Professional Documents
Culture Documents
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,
SEPTEMBER 1989
Compiled by
Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
Stateofficials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Federal Register42CFR Parts413. 430. 447and45CFR Pans 1 & 19 . . . . . . . . . . . . . . . . . . 51
State Medicaid Manual Pan 6 - Payment for Services (Upper Limits) .................... 62
3. Miscellaneous:
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.
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:
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.
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.
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:
3. Physician 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:
9. Patient transportation
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.
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)
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.
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.
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 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 refer to preventive, diagnostic, therapeutic, rehabilitative, or palliative services
provided to an outpatient. There are three federal limitations that are imposed on these services:
Rural health clinic (RHC) services became a mandatory service for the categorically needy in July 1978.
Each RHC is required to have a nurse practitioner (NP) or physician's assistant (PA) on its staff. Therefore,
a clinic can only be certified if the state permits the delivery of primary care by an NP or PA. Services in
certified clinics must be provided and furnished by a physician or by a PA, NP, nurse-midwife, or other 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 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
In addition, the states can place limitations on "other laboratory and X-ray 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:
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 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.
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)).
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.
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:
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.
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:
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.
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)
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)).
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.
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.
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.
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).
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:
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
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:
Discussions outlining these proposals appear in the following pages under Federal Register Vol. 52 No.
147, Friday, July 31, 1987.
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:
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.
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.
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.
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.
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
Region VI 1200 Main Tower Building, Room 2000 Arkansas, Louisiana, New
Dallas, Texas 75202 Mexico, Oklahoma, Texas
2141767-6427
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
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
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
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
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
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 * * *
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).
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 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.
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.
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.
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
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
Diazepam Valium
2 mg Tablet B
5 mg Tablet B
10 mg Tablet B
Dicloxiciliin Sodium Pathocil, Dynapen, etC.
50,000 IU Capsule
Ergoloid Mesylates Hydergine
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)
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)
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
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
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
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
35 mg Tablet, 1000's R
30 mg Capsule M
Addendum A (cant.) PAYMENT FOR SERVICES 04-89
GENERIC NAME GENERIC UPPER COMMONLY KNOWN
UMIT/UNIT Source' BRAND NAMEIS)
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
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
% Total % Total
Skilled Nursing
Facility 13.2 13.0
TOTALS
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
Other care includes early & periodic screening, rural health clinic services and miscellaneous other care.
85
MEDICAID RECIPIENTS AND VENDOR PAYMENTS - 1988
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
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
Ingredient State
Dispensing Reimbursement Formulam MAC
State Fees Copayment Basis Formulary Status (12)
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
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
OTC Status
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.
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
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
BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
RHOOE I S L A N D
VERMONT
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
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
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
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
DENVER: REGION V I I I
COLORADO
MONTANA
NORTH DAKOTA
SOUTH DAKOTA
UTAH
WYOMING
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
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
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
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
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
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
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
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
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
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
~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
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
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
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
DENVER: REGION V I I I
COLORADO
2/ MONTANA
2/ NORTH DAKOTA
SOUTH DAKOTA
2/ UTAH
WYOMING
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
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
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
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
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
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
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
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
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
BOSTON: REGION I
CONNECTICUT
MAINE
MASSACHUSETTS
NEW H A M P S H I R E
6 0 0 ~ISLAND
VERMONT
~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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
SEATTLE: REGION X
ALASKA
IDAHO
DREGON
WASHINGTON
NPC - 1989
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
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.)
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
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
134
F-
NPC - 1989
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
Prevention of Substitution:
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
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.
Eligibility
Criteria:
Age 65+ 62+ None 65+
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
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.
Medicaid
Actual Acquisition Cost
Vermont passed PAA legislation in 1989. Effective July, 1990.
NPC - 1989
ALABAMA
_*
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
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.
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
111. Administration:
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.
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:
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.
Drugs dispensed to Medicaid recipients residing in a long-term care facility (nursing home).
NPC - 1989
21.26 - 46.25
46.26 or more
V. Miscellaneous Remarks:
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
ALASKA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XD()
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
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
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.
Eric S. Hansen, Chief, Medical Assistance 4433 Business Park Blvd., Bldg. M
9071561-2171 Anchorage, AK 99503
-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
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:
' 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:
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.
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.
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.
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.
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
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.
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 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.
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.
I. AHCCCS Officials:
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
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
Ill. Administration:
By the Division of Economic and Medical Services, of the Department of Human Services.
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,
~ a Hanley,
y Asst. Deputy Dir. Office of Medical Services
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.
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.
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).
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:
(Please remit $5.00per manual, including updates, by check or money order payable to "State of California")
M. Kuschnereit, Pharm.
714 P Street, #I640
Sacramento, CA 95814
91 61324-2477
1. Quantity of Medication: This is flexible, but quantities should be consistent with the medical needs of
the patient and may not exceed a 100-day supply except under certain circumstances. Many formulary
maintenance drugs are subject to minimum quantity or maximum frequency of billing controls.
2. Refills: A prescription refill can be dispensed as authorized by prescriber. Exception is allowed for
refill of a reasonable quantity when prescriber is unavailable (pursuant to California law). Fee is pro-
rated so that total fee (for partial quantity and balance of the prescription after prescriber is contacted)
does not exceed fee for same prescription when refilled as routine service.
3. Number of prescriptions: Number of prescriptions for formulary drugs not limited but over-utilization
is limited by prepayment and post-payment controls. These controls include those mentioned in item
1 above supported by on-site audit of provider files.
4. Prior Authorization: Approval may be obtained from a Medi-Cal consultant for covered non-formulary
items or services (including special circumstance override of multiple source drug reimbursement
ceilings or minimum quantitylfrequency of billing limitations). Statewide mail and toll free telephone
requests are accepted in the San Francisco and Los Angeles Medi-Cal Field Offices. Requests must
include adequate information and justification. Authorization may only be granted for the lowest cost
item or service that meets the patient's medical needs.
Non-formulary items
California - 4
5. Pharmacist, to the extent permitted by law, is required to dispense lowest cost brand of a multiple
source item in stock meeting medical needs of the patient.
6. Beneficiary or Prescriber Prior Authorization: On a case by case basis, the Department of Health
Services restricts, through the requirements of prior authorization, the availability of designated
prescription drugs to certain beneficiaries or prescribers found by the Department to be abusing those
benefits.
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.
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 -
COLORADO
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
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
2
LC
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
Eligibility is determined by 63 County Departments of Social Services, and the drug program is administered
by the Colorado Department of Social Services.
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.
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.)
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.
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.
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.
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.
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.
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:
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.
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:
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:
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:
Members:
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
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
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.
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.
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.
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%.
Meyer Rosenkrantz
110 Barthalomew Avenue
Hartford, CT 06106
2031566-8007
Connecticut - 4
2. Fiscal Agent
DELAWARE
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
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
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
111. Administration:
By Division of Economic Services, Department of Health and Social Services, through 3 county offices of
the state agency.
General Exclusions: Only legend item drugs (except for insulin) are reimbursable. Vitamins (except
pediatric vitamins), antacids, etc. can not be reimbursed unless they are legend items. OTC items
cannot be reimbursed. Anorectics are excluded, (except for pediatric hyperactivity and certain sleep
disorders, when certified by the physician). No drugs used solely for infertility.
Formulary: None.
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:
Ruth S. Fischer
Administrator
Medical Assistance Services
Stephen G. Grant
Pharmacist C ~ f l s ~ l t a f l t
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
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
Ill. Administration:
The D.C. Department of Human Services (DHS), Office of Health Care Financing.
