Dep Children . . . . . . . . . . . . 478,577 4.820 367 5,295
Other Title XIX Recipients . . . . . . . . 54.980 457 36 515
"Unduplicated Total - HHS report HCFA - 2082
North Carolina-2
1985
Ill. Administration:
Division of Medical Assistance, Department of Human Resources.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: No payment made for non-legend drugs, except insulin. Payment made for
all legend drugs. Non-legend vitamins are excluded.
8. Formulary: None.
C. Prescribing or Dispensing Limitations:
1. 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 illness should be excluded from the prescription limitation:
(1) End State Renal Diseases
(2) Chemotherapy and Radiation Therapy for Malignancy
(3) Acute Sickle Cell Disease
(4) Hemophilia
(5) End State Lung Diseases
(6) Unstable Diabetes
(7) Terminal Stage-any illness-life-threatening
3. Dollar Limits: None.
4. Generic Substitution: Pharmacists must substitute generically if they have a generically
equivalent product available in stock. The substituted product must be a lower cost product
than the one originally prescribed.
5. Lock-In: Each recipient is locked into one pharmacy of his choice for one month, except in
emergencies.
D. Prescription Charge Formula: The lowest price ~f MAC. EAC or AVVP, plus $3.36 dispensing
fee for each different drug dispensed during a month, or the pharmacist's usual and customary
charge. The pharmacist filling the original prescription will not be reimbursed for refills for the
same drug within a calendar month. $0.50 co-payment/Rx (includes refills).
V. Miscellaneous
Fiscal Agent:
EDS Federal
P.O. Box 300001
Raleigh, NC 27622
NPC
North Carolina-3
1985
Offlclals, Consultants and Committees
1. Department of Human Resources Officials:
Phillip J. Kirk, Jr.
Department of Human Resources
Secretary Albermarle Building
325 N. Salisbury Street
Raleigh, North Carolina 2761 1
Barbara D. Matula
Director
Paul R. Perruzzi
Deputy Director
Jerry W. Wiley. M.D.
Chief Medical Consultant
C. Benny Ridout. R.Ph. "
Pharmacist Consultant
91 9/73-2833
Lillian J. Todd, R.N.
Nurse Consultant
Betty King-Sutton. D.M.D.
Dental Consultant
2. Department of Human Resources Advisory Committees:
A. Pharmaceutical Association, Third Party Committee
Division of Medical Assistance
Kirby Building
Raleigh, North Carolina 27603
William H. Brown
Chairman
108 St. Andrews Drive
Greenville, N.C. 27834
9191756-2877
Charles W. Burkett
9200 Deerpark Lane
Charlotte 281 05
7041371 -8396
William H. Edmondson, Ph.D.
P. 0. Box 13408
Research Triangle Park 27709
9191248-2100
Lamar Creasman
P.O. Box 1538
North Wilkesboro 28659
Joseph A. Edwards, Jr.
521 1 Coronado Drive
Raleigh 27609
W. Darrell Estes
10321 Ram Road
Raleigh 2761 2
9191781 -0161
James R. Hall
Route 1, Box 45-8
Efland 27243
9191544-1 730
Clifford E. Hemingway
5615 Closeburn Road
Charlotte 2821 0
7041554-71 66
Robert A. Leghart
623 Westlake Drive
Amherst, Ohio 44001
Bob Lewis
719 Sandridge Road
Charlotte 28210
North Carolina-4
1985
Ginger Lockamy
670-8 Candlewood Drive
Raleigh 27612
325 N. Salisbury Street
Raleigh 2761 1
Bill Mast
950 Meadow Lane
Henderson 27536
Ernest Rabil
P.O. Box 5892
Winston Salem 27103
9191725-1 722
C. Benny Ridout
Box 88
Morrisville 27560
B. Medical Society Committee on Social Service Programs (including Medicaid):
Hector H. Henry, II, M.D. (U)
Chairman
102 Lake Concord Rd., N.E.
Concord 28607
Edna M. Hoffman, M.D
348 Valley Road
Fayetteville 28305
Campbell W. McMillan, MD (PHO)
N.C. Memorial Hospital
Chapel Hill 27514
W. Samuel Yancy. M.D. (PD)
306 S. Gregson St.
Durham 27701
Consultants
Barbara D. Matula, Director
Division of Medical Assistance
1985 Umstead Drive
Raleigh 27603
Richard W. Furman, M.D. (TS)
State Farm Road
Boone 28607
Charles R. Martin, M.D. (PD)
120 Memorial Drive
Jacksonville 28540
Betty L. Smith, M.D. (P)
P.O. Box 925
Ellenboro 28040
Sarah T. Morrow, MD (PH)
Medical Director
EDS Federal Corporation
491 7 Waters Edge Drive
Raleigh 27606
Lillian J. Todd, RN
Nurse Consultant
Division of Medical Assistance
Raleigh 27603
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society:
George E. Moore
Executive Director
N.C. Medical Society
P.O. Box 27167
222 North Person Street
Raleigh 2761 1
Phone: 9191833-3836
NPC
B. Pharmaceutical Association:
A. H. Mebane, Ill
Executive Director
N.C. Pharmaceutical Assoc.
Box 151
Chapel Hill 27514
Phone: 9191967-2237
C. Osteopathic Society:
Guy T. Funk. D.O.
Secretary-Treasurer
North Carolina Osteopathic Society. Inc.
Box 667
Advance 27006
D. State Board of Pharmacy
David R. Work. Executive Director
P.O. Box H
Carrboro, NC 27510
91 91942-4454
North Carolina-5
1985
NPC
No r t h Dakota-1
1985
NORT H DAKOTA
MEDI CAL ASSI STANCE D R U G PROGRAM ( TI TLE XI X)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other*
O M AB APTD AFDC DAA AB APTD AFDC Children 21 (SFO)
Prescribed
Dr ~~on X X X X X X X X X
inpatient
HosDital Care X X X X X X X X X
Hospital Care X X X X X X X X X
Laboratory &
X-ray Servlce X X X X X X X X X
Skilled Nursing
Home Serv~ces X X X X X X X X X
Phvwan
Services X X X X X X X X X
Dental
- - . .
Services X X X X X X X X X
'SF0 - Slale Funds Only
11. EXPENDITURES FOR DRUGS. Pavment to Pharmacists bv fiscal vear endina June 30. 1984
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 . . . . . . . . . . . .
. . . . . . . . . . . . Adulls-Families wi&p Children
Other Title XIX Recipients . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL
A d . . . . . . . . . . . . . . . . . . . . . .
1984
Expended Recipient
- -
B i d . . . . . . . . . . . . . . . . . . . . . . 3,806 7
Disabled . . . . . . . . . . . . . . . . . . . . . 350.930 873
Children-Families w/ De~ Children . . . . . . . . . . . . 25.874 688 - - ~
Adults-Families w/&p children
Other Title XIX Recipients . .
1983
Expended Recipient
- -
"Unduplicated Total - HHS report HCFA - 2082
NPC
North Dakota-2
1985
Ill. Administration:
North Dakota Department of Human Services
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions:
1 . Anorectics
2. High protein weight reduction supplements
3. Investigational drugs
4. Drugs which have questionable therapeutic value
5. Drugs which are not indicated for the diagnosis
6. DESl (Less-Than Effective) drugs
B. Formulary: None
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: None.
2. Refills: A prescription drug may be refilled up to 5 times or for 12 months after the date
of the original prescription, whichever occurs first, and provided that such refills have been
authorized by the physician.
3. Dollar Limits: None.
D. Prescription Charge Formula: Acquisition Cost plus $3.75 dispensing fee per prescription or
usual and customary retail charge, whichever is lower.
Acquisition Cost: EAC or MAC. EAC is North Dakota AWP
V. Miscellaneous Remarks:
Copayment-No.
Number of Rx claims processed in FY 1984-414,023
Average Rx price during FY 1983-$11.58
Officials, Consultants and Commlttees
1. Department of Human Services Officials:
John Graham
Executive Direct01
LeRoy Bollinger, Administrator
Research and Statistics
Richard Myatt, Director
Medical Services
- - €heel whs7ETY
Administrator
Pharmacy Services
7011224-4023
North Dakota Department
of Human Services
Capitol Building
Bismarck, North Dakota
58505
2. Department of Human Services Advisory Committees:
NPC
North Dakota-3
1985
A. Medical Care Advisory Committee:
Joe Pratschner
(Health Dept. Designee)
Director of Health Facilities
State Department of Health
1200 Missouri Avenue
Bismarck 58505
7011224-2352
Bruce Hetland. M.D.
Mid-Dakota Clinic
Ninth and Rosser
Bismarck 58505
7011223-01 50
Bernice Englehorn
801 112 Collins Avenue
Mandan 55401
7011663-2181
Fred Hulet
116 W. Thayer Avenue
Bismarck 58501
7011223-4131
Bill Congdon, D.D.S.
810 E. Rosser Avenue
Bismarck 58501
7011258-1321
Jon Thomas
Community Action Program
Region VII
2105 Lee Avenue
Bismarck 58501
7011258-2240
B. Commission on Socio-Ecomrnic Affairs:
N. E. Byestol. M.D.
Chairman
Dakota Clinic, Ltd.
Fargo 581 08
J. J. McLoed, Jr., M.D.
ke-chai rman
Orthopardic Cl~nic. P.C
Grank Forks 58201
J. E. Adducci, M.D.
Box 2438
Williston 58801
Bertha Gipp, R.N.
Maternal and Child Health
Division
State Department of Health
Bismarck 58502
701B24-2493
Patricia Kramer, R.Ph
Bismarck Hospital
300 North Seventh
Bismarck 58501
701 1224-6000
Val Rieder
New Rockford 58356
7011947-2936
Ron Row, M.S.W.
Social Work Department
St. Alexius Hospital
Ninth and Rosser
Bismarck 58501
701 1224-7000
Jack Heyne
Center for Independent Living
109 First Street, N.W.
Suite 101 B MSB Bldg.
Manden 58554
7011663-0376
Carter Pendergast
N.D. Group Management Assoc.
Quain & Ramstad Clinic
221 North Fifth
Bismarck 58501
7011222-5200
C. S. Hamilton. Jr., M.D
Fargo Clinic
Fargo 58123
K. S. Helenbolt, M.D.
Blue Shield-ND
4510 13th Avenue, SW
Fargo 58121
J. R. Herr, Jr., M.D.
1213 15th Avenue West
Williston 58801
North Dakota-4
1 985
F. M. Carter. M.D.
Grand Forks Clinic, Ltd
Grand Forks 58201
J. H. Coffey, M.D.
Fargo Clinic
Fargo 581 23
B. L. Dahl. M.D.
West Fargo Medical Center
West Fargo 58078
H. W. Evans. M.D.
Grand Forks Clinic. Ltd.
Grand Forks 58201
M. M. Fiechtner, M.D.
Quain & Ramstad Clinic
Bismarck 58202
W. J. Norberg, Jr., M D
Fargo Clinic
Fargo 581 23
R. L. Odegard, M.D.
Medical Arts Clinic
Minot 58701
N. B. Ordahl, M.D.
Box 1348
Dickenson 59601
D. M. Pfeifle, M.D.
Quain & Ramstad Clinic
Bismarck 58502
C. Pharmacy Advisory Committee:
M ~ N Tokach, Chairman
#1 Riverview Lane
Jamestown 58401
Gordon Mayer
708 Birch Avenue
Harvey 58341
Duane McCullough
422 Main
Oakes 58474
ENin Reuther
701 Third Street
Langdon 58249
D. L. Lamb, M.D.
#504 Professional Bldg.
Fargo 58103
R. S. Larson, M.D
Box A
Velva 58790
0. V. Lindelow, M.D.
Mid Dakota Clinic
Bismarck 58502
R. F. Miller, M.D.
Medical Arts Building
Bismarck 58501
R. F. Morgan. M.D.
316 N. 10th Street
Bismarck 58501
T. M. Polovitz, M.D.
Valley Medical Associates
Grand Forks 58201
D. A. Rinn, M.D.
UND Family Practice Center
Minot 58701
C. R. Thueson. M.D.
Dakota Clinic, Ltd.
Fargo 58108
Dave Just
Box 99
Beulah 58523
Ryn Olig
43 Prairiewood Circle
Fargo 58103
Thomas G. Pettinger (Ex-Officio)
214 Forest Avenue N.
Fargo 58102
John F. Schuld (Ex-Officio)
Box 148
Dickinson 58601
North Dakota-5
1985
Michael J. Berg Elroy Herbel
1308 1 l t h Street, S.W. Box 10
Minot 58701 Elgin 58533
Richmond H. Lapp
1467 Hill Avenue
Gratton 58237
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
Vernon Wagner
Executive Vice President
North Dakota Medical
Association
810 East Rosser Avenue
Box 1 198
Bismarck 58501
Phone: 7011223-9475
B. Pharmaceutical Association:
John Schuld
Secretary-Treasurer
North Dakota Pharmaceutical
Association
P. 0 . Box 148
Dickinson 58601
Phone: 7011225-8650
C. Osteopathic Association:
Harry Homewood, D.O.
Secretary-Treasurer
North Dakota State Osteopathic Association
Box 51 6
Valley City 58072
D. State Board of Pharmacy
William J. Grosz, Executive Secretary
P.O. Box 1354
Bismark 58502
701 1258-1535
OHIO
MEDI CAL ASSI STANCE D R U G PROGRAM ( TI TLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
O M AB APT0 AFDC O M AB APT0 AFDC Children 21 ( SF4
Prescribed
Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X
Laboratow 8
X-ray service X X X X
Skilled Nursing
Home Services X X X X
Physician
Services x x X X
Dental
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by tiscai year ending September 30. 1984
1984 1983
Expended Recipient Expended
- - -
Recipient
-
TOTAL . . .
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . Aged
. . . . . . . . . . . . . . . . . . . . . . Blind
. . . . . . . . . . . . . . . . . . . . . Disabled
. . . . . . . . . . . . Children-Families w/Dep Children
. . . . . . . . . . . . Adults-Families wl h p Children
. . . . . . . . CATEGORICALLY NEEDY NON-CASH TOTAL
. . . . . . . . . . . . . . . . . . . . . . .
Aged Not available
. . . . . . . . . . . . . . . . . . . . . . Blind
. . . . . . . . . . . . . . . . . . . . . Disabled
. . . . . . . . . . . . Children-Families w/Dep Children
. . . . . . . . . . . . Aduik-Families w/Dep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
MEDICALLY NEEDY TOTAL . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . Aged
. . . . . . . . . . . . . . . . . . . . . . Blind
Disabled . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families w/ hp Children
. . . . . . . . . . . . Adulk-Families w/Dep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
"'Unduplicated Total - HHS repolt HCFA - 2082
Ill. Administration:
Ohio Department of Human Services
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: For prescription legend and/or OTC drugs not listed in the formulary, phar-
macist should obtain authorization before filing claim for payment.
B. Formulary: Yes. 1700 drug products.
Contact Person: Robert P. Reid, R.Ph.
