Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
UNDER
STATE MEDICAL ASSISTANCE
PROGRAMS
SEPTEMBER 1985
1
NATIONAL PHARMACEUTICAL COUNCIL. INC
QULSrq T L z ~ u 4~ zLx 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.
Introduction
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 (1979to 1984)
e. Recipients of Prescribed Drugs (1979to 1984)
f. Average Expenditures per Recipient for Prescribed
Drugs (1979to 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
iii
NPC-I
5. Miscellaneous:
The National Pharmaceutical Council, lnc, is dedicated to the enhancement of the quality and integrity
of pharmaceutical services in research, development, manufacturing, and dispensing of prescription
medications and other pharmaceutical products.
The National Pharmaceutical Council, Inc. was founded in 1953 by companies engaged primarily in
the discovery, development, production, and marketing of innovative prescription medicines. Today,
our twenty-eight member companies continue their commitment to major programs of pharmaceutical
research and maintain exacting quality control standards.
Toward this end, NPC undertakes educational activities and provides services to physicians, phar-
macists, manufacturers, professional associations, colleges of pharmacy, medical schools, government
offices and consumers concerning key aspects of health care. NPC services include providing informa-
tion on the quality and cost-effectiveness of pharmaceutical products, the economics of drug programs,
and the notable contributions of research oriented pharmaceutical manufacturers.
Methodology
The statistics and characteristics of each state Medicaid program were obtained from an NPC survey
of state Medicaid program administrators and pharmacy consultants. Other statistics were reported by
the HCFA Medicaid Statistics Branch, Department of Commerce, and state pharmaceutical association
executives.
The narrative and descriptive material was condensed from the Code of Federal Regulations (CFR42),
supplemented by material contained in HCFA publication, "Analysis of State Medicaid Program
Characteristics, 1984" published March, 1985.
"'Acknowledgements -
NPC acknowledges the cooperation and assistance of the many state Medicaid program officials and
their staffs, state pharmaceutical associations, Health Care Financing Administration personnel and
others in supplying data for this compilation.
NPC
PHARMACEUTICAL BENEFITS
UNDER STATE MEDICAL ASSISTANCE PROGRAMS
Medicaid (Title XIX of the federal Social Security Act) is a program of medical assistance, funded by
the federal government and the states, for impoverished individuals who are aged, blind or disabled,
or members of families with dependent children. The states and Puerto Rico, Guam, Virgin Islands and
Northern Mariana Islands each operate Medicaid programs according to state or territorial rules and
criteria that vary widely within a broad framework of federal guidelines, except that Arizona operates a
program as an alternative to Medicaid under a waiver of some basic Medicaid requirements. Federal
funding has also been provided for a Medicaid program in American Samoa.
The original Social Security Act, which was enacted in 1935, made no direct provision for medical
assistance. However, it did establish a system of "categorical" public assistance that allowed the
federal government to share with states the cost of providing maintenance payments to the needy aged
and blind, and to needy families with dependent children. This assistance, which was subsequently
extended to the permanently and totally disabled, could include the cost of some medical care in monthly
assistance payments to recipients.
In 1950, public assistance under the Act was broadened to include federal sharing in "vendor pay-
ments," i.e., direct payments by a state to doctors, nurses, and health care institutions, rather than
to the welfare recipient himself. Although federal sharing in vendor payments created an administra-
tive framework for a welfare medical program, federal funding was so small that only a few states par-
ticipated. Subsequent amendments to the Act made more federal funds available so that, by 1965,
all of the states provided medical vendor payments in their federally aided categorical assistance pro-
grams. Many states also offered an allowance for some items of medical care in welfare payments to
categorical assistance recipients.
Despite these expanded federal and state efforts, the need for medical assistance became so great
that most states could finance only a few services. To help satisfy this need, Title XIX or "Medicaid" was
enacted in the Social Security Amendments of 1965, providing grants to states for medical assistance
programs beginning January 1, 1966. By January 1, 1967, more than half of the states had Medicaid
programs, and by 1970, all of the states except Alaska (which later implemented one) and Arizona
(which implemented an alternative to Medicaid in 1982) had programs. As a result, the federal financial
participation in medical care that had been available through the categorical public assistance programs
was ended because of the availability of federal Medicaid funds and the administrative advantages of
offering medical care exclusively through Medicaid.
The program operates on the basis of a state and federal division of responsibilities. The federal
government establishes regulations, guidelines and policy interpretations which describe the broad
outline within which states can tailor their individual programs. States assume control and direction
of operations. As a result there are 56 (50 states, pius Guam. District of Columbia, Puerto Rico, Samoa,
NPC 1985
Northern Mariana Islands and the Virgin Islands) disiinctly different programs in operation. Funding
is shared between the two bodies, with the federal government matching state health care provider
reimbursements of an authorized rate between 50% and 83% depending on the states per capita income.
Federal law governs certain aspects of Medicaid, and requires that all persons who qualify for Aid
to Families with Dependent Children (AFDC) and most persons who qualify for Supplemental Security
Income (SSI) receive Medicaid coverage. The Federal Government requires states to provide a basic
set of services to people eiigible for Medicaid and to reimburse providers of those services in certain
ways. Reimbursement levels for many sewices are subject to federally established ceilings and, in some
instances, floors.
The states' control over eligibility, for example, is substantial, because states establish eligibility
for AFDC which establishes eligibility for Medicaid. (The same does not hold true for SSi recipients,
whose eligibility is determined primariiy by Federal criteria.) Furthermore, states may voluntarily extend
Medicaid coverage to additional groups of people and expand the range of services covered. States also
have considerable freedom in choosing reimbursement methods for physicians and other health care
providers. Title XIX of the 1965 Social Security Amendments provide the legislature basis for Medicaid.
Medicaid should not be confused with Medicare, which was also established by the Social Security
Amendments of 1965. Medicare is a federally administered medical insurance program for the elderly,
which is administered by the Social Security Administration (SSA).
ADMINISTRATION
Administration of the state Medicaid program is vested in single state agencies. Within each agency,
state plans must designate a medical assistance unit responsible for developing, analyzing, and evaluat-
ing the Medicaid program. The law further requires the states to establish medical care advisory com-
mittees to advise the Medicaid agency director about health and medical services. This committee
must include board certified physicians and other representatives of the health professions, members
of consumer groups, and the director of either the state public welfare or the public health department
(whichever department does not run the Medicaid agency). Activities for administering the state Medicaid
program include: program administration, Medicaid Management Information System (MMIS), claims
processing activity, state administration, and waivers.
Eligibility Determination and Program Administration
States are aiiowed three options for administering coverage of SSI recipients (42 CFR 431.10(c)):
States electing to extend Medicaid to all SSI recipients can enter into an agreement with the Social
Security Administration under Section 1634 of the Act for determi-nations of Medicaid eligibility;
States electing to extend Medicaid eligibility to recipients of SSI can maintain eligibility determinations
on a state level; or
States electing the 209(b) option (where recipients of cash assistance under SSI are not automatically
eligible for Medicaid) can require cash assistance recipients to make a separate application for Medicaid.
Thirty states elected to have federai determination and those 30 states expended 74.4 percent of total
Medicaid expenditures in 1983. Six states elected to extend Medicaid to all recipients of SSI but maintain
eligibility determination on a state level. Those six states expended only 3.0 percent of total Medicaid
expenditures in 1983. Fourteen states elected the 209(b) option, consisting of 22.6 percent of total
Medicaid expenditures.
A state plan must be in operation statewide through a system of local offices under equitable standards
for assistance and administration that are mandatory throughout the state (42 CFR 431.50jb)). However,
the state may choose to administer the program on the state level or by political subdivision of the state.
Forty-four states have chosen to administer the Medicaid program on a state level and accounted for
60.3% of total Medicaid expenditures in 1983. Six states have chosen local administration and those
six states accounted for 39.7 percent of total Medicaid expenditures in 1983. What this means is that
in those states whose program is locally administered, the state plan is mandatory on each of the
political subdivisions. The local administrations do not have the authority to change or disapprove any
NPC 1985
administrative decision of the state Medicaid agency with respect to the application of policies, rules,
and regulations issued by the Medicaid agency.
A state plan must specify a single state agency, established or designated, to administer or supervise
the administration of the plan (42 CFR 431.10(b)). Generally, the administering agency has been the
state health agency; welfare agency, or an umbreila agency. A possible effect of the administering
agency being the health department is that the welfare department has control over the intake of
eligibles in the AFDC and SSliSSP programs, individuals who automatically become eligible for Medicaid.
This separation could create a span of control problems for the Medicaid agencies. Five states have
designated the health depanment, 22 states have designated the welfare department, 20 states have
designated an umbrella agency, and three states have designated other agencies to administer the
Medicaid program. The "other" agencies included the office of the Governor in Alabama and an
independent agencylcommission in Georgia and Mississippi.
SERVICE COVERAGE
The original Title XIX legislation listed fifteen types of medical care for which federal funding would
be received. The last one was very general in nature specifying that "any other medical care, and any
other type of remedial care recognized under state law" was eligible for federal support. By 1970, 21
types of medical care were specified and by 1979, over 30 medical services were listed as acceptable
Medicaid services. Medicaid services can be grouped into seven major categories as follows:
I. Professional Services-treatments provided by physicians, optometrists, dentists, etc.
I!. Nursing Care Services-types of care provided by nurses in hospitals, patient's homes, clinics,
nurse-midwife services, etc.
Ill. Nursing Home Services-types of care available in nursing homes, such as skilled, intermediate, or
general nursing care.
IV. Hospital and Clinic Services-services provided at a hospital, clinic, or other type of medical
treatment center (does not include nursing homes).
V. Drugs, Supplies, and Equipment-includes prescribed drugs and any supplies or equipment needed
to aid in the treatment of a medical problem.
VI. Special Services and Therapy-includes screening, diagnostic, and preventive services as well as
therapy for physical, occupational, or communication disorders.
VII. Institutional Care-care provided to individuals during their stay at mental institutions or tuberculosis
hospitals (includes any institutional stay other than that at regular hospitals or nursing homes).
~lll.0ther-any services provided which facilitate medical treatment that are not covered by any of the
above categories.
MANDATORY SERVICES
In order to participate in Medicaid, there are certain basic services that must be offered in a state's
Medicaid program. There were five of these mandatory services specified in the original legislation of
1965. These services were:
1. lnpatieni hospital services
2. Outpatient hospital services
3. Physician services
4. Independent laboratory and X-ray services
5. Skilled nursing home services. (This service had to be provided only to eligible persons twenty-one
years of age or older.)
NPC
The six additional mandatory services added since 1965 are listed below:
6. Early and periodic screening, diagnostic, and treatment program
7. Family planning services and supplies
8. Home health care services
9. Patient transportation
10. Rura! Health Clinic Services
11. Nurse-midwife services
OPTIONAL SERVICES
In addition to these required programs, the participating states may elect to offer additional services.
Some of these services are defined in the Medicaid rules and regulations. Others have been defined
through federal acceptance of a particular service in a state's plan. A state may include any type of care
recognized under state law and authorized by the Secretary of the Department of Health and Human
Services.
MEDICAID ELIGIBILITY
Medicaid s; the primary source of health care coverage for the poor in America. Through it, medical
services are provided primarily to those people who are eligible to receive cash payments under one of
the existing welfare programs established by the Social Security Act. Basically these eligible persons
fall into two categories those whose eligibility for Medicaid services is mandated at the federal level
and those whose eligibility is determined by the individual state. These categories are described in the
sections below.
Mandatory Coverage
Every state, in order to receive Title XIX funding, must provide Medicaid benefits to certain groups of
"categorically needy" persons. In order to be considered "categorically needy" for Medicaid purposes,
an individual must be receiving financial assistance (maintenance payments), or be eligible for financial
assistance, under Title'XVI, Supplemental Security Income for the Aged, Blind, and Disabled (SSI).
The two largest of these "categorically needy" groups are persons already receiving maintenance
payments through the Aid to Families with Dependent Children program or through the Supplemental
Security Income program. Other groups that are categorically needy and thus automatically eligible for
Medicaid are recipients of mandatory state supplements and persons affected by increases in Social
Security payments.
NPC 1985
MEDICAID SERVICE
(Mandatory Services Indicated by Capital Letters)
I. Professional Services
PHYSICIAN SERVICES
Chiropractors' Services
Podiatrists' Services
Optometrists' Services
Other Practitioners' Services
Dental Services (for persons 21 years of age and older)
II. Nursing Care Services
HOME HEALTH CARE SERVICES (for persons 21 years of age or older)
Personal Care Services
Private Duty Nursing
NURSEMIDWIFE SERVICES
Adult Day Treatment Services
Ill. Nursing Home Services
SKILLED NURSING FACILITY SERVICES (for persons 21 years of age or older)
Intermediate Care Facility Services
Skilled Nursing Facility Services (for persons under 21 years of age)
IV. Hospital and Clinic Services
INPATIENT HOSPITAL SERVICES
OUTPATIENT HOSPITAL SERVICES
RURAL HEALTH CLINIC SERVICES
Clinic Services
Emergency Hospital Services
V. Drugs, Supplies and Equipment
Prescribed Drugs
Dentures
Eyeglasses (for persons 21 years of age and older)
Hearing Aids (for persons 21 years of age and older)
Prosthetic Devices
Vl. Special Services and Therapy
INDEPENDENT LABORATORY & XRAY SERVICES
EARLY & PERIODIC SCREENING, DIAGNOSIS & TREATMENT (EPSDT)
OF CHILDREN (under 21 years of age)
FAMILY PLANNING SERVICES
Diagnostic Services (for persons 21 years of age and older)
Screening Services (for persons 21 years of age and older)
Preventive Services
Physical Therapy
Occupational Therapy
Occupational Therapy
Treatment for Speech, Hearing and Language Disorders
VII. Institutional Care
Inpatient Psychiatric Services (for persons under 22 years of age)
Care in Tuberculosis Institutions (for persons age 65 or older)
Care in Mental Institutions-Intermediate Care Facility Services (for persons age 65 or older)
Care in Mental Institutions-Skilled Nursing Facility (for persons age 65 or older)
Vlll. Othei
TRANSPORTATION TO & FROM MEDICAL SERVICES
Enrollment in Medicare-Part B, Title XVIII, Supplemental Medical lnsurance
Enrollment in Medicare-Part A, Title XVIII, Hospital lnsurance Benefits
6
NPC 1985
In addition to the services listed as being mandatory or optional, Title XIX specifies that "any other
medical care, and any type of remedial care recognized under state law, specified by the Secretary of
the Department of Health and Human Services," is acceptable as a Medicaid service and thus eligible
for federal support.
Optional Coverage
In addition to the groups that must be covered by the state's Medicaid programs, there are other
groups that are "categorically needy" or "medically needy" who may be included in Medicaid at the
Option of each state. That is, the participating states are not required to offer services to these people
unless they elect to do so.
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.
Physkians' Sewices
Physicians' sewices are covered whether provided in the office, the patient's home, a hospital, a skil!ed
nursing facility, or elsewhere. Physicians' services must be within the scope of practice oi medi, c: m or
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.
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.
Prescribed Drugs
Prescribed drugs are simple or compound substances or mixture of substances prescribed for the
cure, mitigation, or prevention of disease, or for health maintenance that are prescribed by a physician
10
NPC 1985
or other licensed practitioner of the healing arts within the scope of their professional practice as defined
and limited by federal and state iaw (42 CFR 440.120). The drugs must be dispensed by licensed
authorized practitioners on a written prescription that is recorded and maintained in the pharmacist's or
practitioner's records.
Two states, Alaska and Wyoming, do not provide prescribed drugs as a separate service to Medicaid
recipients. States place limits on prescription quantities in three different ways: number of prescriptions
that can be filled in a certain time period, number of prescriptions that can be refilled in a certain time
period, and quantity of each prescription.
States further limit prescribed drugs by restricting the quantity of medication for a single prescription.
Some of the "other limits" imposed on prescribed drug services are tha! brand name drug services must
be documented as medically necessary, refills must be filled by the same pharmacy as the original
prescription and flu and pneumococcal vaccines are covered only for persons age 65 and over.
state to perform. In addition to being licensed by the state, the chiropractor must also meet the standard
issued by the Secretary of HHS. These standards include age, education, and licensure standards.
Prosthetic devices are defined by 42 CFR 440.120(c) to mean replacement, corrective, or supportive
devices prescribed by a physician or other licensed practitioner of the healing arts within the scope of
practice as defined by state law. The devices must:
Artificially replace a missing portion of the body
Prevent or correct physical deformity or malfuncticn; or
Support a weak or deformed portion of the body.
Physical therapy according to 42 CFR 440.110(a) refers to services prescribed by a physician and
provided to a recipient by or under the direction of a qualified physical therapist. To be a qualified
physical therapist an individual must be licensed by the state, where applicable, and be a graduate
of a program of physical therapy approved by both the Council on Medical Education of the American
Medical Association and the American Physical Therapy Association or its equivalent. Physical therapy
includes any necessary supplies and equipment.
Occupational therapy (42 CFR 440.1 10(b)) refers to services prescribed by a physician and provided
to a recipient by or under the direction of a qualified occupational therapist. A qualified occupational
therapist is an individual who is either registered by the American Occupational Therapy Association or
who is a graduate of an approved occupational therapy program (by the Council on Medical Education
of the American Medical Association) and engaged in the supplemental clinical experience required by
the American Occupational Therapy Association. Occupational therapy services include any necessary
supplies and equipment.
Services for individuals with speech, hearing and language disorders are provided as an optional ser-
vice in 33 states. These services are diagnostic, screening, preventive, or corrective services provided
by or under the direction of a speech pathologist or audiologist for which a patient is referred by a
physician (42 CFR 440.110(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 s u p e ~ i s e dwork
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 440.130(d)) are medical or remedial services for reduction of physical
or mental disability and restoration of a recipient to his best possible functional level. The services must
be recommended by a physician or other li-censed practitioner of the healing arts within the scope of
his oractice under state law.
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.
The MMlS is a general systems design that can be tailored by state Medicaid agencies to their own
particular needs so long as the system meets federally required minimum performance standards. The
conceptual design includes six subsystems: recipient, provider, claims processing, reference file, sur-
veillance and utilization review, and management and administration reporting. The first four subsystems
work together with the overall objective of processing and paying each eligible provider for every valid
claim. The other two subsystems consolidate and organize data necessary for managing and controlling
the Medicaid program.
Forty-two states have certified MMlSs and operate a mechanized claims processing and information
retrieval system.
Davis and Schoen. Health and the War on Poverty, A Ten Year Appraisal; Brookings Institution, 1978.
Mitchell and Cromwell, "Large Medicaid Practices and Medicaid Mills," Journal of the American
Medical Association, November 1950.
NPC 1985
Quite inadvertently,the architects of the Medicaid program designed built-in reimbursement incentives
that would undermine its overall goal, access by the poor to quality mainstream medicine at reasonable
costs. In the iate seventies through 1980 states tried, with varying levels of success, to contain costs of
the program through the use of more stringent eligibility requirements, imposition of service cutbacks and
limitations, tighter administrative controls, and postponement of increases in physician and pharmacy
reimbursement. Although numbers of recipients declined, the cost per recipient continued to rise sharply.
It became obvious that something had to be done about Medicaid cost-based provider reimbursement
incentives for hospitals and nursing homes which had no real incentive to contain rising costs. Since
the unit of payment was per diem, there was even an incentive to maximize utilization so long as the
Medicaid revenue played a useful role in the overall financial health of hospitals and nursing homes.
Further, Medicaid eligibility rules led physicians to institutionalize patients so they would be eligible for
needed services. The first significant legislative step to redress provider incentives came in 1980 with
the Omnibus Reconciliation Act of 1980 (PL 96-499). The Act replaced Section 249(a) of the 1972 Social
Security Amendments requiring Medicare-based retrospective cost reimbursement principles for nursing
homes. States were freed to reimburse nursing homes on the basis of "reasonable and adequate to the
costs which must be incurred by efficiently and economically operated facilities." Many states moved
swiftly to implement prospective reimbursement methodologies to curb inflation in nursing home costs.
The second significant step in reforming Medicaid provider reimbursement came with passage of
the Omnibus Reconciliation Act of 1981 (PL 97-35). Among other things, the Act, implemented by
federal regulations on September 30, 1981, granted significant new flexibility to the states in setting
provider reimbursement policies for hospitals (Section 2173) and physicians (Section 2174) by relaxing
the constraints which tied payments to Medicare retrospective cost reimbursement principles. States
quickly began to adopt alternate payment methods tailored to their own unique needs. The Act gave
states waiver authority to restrict freedom of choice (section 2175) and to eliminate the institutional bias
towards institutional long-term care through home and community-based care (Section 2176). The Act
also gave the states new flexibility to enter into prepaid service arrangements with non-federally qualified
HMOs and to impose certain copayments on service use by Medicaid recipients.
