.

~- ..

NPC FILE COPY

 NATIONALPHARMACEUTICAL
C O U N C I L . INC.
1030 15TH STREET. N. W.. WI\SHINGTON. D. C. 20005
PHONE:I Z O Z ) 6 5 9 - 2 1 2 1

Dear Reader:

T h i s e i g h t e e n t h annual e d i t i o n o f t h e c o m p i l a t i o n , Pharmaceutical
B e n e f i t s Under S t a t e M e d i c a l A s s i s t a n c e Proqrams, was p r e p a r e d by t h e
N a t i o n a l Pharmaceutical Council, Inc. t o a s s i s t i n your e v a l u a t i o n o f
M e d i c a i d program c h a r a c t e r i s t i c s . NPC r e c o g n i z e s M e d i c a i d as an
i m p o r t a n t h e a l t h c a r e component and, t h e r e f o r e , t h e s i g n i f i c a n c e of c a r e
made a v a i l a b l e t o T i t l e XIX p a t i e n t s . The C o u n c i l shares t h e v i e w h e l d
by p u b l i c h e a l t h o f f i c i a l s t h a t p u b l i c a s s i s t a n c e p a t i e n t s s h o u l d
r e c e i v e t h e same qua1 i t y m e d i c a l c a r e as do o t h e r p a t i e n t s i n t h e
community.

We hope t h a t t h e i n f o r m a t i o n c o n t a i n e d i n t h i s c o m p i l a t i o n c o n t i n u e s t o
a s s i s t i n t h e development, i m p l e m e n t a t i o n and o p e r a t i o n of r e s p o n s i v e
and f i n a n c i a l l y v i a b l e p h a r m a c e u t i c a l programs.

1
S i cerely,

a r k R. Knowle

Council, Inc.

MEMBER COMPANIES

Abbott Laboratories Lederle Laboratories Parke Davis E. R. Squibb &Sons. Inc.

Boehringer lngelheim Ltd.
Burroughs Wellcome Co.
Ciba-Geigy Carporallon
DuPont Pharmaceuticals
Glaxo Inc.
H o e c h ~ t - R O U SPharmaceuticals,
S~~
Johnson &Johnson
Div. of American Cyanamid Co. Div. of Warner-Lamberl Co.
Pfizer inc.
Eli Lilly and Company
A. H. Robins Company
Marlon Laboratories, Inc. Roche Laboratories
Div. of Haffmann-La Roche Inc.
Merck Sharp & Dohme
Div. of Merck & Co., Inc. Sandoz Pharmaceuticals
Div. of Sandoz. inc.
Inc. Merrell Dow Pharmaceuttcals Inc. Schering Corporation
Subsidiary of The Dow Chemical Company Smith Kline & French Laboratories
Stuart Pharmaceuticals
Division of ICI Amerlcas inc
Syntex Laboratories, Inc.
USV Laboratories
Division of Revlon
Health Care G r o w
The Upjohn Company
Winthmp Laboratories
Div. of Sterling Drug Inc.
PHARMACEUTICAL BENEFITS
UNDER

STATE MEDICAL ASSISTANCE

PROGRAMS
AUGUST 1983

Compiled by

NATIONAL PHARMACEUTICAL COUNCIL, INC.

N.W.
1030 15rn STREE~,
WASHINGTON. D.C. 20005
(202) 6592121
 TABLE OF CONTENTS

Page

l n t r o d u c t i on 1

P h a r m a c e u t i c a l B e n e f i t s Under S t a t e Medical A s s i s t a n c e Programs 2

H e a l t h and Human S e r v i c e s R e g i o n a l A d m i n i s t r a t o r s 18

S t a t e M e d i c a i d Drug Program A d m i n i s t r a t o r s 20

G l o s s a r y o f M e d i c a i d Terms 25

M e d i c a i d Program C h a r a c t e r i s t i c s and S t a t i s t i c s 29

Tables

I. C u r r e n t S t a t e M e d i c a i d Data

II. M e d i c a i d Trends

I l l . S t a t e Demographic and Economic C h a r a c t e r i s t i c s

IV. Miscellaneous

U.S. Totals

M e d i c a l A s s i s t a n c e Drug Programs
( A l p h a b e t i c a l l y by S t a t e and/or T e r r i t o r y )
 NATIONAL PHARMCEUTICAL C W N C I L , INC.

T h e National Pharmaceutical Counci I, I nc. is dedicated t o the enhancement o f

the quality and integrity of pharmaceutical services in research, development,
manufacturing, and dispensing o f prescription medications and other
pharmaceutical products.

T h e National Pharmaceutical Council, Inc. was founded in 1953 by companies

engaged primarily in the discovery, development, production, and marketing o f
innovative prescription medicines. Today, our twenty-six member companies
continue their commitment t o major programs of pharmaceutical research and
maintain exacting quality control standards.

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

*** Acknowledgements ***

NPC acknowledges the cooperation and assistance of t h e many state program
officials and their staffs, state pharmaceutical associations, and others in
supplying data for this compilation. Special appreciation is extended t o
; Sally McCue, L a Joila Management Corporation;

T
Richard Beisel, HHS-HCFA-
Harvey Pratt, HHS-HCFA-SBR; and Roland McDevitt, Ph.D., Systemetrics, Inc.
 PHARMCEUTICAL BENEFITS

UNDER STATE MEDICAL ASSISTANCE PROGRAMS

( P r o v i d e d under T i t l e X I X o f t h e S o c i a l S e c u r i t y Amendments)

I. T h i s c o m p i l a t i o n o f d a t a on S t a t e M e d i c a l A s s i s t a n c e Programs ( T i t l e X I X )
has been p r e p a r e d t o p r e s e n t a g e n e r a l o v e r v i e w o f t h e c h a r a c t e r i s t i c s o f
s t a t e programs t o g e t h e r w i t h d e t a i l e d i n f o r m a t i o n on t h e p h a r m a c e u t i c a l
b e n e f i t s provided.

The f o l l o w i n g i n f o r m a t i o n i s p r o v i d e d f o r each s t a t e :

1. R e c i p i e n t groups e l i g i b l e f o r b e n e f i t s
2. B r i e f d e s c r i p t i o n o f t h e M e d i c a i d Program
3. Scope o f t h e S t a t e Drug Program
4. E x i s t i n g r e s t r i c t i o n s o r l i m i t a t i o n s on drugs
5. Data, when a v a i l a b l e , on case l o a d s o r persons e l i g i b l e
t o receive health care benefits including recipients
o f pharmaceutical b e n e f i t s
6. Medicaid o r p u b l i c h e a l t h o f f i c i a l s
7. Pharmacy and m e d i c a l c o n s u l t a n t s t o t h e s t a t e programs
8. Pharmacy and m e d i c a l a d v i s o r y committees
9. S t a t e m e d i c a l and p h a r m a c e u t i c a l a s s o c i a t i o n e x e c u t i v e s

I I . M e d i c a i d i s a j o i n t f e d e r a l and s t a t e program t h a t , s i n c e 1966, has p a i d

f o r much o f t h e m e d i c a l c a r e of low-income Americans. Federal law governs
c e r t a i n a s p e c t s of Medicaid, and r e q u i r e s t h a t a l l persons who q u a l i f y f o r A i d
t o F a m i l i e s w i t h Dependent C h i l d r e (AFDC) and most persons who q u a l i f y f o r
Supplemental S e c u r i t y l ncome (SS r e c e i v e m e d i c a i d coverage. The F e d e r a l
Government r e q u i r e s s t a t e s t o p r o v i d e a b a s i c s e t o f s e r v i c e s t o p e o p l e
e l i g i b l e f o r M e d i c a i d and t o r e i m b u r s e p r o v i d e r s of those s e r v i c e s i n c e r t a i n
ways. Reimbursement l e v e l s f o r many s e r v i c e s a r e s u b j e c t t o f e d e r a l l y
e s t a b l i s h e d c e i l i n g s and, i n some i n s t a n c e s , f l o o r s .

I n many o t h e r r e s p e c t s , t h e s t a t e s have b r o a d d i s c r e t i o n i n a d m i n i s t e r i n g
M e d i c a i d . T h e i r c o n t r o l o v e r e l i g i b i l i t y , f o r example, i s s u b s t a n t i a l ,
because s t a t e s e s t a b l i s h e l i g i b i l i t y f o r AFDC w h i c h e s t a b l i s h e s e l i g i b i l i t y
f o r Medicaid. (The same does n o t h o l d t r u e f o r SSI r e c i p i e n t s , whose
e l i g i b i l i t y i s determined p r i m a r i l y b y Federal c r i t e r i a . ) Furthermore, s t a t e s
may v o l u n t a r i l y e x t e n d M e d i c a i d coverage t o a d d i t i o n a l groups o f p e o p l e and
expand t h e range of s e r v i c e s covered. S t a t e s a l s o have c o n s i d e r a b l e freedom
i n c h o o s i n g reimbursement methods f o r p h y s i c i a n s and o t h e r h e a l t h c a r e
providers.

1) The S S I program, adopted as p a r t o f t h e S o c i a l S e c u r i t y Amendments of

1972, r e p l a c e d s e p a r a t e F e d e r a l / S t a t e c a s h a s s i s t a n c e programs f o r t h e
aged, b l i n d , and d i s a b l e d w i t h a s i n g l e program f i n a n c e d and a d m i n i s t e r e d
by t h e F e d e r a l Government.

2
 P r i o r t o 1950, s t a t e s and l o c a l governments a l o n e f i n a n c e d t h e s m a l l
amount o f p u b l i c l y s u p p o r t e d m e d i c a l c a r e a v a i l a b l e t o l o w income p e o p l e . In
1950, t h e F e d e r a l government began t o a s s i s t s t a t e s i n f u n d i n g m e d i c a l
s e r v i c e s for p u b l i c assistance r e c i p i e n t s . F e d e r a l p a r t i c i p a t i o n remained
l i m i t e d t o a p e r c e n t a g e o f cash and i n - k i n d m e d i c a l b e n e f i t s , up t o maximum
d o l l a r amounts.

F e d e r a l involvement i n f i n a n c i n g h e a l t h c a r e f o r l o w income e l d e r l y
p e o p l e i n c r e a s 5 7 s i g n i f i c a n t l y i n 1960 w i t h t h e i m p l e m e n t a t i o n o f t h e K e r r -
M i l l s program. Under t h e K e r r - M i l l s program, s t a t e s were a l l o w e d t o expand
t h e i r m e d i c a l a s s i s t a n c e programs t o i n c l u d e e l d e r l y p e o p l e whose incomes,
a f t e r s u b t r a c t i n g m e d i c a l expenses, were below s t a t e s t a n d a r d s . These
b e n e f i c i a r i e s were i d e n t i f i e d as t h e " m e d i c a l l y needy". The F e d e r a l
government c o n t r i b u t e d open ended m a t c h i n g funds f o r each s t a t e ' s K e r r - M i l l s
program. The F e d e r a l share o f each s t a t e ' s program was c a l c u l a t e d i n a
f a s h i o n such t h a t i t v a r i e d i n v e r s e l y w i t h t h e p e r c a p i t a income.

I n t h e mid-19605, t h e F e d e r a l r o l e i n p r o v i d i n g m e d i c a l s e r v i c e s t o t h e
poor expanded m a r k e d l y w i t h t h e i n t r o d u c t i o n o f M e d i c a i d . The new program was
designed s i m i l a r t o t h e K e r r - M i l l s program, b u t i t broadened t h e scope o f
coverage t o i n c l u d e w e l f a r e r e c i p i e n t s who were n o t aged and a l l o w e d s t a t e s t o
e x t e n d m e d i c a l l y needy coverage t o t h i s new c a t e g o r y of b e n e f i c a r i e s . An
o r i g i n a l goal o f t h e M e d i c a i d program was t o p r o v i d e comprehensive c a r e t o a l l
t h o s e whose incomes were b e l o w c e r t a i n s t a t e e s t a b l i s h e d s t a n d a r d s , b u t t h i s
goal was l a t e r dropped.

A s t a t e p l a n must s p e c i f y a s i n g l e s t a t e agency, t o a d m i n i s t e r o r
s u p e r v i s e t h e a d m i n i s t r a t i o n o f t h e p l a n ( 4 2 CFR Sec.431.10(b)). Generally,
t h e a d m i n i s t e r i n g agency has been t h e s t a t e h e a l t h agency, w e l f a r e agency, o r
an u m b r e l l a agency. F i v e s t a t e s have d e s i g n a t e d t h e h e a l t h department, 19
s t a t e s have d e s i g n a t e d t h e w e l f a r e department, 22 s t a t e s have d e s i g n a t e d an
u m b r e l l a agency, and f o u r s t a t e s have d e s i g n a t e d o t h e r a g e n c i e s t o a d m i n i s t e r
t h e M e d i c a i d program. The " o t h e r " agencies i n c l u d e d t h e O f f i c e o f t h e
Governor i n Alabama, an independent agency/commission i n G e o r g i a and
M i s s i s s i p p i , and e O f f i c e o f t h e A s s i s t a n c e Commission o f M e d i c a l S e r v i c e s
i n West V i r g i n i a . $7

2) The S o c i a l S e c u r i t y Amendments of 1960 (Publ i c Law 86-778). The program

o f h e a l t h c a r e f o r l o w income e l d e r l y persons was named f o r t h e sponsors
of t h e l e g i s l a t i o n t h a t c r e a t e d i t , Senator R o b e r t K e r r o f Oklahoma and
R e p r e s e n t a t i v e W i l b u r M i l l s o f Arkansas. For a d i s c u s s i o n o f t h i s
h i s t o r y , see R o b e r t Stevens and Rosemary Stevens, W e l f a r e M e d i c i n e i n
America ( F r e e Press, 1974). Source CBO R e p o r t -
Medicaid: Choices f o r
E d beyond. June 1981.

3) L a J o l l a Management C o r p o r a t i o n , R o c k v i l l e , Maryland, HCFA C o n t r a c t No.

500-81-0040. ( S e c t i o n I I )
I l l . M e d i c a l Care and S e r v i c e s P r o v i d e d

F e d e r a l l a w p r o v i d e s a comprehensive l i s t o f s e r v i c e s t h a t = b e
i n c l u d e d i n a s t a t e p l a n . The r e a d e r s h o u l d r e f e r t o i n d i v i d u a l s t a t e t a b l e s
f o r t h e program b e n e f i t s provided.

M e d i c a l c a r e s e r v i c e s t h a t may be p r o v i d e d under t h e c u r r e n t program are:

l n p a t i e n t H o s p i t a l Services (excludes: t u b e r c u l o s i s and m e n t a l

institutions)
(A) O u t p a t i e n t h o s p i t a l s e r v i c e s
(B) Rural h e a l t h c l i n i c services, i n c l u d i n g ambulatory
s e r v i c e s o f f e r e d by a r u r a l h e a l t h c l i n i c and o t h e r w i s e i n c l u d e d
i n t h e s t a t e ' s Medicaid plan.
O t h e r L a b o r a t o r y and X-Ray S e r v i c e s
(A) S k i l l e d Nursing F a c i l i t y Services ( f o r i n d i v i d u a l s
21 o r o v e r )
( 6 ) E a r l y and P e r i o d i c Screening, D i a g n o s i s , and
T r e a t m e n t f o r p h y s i c a l and mental d e f e c t s f o r
e l i g i b l e s under 21
(C) F a m i l y P l a n n i n g S e r v i c e s
Physicians' Services
M e d i c a l and Remedial Care r e c o g n i z e d under s t a t e l a w and p r o v i d e d b y
licensed practitioners
Home H e a l t h Care S e r v i c e s
P r i v a t e Duty Nursing Services
C l i n i c Services
Dental Services
P h y s i c a l Therapy and r e l a t e d s e r v i c e s
P r e s c r i b e d Drugs, d e n t u r e s and p r o s t h e t i c d e v i c e s , and
e y e g l a s s e s p r e s c r i b e d b y a p h y s i c i a n s k i l l e d i n d i s e a s e s of t h e eye o r
an o p t o m e t r i s t - whichever t h e i n d i v i d u a l may s e l e c t
Other D i a g n o s t i c Screening, P r e v e n t i v e and R e h a b i l i t a t i v e
Services
l n p a t i e n t H o s p i t a l , S k i l l e d N u r s i n g and l n t e r m e d i a t e Care F a c i l i t y
S e r v i c e s f o r i n d i v i d u a l s 65 y e a r s o f age o r o v e r i n an i n s t i t u t i o n f o r
t u b e r c u l o s i s o r mental d i s e a s e s
l n t e r m e d i a t e Care F a c i l i t y S e r v i c e s
lnpatient psychiatric hospital services f o r individuals
under 21
Other M e d i c a l o r Remedial Care r e c o g n i z e d under s t a t e l a w
and s p e c i f i e d by S e c r e t a r y , Department o f H e a l t h and Human S e r v i c e s
( HHS)

S e r v i c e s T h a t Must Be -P r o v i d e d :

F o r t h e C a t e g o r i c a l l y Needy:

S t a t e s p a r t i c i p a t i n g i n a T i t l e X I X program must provide the basic

s e r v i c e s 1 t h r o u g h 5, as l i s t e d above.

*"Basic F i v e " s e r v i c e s r e q u i r e d under a l l S t a t e M e d i c a i d programs.

 For t h e M e d i c a l l y Needy ( i f i n c l u d e d i n t h e s t a t e p l a n ) :

A t a minimum, s t a t e s must p r o v i d e e i t h e r t h e " b a s i c f i v e " s e r v i c e s o r any

7 o f t h e f i r s t 16 l i s t e d i n T i t l e X I X , S e c t i o n 1905(a) o f PL 89-97, a s
amended.

IV. Eligibility

The e l i g i b i l i t y p r o v i s i o n s f o r t h i s program a r e among t h e most complex o f

a l l a s s i s t a n c e programs due t o t h e d i s c r e t i o n a f f o r d e d s t a t e s , and t h e
i n t e r r e l a t i o n s h i p s between t h e M e d i c a i d program and t h e AFDC and SSI
programs. A t a minimum, s t a t e s must c o v e r a l l persons who r e c e i v e c a s h
payments f r o m e i t h e r AFOC o r , i n most cases, S S I . S t a t e s have t h e o p t i o n o f
e x t e n d i n g M e d i c a i d coverage t o s p e c i f i e d groups o f i n d i v i d u a l s known as t h e
o p t i o n a l l y c a t e g o r i c a l l y needy and t o t h e m e d i c a l l y needy.

S t a t e s t h a t e s t a b l i s h M e d i c a i d programs must p r o v i d e f o r m e d i c a l
a s i s t a n c e t o t h e c a t e g o r i c a l l y needy. G e n e r a l l y , t h e s e a r e p e r s o n s who a r e
b o t h c a t e g o r i c a l l y r e l a t e d ( e l i g i b l e a s aged, b l i n d , d i s a b l e d , o r a member o f
a f a m i l y w i t h c h i l d r e n d e p r i v e d o f t h e s u p p o r t o f a t l e a s t one p a r e n t ) and
f i n a n c i a l l y e l i g i b l e on t h e b a s i s o f income and resources. The c a t e g o r i c a l l y
needy i n c l u d e a l l cash r e c i p i e n t s o f A i d t o F a m i l i e s w i t h Dependent C h i l d r e n
(AFDC), c e r t a i n o t h e r AFDC r e l a t e d groups, most cash r e c i p i e n t s o f t h e
Supplemental S e c u r i t y l ncome (SS I ) program, and o t h e r SS I r e l a t e d groups.

S t a t e s c a n e l e c t M e d i c a i d coverage f o r s e l e c t e d groups o f i n d i v i d u a l s who

a r e f i n a n c i a l l y e l i g i b l e f o r cash a s s i s t a n c e , b u t i n e l i g i b l e because of
c e r t a i n o t h e r r e q u i r e m e n t s o r because t h e y do n o t w i s h t o r e c e i v e c a s h
assistance.

I n d i v i d u a l s e l i g i b l e under these o p t i o n a l coverage p r o v i s i o n s a r e

c o n s i d e r e d c a t e g o r i c a l l y needy and a r e e l i g i b l e f o r t h e same s e r v i c e s p r o v i d e d
t o groups f o r which t h e F e d e r a l government mandates e l i g i b i l i t y . F u r t h e r , a
M e d i c a i d agency t h a t chooses t o c o v e r an o ~ j i o n a lg r o u p must p r o v i d e M e d i c a i d
t o a l l e l i g i b l e i n d i v i d u a l s i n t h a t group.

V. U t i l i z a t i o n C o n t r o l and Review and M e d i c a l Review

a. U t i l i z a t i o n Control - A s t a t e M e d i c a i d p l a n must r e q u i r e t h e m e d i c a l
a s s i s t a n c e u n i t o f t h e s t a t e M e d i c a i d agency t o e s t a b l i s h and
implement a s t a t e - w i d e s u r v e i l l a n c e and u t i l i z a t i o n c o n t r o l
program. The program must s a f e g u a r d a g a i n s t unnecessary o r
i n a p p r o p r i a t e u t i l i z a t i o n o f c o v e r e d c a r e and s e r v i c e s and excess
payments, and must assess t h e q u a l i t y o f c o v e r e d s e r v i c e s .

4) L a J o l l a Management C o r p o r a t i o n ( S e c t i o n IV)

5
 Federal f i n a n c i a l p a r t i c i p a t i o n i s a v a i l a b l e f o r t h e c o s t s o f
u t i l i z a t i o n c o n t r o l i n accordance w i t h t h e c o n d i t i o n s and a t t h e
r a t e s a p p l i c a b l e t o Medicaid. There a l s o are p e n a l t i e s t h a t may be
imposed by HHS i f t h e s t a t e does not s a t i s f y HHS t h a t c o n t r o l o f t h e
s e r v i c e s has been maintained.

b. U t i l i z a t i o n Review - The Medicaid r e g u l a t i o n s r e q u i r e t h a t each

p a r t i c i p a t i n g h o s p i t a l , Mental H o s p i t a l , S k i l l e d N u r s i n g F a c i l i t y
(SNF), and l n t e r m e d i a t e Care F a c i l i t y (ICF) have a w r i t t e n
u t i l i z a t i o n review p l a n f o r use i n r e v i e w i n g t h e need f o r i n p a t i e n t
c a r e provided. Reviews can be conducted by u t i l i z a t i o n r e v i e w
committees, PSROs, peer review groups or p u b l i c agencies. Medicaid
p l a n s must meet Medicare standards.

c. Medical Review -Medicaid r e g u l a t i o n s r e q u i r e a r e g u l a r program o f

medical review, i n c l u d i n g medical e v a l u a t i o n of each Medicaid SNF
p a t i e n t ' s need f o r the care provided.

d. l n t e r m e d i a t e Care F a c i l i t i e s (ICFs) have a requirement f o r a r e g u l a r

program o f "i ndependant p r o f e s s i o n a l review".

, P r o f e s s i o n a l Standards Review Orqanizations (PSROs)

PSROs a r e a review mechanism, e s t a b l i s h e d by t h e S o c i a l S e c u r i t y

Amendments o f 1972, through which p h y s i c i a n s assume t h e r e s p o n s i b i l i t y
f o r r e v i e w i n g the u t i l i z a t i o n o f s e r v i c e s p r o v i d e d under Medicaid, T i t l e
-
X I X , and Medicare, T i t l e X V I I I . PSROs e v a l u a t e t h e appropriateness o f
medical determinations as they r e l a t e o n l y t o t h e medical n e c e s s i t y of
t h e s e r v i c e s provided, i n accordance w i t h p r o f e s s i o n a l standards.

The Peer Review Improvement Act o f 1982 ( T i t l e I , S u b t i t l e C of the Tax

E q u i t y and F i s c a l R e s p o n s i b i l i t y A c t o f 1982, Pub. L. 97-248) repealed
the P r o f e s s i o n a l Standards Review O r g a n i z a t i o n (PSRO) program and
replaced i t w i t h t h e U t i l i z a t i o n and Q u a l i t y C o n t r o l Peer Review Program,
commonly r e f e r r e d t o as the PRO Program. This Act requires the Secretary
t o e n t e r c o n t r a c t s w i t h p r i v a t e Peer Review O r g a n i z a t i o n s (PROS) f o r t h e
review o f the q u a l i t y , n e c e s s i t y , and appropriateness of h e a l t h care
s e r v i c e s f u r n i s h e d under Medicare.

I t appears t o many observers t h a t PSROs, o r i g i n a l l y scheduled t o be

phased o u t a t t h e end o f 1983, may be funded on an i n d i v i d u a l b a s i s u n t i l
t h e Peer Review Organizations, (PROS), are e s t a b l i s h e d . The t r a n s i t i o n
funding remains u n c e r t a i n a t press time (September 1983). P o t e n t i a l PROS
are p o s i t i o n i n g themselves t o v i e f o r c o n t r a c t s . Medical s o c i e t i e s ,
e x i s t i n g PSROs, and p r i v a t e review c o n t r a c t e r s appear t o be under
c o n s i d e r a t i o n i n a number o f s t a t e s . On o r a f t e r October 1, 1984,
h o s p i t a l s r e c e i v i n g payments under the P r o s p e c t i v e Payment System
-
(Medicare), are r e q u i r e d t o c o n t r a c t w i t h a PRO. The e f f e c t s t h a t t h e
phasing o u t of PSROs w i l l have on t h e Medicaid program a r e unclear a t
t h i s time.
V I I . M e d i c a i d Management I n f o r m a t i o n System (MMIS)

The S o c i a l S e c u r i t y Amendments o f 1972 a u t h o r i z e d 90 p e r c e n t F e d e r a l

f u n d i n g f o r t h e c o s t s o f d e s i g n , development, and i n s t a l l a t i o n o f mechanized
c l a i m s ~ r o c e s s i n gand i n f o r m a t i o n r e t r i e v a l systems, and 75 p e r c e n t F e d e r a l
f u n d i n g f o r t h e c o s t s of o p e r a t i n g such systems.

MMIS i s a general c o n c e p t u a l d e s i g n t h a t can be t a i l o r e d b y s t a t e

M e d i c a i d a g e n c i e s t o t h e i r own p a r t i c u l a r needs, s o l o n g a s t h e system meets
f e d e r a l l y r e q u i r e d minimum performance standards. The c o n c e p t u a l d e s i g n
i n c l u d e s s i x subsystems: r e c i p i e n t , provider, c l a i m processing, reference
f i l e , s u r v e i l l a n c e and u t i l i z a t i o n r e v i e w , as w e l l as management and
a d m i n i s t r a t i o n r e p o r t i n g . The f i r s t f o u r subsystems s e r v e t h e o v e r a l l
o b j e c t i v e o f p r o c e s s i n g c l a i m s and p a y i n g e l i g i b l e p r o v i d e r s f o r v a l i d
claims. The o t h e r two subsystem f u r n i s h d a t a necessary f o r program
m o n i t o r i n g and d e c i s i o n support. 5)
VIII. C h a r a c t e r i s t i c s o f B e n e f i t s Provided

E a r l y and P e r i o d i c Screeninq, O i a q n o s i s and Treatment

E a r l y and p e r i o d i c s c r e e n i n g , d i a g n o s i s and t r e a t m e n t (EPSOT) s e r v i c e s

a r e used t o d e t e r m i n e p h y s i c a l o r mental d e f e c t s i n r e c i p i e n t s under age 21,
and t o p r o v i d e h e a l t h c a r e s e r v i c e s t o c o r r e c t o r a m e l i o r i a t e any d e f e c t s and
c h r o n i c c o n d i t i o n s d i s c o v e r e d . T h e r e a r e c e r t a i n b a s i c s c r e e n i n g and
t r e a t m e n t s e r v i c e s t h a t each s t a t e must p r o v i d e .

Physicians' Services

P h y s i c i a n s ' s e r v i c e s a r e covered whether p r o v i d e d i n t h e o f f i c e , t h e

p a t i e n t ' s home, a h o s p i t a l , a s k i l l e d n u r s i n g f a c i l i t y , o r elsewhere.
P h y s i c i a n s ' s e r v i c e s must be w i t h i n t h e scope of p r a c t i c e of m e d i c i n e o r
o s t e o p a t h y d e f i n e d b y s t a t e law, and must be d e l i v e r e d b y o r under t h e
p e r s o n a l s u p e r v i s i o n o f an i n d i v i d u a l l i c e n s e d under s t a t e l a w t o p r a c t i c e
medicine o r osteopathy.

Home H e a l t h S e r v i c e s

Home h e a l t h s e r v i c e s a r e p r o v i d e d t o r e c i p i e n t s a t t h e i r p l a c e of
r e s i d e n c e ( t h i s does n o t i n c l u d e a h o s p i t a l , s k i l l e d n u r s i n g f a c i l i t y , o r
i n t e r m e d i a t e c a r e f a c i l i t y except f o r home h e a l t h s e r v i c e s i n an ICF t h a t a r e
n o t r e q u i r e d t o be p r o v i d e d b y t h e f a c i l i t y ) . S e r v i c e s must be o r d e r e d b y t h e
r e c i p i e n t ' s p h y s i c i a n as p a r t o f a w r i t t e n p l a n o f c a r e t h a t i s r e v i e w e d b y
t h e r e c i p i e n t ' s p h y s i c i a n e v e r y 60 days. Home h e a l t h s e r v i c e s i n c l u d e t h r e e
mandatory s e r v i c e s ( p a r t - t i m e n u r s i n g , home heal t h a i d e , and m e d i c a l suppl i e s
and equipment), o p t i o n a l s e r v i c e s ( p h y s i c a l t h e r a p y , o c c u p a t i o n a l t h e r a p y ,
speech p a t h o l o g y , and a u d i o l o g y s e r v i c e s ) . Home h e a l t h s e r v i c e s a r e p r o v i d e d

5)' L a J o l l a Management C o r p o r a t i o n , (Section V I I ) .

t o c a t e g o r i c a l l y needy r e c i p i e n t s age 21 and over, and t o t h o s e under 21 o n l y
i f t h e s t a t e p l a n p r o v i d e s SNF s e r v i c e s f o r them.

S k i l l e d Nursinq F a c i l i t y Services

S k i l l e d n u r s i n g f a c i l i t y (SNF) s e r v i c e s a r e p r o v i d e d t o i n d i v i d u a l s age
21 o r o l d e r and do n o t i n c l u d e s e r v i c e s i n i n s t i t u t i o n s f o r t u b e r c u l o s i s o r
mental diseases. These s e r v i c e s must be needed on a d a i l y b a s i s and p r o v i d e d
i n an i n p a t i e n t f a c i l i t y . F e d e r a l r e g u l a t i o n s r e q u i r e t h a t t h e s e r v i c e s be
provided by a f a c i l i t y o r d i s t i n c t p a r t o f a f a c i l i t y t h a t i s c e r t i f i e d t o
meet t h e r e q u i r e m e n t s f o r p a r t i c i p a t i o n and o r d e r e d b y a p h y s i c i a n .

An I n t e r m e d i a t e Care F a c i l i t y (ICF) i s an i n s t i t u t i o n f u l l y m e e t i n g
l i c e n s u r e r e q u i r e m e n t s under s t a t e l a w t o p r o v i d e , on a r e g u l a r b a s i s , h e a l t h -
r e l a t e d s e r v i c e s t o i n d i v i d u a l s who do n o t r e q u i r e t h e degree of c a r e and
treatment which a h o s p i t a l o r s k i l l e d nursing f a c i l i t y i s designed t o provide.

Nurse-Midwife S e r v i c e s

The Omnibus R e c o n c i l i a t i o n A c t of 1980 mandates t h a t payment must be made

f o r n u r s e - m i d w i f e s e r v i c e s t o c a t e g o r i c a l l y needy r e c i p i e n t s .

The law r e q u i r e s s t a t e s t o p r o v i d e coverage f o r n u r s e - m i d w i f e s e r v i c e s t o

t h e e x t e n t t h a t t h e n u r s e - m i d w i f e i s a u t h o r i z e d t o p r a c t i c e under s t a t e l a w o r
r e g u l a t i o n . The s t a t u t e a l s o r e q u i r e s t h a t s t a t e s o f f e r d i r e c t reimbursement
t o nurse-midwives as one o f t h e payment o p t i o n s . Nurse-midwives must be
r e g i s t e r e d nurses who e i t h e r have been c e r t i f i e d b y an o r g a n i z a t i o n r e c o g n i z e d
b y t h e S e c r e t a r y o r have completed a program o f s t u d y and c l i n i c a l e x p e r i e n c e
approved b y t h e S e c r e t a r y . N u r s e - m i d w i f e s e r v i c e s a r e t h o s e concerned w i t h
management o f t h e c a r e o f mothers and newborns t h r o u g h o u t t h e m a t e r n i t y c y c l e .

Family Planning Services

F a m i l y p l a n n i n g s e r v i c e s and s u p p l i e s a r e a l l o w a b l e f o r i n d i v i d u a l s o f
c h i l d b e a r i n g age a s a means of e n a b l i n g them t o f r e e l y d e t e r m i n e t h e number
and s p a c i n g of t h e i r c h i l d r e n . A l t h o u g h t h e r e a r e no F e d e r a l r e g u l a t i o n s
d e f i n i n g what f a m i l y p l a n n i n g s e r v i c e s a s t a t e c a n p r o v i d e , p r o v i s i o n a l
r e g u l a t i o n s define f a m i l y planning services t o include: consultation
( i n c l u d i n g c o u n s e l i n g and p a t i e n t e d u a t i o n ) , e x a m i n a t i o n , and t r e a t m e n t ,
f u r n i s h e d by o r under t h e s u p e r v i s i o n o f a p h y s i c i a n o r p r e s c r i b e d b y a
p h y s i c i a n ; l a b o r a t o r y e x a m i n a t i o n ; m e d i c a l l y approved methods, p r o c e d u r e s ,
p h a r m a c e u t i c a l s u p p l i e s and d e v i c e s t o p r e v e n t c o n c e p t i o n ; n a t u r a l f a m i l y
p l a n n i n g ; d i a g n o s i s and t r e a t m e n t f o r i n f e r t i l i t y ; and v o l u n t a r y
sterilizations. I n a d d i t i o n , s t a t e s may p r o v i d e any o t h e r m e d i c a l l y approved
f a m i l y p l a n n i n g s e r v i c e s , o t h e r t h a n a b o r t i o n , so l o n g as a p h y s i c i a n
f u r n i s h e s these s e r v i c e s , s u p e r v i s e s t h e i r d e l i v e r y o r p r e s c r i b e s m e d i c i n e s .
 Rural H e a l t h C l i n i c Services

Rural h e a l t h c l i n i c (RHC) s e r v i c e s have been a mandatory s e r v i c e f o r t h e

c a t e g o r i c a l l y needy s i n c e J u l y 1978. Each RHC i s r e q u i r e d t o have a nurse
p r a c t i t i o n e r (NP) o r p h y s i c i a n ' s a s s i s t a n t (PA) on i t s s t a f f . Consequently, a
c l i n i c can o n l y be c e r t i f i e d i f t h e s t a t e p e r m i t s t h e d e l i v e r y o f p r i m a r y c a r e
by an NP o r PA. Services i n c e r t i f i e d c l i n i c s must be p r o v i d e d and f u r n i s h e d
by a p h y s i c i a n or by a PA, NP, nurse-midwife, o r o t h e r s p e c i a l i z e d nurse
p r a c t i t i o n e r . Services and s u p p l i e s a r e f u r n i s h e d i n c i d e n t a l t o p r o f e s s i o n a l
services. P a r t - t i m e or i n t e r m i t t e n t v i s i t i n g nurse c a r e and r e l a t e d medical
s u p p l i e s a r e p r o v i d e d i f the c l i n i c i s located i n a H e a l t h Manpower Shortage
Area, t h e s e r v i c e s a r e f u r n i s h e d by nurses employed by t h e c l i n i c , and t h e
s e r v i c e s a r e f u r n i s h e d t o a homebound r e c i p i e n t under a w r i t t e n p l a n of
treatment.

P r e s c r i b e d Druqs

P r e s c r i b e d drugs includes simple o r compound substances o r m i x t u r e s o f

substances p r e s c r i b e d by a p h y s i c i a n or o t h e r l i c e n s e d p r a c t i t i o n e r of t h e
h e a l t h a r t s f o r the cure, m i t i g a t i o n , or p r e v e n t i o n o f disease. The drugs
must be dispensed e i t h e r d i r e c t l y by l i c e n s e d a u t h o r i z e d p r a c t i t i o n e r s or by a
pharmacist a c t i n g on a p r a c t i t i o n e r s p r e s c r i p t i o n .

O u t p a t i e n t H o s p i t a l Services

O u t p a t i e n t h o s p i t a l services mean p r e v e n t i v e , d i a g n o s t i c , t h e r a p e u t i c ,
r e h a b i l i t a t i v e , or p a l l i a t i v e s e r v i c e s p r o v i d e d t o an o u t p a t i e n t . There a r e
t h r e e Federal l i m i t a t i o n s t h a t are imposed on these services:

0 The s e r v i c e s must be p r o v i d e d under t h e d i r e c t i o n o f a p h y s i c i a n o r

dentist

The f a c i l i t y must be l i c e n s e d or f o r m a l l y approved as a h o s p i t a l by

an o f f i c i a l l y designated a u t h o r i t y f o r s t a t e s t a n d a r d - s e t t i n g ; and

0 The f a c i l i t y must meet the requirements f o r p a r t i c i p a t i o n i n

Medicare

S t a t e s a r e f r e e t o s p e c i f y o t h e r l i m i t s on o u t p a t i e n t h o s p i t a l s e r v i c e s and 37
s t a t e s p l u s t h e D i s t r i c t of Columbia have chosen t o do so.

C l i n i c Services

C l i n i c s e r v i c e s means p r e v e n t i v e , d i a g n o s t i c , t h e r a p e u t i c , r e h a b i l i t a t i v e
or p a l l i a t i v e items o r s e r v i c e s p r o v i d e d t o an o u t p a t i e n t , by o r under t h e
d i r e c t i o n o f a p h y s i c i a n o r d e n t i s t , on b e h a l f o f a f a c i l i t y t h a t i s n o t p a r t
of a h o s p i t a b u t i s organized and operated t o p r o v i d e medical c a r e t o
outpatients. 1 b

6) LaJol l a Mangement Corporati on, (Section V I I I).

 Other S e r v i c e s

Other s e r v i c e s p r o v i d e d b u t n o t covered i n t h i s t e x t i n c l u d e : private

d u t y n u r s i n g , d e n t a l s e r v i c e s , dentures, p r o s t h e t i c d e v i c e s and e y e g l a s s e s ,
o t h e r d i a g n o s t i c and s c r e e n i n g and i n p a t i e n t h o s p i t a l s e r v i c e s .

IX. Vendor Druq Program - ( M e d i c a i d T i t l e XIX)

1. Freedom of Choice
S e c t i o n 1902 ( a ) (23) S o c i a l S e c u r i t y Act, Reg. 42 CFR 431.51

Any i n d i v i d u a l e l i g i b l e f o r M e d i c a i d may o b t a i n t h e s e r v i c e s
a v a i l a b l e under t h e s t a t e M e d i c a i d p l a n f r o m any i n s t i t u t i o n ,
agency, pharmacy, p e r s o n o r o r g a n i z a t i o n w h i c h p r o v i d e s such
s e r v i c e s o r arranges f o r t h e i r a v a i l a b i l i t y on a prepayment b a s i s ,
and i s q u a l i f i e d t o p e r f o r m such s e r v i c e s .

I t i s n o t r e q u i r e d t h a t an i n s t i t u t i o n a l l o w a r e c i p i e n t a c h o i c e o f
d r u g p r o v i d e r i f t h e i n s t i t u t i o n (e.g., h o s p i t a l o r n u r s i n g home)
c u s t o m a r i l y i n c l u d e s p h a r m a c e u t i c a l s as p a r t o f i t s t o t a l package o f
services.

S e c t i o n 2175 Freedom o f Choice Waivers. S e c t i o n 2175 a t t e m p t s t o

i n c r e a s e t h e importance of p r i c e c o n s i d e r a t i o n s i n t h e d e c i s i o n
a b o u t h e n , where, and how t o u t i l i z e h e a l t h c a r e s e r v i c e s . Each of
t h e w a i v e r s focuses on a d i f f e r e n t p a r t o f t h e h e a l t h c a r e d e c i s i o n
making process and a l l o w s a s t a t e to:

Implement a p r i m a r y c a r e case mangement system f o c u s i n g on

primary care physicians;

A l l o w a l o c a l i t y t o a c t as c e n t r a l b r o k e r i n a s s i s t i n g
M e d i c a i d r e c i p i e n t s i n s e l e c t i n g among c o m p e t i n g h e a l t h
plans;

S h a r e w i t h r e c i p i e n t s , through t h e p r o v i s i o n o f a d d i t i o n a l
s e r v i c e s , s a v i n g s r e s u l t i n g f r o m r e c i p i e n t s ' use o f more
c o s t - e f f e c t i v e m e d i c a l c a r e ; and

Restrain r e c i p i e n t s t o r e c e i v i n g services (other than i n

emergency s i t u a t i o n s ) from o n l y e f f i c i e n t and c o s t
e f f e c t i v e providers.

The w a i v e r s can be g r a n t e d f o r a p e r i o d of up t o two years, and a

s t a t e may r e q u e s t a c o n t i n u a t i o n .

2. Drug Reimbursement
T i t l e 45 -
PUBLIC WELFARE, S u b t i t l e A -
Department o f H e a l t h and
Human S e r v i c e s , P a r t 19 -
L i m i t a t i o n s on Payment o r Reimbursement
f o r Drugs
 R e q u l a t i o n Sec. 19.1. Purpose. 7, ( a ) T h i s e s t a b l i s h e s Department
o f H e a l t h and Human S e r v i c e s procedures f o r d e t e r m i n i n g d r u g c o s t s
and, where a p p l i c a b l e , d i s p e n s i n g f e e s w h i c h t h e Department w i l l use
f o r t h e purpose o f d e t e r m i n i n g :

(1) Reimbursement t o p r o v i d e r s and heal t h maintenance

o r g a n i z a t i o n s under t h e M e d i c a r e program;

(2) Reimbursement t o s t a t e s under s t a t e a d m i n i s t e r e d heal t h ,

w e l f a r e , and s o c i a l s e r v i c e programs; and

(3) A l l o w a b l e c o s t s under p r o j e c t s f o r h e a l t h s e r v i c e s .

( b ) P o l i c i e s and procedures, w h i c h w i l l be c o n s i s t e n t w i t h t h e
p o l i c i e s and procedures s e t f o r t h i n t h i s P a r t , w i l l be p u b l i s h e d i n
t h e HHS Procurement R e g u l a t i o n s , T i t l e 41, Chapter 3, Code of
F e d e r a l R e g u l a t i o n s , g o v e r n i n g t h e d i r e c t p u r c h a s e of drugs by t h e
Department and t h e purchase o r s u p p l y of d r u g s b y c o n t r a c t o r s o f t h e
Department.

( c ) T h i s P a r t does n o t e s t a b l i s h p r o c e d u r e s f o r f i x i n g t h e a c t u a l
amount o f reimbursement t o w h i c h p r o v i d e r s w i l l be e n t i t l e d f o r
d i s p e n s i n g drugs. Rather, i t e s t a b l i s h e s p r o c e d u r e s f o r s e t t i n g a
l i m i t on what t h e i n d i v i d u a l program r e g u l a t i o n s and p o l i c i e s m i g h t
otherwise provide. I f the authorizing l e g i s l a t i o n f o r a p a r t i c u l a r
program, o r t h e program r e g u l a t i o n o r p o l i c i e s adopted o r i s s u e d
under t h a t l e g i s l a t i o n , p r o v i d e s f o r a l o w e r r a t e of reimbursement
t h a n t h i s r e g u l a t i o n p e r m i t s , t h e n t h e program reimbursement r a t e ,
b e i n g lower, w i l l n e c e s s a r i l y c o n t r o l t h e a c t u a l payment.