Bureau of Medicaid
Policy
30 E. Broad Street. 31st Floor
Columbus, Ohio 43215
6141466-6420
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 closely related to items obtained
from generic manufacturers usually associated with wholesale drug houses.
A drug code is listed in the Ohio Welfare Drug Formulary for each form of generic drug. Trade
names for these 564 drug items are also contained in the formulary.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication:
a. 34-day supply or 100-dosage units (whichever is greater).
b. Amount designated in Ohio Welfare Formulary.
2. Refills: Up to 5 refills. After 5 refills or 6 months (whichever is first) a new prescription is
necessary.
D. Prescription Charge Formula:
1. Legend drugs and selected OTC products in community pharmacies.-Reimbursement is
based on the lowest of:
a. the provider's reasonable and customary charge to the public;
b. the Department's Estimated Acquisition Cost (EAC) (AWP minus 7% plus a dispensing
fee; or
c. the lowest federal- or state-established Maximum Allowable Cost (MAC), for specifically
de~ginated generically equivalent drugs plus a dispensing fee.
2. Nonlegend drugs in community pharmacies.-Reimbursement is based on EAC plus a
dispensing fee.
Dispensing Fee: $2.60 (effective 7/1/78)
Officials, Consultants and Committees
1. Welfare Department Officials:
Patricia Barry
Department of Public Welfare
Director 30 East Broad Street, 32nd flr.
Columbus. Ohio 43215
NPC
Art Evans
Assistant Director
Paul Offner
Deputy Director of
Medicaid Administration
Kathi Glynn
Acting Deputy Director for
Program Development
Bureau of Medicaid Policy
Kenneth C. Page
Bureau Chief
Robert P. Reid. R.Ph.
Pharmacist Consultant
Joel Fisher
Program Planner for
Pharmaceutical Services
Division of Medfcal Assistance
Stanley D. Sells
Division Chief
6141466-2365
Richard Gleckler, R.Ph.
Bureau Chief
Bureau of Medical Operations
Philip J. Rogers. R.Ph.
Pharmacy Consultant
Bureau of Medical Operations
Department of Human Services
30 East Broad Street. 31st Floor
Columbus. Ohio 43215
Department of Public Welfare
30 East Broad Street, 31st flr.
Columbus. Ohio 43215
2. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association B. Pharmaceutical Association
Hart F. Page
Philip W. Cramer
Executive Director Executive Director
Ohio State Medical Association
Ohio State Pharmaceutical Association
600 South High Street
395 E. Broad Street. Suite 320
Columbus 43215 Columbus 43215
Phone: 6141228-6971
Phone: 61 41221 -2391
C. Ohio Osteopathic Association D. State Board of Pharmacy
Jon F. Wills
53 W. 3rd Avenue
Columbus 43201
Phone: 6141299-2107
Franklin Z. Wickharn. Executive Director
65 South Front Street, Room 504
Columbus, Ohio 43215
ind6141466-4143
NPC
OKL AHOMA
MEDI CAL ASSI STANCE DRUG PROGRAM ( TI TLE XI X)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categoricaly Needy Medically Needy (MN) Mher*
OAA AB APTD AFDC OAA A8 APTD AFOC Children 21 (SFOI
Prescribed
Drugs X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X
Outpatient
Hos~i tal 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 Senwes X X X X X X X X X
Physlcian
Services X X X X X X X X X
Dental
Services X X X X X X X X X
Other Benelits: Medically Needy (MN) are eligible i f within catastrophic illness determination according to Deparlment definition and il otherwise
eligible.
'SF0 - Stale Funds Only
II. EXPENDITURES FOR DRUGS. Pavment to Pharmacists bv fiscal vear endino June 30. 1984
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/ De~ Children . . . . . . . . . . . .
Adults-Families w/Dep children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adulls-Families w/Deo Children . . . . . . . . . . . .
Other Title XIX ~eci pi i nt s . . . . . . .
1984 1983
Expended Recipient Expended
- - -
Recipient
-
$76,535,307 117,002" $74,775,001 107,971
'YJnduplicated Total - HHS repon HCFA - 2082
Ill. Administration:
Oklahoma Department of Human Services (DHS)
IV. Provisions Relating to Prescribed Drugs:
Formulary: Yes. Oklahoma List of Covered Drugs
Contact:
Box 53034
Oklahoma City, Oklahoma 73152
H. W. Stansberry
4051521 -3804
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 $3.55 effective 11/1/81. In
no event shall charges to the Welfare Department exceed charges made to the general public
for the same prescription or item.
4. Categories of Drug Coverage (Revised 1/1/80)
Those drugs that are compensable under each category are specified individually by trade name;
otherwise by generic name only.
Antidiarrheals
Antiparkinsonism
Antidepressants
Broncho-Dilators and Antiasthmatics
Opthalmic
Antiarthritics
Antibiotics (Oral and lnjection)
Antibacterials (Oral and Injection)
Glaucoma Drugs
Otic
Antigout
Antineoplastics (Oral and lnjection)
Birth Control
Analgesics
Anticonvulsants
Antinauseants, AntivertigoIAntiemetic
Insulin and Antidiabetics Drugs
Cardiovascular-Broad and Potassium Preparation
Antifungal
Specialized Preparations
5. Prescription Limitations:
Three prescriptions per monthlrecipient.
NPC
6. Quantities:
34-day supply or 100 dosage units, whichever is greater.
5 b C
S$W h ~ C P
7. Legend, Non-Legend and Generic Drugs: CIP.I-J @nbcar,<
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 five times within a 6-
month period.
V. Miscellaneous:
Number of Rx claims processed in FY 1984-1,097,560
Average Rx price during FY 1984-$15.29
Officials, Consultants and Committees
1. Department of Human Services Officials:
Robert Fulton
Director
Michael Fogarty
Assistant Director
Medical Services Administration
Howard Stansberry
Pharmacy Program Administrator
Program Coordinator
4051521 -3804
Department of Human Services
Sequoyah Memorial Office
Bldg.
(P. 0. Box 25352)
Oklahoma City, Oklahoma
731 25
Department of Human Services
4001 Lincoln Boulevard
Oklahoma City. OK 73105
Department of Human Services
P.O. Box 53034
Oklahoma City, OK 73152
2. Advisory Committee on Medical Care for Public Assistance Recipients:
Robert Sukman, M.D.
Chairman
3330 N.W. 56th #206
Oklahoma City, OK 731 12
3. Executive. Officers of State Medical, Pharmaceutical, and Osteopathic Societies:
A. Medical Association: C. Osteopathic Association:
David Bickham Bob E. Jones
Executive Director Executive Director
Oklahoma State Medical Assn. Oklahoma Osteopathic Assn.
601 N. W. Expressway Citizens Bank Tower Building
Oklahoma City 731 18 2200 Classen Boulevard
Phone: 4051843-9571 Oklahoma City 73106
Phone: 4051528-7095
B. Pharmaceutical Association: D. State Board of Pharmacy
John D. Donner Joe Schwemin, Executive Secretary
Executive Director 4545 N. Lincoln, Suite 112
Oklahoma Pharmaceutical Association Oklahoma City, OK 73105
Box 18731 4051521 -381 5
Oklahoma City 73154
Phone: 4051528-3338
NPC
OREGON
MEDI CAL ASSI STANCE D R U G PROGRAM ( TI TLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
O M AB APT0 AFOC OAA AB APT0 AFOC Children 21 (SFO)
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 ~ e i i c e x x x x x x x
Skilled Nursing
Home Services X X X X X X
Physician
Services X X X X X X X
Dental
Se~l ces X X X X X X
Other Benelits: Visual Care. Medical Transportation. Medical Supplies/Equipment. Physical Therapy. Fudiatrist. Chiropractor. Naturopath. ICF.
Family Planning, Abortions, home health agency, Private duty nurse, EPSOT.
'SF0 - State Funds Onlv
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
Exoended
. . . . . . . . . . . . . . . . . . . . . TOTAL $1 4,803,643
. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families wIDep Children . . . . . . . . . . . .
Adults-Families w/Oep Children . . . . . . . . . . . .
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families wIOep Children
Adults-Families wIOep Children . . . . . . . . . . . .
Other Title XlX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
. . . . . . . . . . . . Adults-Families w/Dep Children
Other Title XIX Recipients . . . . . . . . . . . . . . .
1984 1983
Recioient Exoended Recioient
- -
97,454 $14,521,924
Not avail. 8.093.608
1,453,587
206,097
2,976,040
1.153.987
2.303.897
"'Unduplicated Total - HHS report HCFA - 2082
Ill. Administration:
Adult and Family Services Division, Department of Human Resources.
IV. Provisions Relating to Prescribed Drugs:
A. Formulary: An open "formulary" except as noted below.
B. Non-Formulary: Prior approval from state reviewing physician must be obtained for minor tran-
quilizers other then (gener~c) meprobamate or chlordiazepoxide, and amphetamines and am-
phetamine derivatives, isotrenition, legend laxitives, and for certain non legend items.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Not to exceed 100 days supply, except topical preparations, sprays,
aerosol inhalers, and similar preparations.
2. Refills-Schedule Ill, IV, or V drugs are limited to 5 refills.
3. Dollar Limits: None.
D. Prescription Charge Formula:
Payment is the lowest of: (a) usual and customary charges to general public, (b) Maximum
Allowable Cost (MAC) plus dispensing fee of $3.57, (c) Estimated Acquisition Cost (EAC) plus
dispensing fee of $3.57.
Nursing home drug reimbursement is based upon a capitated fee of $0.58 per day per eligible
-or fee system.
V. Miscellaneous Remarks:
Number of Rx claims processed in FY 1984-1,741,703
Average Rx price during PI 1984-$10.99
State MAC program for approximately 292 drugs.
Officials, Consultants and Committees
1. Leo T. Hegstrom
Director
Keith Putnam. Administrator
Adult and Family Services Div
Department of Human Resources
318 Public Services Building
Salem, Oregon 97310
5031378-2263
Byron Carpenter
Assistant Administrator
Health and Social Services Section
Kim Scranton
Assistant Administrator
Field Operations Section
Leonard T. Sytsma
Assistant Administrator
Support Services Section
Michael Kane
Assistant Administrator
Income Maintenance Section
NPC
Vern Fisher
Assistant Administrator
Business Services Section
Charles N. Mortensen, R.Ph
Pharmacy Consultant
2. Consultants to Health and Social Services Section:
Richard J. Cook, D.D.S
Robinhood Prof. Bldg.
18603 Pacific Highway
West Linn 97068
William Dettwyler, M.T.
5555 Sunnyview Road, NE
Salem 97303
William Henry, ND
(Naturopath)
1920 North Kilpatrick
Portland 9721 7
Donald Charlton. DMD
(Dental)
943 Liberty Street, SE
Salem 97302
Merle Berry. O.D.
(Optometric)
Albany Optometric Center
225 W. 2nd
Albany 97321
203 Public Service Building
Salem, OR 97310
5031378-2763
Alfred Scheff, M.D.
(Chief Medical Advisor)
1625 Commercial St., SE
Salem 97302
Robert W. Staley, D.D.S.
1075 Hansen Avenue S.
Salem 97302
Dr. Jan lsselman
1320 Lewis Street. S.E.
Salem 97302
Ranvir Sinanan, M.D.
203 Public Service Building
Salem 97310
Chuck Mortensen
(Pharmacist Consultant)
203 Public Service Building
Salem 97310
5031378-2263
Dan Campbell. D.D.S.
C/O Lebanon Branch, AFS
P. 0. Box 456
Lebanon 97355
3. Division Advisory Committees:
Governor's Advisory Committees on Medical Assistance
for the Underprivileged
MEMBERS
Charles Ross Anthony Public-economics 344-1982
2590 Van Ness 484-0709
Eugene 97403 (home)
Daniel Billmeyer, MD
406 7th Street
Oregon City 97045
Roderick Bunnell
P.O. Box 1071
Portland 97207
Physician
Industry
232
James E. Creswell, DMD
Route 3, Box 428
Klamath Falls 97601
Sister Monica Heeran
Sacred Heart Hospital
P.O. Box 10905
Eugene 97440
Joan E. Krahmer
614 East Main
Hillsboro 97123
Frank McBarron
2225 Loyd Center
Portland 97232
Dennis Marsh
1015 Cornell Avenue
Gladstone 97027
Judge Earle C. Misener
410 H. Avenue
LeGrande 97850
Larrie Noble, R.N
1 1750 SW72nd
Tigard 97223
Rhese Penn, MD
Health Division
1400 SW Fifth Avenue
Portland 97201
Katherine A. Ricker
7458 N. Polk
Portland 97203
Ruth Slick, RN
221 Quarry Street
Oregon City 97045
Dwight Quisenberry R.Ph.
850 Prospect Place, S.
Salem, OR 97302
Dentist
Hosoital Administrator
Public-Mental Health
Physician
Medical Profession-Other
Ambulance
Oregon Counties
Nursing Profession
Director, Maternal
and Child Health
Public-Recipient
Nursing Home
Administrator
Pharmacist
NPC
4. Executive Officers of State Medical, Pharmaceutical and Osteopathic Associations:
A. Medical Association: B. Pharmaceutical Association
Robert L. Dernedde
Executive Director
Oregon Medical Association
5210 SW Corbett Street
Portland 97201
Phone: 5031226-1 555
Executive Secretary
Oregon State Pharmaceutical Assn.
1460 State Street
Salem 97301
Phone: 5031585-4887
C. Osteopathic Association: D. State Board of Pharmacy
Jeff Heatherington
Executive Director
Oregon Osteopathic Association
9221 SW Barbur, Suite 301
Portland 97219
5031244- 7592
Ruth Vandever, Executive Director
P.O. Box 231
State Office Building, Room 904A
1400 SW 5th Avenue
Portland 97207
5031229-5849
NPC
PENNSYLVANI A
MEDI CAL ASSI STANCE DRUG PROGRAM ( TI TLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy
Medically Needy (MN) Other'
OAA AB APTD AFDC O M AB APTD AFDC Children 21 (SFO)
Prescribed
Drugs X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospilal 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
Other Benefits: Family Planning. Home Heallh Care, Ambulance. Clinics ICF Service, Hospital Home Care. Durable Medical Equipment. Prosthetics,
Inpatient Psychiatric Care. School Medical.
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Payment l o Pharmacists by fiscal year ending September 30, 1984.
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
1983
Expended Recipient
- -
$87,570,986 802,731
$64,757,633 678,412
12,227,180 48,815
373,499 1,598
25,333,322 92,768
10,014,759 332,065
16,808,873 214,410
"Unduplicated Total - HHS report HCFA - 2082
NPC
Ill. Administration:
Office of Medical Assistance, Department of Public Welfare.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Payment will not be made to any pharmacy for the following services and
items:
1. Methadone for any use.
2. 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.
3. 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 i f the physician indicates the diagnosis
on the the original prescription.
4. Non-legend drugs in the form of troches, lozenges, throat tablets, cough drops, chewing
gum, mouth washes and similar items.
5. Pharmaceutical services provided to a hospitalized person.
6. 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.
