Pharmaceutical Benefits Under State Medical Assistance Programs, 1985

PHARMACEUTICAL BENEFITS UNDER

STATE MEDICAL ASSISTANCE PROGRAMS

SEPTEMBER 1985

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NATIONAL PHARMACEUTICAL COUNCIL. INC

QULSrq T L z ~ u ~ L 4 z x a u 4

Dear Reader:

This twentieth annual edition of the compilation, Pharmaceutical Benefits Under State Medical Assistance Proqrams, was prepared by the National Pharmaceutical Council, lnc. to assist in your evaluation of Medicaid program characteristics. NPC recognizes Medicaid a s an important health care component and, therefore, the significance of care made available to Title XIX patients. The Council shares the view held by public health officials that public assistance patients should receive the same quality medical care a s do other patients in the community.

W e hope that the information contained in this compilation continues to assist you in the development, implementation and operation of responsive and financially viable pharmaceutical programs.

, Sincerely,

President National Pharmaceutical Council, Inc.

1894 PRESTON WHITE DRIVE. RESTON. VIRGINIA 22091 703~620-6390

PHARMACEUTICAL BENEFITS UNDER

STATE MEDICAL ASSISTANCE PROGRAMS

SEPTEMBER 1985

Compiled by NATIONAL PHARMACEUTICAL COUNCIL, INC.

1894 Preston White Drive. Reston. Virginia 2209 1

TABLE OF CONTENTS

Introduction

Pharmaceutical Benefits Under State Medical Assistance Programs

Health and Human Services Regional Administration

State Medicaid Drug Program Administrators

Glossary of Medicaid Terms

Acronyms

Tables 1. Medicaid Statistics:

Current Data a. Medicaid Drug Reimbursement b. Drug Recipients and Vendor Payments, 1984

Trends c. Medicaid Drug Reimbursement, 1984 versus 1985 d. Vendor Payments for Prescribed Drugs (1979 to 1984) e. Recipients of Prescribed Drugs (1979 to 1984) f. Average Expenditures per Recipient for Prescribed

Drugs (1979 to 1984) g. Percentage of Medicaid Expenditures Allocated to

Prescription Medication (1981 to 1984) h. Ranking of States Based on Medicaid Drug Expenditures i. Ranking of States Based on Average Drug Expenditure

per Recipient

U.S. Totals by type of service j. Medical Assistance Program Benefits (Title XIX)

Total U.S. Vendor Payments by Type of Sewice. I98311984 k. National Title XIX Payments by Type of Service I. National Medicaid Expenditure and Receipt Data m. 1984 National Health Care Expenditures-Where

They Came From n. 1984 National Health Care Expenditures-Where

They Went o. Federal Medical Assistance Percentage ("FMAP")

2. Maximum Allowable Cost Information:

a. List of Federal MAC Drugs

3. Expanded Drug Coverage for the Elderly:

a. Programs Characteristics for States with Elderly Drug Coverage Programs

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4. State Demographic and Economic Characteristics, 1984:

a. State Population. Unemployment, Income, and Age Characteristics

5. Miscellaneous:

a. Pharmacies and Pharmacists b. Key Provisions of State Drug Product Selection Laws

Medical Assistance Drug Programs (Alphabetically by State andlor Territory)

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NATIONAL PHARMACEUTICAL COUNCIL, INC.

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

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

Toward this end, NPC undertakes educational activities and provides services to physicians, 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 (CFR42), supplemented by material contained in HCFA publication, "Analysis of State Medicaid Program Characteristics, 1984" published March, 1985.

"' Acknowledgements - NPC acknowledges the cooperation and assistance of the many state Medicaid program officials and their staffs, state pharmaceutical associations, Health Care Financing Administration personnel and others in supplying data for this compilation.

NPC

PHARMACEUTICAL BENEFITS UNDER STATE MEDICAL ASSISTANCE PROGRAMS

(Provided under Title XIX of the Social Security Amendments)

This compilation of data on State Medical Assistance Programs (Title XIX) has been prepared to present a generai overview of the characteristics of state programs together with detailed information on the pharmaceutical benefits provided.

The following information is provided for each state:

1. Recipient groups eligible for benefits 2. Amount expended for drugs per recipient category 3. Characteristics of the State Drug Program 4. Restrictions or limitations on drugs 5, Medicaid or public health officials 6. Pharmacy and medical consultants to the state programs 7. Pharmacy and medical advisory committees 8. State medical and pharmaceutical association executives 9. State boards of pharmacy

Medicaid (Title XIX of the federal Social Security Act) is a program of medical assistance, funded by the federal government and the states, for impoverished individuals who are aged, blind or disabled, or members of families with dependent children. The states and Puerto Rico, Guam, Virgin Islands and Northern Mariana Islands each operate Medicaid programs according to state or territorial rules and criteria that vary widely within a broad framework of federal guidelines, except that Arizona operates a program as an alternative to Medicaid under a waiver of some basic Medicaid requirements. Federal funding has also been provided for a Medicaid program in American Samoa.

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

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

Despite these expanded federal and state efforts, the need for medical assistance became so great that most states could finance only a few services. To help satisfy this need, Title XIX or "Medicaid" was enacted in the Social Security Amendments of 1965, providing grants to states for medical assistance programs beginning January 1, 1966. By January 1, 1967, more than half of the states had Medicaid programs, and by 1970, all of the states except Alaska (which later implemented one) and Arizona (which implemented an alternative to Medicaid in 1982) had programs. As a result, the federal financial participation in medical care that had been available through the categorical public assistance programs was ended because of the availability of federal Medicaid funds and the administrative advantages of offering medical care exclusively through Medicaid.

The program operates on the basis of a state and federal division of responsibilities. The federal government establishes regulations, guidelines and policy interpretations which describe the broad outline within which states can tailor their individual programs. States assume control and direction of operations. As a result there are 56 (50 states, pius Guam. District of Columbia, Puerto Rico, Samoa,

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Northern Mariana Islands and the Virgin Islands) disiinctly different programs in operation. Funding is shared between the two bodies, with the federal government matching state health care provider reimbursements of an authorized rate between 50% and 83% depending on the states per capita income. Federal law governs certain aspects of Medicaid, and requires that all persons who qualify for Aid to Families with Dependent Children (AFDC) and most persons who qualify for Supplemental Security Income (SSI) receive Medicaid coverage. The Federal Government requires states to provide a basic set of services to people eiigible for Medicaid and to reimburse providers of those services in certain ways. Reimbursement levels for many sewices are subject to federally established ceilings and, in some instances, floors.

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

ADMINISTRATION

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

Eligibility Determination and Program Administration

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

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

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

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

Thirty states elected to have federai determination and those 30 states expended 74.4 percent of total Medicaid expenditures in 1983. Six states elected to extend Medicaid to all recipients of SSI but maintain eligibility determination on a state level. Those six states expended only 3.0 percent of total Medicaid expenditures in 1983. Fourteen states elected the 209(b) option, consisting of 22.6 percent of total Medicaid expenditures.

A state plan must be in operation statewide through a system of local offices under equitable standards for assistance and administration that are mandatory throughout the state (42 CFR 431.50jb)). However, the state may choose to administer the program on the state level or by political subdivision of the state. Forty-four states have chosen to administer the Medicaid program on a state level and accounted for 60.3% of total Medicaid expenditures in 1983. Six states have chosen local administration and those six states accounted for 39.7 percent of total Medicaid expenditures in 1983. What this means is that in those states whose program is locally administered, the state plan is mandatory on each of the political subdivisions. The local administrations do not have the authority to change or disapprove any

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administrative decision of the state Medicaid agency with respect to the application of policies, rules, and regulations issued by the Medicaid agency.

A state plan must specify a single state agency, established or designated, to administer or supervise the administration of the plan (42 CFR 431.10(b)). Generally, the administering agency has been the state health agency; welfare agency, or an umbreila agency. A possible effect of the administering agency being the health department is that the welfare department has control over the intake of eligibles in the AFDC and SSliSSP programs, individuals who automatically become eligible for Medicaid. This separation could create a span of control problems for the Medicaid agencies. Five states have designated the health depanment, 22 states have designated the welfare department, 20 states have designated an umbrella agency, and three states have designated other agencies to administer the Medicaid program. The "other" agencies included the office of the Governor in Alabama and an independent agencylcommission in Georgia and Mississippi.

SERVICE COVERAGE

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

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

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

Ill. Nursing Home Services-types of care available in nursing homes, such as skilled, intermediate, or general nursing care.

IV. Hospital and Clinic Services-services provided at a hospital, clinic, or other type of medical treatment center (does not include nursing homes).

V. Drugs, Supplies, and Equipment-includes prescribed drugs and any supplies or equipment needed to aid in the treatment of a medical problem.

VI. Special Services and Therapy-includes screening, diagnostic, and preventive services as well as therapy for physical, occupational, or communication disorders.

VII. Institutional Care-care provided to individuals during their stay at mental institutions or tuberculosis hospitals (includes any institutional stay other than that at regular hospitals or nursing homes).

~lll.0ther-any services provided which facilitate medical treatment that are not covered by any of the above categories.

MANDATORY SERVICES

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

1. lnpatieni hospital services

2. Outpatient hospital services

3. Physician services

4. Independent laboratory and X-ray services

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

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The six additional mandatory services added since 1965 are listed below:

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

7. Family planning services and supplies

8. Home health care services

9. Patient transportation

10. Rura! Health Clinic Services

11. Nurse-midwife services

OPTIONAL SERVICES

In addition to these required programs, the participating states may elect to offer additional services. Some of these services are defined in the Medicaid rules and regulations. Others have been defined through federal acceptance of a particular service in a state's plan. A state may include any type of care recognized under state law and authorized by the Secretary of the Department of Health and Human Services.

REGULATIONS PERTAINING TO MEDICAID SERVICES

Federal regulations require that the amount and/or duration of each type of medical and remedial care and services furnished under a state's Medicaid plan must be specified in the state plan, and that these types of care and services must be sufficient in amount, duration, or scope to "reasonably achieve" their purpose.

Each plan must include a description of the methods that will be used to assure that the medical and remedial care and services are of high quality, and a description of the standards established by the state to assure high quality care. The regulations also require that fee structures be developed which will result in participation of a sufficient number of providers of services in the program so that eligible persons can receive the medical care and services included in the plan at least to the extent that these are available to the general population. The law further requires that services provided under the plan be available throughout the state. Recipients are to have freedom of choice with iegard to where they receive their care, including an option to obtain their care through organizations that provide servlces or arrange for their ava~lability on a prepayment basis, such as health maintenance organizations.

MEDICAID ELIGIBILITY

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

Mandatory Coverage

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

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

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MEDICAID SERVICE (Mandatory Services Indicated by Capital Letters)

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

II. Nursing Care Services HOME HEALTH CARE SERVICES (for persons 21 years of age or older) Personal Care Services Private Duty Nursing NURSEMIDWIFE SERVICES Adult Day Treatment Services

Ill. Nursing Home Services SKILLED NURSING FACILITY SERVICES (for persons 21 years of age or older) Intermediate Care Facility Services Skilled Nursing Facility Services (for persons under 21 years of age)

IV. Hospital and Clinic Services INPATIENT HOSPITAL SERVICES OUTPATIENT HOSPITAL SERVICES RURAL HEALTH CLINIC SERVICES Clinic Services Emergency Hospital Services

V. Drugs, Supplies and Equipment Prescribed Drugs Dentures Eyeglasses (for persons 21 years of age and older) Hearing Aids (for persons 21 years of age and older) Prosthetic Devices

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

VII. Institutional Care Inpatient Psychiatric Services (for persons under 22 years of age) Care in Tuberculosis Institutions (for persons age 65 or older) Care in Mental Institutions-Intermediate Care Facility Services (for persons age 65 or older) Care in Mental Institutions-Skilled Nursing Facility (for persons age 65 or older)

Vlll. Othei TRANSPORTATION TO & FROM MEDICAL SERVICES Enrollment in Medicare-Part B, Title XVIII, Supplemental Medical lnsurance Enrollment in Medicare-Part A, Title XVIII, Hospital lnsurance Benefits

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

Optional Coverage

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

General Eligibility Requirements

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

CHARACTERISTICS OF BENEFITS PROVIDED

lnpatient Hospital Services

Inpatient hospital services refer to services that are ordinarily furnished in a hospital for the care and treatment of an inpatient. The facility is one maintained primarily for the care and treatment of patients with disorders other than tuberculosis or mental diseases. There are several general federal limitations on inpatient hospital services which are applicable to all states with Medicaid programs (42 CFR 440.10):

The facility must be licensed or formally aproved as a hospital by an officially designated authority for state standard-setting;

0 The facility must meet the requirements for participation in Medicaid;

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

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

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

Outpatient Hospital Services

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

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

0 The facility must be licensed or formally approved as a hospital by an officiaily designated authority for state standardsetling; and

0 The facility must meet the requirements for participation in Medicare

States are free to specify other limits on outpatient hospital services and 40 states have chosen to do so.

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Twenty-two states, accouniing for 54.6% of total Medicaid expenditures for outpatient hospital sewices, place other limits on outpatient hospital services. Examples of "other limits" include: (1) emergency room services are not provided between 5:00 a.m. and 4:00 p.m. in Vermont except for trauma and (2) outpatient services are limited to a maximum of $100 per fiscal year in Florida.

Rural Health Cllnic Services

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

Other Laboratory and XRay Sewices

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

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

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

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

In addition, the states can place limitations on "other laboratory and Xray services."

Skilled Nursing Facility Services

Skilled nursing facility (SNF) services are provided to individuals age 21 or older and do not include services in institutions for tuberculosis or mental diseases (42 CFR 440.40(a)). These services must be needed on a daily basis and provided in an inpatient facility. Federal regulations require that the services be:

0 Pr0vided.b~ a facility or distinct part of a facility that is certified to meet the requirements for participation. These requirements include provider agreements, facility certification, and facility standards; and

Ordered by and under the direction of a physician

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

Early and Pe~jadic Scmening, Diagnosis and Treatment

Early and periodic screening, diagnosis and treatment (EPSDT) refers to screening and diagnostic services to determine physical or mental defects in recipients under age 21 and health care, treatment and other measures to correct or ameliorate any defects and chronic conditions discovered (42 CFR 440.40(b)). There are certain basic screening and treatment services that each state must provide as minimum (42 CFR 441.56). These services include:

e Health and development history screening

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0 Unclothed physical examination

e Developmental assessment

0 lmmunizations which are appropriate for age and health history

a Assessment of nutritional status

0 Vision testing

0 Hearing testing

0 Laboratory procedures appropriate for age and population groups

0 Dental services furnished by direct ieferral to a dentist for diagnosis and treatment for children three years of age and over

0 Treatment for defects for vision and hearing, including eyeglasses and hearing aids; and

0 Dental care needed for relief of pain and infections, restoration of teeth and maintenance of dental health

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

Family Planning Services

Family planning services and supplies are allowable for individuals of child bearing age as a means of enabling individuals to freely determine the number and spacing of their children. Although there are no federal regulations defining what family planning services a state can provide, provisional regulations are written which defined family planning services to be: consultation (including counseling and patient education), examination, and treatment, furnished by or under the supervision of a physicien 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 may provide any medically approved means other than abortion, for family planning purposes, if furnished by or under supervision of a physician or if prescribed by a physician. Abortions are specificaily excluded from family planning services and states are prohibited from considering any abortion as being a family planning service.

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

Physkians' Sewices

Physicians' sewices are covered whether provided in the office, the patient's home, a hospital, a skil!ed , c m or nursing facility, or elsewhere. Physicians' services must be within the scope of practice oi medi :

osteopathy as defined by state law and by or under the personal supervision of an individual ilcensed under state law to practice medicine or osteopathy.

Heme Health Sewices

Home health services are piovided to a recipient at his piace of residence which does not inc i~de a hospital, skilled nursifig facility, or intermediate care facility (ICF) except for home health services in an ICF that are not required to be provided by the facility. Services provided must be on physicians' orders as part of a written plan of care that is reviewed by the physician every 60 days. Home heaith services include three mandatory services (part-time nursing, home health aide, and medicai supp!ies and equipment) and one optional service (physical therapy, occupational therapy, and speech p&hoIog:i and audiology services) (42 CFil 440.70). These services are defined as follows:

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

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

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

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

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

Nurse-Midwife Services

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

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

LIMITATIONS ON OF'TIONAL SERVICES

Intermediate care facility (ICF) services, other than in an institution for tuberculosis or mental diseases, refers to services provided in a facility that fully meets the requirements for a state license to provide on a regular basis, health-related services to individuals who do not require hospital or SNF care but whose mental or physical condition requires services that are above the level of room and board and can be made available only through institutional facilities. The facility must meet all the requirements to be certified for Medicaid (42 CFR 440.150(ab)).

This optional service is provided by all 50 states

Services for Individuals Age 21 end Under

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

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

Prescribed Drugs

Prescribed drugs are simple or compound substances or mixture of substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance that are prescribed by a physician

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or other licensed practitioner of the healing arts within the scope of their professional practice as defined and limited by federal and state iaw (42 CFR 440.120). The drugs must be dispensed by licensed authorized practitioners on a written prescription that is recorded and maintained in the pharmacist's or practitioner's records.

Two states, Alaska and Wyoming, do not provide prescribed drugs as a separate service to Medicaid recipients. States place limits on prescription quantities in three different ways: number of prescriptions that can be filled in a certain time period, number of prescriptions that can be refilled in a certain time period, and quantity of each prescription.

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

Other Optional Services and Equipment

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

Emergency hospital services refer to services that are necessary to prevent death or serious 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 at such a hospital even if it does not meet the conditions for participation under Medicaid or the definition of inpatient or outpatient hospital services.

Personal care services in a recipient's home refer to services prescribed by a physician in accordance with the recipient's plan of treatment and provided by an individual who is qualified to provide the services, supervised by a registered nurse, and not a member of the recipient's family (42 CFR 440.1 70(f)). It should be noted that states which are granted a waiver under Section 2176 for home and community- based services (that an individual needs to avoid institutionalization) are given the latitude to define personal care services differently. As of April 1, 1984, 42 statss had been approved for Section 21 76 waivers.

Private duty nursing services refer to nursing services for recipients who require more individual and continuois care than is available from a visiting nurse or routinely provided by the nursing staff of the hospital or SNF (42 CFR 440.80). These services must be provided by a registered nurse or a licensed practical nurse under the direction of the recipient's physician. The services must be provided in the recipient's home, in a hospital, or in a SNF.

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

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

* The teeth and associated siructure of the oral cavity; and

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

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

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

Chiropractors' services are included under 42 CFR 440.60 "medical or other remedial care provided by licensed practitioners." Chiropractors' services are defined to include only services that consist of treatment by means of manual manipulation of the spine that the chiropractor is legally authorized by the

NPC 1985

state to perform. In addition to being licensed by the state, the chiropractor must also meet the standard issued by the Secretary of HHS. These standards include age, education, and licensure standards.

Prosthetic devices are defined by 42 CFR 440.120(c) to mean replacement, corrective, or supportive devices prescribed by a physician or other licensed practitioner of the healing arts within the scope of practice as defined by state law. The devices must:

Artificially replace a missing portion of the body

Prevent or correct physical deformity or malfuncticn; or

Support a weak or deformed portion of the body.

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

Occupational therapy (42 CFR 440.1 10(b)) refers to services prescribed by a physician and provided to a recipient by or under the direction of a qualified occupational therapist. A qualified occupational therapist is an individual who is either registered by the American Occupational Therapy Association or who is a graduate of an approved occupational therapy program (by the Council on Medical Education of the American Medical Association) and engaged in the supplemental clinical experience required by the American Occupational Therapy Association. Occupational therapy services include any necessary supplies and equipment.

Services for individuals with speech, hearing and language disorders are provided as an optional 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 supe~ised work experience to qualify for the certificate.

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

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

Preventive services (42 CFR 440.130(c)) are those that prevent disease. disability, and other health conditions or their progression; services that prolong life; and services that promote physical and mental health and efficiency. Preventive services must be provided by a physician or other licensed practitioner of the healing arts within the scope of practice under state law.

Rehabilitative services (42 CFR 440.1 30(d)) are medical or remedial services for reduction of physical or mental disability and restoration of a recipient to his best possible functional level. The services must be recommended by a physician or other li-censed practitioner of the healing arts within the scope of his oractice under state law.

MEDICALLY NEEDY COVERAGE AND LIMITATIONS

A state plan must specify that, as a minimum, categorically needy recipients are provided the 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; 12

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Ambulatory services to individuais under age 18 and individuais entitied to institutional services;

Home health services to individuals entitied to SNF services; and

If the state plan includes services either in institutions for mental diseases or in ICF-MRs, it must offer either of the following to each of the medically needy group:

The services contained in 42 CFR sections 440.10 through 440.50 and 440.165 (to the extent nurse-midwives are authorized to practice under state law or regulations);

The services contained in any seven of the sections in 42 CFR 440.10 through 42 CFP 440.165.

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

COST SHARING

States are permitted to require certain recipients to share some of the costs of Medicaid by imposing upon them such payments as enrollment fees, premiums, deductibles, coinsurance, copayments, or similar cost sharing charges (42 CFR 447.50). For states that impose cost sharing payments, the regulations specify the standards and conditions under which states may impose cost sharing, set forth minimum amounts and the methods for determining maximum amounts, and describe limitations on availability that relate to cost sharing requirements. With the passage of the Social Security Amendments of 1972, states were empowered to impose "nominal" cost sharing requirements on optional Medicaid services for cash assistance recipients, and on any services for the medically needy. Section 131 of the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 introduced major changes to Medicaid cost sharing requirements. States may now impose a nominal deductible, coinsurance, copayment, or similar charge upon both categorically needy and medically needy for any service offered under the state plan. Public Law 97248, TEFRA, has been in effect since October 1982 and it prohibits imposition of cost sharing on the following:

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

0 Pregnancy-related services (or, at state option, any service provided to pregnant women);

0 Services provided to certain institutionalized individuals, who are required to spend all of their income for medical care except for a personal needs allowance;

Emergency services;

Family planning services and supplies; and

Services furnished to categorically needy HMO enrollees (or, at state option, services provided to both categorically needy HMO enroiiees (or, at state option, services provided to both categorically needy and medically needy HMO enrollees).

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

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

Medicaid Management Information System

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

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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-two states have certified MMlSs and operate a mechanized claims processing and information retrieval system.

Medicaid Claims Processing Activity

States handle the processing of Medicaid claims in different ways. There is variability in who handles the claims for each service type. Claims processing activities for prescription drugs are handled by fiscal agents in 28 states, by states themselves in 19 states, and by a combination of fiscal agentktate in three states.

Medicaid Quality Control

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

MEDICAID PRINCIPLES OF REIMBURSEMENT

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

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

Davis and Schoen. Health and the War on Poverty, A Ten Year Appraisal; Brookings Institution, 1978. Mitchell and Cromwell, "Large Medicaid Practices and Medicaid Mills," Journal of the American Medical Association, November 1950.

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

The second significant step in reforming Medicaid provider reimbursement came with passage of the Omnibus Reconciliation Act of 1981 (PL 97-35). Among other things, the Act, implemented by federal regulations on September 30, 1981, granted significant new flexibility to the states in setting provider reimbursement policies for hospitals (Section 2173) and physicians (Section 2174) by relaxing the constraints which tied payments to Medicare retrospective cost reimbursement principles. States quickly began to adopt alternate payment methods tailored to their own unique needs. The Act gave states waiver authority to restrict freedom of choice (section 2175) and to eliminate the institutional bias towards institutional long-term care through home and community-based care (Section 2176). The Act also gave the states new flexibility to enter into prepaid service arrangements with non-federally qualified HMOs and to impose certain copayments on service use by Medicaid recipients.

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

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

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

Only nursing home, inpatient hospital, physician, outpatient hospital, free-standing clinics and prescription drug service reimbursement policies are included in this report. These services represent over 90 percent of all Medicaid expenditures nationwide for fiscal year 1984.

Clinkscaie, Robert, "Impact of Medicare's Prospective Payment System (PPS) on State Medicaid Programs,'' Proceedings, First National DRG Conference, Atlantic City, N.J., 1983.

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NURSING HOME RElMBURSEMENT

Expenditures for nursing home services is the largest and most rapidly growing component of national Medicaid outlays. From fiscal year 1982 through fiscal year 1984, Medicaid expenditures for nursing homes increased by approximately 9.4 percent; from $12.9 billion to $14.8 billion in fiscal year 1984. ICFMR nursing expenditures continue to rise at a much higher rate than for SNF and ICF homes. Most state Medicaid programs have departed from Medicare principles of reimbursement in favor of various forms of prospective reimbursement where rates and rate increases are negotiated or determined by formulas prior to each new fiscal year. The prospective methods are generally either facility specific negotiated rates or class rates based on type of facility, size, and location. Some states use a combination of methods.

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

INPATIENT HOSPITAL SERVICES REMBURSEMENT

Inpatient hospital services are the second largest component of Medicaid expenditures nationwide. accounting for $10 billion or 29.5 percent of Medicaid outlays in fiscal year 1984. Prior to the Omnibus Budget Reconciliation Act of 1981, states were generally compelled to use Medicare reasonable cost- based reimbursement principles unless authorized by DHHS to adopt an alternative method.

Post-OBRA Environment

By early 1984, only 17 states (17 percent of national inpatient expenditures) still used the Medicare retrospective cost-based method. The other 33 states (83 percent of total inpatient expenditures) had moved to adopt either an alternative plan or an experimental system of inpatient reimbursement. States using experimental systems based on diagnostic-related groupings (DRGs) are New Jersey, Pennsylvania, Michigan. Ohio, Vermont, and Washington. Most of the other states using alternative 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 encompass all payers. The dates for states using alternative methods represent the year in which the method was approved by DHHS and implemented. By early 1982 the method may have undergone modifications since its original approval. As a result of OBRA 81, many other states are expected to abandon inpatient Medicare reimbursement principles.

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

PHYSICIAN SERVICES REIMBURSEMENT

Expenditures for physician services are the third largest component of Medicaid expenditures. In fiscal year 1984, physician services accounted for $2.2 billion, or 6.5 percent of Medicaid expenditures nationwide. States have broad discretion within general federal guidelines regarding Medicaid 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 Onibus Budget Reconciliation Act of 1981 freed states from the CPR-based upper limit. States are now free to set physician Medicaid reimbursement payments at their discretion so long as they are "adequate and reasonable." The CPR method used by Medicare limits reimbursement to the lowest of the following: a physician's actual charge, the physician's median charge in a recent prior period (customary), or the 75th percentile of charges in that same period (prevailing). Any prevailing charges at or under the 75th percentile criterion are considered "reasonable." In some states, the 75th percentile is determined on the basis of physicians' charges in the same specialty andlor substate region; in others, states use charge data from all physicians regardless of specialty or substate region. Finally, since 1976 an "economic index" has been a2plied to limit the rate

16

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of increases in Medicare prevailing rates. Technically, Medicaid regulations refer to a "usual, customary and reasonable" (UCR) method. Other than confusion over definitions, the UCR method and the CPR methods are the same.4 Within this framework, state Medicaid programs set physician reimbursement rates using the Medicaid method or a fee schedule, whichever is the lower. Some states have delayed in updating physician charge profiles, use artificially low economic indices, or simply elect to reimburse at below Medicare's 75th percentiie of pervailing to the point where they have in reality converted to a fee schedule.

OUTPATIENT HOSPITAL, CLINIC

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

PRESCRIPTION DRUG REIMBURSEMENT

Prescription drug reimbursement conforms to the maximum allowable cost (MAC) system in effect since 1976. This has led to considerable uniformity in drug-specific payments across states; however, states vary in retail pharmacy dispensing fees, recipient copayments, limitations on use, over-the-counter exclusions and formulary status for legend drugs. For example, retail pharmacy dispensing fees (per prescription) range from a low of $2.50 to a high of $4.05. Of the 48 states sponsoring a drug program, 26 charge no copayments; the remainder charge copayments to recipients ranging from $SO to $3.00, most having copayments of $50 to $1 .OO per prescription. A few states made up and downward adjustments to drug copayment levels. Eleven states limit number of new prescriptions per month. Nineteen states use a formulary (limited or restricted drug list). Twenty-six states establish state MACs in addition to the federal MAC list. See chart, detailing state reimbursement characteristics.

VENDOR DRUG PROGRAM PROVISIONS

1. Freedom of Choice. Section 1902 (a) (23) Social Security Act, Reg. 42 CFR 431.51

Any individual eligible ior Medicaid may obtain the services available under the state Medicaid pian from any institution, agency, pharmacy, person or organization which provides such services or arranges for their availability on a prepayment basis, and is qualified to perform such services.

It is not required that an institution allow a recipient a choice of drug provider if the institution (e.g., hospital or nursing home) customarily includes pharmaceuticals as part of its total package of services.

Section 2175 Freedom of Choice Waivers. Section 21 75 attempts to increase the importance oi price considerations in the decision about when, where, and how to utilize health care services. Each of the waivers focuses on a different part of the health care decision making process and allows a state to:

implement a primary care case mangement system focusing on primary care physicians;

Allow a locality to act as central broker in assisting Medicaid recipients in selecting among competing health plans;

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

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Share with recipients, through the provision of additional services, savings resulting from recipients' use of more costeffective medical care; and

Restrain recipients to receiving services (other than in emergency situations) from only efficient and cost effective providers.

The waivers can be granted for a period of up to two years, and a state may request a continuation.

2. Drug Reimbursement. Title 45 PUBLIC WELFARE, Subtitle A Department of Health and Human Services, Part 19-Limitations on Payment or Reimbursement for Drugs

Regulation Sec. 19.1. Purposes

(a) This establishes Department of Health and Human Services procedures for determining drug costs and, where applicable, dispensing fees which the Department will use for the purpose of determining:

(1) Reimbursement to providers and health maintenance organizations under the Medicare program;

(2) Reimbursement to states under state administered health, welfare, and social service programs; and

(3) Allowable costs under projects for health services.

(b) Policies and procedures, which will be consistent with the policies and procedures set forth in this Part, will be published in the HHS Procurement Regulations, Title 41, Chapter 3, Code of Federal Regulations, governing the direct purchase of drugs by the Department and the purchase or supply of drugs by contractors of the Department.

(c) This Part does not establish procedures for fixing the actual amount of reimbursement to which providers will be entitled for dispensing drugs. Rather, it establishes procedures for setting a limit on what the individual program regulations and policies might otherwise provide. If the authorizing legislation for a particular program, or the program regulation or policies adopted or issued under that legislation, provides for a lower rate of reimbursement than this regulation permits, then the program reimbursement rate, being lower, will necessarily control the actual payment.

Regulation Sec. 19.3. Cost Limitati~n.~

(a) The amount which the Department will recognize for reimbursement or payment purposes for any drug used in the programs or activities described in Sec. 19.1 shall not exceed the lowest of:

(1) The maximum allowable cost (MAC) of the drug, if any, established in accordance with Sec. 19.5 plus a reasonable dispensing fee;

(2) The acquisition cost of the drug plus a reasonable dispensing fee; or

(3) The provider's usual and customary charge to the public for the drug; provided that: the MAC established for any drug shall not apply to a brand of that drug prescribed for a patient which the prescriber has certified in his own handwriting is medically necessary for that patient; and provided further, that: where compensation for drug dispensing is included in some other amount payable to the provider by the reimbursing or paying program agency, a separate dispensing fee will not be recognized.

(b) Each program agency shall estimate the acquisition cost of each drug for which it reimburses or pays a provider. Such estimate should be consistent with any drug price information furnished the program agency by the Department.

Federal Register, Vol. 40, 32283, July 31, 1975 Federal Register, Vol. 40, 32283, July 31, 1975 and corrected in Federal Register, Vol. 40, 36342,

August 20, 1975

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Sec. 250.3 (b)(2)(H)-Reasonable Charges

For each multiple source drug designated by the Pharmaceutical Reimbursement Board and published in the Federal Register cost will be iimited to the lower of:

a. the maximum allowable cost (MAC) established by the Board for such drug and published in the Federal Register, or

b. the estimated acquisition cost (EAC as defined in the regulations).

Limitation to the maximum allowable cost established by the Board shall not apply in any case where a physician certifies in his own handwriting that in his medical judgement a specific brand is medically necessary.

The form and procedure for the certification shall be prescribed by the state. An example of an acceptable certification would be a notation "brand necessary". A procedure for checking a box on a form will not constitute an acceptable certification.

For all prescribed drugs the upper limits for which payment is made shall be based on the lower of the cost of the drug plus a dispensing fee or the provider's usual and customary charge to the general public.

3. Pharmaceutical Reimbursement Board (PUB) Pharmaceutical Reimbursement Section Health Care Financing Administration Department of Health and Human Services Establishment of pharmaceutical reimbursement board.

(a) There is established in the Health Care Financing Administration a Pharmaceutical Reimbursement Board consisting of six full time employees of the Department, representing the principal offices and agencies concerned with developing and implementing cost determinations under this part. The Director, Office of Pharmaceutical Reimbursement, shall serve as the Chairman.

(b) The Board may make use of outside consultants to advise it on any technical or complex issues during its consideration of a proposed MAC.

(Outline of procedures only-detail omitted)

(a) Identification of drugs to which MAC may be applied

(b) Review by the Food and Drug Administration

(c) Initial determination of lowest unit price

(d) Proposed MAC

(e) Notice of Comment

(f) Public Hearing(gConduct of hearing

(h) Proposed final determination

(i) Administrator's concurrence

(j) Publication-(Federal Register notice)

A list of Federally MAC'd drugs appears on page **, Table IIA

4. Estimated Acquisition Cost (EAC)

Estimated Acquisition Cost (EAC) applies to all drug products not reimbursable as a maximum allowable cost (MAC) drug product as established by the HHSPharmaceutical Reimbursement Board.

The development of EAC price levels is the responsibility of each state.

HHS will periodicaliy provide each state with product cost data as a guideline to assist in establishing the estimated acquisition costs for that particular state.

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Medicaid-Formula for Determhing EAC for Drugs 70th Percentile "bench mark

HHS Action Transmittal. HCFAAT77113 (LIMB), December 13, 1977. Subject: "Title XiX, Social Security Act: Limitation on Payment or Reimbursement for Drugs: Estimated Acquisition Cost (EAC)."

The intent of the final Medicaid regulations on drug reimbursement is to have each state's estimated acquisition cost as close as feasible to the price generally and currently paid by the provider. The states are, therefore, expected to set their ingredient cost levels as close as possible to actual acquisition cost. The Department's analysis of price data over several months indicates that a specific percentile listing-the 70th-might appropriately be used as a bench mark in determining the degree to which the ingredient cost levels established by states, approach actual acquisition cost. Any state which is found to be reimbursing at a level above the 70th percentile could be expected to provide evidence to indicate that its reimbursement levels are closer to the providers' AAC than the Federal data.

Tne text of the transmittal also states:

"Each program administrator should evaluate the state's method of setting EAC limits for the drug program to assure that drug reimbursement limits are as close as feasible to Actual Acquisition Cost."

5. Formularies in Medicaid Programs

Under existing federal policy, the use of a formulary or limited drug list in a Title XIX program is optional. The policy states, "the basic objective is to enable doctors and pharmacists throughout the state to join in a mutually beneficial selection of high quality drugs of recognized therapeutic value, produced by reputable manufacturers and broad enough to cover virtually any situation" (Medicaid Assistance Manual SRSMSA196 1971).

A drug formulary or list of pharmaceutical products is either open (unrestricted) or closed (restricted). Each state's Medicaid program determines its own formulary status. An open formulary is a list of virtually all prescription drugs approved by the FDA and allows the prescriber to choose the most medically appropriate drug to treat each patient. A closed formulary is a limited list of drugs for which reimbursement will be granted under the state Medicaid program. No drug that is not contained in the list is covered without prior approval by the state. Thus, prescribers are administratively limited in their choice of drugs in treating Medicaid patients.

6. Implementation of Formulary Guidelines

Formulary regulations were codified in Sec. 250.30 (b) (2) (iv) of Title 45, Chapter il, of Code of Federal Regulations as set forth below:

"Drugs. (iv) The use of a formulary is optional, as are provisions for use of generic drugs. Where either is employed, there must be standards for quality, safety and effectiveness under the supervision of professional personnel."

In carrying out the above regulation, state agencies should consider the following guidelines:

0 Any medication included in a formulary shall meet such acceptable standards for drugs as required under the Federal Food, Drug, and Cosmetic Act, as amended, and the applicable requirements of official compendia with respect to identity, strength, safety, quality, purity, and effectiveness.

0 State agencies should adopt procedures which will ensure the greatest economy consistent wiln acceptable standards of identity, strength, safety, quality, purity, and effectiveness.

Any formulary developed for a state's Medicaid Drug Program should not become so rigid that the prescriber's privilege for requesting items outside the formulary in justified sittations is made impossible. The formulary should have due regard for the professional prerogatives of practitioners. It should not place undue restrictions upon the physician insofar as his prescribing practices are concerned.

The state's formulary committee should be composed of practicing physiciins, pharmacologists,

20

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pharmacists, and other professional personnel operating within specific procedures established by the state. It should be charged with the responsibility of revising the formulary when required at specified intervais.

0 A principal purpose of the formulary should be to identify the drugs approved for reimbursement under the program. However, it should permit authorization for the reimbursement of nonlisted items upon professional justification.

Each item should have an assigned code number (preferably, from the FDA National Drug Code Directory.) That code number should lend itself to automatic or electronic data processing for t i e purpose of handling administrative functions with greater efficiency and speed, and at reduced cost.'

XI. Health and Human Services Department, Health Care Financing Administration-An Overview

The Health Care Financing Administration (HCFA) was established in early 1977 to bring into one agency the major federal health care financing programs and their associated quality assurance activity HCFA is responsible for the federal administration of health financing and quality assurance programs.

HCFA's mission is to:

Ensure the effective administration of its program in order to promote the timely delivery of appropriate, quality health care to its beneficiaries;

0 Make certain that beneficiaries are aware of the services for which they are eligible, that these services are accessible to them and are provided in the most effective manner, and;

0 Ensure that its policies and actions promote efficiency and quality within the total health delivery system which services all Americans.

This mission is carried out by ten regional offices, each of which is responsible for the administration of HCFA programs in a given geographic area. The basic functions of a regional office are to: monitor the performance of Medicare contractors, Medicaid state agencies, state survey agencies, and PSROs; interpret Federal health policies and regulations to these organizations; monitor the expenditure oi Federal funds: oversee the operation of quality control programs, and assure effective communication between HCFA, its providers and its beneficiaries.

(Reference-Medical Assistance Manual SRS-MSA-196-1971) Because of the direct relationship between formulary development, maximum allowable cost procedures and the substitution of generic drugs, a table has been inciuded which outlines the provisions of state laws permitting drug substitution by pharmacists, See Table #VIB.

REGION #I Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont

REGIONAL ADMlNlSTRATiVE OFFICE Health and Human Services

Health Care Financing Administration

REGION #2 New Jersey, New York, Puerto Rico, Virgin Islands

REGION #3 Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia

REGION #4 Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee

REGION #5 Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin

REGION #6 Arkansas, Louisiana, New Mexico, Oklahoma, Texas

REGION #7 Iowa, Kansas, Missouri, Nebraska

REGION #8 Colorado, Montana, South Dakota, North Dakota. Utah, Wyoming

REGION #9 Arizona, California, Guam, Hawaii, Nevada, American Samoa

REGION #10 Alaska, Idaho, Oregon, Washington

John F. Kennedy Federal Bldg. Government Center, Room 1309 Boston, Massachusetts 02203

Room 3800 26 Federal Plaza New York, New York 10278

3535 Market Street HCFA Region Ill Philadelphia, Pennsylvania 19101

101 Marietta Tower Suite 701 Atlanta, Georgia 30323

175 West Jackson Boulevard Suite A835 Chicago, Illinois 60604

1200 Main Tower Building Room 2400 Dallas, Texas 75202

New Federal Office Building 601 East 12th Street, Rm. 235 Kansas City, Missouri 64106

1961 Stout Street Federal Office Building, Rm. 628 Denver, Colorado 80294

100 Van Ness Avenue, 14th Floor San Francisco, California 94102

2901 Third Avenue, MS. 407 Seattle, Washington 98121

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OFFICE OF THE INSPECTOR GENERAL REGIONAL OFFICE CONTACT

Region

Region /-Boston

Office of Health Financing lntegrity Room 1305-JFK Building Government Center Boston, Massachusetts 02203 6171223-6881 (FTS) 223-6881

Region 11-New York

Office of Health Financing lntegrity Room 38-1 00 Federal Off ice Building 26 Federal Plaza New York, New York 10278 2121264-5295 (FTS) 264-5292

Region Ill-Phildeiphia

Office of Health Financing lntegrity Room 10460 (P.O. Box 13618 3535 Market Street Philadelphia, Pennsylvania 1910 21 51596-0607 (FTS) 596-0607

Region I V Atlanta

Office of Health Financing integrity Suite 1403 101 Marietta Tower Atlanta, Georgia 30323 4041221 -41 08 (FTS) 242-41 08

Region V Chicago

Office of Health Financing lntegrity Suite A935 175 West Jackson Boulevard Chicago, Illinois 60604 31 21353-9867 (FTS) 353-9867

States

Connecticut Maine Massachusetts New Hampshire Rhode Island Utnadt'

New Jersey New York Puerto Rico Virgin Islands

Delaware District of Columbia Maryland Pennsylvania Virginia West Virginia

Alabama Florida Georgia Kentucky Mississippi North Carolina South Carolina Tennessee

Illinois Indiana Michigan Minnesota Ohio Wisconsin

NPC

Region VI Dallas

Office of Health Financing lntegrity Room 4E6 1100 Commerce Street Dallas, Texas 75242 21 41767-6371 (FTS) 729-6371

Region VII Kansas City

Office of Health Financing lntegrity P.O. Box 26248 1 100 Main Street Kansas City, Missouri 64196 81 61374-3697 (FTS) 758-3697

Region Vl l l Denver

Office of Health Financing lntegrity Room 11 85, 13th Floor Federal Office Building 1961 Stout Street Denver, Colorado 80294 3031844-2491 (FTS) 564-2491

Region IX San Francisco

Office of Health Financing lntegrity 50 United Nations Plaza Room 365 . San Francisco, California 941 02 4151556-3132 (FTS) 556-3132

Region X Seattle

Office of Health Financing lntegrity Mail Stop 408 2901 Third Avenue Seattle, Washington 98121 2061442-0577 (FTS) 399-0577

Arkansas Louisiana New Mexico Oklahoma Texas

Iowa Kansas Missouri Nebraska

Colorado Montana North Dakota South Dakota Wyoming Utah

Arizona California Guam Hawaii Samoa

Alaska Idaho Oregon Washington

NPC

ALABAMA

Sam T. Hardin, P.D. Associate Director Pharmaceutical Program Alabama Medicaid Agency 2500 Fairlane Drive Montgomery, Alabama 36130 (205) 277-271 0

ALASKA

Bob Ogden Chief of Medical Assistance Division of Medical Assistance 4041 "5" Street Juneau, Alaska 99503 (907) 561 -2171

ARIZONA

STATE MEDICAID

DRUG PROGRAM ADMINISTRATOR

Dr. Don Schaller Director Arizona Department of Health Services 124 West Thomas Suite 301 Phoenix, Arizona 85013

ARKANSAS

Mark Crossley Pharmacist Consultant Arkansas Social Services P.O. Box 1437 Little Rock, Arkansas 72203 (501) 371 -5361

CALIFORNIA

Milton Kuschnereit, Pharm. Senior Consulting Pharmacist Medi-Cal Benefits Branch California Health and

Welfare Services 714 P. Street, Room 1640 Sacramento, California 95814 (916) 324-2477

COLORADO

Myrle A. Myers, R.Ph., M.S. Mgr., Pharmacy and Ambulatory Care Services Section Division of Medical Assistance Colorado Department of Social

Services 1575 Sherman Street, Room 101 0 Denver, Colorado 80203 (303) 866-5372

CONNECTICUT

Meyer Rosenkrantz, R.Ph. Pharmacist Consultant Department of Income Maintenance 11 0 Bartholomew Avenue Hartford, Connecticut 06106 (203) 566-8007

DELAWARE

Ruth Fischer Administrator, Medical Services Division of Economic Services, DHSS P.O. Box 906 New Castle, Delaware 19720 (302) 421 -61 39

DISTRICT OF COLUMBIA

James F. Harris, R.Ph. Pharmacy Consultant Office of Health Care Financing Department of Human Services 1331 H Street, NW Washington, D.C. 20005 (202) 727-0753

FLORIDA

Jerry F. Weils Pharmacist Consultant Medicaid Office of Program Development Dept. of Health and Rehabilitative Serv. 131 7 Winewood Boulevard, 5-6. R-243 Tallahassee, Florida 32301 (904) 488-9990

NPC

GEORGIA

Frances Lipscomb. R.Ph. Progam Management Officer Pharmacy Service 2 M.L. King Jr. Drive, S.E. James Floyd Memorial Building West Tower. P.O. Box 38440 Atlanta, Georgia 30334 (404) 656-4044

HAWAII

Omel L. Turk Pharmacist Consultant Public Welfare Division Dept. of Social Services & Housing P.O. Box 339 Honolulu, Hawaii 96809-0339 (808) 548-891 7

IDAHO

Dianne B. Onnen, R.Ph.. M.P.A. Pharmacy Consultant Dept. of Health and Welfare Statehouse Boise, Idaho 83720 (208) 334-4323

ILLINOIS

Ron Gottrich Pharmacy Program Supervisor Medical Assistance Program Illinois Dept. of Public Aid,

2nd Floor 931 East Washington Street Springfield, Illinois 62708 (21 7) 782-0563

INDIANA

Marc Shirley Pharmacy Consultant lndiana State Dept, of Public Welfare 100 North Senate Avenue Room 702 Indianapolis, Indiana 46204 (317) 232-4312

Ronald J. Mahrenholz, R.Ph.. MS. Manager, Operations Section Bureau of Medical Services Dept. of Human Services Hoover State Office Building, 5th Floor Des Moines, Iowa 50319 (51 5) 281 -61 99

KANSAS

Gene Hotchkiss, R.Ph. Pharmacist Consultant Dept. of Social & Rehabilitation Sew State Office Building Topeka, Kansas 6661 2 (91 3) 296-3981

KENTUCKY

Ms. Gene A. Thomas, R.Ph. Division of Medical Assistance Bureau of Social Insurance 275 East Main Street, 3rd Floor Frankfort, Kentucky 40621 (502) 564-4321

LOUISIANA

Merrell Patin Pharmacist Consultant Dept. of Health & Human Resources P.O. Box 44065 Baton Rouge, Louisiana 70808 (504) 342-9320

MAINE

Michael P. O'Donnell, R.Ph. Pharmacy Consultant Br. Med. Sew. Section 11 Dept. of Human Services Statehouse Augusta. Maine 04333 (207) 289-2674

NPC

MARYLAND MISSOURI

Joseph Fine, R.Ph. Section Manager for Pharmacy

Operations Medicai Assist. Operations Admin 300 West Preston Street Baltimore, Maryland 21201 (301) 383-2658

MASSACHUSETTS

Robert Karlyn. B.S., R.Ph. Department of Public Welfare 600 Washington Street, Room 746 Boston, Massachusetts 021 11 (617) 727-1391

MICHIGAN

Robert Levin, D.D.S., Director Bureau of Health Sewices Review Medical Service Administration Department of Social Services P.O. Box 30037 Lansing, Michigan 48909 (617) 373-7720

MINNESOTA

John T. Bush, R.Ph. Pharmacist Consultant Professional Services Section Dept. Public Welfare, Medical Assist. 444 Lafayette Road, P.O. Box 43170 St. Paul, Minnesota 55101 (612) 296-2363

MISSISSIPPI

James T. Steele. R.Ph. Pharmacist Mississippi Medicaid Commission P.O. Box 16786 4785 1-55 North Jackson. Mississippi 39236 (601) 981 -4507 Ext. 145

Susan McCann, Ph.D. Pharmaceutical Consultant, Medical Services Division Department of Sociai Services 227 Metro Drive, P.O. Box 6500 Jefferson City, Missouri 65102 (31 4) 751 -3277

MONTANA

Randal P. Bowsher Pharmacy Consultant, Admin. Officer Dept. Social & Rehabilitation Services P.O. Box 421 0 Helena, Montana 59604 4061444-4540

NEBRASKA

Tom R. Doian, R.Ph. Pharmaceutical Consultant Medical Services Div. Dept. of Social Services 301 Centennial Mall South, 5th Floo~ P.O. Box 95026 Lincoln, Nebraska 68509 (402) 471 -3121

NEVADA

Steven P. Bradford, Pharm.D. Pharmaceutical Consultant Nevada Medicaid Off ice Dept. Human Resources State Capitol Complex 251 Jeanell Drive Carson City, Nevada 89710 (702) 885-4869

NEW HAMPSHIRE

Clifford A. Zilch, R.Ph. Chief, Bureau of Medicai Claims Review Dept. of Health and Welfare Hazen Drive Concord, New Hampshire 03301 (603) 271 -4359

OKLAHOMA

sanford Luger, R.Ph. chief, Bureau of Pharmacy Services Div. of Medical Assistance & Heaith

Services 324 East State Street, CN-712 Trenton, New Jersey 08625 (609) 292-3756

Nick Army, R.Ph. Drug Program Administrator Medical Assistance gept. of Human Services pERA Bldg., Room 524 Santa Fe, New Mexico (505) 827-4315

NEW YORK

Gerald F. Nelligan, R.Ph. Associate Social Services

Medical Assistance Specialist ~mbulatory Standards Unit 40 North Pearl Street Albany, New York 12243 (518) 474-9261

NORTH CAROLINA

C. B. Ridout, R.Ph. pharmacist Consultant Division of Medical Assistance Qept. of Human Resources Kirby Building' 1985 Umstead Drive ~aleigh, North Carolina 27603 (919) 733-2833

NORTH DAKOTA

chuck Gress, R.Ph. ~dministrator of Pharmacy Services Department of Human Services State Capitol Building Bismarck, North Dakota 58505 (701) 224-4023

Robert P. Reid, R.Ph. pharmacist Consultant

Howard Stansberry Pharmacy Program Administrator Dept. of Human Services P.O. Box 53034 Oklahoma City, Oklahoma 73125 (405) 521 -3804

OREGON

Charles N. Mortensen. R.Ph. Pharmacist Consultant Adult and Family Services Division Dept. of Human Resources 203 Public Service Building Salem, Oregon 9731 0 87504-2348 (503) 378-2263

PENNSYLVANIA

Joseph E. Concino, R.Ph. Bureau of Policy and Program Development Department of Public Welfare, Room 510 Health and Welfare Building Harrisburg, Pennsylvania 17120 (717) 787-1 170

RHODE ISLAND

John A. Pagliarini, R.Ph. Assistant Administrator Department of Social & Rehabilitative Services 600 New London Avenue Cranston, Rhode Island 02920 (401) 464-2183

SOUTH CAROLINA

James Assey Medicaid Program Consultant Department of Health & Human Financ P. 0. Box 8206 Columbia, South Carolina 29202-8206 (803) 758-2320

SOUTH DAKOTA

Donald Mahannah, Fi.Ph. Pharmacist Consultant Department of Social Services Medical Services 700 North Illinois Pierre, South Dakota 57501

NPC

Bureau of Medicaid Policy Department of Human Services 30 East Broad Street-31st Floor Columbus, Ohio 43215 (61 4) 466-6420

TENNESSEE

Ronald E. Graham, Pharm.D. Director of Pharmacy Serivces Tennessee Department of Public

Health and Environment 729 Church Street Nashville, Tennessee 37219-5406 (61 5) 741 -01 92

TEXAS

W. Blount Earner, R.Ph., D.Ph. Program Specialist, Vendor Drugs Texas Department of Human Resources Mail Code 541-W, P.O. Box 2960 Austin, Texas 78769 (512) 450-3202

UTAH

RaeDell Ashley, R.Ph. Manager, Program Operations and

Medical Determinations Health Care Financing Utah Department of Health 150 W. North Temple, P.O. Box 2500 Salt Lake City, Utah 841 10 (801) 533-6648

VERMONT

Robert Edson, R.Ph. Pharmacy Consultant Medicaid Division Department of Social Welfare 103 South Main Street Waterbury, Vermont 05676 (802) 241 -2880

VIRGINIA

Mary Ann Johnson, R.Ph. Pharmacist Consultant Medical Assistance Program State Department of Health 109 Governor Street, VMAP Richmond, Virginia 23219 (804) 786-3820

WASHINGTON

William P. Pace, R.Ph. Pharmacist Consultant Office Medical Dir. Mail Stop HB-41 Olympia, Washington 98504 (206) 753-0524

WEST VIRGINIA

Bernard Schlact. R.Ph. Pharmacy Coordinator Division of Medical Care West Virginia Department of Welfare 1900 Washington Street, East Charleston, West Virginia 348-8990

WISCONSIN

Michael Boushon Pharmacist Consultant Wisconsin Dept. of Health

and Social Service P.O. Box 309 Madison, Wisconsin 53701 (608) 266-0722

PUERTO RlCO

Emilia Hoyos Rucabado, M.S. Pharmacist Consultant Department of Health Bldg. A, Call Box 70184 San Juan, Puerto Rico 00936 767-6060 x 2232

NPC 1985

GLOSSARY OF MEDICAID TERMS

0 Capitation (fee): Fee the agency pays periodically to a contractor for each recipient enrolled under a contract for the provision of medical services under the State plan, whether or not the recipient receives the services during the period covered by the fee.

a Categorically Needy. Under Medicaid, categorically needy cases are aged, blind, or disabled individuais or families and children who are otherwise eligible for Medicaid and who meet financial eligibility requirements for AFDC, SSI, or an optional state supplement.

0 Copayment: Copayments are a type of cost-sharing under Medicaid whereby insured or covered persons pay a specified fiat amount per unit of seivice or unit of time, and the insurer pays the rest of the cost.

a Covered Services: Covered services are the specific services and supplies for which Medicaid will provide reimbursement. Covered services under the Medicaid program consist of a combination of mandatory and optional services within each state.

Customary, Prevailing, and Reasonable Charges: Metnod of reimbursement used under Medicare which limits payment to the lowest of the following: a physician's actual charge, the physician's median charge in a recent prior period (customary). or the 75th percentile of charges in that same time period (prevailing).

e Customaw Charge: The charge a physician or supplier usually bills his patients for furnishing a particular service or supply is called the customary charge.

a Diagnosis Related Groups: Tnese groupings are used for incorporating severity of illness measure- ments into the process for prospective payment determination for inpatient hospital sewices.

e Early and Periodic Screening, Diagnosis, and Treatment (EPSDT): The EPSDT program covers screening and diagnostic services to determine physicial or mental defects in recipients under age 21, and health care, treatment, and other measures to correct or ameliorate any defects and chronic conditions discovered.

0 Expenditures: Under Medicaid, "expenditures" refers to an amount paid out by a state agency for the covered medical expenses of eligible participants.

a Family Planning Services: Family planning services are any medically approved means, including diagnosis, treatment, drugs, supplies and devices, and related counseling which are furnished or prescribed by or under the supervision of a physician for individuals of childbearing age for purposes of enabling such individtials freely to determine the number or spacing of their children.

a Fiscal Agent: A fiscal agent (fiscal intermediary) is a contractor that processes or pays vendor claims on behalf of the Medicaid agency.

a Health Maintenance Organizations (HMO's): A health care plan that deliveries comprehensive, coordinated health care services to voluntarily enrolled members on a prepaid basis.

HMO Model Types:

Group Practice or Closed Panel-An HMO that contracts with a medical group, partnership, or corporation composed of health professionals licensed to practice medicine or osteopathy as well as other health professionals necessary for the provision of health services. In a group practice arrangement, all physicians are usually located in one facility and are compensated on a capitation basis.

Individual Practice Association (IPA) or Foundation Model-An HMO that contracts with a partnership, corporation, or association whose major objective is to enter into contractual arrangements with health professionals for the delivery of health service. Unlike the group practice arrangement, the ~ ~ ~ ' o r ~ a n i r a t i o n provides services in a variety of locations, allowing physicians to work directly from their own offices and permitting the HMO members to retain the mode of delivery to which he may be accustomed. Physicians are usually compensated by the IPG. on a fee-for-service arrangemeni.

30

NPC

Staff HMO-An HMO that delivers services through physicians who are on the staff of the HMO, i.e., are paid directiy by the HMO and not through a physician organization or legal entity.

Home Health Agency: A home health agency is a public agency or private organization which is primarily engaged in providing skilled nursing sewlces and other therapeutic services in the patient's home, and which meets certain conditions designed to ensure the health and safety of the individuais who are furnished these services.

0 Home Health Services: Home health services are services and items furnished to an individual who is under the care of a physician by a home health agency, or by others under arrangements made by such agency. The services are furnished under a plan established and periodically reviewed by a physician. The services are provided on a visiting basis in an individual's home and include: parttime or intermittent skilled nursing care; physical, occupational, or speech therapy; medical social services, medical supplies and appliances (other than drugs and biologicals); home health aide services, and services of interns and residents.

0 lnpatient Hospital Services: lnpatient hospital services are items and services furnished to an inpatient of a hospital by the hospital, including bed and board, nursing and related services, diagnostic and therapeutic services, and medical or surgical services.

0 Intermediate Care Facility: An intermediate care facility is an institution furnishing healthrelated care and services to individuals who do not require the degree of care provided by hospitals or skilled nursing facilities as defined under Title XiX (Medicaid) of the Social Security Act.

0 Laboratory and Radiological Services: Laboratory and radiological services are professional and technical laboratory and radiologicai services ordered by a iicensed practitioner and provided in an office or similar facility (other than a hospital outpatient department or clinic) or by a qualified laboratory.

0 Medically Needy: Under Medicaid, medicaily needy cases are aged, blind, or disabled individuals or families and children who are otherwise eligible for Medicaid, and whose income resources are above the limits for eligibility as categorically needy (AFDC or SSI) but are within limits set under the Medicaid state plan.

