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September 1989

Dear Reader:

This twenty-fourth annual edition of the compilation, Pharmaceutical Benefits Under State
Medical Assistance Programs, was prepared by the National Pharmaceutical Council to as-
sist in your evaluation of Medicaid program characteristics. NPC recognizes Medicaid as
an important health care component and believes that public assistance patients should
receive the same quality of care as other patients in the community.

We hope that you find the information contained in this compilation useful in the develop-
ment, implementation and operation of pharmaceutical programs that are responsive to the
needs of Title XIX recipients.

Sincerely,

Mark R. Knowles &


President
PHARMACEUTICAL
BENEFITS
UNDER
STATE MEDICAL ASSISTANCE
PROGRAMS

SEPTEMBER 1989

Compiled by

NATIONAL PHARMACEUTICAL COUNCIL, INC.


1894 Preston White Drive, Reston VA 22091
TABLE OF CONTENTS
Page
...
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Pharmaceutical Benefits Under State Medical Assistance Programs . . . . . . . . . . . . . . . . . . . . . . 1

Impact of Catastrophic Coverage on State Medicaid Programs . . . . . . . . . . . . . . . . . . . . . . . . 23

Glossary of Medicaid Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Regional Administrative Offices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

State Medicaid Drug Program Administrators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Stateofficials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Federal Register42CFR Parts413. 430. 447and45CFR Pans 1 & 19 . . . . . . . . . . . . . . . . . . 51

State Medicaid Manual Pan 6 - Payment for Services (Upper Limits) .................... 62

Tables (Program Characteristics and Statistics)


1. Medicaid Statistics:

A. Title XIX Medical Assistance U.S. Totals by Type of Service . . . . . . . . . . . . . . . 84

B. Medicaid Recipients and Vendor Payments . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

C. Vendor Payments for Prescribed Drugs (1983-1988) . . . . . . . . . . . . . . . . . . . . . 87

D. Recipients of Prescribed Drugs (1983 - 1988) . . . . . . . . . . . . . . . . . . . . . . . . .88

E. Ranking of States Based on Medicaid Drug Expenditures . . . . . . . . . . . . . . . . . 89

F. Average Expenditures per Recipient for Prescribed Drugs (1983 . 1988) . . . . . . . 90

G. Percentage of Medicaid Expenditures Allocated to Prescription


Medication (1984 . 1988) . . . . . . . . . . . . . . . . . . . . . . . . . .

H. Medicaid Drug Reimbursement Chan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92

I. Summary of Medicaid Limitations .Pharmaceuticals . . . . . . . . . . . . . . . . . . . . .95

J. Caveats for using HCFA 2082 Data Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . 97


K. Medicaid Recipients by Type of Service, Region & State . . . . . . . . . . . . . . . . . . 98
L. Medicaid Medical Vendor Payments by Type of Service,
Region & State . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

M. Federal Medical Assistance Percentage ("FMAP) . . . . . . . . . . . . . . . . . . . . . . . 132

2. State Demographic and Economic Characteristics, 1987:

A. State Population, Unemployment, Income, and Age Characteristics . . . . . . . . . . 133

3. Miscellaneous:

A. Pharmacies and Pharmacists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134

B. Key Provisions of State Drug Product Selection Laws . . . . . . . . . . . . . . . . . . . .135

4. Expanded Drug Coverage for the Elderly:

A. Programs Characteristics for States with Elderly Drug


Coverage Programs . . . . . . . . . . . . . . . . . . . . . . .

Medical Assistance Drug Programs


(Alphabetically by State)
Richard W. Fowler, R.Ph
Vice President, Health Programs
National Pharmaceutical Council
Editor

The National Pharmaceutical Council, Inc. is dedicated to the enhancement of the quality and
integrity of pharmaceutical services in research, development, manufacturing, and dispensing of
prescription medications and other pharmaceutical products.

The National Pharmaceutical Council, Inc. was founded in 1953 by companies engaged primarily
in the discovery, development, production, and marketing of innovative prescription medicines.
Today, our thirty member companies continue their commitment to major programs of
pharmaceutical research and maintain exacting quality control standards.

Toward this end, NPC undertakes educational activities and provides services to physicians,
pharmacists, manufacturers, professional associations, colleges of pharmacy, medical schools,
government offices and consumers concerning key aspects of health care. NPC services include
providing information on the quality and cost-effectiveness of pharmaceutical products, the
economics of drug programs, and the notable contributions of research oriented pharmaceutical
manufacturers.

Methodology

The statistics and characteristics of each state Medicaid program were obtained from an NPC
survey of state Medicaid program administrators and pharmacy consultants. Other statistics were
reported by the HCFA Medicaid Statistics Branch, Department of Commerce, and state
pharmaceutical association executives.

The narrative and descriptive material was condensed from the Code of Federal Regulations
(CFR-42), supplemented by material contained in HCFA publication No. 03249, "Analysis of State
Medicaid Program Characteristics, 1986 published August, 1987.

NPC acknowledges the cooperation and assistance of the many


state Medicaid program officials and their staffs, state
pharmaceutical associations, Health Care Financing Administration
personnel, and others in supplying data for this compilation.

iii
PHARMACEUTICAL BENEFITS
UNDER STATE MEDICAL ASSISTANCE PROGRAMS

This compilation of data on State Medical Assistance Programs (Title XIX) has been prepared to present a
general over~iew of the characteristics of state programs together with detailed information on the
pharmaceutical benefits provided. The data collection effon covers all states with medicaid programs.
The following information is provided for each state:

Recipient groups eligible for benefits


Amount expended for drugs per recipient category
Characteristics of the State Drug Program
Restrictions or limitations on drugs
Medicaid or public health officials
Pharmacy and medical consultants to the state programs
Pharmacy and medical advisory committees
State medical and pharmaceutical association executives
State boards of pharmacy

Medicaid (Title XIX of the federal Social Security Act) is a program of medical assistance, funded by the
federal government and the states, for impoverished individuals who are aged, blind or disabled, or members
of families with dependent children. The states and territories of Puerto Rico, Guam, Virgin Islands, American
Samoa, and Northern Mariana Islands each operate Medicaid programs according to state or territorial rules
and criteria that vary widely within a broad framework of federal guidelines. Arizona has an experimental
program marked by organized health plans and capitation.

The original Social Security Act, which was enacted in 1935, made no direct provision for medical assistance.
However, it did establish a system of "categorical" public assistance that allowed the federal government to
share with states the cost of providing maintenance payments to the needy aged and blind, and to needy
families with dependent children. This assistance, which was subsequently extended to the permanently and
totally disabled, could include the cost of some medical care in monthly assistance payments to recipients.

In 1950, public assistance under the Act was broadened to include federal sharing in "vendor payments,"
i.e., direct payments by a state to doctors, nurses, and health care institutions, rather than to the welfare
recipient. Although federal sharing in vendor payments created an administrative framework for a welfare
medical program, federal funding was so small that only a few states participated. Subsequent amendments
to the Act made more federal funds available so that, by 1965, all of the states provided medical vendor
payments in their federally aided categorical assistance programs. Many states also offered an allowance
for some items of medical care in welfare payments to categorical assistance recipients.

Despite these expanded federal and state efforts, the need for medical assistance became so great that
most states could finance only a few services. To help satisfy this need, Title XIX or "Medicaid" was enacted
in the Social Security Amendments of 1965, providing grants to states for medical assistance programs be-
ginning January 1, 1966. By January 1, 1967, more than half of the states had Medicaid programs, and by
1970, all of the states except Alaska (which later implemented one) and Arizona (which implemented an
alternative to Medicaid in 1982) had programs. As a result, the federal financial participation in medical care
that had been available through the categorical public assistance programs was ended because of the
availability of federal Medicaid funds and the administrative advantages of offering medical care exclusively
through Medicaid.
The program operates on the basis of a state and federal division of responsibilities. The federal
government establishes regulations, guidelines and policy interpretations which describe the broad outline
within which states can tailor their individual programs. States assume control and direction of operations.
As a result there are 56 (50 states, plus Guam, District of Columbia, Puerto Rico, Samoa, Northern Mariana
Islands and the Virgin Islands) distinctly different programs in operation. Funding is shared between the two
bodies, with the federal government matching state health care provider reimbursements of an authorized
rate between 50% and 83% depending on the states per capita income. Federal law governs certain
aspects of Medicaid, and requires that all persons who qualify for Aid to Families with Dependent Children
(AFDC) and most persons who qualify for Supplemental Security Income (SSI) receive Medicaid coverage.
The Federal Government requires states to provide a basic set of services to people eligible for Medicaid
and to reimburse providers of those services in certain ways. Reimbursement levels for many services are
subject to federally established ceilings and, in some instances, floors.

The states' control over eligibility, for example, is substantial, because states establish eligibility for AFDC
which establishes eligibility for Medicaid. (The same does not hold true for SSI recipients, whose eligibility
is determined primarily by Federal criteria.) Furthermore, states may voluntarily extend Medicaid coverage
to additional groups of people and expand the range of services covered. States also have considerable
freedom in choosing reimbursement methods for physicians and other health care providers. Title XIX of the
1965 Social Security Amendments provide the legislative basis for Medicaid. Medicaid should not be
confused with Medicare, which was also established by the Social Security Amendments of 1965. Medicare
is a federally administered medical insurance program for the elderly, which is administered by the Social
Security Administration (SSA).

ADMINISTRATION
Administration of the state Medicaid program is vested in single state agencies. Within each agency, state
plans must designate a medical assistance unit responsible for developing, analyzing, and evaluating the
Medicaid program. The law further requires the states to establish medical care advisory committees to
advise the Medicaid agency director about health and medical services. These committees must include
board certified physicians and other representatives of the health professions, members of consumer groups,
and the director of either the state public welfare or the public health department (whichever department
does not run the Medicaid agency). Activities for administering the state Medicaid program include:
program administration, Medicaid Management Information System (MMIS), claims processing activity, state
administration, and waivers.

Eligibility Determination and Program Administration

States are allowed three options for administering coverage of SSI recipients (42 CFR 431.10(c)):

States electing to extend Medicaid to all SSI recipients can enter into an agreement with the Social
Security Administration under Section 1634 of the Act for determinations of Medicaid eligibility;

States electing to extend Medicaid eligibility to recipients of SSI can maintain eligibility determinations
on a state level; or

States electing the 209(b) option (where recipients of cash assistance under SSI are not automatically
eligible for Medicaid) can require cash assistance recipients to make a separate application for
Medicaid.

Thirty-one states elected to have federal determination. Five states elected to extend Medicaid to all
recipients of SSI but maintain eligibility determination on a state level. Fourteen states elected the 209(b)
option.
A state plan must be in operation statewide through a system of local offices under equitable standards for
assistance and administration that are mandatory throughout the state (42 CFR 431.50(b). However, the
state may choose to administer the program on the state level or by political subdivision of the state.
Forty-four states have chosen to administer the Medicaid program on a state level. Six states have chosen
local (county) administration. This means is that in those states whose program is locally administered, the
state plan is mandatory on each of the political subdivisions. The local administrations do not have the
authority to change or disapprove any administrative decision of the state Medicaid agency with respect to
the application of policies, rules, and regulations issued by the Medicaid agency.

A state plan must specify a single state agency, established or designated, to administer or supervise the
administration of the plan (42 CFR 431.10(b)). Generally, the administering agency has been the state
health agency, welfare agency, or an umbrella agency. A possible effect of the administering agency being
the health department is that the welfare department has control over the intake of eligibles in the AFDC and
SSI/SSP programs, individuals who automatically become eligible for Medicaid. This separation could create
a span of control problems for the Medicaid agencies. Three states have designated the health department,
21 states have designated the welfare department, 22 states have designated an umbrella agency, and four
states have designated other agencies to administer the Medicaid program. The "other" agencies included
the office of the Governor in Alabama and an independent agency/commission in Georgia and Mississippi,
and the State Health and Human Services Finance Commission in South Carolina.

SERVICE COVERAGE
The original Title XIX legislation listed fifteen types of medical care for which federal funding would be
received. The last one was very general in nature specifying that "any other medical care, and any other
type of remedial care recognized under state law" was eligible for federal support. By 1970, 21 types of
medical care were specified and by 1979, over 30 medical services were listed as acceptable Medicaid
services.

Medicaid services can be grouped into eight major categories as follows:

1. Professional Services - treatments provided by physicians, optometrists, dentists, etc.

11. Nursing Care Services - types of care provided by nurses in hospitals, patient's homes, clinics,
nurse-midwife services, etc.

111. -
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).

VIII. Other - any services provided which facilitate medical treatment that are not covered by any of the
above categories.

3
MANDATORY SERVICES

In order to participate in Medicaid, there are certain basic services that must be offered in a state's Medicaid
program. There were five of these mandatory services specified in the original legislation of 1965. These
services were:

1. Inpatient hospital services

2. Outpatient hospital services

3. Physician services

4. Independent laboratory and X-ray services

5. Skilled nursing home services. (This service had to be provided only to eligible persons
twenty-one years of age or older.)

The six additional mandatory services added since 1985 are listed below:

6. Early and periodic screening, diagnostic, and treatment program

7. Family planning services and supplies

8. Home health care services

9. Patient transportation

10. Rural Health Clinic Services

II Nurse-midwife services

OPTIONAL SERVICES
In addition to these required programs, the participating states may elect to offer additional services. Some
of these services are defined in the Medicaid rules and regulations. Others have been defined through
federal acceptance of a particular service in a state's plan. A state may include any type of care recog-
nized under state law and authorized by the Secretary of the Department of Health and Human Services.
A list of the Medicaid mandatory and defined optional services is provided beginning on page 5.

REGULATIONS PERTAINING TO MEDICAID SERVICES

Federal regulations require that the amount and/or duration of each type of medical and remedial care and
services furnished under a state's Medicaid plan must be specified in the state plan, and that these types
of care and services must be sufficient in amount, duration, or scope to 'reasonably achieve" their purpose.
Each plan must include a description of the methods that will be used to assure that the medical and
remedial care and services are of high quality, and a description of the standards established by the state
to assure high quality care. The regulations also require that fee structures be developed which will result
in participation of a sufficient number of providers of services in the program so that eligible persons can
receive the medical care and services included in the plan at least to the extent that these are available to
the general population. The law further requires that services provided under the plan be available
throughout the state. Recipients are to have freedom of choice with regard to where they receive their care,
including an option to obtain their care through organizations that provide services or arrange for their
availability on a prepayment basis, such as health maintenance organizations.

MEDICAID ELIGIBILITY
Medicaid is the primary source of health care coverage for the poor in America. Through it, medical sewices
are provided primarily to those people who are eligible to receive cash payments under one of the existing
welfare programs established by the Social Security Act. Basically these eligible persons fall into two
categories - those whose eligibility for Medicaid services is mandated at the federal level and those whose
eligibility is determined by the individual state. These categories are described in the sections below.

Mandatory Coverage

Every state, in order to receive Title XIX funding, must provide Medicaid benefits to certain groups of
'categorically needyversons. In order to be considered "categorically needy' for Medicaid purposes, an
individual must be receiving financial assistance (maintenance payments), or be eligible for financial
assistance, under Title XVI, Supplemental Security Income for the Aged, Blind, and Disabled (SSI).

The two largest of these "categorically needy' groups are persons already receiving maintenance payments
through the Aid to Families with Dependent Children program or through the Supplemental Security Income
program. Other groups that are categorically needy and thus automatically eligible for Medicaid are
recipients of mandatory state supplements and persons' affected by increases in Social Security payments.

MEDICAID SERVICE
(Mandatory Services Indicated by Capital Letters)

PHYSICIAN SERVICES
Chiropractors' Services
Podiatrists' Services
Optometrists' Services
Other Practitioners' Services
Dental Services (for persons 21 years of age and older)

11. Nursing Care Services


HOME HEALTH CARE SERVICES (for persons 21 years of age or older)
Personal Care Services
Private Duty Nursing
NURSE-MIDWIFE SERVICES
Adult Day Treatment Services
111. Nursing Home Services
SKILLED NURSING FACILITY SERVICES (for persons 21 years of age or older)
lntermediate Care Facility Services
Skilled Nursing Facility Services (for persons under 21 years of age)

IV. Hospital and Clinic Services


INPATIENT HOSPITAL SERVICES
OUTPATIENT HOSPITAL SERVICES
RURAL HEALTH CLINIC SERVICES
Clinic Services
Emergency Hospital Services

V. Drugs, Supplies and Equipment


Prescribed Drugs
Dentures
Eyeglasses (for persons 21 years of age and older)
Hearing Aids (for persons 21 years of age and older)
Prosthetic Devices

VI. Special Services and Therapy


INDEPENDENT LABORATORY & X-RAY SERVICES
EARLY & PERIODIC SCREENING, DIAGNOSIS & TREATMENT (EPSDT) OF CHILDREN (under
21 years of age)
FAMILY PLANNING SERVICES
Diagnostic Services (for persons 21 years of age and older)
Screening Services (for persons 21 years of age and older)
Preventive Services
Physical Therapy
Occupational Therapy
Occupational Therapy
Treatment for Speech, Hearing and Language Disorders

VII. Institutional Care


Inpatient Psychiatric Services (for persons under 22 years of age)
Care in Tuberculosis lnstitutions (for persons age 65 or older)
Care in Mental Institutions - lntermediate Care Facility Services (for persons age 65 or 01der)Care
in Mental lnstitutions - Skilled Nursing Facility (for persons age 65 or older)

VIII. Other
TRANSPORTATION TO & FROM MEDICAL SERVICES
Enrollment in Medicare - Part B, Title XVIII, Supplemental Medical InsuranceEnrollrnent in
-
Medicare Part A, Title XVIII, Hospital Insurance Benefits

In addition to the services listed as being mandatory or optional, Title XIX specifies that 'any other medical
care, and any type of remedial care recognized under state law, specified by the Secretary of the Department
of Health and Human Services," is acceptable as a Medicaid service and thus eligible for federal support.
Optional Coverage

In addition to the groups that must be covered by the state's Medicaid programs, there are other groups
that are kategorically needy" or Vnedically needy" who may be included in Medicaid at the Option of each
state. That is, the participating states are not required to offer services to these people unless they elect to
do so.

General Eligibility Requirements

In addition to designating that certain groups of people must be covered by a state's Medicaid plan and
defining other groups that may be covered at the discretion of the state, the federal government specifies
certain general requirements that must be met for Medicaid eligibility. This does not mean that a state
cannot provide coverage for those persons included in the Medicaid plan that do not meet these specified
requirements. Rather, federal matching funds will not be made available to cover the claims for services
provided to these individuals. State and/or local funds must be used to support the medical expenses of
these individuals if the state elects to include them in its Medicaid plan. A Medicaid agency that chooses
to cover an optional group must provide Medicaid to all eligible individuals in that group.

CHARACTERISTICS OF BENEFITS PROVIDED

Inpatient Hospital Services

lnpatient hospital services refer to services that are ordinarily furnished in a hospital for the care and
treatment of an inpatient. The facility is one maintained primarily for the care and treatment of patients with
disorders other than tuberculosis or mental diseases.There are several general federal limitations on inpatient
hospital services which are applicable to all states with Medicaid programs (42 CFR 440.10):
O
The facility must be licensed or formally approved as a hospital by an officially designated
authority for state standard-setting;

The facility must meet the requirements for participation in Medicaid;


" The care and treatment of inpatients must be under the direction of a physician or dentist; and

The facility must have in effect an approved utilization review plan, applicable to all Medicaid
patients, unless a waiver has been granted by the Secretary.

In addition to the federal limitations, each state may impose further limitations on inpatient hospital services.

Outpatient Hospital Services

Outpatient hospital services refer to preventive, diagnostic, therapeutic, rehabilitative, or palliative services
provided to an outpatient. There are three federal limitations that are imposed on these services:

The services must be provided under the direction of a physician or dentist;

The facility must be licensed or formally approved as a hospital by an officially designated


authority for state standard-setting; and
O
The facility must meet the requirements for participation in Medicare.
States are free to specify other limits on outpatient hospital services and 42 states have chosen to do so.
Examples of "other IimitsVnclude: (1) emergency room services are not provided between 8:00 a.m. and
4:00 p.m. in Vermont except for trauma and (2) outpatient services are limited to a maximum of $100 per
fiscal year in Florida.

Rural Heaith Clinic Sewices

Rural health clinic (RHC) services became a mandatory service for the categorically needy in July 1978.
Each RHC is required to have a nurse practitioner (NP) or physician's assistant (PA) on its staff. Therefore,
a clinic can only be certified if the state permits the delivery of primary care by an NP or PA. Services in
certified clinics must be provided and furnished by a physician or by a PA, NP, nurse-midwife, or other spec-
ialized nurse practitioner. Services and supplies are furnished as an incident to professional services.
Part-time or intermittent visiting nurse care and related medical supplies are provided given that the clinic is
located in a Health Manpower Shortage Area, the services are furnished by nurses employer by the clinic,
and the services are furnished under a written plan of treatment to a homebound recipient.

Other Laboratory and X-Ray Services

Other laboratory and X-ray services are professional and technical laboratory and radiological services. As
specified in 42 CFR 440.30 (a-c), federal requirements for Medicaid mandate that these services be:

Ordered and provided by or under the direction of a physician or other licensed practitioner of
the healing arts within the scope of his practice as defined by state law or ordered and billed
by a physician but provided by an independent laboratory;

Provided in an office or similar facility other than a hospital outpatient department or clinic; and

Provided by a laboratory that meets the requirements for participation in Medicare.

In addition, the states can place limitations on "other laboratory and X-ray services."

Skilled Nursing Facility Services

Skilled nursing facility (SNF) services are provided to individuals age 21 or older and do not include services
in institutions for tuberculosis or mental diseases (42 CFR 440,40(a)). These services must be needed on
a daily basis and provided in an inpatient facility. Federal regulations require that the services be:
" Provided by a facility or distinct part of a facility that is certified to meet the requirements for
participation. These requirements include provider agreements, facility certification, and facility
standards; and
" Ordered by and under the direction of a physician

These services include services provided by any facility located on an Indian reservation and certified by
the Secretary of Health and Human Services. Further, the requirements concerning control of the utilization
of Medicaid services impact upon skilled nursing facility services on such areas as certification and re-
certification of need for inpatient care, individuals written plan of care, etc.
Early and Periodic Screening, Diagnosis and Treatment

Early and periodic screening, diagnosis and treatment (EPSDT)refers to screening and diagnostic services
to determine physical or mental defects in recipients under age 21 and health care, treatment and other
measures to correct or ameliorate any defects and chronic conditions discovered (42 CFR 440.40(b)). There
are certain basic screening and treatment services that each state must provide as minimum (42 CFR
441S6). These services include:

Health and development history screening


Unclothed physical examination
Developmental assessment
Immunizations which are appropriate for age and health history
Assessment of nutritional status
Vision testing
Hearing testing
Laboratory procedures appropriate for age and population groups
Dental services furnished by direct referral to a dentist for diagnosis and treatment for children
three years of age and over
Treatment for defects for vision and hearing, including eyeglasses and hearing aids; and
Dental care needed for relief of pain and infections, restoration of teeth and maintenance of
dental health

The state Medicaid agency may provide for any other medical or remedial care specified as a Medicaid
service even if the agency does not otherwise provide for these services to other recipients or provides for
them in a lesser amount, duration or scope.

Family Planning Services

Family planning services and supplies are allowable for individuals of child bearing age as a means of
enabling individuals to freely determine the number and spacing of their children. Although there are no
federal regulations defining what family planning services a state can provide, provisional regulations are
written which defined family planning services to be: consultation (including counseling and patient educa-
tion), examination, and treatment, furnished by or under the supervision of a physician or prescribed by a
physician; laboratory examination; medically approved methods, procedures, pharmaceutical supplies and
devices to prevent conception; natural family planning methods, diagnosis and treatment for infertility; and
voluntary sterilization. In addition, states niay provide any medically approved means other than abortion,
for family planning purposes, if furnished by or under supervision of a physician or if prescribed by a phy-
sician. Abortions are specifically excluded from family planning services and states are prohibited from
considering any abortion as being a family planning service.

Voluntary sterilizations must be included among the range of family planning services offered by a state.
Federal regulations require that the individual to be sterilized voluntarily gives informed written consent and
that the individual must be at least 21 years of age at the time consent is obtained and must be mentally
competent.

Physicians' Services

Physicians' services are covered whether provided in the office, the patient's home, a hospital, a skilled
nursing facility, or elsewhere. Physicians' services must be within the scope of practice of medicine or
osteopathy as defined by state law and by or under the personal supervision of an individual licensed under
state law to practice medicine or osteopathy.
Home Health Services

Home health services are provided to a recipient at his place of residence which does not include a hospital,
skilled nursing facility, or intermediate care facility (ICF) except for home health services in an ICF that are
not required to be provided by the facility. Services provided must be on physicians' orders as part of a
wrinen plan of care that is reviewed by the physician every 60 days. Home health services include three
mandatory services (part-time nursing, home health aide, and medical supplies and equipment) and one
optional service (physical therapy, occupational therapy, and speech pathology and audiology sewices) (42
CFR 440.70). These services are defined as follows:

Part-time nursing - nursing service that is provided on a part-time or intermittent basis by a home
health agency. If there is no home health agency in the area, services may be provided by a
registered nurse who is currently licensed to practice in the state, receives wrinen orders from
the patient's physician, documents the care and services provided, and has had orientation to
acceptable clinical and administrative record-keeping from a health department nurse;

Home Health Aide - home health aide service that is provided by a home health agency;

Medical Supplies and Equipment - Medical supplies, equipment and appliances that are suitable
for use in the home; and

Physical Therapy (PT), Occupational Therapy (OT), and Speech Pathology and Audiology
Services - PT, OT, and speech and hearing services provided by a home health agency or by
a facility licensed by the state to provide medical rehabilitation services.

Home health services are provided to categorically needy recipients age 21 and over and to those under
21 only if the state plan provides SNF services for them.

Nurse-Midwife Services

The Omnibus Reconciliation Act of 1980 mandates that payment must be made for nursemidwife services
to categorically needy recipients (42 CFR 440.165). The effective date of this legislation was July 16, 1982,
or, if state legislation was needed in order to conform, the first day of the first calendar quarter beginning
after the close of the first regular session of the state legislature that began after May 17, 1982.

These provisions require states to provide coverage for nurse-midwife services to the extent that the
nurse-midwife is authorized to practice under state law or regulation. The statute also requires that states
offer direct reimbursement to nurse-midwives as one of the payment options. Nurse-midwives must be
registered nurses who are either certified by an organization recognized by the secretary or have completed
a program of study and clinical experience that has been approved by the secretary. Nurse-midwife services
are those concerned with management of the care of mothers and newborns throughout the maternity cycle.

LIMITATIONS ON OPTIONAL SERVICES

Intermediate care facility (ICF) services, other than in an institution for tuberculosis or mental diseases, refers
to services provided in a facility that fully meets the requirements for a state license to provide on a regular
basis, health-related services to individuals who do not require hospital or SNF care but whose mental or
physical condition requires services that are above the level of room and board and can be made available
only through institutional facilities. The facility must meet all the requirements to be certified for Medicaid (42
CFR 440.1 50(a-b)).

This optional service is provided by all 50 states.


Services for Individuals Age 21 and Under

States may elect to provide two types of services for individuals age 21 and under: (1) skilled nursing
facility services and (2) inpatient psychiatric services. "Skilled nursing facility services for individuals under
age 21" (42 CFR 440.170(d)) are defined to be those services as specified previously that are provided to
recipients under 21 years of age.

Inpatient psychiatric services for individuals under age 21 refer to services that are provided under the
direction of a physician and are provided in an accredited facility or program (42 CFR 440.160). Federal
regulations further specify certification of need, active treatment, and individual plans of care.

Prescribed D ~ g s

Prescribed drugs are simple or compound substances or mixture of substances prescribed for the cure,
mitigation, or prevention of disease, or for health maintenance that are prescribed by a physician or other
licensed practitioner of the healing arts within the scope of their professional practice as defined and limited
by federal and state law (42 CFR 440.120). The drugs must be dispensed by licensed authorized practit-
ioners on a written prescription that is recorded and maintained in the pharmacist's or practitioner's records.

Two states, Alaska and Wyoming, do not provide prescribed drugs as a separate service to Medicaid
recipients. Alaska passed legislation authorizing a one-year pilot project for prescription drugs under
Medicaid (S.B. 255, effective 1 July 1988.) States place limits on prescription quantities in three different
ways: number of prescriptions that can be filled in a certain time period, number of prescriptions that can
be refilled in a certain time period, and quantity of each prescription.

States further limit prescribed drugs by restricting the quantity of medication for a single prescription. Some
of the "other limits"mposed on prescribed drug services are that brand name drug services must be
documented as medically necessary, refills must be filled by the same pharmacy as the original prescription
and flu and pneumococcal vaccines are covered only for persons age 65 and over.

Other Optional Services and Equipment

Clinic services are preventive, diagnostic, therapeutic, rehabilitative or palliative items or services provided
to an outpatient, by or under the direction of a physician or dentist, by a facility that is not part of a hospital
but is organized and operated to provide medical care to outpatients (42 CFR 440.90).

Emergency hospital services refer to services that are necessary to prevent death or serious impairment of
the health of a recipient and because of the threat to life or health necessitates the use of the most
accessible hospital available that is equipped to furnish the services (42 CFR 440.170(e)). The services will
be provided that such a hospital even if it does not meet the conditions for participation under Medicaid or
the definition of inpatient or outpatient hospital services.

Personal care services in a recipient's home refer to services prescribed by a physician in accordance with
the recipient's plan of treatment and provided by an individual who is qualified to provide the services,
supervised by a registered nurse, and not a member of the recipient's family (42 CFR 440.170(f)). It should
be noted that states which are granted a waiver under Section 2176 for home and community-based services
(that an individual needs to avoid institutionalization) are given the latitude to define personal care services
differently. As of April 1, 1984, 42 states had been approved for Section 2176 waivers.
Private duty nursing services refer to nursing services for recipients who require more individual and
continuous care than is available from a visiting nurse or routinely provided by the nursing staff of the
hospital or SNF (42 CFR 440.80). These services must be provided by a registered nurse or a licensed
practical nurse under the direction of the recipient's physician. The services must be provided in the
recipient's home, in a hospital, or in a SNF.

Optometrists are included in the 42 CFR 440.60 category of "medical or other remedial care provided by
licensed practitioners.' They are licensed practitioners and provide medical, remedial care, or services other
than physicians' services, within the scope of practice as defined under the state law.

Dental services (42 CFR 440.100) refer to diagnostic, preventive, or corrective procedures provided by or
under the supervision of a dentist. The services include treatment of:

The teeth and associated structure of the oral cavity; and


Disease, injury, or impairment that may affect the oral or general health of the recipient.

A dentist is defined to be an individual licensed to practice dentistry or oral surgery.

Podiatrists' services are one of the services included under 42 CFR 440.60, "medical or other remedial care
provided by licensed practitioners.These services include any medical or remedial care provided by a
podiatrist licensed and within the scope of practice as defined under state law.

Chiropractors' services are included under 42 CFR 440.60 "medical or other remedial care provided by
licensed practitioners.' Chiropractors' services are defined to include only services that consist of treatment
by means of manual manipulation of the spine that the chiropractor is legally authorized by the state to
perform. In addition to being licensed by the state, the chiropractor must also meet the standard issued by
the Secretary of HHS. These standards include age, education, and licensure standards.

Prosthetic devices are defined by 42 CFR 440.120(c) to mean replacement, corrective, or supportive devices
prescribed by a physician or other licensed practitioner of the healing arts within the scope of practice as
defined by state law. The devices must:
" Artificially replace a missing portion of the body;
Prevent or correct physical deformity or malfunction; or
Support a weak or deformed portion of the body.

Physical therapy according to 42 CFR 440.110(a) refers to services prescribed by a physician and provided
to a recipient by or under the direction of a qualified physical therapist. To be a qualified physical therapist
an individual must be licensed by the state, where applicable, and be a graduate of a program of physical
therapy approved by both the Council on Medical Education of the American Medical Association and the
American Physical Therapy Association or its equivalent. Physical therapy includes any necessary supplies
and equipment.

Occupational therapy (42 CFR 440.1lO(b)) refers to services prescribed by a physician and provided to a
recipient by or under the direction of a qualified occupational therapist. A qualified occupational therapist
is an individual who is either registered by the American Occupational Therapy Association or who is a
graduate of an approved occupational therapy program (by the Council on Medical Education of the
American Medical Association) and engaged in the supplemental clinical experience required by the American
Occupational Therapy Association. Occupational therapy services include any necessary supplies and
equipment.
Services for individuals with speech, hearing and language disorders are provided as an optional service
in 33 states. These services are diagnostic, screening, preventive, or corrective services provided by or
under the direction of a speech pathologist or audiologist for which a patient is referred by a physician (42
CFR 440.1 10(c)). It includes any necessary supplies and equipment. A speech pathologist or audiologist
is an individual who has a certificate of clinical competence from the American Speech and Hearing
Association, has completed the equivalent educational requirements and work experience necessary for the
certificate, or has completed the academic program and is acquiring supervised work experience to qualify
for the certificate.

Diagnostic services (42 CFR 440.130(a)) include medical procedures or supplies recommended by a
physician, or other licensed practitioner of the healing arts, within the scope of his practice under state law.
The services must enable the practitioner to identify the existence, nature or extent of illness, injury, or other
health deviation in a recipient.

Screening services (42 CFR 440.130(b)) refer to the use of standardized tests given under medical direction
in the mass examination of a designated population to detect the existence of one or more particular
diseases.

Preventive services (42 CFR 440.1 30(c)) are those that prevent disease, disability, and other health conditions
or their progression; services that prolong life; and services that promote physical and mental heaith and
efficiency. Preventive services must be provided by a physician or other licensed practitioner of the healing
arts within the scope of practice under state law.

Rehabilitative services (42 CFR 440.130(d)) are medical or remedial services for reduction of physical or
mental disability and restoration of a recipient to his best possible functional level. The services must be
recommended by a physician or other licensed practitioner of the healing arts within the scope of his practice
under state law.

MEDICALLY NEEDY COVERAGE AND LIMITATIONS

A state plan must specify that, as a minimum, categorically needy recipients are provided the mandatory
services. Additionally, if a state plan includes the medically needy, it must provide, as a minimum, the
following services (42 CFR 440.220):
" Prenatal care and delivery services for pregnant women;

Ambulatory services to individuals under age 18 and individuals entitled to institutional services;
" Home health services to individuals entitled to SNF services; and

If the state plan includes services either in institutions for mental diseases or in ICF-MRs, it must
offer either of the following to each of the medically needy group: the services contained in 42
CFR sections 440.10 through 440.50 and 440.165 (to the extent that nurse-midwives are
authorized to practice under state law or regulations); and the services contained in any seven
of the sections in 42 CFR 440.10 through 42 CFR 440.165.

The state can, in addition, provide any other services to the medically needy without being bound by
requirements pertaining to a minimum number of services or a mix of institutional and non-institutional
services. Furthermore, a state may offer one set of services for a certain medically needy group without
being required to offer them to all the medically needy groups.
COST SHARING

States are permitted to require certain recipients to share some of the costs of Medicaid by imposing upon
them such payments as enrollment fees, premiums, deductibles, coinsurance, copayments, or similar cost
sharing charges (42 CFR 447.50). For states that impose cost sharing payments, the regulations specify the
standards and conditions under which states may impose cost sharing, set forth minimum amounts and the
methods for determining maximum amounts, and describe limitations on availability that relate to cost sharing
requirements. With the passage of the Social Security Amendments of 1972, states were empowered to
impose "nominal" cost sharing requirements on optional Medicaid services for cash assistance recipients, and
on any services for the medically needy. Section 131 of the Tax Equity and Fiscal Responsibility Act (TEFRA)
of 1982 introduced major changes to Medicaid cost sharing requirements. States may now impose a nominal
deductible, coinsurance, copayment, or similar charge upon both categorically needy and medically needy
for any service offered under the state plan. Public Law 97-248, TEFRA, has been in effect since October
1982 and it prohibits imposition of cost sharing on the following:

Services furnished to individuals under 18 years of age (or up to 21 at state option);


Pregnancy-related services (or, at state option, any service provided to pregnant women):
Services provided to certain institutionalized individuals, who are required to spend all of their
income for medical care except for a personal needs allowance;
" Emergency services;
" Family planning services and supplies; and
" Services furnished to categorically needy HMO enrolles (or, at state option, services provided
to both categorically needy HMO enrolles (or, at state option, services provided to both
categorically needy and medically needy HMO enrolles).

In addition, no more than one type of charge can be imposed on any service.

While emergency services are excluded from cost sharing, states may apply for waivers of nominal amounts
for non-emergency services furnished in hospital emergency rooms. Such a waiver allows states to impose
a copayment amount up to twice the current maximum for such services. Approval of a waiver request by
HCFA is based partly on the state's assurance that recipients will have access to alternative sources of care.

Medicaid Management Information System

The Social Security Amendments of 1972 authorized 90 percent federal matching to states for the costs of
design, development, and installation or improvement of mechanized claims processing and information
retrieval systems, and 75 percent for the costs of operating such systems, if the system is approved by the
Administrator.

The MMlS is a general systems design that can be tailored by state Medicaid agencies to their own particular
needs so long as the system meets federally required minimum performance standards. The conceptual
design includes six subsystems: recipient, provider, claims processing, reference file, surveillance and
utilization review, and management and administration reporting. The first four subsystems work together
with the overall objective of processing and paying each eligible provider for every valid claim. The other
two subsystems consolidate and organize data necessary for managing and controlling the Medicaid
program.

Forty-four states have certified MMlSs and operate a mechanized claims processing and information retrieval
system. (1988)
Medicaid Claims Processing Activity

States handle the processing of Medicaid claims in different ways. There is variability in who handles the
claims for each service type. Claims processing activities for prescription drugs are handled by fiscal agents
in 30 states, by states themselves in 16 states, and by a combination of fiscal agentlstate in four states.
(1988)

Medicaid Quality Control

Each state agency must operate a Medicaid Quality Control (MQC) system designed to reduce erroneous
expenditures by monitoring eligibility determinations, third-party liability activities, and claims processing (42
CFR 431.800(a)).

MEDICAID PRINCIPLES OF REIMBURSEMENT


From the inception of Medicare and Medicaid in 1965, there were two fundamental axioms related to provider
reimbursement. The first was that reimbursement be based upon reasonable cost or reasonable charges;
basically the same philosophy used by private insurance carriers. This, it was reasoned, would ensure equity
of reimbursement and adequate participation on the part of hospitals and physicians to ensure recipient
access to quality mainstream medicine; i.e., traditional, private, fee-for-service care, just as that enjoyed by
privately insured citizens. The second axiom was freedom of choice; meaning that Medicare and Medicaid
recipients would be free to choose from among many providers of care on the basis of convenience and
satisfaction. The 1972 Social Security Amendments liberalized eligibility for Medicaid to include SSI recipients
(cash assistance to poor elderly, blind, and disabled) and; at state option, certain optionally categorically
needy groups and certain medically needy people who would otherwise qualify for the cash assistance pro-
grams if it were not for moderately excessive income or resources. These policy decisions set the stage for
explosive growth in Medicaid expenditures throughout the remainder of the seventies. Up through fiscal year
1981, Medicaid experienced double-digit annual growth rates, with hospitals and nursing homes representing
three-quarters of total national expenditures.

Although Medicaid has been unquestionably successful in improving access by the poor to health services
generally (Davis and Schoen, 1978), it has been much less successful in ensuring access to mainstream
medical care.' As gatekeepers to the rest of the health care system, private physicians did not respond to
the program as its architects had assumed. Part of this has to do with the welfare stigma of Medicaid clien-
tele and part to do with reimbursement rates for both Medicare and Medicaid falling behind those offered
by private insurance carriers. Over 25 percent of the nation's private practice physicians refuse to treat
Medicaid patients, and participation among key specialists such as OB-GYNS is even lower.2 in the nation's
highly urbanized areas in which the majority of Medicaid recipients live, low office-based physician
participation rates drive large numbers of Medicaid recipients to costly hospital-based settings for routine
primary care; hence, higher costs per recipient.

' Davis and Shoen, Health and the War on Poveny, A Ten Year Appraisal; Brookings Institution,
1978.

Mitchell and Cromwell, "Large Medicaid Practices and Medicaid Mills," Journal of the American
Medical Association, November 1980.
Quite inadvertently, the architects of the Medicaid program designed built-in reimbursement incentives that
would undermine its overall goal, access by the poor to quality mainstream medicine at reasonable costs.
In the late seventies through 1980 states tried, with varying levels of success, to contain costs of the program
through the use of more stringent eligibility requirements, imposition of service cutbacks and limitations,
tighter administrative Controls, and postponement of increases in physician and pharmacy reimbursement.
Although numbers of recipients declined, the cost per recipient continued to rise sharply. It became obvious
to HCFA that something had to be done about Medicaid cost-based provider reimbursement incentives for
hospitals and nursing homes which had no real incentive to contain rising costs. Since the unit of payment
was per diem, there was even an incentive to maximize utilization so long as the Medicaid revenue played
a useful role in the overall financial health of hospitals and nursing homes. Further, Medicaid eligibility rules
led physicians to institutionalize patients so they would be eligible for needed services. The first significant
legislative step to redress provider incentives came in 1980 with the Omnibus Reconciliation Act of 1980 (PL
96-499). The Act replaced Section 249(a) of the 1972 Social Security Amendments requiring Medicare-based
retrospective cost reimbursement principles for nursing homes. States were freed to reimburse nursing
homes on the basis of "reasonable and adequate to the costs which must be incurred by efficiently and
economically operated facilities." Many states moved swiftly to implement prospective reimbursement
methodologies to curb inflation in nursing home costs.

The second significant step in reforming Medicaid provider reimbursement came with passage of the
Omnibus Reconciliation Act of 1981 (PL 9735). Among other things, the Act, implemented by federal
regulations on September 30, 1981, granted significant new flexibility to the states in setting provider
reimbursement policies for hospitals (Section 2173) and physicians (Section 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 copay-
ments on service use by Medicaid recipients.

The third significant piece of legislation affecting Medicaid provider reimbursement policies is the Tax Equity
and Fiscal Responsibility Act of 1982. TEFRA actually rescinded some of the flexibility given to the states
through OBRA 81 by removing the authority given to the Secretary of DHHS to grant waivers for capitation
and prepayment systems to other than federally qualified HMOs and restricted the imposition of nominal
copayments by exempting from any copayment certain recipient types and services. The TEFRA contained
two other important provisions related to Medicaid reimbursement. The first was a requirement that the
Secretary of DHHS recommend a system of prospective reimbursement for the Medicare program which
might apply to the Medicaid inpatient reimbursement setting. The second was an expansion of Section 223
limitations on hospital charges from routine hospital costs per day to the cost per case, including ancillary
costs. Special adjustments are to be made for hospitals which have a disproportionate load of low income
or Medicare patients, and for psychiatric hospitals. Non-SMSA hospitals with less than 50 beds will be
excluded from the limitations.

Another step to reform Medicaid provider reimbursement is the Social Security Act Amendments of 1983.
This Act mandates a three-year phase-in of a case rate prospective reimbursement system for Medicare
that could also be adopted by state Medicaid agencies. The Medicare Prospective Payment System (PPS)
is based on a prospectively determined rate for each patient according to age, sex and diagnostically-related
grouping (DRG). To date, several state Medicaid programs have adapted the new Medicare PPS concept
to their own hospital reimbursement system?

Clinkscale, Robert, "Impact of Medicare's Prospective Payment System (PPS) on State Medicaid
Programs," Proceedings, First Nat~onalDRG Conference, Atlantic City, NJ, 1983.
Further changes to promote economy and to generate savings in the Medicaid programs will result from
implementing section 2314 of the Deficit Reduction Act of 1984 and sections 91 10 and 9509 of the
Consolidated Omnibus Budget Reconcilation Act of 1985 (Pub. L. 99-272), enacted on April 7, 1986. These
changes affect reimbursing providers for patient-care related capital costs by limiting the valuation of assets
acquired as the result of changes in ownership occuring on or after July 18, 1984.

A recent legislative provision intends to clarify the flexibility granted State Medicaid payment systems for
inpatient services. Section 9433 of OBRA 1984 (Pub. L. 99-509), provides that nothing in Title XIX of the
Social Security Act shall be construed as authorizing the Secretary to limit the amount of payment
adjustments that may be under a Medicaid plan with respect to hospitals that serve a disproportionate
number of low-income patients with special needs. This provision is intended to aid only hospitals meeting
the States' definition of a hospital that serves a disproportionate number of such patients. States are now
not limited in the amount of a payment adjustment (e.g., an add-on or a percent increase over a base
payment amount) that may be granted to eligible hospitals for fiscal relief for specific costs incurred in
providing care to these recipients.

Other changes to the Medicaid program will result from recently passed legislation entitled Wedicare
Catastrophic Coverage Act of 1 9 8 8 . ~ r o v i s i o n srelating to the medicaid program include Title Ill, Section
301, requiring medicaid buyers of premiums and cost-sharing for indigent medicare beneficiaries; Section
302, coverage and payments for pregnant women and infants with incomes below the poverty level and
Section 303, protection of income and resources of couples for maintenance of community spouse.

In summary, the above discussion represents a historical perspective or context in which to consider how
states altered their Medicaid provider reimbursement policies in recent years.

Only nursing home, inpatient hospital, physician, outpatient hospital, free-standing clinics and prescription
drug sewice reimbursement policies are included in this report. These services represent about 90.9 percent
of all Medicaid expenditures for fiscal year 1988.

NURSING HOME REIMBURSEMENT


Expenditures for nursing home services is the largest and most rapidly growing component of national
Medicaid outlays. From fiscal year 1982 through fiscal year 1988, Medicaid expenditures for nursing homes
increased from $12.9 billion to $20.2 billion. ICF-MR nursing expenditures continue to rise at a much higher
rate than for SNF and ICF homes. Most state Medicaid programs have departed from Medicare principles
of reimbursement in favor of various forms of prospective reimbursement where rates and rate increases are
negotiated or determined by formulas prior to each new fiscal year. The prospective methods are generally
either facility specific negotiated rates or class rates based on type of facility, size, and location. Some states
use a combination of methods.

Other recent initiatives to contain nursing home Medicaid expenditures include restrictions in licensed bed
capacity, more stringent patient assessment protocols for entry into homes, and emphasis on home and
community-based care settings as an alternative to expensive institutional care.

INPATIENT HOSPITAL SERVICES REIMBURSEMENT


Inpatient hospital services are the second largest component of Medicaid expenditures nationwide, accounting
for $13.5 billion or 27.6 percent of Medicaid outlays in fiscal year 1988. Prior to the Omnibus Budget
Reconciliation Act of 1981, states were generally compelled to use Medicare reasonable cost-based
reimbursement principles unless authorized by DHHS to adopt an alternative method.
post-OBRA Environment

BY early 1984, only 17 states (17 percent of national inpatient expenditures) still used the Medicare
retrospective cost-based method. The other 33 states (83 percent of total inpatient expenditures) had moved
to adopt either an alternative plan or an experimental system of inpatient reimbursement. States using
experimental systems based on diagnostic-relatedgroupings (DRGs) are New Jersey, Pennsylvania, Michigan,
Ohio, Vermont, and Washington. Most of the other states using alternative systems have tended toward
facility-specific budget review, rate of increase control and forms of prospective rate-setting. Among those
states that had departed from Medicare principles by early 1982, only two had extended the method to
private payers (Massachusetts and Rhode Island). The systems in Maryland, New Jersey, and New York en-
compass all payers. The dates for states using alternative methods represent the year in which the method
was approved by DHHS and implemented. By early 1982 the method may have undergone modifications
since its original approval. As a result of OBRA 81, many other states are expected to abandon inpatient
Medicare reimbursement principles.

Between March Of 1983 and March of 1984, the states of Alaska, Arkansas, District of Columbia, Georgia,
Minnesota, Nevada, Oklahoma, Oregon, Tennessee, and Utah altered their Medicare-based inpatient
reimbursement systems to some form of prospective payment.

PHYSICIAN SERVICES REIMBURSEMENT

Expenditures for physician services are the fourth largest component of Medicaid expenditures. In fiscal
year 1988, physician services accounted for $2.9 billion, or 6.0 percent of Medicaid expenditures nationwide.
States have broad discretion within general federal guidelines regarding Medicaid reimbursement to
physicians. Unlike Medicare, which uses the statutorily mandated customary, prevailing and reasonable
(CPR) charge methodology, state Medicaid programs can use either the CPR method or a fee schedule
approach; whichever is the lower. The Omnibus Budget Reconciliation Act of 1981 freed states from the
CPR-based upper limit. States are now free to set physician Medicaid reimbursement payments at their
discretion so long as they are Qdequate and reasonable. "The CPR method used by Medicare limits
reimbursement to the lowest of the following: a physician's actual charge, the physician's median charge
in a recent prior period (customary), or the 75th percentile of charges in that same period (prevailing). Any
prevailing charges at or under the 75th percentile criterion are considered "reasonable.' In some states, the
75th percentile is determined on the basis of physicians' charges in the same specialty and/or sub-state
region; in others, states use charge data from all physicians regardless of specialty or sub-state region.
Finally, since 1976 an %conomic index" has been applied to limit the rate of increases in Medicare prevailing
rates. Technically, Medicaid regulations refer to a "usual, customary and reasonable" (UCR) method. Other
than confusion over definitions, the UCR method and the CPR methods are the same.4 Within this
framework, state Medicaid programs set physician reimbursement rates using the Medicaid method or a fee
schedule, whichever is the lower. Some states have delayed in updating physician charge profiles, use
artificially low economic indices, or simply elect to reimburse at below Medicare's 75th percentile of pre-
vailing to the point where they have in reality converted to a fee schedule.

Spitz, Bruce, State Guide to Medicaid Cost Containment, National Governors' Association and
Intergovernmental Health Policy Project, September 1981.

18
OUTPATIENT HOSPITAL, CLINIC
Outpatient hospital services refer to emergency rooms and hospital-based ambulatory care clinics. Clinics"
refer to free-standing physician-supervisedambulatory care settings; this excludes rural health clinics. Federal
regulations specify only that Medicaid payments for outpatient hospital services cannot exceed charges to
Medicare. Below this ceiling, rates can be altered downward to reflect local conditions and preferences.
There is flexibility to differentiate rates among emergency room care, specialized outpatient services, and
primary care services. As with inpatient care, the trend has been for more and more states to abandon
Medicare principles to reimburse outpatient hospital services in favor of alternate methods. Five states repor-
ted no coverage for free-standing clinic services. Three states reported adherence to Medicare principles.
There were 41 states using alternate methods (these 41 states represented 99 percent of total Medicaid clinic
services expenditures).

PRESCRIPTION DRUG REIMBURSEMENT


(Existing System)

Federal Medicaid regulations dictate the method for reimbursing prescription drugs. Reimbursement is
made on a retrospective, fee-for-service basis with payments limited to the lower of the pharmacy's usual
and customary charge or the cost of the drug product plus an established dispensing fee to cover the
pharmacy's overhead and profit. (Some states have experimented with enrolling Medicaid eligibles in Health
Maintenance Organizations under capitated payment contracts.) In 1976, utilizing the authority to set an
upper limit for services available under Medicaid programs as provided under Section 1902(a)(30)(A) of the
Social Security Act, the Health Care Financing Administration (HCFA), HHS implemented drug reimbursement
rules at 45 CFR Pan 19 pertaining to upper payment limits for Medicaid and other programs. Specifically,
these regulations provided that the amount the Department recognized for drug reimbursement or payment
purposes was not to exceed the lowest of:

the maximum allowable cost (MAC) of the drug, as established by HCFA's pharmaceutical
reimbursement board for certain multi-source drugs (generic drugs), plus a reasonable
dispensing fee;

the estimated acquisition cost (EAC) of the drug (the price generally and currently paid by
providers for a particular drug in the package size most frequently purchased by providers), as
determined by the program agency, plus a reasonable dispensing fee; or

the providers' usual and customary charge to the public for the drug;
" the regulations provided that the MAC would not apply if the prescriber has certified in his or
her own handwriting that a certain brand of that drug is medically necessary for the patient.

The regulations at 45 CFR Part 19 also established within HCFA a pharmaceutical reimbursement board
(PRB). The PRB identified multiple-source drugs for which significant amounts of federal funds were
expended and was responsible for establishing the MAC for those drugs. The PRB set the MAC at the
lowest unit price for which the drug is widely and consistently available. In addition to limiting the level of
payment for multiple-source drugs, the MAC program tended to promote substitution of lower cost drug
products for brand name drugs.
During its decade of implementation, a number of problems and concerns were voiced about the MAC
program by the pharmacies and the pharmaceutical industry. Specific concerns included:

quality of multi-source drugs;

the interpretation 'widely and consistently available-s related to the process used by the PRB
in setting MAC limits;
" the adequacy of drug reimbursement; and

problems and administering the MAC and EAC programs

In 1983, a departmental task force was established to review the Department's drug reimbursement
regulations at 45 CFR Part 19. Subsequent to the Department's review process, an NPRM notice of
proposed rule making was published on August 19, 1986. The NPRM (51 FR 29560) proposed to remove
the Department's rule at 45 CFR Part 19 that limited drug reimbursement under certain federal programs
including Medicaid. The Department proposed three alternative approaches to the current Medicaid rules
(42 CFR 447.331 through 447.334) regarding upper limits for drug reimbursement and invited public comment
on all three suggestions, as well as suggestions for alternatives which would improve any of the three
recommendations. The three recommendations included:

Pharmacists Incentive Program (PhlP)


" revisions to the current MAC programs

Competitive lncentive Program(CIP)

Discussions outlining these proposals appear in the following pages under Federal Register Vol. 52 No.
147, Friday, July 31, 1987.

FINAL RULE ON MEDICAID PRESCRIPTION DRUG REIMBURSEMENT


On Friday, July 31, 1987, the Health Care Financing Administration (HCFA), HHS, published a notice of the
final rule for limits on payments for drugs in the Medicaid program. The regulations adopted in the rule
become effective on October 29, 1987 (52 FR 28648).

Provisions of the final regulations.

In this final rule, HCFA has attempted to (1) respond to public comments on the NPRM (51 FR 2956); (2)
provide maximum flexibility to the states in their administration of the Medicaid program; (3) provide
responsible but not burdensome federal oversight of the Medicaid program; and (4) take advantage of
savings in the marketplace for multiple source drugs.

To accomplish this, HCFA is adopting a federal upper limit standard for certain multiple-source drugs based
upon application of a specific formula. The upper limit for other drugs is similar in that it retains the EAC
as the upper limit standard that state agencies must meet. However, this standard is applied on an
aggregate basis rather than on a prescription specific basis. State agencies are therefore encouraged to
exercise maximum flexibility in establishing their own payment methodologies. (See Federal Reqister, Vol.
52, No. 147, Friday, July 31, 1987, p 28648.)
Multiple-source Drugs:

A multiple-source drug is a drug marketed or sold by two more manufacturers or labelers, or a drug
marketed or sold by the same manufacturer or labeler under two or more different proprietary names or
both under a proprietary name and without such a name.

A specific upper limit for a multiple-source drug may be established if the following requirements are met:

1. All of the formulations of the drug approved by the Food and Drug Administration (FDA) have
been evaluated as therapeutically equivalent in their current edition of the publication, Approved
Drug Products with Therapeutically Equivalent Evaluations, and

2. At least three suppliers list the drug (which is classified by the FDA as Category A in its
publication) in the current editions of published compendia of cost information for drugs available
for sale nationally.

The upper limit for a multiple-source drug for which a specific limit has been established does not apply if
a physician certifies in his or her own handwriting that a specific brand is "medically necessary' for a
particular recipient. The handwritten phrase 'brand necessarv."medicallv necessarv.' or 'brand medically
necessarv' must amear on the face of the prescription. The rule specifically states that a check-off box
on a prescription form is not acceptable, but it does not address the use of two-line prescription forms.

The formula to be used in calculating the aggregate upper limit of payment for certain multiple-source drugs
will be 150% of the least costly therapeutic equivalent that can be purchased by pharmacists in quantities
of 100 tablets or capsules (or if the drug is not commonly available in quantities of 100, the package size
commonly listed), or in the case of liquids the commonly listed size, plus a reasonable dispensing fee.

Other Drugs:

A drug described as 'other drug" is (1) a brand name drug certified as medically necessary by the physician,
(2) a multiple-source drug not subject to the 150% formula; or (3) single-source drugs. Payments for these
drugs must not exceed, in the aggregate, payment levels determined by applying the lower of:

Estimated Acquisition Cost (EAC) plus reasonable dispensing fees or


O
the provider's usual and customary charges to the general public.

States may continue to use their existing EAC program, or adopt another method, as long as their aggregate
expenditures do not exceed what would have been paid under EAC principles.

Conclusion:

The Health Care Financing Administration (HCFA) publishes a list of those multiple-source drugs to which
the upper limit payment formula will apply (see page 62). Revisions to the list will be provided through
Medicaid program issuances 'State Medicaid Manual - Part 6 Payment for Sewices" on a periodic basis. Any
price revisions will be included in these issuances.

The states are required in the rule to submit a state plan that describes their payment methodology for
prescribed drugs. The rule does not prescribe a preferred payment method as long as the state's aggregate
spending in each category is equal to or below the upper limit requirements. States are also required to
submit assurances to HCFA that the requirements are met.
This new rule does not prescribe a preferred payment method for the states, but gives states the flexibility
to determine how they will pay for prescription drugs under Medicaid. As long as the state's aggregate
spending is at or below the amount derived from the formula, the state is free to maintain its current payment
program or adopt other methods. States can alter payment rates for individual drugs, balancing payment
increases for certain products with payment decreases for other drugs so that in the aggregate, the program
does not exceed the established limit. With the establishment of upper limit payment maximums, some states
may alter their current payment methodologies to comply with the established limitations. State programs
will vary, depending upon whether or not state maximum allowable cost programs cover the same drugs
listed by HCFA. States with established MAC programs may remain unaffected if their MAC rates are already
low, or they may have to make certain adjustments in their MAC levels to meet the federal aaareaate
expenditure limits. States without MAC programs may develop a new payment methodology to increase the
use of lower cost generic drug products in order to keep within the upper payment limits, or may simply
adopt HCFA's formula for listed drug products.

Medicaid Smndinq Rose in 1988. States Cover More Women and Children

Medicaid spending rose in 1988 as states took advantage of a new federal law and expanded eligibility for
poor women and their children. Half the states expanded coverage of poor pregnant women, infants, and
children; more are expected to follow suit in 1988-1989. The Omnibus Budget Reconciliation Act of 1986
allowed states to cover those groups if they are in families with income below the federal poverty line. The
1987 growth rate is about the same as in the previous two years, says the Intergovernmental Health Policy
Project (IHPP), but exceeds the 7.5 percent growth rate from 1981 to 1984. States also continued to respond
to the impact of AlDS on Medicaid budgets; all but six covered the costs of AZT: three (CA, IL, WI) offer
higher payments to providers who care for AlDS patients. New Jersey and New Mexico have Medicaid
waivers to provide home and community-based care to AlDS victims; five states plan to seek waivers in 1988.
Ten states offer case management to such groups as the chronically mentally ill and developmentally
disabled, substance abusers, and emotionally disturbed children; eight offer hospice care. The 1989 state
legislative sessions provided additional changes to the Medicaid programs as states attempt to deal with the
priority issues of AIDS, long term care, and indigent care.
IMPACT OF CATASTROPHIC COVERAGE
ON STATE MEDICAID PROGRAMS

Studies done by the Office of Management and Budget and the Congressional Budget Office have analyzed the costs
of catastrophic coverage to the Federal government and the Medicare beneficiaries. The additional costs to a state
Medicaid program are intended to be Offset by program savings, on the basis of an "average" state.

While the catastrophic care bill was intended to be self-funding, a large expenditure for the elderly and disabled has
been shifted to the States.

The impact of the new catastrophic coverage varies widely from one State to another due to demographics and
variations in the Medicaid programs.

Some of the important variables include:

1. Elderly as a percent of total population --the U.S. average is 12.2 percent, varying by state from a low
of 8.2 percent in Utah to a high of 17.8 percent in Florida.

2. Percent of elderly and disabled who are eligible for both Medicare and Medicaid. The U. S. average
is about 81 percent of the Medicaid recipients over 65 and 37 percent of disabled recipients.

3. Percent of elderly living below the poverty level -- a Census Bureau Study using 1979 data showed a
range from 8.3 percent in Connecticut to 34.3 percent in Mississippi. The data were adjusted to 1986
using a recent study by the Census Bureau published in Current Population Reports.

4. State Medicaid eligibility in relation to the Federal poverty level -- the states which are the most
conservative are the hardest hit by the new law. Some liberal states already include eligibles up to or
exceeding the poverty level in their program, and will realize an immediate savings.

Saving Wth Existing Eligibles

Savings can be calculated resulting from changes in Part A coverage, Part B coverage (including the cap on
expenditures), and the drug program, for the existing Medicaid eligibles.

Enhanced Part A benefits -- beneficiaries will now pay Only one in-hospital deductible per year, and will be
allowed as many days of inpatient care as needed without coinsurance. Skilled nursing home coverage has
been extended and hospice care is now included.

A new Part B payment limitation -- beneficiaries pay a deductible of $75 per year and a 20 perceni
copayment on each approved Medicare charge. Beginning January 1, 1990, when the deductible anc
copayments reach $1,370 -- Medicare will pay 100 percent of allowed charges for Part 6 expenses.

A new prescription drug benefit -- beginning January 1, 1990, Medicare will help pay for some intravenous
drugs and drugs used in immunosuppressive therapy. In 1991, this is extended to all prescription drugs.
Additional Costs Due t o Added Eligibles

States will be required to "buy-in" to Medicare for their dual eligibles and pay premiums, deductibles and coinsurance
for all Medicare beneficiaries up to the Federal poverty level.

Dual eligibles are persons eligible for both Medicare and Medicaid. Under those conditions, Medicaid is the payer 1
I
of last resort. The HCFA 2082 report, submitted annually by each state, shows state expenditures for dual eligibles.
The state pays the deductibles and copays which would normally be paid by the Medicare beneficialy. Studies have 1
shown that Medicare pays about 90 percent of Part A coverage and approximately 67 percent of Part B coverage.
1
It is important for a state to buy-in to Medicare for their dual eligibles and to get crossover claims properly identified Ii
and processed.

Baldwin E. Kloer
Eli Lilly and Company
April 26, 1989 (Revised)

IMPACT ON MEDICAID

Although Medicare and Medicaid are separate programs, current law permits states to "buy into' the Medicare Program
for eligible beneficiaries. The Catastrophic Act will require states to phase in a Medicare buy-in for the elderly and
disabled poor based on (1) the percentage of incomes at or below the Federal poverty level ($5770 for an individual
in 1988) and (2) resources at or below twice the Supplemental Security Income program standard for 1988, $3800.
The buy-in requirements will be phased in according to the following schedule (percentage figures refer to Federal
-
poverty level): 1989 - 85%; 1990 - 90%; 1991 95%; 1992 - 100%. Pregnant women and infants up to one year old
with incomes at 100% of the poverty level for a family of three, $9690 for 1988, must also be covered by 1990, an
interim step will provide coverage for those at 75% of the level in 1989.

In 1991, the prescription drug benefit must also be offered to Medicaid-eligible beneficiaries now covered by Medicare,
subject the deductible and the coinsurance. However, states will be required to phase in payment of premiums,
deductibles, and coinsurance for those whose incomes are at or below the poverty level and whose resources are
at or below $3800. Alternatively, states will have to provide the same drug coverage as is offered to Medicaid
recipients. The phase-in will be according to the same schedule as the general buy-in requirement.

Robert Greenberg, J.D.