7. Drugs and devices classified as experimental by the FDA.
8. Drugs and devices not approved for use by the FDA.
9. Placebos.
10. Legend and non-legend soaps, cleansing agents, dentifrices, mouth washes, douche solu-
tions, ear wax removal agents, deodorants, liniments, antiseptics, emollients, and other per-
sonal care and medicine chest items.
11. Legend and nonlegend agueous saline solutions for use other than for intravenous ad-
ministration.
12. Legend and non-legend water preparations such as distilled water, water for injection, and
identical, similar or related products.
13. Food supplements and substitutes.
14. Compounded prescriptions when:
a. Cornpensable items are used in less than therapeutic quantities, or
b. Noncompensable items are compounded.
15. Non-legend drugs not listed in the Appendix to Chapter 1121.
NPC
16. Drugs prescribed in conjunction with sex reassignment Procedures or other noncompensable
surgical procedures.
17. The following items when prescribed for recipients in a skilled nursing and intermediate care
facility services:
a. Intravenous solutions.
b. Noncompensable drugs and items as specified in this section.
c. The following non-legend drugs:
(i) Analgesics
(ii) Antacids
(iii) Antacids with simethicone
(iv) Cough and cold preparations
(v) Contraceptives
(vi) Laxatives and stool softeners
(vii) Ophthalmic preparations
(viii) Diagnostic agents
18. 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.
19. 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.
20. DESl Drugs and identical, similar or related products or combinations of these products.
21, Impregnated gause and identical, similar or related products.
22. 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.
B. Formulary: None
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: the quantity to be dispensed is as prescribed by the physician, not
to exceed a 34 day supply or 100 units, whichever is greater.
2. Refills: Prescriptions may be refilled, as long as total authorization does not exceed a 6
months' or 5-refill 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 per 30
day period. 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 II and 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
4. Dollar limits: none
D. Drug Cost Determination:
1. Payment for compensable legend drugs is based on the current Estimated Acquisition Cost
(EAC) established by the Department.
a. The EAC for legend and non-legend drugs is found by taking the current Drug Topics
Red Book Average Wholesale Price (AWP) for the drug in the most common package
size.
b. The most common package size, for the purposes of finding the EAC, will be the same
as that used by the Department of Health and Human Services.
c. The manufacturer's direct price will be used to find the EAC for a drug when:
(i) The Drug Topics Red Book AWP is not available; or
(ii) The drug is only available directly from the manufacturer and not through a
wholesaler.
2. In cases where the EAC exceeds the Maximum Allowable Cost (MAC), the MAC will apply.
3. The EAC for individual drugs will be updated on a monthly basis as it appears in the Drug
Topics Red Book or its supplements.
E. 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 public" is 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 customary 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 as2.75 dspensing 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 customary charge to the self-paying public.
3. For compound prescriptions, an additional fee of $1.00 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 MAC program has been in effect since September 1, 1978.
5. The EAC program has been in effect since July 1, 1984.
V. Copayment $0.50
On September 1. 1984, Pennsylvania implemented a 50 cent copayrnent for each prescription, new
or refill, received by a recipient. The copayment will not apply to those recipients who are federally
238
NPC Pennsylvania-5
1985
exempt, under 21 years of age, pregnancy cases and long-term care patients, plus patients receiving
drugs in the following categories:
1. Antihypertensive agents
2. Cardiovascular preparations
3. Antiphychotic agents (excluding Schedule C-IV anti-anxiety agents
4. Antidiabetic agents
5. Anticonvulsants
6. Antineoplastic agents
7. Antiglaucoma agents
8. Antiparkinson agents
VI. Recipient Lock-In Program.
A. Approximately 3,058 recipients were restricted to a pharmacy as of June 30. 1985.
B. Approximately 1,310 recipients were restricted to both a pharmacy and a physician as of April
30. 1985
C. Savings per recipient is $42.00 per month for reduced utilization of drug services.
D. Savings per recipient is $83.00 per month for reduced utilization of physician and drug services.
E. Parameters used for the profiles are:
1. $250 for drug services for a three month period
2. 25 prescriptions in three months
3. Three or more pharmacies or other provider types
4. 180 or more disposable syringes in three months.
VII. Miscellaneous
A. Fiscal Intermediary
The Computer Company'
5101 Jonestown Road
Harrisburg. Pennsylvania 171 12
The Computer Company's chief responsibility is clerical in nature and deals with claims process-
ing 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.
B. Number of Rx claims approved in FY 1984-13,815,483'
C. Average amount paid per claim during FY 1984-$8.72*
'Source: Pharmacy, all services, MRS 300, June, 1984.
Officials, Consultants and Committees
1. Welfare Department Officials:
Walter W. Cohen
Secretary
Department of Public Welfare
Health and Welfare Building
Harrisburg, Pennsylvania 17120
Brian T. Baxter
Executive Deputy Secretaly
Gerald F. Radke
Deputy Secretary for Medical
Assistance
NPC
David S. Feinberg
Director Bureau of Pblicy and Program
Development
Richard H. Lee
Director, Bureau of
Reimbursement Methods
Robert B. Kelly
Director. Bureau of Medical
Assistance Operations
Glenn Johnson
Director, Bureau of
Utilization Review
Eileen M. Schoen
Director
Bureau of Provider Relations
2. Consultant Pharmacists:
Joseph E. Concino. R.Ph.
Bureau of Policy and Program
Development
7171787-1170
William M. Peifer, R.Ph.
Bureau of Medical Assistance
Operations
Robert G. Dissinger, R.Ph.
Bureau of Medical Assistance
Operations
S. Charles Modica. R.Ph.
Bureau of Medical Assistance
Operations
John Ferrara, R.Ph.
Bureau of Utilization Review
Michael A. Bimler, R.Ph.
Bureau of Utilization Review
Frank Cwynar. R.Ph.
Bureau of Utilization Review
Department of Public Welfare
Park Penn Building
Harrisburg 171 12
Department of Public Welfare
Park Penn Building
Harrisburg 171 12
Department of Public Welfare
25 North 32nd Street
fihskip l em Camp Hill 17011
John Hocker, R.Ph.
Bureau of Utilization Review
NPC
3. Medical Assistance Advisory Committee:
Member
James M. Redmond
Vice President, Hospital Services
Hospital Association of Pa.
P.O. Box 608
Camp Hill 1701 1
H. William Gross. D.D.S
141 4 Fairmont Street
Allentown 18102
Walter M. Greissinger, M.D.
Central Medical Pavilion
1400 Center Avenue
Pittsburgh 15219
Milton Jacobs
Executive Director
Saunders House
100 Lancaster Avenue
Ph~ladelphia 19151
Robert B. Edmiston. M.D.
Executive Vice President
Professional Affairs
Pa. Blue Shield
Camp Hill 1701 1
Stuart L. Cohen
Urban League of Pittsburgh, Inc.
200 Ross Street
Pittsburgh 15219
Rev. Joseph A. Davis
161 2 Herr Street
Harrisburg 17103
Joseph Garbinski
819 Grove Avenue
Johnstown 15902
Jack B. Ogun
Director
Div. of Drugs, Devices and Cosmetics
930 Health and Welfare Building
Harrisburg 17120
Truman Painton
Erie Co. Geriatric Center
R.D. #2
Gerard 1641 7
Organization
Hospital Association of Pa.
Pa. Dental Association
Pa. Medical Society
Pa. Health Care Assn.
Pa. Blue Shield
Urban League
Tri-County Retired Senior
Volunteer
Southern Allegheny Legal Aid
Pa. Department of Health
Pa. Assn. of County
Affiliated Homes
Melvin F. Johnson
141 5 Market Street
Harrisburg 17103
Francine Gallagher Manley
516 Highland Avenue
Clarks Summit 1841 1
David H. Lowa
The Salvation Army
Market at North Street
Williamsport 17701
Gary N. Clouser
The Brethern Village
P.O. Box 5093
Lancaster 17601
George Weaver. O.D.
36 North Beaver Street
York 17401
Paul Steinberg, D.O.
171 1 South 8th Street
Philadelphia 19148
Dorothy M. Tartaglio
Administrative Assistant
Nursing Home Agency
201 Chestnut Avenue
Altoona 16601
Oscar W. Morrison
Senior Vice President
Beverly Enterprises
Suite 607
214 Senate Avenue
Camp Hill 1701 1
Harrisburg Concerned
Citizens
Scranton-Lackawanna
Human Development Agency
Salvation Army
Pa. Assn. of Non-Profit
Homes for the Aging
Pa. Optometric Assn.
Pa. Osteopathic Medical Assn.
Pa. Assn. of Home Health
Agencies
Pa. Health Care Assn.
NOTE: Mr. Milton Jacobs is currently sewing as Chairman of the Medical Assistance Advisory
Committee.
4. Pharmacy Subcommittee to the Medical Assistance Advisory Committee:
William L. Greene. R.Ph
Chairman
780 West Macada
Bethleham 18017
Samuel D. Brog, R.Ph
102 Buckley Drive
Philadelphia 191 15
Donald E. Schell. R.Ph.
129 Blacksmith Road
Camp Hill 1701 1
John A. Paone. R.Ph.
Wyman Pharmacy
524 East Ohio Street
Pittsburgh 15212
David Dalton, R.Ph.
Rite Aid Corporation
P.O. Box 3165
Harrisburg 17105
Laraine Forry
Pennsylvania Assn. of
Medical Suppliers
C/O Harrisburg Surgical CO
Harrisburg 17108
Cathy Calderone, R.Ph.
York County Hospital and Home
118 Pleasant Acres Road
York 17402
N. E. Monticelli, R.Ph
669 Burclay Lane
Broomall 19008
Benjamin Pulizzi, RPh.
Williamsport Orthopedic and
Prosthetic Co.
138 East 4th Street
Williamsport 17701
Margaret Warwick, R.Ph.
29 Bryan Street
Havertown 19083
Ronald D. Kaufmann, R.Ph,
C/O Clover, Division of
Starwbridge & Clothier
801 Market Street
Philadelphia 19105
5. Executive Officers of State Medical, Pharmaceutical, Podiatry, and Osteopathic Medical Associations:
A. Medical Society: B. Pharmaceutical Association:
John F. Rineman
Executive Vice President
Pa. Medical Society
20 Erford Road
Lemoyne 17043
Phone: 7171763-71 51
Carmen A. DiCello. R.Ph.
Executive Director
Pennsylvania Pharmaceutical
Assoc.
508 North Third Street
Harrisburg 17101
Phone: 71 71234-6151
C. Podiatry Association: D. Osteopathic Medical Association:
Matthew M. Shook. Jr.
Executive Director
Pennsylvania Podiatry
Association
737 Poplar Church Road
Camp Hill 1701 1
Phone: 71 71763-7665
E. State Board of Pharmacy
Marianne Fields
Executive Director
Pennsylvania Osteopathic
Medical Association
1330 Eisenhower Boulevard
Harrisburg 171 11
Phone: 71 71939-931 8
Ann J. Heizenroth, Secretary
P.O. Box 2649
Harrisburg, PA 17105
71 71783-7157
NPC
PUERTO Rl CO
MEDI CAL ASSI STANCE DRUG PROGRAM (TITLE XI X)
Puerto Rico-1
1985
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFOC O M AB APT0 AFDC Children 21 (SFo)
Prescribed
Drugs X X X X
X X X X X X
lnpalient
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
~ent al
Services X X X X
X X X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Payment l o Pharmacists by fiscal year.
1984 1983
Expended
-
Recipient
-
Expended
-
Recipienl
-
. . . . . . . . . . . . . . . . . . . . .
TOTAL
. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL
A@ . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . .
Blind
. . . . . . . . . . . . . . . . . . . . .
Disabled
. . . . . . . . . . . . Children-Families wmep Children
. . . . . . . . . . . . Adults-Families w/Oep Children
. . . . . . . . CATEGORICALLY NEEDY NON-CASH TOTAL No vendor
. . . . . . . . . . . . . . . . . . . . . .
Aged drug program
. . . . . . . . . . . . . . . . . . . . . .
Blind
. . . . . . . . . . . . . . . . . . . . .
Disabled
. . . . . . . . . . . . Children-Families wI0ep Children
. . . . . . . . . . . . Adults-Families w/Dep Children
. . . . . . . . . . . . . . .
Other Tille XIX Recipients
. . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . .
Blind
Disabled . . .
Children-Families W/@D Children
. . . . . . . . . . . . Other Title XIX Recipients
'"Undupiicated Total - HHS reporl HCFA - 2082
NPC
Puerto Rico-2
1985
Ill. Administration:
By the Department of Health through the existing regionalized health care system operated by the
Commonwealth and municipal government.
IV. Provisions Relating to Prescribed Drugs:
Limited to drugs dispensed through pharmacies of public facilities.
Officials, Consultants and Committees
1. Health Department Officials:
Dr. Jaime Rivera Dueno
Secretary
Medical Assistance Program:
Emilia Hoyos Rucabado, M.S
Pharmacist Consultant
Julio Cesar Galarce
Director
Health Economy Office
Department of Health
Call Box 70184
San Juan, Puerto Rico 00936
8091765-9941
P. 0. Box 10037
Caparra Heights Station
San Juan 00922
8091765-9941
Irma Reville De Ferrer
Director
Medical Assistance Program
2. Medical Assistance Advisory Committee:
The advisory committee consists of eleven members appointed by the Governor.
3. Executive Officers of Puerto Rico Medical and Pharmaceutical Societies:
A. Medical Association:
Diego Artiquez Roman
Executive Director
Puerto Rico Medical Association
P. 0. Box 9387
Santorce 00908
Phone: 8091721 -7979
B. Pharmaceutical Association:
Myrna E. Velez
Executive Secretary
Box 206, G P.O.
SanJuan00936
Phone: 809i753-7157
C. Board of Pharmacy
Pedro J. Vanga, Pres~dent
Box 9342
Santurce. P.R. 00908
NPC
Rhode island-1
1985
RHODE I SLAND
MEDI CAL ASSI STANCE DRUG PROGRAM (TITLE XI X)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APT0 AFDC OAA AB APTD AFOC Children 21 (s Fo)
Prescribed
Drugs X X X X X X X X X
~ k p i t a l 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
nentai
- ......