0 Other Practitioners' Services: Other practitioners' services are health care services of iicensed practitioners other than physicians and dentists.

0 Outpatient Hospital Services: Outpatient hospital services are services furnished to outpatients by a participating hospital for diagnosis or treatment of an illness or injury

0 Prescribed Drugs: Prescribed drugs are drugs dispensed by a licensed pharmacist on the 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.

0 Reasonable Charge: In processing claims for Supplementary Medical lnsurance benefits, carriers use HCFA guidelines to establish the reasonable charge for services rendered. The reasonable charge is the lowest of: the actual charge billed by the physician or supplier: the charge the physician or supplier customarily bills his patients for the same services, and the prevailing charge which most physicians or suppliers in that locality biil for the same service. Increases in the physicians' prevailing charge levels are recognized only to the extent justified by an index reflecting changes in the costs of practice and in general earnings.

0 Reasonable Cost: In processing claims for Health lnsurance benefits, intermediaries use HCFA guidelines to determine the reasonable cost incurred by the individual providers in furnishing covered services to enrollees. The reasonable cost is based on the actual cost of providing such services, including direct and indirect costs of providers, and excluding any costs which are unnecessary in the efficient delivery of services covered by the insurance program.

e Recipient: A recipient of Medicaid is an individual who has been determined to be eligible for Medicaid and who has used medical services covered under Medicaid.

NPC 1985

0 Rural Health Clinic: A rural health clinic is an outpatient faciiity which is primarily engaged in furnishing physicians' and other medical and health services, which meets certain other requirements designed to ensure the health and safety of the individuals served by the clinic. The clinic must be located in an area that is not an urbanized area as defined by the Bureau of the Census and that is designated by the Secretary of DHHS either as an area with a shortage of personal health services, or as a health manpower shortage area, and has filed an agreement with the Secretary not to charge any individual or other person for items or services for which such individual is entitled to have payment made by Medicare, except for the amount of any deductible or coinsurance amount applicable.

0 Skilled Nursing Facility (SNF): A skilled nursing facility is an institution which has in effect a trans- fer agreement with one or more participating hospitals, and is primarily engaged in providing to inpatients skilled nursing care and restorative care services, and meets specific regulatory certification requirements.

0 Skilled Nursing Facility Services: SNF services are all services furnished to inpatients of, and billed for by, a formally certified skilled nursing facility that meets standards required by the Secretary of DHHS.

0 SpendDown: Under the Medicaid program, spenddown refers to a method by which an individual establishes Medicaid eligibility by reducing gross income through incurring medical expenses until net income (after medical expenses) meets Medicaid financial requirements.

0 State Buyln: State buyin is the term given to the process by which a state may provide Supplementary Medical Insurance coverage for its needy eligible persons through an agreement with the Federal government under which the state pays the premiums for them.

0 State Plan: The Medicaid State Plan is a comprehensive written commitment by a Medicaid agency to administer or supervise the administration of a Medicaid program in accordance with Federal requirements.

0 Supplemental Security income (SSI): SSI is a program of income support for lowincome aged, blind, and disabled persons established by Title XVI of the Social Security Act.

0 Third-Party Liabllity: Under Medicaid, thirdparty liability exists if there is any entity (including other government programs or insurance) which is or may be liable to pay all or part of the medical cost or injury, disease, or disability of an applicant or recipient of Medicaid.

0 hndor: A medical vendor is an institution, agency, organization, or individual practitioner which provides health or medical services.

NPC

ACRONYMS

AABD AB AFDC APTD CFR CPR DHHS DRGs EPSDT FY HCFA HMO ICF MAC MMlS MQC NMCUES NP OAA OASDl OBR A ORD OT OTC PA PT RHC SNF SSA SSI SSP TDOC TEFRAA UCR

Aid to Aged, Blind, and Disabled Aid to the Blind Aid to Families with Dependent Children Aid to the Permanently and Totally Disabled Code of Federal Regulations Customary Prevailing, and Reasonable (charges) Department of Health and Human Services Diagnostic Related Groupings Early and Periodic Screening, Diagnostic and Treatment Fiscal Year Health Care Financing Administration Health Maintenance Organization Intermediate Care Facility Maximum Allowable Cost Medicaid Management Information System Medicaid Quality Control National Medicare Care Utilization and Expenditures Survey Nurse Practitioner Old Age Assistance Old Age, Survivors, and Disablity Insurance Omnibus Reconciliation Act 1981 Office of Research and Demonstrations Occupational Therapy Overthecounter (drugs) Physician's Assistant Physical Therapy Rural Health Clinic Skilled Nursing Facility Social Security Administration Supplemental Security Income State Supplemental Payments Total Days of Care Tax Equity and Fiscal Responsibility Act Usual, Customary and Reasonable (charges)

I(ED1CAIO DRUG REIWURSMMT Table I A Page Two

...................... ~ i s c a l year 1985 ------------------- .---.------------ Fisca l Year 1984 ------------------- Ingred ien t Fonnu- #State Medicaid Average Average Number o f

Dispensing Copay- Reimburse- Formu- l a r y State MAC'd Drug Ingred. Cost Presc r ip t ion Presc r ip t ions State Fee ment ment Basis l a r y Status MAC Drugs Expenditures Per Claim Price* Processed*

Massachusetts 3.25 AWP/EAC No B yes (4) 58,298,292 12.02 NA

Michigan .O . O AAC Yes C c 10.40 10.8 8.285

Minnesota 4.30 AWP-10% Yes C No 35,655,862 6.80 11.13 3,534,814

Miss iss ipp i c . .O EAC Yes C 12.01 3,340,389

Missouri 2.50 .50-2.0 AMP/EAC Yes C c ,662.55

Montana 2.00-3.75 .50 AWPIEAC No B NO 5,074,659 7.14 10.64 442,069

Nebraska 3.25-4.69 EAC No B Yes 220 11.325.229 9.56 11.74 1,021,640

Nevada 3.78 1.00 AWP-5% No B No 2.941.202 12.69 212,183

New Hampshire 2.85 .75 EAC No B No 4,928,443 N A N A W m New Jersey 3.53-3.87 AMP-016% No B No 67,421,822 7.43 10.54 6,905,548

New Mexico 3.65 AWPIEAC No B Yes 168 9,427,783 9.14 12.79 789,822

New York 2.60 EAC Yes , C No 202.701.752 9.04 11.64 17,928,987

North Carol ina 3.36 .50 AWPIEAC No A No 39,622,195 9.83 12.86 3,316,160

North Dakota 3. 5 EAC NO B B 7.72 11.5 14.023

Ohio 2. 0 AMP-7 Yes C c Oklahoma 3.55 Max. AWPIEAC Yes C Yes 75 16.535.307 11.88 15.29 1,097,560

regon 3. AWPIEAC No B B , 41, 03

Pennsy vania . 5 .5 AWPIE C No B B .72 13,815,483

Rhode Is land 3.25 AWPIEAC No B Yes 10 11.216.084 11.21 1 ,002,061

South Carolina 3.40 .50 AMP-7.5% No B No 22.041.244 9.52 12.05 1,737,968

South Dakota 3.2 1. 0 AWP Yes C c 2.1 284.396

Tennessee 3.36 AAC Yes C Yes 180 53,582,671 9.11 12.36 4,304.448

Table IA Page Three

Fiscal year 1985 ...................... ----------------- Fiscal year 1984 ------------------- Ingredient Formu- #State W i c a i d Average Average Number o f

Dispensing Copay- Reimburse- Formu- l a r y State M a d Drug Ingred. Cost Prescr ipt ion Prescript ions State Fee ment meni Basis l a r y Status MAC Drugs Expenditures Per Claim Price* Processed*

Texas 3.72-4.05 AWPIEAC NO A No 94.794.375 12.35 15.78 6,579,073

Utah 3.25 EAC No B No 5,489,059 5.57 8.82 638.293

Vermont 2.50 1.00 AMP No A Yes 155 5,142.532

V i rg in ia 3.40 SO-1.00 AUPIEAC No 8 Yes 138 7.53 9.88 3,670,206

Washington 3.00-3.70 89XAUP Yes C Yes 142 25,946,074 7.60 10.89 2,631,639

es t i r g l n i a . . - . UP es C c 8.80 895,271

Wisconsin 3.61 .50 AWPIEAC No B Yes 145 46,871,019 6.49 10.41 2,438.506

w R y m ~ n g No Vendor Drug Program

Legend :

(1) Co l lec t ion by pharmacy i s opt ional (2) Plus $0.50 incent ive fee f o r dispensing generic product (3) State funded rec ip ien ts only (4) Most mu1 t i -source drugs (5) Wholesaler cos t p lus a percentage

* Approximate number

A - No drug l i s t - a l l legend drugs reimbursed B - No drug l i s t - bu t ce r t a i n catagories excluded from reimbursement C - Restr ic ted drug l i s t

In fornat ion i n t h i s tab le was obtained from an NPC survey o f State Medicaid Departments

DRUG RECIPIEHTS M D VENDOR PAVNEWTS Table IB Page One

Average Vendor Average Drug % o f Medicaid Tota l Tota l Vendor Expenditure Drug orug Expenditure $ A1 loca ted

State Recipients Medical Payrnents Per Recipient Recipients Payrnents Per Recip ient t o Drugs

A1 abama 315.666 $366,328,236 $1,160 226.256 135,266,930 $156 9.6%

Alaska 24,068 65,612,614 2.726 p ~ ~ p ~

Arizona

Arkansas -5.668 1.689 155.131 33.166.977 214 10.22

Ca l i fo rn ia 3.395.080 3,472,708,099 1.023 2.172200 205.707.914 95 5.9%

Colorado 1 . 26 0, 9. S ,616. 7 5.

Connecticut 220.090 591 .48631 2,460 157,029 159 4.6%

Delaware 47.253 67.988.932 1.439 31.038 98 4.52

D.C. c 5 3 3 9 . 09 5.

F lo r ida 572.127 7 9 0, 6.263 1.29 178 10.

Georgia 421,124 602,508,978 1,431 386.758 68.365.809 177 11.4%

Hawaii 95,413 131,736.032 1.381 71.049 6.428.885 90 4.9%

Idaho 3 , 1 ,543. 93 3.

I l l i n o i s 1.6X299.209 1.328 782.353 125 5.91

Indiana 271,956 642.012.489 2,361 206.532 44.034.163 213 6.9%

~ o w a 200.564 316,511.0 5 0 20.978.23 142 6.

Kansas 2 6 .5 106.755 117.3o5.55-

Kentucky 4 9 9,3 86, .9

Louisiana 3 8 2 . 3 6 7 6 8 2 . 2 4 6 . 4 4 9 1.784 289,689 212 9.0%

Maine 121,843 215,249,151 1 1, 67 159 6 7

7 3 1 , 5 2 5 234.441 32,967,163 141 6.7%

Mas~achusetts r n 3 ~ 9 3 i ~ m 2.413 3lsT6r;578;Tg8,292 154 4 .r Michigan 1,-155,165 r.574,044,207 1.363 764.048 86.822.120 114 5.5%

DRUG RECIPIENTS M D VENDOR PAYMENTS Table I 8 Page Two

Average Vendor Average Drug I o f Medicaid Total Total Vendor Expenditure Drug Drug Expenditure $ Al located

State Recipients Medical Paynents Per Recipient Recipients Paynents Per Recipient t o Drugs

Minnesota 341.174 1947,316,494 $2.777 221,465 $35,655,862 $161 3.8%

Miss iss ipp i 302,437 307.469284 1.017 241,805 38.883.529 161 12.7%

Missouri 356.753 502,254.322 1.550 248,371 29.577.082 119 5.9%

Montana 46.516 92356.743 1,998 30.178 5,074,659 168 5.5%

Nebraska 86.432 151.740.691 1,756 63,473 178 7.5%

Nevada 7,435 % ,9412 .5

New Hampshire 39,433 108,815.390 2.760 27.512 4,928.443 179 4.5%

New Jersey 596,937 1,082.154.989 1.813 484.755 67,421822 139 6.2%

New Mexico 83.026 1,550 59.873 9.427.783 157 7.3%

New York 2,205.138 6,795,024,224 3.081 1,477.239 202.701.752 137 3.0% -

North Carolina 340.499 605,732,042 1,779 236.926 39,622.195 167 6.5%

North Dakota 33.705 97,338,011 2,888 21.240 4,704,007 221 4.8%

Ohio 1,014.647 1,613,303,363 1,590 744.524 142,454,356 191 8.8%

hlahoma 252,450 403223,436 1.597 117.296 16,535.307 141 4.lZ

Oregon 139.413 221,900.783 1,592 97,454 14,803.643 152 6.7%

Pennsy vania 1,059. , 8 ,022. 2 99.095.892 13 5.91

Rhode ls land 4. 34. 06, 02 2 11,216,084 134 4.8%-

South Carolina 231,394 287,729,166 1,243 164,329 22,041,244 134 7.7%

South Dakota 32.552 89,732,636 2.757 19,444 3,474,613 179 3.9%

ennessee 345. 02 4 ,169, 9 53,582,671 21 9.9%

Texas 715.278 1.920 568,155 94,794.375 167 6.9%

Utah 69,353 1.620 47.008 5,489.059 117 4.9%

ennont 0 ,142,532 134 5.8%

DRUG RECIPIENTS AND VENWR PAYMENTS Table IB Page Three

Average Vendor Average Drug % o f Medicaid Total Total Vendor Expenditure Drug Drug Expenditure $ Al located

State Recipients Medical Paynents Per Recipient Recipients Paynents Per Recipient t o Drugs

V i r g i n i a 301,448 1494,225,868 $1,640 221.394 $36,050.372 $163 7.3%

Washington 301.254 501,478,983 1,665 214.123 25.946.074 121 5.2%

West 0 V i r g i n i a 85, 3 2 0, 8.449.268 .3%

Wisconsin 9 ,328 931,685.9 4 9 46,871,019 14 5.0%

Wyoming . 9 9

United States 20.251.575 $34.135.788.352 $1.781 14.004.571 $1.979.822.741 $150 6.32

Excludes Puerto Rico and V i r g i n I s land

Table IC Page One

Ingredient I of Reinbursenent Formulary State State WAC'd

Dispensing Fee Copayaent Basis Formulary Status WAC Drugs State 1985 1984 . 1985 1984 1985 1984 1985 1W 1985 1985 1984 1985

Alabama $3.25 $2.75 .50-3.00 .50-3.00 EAC EM: Yes Yes C No No

Alaska No Vendor Drug Program

Anzona AHCCCS c a p i t a t i o n Plan

Arkansas 3.8 8 E AC NO NO B Yes Yes o

Ca i f o r n i a .O 3. 1 1 Yes Yes C Yes Yes

Colorado 0 3. .50 C Yes Yes 1

Connecticut $3.11[21 $3.11(21 - - MPlEAC AWPIEAC NO No B No No

B B NO NO

ax. $3.95 3.95 50 50 AWP E AC N~ N~ B N~ N~

F lo r ida $3.33 $3.33 - - AWPIEAC EAC No No 8 NO No

Georgia $3.61 13.61 - - , AWP E AC Yes Yes C Yes Yes 19

Hawaii .90 0 Yes Yes c NO NO

Idaho $2.50-3.50 $2.50-3.50 - - AWPIEAC EAC No No B No No

f l l i n o i s 13.46 13.30 - - AAC AM: Yes Yes C Yes Yes 5009

Indiana $3.00 $2.50 - - AWP-3% EAC NO NO B NO NO

Iowa 3. 8 . 8 1.00 0 NO NO B Yes Yes 2-

Kansas . . q Yes NO c Yes NO 1

Kentucky $3.25 $3.25 - AWPIEAC EAC Yes No C Yes Yes 133*

Louisiana $3.67 $3.67 - - EAC EAC No Yes B Yes Yes 392*

Maine $3.20 $3.20 .50 .50 AWP-5% EAC NO Yes B No No

Mary and 3. 0 Yes NO

Table 1 C Page Two

Ingred ien t I o f Reimburse~nent Formulary S ta te State MAC'd

Dispensing Fee Lopayment Basis Fomulary Status MAC Drugs

State 1985 1984 ' 1985 1984 1985 1984 1985 1984 1985 1985 1984 1985

Massachusetts $3.25 $3.09 - - AUPIEAC AUPIEAC NO Yes B Yes Yes (4 )

Michigan $3.00 $2.75 .50 .50 AAC AUPlAAC Yes Yes C Yes Yes 64

Minnesota $4.30 $1.30-5.00 - - AMP-102 EAC Yes Yes C NO NO

Miss iss ipp i $3.33 $3.33 1.00 - EAC EAC Yes Yes C Yes Yes 500*

Missouri 2. 0 . O 0 C Yes Yes 60

Montana $2.00-3.75 $2.00-3.75 .50 - AUPlEAC EAC NO NO B NO NO

Nebraska . - . 9 .28-3.69 - - EAC EAC NO ye6 B Yes Yes 220

Nevada $3.78 $3.78 1.00 1.00 AUP-52 EAC No No B No No

New Hampshire $2.85 $2.85 .75 1.00 EAC EAC NO NO B NO No

New Jersey $3.53-3.87 $3.16-3.38 - - AUP-016% EAC NO NO B NO NO

New Mexico $3.65 $3.65 - - AWPIEAC EAC No Yes B Yes Yes ( 4 )

New York $2.60 $2.60 - - EAC EAC Yes Yes C No No

North Carol ina $3.36 $3.36 .50 .50 AUPIEAC AUPIEAC No No A NO No

North Dakota $3.75 $3.75 - - EAC AMP No No B NO NO

Ohio $2.60 $2.60 - - AUP-7% EAC Yes Yes C Yes No 4 0

Oklahoma 03.55 $3.55 - - AWPIEAC EAC yes yes C Yes NO 75

Oregon $3.57 $3.40 - - AWP/EAC EAC No NO B Yes Yes 292

.-- ~ennsy ivan ia $2.75 $2.75 5 AWPIE C Y No No

khode i s land $3.25 8 3 . r - - AWPIEAC AUP/EAC NO No B Yes Yes 10

South Carol ina $3.40 $3.03 .SO .50 AMP-7% EAC No Yes 6 NO NO

Table I C Page Three

Dispensing Fee

Ingredi ent I of Reimbursement Formulary State State MAC'd

Copayinent Basis Formulary Status MAC Drugs

State 1985 1984 1985 1984 1985 1984 1985 1984 1985 1985 1984 1985

South Dakota $3.25 $3.25 1.00 1.00 AMP EAC Yes No C No No

Tennessee $3.25 $3.25 - - AAC AAC Yes Yes C Yes Yes 180

--- -

Texas $3.72-4.05 $3.45-3.80 - - AWPIEAC AWPIEAC No No A No No

Utah $3.25 $3.25 - - E AC EAC No Yes B No No

Vermont $2.50 12.50 1.00 1.00 AWP AMP NO NO A Yes No 155

V i rg in ia $3.40 $2.85 .50-1.00 .SO-1.00 AWPIEAC EAC No No 8 Yes Yes 138

Washington $3.00-3.70 $3.00-3.70 - - 89%AWP EAC yes Yes C Yes Yes 142

West Vi rg in ia $2.75 $2.75 .50-1.00 .50-1.00 AMP AWP Yes Yes C No No

Uisconsin $3.61 $3.50 .50 - AUPIEAC EAC No Yes B Yes Yes 145

Wyomi ng No Vendor Drug Program

Legend :

(1) Col lect ion by pharmacy i s optional A - No drug l i s t - a l l legend drugs reimbursed (2) Plus $0.50 incent ive fee for dispensing generic product B - NO drug l i s t - but ce r t a i n categories excluded from (3) State funded rec i p i en t only reimbursement (4) Most mu l t i source drugs C - Restr ic ted drug l i s t (5) Wholesaler cost p lus a percentage

Approximate number Information i n t h i s t ab le mas obtained from an NPC Survey o f State Medicaid Departments.

NPC

VENDOR PAYMENTS FOR PRESCRIBED DRUGS

Table 13 Page One

(Amounts in Thousands)

State 1979 1980 1981 1982 1983 1984

U.S. Total $1 , I 79,985 $1,323,011 $1,530,329 $1,599,143 $1,770,834 81,979,822'

Alabama 21,422 19,984 24,243 28,269 31 $1 6 35,266

Arkansas 19,000 21,455 23,165 21,085 28,219 33,166

California 157,014 172,487 207,591 231,590 213,168 205,707

Colorado 9,712 10,823 12,128 14,319 14,896 16,616

Connecticut 14,155 15,393 17,970 17,394 21,265 24,948

Delaware 1,845 2,046 2,301 2,468 2,706 3,049

D.C. 4,935 5,732 6,124 6,717 7,180 8,113

Florida 33,240 38,150 45,743 48.794 60,670 76,184

Georgia 37.000 45,888 54,597 47,706 60,935 68,365

Hawaii 5,122 4,958 4,824 5,204 6,324 6,428

Idaho 2,316 2.222 2,337 2,452 2,463 2,543

Illinois 78,932 92,142 99,015 91,880 96,506 98,044

Indiana 22,184 26,530 30,933 36,483 39,459 44,034

Iowa 13,240 13,916 15,315 16,052 19,031 20,978

Kansas 11,078 13,249 14,460 15,687 15,975 17,305

Kentucky 13.629 14,922 16,615 15,665 19,505 27,996

Louisiana 39,396 45,205 46,037 52,280 57,026 61,313

Maine 8,284 8,213 9,634 10,357 12,403 13,459

Maryland 13,929 16,264 19,342 22,280 28,570 32.967

Massachusetts 32,278 34,651 47,559 49,794 52.752 58,298

Michigan 59,436 69,755 74,525 71,581 77,561 86,822

Minnesota 20,647 23,012 27,447 29,352 30,746 35,655

Mississippi 21,816 26,855 27,157 28.457 36,973 38,883

Missouri 21,107 25,516 31,395 23,011 25,569 29,577

Montana 2,497 2,880 3,521 4,172 3,965 5,074

Nebraska 6,942 7,765 8,888 9,570 10,636 11,325

Nevada 1,393 1,702 2,258 2,412 2,663 2,941

New Hampshire 3,059 3,365 3,726 3,391 4,241 4,928

New Jersey 36,699 42,945 48,369 54,399 61 ,I 25 67,421

New Mexico 4,442 5,294 6,141 6.81 7 7,569 9.427

New York 98,561 120,137 122.648 142,259 173,095 202,701

North Carolina 29,131 32,401 34,598 31,488 35,460 39,622

North Dakota 2,571 2,697 3,310 3,442 4,002 4,704

NPC 1985

Table ID Page Two

(Amounts in Thousands) State 1979 1980 1981 1982 1983 1984 Ohio 46,104 47,953 92,147 96,681 1 17,695 142,454

Oklahoma 7,586 8,621 12,013 12,399 14,775 16,535

Oregon 7,933 8,769 10,215 1 1.408 14,552 14,803

Pennsylvania 70,950 60.315 64,524 75,911 87,571 99,095

Rhode Island 6,962 8,087 9,061 9,760 9,997 11,216

South Carolina 14.371 17,963 21,759 16,866 18,410 22,041

South Dakota 1,720 1,920 2,177 2,934 3, 128 3,474

Tennessee 34,740 40,974 44,003 48,241 47,686 53,582

Texas 58,874 64,227 74,124 76,120 83.933 94,794

Utah 3.783 3,796 4,484 3,622 4,618 5,489

Vermont 3,026 3,468 3,891 3,829 4,151 5,142

Virginia 20,519 23,950 27,121 29.862 31,067 36,050

Washington 15.1 76 17,485 19,380 19,661 21,968 25,946

West Virginia 9,550 10.833 10,868 8.400 591 4 8,449

Wisconsin 31,618 36,103 40,646 36,623 41,125 46,871 ~~ ~ ~

Source: HCFA 2082 reports, compiled by State Medicaid program officials. Although the reports have been reviewed and edited by HCFA, they may still contain some reporting errors. Despite these potential shortcomings the 2082 HCFA data represent the most accurate figures available on utilization of state Medicaid services.

'These totals do not include the Virgin Islands and Puerto Rico.

NPC /

! 985

d R E a P m n s P R E s c R m E D m u G s /' Table IE

Page One

State 1979 1980 1981 1982 1983 1984

U S . Total bd3,277,148 13,720,161 14,248,165 13,668,131 13,678,801 14,001,571"

Alabama 237,383 222,525 223,538 222,109 222,713 226,256

Arkansas 169,073 173,089 171,781 151,711 151,260 155,131

California 2,248,819 2,266,520 2,363,220 2,397,000 2,225,500 2,172,200

Colorado 118,377 95,762 97,582 99,346 103,453 105,519

Connecticut 148,579 150,451 154,473 143,675 153,729 157,029

Delaware 32,369 34,608 34,535 33,743 31,940 31,038

D.C. 78,308 78,328 69,970 69,056 68,338 65,009

Florida 327,873 374,670 408,923 389,534 414,406 429,016

Georgia 307,794 320,550 352,118 330,380 312,218 386,758

Hawaii 80,456 77,845 74,968 75,634 75,458 71,049

Idaho 28,998 29,547 28,995 27,114 27,954 27,249

Illinois 757,237 802,882 835,781 803,391 797,800 782,353

Indiana 167,971 182,400 197,846 21 2,071 203,447 206,532

Iowa 130,370 133,215 140,865 128,389 140,110 !48,00!

Kansas 108,671 108,671 107,550 106,097 104,280 106,755

Kentucky 250,531 252,682 263,380 225,493 251,935 31 1,656

Louisiana 287,731 285,349 300,236 276,307 283,027 289,689

Maine 104,871 61,377 94,328 84,469 84,577 84,396

Maryland 206,257 21 7,405 229,561 226,722 232,522 234,441

Massachusetts 474,396 485,712 488,026 437,710 367,084 378:065

Michigan 659,088 729,394 720,848 742,825 774,896 764,048

Minnesota 190,714 199,721 207,958 206,300 209,514 221,465

Mississippi ~ 226,600 253,466 258,641 232,154 233,956 241,805

Missouri 228,957 240,026 262,935 228,673 237,290 243,371

Montana 26,3f 7 28.612 30,464 32,810 27,715 30,7 78

Nebraska 52,329 53,277 55,403 57,267 60,097 63,473

Nevada 15,622 17,048 19,486 19,116 18,951 18,313

New Hampshire 30,166 30,790 30,304 29,233 29,092 27,512

New Jersey 51 7,656 528,209 525,434 507,658 493,234 484;75.5

New Mexico 59.505 60,702 62,966 60,507 58,324 59,873

New York 1,360,974 1,317,262 1,401,768 1,471,856 1,384,943 : ,477,239 --

North Carolina 281,090 270,169 268,799 237,621 244,187 236,926

North Dakota 20,193 21,973 21,542 20,138 20,575 21,240

Ohio 521,361 520,579 606,702 612.386 670,421 744,524

NPC 1985

Table I€ Page Two

State 1979 1980 1981 1982 1983 1984 Oklahoma 11 1,479 108,366 118,131 104,673 107,971 1 17,296

Oregon 131,111 158,819 111,912 102,258 111,156 97,454

Pennsyivania 680,961 786,013 763,219 590,176 802,731 724,858

Rhode island 84,172 86,418 85,782 83,946 75,751 83,407

South Carolina 173,894 183,569 191,196 168,535 162,074 164,329

South Dakota 18,837 18,723 19,024 19,923 19,812 19,444

Tennessee 257,295 265,135 272,418 271,519 248,128 254,591

Texas 524,494 542,051 565,757 533.520 533,595 568.1 55

Utah 40,839 40,053 45,485 38.688 43,721 47,008

Vermont 35,568 38,851 40,273 38,593 37.905 38,446

Virginia 215,644 236,481 243.71 1 225,290 219,970 221,394

Washingtcn 198,704 208,767 209,566 174,821 185,225 214,123

West Virginia 79,572 105,027 144,221 1 12,497 98,779 115.838

Wiscons~n 267,942 307,072 325,544 305,197 317,137 329.964


'These figures do not include the Virgin Islands and Puerto Rico

NPC

AVERAGE EXPENDITURE PER RECIPIENT FOR PRESCRIBED DRUGS

Table IF Page One

State 1979 1980 1981 1982 1983 1984

U.S. Average $88.87 $96.43 $1 07.41 $1 17.00 $129.00 $i 50.W

Alabama 90.24 89.80 108.45 127.27 142.00 156.00

Arkansas 112.38 123.90 134.85 138.98 187.00 214.00

California 69.82 76.10 87.84 96.62 96.00 95.00

Colorado 82.04 113.02 124.29 144.13 144.00 157.00 Connecticut 95.27 102.31 1 16.33 121 .06 138.00 159.00

Delaware 56.99 59.1 1 64.76 73.13 85.00 98.00

D.C. 63.03 73.18 87.53 97.27 105.00 125.00

Florida 101.38 101.82 111.86 125.26 146.00 178.00

Georgia 120.21 143.15 155.05 144.40 195.00 . 177.00

Hawaii 63.66 63.69 64.35 68.80 84.00 90.00

Idaho 79.85 75.21 80.60 90.45 88.00 93.00

Illinois 104.24 114.76 1 18.47 114.37 121 .OO 125.00

Indiana 132.07 145.45 156.35 172.03 194.00 213.00

Iowa 101 56 104.46 .1 08.72 125.03 136.00 142.00

Kansas 101.94 121.92 134.45 147.85 153.00 162.00

Kentucky 54.40 59.06 63.08 69.47 77.00 90.00

Louisiana 136.92 158.42 153.34 189.21 201 .OO 212.00

Maine 78.99 133.81 102.14 122.62 147.00 159.00 Maryland 67.53 74.81 84.26 98.27 123.00 141 .OO

Massachusetts 68.04 71 3 4 97.45 1 13.76 144.00 154.00

Michigan 90.18 95.63 103.39 96.36 100.00 11 4.00

Minnesota 108.26 1 15.22 131.99 142.28 147.00 161.00

Mississippi 96.27 105.95 105.00 122.58 158.00 161 .OO

Missouri $92.19 $106.31 $1 19.40 $1 00.63 $1 08.00 119.00

Montana . 94.90 100.67 115.58 127.16 143.00 168.00 Nebraska 132.67 145.76 160.43 167.11 177.00 178.00

Nevada 89.16 99.85 1 15.88 126.18 141.00 161.00

New Hampshire 101.39 109.28 122.95 116.00 146.00 179.00

New Jersey 70.90 81.30 92.06 107.16 124.00 139.00

New Mexico 74.66 87.21 97.53 11 2.66 130.00 157.00

New York 72.42 91.20 87.50 96.65 125.00 137.00

North Carolina 103.64 119.93 128.71 132.51 145.00 167.00

North Dakota 127.34 122.72 153.63 170.94 195.00 221 .OO

Ohio 88.43 90.38 151.88 157.88 176.00 191 .OO Oklahoma 68.05 79.55 101.69 11 8.46 137.00 141 .OO

Oregon 60.96 55.21 91.28 111.56 131 .OO 152.00

NPC

Table IF Page Two

State 1979 1980 1981 1982 1983 1984

Pennsylvania 104.19 76.74 84.54 128.62 109.00 137.00

Rhode Island 82.72 93.59 105.63 116.26 132.00 134.00

South Carolina 82.64 97.85 1 13.79 100.07 1 14.00 134.00

South Dakota 91.32 102.54 114.46 147.28 158.00 179.00

Tennessee 138.91 154.54 161.53 177.67 192.00 210.00

Texas 1 10.34 1 18.49 131.02 142.67 157.00 167.00

Utah 92.62 94.76 98.57 93.63 106.00 11 7.00

Vermont 85.08 89.27 96.61 99.23 1 10.00 134.00

Virginia 95.15 101.28 111.28 132.55 141.00 163.00

Washington 76.37 83.76 92.48 1 12.46 1 19.00 121 .OO

West Virginia $1 20.01 $103.14 $75.35 $74.67 $60.00 73.00

Wisconsin 1 18.00 11 7.57 124.86 120.00 130.00 142.00


*These figures do not include the Virgin Islands and Puerto Rico.

NPC

PERCENTAGE OF MEDlCAlD EXPENDITURES ALLOCATED TO PRESCRIPTION MEDICATION

State

U.S. Total

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

Table IG

7983

5.5%

8.6% - -

9.0% 6.0% 5.8% 4.3% 4.4% 3.7% 8.9%

10.1% 4.5% 3.9% 7.2% 6.6% 6.1% 6.3% 4.7% 8.5% 6.0% 6.4% 3.9% 5.5% 3.5%

12.3% 5.5% 4.6% 7.3% 3.6% 4.6% 6.2% 7.4% 2.8% 6.3% 4.8% 8.0% 4.0% 6.4% 5.1% 4.5% 6.6% 4.0% 9.4% 6.4% 4.0% 5.2% 6.4% 5.1%

NPC

West Virginia Wisconsin Wyoming

NPC

RANKING OF STATES BASED ON MEDICAID DRUG EXPENDITURES

Percent 1983 Vendor 1984 Vendor 1983 1 984 Increase

State Drug Payments Drug Payments Ranking Ranking (Dee)

California $213,168,000 $205,708,000 1 1 (3.5%) New York 173,095,000 202,701,000 2 2 17.1 Ohio 117,695,000 142,454,000 3 3 21 .O Pennsylvania 87,571,000 99,096,000 5 4 13.2 Illinois 96,506,000 98,045,000 4 5 (1.6) Texas 83,933,000 94,794,000 6 6 12.9

Michigan 77,561.000 86,822,000 7 7 11.9 Florida 60,670,000 76,184,000 9 8 25.6 Georgia 60,935,000 68,366,000 10 9 12.8

New Jersey 61,125,000 67,422,000 8 10 10.3 Louisiana 57,026,000 61,314.000 11 1 1 7.5 Massachusetts 52,752,000 58,298,000 12 12 10.5

Tennessee 47,686,000 53,583,000 13 13 12.4 Wisconsin 41,125,000 46,871.000 14 14 14.0 Indiana 39,459,000 44,034,000 15 15 11.6

North Carolina 35,460,000 39,622,000 17 16 11.7 Mississippi 36,973,000 38,884,000 16 17 5.2 Virginia 31,067,000 36,050,000 19 18 16.0

Minnesota 30,746,000 35,656,000 20 19 16.0 Alabama 31 5 1 6,000 35,267,000 18 20 11.5 Arkansas 28,219,000 33,167,000 22 21 7.5

Maryland 28,570,000 32,967,000 21 22 15.4 Missouri 25,569,000 29,577,000 23 23 15.7 Kentucky 19,505,000 27,996,000 26 24 44.5

Washington 21,968,000 25,946,000 24 25 18.1 Connecticut 21,265,000 24,949,000 25 26 17.3 South Carolina 18,410,000 22,041.000 28 27 19.6

Iowa 19,031,000 20,978,000 27 28 10.2 Kansas 15,975,000 17,306,000 29 29 8.3 Colorado 14,896,000 16.61 7,000 30 30 11.6

Oklahoma 14,775,000 16,535.000 31 3 1 11.9 Oregon 14,522,000 14,804,000 32 32 1.9 Maine 12,403,000 13,460,000 33 33 8.5

Nebraska 10.636.000 11,325,000 34 34 10.4 Rhode Island 9,997,000 11,216,000 35 35 12.2 New Mexico 7,569,000 9,428,000 36 36 24.6

West Virginia 5,914,000 8,449,000 39 37 42.9 D.C. 7,180.000 8,: 13,000 37 38 (1.9) Hawaii 6,324,000 6,429,000 38 39 1.7

Utah 4.61 8,000 5,489,000 40 40 18.9 Vermont 4,151,000 5,143,000 42 41 23.9 Montana 3,965,000 5,075,000 44 42 28.0

NPC 1985

New Hampshire 4,214,000 4,928,000 41 43 16.9 North Dakota 4,002.000 4,704,000 43 44 15.6 South Dakota 3,128,000 3,475,000 45 45 11.1

Delaware 2,706,000 3.049.000 46 46 12 7 Nevada 2,663,000 2,941,000 47 47 10.4 Idaho 2,463,000 2,544,000 48 48 3.3

Alaska - - Arizona - - Wyoming - - U.S. T O ~ I s i , n 0 , ~ 3 4 , m SI ,WQ,S~~,OOO 11.8%

NPC

State

Table li

RANKING OF STATES BASED ON AVERAGE DRUG EXPENDITURE PER RECIPIENT

Avg. Drug Avg. Drug Expenditure Expanditure 1983 1984

Per Recipient Per Recipient Ranking Ranking

North Dakota $195 $21 8 2 1 Louisiana 201 21 4 1 2 Arkansas 187 214 6 3 Indiana 194 213 4 4 Tennessee 192 211 5 5 Ohio 176 191 8 6

Nebraska 177 185 7 7 South Dakota 158 179 9 8 New Hampshire 146 179 16 9

Georgia 195 177 3 10 Florida 146 176 15 11 Montana 143 168 20 12

Texas 157 167 11 13 North Carolina 145 167 17 14 Virginia 141 163 23 15

Kansas 153 162 12 16 Mississippi 158 161 10 17 Minnesota 147 161 14 18

Nevada 141 161 22 19 Maine 147 160 13 20 Connecticut 138 159 24 21

New Mexico 130 158 29 22 Colorado 144 157 18 23 Alabama 142 156 21 24

Massachusetts 144 154 19 25 Oregon 131 152 28 26 Iowa 136 142 26 27

Wisconsin 130 142 30 28 Oklahoma 137 141 25 29 Maryland 123 141 33 30

New Jersey 124 139 32 31 Rhode Island 132 137 27 32 New York 125 137 31 33

Pennsylvania 109 137 38 34 South Carolina 114 134 36 35 Vermont 110 134 37 36

Illinois 121 125 34 37 Washington 119 121 35 38 Missouri 1 08 119 39 39

Utah 106 117 40 40 Michigan 1 00 114 42 41 D.C. 105 112 41 42

Delaware 85 98 45 43

NPC 1985

California 96 95 43 44 Idaho 88 93 44 45

Hawaii 84 91 46 46 Kentucky 77 90 47 47 West Virginia 60 73 48 48

Alaska Arizona Wyoming

NPC

MEDICAL ASSISTANCE PROGRAM BENEFITS (TITLE XIX) TOTAL UNITED STATES VENDOR PAYMENTS BY TYPE OF SERVICE

Hospital Inpatient

Intermediate Care Facility

Skilled Nursing Facility

Physicians

Drugs

Hospital Outpatient

Dental

Home Health Care

Clinic

Other Practitioners

LabiX-ray

Family Planning

Other Care

Totals $32,204,730,553

Table IJ

--- FY 1984---

Excludes Puerto Rico and Virgin Islands

National Title XIX Payments

By Type of Service T a b l e IK

4.8%

Drugs

5.8%

Physicians

6.5%


14.2:

Hospital Inpatient

! 29.5%

Intermediate cari Facility

29.5%

M 1978

All Other

Hospital Outpati

Drugs 5.93

Physicians

8.8%


Intermediate Care Facility

24.2%

All Other includes: Dental, Home Health Care, Lab/X-ray, Family Planning, Other Practitioners, Other care.

Nat iona l Medicaid Expenditure and Recipient Data

T a b l e IL

AFDC Mu111

Distribution of w e n d i r u r t r by ~lipibility Class, PI 1984

~dis'id Expenditures

PI1970 - niss4

Source : OAIHCFAID~HS

T a b l e I M

1981 NATIONAL HEALTH CARE EXPENDITURES: $387 Billion

Where They Came From

Public Private O Source: Health Care Financing Administration. DHHS.

T a b l e IN

1954 NATIONAL WEALTH CARE EXPENDITURES: $357 Billion

Where They Went

NPC 1985

Table 10

FEDERAL MEDICAL ASSISTANCE PERCENTAGE ("FMAP")

Payment for Care and Sewlces

The federal government pays a percentage-a 50% minimum-of the expenditure each state incurs in providing Medicaid care and services. The federal government's share is referred to as "FMAP" (federal medical assistance percentage). The percentage (FMAP) for each state is computed according to a formula based on the state's per capita income.

Effective October 1, 1985-September 30, 1987 State Percent State Percent

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri

Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York NorthCarolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

The federal Medicaid law (Sections 1903(a)(l), 1903(g), and 1905(b)) requires federal payments to states, on the basis of a federal medical assistance percentage, for part of their expenditures for services provided under their approved Medicaid Plans. Under the FMAP formula in Section 1905(b) of the law. if a state's per capita income equals the national average per capita income, the federal share is 50%. If a state's per capita income is below the national average, the federal share is increased, but not beyond 83%.

Source: CCH Medicare and Medicaid Guide January, 1985.

S e p t e m b e r 1985 LIST OF FEDEM HAC 0RUS

T a b l e I I A

EFFECTIVE DATE

Acetaminnpnen */Codeine. 300mg/30mg Tabs. Acetaminophen wi'codeine, 300mg/60mg Tabs. Amoxicill iit, 250mg Capsules h o x i c i l l in. 500mg Capsules Ampicillin. 250mg Capsales Ampicillin, 500mg Capsules Ampicillin Oral suspension, 125mg/Sml lco"l Ampicillin Oral suspension, 2fOmg/5ml ;oo *i

$0.0780 per Tab. 0.1158 per Tab. 0.2108 per Capsule 0.3942 per Capsule 0.0422 per Capsule 0.1103 per Capsule 0.0114 per ml 0.0205 per ml

Chlordiazepoxide HCI, 5 mg Capsules Chlordiazepoxide HCI, lCmg Capsules Cblordiazepaxide HCI. 25 mg Capsules

0.0140 per Capsule. 0.0211 per Capsule 0.0438 per Capsule

Diphenoxylate HCI with Atropine Sulfa te , 2.5mrr/O.O25ma Tablets 0.0491 per Tablet

0.1030 per Capsule 0.1328 per Capsule 0.1869 per Capsule 0.3382 per Capsule

~ ~

~oxep in . HCI, l h g Capsules Doxepin HCI. 25mg Capsules Doxepin HCI, 50mg Capsules Doxepin HCI, 100 mg Capsules

Erythromycin S te ra te . 250mg Tablets 0.0697 per Tablet

Elutethimide, 500mq Tablets 0.0432 per Tablet

0.0279 per Tablet 0.0384 per Tablet 0.0152 per Tablet 0.0194 per Tablet

Hydralazine HCI. 25mg Tablets Hydralazine HCI. 50mg Tablets Hydrochlorothiazide. 25mg Tablets Hydrochlorothiazide, SOmg Tablets

Neprobama te . 200mg Tablets Meprobamate. 40Cmg Tablets Methocarbamol . 500mg Tablets Methocarbamol . 7501119 Tablets

0.0108 per Tablet 0.0117 per Tablet 0.0496 per Tablet 0.0640 per Tablet

Pen ic i l l in E. Potassium, 400mg Tablets P e n i c i l l i n YK Oral Susp.. 125mg/5m1 Pen ic i l l in YK Oral Susp., 250ng/5m1 P e n i c i l l i n YX, 250mg Tablets Pen ic i l l in YK, 5Ohg Tablets P o t a s s i u ~ Chloride, Oral Liquid 101 Probenecid. 0 . 5 9 Tablets Procainanide HCI. 2 5 h g Capsules Procainamide HCI, 3751119 Capsules Procainamide HCI. 500mg Capsules Propantheline Br, 15mg Tablets Propoxyphene HCI, 65mg Capsules Propoxyphene HCI with APC, 65mg Cap.

0.0237 per Tablet 0.0109 per iul 0.0160 per 11 0.0417 per Tablet 0.0649 per Tablet 0.0030 per ml 0.0644 Tablet 0.0383 per Capsule 0.0505 Capsule 0.0585 per Capsule 0.0235 per Tablet 0.0317 per Capsule 0.0330 per Capsule

quinidine Su l fa t e , 20Dnrg Tablets 0.0688 per Tablet

0.0273 per Tablet

Tetracycline H t E . 25Cmg Capsules Tetracycline HCI, 500rng Capsules Tetracycline HCI, 125mg/5al Syrup

0.0250 per Capsule 0.0394 per Capsule 0.0104 per ni

UPMDEO ORUS COVEMGE mR ME ELDERLY

Table I l l A

Since the enactment ,,f ~ r d i c a r c i n 1965, there have been var ious proposals i n Congress to extend benef i ts t o inc lude ou tpa t ien t p r e s c r i p t i o n drugs. rhe basic r a t i o n a l e f o r the inc jus ion o f p resc r ip t ion medicines genera l l y r e s t s on three points : 1) persons over 65 years o f age use, on the average. 2.5 times the number o f p resc r ip t ions used by younger groups; 2) Persons over 65 general ly l i v e on f i xed incomes; and 3) there i s r e l a t i v e l y l i t t l e p r i v a t e prescr ip- t i o n drug insurance ava i lab le f o r t h i s group. The f i s c a l d i f f i c u l t i e s t h a t surround Medicare have precluded the a d d i t i o n o f t h i s benef i t .

However, hea l th planners and l e g i r l a t o r r a t the s t a t e leve l have pmposed state-f inanced programs for t h e i r e l d e r l y c i t i z e n s , and i n s m e cases ind igen t non-Medicaid e l i g i b l e s . At Present f i v e states. New Jersey. Maine, Maryland, Delaware. I l l i n o i s , and Pennsylvania have implemented programs t o f i n a n c i a l l y a s s i s t e l i g i b l e e l d e r l y i n defray ing p resc r ip t ion drug expenses. Rhode Is land and Connecticut passed l e g i s l a t i o n i n 1985 and are i n the process of implementing s i m i l a r programs.

STATE YEAR ELlGt8ILlTY PROGRAM FISCAL IMPACT POPULATION CCMPARATIVE MEDICAID DATA ENACTED CRITERIA CHARACTERISTICS OVER AGE 65

Cost Per Total Drug Drug Net Orugs # o f Year Recip- Recip- Expend. State Cost

Age Means Test Copay Covered Rx Fee Funding Recipients ( M i l l i o n s ) i e n t s i e n t r ( M i l l i o n s ) ( M i l l i o n r l

NEW JERSEY 1977 65+ $13.250 r $2.00 A l l Rx. $3.53 t o 213 GF 258,441 $64.8 942,000 596,937 484.755 167.4 $33.7 (501) Pharmaceutical $16.250 c l n s u l i n $3.87 113 Assistance t o Aged Test M a t ' l r (Medicaid) L o t t e r y

MAINE 2977 62+ $ 6,200 c 12.00 Host Rx. $3.20 General 10,500 1 1.6 152,000 121.843 84,396 113.5 $ 4.0 (30%) 1 7.400 c heart. BP. (Medicaid) Fund (1984)

lURYWl0 1979 None Ranges from $1.00 A11 Rx 13.45 General 13.100 1 4.5 447.000 324.071 234.441 132.9 $16.5 (501) Pharmacy 1 5.600 r t o +Medicaid (Medicaid) Fund Avg monthly Assistance 111.000 OTC' r enrol lment Program Family o f FY 1985

D W # E * 1982 65+ 1 6.730 s 114 o f Rx Drugs. OuPont 8.100 $ 0.9 67.000 47.253 31.038 1 3.0 $ 1.5 (50%) Pharmacy $ 9.575 c ACC up F o w u l a r y t de Nemurs (enro l led ) (Est.) A s s i s t a n ~ e t o $100 I n s u l i n 6 Founda- 1984 Program per y r Quinine t i o n

PEUNSVLYAWIA 1984 6 5 t $12.000 s $4.00 A l l Rx. $2.75 L o t t e r y 400,000 $70 1.646.000 1,059.725 724.858 $99.1 $43.6 (441) Pharm. Asrt. $15.000 c 30 day (Medicaid) Funds + 484 (FY '85 Contract f o r supply o r pro jected E l d e r l y (PACE) 100 doses $110)

ILLINOIS 1985 65+ $12.000 No Cardiovar- $3.30 General 7.000 NA 1.320.000 1257,954 782,353 $98.0 149.0 (502) household c u l a r druos Fund l o o t e n t i a l

RHDOE ISLAM0 *" 1985 65+ $ 9.000 s 401 of Rx 602 o f n e t General 138.000 104.489 83.407 $11.2 1 4.7 (42%) $12.000 c c o s t ( s p e c i f i c cos t ( i n c l Fund

categor ies) ingreds)

COWWECTICUT *** 1985 407.000 220,090 157.029 124.9 $12.5 (50%)

Not a vendor drug program. A l l Rx's dispensed thr; E lemr ia l Health C l i n i c . Yilmington, OE " Passed l e g i s l a t u r e 1985 -- Program s h a l l begin the p rov is ion of b e n e f i t s no sooner than 1 Oct 1985 and terminate b e n e f i t s no l a t e r than 30 June 1981

**' Passed the l e g i s l a t u r e 1985 -- Task force w i l l develop recamendations for t w l e l e n t i n g the program by 1 0ece.ber 1985. Program scheduled t o take ef fect 1 J u l y 1986

STATE

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas KentucQ Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Plexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania mode Island South Carolina South Dakota Tennessee Texas Stah Vermont Virginia Washington West Virginia ise eon sin Wyoming

T a b l e I i lA STATE POPULATION AND DEMOGiL9PXICS 27-Sep-85

State % of Population State as a % of Per Capita Unem- Population Population

Population total U.S. Personal ployment 65 and 65 and prov. est. Population Income Rate

United States 234,439,000

Over Over

NPC

PHARMACIES & PHARMACISTS

Table VA Page One

PHARMACIES PHARMA- Nursing All C l STS

State Community Chain Hospital Clinic Home Others* Total

GRAND TOTALS: 39,589 16,721 5,380 1,592 790 2,593 66,665 161,522

Alabama 797 330 128 44 10 44 1,353 2,826

Alaska 58 28 21 0 3 1 111 323 Arizona 243 268 71 46 3 80 71 1 2,386

Arkansas 584 116 82 7 4 15 808 1,376

California 3,446 1,242 519 176 5 215 5,603 13,484

Colorado 453 151 52 27 1 83 767 2,573

Connecticut 587 169 1 4 0 0 761 2,078

Delaware 49 71 16 2 4 0 142 429 D.C. 89 77 5 2 2 5 180 396 Florida 1,566 1,054 268 116 347 223 3,574 6,021

Georgia 1,234 558 182 49 26 78 2,127 4,685

Hawaii 75 36 15 11 0 1 138 290 Idaho 1 89 43 40 7 3 25 307 697 Illinois 2.231 670 200 80 19 89 3,289 6,666

Indiana 694 590 127 21 10 33 1,475 4,720

Iowa 542 203 27 45 7 22 846 2,212

Kansas 515 138 147 18 1 32 851 1,516

Kentucky 724 272 113 28 12 27 1,176 2,769

Louisiana 839 380 160 31 4 42 1,456 3,381

Maine 156 119 4 1 1 0 281 497 Maryland . 451 389 62 13 3 27 945 3.651

Massachusetls 947 398 21 8 0 1 1,375 5,625

Michigan 1,540 493 21 9 54 10 101 2,417 6,315

Minnesota 679 192 152 39 5 53 1,120 3,247

Mississippi 680 1 64 119 31 56 5 1,055 1,800

Missouri 888 360 121 49 5 45 1,468 3,737

Montana 166 47 63 8 4 5 293 707 Nebraska 386 80 102 15 4 16 603 1,578

Nevada 88 71 19 4 0 24 206 508 New Hampshire 119 78 35 1 8 1 242 626

New Jersey 1,337 435 89 13 9 10 1,893 6,709

New Mexico 187 83 41 49 2 105 467 866 New York 3,227 840 31 9 56 70 168 4,680 13,549

NPC

Tabie VA Page Two

PHARMACIES PHARMA- Nursing All CISTS

State Community Chain Hospital Clinic Home Others' Total

North Carolina 964 650 131 25 13 56 1,839 2,582

NoFth Dakota 156 18 54 14 2 3 247 696

Ohio 1,490 1,998 77 45 11 142 2,809 8.057

Oklahoma 746 232 53 32 0 57 1,120 2,087

Oregon 446 126 59 20 5 11 667 1,917

Pennsylvania 2,114 918 271 27 66 31 3,427 8,660

Puerto Rico 1,076 86 50 9 0 19 1,240 887

Rhode island 135 82 17 2 1 2 239 699 South Carolina 476 365 61 27 5 32 966 2,526

South Dakota 179 18 60 20 7 9 293 460 Tennessee 94 1 393 166 42 7 54 1,603 2,910

Texas 2,304 1,303 307 111 2 382 4,409 8,588

Utah 224 87 34 9 3 63 420 1,014

Vermont 96 39 18 1 1 1 i 56 267 - Virginia 594 546 119 40 6 48 1,353 3,066

Virgin Islands 0 0 0 0 0 0 0 20

Washington 642 269 126 33 6 40 1,116 3,426

West Virginia 332 169 86 21 2 14 624 1,343

Wisconsin 816 208 122 56 15 39 1,256 2,994

Wyoming 88 22 29 2 0 14 155 415

Pacific Islands 0 0 0 0 0 0 0 6 APOIFPO, Foreign 4 1 0 1 0 0 5 665

* Includes 1,158 Department Stores and 702 Grocery Stores

Source: Business Mailersilnc. March 1985. Official List of the NABP and NCPDP

I P C C W P I L A T I O I KEY PROVISIONS OF STATE DRUG PRQWCT

Permissive How t o Phamacy Formulary 2-Line Rx , o r Prevent Record

Format Mandatory Subst i tu t ion Required

SELECTIOI W S T a b l e V B

Page One

Cost Label Savings Pat ient Specif ic- L i a b i l i t y Pass-on Consent at ions Disclaimer

~~ ~ ~ ~ - p ~ ~

Alabama None Yes P A Yes B NO Yes No

Alaska None No P E(1) No 6 yes No No

Arizona None Yes P A Yes B yes Yes No

Arkansas Negative No P B(1) No B Yes Yes Yes

Ca l i fo rn ia Negative No P 8(1) No B Yes Yes Y ~ S

Colorado None No P B Yes A Yes Yes yes

Connecticut None No P B Yes A Yes Yes Yes -

Delaware P o s i t i v e l l ) Yes P A Yes A Yes Yes No

D.C. Posi t ive No P B Yes B Yes Yes yes

Flor ida Negative(2) No M B Yes A Y ~ S No Yes

Georgia None Y ~ S P A Yes C Yes No No

Hawai i Pos i t i ve ( l 1 No M B Yes B Yes Yes Yes

Idaho None Yes P A Yes A Yes Yes No

I l l i n o i s Posi t ive No P B[Z) Yes B yes No yes

Indiana None Yes P A Yes B yes Yes No

Iowa None NO P B Yes A yes No No

Kansas None Yes (opt.) P A/ B NO B No No No

Kentucky Negative(1) No M B yes B No Yes Yes

Louisiana None No P B Yes A Yes No No

Maine None No P B E ) No D Yes Yes NO

Maryland Posi t ive No P B Yes B Yes Yes yes

T a b l e V B Page Three

Permissive How t o Pharmacy Cost Label Formulary Z-Line Rx o r Prevent Record Savings Pat ient Specif ic- L i a b i l i t y

Fomat Mandatory Subst i tu t ion Required Pass-on Consent at ions Disclaimer

Texas None yes P A Yes B ' Yes Yes Yes

Utah Posi t ive(1) No P B(1) Yes A Yes Yes Yes

Vermont Posi t ive No M B No D Yes Yes NO

V i rg in ia Posi t ive Yes P p Yes es Yes

Washington Posi t ive(1) Yes M A Yes 6 No Yes Yes

west V i rg in ia Negative Yes (opt.) M A/ B Yes A Yes Yes Yes

Wisconsin Posi t ive 1 No P p Yes es Yes

Wyoming None Yes P A yes B No Yes Yes

*Some of the information i n t h i s char t i s based upon NPC s ta f f in te rp re ta t ions o f s ta te statutes and regulat ions.

Legend:

i. '?f%%+DA Therapeutic Equivalency L i s t ( 2 ) Each pharmacy i s t o develop DPS L i s t (3) Each pharmacy i s t o l i s t conunonly used generics from s ta te developed formulary

Permissive o r Mandatory Languaqe: P = Permissive; M = Mandatory (1) unless i n the pharmacist's professional judgement

Prevention of Subs t i tu l i on: ]A) Prescriber 's signature on appropriate l i n e o f 2- l ine p rescr ip t ion (b) Prescriber expressly indicates do not DPS i n some manner

1. Allows use o f preprinted "do not sub'' check-box 2. Box must be checked t o prevent DPS

Cost Savinrts Pass-On: A be passed on t o consumer

B j Drus dispensed must be less exoensive than drug prescribed ( c ) No cost savings pass-on requirement mentioned - (D) No more than usual and customary charge f o r prescribed drug

Patient Consent: (Yes) includes states where consent i s required and those which required the pa t ien t t o be not i f ied l in formed o f subst i tu t ion.

Oklahoma: 0.8. (1961) simply states t ha t i t i s unlawful for a pharmacist t o subs t i tu te wi thout the au thor i t y o f the prescr iber o r purchaser.

Researched and compiled by the National Pharmaceutical Council. Inc. i n conjunction w i th Jesse E. Stewart, ph.~., Associate Professor of Pharmacy Administration, College o f Pharmacy. The Univers i ty of I l l i n o i s a t Chicago.

NPC

A L A B A M A

M E D I C A L A S S I S T A N C E D R U G P R O G R A M (T ITLE XIX)

A l a b a m a - ? 1985

I. BENEFiTS PROVIDED AND GROUPS ELiGlBLE

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

O M AB APT0 AFDC OAA AB PPTD AFOC Children 21 (SFO!

Prescribed Drugs X X X X

inpatient Hospital Care X X X X Outpatlent Hospital Care X X X X

Laboratory & X-ray Service X X X X

Skilled Nursing Home Services X X X X Physician

Dental

Other Benefits: Optometric services; home health care; early, periodic, screening, diagnosis and treatmenl; family planning; !ranspotta!icn.

'SF0 - Slate Funds Only

"'Dental Services EPSDT - under 21 years old

II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending September 30. 1984

. . . . . TOTAL

CATEGORICALLY NEEDY CASH TOTAL Aoed . . . . . . . . . . . .