A. General Exclusions: All legend drugs are covered except those drugs that are listed by FDA as
ineffective. Pursuant to a prescription the following non-legend items are covered: oral analgesics,
oral antacids, insulin, insulin needles and syringes, contraceptive foams and jellies, ferrous sulfate,
prenatal vitamin formulations, geriatric vitamin formulations for recipients 65 years of age and over,
and multivitamin formulations for children 7 years of age and under. All other non-legend items are
excluded.
B. Formulary: None.
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.
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
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:
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)
Laboratoly &
X-ray Service X X X X
Skilled Nursing
Home Services X X X
Physician services X X X X
Dental Services X
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
Ill. Administration:
By the Department of Health and Rehabilitative Services. Claims processing and payment by Contract with
fiscal agent.
B. Formulary: None.
1. Prescribed drugs covered up to $22 per recipient per month ($33 if the recipient is in a nursing
home), limited to legend drugs within program limits plus insulin. Greater expenditures require
prior authorization by the program. Prescription limits effective January 1, 1989: 6
prescriptions monthly for walk-in patients; 8 prescriptions per month for institutionalized
patients.
2. The recipient must present a monthly eligibility card to the provider and must then use the
same provider for the entire calendar month.
3. Maintenance medication should be dispensed and billed for at least a one-month supply.
4. Refills must be authorized by the prescriber and can be made for up to one year, except that
controlled substances can be refilled only in accordance with federal and state regulations.
5. Drugs with questionable efficacy, as rated by the FDA (DESI), are disallowed.
6. Investigational, experimental, blood derivative (e.g. for hemophilia), and appetite suppressant
items are not covered, nor are drugs that are prescribed for other than their approved
indications.
Florida - 3
V. Miscellaneous Remarks:
D. Claims Processor
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
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
ill. Administration:
By the Department of Medical Assistance.
V. Miscellaneous Remarks:
State MAC List = federal MAC plus 85 additional drugs
HAWAII
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
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
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
Administration:
By the State Department of Social Sewices and Housing through its Public Welfare Division and four County
branch offices.
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.
IDAHO
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
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
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.
C. Prescribing or dispensing limitations: Prescription drugs are limited to a 34 day supply with limited
exceptions.
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
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
ILLINOIS
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
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
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
I. Administration:
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.
Ron Gottrich
P.O.Box 19117
Springfield, Illinois 62794-9117
2171782-7532
2. Quantity: A prescription may be refilled only if the prescribing practiiioner has so authorized
on the original prescription. A prescription may be refilled no more than twice and no later
than 3 months from the date of the original prescription. Maintenance Rx's may be refilled for
up to one year.
D. Prescription Charge Formula: Lowest of I ) usual and customary, 2) Department's MAC plus fee.
Professional fee: $3.47.
V. Miscellaneous Information:
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.
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.
Consultants:
lPhA Representative:
IDPH Representative
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
INDIANA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()
Laboratory &
X-ray Service
skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services X X X X
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
Ill. Administration:
The lndiana State Department of Public Welfare.
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
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
. Administration:
A. General Exclusions (diseases, drug categories, etc.): Most non-legend drugs, amphetamine products,
laxative drugs, and legend multiple vitamins require prior authorization.
The lowa Department of Human Sewices adopted an administrative rule which permits coverage for
the following non-prescription drugs.
B. Formulary: None.
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.
V. Miscellaneous Remarks:
Co-payment: $1.00'
Unisys Corporation
P.O. Box 10394
Des Moines, lowa 50306
$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
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
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
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
KANSAS
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
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
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
Ill. Administration:
State Department of Social and Rehabilitation Services.
A. Prescribed drugs. Covered are: (a) legend drugs in a drug list approved by the state Medicaid
agency, excluding drugs that the agency finds ineffective or possibly effective; and (b) selected
nonlegend drugs, devices, and supplies when prescribed for diseases and conditions specified in
the state's Medicaid regulations.
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:
Department Representatives
210
NPC - 1989 Kansas - 4
KENTUCKY
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()
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
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
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.)
4. Drugs not included on the Kentucky Medical Assistance Program Drug List (unless
prsauthorized according to established guidelines and criteria).
5. Medications and supplies used or dispensed by physicians or dentists during home or office
calls.
6. Most non-legend (over-the-counter) drugs except those used to treat diabetes and iron
deficiency anemia, enteric coated aspirin, and buffered aspirin.
6. Formulary: Yes. The list is revised in accordance with recommendations of the Formulary
Subcommittee and in accordance with available funds.
1. Quantity of Medications: For designated classes of maintenance drugs, refills of the original
prescription and subsequent prescriptions for these drugs must be prescribed and dispensed
in quantities of not less than a thirty-day supply unless the prescriber requests an exception
to this policy.
2. Refills: No prescriptions may be refilled more than 5 times or more than 6 months after the
prescription is written.
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:
1. Officials:
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
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
LOUISIANA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
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
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
. Administration:
Public assistance programs are administered by the Department of Health and Hospital.
A. Restricted Formulary.
I. Quantity of Medication: New prescription must be issued for drugs given on a continuing
basis, after 5 refills or after 6 months.
Maximum payment quantity for prescriptions shall be either one month's treatment or 100 unit
doses.
2. Refills: Permitted as indicated by physician within 6 months and not to exceed 5 refills
4. Formulary: Yes.
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
MAINE
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
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
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
Ill. Administration:
A. General Exclusions:
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.
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:
Medical Consultants:
MARYLAND
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()
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.
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
Administration:
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.
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:
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.
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
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
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
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
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
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
Michael J. Weinfeid
14600 Falling Leaf Way
Darnstown, MD 20878
Ex Offcio Members:
MASSACHUSms
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
Laboratory &
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X
Physician Services X X X X X X X X X X
Dental Services X X X X X X X X X X
1987 1988
Expended Recipient Expended Reci~ient
TOTAL $89,829,373 393,742 $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
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.
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.
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.
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
I. Welfare Department:
Carmen CaninoSiegrist, Commissioner Department of Public Weifare
600 Washington Street
Boston, MA 021 1 1
Michigan - 1
MICHIGAN
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XD()
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
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
Ill. Administration:
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.
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
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.
V. Miscellaneous Remarks:
MINNESOTA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
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
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
Ill. Administration:
Minnesota Department of Public Welfare, Income Maintenance Division, Medical Assistance Program.
A. General Exclusions: Certain non-legend, cosmetic, anorectic and nutritional items are not covered.
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).
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
' 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
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.
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
1. Quantity of Medication: Prescription or refill quantities should not exceed the amount shown
in the maximum units column of the formulary. Prescriptions limited to five (5) per month per
recipient (effective 7/1/89).
2. Refills: Prescription refills are limited to three (3), except for maintenance type prescriptions
with a limit of 5. Authorization is required in writing by the prescriber. There are no refill
restrictions on insulin, and no refills are allowed on telephoned prescriptions.
-
NPC - 1989 Mississippi - 3
3. Injections: The Medicaid program will not reimburse drug providers for injectable medications
except for insulin and injectable medications prescribed for residents of nursing homes, and
for those in private homes if the individual is receiving Home Health Services under an
approved plan of treatment. injectable Antipsychotic shall be an exception.
1. Legend Drugs - reimbursement for all legend drug claims is based on the lower of:
a. MACIEAC (ingredient cost) determined for the drug in the quantity dispensed, plus $3.75
dispensing fee (effective 7/1/89). Dispensing physicians receive a fee of $2.63 (effective
7/1/89).
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:
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.
MISSOURI
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
-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
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
II. Administration:
A. General Exclusions:
B. Formulary: Formulary lists 402 drugs by generic names or trade names. For information contact:
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,
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
Under revision.
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
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
NEBRASKA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
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
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
Ill. Administration:
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:
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.)