The third significant piece of legislation affecting Medicaid provider reimbursement policies is the Tax
Equity and Fiscal Responsibility Act of 1982. TEFRA actually rescinded some of the flexibility given to the
states through OBRA 81 by removing the authority given to the Secretary of DHHS to grant waivers for
capitation and prepayment systems to other than federally quaiified HMOs and restricted the imposition
of nominal copayments by exempting from any copayment certain recipient types and services. The
TEFRA contained two other important provisions related to Medicaid reimbursement. The first was a
requirement that the Secretary of DHHS recommend a system of prospective reimbursement for the
Medicare program which might apply to the Medicaid inpatient reimbursement setting. The second was
an expansion of Section 223 limitations on hospital charges from routine hospital costs per day to the
cost per case, including ancillary costs. Special adjustments are to be made for hospitals which have
a disproportionate load of low income or Medicare patients, and for psychiatric hospitals. Non-SMSA
hospitals with less than 50 beds will be excluded from the limitations.
The final legislative step thus far to reform Medicaid provider reimbursement is the Social Security Act
Amendments of 1983. This Act mandates a three-year phase-in of a case rate prospective reimbursement
system for Medicare that could also be adopted by state Medicaid agencies. The Medicare Prospective
Payment System (PPS) is based on a prospectively determined rate for each patient according to age, sex
and diagnostically-related grouping (DRG). To date, several state Medicaid programs have adaptated
the new Medicare PPS concept to their own hospital reimbursement ~ y s t e m . ~
In summary, the above discussion represents a historical perspective or context in which to consider
how states altered their Medicaid provider reimbursement policies in recent years.
Only nursing home, inpatient hospital, physician, outpatient hospital, free-standing clinics and
prescription drug service reimbursement policies are included in this report. These services represent
over 90 percent of all Medicaid expenditures nationwide for fiscal year 1984.
Clinkscaie, Robert, "Impact of Medicare's Prospective Payment System (PPS) on State Medicaid
Programs,'' Proceedings, First National DRG Conference, Atlantic City, N.J., 1983.
NPC 1985
Post-OBRA Environment
By early 1984, only 17 states (17 percent of national inpatient expenditures) still used the Medicare
retrospective cost-based method. The other 33 states (83 percent of total inpatient expenditures)
had moved to adopt either an alternative plan or an experimental system of inpatient reimbursement.
States using experimental systems based on diagnostic-related groupings (DRGs) are New Jersey,
Pennsylvania, Michigan. Ohio, Vermont, and Washington. Most of the other states using alternative sys-
tems have tended toward facility-specific budget review, rate of increase control and forms of prospec-
tive rate-setting. Among those states that had departed from Medicare principles by early 1982, only
two had extended the method to private payers (Massachusetts and Rhode Island). The systems in
Maryland, New Jersey, and New York encompass all payers. The dates for states using alternative
methods represent the year in which the method was approved by DHHS and implemented. By early
1982 the method may have undergone modifications since its original approval. As a result of OBRA 81,
many other states are expected to abandon inpatient Medicare reimbursement principles.
Between March of 1983 and March of 1984, the states of Alaska, Arkansas, District of Columbia,
Georgia, Minnesota, Nevada, Oklahoma, Oregon, Tennessee, and Utah altered their Medicare-based
inpatient reimbursement systems to some form of prospective payment.
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.
Spitz, Bruce. State Guide to Medicaid Cost Containment, National Governors' Association and
Intergovernmental health Policy Project, September 1981
NPC 1985
Share with recipients, through the provision of additional services, savings resulting from
recipients' use of more costeffective medical care; and
Restrain recipients to receiving services (other than in emergency situations) from only efficient
and cost effective providers.
The waivers can be granted for a period of up to two years, and a state may request a continuation.
2. Drug Reimbursement. Title 45 PUBLIC WELFARE, Subtitle A Department of Health and Human
Services, Part 19-Limitations on Payment or Reimbursement for Drugs
Regulation Sec. 19.1. Purposes
(a) This establishes Department of Health and Human Services procedures for determining drug
costs and, where applicable, dispensing fees which the Department will use for the purpose of
determining:
(1) Reimbursement to providers and health maintenance organizations under the Medicare
program;
(2) Reimbursement to states under state administered health, welfare, and social service
programs; and
(3) Allowable costs under projects for health services.
(b) Policies and procedures, which will be consistent with the policies and procedures set forth in this
Part, will be published in the HHS Procurement Regulations, Title 41, Chapter 3, Code of Federal
Regulations, governing the direct purchase of drugs by the Department and the purchase or
supply of drugs by contractors of the Department.
(c) This Part does not establish procedures for fixing the actual amount of reimbursement to which
providers will be entitled for dispensing drugs. Rather, it establishes procedures for setting a
limit on what the individual program regulations and policies might otherwise provide. If the
authorizing legislation for a particular program, or the program regulation or policies adopted
or issued under that legislation, provides for a lower rate of reimbursement than this regulation
permits, then the program reimbursement rate, being lower, will necessarily control the actual
payment.
Regulation Sec. 19.3. Cost 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.
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.
Region States
Region /-Boston
Region Ill-Phildeiphia
Region I V Atlanta
Region V Chicago
Region VI Dallas
Region X Seattle
STATE
MEDICAID
DRUG PROGRAM ADMINISTRATOR
ALABAMA COLORADO
ARIZONA DELAWARE
CALIFORNIA FLORIDA
GEORGIA
MARYLAND MISSOURI
MASSACHUSETTS MONTANA
MICHIGAN NEBRASKA
OREGON
PENNSYLVANIA
NEW YORK
Joseph E. Concino, R.Ph.
Gerald F. Nelligan, R.Ph. Bureau of Policy and Program Development
Associate Social Services Department of Public Welfare, Room 510
Medical Assistance Specialist Health and Welfare Building
~mbulatoryStandards Unit Harrisburg, Pennsylvania 17120
40 North Pearl Street (717) 787-1 170
Albany, New York 12243
(518) 474-9261 RHODE ISLAND
TENNESSEE WASHINGTON
UTAH WISCONSIN
VIRGINIA
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 aprovides
tion services in a variety of locations, allowing
physicians to work directly from their own offices and permitting the HMO members to retain the
mode of delivery to which he may be accustomed. Physicians are usually compensated by the
IPG. on a fee-for-service arrangemeni.
30
NPC
Staff HMO-An HMO that delivers services through physicians who are on the staff of the HMO,
i.e., are paid directiy by the HMO and not through a physician organization or legal entity.
Home Health Agency: A home health agency is a public agency or private organization which is
primarily engaged in providing skilled nursing sewlces and other therapeutic services in the patient's
home, and which meets certain conditions designed to ensure the health and safety of the individuais
who are furnished these services.
0 Home Health Services: Home health services are services and items furnished to an individual who
is under the care of a physician by a home health agency, or by others under arrangements made
by such agency. The services are furnished under a plan established and periodically reviewed
by a physician. The services are provided on a visiting basis in an individual's home and include:
parttime or intermittent skilled nursing care; physical, occupational, or speech therapy; medical
social services, medical supplies and appliances (other than drugs and biologicals); home health
aide services, and services of interns and residents.
0 lnpatient Hospital Services: lnpatient hospital services are items and services furnished to an
inpatient of a hospital by the hospital, including bed and board, nursing and related services,
diagnostic and therapeutic services, and medical or surgical services.
0 Intermediate Care Facility: An intermediate care facility is an institution furnishing healthrelated care
and services to individuals who do not require the degree of care provided by hospitals or skilled
nursing facilities as defined under Title XiX (Medicaid) of the Social Security Act.
0 Laboratory and Radiological Services: Laboratory and radiological services are professional and
technical laboratory and radiologicai services ordered by a iicensed practitioner and provided in
an office or similar facility (other than a hospital outpatient department or clinic) or by a qualified
laboratory.
0 Medically Needy: Under Medicaid, medicaily needy cases are aged, blind, or disabled individuals
or families and children who are otherwise eligible for Medicaid, and whose income resources are
above the limits for eligibility as categorically needy (AFDC or SSI) but are within limits set under the
Medicaid state plan.
0 Other Practitioners' Services: Other practitioners' services are health care services of iicensed
practitioners other than physicians and dentists.
0 Outpatient Hospital Services: Outpatient hospital services are services furnished to outpatients by
a participating hospital for diagnosis or treatment of an illness or injury
0 Prescribed Drugs: Prescribed drugs are drugs dispensed by a licensed pharmacist on the prescrip-
tion of a practitioner licensed by law to administer such drugs, and drugs dispensed by a licensed
practitioner to his own patients. This item does not include a practitioner's drug charges that are not
separable from his other charges, or drugs covered by a hospital's bill.
0 Reasonable Charge: In processing claims for Supplementary Medical lnsurance benefits, carriers
use HCFA guidelines to establish the reasonable charge for services rendered. The reasonable
charge is the lowest of: the actual charge billed by the physician or supplier: the charge the physician
or supplier customarily bills his patients for the same services, and the prevailing charge which most
physicians or suppliers in that locality biil for the same service. Increases in the physicians' prevailing
charge levels are recognized only to the extent justified by an index reflecting changes in the costs
of practice and in general earnings.
0 Reasonable Cost: In processing claims for Health lnsurance benefits, intermediaries use HCFA
guidelines to determine the reasonable cost incurred by the individual providers in furnishing covered
services to enrollees. The reasonable cost is based on the actual cost of providing such services,
including direct and indirect costs of providers, and excluding any costs which are unnecessary in
the efficient delivery of services covered by the insurance program.
e Recipient: A recipient of Medicaid is an individual who has been determined to be eligible for
Medicaid and who has used medical services covered under Medicaid.
NPC 1985
0 Rural Health Clinic: A rural health clinic is an outpatient faciiity which is primarily engaged in
furnishing physicians' and other medical and health services, which meets certain other requirements
designed to ensure the health and safety of the individuals served by the clinic. The clinic must
be located in an area that is not an urbanized area as defined by the Bureau of the Census and
that is designated by the Secretary of DHHS either as an area with a shortage of personal health
services, or as a health manpower shortage area, and has filed an agreement with the Secretary not
to charge any individual or other person for items or services for which such individual is entitled to
have payment made by Medicare, except for the amount of any deductible or coinsurance amount
applicable.
0 Skilled Nursing Facility (SNF): A skilled nursing facility is an institution which has in effect a trans-
fer agreement with one or more participating hospitals, and is primarily engaged in providing to in-
patients skilled nursing care and restorative care services, and meets specific regulatory certification
requirements.
0 Skilled Nursing Facility Services: SNF services are all services furnished to inpatients of, and billed
for by, a formally certified skilled nursing facility that meets standards required by the Secretary of
DHHS.
0 SpendDown: Under the Medicaid program, spenddown refers to a method by which an individual
establishes Medicaid eligibility by reducing gross income through incurring medical expenses until
net income (after medical expenses) meets Medicaid financial requirements.
0 State Buyln: State buyin is the term given to the process by which a state may provide
Supplementary Medical Insurance coverage for its needy eligible persons through an agreement
with the Federal government under which the state pays the premiums for them.
0 State Plan: The Medicaid State Plan is a comprehensive written commitment by a Medicaid agency
to administer or supervise the administration of a Medicaid program in accordance with Federal
requirements.
0 Supplemental Security income (SSI): SSI is a program of income support for lowincome aged,
blind, and disabled persons established by Title XVI of the Social Security Act.
0 Third-Party Liabllity: Under Medicaid, thirdparty liability exists if there is any entity (including other
government programs or insurance) which is or may be liable to pay all or part of the medical cost
or injury, disease, or disability of an applicant or recipient of Medicaid.
0 hndor: A medical vendor is an institution, agency, organization, or individual practitioner which
provides health or medical services.
NPC
ACRONYMS
c
Michigan .O . O AAC Yes C 10.40 10.8 8.285
c
.
Mississippi .O EAC Yes C 12.01 3,340,389
c
Missouri 2.50 .50-2.0 AMP/EAC Yes C ,662.55
New Mexico 3.65 AWPIEAC No B Yes 168 9,427,783 9.14 12.79 789,822
c
C
Ohio 2. 0 AMP-7 Yes
Oklahoma 3.55 Max. AWPIEAC Yes C Yes 75 16.535.307 11.88 15.29 1,097,560
B
regon 3. AWPIEAC No B , 41, 03
B
Pennsy vania .5 .5 AWPIE C No B .72 13,815,483
c
3.2 C
South Dakota 1. 0 AWP Yes 2.1 284.396
Tennessee 3.36 AAC Yes C Yes 180 53,582,671 9.11 12.36 4,304.448
Table I A
Page Three
Fiscal year 1985 ...................... -----------------
F i s c a l 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 P r e s c r i p t i o n Prescriptions
State Fee ment meni Basis l a r y Status MAC Drugs Expenditures Per Claim Price* Processed*
Washington 3.00-3.70 89XAUP Yes C Yes 142 25,946,074 7.60 10.89 2,631,639
c
est i r g l n i a . . - . UP es C 8.80 895,271
Wisconsin 3.61 .50 AWPIEAC No B Yes 145 46,871,019 6.49 10.41 2,438.506
Legend :
(1) C o l l e c t i o n by pharmacy i s o p t i o n a l
(2) Plus $0.50 i n c e n t i v e fee f o r dispensing generic product
(3) State funded r e c i p i e n t s o n l y
(4) Most mu1t i - s o u r c e drugs
(5) Wholesaler c o s t p l u s a percentage
* Approximate number
A - No drug l i s t
-- a l l legend drugs reimbursed
B -
C -
No drug l i s t b u t c e r t a i n catagories excluded from reimbursement
R e s t r i c t e d drug l i s t
Arizona
685.-Arkansas 1.689 155.131 33.166.977 214 10.22
2
Kansas .5 6 106.755 117.3o5.55-
Kentucky 9
4 9,3
86, .9
Louisiana 382.367682.246.449 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 ~ 2.413
m 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
%
Nevada 7,435 ,9412 .5
9
ennessee 345. 02 4 ,169, 53,582,671 21 9.9%
0
ennont ,142,532 134 5.8%
DRUG RECIPIENTS AND VENWR PAYMENTS
Table IB
Page Three
9
Wisconsin 9 ,328 931,685.9 4 46,871,019 14 5.0%
9
Wyoming . 9
0
Colorado 3. .50 C Yes Yes 1
BB NO NO
fllinois 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
0
Iowa 3. 8 .8 1.00 NO NO B Yes Yes -2
q
Kansas . . Yes NO c Yes 1 NO
Ingredient I of
Reimburse~nent Formulary State State MAC'd
Dispensing Fee Lopayment Basis Fomulary Status MAC Drugs
State 1985 1984 ' 1985 1984 1985 1984 1985 1984 1985 1985 1984 1985
Michigan $3.00 $2.75 .50 .50 AAC AUPlAAC Yes Yes C Yes Yes 64
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
Ingredi e n t I of
Reimbursement Formulary State State MAC'd
Dispensing Fee Copayinent Basis Formulary Status MAC Drugs
State 1985 1984 1985 1984 1985 1984 1985 1984 1985 1985 1984 1985
Tennessee $3.25 $3.25 - - AAC AAC Yes Yes C Yes Yes 180
--- -
Virginia $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
Uisconsin $3.61 $3.50 .50 - AUPIEAC EAC No Yes B Yes Yes 145
Legend :
( 1 ) C o l l e c t i o n by pharmacy i s optional
( 2 ) Plus $0.50 i n c e n t i v e fee for dispensing generic product
(3) State funded r e c i p i e n t o n l y
A
B -- No drug l i s t
NO drug l i s t
reimbursement
-- a l l legend drugs reimbursed
b u t c e r t a i n categories excluded from
Table 13
Page One
(Amounts in Thousands)
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 PREscRmED 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 167,971 182,400 197,846 212,071 203,447 206,532
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 206,257 217,405 229,561 226,722 232,522 234,441
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 517,656 528,209 525,434 507,658 493,234 484;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 111,479 108,366 118,131 104,673 107,971 117,296
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 215,644 236,481 243.711 225,290 219,970 221,394
Washingtcn 198,704 208,767 209,566 174,821 185,225 214,123
West Virginia 79,572 105,027 144,221 112,497 98,779 115.838
Wiscons~n 267,942 307,072 325,544 305,197 317,137 329.964
Source: HCFA 2082 reports, compiled by State Medicaid program officials. Although the reports have
been reviewed and edited by HCFA, they may still contain some reporting errors. Despite these potential
shortcomings the 2082 HCFA data represent the most accurate figures available on utilization of state
Medicaid services.
'These figures do not include the Virgin Islands and Puerto Rico
NPC
AVERAGE EXPENDITURE PER RECIPIENT FOR PRESCRIBED DRUGS
Table IF
Page One
State 1979 1980 1981 1982 1983 1984
U.S. Average $88.87 $96.43 $107.41 $117.00 $129.00 50.W
$i
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 59.11 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 10156 104.46 .108.72 125.03 136.00 142.00
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 68.04 713 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 $119.40 $100.63 $108.00 119.00
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
Source: HCFA 2082 reports, compiled by State Medicaid program officials. Although the reports have
been reviewed and edited by HCFA, they may still contain some reporting errors. Despite these potential
shortcomings the 2082 HCFA data represent the most accurate figures available on utilization of state
Medicaid services.
*These figures do not include the Virgin Islands and Puerto Rico.
NPC
State 7983
Alabama 8.6%
Alaska -
Arizona -
Arkansas 9.0%
California 6.0%
Colorado 5.8%
Connecticut 4.3%
Delaware 4.4%
D.C. 3.7%
Florida 8.9%
Georgia 10.1%
Hawaii 4.5%
Idaho 3.9%
Illinois 7.2%
Indiana 6.6%
Iowa 6.1%
Kansas 6.3%
Kentucky 4.7%
Louisiana 8.5%
Maine 6.0%
Maryland 6.4%
Massachusetts 3.9%
Michigan 5.5%
Minnesota 3.5%
Mississippi 12.3%
Missouri 5.5%
Montana 4.6%
Nebraska 7.3%
Nevada 3.6%
New Hampshire 4.6%
New Jersey 6.2%
New Mexico 7.4%
New York 2.8%
North Carolina 6.3%
North Dakota 4.8%
Ohio 8.0%
Oklahoma 4.0%
Oregon 6.4%
Pennsylvania 5.1%
Rhode Island 4.5%
South Carolma 6.6%
South Dakota 4.0%
Tennessee 9.4%
Texas 6.4%
Utah 4.0%
Vermont 5.2%
Virginia 6.4%
Washington 5.1%
NPC
West Virginia
Wisconsin
Wyoming
NPC
Percent
1983 Vendor 1984 Vendor 1983 1984 Increase
State Drug Payments Drug Payments Ranking Ranking (Dee)
Table li
RANKING OF STATES BASED ON
AVERAGE DRUG EXPENDITURE PER RECIPIENT
---FY 1984---
Hospital Inpatient
Physicians
Drugs
Hospital Outpatient
Dental
Clinic
Other Practitioners
LabiX-ray
Family Planning
Other Care
Totals $32,204,730,553
Hospital Inpatient
! 29.5%
4.8%
Drugs
5.8%
Physicians
6.5%
Skilled
Nursing
Facility
14.2:
Intermediate cari
Facility
29.5%
M 1978
All Other
Hospital Outpati
Drugs
5.93
Physicians
8.8%
Skilled Nursing
Facility
Intermediate
Care Facility
24.2%
AFDC Mu111
~dis'id Expenditures
Distribution of w e n d i r u r t r PI1970 - niss4
by ~ l i p i b i l i t yClass, PI 1984
Source : OAIHCFAID~HS
Table IM
Public Private O
Source: Health Care Financing Administration. DHHS.
T a b l e IN
Table 10
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.
Alabama Montana
Alaska Nebraska
Arizona Nevada
Arkansas New Hampshire
California New Jersey
Colorado New Mexico
Connecticut New York
Delaware NorthCarolina
District of Columbia North Dakota
Florida Ohio
Georgia Oklahoma
Guam Oregon
Hawaii Pennsylvania
Idaho Puerto Rico
Illinois Rhode Island
Indiana South Carolina
Iowa South Dakota
Kansas Tennessee
Kentucky Texas
Louisiana Utah
Maine Vermont
Maryland Virgin Islands
Massachusetts Virginia
Michigan Washington
Minnesota West Virginia
Mississippi Wisconsin
Missouri Wyoming
The 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%.
However, h e a l t h planners and l e g i r l a t o r r a t the s t a t e l e v e l have pmposed state-financed 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 i n d i g e n 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 defraying p r e s c r i p t i o n drug expenses. Rhode I s l a n d 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 # of Year Recip- Recip- Expend. State Cost
Age Means Test Copay Covered Rx Fee Funding Recipients ( M i l l i o n s ) ients ientr (Millions) ( 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 lnsulin $3.87 113
Assistance t o Aged Test M a t ' l r (Medicaid) Lottery
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 enrollment
Program Family o f FY 1985
DW#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 Fowularyt de Nemurs (enrolled) (Est.)