1984 1983 Expended Pecipiezt - Recipient - Expended - -

$35,266,939 225,256'" $31,616,230 222,713""

Blind . . . . . . . . . . . . . . . . . . . . . . 321,253 1.084 294,667 1,462

D i s a b l e d . . . . . . . . . . . . . . . . . . . . . 12,459,958 51,365 10,758,949 48,922 . . . . . . . . . . . . Children-Families wiDep Children 1,305,488 38,016 1,203,069 58,761

Adults-Farniiies wlDep Children . . . : . . . . . . . . 2,358,341 58,725 2,184,940 38.183

CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . $4,768,386 Aged . . . . . . . . . . . . . . . . . . . . . . 4,016,798 Blind . . . . . . . . . . . . . . . . . . . . . . 5,652 Disabled . . . . . . . . . . . . . . . . . . . . . 531,761 Children-Families wiDep Children . . . . . . . . . . . . 58,320 Adults-Families wiDep Children . . . . . . . . . . . . 114,661 Other Title XIX Recipients . . . . . . . . . . . . . . . 40,594

. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL $0 Aged . . . . . . . . . . . . . . . . . . . . . . 0 Blind . . . . . . . . . . . . . . . . . . . . . . 0 Disabied . . . . . . . . . . . . . . . . . . . . . 0 Children-Families wIDep Children . . . . . . . . . . . . 0 Adults-Families wiDep Children . . . . . . . . . . . . 0 Other Title XIX Recipients . . . . . . . . . . . . . . . 0

'Vnduplicated Total - HHS report HCFA - 2082

69

Ill. Administration

Alabama Medicaid Agency

IV. Provisions Reiating to Prescribed Drugs:

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

0. Formuiary: Alabama Drug Code Index, which specifies those drugs that may be dispensed on prescription only. Contact person for approving formulary additions: Sam T. Hardin, P.D. (see p. 4)

C. Prescribing or Dispensing Limitations:

1. Quantity of Medication: Normal prescriptions are limited to a maximum 34-day supply with a maximum of 5 refills. The 34-day limitation does not apply to long-term maintenance medication. The quantities (units) of drugs prescribed by a physician SHALL NOT be arbitrarily changed by a pharmacy except by authorization of the physician. The pharmacist should contact the prescribing physician for authorization to reduce the quantity of a non- maintenance medication prescription to the 34-day supply limitation where appropriate. Authorization to reduce the units of a prescription must be noted on the prescription form by the pharmacist. Prescriptions for Title XIX nursing home patients who are on long-range therapy or maintenance drugs must be written for at least a minimum thirty (30) day supply.

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

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

0 The Maximum Allowable Cost (MAC) of the drug plus a dispensing fee

0 The Estimated Acquisition Cost (EAC) of the drug plus a dispensing fee, or

0 The provider's usual and customary charge to the public for the drug.

Professional Fee

0 2.4Retail pharmacies $3.00

0 Institutional pharmacies (hospital pharmacies with outpatient prescription services and skilled nursing facilities pharmacies)

@ Government pharmacies (county, state, or federai pharmacies) 1.65

Dispensing Physicians 1.05

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

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

e Family planning drugs or supplies.

Drilgs dispensed to a Medicaid recipient under 18 years of age

NPC

0 Drugs dispensed to Medicaid eligible pregnant women.

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

CO-PAYMENT (Effective October 1, 1984) Retail Pharmacies

$.01-$7.00 7.01 -$22.00

22.01-$47.00 47.01 or more

V. Miscellaneous Remarks:

1. Fiscal Intermediary:

Alacaid (E.D.S.F.) P.O. Box 3367 Montgomery. Alabama 36109 (205) 834-3330 1-800-392-5741

Officials, Consultants and Committees

1. Officials-Alabama Medicaid Agency

Faye S. Baggiano Commissioner

Clayton H. Schmidt, M.D., Chief Professional Services Div.

p ' a m T. Hardin, P.D., Assoc~ate D~rector Pharmaceutical Program

2. Title XIX Medical Care Advisory Committee:

Permanent Ex Officio Members State Health Officer-

Commissioner-State DPS-

Alabama Medicaid Agency 2500 Fairlane Drive Montgomery, Alabama 36130 (205) 277-2710

Ira L. Myers, M.D. State Public Health Department 434 Monroe Street Montogomery, Alabama 361 30

Appointment Ends July 19, 1987 The Medlcal Association of the State of Alabama

Dr. Leon Frazier, Commissioner State Department of Pensions

and Security 64 North Union Street Montgomery, Alabama 36130 (205) 261 -31 90

Glen D. Bedsole, M.D. 303 S. Ripley Street Montgomery, Alabama 36104

NPC

Alabama Hospital Association

Mr. Frank Perryman Sylacauga Hospital and Nursing Home Sylacauga, Alabama 35151

Alabama Optometric Association Craig McNamara, O.D. 5723 Carmichael Parkway Montgomery, Alabama 361 17

American Association of Medical Assistants

Ms. Nancy Q.Gil1, CMA-A 3005 Hood Road, S. W. Huntsville, Alabama 35805

Medical Group Management Association of Alabama

Mr. William Stewart Department of Medicine 6th Floor MEB University Station Birmingham, Alabama 35294

Appointment Ends July 19, 1986

The Medical Association of the State of Alabama

Roy T. Hager, M.D. 2055 Normandie Drive Montgomery, Alabama 36198

Alabama Pharmaceutical Association

Mr. Jim Scruggs 61 1 Moore Street Marion, Alabama 36756

Alabama State Nurses Association

Mrs. Bonnie Griffith, R.N. P. 0. Box 175 Dadeville, Alabama 36853

Dr. Raymond T. Handy Director, Adult Education Tuskegee Institute Carnegie Hall 3rd Floor Tuskegee Institute, Alabama 35088

Consumer Representative

Mrs. Julie Trant P. 0. Box 6406 Dothan, Alabama 36302

NPC

Alebarna Chapter of Academy of Pediatrics

Dr. Stan Brasfield P. 0. Box 1007 Demopolis Alabama 36732

Medicaid Recipient Representative

Mrs. Lula Gladback 12 Astor Drive Sunshine Village Montgomery, Alabama 36109

Medicaid Recipient Representative

Mrs. Lee Raye Pearson 256-0 Lynwood Montgomery, Alabama 36105 Consumer Representative

Mr. William Glover, Director Area Agency on Aging Southeast Alabama Regional Planning

and Development Commission P. 0. Box 1406 Dothan, Alabama 36301

Montgomery Area Council on Aging

Ms. Ellen Dempsey 1949 Walnut Street Montgomery, Alabama 36106


Mr. Charles G. Spradling, Jr. P. 0. Box 11 765 Birmingham, Alabama 35202

3. Executive Officers of State Medical and Pharmaceutical Societies:

Medical Association Pharmaceutical Association

Lon Conner Executive Director Medical Association of Alabama 19 South Jackson Street P. 0. BOX 1900-C Montgomery, Alabama 36104 2051263-6441

Jon Barganier Executive Director Alabama Pharmaceutical

Association 340 Dexter Avenue Montgomery. Alabama 361 04 2051262-0027

Osteopathic Association

Kenneth D. McLeod, D.O. Secretary Alabama Osteopathic Association 151 1 N. McKenzie Street Foley, Alabama 36535 2051943-1 584

Nursing Home Association

Mr. Fred Draper Executive Vice-president Alabama Nursing Home Association 4140 Carmichael Road Montgomery, Alabama 36106 2051271 -6214

4. State Board of Pharmacy

Hospital Association

Dr. Tommy R. McDougal President Alabama Hospital Association East Station P. 0. Box 17059 Montgomery, Alabama 361 93 20512724781

James W. McLane, Secretary 231 2 City Federal Building Birmingham, Alabama 35203 2051252-8976

NPC

A L A S K A


I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

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

OAA AB A?TD AFDC OAA AB APT0 AFDC Children 21 (SF01

Prescribed Druos

Inpatient Hospital Care X X X X X

Outpatient Hospital Care X X X X X

Laboratory & X-ray Service X X X X X

Skilled Nursing Home Services X X X X X Physician Services X X X X X Dental

Other Benelits: Intermediate Care Facilities; transpoilation; home health care; early and periodic screening, diagnosis and trealment for eligibles under 21; family planning; inlermediate care for the mentally retarded; inpatient psychiatric care; optometrist services; eyeglasses; speech and hearing services; mental health clinic.

'SF0 - State Funds Only

II. EXPENDITURES FOR DRUGS.

1984 1983 Expended Recipient - - Expended Recipient - -

T O T A L . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . Children-Families wlDep Children . . . . . Adults-Families wIDep Children . . . . .

CATEGORICALLY NEEDY NON-CASH TOTAL . Aged . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . Children-Families wlDep Children . . . . . Aduits-Families wlDep Children . . . . .

. . . . . . . . Other Tiile XIX Recipients

. . . . . . . MEDICALLY NEEDY TOTAL Aged . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . Children-Families wlDep Children . . . . . Adults-Famiiies w1Dep Children . . . . .

. . . . . . . . Other Title XIX Recipients

Alaska's Medicaid program does not include drugs, except family planning drugs and drugs dispensed to inpatients of hospitals and nursing homes. (See page 2.)

YJndupIicated Total - HHS report HCFA - 2082

Ill. Administration:

There is no state Title XIX vendor drug program. The Alaska Medical Assistance programs including Medicaid and General Relief-Medical are administered by the Division of Medical Assistance of the Alaska Department of Health and Social Services. This Division also administers general relief - medical assistance and catastrophic illness assistance programs.

IV. Provisions Relating to Prescribed Drugs:

Although drugs are not covered under Medicaid in Alaska, prescriptions are paid from the General Relief-Medical budget for Medicaid recipients who have no other resource for obtaining prescribed medications.


1. Health and Social Services Deparlment Officials:

Robert Pugh, M.S.W. Commissioner

Rod Betit Director

Bob Ogden Chief of Medical Assistance Division of Medical Assistance

2. Alaska Medical Care Advisory Committee:

Sister Barbara Haase Chairman 9071225-51 71

Department of Health and Social Services

Pouch H-01 Juneau, Alaska 9981 1 9071465-3355

Division of Medical Assistance Pouch H-07 Division of Public Assistance

Division of Medical Assistance 4041 B Street Anchorage, Alaska 99503 9071561-2171

Administrator Ketchikan General Hospital 31 00 Tongass Avenue Ketchikan, Alaska 99901


A. Medical Association: C. State Board of Pharmacy

Martha MacDermaid Executive Director . Alaska State Medical Association 4107 Laurel Street, Suite 1 Anchorage 99504 Phone: 9071562-2662

0. Pharmaceutical Association:

Margaret Loden Secretary 3222 Anella Avenue Fairbanks, Alaska 99701 9071479-6793

Frank Zoppo Secretary-Treasurer Alaska Pharmaceutical Association Box 10-1 185 Anchorage 9951 0

NPC Arizona-! ! 985

ARIZONA MEDICAL ASSISTANCE DRUG PROGRAM UNDER TiTLE XIX

Arizona Heaith Care Cost Containment System (AHCCCS pronounced "ACCESS")

AHCCCS Features:

Arizona set the scene for an experimental health-care program when in 1981 the state and HCFA deveioped an aiternative health-care program for the indigent.

The Arizona Health Care Cost Containment System (AHCCCS) was born in a speciai session of the legislature in November 1981, after 10 years of debate. The plan utilizes statelfederal money with supposedly fewer complications tinan the Medicaid programs in place in the other states.

AHCCCS was begun in October 1982 as a three-year experiment for the state's 220,000 indigents. Under this program, hospitals, physicians and other medical-care suppliers treat patients on a prepaid basis. The providers offer bids to the state to treat a certain number of patients for a fixed amount of money each year. Bids are based on what individual providers have determined are average fees for various services.

Administration:

Arizona Heaith Care Containment System (AHCCCS), Arizona Department of Health Services.

General Information:

The Arizona Health Care Cost Containment System (AHCCCS), developed in Senate Biii i0G1, was passed by the Legislature and signed by the Governor in November, 1981. It contains six major mechanisms for restraining health care costs while, at the same time, ensuring that appropriate leveis of quality health care services are provided to eligible persons in a dignified fashion. The goai of these six items is to contribute to the establishment of a health care financing system that is less expensive than conventional fee-for-service systems. The six mechanisms are:

0 Primary Care Physicians Acting as Gatekeepers

0 Prepaid Capitated Financing

0 Competitive Bidding Process

0 Cost Sharing

0 Limitations on Freedom-of-Choice

0 Capitation of the State by the Federai Government

Primary Care'Physicians Acting as Gatekeepers:

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

Prepaid Capitated Financing:

It is the intent of the AHCCCS legislation that providers offer all necessary services to groups of members for a fixed price, for a definite period of time. The law ailows for the creation of consortia to facilitate the establishment of a statewide bidding process. Services are provided on a county-by-county basis, and bids encourage that goal. It is not necessary, however, for a single bidder to bid for all seMces to be delivered in a given county. Providers may bid on a prepaid capitated basis for oniy those services tnsy normally provide. For exampie, a group of physicians may choose to bid oniy for physician services for a particular area; hospitais may do the same; and so on. The law aliows for expansion and contraction of bids to achieve the best possible system. in the event there are insufficient bids for a given area, ine legisiation permits capped fee-for-service arrangements. it is intended, however, that capped fee-for-

NPC Arizona-2 1985

service will be authorized as a last resort oniy.

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

Competitive Bidding Process:

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

The Department of Health Services issues an invitation to qualified providers of health services, at leas: on a biennial basis, to bid to provide services to AHCCCS members in each county. Qualified providers may bid to offer the iull range of AHCCCS services, or any allowable partial grouping of services, in one or more counties.

Cost Sharing:

The fourth major device for containing costs in the AHCCCS model is a provision for cost sharing by users. A statewide co-payment schedule was developed for this purpose, and the medically needy participate in coinsurance cost sharing. It is expected that the imposition of nominal co-payments will ensure optimal effectiveness in the area of service utilization. The Department co-payment schedule accomplishes three objectives: curtailment of over-utilization; enhancement of patient dignity; and service utiiizaiion by members for truly needed health care.

Limitations of Freedom-of-Choice:

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

Capitation of the State by the Federal Government:

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

IMPLEMENTATION OF AHCCCS

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

Provider Participation:

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

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

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

Functions of the AHCCCS Administrator:

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

Contracting Health Plans

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

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

Administrator Organized Health Systems

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

The Administrator Organized Plans must:

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

e Serve as the mechanism for assuring emergency and urgent care for the "emergent members" of AHCCCS.

Serve as back-up systems in the event of a failure of a Contracting Health Plan, or a state decision to terminate a contract.

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

The Organizational Role of the Arizona Department of Health Services:

The Department of Health Services has been charged with the general implementation and monitoring of the AHCCCS program. A Division has been created within the Department (Arizona Health Care Cost Containment System Division) to fulfill that responsibility.

The Department develops the Rules and Regulations; conducts the Administrator bidding process. and provider bidding processes in conjunction with the Administrator; awards the contracts: provides technical assistance to providers for the purpose of forming consortia to contract with AHCCCS; and monitors the overall operation of the program.

It is the Departiment's obligation to contract with a private Administrator who will assume responsibility for the day-to-day operation of the program.

The Operational Role of the AHCCCS Administrator:

Organizationally, the Administrator will assume responsibility for the every day operations of the program, subject to the general supervision of the Department.

NPC Arizona-4 j "5

u:,-,,~~, The AHCCCS Administrator wili have overall responsibility for the following activity areas: V a i 7

Ma. z- Promotion of AHCCCS

0 Procurement of Contract Providers

e Provider Management

0 Provider, Member, and Public Relations

0 Program Operations

AHCCCS became effective December 1, 1981. Services commenced October 1, 1982 and expire September 30. 1985. Funding for first year operation stated to be $105.4 million. Services include: Inpatient, outpatient, laboratory, x-ray, prescription drugs, medical supplies, prosthetic devices, emergency dental care including extractions and dentures, treatment of eye conditions and EPSDT.

The McAuto Systems Group, Inc. of New York was designated AHCCCS administrator, however a contract dispute resulted in the state taking over administration of the plan on March 16, 1984. By June 1984, the AHCCCS program was costing $215 million and serving about 189,000 indigents. The AHCCCS budget request for 1985-86 was expected to reach $276 million. One controversial development in 1984 was the approval by the AHCCCS program and the Arizona Board of Pharmacy of a proposal by the Walgreen Company and the state's largest health care provider to set up mail-order drug distribution for indigent patients. Walgreen held a contract to administer pharmacy services to 61,000 patients at that time. The mail-order distribution was requested by Arizona Physiciansllndependent Practice Association.

Though AHCCCS is a three-year experiment which was to end in October 1985, Governor Bruce Babbitt is prepared to ask the federal government for permission to extend funding for the program for an additional two years.

Official, Consultants and Committees

1. Health Services Department Officials:

Donald F. Schaller, M.D, Director

Arizona Health Care Cost Containment System

124 West Thomas, Suite 301 Phoenix, Arizona 85013


A. Medical Association: C. Osteopathic Association:

Bruce E. Robinson Executive Vice President ,

Arizona Medical Association, Inc. 810 West Bethany Home Road Phoenix 85013 Phone: 6021246-8901

B. Pharmaceutical Association:

Warren J. Ellison, R.Ph. Executive Director Arizona Pharmaceuticai Association 2202 North 7 Street Phoenix 85006 Phone: 6021258-8121

Mr. S. N. Schultz Executive Director Arizona Osteopathic Medical Association 5057 E. Thomas Road Phoenix 8501 8 6021840-0460

D. State Board of Pharmacy

Executive Director Arizonia Board of Pharmacy 1645 North Jefferson Street Phoenix, Arizona 85009 6021255-51 25

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A R K A N S A S



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

O M AB APT0 AFDC O M AB APTD AFDC Children 21 fSFDI

Prescribed Oruos X X X X X X X X X

inpatient Hospital Care X X X X X X X X X

~ospi ta l Care X X X X X X X X X

Laboratory & X-ray Service X X X X X X X X X

Skilled Nursing Home Services X X X X X X X X X Physician services x x x x x x x x x Denial Services X X X X X X X X X

"SF0 - State Funds Only

II. EXPENDITURES FOR DRUGS. Pdyment to Pharmacists by fiscal year ending June 30, 1984

1984 1983 Expended Recipient Expended Recipient - - -

T O T A L . . . . . . . . . . . . . . . . . . . . . $33,166,977 155,131" $28,218,714 151,260

CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $26,151,084 125,344 21,375,519 122,711 Aged . . . . . . . . . . . . . . . . . . . . . . 11,124,351 36,129 5,582,801 35,772 Biind . . . . . . . . . . . . . . . . . . . . . . 340,685 1,194 300,143 1,225 D i s a b l e d . . . . . . . . . . . . . . . . . . . . . 11,057,771 32,510 9,019,490 30,380 Children-Families wlDep Children . . . . . . . . . . . . 1,395,067 34,690 1,218,723 34,304 Adults-Fzmilies ~ 1 0 e p Children . . . . . . . . . . . . 2,233,210 21.130 1,854,362 20,719

CATEGORiCALLY NEEDY NDN-CASH TOTAL A . . . . . . . . . . . . - Blind . . . . . . . . . . . . . . . . . . . . . . 22,596 60 19.068 59 Disabled . . . . . . . . . . . . . . . . . . . . . 1,065,412 2,376 973,090 2,524 Children-Families wIDep Children . . . . . . . . . . . . 3,241 160 3,428 140 Aduits-Families wlDeo Children . . . . . . . . . . . . 8.435 131 6.204 108 Other Title XIX flecipients . . . . . . . . . . . . . . . 61;010 1,402 52;914 1.231

MEDICALLY NEEDY TOTAL Aged . . . . . . . Bind . . . . . . . . . . . . . . . . . . . . . . 902 7 1,424 6 Disabled . . . . . . . . . . . . . . . . . . . . . 325,110 1.544 250,650 1,555 Childreii-Families wlDeo Children . . . . . . . . . . . . 113.431 3,181 87.575 2.536 ~ ~

Adults-Families wlDep children Other Title XIX Recipients . .

"Unduplicated Total - HHS report HCFA - 2082

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ili. Administration:

By the Division of Social Services, of the Department of Human Services.


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

All legend drugs are covered with the following exceptions: investigational drugs, I.V. solutions, amphetamines, anti-obesity agents, irrigating solutions, vaccines, and routine immunizing agents.

0-T-Cs: Pursuant to a prescription the following OTC items are covered: insulin, insulin needles and syringes, analgesics, antacids, calcium lactate, contraceptive foams and jellies, dicalcium phosphate, ferrous fumarate, ferrous gluconate, ferrous sulfate, ferrous cholinate, meclizine HC1, pediatric vitamin drops for children up to three years of age, laxatives and stool softners, nicotinic acid and schedule V narcotics. All other non-legend items are excluded.

B. Formulary: None


1. Quantity of Medication: 33 day supply.

2. Refills: 5 refills within 6 months are allowed, if authorized by prescriber

3. Doilar Limits: None

4. Monthly Limit: Four prescriptions per month per recipient.

D. Prescription Charge Formula:

Legend drugs-estimated acquisition cost plus $3.87 professional fee. Total charge may not exceed provider's prevailing charge to the self-paying public, or any other third-party prescription drug program.


The Arkansas MAC program exists for 20 multi-source drugs. (effective 1 July 1984)

Fiscai intermediary:

Aritansas Blue Cross-Blue Shieid, Inc. 7th and Gaines Streets Little Rock, Arkansas 72203


1. Ray Scott, Director Department of Human Services

Social Services Division:

Commissioner Vacant

Mauda Russell, Director Office of Management Services

Arkansas Dept. of Human Services Division of Social Services P. 0. Box 1437 Little Rock, Arkansas 72203 501 1371 -1 806

Sam Lamey. Director Office of Financial Management

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Gordon Page Office of Program Operations

Kenny Whitlock, Director Office of Medicai Services

Vacant, Director Office of Long Term Care

Ivan H. Smith, Director Office of Legal Services

Al Sliger, Administrator Medical Assistance Section

Mark Crossley, P.D. Pharmacy Consultant 501 I371 -5361

2. Social Services Consultants:

Physicians (Part-time):

W. H. O'Neal, M.D.

Harold Betton, M.D

Guy Ferris. M.D

Thomas D.Honeycutt, M.D

3. Medical Care Advisory Committee

Asa Crow Jack Burge C.C. Long James Webel

Baptist Medical Center Medical Education

Department 9600 West 12th Little Rock, Arkansas 72205

1505 West 1 1 th Little Rock, Arkansas 72202

621 3 Lee Little Rock, Arkansas 72205

4124 West 11th Little Rock, Arkansas 72204

Morriss Henry Walter O'Neal Charles Wilkins


A. Medicai Society:

C. C. Long, M.D. Executive Vice-president Arkansas Medical Society P. 0 . Box 1208 Fort Smith, Arkansas 72902 Phone: 501 1782-821 8

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Norman Canterbury, P.D. Executive Vice President Arkansas Pharmacists Association 81 8 Garland Avenue Little Rock, Arkansas 72201 Phone: 5011372-5250

C. Osteopathic Medical Association:

Bob E. Jones Executive Director Arkansas Osteopathic Medical Association 502 West 16th Street Hope, Arkansas 71801 5011777-8839


Lester Hosto Executive Director P.O. Box 55356 Little Rock, Arkansas 72225 501 1661 -2833

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C A L I F O R N I A

M E D I C A L A S S I S T A N C E D R U G PROGRAM (TITLE XIX)

I. BENEFITS PROViDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MI)

(SSilSSP) Chiidren 21 Prescribed Drugs X X X

Inpatient Hospital Care X X X

Outpatient Hospital Care X X X

Laboratory & X-rav Service

Skilled Nursing Home Services X X X - Physician Services X X X Dental Services X X X

li. EXPENDiTURES FOR DRUGS. Fiscal year ending June 30, 1985

M 1984 Expended - Recipient - Expended -

T O T A L . . . . . . . . . . . . . . . . . . . . . $205,707,921 2,172,200" $213,167,811

CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $165,965,510 1,725000 173,386,305 Aged . . . . . . . . . . . . . . . . . . . . . . 37,366,125 230,280 40,489,841 Blind . . . . . . . . . . . . . . . . . . . . . . 3,833,063 16.300 3,918,064 Disabled . . . . . . . . . . . . . . . . . . . . . 80,009,900 317,320 80,145.731 Children-Families wiDep Children . . . . . . . . . . . . 20,608,211 679,400 21,327,988 Adults-Families wIDep Children . . . . . . . . . . . . 24,148,209 481,700 27,504.679

CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . $2,620,458 64,680 $2,208,170 Aged . . . . . . . . . . . . . . . . . . . . . . 934,927 7,380 836,433 Blind . . . . . . . . . . . . . . . . . . . . . . 26,196 140 15,552 Disabled . . . . . . . . . . . . . . . . . . . . . 559,278 3,280 533,732

. . . . . . . . . . . . . Children-Families wlDep Children 471,658 28,440 365,721 Adults-Families wlDep Children . . . . . . . . . . . . 628,397 25,440 456.730 Other Title XIX Recipients . . . . . . . . . . . . . . . 0 0 0

MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . . Children-Families wIOep Children . . . . . . . . . . . .

. . . . . . . . . . . . Adults-Families w1Dep Children Other Title XIX Recipients . . . . . . . . . . . . . . .

FY 1983 Recipient -

2,225,500

1,793,460 253,240 17,060 327.800 660.560 534,800

61,400 11,440 160

6,000

'"Undupiicated Total - HHS report HCFA - 2082

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By the Health and Welfare Agency with direct supervision by the Department of Health Services. Payment of bilis by the state is processed through a fiscal intermediary, Computer Sciences Corporation

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


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

Formulary CNS stimulants*, i.e., amphetamines and methylphenidate, are only available for epilepsy or Minimal Brain Dysfunction in individuals between 6 and 16 years of age. Contact laxative suppositories can be used only for specific diagnosis (paraplegia or quadriplegia, multiple sclerosis, poliomyelitis, ganglionic blockade processes occurring in the spinal nerve pathways or affecting the lumepilepsy or Minimal Brain Dysfunction in individuals between 6 and 16 years of age. Contact laxative suppositories can be used only for specific diagnosis (paraplegia or quadriplegia, multiple sclerosis, poliomyelitis, ganglionic blockade processes occurring in the spinal nerve pathways or affecting the lumbo-sacral autonomic nervous system pathways related to bowel motility).

Formulary Diazepam* restricted to use in cerebral palsy, athetoid states, and spinal cord degeneration. Nutritional supplements or replacements only for therapeutic use to prevent serious disability or death in patients with medically diagnosed conditions that preclude the full use of regular food-stuffs.

Formulary Baclofen* restricted to use in spasticity resulting from multiple sclerosis or spinal cord injury.

Formulary Carbonacillin' restricted to pseudomonas aerugenosa urinary tract infections.

Formulary CImetidine* restricted to use in treatment of duodenal ulcer, Zollinger-Ellison syndrome, systemic mastocytosis, and multiple endocrine adenomas.

Formulary Dantrolene* restricted to use in spasticity resulting from cerebral palsy, spastic hemys- legia, multiple sclerosis, and spinal cord injury.

Formulary Erythromycin-Sulfkoxayol* restricted to use in acute otitis media.

Formulary Fenoprofen, Ibuprofen, Naproxen, TolmatIn* restricted to use for arthritis.

Formulary Nalodixic Acid* restricted to urinary tract infections resistant to sulfonamides or in patients sensitive to sulfonamides.

Formulary Trumethoprim-Sulfamethoxayolz* restricted to genitourinary tract infections.

Excluded from coverage are multivitamins for persons over five years of age and most OTC household remedies.

9. Formulary: A semi-restrictive formulary system is used. Over 450 drugs (approximately 1,500 separate codes for differing strengths and dosage forms) listed generically in formulary. Many brand names listed alphabetically as cross-index references. The patient's physician or 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:

'other uses require prior authorization.

Computer Sciences Corporation P.O. Box 15000 Sacramento, CA 95813 Ann: Distribution

(Please remit $3.25 per manual, including updates, by check or money order payable to "State of California")

For formulary information contact:

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


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 high volume andlor chronically used oral dosage forms of drugs are subject to minimum quantity or maximum frequency of billing controls.

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

3. Number of prescriptions: Number of prescriptions for formulary drugs not limited but overutilization is limited by prepayment and postpayment controls. These controls include those mentioned in item 1 supported by onsite audit of provider files.

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

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

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

7. Dollar Limits: None.

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

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

2. Federal Maximum Allowble cost (MAC) plus $4.05 professional fee.

3. State Maximum Allowable Ingredient Cost (MAIC) plus $4.05 professional fee.

4. Pharmacy's usual price to general public.

\I. Miscellaneous Remarks:

Drug Price List Updating

Drug prices used to determine reimbursement are updated the 1st day of each even month for price change notices which are effective on or before that date. Price notices are received by Computer Sciences Corporation, P.O. Box 15000, Sacramento, California 95813.

87

Medicai Therapeutics and Drug Advisory Committee

Reacting to the lead responsibility of the Drug Policy Unit in the Benefits Branch, the Medical Therapeutics and Drug Advisory Committee compares the cost, efficacy, misuse potential, essential need, and safety of drugs and makes recommendations as to additions to or deletions from the formulary.

Hospital Discharge Medications

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

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

Cancer and DESl Drugs

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

Maximum Allowable ingredient Cost Program

State MACs are established on over 150 multisource items. List is periodically revised and price limits changed to reflect current market conditions.

Estimated Acquisition Cost (EAC)

Direct prices for certain high volume brands, bulk package size prices for certain high volume drugs, and, "average wholesale prices" for standard packages on rest.


1. Health and Welfare Agency

A. Health and Welfare Agency Officials: David Swoap Secretary

B. Depattment of Health Services: Kenneth Kizer Director

Stan Cubanski Chief Deputy ~irector

Linda Martland Deputy Director

Sue Staats Chief

California Health and Welfare Agency

1600 9th Street Suite 460 Sacramento, California

Department of Health Services

714 "P" Street Sacramento 95814

Department of Health Services 714 " P Street Sacramento 9581 4

Medical Care Services 714 " P Street Sacramento 95814

Medi-Cal Policy Division

714 "P" Street Sacramento 95814

Jerome Hansen Chief

Benefits Branch 714 "P" Street Sacramento 95814

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James Parks Chief (916) 445-1995

Medical Services Section 714 "P" Street, Room 1640 Sacramento 95814

Milton Kuschnereit, Pharm. Sr. Pharmaceutical Program

Consultant (916) 324-2477

C. Advisory Committee to California Department of Health Services:

1. Medical Therapeutics and Drug Advisory Committee:

James Parks Coordinator

David Fung, Pharm Chairman

California Department of Health Services

714 "P" Street Sacramento 9581 4

460 Pollasky Avenue Clovis 9361 2

D. Officers of Computer Sciences Corporation (the Fiscal Intermediary):

Carl Hagenau Computer Sciences Corp, President of P.O. Box 15000

Governmental Services 2000 Evergreen Street Sacramento 9581 3

Glenn Spaulding, Pharm. Manager of Pharmacy

Relations

2. Executive Officers of State Medical and Pharmaceutical

A. Medical Association: B. Pharmaceutical Association:

Willis W. Babb Executive Director California Medical Assn 44 Gough Street San Francisco 941 03

' . Phone: 4151863-5522

Robert C. Johnson Executive Vice President California Pharmacists' Association 1112 I Street Sacramento 95814 Phone: 9161444-781 1

C. Osteopathic Physicians & Surgeons of California:

Matthew L. Weyuker Executive Director, OPSC 921 -1 I th Street, Suite Sacramento 9581 4 Phone: 9161447-2004


Lorie Garris Rice Executive Officer 1020 "N" Street Sacramento, California 5814-5784 91 61445-501 4

Colorado- 1 1985

C O L O R A D O


I. BENEFITS PROVIDED AN0 GROUPS ELIGIBLE

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

OAA AB APT0 AFDC DAA A0 APTD AFDC Children 21 ( S W


Inpatient Hospital Care X X X X

Outpatient Hosoitai Care X X X X

Laboratoiy & X-rav Service

Skilled Nursino Hame service; X X X X Physician Services X X X X Dental Services X

'SFD - State Funds Only

"Dental Services EPSDT - under 21 years old

11. EXPENDITURES FOR DRUGS. Pavment to Pharmacists by fiscal year endino June 30. 1984

T O T A L . . . . . . . . . . . . . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . A d . . . . . . . . . . . . . . . . . . . . . . i d . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . . Children-Families wlDep Children . . . . . . . . . . . . Adults-Families WDep Children . . . . . . . . . . . .

CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . . Chiidren-Families wlOep Children . . . . . . . . . . . . Adulls-Families wIDep Children . . . . . . . . . . . . Other Title XIX Recipients . . . . . . . . . . . . . . .

MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Msabkd . . . . . . . . . . . . . . . . . . . . . Children-Families wlDep Children . . . . . . . . . . . . Adults-Families wlDep Children . . . . . . . . . . . . Other Title XiX Recipien!~ . . . . . . . . . . . . . . .

1984 Expended - Recipient -

$16,616,730 105,919'

$13,652,477 93.021 7,966,083 25,115

26,753 133 2,926,770 9,163

898.710 34,621 1,834,161 24,389

$2,964,253 21,586 1,343,666 5,267

7,167 44 1,257,076 5,452

57.791 3,992 134,107 4,021 164,446 3.052

$0 0 0 0 0 0 0 0 0 0 0 0 0 0


$14,895,527 103,453

12,454,097 92,692 7,135,252 25,450

23,810 143 2,633,758 9,242

894,360 33,979 1,766,917 24.288

$2,441,430 19,594 1,201,455 5,443

3.436 44 944,605 4.784 43,859 3,174 99,895 3.462

148,180 2.848

$0 0 0 0 0 0 0 0 0 0 0 0 0 0

"Undupiicated Tatai - HHS report HCFA - 2082

NPC


Eligibility is determined by 63 County Departments of Social Services, and the drug program is administered by the Colorado Department of Social Services.



Restricted Drug Categories:

1. Prescription-legend drugs not listed in the "ColoRx Drug Formulary".

2. Certain over the counter drugs provided under prior authorization.

3. Payment for restricted drugs authorized only in accordance with non-emergency or emergency procedures as set forth in the Department's Manual Regulations. Volume VIII, Section 8.800.

4. OTC items are not included; exceptions are: insulin, aspirin under certain conditions, with refill limitations as stated in Manual Regulations, Volume VIII, Section 8.800.

B. Formulary: ColoRx Drug Formulary

Only those drugs presently assigned drug numbers in the Formulary are a benefit. (Refer to Manual Regulation Section 8.800 for provisions whereby drugs not listed in the ColoRx Drug Formulary may be allowed as a benefit.)

Controlled Drug Formulary

Section I - Alphabetical drug index in brand name order; if no brand name assigned, the generic name is listed.

Section I1 - Generic drugs are identified as having a Maximum Allowable Price, iisted with price information which is updated periodically.

Section 111 - EAC Price List. High volume drugs reimbursed at greater than 100's size or direct manufacturer's price.


1 . Terminology: The Department encourages appropriate consideration of cost in prescribing and dispensing by the selection of the less expensive trade name or generic product when, in the practitioner's professional judgment, the use of such a product is compatible with the best interests of the patient.

The ColoRx Drug Formulary will not be used by clinic and hospital pharmacies for drug pricing-only for drug code number information. Acquisition cost must be used for unit pricing.

2. Quantity of Medication: New prescriptions for chronic or acute conditions, at the discretion of the physician. However, reasonable amounts for more than a 30-day supply for chronic conditions are recommended. Maximum supply is 100 days.

Exceptfons to the above are:

a. Shelf package size oral liquid medications, in pint size only, or smaller package size when not packaged in pint size.

b. Shelf package size oral tablet and capsule medications in quantities of 100 only or smaller when not available in package size of 100.

c. Prescriptions for less than minimum amounts will be denied reimbursement of the professional fee unless the physician notified the State Department in writing of the medical need for amounts less than a 30-day supply. Medical consultation will determine the decision.

3. Doilar Limits: None.

91

NPC

D. Basis for Reimbursement

1. Benefit drugs shall be reimbursed at the lesser of the Medicaid allowable reimbursement charge, or the provider's reimbursement.

2. The Medicaid allowable reimbursement charge is the sum of the ingredient cost of the drug dispensed and the provider's dispensing fee.

3. Dispensingfee: $3.40 (effective date 7180)

4. The dispensing fee is a pre-determined amount paid to a provider for dispensing a prescription. It is established and periodically adjusted within appropriated funds based upon the results of a cost survey which is designed to measure actual costs of filling prescriptions.

5. The pharmacy dispensing fee for retaii pharmacies shall be based upon the average cost of filling a prescription as determined by the cost survey.

6. Institutional pharmacies shall receive a dispensing fee equal to one-half the retail pharmacy fee.

7. Governmental pharmacies shall receive no fee.

8. Dispensing physicians shall not receive a dispensing fee unless their offices or sites of practice are located more than 25 miles from the nearest participating pharmacy. In the latter case, a fee equal to one-half the retail pharmacy fee will be paid.

E. lngredient Cost

1. lngredient cost for retail pharmacies (estimated acquisition cost) is the price of the drug actually dispensed as defined in (c) below or the M.A.C. or the high volume E.A.C., whichever is less.

2. Benefit drugs dispensed in unit of use (unit dose) packaging will be reimbursed based upon the bulk package size of 100 or pints or if not available in those sizes, the most common size which most closely matches the standard sizes defined above.

3. The ingredient cost for institutional and government pharmacies is defined as the actual cost of acquisition for the drug dispensed or the M.A.C., or the high volume E.A.C., whichever is less.

a. Maximum Allowable Cost (M.A.C.)

The state M.A.C. is the maximum ingredient cost allowed by the Department for certain multiple-source drugs. The establishment of a M.A.C. is subject, but not limited to, the following considerations:

1. multiple manufacturers;

2. broad wholesale price span;

3. availability of drugs to retailers at the selected cost;

4, high volume of Medicaid recipient utilization;

5. bioequivalence or interchangeability.

When Federal M.A.C. limits for multiple source drugs are announced, they will be adopted if they are less than state M.A.C.'s or if no state M.A.C.'s exist.

Section I! of the ColoRx shall identify the generic drugs subject to M.A.C.

The ingredient cost of any drug subject to M.A.C. shall be limited to M.A.C. or wholesale price as determined by the Department, which is less. Exceptions which will allow reimbursement greater than M.A.C. for a drug entity are obtained through the prior authorization mechanism. An exception will be granted if the patient's response to the generic drug is not therapeutic, an allergic reaction is invoived, or any similar situation exists.

NPC

If a recipient requests a brand name for a prescription which is subject to M.A.C., then helshe may pay the ingredient cost difference between the M.A.C. and brand name drug. The recipient must sign the prescription stating that helshe is wiliing to pay the difference in ingredient cost to the pharmacy. The pharmacy will be paid M.A.C. plus a dispensing fee or reimbursement charges whichever is lower.

b. High volume Estimated Acquisition Cost (E.A.C.)

Reimbursement for singie source drugs or certain multiple source drugs which are most frequently prescribed will be based upon average wholesale prices or direct 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 acquistion cost list includes but is not limited to:

1. Single source manufacturers

2. High volume Medicaid recipient utilization

3. Interchangeability problems with multiple source drugs

4. Package sizes in excess of 100;

These drugs will be identified in Section Ill of the ColoRx.

C. Drug Pricing

The Department will maintain a drug pricing file which will be updated at least monthly. The average wholesale price of a drug as determined by the Department, M.A.C., and high colurne E.A.C., will be the basis for setting the prices in the drug pricing file.

The Department will determine the average wholesale price whlch will be placed in the drug pricing file as follows:

1. The average wholesale price as it appears in the Red Book, its supplements, and Medi- Span will be the first source. However, if there is a difference between the two published average wholesale prices, then the Department will set the price as the published amount which is the closes! to the lowest average price charged by two drug wholesalers doing business in Colorado.

2. If there is a price change which does not appear immediately in the Red Book, its supplements or in Medi-Span, then the Department will set the average wholesale price by averaging the wholesale prices of three drug wholesalers doing business in Colorado, until the price is published in the Red Book, its supplements, or in Medi-Span.

3. If the prices or changes do not appear in the publications or the wholesalers' records, then the distributors' or manufacturers' prices will be adjusted to the whoiesale piicing level and used in the drug pricing file as the price of the drug.

If the difference between the pharmacist's invoice purchase price and the average wholesale price which appears in the Red Book, its suplements, or Medi-Span exceeds 18% then the Department may adopt a lower price after a survey is conducted to determine the validity of the published prices. The price from the distributor or manufacturer will be adjusted ihe same as in 3 above.

Special Note:

The Maximum Allowable Cost shall be determined by the Division of Medicai Assistance, based upon professional determination of a quality product available at the least expense possible.

Recommendations from the CoioRx Drug Formulary Advisory Committee of the Medicai Advisory Council is considered in determining the MAC.


Lock-In Review Procedures:

The State Department receives computer processed printouts designed to discover overutilization of drugs prescribed by physicians, dispensed by vendors, and received by eligible recipients.

A Lock-In Review Committee composed of two physicians, one consumer, and three pharmacists meets monthly to review the printouts and make recommendations to the State regarding corrective action. In most cases, the attending physician is notified of the Committee's recommendations. Case-workers are also contacted and informed of the overutilization review on abuse with a request to contact the recipient and explain lock-in and help the recipient choose a physician and pharmacy. Recipient and the family are locked in for a year. A review of the case is then made to determine if the recipient and family should remain locked in. . .,r&

Prescription Data:

Total Rxs . . . 1,534,958 Average Rx Cost. . . $1 1.27

fiscal

Denver. CO 80272


1. Social Services Department Officials:

George A. Goldstein, Ph.D Executive Director

Cecilia Holmes Assistant Director

George E. Kawamura Associate Director for Programs

Andrea Baugher Office of Intergovernment Affairs

Willis H. LaVance Associate Director for

Administration

Gary Angerhofer Director. Bureau of Medical

Assistance

Bonnie Orkow Director, Program Operations

Myrle A. Myers, R.Ph., M.S. Manager, Pharmacy and Ambulatory

Care Services Section Division of Medical Assistance 3031866-5372

Colorado Department of Social Services

1575 Sherman Street Denver. Colorado 80203

James C. Syner, M.D. Medical Consuitant Division of Medical Assistance

NPC

Marjorie Jones, Acting Chief Hospital Services Section Division of Medical Assistance

Mary Ann Seddon Surveillance and Utilization

Review Section

Wes Letz Fiscal Agent Monitoring

Dean Woodward Manager, Appeals

Janell Townsend

Dan Milne Manager, Cost Containment &

Fiscal Agent Monitoring

Richard Allen Manager, Long Term Care

2. Social Services Department Consultant:

Marvin J. Lubeck. M.D Ophthalmology

3. Medical Advisory Committees:

A. Medical Assistance and Services Ad

Walter Ballard, D.D.S. 141 6 Constitution Pueblo, Colorado 81001

Stephen Gill, D.P.M. Denver Foot Clinic, P.C. 3193 South Broadway Englewood, Colorado 801 10

Elmer Houtsma 2316 West Davis Circle Littleton. Colorado 80120

Kenneth R. Huey Longmont United Hospital P. 0. Box 1659 1950 Mountain View Avenue Longmont, Colorado 80501

Charles A. Rademacher, D.O. 1060 Orchard Avenue Grand Junction, Colorado 81501

Members

3865 Cherry Creek North Drive

Denver 8021 0

visory Council:

Donald Schiff M.D. 600 Front Range Road Littleton, Colorado 80120

Anthony J. Makowski Ill, M.D. 3005 East 16th Avenue, Suite 150 Denver, Colorado 80206

Kaye Grounds Rehabilitation and Visiting

Nurse Association 1500 1 1 th Avenue Greeley, Colorado 80631

Hanna Evans, M.D. Clinical Psychologist Common Course 60 Kearney Street Denver, Colorado 80220

Victoria McLane Gow 31 Friendship Lane Colorado Springs, Colorado 80904

NPC

John A. Thomas, O.D. 3405 Wright Street Wheatridge, Colorado 80033

Janet Washburn 1260 South Reed, #4 Lakewood, Colorado 80226

Bernard Tessler 370 South Franklin Street Denver. Colorado 80209

EX OFFlClO MEMBERS:

George A. Goldstein, Ph.D Executive Director Colorado Department of

Social Services 1575 Sherman Street Denver, Colorado 80203

B. ColoRx Drug Formulary Advisory Committee:

Richard A. Haynes, R.Ph., Chairman

130 Pearl Street, #I805 Denver, Colorado 80203

Lillian Bird, R.Ph. 2420 - 71st Street Greeley, Colorado

Franklin L. Connell, R.Ph. P.O. Box 189 Del Norte, Colorado 81 132

Gerri Sorrnani. R.Ph. Musick Drug 309 East Fontanero SJreet .Colorado Springs, Colorado 80907

Don Asher 2770 W. 5th Avenue Denver, Colorado 80204

Jerry D. Harvey, H.Ph. 2201 San Juan Avenue LaJunta, Colorado 81050

William A. Hoover Englewood Pharmacy 3601 South Clarkson Englewood, Colorado 801 10

Mary Ernestine Kotthoff-Burrell, R.N.

11313 San Juan Range Road Littleton, Colorado 80127

Tom Vernon Executive Director Colorado Department of

Colorado Department of Social Services

Duane H. Lambert, R.Ph. 1700 Vine Street Denver, Colorado 80206

Roger R. Pearce, P.Ph., Pharmacy Division

King Soopers 80631 P.O. Box 5567 (65 Tejon Street) Denver, Colorado 80221

Robert W. Piepho, Ph.D., F.C.P. Professor and Assciate Dean Division of Clinical Programs University of Colorado Medical

Center 4200 East Ninth Street-Box C-238 Denver, Colorado 80262

Miles Schuman, R.Ph. Professional Pharmacy 1920 High Street Denver, Colorado 80218

Thomas Perry, M.D. 5440 W. 25th Avenue Edgewater, Colorado 80214

NPC Colorado-8 1985


A. Medical Society: C. Society of Osteopathic Medicine:

R.G. Jerry Bowman Executive Vice-president Colorado Medical Society 6825 E. Tennessee, Bldg. 2, Suite 500 Denver, Colorado 80224 Phone: 303/321-8590

Ms. Kathleen Brennanor Executive Director Colorado Society of Osteopathic Medicine 4701 E. 9th Avenue, Room 304 Denver. Colorado 80220

8. Pharmaceutical Association: D. State Board of Pharmacy

Arthur C. Hassen, Jr. Executive Director Colorado Pharmacal Association 171 1 Pennsylvania Street, Suite 108 Denver, Colorado 80203 Phone: 3031861-0328

David L. Simmons, Administrator 1525 Sherman Street, Room 128 Denver, Colorado 80203 3031866-2526

NPC

C O N N E C T I C U T

M E D I C A L A S S I S T A N C E D R U G P R O G R A M (T ITLE XXIX)



O M A0 APT0 AFDC O M AB APTD AFDC Children 21 (%!I)

Prescribed Drugs X X X X X X X X X X

Inpatient Hosp~tal Care X X X X X X X X X X

Outpatlent Hosp~tal Care X X X X X X X X X X

Laboratory & X-ray Service X X X X X X X X X X

Skilled Nursing Home Services X X X X X X X X X X Phvzicim ,

Services X X X X X X X X X X Dental Swices X X X X X X X X X X


I1 EXPENDITURES FOR DRUGS. PaVment to Pharmacists by fiscal year endinp June 30. 1984

. . . . . . . . . . . . . . . . . . . . . T O T A L

. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disbled . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . Children-Families wiDep Children

. . . . . . . . . . . . Adults-Families wiDep Children

. . . . . . . . CATEGORICALLY NEEDY NON-CASH TOTAL AQed . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . . Children-Families wiOep Children . . . . . . . . . . . .

. . . . . . . . . . . . Aduits-Families wiDep Children . . . . . . . . . . . . . . . Other Title XIX Recipients

. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabied . . . . . . . . . . . . . . . . . . . . .


. . . . . . . . . . . . Adults-Families wiDep Children . . . . . . . . . . . . . . . Other Title XIX Recipients


$24,948,974 157,029"


$21,265,077 153,729

YJnduplicated Total - HHS report HCFA - 2082

NPC


Directed by the State Welfare 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 hyperkenesis; 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 influenze or pneumovax vaccine, irrigating solutions, diabetic and diagnostic testing material and I.V. solutions or sets.

B. Formulary: OTC Drugs Only


1. Physicians are encouraged to prescribe drugs generically, when possible

2. Quant~ty of Medication: Maximum quantity: 30-day supply or 120 tablets or capsules or 1 Ib. powder. For chronic conditions, prescription may cover 120 day supply but no more than 120 tablets or capsules or 1 lb. powder. Oral Contraceptives: 3 months supply may be dispensed at one time.

3. Refills: 6 month refill limit except for oral contraceptives which have a 12 month limit. Controlled substances have a 5 refill or 5 month limit.

4. Dollar Limits: None

D. Prescription Charge Formula: MAC, AWP as listed in Red Book or EAC price set by Department plus fee; or usual and customary if lower.

Fees: Convalescent and nursing homes -cost plus $2.59 "Walk-In" patients - cost plus $3.11

The Department will pay an incentive professional dispensing fee of one dollar per prescription, in addition to any other dispensing fee, for substituting a generically equivalent drug product.


1. lncome Maintenance Officials:

Stephen B. Heintz Commissioner

Thomas Kilcoyne Deputy Commissioner

Department of Income Maintenance 110 Bartholomew Avenue Hartford, Connecticut 06106 2031566-41 20

Mary Nakashian Deputy Commissioner

Sally Bowles Director Medical Care Administration

Dennis Bothamley Chief, Institutional Care Medical Care Administration

Harry Kiernan, D.D.S, Dental Consultant

Meyer Rosenkrantz, R.Ph Pharmacist Consultant 2031566-8007

2. Income Maintenance Consultants (Part-time):

Waldo Maltin, M.D. Arthur V. McDowell, Sr.. M.D Francis Naples, D.D.S. Edmund Ziegler, M.D. H. Kallman, D.P.M. 0 . B. Hill, OD.

3. Title XIX Advisory Committees:

A. Pharmacy Advisory Committee:

State Pharmacy Commission Dr. James O'Brien Mike Williams

Connecticut State Medical Society

Dr. Elliott R. Mayo

Connecticut Pharmaceutical Assoc.

William Summa Edward C. Liska

lncome Maintenance Depaflment

Meyer Rosenkrantz Pharmacist

4. Fiscal Agent

Electronic Data Systems Corp Farmington, CT

5. Average Rx Prices FY 1984 $10.26

6. Executive.Officers of State Medical and Pharmaceutical Societies:

A. Medical Society: T. B. Norbeck Executive Director Conn. State Medical Assoc. 160 St. Ronan Street New Haven, CT 0651 1 Phone: 2031865-0587

C. Society of Osteopathic Medicine: Norman S. Roome, D.O., Secretary Connecticut Osteopathic Medical Society Summit Farm Joy Road RFD Woodstock, CT 06774

B. Pharmaceutical Association: D. State Board of Pharmacy

Daniel C. Leone, P.D. Edward c. Liska, Executive Secretary Executive Director State office Building Connecticut Pharmaceutical Association Hartford, CT 06106 943 Silas Deane Highway 2031566-391 7 Wethersfield, CT 06109 Phone: 2031563.461 9

NPC

seicount3 1 D E L A W A R E




OM AB APTD AFDC O M AB APTD AFOC Children 21 (SFG)

Prescribed

inpatient Hosoital Care

Outpatient Hospital Care X X X X


Skilled Nursing Home Services X X X X Physician Services X X X X Dental


II. MPENDiTURES FOR DRUGS. Payment to Pharmacists by fiscal year ending September 30. 1984

1984 1983 . . Expended - Recipient - Expended - Recipient -

T O T A L . . . . . . . . . . . . . . . . . . . . . $3,049,313 31,038" $2,706,325 31,940

CATEGORICALLY NEEDY CASH TOTAL . . ,

A . . . . . . . . . . . . . . . 0

Blind . . . . . . . . . . . . . . . . . . . . . . 22,389 70 13.312 73 Disabled . . . . . . . . . . . . . . . . . . . . . 92601 1 3,114 760,132 3,205 Children-Families wiDep Children . . . . . . . . . . . . 447,946 13,857 427,925 14,260 Adults-Families wiDep Children . . . . . . . . . . . . 601,542 8,736 574,656 8,990

CATEGORICALLY NEEDY NON-CASH TOTAL Aaed . . . . . . . . . . . . . . - ~ - Blind . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0 Disabled . . . . . . . . . . . . . . . . . . . . . 30,068 110 25,732 113 Children-Families wi0ep Children . . . . . . . . . . . . 19,828 658 17,683 677 Adults-Families w/Dep Children . . . . . . . . . . . . 22,715 497 20,257 512 Other Title XIX Recipients . . . . . . . . . . . . . . . 63,068 1,823 57.348 1,876

MEDICALLY NEEDY TOTAL Aaed . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0 Disabled . . . . . . . . . . . . . . . . . . . . . 0 0 0 0 Children-Families wmep Children . . . . . . . . . . . . 0 0 0 0 Adults-Families wiOep Children . . . . . . . . . . . . 0 0 0 0 Other Title XIX Recipients . . . . . . . . . . . . . . . 0 0 0 0

TJnduplicated Total - HHS report HCFA - 2082

NPC


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


A. General Exclusions:

Only legend item drugs (except for insulin) can be prescribed. Vitamins (except pediatric vitamins), antacids, etc. can not be prescribed unless they are legend items. OTC items cannot be prescribed. Anorectics are excluded, (except for pediatric hyperactivity and certain sleep disorders, when certified by the physician).

B. Formulary: None.


1. Quantity: None. Department requests physician to prescribe reasonable amounts.

2. Refills: Prescription blank has space for physician to authorize renewals.



Payment is based on the actual acquisition cost or maximum allowable cost (MAC) to the pharmacy or MAC, plus a $3.40 dispensing fee, or the usual and customary cost to the general public, whichever is lower.

E. Total number of Rx claims in fiscal year 1984-276,636

IV. Fiscal Intermediary

The Computer Company #1 Pike Creek Center, Suite 402, Wing 2 Wilmington, DE 19808


1. Health and Social Services Department Officials:

Thomas Eichler Secretary

Charles Hayward Director

Department of Health and Social Services

Delaware State Hospital New Castle, Delaware 19720 3021421 -61 39

Division of Economic Services P. 0 . Box 906

New Castle 19720

Ruth Fischer Administrator Medical Assistance Services

Dr. James Salva Medical Consultant

201 8 Naamans Road, Suite 1 B Wilmington 19810

Pharmacist Consultant %fsn

NPC

2. Medical Advisory Committee Members:

Mark Abrarns Delaware Pharmaceutical Assn 2501 Northgate Road Wilrnington, DE 19810

Anne Shane Bader Delaware Medical Society 1925 Lovering Avenue Wilrnington, DE 19806

Dale Bunting Division of Mental Health Director, Social Services Delaware State Hospital New Castle. DE 19720

Bonita DePree Medicaid Recipient-N.C. County 1200 Lancaster Avenue Wilrnington, DE 19805

Carol Guaz-Mandelberg Delaware Health Council 1925 Lovering Avenue Delaware State Hospital

Carol Katz Sussex County Home Services CHEER Program 64 Sussex Drive Lewes, DE 19958

David Levitsky, M.D. Delaware Medical Society 11 0 Christiana Medical Center Newark, DE 19702

Brenda Sims Delaware Review Organization 1601 Concord Pike Suite 92-1 00 Whington, DE

Martin Moss, O.D. Consultant-Vision Care Program 702 North Union Street Wilmington, DE 19805

Patricia Purceli, M.D. Delaware Medical Society 1508 Pennsylvania Avenue Wilmington, DE 19806

Paris Carpenter Medicaid Recipient Sussex County RD 1, Box 209 Lincoln, DE 19960

Donald B. Cowan, DDS Division of Public Health Bureau of Specialized Health Services Jesse Cooper Building Dover, DE 19901

William Duffy Association of Delaware Hospitals Riverside Hospital P. 0 . Box 845 Wiirnington, DE

Elizabeth Henry Division of Aging CT Building, Del. State Hospital New Castle, DE 19720

David Howard, M.D. Delaware Chapter American

Academy of Pediatricians P. 0 . Box 107 Ocean View, DE 19970

Bob Trernain Blue CrossIBlue Shield, Inc 1 Brandywine Gateway Wilrnington. DE 19899

Allen Levine, O.D. Delaware Optometric Society 41 9 North Market Street Wilmington, DE 19803

Charles Moiloy The Computer Company #1 Pike Creek Center Suite 402, Wing 2 Wilrnington, DE 19805

Mabel C. Nowland Visiting Nurse Association 2713 Lancaster Avenue Wilrnington, DE 19805

Olga Ramirez Consumer-Public Task Force 1225 Mayfield Road - Wiimington, DE 19803

103

NPC District o f C o l u m b i a - ! 1 9 8 5

D I S T R I C T OF C O L U M B I A




O M AB APT0 AFDC O M AB APT0 AFDC Children 21 (SFO)

Prescribed o w X X X X X X X X X Inpatient Hospital Care X X X X X X X X X

Outpatient Hospital Care X X X X X X X X X


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


11. EXPENDITURES FOR DRUGS. Pavment to Pharmacists bv fiscal vear endino Seotember 30. 1984


T O T A L . . . . . . . . . . . . . . . . . . . . . $8,113,136 65,009"

CATEGORiCALLY NEEDY CASH TOTAL . . . . . . . . . . 6,541,254 54,431 Aged . . . . . . . . . . . . . . . . . . . . . . 1,134.234 3,613 Blind . . . . . . . . . . . . . . . . . . . . . . 14,723 53 Disabled . . . . . . . . . . . . . . . . . . . . . 2,498,626 7,162 Children-Families wlDep Children . . . . . . . . . . . . 993,806 25,218 Adults-Families wIDep Children . . . . . . . . . . . . 1,896,168 18,375

CATEGORICALLY ~ E E D Y NON-CASH TOTAL . . . . . . . . 892,448 A d . . . . . . . . . . . . . . . . . . . . . . 404,666 Blind . . . . . . . . . . . . . . . . . . . . . . . 0 Disabled . . . . . . . . . . . . . . . . . . . . . 288,388 Chiidren-Families w1Dep Children . . . . . . . . . . . . 32,878 Adults-Families wlDep Children . . . . . . . . . . . . 62.983 Other Title XIX Recipients . . . . . . . . . . . . . . . 103,531

. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL 683,127 A ~ e d . . . . . . . . . . . . . . . . . . . . . . 231,593 B i d . . . . . . . . . . . . . . . . . . . . . . 132 Disabled . . . . . . . . . . . . . . . . . . . . 206,747

. . . . . . . . . . . . Chiidren-Families w1Dep Children 81,405

. . . . . . . . . . . . Adults-Families wiDep Children 157,597 Other Title XIX Recipients . . . . . . . . . . . . . . . 5,650


$7,180,151 68,338

5,774,148 58,010 1,030,505 3,824

12,858 54 2,028,715 7,064

951,752 27,511 1,750,323 19.557

318,361 2,853 109,578 758

3 0 151,545 815

19,371 639 37,005 640

862 1

1,087,642 7,475 491,803 1,630

Vnduplicated Tota - HHS report HCFA - 2082

District of Columbia-2 1985


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

iV. Provisions Relating to Prescribed Drugs'

A. General Exclusions: All legend drugs are covered except those drugs that are listed by FDA as ineffective. Pursuant to a prescription the following non-legend items are covered: oral analgesics, oral antacids, insulin, insulin needles and syringes, contraceptive foams and jellies, ferrous sulfate, prenatal vitamin formulations, geriatric vitamin formulations for recipients 65 years of age and over, and multivitamin formulations for children 7 years of age and under. All other rron-legend items are excluded.