R e q u l a t i o n Sec. 19.3. Cost L i m i t a t i o n . 8, ( a ) The amount w h i c h t h e

Department w i l l r e c o g n i z e f o r reimbursement o r payment purposes f o r
any drug used i n t h e programs o r a c t i v i t i e s d e s c r i b e d i n Sec. 19.1
s h a l l n o t exceed t h e l o w e s t o f :

(1) The maximum a l l o w a b l e c o s t (MAC) o f t h e drug, i f any,

e s t a b l i s h e d i n accordance w i t h Sec. 19.5 p l u s a r e a s o n a b l e
d i s p e n s i n g fee;

(2) The a c q u i s i t i o n c o s t o f t h e drug p l u s a r e a s o n a b l e

d i s p e n s i n g fee; o r

7) F e d e r a l R e g i s t e r , V o l . 40, 32283, J u l y 31, 1975

8) F e d e r a l R e g i s t e r , V o l . 40, 32283, J u l y 31, 1975 and c o r r e c t e d i n F e d e r a l

R e g i s t e r , V o l . 40, 36342, August 20, 1975
 (3) The p r o v i d e r ' s u s u a l and customary c h a r g e t o t h e p u b l i c
f o r t h e drug; p r o v i d e d t h a t : The MAC e s t a b l i s h e d f o r any
drug s h a l l n o t a p p l y t o a b r a n d o f t h a t drug p r e s c r i b e d
f o r a p a t i e n t w h i c h t h e p r e s c r i b e r has c e r t i f i e d i n h i s
own h a n d w r i t i n g i s m e d i c a l l y necessary f o r t h a t p a t i e n t ;
and p r o v i d e d f u r t h e r , t h a t : where compensation f o r d r u g
d i s p e n s i n g i s i n c l u d e d i n some o t h e r amount p a y a b l e t o t h e
p r o v i d e r b y t h e r e i m b u r s i n g o r p a y i n g program agency, a
s e p a r a t e d i s p e n s i n g f e e w i l l n o t be r e c o g n i z e d .

( b ) Each program agency s h a l l e s t i m a t e t h e a c q u i s i t i o n c o s t of each

d r u g f o r which i t reimburses o r pays a p r o v i d e r . Such e s t i m a t e
s h o u l d be c o n s i s t e n t w i t h any d r u g p r i c e i n f o r m a t i o n f u r n i s h e d t h e
p r o g r a m agency by t h e Department.

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

F o r each m u l t i p l e source d r u g d e s i g n a t e d b y t h e P h a r m a c e u t i c a l
Reimbursement Board and p u b l i s h e d i n t h e F e d e r a l R e g i s t e r c o s t w i l l
be l i m i t e d t o t h e lower o f :

a. t h e maximum a l l o w a b l e c o s t (MAC) e s t a b l i s h e d b y t h e Board

f o r such d r u g and pub1 i s h e d i n t h e F e d e r a l R e g i s t e r , o r

b. t h e e s t i m a t e d a c q u i s i t i o n c o s t (EAC - as d e f i n e d i n t h e
regulations).

L i m i t a t i o n t o t h e maximum a l l o w a b l e c o s t e s t a b l i s h e d b y t h e Board
s h a l l n o t a p p l y i n any case where a p h y s i c i a n c e r t i f i e s i n h i s own
h a n d w r i t i n g t h a t i n h i s medical judgement a s p e c i f i c b r a n d i s
m e d i c a l l y necessary.

The form and procedure f o r t h e c e r t i f i c a t i o n s h a l l be p r e s c r i b e d by

t h e s t a t e . An example o f an a c c e p t a b l e c e r t i f i c a t i o n would be a
n o t a t i o n "brand necessary". A p r o c e d u r e f o r c h e c k i n g a box on a
f o r m w i l l n o t c o n s t i t u t e an a c c e p t a b l e c e r t i f i c a t i o n .

F o r a l l p r e s c r i b e d drugs t h e upper l i m i t s f o r w h i c h payment i s made

s h a l l be based on t h e l o w e r of t h e c o s t o f t h e d r u g p l u s a
d i s p e n s i n g f e e o r t h e p r o v i d e r ' s usual and customary c h a r g e t o t h e
g e n e r a l pub1 i c .

3. P h a r m a c e u t i c a l Reimbursement Board (PRB) 9

P h a r m a c e u t i c a l Reimbursement S e c t i o n
H e a l t h Care F i n a n c i n g A d m i n i s t r a t i o n
Department o f H e a l t h and Human S e r v i c e s

9) Formerly established i n O f f i c e o f the A s s i s t a n t Secretary f o r Health,

HEW.
 Establishment of pharmaceutical reimbursement board.

(a) T h e r e is established in t h e Health Care Financing

Administration a Pharmaceutical Reimbursement Board
consisting of six full time employees o f t h e Department,
representing the principal offices and agencies concerned
with developing and implementing cost determinations under
this part. T h e Director, Office of Pharmaceutical
Reimbursement, shall s e r v e a s the Chairman.

(b) T h e Board may make use of outside consultants t o advise it

on any technical o r complex issues during its
consideration of a proposed MAC.

(Outline of procedures only - detail omitted)

(a) ldentif ication of drugs to which M A C may be appl ied

( b ) Review by t h e Food and Drug Administration

(c) Initial determination of lowest unit price

(d) Proposed MAC

(e) Notice of Comment

(f) Public Hearing

(g) Conduct of hearing

(h) Proposed final determination

(i) Administrator's concurrence

(j) Publication - (Federal Register notice)

4. Estimated Acquisition Cost (EAC)

Estimated Acquisition Cost (EAC) applies to all drug p r o d u c t s =

reimbursable as a maximum allowable cost (MAC) drug product as
established by the HHS-Pharmaceutical Reimbursement Board.

T h e development of E A C price levels is the responsibility of each

state.

HHS will periodically provide each state with product cost data
quideline to assist in establishing t h e estimated acquisition c o s t s
for that particular state.

Medicaid - Formula for Determininq EAC for Drugs

70th Percentile - "bench mark"
 HHS A c t i o n T r a n s m i t t a l , HCFA-AT-77-113 (MMB), December 13, 1977.
Subject: " T i t l e XIX, S o c i a l S e c u r i t y Act: L i m i t a t i o n o n Payment o r
Reimbursement f o r Drugs: E s t i m a t e d A c q u i s i t i o n Cost (EAC)."

The i n t e n t o f t h e f i n a l M e d i c a i d r e g u l a t i o n s on d r u g
reimbursement i s t o have each s t a t e ' s e s t i m a t e d a c q u i s i t i o n
c o s t as c l o s e as f e a s i b l e t o t h e p r i c e g e n e r a l l y and c u r r e n t l y
p a i d by t h e p r o v i d e r . The s t a t e s a r e , t h e r e f o r e , expected t o
s e t t h e i r i n g r e d i e n t c o s t l e v e l s as c l o s e as p o s s i b l e t o a c t u a l
a c q u i s i t i o n c o s t . The D e p a r t m e n t ' s a n a l y s i s o f p r i c e d a t a o v e r
s e v e r a l months i n d i c a t e s t h a t a s p e c i f i c p e r c e n t i l e l i s t i n g -
the 70th - m i g h t a p p r o p r i a t e l y be used as a bench mark i n
d e t e r m i n i n g t h e degree t o w h i c h t h e i n g r e d i e n t c o s t l e v e l s
e s t a b l i s h e d by s t a t e s , approach a c t u a l a c q u i s i t i o n c o s t . Any
s t a t e w h i c h i s f o u n d t o be r e i m b u r s i n g a t a l e v e l above t h e
7 0 t h p e r c e n t i l e c o u l d be expected t o p r o v i d e e v i d e n c e t o
i n d i c a t e t h a t i t s reimbursement l e v e l s a r e c l o s e r t o t h e
p r o v i d e r s ' AAC t h a n t h e F e d e r a l data.

The t e x t o f t h e t r a n s m i t t a l a l s o s t a t e s :

"Each program a d m i n i s t r a t o r s h o u l d e v a l u a t e t h e s t a t e ' s method

o f s e t t i n g EAC l i m i t s f o r t h e d r u g program t o a s s u r e t h a t d r u g
reimbursement l i m i t s a r e as c l o s e as f e a s i b l e t o A c t u a l
A c q u i s i t i o n Cost."

5. F o r m u l a r i e s i n M e d i c a i d Proqrams

Under e x i s t i n g f e d e r a l p o l i c y , t h e use of a f o r m u l a r y o r l i m i t e d
d r u g l i s t i n a T i t l e X I X program i s o p t i o n a l . The p o l i c y s t a t e s ,
" t h e b a s i c o b j e c t i v e i s t o e n a b l e d o c t o r s and p h a r m a c i s t s t h r o u g h o u t
t h e s t a t e t o j o i n i n a m u t u a l l y b e n e f i c i a l s e l e c t i o n of h i g h q u a l i t y
drugs of r e c o g n i z e d t h e r a p e u t i c v a l u e , produced b y r e p u t a b l e
m a n u f a c t u r e r s and b r o a d enough t o c o v e r v i r t u a l l y any s i t u a t i o n "
( M e d i c a i d A s s i s t a n c e Manual SRS-MSA-196 1971).

A drug f o r m u l a r y o r l i s t o f p h a r m a c e u t i c a l p r o d u c t s i s e i t h e r open
( u n r e s t r i c t e d ) o r closed ( r e s t r i c t e d ) . Each s t a t e ' s M e d i c a i d
program d e t e r m i n e s i t s own f o r m u l a r y s t a t u s . A n o p e n formulary i s a
l i s t of v i r t u a l l y a l l p r e s c r i p t i o n drugs approved b y t h e FDA and
a l l o w s t h e p r e s c r i b e r t o choose t h e most m e d i c a l l y a p p r o p r i a t e d r u g
t o t r e a t each p a t i e n t . A c l o s e d f o r m u l a r y i s a l i m i t e d l i s t of
drugs f o r w h i c h reimbursement w i l l be g r a n t e d under t h e s t a t e
M e d i c a i d program. No drug t h a t i s n o t c o n t a i n e d i n t h e l i s t i s
covered w i t h o u t p r i o r a p p r o v a l b y t h e s t a t e . Thus, p r e s c r i b e r s a r e
a d m i n i s t r a t i v e l y l i m i t e d i n t h e i r c h o i c e o f drugs i n t r e a t i n g
Medicaid p a t i e n t s .
6. Implementation o f Formulary Guidel ines

F o r m u l a r y r e g u l a t i o n s were c o d i f i e d i n Sec. 250.30 ( b ) ( 2 ) ( i v ) o f

T i t l e 45, Chapter I I , o f Code o f F e d e r a l R e g u l a t i o n s a s s e t f o r t h
be1 ow:

"Drugs. ( i v ) The use o f a f o r m u l a r y i s o p t i o n a l , as a r e

p r o v i s i o n s f o r use o f g e n e r i c drugs. Where e i t h e r i s employed,
t h e r e must be s t a n d a r d s f o r q u a l i t y , s a f e t y , and e f f e c t i v e n e s s
under t h e s u p e r v i s i o n o f p r o f e s s i o n a l personnel."

I n c a r r y i n g o u t t h e above r e g u l a t i o n , s t a t e agencies s h o u l d c o n s i d e r
t h e following guidelines:

0 Any m e d i c a t i o n i n c l u d e d i n a f o r m u l a r y s h a l l meet such

a c c e p t a b l e s t a n d a r d s f o r d r u g s as r e q u i r e d under t h e
F e d e r a l Food, Drug, and Cosmetic A c t , as amended, and t h e
a p p l i c a b l e r e q u i r e m e n t s o f o f f i c i a l compendia w i t h r e s p e c t
t o i d e n t i t y , s t r e n g t h , s a f e t y , q u a l i t y , p u r i t y , and
effectiveness.

S t a t e agencies s h o u l d adopt procedures w h i c h w i l l e n s u r e

t h e g r e a t e s t economy c o n s i s t e n t w i t h a c c e p t a b l e s t a n d a r d s
o f i d e n t i t y , s t r e n g t h , s a f e t y , q u a l i t y , p u r i t y , and
effectiveness.

Any f o r m u l a r y developed f o r a s t a t e ' s M e d i c a i d Drug

Program s h o u l d n o t become s o r i g i d t h a t t h e p r e s c r i b e r ' s
p r i v i l e g e f o r r e q u e s t i n g items o u t s i d e t h e f o r m u l a r y i n
j u s t i f i e d s i t u a t i o n s i s made i m p o s s i b l e . The f o r m u l a r y
s h o u l d have due r e g a r d f o r t h e p r o f e s s i o n a l p r e r o g a t i v e s
of practitioners. I t s h o u l d n o t p l a c e undue r e s t r i c t i o n s
upon t h e p h y s i c i a n i n s o f a r as h i s p r e s c r i b i n g p r a c t i c e s
a r e concerned.

The s t a t e ' s f o r m u l a r y committee s h o u l d be composed o f

p r a c t i c i n g p h y s i c i a n s , p h a r m a c o l o g i s t s , p h a r m a c i s t s , and
o t h e r p r o f e s s i o n a l personnel o p e r a t i n g w i t h i n s p e c i f i c
procedures e s t a b l i s h e d by t h e s t a t e . I t s h o u l d be c h a r g e d
w i t h t h e r e s p o n s i b i l i t y of r e v i s i n g t h e f o r m u l a r y when
required a t specified intervals.

A p r i n c i p a l purpose of t h e f o r m u l a r y s h o u l d be t o i d e n t i f y
t h e d r u g s approved f o r reimbursement under t h e program.
However, i t s h o u l d p e r m i t a u t h o r i z a t i o n f o r t h e
reimbursement o f n o n - l i s t e d i t e m s upon p r o f e s s i o n a l
justification.

Each i t e m s h o u l d have an a s s i g n e d code number ( p r e f e r a b l y ,

f r o m t h e FDA N a t i o n a l Drug Code D i r e c t o r y . ) T h a t code
number s h o u l d l e n d i t s e l f t o a u t o m a t i c o r e l e c t r o n i c d a t a
 p r o c e s s i n g f o r t h e purpose of h a n d l i n g a d m i n i s t r a t i v e
f u n c t i o n s w i t h r e a t e r e f f i c i e n c y and speed, and a t
reduced c o s t . 109

X. R e c i p i e n t Cost S h a r i n g Under M e d i c a i d

F i n a l r e g u l a t i o n s have been i s s u e d b y t h e H e a l t h Care F i n a n c i n g

A d m i n i s t r a t i o n (HCFA) w h i c h remove a l l r e s t r i c t i o n s on s t a t e s from imposing
d e d u c t i b l e s , c o i n s u r a n c e o r copayments on c a t e g o r i c a l l y o r m e d i c a l l y needy
r e c i p i e n t s s u b j e c t t o c e r t a i n e x c e p t i o n s . The r e g u l a t i o n s , w h i c h were i s s u e d
i n f i n a l f o r m e f f e c t i v e F e b r u a r y 8, 1983, a r e based on p r o v i s i o n s c o n t a i n e d i n
t h e Tax E q u i t y and F i s c a l R e s p o n s i b i l i t y A c t o f 1982 (P.L. 97-248) w h i c h
amended M e d i c a i d c o s t s h a r i n g r e q u i r e m e n t s .

Under t h e HCFA's f i n a l r u l e , s t a t e M e d i c a i d programs a r e now p e r m i t t e d t o

impose c o s t s h a r i n g arrangements t h a t p e r t a i n t o r e q u i r e d s e r v i c e s f o r
c a t e g o r i c a l l y o r m e d i c a l l y needy r e c i p i e n t s . However, t h e r e g u l a t i o n s c o n t a i n
a number o f e x c e p t i o n s which p r o h i b i t c o s t s h a r i n g f o r s e r v i c e s f u r n i s h e d t o
i n d i v i d u a l s under 18 y e a r s o f age, s e r v i c e s f u r n i s h e d t o p r e g n a n t women o r i f
t h e s e r v i c e s a r e r e l a t e d t o t h e pregnancy, emergency s e r v i c e s , f a m i l y p l a n n i n g
s e r v i c e s , s e r v i c e s f u r n i s h e d b y a H e a l t h Maintenance O r g a n i z a t i o n (HMO) t o a
c a t e g o r i c a l l y needy r e c i p i e n t , and s e r v i c e s f u r n i s h e d t o i n s t i t u t i o n a l i z e d
i n d i v i d u a l s who a r e r e q u i r e d t o spend a l l t h e i r income f o r m e d i c a l c a r e c o s t s .

I n a d d i t i o n , t h e r e g u l a t i o n s c l e a r l y s p e c i f y t h a t s t a t e M e d i c a i d agencies
must l i m i t p a r t i c i p a t i o n t o p r o v i d e r s who a g r e e t o a c c e p t t h e s t a t e
reimbursement and t h e copayment amount p a i d b y a b e n e f i c i a r y as payment i n
full. However, t h e HCFA r u l e mandates t h a t a p r o v i d e r must a g r e e n o t t o deny
s e r v i c e s t o r e c i p i e n t s who a r e u n a b l e t o pay t h e c o s t s h a r i n g amount.
A c c o r d i n g t o HCFA, t h e i n t e n t o f t h i s p r o v i s i o n i s t o a s s u r e c o n t i n u e d
a v a i l a b i l i t y of s e r v i c e s i n l i g h t of t h e new a u t h o r i t y t h a t has been g i v e n t o
t h e s t a t e s t o impose copayments on t h e M e d i c a i d p o p u l a t i o n . Because o f t h e s e
r e v i s i o n s , s t a t e M e d i c a i d programs a r e r e q u i r e d t o n o t i f y r e c i p i e n t s of t h e
changes i n t h e i r r i g h t s and r e s p o n s i b i l i t i e s , i n c l u d i n g a p r o v i d e r p r o h i b i t i o n
on d e n i a l o f s e r v i c e s . F i n a l l y , t h e r e g u l a t i o n s e s t a b l i s h maximum a l l o w a b l e
copayment amounts based on t h e c o s t of s e r v i c e s p r o v i d e d t o a r e c i p i e n t .

XI. H e a l t h and Human S e r v i c e s Department, H e a l t h Care F i n a n c i n q

Administration -
An Overview

The H e a l t h Care F i n a n c i n g A d m i n i s t r a t i o n (HCFA) was e s t a b l i s h e d i n e a r l y

1977 t o b r i n g i n t o one agency t h e m a j o r f e d e r a l h e a l t h c a r e f i n a n c i n g programs
and t h e i r a s s o c i a t e d q u a l i t y assurance a c t i v i t y . HCFA i s r e s p o n s i b l e f o r t h e
f e d e r a l a d m i n i s t r a t i o n of h e a l t h f i n a n c i n g and q u a l i t y a s s u r a n c e programs.

10) (Reference - Medical A s s i s t a n c e Manual SRS-MSA-196-1971)

Because o f t h e d i r e c t r e l a t i o n s h i p between f o r m u l a r y d e v e l o
a l l o w a b l e c o s t procedures and t h e s u b s t i t u t i o n of g e n e r i
has been i n c l u d e d w h i c h o u t l i n e s t h e p r o v i s i o n s of s t a t e
drug s u b s t i t u t i o n b y p h a r m a c i s t s . See T a b l e #IVB, page
HCFA's m i s s i o n i s to:

E n s u r e t h e e f f e c t i v e a d m i n i s t r a t i o n o f i t s program i n o r d e r t o
promote t h e t i m e l y d e l i v e r y o f a p p r o p r i a t e , q u a l i t y h e a l t h c a r e t o
i t s beneficiaries;

0 Make c e r t a i n t h a t b e n e f i c i a r i e s a r e aware of t h e s e r v i c e s f o r w h i c h
t h e y a r e e l i g i b l e , t h a t t h e s e s e r v i c e s a r e a c c e s s i b l e t o them and
a r e p r o v i d e d i n t h e most e f f e c t i v e manner, and;

E n s u r e t h a t i t s p o l i c i e s and a c t i o n s promote e f f i c i e n c y and q u a l i t y

w i t h i n t h e t o t a l h e a l t h d e l i v e r y system which s e r v i c e s a l l
Americans.

T h i s m i s s i o n i s c a r r i e d o u t by t e n r e g i o n a l o f f i c e s , each of w h i c h i s
r e s p o n s i b l e f o r t h e a d m i n i s t r a t i o n o f HCFA programs i n a g i v e n g e o g r a p h i c
area. The b a s i c f u n c t i o n s of a r e g i o n a l o f f i c e a r e to: monitor the
performance o f M e d i c a r e c o n t r a c t o r s , M e d i c a i d s t a t e agencies, s t a t e s u r v e y
agencies, and PSROs; i n t e r p r e t F e d e r a l h e a l t h p o l i c i e s and r e g u l a t i o n s t o
t h e s e o r g a n i z a t i o n s ; m o n i t o r t h e e x p e n d i t u r e o f F e d e r a l funds; o v e r s e e t h e
o p e r a t i o n of q u a l i t y c o n t r o l programs, and assure e f f e c t i v e communication
between HCFA, i t s p r o v i d e r s and i t s b e n e f i c i a r i e s .
 REG1ONAL ADM I N ISTRATORS
H e a l t h and Human S e r v i c e s
H e a l t h Care F i n a n c i n g A d m i n i s t r a t i o n

REGION #1 - C o n n e c t i c u t , Maine, John F. Kennedy F e d e r a l B l d g .

Massachusetts, New Government C e n t e r , Room 1309
Hampshi re, Rhode Boston, Massachusetts 02203
I s l a n d , Vermont

Regional A d m i n i s t r a t o r : M r . John D. Kennedy

REGION # 2 - New Jersey, New York, F e d e r a l B u i l d i n g , Room 3811

P u e r t o Rico, V i r g i n 26 F e d e r a l P l a z a
Islands New York, New York 10007

Regional A d m i n i s t r a t o r : M r . W i l l i a m Toby, J r .

REGION #3 - Delaware, D i s t r i c t of (P. 0. Box 7760)

Columbia, Maryland, 3535 M a r k e t S t r e e t
Pennsylvania, P h i l a d e l p h i a , P e n n s y l v a n i a 19101
V i r g i n i a , West V i r g i n i a

Regional A d m i n i s t r a t o r : M r . E v e r e t t e F. B r y a n t

REGION #4 - Alabama, F l o r i d a , 101 M a r i e t t a S t r e e t

Georgia, Kentucky, S u i t e 701
Mississippi, North A t l a n t a , G e o r g i a 30323
C a r o l i na, South
C a r o l i na, Tennessee

Regional A d m i n i s t r a t o r : George R. H o l l a n d

REGION #5 - I l l i n o i s , Indiana, 175 West Jackson B o u l e v a r d

Michigan, Minnesota, 8 t h F l o o r , Room A835
Ohio, Wisconsin Chicaqo, I 1 l i n o i s 60604

Regional A d m i n i s t r a t o r : B a r b a r a J. Gagel

REGION #6 - Arkansas, L o u i s i a n a , 1200 M a i n Tower B u i l d i n g

New Mexico, Oklahoma, Room 2400
Texas D a l l a s , Texas 75202

Regional A d m i n i s t r a t o r : M r . J e r r y D. Sconce
HHS/HCFA R e g i o n a l Administrators and ARAs* ( c o n t i n u e d ) :

REGION #7 - Iowa, Kansas, New F e d e r a l O f f i c e B u i l d i n g .

M i s s o u r i , Nebraska 601 E a s t 1 2 t h S t r e e t , Rm. 235
Kansas C i t y , M i s s o u r i 64106

Regional A d m i n i s t r a t o r : M r . Gene Hyde

REGION #8 - Colorado, Montana, 1961 S t o u t S t r e e t

S o u t h Dakota, N o r t h F e d e r a l O f f i c e B u i l d i n g , Rm. 628
Dakota, Utah, Wyoming Denver, C o l o r a d o 80294

Regional A d m i n i s t r a t o r : M r . F r a n c i s T. lshida

REGION #9 - Arizona, C a l i f o r n i a , 100 Van Ness Avenue, 1 4 t h F l o o r

Guam, Hawai i, Nevada, San F r a n c i s c o , C a l i f o r n i a 94102
Amer i can Samoa

Regional A d m i n i s t r a t o r : R o b e r t D. O'Connor

REGION #10 - Alaska, Idaho, 2901 T h i r d Avenue

Oregon, Washington S e a t t l e , Washington 98121

Regional A d m i n i s t r a t o r : M r . Joseph E . Anderson

 STATE
MEDICAID
DRUG PROGRAM ADMINISTRATORS

ALABAMA COLORADO

Sam T. H a r d i n , P.D. M y r l e A. Myers, R.Ph., M.S.

Administrator C h i e f , Pharmacy and A m b u l a t o r y
P h a r m a c e u t i c a l Program Care S e r v i c e s S e c t i o n
Alabama M e d i c a i d Agency D i v i s i o n of M e d i c a l A s s i s t a n c e
2500 F a i r l a n e D r i v e Colorado Department of S o c i a l
Montgomery, Alabama 36130 Services
(205) 277-2710 x310 1575 Sherman S t r e e t , Room 1010
Denver, C o l o r a d o 80203
( 303) 866-5372
ALASKA
Connecticut
Bob Ogden
Assistant Director Meyer Rosenkrantz, R.Ph.
D i v i s i o n o f P u b l i c Assistance Pharmacist Consultant
Chief o f M e d i c a l A s s i s t a n c e Department o f l ncome Maintenance
Pouch H-07 110 Bartholomew Avenue
Juneau, A l a s k a 9981 1 H a r t f o r d , C o n n e c t i c u t 06116
( 9 0 7 ) 465-3030 ( 2 0 3 ) 566-8007 o r 7223 o r 7224

ARIZONA DELAWARE

Donald 8. M a t h i s Roger Anderson, R.Ph.

Director
A r i z o n a Department of H e a l t h S e r v i c e s
C o r p o r a t i o n Commission B u i l d i n g
1200 West Washington, Room 224
Phoenix, A r i z o n a 85007
Pharmacist C o n s u l t a n t
Dept. of H e a l t h and S o c i a l S e r v i c e s
Delaware S t a t e H o s p i t a l
New C a s t l e , Delaware 19720
(302) 421-6132

ARKANSAS D l STR l CT OF COLUMB l A

Tom Brads haw James F. H a r r i s , R.Ph.

Administrator, Medical Assistance Pharmacist Consultant
Section O f f i c e o f H e a l t h Care F i n a n c i n g
Arkansas S o c i a l S e r v i c e s Department of Human S e r v i c e s
P. 0. Box 1437 614 H S t r e e t , NW, Room 708
L i t t l e Rock, Arkansas 72203 Washington, D.C. 20001
(501) 371-2403 (202) 727-0753

CALIFORNIA

M i l t o n K u s c h n e r e i t , Pharm. Rod P r e s n e l l , R.Ph.

S e n i o r C o n s u l t i n g Pharmacist
Medi-Cal B e n e f i t s Branch
C a l i f o r n i a Department of
Heal t h S e r v i c e s
714 P. S t r e e t , Room 1253
Sacramento, Cal i f o r n i a 95814
( 9 1 6 ) 445-0981
Pharmacist Consultant
M e d i c a i d O f f i c e of Program Development
Oept. o f H e a l t h and R e h a b i l i t a t i v e S e r v .
1317 Winewood B o u l e v a r d , 8-6, R-237
T a l l a h a s s e e , F l o r i d a 32301
(904) 488-9990
GEORGIA -
l OWA

F r a n c e s Lipscomb, R.Ph. Ronald J. Mahrenholz, R.Ph., M.S.

Progam Management O f f i c e r Manager, U t i l i z a t i o n Review S e c t i o n
Pharmacy S e r v i c e Bureau o f M e d i c a l S e r v i c e s
2 M.L. K i n g J r . D r i v e , S.E. Oept. o f S o c i a l S e r v i c e s
James F l o y d Memorial B u i l d i n g Hoover S t a t e O f f i c e B u i l d i n g , 5 t h F l o o r
West Tower, P.O. Box 38440 Oes Moines, Iowa 50319
A t l a n t a , G e o r g i a 30334 (515) 281-5755
(404) 656-4037
KANSAS
HAWA I I
Gene H o t c h k i s s , R.Ph.
Omel L. T u r k Pharmacist Consultant
Pharmacist Consultant Dept. o f S o c i a l & R e h a b i l i t a t i o n Serv.
P u b l i c Welfare D i v i s i o n State Office Building
Oept. o f S o c i a l S e r v i c e s & Housing Topeka, Kansas 6661 2
P.O. Box 339 (913) 296-3981
H o n o l u l u , Hawai i 96809
(808) 548-8917 KENTUCKY

l OAHO Gene A. Thomas, R.Ph.

D i v i s i o n o f Medical A s s i s t a n c e
Dianne B. Onnen, R.Ph., M.P.A. Bureau of S o c i a l l nsurance
Pharmacy C o n s u l t a n t 275 East Main S t r e e t , 3 r d F l o o r
Oept. o f H e a l t h and W e l f a r e F r a n k f o r t , Kentucky 40621
Statehouse (502) 564-4321
B o i s e , I d a h o 83720
(208) 334-4323 LOU l S IANA

ILLINOIS E u n i c e R i t c h i e , R.Ph.
Pharmacist Consultant
Dawn A t k i ns M e d i c a l A s s i s t a n c e Programs
Pharmacy Program S u p e r v i s o r Office o f Family Security
M e d i c a l A s s i s t a n c e Program P.O. Box 44065
I l l i n o i s Oept. of P u b l i c A i d , Baton Rouge, L o u i s i a n a 70804
2nd F l o o r ( 5 0 4 ) 342-3889
931 E a s t Washington S t r e e t
S p r i n g f i e l d , l ll i n o i s 62763 -
MAINE
(217) 782-0506
M i c h a e l P. O ' O o n n e l l , R.Ph.
INDIANA Pharmacy C o n s u l t a n t
M e d i c a i d Drug Program
Mark S h i r l e y Oept. o f Human S e r v i c e s
Pharmacy C o n s u l t a n t Statehouse
I n d i a n a S t a t e Dept. o f P u b l i c W e l f a r e Augusta, Maine 04333
100 N o r t h Senate Avenue - Room 701 (207) 289-2674
I n d i a n a p o l i s , I n d i a n a 46204
(317) 232-4705
MARYLAND MISSOURI

Leone W. Marks, R.Ph. R i c h a r d A. R i l e y

S t a f f S p e c i a l i s t f o r Pharmacy
Services
Dept. o f H e a l t h & M e n t a l Hygiene
201 West P r e s t o n S t r e e t
Bal t i m o r e , M a r y l a n d 21201
( 301 ) 383-2658
Pharmaceutical Consul t a n t I I
Div. Family Services, Medical Services
S e c t i o n , Dept. S o c i a l S e r v i c e s
Broadway S t a t e O f f i c e Bldg., P.O. Box 88
J e f f e r s o n C i t y , M i s s o u r i 65103
(314) 751-3399

MASSACHUSETTS MONTANA

C a r o l y n Keal y Gary B l e w e t t
Manager, M e d i c a i d Pharmacy Program Administrator
Dept. of P u b l i c W e l f a r e Economic A s s i s t a n c e D i v . , Dept. o f
600 Washington S t r e e t , Room 746 S o c i a l and Rehabi l i t a t i o n S e r v i c e s
Boston, Massachusetts 02111 P.O. Box 4210 o r 111 Senders
(617) 727-8082 Helena, Montana 59604
(406) 449-3952
MI C H I GAN
NEBRASKA
Vernon K. Smith, Ph.D.
Director Tom R. Dolan, R.Ph.
Bureau of M e d i c a i d l n f o r m a t i on Pharmaceutical Consultant
and P o l i c y M e d i c a l S e r v i c e s Div.,
Development, Dept. o f S o c i a l S e r v i c e s Dept. o f P u b l i c W e i f a r e
921 West Holmes, P.O. Box 30037 301 C e n t e n n i a l M a l l South, 5 t h F l o o r
Lansing, M i c h i g a n 48909 P .O. Box 95026
(617) 373-7720 L i n c o l n , Nebraska 68509
(402) 471-3121, e x t . 360
MINNESOTA
NEVADA
John T. Bush, R.Ph.
Pharmacist C o n s u l t a n t Steven P. B r a d f o r d , Pharm.D.
444 L a f a y e t t e Road Pharmaceutical Consultant
S t . P a u l , Minnesota 55164 Nevada M e d i c a i d O f f i c e
(612) 296-2363 W e l f a r e D i v i s i o n , Dept. Human Resources
S t a t e Capi t o 1 Complex
MISSISSIPPI 251 J e a n e l l D r i v e
Carson C i t y , Nevada 89710
James T. S t e e l e , R.Ph. (702) 885-4775
Pharmacist
M i s s i s s i p p i M e d i c a i d Commission NEW HAMPSHIRE
P.O. Box 16786
4785 i 55 N o r t h , P.O. Box 16786 C l i f f o r d A. Z i l c h , R.Ph.
Jackson, M i s s i s s i p p i 39236 C h i e f , Bureau o f M e d i c a l C l a i m s Review
(601) 354-7464 Dept. o f H e a l t h and W e l f a r e
Hazen D r i v e
Concord, New Hampshire 03301
( 6 0 3 ) 271-4359
NEW JERSEY -
OHIO

S a n f o r d L u g e r , R.Ph.
Chief, Pharmaceutical Services
D i v . of M e d i c a l A s s i s t a n c e & H e a l t h
S e r v i c e s , Dept. o f Human S e r v i c e s
324 E a s t S t a t e S t r e e t , P.O. Box 2486
T r e n t o n , New J e r s e y 08625
( 6 0 9 ) 292-3756
R i c h a r d G l e c k l e r , R.Ph.
Manager o f P r o v i d e r A s s i s t a n c e
Bureau o f M e d i c a i d S e r v i c e s
D i v i s i o n o f Claims P r o c e s s i n g
30 E a s t B r o a d S t r e e t - 38th Floor
Columbus, O h i o 43215
( 6 1 4 ) 466-7814

NEW HEXI CO OKLAHOMA

Donald R. S u t t o n , R.Ph. Howard S t a n s b e r r y

Drug Program A d m i n i s t r a t o r Pharmacy Program A d m i n i s t r a t o r
M e d i c a l A s s i s t a n c e Bureau Dept. of Human S e r v i c e s
Dept. o f Human S e r v i c e s P.O. Box 25352
P.O. Box 2348 Oklahoma C i t y , Oklahoma 73125
Santa Fe, New Mexico 87503 (405) 521-3804
(505) 827-5551
OREGON
NEW YORK
Charles N. Mortensen, R.Ph.
G e r a l d F. N e l l i g a n , R.Ph. Pharmacists Consultant
Associate Social Services A d u l t and F a m i l y S e r v i c e s D i v i s i o n
Medical Assistance S p e c i a l i s t Dept. o f Human Resources
S t a t e Dept. o f S o c i a l S e r v i c e s 203 Publ i c S e r v i c e B u i l d i n g
40 N o r t h P e a r l S t r e e t Salem, Oregon 97310
Albany, New York 12243 (503) 378-2263
( 5 1 8 ) 474-9261
PENNSYLVAN l A
NORTH CAROL I NA
Joseph E. Conci no, R.Ph.
C. 8. R i d o u t , R.Ph. Bureau o f P o l i c y and Program Development
Pharmacist Consultant Dept. o f P u b l i c Welfare, Room 510
D i v i s i o n of M e d i c a l A s s i s t a n c e H e a l t h and W e l f a r e B u i l d i n g
Dept. o f Human Resources H a r r i s b u r g , P e n n s y l v a n i a 17120
410 N. B o y l a n Avenue (717) 787-1170
R a l e i g h , N o r t h C a r o l i n a 27603
(919) 733-6775 RHODE ISLAND

NORTH DAKOTA John A. P a g l i a r i n i , R.Ph.

Chuck Gress, R.Ph.
C o o r d i n a t o r o f Pharmacy S e r v i c e s
Department of Human S e r v i c e s
State Capitol B u i l d i n g
B i smarck, N o r t h Dakota 58505
(701) 224-2321
C h i e f M e d i c a l Care S p e c i a l i s t
Dept. S o c i a l & R e h a b i l i t a t i v e S e r v i c e s
600 New London Avenue
Cranston, Rhode I s l a n d 02920
(401) 464-2184
SOUTH CAROL l NA
J o h n T. Molan
D i v i s i o n D i r e c t o r , Drugs
Department o f S o c i a l S e r v i c e s
P. 0. Box 1520, Roan 525
Columbia, S o u t h C a r o l i n a 29202
SOUTH DAKOTA
Donald Mahannah, R.Ph.
Pharmacist Consultant
Department of S o c i a l S e r v i c e s
Medical Services
Kneip B u i l d i n g
P i e r r e , South Dakota 57501
(605) 773-3495
TENNESSEE
M a r i l y n B. Ekstam, D.Ph.
D i r e c t o r o f Pharmacy S e r v i c e s
Tennessee Department o f P u b l i c
Heal t h & Envi ronment
283 P l u s Park B o u l e v a r d
N a s h v i l l e , Tennessee 37217
( 6 1 5 ) 361-6705
TEXAS
W. B l o u n t Barner, R.Ph., D.Ph.
Program S p e c i a l i s t , Vendor Orugs
Texas Oepartment o f Human
Resources
M a i l Code 541-A, P.O. Box 2960
Aust i n, Texas 78769
(512) 835-0440
-
UTAH
RaeOel l A s h l e y , R.Ph.
Manager, Program O p e r a t i o n s and
M e d i c a l Determi n a t i o n s
H e a l t h Care F i n a n c i n g
U t a h Oepartment o f H e a l t h
P. 0. Box 2500
S a l t Lake C i t y , U t a h 84103
(801 ) 533-6037
VERMONT
Charles P e r r y
C h i e f o f P o l i c y and E v a l u a t i o n
Medicaid D i v i s i o n
Department o f S o c i a l W e l f a r e
103 South M a i n S t r e e t
Waterbury, Vermont 05676
( 8 0 2 ) 241-2880
VIRGINIA
Mary Ann Johnson, R.Ph.
Pharmacist Consultant
Medical A s s i s t a n c e Program
S t a t e Oepartment o f H e a l t h
109 Governor S t r e e t , VMAP
Richmond, V i r g i n i a 23219
(804) 786-3028
WASHINGTON
W i l l i a m P. Pace, R.Ph.
Pharmacist Consultant
O f f i c e Medical P o l i c y & Procedure
M a i l S t o p LK-11
Olympia, Washington 98504
( 206) 753-0524
WEST VIRGINIA
B e r n a r d S c h l a c t , R.Ph.
Pharmacist C o n s u l t a n t
D i v i s i o n o f M e d i c a l Care
West V i r g i n i a Oepartment of W e l f a r e
1900 Washington S t r e e t , E a s t
C h a r l e s t o n , West V i r g i n i a 25305
( 304) 348-8990
WISCONSIN
Ted Col l i n s
Pharmacist C o n s u l t a n t
W i s c o n s i n Dept. o f H e a l t h
and S o c i a l S e r v i c e
One West W i l s o n S t r e e t , Room 325
Madison, W i s c o n s i n 53702
( 6 0 8 ) 266-0722
 a C a t e g o r i c a l l y Needy: Under M e d i c a i d , c a t e g o r i c a l l y needy cases a r e
aged, b l i n d , o r d i s a b l e d i n d i v i d u a l s o r f a m i l i e s and c h i l d r e n who
a r e o t h e r w i s e e l i g i b l e f o r M e d i c a i d and who meet f i n a n c i a l
e l i g i b i l i t y r e q u i r e m e n t s f o r AFDC, SSI, o r an o p t i o n a l s t a t e
supplement.

a Copayment: Copayments a r e a t y p e o f c o s t - s h a r i n g under M e d i c a i d

whereby i n s u r e d o r c o v e r e d persons pay a s p e c i f i e d f l a t amount p e r
u n i t of s e r v i c e o r u n i t o f time, and t h e i n s u r e r pays t h e r e s t of
the cost.

a Covered S e r v i c e s : Covered s e r v i c e s a r e t h e s p e c i f i c s e r v i c e s and

s u p p l i e s f o r w h i c h M e d i c a i d w i l l p r o v i d e reimbursement. Covered
s e r v i c e s under t h e M e d i c a i d program c o n s i s t of a c o m b i n a t i o n of
mandatory and o p t i o n a l s e r v i c e s w i t h i n each s t a t e .

a Customary Charge: The charge a p h y s i c i a n o r s u p p l i e r u s u a l l y b i l l s

h i s p a t i e n t s f o r furnishing a p a r t i c u l a r service o r supply i s c a l l e d
t h e customary charge.

a E a r l y and P e r i o d i c Screening, D i a g n o s i s , and T r e a t m e n t (EPSDT): The

EPSDT program c o v e r s s c r e e n i n g and d i a g n o s t i c s e r v i c e s t o d e t e r m i n e
p h y s i c i a l o r mental d e f e c t s i n r e c i p i e n t s under age 21, and h e a l t h
care, t r e a t m e n t , and o t h e r measures t o c o r r e c t o r a m e l i o r a t e any
d e f e c t s and c h r o n i c c o n d i t i o n s d i s c o v e r e d .

a E s s e n t i a l Spouse: One who i s l i v i n g w i t h an aged, b l i n d , o r

d i s a b l e d i n d i v i d u a l who was r e c e i v i n g cash a s s i s t a n c e and whose
needs were i n c l u d e d i n d e t e r m i n i n g t h e amount o f c a s h payment t o t h e
i n d i v i d u a l under OAA, AB, APTD, o r AABD; and who i s d e t e r m i n e d
essential t o the i n d i v i d u a l ' s well-being.

a Expenditures: Under M e d i c a i d , " e x p e n d i t u r e s " r e f e r s t o an amount

p a i d o u t b y a s t a t e agency f o r t h e c o v e r e d m e d i c a l expenses o f
e l i g i b l e participants.

a Family Planning Services: F a m i l y p l a n n i n g s e r v i c e s a r e any

m e d i c a l l y approved means, i n c l u d i n g d i a g n o s i s , t r e a t m e n t , drugs,
s u p p l i e s and d e v i c e s , and r e l a t e d c o u n s e l i n g w h i c h a r e f u r n i s h e d o r
p r e s c r i b e d b y o r under t h e s u p e r v i s i o n o f a p h y s i c i a n f o r
i n d i v i d u a l s o f c h i l d b e a r i n g age f o r purposes o f e n a b l i n g such
i n d i v i d u a l s f r e e l y t o d e t e r m i n e t h e number o r s p a c i n g o f t h e i r
children.

F i s c a l Agent: A f i s c a l agent ( f i s c a l i n t e r m e d i a r y ) i s a c o n t r a c t o r
t h a t processes o r pays vendor c l a i m s on b e h a l f o f t h e M e d i c a i d
agency.