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.
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.
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.
1. Retail Pharmacies
NPC - 1989 Nebraska - 4
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.
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.
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.
(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
(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.
Under no circumstances, may charge exceed the usual and customary charge to the
general public.
1. Product Cost (FUL, SMAC or EAC) plus the appropriate dispensing fee@), or
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.
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.
NEVADA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
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
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
Ill. Administration:
State Welfare Division of the Department of Human Resources.
A. General: Pharmaceuticals
Covered: The Nevada Medicaid drug program will pay for the following prescribed pharmaceuticals:
1. Most legend pharmaceuticals
2. Insulin
3. Diabetic urine test tablets and test tapes.
4. Prenatal vitaminlmineral supplements, legend or non-legend, intended for prenatal care.
5. Family planning items such as diaphragms, oral contraceptives, foams and jellies.
Excluded: 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):
Formulary: None. (Certain Rx categories are excluded from reimbursement. See Section A above.)
1. Prescriptions. Eligible Medicaid recipients may receive five out-patient prescriptions per month
plus those issued for EITHER prenatal OR family planning purposes. For special authorization
procedures, see 1203.3.
2. Refills. A refill is a prescription subject to the limitations in paragraph A above.
Zeny Ocean, D.D.S., Chair. Sue Coons, Chair. George Harvey, R.Ph., Chair.
Dental Comm. Consumer Recip. Comm. Pharmacy Comm.
NEW HAMPSHIRE
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
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
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
Ill. Administration:
A. General Exclusions: Anorexiant (stimulants) except for treatment of narcolepsy and hyperkinetic
children.
B. Formulary: None.
$2.85/$3.00 fee plus Estimated Acquisition Cost (EAC) or HCFA upper limit or Usual and Customary
Charge, whichever is less.
Maintenance medications are reimbursed by the above formula once every thirty days per recipient
per provider: any refills of maintenance medications within 30 days are reimbursed at cost only.
Co-payment: $0.50 generic, $1.00 brand name multisource, except nursing home patients, under
18 years, family planning and pregnancy prescriptions.
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.
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
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:
B. Formulafy: None.
Exceptions:
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.
1. Payment for legend drugs, contraceptive diaphragms and reimbursable devices shall be based
upon 'Maximum Allowable Cost," or Average Wholesale Price minus 0 - 6%.
(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:
V. Miscellaneous Remarks:
Co-payment: None
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.
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
NEW MEXICO
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
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
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
Ill. Administration:
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.
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
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.
V. Miscellaneous Remarks:
NEW YORK
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
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
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
Ill. Administration:
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.
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.
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.
Co-payment: None
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
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
Ill. Administration:
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.
2. Number of Prescriptions:
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:
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:
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
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
NORTH DAKOTA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XK)
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
I987 1988
Expended Recipient Expended Recipient
TOTAL $7.51 6,587 27,651 $7,797,307 29,284
CATEGORICALLY NEEDY CASH TOTAL 3,756,880 16,700
Aged 1,882,679 2,481
Blind 10,545 20
Disabled 1,489,618 2,758
Children -Families wiDep. Children 371,476 6,937
Adults -Families w/Dep. Children 502,562 4,504
CATEGORICALLY NEEDY NON-CASH TOTAL 329,166 3,060
Aged 51,648 61
Blind 0 0
Disabled 73,221 160
Children -Families w/Dep. Children 74,286 1,283
Adults -Families wiDep. Children 90,908 756
Other Title XIX Recipients 39,108 820
MEDICALLY NEEDY TOTAL 3,694,857 9,261
Aged 2,820,286 5,140
Blind 3,504 1
Disabled 679,127 1,234
Children -Families w/Dep. Children 67,309 986
Adults -Families w/Dep. Children 75,146 870
Other Title XIX Recipients 49,485 1,020
111. Administration:
A. General Exclusions:
1. Anorectics
2. High protein weight reduction supplements
3. Investigational drugs
4. Drugs which have questionable therapeutic value
5. Drugs which are not indicated for the diagnosis
6. DESl (Less-Than Effective) drugs
7. OTCs - except antacids and oral analgesics
B. Formulary: None
2. Refills: A prescription drug may be refilled up to 5 times or for 12 months after the date of
the original prescription, whichever occurs first, and provided that such refills have been
authorized by the physician.
D. Prescription Charge Formula: Acquisition Cost plus $3.75 dispensing fee per prescription or usual
and customary retail charge, whichever is lower.
V. Miscellaneous Remarks:
Co-payment - None
Officials, Consultants and Committees
NE Byestol, MD, Chair J.E. Adducci, M.D. J.J. McLoed, Jr., M.D., Vice Chair.
Dakota Clinic, Ltd. Box 2438 Orthopaedic Clinic, P.D.
Fargo, ND 58108 Williston, ND 58801 Grand Forks, ND 58201
C.S. Hamilton, Jr., MD K.S. Helenbolt, M.D. J.R. Herr, Jr., M.D.
Fargo Clinic Blue Shield - ND 1213 15th Avenue West
Fargo, ND 58123 4510 13th Avenue, SW Williston, ND 58801
Fargo, ND 58121
OHIO
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Sewices X X X X
Physician Sewices X X X X
Dental Sewices X X X X
1987 1988
Expended Recipient Expended Recipient
TOTAL $150,570,202 780,600 $152,609,139 757.81 8
CATEGORICALLY NEEDY CASH TOTAL 94,238,763 608,980
Aged 10,556,077 21,215
Blind 477,640 985
Disabled 43,115,756 78,210
Children -Families w/Dep. Children 13,372,864 317,885
Adults -Families w/Dep. Children 26,716,426
190,685CATEGORICALLY NEEDY NON-CASH TOTAL 58,370,376 148,838
Aged 36,231,512 58,876
Blind 200,365 346
Disabled 18,061,151 27,130
Children -Families w/Dep. Children 940,926 20,514
Adults -Families w/Dep. Children 1,471,120 14,214
Other Tile XIX Recipients 1,465,302 27,758
MEDICALLY NEEDY TOTAL 0 0
Aged 0 0
Blind 0 0
Disabled 0 0
Children -Families wiDep. Children 0 0
Adults -Families w1Dep. Children 0 0
Other Title XIX Recipients 0 0
Ill. Administration:
A. General Exclusions: For prescription legend and/or OTC drugs not listed in the formulary, pharmacist
should obtain authorization before filing claim for payment.
To promote economies in the drug program, practitioners are encouraged to prescribe by generic
name those drugs which consistently demonstrate therapeutic effectiveness and are produced by
pharmaceutical manufacturers with strict quality controls. In filling such generic prescriptions the
pharmacist is expected to dispense the least expensive drug available in his stock. The maximum
price allowed for such generics will be an amount calculated at the 65th percentile of those generics
readily available to Ohio pharmacy providers.
A drug code is listed in the Ohio Welfare Drug Formulary for each form of generic drug. Trade
names for some of these approximately 900 drug items are also contained in the formulary.
I. Quantity of Medication:
2. Refills: 11 for non-controlled drugs up to one year. 13 for birth control drugs up to one year.
Five for Scheduled Ill, IV, V drugs up to six months. None for Scheduled II drugs.