8. Formulary: None.


1. Refills: In general, amounts dispensed are to be limited to quantities sufficient to treat an episode of illness. Maintenance drugs such as thyroid, digitalis, etc. may be dispensed in amounts up to a 30-day supply with 3 refills which must be dispensed within 4 months.

2. Antibiotic medications used in treatment of acute infections are not to be dispensed in excess of a (10) day supply. Birth control tablets may be dispensed in 3-cycle units with a maximum of 3 refills within one year.

3. Dollar Limits: There is no present dollar limitation. Physicians are requested to prescribe reasonable amounts.

4. Formulary: No


The lesser of:

-Maximum allowable charge (MAC) or -Estimated Acquisition Cost (EAC) plus $3.95 fee -The provider's usual charge to the public.

E. Compounded Prescriptions:

-Lesser of EAC of all ingredients plus $4.70. -The provider's usual charge to the public.

F. Co-payment:

$0.50 co-pay by recipient. Does not apply to recipients under 21 years of age, prescriptions for family planning, nursing home patients, or pregnancy related.


Fiscal Intermediary

The Computer Company (TCC) 401 New York Avenue, N.E. Washington, D.C. 20002


1. Department of Human Services Officials:

David E. Rivers Director

Department of Human Services 801 North Capitol Street, N.E. Washington, D.C. 20002

Andrew D. McBride. M.D., M.P.H. 1875 Connecticut Ave., N.W, Commissioner of Public Health Room 825

Washington, D. C. 20009

106

NPC District of Coiumbia-3 1985

Lee Partridge Chief, Office of Health

Care Financing

1331 H Street, N.W., Room 500 Washington, D. C. 20005

James Harris, R.Ph. Pharmacist Consultant Office of Health Care Financing

2. Executive Officers of District Medical and Pharmaceutical Societies:

A. Medical Society: C. Osteopathic Association:

Francisco P. Ferraraccio Executive Secretary Medical Society of the District of Columbia 2007 Eye Street, N.W. Washington, D. C. 20006 Phone: 2021223-2230

Harry Handiesman, O.D. Secretary Osteopathic Assn. of D.C 2804 Ellicott, N.W. Washington, D. C. 20008 Phone: 2021362-2250

0. Pharmaceutical Association: D. Board of Pharmacy

Roscoe Deveoux Carlyle McAdams Acting Executive Director Secretary D.C. Pharmaceutical Association 614 H Street. Room 923 6400 Georgia Ave., N.W., Suite 6 Washington, D. C. 20001 Washington, D. C. 20012 2021727-7468 Phone: 2021829-1 51 5

NPC

F L O R I D A




O M AB APT0 AFDC OAA AB APTD AFOC Children 21 (SFo)

Prescribed Drugs X X X X Inpatient Hospital Care X X X X

~osp i ta l Care X X X X


Skilled Nursing Home Services X X X Physician Services X X X X Dental


II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984

T O T A L . . . . . . . . . . . . . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . . Children-Families w/Dep Children . . . . . . . , . . . ,

Adults-Families w/Dep Children . . . . . . . . . . . .

CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . B h d . . . . . . . . . . . . . . . . , . . , . . . Disabled . . . . . . . . . . . . . . . . . . . . . Children-Families w/Oep Children . . , . . . , . , . . .

Adults-Families w/Dep Children . . . . . . . . . . . . Other Title XIX Recipients . . . . . . . . . . . . . . .

MEDICALLY NEEDY TOTAL . . . . . . . . , . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . .

Children-Families w/Dep Children . . . . . . . . . . . . Adults-Families w/Dep Children . . . . . . . . . . . . Other Title XIX Recipients . . . . . . . , . . , , , . .

1984 Expended Recipient - - Expended -

$76,184,224 429,016" $60,679,046

Not available

Not available

1983 Recipient -

""Undupiicated Total - HHS repoii HCFA - 2082

NPC


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


A. Limitations and Exclusions

1. Vitamins and phosphate binders only for dialysis patients.

2. Protheses; appliances; devices; and personal care items;

3. Non-legend drugs (except for prescribed insulin and buffered and enteric coated aspirin when prescribed as an anti-inflammatory agent only).

4. Anorexiants unless the drug is prescribed for an indication other than obesity (i.e. narcolepsy, hyperkinesis);

5. Topical acne preparations and selenium sulfide preparations;

6. Oral vitamins with exception of fluorinated pediatric vitamins prescribed for pediatric patients;

7. Digestants, except when prescribed for hepatic or pancreatic diseases;

8. Laxatives and Lactulose preparations, except when prescribed as a chelating agent;

9. Oral contraceptives unless prescribed for indications other than birth control;

10. Nursing home floor stock drugs.

8. Formulary: None.


1. Prescribed drugs covered up to $22 per recipient per month ($150 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.

2. The recipient must present a monthly eligibility card to the provider and must then use the same provider for the entire calendar month.

3. Maintenance medication should be dispensed and billed for at least a one-month supply.

4. Refills must be authorized by the prescriber and can be made for up to one year, except that controlled substances can be refilled only in accordance with federal and state regulations.

5. Drugs with questionable efficacy, as rated by the FDA (DESI), are disallowed.

6. Investigational, experimental, blood derivative (e.g. for hemophilia), and appetite suppres- sant items are not covered, nor are drugs that are prescribed for other than their approved indications.


Fee-effective July 1, 1980 Lower of: (1) MAC plus $3.33

(2) EAC plus $3.33 (3) Usual and Customary


A. Some High Volume EACs set at large package size

B. Provisions for medically necessary considerations

C. Maximum Allowable Ingredient Cost (MAIC)

1. Federal MAC drug list

NPC

D. Claims Processol

EDS Federal Corporation Pharmacy Services P.O. Box 9030 Tallahassee. Florida 32314


1. Department of Health and Rehabilitative Services Officials:

David Pingree Secretary

Richard T. Lutz Deputy Assistant Secretary

for Medicaid 9041488-3560

Rod Presnell, R.Ph. Pharmacist Consultant Medicaid Office of Program

Development

Jerry Wells R.Ph. Pharmacist Consultant Medicaid Office of Program

Development 9041488-9990

2. Consultants to Medical Services Program: (Part- time)

Donald 0 . Alford, M.D. Gene L. Davidson, M.D. Larry C. Deeb, M.D. Irving J. Fleet. D.D.S. Charles F. James, M.D. Fred Lindsey, M.D. Richard Lamb. D.D.S. Ms. Janet Shelfer Armanda M. Sittig, M.D. J. Orson Smith, M.D. James A. Stephens, O.D. Sam Tatum, D.D.S.

3. Medicaid Advisory Council:

Mrs. Maggie Bennett 720 West Myrtle Street Lakeland 33801 *Consumer

Ms. Patricia Bryant Post Office box 2104 Miami 33143 *Consumer

Department of Health and Rehabilitative Services

1323 Winewood Boulevard Tallahassee, Florida 32301

131 7 Winewood Boulevard Building 6, Room 233 Tallahassee 32301

131 7 Winewood Boulevard Building 6, Room 237 Tallahassee 32301

1317 Winewood Boulevard Building 6, Room 237 Tallahassee 32301

Medicaid Office 131 7 Winewood Boulevard Tallahassee 32301

George Browning, R.Ph. 1281 South Hickory Street Melbourne 32901 *Florida Pharmacy Association

Mrs. Susie Mae Bums 4205 Maxwell Boulevard South Tallahassee 32301 'Consumer

NPC

Commissioner Pat Glass Manatee County Post Office Box 1000 Bradenton 33506 *State Association of County Commissioners of Florida, Inc.

Mr. Arthur Harris Florida Manor 830 West Michigan Orlando 32804 'Florida Health Care Association

Mrs. Gaylia Howard Route 1 , Box 31 O'Brien 32071 'Consumer

Chris C. Scures, D.D.S. 2122 East Robinson Street Orlando 32803 'Florida Dental Association

Mr. Leon Zucker Vice President Finance, Public Health Trust Jackson Memorial Hospital 161 1 Northwest 12 Avenue Miami 33136 *Florida Hospital Association

4. Florida MAC Advisory Committee:

George Browning, R.Ph. Retail Pharmacy for Nursing

Homes 3730 Thornwood Drive 1281 Hickory Street Melbourne 32901

Lew Becks Nursing Home Pharmacy 5607 Hammock Lane Lauderhill 33319

Virginia Haggerty, R.N. Commission Post Office Box 6985 Orlando 32803 'Florida Nurses Association

Mr. William Hobson 610 South "K" Street Lake Worth 33460 'Consumer

Donald G. Nikolaus. M.D. Mease Hospital and Clinic Dunedin 33528 'Florida Medical Association

Mr. Fatah Wallizada 3656 St. Johns Avenue Jacksonville 32205 'Consumer

Mr. Richard T. Lutz Deputy Assistant Secretary

for Medicaid 131 7 Winewood Boulevard Building 6. Room 233 Tallahassee 32301 'Department of Health and

Rehabilitation Services'

Dick Kaplan Pharmacy Manager Tampa 33618

Jim Powers, R.Ph. . Secretary, Florida

Pharmacy Association 61 0 North Adams Tallahassee 32301

NPC

Lawrence DuBow Wholesaler Lawrence Pharmaceuticals Post Office Box 5386 Jacksonville 32207

Michael Zagorac, R.Ph. Pharmacy Manager C/O Jack Eckard Corporation Post Office Box 4689 Clearwater 33518

DHRS Medicaid Representatives:

Dick Grant, R.Ph. Department of HRS (PDHERx) 131 7 Winewood Boulevard Tallahassee 32301

Mark Sullivan, R.Ph. Pharmacist 1330 Miccosukee Road Tallahassee 32303

Jerry Wells, R.Ph. Department of HRS (PDDE) 1309 Winewood Boulevard Tallahassee 32301



W. Harold Parham Executive Vice-president Florida Medical Association. Inc Post Office Box 241 1 Jacksonville 32203 Phone: 9041356-1571

James B. Powers Executive Director Florida Pharmacy Association 610 North Adams Street Tallahassee 32301 Phone: 9041222-2400

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

Mervin E. Meck, D.O. C. Rod Presnell Secretary-Treasurer, Executive Director Executive D~rector Florida Osteopathic Medical Association 130 North Monroe Street 161 N. Causeway. Suite 1 Tallahassee, Florida 32301 New Smyrna Beach 32070 9041488-7546 Phone: 904/427-3489

NPC

G E O R G I A

M E D I C A L ASSISTANCE D R U G P R O G R A M (TITLE XIX)



O M AB APT0 AFDC O M AB APTD AFOC Children 21 ( S W

Prescribed Drum X X X X

lnoatient Hospital Care X X X X


Laboratory & X-rav Service X X X X

Skilled Nursing Home Se~ ices X X X X Phvsician

Dental Sewices X X X X


Ii. EXPENDITURES FOR DRUGS. hvrnent to Pharmacists bv fiscal vear ending June 30. 1984

. . . . . . . . . . . . . . . . . . . . . T O T A L

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

. . . . . . . . . . . . Adults-Families w l h o Children

CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . A ~ e d . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . Children-Families w/Oep Chiidren

. . . . . . . . . . . . Aduits-Families w/Oep Children . . . . . . . . . . . . . . . Other Title XIX Recipients

. . . . . . . . . . . . . . MEDICALLY NEEOY TOTAL Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . Chiidren-Families w/Oep Chiidren

. . . . . . . . . . . . Adults-Families w /hp Children . . . . . . . . . . . . . . . Other Title XIX Recipients

1984 Expended Recipient - -

$66,365,609 386.758"'

Not avaliable

Not available


"Undupiicated Total - HHS report HCFA - 2082

NPC


By the Department of Medical Assistance.


A. General Exclusions: Drugs not on the drug list

B. Formulary: The Controlled Medical Assistance Drug List. For information contact:

Mrs. Earline D. Jordan 2 M.L. King, Jr. Drive S.E. Floyd Building - West Tower P.O. Box 38440 Atlanta, GA 30334 4041656-4044

C. Prescribing or Dispensing Limitations: I I

1. Quantity of Medication: Physicians are encouraged to prescribe a 30 day supply. Six I

prescriptions per month per recipient except by prior authorization.

3. Refills: According to state and federal law.

4. Dollar Limits: None. I D. Prescription Charge Formula: Lower of, average wholesale price (AWP) plus fee of $3.61, or

MAC plus fee, or usual and customary.

, . V. Miscellaneous Remarks:

Average Rx price during FY 1984 $1 1.86

State MAC List = Federal MAC Plus 19 Additional Drugs


1. Department of Medical Assistance Officials:

Aaron Johnson Commissioner

Russ Toal Deputy Commissioner

Jacqueline Foster, Director Program Mangement

(Mrs.) Earline P. Jordan, R.Ph InstitutionalIAncillary Services

(Mrs.) Frances Lipscomb. R.Ph Program Mangernent Officer Pharmacy Service 4041656-4037

Department of Medical Assistance

James Floyd Memorial Bldg (Twin Towers)

P.O. Box 38440 Atlanta. Georgia 30334 4041656479

w 4

2. Title XIX (Medicaid) Medical Assistance Advisory Committees:

Representatives from each of the following groups:

Medical Association of Georgia Georgia Pharmaceutical Assn. Atlanta Medical Association Georgia Health Care Assn. Georgia Hospital Associat~on Georgia Dental Assn. Georgia Osteopathic Medical Assn.

3. Executive Off~cers of State Medical and Pharmaceutical Societies:

A. Medical Association: C. Osteopathic Medical Assn.:

J.M. Moffatt Executive Director Medical Association of Georgia 938 Peachtree Street. N. E. Atlanta 30309 Phone: 4041876-7535

Ms. Cathy M. Garris Executive Director GA Osteopathic Medical Assn. 2157 ldlewood Road Tucker 30084


Larry L. Braden William C. Miller, Jr. Executive Director Secretary Georgia Pharmaceutical Association 166 Pryor Street, S. W. 2520 Carroll Avenue Atlanta. GA 30303 Atlanta 30341 404656-391 2 Phone: 4041451-1336

NPC

G U A M

M E D I C A L ASS ISTANCE DRUG P R O G R A M (TITLE XIX)

I BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categoc~cally Needy Med~cally Needy (MN) Other'

O M AB APT0 AFOC O M AB APT0 AFDC Ch~ldren 21 (SF@

Prescribed Drugs X X X X X X X X

Inpallen1 Hospltal Care X X X X X X X X

Outpatlent Hospltal Care X X X X X X X X

Laboratow & X-ray Se&e X X X X X X X X

Skilled Nurs~ng Home Sewlces X X X X X X X X Physician Services X X X X X X X X Dental Services X X X X X X X X


Other Benefit: Transportation; prostheses

II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year.

1984 1983 Expended - Recipient - Expended - Recipient -

T O T A L . . . . . . . . . . . . . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . Children-Families w/Dep Children

. . . . . . . . . . . . Adulk-Families w/Dep Children

CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . Children-Families w1Dep Children


. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL Aged . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . Blind Disabled . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . Children-Families w/Dep Children Adults-Families w10ep Children . . . . Other Title XIX Recipients . . . . . . .

NO Data Available

Wnduplicated Total - HHS report HCFA - 2082

NPC

ill. Administration:

By the Department of Public Health and Social Services.


Prescribed drugs are provided to needy persons eligible for services under Title XIX. Providers include the Guam Memorial Hospital pharmacy as well as other privately operated pharmacies.

Dispensing fee-AWP plus $2.75

V. Officials, Consultants and Committees

A. Public Health and Social Services Department Officials:

Dennis G. Rodriguez Director Department of Public Health and Social Services Government of Guam Post Office Box 281 6 Agana. Guam 9691 0

8. Executive Officer of Pharmaceutical Association:

Orencia L. Concepcion Guam Pharmaceutical Association 626 Western Boulevard Jonestown Tamuning, Guam 96911

C. Guam Medical Society:

Pieter Huitema. M.D. President P. 0. Box 8718 Tamuning, Guam 9691 1

NPC

HAWAII

M E D I C A L ASS ISTANCE DRUG P R O G R A M (TITLE XIX)



O M AB APTD AFDC O M AB APTD AFDC Children 21 (SFO)


Inpatient Hospital Care X X X X X X X X X X

Outpatient Hospital Care X X X X X X X X X X

Laboratory & X-ray Service X X X X X X ' X X X X

Skilled Nursing Home Services X X X X X X X X X X Physician Services X X X X X X X X X X Dental Services X X X X X X X X X X


II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30,1984


T O T A L . . . . . . . . . . . . . . . . . . . . . $6,428,885 71,049" $6,324,334 75,458

CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $5,352,071 60,635 5,015,691 65.259 Aged . . . . . . . . . . . . . . . . . . . . . . 832,520 4.093 749.985 3.974 Blind . . . . . . . . . . . . . . . . . . . . . . 54.318 91 12,305 75 Disabled . . . . . . . . . . . . . . . . . . . . . 1.130.762 3.874 998.053 3.692 Children-Families w/Dep Children . . . . . . . . . . . . 1,540,056 33.438 1,547,805 34.616 Adults-Families w/Dep Children . . . . . . . . . . . . 1.794.415 19.139 1,707,543 22,902

CATEGORICALLY NEEDY NON-CASH TOTAL . . . A ~ e d . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . Disabled


. . . . . . . . . . . . Adults-Families w/Dep Children . . . . . . . . . . . . . . . Other Title XIX Recipients


. . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . Disabled


. . . . . . . . . . . . Adults-Families wDep Children Other Title XIX Recipients . . . . . . . . . . . . . .


NPC Hawaii-2 1985


By the State Department of Social Services and Housing through its Public Welfare Division and four county branch offices.

IV. Provisions Relating to Prescribed Drugs

A. Exclusions: Investigational new drugs, and drugs classified as ineffective or possibly effective by the FDA.

B. Formulary: Hawaii State Medicaid Drug Formulary

C. Co-payment: No

D. Prescription Charge Formula: Estimated Acquisitions Cost (EAC) plus dispensing fee $3.22 (eff. July 1, 1985).

E. Program pays for no more than the larger of: 30 days supply or 100 doses.

V. Fiscal Intermediary

Hawaii Medical Service Association Medicaid Program Section P.O. Box 860 Honolulu, Hawaii 96808


1. Social Services and Housing Department Officials:

Franklin Y. K. Sunn Department of Social Services Director and Housing

P. 0. Box 339 Honolulu, Hawaii 96816

Richard K. Paglinawan Deputy Director

Earl S. Motooka Medical Care Administrator

Omel L. Turk, R.Ph. Public Welfare Division Pharmaceutical Consultant (part-time) (same address as above) 8081548-891 7


A. Medical Association:

Jonathan Won Executive Director Hawaii Medical Association 320 Ward Avenue Honolulu 9681 4 Phone: 8081536-7702

C. Hawaii Assn. of Osteopathic Physicians and Surgeons:

Ronald Kienitz, D.O. Secretarynreasurer P. 0. Box M Kameohe, HI 96744

B. Pharmaceutical Assn.: D. State Board of Pharmacy:

Dominic A. Solimando, Jr. President Hawaii Pharmaceutical Assn. P. 0 . Box 1198 Honolulu 96807 Phone: 8081433-5394

Noe Noe Tom, Executive Secretary P. 0. Box 3469 Honolulu, HI 96801 80818590

NPC

I D A H O

M E D I C A L ASS ISTANCE DRUG P R O G R A M (T ITLE XIX)


Type ol Benelit Categorically Needy Medically Needy (MN) Other.

OAA AB APT0 AFDC OAA AB APTD AFDC Children 21 (SFo)



Out~alienl Hospital Care X X X X


Skilled Nursing Home Sefflces X X X X Phvsician . . ., ..-- Services X X X X Dental


II. EXPENDITURES FOR DRUGS. Pdyment to Pharmacisls by f i m l year ending June 30, 1984


T O T A L . . . . . . . . . . . . . . . . . . . . . $2,453,822 27,249" $2,462,560 27,954

CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $1.149.983 19.198 Aged . . . . . . . . . . . . . . . . . . . . . . 186,733 930 Blind . . . . . . . . . . . . . . . . . . . . . . 1.339 16 Disabled . . . . . . . . . . . . . . . . . . . . . 283.633 1.526 Children-Families w/Dep Children . . . . . . . . . . . . 299.241 10.634 Adults-Families w/p?p Children . . . . . . . . . . . . 378.484 6,092

CATEGORICALLY NEEDY NON-CASH TOTAL, . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . Disabled

. . . . . . . . . . . Children Families w10ep Children . . . . . . . . . . . . Adults Families w/Oep Children

. . . . . . . . . . . . . . . Other Title XIX Recipients

MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind

. . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . Children-Families w/Oep Children . . . . . . . . . . . . Adults-Families w/Bp Children



NPC


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


A. Exclusions: Amphetamine and related medication, plus certain therapeutic vitamins.

B. Drug formulary: None

C. Prescribing or dispensing limitations: Prescription drugs are limited to 530.00 per month per recipient. (34 day supply with limited exceptions)

D. Prescription charge formula:

Lower of MAC or EAC plus a variable dispensing fee $2.50-3.50, (unit dose $4.15) according to location, size and Rx volume of the provider, or the provider's usual and customary price to the general public.

V. Miscellaneous Information

Copayment: none Average prescription price during FY 1983: 59.50

Fiscal intermediary

EDS Federal Corporation P.O. Box 1168 Boise, ldaho 83701

Otflclals, Consultants and Committees 1. Health and Welfare Department:

Rose Bowman Director

Depattment of Health and Welfare Statehouse Boise, ldaho 83720 20813344334,

William J. Whiteman, D.Ph. Bureau of Medical Assistance

Dianne 8. Onnen, R.Ph., M.P.A. Supervisor Medicaid Policy Section 20813344323

2. Medical Care Advisory Committee:

Richard D. Adams, Director Health District Ill P. 0. Box 489 Caldwell, ID 83605 459-0744

J. Stephen Anderson Regional Services Manager. Region V Department of Health and Welfare P. 0 . Box 1509 Twin Falls, ID 83301 734-4000

Committee: Ruby Crosby, R.N. St. Benedict's Hospital Jerome, ID 83338 324-4301

Arlene Davidson ldaho Office on Aging Statehouse Boise, ID 83720 334-3220

NPC

Howard Barton ldaho Commission for the Blind Statehouse Boise, ID 83720 334-3220

Laura Barton, R.N. Home Health Services Central District Health Department 1455 North Orchard Boise, ID 83706 375-521 1

The Honorable Pamela I. Bengson Idaho House of Representatives 2704 Raindrop Drive Boise. ID 83706 345-61 68

Brent Brocksome Chartham Management 2465 Overland Road. Boise, ID 83705 343-701 3

Robert Campbell St. Benedict's Hospital Jerome, ID 83338 324-4301

Raiph W. Carpenter, Administrator Division of Health Department of Health and Welfare Statehouse Boise. ID 83720 334-4283

Susan Sutich P. 0 . Box 601 Boise, ID 83701 336-6837

John Watts, Executive Director ldaho State Council on Developmental Disabilities Statehouse Boise, ID 83720 334-4408

Dr. Rodney Heater 827 Center Avenue Payette, ID 83664 642-4434

J. Charles Holden ldaho Association of Counties P. 0. Box 1623 Boise. ID 83701 345-91 26

Dr. John S. Kriz ldaho State Dental Association 8424 Fairview Avenue Boise. ID 83704 376-7740

Randy Robinson, Esq. ldaho Legal Aid Services. Inc Suite A P. 0 . Box 973 Lewiston, ID 83501 743-1 556

Dale Shirk, Exec. Vice President ldaho Health Care Association P. 0 . Box 2623 Boise, ID 83701 343-9735

Don Sower. Executive Director ldaho Medical Association 407 West Bannock Boise, ID 83702 344-7888

Marilyn Loenins Sword ldaho Mental Health Association 1617 Holden Boise, ID 83706 344-8585

Rosemary Wells ldaho State Pharmaceutical Assoc. 1365 North Orchard, Room 103 Boise, ID 83706

NPC Idaho-4 1985


A. Medical Association: 6. Pharmaceutical Association:

Donald W. Sower Executive Director ldaho Medical Association 407 W. Bannock P. 0. Box 2668 Boise 83701 Phone: 2081344-7888

C. Osteopathic Medical Assn.:

Harry E. Kale, D.O. Secretary-Treasurer ldaho Osteopathic Medical Assn. 522 West Main Street Grangeville 83530 2081988-1 133

Rosemary Wells Executive Director ldaho State Pharmaceutical Association 1365 North Orchard Street, Room 103 Boise 83706 Phone: 2081376-2273

D. State Board of Pharmacy:

- %??&-x%ke Director 700 West State Street Boise, ID 83720 2081334-2356

NPC

ILLINOIS

M E D I C A L ASS ISTANCE D R U G P R O G R A M (TITLE XIX)



O M AB APT0 AFOC O M AB APT0 AFOC Children 21 (SFo)

Prescrtbed nn~"< X X X X X X X X X X -."-" Inpatient Hospital Care X X X X X X X X X X


~aboratory & X-ray Service X X X X X X X X X X

Skilled Nursing Home Services X X X X X X X X X X

Physician Services X X X X X X X X X

Denlal Services X X X X X X X X X X

'SF0 - Stale Funds Only

11. MPENOITURES FOR DRUGS. kiyment to Pharmacists by fiscal year ending September 30. 1984

TOTAL

Expended - . . . . . . . . . . . $98,044,838

. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . Children-Families wlDep Children

. . . . . . . . . . . . Adulls-Families wIOep Children

CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . Aged Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . .


. . . . . . . . . . . . Adults-Families wIOep Children . . . . . . . . . . . . . . . Other Title XIX Recipients

. . . . . . . . . . . . . . MEDICALLY NEEOY TOTAL Aged . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . Ch~ldren-Famiiiw w/Dep Children

. . . . . . . . . . . . Adults-Families wlDepChildren . . . . . . . . . . . . . . . Other Title XIX Recipients

1984 Recipient -

"Unduolicated Total - HHS reDolt HCFA - 2082


Illinois Department of Public Aid


A. General Exclusions: Biologicals and drugs available from State Department of Health or other agencies, anorectics, desi-ineffectives, cough syrups, general multivitamins, topical acne preps.

B. Formulary: Pharmacies are encouraged to stock and dispense non-proprietary drugs of 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.

For formulary information contact:

Ms. Dawn Gottrich P.O. Box 4037 Springfield, Illinois 62708 (21 7)782-0506


1. "The pharmacy shall dispense non-proprietary products of quality. Maximum reimbursement to the pharmacy will be based on the price of a non-proprietary item of recognized quality."

2. Quantity: One prescription per patient per drug per month

3. Refills: A prescription may be refilled only if the prescribing practitioner has so authorized on the original prescription. A prescription may be refilled no more than twice and no later than 3 months from the date of the original prescription. Maintenance Rx's may be refilled for up to one year.


D. Prescription Charge Formula: Lowest of 1) usual and customary, 2) Actual Acquisition Cost (AAC) plus fee, or 3) Department's MAC plus fee. Professional fee was increased to 3.46 on 9/1/85.

V. Miscellaneous Information:

State MAC: Yes Approximately 5M) drugs Copayment-none Average prescription price during FY 1984-$8.29

Fiscal Intermediary-none'

Offlclals, Consultants and Commlttees

1. Public Aid Department Officials:

Gregory L. Coler Director

Thomas J. Walsh Administrator Medical Assistance Program

Louis J. Bosco Chief Off ice of Personnel Management and Labor

Department of Public Aid 316 South 2nd Street Springfield 62762 628 East Adams Springfield 62763

316 South 2nd Street Springfield 62762

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John Muller Deputy Administrator Medical Assistance Program

628 East Adam Springfield 62763

Norman L. Ryan 21 6 East Monroe General Services Administrator Springfield 62762

Mary Ann Langston Administrator Policy and Planning

Curt Fleming. Chief Bureau of Research & Analysis

Beverly Knous. Chief Bureau of Information Systems

Dawn Gottrich, Supervisor Drug Program

Ron Gottrich Pharmacist Consultant 21 71702-5385

316 South 2nd Street Springfield 62762

21 6 East Monroe Springfield 62705

100 South Grand Avenue East Springfield 62705

628 East Adams Springfield 62763

628 East Adams Springfield 62763

2. Public Aid Department Advisory Committees:

A. The Department has a State Medical Advisory Committee, composed of physicians appointed by the Director of Public Aid. The members of this Committee are from different areas of the State and are representative of the different speciality fields.

Frederick B. White Chairman

723 North 2nd Street Chillicothe, Illinois 61 523

B. Committee on Drugs and Therapeutics:

A Committee on Drugs and Therapeutics, a standing committee appointed by the lllinois State Medical Society, serves in an advisory capacity to the Department of Public Aid on drug policy and the Drug Manual.

Vincent A. Costano. Jr.. M.D Chairman

Amin N. Daghestani. M.D.

Dorothy Hubler. M.D.

Martin J. Kaplan, M.D

7531 South Stony Island Chicago, Illinois 60649

64 Old Orchard, Suite 205 Skokie 60077

Casey Medical Center Casey, Illinois 62420

11 60 Park Avenue West Highland Park 60035

Robert Reeder, M.D 970 N. 5th Avenue St. Charles 601 74

NPC

Arthur Marks. M.D.

Allan L. Lorincz, M.D.

Consultants: A. Samuel Enloe, R.Ph

Joan E. Cummings, M.D

Harold L. Jensen, M.D.

Arthur R. Peterson, M.D

Dawn Gottrich

101 E. Center Fairfield 62837

5841 S. Maryland, Box 409 Chicago, 11 60637

251 W. First Drive Decatur 62521

Hines V.A. Hospital Hines, 11 60141

3235 Vollmer Road Flossmoor 60422

2740 West Foster Chicago, 11 60625

628 East Adams Springfield, 11 62763

C. Drug Advisory Committee:

A State Drug Advisory Committee, appointed by the Director of the Department of Public Aid to advise on general policies necessary to the operation of a statewide drug program for public assistance recipients.

George Karpman, R.Ph. 901 N. First Springfield 62702

Bernie Evers, R.Ph. Evers Pharmacy 417 West Main Collinsville 62234

Don Gronewold, R.Ph. Don's Pharmacy 100 South Main Street Washington 61571

Rose Mancuso, R.Ph. 1610 Arden Place Joliet 60435

Ron Stevens, R.Ph. Union Prescription Center 646 Summit Caseyville 62232

Robert Mandelbaum, R.Ph Manager 3rd Party Walgreed Company 200 Wilmot Road Deerfield 60015

Sam Enloe, R.Ph., Chairman Enloe's Southtowne Pharmacy 251 West First Drive Decatur 62521

Tom Gulick, R.Ph. Gulick Pharmacy. Inc. 912 North Vermilion Danville 61 832

Sherwood Thomas. R.Ph. Touhy Pharmacy 71 73 North Clark Street Chicago 60626

Jeffrey Veal, R.Ph. 340 East 67th Place Chicago 6061 9

Harry Staub, R.Ph. Cabrini Pharmacy 949 N. Larrabee Chicago 60610

Kenneth L. Gimmy, R.Ph. Rx Gimmy's Drug Store, Inc. 97 South 9th, Rosewood Heights East Alton, 11 62232

NPC

Jerry Handler. R.Ph. Bill Ghodes, R.Ph. 481 1 West Madison 7 Buttonwood Court Chicago, 11 60644 lndianhead Park, 11 60525


A. Medical Society B. Pharmaceutical Association:

Alexander R. Lerner Alan L. Granat Executive Administrator Executive Director Illinois State Medical Society Illinois Pharmaceutical 20 N. Michigan Ave. Suite 7002 Association Chicago, 11 60602 222 W. Adams Street. Suite 546 Phone: 312i782-1654 Chicago 60606

Phone: 31 21236-1 135


Mr. George C. Andrews Gary L. Clayton, Director Executive Director Department of Reg. and Ed., Illinois Association of Osteopathic Pharmacy Section

Physicians and Surgeons. Inc. 320 West Washington Street 900 East Center Street Springfield. IL 62786 Onawa 61350 21 71785-0800 81 5/43-5576


Gary L. Clayton, Director Department of Reg. and Ed., Pharmacy Section 320 West Washington Street Springfield, 11 62786 21 7/785-0800

I N D I A N A

M E D I C A L ASS ISTANCE D R U G P R O G R A M (T ITLE XIX)

I. BENEFITS PROVIOEO AND GROUPS ELIGIBLE


OAA AB APTD AFDC O M AB APTD AFDC Children 21 (SFO)



outpatient Hnsnihl Care X X X X


Skilled Nursing Home Services X X X X Physician Sewices X X X X npntal

Services X X X X


II. EXPENDITURES FOR DRUGS. Payment to Phar~ciStS by fiscal year ending June 30, 1984

T O T A L

1984 1983 Expended Recipient Expended Recipient - - - -

$44,034,165 206,532" $39,459,209 203.447

CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $18,990.471 156,613 $18,071,549 160.720 Aged . . . . . . . . . . . . . . . . . . . . . . 3,466,598 7.222 3,283,885 7,677 Blind . . . . . . . . . . . . . . . . . . . . . . 225,995 583 208,232 597 Disabled . . . . . . . . . . . . . . . . . . . . 6,403,677 12,039 5,671,751 11.993 Children-Families w/Dep Children . . . . . . . . . . . . 2,889.439 82.323 2,767,085 84,057 Adults-Families w/Dep Children . . . . . . . . . . . . 6,004.761 54,446 6,140,598 56.833

CATEGORICALLY mEDY NON-CASH TOTAL . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . Disabled

. . . . . . . . . . . . Children-Families w/Oep Children

. . . . . . . . . . . . Adults-Families w/Dep Children Other Title XIX Recipients . . . . . . . . . . . . . . .

MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Bind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . Children-Families wIOeo Children ~ ~~

. . . . . . . . . . . . Adults-Families wIDep Children . . . . . . . . . . . . . . . Other Title XIX Recipients

'"Unduplicated Total - HHS report HCFA - 2082

NPC


The lndiana State Department of Public Welfare.


A. General Exclusions: (Most OTC drugs are covered) No legend or non-legend anorexics or anti- smoking aids.

6. Formulary: None


1. Quantity of Medication: None.

2. Refills: Allowed as authorized by physician.


4. One dispensing fee paid per legend drug order per recipient per month in nursing home setting.


1. The lowest of the:

a. MAC plus the dispensing fee of $3.00.

b. EAC (Estimated Acquisition Cost) plus the dispensing fee of $3.00. (EAC is 3% less than AWP reported by Drug Topics Red Book)

c. Pharmacy's usual and customary charge to the general public.

V. Miscellanous Information:

Fiscal Intermediary:

EDS Federal Corp 120 W. Market Street Indianapolis, lndiana 46204


1. Welfare Department Officials:

Donald L. Elinzinger Administrator

James H. Cook Assistant Administrator- Administration

Mrs. Tara Lenn French Assistant Administrator- Medicaid

Department of Public Welfare 100 N. Senate Avenue Room 701 Indianapolis, lndiana 46204

William Harding Director Division of Administrative

Services

NPC

Mrs. Mary Kapur Assistant Administrator Local Operations Division

Marc Shirley, P.D. Pharmacy Consultant 31 71232-431 2

2. Advisory Committee for Medical Assistance (Medicaid)

Mary Ludwig, M.D. 674 Sugar Tree Road Crawfordsville, IA 47933

Lawrence E. Allen, M.D. 2009 Brown Street Anderson, IA 4601 4

Mr. Sandy Quarles P. 0 . Bc..506 Kokorno, IA 46901

Mr. George S. Row. Ill 121 West Ripley Street Osgood, lA 47037

Robert C. Shirey, D.D.S 7216 Madison Avenue Indianapolis, IA 46227 31 71786-7643

Mr. Robert Spaulding Department of Mental Health 5 lndiana Square Indianapolis, IA 46204

Albert 6 . Stroud, O.D. 6326 Rucker Road Suite C Indianapolis. IA 46220

Mr. Newell J. Hall, V.P. Director. Professional Services Hook Drug, Inc. 2800 Enterprise Street Indianapolis. IA 46226 3171353-1451

Mr. John Huber. Adm. Sycamore Village Health 2905 West Sycamore Road Kokorno, IA 46901

Mr. Edward W. James 3150 West 19th Place Gary, IA 46402 21 91949-7858

Citizenry of lndiana

Medical Association

Statewide Taxpayer

Agricultural lnterests

State Dental Association

Ex-Officio Represents Mental Health Commissioner

Ootometric Association

Pharmaceutical lnterests

lndiana Health Care Assoc

Labor lnterests

NPC

Mr. George H. James, Adm. Jackson County Hospital 200 South Walnut Street Seymour. IA 47274 8121522-01 12

Mrs. Belle Kasting 1724 Parkview Drive Bedfore. IA 47421

Albert F. Kull, D.O. 203 South Ironwood Drive P. 0 . Box 6172 South Bend, IA 4661 5 21 91282-2481

Mrs. Frances Safford Director. Division of Health Facilities State Board of Health 1330 West Michigan Indianapolis. IA 46202 31 71633-8496

Mrs. Jo Haynes Brooks, R.N. Associate Professor, Nursing Purdue University School of Nursing West Lafayette. IA 47907

Ms. Joyce Burton, L.P.N 21 Rigney Road Terre Haute, IA 47802

Mr. Joseph M. Douglass. Jr. P. 0. Box 276 Angola. IA 46703

Hon. William Dunba~

Hon. Jeffrey K. Espich BOX i58 Uniondale, IA 46791

Mrs. Hazel Gromer 717 N.W. 2nd Street Washington, IA 47501

Mr. Ray Fox Fox & Fox lnsurance Co. 3656 North Washington Boulevard Indianapolis. IA 46205

J. K. Wincklebach. D.P.M. 8144 Madison Avenue Indianapolis, IA 46227

Indiana Hospital Association

Citizenly of Indiana

Association of Osteopathic Physicians & Surgeons

Ex-Officio - Represents Health

State Nurses' Association

Licensed Practical Nurses' Assoc.

Business & Industrial lnterests

State Senate

State Representative

Citizenry

lnsurance lnterests

State Podiatry Association

Charles Watkins, D C. Chiropractic Association 5117 East Washington Street Indianapolis, IA 461219

3. Executive Officers of State Med~cal and Pharmaceutical Societ~es:

A. Medical Association: C. Osteopathic Medical Assoc.:

Donald F. Foy Executive Director lndiana State Medical Association 3936 North Meridian lndianapolis 46208 Phone: 3171925-7545

Thomas D. Hanstrom 8900 Keystone Crossing Suite 659 Indianapolis 46240 Phone: 31 71846-7616


David A. Clark Executive Director Indiana Pharmacists Association 156 E. Market Street, X900 indianapolis 46204 Phone: 31 71634-4968

William Keown, Executive Director 964 North Pennsylvania Avenue Indianapolis, IA 46204 31 71232-2960

NPC


Central administration by the State Department of Human Services


A. General Exclusions (diseases, drug categories, etc.): Most non-legend drugs, amphetamine products, laxative drugs, and legend multiple vitamins require prior authorization.

lowa Medicaid OTC Coverage Rule

The lowa Department of Human Services adopted an administrative rule which permits coverage for the following non-prescription drugs.

Aspirin Tablets 325 mg, 650 Aspirin Tablets Enteric Coated 325 mg, 650 Aspirin Tablets Buffered 325 Acetaminphen Tablets 325 mg, 500 Acetaminophen Elixir 120 mgl5 Acetaminophen Solution 100 mgl Ferrous Sulfate Tablets 300 mg, 325 Ferrous Sulfate Elixir 220 mgl5 ql Ferrous Sulfate Drops 75 mg10.6 ql Ferrous Gluconate Tablets 320 mg, 325 Ferrous Gluconate Elixir 300 mgl5 Ferrous Fumarate Tablets 300 mg, 325

B. Formulary: None.


1. Terminology: None.

2. Quantity of Medication: Prescriptions should be limited to a 30-day supply. Maintenance drugs may be supplied in 90-day quantities.

3. Refills: Permitted.


D. Prescription Charge Formula: Payment will be based on the pharmacist's usual, customary and reasonable charge, but payment may not exceed the current wholesale cost of the drug as defined by the Deparlment of Social Services, plus a professional fee determined to be the 75th percentile of usual and customary fees. Currently $3.78.

E. State MAC list contains 52 drugs


FY 1984

Total number Rx 1,919.937

Average cosVRx for all categories $1 1.29

VI. Claims Processing Intermediary:

Systems Development Corporation P.O. Box 10394 Des Moines, lowa 50306

Source: Statistics Section, Division of Management and Budget. 1. $1 .OO copay (Federal Exclusions) fee: $3.78 fee effective July 1, 1984.

$0.50 incentive fee paid to pharmacy if $1.50 is saved per prescription by the use of generics.

NPC


1. Human Services Department Officials:

Michael V. Reagen, Ph.D. Commissioner

Donald W. Herman Chief Bureau of Medical Services

Ronald J. Mahrenholz. R.Ph., M.S. Manager Operations Section 5151281-6199

2. Human Services Department Advisory Committees:

A. Title XIX Medical Assistance Council:

College of Medicine Paul Seebohm. M.D Associate Dean College of Medicine University Hospitals lowa City 52240

House of Representatives Rep. Andy McKean Morley 5231 2

Rep. Edward G. Parker R.R. 41. Box 128 Mingo 50168

lowa Dental Association Edgar L. Smith, D.D.S. 2214 Forest Des Moines 5031 1

Opticians Assoc. of lo'wa, Inc.

Trish Smallenberger 550 11th Street. Suite 204 Des Moines 50309

lowa Assoc. of Retarded Citizens Mary Etta Lane 1707 High Street Des Moines 50309

Department of Human Services Hoover State Office Building Des Moines, lowa 5031 9 5151281 -8621

lowa Hospital Association Inc. Donald Dunn Suite R. 600 5th Avenue Des Moines 50309

lowa Medical Society Donald C. Young, M.D. 1301 10th Street. Suite 119 Des Moines 5031 6

lowa Nurses Association Marilyn Russell (Mrs.) Public Health Nursing Assoc. Armory Building East 1st & Des Moines Street Des Moines 50309

Health Facilities Assoc. of lowa

R. Buckrnan Brock P. 0 . Box 677 2137 Sunset Road Des Moines 50303

lowa Council of Health Care Care Centers Shirley Clark 2400 N.W. 86th Street. Suite 14 Des Moines 50322

lowa Senate Senator Dale L. Tieden Elkader 52043

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lowa Assembly of Home Health Agencies

Nancy Buitendorp Box 418 Montezuma 501 71

lowa Society of Osteopathic Physicians and Surgeons

Gary Hoff, D.O.

Des Moines 50313

lowa Optometric Association Thomas E. Ward, O.D. 801 Grand Avenue Des Moines 50309

lowa Osteopathic Hospital Association

James Kingsbury 603 E. 12th Street Des Moines 5(X716

lowa Pharmacists Assoc. Thomas R. Temple 8515 Douglas, Suite 24 Des Moines 50322

lowa Pbdiatry Society John C. Korn. D.P.M. Davenport Bank Building Davenport 52801

lowa State Dept. of Health Commissioner Lucas State Office Building Des Moines 50319

lowa Assoc. of Homes for the Aging

Bernard Bowman . 315 E. 5th, Suite 4 Des Moines 50309

8. Pharmaceutical Advisory Committee:

Mark Richards, Des Moines Bill Robinson, Atlantic Phil Weider, Des Moines Dan Keckler, Eldridge Dan Wiese. Davenport Tom Taiber, Waverly Ken Hampson. Ames

Senator Joe Brown Montezuma 501 71

lowa Chiropractic Society Robert Rasmussen, D.C. 3500 2nd Avenue 1440 East Grand, Suite 38

Public Representatives Nancy M. Jones RR #1 Ainsworth 52201

Dorothy J. Eide 701 5th Street. N. E Oelwein 50662

Darlene M. Brown 4519 Grand Des Moines 5031 2

lowa Psychological Assoc. Craig 8. Rypma 2404 Forest Drive Des Moines 50312

Community Mental Health Ctrs. Assoc. of lowa

Holly Oppelt 101 W. Mississippi Dr., Suite 200 Muscatine 52761

Russ Wiesley, Creston Duane Haberichter, Oskaloosa Marion Reis. Sioux City Roger Zobel, West Des Moines Dick Hartig. Dubuque Bev Bartos, lowa City Keith Kouba, Anamosa

NPC

3. Executive Officers of State Medical and Pharm~eutical Societies:

A. Medical Society:

Eldon Huston Executive Vice-president lowa Medical Society 1 OO1 Grand Avenue West Des Moines 50265 Phone: 5151223-1401

8. Pharmacists Association:

Thomas R. Temple. R.Ph.. M.S. Executive Director lowa Pharmacists Association 8515 Douglas, Suite 24 Des Moines 50322 Phone: 5151270-0713

C. lowa Society of Osteopathic Physicians and Surgeons:

F. Walter Tomenga Secretary-Treasurer 508 10th Street. Suite 300 Des Moines 50309 Phone: 51 51283-0002

D. State Board of Pharmacy Examiners

Norman C. Johnson, Executive Secretary 1209 East Court, Executive Hills West Des Moines, lowa 50319 51 51281 -5944

NPC

K A N S A S



Type ol Benefit Categorically Needy Medically Needy (MN) Other'

O M AB APT0 AFDC OAA AB APTD AFDC Children 21 ( w

Prescribed Drugs X X x x X X X X x X

inpatient Hospital Care X X X X X X X X X X



Skilled Nursing Home Services X X X X X X X X X X Physician Services X X X X X X X X X X Dental Services X X X X X X X X X

Other Benefits: Home Health Care: Clinic Services: Rehabilitative Services; Prostheseis; Preventive Services; Family Planning Services; Chiropractic Services; Optometric Services; and Communily Based Alternative Services.




. . . . . . . . . . . . . . . . . . . . . T O T A L $1 7,305.550 106,755"

. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL Not available Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . .


. . . . . . . . . . . . Adults-Families w/Dep Children

. . . . . . . . CATEGORiCALLY NEEDY NON-CASH TOTAL Aged Blind . . . . . . . . . . . . . . . . . . . . . . Disabled



. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . Children-Families w/Dep Children . . . . . . . . . . . .

. . . . . . . . . . . . Adulk-Families w/Oep Children Other Title XiX Recipients . . . . . . . . . . . . . . .


$15,974,742 104,280

8,345,640 80.214 2,349.735 7.204

'VJndupiicated Total - HHS report HCFA - 2082

NPC


State Department of Social and Rehabilitation Services.


A. Prescribed drugs. Covered are: (a) legend drugs in a formulary approved by the state Medicaid agency, excluding drugs that the agency finds ineffective or possibly effective; and (b) seleted nonlegend drugs, devices, and supplies when prescribed for diseases and conditions specified in the state's Medicaid regulations.

0. Formulary: Restricted drug list.


1. Quantity of Medication: Maximum of a 100-day supply. Minimum quantities of a 100-dose or 30-day supply should be prescribed and dispensed for maintenance drugs.

2. Refills: As authorized by the prescriber up to a one-year period from the date of issuance of the prescription.

3. Dollar Limits: A prescription claim in excess of $75 is reviewed prior to payment.

D. Prescription Charge Formula: Variable fee per prescription established for each individual participating pharmacy within the range of $2.46 to $4.67 for N-1984.

Pharmacies are reimbursed on the basis of product acquisition cost plus a professional fee. This applies to all covered legend and non-legend drugs. The professional fees are based upon each individual pharmacy's historical operating costs as determined by analysis of data submitted by each pharmacy to the agency. Professional fee determination is limited to the lowest of: (a) The 85th percentile of allocated costs per prescription for all pharmacies filing a cost report plus a reasonable profit, or (b) usual and customary fee charges of each individual pharmacy as determined. "Acquisition cost" means the allowable price delermined by the agency for each covered drug in accordance with state and federal regulations.

Effective May 1, 1983, a recipient co-pay charge of $1.00 was applied to each new and refill prescription.


1. Social and Rehabilitation Services Department Officials:

Dr. Robert C. Harder Secretary

John Schneider, Commissioner Income Maintenance and

Medical Services

Robin Smith, Director Public Assistance Section

L. Kathryn Klassen, R.N.. M.S. Director Division of Medical Programs

Department of Social and Rehabilitation Services

State Office Building Topeka, Kansas 66612

Department of Administration State Capitol Topeka, Kansas 6661 2

Alden Shields. Budget Director Department of Administration

NPC

Joyce Sugrue, A.N. Coordinator of Medical Services

Elaine Hacker, M.D. Utilization Review Administrator

Gene Hotchkiss, R.Ph. Pharmacist Consultant 91 31296-3981

2. Governor's Medical Advisory Committee:

Daniel A. Shea, O.D. 2720 East 21st Street Wichita, Kansas 67214

Fenton Williams, M.D. 15401 England Drive Stanley, Kansas 66223

Stuart Averill, M.D. Menninger Foundation P.O. Box 829 Topeka, Kansas 66601

Joseph Hollowell, M.D. Director of Health Department of Health and

Environment Topeka 66620

David Domann, R.Ph. M.S FASCP 504 Commercial

Ben Rubin, M.D. 121 S. 17th Street Kansas city. KS 661 02

James Reeves, DPM 930 Iowa-Suite 2 Lawrence. KS 66044

Mary Reyer Topeka Resource Center

for Handicapped 1119 S.W. 10th Topeka, KS 66604

Department Representatives

James Hawkins Clinicare Family Health Services 510 Southwest Boulevard Kansas City 661 03

Robert Anderson Family Consulatation Services 560 North Exposition Wichita Kansas 67205

Alice Fisher 226 Woodruff Topeka

Robert E. Johnson, Committee Chairman Administrator Miama County Hospital 501 South Hospital Drive b o l o 66071

Betty Schultz 971 Manos Crest Kansas City. KS 66101

E. Robert Sinnett, Ph.D, 21 7 Southwind Place Manhattan, KS 66502

Tom Jones, D.D.J. 398 New Brotherhood Bldg. Kansas City, KS

Verden Ellefson Assoc. Director, Finance Providence-St. Margaret

Health Center Kansas City, KS 661 12

Dr. Robert C. Hardner L. Kathryn Klassen, R.N., M.S Elaine Hacker, M.D.

3. Executive Off~cers of State Medical and Pharmaceutical Societies:

A. Medical Society: C. Osteopathic Medical Association:

Jere Slaughter Executive Director Kansas Medical Society 1300 Topeka Boulevard Topeka 66612 Phone: 9131235-2363

Mr. Harold Reihm Executive Director Kansas Assn. of Osteopathic Medicine 1325 S.W. Topeka Boulevard Topeka 6661 2 Phone: 91 31234-5563


Kenneth W. Schafermeyer Everett L. Willoughby Executive Director Executive Secretary Kansas Pharmaceutical Association 503 Kansas Avenue. Suite 328 1308 West 10th Street P. 0 . Box 1007 Topeka 66604 Topeka. Kansas 66601 Phone: 91 31232-0439 91 312964066

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K E N T U C K Y




O M AB APTD AFDC O M AB APTD AFOC Children 21 (SFO) . ,

Prescribed O N ~ S X X x X x x x x x Inpatient Hospital Care X X X X X X X X X Outpatient Hos~ital Care X X X X X X X X X Laboratow & X-ray service X X X X X X X X X Skilled Nursing Home Services X X X X X X X X X Physician Services X X X X X X X X X Dental Services X X X X X X X X X


II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30. 1984

1984 1983 Expended Recipient Expended - - - Recipienl -

T O T A L . . . . . . . . . . . . . . . . . . . . . $27,996,238 31 1,656" $1 9,505,335 251,935

CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $25,120,076 242,042 17.523.811 198,829 Aged . . . . . . . . . . . . . . . . . . . . . . 7,058,004 41,121 4,939.793 31,275 Blind . . . . . . . . . . . . . . . . . . . . . . 320,138 2,005 226.055 1.530 Disabled . . . . . . . . . . . . . . . . . . . . . 12,711,842 62.142 8.474.930 45,227 Children-Families wIDep Children . . . . . . . . . . . . 1.788.787 82,227 1.486.258 74,508 Adults-Families w1Dep Children . . . . . . . . . . . . 3,241,305 54,547 2,396,775 46.012

CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . 240.091 5,298 236,368 5,437 Aged . . . . . . . . . . . . . . . . . . . . . . 85,882 501 95,055 497

. . . . . . . . . . . . . . . . . . . . . . Blind 1,217 5 1,436 8 Disabled . . . . . . . . . . . . . . . . . . . . . 57,087 262 55,463 243 Children-Families wlDep Children . . . . . . . . . . . . 33,357 2,677 30,255 2,399 Adults-Families wIDep Children . . . . . . . . . . . . 62,548 2.483 54,159 2.290 Other Title XIX Recipients . . . . . . . . . . . . . . . 0 0 0 0

MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . 2,636,071 75.121 1,745,156 56.636 Aged . . . . . . . . . . . . . . . . . . . . . . 123.296 1,482 115,534 1,480 Blind . . . . . . . . . . . . . . . . . . . . . . 1,433 9 1,585 8 Disabled . . . . . . . . . . . . . . . . . . . . . 183,512 1,503 148,684 1.380 Children-Families wIDep Children . . . . . . . . . . . . 744.355 36,049 507,783 27.052 Adults-Families wIOep Children . . . . . . . . . . . . 1,550.733 34.633 946,488 25.421 Other Title XIX Recipienls . . . . . . . . . . . . . . . 32,742 1.445 25,032 1,295

Wnduplicated Total - HHS repoil HCFA - 2082


By the Division for Medical Assistance within the Department for Social Insurance, within the Cabinet for Human Resources.


A. General Exclusions (diseases, drug categories, etc.): The following are items which are not covered under the pharmacy benefits area of the program:

1. Most medical supply items such as bedpans, urinals, ice bags, etc. (Note: Insulin syringes are covered.)

2. Medicine cabinet supplies and drug staples

3. Drugs available through other programs or agencies

4. Drugs not included on the Kentucky Medical Assistance Program Drug List (unless preauthorized according to established guidelines and criteria).

5. Medications and supplies used or dispensed by physicians or dentists during home or office calls.

6. Most non-legend (over-the-counter) drugs except those used to treat diabetes and iron deficiency anemia and enteric coated aspirin.

B. Formulary Yes. The list is revised in accordance with recommendations of the Formulary Subcommittee and in accordance with available funds.


1. Quantity of Medications: None.

2. Refills: No prescriptions may be refilled more than 5 times or more than 6 months after the prescription is written.


D. Prescription Charge - Reimbursement Formula:

1. All covered outpatient pharmacy benefits provided to Kentucky Medical Assistance Program recipients are to be billed to the Program at the usual charge to the general public for the same product and service(s).

Reimbursement to the pharmacy consists of the lowest of: (1) the usual and customary charge; (2) the MAC, if any, plus dispensing fee; or (3) the EAC plus dispensing fee.

2. The dispensing fee is $3.25.

3. Co-payment - none:

4. State MAC list contains 133 drugs


Payment for drugs is limited to those pharmacies which affiliate themselves with the Medical Assistance Program by completing the "Agreement of Participating Pharmacies."


Electronic Data Systems Corp

Dallas. Texas

Average Fix price during FY 1984 - $7.86


1. Officials:

E. Austin, Jr. Secretary

Jack F. Waddell Commissioner

James B. Gooding, Director Division of Medical Assistance

Cabinet for Human Resources 4th Floor, CHR Building 275 East Main Street Frankfort, Kentucky 40621

Department for Social Insurance 3rd Floor, DHR Building 275 East Main Street Frankfort 40621

(Miss) Gene A. Thomas, R.Ph. Division of Medical Assistance 5021564-4321

2. State Advisory Council on Medical Assistance appointed by the Governor, is composed of members representing pharmacy, hospitals, registered nurses, medical doctors, dentists, nursing homes, optometrists, podiatrists; meet quarterly or more often.