Assistan~e t o $100 Insulin 6 Founda- 1984
Program per y r Quinine tion
PEUNSVLYAWIA 1984 65t $12.000 s $4.00 A l l Rx. $2.75 Lottery 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 projected
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 lootential
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 cost (specific cost ( i n c l Fund
categories) ingreds)
Not a vendor drug program. A l l Rx's dispensed thr; Elemrial 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 t h e p r o v i s i o n 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 t h e program by 1 0ece.ber 1985. Program scheduled t o take
effect 1 J u l y 1986
T a b l e IilA
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
STATE prov. est. Population Income Rate Over Over
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
United States 234,439,000
NPC
PHARMACIES PHARMA-
Nursing All ClSTS
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 189 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 1,540 493 219 54 10 101 2,417 6,315
Minnesota 679 192 152 39 5 53 1,120 3,247
Mississippi 680 164 119 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
Source: Business Mailersilnc. March 1985. Official List of the NABP and NCPDP
IPC CWPILATIOI
KEY PROVISIONS OF STATE DRUG PRQWCT SELECTIOI W S
Table VB
Page One
Legend:
Prevention of S u b s t i t u l i on:
]A) Prescriber's signature on appropriate l i n e o f 2 - l i n e p r e s c r i p t i o n
( b ) Prescriber expressly i n d i c a t e s do n o t DPS i n some manner
1. Allows use o f preprinted "do n o t sub'' check-box
2. Box must be checked t o prevent DPS
Researched and compiled by the National Pharmaceutical Council. Inc. i n conjunction w i t h Jesse E. Stewart, ph.~.,
Associate Professor of Pharmacy Administration, College o f Pharmacy. The U n i v e r s i t y of I l l i n o i s a t Chicago.
NPC Alabama-?
1985
ALABAMA
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 I T L E XIX)
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
1984 1983
-
Expended -
Recipient
-
Expended
-
Pecipiezt
TOTAL . . . . . $35,266,939 225,256'" $31,616,230 222,713""
CATEGORICALLY NEEDY CASH TOTAL
Aoed . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . . 321,253 1.084 294,667 1,462
Disabled.. . . . . . . . . . . . . . . . . . . . 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
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 b e
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
$.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
Consumer Representative
Consumer Representative
James W. McLane,
Secretary
2312 City Federal Building
Birmingham, Alabama 35203
2051252-8976
NPC
ALASKA
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)
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
1984 1983
-
Expended -
Recipient -
Expended
-
Recipient
TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . .
Children-Families wlDep Children . . . . .
Adults-Families wIDep Children . . . . .
CATEGORICALLY NEEDY NON-CASH TOTAL .
Aged . . . . . . . . . . . . . . . Alaska's Medicaid program does not include
Blind . . . . . . . . . . . . . . . drugs, except family planning drugs and
Disabled . . . . . . . . . . . . . drugs dispensed to inpatients of hospitals and
Children-Families wlDep Children . . . . . nursing homes. (See page 2.)
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 . . . . . . . .
0. Pharmaceutical Association:
Frank Zoppo
Secretary-Treasurer
Alaska Pharmaceutical Association
Box 10-1185
Anchorage 99510
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 ~rovidesthat 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
IMPLEMENTATION OF AHCCCS
AHCCCS is based on pians that have been tested, in part, on smaller scales in different areas of
the country. By combining a number of key mechanisms on a statewide basis, AHCCCS represents a
novel health care modei. The purpose of this section is to present a discussion of how the key concepts
embodied in the AHCCCS legislation will be implemented and rendered operational.
Provider Participation:
Providers may participate in AHCCCS in three different ways. First, they may enter the competitive
bidding process with prepaid capitated pians as either full or partial benefit providers.
The second mode of participation is on a capped fee-for-service basis. Here, providers agree
to accept capped fee payments as payments in full. Capped fee-for-service arrangements will be
authorized as a last resort only and when there are insufficient bids for a given area.
NPC
Finally, the third means of participation concerns the provision of emergency medical services by
non-AHCCCS providers. No formal contract is required for this mode of participation, and reimbursement
will be allowed almost exclusively for emergency services.
Functions of the AHCCCS Administrator:
The AHCCCS contract Administrator contracts with full benefit capitated providers to serve AHCCCS
members; and create a number of organized health systems through a network of contracts with
providers, as necessary to complement the capitated system.
ARKANSAS
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)
~ospitalCare 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
II. EXPENDITURES FOR DRUGS. Pdyment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
-
Expended
-
Recipient
-
Expended Recipient
TOTAL . . . . . . . . . . . . . . . . . . . . . $33,166,977 155,131" $28,218,714 151,260
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $26,151,084 125,344 21,375,519 122,711
Aged . . . . . . . . . . . . . . . . . . . . . . 11,124,351 36,129 5,582,801 35,772
Biind . . . . . . . . . . . . . . . . . . . . . . 340,685 1,194 300,143 1,225
Disabled.. . . . . . . . . . . . . . . . . . . . 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 pChildren . . . . . . . . . . . . 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 . .
ili. Administration:
By the Division of Social Services, of the Department of Human Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions (diseases, drug categories, etc.):
All legend drugs are covered with the following exceptions: investigational drugs, I.V. solu-
tions, amphetamines, anti-obesity agents, irrigating solutions, vaccines, and routine immunizing
agents.
0-T-Cs: Pursuant to a prescription the following OTC items are covered: insulin, insulin needles
and syringes, analgesics, antacids, calcium lactate, contraceptive foams and jellies, dicalcium
phosphate, ferrous fumarate, ferrous gluconate, ferrous sulfate, ferrous cholinate, meclizine HC1,
pediatric vitamin drops for children up to three years of age, laxatives and stool softners, nicotinic
acid and schedule V narcotics. All other non-legend items are excluded.
B. Formulary: None
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: 33 day supply.
2. Refills: 5 refills within 6 months are allowed, if authorized by prescriber
3. Doilar Limits: None
4. Monthly Limit: Four prescriptions per month per recipient.
D. Prescription Charge Formula:
Legend drugs-estimated acquisition cost plus $3.87 professional fee. Total charge may not
exceed provider's prevailing charge to the self-paying public, or any other third-party prescription
drug program.
V. Miscellaneous Remarks:
The Arkansas MAC program exists for 20 multi-source drugs. (effective 1 July 1984)
Fiscai intermediary:
Aritansas Blue Cross-Blue Shieid, Inc.
7th and Gaines Streets
Little Rock, Arkansas 72203
Commissioner
Vacant
Gordon Page
Office of Program Operations
Vacant, Director
Office of Long Term Care
Al Sliger, Administrator
Medical Assistance Section
Physicians (Part-time):
8. Pharmaceutical Association:
Norman Canterbury, P.D.
Executive Vice President
Arkansas Pharmacists Association
81 8 Garland Avenue
Little Rock, Arkansas 72201
Phone: 5011372-5250
C. Osteopathic Medical Association:
Bob E. Jones
Executive Director
Arkansas Osteopathic Medical Association
502 West 16th Street
Hope, Arkansas 71801
5011777-8839
5. State Board of Pharmacy
Lester Hosto
Executive Director
P.O. Box 55356
Little Rock, Arkansas 72225
5011661-2833
NPC
CALIFORNIA
M E D I C A L A S S I S T A N C E D R U G PROGRAM (TITLE XIX)
li. EXPENDiTURES FOR DRUGS. Fiscal year ending June 30, 1985
M 1984 FY 1983
-
Expended -
Recipient -
Expended -
Recipient
Ill. Administration:
By the Health and Welfare Agency with direct supervision by the Department of Health Services.
Payment of bilis by the state is processed through a fiscal intermediary, Computer Sciences
Corporation
Under the generat direction of tine Department of Health Services' Medi-Cal Policy Division, the Drug
Policy Unit of the Benefits Branch monitors the full scope and quality of pharmaceutical benefits
covered under the provisions of the California Medical Assistance Program. This Unit, additionally,
has the prime responsibility for both the evaluation and formulation of UtilizationiCost Controls and
the development, implementation, and interpretation of policies and regulations concerning the full
scope of pharmaceutical benefits.
IV. Provisions Relating to Prescribed Drugs:
A. General Limitations and Exclusions (diseases, drug categories, etc.):
Formulary CNS stimulants*, i.e., amphetamines and methylphenidate, are only available for
epilepsy or Minimal Brain Dysfunction in individuals between 6 and 16 years of age. Contact
laxative suppositories can be used only for specific diagnosis (paraplegia or quadriplegia,
multiple sclerosis, poliomyelitis, ganglionic blockade processes occurring in the spinal nerve
pathways or affecting the lumepilepsy or Minimal Brain Dysfunction in individuals between 6
and 16 years of age. Contact laxative suppositories can be used only for specific diagnosis
(paraplegia or quadriplegia, multiple sclerosis, poliomyelitis, ganglionic blockade processes
occurring in the spinal nerve pathways or affecting the lumbo-sacral autonomic nervous system
pathways related to bowel motility).
Formulary Diazepam* restricted to use in cerebral palsy, athetoid states, and spinal cord
degeneration. Nutritional supplements or replacements only for therapeutic use to prevent
serious disability or death in patients with medically diagnosed conditions that preclude the full
use of regular food-stuffs.
Formulary Baclofen* restricted to use in spasticity resulting from multiple sclerosis or spinal cord
injury.
Formulary Carbonacillin' restricted to pseudomonas aerugenosa urinary tract infections.
Formulary CImetidine* restricted to use in treatment of duodenal ulcer, Zollinger-Ellison
syndrome, systemic mastocytosis, and multiple endocrine adenomas.
Formulary Dantrolene* restricted to use in spasticity resulting from cerebral palsy, spastic hemys-
legia, multiple sclerosis, and spinal cord injury.
Formulary Erythromycin-Sulfkoxayol* restricted to use in acute otitis media.
Formulary Fenoprofen, Ibuprofen, Naproxen, TolmatIn* restricted to use for arthritis.
Formulary Nalodixic Acid* restricted to urinary tract infections resistant to sulfonamides or in
patients sensitive to sulfonamides.
Formulary Trumethoprim-Sulfamethoxayolz* restricted to genitourinary tract infections.
Excluded from coverage are multivitamins for persons over five years of age and most OTC
household remedies.
9. Formulary: A semi-restrictive formulary system is used. Over 450 drugs (approximately 1,500
separate codes for differing strengths and dosage forms) listed generically in formulary. Many
brand names listed alphabetically as cross-index references. The patient's physician or phar-
macist may request authorization from the local Medi-Cal Consultant for approval of unlisted
drugs or for listed drugs which are restricted to specific use(s).
Medi-Cal Drug Formulary may be obtained by ordering the Pharmacy Provider Manual from:
Willis W. Babb
Executive Director Robert C. Johnson
California Medical Assn Executive Vice President
44 Gough Street California Pharmacists' Association
San Francisco 94103 1112 I Street
' . Phone: 4151863-5522 Sacramento 95814
Phone: 9161444-7811
Matthew L. Weyuker
Executive Director, OPSC
921-1I t h Street, Suite
Sacramento 95814
Phone: 9161447-2004
3. State Board of Pharmacy
Lorie Garris Rice
Executive Officer
1020 "N" Street
Sacramento, California 5814-5784
9161445-5014
Colorado- 1
1985
COLORADO
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)
11. EXPENDITURES FOR DRUGS. Pavment to Pharmacists by fiscal year endino June 30. 1984
1984 1983
TOTAL . . . . . . . . . . . . . . . . . . . . .
-
Expended
-
Recipient
- -
Expended Recipient
$16,616,730 105,919' $14,895,527 103,453
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $13,652,477 93.021 12,454,097 92,692
A d . . . . . . . . . . . . . . . . . . . . . . 7,966,083 25,115 7,135,252 25,450
i d . . . . . . . . . . . . . . . . . . . . . . 26,753 133 23,810 143
Disabled . . . . . . . . . . . . . . . . . . . . . 2,926,770 9,163 2,633,758 9,242
Children-Families wlDep Children . . . . . . . . . . . . 898.710 34,621 894,360 33,979
Adults-Families WDep Children . . . . . . . . . . . . 1,834,161 24,389 1,766,917 24.288
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . $2,964,253 21,586 $2,441,430 19,594
Aged . . . . . . . . . . . . . . . . . . . . . . 1,343,666 5,267 1,201,455 5,443
Blind . . . . . . . . . . . . . . . . . . . . . . 7,167 44 3.436 44
Disabled . . . . . . . . . . . . . . . . . . . . . 1,257,076 5,452 944,605 4.784
Chiidren-Families wlOep Children . . . . . . . . . . . . 57.791 3,992 43,859 3,174
Adulls-Families wIDep Children . . . . . . . . . . . . 134,107 4,021 99,895 3.462
Other Title XIX Recipients . . . . . . . . . . . . . . . 164,446 3.052 148,180 2.848
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . $0 0 $0 0
Aged . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0
Blind . . . . . . . . . . . . . . . . . . . . . . 0 0 0 0
Msabkd . . . . . . . . . . . . . . . . . . . . . 0 0 0 0
Children-Families wlDep Children . . . . . . . . . . . . 0 0 0 0
Adults-Families wlDep Children . . . . . . . . . . . . 0 0 0 0
Other Title XiX Recipien!~ . . . . . . . . . . . . . . . 0 0 0 0
Ill. Administration:
Eligibility is determined by 63 County Departments of Social Services, and the drug program is
administered by the Colorado Department of Social Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions (diseases, drug categories, etc.):
Restricted Drug Categories:
1. Prescription-legend drugs not listed in the "ColoRx Drug Formulary".
2. Certain over the counter drugs provided under prior authorization.
3. Payment for restricted drugs authorized only in accordance with non-emergency or emer-
gency procedures as set forth in the Department's Manual Regulations. Volume VIII, Section
8.800.
4. OTC items are not included; exceptions are: insulin, aspirin under certain conditions, with
refill limitations as stated in Manual Regulations, Volume VIII, Section 8.800.
B. Formulary: ColoRx Drug Formulary
Only those drugs presently assigned drug numbers in the Formulary are a benefit. (Refer to
Manual Regulation Section 8.800 for provisions whereby drugs not listed in the ColoRx Drug
Formulary may be allowed as a benefit.)
Controlled Drug Formulary
Section I - Alphabetical drug index in brand name order; if no brand name assigned, the
generic name is listed.
Section I1 - Generic drugs are identified as having a Maximum Allowable Price, iisted with
price information which is updated periodically.
Section 111 - EAC Price List. High volume drugs reimbursed at greater than 100's size or
direct manufacturer's price.
C. Prescribing or Dispensing Limitations:
1 . Terminology: The Department encourages appropriate consideration of cost in prescribing
and dispensing by the selection of the less expensive trade name or generic product when,
in the practitioner's professional judgment, the use of such a product is compatible with the
best interests of the patient.
The ColoRx Drug Formulary will not be used by clinic and hospital pharmacies for drug
pricing-only for drug code number information. Acquisition cost must be used for unit
pricing.
2. Quantity of Medication: New prescriptions for chronic or acute conditions, at the discretion
of the physician. However, reasonable amounts for more than a 30-day supply for chronic
conditions are recommended. Maximum supply is 100 days.
Exceptfons to the above are:
a. Shelf package size oral liquid medications, in pint size only, or smaller package size
when not packaged in pint size.
b. Shelf package size oral tablet and capsule medications in quantities of 100 only or
smaller when not available in package size of 100.
c. Prescriptions for less than minimum amounts will be denied reimbursement of the profes-
sional fee unless the physician notified the State Department in writing of the medical
need for amounts less than a 30-day supply. Medical consultation will determine the
decision.
3. Doilar Limits: None.
91
NPC
If a recipient requests a brand name for a prescription which is subject to M.A.C., then
helshe may pay the ingredient cost difference between the M.A.C. and brand name
drug. The recipient must sign the prescription stating that helshe is wiliing to pay the
difference in ingredient cost to the pharmacy. The pharmacy will be paid M.A.C. plus a
dispensing fee or reimbursement charges whichever is lower.
b. High volume Estimated Acquisition Cost (E.A.C.)
Reimbursement for singie source drugs or certain multiple source drugs which are most
frequently prescribed will be based upon average wholesale prices or direct manufac-
turers' prices for package sizes containing quantities greater than 100 dosage units or
less if not available in 100's. Basis for inclusion in the high volume estimated acquistion
cost list includes but is not limited to:
1. Single source manufacturers
2. High volume Medicaid recipient utilization
3. Interchangeability problems with multiple source drugs
4. Package sizes in excess of 100;
These drugs will be identified in Section Ill of the ColoRx.
C. Drug Pricing
The Department will maintain a drug pricing file which will be updated at least monthly.
The average wholesale price of a drug as determined by the Department, M.A.C., and high
colurne E.A.C., will be the basis for setting the prices in the drug pricing file.
The Department will determine the average wholesale price whlch will be placed in the drug
pricing file as follows:
1. The average wholesale price as it appears in the Red Book, its supplements, and Medi-
Span will be the first source. However, if there is a difference between the two published
average wholesale prices, then the Department will set the price as the published amount
which is the closes! to the lowest average price charged by two drug wholesalers doing
business in Colorado.
2. If there is a price change which does not appear immediately in the Red Book, its
supplements or in Medi-Span, then the Department will set the average wholesale price
by averaging the wholesale prices of three drug wholesalers doing business in Colorado,
until the price is published in the Red Book, its supplements, or in Medi-Span.
3. If the prices or changes do not appear in the publications or the wholesalers' records,
then the distributors' or manufacturers' prices will be adjusted to the whoiesale piicing
level and used in the drug pricing file as the price of the drug.
If the difference between the pharmacist's invoice purchase price and the average wholesale
price which appears in the Red Book, its suplements, or Medi-Span exceeds 18% then the
Department may adopt a lower price after a survey is conducted to determine the validity
of the published prices. The price from the distributor or manufacturer will be adjusted ihe
same as in 3 above.
Special Note:
The Maximum Allowable Cost shall be determined by the Division of Medicai Assistance, based
upon professional determination of a quality product available at the least expense possible.
Recommendations from the CoioRx Drug Formulary Advisory Committee of the Medicai Advisory
Council is considered in determining the MAC.
V. Miscellaneous Remarks:
Lock-In Review Procedures:
The State Department receives computer processed printouts designed to discover overutilization of
drugs prescribed by physicians, dispensed by vendors, and received by eligible recipients.
A Lock-In Review Committee composed of two physicians, one consumer, and three pharmacists
meets monthly to review the printouts and make recommendations to the State regarding corrective
action. In most cases, the attending physician is notified of the Committee's recommendations.
Case-workers are also contacted and informed of the overutilization review on abuse with a request
to contact the recipient and explain lock-in and help the recipient choose a physician and pharmacy.
Recipient and the family are locked in for a year. A review of the case is then made to determine if
the recipient and family should remain locked in. . .,r&
Prescription Data: fiscal
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
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 3865 Cherry Creek
Ophthalmology North Drive
Denver 80210
3. Medical Advisory Committees:
A. Medical Assistance and Services Advisory Council:
Members
Walter Ballard, D.D.S. Donald Schiff M.D.
1416 Constitution 600 Front Range Road
Pueblo, Colorado 81001 Littleton, Colorado 80120
Kenneth R. Huey
Longmont United Hospital Hanna Evans, M.D.
P. 0. Box 1659 Clinical Psychologist
1950 Mountain View Avenue Common Course
Longmont, Colorado 80501 60 Kearney Street
Denver, Colorado 80220
Bernard Tessler
370 South Franklin Street
Denver. Colorado 80209
EX OFFlClO MEMBERS:
CONNECTICUT
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 I T L E XXIX)
I1 EXPENDITURES FOR DRUGS. PaVment to Pharmacists by fiscal year endinp June 30. 1984
1984 1983
-
Expended
-
Recipient -
Expended
-
Recipient
TOTAL . . . . . . . . . . . . . . . . . . . . . $24,948,974 157,029" $21,265,077 153,729
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 . . . . . . . . . . . . . . . . . . . . .
Children-Families wiDep Children . . . . . . . . . . . .
Adults-Families wiDep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
Ill. Administration:
Directed by the State Welfare Department through seven district offices and one town delegated this
special authority.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions (diseases, drug categories, etc.):
1. Will not pay for experimental drugs, anti-obesity drugs, drugs available free from the
Department of Health Services. DESl drugs.
2. Prior authorization required for: non-legend drugs not listed on Connecticut Drug List;
Amphetamines except when used for narcolepsy and hyperkenesis; vitamins except prena-
tal, pediatric prior to 7th birthday and fluoride prior to 14th birthday; nutritional supplements.
3. Nursing home patients: The department will not pay for drugs used in routine care and
treatment of patients normally covered in per diem rate except by prior authorization. Prior
authorization required for influenze or pneumovax vaccine, irrigating solutions, diabetic and
diagnostic testing material and I.V. solutions or sets.
B. Formulary: OTC Drugs Only
C. Prescribing or Dispensing Limitations:
1. Physicians are encouraged to prescribe drugs generically, when possible
2. Quant~tyof 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.
Thomas Kilcoyne
Deputy Commissioner
Mary Nakashian
Deputy Commissioner
Sally Bowles
Director
Medical Care Administration
Dennis Bothamley
Chief, Institutional Care
Medical Care Administration
seicount3 1
DELAWARE
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 I T L E XIX)
inpatient
Hosoital Care
Outpatient
Hospital Care X X X X
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X X
Physician
Services X X X X
Dental
II. MPENDiTURES FOR DRUGS. Payment to Pharmacists by fiscal year ending September 30. 1984
1984
.. 1983
-
Expended -
Recipient
-
Expended
-
Recipient
TOTAL . . . . . . . . . . . . . . . . . . . . . $3,049,313 31,038" $2,706,325 31,940
CATEGORICALLY NEEDY CASH TOTAL . . ,
A0
. . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . . 22,389 70 13.312 73
Disabled . . . . . . . . . . . . . . . . . . . . . 926011 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 . . . . . . .