Services X X X X X X X X X
'SFO-State Funds Only
II. EXPENDITURES FOR DRUGS. Payment to Pharmacisls by liscal year ending June 30. 1984
TOTAL
1984 1983
Expended Recipient
- -
Expended Recipient
- -
511,216,085 . . . . . . . 83,407 $9,996,519 75, 751
CATEGORiCALLY NEEDY CASH TOTAL . . . . . . . . . . $6,063,023 59,575 $5,247,309 56.641
A d . . . . . . . . . . . . . . . . . . . . . . 1.083637 4,830 962,180 4,592
~o~~
Blind . . . . . . . . . . . . . . . . . . . . . . 37.249 178 29.503 164
Disabled . . . . . . . . . . . . . . . . . . . . . 2,593,616 9.149 2,136,616 8.510
Children-Families w!Dep Children . . . . . . . . . . . . 864.725 27,511 799.714 26.424
Adults-Families w!Dep Children . . . . . . . . . . . . 1,483,796 17,907 1.319.296 16,951
. . . . . . . . CATEGORICALLY NEEDY NON-CASH TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . Disabled
. . . . . . . . . . . . Chiidren-Families w1Dep Children
. . . . . . . . . . . . Adults-Families w!Dep Children
. . . . . . . . . . . . . . . Other Title XiX Recipients
. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families wlDep Children
. . . . . . . . . . . . Adults-Families wiDep Children
. . . . . . . . . . . . . . . Other Title XlX Recipients
"Unduplicated Tolal-HHS report HCFA-2082
NPC Rhode Island-2
1985
Ill. Administration:
State Department of Social and Rehabilitative Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions:
OTC and certain Medicine Chest Items and lnjectables:
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 $10 per 100 tablets/capsules or pint), expensive
andlor new preparations.
Prescribed drugs requiring prior authorization may be refilled if requested by the attending
physician and approved by the Division of Medical Services.
€3. Formulary: None
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: One month's supply of drugs.
2. Maintenance Medication: The attending physician may prescribe certain maintenance drugs
up to a maximum 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-convulsants, coronary vasodilators, tranquilizers, antidepressants, hormones.
etc.
Refills are not allowed for specified drugs, e.g., antibiotics, central nervous system stimulants,
narcotics (Schedule 11. Ill), Corticosteroids and appetite depressants, benzodiazepines.
4. Dollar Limits: None
D. Prescription Charge Formula:
1. Prescription Drugs Dispensed to Eligible Recipients Residing in Their Own Homes
A Professional Fee for Service of $3.10 will be allowed for all prescriptions in addition to the
cost of the drug. ($3.25 effective October 1, 1985)
In accordance with federal regulation the upper limit for payment for prescribed drugs will
be based upon the unit cost of the drug plus a dispensing fee 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 unit cost of the drug plus 50 percent, the usual and customary charge to the general
public, or the unit 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 52.60 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 unit cost of the drug plus a dispensing fee 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 unit cost of the drug plus 50 percent, the usual and customary charge to the general
public, or the unit cost plus the Professional Fee for Service.
3. The cost of the drug to the pharmacist in this professional fee-for-service method of payment
will be based upon the AWP listings in the Red Book, per 100 tabletslcapsules or pint of
NPC
Rhode Island-3
1985
liquid except for direct purchases from the following manufacturers:
Abbott-Ross
Lederle
Merck Sharp & Dohme
Parke-Davis & Co.
Warner-Chilcott
Pfiphannics
Pfizer-Roerig
Squibb
Upjohn
Wyeth
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 up to a maximum of 100
tablets, capsules or equivalent, or a 30 days' supply of these drugs-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 $10 per pint of liquid or 100 tablets or capsules.
V. Miscellaneous Remarks:
Copayment-No
Number of Rx claims processed in FY 1984-1,002.061
Average Rx price during PI 1983-$11.21
Officials, Consultants and Committees
1. Social and Rehabilitative Services Department Officials:
hancy V. Bordeleau
Director
Anthony Barile. M.P.A
Assistant Director
Medical Services
Department of Social and
Rehabilitative Services
600 New London Avenue
Cranston, Rhode island 02920
John A. Pagliarini. R.Ph.
Chief Medical Care Specialist
4011464-2184
2. Social and Rehabilitative Services Department Advisory Committees:
A. Medical Assistance Committees:
(1) Medical Advisory Committee on Pharmacy:
NPC
Dr. Heber W. Youngken, Jr., Chairman
Joan Abar,D.O. Peter Mathieu, M.D.
Vincent Alianiello. R.Ph.
Joseph Navach, R.Ph.
Walter Carnevale. R.Ph.
Hon. Anthony Soloman,
John DeFeo. Ph.D. State Treasurer
John DePasquale, R.Ph.
Ira Wellins. R.Ph.
Joseph Galina Richard Yacino, R.Ph.
Louis Jeffrey, R.Ph.
(2) Rhode lsland Pharmaceutical Association:
Henrique Pedro, R.Ph.. President
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society:
Norman A. Baxter. Ph.D.
Executive Director
Rhode lsland Medical Society
106 Francis Street
Providence 02903
Phone: 4011331 -3207
B. Pharmaceutical Association:
Judge J. S. Gendron, R.Ph.
Executive Director
Rhode lsland Pharmaceutical Association
23 Broad Street
Pawtucket 02860
Phone: 4011725-4141
C. Osteopathic Association:
Reuben L. Alexander, D.O.
Secretary
Rhode lsland Osteopathic Physicians
and Surgeons
849 Post Road
Warwick 02888
Phone: 4011781-3940
4. State Board of Pharmacy
John Haronian. Secretary
304 Cannon Building
75 Davis Street
Providence, R.I. 02908
4011277-2837
South Carolina-1
1985
SOUT H CAROLI NA
MEDI CAL ASSI STANCE D R U G PROGRAM (TITLE XI X)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other'
O M A0 APT0 AFDC O M AB APT0 AFDC Children 21 (SFOI
Prescribed
Drugs X X X X X
Inpatient
Hospital Care X X X X X
outpatikt
HosDilal Care X X X X X
X-ray ~ e ~ i c e X X X X X
Skilled Nursing
Home Services X X X X X
Physician
Services X X X X X
Dental
Services X X X X X
Other Benefits: Home Health Services. Rural Health Clinic Services. Medical Transporlation. Podiatrist Services. Optometrists Services, Chiropractic
Services. Durable Medical Equipmenl, Intermediate Care Facilities Services.
'SFO-State Funds Only
II. EXPENDITURES FOR DRUGS. Favment to Pharmacists bv fiscal vear ending June 30. 1984
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 . . . . . . . . . . . . . . . . . . . . .
Childrendamilies w/Dep Children . . . . . . . . . . . .
Adults-Families w/Dep Children . . . . . . . . . . . .
. . . . . . . . . . . . . . . Other Title XIX Recipients
. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
1984
Expended Recipient
- -
Disabled . . . . . . . . . . . . . . . . . . . . . 0 0
Children-Families w/Dep Children . . . . . . . . . . . . 0 0
Adults-Families wI D~D Children . . . . . . . . . . . . 0 0
. . . . . . . . . . . . . . . Other Title XIX ~eci ~i ent s 0 0
1983
Expended
-
Recipient
-
'"Unduplicated Total-HHS report HCFA-2082
NPC
Ill. Administration:
State Health and Human Services Finances Commission
IV. Provisions Relating to Prescribed Drugs:
A. Scope of Non-Formulary 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:
1. Adult vitamins and vitamin combinations; (Prenatal vitamins for females and fluoride vitamins
for children are covered.)
2. Amphetamines and obesity control drugs;
3. Experimental drugs;
4, Immunizing agents (Pneumovax is covered under Physicians' Services):
5. 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.
6. Over-the-counter (OTC) drugs except: Insulin, Insulin syringes, family planning supplies, all
aspirin products, and OTC products listed below:
Actifed Tablets Gelusil II Liquid
Actifed Syrup Hydrocortisone 5% Cr.lOint.
Alternagel Liquid Insulin-all forms
A.S.A. Enseals 5 gr Insulin syringes
A.S.A. Enseals 10 gr
Maalox Suspension
Ascriptin Tablets Maalox #I Tablets
Ascriptin AID Tablets
Maalox #2 Tablets
Aspirin-all forms Maalox Plus Tablets
Basaljel Capsules Maalox Plus Susp.
Basaljel Swallow Tabs
Maalox Therapeutic Conc.
Basaljel Suspension
Micatin Cr. 2% 15 gm.
Basaljel Ext. Strength
Micatin Cr. 2% 30 gm.
Suspension Mylanta Liquid
Bronkotabs Mylanta Tablets
Cama Inlay Tablets
Mylanta II Liquid
Camalox Susp. Mylanta II Tablets
Camalox Tablets Mylicon 80 Tablets
Cerose DM
Niacin 100 mg Tablets
Contraceptive Condoms
Novafed Liquid
Contraceptive Vaginal
Parapectolin
CrIJels
Phazyme
Contraceptive Foams
Riopan Tablets
Debrisan Beads Unit
Riopan Suspension
4 gm 7s
Riopan Chewable Tablets
Debrisan Beads Unit
Riopan Plus Suspension
4 gm 14s
Riopan Plus Tablets
Dirnetane Elixir Robitussin AC
Dimetane 4 mg Tablets
Robitussin DAC
Dimetane Ext. 8 mg
Tedral Elixir
Dimetane Ext. 12 rng
Tedral Tablets
Dimenhydrinate 50 mg Tab. Titralic Liquid
South Carolina-3
1985
Tussar SF
Valadol Tablets
Dimenhydrinate Liquid
Donnagel PG Susp.
Ecotrin Tablets
Gaviscon Liquid
Gaviscon 2 Tablets
Gelusil Tablets
Gelusil Liquid
Gelusil II Tablets
B. Formulary: None
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: None (90 day supply maximum)
In acute conditions, physician requested to limit supply to a minimum of ten (10) days. In
chronic conditions and for maintenance drugs, a minimum of a thirty (30) day supply where
appropriate, a ninety (90) day supply maximum is allowed and encouraged.
2. Refills:
The prescriber authorizes the number of refills.
3. Dollar Limits: None
4. Recipients are limited to three (3) prescriptions per month.
D. Prescription Charge Formula:
Medicaid reimbursement for pharmacy services will be based on the lower of: the South Carolina
Estimated Acquisition Cost (SCEAC); federal maximum allowable cost (MAC) or the provider's
submitted usual and customary charge.
Dispensing fee is $3.40 (2.90 + .50 copay. = 3.40)
Copayment-Providers are authorized to collect a CO-PAY of fifty cents ($0.50) per prescription
from the client, except for clients in long term care facilities, family planning, EPSDT, pregnancy-
related prescriptions, and recipient under 21 years of age.
V. Miscellaneous Remarks:
It is required that each recipient choose one pharmacy for a month.
Officials, Consultants and Committees
1. South Carolina State Health and Human Services Finance Commission
Dennis Caldwell
Health and Human Services Finance
Executive Director Commission
803/758-3175 P.O. Box 8206
Columbia. S.C. 29202-8206
Gwen Power
Bureau of Health Services
803/758-8182
1801 Main Street
Columbia. S.C. 29202
James M. Assey. RPh.
Medicaid Program Consultant
803/758-2320
South Carolina-4
1985
Debbie Francis, R.Ph.
Supervisor, Drug Program
6031758-21 70
2. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
William F. Mann
Executive Vice President
South Carolina Medical Association
P. 0 . Box 11188
Columbia 2921 1
Phone: 8031796-6207
8. Pharmaceutical Association:
Sharon Fennell
Executive Director
South Carolina Pharmaceutical
Association
1405 Calhoun Street
Columbia 29201
Phone: 8031254-1 065
C. Osteopathic Association
J. W. Nichols, D.O.
Secretary-Treasurer
South Carolina Osteopathic Assn.
101 7 Fair Street
Camden 29020
Phone: 8031432-4498
4. State Board of Pharmacy
C. Douglas Chavous, Executive Secretary
P.O. Box 11927
Columbia. S.C. 29211
8031758-5447
NPC
South Dakota-1
1985
SOUTH DAKOTA
MEDI CAL ASSI STANCE DRUG PROGRAM ( TI TLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type ol Benefit Categorically Needy Medically Needy (MN) Other.
O M A6 APTD AFDC O M AB APTD AFDC Children 21 (SFo)
Prescribed Renal
Orugs X X X X Disease
Inpatient Renal
Hospital Care X X X X Disease
Oulpatient R e ~ l
Hospital Care X X X X Disease
Laboratory & Renal
X-ray Service X X X X Disease
Skilled Nursing
Home Services X X X X
Physician Renal
Services X X X X Disease
Dental
Services X X X X
'SFO-State Funds Only
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
Expended
-
Recipient
-
Expended
-
Recipient
-
TOTAL
. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL
. . . . . . . . . . . . . . . . . . . . . . Aged
. . . . . . . . . . . . . . . . . . . . . .
Blind
. . . . . . . . . . . . . . . . . . . . . Disabled
. . . . . . . . . . . . Children-Families wi0ep Children
. . . . . . . . . . . . Adults-Families wIDep Children
. . . . . . . . CATEGORICALLY NEEDY NON-CASH TOTAL
. . . . . . . . . . . . . . . . . . . . . . Aged
Blind . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . Disabled
. . . . . . . . . . . . Children-Families w/Dep Children
. . . . . . . . . . . . Adults-Families wiDep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL
. . . . . . . . . . . . . . . . . . . . . . Aged
Blind . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . Disabled
. . . . . . . . . . . . Children-Families wiDep Children
. . . . . . . . . . . . Adults-Families wi0ep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
TJnduplicaled Total-HHS report HCFA-2082
NPC South Dakota--2
1985
Ill. Administration:
State Department of Social Services, Office of Medical Services.
IV. Provisions Relating to Prescribed Drugs:
A. Exclusions: The program is limited to legend prescription drugs as specified in the state's
Medicaid regulations, and to insulin.
6. Formulary: Administrative Rule, adopted July 1, 1983 states:
"Certain drug payments limited to generic drug form. Payment for the brand name drugs shall
be limited to the generic drug form, unless the prescriber indicates in writing on the prescription
a medical reason why the generic drug may not be used. If the prescription is an oral or call-
back prescription, the pharmacist may document the prescriber's reason for requiring the brand
name drug." (96 drugs and drug dosage forms are affected)
C. Prescribing or Dispensing Limitations:
1. Quantity: Maintenance drugs requiring more than one dose per day must be dispensed
in units of at least 100 or a 30 day supply, if more than 100 unit are required per month.
Maintenance prescriptions for family planning items must be dispensed in at least a 3 month
supply. (New family planning prescriptions can be in smaller units.)
2. Refills: Refills of maintenance drugs costing less than $4.25 per 100 are limited to the greater
of 100 or a 30 day supply.
3. Dollar limits: None.
D. Prescription charge formula: Payment is the lower of: (a) MAC plus dispensing fee of $3.25, (b)
EAC plus dispensing fee of $3.25, or usual and customary charge to the general public.
V. Miscellaneous
A. 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.)
€3. Number of claims processed in FY 1984-284,396
C. Average Rx price during FY 1984-$12.17
Officials, Consultants and Committees
1. James Ellenbecker Department of Social Services
Secretary 700 North Illinois
Department of Social Services Pierre, South Dakota 57501
E ~ i n Schumacher
Program Administrator
Medical Services
Donald Mahannah. P.D.