1. Legend drugs and selected OTC products. Reimbursement based on the lowest of:
a. the provider's submitted charge, which should reflect his usual and customary charge
to the general public;
b. the Department's Estimated Acquisition Cost (EAC) (AWP minus 7% plus a dispensing
fee, or direct price if applicable, plus a dispensing fee; or
NPC - 1989 Ohio - 3
Herbert E. Gillen
Executive Director Ernest "Ernie" Boyd
OH State Medical Assn. Executive Director
1500 Lakeshore Drive OH State Pharmaceutical Assn.
Columbus, OH 43204 395 E. Broad Street, Suite 320
6141486-2401 Columbus, OH 43215
6141464-1874
OKLAHOMA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
Laboratory &
X-ray Service
skilled Nursing
Home Services X X X X X X X X X
Physician Services X X X X X X X X X
Dental Services X X X X X X X X X
1987 1988
Expended Recipient Expended Recipient
TOTAL $31,075,003 154,369 $34,096,431 158.472
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL $7,724,937 28,364 9,297,038 30,516
Aged 6,136,292 16,994 7,096,047 15,636
Blind 3,991 15 5,475 19
Disabled 1,253,037 4,100 1,625,502 3,911
Children -Families w/Dep. Children 269,794 6,286 275,480 6,887
Adults -Families w/Dep. Children 47,417 648 99,226 1,083
Other Title XIX Recipients 14,406 457 195,308 3,811
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
111. Administration:
Provider Participation:
1. Pharmacy or Pharmacist:
Any pharmacy or pharmacist who has current license with the Oklahoma State Board of Pharmacy and
is free from any Pharmacy Board restrictions shall be entitled to be a participating provider under this
program.
2. Prescribing Practitioners:
Prescribing practitioners, authorized and licensed to practice the healing art as defined and limited by
Federal and state laws who choose to provide their own pharmaceuticals, may not be participating
providers at the present time.
3. Reimbursement Fee:
Estimated Acquisition Cost (EAC) plus maximum dispensing fee of $3.55 effective 11/1/81. In no event
shall charges to the Welfare Department exceed charges made to the general public for the same
prescription or item.
Those drugs that are compensable under each category are specified individually by trade name;
otherwise by generic name only.
Antidiarrheals Antiparkinsonism
Broncho-Dilators & Antiasthmatics Antidepressants
Opthalmic Antiarthritics
Antibiotics (Oral & Injection) Glaucoma Drugs
Antibacterials (Oral & Injection) Otic
Antineoplastics (Oral & Injection) Antigout
Birth Control Analgesics
Antinauseants, AntivertigolAntiemetic Anticonvulsants
Insulin & Antidiabetics Drugs Antifungal
Cardiovascular-Broad & Potassium Preparation Specialized Preparations
Three prescriptions per monthirecipient, for outpatients. ICF-MR and nursing home recipients are
limited to 5 per month.
NPC - 1989 Oklahoma - 3
6. Quantities:
34-day supply.
8. Refills:
Refills shall be provided only if authorized by the prescriber, no more than 1 year.
OREGON
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()
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
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 Tile XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Tile XIX Recipients
Ill. Administration:
B. Non-Formulary: Prior approval from state reviewing physician must be obtained for minor tranquilizers
other then (generic) meprobamate or chlordiazepoxide, and amphetamines and amphetamine
derivatives, isotrenition, legend laxatives, pentamidine, ATT, Persantine, and certain non legend items.
I. Quantity of Medication: Not to exceed 100 days supply, except topical preparations, sprays,
aerosol inhalers, and birth control tablets.
Estimated acquisition cost (EAC) defined as the lesser of: (1) 89% AWP or direct price (9 selected
companies) (2) the Oregon MAC or HCFA upper limits for multiple source drugs or (3) the usual and
customary charge plus a dispensing fee of $3.52 or $3.83.
Richard J. Cook, D.D.S. Donald Charlton, MD Edward Hendricks, MD, MPH, Dir.
Robinhood Prof. Bldg. 943 Liberty Street, SE 203 Public Service Bldg.
18603 Pacific Highway Salem, OR 97302 Salem, OR 97310
West Linn, OR 97068
a
NPC - 1989 -
Oregon 3
PENNSYLVANIA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
Laboratory &
X-ray Service
Skilled Nursing
Home Services X X X X X X X X X X
Physician Services X X X X X X X X X X
Dental Services X X X X X X
1987 1988
Expended Recipient Expended Recipient
TOTAL $143,387,994 693,928 $157,192,136 679,852
CATEGORICALLY NEEDY CASH TOTAL 113,061,666 548,906
Aged 21,318,166 41,337
Blind 483,505 1,011
Disabled 55,135,936 100,999
Children -Families w/Dep. Children 14,679,275 264,498
Adults -Families w/Dep. Children 21,444,764 146,835
CATEGORICALLY NEEDY NON-CASH TOTAL 44,021,589 158,849
Aged 29,641,992 50,921
Blind 4,571 16
Disabled 9,472,769 15,909
Children -Families w/Dep. Children 1,445,997 37,311
Adults -Families w1Dep. Children 1,648,933 20.1 59
Other Title XIX Recipients 1,807,327 36,768
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
Ill. Administration:
public or private health insurance plans or programs which make payments to pharmacies on
behalf of eligible recipients or beneficiaries. As a result of this revised payment methodology,
pharmacies-are reimbursed an additional amount not to exceed 25 cents for each welfare
prescription that would ordinarily be paid on a usual and custornary basis. The amount of the
total payment will not exceed the cost of the drug plus the dispensing fee.
2. A licensed retail pharmacy's maximum reimbursement for all compensable legend and
nonlegend drugs shall be the cost of the drug plus a $2.75 disDensinq fee or the pharmacy's
usual and customary charge to third party payors, whichever is lower. For purposes of Medical
Assistance reimbursement, the usual and customary charge to third party payors may not
exceed 25 cents per prescription higher than the usual and customary charge to the self-
paying public. The cost of the drug shall be either the MAC, EAC, or AWP. Although payment
shall be made in accordance with this method of payment, the pharmacy is required to bill
the Department at its usual and custornary charge to the self-paying public.
NPC - 1989 Pennsylvania - 6
3. For compound prescriptions, an additional fee of $1.OO is allowed to a pharmacy, bringing the
total dispensing fee to $3.75. A compound prescriptionfor the purposes of medical assistance
payment is one which is prepared at the time of dispensing and involves the weighing of at
least one solid ingredient which must be a compensable item or a legend drug in a therapeutic
amount.
4. The federal MAC program has been in effect since September I , 1978.
5. The EAC program has been in effect since July I, 1984
6. The state MAC program has been in effect since March 15, 1987.
Copayment $0.50
On September I,1984, Pennsylvania implemented a 50 cent copayment for each prescription, new or refill,
received by a recipient. The copayment will apply to those recipients who are federally exempt, under
21 years of age, pregnancy cases and long-term care patients, plus patients receiving drugs in the following
categories:
Antihypertensive agents
Cardiovascular preparations
Antiphychotic agents (excluding Schedule C-IV anti-anxiety agents
Antidiabetic agents
Anticonvulsants
Antineoplastic agents
Antiglaucoma agents
Antiparkinson agents
VI. Recipient Lock-In Program
The Computer Company's chief responsibility is clerical in nature and deals with claims processing
only, i.e., opening of mail, key punching claim information, microfilming, etc. All claims resolutions
and problems are handled by the department's in-house data facilities.