American Journal of Hospital Pharmacy
December 1988
GLOSSARY OF MEDICAID TERMS

Actual acquisition cost: The pharmacist's net payment made to purchase a drug product, after taking into
account such items as purchasing allowances, discounts, rebates and the like.
Average Wholesale Price (AWP): The composite wholesale prices charged on a specific commodity that is
assigned by the drug manufacturer and is listed in either the Red or Blue Books.
Capitation (fee): A per-member, monthly payment to a provider that covers contracted services, and is paid
in advance of this delivery. In essence, a provider agrees to provide specified services to HMO members
for this fixed, predetermined payment for a specified length of time (usually a year), regardless of how many
times the member uses the service. The rate can be fixed for all members, e.g., $10 per month, or it can
be adjusted for the age and sex of the member, based on actuarial projections of medical utilization.
Categorically Needy: Under Medicaid, categorically needy cases are aged, blind, or disabled individuals or
families and children who are otherwise eligible for Medicaid and who meet financial eligibility requirements
for AFDC, SSI, or an optional state supplement.
Coinsurance: A cost-sharing requirement under a health insurance policy which provides that the insured
will assume a portion or percentage of the costs of covered services.
Copayment: Copayments are a type of cost-sharing under Medicaid whereby insured or covered persons
pay a specified flat amount per unit of service or unit of time, and the insurer pays the rest of the cost.
Covered Services: Covered services are the specific services and supplies for which Medicaid will provide
reimbursement. Covered services under the Medicaid program consist of a combination of mandatory and
optional services within each state.
Customary, Prevailing, and Reasonable Charges: Method of reimbursement used under Medicare which limits
payment to the lowest of the following: a physician's actual charge, the physician's median charge in a
recent prior period (customary), or the 75th percentile of charges in that same time period (prevailing).
Customary Charge: The charge a physician or supplier usually bills his patients for furnishing a particular
service or supply is called the customary charge.
Deductible: A set dollar amount that a person must pay before insurance coverage for medical expenses
can begin.
Diagnosis Related Groups (DRGs): A classification system for hospital inpatients that groups patients
according to principal diagnosis, presence of a surgical procedure, age, presence or absence of significant
comorbidities or complications, and other relevant criteria. Originally developed at Yale University for use in
hospital utilization review, the DRG system is now used by the federal government for hospital payment under
Medicare. The set now in use, developed using 1979 data, includes 470 DRGs.
D N Utilization:
~ The prescribing, dispensing, administering and ingestion or use of pharmaceutical products.
Drug Utilization Review: Used by Medicaid and other health plans to monitor the frequency and usage of
prescriptions. Typically, a DUR committee examines the number of prescriptions per member per month and
the average cost per prescription. The utilization and costs of pharmaceuticals are reviewed by the
comminee for each physician, physician group, medical specialty, retail pharmacy, employee group, and
member.
Early and Periodic Screening, Diagnosis, and Treatment (EPSDTj: The EPSDT program covers screening
and diagnostic services to determine physical or mental defects in recipients under age 21, and health care,
treatment, and other measures to correct or ameliorate any defects and chronic conditions discovered.
Estimated Acquisition Cost (EAC): Estimated acquisition cost based on price information supplied at regular
intervals by the DHHS. This information will show estimated costs to groups of providers classified by dollar
volume of drug sales.
Expenditures: Under Medicaid, "expenditures" refers to an amount paid out by a state agency for the
covered medical expenses of eligible participants.
Family Planning Services: Family planning services are any medically approved means, including diagnosis,
treatment, drugs, supplies and devices, and related counseling which are furnished or prescribed by or under
the supervision of a physician for individuals of childbearing age for purposes of enabling such individuals
freely to determine the number or spacing of their children.
Federally Qualified HMOs: HMOs that meet certain federally stipulated provisions aimed at protecting
consumers: e.g., providing a broad range of basic health services, assuring financial solvency, and
monitoring the quality of care. HMOs must apply to the federal government for qualification. The process
is administered by the Office of Prepaid Health Care of the Health Care Financing Administration (HGFA),
Department of Health and Human Services (DHHS).
Fee for Sewice: A system of payment for health care whereby a fee is rendered for each sewice delivered.
This traditional method contrasts with that used in the prepaid sector, where services are covered by a fixed
payment made in advance that is independent of the number of services rendered.

Fiscal Agent: A fiscal agent is a contractor that processes or pays vendor claims on behalf of the Medicaid
agency.
Fiscal Intermediary: The agent (Blue Cross or an insurance company, for example) that has contracted with
providers of service to process claims for reimbursement under health care coverage. In addition to handling
financial matters, it may perform other functions such as providing consultative services or sewing as a center
for communicating with providers and making audits of providers' records.

Fiscal Year: Any twelve month period for which annual accounts are kept. The Federal Government's fiscal
year extends from October 1 to the following September 30.

Fiied Fee: An established 'Yee" schedule for pharmacy services allowed by certain government and private
third-party programs in lieu of cost-of-doing business markups.
Formulq: A list of selected pharmaceuticals and their appropriate dosages felt to be the most useful and
cost effective for patient care. Organizations often develop a formulary under the aegis of a pharmacy and
therapeutics (P&T) committee. In HMOs, physicians are often required to prescribe from the formulary.
Gatekeeper: The primary care HMO physician who must authorize all medical services, e.g., hospitalizations,
diagnostic workups, and specialty referrals, as a condition of their being covered by the HMO. For instance,
a patient is not covered for a visit to a specialist without prior approval of the generalist.
Generic Substitution: Substituting a generic version of a branded off-patent pharmaceutical for the branded
product when the latter is prescribed. Some HMOs and Medicaid programs mandate generic substitution.
Mandatory generic substitution within the Medicare program is currently being debated in Congress.
Health Maintenance Organizations (HMO's): In broad terms, an HMO is a form of health insurance. An HMO
provides health care services for members who prepay a premium that generally covers a specified range
of both inpatient and ambulatory care. Providers share the risk of the cost of care with the HMO.
Prescription drugs may be included either as part of the basic benefit package or as an option. Traditionally,
there have been four main types or models of HMOs, classified according to the financial and organizational
arrangements between the HMO and its physicians.

HMO - Model Types:


Group Practice or Closed Panel -The HMO contracts with a group of physicians, which is paid a set
amount per patient to provide a specified range of services. The group of physicians determines the
compensation of each individual physician, often sharing profits. The practice may be located in a hospital
setting or clinic. Like staff model HMOs, the medical facility usually contains a pharmacy, but in some cases
the HMO contracts for pharmacy services.
Staff HMO - An HMO that hires its physicians individually and pays them a Salary to practice in the
HMO facility or clinic. Because physicians in this model and group model HMOs traditionally have had few,
if any, fee-for-service patients of their own, both models are often referred to as closed-panel HMOs. The
physicians are subject to the policies of the HMO management. The HMO facility often contains a pharmacy,
but in some cases the HMO will contract for pharmacy services. As in all the models, the affiliated pharmacy
may be paid either a fee for service or a capitation.
Network - A Network Model HMO is essentially an IPA of group practices rather than individual
physicians. Each of the contracted group practices sees HMO patients as well as fee-for-se~icepatients
in its group offices.
Home Health Services: Home health services are services and items furnished to an individual who is under
the care of a physician by a home health agency, or by others under arrangements made by such agency.
The services are furnished under a plan established and periodically reviewed by a physician. The services
are provided on a visiting basis in an individual's home and include: part-time Or intermittent skilled nursing
care; physical, occupational, or speech therapy; medical social services, medical supplies and appliances
(other than drugs and biologicals); home health aide services, and services of interns and residents.
Home Health Agency: A home health agency is a public agency or private organization which is primarily
engaged in providing skilled nursing services and other therapeutic services in the patient's home, and which
meets certain conditions designed to ensure the health and safety of the individuals who are furnished these
services.
Hybrid Model HMO: An HMO that combines attributes of more than one of the four principal HMO models
and hence is not classifiable in any one of the four categories.

There are exceptions to these definitions. For instance, a group model HMO may allow its physicians to see
a number of fee-for-semjce patients. As competition increases in the health care marketplace, hMOs are
varying their traditional organizational and financial arrangements on a large scale. A knowledge of the four
basic models, however, facilitates a basic understanding of the organization of the industry.
Indemnity Benefit: The patient or consumer pays directly for the services or products and is reimbursed by
a third pany.
Ind'~idua1Practice Association (IPA): An IPA contracts with individual physicians who see HMO members
as well as their own patients, in their own private offices. It is the ability of IPA physicians to see both HMO
and private patients in their own offices that principally differentiates an IPA from a group or staff HMO.
Physicians in an IPA are paid either on a capitation or a modified fee-for-service basis. An IPA HMO may
also contract with chain or independent pharmacies to dispense prescriptions to members.
Inpatient Hospital Services: lnpatient hospital services are items and services furnished to an inpatient of
a hospital by the hospital, including bed and board, nursing and related sen/ices, diagnostic and therapeu-
tic services, and medical or surgical services.
Intermediate Care Facility: An intermediate care facility is an institution furnishing health-related care and
services to individuals who do not require the degree of care provided by hospitals or skilled nursing facii-
ities as defined under Title XIX (Medicaid) of the Social Security Act.
Laboratory and Radiological Services: Laboratory and radiological ?.elvices are Professional and technical
laboratory and radiological services ordered by a licensed practitioner and provided in an office or similar
facility (other than a hospital outpatient department or clinic) or by a qualified laboratory.
Legend Drug: A drug product that cannot be dispensed legally without a prescription.
Managed Care: A relatively new term coined originally to refer to the prepaid health care sector, e.g., HMOs
and CMPs, where care is provided under a fixed budget and costs are therein capable of being Wanaged:
Increasingly, the term is being used by many analysts to include PPOS and even forms of indemnity
insurance Coverage that incorporate preadmission certification and other utilization controls.
Maximum Allowable Cost, or 'Reasonable Cost Range': A maximum cost is fixed for which the pharmacist
can be reimbursed for selected products, as identified in a 'formulary."
Medicaid: A government health program, established by Title XIX of the Social Securlty Act, for people with
low incomes. Each state administers its own program. Medicaid is funded by both the state and federal
governments.
Medicaid Management Information System: Federally developed set of guidelines for computer system
design to achieve national standardization of Medicaid claims processing, payment, review and reporting for
all medical health care claims.
Medically Needy: Under Medicaid, medically needy cases are aged, blind, or disabled individuals or families
and children who are otherwise eligible for Medicaid, and whose income resources are above the limits for
eligibility as categorically needy (AFDC or SSI) but are within limits set under the Medicaid state plan.
Medicare: A federal health insurance program, established by Title XVlll of the Social Security Act, for elderly
and disabled. It is funded principally by FICA payroll deductions and somewhat by general revenues. It is
administered by the Health Care Financing Administration (HCFA), Department of Health and Human Services
(DHHS) of the federal government. It has a program to enable the elderly to enroll in HMOs.
Other Practitioners' Services: Other practitioners' services are health care services of licensed practitioners
other than physicians and dentists.
Outpatient Hospital Services: Outpatient hospital services are services furnished to outpatients by a
participating hospital for diagnosis or treatment of an illness or injury.
Peer Review A review by members of the profession "peers' regarding the quality of care provided a patient,
including documentation of care (medical audit), diagnostic steps used, conclusions reached, therapy given,
appropriateness of utilization (utilization review), and reasonableness of charges claimed.
Peer Review Organization (PRO): An organization which contracts with the federal government to conduct
utilization review for the Medicare program. PROSare intended to prevent overutilization of hospital services
and to assure the quality of care provided to Medicare beneficiaries.
Prepaid Group Practice Plans: Organized medical groups of essentially full-time physicians in appropriate
specialties, as well as other professional and subprofessional personnel, who, for regular compensation,
undertake to provide comprehensive care to an enrolled population for premium payments that are made in
advance by the consumer and/or their employers.
Preferred Provider Organization (PPO): Typically, a group of hospitals, physicians and/or pharmacists that
contracts on a discounted fee-for-sewice basis with employers, insurance carriers, or a third-party
administrator to provide services to subscribers. Provider charges are usually 10%to 20% below usual fees.
There is substantial variation in organizational and financial arrangements amount PPOs. PPOs are often
formed as a competitive response to HMOs. There are exceptions to this definition of PPOs, just as there
are to that for HMOs. For example, some PPOs are now emerging that require providers to share in the
financial risk, and others are employing the gatekeeper concept.
P r e s c n i D ~ g s :Prescribed drugs are drugs dispensed by a licensed pharmacist on the prescription of
a practitioner licensed by law to administer such drugs, and drugs dispensed by a licensed practitioner to
his own patients. This item does not include a practitioner's drug charges that are not separable from his
other charges, or drugs covered by a hospital's bill.
Prospective Payment Assessment Commission (ProPAC): A 15 member commission, appointed by the
Director of the Office of Technology Assessment, which makes recommendations to the Secretaty of Health
and Human Services on various aspects of the diagnosis related group system of Medicare reimbursement.
it will advise the Secretary on the appropriate annual percentage change in DRG payment rates and on the
need for changes in the DRG classification system, (e.g., new DRGs, modifications to existing DRGs) and
in the weighing of individual DRGs.
Prospectke Financing: Financing for health care services based on prices or budgets determined prior to
the delivery of service. Payments can be per unit of service, per member, or per time period. In all its forms
prospective financing differs from cost-based reimbursement, under which a provider is paid for costs
incurred.
Rate Setting: A form of financing under which hospitals or nursing homes are paid prices which are
prospectively determined, generally by a state agency. Prospectively determined prices may be paid by all
payers for all covered services, as in all payer systems, or by only some payers. The unit of payment can
be service, patient, or time period. (See "Prospective Financing")
Rational D N Therapy:
~ Prescribing the right drug for the right patient, at the right time, in the right amounts,
and with due consideration of relative costs.
Reasonable Charge: In processing claims for Supplementary Medical lnsurance benefits, carriers use HCFA
guidelines to establish the reasonable charge for services rendered. The reasonable charge is the lowest
oi: the actual charge billed by the physician or supplier; the charge the physician or supplier customarily
bills his patients for the same services, and the prevailing charge which most physicians or suppliers in that
locality bill for the same service. Increases in the physicians' prevailing charge levels are recognized only
to the extent justified by an index reflecting changes in the costs of practice and in general earnings.
Reasonable Cost: In processing claims for Health lnsurance benefits, intermediaries use HCFA guidelines
to determine the reasonable cost incurred by the individual providers in furnishing covered services to
enrolles. The reasonable cost is based on the actual cost of providing such services, including direct and
indirect costs of providers, and excluding any costs which are unnecessary in the efficient delivery of services
covered by the insurance program.
Recipient: A recipient of Medicaid is an individual who has been determined to be eligible for Medicaid and
who has used medical services covered under Medicaid.
Restrictive Formulary: A list of the drug products that are available to physicians for use in treating their
patients within an institution or health care financing system. Restrictive formularies are used by some
hospitals and certain state Medicaid programs to limit prescribing and reimbursement to only certain
products.
Rural Health Clinic: A rural health clinic is an outpatient facility which is primarily engaged in furnishing
physicians' and other medical and health services, which meets certain other requirements designed to
ensure the health and safety of the individuals served by the clinic. The clinic must be located in an area
that is not an urbanized area as defined by the Bureau of the Census and that is designated by the
Secretary of DHHS either as an area with a shortage of personal health services, or as a health manpower
shortage area, and has filed an agreement with the Secretary not to charge any individual or other person
for items or services for which such individual is entitled to have payment made by Medicare, except for the
amount of any deductible or coinsurance amount applicable.
Skilled Nursing Facilily (SNF): A skilled nursing facility is an institution which has in effect a transfer
agreement with one or more participating hospitals, and is primarily engaged in providing to inpatients skilled
nursing care and restorative care services, and meets specific regulatory certification requirements.
Skilled Nursing Facility Services: SNF services are all services furnished to inpatients of, and billed for by,
a formally certified skilled nursing facility that meets standards required by the Secretary of DHHS.
Spend-Down: Under the Medicaid program, spend-down refers to a method by which an individual
establishes Medicaid eligibility by reducing gross income through incurring medical expenses until net income
(after medical expenses) meets Medicaid financial requirements.
State Buy-In: State buy-in is the term given to the process by which a state may provide Supplementary
Medical lnsurance coverage for its needy eligible persons through an agreement with the Federal government
under which the state pays the premiums for them.
State Plan: The Medicaid State Plan is a comprehensive written commitment by a Medicaid agency to
administer or supervise the administration of a Medicaid program in accordance with Federal requirements.
Supplemental Security Income (SSI): SSI is a program of income support for low-income aged, blind, and
disabled persons established by Title XVI of the Social Security Act.
Therapeutic S u b s t i i o n : A practice entailing a pharmacist's dispensing a drug felt to be therapeutically
equivalent to the drug prescribed by a physician without obtaining permission from the prescribing physician.
Generally, the P&T committee of an HMO will formally approve the therapeutic substitutions that it feels are
permissible, and only those so designated can be made by the pharmacist dispensing for the HMO.
Third-Party Liability: Under Medicaid, third-party liability exists if there is any entity (including other
government programs or insurance) which is or may be liable to pay all or part of the medical cost or in-
jury, disease, or disability of an applicant or recipient of Medicaid.
Usual. Customary and Reasonable Charges: Method of reimbursement used under Medicaid by which State
Medicaid programs set reimbursements rates using the Medicare method or a fee schedule, whichever is
lower.
Wnhhold: The portion of the monthly capitation payment to physicians withheld by the HMO until the end
of the year or other time period to create an incentive for efficient care. The withhold is 'at risk": if the
physician exceeds utilization norms, he does not receive it. It serves as a financial incentive for lower
utilization. The withhold can cover all services or be specific to hospital care, laboratory usage, or specialty
referrals.
Vendor: A medical vendor is an institution, agency, organization, or individual practitioner which provides
health or medical services.
Vendor Payments: In welfare programs, direct payments are made by the state to such providers as
physicians, pharmacists and health care institutions rather than to the welfare recipient himself.
ACRONYMS

AABD Aid to Aged, Blind, and Disabled


AB Aid to the Blind
AFDC Aid to Families with Dependent Children
APTD Aid to the Permanently and Totally Disabled
ARF Area Resource File
CFR Code of Federal Regulations
COBRA Consolidated Omnibus Reconciliation Act of 1985
CPR Customary Prevailing, and Reasonable (charges)
CPT Current Procedural Terminology
DEFRA Deficit Reduction Act of 1984
DHHS Department of Health and Human Services
DRGs Diagnostic Related Groupings
EPSDT Early and Periodic Screening, Diagnostic and Treatment
FFP Federal Financial Participation
FY Fiscal Year
HCFA Health Care Financing Administration
HI0 Health Insuring Organizations
HMO Health Maintenance Organization
ICF lntermediate Care Facility
ICF-MR lntermediate Care Facility for the Mentally Retarded
MAC Maximum Allowable Cost
MMlS Medicaid Management Information System
MQC Medicaid Quality Control
NMCUES National Medicare Care Utilization and Expenditure Survey
NP Nurse Practitioner
OAA Old Age Assistance
OACT Office of the Actuary
OASDl Old Age, Survivors, and Disability Insurance
OBRA Omnibus Reconciliation Act - 1981
ORD Office of Research and Demonstrations
OT Occupational Therapy
OTC Over-the-counter (drugs)
PCF Program Characteristics File
PA Physician's Assistant
PT Physical Therapy
RHC Rural Health Clinic
SNF Skilled Nursing Facility
SSA Social Security Administration
SSI Supplemental Security Income
SSP State supplemental Payments
TEFRA Tax Equity and Fiscal Responsibility Act
TDOC Total Days of Care
UCR Usual, Customary and Reasonable (charges)
REGIONAL ADMINISTRATIVE OFFICES
Heath and Human Services
Heaith Care Financing Administration

Region I John F. Kennedy Federal Bldg. Connecticut, Maine,


Government Center, Room 1309 Massachusetts, New
Boston, Massachusetts 02203 Hampshire, Rhode Island,
6171565-1188 Vermont

Region II Room 381 1 New Jersey, New York,


26 Federal Plaza Puerto Rico, Virgin Islands
New York, New York 10278
21 21264-4488

Region Ill 3535 Market Street Delaware, District of


P. 0.Box 7760 Columbia, Maryland,
Philadelphia, Pennsylvania 19101 Virginia, West Virginia
21 51596-0324 Pennsylvania

Region N 101 Marietta Tower Alabama, Florida, Georgia,


Suite 701 Kentucky, Mississippi, North
Atlanta, Georgia 30323 Carolina, South Carolina,
4041331-2329 Tennessee

Region V 105 West Adams Street Illinois, Indiana, Michigan,


15th Floor Minnesota, Ohio, Wisconsin
Chicago, Illinois 60603-6201
3121886-6432

Region VI 1200 Main Tower Building, Room 2000 Arkansas, Louisiana, New
Dallas, Texas 75202 Mexico, Oklahoma, Texas
2141767-6427

Region VII New Federal Office Building Iowa, Kansas, Missouri,


601 East 12th Street, Room 235 Nebraska
Kansas City, Missouri 64106
8161426-5233

Region Vlll 1961 Stout Street Colorado, Montana, South


Federal Office Building, Room 576 Dakota, North Dakota, Utah,
Denver, Colorado 80294 Wyoming
3031844-2111

Region K 75 Hawthorne Street, 4th & 5th Floors Arizona, California, Hawaii,
San Francisco, California 94105 Nevada, and Pacific Islands
41 51995-6146

Region X 2201 6th Avenue, Mail Stop RX-40 Alaska, Idaho, Oregon,
Seattle, Washington 98121 Washington
2061442-0425
STATE
MEDICAID
DRUG PROGRAM ADMINISTRATORS

ALABAMA ALASKA
Larry A. Tatum, R.Ph. Eric S. Hansen
Associate Director Chief, Medical Assistance
pharmaceutical Programs Alaska Div. of Medical Assistance, DHSS
Alabama Medicaid Agency 4433 Business Park Boulevard
2500 Fairlane Drive Building M
Montgomery, AL 36130 Anchorage, AK 99503
2051277-2710 9071561-2171

ARIZONA ARKANSAS
George Carlson, R.N., C.P.M. Thelma Underwood
Medicaid Pharmacy Coordinator Pharmacist Consultant
Arizona Health Care Containment System Arkansas Social Services Division
801 E. Jefferson Street P. 0. BOX1437
Phoenix, AZ 85034 Little Rock, AR 72203
60212343655 5011682-8364

CALIFORNIA COLORADO
Milton Kushnereit, Pharm.D. Stanley G. Callas, R.Ph.
Senior Consulting Pharmacist Manager
Medi-Cal Benefits Branch PharmacylAmbulatory Care Services Section
California Healthwelfare Services CO Div. of Medical Assistance
714 P Street, Room 1640 Colorado Dept. of Social Services
Sacramento, CA 95814 1575 Sherman Street
Denver, CO 80203
I 9161324-2477
3031866-5508

CONNECTICUT DELAWARE
Meyer Rosenkrantz, P.D. Ruth S. Fischer
Pharmacist Consultant Administrator, Medical Services
Connecticut Dept. of Income Maintenance Delaware Dept. of Health & Human Services
110 Bartholomew Avenue P. 0. Box 906
Hartford, CT 06106 New Castle, DE 19720
2031566-8007 3021421-6139

DISTRICT OF COLUMBIA FLORIDA


James F. Harris, R.Ph. Jerry F. Wells
Pharmacy Consultant Pharmacist Consultant
DC Department of Human Services Medicaid Office
1331 H Street, N. W. FL Department of Health & Human Services
Suite 500 1317 Winewood Blvd.
Washington, DC 20005 Building 6, Room 243
2021727.0753 Tallahassee, FL 32301
9041487-4441
GEORGIA HAWAII
Frances Lipscomb, R.Ph. Omel L. Turk
Program Management Officer Pharmacist Consultant
Georgia Dept. of Medical Assistance Public Welfare Division
2 Martin Luther Dr., S. E. HI Dept. of Social Services & Housing
James Floyd Memorial Bldg. P. 0. Box 339
West Tower, P. 0. Box 38440 Honolulu, HI 96816-0339
Atlanta, GA 30334 8081546-8917
40416564044

IDAHO ILLINOIS
Mary K. Wheatley, R.Ph. Ronald W. Gonrich, R.Ph.
Pharmacy Services Specialist Manager, Drug Section
Idaho Dept. of Health & Welfare Div. of Food, Drugs, Dairies
450 W. State Street Illinois Dept. of Public Health
Boise, ID 83720 628 East Adams St. 4th FI.
20813345795 Springfield, IL 62761
2171782-7532

INDIANA IOWA
Marc Shirley Ronald J. Mahrenholz, R.Ph.
Pharmacy Consultant Manager, Operations Section
Indiana State Dept. of Public Welfare Bureau of Medical Services
100 N. Senate Ave., Room 702 Iowa Dept. of Human Services
Indianapolis, IN 46204 Hoover State Office Bldg.
3171232-4343 5th Floor
Des Moines, IA 50319
5151281-6199

KANSAS KENTUCKY
E. Eugene Stephens, R.Ph. Gene A. Thomas, R.Ph.
Mgr. Pharmacy Services Program Dept. for Medicaid Services
Kansas Division of Medical Programs Kentucky Bureau of Social Insurance
Docking State Office Building, #6825 275 E. Main St. 3-E CHR Bldg.
Topeka, KS 66612 Frankfort, KY 40621
9131296-3981 5021564-4321

LOUISIANA MAINE
Carolyn Maggio Michael P. O'Donnell, R.Ph.
Medical Assistance Program Pharmacy Consultant
Louisiana Dept. of HealthIHuman Resources Br. Medical Svces. Station II
P. 0. Box 94065 Maine Dept. of Human Services
Baton Rouge, LA 70804 Statehouse
5041342-3891 Augusta, ME 04333
2071289-2674

MARYLAND MASSACHUSElTS
Leone W. Marks, R.Ph. Arnold H. Shapiro
Staff Specialist for Pharmacy Services Massachusetts Department of Public Welfare
Maryland Health Systems Financing Admin. 600 Washington St.
300 West Preston Street Boston, MA 021 11
Baltimore, MD 21201 6171348-5217
3011225-1459
MICHIGAN MINNESOTA
Sandy Kramer, R.Ph. John T. Bush, R.Ph.
pharmacy Program Specialist Pharmacist Consultant
Medical Service Administration Minnesota Medical Assistance Program
Michigan Dept. of Social Services Health Services Policy, 6th Floor
921 West Holmes 44 Lafayette Rd.
Lansing, MI 48910 St. Paul, MN 55155
5171335-5127 6121296-2363

MISSISSIPPI MISSOURI
James T. Steele, R.Ph. Susan McCann, Ph.D.
Pharmacist Pharmaceutical Consultant
Mississippi Div. of Medicaid Medical Services Division
Suite 801, Robert E. Lee Building Missouri Dept, of Social Services
239 North Lamar Street 227 Metro Drive, P.O. 6500
Jackson, MS 39201-131 1 Jefferson City, MO 65102
6011359-6135 31417513277

MONTANA NEBRASKA
Karl E. Banschbach Daniel W. Snodgrass, R.Ph.
Administrative Officer Pharmaceutical Consultant
Montana Department of SocialIRehab. Services Medical Services Division
P. 0. Box 4210 Nebraska Department of Social Services
Helena, MT 59604 301 Centennial Mall South
4061444-4540 5th Floor, P.O. 95026
Lincoln, NE 68509
4021471-9379

NEVADA NEW HAMPSHIRE


Steven P. Bradford, Pharm.D. Edward J. Pierce, R.Ph.
Pharmaceutical Consultant Office of Medical Service
Nevada Medicaid Office New Hampshire Div. of Human Services
Dept. of Human Resources 6 Hazen Drive
State Capitol Complex, 2527 N. Carson St. Concord, NH 03301
Carson City, NV 89710 60312714393
7021885-4869

NEW JERSEY NEW MEXICO


Sanford Luger, R.Ph. Robert Stevens
Chief Consultant Drug Program Administrator
New Jersey Div. of Medical Assist.lHealth Ser. Medical Assistance Programs
7 Quakerbridge Plaza, CN 712 New Mexico Dept. of Human Services
Trenton, NJ 08625 PERA Bldg., Rm. 524
609f588-2724 P.O. Box 2348
Santa Fe, NM 87504-2348
50518274315

NEW YORK NORTH CAROUNA


Michael A. Felzano C. Benny Ridout, R.Ph.
Medical Review Analyst IV Pharmacist Consultant
New York Dept. of Social Services Div. of Medical Assistance
40 North Pearl Street North Carolina Dept. of Human Resources
Albany, NY I2243 Kirby Bldg, 1985 Urnstead Dr.
5181473-5602 Raleigh, NC 27603
9191733-2833
NORTH DAKOTA OHIO
Patricia A. Kramer, R.Ph. Robert P. Reid, R.Ph.
Administrator, Pharmacy Services Pharmacist Consultant
Medical Services Division Bureau of Medicaid Policy
North Dakota Dept. of Human Services Ohio Dept. of Human Services
State Capitol Bldg., Judicial Wing 30 E. Broad St., 31st FI.
Bismarck, ND 58505 Columbus, OH 43215
7011224-4023 6141466-6420

OKLAHOMA OREGON
Howard Stansberry James E. Peters, Ph.D., R.Ph.
Program Administrator, Medical Sew. Div. Medicaid Pharmacy Prog. Mgr.
Oklahoma Department of Human Services Health Services Section
P.O. Box 25352, 4001 N. Lincoln Blvd. Oregon Dept. of Human Resources
Oklahoma City, OK 73125 203 Public Service Bldg.
4051557-2539 Salem, OR 97310
5031378-5581

PENNSYLVANIA RHODE ISLAND


Joseph E. Concino, P.D. John A. Pagliarini, R.Ph.
PA Division of Outpatient Programs Chief of Pharmacy
Section of Pharmacy & Ancillary Services Rhode Island Dept. of Human Services
P. 0. Box 8043 600 New London Avenue
Harrisburg, PA 17105 Cranston, RI 02920
7171782-6142 4011464-2184

S O U M CAROLINA S O U M DAKOTA
James M. Assey Donald Mahannah, P.D.
Medicaid Program Consultant Pharmacist Consultant
SC HealthIHuman Services Finance Comrnision South Dakota Dept. of Social Services
P.O. Box 8206 Medical Services
Columbia, SC 29202-8206 700 Governor Drive
8031253-6138 Pierre, SD 57501
6051773-3495

TENNESSEE TEXAS
(vacant) Robert S. Nash, R.Ph.
Director of Pharmacy Services Program Specialist, Vendor Drugs
Tennessee Dept. of Public HealthIEnvironrnent Texas Dept. of Human Services
729 Church Street P. 0. Box 2960, Mail Code 541-W
Nashville, TN 37214 Austin, TX 78769
6151741-0213 5121450-3198

UTAH VERMONT
RaeDell Ashley, R.Ph. Robert Thomas
Manager, Policy and Planning Quality Assurance Specialist
Health Care Financing Medicaid Division
Utah Dept. of Health Vermont Dept. of Social Welfare
288 N. 1460 West 103 S. Main Street
Salt Lake City, UT 84116-0580 Waterbury, VT 05676
8011538-6495 8021241-2744
VIRGINIA WASHINGTON
Mary Ann Johnson, R.Ph. William P. Pace, R.Ph.
Pharmacist Consultant Pharmacist Consultant
Medical Assistance Program Washington State Div. of Medical Assistance
Virginia State Department of Health Mail Stop Hb-41
Suite 1300, 600 E. Broad Street Olympia, WA 98504-0095
Richmond, VA 23218 2061753-0524
8041786-3820

WEST VIRGINIA WISCONSIN


Ann Bond Smith, R.Ph. Michael Boushon, R.Ph.
Pharmacy Coordinator Pharmacist Consultant
Division of Medical Care Wisc. Dept. HealthJSoc. Svce.
West Vjrginia Department of Welfare 1 W. Wilson Street
1900 Washington Street, East P.O. Box 309
Charleston, WV 25305 Madison, WI 53701
3041348-8990 6081266-0722

WYOMING
Fred Lund
Pharmaceutical Consultant
Division of Health & Medical Services
117 Hathaway Building, Room 454
Cheyenne, WY 82002
STATE OFFICIALS

ALABAMA ARIZONA
Governor Governor
Honorable Guy Hunt Honorable Rose Mofford
Governor of Alabama Governor of Arizona
11 South Union Street State House
Montgomery, AL 36130 1700 W. Washington
2051261-7100 Phoenix, AZ 85007
Governor's DC Office 60215434331
Ms. Judith Pittman Single state Agency Director
2021624-5820 Leonard J. Kirschner, M.D., MPH
Single State Agency Director Director Arizona Health Care Cost Containment
Ms. Carol A. Herrmann System (AHCCCS)
Commissioner 801 East Jefferson Street
Alabama Medicaid Agency Phoenix, AZ 85034
2500 Fairlane Drive 6021234.3655 ext. 4053
Montgomery, AL 361 10 Medicaid Director
2051277-2710 Leonard J. Kirschner, M.D., MPH
R4edica.d Director (see above)
Ms. Carol Herrmann
(see above)
ARKANSAS
Governor
ALASKA Honorable Bill Clinton
Governor Governor of Arkansas
Honorable Steve Cowper State Capitol Building
Governor of Alaska Little Rock, AR 72201
P. 0. Box A 5011682-2345
Juneau, AK 99811-0101 Single state Agency Director
9071465-3500 Mr. Walt Patterson
Governor's DC Office Director
Mr. John Katz Arkansas Dept. of Human Services
2021624-5858 P. 0. Box 1437, 7th and Main Streets
Single State Agency Director Little Rock, AR 72203
Ms. Myra M. Munson 5011682-8650
Commissioner Medicaid Director
AK Dept. of Health & Social Services Mr. Ray Hanley, Director
P. 0. Box H Office of Medical Services
Juneau, AK 99811-0601 Arkansas Dept. of Human Services
9071465-3030 P. 0. Box 1437, Slot 1100
Medicaid Director Little Rock, AR 72203-1437
Ms. Kim Busch 5011682-8292
Director
Div. of Medical Assistance
Dept. of Health & Social Services
P. 0. Box H-07
Juneau, AK 99811-0601
9071465-3355
CAUFORNIA CONNECTICUT
Governor Governor
Honorable George Deukmejian Honorable William A. O'Neill
Governor of California Governor of Connecticut
state Capitol State Capitol
First Floor Hartford, CT 06106
Sacramento, CA 95814 2031566-4840
9161445-0282 Governor's DC Ofice
Governo<s DC Office Ms. Ann L. Sullivan
Mr. Robert J. Moore 2021347-4535
2021347-6894 Single State Agency Director
Single State Agency Director Ms. Lorraine Aronson
Kenneth W. Kier, M.D., MPH Commissioner
Director Dept. of Health Sewices Dept. of Income Maintenance
714 P Street, Room 1253 110 Bartholomew Avenue
Sacramento, CA 95814 Hartford, CT 06106
9161445-1248 2031566-2008
Medicaid Director Medicaid Director
Mr. John Rodriquez Ms. Linda Schofield
Deputy Director Director
Medical Care Semkes Medical Care Administration
Dept. of Health Services Dept. of Income Maintenance
714 P Street, Room 1253 110 Bartholomew Avenue
Sacramento, CA 95814 Hartford, CT 06106
9161322-5824 2031566-2934

COLORADO DELAWARE
Governor Governor
Honorable Roy Romer Honorable Michael N. Castle
Governor of Colorado Governor of Delaware
State Capitol, Room 136 Legislative Hall
Denver, CO 80203 Dover, DE 19901
3031866-2471 3021736-4101
Single state Agency Director Governor's DC Office
Ms. Irene M. lbarra Mr. Goodrich H. Stokes
Executive Director 2021624-7724
Colorado Dept. of Social Services Single State Agency Director
1575 Sherman Street, 8th Floor Mr. Thomas P. Eichler
Denver, CO 80203-1714 Secretary
3031866-5800 DE Dept. of Health 8 Social Services
Medicaid Director 1901 North DuPont Highway
Mr. Gary Toerber New Castle, DE 19720
Director 3021421-6705
Bureau of Medical Services Medicaid Director
Dept. of Social Services Ms. Ruth S. Fischer
1575 Sherman Street, 6th Floor Medicaid Director
Denver, CO 80203-1714 Dept. of Health & Social Services
3031866-5901 Delaware State Hospital
New Castle, DE 19720
3021421-6139
WASHINGTON, D.C. GEORGIA
Mwr Governor
Honorable Marion Barry, Jr. Honorable Joe Frank Harris
Mayor, District of Columbia Governor of Georgia
District Building, Suite 520 State Capitol
1350 Pennsylvania Avenue, N.W. Atlanta, GA 30334
Washington, D. C. 20004 4041656-1776
2021727-6319 Governor's DC Office
Single State Agency Director Ms. Jan Finn
Mr. Peter G. Parham 2021624-5437
Director Single State Agency Director
Dept. of Human Services Mr. Aaron J. Johnson
801 North Capitol Street, Room 700 Commissioner
Washington, D. C. 20002 GA Dept. of Medical Assistance
2021727-0310 2 Martin Luther King, Jr., Drive, SE
Medicaid Director 1220-CWest Tower
Ms. Lee Partridge Atlanta, GA 30334
Chief, Office of Health Care Financing 4041656-4479
D.C. Dept. of Human Services Medicaid Director
1331 H Street, N.W., Suite 500 Mr. Aaron J. Johnson
Washington, D. C. 20005 (see above)
2021727-0735

HAWAII
FLORIDA Governor
Governor Honorable John D. Waihee, Ill
Honorable Bob Martinez Governor of Hawaii
Governor of Florida State Capitol
State Capitol Honolulu, HI 96813
Tallahassee, FL 32399 8081548-5420
9041488-2272 Governor's DC Office
Governor's DC Office Ms. Janice C. Lipsen
Ms. Lynda Davis 20U785-0550
2OU624-5885 Single State Agency Director
Single Smte Agency Director Ms. Winona E. Rubin
Mr. Gregory L. Coler Director
Secretary HI Department of Social Services
FL Dept. of Health & P. 0. Box 339
Rehabilitative Sewices Honolulu, HI 96809
1317 Winewood Boulevard 8081548-6260
Building 2,Room 432 Medicaid Director
Tallahassee, FL 32399-0700 Mr. Earl Motooka
9041488-7721 Administrator
Medicaid Director Health Care Administration Division
Mr. Gary J. Clarke Dept. of Social Services & Housing
Asst. Secretary for Medicaid P. 0. Box 339
Dept. of Health & Rehab. Services Honolulu, HI 96809
1317 Winewood Boulevard 8081548-6584
Building 6,Room 233
Tallahassee, FL 32399-0700
9041488-3560
IDAHO INDIANA
Governor Governor
Honorable Cecil D. Andrus Honorable Evan Bayh
Governor of Idaho Governor of Indiana
State Capitol State Capitol, Room 206
Boise, ID 83720 Indianapolis, IN 46204
208/334-2100 31 71232-4567
single State Agency Director Governor's DC Office
Mr. Richard P. Donovan Mr. Tom Koutsoumpas
Director 202l785-2615
ID Dept. of Health & Welfare Single State Agency Director
State House Ms. Suzanne L. Magnate
Boise, ID 83720 Commissioner
2081334-5500 IN Dept. of Public Welfare
Medicaid Director State Office Building
Mrs. Jean Schoonover 100 N. Senate Avenue, Room 701
Chief, Bureau of Medical Assistance Indianapolis, IN 46204
Dept. of Health &Welfare 31 71232-4705
450 West State Street Medicaid Director
Statehouse Mail Gary Kyzr-Sheeley, Ph.D.
Boise, ID 83720 Director, Medicaid Division
2081334-5794 IN State Dept of Public Welfare
State Office Bldg, Room 702
Indianapolis, IN 46204
ILLINOIS 31 71232-4333
Governor
Honorable James R. Thompson
Governor of Illinois IOWA
State Capitol Governor
Springfield, IL 62706 Honorable Terry Branstad
21 71782-6830 Governor of Iowa
Governor's DC Office State Capitol
Mr. Douglas Richardson Des Moines, IA 50319
2021624-7760 51 51281-5211
Single State Agency Director Governor's DC Office
Ms. Susan S. Suter Mr. Philip C. Smith
Director 2021624-5442
IL Dept. of Public Aid Single State Agency Director
Jesse B. Harris Bldg. II, 3rd Floor Mr. Charles M. Palmer
I00 S. Grand Avenue, East Director
Springfield, IL 62762 IA Dept. of Human Services
21 71782-6716 Hoover State Office Bldg.
Medicaid Director 5th Floor
Mr. Tim Claborn Des Moines, IA 5031 9
Administrator 51 51281 -5452
Division of Medical Programs Medicaid Director
IL Dept, of Public Aid Mr. Donald Herman
201 South Grand Avenue, East Chief, Bureau of Medical Services
Springfield, IL 62743-0001 Dept, of Human Sewices
21 71782-2570 Hoover State Office Bldg, 5th Floor
Des Moines, IA 50319
51 51281-8794
KANSAS LOUISIANA
Governor Governor
Honorable John Michael Hayden Honorable Buddy Roemer
Governor of Kansas Governor of Louisiana
State Capitol Building State Capitol, P. 0. Box 94004
Topeka, KS 66612 Baton Rouge, LA 70804
9131296-3232 5041342-7015
Governor's DC Office Governor's DC Office
Ms. Jennifer S. Stradinger Mr. James A. Burns
2021785-6966 2021624-8195
Single State Agency Director Single State Agency Director
Mr. Winston Barton Mr. David L. Ramsey
Secretary Secretary
KS Dept. of Social & Dept. of Health & Hospitals
Rehabilitation Services P. 0.Box 3776
Docking State Office Building Baton Rouge, LA 70821
6th Floor 5041342-671I
Topeka, KS 66612 Medicaid Director
91312963271 Ms. Carolyn Maggio
Medicaid Director Director
Ms. L. Kathryn Klassen, R.N., MS. Bureau of Health Service Finance
Director P. 0. Box 91030
Medical Services Division Baton Rouge, LA 70821-9030
Dept. of Social & Rehab. Services 5041342-3891
n ~ Office Building
~ 6 c k i State
Room 628-S
Topeka, KS 66612 MAINE
91312963981 Governor
Honorable John R. McKernan, Jr.
Governor of Maine
KENTUCKY State House, Station 1
Governor Augusta, ME 04333
Honorable Wallace G. Wilkinson 2071289-3531
Governor of Kentucky Governor's DC Office
State Capitol Mr. Donald R. Larrabee
Frankfort, KY 40601 2021638-5865
5021564-2611 Single State Agency Director
Governor's DC Office Mr. Rollin lves
Ms. Linda Breathin Commissioner
2021624-7741 ME Dept. of Human Services
Single State Agency Director 221 State Street
Mr. Roy Butler State House, Station 11
Commissioner Augusta, ME 04333
Dept. of Medicaid Services 2071289-2736
275 East Main Street Medicaid Director
Frankfort, KY 40621 Ms. Elaine Fuller
5021564-4321 Director
Medicaid Director Bureau of Medical Services
Mr. Roy Butler Dept. of Human Services
(see above) State House, Station 11
Augusta, ME 04333
20712892674
MARYLAND MICHIGAN
Governor Governor
Honorable William Donald Schaefer Honorable James J. Blanchard
Governor of Maryland Governor of Michigan
State House State Capitol
~nnapolis,MD 21401 Lansing, MI 48909
3011974-3901 5171373-3423
Governor's Dc Office Governor's DC Office
Ms. Monica Healy Mr. E. Douglas Frost
20216382215 2021624-5840
Single State Agency Director Single State Agency Director
Ms. Adele Wiback, R.N., MS. Mr. C. Patrick Babcock
Secretary Director
MD Dept. of Health & Mental Hygiene MI Dept. of Social Services
Herbert R. O'Connor Bldg. P. 0. Box 30037
201 West Preston Street Lansing, MI 48909
Baltimore, MD 21201 5171373-2000
3011225-6500 Medicaid Director
Medicaid Director Mr. Kevin Seitz
Mr. Nelson Sabatini Director, Medical Services Admin.
Deputy Secretary Dept. of Social Services
Health Care Policy, Finance & Regul. P. 0.Box 30037
Dept. of Health & Mental Hygiene Lansing, MI 48910
201 West Preston Street, Rm. 525 5171334-7262
Baltimore, MD 21201
3011225-6535
MINNESOTA
Governor
MASSACHUSETTS Honorable Rudy Perpich
Governor Governor of Minnesota
Honorable Michael S. Dukakis State Capitol
Governor of Massachusetts St. Paul, MN 55155
Executive Office, State House 6121296.3391
Boston, MA 02133 Governor's DC Office
6171727-9173 Ms. Barbara Rohde
Governor's DC Office 2021624-5308
Mr. Mark Gearan Single State Agency Director
2021624-7713 Ms. Sandra Gardebring
Single State Agency Director Commissioner
Ms. Carmen S. Canino-Siegrist MN Dept. of Human Services
Commissioner 444 Lafayette Road, 2nd Floor
Dept. of Public Welfare St. Paul, MN 55155-3815
180 Tremont Street 612/296-2701
Boston, MA 02111 Medicaid Director
6171574-0200 Mr. Robert Baird
Medicaid Director Director
Mr. Bruce M. Bullen Health Care Programs Division
Associate Commissioner for Medical Payments Dept. of Human Services
Dept. of Public Welfare 444 Lafayette Road, 6th Floor
180 Tremont Street, 13th Floor St. Paul, MN 55155-3848
Boston, MA 02111 6121296.2766
6171574-0205
MISSISSIPPI MONTANA
Governor Governor
Honorabie Ray Mabus Honorable Stan Stephens
Governor of Mississippi Governor of Montana
State Capitol State Capitol
Jackson, MS 39205 Helena, MT 59620
601/3593150 406144431 11
Governor3 DC Office Single Srate Agency Director
Mr. William Simpson Ms. Julia Robinson
202/452-1003 Director
Single State Agency Director MT Dept. of Social &
J. Clinton Smith, M.D. Rehabilitation Services
Director, Div. of Medicaid P. 0. Box 4210
Office of the Governor 11ISanders
Robert E. Lee Building Helena, MT 59604
239 North Lamar Street, Room 801 4061444-5622
Jackson, MS 39201-1311 Medciadi Director
6011359-6050 Mr. John Donwen
Medim-d Director Acting Administrator
J. Clinton Smlh, M.D. Economic Assistance Division
(see above) Dept. of Social & Rehab. Services
P. 0. Box 4210
Helena, MT 59604
MISSOURI 4061444-4540
Governor
Honorable John Ashcroft
Governor of Missouri NEBRASKA
State Capitol Governor
P. 0. Box 720 Honorabie Kay A. Orr
Jefferson City, MO 65102 Governor of Nebraska
31417513222 P. 0. Box 94848
Governor's DC Office Lincoln, NE 68509
Ms. Marise Stewart 402/471-2244
2021624-7720 Single Slate Agency Director
Single State Agency Director Kermit R. McMurry, Ph.D.
Mr. Gary Stangler Director
Director NE Dept. of Social Services
MO Dept. of Social Services 301 Centennial Mall South
P. 0. Box 1527 5th Floor
Jefferson City, MO 65102 Lincoln, NE 68509
3141751-4815 4021471-3121
Medicaid Director Medicaid Director
Ms. Donna Checkett Mr. Robert Seiffert
Director Administrator
Division of Medical Services Medical Services Division
Dept. of Social Services Dept. of Social Services
P. 0. Box 6500 5th Floor
Jefferson City, MO 65102 301 Centennial Mail South
3141751-6529 Lincoln, NE 68509
4021471-9330
NEW JERSEY
Governor Governor
Honorable Robert J. Miiier Honorable Thomas H. Kean
Governor of Nevada Governor of New Jersey
state CapLol State House CN-001
Carson City, NV 89710 Trenton, NJ 08625
7021885-5670 6091292-6000
&nernofs DC Olfice Governofs DC Office
Mr. R. Leo Penne Ms. Alice Tetelman
202/624-5405 2021638-0631
singe State Agency Director Single State Agency Director
Mr. Jerry Griepentrog Drew Aitman, Ph.D.
Director Commissioner
NV Dept, of Human Resources NJ Dept. of Human Sewices
Kinkead sldg. - Capitol Complex Capitol Place One CN-700
505 East King Street, Rm. 600 222 South Warren Street
Carson City, NV 89710 Trehton, NJ 08625
70218854730 6091292-3717
dM
a
ice
d
i Director Medicaid Director
Ms. April Heff Mr. Saul M. Kilstein
Deputy Administrator Director
NV Medicaid, Welfare Division Div. of Medical Assistance & Health Services
Dept. of Human Resources Dept. of Human Sewices
2527 North Canon Street CN-712, 7 Quakerbridge Plaza
Carson City, NV 89710 Trenton, NJ 08625
702/885-4378 6091588-2602

NEW HAMPSHIRE NEW M W C O


Gwemor Governor
Honorable Judd Gregg Honorable Garrey Carruthers
Governor of New Hampshire Governor of New Mexico
State House State Capitol
Concord, NH 03301 Santa Fe, NM 87503
6031271-2121 Single State Agency Director
Single W e Agency Director Mr. Alex Valdez
Ms. M. Mary Mongan Cabinet Secretary
Commissioner Human Services Dept.
NH Dept. of Health & Human Services P. 0. Box 2348
6 Hazen Drive PERA Building, Room 301
Concord, NH 03301-6521 Santa Fe, NM 87504-2348
6031271-4331 5051827-4072
Medicaid Director Medicaid Director
Mr. Philip Soule', Sr. Vacant
Administrator Contact: Mr. Larry Martinez
Office of Medical Sewices Chief, Program Support Bureau
NH Div. of Human Services Dept. of Human Services
Dept. of Health & Human Services P. 0. Box 2348
6 Hazen Drive Santa Fe, NM 87504-2348
Concord, NH 03301-6521 5051827-4315
6031271-4353
NEW YORK NORTH DAKOTA
Governor Governor
Honorable Mario Cuomo Honorable George Sinner
Governor of New York Governor of North Dakota
Executive Chamber State Capitol, Ground Floor
State Capitol Bismarck, ND 58505
Albany, NY 12224 7011224.2200
5181474-7516 Single State Agency Director
Garemor's DC Office Mr. John Graham
Mr. Brad Johnson Executive Director
2021638-1311 ND Dept. of Human Services
Single State Agency Director State Capitol, Judicial Wing
Mr. Cesar A. Perales 600 East Boulevard
Commissioner Bismarck, ND 58505
NY State Dept. of Social Services 7011224-2310
Ten Eyck Office Building Medicaid Director
40 North Pearl Street Mr. Richard Myatt
Albany, NY 12243 Director, Medical Services
5181474-9475 ND Dept. of Human Services
Medicaid Director State Capitol, Judicial Wing
Ms. JoAnn A. Costantino 600 East Boulevard
Dep. Comm., Div. of Medical Assistance Bismarck, ND 58505-0251
State Dept. of Social Services 701/2242321
Ten Eyck Office Building
40 North Pearl Street
Albany, NY 12243-0001 OHIO
5181474-9123 Governor
Honorable Richard F. Celeste
Governor of the State of Ohio
NORTH CAROLINA 77 South High Street
Governor 30th Floor
Honorable James G. Marlin Columbus, OH 43266-0601
Governor of North Carolina 61414664555
State Capitol Governor's DC Office
Raleigh, NC 27603 Mr. Gary Falle
9191733-5811 20216245844
G m r n d s DC Office Single State Agency Director
Ms. Karen Robert Ms. Patricia K. Barry
2021624-5630 Director, OH Dept. of Human Services
Single State Agency Director 30 East Broad Street
Mr. David Flaherty 32nd Floor
Secretary, Dept. of Human Resources Columbus, OH 43266-0423
325 N. Salisbuly Street 6141466-6282
Raleigh, NC 27611 A4edica.d Director
919/73-4534 Paul Offner, Deputy Director
Medicaid Director Benefits Administration
Ms. Barbara Matula Medicaid Administration
Director, Div. of Medical Assistance Dept. of Human Services
Dept. of Human Resources 30 East Broad Street, 31st Floor
1985 Umstead Drive Columbus, OH 43266-0423
Raleigh, NC 27603 6141466-3196
9191733-2060
OKLAHOMA PENNSYLVANIA
Governor Governor
Honorable Henty Bellmon Honorable Robert P. Casey
Governor of Oklahoma Governor of Pennsylvania
212 State Capitol 225 Main Capitol Building
Oklahoma City, OK 73105 Harrisburg, PA 17120
4051521-2342 7171787-2500
Single State Agency Director Governor's DC Office
Mr. Phil Watson Mr. Philip Jehle
Director 2021624-7828
OK Dept. of Human Services Single State Agency Director
p. 0. Box 25352 Mr. John White
Oklahoma City, OK 73125 Secretary
40515213646 Dept. of Public Welfare, Room 333
Medicaid Director Health & Welfare Building
Mr. Charles Brodt Harrisburg, PA 17120
Assistant Director 717/7874600
Division of Medical Services Medicaid Director
Dept, of Human Services Ms. Eileen M. Schoen
P. 0. Box 25352 Deputy Secretary
Oklahoma City, OK 73125 Medical Assistance Programs
405/557-2539 Room 515
Dept. of Public Welfare
Health & Welfare Building
Harrisburg, PA 17120
OREGON 7171787-1870
Governor
Honorable Neil Goldschmidt
Governor of Oregon RHODE ISLAND
State Capitol Governor
Salem, OR 97310 Honorable Edward D. DiPrete
50313784344 Governor of Rhode Island
Single State Agency Director State House
Mr. Kevin Concannon Providence, RI 02903
Director 4011277-2080
Dept. of Human Resources Single State Agency Director
318 Public Service Building Ms. Nancy V. Bordeleau
Salem, OR 97310 Director
50313783034 RI Dept. of Human Services
Medicaid Director Aime J. Forand Building
Ms. Jean I. Thorne 600 New London Avenue
Assistant Administrator Cranston, RI 02920
Adult & Family Services Division 4011464-2121
Dept, of Human Resources Medicaid Director
203 Public Service Building Mr. Anthony Barile
Salem, OR 97310 Associate Director
5031378-2263 Division of Medical Services
Dept. of Human Services
Aime J. Forand Building
600 New London Avenue
Cranston, RI 02920
4011464-3575
SOUTH CAROUNA TENNESSEE
Governor Governor
Honorable Carroll A. Campbell, Jr. Honorable Ned McWherter
Governor of South Carolina Governor of Tennessee
P. 0. Box 11369 State Capitol
Columbia, SC 29211 Nashville, TN 37219
8031734-9818 6151741-2001
Governor's DC Office Single State Agency Director
Ms. Nikki McNamee Mr. J. W. Luna
2021624-7784 Commissioner
Single Stare Agency Director TN Dept. of Health & Environment
Eugene A. Laurent, Ph.D. 344 Cordell Hull Building
Executive Director Nashville, TN 37219
SC State Health & Human Services 6151741-3111
Finance commission Medicaid Director
P. 0. Box 8206 Mr. Manny Martins
Columbia, SC 29202-8206 Assistant Commissioner & Director
80312536100 Bureau of Medicaid
Medicaid Director Dept. of Health & Environment
Ms. Gwendolyn G. Power 729 Church Street
Deputy Executive DirectoriPrograms Nashville, TN 37219
Health & Human Services 6151741-0213
Finance Commission
P. 0. Box 8206
Columbia, SC 29202-8206 TEXAS
8031253-6100 Governor
Honorable William Clements, Jr.
Governor of Texas
SOUTH DAKOTA State Capitol
Governor Austin, TX 78711
Honorable George S. Mickelson 5121463-2000
Governor of South Dakota Governor's DC Office
500 East Capitol Mr. Henry Gandy
Pierre, SD 57501 2021488-3927
6051773-3212 Single State Agency Director
Governor's DC Office Mr. Ron Lindsay
Mr. Thomas Kindness Commissioner
2021429-6060 Dept, of Human Services
Single State Agency Director P. 0. Box 149030
Mr. James W. Ellenbecker Austin, TX 78714-9030
Secretary 5121450-3011
SD Dept. of Social Services Medicaid Director
Kneip Building, 700 Governor's Drive Dr. Donald Kelley
Pierre, SD 57501-2291 Deputy Commissioner
6051773-3165 Health Care Services
Medicaid Director Dept. of Human Services
Mr. Ervin Schumacher P. 0. Box 149030
Program Administrator, Medical Services Austin, TX 78714-9030
Dept. of Social Services 5121450-3050
Kneip Building, 700 Governor's Drive
Pierre, SD 57501-2291
6051773-3495
VIRGINIA
Goyemor Governor
Honorable Norman H. Bangerter Honorable Gerald L. Baliles
Governor of Utah Governor of Virginia
state Capitol State Capitol
Salt Lake City, UT 84114 Richmond, VA 23219
8Ol/538-lOOO 8041786-2211
overn nor's D C Offce Governor's DC Ofice
Ms. Deborah Turner Mr. Stewart Gamage
Single State Agency Director 202l783-1769
Suzanne Dandoy, M.D., MPH Single State Agency Director
Executive Director Ms. Eva S. Teig
Utah Dept. of Health Secretary
P, 0. Box 16700 Health & Human Resources
Salt Lake City, UT 841 16-0700 P. 0. BOX 1475
8011538-6111 Richmond, VA 23212
Medicaid Director 8041786-7765
Mr. Rod Betit Medicaid Director
Director Mr. Bruce Kozlowski
Division of Health Care Financing Director
UT Dept. of Health VA Dept. of Medical Assistance Services
P. 0. Box 16580 600 East Broad Street, Room 1300
Salt Lake City, UT 84116-0580 Richmond, VA 2321 9
8011538-6151 8041786-7933

VERMONT WASHINGTON
Governor Governor
Honorable Madeleine M. Kunin Honorable Booth Gardner
Governor of Vermont Governor of Washington
Pavilion Office Building Legislative Building
Montpelier, VT 05602 Olympia, WA 98504
8021828-3333 2061753-6780
Single Slate Agency Director Single State Agency Director
Ms. Gretchen B. Morse Mr. Dick Thompson
Secretary Secretaty
VT Agency of Human Services WA Dept. of Social & Health Services
103 South Main Street 12th & Franklin, Mail Stop 08-44
Waterbury, W 05676 Olympia, WA 98504
8021241-2220 2061753-3395
Medicaid Director Medicaid Director
Mr. Elmo A. Sassorossi Mr. Ron Kero
Director Director
Division of Medicaid Division of Medical Assistance
Dept. of Social Welfare Gept. of Social & Health Services
Vl Agency of Human Services 12th & Franklin, Mail Stop HB-41
103 South Main Street Olympia, WA 98504
Waterbury, Vl 05676 2061753-1777
8021241-2880
WEST VIRGINIA WYOMING
Governor Governor
Honorable Gaston Caperton Honorable Mike Sullivan
Governor of West Virginia Governor of Wyoming
State Capitol State Capitol
Charleston, WV 25305 Cheyenne, WY 82002
3041340-1600 3071777-7434
Single State Agency Director Single State Agency Director
Mr. Nicholas R. DeMarco R. Larry Meuli, M.D.
Interim Bureau Administrator Administrator
Bureau of Medical Services WY Dept. of Health Services
WV Dept. of Human Services 2300 Capitol Avenue
1900 Washington Street, East Hathaway Building, 4th Floor
Charleston, WV 25305 Cheyenne, WY 82002
3041348-8990 3071777-7121
Medicaid Director Medicaid Director
Ms. Helen Condry Mr. Kenneth C. Kamis
Director Director
Division of Medical Care Medical Assistance Services
WV Dept. of Human Services Dept. of Health & Social Services
1900 Washington Street, East Hathaway Building, 4th Floor
Charleston, WV 25305 Cheyenne, WY 82002
3041348-8990 3071777-7531