Pharmacist Consultant
Medical Services
6051773.3495
South Dakota-3
1985
2. Medical Advisory Committee (MAC):
Lloyd Jones, Pharmacist
Jones Drug
609 Sixth Avenue
Aberdeen 57401
Paul I. Engbrecht, Nursing Home Administrator
Administrator
The Tieszen Memorial Home
437 State Street
Marion 57043
Dennis Johnson. M.D.. Physician
1301 South Ninth, 46700
Sioux Falls 571 05
Glenn W. Robeson, O.D., Optometrist
34 Third Street. SE
Huron 57350
James D. M. Russell. Hospital Administrator
Administrator
St. Mary's Hospital
Pierre 57501
Alvin A. Buechler, DDS. Dentist
Box L
Gettysburg 57442
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
Robert D. Johnson
Executive Secretary
South Dakota State Medical Association
608 West Avenue North
Sioux Falls 57104
6051336- 1965
B. Pharmaceutical Association:
Harold H. Schuler
Secretary
South Dakota Pharmaceutical Association
222 East Capitol
(Box 51 8)
Pierre 57501
6051224-2338
C. Osteopathic Association:
David Calver, D.O.
Secretary-Treasurer
South Dakota Society of Osteopathic
Physicians & Surgeons
C/O Massa-Berry Clinic
Sturgis 57785
6051347-361 6
South Dakota-4
1985
4. State Board of Pharmacy
(See above)
NPC
TENNESSEE
MEDI CAL ASSI STANCE DRUG PROGRAM ( TI TLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benelit Categorically Needy Medically Needy (MN) Other'
O M AB APTD AFDC O M AB APT0 AFDC Children 21 (SFO)
-- -
Prescribed
X X X X
". *. *. **
Drugs
Inpatient
X X X X
.. *. .* .*
Hospital Care
Oulpatient
X X X X
.. *. *. .*
Hospital Care
Laboratory &
. . . .
X X X X
.*
X-ray Service
Skilled NurSinQ
X X X X
.. *. .*
Home Services NO
Physician
. . . . . .
X X X X
Services
Dental Covered only il EPSDT ......
Services or under 21
Other Benelils: Home health services: community health clinics; intermediale health care facilities; family planning services, rural health
clinics; early periodic screening and treatment (EPSO&T)
'SFO-State Funds Only
"Caretaker over 21
I 1
EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30. 1984
1984 1983
Expended Recipient
- -
Expended
-
Recipient
-
TOTAL . . . . . . . . . . . . . . . . . . . . . $53,582,671 254,591 "' $47,686,404 248.128
CATEGORICALLY NEEDY CASH TOTAL
Aoed . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . . 432.995 1.614 371.335 1.557
Di s abl ed. . . . . . . . . . . . . . . . . . . . . 21,792,514 63,311 19,006,795 60.983
Children-Families wIDep Children . . . . . . . . . . . . 2.315.341 68.076 2,150,670 69,007
Adulb-Families w/Dep Children . . . . . . . . . . . . 4,007,984 36.620 3,549.089 36.303
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . Aged
. . . . . . . . . . . . . . . . . . . . . .
Blind
. . . . . . . . . . . . . . . . . . . . .
Disabled
. . . . . . . . . . . . Children-Families w/Oep Children
. . . . . . . . . . . . Adults-Families w/Dep Children
. . . . . . . . . . . . . . . Other Title XIX Recipienls
. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL
. . . . . . . . . . . . . . . . . . . . . .
Aged
. . . . . . . . . . . . . . . . . . . . . . blind
Disabled . . . .
Children-Families w/Oeo Children
Other Tille XIX Recipients . . . . . . . . . . . 21,689
"*Unduplicated Total-HHS report HCFA-2M12
NPC
Ill. Administration:
Tennessee Department of Health and Environment
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: OTC drugs (except insulin), cough and cold preparations, anoretic drugs
(except for amphetamines and derivatives for only specific indications of narcolepsy and the
hyperkinetic child).
8. Formulary: "Tennessee Medicaid Drug Formulary"; Restricted Formulary. For information contact:
Ronald E. Graham, Pharm.D.
729 Church Street
Nashville. Tennessee 37219-5406
615/74l-O192
C. Prescribing or Dispensing Limitations:
1. Terminology: May prescribe and dispense brand name drugs but encourage usage of
generic drugs for potential cost savings.
2. Quantity of Medication:
a. One month's supply.
b. Limit of 7 prescription and/or refills per month.
3. Refills: Covered only if specifically authorized by the prescribing physician on the original
prescription. Five refills within 6 months.
4. Dollar Limits: None.
5. MAC (Maximum Allowable Cost). 180 drugs in addition to federal MAC drugs. Approved
Manufacturer's List established based upon bioequivalence.
D. Prescription Charge Formula: Acquisition cost plus professional fee of 53.36 maximum, or usual
and customary-whichever is lower.
Lesser of:
1. Actual acquisition cost-plus-fee, or
2 Maximum allowable cost-plus-fee, or
3. Usual and customary charge.
V. Miscellaneous
Fiscal Intermediary
EDS Federal Corporation
301 South Perimeter Park Drive
Nashville. Tennessee 3721 1
Number of Rx Claims Processed in FY 1984-4,304,448
Average Rx Price During PI 1983-512.36
Officials, Consultants and Committees
1. Health Department:
A. Officials:
James E. Word, M.P.H.
Commissioner
Tennessee Department of
Health and Environment
344 Cordell Hull Building
Nashville, Tennessee 37219
NPC
Ronald E. Graham, Pharm.D.
Director of Pharmacy
Services
61 51741 -0192
Sandra J. Daniel
Director
Billy W. Huffines
Director, Division of
Medical Assistance-
Medicaid
Peggy A. Alsup, M.D.,
Bureau Medical Director
Medicaid Administration
729 Church Street
Nashville 3721 9-5406
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).
MEMBERS REPRESENTATION
Edward W. Reed, M.D. Chrmn,
975 Thomas Street
Memphis. TN 38107
(527-4484)
Sammie Lynn Puett
11 1 Seventh Avenue, North
Nashville. TN 37203
(741 -3241)
Hays Mitchell. M.D.
Bradley Medical Center
Cleveland. TN 3731 1
(472-6551 )
David Lillard
Lillard's Pharmacy
81 North Tillman Street
Memphis, TN 381 11
Bill McCaskell
Trevecca Health Care Center
329 Murfreesboro Road
Nashville, TN 37210
(244-6900)
Physician (Urban)
Commissioner
Tennessee Department of
Human Services
Physician (Rural)
Pharmacist
Administrator
NPC
Imogene Kaserman, R.N,
Lakeshore Mental Health
5908 Lyons View Drive
Knoxville, TN 38301
(584-1 561)
Betty J. Thompson
Family Nurse Clinican
Metro Health Department
East Station
1015 E. Trinity Lane
Nashville. TN 37216
(227-8140)
Jerre Hale, D.D.S.
300 Bryant St.
Smithville, TN 37166
(597-4737)
Thomas L. Adams
Retail Clerks Union,
Local 1557
203 North 11 th Street
Nashville, TN 37206
Elizabeth Marbuy
2300 Wilson Street
Apt. 6-A
Chattanooga, TN 37406
Betty R. Tenpenny
1007 West Parkway
Knoxville, TN 37912
John G. Green
1015 Mitchell
Cookeville, TN 38501
'John L. Brown
Director. Benefits
Northern Telecom, Inc.
259 Cumberland Bend
Metro Center
Nashville, TN 37228
(256-5900)
John Watson
United Way of Greater Memphis
3489 Poplar Ave.
Suite One
Memphis, TN 381 11
2. Medicaid Formulary Advisory Committee:
Nurse
Nurse
Dentist
Consumer
Consumer (Medicaid
recipient)
Consumer Representative
Consumer
(HMO Representative)
Consumer
(Labor Representative)
Eight members appointed by the Commissioner for three-year terms (initial terms will be Stag-
gered). Five members will be pharmacists. Each pharmacist member will be selected from nomina-
tions submitted by the Tennessee Pharmaceutical Association. Three 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 program-preferably enrolled providers.
MEMBERS OCCUPAT/ON
Horton Jones
Jones Pharmacy
14th and Buchanan Street
Nashville, TN 37208
Terry Brimer, Pharm.D.
Doctor's Hospital Pharmacy
726 McFarland Avenue
Morristown, TN 37813
Dianna C. Drake. D.Ph.
1100 Shadyland Drive
Knoxville. TN 37919
Ray Marcrom. Pharm.D.
Marcrom's Pharmacy
1277 McArthur Street
Manchester. TN 37355
Earl Marshall. D.Ph.
Hollywood Pharmacy Mart. Inc.
903 Hollywood
Jackson. TN 38301
Stephen Schillig. M.D.
Metropolitan Board of Hospitals
72 Hermitage Avenue
Nashville. TN 37210
Charles W. White, M.D.
14 Hospital Drive
Lexington. TN 38351
Carl T. Duer, M.D.
Route 9
Crossville, TN 38555
Community Pharmacist
Clinical and Institutional
Pharmacist
Institutional Pharmacist
Community Pharmacist
Community Pharmacist
Physician
Middle TN
Physician
West TN
Physician
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: B. Pharmaceutical Association:
L. Hadley Williams
Executive Director
TN Medical Association
1 12 Louise Avenue
Nashville 37203
Phone: 6151327-1451
Tom C. Sharp. Jr.
Executive Secretary
TN Pharmaceutical Assoc.
226 Capitol Blvd.,
Suite 308
Nashville 37219
Phone: 6151256-3023
C. Osteopathic Association:
Paul Grayson, D.O.
Secretary-Treasurer
Tennessee Osteopathic Medical Association
Box 390
Pikeville 37367
61 51447-2606
4. State Board of Pharmacy
J. Floyd Ferrell, Jr., Director
404 Doctors Building
706 Church Street
Nashville, Tennessee 37219
6151741 -2718
NPC
TEXAS
MEDI CAL ASSI STANCE D R U G PROGRAM ( TI TLE XIX)
I. BENEFITS PROVIDED AN0 GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other.
O M AB APT0 AFDC OAA AB APTD AFOC Children 21 WO)
Prescribed
0r11ns X X X X X X
Inpatient
Hospital Care X X X X X X
Out~atient
~oi pi t al care x x x x x x
Laboratory &
X-rav Service X X X X X X
Skilled Nursing
Home Services X X X X X X
Physician
Services X X X X
.. *.
Oenlal
Services Limited X X X X
Other Benefits: Eye relractions, prosthestic lens; home health services; ambulance, chiropractor; podiatrist; eye glasses; hearing aids, Ambulatory
Surgical Center Service
'SF0 - State Funds Only
" - EPSDT only
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by liscal year ending August 31. 1984
1984 1983
Expended Recipient
- -
Expended
-
Recipient
-
TOTAL . . . . . . . . . . . . . . . . . . . . . $94,794,375 568,155'' $83,933,346 533.595
. . . . . . . . . . CATEGORICALLY NEEOY CASH TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . . 37,434,506 140.772
Blind . . . . . . . . . . . . . . . . . . . . . . 758,961 3,507
Di s a b l e d . . . . . . . . . . . . . . . . . . . . . 18,991.318 78,069
Children-Families w/Dep Children . . . . . . . . . . . . 6,650.930 186.604
Adulb-Families w/Dep Children . . . . . . . . . . . . 8.80(1,236 100,742
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families wDep Children
. . . . . . . . . . . . Adults-Families w/Dep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
. . . . . . . . . . . . . . MEDICALLY NEEOY TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families w/Dep Children
Adults-Families wDep Children . . . . . . . . . . . .
Other Title XiX Recipients . . . . . . . . . . . . . . .
"Unduplicated Total - HHS reporl HCFA - 2082
NPC
Ill. Administration:
Vendor drug program was implemented September 1, 1971.
Texas Department of Human Resources.
IV. Provisions Relating to Prescribed Drugs:
Pharmacy services under the vendor drug program include the dispensing of most legend drugs
and certain non-legend drugs to eligible recipients. Only pharmaceuticals which meet the FDA
requirements, are approved for marketing and are approved by the Texas Department of Human
Resources 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 reim-
bursement formula and vendor payment to hospitals, nursing homes and institutions.
A. General Exclusions (diseases, drug categories, etc.): Adult vitamins and adult vitamin com-
binations, 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.
6. 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:
Raul Martinez, Jr., R.Ph.
Director, Product Enrollment, Vendor Drugs
Texas Department of Human Resources
P.O. BOX 2960 (541-A)
Austin, Texas 78769
5121835-0440, ext. 2595
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Prescribed quantity cannot exceed a six month supply.
2. Refills: Five refills, but total amount may not exceed 6 months' supply.
D. Prescription Charge Formula:
1. For prescription legend medication:
Acquisition cost plus a variable dispensing fee up to a maximum of $4.05 per prescription
(range $3.72-$4.05*) based on a point system of services rendered, or usual and cus-
tomaary total price, whichever is lower.
Acquisition Cost: Current Red Book cost of direct cost or invoice cost. MAC based on
wholesale or direct cost as indicated by the provider.
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.
V. Miscellaneous Remarks:
The dispensing fee, which includes all costs of filling a prescription, was established by cost
accounting and service evaluation of the expenses involved in dispensing a prescription. Therefore,
fees paid to providers who do not experience all cost and service factors considered in arriving at
the fee, may be less than the maximum allowable fee.
Copayment-None.
Number of claims processed in FY 1984-6,579,073
NPC
Average Rx price during FY 1983-$15.78
'Plus $.06 if on tape.
Plus $.08 patient profits
Plus $.08 delivery service
Plus $.03 emergency service
Plus $.03 continuing education
Officials, consultantsrand Committees
1. Department of Human Resources Off iciak:
Marlin W. Johnston
Commissioner
Merle E. Springer
Executive Deputy commissioner
Ms. Mary Polk
Executive Assistant
Martin Dukler
Deputy Commissioner for Programs
Hillary Connor, M.D.
Deputy Commissioner for
Health Care Services
Dr. Janice Caldwell
Associate Commissioner
Services to Aged & Disabled
ROY E. Westerfield
Director of
Projects for Health Care
Alternatives
Vendor Drug Program:
W. B. Barner. R.Ph.. D.Ph.
Program Specialist
51 21540-3202
Texas Department of Human
Resources
Post Off ice Box 2960
701 West 51 st Street
Austin, Texas 78769
Raul Martinez, Jr.. R.Ph.
Staff Specialist
5121540-3181
2. Executive Officers of State Medical and Pharmaceutical Societies:
NPC
A. Medical Association:
C. Lincoln Williston
Executive Director
Texas Medical Association
1801 N. Lamar Boulevard
Austin 78701
Phone: 5121477-6704
8. Pharmaceutical Association:
Luther R. Parker
Executive Director
Texas Pharmaceutical Assoc.
P. 0. Box 14706
1624 East Anderson Lane
Austin 78761
Phone: 5121836-8350
C. Osteopathic Association:
Tex Roberts
Executive Director
Texas Osteopathic Medical Association
226 Bailey Avenue
Fort Worth 761 07
81 71336-0549
3. State Board of Pharmacy
Fred S. Brinkley. Jr.,
Executive DirectorlSecretary
21 1 East 7th Street. Suite 1121
Austin. Texas 78701
51 21478-9827
NPC
UTAH
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other*
O M AB APT0 AFDC OAA AB APT0 AFDC Chlldren 21 (SFo)
Prescribed
n n m X X X X X X X X X X
Inpatient
Hosoital Care X X X X X X X X X X
Outoatient
~oi pi l al 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
Other Benefits: Home health, clinic services. transportation, family planning; medical supplies, Early Periodic Screening for Children; services of
psychologists, physical therapists, speech therapists, podiatrists, osteopaths, optometrists and audiologists.