A. Advisory Council for Medical Assistance:

Ellen Buchart, R.N. (Chrmn) Robert N. McLeod, M.D. Jefferson County 515 Mockingbird Drive

Health Department Somerset 42501 400 East Gray Street Louisville 40202 Ms. Alice LeMaster

227 Douglas Avenue Larry Spears, R.Ph. Frankfort 40601 C/O Grant County Drugs Dry Ridge 41035 Ms. Wanda Humphreys

North Race Street. William K. Rich, D.M.D. P.O. Box 257 129 Ridgelea Drive Glasgow 42141 Williamstown 41097

Ms. Oteria L. O'Rear Ms. Elizabeth Moeller 835 Charles Avenue Graham 42344 Lexington 40508

C.A. Nava, D.P.M. Secretary Kentucky State Board

of Podiatry 110 North Hubbard Lane Louisville 40207

Nedra Divine Administratrix Dover Manor 112 Dover Drive Georgetown 40324

Mr. Mark Whitaker 731 Jackson Owensboro 42301

Ms. Doris Elrod Kevil42053

Thomas W. Grant Good Samaritan Hospital 310 South Limestone Street Lexington 40503

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Wayne Helderman, O.D. 20 Broadway Mt. Sterling 40353

Frances Johnson 308 St. Johns Court, Apt. C Frankfort 40601

Brenda Manns Route I , Owenton Road Frankfort 40601

Formulary Subcommittee

Samuel R. Scott, M.D. Acting Chairman 1302 Richmond Road Lexington 40506

James Sieg, Ph.D. University of Kentucky College of Pharmacy Lexington 40506

J. Thomas Badgett, Ph.D. M.D. Director, Ambulatory Pediatrics University of Louisville Health Sciences Center Department of Pediatrics Louisville 40292

Ms. Ellen Buchart, R.N. Jefferson County Health

Department 400 East Gray Street Louisville 40202

B. Pharmacy Technical Advisory Committee:

Dr. Condit Steil Chairman Trover Clinic Madisonville 42431

Michael Sheets, R.Ph. 903 Lyndon Lane Louisville 40222

Jack F. Waddell (ex officio) Commissioner Department for Social Insurance CHR Building, 3rd Floor Frankfort 40621

E. Austin, Jr. (ex officio) Secretary Cabinet for Human Resources CHR Building, 4th Floor Frankfort 40621

R. N. Smith Smith's Pharmacy Burkesville 4271 7

Stephen Jasper, M.D. Family Practice Clinic 340 Bogle Street Somerset 42501

Charles H. Jarboe. Ph.D. Dept. of Pharmacolo~y~oxicology School of Medicine University of Louisville Louisville 40292

Chester L. Parker. Phan.D.,R.Ph. 181 6 Darien Drive Lexington, 40201

Chester L. Parker. Pharm.D. 1816 Darien Drive Lexington 40201

James E. Garrett. R.Ph. Pharmacare, Inc. 21 1 Geri Lane Richmond 40475

Paul Ruwe, R.Ph. 1 1 Edna Lane Ft. Wright 4101 1

David Hancock, R.Ph 401 Park Row Bowling Green 42101



Robert Cox Executive Vice President Kentucky Medical Association 3532 Ephraim McDowell Drive Louisville 40205 Phone: 50Z459-9790


Paul Davis. R.Ph. Executive Director Kentucky Pharmacists Association P. 0. Box 715. 1228 U.S. Hwy. 1275 Frankfort 40602 Phone: 50Z227-2303


Vacant Executive Director Kentucky Osteopathic Medical Association 208 Crossfied Drive Versailles 40383 Phone: 6061873-8044


Richard L. Ross Executive Director 1228 US. 127 South Frankfort 40601 5021564-3833

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Louisiana




OAA AB APT0 AFDC O M AB APTD AFDC Children 21 (SFO)


Inpatient Hnsnital Care X X X X X X X X X X





If. EXPENDITURES FOR DRUGS. Fayment to Pharmacists by fiscal year ending June 30, 1984


T O T A L .


$61,313,800 289.689"

CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $48,982,322 61,869 Aged . . . . . . . . . . . . . . . . . . . . . . 25,030,357 1,310 Blind . . . . . . . . . . . . . . . . . . . . . . 419,683 43.505 D i s a b l e d . . . . . . . . . . . . . . . . . . . . . 14,720,769 144,178 Children-Families w/Dep Children . . . . . . . . . . . . 8,270,866 4.357

. . . . . . . . . . . . Adults-Families w/Dep Children 540.647 28.333

. . . . . . . . CATEGORICALLY NEEDY NDN-CASH TOTAL Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . Children-Families wIDep Children

. . . . . . . . . . . . Adults-Families w/Dep Children . . . . . . . . . . . . . . . Olher Title XIX Recipients

. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL Aged Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . .




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Public assistance prosrams are administered by the State Office of Family Security. Department of Health and Human Services.


A. Prescribed legend and non-legend drugs (OTC) are reimbursed; except experimental drugs, anorexics and anti-anemia drugs, cough and cold preparations, vitamins, certain gastroin- testinal drugs, and certain minor tranquilizers.

B. Prescribing or Dispensing Limitations:

1. Quantity of Medication: New prescription must be issued for drugs given on a continuing basis, after 5 refills or after 6 months.

Maximum payment quantity for prescriptions shall be either one month's treatment or 100 unit doses.

2. Refills: Permitted as indicated by physician within 6 months and not to exceed 5 refills.


4. Formulary: No.

C. Prescription Charge Formula:

1. The maximum payment for a prescription is estimated acquisition cost or MAC plus $3.67 dispensing fee.

D. Fiscal Intermediary:

The Computer Company P.O. Box 4169 Baton Rouge, Louisiana 70821

E. Number of Rx claims processed in FY 1984-4,928,534

Average Rx price FY 1984-$12.32


1. Health and Human Resources Administration Officials:

Sandra L. Robinson. M.D., M.P.H. Department of Health and Human Secretary Resources

P. 0 . Box 3776

Marjoria Stewart Assistant Secretary

J. Christopher, Division Directol Division of Medical Assistance

Carolyn Maggio (Mrs.) Assistant Division Director Medical Assistance Programs 5041342-3937

Office of Family Security 755 Riverside North P.O. Box 44065 Baton Rouge, Louisiana 70804

Merrill A. Patin, R.Ph. Pharmacist Consultant II 5041342-9320

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Edward J. Daigle. R.Ph. Pharmacist Consultant I



Dave L. Tarver Executive Director Louisiana State Medical Society 1700 Josephine Street New Orleans 701 13 Phone: 5041561-1033


Peter Caldwell Executive Vice President Louisiana State Pharmacists Assn 2337 St. Claude Avenue New Orleans 701 17 Phone: 50419447545

Charles S. Wyckoff, D.O. Secretary-Treasurer Louisiana Association of Osteopathic Physicians 333 St. Charles Avenue - 412 New Orleans 70130 Phone: 5041588-9494


Howard B. Bolton, Executive Dir. 5615 Corporate Boulevard, Ste. 8E Baton Rouge 70808 5041925-6496

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MAINE



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

O M AB APTD AFDC O M AB APTD AFDC Children 21 ( W Prescribed . . - - -. . - - - Drugs X X X X X X X X X X

Hospital Care X X X X X X X X X X Outpatient Hospital Care X X X X X X X X X X ~ a b o r a t o i & X-ray Service X X X X X X X X X X Skilled Nursing Home Services X X X X X X X X X X Physician Services x X X X X X X X X X Dental Services X X X X X X X X(1) X(1) X

'SF0 - State Funds Only (Catastrophic Illness Program in FY 83)

(1) Routine dental services; other categories eligible for non-routine dental service only.


T O T A L


. . . . . $13,459,553 84,396"

. . . . . . . . . . CATEGORiCALLY NEEDY CASH TOTAL A g d . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . Chiidren-Families w/Dep Children


. . . . . . . . CATEGORICALLY NEEDY NON-CASH TOTAL Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . .


. . . . . . . . . . . . Adults-Families w/Oep Children Other Title XIX Recipients . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . . Chiidren-Families w/Dep Children . . . . . . . . . . . .

. . . . . . . . . . . . Aduits-Families w/Dep Children Other Title XIX Recipients . . . . . . . . . . . . . . .

"Undupiicated Total - HHS repod HCFA - 2082

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State Department of Human Services.



1. OTC drugs, except insulin and artificial tears.

2. Combination antibiotics.

3. Symptomatic remedies for common colds and coughs resulting from common colds.

4. All vitamins and vitamin preparations.

5. All amphetamines, straight or in combination, and all obesity control drugs. (Authorization for amphetamines or methylphenidate in documented cases of narcolepsy or hyperkinesis may be obtained upon request.)

6. lnjectables when oral medication is available for equally effective treatment.

Prior authorization may be obtained in the case of necessary exceptions.

B. Formulary: Open formulary, except for certain therapeutic categories.


1. Quantity of Medication: Refills for chronic conditions can be for no less than a 30 day supply unless the prescriber specifically directs otherwise.

3. Refills: A prescription can be refilled up to five times within six months if specifically ordered.


D. Prescription Charge Formula: Usual and Customary. EAC plus a professional fee of $3.20 or MAC plus a professional fee of $3.20. whichever is lower. (EAC for the top 150 drugs = AWP 5% or direct prices, whichever applies.)

E. Copayment: $0.50

V. Miscellaneous:

Average Rx price during PI 1984-$10.49

Fiscal Intermediary: Good Health SystemslLow Cost Drug Program P. 0. Box 508 Augusta, ME 04330


1. Human Services Department Officials:

Michael R. Petit Commissioner

Robert B. McKeagney, Jr. Deputy Commissioner

Gordon A. Browne Director Bureau of Medical Services

Department of Human Services State House Augusta, Maine 043g3

Health and Medical Services (address same as above)

Department of Human Services State House Augusta, Maine 04333

James H. Lewis Assistant Bureau Director Medicaid Operations Bureau of Medical Services

Michael P. O'Donnell, R.Ph. Pharmacist Consultant 2071289-2674

Margaret Ross Director Medicaid Surveillance and

Utilization Review

Medical Consultants:

Allen Elkins, M.D. Psychiatric

D. K. McFadden, D.0, Osteopathic

Donald Ellis, O.D. Optometric

J.D. Reeder. D.C. Chiropractic

2. Medical Assistance Advisory Committee:

A. Dewey Richards, M.D Chairman

Dept. of Human Services Bureau of Medical Services Station X I 1

11 Gage Street Bridgton 04009



Frank 0. Stred Executive Director Maine Medical Association 524 Western Avenue Augusta 04330 Phone: 2071622-3374

Philip N. Johnson Executive Director Maine Osteopathic Association 303 State Street Augusta 04330 Phone: 2071623-1 101


Irving 6. Faunce, Jr. Executive Director Maine Pharmacy Association 345 Water Street P. 0. Box 488 Gardiner 04345 Phone: 2071582-1433

Richard 0 . Campbell. Secretary 1 Northwood Road Lewiston, Maine 04240 2071783-9769

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M A R Y L A N D




OAA AB APTD AFOC OAA AB APTD AFDC Children 21 (SF@



Outpatient Hospital Care X X X X X X X X X X Laboratory & X-ray Service X X X X X X X X X X

Skilled Nursing Home Services X X X X X X X X X X - -

Physician Services X X X X X X X X X X Dental Services X X X X X X X X X X

^SF0 - Slate Funds Only

'Limited services available. Expanded services available to EPSDT eligibles.

II. MPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30. 1984


T O T A L . . . . . . . . . . . . . . . . . . . . . $32,967,163 234,441 "' $28,570,406 232,522"'

CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . 24,118,862 197.802 $20,227.522 191,147 Aged . . . . . . . . . . . . . . . . . . . . . . 5,000.879 15,139 4,048.467 14,200 Blind . . . . . . . . . . . . . . . . . . . . . . 83,082 292 70.110 271 Disabled . . . . . . . . . . . . . . . . . . . . . 8,540,228 25,599 7,029,831 24.317 Children-Families w/Dep Children . . . . . . . . . . . . 4,212,994 98,078 3.458.693 92,196 Adults-Families wIDep Children . . . . . . . . . . . . 6,281,729 58.694 5,620,421 60,163

CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . 0 0 0 0 1 Aged . . . . . . . . . . . . . . . . . . . . . 0 0 0 0 Blind . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0 Children-Families wlllep Children . . . . . . . . . . 0 0 0 0 Adults -Families w/Dep Children . . . . . . . . . . . . 0 0 0 0 Other Title XIX Recipients . . . . . . . . . . . . . . . 0 0 0 0

. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind

. . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . Children-Families wIDep Children . . . . . . . . . . . . Adults-Families wIDep Children


""Unduplicated Total - HHS report HCFA - 2082

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State Department of Health and Mental Hygiene.


A. General Exclusions: (a) experimental or investigational drugs; (b) food supplements or infant formulas; (c) prescriptions and injections for central nervous system stimulants and anorectic agents used for weight control; (d) "less-than-effective" drugs under federal regulations; and (e) certain other items as specified in the state's Medicaid plan.

0. Coverage of non-legend drugs is limited to insulin, and Schedule V cough preparations, needles and syringes, contraceptives other than condoms and specially formulated nutritional preparations when preauthorized by the program.

1. Quantity of Medication: The prescriber may order up to a 100-day supply of the medication on a single prescription, except for birth control pills which are limited to a 6-cycle supply.

2. Refills:

a. Maximum number of refills authorized on a prescription is two. The original prescription and its refills may not exceed a 100 day supply.

b. Refills may not be dispensed after 100 days of date of original prescription.

3. Dollar Limits: Prior authorization required from Medical Assistance Compliance Administration when usual and customary charge exceeds $60 and prescribed amount is more than a 34 day supply.

4. Formulary: The program has an "Open Formulary." The program does not restrict prescribers in their selection of drug products except for the exclusions stated in section 1V.A..

5. Reimbursement:

a. Drug ingredient cost is calculated under one of the following procedures:

(1) Maximum Allowable Cost (MAC) - this list, which contained 44 price-controlled drugs in fiscal year 1984, is continually updated to reflect deletions and additions made by the Health Care Financing Administration of the Department of Health and Human Services.

(2) Interchangeable Drug Cost (IDC) effective June 1. 1985, the state of Maryland 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 particular brand is to be dispensed. This IDC is based upon the lowest cost at which an approved interchangeable product can be guaranteed available throughout the state. As of June 1. 1985. there are 237 products representing 97 drug entities on the list.

(3) Usual Source and Quantity List for High Utilization Drugs effective June 1, 1985, the state of Maryland maintains a list of products which are usually purchased directly from manufacturers and/or in larger than minimum package size. Reimbursement for these products is based on the less expensive source of supply or package size. As of June 1, 1984, 53 products representing 34 drug entities are included in this list.

(4) Estimated Acquisition Cost (EAC) for all other drugs, reimbursement levels are based upon the price of standard size packages (a) available from wholesalers within the state, or if not available from these wholesalers, (b) manufacturers' d~rect prices.

b. Reimbursement will be the lower of:

-the usual and customary fee; -the calculated ingredient cost plus $3.45 dispensing fee.

V. Miscellaneous:

Number of Rx claim processed in FY 1984 (July, 1983 June, 1984) 2,987,328

Average prescription price during FY 1983 $13.07

155

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A copayment of $.50 applies only to state funded recipients of medical assistance. No copayment for recipients in federal categories, or those receiving EPSDT and family planning related services.

Maryland Pharmacy Assistance Program

The Maryland Pharmacy Assistance Program, established by the Maryland General Assembly in 1978, is administered by the Assistant Secretary for Medical Care Programs and supported entirely by state funds. The purpose of this program is to help low-income families and individuals who are not eligible for Medical Assistance pay for prescription drugs. Schedule V cough preparations, needles and syringes, contraceptives except condoms and certain formulated nutritional preparations.

Eligibility for Pharmacy Assistance is based on the financial resources available to the family unit. As a result of the passage of Senate Bill 124 by the 1982 General Assembly, the maximum allowable fiscal year 1983 income levels were increased by 7.4%. This law also allows the Program to increase its income levels each year by the annual Social Security cost-of living percentage increase, not to exceed 8%. The resource standards for the Pharmacy Assistance Program are the same as those for the Maryland Medical Assistance Program. The following chart shows the gross income and resource standards effective during fiscal year 1985.

Gross hcome Resource Family Size Standards Standards

1 $5,400 $2,500 2 6,000 2,600 3 6,500 2.700 4 7,100 2,8W 5 7.650 2.900 6 8,200 3,000 7 8.750 3.100 8 9,400 3,200 9 10,050 3,300 10 10,650 3,400

Each additional person + 600 + 100 In the fiscal year 1984. there was an average enrollment of 11,370 per month. The program paid

$3,494,592 for 234.845 prescriptions, an average of $14.88 per prescription. Providers are reimbursed the lower of:

-usual and customary fee -ingredient cost as calculated under Medical Assistance regulations plus a $3.45 dispensing fee

Recipients are responsible for a $1 .OO copayment for each prescription and each refill. The state pays the remainder of total reimbursement.


1. Health and Mental Hygeine Department Officials:

Adele Wilzack Secretary

Douglas H. Morgan Assistant Secretary for Medical Care Programs

Kathleen B. Becker Chief. Division of Specialized

Health Services

Department of Health and Mental Hygiene

201 W. Preston Street Baltimore, Maryland 21201

Medical Assistance Policy Admin. 300 W. Preston Street Baltimore. Maryland 21201

Leone W. Marks, R.Ph. -acy

&+.A- QL

Joseph Fine, P.D. Section Manager, Pharmacy

Operations 301 1383-6893

George Lichter, P.D. Manager, Pharmacy Operations

Administration 301B25-1745

Charles Sandler, R.Ph. Pharmacy Consultant 301 1225-1 746

John W. Baker Program Manager 301 1225-5392

2. Medicaid/Pharmacy Liaison Committee:

Chairman David Banta, Executive Director 650 West Lombard Street Baltimore, Maryland 21202

Stanton G. Ades, P.D. P.O. Box 87 Stevenson. Maryland 21 153

Adolph Baer. P.D. Fisher's Pharmacy 18935 Woodburn Road Hagerstown, Maryland 21740

Samuel Lichter, P.D. Randallstown, Maryland 21 133

Robert Martin, P.D. Route 1, Box 75M LaVale, Maryland 21 502

Ronald Sanford. P.D. Dart Drugs 1336 Denbright Street Baltimore, Maryland

Ronald Telak, P.D. Maryland General Hospital Pharmacy Department 827 Linden Avenue Baltimore, Maryland 21201

Medical Assistance Operations Administration

201 W. Preston Street Baltimore, Maryland 21201

Medical Assistance Compliance Administration 300 West Preston Street Baltimore, Maryland 21201

Medical Assistance Compliance Administration 300 W. Preston Street Baltimore, Maryland 21201

Pharmacy Assistance Program P. 0. Box 386 Baltimore, Maryland 21203

Martin Mintz, R.Ph. Northern Pharmacy 6701 Harford Road Baltimore, Maryland 21234

Dr. Frank Palumbo University of Malyland School

of Pharmacy 636 West Lombard Street

Murray Polonsky, P.D. Accredited Surgical Company 415 East Wayne Avenue Silver Spring. Maryland 20901 4001 Carthage Road David Rombro, P.D MacGillivray's Pharmacy 900 North Charles Street Baltimore, Maryland 21201

Melvin Rubin, P.D. Paradise Pharmacy 231 6 Sugarcone Road Baltimore, Maryland 21209

21228 Angelo Voxakis, P.D. Outpatient Pharmacy University Hospital 22 South Greene St., Rm. 1101 Baltimore. Maryland 21201

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Medical Assistance Staff Committee Members

Kathleen B. Becker Joseph Fine, R.Ph. Jeanne E. Fisher Leone W. Marks, R.Ph. Charles Sandler. R.Ph.


Douglas H. Morgan Assistant Secretary Medical Care Programs 201 W. Preston Street, Room 516 Baltimore. Maryland 21201

Lee Bernhardt, Director Government Programs Blue Cross/Blue Shield of Maryland 700 East Joppa Road Baltimore. Maryland 21204

Millie Tyssowski 2500 Pickwick Road Baltimore, Maryland 21207

William Hankins, Assistant Director Bon Secours Hospital 2000 West Baltimore Street Baltimore, Maryland 21223

Douglas H. Morgan Assistant Secretary for

Medical Care Programs 201 West Preston Street. Room 516 Baltimore, Maryland 21201

Allen Bennett, P.D. Park West Medical Center, Inc 3319 West Belvedere Avenue Baltimore, Maryland 21215

Lee Bernhardt. Director Government Programs Blue Cross/Blue Shield of Maryland 700 East Joppa Road Baltimore, Maryland 21204

Peter Borchardt, Executive Director De lma~a Foundation for Medical Care 108 North Harrison Street Easton, Maryland 21601

Jack Bovaird, Assistant Director Associated Catholic Charities 320 Cathedral Street Baltimore. Maryland 21201

Dept. of Health and Mental Hygiene Representative

Administrator. Blue CrosslBlue Shield of Maryland

Acting Chairperson Consumer Representative

Vice Chairperson. Maryland Hospital Assoc. Representative

Dept. of Health and Mental Hygiene Representative

Maryland Primary Care Assoc. Representative

Administrator, Blue Cross1 Blue Shield of Maryland

Administrator, Utilization Control Agent

Consumer Re~resentative

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John Braxton, Jr., M.D. 4432 Park Heights Avenue Baltimore, Maryland 21215

Mildred Bright 21 12 Jefferson Street Baltimore, Maryland 21205

Mrs. Loretta Brown 2019 North Payson Street Baltimore. Maryland 21217

Mrs. Eva Brown Basilica Place 124 West Franklin Street Baltimore, Maryland 21201

Richard Buck. Executive Director Pickersgill Home 615 Chestnut Avenue Baltimore, Maryland 21204

Darrell R. Cammack. Jr.. Administrator Ivy Hall Nursing Home 19 Harrison Avenue Baltimore, Maryland 21220

Mrs. Phyllis Colston 7850 Willing Court Pasadena, Maryland 21 122

Jean Dockhorn 3603 Monterey Road Baltimore, Maryland 21218

Ronald Harris 1423 Winston Avenue Baltimore, Maryland 21239

Rosalyn Hurwitz-Hartman Director. Nursing Home Advocacy

Project Maryland Conference of Social Concern 1301 Park Avenue Baltimore. Maryland 2121 7

Benjamin J. Kimbers. Jr.. D.D.S. Madison Park Professional Building 932 West North Avenue Baltimore, Maryland 21217

Harry F. Klinefelter, M.D. Physician, 550 North Broadway, Room 401 Baltimore. Maryland 21205

Maryland-6 1985

Monumental City Medical Society Representative




Nursing Home Representatives

Nursing Home Representative





Maryland State Dental Association Re~resentative

private practice

NPC

Joseph L. LaAsmar. Associate Executive Director

Chesapeake Physicians, P.A. P.O. Box 9048 Baltimore, Maryland 21222

Eileen Leaman 27 Maple Avenue Baltimore, Maryland 21228

Mrs. Felicia Martin 1007 McDonough Street Baltimore, Maryland 21 205

Edward Matricardi, Program Director HARBEL Community Mental Health Center 5807 Hariord Road Baltimore, Maryland 21214

Helen B. McAllister, M.D. 61 00 Westchester Park Drive, X611 College Park, Maryland 20714

Maureen McCleary, Director Bureau of Adult Health Services Prince George's County Health Dept, Cheverly. Maryland 20785

Mrs. Cecilia Moore 1328 North Mount Street Baltimore. Maryland 21217

Gladys Moran Consumer Representative 618 North Castle Street Baltimore. Maryland 21205

Ethel Pace 1707 Moreland Avenue Baltimore. Maryland 21 21 6

Regina M. Phillips. R.N. 506 Moonflower Court Millersville, Maryland 21 108

Melvin Rubin 2316 Sugarcone Road Baltimore, Maryland 21209

Barbara Spence. DSW Director Department of Social Work Johns Hopkins Hospital 600 North Wolfe Street Baltimore, Maryland 21205

Administrator, HMO



Administrator, Community Mental Health Center

Health Officer, Prince George's County

Maryland Assoc. of Home Health Agencies Representative



Maryland Nurses Association Representative

Maryland Pharmaceutical Association Representative

Society of Hospital Social Work Directors Representative

Mrs. Jackie J. Vickers Health Planning Council of Director of Senior Programs Eastern Shore Representative 203 Belvedere Avenue Cambridge, Maryland 21613

Gloria Washington, Department of Human Resources Medical Assistance Division Representative Income Maintenance Administration 300 West Preston Street Baltimore, Maryland 21201


A. Medical Soc~ety:

Mr. John Sargeant Executive Director Medical and Chirurgical Faculty of Maryland 1121 Cathedral Street Baltimore 21201 Phone: 3011539-0872


David A. Banta. R.Ph. Executive Director Maryland Pharmaceutical Association 650 W. Lombard Street Baltimore 21201 Phone: 3011727-0746

C. Osteopathic Association:

Lawrence I. Silverberg. D.O. Maryland Osteopathic Association Route 32 at Route 144 West Friendship. Maryland 21794 3011442-2266

D. State Board of Pharmacy Paul Friedman. Secretary 201 West Preston Street Baltimore, Maryland 21201 301 1383-7245

NPC

M A S S A C H U S E l T S


I. BENEFITS PROViDEO AND GROUPS ELIGIBLE


O M AB APTD AFDC OAA A0 APTD AFDC Children 21 (SFO)


Inpatient Hospital Care X X X X X X X X X


---

X-ray Service X X X X X X X X X X

Skilled Nursing Home Services X X X X X X X X X Physician Services X X X X X X X X X X Dental Services X X X X X X X X X X

Other Benefits: Intermediate care facilities, clinics, mental health services, ambulance and other medically necessary transporlalion, special duly nursing, adult day health, adult foster care, vision care services, kidney dialysis, family planning, centers for independent living, community health center services.

'SF0 - Stale Funds Only eligibles.

11. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30. 1984

1984 1983 Expended - Recipient Expended - - Recipient -

T O T A L . . . . . . . . . . . . . . . . . . . . . $58,298,292 378,065'' $52,752,436 367,084

. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL Not available . . . . . . . . . . . . . . . . . . . . . . Aged

Blind . . . . . . . . . . . . . . . . . . . . Disabled

. . . . . . . . . . Children-Families w/Dep Children Adults-Families w/Dep Children . . . . . . . . . .

CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . Children -Families w/Dep Children

. . . . . . . . . . . . Adults -Families w/Dep Children

MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . . Children-Families w/Dep Children . . . . . . . . . . . .


Wndupiicated Total - HHS report HCFA - 2082


State Department of Public Welfare.


A. General Exclusions: Immunizing biologicals available from DPH, legend vitamins not on Drug List, non-legend drugs not on Drug List. Restrictions on certain therapeutic classes. Legend cough and cold medications excluded. Restrictions on propoxyphene containing products.

B. Formulary: Yes. (Massachusetts list of interchangeable drugs for multisource drugs.)


1. Quantity of Medication: Not more than a 6-month supply may be prescribed.

2. Refills: Prescription may be refilled, as long as total authorization does not exceed a 6- months' or Brefills supply from time of original prescription.



1. Legend Drugs: $3.25 dispensing fee (effective 711 5/85).

2. Compounded prescriptions

a. Compounded prescriptions $4.09 dispensing fee.

b. Suppositories, tablet triturates, capsules $5.09 dispensing fee

3. Payment shall be for the lower of the usual and customary charge or MAC or MMAC or EAC cost plus dispensing fee, or AWP plus dispensing fee.

4. Non-Legend Drugs: Not to exceed the lower of: (A) EAC plus dispensing fee. (6) Usual and customary charge to pharmacy's retail customers.


For A6 drugs, supplier bills State Commission for the Blind directly, which pays vendor pharmacy through intermediary.

Fiscal Intermediary: 1983 Systems Development Corp P.O. Box 9101 Somewille, Massachusens 02145 61 71625-01 20

Officials, Consultants and Commlttees

1. Welfare Department:

A. Officials

Charles Atkins Commissioner

Carmen Canino Acting Assistant Commissioner

Herbert B. Hechtman, M.D Medical Director

Department of Public Welfare 600 Washington Street Boston, Massachusens 021 11

Robert Karlyn, B.S., RPh. Medicaid Pharmacy Program Consultant 61 71727-1 391

NPC


A. Medical Society: C. Osteopathic Society:

William B. Munier. M.D. Executive Vice President Massachusetts Medical Society 1440 Main Street Watham 02254 Phone: 61 71893-4610

Mrs. Gladys M. Davis Executive Secretary Massachusetts Osteopathic Society Inc. Box 147 Reading 01867 61 71944.5586


Ray Charpentier Executive Director Massachusetts State Pharmaceutical Association 210 Lincoln Street Boston 021 11 61 71423-7222


Charles F. Monahan, Jr. Executive Secretary 100 Cambridge Street. Room 1520 Boston. Massachusetts 02202 61 71727-3076

Charles F. Monahan, Jr. Executive Secretary 100 Cambridge Street. Room 1520 Boston, Massachusetts 02202 61 717273076 61 7/944-5586

NPC

M I C H I G A N




OM AB APTD AFDC O M AB APT0 AFOC Children 21 (SFOI

Prescribed Drugs X X X X X X X X X X Inpatient Hospital Care X X X X X X X X X X Outoatient ~ & a l Care X X X X X X X X X X

Laboratow & X-ray Service X X X X X X X X X X

Skilled Nursing Home Services X X X X X X X X X X Physician Services X X X X X X X X X X Dental Services (- Limited -) X (Limited)

Other Benefits: Transportation; Limited Vision & Hearing; Limited Medical Supplies & Equipment; Family Planning; Alcoholism & Drug Withdrawal; Psychiatric Services. Special note: There are exclusions and limitations applicable to all services, and prior authorization is required for some.

'SF0 -State Funds Only eligibles

11. EXPENDITURES FOR DRUGS. hvment to Pharmacists bv fiscal vear endina Seotember 30. 1984

Expended - Recipient - Expended - TOTAL . . . . . . . . . . . . . . . . . . . . . $86,822,1 20 764,1348" $77,560,984

CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . Children-Families.w/Oep Children Adults-Families w1Dep Children . . . . . . . . . . . .

. . . . . . . . CATEGORICALLY NEEDY NON-CASH TOTAL Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . Disabled Children-Families w l h p Children . . . . . . . . . . . .

. . . . . . . . . . . . Adults-Families wlDep Children . . . . . . . . . . . . . . . Other Title XIX Recipients

. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . . Children-Families wlDep Children . . . . . . . . . . . .

. . . . . . . . . . . . Adults-Families w/Deo Children Other Title XIX ~ecipients

Recipient - 774,896

665,257 28,185 1.399

64,306 340.473 240.029

40,881 3,716

52 6,535

16,129 17.863

0

96.757 40,351

111 24.375 10,779 12,693 12.056


111. Administration:

Michigan Department of Social Services.


A. General Exclusions and Restrictions:

Anorectics - Noncovered benefits; exception: prior authorization is given for certain diagnoses.

OTCs Noncovered benefit; exception: 1) insulin, 2) chronic renal disease drugs, 3) family planning drugs, 4) medical supplies, and 5) reactivate supplies.

Analgesics - Selected products are noncovered benefits (i.e.. Darvocet-N. Ponstel, Talwin, Talwin Compound).

Benzodiazepines - (used for anti-anxiety) - Chlordiazepoxide HCL and equivalents are the only covered products (i.e., Antivan, Azene, Centrax. Serax. Tranzene, Valium, Verstran were restricted).

Desi Drugs (Drug Efficacy Study Implementation) - Coverage of certain proposed less-than- effective drugs is restricted base don federal regulation.

Hematinics, Antacids. Anti-Vertigo Drugs and Laxat~ves - Noncovered benefit; exception: certain pediatric iron products.

Vitamins - Noncovered benefit; exceptions: 1) prenatal vitamins and 2) fluoride pedo-drops.

Cough and Cold Preparations - Noncovered benefits; exception: antihistamines.

Abused Drugs - Mequin, Parest, PBZ, Quaalude and Tripelenamine HCL (effective October 1, 1982). Doriden. Glutethimide and Placidyl (effective 4/01/83).

Potassium Replacements - Covered products are liquid potassium replacements and potassium tablets and capsules with a maximum therapeutic price limit.

Sandimmune - Prior authorization required.

Drugs Withdrawn Because of Safety - Coverage restricted the date the program is notified.

B. Formulary: Yes.

For information regarding the formulary contact:

Frank Loll, R.Ph. Bureau of Health Services Review Medical Services Administration P. 0 . Box 30007 Lansing, Michigan 48909 51 71373.0953

C. Prescribing or dispensing limitations: Prescribed quantities should be limited to an amount necessary to keep the recipient supplied during the therapy regimen. In certain cases and conditions, more than a month's supply will be appropriate. However, in no instance may more than 120 days supply be dispensed per prescription.

D. Prescription Charge Formula: Reimbursement for legend drugs is limited to the Lower of:

1. Actual acquisition cost, plus professional fee not to exceed $3.00 plus selected $0.50 copay or

2. The M.A.C.' rate, plus professional fee not to exceed $3.00 plus selected $0.50 copay or

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

'Maximum Allowable Costs


Total Rx claims processed in FY 1984 10,888,285 Average Rx price during FY 1984 $10.40

Selected co-pay provision:

A $0.50 co-pay is assessed the patient when a branded drug product is dispensed. When generic drugs are dispensed no co-pay is required.

Otflclala, Consultants and Comrnlttees


Agnes M. Mansour, Ph.D. Director

Kevin L. Seitz Director

Dennis DuCap. Director Office of Support Services

Vernon K. Smith, Ph.D. Director. Bureau of Program

Pblicy

Keith F. Cole, Director Bureau of Medicaid Operations

Robert Levin, D.D.S., Director Bureau of Health Services Review

Richard Maharan. Director Bureau of Medicaid Fiscal

Review

51 7,373-7720 @" 2. Social Services Department Advisory Committees:

A. State Medical Care Advisory Council:

Consumer Members

Ms. Ella Bragg 1541 1 Wabash Detroit 48238

Mr. Samuel L. Davis 23555 Northwestern Hwy. Southfield 48075

Mr. William Fairgrieve 300 North Washington Square Suite 31 1 Lansing 48933

Michigan Department of Social Services

P. 0 . Box 30037 Lansing, Michigan 48909

Medical Services Administration (same as above)

-Michigan Welfare Rights Organization

-Michigan Association for Emotionally Disturbed Children

-Michigan League for Human Services

NPC

Ms. Connie Marin 131 4 Ballard. Street Lansing 48906

Mrs. Clarice Jones 2812 Woodruf, Apt. +3 Lansing 4891 2

Mrs. Janet Saxton 1309 Reo Road Lansing 4891 0

Ms. Sharon Sebright R #2,6657 U Avenue, West Schoolcraft 49087

Mr. Paul N. Shaheen 320 West Ottawa Lansing 48933

Ms. Jean Thompson 550 Collingwood East Lansing 48823

Ms. Dorothy Walker 8721 East Jefferson Avenue Detroit 48214

Provider Representatives

Mr. Reginald P. Ayala Southwest Detroit Hospital 2401 20th Street Detroit 4821 6

Mr. Dean Barker, R.Ph. Smith Pharmacy 226 East Grand River Lansing 48906

Ms. Sandra Billingslea Michigan HMO Plans, Inc 7650 Second Avenue Detroit 48202

Dorothy E. Carnegie, D.O. Professor of Internal Medicine College of Osteopathic Medicine Michigan State University East Lansing 48824

Lloyd Ganton Arbor Manor Care Center 151 2nd Street Spring Arbor 49283

-Cristo Rey Community Center

-American Association of Retired Persons

-Consumer Member at Large

-Michigan Council on Maternal and Child Health

-Citizens for Better Care

-United Auto Workers

Michigan Hospital Association

-Michigan Pharmacists Association

-Association of HMOs in Michigan

-Michigan Association of Osteopathic Physicians and Surgeons

-Health Care Association of Michigan

Lilo Hoelzel-Seipp. R.N., Ph.D. -Michigan Nurses Association R.R. Y1 Holly Drive T h o m ~ ~ ~ n ~ i l l e 49683

Robert L. Leeser. M.D. -Michigan State Medical Society 210 North Oliver Charlotte 48813

Richard F. Stilwill, D.D.S. 6020 North Hagadorn, Suite 4 East Lansing 48823

Grant Wiig, D.P.M. 305 North West Avenue

-Michigan Dental Association

-Michigan Association of Podiatrists

Government Representatives Mr. Dominic A. D'Annunzio -Michigan Insurance Bureau 7419 Yorktown, Rt. #2 Lansing 4891 7

Mr. James P. Grannan 3001 West Big Beaver Road Suite 700 Troy 48084

Ms. Judy Niles 930 West Holmes Road Lansing 4891 0

Dr. Gloria R. Smith P. 0 . Box 30035 Lansing 48909

Dr. Vernon K. Smith P. 0. Box 30037 Lansing 48909

-Michigan Association of Health Systems Agencies

-1ngham County Department of Social Services

-Michigan Department of Public Health

-Michigan Department of Social Services

3. Executive Officers of State Medical, Pharmaceutical, and Osteopathic Associations:


Warren Tryloff Executive Director Michigan State Medical Society 120 West Saginaw East Lansing 48823 Phone: 51 71337-1 351


Louis Sesti, R.Ph. Executive Director Michigan Pharmacists Association 815 N. Washington Avenue Lansing 48906 Phone: 51 71484-1 466

D. A. DeShaw Executive Director Michigan Assoc. of Osteopathic Physicians & Surgeons. Inc. 33100 Freedom Road Farrnington 48024 Phone: 3131476-2800


Herman Fishman, Licensing Executive North Ottawa Tower 61 1 West Ottawa Street, P.O. Box 30018 Lansing, Michigan 48909

NPC

MINNESOTA



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

OAA AB APT0 AFDC OAA AB APT0 AFDC Children 21 (SFo)

Prescribed Drum X X X X X X X X X


Oulpatient Hospital Care X X X X X X X X X

Laboratory & X-rav Senrice X X X X X X X X X

Skilled Nursing Home Services X X X X X X X X X physician Services X X X X X X X X X Dental Services X X X X X X X X X


II. EXPENDITURES FOR DRUGS. Pavment to Pharmacists bv fiscal vear endino June 30. 1984


T O T A L . . . . . . . . . . . . . . . . . . . . . $35,655,862" 221.46s"

CATEGORICALLY NEEDY CASH TOTAL $15,611,255 148.286 Aged . . . . . . . . . . . . . . . . . . . . . . 3,278.777 9,032 Blind . . . . . . . . . . . . . . . . . . . . . . 117.802 345 Disabled . . . . . . . . . . . . . . . . . . . . . 6,128,761 14.978 Children-Families wlDep Children . . . . . . . . . . . . 2,122,283 70.092 Adults-Families w/Dep Children . . . . . . . . . . . . 3.963.632 53,839

CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . 7,271.002 18,753 Aged . . . . . . . . . . . . . . . . . . . . . . 5,448.770 11,714 Blind . . . . . . . . . . . . . . . . . . . . . . 30.058 60 Disabled . . . . . . . . . . . . . . . . . . . . . 1,667,049 3.531 Children-Families w/Dep Children . . . . . . . . . . . . 42,942 1.756 Adults-Families w/Dep Children . . . . . . . . . . . . 80,358 1.664 Other Title XIX Recipients . . . . . . . . . . . . . . . 1,825 28

MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . 12,773,605 51.555 Aged . . . . . . . . . . . . . . . . . . . . . . 8,926,414 21,958 Blind . . . . . . . . . . . . . . . . . . . . . . 34.694 94 Disabled . . . . . . . . . . . . . . .; . . . 2,814,329 6.729 Children-Families w/Dep Children . . . . . . . . .? . . . 118,329 4.228 Adults-Families w/Dep Children . . . . . . . . . . . . 320.995 4.426 Othe: Title XIX Recipients . . . . . . . . . . . . . . . 558,993 14,120


Ylnduplicated Total - HHS report HCFA - 2082


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.

8. Formulary: Yes. (Restricted drug list.)

Thomas A. Kellenberger, Pharm.D. Professional Services Section Department of Public Welfare 444 Lafayette Road. P.O. Box 43170 St. Paul. Minnesota 55164 6121296-7850

C. Prescribing or Dispensing Limitations: 1. Refills are limited to 5 times or 6 months, whichever comes first. Contraceptives may be filled to provide a 12-month supply.

D. Prescription Charge Formula: Reimbursement is based on the pharmacist's submitted charge or the State Department of Public Welfare's maximum price, whichever is lower. Reimbursement fee is $4.30 (effective July 1, 1985).

E. Ingredient reimbursement basis: AWP minus 10%.



Leonard Levine Commissioner 61 21296-61 17

Robert C. Baird Assistant Commissioner Bureau of Income Maintenance

Thomas A. Gayiord, R.Ph. Director Health Care Programs

Thomas A. Kellenberger, Pharm.D Director Drug Utilization Review Program

John T. Bush, R.Ph. Pharmacist Consultant 6121296-2363

2. Welfare Department Advisory Committees:

A. Professional Medical Advisory Committee:

Irving C. Bernstein. M.D. 101 1 Medical Arts Bldg. Minneapolis 55402

Department of Public Welfare Centennial Office Building 658 Cedar Street St. Paul, Minnesota 55105

444 Lafayette Road St. Paul 55164

Lyle Hay. M.D. Route 1, Box 3028 Buffalo 5531 3

NPC

David Craig, M.D. St. Paul Internist 590 Park Street, Suite 408 St. Paul 55103

Peter Fehr, M.D. 3931 Crystal Lake Blvd Minneapolis 55422

Frank S. Babb, M.D. St. Anthony Orthopaedic Clinic 1661 St. Anthony, Suite 200 St. Paul 55104

Kathleen Simo, M.D. South Medical Clinic Nicollet Avenue Minneapolis 55408

Lyle French, M.D. 5620 West Bararian Path Minneapolis 55432

Dorothy Bernstein. M.D. 101 1 Medical Arts Bldg. Minneapolis 55404

Miland E. Knapp, M.D. 21020 Oak Lane Excelsior 55331

John J. Reagan, M.D. 1431 Medical Arts Building Minneapolis 55402

Henry Blissenbach, Pharm.D. Merrill Chesler, M.D. 2119 Aztec Physicians & Surgeons Bldg. Mendota Heights 55120 63 S. 9th Street Minneapolis 55402 Shirley Mink. Ph.D.

110 E. 18th Street John McNeil, M.D. Minneapolis 55403 1224 Lowry Building St. Paul 55102

8. Minnesota State Pharmaceutical Association Welfare Task Force:

Donald Gibson - Duluth Michael E. O'Toole. R.Ph. - Minneapolis Roger Vadheim. R.Ph. -Tyler

(Chairman) William F. Appel, R.Ph. - Minneapolis Kent F. Olson, R.Ph. - Hopkins Barry M. Krelitz. R.Ph. - Edina Carl W. Oberg. R.Ph. - Duluth

3. Executive.Officers of State Medical and Pharmaceutical Societies:

A. Medical Association: C. Osteopathic Medical Society:

Douglas A. Shaw Robert N. Sampson, D.O. Chief Executive Officer Executive Director Minnesota State MedicalAssociation Minnesota Osteopathic Medical 2221 University Avenue, S.E. Society Suite 400 Hoffman Clinic Minneapolis 55414 Hoffman 56339 Phone: 61 21378-1 875 Phone: 61 21986-2038

NPC


Donald A. Dee. R.Ph. David Holmstrom, Secretary Executive Director 717 Delaware Street, S.E., Room 351 Minnesota State Pharmaceutical Association Minneapolis, Minnesota 55414 Health Associations Center 61 21623-541 1 2221 University Avenue, S.E., Suite 326 Minneapolis 55414 Phone: 6121378-1414

4. State Board of Pharmacy:

David Holmstrorn. Secretary 717 Delaware Street. S.E., Room 351 Minneapolis, Minnesota 55414 6121623-541 1

NPC

MISSISSIPPI



Type of BeneM Catworically Needy Medically Needy (MN) Other*

OAA A8 APTD AFDC OAA AB APTD AFDC Children 21 lSFOl ~ ~ . . Prescribed Drugs X X X X

Hospital Care X X X X


Laboratory & X-rav Service X X X X

Skilled Nursing Home Services X X X X Phvsician ,- - Serv~ces X X X X Dental Services X X X X


II. EXPENDITURES FOR DRUGS. Paymenl to Pharmacists by fiscal year ending June 30, 1984


T O T A L . . . . . . . . . . . . . . . . . . . . . $38,883,529 241.805** $34,623,626 230.248"

. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL $35,195,869 . . . . . . . . . . . . . . . . . . . . . . Aged 13.604.631

Blind . . . . . . . . . . . . . . . . . . . . . . 369,211 D i s a b l e d . . . . . . . . . . . . . . . . . . . . . 14,788.923

. . . . . . . . . . . . Children-Families w1Dep Children 2,965.729

. . . . . . . . . . . . Adults-Families w1Dep Children 3,467,375

CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . 4,935.787 Aged . . . . . . . . . . . . . . . . . . . . . . 3816.520 Blind 12.040 Disabled . . . . . . . . . . . . . . . . . . 714,343

. . . . . . . . . . . . Children-Families w/Dep Children 160.527

. . . . . . . . . . . . Adults-Families w/Dep Children 208,685 Other Title XIX Recipients 23,672

MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . 0 Aged . . . . . . . . . . . . . . . . . . . . . . 0 Blind . . . . . . . . . . . . . . . . . . . . . . 0 Disabled . . . . . . . . . . . . . . . . . . . . . 0 Children-Families w/Dep Children . . . . . . . . . . . . 0 Adulk-Families wlDep Children . . . . . . . . . . . . 0 Other Tille XIX Recipients . . . . . . . . . . . . . . . 0

"Unduplicated Tota - HHS reporl HCFA - 2082


Mississippi Medicaid Commission.

IV. Provisions Relating to Prescribed Drugs.


1. Reimbursement is limited to drugs listed in the formulary.

2. Exclusions are amphetamines, obesity control drugs, vitamins, cold and cough preparations, certain peripheral vasodilators, and those drugs classified as mild tranquilizers.

8. Formulary: Restricted formulary. For formulary information contact:

James T. Steele Mississippi Medicaid Commission P.O. Box 16786 Jackson, Mississippi 39236 6011981 -4507, Ext. 145


1. Quantity of Medication: Prescription or refill quantities should not exceed the amount shown in the maximum units column of the formulary. Prescriptions limited to four (4) per month per recipient.

2. Refills: Prescription refills are limited to three (3), except for maintenance type prescriptions with a limit of 5. Authorization is required in writing by the prescriber. There are no refill restrictions on insulin, and no refills are allowed on telephoned prescriptions.

3. Injections: The Medicaid program will not reimburse drug providers for injectable medications except for insulin and injectable medications prescribed for residents of nursing homes, and for those in private homes if the individual is receiving Home Health Services under an approved plan of treatment. Injectable Prolixin shall be an exception.



1. Legend Drugs - reimbursement for all legend drug claims is based on the lower of:

a. MAClEAC (ingredient cost) determined for the drug in the quantity dispensed, plus $3.33 dispensing fee. Dispensing physicians receive a fee of $2.10.

b. The usual and customary retail charge.

c. Co-payment: $1.00.

2. Reimbursement for non-legend drugs are based on the lower of usual and customary charge or the maximum over-the-counter price set for that item listed in formulary. Usual and customary of a non-legend drug is to be the shelf price.

3. Compounded prescriptions for topical use are covered if at least one legend drug (in therapeutic amounts) is included in the ingredients.

4. Compounded oral medications when all ingredients are covered separately under their own drug codes in the formulary.


Medicaid eligible persons received 3,340,389 prescriptions during Fiscal Year 1984. This represents a decrease of 63,661 prescriptions or 01.9%from Fiscal Year 1983.

Average Rx price during PI 1983 - $12.01

Fiscal intermediary:

E.D.S. Federal P. 0 . Box 31475 Jackson, MS 39206


1. Office of the Governor. Division fo Medicaid (Bill Alain, Governor)

B.F. Simmons Director

James T. Steele, R.Ph. Pharmacist

Office of the Governor Division of Medicaid (P. 0. Box 16786) 4785 1-55 Frontage Road Jackson, Mississippi 39236

2. Title XIX Technical Advisory Committee:

There are six (6) technical advisory committees. Each committee consists of individuals who are health care professionals identified with the responsibility of the committee to which they are appointed.



Charles L. Mathews Executive Secretary MS State Medical Assoc 735 Riverside Drive Jackson 39216 Phone: 60113545433

Phylliss M. Moret, R.Ph. Executive Director Mississippi Pharmacists Assoc 401 E. Capitol St., Suite 504 Jackson 39201 Phone: 601/944-0416


Ronald Powell, D.O. Secretaryrrreasurer 330 W. Broad Street ~ e s i Point, MS 39773

H.W. Holleman. Executive Director Suite 107-F, C & 1 Plaza 2310 Highway 80 West Jackson, MS 39204 6011354-6750

NPC

M I S S O U R I




O M AB APT0 AFDC OM A8 APTD AFDC Children 21 W O )

Prescribed Drugs X X X X X

inpatient Hosoital Care

Hosp~tal Care X X X X X

Laboratory & X-ray S e ~ ~ c e X X X X X

Sk~lled Nurslng Home Services X X X X X Phys~c~an Serv~ces X X X X X Dental Se~ lces X X X X X


II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30. 1984

TOTAL

19ffl 1983 Expended - Rec~pient - Expended Recipient - -

. . . . . $29,577,083 248,371" $25,569,347 237,290

CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . 12,649.514 170,551 11,W)5,615 163.919 Aged . . . . . . . . . . . . . . . . . . . . . . 4,500,173 19.960 4,634,232 23.334 Blind . . . . . . . . . . . . . . . . . . . . . . 262.911 1.053 258,122 1.209 Disabled . . . . . . . . . . . . . . . . . . . . . 2,930,762 10.475 2,719,315 11,090 Children-Families wIDep Children . . . . . . . . . . . . 1,925,546 . 81.358 1,640,793 75.878 Adults-Families w l k p Children . . . . . . . . . . . . 3,030,121 57,705 2,553,153 52,408

CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . $16,927,569 77,820 13,763,732 73,371 Aoed . . . . : . . . . . . . . . . . . . . . . . 9,081,844 35,896 7,609,230 33.726

Disabled . . . . . . . . . . . . . . . . . . . . . Children-Families w l k o Children . . . . . . . . . . . . Adults-Families wIDep children . . . . . . . . . . . . Other Title XIX Recipients . . . . . . . . . . . . . . .

MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . . Children-Families w l k p Children . . . . . . . . . . . . Adults-Families w l k o Children . . . . . . . . . . . . Other Title XIX ~ecip i ints

"Undupliraled Total - HHS report HCFA - 2082

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Division of Family Services of the State Department of Social Services.


A. General Exclusions: Exclusions governed by Formulary.

8. Formulary: Formulary lists 402 drugs by generic names or trade names. For information contact:

Susan McCann, P.D. Pharmacy Consultant P.O. Box 6500 Jefferson City. Missouri 65102 314/751-3277

State allows payment only for the drugs in the formulary.


1. Quantity of Medication: Physician encouraged to prescribe 34-day or 100 doses supply but may, at his own discretion, prescribe up to a maximum 90-day supply.

2. Refills: Federal regulations must be observed for all drugs on the formulary which are listed in BNDD Schedules 2. 3, 4, and 5. All other prescriptions refilled should be in accordance with the directions given by the prescribing physician.

3. Five Rx limitation per month per recipient. Certain drugs which are commonly prescribed for long-term chronic medical conditions are exempt from limitation.

D. Prescription Charge Formula: The lowest of the following: Federal MAC. Missouri MAC, AWP, or Direct plus $2.50 fee or usual and customary, whichever is lower.

E. Co-payment (variable) -$0.50 co-payment when acquisition is $10.00 or less -$1.00 co-payment when acquisition $10.01 to $25.00 -$2.00 co-payment when acquisition cost is $25.01 or more -Go-payment retained by pharmacist.

F. Drug Exception Process:

Certain nonsteroidal anti-inflammatory drugs covered on a prior authorization basis for recipients with diagnosis of rheumatoid arthritis or juvenile rheumatoid arthritis who cannot tolerate aspirin.


All prescriptions must be filled with drugs that meet USP standards. Participating pharmacies sign a participation agreement with the State Department. All dispensing physicians participating in the program are required to keep prescription files the same as pharmacies.

Missouri formulary is a restricted formulary, restriction being that the State only pays for drugs listed on the formulary, or drugs that are chemically equivalent to drugs listed. Any drug that is chemically equivalent to a trade name drug listed as acceptable for reimbursement. And likewise any trade name drug that is not listed, but is equivalent to a generic drug listed, is reimbursable under the drug program.

Method of reimbursement payment is based on acquisition cost plus a dispensing fee of $2.50 per prescription filled. Acquisition may vary depending whether it is based on AWP. Direct Price and Federal or Missouri MAC. The master drug file contains all acceptable drugs and their appropriate NDC (National Drug Code) number.

AWP (Average Wholesale Price), any drug that is not manufactured by Abbott. Lederle. Merck Sharp & Dohme, Parke-Davis. Pfizer, Roerig. Squibb, Upjohn and Wyeth, or is not a Federal or Missouri MAC drug will be based on the AWP. The majority of drugs listed are based on AWP. The method of pricing will be taken from the NDC number.

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Any drug manufactured by Abbott, Lederle. Merck Sharp & Dohme. Parke-Davis. Pfizer, Roerig, Squibb, Upjohn and Wyeth, acquisition cost will be based on the manufacturer's direct price.

The Federal Government has 19 drugs listed as MAC (Maximum Allowable Cost). Missouri has 41 drugs listed as MAC (Maximum Allowable Cost). These 60 drugs have a maximum price that will be paid.

All pharmacists and physicians that participate in the Missouri Title XIX Medicaid Drug Vendor Program have been issued a listing of all MAC drugs, a listing of the manufacturers that the Division of Family Services limits price to direct price.

By following these guidelines the Division of Family Services feels that the pharmacist has a freedom of choice of products and package sizes in which he or she may stock their inventory.

Fiscal intermediary: General American-Consultec 701 So. Country Club Drive Jefferson City, Missouri 65101

Number of drug claims processed in FY 1984 - 3,622,556

Average prescription price during FY 1984 - $8.77



Joseph J. O'Hara Director

Susan Turner Director,

Jane Y. Kruse Director

David G. Foshage Administrator SurveillancelUtilization

Review Systems (SURS)

Susan McCann Pharmacist Consultant

Everett Harris, D.O., Physician Consultant

Michael Wilson, D.O., Physician Consultant

Department of Social Services Broadway State Office Building P. 0. Box 1527 Jefferson City. Missouri 65103

Division of Family Services P. 0. Box 88 Jefferson City, Missouri 65103

Division of Medical Services 308 East High Street P. 0. Box 6500 Jefferson City 65102

2. Medical Advisory Committee to the State Division of Family Services:

Chairman Lesiie F. Bond, M.D. 3400 North Kingshighway St. Louis, Missouri 631 15 (31 4) 385-3600

Vice Chairman B. David Hartwig, R.Ph. Red Cross Pharmacy 52 Arrow Street Marshall. Missouri 65340 (81 6) 886-5533

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J.B. "Jet" Banks 1442 A North Grand St. Louis, ~issouri 31 41533-1 900

Ms. Eddie Maw Binion 9463 Indian Meadow Drive 302 St. Louis, Missouri 63132 (314) 997-1 81 5. 421 -5322

James E. Canter, 13.0. D. 410 Northeast Street California, Missouri 65018 (31 4) 796-31 11

Erma Cunningham Executive Director Missouri River Home Health Agency 219 East Dunklin Jefferson City. Missouri 65101 31 416355643

Representative Russell Goward 4015 Fair Avenue St. Louis, Missouri 31 41652-0200

Bob Griffith Griffith Company 48 Doctors Park Cape Girardeau, Missouri 63701 (31 4) 334-6003

Jonathan G. Hanson. D.D.S. 1407 Southwest Boulevard Jefferson City, Missouri 65101

Doretta Henderson 1615 Mary Lou Williams Lane Kansas City, Missouri 64106 8 16142 1-2075

Ex-Off icio Members:

Roben Hotchkiss, M.D. Division of Health 63106 Broadway State Office Building P. 0 . Box 570 Jefferson City, Missouri 65102

Dennis L. Hunter, OD. West Morgan Marshall, Missouri 65340 (81 6) 886-551 7

Patrick Morton Associate Hospital Director of

Financial Services MU Hospital and Clinics One Hospital Drive

Columbia, Missouri 65212 31 41882-291 2

Homer S. Spiers. Administrator Resthaven Nursing Home 1500 West Truman Road Independence, Missouri 64050 (81 6) 254-3500

631 15 John Vogt. MSW 805 East 41 st Street Kansas City, Missouri 641 10 H. 8161531-5857; Of. 8161471-5930

Senator Harry Wiggins 7817 Terrace Street Kansas City, Missouri 641 14

Starks Williams, M.D. 1734 East 63rd Street Kansas City. Missouri 641 10 8161 H. 373-4831; Of. 361-6699

Norman McCann, President Missouri Baptist Hospital 301 5 North Ballasl Road St. Louis, Missouri 63131 3141432-1212

Joyne Leet Executive Director Primary Care Council of

Metropolitan St. Louis, Inc. 4900 Delmar Boulevard St. Louis, Missouri 63108 3 1 4/36 1 -2330

Missouri 5 19H!i

3. Pharmacy Advisory Committee:

Chairman B. David Hartwig, R.Ph Red Cross Pharmacy 52 Arrow Street Marshall 65340 8161886-5533

Bill Fitzpatrick. R.Ph. Fitzpatrick Pharmacy 130 Manchester Ballwin, Missouri 6301 1 (314) 394-6622, 576-1 300

Tom Gibson, R.Ph. Waverly Pharmacy Kelling and Broadway Waverly 64096 (81 6) 493-2271

Eules Hively, R.Ph. Teko Pharmacy 501 Teaco Kennett, Missouri 63857 (31 4) 888-6673

Jack Littrell, R.Ph. Blue Valley Pharmacy 581 1 Truman Road Kansas City, Missouri 64126 (816) 483-4405,436-4700,373-0942

Max Maupin. R.Ph. Hillcrest Pharmacy Hillcrest Shopping Center Rolla, Missouri 65401 (31 4) 364-3258

James S. Osborn, R.Ph. Osborn Medical Tower Pharmacy 1443 North Robberson Springfield 65802 (41 7) 866-4341


A. Medical Association: . C. Osteopathic Association:

Royal Cooper Executive Secretary Missouri State Medical Assoc. 1 13 Madison Street P. 0. Box 1028 Jefferson City 65101 Phone: 3141636-5151

Edward Borman, J.D. Executive Director Missouri Assoc. of Osteopathic Physicians and Surgeons P. 0 . Box 748 Jefferson City 65102 Phone: 31 41634341 5

€3. Pharmaceutical Association: D. State Board of Pharmacy

J0hn.B. Zatti. R.Ph. Chief Executive Officer Missouri Pharmaceutical Assoc. 410 Madison Street Jefferson City 65101 Phone: 3141636-7522

Kevin E. Kinkade, Executive Director P.O. Box 625 Jefferson City, Missouri 65102 3141751 -2334

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M O N T A N A

M E D I C A L ASS ISTANCE D R U G P R O G R A M (T ITLE XM)


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

O M AB APT0 AFDC OAA AB APT0 AFDC Children 21 (SFO)

Prescribed Drugs X X X X X X X X X

Inpatient Hospital Care x X X X X X X X X



Skilled Nursing Home Services X X X X X X X X X - -

Physician Services X X X X X X X X X

Denlal Services X X X X X X X X X



1984 1983 Expended Recipient Recipienl - - Expended - -

T O T A L

CATEGORICALLY NEEDY CASH TOTAL A " P ~ . . . . . . . ., ..