Pennsylvania - 7
2. Consultant Pharmacists:
PA Forum for Primary Health Care Eagleville Hospital Alma llery Medical Center
Hubert Gordon Fred Carey Wilfred Payne
Executive Director Chief Executive Officer 7227 Hamilton Avenue
1017 Mumma Road Eagleville, PA 19408 Pittsburgh, PA 15208
Worrnleysburg, PA 17043
RHODE ISLAND
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Laboratory &
X-ray Service
Skilled Nursing
Home Services X X X X X X X X X
Physician Services X X X X X X X X X
~ e i l t aServices
l X X X X X X X X X
1987 1988
Expended Recipient Expended Recipient
TOTAL $14,426,849 73,127 $15,934,358 72,899
CATEGORICALLY NEEDY CASH TOTAL 8,512,606 55,961 9,442,700 56,313
Aged 1,705,462 4,031 2,056,620 5,494
Blind 55,480 180 67,987 174
Disabled 4,145,668 10,717 4,720,407 11,167
Children -Families w/Dep. Children 966,043 24,435 1,001,870 24,427
Adults -Families w/Dep. Children 1,639,953 15,598 1,595,816 15,051
CATEGORICALLY NEEDY NON-CASH TOTAL 2,717,544 7,720 2,605,268 6,923
Aged 1,818,220 5,165 1,431,209 3,803
Blind 8,644 25 9,017 24
Disabled 760,448 2,160 1,010,977 2,687
Children -Families wIDep. Children 36,076 103 42,676 114
Adults -Families w/Dep. Children 61,243 174 72,457 192
Other Title XIX Recipients 32,913 93 38,932 103
MEDICALLY NEEDY TOTAL 3,196,700 9,446 3,886,390 9,663
Aged 2,483,835 6,976 2,995,629 7,181
Blind 7,033 18 7,773 20
Disabled 668,430 1,658 841,015 1,805
Children -Families w/Dep. Children 17,582 570 15,157 457
Adults -Families w/Dep. Children 19,820 224 26,816 200
Other Title XIX Recipients 0 0 0 0
Ill. Administration:
General Exclusions:
Prior authorization is required for all injectables (excluding insulin and adrenalin), appetite
depressant drugs, central nervous system stimulants, expensive vitamins, hematinics and
lipotropic preparations (selling for over $10 per I 0 0 tabiets/capsules or pint), expensive and/or
new preparations.
Prescribed drugs requiring prior authorization may be refilled if requested by the attending physician
and approved by the Division of Medical Services.
Formulary: None
2. Maintenance Medication: The attending physician may prescribe certain maintenance drugs
of 100 tablets, capsules or pint of liquid or a 30-days' supply of these drugs --whichever is
greater.
3. Refills: Refills to a maximum of five are allowed for specified drugs: anti-hypertensives,
diuretics, anti-convuisants, coronary vasodilators, tranquilizers, antidepressants, hormones,
antibiotics, etc.
Refills are not allowed for specified drugs, e.g., central nervous system stimulants, narcotics
(Schedule 11, Ill), Corticosteroids, appetite depressants and pentazocine.
A Professional Fee for Service of $3.40 will be allowed for all prescriptions in addition to the
cost of the drug.
In accordance with federal regulation the upper limit for payment for prescribed drugs will be
based upon the amount allowed by the Medical Assistance Program or the usual and
customary charge to the general public, whichever is lower.
NPC - 1989 Rhode Island - 3
Payment for over-the-counter drugs (non-legend drugs) will be based upon the lower of either
the allowable cost of the drug plus 50 percent, the usual and customary charge to the general
public, or the allowable cost plus the Professional Fee for Service.
A Special Professional Fee for Service of $2.85 will be allowed for these prescriptions in
addition to the cost of the drug to the pharmacist.
In accordance with federal regulation the upper limit for payment for prescribed drugs will be
based upon the amount allowed by the Medical Assistance Program or the usual and
customary charge to the general public, whichever is lower.
Payment for over-the-counter drugs (non-legend drugs) will be based upon the lower of either
the allowable cost of the drug plus 50 percent, the usual and customary charge to the general
public, or the allowable cost plus the Professional Fee for Service.
3. The estimated acquisition cost for products manufactured by the following pharmaceutical
companies is the direct reimbursements:
Miscellaneous Remarks:
NPC - 1989 Rhode Island - 4
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
I987
Expended Recipient
TOTAL $32385,360 187,520
CATEGORICALLY NEEDY CASH TOTAL $28,508,890 168,211
Aged 8,841,772 30,616
Blind 419,409 1,541
Disabled 14,628,548 47,765
Children -Families w/Dep. Children 1,720,876 53,380
Adults -Families w/Dep. Children 2,898,283 35,560
CATEGORICALLY NEEDY NON-CASH TOTAL $3,831,936 22,233
Aged 2,681,176 7,713
Blind 7,809 20
Disabled 745,341 1,970
Children -Families w1Dep. Children 181,013 6,160
Adults -Families w/Dep. Children 181,991 5,535
Other Title XIX Recipients 34,603 863
MEDICALLY NEEDY TOTAL $44,533 1,930
Aged 0 0
Blind 0 0
Disabled 0 0
Children -Families w/Dep. Children 0 0
Adults -Families wIDep. Children 13,791 609
Other Title XIX Recipients 30,741 1,327
Ill. Administration:
A. Scope of Non-Formulaty Drug Program - Effective October 1, 1984, providers will be reimbursed for
most legend drugs and for certain non-legend (OTC) drugs within the three prescription limit.
Exclusions to this coverage are as follows:
Adult vitamins and vitamin combinations; (Prenatal vitamins for females, fluoride vitamins for
children and Rocaltrol for renal patients are covered.)
Experimental drugs;
Drug Efficacy Study Implementation (DESI) Drugs. Drugs determined by the Food and Drug
Administration (FDA) to be ineffective are not reimbursable by Medicare or Medicaid.
In acute conditions, physician requested to limit supply to a minimum of ten (10) days. In
chronic conditions and for maintenance drugs, a minimum of a thirty (30) day supply where
appropriate, a ninety (90) day supply maximum is allowed and encouraged.
2 Refills:
Medicaid reimbursement for pharmacy sewices will be based on the lower of: the South Carolina
Estimated Acquisition Cost (SCEAC): federal maximum allowable cost (MAC), AWP minus 9.594, or
the provider%submitted usual and customary charge.
Miscellaneous Remarks:
SOUTH DAKOTA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()
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
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
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
Ill. Administration:
A. Exclusions: The program is limited to legend prescription drugs as specified in the state's Medicaid
regulations, and to insulin.
B. Formulaly: Generic mandate deleted on Janualy 1, 1988. FUL prices plus 40 state MAC prices now
apply.
1. Quantity: Maintenance drugs requiring more than one dose per day must be dispensed in
units of at least 100 or a 30 day supply, if more than 100 unit are required per month.
Maintenance prescriptions for family planning items must be dispensed in at least a 3 month
supply. (New family planning prescriptions can be in smaller units.)
D. Prescription charge formula: Payment is the lower of: (a) FUL, state MAC plus dispensing fee of
$4.25, (b) EAC plus dispensing fee of $4.25, or usual and customaly charge to the general public.
EAC = AWP minus 10.5%.
V. Miscellaneous
'Cost sharing for prescriptions is $1.00 for each prescription and $1.00 for each prescription refilled."
(Exemptions include patients under 18 years, residents of home or community-based services, services
related to pregnancy, residents of long term care facilities, family planning and emergency hospital services.)
TENNESSEE
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
I. BENEFITS PROVIDED AND GROUPS ELIGIBLE
1987 1988
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 w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
/
1
Ill. Administration:
Tennessee Department of Health and Environment
V. Miscellaneous
Fiscal Intermediary: The Virginia Computer Company
729 Church Street
Nashville, TN 37219
1. Health Depanment:
A. Officials:
J. W. Luna, M.P.H., Commissioner TN Dept. of Health/Environment
344 Cordell Hull Building
Nashville, TN 37219
NPC - 1989 Tennessee - 3
I Cornrnunily Pharmacist
Horton Jones, D.Ph.
Clinical/lnstit. Pharm.
Terry Brimer, Pharm.D.
Institutional Pharmacist
Dianna C. Drake, D.Ph.