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by liscat year ending September 30, 1984
TOTAL . . . . . . . . . . . . . . . . . . . . .
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families wIOep Children
. . . . . . . . . . . . Adulfs-Families wDep Children
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . Disabled
. . . . . . . . . . . . Children-Families wI0ep Children
. . . . . . . . . . . . Adults-Families wIDep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families wlOep Children . . . . . . . . . . . .
. . . . . . . . . . . . Adults-Families wlDep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
Expended
-
$5,489,057
$3,260,569
564,575
9,106
1,043,198
549.390
1,094,300
$1,727,256
1,034.161
2,184
540,813
37,185
112,913
0
$501,232
215,439
2,305
139,668
131
843
142.846
1984
Recipient
-
47,008
35,852
2.054
37
3,266
18,358
13.420
7,744
3,257
7
1,500
1,475
1,566
0
5,511
694
6
413
6
25
4.395
Expended
-
$4,618,072
$2.597393
500,4W
5,483
904,273
435.629
751.608
$633,353
297.596
4,047
239,608
36,324
55.778
0
$1,387,326
825.802
239
361,612
17,240
52,591
129,842
1983
Recipient
-
43,721
31,724
1.988
37
3,125
15.905
10,788
4,862
1,149
15
882
1.631
1,208
0
9,148
2,649
1
948
664
639
4,315
"Unduplicated Total - HHS report HCFA - 2082
Ill. Administration:
Division of Health Care Financing, State Department of Health
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions:
Vitamins, (except for expectant mothers and children to age 5), anorectics; (except for am-
phetamines and derivatives only for specific indications of narcolepsy and the hyperkinesis.)
Other categories-minor tranquilizers and antiarthritics require prior approval.
B. Formulary: modified open formulary (effective January 1, 1985),
C. 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 "sustaining" drugs, for which a 100-day supply is authorized.
D. Prescription Charge Formula:
Lowest of EACIMAC Cost plus professional fee of $3.25, or usual and customary charges to the
private sector.
Offlclals, Consultants and Committees
1. Department of Health Officials:
Peter C. Van Dyck,MD
Acting Executive Director
Glen Blonquist Acting Director
Division of Health Care Financing
RaeDell Ashley
Manager, Program Operations
and Medical Determination
Department of Social Services Officials:
Norman G. Angus
Director
Department of Health
150 West North Temple
Salt Lake City, Utah 84103
801 1533-6151
Department of Social Services
150 West North Temple
Salt Lake City 84103
Cindy Haig, Director
Office of Assistance Payments
2. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: 6. Osteopathic Association:
J. Leon Sorenson
Executive Director
Utah State Medical Assoc.
540 East 5th South
Salt Lake City 84102
Phone: 8011355-7477
Katherine V. Greenwood, D.0
Suite 201
750 N. 200 N.
Provo 84601
801 1377-3871
NPC
C. Pharmaceutical Association:
C. Neil Jensen
Executive Director
Utah Pharmaceutical Assoc.
1062 East 21st South, Ste. 212
Salt Lake City 841 06
Phone: 801/484-9141
D. State Board of Pharmacy:
Robert G. Bowen, Director
Division of Registration
160 East 300 S
P.O. Box 45802
Salt Lake City, Utah 84145
8011530-6634
NPC
VERMONT
MEDI CAL ASSI STANCE DRUG PROGRAM (TITLE XI X)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Dther'
O M AB APTD AFDC OAA A0 APTD AFDC Children 21 ( SFO)
Prescribed
Dr ~~ns X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X X
Laboratory &
X-rav Service 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
nsnbl
Services X X
Other Benelits:
Vision Care X X X X X X X X X X
'SF0 - State Funds Only
II. EXPENOITURES FOR DRUGS. Pdyment to Pharmacists by fiscal year ending September 30. 1984
1984 1983
Exoended Recioient Exoended Recioient
TOTAL
. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL
. . . . . . . . . . . . . . . . . . . . . . Aged
. . . . . . . . . . . . . . . . . . . . . . Blind
. . . . . . . . . . . . . . . . . . . . . Disabled
. . . . . . . . . . . . Children-Families w/Dep Children
. . . . . . . . . . . . Adults-Families w/Oep Children
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . Aged
. . . . . . . . . . . . . . . . . . . . . . Blind
Disabled . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families wiOep Children
. . . . . . . . . . . . Adults-Families w/Oep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL
. . . . . . . . . . . . . . . . . . . . . . Aged
. . . . . . . . . . . . . . . . . . . . . . Blind
Disabled . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families w/Dep Children
. . . . . . . . . . . . Adults-Families w/Oep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
"Undupiicated Total - HHS report HCFA - 2082
NPC
Ill. Administration:
Agency of Human Services.
IV. Provisions Relating to Prescribed Drugs:
Program allows the welfare 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
softeners.
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.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Initial prescription should be sufficient to allow for the determination
of the patient's tolerance of the medication without creating unnecessary waste (expense) to
the program. This quantity could be up to a 60-day supply on all maintenance medication
prescriptions.
2. Refills: Up to 5 refills may be authorized by physician,
D. Prescription Charge Formula: Pharmacies bill their usual and customary charge. Medicaid pays
the lower of:
1. Usual and customary
2. AWP plus $2.50 fee
3. the maximum allowable cost plus fee
E. Co-pay of $1 .OOper dispensation required (excluding standard federal exemptions).
V. Miscellaneous
Fiscal Intermediary:
EDS Federal
P. 0. Box 1 102
South Burlington, Vermont 05401
Officials, Consultants and Committees
1. Agency of Human Services:
Gretchen Morse
Secretary
2. Social Welfare Department:
Elmo A. Sassorossi
Director
Medicaid Division
Agency of Human Services
103 S. Main Street
Waterbury 05676
8021241 -2880
Medicaid Division
103 South Main Street
Waterbury 05676
James Bane
Deputy Director
Medicaid Division
Charles Perry
Chief of Policy & Evaluation
8021241 -2880
Robert Edson, R.Ph.
Pharmacy Consultant
3. Medicaid Pharmacy Peer Review Committee:
Michael Scollins. M.D., Chairman
James Craddock, R.Ph
Edgar Hyde, M.D
James Lill, R.Ph.
John Low, R.Ph.
4. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society:
Robert Vautier
Executive Director
Vermont Medical Society
136 Main Street
Montpelier 05602
Phone: 8021223-7890
8. Pharmaceutical Association:
Philip J. O'Neill
Executive Secretary
Vermont Pharmaceutical Association
P. 0. Box 926
Bennington 05201
Phone: 80214424943
C. Ostedpathic Association:
Charles R. Norton, D.O.
Secretary-Treasurer
Vermont State Association Osteopathic
Physicians and Surgeons, Inc.
P.O. Box 341
South Hero, Vermont 05486
8021372-4200
5. State Board of Pharmacy
Mary Ellen Grupp, Secretary
26 Terrace Street
Redstone Building
Montpelier, Vermont 05602
8021828-2372
Department of Social Welfare
Medicaid Division
103 South Main Street
Waterbury 05676
NPC
VI RGI N I SLANDS
MEDI CAL ASSI STANCE DRUG PROGRAM ( TI TLE XI X)
Vi r g i n I s l ands - 1
1985
I. BENEFITS PROVIDED AN0 GROUPS ELIGIBLE
Type of Benelit Categorically Needy Medically Needy (MN) Other'
OAA AB APT0 AFOC OAA AB APT0 AFDC Children 21 (SFo)
Prescribed
Drugs X X X X X X X X
X X
lnpalient
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
Laboralory &
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
Other Benefils: Home health services: EPSDT: clinic services, prosthetic devices and dentures; eyeglasses; ambulance service and other
transportation.
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Fiscal year ending Seplember 30, 1984
1984 1983
Expended Recipient
- -
Expended
-
Recipienl
-
TOTAL . . . . . . . . . . . . . . . . . . . . . $368,129 8,217 $363,239
13,271
. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL
. . . . . . . . . . . . . . . . . . . . . . Aged
. . . . . . . . . . . . . . . . . . . . . .
Blind
. . . . . . . . . . . . . . . . . . . . . Disabled
. . . . . . . . . . . . Children-Families w/Dep Children
. . . . . . . . . . . . Adulls-Families wIOep Children
. . . . . . . . CATEGORICALLY NEEDY NON-CASH TOTAL
. . . . . . . . . . . . . . . . . . . . . .
Aged
. . . . . . . . . . . . . . . . . . . . . .
Blind
. . . . . . . . . . . . . . . . . . . . . Disabled
. . . . . . . . . . . . Children-Families w10ep Children
. . . . . . . . . . . . Adults-Families w/Dep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL
A . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . Blind
. . . . . . . . . . . . . . . . . . . . . Disabled
. . . . . . . . . . . . Children-Families w/&p Children
. . . . . . . . . . . . Adults-Families w/Oep Children
Other Tille XIX Recipients . . . . . . . . . . . . . . .
Virgin Islands-2
1985
Ill. Administration:
Department of Health
IV. Provisions Relating to Prescribed Drugs:
Broad coverage as provided by public medical facilities.
Private facilities are used when the prescribed drug is not available at the public medical facility
or designated hospital pharmacy. However, such private pharmacies used must have signed a
provider's agreement with the agency.
Prescription Charge Formula: The pharmacists actual cost plus a $2.40 dispensing fee, except in
institutions where drugs are included in the reimbursement formula, or except where a public agency
makes bulk purchases of drugs in accordance with statutes or regulations governing such purchases.
Otflcials, Consultants and Committees
A. Health Department:
1. Officials:
Roy L. Schneider. M.D.
Commissioner
Jeannette A. Mahoney,
A.C.S.W., M.P.H.
Director, Health Insurance
and Medical Assistance
2. Medical Care Advisory Committee:
Not available
8. Social Welfare Department Official:
Gwendolyn C. Blake (Mrs.)
Commissioner
C. Executive Officer of Virgin lslands Medical Society:
Bureau of Health insurance
and Medical Assistance
P. 0. Box 7309
Charlotte Amalie
St. Thomas
Virgin lslands 00801
8091774-4624
Department of Social Welfare
Charlotte Amalie
St. Thomas 00801
Jose F. Poblete, M.D.
Virgin lslands Medical Society
Charlotte Amalie
St. Thomas. Virgin lslands 00801
NPC
VI RGI NI A
MEDI CAL ASSI STANCE DRUG PROGRAM ( TI TLE XI X)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefil Categorically Needy Medically Needy (MN) Other'
Children 21 lSFOl OAA AB APT0 AFOC O M AB APT0 AFDC ~ ~ , .
Prescribed
oruos X X X X X X X X X
lnpalient
Hospital Care X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X
Laboratory 8
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 All eligible recipienls
Services under age 21
'SF0 - Slate Funds Only
II. EXPENDITURES FOR DRUGS. Paymenl to Pharmacists by fiscal year ending June 30, 1984
1984
Expended Recipienl
- -
TOTAL . . . . . . . . . . . . . . . . . . . . . $36,050,372 221,394"
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $26,095,571 189,964
Aged . . . . . . . . . . . . . . . . . . . . . . 9,062,443 29.492
Blind . . . . . . . . . . . . . . . . . . . . . . 232,931 848
Disabled . . . . . . . . . . . . . . . . . . . . . 9,849.646 31,322
Children-Families w1Oep Children . . . . . . . . . . . . 2,568,490 77,034
Adults-Families wlOep Children . . . . . . . . . . . . 4,382,061 51,268
. . . . . . . . CATEGORICALLY NEEDY NON-CASH TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families w/Dep Children
. . . . . . . . . . . . Adulls-Families wlOep Children
. . . . . . . . . . . . . . . Other Tille XIX Recipients
. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Children-Families wlDep Children
. . . . . . . . . . . . Adults-Families w/Oep Children
. . . . . . . . . . . . . . . Other Title XIX Recipients
1983
Expended
-
Recipienl
-
$31,067,436 219.970
YJnduplicated Tolal - HHS report HCFA - 2082
Ill. Administration:
By the Department of Medical Assistance Services. Eligibility determination by the Department of
Social Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions:
Non-legend drugs except family planning drugs and supplies, insulin, and insulin syringes and
needles. Anorectic drugs and designated DESl drugs.
B. Formulary: None,
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Physicians requested to prescribe maintenance drugs in quantities
reflecting a 30-day supply, or 100 units or doses.
2. Refills: Physicians may authorize refills according to legal requirements.
D. Prescription Charge Formula:
State Reimbursement-Based upon the lower of:
MACIAWPIEAC plus fee or usual and customary charge minus applicable co-pay;
Pharmacy fee, $3.40
Co-payment
$0.50/Rx for which the State pays $10 or less
$1.001Rx for which the State pays more than $10
(Exclusions, under 21, pregnancy related, and nursing home patients)
Nursing Home Rxs Unit-Dose
Note: 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 tablet or capsule or 10 ml oral liquids.
Packaging allowance . . . . . . . . $0.01 57ldose
Plus an additional . . . . . . . $O.Ol/metric quantity
Legend Drugs
MACIAWPIEAC plus $3.40 fee or usual and customary charge.
Prescription Payment Limitation
One monthly prescription fee per legend drug dispensed.
0-1-Cs
Lower of cost plus markup (50%) or usual and customary charge
State MAC drugs (OTC) = 1 1.
Maximum Allowable Cost Drugs
V. Miscellaneous
State MAC Program-Yes, 138 drugs.
Number of claims processed in FY 1984-3,670,208 (6.3% increase)
Average Rx price during FY 1984-$9.88 (7.9% increase)
NPC
Fiscal Intermediary:
The Computer Company (TCC)
P.O. Box 6987
Richmond, Virginia 23230
Officials, Consultants and Committees
1. Health Department Officials:
Ray T. Sorrell
Director
8041786-7933
Bruce U. Kozlowski
Deputy Director
804i786- 7933
Mary Ann Johnson. R.Ph. (Mrs.)
Pharmacist
Health Services Review
8041786-3820
Malcolm 0. Perkins
Manager, Provider Relations
Division of Operations &
Provider Services
Office of Medical Assistance
804/786-7781
2. Governor's Advisory Committee on Medicaid:
Medical Society of VA
C. Barrie Cook, M.D.
Frank S. Royal, M.D. (Old Dominion
Society)
VA Academy of General Practice
A. Epes Harris. Jr., M.D
Virginia Hospital Association
Craig R. Cudworth
VA Pharmaceutical Association
Thomas A. Abbott, R.Ph.
James V. Morgan, R.Ph.
Virginia Nurses Association
Department of Medical Assistance
Services
Richmond. Virginia 23219
Blue CrosslBlue Shield of VA
Ronald H. Bargatze
Virginia State Dental Assoc
Byard S. Deputy, D.D.S
Harry L. Hodges, D.D.S
Barry Shipman, D.M.D. (Dental School)
Private insurance Carriers
John L. Tuttle
Medical School Representative
Gary G. Suter, M.D
Pamcipants Advisory Council
Lucy S. Wohlford, R.N.