WlSCONSlN
Governor
Honorable Tommy G. Thompson
Governor of Wisconsin
State Capitol
Madison, WI 53702
6081266-1212
Governor's DC Office
Mr. David Beightol
202/624-5870
Single State Agency Director
Ms. Patricia Goodrich
Secretary
WI Dept. of Health & Social Services
1 West Wilson Street
Room 650
P. 0. BOX7850
Madison, WI 53707
6081266-3681
Medicaid Director
Ms. Christine Nye
Director, Bureau of Health Care Financing
Division of Health
WI Dept. of Health & Social Services
P. 0. Box 309
Madison, WI 53701
6081266-2522
Department of Health and Human recognizes for drug reimbursement or Medicaid State agency's best estimate
SSMC~S payment purposes will not exceed the of the price generaity paid by providers)
lowest of- plus a reasonable dispensing fee; or
~ ~ a lCare
t h Financing Administration 0 The maximum allowable cost (MAC) The provider's usual and customary
42 CFR Pats 413, 430, and 447 of the drug, as estabiished by HCFA's charge to the pubiic for the drug.
Pharmaceutical Reimbursement Board The Medicaid reguiations also provide
45 CFR Pats 1 and 19 for certain mukiple source drugs that the MAC will not apply if the
[BEw-w (generic drugs), plus a reasonable prescriber has certified in his own
dispensing fee; handwriting that a celtain brand of that
Medicare and Medicaid Programs; O The estimated acquisition cost (EAC) drug is medically necessary for the
timits on Payments for Drugs; of the drug (the price generally and patient.
AGENCY: Health Care Financing currently paid by providers for a
B. Problems and Concerns
Administration (HCFA), HHS. drug in the package size most
frequently purchased by providers), as in 1983, a Departmental Task Force
ACTION: Final rule. determined by the program agency, was established to review the
plus a reasonable dispensing fee; or Department's drug reimbursement
s U M W . This rule eliminates current 0 The provider's usual and customary regulations at 45 CFR Part 19. Specific
Departmental procedures for setting charge to the pubiic for the drug. concerns presented to the Task Force
limits on payments for drugs supplied The regulations provide that the MAC included-
under certain Federal health programs; wiil not apply if the prescriber has The quality of muhipie source drugs;
certified in his own handwriting that a 0 The interpretation of Widely and
and revises Medicaid rules concerning
the methodology for determining upper specific brand of that drug is medically consistently available' as related to the
limits for drug reimbursement. This rule necessary for the patient. The process used by the PRB in setting
enables the Federai and State regulations at 45 CFR Part 19 aiso MAC iimits;
governments to take advantage of establish within HCFA a Pharmaceutical The adequacy of drug reimbursement;
savings that are currently available in Reimbursement Board (PRB). The PRB and
the marketplace for multiple source identifies multiple source drugs for O Problems in administering the MAC

drugs. It aiso maintains State flexibility which significant amounts of Federai and EAC programs (for example, the
in the administration of the Medicaid funds are or may be expended and is short time that the Medicaid agencies
program. responsible for estabiishing the MAC for have to implement MAC limits once they
those drugs. The process by which a become effective, and the lack of a
E F E C M E D A E The reguiations are MAC is established includes PRB mechanism for raising the MAC limits
eflective October 29, 1987. State
~ -
aaencies have 90 days from the
publication date of this regulation until
consultation with the Food and Drug
Administration (FDA), opportuniw for
quickly when necessary due to changes
in the market).
We agree that the process of approving
pubiic comment on a proposed notice
the effective date in which to submit a of the MAC limit published in the a MAC for a specific drug is lengthy.
State plan amendment and the required This has been of concern parlicularly
Federal Register, a pubiic hearing, and
attachment. publication of the final MAC since the passage of the Drug Price
FOR FURTHER INFORMATION determination in the Federai Register. Competition and Patent Term Extension
CONTACT: Anthony Lovecchio, (301) The PRB sets the MAC at the lowest Act of 1984 (Pub. L. 98417). This law
5944010. unit price at which the drug is widely streamlines the FDA approval process
and consistently available. In addition to for certain drugs. The resuit of this law
SUPPLEMENTARY INFORMATION: limiting the level of payment for multiple is that therapeutically equivalent
L Background source drugs, the MAC program tends (generic) drugs wiil be coming into the
to promote substitution of lower cost marketplace more quickly than in the
A. Existing System
(generic) drug products for brand-name past. As evidenced by the current MAC
In 1976, the Department implemented drugs, since the latter are frequently program, we are interested in
drug reimbursement rules at 45 CFR available only at prices higher than the encouraging the use of therapeutically
Part 19 under the authority of statutes MAC limits. equivaient drugs. We would like to
pertaining to upper payment limits for Similar to the Department reguiations adopt a Medicaid drug policy that would
Medicaid and other programs. The (45 CFR Part 19) that set limits to allow us promptly to adjust payment
authoii to set an upper payment limit Federal payments for drugs are the upper limits to reflect the availability of
for sewices available under the Medicaid regulations at 42 CFR 447.331 new drug equivalents as they enter the
Medicaid program is provided under through 447.334. The regulations at marketplace. Bssed on the concerns
section 1902(a)(30)(A) of the Social 50447.331 through 447.334 limit the addressed above and the Deparlment's
S e c u i i Act. amounts that State Medicaid agencies desire to take advantage of savings that
The Department rules are intended to may ciaim for Federai matching are currently available in the
ensure that the Federai government acts purposes under the Medicaid program. marketplace for mukipie source drugs,
as a prudent buyer of drugs under These limits are the same as those we published a Notice of Proposed
certain Federal health programs. The specified in 45 CFR Part 19. Thus. the Ruiemaking (NPRM) on August 19,1986
Set limits on payments for drugs Medicaid agency must ciaim no more (51 FR 29560). The NPRM announced
supplied under Medicaid and other for each drug than the lowest of - proposed revisions to our procedures
Programs. M the Federal programs 0 The MAC of the drug, as established for estabiishing upper limits for drug
imolved, these rules have the greatest by the HCFA PRB for certain mukiple payments and provided a Wday public
impact on the Medicaid program. source drugs, plus a reasonable comment period. On September 18,
Specifically, these regulations provide dispensing fee; 1986, we published a second notice in
that -the amount the Department O The EAC of the drug (that is, the the Federal Register (51 FR 33086)
announcing an extension of the Incentive Program, a proposed revision EAC plus a dispensing fee, or the
comment period, the availability of new of the existing MAC program, and the provider's usual and customary charge
data to anyone wishing to perform an Competitive incentive program. to the general public, whichever is $
independent review and analysis, and lower.
clarifications to the proposal.
A. Pharmacists'Incentive Program (PhlP)
As proposed, PhlP wouid have
We proposed that the MAC program be
operated directly by HCFA rather than
$a
I!. Provisions of the Propmed
replaced the current Federai MAC under a special board. We aiso
i
Regulations program for multiple source drugs. proposed to continue to use much of
We proposed to remove the Other drugs would continue to be paid the current process for establishing MAC
Departmental ruies at 45 CFR Part 19 the EAC or the provider's usual and iimits. We would continue to publish the
that limit drug reimbursement under customary charge to the general public, proposed MAC limits in the Federai
certain Federai health programs whichever is lower. Register; utilize a comment period: and
including Medicaid, Medicare. Public We proposed to base PhlP on a attar considering all of the comments,
HeaRh Service (for example, Indian specific formula that would establish publish the finai notice in the Federai
Health Services), and other payment levels above which Federai Register. However, the process would
Departmental grantees. We proposed financial participation (FFP) wouid not be shortened by not conducting a
the removal of these ruies because they be recognized. A PhlP limii wouid be public hearing before the PRB and
have little impact upon programs other estabiished only for those muitiple eliminating the requirement for specific
than Medicaid and because similar rules source drugs for which: (1) Ali of the PRB consultation with FDA for each
exist in the Medicaid regulations. In the formuiations of the drug approved by drug.
NPRM, we noted that to the extent that FDA have been evaiuated as We proposed three new requirements
specific iimits are useful for those other therapeutically equivalent; and (2) at that we wouid consider before
programs, other authorities exist for least three suppliers adverlise the drug establishing a MAC limit. The first
applying the limits. We aiso proposed (which has been classified by the FDA requirement wouid be that ail of the
three akernative approaches to the as category "A' in the FDA's therapeutic formuiations of the drug approved by
current Medicaid rules (42 CFR 447.331 equivalence evaluations publication) in the FDA have been evaiuated as
through 447.334) regarding upper iimits either the Red Book or Blue Book, therapeutically equivaient. The second
far drug reimbursement and invited whichever we wouid choose to use. We requirement would be that at least three
public comment on all three as well as proposed that the PhlP limA be set at sumliers advertise the drua (which has
suggestionsfor alternatives which would 150 percent of the lowest priced be& classified by the FD& ' category
improve any of the three, inciuding multiple source drug advertised in the 'A' in the FDA's therapeutic equivalence
possible combinations of options. The Red Book or Blue b o k , whichever is evaluations Dubiicationl in theked Book
three approaches were intended to lower. Thus, the pharmacist couid be or Blue Bodk. Finally, we specified that
enable the Medioaid program to take reimbursed the ingredient costs of a we wouid expect to reduce total State
advantage of the savings available in drug at 150 percent of the lowest priced and Federal Medicaid expenditures by
the marketplace for therapeutically multiple source drug plus the at least $50,000 annuelk for any drug
equivalent multiple source drugs. We State-established dispensing fee. in for which a MAC limit is to be
proposed that all three approaches order to ensure that the PhlP upper established.
wouid be subjectto'physician override'. limits for muitiple source drugs wouid We specified in the proposed
This means that the upper limits be reasonable for extremely low cost regulations that we would survey drug
established for multiple source drugs and high cost drugs, we proposed to wholesalers for assurances that they: (1)
wouid not apply if the prescribing set minimum and maximum markups. Are carrying the muitiple source
physician certifies that a brand name We proposed a minimum markup of products at or beiow the proposed MAC
drug is medically necessary. $1.50 over the cost of the least costlv iimits; or (2) would carry the products in
We stated that under the finai rule, advertised drug product and a the event that limits are estabiished. We
which wouid adopt one of these maximum markup of $4.00 over the cost also stated that, initially, we would
a~~roaches. State aclencies wouid be of the ieast costly adverlised drug conduct surveys to determine the prices
required for purp&es of Federai product. While PhlP would reimburse at which the multiple souroe drugs that
financial participation (FFP) to adhere to drug ingredients at a rate that is slightly meet the MAC criteria are widely and
the upper iimits set by the adopted above the lowest cost at which they consistentiy available.
approach. However, in accordance with may be obtained, it would have the in order to provide some flexibility in
State flexibility in the administration of advantages of being easily the MAC iimits, we proposed to waive
the Medicaid program, a State agency administrable (once drug prices are specific MAC iimits in a State upon the
wouid be permitted to utilize an obtained), easily updated for new drug State Medioaid agency's request and
alternative drug reimbursement system prices, and likely to produce substantial demonstration that the volume of the
if aggregate payments under that savings for the Medicaid program. drug in that State is too low to justify
system would not exceed the upper administering the limit or that there are
B. Revisions to the MAC Program
limits set by the adopted approach. availabili problems in that State for
Specifically, the maximum amount of We alternatively proposed to apply that particular product under the MAC
State drug expenditures that would MAC limits to drugs purchased under limit. We also proposed to suspend or
qualify for FFP could not exceed, in the the Medicaid program using a revised raise temporarily a MAC iimit if the
aggregate, the upper limit of payment process. Under that process, we product becomes unavailable at or
for certain drugs described in listings proposed to eliminate the PRB and to beiow the iimit.
established by HCFA under the streamline the procedures for
establishing MAC limits for selected C. Competitive Incentive Program (CIP)
approech adopted under the final rule.
The three approaches are discussed multiple source drugs. Mher drugs As proposed, CIP wouid have replaced
below and include the Pharmacists' would continue to be paid for at the the current MAC and EAC programs.
Under CiP, the starting point for decided that prescribing a preferred should be allowed to design and
establishing an upper limit for payment method would be unnecessary develop their own payment systems, in
,imbursement for all drugs would be and counterproductive. Instead, we order to respond to Stateapecitic
the price that the pharmacy charges decided that encouragement of State marketplace economics; and, Federal
p&ate retail customers for that drug, at flexibility is the most important aspect of regulations should be kept to a
that time, and in that quantity. Because reform in terms of avoiding disruption minimum. Commenters were concerned
~p payment wouid be based on the and bringing drug payments into that unnecessary Federal regulation
pharmacist's retail charge, Medicaid conformance with the flexibility we allow would restrict price competition and
would participate in the retail States for other Medicaid services, in stifle State innovation in the area of
pharmaceutical market in a way similar addition to this general conclusion, each payment policies and practices. Further.
to that of a pharmacy's non-Medicaid option had significant weaknesses. commenters were concerned that the
customer or third party payor. CIP We have decided to eliminate the PhlP, proposais would limit the ability of State
would depend upon the competitive CIP and MAC revisions as proposed. agencies to monnor timely changes in
market place to regulate prices. We decided to eliminate the MAC drug availability, costs and usage
Under CIP, we proposed to appiy a requirements because of the patterns, as well as the ability to react to
mandatory discount to the pharmacist's commenters and our concerns that the these changes. The commenters
retail charge and a screen of charges to MAC rate setting process is too lengthy indicated that these issues are problems
protect the Medicaid program from and time consuming. We determined experienced by State agencies under
excessive oharges. The mandatoiy that MAC wouid not achieve timely the current regulations and expressed
discount on leading brand name drugs budget savings, simplified program the desire to avoid continued Federal
would be greater than the discount administration, or increased State intrusion into existing programs that
applied to other drugs. Thus, an flexibility in the design and operation of have proven to be cost-effective and
incentive would be created for the drug payment systems. innovative.
pharmacist to use non-brand multiple We did not implement CIP as Response: Although it was not readily
source drugs (generics). discussed in the NPRM due to the apparent judged by the tenor of the
We proposed that the mandatory consensus expressed bv many State comments, we had intended to provide
discount on leading brand name and agencies regarding administrative costs State Medicaid agencies with increased
multiple source drugs would appiy only and implementation problems. However, flexibility through the proposed rule. We
to certain drugs. These wouid be drugs in the context of State flexibilitv, we are proposed to establish an upper limit
for which: (1) All of the tormuiations of allowing State agencies to use the CIP standard that would permit a State
the drug approved by the FDA have concept of competitive pricing should agency to design and operate, or
been evaluated as therapeutically the State select this option. maintain the current operation of, its
equivalent; and (2) at least three For the purpose of determining an own payment system. The responsibility
suppliers adveltise the drug (which has aggregate limit to ,State spending (but of the State agency would be to make a
been olassified bv the FDA as catesow- . not as a payment method for individual finding that the maximum amount of
'A' in the FDA's therapeutic equivalence prescriptions), we are adopting that part State drug expendhures that would
evaluations publication) in the Red Book of PhlP that relates to the formula quality tor FFP could not exceed, in the
or Blue Book. concept for setting upper limits for aggregate, the upper limit payment level
In the notice published on September mukiple source drugs because it is the established by HCFA under the final
18, 1986, we clarified the proposal and least burdensome administratively for rule. This approach would allow State
proposed further alternatives relating to HCFA and the State agencies, responds agencies to maintain control over their
the screen of oharges under CIP. to changes in drug pricing so that pharmaceuticalreimbursementprograms
Medicaid program payments will reflect while providing the Federal government
Ill. Discussion of Comments
savings achievable from lower price needed oversight and control of
We received approximately 123 tirnely multiple source drugs, and is readily expenditures. In order to claity our
items of correspondence in response to updated. Furthermore, by setting an intent, we are revising the language we
the proposed notice. The mmmenlers aggregate iimit for multiple source had proposed.
represented trade associations, drugs, we believe that we can provide Comment: Several commenters argued
manufacturers, State pharmacy more than adequate flexibility to States that HCFA could save $324 million in
associations, State agencies and drug to use payment standards that reflect combined State and Federal
stores. In general, comments were the prices and avaiiabiiity of particular expenditures tor prescription drugs
negative to portions of all three drugs. Additionaiiy, as we stated in the between 1986 and 1990 as the resuit of
proposals. For example, regarding the NPRM, based on a study of the 60 patents expiring on several drugs, and
CIP proposal, 35 of the 39 State entities that would be iisted initially, we that no regulatory action was, therefore.
agencies responding indicated that CiP can be assured of an adequate supply necessary to achieve our savings
wouid be costk from an administrative of the product at or below the iimit We objectives.
viewpoint. Regirding PhiP, some State note that this list of 60 entities includes Response: As discussed in section
agencies questioned the use of the Red those drugs for which a current MAC V.E.3.of this preamble, implementing
~ i o kand Blue Book, stating that iimit has been established. the 150 percent aggregate limit on iisted
average wholesale prices listed in these A summary of the comments and our drugs is estimated to save
publications are often overstated. With responses to them follows. approximately $270 million over the next
respect to the MAC proposal, f i e years, taking into account drugs
A. State Flexibiiity
commenten indicated that the MAC rate coming off patent and allowing for
hefting process would remain a time Comment: The predominant themes physician certification of brand named
consuming and burdensome process. expressed by the commenters were: The products as being medically necessary.
Atler review of all comments and further proposed rules were unnecessarily We doubt whether States and HCFA
deliberation within the Depaltment, we intrusive; the Medicaid State agancies wouid be assured of realizing those
savings, or the savings that commenters the basis for the approval of the State implementing aggregate upper limit
estimate, without the kind of limits we plan. The agency findings will be standards on the State's Medicaid
are implementing in this rule. We monitored through State assessments payments (expenditures) for drugs, a
believe that these limits will not operate and other evaluations or auditing State will have the ability to make
to constrain dispensing or pricing ~rocedures to review the State payment at levels above the specific
behavior and it is both appropriate and documentation underlying the assurance standard for certain drugs, provid;d that
necessary to establish upper payment without the need for specialized annual the agency makes the payment at levels
limits in order to ensure that program reporting by the States. Consistent with below the specific standard for other
payments reflect the savings available other aspects of the Medicaid program, drug products. This added State
from lower cost therapeutically if HCFA finds a problem with a State's flexibility will virtually guarantee
equivalent drugs. assurance. HCFA can request the State widespread availability of all affected
to provide data to support its assurance drugs provided that the State agency
8. Stafe Plans and, if aDpropriate. HCFA wiil disallow can determine that in the aggregate for
Comment: Many commenters thought FFP or consider whether the State ought those drugs, the State achieved savings
that ifa State agency wished to use an to be subject to the statute's compliance equal to or greater than the HCFA
alternative payment system to the one procedures. upper limit standard.
that would be established as the upper In reference to the quality of those
C. Implementation of PhlP or CIP
limit standard, the agency would have muRiple source drugs to which we will
to secure a program waiver under the Comment: Many commenters expressed apply the 150 percent markup, we
provisions of section 1915 of the Act. confusion or raised questions about the believe that the FDA assurance that all
The perception was that this process absence of operational details for PhiP of the formulations it has approved have
was very rigorous and entailed and CIP. States were particularly been evaluated as therapeutically
considerable State effolts for justifying concerned about the significant changes equivalent in the most current edition of
the waiver. that would occur in current operations their publication 'Approved Drug
Response: R was our intent that, (for example, data collection, Products with Therapeutio Equivalence
regardless of whether a State agency
follows the approach established by
- -
,Droorammina modifications. . Davment
. .
screens, monitoring price changes) and
Evaiuations'is adequate.
E. Additional Compendia
HCFA or uses an alternative drug accompanying
~ . . costs, to implement PhlP
payment system, a State agency would or CiP. Comment: One commenter requested
not be required to obtain a program Response: We deliberately did not inclusion of its publication, which is a
waiver. The NPRM proposed a process include specific technical details in the national compendium of drug cost
under which a State agency would be NPRM because the objective of the information, among the publications that
free to establish any payment system it proposals was to establish a will be used in determining the upper
wouid choose (except when freedom of methodology for setting a standard for iimit payment for multiple source drugs.
choice or provider contracting is Medicaid upper payment limits for Response: We agree with the
involved which would then require a purposes of FFP. We did not intend to commenter that publications other than
waiver). The State agency must describe set forth or describe the intricate details the Red Book and Blue Book, which
the methodology in its State plan which of a particular payment system. . .
were the onlv sources we Drooosed to
is subject to the usual State plan Nonetheless, we did set forth a sufficient use, can be used. Thus, we are revising
approval process. amount of technical detail to allow the regulations. The final rules will state
Because the proposed language commenters to identify potential that h determining the upper limit
regarding the State plan approval problems and solutions, and we took payment levels for multipie source
process caused some confusion, we are these into account in reaching the final drugs, we wili select from ail available
revising it to make clear that drug decision. We do not intend to impose national compendia of drug cost
payment methodologies must conform unnecessary or expensive operational information that reflect drug prices and
to all State plan requirements as must requirements on States. Rather, it was availability on a national level. As we
any other sewice. Under this final rule, our intent to permit State agencies to publish these upper limits in State
we are c l a i l i n g that all State agencies exercise maximum flexibility in designing Medicaid program issuances, we will
are required to: (1) Describe a payment system subject only to the identify the source of our drug price
compreh&ively the agenhs payment maximum payment ievels established by information. We periodioally will publish
methodology for prescriptiondrugs in its this regulation. these upper limits in our Medicaid
State plan; (2) make two findings, one Manual to assure comprehensive
D. Aveilabilify and Ouaiity of Drugs
for therapeutically equivalent muitipie knowledge of upper limits for multiple
source drugs and one for all other Comment: Several commenters wrote source drugs and to reduce the need
drugs,
- . through - mathematical requeJting that we demonstrate that the for State agencies to do Independent
computation, analysis and comparison availability and quality of drugs would research and computation,
to determine that the payment ieveis not be adversely affected under the
F. Dispensing Fees
under its payment methodology will not proposed Medicaid drug reform
exceed the payment levels that wouid alternatives. Comment: Several commenters
result from the application of the system Response: it is our belief that the suggested that either we delete tfie
promulgated by HCFA as the upper application of the 150 percent upper requirement in current regulations for
iimit; (3) make an assurance to us that limR standard that we are adopting for State surveys of dispensing fee costs or
it has made such findings; and (4) certain multiple source drugs wiil yield require State agencies to update these
maintain and make available to HCFA. a payment level that will be great fees in s periodic manner.
upon request documentation to support enoughto assure widespread availability Response: In the interest of State
the finding. of drug products. flexibility and to avoid imposing
The agency's assurance wili serve as Furthermore, because we are unnecessary Federal procedural
requirements as to how State agencies that the upper limits established for established at W day intervals. The
establish such fees, we are deleting the specific (listed) multiple source drugs agency is concerned about having
current requirement at 8447,333 will not apply if the prescribing sufficient lead-time for wholesalers and
regarding dispensing fees. State physician certifies that a brand name pharmacies to adjust inventories to
agencies will still be required to drug is medically necessary. These comply with the upper limit standard.
determine reasonable dispensing fees payments will not be Included in the Response: We believe that we are
or, if dispensing fees are not paid calculation for compliance with the providing an adequate period of time for
separarely, to impute an amount upper limit for multiple source drugs. these adjustments to occur. These
equivalent to a reasonable dispensing Instead, In these instances, the upper regulations are effective October 29,
fee, In order to include those amounts limit for all other (non-listed) drugs will 1987. This allows State agencies 90
in the calculations and comparisons appiy As under current regulations, a days from the date of publication to the
they make to meet the upper limit State agency may choose to elaborate effective date of these final regulations
standard for FFP. We expect that most and be more stringent regarding this in which to submit their plan
States will continue their present
~~
standard if it chooses. amendment and required attachment.
activities to establish a reasonable I.Acceptable Upper Limit Assurance K. Impact Analysis
dispensing fee level and will document
the$e and any new activities in their Comment: Several State agencies asked Comment: Several commenters criticized
State plan. Such activities could include: for guidance in making annual findings us for not providing sufficient detaii in
(1) Audits and sulveys of pharmacy regarding the upper limit determinations our impact analysis to permit a
omrational
-7 - .,
costs:. (2) com~ilation of and in deciding what constitutes an comparison of the relative effects of the
data regarding professional salaries and adequate assurance regarding the upper three alternatives presented in the
fees: and. (3) analysis of compiled data limit determinations when proposing NPRM. In particular, one commenter
regarding pharmacy overhead costs, State plan amendments. stated that we failed to support our
profits, etc. Response: We are requiring in the final contentions that all three proposals
rule two findings. We are requiring an would reduce Visruptions'of drugs to
G. Use of 'Smad Cards' and 'Vouchers' annual finding relating specifically to the retail outlets and achieve substantial
Comment: Several commenters multiple source drugs which HCFA will savings through encouraging the use of
suggested that HCFA adopt the use of identify through Medicaid program low cost generic substitutions.
a 'smart card' or 'voucher' payment issuances. We also are requiring a Response: As we explain in section V.
system for payment of prescription drug separate triennial flnding relating to the of this preamble, the combination of
claims. These commenters 1nd.ca1edmat categofy of "other drugs'. having to analyze an extremely complex
these systems would save significant The finding for the listed multiple source industry with very little data makes it
amounts of expenditures. drugs wili confirm that the agency's difficult to formulate a comprehensive
Response: As we noted in the preamble payment rates for these drugs do not empirically grounded Impact analysis.
to the NPRM, the use of a voucher or exceed the aggregate payment levels Based on the information available to us
bank draft payment (smart card) system determined by applying the upper limit at the time of the NPRM, we did not
by State agencies was not one of the formula plus a dispensing fee. The expect any of the three proposals
issues addressed in the proposal
. . to flnding for the category of 'other drugs' offered in the NPRM to have an annual
establish upper payment limits. The wili confirm that a State agency's effect on the economy of $100 million or
methodology of determining an upper aggregate expenditures for these drugs more. Thus, we were not required under
limit for prescription drug payments was under their chosen payment Executive Order 12291 to propose an
the subject of the NPRM, not the claims methodology, will not exceed aggregate impact analysis. Yet, because we were
payment process. The use of a voucher payment under the EAC criteria that are concerned, at the time the NPRM was
or 'smart card' claims payment system retained for this rule. (Under this rule, published, that one or more of the
is something which State agencies may the EAC criteria are applied as an upper proposals might have an annual effect
do at present. If State agencies limit on an aggregate basis rather than of $100 million or more, and because
determine that such a system to process on a prescription by prescription basis.) we expected our proposals to generate
claims is workable, efficient and more The findings for both the listed multiple considerable public debate, we
cost-effective than their current system. source drugs or 'other drugs" can be voluntarily prepared an analysis that met
and that system meets Medicaid supported by any documented the criteria of the Executive Order.
program requirements, then, indeed, we acceptable method of sampling, Comment: One commenter claimed that
encourage the individual agencies to imputation and statistical analysis that in our impact analysis, we failed to
adopt such a claims payment system. the State agency uses in making Its evaluate the effects of our proposals on
determination. The State agency wili the research and development of new
H. Physician's Override then make an assurance to HCFA that it drugs.
Comment: Several commenters has made the required findings. That Response: it is far from clear to us what
recommended that we delete the assurance to HCFA will constitute a impact our proposals would have on the
physician override requirement while presumption of validity of the findings research and development of new
one State agency recommended that we and will selve as the basis for approval drugs. These proposals are attempts on
strengthen the requirement. of the State plan our part to take advantage of the
Response: We are retaining the competiiive forces at work in the
J. Phase-In Upper Limit Standard for
physician override requirement as marketplace. Companies that develop
Multiple Source Drugs
Proposed in the NPRM. This new drugs are provided protection
requirement Is a safeguard that assures Comment: One State agency under patent from compdiion for a
that the physician can select the drug recommended that the upper limit certain period of time during which they
that is medically necessaty and best standard for multiple source drugs may charge prices high enough,
s u b d for his or her patient. This means consist of between 15-20 specific limits presumably, t o recover their

..>.-
,~
~-
development costs associated with the of our adopting aggregate iimits as the revisions to the list will be provided to
drug in question or to subsidize the upper limit standards, State agencies State agencies through Medicaid
research and development costs of are encouraged to exercise maximum program issuances on a timely, periodic
other drugs. Once the patent expires. State flexibilitv in estabiishina their own basis (possibly semi-annually). The
however, other pharmaceutical firms payment me~hodologies. i e do not effedive date of the new prices will be
may copy the drug, and once approved intend that our adoption of the formula subsequent to the issuance of the
by the FDA, they may market the same approach to set iimits for multiple listing. As did the NPRM, the final rule
drug and set their own price. Our source drugs be construed as an wiil specify that the drugs to which this
proposals were designed to take indicator of the Federally preferred formula will be applied must have been
advantage of this competition among payment system. The use of the formula evaluated as therapeutically equivalent
drugs that are no longer under patent approach is primarily due to the by the FDA. Similar to the NPRM, the
and not intended to prevent the straight-forward application and final rule will specify that at least three
development of new drugs. We were administrative ease in setting upper suppliers list the drug in a national
merely seeking to participate in the limits. We encourage State agencies to compendium. The NPRM stated that
market as prudent buyers. establish any program that wiil three suppliers would advertise the drug
substitute lower-priced alternatives for in the Red Book or Blue Book.
L. Application to Medicare drugs. We hope that the State agencies The formula to be used in calculating
Comment: One commenter specifically wiii be innovative in these programs and the upper limit of payment for certain
requested clarification that the find ways to assure the availability at multiple source drugs will be 150
alternative selected by the Department reasonable prices of multiple-source percent of the least costly therapeutic
for the final rule would not apply to the -
druas. One wav thev could do this
w o ~ l ooe to encourage reta;l pharmacy
equivalent that can be purchased by
pharmacists in quantities of 100 tablets
Medicare program and that hospitals
and hospital-based skilled nursing panicipat an .n tnc Med caio program oy or capsules (or if the drug is not
facilities would be exempt under permining them to retain profits from tha commonly available in quantities of 100,
Medicare. sale of listed drugs to Medicaid the package size commonly listed), or in
Response: As we stated in the NPRM, recipients. Other alternative payment the case of liquids, the commonly listed
we are deleting the referenoes to the systems could include, for example, size. As we stated in the NPRM, we
MAC program contained in the Medicare contracting on a oompetitive basis for chose the markup of 150 percent in
regulations concerning allowable costs pharmaceutical sewices with selected order to meet the following two
for drugs. (in the NPRM, we noted that pharmacies to which recipients may go objectives: (1) That the markup be high
we would delete 5405.433. However. for drugs without incurring a copayment enough to assure that pharmacists can
that regulation has since been or a system which entails charge normally obtain and stock an equivalent
redesignated and is now located at screens andlor mandatory discounts. produd without losing money on
g413.110. Thus, in this final rule, we are Additionally, State agencies may initiate acquisition costs of incurring the
deleting g413.110.) The upper limits for or retain already existing so-called expense of departure from normal
drugs contained in this final rule pertain "mini-MAC" programs, which they have purchasing channels, and (2) that the
only to the Medicaid program. They do established on specific drugs either at markup not be so high as to cost the
n o t apply t o hospitals and levels lower than those established Medicaid program unnecessary money.
hospital-based skilled nursing facilities under the current Federal MAC limits or in other words, the 150 percent is
under Medicare. an drugs not now covered by MAC intended to balance the interests of both
limits. This system of aggregate upper pharmacists and the government in
N. Provisions of the Final Regulations
iimits wiil allow State agencies to alter achieving efficiency, economy and
in this final rule, we have attempted to: payment rates for specific listed drugs quality of care as specified in section
(1) Respond to the public comments on without first having to obtain permission 1902(a)(30) of the Ad.
the NPRM; (2) provide maximum from HCFA. The agencies then will be In the NPRM, we stated that we would
flexibility to the States in their able to respond rapidly to sudden price use the Red Book or Blue Book to
administration of the Medicaid program; fluctuations, which may threaten the determine the least costly therapeutic
(3) provide responsible, but not supply of specific drugs on the HCFA equivalent that can be purchased by
burdensome Federal oversight of the lid without having to pursue a pharmacists. In this final rule, however,
Medicaid program; and, (4) take cumbersome approval process. A final we are deleting the reference to these
advantaae of savings resulting from the advantage of the aggregate limit specific sources and are specifying that
availabiky of less costly, but safe and methodology is the ease of we will publish and use the list of ail
effective, generic drug substitutes. administration at the Federal level and current edlions (or updates) of
To accomplish this, we are drawing the lack of administrative burden on acceptable published drug compendia
from various aspects of the proposals. State programs. available for sale nationally. Although
The Federal upper limit standard we are State agencies wiil need to calculate or
~. -
ado~tina for certain multiple source
drugs Is based on the appijcation of a
A. Multiple Source Drugs
The Federai upper limit standard that
impute a dispensing fee (if they do not
pay for the dispensing fee separately) in
soecific formula similar to that described we have adopted for certain multiple order to determine % they meet the
in the NPRM. The upper limit for other source drugs is based on an aggregate upper iimit standard for certain multiple
drugs is similar to that in the NPRM In payment amount equal to an amount source drugs, we are deieting the
that it retains the EAC limits as the that includes the ingredient cost of the current 5447.3'33 that recommends how
upper limit standard that State agencies druo calculated accordino to the formula agencies are to establish the dispensing
must meet, However, this standard is described below and -a reasonable fee.
applied on an aggregate rather than on dispensing fee. HCFA wiii determine to As originally proposed under ail
a prescription specific basis. which drugs the formula wiil be applied. options, this final rule will provide that il
We want to emphasize that as a result The listing of these drugs end any a physician certifies that a brand name
drug is medically necessary, the upper wiil be required, in accordance with Exec~tive~Order (E.O.) 12291 requires
limit for payment based on the formula §447.333(b)(1) of this finai rule, to make us to prepare and publish a finai
will not apply. The upper iimit for two separate and distinct findings that regulatory impact analysis for any finai
payment of 'other drugs' (discussed in expenditures for listed multiple source regulation that meets one of the E.O.
section 1V.B ) wiil apply. in the future, drugs on the one hand, and for all other criteria for a "major rule": that is, that
the formula approach to setting an drugs on the other, under their payment would be likely to result in: An annual
upper iimit will be evaluated. We are methodology wiil not exceed the upper effect on the the economy of $100
aware of several State agencies now in iimits established by HCFA. All State million or more; a major increase in
the process of negotiating competitive agencies will be required to maintain costs or prices for consumers, individual
bids for discounts or rebates from drug the supporting documentation and to industries, Federal, State, or local
manufacturers and suppliers. Other provide HCFA with an assurance that government agencies, or q e o ~ r a ~ h i c
agencies are considering selective they have made the required findings. regions; or significant advers; .&tikcis on
-
contractina with ~roviders
(preferred provider
or pharmacies
organizations).
We note that we also have changed
the requirements for findings and
competition, employment, investment,
productivity, innovation, or on the a b i i i i
Additionally, the interaction of assurances to differ with regard to each of United States-based enterprises to
competitive pricing and creative drug category. We will require an compete with foreign-based enterprises
marketing may cause dynamics in the annual finding for multiple source drugs in domestic or export markets.
market that would necessitate a revision and a triennial finding for all other The local character of retail
of our policy. Thus, we will monitor the drugs. The findings for multiple source pharmaceutical markets, the large
implementation of this policy, as well as drugs will be required at least annually number of parties that participate in
the various payment systems used by because the State agencies efforts will those markets, the variety of products
State agencies and the dynamics of the be directed primarily at comparing State sold, the numerous distribution channels
marketplace, in order to make timely payments, in the aggregate, to the through which these products flow, and
revisions to the policy for Medicaid maximum ingredient costs published by a general lack of data adequately
upper limits for drug payments. HCFA. describing these various aspects of the
However, for all other drugs, State market ail make it extremely difficult for
6. Other Drugs agencies wiil first have to determine the us to determine how and to what
In this final ruie, we specify that the estimated acquisition costs before degree this final rule will affect market
agency payment for certified brand making comparisons on the aggregate participants. For these reasons, we
name drugs and drugs other than basis. it is because of the various cannot say with any degree of certainfy
muitiple source drugs for which a activities States will need to pursue in whether this ruie will meat or exceed the
specific limit has been established must order to make the findings for ail other Executive Order's criteria for a major
not exceed, in the aggregate, the level drugs that we are requiring that this be rule. However, because of its
of payment calculated by applying the done at least every three years. We controversial nature, we are providing a
lower of (1) the EAC plus a dispensing anticipate that the trienniai findings and regulatory impact analysis.
fee; or (2) the provider's usual and assurances for all other drugs will In addition, we generally prepare a final
customary charges to the general lessen the administrativeireporting regulatory flexibility analysis that is
public. burdens on State agencies and maintain consistent with the Regulatory Flexibility
Under these rules, the Federai a i w e l of accountability for purposes of Act (RFA) (5 U.S.C. 601 through 612),
requirement for States to use the EAC FFP. unless the Secretary CeRifies that a final
method of payment will be eliminated. Apart from the initial plan submission, regulation wiil not have a significant
However, because the rule merely and s.bseq,ent eswrsnces an aeoncy. economic impact on a substantial
establishes an upper limit concept and which has determmed that n 8 adopt'ng number of smaii entities. Although the
does not describe the specific a new methodology .. or making most direct effect of this rule will be on
methodology for payment, State s.gn'ficant cnangcs .n .ts paymenr rates States, States are not smail entities
agencies may continue their practice of or to 11s existing system. be reqdred under the RFA. The economic size of
estabiishina -
" EACs for the inaredient to probloe rlCFA wth tne req-is le Stale Medicaid participating retail pharmacies
range from large national corporate
costs and adding to it a dispensing fee. amendments and the assurance
Such practices will be acceptabie, as that it has made the necessary findings. chains t o small independent
will a system of establishing single-owner outlets. Yet because retaii
D. Other Changes pharmaceutical markets appear to be
chargelpayment screens based on
Statewide or regionai customary and As proposed, this finai ruie will remove largely local in nature, retaii pharmacies
usual prices. the Departmental rules at 45 CFR Part operate in these markets as smaii
The State's findings in regard to 19 that limit drug reimbursement under entities. For Durooses of the RFA. ~~,
whether the Statewide aggregate upper certain Federal health programs. These therefore, we cbnsider pharmacies to be
limit test is met must demonstrate that ruies have little impact upon programs smaii entities. Other entities that may be
aggregate payments do not exceed other than Medicaid, and the Medicaid affected by this finai ruie, for example,
payment as calculated under the EAC regulations concerning upper limits for wholesale distributors and
principles. drug payments are being revised under manufacturers, also may qualify as smail
this final rule. We also are deleting entities under the RFA, but are mora
C. State Plan Requirements, Findings cross references to 45 CFR Part 19 iikeiy to participate in regionai or
and Assurances contained in 42 CFR 430.0(b)(Z)(ii) and national markets, and thus, are more
We are revising the proposed language 45 CFR 1.2, and the reference to MAC likely to take on the characteristics of
concerning State agency assurances iimits in 42 CFR 413.110. large firms. For this reason, plus the fact
regarding drug payment systems. We that this rule is not explicitly directed at
V. Regulatoty Impact Statement
are clarifying that all agencies. these other entiiies or expected to affect
regardless of the payment system used, A. introduction them directly, we are not considering
to alter payment rates for specific iisted financial ability to provide for needed
them as small entities for purposes of
drugs without first having to obtain services.
this rule.
permission from HCFA. States then wiil E. Expected impact of Limits Placed on
B. Objectives be able to respond rapidly to sudden Listed Drugs
Through promulgation of this final rule, price fluctuations which may threaten
we hope to achieve several objectives the supply of specific drugs on the I. increased State Flexibility
we view as essential for providing HCFA list without having to pursue a As described in section IV of this
acceptable care to Medicaid recipients cumbersome approval process. A final preamble and in §§447.332(a) and
and for increasing the efficiency with advantage of the aggregate limit 447.331 of the rule, HCFA will prescribe
which pharmaceutical products and methodology is ease of administration at aggregate upper limits on certain
services are delivered to recipients. the Federal level and the lack of therapeutically equivalent
These objectives are to: administrative burden on State multiple-souroe drugs we determine to
o ~stabiish simple, administrable programs. be readily available, and on sole source
methods of applying iwo separate and D. Small Entities Affected and other multiple-source drugs. The
distinct upper limits on State Medicaid limit for readily available drugs is to be
expenditures: one for certain The drug industry is highly complex based on 150 percent of the lowest
therapeutically equivalent multiple and multi-layered, with a variety of known price for each drug o n the list.
source drugs, and one for ail other manufacturing, distribution, and retail The limit for sole source and other
drugs. sales arrangements that not only differ multiple-source drugs will be based on
0 Promote wider and more efficient
according to geographic location, but the amounts paid by other payors.
distribution of pharmaceutical products aiso vary by product. Further, under the Since we are setting separate aggregate
and services, and avoid potential Medicaid program, the immediate payor limits on what we are calling 'iisted
disruptions in the supply of drug (that is, the State) is distinct from the drugs' and on 'other drugs', States wiil
products that appear to be a major purchaser (usually the recipient) or the be free to make payments for individual
drawback of the present method of orderer (the physician), both of whom drugs on any reasonable basis as long
reimbursing retail are key decision makers for each as total payments for each group of
~harmacistsunder the MAC Program. specific purchase of drugs. These rules drugs do not exceed the aggregate limit
Conserve scarce Federal and State wili directly affect only the State, and on that group. This approach should
resources through encouraging the more even then, these rules do not control the help avoid disruptions in the supply of
judicious purchasing of pharmaceuticals option available to the State, but listed drugs in circumstances in which
on behalf of Medicaid recipients, thus establish limits on the extent that we wili acquisition costs may exceed the listed
achieving some budget savings, while share in the State's overall expenditures price used in establishing the HCFA
preserving or enhancing current levels for covered drugs. It is each State's limits.
of service. actions, taken in some measure in State agencies should determine,
in pursuing these objectives, we also response to these upper limits, that will independent of the 150 percent formula,
wish to give State agencies the in turn affect other parties. appropriate payment levels for the iisted
incentive to encourage prudent As a resutt, it is difficult for us to clearly multiple-source drugs. We would not
purchasing practices on the part of retail identify the entities affected by these expect a State agency to adopt direothl
pharmacists and foster price competition regulations, and nearly impossible to fix the upper limit methodology as a
among wholesale suppliers and the magnitude of any impact. At best, payment method be does not gear
manufacturers of multiple source drugs. we can only identify broad categories of payments to markups appropriate to the
small entities that may be affected in actual costs of acquiring and dispensing
C. Impact on State Agencies some fashion by this ruie, such as retail these drugs. Under these final
The aggregate payment limit on HCFA drug outlets and pharmacists, wholesale regulations, State agencies will be able
listed drugs as well as the general limit drug distributors, and manufacturers. to make higher payments for some
on sole-source and non-listed multiple Through requiring States to establish listed drugs as long as they pay at rates
source drugs, afford State agencies programs to make payments which lower than those listed for other drugs
wide latitude in developing their own refled the availability of lower cost on the list. By providing this measure of
payment schemes to suit local alternatives when three or more flexibility, we expect that State agencies
conditions and unusual circumstances therapeutically equivalent generic will be able to ensure that iisted drugs
that may arise from time to time. For alternatives are available, this ruie wiil will be generally available to recipients.
example, State agencies may retain affect the behavior of retail pharmacists As a counterpart to allowing State
already existing so called 'mini-MAC' who receive Medicaid payments. As a agencies the freedom to set their own
programs, which they have established result of the response of pharmacists to minimum price floor on drugs in order
on specific drugs either at levels lower State programs, we expect there to be to cover pharmacists' ingredient costs,
than those established under the effects on drug manufacturers and they also have the authority to set an
Federal MAC limits or on drugs not now wholesale distributors. Also, it is upper limit on the mark-up of specific
covered by MAC limits. Also, under the conceivable that this rule might make drugs on the HCFA list. Since we are
aggregate limits. State agencies are free physicians more aware of the availability not placing maximum payment limits on
to experiment with alternative payment of low cost generic drugs that could be individual drugs, drugs with high
systems, for example, letting contracts substituted for higher cost leading brand compendia prices could generate
on a competitive basis for drugs, and thus produce changes in extremely high payment levels. Unless
~harmaceuticalservices with selected physician prescribing practices. an agency's payment methodology
pnarmacias to wn:ch recipients may go Furthermore, by making payments more ensured otherwise, a Medicaid agency
for o r ~ g rsr ~ l n oinc~rring
~t a copaymenl. prudent, we hope to affect Medicaid could end up paying inappropriately
or sb stems .dent'cai or s m!ar to PnP or recipients positively by improving the high rates for some drugs while still
CIP: This system wiil aiso allow States States' and Federal government's being in compliance with the aggregate
upper limit Nevertheless, we believe sizable poltions of their total sales These savings estimates are at the
States may establish maximum payment among Medicaid recipients. However, limits presented in this rule and
limits in order to offset the minimum we suspect that price competition would represent only the Federal ponion, and
payment ieveis necessaly to ensure be carried on in the form of discounts, whiie we generally calculate the States
reasonable compensation for very low promotional campaigns and other share of any savings to be about 82
priced drugs. incentives aimed at the retail percent of the Federal share (assuming
Similarly. State agencies may employ pharmacists. the average FFP rate to be 55 percent),
essentially the same approach in Such tactics would work to the State savings or additional Federai
meeting the limits for all other drugs. advantage of both retail druggists and savings will largely depend on the plans
That is, the same principsl of balancing wholesalers. Retail pharmacists would State Medicaid agencies adopt in
payment increases for some drugs with gain by being able to purchase drugs at response to the Federal upper limit
decreases for other drugs also applies prices beiow the HCFA list rice, while
in determining whether aggregate khoiesaiers could gradually push the
payments exceed the limit. For reasons benchmark price upwards without
F. Alternafives Considered
of economy, availability, or therapeutic loosing sales. Although, historically, it
efficacy, a State agency may Want to has been the large retail outlets that In the NPRM, we proposed three
raise or lower the amount it pays for have benefited the most from wholesale alternative payment schemes for
certain drugs in efforts to influence the discount practices, if adopted by a reimbursing pharmacy costs of
supply of specific drugs. Under the substantial number of State agencies, providing drugs and pharmacy services
aggregate limit methodology any our policy of using pubiished prices as to Medicaid recipients. Two of the
change in payments above or below the a basis for determining payment levels proposals, the PhlP and reformed MAC
lower of the EAC or customary charges may cause wholesalers to invent new program, were efforts to strengthen our
for specific drugs must be balanced ways of offering discounts to the smaller policies on payments for readily
with a corresponding reduction or independent retail outlets, thereby available generic drugs, whiie the third
increase in payments for other drugs expanding the practice of discounting to proposal, CIP, was designed as an all
within the all 'othef drug payment those outlets and enabling them to have inclusive payment scheme that would
category. access to less expensive sources of cover both muitipia and single source
pharmaceuticals. The drawback is that drugs.
2. Possible Effects on Wholesale neither State programs nor the Federal in evaluating the three alternatives, we
Distributors and Manufacturers Medicaid program will benefit from such considered comments and the
reductions in wholesale prices. avaiiabiliq of resources to implement
in the previous section, we discussed the proposed alternatives. it became
the possible effects of building into our 3. Savings
clear almost immediately, that of the
rates for ingredients a profit margin for Based on current State spending for three alternative presented.
pharmacists. We expressed the hope prescription drugs, and the potential for implementation of CIP wouid be the
that States would recognize the savings to be gained from drugs most problematic. Several obstacles
advantage of providing pharmacistswith currently under patent losing their proved insurmountable. These were:
an incentive to participate in the protection, we estimated savings to the 9 The added cost of implementing CIP
Medicaid program and to stimulate Federal government over the next five for multiple source drugs appeared to
pharmacists to engage in prudent fiscal years from implementing an be considerable. Based on comments
purchasing practices and the aggregate upper limit on readily received and our own research, the
substitution of lower cost therapeutically available multiple source drugs to be administrative costs were estimated to
equivalent products. In addition to $270 million. (This assumes that the be about $7 million to implement CIP
these effects, we believe that our aggregate limits an listed multiple nationally.
method of calculating the aggregate source drugs would be appiied to 0 We could not determine the impact of
upper limit on payment to States may payments for at least 60 drugs which we CIP because of the iaok of reliable data
have consequences for other sectors of identified for purposes of applying the on retail drug charges.
the industw: .
, In Dalticuiar on wholesalers proposed PhlP limits in the NPRM.) Our CIP could not be im~lemented
and manufacturers. Although these savings estimates also incorporate a quickly.
entities may not fii the definition of small factor to account for physicians Our reasons for rejecting the reformed
entities as discussed section V.A. of this exercising their privilege of specifying a version of the MAC program had to do
preamble, nevertheless the manner in particular brand in accordance with largely with our conclusion that even
which this initiative affects these entities 5447.331 (c). The following table shows with the reforms we were proposing, the
may have an Impact on pharmacies and the Federal savings by fiscal year (FY), program wouid stilt prove to be too
on our ability to manage the program. and assumes that actual implementation cumbersome to enable us to respond to
By using the lowest compendia Price of the provisions at the Stale level will the rapidly changing drug market
for a drug as the benchmark for our begin April, 1988.
listed drug rates, the low price supplier
may be encouraged to raise its
pubiished price to a point just beiow the
next higher price. Other drug
wholesalers and manufacturers may
tend to lower their published prices so
the range of published prices would
begin to narrow and cluster around the
low end of the price scale We would
expect to see such pricing pafierns
develop only for those drugs which had
~ h u s by
, a process of elimination, the Reduction Act (44 U.S.C. 3507). A notice (Sec. 1102 of the Social Security Act (42
Federal upper limit for selected wili be published in the Federal Register U.S.C. 1302))
therapeutically equivalent multiple when approval is obtained. Comments 430.0 [AMENDED]
source drugs is based on an aggregate on the information collection
payment amount equal to the ingredient requirements should be sent directly to 2. In ~430.0(b)(2)(1iJ,the reference to
cost of the drug calculated according to Allison Herron, Office of information and "Pa 11BLimitations on Pavment or
the 150 percent markup formula plus
the dispensing fee established by the
Regulatory Affairs, Office of
Management and Budget, Room 3208,
Reimbursement for Drugs' is removed.
111.42 CFR Part 447 is amended as set J
State agency. The upper limit for all New Executive Office Building, forth below:
other drugs is an aggregate upper iimit Washington, DC 20503 A. The authority for Pan 447 continues
that does not exceed the iimit as L k l of Subjects to read as foliows:
calculated under the EAC principles.
42 CFR Part 413 Authority: Sec. 1102 of the Social
G. Conclusions Security A d (42 U.S.C. 1302) unless
Health facilities, Kidney diseases, otherwise noted.
We recognize that we have presented Medicare, Reporting and recordkeeping
a somewhat limited discussion of the requirements. B. The table of contents is amended by
potential effects this rule may have on adding a new S447.301 and by revising
States and other entities. As we have 42 CFR Part 430 the entries for 8S47.331 through
pointed out, there are many reasons for Grant programs-health, Medicaid. 447.333 as follows:
our inability to present a more thorough
analysis. The complex market structures 42 CFR Part 447 PART 447-PAYMEMS FOR SERVICES
that operate at national, regional and Accounting, Administrative practice and . I * * *

local levels, the proprietary and highly procedure. Grant programs-health,


competitive nature of these markets, and Subpart DPayment Memods for Other
Health facilities, Health professions, institutionaland NoninsthmonalServices
the combined effects of different Medicaid. Reporting and recordkeeping
participants (States, pharmacies. requirements, Rural areas.
physicians, recipients, distributors,
manufacturers) interacting with one 45 CFR Part 1
another create analytical problems that Sec.
Organization and functions. 447.301 Definitions.
are beyond our capacity to analyze. The
flexibility provided the States means that 45 CFR Part 19 t * * . *
a variety of payment systems or Administrative practice and procedure,
methods will be used subject to the 447.331 Drugs: Aggregate upper limits
Drugs, Health care, Health maintenance of payment.
established payment standards noted in organizations, Medicare
this final rule. We cannot predict with 42 CFR Chapter IV is amended as set ..
447.332 Umer limitsfor multi~le
source
any certainty what decisions the States drugs.
forth below: 447.333 State plan requirements,
will make over time, particularly as they
experiment with new and improved 1. 42 CFR Part 413 is amended as set findings and assurances.
payment methods. forth below: . * * * *
We do, however, recognize that the PART 413-PRINCIPLES OF
establishment of the two upper limits C. Section 447.301 is added to Subpart
R E A S O N A B L E C O S T D to read as follows:
described in section lV of this preamble REIMBURSEMENT: PAYMENT FOR
represents only a partial solution to the
problems of drug availability, increased
efficiency in the allocation of resources, For the purposes of this subpart- 'Brand
retail pharmacists satisfaction with A. The authority citation continues to name" means any registeredtrade name
payment levels, and the provision of read as follows: commonly used to identity a drug.
adequate pharmacy sewices to "Estimatedacquisition cosr means the
Authority: Secs. 1102, 1122 1814(b), agency's best estimate of the price
Medicaid recipients. Each State agency 1815. 1833(a), 1861(v). 1871, 1881. and
will evolve its own payment generally and currently paid by
1886 of the Social Security Act as providers for a drug marketed or sold
methodology and solutions to local amended (42 U.S.C. 1302, 1320a-1,
probiems. Each State agency wili have by a particular manufacturer or iabeler
1395f(b), 13958, 13951(a), 1395x(v), in the package size of drug most
to identify and decide on the trade-offs 1395hh,1395rr, and 1 3 9 5 ~ ) .
it wishes to make with the frequently purchased by providers.
understanding that some of the side B. The table of contents for Subpart F is "Multiple source drug' means a drug
effects of a particular payment method amended by removing 5413.110. marketed or sold by two or more
may be counter productive with respect manufacturers or iabelen or a drug
§ 413.1 10 [Removedl marketed or sold by the same
to achieving stated objectives.
C. Section 413,110 is removed. manufacturer or iabeier under two or
VI. Papemork Requirements more different proprietary names or both
11. 42 CFR 430.0 is amended as set
Section 447.333 of this rule contains under a proprietaly name and without
forth below:
information collection requirements. The such a name.
public is not required to comply with the PART 430GRAFCTS TO STATES FOR D. Section 447.331 is revised to read as
information collection requirements until MEDICAL ASSISTANCE PROGRAMS f0liows:
the Executive Office of Management and 1. The authority for Part 430 continues 8 447.331 DNP: Aggregate upper
Budget approves these requirements to read as follows: limits of payment
under section 3507 of the Paperwork
(a) Multiple source drugs. Except for (which has been classified by the FDA requirements set forth In S0447.331 and
brand name drugs that are certified in as categoy 'A" in Rs publication. 447.332 concerning upper limits and in
accordance with paragraph (c) of this Approved Drug Products with paragraph (b)(l) of this section
section, the agency payment for multipie Therapeutic Equivalence Evaluations, concerning agency findings are met.
source drugs must not exceed, the including supplements or in successor (0) Recordkeeping. The agency must
amount
-. - that would result from the publications) based on all listings maintain and make available to HCFA,
application of the specific limits contained in current editions (or upon request, data, mathematical or
established i n accordance with updates) of published compendia of statistical computations, comparisons,
5447,332. i a specific limit has not been cost information for drugs available for and any other pertinent records to
established under 5447.332, then the sale nationally. support its findings and assurances.
rule for 'other drugs' set forth in (2) HCFA publishes the iist of multiple
SUBTITLEADEPAFiTh4ENT OF HEALTH
paragraph (b) applies. source drugs for which upper limits
AND HUMAN SEMCES; GENERAL
(b) Other drugs. The agency payments have been established and any
ADMIN6TFWON
for brand name drugs certified in revisions to the iist in Medicaid program
acoordance with paragraph (c) of this instructions. iV. 45 CFR Subtitle A is amended as set
section and drugs other than multiple (3) HCFA will identify the sources used forth below:
source drugs for which a specific limit in compiling these lists. A. The table of contents for Subtitie A
has been established under 8447.332 (b) Specific upper limits. The agency's
is amended by removing "Palt 19,
must not exceed in the aggregate. payments for muitiple source drugs
payment levels that the agency has identified and iisted in accordance with 'Limitations on Payment or
determined by applying the lower of paragraph (a) of this. section must not Reimbursement for Drugs".
exceed, in the aggregate, payment
the PART 1 - HHS's REGULATIONS
(1) Estimated acquisition costs plus levels determined by applying for each
reasonable dispensing fees established drug entity a reasonable dispensing fee 6. The authority citation for Part 1
by the agency; or established by the agency plus an continues to read as follows:
(2) Providers' usual and customary amount established by HCFA that is
(5 U.S.C. 301)
charges to the general public. equal to 150 percent of the pubiished
(c) Cdfication of brand name drugs. price for the ieast costly therapeutic 5 1.2 [Amendedl
(1) The upper limit for payments equivalent (using all available national
C. In 51.2 of Subpart A, the last bullet
mukiple source drugs for which a compendia) that can be purchased by
point antiiled 'Miscellaneous' is
specifio limit has been established pharmacists in quantities of 100 tablets
amended by removing the reference to
under 5447.332 doas not apply if a or capsules (or, if the drug is not
Part 19.
physician certaies in his or her own commonly available in quantities of 100,
handwriting that a specific brand is the package sizg commonly listed) or, in PART l~llMlTAllONSON PAYMENT
medically neoessaty for a particular the case of liquids, the commonly listed OR REIMBURSEMENT FOR DRUGS
recipient. size. IREMOVEDI
(2) The agency must decide what F. Section 447.333 is revised as D. Subtitle Ais amended by removing
certification form and procedure are follows:
Part 19, 'Limitations on Payment or
used. % 447.333 State plan requirements, Reimbursement for Drugs'.
(3) A checkoff box on a form is not
findings and assurances. (Catalog of Federal Domestic Ass;stance
acceptable but a notation like 'brand
necessary' is allowable. .
(a1. State olan. The State dan musi Program No 13 714, Meoical Assistance
Program: 13.773. MedicareHos~itai
(4) The agency may allow providers to describe comprehensively the agency's - .
keep the certification forms U the forms payment methodology for prescription I n s u r a n c e ; 13.77'4,
will be available for inspection by the Medicare-Supplementary Medical
agency or HHS. (b) indi dings and assurances. Upon insurance)
E. Section 447.332 is revised as proposing significant State plan changes
Dated: June 15, 1987
follows: in paymentsfor prescription drugs, and
at ieast annually for multiple source William L Roper,
s 447.332 Upper limb for rnulSple drugs and triennially for all other drugs, Administrator, Health Care Financing
source drugs. - . must make the following
the agenw Administration
findings and assurances:
..
(a1 Establishment and issuance of a
(1) Findings. The agency must make the Approved: June 16, 1987.
listing.
following separate and distinct findings: 058 R. Bowen,
(1) HCFA will establish listings that (i) in the aggregate, its Medicaid
identify and set upper limits for multiple Secretaty.
expenditures for multiple source drugs,
source drugs that meet the following identified and iisted in accordance with
requirements: [FR Doc. 87-17384 Filed 7-3087; 8:45
5447.332(a) of this subpart, are in
(i) All of the formulations of the drug accordance with the upper limits am1
approved by the Food and Drug
specified in §447.332(b) of this subpart; BILLING CODE 412Mll-M
Administration (FDA) have been
and
evaluated as therapeutically equivalent
(ii) in the aggregate, its Medicaid
in the most current edition of their
expenditures for all other drugs are in
publication, Approved Drug Products
accordance with 8447.331 of this
with Therapeutic EquivalenceEvaluations
subpart.
(including supplements or in successor
(2) kssurances. The agency must make
publications).
assurances satisfactory to HCFA that the
(ii) At least three suppliers list the drug
STATE MEDICAID MANUAL Departmentof Health and Human
Services
Part 6 -- Payment for Services Health Care Financing
Administration

TmmitLal No. 12 Daie: April 1989

REVISED MATERIAL REVISED PAGES REPLACED PAGES


Addendum A A1-A22 (22 pp.) A1-A20 (20 pp.)

CHANGED IMPLEMENTING INSTRUCTIONS - EFFECTIVE DATE: June I , 1989

Addendum A. - This issuance revises Addendum A to the State Medicaid Manual S6305 in order to
reflect the update of drug ingredient prices utilized by States to establish upper limits for prescription
drugs.

As you will note, this periodic update of the listing of therapeutically equivalent mukiple-source
prescription drugs includes oral-contraceptive products that meet the definitions set forth in 42 CFR
447.331 ff. Although these products are now subject to the aggregate upper limits as specified in the
regulations, we believe it appropriate to reiterate that where a state determines that for various policy
reasons, that it is preferable to make payments for the brand-name products, they are free to do so as
long as the excess payments are offset through payments for other multiple-source drugs in such a
manner that the aggregate upper-limit test would still be met. Additionally, the same rules regarding
physician certification of brand-name medically necessary apply to these products added to the listing
of multiple source drugs.

NOTE: Brackets have not been used since Addendum A is being entirely replaced
SPECIFIC UPPER LIMITS FOR MULTIPLE SOURCE AND "OTHER DRUGS"

In 1976, the Department of Health and Human Services (HHS) implemented drug reimbursement rules at 45 CFR
Part 19 under the authority of statutes pertaining to upper payment limits for Medicaid and other programs. The
authority to set an upper payment limit for services available under the Medicaid program is provided under
81902(a)(30)(A) of the Social Security Act.

HHS rules are intended to ensure that the Federal Government acts as a prudent buyer of drugs under Federal
health programs. The rules set limits on payments for drugs supplied under Medicaid and other programs. Of the
Federal programs involved, these rules have the greatest impact on the Medicaid program.

In 1983, an HHS Task Force was established to review the Department's drug reimbursement regulations at 45 CFR
Part 19. Specific concerns presented to the Task Force coupled with the Department's desire to take advantage
of savings that are currently available in the marketplace for multiple source drugs, resulted in a revision of the
regulations to change the procedures for drug payments. The final regulation was published on July 31, 1987 (52
Fed. Reg. 28648).

6305.1 Upper Limits Requirements


A. Multiple Source Drugs
I. Definition

A multiple source drug is a drug marketed or sold by two or more manufacturers or labelers, or a drug marketed
or sold by the same manufacturer or labeler under two or more different proprietary names or both under a
proprietary name and without such a name.

2. Establishment of Limits

Under the authority of a1902(a)(30)(A) and the regulations in 42 CFR 447.332, HCFA establishes a specific upper
limit for a multiple source drug if the following requirements are met:

All of the formulations of the drug approved by the Food and Drug Administration (FDA) have been
evaluated as therapeutically equivalent in the current edition of the publication, Approved Drug Products
with Therapeutic Equivalence Evaluations (including supplements or in successor publications); and

At least three suppliers list the drug (which has been classified by the FDA as category "A" in its
publication, Approved Drug Products with Therapeutic Equivalence Evaluations (including supplements
or in successor publications) in the current editions (or updates) of published compendia of cost
information for drugs available for sale nationally (e.g., Red Book, Blue Book, Medispan).

3. Awwlication of Limits
Payments for multiple source drugs identified and listed in the accompanying addendum must not exceed, in the
aggregate, payment levels determined by applying to each drug entity a reasonable dispensing fee, established by
the State, plus an amount based on the limit per unit set forth in the accompanying addendum, which HCFA has
determined to be equal to 150 percent of the published price in any of the above compendia for the least costly
therapeutic equivalent that can be purchased by pharmacists in quantities of 100 tablets or capsules, (or, if the drug
is not commonly available in quantities of 100, the package size commonly listed or, in the case of liquids, the
commonly listed size).

The upper limit for multiple source drugs for which a specific limit has been established does not apply if a
physician certifies in his or her own handwritina that a specific brand is "medicallv necessarv" for a particular
recipient. The handwritten phrase 'brand necessary" or "brand medically necessary" must appear on the face of
the prescription. A dual line prescription form does not satisfy the certification requirement. A checkoff box on a
form is not acceptable, but, again, a notation like "brand necessary" is allowable. For telephone prescriptions,
decide what certification form and procedures should be used. Providers may be allowed to keep the certification
forms if the forms will be available for inspection by their agency or HHS.
B. 'Other Drugs'
A drug described as an "other drug" is a brand name drug certified as medically necessary by a physician
or a drug other than a multiple source drug. (See s6305.1.A.) Payments for these drugs must not exceed,
in the aggregate, payment levels determined by applying the lower of the:

Estimated acquisition costs, plus reasonable dispensing fees, or


The provider's usual and customary charges to the general public.

Estimated acquisition costs mean the agency's best estimate of the price generally, and currently, paid
by providers for a drug marketed or sold by a particular manufacturer or labeler in the package size most
frequently purchased by providers.

6305.2 State Plan And Procedural Requirements -


k State Plan
As required by 42 CFR 447.333(a) the State plan must describe comprehensively, your payment
methodology for prescription drugs.

B. Findings
As required by 42 CFR 447.333(b), upon proposing significant State plan changes in payments for
prescription drugs, and at least annually for multiple source drugs and triennially for all other drugs, you
must make the following separate and distinct findings, which may not be aggregated for these purposes.
The findings can be supported by any documented, acceptable method of sampling, imputation and
statistical analysis used to make the determinations:

In the aggregate, Medicaid expenditures for multiple source drugs, identified and listed in accordance
with e6305.1.A., Multiple Source Drugs, are in accordance with the upper limit requirements, established
by that section, and
" In the aggregate, Medicaid expenditures for all 'other drugs" are in accordance with the respective
requirements noted in ~6305.1.B.

C. Assurances
Regulations in 42 CFR 447.333(b)(2) require that, upon proposing significant State plan changes in
payments for prescription drugs, and at least annually for multiple source drugs and triennially for other
drugs, you must make assurances satisfactory to HCFA that the requirements in s and ~6305.2are met.
The acceptance of satisfactory assurances is the basis of approval of a State plan.

D. Recordkeeping
As required by 42 CFR 447.333(c), you must maintain and make available to HCFA, upon request, data,
mathematical or statistical computations, comparisons and any other pertinent records to support your
findings and assurances.

E. Upper Limits and Federal Financial Participation (FFP)


In your assurance letter indicate that you pay no more than the upper limits described in ~6305.1,in
accordance with 42 CFR 447.304(a), since as required by 42 CFR 447.304(c) FFP is unavailable for
payments for services that exceed the upper limits.

6305.3 Upper Limit Drug Price List Update for Multiple Source Drugs

We have developed a price listing of multiple source drugs to which the formula in ~6305.1applies. The listing of
these drugs and any revision to the list will be provided through Medicaid program issuances on a periodic basis
(possibly, semi-annually). The effective date of the new prices will be subsequent to the issuance of each new
listing and will be included in the issuance. The listing is presented as an addendum.
04-89 PAYMENT FOR SERVICES Addendum A

Addendum A. -- The following listing of multiple source drugs meets the criteria set forth in 42 CFR 447.332. The
listing was developed by applying the 150 percent formula to the lowest price listed (in package sizes of 100 units,
unless otherwise noted) in any of the published compendia of cost information of drugs. Where a double asterisk
(**) appears the result of the application of the 150 percent formula yields a Federal financial participation (FFP)
limit that exceeds the commonly known brand name listed price. (You may want to consider making downward
adjustments in these instances and apply the excess amount to other drug payments.) The regulations at
447.333(b) set forth the aggregate upper limit test that must be met for FFP purposes. This listing is based on data
published in the December 1988 Red Book microfiche, a December 1988 First Data Banks analysis (Blue Book),
and the 1st quarter 1989 Generic Buying and Reimbursement Guide of Medi-Span and a December 1988 Medispan
analysis. All upper limts are expressed in a per unit basis, e.g., tablet, capsule.

The effective date of this list is June 1. 1989.