11) L a J o l l a Management C o r p o r a t i o n , (Glossary)

Home H e a l t h Agency: A home h e a l t h agency i s a p u b l i c agency o r
p r i v a t e o r g a n i z a t i o n w h i c h i s p r i m a r i l y engaged i n p r o v i d i n g s k i l l e d
n u r s i n g s e r v i c e s and o t h e r t h e r a p e u t i c s e r v i c e s i n t h e p a t i e n t ' s
home, and w h i c h meets c e r t a i n c o n d i t i o n s d e s i g n e d t o e n s u r e t h e
h e a l t h and s a f e t y o f t h e i n d i v i d u a l s who a r e f u r n i s h e d t h e s e
services.

Home H e a l t h S e r v i c e s : Home h e a l t h s e r v i c e s a r e s e r v i c e s and i t e m s

f u r n i s h e d t o an i n d i v i d u a l who i s under t h e c a r e of a p h y s i c i a n b y a
home h e a l t h agency, o r b y o t h e r s under arrangements made b y such
agency. The s e r v i c e s a r e f u r n i s h e d under a p l a n e s t a b l i s h e d and
p e r i o d i c a l l y reviewed b y a p h y s i c i a n . The s e r v i c e s a r e p r o v i d e d on
a v i s i t i n g b a s i s i n an i n d i v i d u a l ' s home and i n c l u d e : part-time or
i n t e r m i t t e n t s k i l l e d n u r s i n g care; p h y s i c a l , o c c u p a t i o n a l , o r speech
t h e r a p y ; m e d i c a l s o c i a l s e r v i c e s , m e d i c a l s u p p l i e s and a p p l i a n c e s
( o t h e r t h a n drugs and b i o l o g i c a l s ) ; home h e a l t h a i d e s e r v i c e s , and
s e r v i c e s o f i n t e r n s and r e s i d e n t s .

I n p a t i e n t H o s p i t a l Services: I n p a t i e n t h o s p i t a l s e r v i c e s a r e items
and s e r v i c e s f u r n i s h e d t o an i n p a t i e n t o f a h o s p i t a l by t h e
h o s p i t a l , i n c l u d i n g bed and board, n u r s i n g and r e l a t e d s e r v i c e s ,
d i a g n o s t i c and t h e r a p e u t i c s e r v i c e s , and m e d i c a l o r s u r g i c a l
services.

I n t e r m e d i a t e Care F a c i l i t y : An i n t e r m e d i a t e c a r e f a c i l i t y i s an
i n s t i t u t i o n f u r n i s h i n g h e a l t h - r e l a t e d c a r e and s e r v i c e s t o
i n d i v i d u a l s who do n o t r e q u i r e t h e degree of c a r e p r o v i d e d b y
h o s p i t a l s o r s k i l l e d n u r s i n g f a c i l i t i e s a s d e f i n e d under T i t l e X I X
(Medicaid) of the Social S e c u r i t y Act.

L a b o r a t o r y and R a d i o l o g i c a l S e r v i c e s : L a b o r a t o r y and r a d i o l o g i c a l
s e r v i c e s a r e p r o f e s s i o n a l and t e c h n i c a l l a b o r a t o r y and r a d i o l o g i c a l
s e r v i c e s o r d e r e d b y a l i c e n s e d p r a c t i t i o n e r and p r o v i d e d i n an
o f f i c e o r s i m i l a r f a c i l i t y ( o t h e r than a h o s p i t a l o u t p a t i e n t
department o r c l i n i c ) o r b y a q u a l i f i e d l a b o r a t o r y .

M e d i c a l l y Needy: Under M e d i c a i d , m e d i c a l l y needy cases a r e aged,

b l i n d , o r d i s a b l e d i n d i v i d u a l s o r f a m i l i e s and c h i l d r e n who a r e
o t h e r w i s e e l i g i b l e f o r M e d i c a i d , and whose income r e s o u r c e s a r e
above t h e l i m i t s f o r e l i g i b i l i t y a s c a t e g o r i c a l l y needy (AFDC o r
SSI) b u t a r e w i t h i n l i m i t s s e t under t h e M e d i c a i d s t a t e p l a n .

Other P r a c t i t i o n e r s ' Services: Other p r a c t i t i o n e r s ' s e r v i c e s a r e

h e a l t h care services o f licensed p r a c t i t i o n e r s other than physicians
and d e n t i s t s .

Outpatient Hospital Services: Outpatient hospital services are

services furnished t o outpatients by a p a r t i c i p a t i n g hospital for
d i a g n o s i s o r t r e a t m e n t o f an i l l n e s s o r i n j u r y .
0 P r e s c r i b e d Drugs: P r e s c r i b e d drugs a r e drugs d i s p e n s e d b y a
l i c e n s e d p h a r m a c i s t on t h e p r e s c r i p t i o n o f a p r a c t i t i o n e r l i c e n s e d
by l a w t o a d m i n i s t e r such drugs, and drugs dispensed b y a l i c e n s e d
p r a c t i t i o n e r t o h i s own p a t i e n t s . T h i s i t e m does n o t i n c l u d e a
p r a c t i t i o n e r ' s drug charges t h a t a r e n o t s e p a r a b l e from h i s o t h e r
charges, o r d r u g s c o v e r e d b y a h o s p i t a l ' s b i l l .

0 Reasonable Charge: I n p r o c e s s i n g c l a i m s f o r Supplementary M e d i c a l

I n s u r a n c e b e n e f i t s , c a r r i e r s use HCFA g u i d e l i n e s t o e s t a b l i s h t h e
r e a s o n a b l e charge f o r s e r v i c e s rendered. The r e a s o n a b l e c h a r g e i s
t h e lowest of: t h e a c t u a l charge b i l l e d b y t h e p h y s i c i a n o r
s u p p l i e r ; t h e charge t h e p h y s i c i a n o r s u p p l i e r c u s t o m a r i l y b i l l s
h i s p a t i e n t s f o r t h e same s e r v i c e s , and t h e p r e v a i l i n g c h a r g e w h i c h
most p h y s i c i a n s o r s u p p l i e r s i n t h a t l o c a l i t y b i l l f o r t h e same
service. Increases i n t h e physicians' p r e v a i l i n g charge l e v e l s a r e
r e c o g n i z e d o n l y t o t h e e x t e n t j u s t i f i e d b y an index r e f l e c t i n g
changes i n t h e c o s t s of p r a c t i c e and i n g e n e r a l e a r n i n g s .

0 Reasonable Cost: I n processing claims f o r Health Insurance

b e n e f i t s , i n t e r m e d i a r i e s use HCFA g u i d e l i n e s t o d e t e r m i n e t h e
reasonable cost incurred by t h e i n d i v i d u a l p r o v i d e r s i n f u r n i s h i n g
covered s e r v i c e s t o enrollees. The r e a s o n a b l e c o s t i s based on t h e
a c t u a l c o s t o f p r o v i d i n g such s e r v i c e s , i n c l u d i n g d i r e c t and
i n d i r e c t c o s t s of p r o v i d e r s , and e x c l u d i n g any c o s t s w h i c h a r e
unnecessary i n t h e e f f i c i e n t d e l i v e r y of s e r v i c e s c o v e r e d b y t h e
i n s u r a n c e program.

0 Recipient: A r e c i p i e n t o f M e d i c a i d i s an i n d i v i d u a l who has been

d e t e r m i n e d t o be e l i g i b l e f o r M e d i c a i d and who has used m e d i c a l
s e r v i c e s covered under M e d i c a i d .

R u r a l H e a l t h C l i n i c : A r u r a l h e a l t h c l i n i c i s an o u t p a t i e n t
f a c i l i t y w h i c h i s p r i m a r i l y engaged i n f u r n i s h i n g p h y s i c i a n s ' and
o t h e r m e d i c a l and h e a l t h s e r v i c e s , which meets c e r t a i n o t h e r
r e q u i r e m e n t s designed t o ensure t h e h e a l t h and s a f e t y o f t h e
i n d i v i d u a l s s e r v e d b y t h e c l i n i c . The c l i n i c must be l o c a t e d i n an
area t h a t i s n o t an u r b a n i z e d area as d e f i n e d b y t h e Bureau o f t h e
Census and t h a t i s d e s i g n a t e d b y t h e S e c r e t a r y o f DHHS e i t h e r as a n
a r e a w i t h a s h o r t a g e of p e r s o n a l h e a l t h s e r v i c e s , o r as a h e a l t h
manpower s h o r t a g e area, and has f i l e d an agreement w i t h t h e
S e c r e t a r y n o t t o charge any i n d i v i d u a l o r o t h e r p e r s o n f o r items o r
s e r v i c e s f o r w h i c h such i n d i v i d u a l i s e n t i t l e d t o have payment made
by Medicare, e x c e p t f o r t h e amount o f any d e d u c t i b l e o r c o i n s u r a n c e
amount a p p l i c a b l e .

b S k i l l e d N u r s i n g F a c i l i t y (SNF): A s k i l l e d n u r s i n g f a c i l i t y i s an
i n s t i t u t i o n w h i c h has i n e f f e c t a t r a n s f e r agreement w i t h one o r
more p a r t i c i p a t i n g h o s p i t a l s , and which i s p r i m a r i l y engaged i n
p r o v i d i n g t o i n p a t i e n t s s k i l l e d n u r s i n g c a r e and r e s t o r a t i v e c a r e
s e r v i c e s , and meets s p e c i f i c r e g u l a t o r y c e r t i f i c a t i o n r e q u i r e m e n t s .
 S k i l l e d N u r s i n g F a c i l i t y Services: SNF s e r v i c e s a r e a l l s e r v i c e s
f u r n i s h e d t o i n p a t i e n t s o f , and b i l l e d f o r by, a f o r m a l l y c e r t i f i e d
s k i l l e d n u r s i n g f a c i l i t y t h a t meets s t a n d a r d s r e q u i r e d b y t h e
S e c r e t a r y o f DHHS.

a Spend-Down: Under t h e M e d i c a i d program, spend-down r e f e r s t o a

method b y w h i c h an i n d i v i d u a l e s t a b l i s h e s M e d i c a i d e l i g i b i l i t y b y
r e d u c i n g g r o s s income t h r o u g h i n c u r r i n g m e d i c a l expenses u n t i l n e t
income ( a f t e r m e d i c a l expenses) meets M e d i c a i d f i n a n c i a l
requirements.

S t a t e Buy-In: S t a t e b u y - i n i s t h e term g i v e n t o the process b y

w h i c h a s t a t e may p r o v i d e Supplementay M e d i c a l I n s u r a n c e c o v e r a g e
f o r i t s needy e l i g i b l e persons t h r o u g h an agreement w i t h t h e F e d e r a l
government under w h i c h t h e s t a t e pays t h e premiums f o r them.

S t a t e Plan: The M e d i c a i d S t a t e P l a n i s a comprehensive w r i t t e n

commitment b y a M e d i c a i d agency t o a d m i n i s t e r o r s u p e r v i s e t h e
a d m i n i s t r a t i o n of a M e d i c a i d program i n accordance w i t h F e d e r a l
r e q u i rements.

Supplemental S e c u r i t y Income (SSI): S S I i s a program o f income

s u p p o r t f o r low-income aged, b l i n d , and d i s a b l e d p e r s o n s e s t a b l i s h e d
by T i t l e XVI of t h e S o c i a l S e c u r i t y A c t .

0 T h i r d - P a r t y L i a b i l i t y : Under M e d i c a i d , t h i r d - p a r t y l i a b i l i t y e x i s t s
i f t h e r e i s any e n t i t y ( i n c l u d i n g o t h e r government programs o r
i n s u r a n c e ) w h i c h i s o r may be l i a b l e t o pay a l l o r p a r t o f t h e
m e d i c a l c o s t o r i n j u r y , disease, o r d i s a b i l i t y of an a p p l i c a n t o r
r e c i p i e n t of Medicaid.

Vendor: A m e d i c a l vendor i s an i n s t i t u t i o n , agency, o r g a n i z a t i o n ,

o r i n d i v i d u a l p r a c t i t i o n e r which provides h e a l t h o r medical
services.
 MEDl CAI D PROGRAM CHARACTERISTICS AND STATIST1 CS

I. C u r r e n t S t a t e M e d i c a i d Data

A. "Medicaid Drug Reimbursement" ( I n c l u d e s d i s p e n s i n g f e e s , copay,

i n g r e d i e n t reimbursement b a s i s , f o r m u l a r y , MAC, d o l l a r reimbursement,
average Rx p r i c e and number of Rxs' processed.)

B. "Drug R e c i p i e n t s and Vendor Payments, 1982" ( I n c l u d e s s t a t e

p o p u l a t i o n , t o t a l r e c i p i e n t s , drug r e c i p i e n t s , t o t a l vendor m e d i c a l
payments, vendor d r u g payments.)

II. M e d i c a i d Trends

A. ' V e n d o r Payments f o r P r e s c r i b e d Drugs"

6. " R e c i p i e n t s o f P r e s c r i b e d Drugs"

C. "Average E x p e n d i t u r e p e r R e c i p i e n t f o r P r e s c r i b e d Drugs"

D. " T o t a l E x p e n d i t u r e s & Drug E x p e n d i t u r e s f o r 1977-1982," t o t a l U.S.

figures

E. "Total R e c i p i e n t s & Drug R e c i p i e n t s f o r 1977-1982," t o t a l U.S. figures

F. "Average E x p e n d i t u r e s p e r r e c i p i e n t ( f o r a l l s e r v i c e s ) and Average

E x p e n d i t u r e s p e r r e c i p i e n t ( f o r d r u g s ) , 1977-1982," t o t a l U.S. f i g u r e s

Ill S t a t e Demographic and Economic C h a r a c t e r i s t i c s

A. " S t a t e P o p u l a t i o n and Economic C h a r a c t e r i s t i c s "

B. " S t a t e P o p u l a t i o n C h a r a c t e r i s t i c s , Ages 65 and o v e r "

IV. Miscellaneous

A. "Pharmacies and Pharmacists"

B. "Drug S u b s t i t u t i o n P e r m i t t e d due t o M o d i f i c a t i o n o f S t a t e Laws o r

Regulations"
 HEDICAID DRUG REIWURSEHEHT
T a b l e IA
Page One
August 1983

------------------ ~ 1983 ------------------

iyear ~ ~ ~ l ------------- ------------
F i s c a l Year 1982
Ingredient M e d i c a i d Drug Average Number o f
Dispensing Reimbursement State Reimbursement Prescription Prescriptions
State Fee Copayment Basis F o r m u l a r y MAC Millions $ Price Processed

Alabama 2-75 .SO-3.00 EAC Yes No 28.3 8.80 3,213,290

Alaska No Vendor Drug Program

Arizona New C a p i t a t i o n p l a n comnenced October 1982

Arkansas 3-58 EAC No Yes 21.0 10.06 2,209, 000*

California 3.60 1.00 EAC Yes Yes 231.6 9-56 28,000,000*

W
Colorado 3.40 AWP/EAC Yes Yes 14.3 10.22 1,401,458
0
Connecticut 3.11 AWP/EAC No No 17.4 9.24 2,215,134

Delaware 3.20 AAC No No 2.5 8.50 293,046"

D.C. -
3 27 -50 EAC No No 6 -7 10.47 782,368

Florida 3.33 EA C No No 48.8 8.23 6,192,000

Georgia 3.61 EAC Yes Yes 47.7 10.23 NA

Hawa i i 3.22 EAC Yes No -

5 2 7.04 513,000

l daho 2.50-3.50 EAC No No 2.5 7.95 210,764

Illinois 2.78 AAC Yes Yes 91.9 7.24 15,052,540

 T a b l e IA
Page Two
------------------ ~ iyear ~ ------------------
1983 ~ ~ l ------------- -----------
F i s c a l Year 1982
Ingredient M e d i c a i d Drug Average Number o f
Dispensing Reimbursement State Reimbursement Prescription Prescriptions
State Fee Copayment Basis Formulary MAC Millions $ Price Processed

l nd i ana 2.50 EAC No No 36.5 NA NA

l owa 3.74 .50 EAC No No 16.0 9.39 1,743,056

Kansas 1.60-4.23 1.00 EAC No No 15.7 NA NA

Kentucky 2.35 EAC Yes Yes 15.7 7.00 3,350,768

Lou i s i ana 3.67 EAC Yes Yes 52.3 10.44 5,010,988

Ma i ne 3.20 -50 EAC No Yes 10.4 10.26 1,400,000*

2 Maryland 3.25 AWP/EAC Yes No 22.3 9.63 2,777,773

Massachusetts 2.92 AWP/EAC No No 49.8 9-25" NA

Michigan 2.65 -50 AWP /AAC No Yes 71.6 7.76 10,953,406

Minnesota 1.30-5.00 EAC No Yes 29.4 NA 3,500,000*

Mississippi 3.17 EAC Yes Yes 28.5 9.06 3,196,542

Missouri 2.50 .SO-1 .OO EAC Yes Yes 23.0 7.76 4,959,272

Montana 2.00-3.75 EAC No No 4.2 NA NA

c
Nebraska 2 - 9 -3.35 EAC 9. 9.94 962,738

Nevada 3.78 1 .OO EAC No No 2.4 11.74 210,614

L .-
m u a
L
al w n VI
> I E -
m.- "7
- r a m
m - a m
t,
 T a b l e IA
Page Four

------------------ F i s c a l year 1983 ------------------ ------------- F i s c a l Year 1982 -----------

Ingredient M e d i c a i d Drug Average Number of
Dispensing Reimbursement State Reimbursement Prescr. Prescriptions
State Fee Copayment B a s i s Formulary MAC M i l 1i o n s $ Price Processed

Texas 3.45-3.75 AWP/EAC No No 76.1 12.09 6,500,000*

Utah 3.25 EAC Yes Yes 3.6 N4 NA

Vermont 2.50 1.00 AWP No No 3.8 8.61 520, OOO*

Virginia 2-85 .50-100 EAC No Yes 29.9 8.49 3,515,863

Washington 3.04-3.33 EAC Yes Yes 19.7 8.72 2,223,062

West V i r g i n i a 2.75 .SO-1.00 AWP NO No 8.4 7.94 995 580

Wisconsin 3.40 EAC No Yes 36.6 9.59 2,463,015

Wyoming No Vendor Drug Program

NA Not a v a i l a b l e
* Approximate f i g u r e I n f o r m a t i o n i n t h i s t a b l e was g a t h e r e d
it* $8.21 r e t a i l - 9.65 N.H. i n an NPC survey o f S t a t e M e d i c a i d Departments
AAC A c t u a l A c q u i s i t i o n Cost
AWP Average Wholesale P r i c e
EAC E s t i m a t e d A c q u i s i t i o n Cost
MAC MaximumAllowableCost
 DRU6 RECIPIENTS AND VENDOR PAYMEHTS
T a b l e 18
Page One

Population Total Drug T o t a l Vendor Vendor D r u g

Estimates Recipients Recipients M e d i c a l Payments Payments
State 1982 1982 1982 1982 1982

TOTALS 228,675,000 20,357,846 13,668,131 $29,905,882,221 $1,599,143,115**

Alabama 3,943,000 321,768 222,109 $338,095,729 $28,268,860

Arkansas 2,291,000 196,367 151 $ 7 11 266,590,253 21,084,674

California 24,724,000 3,747,880 2,397,000 3,536,5471905 231,589,629
Colorado 3,045,000 143,656 99,346 244,004,901 14,319,204
Connect i c u t 3,153,000 197,638 143,675 358,310,961 17,393,516
Delaware 602,000 48,201 33,743 55,770,487 29467,758
D.C. 631,000 108,426 69,056 178,911,908 6,716,803
Florida 10,416,000 502,118 389,534 553,440,857 48,793,813

Georg i a 51639,000 437,699 330,380 569,578,741 47,705,788

Hawa i i 994,000 102,053 75,634 125,0399793 5,203,982
l daho 965,000 39,858 27,114 63,529,288 2,452,372
Illinois 11,448,000 1,063,450 803,391 1,344,372,658 91 ,880,277
l nd i ana 5,471,000 238,322 212,071 494,755,700 36,482,742
l owa 2,905,000 179,602 128,389 287,340,667 16,052,041
Kansas 2,408,000 147,833 106,097 233,051,232 15,686,744

Kentucky 3,667,000 352,545 225,493 341,335,754 15,665,394

Lou i s i ana 4,362,000 388,789 276,307 5771795,790 52,280,483
Ma i ne 1,133,000 127,096 84,469 177,753,743 10,357,320
Maryland 4,265,000 323,207 226,722 417,714,927 22,279,885
Massachusetts 5,781,000 669,661 437,710 1,207,453891 49,793 507
Michigan 9,109,000 1,174,833 742,825 1,292,630,601 71,581,129
 Table I B
Page Two

Population Total Drug T o t a l Vendor Vendor Drug

Estimates Recipients Recipients Medical Payments Payments
State 1982 1982 1982 1982 1982

M i nnesota 4,133,000 323,291 206,300 795,512,058 29,351,971

Mississippi 2,551,000 303,621 232,154 262,866,987 28,456,785
Missouri 4,951,000 337,961 228,673 384,366,856 23,010,936
Montana 801,000 53,054 32,810 86,531,651 4,172,052
Nebraska 1,586,000 77,729 57,267 1349894,787 9,570,089
Nevada 881,000 28,650 19,116 65,445,407 2,412,107
New Hampshire 951,000 43,805 29 233 86,670,697 3,391,071
New Jersey 7,438,000 636,341 507,658 874,734,194 54,399,078
New Mexico 1,359,000 90,564 60,507 97 ,458 668 6,816,777
New York 1796591000 2,353,199 1,471,856 6,092,344,845 142,259,415
North Carolina 6,019,000 353,841 237,621 482,837,674 31,487,710
N o r t h Dakota 670,000 31,092 20,138 65,936,600 3,442,360
Ohio 10,791,000 878,338 612,386 1,227,098,294 969680,851

Oklahoma 3,177,000 242,660 104,673 361,621,172 12,399,258

0 regon 2,649,000 165,697 102,258 187,887,740 11,408,358

Pennsylvania 11,865,000 1,098,237 590,176 1,651,772,347 75,910,783

Rhode I s l a n d 958,000 123,896 83,946 200,950 223 9,759,518
South C a r o l i n a 3,203,000 250,149 168,535 278,921,835 16,866,105

South Dakota 691,000 35,655 19,923 76,916,110 2,934,208

Tennessee 4,651,000 ?62,989 271,519 464,334,956 48,240,804

Texas 15,280,000 676,295 533,520 1,157,521,944 76,119,898

Utah 1,554,000 59,566 38,688 97,920,681 3,622,172
Vermont 516,000 54,234 38,593 78,414,526 3,829,494
 Table IB
Page T h r e e

Population Total Drug T o t a l Vendor Vendor Drug

Estimates Recipients Recipients Medical Payments Payments
State 1982 1982 1982 1982 1982

Virginia 5,491,000 318,991 225,290 472,559,647 29,861,646

Washington 4,245,000 253,073 174,821 425,884,318 19,661,039

West V i r g i n i a 1,948,000 178,254 112,497 121,005,881 8,400,067

Wisconsin 4,765,000 459,836 305,197 820,891,100 36,622,642

Wyoming 502,000 12,161 -- 18,943,846 --

*Source: "P25: P o p u l a t i o n E s t i m a t e s and P r o j e c t i o n s , " U.S. Department of Comnerce.

A l l o t h e r data: Source: HCFA 2082 r e p o r t s , compiled b y S t a t e M e d i c a i d program
officials. A l t h o u g h t h e r e p o r t s have been reviewed and e d i t e d b y HCFA, t h e y may
s t i l l c o n t a i n some r e p o r t i n g e r r o r s . D e s p i t e these p o t e n t i a l shortcomings t h e
2082 HCFA d a t a r e p r e s e n t t h e most a c c u r a t e f i g u r e s a v a i l a b l e on u t i l i z a t i o n o f
s t a t e Medicaid services.

**These t o t a l s do -
n o t i n c l u d e t h e V i r g i n I s l a n d s and P u e r t o Rico.
 VENDOR PAYMEWS FOR PRESCRIBED DRUGS

Table I I A
Page One
(Amounts i n Thousands)

State 1977 1978 1979 1980 1981 1982

U S . Total $1,004,083 $1,063,429 $1,179,985 $1 ,323,011 $1,530,329 $1,599,143*

A labarna 17,859 17,686 21,422 19,984 24,243 28,269

Arkansas 14,133 15,813 lg,OOO 21,455 23,165 21,085

California 148,934 147,801 157,014 172,487 207,591 231,590

Colorado 8,790 9,684 9,712 10,823 12,128 14,319

Connecticut 12,092 13,392 14,155 15,393 17,970 17,394

Delaware 1,518 1,603 1,845 2,046 2,301 2,468

D.C. 5,170 4,428 4,935 5,732 6,124 6,717

Florida 23,083 22,684 33,240 38,150 451743 48,794

Georgia 29,413 34,635 37,000 45,888 54,597 47,706

Hawa i i 4,073 4,623 5,122 4,958 4,824 5,204

l daho 1,668 1,943 2,316 2,222 2,337 2,452

Illinois 68,146 72,642 78,932 92,142 99,015 91,880

l nd i ana 19,753 21,188 22,184 26,530 30 ,933 36,483

l owa 9,249 11,373 13,240 13,916 15,315 16,052

Kansas 11,956 11,137 11,078 13,249 14,460 15,687

Kentucky 12,041 11,764 13,629 14,922 16,615 15,665

Lou i s i ana 29,492 33,847 39 396 45,205 46,037 52,280

Ma i ne 6,170 7,132 8,284 8,213 9,634 10,357

Maryland 14,856 12,806 13,929 16,264 19,342 22,280

Massachusetts 27,685 26,135 32,278 34,651 471559 49,794

Michigan 46,611 53,470 59,436 69,755 74 525 71,581

Minnesota 17,031 18,583 20,647 23,012 27,447 29,352

 T a b l e I IA
Page Two
(Amounts i n Thousands)

State 1977 1978 1979 1980 1981 1982

Mississippi 19,534 24,312 21,816 26,855 27,157 28,457

Missouri 17,199 20,282 21,107 25,516 31,395 23,011
Montana 2,281 2,351 2,497 2,880 3,521 4,172
Nebraska 5,634 6,306 6,942 7,765 8,888 9,570
Nevada 1,009 1,099 1,393 1,702 2,258 2,412
New Hampshire 2,730 2,792 3,059 3,365 3,726 3,391
New Jersey 29,289 31,683 36,699 42,945 48,369 54,399
New Mex i co 4,174 4,007 4,442 5,294 6,141 6,817
New York 103,200 89,882 98,561 120,137 122,648 142,259
North Carolina 26,356 26,695 29,131 32,401 34,598 31,488
N o r t h Dakota 2,218 2 396 2,571 2,697 3,310 3,442
Ohio 38,458 39,459 46,104 47,953 92,147 96,681
Oklahoma 5,310 6,528 7,5486 8,621 12,013 12,399
Oregon 6,042 7,360 7,933 8,769 10,215 11,408
Pennsylvania 62,983 66,804 70,950 60,315 64,524 75,911
Rhode I s l a n d 6,356 6,485 6,962 8,087 9,061 9 ,760
South Carol i na 11,857 11,513 14 37 1 17,963 21,759 16,866
South Dakota 1,206 1,453 1,720 1,920 2,177 2,934
Tennessee 26,510 30,871 34,740 40,974 44,003 48,241
Texas 48,982 52,537 58,874 64,227 74,124 76,120
Utah 2,980 3,494 3,783 3,796 4,484 3,622
Vermont 2,925 2,825 3,026 3,468 3,891 3,829
Virginia 15,014 17,490 20,519 23,950 27,121 29,862
 T a b l e I IA
Page T h r e e
(Amounts i n Thousands)

State 1977 1978 1979 1980 1981 1982

Washington 13,337 13,754 15,176 17,485 19,380 19,661

West V i r g i n i a 7,093 7,796 9,550 10,833 10,868 8,400

Wisconsin 21,681 28,889 31,618 36,103 40,646 36,623

Source: HCFA 2082 r e p o r t s , c o m p i l e d b y S t a t e M e d i c a i d program o f f i c i a l s . Although

t h e r e p o r t s have been r e v i e w e d and e d i t e d b y HCFA, t h e y may s t i l l c o n t a i n some
reporting errors. D e s p i t e these p o t e n t i a l s h o r t c o m i n g s t h e 2082 HCFA d a t a
r e p r e s e n t t h e most a c c u r a t e f i g u r e s a v a i l a b l e on u t i l i z a t i o n of s t a t e M e d i c a i d
services .
*These t o t a l s do not i n c l u d e t h e V i r g i n l s l a n d s and P u e r t o R i c o .
 RECIPIENTS OF PRESCRIBED DRUGS
Table l l B
Page One

State 1977 1978 1979 1980 1981 1982

U.S. Total 14,190,163 14,223,988 13,277,148 13,720,161 14,248,165 13,668,131

Alabama 237,639 228,986 237,383 222,525 223,538 222,109

Arkansas 173,204 169,637 169,073 173,089 171,781 151,711

California 2,332,341 2,313,385 2,248,819 2,266,520 2,363,220 2,397,000

Coi orado 140,176 133,453 118,377 95,762 97,582 99,346

Connecticut 180,923 146,624 148,579 150,451 154,473 143,675
Delaware 391454 46,426 32,369 34,608 34,535 33,743
D.C. 95 ,292 81,751 78,308 78,328 69,970 69,056

Florida 328,050 332,316 327,873 374,670 408,923 389,534

Georgia 344,098 323,056 307,794 320,550 352,118 330,380
Hawa i i 72,886 78,820 80,456 77,845 74,968 75,634
l daho 28,449 44,310 28,998 29,547 28,995 27,114
Illinois 840,741 803,633 757,237 802,882 835,781 803,391
Indiana 179,154 174,293 167,971 182,400 197,846 212,071
l owa 121,093 127,926 130,370 133,215 140,865 128,389
Kansas 140,251 125,062 108,671 108,671 107,550 106,097
Kentucky 280,167 280,167 250,531 252,682 263,380 225,493
Lou i s i ana 284,938 280,226 287,731 285,349 300,236 276,307
Ma i ne 86,189 91,965 104,871 61,377 94,328 84,469
Maryland 256,103 214,176 206,257 217,405 229,561 226,722
Massachusetts 526,184 467,541 474,396 485,712 488,026 437,710
Michigan 666,699 652,312 659,088 729,394 720,848 742,825
Minnesota 178,834 204,651 190,714 199,721 207,958 206,300
Mississippi 235,657 238,070 226,600 253,466 258,641 232,154
 T a b l e l lB
Page Two
(Amounts i n Thousands)

State 1977 1978 1979 1980 1981 1982

Missouri 272,391 252,310 228,957 240,026 262,935 228,673

Montana 27,086 27,113 26,317 28,612 30,464 32,810
Nebraska 49,215 51,912 52,329 53,277 55,403 57,267
Nevada 15,891 15,269 15,622 17,048 19,486 19,116
New Hampshire 33,916 31,728 30,166 30,790 30,304 29,233
New Jersey 499,312 508,590 517,656 528 ,209 525,434 507,658
New Mexico 56,823 58,477 59,505 60,702 62,966 60,507
New York 1,3729026 1,315,607 1,360,974 1,317,262 1,401,768 1,471,856
North Carol ina 272,882 279,954 281,090 270,169 268,799 237,621
North Dakota 19,421 20,038 20,193 21,973 21,542 20,138
Ohio 566,397 543,893 521,361 520,579 606,702 612,386
Okl ahoma 25,350 108,282 111,479 108,366 118,131 104,673
Oregon 128,839 131,356 131,111 158,819 111,912 102,258
Pennsylvania 1,104,011 1,354,421 680,961 786,013 763,219 590,176
9
Rhode I s l a n d 69,575 86,418 85,7 2 83,946
SouthCarolina 165,509 165,090 173,894 183,569 191,196 168,535
South Dakota 19,547 20 509 18,837 18,723 19,024 19,923
Tennessee 262,021 258,522 257,295 265,135 272,418 271,519
Texas 547,032 536,411 524,494 542,051 565,757 533,520
Utah 40,683 42,230 40,839 40,053 45,485 38,688
Vermont 38,268 35,457 35,568 38,851 40,273 38,593
Virginia 215,224 215,527 215,644 236,481 243,711 225,290
Washington 198,256 197,524 198,704 208,767 209,566 174,821
 Table I It3
Page Three
(Amounts i n Thousands)

State 1977 1978 1979 1980 1981 1982

West V i r g i n i a 124,516 127,379 79,572 105,027 144,221 112,497

Wisconsin 297,450 280,191 267,942 307,072 325,544 305,197

Source: HCFA 2082 reports, compiled by State Medicaid program o f f i c i a l s . A1 though

t h e r e p o r t s have been reviewed and e d i t e d by HCFA, they may s t i l l c o n t a i n sane
r e p o r t i n g e r r o r s . Despite these p o t e n t i a1 shortcomings the 2082 HCFA data
represent t h e most accurate f i g u r e s a v a i l a b l e on u t i l i z a t i o n of s t a t e Medicaid
services.
 AVERAGE EXPENDITURE PER REClP IEHT FOR PRESCRIBED DRUGS

Table I I C
Page One
State 1977 1978 1979 1980 1981 1982

U S . Average $70.76 $74.46 $88.87 $96.43 $107.41 $117.00

Alabama 75-15 77.23 90.24 89.80 108.45 127.27

Arkansas 81.60 93.21 112.38 123.90 134.85 138.98

California 63.86 63.89 69.82 76.10 87.84 96.62

0
Col orado 62.70 113.02 12 .29 144.13
Connect i c u t 66.83 91 -34 95.27 102.31 116.33 121.06
Delaware 38.46 34.53 56.99 59.11 64.76 73.13
D.C. 54.26 54.16 63-03 73.18 87.53 97.27

Florida 70.36 68.26 101.38 101.82 111.86 125.26

1
Georgia 155.05 144. 0
Hawa i i 55.88 58 -66 63.66 63.69 64.35 68.80

1 daho 58.65 43.84 79.85 75.21 80.60 90.45

1
Illinois 81 .05 114.76 11 .47 114.37
l nd iana 110.25 121.57 132.07 145.45 156.35 172.03

1om 76.38 88.90 101.56 104.46 108.72 125.03

Kansas 85.24 89-05 101.94 121.92 134.45 147.85

Kentucky 42.98 41 -99 54.40 59.06 63.08 69 -47
Lou i s iana 103.50 120.79 136.92 158.42 153.34 189.21
Ma i ne 71 a59 77.55 78 -99 133.81 102.14 122.62

Maryland 58 .01 59.79 67.53 74.81 84.26 98.27

Massachusetts 52.61 55.90 68.04 71 -34 97.45 113.76

Michigan 69.91 81.97 90.18 95.63 103.39 96-36

M i nnesota 95.23 90.80 108.26 115.22 131.99 142.28

Mississippi 82.89 102.12 96.27 105.95 105.00 122.58
 Table I I C
Page Two

State 1977 1978 1979 1980 1981 1982

Missouri $63.14 $80.38 $92.19 $106.31 $119.40 $100.63

Montana 84.20 86 -71 94.90 100.67 115.58 127.16
Nebraska 114.47 121.47 132.67 145.76 160.43 167.11
Nevada 63.52 71.95 89.16 99.85 115.88 126.18
New Hamps h i r e 80.49 87 -99 101.39 109.28 122.95 116.00
New Jersey 58.66 62.30 70.90 81.30 92.06 107.16
New Mexico 73.46 68.52 74.66 87.21 97.53 112.66
New York 75.22 68.32 72.42 91.20 87.50 96 -65
North Carol i na 96.59 95.35 103.64 119.93 128.71 132.51
N o r t h Dakota 114.22 119.59 127.34 122.72 153.63 170.94
Ohio 67-90 72.55 88.43 90.38 151.88 157 -88
Oklahoma 209.45 60.29 68.05 79.55 101.69 118.46
Oregon 46.90 56.03 60.96 55.21 91.28 111.56
Pennsylvania 47.99 49.32 104.19 76.74 84.54 128.62
Rhode I s l a n d 91.35 74.19 82.72 93.59 105.63 116.26
South C a r o l i n a 71.64 69.74 82.64 97.85 113.79 100.07
South Dakota 61.72 70.85 91-32 102.54 114.46 147.28
Tennessee 101.17 119.41 138.91 154.54 161.53 177.67
Texas 89.54 97.94 110.34 118.49 131.02 142.67
Utah 73.26 82.74 92.62 94.78 -
98 57 93.63
Vermont 76.45 79.66 85.08 89-27 96.61 99.23
Virginia 69.76 81.15 95.15 101.28 1 1 1.28 132.55
Washington 67.27 69.63 76.37 83.76 92.48 112.46
 Table I I C
Page T h r e e

State 1977 1978 1979 1980 1981 1982

West V i r g i n i a 56.96 61.20 120.01 103.14 75.35 74.67

Wisconsin 72.89 103.10 118.00 117.57 124.86 120.00

Source: HCFA 2082 r e p o r t s , c o m p i l e d by S t a t e M e d i c a i d program o f f i c i a l s . Although

t h e r e p o r t s have been reviewed and e d i t e d b y HCFA, t h e y may s t i l l c o n t a i n some
reporting errors. D e s p i t e t h e s e p o t e n t i a l s h o r t c o m i n g s t h e 2082 HCFA d a t a
r e p r e s e n t t h e most a c c u r a t e f i g u r e s a v a i l a b l e on u t i l i z a t i o n o f s t a t e M e d i c a i d
services.
 TOTAL EXPENDITURES C DRUG EXPENDITURES FOR 1977 - 1982
Chart I I D

EXPENDITURES
i n MILLIONS
o f DOLLARS

30000

27500

25000

22500

20000

17500

15000

12500

10000

7500

5000

2500

YEAR
Legend:

$ - T o t a l Expenditures
D - Drug E x p e n d i t u r e s
 TOTAL RECIPIENTS 5 DRUG RECIPIENTS FOR 1977 - 1982

Chart I I E

RECIPIENTS
i n MILLIONS

24

23

22

21

20

19

18

17

16

15

14

13

12

1977 1978 1979 1980 1981 1982

YEAR

Leaend:
*-
<

Total Recipients
0- Drugs R e c i p i e n t s
 AVERAGE EXPENDITURES PER RECIPIENT FOR ALL SERVICES AND FOR DRUGS

Chart I IF
AVERAGE
EXPENDITURES

1500

1400

1300

1200

1100

1000

900

800

700

600

500

400

300

200

100

0
1977 1978 1979 1980 1981 1982
YEAR
Leaend:
*-<
T o t a l Average E x p e n d i t u r e for a l l S e r v i c e s
D- Drugs Average E x p e n d i t u r e f o r Drugs

48
 STATE POPULATION AH0 ECOllOHlC CHARACTERISTICS
Table l l l A
Page One

Population % of N a t ' l Compounded Per C a p i t a Annual

Estimate P o p u l a t i o n Growth Rate Personal Income Unemployment R a t e
State 1982 1982 1977-1982 1982 1982

Alabama 3,943,000 1 a703 .83 $8,581 14.6

Alaska 438,000 .I89 2.04 15,200 9.7
Arizona 2,860,000 1.235 3-34 10,201 10.2
Arkansas 2,291,000 -989 .75 8,332 10.1
California 24,724,000 10.678 2.04 12,543 9 -6
Colorado 3,045,000 1.315 2.46 11,776 7.6
Connecticut 3,153,000 1.362 .41 13,687 7.0
Delaware 602,000 .260 -23 11,796 8.6
O.C. 637,000 -273 -1.54 14,347 10.4
Florida 10,416,000 4.499 3.22 10,875 8.0
Georgia 5,639,000 2.435 1-59 9,514 7.85
Hawa i i 994 000 .429 1.65 1 1,602 6.8
l daho 965,000 .417 1.79 9,259 9 -6
Illinois 11,448,000 4.944 -07 12,162 10.9
Indiana 5,471,000 2.363 .24 10,109 12.1
l owa 2,905,000 1.255 -.06 10,532 8.9
Kansas 2,408,000 1.040 -76 11,448 6.5
Kentucky 3,667,000 1.584 -51 8,861 11.1

Louisiana 4,362,000 1.884 1.67 10,083 10.7

Maine 1,133,000 a489 .50 9,033 8.6
Maryland 4,265,000 1.842 -33 12,194 8.4
Massachusetts 5,781,000 2.497 -13 11,921 7.9
 T a b l e l l lA
Page Two

Population % o f Nat'l Compounded Per C a p i t a Annual

Estimate Population Growth Rate Personal Income Unemployment R a t e
State 1982 1982 1977-1982 1982 1982

Michigan 9,109,000 3.934 -.11 11,052 15.0

Minnesota 4,133,000 1.785 -76 11,082 7-8

Mississippi 2,551,000 1.102 .73 7 792 11.1

Missouri 4,951,000 2.138 .43 10,175 9.3

Montana 801,000 .346 .77 9,750 9.1

Nebraska 1,586,000 .685 .41 10,489 6.1

Nevada 881,000 .381 5-38 11,748 10.2

New Hampshire 951,000 .411 1.75 10,710 7.2

New J e r s e y 7,438,000 3.212 .26 13,027 8.7

New Mexico 1,359,000 587 2.10 8,997 9.2

New York 17,659,000 7.627 -.22 12,328 8.3

N o r t h C a r o l i n a 6,019,000 2.600 1.21 9,032 9.3

N o r t h Dakota 670,000 .289 .64 10,746 5.7

Ohio 10,791,000 4.661 .04 10,783 12.2

Oklahoma 3,177,000 1.372 2.08 10,776 5 -9

Oregon 2,649,000 1.144 1.67 10,392 11.6

Pennsylvania 11,865,000 5.125 -.03 10,943 10.6

Rhode l s l a n d 958,000 .414 .06 10,730 10.0

South C a r o l i n a 3,203,000 1.383 1.39 8,468 11.1

South Dakota 691,000 .298 .06 9,506 5.4

Tennessee 4,651,000 2.009 1.11 8,849 12.0

Texas 15,280,000 6.599 2.98 11,352 6.5

Utah 1,554,000 -671 3.38 8,733 8.0

 Table lllA
Page Three

Population % of Nat' I Compounded Per Capita Annual

Estimate Population Growth Rate Personal Income Unemployment Rate
State 1982 1982 1977-1982 1982 1982

Vermont 516,000 2.372 1 .07 9,446 7.2

Virginia 5,491,000 .223 -96 11,003 7.7

Washington 4,245,000 1.833 2-39 11,635 12.1

West Virginia 1,948,000 .841 .44 8,856 14.3

Wisconsin 4,765,000 2.058 -65 10,497 10.7

Wyoming 502,000 .217 4-03 11.970 6.2

--

Source: SysteMetrics, Inc., a division of Data Resources, Inc.