P
Jones Pharmacy Dr.s' Hospital Pharmacy 1100 Shadyland Drive
14th and Buchanan St 726 McFarland Avenue Knoxville, TN 37919
Nashville, TN 37208 Morristown, TN 37813
x
Tennessee - 4
NPC - 1989
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
Ill. Administration:
Pharmacy services under the vendor drug program include the dispensing of most legend drugs and certain
non-legend drugs to eligible recipients. Only pharmaceuticals which meet the FDA requirements, are
approved for marketing and are approved by the Texas Department of Human Services for use in the
vendor drug program, may be supplied.
Certain OTC drugs are covered on a prescription basis except as otherwise provided in the reimbursement
formula and vendor payment to hospitals, nursing homes and institutions.
A. General Exclusions (diseases, drug categories, etc.): Adult vitamins and adult vitamin combinations,
amphetamines and obesity control drugs, appliances, durable medical equipment (bedpans, etc. -
either rental or purchase), elastic stockings, experimental drugs, fertility agents, first aid supplies,
foods, food supplements or additives, immunizing agents, medical supplies, oxygen, supports and
suspensories, syringes, needles and trusses.
B. Formulary: None. However, the Texas Drug Code Index is utilized for product identification and
claims processing and contains those drugs which are covered under the program.
$3.26 average dispensing expense (ADE) formula for payment: (EAC + 3.26) divided by 0.945
= amount paid + $.I0 delivery service.
V. Miscellaneous Remarks:
The dispensing fee, which includes all costs of filling a prescription, was established by cost accounting
and service evaluation of the expenses involved in dispensing a prescription. Therefore, fees paid to
providers who do not experience all cost and service factors considered in arriving at the fee, may be less
than the maximum allowable fee.
Copayment - None.
UTAH
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()
Laboratory &
X-rav Service
skilled Nursing
Home Services X X X X X X X X X X
Physician Services X X X X X X X X X X
Dental Services X X X X X X X X X X
Ill. Administration:
Division of Health Care Financing, State Department of Health.
325
VPC - 1989 Utah - 3
VERMONT
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XU()
Laboratory &
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X X
Physician Services X X
Dental Services X X X X X X X X X X
-
3 F 0 State Funds Only
1987 1988
Expended Recipient Expended Reci~ient
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep.children
Other Title XIX ~ e c i ~ i e n t s
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
I. Administration:
Program allows the weKare recipient to have free choice of physicians and pharmacists; lock-in provision
for mis-utilizers.
A. General Exclusions: prior authorization is required for therapeutic vitamins, cathartics, antacids,
analgesics and fecal softenen.
The National Drug Code Directory is now being used as a drug manual for coding purposes. For
information or submissions contact:
Stan Lane
Health Department
60 Main Street
Burlington, VT 05401
8021663-7200
V. Miscellaneous
Fiscal Intermediary: EDS Federal
P. 0. Box 1102
South Burlington, VT 05401
Laboratory &
X-ray Service X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X
Physician Services X X X X X X X X X
Dental Services All eligible recipients under age 21
I987 I988
Expended Recipient Expended Recipient
TOTAL $55,496,164 232.173 $63,203,806 236,909
CATEGORICALLY NEEDY CASH TOTAL $40,934,813 189,808 46,745,814 187,046
Aged 14,550,263 32,201 16,789,917 32,877
Blind 346,650 896 389,944 883
Disabled 16,923,427 37,119 20,047,174 39,030
Children -Families w/Dep. Children 3,439,629 72,670 3,633,074 69,877
Adults -Families w/Dep. Children 5,674,845 46,922 5,885,705 44,379
CATEGORICALLY NEEDY NON-CASH TOTAL $1,817,028 16,241 2,472,557 22,129
Aged 688,828 1,304 906,777 1,536
Blind 9,681 22 13,767 29
Disabled 395,910 644 440,458 724
Children -Families w/Dep. Children 122,460 2,914 228,462 5,080
Adults -Families wjDep. Children 299,568 5,547 457,696 7,262
Other Title XIX Recipients 300,580 5,810 425,397 7,498
MEDICALLY NEEDY TOTAL $12,744,323 26,124 13,979,504 27,417
Aged 10,169,033 15,685 11,068,185 16,097
Blind 56,458 92 63,774 93
Disabled 2,148,301 3,385 2,410,493 3,532
Children -Families w/Dep. Children 277,127 4,885 301,126 4,821
Adults -Families w/Dep. Children 41,310 1,007 54,892 1,210
Other Title XIX Recipients 52,094 1,070 81,054 1,664
Ill. Administration:
By the Department of Medical Assistance Services. Eligibility determination by the Department of Social
Services.
A. General Exclusions: Non-legend drugs except family planning drugs and supplies, insulin, insulin
syringes and needles; and effective July 1, 1989, diabetic test strips for recipients under 21 years
of age. Anorectic drugs and designated DESl drugs; and effective July 1, 1989, transdermal delivery
systems.
B. Formulary: None.
State Reimbursement - Based upon the lower of MACIEAC plus fee if legend or usual and customary
charge minus applicable co-pay
1. All providers of unit-dose must be certified by Medicaid program - for computer purposes.
2. Unit-dose applies to tablets and capsules and oral liquid dosage forms. Each t a l a or
capsule or 10 ml oral liquids.
Legend Drugs:
One dispensing fee per legend drug per month. Previously applicable to dispensing for services to
nursing home recipients; effective July 1, 1989, applicable to dispensing for services to
noninstitutionalized recipients.
NPC - 1989 Virginia - 3
V. Miscellaneous
Ex Officio:
WASHINGTON
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
Laboratory &
X-ray Service X X X X X X X X X X
Skilled Nursing X X X X X X X X X X
Home Services X X X X X X X X X X
Phvsician Services X X X X X X X X X X
~ e h t aServices
l X X X X X X X X X
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 wIDep. Children
Adults -Families w1Dep. Children
Other Tile XIX Recipients
Optional Categorically Needy
Ill. Administration:
By Division of Medical Assistance, Department of Social and Health Services. The Central Authorization Unit
(CAU) reviews the need for non-formulary drugs.
A. General Exclusions: Medicine chest drugs are not provided. Non-formulary drugs are provided in
an emergent life-endangering situation and/or medically mandatory.
B. Formulary: Includes approximately 2,900 listings by drug product name, quantity, dosage form and
strength. Formulary is revised 2 to 3 times annually.
2. Refills: No more than 2 refills in any 30-day period unless prescription and refills are in amount
of 100's.
D. Prescription Charge Formula: The amount shall not exceed the usual and customary charge to the
public or the maximum allowed by the department.
The maximum charge to the department is to be estimated acquisition cost (EAC) (as determined
by the Division of Medical Assistance) plus a dispensing fee for service.
Effective 9/1/88:
V. Miscellaneous
William P. Pace, R.Ph., Pharmacist Consultant Office of Medical & Program Policy
2061753-0524 HB-41
Olympia, WA 98504
-
Joan Baumgartner, MD State Office, Olympia Wesley M. Brock, M.D. - State Office, Olympia
-
Michael D. McGee, MD State Office, Olympia James A. Moore, MD - State Office, Olympia
Part-time:
-
James B. Hutchinson, DDS (Dental) State Office Olympia
Curtis C. Sapp, DDS (Orthodontia) - State Office Olympia
Jerrol R. Neupert, MD (Opthomalogy) - Seattle
Members:
Ron W. Kero, Director Debbie Meyer, Secretary Steve Peterson, Acting Chief
Division of Medical Assistance Div. of Medical Assistance Off. Analysis/Medical Review
HE41 HB-41 HA-41
Olympia, WA 98504 Olympia, WA 98504 Olympia, WA 98504
James A. Peterson, Assist. Dir. Tom Bedell, Acting Chief Jeffery J Graham, MD'
Div. of Medical Assistance Off. of Provider Services Medical Director
HB-41 HA-11 Off. of Med.lProgram Policy
Olympia, WA 98504 Olympia, WA 98504 HB-41
Olympia, WA 98504
'Responsible for approving new formulary additions.