GENERIC NAME GENERIC UPPER COMMONLY KNOWN


UMITIUNIT Source' BRAND NAME(S)

Acetaminophen; Butalbial; Fioricet


Caffeine 325 mg; 50 mg; 40 mg
Tablet
Acetaminophen; Codeine Tylenol w/Codeine
300 mg; 15 mg Tablet (#2)
300 mg; 30 mg Tablet (#3)
300 mg; 60 mg Tablet (#4)
120 mg/5 ml; 12 mgl5 ml Elixir,
Oral 480 ml
Acetaminophen; Hydrocodone Bitartrate Vicodin, Lortab 5, etc.
500 mg; 5 mg Tablet
Acetaminophen; Oxycodone Hydrochloride Percocet
325 mg; 5 mg Tablet
Acetic Acid Glacial; Hydrocortisone Vosol HC,
Orlex HC
2%;1% Acetasol HC
SoluntionlDrops, Otic
10 ml.
Acetaminophen; Propoxyphene Hydrochloride Dolene AP-65
Wygesic
650 mg; 65 mg Tablet
Acetaminophen; Propoxyphene Napsylate Da~ocet-N100
325 mg; 50 mg Tablet Propacet
650 mg; 100 mg Tablet

'B = Blue Book M = Medispan R = Red Book


Addendum A (cant.) PAYMENT FOR SERVICES 04-89
GENERIC NAME GENERIC UPPER COMMONLY KNOWN
UMrrRlNlT Source' BRAND NAMEIS)

Acetazolamide Diamox
250 mg Tablet
Allopurinol Zyloprim
Lopurin
100 mg Tablet
300 mg Tablet
Amantidine Hydrochloride Symmetrel
100 mg Capsule
Aminophylline Aminophyllin
Solution Oral 105 mg15 ml
240 ml
Amitriptyline. Hydrochloride; Limbitrol
Chlordiazepoxide
12.5 mg; 5 mg
25 mg; 10 mg
Amoxicillin Polymox, Larotid,
Amoxil,
250 mg Capsule Trimox
500 mg Capsule 50's Ulimax
125 mgl5 ml 80 ml PwdIRecon. Wymox, etc.
125 mg15 ml 100 ml PwdIRecon.
125 mu5 ml 150 ml PwdIRecon.
250 mg/5 ml 80 ml PwdIRecon.
250 mu5 ml 100 ml PwdIRecon.
250 mg/5 ml 150 ml PwdIRecon.
AmpicillinIAmpicillin Trihydrate Amcill, Omnipen,
Polycillin,
250 mg Capsule Principen, etc.
500 mg Capsule
125 mg15 ml 100 ml PwdIRecon.
125 mg15 ml 200 ml PwdIRecon.
250 mg15 ml 100 ml Pwd/Recon.
250 mu5 ml 200 ml PwdlRecon.
Aspirin; Butalbital; Caffeine Fiorinal
Lanorinal
325 mg; 50 mg; 40 mg Tablet
Aspirin; Caffeine; Orphenadrine Citrate
385 mg; 30 mg; 25 mg Tablet Norgesic
770 mg; 60 mg; 50 mg Tablet Norgesic Forte
Addendum A (cont.) PAYMENT FOR SERVICES 04-89
GENERIC NAME GENERIC UPPER COMMONLY KNOWN
UMITIUNIT Source* BRAND NAME61

Aspirin; Caffeine; Propoxyphene


Hydrochloride Da~on
Compound 65, etc.
389 mg; 32.4 mg; 65 mg Capsule
Aspirin; Carisoprodol
325 mg; 200 mg Tablet Soma Compound
Aspirin, Oxycodone Hydrochloride; Percodan
Oxycodone Terephthalate Codoxy
325 mg; 4.5 mg; 0.38 mg Tablet
Aspirin, Meprobamate Equagesic
325 mg; 200 mg Tablet
Atropine Sulfate; Diphenoxylate
Hydrochloride Lomotil, Colonaid,
0.025 mg15 ml; 2.5 mgl5 ml Oral Lomonate (liq. only)
Soluntion 60 ml
0.025 mg; 2.5 mg Tablet
Bacitracin Zinc; Neomycin Sulfate Neosporin, etc.
Polymyxin B Sulfate 400 unitslgm; Neo-Polycin
eq 3.5 mg Basefgm
Ointment; Opthalmic
3.5 gm
Baclofen
10 mg Tablet Lioresal
20 mg Tablet Lioresal DS
Benztropine Mesylate Cogentin
0.5 mg Tablet
1 mg Tablet
2 rng Tablet
Betamethasone Valerate Valisone
0.1 % base Cream
15 gm
45 gm
0.1% base Lotion 60 ml
0.1% base Ointment
15 gm
45 gm
Addendum A (cant.) PAYMENT FOR SERVICES 04-89
GENERIC NAME GENERIC UPPER COMMONLY KNOWN
UMlTlUNlT Source' BRAND NAME61

Bethanechol Chloride Urecholine


25 mg Tablet
Bromodiphenhydramine Hydrochloride; Bromanyl, Ambenyl,
Codeine Phosphate 12.5 mgl5 ml; 10mg15 ml
Syrup, Oral 480 ml
Butabarbital Sodium Butisol Sodium
30 mg/5 ml Elixir 480 ml
15 mg Tablet 1000's
30 mg Tablet 1000's
Caffeine; Ergotamine Tartrate Cafergot
Ercatab
100 mg; 1 mg Tablet Wigraine
Carbarnazepine Tegretol
200 mg Tablet
100 mg Tablet, Chewable
Carisoprodol Soma,
Rela
350 mg Tablet
Cephalexin Keflex
250 mg Capsule
500 mg Capsule
125 mg Base15 ml PwdIRecon.
100 mi
200 ml
250 mg base15 ml PwdlRecon.
100 mi
200 ml
Cephradine Velosef, Anspor
250 mg Capsule
500 mg Capsule
Chloramphenicol Chlorofair,
Chloromycetin
Ointment; Pothalmic 1%
3.5 gm
Solutionldrops; Opthalmic 0.5%
Addendum A (c0nt.l PAYMENT FOR SERVICES
GENERIC UPPER COMMONLY KNOWN
GENERIC NAME
UMiT/UNiT Source' BRAND NAME61

Chlordiazepoxide Hydrochloride Librium

5 mg Capsule
10 mg Capsule
25 mg Capsule
Diuril
chlorothiazide
500 mg Tablet
Diabinese
chlorpropamide
100 mg Tablet
250 mg Tablet
Hygroton
Chlorthalidone
25 mg Tablet
50 mg Tablet
Cleocin
Clindamycin Hydrochloride
75 mg Capsule
i50 mg Capsule
Paraflex
Parafon Forte DSC
250 mg Tablet
500 mg Tablet
Clofibrate Atromid-S

500 mg Capsule
Clonidine Hydrochloride Catapress

0.1 mg Tablet
0.2 mg Tablet
0.3 mg Tablet
Clorazepate Dipotassium Tranxene

3.75 mg Tablet
7.5 mg Tablet
15 mg Tablet
Cloxacillin Sodium Tegopen, Cloxapen, etc.

250 mg Capsule
500 mg Capsule
125 mg/5 ml 100 ml Pwd/Oral
Suspension
Addendum A (cant.) PAYMENT FOR SERVICES 04-89
GENERIC NAME GENERIC UPPER COMMONLY KNOWN
UMITNNIT source' BRAND NAME(S1

Codeine Phosphate; Phenylephrine Phenergan VC


Hydrochloride; Promethazine Hydrochloride with
10 mg/5 ml; 5 mg/5 ml; 6.25 mg/5 ml Codeine
Syrup 480 ml M
Codeine Phosphate; Promethazine Phenergan wlcodeine
Hydrochloride 10 mg/5 ml; 6.25 mg15 ml
Syrup 480 ml M
Codeine Phosphate; Pseudoephedrine
Hydrochloride; Triprolidine
Hydrochloride 10 mgl5 ml;
30 mg15 ml; 1.25 mg/5 ml
Syrup 480 ml M
Cyproheptadine Hydrochloride Periactin
4 mg Tablets M
2 mgl5 ml Syrup 480 ml M
Desipramine Hydrochloride Norpramin
10 mg Tablet B
25 mg Tablet R
50 mg Tablet M
75 mg Tablet M
I00 mg Tablet M
150 mg Tablet B
Dexamethasone; Neomycin Sulfate; Maxitrol, Dexasporin
Polymyxin B Sulfate 0.1%; 0.12%; EQ
3.5 mg Basehg; 10,000 unitslgrn
Ointment; Opthalmic
3.5 gm M
0.1%; EQ 3.5 mg base ml; 10,0OO/ml
Suspension/Drops; Opthalmic Dexacidin, Maxitrol
5 ml M
Dexamethasone Sodium Phosphate; Neodecadron
Neomycin Sulfate EQ 0.1%
Phosphate; EQ 3.5% Base/ ml
Solution/Drops Opthalmic
5 ml B
Dextromethorphan Hydrobromide; Promethazine
Hydrochloride 15 mgl5 ml; 6.25 mgl5 ml Phenergan
w1Dextromethorphan
Syrup 480 ml M
Addendum A (cont.) PAYMENT FOR SERVICES 04-89

GENERIC NAME GENERIC UPPER COMMONLY KNOWN


UMWNIT Source' BRAND NAMElS)

Diazepam Valium
2 mg Tablet B
5 mg Tablet B
10 mg Tablet B
Dicloxiciliin Sodium Pathocil, Dynapen, etC.

250 rng Capsule


500 mg Capsule
Dicyclornine Hydrochloride Bentyl
10 mg Capsule
20 mg Tablet
Diethylproprion Hydrochloride Tenuate, Tepanil, etc.
25 mg Tablet
Diphenhydramine Hydrochloride Benadryl
25 mg Capsule
50 mg Capsule
12.5 mg/5 ml. Elixir, 480 rnl
Disopyramide Phosphate Norpace
I00 mg Capsule
I50 mg Capsule
Doxepin Hydrochloride Adapin, Sinequan, etc.
10 rng Capsule
25 Mg Capsule
50 rng Capsule
75 mg Capsule
100 mg Capsule
10 rnglml Oral Concentrate 120 rnl
Doxycycline Hyclate Vibrarnycin, Vibra-Tabs,
etc.
100 mg Capsule, 50's
100 rng Tablet, 50's
Ergocalciferol Deltalin, Drisdol, etC.

50,000 IU Capsule
Ergoloid Mesylates Hydergine

1 rng Tablet; Oral


1 rng Tablet; Sublingual
Addendum A (cant.) PAYMENT FOR SERVICES 04-89
GENERIC W E GENERIC UPPER COMMONLY KNOWN
LIMlTluNrr Source' BRAND NAMEfS)

Erythromycin E-Mycin, ERY-TAB,


Robimycin
250 mg Enteric Coated Tablets B
Ointment; Opthalmic 5 mglgm Ilotycin, etc.
3.5 gm M
Solution; Topical 2%, 60 ml M Elyderm, etc.
Ewhromycin Estolate
125 mg/5 ml Oral Suspension 480 rnl
250 mg15 rnl Oral Suspension 480 rnl
Erythromycin Ethylsuccinate E.E.S., Pediamycin, etc.
200 mg/5 ml Oral Suspension 480 rnl
400 mg/5 rnl Oral Suspension 480 rnl
400 mg Tablet
Erythromycin Ethysuccinate; Pedizole
Sulfisoxazole Acetyl EQ 200 mg
Base15 ml; 600 mg Base15 ml
B
B
B
Erythromycin Stearate Erythrocin
250 mg Tablet B
500 mg Tablet B
Ethinyl Estradiol; Norethindrone Ortho-Novum,
Norethin
0.035 mg; 0.5 mg
Tablet, Oral-21 B
Tablet, Oral-28 B
Ethinyl Estradiol: Norethindrone Ortho-Novurn,
Norethin
0.035 mg; 1 mg
Tablet, Oral-21 B
Tablet, Oral-28 B
Fenoprofen Calcium Nalfon, Nalfon 200
200 mg Capsule B
300 rng Capsule M
600 mg Capsule M
Addendum A (cont.) PAYMENT FOR SERVICES 04-89
GENERIC NAME GENERIC UPPER COMMONLY KNOWN
UMITRlNIT Source' BRAND NAME61

Fluocinolone Acetonide Fluocet, Synalar, etc.


Cream; Topical 0.01%
15 gm
60 gm
Ointment; Topical 0.025% Fluonid, etc.
15 gm
60 mg
Solution; Topical 0.01% Fluotrex, etc.
20 ml
60 ml
Fluocinonide Lidex, Vasoderm, etc.
Cream; Topical 0.05%
15 gm
30 mg
60 mg
Flurazepam Hydrochloride Dalmane
15 mg Capsules
30 mg Capsules
Folic Acid Folvite
1 mg Tablet (1 000's)
Furosemide Lasix
20 mg Tablet
40 mg Tablet
80 mg Tablet
Gentamicin Suifate
Cream; Topical EQ 1 mg Baselmg M Garamycin, etc.
15 g m ~
Ointment; Opthalmic EQ 3 mg Baselgm Gentacidin, etc.
3.5 gm M
Ointment; Topical EQ 1 mg Baselgm
15 gm
Solution/Drops; Ophthalmic EQ
3 mg Baselml
5 ml M
Gramicidin; Neomycin Sulfate; Neosporin
Polymyxin B Sulfate
SolutionIDrops; Ophthalmic 0.025 mg/ml;
EQ 1.75 mg Baselmi; 10,000 unitslml
Addendum A (cont.) PAYMENT FOR SERVICES 04-89
GENERIC NAME GENERIC UPPER COMMONLY KNOWN
UMITNNIT Source. BRAND NAME(SI

Haloperidol Haldol
0.5 mg Tablet
1 mg Tablet
2 mg Tablet
5 rng Tablet
10 mg Tablet
20 mg Tablet
Haloperidol Lactate Haldol
2 mglml Oral Concentrate 120 rnl
Homatropine Methylbromide; Hydocodone Hycodan, etc.
Bitartrate 1.5 mgl5 rnl; 5 mg/5 ml
Oral Syrup 480 rnl
Hydralazine Hydrochloride
10 mg Tablet
25 mg Tablet
50 mg Tablet
100 mg Tablet
Hydralazine Hydrochloride; Apresazide
Hydrochlorothiazide
25 mg; 25 rng Capsule
50 mg; 50 mg Capsule
100 mg; 50 mg Capsule
Hydrochlorothiazide Hydrodiuril, Esidrix,
etc.
25 mg Tablet
50 mg Tablet
100 mg Tablet
Hydrochlorothiazide; Methyldopa Aldoril 15, 25, D30, D50
15 mg: 250 mg Tablet
25 mg; 250 mg Tablet
30 mg; 50 mg Tablet
50 mg; 500 rng Tablet
Hydrochlorothiazide; Propranolol Inderide - 40125;
Hydrochloride lnderide - 80125
25 mg; 40 rng Tablet
25 mg; 80 mg Tablet
Hydrochlorothiazide; Spironolactone
25 rng; 25 rng Tablet
Addendum A Icont.) PAYMENT FOR SERVICES 04-89
GENERIC NAME GENERIC UPPER COMMONLY KNOWN
UMF/UNF Source' BRAND NAMElS)

Hydrochorothazide, Triamterene Dyazide


25 mg; 50 mg Capsule B
50 mg; 75 mg Tablet M Maxzide
Hydrocortisone
Cream, Topical 1%
20 gm
30 gm
Lotion; Topical 1% Cetacort, Dermacort, etc
120 ml
Ointment; Topical Cortril, Pentcort, etc.
1% 20 gm
30 mg
2.5% 20 gm
Hydrocortisone; Neomycin Sulfate;
Polymyxin B Sulfate 1%; EQ 3.5 mg Baselml;
l0,OOOlml Cortisporin, etc.
Solution/Drops; Otic
10 ml Cortisporin
Suspension; Otic Otocort, etc.
10 ml
Hydroxyzine Hydrochloride Atarax
10 mg Tablet
25 mg Tablet
50 mg Tablet
10 mg/5 ml Oral Syrup 480 ml
Hydroxyzine Pamoate Vistaril
25 mg Capsule
50 mg Capsule
Ibuprofen Motrin, Rufin
400 mg Tablet
600 mg Tablet
800 mg Tablet
lmipramine Hydrochloride Tofranil
25 mg Tablet
50 mg Tablet
Addendum A (cant.) PAYMENT FOR SERVICES
GENERIC NAME GENERIC UPPER COMMONLY KNOWN
LlMITbJNIT Source' BRAND NAMEIS)

lndomethacin lndocin
25 mg Capsule
50 mg Capsule
75 mg Capsule, Controlled Release lndocin SR
lsoetharine Hydrochloride Bronkosol
1%solution; Inhalation
10 ml .3285
lsoniazid INH, etc.
300 mg Tablet
lsosorbide Dinitrate
5 mg Tablet; Oral lsordil
10 mg Tablet; Oral
20 mg Tablet; Oral
30 mg Tablet; Oral
40 mg Tablet; Oral
2.5 mg Tablet; Sublingual
5 mg Tablet; Sublingual
10 mg Tablet; Sublingual
Lactulose
10 mg/ 15 ml Syrup; Oral 480 ml Chronulac
Lindane
Lotion; Topical 1% Kwell, Scabene
60 ml
480 ml
Shampoo; Topical 1% Scabene, Kwell
60 ml
480 rnl
Lithium Carbonate Eskalith. Lithonate
300 mg Capsule
300 mg Tablet Eskalith
Lithium Citrate Cibalith-S, etc.
300 mg/5 ml 480 rnl
Lorazepam Ativan
0.5 mg Tablet
1 rng Tablet
2 mg Tablet
Addendum A kont.) PAYMENT FOR SERVICES 04-89
GENERIC NAME GENERIC UPPER COMMONLY KNOWN
UMlT/UNlT Source' BRAND NAMEIS)

Loxapine Succinate Loxitane


5 mg Capsule M
10 mg Capsule B
25 mg Capsule B
50 mg Capsule B
Maprotiline Hydrochloride Ludiomil

25 mg Tablet
50 mg Tablet
75 mg Tablet
Meclizine Hydrochloride Antivert
12.5 mg Oral Tablet
25 mg Oral Tablet
Meclofenamate Sodium Meclornen
50 mg Capsule
100 mg Capsule
Mefenamic Acid Ponstel
" 250 mg Capsule
Megestrol Acetate Megace
20 mg Tablet
40 mg Tablet
Meperidine Hydrochloride Demerol

50 mg Tablet
100 mg Tablet
Meprobamate Miltown, Equanil
200 mg Tablet
400 mg Tablet
Mestranol; Norethindrone
0.05 mg; I mg
Tablet, Oral21 Norethin 1/50 M-21
Tablet, Oral-28 Norethin 1/50 M-28

Metaproterenol Sulfate Alupent

10 mg Tablet
20 mg Tablet
Methocarbamol Robaxin

500 mg Tablet
750 mg Tablet
Addendum A Ic0nt.l PAYMENT FOR SERVICES 04-89
GENERIC NAME GENERIC UPPER COMMONLY KNOWN
LlMIT/UNlT Source' BRAND NAME61

Methyclothiazide Aquatensen, Enduron,


etc.
2.5 mg Tablet
5 mg Tablet
Methyldopa Aldomet
125 mg Tablet
250 mg Tablet
500 mg Tablet
Methylphenidate Hydrochloride Ritalin
5 mg Tablet
10 mg Tablet
20 mg Tablet
20 rng Tablet, Controlled Release
Metoclopramide Hydrochloride Reglan
5 mg Tablet
10 rng Tablet
Metronidazole Flagyl
250 mg Tablet
500 mg Tablet
Minoxidil Loniten
10 mg Tablet
Nalidixic Acid Neggram
250 mg Tablet
500 mg Tablet
1 gm Tablet
Naphazoline Hydrochloride Vasocon
SolutionJDrops; Ophthalmic 0.1%
15 ml
Nitrofurantoin, Macrocrystalline Macrodantin
50 mg Capsule
100 rng Capsule
Nystatin Mycostatin
Suspension, Oral
lo0,OoOUnitd5 ml
60 mi
Addendum A (cant.) PAYMENT FOR SERVICES 04-89

GENERIC NAME GENERIC UPPER COMMONLY KNOWN


LlMIT/UNIT Source' BRAND NAME61

Nystatin Mycostatin

Cream:Topical
i00,000 Unitstgrn
15 gm
30 gm
Ointment; Topical Nilstat, etc.

Tablet Gginal
100,000 Units 15's ,1680 R
30's .I474 R
Nystatin; Triarncinolone Acetonide
100,000 Unitslgrn; 0.1%
Cream; Topical Mycolog II, etc.
15 gm M
30 gm M
60 gm M
Ointment; Topical Mycolog II, etc.
15 gm M
30 grn
60 gm
Oxtriphylline Choledyl

20 mg Enteric Coated Tablet


Oxybutynin Chloride Ditropan

5 mg Tablet
Pencillin V Potassium
125 mg/5 rnl 100 rnl PwdiRecon. B Pen-Vee K, V-cillin K,
125 mg/5 rnl 200 mi PwdiRecon. R
250 rngl5 ml 100 rnl PwdtRecon. R
250 mg/5 rnl 200 rnl PwdiRecon. R
250 mg Tablet R
500 rng Tablet B

Phendimetrazine Tartrate Plegine, etc.

35 mg Tablet, 1000's R

Phentermine Hydrochloride Fastin, etc.

30 mg Capsule M
Addendum A (cant.) PAYMENT FOR SERVICES 04-89
GENERIC NAME GENERIC UPPER COMMONLY KNOWN
UMIT/UNIT Source' BRAND NAMEIS)

Phenylbutazone Azolid; Butazolidin, etc.


100 mg Tablet
100 mg Capsule
Phenylephrine Hydrochloride; Phenergan VC
Promethazine Hydrochloride
5 mgI5 ml; 6.25 mgl5 ml
Syrup, Oral 480 ml
Phenytoin Sodium Dilantin
100 mg Capsule Extended Release
Prednisolone Acetate; Sulfacetamide Sodium
0.5%; 10% Suspension/Drops; Ophthalmic Metimyd, Predsulfair
5 ml
Primidone Mysoline
250 mg Tablet
Probenecid Benemid
500 mg Tablet
procainamide Hydrochloride Pronestyl, etc.
250 mg Capsule
375 mg Capsule
500 mg Capsule
250 mg Tablet, Controlled Release
500 mg Tablet, Controlled Release
750 mg Tablet, Controlled Release
Prochlorperazine Maleate Compazine
5 mg Tablet
10 mg Tablet
25 mg Tablet
Promethazine Hydrochloride Phenergan Plain
6.25 mgl5 ml Syrup 480 ml
Propantheline Bromide Pro-Banthine
15 mg Tablet
Propoxyphene Hydrochloride Darvon
65 mg Capsule
Propranolol Hydrochloride lnderal
10 mg Tablet
20 mg Tablet
Addendum A (cont.) PAYMENT FOR SERVICES 04-89
GENERIC NAME GENERIC UPPER COMMONLY KNOWN
LIMITAJNIT Source' BRAND NAME61

Propranolol Hydrochloride lnderal


40 mg Tablet
60 mg Tablet
80 mg Tablet
90 mg Tablet
Quinidine Sulfate Cin-Quin, Quinora, etc.
200 mg Tablet
300 mg Tablet
Selenium Sulfide Selsun, etc.
Lotion/Shampoo; Topical 2.5%
120 ml
Spironolactone Aldactone
25 mg Tablet
Sulfacetamide Sodium Sulfair, etc
Ointment, Ophthalmic 10%
3.5 gm
Solution/Drops, Ophthalmic 10% Bleph-10, etc.
15 ml
Sulfamethoxazole Gantanol
500 mg Tablet
Sulfamethoxazole; Trimethoprim Bactrim Septra, etc.
200 mg/5 ml; 40 mg/5 ml
Oral Suspension 480 ml
400 mg; 80 mg Tablet
800 mg; 160 mg DS Tablet
Sulfisoxazole Gantrisin
500 mg Tablet
Temazepam RestOril
15 mg Capsule
30 mg Capsule
Tetracycline Hydrochloride Achromycin, Sumycin, etc.
125 rngl5 rnl Syrup 480 ml
250 mg Capsule
500 mg Capsule
Theophylline Elixophyllin, Lanophyllin
Theolixir, Elixomin, etc.
80 mg115 ml Elixir 480 ml
Addendum A (cant.) PAYMENT FOR SERVICES
GENERIC NAME GENERIC UPPER COMMONLY KNOWN
UMiT/UNIT Source' BRAND NAMEIS)

Thioridazine Hydrochloride Mellaril

10 mg Tablet
15 mg Tablet
25 mg Tablet
50 mg Tablet
100 mg Tablet
150 mg Tablet
200 mg Tablet
30 mglml Oral Concentrate 120 ml
100 mg/ml Oral Concentrate 120 ml
Thiothixene Hydrochloride Navane
1 mg Capsule
2 mg Capsule
5 mg Capsule
10 mg Capsule
Tolazamide Tolinase
100 mg Tablet
250 mg Tablet
500 mg Tablet
Tolbutamide Orinase
500 mg Tablet
Trazodone Hydrochloride Desyrel
50 mg Tablet
100 mg Tablet
Triamcinolone Acetonide Aristocort, Kenalog
Cream, Topical
0.025% I5 gm
80 gm
0.1% 15 gm
80 gm
Ointment, Topical
0.1% 15 gm
80 gm
Lotion, Topical
.025% 60 ml
.I% 15 ml
60 ml
Addendum A Icont.) PAYMENT FOR SERVICES 04-89

GENERIC NAME GENERIC UPPER COMMONLY KNOWN


UMITRlNrr Source' BRAND NAME61

Trifluoperazine Hydrochloride Stelazine

2 mg Tablet
5 mg Tablet
10 mg Tablet
Trihexyphenidyl Hydrochloride Artane
2 mg Tablet
5 mg Tablet
Trimethoprim
100 mg Tablet Proloprim, Trimpex
200 mg Tablet Trimpex 200, etc.
Valproate Sodium Depakene

Syrup: Oral
250 mg Base15 ml
Valproic Acid Depakene

250 mg Capsule
Verapamil Hydrochloride Calan, Isoptin, etc.

80 mg Tablet
120 mg Tablet
NPC - 1989

MEDICAL ASSISTANCE PROGRAM BENEFITS (TITLE XIX)


TOTAL UNITED STATES VENDOR PAYMENTS BY WPE OF SERVICE

% Total % Total

Intermediate Care Facility 28.7 30.5

Hospital Inpatient 28.1 27.6

Skilled Nursing
Facility 13.2 13.0

Pharmaceuticals 6.6 6.7

Physicians 5.9 6.0

Hospital Outpatient 4.9 4.9

Home Health Care 3.8 4.1

Clinic 2.1 2.2

Dental 1.2 1.1

LabK-ray 1.o 1.I

Family Planning 0.5 0.4

Other Practitioners 0.6 0.5

Other Care 3.0 3.2

TOTALS

Above figures include Puerto Rico and the Virgin Islands.

Other care includes: early and periodic screening, rural health clinic services and miscellaneous other care.

NOTE: The totals used on this chart are detailed on pages 98-131, obtained from the HCFA 2082 report
dated June 1989.
-
NPC-I 989

MEDICAL ASSISTANCE PROGFWM BENEFITS (TITLE XIX)


TOTAL U. S. VENDOR PAYMENTS BY TYPE OF SERVICE
1988

Other care includes early & periodic screening, rural health clinic services and miscellaneous other care.

85
MEDICAID RECIPIENTS AND VENDOR PAYMENTS - 1988

Total Vendor Average Average


Total Medical Expenditure States Expenditure
State Recipients Payments Per Recipient By Ranking Per Recipient

Alabama 305,302 Mississippi


Alaska 32,892 West Virginia
Arkansas 226,733 California
California 3,674,940 Alabama
Colorado 179,587 Michigan
Connecticut 212,881 Wyoming
Delaware 37,150 Kentucky
District of Columbia 96.705 Montana
Florida Hawaii
Georgia South Carolina
Hawaii Oregon
ldaho Illinois
Illinois Louisiana
lndiana Missouri
lowa Texas
Kansas Tennessee
Kentucky Arkansas
Louisiana Florida
Maine Kansas
Maryland Georgia
Massachusens New Mexico
Michigan Pennsylvania
Minnesota lowa
Mississippi Ohio
Missouri Washington
Montana Utah
Nebraska Nebraska
Nevada Vermont
New Hampshire Virginia
New York North Carolina
New Jersey Oklahoma
New Mexico Wisconsin
North Dakota Colorado
North Carolina Nevada
Ohio Maryland
Oklahoma ldaho
Oregon Delaware
Pennsylvania Maine
Rhode Island Alaska
South Dakota South Dakota
South Carolina New Jersey
Tennessee Minnesota
Texas Rhode Island
Utah lndiana
Vermont North Dakota
Virginia Massachusetts
Washington District of Colun
West Virginia Connecticut
Wisconsin New York
Wyoming New Hampshire

United States
C - 1989 RECIPIENTS OF PRESCRIBED DRUGS

4TE
Total

bama
ska
ansas
iifornia
lorado
nnecticut
aware

rida
orgia
uaii
h0
lois
iana
fa
isas
itucky
~isiana
ine
ryland
ssachusetts
:higan
lnesota
isissippi
souri
ntana
braska
irada
N Hampshire
N Jersey
N Mexico
N York
rth Carolina
rth Dakota
io
lahoma
:gon
insylvania
3de island
~ t Carolina
h
~ t Dakota
h
messee
:as
lh
'mont
jnia
shington
st Virginia
;consin

Jrce: HCFA 2082 reports, compiled by state Medicaid program officials. Although the reports have been reviewed and
ted by HCFA, they do not guarantee the accuracy of the data. (See caveats p. 97) Despite these caveats, the 2082
a represents the most accurate figures available On the utilization of state Medicaid services.
AVERAGE EXPENDITURE PER RECIPIENT FOR PRESCRIBED DRUGS
ATE
Average
ibama
!ska
ransas
lifornia
,lorado
nnecticut
laware
:'
rida
!orgia
iwaii
ih0
iois
iiana
va
.nsas
ntuckyi
uisiana
aine
aryland
assachusetts
chigan
nnesota
ssissippi
ssouri
mtana
?braska
wada
?w Hampshirei
?W Jerseyi
?w Mexico
?w Yorki
xth Carolina
~ r t hDakota
iio
dahoma
'egon
mnsylvania
lode Island
~ u t hCarolina
~uth Dakota
mnessee
lxas
:ah
3rmont
rginia
ashington
'est Virginia
'isconsin
Iurce: HCFA 2082 reports, compiled by state Medicaid program officials. Although the reports have been reviewed
i d edited by HCFA, they do not guarantee the accuracy of the data. (See caveats p. 97) Despite these caveats, the
182 data represents the most accurate figures available on the utilization of state Medicaid sewices.

' Jurisdictions reporting some or all nursing home prescription expenditures in per diem nursing home rate
90
NPC - 1989

PERCENTAGE OF MEDICAID EXPENDITURES


ALLOCATED TO PRESCRIPTION MEDICATION

STATE
US Total

Alabama
Alaska
Arkansas
California
Colorado
Connecticut
Delaware
DC
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
NPC - 1989

MEDICAID DRUG REIMBURSEMENT REPORT

Ingredient State
Dispensing Reimbursement Formulam MAC
State Fees Copayment Basis Formulary Status (12)

Alabama $3.75 $ .50 - 3.00 WAC+9.2% Yes C


Alaska 3.45-1 1.46 AWP-5% No B
Arizona 2.50 AHCCCS - Arizona Health Care Cost Containment System
Arkansas 4.01 AWP yes C Yes
California 4.05 EAC Yes C Yes
Colorado 3.78 EAC (4) Yes C Yes
Connecticut 3.55 (1) AWP-8% No B NO
Delaware 3.65 AAC No B NO
D.C. 4.25 AWP-10% NO B NO
Florida 4.23 WAC+7% NO B NO
Georgia 4.26 AWP-10% Yes C Yes
Hawaii 4.14 AWP-10.5% Yes C NO
Idaho 4.00 AWPIEAC NO B No
Illinois 3.47 AWP-10% Yes C Yes
Indiana 3.00 AWP3% NO B NO
Iowa 3.78 (1) AWP No B Yes
Kansas 2.79-5.26 EAC Yes C Yes
Kentucky 3.25 EAC Yes C Yes
Louisiana 3.51 AWP-10.5% No B Yes
Maine 3.55 EAC No B Yes
Ma~yland 3.70 EAC No B Yes
Massachusetts 3.88 WAC+lO% No B Yes
Michigan 3.65 AAC (5) Yes C Yes
Minnesota 4.20 AWP-10% Yes C Yes
Mississippi 3.75 EAC Yes C Yes
Missouri 3.00 AWPIEAC Yes C Yes
Montana 2.00-4.00 AWP-10% No A No
Nebraska 2.84-5.05 (6) No B Yes
Nevada 3.95 (7) No B No
New Hampshire 2.85-3.00 AWP No B No
New Jersey 3.73-4.07 EAC (9) Yes B NO
New Mexico 3.65 AWP-10.5% No B Yes
New York 2.60 EAC Yes C Yes
North Carolina 4.24 AWPIEAC No A NO
North Dakota 3.75 AWPIEAC No B No
Ohio 3.23 EAC (1 0) Yes C Yes
Oklahoma 3.55 AAC Yes C Yes
Oregon 3.52-3.83 EAC No B Yes
Pennsylvania 2.75 EAC No B Yes
Rhode Island 3.40 EACIAWP No B Yes
South Carolina 4.05 AWP-9.5% No B Yes
South Dakota 4.25 AWP-I 0.5% Yes B Yes
Tennessee 4.21 AWP-7% Yes C Yes
Texas (3) EAC (8) No B Yes
Utah 3.65 AWP-12% No B Yes
Vermont 2.75 AWPIEAC No B Yes
Virginia 3.40 EAC No B Yes
Washington 3.1 5-4.20 EAC Yes C Yes
West Virginia 2.75 EACIAWP Yes C Yes
Wisconsin 3.72 EAC No B Yes
Wyoming 4.16 EAC No B No

See legend page 94


NPC - 1989

LEGEND:

Connecticut, Iowa: Plus incentive fee for dispensing a lower cost product
California: Collection by pharmacy is optional
Texas: Amount paid pharmacy equals (EAC + $3.26) divided by 0.945
Colorado: AWP or direct cost of wholesaler cost plus 18%
Michigan: AAC with AWP minus 10% screens
Nebraska: WAC plus 12.52% or AWP minus 8.71%, whichever is less
Nevada: EAC or AWP minus 10%
Texas: EAC equals lower of AWP minus 10.49% or WAC plus 12% or direct price or federal
upper limit
New Jersey: Lowest of AWP, AWP - 6% (under $25), and WAC + 25%
Ohio: EAC equals a combination of AWP minus 7%, direct price, AWP for scheduled II, 65th
percentile MAC'd drugs
Most multisource products
State MAC'S are in addition to Federal Upper Limits (FUL) list
Wyoming: MMlS data not available until FY 89

A = No drug list - all legend drugs reimbursed


B = No drug list - but certain categories are excluded from reimbursement
C = Restricted drug list

NOTE: The dispensing fees, copayments, ingredient reimbursement, formulary and MAC data
are current to August 1989.

The vendor payment, average Rx price, and prescriptions processed data are close
approximations based upon the 1988 fiscal year.
NPC - 1989

SUMMARY OF MEDICAID LIMITATIONS - PHARMACEUTICALS

Fbc Limit Refill Limit Quan. Limit tmiL= OTC Status


Alabama No Yes (1) NO NO D
Alaska No No Yes (12) No D
Arizona'
Arkansas Yes (6) No No No C
California No Yes Yes No B
Colorado No No Yes No C
Connecticut No Yes (6) Yes No C
Delaware No No No No C
District of Columbia No Yes (3) Yes (12) No C
Florida Yes No NO No C
Georgia Yes (6) No Yes (12) No C
Hawaii No No Yes No C
Idaho No No Yes (12) No C
Illinois No No Yes No C
Indiana No (10) No NO No B
Iowa No No NO No C
Kansas No NO No No C
Kentucky No Yes (1) Yes (12) No C
Louisiana No Yes (1) Yes No C
Maine No Yes (I) NO No C
Maryland No Yes (2) Yes No C
Massachusetts NO NO Yes No C
Michigan No Yes (1) Yes No C
Minnesota NO Yes (5) Yes (1 3) No C
Mississippi Yes (4) Yes (1) Yes No C
Missouri Yes (5) NO No No C
Montana No No Yes No C
Nebraska No NO Yes (7) No B
Nevada Yes (5) No Yes (12) No C
New Hampshire NO Yes (1) Yes (12) No B
New Jersey NO Yes (1) Yes (14) No C
New Mexico NO Yes No No C
New York Yes Yes (1) No No C
North Carolina Yes (6) No No No D
North Dakota NO Yes (1) No No C
Ohio NO Yes Yes No C
Oklahoma Yes (3) NO Yes (12) NO D
Oregon No NO Yes (13) No C
Pennsylvania NO Yes (I) Yes No B
Rhode Island NO Yes (1) Yes (12) No B
South Carolina Yes (4) NO Yes (13) No C
South Dakota NO NO No No C
Tennessee Yes (9) Yes (1) Yes (12) No C
Texas Yes (3) Yes (1) Yes (15) No C
Utah No No Yes (12) No C
Vermont NO Yes (1) Yes No C
Virginia NO NO NO NO B
Washington NO NO (2) Yes (12) No C
West Virginia NO Yes (1) Yes (12) No C
Wisconsin NO Yes Yes (12) No C
Wyoming NO Yes (I) No No C
See next page for key deilniLions

' AHCCCS Capitation Plan


KEY

(1) 5 Refill Limit


(2) 2 Refill Limit
(3) 3 Rx's Per Month
(4) 4 Rx's Per Month
(5) 5 Rx's Per Month
(6) 6 Rx's Per Month
(7) Some, But Not All Rx's
(8) 3 Refill Limit
(9) 7 Rx's Per Month
(10) In Long Term Care Facility Only
(2 Dispensing Fees/Drug/RecipienffMonth)
(11) Up To One Year
(12) 30 Days Supply or 100 Units
(13) 100 Days Supply
(14) 60 Days or 100 Units
(15) 180 Days Supply

OTC Status

A - All OTC's Reimbursed


B - Most OTC's Reimbursed
C - Few OTC's Reimbursed
D - None
CAVEATS FOR BASIC N 88 HCFA 2082 DATA TABLES
February 3, 1989

The data in the anached tables are based on information reported to the Health Care Financing
Administration (HCFA) for federal fiscal years ending September 30 on the Form HCFA 2082. Statistical
Report on Medical Care: Eliaibles, Recipients, Payments, and Services. HCFA provides the data in
these tables as a public service. HCFA does not guarantee the accuracy of the data, which were
obtained from State Medicaid Agencies.

When using the data keep the following caveat in mind:


o Counts of recipients and eligibles stratified by Maintenance Assistance Status (MAS) and
Basis of Eligibility (BOE) generally count each person only once -- based on the person's
MASIBOE as of his first appearance on the Medicaid rolls during the federal fiscal year
covered by the report.

Note, however, that some States report duplicated counts of recipients in the MASIBOE
stratification cells. That is, they report an individual in as many stratification cells as the
individual had different MASIBOE statuses during the year. In such cases, the sum of
all MASIBOE cells will be greater than the Total Recipients" number.
o
Expenditure data include payments for all claims adjudicated or paid during the fiscal
year covered by the report. Note that this is not the same as summing payments for
services that were rendered during the report period.

o Some States fail to submit the HCFA 2082 for a particular year. When this happens,
HCFA estimates the current year's HCFA 2082 data for missing States based upon prior
year's submissions and information the State entered on HCFA 64 (the form States use
to claim reimbursement for Federal matching funds for Medicaid).

HCFA 2082s submitted by States frequently contain obvious errors in one or more cells
in the form. For cells obviously in error, HCFA estimates values that appear to be more
reasonable.
e Certain States submitted a revised HCFA 2082 that may have amended some data
originally reported. States which submitted amended data are indicated.

Questions about these tables or other Medicaid data should be directed to Tony Parker at 3011966-
7917 or FTS 646-7917.
JUNE 23. 1989
F
TABLE 1. M E D I C A I D R E C I P I E N T S BY MAINTENANCE ASSISTANCE STATUS A N 0 BY REGION AND
STATE: F I S C A L YEAR 1988

BOSTON: REGION I
CONNECTICUT
2/ MAINE
11 MASSACHUSETTS
NEW HAMPSHIRE
RHOOE I S L A N D
VERMONT

NEW YORK: REGION


2/ NEW JERSEY
NEW YORK
3/ PUERTO R I C O
V I R G I N ISLANDS

PHILADELPHIA: REGION 111


DELAWARE
D I S T.~
R-I C-T OF COLUMBIA
YLAND

ATLANTA: REGION I V
2/ ALABAMA
FLORf OA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH CAROLINA
SOUTH CAROLINA

CHICAGO: REGION V
ILLINOIS
INDIANA
MICHIGAN
MINNESOTA
OHO
I-
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW MEXICO
OKLAHOMA
TEXAS

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

DENVER: REGION V I I I
COLORADO
2/ MONTANA
2/ NORTH OAKOTA
-
- - ... DAKOTA
SOUTI4 -

2/ UTAH
WYOMING

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X 808.424


ALASKA 26.691
IDAHO 27,669
OREGON 122.076
WASHINGTON 403.272 332.199
MASSACHUSETTS B L I N D R E C I P I E N T A N 0 EXPENOITURE OATA ARE E S T I M A T E D .
I/
2/ MEOSTAT STATES' R E C I P I E N T AND EXPENDITURE OATA.
- 8 sunrrrTfs STATES' DATA ARE ESTIMATED.
JUNE 2 3 . 1989
T A B L E 1. M E D I C A I D R E C I P I E N T S BY M A I N T E N A N C E ASSISTANCE STATUS AN0 BY R E G I O N AND
(CONT) STATE: F I S C A L YEAR 1988
OPTIONAL MAINTENANCE
MEDICALLY CATEGORICALLY ASSISTANCE
----YEEQI---- SIBIYS-UNYNQb!b
-BEGZPY--bYQ--81AIE----
ALL JURISDICTIONS
---NEEQY--
3,604,619 89,531 44.818

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHOOE I S L A N D
VERMONT

NEW YORK: R E G I O N I1 1,192.479


NEW JERSEY 4,652
NEW YORK 567.298
PUERTO R I C O 613.257
VIRGIN ISLANDS 7,262

PHILADELPHIA: R E G I O N I11 263.866


-DELAWARE
.-. . - 0
D I S T R I C T O F COLUMBIA
MARYLAND
PENNSYLVANIA
VIRGINIA
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH CAROLINA
SOUTH C A R O L I N A
TENNESSEE

CHICAGO: REQION V
ILLINOIS
I N D I- A N A
MICHIGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEY M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
MISSOURI
NEBRASKA

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

SAN F R A N C I S C O : REGION I X 901.339


CALIFORNIA 881.000
HAWAII 20.339
NEVADA 0
J U N E 23, 1989
T A B L E 2. M E D I C A I D R E C I P I E N T S BY B A S I S O F E L I G I B I L I T Y AND B Y R E G I O N A N 0 S T A T E :
F I S C A L YEAR 1988

TOTAL AGE 65 PERMANENTLY AND


IBIBbCI-PISBBLEQ
3,401,136

BOSTON: REGION I 166.6-


CONNECTICUT 26.862
MATNE 19.696
88.148
6.093
19.761 *,,*~ : ~
VERMONT 7.188 .,&

PHILADELPHIA: R E G I O N I11
DELAWARE
D I S T R I C T O F COLUMBIA
MARYLAND
PENNSYLVANIA
VIRGINIA
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH C- A R O L I N A
~

SOUTH CAROLINA
TENNESSEE

CHICAGO: REGION V
ILLINOIS
INDIANA
MICHIGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
MISSOURI
NEBRASKA

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

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
-- . -
T n .A.U. n
OREGON
WASHINGTON
-
-
J U N E 2 3 . 1989
TABLE 2 . M E D I C A I D R E C I P I E N T S B Y B A S I S O F ELIGIBILITY AND BY R E G I O N A N 0 S T A T E :
( C ~ ~ F ~ I S) C A L YEAR 1 9 8 8
AFOC OTHER BASIS OF
CHILDREN AFOC TITLE XIX ELIG
--
RMIQN--~NP--SI&IE----
ALL J U R I S D I C T I O N S
UNDER-21
10,037.347
ADULIS
5.603.317
RECIPEENIS
1,343,460
-UN_YNPYN_
44,960

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHOOE I S L A N D
VERMONT

NEW YORK: R E G I O N I1
NEW J E R S E Y
NEW YORK
PUERTO R I C O
VIRGIN ISLANDS

PHILADELPHIA: REGION 1x1 1.028.137


.- ARE
FLAWA 18.377
DISTRICT OF COLUMBIA 44,273
MARYLAND 163,823
PENNSYLVANIA 596.215
VIRGINIA 122.222
WEST V I R G I N I A 93.227

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH CAROLINA
SOUTH C A R O L I N A
TENNESSEE

CHICAGO: REGION V
ILLINOIS
INDIANA
MICHIGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I 358,757


IOWA 88,071
KANSAS

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

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IDAHO
OREGON
WASHINGTON
J U N E 23. 1989
ABLE 3. M E D I C A I D R E C I P I E N T S BY T Y P E O F S E R V I C E A N 0 BY R E O I O N AND S T A T E :
F I S C A L YEAR 1988

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHOOE I S L A N D
VERMONT

NEW YORK: R E G I O N 11
NEW J E R S E Y
NEW YORK
PUERTO R I C O
VIRGIN ISLANDS

PHILADELPHIA: R E G I O N 111
DELAWARE
D I S T R I C T O F COLUMBIA
MARYLAND
PENNSYLVANIA
VIRGINIA
WEST V I W I N I A

ATLANTA: R E G I O N 1'4'
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

on10
WISCONSIN

DALLAS: REOION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
MISSOURI
NEBRASKA

DENVER :
COLC

NOR'
SOUTH
--. I
UTAH
WYDWING

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IDAHO
OREGON
WASHINGTON
T A B L E 3. M E D I C A I D R E C I P I E N T S B Y T Y P E OF S E R V I C E A N 0 BY R E G I O N A N 0 S T A T E :
(CONT) F I S C A L YEAR 1988
IYIESMEPLBIS--cbBE--E&GZCIILES
MENTALLY ALL PHYSICIAN DENTAL
-BEEIQY--bYQ--SIbIE---- BEIbBDED PIHEC! SSRYIEES SSBYICE~
ALL JURISDICTIONS 145,408 865.589 15.265.198 5.071.950

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHOOE I S L A N D
VERMONT

NEW YORK: REGION I1


NEW J E R S E Y
NEW YORK
PUERTO R I C O
VIRGIN ISLANDS

PHILADELPHIA: R E G I O N 111
DELAWARE
D I S T R I C T OF COLUMBIA
MARYLAND
PENNSYLVANIA
VIRGINIA
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH CAROLINA
SOUTH C A R O L I N A
TENNESSEE

CHICAGO: REGION V
ILLINOIS
INDIANA
MICHIGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
I O UA

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

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA

SEATTLE: REOIDN X
A L-A S- K A
IDAHO
OREGON
WASHINGTON
J U N E 23, 1989
T A B L E 3. M E D I C A I D R E C I P I E N T S BY T Y P E O F S E R V I C E A N 0 BY R E G I O N A N 0 S T A T E :
(CONT) F I S C A L YEAR 1988

OUTPATIENT CLINIC LAB A


YPSPII64 SEBYIGES --X_=R&Y_-
10,532,976 2,256.420 7,679,294

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHODE I S L A N D
VERMONT

NEW YORK: REGION I1


NEW J E R S E Y
NEW YORK
PUERTO R I C O

PHILADELPHIA: R E G I O N I11
DELAWARE
D I S T R I C T O F COLUMBIA
MARYLAND
PENNSYLVANIA
VIRGINIA
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

CHICAGO: REGION V
ILLINOIS
INDIANA
MICHIGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
. .. .~ -~

LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
MISSOURI
NEBRASKA

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

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
-
- ....-
TnAYn
OREGON
WASHINGTON
JUNE 23, 1989
TABLE 3. M E D I C A I D R E C I P I E N T S BY T Y P E O F S E R V I C E AND BY REG; I O N AND S T A T E :
(CONT) F I S C A L YEAR 1988
EARLY AN0
HOME PRESCRIBED FAMILY PERIODIC
- - -- -
HEAL-
TH- ----------
DRUGS
569,097 16,323,372

BOSTON: REGION I
CONNECTICUT
. ...- ..-
MASSACHUSETTS
NEW H A M P S H I R E
RHODE I S L A N D

NEW YORK: REGION I1


N F W JERSEY
.
vnw
!TO R I C O
ISLANDS

A: R E G I O N 111
YARE
R I C T O F COLUMBIA
0
VANIA
VIROINIA
WEST V I R G I N I A

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

CHICAOO: REGION V
ILLINOIS
INDIANA
MICHIGAN .
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
K~NSAS
MISSOURI
YEBRASKA

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

SAN F R A N C I S C O : REGION I X
CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
I ALASKA
I IDAHO
I: OREGON
WASHINGTON
J U N E 23. 1989
TABLE 3. M E D I C A I D R E C I P I E N T S BY T Y P E O F S E R V I C E AND B Y R E G I O N AND S T A T E :
(CONT) F I S C A L YEAR 1988
RURAL
HEALTH SERVICE
-cLlNIE YNKNPYN
140.380 36

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHOOE I S L A N D
VERMONT

NEW YORK: REGION


NEW J E R S E Y
NEW YORK
PUERTO R I C O
VIRGIN ISLANDS

PHILADELPHIA: R E G I O N 111
DELAWARE
D I S T R I C T O F COLUMBIA
MARYLAND
PENNSYLVANIA
VIRGINIA
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

on10
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
MISSOURI
NEBRASKA

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

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IDAHO
OREGON
WASHINGTON
i
-
J U N E 23, 1989
TABLE 4. C A T E G O R I C A L L Y NEEDY M E D I C A I D R E C I P I E N T S WHO R E C E I V E CASH PAYMENTS
BY B A S I S O F E L I G I B I L I T Y AND B Y R E G I O N A N 0 S T A T E : F I S C A L YEAR 1988

A G E 65
nm-wm
1,561,247

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
AW~DE ISLAND
VERMONT

NEW YORK: REGION I1


NEW J E R S E Y
NEW YORK
PUERTO R I C O
VIRGIN ISLANDS

~HILAOELPHIA: R E G I O N I11
DELAWARE
D I S T R I C T OF COLUMBIA

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

CHICAGO: REGION V
ILLINOIS
INDIANA
MICHIQAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

DENVER: REGION V I I I
COLORADO
. .-..
MnYTALIA
.7...-

NORTH OAKOTA
SOUTH OAKOTA
UTAH
WYOMING

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IDAHO
OREGON
WASHINGTON
- - ~~
~ ~
~ - .---
~~ -

J U N E 23. 1989
T A B L E 4. C A T E G O R I C A L L Y NEEDY M E D I C A I D R E C I P I E N T S WHO R E C E I V E CASH PAYMENTS
(CONT) BY B A S I S OF E L I G I B I L I T Y AND BY R E G I O N A N 0 S T A T E : F I S C A L YEAR 1988
AFOC B A S I S OF
AFOC ELIG
-BSPIQN--4NP--SI4IE---- ---6QULIS UYKNQVY
A L L JURISDICTIONS 4.077.272 162

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHODE I S L A N D
VERMONT

NEW YORK: R E G I O N I1
N W JERSEY
N W YORK
WERTO RICO
VIRGIN ISLANDS

PHILADELPHIA: R E G I O N 111
DELAWARE
D I S T R I C T OF COLUMBIA
MARYLAND
PENNSYLVANIA
VIRQINIA
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
.-. .
, - -
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

CHICAGO: REGION V
ILLINOIS
INDIANA
MICHIGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
iOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
MISSOURI
NEBRASKA

DENVER: REGION V I I I
COLORADO
MONTANA 20; o o i
NORTH DAKOTA 11.221
SOUTH DAKOTA 14,934
UTAH 27.032
WYOMING

SAN F R A N C I S C O : REGION I X
CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IDAHO
OREGON
WASHINGTON
JUNE 23. 1989
TABLE 5 . C A T E G O R I C A L L Y NEEDY M E D I C A I D R E C I P I E N T S WHO 00 NOT R E C E I V E CASH PAYMENTS
B Y B A S I S O F E L I G I B I L I T Y A N 0 BY R E G I O N AND S T A T E : F I S C A L YEAR 1988

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHODE I S L A N D
VERMONT

*NEW YORK: R E G I O N I1
NEW J E R S E Y
NEW YORK
PUERTO R I C O
VIRGIN ISLANDS

PHILADELPHIA: R E G I O N I11
DELAWARE
D I S T R I C T O F COLUMBIA
MARYLAND
PENNSYLVANIA
VIRGINIA
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

CHICAGO: REGION V
ILLINOIS
INDIANA
MICHIGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA.
KANSAS
MISSOURI
NEBRASKA

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

SAN F R A N C I S C O : REGION I X
CALIFORNIA
HAWAII
NEVADA
JUNE 23. 1989
\BLE 5 . C A T E G O R I C A L L Y NEEDY M E D I C A I D R E C I P I E N T S WHO DO NOT R E C E I V E CASH PAYMENTS
B Y B A S I S O F E L I G I B I L I T Y AND BY R E G I O N A N 0 S T A T E : F I S C A L YEAR 1988
(CONT)
OTHER B A S I S OF
AFDC TITLE XIX ELIG
AQYLIS REGIPIENIS YMKYWY
683.223 446.176 20

IOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
MEW H
.. A M P S H I R E
RHDDE ISLAND
VERMONT

YEWYORK: R E G I O N 11
NEW J E R S E Y
NEW YORK
PUERTO R I C O
VIRGIN ISLANDS

PHILADELPHIA: REGION 1 x 1
DELAWARE
D I S T R I C T OF COLUMBIA
MARYLANO
PENNSYLVANIA
VIRGINIA
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
NISSOURI
NEBRASKA

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

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IDAHO
OREGON
J U N E 23, 1989
T A B L E 6. M E D I C A L L Y NEEDY M E D I C A I D R E C I P I E N T S WHO DO NOT R E C E I V E CASH PAYMENTS
B Y B A S I S OF E L I G I B I L I T Y AND BY R E G I O N AND S T A T E : F I S C A L YEAR 1 9 8 8

TOTAL
REGElEN-IS
3,604,619

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHOOE I S L A N D
VERMONT

NEW YORK: R E G I O N I1
NEW J E R S E Y
YEW YORK
PUERTO R I C O
VIRGIN ISLANDS

PHILADELPHIA: R E G I O N I11
DELAWARE
D I S T R I C T O F COLUMBIA
MARYLAND
PENNSYLVANIA
VR
IGN
IA
I
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORQIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

CHICAGO: REGION V
ILLINOIS
- .-
. D-I A..N..A. .
TN
MICHIGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS

OKLAHOMA
TEXAS

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

SAN F R A N C I S C O : REGION I X
CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IDAHO
OREGON
WASHINGTON
J U N E 23. 1989
.ABLE 6 . M E D I C A L L Y NEEDY M E D I C A I D R E C I P I E N T S WHO DO NOT R E C E I V E CASH PAYMENTS
(CONT) B Y B A S I S O F E L I G I B I L l T Y AND B Y R E G I O N A N 0 S T A T E : F I S C A L YEAR 1988

AFOC OTHER B A S I S OF
CHILDREN AFOC TITLE XIX ELIG
YMDEB-21 REGPIENIS UNKNQUN
897.730 885,567 0

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
R ~ O D EI S L A N D
VERMONT

NEW YORK: R E G I O N 11
NEW J E R S E Y
NEW YORK
PUERTO R I C O
VIRGIN ISLANDS

PHILADELPHIA: R E G I O N 111
DELAWARE
D I S T R -I C T O F C O L U M B I A
MARYLAND
PENNSYLVANIA
VIRGINIA
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

CHICAGO: REGION V
ILLINOIS
INDIANA
MICHIGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
N W MEXICO
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
VISSOURI
NEBRASKA

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

SAN F R A N C I S C O : REGION I X
CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IDAHO
OREGON
WASHINGTON
J U N E 23. 1 9 8 9
T A B L E 7. M E D I C A I D M E D I C A L VENDOR PAYMENTS BY MAINTENANCE A S S I S T A N C E S T A T U S O F R E C I P I E N T
AND B Y R E G I O N AND S T A T E : F I S C A L YEI

BOSTON: REGION I
CONNECTICUT
2/ MAINE
I-,
1 MASSACHUSETTS
NEW HAMPSHIRE
RHOOE I S L A N D
VERMONT

NEW YORK: REGION I1


2 1 NEW J E R S E Y

PHILADELPHIA: R E G I O N I11
DELAWARE
DISTRICT OF COLUMBIA
MARYLAND
PENNSYLVANIA
VIRGINIA
WEST V I R G I N I A

ATLANTA: REGION I V
2/ ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

CHICAGO: REGION V
ILLINOIS
INDIANA
MICHIGAN
MN
INESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I 1,724.107.743


2/ IOWA 472,237,173
337.997.331
686.468.697
227,404,542

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

SAN FRANCISCO: REGION I X 5,475,379,568 3,187,617,565


CALIFORNIA 5,226,773,277 3.052.745.740
HAWAII 154,967,251 78,537,760
NEVADA 94,639.060 56.334.065

SEATTLE: REGION X 1,401,541,311 716.894.116


A-
LASKA 94.867.649 64.698.388 . -
TDAHD 123.089.041 29.273.470 93:816.671
T A B L E 7.
(cONT) F I S C A L YEAR 1988

MEDICALLY
OPTIONAL
CATEGORICALLY
J U N E 23. 1989
M E D I C A I D M E D I C A L VENDOR PAYMENTS BY M A I N T E N A N C E A S S I S T A N C E S T A T U S O F R E C I P I E N T
AND B Y R E G I O N AN0 S T A T E :
MAINTENANCE
ASSISTANCE
i
----------- ---
NEEDY
13,068,364,127
----YEEPZ----
123,562.827
SIAIUS-YIKIPYI
52,664.824

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHOOE I S L A N D

NEW YORK: REGION


NEW J E R S E Y
NEW YORK
PUERTO R I C O
VIRGIN ISLANDS

PHILADELPHIA: R E G I O N 111
DELAWARE
D I S T R I C T O F COLUMBIA
MARYLAND
PENNSYLVANIA
VIRGINIA
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEOROIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
MISSOURI
NEBRASKA

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

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IDAHO
OREGON
WASHINGTON
J U N E 23. 1989
T A B L E 8. M E D I C A I D M E D I C A L \'ENDOR PAYMENTS BY BASIS OF ELG
IB
IL
IT
IY OF RECIPIENT
A N 0 BY R E G I O N AN0 S T A T E : F I S C A L YEAR 1988

TOTAL A G E 65 PERMANENTLY A N 0
tAYVENI5 6ND--PLDER BCENQNESS IPIdLLI-PISdBhEP
48.710.157.836 17.135.323.201 343,756,610 18.260.087.009

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHOOE I S L A N D
VERMONT

NEW YORK: R E G I O N I1
NEW J E R S E Y
NEW YORK
PUERTO R I C O
VIRGIN ISLANDS

PHILADELPHIA: R E G I O N I11
DELAWARE
D I S T R I C T O F COLUMBIA
MARYLAND
PENNSYLVANIA
VIRGINIA
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEOROIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
MISSOURI

SOUTH DAKOTA
UTAH
WYOMING

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IDAHO
OREGON
WASHINGTON
r
!
JUNE 2 3 , 1989
r m L E 8. MEOICAID MEDICAL VENDOR PAYMENTS BY BASIS OF ELI G I B I L I T Y O F R E C I P I E N T j
(cONT) A N 0 BY R E G I O N A N 0 S T A T E : F I S C A L YEAR 1988

AFOC
CHILDREN AFDC

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHOOE I S L A N D
VERMONT

NEW YORK: REGION I1


NEW J E R S E Y
NEW YORK
PUERTO R I C O
VIRGIN ISLANDS

D..-
. u T-. - --
I A.D F L P H-I A : R E- G -I O N I11 676.460.289 541.416.858
---..-....-
nFI A W A R F
D I S T R I C T OF C O L U M B I A
-- .-- .
11:018:0~8
47,161,206
.- 9 1877 988
42;080; 1 5 4
MARYLAND 139.586.849 103,037,611
PENNSYLVANIA 388,090,666 246,863,607
VIRGINIA
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

CHICAGO: REGION V
ILLINOIS
INDIANA
MICHIGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: R E G I O N VI
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
MISSOURI
NEBRASKA

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

SAN F R A N C I S C O : REGION IX 707.787.895 1.000.478.615

SEATTLE: REGION X

--. -
ALASKA
...
TnAHO
OREGON
WASHINGTON
J U N E 23. 1989
TABLE 9 . MEDICAID MEDICAL VENDOR PAYMENTS BY TYPE OF SERVICE AND BY REGION AND STATE:
F I S C A L YEAR 1988

BOSTON: REGION I
CONNECTICUT
MAINE

VERMONT

NEW YORK: REGION I1


NEW J E R S E Y
.--
.NFW -
v. n..
w..
PUERTO R I C O
VIRGIN ISLANDS

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

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

CHICAGO: REGION V
ILLINOIS
INDIANA
MICHIGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
.ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

NEBRASKA

SOUTH DAKOTA
UTAH
WYOMING

SAN F R A N C I S C O : REGION I X
CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IDAHO
OREGON
WASHINGTON
J U N E 23, 1989
T A B L E 9. M E D I C A I D M E D I C A L VENDOR PAYMENTS B Y T Y P E O F S E R V I C E AND BY R E G I O N A N 0 S T A T E :
(CONT) F I S C A L YEAR 1988
ALL

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHQDEISLAND
VERMONT

NEW YORK: REGION I1


NEW J E R S E Y
NEW YORK
PUERTO R I C O
VIRGIN ISLANDS

PHILADELPHIA: R E G I O N I11
DELAWARE
D I S T R I C T O F COLUMBIA
MARYLAND
PENNSYLVANIA
VIRGINIA
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

OHIO
WISCONSIN

OKLAHOMA

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
MISSOURI

DENVER: REGION V I I I
COLORADO
MONTANA
NORTH DAKOTA

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IOAHO
OREGON
WASHINGTON
J U N E 23, 1 9 8 9
2 TABLE 9. M E D I C A I D M E D I C A L VENDOR PAYMENTS B Y T Y P E O F S E R V I C E A N 0 BY R E G I O N A N 0 S T A T E :
(CONT) F I S C A L YEAR 1988

OTnER OUTPATIENT CLINIC


esncIrmm hgsr114~ SEBYICES-
284.235.721 2.413.028.723 1.105.212.592

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
6 0 0 ~ISLAND
VERMONT

NEW YORK: REGION I1


NEW J E R S E Y
NEW YORK
PUERTO R I C O

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

ATLANTA: REGION I V
ALABAMA
FLORIDA
OEOROIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
MISSOURI
NEBRASKA

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

SAN FRANC
- -I -S C O :
~
REGION I X
CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
J U N E 23. 1989
TABLE 9 . M E D I C A I D M E D I C A L VENDOR PAYMENTS B Y TYPE O F S E R V I C E AND B Y R E G I O N AND S T A T E :
(CONT) F I S C A L YEAR 1 9 8 8