Mary B. Evans
Sharon P. Urofsky
NPC
VA Health Care Association Unknown
James K. Meharg, Jr.
Ex Officio
William L. Lukhard
Commissioner
Joseph J. Bevilacqua, PhD
Commissioner
Ms. Jessie Key
Mr. Richard Merritt
State Department of Welfare
State Department of Mental
Health and Mental Retardation
James B. Kenley, M.D.
State Department of Health
Commissioner
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: C. Osteopathic Association:
James L. Moore
Executive Vice-president
Medical Society of Virginia
4205 Dover Road
Richmond 23221
Phone: 8041353-2721
B. Pharmaceutical Association:
Paul Galanti
Executive Director
Virginia Pharmaceutical Assn.
31 19 West Clay Street
Richmond 23230
Phone: 8041355-7941
4. State Board of Pharmacy
L. R. Luxton, D.O.
Secretary-Treasurer
Virginia Osteopathic Medical Assn.
LB & B Building
Waynesboro 22980
Phone: 7031943-3341
J. B. Carson, Executive Director
517 West Grace Street
P.O. Box 27708
Richmond, VA 23261
8041786-0239
NPC
WASHI NGTON
MEDI CAL ASSI STANCE DRUG PROGRAM ( TI TLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type ol Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC DAA AB APT0 AFDC Children 21# (SFO)
Prescribed
nrmc X X X X X X X X X X
Inpatient
Hospila Care X X X X X X X X X X
Outoatient
~ o i ~ i l a l 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
Denla
Services Limited Xo
2 - Children under 21 0 - Children (EPSDT) only
# - Limited to children in foster care, subsidized adoption. SNH, IFC, iCMR or inpatient psychiatric facility
'SF0 - State Funds Only
11. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
Expended
-
Recipient
-
Expended
-
Recipient
-
TOTAL . . . . . . . . . . . . . . . . . . . . . $25,946.074 214,123" $21,967,959 185, 225
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $8,604.816 149,727
Aaed . . . . . . . . . . . . . . . . . . . . . . 987,510 3,229
Blind . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . Children-Families'wIDep Children
Adults-Families w1Dep Children . . . . . . . . . . .
. . . . . . . . CATEGORICALLY NEEDY NON-CASH TOTAL
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Chiidren-Families wlOep Children
Adulls-Families w1Dep Children . . . . . . . . . . . .
. . . . . . . . . . . . . . . Other Title XIX Recipienls
MEDICALLY NEEDY TOTAL
Aged . . . .
Blind . . . . . . . . . . . . . . . . . . . . . . 4,268
19
Disabled . . . . . . . . . . . . . . . . . . . . 514.601 2,046
Children-Families wlDeo Children . . . . . . . . . . . . 32.389 1,551
Adults-Families w/Dep 'Children . . . . . . . . . . . . 96,600 1,741
Other Title XIX Recipients . . . . . . . . . . . . . . . 0 0
"Undupiicated Total - HHS repurl HCFA - 2082
NPC
Ill. Administration:
By Division of Medical Assistance, Department of Social and Health Services. The local Medical
Consultants review the need for non-formulary drugs.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions:
Medicine chest drugs are not provided. Non-formulary drugs are provided in an emergent life-
endangering situation and/or medically mandatory.
B. Formulary: Includes 2,800 listings by drug product name, quantity, dosage form and strength.
Formulary is revised 2 to 3 times annually.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: No maximums: minimum of 30 days supply for maintenance medica-
tions.
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.
$3.70-Unit dose systems (Nursing Home Rxs)
$3.00-Retail pharmacies, filling over 35,000 Rxs annually
$3.40-Retail pharmacies, filling 15,000-35,000 Rxs annually
$3.70-Retail pharmacies, filling 35,000 or less Rxs annually
V. Miscellaneous
Copayment-None.
State MAC-144 drugs
Claims processing agent: Consultec, Inc.
P.O. Box 9245
Mail Stop HA-1 1
Olympia, Washington 98504
Number of Rx claims processed in CY 1984-2,631,639 (paid)
Average Rx price during CY 1984-410.89
Officials, Consultants and Committees
1. Social and Health Services Department Officials:
Karen Rahm
Secretary
Gerald J. Reilly
Director
Department of Social and
Health Services
06-44
Olympia, Washington 98504
Division of Medical
Assistance
HB-11
Olympia 98504
NPC
Guthrie L.Turner. Jr., M.D
Medical Director
Office of Medical Director
HB-41
Olympia 98504
William P. Pace, R.Ph. Office of Medical Director
Pharmacist Consultant HB-41
Olympia 98504
2. Social and Health Services Department Medical Consultants
A. Full-time: Local Office
Wesley M. Brock, M.D.
Michael D. McGee, M.D.
Norman Meckstroth, M.D.
Edward P. Palmason. M.D.
Joseph F. Powers, M.D.
B. Part-time
Joan Baumgartner, M.D.
Howard A. Boyd. M.D.
Walter A. Boyle. M.D.
Robert Bright, M.D.
Raymond J. Bunker, M.D.
Cary H. Coppock, M.D.
Lyle J. Cowan, M.D.
John Dalton, M.D.
Lowell L. Eddy, M.D.
Ernest Eytinge, M.D.
Burton A. Foote. M.D.
Arnold J. Herrmann, M.D.
Michael H. Higgins, M.D.
Paul Johnson, M.D.
Kenneth H. Kinard. M.D.
Jefferson D. Kyle, M.D.
Albert V. Mills, M.D.
James A. Moore, M.D.
Carl C. Walters, M.D.
John Walz, M.D.
Dental
Howard B. Henderson, D.M.D.
Curlis C. Sapp, D.D.S.
Podiatry
Robert E. Wendel, D.P.M
State Office, Olympia
State Office, Olympia
Spokane
RMU-Seattle
Port Angeles
Port Townsend
Pierce Central
RMU-Seattle
State Office. Olympia
Kelso
Bremerton
Wenatchee
Pierce Central
OmakIOkanogan
Olympia. Shelton, Chehalis
RMU-Seattle
Everett
Ellensburg
Pierce Central
Spokane
RMU-Seattle
Everett
Spokane
Pasco, Walla Walla
Aberdeen, South Bend
Yakima
Vancouver
Office of Medical Director, Olympia
Office of Medical Director, Olympia
Opthalmology
Jerrol R. Neupeer. M.D. RMU-Seattle
3. Department of Social and Health Services Title XIX Advisory Committee:
NPC
Members:
Andrade Man, Chairperson
Childrens Orthopedic Hospital
4800 Sand Point Way, N.E.
Seattle, WA 98105
2061643-4750 or 526-2003
John A. Beare, M.D. (Ex Officio)
DSHS-Division of Health
Mail Stop ET-21
Olympia. WA 98504
(206)753-5871
Dixie Cole
909 University Street
Seattle, WA 98101
(206)382-9700
J. Keith Wilson
821 H Street
Centralia, WA 98531
(509)736-7881
Sheldon Biback, M.D.
3216 N.E. 45th Place
Seattle, WA 98105
(206)524-2600
Willie Cain
181 4 East Alton
Pasco, WA 99301
5091547-0242
Harriet J. Greenwood
9009 Greenwood Avenue North
# 3 l l
Seattle, WA 98103
(206)784-5378
Craig Karpilow, M.D.
4608 S.W. Hill Street
Seattle, WA 98188
(206)575-7881
Robert I. Jetland
Harborview Medical Center
325 Ninth Avenue
Seattle, WA 981 04
(206)223-3036
Louis 0. Stewart
2809 Yelm Highway
Olympia, WA 98501
(206)491-5886
(206)682-6002
Ray Westeren
Silverwood
9905-19th Avenue, S.E
Seattle, WA 98204
(206)338-1122
Vernon Doyl
East 1212 ~ i n a Avenue
Spokane, WA 99202
(509)534-3912
Lawrence Mast, D.D.S
1126-112th N.E.
Bellevue, WA 98004
2061455-9721
DSHS Staff Members:
Gerald J. Reilly, Director
Division of Medical Assistance
HB-41
Olympia, WA 98504
Peggy Flemer, Secretary
Division of Medical Assistance
HB-41
Olympia
James Peterson, Chief
Office of Analysis and Medical Review
HA-41
Olympia
Mike Stewart, Chief
Office of Provider Services
HA-1 1
Olympia, WA 98504
* Guthrie L. Turner, Jr.. M.D.
Medical Director
Office of Medical Director
HB-41
Olympia 98504
(206)753-5839
'Responsible for approving new formulary additions.
4. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: C. Osteopathic Association:
Harlan R. Knudson
Executive Director
Washington State Medical Assn
900 United Airlines Building
2033 Sixth Avenue, Suite 900
Seattle 98121
Phone: 2061623-4801
Mr. W. Lawless
Executive Director
Wash. Osteopathic Medical Assn.
4210 S.W. Oregon
Seattle 981 16
2061937-5358
6. Pharmaceutical Association: D. State Board of Pharmacy
Raymond A. Olson
Executive Director
Wash. State Pharmaceutical Assn.
1415 Seneca SW, Suite 200
Renton 98055
Phone: 2061228-71 71
Donald H. Williams, Exec. Secretary
WEA Building 319 E. 7th Ave.
Olympia. WA 98504
5061753-6834
5. State Board of Pharmacy
Donald H. Williams, Exec. Secretary
WEA Building 319 E. 7th Ave.
Olympia, WA 98504
506/753-6834
West Vi r gi ni a- 1
1985
WE S T VI RGI NI A
MEDI CAL ASSI STANCE DRUG PROGRAM ( TI TLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Mher'
OAA A0 APTD AFDC O M AB APTD AFDC Chlldren 21 WO)
Prescribed
Oruos X X X X X X X
Hospital Care X X X X X X X
outpatient
Hospita Care X X X X X X X
Laboratory &
X-ray Service X X X X X X X
Skllied Nursing
Home Services X X X X X X X X
Phys~clan
Services X X X X X X X X
Dental
Services X X X X X X X X
Other Benefits: Intermediate Nursing Services, Rural Health Clinics, Durable Medical Equipment and Medical Supplies, Prosthetics and Orlhotlcs,
Vision Care.
^SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Pdyment to Pharmacists by f i xai year ending June 30, 1984
1984 1983
Expended
-
Recipient Expended
- -
Recipient
-
TOTAL . . . . . . . . . . . . . . . . . . . . . $8,449,268 115,838.' $5,913,547 98,779
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $6832.080 97,636 $4,773,176 82,228
Aged . . . . . . . . . . . . . . . . . . . . . . 2,002,767 12,741 1,570,547 12,729
Blind . . . . . . . . . . . . . . . . . . . . . . 36,380 231 26,913 233
Disabled . . . . . . . . . . . . . . . . . . . . . 2,798,949 17,387 2,053,003 16,299
. . . . . . . . . . . . Chiidren-FamiiieswIDep Children 915,794 40,400 484,362 31,779
. . . . . . . . . . . . Adults-Families wIOep Children 1,070.291 26.834 638.351 21,550
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . $1,317,309 12,936 $918,353 11,444
Aged . . . . . . . . . . . . . . . . . . . . . . 922,828 4,377 655,560 4,175
Wind . . . . . . . . . . . . . . . . . . . . . . 986 6 868 5
Disabled . . . . . . . . . . . . . . . . . . . . . 216,529 1,228 154,566 1,202
. . . . . . . . . . . . Children-Families wIDep Children 57,608 3,302 37,071 2,802
. . . . . . . . . . . . Aduits-Families wIOep Children 88.273 3,184 58,023 2,812
Other Title XIX Recipients . . . . . . . . . . . . . . . 0 0 10,465 476
. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL $299,879 7,069 $224,018 6.615
Aged . . . . . . . . . . . . . . . . . . . . . . 100,601 1,448 83,210 1,445
Blind . . . . . . . . . . . . . . . . . . . . . . . 821 8 420 7
Disabled . . . . . . . . . . . . . . . . . . . . . 92,328 1,120 67,859 1.095
. . . . . . . . . . . . Chiidren-Families w/Oep Children 35,265 2,261 26.179 2.1M
. . . . . . . . . . . . Aduits-Families wIOeo Children 70.864 2.248 46.350 2.004
. . . . . . . . . . . . . . . Other Title XIX ~eci ~i ent s 0 0 0 0
"Undupiicated Total - HHS report HCFA - 2082
NPC
West Virginia-2
1985
Ill. ~dministraiion:
The Division of Medical Care, Department of Human Services, is the medical assistance unit repon-
sible for the administration of the Title XIX program. Eligibility for program benefits is determined
by the local Welfare offices for AFDC and medically needy individuals. Individuals eligible for SSI
benefits are covered for Medicaid as categorically needy, aged and disabled.
IV. Provisions Relating to Prescribed Drugs:
PROGRAM COVERAGE
A. All 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 Formulary, 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 vitaminhitamin 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, under-
pads, and other items required for home care, and covered by the Department based on a
treatment plan developed for the individual client.
3. Vitaminlvitamin mineral preparations for End-State Renal Disease patients and other medica-
tions related to End-Stage Renal Disease services.
4. Life sustaining, critical, or necessary drugs not included in the formulary.
EMERGENCY COVERAGE
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 progrm 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.
West Virginia-3
1985
NON-COVERED SERVICES
The following drugs and drug products are not payable:
1. 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.
(f) "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) Vitaminlvitamin 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
For information contact: Bernard Schlact
Pharmacy Consultant
W.V. Department of Human Services
Division of Medical Care
1900 Washington Street, E.
Charleston, West Virginia 25305
3041348-8990
C. Prescribing or Dispensing Limitations:
QUANTITY AND FREQUENCY
Covered legend and non-legend drugs are payable as prescribed by a licensed practitioner up to
a 30-day supply with a maximum of five refills.
Exception:
1. Antibiotics and analgesics are limited to a maximum of ten days with no refills. (See prior
authorization.)
2. Excluding phenobarbital, sedatives and hypnotics are limited to a maximum of 30 days with no
refills.
NPC
West Virginia-4
1985
D. Prescription Charge Formula:
1. Maximum reimbursement for each drug claim processed will be based on the lowest of:
(a) The maximum allowable cost (MAC) for each multiple-source drug as defined by the
Pharmaceutical Reimbursement Board and published in the Federal Register plus a dispens-
ing fee. See Appendix G for listing of MAC drugs.
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:
1. If the maximum allowable payment is under $10.99, the reduction will be $0.50 per prescription.
2. If the maximum allowable payment is $1 1 .OO or more, the reduction will be $1 .OOper 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).