WEST VIRGINIA
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
Laboratory &
X-ray Service X X X X X X X
Skilled Nursing
Home Services X X X X X X X X
Physician Services X X X X X X X X
Dental Services X X X X X X X X
1987 1988
Ex~ended Recipient Expended Recipient
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
MEDICALLY NEEDY TOTAL
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families wlDep. Children
Other Title XIX Recipients
Ill. Administration:
The Division of Medical Care, Department of Human Services, is the medical assistance unit responsible
for the administration of the Title XIX program. Eligibility for program benefits is determined by the local
Welfare offices for AFDC and medically needy individuals. Individuals eligible for SSI benefits are covered
for Medicaid as categorically needy, aged and disabled.
PROGRAM COVERAGE:
A. Ail covered drugs, whether legend or non-legend, must be prescribed by a physician or other
practitioner qualified under State law. Applicable State and Federal law governing dispensing of
drugs and biologists must be followed:
Drugs identified in the Medicaid Drug Formulaty, listed by product or therapeutic class, are covered
without prior authorization.
COVERED SERVICES:
1. Legend Drugs
2. Non-Legend Drugs
Exception:
Non-legend drug coverage does not apply for clients residing in long-term care facilities
(SNFIICF).
Consideration may be given on special drug needs of a client by the Medical Director on an individual basis
based on medical information supplied by the attending physician in the format specified by the State.
1. Antibiotics and analgesics for chronic usage; i.e., over ten days.
2. Medical supplies and equipment. Medical Supplies; i.e., bandages, colostomy bags, underpads,
and other items required for home care, and covered by the Department based on a treatment plan
developed for the individual client.
NPC - 1989 West Virginia - 3
3. Viiamin/vitamin mineral preparations for End-State Renal Disease patients and other medications
related to End-Stage Renal Disease services.
EMERGENCYCOVERAGE
If a physician determines that a particular drug is needed for his patient which is not included on the
formulary list, and is not excluded from program coverage, and that an emergency situations exists, he may
so indicate by writing "emergency" on the prescription above his signature. These prescriptions will be
covered up to a ten-day supply with no refill. Continuous therapy, if needed, will require prior authorization.
NON-COVERED SERVICES
3. Exceptions:
1. Pharmacy Services: Services are available for certain children under 21 years of age receiving
medical care within the Division of Handicapped Children's Services. These services are not limited
to children of families receiving public assistance grants.
2. Scope of Services: Prescriptions are limited to a one-month supply with maximum of five monthly
refills in any six-month period.
Covered legend and non-legend drugs are payable as prescribed by a licensed practitioner up to
a 30-day supply with a maximum of five refills.
Exception:
1. Antibiotics and analgesics are limited to a maximum of ten days with no refills. (See prior
authorization.)
2. Excluding phenobarbital, sedatives and hypnotics are limited to a maximum of 30 days with
no refills.
1. Maximum reimbursement for each drug claim processed will be based on the lowest of:
(a) The maximum allowable cost (MAC) for each multiple-source drug as defined by the
Pharmaceutical Reimbursement Board and published in the Federal Register plus a
dispensing fee.
Exception: The MAC shall not apply in any case where a physician certifies in his own
handwriting that in his medical judgement a specific brand is medically necessary for
a particular patient. A notation like "brand necessary" written by the physician on the
prescription above the physician's signature is an acceptable certification. A procedure
for checking a box on a form will not constitute an acceptable certification.
All such certified prescriptions must be maintained in the pharmacy files and made
available for inspection by the Department of Health and Human Services and the
Department of Welfare.
(b) The estimated acquisition cost (EAC) for each multiple-source drug as defined by the
State plus a dispensing fee.
(c) The acquisition cost or average wholesale price (AWP) for all other prescribed drugs
plus a dispensing fee.
(d) The usual and customary price charged by the pharmacy to the general public including
any sale price which may be in effect on the date of service.
NPC - 1989 West Virginia - 5
A. For covered legend and non-legend drugs, a professional dispensing fee of $2.75 will. be
added to the Federally established MAC or State-established acquisition cost price of each
prescribed drug.
B. For a compounded prescription, an additional $1.00 will be added to the dispensing fee. A
compound prescription is defined as any legend medicament requiring a combination of any
two or more substances to exclude normal reconstitution operations.
C. Unit dose drug delivery systems are reimbursed under the same provisions as other legend
drug services to Medicaid patients. Legend drugs are reimbursed on a 30-day basis
regardless of drug delivery system or how the pharmacist may choose to dispense.
CO-PAYMENT
A co-payment is required for each prescription filled on and after March 10, 1981, with the exception
of those items specifically excluded from the co-pay requirement. The recipient co-payment per
prescription will be deducted from the maximum allowable payment (prescription charge formula) to
determine the amount payable for each prescription billed to the programs.
I. If the maximum allowable payment is under $10.99, the reduction will be $0.50 per prescription.
2. If the maximum allowable payment is $11.00 or more, the reduction will be $1.00 per
prescription.
V. Miscellaneous:
Regular Members:
Alternate Members:
Pharmacy:
David P. Elliott John W. Chambers, Ph.D. Patrick M. Regan, R.Ph.
Asst. Prof. & Vice Chair. Professor & Chairman Rite Aid Pharmacy # I 634
W V U School of Pharmacy Dept. of Pharmacology 8333 Court Avenue
3110 MacCorkle Avenue, SE WV School/Osteopathic Med Hamlin, WV 25523
Charleston, WV 25304 400 North Lee Street
Lewisburg, WV 24901
Tom Carson, R.Ph.
College Drug Store Roger Shallis, R. Ph.
Drawer 50 South Berkeley Pharmacy
Montgomery, WV 25136 Inwood, WV 25428
Medicine: Chairman:
Shirley Neitch, MD Douglas Glover, MD, R.Ph. John P. Hutton, MD
Assoc. Prof. of Medicine Dept. of OBIGYN Clinical Director
Chief, Section of Geriatrics WV University Medical Ctr. Shawnee Hills Community
Marshall Univ. Sch. Medicine Morgantown, WV 26506 Mental Health Center
Huntington, WV 25701 51I Morris Street
Charleston, WV 25301
James T. Hughes, MD Richard G. Starr, MD
Internist Internist Patricia Jones
Jackson Medical Center 220 Professional Park Rt. 1, Box 319-A
Ripley, WV 25271 Beckley, WV 25801 Charleston, WV 25312
James H. Walker, M.D. Ann Bond Smith, R.Ph. J. L. Mangus, M.D., R.Ph.