0
Blind . . . . . . . . . . . . . . . . . . . . . . 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
Ill. Administration:
By Division of Economic Services, Department of Health and Social Services, through 3 county offices
of the state agency.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions:
Only legend item drugs (except for insulin) can be prescribed. Vitamins (except pediatric
vitamins), antacids, etc. can not be prescribed unless they are legend items. OTC items cannot
be prescribed. Anorectics are excluded, (except for pediatric hyperactivity and certain sleep
disorders, when certified by the physician).
B. Formulary: None.
C. Prescribing or Dispensing Limitations:
1. Quantity: None. Department requests physician to prescribe reasonable amounts.
2. Refills: Prescription blank has space for physician to authorize renewals.
3. Dollar Limits: None.
D. Prescription Charge Formula:
Payment is based on the actual acquisition cost or maximum allowable cost (MAC) to the
pharmacy or MAC, plus a $3.40 dispensing fee, or the usual and customary cost to the general
public, whichever is lower.
E. Total number of Rx claims in fiscal year 1984-276,636
IV. Fiscal Intermediary
The Computer Company
#1 Pike Creek Center, Suite 402, Wing 2
Wilmington, DE 19808
Ruth Fischer
Administrator
Medical Assistance Services
Pharmacist Consultant
%fsn
NPC
D I S T R I C T OF C O L U M B I 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 (TITLE XIX)
11. EXPENDITURES FOR DRUGS. Pavment to Pharmacists bv fiscal vear endino Seotember 30. 1984
1984 1983
-
Expended
-
Recipient
- -
Expended Recipient
TOTAL. . . . . . . . . . . . . . . . . . . . . $8,113,136 65,009" $7,180,151 68,338
CATEGORiCALLY NEEDY CASH TOTAL . . . . . . . . . . 6,541,254 54,431 5,774,148 58,010
Aged . . . . . . . . . . . . . . . . . . . . . . 1,134.234 3,613 1,030,505 3,824
Blind . . . . . . . . . . . . . . . . . . . . . . 14,723 53 12,858 54
Disabled . . . . . . . . . . . . . . . . . . . . . 2,498,626 7,162 2,028,715 7,064
Children-Families wlDep Children . . . . . . . . . . . . 993,806 25,218 951,752 27,511
Adults-Families wIDep Children . . . . . . . . . . . . 1,896,168 18,375 1,750,323 19.557
CATEGORICALLY ~ E E D YNON-CASH TOTAL . . . . . . . . 892,448 318,361 2,853
A d . . . . . . . . . . . . . . . . . . . . . . 404,666 109,578 758
Blind . . . . . . . . . . . . . . . . . . . . . . . 0 3 0
Disabled . . . . . . . . . . . . . . . . . . . . . 288,388 151,545 815
Chiidren-Families w1Dep Children . . . . . . . . . . . . 32,878 19,371 639
Adults-Families wlDep Children . . . . . . . . . . . . 62.983 37,005 640
Other Title XIX Recipients . . . . . . . . . . . . . . . 103,531 862 1
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . 683,127 1,087,642 7,475
A~ed . . . . . . . . . . . . . . . . . . . . . . 231,593 491,803 1,630
Bid . . . . . . . . . . . . . . . . . . . . . . 132
Disabled . . . . . . . . . . . . . . . . . . . . 206,747
Chiidren-Families w1Dep Children . . . . . . . . . . . . 81,405
Adults-Families wiDep Children . . . . . . . . . . . . 157,597
Other Title XIX Recipients . . . . . . . . . . . . . . . 5,650
Ill. Administration:
The D.C. Department of Human Services (DHS), Office of Health Care Financing.
iV. Provisions Relating to Prescribed Drugs'
A. General Exclusions: All legend drugs are covered except those drugs that are listed by FDA
as ineffective. Pursuant to a prescription the following non-legend items are covered: oral
analgesics, oral antacids, insulin, insulin needles and syringes, contraceptive foams and jellies,
ferrous sulfate, prenatal vitamin formulations, geriatric vitamin formulations for recipients 65 years
of age and over, and multivitamin formulations for children 7 years of age and under. All other
rron-legend items are excluded.
8 . Formulary: None.
C. Prescribing or Dispensing Limitations:
1. Refills: In general, amounts dispensed are to be limited to quantities sufficient to treat an
episode of illness. Maintenance drugs such as thyroid, digitalis, etc. may be dispensed 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
D. Prescription Charge Formula:
The lesser of:
-Maximum allowable charge (MAC) or
-Estimated Acquisition Cost (EAC) plus $3.95 fee
-The provider's usual charge to the public.
E. Compounded Prescriptions:
-Lesser of EAC of all ingredients plus $4.70.
-The provider's usual charge to the public.
F. Co-payment:
$0.50 co-pay by recipient. Does not apply to recipients under 21 years of age, prescriptions
for family planning, nursing home patients, or pregnancy related.
V. Miscellaneous Remarks:
Fiscal Intermediary
The Computer Company (TCC)
401 New York Avenue, N.E.
Washington, D.C. 20002
FLORIDA
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 I T L E XIX)
~ospitalCare X X X X
Laboratory &
X-ray Service X X X X
Skilled Nursing
Home Services X X X
Physician
Services X X X X
Dental
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
-
Expended -
Recipient -
Expended
-
Recipient
TOTAL . . . ..... . . .......... . $76,184,224 429,016" $60,679,046
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . Not available
Aged . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . , . . . ,
Ill. Administration:
By the Department of Health and Rehabilitative Services. Claims processing and payment by
contract with fiscal agent.
IV. Provisions Relating to Prescribed Drugs:
A. Limitations and Exclusions
1. Vitamins and phosphate binders only for dialysis patients.
2. Protheses; appliances; devices; and personal care items;
3. Non-legend drugs (except for prescribed insulin and buffered and enteric coated aspirin
when prescribed as an anti-inflammatory agent only).
4. Anorexiants unless the drug is prescribed for an indication other than obesity (i.e. narcolepsy,
hyperkinesis);
5. Topical acne preparations and selenium sulfide preparations;
6. Oral vitamins with exception of fluorinated pediatric vitamins prescribed for pediatric patients;
7. Digestants, except when prescribed for hepatic or pancreatic diseases;
8. Laxatives and Lactulose preparations, except when prescribed as a chelating agent;
9. Oral contraceptives unless prescribed for indications other than birth control;
10. Nursing home floor stock drugs.
8. Formulary: None.
C. Prescribing or Dispensing Limitations:
1. Prescribed drugs covered up to $22 per recipient per month ($150 if the recipient is in a
nursing home), limited to legend drugs within program limits plus insulin. Greater expendi-
tures require prior authorization by the program.
2. The recipient must present a monthly eligibility card to the provider and must then use the
same provider for the entire calendar month.
3. Maintenance medication should be dispensed and billed for at least a one-month supply.
4. Refills must be authorized by the prescriber and can be made for up to one year, except that
controlled substances can be refilled only in accordance with federal and state regulations.
5. Drugs with questionable efficacy, as rated by the FDA (DESI), are disallowed.
6. Investigational, experimental, blood derivative (e.g. for hemophilia), and appetite suppres-
sant items are not covered, nor are drugs that are prescribed for other than their approved
indications.
D. Prescription Charge Formula:
Fee-effective July 1, 1980
Lower of: (1) MAC plus $3.33
(2) EAC plus $3.33
(3) Usual and Customary
V. Miscellaneous Remarks:
A. Some High Volume EACs set at large package size
B. Provisions for medically necessary considerations
C. Maximum Allowable Ingredient Cost (MAIC)
1. Federal MAC drug list
NPC
D. Claims Processol
EDS Federal Corporation
Pharmacy Services
P.O. Box 9030
Tallahassee. Florida 32314
GEORGIA
M E D I C A L ASSISTANCE D R U G P R O G R A M (TITLE XIX)
Dental
Sewices X X X X
Ii. EXPENDITURES FOR DRUGS. hvrnent to Pharmacists bv fiscal vear ending June 30. 1984
1984 1983
-
Expended -
Recipient -
Expended -
Recipient
Ill. Administration:
By the Department of Medical Assistance.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Drugs not on the drug list
B. Formulary: The Controlled Medical Assistance Drug List. For information contact:
Mrs. Earline D. Jordan
2 M.L. King, Jr. Drive S.E.
Floyd Building - West Tower
P.O. Box 38440
Atlanta, GA 30334
4041656-4044
I
C. Prescribing or Dispensing Limitations:
II
1. Quantity of Medication: Physicians are encouraged to prescribe a 30 day supply. Six
prescriptions per month per recipient except by prior authorization.
3. Refills: According to state and federal law.
4. Dollar Limits: None. I
D. Prescription Charge Formula: Lower of, average wholesale price (AWP) plus fee of $3.61, or
MAC plus fee, or usual and customary.
, .
V. Miscellaneous Remarks:
Average Rx price during FY 1984 $1 1.86
State MAC List = Federal MAC Plus 19 Additional Drugs
Officials, Consultants and Committees
1. Department of Medical Assistance Officials:
GUAM
M E D I C A L A S S I S T A N C E DRUG P R O G R A M (TITLE XIX)
1984 1983
-
Expended -
Recipient
-
Expended
-
Recipient
TOTAL .....................
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adulk-Families w/Dep Children . . . . . . . . . . . .
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . NO Data
Available
Children-Families w1Dep Children . . . . . . . . . . . .
Adults-Families wiDep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adults-Families w10ep Children . . . .
Other Title XIX Recipients . . . . . . .
ill. Administration:
By the Department of Public Health and Social Services.
IV. Provisions Relating to Prescribed Drugs:
Prescribed drugs are provided to needy persons eligible for services under Title XIX. Providers
include the Guam Memorial Hospital pharmacy as well as other privately operated pharmacies.
Dispensing fee-AWP plus $2.75
V. Officials, Consultants and Committees
A. Public Health and Social Services Department Officials:
Dennis G. Rodriguez
Director
Department of Public Health
and Social Services
Government of Guam
Post Office Box 2816
Agana. Guam 96910
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 96911
NPC
HAWAII
M E D I C A L A S S I S T A N C E DRUG P R O G R A M (TITLE XIX)
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30,1984
1984 1983
-
Expended -
Recipient -
Expended
-
Recipient
Ill. Administration:
By the State Department of Social Services and Housing through its Public Welfare Division and four
county branch offices.
IV. Provisions Relating to Prescribed Drugs
A. Exclusions: Investigational new drugs, and drugs classified as ineffective or possibly effective
by the FDA.
B. Formulary: Hawaii State Medicaid Drug Formulary
C. Co-payment: No
D. Prescription Charge Formula: Estimated Acquisitions Cost (EAC) plus dispensing fee $3.22 (eff.
July 1, 1985).
E. Program pays for no more than the larger of: 30 days supply or 100 doses.
V. Fiscal Intermediary
Hawaii Medical Service Association
Medicaid Program Section
P.O. Box 860
Honolulu, Hawaii 96808
Officials, Consultants and Committees
1. Social Services and Housing Department Officials:
Franklin Y. K. Sunn Department of Social Services
Director and Housing
P. 0. Box 339
Honolulu, Hawaii 96816
Richard K. Paglinawan
Deputy Director
Earl S. Motooka
Medical Care Administrator
IDAHO
M E D I C A L A S S I S T A N C E DRUG P R O G R A M ( T I T L E XIX)
II. EXPENDITURES FOR DRUGS. Pdyment to Pharmacisls by f i m l year ending June 30, 1984
1984 1983
- -
Expended Recipient
-
Expended
-
Recipient
Ill. Administration:
By the State Department of Health and Welfare through seven regional offices, each serving five or
more of the state's 44 counties.
IV. Provisions Relating to Prescribed Drugs:
A. Exclusions: Amphetamine and related medication, plus certain therapeutic vitamins.
B. Drug formulary: None
C. Prescribing or dispensing limitations: Prescription drugs are limited to 530.00 per month per
recipient. (34 day supply with limited exceptions)
D. Prescription charge formula:
Lower of MAC or EAC plus a variable dispensing fee $2.50-3.50, (unit dose $4.15) accord-
ing to location, size and Rx volume of the provider, or the provider's usual and customary
price to the general public.
V. Miscellaneous Information
Copayment: none
Average prescription price during FY 1983: 59.50
Fiscal intermediary
EDS Federal Corporation
P.O. Box 1168
Boise, ldaho 83701
Otflclals, Consultants and Committees
1. Health and Welfare Department:
ILLINOIS
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)
Outpatient
Hospital Care X X X X X X X X X X
~aboratory&
X-ray Service X X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X X
Physician
Services X X X X X X X X X
Denlal
Services X X X X X X X X X X
11. MPENOITURES FOR DRUGS. kiyment to Pharmacists by fiscal year ending September 30. 1984
1984
-
Expended -
Recipient
Fiscal Intermediary-none'
Consultants:
A. Samuel Enloe, R.Ph 251 W. First Drive
Decatur 62521
II. EXPENDITURES FOR DRUGS. Payment to Phar~ciStSby fiscal year ending June 30, 1984
1984 1983
-
Expended -
Recipient -
Expended -
Recipient
TOTAL $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
~ ~~
Ill. Administration:
The lndiana State Department of Public Welfare.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: (Most OTC drugs are covered) No legend or non-legend anorexics or anti-
smoking aids.
6. Formulary: None
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: None.
2. Refills: Allowed as authorized by physician.
3. Dollar Limits: None.
4. One dispensing fee paid per legend drug order per recipient per month in nursing home
setting.
D. Prescription Charge Formula:
1. The lowest of the:
a. MAC plus the dispensing fee of $3.00.
b. EAC (Estimated Acquisition Cost) plus the dispensing fee of $3.00. (EAC is 3% less than
AWP reported by Drug Topics Red Book)
c. Pharmacy's usual and customary charge to the general public.
V. Miscellanous Information:
Fiscal Intermediary:
EDS Federal Corp
120 W. Market Street
Indianapolis, lndiana 46204
James H. Cook
Assistant Administrator-
Administration
William Harding
Director
Division of Administrative
Services
NPC
Ill. Administration:
Central administration by the State Department of Human Services
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions (diseases, drug categories, etc.): Most non-legend drugs, amphetamine
products, laxative drugs, and legend multiple vitamins require prior authorization.
KANSAS
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)
Other Benefits: Home Health Care: Clinic Services: Rehabilitative Services; Prostheseis; Preventive Services; Family Planning Services; Chiropractic
Services; Optometric Services; and Communily Based Alternative Services.
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
-
Expended -
Recipient -
Expended -
Recipient
Ill. Administration:
State Department of Social and Rehabilitation Services.
IV. Provisions Relating to Prescribed Drugs:
A. Prescribed drugs. Covered are: (a) legend drugs in a formulary approved by the state Medicaid
agency, excluding drugs that the agency finds ineffective or possibly effective; and (b) seleted
nonlegend drugs, devices, and supplies when prescribed for diseases and conditions specified
in the state's Medicaid regulations.
0. Formulary: Restricted drug list.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Maximum of a 100-day supply. Minimum quantities of a 100-dose or
30-day supply should be prescribed and dispensed for maintenance drugs.
2. Refills: As authorized by the prescriber up to a one-year period from the date of issuance of
the prescription.
3. Dollar Limits: A prescription claim in excess of $75 is reviewed prior to payment.
D. Prescription Charge Formula: Variable fee per prescription established for each individual par-
ticipating pharmacy within the range of $2.46 to $4.67 for N-1984.
Pharmacies are reimbursed on the basis of product acquisition cost plus a professional fee. This
applies to all covered legend and non-legend drugs. The professional fees are based upon each
individual pharmacy's historical operating costs as determined by analysis of data submitted by
each pharmacy to the agency. Professional fee determination is limited to the lowest of: (a) The
85th percentile of allocated costs per prescription for all pharmacies filing a cost report plus
a reasonable profit, or (b) usual and customary fee charges of each individual pharmacy as
determined. "Acquisition cost" means the allowable price delermined by the agency for each
covered drug in accordance with state and federal regulations.
Effective May 1, 1983, a recipient co-pay charge of $1.00 was applied to each new and refill
prescription.
Department Representatives
KENTUCKY
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)
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30. 1984
1984 1983
-
Expended -
Recipient
-
Expended -
Recipienl
TOTAL . . . . . . . . . . . . . . . . . . . . . $27,996,238 311,656" $19,505,335 251,935
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
Formulary Subcommittee
Louisiana
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)
If. EXPENDITURES FOR DRUGS. Fayment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
-
Expended -
Recipient -
Expended
-
Recipient
Ill. Administration:
Public assistance prosrams are administered by the State Office of Family Security. Department of
Health and Human Services.
IV. Provisions Relating to Prescribed Drugs:
A. Prescribed legend and non-legend drugs (OTC) are reimbursed; except experimental drugs,
anorexics and anti-anemia drugs, cough and cold preparations, vitamins, certain gastroin-
testinal drugs, and certain minor tranquilizers.
B. Prescribing or Dispensing Limitations:
1. Quantity of Medication: New prescription must be issued for drugs given on a continuing
basis, after 5 refills or after 6 months.
Maximum payment quantity for prescriptions shall be either one month's treatment or
100 unit doses.
2. Refills: Permitted as indicated by physician within 6 months and not to exceed 5 refills.
3. Dollar Limits: None.
4. Formulary: No.
C. Prescription Charge Formula:
1. The maximum payment for a prescription is estimated acquisition cost or MAC plus $3.67
dispensing fee.
D. Fiscal Intermediary:
The Computer Company
P.O. Box 4169
Baton Rouge, Louisiana 70821
E. Number of Rx claims processed in FY 1984-4,928,534
Average Rx price FY 1984-$12.32
MAINE
M E D I C A L ASSISTANCE D R U G P R O G R A M (TITLE XIX)
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
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
1984
-
Expended -
Recipient
TOTAL ..... $13,459,553 84,396"
CATEGORiCALLY NEEDY CASH TOTAL . . . . . . . . . .
Agd . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Chiidren-Families w/Dep Children . . . . . . . . . . . .
Adults-Families w/Dep Children . . . . . . . . . . . .
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adults-Families w/Oep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Chiidren-Families w/Dep Children . . . . . . . . . . . .
Aduits-Families w/Dep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
Ill. Administration:
State Department of Human Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions:
1. OTC drugs, except insulin and artificial tears.
2. Combination antibiotics.
3. Symptomatic remedies for common colds and coughs resulting from common colds.
4. All vitamins and vitamin preparations.
5. All amphetamines, straight or in combination, and all obesity control drugs. (Authorization
for amphetamines or methylphenidate in documented cases of narcolepsy or hyperkinesis
may be obtained upon request.)
6. lnjectables when oral medication is available for equally effective treatment.
Prior authorization may be obtained in the case of necessary exceptions.
B. Formulary: Open formulary, except for certain therapeutic categories.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Refills for chronic conditions can be for no less than a 30 day supply
unless the prescriber specifically directs otherwise.
3. Refills: A prescription can be refilled up to five times within six months if specifically ordered.
4. Dollar Limits: None.
D. Prescription Charge Formula: Usual and Customary. EAC plus a professional fee of $3.20 or MAC
plus a professional fee of $3.20. whichever is lower. (EAC for the top 150 drugs = AWP 5%
or direct prices, whichever applies.)
E. Copayment: $0.50
V. Miscellaneous:
Average Rx price during PI 1984-$10.49
Fiscal Intermediary: Good Health SystemslLow Cost Drug Program
P. 0. Box 508
Augusta, ME 04330
Margaret Ross
Director
Medicaid Surveillance and
Utilization Review
Medical Consultants:
D. K. McFadden, D.0,
Osteopathic
MARYLAND
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)
II. MPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30. 1984
1984 1983
-
Expended
-
Recipient
-
Expended
-
Recipient
Ill. Administration:
State Department of Health and Mental Hygiene.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: (a) experimental or investigational drugs; (b) food supplements or infant
formulas; (c) prescriptions and injections for central nervous system stimulants and anorectic
agents used for weight control; (d) "less-than-effective"drugs under federal regulations; and (e)
certain other items as specified in the state's Medicaid plan.
0. Coverage of non-legend drugs is limited to insulin, and Schedule V cough preparations, needles
and syringes, contraceptives other than condoms and specially formulated nutritional prepara-
tions when preauthorized by the program.
1. Quantity of Medication: The prescriber may order up to a 100-day supply of the medication
on a single prescription, except for birth control pills which are limited to a 6-cycle supply.
2. Refills:
a. Maximum number of refills authorized on a prescription is two. The original prescription
and its refills may not exceed a 100 day supply.
b. Refills may not be dispensed after 100 days of date of original prescription.
3. Dollar Limits: Prior authorization required from Medical Assistance Compliance
Administration when usual and customary charge exceeds $60 and prescribed amount is
more than a 34 day supply.
4. Formulary: The program has an "Open Formulary." The program does not restrict prescribers
in their selection of drug products except for the exclusions stated in section 1V.A..