 STATE POPULATION CHARACTERISTICS, AGES 65 AND OVER

Table l l l B
Page One

Population % of S t a t e Compounded Growth

65 and over Population Rate, Ages 65+
1982 65 and o v e r 1977-1982

Alabama 461,000 11.692 2.98

Alaska 13,000 2.968 7 -63

Arizona 340,000 11 .888 6.09

Arkansas 323,000 14.099 2.46

California 2,553,000 10.326 3.18

Colorado 264,000 8.670 3.25

Connecticut 387,000 12.274 2.68

Delaware 63,000 10.465 3.52

0.C. 73,000 11.569 .28

Florida 1,808,000 17.358 4.54

Georgia 549,000 9.736 3.69

Hawa i i 85,000 8.551 6.17

l daho 101,000 10.466 3.75

Illinois 1,313,000 11.469 1.97

Indiana 614,000 11 .223 2.11

l owa 401,000 13.804 1.40

Kansas 316,000 13.123 1.52

Kentucky 426,000 11.617 2.26

Louisiana 419,000 9.606 2.91

Maine 147,000 12.974 2.49

Maryland 420,000 9.848 3.13

Massachusetts 751,000 12.991 1.71

 Table l l l B
Page Two

Population % of State Compounded Growth

65 and over Population Rate, Ages 65+
State 1982 65 and o v e r 1977-1982

Michigan 964,000 10.583 2.52

Minnesota 502,000 12.146 1.99

Mississippi 299,000 11.721 2.52

Missouri 666,000 13.452 1.44

Montana 90,000 11.236 2.64

Nebraska 212,000 13.367 1.17

Nevada 77 000 8.740 8-59

New Hampshire 109,000 11.462 3.23

New J e r s e y 900,000 12.100 2.21

New Mexico 126,000 9.272 4.94

New York 2,198,000 12.447 1.13

N o r t h C a r o l i na 648,000 10.766 4.06

N o r t h Dakota 84,000 12.537 1.76

Ohio 1,224,000 11.343 2.01

Ok l ahoma 390,000 12.276 2.25

Oregon 325,000 12.269 3.32

Pennsylvania 1,606,000 13.536 2.31

Rhode I s l a n d 132,000 13 -779 2.27

South C a r o l i n a 310,000 9.678 4.56

South Dakota 94,000 13.603 1-33

Tennessee 542,000 11.653 3.11

Texas 1,442,000 9.437 3-25

Utah 118,000 7.593 3.78

 Table I I I B
Page Three

Population % of State Compounded Growth

65 and over Population Rate, Ages 65+
State 1982 65 and over 1977-1982

Vermont 60,000 9.780 3.42

Virginia 537,000 11.628 2.13
Washington 464,000 10.931 3.64
West Virginia 247,000 12.680 2.44
Wisconsin 592,000 12.424 2.05
Wyoming 39,000 7.769 2.19

Source: SysteMetrics, Inc., a division of Data Resources, Inc.

 PHARMACIES 5 PHARMACISTS
T a b l e IVA
Page One
PHARMACIES
Nursing All PHARMA-
STATE Comnunity Chain Hospital Clinic Home Others* Total CISTS

GRAND TOTALS: 39,079 14,404 5,053 1,460 711 2,203 62,910 147,194
Alabama 850 290 60 25 12 38 1,275 2,922**
Alaska 55 23 20 0 3 2 103 218
Arizona 246 25 1 70 39 4 67 677 2,149""
Arkansas 59 7 111 82 4 4 8 806 1,353
California 3,295 1,139 516 158 5 182 5,295 11,852
Colorado 435 135 51 25 1 53 700 2,189**
Connecticut 583 126 1 3 0 0 713 1,874
Delaware 46 66 16 2 4 0 134 379**
D.C. 88 70 4 1 2 3 168 403

Florida 1,534 876 225 85 29 3 184 3,197 5,436

Georg i a 1,189 472 182 48 27 76 1,994 4,452**
Hawa i i 70 32 15 11 0 0 128 274

l daho 198 46 40 6 3 11 304 667

Illinois 2,143 560 191 82 19 88 3,083 5,658

l nd i ana 705 529 127 21 9 21 1,412 4,262**

l owa 543 185 25 42 7 25 827 2,180**

Kansas 518 105 146 22 2 24 817 1,325

Kentucky 708 248 107 27 11 28 1,129 2,342**

Louisiana 809 329 160 27 4 39 1,368 2,985**

Maryland 423 366 62 12 2 18 883 3,537**

Massachusetts 1,092 312 19 6 0 1 1,430 4,832**
Michigan 1,583 404 215 49 10 109 2,370 6,287
 T a b l e IVA
Page Two
PHARMACIES
Nursing All PHARMA-
STATE Comnunity Chain Hospital Clinic Home Others* Total CISTS

Minnesota 678 186 149 35 6 37 1,091 3,102**

Mississippi 662 144 118 27 50 5 1,006 1,789

Missouri 888 315 99 44 4 37 1,387 3,289""

Montana 171 39 63 8 3 4 288 702

Nebraska 385 65 14 9 4 15 492 323

Nevada 85 68 18 3 0 17 191 521

New Hampshire 121 58 32 1 8 1 221 610**

New Jersey 1,294 377 86 12 8 10 1,787 6,210""

New Mexico 183 77 41 50 2 93 446 871""

New York 3,151 684 316 64 68 157 4,440 12,400

North C a r o l i n a 94 1 508 132 23 13 56 1,673 2,245

N o r t h Dakota 150 19 47 14 2 4 236 664""

Ohio 1,486 88 0 75 39 11 136 2,627 7,511""

Oklahoma 714 194 52 29 0 42 1,031 2,020

Oregon 439 111 58 20 5 9 642 1,895""

Pennsylvania 2,054 79 0 250 24 55 31 3,204 8,526""

Puerto Rico 99 1 86 44 8 0 17 1,146 788

Rhode I s l a n d 133 68 17 2 1 2 223 623

South Carol i na 47 4 308 57 19 6 29 893 2,333""

South Dakota 177 14 59 18 4 7 279 420

Tennessee 93 1 303 166 42 7 55 1,504 2,538

Texas 2,331 1,146 307 114 3 298 4,199 7,732""

Utah 227 91 33 9 0 36 396 1,051""

Vermont 90 32 18 0 0 1 141 244

 T a b l e IVA
Page T h r e e
PHARMACIES
Nursing All PHARMA-
STATE Comnunity Chain Hospital Clinic Home Others* Total CISTS

Virginia 576 489 113 38 6 36 1,258 2,989

V i r g i n Islands 0 0 0 0 0 0 0 18

Washington 693 245 120 35 5 29 1,127 3,090

West V i r g i n i a 308 140 86 21 2 14 57 1 1,235**

Wisconsin 793 181 116 54 15 38 1,197 2,980

Wyoming 87 21 29 2 o 10 149 419

P a c i f i c Islands 0 0 0 0 0 0 0 6
APO/FPO, Foreign 1 0 0 0 0 0 1 7

* I n c l u d e s 1,112 Department S t o r e s and 420 G r o c e r y S t o r e s

** 72,258 Newly L i c e n s e d o r Re-Licensed R.Ph.s.

Source: B u s i n e s s M a i l e r d l n c . March 1983, O f f i c i a l L i s t o f t h e NABP and NCPDP

 R e v i s e d 3/20/83
T a b l e IVB
Page One

Two-Line P e r m i s s i v e How S u b s t i t u t i o n Pharmacy Cost Patient

Year Year Formulary RxForm or Can Be Record Savings Notification
State E n a c t e d Amended L i m i t a t i o n s P r o v i s i o n s M a n d a t o r y P r e v e n t e d Requi r e d Pass-on Requi r e d

Alabama 1979 None Yes P A Yes No No

Alaska 1976 None Yes P C No Yes Yes

Arizona 1978 1979 None Yes P A Yes Yes Yes

Arkansas 1975 Negative No P B No Yes Yes

California 1975 1980 Negative No P B No No Yes

~n Colorado 1976 None No P B No Yes Yes

m
Connecticut 1976 None No P B Yes Yes Yes

Delaware 1976 1981 Positive Yes P A Yes Yes Yes

D.C. 1976 Positive No P B Yes No NO

Florida 1974 1976 Negative No M(6) B Yes Yes Yes

Georgia 1977 None Yes P A Yes No No

Hawa i i 1980 Positive No M(8) B(9) Yes Yes Yes

l daho 1978(1) None Yes P A Yes Yes Yes

Illinois 1977 1981 Positive No P B Yes No No

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 T a b l e IVB
Page F o u r

Two-Line P e r m i s s i v e How S u b s t i t u t i o n Pharmacy Cost Patient

Year Year Formulary RxForm or Can Be Record Savings Notification
State -
E n a c t e d Amended L i m i t a t i o n s P r o v i s i o n s Mandatory P r e v e n t e d Required Pass-on Required

Virginia 1977 1978 Positive Yes P A Yes No Yes

Washington 1977 1979 Neg(4) o r Pos Yes M A Yes Yes Yes

West V i r g i n i a 1978 Negative Yes ( 2 ) p (5) A,B (2) Yes Yes Yes

Wisconsin 1976 Positive No P B No Yes Yes

Wyoming 1979 None Yes P A Yes Yes No

*Some o f t h e i n f o r m a t i o n i n t h i s c h a r t i s based upon NPC s t a f f i n t e r p r e t a t i o n s of s t a t e s t a t u t e s and r e g u l a t i o n s .

M.D. must g i v e e x p r e s s p r i o r a p p r o v a l b y s i g n i n g on t h e a p p r o p r i a t e l i n e on t h e p r e s c r i p t i o n f o r s u b s t i t u t i o n
t o take place.
P h a r m a c i s t i s a u t o m a t i c a l l y a u t h o r i z e d t o s u b s t i t u t e u n l e s s M.D. i n d i c a t e s e x p r e s s d i s a p p r o v a l , such as b y
i n d i c a t i n g "Dispense as w r i t t e n " , "No s u b s t i t u t i o n " , "Do n o t s u b s t i t u t e " , "Brand necessary", o r " M e d i c a l l y
necessary".
I n Alaska, M.D. must p e r m i t o r deny s u b s t i t u t i o n , b u t a u t h o r i t y t o s u b s t i t u t e i s d e n i e d i f M.D. f a i l s t o make
any i n d i c a t i o n . Two l i n e Rx forms a r e o p t i o n a l .
On w r i t t e n p r e s c r i p t i o n s t h e p h a r m a c i s t i s a u t h o r i z e d t o s u b s t i t u t e u n l e s s t h e p r a c t i t i o n e r p r o h i b i t s i n
w r i t i n g o r by p r i n t e d form. O r a l p r e s c r i p t i o n s must be d i s p e n s e d as t r a n s c r i b e d , u n l e s s t h e p r a c t i t i o n e r
i n s t r u c t s t h a t product s e l e c t i o n i s permitted.

IDAHO: R e g u l a t i o n adopted b y t h e Idaho S t a t e Board of Pharmacy, e f f e c t i v e January 3, 1978 (7-665-68). All

p r e s c r i p t i o n s must c o n t a i n two s i g n a t u r e s l i n e s a f t e r J u l y 1, 1978.

KANSAS, NORTH CAROLINA, MISSISSIPPI, WEST VIRGINIA: Two s i g n a t u r e l i n e s on t h e p r e s c r i p t i o n a r e o p t i o n a l . If

an Rx f o r m w i t h o u t t h e two l i n e s i s u t i l i z e d by t h e p r e s c r i b e r , he o r she must w r i t e " d i s p e n s e a s w r i t t e n " , in
h i s o r h e r own h a n d w r i t i n g t o p r e v e n t s u b s t i t u t i o n .
 T a b l e IVB
Page F i v e

MINNESOTA: I n cases where t h e a c t u a l manufacturer of t h e p r o d u c t t o b e s u b s t i t u t e d i s t h e same as t h e

manufacturer of t h e p r e s c r i b e d name brand, M.D. may n o t p r e v e n t s u b s t i t u t i o n .

WASHINGTON, UTAH: Board o f Pharmacy i s empowered b u t n o t r e q u i r e d t o adopt n e g a t i v e o r p o s i t i v e f o r m u l a r y .

WEST VIRGINIA: The p h a r m a c i s t " s h a l l s u b s t i t u t e . . ., u n l e s s i n h i s p r o f e s s i o n a l judgement ... 11

FLORIDA: F l o r i d a p r o d u c t s e l e c t i o n law s t a t e s t h a t t h e p h a r m a c i s t " s h a l l " , u n l e s s r e q u e s t e d o t h e r w i s e b y t h e

purchaser. I n t h e absence o f t h e p r e s c r i b e r s ' " M e d i c a l l y necessary" d e s i g n a t i o n , t h e p h a r m a c i s t s h a l l
s u b s t i t u t e a l e s s expensive generic e q u i v a l e n t drug product from a formulary o f s u b s t i t u t a b l e drug products
e s t a b l i s h e d by each community pharmacy.

NORTH DAKOTA: Law r e q u i r e s t h e words "Brand necessary" t o be w r i t t e n on T i t l e X I X p r e s c r i p t i o n s i n t h e

p r a c t i t i o n e r s own h a n d w r i t i n g , i n a d d i t i o n t o s i g n i n g t h e DAW s i d e o f t h e p r e s c r i p t i o n form.

HAWAII: Requires t h e p h a r m a c i s t t o o f f e r l e s s expensive g e n e r i c e q u i v a l e n t p r o d u c t s when a v a i l a b l e .

HAWAII: O r a l p r e s c r i p t i o n s a r e r e q u i r e d t o have a "Do Not S u b s t i t u t e " statement by t h e p r e s c r i b e r t o p r e v e n t

substitution.

LOUISIANA: A p h a r m a c i s t may s e l e c t o n l y drug p r o d u c t s determined by FDA t o be p h a r m a c e u t i c a l l y o r

t h e r a p e u t i c a l l y e q u i v a l e n t o r interchangeable.

OHIO:
- P a t i e n t n o t i f i c a t i o n i s n o t r e q u i r e d f o r s t a t e agency Rx's, i n c l u d i n g Medicaid.

OKLAHOMA: A 1976 Oklahoma A t t o r n e y General O p i n i o n s t a t e s , "A Pharmacist may make a g e n e r i c s u b s t i t u t i o n w i t h

t h e consent of e i t h e r t h e p r e s c r i b e r 2 t h e purchaser."
 United States - 1
1983
MOICAL ASSISTANCE PROGRAM BENEFITS (TITLE XIX)*
I. TOTAL UNITED STATES VENDOR PAYMENTS B Y TYPE OF SERVICE,
compared t o 1978

Drugs $1,599,464 5.4% $1,088,237 6 .o%

Family Planning 134,126 0.4 112,833 0.8

O t h e r Care

Clinic 41 1,320 1.4 222,006 1.2

Hane H e a l t h 495 530 1.6 211,345 1.2

Dental 503,944 1.6 388,097 2.1

Other P r a c t i t i o n e r s 225,897 0.7 140,254 0.8

H o s p i t a l Out-Patient 1,597,801 5.3 821,843 4.5

Physicians 2,107,392 7.0 1,595,399 8.8

Hospital In-Patient 8,853,143 29.6 30.8

Totals $29,905,890 $18,133,709*"

* I n d i v i d u a l s t a t e i n f o r m a t i o n may be f o u n d on t h e f i r s t page o f each
s t a t e section.
** These t o t a l s do i n c l u d e t h e V i r g i n I s l a n d s .
 United States -2
1983

NATIOIUL
E D I W ASSISTANCE PROGRAn ( T I T L E X I X ) PAYMEN'TS
by type o f service
f F Y 1975, 1980, 1982)
 NPC United States .3
1983
II . EXPENDITURES FOR DRUGS. 1981 and 1982*
Expenditures Recipients
1981 1982 1981 1982
TOTAL .................. $1.530.329. 299 $1.599.143. 115 14.248. 165 13.668. 131
CATEGORICALLY NEEDY CASH TOTAL . . . . $1.075.859. 479
Aged .................. 313.752. 008
Blind ................. 9.867. 371
Disabled ................ 366.528. 602
Children -
F a m i l i e s w/Dep C h i l d r e n ... 158.917. 265
Adults -
F a m i l i e s w/Dep C h i l d r e n .... 226.794. 233
CATEGORICALLY NEEDY NON-CASH TOTAL . . . 229.576. 309
Aged . . . . . . . . . . . . . . . . . . 168.106. 753
Blind . . . . . . . . . . . . . . . . . 1.617. 713
Disabled . . . . . . . . . . . . . . . . 47.803. 478
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n . . .
m
m 4.569. 566
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . . . 4.734. 676
Other T i t l e XIX R e c i p i e n t s . . . . . . 2.744. 123
MEDl CALLY NEEDY TOTAL . . . . . . . . . . 224.893. 511 195.456. 565 1.649. 363 1.457. 406
Aged . . . . . . . . . . . . . . . . . . 127.669. 183 120.408. 441 620. 466 558. 112
Blind . . . . . . . . . . . . . . . . . 1.007. 429 869. 135 5. 231 3. 569
Disabled . . . . . . . . . . . . 70.710. 642 48.131. 564 345.529 272. 426
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 7.520. 628 7.052. 554 296. 282 262. 338
A d u l t s - F a m i l i e s w/Oep C h i l d r e n . . . . 10.907. 066 11.028. 05.5 214. 341 205. 294
Other T i t l e XIX R e c i p i e n t s . . . . . 7.078. 563 7.966. 816 180. 183 172. 410

* I n d i v i d u a l s t a t e c h a r t s a r e on t h e f i r s t page o f each s t a t e s e c t i o n .
 Alabama -
1
1983
MABAM

M€DlCAL ASSISTANCE DRUG PROGRAM (TITLE X I X )

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA A6 APT0 AFDC OAA AB APTD AFDC C h i l d r e n 21 (SFO)
Prescribed

l n7o a t i e n t
H o s p i t a l Care X X X X
Outpatient
H o s p i t a l Care X X X X
Laboratory &
X-ray S e r v i c e X X X X
S k i l l e d Nursing .
Home S e r v i c e s X X X X
Physician
Services X X X X
Dental
Services x**
O t h e r B e n e f i t s : Optornetric s e r v i c e s ; home h e a l t h c a r e ; e a r l y , p e r i o d i c , screening,
d i a g n o s i s and t r e a t m e n t ; f a m i l y p l a n n i n g ; t r a n s p o r t a t i o n .
*SF0 - S t a t e Funds O n l y
**Dental S e r v i c e s EPSDT -under 21 y e a r s o l d

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982
1981 1982
Expended R e c i p i e n t Expended Recipient

TOTM............................... $24,242,873 223,538*** $28,268,860 222,109***

CATEGORICALLY NEEDY CASH TOTAL...... $20,347,842 209,079 $23,747,356 204,502

Aged.. ...............-.............. 10,259,388 71,174 11,539,306 63,468
Blind..... .......................... 21 1,608 1,487 263,294 1,562
Disabled ............................ 7,608,117 48,329 9,212,079 48,647
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 780,397 52,076 888,335 53,145
A d u l t s - F a m i l i e s w/Oep Children..... 1,488,332 36,652 1,844,342 38,284

CATEGORICALLY NEEDY NON-CASH TOTAL.. $3,895,031 30,833 $4,521,504 22,806

Aged. .... . ...... . .... .......... ..... 3,245,477 13,658 3,844,925 14,077
Blind....... ........................ 4,600 27 5,975 25
Disabled ............................ 452,355 1,942 563,555 1,990
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n . . . 66,583 6,786 27,119 2,408
A d u l t s - F a m i l i e s w/Oep Children..... 93,422 6,522 48,145 2,527
Other T i t l e X I X R e c i p i e n t s .......... 32,594 1,985 31,785 1,856

MEDICALLY NEEDY TOTAL ............... $0 0

Aged ................................ 0 0
B l i n d . . ............................. 0 0
Disabled........ .................... 0 0
Chi l dren -Fami l i e s w/Oep Chi l d r e n . . . 0 0
A d u l t s - F a m i l i e s w/Oep C h i l d r e n . . ... 0 0
Other T i t l e X I X R e c i p i e n t s .......... 0 0

---Undupl i c a t e d T o t a l
*A*
- HHS r e p o r t HCFA
66
- 2082
NPC Alabama -2
1983

I l l . Administration:

Alabama Medicaid Agency

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General Exclusions: Vitamins, food supplements, and a n t i - o b e s i t y ,

cough and c o l d p r e p a r a t i o n s , c e r t a i n drug p r o d u c t s c l a s s i f i e d as
l a c k i n g adequate evidence of e f f e c t i v e n e s s .

0. Formulary: Alabama Drug Code Index, which s p e c i f i e s those drugs t h a t

may be dispensed on p r e s c r i p t i o n o n l y .

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Q u a n t i t y o f Medication: Normal p r e s c r i p t i o n s a r e l i m i t e d t o a
maximum 34-day supply w i t h a maximum o f 5 r e f i l l s . The 34-day
l i m i t a t i o n does not apply t o long-term maintenance medication.
The q u a n t i t m t s ) of drugs p r e s c r i b e d by a p h y s i c i a n SHALL
-
NOT be a r b i t r a r i l y changed by a pharmacy except by a u t h o r i z a t i o n
of t h e p h y s i c i a n . The pharmacist should c o n t a c t t h e p r e s c r i b i n g
p h y s i c i a n f o r a u t h o r i z a t i o n t o reduce t h e q u a n t i t y o f a non-
maintenance medication p r e s c r i p t i o n t o t h e 34-day supply
l i m i t a t i o n where a p p r o p r i a t e . A u t h o r i z a t i o n t o reduce t h e u n i t s
o f a p r e s c r i p t i o n must be noted on t h e p r e s c r i p t i o n form by t h e
pharmacist. P r e s c r i p t i o n s f o r T i t l e X I X n u r s i n g home p a t i e n t s who
are on long-range therapy or maintenance drugs must be w r i t t e n f o r
a t l e a s t a minimum t h i r t y (30) day supply.

2. Refills: When a u t h o r i z e d by p r e s c r i b e r , a maximum o f f i v e ( 5 )

r e f i l l s w i t h i n a s i x month period. ( s u b j e c t t o DS/UR). All
p r e s c r i p t i o n s should be r e f i l l e d o n l y i n q u a n t i t i e s comnensurate
w i t h dosage schedule and r e f i l l i n s t r u c t i o n s .

3. Limit of 6 p r e s c r i p t i o n s per r e c i p i e n t p e r month ( E f f . 7/8/83).

D. P r e s c r i p t i o n Charge Formula: Medicaid pays f o r p r e s c r i b e d legend and
non-legend drugs a u t h o r i z e d under t h e program based upon and s h a l l n o t
exceed the lowest o f :

1. The Maximum A l l o w a b l e Cost (MAC) of t h e drug p l u s a dispensing

fee.

2. The Estimated A c q u i s i t i o n Cost (EAC) of t h e drug p l u s a dispensing

fee, or

3. The p r o v i d e r ' s Usual and Customary charge t o t h e p u b l i c f o r t h e

drug.
 Alabama - 3
1983

P r e s c r i p t i o n Charge Formula ( c o n t i n u e d ) :

P r o f e s s i o n a l Fee

Reta i l pharmacies

I n s t i t u t i o n a l pharmacies ( h o s p i t a l
pharmacies w i t h o u t p a t i e n t
p r e s c r i p t i o n s e r v i c e s and s k i l l e d
n u r s i n g f a c i l i t i e s pharmacies)

Government pharmacies ( c o u n t y , state,

o r f e d e r a l pharmacies)

Dispensing Physicians .75

E. V a r i a b l e Co-Payment f o r P r e s c r i p t i o n Drugs

EXEMPTIONS: No co-payment amount i s t o be c o l l e c t e d b y t h e pharmacy o r

p a i d by t h e r e c i p i e n t on t h e f o l l o w i n g :

F a m i l y p l a n n i n g d r u g s o r s u p p l i e s ; under 21 y e a r s o f age,

Drugs used i n t h e t r e a t m e n t o f c o n d i t i o n s i d e n t i f i e d t h r o u g h t h e
EPSDT program; pregnancy cases,

Drugs dispensed t o M e d i c a i d r e c i p i e n t s r e s i d i n g i n a n u r s i n g home

f a c i l i t y i n Alabama.

CO-PAYME NT

$ .50 $ . O l - $ 7.25
1 .OO 7.26-$22.25
2.00 22.26-$47.25
3.00 47.25 o r more

V. M i s c e l l a n e o u s Remarks:
FY 1982
COST AND USE DATA

No. o f Drug R e c i p i e n t s
% o f Eligibles
No. o f P r e s c r i p t i o n s
P r e s c r i p t i o n s per Recipients
P r i c e per Recipient
T o t a l Drug Costs
Average Rx P r i c e

*Alabama M e d i c a i d 1 0 t h Annual R e p o r t 10/1/81 - 9/30/82

F i s c a l Intermediary: A l a c a i d (E.D.S.F.)
P.O. Box 5950-C.. ~

Montgomery, Alabama 36103

NPC Alabama - 4
1983

Officials, C o n s u l t a n t s and Committees

1. Officials:

Faye S. Baggiano Alabama M e d i c a i d Agency

A c t i n g Commissioner 2500 F a i r l a n e D r i v e
Alabama M e d i c a i d Agency Montgomery, Alabama 36130

C l a y t o n H. Schmidt, M.D.
Chief, Professional Services Div.
Alabama M e d i c a i d Agency

Sam T. H a r d i n , P.D.
Administrator
P h a r m a c e u t i c a l Program
205/277-2710, E x t . 300

2. T i t l e X I X Medical Care A d v i s o r y Committee:

C. l v e y W i l l i a m s o n , M.D.
The M e d i c a l A s s o c i a t i o n
1555 S p r i n g h i l l Avenue
M o b i l e 36604

Permanent E x - O f f i c i o Members

O r . Leon F r a z i e r
Commissioner, S t a t e Department of
Pensions and S e c u r i t y
64 N o r t h Union S t r e e t
Montgomery 36130

I r a L. Myers, M.D.
S t a t e P u b l i c H e a l t h Oepartment
434 Monroe S t r e e t
Montgomery 36130

Alabama H o s p i t a l A s s o c i a t i o n Alabama P h a r m a c e u t i c a l Assoc.

Frank Perryman, Vice-Chrmn. Anthony J. B r o o k l e r e

Sylacauga H o s p i t a l & N u r s i n g Home 1616 F o r e s t d a l e P l a z a
Sy Iacauga 35150 Birmingham 35214

Alabama N u r s i n q Home Assoc. Alabama O p t o m e t r i c Assoc.

Ms. M i l d r e d Jobe, A d m i n i s t r a t o r C r a i g R. McNamara

N u r s i n g Home o f Camden, Alabama 116 E. B r i d g e S t r e e t
P. 0. Box 486 Wetumpka 36092
Camden 36126

June 1977 M e d i c a i d program t r a n s f e r r e d from H e a l t h Oepartment o f G o v e r n o r ' s O f f i c e

as S i n g l e S t a t e Agency b y E x e c u t i v e Order.
 Alabama - 5
1983

T i t l e X I X M e d i c a l Care A d v i s o r y Committee ( c o n t i n u e d ) :

American A s s o c i a t i o n M e d i c a l
Assistants Consumer R e p r e s e n t a t i v e s

Mrs. Jean Yarbrough Mary Ann Darby

Route 1, Box 355 P. 0. Box 4010
E n t e r p r i s e 36330 Montgomery 36195

Medical A s s o c i a t i o n o f t h e E l l e n Dempsey
S t a t e o f Alabama 1949 Walnut S t r e e t
Montgomery 36106
Wheeler A. Gunnels, M.D.
715 B r a n t l e y S t r e e t C h a r l e s G. S p r a d l i n g
Opp 37467 1840 7 t h Avenue N.
Birmingham 35203
C. l v e y W i l l i a m s o n , M.D.
1555 S p r i n g h i l l Avenue J u l i a Trant
M o b i l e 36604 P. 0. Box 6406
Dothan 36302. .
S t a t e B o a r d o f Mental H e a l t h
Sister Merrillac, Administrator
Ms. Bess H a t c h e r 3721 Wares F e r r y Road
873 O e l c r i s t D r i v e Montgomery 36109
Burmingham 35226
M r . Mark T h o r n h i l l
S t a t e Department o f P e n s i o n s O f f i c e o f Voluntary C i t i z e n
G Security Participation
Montgomery 36130
D r . Leon F r a z i e r
Commissioner Honorable Thomas A. Snowden
64 N o r t h U n i o n S t r e e t P. 0. Box 825
Montgomery 36130 Columbiana 35051

3. E x e c u t i v e O f f i c e r s o f S t a t e Medical and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical Association: B. Pharmaceutical Association:

Lon Conner Jon B a r g a n i e r

Executive D i r e c t o r Executive D i r e c t o r
Medical Association of Alabama P h a r m a c e u t i c a l
t h e S t a t e o f Alabama Association
19 South Jackson S t r e e t 340 D e x t e r Avenue
Montgomery 36104 Montgomery 36104
Phone: 205/263-6441 Phone: 205/262-0027

C. Osteopathic Association:

Kenneth D. McLeod, 0.0.

Secretary
Alabama O s t e o p a t h i c A s s o c i a t i o n
1511 N. McKenzie S t r e e t
F o l e y 36535
205/943-1584
 Alaska - 1
1983

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e q o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTO AFOC OAA AB APTO AFOC C h i i d r e n < 2 1 (SFO)
Prescribed
Drugs
lnpat ient
H o s p i t a l Care X X X X X
Outpatient
H o s p i t a l Care X X X X X
Laboratory &
X-ray S e r v i c e X X X X X
S k i l l e d Nursina .
Home S e r v i c e s X X X X X
Physician
Services X X X X X
.D
......e n t a l
Services X , X X X
Other B e n e f i t s : I n t e r m e d i a t e Care F a c i l i t i e s ; t r a n s p o r t a t i o n ; home h e a l t h c a r e ;
e a r l y and p e r i o d i c s c r e e n i n g , d i a g n o s i s and t r e a t m e n t f o r e l i g i b l e s under 21; f a m i l y
planning; intermediate care f o r t h e m e n t a l l y retarded; i n p a t i e n t p s y c h i a t r i c care;
o p t o m e t r i s t s e r v i c e s ; eyeglasses; speech and h e a r i n g s e r v i c e s ; m e n t a l h e a l t h c l i n i c .
*SF0 - S t a t e Funds Only

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982
1981 1982
~ x ~ e n d e dR- e c i p i e n t ~ x ~ e n d e dR e c i p i e n t

TOTAL ...............................
CATEGORICALLY NEEOY CASH TOTAL ......
Aged ................................
Blind..... ..........................
Disabled.......... ..................
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n ...
A d u l t s - F a m i l i e s w/Oep Children.....

CATEGORICALLY NEEOY NON-CASH TOTAL..

Aged ................................ A l a s k a ' s M e d i c a i d program
Blind.. ............................. does n o t i n c l u d e drugs, e x c e p t
Disabled............. ............... f a m i l y p l a n n i n g d r u g s and
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n . . . drugs dispensed t o i n p a t i e n t s
A d u l t s - F a m i l i e s w/Oep Children..... of h o s p i t a l s and n u r s i n g homes.
Other T i t l e XIX R e c i p i e n t s ..........
MEDICALLY NEEOY TOTAL ...............
Aged ................................
Blind. ..............................
Disabled ............................
...
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n
.
A d u l t s - F a m i l i e s w/Oep C h i l d r e n . . . .
..........
Other T i t l e X I X R e c i p i e n t s

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

71
NPC Alaska - 2
1983

I I I . Administration:

There i s no s t a t e T i t l e XIX vendor drug program. The A l a s k a M e d i c a l

A s s i s t a n c e programs i n c l u d i n g M e d i c a i d and General R e l i e f - M e d i c a l a r e
a d m i n i s t e r e d by t h e D i v i s i o n o f P u b l i c A s s i s t a n c e ( f o r m e r l y t h e D i v i s i o n of
Medical A s s i s t a n c e ) of t h e Alaska Department of H e a l t h and S o c i a l
Services. T h i s D i v i s i o n a l s o i n c l u d e s t h e c a t e g o r i c a l a s s i s t a n c e programs
(OAA, AB, APTD, and AFDC) and makes e l i g i b i l i t y d e t e r m i n a t i o n s .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A l t h o u g h drugs a r e n o t c o v e r e d under M e d i c a i d i n Alaska, p r e s c r i p t i o n s a r e

p a i d from t h e General R e l i e f - M e d i c a l budget f o r M e d i c a i d r e c i p i e n t s who have
no o t h e r r e s o u r c e f o r o b t a i n i n g p r e s c r i b e d m e d i c a t i o n s .
 Alaska -3
1983

Officials, Consultants and Committees

1. Health and Social Services Department Officials:

Robert Smith, Ph.0. Department of Health and

Commissioner Social Services
Pouch H-01
Juneau, Alaska 9981 1

Rod Bet it (as above)

Director Pouch H-07
Division of Public Assistance

Bob Ogden (as above)

Assistant Director Pouch H-07
Division of Public Assistance
Chief of Medical Assistance

2. Alaska Medical Care Advisory Committee:

David Swanson, R.Ph. P. 0. Box 1

Cha i rman Fairbanks 99707
-2556

3. Executive Officers of State Medical and Pharmaceutical Societies:

A. Medical Association:

Martha MacOermaid
Administrative Secretary
Alaska State Medical Association
4107 Laurel Street, Suite 1
Anchorage 99504
Phone: 907/277-6891

B. Pharmaceutical Association:

Kendall Pederson
President
Alaska Pharmaceutical Association
Box 101185
Anchorage 9951 0
 Arizona - 1
1983

N£DlCAL ASSISTANCE DRU6 PROGRAH UNDER TITLE X I X

A r i z o n a H e a l t h Care Cost Containment System

(AHCCCS pronounced "ACCESS")

AHCCCS F e a t u r e s :

The A r i z o n a s t a t e l e g i s l a t u r e s e t t h e scene f o r i t s e x p e r i e m n t a l h e a l t h - c a r e
program when i t r e f u s e d t o a c c e p t M e d i c a i d f u n d i n g f r o m t h e f e d e r a l government.
I n 1981 t h e s t a t e b u s i e d i t s e l f w i t h d e v e l o p i n g an a l t e r n a t i v e h e a l t h - c a r e
program f o r t h e i n d i g e n t t h a t would keep A r i z o n a o u t o f t h e t r o u b l e d M e d i c a i d
program b u t g e t f e d e r a l h e a l t h f u n d i n g i n t o t h e s t a t e .

The A r i z o n a H e a l t h Care Cost Containment System (AHCCCS) was b o r n i n a

s p e c i a l s e s s i o n of t h e l e g i s l a t u r e i n November 1981, a f t e r 10 y e a r s o f debate
o v e r c r e a t i n g a s t a t e h e a l t h - c a r e program. A r i z o n a l e g i s l a t o r s c o n g r a t u l a t e d
themselves -- t h e i r p l a n would i n c l u d e f e d e r a l money f o r t h e i r s t a t e w i t h
supposedly fewer s t r i n g s a t t a c h e d t h a n t h e M e d i c a i d program a t work i n t h e o t h e r
49 s t a t e s .

AHCCCS i s a t h r e e - y e a r e x p e r i m e n t f o r t h e s t a t e ' s 220,000 i n d i g e n t s . Under

t h i s program, h o s p i t a l s , p h y s i c i a n s and o t h e r m e d i c a l - c a r e s u p p l i e r s t r e a t
p a t i e n t s on a p r e p a i d b a s i s . The p r o v i d e r s o f f e r b i d s t o t h e s t a t e t o t r e a t a
c e r t a i n number o f p a t i e n t s f o r a f i x e d amount o f money each y e a r . B i d s a r e based
on what i n d i v i d u a l p r o v i d e r s have determined a r e average f e e s f o r v a r i o u s
services.

Administration:

A r i z o n a H e a l t h Care Containment System (AHCCCS), A r i z o n a Department of

Health Services. Administrator: MCAUTO Systems.

General I n f o r m a t i o n :

The A r i z o n a H e a l t h Care Cost Containment System (AHCCCS) was developed i n

Senate B i l l 1001 w h i c h was passed b y t h e L e g i s l a t u r e and s i g n e d b y t h e Governor
i n November, 1981. I t c o n t a i n s s i x m a j o r mechanisms f o r r e s t r a i n i n g h e a l t h c a r e
c o s t s w h i l e , a t t h e same time, e n s u r i n g t h a t a p p r o p r i a t e l e v e l s of q u a l i t y h e a l t h
c a r e s e r v i c e s a r e p r o v i d e d t o e l i g i b l e persons i n a d i g n i f i e d f a s h i o n . The g o a l
o f t h e s e s i x items i s t o c o n t r i b u t e t o t h e e s t a b l i s h m e n t of a h e a l t h c a r e
f i n a n c i n g system t h a t i s l e s s e x p e n s i v e t h a n c o n v e n t i o n a l f e e - f o r - s e r v i c e
systems. The s i x mechanisms are:

o P r i m a r y Care P h y s i c i a n s A c t i n g as Gatekeepers
o Prepaid Capitated Financing
o C o m p e t i t i v e B i d d i n g Process
o Cost S h a r i n g
o L i m i t a t i o n s on Freedom-of-Choice
o C a p i t a t i o n o f t h e S t a t e b y t h e F e d e r a l Government

P r i v a t e P r a c t i c e E d i t o r i a l , June 1983.
N PC Arizona - 2
1983

P r i m a r y Care P h y s i c i a n s A c t i n g a s Gatekeepers:

The AHCCCS l e g i s l a t i o n p r o v i d e s t h a t a l l membe r s mu1st be under t h e c a r e and

supervision c a r e p h y s i' c i a n who w i l l assume t h e r o l e of case
manager. A s t a t e w i d e network o f p r i m a r y c a r e p h y s i c i a n s , a c t i n g a s case
managers, w i l l t h e r e b y be e s t a b l i s h e d t o p e r f o r m a g a t e k e e p i n g f u n c t i o n f o r t h e
system. Because a l l c a r e must be approved by t h e p r i m a r y c a r e p h y s i c i a n s , t h e
p r i m a r y c a r e network w i l l e l i m i n a t e s e l f - r e f e r r a l s t o s p e c i a l i s t s and d i m i n i s h
e x c e s s i v e u s e o f emergency rooms--both o f w h i c h have c o n t r i b u t e d s u b s t a n t i a l l y t o
h i g h medical c o s t s .

Prepaid Capitated Financing:

I t i s t h e i n t e n t of t h e AHCCCS l e g i s l a t i o n t h a t p r o v i d e r s o f f e r a l l
necessary s e r v i c e s t o groups o f members f o r a f i x e d p r i c e , f o r a d e f i n i t e p e r i o d
o f time. The law a l l o w s f o r t h e c r e a t i o n o f c o n s o r t i a t o f a c i l i t a t e t h e
e s t a b l i s h m e n t o f a s t a t e w i d e b i d d i n g process. I t i s expected t h a t s e r v i c e s w i l l
be p r o v i d e d on a c o u n t y - b y - c o u n t y b a s i s , and b i d s w i l l be encouraged t o e f f e c t
that goal. I t w i l l n o t be necessary, however, f o r a s i n g l e b i d d e r t o b i d f o r a l l
s e r v i c e s t o b e d e l i v e r e d i n a g i v e n county. P r o v i d e r s may b i d on a p r e p a i d
c a p i t a t e d b a s i s f o r o n l y those services they normally provide. F o r example, a
group o f p h y s i c i a n s may choose t o b i d o n l y f o r p h y s i c i a n s e r v i c e s f o r a
p a r t i c u l a r a r e a ; h o s p i t a l s may do t h e same; and so on. The l a w a l l o w s f o r
expansion and c o n t r a c t i o n o f b i d s t o a c h i e v e t h e b e s t p o s s i b l e system. In the
e v e n t t h e r e a r e i n s u f f i c i e n t b i d s f o r a g i v e n area, t h e l e g i s l a t i o n p e r m i t s
capped f e e - f o r - s e r v i c e arrangements. I t i s i n t e n d e d , however, t h a t capped f e e -
f o r - s e r v i c e w i l l be a u t h o r i z e d as a l a s t r e s o r t o n l y .

I n essence, AHCCCS p r o v i d e r s w i l l r e p r e s e n t forms of p r e p a i d h e a l t h p l a n s

(PHPs), h e a l t h maintenance o r g a n i z a t i o n s (HMOs), and o t h e r t y p e s o f o r g a n i z e d
h e a l t h d e l i v e r y systems. As such, t h e y w i l l c h a r g e a f i x e d f e e p e r i n d i v i d u a l
e n r o l l e d (i.e., a c a p i t a t i o n r a t e ) and assume r e s p o n s i b i l i t y f o r p r o v i d i n g a
b r o a d a r r a y of h e a l t h c a r e s e r v i c e s t o members.

C o m p e t i t i v e B i d d i n g Process:

The s t a t e w i d e c o m p e t i t i v e a s p e c t o f t h e b i d p r o c e s s f o r s e l e c t i n g p r o v i d e r s
who w i l l be o f f e r i n g t h e p r e p a i d c a p i t a t e d s e r v i c e s i s t h e most u n i q u e f e a t u r e o f
t h e AHCCCS model. A p r o v i d e r c o m p e t i t i o n o f t h i s magnitude has n e v e r been
a t t e m p t e d i n any o t h e r s t a t e . A r i z o n a DHS b e l i e v e s t h a t c o m p e t i t i v e b i d d i n g f o r
h e a l t h c a r e s e r v i c e c o n t r a c t s , as opposed t o c o n v e n t i o n a l n e g o t i a t i o n processes,
w i l l p r o v i d e accessable c o s t - e f f e c t i v e d e l i v e r y o f h e a l t h c a r e w i t h o u t
s a c r i f i c i n g q u a l i t y performance.

The Department of H e a l t h S e r v i c e s w i l l i s s u e an i n v i t a t i o n t o q u a l i f i e d
p r o v i d e r s o f h e a l t h s e r v i c e s , a t l e a s t on a b i e n n i a l b a s i s , t o b i d t o p r o v i d e
s e r v i c e s t o AHCCCS members i n each county. Q u a l i f i e d p r o v i d e r s may b i d t o o f f e r
t h e f u l l range of AHCCCS s e r v i c e s , o r any a l l o w a b l e p a r t i a l g r o u p i n g of s e r v i c e s ,
i n one o r more c o u n t i e s .
NPC Arizona - 3
1983

Cost S h a r i n g :

The f o u r t h m a j o r d e v i c e f o r c o n t a i n i n g c o s t s i n t h e AHCCCS model i s a

p r o v i s i o n f o r c o s t s h a r i n g by members. A s t a t e w i d e co-payment s c h e d u l e w i l l b e
developed f o r t h i s purpose; and t h e m e d i c a l l y needy w i l l p a r t i c i p a t e i n
coinsurance c o s t sharing. I t i s e x p e c t e d t h a t t h e i m p o s i t i o n o f nominal c o -
payments w i l l ensure o p t i m a l e f f e c t i v e n e s s i n t h e a r e a o f s e r v i c e u t i l i z a t i o n .
The Department w i l l d e s i g n a co-payment s c h e d u l e t h a t accomplishes t h r e e
objectives: c u r t a i l m e n t o f o v e r - u t i l i z a t i o n ; enhancement of p a t i e n t d i g n i t y ; and
s e r v i c e u t i l i z a t i o n by members f o r t r u l y needed h e a l t h c a r e .

L i m i t a t i o n s of Freedom-of-Choice:

The f i f t h m a j o r i t e m f o r c o n t a i n i n g c o s t s i s a r e s t r i c t i o n on
p r o v i d e r / p h y s i c i a n s e l e c t i o n by AHCCCS members. Unlike conventional d e l i v e r y
models, A r i z o n a w i l l n o t r e l y on f e e - f o r - s e r v i c e arrangements. The goal i s t o
have t h e s t a t e c o m p l e t e l y b l a n k e t e d w i t h p r e p a i d c a p i t a t e d arrangements. Members
w i l l be l i n k e d t o s e l e c t e d o r a s s i g n e d p l a n s f o r d e f i n i t e d u r a t i o n s of t i m e .
Freedom-of-choice w i l l be p e r m i t t e d t o t h e e x t e n t p r a c t i c a b l e f o r members t o
s e l e c t t h e p a r t i c u l a r group w i t h w h i c h t o e n r o l l , as w e l l as t h e p r i m a r y c a r e
p h y s i c i a n w i t h i n t h e s e l e c t e d group. Capped f e e - f o r - s e r v i c e h e a l t h s e r v i c e
c o n t r a c t s w i l l be used as a l a s t r e s o r t , and o n l y i n areas n o t c o v e r e d b y p r e p a i d
c a p i t a t e d plans.