.

Blind . . . . . . . . . . . . . . . . . . . . . . 13.204 73 13.508 68 Disabled 985.920 3.975 904.438 . . . . . . . . . . . . . . . . . . . . . 3.499 Children-Families w/Dep Children 252,740 9,615 215.449 . . . . . . . . . . . . 8,655 Adults-Families w/Oep Children 495.757 6,995 . . . . . . . . . . . . 387,585 6,033 Other 11,108 162 . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . CATEGORICALLY NEEDY NON-CASH TOTAL 1.866.599 Aged . . . . . . . . . . . . . . . . . . . . . . 1,208,898 Blind . . . . . . . . . . . . . . . . . . . . . . 4,805 Disabled . . . . . . . . . . . . . . . . . . 489.394 Children-Families w1Dep Children . . . . . . . . . 81,234 Adults-Families w/Dep Children . . . . . . . . . . . . 76.631 Other Title XIX Recipients . . . . . . . . . . . . . . . 5.636

. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL 1,050,007 Aged . . . . . . . . . . . . . . . . . . . . 579.1 86 Blind . . . . . . . . . . . . . . . . . . . . . . 5.190 Disabled . . . . . . . . . . . . . . . . . . . 445,254 Children-Families w l k p Children . . . . . . . . . . . . 2,721 Adults-Families wlOep Children . . . . . . . . . . . . 15,857 Olher Title XIX Recipienls . . . . . . . . . . . . . . . 2,804

"Unduglicated Total - HHS report HCFA - 2082

ill. Administration:

State Department of Social and Rehabilitation Services


A. General Exclusions: Provided are all prescription drugs and those over-the-counter drugs in the following classes: insulin, laxatives, antacids. Both types must be prescribed by a licensed practitioner (physician, dentist, or podiatrist).

8. Formulary: None.



2. Refills: As directed by licensed practitioner.

3. Dollar Limits: No limit.

4. For chronic conditions prescription must be a minimum of 100 units or one month's supply.

D. Prescription Charge Formula: Drugs will be paid at the usual retail rate or estimated acquisition cost or maximum allowable cost, plus a dispensing fee - whichever is lower. Dispensing fees range from $2.00 to $3.75. Additional $0.75 per Rx allowed for unit dose systems.

E. Co-payment - $0.50 (Federal exemptions apply)

Offlclals, Consultants and Committees

1. Social and Rehabilitation Services Department Officials:

Dave Lewis Director

Jack Ellery, Administrator Economic Assistance Division

Lowell Uda, Chief Medicaid Services Bureau

Department of Social and Rehabilitation Services

P. 0. Box 4210 Helena. Montana 59604

John Larson, Chief Medicaid Financing Bureau

Randal P. Bowsher 4061444-4540

2. Montana Medical Care Advisory Council:

James Conway John Jacobson. M.D. Lowell Uda John Layne, M.D.

Calvin Bohleen Gary Blewett Charles Briggs Jack Ellery

3. Social and Rehabilitation Services Economic Assistance Division:

Dale Haefer Administrative Officer

Barbara Bartell Administrative Officer

Karl Banschbach Medical Care Specialist

Paul Miller Medical Care Specialist

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John Kall, D.D.S. Dental Consultant

Joyce DeCunzo Administrative Officer

John Patrick Administrative Officer

Charles Williams Administrative Officer

Randy Bowsher Administrative Officer

Robert Olesen Administrative Officer

Brian Camoure Administrative Officer



G. Brian Zins Executive Director Montana Medical Association 2021 1 1 th Avenue. Suite 12 Helena 59601 Phone: 4061443-4000


Robert Likewise Executive Director Montana State Pharmaceutical Association P.O. Box 4718 Helena 59604 Phone: 40614494843


Phillip L. Dean, D.O. Secretary-Treasurer Montana Osteopathic Association Box 1299 Malta, Montana 59538


warre;? Amole, Executive Director 510 1st Avenue. N.. Suite 100 Great Falls, Montana 59401 4061761 -5131

N E B R A S K A




O M AB APT0 AFDC OAA AB APT0 AFDC Children 21 lSFOI

Prescribed Drugs X X X X X X X X X X Inpatient Hospital Care X X X X X X X X X X Outpatient Hnsnital Care X X X X X X X X X X

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



1984 1983 Expended Recipient Expended Recipient - - - -

. . . . . . . . . . . . . . . . . . . . . T O T A L $1 1,325,229 63,473'. $10,642,008 60,421

CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $6,929.099 50,252 $6,381,812 47,738 Aoed . . . . . . . . . . . . . . . . . . . . . . 2,209,371 5.332 2847.696 5.169

0~~

Blind . . . . . . . . . . . . . . . . . . . . . . 37,753 124 40,636 142 Disabled . . . . . . . . . . . . . . . . . . . . . 2,553,456 6,229 2,329.579 6,155

. . . . . . . . . . . . Children-Families w/Dep Children 814.476 22,689 764,667 26,572

. . . . . . . . . . . . Adults-Families w/Oep Children 1.314.043 15.888 1,199.232 14.700

CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . $163.290 3.705 $141,525 3.350 Aged . . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0 Blind 0 0 0 0 Disabled 0 0 0 0 Children-Families w/Dep Children . . . . . . . . . . . . 28,344 1,183 22,888 994

. . . . . . . . . . . . Adults-Families w/Oep Children 45,673 970 32.304 739 Other Title XIX Recipients . . . . . . . . . . . . . . . 89,280 1.552 86,333 1,617

MEDICALLY Aged . . Blind . . Disabled

NEEDY . . . . . .

TOTAL . . . . . . . . . . . . . . $4232,579 9,498 4,118,451 9,338 . . . . . . . . . . . . . . . . . 3,564992 8,026 3.479.871 7.868 . . . . . . . . . . . . . . . . . 6,392 12 6,106 12 . . . . . . . . . . . . . . . . . 640,431 ....... 1,181 61 1.394 1,194

Children-Families w/Dep Children . . . . . . . . . . . . 4,840 159 3.569 144 Adults-Families w/Dep Children . . . . . . . . . . . . 15,595 116 16.553 113 Other Title XIX Recipients . . . . . . . . . . . . . . . 329 4 958 7

*'Unduplicated Total - HHS report HCFA - 2082

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111. Administration:

State Department of Social Services.

iV. Provisions Relating to Prescribed Drugs:

A. General Exclusions: Experimental drugs; weight control and appetite depressant drugs, except for use in narcolepsy or hyperkineses in children with granted prior approval; OTC drugs that are not listed in the "Official Drug Guide" and have not been prescribed by a licensed practitioner; drugs that are marketed without required FDA approval; drugs marketed that infringe on patent rights; prior authorization is required for certain other items.

8. Formulary: None. The "Official Drug Guide" is a list of drugs together with identification members for billing purposes. For Drug Guide Information, contact:

Mr. Tom Dolan. R.Ph. Nebraska Dept. of Social Services P.O. Box 95026 Lincoln, Nebraska 68509 4021471 -3121

C. Prescribing or Dispensing Limitations:'

1. Quantity of Medication: Maintenance-type drugs limited to purchases of at least a 30-day supply, unless an exception is specifically allowed. Cardiac glycosides, thyroid, vitamins and Dilantin will be limited to purchases of not less than 100's.

The Department of Social Services further requires that any other maintenance drug or any drug used in a chronic manner be PRESCRIBED and DISPENSED in a minimum of a one- month supply.

(Note: Prescriptions which are written for quantities larger than a month's supply are not to be reduced to a month's supply. The Nebraska Department of Social Services will consider any form of prescription splitting as fraudulent.)

Exceptions to the Quantity Limitations:

a. When the prescribing physician first introduces a maintenance drug to a patient's course of therapy, the physician is allowed to prescribe as his judgment dictates. Physicians and Pharmacists MUST indicate on the claim form that this is the initial filling of the medication.

Any subsequent dispensing of this maintenance drug must be prescribed and dispensed in at least a month's supply or the required 100 doses.

b. When the prescribing physician's professional judgment indicates that these quantities of medication wwid not be in the patient's best medical interest, the physician may prescribe as his judgment directs; but the claim form MUST clearly indicate that an exception to the requirement is being made.

c. if, in the Pharmacist's professional judgment, an exception to the requirements must be made, the Pharmacist also MUST clearly indicate this on the claim form.

d. Schedule II drugs are exceptions.

e. Original shelf packages: The Department of Social Services will accept CERTAIN original shelf package sizes of medication.

* Medical Services, Department of Social Services. State of Nebraska. Nebraska DSS Program Manual issued November 24. 1982. as amended.

(1) An original shelf package of 16 fluid ounces, or less when not packaged in the pint size, will be sufficient for our quantity limitations requirement for liquids, but will not be sufficient, for the supplemental dispensing fee unless it's a full month's supply.

(2) Original shelf packages of 100 tablets or capsules of ROUTINELY prescribed drugs will NOT be acceptable as sufficient for fulfillment of our quantity limitations requirement. The full month's supply must be prescribed and dispensed.

(3) An original shelf package of 100 tablets or capsules, or less when not available in the 100 size for SELDOM prescribed solid dosage drugs will be sufficient for our quantity limitations requirement, but will not be sufficient for the supplemental dispensing fee unless it is a full month's supply.

(4) Ready-made ointments, creams, etc., when used in a chronic or maintenance manner, may be dispensed in an original shelf package size provided it is the original size closest to the needed amount of medication.

(5) The determination of whether a claim violates our regulations or not, would, by necessity, have to be made by the Department of Social Services professional staff. Any claim deemed to be in violation or not an exception to our rulings, will not be compensated with the dispensing fee.

Any disagreement with a determination may be arbitrated through the NEBRASKA PHARMACISTS ASSOCIATION'S ADVISORY COMMITTEE.

3. Refills: As authorized by the prescribing physician.



1. Retail Pharmacies

a. "Assigned" Dispensing fee.

A dispensing fee will be assigned by the Nebraska Department of Social Services, to each individual pharmacy. The fee will be calculated from the information obtained through the Department's Prescription Survey. Each Pharmacy will be notified of its dispensing fee.

b. "Maintenance Drug-Month Supply" Supplemental fee.

In addition to the "assigned" dispensing fee for each retail pharmacy, there is a 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 month3 therapy

c. The department assigns a dispensing fee to a dispensing physician only when there is no pharmacy within a 25 mile radius of the physician's place of practice.

Variable Pharmacy Fee for individual pharmacy determined from survey data submitted to state:

EAC, SMAC. MAC plus determined store fee: minimum $3.25 to maximum $4.69.

or usual and customary, whichever is lower.

2. DETERMINING DRUG OR INGREDIENT COST

a. General Information

(1) Maximum Allowable Cost (M.A.C.)

Certain multiple source products will have a maximum allowable cost designated by the Federal Pharmaceutical Reimbursement Board, Department of Health, Education, and Welfare. The M.A.C. value will be Me lowest cost at whlch the drug is widely and consistently available.

187

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The determination of which products will be designated M.A.C. items will be the direct responsibility of the Reimbursement Board. The Nebraska Department of Social Services will NOT have authority to increase the M.A.C. of any product. Any individual or organization may at any time request that a M.A.C. determination be revised or withdrawn. All requests must be submitted directly to the Pharmaceutical Reimbursement Board, DHHSIHCFA, 6401 Security Blvd.. Rm. 1-C-5 East Low Rise Bldg., Baltimore. Maryland 21235.

All pharmacies will be notified by the Nebraska Department of Social Services as to which items have been designated as M.A.C. products and what their respective M.A.C. values are.

(2) State Maximum Allowable Cost (SMAC): NDSS designates a state maximum allowable cost (SMAC) for certain drug products available from multiple manufacturers. The SMAC value is the cost at which the multiple-source drug is widely and consistently available to pharmacy providers in Nebraska. The determination of which products are designated SMAC items is the direct responsibility of the Division of Medical Services in conjunction with the Nebraska Pharmacists Association's Advisory Committee. Any individual or organization may request a revision in a SMAC value directly from NDSS at any time.

(3) Estimated Acquisition Cost (EAC): All drug products, including the federally- designated MAC and state-designated SMAC drugs, are assigned an estimated acquisition cost (EAC) as required by 42 CFR 447.332 (a)

(4) The EAC of any product is the cost at which most prudent providers may obtain the item. NDSS is responsible for assigning the EAC values to all drugs. Any individual or organization may at any time request a revision in an EAC value directly from NDSS.

b. Cost Limitations

The Nebraska Medicaid Drug Program is required to reimburse product cost at the LOWEST of:

(1) the M.A.C. or S.M.A.C. of the drug, if one has been established, or,

(2) the E.A.C. for that drug,

The M.A.C. limitation will not apply when the prescribing physician certifies on a Form MC-6 that a specific brand is medically necessary. In these cases, the E.A.C. will be the maximum allowable cost.

The S.M.A.C. limitation may be overriden by contacting the medical director by phone or mail.

4. PRICING INSTRUCTION (DRUGS)

UNDER NO CIRCUMSTANCES, MAY ANY CHARGE EXCEED THE USUAL AND CUSTOMARY CHARGE TO THE GENERAL PUBLIC.

a. Compounded Prescriptions and Legend Drugs

These drugs will be reimbursed at the lesser value of either:

1. Product Cost (M.A.C.. S.M.A.C. or E.A.C.) plus the appropriate dispensing fee(s), or

2. The usual and customary charge to the general public

b. Listed Over-the-counter Drugs

These items will be reimbursed at the lesser value of either:

1. Product Cost (M.A.C., S.M.A.C. or E.A.C.) plus the appropriate dispensing fee(s), or

2. The usual and customary sheMprice to the general public

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Section 2500-PRODUCTS REQUIRING PRIOR APPROVAL

Certain products require that approval be granted PRIOR to their payment.

PHYSICIANS wishing to prescribe these products MUST obtain approval from:

The Medical Director Medical Services Division Nebraska Department of Social Services 301 Centennial Mall South Fifth Floor Lincoln, Nebraska 68509

The Department of Social Services will notify the prescribing physician and the pharmacy of the recipient's choice, whenever these requests are approved.

V. Miscellaneous:

Co-payment-None.

Number of claims processed in FY 1984-1,021,640

Average prescription price during FY 1984-$11.74.



Gina C. Dunning Director

Robert Seiffert Administrator Division of Medical Services

Ms. Kris Logsdon Surveillance and Utilization Review Consultant

Dr. Christine Wright. M.D. Medical Consultant

Dr. Edward J. Smith, M.D. Medical Director Division of Medical Services

Tom R. Dolan. R.Ph. Pharmaceutical Consultant Division of Medical Services 4021471 -31 21

Max J. Ward, R.P. Pharmacist Division of Payment and Data Services 4021471 -3121, Ext. 315

Gary J. Cheloha, R.Ph. Assistant to Administrator Division of Medical Services 4021471 -31 21. Ext. 132

Department of Social Services 301 Centennial Mall South 5th Floor Lincoln, Nebraska 68509

2. Social Services Department Medical Care Advisory Committee:

Evelyn Runyon 261 5 No. 102 Avenue Omaha NE 68134

Warren Bosley, MD 181 1 West Znd, Suite 360 Grand Island. NE 68801

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Edmund Schneider. O.D. Lincoln Vision Clinic 810 North 48th Street Lincoln 68504

Robert Marshall, Pharm.D. Nebraska Pharmacists Assoc. 600 S. 12th Street Lincoln 68508

Gregg Wright, MD, Director Department of Health 301Centennial Mall South. 3rd FI. Lincoln, NE 68509

Larry Rennecker Senior Vice President Bergan Mercy Hospital 7500 Mercy Road Omaha, NE 68124

Faye Sorenson, RN Director of Nursing Services Jennie M. Melham Memorial Med. Ctr. Broken Bow, NE 68822

Steve Lorenzen, Director Federal Programs Blue Cross-Blue Shield of NE P.O. Box 3248 Main Post Office Station Omaha, NE 68180

Diannae Kascht 1528 D Street Lincoln, NE 68502

Jack Vetter, President Vetter Health Services 12614 Sky Park Drive Omaha, NE 68137

Thomas Kiefer. DDS 2602 J Street Omaha, NE 68137

Peter R. Kongstvedt. MD Executive Director Health America of Lincoln 17th & N Streets Lincoln, NE 68508

Keith Mueller, PhD Political Science Department University of Nebraska Lincoln, NE 68588-0328

Pat Snyder, NHA, Administrator Lancaster Manor 1145 South Street Lincoln. NE 68502

Steve Petruconis, Vice President St. Elizabeth Community Health Center 555 South 70th Street Lincoln, NE 68510

Doris Gunn 2410 T Street Lincoln, NE 68503

Shirley A. Munn-White General Manager Capitol Medical 271 1 0 Street Lincoln, NE 68510

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Kenneth Neff Executive Secretary Nebraska Medical Association 1902 First National Bank Bldg. Lincoln 68508 Phone: 4021432-7585


Robert Marshall, Pharm.D. Executive Director Nebraska Pharmacists Association 600 S. 12th Street Lincoln 68508 Phone: 4021475-4274

C. Osteopathic Physicians and Surgeons:

A. G. Zuspan. D.O. Secretary Nebraska Association Osteopathic Physicians and Surgeons 121 0 13th Street Aurora 68818 4121694-2525


Laura J. Partsch. Director P.O. Box 95007 Lincoln, NE 68509 402/471-2115

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NEVADA



Type of Benel~t Categor~caliy Needy Medically Needy (MN) Other"

O M AB APT0 AFDC O M AB APT0 AFDC Ch~ldren 21 (SFO)

Prescribed Drugs X X X X lnnat~anl ... v- .. - ... Hospital Care X X X X Outpatient Hospital Care X X X X Laboratory & X-ray S ~ N I C ~ X X X X Skilled Nursing Home Services X X X X Phv~irian


11. EXPENOiTURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984


. . . . . . . . . . . . . . . . . . . . . T O T A L

. . . . . . . . . . CATEGORICALLY NEEOY CASH TOTAL Aged . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . Blind Disabled

. . . . . . . . . . . . Chiidren-Families wloep Children

. . . . . . . . . . . . Adults-Families wIDep Chiidren

. . . . . . . . CATEGORICALLY QEEDY NON-CASH TOTAL Aged . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . Disabled

. . . . . . . . . . . . Children-Families w l b p Children

. . . . . . . . . . . . Adults-Families w/Dep Chiidren . . . . . . . . . . . . . . . Other Title XiX Recipients

. . . . . . . . . . . . . . MEDICALLY NEEOY TOTAL . . . . . . . . . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind

Disabled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Children-Families wIDep Chiidren

Aduits-Families w l b p Children . . . . . . . . . . . . Other Title XIX Recipients . . . . . . . . . . . . . . .

"'Undu~licated Total - HHS repolt HCFA - 2082


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. Legend pharmaceuticals 2. Insulin 3. Diabetic urine test tablets and test tapes.

4. Prenatal vitamin/mineral supplements, legend or non-legend, intended for prenatal care.

5. Family planning items such as diaphragms, oral contraceptives, foams and jellies.

Excluded. Nevada Medicaid will not pay for the following:

1. Anorectics used for obesity control. 2. Amphetamine combinations. 3. Radiopaque agents (e.g.. Telepaque, Hypaque. Barium Sulfate). 4. Radiographic adjuncts (e.g., Perchloracap). 5. Pharmaceuticals designated "ineffective," or "less than effective" (including identical, related,

or similar drugs) by the FDA as to substance or diagnosis for which prescribed. 6. Pharmaceuticals considered "experimental" as to substance or diagnosis for which

prescribed.

Exceptions: Nevada Medicaid will not pay for the following unless prior-authorized by the Medicaid Office on form NMO-3, Treatment Authorization Request (TAR):

1. Amphetamine (e.g., Dexedrine). 2. Aspirin (e.g.. Zorprin, Easprin) 3. Ergoloid mesylates (e.g., Hydergine). 4. Ethaverine (e.g., Ethatab). 5. Fluoride preparations. 6. Glucose blood test strips. 7. Methylphenidate (e.g.. Ritalin). 8. Nicotine preparations (e.g., Nicorette). 9. Nicotinic acid in oral or injectible form.

10. Nitroglycerin transdermal systems (e.g., Nitrodisc, Nitro-Dur. Transderm-Nitro. 11. Non-legend pharmaceuticals. 12. Papaverine (e.g., Pavabid). 13. Pemoline (e.g.. Cylert) 14. Quinine (e.g., Quinamm) 15. Vitamins, vitaminlmineral combinations or hematinics. 16. Appliances, sundries and supplies; see 1202.4. 17. Nutritional supplements or replacements; see 1202.5 and 1203.3. 18. Those vaccines not readily available free of charge.

B. Formulary: None. (Certain Rx categories are excluded from reimbursement. See Section B above.)


Limitations

1. Prescriptions. Eligible Medicaid recipients may receive three out-patient prescriptions per month plus those issued for EITHER prenatal OR family planning purposes. For special authorization procedures. see 1203.3.

2. Refills. A refill is a prescription subject to the limitations of paragraph A above.

NPC


1. Reimbursement: Legend Drugs

Reimbursement for legend pharmaceuticals is the lowest of (1) maximum allowable cost (MAC) plus the professional fee, (2) estimated acquisition cost (EAC) plus the professional fee, or (3) that pharmacy's usual charge to the general public. The professional fee is currently $3.78 per prescription. (EAC is defined as AWP minus 5%).


Copayment by Recipient

Recipients are required to pay the pharmaceutical provider $1.00 copayment for each prescription received:

A. Exemptions from the copayment requirement are the following:

1. Inpatients, except when receiving "take home" prescriptions on day of discharge.

2. Family planning prescriptions (oral contraceptives, diaphragms, foams and jellies).

3. Those ~ndividuals whose Medical Certificates ere printed "EXEMPT FROM CO-PAYMENT".

Miscellaneous:

Fiscal intermediary:

Blue Shield of Nevada P.O. Box 10330 Reno, Nevada 89510

Number of claims processed PI 1984-212,183

Average prescription price during FY 1984-$12.69

Officials, Conaultants and Committees

1. Human Resources Department Officials:

Jerry Griepentrog Director

Sharon Murphy, Administrator State Welfare Division

Keith W. Macdonaid, R.Ph. Chief, Medical Services

Jane Feldmen Statistician Ill

James I. Laird, M.D. Medical Consultant Nevada Medicaid Off ice

Steven P. Bradford, Pharm.D, Pharmaceutical Consultant Nevada Medicaid Office 7021885-4869

Department of Human Resources State Capital Complex Carson City, Nevada 89710

NPC

2. Advisory Committees of the Welfare Division:

A. Medical Care Advisory Group:

Harry P. Massoth, D.D.S -Chairman, Executive Committee

Tom Collier -Chairman. Hospital Committee

John Stutchman -Chairman. Long Term Care Committee

Michael Jones, M.D. -Chairman, Physicians Committee

Harry P. Massoth. D.DS -Chairman. Dental Committee

Vacant -Chairman, Consumer Recipient Committee

Vacant -Chairman, Pharmacy Committee

6 . Drug Utilization Review:

Steven P. Bradford, Pharm.D.



Richard C. Pugh Executive Director Nevada State Medical Association 3660 Baker Lane Reno 89509 Phone: 7021825-6788


Robert C. Johnson Executive Officer Nevada Pharmaceutical Association 11 12 I Street Sacramento. CA 95814 Phone: 9161444-781 1


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


Elliott King. Secretary 1201 Terminal Way, Suite 212 Reno. Nevada 89502 7021322-0691

NPC New Hampshire-l 1985

N E W H A M P S H I R E




OAA AB APTD AFDC OAA AB APT0 AFDC Children 21 ISFO)



Outpatient Hosoital Care X X X X X X X X X X

Laboratorv & X-ray Service X X X X X X X X X X



IN. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984

1984 1983 Expended - Recipient - Expended Recipient - -

T O T A L . . . . . . . . . . . . . . . . . . . . . $4,928,443 27,512" $4,240,571 29,092

CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . Aoed . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . . Children-Families w/Dep Children . . . . . . . . . . . . Adulk-Families w/Dep Children . . . . . . . . . . . .


. . . . . . . . . . . . Children-Families w/Dep Children Adulk-Families w/Dep Children . . . . . . . . . . . .


MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . . Children-Families w l b p Children . . . . . . . . . . . . Adults-Families w/Deo Children . . . . . . . . . . . . Other Title XIX ~ecipients . . . . . . . . . . . . . . . 60 3

"Unduplicated Total - HHS repori HCFA - 2082

New Hampshire-2 1985


Office of Medical Services, Department of Health and Welfare.


A. General Exclusions: Anorexiant (stimulants) except for treatment of narcolepsy and hyperkinetic children; and vitamins for patients over 7 years of age.

B. Formulary: None.


1. Quantity of Medication: Prescriptions limited to 100 day supply; three prescriptions, including refills for recipient per month.



$2.85 fee plus Estimated Acquisition Cost (EAC) or Maximum Allowable Cost (MAC) or Usual and Customary Charge, whichever is less.

Maintenance medications are reimbursed by the above formula once every thirty days per recipient per provider: any refills of maintenance medications within 30 days are reimbursed at cost only.

Co-payment: $0.75, except nursing home patients, under 18 years, family planning and pregnancy prescriptions.


1. Health and Welfare Department Officials:

Mary Mongan Acting Commissioner

Department of Health and Welfare

Health and Welfare Building Hazen Drive Concord, New Hampshire 03301 6031271 -4353

Philip Soule Administrator Office of Medical Services Division of Welfare

Clifford A. Zilch, P.D. Chief, Bureau of Medical Claims

Review Off ice of Medical Services Division of Welfare

Edward J. Pierce, P.D. Pharmaceutical Services Specialist Office of Medical Services Division of Welfare


This committee consists of 30 members representing providers and consumers of health care, as well as the various agencies interested in health care in the State.

NPC New Hampshire-3 1985

3. Executive Officers of State Medical and Pharmaceutical Services:

A. Medical Society: B. Pharmaceutical Association:

Palmer P. Jones Executive Officer New Hampshire Medical

Society 4 Park Street Concord 03301 Phone: 6031224-1 909

Maurice E. Goulet, P.D., M.S. Executive Director New Hampshire Pharmaceutical

Association 194 North Main Street

Concord 03301 Phone: 6031225-2231

C. Osteopathic Association: D. State Board of Pharmacy

William J. Kirmes. D.O. Secretary-Treasurer New Hampshire Osteopathic Assn. 13 North Street Manchester 03104 6031623-6757


Paul Boisseau, Secretary Health and Welfare Building Hazen Drive Concord, New Hampshire 03301 6031271 -2350

Paul Boisseau, Secretary Health and Welfare Building Hazen Drive Concord. New Hampshire 03301 6031271 -2350

NPC I

New Jersey- 1 19%

N E W J E R S E Y

M E D I C A L ASS ISTANCE DRUG P R O G R A M (T ITLE XIX)



D M AB APTD AFDC OAA AB APTD AFDC Children 21 iSFOl

Prescribed Druos

Hospital Care X X X X

Outpallent Hospila Care X X X X


Skilled Nursing Home Services X X X X Phvsician

Dental Services X X X X

Other Benefits: Home Health Agency Services, Independent Clinic Services. Podiatrist, Chiropractor. Optomelrlst and Optical Appliances. Ambulance and Invalid Coach, Medical Equipment and Prosthetic Devices.

'SF0 - State Funds Only (PAAD, Pharmaceutical Assistance to the Aged).

11. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending September 30. 1984


T O T A L . . . . . . . . . . . . . . . . . . . . . $67,421,822 484,755" $61,125,306 493,234

. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL $53,660,744 428,198 $48,869,000 437.859 Aged . . . . . . . . . . . . . . . . . . . . . . 9,008,458 27,818 8,010,000 27.287 Blind 251,791 892 225,000 857 Disabled. . . . . . . . . . . . . . . . . . . . . 18,213,167 49,949 15,413.000 47,237 Children-Families wIOep Children . . . . . . . . . . . . 12.121.532 225.802 11,375,000 233,421 Adults-Families wpep Children . . . . . . . . . . . . 14,065,796 123,731 13,844.000 129,057

CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . $13,761,078 65,731 12,255,000 64.982 Aged . . . . . . . . . . . . . . . . . . . . . . 10.008.465 24.996 9.020.000 24,487 Blind . . . . . . . . . . . . . . . . . . . . . . 12,803 47 11,000 41 i b l d . . . . . . . . . . . . . . . . . . . . . 1,890,677 4,505 1,648,000 4,271 Children-Families wiDep Children . . . . . . . . . . . . 877,715 19,645 777.000 19,946

. . . . . . . . . . . . Adults-Families w/Dep Children 338,915 7,797 320.000 8.145 . . . . . . . . . . . . . . . Other Title XIX Recipients 632,503 8,741 478.000 8.092

. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL $0 0 $0 0 A d . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0 Blind . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0 Disabled . . . . . . . . . . . . . . . . . . . . . 0 0 0 0 Children-Families w/Dep Children . . . . . . . . . . . . 0 0 0 0

. . . . . . . . . . . . Adults-Families w/Oep Children 0 0 0 0 . . . . . . . . . . . . . . . Other Title XIX Recipients 0 0 0 0

"*Undoplicaled Total - HHS report HCFA - 2082

New Jersey-2 1985


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


A. General Exclusions: Experimental drugs, antiobesics and anorexiants.

B. Formulary: None.


1. Quantity of Medication: The quantity of medication prescribed should provide a sufficient amount of medication necessary for the duration of the illness or an amount sufficient to cover the interval between visits, but may not exceed a 60day supply or 100 unit doses whichever is greater.

Exceptions:

a. Oral contraceptives may be prescribed for up to a 3-month supply.

b. Vitamins and vitamin-mineral combinations may be dispensed for up to a 100-day supply.

2. Refills: Prescription refills will be limited to 5 times within a 6-month period if so indicated by the prescriber on the original prescription.

Exceptions:

a. Oral contraceptives originally prescribed for a 3-month supply may be refilled 3 times within one year.

b. Vitamins and vitamin-mineral combinations originally prescribed for 100 day supply may be refilled 2 times within one year.

3. Dollar Limitations: None.


1. Payment for legend drugs, contraceptive diaphragms and reimbursable devices shall be based upon "Maximum Allowable Cost." or Average Wholesale Price minus 0-6%.

a. Maximum Allowable Cost is defined as:

(1) The "Maximum Allowable Cost" (MAC) price published by the Pharmaceutical Reimbursement Board of the Department of Health and Human Services for listed multi-source drugs or established by the Division of Medical Assistance and Health Services; or

. (2) The Average Wholesale Price (AWP) listed for the most frequently purchased package size (as defined by the N.J. Medicaid Program) in the current "Drug Topics Red Book" (published by Medical Economics Co.. Oradell. New Jersey 07649). and supplements; price changes listed by the same publisher in "Drug Topics Magazine" or other appropriate sources; or designated prices defined in section 10:51-1.6. In the case of unlisted or undesignated AWP "costs or of typographical errors, the known correct price will be used as maximum.

2. Maximum cost for each eligible prescription claim not covered by section 10:51-1.16(a)l shall be subject to the following fiscal conditions based upon six categories, as determined by the N.J. Medicaid program based on the previous year's total prescription volume for each participating pharmacy. The categories shall be reviewed annually and adjusted as appropriate.

a. To determine a provider's total prescription volume, which shall include all prescriptions filled, both new and refills, for private patients. Medicaid, PAA, and other third party recipients for the previous calendar year, each pharmacy provider shall submit in writing, an annual report certifying its prescription volume. Failure to submit this

NPC New Jersey-3 1985

report annually will result in the provider being placed in the maximum discount category (category VI) for the year of non-compliance, or until the required report is received.

Note: Those pharmacy providers who have been in business for less than one calendar year will have their prescription volume projected for the entire year, to determine the appropriate category.

b. Category I: Pharmacies whose total prescription volume in the preceding calendar year was not more than 14,999 prescriptions.

(1) Pharmacy providers in this category shall receive reimbursement for Medicaid prescription claims for legend drugs at average wholesale price (AWP), as defined in section 10:51-1.16a.. as the maximum.

c. Category II: Pharmacies whose total prescription volume in the preceding calendar year was at least 15.000 but not greater than 19,999 prescriptions.

(1) Pharmacy providers in this category shall receive reimbursement for Medicaid prescription claims for legend drugs at average wholesale price (AWP), as defined in section 10:51-1.16a. less two per cent, as the maximum.

d. Category Ill: Pharmacies whose total prescription volume in the preceding calendar year was at least 20,000 but not greater than 29.999 prescriptions.

(1) Pharmacy providers in this category shall receive reimbursement for Medicaid prescription claims for legend drugs at the average wholesale price (AWP), as defined in section 10:51-1.16a, less three per cent, as the maximum.

e. Category IV: Pharmacies whose total prescription volume in the previous calendar year was at least 30,000 but not greater than 39,999 prescriptions.

(1) Pharmacy providers in this category shall receive reimbursement for Medicaid prescription claims for legend drugs at average wholesale price (AWP), as defined in section 10:51-1.16a. less four per cent. as the maximum.

f. Category V: Pharmacies whose total prescription volume in the preceding calendar year was at least 40,000 but not greater than 49.999 prescriptions.

(1) Pharmacy providers in this cateogry shall receive reimbursement for Medicaid prescription claims for legend drugs at average wholesale price (AWP), as defined in section 10:51-1.16a, less five per cent, as the maximum.

g. Category VI: Pharmacies whose total prescription volume in the preceding calendar year was 50,000 prescriptions or more.

(1) Pharmacy providers in this category shall receive reimbursement for Medicaid prescription claims for legend drugs at average wholesale price (AWP), as defined in section 10:51-1.16a. less six per cent. as the maximum.

Notes: (1) If the published MAC price as defined in section 10:51-1.16(a)li is higher than the price which would be paid under section 10:51-1.16(a)lii. then section 10:51- 1.16(a)lii, will apply.

(2) The appropriate calculated discount will be automtically deducted (by Blue Cross of New Jersey) from each eligible legend drug claim during the claim processing procedures.

(3) For prescription drugs costing more than $24.99 there will be no discount from the average wholesale price (AWP).

New Jersey-4 1985

Dispensing Fee

The dispensing and services fee ranges from $3.53 to a maximum of $3.87 depending upon the number and types of services agreed to by the provider.

Service Fee

1. 24 hour emergency service availability 2. Patient Consultation 3. Impact Allowance

INCREMENT $0.1 1 $0.08 $0.1 5

In completing the Pharmacy Provider Service Agreement the provider agrees to provide all services at no additional charge to the Medicaid or PAA recipient. Under no circumstances are any additional administrative charges allowed.

The Pharmacy Manual further stetes the following: The maximum charge to the New Jersey Health Services Program for a legend drug may not exceed the lowest of the following:

a. Cost plus dispensing fee as outlined herein.

b. Usual and customary charges andlor posted or advertised charges.

c. Other third party prescription plan charges, when contracts or agreements to participate have been entered into subsequent to the adoption of this regulation.



Blue Cross of New Jersey 33 Washington Street Newark. New Jersey 07101

Number of Rx claims processed in FY 1984-6,905,548

Average Rx price during FY 1984-Retail: $10.54

Copayment: None

Medicaid Personal Physician Plan (MP Plan) Demonstration Project

The New Jersey Medicaid Program has implemented a four-year Statewide Competition Demonstration Project, called the Medicaid Personal Physician Plan (MP Plan), which will provide medical care in a manner different from the present Medicaid system. The Plan is classified as a Primary Care Network or a health care delivery system whereby all of the Medicaid elibible's health care is obtained through, but not necessarily from, a single primary care provider. It was developed under guidelines established by the Health Care Financing Administration for funding which led to the inclusion of the following key elements:

(1) a primary care physician who would be responsible for the provision of all primary care delivery, referral, and ancillary services for non-institutional Medicaid eligibles;

(2) a capitation system of reimbursement, instead of fee-for-service, for a physician participating in the Plan as a Physician Case Manager (PCM):

(3) a broker concept for marketing, enrollment, grievance system and quality asurance monitoring and Plan reporting functions;

(4) the stimulation of competition among certain types of Medicaid providers by providing strengthened alternatives to primary care in the hospital Emergency Room (ER) and Outpatient Department setting (OPD).

The role of Physician Case Manager has potential to (1) discourage doctor shopping, self-referral, and inappropriate and excessive utilization of Medicaid eligible services and (2) to effect better control over almost 500 million dollars of New Jersey Medicaid's total expenditures annually without reducing quality

NPC New Jersey-5 1985

or scope of care provided. This concept of the Physician Case Manager controlling costs has received wide s u ~ ~ o r t throughout the country since this role negates the need for increased government regulation and harsh budget caps

The MP Plan will be phased in throughout the State over a four-year period, or sooner if feasible. It will be implemented first in Morris, Sussex and Warren counties. Participating providers may be in solo practice; group practice; professional corporation or association; health maintenance organization (HMO); independent, free-standing clinic; or in a hospital affiliated entity which allows for primary care services and is not subject to DRG reimbursement principles.

The participation of physicians and Medicaid eligibles in the Demonstration Project is voluntary. A physician may participate in the MP Plan and continue to participate in the current Medicaid Program under the usual conditions.

Ofticlals, Consultants and Committees

1. Department of Human Resources Officials:

George J. Albanese Department of Human Services Commissioner Division of Assistance and

Health Services 324 East State Street P. 0. Box 2486 Trenton, New Jersey 08625

Thomas M. Russo Director

I. F. Erlichman Medical Director

Sanford Luger, R.Ph., Chief Pharmaceutical Services 6091292-3756

Division of Medical Assistance and Health Services

(same address as above)

2. Medical Assistance Advisory Council: (under revision)


A. Medical Society: C. Osteopathic Physicians & Surgeons Assn.:

Vincent A. Maressa Eleanore Farley Executive Director Executive Director Medical Society of New Jersey New Jersey Assn. Osteopathic Physicians 2 Princess Road and Surgeons Lawrenceville 08648 1212 Stuyvesant Avenue Phone: 6091896-1 766 Trenton 08618 6091393-81 14


Alvin N. Geser Robert J. Terranova Executive Off ~cer Executive Secretary New Jersey Pharmaceutical Assn. 1 100 Raymond Boulevard 118 W. State Street Newark, New Jersey 07102 Trenton 08608 2011648-2433 Phone: 6091394-5596

NPC New Mexico-1 1985

N E W M E X I C O



Type of Benef~t Categorically Needy Med~cally Needy (MN) Other'

O M AB APTD AFDC O M A0 APTD AFOC Chlldren 21 (SFO)


Inpatlent Hoso~tal Care X X X X X

Outpatlent Hosp~tai Care X X X X X

Laboratory 8 X-ray S e ~ l c e X X X X X

Sk~lled Nurslng Home Servlces X X X X X Physlclan Servlces X X X X X Dental Se~ lces X X X X X

Other Benefits: Private Duty Nursing. Home Health Services. Orthotic appliances and Prosthesis. Family Planning Services. Transporlatlon and Mainterme. Psychiatric and Psychological Services. Optometry. Podiatry.

'SF0 - Sfate Funds Only


1984 1983 Emended Reci~ient Emended Reci~ient - - - -

T O T A L . . . . . . . . . . . . . . . . . . . . . $9,427,783 59,873" $7,569,254 58,324

. . . CATEGORICALLY NEEDY CASH TOTAL Aged . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . Disabled

. . . . . Children-Families w/Dep Children

. . . . . Adults-Families w(0ep Children

CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aged

Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . Children-Families w/Dep Children Adults-Families w/Dep Children . . . . . . . . . . . .


. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . Children-Families w/Rp Children

. . . . . . . . . . . . Adult-Families w/Dep Children . . . . . . . . . . . . . . . Other Title XIX Recipients

$Not available




Department of Human Services.

IV. Provisions Relating to Prescribing Drugs:


1. Drugs for treatment of tuberculosis are not included.

2. Medications supplied by the New Mexico State Hospital to clients on convalescent leave from hospital are not included.

3. Drugs and immunizations available from any other source are not included.

4. Legend multiple vitamins, tonic preparations and combinations thereof with minerals, hormones, stimulants or other compounds which are available as separate entities for treatment of specific conditions.

5. Hematinics except non-sustained release forms of Ferrous Sulfate, Ferrous Gluconate. Ferrous Fumarate.

6. Amphetamines and combinations of amphetamines with other therapeutic agents; amphetamine-like sympathomimetic compounds used for obesity control including any combination of such compounds with other therapeutic agents.

7. Drugs classified by FDA as "Ineffective" or "Possibly Effective"

8. Hypnotic drugs.

9. OTC items with the following exceptions (the exceptions are covered by the program):

a. Insulin.

b. Antacids for active gastric and duodenal ulcers.

c. Infant vitamin drops for children up to one year of age.

d. Salicylates and acetaminophen.

e. Non-sustained release forms of Ferrous Sulfate, Ferrous Gluconate, Ferrous Fumarate.

B. Formulary: Open formulary subject to above-stated limitations. For formulary information contact:

Nick Army Medical Assistance Bureau P.O. Box 2348 Santa Fe, New Mexico 87504-2348 5051827-431 5


1. Quantity of Medication: 6 months supply maximum

2. Refills: Payment will be made to a particular pharmacy only three times for the same drug for the same client in any 90-day period.


1 . Prescriptions reimbursed at the lesser of the following:

a. Cost (MAC or EAC) dispensed plus fee ($3.65) or,

b. The usual and customary charge by the pharmacy to the general public


New Mexico-3 1985

Fiscal Intermedialy:

EDS Federal Corporation 4665 Indian School Road. N.E.. Suite A-1 14 Albuquerque. New Mexico 871 10

Number of Rx claims processed in FY 1984-789.822

Average Rx price during FY 1984-$12.79


1. De~artment of Human Services:

Juan R. Vigil Secretary

Jane Cotter Director Income Support Division

Bruce Weydemeyer Acting Bureau Chief Medical Assistance Bureau

Department of Human Services P. 0. Box 2348 SantaFe, New Mexico 87503 5051827-4315

F. Richard Atkinson Administrator Medical Assistance Bureau

Nick Army, R.Ph. Drug Program Administrator Medical Assistance Bureau

2. ISD Policy Advisory Committee Members:

(pending)

3. NMPHA Committee Third Party Payments:

Liaison Committee for NM Pharmaceutical Association meets each month.

Robert Ghattas. R.Ph. Neil Johnon, R.Ph. Durans Pharmacy Clinical Pharmacy 181 5 Central, N.W. 5002 Gibson, S.E. Albuquerque 87104 Albuquerque 87108 5051247-41 41

Victor Castillo. R.Ph. Robert Lee, R.Ph. Victor's Pharmacy Lee's Pharmacy 1643 lsleta, S.W. 4403 4th Street. N.W. Albuquerque 87105 Albuquerque 871 07 5051345-3533

Jack E. Hilligoss Executive Director, NMPHA 4800 Zuni. S.E. Albuquerque 871 08



A. Medical Society:

Ralph R. Marshall Executive Director New Mexico Medical Society 303 San Mateo Blvd., NE Albuquerque 87108 Phone: 5051266-7868


Jack E. Hilligoss Executive Director New Mexico Pharmaceutical Association 4800 Zuni. S.E. Albuquerque 87108 Phone: 5051265-8720


Thomas P. Thompson Executive Director New Mexico Osteopathic Medical Association P.O. Box 3096 Albuquerque 871 10 Phone: 5051299-8900


Olive Vaughn, Administrator 2340 Menaul. N.E. - Suite 216 Albuquerque. NM 87107 505/841-6311

NPC New York-I 1985

N E W Y O R K




O M AB APT0 AFDC OAA A8 APTD AFDC Children 21 (SF@

Prescribed ONQS X X X X x X X x X X inoatient ~ i s ~ i t a l Care X X X X X X X X X X

~ospi ta l Care X X X X X X X X X X

Laboratory & x-ray service x x x x x x x x x x Skilled Nursing Home Services X X X X X X X X X X Phwicim ". Services X X X X X X X X X X Dental Services X X X X X X X X X X

Other Benefits: Prosthetic and Onhotic deviceslsupplies; eye services; podiatry services: family planning; EPSDT (CHAP); clinics; private duty nursing in hospital selting; home care; transpollation; rehabilitation therapies


II. EXPENDITURES FOR DRUGS. Pavment to Pharmacists bv fiscal vear endina Se~tember 30. 1984

T O T A L . . . . . . . . . . . . . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . . Children-Families.w/Dep Children . . . . . . . . . . . . Adults-Families w/Dep Children . . . . . . . . . . . . Other

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

MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . A ~ e d . . . . . . . . . . . . . . . . . . . . . .

Disabled . . . . . . . . . . . Children-Families w/Deo Children . . ~ ~

Adults-Families w/Oep children Other Title XIX Recipients . .

"'Unduplicated Total - HHS repon HCFA - 2082

209

NPC New York-2 1985


State Department of Social Services.


A. General Exclusions: No restrictions except: (See V. Miscellaneous Remarks)

1. Prescribed vitamins and minerals not prescribed for medical necessity.

2. Amphetamines and other drugs whose sole clinical use is for reduction of weight.

3. Limited coverage of non-prescription drugs.

B. Formulary: Coverage of prescription drugs is limited to list of Medicaid Reimbursable Prescription Drugs. For information contact:

David G. Starks Medicaid Reimbursement Drug Lists Bureau of Standards Development New York State Department of Health Room 2074, Corning Tower Albany, NY 12237


1. Quadity of Medication: Drugs and sickroom supplies shall be prescribed in sufficient quantity consistent with the health needs of the patient and sound medical practice.

2. Refills: Refills cannot exceed 5, and the life of a prescription cannot exceed 6 months.



1. Maximum Reimbursable Pricing Schedule

Maximum reimbursement shall be based on the lowest of:

a. the maximum allowable cost (MAC) plus applicable dispensing fee; or

b. the estimated acquisition cost (EAC) established by the State, plus applicable dispensing fee; or

c. the usual and customary price charged by the pharmacy provider to the general public, including any sale price which may be in effect on the date of service.

2. Dispensing Fee, $2.60


The Medicaid drug list applies only to prescription andlor fiscal orders filled in community pharmacies.

Based on mandated payment criteria for prescription drugs, many non-essential and high priced drug products are excluded, e.g.. those not essential to sustain life, relieve or prevent severe pain, or prevent disease or continuing disability; sustained release medications; anti-flatulence products; cough enzymes; muscle relaxants: vitamins and vitaminlmineral preparations; and dermatologicals. Many combination drugs and comfort products are also excluded.


McAuto Systems Group, Inc. 800 North Pearl Street Albany, New York 12204

Copayment: None

Number Rx claims processed in FY 1984-17,928,987

New York-3 1985


O f clals, Consultants and Committees


Cesar A. Perales Commissioner

Mary Jo Bane Executive Deputy Commissioner

Robert Osborne Deputy Commissioner Division of Medical Assistance

Mildred B. Shapiro Associate Commissioner Division of Medical Assistance

Richard T. Cody Assistant Commissioner for

Eligibility Division of Medical Assistance

Ralph Pogoda Assistant Commissioner Standards and Operations

Gerard F. Nelligan, R.Ph. Associate Social Services

Medical Assistance Specialist 5181474-9261

Martin Roysher Associate Commissioner Program Analysis and Utilization

Review

2. Social Services Advisory Committees:

A.Medical Advisory Committee:

A. Medical Advisory Committee:

Ms. Beverly Hart Child Development Associate Comprehensive Interdisciplinary

Development Services 318 Madison Elmira 14901

Charles Barr, D.D.S. Director of Dentistry Beth lsreal Medical Center 10 Nathan D. Perlman Place New York 10003

Department of Social Services 40 North Fearl Street Albany, New York 12243 5181474-9130

David Axelrod, M.D. Commissioner New York State Department of Health Empire State Plaza Tower Building Albany 12237

Mr. Ebie Brown 115 Woodlawn Avenue. #2N Saratoga Springs 12866

NPC New York-4 1985

Beatrice Kresky. M.D., M.P.H., James G. Lione. M.D. Chairman New York State Chairman

Department of Ambulatory Care. . . . Flushing Hospital and Jamaica Hospital Medical Center Jamaica 11418 4500 Parsons Boulevard

Flushing 11 355

Elena Padilla. Ph.D. 3 Washington Square Village Apt. 15-0 New York 1001 2

Ms. Katherine Simmons Executive Director Visitin Nurse Association

of S 7 aten Island 400 Lake Avenue - Mariners Harbor Staten Island 10303

Mr. Ebun Adelona P.O. Box 1405 New York 10027

Arcy Degni. Secretary Treasurer New York State Building and

Construction Trades Council AFL-CIO 17 Jewett Place Utica 13501

Mrs. Gleniss Schonholz Administrator Long Island Jewish Hillside

Medical Center New Hyde Park 11042

3. Public Health Department:

David Axelrod, M.D. Commissioner 5181474-201 1

Harold Rakov, Professor 26 Coleman Creek Road Brockport 14420

Robert H. Randles, M.D. Medical Director St. Peter's Hosp~tal 315 South Manning Boulevard Albany 12208

Ms. Isabel Appellaniz Ridgewood Bushwick Senior

Citizen Council 319 Stanhope Street Brooklyn 11237

Rufus Nichols. M.D. 736 Eastern Parkway Brooklyn 11213

Ms. Marilyn Saviola Apt 1 l -H 175 Willoughby Street Brooklyn 11201

Department of Health Tower Building Empire State Plaza Albany 12237


A. Medical Society:

Edward Siegal Executive Vice President Medical Society of the State of New York 420 Lakevllle Road Lake Success 11042 Phone: 51 61488-61 00

NPC New York-5 1985


Executive Director (vacant) Pharmaceutical Society of the State of New York Pine West Plaza IV Washington Avenue Extension Albany. New York 12205 5181869-6595

C. Osteopathic Soc~ety:

8. C. Scharf, D.O. Executive Director New York State Osteopathic Medical Society, Inc. 1973 Morris Gate Seaford 11 783 5161826-2212


Dr. Albert J. Sica, Executive Secretary Cultural Education Center, Rm. 3035 Albany, New York 12230 5181474-3848

NPC North Carolina-1 1985

N O R T H C A R O L I N A



Type of Benefit Categorically Needy Medically Needy (MN) o the r

O M AB APT0 AFDC O M A8 APTD AFDC Children 21 (SFo)




7

X-ray Service X X X X X X X X X

Skilled Nursing Home Services X X X X X X X X X Physlc~an Servlces X X X X X X X X X Dental S e ~ ~ c e s X X X X X X X X X


It. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30. 1984

1984 1983 Expended Recipient - - Expended - Recipient -

T O T A L . . . . . . . . . . . . . . . . . . . . . $39,622,195 236,926.' $3Fb460 244,187'

CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . 23,116,546 171.562 21.639 192.567 Aoed . . . . . . . . . . . . . . . . . . . . . . 7,308.543 20,424 7.222 32.384

Disabled . . . . . . . . . . . . . . . . . Children-Families w/[)eo Children

Adults-~arnllies w/Dep children

CATEGORICALLY NEEDY NON-CASH TOTAL Aged . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . .

. . . . Children-Families w/Dep Children

. . . . Adults-Families w/Dep Children Other Title XIX Recipients . . . . . . .

MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . 14,949.788 49,855 12.420 55.105 Aged . . . . . . . . . . . . . . . . . . . . . . 11,451,299 32.340 9,602 35,628 Blind . . . . . . . . . . . . . . . . . . . . . . 117.801 379 109 536 Disabled . . . . . . . . . . . . . . . . . . . 2,717,869 8,217 2.189 9,154 Children-Families w/Dep Children . . . . . . . . . . . . 129.262 3,642 117 3.971 Adults-Families w1Dep Children . . . . . . . . . . . . 478,577 4.820 367 5,295 Other Title XIX Recipients . . . . . . . . 54.980 457 36 515


North Carolina-2 1985


Division of Medical Assistance, Department of Human Resources.


A. General Exclusions: No payment made for non-legend drugs, except insulin. Payment made for all legend drugs. Non-legend vitamins are excluded.

8. Formulary: None.



2. Number of Prescriptions:

a. Six per month per recipient.

b. Prescription Limit Exemptions for Certain Recipients

The General Assembly has determined that exemptions to the six (6) prescription limit per month may be authorized by the Department of Human Resources "where the life of the patient would be threatened without additional care." Therefore, patients being treated for the following illness should be excluded from the prescription limitation:

(1) End State Renal Diseases

(2) Chemotherapy and Radiation Therapy for Malignancy

(3) Acute Sickle Cell Disease

(4) Hemophilia

(5) End State Lung Diseases

(6) Unstable Diabetes

(7) Terminal Stage-any illness-life-threatening


4. Generic Substitution: Pharmacists must substitute generically if they have a generically equivalent product available in stock. The substituted product must be a lower cost product than the one originally prescribed.

5. Lock-In: Each recipient is locked into one pharmacy of his choice for one month, except in emergencies.

D. Prescription Charge Formula: The lowest price ~f MAC. EAC or AVVP, plus $3.36 dispensing fee for each different drug dispensed during a month, or the pharmacist's usual and customary charge. The pharmacist filling the original prescription will not be reimbursed for refills for the same drug within a calendar month. $0.50 co-payment/Rx (includes refills).

V. Miscellaneous

Fiscal Agent:

EDS Federal P.O. Box 300001 Raleigh, NC 27622

NPC North Carolina-3 1985


1. Department of Human Resources Officials:

Phillip J. Kirk, Jr. Department of Human Resources Secretary Albermarle Building

325 N. Salisbury Street Raleigh, North Carolina 2761 1

Barbara D. Matula Director

Paul R. Perruzzi Deputy Director

Jerry W. Wiley. M.D. Chief Medical Consultant

C. Benny Ridout. R.Ph. " Pharmacist Consultant 91 9/73-2833

Lillian J. Todd, R.N. Nurse Consultant

Betty King-Sutton. D.M.D. Dental Consultant

2. Department of Human Resources Advisory Committees:

A. Pharmaceutical Association, Third Party Committee

Division of Medical Assistance Kirby Building Raleigh, North Carolina 27603

William H. Brown Chairman 108 St. Andrews Drive Greenville, N.C. 27834 9191756-2877

Charles W. Burkett 9200 Deerpark Lane Charlotte 281 05 7041371 -8396

William H. Edmondson, Ph.D. P. 0 . Box 13408 Research Triangle Park 27709 9191248-2100

Lamar Creasman P.O. Box 1538 North Wilkesboro 28659

Joseph A. Edwards, Jr. 521 1 Coronado Drive Raleigh 27609

W. Darrell Estes 10321 Ram Road Raleigh 2761 2 9191781 -0161

James R. Hall Route 1, Box 45-8 Efland 27243 9191544-1 730

Clifford E. Hemingway 5615 Closeburn Road Charlotte 2821 0 7041554-71 66

Robert A. Leghart 623 Westlake Drive Amherst, Ohio 44001

Bob Lewis 719 Sandridge Road Charlotte 28210


Ginger Lockamy 670-8 Candlewood Drive Raleigh 27612 325 N. Salisbury Street Raleigh 2761 1 Bill Mast 950 Meadow Lane Henderson 27536

Ernest Rabil P.O. Box 5892 Winston Salem 27103 9191725-1 722

C. Benny Ridout Box 88 Morrisville 27560

B. Medical Society Committee on Social Service Programs (including Medicaid):

Hector H. Henry, II, M.D. (U) Chairman 102 Lake Concord Rd., N.E. Concord 28607

Edna M. Hoffman, M.D 348 Valley Road Fayetteville 28305

Campbell W. McMillan, MD (PHO) N.C. Memorial Hospital Chapel Hill 27514

W. Samuel Yancy. M.D. (PD) 306 S. Gregson St. Durham 27701

Consultants

Barbara D. Matula, Director Division of Medical Assistance 1985 Umstead Drive Raleigh 27603

Richard W. Furman, M.D. (TS) State Farm Road Boone 28607

Charles R. Martin, M.D. (PD) 120 Memorial Drive Jacksonville 28540

Betty L. Smith, M.D. (P) P.O. Box 925 Ellenboro 28040

Sarah T. Morrow, MD (PH) Medical Director EDS Federal Corporation 491 7 Waters Edge Drive Raleigh 27606

Lillian J. Todd, RN Nurse Consultant Division of Medical Assistance Raleigh 27603


A. Medical Society:

George E. Moore Executive Director N.C. Medical Society P.O. Box 27167 222 North Person Street Raleigh 2761 1 Phone: 9191833-3836

NPC


A. H. Mebane, Ill Executive Director N.C. Pharmaceutical Assoc. Box 151 Chapel Hill 27514 Phone: 9191967-2237

C. Osteopathic Society:

Guy T. Funk. D.O. Secretary-Treasurer North Carolina Osteopathic Society. Inc. Box 667 Advance 27006


David R. Work. Executive Director P.O. Box H Carrboro, NC 27510 91 91942-4454


NPC N o r t h Dakota-1 1985

N O R T H DAKOTA




O M AB APTD AFDC DAA AB APTD AFDC Children 21 (SFO)

Prescribed D r ~ ~ o n X X X X X X X X X

inpatient HosDital Care X X X X X X X X X

Hospital Care X X X X X X X X X

Laboratory & X-ray Servlce X X X X X X X X X

Skilled Nursing Home Serv~ces X X X X X X X X X Phvwan Services X X X X X X X X X Dental - - . . Services X X X X X X X X X

'SF0 - Slale Funds Only

11. EXPENDITURES FOR DRUGS. Pavment to Pharmacists bv fiscal vear endina June 30. 1984

T O T A L . . . . . . . . . . . . . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . .


. . . . . . . . . . . . . Adults-Families w/Dep Children

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

. . . . . . . . . . . . Adulls-Families wi&p Children Other Title XIX Recipients . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL A d . . . . . . . . . . . . . . . . . . . . . .


B i d . . . . . . . . . . . . . . . . . . . . . . 3,806 7 Disabled . . . . . . . . . . . . . . . . . . . . . 350.930 873 Children-Families w/De~ Children . . . . . . . . . . . . 25.874 688 - - ~

Adults-Families w/&p children Other Title XIX Recipients . .



NPC North Dakota-2 1985


North Dakota Department of Human Services



1 . Anorectics 2. High protein weight reduction supplements 3. Investigational drugs 4. Drugs which have questionable therapeutic value 5. Drugs which are not indicated for the diagnosis 6. DESl (Less-Than Effective) drugs

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.

Acquisition Cost: EAC or MAC. EAC is North Dakota AWP


Copayment-No.

Number of Rx claims processed in FY 1984-414,023


Officials, Consultants and Commlttees


John Graham Executive Direct01

LeRoy Bollinger, Administrator Research and Statistics

Richard Myatt, Director Medical Services

- -€heelwhs7ETY Administrator Pharmacy Services 7011224-4023

North Dakota Department of Human Services

Capitol Building Bismarck, North Dakota

58505

2. Department of Human Services Advisory Committees:

NPC North Dakota-3 1985

A. Medical Care Advisory Committee:

Joe Pratschner (Health Dept. Designee) Director of Health Facilities State Department of Health 1200 Missouri Avenue Bismarck 58505 7011224-2352

Bruce Hetland. M.D. Mid-Dakota Clinic Ninth and Rosser Bismarck 58505 7011223-01 50

Bernice Englehorn 801 112 Collins Avenue Mandan 55401 7011663-2181

Fred Hulet 116 W. Thayer Avenue Bismarck 58501 7011223-4131

Bill Congdon, D.D.S. 810 E. Rosser Avenue Bismarck 58501 7011258-1321

Jon Thomas Community Action Program

Region VII 2105 Lee Avenue Bismarck 58501 7011258-2240

B. Commission on Socio-Ecomrnic Affairs:

N. E. Byestol. M.D. Chairman Dakota Clinic, Ltd. Fargo 581 08

J. J. McLoed, Jr., M.D. ke-chairman Orthopardic Cl~nic. P.C Grank Forks 58201

J. E. Adducci, M.D. Box 2438 Williston 58801

Bertha Gipp, R.N. Maternal and Child Health

Division State Department of Health Bismarck 58502 701B24-2493

Patricia Kramer, R.Ph Bismarck Hospital 300 North Seventh Bismarck 58501 701 1224-6000

Val Rieder New Rockford 58356 7011947-2936

Ron Row, M.S.W. Social Work Department St. Alexius Hospital Ninth and Rosser Bismarck 58501 701 1224-7000

Jack Heyne Center for Independent Living 109 First Street, N.W. Suite 101 B MSB Bldg. Manden 58554 7011663-0376

Carter Pendergast N.D. Group Management Assoc. Quain & Ramstad Clinic 221 North Fifth Bismarck 58501 7011222-5200

C. S. Hamilton. Jr., M.D Fargo Clinic Fargo 58123

K. S. Helenbolt, M.D. Blue Shield-ND 4510 13th Avenue, SW Fargo 58121

J. R. Herr, Jr., M.D. 1213 15th Avenue West Williston 58801

North Dakota-4 1 985

F. M. Carter. M.D. Grand Forks Clinic, Ltd Grand Forks 58201

J. H. Coffey, M.D. Fargo Clinic Fargo 581 23

B. L. Dahl. M.D. West Fargo Medical Center West Fargo 58078

H. W. Evans. M.D. Grand Forks Clinic. Ltd. Grand Forks 58201

M. M. Fiechtner, M.D. Quain & Ramstad Clinic Bismarck 58202

W. J. Norberg, Jr., M D Fargo Clinic Fargo 581 23

R. L. Odegard, M.D. Medical Arts Clinic Minot 58701

N. B. Ordahl, M.D. Box 1348 Dickenson 59601

D. M. Pfeifle, M.D. Quain & Ramstad Clinic Bismarck 58502

C. Pharmacy Advisory Committee:

M ~ N Tokach, Chairman #1 Riverview Lane Jamestown 58401

Gordon Mayer 708 Birch Avenue Harvey 58341

Duane McCullough 422 Main Oakes 58474

ENin Reuther 701 Third Street Langdon 58249

D. L. Lamb, M.D. #504 Professional Bldg. Fargo 58103

R. S. Larson, M.D Box A Velva 58790

0 . V. Lindelow, M.D. Mid Dakota Clinic Bismarck 58502

R. F. Miller, M.D. Medical Arts Building Bismarck 58501

R. F. Morgan. M.D. 316 N. 10th Street Bismarck 58501

T. M. Polovitz, M.D. Valley Medical Associates Grand Forks 58201

D. A. Rinn, M.D. UND Family Practice Center Minot 58701

C. R. Thueson. M.D. Dakota Clinic, Ltd. Fargo 58108

Dave Just Box 99 Beulah 58523

Ryn Olig 43 Prairiewood Circle Fargo 58103

Thomas G. Pettinger (Ex-Officio) 214 Forest Avenue N. Fargo 58102

John F. Schuld (Ex-Officio) Box 148 Dickinson 58601

North Dakota-5 1985

Michael J. Berg Elroy Herbel 1308 1 l t h Street, S.W. Box 10 Minot 58701 Elgin 58533

Richmond H. Lapp 1467 Hill Avenue Gratton 58237



Vernon Wagner Executive Vice President North Dakota Medical Association 810 East Rosser Avenue Box 1 198 Bismarck 58501 Phone: 7011223-9475


John Schuld Secretary-Treasurer North Dakota Pharmaceutical Association P. 0 . Box 148 Dickinson 58601 Phone: 7011225-8650


Harry Homewood, D.O. Secretary-Treasurer North Dakota State Osteopathic Association Box 51 6 Valley City 58072


William J. Grosz, Executive Secretary P.O. Box 1354 Bismark 58502 701 1258-1535

OHIO




O M AB APT0 AFDC O M AB APT0 AFDC Children 21 (SF4




Laboratow 8 X-ray service X X X X

Skilled Nursing Home Services X X X X Physician Services x x X X Dental


II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by tiscai year ending September 30. 1984

1984 1983 Expended Recipient Expended - - - Recipient -

T O T A L . . . CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . Aged

. . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . Disabled


. . . . . . . . . . . . Adults-Families w l h p Children

. . . . . . . . CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . . . . . . . . . . . . . . . . Aged Not available . . . . . . . . . . . . . . . . . . . . . . Blind

. . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . Children-Families w/Dep Children . . . . . . . . . . . . Aduik-Families w/Dep Children


MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind

Disabled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Children-Families w / h p Children . . . . . . . . . . . . Adulk-Families w/Dep Children


"'Unduplicated Total - HHS repolt HCFA - 2082


Ohio Department of Human Services


A. General Exclusions: For prescription legend and/or OTC drugs not listed in the formulary, pharmacist should obtain authorization before filing claim for payment.

B. Formulary: Yes. 1700 drug products.

Contact Person: Robert P. Reid, R.Ph. Bureau of Medicaid Policy 30 E. Broad Street. 31st Floor Columbus, Ohio 43215 6141466-6420

To promote economies in the drug program, practitioners are encouraged to prescribe by generic name those drugs which consistently demonstrate therapeutic effectiveness and are produced by pharmaceutical manufacturers with strict quality controls. In filling such generic prescriptions the pharmacist is expected to dispense the least expensive drug available in his stock. The maximum price allowed for such generics will be an amount closely related to items obtained from generic manufacturers usually associated with wholesale drug houses.

A drug code is listed in the Ohio Welfare Drug Formulary for each form of generic drug. Trade names for these 564 drug items are also contained in the formulary.


1. Quantity of Medication:

a. 34-day supply or 100-dosage units (whichever is greater).

b. Amount designated in Ohio Welfare Formulary.

2. Refills: Up to 5 refills. After 5 refills or 6 months (whichever is first) a new prescription is necessary.


1. Legend drugs and selected OTC products in community pharmacies.-Reimbursement is based on the lowest of:

a. the provider's reasonable and customary charge to the public;

b. the Department's Estimated Acquisition Cost (EAC) (AWP minus 7% plus a dispensing fee; or

c. the lowest federal- or state-established Maximum Allowable Cost (MAC), for specifically de~ginated generically equivalent drugs plus a dispensing fee.

2. Nonlegend drugs in community pharmacies.-Reimbursement is based on EAC plus a dispensing fee.

Dispensing Fee: $2.60 (effective 7/1/78)



Patricia Barry Department of Public Welfare Director 30 East Broad Street, 32nd flr.

Columbus. Ohio 43215

NPC

Art Evans Assistant Director

Paul Offner Deputy Director of

Medicaid Administration

Kathi Glynn Acting Deputy Director for

Program Development

Bureau of Medicaid Policy Kenneth C. Page Bureau Chief

Robert P. Reid. R.Ph. Pharmacist Consultant

Joel Fisher Program Planner for

Pharmaceutical Services

Division of Medfcal Assistance Stanley D. Sells Division Chief 6141466-2365

Richard Gleckler, R.Ph. Bureau Chief Bureau of Medical Operations

Philip J. Rogers. R.Ph. Pharmacy Consultant Bureau of Medical Operations

Department of Human Services 30 East Broad Street. 31st Floor Columbus. Ohio 43215

Department of Public Welfare 30 East Broad Street, 31st flr. Columbus. Ohio 43215


A. Medical Association B. Pharmaceutical Association

Hart F. Page Philip W. Cramer Executive Director Executive Director Ohio State Medical Association Ohio State Pharmaceutical Association 600 South High Street 395 E. Broad Street. Suite 320 Columbus 43215 Columbus 43215 Phone: 6141228-6971 Phone: 61 41221 -2391

C. Ohio Osteopathic Association D. State Board of Pharmacy

Jon F. Wills 53 W. 3rd Avenue Columbus 43201 Phone: 6141299-2107

Franklin Z. Wickharn. Executive Director 65 South Front Street, Room 504 Columbus, Ohio 43215

ind6141466-4143

NPC

O K L A H O M A



Type of Benefit Categoricaly Needy Medically Needy (MN) Mher*

OAA AB APTD AFDC OAA A8 APTD AFOC Children 21 (SFOI

Prescribed Drugs X X X X X X X X X Inpatient Hospital Care X X X X X X X X X Outpatient Hos~ital Care X X X X X X X X X Laboratory & X-ray service X X X X X X X X X Skilled Nursing Home Senwes X X X X X X X X X Physlcian Services X X X X X X X X X Dental Services X X X X X X X X X

Other Benelits: Medically Needy (MN) are eligible i f within catastrophic illness determination according to Deparlment definition and il otherwise eligible.


II. EXPENDITURES FOR DRUGS. Pavment to Pharmacists bv fiscal vear endino June 30. 1984

TOTAL

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

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

MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . . Children-Families w/Dep Children . . . . . . . . . . . . Adulls-Families w/Deo Children . . . . . . . . . . . . Other Title XIX ~ecipi ints . . . . . . .

1984 1983 Expended Recipient Expended - - - Recipient -

$76,535,307 117,002" $74,775,001 107,971

'YJnduplicated Total - HHS repon HCFA - 2082


Oklahoma Department of Human Services (DHS)


Formulary: Yes. Oklahoma List of Covered Drugs

Contact: Box 53034 Oklahoma City, Oklahoma 73152

H. W. Stansberry

4051521 -3804

Provider Participation:

1. Pharmacy or Pharmacist:

Any pharmacy or pharmacist who has current license with the Oklahoma State Board of Pharmacy and is free from any Pharmacy Board restrictions shall be entitled to be a participating provider under this program.

2. Prescribing Practitioners:

Prescribing practitioners, authorized and licensed to practice the healing art as defined and limited by Federal and state laws who choose to provide their own pharmaceuticals, may not be participating providers at the present time.

3. Reimbursement Fee:

Estimated Acquisition Cost (EAC) plus maximum dispensing fee of $3.55 effective 11/1/81. In no event shall charges to the Welfare Department exceed charges made to the general public for the same prescription or item.

4. Categories of Drug Coverage (Revised 1/1/80)

Those drugs that are compensable under each category are specified individually by trade name; otherwise by generic name only.

Antidiarrheals Antiparkinsonism Antidepressants Broncho-Dilators and Antiasthmatics Opthalmic Antiarthritics Antibiotics (Oral and lnjection) Antibacterials (Oral and Injection) Glaucoma Drugs Otic Antigout Antineoplastics (Oral and lnjection) Birth Control Analgesics Anticonvulsants Antinauseants, AntivertigoIAntiemetic Insulin and Antidiabetics Drugs Cardiovascular-Broad and Potassium Preparation Antifungal Specialized Preparations

5. Prescription Limitations:

Three prescriptions per monthlrecipient.

NPC

6. Quantities:

34-day supply or 100 dosage units, whichever is greater. 5 b C S$W h ~ C P

7. Legend, Non-Legend and Generic Drugs: CIP.I-J @nbcar,<

Only legend drugs in the designated categories and insulin are covered in the program.

8. Refills:

Refills shall be provided only if authorized by the prescriber, no more than five times within a 6- month period.

V. Miscellaneous:





Robert Fulton Director

Michael Fogarty Assistant Director Medical Services Administration

Howard Stansberry Pharmacy Program Administrator Program Coordinator 4051521 -3804

Department of Human Services Sequoyah Memorial Office

Bldg. (P. 0 . Box 25352) Oklahoma City, Oklahoma

731 25

Department of Human Services 4001 Lincoln Boulevard Oklahoma City. OK 73105

Department of Human Services P.O. Box 53034 Oklahoma City, OK 73152

2. Advisory Committee on Medical Care for Public Assistance Recipients:

Robert Sukman, M.D. Chairman

3330 N.W. 56th #206 Oklahoma City, OK 731 12

3. Executive. Officers of State Medical, Pharmaceutical, and Osteopathic Societies:


David Bickham Bob E. Jones Executive Director Executive Director Oklahoma State Medical Assn. Oklahoma Osteopathic Assn. 601 N. W. Expressway Citizens Bank Tower Building Oklahoma City 731 18 2200 Classen Boulevard Phone: 4051843-9571 Oklahoma City 73106

Phone: 4051528-7095 B. Pharmaceutical Association: D. State Board of Pharmacy

John D. Donner Joe Schwemin, Executive Secretary Executive Director 4545 N. Lincoln, Suite 112 Oklahoma Pharmaceutical Association Oklahoma City, OK 73105 Box 18731 4051521 -381 5 Oklahoma City 73154 Phone: 4051528-3338

NPC

O R E G O N




O M AB APT0 AFOC OAA AB APT0 AFOC Children 21 (SFO)

Prescribed Drugs X X X X X X X

Inpatient Hospital Care X X X X X X X

Outpatient Hospital Care X X X X X X X

Laboratory & x-ray ~ e i i c e x x x x x x x Skilled Nursing Home Services X X X X X X Physician Services X X X X X X X Dental Se~ lces X X X X X X

Other Benelits: Visual Care. Medical Transportation. Medical Supplies/Equipment. Physical Therapy. Fudiatrist. Chiropractor. Naturopath. ICF. Family Planning, Abortions, home health agency, Private duty nurse, EPSOT.

'SF0 - State Funds Onlv


Exoended

. . . . . . . . . . . . . . . . . . . . . T O T A L $1 4,803,643

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


. . . . . . . . . . . . Children-Families wIOep Children Adults-Families wIOep Children . . . . . . . . . . . . Other Title XlX Recipients . . . . . . . . . . . . . . .

MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . . Children-Families w/Dep Children . . . . . . . . . . . .


1984 1983 Recioient Exoended Recioient - - 97,454 $14,521,924

Not avail. 8.093.608 1,453,587

206,097 2,976,040 1.153.987 2.303.897

"'Unduplicated Total - HHS report HCFA - 2082


Adult and Family Services Division, Department of Human Resources.


A. Formulary: An open "formulary" except as noted below.

B. Non-Formulary: Prior approval from state reviewing physician must be obtained for minor tranquilizers other then (gener~c) meprobamate or chlordiazepoxide, and amphetamines and amphetamine derivatives, isotrenition, legend laxitives, and for certain non legend items.


1. Quantity of Medication: Not to exceed 100 days supply, except topical preparations, sprays, aerosol inhalers, and similar preparations.

2. Refills-Schedule Ill, IV, or V drugs are limited to 5 refills.



Payment is the lowest of: (a) usual and customary charges to general public, (b) Maximum Allowable Cost (MAC) plus dispensing fee of $3.57, (c) Estimated Acquisition Cost (EAC) plus dispensing fee of $3.57.

Nursing home drug reimbursement is based upon a capitated fee of $0.58 per day per eligible -or fee system.




State MAC program for approximately 292 drugs.


1. Leo T. Hegstrom Director

Keith Putnam. Administrator Adult and Family Services Div

Department of Human Resources 318 Public Services Building Salem, Oregon 97310 5031378-2263

Byron Carpenter Assistant Administrator Health and Social Services Section

Kim Scranton Assistant Administrator Field Operations Section

Leonard T. Sytsma Assistant Administrator Support Services Section

Michael Kane Assistant Administrator Income Maintenance Section

NPC

Vern Fisher Assistant Administrator Business Services Section

Charles N. Mortensen, R.Ph Pharmacy Consultant

2. Consultants to Health and Social Services Section:

Richard J. Cook, D.D.S Robinhood Prof. Bldg. 18603 Pacific Highway West Linn 97068

William Dettwyler, M.T. 5555 Sunnyview Road, NE Salem 97303

William Henry, ND (Naturopath) 1920 North Kilpatrick Portland 9721 7

Donald Charlton. DMD (Dental)

943 Liberty Street, SE Salem 97302

Merle Berry. O.D. (Optometric)

Albany Optometric Center 225 W. 2nd Albany 97321

203 Public Service Building Salem, OR 97310 5031378-2763

Alfred Scheff, M.D. (Chief Medical Advisor) 1625 Commercial St., SE Salem 97302

Robert W. Staley, D.D.S. 1075 Hansen Avenue S. Salem 97302

Dr. Jan lsselman 1320 Lewis Street. S.E. Salem 97302

Ranvir Sinanan, M.D. 203 Public Service Building Salem 97310

Chuck Mortensen (Pharmacist Consultant) 203 Public Service Building Salem 97310 5031378-2263

Dan Campbell. D.D.S. C/O Lebanon Branch, AFS P. 0. Box 456 Lebanon 97355

3. Division Advisory Committees: Governor's Advisory Committees on Medical Assistance

for the Underprivileged MEMBERS

Charles Ross Anthony Public-economics 344-1982 2590 Van Ness 484-0709 Eugene 97403 (home)

Daniel Billmeyer, MD 406 7th Street Oregon City 97045

Roderick Bunnell P.O. Box 1071 Portland 97207

Physician

Industry

232

James E. Creswell, DMD Route 3, Box 428 Klamath Falls 97601

Sister Monica Heeran Sacred Heart Hospital P.O. Box 10905 Eugene 97440

Joan E. Krahmer 614 East Main Hillsboro 97123

Frank McBarron 2225 Loyd Center Portland 97232

Dennis Marsh 1015 Cornell Avenue Gladstone 97027

Judge Earle C. Misener 410 H. Avenue LeGrande 97850

Larrie Noble, R.N 1 1750 SW 72nd Tigard 97223

Rhese Penn, MD Health Division 1400 SW Fifth Avenue Portland 97201

Katherine A. Ricker 7458 N. Polk Portland 97203

Ruth Slick, RN 221 Quarry Street Oregon City 97045

Dwight Quisenberry R.Ph. 850 Prospect Place, S. Salem, OR 97302

Dentist

Hosoital Administrator

Public-Mental Health

Physician

Medical Profession-Other Ambulance

Oregon Counties

Nursing Profession

Director, Maternal and Child Health

Public-Recipient

Nursing Home Administrator

Pharmacist

NPC

4. Executive Officers of State Medical, Pharmaceutical and Osteopathic Associations:

A. Medical Association: B. Pharmaceutical Association

Robert L. Dernedde Executive Director Oregon Medical Association 5210 SW Corbett Street Portland 97201 Phone: 5031226-1 555

Executive Secretary Oregon State Pharmaceutical Assn. 1460 State Street Salem 97301 Phone: 5031585-4887

C. Osteopathic Association: D. State Board of Pharmacy

Jeff Heatherington Executive Director Oregon Osteopathic Association 9221 SW Barbur, Suite 301 Portland 97219 5031244- 7592

Ruth Vandever, Executive Director P.O. Box 231 State Office Building, Room 904A 1400 SW 5th Avenue Portland 97207 5031229-5849

NPC

PENNSYLVANIA




OAA AB APTD AFDC O M AB APTD AFDC Children 21 (SFO)



Outpatient Hospilal Care X X X X X X X X X X


Skilled Nursing Home Services X X X X X X X X X X Physician Services X X X X X X X X X X Dental Services X X X X X X

Other Benefits: Family Planning. Home Heallh Care, Ambulance. Clinics ICF Service, Hospital Home Care. Durable Medical Equipment. Prosthetics, Inpatient Psychiatric Care. School Medical.


II. EXPENDITURES FOR DRUGS. Payment lo Pharmacists by fiscal year ending September 30, 1984.

T O T A L

. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . .



. . . . . . . . CATEGORICALLY NEEDY NON-CASH TOTAL Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . .



. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . .




$87,570,986 802,731

$64,757,633 678,412 12,227,180 48,815

373,499 1,598 25,333,322 92,768 10,014,759 332,065 16,808,873 214,410


NPC


Office of Medical Assistance, Department of Public Welfare.


A. General Exclusions: Payment will not be made to any pharmacy for the following services and items:

1. Methadone for any use.

2. Drugs for treatment of pulmonary tuberculosis. However, those tuberculosis drugs which are prescribed for the prevention of meningococcal meningitis are compensable if the diagnosis appears on the prescription.

3. Drugs and other items prescribed for obesity, appetite control, cessation of smoking or other similar or related habit-altering tendencies. However, drugs which have been cleared for use in the treatment of hyperkinesis in children and primary and secondary narcolepsy due to structural damage of the brain are compensable if the physician indicates the diagnosis on the the original prescription.

4. Non-legend drugs in the form of troches, lozenges, throat tablets, cough drops, chewing gum, mouth washes and similar items.

5. Pharmaceutical services provided to a hospitalized person.

6. Single entity and multiple vitamins except for the following:

a. Single entity and multiple vitamin preparations with or without fluorides for children under three (3) years of age.

b. A prescription drug product which contains a single entity vitamin combined with a legend drug.

C. Vitamin D and its analogs.

d. Nicotinic acid and its amides.

e. Vitamin K and its analogs.

f. Folic Acid

g. Single entity and multiple vitamin preparations when prescribed for prenatal use.

7. Drugs and devices classified as experimental by the FDA.

8. Drugs and devices not approved for use by the FDA.

9. Placebos.

10. Legend and non-legend soaps, cleansing agents, dentifrices, mouth washes, douche solutions, ear wax removal agents, deodorants, liniments, antiseptics, emollients, and other personal care and medicine chest items.

11. Legend and nonlegend agueous saline solutions for use other than for intravenous administration.

12. Legend and non-legend water preparations such as distilled water, water for injection, and identical, similar or related products.

13. Food supplements and substitutes.

14. Compounded prescriptions when:

a. Cornpensable items are used in less than therapeutic quantities, or

b. Noncompensable items are compounded.

15. Non-legend drugs not listed in the Appendix to Chapter 1121.

NPC

16. Drugs prescribed in conjunction with sex reassignment Procedures or other noncompensable surgical procedures.

17. The following items when prescribed for recipients in a skilled nursing and intermediate care facility services:

a. Intravenous solutions.

b. Noncompensable drugs and items as specified in this section.

c. The following non-legend drugs:

(i) Analgesics (ii) Antacids (iii) Antacids with simethicone (iv) Cough and cold preparations (v) Contraceptives (vi) Laxatives and stool softeners (vii) Ophthalmic preparations (viii) Diagnostic agents

18. Items prescribed or ordered by a prescriber who has been barred or suspended from participation in the Medical Assistance Program. The Department will periodically send pharmacies a list of the names of suspended, terminated or reinstated practitioners and the dates of the various actions. Pharmacies are responsible for checking this list before filling prescriptions.

19. Prescriptions or orders filled by a pharmacy other than the one to which a recipient has been restricted. The Department will issue special medical services eligibility cards to resricted recipients indicating the name of the pharmacy to which the recipient is restricted. Pharmacies are responsible for checking the recipient's Medical Services Eligibility Card before filling the prescription.

20. DESl Drugs and identical, similar or related products or combinations of these products.

21, Impregnated gause and identical, similar or related products.

22. A pharmaceutical service for which payments is available from another public agency or another insurance or health program except for those drugs prescribed through the county mental/mental retardation programs.

B. Formulary: None


1. Quantity of Medication: the quantity to be dispensed is as prescribed by the physician, not to exceed a 34 day supply or 100 units, whichever is greater.

2. Refills: Prescriptions may be refilled, as long as total authorization does not exceed a 6 months' or 5-refill supply from the time of original prescription.

3. Limitations on Dispensing Fees: payment to a pharmacy for prescriptions dispensed to a recipient in either a skilled nursing facility, an intermediate care facility, or an intermediate care facility for the mentally retarded are limited to one dispensing fee per drug per 30 day period. For the purposes of this limitation, a drug is defined as an entity or dosage form which has the same active ingredient in the same strength or the same combination of ingredients in the same strengths. This limitation does not apply to:

a. Antibiotics b. Anti-infectives c. Schedule II and Ill analgesics d. Topical and injectable preparations dispensed in the manufacturer's original package

size e. Ophthalmic and otic preparations dispensed in the manufacturer's original package size

f. Compensable compounded prescriptions g. Insulin

4. Dollar limits: none

D. Drug Cost Determination:

1. Payment for compensable legend drugs is based on the current Estimated Acquisition Cost (EAC) established by the Department.

a. The EAC for legend and non-legend drugs is found by taking the current Drug Topics Red Book Average Wholesale Price (AWP) for the drug in the most common package size.

b. The most common package size, for the purposes of finding the EAC, will be the same as that used by the Department of Health and Human Services.

c. The manufacturer's direct price will be used to find the EAC for a drug when:

(i) The Drug Topics Red Book AWP is not available; or (ii) The drug is only available directly from the manufacturer and not through a

wholesaler.

2. In cases where the EAC exceeds the Maximum Allowable Cost (MAC), the MAC will apply.

3. The EAC for individual drugs will be updated on a monthly basis as it appears in the Drug Topics Red Book or its supplements.

E. Prescription Charge Formula:

1. On May 16. 1981. Pennsylvania revised its payment methodology to pharmacies. This revised payment methodology, which has been approved by the federal government as part of the State's approved State Plan, recognizes a difference between a pharmacy's usual and customary charge to the self-paying public and the pharmacy's usual and customary charge to third party payors. The "self-paying public" is defined as all persons whose costs for prescribed drugs are not covered by a third party payor. "Third party payors" are defined as public or private health insurance plans or programs which make payments to pharmacies on behalf of eligible recipients or beneficiaries. As a result of this revised payment methodology, pharmacies are reimbursed an additional amount not to exceed 25 cents for each welfare prescription that would ordinarily be paid on a usual and customary basis. The amount of the total payment will not exceed the cost of the drug plus the dispensing fee.

2. A licensed retail pharmacy's maximum reimbursement for all compensable legend and nonlegend drugs shall be the cost of the drug plus as2.75 dspensing fee or the pharmacy's usual and customary charge to third party payors, whichever is lower. For purposes of Medical Assistance reimbursement, the usual and customary charge to third party payors may not exceed 25 cents per prescription higher than the usual and customary charge to the self-paying public. The cost of the drug shall be either the MAC, EAC, or AWP. Although payment shall be made in accordance with this method of payment, the pharmacy is required to bill the Department at its usual and customary charge to the self-paying public.

3. For compound prescriptions, an additional fee of $1.00 is allowed to a pharmacy, bringing the total dispensing fee to $3.75. A compound prescription for the purposes of medical assistance payment is one which is prepared at the time of dispensing and involves the weighing of at least one solid ingredient which must be a compensable item or a legend drug in a therapeutic amount.

4. The MAC program has been in effect since September 1, 1978.

5. The EAC program has been in effect since July 1, 1984.

V. Copayment $0.50

On September 1. 1984, Pennsylvania implemented a 50 cent copayrnent for each prescription, new or refill, received by a recipient. The copayment will not apply to those recipients who are federally

238

NPC Pennsylvania-5 1985

exempt, under 21 years of age, pregnancy cases and long-term care patients, plus patients receiving drugs in the following categories:

1. Antihypertensive agents 2. Cardiovascular preparations 3. Antiphychotic agents (excluding Schedule C-IV anti-anxiety agents 4. Antidiabetic agents 5. Anticonvulsants 6. Antineoplastic agents

7. Antiglaucoma agents 8. Antiparkinson agents

VI. Recipient Lock-In Program.

A. Approximately 3,058 recipients were restricted to a pharmacy as of June 30. 1985.

B. Approximately 1,310 recipients were restricted to both a pharmacy and a physician as of April 30. 1985

C. Savings per recipient is $42.00 per month for reduced utilization of drug services.

D. Savings per recipient is $83.00 per month for reduced utilization of physician and drug services.

E. Parameters used for the profiles are:

1. $250 for drug services for a three month period 2. 25 prescriptions in three months 3. Three or more pharmacies or other provider types 4. 180 or more disposable syringes in three months.

VII. Miscellaneous

A. Fiscal Intermediary

The Computer Company' 5101 Jonestown Road Harrisburg. Pennsylvania 171 12

The Computer Company's chief responsibility is clerical in nature and deals with claims 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.

B. Number of Rx claims approved in FY 1984-13,815,483'

C. Average amount paid per claim during FY 1984-$8.72*

'Source: Pharmacy, all services, MRS 300, June, 1984.



Walter W. Cohen Secretary

Department of Public Welfare Health and Welfare Building Harrisburg, Pennsylvania 17120

Brian T. Baxter Executive Deputy Secretaly

Gerald F. Radke Deputy Secretary for Medical

Assistance

NPC

David S. Feinberg Director Bureau of Pblicy and Program

Development

Richard H. Lee Director, Bureau of

Reimbursement Methods

Robert B. Kelly Director. Bureau of Medical

Assistance Operations

Glenn Johnson Director, Bureau of

Utilization Review

Eileen M. Schoen Director Bureau of Provider Relations

2. Consultant Pharmacists:

Joseph E. Concino. R.Ph. Bureau of Policy and Program

Development 7171787-1170

William M. Peifer, R.Ph. Bureau of Medical Assistance

Operations

Robert G. Dissinger, R.Ph. Bureau of Medical Assistance

Operations

S. Charles Modica. R.Ph. Bureau of Medical Assistance

Operations

John Ferrara, R.Ph. Bureau of Utilization Review

Michael A. Bimler, R.Ph. Bureau of Utilization Review

Frank Cwynar. R.Ph. Bureau of Utilization Review

Department of Public Welfare Park Penn Building Harrisburg 171 12

Department of Public Welfare Park Penn Building Harrisburg 171 12

Department of Public Welfare 25 North 32nd Street fihskip lem Camp Hill 17011

John Hocker, R.Ph. Bureau of Utilization Review

NPC


Member

James M. Redmond Vice President, Hospital Services Hospital Association of Pa. P.O. Box 608 Camp Hill 1701 1

H. William Gross. D.D.S 141 4 Fairmont Street Allentown 18102

Walter M. Greissinger, M.D. Central Medical Pavilion 1400 Center Avenue Pittsburgh 15219

Milton Jacobs Executive Director Saunders House 100 Lancaster Avenue Ph~ladelphia 19151

Robert B. Edmiston. M.D. Executive Vice President Professional Affairs Pa. Blue Shield Camp Hill 1701 1

Stuart L. Cohen Urban League of Pittsburgh, Inc. 200 Ross Street Pittsburgh 15219

Rev. Joseph A. Davis 161 2 Herr Street Harrisburg 17103

Joseph Garbinski 819 Grove Avenue Johnstown 15902

Jack B. Ogun Director Div. of Drugs, Devices and Cosmetics 930 Health and Welfare Building Harrisburg 17120

Truman Painton Erie Co. Geriatric Center R.D. #2 Gerard 1641 7

Organization

Hospital Association of Pa.

Pa. Dental Association

Pa. Medical Society

Pa. Health Care Assn.

Pa. Blue Shield

Urban League

Tri-County Retired Senior Volunteer

Southern Allegheny Legal Aid

Pa. Department of Health

Pa. Assn. of County Affiliated Homes

Melvin F. Johnson 141 5 Market Street Harrisburg 17103

Francine Gallagher Manley 516 Highland Avenue Clarks Summit 1841 1

David H. Lowa The Salvation Army Market at North Street Williamsport 17701

Gary N. Clouser The Brethern Village P.O. Box 5093 Lancaster 17601

George Weaver. O.D. 36 North Beaver Street York 17401

Paul Steinberg, D.O. 171 1 South 8th Street Philadelphia 19148

Dorothy M. Tartaglio Administrative Assistant Nursing Home Agency 201 Chestnut Avenue Altoona 16601

Oscar W. Morrison Senior Vice President Beverly Enterprises Suite 607 214 Senate Avenue Camp Hill 1701 1

Harrisburg Concerned Citizens

Scranton-Lackawanna Human Development Agency

Salvation Army

Pa. Assn. of Non-Profit Homes for the Aging

Pa. Optometric Assn.

Pa. Osteopathic Medical Assn.

Pa. Assn. of Home Health Agencies

Pa. Health Care Assn.

NOTE: Mr. Milton Jacobs is currently sewing as Chairman of the Medical Assistance Advisory Committee.

4. Pharmacy Subcommittee to the Medical Assistance Advisory Committee:

William L. Greene. R.Ph Chairman 780 West Macada Bethleham 18017

Samuel D. Brog, R.Ph 102 Buckley Drive Philadelphia 191 15

Donald E. Schell. R.Ph. 129 Blacksmith Road Camp Hill 1701 1

John A. Paone. R.Ph. Wyman Pharmacy 524 East Ohio Street Pittsburgh 15212

David Dalton, R.Ph. Rite Aid Corporation P.O. Box 3165 Harrisburg 17105

Laraine Forry Pennsylvania Assn. of

Medical Suppliers C/O Harrisburg Surgical CO Harrisburg 17108

Cathy Calderone, R.Ph. York County Hospital and Home 118 Pleasant Acres Road York 17402

N. E. Monticelli, R.Ph 669 Burclay Lane Broomall 19008

Benjamin Pulizzi, RPh. Williamsport Orthopedic and

Prosthetic Co. 138 East 4th Street Williamsport 17701

Margaret Warwick, R.Ph. 29 Bryan Street Havertown 19083

Ronald D. Kaufmann, R.Ph, C/O Clover, Division of

Starwbridge & Clothier 801 Market Street Philadelphia 19105

5. Executive Officers of State Medical, Pharmaceutical, Podiatry, and Osteopathic Medical Associations:


John F. Rineman Executive Vice President Pa. Medical Society 20 Erford Road Lemoyne 17043 Phone: 7171763-71 51

Carmen A. DiCello. R.Ph. Executive Director Pennsylvania Pharmaceutical

Assoc. 508 North Third Street Harrisburg 17101 Phone: 71 71234-6151

C. Podiatry Association: D. Osteopathic Medical Association:

Matthew M. Shook. Jr. Executive Director Pennsylvania Podiatry

Association 737 Poplar Church Road Camp Hill 1701 1 Phone: 71 71763-7665

E. State Board of Pharmacy

Marianne Fields Executive Director Pennsylvania Osteopathic

Medical Association 1330 Eisenhower Boulevard Harrisburg 171 11 Phone: 71 71939-931 8

Ann J. Heizenroth, Secretary P.O. Box 2649 Harrisburg, PA 17105 71 71783-7157

NPC

P U E R T O R l C O


Puerto Rico-1 1985



OAA AB APTD AFOC O M AB APT0 AFDC Children 21 (SFo)


lnpalient Hospital Care X X X X X X X X X X

Outpatient Hospital Care X X X X X X X X X X Laboratory & X-ray Service X X X X X X X X X X

Skilled Nursing Home Services X X X X X X X X X X Physician Services X X X X X X X X X X ~en ta l Services X X X X X X X X X X


II. EXPENDITURES FOR DRUGS. Payment lo Pharmacists by fiscal year.

1984 1983 Expended - Recipient - Expended - Recipienl -

. . . . . . . . . . . . . . . . . . . . . T O T A L

. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL A@ . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . Disabled

. . . . . . . . . . . . Children-Families wmep Children

. . . . . . . . . . . . Adults-Families w/Oep Children

. . . . . . . . CATEGORICALLY NEEDY NON-CASH TOTAL No vendor . . . . . . . . . . . . . . . . . . . . . . Aged drug program . . . . . . . . . . . . . . . . . . . . . . Blind

. . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . Children-Families wI0ep Children . . . . . . . . . . . . Adults-Families w/Dep Children

. . . . . . . . . . . . . . . Other Tille XIX Recipients


. . . . . . . . . . . . . . . . . . . . . . Blind Disabled . . . Children-Families W/@D Children

. . . . . . . . . . . . Other Title XIX Recipients

'"Undupiicated Total - HHS reporl HCFA - 2082

NPC Puerto Rico-2 1985


By the Department of Health through the existing regionalized health care system operated by the Commonwealth and municipal government.


Limited to drugs dispensed through pharmacies of public facilities.


1. Health Department Officials:

Dr. Jaime Rivera Dueno Secretary

Medical Assistance Program: Emilia Hoyos Rucabado, M.S Pharmacist Consultant

Julio Cesar Galarce Director Health Economy Office

Department of Health Call Box 70184 San Juan, Puerto Rico 00936 8091765-9941

P. 0. Box 10037 Caparra Heights Station San Juan 00922 8091765-9941

Irma Reville De Ferrer Director Medical Assistance Program


The advisory committee consists of eleven members appointed by the Governor.

3. Executive Officers of Puerto Rico Medical and Pharmaceutical Societies:


Diego Artiquez Roman Executive Director Puerto Rico Medical Association P. 0 . Box 9387 Santorce 00908 Phone: 8091721 -7979


Myrna E. Velez Executive Secretary Box 206, G P.O. SanJuan00936 Phone: 809i753-7157

C. Board of Pharmacy

Pedro J. Vanga, Pres~dent Box 9342 Santurce. P.R. 00908

NPC Rhode island-1 1985

R H O D E I S L A N D




OAA AB APT0 AFDC OAA AB APTD AFOC Children 21 (s Fo)


~ k p i t a l Care X X X X X X X X X



Skilled Nursing Home Services X X X X X X X X X Physician Services X X X X X X X X X nentai - ...... Services X X X X X X X X X

'SFO-State Funds Only

II. EXPENDITURES FOR DRUGS. Payment to Pharmacisls by liscal year ending June 30. 1984

TOTAL


511,216,085 . . . . . . . 83,407 $9,996,519 75,751

CATEGORiCALLY NEEDY CASH TOTAL . . . . . . . . . . $6,063,023 59,575 $5,247,309 56.641 A d . . . . . . . . . . . . . . . . . . . . . . 1.083637 4,830 962,180 4,592 ~o~~

Blind . . . . . . . . . . . . . . . . . . . . . . 37.249 178 29.503 164 Disabled . . . . . . . . . . . . . . . . . . . . . 2,593,616 9.149 2,136,616 8.510 Children-Families w!Dep Children . . . . . . . . . . . . 864.725 27,511 799.714 26.424 Adults-Families w!Dep Children . . . . . . . . . . . . 1,483,796 17,907 1.319.296 16,951


. . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . Chiidren-Families w1Dep Children . . . . . . . . . . . . Adults-Families w!Dep Children

. . . . . . . . . . . . . . . Other Title XiX Recipients



. . . . . . . . . . . . Adults-Families wiDep Children . . . . . . . . . . . . . . . Other Title XlX Recipients

"Unduplicated Tolal-HHS report HCFA-2082

NPC Rhode Island-2 1985


State Department of Social and Rehabilitative Services.


A. General Exclusions: OTC and certain Medicine Chest Items and lnjectables:

Prior authorization is required for all injectables (excluding insulin and adrenalin), appetite depressant drugs, central nervous system stimulants, expensive vitamins, hematinics and lipotropic preparations (selling for over $10 per 100 tablets/capsules or pint), expensive andlor new preparations.

Prescribed drugs requiring prior authorization may be refilled if requested by the attending physician and approved by the Division of Medical Services.

€3. Formulary: None


1. Quantity of Medication: One month's supply of drugs.

2. Maintenance Medication: The attending physician may prescribe certain maintenance drugs up to a maximum of 100 tablets, capsules or pint of liquid or a 30-days' supply of these drugs-whichever is greater.

3. Refills: Refills to a maximum of five are allowed for specified drugs: anti-hypertensives, diuretics, anti-convulsants, coronary vasodilators, tranquilizers, antidepressants, hormones. etc.

Refills are not allowed for specified drugs, e.g., antibiotics, central nervous system stimulants, narcotics (Schedule 11. Ill), Corticosteroids and appetite depressants, benzodiazepines.



1. Prescription Drugs Dispensed to Eligible Recipients Residing in Their Own Homes

A Professional Fee for Service of $3.10 will be allowed for all prescriptions in addition to the cost of the drug. ($3.25 effective October 1, 1985)

In accordance with federal regulation the upper limit for payment for prescribed drugs will be based upon the unit cost of the drug plus a dispensing fee or the usual and customary charge to the general public, whichever is lower.

Payment for over-the-counter drugs (non-legend drugs) will be based upon the lower of either the unit cost of the drug plus 50 percent, the usual and customary charge to the general public, or the unit cost plus the Professional Fee for Service.

2. Prescription Drugs Dispensed to Recipients Residing in Skilled Nursing or Intermediate Care Facilities:

A Special Professional Fee for Service of 52.60 will be allowed for these prescriptions in addition to the cost of the drug to the pharmacist.

In accordance with federal regulation the upper limit for payment for prescribed drugs will be based upon the unit cost of the drug plus a dispensing fee or the usual and customary charge to the general public, whichever is lower.

Payment for over-the-counter drugs (non-legend drugs) will be based upon the lower of either the unit cost of the drug plus 50 percent, the usual and customary charge to the general public, or the unit cost plus the Professional Fee for Service.

3. The cost of the drug to the pharmacist in this professional fee-for-service method of payment will be based upon the AWP listings in the Red Book, per 100 tabletslcapsules or pint of

NPC Rhode Island-3 1985

liquid except for direct purchases from the following manufacturers:

Abbott-Ross Lederle Merck Sharp & Dohme Parke-Davis & Co. Warner-Chilcott

Pfiphannics Pfizer-Roerig Squibb Upjohn Wyeth

4. The quantity of the drug dispensed on the original prescription would be determined on the basis of a 30-day supply to the patient. A maximum of 5 refills in addition to the original prescription will be allowed when so indicated by the physician.

5. The attending physician may prescribe certain maintenance drugs up to a maximum of 100 tablets, capsules or equivalent, or a 30 days' supply of these drugs-whichever is greater.

The following classes of drugs are considered as maintenance drugs:

a. Anti-diabetic preparations

b. Anticonvulsants

c. Antihypertensives

d. Cardiovascular preparations, namely:

(1) Anti-anginal

(2) Digitalis and the cardiac glycosides

e. Diuretics

f. Hormones, including thyroid preparations

g. Vitamins, hematinics and lipotropic preparations for which the total charge to the Medical Assistance Program does not exceed $10 per pint of liquid or 100 tablets or capsules.


Copayment-No

Number of Rx claims processed in FY 1984-1,002.061



1. Social and Rehabilitative Services Department Officials:

hancy V. Bordeleau Director

Anthony Barile. M.P.A Assistant Director Medical Services

Department of Social and Rehabilitative Services

600 New London Avenue Cranston, Rhode island 02920

John A. Pagliarini. R.Ph. Chief Medical Care Specialist 4011464-2184

2. Social and Rehabilitative Services Department Advisory Committees:

A. Medical Assistance Committees:

(1) Medical Advisory Committee on Pharmacy:

NPC

Dr. Heber W. Youngken, Jr., Chairman

Joan Abar,D.O. Peter Mathieu, M.D. Vincent Alianiello. R.Ph. Joseph Navach, R.Ph. Walter Carnevale. R.Ph. Hon. Anthony Soloman, John DeFeo. Ph.D. State Treasurer John DePasquale, R.Ph. Ira Wellins. R.Ph. Joseph Galina Richard Yacino, R.Ph. Louis Jeffrey, R.Ph.

(2) Rhode lsland Pharmaceutical Association:

Henrique Pedro, R.Ph.. President


A. Medical Society:

Norman A. Baxter. Ph.D. Executive Director Rhode lsland Medical Society 106 Francis Street Providence 02903 Phone: 4011331 -3207


Judge J. S. Gendron, R.Ph. Executive Director Rhode lsland Pharmaceutical Association 23 Broad Street Pawtucket 02860 Phone: 4011725-4141


Reuben L. Alexander, D.O. Secretary Rhode lsland Osteopathic Physicians and Surgeons 849 Post Road Warwick 02888 Phone: 4011781-3940


John Haronian. Secretary 304 Cannon Building 75 Davis Street Providence, R.I. 02908 4011277-2837

South Carolina-1 1985

S O U T H C A R O L I N A




O M A0 APT0 AFDC O M AB APT0 AFDC Children 21 (SFOI


Inpatient Hospital Care X X X X X

outpatikt HosDilal Care X X X X X

X-ray ~ e ~ i c e X X X X X

Skilled Nursing Home Services X X X X X Physician Services X X X X X Dental Services X X X X X

Other Benefits: Home Health Services. Rural Health Clinic Services. Medical Transporlation. Podiatrist Services. Optometrists Services, Chiropractic Services. Durable Medical Equipmenl, Intermediate Care Facilities Services.


II. EXPENDITURES FOR DRUGS. Favment to Pharmacists bv fiscal vear ending June 30. 1984

T O T A L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL

Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . . Children-Families w/Dep Children . . . . . . . . . . . .


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


. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . .


Disabled . . . . . . . . . . . . . . . . . . . . . 0 0 Children-Families w/Dep Children . . . . . . . . . . . . 0 0 Adults-Families w ID~D Children . . . . . . . . . . . . 0 0

. . . . . . . . . . . . . . . Other Title XIX ~ec i~ i en t s 0 0


'"Unduplicated Total-HHS report HCFA-2082

NPC


State Health and Human Services Finances Commission


A. Scope of Non-Formulary Drug Program-Effective October 1 . 1984, providers will be reimbursed for most legend drugs and for certain non-legend (OTC) drugs within the three prescription limit. Exclusions to this coverage are as follows:

1. Adult vitamins and vitamin combinations; (Prenatal vitamins for females and fluoride vitamins for children are covered.)

2. Amphetamines and obesity control drugs;

3. Experimental drugs;

4, Immunizing agents (Pneumovax is covered under Physicians' Services):

5. Drug Efficacy Study Implementation (DESI) Drugs. Drugs determined by the Food and Drug Administration (FDA) to be ineffective are not reimbursable by Medicare or Medicaid.

6. Over-the-counter (OTC) drugs except: Insulin, Insulin syringes, family planning supplies, all aspirin products, and OTC products listed below:

Actifed Tablets Gelusil II Liquid Actifed Syrup Hydrocortisone 5% Cr.lOint. Alternagel Liquid Insulin-all forms A.S.A. Enseals 5 gr Insulin syringes A.S.A. Enseals 10 gr Maalox Suspension Ascriptin Tablets Maalox # I Tablets Ascriptin AID Tablets Maalox #2 Tablets Aspirin-all forms Maalox Plus Tablets Basaljel Capsules Maalox Plus Susp. Basaljel Swallow Tabs Maalox Therapeutic Conc. Basaljel Suspension Micatin Cr. 2% 15 gm. Basaljel Ext. Strength Micatin Cr. 2% 30 gm.

Suspension Mylanta Liquid Bronkotabs Mylanta Tablets Cama Inlay Tablets Mylanta II Liquid Camalox Susp. Mylanta II Tablets Camalox Tablets Mylicon 80 Tablets Cerose DM Niacin 100 mg Tablets Contraceptive Condoms Novafed Liquid Contraceptive Vaginal Parapectolin

CrIJels Phazyme Contraceptive Foams Riopan Tablets Debrisan Beads Unit Riopan Suspension

4 gm 7s Riopan Chewable Tablets Debrisan Beads Unit Riopan Plus Suspension

4 gm 14s Riopan Plus Tablets Dirnetane Elixir Robitussin AC Dimetane 4 mg Tablets Robitussin DAC Dimetane Ext. 8 mg Tedral Elixir Dimetane Ext. 12 rng Tedral Tablets Dimenhydrinate 50 mg Tab. Titralic Liquid


Tussar SF Valadol Tablets

Dimenhydrinate Liquid Donnagel PG Susp. Ecotrin Tablets Gaviscon Liquid Gaviscon 2 Tablets Gelusil Tablets Gelusil Liquid Gelusil II Tablets

B. Formulary: None


1. Quantity of Medication: None (90 day supply maximum)

In acute conditions, physician requested to limit supply to a minimum of ten (10) days. In chronic conditions and for maintenance drugs, a minimum of a thirty (30) day supply where appropriate, a ninety (90) day supply maximum is allowed and encouraged.

2. Refills:

The prescriber authorizes the number of refills.


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


Medicaid reimbursement for pharmacy services will be based on the lower of: the South Carolina Estimated Acquisition Cost (SCEAC); federal maximum allowable cost (MAC) or the provider's submitted usual and customary charge.

Dispensing fee is $3.40 (2.90 + .50 copay. = 3.40)

Copayment-Providers are authorized to collect a CO-PAY of fifty cents ($0.50) per prescription from the client, except for clients in long term care facilities, family planning, EPSDT, pregnancy- related prescriptions, and recipient under 21 years of age.


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


1. South Carolina State Health and Human Services Finance Commission

Dennis Caldwell Health and Human Services Finance Executive Director Commission 803/758-3175 P.O. Box 8206

Columbia. S.C. 29202-8206

Gwen Power Bureau of Health Services 803/758-8182

1801 Main Street Columbia. S.C. 29202

James M. Assey. RPh. Medicaid Program Consultant 803/758-2320


Debbie Francis, R.Ph. Supervisor, Drug Program 6031758-21 70



William F. Mann Executive Vice President South Carolina Medical Association P. 0 . Box 11188 Columbia 2921 1 Phone: 8031796-6207


Sharon Fennell Executive Director South Carolina Pharmaceutical Association 1405 Calhoun Street Columbia 29201 Phone: 8031254-1 065

C. Osteopathic Association

J. W. Nichols, D.O. Secretary-Treasurer South Carolina Osteopathic Assn. 101 7 Fair Street Camden 29020 Phone: 8031432-4498


C. Douglas Chavous, Executive Secretary P.O. Box 11927 Columbia. S.C. 29211 8031758-5447

NPC South Dakota-1 1985

SOUTH DAKOTA



Type ol Benefit Categorically Needy Medically Needy (MN) Other.

O M A6 APTD AFDC O M AB APTD AFDC Children 21 (SFo)

Prescribed Renal Orugs X X X X Disease

Inpatient Renal Hospital Care X X X X Disease

Oulpatient R e ~ l Hospital Care X X X X Disease

Laboratory & Renal X-ray Service X X X X Disease

Skilled Nursing Home Services X X X X Physician Renal Services X X X X Disease Dental Services X X X X




TOTAL

. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind

. . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . Children-Families wi0ep Children . . . . . . . . . . . . Adults-Families wIDep Children

. . . . . . . . CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . . . . . . . . . . . . . . . Aged

Blind . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Disabled



. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . . . . . . . . . Aged

Blind . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Disabled


. . . . . . . . . . . . Adults-Families wi0ep Children . . . . . . . . . . . . . . . Other Title XIX Recipients

TJnduplicaled Total-HHS report HCFA-2082

NPC South Dakota--2 1985


State Department of Social Services, Office of Medical Services.


A. Exclusions: The program is limited to legend prescription drugs as specified in the state's Medicaid regulations, and to insulin.

6 . Formulary: Administrative Rule, adopted July 1, 1983 states:

"Certain drug payments limited to generic drug form. Payment for the brand name drugs shall be limited to the generic drug form, unless the prescriber indicates in writing on the prescription a medical reason why the generic drug may not be used. If the prescription is an oral or call- back prescription, the pharmacist may document the prescriber's reason for requiring the brand name drug." (96 drugs and drug dosage forms are affected)


1. Quantity: Maintenance drugs requiring more than one dose per day must be dispensed in units of at least 100 or a 30 day supply, if more than 100 unit are required per month. Maintenance prescriptions for family planning items must be dispensed in at least a 3 month supply. (New family planning prescriptions can be in smaller units.)

2. Refills: Refills of maintenance drugs costing less than $4.25 per 100 are limited to the greater of 100 or a 30 day supply.

3. Dollar limits: None.

D. Prescription charge formula: Payment is the lower of: (a) MAC plus dispensing fee of $3.25, (b) EAC plus dispensing fee of $3.25, or usual and customary charge to the general public.

V. Miscellaneous

A. Administrative Rule, adopted July 1. 1983 states:

"Cost sharing for prescriptions is $1.00 for each prescription and $1.00 for each prescription refilled." (Exemptions include patients under 18 years, residents of home or community-based services, services related to pregnancy, residents of long term care facilities, family planning and emergency hospital services.)

€3. Number of claims processed in FY 1984-284,396

C. Average Rx price during FY 1984-$12.17

Officials, Consultants and Committees 1. James Ellenbecker Department of Social Services

Secretary 700 North Illinois Department of Social Services Pierre, South Dakota 57501

E ~ i n Schumacher Program Administrator Medical Services

Donald Mahannah. P.D. Pharmacist Consultant Medical Services 6051773.3495

South Dakota-3 1985

2. Medical Advisory Committee (MAC):

Lloyd Jones, Pharmacist Jones Drug 609 Sixth Avenue Aberdeen 57401

Paul I. Engbrecht, Nursing Home Administrator Administrator The Tieszen Memorial Home 437 State Street Marion 57043

Dennis Johnson. M.D.. Physician 1301 South Ninth, 46700 Sioux Falls 571 05

Glenn W. Robeson, O.D., Optometrist 34 Third Street. SE Huron 57350

James D. M. Russell. Hospital Administrator Administrator St. Mary's Hospital Pierre 57501

Alvin A. Buechler, DDS. Dentist Box L Gettysburg 57442



Robert D. Johnson Executive Secretary South Dakota State Medical Association 608 West Avenue North Sioux Falls 57104 6051336- 1965


Harold H. Schuler Secretary South Dakota Pharmaceutical Association 222 East Capitol (Box 51 8) Pierre 57501 6051224-2338


David Calver, D.O. Secretary-Treasurer South Dakota Society of Osteopathic Physicians & Surgeons C/O Massa-Berry Clinic Sturgis 57785 6051347-361 6

South Dakota-4 1985


(See above)

NPC

TENNESSEE

M E D I C A L ASSISTANCE D R U G P R O G R A M (T ITLE XIX)


Type of Benelit Categorically Needy Medically Needy (MN) Other'

O M AB APTD AFDC O M AB APT0 AFDC Children 21 (SFO) -- -

Prescribed X X X X ". *. *. **

Drugs

Inpatient X X X X .. *. .* .*

Hospital Care

Oulpatient X X X X .. *. *. .*

Hospital Care

Laboratory & . . . . X X X X .* X-ray Service

Skilled NurSinQ X X X X .. *. .*

Home Services NO Physician . . . . . . X X X X Services Dental Covered only il EPSDT ......

Services or under 21

Other Benelils: Home health services: community health clinics; intermediale health care facilities; family planning services, rural health clinics; early periodic screening and treatment (EPSO&T)

'SFO-State Funds Only "Caretaker over 21

I1 EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30. 1984


TOTAL . . . . . . . . . . . . . . . . . . . . . $53,582,671 254,591 "' $47,686,404 248.128

CATEGORICALLY NEEDY CASH TOTAL Aoed . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . 432.995 1.614 371.335 1.557 D i s a b l e d . . . . . . . . . . . . . . . . . . . . . 21,792,514 63,311 19,006,795 60.983 Children-Families wIDep Children . . . . . . . . . . . . 2.315.341 68.076 2,150,670 69,007 Adulb-Families w/Dep Children . . . . . . . . . . . . 4,007,984 36.620 3,549.089 36.303

CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind

. . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . Children-Families w/Oep Children . . . . . . . . . . . . Adults-Families w/Dep Children

. . . . . . . . . . . . . . . Other Title XIX Recipienls

. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . blind

Disabled . . . . Children-Families w/Oeo Children

Other Tille XIX Recipients . . . . . . . . . . . 21,689

"*Unduplicated Total-HHS report HCFA-2M12

NPC


Tennessee Department of Health and Environment


A. General Exclusions: OTC drugs (except insulin), cough and cold preparations, anoretic drugs (except for amphetamines and derivatives for only specific indications of narcolepsy and the hyperkinetic child).