HOME PRESCRIBED

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHODE I S L A N D
VERMONT

NEW YORK: R E G I O N 11
NEW J E R S E Y

PHILADELPHIA: R E G I O N I11
DELAWARE
D I S T R I C T OF COLUMBIA
MARYLAND
PENNSYLVANIA
VIRGINIA
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH CAROLINA
SOUTH C A R O L I N A
TENNESSEE

CHICAGO: REGION V
ILLINOIS
I-N D
- I-A N A
MICHIGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REOION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
TOWA
KANSAS
MISSOURI
NEBRASKA

DENVER:
~
REOIO
-N ~V I I I
COLORADO
MONTANA
NORTH DAKOTA
SOUTH DAKOTA
UTAH
WYOMING

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA

SEATTLE: REOION X
ALASKA
IDAHO
OREGON
WASHINGTON
J U N E 23, 1989
TABLE 9. M E D I C A I D M E D I C A L VENDOR PAYMENTS BY T Y P E OF S E R V I C E A N 0 B Y R E G I O N A N 0 S T A T E :
(CONT) F I S C A L YEAR 1 9 8 8
RURAL
HEALTH OTHER SERVICE
28BE- YNENQYN
1.431.007.209 41.811

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHDDE I S L A N D
VERMONT

NEW YORK: REGION I1


NEW J E R S E Y
NEW YORK
PUERTO R I C O
VIRGIN ISLANDS

PHILADELPHIA: R E G I O N I11
DELAWARE
DISTRICT OF COLUMBIA
..... . .-. ...-
MARYLAND
PENNSYLVANIA
VIRGINIA
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA

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

CHICAGO: REGION V
ILLINOIS
INDIANA
MICHIGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
MISSOURI
NEBRASKA

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

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA
J U N E 23. 1589
T A B L E 10. M E D I C A I D M E D I C A L VENDOR PAYMENTS FOR C A T E G O R I C A L L Y NEEDY R E C I P I E N T S WHO
R-E C E I V E CASH PAYMENTS BY B A S I S O F E L I G I B I L I T Y A N 0 B Y R E G I O N AND S T A T E :
.F T S C A L YEAR -. 1988 .-
TOTAL AGE 65 PERMANENTLY AND
REQIQY--BN-P_-SIAIE-_---- PAIBEYIS AND--PLPEB BC61PN-ESS IPIAhLLPISbBhEP
ALL JURISDICTIONS 24.583.768.754 4.183.887.631 234,587,080 11,132,951.532

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEU H A M P S H I R E
RHODE I S L A N D
VERMONT

NEW YORK: R E G I O N I1
NEW J E R S E Y
NEW YORK
PUERTO R I C O
VIRGIN ISLANDS

PHILADELPHIA: R E G I O N 111
DELAWARE
D I S T R I C T OF COLUMBIA
MARYLAND
PENNSYLVANIA
VIRGINIA
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

CHICAGO: REGION V
ILLINOIS
INDIANA
MICHIGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
.......~

LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
- -
...... ..
KANSAS
MISSOURI
NEBRASKA

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

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IDAHO
OREGON
WASHINGTON
- - ..- -- , --
T A B L E 10. M E D I C A I D M E D I C A L VENDOR PAYMENTS FOR C A T E G O R I C A L L Y NEEDY R E C I P I E N T S WHO
(CONT) R E C E I V E CASH PAYMENTS BY B A S I S O F E L I G I B I L I T Y AND BY R E G I O N AND S T A T E :
F I S C A L YEAR 1988
AFDC B A S I S OF

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHODE I S L A N D
VERMONT

NEW YORK: REGION I1


NEW JERSEY
NEU YORK
PUERTO R I C O
VIRGIN ISLANDS

PHILADELPHIA: R E G I O N I11
DELAWARE
- .... .. ~-
O I S T lR I C T O F COLUMBIA
MIW Y L A N O
PISNNSYLVANIA
V I R G :I N I A
WEST V I R G I N I A

ATLANTA: REGION VI
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

CHICAGO: REGION V
ILLINOIS
INDIANA
M I.-
C H -~
IGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
MISSOURI
NEBRASKA

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

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IDAHO
OREGON
WASHINGTON
J U N E 23, 1989
T A B L E 11. M E D I C A I D M E D I C A L VENDOR PAYMENTS FOR C A T E G O R I C A L L Y NEEDY R E C I P I E N T S WHO DO NOT
R E C E I V E CASH PAYMENTS BY B A S I S OF E L I G I B I L I T Y A N 0 BY R E G I O N A N 0 S T A T E :
FISCAL YEAR 1 9 8 8
TOTAL P E R M A N E N T L Y AND
PAIMENlS BCEIPIESS IPIBLCI-PES6BCEP
10,881.797.304 61.906.847 3,198,237.608

BOSTON: REGION I
CONNECTICUT
.-.- -
,M,.A T N F
MASSACHUSETTS
NEW H A M P S H I R E
RHODE I S L A N D
VERMONT

NEW YORK: REGION I1


NEW J E R S E Y
NEW YORK
PUERTO R I C O
VIRGIN ISLANDS

PHILADELPHIA: R E G I O N 111
DELAWARE
D I S T R I C T O F COLUMBIA
MARYLAND
PENNSYLVANIA
VIRGINIA
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

CHICAGO: REGION V
ILLINOIS
INDIANA
MICHIGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
MISSOURI
NEBRASKA

REGION V I I I
IRADO

SOUTH DAKOTA
UTAH
WYOMING

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IDAHO
OREGON
WASHINGTON
J U N E 23. 1989
T A B L E 11. M E D I C A I D M E D I C A L VENDOR PAYMENTS FOR C A T E G O R I C A L L Y NEEDY R E C I P I E N T S WHO DO NOT
(CONT) R E C E I V E CASH PAYMENTS B Y B A S I S O F E L I G I B I L I T Y AN0 BY R E G I O N A N 0 S T A T E :
F I S C A L YEAR 1988
AFOC B A S I S OF
CHILDREN AFOC ELIG
UN_K_N_O_YN-
11.266

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHODE I S L A N D
VERMONT

PHILADELPHIA: R E G I O N I11 83.590.552 43,428,388


-tD-xI S-l .AWARE
~.-.. -
TRICT O F COLUMBIA
1.148.316
137; 279
-.-- .
1.123.719
219.454
MARYLAND 1,504,430 781.238
PENNSYLVANIA 72.765.282 17.441.635
VIRGINIA 4,316,305 17,809.053
WEST V I R G I N I A 3.718.940 6,053,289

ATL.ANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

CHICAGO: REGION V
ILLINOIS
INDIANA
MICHIGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I 24,623,840


IOWA 5.448.553
......-..-
KANSAS 4.766.256
MISSOURI 9.321.488
NEBRASKA 4,987,543

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

S I N FRANCISCO: REG1
CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IDAHO
OREGON
WASHINGTON
I
I
J U N E 23, 1989
r A B L E 12. M E D I C A I D M E D I C A L VENDOR PAYMENTS FOR M E D I C A L L Y NEEDY R E C I P I E N T S
BY B A S I S OF E L I G I B I L I T Y AN0 BY REGION A N 0 S T A T E : F I S C A L YEAR 1 9 8 8

TOTAL
- - A C E 66 PERMANENTLY A N 0
REOIQY--AYD--SIAIE----- P4YMEYIS
ALL JURISDICTIONS 13,068,364,127

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHOOE I S L A N D
VERMONT

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

PHILADELPHIA: R E G I O N 111
DELAWARE
D I S T R I C T OF COLUMBIA
MARYLAND
PENNSYLVANIA
VR
IGN
IA
I
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

CHICAGO: REGION V
ILLINOIS
INDIANA
MICHIGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
MISSOURI
NEBRASKA

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

SAN F R A N C I S C O : REGION I X
CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IDAHO
OREGON
WASHINGTON
JUNE 2 3 , 1989
T A B L E 12. M E D I C A I D M E D I C A L VENDOR PAYWENTS FOR M E D I C A L L Y NEEDY R E C I P I E N T S
(CONT) BY B A S I S OF E L I G I B I L I T Y AND BY R E G I O N A N 0 S T A T E : F I S C A L YEAR 1988

AFDC OTHER B A S I S OF
CHILDREN AFOC TITLE XIX ELIG
YNPER-21 YY'6YQIY
704,867,235 0

NEW H A M P S H I R E
RHOOE I S L A N D
VERMONT

NEW YORK: REGION I1


NEW J E R S E Y
NEW YORK
PUERTO R I C O
V I R G I N ISLANDS

PHILADELPHIA: R E G I O N 111
DELAWARE
D I S T R I C T OF COLUMBIA
MARYLAND
PENNSYLVANIA
VIRGINIA
WEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA

TENNESSEE

OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
MISSOURI
NEBRASKA

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

S I N FRANCISCO: REGION I X
CALIFORNIA
HAWAII
I NEVADA

SEATTLE: REQION X
ALASKA
IDAHO
OREGON
WASHINGTON
J U N E 23. 1989
T A B L E 13. O P T I O N A L C A T E G O R I C A L L Y NEEDY M E D I C A I D R E C I P I E N T S BY B A S I S O F E L I G I B I L I T Y
AN0 BY R E G I O N A N 0 S T A T E : F I S C A L YEAR 1988

TOTAL AGE 65 PERMANENTLY AND


IQI4LLY-PI588LEQ
2,017 4
+
.*,
BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHOOE I S L A N D
VERMONT

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

PHILADELPHIA: R E G I O N I11
DELAWARE -
D I S T R I C T OF COLUMBIA 1,122
MARYLAND 7.805
PENNSYLVANIA 7.277
VIRGINIA 873
WEST V I R G I N I A 4.088

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

CHICAGO: REGION V
ILLINOIS
INDIANA
MICHIGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
MISSOURI
NEBRASKA

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

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IDAHO
OREGON
WASHINGTON
J U N E 23, 1989
T A B L E 13. O P T I O N A L C A T E G O R I C A L L Y NEEDY M E D I C A I D R E C I P I E N T S BY B A S I S O F E L I G I B I L I T Y
(CONT) AN0 BY REGION AN0 S T A T E : F I S C A L YEAR 1988

AFOC B A S I S OF
CHILDREN AFOC ELIG
UNDER21 YNKYQYIN
27,666 0

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHOOE I S L A N D
VERMONT

NEW YORK: REGION


NEW JERSEY
NEW YORK
PUERTO R I C O
VIRGIN ISLANDS

PHILADELPHIA: R E G I O N I11
DELAWARE
D I S T R I C T OF COLUMBIA
MARYLAND
PENNSYLVANIA
VIRGINIA
YEST V I R G I N I A

ATLANTA: REGION I V
ALABAMA
FLORIDA
GEORGIA
KENTUCKY
MISSISSIPPI
NORTH C A R O L I N A
SOUTH C A R O L I N A
TENNESSEE

OHIO
WISCONSIN

OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
KANSAS
MISSOURI
NEBRASKA

DENVER: REGION V I I I
COL.ORAOO
MONTANA
NORTH DAKOTA
SOUTH DAKOTA
UTAH
WYOMING

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IDAHO
OREGON
WASHINGTON
J U N E 23, 1989
T A B L E 14. M E D I C A I D M E D I C A L VENDOR PAYMENTS FOR O P T I O N A L C A T E G O R I C A L L Y NEEDY R E C I P I E N T S
BY B A S I S O F E L I G I B I L I T Y AND BY R E G I O N AND S T A T E : F I S C A L YEAR 1988

TOTAL AGE 65 PERMANENTLY A N 0


PAIMENTS bNP-AbEB BCIMPIESS IQIbhLY-QISbBLEP
123,562,827 5.617.209 185.946 8,416,722

BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHOOE I S L A N D
VERMONT

NEW YORK: R E G I O N 11
NEW JERSEY
NEW YORK
PUERTO R I C O
V I R G I N ISLANDS

PHILADELPHIA: R E G I O N I11
DELAWARE
D I S T R I C T O F COLUMBIA
MARYLAND
PENNSYLVANIA
VIRGINIA
WEST V I R G I N I A

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

CHICAGO: REGION V
ILLINOIS
INDIANA
MICHIGAN
MINNESOTA
OHIO
WISCONSIN

DALLAS: REGION V I
ARKANSAS
LOUISIANA
NEW M E X I C O
OKLAHOMA
TEXAS

KANSAS C I T Y : REGION V I I
IOWA
.....-..-
KANSAS
MISSOURI
NEBRASKA

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

SAN FRANCISCO: REGION I X


CALIFORNIA
HAWAII
NEVADA

SEATTLE: REGION X
ALASKA
IDAHO
DREGON
WASHINGTON
NPC - 1989

FEDERAL MEDICAL ASSISTANCE PERCENTAGE (FMAP)

The federal government pays states for part of their expenditures under Medicaid for providing services
and for administration of their medicaid programs. The following FMAP table is used to determine the
amount of federal matching in state medical expenditures. The state provides separately for federal
matching of administrative costs.

Service Expenditures

Effective October 1, 1989 - September 30, 1990

State Percent State Percent

Alabama Montana
Alaska Nebraska
Arizona Nevada
Arkansas New Hampshire
California New Jersey
Colorado New Mexico
Connecticut New York
Delaware North Carolina
DC North Dakota
Florida Ohio
Georgia Oklahoma
Guam Oregon
Hawaii Pennsylvania
Idaho Puerto Rico
Illinois Rhode Island
Indiana South Carolina
Iowa South Dakota
Kansas Tennessee
Kentucky Texas
Louisiana Utah
Maine Vermont
Maryland Virgin Islands
Massachusetts Virginia
Michigan Washington
Minnesota West Virginia
Mississippi Wisconsin
Missouri Wyoming

The above percentage (FMAP) is based upon the state's per capita income; if a state's per capita income
is equal to the national average, the federal share is 50%. If a state's per capita income is below the
national average, the federal share is increased to a maximum of 83%.

Cost sharing for administrative expenditures vary with the services, i.e., 75% for training, 90% for
designing, developing or installing mechanized claims processing and information retrieval, etc. (Federal
Medicaid Law (Section 1903(a)(2) et seg.)

Source: CCH Medicare and Medicaid Guide 1989 (14,905)

132
STATE POPULATION AND DEMOGRAPHICS, 1987-88
State %of
Population State
asa%of Per Capita Unem- Population Population
Population total U.S. Personal ployment 65 and 65 and
STATE prw. est. Population Income Rate Over Over

Alabama 4,066,000 1.7% $1 1,947 505,000 12.4%


Alaska 540,000 0.2% $18,321 19,000 3.5%
Arizona 3,372,000 1.4% $14,310 430,000 12.8%
Arkansas 2,379,000 1.O% $11,538 348,000 14.6%
California 27,255,000 11.2% $17,841 2,944,000 10.8%
Colorado 3,284,000 1.3% $15,594 305,000 9.3%
Connecticut 3,199,000 1.3% $21,197 429,000 13.4%
Delaware 638,000 0.3% $16,510 75,000 11.8%
D. C. 629,000 0.3% $20,057 77,000 12.2%
Florida 11,803,000 4.8% $15,584 2,140,000 18.1%
Georgia 6,161,000 2.5% $14,320 623,000 10.1%
Hawaii 1,068,000 0.4% $15,677 109,000 10.2%
Idaho 1,002,000 0.4% $11,875 115,000 11.5%
Illinois 11,569,000 4.8% $16,421 1,405,000 12.1%
Indiana 5,510,000 2.3% $13,935 670,000 12.2%
Iowa 2,841,000 1.2% $14,230 421,000 14.8%
Kansas 2,466,000 1.O% $15.143 336,000 13.6%
Kentucky 3,732,000 1.5% $11,997 457,000 12.2%
Louisiana 4,513,000 1.9% $11,482 481,000 10.7%
Maine 1,I 77,000 0.5% $13,971 159,000 13.5%
Maryland 4,493,000 1.8% $18,174 486,000 10.8%
Massachusetts 5,846,000 2.4% $19,053 800,000 13.7%
Michigan 9,180,000 3.8% $15,428 1,058,000 11.5%
Minnesota 4,226,000 1.7% $15,906 534,000 12.6%
Mississippi 2,633,000 1.1% $10,302 318,000 12.1%
Missouri 5,081,000 2.1 % $14,663 703,000 13.8%
Montana 817,000 0.3% $12,291 101,000 12.4%
Nebraska 1,597,000 0.7% $14,297 220,000 13.8%
Nevada 974,000 0.4% $16,396 106,000 10.9%
New Hampshire 1,038,000 0.4% $17,895 121,000 11.7%
New Jersey 7,650,000 3.1% $20,321 994,000 13.0%
New Mexico 1,488,000 0.6% $1 1,861 150,000 10.1%
New York 17,798,000 7.3% $18,017 2,309,000 13.0%
North Carolina 6,366,000 2.6% $13,322 754,000 11.8%
North Dakota 677,000 0.3% $12,961 90,000 13.3%
Ohio 10,762,000 4.4% $14,605 1,346,000 12.5%
Oklahoma 3,309,000 1.4% $12,558 418,000 12.6%
Oregon 2,705,000 1.1% $14,Ol 8 373,000 13.8%
Pennsylvania 11,903,000 4.9% $15,208 1,764,000 14.8%
Rhode Island 979,000 0.4% $16,640 145,000 14.8%
South Carolina 3,397,000 1.4% $12,036 367,000 :0.8%
South Dakota 709,000 0.3% $12,550 100,000 14.1%
Tennessee 4,822,000 2.0% $12,878 602,000 12.5%
Texas 16,825,000 6.9% $13,888 1,627,000 9.7%
Utah 1,675,000 0.7% $11,386 138,000 8.2%
Vermont 544,000 0.2% $14,299 65,000 11.9%
Virginia 5,826,000 2.4% $16,516 623,000 10.7%
Washington 4,487,000 1.8% $15,642 536,000 11.9%
West Virginia 1,912,000 0.8% $10,992 264,000 13.8%
Wisconsin 4,792,000 2.0% $14,723 633,000 13.2%
Wyoming 506,000 0.2% $12,706 44,000 8.7%
United States 242,221,000 $14,755 29,837,000

133
PHARMACIES AND PHARMACISTS
PHARMACIES PHARMACISTS
Nursing Ail
STATE Community Chain Hospital Clinic Home others' Total

TOTALS: 34,944

Alabama 782
Alaska 49
Arizona 224
Arkansas 547
California 2,980
Colorado 380
Connecticut 467
Delaware 35
District of Columbia 69
Florida 1,317
Georgia 968
Hawaii 84
Idaho 179
Illinois 1,771
Indiana 560
Iowa 504
Kansas 445
Kentucky 651
Louisiana 732
Maine loa
Maryland 446
Massachusetts 749
Michigan 1,346
Minnesota 6354
Mississippi 670
Missouri 890
Montana 159
Nebraska 359
Nevada 74
New Hampshire 112
New Jersey 1.277
New Mexico 154
New York 3,203
North Carolina 844
Nolth Dakota 153
Ohio 1,168
Oklahoma 710
Oregon 356
Pennsylvania 1,818
Puerto Rico 916
Rhode Island 113
South Carolina 469
South Dakota 162
Tennessee 777
Texas 2,099
Utah 205
Vermont 89
Virginia 586
Washington 607
West Virginia 262
Wisconsin 768
Wyoming 82

NCPDP-NABP List, Business Mailenilnc., 1989

' Includes 1,098 Depattment Stores and 859 Grocery Stores

134
F-
NPC - 1989

KEY PROVISIONS OF STATE DRUG PRODUCT SELECTION LAWS

Permissive
2-Line Rx or
State Formulary Format Mandatory
Alabama None Yes P
Alaska None NO P
Arizona Negative Yes P
Arkansas Negative No P
California Negative No P
Colorado None No P
Connecticut None NO P
Delaware Positive (1) Yes P
D.C. Positive NO P
Florida Negative (2) No M
Georgia None No P
Hawaii Positive (1) NO M
Idaho None Yes P
Illinois Positive NO P~
Indiana None Yes P
Iowa Negative NO P
Kansas None Yes (optional) P
Kentucky Negative (1) No M
Louisiana None No P
Maine None No P
Maryland Positive NO P
Massachusetts Positive NO M
Michigan None No P
Minnesota None No P
Mississippi None Yes M
Missouri Negative Yes P
Montana None No P
Nebraska Positive No P
Nevada Positive (1) No P
New Hampshire Positive (1) NO P
New Jersey Positive Yes M
New Mexico Positive (1) NO P
New York Positive No M
North Carolina None Yes (optional) P
North Dakota None Yes P
Ohio Positive (2) NO P
Oklahoma (See legend)
Oregon None NO P
Pennsylvania Positive (3) No M
Rhode Island Negative Yes M
South Carolina None Yes P
South Dakota None Yes P
Tennessee Positive Yes P
Texas None Yes P
Utah Positive (1) No P
Vermont Positive No M
Virginia Positive Yes P
Washington Positive (1) Yes M
West Virginia Negative No M (1)
Wisconsin Positive (1) No P
Wyoming None Yes P A
See legend page 737

135
NPC - 1989
KEY PROVISIONS OF STATE DRUG PRODUCT SELECTION LAWS
Pharmacy Cost
Record Savings Patient Label Liability
State Required Pass-On Consent Specifications Disclaimer

Alabama Yes B No Yes No


Alaska No B Yes No NO
Arizona Yes B Yes Yes Yes
Arkansas No B Yes Yes Yes
California No B Yes Yes Yes
Colorado Yes A Yes Yes Yes
Connecticut Yes A Yes Yes Yes
Delaware Yes A Yes Yes No
D.C. Yes B Yes Yes Yes
Florida Yes A Yes No Yes
Georgia Yes C Yes No No
Hawaii Yes B Yes Yes Yes
Idaho Yes A Yes Yes NO
Illinois Yes B Yes No Yes
Indiana Yes B Yes Yes No
Iowa Yes A Yes No No
Kansas No B No No NO
Kentucky Yes B No Yes Yes
Louisiana Yes A Yes No No
Maine No D Yes Yes No
Maryland Yes B Yes Yes Yes
Massachusetts No B No Yes No
Michigan Yes A Yes Yes No
Minnesota No A Yes Yes No
Mississippi No B Yes Yes Yes
Missouri Yes B Yes Yes Yes
Montana NO A Yes Yes Yes
Nebraska NO A Yes Yes Yes
Nevada Yes B Yes No Yes
New Hampshire Yes B Yes Yes Yes
New Jersey NO A Yes No No
New Mexico NO A No Yes No
New York Yes B Yes Yes NO
North Carolina Yes B No Yes Yes
North Dakota Yes B Yes Yes Yes
Ohio No A Yes Yes Yes
Oklahoma
Oregon Yes B Yes Yes Yes
Pennsylvania Yes B Yes Yes Yes
Rhode Island Yes A No No Yes
South Carolina Yes C Yes Yes NO
South Dakota No C No No No
Tennessee Yes A No No Yes
Texas Yes B Yes Yes Yes
Utah Yes A Yes Yes Yes
Vermont No D Yes Yes No
Virginia Yes B Yes Yes Yes
Washington Yes B No Yes Yes
West Virginia Yes A Yes Yes Yes
Wisconsin No B Yes Yes Yes
Wyoming Yes B No Yes Yes
See legend page 137
LEGEND:

Formulary: (1) uses FDA Therapeutic Equivalency List


(2) each pharmacy is to develop DPS List
(3) each pharmacy is to list commonly used generics from state- developed
formulary

Permissive or Mandatory Language:

P = Permissive (R.Ph. "May")


M = Mandatory (R.Ph. 'Shall")
(1) Unless in the pharmacist's judgment ......

Prevention of Substitution:

(A) prescriber's signature on appropriate line of 2-line prescription form


(8) prescriber expressly indicates 'do not substituteqn some manner
(1) allows use of preprinted 'do not sub" check-box
(2) box must be checked to prevent DPS
(3) prescriber must write 'brand medically necessary"

Cost Savings Pass-on:

full savings must be passed on to consumer


drug dispensed must be less expensive than drug prescribed
no cost savings pass-on requirement mentioned
no more than usual and customary charge for prescribed drug

includes states where consent is required and those which require the patient
to be notifiedlinformed of the substitution

Oklahoma: The law (1961) simply states that it is unlawful for a pharmacist to substitute
without the authority of the prescriber or purchaser

Researched and compiled by the National Pharmaceutical Council, Reston, Va

137
NPC - 1989 E X P A N D E D D R U G C O V E R A G E

This manual primarily focuses on prescription drug benefits under Medicaid, Title XIX of the Social Security Act, for
persons with low incomes and dependant children. In response to a growing need for prescription drug coverage to
the elderly, who consume considerably more drugs than the average American, state health planners and legislators
in nine states have developed state-funded programs for their elderly citizens. Each of these programs differ somewhat
and their characteristics are listed below.

New Jersey Maine Mawland Delaware'


Year
Enacted: 1977 1977 1979 1982

Eligibility
Criteria:
Age 65+ 62+ None 65+

Means test $13,650 s $7,000 s $6,700 s to $8,150 s


$16,750 C $9,000 c $13,000 $11,500 C
under age 65 Fam. of 10
w/SS disability

Program
Characteristics:
COP~Y $2.00 $2.00 $1.OO 10% AAC4

Rxs covered All legend Rx, Most Rx, heart, All Rx + Rx drugs, formulary
insulin test materials BP, COPD, diabetes Medicaid OTCs + insulin/quinine
No DESl list drugs antiarthritic
Rx fee
to Pharmacy $3.63 to 3.973 $3.39

Fiscal Impact:
Funding 56.9% General fund General fund General fund The Nemours
43.1 % Casino Revenue Foundation
Fund
# recipients 246,693 16,659 12,000 (enrolled) 1988
Cost per yearz $108.6 $6.9 $1.65

Pop. over age 65: 994,000 159,000 486,000 75,000

Comp. Medicaid
Rx Data 1988:
Tot. Recipients 533,076 119,483 319,929 37,150
Rx Recipients 436,269 91,089 221,219 26,193
Rx Expend.' $105.0 $22.9 $46.9 $4.6
Net State Cost2 $52.5 (50%) $7.2 (33%) $23.5 (50%) $2.1 (48%)

~ o atvendor drug program. All W s dispensed through Nemours Memorial Health Clinic, Wilrnington, DE
Millions
F 0 R T H E E L D E R L Y

Note: Congress passed and President Reagan signed the Catastrophic Care Act of 1988. Section 202 of that act will
provide for coverage of catastrophic expenses for prescription drugs beginning in 1991.

pennsvhmnia m Rhode Island Connecticut New Yolk

1984 1985 1985 1986 1987

less than $14,000 $12,000 s less than $9,000-15,000 s


$12,000 s household $15,000 c $13,300 s $12,000-20,000 c
$15,000 m $16,000 c (low-moderate
over 16 & disabled 18-64 income)
disabled Title II & XVI

No 40% of cost $4.00

All Rx, 30- Cardiovascular Rx, Rx (specific All 'State" All Rx


day ~ U P P ~ antiarthritic, categories) Rx
or 100 units insulin insulin
No DESl or Exp. needles & syr. needles & syr.
$2.75= $3.60 60% net cost $3.553 $2.75
(incl. ingreds.) ($.50 generic to
incentive fee) $3.00

Lottery General fund General fund General fund General fund


funds

Medicaid
Actual Acquisition Cost
Vermont passed PAA legislation in 1989. Effective July, 1990.
NPC - 1989

ALABAMA
_*
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE -


Type of Benefit Categorically Needy Medically Needy (MN) Other'
OAA AB APTD AFDC OAA AB APTD AFDC Children<21 ISFO)
Prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X

Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services X"

-
'SF0 State Funds Only
"Dental Services EPSDT - under 21 years old.

I!. EXPENDITURES FOR DRUGS.

1987 I988
Expended Recipient Expended :Recipient
TOTAL $44,701,304 227.794 $48.1 07,554 226,602
CATEGORICALLY NEEDY CASH TOTAL 38,714,959 211,421 41,139,722 205,178
Aged 15,531,235 54,562 15,898,208 51,730
Blind 385,189 1,404 418,016 1,395
Disabled 18,367,101 60,732 20,437,432 63,094
Children -Families w/Dep. Children 1,784,103 58,974 1,763,461 55,561
Adults -Families w/Dep. Children 2,647,331 36,781 2,617,605 34,259
CATEGORICALLY NEEDY NON-CASH TOTAL 5,986,345 22,049 6,972,832 29,092
Aged 5,041,026 12,677 5,753,387 13,269
Blind 4,559 15 2,514 16
Disabled 730,000 1,705 817,130 1,833
Children -Families w/Dep. Children 62,494 2,495 138,888 5,837
Adults -Families w/Dep. Children 105,717 3,847 204,168 6,335
Other Title XIX Recipients 42,549 1,490 56,745 1,907
MEDICALLY NEEDY TOTAL 0 0 0 0
Aged 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/Dep. Children 0 0 0 0
Other Title XIX Recipients 0 0 0 0

HHS report HCFA - 2082


Alabama - 2

111. Administration:

Alabama Medicaid Agency

IV. Provisions Relating to Prescribed Drugs:

A. General Exclusions: Vitamins, food supplements, and anti-obesity, cough and cold preparations,
certain drug products classified by FDA as less than effective.

6. Formulary: Alabama Medicaid Formulary, which specifies those drugs that may be dispensed on
prescription only. Contact person for approving formulary additions: , Non-formulary products are
available via a prior authorization procedure.

C. Prescribing or Dispensing Limitations:

I. Quantity of Medication: Normal prescriptions are limited to a maximum of 5 refills. The


quantities (units) of drugs prescribed by a physician SHALL NOT be arbitrarily changed by
a pharmacy except by authorization of the physician. Authorization to alter the units of a
prescription must be noted on the prescription form by the pharmacist. Prescriptions for Title
XIX nursing home patients who are on long-range therapy or maintenance drugs should be
written for at least a minimum thirty (30) day supply.

2. Refills: When authorized by prescriber, a prescription may be refilled a maximum of five (5)
times. (subject to DSIUR). All prescriptions should be refilled only in quantities
commensurate with dosage schedule and refill instructions.

D. Prescription Charge Formula: Medicaid pays for prescribed legend and non-legend drugs authorized
under the program based upon and shall not exceed the lowest of:

The Maximum Allowable Cost (MAC) of the drug plus a dispensing fee.
" The Estimated Acquisition Cost (EAC) of the drug plus a dispensing fee, or
The provider's usual and customary charge to the public for the drug.

Professional Fee:

Retail pharmacies: $3.75

E. Variable Co-Payment for Prescription Drugs. Medicaid patients are required to pay and pharmacies
are reauired to collect the maximum designated variable co-pay amount for each prescription filled
and each refill.

MEMPTIONS: No co-payment amount is to be collected by the pharmacy or paid by the recipient


on the following:
= Family planning drugs or supplies.
Drugs dispensed to a Medicaid recipient under 18 years of age.
Drugs dispensed to Medicaid eligible pregnant women.

Drugs dispensed to Medicaid recipients residing in a long-term care facility (nursing home).
NPC - 1989

Co-payment (Effective November I , 1988) Retail Pharmacies:

Drua lnaredient Cost Copav Amount for Collection


-
$00.00 $ 6.25 $0.50

21.26 - 46.25
46.26 or more

V. Miscellaneous Remarks:

1. Fiscal Intermediary: Price adjustments to:

E.D.S. First Data Bank


P.O. Box 7600 1111 Bayhill Drive
Montgomery, AL 36107 San Bruno, CA 94066
(205) 834-3330
1-800-392-5741

Officials, Consultants and Committees

1. Officials - Alabama Medicaid Agency:

Carol A. Herrmann Alabama Medicaid Agency


Commissioner 2500 Fairlane Drive
Montgomery, AL 36130
2051277-2710

James F. Mracek, M.D.


Professional Sewices Div.

Larry A. Tatum, R.Ph., Associate Director Alabama Medicaid Agency


Pharmaceutical Programs 2500 Fairlane Drive
Montgomery, AL 36130
2051277-2710

2. Title XIX Medical Care Advisory Committee:

Earl Fox, M.D. Andrew P. Hornsby, Jr. Ms. Jean Yarbrough


State Health Officer Commissioner American Assn. Med. Assist.
State Public Health Dept. Department of Human Rt. 1 Box 355
434 Monroe Street, Room 381 Resources Enterprise, AL 36330
Montgomery, AL 36130 64 N. Union Street
2051261-5052 Montgomery, AL 36130
2051261-3190
F
-
NPC - 1989 Alabama - 4

Frank Perryman Craig McNamara, O.D.


AL Hospital Association AL Optometric Association
Sylacauga Hospital/Nursing Home 5723 Carmichael Parkway
Sylacauga, AL 35151 Montgomery, AL 36117

William Stewart Roy T. Hager, M.D. Jim Scruggs


Med. Grp. Managemt. Assn. of AL Med. Assn. of AL AL Pharmaceutical Assn.
Dept. of Medicine 2055 Normandie Drive 61 1 Moore Street
6th FI. MEB, University Station Montgomery, AL 36198 Marion, AL 36756
Birmingham, AL 35294

Ms. Elizabeth Norris Sandra Hullett, M.D. Dr. A. Z. Holloway


AL State Nurses Association Health Services Director Consumer Representative
360 N. Hull P. 0. BOX 71 1 3086 ~ o s aParks Avenue
Montgomery, AL 36197 Eutaw, AL 35462 Montgomery, AL 36105

Dr. Joe Sharp Diane Betts Mrs. Gwendolyn Tallie


AL Chapter of Acad. of Pediatrics Medicaid Recipient Rep. Medicaid Recipient Rep.
P.O.Box 1001 122 Pegler Street 460 Caroline Street
Troy, AL 36081 Prattville, AL 36067 Montgomery, AL 36104

Mike Woodall, Director Mrs. Euthel Garrett Hill Charles G. Sprading, Jr.
Central AL Aging Consortium 6209 20th Avenue Consumer Representative
818 S. Perry Langdale, AL 36854 P.0. BOX11765
Montgomery, AL 36104 Birmingham, AL 35202

3. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Association: Pharmaceutical Association: C. Osteopathic Association

Lon Conner Sharon Taylor Kenneth D. McLeod, D.O.


Executive Director Acting Executive Director Secretary
Medical Association of AL AL Pharmaceutical Assn. AL Osteopathic Association
19 South Jackson Street 340 Dexter Avenue 1511 N. McKenzie Street
P. 0. Box 1900-C Montgomery, AL 36104 Foley, AL 36535'
Montgomery, AL 36197 2051262-0027 2051943-1584
2051263-6441

D. State Board of Pharmacy: Nursing Home Association: F. Hospital Association:

James W. McLane Sen. William H. Drinkard Dr. Tommy R. McDougal


Secretarv Executive Vice-president President
1 perimeter Park South, Suite 425 AL Nursing Home Association AL Hospital Association
US. 280 at 1-495 4140 Carmichael Road East Station, P.O. Box 17059
Birmingham, AL 35243 Montgomery, AL 36106 Montgomery, AL 36193
2051967-0130 2051271-6214 2051272-8781
1
NPC - 1989 Alaska - 1

ALASKA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XD()

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other*


OAA AB APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X

Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services X

*SF0 - State Funds Only


II. EXPENDITURES FOR DRUGS

TOTAL
CATEGORICALLY NEEDY CASH TOTAL

Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL Alaska's Medicaid program was amended by
Aged the passage of legislation (H.B.70) in 1989,
Blind which added prescribed medicines to the list
Disabled of optional services, effective July I , 1989.
Children -Families wIDep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients

HHS report HCFA - 2082


NPC - 1989 Alaska -:

111. Administration: Health and Social Services Department

IV. Provisions Relating to Prescribed Drugs:

A. Ingredient Reimbursement Basis: AWP minus 5%.

B. State Maximum Allowable Cost List parallels federal FMAC list. Override requires "Brand Medicall\
Necessary.'

C. No formulary.

Certain classes of prescriptions are restricted, i.e., amphetamines (except for narcolepsy and hyperactivity)
DESI; infertility drugs.

D. Formulary information and additions should be addressed to:

Mr. Eric Hansen


Chief, Medical Assistance
DHSS
4433 Business Park Blvd.
Anchorage, AK 99503
9071561-2171

E. Pharmacy Fee: Variable $3.45 - $1 1.46, effective February 1, 1989.

G. Quantities limited to 30-day supply.

H. No OTC drugs reimbursed

Officials, Consultants and Committees

1. Health and Social Services Department Officials:

Myra M. Munson, Commissioner Department of Health and Social Services


9071465-3030 Pouch H-01
Juneau, AK 9981 1

Kimberly B. Busch, Director Division of Medical Assistance, DHSS


9071465-3355 Pouch H-07
Juneau, AK 9981 1

Eric S. Hansen, Chief, Medical Assistance 4433 Business Park Blvd., Bldg. M
9071561-2171 Anchorage, AK 99503

2. William F. Davnie, R.Ph., Medicaid Pharm. Cons. 13121 Biscayne Circle


9071345-0644 Anchorage, AK 99516

3. Alaska Medical Care Advisory Committee:

John White. DDS, Chairman P. 0. Box 757


9071543-2926 Bethel, AK 99559
NPC - 1989

3. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Association: B. Pharmaceutical Association: C. State Board of Pharmacy:

Raymond G. Schalow Ruth Alton Christy Nielsen


Executive Director President-elect Secretary
AK State Medical Assn. AK Pharmaceutical Association P. 0.Box D-LIC
2401 East 42nd Avenue Box 10-1185 Juneau, AK 9981 1
Anchorage, AK 99508 Anchorage, AK 99510 9071465-2541
9071562-2662 90713456428
Arizona -1
ARIZONA
MEDICAL ASSISTANCE DRUG PROGRAM UNDER TITLE XIX
Arizona Health Care Cost Containment System
(AHCCCS - pronounced "ACCESS)

-EXPENDITURESFOR DRUGS
1987 1988
Expended Recipient Expended Recipient
TOTAL 96,280
CATEGORICALLY NEEDY CASH TOTAL 90,435
Aged 6,627
Blind 385
Disabled 18,679
Children -Families w/Dep. Children 44,556
~ d u l t s-Families w/Dep. Children 20,270
CATEGORICALLY NEEDY NON-CASH TOTAL 7,490
Aged 72
Blind 9
Disabled 400
Children -Families w/Dep. Children 5,567
Adults -Families w/Dep. Children 1,445
Other Title XIX Recipients 0
OPTIONAL CATEGORICALLY NEEDY 1,476
Aged 0
Blind 0
Disabled 0
Children -Families w/Dep. Children 513
Adults -Families w/Dep. Children 967
Other Title XIX Recipients 0

HHS report HCFA - 2082

AHCCCS Features:

The Arizona Health Care Cost-ContainmentSystem (AHCCCS) is an experimental Medicaid program. Begun in October
1982, it serves as a new model for providing medical services to the indigent. Typically, Medicaid programs have
incorporated the traditional hallmarks of the US health care system: namely, independent providers and fee-for-service
reimbursement. In contrast, the AHCCCS model is marked by organized health plans and capitation.

In traditional Medicaid programs, the states assume responsibility for contracting with individual pharmacies and
reimbursing them. In the AHCCCS model however, the state contracts instead with pre-paid health plans, HMOs and
HMO-like entities. These plans are paid on a capitation basis and are responsible for providing all of the sewices
covered by the program. Thus, the delivery of pharmacy services is the responsibility of each prepaid plan.'
Administration:

Arizona Health Care Containment System (AHCCCS).

' McGhan et al, American Pharmacy, vol. N526, no. 11, November 1986.

147
NPC - 1989 Arizona - 2

General Information:

The Arizona Health Care Cost Containment System (AHCCCS), developed in Senate Bill 1001, was passed by the
Legislature and signed by the Governor in November, 1981. It contains six major mechanisms for restraining health
care costs while, at the same time, ensuring that appropriate levels of quality health care services are provided to
eligible persons in a dignified fashion. The goal of these six items is to contribute to the establishment of a health care
financing system that is less expensive than conventional fee-for-service systems. The six mechanisms are:

o Primary Care Physicians Acting as Gatekeepers


o Prepaid Capitated Financing
Competitive Bidding Process
o Cost Sharing
Limitations on Freedom-of-Choice
O Capitation of the State by the Federal Government

Primaty Care Physicians Acting as Gatekeepers:

The AHCCCS legislation provides that all members must be under the care and supervision of a primary care physician
who will assume the role of case manager. A statewide network of primary care physicians, acting as case managers,
will thereby be established to perform a gatekeeping function for the system. Because all care must be approved by
the primary care physicians, the primary care network will eliminate self-referrals to specialists and diminish excessive
use of emergency rooms--both of which have contributed substantially to high medical costs.

Prepaid Capitated Financing:

It is the intent of the AHCCCS legislation that providers offer all necessary services to groups of members for a fixed
price, for a definite period of time. The law allows for the creation of consortia to facilitate the establishment of a
statewide bidding process. Services are provided on a county-by-county basis, and bids encourage that goal. It is
not necessary, however, for a single bidder to bid for all services to be delivered in a given county. Providers may
bid on a prepaid capitated basis for only those services they normally provide. For example, a group of physicians
may choose to bid only for physician services for a particular area; hospitals may do the same; and so on. The law
allows for expansion and contraction of bids to achieve the best possible system. In the event thers are insufficient
bids for a given area, the legislation permits capped fee-for-service arrangements. It is intended, however, that capped
fee-for-service will be authorized as a last resort only.

In essence, AHCCCS providers represent forms of prepaid health plans (PHPs), health maintenance organizations
(HMOs), and other types of organized health delivery systems. As such, they charge a fixed fee per individual enrolled
(i.e., a capitation rate) and assume responsibility for providing a broad array of health care services to members.

Competitive Bidding Process:

The statewide competitive aspect of the bid process for selecting providers and offering the prepaid capitated services
is the most unique feature of the AHCCCS model. A provider competition of this magnitude has never been attempted
in any other state. The AHCCCS administration believes competitive bidding forhealth care service contracts, as
opposed to conventional negotiation processes, will provide accessible cost-effective delivery of health care without
sacrificing quality performance.

The AI-ICCCS administration issues an invitation to qualified providers of health services, at least on a biennial basis,
to bid to provide services to AHCCCS members in each County. Qualified providers may bid to offer the full range
of AHCCCS services, or any allowable partial grouping of services, in one or more counties.
Arizona - 3

cost Sharing:

The fourth major device for containing costs in the AHCCCS model is a provision for cost sharing by users. A
gatewide co-payment schedule was developed for this purpose, and the medically needy participate in coinsurance
sharing. It is expected that the imposition of nominal co-payments will ensure optimal effectiveness in the area
of service utilization. The Department co-payment schedule accomplishes three objectives: curtailment of
over-utilizatiOn; enhancement Of patient dignity; and service utilization by members for truly needed health care, There
is no co-payment for drugs and medication, prenatal care including all obstetrical visits, members in long care facilities
and for visits scheduled by the primary care physician or practitioner, and not at the request of the member.

Limitations of Freedom-of-Choice:

The fifth major item for containing costs is a restriction on provideriphysician selection by AHCCCS members. Unlike
conventional delivery models, Arizona does not rely on fee-for-service arrangements. The goal is to have the state
completely blanketed with prepaid capitated arrangements. Members are linked to selected or assigned plans for
definite durations of time. Freedom-of-choiceis permitted to the extent practicable for members to select the particular
group with which t o enroll, as well as the primary care physician within the selected group. Capped fee-for-sewice
health service contracts is used as a last resort, and only in areas not covered by prepaid capitated plans.

Capitation of the State by the Federal Government:

The State of Arizona will itself be capitated by the Federal Government and therefore will be at financial risk for
containing health care costs. Capitation rates will be established according to sound actuarial principles, and will
represent no more than 95 percent of the estimated cost of services delivered in Arizona under conventional
fee-for-service arrangements. Capitation provides a key incentive for the state to monitor health care costs on a careful
and continuous basis.

IMPLEMENTATION OF AHCCCS

AHCCCS is based on plans that have been tested, in part, on smaller scales in different areas of the country. By
combining a number of key mechanisms on a statewide basis, AHCCCS represents a novel health care model. The
purpose of this section is to present a discussion of how the key concepts embodied in the AHCCCS legislation will
be implemented and rendered operational.

Provider Participation:

Providers may participate in AHCCCS in three different ways. First, they may enter the competitive bidding process
with prepaid capitated plans as either full or partial benefit providers.

The second mode of participation is on a capped fee-for-service basis. Here, providers agree to accept capped fee
payments as payments in full. Capped fee-for-sewice arrangements will be authorized as a last resort only and when
there are insufficient bids for a given area.

Finally, the third means of participation concerns the provision of emergency medical services by non-AHCCCS
providers. No formal contract is required for this mode of participation, and reimbursement will be allowed almost
exclusively for emergency services.

Functions of the AHCCCS Administration:

The AHCCCS Administration contracts with full benefit capitated providers to serve AHCCCS members; and create a
number of organized health systems through a network of contracts with providers, as necessary to complement the
capitated system.
NPC - 1983

Contracting Health Plans

Under the Contracting Health Plan arrangement, plans are defined in terms of explicit groups of providers organized
into consortia or more formal entities. These consortia, or formal entities, are /capable of providing the full range of
AHCCCS benefits within a defined service area for all AHCCCS members who elect to join the plans, up to a
predetermined capacity. This is the dominant mode of operation within AHCCCS--with two or more competing plans
wherever possible.

The Contracting Health Plans are delivery systems, not simply insurance plans, but they need not be Health
Maintenance Organizations by any legal or conventional definition of the term. The AHCCCS legislation provides for
the creation of provider consortia for the purpose of participation In the program. The Contracting Health Plan may
be a loosely organized system, but it must be capable of providing the full range of AHCCCS benefits to a defined
population at a capitation rate.

Administration Organized Health Systems

The Administration Organized Health Systems serve as back-up to the full benefit capitated plans, assuring there are
no service area gaps in the state and there is at least one alternative choice in those areas covered by a Contracting
Health Plan. The Administration Organized Plans must:

Be prepared to function as the routine health care delivery systems in any area of the State not adequately
covered by Contracting Health Plans.

Serve as the mechanism for assuring emergency and urgent care for the "emergent members" of AHCCCS
o Serve as back-up systems in the event of a failure of a Contracting Health Plan, or a state decision to terminate
a contract.

Operate within a fixed budget, regardless of the number of members enrolled. The Contracting Health Plans
will draw funds out of the total AHCCCS budget in direct proportion to the number of AHCCCS members they
serve, leaving the Administration Organized Health Systems with a residual budget.

The Organizationai Role of the AHCCCS Administration:

The AHCCCS Administration has been charged with the general implementation and monitoring of the AHCCCS
program.

The AHCCCS Administration develops the Rules and Regulations; computes provider bidding processes; awards the
contracts; provides technical assistance to providers for the purpose of forming consortia to contract with AHCCCS;
and monitors the overall operation of the program.

The Operational Role of the AHCCCS Administration

Organizationaily, the AHCCCS Administration will assume responsibility for the every day operations of the program.

The AHCCCS Administration will have overall responsibility for the following activity areas:

Promotion of AHCCCS
Procurement of Contract Providers
Provider Management
Provider, Member, and Public Relations
Program Operations
Arizona -5

AHCCCS became effective December 1, 1981, and services commenced October 1, 1982. Services include: Inpatient,
outpatient, laboratory, x-ray, prescription drugs, medical supplies, prosthetic devices, emergency dental care including
extractions and dentures, treatment of eye conditions and EPSDT.

~hough AHCCCS was a three-year experiment which was to end in October 1985, the federal government continues
to extend funding for the program. In 1988, AHCCCS received a five year extension from the federal government.

Medical Plans and Administrators

Arizona Physicians, IPA - 602/274-6102 University Famli-Care


4041 N. Central Bldg. B 1650 East Fort Lowell Blvd., Suite 208
phoenix, AZ 85012 Tucson, AZ 85719
Med. Dir. - Peter Thomas, MD Med. Dir. - Barbara Warren, M.D.
Administrator - Mary Warren Administrator - Mark Williams

Comprehenske AHCCCS Plan - 60217793366 Doctor's Health Plan, PC - 602/428-7801


1325 North Beaver, Suite 101 PO Box 249
Flagstaff, AZ 86001 Safford, AZ 85548
Med. Dir. - William Finney, MD Med. Dir. - Jack Bennett, MD
Administrator - Carla Conway Administrator - Jim Burns

FHP of NE Arizona - W 5 3 7 4 3 7 5 Mercy Care Plan - M)2/263-7100


PO Box 425 77 E. Thomas Road, Suite 150
Show Low, AZ 85901 Phoenix, AZ 85012
Med. Dir. - Ken Jackson, MD Med. Dir. - Michael Grossman, M.D.
Administrator - Jim Burns Administrator - Kathy Byrne

No. Arizona FHP - W634-2216 No. Arizona FHP - 602J445-0482


PO Box 276 1155 lronspring Plaza
Cottonwood, AZ 86326 Prescott, AZ 86301
Med. Dir. - Henry Kaldenbaugh, MD Med. Dir. - Glen Overley, M.D.
Administrator - Jim Burns Administrator - Jim Burns

Pinal General - 602/868-5841 Pima Health Plan - 602/573-0042


PO Box 789 150 W. Congress, Room 304A
Florence, AZ 85232 Tucson, AZ 85701-1305
-
Med. Dir. Paul Kaiser, D.O. Med. Dir. - Samual Goldfein, M.D
Administrator - Mary Fields Administrator - Paul Axinn

Gila Medical Services - 602/4734441 Maricopa County Health Plan602/267-5900


Claypool Medical Center 2601 East Roosevelt
315 N. Broad Street Phoenix, AZ 85008
Claypool, AZ 85532 Med. Dir. - Leonard Tamsky, M.D.
Med. Dir. - Charles Bejarano, MD Assoc. Med. Dirs. - Gary Yates, M.D./Ann Young, M.D.
-
Administrator Art Bejarand Administrator - Foster Northrup

Phoenk Health Plan - 60212528970 SHSIMedical Care Systems


1301 South Seventh Avenue P. 0. Box 238
Phoenix, AZ 85003 Springerville, AZ 85938
-
Med. Dir. Rodney Armstead, M.D. Med. Dir. - Fred Hosler, M.D.
Administrator - Craig Keffelor Administrator - Rick Shrake
NPC - 1989

Officials, Consultants and Committees

I. AHCCCS Officials:

Dr. Len Kirschner Arizona Health Care Cost Containment Sys.


Director 801 E. Jefferson
Phoenix, AZ 85034
David A. Lowenberg 6021234-3655
Deputy Director

2. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Association: B. Pharmaceutical Association:

Chic Older Daniel Boesen


Executive Vice President Executive Director
Arizona Medical Association, Inc. Arizona Pharmaceutical Assoc.
810 West Bethany Home Road 2202 North 7th Street
Phoenix, AZ 85013 Phoenix, AZ 85006-1604
6021246-8901 6021258-8121

C. Osteopathic Association: D. State Board of Pharmacy

Mr. Ted Podleski L. A. Lloyd


Executive Director Executive Director
Arizona Osteopathic Medical Assn. Arizona Board of Pharmacy
5057 E. Thomas Road -
5060 North 19th Ave. Suite 101
Phoenix, AZ 85018 Phoenix, AZ 85015
6021840-0460 602/255-5125
Arkansas -1
ARKANSAS

MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

1. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other*


OAA AB APTD AFDC OAA AB APTD AFDC Children<21
prescribed Drugs X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X

Laboratoly &
x-ray Sewice X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X
Physician Sewices X X X X X X X X X
Dental Sewices X X X X X X X X X

*SF0 - State Funds Only


II. EXPENDITURES FOR DRUGS.

1987 .I988
Expended Recipient Exwnded Recipient
TOTAL $43,240,168 167,760 $40,982,879 174,287
CATEGORICALLY NEEDY CASH TOTAL $33,762,289 131,877 31,739,588 130,954
Aged 12,374,761 31,706 10,962,996 29,570
Blind 408,536 1,184 382,231 1,124
Disabled 16,048,209 37,155 16,062,991 38,740
Children -Families w/Dep. Children 2,035,499 39,287 1,824,273 39,378
Adults -Families w/Dep. Children 2,895,283 22,545 2,507,094 22,142
CATEGORICALLY NEEDY NON-CASH TOTAL $8,216,046 19,886 7,739,667 20,063
Aged 6,910,070 14,249 6,453,677 14,846
Blind 12,565 21 9,313 18
Disabled i,070,780 1,776 1,097,824 1,832
Children -Families w/Dep. Children 65,291 1,262 49,665 1,012
Adults -Families w/Dep. Children 89,883 1,485 79,380 1,354
Other Title XIX Recipients 67,455 1,093 49,805 1,001
MEDICALLY NEEDY TOTAL $1,261,992 15,497 1.I 74.925 14.976
Aged 93,409 499
Blind 443 3
Disabled 168,428 684
Children -Families w/Dep. Children 198,137 4,096
Adults -Families w/Dep. Children 415,871 3,780
Other Title XIX Recipients 285,701 6,435

HHS report HCFA - 2082


NPC - 1989 Arkansas - 2

Ill. Administration:

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

IV. Provisions Relating to Prescribed Drugs:

A. General Exclusions (diseases, drug categories, etc.):

Experimental of investigational drugs Anorectic agents


Food Supplements of infant formula DESl drugs
Vaccines and routine immunizing agents Sedative-hypnotics
Fertility drugs Irrigating solutions
.<at
OTCs: Pursuant to a prescription, the following OTC items are covered: insulin, insulin needles and syringes, $
!:
analgesics, antacids, family planning supplies and certain multiple source laxatives, antihistamines,
decongestants and iron products. :a
3,..:
+?
Formula~y: Yes .,-

Prescribing or Dispensing Limitations:

1. Quantity of Medication: 33 day supply.


2. Refills: 5 refills within 6 months are allowed, if authorized by prescriber.
3. Dollar Limits: None
4. Monthly Limit: Four prescriptions per month per recipient.

Prescription Charge Formula:

Legend drugs - lower of the EAC plus $4.01 professional fee or HCFNstate upper limit plus $4.01
dispensing fee. Total charge may not exceed provider's charge to the self-paying public.

V. Miscellaneous Remarks:

The Arkansas generic upper limit program exists for 34 multi-source drugs,

Fiscal intermediary: EDS Federal


PO Box 2501
Little Rock, AR 72203
5011664-6608

Officials. Consultants and Committees

1. Walt Patterson, Director Arkansas Dept. of Human Services


Department of Human Services Division of Economic & Medical Sew.
P. 0. Box 1437, Slot 326
Little Rock, Arkansas 72203
5011682-8650
Arkansas - 3

Kenny Whitlock, Deputy Director Division of Economic & Medical Services

~ a Hanley,
y Asst. Deputy Dir. Office of Medical Services

Rebecca Meredih, Asst. Deputy Dir. General Accounting

judy Kerr, Administrator Program Planning & Development

Thelma Undetwood, P.D. Pharmacy Consultant


501/862-8363 Office of Medical Services
AR Dept of Human Services
PO Box 1437,Slot 1 1 03
Little Rock, AR 72203

Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Society: B. Pharmaceutical Association:

Kenneth L. LaMastus, CAE Norman Canterbury, P.D.


Executive Vice-president Executive Vice President
Arkansas Medical Society Arkansas Pharmacists Association
10 Corporate Hill Dr., P.O. Box 5776 417 South Victory
Little Rock, AR 72215 Little Rock, AR 72201
5011224-8967 501/372-5250

C. Osteopathic Medical Association: D. State Board of Pharmacy:

Bob E. Jones Lester Hosto, P.D.


Executive Director Executive Director
Arkansas Osteopathic Medical Association P. 0. Box 55356
101 Windwood Drive Liile Rock, AR 72225
Beebe, AR 72012 501/661-2833
5011882-5433
California - 2

111. Administration:
the Health and Welfare Agency with direct supervision by the Department of Health Services. Payment of bills by
the state is processed through a fiscal intermediary, Electronic Data Systems,

Under the general direction of the Department of Health Services' Medi-Cal Policy Division, the Drug Policy Unit of the
Benefits Branch monitors the full scope and quality of pharmaceutical benefits covered under the provisions of the
california Medical Assistance Program. This unit, additionally, has the prime responsibility for both the evaluation and
formulation of Utilization/Cost Controls and the development, implementation, and interpretation of policies and
concerning the full scope of pharmaceutical benefits.

IV. Provisions Relating to Prescribed Drugs:

A. Examples of General Limitations and Exclusions (diseases, drug categories, etc.):

Formulary CNS stimulants', i.e., amphetamines and methylphenidate, are only available for epilepsy or
attention deficit disorder in individuals between 6 and 16 years of age.
Formulary Diazepam' restricted to use in cerebral palsy, athetoid states, and spinal cord degeneration.
Formulary Baclofen' restricted to use in spasticity resulting from multiple sclerosis or spiml cord injury,
Formulary Carbenicillinl restricted to pseudomonas aeruginosa urinary tract infections.
Formulary Cirnetidine and Famatodine' restricted to use in treatment of duodenal ulcer, Zollinger-Ellison
syndrome, systemic mastocytosis, and multiple endocrine adenomas.
Formulary Dantrolenel restricted to use in spasticity resulting from cerebral palsy, spastic hemiplegia, multiple
sclerosis, and spinal cord injury.
Formulary ErythromycinSulfisoxazolel restricted to use in acute otitis media.
Formulary Fenoprofen, Ibuprofen, Naproxen, Piroxicarn. Salsalate, Sulindac, Tolrnetin' restricted to use for
arthritis.
Formulary Nalidkic Acid' restricted to urinary tract and prostatic infections.
Formulary TrirnethoprirnSulfarnethoxazole' restricted to urinary tract and prostatic infections, otitis media,
shigellosis, pneumocystitis carinii pneumonitis.
Formulary Cefaclor Capsules' restricted to treatment of lower respiratory tract infections in persons age 50
and over.
Formulary lsotretinoin Capsules' restricted to treatment of severe recalcitrant cystic acne.
Formulary Acylovir Capsules1 restricted to herpes genitalis or for immunocomprornised patients.
Formulary Zidovudine' restricted to use in the management of certain adult patients with symptomatic HIV
infection (AIDS and advanced ARC) who have a history of cytologically confirmed pneumocystis carinii
pneumonia or an absolute CD4 (Tr helperlinducer) lymphocyte count of less than 200/mm in the peripheral
blood before therapy is begun.
Formulary Codeine Combinations' payment to a pharmacy for ASA or APAP with codeine 15 mg. limited to
a maximum dispensing quantity of 60 tablets or capsules and a meximum of 3 claims for the same beneficiary
in any 75-day period. Payment to a pharmacy for ASA or APAP with codeine 30 mg. limited to a maximum
dispensing quantity of 45 tablets or capsules and a maximum of 3 claims for the same beneficiary in any
75-day period. Payment to a pharmacy for a claim that exceeds a maximum is limited only to cost for the
quantity dispensed, up to the maximum dispensing quantity. No professional fee paid. Exceptions require
prior authorization. One grain codeine combination tablets2 are covered, subject to prior authorizatioc.

Other uses require prior authorization


NPC - 1989

Excluded from coverage are multivitamins for persons over five years of age and most OTC household
remedies. Contact laxative suppositoriesz can be used only for specific diagnosis (paraplegia or
quadriplegia, multiple sclerosis, poliomyelitis, ganglionic blockade processes occurring in the spinal nerve
pathways or affecting the lumbo-sacral autonomic nervous system pathways related to bowel motility).

Nutritional supplements2 or replacements may be covered, subject to prior authorization, if used as a


therapeutic regimen to prevent serious disability or death in patients with medically diagnosed conditions that
preclude the full use of regular foodstuffs.

B. Formulary: A semi-restrictiveformulary system is used. Over 450 drugs (approximately 1,500separate codes
for differing strengths and dosage forms) listed generically in formulary. The patient's physician or pharmacist
may request authorization from the local Medi-Cal consultant for approval of unlisted drugs or for listed drugs
which are restricted to specific use(s).

Medi-Cal Drug Formulary may be obtained by ordering the Pharmacy Provider Manual from:

Electronic Data Systems


P. 0. Box 13029
Sacramento, CA 95813-4029

(Please remit $5.00per manual, including updates, by check or money order payable to "State of California")

For formulary and drug program information contact:

M. Kuschnereit, Pharm.
714 P Street, #I640
Sacramento, CA 95814
91 61324-2477

C. Prescribing or Dispensing Limitations:

1. Quantity of Medication: This is flexible, but quantities should be consistent with the medical needs of
the patient and may not exceed a 100-day supply except under certain circumstances. Many formulary
maintenance drugs are subject to minimum quantity or maximum frequency of billing controls.

2. Refills: A prescription refill can be dispensed as authorized by prescriber. Exception is allowed for
refill of a reasonable quantity when prescriber is unavailable (pursuant to California law). Fee is pro-
rated so that total fee (for partial quantity and balance of the prescription after prescriber is contacted)
does not exceed fee for same prescription when refilled as routine service.

3. Number of prescriptions: Number of prescriptions for formulary drugs not limited but over-utilization
is limited by prepayment and post-payment controls. These controls include those mentioned in item
1 above supported by on-site audit of provider files.

4. Prior Authorization: Approval may be obtained from a Medi-Cal consultant for covered non-formulary
items or services (including special circumstance override of multiple source drug reimbursement
ceilings or minimum quantitylfrequency of billing limitations). Statewide mail and toll free telephone
requests are accepted in the San Francisco and Los Angeles Medi-Cal Field Offices. Requests must
include adequate information and justification. Authorization may only be granted for the lowest cost
item or service that meets the patient's medical needs.

Non-formulary items
California - 4

5. Pharmacist, to the extent permitted by law, is required to dispense lowest cost brand of a multiple
source item in stock meeting medical needs of the patient.

6. Beneficiary or Prescriber Prior Authorization: On a case by case basis, the Department of Health
Services restricts, through the requirements of prior authorization, the availability of designated
prescription drugs to certain beneficiaries or prescribers found by the Department to be abusing those
benefits.

7. Dollar Limits: None,

D. Prescription Charge Formula: Reimbursement is based on the lowest of:

1. Estimated Acquisition Cost (EAC) plus $4.05 professional fee.


2. Federal Allowable cost (FAC) plus $4.05 professional fee.
3. State Maximum Allowable lngredient Cost (MAIC) plus $4.05 professional fee.
4. Pharmacy's usual price to general public.

V. Miscellaneous Remarks:

Drug Price List Updating: Drug prices used to determine reimbursement are updated the first day of each month
for price change notices which are effective on or before that date. Price notices are received by Electronic Data
Systems, P. 0.Box 13029, Sacramento, California 95813-4929.

Copayment: with certain exceptions, recipients are obligated to copay $1.00 per prescription. Copay may be
collected and retained or waived by the pharmacy. Pharmacy reimbursement is not reduced by the copayment.
Pharmacy may not deny a prescription to an individual due to that individual's inability to copay.

Medical Therapeutics and Drug Advisory Committee: reacting to the lead responsibility of the Medical Services
Section in the Benefits Branch, the Medical Therapeutics and Drug Advisory Committee, composed of physicians
and pharmacists from the private sector, compares the cost, efficacy, misuse potential, essential need, and safety
of drugs and makes recommendations as to additions to or deletions from the formulary.

Hospital Discharge Medications

1. The quantities furnished as discharge medications are limited to not more than a 10-day supply.

2. The charges are incorporated in the hospital's claims for inpatient services.

Cancer and DESl Drugs: Any antineoplastic drug approved by FDA for the treatment of cancer is available through
the Formulary. Most DESl drugs rated less-than- effective by FDA are not.

Maximum Allowable lngredient Cost Program: State MACs are established on over 155 multi-source items. List
is periodically revised and price limits changed to reflect current market conditions.

Estimated Acquisition Cost (EAC): Direct prices for certain high volume brands, bulk package size prices for certain
high volume drugs, and, "average wholesale prices" for standard packages on rest.

Drug Utilization Review (DUR): project is being conducted to test costibenefit of this process. Completion date,
June 30, 1991.