Acting Medical Director Division of Medical Care Medical Director
Div. Handicapped Children's Sew. Dept. of Human Services Division of Medical
Dept. of Human Services Dept, of Human Services
C. Jean Cebula, R.N. Laurie Tully, R.N. Joan Faris, R.N., M.S.N.
Division of Medical Care Handicapped Children's Sew. Office of Behavioral Health Services
Dept, of Human Services Dept. of Human Services Dept. of Health
WISCONSIN
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
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
1987
Expended Reci~ient
TOTAL $66,232,967 281,675
CATEGORICALLY NEEDY CASH TOTAL $37,643,353 228,668
Aged 8,140,516 23,018
Blind 306,064 868
Disabled 20,884,881 46,836
Children -Families w/Dep. Children 3,533,171 95,992
Adults -Families wIDep. Children 4,778,721 63,626
CA~EGORICALLYNEEDY NON-CASH TOTAL $25,959,037 97,538
Aged 18,200,002 35,542
Blind 14,873 33
Disabled 5,086,247 9,039
Children -Families w1Dep. Children 619,470 26,468
Adults -Families w/Dep. Children 894,851 23,317
Other Title XIX Recipients 1,143,594 4,496
MEDICALLY NEEDY TOTAL $2,630,577 12,537
Aged 1,506,102 5,358
Blind 7,949 18
Disabled 970,132 2,886
Children -Families w/Dep. Children 111,496 3,851
Adults -Families w/Dep. Children 33,123 453
Other Title XIX Recipients 1,775 30
Ill. Administration:
General Exclusions:
Formulary: No. Negative formulary includes (1) Alginic acid containing antacids; (2) propoxyphene
napsylate; (3) quinine sulfate; (4) progesterone for PMS; (5) chlordiazepoxidelamitriptyline combos;
(6) papa~arinehydrochloride.
1. Quantity of Medication: Pharmacists may not dispense more than 34-day supply of a legend
drug. Certain exceptions for maintenance drugs (100 day supply).
1. Traditional (non-unit dose) dispensing reimbursed at the lowest of: Estimated Acquisition Cost
(EAC) plus $3.72 professional fee; Maximum Allowable Cost (MAC) plus $3.72 professional fee;
or providers usual and customary. Maximum of two dispensing fees per month.
2. Unit Dose Dispensing - reimbursement at the lowest of: Estimated Acquisition Cost (EAC) plus
$5.73 professional fee; MaximumAllowable Cost (MAC) plus $5.73 professional fee; or providers
usual and customary.
Reimbursement limited to one unit dose professional fee per drug per month.
Miscellaneous Remarks:
B. Co-payment: All legend and over-the-counter drugs except family planning drugs are subject to a
$.50 co-payment. Residents of Skilled Nursing Facilities (SNF) or Intermediate Care Facilities (ICF),
subsidized adoption recipients, children under age 18 and HMO enrollees are exempt from the co-
payment. (Co-payments limited to 10 per month)
NPC - 1989 Wisconsin - 3
WYOMING
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician Services X X X X
Dental Services
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 Wyoming implemented a temporary Medicaid
Disabled Pharmaceutical Services Program, effective
Children - Families w/Dep. Children August I,1988, at the regular state administrative
~ d u l t s- Families w/Dep. Children match. A full MMIS, including the pharmacy
Other Title XIX Recipients program, will be implemented on July I , 1989.
HCFA 2082 data will not be available for Federal
MEDICALLY NEEDY TOTAL FY 1988.
Aged
Blind
Disabled
Children -Families w/Dep. Children
Adults -Families w/Dep. Children
Other Title XIX Recipients
Ill. Administration:
The Medicaid (Title XIX) Program is administered by the Medical Assistance Services Unit within the Division
of Health and Medical Services, Department of Health and Social Services.
A. General Exclusions: Experimental drugs; anorexiants, except amphetamines and derivatives which are used
for narcolepsy and hyperkinetic states; fertility medication; products to stimulate hair growth; DESl drugs;
OTC drugs for in-home patients that are not listed in the Medicaid manual. Prior authorization is required
for AIDS medications, compounded drugs, home IV solutions, legend vitamins other than pediatric and
prenatal, nutritional supplements and post-transplant medications.
B. Formulary: Open with exceptions as listed above. The First Data Bank, National Drug Data File, provides
the fiscal agent with the Average Wholesale Unit Price and Date (Blue Book).
C. Prescribing or Dispensing Limitations: Each prescription shall be dispensed in the quantity ordered by a
physician, except as provided below:
Chronic conditions - prescriptions for chronic conditions for which a physician has not ordered a
specific quantity shall be dispensed in quantities of 100 or a minimum of one month's supply of
medication.
Acute Conditions - prescriptions for acute conditions for which a physician has not ordered a specific
quantity shall be dispensed in sufficient quantities to cover the period of time for which the condition
is being treated, except for injectable antibiotics, which may be dispensed in sufficient quantities to
cover a three-day period.
Schedule II drugs cannot be refilled.
0 Schedule Ill or IV drugs cannot be filled or refilled when the prescription is more than 6 months old.
Schedule Ill or IV drugs cannot be refilled more than 5 times.
Notwithstanding the above, prescriptions for all conditions may not be dispensed in quantities greater than
100 dosages or one month's supply, whichever is greater.
NO dollar limits.
Prescription splitting is prohibited. If a pharmacy does not have a sufficient supply of a product to fill a
prescription completely, it may only charge a dispensing fee when the initial amcunt of the product is
dispensed. The charge for the balance of the prescription must be for the cost of the product only.
D. Prescription Charge Formula: Payments for pharmacy services shall be the lowest of the following:
The average wholesale price (AWP) of the ingredient plus a dispensing fee;
The federally mandated maximum allowable cost (FMAC) plus a dispensing fee;
The pharmacy's usual and customary charge to the public, as indicated by the claim; or
The upper limit established by the Health Care Financing Administration (HCFA) for multiple source
drugs, except if "brand necessary" Or "medically necessary" is noted on the prescription by the
prescriber.
NPC - 1989 Wyoming -3
E. Medicaid Dispensing Fee: The Medicaid dispensing fee for pharmacies is $4.16 or the customary markup
for the prescription filled, whichever is lower. The Medicaid dispensing fee for physicians dispensing
prescriptions is $2.00 per prescription.
Providers of nursing home 'unit dose" prescriptions are to bill the Medicaid program no more than once
a month per recipient and are allowed only one dispensing fee per prescription for chronic conditions, i.e.,
to be provided in quantities of 100 or a minimum-of one month's supply. The Medicaid maximum limits
(i.e., the greater of 100 doses or one month's supply) also apply except for Schedule II drugs.
V. Miscellaneous:
Copayment: A $1.00 charge per prescription is imposed on Medicaid recipientsfor pharmaceutical services.
The following recipients or products are exempt from the copayment:
o Foster care children
Primary Pharmacy: Recipients using pharmacy sewices will be restricted to receiving sewices from the
pharmacy filling the initial prescription for any one month of eligibility. The first pharmacy filling a
prescription for the month will retain that portion of the Medicaid Identification Card authorizing pharmacy
services. A Medicaid-enrolled pharmacy that is not the designated provider may provide and be paid for
-
sewices to these recipients only under the following circumstances:
In a real medical emergency where a delay in treatment may cause death or result in a lasting injury
or harm to the recipient.
When the primary pharmacy does not stock or is unable to obtain the drug or cannot fill the entire
prescription.
Abbott Laboratories
Boehringer Ingelheim Pharmaceuticals, Inc.
Bristol-MyersUS. Pharmaceutical Group
Burroughs Wellcome Co.
CIBA-GEIGY Corporation
DuPont Pharmaceuticals
Glaxo Inc.
Hoechst-RousselPharmaceuticals, Inc.
ICI Pharmaceuticals Group
Johnson & Johnson
Lederle Laboratories
Eli Lilly and Company
Marion Laboratories, Inc.
Merck Sharp & Dohme
Merrell Dow Pharmaceuticals Inc.
Miles, Inc.
Norwich Eaton Pharmaceuticals
Parke-Davis
F'fizer Inc.
AH. Robins Company
Roche Laboratories
Rorer Pharmaceuticals
Sandoz Pharmaceuticals
Schering Corporation
G.D. Searle & Company
Smith Kline & French Laboratories
E.R Squibb & Sons, Inc.
Syntex Laboratories, Inc.
The Upjohn Company
Winthrop Pharmaceuticals