C a p i t a t i o n o f t h e S t a t e b y t h e F e d e r a l Government:

The S t a t e o f A r i z o n a w i l l i t s e l f be c a p i t a t e d by t h e F e d e r a l Government and

t h e r e f o r e w i l l be a t f i n a n c i a l r i s k f o r c o n t a i n i n g h e a l t h c a r e c o s t s . Capitation
r a t e s w i l l be e s t a b l i s h e d a c c o r d i n g t o sound a c t u a r i a l p r i n c i p l e s , and w i l l
r e p r e s e n t no more t h a n 95 p e r c e n t o f t h e e s t i m a t e d c o s t of s e r v i c e s c u r r e n t l y
d e l i v e r e d i n A r i z o n a under c o n v e n t i o n a l f e e - f o r - s e r v i c e arrangements. Capitation
o f t h e s t a t e w i l l p r o v i d e a key i n c e n t i v e f o r t h e s t a t e t o m o n i t o r h e a l t h c a r e
c o s t s on a c a r e f u l and c o n t i n u o u s b a s i s .

IMPLEMENTATION OF AHCCCS

AHCCCS i s based on i d e a s t h a t have been t e s t e d , i n p a r t , on s m a l l e r s c a l e s

i n d i f f e r e n t areas of t h e c o u n t r y . By combining a number of k e y mechanisms on a
s t a t e w i d e b a s i s , AHCCCS r e p r e s e n t s a novel h e a l t h c a r e model. The p u r p o s e of
t h i s s e c t i o n i s t o p r e s e n t a d i s c u s s i o n o f how t h e key c o n c e p t s embodied i n t h e
AHCCCS l e g i s l a t i o n w i l l be implemented and r e n d e r e d o p e r a t i o n a l .

Provider P a r t i c i p a t i o n :

P r o v i d e r s may p a r t i c i p a t e i n AHCCCS i n t h r e e d i f f e r e n t ways. F i r s t , they

may e n t e r t h e c o m p e t i t i v e b i d d i n g p r o c e s s w i t h p r e p a i d c a p i t a t e d p l a n s a s e i t h e r
f u l l or p a r t i a l benefit providers.
 Arizona - 4
1983

The second mode of p a r t i c i p a t i o n i s on a capped f e e - f o r - s e r v i c e b a s i s .

Here, p r o v i d e r s agree t o a c c e p t capped fee payments as payments i n f u l l . Capped
f e e - f o r - s e r v i c e arrangements w i l l be a u t h o r i z e d as a l a s t r e s o r t o n l y and when
t h e r e a r e i n s u f f i c i e n t b i d s f o r a g i v e n area.

F i n a l l y , t h e t h i r d means o f p a r t i c i p a t i o n concerns t h e p r o v i s i o n o f
emergency m e d i c a l s e r v i c e s b y non-AHCCCS p r o v i d e r s . No formal c o n t r a c t i s
r e q u i r e d f o r t h i s mode of p a r t i c i p a t i o n , and reimbursement w i l l be a l l o w e d a l m o s t
e x c l u s i v e l y f o r emergency s e r v i c e s .

F u n c t i o n s o f t h e AHCCCS A d m i n i s t r a t o r :

The AHCCCS c o n t r a c t A d m i n i s t r a t o r w i l l c o n t r a c t w i t h f u l l b e n e f i t c a p i t a t e d
p r o v i d e r s t o s e r v e AHCCCS members; and c r e a t e a number of o r g a n i z e d h e a l t h
systems t h r o u g h a network o f c o n t r a c t s w i t h p r o v i d e r s , as n e c e s s a r y t o complement
t h e c a p i t a t e d system.

Contracting Health Plans

Under t h e C o n t r a c t i n g H e a l t h P l a n arrangement, p l a n s a r e d e f i n e d i n t e r m s o f
e x p l i c i t groups of p r o v i d e r s o r g a n i z e d i n t o c o n s o r t i a o r more f o r m a l e n t i t i e s .
These c o n s o r t i a , o r more f o r m a l e n t i t i e s , a r e c a p a b l e o f p r o v i d i n g t h e f u l l r a n g e
of AHCCCS b e n e f i t s w i t h i n a d e f i n e d s e r v i c e a r e a f o r a l l AHCCCS members who e l e c t
t o j o i n t h e p l a n s , up t o a p r e d e t e r m i n e d c a p a c i t y . T h i s i s e x p e c t e d t o be t h e
dominant mode o f o p e r a t i o n w i t h i n AHCCCS--with two o r more c o m p e t i n g p l a n s
wherever p o s s i b l e .

The C o n t r a c t i n g H e a l t h P l a n s a r e d e l i v e r y systems, n o t s i m p l y i n s u r a n c e
p l a n s , b u t t h e y need n o t be H e a l t h Maintenance O r g a n i z a t i o n s b y any l e g a l o r
c o n v e n t i o n a l d e f i n i t i o n o f t h e term. The AHCCCS l e g i s l a t i o n p r o v i d e s f o r t h e
c r e a t i o n o f p r o v i d e r c o n s o r t i a f o r t h e purpose o f p a r t i c i p a t i o n i n t h e program.
The C o n t r a c t i n g H e a l t h P l a n may be a l o o s e l y o r g a n i z e d system, b u t i t must be
c a p a b l e of p r o v i d i n g t h e f u l l range of AHCCCS b e b e f i t s t o a d e f i n e d p o p u l a t i o n a t
a c a p i t a t i o n rate.

A d m i n i s t r a t o r Organized H e a l t h Systems

The A d m i n i s t r a t o r O r g a n i z e d H e a l t h Systems s e r v e as back-up t o t h e f u l l

b e n e f i t c a p i t a t e d p l a n s , a s s u r i n g t h a t t h e r e a r e no s e r v i c e a r e a gaps i n t h e
s t a t e and t h a t t h e r e i s a t l e a s t one a l t e r n a t i v e c h o i c e i n t h o s e a r e a s c o v e r e d b y
a C o n t r a c t i n g H e a l t h Plan.

The A d m i n i s t r a t o r O r g a n i z e d P l a n s must:

o Be p r e p a r e d t o f u n c t i o n as t h e r o u t i n e h e a l t h c a r e d e l i v e r y systems i n
any a r e a o f t h e S t a t e n o t a d e q u a t e l y c o v e r e d b y C o n t r a c t i n g H e a l t h
Plans.

o Serve as t h e mechanism f o r a s s u r i n g emergency and u r g e n t c a r e f o r t h e

"emergent members" o f AHCCCS.
 Arizona - 5
1983

o S e r v e as back-up systems i n t h e e v e n t o f a f a i l u r e of a C o n t r a c t i n g
H e a l t h Plan, o r a s t a t e d e c i s i o n t o terminate a c o n t r a c t .

o O p e r a t e w i t h i n a f i x e d budget, r e g a r d l e s s o f t h e number o f members

enrolled. The C o n t r a c t i n g H e a l t h P l a n s w i l l draw funds o u t of t h e
t o t a l AHCCCS budget i n d i r e c t p r o p o r t i o n t o t h e number o f AHCCCS
members they serve, l e a v i n g t h e A d m i n i s t r a t o r Organized H e a l t h Systems
w i t h a r e s i d u a l budget.

The O r g a n i z a t i o n a l R o l e of t h e A r i z o n a Department of H e a l t h S e r v i c e s :

The Department o f H e a l t h S e r v i c e s has been charged w i t h t h e g e n e r a l

i m p l e m e n t a t i o n and m o n i t o r i n g of t h e AHCCCS program. A D i v i s i o n has been c r e a t e d
w i t h i n t h e Department ( A r i z o n a H e a l t h Care Cost Containment System D i v i s i o n ) t o
f u l f i l l that responsibility.

I t w i l l be t h e t a s k of t h e Department to: d e v e l o p t h e R u l e s and

R e g u l a t i o n s ; c o n d u c t t h e A d m i n i s t r a t o r b i d d i n g process, and p r o v i d e r b i d d i n g
processes i n c o n j u n c t i o n w i t h t h e A d m i n i s t r a t o r ; award t h e c o n t r a c t s ; p r o v i d e
t e c h n i c a l a s s i s t a n c e t o p r o v i d e r s f o r t h e purpose o f f o r m i n g c o n s o r t i a t o
c o n t r a c t w i t h AHCCCS; and m o n i t o r t h e o v e r a l l o p e r a t i o n o f t h e program.

I t i s t h e Department's o b l i g a t i o n t o c o n t r a c t w i t h a p r i v a t e A d m i n i s t r a t o r
who w i l l assume r e s p o n s i b i l i t y f o r t h e day-to-day o p e r a t i o n of t h e program. As
t h e c a p a c i t y o f t h e A d m i n i s t r a t o r t o d e f i n e and o p e r a t e t h e program i n c r e a s e s ,
t h e r o l e o f t h e D i v i s i o n w i l l become one of g e n e r a l s u p e r v i s i o n , e v a l u a t i o n , and
guidance o f t h e e n t i r e program.

The O p e r a t i o n a l R o l e o f t h e AHCCCS A d m i n i s t r a t o r :

O r g a n i z a t i o n a l l y , t h e A d m i n i s t r a t o r w i l l assume r e s p o n s i b i l i t y f o r t h e e v e r y
day o p e r a t i o n s o f t h e program, s u b j e c t t o t h e g e n e r a l s u p e r v i s i o n o f t h e
Department.

The AHCCCS A d m i n i s t r a t o r w i l l have o v e r a l l r e s p o n s i b i l i t y f o r t h e f o l l o w i n g

a c t i v i t y areas:

o P r o m o t i o n of AHCCCS
o Procurement of C o n t r a c t P r o v i d e r s
o P r o v i d e r Management
o P r o v i d e r , Member, and P u b l i c R e l a t i o n s
o Program Operat i o n s

AHCCCS became e f f e c t i v e December 1, 1981 and e x p i r e s September 30, 1985.

S e r v i c e s comnenced October 1, 1982. F u n d i n g f o r f i r s t y e a r o p e r a t i o n s t a t e d t o
be $105.4 m i l l i o n . Services include: I n p a t i e n t , o u t p a t i e n t , laboratory, x-ray,
p r e s c r i p t i o n drugs, m e d i c a l s u p p l i e s , p r o s t h e t i c d e v i c e s , emergency d e n t a l c a r e
i n c l u d i n g e x t r a c t i o n s and d e n t u r e s , t r e a t m e n t of eye c o n d i t i o n s and EPSDT.
NPC Arizona - 6
1983

Official, C o n s u l t a n t s and Committees

1. H e a l t h S e r v i c e s Department O f f i c i a l s :

Donald B. M a t h i s A r i z o n a H e a l t h Care Cost Containment

O i rector System
1200 W. Washington, Room 224
Phoenix, A r i z o n a 85007

AHCCS A d m i n i s t r a t o r
MCAUTO Systems
124 West Thomas
Phoenix, A r i z o n a 85005
602/234-3655

2. E x e c u t i v e O f f i c e r s of S t a t e M e d i c a l and P h a r m a c e u t i c a l Sac i e t i e s :

A. Medical A s s o c i a t i o n :

Bruce E. Robinson
Executive D i r e c t o r
Arizona Medical Association, Inc.
810 West Bethany Home Road
Phoenix 85013
Phone: 602/263-8900

B. Pharmaceutical A s s o c i a t i o n :

Warren J. E l l ison, R.Ph.

Executive D i r e c t o r
A r i z o n a Pharmaceutical A s s o c i a t i o n
2202 N o r t h 7 S t r e e t
Phoenix 85006
Phone: 602/258-8121

C. Osteopathic Association:

M r . S. N. Schul t z
Executive O i r e c t o r
Arizona Osteopathic Medical A s s o c i a t i o n
5057 E. Thomas Road
Phoenix 85018
602/840-0460
NPC Arkansas - 1
1983
ARKANSAS

K D I C M ASSISTANCE DRUG PROGRAM (TITLE X I X )

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*

OAA AB APTD AFDC OAA A6 APTD AFDC C h i l d r e w 2 1 (SFO)
Prescribed
Drugs X X X X X X X X X
lnpat ient
H o s p i t a l Care X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X
Laboratorv &
X-ray S e r v i c e X X X X X X X X X
S k i l l e d Nursina d

Home S e r v i c e s X X X X X X X X X
Physician
Services X X X X X X X X X
D......
ental
Services X X X X X X X X X
*SF0 - S t a t e Funds Only

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982
1981 1982
~ x ~ e n d e dR- e c i p i e n t ~xpended- Recipient

TOTAL ............................... $23,165,227 171,781++ $21,084,674 151,711**

CATEGORICALLY NEEDY CASH TOTAL...... $18,250,280 142,088 $16,415,811 125,344
Aged ................................ 8,483,198 40,840 7,558,444 37,671
Blind ............................... 236,955 1,288 219,279 1,253
Disabled.. .......................... 6,679,520 31,031 6,525,993 30,416
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 1,138,285 43,856 804,279 34,710
.....
A d u l t s - F a m i l i e s w/Dep C h i l d r e n 1,712,322 25,100 1,307,816 21,316
CATEGORICALLY NEEDY NON-CASH TOTAL..
Aged ................................
Blind........ .......................
Disabled..... .......................
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n ...
A d u l t s - F a m i l i e s w/Dep Children.....
O t h e r T i t l e XIX R e c i p i e n t s ..........
MEDICALLY NEEDY TOTAL ...............
Aged ................................
Blind...............................
Disabled.. ..........................
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . .
A d u l t s - F a m i l i e s w/Dep Children.....
Other T i t l e X I X R e c i p i e n t s ..........
**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082
80
 Arkansas - 2
1983

I l l . Administration:
By t h e Division of Social Services, of the Department of Human Services.
T h e Prescription Drug Program was implemented September 1 , 1973.

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. solutions, amphetamines, anti-obesity
agents, irrigating solutions, vaccines, and routine immunizing agents.

0-T-Cs: Pursuant to a prescription t h e followinq OTC items a r e

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 HCl, pediatric vitamin drops for children up t o three years o f
age, laxatives and stool softners, nicotinic acid and schedule V
narcotics. All other non-legend items are excluded.

8. Formulary: None

C. Prescribing or Dispensing Limitations:

1. Quantity of Medication: 3 0 day supply.

2. Refills: 5 refills within 6 months are allowed, if authorized by

prescriber.

3. Dollar Limits: None

D. Prescription Charge Formula:

Legend drugs - estimated acquisition cost plus $3.58 professional fee.

Total charge may not exceed provider's prevailing charge t o the self-
paying public, or any other third-party prescription drug program.

V. Miscellaneous Remarks:

T h e Arkansas MAC program exists for 3 multi-source drugs.

Average prescription price during FY 1982 (ingredient and fee) $10.06.

Fiscal intermediary:

Blue Cross-Blue Shield

7th and Gaines
Little Rock, Arkansas 72205
 Arkansas - 3
1983

Officials, Consultants and Committees

1. Social Services Officials:

Mrs. Dorothy K. Rappeport Arkansas Dept. o f Human Services

Commissioner Division o f Social Services
P. 0. Box 1437
Little Rock, Arkansas 72203

Mauda Russell, Director

Office of Management Services

Sam Lamey, Director

Office of Financial Management

Kenny Whitlock, Director

Office of Program Operations

W. M. Mooney, Jr., Director

Office of Medical Services

Jim Barnhil I , Director

Office of Long Term Care

Ivan H. Smith, Director

Office of Legal Services

Tom Bradshaw, Administrator

Medical Assistance Section

Mark Crossley, P.D.

Pharmacy Consultant
501/371-2091

2. Social Services Consultants:

Physicians (Part-time):

W. H. O'Neal, M.D. Baptist Medical Center

Medical Education
Department
9600 West 12th
Little Rock 72205

Roy A. Brinkley, M.D. Baptist Medical Center

9600 West 12th
Little Rock 72205

Robert E. Richardson, M.D. 500 South University

Little Rock 72205
 Arkansas - 4
1983

3. M e d i c a l Care A d v i s o r y Committee

Asa Crow M o r r i s s Henry

P u r c e l l Smith W a l t e r O'Neal
Jack Burge H. E l v i n S h u f f i e l d
C.C. Long

4. E x e c u t i v e O f f i c e r s of S t a t e Medical and P h a r m a c e u t i c a l
Societies:

A. Medical S o c i e t y :

C. C . Long, M.D.
Executive Vice-president
Arkansas Medical S o c i e t y
P. 0. Box 1208
F o r t S m i t h 72902
Phone: 5011782-8218

B. Pharmaceutical Association:

C h a r l e s West, P.O.
Executive Vice President
Arkansas P h a r m a c i s t s A s s o c i a t i o n
818 Garland Avenue
L i t t l e Rock 72201
Phone: 501/372-5250

C. Osteopathic Association:

Steven W. W r i g h t , D.O.
Secretary
Arkansas A s s o c i a t i o n o f O s t e o p a t h i c P h y s i c i a n s
and Surgeons
Route 2, Box 257
F a i r f i e l d Bay 72088
NPC California - 1
1983

CALIFORNIA

MEDICAL ASSISTANCE DRUG PROGRAn (TITLE X I X )

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Adults

(SSI/SSP) OAA AB APTD AFDC OAA AB APTD AFDC Chi ldrenC21 (SFO)*
Prescribed
Drugs X X X X X X X X X X
l npat i e n t
H o s p i t a l Care X X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X X
Laboratory &
X-ray S e r v i c e X X X X X X X X X X
S k i l l e d Nursina -
Home S e r v i c e s X X X X X X X X X X
Physician
Services X X X X X X X X X X
Dental
Services X X X X X X X X X X
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

June 30, 1982
1981 1982
Expended Recipient Expended Recipient

TOTAL.. ...........................$207,50,6 2,363,220** $231,589,629 2,397,000**

CATEGORICALLY NEEDY CASH TOTAL ....$166,664,193 1,865,180

Aged .............................. 43,508,753
B l i n d . . . .......................... 3,014,462
Disabled... ....................... 73,777,225
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . 20,784,730
..
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . 25,579,023

CAT. NEEDY NON-CASH TOTAL..... .... $170,126

Aged .............................. 4,869
B l i n d . ............................ 0
Disabled... ....................... 358
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . 81,738
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . . 83,161
........
Other T i t l e X I X R e c i p i e n t s 0

MEDICALLY NEEDY TOTAL.. ........... $40,756,376

Aged .............................. 21,277,431
B l i n d . . . .......................... 202,124
D i s a b l e d . . ........................ 10,188,217
C h i l d r e n -Famil i e s w/Dep C h i l d r e n . 2,483,878
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . . 3,860,721
Other T i t l e X I X R e c i p i e n t s ........ 2,744,005

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

84
 California - 2
1983
I l l . Administration:
By the Health and Welfare Agency with direct supervision by the
Department of Health Services. Payment of bills by the state is
processed through a fiscal intermediary, Computer Sciences Corporation.
Under the general direction of the Department of Health Services' Health
Care Policy and Standards Division, the Pharmaceutical Services Unit of
the Benefits Branch monitors the full scope and quality of pharmaceutical
benefits covered under the provisions of the California Medical
Assistance Program. This Unit, additionally, has the prime
responsibility for both the evaluation and formulation of
Utilization/Cost Controls and the development, implementation, and
interpretation of policies and regulations concerning the full scope of
pharmaceutical benefits.

IV. Provisions Relating to Prescribed Drugs:

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

Multivitamins for persons over five years of age; most OTC household
remedies; non-legend and non-narcotic analgesics except aspirin and
acetaminophen. CNS stimulants, i.e., amphetamines and
methylphenidate, are generally 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 lumbo-sacral autonomic nervous system
pathways related to bowel motility). Diazepam restricted to use in
cerebral palsy, athetoid states, and spinal cord degeneration (other
clinical conditions require prior authorization). 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.
Availability of sedative/hypnotics, dermatologics and non-steroidal
antiinflammatory agents is restricted to prior authorization by a
Medi-Cal consultant. Exceptions are phenobarbital for the treatment
of convulsive disorders and gamma benzene hexachloride. The
following items are excluded from coverage: quinine, anticholinergic
agents except atropine, or belladonna with or without phenobarbital;
antipruritics; narcotic analgesics except those requiring triplicate
prescription, and those containing grain combined with aspirin or
acetaminophen; antihistamines alone or in combination, cough
preparations and nasal decongestants except when authorized by a
consultant for patients in intermediate care or skilled nursing
facilities; and ophtalmic decongentants used for the symptomatic
relief of minor eye irritations. Diuretics other than certain
carbonic anhydrase inhibitors, potassium sparing types, loop-types
and hydrochlorothiazide which are listed on the Formulary, require
prior authorization.
 California - 3
1983
B. Formulary: A semi-restrictive formulary system is used. Over 350
drugs (approximately 1,000 separate codes for differing strengths and
dosage forms) listed generically in formulary. Many brand names
listed alphabetically as cross-index references. The patient's
physician or pharmacist may request authorization from the local
Medi-Cal Consultant for approval of unlisted drugs or for listed
drugs which are restricted to specific use(s).

Medi-Cal Drug Formulary may be obtained by ordering the Pharmacy

Provider Manual from:

Computer Sciences Corporation

P.O. BOX 15000
Sacramento, CA 95813
Attn: Distribution
(Please remit $3.25 per manual, including updates, by check or money
order payable to "State of Cal iforni a")

For Formulary Information contact:

M. Kuschnereit, Pharmacist
714 P Street, #I640
Sacramento, CA 95814
916/324-2477
C. Prescribing or Dispensing Limitations:

1. Quantity of Medication: This is flexible, but quantities should

be consistent with the medical needs of the patient and may not
exceed a 100-day supply except under certain circumstances. Many
high volume and/or chronically used oral dosage forms of drugs
are subject to minimum or maximum quantity limitations/or maximum
frequency of billing controls.

2. Refills: A prescription refill can be dispensed after

authorization by prescriber. Exception is allowed for refill of
a reasonable quantity when prescriber is unavailable (pursuant to
California law). Fee is prorated so that total fee (for
authorized partial quantity and balance of the prescription after
prescriber is contacted) does not exceed fee for same
prescription when refilled as routine service.

3. Number of prescriptions: Number of formulary drugs not limited

but overutilization limited by prepayment and postpayment
controls. These controls include those mentioned in item 1
supported by onsite audit of provider files.

4. Prior Authorization: Approval may be obtained from a Medi-Cal

consultant for covered non-formuiary items or services (including
special circumstance override of MAC type price ceilings or
minimum quantity/frequency of billing limitations). Statewide
NPC California - 4
1983

m a i l and t o l l f r e e t e l e p h o n e r e q u e s t s a r e a c c e p t e d i n t h e San
F r a n c i s c o and Los Angeles Medi-Cal F i e l d O f f i c e s . Requests must
i n c l u d e adequate i n f o r m a t i o n and j u s t i f i c a t i o n . Authorization
may o n l y be g r a n t e d f o r t h e l o w e s t c o s t i t e m o r s e r v i c e t h a t
meets t h e p a t i e n t ' s m e d i c a l needs.

5. Pharmacist, t o t h e e x t e n t p e r m i t t e d by law, i s r e q u i r e d t o
dispense l o w e s t c o s t b r a n d o f a m u l t i p l e s o u r c e i t e m i n s t o c k
m e e t i n g m e d i c a l needs o f t h e p a t i e n t .

6. Beneficiary Prior Authorization: The Department o f H e a l t h

S e r v i c e s r e s t r i c t s , t h r o u g h t h e r e q u i r e m e n t s of p r i o r
a u t h o r i z a t i o n , t h e a v a i l a b i l i t y o f designated p r e s c r i p t i o n drugs
t o c e r t a i n b e n e f i c i a r i e s found by t h e Department t o be a b u s i n g
those b e n e f i t s .

D. P r e s c r i p t i o n Charge Formula: Reimbursement i s based on t h e l o w e s t

of:

1. E s t i m a t e d A c q u i s i t i o n Cost ( E A C ) p l u s $3.60 p r o f e s s i o n a 1 fee.

2. F e d e r a l Maximum A1 l o w b l e c o s t (MAC) p l u s $3.60 p r o f e s s i o n a l fee.

3. S t a t e Maximum A l l o w a b l e I n g r e d i e n t Cost (MAIC) p l u s $3.60

p r o f e s s i o n a l fee.

4. Pharmacy's u s u a l p r i c e t o g e n e r a l p u b l i c .

V. M i s c e l l a n e o u s Remarks:

M e d i c a l T h e r a p e u t i c s and Drug A d v i s o r y C o m n i t t e e

R e a c t i n g t o t h e l e a d r e s p o n s i b i l i t y of t h e P h a r m a c e u t i c a l Standards U n i t
i n t h e B e n e f i t s Branch, t h e Medical T h e r a p e u t i c s and Drug A d v i s o r y
C o n m i t t e e compares t h e c o s t , e f f i c a c y , misuse p o t e n t i a l , e s s e n t i a l need,
and s a f e t y o f drugs and makes recommendations as t o a d d i t i o n s t o o r
d e l e t i o n s from the formulary.

H o s p i t a l Discharge Medications

1. The q u a n t i t i e s f u r n i s h e d as d i s c h a r g e m e d i c a t i o n s a r e l i m i t e d t o n o t
more t h a n a 10-day s u p p l y .

2. The charges a r e i n c o r p o r a t e d i n t h e h o s p i t a l ' s c l a i m s f o r inpatient

services.
 California - 5
1983

Cancer and DESl Drugs

Any d r u g approved by FDA f o r t h e t r e a t m e n t of cancer i s a v a i l a b l e t h r o u g h

t h e Formulary. Host D E S l drugs r a t e d l e s s - t h a n - e f f e c t i v e by FDA a r e n o t .

Maximum A l l o w a b l e I n g r e d i e n t Cost Program

S t a t e MACs a r e e s t a b l i s h e d on over 150 m u l t i s o u r c e i t e m s . List is

p e r i o d i c a l l y r e v i s e d and p r i c e l i m i t s changed t o r e f l e c t c u r r e n t m a r k e t
conditions.

Numbered Rx Claims Processed i n FY 1982

( A p p r o x i m a t l y ) 28 m i l l i o n .

Average Rx P r i c e FY 1982 ( I n g r e d i e n t Cost P l u s Fee)

( A p p r o x i m t e l y ) $9.56
 California - 6
1983

Officials, C o n s u l t a n t s and Comnittees

1. H e a l t h and Welfare Agency

A. H e a l t h and W e l f a r e Agency O f f i c i a l s :

D a v i d Swoap C a l i f o r n i a H e a l t h and
Secretary W e l f a r e Agency
1600 9 t h S t r e e t
S u i t e 460
Sacramento, C a l i f o r n i a
958 14

0. Department of H e a l t h S e r v i c e s :

P e t e r Rank Department o f H e a l t h
Director Services
714 "P" S t r e e t
Sacramento 95814

R o b e r t Fugi na Departmentof H e a l t h S e r v i c e s
C h i e f Deputy D i r e c t o r 714 "P" S t r e e t
Sacramento 95814

Ronald K a l d o r Med i -Ca l

Deputy D i r e c t o r 714 "P" S t r e e t
Sacramento 95814

J o Ann Wray ( a c t i n g ) H e a l t h Care P o l i c y and

Deputy D i r e c t o r Standards D i v i s i o n
714 "P" S t r e e t
Sacramento 95814

D o r i s Soderberg B e n e f i t s Branch
Chief 714 "P" S t r e e t
Sacramento 95814

W i l l i a m A. W h i t e
Assistant Chief
( 9 1 6 ) 445-1995

M i l t o n K u s c h n e r e i t , Pharm.
Pharmaceutical Program C o n s u l t a n t
(916) 324-2477
NPC California - 7
1983

C. A d v i s o r y Committee t o C a l i f o r n i a Oepartment of H e a l t h
Services:

1. Medical T h e r a p e u t i c s and Drug A d v i s o r y Committee:

W i l l i a m A. W h i t e C a l i f o r n i a Oepartment o f
Coordinator Health Services
714 "P" S t r e e t
Sacramento 95814

D a v i d Fung, Pharm. 460 P o l l a s k y Avenue

A c t i n g Chairman C l o v i s 93612

0. O f f i c e r s o f Computer Sciences C o r p o r a t i o n ( t h e F i s c a l
Intermediary):

Ross Forncrook Computer Sciences Corp.

P r e s i d e n t of P.O. Box 15000
Governmental S e r v i c e s 2000 E v e r g r e e n S t r e e t
Sacramento 95813

Glenn Spaulding, Pharm.

Manager o f Pharmacy
Relations

2. E x e c u t i v e O f f i c e r s o f S t a t e M e d i c a l and P h a r m a c e u t i c a l
Associations:

Medical A s s o c i a t i o n :

W i l l W. Babb
Executive D i r e c t o r
C a l i f o r n i a Medical A s s o c i a t i o n
731 Market S t r e e t
San F r a n c i s c o 94103
Phone: 415/777-2000

Pharmaceutical Association:

Robert C. Johnson
Executive Vice President
C a l i f o r n i a Pharmacists' Association
555 C a p i t o l M a l l , S u i t e 645
Sacramento 95814
Phone: 916/444-7811

O s t e o p a t h i c P h y s i c i a n s & Surgeons o f C a l i f o r n i a :

Matthew L. Weyuker
E x e c u t i v e O i r e c t o r , OPSC
921-11th S t r e e t
S u i t e 1200
Sacramento 95814
 Colorado - 1
1983
COLORADO

mDICAL ASSISTANCE DRUG PROGRAH (TITLE X I X )

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l ly Needy (MN) Other*

OAA AB APTD AFDC OAA AB APTD AFDC Chi l d r e n < 2 1 (SFO)
Prescribed
Drugs X X X X
Inpatient
H o s p i t a l Care X X X X
Outpatient
H o s p i t a l Care X X X X
Laboratory &
X-ray S e r v i c e X X X X
S k i l l e d Nursina d

Home S e r v i c e s X X X X
Physician
Services X X X X
Dental
Services X
*SF0 - S t a t e Funds Only

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982
1981 1982
Expended Recipient Expended Recipient

TOTAL ............................... $12,128,456 97,582** $14,319,204 99,346**

C A T E G O R I C A L L Y N E E D Y C A S H T O T A L ...... $10,338,166 89,611 $12,058,644 88,302
Aged ................................ 6,153,348 26,359 7,246,312 25,841
B l i n d ............................... 16,419 128 21,976 119
Disabled.... ........................ 2,054,395 9,018 2,469,712 8,976
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 749,470 32,159 791,492 31,949
A d u l t s - F a m i l i e s w / D e p C h i l d r e n ..... 1,364,534 21,947 1,529,152 21,827
CATEGORICALLY NEEDY NON-CASH TOTAL.. $1,790,290
Aged ................................ 899,699
Blind ............................... 4,400
Disabled...... ...................... 689,498
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 20,050
A d u l t s - F a m i l i e s w/Dep Children..... 38,950
O t h e r T i t l e XIX R e c i p i e n t s .......... 137,693
MEDICALLY NEEDY TOTAL............... $0
Aged ................................ 0
Blind......... ...................... 0
Disabled...... ...................... 0
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n ... 0
A d u l t s - F a m i l i e s w/Dep C h i l d r e n ..... 0
Other T i t l e X I X R e c i p i e n t s .......... 0
**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082
91
 Colorado - 2
1983

I l l . Administration:

E l i g i b i l i t y i s determined b y 63 County Departments o f S o c i a l S e r v i c e s , and

t h e d r u g program i s a d m i n i s t e r e d b y t h e C o l o r a d o Department o f S o c i a l
Services.

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s ( d i s e a s e s , d r u g c a t e g o r i e s , e t c . ) :

R e s t r i c t e d Drug C a t e g o r i e s :

1. Dextro-Amphetami ne
2. A l l prescription-legend vitamins, including v i t a m i n
B-12 o r l i v e r e x t r a c t i n j e c t a b l e s
3. Methadone ( D o l o p h i ne)
4. P r e s c r i p t i o n - l e g e n d drugs n o t l i s t e d i n t h e
"ColoR, Drug Formulary".

Payment f o r r e s t r i c t e d drugs a u t h o r i z e d o n l y i n accordance w i t h non-

emergency o r emergency p r o c e d u r e s a s s e t f o r t h i n t h e D e p a r t m e n t ' s
Manual R e g u l a t i o n s , Volume IV, Supplement "A", S e c t i o n A-4336.53.

5. OTC i t e m s a r e n o t i n c l u d e d ; e x c e p t i o n s a r e :
i n s u l i n , a s p i r i n under c e r t a i n c o n d i t i o n s , w i t h r e f i l l l i m i t a t i o n s
as s t a t e d i n Manual R e g u l a t i o n s , Volume IV, Supplement "A", S e c t i o n
A-4336.52.

B. Formulary: ColoRv Drug F o r m u l a r y

O n l y those drugs p r e s e n t l y a s s i g n e d drug numbers i n t h e F o r m u l a r y a r e a

benefit. ( R e f e r t o Manual R e g u l a t i o n S e c t i o n A-4336.53 f o r p r o v i s i o n s
whereby drugs n o t l i s t e d i n t h e ColoRv Drug F o r m u l a r y may be a l l o w e d as
a benefit.)

C o n t r o l l e d Drug F o r m u l a r y

Section I -
A l p h a b e t i c a l drug i n d e x i n b r a n d name o r d e r ; i f no b r a n d
name assigned, t h e g e n e r i c name i s l i s t e d .

Section I I -
Generic drugs a r e i d e n t i f i e d as h a v i n g a Maximum
Allowable Price, l i s t e d w i t h p r i c e i n f o r m a t i o n which i s updated
periodically.

Section I l l -
EAC P r i c e L i s t . High volume drugs r e i m b u r s e d a t
greater than 100's s i z e o r d i r e c t manufacturer's p r i c e .
NPC Colorado - 3
1983

C. P r e s c r i b i n g or Dispensing L i m i t a t i o n s :

1. Terminology: The Department encourages a p p r o p r i a t e c o n s i d e r a t i o n o f

c o s t i n p r e s c r i b i n g and d i s p e n s i n g b y t h e s e l e c t i o n o f t h e l e s s
e x p e n s i v e t r a d e name o r g e n e r i c p r o d u c t when, i n t h e p r a c t i t i o n e r ' s
p r o f e s s i o n a l judgment, t h e use of such a p r o d u c t i s c o m p a t i b l e w i t h
the best interests o f the patient.

The ColoR, Drug F o r m u l a r y w i l l n o t be used b y c l i n i c and h o s p i t a l

pharmacies f o r drug p r i c i n g - o n l y f o r drug code number
i n f o r m a t i o n . A c q u i s i t i o n c o s t must be used f o r u n i t p r i c i n g .

2. Q u a n t i t y o f Medication: New p r e s c r i p t i o n s f o r c h r o n i c o r a c u t e
conditions, a t the d i s c r e t i o n of the physician. However, r e a s o n a b l e
amounts f o r more t h a n a 30-day s u p p l y f o r c h r o n i c c o n d i t i o n s a r e
recomnended. I n s u l i n and c o n t r a c e p t i v e d e v i c e s f o r more t h a n 90
days r e q u i r e new p r e s c r i p t i o n s . Maximum s u p p l y i s 100 days.

E x c e p t i o n s t o t h e above are:

A n t i b i o t i c m e d i c a t i o n s and drugs f o r s h o r t - t e r m i l l n e s s e s .
Narcotic prescriptions.
I n t r a v e n o u s and subcutaneous s o l u t i o n s .
Prescribed i n j e c t a b l e medications.
S h e l f package s i z e o r a l l i q u i d m e d i c a t i o n s , i n p i n t s i z e o n l y ,
o r s m a l l e r package s i z e when not packaged i n p i n t s i z e .
S h e l f package s i z e o r a l t a b l e t and c a p s u l e m e d i c a t i o n s i n
q u a n t i t i e s o f 100 o n l y o r s m a l l e r when n o t a v a i l a b l e i n package
s i z e of 100.
Analgesics (prescription-legend).
Cough s y r u p s ( p r e s c r i p t i o n - l e g e n d ) .
A l l c o l d p r e p a r a t i o n s t o include: A n t i h i s t a m i n e s and
d e c o n g e s t a n t s and/or c o l d p r e p a r a t i o n c o m b i n a t i o n s
(prescription-legend).
.
Ant i - n e o p l a s t i c s ( p r e s c r i p t i o n - l e g e n d )
Anthelmintics (prescription-legend).

P r e s c r i p t i o n s f o r l e s s t h a n minimum amounts w i l l be d e n i e d
reimbursement of t h e p r o f e s s i o n a l fee u n l e s s t h e p h y s i c i a n n o t i f i e d
t h e S t a t e Department i n w r i t i n g o f t h e m e d i c a l need f o r amounts l e s s
t h a n a 30 o r 90-days supply. Medical c o n s u l t a t i o n w i l l d e t e r m i n e
the decision.

3. Dollar Limits: None.

 Colorado - 4
1983

D. P r e s c r i p t i o n Charge Formula:

1. Community P h a r m a c i s t (based on whichever i s lower):

a. Red Book p r i c e o r EAC p r i c e o f t h e d r u g p l u s $3.40 p r o f e s s i o n a l

fee.
b. Maximum A l l o w a b l e P r i c e p l u s $3.40 p r o f e s s i o n a l f e e (See A -
4336.4 f o r i n f ormat i o n r e g a r d i n g MAP).
c. The p r i c e charged t o t h e g e n e r a l p u b l i c .

ColoR p r i c e i s d e t e r m i n e d f r o m t h e most c u r r e n t i s s u e o f t h e Red

-its Supplements t o t h e Red Book, and c u r r e n t e d i t i o n s of t h e
Drug Topics.

S i n c e t h e Red Book i s n o t c o n s i s t e n t i n p r o v i d i n g i n f o r m a t i o n f o r
a l l d r u g s , t h e o r d e r of p r i o r i t y i n d e t e r m i n i n g t h e c o s t o f t h e d r u g
a l l o w a b l e i s as f o l l o w s :

(1) Wholesale p r i c e .
(2) AWP
(3) D i r e c t p r i c e p l u s 17.6% markup ( t h e p r i c e a l l o w e d i n t h e ColoR,
i s d e t e r m i n e d by d i v i d i n g t h e m a n u f a c t u r e r ' s d i r e c t p r i c e by
.85).
For d r u g s n o t l i s t e d i n Red Book o r i t s Supplements, b u t w h i c h a r e
c o n t a i n e d i n t h e ColoR ,
t h e c o s t o f t h e d r u g a l l o w e d w i l l be
d e t e r m i n e d by u s i s m a n u f a c t u r e r ' s d i r e c t c o s t t o t h e pharmacy
and a d d i n g a 17.6% markup.

C u r r e n t MAP i s based on package s i z e o f 100 o r p i n t s i z e , o r t h e

next smaller s i z e i f not marketed i n 100's o r p i n t s . I f packaged
in:

S i z e o f Packaqe Base P r i c e

100's 100's
5 0 ' s and 5 0 0 ' s 50's
5 oz. and 16 oz 16 oz.
Only i n 2 o z . 2 02.

S p e c i a l Note:

The Maximum A l l o w a b l e P r i c e s h a l l b e d e t e r m i n e d b y t h e D i v i s i o n of
M e d i c a l A s s i s t a n c e , based upon a p r o f e s s i o n a l d e t e r m i n a t i o n of a
q u a l i t y p r o d u c t a v a i l a b l e a t t h e l e a s t expense p o s s i b l e .
Recomnendations f r o m t h e ColoRV Druq F o r m u l a r y A d v i s o r y Committee o f
t h e M e d i c a l A d v i s o r y C o u n c i l i s c o n s i d e r e d i n d e t e r m i n i n g t h e MAP.
NPC Colorado - 5
1983

2. Medical I n s t i t u t i o n P h a r m a c i s t s o r C l i n i c P h a r m a c i s t s :

A c t u a l c o s t o f t h e d r u g p l u s a p r o f e s s i o n a l f e e of $1.65. (no
payment w i l l be made i n excess o f t h e MAP s e t f o r t h i n t h e C o l oRx.)

3. Government-Owned o r Operated C l i n i c s :

A c t u a l c o s t of t h e d r u g o n l y ( n o p r o f e s s i o n a l f e e i s a l l o w e d ) . No
R
payment w i l l be made i n excess of t h e MAP s e t f o r t h i n t h e -.C o l o x.
I n c l u d e s C i t y o f Denver o p e r a t e d Neighborhood H e a l t h Centers.

4. -
Physicians:

P h y s i c i a n s must b i l l t h e c o s t o f d r u g s n o n - s e l f - a d m i n i s t e r e d on
" i n j e c t a b l e s " dispensed by them i n t h e i r o f f i c e t o t h e F i s c a l Agent
( B l u e Cross/Blue S h i e l d ) . Form MED-2 w i l l n o t be used by p h y s i c i a n s
f o r t h i s purpose.

D i s p e n s i n g p h y s i c i a n s w i l l r e c e i v e t h e a c t u a l c o s t o f t h e drug, o r
t h e l o w e s t p r i c e p r e s c r i b e d i n Manual R e g u l a t i o n A-4336.7. If t h e
p h y s i c i a n i s 25 m i l e s o r beyond f r o m a p a r t i c i p a t i n g pharmacy, t h e
p h y s i c i a n may r e q u e s t c o n s i d e r a t i o n t o r e c e i v e c o s t p l u s $1 -65 p e r
prescription. Physician-owned pharmacies t h a t have a r e g i s t e r e d
p h a r m a c i s t on d u t y w i l l r e c e i v e $3.40 p r o f e s s i o n a l fee.

V. M i s c e l l a n e o u s Remarks:

L o c k - I n Review Procedures:

The S t a t e Department r e c e i v e s computer processed p r i n t o u t s d e s i g n e d t o

d i s c o v e r o v e r u t i l i z a t i o n o f drugs p r e s c r i b e d by p h y s i c i a n s , d i s p e n s e d b y
vendors, and r e c e i v e d by e l i g i b l e r e c i p i e n t s .

A L o c k - I n Review Committee composed o f two p h y s i c i a n s , one consumer, and

t h r e e p h a r m a c i s t s meets m o n t h l y t o r e v i e w t h e p r i n t o u t s and make
recommendations t o t h e S t a t e r e g a r d i n g c o r r e c t i v e a c t i o n . I n most cases,
t h e a t t e n d i n g p h y s i c i a n i s n o t i f i e d o f t h e Committee's recomnendations.
Case-workers a r e a l s o c o n t a c t e d and i n f o r m e d o f t h e o v e r u t i l i z a t i o n r e v i e w
on abuse w i t h a r e q u e s t t o c o n t a c t t h e r e c i p i e n t and e x p l a i n l o c k - i n and
h e l p t h e r e c i p i e n t choose a p h y s i c i a n and pharmacy. R e c i p i e n t and t h e
f a m i l y a r e locked i n f o r a year. A r e v i e w o f t h e case i s t h e n made t o
determine i f t h e r e c i p i e n t and f a m i l y s h o u l d remain l o c k e d i n .