Federal Allowable Cost (FAC): Implemented as issued and updated by Health Care Financing Administration.
Reimbursement limit is temporarily discontinued when an item is not available at or below the FAC.
NPC - 1989 California -

Officials, Consultants and Committees

1. Health and Welfare Agency:

A. Health and Welfare Agency Officials:

Clifford L. Allenby California Health and Welfare Agency


Secretary 1600 9th Street
Suite 460
Sacramento, CA 95814

B. Department of Health Services:

Kenneth W. Kizer, M.D. Department of Health Services


Director 714 "P" Street, P. 0. Box 942732
Sacramento, CA 92434-7320

Stanley Cubanski Department of Health Services


Chief Deputy Director

John Rodriguez Medical Care Services


Deputy Director

Virgil J. Toney Medi-Cal Policy Division


Chief

Thomas J. Elkin Benefits Branch


Chief

Richard lniquez Medical Services Section


Chief Room 1640
(916) 445-1 995

C. Advisory Committee to California Department of Health Services:

1. Medical Therapeutics and Drug Advisory Committee:

Richard lniquez California Department of Health Services


Coordinator 714 " P Street, Room 1640
P. 0. BOX942732
Sacramento, CA 92434-7320

David K. Fung, Pharm. 460 Pollasky Avenue


Chairman Clovis, CA 93612

D. Officers of Electronic Data Systems (the Fiscal Intermediary):

John G. Crysler Electronic Data Systems


Executive Program Director 3215 Prospect Park Drive
EDS-Medi-Cal Rancho Cordova, CA 95670
9161636.1 000
California - 6

Medical Association: B. Pharmaceutical Association:

Robert H. Elsner Robert C. Johnson


Executive VPICEO Executive Vice President
California Medical Assn. California Pharmacists' Assn.
221 Main Street 1112 l Street, Ste.300
San Francisco, CA 94120-7690 Sacramento, CA 95814-2865
4151541-0900 9161444-781 I
(fax) 9161443-1915

Osteopathic Physicians & D. State Board of Pharmacy:


Surgeons of California:

Matthew L. Weyuker Lorie Garris Rice


Executive Director, OPSC Executive Officer
1010-11th Street, Suite 220 1020 N Street, Room 448
Sacramento,CA 95814 Sacramento, CA 95814-5784
9161447-2004 9161445-5014
NPC - 1989 Colorado - 1

COLORADO
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other'


OAA AB APTD AFDC OAA AB APTD AFDC Childrenc21 (SFOI
Prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X

Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Sewices X X X X

*SF0 - State Funds Only


:*
v>

2
LC

II. EXPENDITURES FOR DRUGS. ?


1987 1988
Ex~endedRecipient Emended Recipient ,:3.
i
~~,
TOTAL $22,444,856 110.31 9 $28,269,316 117,136 p
<."
CATEGORICALLY NEEDY CASH TOTAL .sz

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

HHS repon HCFA - 2082


Colorado 2 -

Eligibility is determined by 63 County Departments of Social Services, and the drug program is administered
by the Colorado Department of Social Services.

IV. Provisions Relating to Prescribed Drugs:

A. General Exclusions (diseases, drug categories, etc.):

Restricted Drug Categories:

1. Prescription-legend drugs not listed in the "ColoRx Drug Formulary."

2. Certain over the counter drugs provided under prior authorization.

3. Payment for restricted drugs authorized only in accordance with non-emergency or emergency
procedures as set forth in the Department's Manual Regulations, Volume VIII, Section 8.800.

4. OTC items are not included; exceptions are: insulin, aspirin under certain conditions, with refill
limitations as stated in Manual Regulations, Volume VIII, Section 8.800.

B. Formulary: ColoRx Drug Formulary

Only those drugs presently assigned drug numbers in the Formulary are a benefit. (Refer to Manual
Regulation Section 8.800 for provisions whereby drugs not listed in the ColoRx Drug Formulary may
be allowed as a benefit.)

Controlled Drug Formulary:

Section I - Alphabetical drug index in brand name order; if no brand name assigned, the generic
name is listed.

Section II -Generic drugs identified as having a Maximum Allowable Price, listed with price information
which is updated periodically.

Section Ill - EAC Price List. High volume drugs reimbursed at greater than 100's size or direct
manufacturer's price.

C. Prescribing or Dispensing Limitations:

I. Terminology: The Department encourages appropriate consideration of cost in prescribing and


dispensina bv the selection of the less expensive trade name or generic product when, in the
pr&tition&s~professional judgment, the 'use of such a product-is compatible with the best
interests of the patient.
The ColoRx Drug Formulary will not be used by clinic and hospital pharmacies for drug pricing
- only for drug code number information, Acquisition cost must be used for unit pricing.
2. Quantity of Medication: New prescriptions for chronic or acute conditions, at the discretion
of the physician. However, reasonable amounts for more than a 30-day supply for chronic
conditions are recommended. Maximum supply is 100 days.
NPC - 1989

Exceptions to the above are:


-
Shelf package size oral liquid medications, in pint size only, or smaller package size >'
a.
when not packaged in pint size.

b. Shelf package size oral tablet and capsule medications in quantities of 100 only or
smaller when not available in package size of 100.

c. Prescriptions for less than minimum amounts will be denied reimbursement of the
professional fee unless the physician notified the State Department in writing of the
medical need for amounts less than a 30-day supply. Medical consultation will determine
the decision.

3. Dollar Limits: None.

D. Basis for Reimbursement:

1. Benefit drugs shall be reimbursed at the lesser of the Medicaid allowable reimbursement
charge, or the provider's usual and customary charge or whatever is accepted from any third
party, discounts, rebates, etc.

2. The Medicaid allowable reimbursement charge is the sum of the ingredient cost of the drug
dispensed and the provider's dispensing fee.

3. Dispensing fee: $3.78 as of July 1, 1986. The patient copayment is $1.00.

4. The dispensing fee is a pre-determinedamount paid to a provider for dispensing a prescription.


It is established and periodically adjusted within appropriated
. . . funds based upon the results
of a cost survey which is designed to measure actual costs of filling prescriptions.

5. The pharmacy dispensing fee for retail pharmacies shall be based upon the average cost of
filling a prescription as determined by the cost survey subject to appropriated funds.

6. Institutional pharmacies shall receive a dispensing fee equal to one-half the retail pharmacy
fee.

7. Governmental pharmacies shall receive no fee.

8. Dispensing physicians shall not receive a dispensing fee unless their offices or sites of practice
are located more than 25 miles from the nearest participating pharmacy. In the latter case,
a fee equal to one-half the retail pharmacy fee will be paid.

E. lngredient Cost:

1. lngredient cost for retail pharmacies (estimated acquisition cost) is the price of the drug actually
dispensed as defined in (c) below or the MAC or the high volume EAC, whichever is less.
Colorado - 4

2. Benefit drugs dispensed in unit of use (unit dose) packaging will be reimbursed based upon
the bulk package size of 100 or pints or if not available in those sizes, the most common size
which most closely matches the standard sizes defined above.

3. The ingredient cost for institutional and government pharmacies is defined as the actual Cost
of acquisition for the drug dispensed or the MAC, or the high volume EAC, whichever is less.

a. Maximum Allowable Cost (MAC)

The state MAC is the maximum ingredient cost allowed by the Department for certain
multiple-source drugs. The establishment of a MAC is subject, but not limited to, the
following considerations:

(1) multiple manufacturers;


(2) broad wholesale price span;
(3) availability of drugs to retailers at the selected cost;
(4) high volume of Medicaid recipient utilization;
(5) bioequivalence or interchangeability.

When federal MAC limits for multiple source drugs are announced, they will be adopted
if they are less than state MAC's or if no state MAC's exist.

Section II of the ColoRx shall identlfy the generic drugs subject to MAC

The ingredient cost of any drug subject to MAC shall be limited to MAC or wholesale
price as determined by the Department, which is less. Exceptions which will allow
reimbursement greater than MAC for a drug entity are obtained through the prior
authorization mechanism. An exception will be granted if the patient's response to the
generic drug is not therapeutic, an allergic reaction is involved, or any similar situation
exists.

If a recipient requests a brand name for a prescription which is subject to MAC, then
helshe may pay the ingredient cost difference between the MAC and brand name drug.
The recipient must sign the prescription stating that helshe is willing to pay the
difference in ingredient cost to the pharmacy. The pharmacy will be paid MAC plus a
dispensing fee or reimbursement charges whichever is lower.

b. High volume Estimated Acquisition Cost (EAC)

Reimbursement for single source drugs or certain multiple source drugs which are most
frequently prescribed will be based upon average wholesale prices or direct
manufacturers' prices for package sizes containing quantities greater than 100 dosage
units or less if not available in 100's. Basis for inclusion in the high volume estimated
acquisition cost list includes but is not limited to:

(1) Single source manufacturers;


(2) High volume Medicaid recipient uutilization;
NPC - 1989

(3) Interchangeability problems with multiple source drugs;


(4) Package sizes in excess of 100;

These drugs will be identified in Section Ill of the ColoRx.

c. Drug Pricing

The Department will maintain a drug pricing file which will be updated at least monthly.
The average wholesale price of a drug as determined by the Department, MAC, and high
volume EAC, will be the basis for setting the prices in the drug pricing file.

The Department will determine the average wholesale price which will be placed in the
drug pricing file as follows:

(1) The average wholesale price as it appears in the Red Book, its supplements,
and Medi-Span will be the first source. However, if there is a difference between
the two published average wholesale prices, then the Department will set the price
as the published amount which is the closest to the lowest average price charged
by two drug wholesalers doing business in Colorado.

(2) If there is a price change which does not appear immediately in the Red Book,
its supplements or in Medi-Span, then the Department will set the average
wholesale price by averaging the wholesale prices of three drug wholesalers doing
business in Colorado, until the price is published in the Red Book, its
supplements, or in Medi-Span.

(3) If the prices or changes do not appear in the publications or the wholesalers'
records, then the distributors' or manufacturers' prices will be adjusted to the
wholesale pricing level and used in the drug pricing file as the price of the drug.

If the difference between the pharmacist's invoice purchase price and the average
wholesale price which appears in the Red Book, its supplements, or Medi-Span exceeds
18%, then the Department may adopt a lower price after a survey is conducted to
determine the validity of the published prices. The price from the distributor or
manufacturer will be adjusted the same as in 3 above.

Special Note:

The Maximum Allowable Cost shall be determined by the Division of Medical Assistance, based upon
professional determination of a quality product available at the least expense possible.

Recommendations from the ColoRx Drug Formula/y Advisory Committee of the Medical Advisory Council
is considered in. determining the MAC.
T
NPC - 1989 Colorado - 6

V. Miscellaneous Remarks:

Lock-In Review Procedures:

The State Department receives computer processed printouts designed to discover over-utilization of drugs
prescribed by physicians, dispensed by vendors, and received by eligible recipients.

A Lock-In Review Committee composed of two physicians, one consumer, and three pharmacists meets monthly
to review the printouts and make recommendations to the State regarding corrective action. In most cases, the
attending physician is notified of the Cornminee's recommendations. Case-workers are also contacted and
informed of the over-utilization review on abuse with a request to contact the recipient and explain lock-in and help
the recipient choose a physician and pharmacy. Recipient and the family are locked in for a year. A review of
the case is then made to determine if the recipient and family should remain locked in.

Fiscal Intermediary:

Blue CrossIBlue Shield


700 Broadway
Denver, CO 80237

Officials, Consultants and Committees

I. Social Services Department Officials:

Irene M. Ibarra. Executive Director Colorado Department of Social Sewices


P.O. Box I81000
Denver, Colorado 80218-0899

Mark L'kvan, Deputy Director

Garry A. Toerber, Ph.D., Director Bureau of Medical Assistance

David West, Director Program Services

Donna Bishop, Director Program Support

Stanley G. Callas, R.Ph., Manager PharmacyIAmbulatory Care Svces. Sect.


3031866-5508 Division of Medical Assistance

James C. Syner, M.D., Medical Consultant Division of Medical Assistance

Jordon Stevens, Manager Hospital Services Section


Division of Medical Assistance
Mary Ann Seddon, Manager Su~eillance/UtilizationReview Sect

Marion McLain, Manager HMO Section


NPC - 1989 Colorado - 7

Alena Gratts, Manager Fiscal Agent Monitoring

Dean Woodward, Manager Physician Services

Janell Little, Manager Third Party Recovery & Liabilities

Richard Allen, Manager Long Term Care

Wes Letz, Manager Appeals

2. Social Services Department Consultant:

Marvin J. Lubeck, M.D. 3865 Cherry Creek


Ophthalmology North Drive
Denver, CO 80210

3. Medical Advisory Committees:

A. Medical Assistance and Sewices Advisory Council:

Members:

John Thomas, OD Ernestine Kotthoff-Burrell, RN Donald Schiff, MD


3405 Wright Street 11313 San Juan Range Road 4200 E. 9th Ave., BOXC230
Wheatridge, CO 80033 Littleton, CO 80127 Denver, CO 80262

Jess Hayden, Jr., DMD Richard McCoy, Jr., R.Ph. Donna Rayer, RN
2465 S. Downing St., Ste. 108 2852 Dexter 6060 East lliff
Denver, CO 80210 Denver, CO 80207 Denver, CO 80222

Tony Makowski, M.D. Jo Ann Welier David Harmon, DO


206 W. County Line Road 15580 E. 144th Avenue 1060 Orchard
Middleton, CO Brighton, CO 80601 Grand Junction, CO 81501

David Holz, DPM Florangel Mendez-Cottingham Ronald Ellis, MD


5161 E. Arapahoe #260 1390 Logan Street #315 950 E. Haward, Suite 470
Littleton, CO 80122 Denver, CO 80203 Denver, CO 80210

Ex-Officio Members: Recordinq Secretary:

Irene Ubarra Thomas Vernon, M.D. Carole Allen


Executive Director Executive Director Bureau of Medical Services
CO Dept, of Social Services CO Department of Health PO Box 181000
717 17th Street 4210 E. 11th Avenue Denver, CO 80218-0899
Denver, CO 80218 Denver, CO 80220
Colorado - 8

B. ColoRx Drug Formulary Advisory Committee:

Richard A. Haynes, R.Ph. Roger R. Pearce, R.Ph. Gerri Sormani, R.Ph.


Chairman Pharmacy Div., King Soopers Musick Drug
130 Pearl Street, #I805 P.O. Box 5567, 65 Tejon St. 309 East Fontanero Steet
Denver, CO 80203 Denver, CO 80221 Colorado Springs, CO 80907

Don Asher Jerry D. Harvey, R.Ph. Duane H. Lambert, R.Ph.


300 Hudson 2201 San Juan Avenue 1315 South Clarkson
Denver, CO 80204 La Junta, CO 81050 Denver, CO 80210

Steve Taylor, R.Ph. Roger Thompson, R.Ph. Thomas Perry, M.D.


1077 S. Federal Blvd. Prof. Pharmacy of Derby 5440 W. 25th Avenue
Denver, CO 80219 6401 E. 72nd Avenue Edgewater, CO 80214
Commerce City, CO 80822
Lillian Bird, R.Ph. Gregory Tosiou
2420 71st Street Duane Hess, R.Ph. 400 E. Colfax
Greeley, CO 80631 5421 Manitou Road Denver. CO 80203
Middleton. CO 80123

4. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Society: B. Pharmaceutical Association:

Harold F. F ~ y e S. Thomas Gray


Executive Vice-president Executive Director
Colorado Medical Society CO Pharmaceutical Association
P.O. Box 17550 770 Grant Street, Ste. 244
Denver, CO 80217 Denver, CO 80203
3031779-5455 303/861-0328

C. Society of Osteopathic Medicine: D. State Board of Pharmacy:

Kathleen Brennan David L. (Mike) Simmons


Executive Director Administrator
CO Society of Osteopathic Medicine 1525 Sherman St., Rm. 128
50 S. Steele Street Denver, CO 80203-1751
Denver, CO 80209 3031866-2526
3031322-1752
NPC - 1989 Connecticut - 1
CONNECTICUT
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other'


OAA AB APTD AFDC OAA AB APTD AFDC Childrenc21
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X X

Laboratory &
X-ray Service
~ k i l l k dNursing
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.

1987
Ex~ended Recipient
TOTAL $37,603,536 152,137
CATEGORICALLY NEEDY CASH TOTAL $14,561,090 99,256
Aged 2,948,284 5,560
Blind 51,160 85
Disabled 5,101,593 9,023
Children -Families w/Dep. Children 2,447,896 52,540
Adults -Families w/Dep. Children 4,012,157 32,048
CATEGORICALLY NEEDY NON-CASH TOTAL $6,912,734 15,863
Aged 4,360,108 7,298
Blind 15,955 28
Disabled 2,006,796 3,358
Children -Families w/Dep. Children 120,517 1,755
Adults -Families w/Dep. Children 240,027 1,406
Other Title XIX Recipients 169,331 2,018
MEDICALLY NEEDY TOTAL $16,129,712 37,018
Aged 10,173,585 17,029
Blind 37,228 67
Disabled 4,682,524 7,835
Children -Families w/Dep. Children 281,207 4,096
Adults -Families w/Dep. Children 560,064 3,281
Other Title XIX Recipients 395,104 4,710
HHS report HCFA - 2082
Connecticut - 2

111. Administration:

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

IV. Provisions Relating to Prescribed Drugs:

A. General Exclusions (diseases, drug categories, etc.):

1. Will not pay for experimental drugs, anti-obesity drugs, drugs available free from the Department of
Health Services, DESl drugs.

2. Prior authorization required for: non-legend drugs not listed on Connecticut Drug List; Amphetamines
except when used for narcolepsy and hyperkinesis: vitamins except prenatal, pediatric prior to 7th
birthday and fluoride prior to 14th birthday; nutritional supplements.

3. Nursing home patients: The department will not pay for drugs used in routine care and treatment
of patients normally covered in per diem rate except by prior authorization. Prior authorization
required for influenza or pneumovax vaccine, irrigating solutions, diabetic and diagnostic testing
material and I.V. solutions or sets.

B. Formulary: OTC Drugs Only

C. Prescribing or Dispensing Limitations:

1. Physicians are encouraged to prescribe drugs generically, when possible.

2. Quantity of Medication: Maximum quantity: 30-day supply or 120 tablets or capsules or 1 lb. powder.
For chronic conditions, prescription may cover 120 day supply but no more than 120 tablets or
capsules or 1 lb. powder. Oral Contraceptives: 3 months supply may be dispensed at one time.

3. Refills: 6 month refill limit except for oral contraceptives which have a 12 month limit. Controlled
substances have a 5 refill or 6 month limit.

4. Dollar Limits: None

D. Prescription Charge Formula: MAC, AWP as listed in Red Book or EAC price set by Department plus fee;
or usual and customary if lower. EAC = AWP minus 8%.

Fees: Convalescent and nursing homes - cost plus $3.03


Walk-In" patients - cost plus $3.55
The Department will pay an incentive professional dispensing fee of fifty cents per prescription, in addition
to any other dispensing fee, for substituting a generically equivalent drug product.
NPC - 1989 Connecticut - 3

Officials, Consultants and Committees

1. Income Maintenance Officials:

Lorraine M. Aronson Department of Income Maintenance


Commissioner 110 Bartholomew Avenue
Hartford, Connecticut 06106
2031566-2008

Sally Bowles, Deputy Commissioner


2031566-2759

Bradford Blancard, Deputy Commissioner


3021566-2759

Linda Schofield, Director, Medical Care Administration


2031566-2934

Bill Diamond, Chief, Medicaid Policy & Program Implementation


2031566-6650

Patricia Smith, M.D., Medical Director


2031566-6438

Margaret R. Lempitsky, Chief of Long Term Care


2031566-2049

Jan VanTassell, Manager, Alternate Care Unit


2031566-1905

David Parrella, Manager, Issues Analysis Una


2031566-1330

Maureen Mohyde, Manager, Policy Unit


2031566-3761

Kathy Esposito, Manager, Operations Unit


2031566-2045

Julie Pollard, Manager, Medical Unit


2031566-3990

Meyer Rosenkrantz
110 Barthalomew Avenue
Hartford, CT 06106
2031566-8007
Connecticut - 4

2. Fiscal Agent

Electronic Data Systems Corp


Farmington, CT

3. Income Maintenance Consultants

Fran Naples, D.D.S.


Kenneth Lambert, D.D.S.
Meyer Rosenkrantz, P.D.
Ned Zeigler, M.D.
Joseph Dushaine, M.D.

Income Maintenance Consultants (Part time)

William Pehl, O.D.


Padam Jain, M.D.
Elizabeth Geary, P.D.

4. Title XIX Advisory Committee

State Pharmacy Commission CT Pharmaceutical Association


Dr. James O'Brien William Summa, P.D.
Michael Williams Edward C. Liska, P.D.

CT State Medical Society lncome Maintenance Dept.


Dr. Elliott R. Mayo Meyer Rosenkrantz, P.D., Pharmacist

5. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Society: B. Pharmaceutical Association

T. B. Norbeck Daniel C. Leone, P.D.


Executive Director Executive Director
Conn. State Medical Association Connecticut Pharmaceutical Association
160 St. Ronan Street 35 Cold Spring Rd., Ste. 125
New Haven, CT 06511 Rocky Hill, CT 06067-3100
Phone: 2031865-0587 2031563-4619

C. Society of Osteopathic Medicine: D. CT Commission of Pharmacy:

Hunter M. Addis, D.O. Sharon Milton-Wilhelm


Secretary Board Administrator
Connecticut Osteopathic Medical Society State Office Building, Rm. 61-A
225 Main Street Hartford, CT 06106
Manchester, CT 06040 2031566.4832
NPC - 1989 Delaware - 1

DELAWARE
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other.


OAA AB APTD AFDC OAA AB APTD AFDC Children<21 (SFOI
Prescribed Drugs X X X X
inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X

Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services X X X X

'SF0 - State Funds Only


Ii. EXPENDITURES FOR DRUGS

1987 1988
Expended Recipient Ex~endedRecipient
TOTAL $4,486,023 27,064 $4,622804 26.193
CATEGORICALLY NEEDY CASH TOTAL $3,796,124 25,046
Aged 965,468 2,441
Blind 34,758 89
Disabled 1,645,282 4,227
Children -Families wIDep. Children 529,585 11,689
~ d u l t s-Families w1Dep. Children 621,031 6,729
CATEGORICALLY NEEDY NON-CASH TOTAL $689,899 3,654
Aged 511,299 1,064
Blind 326 1
Disabled 68,791 215
Children -Families wiDep. Children 27,656 862
Adults -Families w/Dep. Children 44,100 738
Other Title XIX Recipients 37,727 793
MEDICALLY NEEDY TOTAL $0 0
Aged 0 0
Blind 0 0
Disabled 0 0
Children -Families w/Dep. Children 0 0
Adults -Families w/Dep. Children 0 0
Other Title XIX Recipients 0 0

HHS report HCFA - 2082


F

NPC - 1989 Delaware - 2

111. Administration:

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

IV. Provisions Relating to Prescribed Drugs:

General Exclusions: Only legend item drugs (except for insulin) are reimbursable. Vitamins (except
pediatric vitamins), antacids, etc. can not be reimbursed unless they are legend items. OTC items
cannot be reimbursed. Anorectics are excluded, (except for pediatric hyperactivity and certain sleep
disorders, when certified by the physician). No drugs used solely for infertility.

Formulary: None.

Prescribing or Dispensing Limitations:

1. Quantity: None. Department requests physician to prescribe reasonable amounts


2. Refills: Prescription blank has space for physician to authorize renewals.
3. Dollar Limits: None.

Prescription Charge Formula:

Payment is based on the actual acquisition cost or maximum allowable cost (MAC) plus a $3.65
dispensing fee, or the usual and Customary cost to the general public, whichever is lower.

V. Fiscal Intermediary:

The Computer Company


Omega Professional Center
Bldg. J, Suite 25
Newark, DE 19713

Officials, Consultants and Committees

1. Health and Social Services Department Officials:

Thomas P. Eichler Department of Health and Social Services


Secretary Delaware State Hospital
New Castle, DE 19720
3021421-6139

Phyllis T. Hazel Division of Social Services


Director P. 0. Box 906
New Castle 19720
NPC - 1989

Ruth S. Fischer
Administrator
Medical Assistance Services

Dr. James B. Salva


Medical Consultant

Stephen G. Grant
Pharmacist C ~ f l s ~ l t a f l t

2. Medical Advisory Committee Members:

Robert G. Kenrick, M.D. Anne Aldridge, M.D.


Chairperson 612 Ferry Cut Off
A. I. duPont Institute New Castle, DE 19720
1600 Rockland Road
Wilmington, DE 19803 Judith Brimer
209 McCallmont Road
Rhoslyn J. Bishoff, M.D. New Castle, DE 19720
15 Park Drive
Dover, DE 199013799 Sister Jeanne Cashman, O.S.U.
Ursuline Academy Convent
Amos Burke, Director 1104 Pennsylvania Avenue
Bureau of Health Planning & Resources Management Wilmington, DE 19806
Robbins Building, Silver Lake Plaza
Silver Lake Boulevard Neil McLaughlin, Director
Dover, DE 19901 Community Mental Health Center
Fernhook
Richard Ellis 14 Central Avenue
Director of Finance New Castle, DE 19720
Medical Center of Delaware
P. 0. Box 1668, 501 West 14th Street David J. Richard
Wilmington, DE 19899 Executive Director
Delaware Assoc for Retarded Citizens, Inc.
Lyman Olsen, Director 240 N. James Street, 8-2
Division of Public Health Tower Office Park
Robbins Building, Silver Lake Plaza Wilmington, DE 19804
Silver Lake Boulevard
Dover, DE 19901 Norman Taub, M.D.
1802 West Cedar Avenue
Edward R. Sobel, D.O. Lewes, DE 19958
1100 S. Broom Street
Wilmington, DE 19805 Daniel G. Thurman
The Milton & Hattie Kutz Home
704 River Road
Wilmington, DE 19809
3. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Society: B. Pharmaceutical Society:

Anne Shane Bader Janice A. Gaska


Executive Director Executive Director
Medical Society of DE DE Pharmaceutical Society
1925 Lovering Avenue 707 Philadelphia Pike
Wilmington, DE 19806 Wilmington, DE 19809-2599
3021658-7596 3021762-6019

C. Osteopathic Society: D. State Board of Pharmacy:

Raymond H. Rickards, D.O. Martin Golden, Secretary


Executive Secretary 802 Silver Lake Boulevard
DE State Osteopathic Medical Society Silver Lake Plaza
1109 Nottingham Road - P.O. Box 845 Dover, DE 19901
Wilmington, DE 19899 3021736-4708
3021764-6120, ext. 295
NPC - 1989 District of Columbia -1
DISTRICT OF COLUMBIA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other'


OAA AB APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs X X X X X X X X X
Inpatient
Hosoital Care
outpatient
Hospital Care X X X X X X X X X

Laborato~y&
X-ray Service
~ k i l l k dNursing
Home Services X X X X X X X X X
Phvsician Services X X X X X X X X X
~ e h aServices
l X X X X X

'SF0 - State Funds Only


II. EXPENDITURES FOR DRUGS.

1987 1988
Expended Recipient Expended Recipient
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families wiDep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families wiDep. Children
~ d u l t s-Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families wiDep. Children
~ d u l t s-Families wIDep. Children
Other Title XIX Recipients

HHS report HCFA 2082 -


NPC - 1989 District of Columbia - 2

Ill. Administration:

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

IV. Provisions Relating to Prescribed Drugs:

A. General Exclusions: All legend drugs are covered except those drugs that are listed by FDA as
ineffective. Pursuant to a prescription the following non-legend items are covered: oral analgesics,
oral antacids, insulin, insulin needles and syringes, contraceptive foams and jellies, ferrous sulfate,
prenatal vitamin formulations, geriatric vitamin formulations for recipients 65 years of age and over,
and multivitamin formulations for children 7 years of age and under. All other non-legend items are
excluded.

B. Formulary: None.

C. Prescribing or Dispensing Limitations:

1. Refills: In general, amounts dispensed are to be limited to quantities sufficient to treat an


episode of illness. Maintenance drugs such as thyroid, digitalis, etc. may be dispensed in
amounts up to a 30-day supply with 3 refills which must be dispensed within 4 months.

2. Antibiotic medications used in treatment of acute infections are not to be dispensed in excess
of a (10) day supply. Birth control tablets may be dispensed in 3-cycle units with a maximum
of 3 refills within one year.

3. Dollar Limits: There is no present dollar limitation. Physicians are requested to prescribe
reasonable amounts.

D. Prescription Charge Formula:

The lesser of: - Upper limit established by HCFA or the AWP - 10% plus a
dispensing fee of $4.25 or
- Usual and customary to the public

E. Compounded Prescriptions: - Allowable charges of all billable ingredients plus $5.10


- The provider's usual charge to the public.

F. Co-payment: $0.50 co-pay by recipient. Does not apply to recipients under 21 years of age,
prescriptions for family planning, nursing home patients, or pregnancy related.

V. Miscellaneous Remarks:

Fiscal Intermediary: The Computer Company FCC)


122 C Street, N. W.
Washington, D.C. 20001
District of Columbia - 3

Officials, Consultants and Committees

1. Department of Human Services Officials:

Peter Parham Department of Human Services


Director 801 North Capitol Street, N.E.
Washington, D.C. 20002

Reed Tuckson 1660 L Street, N.W.


Commissioner of Public Health 12th Floor
Washington, D. C. 20036

Lee Partridge 1331 H Street, N.W., Room 500


Chief, Office of Health Care Financing Washington, 5. C. 20005

James Harris, R.Ph.


Pharmacist Consultant
Office of Health Care Financing
202/727-0753

2. Executive Officers of District Medical and Pharmaceutical Societies:

Medical Society: B. Pharmaceutical Association:

P. Douglas Torrence John Smith


Executive Director President
Medical Society of D.C. D.C. Pharmaceutical Assn.
1707 L. Street, N. W., Suite 400 6400 Georgia Ave., NW, Suite 6
Washingon, D.C. 20036 Washington, D. C. 20012
2021466-1800 2021629-1515

Osteopathic Association: D. Board of Pharmacy:

Harry Handlesman, O.D. Carlyle McAdams


Secretary Secretary
Osteopathic Association of D.C. 614 H Street - Room 923
2804 Ellicon, N.W. Washington, D.C. 20001
Washington, D.C. 20008 2021727-7468
20213622250

Medico-Chirogical Society of D.C.

Jacqueline D. Savage
Executive Secretafy
P.O. Box 77013
Washington, D.C. 20013
2021347-47 70
NPC - 1989 Florida - 1

FLORIDA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other'


OAA AB APTD AFDC OAA AB APTD AFDC Children<21 (SFOI
prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X

Laboratoly &
X-ray Service X X X X
Skilled Nursing
Home Services X X X
Physician services X X X X
Dental Services X

'SF0 - State Funds Only


II. EXPENDITURES FOR DRUGS,

1987 1988
Expended Recipient Expended Recipient
TOTAL $1 16,229,852 469.31 5 $136,174,904 522,422
CATEGORICALLY NEEDY CASH TOTAL $93,814,378 391,047 106,316,853 409,458
Aged 36,603,054 73,695 40,449,430 74,243
Blind 965,183 2,586 1,145,441 2,574
Disabled 5,282,505 101,452 52,721,563 108,477
Children -Families w1Dep. Children 5,071,394 136,302 5,390,070 144,847
Adults -Families w/Dep. Children 5,892,241 11,012 6'61 0,347 79,317
CATEGORICALLY NEEDY NON-CASH TOTAL 20,950,413 64,724 27,514,182 97,261
Aged 17,688,499 33,276 22,046,455 40,627
Blind 9,205 14 16,229 16
Disabled 2,308,352 4,284 3,695,049 7,173
Children -Families w/Dep. Children 341,125 12,858 679,847 23,771
Adults -Families w/Dep. Children 378,063 9,129 737,415 18,785
Other Title XIX Recipients 225,166 5,163 339,184 6,889
MEDICALLY NEEDY TOTAL $1,465,060 13,544 2,343,905 15,703
Aged 532,079 2,392 682,676 2,884
Blind 6,346 29 3,548 28
Disabled 570,630 2,154 1,120,393 3,025
Children -Families w/Dep. Children 89,938 3,719 131,913 4,397
Adults -Families w/Dep. Children 220,017 3,537 360,593 3,850
Other Title XIX Recipients 46,048 1,713 44,779 1,519

HHS report HCFA 2082 -


NPC - 1989

Ill. Administration:

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

IV. Provisions Relating to Prescribed Drugs:

A. Limitations and Exclusions:

1. Vitamins and phosphate binders only for dialysis patients.


2. Protheses; appliances; devices; and personal care items;
3. Non-legend drugs (except for prescribed insulin and buffered and enteric coated aspirin when
prescribed as an anti-inflammatory agent only).
4. Anorexiants unless the drug is prescribed for an indication other than obesity (i.e. narcolepsy,
hyperkinesis);
5. Topical acne preparations and selenium sulfide preparations;
6. Oral vitamins with exception of fluorinated pediatric vitamins prescribed for pediatric patients,
vitamins for dialysis patients, prenatal vitamins & hematinics for nursing home recipients;
7. Digestants, except when prescribed for hepatic or pancreatic diseases;
8. Laxatives and Lactulose preparations, except when prescribed as a chelating agent;
9. Nursing home floor stock drugs,

B. Formulary: None.

C. Prescribing or Dispensing Limitations:

1. Prescribed drugs covered up to $22 per recipient per month ($33 if the recipient is in a nursing
home), limited to legend drugs within program limits plus insulin. Greater expenditures require
prior authorization by the program. Prescription limits effective January 1, 1989: 6
prescriptions monthly for walk-in patients; 8 prescriptions per month for institutionalized
patients.
2. The recipient must present a monthly eligibility card to the provider and must then use the
same provider for the entire calendar month.
3. Maintenance medication should be dispensed and billed for at least a one-month supply.
4. Refills must be authorized by the prescriber and can be made for up to one year, except that
controlled substances can be refilled only in accordance with federal and state regulations.
5. Drugs with questionable efficacy, as rated by the FDA (DESI), are disallowed.
6. Investigational, experimental, blood derivative (e.g. for hemophilia), and appetite suppressant
items are not covered, nor are drugs that are prescribed for other than their approved
indications.
Florida - 3

D. Prescription Charge Formula:

Fee - effective March 11, 1986


Lower of: (1) GULP plus $4.23
(2) EAC plus $4.23 (EAC is wholesaler acquisition plus 7%)
(3) Usual and Customary

V. Miscellaneous Remarks:

A. Some High Volume EACs set at large package size


B. Provisions for medically necessary considerations
C. General Upper Limit Price (GULP)

1. Federal GULP drug list


2. Generic drugs are required to be dispensed if stocked by pharmacy and prescriber does not include
medically necessary" statement.

D. Claims Processor

EDS Federal Corporation


Pharmacy Services
P.O. Box 9030
Tallahassee, Florida 32314

Officials, Consultants and Cornrni-mees

1. Department of Health and Rehabilitative Services Officials:

Gregory Coler, Secretary Department of Health & Rehabilitative Services


1323 Winewood Boulevard
Tallahassee, FL 32399

Gary Clarke, Deputy Assist. Secretary 1317 Winewood Boulevard


for Medicaid Building 6, Room 233
9041488-3560 Tallahassee, FL 32399-0700

Jerry Wells R.Ph., Pharmacist Consultant 1317 Winewood Boulevard


Medicaid Office of Program Development Building 6, Room 243
9041487-4441 Tallahassee, FL 32399-0700

2 Consultants to Medical Services Program: (Part-time)

Donald 0. Alford, M.D. Charles F. James, M.D. Armanda M. Sittig, M.D. Medicaid Office
Gene L. Davidson, M.D. Fred Lindsey, M.D. J. Orson Smith, M.D. 1317 Winewood Blvd.
Larry C. Deeb, M.D. Richard Lamb, D . D S James A. Stephens, O.D. Tallahassee, FL
Irving J. Fleet, D.D.S. Janet Shelfer Sam Tatum, D.D.S 32301
Florida - 4
NPC - 1989

3. Medicaid Advisory Council:

Chairperson: Peggy Richardson


Stephen G. Reeder, R.Ph. 550 San Bernadino
1314 N. Palafox North Ft. Myers, FL 33903
Pensacola, Florida 32501 (Consumer - District 8)
9041438-6323
(Florida Pharmacy Association) Charles B. Mclntosh, M.D.
3160 W. Edgewood Avenue
Ms. Bernice Jackson Jacksonville, FL 32209
Dir, Brevard Co. Social Services 9041765-5249
2575 N. Courtney Parkway (FL Medical Association)
Merrin Island, FL 32953
3051453-9513 Vernon K. Yon
(FL Assoc. of County Welfare Exec.) 4106 Arklow Drive
Tallahassee, FL 32308
Thomas P. Floyd, D.M.D. 9041488-8462
400 Executive Center Drive, Suite 105 (Consumer - District 2)
West Palm Beach, FL 33401
4071684-3331 Don Winstead
(FL Dental Association) Asst. Secretary/Economic Services
Dept. of Health & Rehabilitative Sew.
Charles Fieldus, C.P.A. 1317 Winewood Blvd, Bldg. 6, Rm. 205
Vice PresidentIFinance Tallahassee, FL 32301
Shands Teaching Hospital (9041488-3271
Box J-327
Gainesville, FL 32610 Gary J. Clarke
9041371-7280 Asst. Secretary for Medicaid
(FL Hospital Association) Dept. of Health & Rehabilitative Sew.
1317 Winwood Blvd, Bldg. 6,Rm. 205
Tallahassee, FL 32301
9041488-3560

4. Florida MAC Advisory Committee:

George Browning, R.Ph. Dick Kaplan


Retail Pharmacy for Nursing Homes Pharmacy Manager
1281 Hickory Street 3730 Thornwood Drive
Melbourne, FL 32901 Tampa, FL 33618

Lew Becks Jim Powers, R.Ph.


Nursing Home Pharmacy Secretary
5607 Hammock Lane Florida Pharmacy Association
Lauderhill, FL 33319 610 North Adams
Tallahassee, FL 32301

Lawrence DuBow Mark Sullivan, R.Ph.


Wholesaler Pharmacist
Lawrence Pharmaceuticals 1330 Miccosukee Road
P.O. Box 5386 Tallahassee, FL 32303
Jacksonville, FL 32207
NPC - 1989 Florida - 5

DHRS Medicaid Representative: Jerry Wells, R.Ph.


Department of HRS (PDDE)
1309 Winewood Boulevard
Tallahassee, FL 32399

5. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Association: B. Pharmaceutical Association:

Donald C. Jones James B. Powers


Executive Vice President Executive Vice President
Florida Medical Association, Inc, Florida Pharmacy Association
760 Riverside Avenue 610 North Adams Street
Jacksonville, FL 32203 Tallahassee, FL 32301
9041356-1571 9041222-2400

C. Osteopathic Medical Association: D. State Board of Pharmacy:

Steven 2.Winn C. Rod Presnell


Secretary-Treasurer, Executive Director Executive Director
Florida Osteopathic Medical Association 130 North Monroe Street
2007 Apalachee Parkway Tallahassee, FL 32399-0750
Tallahassee, FL 32301 9041488-7546
904878-7364
NPC - 1989 Georgia - 1
GEORGlA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN)" Other'


OAA AB APTD AFDC O M AB APTD AFDC"'Children<l8
Prescribed Drugs X X X X X X
Inpatient
Hospital Care X X X X X X
Outpatient
Hospital Care X X X X X X

Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Sewices X X X X
Physician Services X X X X
Dental Services X X X X

'SF0 - State Funds Only


"Aged, Blind & Disabled (all services) effective April, 1990
"'Pregnant Women Only

II. EXPENDITURES FOR DRUGS.


1987
Expended Recipient
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients

HHS report HCFA - 2082


NPC - 1989 Georgia - 2

ill. Administration:
By the Department of Medical Assistance.

IV. Provisions Relating to Prescribed Drugs:


A. General Exclusions: drugs not on the drug list.
B. Formulary: The Controlled Medical Assistance Drug List. For information contact:
(Vacant)
2 Martin Luther King, Jr. Drive S.E.
Floyd Building - west Tower
P.O. Box 38440
Atlanta, GA 30334
4041656-4044
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Physicians are encouraged to prescribe a 30 day supply. Six
prescriptions per month per recipient except by prior authorization.
2. Refills: According to state and federal law.
3. Dollar Limits: None.
D. Prescription Charge Formula: Lower of, average wholesale price (AWP) minus 10% plus fee of $4.26
or MAC plus fee, or usual and customary.
No copayment

V. Miscellaneous Remarks:
State MAC List = federal MAC plus 85 additional drugs

Officials, Consultants and Committees

1. Department of Medical Assistance Officials:

Aaron Johnson Department of Medical Assistance


Commissioner James Floyd Memorial Building
(Twin Towers) P.0, Box 38440
Atlanta, GA 30334
4041656-4479
Russ Toal
Deputy Commissioner

John W. Neal, Jr., Director


Program Management

Frances Lipscomb, R.Ph.


Program Management Officer
Pharmacy Service
4041656-4044
w

IPC - 1989 Georgia - 3

I. Title XIX (Medicaid) Medical Assistance Advisory Committees:

Representatives from each of the following groups:

Medical Association of Georgia Georgia Pharmaceutical Association


Atlanta Medical Association Georgia Health Care Association
Georgia Hospital Association Georgia Dental Association
Georgia Osteopathic Medical Association

I. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Association: C. Osteopathic Medical Association:

Paul Shanor Cathy M. Garris


Executive Director Executive Director
Medical Association of Georgia GA Osteopathic Medical Association
938 Peachtree Street, N. E. 1847-A Peeler Road
Atlanta, GA 30309 Atlanta, GA 30338
4041876-7535 4041399-6865

B. Pharmaceutical Association: D. State Board of Pharmacy:

Larry R. Braden William G. Miller, Jr.


Executive Vice President Joint Secretary
Georgia Pharmaceutical Association 166 Pryor Street, S.W.
20 Lenox Pointe, P.O. Box 95527 Atlanta, GA 30303
Atlanta, GA 30347 4041656-3912
4041231-5074
NPC - 1989 Hawaii - 1

HAWAII
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Othei


OAA AB APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X

Laboratory &
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X X
Physician Services X X X X X X X X X X
Dental Services X X X X X X X X X X

SF0 - State Funds Only


II. EXPENDITURES FOR DRUGS.

1987 1988
Expended Recipient Emended Recipient
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Tile XIX Recipients

HHS report HCFA - 2082


Hawaii - 2

Administration:

By the State Department of Social Sewices and Housing through its Public Welfare Division and four County
branch offices.

I.Provisions Relating to Prescribed Drugs:

A. Exclusions: Investigational new drugs, and drugs classified as ineffective or possibly effective by the
FDA.

B. Formulary: Drugs not listed in the Hawaii State Medicaid Drug Formulary require prior authorization.

C. Co-payment: No.

D. Prescription Drugs: Payment for drugs listed in the formulary is limited to the federally established
MAC price, or Estimated Acquisition Cost (EAC) plus dispensing fee $4.14 (effective July 1, 1989).

E. Program pays for no more than the larger of: 30-day supply or 100 doses.

V. Fiscal Intermediary: Hawaii Medical Service Association


Medicaid Program Section
P.O. Box 860
Honolulu, HI 96808

Officials, Consultants and CommiItees

1. Social Services and Housing Department Officials:

Winona Rubin. Director Department of Social Services and Housing


P.O. Box 339
Honolulu, HI 96809
8081548-6260

Medical Care Administrator (vacant)

Ornel L. Turk, R.Ph., Pharmaceutical Consultant 8081548-8917


NPC - 1989 Hawaii - 3

2. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Association: 8. Pharmaceutical Association:

Jonathan Won Edmund Ehlke


Executive Director Executive Director
Hawaii Medical Association Hawaii Pharmaceutical Association
1380 S. Beretania Street P.O. Box 1198
Honolulu, HI 96814 Ho~OIUIU, HI 96807
8081536.7702 8081547-4745

C. Osteopathic Medical Association: D. State Board of Pharmacy:

Alan R. Becker Jerold Sakoda


SecretaryFreasurer Executive Secretary
122 Oneawa Street P.O. Box 3469
Kailua, HI 96734 Honolulu, HI 96801
Honolulu, HI 96815 8081548-3086
NPC - 1989 ldaho - 1

IDAHO
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other'


OAA AB APTD AFDC OAA AB APTD AFDC ChildreM21
Prescribed Drugs X X X X
Inpatient
Hospital Care
outpatient
Hospital Care X X X X

Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician Sewices X X X X
Dental Sewices X

'SF0 - State Funds Only'

11. EXPENDITURES FOR DRUGS.

1987 1988
Expended Recipient Expended Recipient
TOTAL $2,920,363 28,020 $8,102,202 33,281
CATEGORICALLY NEEDY CASH TOTAL $1,519,289 18,915 2,603,370 19,429
Aged 247,635 958 477,585 893
Blind 1,876 17 5,725 17
Disabled 462,722 1,889 872,558 1,662
Children -Families w/Dep. Children 366,202 10,367 491,530 11,037
~ d u l t s-Families w/Dep. Children 440,852 5,684 755,971 5,820
CATEGORICALLY NEEDY NON-CASH TOTAL $1,401,073 9,105 5,498,831 13,852
Aged 645,332 3,509 2,823,598 4,872
Blind 1,970 10 4,309 7
Disabled 645,931 3,271 2,424,184 4,679
Children -Families w/Dep. Children 55,122 1,576 1 1 5,627 2,938
Adults -Families w/Dep. Children 37,728 615 107,121 1,153
Other Title XIX Recipients 14,988 1 24 23,990 203
MEDICALLY NEEDY TOTAL 1988 data reflect major changes in the ldaho
Aged Medicaid program, effective July I, 1987.
Blind Nursing home patient utilization is now reported
Disabled in the vendor program. In addition, medications
Children -Families w/Dep. Children which exceed the $30.00per month per patient
Adults -Families w/Dep. Children limit are paid via county funds, but are now
Other Title XIX Recipients reported in the total expenditure data. This
now provides a comprehensive pharmaceutical
-
HHS report HCFA 2082 benefit for Medicaid eligibles.

192
NPC - 1989 ldaho - 2

Ill. Administration:

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

IV. Provisions Relating to Prescribed Drugs:


A. Exclusions: Amphetamines, anorexic and related medication; non-legend medications except insulin
and insulin syringes; ovulation stimulants, DESl list in-effect; diet supplements; isotretinoin, nicotine
chewing gum; multivitamins, except for prenatal and pediatric fluoride-containing products; topicals;
minoxidil, benzoyl peroxide; clindamycin; erythromycin; meclomycin, tetracycline, tretinoin (except for
one indication).

B. Drug formulary: None

C. Prescribing or dispensing limitations: Prescription drugs are limited to a 34 day supply with limited
exceptions.

D. Prescription charge formula:

Lower of HCFA or EAC plus a variable dispensing fee $4.00, (unit dose $4.15) or the provider's
usual and customary price to the general public.

Miscellaneous Information:

Copayment - none

Fiscal intermediary: EDS Federal Corporation


P.O. Box 23
Boise, ID 83707

Officials, Consultants and Committees

1. Health and Welfare Department:

Richard Donovan, Director Department of Health and Welfare


Statehouse
Boise, ldaho 83720
2081334-5795

Jean Schoonover, Chief Bureau of Medical Assistance

William J. Whiteman, D.Ph., Supervisor Medicaid Policy Section

Mary K. Wheatley, R.Ph., Pharmacy


Services Specialist

2. Medical Care Advisory Committee:

Ruby Crosby, R.N. Arlene Davidson John Watts, Executive Dir.


St. Benedict's Hospital ID Office on Aging ID Council on Develop. Disabil.
Jerome, ID 83338 Statehouse Statehouse
Boise, ID 83720 Boise, ID 83720
ldaho - 3

Howard Barton Dr. Rodney Heater Larry Benton


ID Commission for the Blind 827 Center Avenue Idaho Health Care Association
Statehouse Payette, ID 83664 P. 0.Box 2623
Boise, ID 83720 Boise, ID 83701

J. Charles Holden Brian Lowry, D.D.S. Beverly Carpentier


ldaho Association of Counties ID State Dental Assn. ID Pharmacists Association
P. 0. Box 1623 9460 Franklin Road 3120 Crescent Rim Drive #I 03
Boise, ID 83701 Boise, ID 83704 Boise, ID 83706

Randy Robinson, Esq. Dick Schultz, Administrator Huey R. Reed, Director


ID Legal Aid Services, Inc. Division of Health Central District Health
Suite A, P.O. Box 973 Dept. of Health and Welfare 1455 N. Orchard
Lewiston, ID 83501 Statehouse Boise. ID 83706
Boise, ID 83720

Jan Cox Sharon Hubler Don Sower, Executive Dir.


Elmore Memorial Hospital ID Mental health Assn. ID Medical Association
P.O. Drawer 'H' 715 S. Capitol Blvd. #401 407 West Bannock
Mt. Home, ID 83647 Boise, ID 83702 Boise, ID 83702

Ward Dickey, M.D. Trudy Sheffield, R.N. Mary Anne Saunders, Director
125 E. ldaho #304 North ldaho Home Health -
H & W Region IV
Boise, ID 83702 2170 Ironwood Center Drive 1 105 S. Orchard
Coeur d'Alene, ID 83814 Boise, ID 83704

3. Executive Officers of State Medical and Pharmaceutical Societies:


A. Medical Association: B. Pharmaceutical Association:

Donald W. Sower Jo An Condie


Executive Director Executive Director
ldaho Medical Association ldaho State Pharmaceutical Association
305 West Jefferson, P.O. Box 2668 1365 N. Orchard Street, Room 103
Boise, ID 83701 Boise, ID 83706
2081344-7888 2081376-2273

C. Osteopathic Medical Association: D. State Board of Pharmacy:

Harry E. Kale, D.O. Richard K. Markuson


Secretary-Treasurer Executive Director
ldaho Osteopathic Medical Association 500 S. 10th Street, Suite 100
522 West Main Street Boise, ID 83720-0001
Grangeville, ID 83530 2081334-2356
2081983-1133
NPC - 1989 Illinois - 1

ILLINOIS
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other.


OAA AB APTD AFDC OAA AB APTD AFDC Childrenx21
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X X

Laboratory 8
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X X
Physician Services X X X X X X X X X X
Dental Services X X X X X X X X X X

'SF0 - State Funds Only


II. EXPENDITURES FOR DRUGS

1987 1988
Expended ReciDient Expended RecipieM
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients

HHS report HCFA - 2082


Illinois - 2

I. Administration:

Illinois Department of Public Aid

V. Provisions Relating to Prescribed Drugs:


A. General Exclusions: Biologicals and drugs available from State Department of Health or other
agencies, anorectics, DESI-ineffectives (including identical, similar and related products), cough
syrups, general multivitamins, topical acne preps.

B. Formulary: Pharmacies are encouraged to stock and dispense non-proprietary drugs of recognized
quality. If a drug is listed in the Drug Manual by generic name and the identical drug is prescribed
by trade name, the pharmacist may dispense the trade name product; however, payment will be
based on cost of the generic product. The pharmacist may so advise the practitioner to obtain his
permission to dispense the generic product which does not exceed the maximum allowable price.
Coverage is limited to items in the department's Drug Manual unless prior authorization is obtained
for exceptions.

For formulary information contact:

Ron Gottrich
P.O.Box 19117
Springfield, Illinois 62794-9117
2171782-7532

C. Prescribing or Dispensing Limitations:

1. The pharmacy shall dispense non-proprietary products of quality. Maximum reimbursement


to the pharmacy will be based on the price of a non-proprietary item of recognized quality.'

2. Quantity: A prescription may be refilled only if the prescribing practiiioner has so authorized
on the original prescription. A prescription may be refilled no more than twice and no later
than 3 months from the date of the original prescription. Maintenance Rx's may be refilled for
up to one year.

3. Dollar Limits: None.

D. Prescription Charge Formula: Lowest of I ) usual and customary, 2) Department's MAC plus fee.
Professional fee: $3.47.

V. Miscellaneous Information:

State MAC: Yes.


Approximately 3000 drugs
Copayment - none
-
Fiscal Intermediary none
NPC - 1989 Illinois - 3

Officials, Consultants and Committees

1. Public Aid Department Officials:

Susan S. Suter Department of Public Aid


Director 100 S. Grand Avenue East
Springfield, IL 62704
2171782-6716
Mary Ann Langston, Administrator Policy and Planning
Norman L. Ryan
General Services Administrator
Sally Ferguson, Chief Bureau of Research & Analysis
Tim Claborn, Administrator 201 S. Grand Avenue East
Medical Assistance Program Springfield, IL 62762
Ron Gottrich, R.Ph., Pharmacist Consultant 3rd Floor
2171782-7532
Maureen Mulhall, Chief
Bureau of Medical Practitioner Services 3rd Floor

2. Public Aid Department Advisory Committees:

A. The Department has a State Medical Advisory Committee, composed of physicians appointed by the Director
of Public Aid. The members of this Committee are from different areas of the State and are representative
of the different specialty fields.

Frederick B. White, M.D., Chairman 723 North 2nd Street


Chillicothe, IL 61523

B. Committee on Drugs and Therapeutics:

A Committee on Drugs and Therapeutics, a standing committee appointed by the Illinois State Medical
Society, serves in an advisory capacity to the Department of Public Aid on drug policy and the Drug
Manual.

Joseph B. Perez, M.D. 5713 Strathmoor Drive, Ste. 2


Chairman Rockford, IL 61107
8151398-5456

Lawrence L. Hirsch, M.D. 1324 Coventry Lane


Northbrook, IL 60062
3121578-3338

Nicholas C. Bellios, M.D. 2504 Washington


Waukegan, IL 60085
3121249-3660

Marshall Blankenship, M.D. 4647 W. 103rd Street


Oak Lawn, IL 60435
31213373641
-.
IPC - 1989 Illinois - 4

Theodore M. Kanellakes, M.D. 229 N.Hammes Avenue


Joliet, IL 60435
8151744-2300

Armand Littman, M.D. 9 Martha Lane


Evanston, IL 60201
3121261-6700
Allan L. Lorincz, M.D. 5841 S. Malyland, Box 409
Chicago, IL 60637
3121702-6558

Patrick R. Staunton, M.D. 540 Linden


Oak Park, IL 60302
3121696-5887

Consultants:

Phillip D. Boren, M.D. Doctor's Clinic


6181382-4193 S. Plum Street
Cormi, IL 62821

Joan E. Cummings, M.D. Hines V.A. Hospital


312/343-7200 Hines, 1L 60141

M. Anita Johnson, M.D. St. Maly of Nazareth


3121770-2000 EENT Dept.
2233 W. Division
Chicago, IL 60622

Vincent A. Costanzo, Jr., M.D. 7501 South Stony Island


312/947-7310 Chicago, IL 60649

lPhA Representative:

Sam Enloe, Jr. R. Ph. 261 W. First Drive


Decatur, IL 62521

IL State Medical Society

Kenneth E. Ryan 20 N. Michigan Avenue, Ste. 700


Director, Dept. of Economics Chicago, IL 60602
312/782-1654

IDPH Representative

Ron Gottrich, R.Ph 525 W. Jefferson


IL Dept. of Public Health Springfield, IL 62761
2171782-7532
NPC - 1989 Illinois - 5

C. Drug Advisory Committee:

A State Drug Advisory Committee, appointed by the Director of the Department of Public Aid to advise on
general policies necessary to the operation of a statewide drug program for public assistance recipients.

Sam Enloe, R.Ph., Chairman George Karpman, R.Ph. Bernie Evers, R.Ph.
Enloe's Southtowne Pharmacy 901 N. First Evers Pharmacy
261 West First Drive Springfield, IL 62702 417 West Main
Decatur, IL 62521 Collinsville, lL 62234
Tom Gulick, R.Ph. Don Gronewold, R.Ph. Shewood Thomas, R.Ph.
Gulick Pharmacy, Inc Don's Pharmacy Touhy Pharmacy
912 North Vermilion 100 South Main Street 7173 North Clark Street
Danville, IL 61832 Washington, IL 61571 Chicago, IL 60626
Rose Mancuso, R.Ph. Ron Stephens, R.Ph. Jeffrey Veal, R.Ph.
1610 Arden Place 83 West Lake Drive Watson's Malmart
Joliet, IL 60435 Troy, IL 62294 6333 S. Green Street
Chicago, IL 60621
Harry Staub, R.Ph. Kenneth L. Gimmy, R.Ph.
Cabrini Pharmacy Gimrny's Drug Store, Inc
949 N. Larrabee 97 South 9th, Rosewood Heights
Chicago, IL 60610 East Alton, iL 62232
Jerry Handler, R.Ph. Bill Ghodes, R.Ph.
4811 West Madison 7 Buttonwood Court
Chicago, IL 60644 lndianhead Park, IL 60525

3. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Society: B. Pharmaceutical Association:

Alexander R. Lerner Edward Halstead, R.Ph.


Executive Vice President Acting Executive Director
IL State Medical Society IL Pharmacists Association
20 N. Michigan Ave, Suite 700 223 W. Jackson, Suite 1000
Chicago, IL 60602-4890 Chicago, IL 60606-5307
3121782-1654 3121939-7300

C. Osteopathic Medical Association: D. State Board of Pharmacy:

Mr. George C. Andrews, Stephen F. Selcke


Executive Director Director
IL Association of Osteopathic Dept. of Professional Regulation
Physicians and Surgeons, Inc. Pharmacy Section
809 East Center Street 320 West Washington Street
OnawaJL 61350 Springfield, IL 62786
8151434-5576 2171785-0800
Indiana -1 I
NPC - 1989

INDIANA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE


,
I

Type of Benefit Categorically Needy Medically Needy (MN) Other'


OAA AB APTD AFDC OAA AB APTD AFDC Children<21 (SFOI
Prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatlent
Hospital Care X X X X

Laboratory &
X-ray Service
skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services X X X X

'SF0 - State Funds Only


II. EXPENDITURES FOR DRUGS.

1987 1988
Expended Recipient Expended Recipient
TOTAL $88,483,051 243,531
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

HS report HCFA - 2082


NPC - 1989 lndiana - 2

Ill. Administration:
The lndiana State Department of Public Welfare.

IV. Provisions Relating to Prescribed Drugs:


A. General Exclusions: (Most OTC drugs are covered) No legend or non-legend anorexics or
experimental, or DESl drugs.
B. Formulary: None.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: None.
2. Refills: Allowed as authorized by physician.
3. Dollar Limits: None.
4. Up to two dispensing fees paid per legend drug order per recipient per month in nursing home
setting.
D. Prescription Charge Formula:
1. The lowest of the:
a. MAC plus the dispensing fee of $3.00.
b. EAC (Estimated Acquisition Cost) plus the dispensing fee of $3.00. (EAC is 3% less than
AWP reported by Drug Topics Red Book)
c. Pharmacy's usual and customary charge to the general public.
V. Miscellaneous Information:
Fiscal Intermediary: Blue CrossIBlue Shield of IN
8350 Craig Street - Suite 250
Indianapolis, IN 46250

Officials, Consultants and Committees

1. Welfare Department Officials:


Mrs. Suzanne L. Magnate Department of Public Welfare
Administrator 100 N. Senate Avenue
Room 701
Indianapolis, IN 46204
3171232.431 2
(Vacant), Assistant Administrator
Medicaid
Mary Kapur, Assistant Administrator
Local Operations Division
Marc Shirley, P.D., Pharmacy Consultant
Indiana - 3

Advisory Committee for Medical Assistance (Medicaid):


Sen. Virginia Blankenbaker Delano Bryant Richard L. Issacson, DPM
5019 N. Meridian St. 2028 Country Club Road 8424 Naab Rd., Ste. 2-L
Indianapolis, IN 46208 Indianapolis, IN 46234 Indianapolis, IN 46260

Jo Haynes Brooks, R.N., D.N.S. Ray Fox Albert F. Kull, D.O.


Assoc. Professor, Nursing Fox & Fox Insurance Co. 203 South Ironwood Drive
Purdue Univ. School of Nursing 101 E. 38th Street P. 0. Box 6172
West Lafayette, IN 47907 Indianapolis, IN 46205 South Bend, IN 46615

John Reed Joe D. Hunt, Director Mrs. Belle Kasting


Dir., Third Party Affairs Bur./Policy Development 1724 Parkview Drive
Hook-SupeRx., Inc. State Board of Health Bedford, IN 47421
2800 Enterprise St. 1330 W. Michigan
Indianapolis, IN 46226 Indianapolis, IN 46202

Frank McAllister Barbara J. Miller Chris C. Paprocki, D.C.


4327 Valley Way Drive P. 0. Box 277 420 North US. 31
Greenwood, IN 46142 Syracuse, IN 46567 Whieland, IN 46184

Mr. Sandy Quarles George S. Row, Ill Robert C. Shirey, D . D S


P. 0. Box 506 121 West Ripley Street 7216 Madison Avenue
Kokomo, IN 46901 Osgood, IN 47037 Indianapolis, IN 46227

Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Association: B. Pharmaceutical Association:

Richard R. King David A. Clark


Executive Director Executive Director
lndiana State Medical Association lndiana Pharmacists Association
3935 N. Meridian Street 156 E. Market Street, #900
Indianapolis, IN 46208 Indianapolis, IN 46204
3171925-7545 3171634-4968

C. Osteopathic Medical Association: D. State Board of Pharmacy:

Stephan J. Noone Mary Gaughan


3520 Guion Road #i06 Executive Director
Indianapolis, IN 46222 lndiana Health Professions Bureau
31719263009 One American Square Suite 1020
Indianapolis, IN 46282
3171232-2960
NPC - 1989
IOWA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other'


OAA AB APTD AFDC OAA AB APTD AFDC' Childrew21
Prescribed Drugs X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X

Laboratory &
X-ray Service X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X
Physician Services X X X X X X X X X
Dental Services X X X X X X X X X

'SF0 - State Funds Only


+ Pregnant women

II. EXPENDITURES FOR DRUGS.

I987 1988
Expended Recipient Expended Recipient
TOTAL $33,7i7,984 174,376 38,298,744 171,584
CATEGORICALLY NEEDY CASH TOTAL $19,406,031 126,693 22,513,728 121,759
Aged 3,865,983 8,648 4,800,750 9,332
Blind 184,664 507 215,669 509
Disabled 7,604,133 17,927 9,780,252 19,693
Children -Families w/Dep. Children 3,295,925 58,750 3,354,071 55,270
Adults -Families w/Dep. Children 4,455,326 40,861 4,362,986 36,955
CATEGORICALLY NEEDY NON-CASH TOTAL $12,094,059 38,461 12,314,606 38,741
Aged 9,198,832 16,722 9,448,469 16,322
Blind 50,127 79 42,414 64
Disabled 1,467,174 2,266 1,222,873 1,896
Children -Families w/Dep. Children 276,304 5,757 321,114 6,197
Adults -Families w/Dep. Children 618,215 6,048 766,361 6,738
Other Title XIX Recipients 12,094,059 7,589 513,375 7,524
MEDICALLY NEEDY TOTAL $2,272,933 9,162 3,465,116 11,059
Aged 1,200,615 2,884 1,876,507 3,729
Blind 5,439 21 6,947 19
Disabled 870,437 1,977 1,328,870 2,452
Children -Families w/Dep. Children 55,706 1,140 60,446 1,108
A d u b -Families w/Dep. Children 17,018 399 18,166 429
Other Title XIX Recipients 123,718 2,741 174,180 3,322

HHS report HCFA - 2082


Iowa - 2

. Administration:

Central administration by the State Department of Human Services.