NPC
V. Miscellaneous
Claims processor:
West Virginia- $
19p
NPC
West Virginia-6
1985
The Computer Company
Richmond. Virginia
Number of claims processed in FY 1984-895,271
Average Rx price during FY 1984-$8.80
Officials, Consultants and Committees
1. Welfare Department Officials:
Sharon 6. Lord, Ph.D,
Commissioner
Assistant Commissioner
Medical Services
J. L. Mangus. M.D.
Medical Director (Half-time)
Division of Medical Care
(Mrs.) Helen M. Condry, Director
Division of Medical Care
Auburn A. Cooper
Administrative Assistant
Division of Medical Care
William 6. Rossman, M.D
Psychiatrist Consultant
West Virginia Department of
Human Services
1900 Washington Street, East
Charleston, W. Va. 25305
- 3, R.Ph.
Pharmaceutical Coordinator
3041348-8990
Bert Bradford, Jr.. M.D.
Medical Consultant (Part-time)
Robert Crawford, M.D.
Medical Consultant (Part-time)
F. A. Sines, D.D.S.
Dental Consultant (Part-time)
David Heitmeyer, Section Chief
Research & Statistics Unit
2. Welfare Department Medical Services Advisory Council:
A. Medical Sewice Fund (MSF) Advisory Council Members:
NPC
West Virginia-7
1985
Regular Members
Mr. Fred Blair, Executive Director
Ohio Valley Medical Center, inc.
2000 Eoff Street
Wheeling 26003
Mrs. Alice M. Couch, Administrator
Valley Haven Rest Home, Inc.
R.D. 2, Box 44
Wellsburg 26070
Jack E. Fruth. R.Ph.
Fruth Pharmacy
2501 Jackson Avenue
Pt. Pleasant 25550
Mr. Joseph Powell, President
West Virginia Labor Federation (AFL-CIO)
501 Broad Street
Charleston 2531 1
Mr. Daniel W. Farley, Administrator
Glenwood Park United Methodist Home
Route 1, Box 464
Princeton 24740
L. Clark Hansbarger, M.D., Director
West Virginia Department of Health
1800 Washington Street, East
Charleston 25305
Thomas L. Carson, R.Ph,
College Drug Store, Inc.
Drawer 510
Montgomery 251 36
Ms. Nancy W. Comer
360 Laurel Street
Morgantown 26505
Mr. Robert Eakin, President
Memorial General Hospital
1200 Harrison Avenue
Elkins 26241
Mrs.Carol J. Miller, Director
Healthwise, Inc. (HMO)
Suite 313-Raleigh County Bank Building
Beckley 25801
Mrs. Opal Riling
1546 Kanawha Boulevard, East
Apartment 719
Charleston 2531 1
Harry Shannon, M.D.
P.O. Box 659
Parkersburg 26101
Ms. Patricia Sumner
Route 2, Box 214
Hurricane 25526
Mrs. Jackie Withrow
1301 Maxwell Hill Road
Beckley 25801
Mrs. Rita Tanner
1 100 Louise Avenue
Morgantown 26505
Mr. Mark Nesselroad, General Manager
West Virginia Operations
Crossgates, Inc.
3555 Washington Road
McMurray, Pennsylvania
Alternate Members
Ms. Sarah M. Kerns
1546 Kanawha Boulevard, East
Apartment #305
Charleston 2531 1
Mr. Jack R. McComas, Secretarynreasurer
West Virginia Labor Federation AFL-CIO
501 Broad Street
Charleston 25301
Linda R. Hickman, R.N.
Operations Supervisor
Healthwise, Inc. (HMO)
Suite 313,
Raleight County Bank Building
Beckley 25801
Mrs. Edith Sanderson
C/O Beckley Farmer's Market
Box 117
Skelton 25955
West Virginia-8
1985
B. Welfare Committee Members of the West Virginia Pharmaceutical Association:
Mr. Arlie Winters, Jr., Chairman
P. 0. Box 96
Berkeley Springs 2541 1
S. Elwood Bare
1002 Greenbriar Avenue
Ronceverte 24970
Benjamin Carson
409 Monroe Street
Montgomery 251 36
Ann Bond Smith
P.O. Box 225
Clendenin 25036
David Dowyer, Student Representative
West Virginia University
School of Pharmacy
Morgantown 26506
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association: 8. Pharmaceutical Association:
Bert Scholten
Executive Secretary
West Virginia State
Medical Association
Box 1031
Charleston 25324
Phone: 3041346-0551
C. Osteopathic Medicine:
A. Robert Dzmura, D.O.
4850 Eoff Street
Benwood 26031
Phone: 3041233-1 656
4. State Board of Pharmacy
Richard D. Stevens
Executive Director
West Virginia Pharmacists Association
Suite 4
4004 MacCorkle Avenue, SE
Charleston 25304
Phone: 3041925-7204
C. Herbert Traubert, Secretary
150 Rockdale Road
Follansbee. West Virginia 26037
3041527- 1270
NPC
WISCONSIN
MEDI CAL ASSI STANCE D R U G P R O G R A M (TITLE XI X)
I. BENEFITS PROVIDED AN0 GROUPS ELIGIBLE
Type of Benefit
Prewrihnrl
Categorically Needy Medically Needy (MN) Other'
OAA AB APT0 AFDC OAA AB APT0 AFDC Children 21 (SF@
. . -- -. . - - -
Oruos X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X X
Laboratory &
X-rav Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X X
Physician
Services X X X X X X X X X X
Dental
Services X X X X X
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Pavrnent to Pharmacists bv fiscal vear ending June 30. 1984
1984
Expended Recipient
- -
. . . . . . . . . . . . . . . . . . . . . T OT AL $46,871,019 329.964"
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . Aged
. . . . . . . . . . . . . . . . . . . . . . Blind
Disabled . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adulk-Families w/Dep Children . . . . . . . . . . . .
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . Aged
. . . . . . . . . . . . . . . . . . . . . . Blind
. . . . . . . . . . . . . . . . . . . . . Disabled
Children-Families w1Dep Children . . . . . . . . . . . .
. . . . . . . . . . . . Adults-Families w/Dep Children
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . Aged
. . . . . . . . . . . . . . . . . . . . . . Blind
. . . . . . . . . . . . . . . . . . . . . Disabled
Children-Families w/Dep Children . . . . . . . . . . . .
Adults-Families w/Dep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
1983
Exoended Reci ~i ent
"Unduplicated Total - HHS report HCFA - 2082
Ill. Administration:
The State Department of Health and Social Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions:
1. Legend laxatives and nonprenatal vitamins.
2. All non-legend pharmaceuticals except Insulin, antacids and analgesics.
6. Formulary: No.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Pharmacists may not dispense more than 34-day supply of a legend
drug.
2. Refills: Maximum of 11 refills during a 12-month period for non-scheduled medications.
3. Dollar Limits: None
D. Prescription Charge Formula:
1. Traditional (non-unit dose) dispensing reimbursed at the lowest of: Estimated Acquisition Cost
(EAC) plus $3.61 professional fee; Maximum Allowable Cost (MAC) plus $3.61 professional
fee; or providers usual and customary
2. Unit Dose Dispensing:
Reimbursement at the lowest of: Estimated Acquisition Cost (EAC) plus $5.56 professional
fee; Maximum Allowable Cost (MAC) plus $5.56 professional fee; or providers usual and
customary.
Reimbursement limited to one unit dose professional fee per drug per month.
V. Miscellaneous Remarks:
A. Prior Authorization Required on the Following Drugs:
1. All anorectics
2. Cephulac
3. Debrisan
4. Derifil
5. Decubitex
6. Medically Needy Recipients
Medically Needy recipients who do not reside in a Skilled Nursing Facility (SNF) or lntermediate
Care Facility (ICF) are eligible for only five categories of legend drug:
1. Antibiotics
2. Anticonvulsants
3. Muscle Relaxants
4. Psychotropics
5. Family Planning Drugs
C. Copayment
All legend and over-the-counter drugs except family planning drugs are subject to a $SO copay-
ment. Residents of Skilled Nursing Facilities (SNF) or lntermediate Care Facilities (ICF), sub-
sidized adoption recipients, children under age 18 and HMO enrollees are exempt from the
copayment. (Copayments limited to 10 per month)
D. State MAC Program-Yes. (145 entities; 69 separate compounds)
E. Fiscal Intermediary:
EDS-FederW
F. Number of claims processed in FY 1984-2,4638,506
G. Average Rx price during FY 1984-$10.41
Officials, Consultants and Committees
1. Health and Social Services Department Officials:
Linda Reivitz
Secretary
Katie Morrison
Administrator
Division of Health
Steve Handrich
Director
Bureau of Health Care Financing
(Medicaid)
Department of Health and Social Services
State Office Building
One West Wilson Street
Madison, Wisconsin 53702
Alfred Dally, M.D.
Physician Consultant
Michael Boushon
Pharmacy Practices Cons~ltant
6081266-0722
2. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society:
B. Pharmaceutical Association:
Earl Thayer
Secretary-General Manager
State Medical Society of Wisconsin
330 East Lakeside
Box 1109
Madison 53701
Phone: 6081257-6781
C. Osteopathic Association:
Mr. Robert J. Finnegan
Executive Director
Wisc. Assn. of Osteopathic
Physicians and Surgeons
34615 Road E.
Oconomowoc 53066
Phone: 4 141567-0520
Robert E. Henry
Executive Director
Wisconsin Pharmaceutical Assoc.
202 Price Place
Madison 53705
Phone: 6081238-5515
D. State Board of Pharmacy
Sharon Russell, Program Assistant
P.O. Box 8936
1400 East Washington Avenue
Madison, Wisconsin 53708
6081266-8794
NPC
WYOMI NG
MEDI CAL ASSI STANCE DRUG PROGRAM ( TI TLE XI X)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other*
O M AB APT0 AFDC O M AB APT0 AFDC Children 21 (SF01
Prescribed
Drugs
Inpatient
Hospital Care X X X X
Outpatient
Hosoital 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
Olher Benefits: Dental and optometric services, eyeglasses and hearing aids for eligible patients under 21 years ol age, home services.
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS.
1984 1983
Exoended Recioient Exoended Recioient
. . . . . . . . . . . . . . . . . . . . . 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 No vendor
-
Children-Fanilies w/&p Children . . . . . . . . . . . . drug program
. . . . . . . . . . . . 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 . . . . . . . . . . . . . . .
"Unduplicated Total - HHS report HCFA - 2082
Ill. Administration:
The Medical Assistance Program is administered by the Division of Medical Services of the
Department of Health and Social Services.
IV. Provisions Relating to Prescribed Drugs:
No state vendor drug program
Officials, Consultants and Committees
1. Health and Social Services Department Officials:
Kathleen Kardan
Director
Department of Health and Social Services
317 Hathaway Building
Cheyenne, Wyoming 82002
2. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: C. Osteopathic Association:
Roger Brown
Executive Secretary
Wyoming State Medical Society
1920 Evans
P. 0. Drawer 4009
Cheyenne 82001
Phone: 3071635-2424
Laramie, Wyoming 82070
Phone: 3071766-6126
3. State Board of Pharmacy
David A. Vick, D.O.
Secretary-Treasurer
Wyoming Association of
Osteopathic Physicians and Surgeons '
Box1 298
Worland 82401
Marilynn H. Mitchell, Executive Director
1720 S. Poplar Street. Suite 5
Casper, Wyoming 82601
307/234,0294
NATIONAL PHARMACEUTICAL COUNCIL, INC.
ABBOTT LABORATORIES
Abbott Park
North Chicago, Illinois 60064
BOEHRINGER INGELHEIM LTD.
90 East Ridge
Ridgefield, Connecticut 06877
BURROUGHS WELLCOME CO.
3030 Cornwallis Road
Research Triangle Park, NC 27709
CIBA-GEIGY CORPORATION
556 Morris Avenue
Summit, New Jersey 07901
DuPONT PHARMACEUTICALS
One Rodney Square
Wilmingtan, Delaware 19898
GLAXO INC.
Five Moore Dri ve
Research Triangle Park, NC 27709
PARKE-DAVIS
20 1 Tabor Road
Morris Plains, New Jersey 07950
PFIZER INC.
235 East 42nd Street
New York, New York 10017
A.H. ROBINS COMPANY
1407 Sherwood Avenue
Richmond, Virginia 23220
ROCHE LABORATORIES
340 Kingslond Street
Nutley, New Jersey 07 l I 0
SANDOZ PHARMACEUTICALS
Route 10
East Hanover, New Jersey 07936
SCHERING PLOUGH CORPORATION
Galloping Hi l l Road
Kenilworth, New Jersey 07033
HOECHST-ROUSSEL PHARMACEUTICALS INC. SEARLE PHARMACEUTICALS
Route 202-206 North
Sornerville, New Jersey 08876
LEDERLE LABORATORIES
Berdan Avenue
Wayne, New Jersey 07470
ELI Ll LLY AND COMPANY
307 East McCarty Street
Indianapolis, Indiana 46285
MARION LABORATORIES, INC.
10236 Bunker Ridge Road
Kansas City, Missouri 64137
McNEIL PHARMACEUTICALS
Spring House, Pennsylvania 19477
MERCK SHARP & DOHME
Division of Merck & Co.
West Point, Pennsylvania 19486
MERRELL DOW PHARMACEUTICALS, INC.
2 1 10 East Galbraith Road
Cincinnati, Ohio 45215
NORWICH EATON PHARMACEUTICALS
17 Eoton Avenue
Norwich, New Yark 13815
5200 Old Orchard Road
Skokie, Illinois 60077
SMITH KLl NE & FRENCH LABORATORIES
P.O. Box 7929
Philadelphia, Pennsylvania 19101
E.R. SQUIBB & SONS, INC.
P.O. Box 4000
Princeton, New Jersey 08540
STUART PHARMACEUTICALS
Division of ICI Americas Inc.
Wilrnington, Delaware 19897
SYNTEX LABORATORIES
340 1 Hi l l vi ew Avenue
Palo Alto, California 94304
THE UPJOHN COMPANY
7000 Portage Road
Kalamazoo, Michigan 49001
USV LABORATORIES
303 South Broadway
Tarrytown, New York 1059 1
WINTHROP-BREON LABORATORIES
90 Park Avenue
New York, New Yark 10016
ORTHO PHARMACEUTICAL CORPORATION
Route 202
Raritan, New Jersey 08869
Companies
Abbott Paboratories
Boehringer lngelheim Ltd.
Burroughs Wellcome Co. '
Ciba-Geigy Corporation
DuPont Pharmaceuticals
Glaxo Inc.
~oechst-Roussel Pharmaceuticals, Inc.
Johnson & Johnson
Lederle Laboratories
Eli Lilly and Company
Marion Laboratories. InC.
Merck Sharp & Dohme
Merrell Dow Pharmaceuticals Inc.
Norwich Eaton Pharmaceuticals
Parke-Davis -..
Pfizer Inc. ..
~
A. H. Robins Company
Roche Laboratories
.- ~
, Sandoz Pharmaceuticals
Schering Corporation
Searle Pharmaceutical Group
Smith Kline & French Laboratories
E. R. Squibb &Sons. Inc.
Stuart Pharmaceuticals
~ - Syntex Laboratories. Inc.
The Upjohn Company
USV Laboratories
Winthrop-Breon ~aboratories

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