P r e s c r i p t i o n Data:

T o t a l Rxs ....... . 1,401,458

Average Rx Cost . . . . . $10.22
Fiscal lntermediary

B l u e Cross
700 Broadway
Denver, CO 80272
NPC Colorado - 6
1983

Officials, C o n s u l t a n t s and Committees

1. S o c i a l S e r v i c e s Department O f f i c i a l s :

George A. G o l d s t e i n , Ph.D. C o l o r a d o Department o f

Executive D i r e c t o r Social Services
1575 Sherman S t r e e t
Denver, C o l o r a d o 80203

Susan C h r i s t i e
Associate D i r e c t o r f o r
Operat i o n s

George E. Kawamura
A s s o c i a t e D i r e c t o r f o r Programs

R o b e r t J. Husson
O f f i c e o f Intergovernment A f f a i r s

W i l l i s H. LaVance
Associate D i r e c t o r f o r
Administration

G a r r y A. Toerber, Ph.D.
D i r e c t o r , D i v i s i o n o f Medical
Assistance

M y r l e A. Myers, R.Ph., M.S.

C h i e f , Pharmacy and Ambulatory
Care S e r v i c e s S e c t i o n
D i v i s i o n of Medical A s s i s t a n c e
303/866-5372

James C. Syner, M.D.

Medical C o n s u l t a n t
D i v i s i o n of M e d i c a l A s s i s t a n c e

M a r j o r i e Jones, A c t i n g Chief
Hospital Services Section
D i v i s i o n o f Medical A s s i s t a n c e

Donna Megeath
S u r v e i l l a n c e and U t i l i z a t i o n
Rev iew S e c t i o n

2. S o c i a l S e r v i c e s Department C o n s u l t a n t :

M a r v i n J. Lubeck, M.D. 3865 C h e r r y Creek

Ophthalmology North D r i v e
Denver 80210
NPC Colorado - 7
1983

3. M e d i c a l A d v i s o r y Committees:

A. M e d i c a l A s s i s t a n c e and S e r v i c e s A d v i s o r y C o u n c i l :

Members Representing

W a l t e r B a l l a r d , D.D.S. Dentist
1416 C o n s t i t u t i o n
Pueblo, C o l o r a d o 81001

A n i t a Basham Colorado H o s p i t a l
Poudre Val l e y H o s p i t a l Association
1024 Lemay Avenue
F o r t C o l l i n s , Colorado 80524

Stephen G i l l , D.P.M. Podiatrist

1410 South M a r i o n S t r e e t Denver F o o t C l i n i c , P.C.
Denver, C o l o r a d o 80210 3193 S. Broadway

R i c h a r d L. Haney, D.D. Optometrist

W r i t e r ' s Tower Bldg.
1660 S. A l b i o n
Denver, C o l o r a d o 80222

Roger A. Lueck, M.D. D o c t o r of M e d i c i n e

4701 South l d a l i a S t r e e t
Aurora, C o l o r a d o 80015

Helen M a d r i d Publ i c
3165 l n g a l l s S t r e e t
Wheatridge, C o l o r a d o 80214

Mary Lou Parmelee Public

586 South G a y l o r d
Denver, C o l o r a d o 80209

Donald S c h i f f , M.D. D o c t o r of M e d i c i n e
L i t t l e t o n C l i n i c P. C.
1950 W. L i t t l e t o n B l v d .
L i t t l e t o n , C o l o r a d o 80120

P h y l l i s R. S c h u l t z , R.N. Professional
5700 East C o r n e l l Avenue Nurse
Denver, C o l o r a d o 80222 (CHAIRWOMAN)

M i l e s Schuman Pharmacist
1920 H i g h S t r e e t
Denver, C o l o r a d o 80218

Bobbie Cumnings Smith N u r s i n g Homes

12120 West C a r o l i n a D r i v e
Lakewood, C o l o r a d o 80228
 Colorado - 8
1983

M e d i c a l A s s i s t a n c e and S e r v i c e s A d v i s o r y C o u n c i l
(continued):

J a n e t Washburn Public
1260 South Reed, #4
Lakewood, C o l o r a d o 80226

EX OFFlClO MEMBERS:

George A. G o l d s t e i n , Ph.0. Executive D i r e c t o r

1575 Sherman S t r e e t C o l o r a d o Department o f
Oenver, C o l o r a d o 80203 Social Services

F r a n k T r a y l o r , M.D. Executive D i r e c t o r
4210 East 1 1 t h Avenue Colorado Department of
Denver, C o l o r a d o 80220 Health

COLORADO BOARD OF SOCIAL SERVICES

LIAISON TO THE MEDICAL ADVISORY COUNCIL

F l o Mendez
1665 Grant S t r e e t
Denver, C o l o r a d o 80203

RECORDING SECRETARY

Ms. Jeane R . G a r r i s o n
20 B i r d i e Lane
L i t t l e t o n , C o l o r a d o 80123

Ms. S h e i l a Harper
5630 W. Dakota
Oenver, C o l o r a d o 80226

B. ColoRx Drug F o r m u l a r y A d v i s o r y Committee:

R i c h a r d A. Haynes, R.Ph., Duane H. Lambert, R.Ph.

Cha i rman
130 P e a r l S t r e e t , # I 8 0 5
Oenver, C o l o r a d o 80203
L i l l i a n B i r d , R.Ph.
2420 - 71st Street
Greeley, C o l o r a d o 80631
F r a n k l i n L. C o n n e l l ,
P.O. Box 189
Del Norte, C o l o r a d o
1700 V i n e S t r e e t
Denver, C o l o r a d o 80206
Roger R. Pearce, P.Ph.,
Pharmacy D i v i s i o n
K i n g Soopers
P.O. Box 5567 ( 6 5 T e j o n S t r e e t )
Denver, C o l o r a d o 80221
R.Ph.
81132
 Colorado - 9
1983

ColoRx Drug F o r m u l a r y A d v i s o r y Committee ( c o n t i n u e d ) :

Gerr i Sormani, R.Ph. R o b e r t W. Piepho, Ph.O., F.C.P.

M u s i c k Drug P r o f e s s o r and A s s o c i a t e Dean
309 East F o n t a n e r o S t r e e t D i v i s i o n o f C l i n i c a l Programs
Colorado Springs, Colorado U n i v e r s i t y o f Colorado Medical
80907 Center
4200 E a s t N i n t h S t r e e t - B o x C-238
Don Asher Denver, C o l o r a d o 80262
2770 W. 5 t h Avenue
Denver, Colorado 80204 M i l e s Schuman, R.Ph.
P r o f e s s i o n a l Pharmacy
J e r r y D. Harvey, R.Ph. 1920 H i g h S t r e e t
2201 San Juan Avenue Denver, C o l o r a d o 80218
LaJunta, Colorado 81050
Thomas P e r r y , M.D.
5440 W. 2 5 t h Avenue
Edgewater, C o l o r a d o 80214

4. E x e c u t i v e O f f i c e r s o f S t a t e Medical and P h a r m a c e u t i c a l
Societies:

A. Medical Society:

R.G. Bowman
Executive Vice-president
Colorado M e d i c a l S o c i e t y
1601 E a s t N i n e t e e n t h Avenue
Denver 8021 8
Phone: 303/534-8580

B. Pharmaceutical Association:

A r t h u r C. Hassen, J r .
Executive D i r e c t o r
C o l o r a d o Pharmacal A s s o c i a t i o n
1711 P e n n s y l v a n i a S t r e e t
Denver 80203
Phone: 303/861-0328

C. S o c i e t y of O s t e o p a t h i c M e d i c i n e :

Elwyn D. B a t c h e l o r
Executive D i r e c t o r
Colorado S o c i e t y o f O s t e o p a t h i c M e d i c i n e
4701 E. 9 t h Avenue, Room 304
Denver 80220
NPC Connecticut - 1
1983
ClMNECTl CUT

M D I U I L ASSISTANCE DRUG PROGRAM (TITLE X I X )

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*

OAA A0 APTD AFDC OAA AB APTD AFDC Chi l d r e n < 2 1 (SFD)
Prescribed
Drugs X X X X X X X X X X
lnpat ie n t
H o s p i t a l Care X X X X X X X X X X
O u t,o-a t i e n t
H o s p i t a l Care X X X X X X X X X X
Laboratory &
X-ray S e r v i c e X X X X X X X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X X X X X X X
Physician
Services X X X X X X X X X X
Dental
Services X X X X X X X X X X
*SF0 - S t a t e Funds Only

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

June 30, 1982
1981 1982
Expended Recipient Expended Recipient

TOTAL.. ............................. $17,970,109 154,473** $17,393,516 143,675**

CATEGORICALLY NEEDY CASH TOTAL ...... $ 7,820,994 114,513 $ 7,208,675 103,470
Aged ................................ 1,060,730 4,441 1,140,391 4,424
B l i n d ............................... 12,182 65 13,887 58
D i s a b l e d ............................ 1,463,106 5,590 1,625,834 5,589
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . .. 2,097,710 67,574 1,648,580 56,782
A d u l t s - F a m i l i e s w / D e p C h i l d r e n ..... 3,187,266 36,843 2,779,983 36,617
CATEGORICALLY NEEDY NON-CASH TOTAL.. $0 0 $0 0
Aged ................................ 0 0 0 0
Blind ............................... 0 0 0 0
Disabled. ........................... 0 0 0 0
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 0 0 0 0
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . . . . 0 0 0 0
Other T i t l e XIX R e c i p i e n t s .......... 0 0 0 0

MEDICALLY NEEOYTOTAL ............... $10,149,115 39,960 $10,184,841 40,205

Aged ................................ 6,897,975 23,013 6,908,586 21,979
B l i n d ............................... 25,138 77 26,720 84
Disabled... ......................... 2,809,520 9,635 2,780,118 9,207
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 189,178 4,516 64,654 2,083
A d u l t s - F a m i l i e s w/Dep C h i l d r e n ..... 219,446 2,522 156,737 1,793
Other T i t l e XIX R e c i p i e n t s .......... 7,858 197 248,026 5,059
**Undupl i c a t e d T o t a l - HHS r e p o r t HCFA - 2082
100
 Connecticut -2
1983

I l l . Administration:
Directly by the State Welfare Department through seven district offices and
o n e town delegated this special authority.

IV. Provisions Relating t o Prescribed Drugs:

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

1. Will not pay for experimental drugs, anti-obesity drugs, drugs

available free from t h e Department of Health Services, OESl drugs.

2. Prior authorization required for: non-legend drugs not listed o n

Connecticut Drug List; Amphetamines except when used for narcolepsy
and hyperkenesis; vitamins except prenatal, pediatric prior to 7 t h
birthday and fluoride prior to 14th birthday; nutritional
supplements.

3. Nursing home patients: will not pay for drugs used in routine care
and treatment of patients normally covered in per diem rate except
by prior authorization for large amounts for an individual
patient. Prior authorization required for influenza or pneumovax
vacc i ne.

B. Formulary: OTC Drugs Only

C. Prescribing or Dispensing Limitations:

1. Physicians are encouraged to prescribe drugs generically, when

possible.

2. Quantity of Medication: Maximum quantity: 30-day supply or 120

tablets or capsules or 1 lb. powder. For chronic conditions,
prescription may cover 120 day supply but no more than 120 tablets
or capsules or 1 lb. powder.

Oral Contraceptives: 3 months supply may be dispensed at o n e time.

3. Refills: 6 month refill limit except for oral contraceptives which
have a 12 month limit.

4. Dollar Limits: None

D. Prescription Charge Formula: MAC, AWP as listed in Red Book o r E A C

price set by Department plus fee; or usual and customary if lower.

Fees:

Convalescent and nursing homes - cost plus $2.59 (eff. 1/82)

"Walk-In" patients - cost plus $3.11 ,I
 Connecticut - 3
1983

Effective July 1 , 1983, the Department will pay an incentive professional

dispensing f e e of twenty-five cents per prescription, in addition t o any
other dispensing fee, for substituting a generically equivalent drug
product.
NPC Connecticut - 4
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. Income Maintenance O f f i c i a l s :

Stephen B. H e i n t z Department o f Income Maintenance

Commissioner 110 Bartholomew Avenue
H a r t f o r d , C o n n e c t i c u t 06106

Thomas K i l c o y n e
Deputy Commissioner

Mary Nakashi an
Deputy Commissioner

To be announced s h o r t l y
Director
M e d i c a l Care A d m i n i s t r a t i o n

Dennis Bothamley
C h i e f , I n s t i t u t i o n a l Care
M e d i c a l Care A d m i n i s t r a t i o n

C l a i r C a l l a n , M.D.
Associate Medical D i r e c t o r

H a r r y K i e r n a n , D.D.S.
Dental Consultant

Meyer Rosenkrantz, R.Ph.

Pharmacist Consultant

2. l ncome Maintenance C o n s u l t a n t s ( P a r t - t i m e ) :

Waldo M a r t i n , M.D.
A r t h u r V. McDowell, Sr., M.D.
F r a n c i s Naples, D.D.S.
Edmund Z i e g l e r , M.O.
H. Kallman, D.P.M.
0. 0 . H i l l , O.D.

3. T i t l e X I X A d v i s o r y Committees:

A. Pharmacy A d v i s o r y Committee:

S t a t e Pharmacy Commission Connecticut Pharmaceutical

Dr. James O ' B r i e n Assoc.
Mike W i l l i a m s Dan Leone
W i l l i a m Sumna
Edward C. L i s k a
NPC Connecticut - 5
1983

Pharmacy A d v i s o r y Committee
(continued)

Connecticut S t a t e Medical Income M a i n t e n a n c e

Society Department
D r . E l l i o t t R. Mayo Stephen H. P r e s s
Meyer R o s e n k r a n t z
(Pharmacist)

4. F i s c a l Agent

E l e c t r o n i c Data Systems Corp

Farmington, C o n n e c t i c u t

5. Average Rx P r i c e s FY 1982 $9.24

6. E x e c u t i v e O f f i c e r s of S t a t e Medical and P h a r m a c e u t i c a l
Societies:

A. Medical S o c i e t y :

T. B. Norbeck
Executive D i r e c t o r
Conn. S t a t e M e d i c a l Assoc.
160 S t . Ronan S t r e e t
New Haven 0651 1
Phone: 203/865-0587

6. Pharmaceutical Association:

D a n i e l C. Leone, D.O.
Executive D i r e c t o r
Connecticut Pharmaceutical A s s o c i a t i o n
943 S i l a s Deane Highway
W e t h e r s f i e l d 06109
Phone: 203/563-4619

C. Society o f Osteopathic Medicine:

Norman S. Roome. D.O., Secretary

Connecticut Society o f Osteopathic
P h y s i c i a n s and Surgeons
16 South Main S t r e e t
New M i l f o r d 06774
 Delaware - 1
1983

DELAWARE

MEDICAL ASSISTANCE DRUG PROGRAM (TITLE X I X )

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l ly Needy (MN) Other*

O M AB APTD AFDC DAA AB APTD AFDC C h i l d r e n < 2 1 (SFO)
Prescribed
Drugs X X X X
lnpat ie n t
H o s p i t a l Care X X X X
Outpatient
H o s p i t a l Care X X X X
Laboratory &
X-ray S e r v i c e X X X X
S k i l l e d Nursina 0

Home S e r v i c e s X X X X
Physician
Services X X X X
Dental
Services X
*SF0 - S t a t e Funds Only

11. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982
1981 1982
~ x ~ e n d e dR- e c i p i e n t ~xpended- Recipient

TOTAL............................... $2,301,113 35,535** $2,467,758

CATEGORICALLY NEEDY CASH TOTAL.. .... $2,033,554 32,742 $2,161,652

Aged ................................ 502,619 2,585 530 ,355
Blind ............................... 9,943 69 8,850
Disabled ............................ 582,877 3,202 674,036
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 421,556 16,833 404,926
.....
A d u l t s - F a m i l i e s w/Dep C h i l d r e n 516,559 10,081 543,485

CATEGORICALLY NEEDY NON-CASH TOTAL.. $267,559 3,589 5306,106 3,504

Aged ................................ 175,866 808 21 1,323 80 5
Blind. .............................. 14 1 0 0
Disabled ............................ 25,820 152 27,170 124
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 11,142 566 9,692 480
A d u l t s - F a m i l i e s w/Dep Children..... 16,414 508 13,364 379
..........
Other T i t l e X I X R e c i p i e n t s 38,303 1,573 44,557 1,737

MEDICALLY NEEDY TOTAL.. ............. $0 0

Aged ................................ 0 0
Blind........ ....................... 0 0
Disabled............................ 0 0
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 0 0
A d u l t s - F a m i l i e s w/Dep Children..... 0 0
Other T i t l e X I X R e c i p i e n t s .......... 0 0

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

105
 Delaware - 2
1983

I I I. Administration:

Division of Social 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 vi tamins), 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).

8. 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 to the pharmacy or

MAC, plus a $3.20 dispensing fee, or the usual and customary cost to
the general public, whichever is lower.

IV. Fiscal Intermediary

The Computer Company

#1 Pike Creek Center, Suite 402, Wing 2
Wilmingtron, DE 19808
 Delaware - 3
1983
Officials, Consultants and Committees

1. Health and Social Services Department Officials:

Patricia Schram Department of Health and

Secretary Social Services
Delaware State Hospital
New Castle, Delaware 19720

Charles Hayward Division of Economic Services

Di rector P. 0. Box 906
New Castle 19720

Richard J. Cherrin
Administrator
Medical Assistance Services

Dr. James Salva 2018 Naamans Road, Suite 1 B

Medical Consultant Wilmington 19810

Roger Andersen, R.Ph. P. 0. Box 309

(Part-time) Wilmington 19899
Pharmacist Consultant
302/421-6132

2. Medical Advisory Comnittee Members:

Mark Abrams Delaware Pharmaceutical Association

2501 Northgate Road
Wilmington 19810

Roger Andersen Pharmaceutical Consultant

613 Foulkstone Road Division of Economic Services
Wilmington 19803

Anne Bader Delaware Medical Society

1925 Lovering Avenue
Wilmington 19806

Dale Bunting Division of Mental Health

Director of Social Services
Delaware State Hospital
New Castle 19720

Par is Carpenter Sussex County-Medicaid Recipient

RD 1 Box 209
Lincoln 19960

Donald B. Cowan, D.D.S. Division of Public Health

DPH-Bureau of Special ized Bureau of Special ized Health
Health Services Services
Jesse Cooper Bldg.
Dover 19901
 Delaware - 4
1983

M e d i c a l A d v i s o r y Committee Members ( c o n t i n u e d ) :

B u r t o n Church A s s o c i a t i o n of Delaware H o s p i t a l s
S t . Francis Hospital
7 t h & Clayton Streets
W i l m i n g t o n 19806

B o n i t a DePree New C a s t l e County-Medicaid

1200 L a n c a s t e r Avenue Recipient
W i l m i n g t o n 19805

Gary Ferguson Delaware H e a l t h C o u n c i l

1925 L o v e r i n g Avenue
W i l m i n g t o n 19806

Frances Gunner New C a s t l e County

1625 G i l p i n Avenue Medicaid Recipient
L i n c o l n Towers
W i l m i n g t o n 19806

E l i z a b e t h Henry D i v i s i o n o f Aging
C.T. B l d g .
Delaware S t a t e H o s p i t a l
New C a s t l e 19720

D a v i d Howard, M.D. Delaware Chapter-American

P. 0. Box 107 Academy o f P e d i a t r i c i a n s
Ocean View 19970

C a r o l Katz Sussex County Home S e r v i c e s ,

64 Sussex D r i v e CHEER PROGRAM
Lewes 19958 Consumer

David K r i g s t e i n B l u e Cross B l u e S h i e l d , Inc.

201 W. 1 4 t h S t r e e t
W i l m i n g t o n 19801

A l l e n L e v i n e , O.D. Delaware O p t o m e t r i c S o c i e t y
419 N. M a r k e t S t r e e t
W i l m i n g t o n 19803

D a v i d L e v i t s k y , M.D. Delaware M e d i c a l S o c i e t y
110 C h r i s t i a n a M e d i c a l Center
Newark 19702

Leon Levy, D.D.S. Delaware D e n t a l S o c i e t y

1905 Delaware Avenue
W i l m i n g t o n 19803
NPC Delaware - 5
1983

M e d i c a l A d v i s o r y Committee Members ( c o n t i n u e d ) :

Carolyn Lipp Oelaware Review O r g a n i z a t i o n

1601 Concord P i k e
S u i t e 92-100
W i l m i n g t o n 19803

Charles Molloy The Computer Company

# 1 P i k e Creek C e n t e r
S u i t e 402, Wing 2
W i l m i n g t o n 19808

M a r t i n Moss, O.D. C o n s u l t a n t - V i s i o n Care Program

702 N. Union S t r e e t Medical S e r v i c e s
W i l m i n g t o n 19805

Mabel C. Nowland V i s i t i n g Nurse A s s o c i a t i o n

2713 L a n c a s t e r Avenue
W i l m i n g t o n 19805

P a t r i c i a P u r c e l l , M.O. Oelaware M e d i c a l S o c i e t y
1508 P e n n s y l v a n i a Avenue
W i l m i n g t o n 19806

Olga Ramirez Consumer-Pub1 i c Task F o r c e

1225 M a y f i e l d Road
W i l m i n g t o n 19803

R o b e r t Reed Oelaware H e a l t h Care F a c i l i t i e s

Retirement f o r L i v i n g
Tigani Building
F o u l k Road
W i l m i n g t o n 19803

James B. Salva, M.D. Medicaid

601 New C a s t l e Avenue
W i l m i n g t o n 19801

Frank J. Shannon, Jr., M.O. D i v i s i o n of P u b l i c H e a l t h

Jesse Cooper B u i l d i n g
Dover 19901

Pat V o s h e l l e Consumer-Sussex County

O u t r e a c h Worker
63 Sussex D r i v e
Lewes 19958

Darlene Finney Consumer-Kent County

1831 DuPont Highway
Dover 19901
NPC Delaware - 6
1983

3. Executive Officers of State Medical and Pharmaceutical

Societies:

A. Medical Society: B. Pharmaceutical Society:

Ann Shane Bader (Mrs.) Ms. Christine L. Bailey

Executive Director Executive Director
Medical Society of Dela. Delaware Pharmaceutical
1925 Lovering Avenue Society
Wi lmington 19806 716 Philadelphia Pike
Phone: 302/658-7596 Wilmington 19809
Phone: 302/762-6019

C. Osteopathic Society:

Allan W. Levy, D.O.

Secretary
Delaware State Osteopathic Medical Society
llO9 Nottingham Road
Wilmington 19809
 D i s t r i c t o f Columbia - 1
1983

DISTRICT ff CMUMIIA
E D I U L ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l ly Needy (MN) Other*

OAA AB APTD AFDC OAA AB APTD AFDC Chi l d r e n < 2 1 (SFO)
Prescribed
Drugs X X X X X X X X X
l noat i e n t
~ o ; ~ i t a lCare X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X
Laboratory &
X-ray ~ e r ; i c e X X X X X X X X X
S k i l l e d Nursina
Home S e r v i c e s X X X X X X X X X
Physician
Services X X X X X X X X X
Dental
Services X X X X
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payments t o P h a r m a c i s t s by f i s c a l year e n d i n g

September 30, 1982
1981 1982
Expended R e c i p i e n t Expended Recipient

TOTAL... ............................ 56,124,337

CATEGORICALLY NEEDY CASH TOTAL...... $4,948,464
Aged.. .............................. 850,682
Blind... ............................ 10,351
Disabled... ......................... 1,613,199
...
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n 554,228
A d u l t s - F a m i l i e s w/Dep C h i l d r e n ..... 1,920,004

CATEGORICALLY NEEDY NDN-CASH TOTAL.. $85,742

Aged ................................ 1,715
Blind.... ........................... 0
Disabled ............................ 70,566
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 5,573
A d u l t s - F a m i l i e s w/Dep Children.... . 7,888
Other T i t l e X I X R e c i p i e n t s .......... 0

MEDICALLY NEEDY TOTAL.. ............. $1,090,131

Aged ................................ 543,975
Blind.... ........................... 1,090
Disabled ............................ 320,499
77,399
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . .
.... 147,168
A d u l t s - F a m i l i e s w/Dep C h i l d r e n .
..........
Other T i t l e X I X R e c i p i e n t s 0

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

11 1
 D i s t r i c t o f Columbia - 2
1983

I II. Administration:

The D.C. Department of Human S e r v i c e s (DHS), O f f i c e of H e a l t h Care

Financing.

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s : A l l l e g e n d drugs a r e c o v e r e d e x c e p t t h o s e d r u g s
t h a t a r e l i s t e d by FDA as i n e f f e c t i v e . Pursuant t o a p r e s c r i p t i o n t h e
f o l l o w i n g non-legend i t e m s a r e covered: o r a l analgesics, o r a l antacids,
i n s u l i n , i n s u l i n needles and s y r i n g e s , c o n t r a c e p t i v e foams and j e l l i e s ,
ferrous sulfate, prenatal vitamin formulations, g e r i a t r i c v i t a m i n
f o r m u l a t i o n s f o r r e c i p i e n t s 65 y e a r s o f age and over, and m u l t i v i t a m i n
f o r m u l a t i o n s f o r c h i l d r e n 7 y e a r s o f age and under. A l l o t h e r non-
legend items a r e excluded.

B. Formulary: None.

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Refills: I n g e n e r a l , amounts dispensed a r e t o b e l i m i t e d t o

q u a n t i t i e s s u f f i c i e n t t o t r e a t an e p i s o d e of i l l n e s s . Maintenance
drugs such as t h y r o i d , d i g i t a l i s , e t c . may be d i s p e n s e d i n amounts
-
up t o a 30-day s u p p l y w i t h 3 r e f i l l s which must be dispensed w i t h i n
4 months.

2. A n t i b i o t i c m e d i c a t i o n s used i n t r e a t m e n t of a c u t e i n f e c t i o n s a r e
n o t t o be dispensed i n excess o f a ( 1 0 ) day s u p p l y . B i r t h control
t a b l e t s may be dispensed i n 3 - c y c l e u n i t s w i t h a maximum of 3
r e f i l l s w i t h i n one y e a r .

3. Dollar Limits: There i s no p r e s e n t d o l l a r l i m i t a t i o n . Physicians

a r e r e q u e s t e d t o p r e s c r i b e r e a s o n a b l e amounts.

4. Formulary: No

D. P r e s c r i p t i o n Charge Formula:

The l e s s e r o f :

- Maximum a l l o w a b l e charge (MAC) p l u s $3.27" o r

- E s t i m a t e d A c q u i s i t i o n Cost (EAC) p l u s $3.27" o r
- The p r o v i d e r ' s u s u a l c h a r g e t o t h e p u b l i c . *

E. Compounded P r e s c r i p t i o n s :

- Lesser of EAC of a l l i n g r e d i e n t s p l u s $4.05.

- The p r o v i d e r ' s u s u a l c h a r g e t o t h e p u b l i c .

"$0.50 co-pay by r e c i p i e n t . Does n o t a p p l y t o r e c i p i e n t s under 21 y e a r s o f age,

p r e s c r i p t i o n s f o r f a m i l y p l a n n i n g , n u r s i n g home p a t i e n t s , o r pregnancy r e l a t e d .
NPC D i s t r i c t o f Columbia - 3
1983

V. Miscellaneous Remarks:

F i s c a l Intermediary:

The Computer Company (TCC)

401 New York Avenue, N.E.
Washington, O . C . 20002
NPC D i s t r i c t o f Columbia - 4
1983

Officials, C o n s u l t a n t s and Committees

1. D e p a r t m e n t o f Human S e r v i c e s O f f i c i a l s :

James A. Buford Department o f Human S e r v i c e s

O i rector 801 N o r t h C a p i t o l S t r e e t , N.E.
Washington, D.C. 20002

M a r t i n E. Levy, M.D., M.P.H. 1875 C o n n e c t i c u t Ave., N.W.

Commissioner of P u b l i c H e a l t h Room 825
Washington, D. C . 20009

P e t e r 6. Coppola 614 H S t r e e t , N.W., Room 708

C h i e f , O f f i c e of H e a l t h Washington, D. C. 20001
Care F i n a n c i n g

James H a r r i s , R.Ph.
Pharmacist Consultant
O f f i c e o f H e a l t h Care F i n a n c i n g

2. E x e c u t i v e O f f i c e r s of D i s t r i c t Medical and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical Society:

F r a n c i s c o P. F e r r a r a c c i o
Executive Secretary
M e d i c a l S o c i e t y of t h e
D i s t r i c t o f Columbia
2007 Eye S t r e e t , N.W.
Washington, D. C. 20006
Phone: 202/223-2230

B. Pharmaceutical Association:

Chauncey I. Cooper, Ph.D.

Executive Di r e c t o r
Washington, D.C. P h a r m a c e u t i c a l A s s o c i a t i o n
5506 C o n n e c t i c u t Avenue, N.W.
Washington, D. C. 20015
Phone: 202/363-0305

C. Osteopathic Association:

H a r r y Handelsman, D.O.
Secretary
O s t e o p a t h i c A s s o c i a t i o n o f t h e D i s t r i c t o f Columbia
2804 E l l i c o t t , N.W.
Washington, D.C. 20008
 Florida- 1
1983

FLORIDA

rYDl CAL ASS l STANCE DRUG PROGRAM (TITLE X I X)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*

OAA AB APTD AFOC OAA AB APTD AFDC C h i l d r e n < 2 1 (SFO)
P r e s c r i bed
Oruqs X X X X
l npat ient
H o s p i t a l Care X X X X
Outpatient
H o s p i t a l Care X X X X
Laboratory &
X-ray S e r v i c e X X X X
S k i l l e d Nursina .,
Home S e r v i c e s X X X
Physician
Services X X X X
Dental
Services X X X X
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s by f i s c a l y e a r e n d i n g

September 30, 1982
1981 1982
~ x ~ e n d e dR- e c i p i e n t ~xpended Recipient

TOTAL............................... $45,742,557 408,923** $48,793,813 389,534**

CATEGORI CALLY NEEDY CASH TOTAL.. .... $39,554,681 369,142 $41,880,590 354,452
Aged ................................ 16,994,922 82,257 17,732,942 76,697
Blind... ............................ 345,858 2,269 380,371 2 297
Disabled.. . . .. ... ........... ...... .. 14,433,266 78,919 16,172,789 78,015
... 3,922,142
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n 132,444 3,790,680 122,826
.. 3,858,493
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . . 77,791 3,803,808 74,660

CATEGORICALLY NEEDY NON-CASH TOTAL.. $6,187,876 40,544 $6,913,223 41,437

Aged ................................ 5,222,095 23,535 5,764,533 23,557
Blind. .............................. 6,507 44 7,414 38
Disabled.. .......................... 658,891 3,052 817,648 3,117
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n . . . 200,652 9,724 202,845 9,665
A d u l t s - F a m i l i e s w/Oep C h i l d r e n . . . . . 99,731 4,228 120,783 5,096
Other T i t l e XIX R e c i p i e n t s .......... 0 0 0 0

MEDICALLY NEEDY TOTAL............... $0 0 $0 0

Aged ................................ 0 0 0 0
Blind. .............................. 0 0 0 0
Disabled ............................ 0 0 0 0
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n . . . 0 0 0 0
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . ... 0 0 0 0
Other T i t l e X I X R e c i p i e n t s .......... 0 0 0 0

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

11 5
 Florida - 3
1983

P r e s c r i b i n g o r Dispensing L i m i t a t i o n s (continued):

The r e c i p i e n t must p r e s e n t a m o n t h l y e l i g i b i l i t y c a r d t o t h e
p r o v i d e r and must t h e n use t h e same p r o v i d e r f o r t h e e n t i r e
c a l e n d a r month.

Maintenance m e d i c a t i o n s h o u l d be dispensed and b i l l e d f o r a t l e a s t

a one-month s u p p l y o r 100 u n i t s .

R e f i l l s must be a u t h o r i z e d b y t h e p r e s c r i b e r and can b e made f o r up

t o one year, e x c e p t t h a t c o n t r o l l e d s u b s t a n c e s c a n be r e f i l l e d o n l y
i n accordance w i t h f e d e r a l and s t a t e r e g u l a t i o n s .

Drugs w i t h q u e s t i o n a b l e e f f i c a c y , as r a t e d b y t h e FDA (OESI), a r e

d i s a l l o w e d u n l e s s t h e a t t e n d i n g p h y s i c i a n can j u s t i f y t h e i r use and
t h e p r i o r approval by t h e Department's c o n s u l t a n t p h y s i c i a n .

I n v e s t i g a t i o n a l , e x p e r i m e n t a l , b l o o d d e r i v a t i v e (e.g. f o r
h e m o p h i l i a ) , and a p p e t i t e s u p p r e s s a n t i t e m s a r e n o t covered, nor
a r e drugs t h a t a r e p r e s c r i b e d f o r o t h e r t h a n t h e i r approved
indications.

D. P r e s c r i p t i o n Charge Formula:

Fee - e f f e c t i v e J u l y 1, 1982
Lower of: (1) MAC p l u s $3.33
(2) EAC p l u s $3.33
(3) Usual and Customary

M i s c e l l a n e o u s Remarks:

A. A l l drugs have an EAC ( E s t i m a t e d A c q u i s i t i o n C o s t )

B. Some H i g h Volume EACs s e t a t l a r g e package s i z e

C. P r o v i s i o n s f o r m e d i c a l l y necessary c o n s i d e r a t i o n s

D. Maximum A l l o w a b l e I n g r e d i e n t Cost (M4IC)

1. F e d e r a l MAC d r u g 1 i s t

E. Number o f Rx c l a i m s processed i n FY 1982 ( I n g r e d i e n t c o s t and f e e )

F. Average p r e s c r i p t i o n p r i c e d u r i n g FY 1982 ( I n g r e d i e n t c o s t and f e e )

$8.23

G. Claims P r o c e s s o r

EDS F e d e r a l C o r p o r a t i o n
Pharmacy S e r v i c e s
P.O. Box 9030
T a l l a h a s s e e , F l o r i d a 32314
 Florida - 3
1983

P r e s c r i b i n g o r Dispensing L i m i t a t i o n s (continued):

2. The r e c i p i e n t must p r e s e n t a m o n t h l y e l i g i b i l i t y c a r d t o t h e
p r o v i d e r and must t h e n use t h e same p r o v i d e r f o r t h e e n t i r e
c a l e n d a r month.

3. Maintenance m e d i c a t i o n s h o u l d be dispensed and b i l l e d f o r a t l e a s t

a one-month s u p p l y o r 100 u n i t s .

4. R e f i l l s must be a u t h o r i z e d b y t h e p r e s c r i b e r and c a n be made f o r up

t o one year, e x c e p t t h a t c o n t r o l l e d substances c a n b e r e f i l l e d o n l y
i n accordance w i t h f e d e r a l and s t a t e r e g u l a t i o n s .

5. Drugs w i t h q u e s t i o n a b l e e f f i c a c y , as r a t e d by t h e FDA (DESI), a r e

d i s a l l o w e d u n l e s s t h e a t t e n d i n g p h y s i c i a n can j u s t i f y t h e i r use and
t h e p r i o r a p p r o v a l b y t h e Department's c o n s u l t a n t p h y s i c i a n .

6. I n v e s t i g a t i o n a l , e x p e r i m e n t a l , b l o o d d e r i v a t i v e (e.g. for
h e m o p h i l i a ) , and a p p e t i t e s u p p r e s s a n t i t e m s a r e n o t covered, nor
a r e drugs t h a t a r e p r e s c r i b e d f o r o t h e r t h a n t h e i r approved
indications.

D. P r e s c r i p t i o n Charge Formula:

Fee -
effective J u l y 1, 1982
Lower o f : (1) MAC p l u s $3.33
(2) EAC p l u s $3.33
(3) Usual and Customary

V. M i s c e l l a n e o u s Remarks:

A. A l l drugs have an EAC ( E s t i m a t e d A c q u i s i t i o n Cost)

B. Some H i g h Volume EACs s e t a t l a r g e package s i z e

C. P r o v i s i o n s f o r m e d i c a l l y necessary c o n s i d e r a t i o n s

D. Maximum A l l o w a b l e I n g r e d i e n t Cost ( M A I C )

1. F e d e r a l MAC d r u g l i s t

E. Number of Rx c l a i m s processed i n FY 1982 ( I n g r e d i e n t c o s t and f e e )

F. Average p r e s c r i p t i o n p r i c e d u r i n g FY 1982 ( I n g r e d i e n t c o s t and f e e )

$8.23

G. Claims P r o c e s s o r

EDS F e d e r a l C o r p o r a t i o n
Pharmacy S e r v i c e s
P.O. Box 9030
T a l l a h a s s e e , F l o r i d a 32314
 Florida - 4
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. Depar.tment o f H e a l t h and R e h a b i l i t a t i v e S e r v i c e s O f f i c i a l s :

D a v i d P ingree Oepartment o f H e a l t h and

Secretary Rehabilitative Services
1323 Winewood B o u l e v a r d
T a l l a h a s s e e , F l o r i d a 32301

R i c h a r d T. L u t z 1309 W i newood B o u l e v a r d
Deputy A s s i s t a n t S e c r e t a r y B u i l d i n g 6, Room 233
f o r Medicaid T a l l a h a s s e e 32301

Rod P r e s n e l l , R.Ph. 1309 Winewood B o u l e v a r d

Pharmacist Consultant B u i l d i n g 6, Room237
M e d i c a i d O f f i c e of Program T a l l a h a s s e e 32301
Development

J e r r y H i l l , R.Ph. 1309 W i newood B o u l e v a r d

Pharmacist Consultant B u i l d i n g 6, Room 237
M e d i c a i d O f f i c e of Program T a l l a h a s s e e 32301
Development

2. C o n s u l t a n t s t o M e d i c a l S e r v i c e s Program: (Part- time)

Donald 0. A l f o r d , M.D. Medicaid O f f i c e

Gene L. Davidson, M.D. 1309 W i newood B o u l e v a r d
L a r r y C. Deeb, M.O. T a l l a h a s s e e 32301
I r v i n g J. F l e e t , D.O.S.
C h a r l e s F. James, M.D.
Fred L i n d s e y , M.D.
I v a n B. R o b e r t s , D.D.S.
Ms. J a n e t S h e l f e r
Armanda M. S i t t i g , M.0.
J. Orson Smith, M.D.
James A. Stephens, O.D.
Sam Tatum, O.D.S.

3. Medicaid Advisory Council:

Mrs. Maggie B e n n e t t George Browning, R.Ph.

720 West M y r t l e S t r e e t 1281 South H i c k o r y S t r e e t
L a k e l a n d 33801 Melbourne 32901
*Consumer * F l o r i d a Pharmacy A s s o c i a t i o n

Ms. P a t r i c i a B r y a n t Mrs. S u s i e Mae Burns

P o s t O f f i c e box 2104 4205 Maxwell B o u l e v a r d S o u t h
Miami 33143 T a l l a h a s s e e 32301
*Consumer *Consumer
 Florida - 5
1983

M e d i c a i d Advisory Council (continued):

Canmissioner P a t Glass V i r g i n i a Haggerty, R.N.

Manatee County Commission P o s t O f f i c e Box 6985
P o s t O f f i c e Box 1000 O r l a n d o 32803
B r a d e n t o n 33506 * F l o r i d a Nurses A s s o c i a t i o n
* S t a t e A s s o c i a t i o n o f County
Commissioners o f F l o r i d a , I n c .

Mr. Arthur Harris M r . W i l l i a m Hobson

F l o r i d a Manor 610 S o u t h "K" S t r e e t
830 West M i c h i g a n Lake Worth 33460
O r l a n d o 32804 *Consumer
* F l o r i d a H e a l t h Care A s s o c i a t i o n

Mrs. G a y l i a Howard Donald G. N i k o l a u s , M.D.

Route 1, Box 31 Mease H o s p i t a l and C l i n i c
O I B r i e n 32071 Dunedi n 33528
*Consumer * F l o r i d a Medical A s s o c i a t i o n

C h r i s C. Scures, D.D.S. Mr. Fatah Wallizada

2122 E a s t Robinson S t r e e t 3656 S t . Johns Avenue
O r l a n d o 32803 J a c k s o n v i l l e 32205
* F l o r i d a Dental A s s o c i a t i o n *Consumer

M r . Leon Zucker
Vice President
Finance, P u b l i c H e a l t h T r u s t
Jackson Memorial H o s p i t a l
1611 N o r t h w e s t 12 Avenue
Miami 33136
*Florida Hospital Association
M r . R i c h a r d T. L u t z
Deputy A s s i s t a n t S e c r e t a r y
f o r Medicaid
1317 Winewood B o u l e v a r d
B u i l d i n g 6, Room 233
T a l l a h a s s e e 32301
*Department o f H e a l t h and
R e h a b i l i t a t i o n Services

4. F l o r i d a MAC A d v i s o r y Committee:

George Browning, R.Ph. R e t a i l Pharmacy f o r N u r s i n g

1281 H i c k o r y S t r e e t Homes
Melbourne 32901

Lew Becks N u r s i n g Home Pharmacy

5607 Hamnock Lane
L a u d e r h i l l 33319

Lawrence DuBow Wholesaler

Lawrence P h a r m a c e u t i c a l s
P o s t O f f i c e Box 5386
J a c k s o n v i l l e 32207
NPC Florida - 6
1983

F l o r i d a MAC A d v i s o r y Committee ( c o n t i n u e d ) :

Dick Kaplan Pharmacy Manager

3730 Thornwood D r i v e
Tampa 33618

J i m Powers, R.Ph. Secretary, F l o r i d a

610 N o r t h Adams Pharmacy A s s o c i a t i o n
T a l l a h a s s e e 32301

Mark S u l l i v a n , R.Ph. Pharmacist

1330 Miccosukee Road
T a l l a h a s s e e 32303

M i c h a e l Zagorac, R.Ph. Pharmacy Manager

C / O Jack Eckard C o r p o r a t i o n
p o s t O f f i c e Box 4689
C l e a r w a t e r 33518

DHRS M e d i c a i d R e p r e s e n t a t i v e s :

D i c k Grant, R.Ph. Rod P r e s n e l l , R.Ph.