I. Provisions Relating to Prescribed Drugs:

A. General Exclusions (diseases, drug categories, etc.): Most non-legend drugs, amphetamine products,
laxative drugs, and legend multiple vitamins require prior authorization.

lowa Medicaid OTC Coverage Rule

The lowa Department of Human Sewices adopted an administrative rule which permits coverage for
the following non-prescription drugs.

Aspirin Tablets 325 mg, 650 mg


Aspirin Tablets Enteric Coated 325 mg, 650 mg
Aspirin Tablets Buffered 325 mg
Acetaminphen Tablets 325 mg, 500 mg
Acetaminophen Elixir 120 mg/5 ml
Acetaminophen Solution 100 mg/ml
Ferrous Sulfate Tablets 300 mg, 325 mg
Ferrous Sulfate Elixir 220 mg15 ml
Ferrous Sulfate Drops 75 mg10.6 ml
Ferrous Gluconate Tablets 320 mg, 325 mg
Ferrous Gluconate Elixir 300 mg15 ml
Ferrous Fumarate Tablets 300 mg, 325 mg

B. Formulary: None.

C. Prescribing or Disperising Limitations:

1. Terminology: None.
2. Quantity of Medication: Prescriptionsshould be limited to a 30-day supply. Maintenance drugs
may be supplied in 90-day quantities.
3. Refills: Permitted.
4. Dollar Limits: None.

D. Prescription Charge Formula: Payment will be based on the pharmacist's usual, customary and
reasonable charge, but payment may not exceed the average wholesale price, plus a professional
fee determined to be the 75th percentile of usual and customafy fees. Currently 8.78.

E. State MAC list contains 35 drugs


NPC - 1989

V. Miscellaneous Remarks:

Co-payment: $1.00'

Incentive fee: $.SO2

VI. Claims Processing Intermediary:

Unisys Corporation
P.O. Box 10394
Des Moines, lowa 50306

Ofticials, Consultants and Committees

1. Human Services Department Officials:

Charles M. Palmer Dept. of Hurhan Services


Director Hoover State Office Bldg.
Des Moines, lowa 50319
5151281-8621
Donald W. Herman, Chief
Bureau of Medical Services

Ronald J. Mahrenholz, R.Ph., MS., Supervisor


Non-Institutional Services & Utilization Review Section
5151281-6199

2. Human Services Department Advisory Committees:

A. Title XIX Medical Assistance Council:

College of Medicine Iowa Nurses Association House of Representat~es


Charles M. Helms, MD, Ph.D. Mary Hosford Rep. Andy McKean
Associate Dean 100 Court Avenue 9 LL 509 S. Oak
College of Medicine Des Moines, IA 50309 Anamosa, IA 52205
University Hospitals
lowa City, IA 52240 Rep. Mike Peters
1505 Glendale Bhd.
Sioux City, IA 51105

$1 .OO co-pay (federal exclusions) fee: $3.78 fee effective July I , 1984.

$50 incentive fee paid to pharmacy if $1.50 is saved per prescription by the use of generics.

205
-
lowa 4

lowa M e d i i Society lowa Hospital Association lowa Dental Assoc'lation


Donald C. Young, M.D. Donald Dunn Dan Todd, D.D.S.
1301 Pennsyvlania St. 100 E. Grand Avenue 1454 30th Stret, Suite 2088
Des Moines, IA 5031 6 Des Moines, IA 50309 West Des Moines, IA 50265

Opticians Assn. of IA IA Health Care Association IA Cncl. of Health Care Centers


Charles Ericson Paul A. Romans Jennifer Tyler
P. 0. Box 3914 950 12th Street 303 Locust Street
Des Moines, IA 50322 Des Moines, IA 50309 Des Moines, IA 50309

IA Assn. of Retarded Ciizens IA Assn. for Home Care IA Osteopathic Medical Assn.
Mary Ena Lane Marilyn Russell Gregory L. G a ~ i n D.O.
,
715 E. Locust P. 0. Box 4985 1351 W. Central Park, Ste 1100
Des Moines, IA 50309 Des Moines, IA 50306-4985 Davenport, IA 52804

lowa Senate lowa Chiropractic Society IA Optometic Assn.


Sen. Linn Fuhrman Robert Rasmussen, D.C. Russell R. Campbell
Box 87 3500 2nd Ave. Suite 1 1 5721 Merle Hay Road
Aurelia, IA 51005 Des Moines, IA 50309 Johnston. IA 50131

Sen. Michael Gronstal IA Pharmacists Assn IA Podiatry Society


220 Bennett Avenue Thomas R. Temple John C. Korn, D.P.M.
Council Bluffs, IA 51501 8515 Douglas, Ste 16 207 Professional Arts Bldg.
Des Moines, IA 50322 Davenport, IA 52803

IA Osteopath. Hospital Assn. IA Assn. of Homes for the Aging IA Psychological Assn.
Darla Giese William Thayer Don Kaesser, Ph.D.
603 E. 12th Street 613 West North Street 2400 86th St., Ste 30
Des Moines, IA 50307 Madrid, IA 50156 Des Moines, IA 50322

IA State Dept. of Public Health Community of Mental Health Centers of IA


Ronald D. Eckoff, M.D. William Cropp
Lucas State Office Bldg. 1309 Center Street
Des Moines, IA 50319 Des Moines, IA 50309

Public Representatives:
Dorothy J. Eide Nancy M. Jones Owil Nelson
RR 2, Box 74 RR #I 1534 Second Street
Decorah, IA 52101 Ainsworth. IA Boone, IA 50036

B. Pharmaceutical Advisory Committee:

Mark Richards, Des Moines Russ Wiesley, Des Moines


Bill Robinson, Oakland Terry Jacobsen, Osceola
Leon Galehouse, Cedar Falls Marion Reis, Sioux City
Doug Fitzgerald, Des Moines Ray Buser, Cedar Rapids
Ken Hampson, Ames David Persinger, West Des Moines
Bob Sack, Manchester Mike Siefert, Des Moines
NPC - 1989

3. Executive Officers of State Medical and Pharmceutical Societies:

A. Medical Society: B. Pharmacists Association:

Eldon Huston Thomas R. Temple, R.Ph., MS.


Executive Vice-president Executive Vice President
lowa Medical Society lowa Pharmacists Association
1001 Grand Avenue 8515 Douglas, Suite 16
West Des Moines, IA 50265 Des Moines, IA 50322
51 51223-1401 51 51270-0713

C. IA Osteopathic Medical Association: D. State Board of Pharmacy Examiners:

Norman Pawlewski Norman C. Johnson


Executive Director Executive Secretary
1 1 13 Locust STreet, Suite 28 1209 East Court, Executive Hills West
Des Moines, IA 50309 Des Moines, IA 5031 9-0075
51 51283-0002 51 51281 -5944
Kansas - 1

KANSAS
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

BENEFITS PROVIDED AND GROUPS ELIGIBLE

fpe of Benefii Categorically Needy Medically Needy (MN) Other'


OAA AB APTD AFDC OAA AB APTD AFDC Children<2l
rescribed Drugs X X X X X X X X X X
patient
losoital Care
lutpatient
lospital Care X X X X X X X X X X

aboratory &
:-ray Service
;killed Nursing
iome Services X X X X X X X X X X
'hysician Services X X X X X X X X X X
)ental Services ................................................ ..........
KAN Be Healthy (EPSDT)............. ....................
SF0 - State Funds Only

I. EXPENDITURES FOR DRUGS.

1987 1988
Expended Recioient Expended Recipient
rOTAL $20,~~,958 92,797 $23,278,380 114,165
2ATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients

HHS report HCFA - 2082


NPC - 1989 Kansas - 2

Ill. Administration:
State Department of Social and Rehabilitation Services.

IV. Provisions Relating to Prescribed Drugs:

A. Prescribed drugs. Covered are: (a) legend drugs in a drug list approved by the state Medicaid
agency, excluding drugs that the agency finds ineffective or possibly effective; and (b) selected
nonlegend drugs, devices, and supplies when prescribed for diseases and conditions specified in
the state's Medicaid regulations.

B. Formulary: Restricted drug list.

C. Prescribing or Dispensing Limitations:


1. Quantity of Medication: Maximum of a 100-day supply. Minimum quantities of a 100-dose or
30-day supply should be prescribed and dispensed for maintenance drugs.
2. Refills: As authorized by the prescriber up to a one-year period from the date of issuance of
the prescription.

D. Prescription Charge Formula: Variable fee per prescription established for each individual
participating pharmacy within the range of $2.79 to $5.26.

Pharmacies are reimbursed on the basis of product acquisition cost plus a professional fee. This
applies to all covered legend drugs. Covered non-legend drugs are reimbursed at the lesser of usual
and customary selling price or allowable acquisition cost plus the assigned dispensing fee. The
professionalfees are based upon each individual pharmacy's historical operating costs as determined
by analysis of data submitted by each pharmacy to the agency. Professional fee determination is
limited to the lowest of: (a) The 85th percentile of allocated costs per prescription for all pharmacies
filing a cost report plus a reasonable profit, or (b) usual and customary fee charges of each individual
pharmacy as determined. "Acquisition cost'rneans the allowable price determined by the agency
for each covered drug in accordance with state and federal regulations.
Ingredient reimbursement basis: a combination of AWP-EAC; direct prices for eight companies; lower
of SMAC, FUL or EAC on multisource; NDC specific AWP as EAC on others.
A recipient co-pay charge of $1.00 was applied to each new and refill prescription.

E. Fiscal agent:

EDS Federal Corporation Carolyn L. Counts


P.O. Box 4649 Director of Provider Services
Topeka, KS 66604
9131273-5700
Kansas - 3

ORicials. Consultants and Committees

Social and Rehabilitation Services Department Officials:

Winston Barton, Secretary Dept. of SociaVRehab. Services


913,296-3981 Docking State Office Building
915 SW Harrison
Topeka, KS 66612

L. Kathryn Klassen, R.N., MS.


Director
Division of Medical Programs

Elaine Hacker, M.D.


Utilization Review Administrator

E. Eugene Stephens, R.Ph. Div. of Medical Programs


Manager, Pharmacy Services Program Rm. 6285, Docking State Office Bldg.
9131296-3981 Topeka, KS 66612

Governor's Medical Care Advisory Committee:

Robert Anderson Stuart Averill, M.D. Roger Gausman


Family Consultation Services Menninger Foundation 1311 Wheatland
560 North Exposition P. 0. Box 829 Hutchinson, KS 67501
Wichita, KS 67203 Topeka, KS 66601

Virginia Tucker, MD Juanita DeMott Roy Mitzi Richards


Healh and Environment St. Francis Hospital Homecare Inc.
Landon State Office Building 1700 West 7th Street 2803 Claflin
900 SW Jackson Topeka, KS 66606 Manhattan. KS 67501
Topeka, KS 66612

Floyd Eaton, Admin. Mary Reyer Jeanette Dickes, RPh.


Countyside Health Center Topeka Res Ctr for Handicapped 2003 Regency Parkway
3501 Seward 1119 SW loth Topeka, KS 66614
Topeka, KS 66616 Topeka, KS 66604

Betty Schultz Sandra Kelly Fred E. Patrick, M.D.


PO Box 15122 706 SW Tyler 904 Mulvane
Kansas City, KS 66115 Topeka, KS 66603 Topeka, KS 66606

James Reeves, DPM


930 Iowa - Suite 2
Lawrence, KS 66044

Department Representatives

Winston Barton L. Kathryn Klassen, RN, MS Elaine Hacker, MD

210
NPC - 1989 Kansas - 4

3. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Society: B. Pharmaceutical Association:

Jerry Slaughter Robert R. Williams


Executive Director Executive Director
Kansas Medical Society KS Pharmaceutical Association
1300 Topeka Boulevard 1308 West 10th Street
Topeka, KS 66612 Topeka, KS 66604-1299
9131235-2383 9131232-0439

C. Osteopathic Medical Association: D. State Board of Pharmacy:

Harold Riehm Thomas Hitchcock, R.Ph.


Executive Director Executive Secretary
Kansas Assn. of Osteopathic Medicine 900 Jackson, Rm 513
1260 S.W. Topeka Boulevard Topeka, KS 66612-1220
Topeka, KS 66612 91312964056
9131234-5563
Kentucky - 1

KENTUCKY
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()

, BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other*


OAA AB APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X

Laboratory &
X-ray Service X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X
Physician Services X X X X X X X X X
Dental Services X X X X X X X X X

'SF0 - State Funds Only


11. EXPENDITURES FOR DRUGS.

1987 1988
Expended Recipient Expended Recipient
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
~ d u l t s-Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Tile XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients

HHS report HCFA - 2082


NPC - 1989 Kentucky - 2

Ill. Administration:

By the Depanment for Medicaid Services, within the Cabinet for Human Resources,
IV. Provisions Relating to Prescribed Drugs:

A. General Exclusions (diseases, drug categories, etc.): The following are items which are not covered
under the pharmacy benefits area of the program:

1. Most medical supply items such as bedpans, urinals, ice bags, etc. (Note: Insulin syringes are
covered.)

2. Medicine cabinet supplies and drug staples

3. Drugs available through other programs or agencies

4. Drugs not included on the Kentucky Medical Assistance Program Drug List (unless
prsauthorized according to established guidelines and criteria).

5. Medications and supplies used or dispensed by physicians or dentists during home or office
calls.

6. Most non-legend (over-the-counter) drugs except those used to treat diabetes and iron
deficiency anemia, enteric coated aspirin, and buffered aspirin.

6. Formulary: Yes. The list is revised in accordance with recommendations of the Formulary
Subcommittee and in accordance with available funds.

C. Prescribing or Dispensing Limitations:

1. Quantity of Medications: For designated classes of maintenance drugs, refills of the original
prescription and subsequent prescriptions for these drugs must be prescribed and dispensed
in quantities of not less than a thirty-day supply unless the prescriber requests an exception
to this policy.

2. Refills: No prescriptions may be refilled more than 5 times or more than 6 months after the
prescription is written.

3. Dollar Limits: None,

D. Prescription Charge -- Reimbursement Formula:

1. All covered outpatient pharmacy benefits provided to Kentucky Medical Assistance Program
recipients are to be billed to the Program at the usual charge to the general public for the
same product and service(s).

Reimbursement to the pharmacy consists of the lowest of: (1) the usual and customary
charge; (2) the MAC, if any, plus dispensing fee; or (3) the EAC plus dispensing fee.

(conr. on page 3)
-
Kentucky 3

The most frequently purchased package size and the most frequent method of purchase (AWP
or direct), as reported by suppliers and wholesalers. When AWP is used. it is reduced by five
percent.
2. The dispensing fee is $3.25.
3. Co-payment - none.
4. State MAC list contains 268 drugs as of April 1, 1989.

1. Fiscal Intermediary:

Electronic Data Systems Corp


Dallas, Texas

Officials, Consultants and Cwnm.Wees

1. Officials:

Harry J. Cowherd, M.D. Cabinet for Human Resources


Secretary 4th Floor, CHR Builg'ing
275 East Main Street
Frankfort, KY 40621
5021564-4321

ROY Butler Department for Medicaid Services


Commissioner 3rd Flwr, DHR Building
275 East Main Street
Frankfort, KY 40621

Gene A. Thomas, RPh. Department for Medicaid Services


50215643476
2. State Advisory Council on Medical Assistance: appointed by the Governor, is composed of members representing
pharmacy, hospitals, registered nurses, medical doctors, dentists, nursing homes, optometrists, podiatrists; meet
quarterly or more often.

A. Advisory Council for Medical Assistance:

Ellen Buchart, R.N. (Chair) C.A. Nava, DPM, Secretary Gwen Click
Jefferson Cnty. Health Dept. KY State Board of Pharmacy lwine Health Care
400 East Gray Street 110 North Hubbard Lane Wallace Dr. & Bertha Street
Louisville, KY 40202 Louisville, KY 40207 Iwine, KY 40336

Nellie Stewart Louis B. Hollkamp Edward Schottland, Sr. VP


Rose Manor Nursing Home Visiting Nurse Association Kosair Children's Hospital
3056 Cleveland Road 101 West Chestnut Street PO Box 35070
Lexington, KY 40516 Louisville, KY 40202 Louisville, KY 40232

Katherine Stephens Gladys Trueax


649 Lakeshore Drive 333 East 4th Street, #B-4
Lexington, KY 40502 Frankfort, KY 40601
NPC - 1989 Kentucky - 4

Roy Butler Harly J. Cowherd, M.D. Chester Parker, Pharm.D., R.Ph.


Dept. for Medicaid Sewices Cabinet for Human Resources 1816 Darien Drive
CHR Building, 3rd FI. CHR Building, 4th FI. Lexington, KY 40504
Frankfort, KY 40621 Frankfort, KY 40621

William Rich, DMD William Watkins, M.D. Bob Gray


111 Humes Ridge Rd., Box 27 401 Bogle Street 2636 Windsor Avenue
Williamstown, KY 41097 Somerset, KY 42501 Owensboro, KY 42301

Loretta Lawson Bernard Zakem, O.D. Anna Robinson


727 South 44th Street 4130 Taylor Boulevard Rt. 8, Box 74, Evergreen Rd.
Louisville, KY 40211 Louisville, KY 40215 Frankfort. KY 40601

Elizabeth Moeller
Graham, KY 42344

Formulary Subcommittee

Samuel Scott, M.D. (Chair) R. N. Smith, R.Ph. Chester L. Parker, P.D., R.Ph.
1302 Richmond Road Smith's Pharmacy 1816 Darien Drive
Lexington, KY 40502 Burkesville, KY 42717 Lexington, KY 40504

Jansen D. Diener, M.D. Thomas S. Foster, Pharm.D. Ellen Burchan, RN


1023 Sanibel Way Dept. of Pharmacy, Rm. C114B Jefferson Co. Health Dept.
Suite A Univ. of KY Medical Center 400 East Gray Street
LaGrange, KY 40031 Lexington, KY 40536 Louisville. KY 40202

Nancy Jo Matyunas, Pharm.D. Thomas Badgett, Ph.D., MD


Clinical Instructor in Ped. Dept. of Pediatrics
Adj. Instructor in Pharmacology Kosair Childrens Hospital
U of L School of Medicine PO Box 35090
Louisville, KY 40292 Louisville, KY 40232

B. Pharmacy Technical Advisory Committee:

Mike Leake J. Michael Schutte, R.Ph. Clarence Sullivan, Ill, R.Ph.


P. 0. Box 726 13200 Urton Lane 3741 Forest Green Drive
Danville, KY 40422 Louisville, KY 40243 Lexington, KY 40503

Tom Houchens, Chairman Paul Ruwe, R.Ph. Robert L. Barnett, Jr.


220 Chippewa 11 Edna Lane Interim Executive Director
London, KY 40741 Ft. Wright, KY 41011 KY Pharmacists Association, Inc.
Frankfort, KY 40602
Kentucky - 5

Pharmacy Technical Advisory Committee Alternates:

Carl C. Sutherland, R.Ph. R. N. Smith, R.Ph. Steve Adams, R.Ph.


Director of Pharmacy P. 0. Box 247 217 Lexington Street
Fleming County Hospital Burkesville, KY 42717 Lancaster, KY 40444
Flemingsburg, KY 41041

Chester L. Parker, PharmD., R.Ph


1816 Darien Drive
Lexington, KY 40504

I. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Association: Pharmaceutical Association:

Robert G.Cox Robert Barnen


Executive Vice President Interim Executive Director
KY Medical Association KY Pharmacists Association
3532 Ephraim McDowell Drive 1228 U. S. Highway 127 S.
Louisville, KY 40205 Frankfort, KY 40601
502/459-9790 5021227-2303

C. Osteopathic Medical Association: State Board of Pharmacy:

Executive Director Richard L. Ross


KY Osteopathic Medical Association Executive Director
208 Crossfied Drive 1228 U.S. 127 South
Versailles, KY 40383 Frankfort, KY 40601
6061873-8044 5021564-3833
NPC - 1989 Louisiana - 1

LOUISIANA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other*


OAA AB APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X X

Laboratory &
X-ray Service
s k i l i d Nursing
Home Services X X X X X X X X X X
Physician Services X X X X X X X X X X
Dental Services X X X X X X X X X X

'SF0 - State Funds Only


II. EXPENDITURES FOR DRUGS.

1987 1988
Expended Recipient Ex~endedRecipient
TOTAL $86,566,603 356,806 $84,955,349 320,004
CATEGORICALLY NEEDY CASH TOTAL
Age4
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w1Dep. Children
Other Title XIX Recipients

HHS reporf HCFA 2082 -


Louisiana - 2

. Administration:

Public assistance programs are administered by the Department of Health and Hospital.

1, Provisions Relating to Prescribed Drugs:

A. Restricted Formulary.

B. Prescribing or Dispensing Limitations:

I. Quantity of Medication: New prescription must be issued for drugs given on a continuing
basis, after 5 refills or after 6 months.

Maximum payment quantity for prescriptions shall be either one month's treatment or 100 unit
doses.

2. Refills: Permitted as indicated by physician within 6 months and not to exceed 5 refills

3. Dollar Limits: None.

4. Formulary: Yes.

C. Prescription Charge Formula:

1. The maximum payment for a prescription is estimated acquisition cost (EAC), UIC or MAC
whichever is lower plus $3.51 dispensing fee.

D. Fiscal Intermediary:

Unisys
P.O. Box 3396
Baton Rouge, LA 70821

Officials, Consultants and Committees

I. Department of Health and Hospital Administration Officials:

David L. Ramsey Department of Health and Hospital


Secretary 755 Riverside North
Baton Rouge, LA 70804
504/342-3947
NPC - 1989 Louisiana - 3

Carolyn 0. Maggio, P. D., Director


Bureau of Health Services Financing
50413424891

M. J. Terrebonne, P. D., Pharmacist Consultant II


50413424956

2. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Society: 8. Pharmaceutical Association:

Dave L. Tamer Linda Foreman


Executive Director Executive Director
Louisiana State Medical Society Louisiana State Pharmacists Association
1700 Josephine Street 2337 St. Claude Avenue
New Orleans, LA 70113 New Orleans, LA 70117-8441
5041561-1033 5041949-7545

C. Osteopathic Association: D. State Board of Pharmacy

Charles S. Wyckoff, D.O. Howard 8. Bolton


Secretary-Treasurer Executive Director
LA Assn. of Osteopathic Physicians 5615 Corporate Boulevard, Suite 8E
-
333 St. Charles Avenue 412 Baton Rouge, LA 70808
New Orleans, LA 70130 5041925-6496
50415859494
UPC - 1989 Maine - 1

MAINE
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other'


OAA AB APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care

Laboratory &
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X X
Physician Sewices X X X X X X X X X X
Dental Services X X X X X X X X+ X+ X

'SF0 - State Funds Only


'Routine dental services; other categories eligible for non-routine dental service only.

II. EXPENDITURES FOR DRUGS.

1987 1988
Expended Recipient Expended Recipient
TOTAL $21,086.1 07 91,507 22,994,787 91,089
CATEGORICALLY NEEDY CASH TOTAL $13,621,049 70,679 13,649,448 62,886
Aged 3,321,969 7,929 3,191,707 6,679
Blind 67,875 199 65,655 172
Disabled 6,807,262 13,881 7,211,996 13,565
Children -Families w/Dep. Children 1,146,677 28,388 1,118,164 24,868
Adults -Families w/Dep. Children 2,277,266 20,682 2,061,926 17,602
CATEGORICALLY NEEDY NON-CASH TOTAL $6,478,082 23,408 8,195,831 24,558
Aged 4,718,998 9,231 5,883,374 9,877
Blind 3,691 15 5,442 13
Disabled 1,232,669 3,164 1,542,019 2,986
Children -Families w/Dep. Children 279,655 7,464 231,262 5,312
Adults -Families w/Dep. Children 243,069 3,853 383,144 3,568
Other Title XIX Recipients 0 0 150,590 2,792
MEDICALLY NEEDY TOTAL $986,976 3,886 1,131,171 484
Aged 422,559 1,136 525,548 975
Blind 3,731 6 5,528 6
Disabled 407,249 835 452,184 703
Children -Families w/Dep. Children 74,637 1,303 66,156 1,I 52
Adults -Families w/Dep. Children 78,800 684 81,755 652
Other Title XIX Recipients 0 0 0 0

HHS report HCFA - 2082


NPC - 1989 Maine - 2

Ill. Administration:

State Department of Human Services.

IV. Provisions relating to prescribed drugs:

A. General Exclusions:

1. OTC drugs, except insulin and artificial tears


2. Combination antibiotics
3. Symptomatic remedies for common colds and coughs resulting from common colds
4. All vitamins and vitamin preparations
5. All amphetamines, straight or in combination, and all obesity control drugs. (Authorization for
amphetamines or methylphenidate in documented cases of narcolepsy or hyperkinesis may
be obtained upon request.)

6. lnjectables when oral medication is available for equally effective treatment

Prior authorization may be obtained in the case of necessary exceptions

B. Formulary: open formulary, except for certain therapeutic categories.

C. Prescribing or dispensing limitations:

1. Quantity of medication: refills for chronic conditions can be for no less than a 30 day supply
unless the prescriber specifically directs otherwise.

2. Refills: a prescription can be refilled up to five times within six months if specifically ordered.

3. Dollar limits: none.

D. Prescription charge formula: usual and customary, EAC plus a professionalfee of $3.55 or MAC plus
a professional fee of $3.35, whichever is lower. (EAC for the top 150 drugs = AWP minus 5% or
direct prices, whichever applies.)

V. Miscellaneous:

Fiscal intermediary: Good Health SystemsiLow Cost Drug Program


P.O. Box 508
Augusta, ME 04330
Maine - 3

Officials, Consultants and Committees

Human Services Department Officials:

H. Rollin Ives, Commissioner Department of Human Services


2071289-2736 State House, Station 11
Augusta, ME 04333

Trish Riley, Associate Deputy Commissioner HealthIMedical Services

Sarah Krevans, Acting Director Bureau of Medical Services

Elaine Fuller, Deputy Director, Health Programs Bureau of Medical Services

James H. Lewis, Assistant Bureau Director Bureau of Medical Services

Michael P. O'Donnell, R.Ph., Pharmacist Consultant 2071289-2674

Margaret Ross, Director Medicaid Surveil./Utilization Review

Medical Consultants:

Allen Elkins, M.D. - Psychiatric Donald Ellis, O.D. - Opt~fWtriC


D.K. McFadden, D.O. - Osteopathic J.D. Reeder, D.C. - Chiropractic

Medical Assistance Advisory Committee: A. Dewey Richards, M.D., Chair


11 Gage Street
Bridgton, ME 04009

Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Association: B. Pharmaceutical Association:

Frank 0. Stred Stanley Stewart


Executive Vice President Executive Director
Maine Medical Association Maine Pharmacy Association
P. 0. Box 190 P.0 Box 817
Manchester, ME 04351 Bangor, ME 04401-0817
207/622-3374 2071947-0885

C. Osteopathic Association: D. State Board of Pharmacy:

David A. De Turk Richard Labonte


Executive Director President
Maine Osteopathic Association Maine Commission of Pharmacy
303 State Street Health Station No. 35
Augusta, ME 04330 Augusta, ME 04333
2071623-1I 0 1 2071783.9769
NPC - 1989 Maryland - 1

MARYLAND
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other*


OAA AB APTD AFDC OAA AB APTD AFDC Childrenc21
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care

Laboratory &
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X X
Physician Services X X X X X X X X X X
Dental Services X X X X X X X X X X+

-
'SF0 State Funds Only
+ Limited services available. Expanded services available to EPSDT eligibles.

II. EXPENDITURES FOR DRUGS.

1987 1988
Expended Recipient Emended Recipient
TOTAL ' $45,329,906 224,980 46,858,969 221.21 9
CATEGORICALLY NEEDY CASH TOTAL $31,642,088 186,066 31,663,743 177,118
Aged 6,999,284 15,647 7,059,435 15,506
Blind 108,023 283 108,643 292
Disabled 13,921,020 28,832 14,856,289 31,324
Children -Families w/Dep. Children 4,210,884 90,358 3,850,731 83,710
Adults -Families w/Dep. Children 6,402,877 50,946 5,788,645 46,286
CATEGORICALLY NEEDY NON-CASH TOTAL $532,959 2,261 601,882 2,522
Aged 171,346 303 179,348 299
Blind 3,414 3 2,237 3
Disabled 274,398 481 333,318 648
Children -Families w/Dep. Children 33,667 868 42,940 950
Adults -Families w/Dep. Children 50,134 606 44,039 622
Other Title XIX Recipients 0 0 0 0
MEDICALLY NEEDY TOTAL $13,151,102 36,453 14,442,374 37,370
Aged 9,824,188 17,683 10,800,629 18,312
Blind 5,126 10 3,633 8
Disabled 2,216,105 4,063 2,472,823 4,125
Children -Families w/Dep. Children 355,047 7,567 362,862 7,516
Adults -Families w/Dep. Children 560,765 4,399 563,358 4,245
Other Tile XIX Recipients 189,871 2,731 239,069 3,164

HHS report HCFA - 2082


Maryland - 2

Administration:

State Department of Health and Mental Hygiene.

Provisions Relating to Prescribed Drugs:

A. General Exclusions: (a) experimental or investigational drugs; (b) food supplements or infant formulas; (c)
prescriptions and injections for central nervous system stimulants and anorectic agents used for weight
control; (d) 'less-than-effective' drugs under federal regulations; and (e) certain other items as specified in
the state's Medicaid plan.

B. Coverage of non-legend drugs is limited to insulin, and Schedule V cough preparations, enteric coated
aspirin, contraceptives and hypodermic needles and syringes. Specially formulated nutritional preparations
are covered when preauthorized by the program.

1. Quantity of Medication: The amount of medication to be dispensed on a prescription at one time


is limled to a less than 34-day supply except for specific maintenance drugs for chronic conditions,
where up to a 100-day supply may be dispensed at one time. Prescriptions are limited to an original
and two refills for which the total quantity may not exceed a 100-day supply, except for birth control
pills which are limited to a six-cycle supply, and oral sodium flouride preparations used to prevent
dental caries which are limited to a 120-day supply with two refills.

2. Refills:

a. The maximum number of refills authorized on a prescription is two. The original prescription
and its refills may not exceed a 100-day supply except for birth control pills and oral sodium
flouride preparations.

b. Refills may not be dispensed after 100 days of date of original prescription except for birth
control pills and oral sodium flouride preparations.

3. Dollar Limits: Prior authorization required from the Medical Assistance Compliance Administration
when the usual and customary charge exceeds $100 and the prescribed amount is more than a 34
day supply. Preauthorization is needed for any prescription with a usual and customaly charge
exceeding $400.

4. Formulary: The program has an open formulary. The program does not restrict prescribers in their
selection of drug products except for the exclusions stated in section 1V.A. The prescriber must
indicate on the prescription "brand necessary' or 'brand medically necessary" when a specific brand
of an interchangeable multiple source drug is desired.

5. Reimbursement:

a. Drug ingredient cost is calculated under one of the following procedures:

I. -
Interchangeable Drug Cost (IDC) effective June 1, 1985, the state of Maryland maintains
a list of approved interchangeable multiple source drugs for which a maximum
reimbursement (the IDC) will be allowed unless the prescriber has indicated that a
specific brand is medically necessary and is to be dispensed. This IDC is based upon
the lowest cost at which an approved interchangeable product can be guaranteed
available throughout the state. As of February 15, 1989, there are 422 products
representing 168 drug entities on the list.
NPC - 1989 Maryland - 3

2. Usual Source and Quantity List for High Utilization Drugs - effective June 1, 1985, the
state of Maryland maintains a list of highly utilized products which are usually purchased
directly from manufacturers and/or in larger than minimum package size. Reimbursement
for these products is based on the least expensive source of supply or package size.
As of December 31, 1988, 116 products representing 57 drug entities are included in
this list.

3. Estimated Acquisition Cost (EAC) -for all other drugs, reimbursement levels are based
upon the price of standard size packages (a) available from wholesalers within the state,
or if not available from these wholesalers, (b) manufacturers' direct prices.

b. Reimbursement will be the lower of: (1) the usual and customary fee; (2) the calculated
ingredient cost plus $3.70 dispensing fee (eff. 7/1/87).

V. Miscellaneous:

Number of Rx claim processed in FY 1988 (July, 1987 - June, 1988) - 3.2 million
Average prescription price during FY 1988- $16.95

Effective November 15, 1988, a copayment of $1.25 applies to state funded recipients except for those
under 21 and for family planning services and a copayment of $.50 applies to recipients in federal
categories. This co-payment does not apply to family planning services or to recipients who are under 21,
pregnant, enrolled in HMO's or who are residents of long-term care facilities (nursing homes). Effective July
11, 1988, the Program covers condoms dispensed by a pharmacist when a recipient presenta a valid
Medical Assistance card. Only 12 condoms are dispensed at one time; natural condoms are not covered;
a prescription is not necessary; a co-payment is not charged.

Maryland Pharmacy Assistance Program

The Maryland Pharmacy Assistance Program, established by the Maryland General Assembly in 1978, is
administered by the Depuv Secretary for Health Care Policy, Finance and Regulations and supported
entirely by state funds. The purpose of this program is to help low-income families and individuals who are
not eligible for Medical Assistance pay for prescription drugs, Schedule V cough preparations, enteric coated
aspirin, needles and syringes, contraceptives, insulin and certain nutritional formulations.

In Fiscal Year 1988, there was an average enrollment of 16,659 per month. The program paid $6,905,420
for 370,065 prescriptions, an average of $18.66 per prescription. Providers are reimbursed the lower of:
(1) usual and customary fee; or (2) ingredient cost as calculated under Medical Assistance regulations plus
a $3.70 dispensing fee.

Recipients are responsible for a $1.00 copayment for each prescription and each refill. The state pays the
remainder of total reimbursement.
Maryland - 4

Officials, Consultants and Committees

Health and Mental Hygiene Department Officials:

Adele Wilzack Department of HealthIMental Hygiene


Secreta~y 201 W. Preston Street
Baltimore, MD 21201

Nelson J. Sabatini 201 W. Preston Street


Deputy Secretary Baltimore, MD 21201
Healh Care Policy Finance & Regulation

Joseph M. Millstone 300 W. Preston Street


Director Baltimore. MD 21201
Medical Care Policy Administration

Patricia C. Burkholder 300 W. Preston Street


Chief, Division of Acute Care Baltimore, MD 21201
Medical Care Policy Administration
3011225-1455

Leone W. Marks, R.Ph., Staff Specialist Medical Care Policy Administration


-
Pharmacy Services 3011225-1459 300 West Preston Street
Balimore, MD 21201

Joseph Fine, P.D., Chief Medical Care Operations Administration


Division of Invoice Processing - 3011225-5370 201 W. Preston Street
Baltimore, MD 21201

John W. Baker, Program Manager PO Box 386


Pharmacy Assistance Program Baltimore, MD 21203
3011225-5392

MedicaidIPharmacy Liaison Committee:

Mark Levi, R.Ph., Chairman Adolph Baer, R.Ph. Roger G. Heer, R.Ph.
Medical Arts Pharmacy Fishers' Pharmacy Greater Baltimore Pharmacy
816 Cathedral Street 1835 Woodburn Road 6565 North Charles Street
Baltimore, MD 21201 Hagerstown, MD 21740 Baltimore, MD 21204

Philip Marsiglia, R. Ph. Martin Mintz, R.Ph. Frank Palumbo, Ph.D.


Cherry Hill Pharmacy Clinic Northern Pharmacy U of MD, School of Pharmacy
608 Cherry Hill Road 6701 Harford Road 636 W. Lombard Street
Baltimore, MD 21255 Baltimore, MD 21201 Baltimore, MD 21201

David Rombro, R.Ph. Melvin Rubin, R.Ph. Samuel Lichter, R.Ph.


MacGillivray's Pharmacy Paradise Pharmacy 4001 Carthage Road
900 N. Charles Street 2316 Sugarcane Road Randallstown, MD 21133
Baltimore, MD 21201 Baltimore, MD 21209

Stanton G. Ades, R.Ph. Madeline Feinberg, R.Ph. Robert Martin, Jr. R.Ph.
P. 0. Box 87 1901 Briggs Road 501 Center Street
Stevenson, MD 21153 Silver Spring, MD 20906 Cumberland, MD 21052
NPC - 1989 Maryland - 5

Murray Polonsky, R. Ph. George Voxakis, R.Ph.


415 E. Wayne Avenue 1628 Weyburn Road
Silver Spring, MD 20901 Baltimore, MD 21237

Medical Assistance Staff Committee Members


Patricia C. Burkholder - Policy Joseph L. Fine, R.Ph. - Operations
-
George Lichter, R.Ph. compliance -
~ e o n eW. Marks, R.Ph. Policy
Frank Tetkowski, R.Ph. - Compliance

3. M e d i i Assistance Advisory Committee:


Chairman
Jack Bovaird, Asst. Dir. Rosemary Atkinson Kathryn Cannan
Assoc. Catholic Charities MD Energy Asa. Program West MD Health Plan Agency
320 Cathedral Street 1114 N. Mount Street 153 Baltimore Street
Baltimore, MD 21201 Baltimore, MD 21217 Cumberland, MD 21502

Linda Clark, RN, Exec VP Jacqueline Fassett William Hankins, Asst. Dir.
D e l m a ~ aFound. for Medical Care Sinai Hosp. of Baltimore Bons Secours Hospital
341 B North Aurora St. Belvedere at Greenspring 2000 West Baltimore St.
Easton, MD 21601 Baltimore, MD 21215 Baltimore, MD 21223

Benjamin J. Kimbers, Jr., D.D.S. David S. Klein Caren Berry


Madison Park Prof. Bldg. 400 East Pratt St. 41 1 N. Baltimore St.
932 West North Avenue Suite 800 Baltimore, MD 21201
Baltimore, MD 21217 Baltimore, MD 21202

John Braxton, Jr., M.D. Ray Brodie, Jr., M.D. Phyllis Colson Burley
4432 Park Heights Avenue 844 North Carey Street 2859 Woodbrooke Avenue
Baltimore, MD 21215 Baltimore, MD 21217 Baltimore, MD 21217

Dorothy Council Jean Dockhorn Dorothy Egbert


1100 N. Bolton St., #210 109-D Versailles Circle 104 West Third Street
Baltimore, MD 21201 Baltimore, MD 21204 Frederick, MD 21701

Deborah Lee Fritz, Ph.D. Clara Kimbro, R.N., Dr.Ph. Eileen Leaman
3701 DuPont Avenue 10470 Waterfowl Terrace 27 Maple Avenue
Kensington, MD 20895 Columbia, MD 21044 Baltimore, MD 21228

Kathleen W. Lopez Jacqueline Lynch Phillip R. Marsiglia, R.Ph.


604 East 38th Street 1610 E. Monument Street, #5 3910 Dance Mill Road
Baltimore, MD 21218 Baltimore, MD 21205 Phoenix, MD 21131

Edward Matricardi Helen McAllister, M.D. Diane Pedersen


Dir. Bur of Mental Health Health Officer, PG County Dir. Home CareIHospice
105 West Chesapeake Avenue Hospital Road St. Agnes Hospital
Towson, MD 21204 Cheverly, MD 20785 900 Caton Avenue
Baltimore, MD 21229
Beverly Paul Michael Rashid
Coor., Prov. Relations Director West Baltimore Paula McLellan
Chesapeake Health Plan Community Health Center 2301 Catcef Street
814 Light Street 1501 Division Street Annapolis, MD 21401
Baltimore, MD 21230 Baltimore, MD 21217
r
Maryland - 6

Ethel Pace Denise Wheatley Rowe Donna Sewell


1707Moreland Avenue 3817 West Rogers Avenue 610 ReSe~oirStreet
Baltimore, MD 21216 Baltimore, MD 21215 Baltimore, MD 21217

Michael J. Weinfeid
14600 Falling Leaf Way
Darnstown, MD 20878

Ex Offcio Members:

Harry Klinefelter, M.D. Kenneth Albrecht


550 N. Broadway, Rm. 401 Medicaid State Rep.
Baltimore, MD 21205 HCFA
US. HHS
Lawrence Payne, Director 3535 Market Street
Medical Care Compliance Admins. Philadelphia, PA 19101
300 W. Preston Street
Baltimore, MD 21201

Nelson Sabatini Gloria Washington


Dep. Sec, for Health Policy, Finance, Medical Assistance Division
and Regulation Income Maintenance Administration
5th Floor, 201 W. Preston Street 311 W. Saratoga St., 6th FI.
Baltimore, MD 21201 Baltimore, MD 21201

4. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Society: B. Pharmaceutical Association:

Angelo Troisi Gregory J. Wood


Executive Director Executive Director
Medical1 Chirurgical Faculty of MD MD Pharmacists Assn.
121 1 Cathedral Street 650 W. Lombard Street
Baltimore, MD 21201 Baltimore, MD 21201-1572
3011539-0072 3011727-0746

C. State Board of Pharmacy: D. Maryland Osteopathic Association

Roslyn Scheer Lawrence Silverberg, P.D.


Executive Director President
201 W. Preston Street Routes 32 & 144
Baltimore, MD 21201 West Friendship, MD 21794
301 1225.591 0 3011489-7272
Massachusetis - 1

MASSACHUSms
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other'


OAA AB APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X

Laboratory &
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X
Physician Services X X X X X X X X X X
Dental Services X X X X X X X X X X

'SF0 - State Funds Only


II. EXPENDITURES FOR DRUGS

1987 1988
Expended Recipient Expended Reci~ient
TOTAL $89,829,373 393,742 $1W,305,001 $397,302
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients

HHS report HCFA - 2082


, Administration:

State Department of Public Welfare.

f. Provisions Relating to Prescribed Drugs:

A. General Exclusions: Immunizing biologicals available from DPH, legend vitamins not on Drug Lia,
non-legend drugs not on Drug List. Restrictions on certain therapeutic classes. Legend cough and
cold medications excluded. Restrictions on propoxyphene containing products.

B. Formulary: No.

C. Prescribing or Dispensing Limitations:

1. Quantity of Medication: Not more than a Smonth supply may be prescribed.

2. Refills: Prescription may be refilled, as long as total authorization does not exceed a 6-months'
or 5-refills supply from time of original prescription.

3. Dollar Limits: None.

D. Prescription Charge Formula:

I. Legend Drugs: $3.88 dispensing fee.

2. Payment shall be for the lower of the usual and customary charge or MAC or MMAC or EAC
cost plus dispensing fee, or AWP plus dispensing fee.

3. Non-Legend Drugs: Not to exceed the lower of: (A) EAC plus dispensing fee. (8) Usual and
customary charge to pharmacy's retail customers.

V. Miscellaneous Remarks:

For AB drugs, supplier bills State Commission for the Blind directly, which pays vendor pharmacy through
intermediary.

Fiscal Intermediary: Unisys Corporation


P;O. Box 9101
Somerville, MA 02145
6171625-0120

Multisource: payment shall be for the lower of the usual and customary charge, or MMAC or FUL plus a
dispensing fee.

All other: payment shall be for the lower of the usual and customary charge, or EAC plus a dispensing
fee. EAC is defined as WAC plus 10%.
Massachusetts - 3

Ofkials, Consultants and Committees

I. Welfare Department:
Carmen CaninoSiegrist, Commissioner Department of Public Weifare
600 Washington Street
Boston, MA 021 1 1

Arnold H. Shapiro, R.Ph.


Pharmacy Program Manager

2. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Society: Pharmaceutical Association:

William M. McDermott, M.D. Jeffrey J. Burgoyne


Executive Vice President Executive Director
Massachusetts Medical Society MA State Pharmaceutical Assn.
1440 Main Street 27 Cambridge St., P. 0. Box 160
Waltham, MA 02254-9118 Burlington, MA 01803
61718934610 6171272-7679

C. Osteopathic Society: State Board of Pharmacy:

Gladys M. Davis Harold R. Parlamian, R.Ph.


Executive Secretary Executive Secretary
MA Osteopathic Society Inc. 100 Cambridge Street
237 Main Street, Box 147 Room 1514
Reading, MA 01867 Boston, MA 02202-0001
6171944-5586 6171727-9954
-7-

Michigan - 1

MICHIGAN
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XD()

BENEFITS PROVIDED AND GROUPS ELIGIBLE

fpe of Benefit Categorically Needy Medically Needy (MN) Other'


OAA AB APTD AFDC OAA AB APTD AFDC Childrew21
rescribed Drugs X X X X X X X X X
patient
o s ~ i t aCare
l
utpatient
ospital Care X X X X X X X X X

aboratory &
-ray Service X X X X X X X X X
killed Nursing
lome Services X X X X X X X X X
hysician Services X X X X X X X X X
lemal Services ----- Limited for all eligibles -----

-
S O State Funds Only

. EXPENDITURES FOR DRUGS.

1987 1988
Expended Recipient Expended Recipient
'OTAL $129,397,205 731,462 $139,447,906 731,246
>ATEGORICALLY NEEDY CASH TOTAL $92,659,151 612,743 98,444,518 611,507
\ged 11,157,068 27,128 11,934,663 26,456
Hind 595,141 1,551 654,982 1,569
Iisabled 39,768,200 84,946 43,741,047 87,985
:hildren -Families wIDep. Children 13,222,779 293,946 14,132,484 293,258
idults -Families w/Dep. Children 27,915,963 214,609 27,981,372 211,504
>ATEGORICALLY NEEDY NON-CASH TOTAL $5,479,931 38,850 6,269,752 38,522
4ged 2,397,640 7,194 2,887,791 7,427
3lind 24,460 149 32,876 151
Iisabled 2,093,520 11,187 2,341,362 10,625
:hildren -Families wIDep. Children 287,249 11,428 308,991 11,389
4dults -Families w/Dep. Children 677,062 13,133 698,732 12,821
Ither Tile XIX Recipients 0 0 0 0
dEDICALLY NEEDY TOTAL $31,258,123 119,636 34,733,636 119,071
4ged 19,219,103 41,572 21,446,975 42,297
3lind 44,326 117 53,259 120
Iisabled 8,561,501 19,417 9,727,108 20,174
Zhildren -Families w/Dep. Children 412,735 12,525 403,046 11,741
4dults -Families wIDep. Children 1,223,305 13,478 1,254,890 12,838
3ther Title XIX Recipients 1,797,153 35,759 1,848,358 35,222

i H S report HCFA - 2082


NPC - 1989 Michigan - 2

Ill. Administration:

Michigan Department of Social Services, Medical Services Administration

IV. Provisions Relating to Prescribed Drugs:

A. General Exclusions and Restrictions:

The Medical Services Administration has a closed drug formulary for pharmacies. The intent is to
maintain coverage of economical products for most drug classes. For example, selected over-the-
counter drugs are covered if ordered by prescription, and selected forms of potassium replacements
are covered. (Liquids and oral solids are covered, but not effervescent tablets and powder packets.)
Also, to utilize available funds, certain drugs are only covered generically (e.g., Acetaminophen with
Codeine, Chlorodiazepoxide, Cephalexin, etc.).

The Department believes that a closed drug formulary is preferable to the elimination of entire drug
classes for controlling Program costs. However, the Program does not cover cough/cold preparations
and multiple vitamins except prenatal vitamins and fluoride supplements.

B. Formulary: Yes. For information regarding the formulary contact:

Frank Loll, R.Ph.


Bureau of Health Services Review
Medical Services Administration
P. 0.Box 30007, 921 W. Holmes
Lansing, Michigan 48909
5171335-5265

C. Prescribing or dispensing limitations: Prescribed quantities should be limited to an amount necessary


to keep the recipient supplied during the therapy regimen. In certain cases and conditions, more
than a month's supply will be appropriate. However, in no instance may more than 120 days supply
be dispensed per prescription.

D. Prescription Charge Formula: Reimbursement for legend drugs is limited to the Lower of:

1. Actual acquisition cost (AWP minus 10% ceiling), plus professional fee not to exceed $3.65
minus selected $0.50 patient copay or

2. The MAC rate, plus professional fee not to exceed $3.65 or

3. The provider's usual and customary charge to the general public.


NPC - 1989 Michigan - 3 I

Selected co-payment provision:

A $0.50 co-payment is assessed the patient when a branded drug product is dispensed. When generic
drugs that are MAC'd are dispensed no co-payment is required.

Ambulatory recipients age 21 and older are required to pay a $.50 co-payment for most legend drugs.
If the recipient is unable to pay a required copayment on the date of service, the pharmacy cannot refuse
to render the service. However, the pharmacy may bill the recipient for the co-payment amount, and helshe
is responsible for paying it. If the recipient fails to pay a co-payment, the pharmacy could, in the future,
refuse to serve the recipient as a Medicaid recipient.

Recipients are not required to make a co-payment if:

they are under age 21, or


they reside in a long-term care facility (nursing home, hospital long-term care facility, or
medical care facility
they are enrolled in the Physician Sponsor Plan, or Health Maintenance Organization (HMO)
or some Clinic Plans.
Drugs not requiring a co-payment include: pregnancy-related; over the counter drugs; insulin and syringes;
family planning; dietary formulas; reagents; and MAC drugs.

V. Miscellaneous Remarks:

Contractor for price updates: First Data Bank


1111 Bayhill Drive
San Bruno, CA 94066
4151588-5454

ORiciak, Consuitants and Committees

1. Social Services Department Officials:

Patrick Babcock, Ph.D., Director MI Department of Social Sewices


P. 0. BOX 30037
Lansing, MI 48909

Kevin L. Seitz, Director Medical Services Administration


921 W. Holmes Road
Lansing, MI 48910

Dennis DuCap, Director


Office of Support Services

Vernon K. Smith, Ph.D., Director


Bureau of Program Policy
NPC - 1989 Michigan - 4

Kenh F. Cole, Director


Bureau of Medicaid Operations

Robert Levin, D.D.S., Director


Bureau of Health Services Review

Sandy Kramer, Pharmacy Program Specialist


Acting Section Manager
Bureau of Program Policy
517/35-5127

2. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Society: B. Pharmaceutical Association:

Bruce Ambrose Larry D. Wagenknecht


Executive Director Executive Director
MI State Medical Society MI Pharmacists Association
120 West Saginaw 815 N. Washington Avenue
East Lansing, MI 48826-0950 Lansing, MI 48906
5171337-1351 5171484-1466

C. Osteopathic Association: D. State Board of Pharmacy:

D. A. DeShaw Cathy Seyka


Executive Director Administrative Assistant
MI Assoc. of Osteopathic 611 W. Ottawa, P. 0. Box 30018
Physicians & Surgeons, Inc. Lansing, MI 48909
33100 Freedom Road 5171373-0620
Farmington, MI 48024
3131476-2800
T-
Minnesota - 1

MINNESOTA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

1. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Othei


OAA A0 APTD AFDC OAA AB APTD AFDC Children<21 (SFO)
Prescribed Drugs X X X X X X X X X
Inpatient
Hospital Care
outpatient
Hospital Care

Laboratory &
X-ray Sewice
Skilled Nursing
Home Services X X X X X X X X X
Physician Services X X X X X X X X X
Dental Services X X X X X X X X X

'SF0 - State Funds Only


II. EXPENDITURES FOR DRUGS.

1987 1988
Expended Recipient Expended Recipient
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families wIDep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients

HHS report HCFA - 2082


NPC - 1989 Minnesota - 2

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.

B. Formulary: Yes. (Restricted drug list.)

Rick Bruzek, Pharm.D.


Professional Services Section
Department of Human Services
444 Lafayette Road, P. 0. Box 43170
St. Paul, Minnesota 55164
6121297-2529

C. Prescribing or Dispensing Limitations: Refills are limited to 5 times or 6 months, whichever comes
first. Contraceptives may be filled to provide a 3-month supply.

D. Prescription Charge Formula: Reimbursement is based on the pharmacist's submitted charge or the
State Department of Human Services' maximum price, whichever is lower. Reimbursement fee is
$4.20 (effective January 1, 1989).

E. Ingredient reimbursement basis: AWP minus 10%

Offcials. Consultants and Committees

1. Department of Human Services Officials:

Sandra Gardebring, Commissioner Department of Human Services


Charles C. Schultz, Dep. Commissioner Centennial Office Building
Maria Gomez, Assistant Commissioner 444 Lafayette Road
St. Paul, MN 55155
6121296-2701

Robert C. Baird, Deputy Assistant Commissioner 444 Lafayette Road


Health Care & Residential Programs St. Paul, MN 55155
6121296-6117

Rick Bruzek, Pharm.D., Director


Drug Utilization Review, Drug Formulary

Ronald Rogers, Pharmacy Policy, Consultant


-
NPC 1989 Minnesota - 3

Dept. of Human Services Committees:

Professional Medical Advisory Committee:

W. S. Akre, O.D. David Craig, M.D. Louis Furlong


Box 727 4300 W. River Parkway 905 White Bear Avenue
New Ulm, MN 56073 Minneapolis, MN 55406 St. Paul, MN 55106

David A. Paulson, M.D. Kathleen Simo, M.D. Karen Thorkelson, Ph.D.


Hennepin Faculty Associates South Medical Clinic 4601 York Avenue South
825 S. 8th Street, Suite 350 4310 Nicollet Avenue Minneapolis, MN 55410
Minneapolis, MN 55404 Minneapolis, MN 55408

Executive Officers of State Medical and Pharmaceutical Societies:

Medical Association: B. Pharmaceutical Association:

Steven D. Caner William E. Bond


Chief Executive Officer Executive Director
MN State Medical Association Mn State Pharmaceutical Associatjon
2221 University Avenue, S.E., Suite 400 2221 University Avenue, S.E., Suite 326
Minneapolis, MN 55414 Minneapolis, MN 55414
6121378-1875 6121378-1414

Osteopathic Medical Society: D. State Board of Pharmacy:

Robert N. Sampson, D.O. David Holmstrom


Executive Director Executive Director
MN Osteopathic Medical Society 2700 University Avenue W. Suite 107
Hoffman Clinic St. Paul, MN 55114-1079
Hoffman, MN 56339 612f642-0541
612/98&2038
NPC - 1989 Mississippi - 1
MISSISSIPPI
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other'


OAA AB APTD AFDC OAA AB APTD AFDC Childrenc21
Prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X

Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services X X X X

S F 0 - State Funds Only

II. EXPENDITURES FOR DRUGS.


1987
Expended Reci~ient
TOTAL $46,493,654 265,842
CATEGORICALLY NEEDY CASH TOTAL 21,759,030 166,409
Aged 6,448,670 22,757
Blind 190,624 838
Disabled 9,266,184 32,812
Children -Families w/Dep. Children 3,263,855 77,331
Adults -Families w/Dep. Children 2,589,697 326714
CATEGORICALLY NEEDY NON-CASH TOTAL 24,734,624 99,433
Aged 11,734,998 32,787
Blind 223,170 679
Disabled 9,712,524 24,605
Children -Families w/Dep. Children 832,236 13,039
Adults -Families w/Dep. Children 1,766,759 16,867
Other Tltle XIX Recipients 464,937 11,456
MEDICALLY NEEDY TOTAL $0 0
Aged 0 0
Blind 0 0
Disabled 0 0
Children -Families w/Dep. Children 0 0
Adults -Families w/Dep. Children 0 0
Other Title XIX Recipients 0 0

HHS report HCFA - 2082

' Mississippi reports drug expenditure of $49,913,962 for fiscal year ending June 30, 1988.
HCFA reports $47,266,631 in expenditures for the Federal fiscal year ending September 30, 1988.
Mississippi - 2
T!
NPC - 1989

Ill. Administration:

Division of Medicaid

IV. Provisions Relating to Prescribed Drugs.

A. General Exclusions:

1. Reimbursement is limited to drugs listed in the formulary. Legend drugs and insulin and such
other lifesaving drugs as may be determined by the commission, but no over-the-counter drugs
except buffered aspirin, sodium salicylate, nicotinic acid, ferrous sulfate, kaolin, pectin,
belladonna alkaloids and powdered opium, aluminum and magnesium hydroxide, and basal
gel (for dialysis patients only). The commission shall not pay more for prescribed drugs than
the lower of ingredient cost plus a reasonable dispensing fee or the provider's usual and
customary charge to the general public. The ingredient cost shall not exceed the lower of the
maximum allowable cost (MAC) established by the Pharmaceutical Reimbursement Board and
published in the Federal Register or the estimated acquisition cost (EAC). As used in this
subsection, 'estimated acquisition costmeans the commission's best estimate of what price
providers generally are paying for a drug in the package size that providers buy most
frequently. Product selection shall be made in compliance with existing state law; however,
the commission may reimburse as if the prescription had been filled under the generic name.
The commission may provide otherwise in the case of specified drugs when the consensus
of competent medical advice is that trademarked drugs are substantially more ef ective. The
commission shall periodically survey pharmacy operations and consider the results of the
survey to set reasonable dispensing fees.

2. Exclusions are amphetamines, obesity control drugs, vitamins, cold and cough preparations,
certain peripheral vasodilators, and those drugs classified as mild tranquilizers.

B. Formulary: Restricted formulary. For formulary information contact:

James T. Steefe
Office of the Governor
Division of Medicaid
Suite 801, Robert E. Lee Building
239 North Lamar Street
Jackson, MS 39201-1311
6011359-6135

C. Prescribing or Dispensing Limitations:

1. Quantity of Medication: Prescription or refill quantities should not exceed the amount shown
in the maximum units column of the formulary. Prescriptions limited to five (5) per month per
recipient (effective 7/1/89).

2. Refills: Prescription refills are limited to three (3), except for maintenance type prescriptions
with a limit of 5. Authorization is required in writing by the prescriber. There are no refill
restrictions on insulin, and no refills are allowed on telephoned prescriptions.
-
NPC - 1989 Mississippi - 3

3. Injections: The Medicaid program will not reimburse drug providers for injectable medications
except for insulin and injectable medications prescribed for residents of nursing homes, and
for those in private homes if the individual is receiving Home Health Services under an
approved plan of treatment. injectable Antipsychotic shall be an exception.

4. Dollar Limits: None.

D. Prescription Charge Formula:

1. Legend Drugs - reimbursement for all legend drug claims is based on the lower of:

a. MACIEAC (ingredient cost) determined for the drug in the quantity dispensed, plus $3.75
dispensing fee (effective 7/1/89). Dispensing physicians receive a fee of $2.63 (effective
7/1/89).

b. The usual and customary retail charge.


c. Go-payment: $1.00.

2. Reimbursement for non-legend drugs are based on the lower of usual and customary charge
or the maximum over-the-counter price set for that item listed in formulary. Usual and
customary of a non-legend drug is to be the shelf price.

3. Compounded prescriptions for topical use are covered if at least one legend drug (in
therapeutic amounts) is included in the ingredients.

4. Compounded oral medications when all ingredients are covered separately under their own
drug codes in the formulary.

V. Miscellaneous Remarks:

Fiscal intermediary: Blue Cross/Blue Shield


P. 0.Box 23061
Jackson, MS 39225-3061

Officials, Consultants and Committees

1. Office of the Governor, Division of Medicaid (Ray Mabus, Governor)

J. Clinton Smith, M.D., M.P.H. Office of the Governor


Director Division of Medicaid
Suite 801, Robert E. Lee Bldg.
239 North Lamar Street
Jackson, MS 39201-1311
601\359-6059

James T. Steele, R.Ph., Pharmacist


Mississippi - 4

Title XIX Technical Advisory Committee:

There are six technical advisory committees. Each committee consists of individuals who are health care
professionals identified with the responsibility of the committee to which they are appointed.

!, Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Association: B, Pharmaceutical Association:

Charles L. Mathews Phylliss M. Moret, RPh.


Executive Director Executive Director
MS State Medical Association MS Pharmacists Association
P. 0. Box 5229 341 Edgewood Terrace Drive
Jackson, MS 39216 Jackson, MS 39206-6217
6011354-5433 601/981-0416

C. Osteopathic Medical Association: D. State Board of Pharmacy:

Eric Dahl, D.O. H.W. Holleman


Secretary Treasurer Executive Director
100 Village East Centre Suite 1765, C & F Plaza
Suite 8-4 2310 Highway 80 West
Philadelphia, MS 39350 Jackson, MS 39204-2391
601/354-6750
NPC - 1989 Missouri - 1

MISSOURI
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other'


OAA AB APTD AFDC OAA AB APTD AFDC C h i l d r e ~ 2 1
Prescribed Drugs X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X

-Laboratory &
X-ray Service X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X
Physician Services X X X X X X X X X
Dental Services X X X X X X X X X

'SF0 - State Funds Only


II. EXPENDITURES FOR DRUGS.

1987 I988
Expended Recipient Expended Recipient
TOTAL $46,483,890 271,220 $54,861,210 282,932
CATEGORICALLY NEEDY CASH TOTAL $16,046,804 175,918 16,839,170 173,735
Aged 4,201,919 12,575 4,177,297 10,714
Blind 370,749 975 408,524 955
Disabled 3,703,166 8,739 3,931,622 8,413
Children -Families wIDep. Children 3,438,713 93,501 3,698,346 94,752
Adults -Families w/Dep. Children 4,322,762 59,893 4,599,243 58,222
CATEGORICALLY NEEDY NON-CASH TOTAL $30,437,086 95,302 38,022,039 109,197
Aged 15,797,548 42,026 19,262,120 44,515
Blind 55,513 122 60,063 121
Disabled 13,895,928 38,814 17,677,603 42,623
Children -Families wIDep. Children 305,128 7,949 383,512 9,631
Adults -Families w1Dep. Children 352,725 5,289 468,580 6,623
Other Title XIX Recipients 30,242 1,102 170,158 5,684
MEDICALLY NEEDY TOTAL $0 0 0 0
Aged 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 wIDep. Children 0 0 0 0
Other Tale XIX Recipients 0 0 0 0

HHS report HCFA - 2082


T
JPC - 1989 Missouri - 2

II. Administration:

Division of Family Services of the State Department of Social Services.

V. Provisions Relating to Prescribed Drugs:

A. General Exclusions:

Exclusions governed by formulary

B. Formulary: Formulary lists 402 drugs by generic names or trade names. For information contact:

Susan McCann, P.D.


Pharmacy Consultant
P.O. Box 6500
Jefferson City, MO 65102-6500
3141751-3277

State allows payment only for the drugs in the formulary

C. Prescribing or Dispensing Limitations:

1. Quantity of Medication: Physician encouraged to prescribe 34-day or 100 doses supply but
may, at his own discretion, prescribe up to a maximum 90-day supply.

2. Refills: Federal regulations must be observed for all drugs on the formulary which are listed
in BNDD Schedules 2, 3, 4, and 5. All other prescriptions refilled should be in accordance
with the directions given by the prescribing physician.

3. Five Rx limitation per month per recipient. Certain drugs which are commonly prescribed for
long-term chronic medical conditions are exempt from limitation.

D. Prescription Charge Formula: The lowest of the following:Federal MAC, Missouri MAC, AWP, or Direct
plus $3.00 fee or usual and customary, whichever is lower,

E. Co-payment (variable) - $0.50 co-payment when acquisition is $10.00 or less


$1.00 co-payment when acquisition $10.01 to $25.00
$2.00 co-payment when acquisition cost is $25.01 or more
Co-payment retained by pharmacist.

F. Drug Exception Process:

Certain nonsteroidal anti-inflammatory drugs covered on a prior authorization basis for recipients with
diagnosis of rheumatoid arthritis or juvenile rheumatoid arthritis who cannot tolerate aspirin.