5. Reimbursement:
a. Drug ingredient cost is calculated under one of the following procedures:
(1) Maximum Allowable Cost (MAC) - this list, which contained 44 price-controlled drugs in
fiscal year 1984, is continually updated to reflect deletions and additions made by the
Health Care Financing Administration of the Department of Health and Human Services.
(2) Interchangeable Drug Cost (IDC) effective June 1. 1985, the state of Maryland main-
tains a list of approved interchangeable multiple source drugs for which a maximum
reimbursement (the IDC) will be allowed, unless the prescriber has indicated that a par-
ticular brand is to be dispensed. This IDC is based upon the lowest cost at which an
approved interchangeable product can be guaranteed available throughout the state.
As of June 1. 1985. there are 237 products representing 97 drug entities on the list.
(3) Usual Source and Quantity List for High Utilization Drugs effective June 1, 1985, the
state of Maryland maintains a list of products which are usually purchased directly from
manufacturers and/or in larger than minimum package size. Reimbursement for these
products is based on the less expensive source of supply or package size. As of June
1, 1984, 53 products representing 34 drug entities are included in this list.
(4) Estimated Acquisition Cost (EAC) for all other drugs, reimbursement levels are based
upon the price of standard size packages (a) available from wholesalers within the state,
or if not available from these wholesalers, (b) manufacturers' d~rectprices.
b. Reimbursement will be the lower of:
-the usual and customary fee;
-the calculated ingredient cost plus $3.45 dispensing fee.
V. Miscellaneous:
Number of Rx claim processed in FY 1984 (July, 1983 June, 1984) 2,987,328
Average prescription price during FY 1983 $13.07
155
NPC
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 11,370per month. The program paid
$3,494,592for 234.845 prescriptions, an average of $14.88per prescription. Providers are reimbursed
the lower of:
-usual and customary fee
-ingredient cost as calculated under Medical Assistance regulations plus a $3.45dispensing fee
Recipients are responsible for a $1 .OOcopayment for each prescription and each refill. The state
pays the remainder of total reimbursement.
Douglas H. Morgan
Assistant Secretary for
Medical Care Programs
Kathleen B. Becker
Joseph Fine, R.Ph.
Jeanne E. Fisher
Leone W. Marks, R.Ph.
Charles Sandler. R.Ph.
3. Medical Assistance Advisory Committee:
MASSACHUSElTS
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)
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
A. Officials
MICHIGAN
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)
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.
11. EXPENDITURES FOR DRUGS. hvment to Pharmacists bv fiscal vear endina Seotember 30. 1984
TOTAL .....................
-
Expended
$86,822,120
-
Recipient
764,1348"
-
Expended
$77,560,984
-
Recipient
774,896
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . 665,257
Aged . . . . . . . . . . . . . . . . . . . . . . 28,185
Blind . . . . . . . . . . . . . . . . . . . . . . 1.399
Disabled . . . . . . . . . . . . . . . . . . . . . 64,306
Children-Families.w/Oep Children . . . . . . . . . . . . 340.473
Adults-Families w1Dep Children . . . . . . . . . . . . 240.029
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . 40,881
Aged . . . . . . . . . . . . . . . . . . . . . . 3,716
Blind . . . . . . . . . . . . . . . . . . . . . . 52
Disabled . . . . . . . . . . . . . . . . . . . . . 6,535
Children-Families w l h p Children . . . . . . . . . . . . 16,129
Adults-Families wlDep Children . . . . . . . . . . . . 17.863
Other Title XIX Recipients . . . . . . . . . . . . . . . 0
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . 96.757
Aged . . . . . . . . . . . . . . . . . . . . . . 40,351
Blind . . . . . . . . . . . . . . . . . . . . . . 111
Disabled . . . . . . . . . . . . . . . . . . . . . 24.375
Children-Families wlDep Children . . . . . . . . . . . . 10,779
Adults-Families w/Deo Children . . . . . . . . . . . . 12,693
Other Title XIX ~ecipients 12.056
517,373-7720 @"
2. Social Services Department Advisory Committees:
A. State Medical Care Advisory Council:
Consumer Members
Provider Representatives
Government Representatives
Mr. Dominic A. D'Annunzio -Michigan Insurance Bureau
7419 Yorktown, Rt. #2
Lansing 48917
MINNESOTA
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)
II. EXPENDITURES FOR DRUGS. Pavment to Pharmacists bv fiscal vear endino June 30. 1984
1984 1983
-
Expended
-
Recipient -
Expended -
Recipient
TOTAL ..................... $35,655,862" 221.46s"
CATEGORICALLY NEEDY CASH TOTAL $15,611,255 148.286
Aged . . . . . . . . . . . . . . . . . . . . . . 3,278.777 9,032
Blind . . . . . . . . . . . . . . . . . . . . . . 117.802 345
Disabled . . . . . . . . . . . . . . . . . . . . . 6,128,761 14.978
Children-Families wlDep Children . . . . . . . . . . . . 2,122,283 70.092
Adults-Families w/Dep Children . . . . . . . . . . . . 3.963.632 53,839
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . 7,271.002 18,753
Aged . . . . . . . . . . . . . . . . . . . . . . 5,448.770 11,714
Blind . . . . . . . . . . . . . . . . . . . . . . 30.058 60
Disabled . . . . . . . . . . . . . . . . . . . . . 1,667,049 3.531
Children-Families w/Dep Children . . . . . . . . . . . . 42,942 1.756
Adults-Families w/Dep Children . . . . . . . . . . . . 80,358 1.664
Other Title XIX Recipients . . . . . . . . . . . . . . . 1,825 28
MEDICALLY NEEDY TOTAL . . . . . . . . .
. . . . . 12,773,605 51.555
Aged . . . . . . . . . . . . . . . . .
. . . . . 8,926,414 21,958
Blind . . . . . . . . . . . . . . . . .
. . . . . 34.694 94
Disabled . . . . . . . . . . ..; . . .
. . . 2,814,329 6.729
Children-Families w/Dep Children . . . . . . . . .? . . . 118,329 4.228
Adults-Families w/Dep Children . . . . . . . . . . . . 320.995 4.426
Othe: Title XIX Recipients . . . . . . . . . . . . . . . 558,993 14,120
MISSISSIPPI
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 I T L E XIX)
Hospital Care X X X X
Outpatient
Hospital Care X X X X
Laboratory &
X-rav Service X X X X
Skilled Nursing
Home Services X X X X
Phvsician
,- -
Serv~ces X X X X
Dental
Services X X X X
II. EXPENDITURES FOR DRUGS. Paymenl to Pharmacists by fiscal year ending June 30, 1984
1984 1983
-
Expended
-
Recipient -
Expended -
Recipient
MISSOURI
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)
Hosp~talCare X X X X X
Laboratory &
X-ray S e ~ ~ c e X X X X X
Sk~lledNurslng
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
19ffl 1983
-
Expended -
Rec~pient
-
Expended -
Recipient
TOTAL ..... $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 ~ecipiints
Ill. Administration:
Division of Family Services of the State Department of Social Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Exclusions governed by Formulary.
8. Formulary: Formulary lists 402 drugs by generic names or trade names. For information contact:
Susan McCann, P.D.
Pharmacy Consultant
P.O. Box 6500
Jefferson City. Missouri 65102
314/751-3277
State allows payment only for the drugs in the formulary.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Physician encouraged to prescribe 34-day or 100 doses supply but
may, at his own discretion, prescribe up to a maximum 90-day supply.
2. Refills: Federal regulations must be observed for all drugs on the formulary which are listed
in BNDD Schedules 2. 3, 4, and 5. All other prescriptions refilled should be in accordance
with the directions given by the prescribing physician.
3. Five Rx limitation per month per recipient. Certain drugs which are commonly prescribed for
long-term chronic medical conditions are exempt from limitation.
D. Prescription Charge Formula: The lowest of the following: Federal MAC. Missouri MAC, AWP, or
Direct plus $2.50 fee or usual and customary, whichever is lower.
E. Co-payment (variable) -$0.50 co-payment when acquisition is $10.00 or less
-$1.00 co-payment when acquisition $10.01 to $25.00
-$2.00 co-payment when acquisition cost is $25.01 or more
-Go-payment retained by pharmacist.
F. Drug Exception Process:
Certain nonsteroidal anti-inflammatory drugs covered on a prior authorization basis for recipients
with diagnosis of rheumatoid arthritis or juvenile rheumatoid arthritis who cannot tolerate aspirin.
V. Miscellaneous Remarks:
All prescriptions must be filled with drugs that meet USP standards. Participating pharmacies sign
a participation agreement with the State Department. All dispensing physicians participating in the
program are required to keep prescription files the same as pharmacies.
Missouri formulary is a restricted formulary, restriction being that the State only pays for drugs listed
on the formulary, or drugs that are chemically equivalent to drugs listed. Any drug that is chemically
equivalent to a trade name drug listed as acceptable for reimbursement. And likewise any trade
name drug that is not listed, but is equivalent to a generic drug listed, is reimbursable under the
drug program.
Method of reimbursement payment is based on acquisition cost plus a dispensing fee of $2.50 per
prescription filled. Acquisition may vary depending whether it is based on AWP. Direct Price and
Federal or Missouri MAC. The master drug file contains all acceptable drugs and their appropriate
NDC (National Drug Code) number.
AWP (Average Wholesale Price), any drug that is not manufactured by Abbott. Lederle. Merck Sharp
& Dohme, Parke-Davis. Pfizer, Roerig. Squibb, Upjohn and Wyeth, or is not a Federal or Missouri
MAC drug will be based on the AWP. The majority of drugs listed are based on AWP. The method
of pricing will be taken from the NDC number.
NPC
Any drug manufactured by Abbott, Lederle. Merck Sharp & Dohme. Parke-Davis. Pfizer, Roerig,
Squibb, Upjohn and Wyeth, acquisition cost will be based on the manufacturer's direct price.
The Federal Government has 19 drugs listed as MAC (Maximum Allowable Cost). Missouri has 41
drugs listed as MAC (Maximum Allowable Cost). These 60 drugs have a maximum price that will be
paid.
All pharmacists and physicians that participate in the Missouri Title XIX Medicaid Drug Vendor
Program have been issued a listing of all MAC drugs, a listing of the manufacturers that the Division
of Family Services limits price to direct price.
By following these guidelines the Division of Family Services feels that the pharmacist has a freedom
of choice of products and package sizes in which he or she may stock their inventory.
Fiscal intermediary: General American-Consultec
701 So. Country Club Drive
Jefferson City, Missouri 65101
Number of drug claims processed in FY 1984 - 3,622,556
Average prescription price during FY 1984 - $8.77
David G. Foshage
Administrator
SurveillancelUtilization
Review Systems (SURS)
Susan McCann
Pharmacist Consultant
Joyne Leet
Executive Director
Primary Care Council of
Metropolitan St. Louis, Inc.
4900 Delmar Boulevard
St. Louis, Missouri 63108
3 14/36 1-2330
Missouri 5
19H!i
MONTANA
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 XM)
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
-
Expended
-
Recipient -
Expended
-
Recipienl
TOTAL
CATEGORICALLY NEEDY CASH TOTAL
A"P~ .
. . . . . . . ., ..
Blind . . . . . . . . . . . . . . . . . . . . . . 13.204 73 13.508 68
Disabled . . . . . . . . . . . . . . . . . . . . . 985.920 3.975 904.438 3.499
Children-Families w/Dep Children. . . . . . . . . . . . 252,740 9,615 215.449 8,655
Adults-Families w/Oep Children . . . . . . . . . . . . 495.757 6,995 387,585 6,033
Other . . . . . . . . . . . . . . . . . . . . . . 11,108 162
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . 1.866.599
Aged . . . . . . . . . . . . . . . . . . . . . . 1,208,898
Blind . . . . . . . . . . . . . . . . . . . . . . 4,805
Disabled . . . . . . . . . . . . . . . . . . 489.394
Children-Families w1Dep Children . . . . . . . . . 81,234
Adults-Families w/Dep Children . . . . . . . . . . . . 76.631
Other Title XIX Recipients . . . . . . . . . . . . . . . 5.636
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . 1,050,007
Aged . . . . . . . . . . . . . . . . . . . . 579.1 86
Blind . . . . . . . . . . . . . . . . . . . . . . 5.190
Disabled . . . . . . . . . . . . . . . . . . . 445,254
Children-Families w l k p Children . . . . . . . . . . . . 2,721
Adults-Families wlOep Children . . . . . . . . . . . . 15,857
Olher Title XIX Recipienls . . . . . . . . . . . . . . . 2,804
Randal P. Bowsher
4061444-4540
2. Montana Medical Care Advisory Council:
James Conway Calvin Bohleen
John Jacobson. M.D. Gary Blewett
Lowell Uda Charles Briggs
John Layne, M.D. Jack Ellery
3. Social and Rehabilitation Services Economic Assistance Division:
Dale Haefer Karl Banschbach
Administrative Officer Medical Care Specialist
Brian Camoure
Administrative Officer
4. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
G. Brian Zins
Executive Director
Montana Medical Association
2021 11th Avenue. Suite 12
Helena 59601
Phone: 4061443-4000
6. Pharmaceutical Association:
Robert Likewise
Executive Director
Montana State Pharmaceutical Association
P.O. Box 4718
Helena 59604
Phone: 40614494843
C. Osteopathic Association:
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
-
Expended -
Recipient -
Expended -
Recipient
TOTAL ..................... $1 1,325,229 63,473'. $10,642,008 60,421
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $6,929.099 50,252 $6,381,812 47,738
Aoed . . . . . . . . . . . .
0~~
. . . . . . . . . . 2,209,371 5.332 2847.696 5.169
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
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 identificationmembers
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 require-
ment. The full month's supply must be prescribed and dispensed.
(3) An original shelf package of 100 tablets or capsules, or less when not available in the
100 size for SELDOM prescribed solid dosage drugs will be sufficient for our quantity
limitations requirement, but will not be sufficient for the supplemental dispensing fee
unless it is a full month's supply.
(4) Ready-made ointments, creams, etc., when used in a chronic or maintenance man-
ner, may be dispensed in an original shelf package size provided it is the original
size closest to the needed amount of medication.
(5) The determination of whether a claim violates our regulations or not, would, by
necessity, have to be made by the Department of Social Services professional staff.
Any claim deemed to be in violation or not an exception to our rulings, will not be
compensated with the dispensing fee.
Any disagreement with a determination may be arbitrated through the NEBRASKA
PHARMACISTS ASSOCIATION'S ADVISORY COMMITTEE.
3. Refills: As authorized by the prescribing physician.
4. Dollar Limits: None.
D. Prescription Charge Formula:
1. Retail Pharmacies
a. "Assigned" Dispensing fee.
A dispensing fee will be assigned by the Nebraska Department of Social Services, to
each individual pharmacy. The fee will be calculated from the information obtained
through the Department's Prescription Survey. Each Pharmacy will be notified of its
dispensing fee.
b. "Maintenance Drug-Month Supply"
Supplemental fee.
In addition to the "assigned" dispensing fee for each retail pharmacy, there is a main-
tenance drug-month supply supplemental fee of $1.00. This additional fee may be
charged provided that a MAINTENANCE DRUG or drug used in a chronic manner is
dispensed in a quantity sufficient to provide an entire month3 therapy
c. The department assigns a dispensing fee to a dispensing physician only when there is
no pharmacy within a 25 mile radius of the physician's place of practice.
Variable Pharmacy Fee for individual pharmacy determined from survey data submitted to state:
EAC, SMAC. MAC plus determined store fee: minimum $3.25 to maximum $4.69.
or usual and customary, whichever is lower.
2. DETERMINING DRUG OR INGREDIENT COST
a. General Information
(1) Maximum Allowable Cost (M.A.C.)
Certain multiple source products will have a maximum allowable cost designated by
the Federal Pharmaceutical Reimbursement Board, Department of Health, Education,
and Welfare. The M.A.C. value will be Me lowest cost at whlch the drug is widely
and consistently available.
187
NPC
The determination of which products will be designated M.A.C. items will be the
direct responsibility of the Reimbursement Board. The Nebraska Department of
Social Services will NOT have authority to increase the M.A.C. of any product. Any
individual or organization may at any time request that a M.A.C. determination be
revised or withdrawn. All requests must be submitted directly to the Pharmaceutical
Reimbursement Board, DHHSIHCFA, 6401 Security Blvd.. Rm. 1-C-5 East Low Rise
Bldg., Baltimore. Maryland 21235.
All pharmacies will be notified by the Nebraska Department of Social Services as
to which items have been designated as M.A.C. products and what their respective
M.A.C. values are.
(2) State Maximum Allowable Cost (SMAC): NDSS designates a state maximum allow-
able cost (SMAC) for certain drug products available from multiple manufacturers.
The SMAC value is the cost at which the multiple-source drug is widely and con-
sistently available to pharmacy providers in Nebraska. The determination of which
products are designated SMAC items is the direct responsibility of the Division
of Medical Services in conjunction with the Nebraska Pharmacists Association's
Advisory Committee. Any individual or organization may request a revision in a
SMAC value directly from NDSS at any time.
(3) Estimated Acquisition Cost (EAC): All drug products, including the federally-
designated MAC and state-designated SMAC drugs, are assigned an estimated ac-
quisition cost (EAC) as required by 42 CFR 447.332 (a)
(4) The EAC of any product is the cost at which most prudent providers may obtain the
item. NDSS is responsible for assigning the EAC values to all drugs. Any individual
or organization may at any time request a revision in an EAC value directly from
NDSS.
b. Cost Limitations
The Nebraska Medicaid Drug Program is required to reimburse product cost at the
LOWEST of:
(1) the M.A.C. or S.M.A.C. of the drug, 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
NPC
Robert Seiffert
Administrator
Division of Medical Services
Peter R. Kongstvedt. MD
Gregg Wright, MD, Director Executive Director
Department of Health Health America of Lincoln
301Centennial Mall South. 3rd FI. 17th & N Streets
Lincoln, NE 68509 Lincoln, NE 68508
Diannae Kascht
1528 D Street Shirley A. Munn-White
Lincoln, NE 68502 General Manager
Capitol Medical
271 1 0 Street
Lincoln, NE 68510
NPC
NEVADA
M E D I C A L ASSISTANCE D R U G P R O G R A M (TITLE XIX)
11. EXPENOiTURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
- -
Expended Recipient -
Expended -
Recipient
TOTAL .....................
CATEGORICALLY NEEOY CASH TOTAL . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled
Chiidren-Families wloep Children . . . . . . . . . . . .
Adults-Families wIDep Chiidren . . . . . . . . . . . .
CATEGORICALLY QEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w l b p Children . . . . . . . . . . . .
Adults-Families w/Dep Chiidren . . . . . . . . . . . .
Other Title XiX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEOY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families wIDep Chiidren . . . . . . . . . . . .
Aduits-Families w l b p Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
Jane Feldmen
Statistician Ill
N E W HAMPSHIRE
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)
N
I . EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
-
Expended
-
Recipient -
Expended -
Recipient
TOTAL ..................... $4,928,443 27,512" $4,240,571 29,092
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
Aoed . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adulk-Families w/Dep Children . . . . . . . . . . . .
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adulk-Families w/Dep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w l b p Children . . . . . . . . . . . .
Adults-Families w/Deo Children . . . . . . . . . . . .
Other Title XIX ~ecipients . . . . . . . . . . . . . . . 60 3
Ill. Administration:
Office of Medical Services, Department of Health and Welfare.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Anorexiant (stimulants) except for treatment of narcolepsy and hyperkinetic
children; and vitamins for patients over 7 years of age.
B. Formulary: None.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Prescriptions limited to 100 day supply; three prescriptions, including
refills for recipient per month.
2. Dollar Limits: None.
D. Prescription Charge Formula:
$2.85 fee plus Estimated Acquisition Cost (EAC) or Maximum Allowable Cost (MAC) or Usual
and Customary Charge, whichever is less.
Maintenance medications are reimbursed by the above formula once every thirty days per
recipient per provider: any refills of maintenance medications within 30 days are reimbursed
at cost only.
Co-payment: $0.75, except nursing home patients, under 18 years, family planning and preg-
nancy prescriptions.
Philip Soule
Administrator
Office of Medical Services
Division of Welfare
Hospital Care X X X X
Outpallent
Hospila Care X X X X
Laboratory &
X-rav Service
Skilled Nursing
Home Services X X X X
Phvsician
Dental
Services X X X X
Other Benefits: Home Health Agency Services, Independent Clinic Services. Podiatrist, Chiropractor. Optomelrlst and Optical Appliances. Ambulance
and Invalid Coach, Medical Equipment and Prosthetic Devices.
'SF0 - State Funds Only (PAAD, Pharmaceutical Assistance to the Aged).
11. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending September 30. 1984
1984 1983
-
Expended -
Recipient -
Expended -
Recipient
TOTAL . . . . . . . . . . . . . . . . . . . . . $67,421,822 484,755" $61,125,306 493,234
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $53,660,744 428,198 $48,869,000 437.859
Aged . . . . . . . . . . . . . . . . . . . . . . 9,008,458 27,818 8,010,000 27.287
Blind 251,791 892 225,000 857
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
Ill. Administration:
Division of Medical Assistance and Health Services, Department of Health Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Experimental drugs, antiobesics and anorexiants.