Department o f HRS (PDHERx) Department o f HRS (PDDE)
1317 Winewood B o u l e v a r d 1309 W i newood B o u l e v a r d
T a l l a h a s s e e 32301 T a l l a h a s s e e 32301

J e r r y H i l l , R.Ph.
Department o f HRS (PDDE)
1309 Winewood B o u l e v a r d
T a l l a h a s s e e 32301

5. E x e c u t i v e O f f i c e r s o f S t a t e M e d i c a l and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical A s s o c i a t i o n : B. Pharmaceutical A s s o c i a t i o n :

W. H a r o l d Parham James B. Powers

Executive Vice-president Executive D i r e c t o r
F l o r i d a Medical Association, Inc. F l o r i d a Pharmacy A s s o c i a t i o n
P o s t O f f i c e Box 2411 610 N o r t h Adams S t r e e t
J a c k s o n v i l l e 32203 Tal l a h a s s e e 32301
Phone: 904/356-1571 Phone: 904/222-2400

C. Osteopathic Medical Association:

M e r v i n E. Meck, D.O.
Secretary-Treasurer, Executive D i r e c t o r
F l o r i d a Osteopathic Medical A s s o c i a t i o n
161 N. Causeway
New Smyrna Beach 32069
NPC Georgia - 1
1983
GEORG l A
HEDICAL ASSISTANCE DRUG PROGRAM ( T I T L E X I X )

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) ' Other*
O M AB APTD AFDC O M AB APTD AFDC C h i l d r e n c 2 1 (SFO)
Prescribed
Druqs X X X X
l npatient
nosp it a l Care X X X X
Outpatient
H o s p i t a l Care X X X X
Laboratorv E
X-ray S e r v i c e X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X
Physician
Services X X X X
Dental
Services X X X X
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s by f i s c a l y e a r e n d i n g

September 30, 1982

1981 1982
Expended Recipient Expended Recipient

TOTAL.. ............................. $54,596,928 352,l l8** $47,705,788 330,380""

CATEGORICALLY NEEDY CASH TOTAL.. .... $43,360,638 319,170 $39,026,645 300,504
Aged ................................ 15,913,050 65,791 13,566,325 60,032
Blind................. .............. 532,199 2,496 498,546 2,417
Disabled.. ...........,.,............ 19,491,229 74,875 17,769,051 72,836
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 2,675,698 111,504 2,509,331 100,649
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . .... 4,748,462 65,715 4,683,392 65,794
CATEGORICALLY NEEDY NON-CASH TOTAL.. $11,236,290 43,889 $8,679,143 37,947
Aged.. ...... ........................ 9,039,430 23,897 6,900,883 22,007
Blind ............................... 27,788 87 24,452 93
Disabled.. .......................... 1,789,893 4,664 1,465,903 4,424
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n ... 196,366 9,133 116,699 6,278
A d u l t s - F a m i l i e s w/Dep Children..... 137,495 4,684 127,233 4,279
Other T i t l e XIX R e c i p i e n t s .......... 45,318 1,604 43,983 1,396

MEDICALLY NEEDY TOTAL...... ......... $0 0 $0 0

Aged ................................ 0 0 0 0
B l i n d . .............................. 0 0 0 0
D i s a b l e d . . .......................... 0 0 0 0
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n . . . 0 0 0 0
A d u l t s - F a m i l i e s w/Dep C h i l d r e n ..... 0 0 0 0
Other T i t l e X I X R e c i p i e n t s .......... 0 0 0 0

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

121
 Georgia - 18
1983

1) The Georgia Dept. of Medical A s s i s t a n c e does n o t p r o v i d e f o r a M e d i c a l l y

Needy c a t e g o r y . I n s t e a d , b e n e f i t s a r e p r o v i d e d t o r e c i p i e n t s under a
Maintenance A s s i s t a n c e Only C l a s s i f i c a t i o n . Maintenance ( M e d i c a l ) A s s i s t a n c e
Only i s p r o v i d e d t o t h o s e r e c i p i e n t s e l i g i b l e t o r e c e i v e m e d i c a l s e r v i c e s b u t
who do n o t , f o r v a r i o u s reasons, r e c e i v e money payments. The MA0 c a t e g o r y
d i f f e r s f r o m t h e MN i n terms o f e l i g i b i l i t y r e q u i r e m e n t s . MA0 c o v e r s t h e same
t y p e o f b e n e f i t s f o r each r e l a t e d c a t e g o r y o f r e c i p i e n t s as t h o s e checked f o r
money payments. A l s o , p l e a s e n o t e t h a t t h e e x p e n d i t u r e s l i s t e d f o r MNs i n
S e c t i o n I I a r e a c t u a l l y t h o s e f o r G e o r g i a ' s MA0 r e c i p i e n t s .

Source: FY-82 N C S S 2082 R e p o r t

FY-82 Annual R e p o r t
NPC Georgia - 2
1983

Ill. Administration:

By t h e Department o f Medical A s s i s t a n c e .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s :
Drugs n o t on t h e d r u g l i s t .

B. F o r m u l a r y : The C o n t r o l l e d M e d i c a l A s s i s t a n c e Drug L i s t . For

information contact:

Mrs. E a r l i n e D. J o r d a n
2 M.L. King, J r . D r i v e S.E.
Floyd Building -
West Tower
A t l a n t a , GA 30334
404/656-4044

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Q u a n t i t y of Medication: P h y s i c i a n s a r e encouraged t o p r e s c r i b e a 30
day s u p p l y . S i x p r e s c r i p t i o n s p e r month p e r r e c i p i e n t e x c e p t b y
p r i o r authorization.

3. Refills: A c c o r d i n g t o s t a t e and f e d e r a l law.

4. Dollar Limits: None.

D. P r e s c r i p t i o n Charge Formula: Lower o f , e s t i m a t e d a c q u i s i t i o n c o s t (EAC)

p l u s f e e o f $3.61, o r MAC p l u s fee, o r u s u a l and customary. N o n - p r o f i t
institutions - $3.17.

No copayment

V. M i s c e l l a n e o u s Remarks:

Average Rx p r i c e d u r i n g FY 1982 - $10.23

S t a t e MAC L i s t = F e d e r a l MAC P l u s 11 A d d i t i o n a l Drugs

NPC Georgia - 3
1983

Officials, C o n s u l t a n t s and Committees

1. Department o f Medical A s s i s t a n c e O f f i c i a l s :

Aaron Johnson Department o f M e d i c a l

Commissioner Assistance
James F l o y d Memorial B l d g .
( T w i n Towers)
P.O. Box 38440
A t l a n t a , G e o r g i a 30334

Russ Toal
A s s i s t a n t Comnissioner

Jacqueline Foster, Director

Program Mangement

(Mrs.) E a r l i n e P. Jordan, R.Ph.

I n s t i t u t i o n a l / A n c i l l a r y Services

(Mrs.) Frances Lipscomb, R.Ph.

Program Mangement O f f i c e r
Pharmacy S e r v i c e

T i t l e X I X ( M e d i c a i d ) M e d i c a l A s s i s t a n c e A d v i s o r y Comnittees:

R e p r e s e n t a t i v e s from each o f t h e f o l l o w i n g groups:

Medical A s s o c i a t i o n o f Georgia
Atlanta Medical A s s o c i a t i o n
Georgia Hospital Association
Georgia Pharmaceutical A s s o c i a t i o n
Georgia H e a l t h Care A s s o c i a t i o n
Georgia O s t e o p a t h i c Medical A s s o c i a t i o n
Georgia Dental A s s o c i a t i o n

E x e c u t i v e O f f i c e r s o f S t a t e M e d i c a l and P h a r m a c e u t i c a l
Societies:

A. Medical A s s o c i a t i o n :

J.M. Moffatt
Executive D i r e c t o r
Medical A s s o c i a t i o n o f Georgia
938 Peachtree S t r e e t , N. E.
A t l a n t a 30309
Phone: 404/876-7535
NPC Georgia - 4
1983

E x e c u t i v e O f f i c e r s o f S t a t e Medical and P h a r m a c e u t i c a l
Societies (continued):

B. Pharmaceutical Association:

L a r r y L. Braden
Executive D i r e c t o r
Georgia P h a r m a c e u t i c a l A s s o c i a t i o n
2520 C a r r o l l Avenue
A t l a n t a 30341
Phone: 404/451-1336

C. O s t e o p a t h i c Medical A s s o c i a t i o n :

Ms. Cathy M. G a r r i s
Executive Director
Georgia O s t e o p a t h i c Medical A s s o c i a t i o n
2157 ldlewood Road
Tucker 30084
 Guam - 1
1983

WDICAL ASSISTANCE DRUG P R O G R M (TITLE XIX)

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l ly Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC C h i l d r e n < 2 1 (SFO)
Prescribed
Drugs X X X X X X X X
l npat ie n t
H o s p i t a l Care X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X
Laboratory &
X-ray S e r v i c e X X X X X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X X X X X
Physician
Services X X X X X X X X
Dental
Services X X X X X X X X
"SF0 - S t a t e Funds O n l y
Other B e n e f i t : Transportation; prostheses

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982

1981 1982
Expended R e c i p i e n t Expended Recipient

TOTAL ...............................
CATEGORICALLY NEEDY CASH TOTAL......
Aged ................................
Blind ...............................
Disabled. ...........................
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . .
A d u l t s - F a m i l i e s w/Dep Children.....

CATEGORICALLY NEEDY NON-CASH TOTAL..

Aged ................................
Blind ...............................
Disabled ............................ No Data A v a i l a b l e
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . .
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . . ..
..........
Other T i t l e X I X R e c i p i e n t s

MEDl CALLY NEEDY TOTAL.. .............

Aged ................................
B l i n d . ..............................
D i s a b l e d . . ..........................
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n ...
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . ...
Other T i t l e X I X R e c i p i e n t s ..........
**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082
126
NPC Guam - 2
1982

I l l . Administration:

By t h e Department o f P u b l i c H e a l t h and S o c i a l S e r v i c e s .

P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

P r e s c r i b e d drugs a r e p r o v i d e d t o needy persons e l i g i b l e f o r s e r v i c e s under

T i t l e XIX. P r o v i d e r s i n c l u d e t h e Guam Memorial H o s p i t a l pharmacy as w e l l as
o t h e r p r i v a t e l y o p e r a t e d pharmacies.

D i s p e n s i n g fee - AWP p l u s $2.75

O f f i c i a l s , C o n s u l t a n t s and Committees

A. P u b l i c H e a l t h and S o c i a l S e r v i c e s Department O f f i c i a l s :

F r a n k l i n S. Cruz, Ed.D. Department o f P u b l i c H e a l t h

Director and S o c i a l S e r v i c e s
Government o f Guam
Post O f f i c e Box 2816
Agana, Guam 96910

Mabel M. F. Chen
Supervisor
Medical Care S e r v i c e

6. E x e c u t i v e O f f i c e r of P h a r m a c e u t i c a l A s s o c i a t i o n :

Orencia L. Concepcion
Guam P h a r m a c e u t i c a l A s s o c i a t i o n
626 Western B o u l e v a r d
Jonestown
Tamun ing, Guam 969 11
 Hawa i i - 1
1983

WED1 CAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APT0 AFDC OAA AB APTD AFDC C h i l d r e n < 2 1 (SF())
Prescribed
Drugs X X X X X X X X X X
l npat ie n t
H o s p i t a l Care X X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X X
Laboratory &
X-ray ~ e r ; i c e X X X X X X X X X X
S k i l l e d Nursina <

Home S e r v i c e s X X X X X X X X X X
Physician
Services X X X X X X X X X X
- - .. - - 1
Denta .
Services X X X X X X X X X X
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982

1981 1982
Expended R e c i p i e n t Expended Rec i p i e n t

TOTAL...................... ......... $4,823,966 74,968**

CATEGORICALLY NEEDY CASH TOTAL.. .... $3,694,830 62,977

Aged ................................ 553,315 3,557
Blind............ ................... 6,076 69
D i s a b l e d . . .......................... 553,842 2,951
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . .. 1,235,414 35,718
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . .... 1,346,183 20,682

CATEGORICALLY NEEDY NON-CASH TOTAL.. $345,091 3,835

Aged ................................ 222,982 1,124
Blind........ ....................... 1,110 9
Disabled ............................ 47,174 254
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 41,526 1,555
A d u l t s - F a m i l i e s w/Dep Children..... 31,657 866
..........
Other T i t l e X I X R e c i p i e n t s 642 27

MEDICALLY NEEDY TOTAL.. ............. $784,045 8,522

Aged ................................ 356,465 2,768
Blind...... ......................... 3,161 31
Disabled..... ....................... 295,108 1,715
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 62,687 2,376
A d u l t s - F a m i l i e s w/Dep C h i l d r e n ..... 48,080 1,119
Other T i t l e X I X R e c i p i e n t s .......... 18,544 513

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

128
 Hawa i i - 2
1983

I l l . Administration:

By t h e S t a t e Department o f S o c i a l S e r v i c e s and Housing t h r o u g h i t s P u b l i c

W e l f a r e D i v i s i o n and f o u r c o u n t y branch o f f i c e s .

I V . P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs

A. Exclusions: I n v e s t i g a t i o n a l new drugs, and drugs c l a s s i f i e d a s

i n e f f e c t i v e o r p o s s i b l y e f f e c t i v e b y t h e FDA.

0. Formulary: Yes, Hawaii S t a t e M e d i c a i d Drug Formulary

D. P r e s c r i p t i o n Charge Formula: E s t i m a t e d A c q u i s i t i o n s Cost (EAC) p l u s

d i s p e n s i n g f e e $3.22.

V. F i s c a l I n t e r m e d i a r y

Hawaii M e d i c a l S e r v i c e A s s o c i a t i o n
M e d i c a i d Program S e c t i o n
P.O. Box 860
Honolulu, Hawa i i 96808

Average Rx p r i c e d u r i n g FY 1982 - 57-04

NPC Hawa i i - 3
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. S o c i a l S e r v i c e s and Housing Department O f f i c i a l s :

F r a n k l i n Y. K. Sunn Department o f S o c i a l S e r v i c e s
Director and Housing
P. 0. Box 339
H o n o l u l u , Hawai i 96809-0339

A l f r e d K. Suga
Deputy D i r e c t o r

Raymond S a t o
Administrative Services Officer

S h i g e m i t s u Nakashima P u b l i c Welfare D i v i s i o n
P u b l i c Welfare Administrator (same address a s above)

E a r l S . Motooka
M e d i c a l Care A d m i n i s t r a t o r

Wayne S. Hansen, M.D.

Medical Consultant

John A. Sheedy, M.D.

Medical Consultant

F l o r a n c e Chinn, M.D.
Medical Consultant

Benjamin Sherman, D.D.S.

Dental Consultant ( p a r t - t i m e )

Omel L . Turk, R.Ph.

Pharmaceutical Consultant ( p a r t - t i m e )

C h a r l o t t e M. F l o r i n e , M.D.
P s y c h i a t r i c Consultant ( p a r t - t i m e )

2. S o c i a l S e r v i c e s and Housing Department Medical Care A d v i s o r y

Committee:

Y. K. Look, O.D. 1441 K a p i o l a n i B l v d . ,

Chai rman #517
H o n o l u l u , H a w a i i 96814

Roy F. Fuboyama, M.D. K a l i h i Medical Center

Physician 2055 N o r t h K i n g S t r e e t
H o n o l u l u 96819
NPC Hawa i i - 4
1983
S o c i a l S e r v i c e s and Housing Department M e d i c a l Care A d v i s o r y
Committee ( c o n t i n u e d ) :

Lee Simmons, M.D. 1380 L u s i t a n a S t r e e t , #407

Physician H o n o l u l u 96813

Paul M c C a l l i n , M.D. Kaiser Foundation Health

Physician Plan, Inc.
1697 A l a Moana B o u l e v a r d
H o n o l u l u 96815

R i c h a r d Kato, ACSW A l o h a U n i t e d Way

S o c i a l Worker P.O. BOX 1096
H o n o l u l u 96808

M i c h a e l Matsuura S t . Francis Hospital

H o s ~ i t a lA d m i n i s t r a t o r 2230 L i l i h a S t r e e t
H o n o l u l u 96817

C l i f f o r d M i l l e r , Jr. Ann P e a r l Care Home, I n c .

Long Term Care A d m i n i s t r a t o r 45-181 W a i k a l u a Road
Kaneohe 96744

John Chalmers, M.D Department o f H e a l t h

Department o f Heal t h 1250 Punchbowl S t r e e t
Representative H o n o l u l u 96813

Saburo F u j i s a k i 451 Atkinson D r i v e

Labor R e p r e s e n t a t i v e H o n o l u l u 96814

Rev. G e r a l d G i f f o r d St. E l i z a b e t h E p i s c o p a l Church

Pastor 720 N. K i n g S t r e e t
H o n o l u l u 96817

James Asato, R.Ph. Leahi H o s p i t a l

Pharmacist 3675 K i l a u e a Avenue
H o n o l u l u 96816

Ned W i e d e r h o l t 855 Aalapapa D r i v e

R e p r e s e n t a t i v e from School K a i l u a 96734
o f Public Health

Ms. Roberta Rosea 1993 S. K i h e i Road, A p t . # 403

Recipient Maui - K i h e i , Maui 96723

Ms. S t e p h a n i e T a r l ep 1875 S. K i h e i Road, A p t . #I10

Recipient -Hawaii Hilo 96720
Joyce D a h l b e r g P.O. box 1824
Recipient -
Kauai L i h u e , Kauai 96766
 Hawa i i - 5
1983

Social Services and Housing Department Medical Care Advisory

Committee (continued):

Y.K. Look, 0.0. 1441 Kapiolani Blvd., Room 517

Optometrist Honolulu 96814

Walter Fo, Ph.D. 4211 Waialae Avenue

Psychologist Suite 206
Honolulu 96816

Ms. Dorothy K. Nobriga 69 lpuka Street

Recipient - Hawaii Hilo 96720

Johanna Mokiao Welfare Recipient Advisory

Rosie Spesi nger Counc i l
Recipient - Oahu 810 N. Vineyard Boulevard
Honolulu 96817

James L. Watson, D.0.S. Kailua Professional Center

Dentist 30 Aulike Street, Suite 305
Kailua 96734

Patricia K. Osgood, R.N., M.S. Hawaii Nurses Association

Nurse 677 Ala Moana Boulevard
Suite 1014
Honolulu 96813

Henry Miyoi 1932 Kealakai Street, Room 2

Businessman Honolulu 96817

3. Executive Officers of State Medical and Pharmaceutical

Societies:

A. Medical Association:

Jon Won
Executive Director
Hawaii Medical Association
320 Ward Avenue
Honolulu 96814
Phone: 808/536-7702

8. Pharmaceutical Association:

Carol A. Parker
President
Hawaii Pharmaceutical Association
P. 0. Box 1198
Honolulu 96807
Phone: 808/623-0977
 Idaho - 1
1983

lOAHO

HEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I . BENEFITS PROVIDED AN0 GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APT0 AFDC OAA AB APT0 AFOC Chi l d r e n < 2 1 (SFO)
P r e s c r i bed
Drugs X X X X
l n p a t i ent
H o s p i t a l Care X X X X
Outpatient
H o s p i t a l Care X X X X
Laboratory &
X-ray S e r v i c e X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X
Phvsician
Services X X X X
Dental
Services X
*SF0 - S t a t e Funds O n l y

I I. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982

1981 1982
Expended R e c i p i e n t Expended Recipient

TOTAL.. ............................. $2,337,100 28,995** $2,452,372 27.11 4**

CATEGORICALLY NEEDY CASH TOTAL...... $1,150,771 21,961 1,104,266 19,579

Aged ................................ 262,822 1,658 236,543 1 395
Blind ............................... 2,596 33 2,606 26
Disabled...... ...................... 326,232 2,098 314,317 1,838
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n . . . 239,148 11,699 231,337 10,402
A d u l t s - F a m i l i e s w/Oep Children..... 319,973 6,676 319,463 6,056

CATEGORICALLY NEEOY NON-CASH TOTAL.. $1,186,329 $1,348,106 8,471

Aged.. ... ..... . ... .......... .. ..... . 733,041 813,474 4,266
Blind ............................... 4,563 6,619 42
Oisabled....................... ..... 420,559 488,830 2,823
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 8,634 12,547 637
A d u l t s - F a m i l i e s w/Dep C h i l d r e n ..... 9,699 13,079 421
Other T i t l e XIX R e c i p i e n t s .......... 9,833 13,557 339

M E O l CALLY NEEDY TOTAL.. ... ... ...... . $0 $0 0

Aged ................................ 0 0 0
Blind............................... 0 0 0
Disabled ............................ 0 0 0
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 0 0 0
A d u l t s - F a m i l i e s w/Oep Children..... 0 0 0
Other T i t i e XIX R e c i p i e n t s .......... 0 0 0

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

133
NPC ldaho - 2
1983

I I I . 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 $30.00 pTr month per recipient. ( 3 4 day supply with limited
except i ons)

D. Prescription charge formula:

Lower of MAC or EAC plus a variable dispensing fee $2.50 - 3.50,

according to location, size and Rx volume of the provider, or the
provider's usual and customary price to the general public.

V . Miscellaneous Information

Copayment - none (effective 3/19/83)

Average prescription price during FY 1982 - $7.95

Fiscal intermediary

EDS Federal Corporation

P.O. BOX 1168
Boise, ldaho 83701

1. Commerce Clearing House - Medicaid Guide 1983

 ldaho - 3
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. H e a l t h and W e l f a r e Oepartment:

Rose Bowman Oepartment o f H e a l t h and W e l f a r e

Director Statehouse
Boise, l d a h o 83720
208/334-4334

P e n n i e B j o r n s t a d , Chief
Bureau o f B e n e f i t Payments

Dianne B. Onnen, R.Ph., M.P.A.

Pharmacy C o n s u l t a n t
208/334-4323

2. M e d i c a l Care A d v i s o r y Committee:

R i c h a r d 0. Adams R o b e r t Campbell
Director, Health O i s t r i c t I l l S t , Benedict's Hospital
P. 0. Box 489 Jerome 83338
Cal d w e l l 83605 208/324-4301
208/459-0744
Ruby Crosby, R.N.
J . Stephen Anderson St. Benedict's Hospital
R e g i o n a l S e r v i c e s Manager Jerome 83338
H e a l t h and Welfare, R e g i o n V 208/324-4301
Box 1509
T w i n F a l I s 83301 O r . Rodney H e a t e r
827 Center Avenue
Howard B a r t o n P a y e t t e 83664
Commission f o r t h e B l i n d 208/642-4434
Statehouse
B o i s e 83720 J. C h a r l e s (Chuck) H o l d e n
208/334-3220 l d a h o A s s o c i a t i o n of C o u n t i e s
P.O. Box 1623
L a u r a B a r t o n , R.N. B o i s e 83701
C e n t r a l O i s t r i c t H e a l t h Oepartment 2081345-91 26
Home H e a l t h S e r v i c e s
1455 N o r t h Orchard The H o n o r a b l e E l a i n e Kearnes
B o i s e 83706 l d a h o House o f R e p r e s e n t a t i v e s
208/375-5211 3040 Gustafson C i r c l e
l daho Fa l l s 8340 1
Robert Berntson 208/522-6875
l d a h o S t a t e P h a r m a c e u t i c a l Assoc.
145 M a r j a c q
l daho F a l l s 83401
208/523-1384
 ldaho - 4
1983

M e d i c a l Care A d v i s o r y Committee ( c o n t i n u e d ) :

John S. K r i z , D.D.S. Mari ly n L e o n i ng Sword

ldaho Dental A s s o c i a t i o n l d a h o M e n t a l H e a l t h Assoc.
8424 F a i r v i e w Avenue 3105-1/2 S t a t e S t r e e t
B o i s e 83704 B o i s e 83703
208/376-7740 208/344-8585

The H o n o r a b l e L a i r d Noh A r l e n e Warner

ldaho S t a t e Senate O f f i c e on A g i n g
Route No. 1, Box 65 Statehouse
K i m b e r l y 83341 Boise
208/733-3617 208/334-3833

Dale S h i r k , Executive Connie W h i t t i n g t o n

Vice President 792 N o r t h 3 0 t h S t r e e t
ldaho H e a l t h F a c i l i t i e s , Inc. B o i s e 83703
P.O. Box 2623 208/336-4117
B o i s e 83701
208/343-9735 B r e n t Brocksome
Chartham Management
Don Sower, E x e c u t i v e D i r e c t o r 2465 O v e r l a n d Road, S u i t e A
ldaho M e d i c a l A s s o c i a t i o n B o i s e 83705
407 W. Bannock 208/343-7013
B o i s e 83702
208/344-7888

3. E x e c u t i v e O f f i c e r s o f S t a t e Medical and P h a r m a c e u t i c a l
Societies:

A. Medical A s s o c i a t i o n : B. Pharmaceutical A s s o c i a t i o n :

D . Sower Rosemary W e l l s
Executive D i r e c t o r Executive D i r e c t o r
l daho M e d i c a l A s s o c i a t i o n l daho S t a t e P h a r m a c e u t i c a l
P. 0. Box 2668 Association
B o i s e 83702 C l i n t & Graham B u i l d i n g
Phone: 2081'344-7888 1365 N o r t h Orchard S t r e e t , Room 103
B o i s e 83704
Phone: 208/376-2273

C. Osteopathic Medical Association:

H a r r y E. Kale, D.O.
Secretary-Treasurer
ldaho O s t e o p a t h i c M e d i c a l A s s o c i a t i o n
522 West Main S t r e e t
Grangev i l l e 83530
208/988-1133
 Illinois - 1
1983

ILLINOIS

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e q o r i c a l l y Needy M e d i c a l ly Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC Chi I d r e 6 2 1 (SFO)
Prescribed
Drugs X X X X X X X X X X
l noat i e n t
H O ; ~ t ~a l Care X X X X X X X X X X
O-u t o a t i e n t
H o s p i t a l Care X X X X X X X X X X
Laboratory &
X-ray S e r v i c e X X X X X X X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X X X X X X X
Physician
Services X X X X X X X X X X
Dental
Services X X X X X X X X X X
*SF0 - S t a t e Funds Only

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l year e n d i n g

September 30, 1982

1981 1982
Expended R e c i p i e n t Expended Recipient

TOTAL ............................... $99,014,692 835,781** $91,880,277 803,391**

CATEGORICALLY NEEDY CASH TOTAL ...... $53,843,166 665,642
Aged ................................ 2,515,992 9,450
Blind ............................... 71,163 35 1
Disabled ............................ 11,585,460 40,675
C h i l d r e n - F a m i l i e s w/Dep Children... 17,496,882 419,987
A d u l t s - F a m i l i e s w/Dep Children..... 22,173,669 195,179

CATEGORICALLY NEEDY NON-CASH TOTAL.. $714,821 11,085

Aged ................................ 0 0
Blind...... ......................... 0 0
Disabled...... ...................... 0 0
C h i l d r e n - F a m i l i e s w/Dep Children...
315,275 7,568
..... 399,546
A d u l t s - F a m i l i e s w/Dep C h i l d r e n 3,517
..........
Other T i t l e XIX R e c i p i e n t s 0 0

MEDICALLY NEEDY TOTAL.. ............. $44,456,705 159,054

Aged.. .............................. 18,873,450 59,605
Blind.... ........................... 182,464 73 2
Disabled.. .......................... 23,833,785 70,508
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 486,407 13,448
A d u l t s - F a m i l i e s w/Dep Children..... 858,040 8,478
Other T i t l e X I X R e c i p i e n t s .......... 222,559 6,283

**Unduplicated T o t a l - HHS r e p o r t HCFA

137
 Illinois - 2
1983

1 1 1 . Administration:

l l l i n o i s Department o f P u b l i c A i d

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s :
B i o l o g i c a l s and d r u g s a v a i l a b l e from S t a t e Department of H e a l t h o r o t h e r
agencies, a n o r e c t i c s .

B. Formulary: Pharmacies a r e encouraged t o s t o c k and d i s p e n s e non-

p r o p r i e t a r y drugs of recognized q u a l i t y . If a drug i s l i s t e d i n the
Oruq Manual by g e n e r i c name and t h e i d e n t i c a l d r u g i s p r e s c r i b e d b y
t r a d e name, t h e p h a r m a c i s t may d i s p e n s e t h e t r a d e name p r o d u c t ; however,
payment w i l l be based on c o s t of t h e g e n e r i c p r o d u c t . The p h a r m a c i s t
may so a d v i s e t h e p r a c t i t i o n e r t o o b t a i n h i s p e r m i s s i o n t o d i s p e n s e t h e
g e n e r i c p r o d u c t rvhich does n o t exceed t h e maximum a l l o w a b l e p r i c e .

For formulary information contact:

Ms. Dawn A t k i ns
P.O. Box 4037
Springfield, I l l i n o i s 62708
(217)782-0506

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. "The pharmacy s h a l l d i s p e n s e n o n - p r o p r i e t a r y p r o d u c t s o f q u a l i t y .
Maximum reimbursement t o t h e pharmacy w i l l be based o n t h e p r i c e of
a n o n - p r o p r i e t a r y i t e m of r e c o g n i z e d q u a l i t y . "

I f t h e p h a r m a c i s t d i s p e n s e s a t r a d e name p r o d u c t , t h e c h a r g e t o t h e
Department of P u b l i c A i d c a n n o t exceed t h a t c h a r g e based o n t h e
maximum a l l o w a b l e c h a r q e o r c o s t i n d i c a t e d i n t h e Drug Manual.

2. Quantity: One p r e s c r i p t i o n p e r p a t i e n t p e r d r u g p e r month.

3. Refills: A p r e s c r i p t i o n may be r e f i l l e d o n l y i f t h e p r e s c r i b i n g
p r a c t i t i o n e r has so a u t h o r i z e d on t h e o r i g i n a l p r e s c r i p t i o n . A
p r e s c r i p t i o n may b e r e f i l l e d no more t h a n t w i c e and n o l a t e r t h a n 3
months f r o m t h e d a t e o f t h e o r i g i n a l p r e s c r i p t i o n . M a i n t e n a n c e RXis
may be r e f i l l e d f o r up t o one year.

4. Dollar Limits: None.

0. P r e s c r i p t i o n Charge Formula: Lowest of 1) u s u a l and customary, 2)

A c t u a l A c q u i s i t i o n Cost (AAC) p l u s fee, o r 3 ) D e p a r t m e n t ' s MAC p l u s
f e e . P r o f e s s i o n a l f e e d u r i n g FY 1982 was $3.00, r e d u c e d t o $2.78 o n
3/3/83.
NPC Illinois - 3
1983

V. Miscellaneous Information:

S t a t e MAC: Yes
A p p r o x i m a t e l y 500 d r u g s
Copayrnent - none
A v e r a g e p r e s c r i p t i o n p r i c e d u r i n g FY 1982 - $7.24

Fiscal Intermediary - none

 Illinois - 4
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. Pub1 i c A i d Department O f f i c i a l s :

J e f f r e y C. Miller Department of P u b l i c A i d
Director 316 South 2nd S t r e e t
Spr i n g f ie l d 62762

Betsy Skloot 628 E a s t Adams

Administrator Spr i ngf i e l d 62763
M e d i c a l A s s i s t a n c e Program

L o u i s J. Bosco 316 South 2nd S t r e e t

Chief S p r i n g f i e l d 62762
O f f i c e o f Personnel Management
and Labor

Theron A s l a k s e n 628 E a s t Adams

Deputy A d m i n i s t r a t o r S p r i n g f i e l d 62763
M e d i c a l A s s i s t a n c e Program

Norman L . Ryan 216 E a s t Monroe

General S e r v i c e s A d m i n i s t r a t o r S p r i n g f i e l d 62762

Mary Ann Langston 316 South 2nd S t r e e t

Administrator S p r i n g f i e l d 62762
P o l i c y and P l a n n i n g

Mark C a m i l l e , Chief 216 E a s t Monroe

Research & A n a l y s i s S p r i n g f i e l d 62706

B e v e r l y Knous, Chief 216 E a s t Monroe

Bureau o f l n f o r m a t i on Systems S p r i n g f i e l d 62762

Dawn A t k i n s , S u p e r v i s o r 931 E a s t Washington

Drug Program S p r i n g f i e l d 62763
217/782-0506

Ron G o t t r i c h 931 E a s t Washington

Pharmacist Consultant S p r i n g f i e l d 62763

2. P u b l i c A i d Department A d v i s o r y Committees:

A. The Department has a S t a t e M e d i c a l A d v i s o r y Committee, composed o f

p h y s i c i a n s a p p o i n t e d by t h e D i r e c t o r o f P u b l i c A i d . The members o f t h i s
Committee a r e from d i f f e r e n t areas o f t h e S t a t e and a r e r e p r e s e n t a t i v e of
the d i f f e r e n t s p e c i a l i t y f i e l d s .

F r e d e r i c k 6. W h i t e 723 N o r t h 2nd S t r e e t
Cha i rman C h i l l i c o t h e , l ll i n o i s 61523
 Illinois - 5
1983

B. Committee on Drugs and T h e r a p e u t i c s :

A Committee on Drugs and T h e r a p e u t i c s , a s t a n d i n g committee a p p o i n t e d b y

t h e I l l i n o i s S t a t e M e d i c a l S o c i e t y , s e r v e s i n an a d v i s o r y c a p a c i t y t o t h e
Department o f P u b l i c A i d on drug p o l i c y and t h e Drug Manual.

Joseph H. Skom, M.D. 707 F a i r b a n k s C o u r t

Cha i rman Chicago, I l l i n o i s 60611

Amin N. Oaghestani, M.O. 64 O l d Orchard, S u i t e 205

S k o k i e 60077

l g n a c i o Del V a l l e , M.O. 311 S. M a i n S t r e e t

T a y l o r v i l l e 62568

D o r o t h y H u b l e r , M.D. Casey M e d i c a l Center

Casey 62420

John Hyde, M.D. 603 F o r e s t Avenue

Oak Park 60302

R o b e r t Reeder, M.O. 970 N. 5 t h Avenue

S t . C h a r l e s 60174

Consultants:

A. Samuel E n l o e , R.Ph. 251 W. F i r s t D r i v e

Decatur 62521

K e r r i s o n J u n i p e r , M.O. SIU School o f M e d i c i n e

P. 0. Box 3926
S p r i n g f i e l d 62708

V i n c e n t A. Costanzo, Jr., 7531 S o u t h Stony I s l a n d

M.D. Chicago 60649

C. Drug A d v i s o r y Committee:

A S t a t e Drug A d v i s o r y Committee, a p p o i n t e d by t h e D i r e c t o r of t h e
Department o f P u b l i c A i d t o a d v i s e on g e n e r a l p o l i c i e s necessary t o t h e
o p e r a t i o n o f a s t a t e w i d e drug program f o r p u b l i c a s s i s t a n c e r e c i p i e n t s .

Sam Enloe, R.Ph., Chairman Ed Monroe, R.Ph.

E n l o e ' s Southtowne Pharmacy Monroe Pharmacy
251 West F i r s t D r i v e 6828 N o r t h Frostwood Parkway
Decatur 62521 P e o r i a 61615

B e r n i e Evers, R.Ph. Tom G u l i c k , R.Ph.

Evers Pharmacy G u l i c k Pharmacy, I n c .
417 West M a i n 912 N o r t h V e r m i l i o n
Col l i n s v i l l e 62234 D a n v i l l e 61832
NPC

Drug A d v i s o r y Connni t t e e ( c o n t i n u e d ) :

Don Gronewold, R.Ph. Sherwood Thomas, R.Ph.

Don's Pharmacy Touhy Pharmacy
100 South M a i n S t r e e t 7173 N o r t h C l a r k S t r e e t
Washington 61571 Ch icago 60626

Rose Mancuso, R.Ph. J e f f r e y Veal, R.Ph.

1610 Arden P l a c e 340 E a s t 8 7 t h P l a c e
J o l i e t 60435 Chicago 60619

Ed M i l l e r , R.Ph.
400 E a s t Randolph S t r e e t , #I930
#I930
Chicago 60601

E x e c u t i v e O f f i c e r s o f S t a t e M e d i c a l and P h a r m a c e u t i c a l
Societies:

A. Medical Society: 0. P h a r m a c e u t i c a l A s s o c i a t i o n :

Al Lerner A l a n L. Granat
Executive Administrator Executive D i r e c t o r
I l l i n o i s S t a t e Medical S o c i e t y I l l i n o i s Pharmaceutical
55 E a s t Monroe, S u i t e 3510 Association
Chicago 60603 222 W. Adams S t r e e t , S u i t e 546
Phone: 312/782-1654 Chicago 60606
Phone: 312/236-1135

C. Osteopathic Medical Association:

M r . George C. Andrews
Executive D i r e c t o r
I l l i n o i s A s s o c i a t i o n o f Osteopathic
P h y s i c i a n s and Surgeons, I n c .
900 East C e n t e r S t r e e t
Ottawa 61350
815/434-5576
NPC Indiana - 1
1983
INDIANA

KDlCAL ASSISTANCE DRUG PROGRAn (TITLE XIX)

I . BENEFITS PROVIDED AN0 GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l ly Needy M e d i c a l l y Needy (MN) Other*
OAA AB APT0 AFOC OAA AB APT0 AFOC C h i l d r e n < 2 1 (SFO)
Prescribed
Drugs X X X X
l n p a t ie n t
H o s p i t a l Care X X X X
Outpatient
H o s p i t a l Care X X X X
Laboratory &
X-ray ~ e r ; i c e X X X X
S k i l l e d N u r s i n -q
Home S e r v i c e s X X X X
Physician
Services X X X X
D -e n t a l
~

Services X X X X
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

June 30, 1982

1981 1982
Expended R e c i p i e n t Expended Recipient

TOTAL.. ............................. $30,933,306 197,846**

CATEGORICALLY NEEDY CASH TOTAL.. .... $14,243,896 157,234

Aged ................................ 2,960,697 8,081
Blind....... ........................ 156,865 563
Disabled.......... .................. 4,202,453 10,934
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n ... 2,310,305 84,397
A d u l t s - F a m i l i e s w/Oep Children..... 4,613,576 53,259

CATEGORICALLY NEEDY NON-CASH TOTAL.. $16,689,410 40,612

Aged.. .............................. 10,364,260 21,989
Blind....... ........................ 88,360 233
Disabled.. .......................... 5,976,703 13,806
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n . . . 110,047 3,108
A d u l t s - F a m i l i e s w/Oep Children..... 150,040 1,476
Other T i t l e XIX R e c i p i e n t s .......... 0 0

ME01 CALLY NEEDY TOTAL. .............. $0 0

Aged ................................ 0 0
Blind....... ........................ 0 0
Disabled............................ 0 0
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n . . . 0 0
A d u l t s - F a m i l i e s w/Dep Children..... 0 0
Other T i t l e X I X R e c i p i e n t s .......... 0 0

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

143
 lndiana - 2
1983

I I I. Administration:

The l n d i a n a S t a t e Department of P u b l i c W e l f a r e .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s : None.

8. Formulary: None.

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Q u a n t i t y o f Medication: None.

2. Refills: A l l o w e d as a u t h o r i z e d by p h y s i c i a n .

3. Dollar Limits: None.

D. P r e s c r i p t i o n Charge Formula:

1. The l o w e s t of t h e :

a. MAC p l u s t h e d i s p e n s i n g f e e of $2.50.

b. EAC ( E s t i m a t e d A c q u i s i t i o n C o s t ) p l u s t h e d i s p e n s i n g f e e o f
$2.50. (EAC i s 3% l e s s t h a n AWP r e p o r t e d b y Drug T o p i c s Red
Book)

c. Pharmacy's u s u a l and customary c h a r g e t o t h e g e n e r a l p u b l i c .

V. M i s c e l l a n o u s I n f o r m a t i o n :

F i s c a l Intermediary:

EDS F e d e r a l Corp
120 W. Market S t r e e t
Indianapolis, lndiana 46240
 lndiana - 3
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. W e l f a r e Department O f f i c i a l s :

Donald L . B l i n z i n g e r Department o f P u b l i c W e l f a r e
Administrator 100 N. Senate Avenue
Room 701
I n d i a n a p o l i s , l n d i a n a 46204

James H. C w k
Assistant Administrator-
Administration

Robert F. Smith
Assistant Administrator-
Medicaid

W i l l i a m Harding
Director
D i v i s i o n of A d m i n i s t r a t i v e
Services

Mrs. Nary Kapur

Assistant Administrator
Local Operations D i v i s i o n

Mark S h i r l e y
Pharmacy C o n s u l t a n t

2. A d v i s o r y Committee f o r M e d i c a l A s s i s t a n c e ( M e d i c a i d )

Hon. W i l l i a m Dunbar - lndiana S t a t e Senate

219 West 1 1 t h S t r e e t
Anderson 46016

John Cervenka - S t a t e w i d e Taxpayer

R.R. 1, Box 121
N o r t h Judson

Hon. J e f f e r y K. E s p i c h - House of R e p r e s e n t a t i v e s
Box 158
Uni ondal e 46791

Demetri us Ewi ng - C i t i z e n r y of lndiana

513 South 1 5 t h S t r e e t
T e r r e Haute 47801

L o w e l l G. F o s t e r , M.D. - l n d i a n a P s y c h i a t r i c Assoc.
3500 L a f a y e t t e Road, S u i t e 103
l nd i anapol i s 46222
 lndiana - 4
1983

A d v i s o r y Committee f o r M e d i c a l A s s i s t a n c e ( c o n t i n u e d ) :

Newel l J. Hal I, V i c e P r e s d i e n t - Indiana Pharmaceutical

D i r e c t o r , Professional Services Association, Inc.
Hook Drug, I nc.
2800 E n t e r p r i s e S t r e e t
l nd ianapol i s 46226

C a r l 0. H i c k s - Agricultural lnterests
R .R.
P e r r y s v i l l e 47974

John Huber, A d m i n i s t r a t o r - l n d i a n a H e a l t h Care Assoc.

Sycamore V i l l a g e H e a l t h
Care C e n t e r
2905 West Sycamore Road
Kokomo 46901

Edward W. James - Labor l n t e r e s t s

3150 West 1 9 t h P l a c e
Gary 46402

George H. James, A d m i n i s t r a t o r - Indiana H o s p i t a l A s s o c i a t i o n

Jackson County H o s p i t a l
200 South Walnut S t r e e t
Seymour 47274

J o Haynes Books, R.N. - I n d i a n a S t a t e N u r s e s ' Assoc.

Associate Professor, Nursing
Purdue U n i v e r s i t y School o f N u r s i n g
West L a f a y e t t e 47907

A l b e r t F. K u l l , 0.0. - l n d i a n a A s s o c i a t i o n of
203 South Ironwood D r i v e Osteopathic Physicians
P. 0. Box 6172 and Surgeons
South Bend 46615

Mrs. F r a n c i s Mitcham - lndiana S t a t e Licensed

3436 N o r t h L a S a l l e P r a c t i c a l Nurses'
I n d i a n a p o l i s 46218 Association, Inc.

George F. P a r k e r , M.O. - l n d i a n a C h a p t e r American

1502 N o r t h Emerson Avenue Academy o f P e d i a t r i c s
l n d i a n a p o l i s 46219

C l i f f o r d A. B e y l e n - Ex-Officio - Representing
D i v i s i o n of M e d i c a l Care S t a t e H e a l t h Commissioner
Administration
lndiana S t a t e Board o f H e a l t h
1330 West M i c h i g a n S t r e e t
I n d i a n a p o l i s 46202
NPC lndiana - 5
1983

A d v i s o r y Comni t e e f o r Medical A s s i s t a n c e ( c o n t i n u e d ) :

Mrs. M a r i e Peacock, R.N. - C i t i z e n r y o f lndiana

2300 E x e c u t i v e D r i v e
Kokomo 46901

R o b e r t S h i r e y , D.O.S., - l n d i a n a S t a t e D e n t a l Assoc.
Chairman
l n d i a n a S t a t e D e n t a l Assoc.
1121 West M i c h i g a n S t r e e t
l n d i a n a p o l i s 46202

Robert Spaulding

A l b e r t 0 . Stroud, 0.0. - l n d i a n a O ~ t o m e t r i cAssoc.

6326 Rucker Road, S u i t e C
l n d i a n a p o l i s 46220

J. K. Wicklebach, O.P.M. - lndiana State Podiatry

5921 E a s t Washington S t r e e t
l n d i a n a p o l i s 46219

C h a r l e s Watkins, O.C. - lndiana State C h i r o p r a c t i c

5117 E a s t Washington S t r e e t Association
l n d i a n a p o l i s 46219

A r v i n e G. P o p p l e w e l l , M.D. - State Medical Association

6555 G l a c i e r D r i v e
l n d i a n a p o l i s 46217

3. E x e c u t i v e O f f i c e r s of S t a t e M e d i c a l and P h a r m a c e u t i c a l
Societies:

A. Medical Association:

Donald F. Foy
Executive D i r e c t o r
lndiana S t a t e Medical A s s o c i a t i o n
3936 N o r t h M e r i d i a n
l n d i a n a p o l i s 46208
Phone: 317/925-7545

B. Pharmaceutical Association:

D a v i d A. C l a r k
Executive D i r e c t o r
lndiana Pharmacists A s s o c i a t i o n
156 E. Market S t r e e t , #YO0
l n d i a n a p o l i s 46204
Phone: 317/634-4968
NPC

I l l . Administration:

Central administration by the State Department of Social Services.