V. Miscellaneous Remarks:

All prescriptions must be filled with drugs that meet USP standards. Participating pharmacies sign a
participation agreement with the State Department. All dispensing physicians participating in the program
are required to keep prescription files the same as pharmacies.
NPC - 1989 Missouri - 3

Missouri formulary is a restricted formulary, restriction being that the State only pays for drugs listed on the
formulary, or drugs that are chemically equivalent to drugs listed. Any drug that is chemically equivalent
to a trade name drug listed as acceptable for reimbursement. And likewise any trade name drug that is
not listed, but is equivalent to a generic drug listed, is reimbursable under the drug program.
Method of reimbursement payment is based on acquisition cost plus a dispensing fee of $3.00 per
prescription filled. Acquisition may vary depending whether it is based on AWP, Direct Price and Federal
or Missouri MAC. The master drug file contains all acceptable drugs and their appropriate NDC (National
Drug Code) number.
AWP, any drug that is not manufactured by Abbon, Lederle, Merck Sharp & Dohme, Parke-Davis, Pfizer,
Roerig, Squibb, Upjohn and Wyeth, or is not a federal or Missouri MAC drug will be based on the AWP.
The majority of drugs listed are based on AWP. The method of pricing will be taken from the NDC number.
Any drug manufactured by Abbott, Lederle, Merck Sharp & Dohme, Parke-Davis, Pfizer, Roerig, Squibb.
Upjohn and Wyeth, acquisition cost will be based on the manufacturer's direct price.
Missouri has 59 drugs listed as MAC which have a maximum price that will be paid.
All pharmacists and physicians that participate in the Missouri Title XIX Medicaid Drug Vendor Program have
been issued a listing of all MAC drugs, a listing of the manufacturers that the Division of Family Services
limits price to direct price.
By following these guidelines the Division of Family S e ~ i c e sfeels that the pharmacist has a freedom of
choice of products and package sizes in which he or she may stock their inventory.
Fiscal intermediary: General American-Consultec
701 So. Country Club Drive
Jefferson City, MO 65101

Officials, Consultants and Committees

1. Social Services Department Officials:

Gary J. Stangler, Director Department of Social Services


Broadway State Office Building
P.O. Box 1527
Jefferson City, MO 65102
Donna Checken, Director Division of Medical Services
Director 308 East High Street
P.O. Box 6500
Jefferson City, MO 65102
Susan McCann, Pharmaceutical Consultant 3141751-3277
Everett Harris, D.O., Physician Consultant
Michael Wilson, D.O., Physician Consultant

2. Joint PharmacyIPhysician Subcommittee:

Joseph C. Blanton, M.D. Douglass S. Weidner, D.P.M. Michael H. Ledbener, D.0


Ferguson Medical Group Phelps County Medical Center Dogwood Medical Center
1012 North Main 1100 West Tenth, Ste 220 Route 1, Box 27C
Sikeston, MO 63801 Rolla, MO 65401 Osage Beach, MO 65065
3141471-0330 3141341-3110 3141348-0209
Missouri - 4
I

Fred E. Bodenhamer, OD. James E. Canter, D.0 Cynthia Elliott, M.D.


124 East Dunklin St. 706 East Smith 91 I South Brentwood, Ste. 331
Jefferson City, MO 65101 California, MO 65018 Clayton, MO 63105
31 41635-2020 31 41751 -2929 3141727-6565
Denzil J. Hawes-Davis, D.O. Mark Kasten, M.D.
1125South Madison Street 63 Doctors' Park
Jefferson City, MO 65101 Cape Girardeau, MO 63701
31 41635-7141 31 41334-4765

I. Medical Advisory Committee to the State Division of Family S e ~ i c e s :

Under revision.

1. Pharmacy Advisoly Committee:

Blaine AlberLy, P.D. Gary W. Morrison, P.D. Donald R. Brown, P.D.


D & H Drug Lincoln County Pharmacy 1031 West Riverside
1001 West Broadway #8 Lincoln Center Springfield, MO 65807
Columbia, MO 65203 Troy, MO 63379 41 7/03-7383
3141442-6105 3141528-8241
Robert W. Piepho, Ph.D., F.C.P. Kermit Fendler, Pharm.D. David R. flush, Pharm.D.
Dean & Professor Chairman Dept. of Family Medicine
u of MO-KC Sch. of Pharmacy 10 West 74th Street Truman Medical Center East
Katz Pharmacy Bldg Kansas City, MO 64114 7900 Lee's Summit Road
5005 Rockhill Road 9131362-1229 Kansas City, MO 64139
Kansas City, MO 64110-2499 81613734475,X 2063
81 61276-1 607
W. R. "Bill" Howell Gordon Ireland, Pharm.D.
1 1 103 Queensway Drive 35 Chestnut Hill Lane
St. Louis, MO 63146 St. Louis, MO 63119
3141872-8626 3141768-141 8

5. Executive Officers Of State Medical and Pharmaceutical Societies:

A. Medical Association: B. Pharmaceutical Association:


Royal Cooper George Oestrich
Executive Secretary Executive Director
Missouri State Medical Assn. MO Pharmaceutical Assn.
113 Madison Street, P.O. Box 1028 410 Madison Street
Jefferson City, MO 65102 Jefferson City, MO 65101-3189
31 41636-5151 3141636-7522

C. Osteopathic Association: D. State Board o f Pharmacy:


Bonnie Bowles Kevin E. Kinkade
Executive Director Executive Director
MO Assn. of Osteo. Physicians/Surgeons P.O. Box 625
1423 Randy Lane - P.O. Box 748 Jefferson City, MO 65102
Jefferson City, MO 65102 3141751-2334
31416343415
NPC - 1989 Montana -1
MONTANA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other'


OAA AB APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X
Outpatient
Hospital Care

Laboratoty &
X-ray Service X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X
Physician Services X X X X X X X X X
Dental Services X X X X X X X X X

'SF0 - State Funds Only


II. EXPENDITURES FOR DRUGS.

I987 1988
Expended Recipient Expended Recipient
TOTAL $7,837,338 38,674 58,530,665 50,673
CATEGORICALLY NEEDY CASH TOTAL $4,131,999 28,032 4,633,799 28,820
Aged 733,278 1,653 712,052 1,639
Blind 16,399 54 19, 143 53
Disabled 1,971,771 4,353 2,437,918 5,356
Children -Families w/Dep. Children 498,136 12,553 508,832 12,447
Adults -Families w/Dep. Children 912,413 9,403 955,525 9,309
CATEGORICALLY NEEDY NON-CASH TOTAL $1,884,547 6,587 1,513,581 6,324
Aged 876,199 1,698 802,976 1,526
Blind 4,500 10 1,444 5
Disabled 813,816 1,592 472,149 908
Children -Families w/Dep. Children 47,777 1,193 61,998 1,517
Adults -Families w/Dep. Children 86,123 1,144 117,404 1,375
Other Title XIX Recipients 56,130 950 57,610 993
MEDICALLY NEEDY TOTAL $1,820,781 4,055 1,798,663 3,863
Aged 1,412,955 2,504 1,385,030 2,441
Blind 1,552 4 1,322 3
Disabled 336,911 610 333,746 556
Children -Families w/Dep. Children 16,537 438 15,391 390
Adults -Families w/Dep. Children 49,483 448 60,161 421
Other Title XIX Recipients 3.350 51 3,013 52

HHS report HCFA - 2082


II. Administration:

State Department of Social and Rehabilitation Services.

V. Provisions Relating to Prescribed Drugs:


A. General Exclusions: Provided are all prescription drugs and those over-the-counter drugs in the
following classes: insulin, laxatives, antacids. Both types must be prescribed by a licensed
practitioner (physician, dentist, podiatrist, optometrist, physician assistant or nurse specialist).
B. Formula~y: None.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: effective 7/1/87, maximum 100 doses or 34 day supply, whichever is
greater.
2. Refills: As directed by licensed practitioner.
3. Dollar Limits: No limit.
4. For chronic conditions prescription must be a minimum of 100 units or one month's supply.
D. Prescription Charge Formula: Drugs will be paid at the usual retail rate or estimated acquisition cost
or maximum allowable cost, plus a dispensing fee - whichever is lower. Dispensing fees range from
$2.00 to $4.00 (effective 7/1;89). ~dciitional$0.75 per Rx allowed for unit dose systems.
E. Co-payment - $1.00 effective 7/1/87

Officials, Consultants and Committees

1 . Social and Rehabilitation Services Department Officials:

Julia E. Robinson, Director Dept. of SocialIRehab. Services


P.O. BOX4210
Helena, MT 59604
4041444-4540

John Donwen, Administrator Economic Assistance Div.

John L. Chappuis, Chief Medicaid Bureau

Lowell Uda, Supervisor Medicaid Services Section

Karl Banschbach, Administrative Officer

2. Montana Medical Care Advisoty Council:

John Donwen, Administrator Erich Merdiner, Chief Donald Pezzini


Economic Assist. Div. Prog. Integrity Bureau Dept. of Health & Environmental Sciences
Dept. of Social/Rehabilitation Dept, of SociaP~ehabilitation Cogswell Bldg., Room C108
P. 0. Box 4210 P. 0. Box 4210 Helena, MT 59620
Helena, MT 59604 Helena, MT 59604 4061444-4544
Montana - 3

Hugh Standley Jeffrey H. Strickler, M.D. William E. Boharski


4629 Chandler 300 N. Montana Avenue P. 0. Box 2965
Missoula, MT 59801 Helena, MT 59601 Kalispell, MT 59901
4061543-5245 4061449-5563

Gwen Kloeber Paul S. Donalson, M.D. William Peters, M.D.


State Workers' Comp. Ins. Fund 405 Saddle Drive 300 N. Wilson, Suite 2004
Dept. Labor & Industry Helena, MT 59601 Bozeman, MT 59715
50 S. Last Chance Gulch 4061587-9202
Helena, MT 59604 R. 0. Marks
4061444-6485 2831 Ft. Misioula Road
Missoula, MT 59801

3. Social and Rehabilitation Services Economic Assistance Division:

Dee Capp Karl Banschbach Randall Bowser


Administrative Officer Administrative Officer Program Officer

Mary Dalton Paul Miller John Kall, D D S .


Administrative Officer Administrative Officer Dental Consultant

Joyce DeCunzo John Patrick Charles Williams


Administrative Officer Medicaid Supervisor Administrative Officer

Kelly Williams Pat Huber John Chappuis


Administrative Officer Administrative Officer Chief Medicaid Bureau

4. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Association: B. Pharmaceutical Association:

G. Brian Zins Robert Likewise


Executive Director Executive Director
MT Medical Association MT State Pharmaceutical Assn.
2021 Il t h Avenue, Suite 12 P.O. Box 4718, 4376 Head Drive
Helena, MT 59601 Helena, MT 59604
4061443-4000 4061449-3843

C. Osteopathic Association: D. State Board of Pharmacy:

Patrick Frankl, D.O. Warren Arnole


Secretary-Treasurer Executive Director
MT Osteopathic Association 510 1st Avenue, N. Suite 100
Box 2004 Great Falls, MT 59401-2581
Phillipsburg, MT 59858 4061761-51311444-5436
B
NPC - 1989 Nebraska - 1

NEBRASKA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other'


OAA AB APTD AFDC OAA AB APTD AFDC Childrenc21
Prescribed Drugs X X X X X X X
Inpatient
Hospital Care X X X X X X X
Outpatient
Hospital Care X X X X X X X

Laboratory &
X-ray Sewice X X X X X X X
Skilled Nursing
Home Services X X X X X X X
Physician Services X X X X X X X
Dental Services X X X X X X X

'SF0 - State Funds Only


11. EXPENDITURES FOR DRUGS

1987 I988
Expended Recipient Expended Recipient
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w1Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families wIDep. Children
Adults -Families wiDep. Children
Other Title XIX Recipients

HHS report MRS 115


NPC - 1989 Nebraska - 2

Ill. Administration:

State Department of Social Services.

IV. Provisions Relating to Prescribed Drugs:

A. General Exclusions: Experimental drugs; weight control and appetite depressant drugs, except for
use in narcolepsy or hyperkinesis in children with granted prior approval; OTC drugs that are not
listed in the "Official Drug Guide" and have not been prescribed by a licensed practitioner; drugs that
are marketed without required FDA approval; drugs marketed that infringe on patent rights; prior
authorization is required for certain other items.

6. Formulary: None. The "Official Drug Guide" is a list of drugs together with identification members
for billing purposes. For Drug Guide Information, contact:

Daniel W. Snodgrass, R.Ph.


Nebraska Dept. of Social Services
P.O.Box 95026
Lincoln, NE 68509
4021471-3121

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.

' Medical Services, Department of Social Services, State of Nebraska. Nebraska DSS Program
Manual, issued November 24, 1982, as amended.
Nebraska - 3

b. When the prescribing physician's professional judgment indicates that these quantities
of medication would not be in the patient's best medical interest, the physician may
prescribe as his judgment directs; but the claim form must clearly indicate that an
exception to the requirement is being made.

c. If, in the Pharmacist's professional judgment, an exception to the requirements must be


made, the Pharmacist also must clearly indicate this on the claim form.

d. Schedule II drugs are exceptions.

e. Original shelf packages: The Department of Social Services will accept certain original
shelf package sizes of medication.

An original shelf package of 16 fluid ounces, or less when not packaged in the
pint size, will be sufficient for our quantity limitations requirement for liquids, but
will not be sufficient, for the supplemental dispensing fee unless a's a full month's
supply.

Original shelf packages of 100 tablets or capsules of routinely prescribed drugs


will be acceptable as sufficient for fulfillment of our quantity limitations
requirement. The full month's supply must be prescribed and dispensed.

An original shelf package of 100 tablets or capsules, or less when not available
in the 100 size for seldom prescribed solid dosage drugs will be sufficient for our
quantity limitations requirement, but will not be sufficient for the supplemental
dispensing fee unless it is a full month's supply.

Ready-made ointments, creams, etc., when used in a chronic or maintenance


manner, may be dispensed in an original shelf package size provided it is the
original size closest to the needed amount of medication.

The determination of whether a claim violates our regulations or not, would, by


necessity, have to be made by the Department of Social Services professional
staff. Any claim deemed to be in violation or not an exception to our rulings, will
not be compensated with the dispensing fee.

Any disagreement with a determination may be arbitrated through the Nebraska


Pharmacists Association's Advisory Committee.

3. Refills: As authorized by the prescribing physician,

4. Dollar Limits: None.

D. Prescription Charge Formula:

1. Retail Pharmacies
NPC - 1989 Nebraska - 4

a. 'Assigned" dispensing fee.

A dispensing fee will be assigned by the Nebraska Department of Social Services, to each
individual pharmacy. The fee will be calculated from the information obtained through the
Department's Prescription Survey. Each Pharmacy will be notified of its dispensing fee.

b. maintenance Drug-Month Supply"


Supplemental fee.

In addition to the "assigned' dispensing fee for each retail pharmacy, there is a maintenance
drug-month supply supplemental fee of $1.00. This additional fee may be charged provided
that a maintenance drug or drug used in a chronic manner is dispensed in a quantity sufficient
to provide an entire month's therapy.

c. The department assigns a dispensing fee to a dispensing physician only when there is no
pharmacy within a 25 mile radius of the physician's place of practice.

Variable Pharmacy Fee for individual pharmacy determined from survey data submitted to state:

EAC, SMAC, MAC plus determined store fee: minimum $2.84 to maximum $5.05 or usual 2nd
customary, whichever is lower.

2. Determining drug or ingredient cost:

a. General Information

(1) Federal UpDer Limit (FUL): Certain mukiple source drug products will have an
upper limit of reimbursement assigned by the Federal Government. This limit is
equal to 150 percent of the product's lowest price that is published in current
national compendia of drug cost information. Additionally, at least three suppliers
must list the product which has been classified by the Food and Drug
Administration as category A in its most recent publication of Approved Drug
Products with Therapeutic Equivalence Evaluations.

All pharmacies will be notified by the Nebraska Department of Social Services


as to which products the Medical Services Division have designated as FUL
products and what their respective FUL values are.

(2) State Maximum Allowable Cost (SMAC): Certain drug products available from
multi~lemanufacturers will have a state maximum allowable cost designated by
the Medical Se,rvices Division of the Nebraska Department of Social ~ e i c e s .he
SMAC value is the cost at which the drug is widely and consistently available to
pharmacy providers in Nebraska. The determination of which products are
designated SMAC products is the direct responsibility of the Medical Services
Division in conjunction with the Nebraska Pharmacists Association Medicaid
Advisory Committee. Any individual or organization may at any time request a
revision in a SMAC value directly from the Nebraska Department of Social
Services.
..,.
NPC - 1989 Nebraska - 5 .~.
,<q

All pharmacists will be notified by the Nebraska Department of Social Services


as to which products have been designated as SMAC products and what their
respective SMAC values are.

(3) Estimated Acquisition Cost (EAC): All drug products, including the FUL products,
will be assigned an estimated acquisition cost. The EAC of any product will be
the actual cost at which most Nebraska providers may obtain the product. The
Nebraska Department of Social Services will be responsiblefor assigning the EAC
values to all drugs. Any individual or organization may at any time request a
revision in an EAC value directly from the Nebraska Department of Social Services.

b. Cost Limitations

The Nebraska Medicaid Drug Program is required to reimburse product cost at the
lowest of:

(1) Product cost (FUL, SMAC, or EAC) plus the appropriate dispensing fee($;
(2) The pharmacy's usual and customary charge to the general public;
(3) The submitted charge; or
(4) Payment levels for all drugs will not exceed, in the aggregrate, upper levels of
reimbursement established by federal code or regulation.

The FUL or SMAC limitations will not apply in any case where the prescribing physician
certifies that a specific brand is medically necessary. In these cases, the EAC will be
the maximum allowable cost.

4. Pricing Instruction (Drugs)

Under no circumstances, may charge exceed the usual and customary charge to the
general public.

a. Compounded Prescriptions and Legend Drugs

These drugs will be reimbursed at the lesser value of either:

1. Product Cost (FUL, SMAC or EAC) plus the appropriate dispensing fee@), or

2. The usual and customary charge to the general public.

b. Listed over-the-counter drugs

These items will be reimbursed at the lesser value of either:


I. Product Cost (FUL, SMAC or EAC) plus the appropriate dispensing fee@), or
Nebraska - 6

2. The usual and customary shelf mice to the general public.

Section 2500 - Products Requiring Prior Approval

Certain products require that approval be granted prior to their payment.

Physicians wishing to prescribe these products MUST obtain approval from:

The Medical Director (or designee)


Medical Services Division
Nebraska Department of Social Services
301 Centennial Mall South
Fifth Floor
Lincoln, Nebraska 68509

The Department of Social Services will notify the prescribing physician and the pharmacy of the recipient's choice,
whenever these requests are approved.

V. Miscellaneous:
Co-payment - None.

Officials, Consultants and Committees

1. Social Services Department Officials:

Kermit McMurry, Ph.D., Director Department of Social Services


301 Centennial Mall S., 5th FI.
Lincoln, NE 68509
Robert Seiffert, Administrator Division of Medical Services
Ms. Kris Logsdon, Surveillanc.e/Utilization
Review Consultant
Christine Wright, M.D., Medical Director Division of Medical Services
Daniel W. Snodgrass, R.Ph., Pharmaceut. Consultant Division of Medical Services
4021471-9379
Melvin Clothier, Admin. of Medical Programs Division of Medical Services
4021471-9301
Max J. Ward, R.Ph., Pharmacist Div. of Payment and Data Services
4021471-9319

2. Social Services Department Medical Care Advisory Committee:

Warren Bosley, M.D. Tom Ferraro Thomas Kiefer, D.D.S.


1811 West 2nd, Suite 360 Health America of Lincoln 2602 J Street
Grand Island, NE 68801 17th & N Streets Omaha, NE 68107
Lincoln, NE
\PC - 1989 Nebraska - 7

Ray Schweiger Steve Lorenzen Keith Mueller, Ph.D.


Assistant Administrator Director, Fed. Prog. Political Science Dept.
Lincoln General Hospital Blue CrosdBlue Shield of NE Univ. of Nebraska
2300 south 16th street Main P. 0. Station, Box 3248 Lincoln, NE 68588-0328
Lincoln, NE 68107 Omaha, NE 68180

Tom Robinson Evelyn Runyon Edmund Schneider, OD.


Capital Medical 2616 North 102nd Avenue Lincoln Vision Clinic
500 North 66th St. Omaha, NE 68134 810 North 48th Street
Lincoln, NE 68505 Lincoln, NE 68504

Julie Thelen, R.N. Pat Snyder, Ex. Director Gregg Wright, M.D., Dir.
Director, Home & Comm. Nebraska Health Care Assoc. Department of Health
Health Agency Suite 7, 3100 0 Street 301 Centennial Mall S, 3rd FI.
Grt. Plains Reg. Med. Ctr. Lincoln, NE 68510 Lincoln, NE 68509
P. 0. Box 1167 North Plane, NE 69103-1167

Notices and memos are sent to: Kermit McMurry, Robert Seiffert, Me1 Clothier, Chris Wright, Nancy Staley, and
John Woody.

3. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Association: B. Pharmaceutical Association:

William Schellpeper Thomas R. Dolan, R.Ph.


Executive Secretaiy Executive Director
NE Medical Association NE Pharmacists Association
1512 First Tiers Bank Bldg. 5440 South Street, Ste. 1200
Lincoln, NE 68508 Lincoln, NE 68506
40214744472 4021488-5002 or 8001742-0029

C. Osteopathic Physicians & Surgeons: D. State Board of Pharmacy:

Arthur Weaver, D.O. Helen L. Meeks


Secretary Director
NE Assn. of Osteopathic Physicians/Surgeons Bureau of Examining Boards
8552 Cass Street P.O. Box 95007
Omaha. NE 68114 Lincoln, NE 68509-5007
4021390-0900 4021471-2115
NPC - 1989 Nevada - 1

NEVADA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other'


OAA A6 APTD AFDC OAA AB APTD AFDC Childrenc21
Prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X

Laboratory &
X-ray Sewice X X X X
Skilled Nursing
Home Services X X X X
Physician Sewices X X X X
Dental Sewices X X X X

'SF0 - State Funds Only


II. EXPENDITURES FOR DRUGS.

1987 $988
Expended Recipient Expended Recipient
TOTAL $4,751.062 21,764 $5,045,498 23,195
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients

HHS report HCFA - 2082


-
NPC 1989 Nevada - 2

Ill. Administration:
State Welfare Division of the Department of Human Resources.

IV. Provisions Relating to Prescribed Drugs:

A. General: Pharmaceuticals
Covered: The Nevada Medicaid drug program will pay for the following prescribed pharmaceuticals:
1. Most legend pharmaceuticals
2. Insulin
3. Diabetic urine test tablets and test tapes.
4. Prenatal vitaminlmineral supplements, legend or non-legend, intended for prenatal care.
5. Family planning items such as diaphragms, oral contraceptives, foams and jellies.
Excluded: Nevada Medicaid will not pay for the following:
Anorectics used for obesity control.
Amphetamine combinations.
Fertility drugs (e.g. Clomid, Metrodin, Pergonal)
Yohimbine (e.g., Yocon)
Radiopaque agents (e.g., Telepaque, Hypaque, Barium Sulfate)
Radiographic adjuncts (e.g., Perchloracap).
Pharmaceuticals designed "ineffective," or "ess than effective' (including identical, related, or
similar drugs) by the FDA.
Pharmaceuticals considered "experimental" as to substance or diagnosis for which prescribed.

Exceptions: Nevada Medicaid will not pay for the following unless prior-authorized by the Medicaid Office on form
NMO-3, Payment Authorization Request (PAR):

Amphetamine (e.g., Dexedrine).


Aspirin (e.g., Zorprin, Easprin)
Amphetamine (e.g., Dexedrine).
Aspirin (e.g., Zorprin, Easprin).
Chorionic Gonadotropin (HCG).
Dipyridamole (e.g. Persantine)
Ergoloid mesylates (e.g., Hydergine).
Ethaverine (e.g., Ethatab).
Fluoride preparations.
Glucose blood test strips.
Growth hormone (Protopin).
Laxative (e.g., Chronulac, Golytely, Clysodrast).
Methylphenidate (e.g., Ritalin).
Nicotine preparation (e.g., Nicorette).
Nicotinic acid in oral or injectible form.
Non-legend pharmaceuticals.
Papaverine (e.g., Pavabid).
Pemoline (e.g., Cylert).
Quinine (e.g., Quinamm).
Transdermal patch systems (e.g., Nitrodisc, Nitro-Dur, Transderm-Nitro, Estraderm, Transderm-
Scop, Catapres-TTS).
Vitamins, vitaminlmineral combinations or hematinics.
NPC - 1989 Nevada - 3

23. Appliances, sundries and supplies.


24. Nutritional supplements or replacements.
25. Intravenous therapy.
26. Those vaccines not readily available free of charge

Formulary: None. (Certain Rx categories are excluded from reimbursement. See Section A above.)

Prescribing or Dispensing Limitations:

1. Prescriptions. Eligible Medicaid recipients may receive five out-patient prescriptions per month
plus those issued for EITHER prenatal OR family planning purposes. For special authorization
procedures, see 1203.3.
2. Refills. A refill is a prescription subject to the limitations in paragraph A above.

Prescription Charge Formula:

1. Reimbursement: Legend Drugs


Reimbursement for legend pharmaceuticals is the lowest of (1) specific upper limit (SUL) plus the
professional fee, (2) estimated acquisition cost (EAC) plus the professional fee, or (3) that pharmacy's
usual charge to the general public. The professional fee is currently $3.95 per prescription. (EAC
is defined as AWP minus 10%).

Fiscal intermediary: Blue Shield of Nevada


P.O. Box 10330
Reno, NV 89510

Officials, Consultants and Committees

1. Human Resources Department Officials:

Jerry Griepentrog, Director Department of Human Resources


State Capital Complex
505 East King St. Room 600
Carson City, NV 89710

Linda Ryan, Administrator


State Welfare Division
NPC - 1989

Bill Engel, Chief


Medical Services

Jaime Wheeler, M.D., Medical Consultant


Nevada Medicaid Office

Steven P. Bradford, Pharm.D., Pharmaceutical Consultant


Nevada Medicaid Office

2. Advisory Committees of the Welfare Division:

Medical Care Advisory Group:


..
George Harvey, R.Ph. James Lamb, Chair. Jane Hirsch, Chair. .:..
Executive Comm. Hospital Comm. Long Term Care Comrn.

Zeny Ocean, D.D.S., Chair. Sue Coons, Chair. George Harvey, R.Ph., Chair.
Dental Comm. Consumer Recip. Comm. Pharmacy Comm.

Michael Fischer, M.D., Chair.


Physician C O ! ~ .

Drug Utilization Review: Steven P. Bradford, PharmD

3. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Association: B. Pharmaceutical Association:

Larry Matheis Karen Peska


Executive Director Executive Director
NV State Medical Assn NV Pharmaceutical Assn,
3660 Baker Lane 3660 Baker Lane
Reno, NV 89509 Reno, NV 89509-5413
7021825-6788 7021826-3981

C. Osteopathic Association: D. State Board of Pharmacy:

Jeffrey E. Brookman, D.O. Keith W. MacDonald, R.Ph.


Secretary-Treasurer Executive Secretary
NV Osteopathic Medical Assn 1201 Terminal Way
2300 South Rancho Rd. Suite 212
Las Vegas, NV 89102 Reno, NV 89502
7021384-0414 7021322-0691
New Hampshire - 1

NEW HAMPSHIRE
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

~ y p eof Benefit Categorically Needy Medically Needy (MN) Other*


OAA AB APTD AFDC OAA AB APTD AFDC Childrenc21
prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X X

Laboratory &
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X X
physician Services X X X X X X X X X X
Dental Services X X X X X X X X X X

S F 0 - State Funds Only

11. EXPENDITURES FOR DRUGS.

1987 1988
Expended Recipient Expended Recipient
$7,296,693 25,497 $8,242,701 25,438
CATEGORICALLY NEEDY CASH TOTAL 2,570,007 13,879 2,667,934 13,525
534,057 1,235 570,335 1,207
41,377 126 50,436 141
1,389,370 3,031 1,456,812 2,778
Children -Families wIDep. Children 192,944 4,173 186,243 3,998
Adults -Families w1Dep. Children 412,257 5,314 403,953 5,400
CATEGORICALLY NEEDY NON-CASH TOTAL 3,277,669 8,427 3,711,459 7,119
2,401,810 3,752 2,831,209 3,827
41,822 80 48,730 85
564,808 958 656,056 991
Children -Families wIDep. Children 72,414 946 59,970 750
Adults -Families wIDep. Children 196,813 2,691 115,340 1,465
Other Title XIX Recipients 0 0 0 0
MEDICALLY NEEDY TOTAL 1,449,016 3,191 1,863,460 4,795
1,067,111 1,913 1,351,754 2,168
12,149 24 14,800 24
31 5,568 548 352,585 608
Children -Families wiDep. Children 7,660 156 22,193 429
Adults -Families w/Dep. Children 45,700 537 121,768 1,555
Other Title XIX Recipients 825 13 358 11

HHS report HCFA - 2082


-
NPC 1989 New Hampshire - 2

Ill. Administration:

Office of Medical Services, Department of Health and Human Services

IV. Provisions Relating to Prescribed Drugs:

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

B. Formulary: None.

C. Prescribing or Dispensing Limitations:

1. Quantity of Medication: Prescriptions limited to 100 day supply.


2. Dollar Limits: None.

D. Prescription Charge Formula:

$2.85/$3.00 fee plus Estimated Acquisition Cost (EAC) or HCFA upper limit or Usual and Customary
Charge, whichever is less.

Maintenance medications are reimbursed by the above formula once every thirty days per recipient
per provider: any refills of maintenance medications within 30 days are reimbursed at cost only.

Co-payment: $0.50 generic, $1.00 brand name multisource, except nursing home patients, under
18 years, family planning and pregnancy prescriptions.

Officials, Consultants and Cornmiltees

1. Dept of Healh and Human Services Officials:

Mary Mongan, Commissioner Department of Health and Human Services


Health and Human Services Building
6 Hazen Drive
Concord. NH 03301
6031271-4353

Philip Soule, Administrator Office of Medical Services


Division of Human Services

Roben W. Moore Office of Medical Services


Contract Administration Division of Human Services

Edward J. Pierce, P.D., Pharmaceutical Office of Medical Services


Services Specialist Division of Human Services
NPC - 1989 New Hampshire - 3

2. Medical Care Advisory Committee:

This committee consists of 30 members representing providers and consumers of health care, as well as the
various agencies interested in health care in the State.

3. Executive Officers of State Medical and Pharmaceutical Services:

A. Medical Society: B. Pharmaceutical Association:

Palmer P. Jones Maurice E. Goulet, P.D., M.S.


Executive Vice President Executive Director
NH Medical Society NH Pharmaceutical Association
4 Park Street 44 S. Main Street
Concord, NH 03301-6389 Pennacook, NU 03303
6031224-1909 6031753-8759

C. Osteopathic Association: D. State Board of Pharmacy:

Edythe L. Craig, D.O. Paul G. Boisseau


Secretary-Treasurer Secretary
NH Osteopathic Assnociation Health & Human Service Building
P.O. Box 421 6 Hazen Drive
Bradford, NH 03221 Concord, NH 03301
938-2110 6031271-2350
NPC - 1989 New Jersey - 1
NEW JERSEY
MEDICAL ASSISTANCE DRUG PROGRAM WTLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other.


OAA AB APTD AFDC OAA AB APTD AFDC Childrene21
Prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
outpatient
Hospital Care

Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services X X X X

'SF0 - State Funds Only


II. EXPENDITURES FOR DRUGS.
HHS report HCFA - 2082 1987 1988
Expended Recipient 'Expended Recipient
TOTAL 893,872,997 446,071 $105,052,185 436,269
CATEGORICALLY NEEDY CASH TOTAL 80,676,210 350,855
Aged 14,375,620 26,682
Blind 444133 915
Disabled 36,942,110 60,954
Children -Families w/Dep. Children 13,429,223 172,093
Adults -Families w/Dep. Children 15,485,124 90,201
CATEGORICALLY NEEDY NON-CASH TOTAL 22,406,225 72,237
Aged 14,860,110 29,037
Blind 32,726 76
Disabled 4,402,941 6,668
Children -Families w/Dep. Children 1,432,808 20,566
Adults -Families w/Dep. Children 1,092,998 9,408
Other Title XIX Recipients 638,642 6,482
MEDICALLY NEEDY TOTAL 231,712 2,649
Aged 4,904 11
Blind 0 0
Disabled 18,392 45
Children -Famiiies w/Dep. Children 205,463 2,547
Adults -Families w/Dep. Children 2,953 46
Other Title XIX Recipients 0 0

Nursing home pharmaceuticals data not included in 2082 form. Unit dose fee plus consultation fee = $4,318,405.
Nursing home capitation = $5,416,306.
NPC - 1989 New Jersey - 2

Ill. Administration:

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

IV. Provisions Relating to Prescribed Drugs:

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

B. Formulafy: None.

C. Prescribing or Dispensing Limitations:

1. Quantity of Medication: The quantity of medication prescribed should provide a sufficient


amount of medication necessary for the duration of the illness or an amount sufficient to cover
the interval between visits, but may not exceed a 60-day supply or 100 unit doses whichever
is greater.

Exceptions:

a. Oral contraceptives may be prescribed for up to a 3-month supply.

b. Vitamins and vitamin-mineralcombinations may be dispensedfor up to a IOO-day supply.

2. Refills: Prescription refills will be limited to 5 times within a 6-month period if so indicated by
the prescriber on the original prescription.

Exceptions:

a. Oral contraceptives originally prescribed for a 3-month supply may be refilled 3 times
within one year.

b. Vitamins and vitamin-mineral combinations originally prescribed for 100 day supply may
be refilled 2 times within one year.

3. Dollar Limitations: None,

D. Prescription Charge Formula:

1. Payment for legend drugs, contraceptive diaphragms and reimbursable devices shall be based
upon 'Maximum Allowable Cost," or Average Wholesale Price minus 0 - 6%.

a. Maximum Allowable Cost is defined as:

(1) The "Maximum Allowable CostYMAC) price published periodically by the Health
Care Finance Administration (HCFA) of the Federal Department of Health and
Human Services for listed multi-source drugs or established by the Division of
Medical Assistance and Health Services; or
New Jersey - 3

(2) Subject to the limits of Section (b) below. The Estimated Acquisition Cost (EAC)
herein defined as lower of the Average Wholesale Price (AWP) listed for the most
frequently purchased package size (as defined by the Division of Medical
Assistance and Health Services) in current national price compendia or other
appropriate sources, and their supplements; price changes listed in the national
price compendia; or designated prices defined in Section 10:51-1.6. In the case
of unlisted or undesignated AWP "costs" or of typographical errors, the known
correct price will be used as maximum.

b. If the published MAC price as defined in (a)l. above is higher than the price which
would be paid under (a)2. above, then (a)l. above will apply.

2. Maximum cost for each eligible prescription claim not covered by section (a)l, above shall be
subject to the following fiscal conditions based upon six categories, as determined by the N.J.
Medicaid program based on the previous year's total prescription volume for each participating
pharmacy. The categories shall be reviewed annually and adjusted as appropriate.

a. To determine a provider's total prescription volume, which shall include all prescriptions
filled, both new and refills, for private patients, Medicaid, PAA, and other third party
recipients for the previous calendar year, each pharmacy provider shall submit in writing,
an annual report certifying its prescription volume. Failure to submit this report annually
will result in the provider being placed in the maximum discount category (category VI)
for the year of non-compliance, or until the required report is received.

Note: Those pharmacy providers who have been in business for less than one calendar
year will have their prescription volume projected for the entire year, to determine the
appropriate category.

b. Category I: Pharmacies whose total prescription volume in the preceding calendar year
was not more than 14,999 prescriptions.

(1) Pharmacy providers in this categoty shall receive reimbursement for Medicaid
prescription claims for legend drugs at average wholesale price (AWP), as defined
in section 10:51-1.16a., as the maximum.

c. Category II: Pharmacies whose total prescription volume in the preceding calendar year
was at least 15,000 but not greater than 19,999 prescriptions.

(1) Pharmacy providers in this category shall receive reimbursement for Medicaid
prescription claims for legend drugs at average wholesale price (AWP), as defined
in section 10:51-1.I 6a, less two per cent, as the maximum.

d. Category Ill: Pharmacies whose total prescription volume in the preceding calendar year
was at least 20,000 but not greater than 29,999 prescriptions.
NPC - 1989 New Jersey -4

(1) Pharmacy providers in this category shall receive reimbursement for Medicaid
prescription claims for legend drugs at the average wholesale price (AWP), as
defined in section 10:51-1.16a, less three per cent, as the maximum.

e. Category IV: Pharmacies whose total prescription volume in the previous calendar year
was at least 30,000 but not greater than 39,999 prescriptions.

(1) Pharmacy providers in this category shall receive reimbursement for Medicaid
prescription claims for legend drugs at average wholesale price (AWP), as defined
in section 10:51-1. I 6a, less four per cent, as the maximum.

f. Category V: Pharmacies whose total prescription volume in the preceding calendar year
was at least 40,000 but not greater than 49,999 prescriptions.

(1) Pharmacy providers in this category shall receive reimbursement for Medicaid
prescription claims for legend drugs at average wholesale price (AWP), as defined
in section 10:51-1.16a, less five per cent, as the maximum.

g. Category VI: Pharmacies whose total prescription volume in the preceding calendar year
was 50,000 prescriptions or more.

(1) Pharmacy providers in this category shall receive reimbursement for Medicaid
prescription claims for legend drugs at average wholesale price (AWP), as defined
in section 10:51-1.16a, less six per cent, as the maximum.

Notes:(l) If the published MAC price as defined in section 10:51-1.16(a)li is higher than
the price which would be paid under section 10:51-l.l6(a)lii, then section 10:51-
1.1 6(a)l ii, will apply.

(2) The appropriate calculated discount will be automatically deducted (by Blue Cross
of New Jersey) from each eligible legend drug claim during the claim processing
procedures.

(3) For prescription drugs costing more than $24.99 there will be no discount from
the average wholesale price (AWP).

Dispensing Fee

The dispensing and services fee ranges from $3.73 to a maximum of $4.07 depending upon the number
and types of services agreed to by the provider.

Service Fee

Increment
1. 24 hour emergency service availability $0.11
2. Patient Consultation $0.08
3. Impact Allowance $0.15
NPC - 1989 New Jersey 5 - 1

In completing the Pharmacy Provider Service Agreement the provider agrees to provide all services at no
additional charge to the Medicaid or PAA recipient. Under no circumstances are any additional
administrative charges allowed.

The Pharmacy Manual further states the following: The maximum charge to the New Jersey Health Services
Program for a legend drug may not exceed the lowest of the following:

a. Cost plus dispensing fee as outlined herein.


b. Usual and customary charges and/or posted or advertised charges.
c. Other third party prescription plan charges, when contracts or agreements to participate have been
entered into subsequent to the adoption of this regulation.

V. Miscellaneous Remarks:

Fiscal Intermediary: Blue Cross of New Jersey


33 Washington Street
Newark, NJ 07101

Co-payment: None

The Garden State Health Plan is as follows:

The New Jersey Medicaid program has implemented a State certified managed health care plan called the
Garden State Health Plan (GSHP). The Plan is a prepaid, primary care network model health plan whereby
all of the Medicaid eligible's health care is managed by a primary care physician.

The Garden State Health Plan is offered to Medicaid eligibles on a voluntary basis as an alternative to the
existing New Jersey Medicaid fee-for-service program. Physician case management is the key component
of the Plan whereby participating Medicaid physicians contract with the Plan to provide primary care and
to case manage all other health and medical services to Medicaid eligibles who enroll in the Plan.

The key goals of the Plan are:

1. To enhance the level of wellness of Medicaid eligibles;

2. To provide continuity of care and physician case management in the provision of total health care to
Medicaid eligibles;

3. To avoid inappropriate care and unnecessary utilization of health care services in inappropriate settings.

Medicaid approved physicians are offered the opportunity to participate in the Garden State Health Plan
and assume the role of physician case manager (PCM). The PCM is available to members on a 24 hour,
seven day a week basis, either directly or through coverage arrangements.

The Garden State Health Plan is currently implemented in 10 counties (Atlantic, Burlington, Camden, Essex,
Mercer, Middlesex, Morris, Passaic, Sussex, and Union Counties) and will eventually be phased-in
throughout the State.
NPC - 1989 New Jersey - 6

Officials, Consultants and Committees

I. Department of Human Resources Officials:

Drew Altman, Commissioner Department of Human Sewices


Capitol Place 1
Trenton, NJ 08625

Thomas M. Russo. Director Div. of Med. Assist./Health Sew


CN712
7 Quakerbridge Plaza
Trenton, NJ 08625

I. F. Erlichman, M.D., Medical Director

Sanford Luger, R.Ph., Chief


Pharmaceutical Sewices

2. Medical Assistance Advisory Council: (under revision)

3. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Society: B. Pharmaceutical Association:

Vincent A. Maressa Alvin N. Geser


Executive Director Executive Officer
Medical Society of NJ NJ Pharmaceutical Association
2 Princess Road 120 W. State Street
Lawrenceville, NJ 08648 Trenton, NJ 08608-1102
6091896-1766 6091394-5596

C. Osteopathic Physicianslsurgeons Association: D. State Board of Pharmacy:

Eleanore Farley H. Lee Gladstein, R.Ph.


Executive Director Executive Director
NJ Assn. of Osteo. PhysiciansISurgeons 1100 Raymond Boulevard
1212 Stuyvesant Avenue Newark, NJ 07102
Trenton, NJ 08618 2011648-2433
6091393-8114
--
NPC - 1989 -
New Mexico I

NEW MEXICO
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other'


OAA AB APTD AFDC OAA AB APTD AFDC Childrew21
Prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X

Laboratoly &
X-ray Service X X X X
Skilled Nursing
Home Sewices X X X X
Physician Services X X X X
Dental Services X X X X

'SF0 - State Funds Only


II. EXPENDITURES FOR DRUGS.

I987 1988
Expended Recipient Expended Recipient
TOTAL $14,689,445 71,045 $1 8.01 5,021 77.265
CATEGORICALLY NEEDY CASH TOTAL $12,508,125 64,337 15,104,123 67,100
Aged 2,295,036 6,834 2,714,437 6,942
Blind 119,843 357 147,306 360
Disabled 6,498,967 14,709 7,950,964 15,427
Children -Families w/Dep. Children 1,333,066 26,712 1,617,847 27,922
Adults -Families w/Dep. Children 2,261,213 15,725 2,673,569 16,449
CATEGORICALLY NEEDY NON-CASH TOTAL $2,181,320 6,708 2,882,390 9,283
Aged 1,578,747 3,206 2,139,147 3,772
Blind 1,404 8 2,516 8
Disabled 333,883 552 470,511 764
Children -Families w/Dep. Children 62,045 1,207 146,735 2,880
Adults -Families wIDep. Children 53,740 876 78,390 1,117
Other Tile XIX Recipients 151,501 859 45,091 742
MEDICALLY NEEDY TOTAL $0 0 0 0
Aged 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/Dep. Children 0 0 0 0
Other Title XIX Recipients 0 0 0 0

HHS report HCFA - 2082


NPC - 1989 New Mexico - 2

Ill. Administration:

Human Services Department (HSD)

IV. Provisions Relating to Prescribing Drugs:

A. General Exclusions:

Drugs for treatment of tuberculosis, experimental and cosmetic drugs are not included.

Medications supplied by the New Mexico State Hospital to clients on convalescent leave from
hospital are not included.

Drugs and immunizations available from any other source are not included,

Legend multiple vitamins, tonic preparations and combinations thereof with minerals, hormones,
stimulants or other compounds which are available as separate entities for treatment of specific
conditions.

Hematinics except non-sustained release forms of Ferrous Sulfate, Ferrous Gluconate, Ferrous
Fumarate.

Amphetamines and combinations of amphetamines with other therapeutic agents;


amphetamine-like sympathomimetic compounds used for obesity control including any
combination of such compounds with other therapeutic agents.

Drugs classified by FDA as "Ineffective" or "Possibly Effective",

Hypnotic drugs.

OTC items with the following exceptions (the exceptions are covered by the program):

a. Insulin.
b. Antacids for active gastric and duodenal ulcers.
c. Infant vitamin drops for children up to one year of age.
d. Salicylates and acetaminophen.
e. Non-sustained release forms of Ferrous Sulfate, Ferrous Gluconate, Ferrous Fumarate.

B. Formulary: Open formulary subject to above-stated limitations. For formulary information contact:

Robert Stevens
Medical Assistance Division
P.O. Box 2348
Santa Fe, NM 87504-2348
5051827-4315
w

NPC - 1989 New Mexico - 3

C. Prescribing or Dispensing Limitations:

I. Quantity of Medication: 6 months supply maximum.

2. Refills: Payment will be made to a particular pharmacy only three times for the same drug for
the same client in any 90-day period.

D. Prescription Charge Formula:

I. Prescriptions reimbursed at the lesser of the following:

a. Cost (MAC or EAC) dispensed plus fee ($3.65)or,


b. The usual and customary charge by the pharmacy to the general public,

EAC = AWP minus 10.5%.

V. Miscellaneous Remarks:

Fiscal Intermediary: EDS Federal Corporation


5801 Osuna N.E.
Albuquerque, NM 87109

Officials, Consultants and Committees

I. Human Services Department:

Alex Valdez, Secretary Human Services Department


P.O. Box 2348
Santa Fe, NM 87504-2348
50518274315
Dennis Boyd, Dep. Secretary

Larry Martinez, Bureau Chief Program Support Division

Bruce Weydemeyer, Bureau Chief Medical Services Division

Robert Stevens, R.Ph., Drug Prog. Admin. Medical Assistance Division

2. Medical Advisory Committee Members:

Neal Johnson Chris Garcia Michael Kaufman, M. D.


Clinical Pharmacy Legal Aid Society of Albuq. P. 0. Box 5775
5121 Gibson Blvd. SE 1020 Tijeras, NE Taos, NM 87571
Albuquerque, NM 87108 Albuquerque, NM 87106 5051758-2224
5051262-1425 5051243-7871

Bert Umland, M.D. John Foley, Executive Director Alicia Craft


Division of Family Practice NMARC Indigent Hospital Claims Admin.
UNM Medical Center 8210 La Mirada N E P.O. Box 1119
Albuquerque, NM 87131 Suite 500 Los Lunas, NM 87031
5051277-2165 Albuquerque, NM 87109
NPC - 1989 New Mexico - 4

Kathleen Brook, Ph.D. John S. Johnson, Ed.D. E. E. Vex" Rinerbush


4236 Winchester AARP Sandia Lab. Org 0133
Las Cruces, NM 88001 P. 0. Box 457 P. 0. Box 5800
5051646-4905 Las Vegas, NM 87701 Albuquerque, NM 87105
5051425-7116 5051844-9420
Howard Shaver, Pres.
NM Hospital Association NM Primary Care Assn. Linda Sechovec, Ex. Dir.
P. 0. Box 36090 2340 Alamo, SE, Suite 304 NM Health Care Assn.
Albuquerque, NM 87176 Albuquerque, NM 87106 1024 Eubank, NE, Suite D
5051889-3393 5051242-0281 Albuquerque, NM 87112
5051296-0021
Herk Maldonado
DirJHealth Affairs Karen Wells, R.N., Ex. Dir. Carla Muth, R.N., Secretary
NM Blue CrosslBlue Shield NM Assn. for Home Care NM Health & Environment Dept.
12800 Indian School Road, NE Route 9, Box 90M Harold Runnels Bldg., 4th FI.
Albuquerque, NM 871 12 Santa Fe, NM 87505 P. 0. Box 968
50512913526 5051988-1186 Santa Fe, NM 87504-0968
5051827-2613

3. NMPHA Committee Third Party Payments:

Liaison Comminee for NM Pharmaceutical Association meets each month.

Robert Ghanas, R.Ph. Neil Johnson, R.Ph. Victor Castillo, R.Ph.


Durans Pharmacy Clinical Pharmacy Victor's Pharmacy
1815 Central, N.W. 5002 Gibson, S.E. 1643 lsleta, S.W.
Albuquerque, NM 87104 Albuquerque, NM 87108 Albuquerque, NM 87105

Dale Tinker, Executive Director, NMPHA


4800 Zuni, S.E.
Albuquerque, NM 87108

4. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Society: Pharmaceutical Association:

Glenn R. Marshall, Executive Director Dale Tinker, Executive Director


NM Medical Society NM Pharmaceutical Association
303 San Mateo Blvd., NE 48000 Zuni, S.E.
Albuquerque, NM 87108 Albuquerque, NM 87108-2830
5051266-7868 5051265-8720

C. Osteopathic Medical Association: State Board of Pharmacy:

Thomas P. Thompson, Executive Director James T. Daily


NM Osteopathic Medical Association Acting Executive Director
P. 0. Box 3096 4125 Carlisle N.E.
Albuquerque, NM 87110 Albuquerque, NM 87107
5051884-0201 5051841-6311
q-

NPC - 1989 New York - 1

NEW YORK
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other'


OAA AB APTD AFDC OAA AB APTD AFDC Children<21
Prescribed Drugs X X X X X X X X X X
Inpatient
Hospital Care X X X X X X X X X X
outpatient
Hospital Care

Laboratory &
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X X
Physician Services X X X X X X X X X X
Dental Services X X X X X X X X X X

'SF0 - State Funds Only


11. EXPENDITURES FOR DRUGS.

1987 1988
Expended ReCi~ient Expended Recipient
TOTAL $394,893,872 1,529,889
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families wIDep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients

HHS report HCFA - 2082


NPC - 1989 New York -2

Ill. Administration:

State Department of Social Services.

IV. Provisions Relating to Prescribed Drugs:

A. General Exclusions: No restrictions except: (See V. Miscellaneous Remarks)

1. Prescribed vitamins and minerals not prescribed for medical necessity.


2. Amphetamines and other drugs whose sole clinical use is for reduction of weight.
3. Limited coverage of non-prescription drugs.

8. Formulary: Coverage of prescription drugs is limited to list of Medicaid reimbursable Prescription


drugs. For information contact:

Medicaid Reimbursement Drug Lists


Bureau of Standards Development
New York State Department of Health
Room 2074, Corning Tower
Albany, NY 12237

C. Prescribing or Dispensing Limitations:

1. Quantity of Medication: Drugs and sickroom supplies shall be prescribed in sufficient quantity
consistent with the health needs of the patient and sound medical practice.

2. Refills: Refills cannot exceed 5, and the life of a prescription cannot exceed 6 months.

3. Dollar Limits: None.

D. Prescription Charge Formula:

1. Maximum Reimbursable Pricing Schedule is as follows:

a. Payment for multiple source drugs must not exceed the aggregate of the specified upper
limit set by the federal Health Care Financing Administration (HCFA), plus a dispensing
fee, for a particular drug; and

b. Payment for brand name drugs and other multiple source drugs not covered by clause
(a) will be the lower of: the estimated acquisition cost plus a dispensing fee; or

c. The provider's usual and customary price charged to the general public.

2. Dispensing Fee, $2.60

V. Miscellaneous Remarks:

The Medicaid drug list applies only to prescription and/or fiscal orders filled in community pharmacies.
\PC - 1989 New York -3

Based on mandated payment criteria for prescription drugs, many non essential and high priced drug
products are excluded, e.g., those not essential to sustain life, relieve or prevent severe pain, or prevent
disease or continuing disability: sustained release medications; anti flatulence products; cough enzymes;
muscle relaxants; vitamins and vitaminlminerai preparations; and dermatologicals. Many combination drugs
and comfort products are also excluded.

Fiscal Intermediary: Computer Sciences Corp. (CSG)


800 North Pearl Street
Albany, NY 12204

Co-payment: None

Officials, Consultants and Committees

1. Social Services Department Officials:

Cesar A. Perales, Commissioner Dept. of Social Services


5181474-9130 40 North Pearl Street
Albany, NY 12243

Jo-Ann Constantino, Deputy Commissioner Division of Medical Assistance

Mary Alice Brankman, Director Dept. of Social Services


5181474-9219 40 North Pearl Street
Albany, NY 12243

Michael A. Falzano, Medicaid Review Analyst IV (SUR) Bur. of Ambulatory Services


Inpatient Care & Contracts

2. Social Services Advisory Committees:

A. Medical Advisory Committee:

Ebun Adelona, R.N., Ph.D. David Axelrod, M.D. Ebie Brown


P. 0.BOX1405, 92 Commissioner C/O Barss
Morningside #34 NYS Dept. of Health 53 Van Dorn Street
New York, NY 10027 Empire State PI., Corning Tower Saratoga Spring, NY 12866-1216
Albany, NY 12237

Ruben P. Cowart, D.D.S. John L. S. Holloman Beatrice Kresky, M.D., MPH, Chair.
Executive Director 27-40 Ericsson Street Dept. of Ambulatory Care
Syracuse Community Health Center East Elmhurst, NY 11369 Jamaica Hospital
819 South Saiina Street Jamaica, NY 11418
Syracuse, NY 13202 Hugh M. Morales, M.D., PC
Medical Director Mrs. Gleniss Schonholz
Mary Lou Penengill Bronx Mental Health Center Senior Vice President
84 Westover Drive Psychiatry & Neurology Long Island Jewish Medical Ctr.
Webster, NY 14580 1211 Gerard Avenue New Hyde Park, NY 11042
Bronx. NY 10452
NPC - 1989 New York -4

William O'Dwyer, M.D. Hildamar Ortiz Walter Singer, Ph.D.


14 Loudon Parkway 1248 St. Nichols Avenue 5 Barry Court
Loudonville, NY 12211 New York, NY 10032 Loudonville, NY 12211

Elena Padilla, Ph.D. Robert H. Randles, M.D.


3 Washington Sq. Village Medical Director
Apt. 15-0 St. Peter's Hospital
New York, NY 10012 315 S. Manning Blvd.
Albany, NY 12208

3. Pharmacy Advisory Committee 1988:

John P. Navarra (Chairman) John Westerman, Jr. Thomas F. Golden, Jr.


Town Drugs Ace Drug Co. Golden Drugs, Inc.
1090 Amsterdam Avenue 22 Continental Drive Park Plaza
New York, NY 10025 New Windsor, NY 12550 Mechanicville, NY 12118

Mahmud AIam Kandyce J. Daley Stephen L. Giroux


Hina Drug Corp. Fays Drug Co., Inc. Middleport Family Health Center
434 Rockaway Avenue 7245 Henry Clay Blvd 81 Rochester Road, Box 188
Brooklyn, NY 11212 Liverpool, NY 13088 Middleport, NY 14105

James Marinos Vincent Conte Neil Goldman


2768 East 66th St. Moby Drugs 33-39 80th Street
Brooklyn, NY 11234 226 Main Street Jackson Heights, NY 11372
Farmingdale, NY 11725

4. Public Health Department:

David Axelrod, M.D., Commissioner Department of Health


5181474-2011 Corning Tower Building
Empire State Plaza
Albany, NY 12237

5. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Society: Pharmaceutical Association:

Donald F.Foy Elizabeth Lasky, Executive Director


Executive Vice President Pharm. Society, State of NY
Medical Society of the State of NY Pine West Plaza IV
420 Lakeville Road Washington Avenue Extension
Lake Success, NY 11042 Albany, NY 12205
5161488-6100 5181869-6595

C. Osteopathic Society: State Board of Pharmacy:

E. Wayne 'Harbinger, D.O. Lawrence H. Mokhiber


Executive Director Executive Secretary
NY State Osteopathic Medical Society, Inc. Cultural Education Center
87 South Lake Avenue Room 3035
Albany, NY 12203 Albany, NY 12230
5181663-8812 5181474-3848
1
NPC - 1989 North Carolina - 1
NORTH CAROLINA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other'


OAA AB APTD AFDC OAA AB APTD AFDC Childrenc21
Prescribed Drugs X X X X
Inpatient
Hospital Care X X X X
Outpatient
Hospital Care X X X X

Laboratory &
X-ray Sewice X X X X
Skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services X X X X

S F 0 - State Funds Only

II. EXPENDITURES FOR DRUGS. 19871988


Ex~endedRecipient Ex~endedRecipient
TOTAL $65.51 1.242
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w1Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w1Dep. Children
Other Tile XIX Recipients
MEDICALLY NEEDY TOTAL $19,467,206
Aged 14,040,626
Blind 105,343
Disabled 3,971,547
Children -Families w/Dep. Children 417,538
Adults -Families w1Dep. Children 865,602
Other Tile XIX Recipients 66,550
SOBRA Expansion Coverage to Pregnant Women and Children below
100% Poverty (Optional Categorically Needy) effective 10187
Children
Pregnant Women

HHS report HCFA - 2082


NPC - 1989 North Carolina - 2

Ill. Administration:

Division of Medical Assistance, Department of Human Resources.

IV. Provisions Relating to Prescribed Drugs:

A. General Exclusions: No payment made for non-legend drugs, except insulin. Payment made for all
legend drugs. Non-legend vitamins are excluded.

B. Formulary: None.

C. Prescribing or Dispensing Limitations:

I. Quantity of Medication: None.

2. Number of Prescriptions:

a. Six per month per recipient

b. Prescription Limit Exemptions for Certain Recipients

The General Assembly has determined that exemptions to the six (6) prescription limit
per month may be authorized by the Department of Human Resources "where the life
of the patient would be threatened without additional care." Therefore, patients being
treated for the following illnesses should be excluded from the prescription limitation:

(1) End State Renal Diseases


(2) Chemotherapy and Radiation Therapy for Malignancy
(3) Acute Sickle Cell Disease
(4) Hemophilia
(5) End State Lung Diseases
(6) Unstable Diabetes
(7) Terminal Stage - any illness - life-threatening

3. Dollar Limits: None.

4. Generic Substitution: Pharmacists must substitute generically if they have a generically


equivalent product available in stock. The substituted product must be a lower cost product
than the one originally prescribed.

5. Lock-In: Each recipient is locked into one pharmacy of his choice for one month, except in
emergencies.

D. Prescription Charge Formula: The lowest price of MAC or AWP, plus $4.04 dispensing fee for each
different drug dispensed during a month, or AWP, plus lowest dispensing fee accepted from other
third party payers. The pharmacist filling the original prescription be reimbursed for refills
for the same drug within a calendar month. $0.50 co-payment/Rx (includes refills).
NPC - 1989 North Carolina .3 a

V. Miscellaneous:

Fiscal Agent: EDS Federal


P.O. Box 300001
Raleigh, NC 27622

Officials, Consultants and Committees

1. Department of Human Resources Officials:

David T. Flaherty, Secretary Depanment of Human Resources


Albermarle Building
325 N. Salisbury Street
Raleigh, NC 27611

Barbara D. Matula, Director Division of Medical Assistance


1985 Umstead Drive
Raleigh, NC 27603

Paul R. Perruui, Deputy Director


Ray J. DiNapoli, Medical Director
C. Benny Ridout, R.Ph., Pharmacist Consultant
Lillian J. Todd, R.N., Nurse Consultant
Betty King-Sutton, D.M.D., Dental Consultant

2. Department of Human Resources Advisory Comminees:

A. Pharmaceutical Association, Third Party Committee:

William H. Mast, Chair. Samuel B. Peneway Gary Bowman


950 Meadow Lane 1504 Tree Top Lane 1512 Peace Street
Henderson, NC 27536 Roc@ Mount, NC 27804 Henderson, NC 27536

David Hix Susan Chiny Pitts Chris Dixon


119 E. Main St. P. 0 . Box 1224 27 O'Hara Drive
Gibsonville, NC 27249 Glen Alpine, NC 28628 New Bern, NC 28560

Jerry Kennedy Jerry D. Rhoades C. B. (Benny) Rideout


2133 Canterbury Drive Box 2 Sox 88
Burlington, NC 27215 Southern Pines, NC 28387 Morrisville, NC 27560

A. G. Hartzema James R. Hall Joe Minton


CB #7360, Beard Hall C/O VIP Computer Systems Colonial Pharmacy, Inc.
UNC School of Pharmacy P. 0. Box 3457 704 E. Main Street
Chapel Hill, NC 27599-7360 Chapel Hill, NC 27599 Mwfreeshoro, NC 27855
North Carolina - 4

Catherine C. Simmons Julian Upchurch, Advisor John W. Watson


Route 2,Box 282 5201 Pine Way 13 Forest Avenue
Siler C i i , NC 27344 Durham, NC 27712 Tabor City, NC 28463

Mike J. Stegall Ed Vaughn


Glenwood Village Pharmacy Vaughn Independent Pharmacy
2921 Essex Circle 503 W. Main Street
Raleigh, NC 27608 Carrboro, NC 2751 0

B. Medical Society, Department of Human Resources Liaison Committee

John L. McCain, M.D. Donald T. Lucey, M.D. Robert G. Brame, M.D.


Chairman 2800 Blue Ridge Blvd. ECU School of Medicine
Wilson Clinic St. 403 Dept. of OB/GYN
Wilson, NC 27893 Raleigh, NC 27607 Greenville, NC 27834

Hervy B. Kornegay, Sr., M.D. Jessica S. Saxe, M.D. Charles K. Scott, M.D.
238 Smith Chapel Road 2216 Dilworth Dr, W. 530 W. Webb Avenue
Mt. Olive, NC 28365 Charlotte, NC 28203 Burlington, NC 27215

Angus M. McBryde, Jr., M.D. Phillip E. Stover, M.D. Charles R. Martin, M.D.
120 Providence Road 519 N. Bickett Blvd. 120 Memorial Drive
Charlotte, NC 28207 Louisburg, NC 27549 Jacksonville, NC 28540

Charles R. Vernon, M.D. Thomas E. Castelloe, M.D Eugene H. Wade, M.D.


7230 Wrightsville Avenue P. 0. Box 10707 723 Edith Street
Wilmington, NC 28403 Raleigh, NC 27605 Burlington, NC 27215

M. Robert Cooper, M.D. W. Samuel Yancy, M.D. Raphael J. Dinapoli, Jr. M.D.
300 S. Hawthorne Road 306 S. Gregson Street 1985 Umstead Drive
WinstonSalem, NC 271 03 Durham, NC 27701 Raleigh, NC 27603

Thad B. Wester, M.D. Hector H. Henry, II, M.D. James S. Parsons, M.D.
1001-101 Brighthurst Drive 102 Lake Concord Road, N.E. 704 W. Jones Street
Raleigh, NC 27605 Concord, NC 28025 Raleigh, NC 27603

George Johnson, Jr., M.D. Campbell W. McMillan, M.D. Joseph A. Moylan, M.D.
Vice-chairman UNC, Dept. of Pediatrics Duke Medical Center
CB #7050 UNC Dept of Surgery CB #7220 Box 3947
Chapel Hill, NC 27599 Chapel Hill, NC 27599 Durham, NC 27110

Consultants:
James D. Bernstein Jesse Goodman Barbara D. Matula
Dept. of Human Resources Dept. of Human Resources Division of Medical Assistance
Health Resources Devl. Sect. Governmental Liaison Sew. 1985 Umstead Drive
701 Barbour Drive 325 N. Salisbury Street Raleigh, NC 27603
Raleigh, NC 27603 Raleigh, NC 2761 I
zm

NPC - 1989 North Carolina - 5

Mrs. John C. Faris (Aux.) Elizabeth P. Joyner Pam Silberman


2720 Bitting Road P. 0. Box 1390 P. 0. Box 27343
Winston-Salem, NC 27104 New Bern, NC 28560 Raleigh, NC 27611

Lillian J. Todd, R.N.


Division of Medical Assistance
1985 Umstead Drive
Raleigh, NC 27603

3. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Society: B. Pharmaceutical Association:

George E. Moore A.H. Mebane, Ill


Executive Director Executive Director
NC Medical Society NC Pharmaceutical Assn.
222 North Person St., P.O. Box 27167 Box 151
Raleigh, NC 2761 1-7167 Chapel Hill, NC 27514-0151
9191833-3836 9191967-2237

C. Osteopathic Association: State Board of Pharmacy:

Guy T. Funk, D.O. David R. Work


Secretary Treasurer Executive Director
NC Osteopathic Society, Inc. P.O. Box H
Box 667 Bermuda Road Carrboro, NC 27510-0747
Advance, NC 27006 9191942-4454
NPC