B. Formulary: None.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: The quantity of medication prescribed should provide a sufficient
amount of medication necessary for the duration of the illness or an amount sufficient to
cover the interval between visits, but may not exceed a 60day supply or 100 unit doses
whichever is greater.
Exceptions:
a. Oral contraceptives may be prescribed for up to a 3-month supply.
b. Vitamins and vitamin-mineral combinations may be dispensed for up to a 100-day supply.
2. Refills: Prescription refills will be limited to 5 times within a 6-month period if so indicated by
the prescriber on the original prescription.
Exceptions:
a. Oral contraceptives originally prescribed for a 3-month supply may be refilled 3 times
within one year.
b. Vitamins and vitamin-mineral combinations originally prescribed for 100 day supply may
be refilled 2 times within one year.
3. Dollar Limitations: None.
D. Prescription Charge Formula:
1. Payment for legend drugs, contraceptive diaphragms and reimbursable devices shall be
based upon "Maximum Allowable Cost." or Average Wholesale Price minus 0-6%.
a. Maximum Allowable Cost is defined as:
(1) The "Maximum Allowable Cost" (MAC) price published by the Pharmaceutical
Reimbursement Board of the Department of Health and Human Services for listed
multi-source drugs or established by the Division of Medical Assistance and Health
Services; or
. (2) The Average Wholesale Price (AWP) listed for the most frequently purchased
package size (as defined by the N.J. Medicaid Program) in the current "Drug Topics
Red Book" (published by Medical Economics Co.. Oradell. New Jersey 07649). and
supplements; price changes listed by the same publisher in "Drug Topics Magazine"
or other appropriate sources; or designated prices defined in section 10:51-1.6. In
the case of unlisted or undesignated AWP "costs or of typographical errors, the
known correct price will be used as maximum.
2. Maximum cost for each eligible prescription claim not covered by section 10:51-1.16(a)l
shall be subject to the following fiscal conditions based upon six categories, as determined
by the N.J. Medicaid program based on the previous year's total prescription volume for
each participating pharmacy. The categories shall be reviewed annually and adjusted as
appropriate.
a. To determine a provider's total prescription volume, which shall include all prescriptions
filled, both new and refills, for private patients. Medicaid, PAA, and other third party
recipients for the previous calendar year, each pharmacy provider shall submit in writing,
an annual report certifying its prescription volume. Failure to submit this
NPC New Jersey-3
1985
report annually will result in the provider being placed in the maximum discount category
(category VI) for the year of non-compliance, or until the required report is received.
Note: Those pharmacy providers who have been in business for less than one calendar
year will have their prescription volume projected for the entire year, to determine the
appropriate category.
b. Category I: Pharmacies whose total prescription volume in the preceding calendar year
was not more than 14,999 prescriptions.
(1) Pharmacy providers in this category shall receive reimbursement for Medicaid
prescription claims for legend drugs at average wholesale price (AWP), as defined
in section 10:51-1.16a.. as the maximum.
c. Category II: Pharmacies whose total prescription volume in the preceding calendar year
was at least 15.000 but not greater than 19,999 prescriptions.
(1) Pharmacy providers in this category shall receive reimbursement for Medicaid
prescription claims for legend drugs at average wholesale price (AWP), as defined
in section 10:51-1.16a. less two per cent, as the maximum.
d. Category Ill: Pharmacies whose total prescription volume in the preceding calendar year
was at least 20,000 but not greater than 29.999 prescriptions.
(1) Pharmacy providers in this category shall receive reimbursement for Medicaid
prescription claims for legend drugs at the average wholesale price (AWP), as
defined in section 10:51-1.16a, less three per cent, as the maximum.
e. Category IV: Pharmacies whose total prescription volume in the previous calendar year
was at least 30,000 but not greater than 39,999 prescriptions.
(1) Pharmacy providers in this category shall receive reimbursement for Medicaid
prescription claims for legend drugs at average wholesale price (AWP), as defined
in section 10:51-1.16a. less four per cent. as the maximum.
f. Category V: Pharmacies whose total prescription volume in the preceding calendar year
was at least 40,000 but not greater than 49.999 prescriptions.
(1) Pharmacy providers in this cateogry shall receive reimbursement for Medicaid
prescription claims for legend drugs at average wholesale price (AWP), as defined
in section 10:51-1.16a, less five per cent, as the maximum.
g. Category VI: Pharmacies whose total prescription volume in the preceding calendar year
was 50,000 prescriptions or more.
(1) Pharmacy providers in this category shall receive reimbursement for Medicaid
prescription claims for legend drugs at average wholesale price (AWP), as defined
in section 10:51-1.16a. less six per cent. as the maximum.
Notes: (1) If the published MAC price as defined in section 10:51-1.16(a)li is higher
than the price which would be paid under section 10:51-1.16(a)lii. then section 10:51-
1.16(a)lii, will apply.
(2) The appropriate calculated discount will be automtically deducted (by Blue Cross
of New Jersey) from each eligible legend drug claim during the claim processing
procedures.
(3) For prescription drugs costing more than $24.99 there will be no discount from the
average wholesale price (AWP).
New Jersey-4
1985
Dispensing Fee
The dispensing and services fee ranges from $3.53 to a maximum of $3.87 depending upon the number
and types of services agreed to by the provider.
Service Fee
INCREMENT
1. 24 hour emergency service availability $0.1 1
2. Patient Consultation $0.08
3. Impact Allowance $0.1 5
In completing the Pharmacy Provider Service Agreement the provider agrees to provide all services
at no additional charge to the Medicaid or PAA recipient. Under no circumstances are any additional
administrative charges allowed.
The Pharmacy Manual further stetes the following: The maximum charge to the New Jersey Health
Services Program for a legend drug may not exceed the lowest of the following:
a. Cost plus dispensing fee as outlined herein.
b. Usual and customary charges andlor posted or advertised charges.
c. Other third party prescription plan charges, when contracts or agreements to participate have
been entered into subsequent to the adoption of this regulation.
V. Miscellaneous Remarks:
Fiscal Intermediary:
Blue Cross of New Jersey
33 Washington Street
Newark. New Jersey 07101
Number of Rx claims processed in FY 1984-6,905,548
Average Rx price during FY 1984-Retail: $10.54
Copayment: None
Medicaid Personal Physician Plan (MP Plan) Demonstration Project
The New Jersey Medicaid Program has implemented a four-year Statewide Competition Demonstration
Project, called the Medicaid Personal Physician Plan (MP Plan), which will provide medical care in a
manner different from the present Medicaid system. The Plan is classified as a Primary Care Network
or a health care delivery system whereby all of the Medicaid elibible's health care is obtained through,
but not necessarily from, a single primary care provider. It was developed under guidelines established
by the Health Care Financing Administration for funding which led to the inclusion of the following key
elements:
(1) a primary care physician who would be responsible for the provision of all primary care delivery,
referral, and ancillary services for non-institutional Medicaid eligibles;
(2) a capitation system of reimbursement, instead of fee-for-service, for a physician participating in
the Plan as a Physician Case Manager (PCM):
(3) a broker concept for marketing, enrollment, grievance system and quality asurance monitoring
and Plan reporting functions;
(4) the stimulation of competition among certain types of Medicaid providers by providing
strengthened alternatives to primary care in the hospital Emergency Room (ER) and Outpatient
Department setting (OPD).
The role of Physician Case Manager has potential to (1) discourage doctor shopping, self-referral, and
inappropriate and excessive utilization of Medicaid eligible services and (2) to effect better control over
almost 500 million dollars of New Jersey Medicaid's total expenditures annually without reducing quality
NPC New Jersey-5
1985
or scope of care provided. This concept of the Physician Case Manager controlling costs has received
wide s u ~ ~ othroughout
rt 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.
I. F. Erlichman
Medical Director
N E W MEXICO
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)
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
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
-
Emended -
Reci~ient -
Emended -
Reci~ient
TOTAL ..................... $9,427,783 59,873" $7,569,254 58,324
CATEGORICALLY NEEDY CASH TOTAL . . . $Not available
Aged . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . .
Disabled
Children-Families w/Dep Children . . . . .
Adults-Families w(0ep Children . .
. . .
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adults-Families w/Dep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Rp Children . . . . . . . . . . . .
Adult-Families w/Dep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
Ill. Administration:
Department of Human Services.
IV. Provisions Relating to Prescribing Drugs:
A. General Exclusions:
1. Drugs for treatment of tuberculosis are not included.
2. Medications supplied by the New Mexico State Hospital to clients on convalescent leave
from hospital are not included.
3. Drugs and immunizations available from any other source are not included.
4. Legend multiple vitamins, tonic preparations and combinations thereof with minerals, hor-
mones, stimulants or other compounds which are available as separate entities for treatment
of specific conditions.
5. Hematinics except non-sustained release forms of Ferrous Sulfate, Ferrous Gluconate.
Ferrous Fumarate.
6. Amphetamines and combinations of amphetamines with other therapeutic agents;
amphetamine-like sympathomimetic compounds used for obesity control including any com-
bination of such compounds with other therapeutic agents.
7. Drugs classified by FDA as "Ineffective" or "Possibly Effective"
8. Hypnotic drugs.
9. OTC items with the following exceptions (the exceptions are covered by the program):
a. Insulin.
b. Antacids for active gastric and duodenal ulcers.
c. Infant vitamin drops for children up to one year of age.
d. Salicylates and acetaminophen.
e. Non-sustained release forms of Ferrous Sulfate, Ferrous Gluconate, Ferrous Fumarate.
B. Formulary: Open formulary subject to above-stated limitations. For formulary information contact:
Nick Army
Medical Assistance Bureau
P.O. Box 2348
Santa Fe, New Mexico 87504-2348
5051827-431 5
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: 6 months supply maximum
2. Refills: Payment will be made to a particular pharmacy only three times for the same drug
for the same client in any 90-day period.
D. Prescription Charge Formula:
1 . Prescriptions reimbursed at the lesser of the following:
a. Cost (MAC or EAC) dispensed plus fee ($3.65) or,
b. The usual and customary charge by the pharmacy to the general public
V. Miscellaneous Remarks:
New Mexico-3
1985
Fiscal Intermedialy:
EDS Federal Corporation
4665 Indian School Road. N.E.. Suite A-1 14
Albuquerque. New Mexico 871 10
Number of Rx claims processed in FY 1984-789.822
Average Rx price during FY 1984-$12.79
Bruce Weydemeyer
Acting Bureau Chief
Medical Assistance Bureau
F. Richard Atkinson
Administrator
Medical Assistance Bureau
Jack E. Hilligoss
Executive Director, NMPHA
4800 Zuni. S.E.
Albuquerque 87108
4. Executive Officers of State Medical and Pharmaceutical Societies:
NPC New Mexico-4
1985
A. Medical Society:
Ralph R. Marshall
Executive Director
New Mexico Medical Society
303 San Mateo Blvd., NE
Albuquerque 87108
Phone: 5051266-7868
B. Pharmaceutical Association:
Jack E. Hilligoss
Executive Director
New Mexico Pharmaceutical Association
4800 Zuni. S.E.
Albuquerque 87108
Phone: 5051265-8720
C. Osteopathic Medical Association:
Thomas P. Thompson
Executive Director
New Mexico Osteopathic Medical
Association
P.O. Box 3096
Albuquerque 87110
Phone: 5051299-8900
D. State Board of Pharmacy
Olive Vaughn, Administrator
2340 Menaul. N.E. - Suite 216
Albuquerque. NM 87107
505/841-6311
NPC New York-I
1985
N E W YORK
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)
~ospitalCare X X X X X X X X X X
Laboratory &
x-ray service x x x x x x x x x x
Skilled Nursing
Home Services X X X X X X X X X X
Phwicim ".
Services X X X X X X X X X X
Dental
Services X X X X X X X X X X
Other Benefits: Prosthetic and Onhotic deviceslsupplies; eye services; podiatry services: family planning; EPSDT (CHAP); clinics; private duty
nursing in hospital selting; home care; transpollation; rehabilitation therapies
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Pavment to Pharmacists bv fiscal vear endina Se~tember30.1984
TOTAL .....................
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families.w/Dep Children . . . . . . . . . . . .
Adults-Families w/Dep Children . . . . . . . . . . . .
Other
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w1Dep Children . . . . . . . . . . . .
Adults-Families wIDep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
A~ed . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . .
Children-Families w/Deo Children . .
~ ~
Ill. Administration:
State Department of Social Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: No restrictions except: (See V. Miscellaneous Remarks)
1. Prescribed vitamins and minerals not prescribed for medical necessity.
2. Amphetamines and other drugs whose sole clinical use is for reduction of weight.
3. Limited coverage of non-prescription drugs.
B. Formulary: Coverage of prescription drugs is limited to list of Medicaid Reimbursable Prescription
Drugs. For information contact:
David G. Starks
Medicaid Reimbursement Drug Lists
Bureau of Standards Development
New York State Department of Health
Room 2074, Corning Tower
Albany, NY 12237
C. Prescribing or Dispensing Limitations:
1. Quadity of Medication: Drugs and sickroom supplies shall be prescribed in sufficient quantity
consistent with the health needs of the patient and sound medical practice.
2. Refills: Refills cannot exceed 5, and the life of a prescription cannot exceed 6 months.
3. Dollar Limits: None.
D. Prescription Charge Formula:
1. Maximum Reimbursable Pricing Schedule
Maximum reimbursement shall be based on the lowest of:
a. the maximum allowable cost (MAC) plus applicable dispensing fee; or
b. the estimated acquisition cost (EAC) established by the State, plus applicable dis-
pensing fee; or
c. the usual and customary price charged by the pharmacy provider to the general
public, including any sale price which may be in effect on the date of service.
2. Dispensing Fee, $2.60
V. Miscellaneous Remarks:
The Medicaid drug list applies only to prescription andlor fiscal orders filled in community phar-
macies.
Based on mandated payment criteria for prescription drugs, many non-essential and high priced
drug products are excluded, e.g.. those not essential to sustain life, relieve or prevent severe pain,
or prevent disease or continuing disability; sustained release medications; anti-flatulence products;
cough enzymes; muscle relaxants: vitamins and vitaminlmineral preparations; and dermatologicals.
Many combination drugs and comfort products are also excluded.
Fiscal Intermediary:
McAuto Systems Group, Inc.
800 North Pearl Street
Albany, New York 12204
Copayment: None
Number Rx claims processed in FY 1984-17,928,987
New York-3
1985
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
Martin Roysher
Associate Commissioner
Program Analysis and Utilization
Review
2. Social Services Advisory Committees:
A.Medical Advisory Committee:
A. Medical Advisory Committee:
B. Pharmaceutical Association:
Executive Director (vacant)
Pharmaceutical Society of the
State of New York
Pine West Plaza IV
Washington Avenue Extension
Albany. New York 12205
5181869-6595
C. Osteopathic Soc~ety:
8. C. Scharf, D.O.
Executive Director
New York State Osteopathic
Medical Society, Inc.
1973 Morris Gate
Seaford 11783
5161826-2212
D. State Board of Pharmacy
Dr. Albert J. Sica, Executive Secretary
Cultural Education Center, Rm. 3035
Albany, New York 12230
5181474-3848
NPC North Carolina-1
1985
NORTH CAROLINA
M E D I C A L ASSISTANCE D R U G P R O G R A M (TITLE XIX)
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
Se~~ces 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
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 . . . . . . .
Ill. Administration:
Division of Medical Assistance, Department of Human Resources.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: No payment made for non-legend drugs, except insulin. Payment made for
all legend drugs. Non-legend vitamins are excluded.
8. Formulary: None.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: None.
2. Number of Prescriptions:
a. Six per month per recipient.
b. Prescription Limit Exemptions for Certain Recipients
The General Assembly has determined that exemptions to the six (6) prescription limit
per month may be authorized by the Department of Human Resources "where the life
of the patient would be threatened without additional care." Therefore, patients being
treated for the following illness should be excluded from the prescription limitation:
(1) End State Renal Diseases
(2) Chemotherapy and Radiation Therapy for Malignancy
(3) Acute Sickle Cell Disease
(4) Hemophilia
(5) End State Lung Diseases
(6) Unstable Diabetes
(7) Terminal Stage-any illness-life-threatening
3. Dollar Limits: None.
4. Generic Substitution: Pharmacists must substitute generically if they have a generically
equivalent product available in stock. The substituted product must be a lower cost product
than the one originally prescribed.
5. Lock-In: Each recipient is locked into one pharmacy of his choice for one month, except in
emergencies.
D. Prescription Charge Formula: The lowest price ~f MAC. EAC or AVVP, plus $3.36 dispensing
fee for each different drug dispensed during a month, or the pharmacist's usual and customary
charge. The pharmacist filling the original prescription will not be reimbursed for refills for the
same drug within a calendar month. $0.50 co-payment/Rx (includes refills).
V. Miscellaneous
Fiscal Agent:
EDS Federal
P.O. Box 300001
Raleigh, NC 27622
NPC North Carolina-3
1985
Paul R. Perruzzi
Deputy Director
Consultants
N O R T H DAKOTA
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)
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
11. EXPENDITURES FOR DRUGS. Pavment to Pharmacists bv fiscal vear endina June 30. 1984
1984 1983
-
Expended -
Recipient -
Expended -
Recipient
TOTAL . . . . . . . . . . . . . . . . . . . . .
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adults-Families w/Dep Children . . . . . . . . . . . . .
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adulls-Families wi&p Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
A d . . . . . . . . . . . . . . . . . . . . . .
Bid . . . . . . . . . . . . . . . . . . . . . . 3,806 7
Disabled . . . . . . . . . . . . . . . . . . . . . 350.930 873
Children-Families
- - ~
w/De~Children . . . . . . . . . . . . 25.874 688
Adults-Families w/&p children
Other Title XIX Recipients . .
Ill. Administration:
North Dakota Department of Human Services
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions:
1. Anorectics
2. High protein weight reduction supplements
3. Investigational drugs
4. Drugs which have questionable therapeutic value
5. Drugs which are not indicated for the diagnosis
6. DESl (Less-Than Effective) drugs
B. Formulary: None
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: None.
2. Refills: A prescription drug may be refilled up to 5 times or for 12 months after the date
of the original prescription, whichever occurs first, and provided that such refills have been
authorized by the physician.
3. Dollar Limits: None.
D. Prescription Charge Formula: Acquisition Cost plus $3.75 dispensing fee per prescription or
usual and customary retail charge, whichever is lower.
Acquisition Cost: EAC or MAC. EAC is North Dakota AWP
V. Miscellaneous Remarks:
Copayment-No.
Number of Rx claims processed in FY 1984-414,023
Average Rx price during FY 1983-$11.58
--€heelwhs7ETY
Administrator
Pharmacy Services
7011224-4023
2. Department of Human Services Advisory Committees:
NPC North Dakota-3
1985
D. M. Pfeifle, M.D.
Quain & Ramstad Clinic
Bismarck 58502
C. Pharmacy Advisory Committee:
M ~ N
Tokach, Chairman Dave Just
#1 Riverview Lane Box 99
Jamestown 58401 Beulah 58523
Richmond H. Lapp
1467 Hill Avenue
Gratton 58237
3. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Association:
Vernon Wagner
Executive Vice President
North Dakota Medical
Association
810 East Rosser Avenue
Box 1198
Bismarck 58501
Phone: 7011223-9475
B. Pharmaceutical Association:
John Schuld
Secretary-Treasurer
North Dakota Pharmaceutical
Association
P. 0 . Box 148
Dickinson 58601
Phone: 7011225-8650
C. Osteopathic Association:
Harry Homewood, D.O.
Secretary-Treasurer
North Dakota State Osteopathic Association
Box 516
Valley City 58072
D. State Board of Pharmacy
William J. Grosz, Executive Secretary
P.O. Box 1354
Bismark 58502
7011258-1535
OHIO
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)
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by tiscai year ending September 30. 1984
1984 1983
-
Expended
-
Recipient -
Expended -
Recipient
TOTAL ...
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adults-Families 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 . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . .
Children-Families w / h p Children . . . . . . . . . . . .
Adulk-Families w/Dep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
Art Evans
Assistant Director
Paul Offner
Deputy Director of
Medicaid Administration
Kathi Glynn
Acting Deputy Director for
Program Development
Joel Fisher
Program Planner for
Pharmaceutical Services
OKLAHOMA
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)
Other Benelits: Medically Needy (MN) are eligible i f within catastrophic illness determination according to Deparlment definition and il otherwise
eligible.
'SF0 - Stale Funds Only
II. EXPENDITURES FOR DRUGS. Pavment to Pharmacists bv fiscal vear endino June 30. 1984
1984 1983
-
Expended -
Recipient
-
Expended
-
Recipient
TOTAL $76,535,307 117,002" $74,775,001 107,971
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adults-Families w/Dep Children . . . . . . . . . . . .
CATEGORICALLY NEEDY NON-CASH TOTAL . . . .
Aged . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/De~Children . . . . . . . . . . . .
Adults-Families w/Dep children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adulls-Families w/Deo Children . . . . . . . . . . . .
Other Title XIX ~ecipiints . . . . . . .