8. Formulary: "Tennessee Medicaid Drug Formulary"; Restricted Formulary. For information contact:

Ronald E. Graham, Pharm.D. 729 Church Street Nashville. Tennessee 37219-5406 615/74l-O192


1. Terminology: May prescribe and dispense brand name drugs but encourage usage of generic drugs for potential cost savings.

2. Quantity of Medication:

a. One month's supply.

b. Limit of 7 prescription and/or refills per month.

3. Refills: Covered only if specifically authorized by the prescribing physician on the original prescription. Five refills within 6 months.


5. MAC (Maximum Allowable Cost). 180 drugs in addition to federal MAC drugs. Approved Manufacturer's List established based upon bioequivalence.

D. Prescription Charge Formula: Acquisition cost plus professional fee of 53.36 maximum, or usual and customary-whichever is lower.

Lesser of:

1. Actual acquisition cost-plus-fee, or

2 Maximum allowable cost-plus-fee, or

3. Usual and customary charge.

V. Miscellaneous

Fiscal Intermediary

EDS Federal Corporation 301 South Perimeter Park Drive Nashville. Tennessee 3721 1

Number of Rx Claims Processed in FY 1984-4,304,448

Average Rx Price During PI 1983-512.36


1. Health Department:

A. Officials:

James E. Word, M.P.H. Commissioner

Tennessee Department of Health and Environment

344 Cordell Hull Building Nashville, Tennessee 37219

NPC

Ronald E. Graham, Pharm.D. Director of Pharmacy

Services 61 51741 -0192

Sandra J. Daniel Director

Billy W. Huffines Director, Division of

Medical Assistance- Medicaid

Peggy A. Alsup, M.D., Bureau Medical Director

Medicaid Administration 729 Church Street

Nashville 3721 9-5406

B. Medicaid Medical Care Advisory Committee:

Fifteen members appointed by the Governor for three-year terms (except initial appointments). One member shall be the Commissioner of the Department of Human Services; seven members shall be representatives of consumer groups and organizations (including Medicaid recipients, labor unions, HMO's, etc.); and seven members shall be Medicaid providers (one physician from a rural area, one physician from an urban area, one nurse, one dentist, one pharmacist. one nursing home administrator, and one hospital administrator).

MEMBERS REPRESENTATION

Edward W. Reed, M.D. Chrmn, 975 Thomas Street Memphis. TN 38107 (527-4484)

Sammie Lynn Puett 11 1 Seventh Avenue, North Nashville. TN 37203 (741 -3241)

Hays Mitchell. M.D. Bradley Medical Center Cleveland. TN 3731 1 (472-6551 )

David Lillard Lillard's Pharmacy 81 North Tillman Street Memphis, TN 381 11

Bill McCaskell Trevecca Health Care Center 329 Murfreesboro Road Nashville, TN 37210 (244-6900)

Physician (Urban)

Commissioner Tennessee Department of

Human Services

Physician (Rural)

Pharmacist

Administrator

NPC

Imogene Kaserman, R.N, Lakeshore Mental Health 5908 Lyons View Drive Knoxville, TN 38301 (584-1 561)

Betty J. Thompson Family Nurse Clinican Metro Health Department East Station 1015 E. Trinity Lane Nashville. TN 37216 (227-8140)

Jerre Hale, D.D.S. 300 Bryant St. Smithville, TN 37166 (597-4737)

Thomas L. Adams Retail Clerks Union,

Local 1557 203 North 11 th Street Nashville, TN 37206

Elizabeth Marbuy 2300 Wilson Street Apt. 6-A Chattanooga, TN 37406

Betty R. Tenpenny 1007 West Parkway Knoxville, TN 37912

John G. Green 1015 Mitchell Cookeville, TN 38501

'John L. Brown Director. Benefits Northern Telecom, Inc. 259 Cumberland Bend Metro Center Nashville, TN 37228 (256-5900)

John Watson United Way of Greater Memphis 3489 Poplar Ave. Suite One Memphis, TN 381 11

2. Medicaid Formulary Advisory Committee:

Nurse

Nurse

Dentist

Consumer

Consumer (Medicaid recipient)


Consumer (HMO Representative)

Consumer (Labor Representative)

Eight members appointed by the Commissioner for three-year terms (initial terms will be Stag- gered). Five members will be pharmacists. Each pharmacist member will be selected from nomina-

tions submitted by the Tennessee Pharmaceutical Association. Three members will be physicians. Each physician member will be selected from nominations submitted by the Tennessee Medical Association. Members should be familiar with the Medicaid program-preferably enrolled providers.

MEMBERS OCCUPAT/ON

Horton Jones Jones Pharmacy 14th and Buchanan Street Nashville, TN 37208

Terry Brimer, Pharm.D. Doctor's Hospital Pharmacy 726 McFarland Avenue Morristown, TN 37813

Dianna C. Drake. D.Ph. 1100 Shadyland Drive Knoxville. TN 37919

Ray Marcrom. Pharm.D. Marcrom's Pharmacy 1277 McArthur Street Manchester. TN 37355

Earl Marshall. D.Ph. Hollywood Pharmacy Mart. Inc. 903 Hollywood Jackson. TN 38301

Stephen Schillig. M.D. Metropolitan Board of Hospitals 72 Hermitage Avenue Nashville. TN 37210

Charles W. White, M.D. 14 Hospital Drive Lexington. TN 38351

Carl T. Duer, M.D. Route 9 Crossville, TN 38555

Community Pharmacist

Clinical and Institutional Pharmacist

Institutional Pharmacist



Physician Middle TN

Physician West TN

Physician



L. Hadley Williams Executive Director TN Medical Association 1 12 Louise Avenue Nashville 37203 Phone: 6151327-1451

Tom C. Sharp. Jr. Executive Secretary TN Pharmaceutical Assoc. 226 Capitol Blvd.,

Suite 308 Nashville 37219 Phone: 6151256-3023


Paul Grayson, D.O. Secretary-Treasurer Tennessee Osteopathic Medical Association Box 390 Pikeville 37367 61 51447-2606


J. Floyd Ferrell, Jr., Director 404 Doctors Building 706 Church Street Nashville, Tennessee 37219 6151741 -2718

NPC

T E X A S



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

O M AB APT0 AFDC OAA AB APTD AFOC Children 21 W O )

Prescribed 0r11ns X X X X X X

Inpatient Hospital Care X X X X X X

Out~atient ~o ip i t a l care x x x x x x Laboratory & X-rav Service X X X X X X

Skilled Nursing Home Services X X X X X X Physician Services X X X X .. *.

Oenlal Services Limited X X X X

Other Benefits: Eye relractions, prosthestic lens; home health services; ambulance, chiropractor; podiatrist; eye glasses; hearing aids, Ambulatory Surgical Center Service

'SF0 - State Funds Only " - EPSDT only

II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by liscal year ending August 31. 1984


T O T A L . . . . . . . . . . . . . . . . . . . . . $94,794,375 568,155'' $83,933,346 533.595

. . . . . . . . . . CATEGORICALLY NEEOY CASH TOTAL Aged . . . . . . . . . . . . . . . . . . . . . . 37,434,506 140.772 Blind . . . . . . . . . . . . . . . . . . . . . . 758,961 3,507 D i s a b l e d . . . . . . . . . . . . . . . . . . . . . 18,991.318 78,069 Children-Families w/Dep Children . . . . . . . . . . . . 6,650.930 186.604 Adulb-Families w/Dep Children . . . . . . . . . . . . 8.80(1,236 100,742


. . . . . . . . . . . . Children-Families wDep Children


. . . . . . . . . . . . . . MEDICALLY NEEOY TOTAL Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . Children-Families w/Dep Children Adults-Families wDep Children . . . . . . . . . . . . Other Title XiX Recipients . . . . . . . . . . . . . . .

"Unduplicated Total - HHS reporl HCFA - 2082

NPC


Vendor drug program was implemented September 1, 1971.

Texas Department of Human Resources.


Pharmacy services under the vendor drug program include the dispensing of most legend drugs and certain non-legend drugs to eligible recipients. Only pharmaceuticals which meet the FDA requirements, are approved for marketing and are approved by the Texas Department of Human Resources for use in the vendor drug program, may be supplied.

Certain OTC drugs are covered on a prescription basis except as otherwise provided in the 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.

6. Formulary: None. However, the Texas Drug Code Index is utilized for product identification and claims processing and contains those drugs which are covered under the program.

For information contact:

Raul Martinez, Jr., R.Ph. Director, Product Enrollment, Vendor Drugs Texas Department of Human Resources P.O. BOX 2960 (541-A) Austin, Texas 78769 5121835-0440, ext. 2595


1. Quantity of Medication: Prescribed quantity cannot exceed a six month supply.

2. Refills: Five refills, but total amount may not exceed 6 months' supply.


1. For prescription legend medication:

Acquisition cost plus a variable dispensing fee up to a maximum of $4.05 per prescription (range $3.72-$4.05*) based on a point system of services rendered, or usual and cus- tomaary total price, whichever is lower.

Acquisition Cost: Current Red Book cost of direct cost or invoice cost. MAC based on wholesale or direct cost as indicated by the provider.

2. Insulin and approved non-legend drugs on prescription: pharmacists and dispensing physicians will be reimbursed on the basis of usual charges to the general public or cost plus 50% of cost, whichever is lower; 50% of cost not to exceed assigned variable dispensing fee.


The dispensing fee, which includes all costs of filling a prescription, was established by cost accounting and service evaluation of the expenses involved in dispensing a prescription. Therefore, fees paid to providers who do not experience all cost and service factors considered in arriving at the fee, may be less than the maximum allowable fee.

Copayment-None.

Number of claims processed in FY 1984-6,579,073

NPC


'Plus $.06 if on tape.

Plus $.08 patient profits

Plus $.08 delivery service

Plus $.03 emergency service

Plus $.03 continuing education

Officials, consultantsrand Committees

1. Department of Human Resources Off iciak:

Marlin W. Johnston Commissioner

Merle E. Springer Executive Deputy commissioner

Ms. Mary Polk Executive Assistant

Martin Dukler Deputy Commissioner for Programs

Hillary Connor, M.D. Deputy Commissioner for

Health Care Services

Dr. Janice Caldwell Associate Commissioner

Services to Aged & Disabled

ROY E. Westerfield Director of

Projects for Health Care Alternatives

Vendor Drug Program:

W. B. Barner. R.Ph.. D.Ph. Program Specialist 51 21540-3202

Texas Department of Human Resources Post Off ice Box 2960 701 West 51 st Street Austin, Texas 78769

Raul Martinez, Jr.. R.Ph. Staff Specialist 5121540-3181


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C. Lincoln Williston Executive Director Texas Medical Association 1801 N. Lamar Boulevard Austin 78701 Phone: 5121477-6704


Luther R. Parker Executive Director Texas Pharmaceutical Assoc. P. 0. Box 14706 1624 East Anderson Lane Austin 78761 Phone: 5121836-8350


Tex Roberts Executive Director Texas Osteopathic Medical Association 226 Bailey Avenue Fort Worth 761 07 81 71336-0549


Fred S. Brinkley. Jr., Executive DirectorlSecretary 21 1 East 7th Street. Suite 1121 Austin. Texas 78701 51 21478-9827

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UTAH

MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)



O M AB APT0 AFDC OAA AB APT0 AFDC Chlldren 21 (SFo)

Prescribed n n m X X X X X X X X X X

Inpatient Hosoital Care X X X X X X X X X X

Outoatient ~ o i p i l a l Care X X X X X X X X X X



Other Benefits: Home health, clinic services. transportation, family planning; medical supplies, Early Periodic Screening for Children; services of psychologists, physical therapists, speech therapists, podiatrists, osteopaths, optometrists and audiologists.


II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by liscat year ending September 30, 1984

TOTAL . . . . . . . . . . . . . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . Children-Families wIOep Children

. . . . . . . . . . . . Adulfs-Families wDep Children

CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . Children-Families wI0ep Children . . . . . . . . . . . . Adults-Families wIDep Children


. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . . Children-Families wlOep Children . . . . . . . . . . . .

. . . . . . . . . . . . Adults-Families wlDep Children . . . . . . . . . . . . . . . Other Title XIX Recipients

Expended - $5,489,057

$3,260,569 564,575 9,106

1,043,198 549.390

1,094,300

$1,727,256 1,034.161

2,184 540,813 37,185 112,913

0

$501,232 215,439 2,305

139,668 131 843

142.846

1984 Recipient - 47,008

35,852 2.054 37

3,266 18,358 13.420

7,744 3,257

7 1,500 1,475 1,566

0

5,511 694 6

413 6 25

4.395

Expended - $4,618,072

$2.597393 500,4W 5,483

904,273 435.629 751.608

$633,353 297.596 4,047

239,608 36,324 55.778

0

$1,387,326 825.802

239 361,612 17,240 52,591 129,842

1983 Recipient - 43,721

31,724 1.988 37

3,125 15.905 10,788

4,862 1,149 15 882

1.631 1,208

0

9,148 2,649

1 948 664 639

4,315



Division of Health Care Financing, State Department of Health



Vitamins, (except for expectant mothers and children to age 5), anorectics; (except for amphetamines and derivatives only for specific indications of narcolepsy and the hyperkinesis.) Other categories-minor tranquilizers and antiarthritics require prior approval.

B. Formulary: modified open formulary (effective January 1, 1985),


Quantity of Medication: In general, the quantity of medication shall be limited to a supply not to exceed 30 days except for "sustaining" drugs, for which a 100-day supply is authorized.


Lowest of EACIMAC Cost plus professional fee of $3.25, or usual and customary charges to the private sector.


1. Department of Health Officials:

Peter C. Van Dyck,MD Acting Executive Director

Glen Blonquist Acting Director Division of Health Care Financing

RaeDell Ashley Manager, Program Operations

and Medical Determination

Department of Social Services Officials:

Norman G. Angus Director

Department of Health 150 West North Temple Salt Lake City, Utah 84103 801 1533-6151

Department of Social Services 150 West North Temple Salt Lake City 84103

Cindy Haig, Director Office of Assistance Payments


A. Medical Association: 6. Osteopathic Association:

J. Leon Sorenson Executive Director Utah State Medical Assoc. 540 East 5th South Salt Lake City 84102 Phone: 8011355-7477

Katherine V. Greenwood, D.0 Suite 201 750 N. 200 N. Provo 84601 801 1377-3871

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C. Pharmaceutical Association:

C. Neil Jensen Executive Director Utah Pharmaceutical Assoc. 1062 East 21st South, Ste. 212 Salt Lake City 841 06 Phone: 801/484-9141


Robert G. Bowen, Director Division of Registration 160 East 300 S P.O. Box 45802 Salt Lake City, Utah 84145 8011530-6634

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V E R M O N T



Type of Benefit Categorically Needy Medically Needy (MN) Dther'

O M AB APTD AFDC OAA A0 APTD AFDC Children 21 ( SFO)

Prescribed D r ~ ~ n s X X X X X X X X X X



Laboratory & X-rav Service X X X X X X X X X X

Skilled Nursing Home Services X X X X X X X X X X Physician Services X X X X X X X X X X nsnbl Services X X Other Benelits: Vision Care X X X X X X X X X X


II. EXPENOITURES FOR DRUGS. Pdyment to Pharmacists by fiscal year ending September 30. 1984

1984 1983 Exoended Recioient Exoended Recioient

TOTAL


. . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . Children-Families w/Dep Children . . . . . . . . . . . . Adults-Families w/Oep Children


Disabled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Children-Families wiOep Children . . . . . . . . . . . . Adults-Families w/Oep Children


. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind

Disabled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Children-Families w/Dep Children . . . . . . . . . . . . Adults-Families w/Oep Children



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Agency of Human Services.


Program allows the welfare recipient to have free choice of physicians and pharmacists; lock-in provision for mis-utilizers.


Prior authorization is required for therapeutic vitamins, cathartics, antacids, analgesics and fecal softeners.

B. Formulary: None, provided drug is included in Official Compendia.

The National Drug Code Directory is now being used as a drug manual for coding purposes.


1. Quantity of Medication: Initial prescription should be sufficient to allow for the determination of the patient's tolerance of the medication without creating unnecessary waste (expense) to the program. This quantity could be up to a 60-day supply on all maintenance medication prescriptions.

2. Refills: Up to 5 refills may be authorized by physician,

D. Prescription Charge Formula: Pharmacies bill their usual and customary charge. Medicaid pays the lower of:

1. Usual and customary

2. AWP plus $2.50 fee

3. the maximum allowable cost plus fee

E. Co-pay of $1 .OO per dispensation required (excluding standard federal exemptions).

V. Miscellaneous


EDS Federal P. 0. Box 1 102 South Burlington, Vermont 05401


1. Agency of Human Services:

Gretchen Morse Secretary

2. Social Welfare Department: Elmo A. Sassorossi Director Medicaid Division

Agency of Human Services 103 S. Main Street Waterbury 05676 8021241 -2880

Medicaid Division 103 South Main Street Waterbury 05676

James Bane Deputy Director Medicaid Division

Charles Perry Chief of Policy & Evaluation 8021241 -2880

Robert Edson, R.Ph. Pharmacy Consultant

3. Medicaid Pharmacy Peer Review Committee:

Michael Scollins. M.D., Chairman

James Craddock, R.Ph

Edgar Hyde, M.D

James Lill, R.Ph.

John Low, R.Ph.


A. Medical Society:

Robert Vautier Executive Director Vermont Medical Society 136 Main Street Montpelier 05602 Phone: 8021223-7890


Philip J. O'Neill Executive Secretary Vermont Pharmaceutical Association P. 0. Box 926 Bennington 05201 Phone: 80214424943

C. Ostedpathic Association:

Charles R. Norton, D.O. Secretary-Treasurer Vermont State Association Osteopathic Physicians and Surgeons, Inc. P.O. Box 341 South Hero, Vermont 05486 8021372-4200


Mary Ellen Grupp, Secretary 26 Terrace Street Redstone Building Montpelier, Vermont 05602 8021828-2372

Department of Social Welfare Medicaid Division 103 South Main Street Waterbury 05676

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VIRGIN ISLANDS


V i r g i n I s l a n d s - 1 1985


Type of Benelit Categorically Needy Medically Needy (MN) Other'

OAA AB APT0 AFOC OAA AB APT0 AFDC Children 21 (SFo)


lnpalient Hospital Care x x X X X X X X X X

outpatient Hospital Care X X X X X X X X X X

Laboralory & X-ray Service X X X X X X X X X X

Skilled Nursing Home Services X X X X X X X X X X Physician Services X X X X X X X X X X Dental Services x X x X x x x x X X

Other Benefils: Home health services: EPSDT: clinic services, prosthetic devices and dentures; eyeglasses; ambulance service and other transportation.


II. EXPENDITURES FOR DRUGS. Fiscal year ending Seplember 30, 1984

1984 1983 Expended Recipient - - Expended - Recipienl -

TOTAL . . . . . . . . . . . . . . . . . . . . . $368,129 8,217 $363,239 13,271


. . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . Children-Families w/Dep Children . . . . . . . . . . . . Adulls-Families wIOep Children

. . . . . . . . CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind

. . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . Children-Families w10ep Children . . . . . . . . . . . . Adults-Families w/Dep Children


. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL A . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . Disabled

. . . . . . . . . . . . Children-Families w/&p Children

. . . . . . . . . . . . Adults-Families w/Oep Children Other Tille XIX Recipients . . . . . . . . . . . . . . .

Virgin Islands-2 1985


Department of Health


Broad coverage as provided by public medical facilities.

Private facilities are used when the prescribed drug is not available at the public medical facility or designated hospital pharmacy. However, such private pharmacies used must have signed a provider's agreement with the agency.

Prescription Charge Formula: The pharmacists actual cost plus a $2.40 dispensing fee, except in institutions where drugs are included in the reimbursement formula, or except where a public agency makes bulk purchases of drugs in accordance with statutes or regulations governing such purchases.

Otflcials, Consultants and Committees

A. Health Department:

1. Officials:

Roy L. Schneider. M.D. Commissioner

Jeannette A. Mahoney, A.C.S.W., M.P.H.

Director, Health Insurance and Medical Assistance


Not available

8. Social Welfare Department Official:

Gwendolyn C. Blake (Mrs.) Commissioner

C. Executive Officer of Virgin lslands Medical Society:

Bureau of Health insurance and Medical Assistance

P. 0 . Box 7309 Charlotte Amalie St. Thomas Virgin lslands 00801 8091774-4624

Department of Social Welfare Charlotte Amalie St. Thomas 00801

Jose F. Poblete, M.D. Virgin lslands Medical Society Charlotte Amalie St. Thomas. Virgin lslands 00801

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VIRGINIA



Type of Benefil Categorically Needy Medically Needy (MN) Other'

Children 21 lSFOl OAA AB APT0 AFOC O M AB APT0 AFDC ~ ~ , . Prescribed oruos X X X X X X X X X

lnpalient Hospital Care X X X X X X X X X


Laboratory 8 X-ray Service X X X X X X X X X

Skilled Nursing Home Services X X X X X X X X X Physician Services X X X X X X X X X Dental All eligible recipienls Services under age 21

'SF0 - Slate Funds Only

II. EXPENDITURES FOR DRUGS. Paymenl to Pharmacists by fiscal year ending June 30, 1984

1984 Expended Recipienl - -

T O T A L . . . . . . . . . . . . . . . . . . . . . $36,050,372 221,394"

CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $26,095,571 189,964 Aged . . . . . . . . . . . . . . . . . . . . . . 9,062,443 29.492 Blind . . . . . . . . . . . . . . . . . . . . . . 232,931 848 Disabled . . . . . . . . . . . . . . . . . . . . . 9,849.646 31,322 Children-Families w1Oep Children . . . . . . . . . . . . 2,568,490 77,034 Adults-Families wlOep Children . . . . . . . . . . . . 4,382,061 51,268



. . . . . . . . . . . . Adulls-Families wlOep Children . . . . . . . . . . . . . . . Other Tille XIX Recipients



. . . . . . . . . . . . Adults-Families w/Oep Children . . . . . . . . . . . . . . . Other Title XIX Recipients

1983 Expended - Recipienl -

$31,067,436 219.970

YJnduplicated Tolal - HHS report HCFA - 2082


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



Non-legend drugs except family planning drugs and supplies, insulin, and insulin syringes and needles. Anorectic drugs and designated DESl drugs.

B. Formulary: None,


1. Quantity of Medication: Physicians requested to prescribe maintenance drugs in quantities reflecting a 30-day supply, or 100 units or doses.

2. Refills: Physicians may authorize refills according to legal requirements.


State Reimbursement-Based upon the lower of:

MACIAWPIEAC plus fee or usual and customary charge minus applicable co-pay;

Pharmacy fee, $3.40

Co-payment

$0.50/Rx for which the State pays $10 or less $1.001Rx for which the State pays more than $10 (Exclusions, under 21, pregnancy related, and nursing home patients)

Nursing Home Rxs Unit-Dose

Note: 1. All providers of unit-dose must be certified by Medicaid program-for computer purposes.

2. Unit-dose applies to tablets and capsules and oral liquid dosage forms.

Each tablet or capsule or 10 ml oral liquids.

Packaging allowance . . . . . . . . $0.01 57ldose

Plus an additional . . . . . . . $O.Ol/metric quantity

Legend Drugs

MACIAWPIEAC plus $3.40 fee or usual and customary charge.

Prescription Payment Limitation

One monthly prescription fee per legend drug dispensed.

0-1-Cs

Lower of cost plus markup (50%) or usual and customary charge State MAC drugs (OTC) = 1 1. Maximum Allowable Cost Drugs

V. Miscellaneous

State MAC Program-Yes, 138 drugs.

Number of claims processed in FY 1984-3,670,208 (6.3% increase)

Average Rx price during FY 1984-$9.88 (7.9% increase)

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The Computer Company (TCC) P.O. Box 6987 Richmond, Virginia 23230


1. Health Department Officials:

Ray T. Sorrell Director 8041786-7933

Bruce U. Kozlowski Deputy Director 804i786- 7933

Mary Ann Johnson. R.Ph. (Mrs.) Pharmacist Health Services Review 8041786-3820

Malcolm 0. Perkins Manager, Provider Relations Division of Operations &

Provider Services Office of Medical Assistance 804/786-7781

2. Governor's Advisory Committee on Medicaid:

Medical Society of VA

C. Barrie Cook, M.D. Frank S. Royal, M.D. (Old Dominion

Society)

VA Academy of General Practice

A. Epes Harris. Jr., M.D

Virginia Hospital Association

Craig R. Cudworth

VA Pharmaceutical Association

Thomas A. Abbott, R.Ph. James V. Morgan, R.Ph.

Virginia Nurses Association

Department of Medical Assistance Services

Richmond. Virginia 23219

Blue CrosslBlue Shield of VA

Ronald H. Bargatze

Virginia State Dental Assoc

Byard S. Deputy, D.D.S Harry L. Hodges, D.D.S Barry Shipman, D.M.D. (Dental School)

Private insurance Carriers

John L. Tuttle

Medical School Representative

Gary G. Suter, M.D

Pamcipants Advisory Council

Lucy S. Wohlford, R.N. Mary B. Evans Sharon P. Urofsky

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VA Health Care Association Unknown

James K. Meharg, Jr.

Ex Officio

William L. Lukhard Commissioner

Joseph J. Bevilacqua, P h D Commissioner

Ms. Jessie Key Mr. Richard Merritt

State Department of Welfare

State Department of Mental Health and Mental Retardation

James B. Kenley, M.D. State Department of Health Commissioner



James L. Moore Executive Vice-president Medical Society of Virginia 4205 Dover Road Richmond 23221 Phone: 8041353-2721


Paul Galanti Executive Director Virginia Pharmaceutical Assn. 31 19 West Clay Street Richmond 23230 Phone: 8041355-7941


L. R. Luxton, D.O. Secretary-Treasurer Virginia Osteopathic Medical Assn. LB & B Building Waynesboro 22980 Phone: 7031943-3341

J. B. Carson, Executive Director 517 West Grace Street P.O. Box 27708 Richmond, VA 23261 8041786-0239

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WASHINGTON



Type ol Benefit Categorically Needy Medically Needy (MN) Other'

OAA AB APTD AFDC DAA AB APT0 AFDC Children 21# (SFO)

Prescribed nrmc X X X X X X X X X X

Inpatient Hospila Care X X X X X X X X X X

Outoatient ~ o i ~ i l a l Care X X X X X X X X X X


Skilled Nursing ~~

Home Services X X X X X X X X X X Physician Services X X X X X X X X X X Denla Services Limited Xo

2 - Children under 21 0 - Children (EPSDT) only # - Limited to children in foster care, subsidized adoption. SNH, IFC, iCMR or inpatient psychiatric facility


11. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984


T O T A L . . . . . . . . . . . . . . . . . . . . . $25,946.074 214,123" $21,967,959 185,225

CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $8,604.816 149,727 Aaed . . . . . . . . . . . . . . . . . . . . . . 987,510 3,229 Blind . . . . . . . . . . . . . . . . . . . . . Disabled . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . Children-Families'wIDep Children Adults-Families w1Dep Children . . . . . . . . . . .


. . . . . . . . . . . . Chiidren-Families wlOep Children Adulls-Families w1Dep Children . . . . . . . . . . . .

. . . . . . . . . . . . . . . Other Title XIX Recipienls

MEDICALLY NEEDY TOTAL Aged . . . . Blind . . . . . . . . . . . . . . . . . . . . . . 4,268 19 Disabled . . . . . . . . . . . . . . . . . . . . 514.601 2,046 Children-Families wlDeo Children . . . . . . . . . . . . 32.389 1,551 Adults-Families w/Dep 'Children . . . . . . . . . . . . 96,600 1,741 Other Title XIX Recipients . . . . . . . . . . . . . . . 0 0

"Undupiicated Total - HHS repurl HCFA - 2082

NPC


By Division of Medical Assistance, Department of Social and Health Services. The local Medical Consultants review the need for non-formulary drugs.



Medicine chest drugs are not provided. Non-formulary drugs are provided in an emergent life- endangering situation and/or medically mandatory.

B. Formulary: Includes 2,800 listings by drug product name, quantity, dosage form and strength. Formulary is revised 2 to 3 times annually.


1. Quantity of Medication: No maximums: minimum of 30 days supply for maintenance medications.

2. Refills: No more than 2 refills in any 30-day period unless prescription and refills are in amount of 100's.

3. Dollar Limits: State and Federal MAC where listed

D. Prescription Charge Formula: The amount shall not exceed the usual and customary charge to the public or the maximum allowed by the department.

The maximum charge to the department is to be estimated acquisition cost (EAC) (as determined by the Division of Medical Assistance) plus a dispensing fee for service.

$3.70-Unit dose systems (Nursing Home Rxs) $3.00-Retail pharmacies, filling over 35,000 Rxs annually $3.40-Retail pharmacies, filling 15,000-35,000 Rxs annually $3.70-Retail pharmacies, filling 35,000 or less Rxs annually

V. Miscellaneous

Copayment-None. State MAC-144 drugs Claims processing agent: Consultec, Inc.

P.O. Box 9245 Mail Stop HA-1 1 Olympia, Washington 98504

Number of Rx claims processed in CY 1984-2,631,639 (paid)

Average Rx price during CY 1984-410.89


1. Social and Health Services Department Officials:

Karen Rahm Secretary

Gerald J. Reilly Director

Department of Social and Health Services

06-44 Olympia, Washington 98504

Division of Medical Assistance

HB-11 Olympia 98504

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Guthrie L.Turner. Jr., M.D Medical Director

Office of Medical Director HB-41 Olympia 98504

William P. Pace, R.Ph. Office of Medical Director Pharmacist Consultant HB-41

Olympia 98504

2. Social and Health Services Department Medical Consultants

A. Full-time: Local Office

Wesley M. Brock, M.D. Michael D. McGee, M.D. Norman Meckstroth, M.D. Edward P. Palmason. M.D.

Joseph F. Powers, M.D.

B. Part-time

Joan Baumgartner, M.D. Howard A. Boyd. M.D. Walter A. Boyle. M.D. Robert Bright, M.D. Raymond J. Bunker, M.D. Cary H. Coppock, M.D. Lyle J. Cowan, M.D. John Dalton, M.D. Lowell L. Eddy, M.D. Ernest Eytinge, M.D. Burton A. Foote. M.D. Arnold J. Herrmann, M.D. Michael H. Higgins, M.D. Paul Johnson, M.D. Kenneth H. Kinard. M.D. Jefferson D. Kyle, M.D. Albert V. Mills, M.D. James A. Moore, M.D. Carl C. Walters, M.D. John Walz, M.D.

Dental Howard B. Henderson, D.M.D. Curlis C. Sapp, D.D.S.

Podiatry Robert E. Wendel, D.P.M

State Office, Olympia State Office, Olympia Spokane RMU-Seattle Port Angeles Port Townsend Pierce Central

RMU-Seattle State Office. Olympia Kelso Bremerton Wenatchee Pierce Central OmakIOkanogan Olympia. Shelton, Chehalis RMU-Seattle Everett Ellensburg Pierce Central Spokane RMU-Seattle Everett Spokane Pasco, Walla Walla Aberdeen, South Bend Yakima Vancouver

Office of Medical Director, Olympia Office of Medical Director, Olympia

Opthalmology Jerrol R. Neupeer. M.D. RMU-Seattle

3. Department of Social and Health Services Title XIX Advisory Committee:

NPC

Members:

Andrade Man, Chairperson Childrens Orthopedic Hospital 4800 Sand Point Way, N.E. Seattle, WA 98105 2061643-4750 or 526-2003

John A. Beare, M.D. (Ex Officio) DSHS-Division of Health Mail Stop ET-21 Olympia. WA 98504 (206)753-5871

Dixie Cole 909 University Street Seattle, WA 98101 (206)382-9700

J. Keith Wilson 821 H Street Centralia, WA 98531 (509)736-7881

Sheldon Biback, M.D. 3216 N.E. 45th Place Seattle, WA 98105 (206)524-2600

Willie Cain 181 4 East Alton Pasco, WA 99301 5091547-0242

Harriet J. Greenwood 9009 Greenwood Avenue North # 3 l l Seattle, WA 98103 (206)784-5378

Craig Karpilow, M.D. 4608 S.W. Hill Street Seattle, WA 98188 (206)575-7881

Robert I. Jetland Harborview Medical Center 325 Ninth Avenue Seattle, WA 981 04 (206)223-3036

Louis 0. Stewart 2809 Yelm Highway Olympia, WA 98501 (206)491-5886 (206)682-6002

Ray Westeren Silverwood 9905-19th Avenue, S.E Seattle, WA 98204 (206)338-1122

Vernon Doyl East 1212 ~ i n a Avenue Spokane, WA 99202 (509)534-3912

Lawrence Mast, D.D.S 1126-112th N.E. Bellevue, WA 98004 2061455-9721

DSHS Staff Members:

Gerald J. Reilly, Director Division of Medical Assistance HB-41 Olympia, WA 98504

Peggy Flemer, Secretary Division of Medical Assistance HB-41 Olympia

James Peterson, Chief Office of Analysis and Medical Review HA-41 Olympia

Mike Stewart, Chief Office of Provider Services HA-1 1 Olympia, WA 98504

* Guthrie L. Turner, Jr.. M.D. Medical Director Office of Medical Director HB-41 Olympia 98504 (206)753-5839

'Responsible for approving new formulary additions.



Harlan R. Knudson Executive Director Washington State Medical Assn 900 United Airlines Building 2033 Sixth Avenue, Suite 900 Seattle 98121 Phone: 2061623-4801

Mr. W. Lawless Executive Director Wash. Osteopathic Medical Assn. 4210 S.W. Oregon Seattle 981 16 2061937-5358


Raymond A. Olson Executive Director Wash. State Pharmaceutical Assn. 1415 Seneca SW, Suite 200 Renton 98055 Phone: 2061228-71 71

Donald H. Williams, Exec. Secretary WEA Building 319 E. 7th Ave. Olympia. WA 98504 5061753-6834

5. State Board of Pharmacy Donald H. Williams, Exec. Secretary WEA Building 319 E. 7th Ave. Olympia, WA 98504 506/753-6834

West V i rg i n i a -1 1985

W E S T VIRGINIA

M E D I C A L ASSISTANCE D R U G P R O G R A M (T ITLE XIX)


Type of Benefit Categorically Needy Medically Needy (MN) Mher'

OAA A0 APTD AFDC O M AB APTD AFDC Chlldren 21 W O )

Prescribed Oruos X X X X X X X

Hospital Care X X X X X X X outpatient Hospita Care X X X X X X X Laboratory & X-ray Service X X X X X X X Skllied Nursing Home Services X X X X X X X X Phys~clan Services X X X X X X X X Dental Services X X X X X X X X

Other Benefits: Intermediate Nursing Services, Rural Health Clinics, Durable Medical Equipment and Medical Supplies, Prosthetics and Orlhotlcs, Vision Care.

^SF0 - State Funds Only

II. EXPENDITURES FOR DRUGS. Pdyment to Pharmacists by f i xa i year ending June 30, 1984


T O T A L . . . . . . . . . . . . . . . . . . . . . $8,449,268 115,838.' $5,913,547 98,779

CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $6832.080 97,636 $4,773,176 82,228 Aged . . . . . . . . . . . . . . . . . . . . . . 2,002,767 12,741 1,570,547 12,729 Blind . . . . . . . . . . . . . . . . . . . . . . 36,380 231 26,913 233 Disabled . . . . . . . . . . . . . . . . . . . . . 2,798,949 17,387 2,053,003 16,299

. . . . . . . . . . . . Chiidren-FamiiieswIDep Children 915,794 40,400 484,362 31,779

. . . . . . . . . . . . Adults-Families wIOep Children 1,070.291 26.834 638.351 21,550

CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . $1,317,309 12,936 $918,353 11,444 Aged . . . . . . . . . . . . . . . . . . . . . . 922,828 4,377 655,560 4,175 Wind . . . . . . . . . . . . . . . . . . . . . . 986 6 868 5 Disabled . . . . . . . . . . . . . . . . . . . . . 216,529 1,228 154,566 1,202

. . . . . . . . . . . . Children-Families wIDep Children 57,608 3,302 37,071 2,802

. . . . . . . . . . . . Aduits-Families wIOep Children 88.273 3,184 58,023 2,812 Other Title XIX Recipients . . . . . . . . . . . . . . . 0 0 10,465 476

. . . . . . . . . . . . . . MEDICALLY NEEDY TOTAL $299,879 7,069 $224,018 6.615 Aged . . . . . . . . . . . . . . . . . . . . . . 100,601 1,448 83,210 1,445 Blind . . . . . . . . . . . . . . . . . . . . . . . 821 8 420 7 Disabled . . . . . . . . . . . . . . . . . . . . . 92,328 1,120 67,859 1.095

. . . . . . . . . . . . Chiidren-Families w/Oep Children 35,265 2,261 26.179 2.1M

. . . . . . . . . . . . Aduits-Families wIOeo Children 70.864 2.248 46.350 2.004 . . . . . . . . . . . . . . . Other Title XIX ~ec i~ i en t s 0 0 0 0


NPC West Virginia-2 1985

Ill. ~dministraiion:

The Division of Medical Care, Department of Human Services, is the medical assistance unit repon- sible for the administration of the Title XIX program. Eligibility for program benefits is determined by the local Welfare offices for AFDC and medically needy individuals. Individuals eligible for SSI benefits are covered for Medicaid as categorically needy, aged and disabled.


PROGRAM COVERAGE

A. All covered drugs, whether legend or non-legend, must be-prescribed by a physician or other practitioner qualified under State law. Applicable State and Federal law governing dispensing of drugs and biologists must be followed:

Drugs identified in the Medicaid Drug Formulary, listed by product or therapeutic class, are covered without prior authorization.

COVERED SERVICES

1 . Legend Drugs

Legend drugs including injectables are covered unless specifically excluded.

2. Non-Legend Drugs

The following non-legend drugs are covered:

(a) Family planning supplies. (b) Insulin. (c) Diabetic syringes, needles, and testing kits. (d) ESRD vitaminhitamin mineral preparations, and other medications related to End Stage

Renal Disease services.

Exception:

Non-legend drug coverage does not apply for clients residing in long-term care facilities (SNFIICF).

COVERAGE WITH PRIOR AUTHORIZATION

Consideration may be given on special drug needs of a client by the Medical Director on an individual basis based on medical information supplied by the attending physician in the format specified by the State.

Specific items covered by prior authorization are:

1. Antibiotics and analgesics for chronic usage; i.e.. over ten days.

2. Medical supplies and equipment. Medical supplies; i.e.. bandages, colostomy bags, under- pads, and other items required for home care, and covered by the Department based on a treatment plan developed for the individual client.

3. Vitaminlvitamin mineral preparations for End-State Renal Disease patients and other medications related to End-Stage Renal Disease services.

4. Life sustaining, critical, or necessary drugs not included in the formulary.

EMERGENCY COVERAGE

If a physician determines that a particular drug is needed for his patient which is not included on the formulary list, and is not excluded from progrm coverage, and that an emergency situations exists, he may so indicate by writing "emergency" on the prescription above his signature. These prescriptions will be covered up to a ten-day supply with no refill. Continuous therapy, if needed, will require prior authorization.

West Virginia-3 1985

NON-COVERED SERVICES

The following drugs and drug products are not payable:

1. Non-legend drugs except for those identified in IV. A.2.

2. Legend drugs and drug products as follows:

(a) Appetite depressants andlor drug products for weight control. (b) Fecal softening agents; laxatives. (c) Food, food products-as labeled by F.D.A. (d) Experimental drugs; i.e., drugs under development, in clinical testing, or other processes

short of being fully approved by the F.D.A. (e) Oral vitamins, vitamin and mineral combinations, geriatric tonics. (f) "Minor tranquilizers" identified by the Department.

(g) Drugs determined by the F.D.A. of the Department of Health and Human Services to lack substantial evidence of effectiveness published in the Federal Register, Volume 46, Number 210, dated Friday, October 30. 1981. Also, identical, related or similar drugs are included.

3. Exceptions:

The following exceptions are made:

(a) Vitamins A, K, and D. (b) Vitaminlvitamin and mineral preparations for End-Stage Renal Disease patients, and other

medications related to End Stage Renal Disease services.

HANDICAPPED CHILDREN'S SERVICES PROGRAM

1. Pharmacy Services

Services are available for certain children under 21 years of age receiving medical care within the Division of Handicapped Children's Services. These services are not limited to children of families receiving public assistance grants.

2. Scope of Services

Prescriptions are limited to a one-month supply with maximum of five monthly refills in any six-month period.

B. Formulary: West Virginia Medicaid Drug Formulary List

For information contact: Bernard Schlact Pharmacy Consultant W.V. Department of Human Services Division of Medical Care 1900 Washington Street, E. Charleston, West Virginia 25305 3041348-8990


QUANTITY AND FREQUENCY

Covered legend and non-legend drugs are payable as prescribed by a licensed practitioner up to a 30-day supply with a maximum of five refills.

Exception:

1. Antibiotics and analgesics are limited to a maximum of ten days with no refills. (See prior authorization.)

2. Excluding phenobarbital, sedatives and hypnotics are limited to a maximum of 30 days with no refills.



1. Maximum reimbursement for each drug claim processed will be based on the lowest of:

(a) The maximum allowable cost (MAC) for each multiple-source drug as defined by the Pharmaceutical Reimbursement Board and published in the Federal Register plus a dispensing fee. See Appendix G for listing of MAC drugs.

Exception:

The MAC shall not apply in any case where a physician certifies in his own handwriting that in his medical judgement a specific brand is medically necessary for a particular patient. A notation like "brand necessary" written by the physician on the prescription above the physician's signature is an acceptable certification. A procedure for checking a box on a form will not constitute an acceptable certification.

All such certified prescriptions must be maintained in the pharmacy files and made available for inspection by the Department of Health and Human Services and the Department of Welfare.

(b) The estimated acquisition cost (EAC) for each multiple-source drug as defined by the State plus a dispensing fee.

(c) The acquisition cost or average wholesale price (AWP) for all other prescribed drugs plus a dispensing fee.

(d) The usual and customary price charged by the pharmacy to the general public including any sale price which may be in effect on the date of service.

APPLICATION OF DISPENSING FEE

A. For covered legend and non-legend drugs, a professional dispensing fee of $2.75 will be added to the Federally established MAC or State-established acquisition cost price of each prescribed drug.

B. For a compounded prescription, an additional $1.00 will be added to the dispensing fee. A compound prescription is defined as any legend medicament requiring a combination of any two or more substances to exclude normal reconstitution operations.

C. Unit dose drug delivery systems are reimbursed under the same provisions as other legend drug services to Medicaid patients. Legend drugs are reimbursed on a 30-day basis regardless of drug delivery system or how the pharmacist may choose to dispense.

CO-PAYMENT

A co-payment is required for each prescription filled on and after March 10, 1981, with the exception of those items specifically excluded from the co-pay requirement. The recipient co-payment per prescription will be deducted from the maximum allowable payment (prescription charge formula) to determine the amount payable for each prescription billed to the programs.

The deduction will apply as follows:

1. If the maximum allowable payment is under $10.99, the reduction will be $0.50 per prescription.

2. If the maximum allowable payment is $1 1 .OO or more, the reduction will be $1 .OO per prescription.

Excluded from the Co-Pay Requirement:

(a) Family Planning Services and Supplies.

(b) Prescriptions originating with the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT).

NPC

V. Miscellaneous

Claims processor:

West Virginia- $ 19p


The Computer Company Richmond. Virginia

Number of claims processed in FY 1984-895,271




Sharon 6. Lord, Ph.D, Commissioner

Assistant Commissioner Medical Services

J. L. Mangus. M.D. Medical Director (Half-time) Division of Medical Care

(Mrs.) Helen M. Condry, Director Division of Medical Care

Auburn A. Cooper Administrative Assistant Division of Medical Care

William 6. Rossman, M.D Psychiatrist Consultant

West Virginia Department of Human Services

1900 Washington Street, East Charleston, W. Va. 25305

-3, R.Ph. Pharmaceutical Coordinator 3041348-8990

Bert Bradford, Jr.. M.D. Medical Consultant (Part-time)

Robert Crawford, M.D. Medical Consultant (Part-time)

F. A. Sines, D.D.S. Dental Consultant (Part-time)

David Heitmeyer, Section Chief Research & Statistics Unit

2. Welfare Department Medical Services Advisory Council:

A. Medical Sewice Fund (MSF) Advisory Council Members:


Regular Members

Mr. Fred Blair, Executive Director Ohio Valley Medical Center, inc. 2000 Eoff Street Wheeling 26003

Mrs. Alice M. Couch, Administrator Valley Haven Rest Home, Inc. R.D. 2, Box 44 Wellsburg 26070

Jack E. Fruth. R.Ph. Fruth Pharmacy 2501 Jackson Avenue Pt. Pleasant 25550

Mr. Joseph Powell, President West Virginia Labor Federation (AFL-CIO) 501 Broad Street Charleston 2531 1

Mr. Daniel W. Farley, Administrator Glenwood Park United Methodist Home Route 1, Box 464 Princeton 24740

L. Clark Hansbarger, M.D., Director West Virginia Department of Health 1800 Washington Street, East Charleston 25305

Thomas L. Carson, R.Ph, College Drug Store, Inc. Drawer 510 Montgomery 251 36

Ms. Nancy W. Comer 360 Laurel Street Morgantown 26505

Mr. Robert Eakin, President Memorial General Hospital 1200 Harrison Avenue Elkins 26241

Mrs.Carol J. Miller, Director Healthwise, Inc. (HMO) Suite 313-Raleigh County Bank Building Beckley 25801

Mrs. Opal Riling 1546 Kanawha Boulevard, East Apartment 719 Charleston 2531 1

Harry Shannon, M.D. P.O. Box 659 Parkersburg 26101

Ms. Patricia Sumner Route 2, Box 214 Hurricane 25526

Mrs. Jackie Withrow 1301 Maxwell Hill Road Beckley 25801

Mrs. Rita Tanner 1 100 Louise Avenue Morgantown 26505

Mr. Mark Nesselroad, General Manager West Virginia Operations Crossgates, Inc. 3555 Washington Road McMurray, Pennsylvania

Alternate Members

Ms. Sarah M. Kerns 1546 Kanawha Boulevard, East Apartment #305 Charleston 2531 1

Mr. Jack R. McComas, Secretarynreasurer West Virginia Labor Federation AFL-CIO 501 Broad Street Charleston 25301

Linda R. Hickman, R.N. Operations Supervisor Healthwise, Inc. (HMO) Suite 313, Raleight County Bank Building Beckley 25801

Mrs. Edith Sanderson C/O Beckley Farmer's Market Box 117 Skelton 25955

West Virginia-8 1985

B. Welfare Committee Members of the West Virginia Pharmaceutical Association:

Mr. Arlie Winters, Jr., Chairman P. 0. Box 96 Berkeley Springs 2541 1

S. Elwood Bare 1002 Greenbriar Avenue Ronceverte 24970

Benjamin Carson 409 Monroe Street Montgomery 251 36

Ann Bond Smith P.O. Box 225 Clendenin 25036

David Dowyer, Student Representative West Virginia University School of Pharmacy Morgantown 26506


A. Medical Association: 8. Pharmaceutical Association:

Bert Scholten Executive Secretary West Virginia State

Medical Association Box 1031 Charleston 25324 Phone: 3041346-0551

C. Osteopathic Medicine:

A. Robert Dzmura, D.O. 4850 Eoff Street Benwood 26031 Phone: 3041233-1 656


Richard D. Stevens Executive Director West Virginia Pharmacists Association Suite 4 4004 MacCorkle Avenue, SE Charleston 25304 Phone: 3041925-7204

C. Herbert Traubert, Secretary 150 Rockdale Road Follansbee. West Virginia 26037 3041527- 1270

NPC

WISCONSIN

M E D I C A L A S S I S T A N C E D R U G P R O G R A M (TITLE XIX)


Type of Benefit

Prewrihnrl

Categorically Needy Medically Needy (MN) Other'

OAA AB APT0 AFDC OAA AB APT0 AFDC Children 21 (SF@

. . -- -. . - - - Oruos X X X X X X X X X X



Laboratory & X-rav Service X X X X X X X X X X

Skilled Nursing Home Services X X X X X X X X X X Physician Services X X X X X X X X X X Dental Services X X X X X


II. EXPENDITURES FOR DRUGS. Pavrnent to Pharmacists bv fiscal vear ending June 30. 1984


. . . . . . . . . . . . . . . . . . . . . T O T A L $46,871,019 329.964"

CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind

Disabled . . . . . . . . . . . . . . . . . . . . Children-Families w/Dep Children . . . . . . . . . . . . Adulk-Families w/Dep Children . . . . . . . . . . . .


. . . . . . . . . . . . . . . . . . . . . Disabled Children-Families w1Dep Children . . . . . . . . . . . .


MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aged . . . . . . . . . . . . . . . . . . . . . . Blind

. . . . . . . . . . . . . . . . . . . . . Disabled Children-Families w/Dep Children . . . . . . . . . . . . Adults-Families w/Dep Children . . . . . . . . . . . . Other Title XIX Recipients . . . . . . . . . . . . . . .

1983 Exoended Reci~ient



The State Department of Health and Social Services.



1. Legend laxatives and nonprenatal vitamins.

2. All non-legend pharmaceuticals except Insulin, antacids and analgesics.

6. Formulary: No.


1. Quantity of Medication: Pharmacists may not dispense more than 34-day supply of a legend drug.

2. Refills: Maximum of 11 refills during a 12-month period for non-scheduled medications.



1. Traditional (non-unit dose) dispensing reimbursed at the lowest of: Estimated Acquisition Cost (EAC) plus $3.61 professional fee; Maximum Allowable Cost (MAC) plus $3.61 professional fee; or providers usual and customary

2. Unit Dose Dispensing:

Reimbursement at the lowest of: Estimated Acquisition Cost (EAC) plus $5.56 professional fee; Maximum Allowable Cost (MAC) plus $5.56 professional fee; or providers usual and customary.

Reimbursement limited to one unit dose professional fee per drug per month.


A. Prior Authorization Required on the Following Drugs:

1. All anorectics 2. Cephulac 3. Debrisan

4. Derifil 5. Decubitex

6. Medically Needy Recipients

Medically Needy recipients who do not reside in a Skilled Nursing Facility (SNF) or lntermediate Care Facility (ICF) are eligible for only five categories of legend drug:

1. Antibiotics 2. Anticonvulsants 3. Muscle Relaxants

4. Psychotropics 5. Family Planning Drugs

C. Copayment

All legend and over-the-counter drugs except family planning drugs are subject to a $SO copayment. Residents of Skilled Nursing Facilities (SNF) or lntermediate Care Facilities (ICF), subsidized adoption recipients, children under age 18 and HMO enrollees are exempt from the copayment. (Copayments limited to 10 per month)

D. State MAC Program-Yes. (145 entities; 69 separate compounds)

E. Fiscal Intermediary:

EDS-FederW

F. Number of claims processed in FY 1984-2,4638,506

G. Average Rx price during FY 1984-$10.41



Linda Reivitz Secretary

Katie Morrison Administrator Division of Health

Steve Handrich Director Bureau of Health Care Financing (Medicaid)

Department of Health and Social Services State Office Building One West Wilson Street Madison, Wisconsin 53702

Alfred Dally, M.D. Physician Consultant

Michael Boushon Pharmacy Practices Cons~ltant 6081266-0722



Earl Thayer Secretary-General Manager State Medical Society of Wisconsin 330 East Lakeside Box 1109 Madison 53701 Phone: 6081257-6781


Mr. Robert J. Finnegan Executive Director Wisc. Assn. of Osteopathic

Physicians and Surgeons 34615 Road E. Oconomowoc 53066 Phone: 4 141567-0520

Robert E. Henry Executive Director Wisconsin Pharmaceutical Assoc. 202 Price Place Madison 53705 Phone: 6081238-5515


Sharon Russell, Program Assistant P.O. Box 8936 1400 East Washington Avenue Madison, Wisconsin 53708 6081266-8794

NPC

W Y O M I N G




O M AB APT0 AFDC O M AB APT0 AFDC Children 21 (SF01

Prescribed Drugs


Outpatient Hosoital Care X X X X

Laboratory & X-ray service X X X X

Skilled Nursing Home Services X X X X Physician Services X X X X Dental Services

Olher Benefits: Dental and optometric services, eyeglasses and hearing aids for eligible patients under 21 years ol age, home services.


II. EXPENDITURES FOR DRUGS.

1984 1983 Exoended Recioient Exoended Recioient

. . . . . . . . . . . . . . . . . . . . . T O T A L

. . . . . . . . . . CATEGORICALLY NEEDY CASH TOTAL Aged . . . . . . . . . . . . . . . . . . . . . . Blind . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . Disabled Children-Families w/Dep Children . . . . . . . . . . . . Adults-Families w/Dep Children . . . . . . . . . . . .


. . . . . . . . . . . . . . . . . . . . . Disabled No vendor - Children-Fanilies w/&p Children . . . . . . . . . . . . drug program







The Medical Assistance Program is administered by the Division of Medical Services of the Department of Health and Social Services.


No state vendor drug program



Kathleen Kardan Director

Department of Health and Social Services 317 Hathaway Building Cheyenne, Wyoming 82002



Roger Brown Executive Secretary Wyoming State Medical Society 1920 Evans P. 0. Drawer 4009 Cheyenne 82001 Phone: 3071635-2424

Laramie, Wyoming 82070 Phone: 3071766-6126


David A. Vick, D.O. Secretary-Treasurer Wyoming Association of Osteopathic Physicians and Surgeons ' Box1 298 Worland 82401

Marilynn H. Mitchell, Executive Director 1720 S. Poplar Street. Suite 5 Casper, Wyoming 82601 307/234,0294

NATIONAL PHARMACEUTICAL COUNCIL, INC.

ABBOTT LABORATORIES Abbott Park North Chicago, Illinois 60064

BOEHRINGER INGELHEIM LTD. 90 East Ridge Ridgefield, Connecticut 06877

BURROUGHS WELLCOME CO. 3030 Cornwallis Road Research Triangle Park, NC 27709

CIBA-GEIGY CORPORATION 556 Morris Avenue Summit, New Jersey 07901

DuPONT PHARMACEUTICALS One Rodney Square Wilmingtan, Delaware 19898

GLAXO INC. Five Moore Drive Research Triangle Park, NC 27709

PARKE-DAVIS 20 1 Tabor Road Morris Plains, New Jersey 07950

PFIZER INC. 235 East 42nd Street New York, New York 10017

A.H. ROBINS COMPANY 1407 Sherwood Avenue Richmond, Virginia 23220

ROCHE LABORATORIES 340 Kingslond Street Nutley, New Jersey 07 l I 0

SANDOZ PHARMACEUTICALS Route 10 East Hanover, New Jersey 07936

SCHERING PLOUGH CORPORATION Galloping Hi l l Road Kenilworth, New Jersey 07033

HOECHST-ROUSSEL PHARMACEUTICALS INC. SEARLE PHARMACEUTICALS Route 202-206 North Sornerville, New Jersey 08876

LEDERLE LABORATORIES Berdan Avenue Wayne, New Jersey 07470

ELI L lLLY AND COMPANY 307 East McCarty Street Indianapolis, Indiana 46285

MARION LABORATORIES, INC. 10236 Bunker Ridge Road Kansas City, Missouri 64137

McNEIL PHARMACEUTICALS Spring House, Pennsylvania 19477

MERCK SHARP & DOHME Division of Merck & Co. West Point, Pennsylvania 19486

MERRELL DOW PHARMACEUTICALS, INC. 2 1 10 East Galbraith Road Cincinnati, Ohio 45215

NORWICH EATON PHARMACEUTICALS 17 Eoton Avenue Norwich, New Yark 13815

5200 Old Orchard Road Skokie, Illinois 60077

SMITH KLlNE & FRENCH LABORATORIES P.O. Box 7929 Philadelphia, Pennsylvania 19101

E.R. SQUIBB & SONS, INC. P.O. Box 4000 Princeton, New Jersey 08540

STUART PHARMACEUTICALS Division o f ICI Americas Inc. Wilrnington, Delaware 19897

SYNTEX LABORATORIES 340 1 Hillview Avenue Palo Alto, California 94304

THE UPJOHN COMPANY 7000 Portage Road Kalamazoo, Michigan 49001

USV LABORATORIES 303 South Broadway Tarrytown, New York 1059 1

WINTHROP-BREON LABORATORIES 90 Park Avenue New York, New Yark 10016

ORTHO PHARMACEUTICAL CORPORATION Route 202 Raritan, New Jersey 08869

Companies Abbott Paboratories

Boehringer lngelheim Ltd. Burroughs Wellcome Co. ' Ciba-Geigy Corporation DuPont Pharmaceuticals

Glaxo Inc. ~oechst-Roussel Pharmaceuticals, Inc.

Johnson & Johnson Lederle Laboratories Eli Lilly and Company

Marion Laboratories. InC. Merck Sharp & Dohme

Merrell Dow Pharmaceuticals Inc. Norwich Eaton Pharmaceuticals

Parke-Davis -..

Pfizer Inc. .. ~ A. H. Robins Company

Roche Laboratories .- ~ , Sandoz Pharmaceuticals

Schering Corporation Searle Pharmaceutical Group

Smith Kline & French Laboratories E. R. Squibb &Sons. Inc. Stuart Pharmaceuticals

~ - Syntex Laboratories. Inc.

The Upjohn Company USV Laboratories

Winthrop-Breon ~aboratories

Documents

Pharmaceutical Benefits Under State Medical Assistance Programs, 1985