6. Quantities:
5bC
34-day supply or 100 dosage units, whichever is greater. S$W h ~ C P
7. Legend, Non-Legend and Generic Drugs: CIP.I-J @nbcar,<
Only legend drugs in the designated categories and insulin are covered in the program.
8. Refills:
Refills shall be provided only if authorized by the prescriber, no more than five times within a 6-
month period.
V. Miscellaneous:
Number of Rx claims processed in FY 1984-1,097,560
Average Rx price during FY 1984-$15.29
OREGON
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)
Other Benelits: Visual Care. Medical Transportation. Medical Supplies/Equipment. Physical Therapy. Fudiatrist. Chiropractor. Naturopath. ICF.
Family Planning, Abortions, home health agency, Private duty nurse, EPSOT.
'SF0 - State Funds Onlv
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
Exoended
-
Recioient -
Exoended Recioient
TOTAL . . . . . . . . . . . . . . . . . . . . . $1 4,803,643 97,454 $14,521,924
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . Not avail. 8.093.608
Aged . . . . . . . . . . . . . . . . . . . . . . 1,453,587
Blind . . . . . . . . . . . . . . . . . . . . . . 206,097
Disabled . . . . . . . . . . . . . . . . . . . . . 2,976,040
Children-Families wIDep Children . . . . . . . . . . . . 1.153.987
Adults-Families w/Oep Children . . . . . . . . . . . . 2.303.897
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families wIOep Children . . . . . . . . . . . .
Adults-Families wIOep Children . . . . . . . . . . . .
Other Title XlX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adults-Families w/Dep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
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
232
James E. Creswell, DMD Dentist
Route 3, Box 428
Klamath Falls 97601
Robert L. Dernedde
Executive Director Executive Secretary
Oregon Medical Association Oregon State Pharmaceutical Assn.
5210 SW Corbett Street 1460 State Street
Portland 97201 Salem 97301
Phone: 5031226-1 555 Phone: 5031585-4887
PENNSYLVANIA
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)
Other Benefits: Family Planning. Home Heallh Care, Ambulance. Clinics ICF Service, Hospital Home Care. Durable Medical Equipment. Prosthetics,
Inpatient Psychiatric Care. School Medical.
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Payment lo Pharmacists by fiscal year ending September 30, 1984.
1983
-
Expended Recipient
-
TOTAL $87,570,986 802,731
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $64,757,633 678,412
Aged . . . . . . . . . . . . . . . . . . . . . . 12,227,180 48,815
Blind . . . . . . . . . . . . . . . . . . . . . . 373,499 1,598
Disabled . . . . . . . . . . . . . . . . . . . . . 25,333,322 92,768
Children-Families w/Dep Children . . . . . . . . . . . . 10,014,759 332,065
Adults-Families w/Dep Children . . . . . . . . . . . . 16,808,873 214,410
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adults-Families w/Dep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adults-Families w/Dep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
Ill. Administration:
Office of Medical Assistance, Department of Public Welfare.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: Payment will not be made to any pharmacy for the following services and
items:
1. Methadone for any use.
2. Drugs for treatment of pulmonary tuberculosis. However, those tuberculosis drugs which are
prescribed for the prevention of meningococcal meningitis are compensable if the diagnosis
appears on the prescription.
3. Drugs and other items prescribed for obesity, appetite control, cessation of smoking or other
similar or related habit-altering tendencies. However, drugs which have been cleared for
use in the treatment of hyperkinesis in children and primary and secondary narcolepsy due
to structural damage of the brain are compensable 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 solu-
tions, ear wax removal agents, deodorants, liniments, antiseptics, emollients, and other per-
sonal care and medicine chest items.
11. Legend and nonlegend agueous saline solutions for use other than for intravenous ad-
ministration.
12. Legend and non-legend water preparations such as distilled water, water for injection, and
identical, similar or related products.
13. Food supplements and substitutes.
14. Compounded prescriptions when:
a. Cornpensable items are used in less than therapeutic quantities, or
b. Noncompensable items are compounded.
15. Non-legend drugs not listed in the Appendix to Chapter 1121.
NPC
16. Drugs prescribed in conjunction with sex reassignment Procedures or other noncompensable
surgical procedures.
17. The following items when prescribed for recipients in a skilled nursing and intermediate care
facility services:
a. Intravenous solutions.
b. Noncompensable drugs and items as specified in this section.
c. The following non-legend drugs:
(i) Analgesics
(ii) Antacids
(iii) Antacids with simethicone
(iv) Cough and cold preparations
(v) Contraceptives
(vi) Laxatives and stool softeners
(vii) Ophthalmic preparations
(viii) Diagnostic agents
18. Items prescribed or ordered by a prescriber who has been barred or suspended from
participation in the Medical Assistance Program. The Department will periodically send
pharmacies a list of the names of suspended, terminated or reinstated practitioners and the
dates of the various actions. Pharmacies are responsible for checking this list before filling
prescriptions.
19. Prescriptions or orders filled by a pharmacy other than the one to which a recipient has
been restricted. The Department will issue special medical services eligibility cards to
resricted recipients indicating the name of the pharmacy to which the recipient is restricted.
Pharmacies are responsible for checking the recipient's Medical Services Eligibility Card
before filling the prescription.
20. DESl Drugs and identical, similar or related products or combinations of these products.
21, Impregnated gause and identical, similar or related products.
22. A pharmaceutical service for which payments is available from another public agency or
another insurance or health program except for those drugs prescribed through the county
mental/mental retardation programs.
B. Formulary: None
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: the quantity to be dispensed is as prescribed by the physician, not
to exceed a 34 day supply or 100 units, whichever is greater.
2. Refills: Prescriptions may be refilled, as long as total authorization does not exceed a 6
months' or 5-refill supply from the time of original prescription.
3. Limitations on Dispensing Fees: payment to a pharmacy for prescriptions dispensed to a
recipient in either a skilled nursing facility, an intermediate care facility, or an intermediate
care facility for the mentally retarded are limited to one dispensing fee per drug per 30
day period. For the purposes of this limitation, a drug is defined as an entity or dosage
form which has the same active ingredient in the same strength or the same combination of
ingredients in the same strengths. This limitation does not apply to:
a. Antibiotics
b. Anti-infectives
c. Schedule II and Ill analgesics
d. Topical and injectable preparations dispensed in the manufacturer's original package
size
e. Ophthalmic and otic preparations dispensed in the manufacturer's original package size
f. Compensable compounded prescriptions
g. Insulin
4. Dollar limits: none
D. Drug Cost Determination:
1. Payment for compensable legend drugs is based on the current Estimated Acquisition Cost
(EAC) established by the Department.
a. The EAC for legend and non-legend drugs is found by taking the current Drug Topics
Red Book Average Wholesale Price (AWP) for the drug in the most common package
size.
b. The most common package size, for the purposes of finding the EAC, will be the same
as that used by the Department of Health and Human Services.
c. The manufacturer's direct price will be used to find the EAC for a drug when:
(i) The Drug Topics Red Book AWP is not available; or
(ii) The drug is only available directly from the manufacturer and not through a
wholesaler.
2. In cases where the EAC exceeds the Maximum Allowable Cost (MAC), the MAC will apply.
3. The EAC for individual drugs will be updated on a monthly basis as it appears in the Drug
Topics Red Book or its supplements.
E. Prescription Charge Formula:
1. On May 16. 1981. Pennsylvania revised its payment methodology to pharmacies. This
revised payment methodology, which has been approved by the federal government as part
of the State's approved State Plan, recognizes a difference between a pharmacy's usual and
customary charge to the self-paying public and the pharmacy's usual and customary charge
to third party payors. The "self-paying public" is defined as all persons whose costs for
prescribed drugs are not covered by a third party payor. "Third party payors" are defined as
public or private health insurance plans or programs which make payments to pharmacies on
behalf of eligible recipients or beneficiaries. As a result of this revised payment methodology,
pharmacies are reimbursed an additional amount not to exceed 25 cents for each welfare
prescription that would ordinarily be paid on a usual and customary basis. The amount of
the total payment will not exceed the cost of the drug plus the dispensing fee.
2. A licensed retail pharmacy's maximum reimbursement for all compensable legend and
nonlegend drugs shall be the cost of the drug plus as2.75 dspensing fee or the pharmacy's
usual and customary charge to third party payors, whichever is lower. For purposes of
Medical Assistance reimbursement, the usual and customary charge to third party payors
may not exceed 25 cents per prescription higher than the usual and customary charge to
the self-paying public. The cost of the drug shall be either the MAC, EAC, or AWP. Although
payment shall be made in accordance with this method of payment, the pharmacy is required
to bill the Department at its usual and customary charge to the self-paying public.
3. For compound prescriptions, an additional fee of $1.00 is allowed to a pharmacy, bringing
the total dispensing fee to $3.75. A compound prescription for the purposes of medical
assistance payment is one which is prepared at the time of dispensing and involves the
weighing of at least one solid ingredient which must be a compensable item or a legend
drug in a therapeutic amount.
4. The MAC program has been in effect since September 1, 1978.
5. The EAC program has been in effect since July 1, 1984.
V. Copayment $0.50
On September 1. 1984, Pennsylvania implemented a 50 cent copayrnent for each prescription, new
or refill, received by a recipient. The copayment will not apply to those recipients who are federally
238
NPC Pennsylvania-5
1985
exempt, under 21 years of age, pregnancy cases and long-term care patients, plus patients receiving
drugs in the following categories:
1. Antihypertensive agents
2. Cardiovascular preparations
3. Antiphychotic agents (excluding Schedule C-IV anti-anxiety agents
4. Antidiabetic agents
5. Anticonvulsants
6. Antineoplastic agents
7. Antiglaucoma agents
8. Antiparkinson agents
VI. Recipient Lock-In Program.
A. Approximately 3,058 recipients were restricted to a pharmacy as of June 30. 1985.
B. Approximately 1,310 recipients were restricted to both a pharmacy and a physician as of April
30. 1985
C. Savings per recipient is $42.00 per month for reduced utilization of drug services.
D. Savings per recipient is $83.00 per month for reduced utilization of physician and drug services.
E. Parameters used for the profiles are:
1. $250 for drug services for a three month period
2. 25 prescriptions in three months
3. Three or more pharmacies or other provider types
4. 180 or more disposable syringes in three months.
VII. Miscellaneous
A. Fiscal Intermediary
The Computer Company'
5101 Jonestown Road
Harrisburg. Pennsylvania 17112
The Computer Company's chief responsibility is clerical in nature and deals with claims process-
ing only, i.e.. opening of mail, key-punching claim information, microfilming, etc. All claims
resolutions and problems are handled by the department's in-house data facilities.
B. Number of Rx claims approved in FY 1984-13,815,483'
C. Average amount paid per claim during FY 1984-$8.72*
'Source: Pharmacy, all services, MRS 300, June, 1984.
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
Member Organization
PUERTO RlCO
M E D I C A L ASSISTANCE D R U G P R O G R A M (TITLE XIX)
1984 1983
-
Expended -
Recipient
-
Expended
-
Recipienl
TOTAL .....................
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
A@ . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families wmep Children . . . . . . . . . . . .
Adults-Families w/Oep Children . . . . . . . . . . . .
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . No vendor
Aged . . . . . . . . . . . . . . . . . . . . . . drug program
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families wI0ep Children . . . . . . . . . . . .
Adults-Families w/Dep Children . . . . . . . . . . . .
Other Tille XIX Recipients . . . . . . . . . . . . . . .
Ill. Administration:
By the Department of Health through the existing regionalized health care system operated by the
Commonwealth and municipal government.
IV. Provisions Relating to Prescribed Drugs:
Limited to drugs dispensed through pharmacies of public facilities.
RHODE ISLAND
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)
~ k p i t aCare
l X X X X X X X X X
Outpatient
Hospital Care X X X X X X X X X
Laboratory &
X-ray Service X X X X X X X X X
Skilled Nursing
Home Services X X X X X X X X X
Physician
Services X X X X X X X X X
-...
nentai
Services X X X X X X X X X
II. EXPENDITURES FOR DRUGS. Payment to Pharmacisls by liscal year ending June 30. 1984
1984 1983
-
Expended -
Recipient -
Expended -
Recipient
Ill. Administration:
State Department of Social and Rehabilitative Services.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions:
OTC and certain Medicine Chest Items and lnjectables:
Prior authorization is required for all injectables (excluding insulin and adrenalin), appetite
depressant drugs, central nervous system stimulants, expensive vitamins, hematinics and
lipotropic preparations (selling for over $10 per 100 tablets/capsules or pint), expensive
andlor new preparations.
Prescribed drugs requiring prior authorization may be refilled if requested by the attending
physician and approved by the Division of Medical Services.
€3. Formulary: None
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: One month's supply of drugs.
2. Maintenance Medication: The attending physician may prescribe certain maintenance drugs
up to a maximum of 100 tablets, capsules or pint of liquid or a 30-days' supply of these
drugs-whichever is greater.
3. Refills: Refills to a maximum of five are allowed for specified drugs: anti-hypertensives,
diuretics, anti-convulsants, coronary vasodilators, tranquilizers, antidepressants, hormones.
etc.
Refills are not allowed for specified drugs, e.g., antibiotics, central nervous system stimulants,
narcotics (Schedule 11. Ill), Corticosteroids and appetite depressants, benzodiazepines.
4. Dollar Limits: None
D. Prescription Charge Formula:
1. Prescription Drugs Dispensed to Eligible Recipients Residing in Their Own Homes
A Professional Fee for Service of $3.10 will be allowed for all prescriptions in addition to the
cost of the drug. ($3.25 effective October 1, 1985)
In accordance with federal regulation the upper limit for payment for prescribed drugs will
be based upon the unit cost of the drug plus a dispensing fee or the usual and customary
charge to the general public, whichever is lower.
Payment for over-the-counterdrugs (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-counterdrugs (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-servicemethod of payment
will be based upon the AWP listings in the Red Book, per 100 tabletslcapsules or pint of
NPC Rhode Island-3
1985
Abbott-Ross Pfiphannics
Lederle Pfizer-Roerig
Merck Sharp & Dohme Squibb
Parke-Davis & Co. Upjohn
Warner-Chilcott Wyeth
4. The quantity of the drug dispensed on the original prescription would be determined on the
basis of a 30-day supply to the patient. A maximum of 5 refills in addition to the original
prescription will be allowed when so indicated by the physician.
5. The attending physician may prescribe certain maintenance drugs up to a maximum of 100
tablets, capsules or equivalent, or a 30 days' supply of these drugs-whichever is greater.
The following classes of drugs are considered as maintenance drugs:
a. Anti-diabetic preparations
b. Anticonvulsants
c. Antihypertensives
d. Cardiovascular preparations, namely:
(1) Anti-anginal
(2) Digitalis and the cardiac glycosides
e. Diuretics
f. Hormones, including thyroid preparations
g. Vitamins, hematinics and lipotropic preparations for which the total charge to the Medical
Assistance Program does not exceed $10 per pint of liquid or 100 tablets or capsules.
V. Miscellaneous Remarks:
Copayment-No
Number of Rx claims processed in FY 1984-1,002.061
Average Rx price during PI 1983-$11.21
SOUTH CAROLINA
M E D I C A L ASSISTANCE D R U G P R O G R A M (TITLE XIX)
X-ray ~ e ~ i c e X X X X X
Skilled Nursing
Home Services X X X X X
Physician
Services X X X X X
Dental
Services X X X X X
Other Benefits: Home Health Services. Rural Health Clinic Services. Medical Transporlation. Podiatrist Services. Optometrists Services, Chiropractic
Services. Durable Medical Equipmenl, Intermediate Care Facilities Services.
'SFO-State Funds Only
II. EXPENDITURES FOR DRUGS. Favment to Pharmacists bv fiscal vear ending June 30. 1984
1984 1983
-
Expended -
Recipient -
Expended -
Recipient
TOTAL . . . . . . . . . . . . . . . . . . . . .
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adults-Families w/Dep Children . . . . . . . . . . . .
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Childrendamilies w/Dep Children . . . . . . . . . . . .
Adults-Families w/Dep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . . 0 0
Children-Families w/Dep Children . . . . . . . . . . . . 0 0
Adults-Families w I D ~ DChildren . . . . . . . . . . . . 0 0
Other Title XIX ~ e c i ~ i e n t .s . . . . . . . . . . . . . . 0 0
Ill. Administration:
State Health and Human Services Finances Commission
IV. Provisions Relating to Prescribed Drugs:
A. Scope of Non-Formulary Drug Program-Effective October 1 . 1984, providers will be reimbursed
for most legend drugs and for certain non-legend (OTC) drugs within the three prescription limit.
Exclusions to this coverage are as follows:
1. Adult vitamins and vitamin combinations; (Prenatal vitamins for females and fluoride vitamins
for children are covered.)
2. Amphetamines and obesity control drugs;
3. Experimental drugs;
4, Immunizing agents (Pneumovax is covered under Physicians' Services):
5. Drug Efficacy Study Implementation(DESI) Drugs. Drugs determined by the Food and Drug
Administration (FDA) to be ineffective are not reimbursable by Medicare or Medicaid.
6. Over-the-counter (OTC) drugs except: Insulin, Insulin syringes, family planning supplies, all
aspirin products, and OTC products listed below:
SOUTH D A K O T 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 (TITLE XIX)
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
-
Expended
-
Recipient
-
Expended
-
Recipient
TOTAL
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families wi0ep Children . . . . . . . . . . . .
Adults-Families wIDep Children . . . . . . . . . . . .
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adults-Families wiDep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families wiDep Children . . . . . . . . . . . .
Adults-Families wi0ep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
Ill. Administration:
State Department of Social Services, Office of Medical Services.
IV. Provisions Relating to Prescribed Drugs:
A. Exclusions: The program is limited to legend prescription drugs as specified in the state's
Medicaid regulations, and to insulin.
6 . Formulary: Administrative Rule, adopted July 1, 1983 states:
"Certain drug payments limited to generic drug form. Payment for the brand name drugs shall
be limited to the generic drug form, unless the prescriber indicates in writing on the prescription
a medical reason why the generic drug may not be used. If the prescription is an oral or call-
back prescription, the pharmacist may document the prescriber's reason for requiring the brand
name drug." (96 drugs and drug dosage forms are affected)
C. Prescribing or Dispensing Limitations:
1. Quantity: Maintenance drugs requiring more than one dose per day must be dispensed
in units of at least 100 or a 30 day supply, if more than 100 unit are required per month.
Maintenance prescriptions for family planning items must be dispensed in at least a 3 month
supply. (New family planning prescriptions can be in smaller units.)
2. Refills: Refills of maintenance drugs costing less than $4.25 per 100 are limited to the greater
of 100 or a 30 day supply.
3. Dollar limits: None.
D. Prescription charge formula: Payment is the lower of: (a) MAC plus dispensing fee of $3.25, (b)
EAC plus dispensing fee of $3.25, or usual and customary charge to the general public.
V. Miscellaneous
A. Administrative Rule, adopted July 1. 1983 states:
"Cost sharing for prescriptions is $1.00 for each prescription and $1.00 for each prescription
refilled." (Exemptions include patients under 18 years, residents of home or community-based
services, services related to pregnancy, residents of long term care facilities, family planning
and emergency hospital services.)
€3. Number of claims processed in FY 1984-284,396
C. Average Rx price during FY 1984-$12.17
E ~ i Schumacher
n
Program Administrator
Medical Services
(See above)
NPC
TENNESSEE
M E D I C A L ASSISTANCE D R U G P R O G R A M (TITLE XIX)
Drugs
-
Prescribed
X X X X ". *. *. **
Inpatient
Hospital Care X X X X
.. *. .* .*
Oulpatient
Hospital Care X X X X .. *. *. .*
Laboratory &
X-ray Service X X X X .... .*
Skilled NurSinQ
Home Services X X X X .. *. .*
NO
Physician
Services X X X X ......
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)
I1 EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30. 1984
1984 1983
-
Expended -
Recipient -
Expended -
Recipient
Ill. Administration:
Tennessee Department of Health and Environment
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions: OTC drugs (except insulin), cough and cold preparations, anoretic drugs
(except for amphetamines and derivatives for only specific indications of narcolepsy and the
hyperkinetic child).
8. Formulary: "Tennessee Medicaid Drug Formulary"; Restricted Formulary. For information contact:
Ronald E. Graham, Pharm.D.
729 Church Street
Nashville. Tennessee 37219-5406
615/74l-O192
C. Prescribing or Dispensing Limitations:
1. Terminology: May prescribe and dispense brand name drugs but encourage usage of
generic drugs for potential cost savings.
2. Quantity of Medication:
a. One month's supply.
b. Limit of 7 prescription and/or refills per month.
3. Refills: Covered only if specifically authorized by the prescribing physician on the original
prescription. Five refills within 6 months.
4. Dollar Limits: None.
5. MAC (Maximum Allowable Cost). 180 drugs in addition to federal MAC drugs. Approved
Manufacturer's List established based upon bioequivalence.
D. Prescription Charge Formula: Acquisition cost plus professional fee of 53.36 maximum, or usual
and customary-whichever is lower.
Lesser of:
1. Actual acquisition cost-plus-fee, or
2 Maximum allowable cost-plus-fee, or
3. Usual and customary charge.
V. Miscellaneous
Fiscal Intermediary
EDS Federal Corporation
301 South Perimeter Park Drive
Nashville. Tennessee 3721 1
Number of Rx Claims Processed in FY 1984-4,304,448
Average Rx Price During PI 1983-512.36
Sandra J. Daniel
Director
Billy W. Huffines
Director, Division of
Medical Assistance-
Medicaid
John G. Green
1015 Mitchell
Cookeville, TN 38501
MEMBERS OCCUPAT/ON
TEXAS
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)
Oenlal
Services Limited X X X X
Other Benefits: Eye relractions, prosthestic lens; home health services; ambulance, chiropractor; podiatrist; eye glasses; hearing aids, Ambulatory
Surgical Center Service
'SF0 - State Funds Only
" - EPSDT only
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by liscal year ending August 31. 1984
1984 1983
-
Expended -
Recipient -
Expended -
Recipient
TOTAL . . . . . . . . . . . . . . . . . . . . . $94,794,375 568,155'' $83,933,346 533.595
CATEGORICALLY NEEOY CASH TOTAL . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . . 37,434,506 140.772
Blind . . . . . . . . . . . . . . . . . . . . . . 758,961 3,507
Disabled.. . . . . . . . . . . . . . . . . . . . 18,991.318 78,069
Children-Families w/Dep Children . . . . . . . . . . . . 6,650.930 186.604
Adulb-Families w/Dep Children . . . . . . . . . . . . 8.80(1,236 100,742
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families wDep Children . . . . . . . . . . . .
Adults-Families w/Dep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEOY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adults-Families wDep Children . . . . . . . . . . . .
Other Title XiX Recipients . . . . . . . . . . . . . . .
Ill. Administration:
Vendor drug program was implemented September 1, 1971.
Texas Department of Human Resources.
IV. Provisions Relating to Prescribed Drugs:
Pharmacy services under the vendor drug program include the dispensing of most legend drugs
and certain non-legend drugs to eligible recipients. Only pharmaceuticals which meet the FDA
requirements, are approved for marketing and are approved by the Texas Department of Human
Resources for use in the vendor drug program, may be supplied.
Certain OTC drugs are covered on a prescription basis except as otherwise provided in the reim-
bursement formula and vendor payment to hospitals, nursing homes and institutions.
A. General Exclusions (diseases, drug categories, etc.): Adult vitamins and adult vitamin com-
binations, amphetamines and obesity control drugs, appliances, durable medical equipment
(bedpans, etc.-either rental or purchase), elastic stockings, experimental drugs, fertility agents,
first aid supplies, foods, food supplements or additives, immunizing agents, medical supplies,
oxygen, supports and suspensories, syringes, needles and trusses.
6. Formulary: None. However, the Texas Drug Code Index is utilized for product identification and
claims processing and contains those drugs which are covered under the program.
For information contact:
Raul Martinez, Jr., R.Ph.
Director, Product Enrollment, Vendor Drugs
Texas Department of Human Resources
P.O. BOX2960 (541-A)
Austin, Texas 78769
5121835-0440, ext. 2595
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Prescribed quantity cannot exceed a six month supply.
2. Refills: Five refills, but total amount may not exceed 6 months' supply.
D. Prescription Charge Formula:
1. For prescription legend medication:
Acquisition cost plus a variable dispensing fee up to a maximum of $4.05 per prescription
(range $3.72-$4.05*) based on a point system of services rendered, or usual and cus-
tomaary total price, whichever is lower.
Acquisition Cost: Current Red Book cost of direct cost or invoice cost. MAC based on
wholesale or direct cost as indicated by the provider.
2. Insulin and approved non-legend drugs on prescription: pharmacists and dispensing
physicians will be reimbursed on the basis of usual charges to the general public or cost plus
50% of cost, whichever is lower; 50% of cost not to exceed assigned variable dispensing
fee.
V. Miscellaneous Remarks:
The dispensing fee, which includes all costs of filling a prescription, was established by cost
accounting and service evaluation of the expenses involved in dispensing a prescription. Therefore,
fees paid to providers who do not experience all cost and service factors considered in arriving at
the fee, may be less than the maximum allowable fee.
Copayment-None.
Number of claims processed in FY 1984-6,579,073
NPC
Officials, consultantsrandCommittees
1. Department of Human Resources Off iciak:
Marlin W. Johnston Texas Department of Human
Commissioner Resources
Post Off ice Box 2960
701 West 51st Street
Austin, Texas 78769
Merle E. Springer
Executive Deputy commissioner
Martin Dukler
Deputy Commissioner for Programs
ROY E. Westerfield
Director of
Projects for Health Care
Alternatives
A. Medical Association:
C. Lincoln Williston
Executive Director
Texas Medical Association
1801 N. Lamar Boulevard
Austin 78701
Phone: 5121477-6704
8. Pharmaceutical Association:
Luther R. Parker
Executive Director
Texas Pharmaceutical Assoc.
P. 0. Box 14706
1624 East Anderson Lane
Austin 78761
Phone: 5121836-8350
C. Osteopathic Association:
Tex Roberts
Executive Director
Texas Osteopathic Medical Association
226 Bailey Avenue
Fort Worth 76107
8171336-0549
3. State Board of Pharmacy
Fred S. Brinkley. Jr.,
Executive DirectorlSecretary
211 East 7th Street. Suite 1121
Austin. Texas 78701
5121478-9827
NPC
UTAH
MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)
Other Benefits: Home health, clinic services. transportation, family planning; medical supplies, Early Periodic Screening for Children; services of
psychologists, physical therapists, speech therapists, podiatrists, osteopaths, optometrists and audiologists.
'SF0 - State Funds Only
II. EXPENDITURES FOR DRUGS. Payment to Pharmacists by liscat year ending September 30,1984
1984 1983
-
Expended -
Recipient -
Expended -
Recipient
RaeDell Ashley
Manager, Program Operations
and Medical Determination
VERMONT
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)
1984 1983
Exoended Recioient Exoended Recioient
TOTAL
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adults-Families w/Oep Children . . . . . . . . . . . .
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . .
Children-Families wiOep Children . . . . . . . . . . . .
Adults-Families w/Oep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adults-Families w/Oep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
Ill. Administration:
Agency of Human Services.
IV. Provisions Relating to Prescribed Drugs:
Program allows the welfare recipient to have free choice of physicians and pharmacists; lock-in
provision for mis-utilizers.
A. General Exclusions:
Prior authorization is required for therapeutic vitamins, cathartics, antacids, analgesics and fecal
softeners.
B. Formulary: None, provided drug is included in Official Compendia.
The National Drug Code Directory is now being used as a drug manual for coding purposes.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: Initial prescription should be sufficient to allow for the determination
of the patient's tolerance of the medication without creating unnecessary waste (expense) to
the program. This quantity could be up to a 60-day supply on all maintenance medication
prescriptions.
2. Refills: Up to 5 refills may be authorized by physician,
D. Prescription Charge Formula: Pharmacies bill their usual and customary charge. Medicaid pays
the lower of:
1. Usual and customary
2. AWP plus $2.50 fee
3. the maximum allowable cost plus fee
E. Co-pay of $1.OO per dispensation required (excluding standard federal exemptions).
V. Miscellaneous
Fiscal Intermediary:
EDS Federal
P. 0. Box 1102
South Burlington, Vermont 05401
James Bane
Deputy Director
Medicaid Division
Charles Perry
Chief of Policy & Evaluation
8021241-2880
VIRGIN ISLANDS
M E D I C A L ASSISTANCE D R U G P R O G R A M (TITLE XIX)
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
Ill. Administration:
Department of Health
IV. Provisions Relating to Prescribed Drugs:
Broad coverage as provided by public medical facilities.
Private facilities are used when the prescribed drug is not available at the public medical facility
or designated hospital pharmacy. However, such private pharmacies used must have signed a
provider's agreement with the agency.
Prescription Charge Formula: The pharmacists actual cost plus a $2.40 dispensing fee, except in
institutions where drugs are included in the reimbursement formula, or except where a public agency
makes bulk purchases of drugs in accordance with statutes or regulations governing such purchases.
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.) Department of Social Welfare
Commissioner Charlotte Amalie
St. Thomas 00801
C. Executive Officer of Virgin lslands Medical Society:
Jose F. Poblete, M.D.
Virgin lslands Medical Society
Charlotte Amalie
St. Thomas. Virgin lslands 00801
NPC
VIRGINIA
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)
II. EXPENDITURES FOR DRUGS. Paymenl to Pharmacists by fiscal year ending June 30, 1984
1984 1983
-
Expended -
Recipienl -
Expended -
Recipienl
Fiscal Intermediary:
The Computer Company (TCC)
P.O. Box 6987
Richmond, Virginia 23230
Bruce U. Kozlowski
Deputy Director
804i786- 7933
Malcolm 0. Perkins
Manager, Provider Relations
Division of Operations &
Provider Services
Office of Medical Assistance
804/786-7781
Ex Officio
B. Pharmaceutical Association:
Paul Galanti
Executive Director
Virginia Pharmaceutical Assn.
3119 West Clay Street
Richmond 23230
Phone: 8041355-7941
4. State Board of Pharmacy
J. B. Carson, Executive Director
517 West Grace Street
P.O. Box 27708
Richmond, VA 23261
8041786-0239
NPC
WASHINGTON
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)
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
11. EXPENDITURES FOR DRUGS. Payment to Pharmacists by fiscal year ending June 30, 1984
1984 1983
-
Expended -
Recipient
-
Expended -
Recipient
Ill. Administration:
By Division of Medical Assistance, Department of Social and Health Services. The local Medical
Consultants review the need for non-formulary drugs.
IV. Provisions Relating to Prescribed Drugs:
A. General Exclusions:
Medicine chest drugs are not provided. Non-formulary drugs are provided in an emergent life-
endangering situation and/or medically mandatory.
B. Formulary: Includes 2,800 listings by drug product name, quantity, dosage form and strength.
Formulary is revised 2 to 3 times annually.
C. Prescribing or Dispensing Limitations:
1. Quantity of Medication: No maximums: minimum of 30 days supply for maintenance medica-
tions.
2. Refills: No more than 2 refills in any 30-day period unless prescription and refills are in
amount of 100's.
3. Dollar Limits: State and Federal MAC where listed
D. Prescription Charge Formula: The amount shall not exceed the usual and customary charge to
the public or the maximum allowed by the department.
The maximum charge to the department is to be estimated acquisition cost (EAC) (as determined
by the Division of Medical Assistance) plus a dispensing fee for service.
B. Part-time
Dental
Howard B. Henderson, D.M.D. Office of Medical Director, Olympia
Curlis C. Sapp, D.D.S. Office of Medical Director, Olympia
Podiatry
Robert E. Wendel, D.P.M
Opthalmology
Jerrol R. Neupeer. M.D. RMU-Seattle
3. Department of Social and Health Services Title XIX Advisory Committee:
NPC
Members:
Andrade Man, Chairperson Harriet J. Greenwood
Childrens Orthopedic Hospital 9009 Greenwood Avenue North
4800 Sand Point Way, N.E. #3ll
Seattle, WA 98105 Seattle, WA 98103
2061643-4750 or 526-2003 (206)784-5378
W E S T VIRGINIA
M E D I C A L ASSISTANCE D R U G P R O G R A M (TITLE XIX)
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 fixai year ending June 30, 1984
1984 1983
-
Expended -
Recipient -
Expended -
Recipient
TOTAL ..................... $8,449,268 115,838.' $5,913,547 98,779
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . . $6832.080 97,636 $4,773,176 82,228
Aged . . . . . . . . . . . . . . . . . . . . . . 2,002,767 12,741 1,570,547 12,729
Blind . . . . . . . . . . . . . . . . . . . . . . 36,380 231 26,913 233
Disabled . . . . . . . . . . . . . . . . . . . . . 2,798,949 17,387 2,053,003 16,299
Chiidren-FamiiieswIDep Children . . . . . . . . . . . . 915,794 40,400 484,362 31,779
Adults-Families wIOep Children . . . . . . . . . . . . 1,070.291 26.834 638.351 21,550
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . . $1,317,309 12,936 $918,353 11,444
Aged . . . . . . . . . . . . . . . . . . . . . . 922,828 4,377 655,560 4,175
Wind . . . . . . . . . . . . . . . . . . . . . . 986 6 868 5
Disabled . . . . . . . . . . . . . . . . . . . . . 216,529 1,228 154,566 1,202
Children-Families wIDep Children . . . . . . . . . . . . 57,608 3,302 37,071 2,802
Aduits-Families wIOep Children . . . . . . . . . . . . 88.273 3,184 58,023 2,812
Other Title XIX Recipients . . . . . . . . . . . . . . . 0 0 10,465 476
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . . $299,879 7,069 $224,018 6.615
Aged . . . . . . . . . . . . . . . . . . . . . . 100,601 1,448 83,210 1,445
Blind . . . . . . . . . . . . . . . . . . . . . . . 821 8 420 7
Disabled . . . . . . . . . . . . . . . . . . . . . 92,328 1,120 67,859 1.095
Chiidren-Families w/Oep Children . . . . . . . . . . . . 35,265 2,261 26.179 2.1M
Aduits-Families wIOeo Children . . . . . . . . . . . . 70.864 2.248 46.350 2.004
Other Title XIX ~eci~ients. . . . . . . . . . . . . . . 0 0 0 0
Ill. ~dministraiion:
The Division of Medical Care, Department of Human Services, is the medical assistance unit repon-
sible for the administration of the Title XIX program. Eligibility for program benefits is determined
by the local Welfare offices for AFDC and medically needy individuals. Individuals eligible for SSI
benefits are covered for Medicaid as categorically needy, aged and disabled.
IV. Provisions Relating to Prescribed Drugs:
PROGRAM COVERAGE
A. All covered drugs, whether legend or non-legend, must be-prescribed by a physician or other
practitioner qualified under State law. Applicable State and Federal law governing dispensing
of drugs and biologists must be followed:
Drugs identified in the Medicaid Drug Formulary, listed by product or therapeutic class, are
covered without prior authorization.
COVERED SERVICES
1 . Legend Drugs
Legend drugs including injectables are covered unless specifically excluded.
2. Non-Legend Drugs
The following non-legend drugs are covered:
(a) Family planning supplies.
(b) Insulin.
(c) Diabetic syringes, needles, and testing kits.
(d) ESRD vitaminhitamin mineral preparations, and other medications related to End Stage
Renal Disease services.
Exception:
Non-legend drug coverage does not apply for clients residing in long-term care facilities
(SNFIICF).
COVERAGE WITH PRIOR AUTHORIZATION
Consideration may be given on special drug needs of a client by the Medical Director on an individual
basis based on medical information supplied by the attending physician in the format specified by
the State.
Specific items covered by prior authorization are:
1. Antibiotics and analgesics for chronic usage; i.e.. over ten days.
2. Medical supplies and equipment. Medical supplies; i.e.. bandages, colostomy bags, under-
pads, and other items required for home care, and covered by the Department based on a
treatment plan developed for the individual client.
3. Vitaminlvitamin mineral preparations for End-State Renal Disease patients and other medica-
tions related to End-Stage Renal Disease services.
4. Life sustaining, critical, or necessary drugs not included in the formulary.
EMERGENCY COVERAGE
If a physician determines that a particular drug is needed for his patient which is not included on
the formulary list, and is not excluded from progrm coverage, and that an emergency situations
exists, he may so indicate by writing "emergency" on the prescription above his signature. These
prescriptions will be covered up to a ten-day supply with no refill. Continuous therapy, if needed,
will require prior authorization.
West Virginia-3
1985
NON-COVERED SERVICES
The following drugs and drug products are not payable:
1. Non-legend drugs except for those identified in IV. A.2.
2. Legend drugs and drug products as follows:
(a) Appetite depressants andlor drug products for weight control.
(b) Fecal softening agents; laxatives.
(c) Food, food products-as labeled by F.D.A.
(d) Experimental drugs; i.e., drugs under development, in clinical testing, or other processes
short of being fully approved by the F.D.A.
(e) Oral vitamins, vitamin and mineral combinations, geriatric tonics.
(f) "Minor tranquilizers" identified by the Department.
(g) Drugs determined by the F.D.A. of the Department of Health and Human Services to lack
substantial evidence of effectiveness published in the Federal Register, Volume 46, Number
210, dated Friday, October 30. 1981. Also, identical, related or similar drugs are included.
3. Exceptions:
The following exceptions are made:
(a) Vitamins A, K, and D.
(b) Vitaminlvitamin and mineral preparations for End-Stage Renal Disease patients, and other
medications related to End Stage Renal Disease services.
HANDICAPPED CHILDREN'S SERVICES PROGRAM
1. Pharmacy Services
Services are available for certain children under 21 years of age receiving medical care within
the Division of Handicapped Children's Services. These services are not limited to children of
families receiving public assistance grants.
2. Scope of Services
Prescriptions are limited to a one-month supply with maximum of five monthly refills in any six-month
period.
B. Formulary: West Virginia Medicaid Drug Formulary List
For information contact: Bernard Schlact
Pharmacy Consultant
W.V. Department of Human Services
Division of Medical Care
1900 Washington Street, E.
Charleston, West Virginia 25305
3041348-8990
C. Prescribing or Dispensing Limitations:
QUANTITY AND FREQUENCY
Covered legend and non-legend drugs are payable as prescribed by a licensed practitioner up to
a 30-day supply with a maximum of five refills.
Exception:
1. Antibiotics and analgesics are limited to a maximum of ten days with no refills. (See prior
authorization.)
2. Excluding phenobarbital, sedatives and hypnotics are limited to a maximum of 30 days with no
refills.
NPC West Virginia-4
1985
Assistant Commissioner
Medical Services
J. L. Mangus. M.D.
Medical Director (Half-time)
Division of Medical Care
Auburn A. Cooper
Administrative Assistant
Division of Medical Care
3
-, R.Ph.
Pharmaceutical Coordinator
3041348-8990
F. A. Sines, D.D.S.
Dental Consultant (Part-time)
Regular Members
C. Osteopathic Medicine:
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)
II. EXPENDITURES FOR DRUGS. Pavrnent to Pharmacists bv fiscal vear ending June 30. 1984
1984 1983
-
Expended -
Recipient Exoended Reci~ient
TOTAL . . . . . . . . . . . . . . . . . . . . . $46,871,019 329.964"
CATEGORICALLY NEEDY CASH TOTAL . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adulk-Families w/Dep Children . . . . . . . . . . . .
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w1Dep Children . . . . . . . . . . . .
Adults-Families w/Dep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adults-Families w/Dep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
1. Antibiotics 4. Psychotropics
2. Anticonvulsants 5. Family Planning Drugs
3. Muscle Relaxants
C. Copayment
All legend and over-the-counter drugs except family planning drugs are subject to a $SO copay-
ment. Residents of Skilled Nursing Facilities (SNF) or lntermediate Care Facilities (ICF), sub-
sidized adoption recipients, children under age 18 and HMO enrollees are exempt from the
copayment. (Copayments limited to 10 per month)
D. State MAC Program-Yes. (145 entities; 69 separate compounds)
E. Fiscal Intermediary:
EDS-FederW
F. Number of claims processed in FY 1984-2,4638,506
G. Average Rx price during FY 1984-$10.41
Katie Morrison
Administrator
Division of Health
Steve Handrich
Director
Bureau of Health Care Financing
(Medicaid)
Michael Boushon
Pharmacy Practices Cons~ltant
6081266-0722
2. Executive Officers of State Medical and Pharmaceutical Societies:
A. Medical Society: B. Pharmaceutical Association:
WYOMING
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)
Olher Benefits: Dental and optometric services, eyeglasses and hearing aids for eligible patients under 21 years ol age, home services.
'SF0 - State Funds Only
1984 1983
Exoended Recioient Exoended Recioient
TOTAL .....................
CATEGORICALLY NEEDY CASH TOTAL . .
. . . . . . . .
Aged . . . . . . . . . . . . . .
. . . . . . . .
Blind . . . . . . . . . . . . . .
. . . . . . . .
Disabled . . . . . . . . . . . . .
. . . . . . . .
Children-Families w/Dep Children . . . .
. . . . . . . .
Adults-Families w/Dep Children . . . .
. . . . . . . .
CATEGORICALLY NEEDY NON-CASH TOTAL . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . . -
No vendor
Children-Fanilies w/&p Children . . . . . . . . . . . . drug program
Adults-Families w/Dep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
MEDICALLY NEEDY TOTAL . . . . . . . . . . . . . .
Aged . . . . . . . . . . . . . . . . . . . . . .
Blind . . . . . . . . . . . . . . . . . . . . . .
Disabled . . . . . . . . . . . . . . . . . . . . .
Children-Families w/Dep Children . . . . . . . . . . . .
Adults-Families w/Dep Children . . . . . . . . . . . .
Other Title XIX Recipients . . . . . . . . . . . . . . .
Roche Laboratories
,.-
~
Sandoz Pharmaceuticals
Schering Corporation
Searle Pharmaceutical Group
Smith Kline & French Laboratories
E. R. Squibb &Sons. Inc.
Stuart Pharmaceuticals
~
- Syntex Laboratories. Inc.