IV. Provisions Relating to Prescribed Drugs:

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

Non-legend drugs, amphetamine products, and legend multiple vitamins.
Also laxative drugs effective 7/1/80.

0. Formulary: None.

C. Prescribing or Dispensing Limitations:

1. Terminology: None.

2. Quantity of Medication: Prescriptions should be limited to a 30-day

supply. Maintenance drugs may be supplied in 90-day quantities.

3. Refills: Permitted.

4. Dollar Limits: None.

D. Prescription Charge Formula: Payment will be based on the pharmacist's

usual, c u s t m a r y and reasonable charge, but payment may not exceed the
current wholesale cost of the drug as defined by the Department of
Social Services, plus a professional fee determined to be he 75th
percentile of usual and customary fees. Currently $3.74. 1 !
V. Miscellaneous Remarks:

FY -
1982

Total number Rx

Average cost/Rx for all categories

VI. Claims Processing Intermediary:

Systems Development Corporation

P.O. Box 10394
Des Moines, Iowa 50306

Source: S t a t i s t i c s S e c t i o n , D i v i s i o n of A d m i n i s t r a t i o n .

1) $0.50 copay (Federal Exclusions) fee. $3.74 fee effective July 1, 1983.
 lowa - 3
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. S o c i a l S e r v i c e s Department O f f i c i a l s :

M i c h a e l V. Reagen, Ph.D. Department o f S o c i a l S e r v i c e s

Commissioner Hoover S t a t e O f f i c e B u i l d i n g
Des Moines, lowa 50319

Donald L. Kassar
Chief
Bureau o f M e d i c a l S e r v i c e s

R o n a l d J. Mahrenholz, R.Ph., M.S.

Manager
U t i l i z a t i o n Review S e c t i o n

2. S o c i a l S e r v i c e s Department A d v i s o r y Committees:

A. T i t l e XIX M e d i c a l A s s i s t a n c e C o u n c i l :

C o l l e g e of M e d i c i n e lowa H o s p i t a l A s s o c i a t i o n I n c .
Paul Seebohm. M.D. Donald Dunn
A s s o c i a t e Dean S u i t e R, 600 5 t h Avenue
C o l l e g e of M e d i c i n e Des Moines 50309
University Hospitals
lowa C i t y 52240 lowa M e d i c a l S o c i e t y
Donald C. Younq, M.O.
House o f R e p r e s e n t a t i v e s 1301 1 0 t h s t r e e t , S u i t e 119
Rep. Andy McKean Des Moines 50316
M o r l e y 52312
lowa Nurses A s s o c i a t i o n
Rep. Rodney H a l v o r s o n M a r i l v n R u s s e l l (Mrs.)
1030 N o r t h 7 t h S t . P u b l i c H e a l t h N u r s i n g Assoc.
F o r t Dodge 50501 Armory B u i l d i n g
E a s t 1 s t & Des Moines S t r e e t
lowa D e n t a l A s s o c i a t i o n Oes Moines 50309
C. E. O'Meara
530 3 9 t h S t r e e t H e a l t h F a c i l i t i e s Assoc. o f
Des Moines 50309 -l owa
R. Buckman Brock
O p t i c i a n s Assoc. o f lowa, P. 0. Box 677
-I. nc..
Everett Hainline
2137 Sunset Road
Des Moines 50303
1460 7 5 t h S t r e e t
Des Moines 50311
 lowa - 4
1983

T i t l e XIX M e d i c a l A s s i s t a n c e C o u n c i l ( c o n t i n u e d ) :

Iowa S o c i e t y o f O s t e o p a t h i c Iowa Senate

P h y s i c i a n s and Surgeons Senator D a l e L. T i e d e n
Dante R. T o r i e l l o , D.O. E l k a d e r 52043
623 E. 1 2 t h S t r e e t
Oes Moi nes 50316 Iowa C h i r o p r a c t i c S o c i e t y
Mrs. P a t M i t c h e l l
Iowa O p t o m e t r i c A s s o c i a t i o n 3500 2nd Avenue, S u i t e 2
Thomas E. Ward, O.D. Des Moines 50313
801 Grand- Avenue
.. -.
Oes Moines 50309 P u b l i c Represenatives
Mary E l l e n Evans (Mrs.)
lowa O s t e o p a t h i c H o s p i t a l 2503 F u l t o n Avenue
Association Davenport 52803
James K i n a s b u r v
603 E. 1 2 t h ~ t k e e t Sharon L. Geers
Oes Moines 50316 1200 3 5 t h S t r e e t , S u i t e 120
West Oes Moines 50265
lowa P h a r m a c i s t s Assoc.
Thomas R. Temple Deidra R e i l l y
8515 Douglas, S u i t e 24 1332 2 3 r d S t r e e t , A p t . 8
Oes Moines 50322 Des Moines 50311

lowa P o d i a t r y S o c i e t y R o b e r t L. B r a y
Tom Anderson, D.P.M. 4129 F o r e s t Avenue
Box 430 Oes Moines 50311
Oecorah 52101

lowa S t a t e Oept. of H e a l t h
Norman Pawlewski
Commissioner
Lucas S t a t e O f f i c e B u i l d i n g
Oes Moines 50319

B. P h a r m a c e u t i c a l A d v i s o r y Committee:

Mark R i c h a r d s , Oes Moines

B i l l Robinson, A t l a n t i c
P h i l Weider, Des Moines
Dan K e c k l e r , E l d r i d g e
Nancy Riggs, Oes Moines
A1 Shepley, M t . Vernon
K a r l Hunter, C l i n t o n
Ken Hampson, Ames
Russ Wiesley, U r b a n d a l e
Duane H a b e r i c h t e r , Oskaloosa
Marion Reis, Sioux C i t y
Roger Zobel, West Oes Moines
L o n n i e Col t r a i n , E l d o n
 lowa - 5
1983

3. E x e c u t i v e O f f i c e r s o f S t a t e Medica! and P h a r m c e u t i c a l
Societies:

A. Medical Society:

E l d o n Huston
Executive Vice-president
lowa M e d i c a l S o c i e t y
1001 Grand Avenue
West Des Moines 50265
Phone: 515/223-1401

B. Pharmacists Association:

Thomas R. Temple, R.Ph., M.S.

Executive Director
lowa P h a r m a c i s t s A s s o c i a t i o n
8575 Douglas, S u i t e 24
Des Moines 50322
Phone: 515/270-0713
 Kansas - 1
1983

mOICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e q o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC Chi I d r e 6 2 1 (SFO)
Prescribed
Oruqs X X X X X X X X X X
l npat i e n t
H o s p i t a l Care X X X X X X X X X X
Outpatient
Hosp i t a 1 Care
- X X X X X X X X X X
Laboratory &
X-ray S e r v i c e X X X X X X X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X X X X X X X
Physician
Services X X X X X X X X X X
Dental
Services X X X X X X X X X
Other B e n e f i t s : Home H e a l t h Care; C l i n i c S e r v i c e s ; R e h a b i l i t a t i v e S e r v i c e s ;
Prostheses; P r e v e n t i v e Services; Family Planning Services; C h i r o p r a c t i c Services;
O p t o m e t r i c S e r v i c e s ; and Community Based A l t e r n a t e S e r v i c e s .
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

June 30, 1982

1981 1982
Expended R e c i p i e n t Expended Recipient

TOTAL ............................... $14,460,222 107,550** $15,686,744 106,097**

CATEGORICALLY NEEDY CASH TOTAL.. .... $7,025,434 78,661 $8,007,814 80,939

Aged.. .............................. 2,137,567 8,102 2,342,194 7,692
B l i n d ............................... 38,339 186 42,220 163
D i s a b l e d . ........................... 2,216,722 8,399 2,569,024 8,459
C h i l d r e n -Fami 1 i e s w/Dep Children... 1,087,810 42,033 1,188,504 42,452
A d u l t s - F a m i l i e s w/Dep Children..... 1,544,996 21,292 1,865,872 23,544

CATEGORICALLY NEEDY NON-CASH TOTAL.. $112,263 5,325 $87,610 2,243

Aged ................................ 19 2 0 0
Blind......... ...................... 0 0 0 0
Disabled..... ....................... 278 2 0 0
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n ... 43,876 2,932 84,060 2,118
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . .... 65,454 2,348 2,770 112
..........
Other T i t l e X I X R e c i p i e n t s 2,636 61 78 0 13

MEDICALLY NEEDY TOTAL. .............. $7,322,525 29,717 $7,591,320 25,942

Aged ................................ 5,553,520 17,311 5,845,771 16,187
Blind............ ................... 27,753 89 25,317 73
D i s a b l e d . ........................... 1,422,650 4,497 1,495,734 4,163
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 123,347 4,530 76,850 3,314
A d u l t s - F a m i l i e s w/Dep Children..... 138,051 2,193 142,508 2,352
Other T i t l e X I X R e c i p i e n t s .......... 57,204 1,506 5,140 193

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

153
 Kansas - 2
1983

I l l . 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.

B. Formulary: None.

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 participating pharmacy within the range of $1.60 to
$4.23 for FY-1982.

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
determined by the agency for each covered drug in accordance with
federal regulations.

Effective May 1 , 1983, a recipient co-pay charge of $1.00 was applied to

each new and refill prescription.
NPC Kansas - 3
1983

O f f i c i a l s , Consultants and Committees

1. Social and R e h a b i l i t a t i o n Services Department O f f i c i a l s :

D r . Robert C. Harder Department o f S o c i a l and

Secretary R e h a b i l i t a t i o n Services
State Office Building
Topeka, Kansas 66612

S a l l y Anderson, D i r e c t o r
l ncome Ma i ntenance

Robin Smith, D i r e c t o r
P u b l i c Assistance Section

L. Kathryn Klassen, R.N., M.S.

Director
D i v i s i o n o f Medical Programs

Lynn Muchmore, Budget D i r e c t o r

Department o f A d m i n i s t r a t i o n

Joyce Sugrue, R.N.

Coordinator o f Medical Services

E l a i n e Hacker, M.D.
U t i l i z a t i o n Review A d m i n i s t r a t o r

Gene Hotchkiss, R.Ph.

Pharmacist Consultant

2. Governor's Medical Advisory Committee:

C l i n t Willsie, Director Daniel A. Shea, O.D.

Sedgwick County Development of 2720 East 21st S t r e e t
Mental H e a l t h Wichita, Kansas 67214
1801 East Tenth S t r e e t
Wichita 67214 Helen Jones
Department o f Aging
Dean C o l l i n s , M.D. 2700 West S i x t h S t r e e t
Menni nger Foundation Topeka 66606
P. 0. Box 829
Topeka 66601 James Hawk i ns
C l i n i c a r e Family H e a l t h Services
Theodore Young, M.D. 510 Southwest Boulevard
107 Medical A r t s B u i l d i n g Kansas C i t y 66103
Topeka 66604
 Kansas - 4
1983

G o v e r n o r ' s M e d i c a l A d v i s o r y Committee ( c o n t i n u e d ) :

Warren W. A b b o t t , D.P.M. Thomas McEvoy, A d m i n i s t r a t o r

1919 West 1 0 t h S t r e e t Leavenworth County Convelescent
Topeka 66604 l n f i rmary
Broadway & Rees
A l i c e Fisher Leavenworth 66048
226 Woodruff
Topeka W i l l i a m J. Ciskey, M.D.
1602 N o r t h Elm
Joseph H o l l o w e l I, M.D. Eureka 67048
D i r e c t o r of H e a l t h
Department of H e a l t h and
Environment
6700 South Topeka B l v d . Department R e p r e s e n t a t i v e s
Topeka 66620
Dr. R o b e r t C. H a r d e r
H a r l e y R u s s e l l , R.Ph., Chairman
R u s s e l l Drugs, Inc. L. K a t h r y n Klassen, R.N., M.S.
3400 S o u t h F o u r t h
E l a i n e Hacker, M.D.

Robert O'Brien Gene H o t c h k i s s , R.Ph.

S e n i o r V i c e P r e s i dent
Wesley M e d i c a l Center
550 N o r t h H i l l s i d e
W i c h i t a 67214

R o b e r t E. Johnson
Admini s t r a t o r
Miama County H o s p i t a l
501 S o u t h H o s p i t a l D r i v e
P a o l o 66071
 Kansas - 5
1983

3. E x e c u t i v e O f f i c e r s o f S t a t e Medical and P h a r m a c e u t i c a l
Societies:

A. Medical Society:

Steve C a r t e r
Executive D i r e c t o r
Kansas M e d i c a l S o c i e t y
1300 Topeka B o u l e v a r d
Topeka 66612
Phone: 913/235-2383

8. Pharmaceutical Association:

Kenneth W. Schafermeyer
Executive D i r e c t o r
Kansas P h a r m a c e u t i c a l A s s o c i a t i o n
1308 West 1 0 t h S t r e e t
Topeka 66604
Phone: 913/232-0439

C. Osteopathic Medical Association:

M r . H a r o l d Reihm
Executive D i r e c t o r
Kansas A s s o c i a t i o n o f O s t e o p a t h i c M e d i c i n e
F i r s t N a t i o n a l Bank Tower -
1425
Topeka 66603
 Kentucky - 1
1983

KENTUCKY

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APT0 AFOC OAA AB APT0 AFOC C h i l d r e n Q l (SFO)
Prescribed
Druqs X X X X X X X X X
l m a t ie n t
~ o i ~ i t Carea l X X X X X X X X X
Outoat i e n t
H o s p i t a l Care X X X X X X X X X
Laboratory &
X-ray S e r v i c e X X X X X X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X X X X X X
Physician
Services X X X X X X X X X
Dental
Services X X X X X X X X X
*SF0 - S t a t e Funds Only

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s by f i s c a l year e n d i n g

September 30, 1982

1981 1982
Expended R e c i p i e n t Expended Recipient

TOTAL ............................... $16,615,252 263,380** $15,665,394

CATEGORICALLY NEEDY CASH TOTAL ...... $14,898,408 212,561

Aged ................................ 4,460,087 35,991
Blind. .............................. 188,449 1,555
Disabled ............................ 6,457,132 43,466
.
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n . . 1,734,152 85,213
.....
A d u l t s -Families w/OepChildren 2,058,588 47,524

CATEGORICALLY NEEDY NON-CASH TOTAL.. $0 0

Aged ................................ 0 0
Blind ............................... 0 0
Disabled....... ..................... 0 0
C h i l d r e n - F a m i l i e s w/Oep Children... 0 0
A d u l t s - F a m i l i e s w/Oep C h i l d r e n..... 0 0
Other T i t l e X I X R e c i p i e n t s .......... 0 0

ME01 CALLY NEEDY TOTAL.. ............. $1,716,844 57,970

Aged ................................ 178,980 2,341
Blind........... .................... 2,266 16
Disabled........ .................... 227,297 2,115
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n . . . 486,889 25,272
A d u l t s - F a m i l i e s w/Oep Children..... 658,347 20,550
Other T i t l e XIX R e c i p i e n t s .......... 163,065 8,375

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

 Kentucky - 2
1983

I l l . Administration:

By t h e D i v i s i o n f o r Medical A s s i s t a n c e w i t h i n t h e Department f o r S o c i a l
Insurance, w i t h i n t h e C a b i n e t f o r Human Resources.

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s ( d i s e a s e s , d r u g c a t e g o r i e s , e t c . ) :
The f o l l o w i n g a r e items w h i c h a r e n o t c o v e r e d under t h e pharmacy
b e n e f i t s a r e a o f t h e program:

1. Most m e d i c a l s u p p l y items such as bedpans, u r i n a l s , i c e bags, e t c .

(Note: l n s u l i n s y r i n g e s a r e covered.)

2. M e d i c i n e c a b i n e t s u p p l i e s and d r u g s t a p l e s .

3. Drugs a v a i l a b l e t h r o u g h o t h e r programs o r a g e n c i e s .

4. Drugs n o t i n c l u d e d on t h e Kentucky Medical A s s i s t a n c e Program Drug

L i s t ( u n l e s s p r e - a u t h o r i z e d a c c o r d i n g t o e s t a b l i s h e d g u i d e l i n e s and
criteria).

5. M e d i c a t i o n s and s u p p l i e s used o r dispensed by p h y s i c i a n s o r d e n t i s t s

d u r i n g home o r o f f i c e c a l l s .

6. Most non-legend ( o v e r - t h e - c o u n t e r ) drugs e x c e p t t h o s e used t o t r e a t

d i a b e t e s and i r o n d e f i c i e n c y anemia and e n t e r i c c o a t e d a s p i r i n .

B. Formulary: Yes. T h i s l i s t i s r e v i s e d i n accordance w i t h

recommendations of t h e F o r m u l a r y Subcommittee and i n accordance w i t h
a v a i l a b l e funds.

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Q u a n t i t y of M e d i c a t i o n s : None.

2. Refills: No p r e s c r i p t i o n s may be r e f i l l e d more t h a n 5 t i m e s o r more

t h a n 6 months a f t e r t h e p r e s c r i p t i o n i s w r i t t e n .

3. Dollar Limits: None.

D. P r e s c r i p t i o n Charge -- Reimbursement Formula:

1. A l l c o v e r e d o u t p a t i e n t pharmacy b e n e f i t s p r o v i d e d t o K e n t u c k y
Medical A s s i s t a n c e Program r e c i p i e n t s a r e t o b e b i l l e d t o t h e
Program a t t h e u s u a l charge t o t h e g e n e r a l p u b l i c f o r t h e same
p r o d u c t and s e r v i c e ( s ) .
NPC Kentucky - 3
1983

P r e s c r i p t i o n Charge -- Reimbursement Formula ( c o n t i n u e d ) :

Reimbursement t o t h e pharmacy c o n s i s t s o f t h e l o w e s t o f : ( 1 ) the

u s u a l and customary charge; ( 2 ) t h e MAC, i f any, p l u s d i s p e n s i n g
fee; o r ( 3 ) t h e EAC p l u s d i s p e n s i n g f e e .

2. The d i s p e n s i n g fee i s $2.35.

3. Co-payment - none.

V. M i s c e l l a n e o u s Remarks:

Payment f o r d r u g s i s l i m i t e d t o those pharmacies w h i c h a f f i l i a t e themselves

w i t h t h e Medical A s s i s t a n c e Program by c o m p l e t i n g t h e "Agreement o f
P a r t i c i p a t i n g Pharmacies."

Fiscal Intermediary:

E l e c t r o n i c Data Systems Corp

D a l l a s , Texas

Average Rx p r i c e d u r i n g FY 1982 - $7.00

 Officials, Consultants and Committees

1. Officials:

Buddy H. Adams Cabinet f o r Human Resources

Secretary 4 t h F l o o r , DHR B u i l d i n g
275 East Maln S t r e e t
F r a n k f o r t , Kentucky 40621

John Cubine Department f o r S o c i a l Insurance

Commissioner 3rd Floor, DHR B u i l d i n g
275 East Main S t r e e t
F r a n k f o r t 40621

James B. Gooding, D i r e c t o r
D i v i s i o n of Medical Assistance

(Miss) Gene A. Thomas, R.Ph.

D i v i s i o n of Medical Assistance
502/564-4321

S t a t e Advisory Council on Medical Assistance appointed by t h e Governor, i s

composed of members representing pharmacy, h o s p i t a l s , r e g i s t e r e d nurses,
medical doctors, d e n t i s t s , nursing homes, optometrists, p o d i a t r i s t s ; meet
q u a r t e r l y or more often.

A. Advisory Council f o r Medical Assistance:

Howard L. Bost, Ph.D. (Chrmn) Ms. A l i c e LeMaster

A s s i s t a n t Vice President f o r 227 Douglas Avenue
Program G P o l i c y Planning F r a n k f o r t 40601
U n i v e r s i t y of Kentucky
Medical Center L a r r y H. Spears, R.Ph.
Lexington 40506 C/O Grant County Drugs
Dry Ridge 41035
Theodore E. Logan, Jr.,
D.M.D. Ms. Wanda Humphreys
4229 Bardstown Road North Race S t r e e t
L o u i s v i l l e 40218 Glasgow 42141

Nawanda Daniel s E.P. H i l t o n

801 South 3 5 t h S t r e e t 219 Lyons D r i v e
L o u i s v i l l e 40211 F r a n k f o r t 40601

Robert N. McLeod, M.O. Suzanne Vance

500 Bourne Avenue 12708 S t . C l a i r D r i v e
Somerset 42501 Middletown 40243
 Kentucky - 5
1983

A d v i s o r y Counci l f o r Medical A s s i s t a n c e ( c o n t i n u e d ) :

C. A. Nava, D.P.M. E l l e n B u c h a r t , R.N.

Secretary J e f f e r s o n County H e a l t h Department
Kentucky S t a t e Board 400 East Gray S t r e e t
o f Podiatry L o u i s v i l l e 40202
110 N o r t h Hubbard Lane
L o u i s v i l l e 40207 J e r r y Rogers
550 H i g h S t r e e t
Nedra Dav i ne B o w l i n g Green 42101
Administratrix
Dover Manor Thomas W. G r a n t
Scot l a n d Wood D r i v e Good Samaritan H o s p i t a l
Georgetown 40324 310 South L i m e s t o n e S t r e e t
L e x i n g t o n 40503
Wayne Helderman, O.D.
20 Broadway John Cubine ( e x o f f i c i o )
M t . S t e r l i n g 40353 Comm i 55 i oner
Department f o r S o c i a l I n s u r a n c e
Frances Johnson DHR B u i l d i n g , 3 r d F l o o r
308 S t . Johns Court, Apt. C F r a n k f o r t 40621
F r a n k f o r t 40601
Buddy H. Adams ( e x o f f i c i o )
Secretary
C a b i n e t f o r Human Resources
DHR B u i l d i n g , 4 t h F l o o r
F r a n k f o r t 40621

F o r m u l a r y Subcommittee

Robert N. McLeod, M.D. R. N. Smith

Cha i rman S m i t h ' s Pharmacy
500 Bourne Avenue B u r k e s v i l l e 42717
Somerset 42501
Samuel R. S c o t t , M.D.
James Sieg, Ph.D. 1302 Richmond Road
U n i v e r s i t y o f Kentucky L e x i n g t o n 40508
C o l l e g e of Pharmacy
L e x i n g t o n 40506 Thomas G. S c h a r f f , Ph.0.
Department o f Pharmacology
John M. B a i r d , M.0 H e a l t h Sciences C e n t e r
216 Maple Avenue University o f Louisville
D a n v i l l e 40422 Post O f f i c e Box 1055
L o u i s v i l l e 40201
Ms. E l l e n Buchart, R.N.
J e f f e r s o n County H e a l t h Chester L. P a r k e r , Pharrn.0.
Department 1816 D a r i e n D r i v e
400 East Gray S t r e e t L e x i n g t o n 40201
L o u i s v i l l e 40202
NPC Kentucky - 6
1983

B. Pharmacy T e c h n i c a l A d v i s o r y Comnittee:

Or. C o n d i t S t e i l James E. G a r r e t t , R.Ph.

Cha i rman Pharmacare, Inc.
Trover C l in i c 211 Geri Lane
Mad i sonv i l le 42431 Richmond 40475

Michael Sheets, R.Ph. B i l l S h i n k l e , R.Ph.

903 Lyndon Lane 621 Cherrywood O r i v e
L o u i s v i l l e 40222 El i z a b e t h t o w n 42701

D a v i d Hancock, R.Ph.
401 Park Row
B o w l i n g Green 42101

3. E x e c u t i v e O f f i c e r s o f S t a t e Medical and Pharmaceutical

Societies:

A. Medical A s s o c i a t i o n :

Robert K l i n g l e s m i t h
Executive D i r e c t o r
Kentucky Medical A s s o c i a t i o n
3532 Ephra im McDowell O r i v e
Lou i sv i I 1e 40205
Phone: 502/459-9790

8. Pharmaceutical A s s o c i a t i o n :

Paul Davis, R.Ph.

Executive D i r e c t o r
Kentucky Pharmacists A s s o c i a t i o n
P. 0. Box 715, 1228 U.S. Hwy. 1275
F r a n k f o r t 40602
Phone: 502/227-2303

C. D s t e o p a t h i c Medical A s s o c i a t i o n :

Lewis C. Cheatham
Executive D i r e c t o r
Kentucky D s t e o p a t h i c Medical A s s o c i a t i o n
412 Camp S t r e e t
L o u i s v i l l e 40203
 Louisiana -1
1983

LOUISIANA

HEOICAL ASSISTANCE DRUG PROGRAM (TITLE X I X )

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC C h i l d r e n c 2 1 (SFO)
Prescribed
Drugs X X X X X X X X X X
l noat i e n t
H o s p i t a l Care X X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X X
Laboratory &
X-ray S e r v i c e X X X X X X X X X X
S k i l l e d N u r s i n -q
Home S e r v i c e s X X X X X X X X X X
Physician
Services X X X X X X X X X X
Dental
Services X X X X X X X X X X
*SF0 - S t a t e Funds Only

II. EXPENDITURES FOR DRUGS. Payments t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

June 30, 1982

1981 1982
Expended R e c i p i e n t Expended Recipient

TOTAL *..............................$46,037,401 300,236** $52,280,483 276,307**

CATEGORI CALLY NEEDY CASH TOTAL.. ....

Aged ................................
B l i n d . ..............................
Disabled... .........................
C h i l d r e n - F a m i l i e s w/Dep Children...
A d u l t s - F a m i l i e s w/Dep C h i l d r e n .....
CATEGORICALLY NEEOY NON-CASH TOTAL..
Aged ................................
Blind.... ...........................
Disabled..... .......................
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . ..
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . . ..
Other T i t l e X I X R e c i p i e n t s ..........
MEDICALLY NEEDY TOTAL. .............. $442,447 3,914 $600,371 5,123
Aged ................................ 70,127 503 147,284 1,239
B l i n d ............................... 0 0 23 1 2
D i s a b l e d ............................ 222,674 1,191 308,058 1,771
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 40,141 1,298 42,013 1,455
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . . .. 109 505 922 102,731 1,034
Other T i t l e X I X R e c i p i e n t s .......... 0 0 54 4

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

164
NP C Louisiana - 2
1983

I l l . Administration:

P u b l i c a s s i s t a n c e programs are admi n i s t e r e d by t h e S t a t e O f f i c e o f Family

S e c u r i t y , Department o f H e a l t h and Human Services.

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. P r e s c r i b e d legend and non-legend drugs (OTC) a r e reimbursed.

B. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Q u a n t i t y o f Medication: New p r e s c r i p t i o n must be issued f o r drugs

g i v e n on a c o n t i n u i n g basis, a f t e r 5 r e f i l l s or a f t e r 6 months.

Maximum payment q u a n t i t y f o r p r e s c r i p t i o n s s h a l l be e i t h e r one

nwnth's treatment or 100 u n i t doses.

2. Refills: P e r m i t t e d as i n d i c a t e d by p h y s i c i a n w i t h i n 6 months and

n o t t o exceed 5 r e f i l l s .

3. Dollar Limits: None.

C. P r e s c r i p t i o n Charge Formula:

1. The maximum payment f o r a p r e s c r i p t i o n i s estimated a c q u i s i t i o n c o s t

p l u s $3.67 dispensing fee.

D. F i s c a l Intermediary:

The Computer Company

P.O. Box 4169
Baton Rouge, L o u i s i a n a 70821

E. Number o f Rx c l a i m s processed i n FY 1982 - 5,010,988

Average Rx p r i c e FY 1982 - $10.44

 Louisiana - 3
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. H e a l t h and Human Resources A d m i n i s t r a t i o n O f f i c i a l s :

R.P .
Gu iss i nger Department o f H e a l t h and Human
Resources
Secretary
P. 0. Box 3776
B a t o n Rouge, L o u i s i a n a 70804

R. K. Banks Office o f Family S e c u r i t y

Assistant Secretary 755 R i v e r s i d e N o r t h
P.O. Box 44065
B a t o n Rouge, L o u i s i a n a 70804

Jake Canova
Deputy A s s i s t a n t S e c r e t a r y

W a l t e r S. McLean, Jr.
A s s i s t a n t D i r e c t o r f o r Operations
M e d i c a l A s s i s t a n c e Programs

C a r o l y n Maggio (Mrs.)
Director
M e d i c a l A s s i s t a n c e Programs

E u n i c e R i t c h i e , R.Ph.
Pharmacist Consultant
Medica 1 A s s i s t a n c e Programs

2. O f f i c e o f F a m i l y S e c u r i t y A d v i s o r y Committees:

A. M e d i c a l A d v i s o r y Committee:

( T o be a p p o i n t e d )

B. Pharmacy Program A d v i s o r y Committee:

(Ad Hoc B a s i s On1 y )

 Louisiana - 4
1983

3. E x e c u t i v e O f f i c e r s o f S t a t e Medical and P h a r m a c e u t i c a l
Societies:

A. Medical S o c i e t y :

James S t e w a r t , M.D.
Executive Vice President
L o u i s i a n a S t a t e Medical S o c i e t y
1700 Josephine S t r e e t
New O r l e a n s 70113
Phone: 504/561-1033

6. Pharmaceutical Association:

Peter Caldwell
Executive Vice President
Louisiana S t a t e Pharmacists A s s o c i a t i o n
2337 S t . Claude Avenue
New O r l e a n s 70117
Phone: 504/949-7545

C. Osteopathic Association:

C h a r l e s S. Wyckoff, 0.0.
Sec r e t a r y - T r e a s u r e r
Louisiana Association o f Osteopathic Physicians
333 S t . Charles Avenue -
412
New O r l e a n s 70115
 Maine - 1
1983

E D I C A L ASSISTANCE DRUG PROGRAH (TITLE X I X )

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l ly Needy (MN) Other*
OAAABAPTDAFDC OAAABAPTDAFDC C h i l d r e n c 2 1 (SFO)
Prescribed
Drugs X X X X X X X X X
l npat i e n t
H o s p i t a l Care X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X
Laboratory &
X-ray S e r v i c e X X X X X X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X X X X X X
Physician
Services X X X X X X X X X
Dental
Services X X X X X X X X X
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982

1981 1982
Expended R e c i p i e n t Expended Recipient

CATEGORICALLY NEEDY CASH TOTAL..... . $5,789,935 64,469 6,359,062 61,102

Aged.. .............................. 1,819,644 9,268 1,938,671 8,681
Blind ............................... 34,347 185 37,524 185
Disabled... ......................... 2,296,453 9,970 2,723,812 10,320
..
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . 542,583 26,299 514,401 24,322
.....
A d u l t s - F a m i l i e s w/Oep C h i l d r e n 1,096,908 18,747 1,144,654 17,861

CATEGORICALLY NEEDY NON-CASH TOTAL.. $3,151,361 19,782 31555,497 21,291

Aged. ............................... 2,321,800 9,416 2,574,186 9,006
Blind.. ............................. 1,888 7 2,090 11
Disabled..... ....................... 596,833 2,095 671,315 2,744
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n ... 194,856 7,098 271,384 8,530
A d u l t s - F a m i l i e s w/Oep C h i l d r e n ..... 1,705 23 752 12
Other T i t l e XIX R e c i p i e n t s .......... 34,279 1,143 35,770 1,141

MEDI CALLY NEEDY TOTAL.. ............. $693,129 10,077 $442,761 6,980

Aged ................................ 216,447 1,190 116,030 639
Blind..... .......................... 414 2 8 1
D i s a b l e d ............................ 211,071 1,026 127,293 603
C h i l d r e n - F a m i l i e s w / D e p C h i l d r e n ... 106,079 5,108 90,484 4,112
A d u l t s - F a m i l i e s w/Oep C h i l d r e n ..... 159,118 2,751 108,946 2,038
Other T i t l e X I X R e c i p i e n t s .......... 0 0 0 0

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

168
 Maine - 2
1983

I I I . 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
comnon 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: None:

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.

0. 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.

E. Copayment: $0.50

V. Miscellaneous:
Average Rx price during FY 1982 - $10.26

Number of Rx claims processes FY 1982 - 1,400,000

 Maine -3
1983
M i s c e l l a n e o u s Remarks ( c o n t i n u e d ) :

The Department of Human S e r v i c e s s t r o n g l y urges p a r t i c i p a t i n g p r a c t i t i o n e r s

t o p r e s c r i b e d r u g s i n g e n e r i c terms whenever p o s s i b l e . The p h a r m a c i s t i s
e x p e c t e d t o s u p p l y such g e n e r i c p r e p a r a t i o n s a t a r e a s o n a b l e c o s t w h i c h does
not s a c r i f i c e q u a l i t y . A d r u g dispensed b y a p h a r m a c i s t o n p r e s c r i p t i o n and
b i l l e d t o t h e Department o f Human S e r v i c e s b y i t s n o n - p r o p r i e t a r y name must
be e q u a l i n pharmacologic and t h e r a p e u t i c q u a l i t i e s t o i t s t r a d e name
counterpart.

The S t a t e processes c l a i m s under t h e M M l S Program.

Druqs f o r t h e E l d e r l y Program ( P h a r m a c e u t i c a l A s s i s t a n c e Programs f o r t h e

Aged -
PAA)

Program f o r non-Medicaid e l i g i b l e persons, w i t h a $2 copayment f o r each

prescription.

E l i g i b i l i t y Requirements:

1. Legal r e s i d e n t o f t h e s t a t e of Maine.

2. 62 Years o f age o r o l d e r , d i s a b l e d widows o r widowers age 5 5 o r

o l d e r who a r e n o t r e m a r r i e d , o r a r e 62 y e a r s of age o r o l d e r and
members of a household of an i n d i v i d u a l who has been d e t e r m i n e d
e l i g i b l e b y t h e Bureau o f T a x a t i o n f o r t h e Drugs f o r t h e E l d e r l y
Program and whose name appeared on t h e a p p l i c a n t ' s a p p l i c a t i o n .

3. Each o f t h e above must be d e s i g n a t e d by t h e Bureau o f T a x a t i o n as

m e e t i n g t h e f i n a n c i a l g u i d e 1 i n e s f o r t h e Tax and Rent Refund
Program.

4. Persons e l i g i b l e f o r M e d i c a i d o r who r e c e i v e S t a t e Supplemental

Income b e n e f i t s a r e n o t e l i g i b l e f o r t h e Drugs f o r t h e E l d e r l y
Program.

C a t a s t r o p h i c l l l n e s s Proqram
(Maine Publ i c Law 768 - (l974), e f f . 7/1/74)
1. P r o v i d e s f o r a c a t a s t r o p h i c i l l n e s s program.

2. Supported b y s t a t e funds o n l y .

3. Purpose -
p r o v i d e b a s i c b u t l i m i t e d h e a l t h c a r e when i n d i v i d u a l s cannot
pay f o r such c a r e f r o m t h e i r own o r o t h e r r e s o u r c e s .

4. Eligibility: (individual basis - 1 year)

a. I n d i v i d u a l must a p p l y f o r a l l o t h e r h e a l t h b e n e f i t s .

b. 20% o f n e t income b e f o r e t a x e s .
NPC Maine - 4
1983

Miscellaneous Remarks (continued):

c. 10% o f n e t worth exceeding $20,000 and $1,000 d e d u c t i b l e .

d. Payments a r e made only t o vendors o r p r o v i d e r s of c a r e .

 Maine -5
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. Human S e r v i c e s Department O f f i c i a l s :

M i c h a e l R. P e t i t Department o f Human S e r v i c e s
Commissioner S t a t e House
Augusta, Maine 04333

F r a n c e s G. McGinty H e a l t h and M e d i c a l S e r v i c e s
Deputy Commissioner ( a d d r e s s same as above)

James H. Lewis, M.P.H.

Director
Bureau o f Medical S e r v i c e s

B e v e r l y Johnson, R.N.
Assistant Director
Bureau o f M e d i c a l S e r v i c e s

E. Raymond Dow
Director
M e d i c a i d P l a n s and P o l i c y

M i c h a e l D. O ' O o n n e l l , R.Ph.
Pharmacist Consultant
207/289-2674

P r i s c i l l a Carney
Director
M e d i c a i d S u r v e i l l a n c e and
U t i l i z a t i o n Review

Medical Consultants:

A l l e n E l k i n s , M.D.
Psychiatric

D. K. McFadden, D.O.
Osteopathic

Donald E l l i s , O.D.
Optometric

K e v i n H i l l , M.D.
Ophthalmologist

J. D. Reeder, D.C.
Chiropractic
NPC Maine - 6
1983

2. Medical A s s i s t a n c e A d v i s o r y Comnittee:

A. Dewey R i c h a r d s , M.D. 11 Gage S t r e e t

Cha irman B r i d g t o n 04009

3. E x e c u t i v e O f f i c e r s o f S t a t e Medical and P h a r m a c e u t i c a l
Societies:

A. Medical Association:

Frank 0. S t r e d
Executive D i r e c t o r
Maine Medical A s s o c i a t i o n
524 Western Avenue
Augusta 04330
Phone: 207/622-3374

B. Pharmaceutical A s s o c i a t i o n :

H a r l a n d Goodwin, J r .
Executive Secretary
Maine P h a r m a c e u t i c a l A s s o c i a t i o n
P. 0. Sox 189
South Berwick 03908
Phone: 207/384-5653

C. Osteopathic Association:

P h i 1 i p N. Johnson
Executive D i r e c t o r
Maine O s t e o p a t h i c A s s o c i a t i o n
303 S t a t e S t r e e t
Augusta 04330
Phone: 207/623-1101
 Maryland - 1
1983

MRYLAWD

MEDICAL ASSISTANCE DRUG PROGRAM ( T I T L E X I X )

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e q o r i c a l l y Needy M e d i c a l ly Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC C h i l d r e n Q l (SFO)
Prescribed
Druqs X X X X X X X X X X
lnpat ie n t
H o s p i t a l Care X X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X X
Laboratorv E
X-ray S e r v i c e X X X X X X X X X X
S k i l l e d Nursina 2

Home S e r v i c e s X X X X X X X X X X
Phvsician
Services X X X X X X X X X X
D-e n~-tal
Services X X X X X X X X X X
"SF0 - S t a t e Funds Only

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982
-
1981 fi82
Expended R e c i p i e n t Expended Recipient

TOTAL ............................... $19,342,312 229,561** $22,279,885 226,722**

CATEGORICALLY NEEDY CASH TOTAL.. .... $13,477,489 192,060 $15,592,578 189,073

Aged ................................ 2,951,135 15,424 3,302,440 14,697
Blind ............................... 48,129 269 51,839 260
Disabled ............................ 4,449,979 24,042 5,358,725 23,987
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . .
2,348,799 93,199 2,553,256 90,208
... 3,679,447
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . 59,126 4,326,318 59,921

CATEGORICALLY NEEDY NDN-CASH TOTAL..

Aged ................................
Blind.. .............................
Disabled ............................
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . .
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . ...
..........
Other T i t l e X I X R e c i p i e n t s

MEDICALLY NEEDY TOTAL.. .............

Aged ................................
B l i n d . . .............................
Disabled... .........................
C h i l d r e n -Famil i e s w/Dep C h i l d r e n . . .
A d u l t s - F a m i l i e s w/Dep C h i l d r e n .....
Other T i t l e XIX R e c i p i e n t s ..........
+*Unduplicated T o t a l - HHS r e p o r t HCFA - 2082
174
 Maryland -2
1983

I 1 1 . Administration:
State Department of Health and Mental Hygiene.

IV. Provisions Relating t o Prescribed Drugs:

A. General Exclusions: (a) experimental or investigational drugs; (b) food

supplements or infant formulas; (c) prescriptions and injections f o r
central nervous system stimulants and anorectic agents used for weight
control ; (d) "less-than-effective" drugs under federal regulations; and
(e) certain other items as specified in the state's Medicaid plan.

B. Coverage of nonlegend drugs is limited t o insulin and S c h e d u l e V c o u g h

preparations.

1. Quantity of Medication: T h e prescriber may order up t o a 100-day

supply o f the medication on a single prescription, except for birth
control pills h i c h a r e limited t o a 6-cycle supply (180 days).

2. Refills:

a. Maximum number of refills authorized on a prescription is two.

b. Refills may not be dispensed after 100 days of date of original

prescription.

3. Dollar Limits: Prior authorization r e w i r e d from Medical Assistance

Compl iance Admini strat ion when usual and customary c h a r g e e x c e e d s
$40.

4. Formulary: Yes. For information contact:

Mr. Charles T r e g o e
Division of Drug Control
201 W. Preston Street
Baltimore, Maryland 21201
301 /383-2729

5. T o encourage the use of approved generic drug products, pharmacies

and physicians a r e provided with a list o f therapeutically
equivalent drug products. T h e Program a l s o maintains a list of
drugs with maximum allowable cost (MAC) limits. T h i s list, which
contained 46 price controlled drugs in fiscal year 1982, is
continually updated t o reflect deletions and additions m a d e by t h e
Pharmaceutical Reimbursement Board of the Health Care Financing
Administration.
 Maryland - 3
1983

C. P r e s c r i p t i o n Charge Formula:

Legend drugs - An upper p r i c e l i m i t has been e s t a b l i s h e d , known as t h e

E s t i m a t e d A c q u i s i t i o n Cost (EAC) f o r s i n g l e s o u r c e d r u g s o r t h e Maximum
A l l o w a b l e Cost (MAC) f o r m u l t i p l e source drugs.

Reimbursement w i l l be t h e l o w e r o f :
- A l l o w a b l e c o s t p l u s $3.25 d i s p e n s i n g fee, or
- Usual and customary

V. Miscellaneous:

Number o f Rx c l a i m processed i n FY 1982 - 2,777,773

Average p r e s c r i p t i o n p r i c e d u r i n g FY 1982 -
$9.63

A copayment o f $.SO a p p l i e s o n l y t o s t a t e funded r e c i p i e n t s of medical

a s s i s t a n c e . No copayment f o r r e c i p i e n t s i n F e d e r a l c a t e g o r i e s , o r t h o s e
r e c e i v i n g EPSDT and F a m i l y P l a n n i n g r e l a t e d s e r v i c e s .

M a r y l a n d Pharmacy A s s i s t a n c e Program

The M a r y l a n d Pharmacy A s s i s t a n c e Program, e s t a b l i s h e d b y t h e M a r y l a n d

General Assembly i n 1978, i s a d m i n i s t e r e d b y t h e A s s i s t a n t S e c r e t a r y f o r M e d i c a l
Care Programs and s u p p o r t e d e n t i r e l y by s t a t e funds. The purpose o f t h i s p r o g r a m
i s t o h e l p low-income f a m i l i e s and i n d i v i d u a l s who a r e n o t e l i g i b l e f o r M e d i c a l
A s s i s t a n c e pay f o r p r e s c r i p t i o n s , i n s u l i n , and c e r t a i n m e d i c a l s u p p l i e s .

E l i g i b i l i t y f o r Pharmacy A s s i s t a n c e i s based on t h e f i n a n c i a l r e s o u r c e s
available t o the family unit. I n f i s c a l year 1982, t h e maximum a l l o w a b l e income
l e v e l was i n c r e a s e d by $200, making t h e g r o s s income s t a n d a r d $1,700 above t h e
Medical Assistance scale. The a s s e t s t a n d a r d f o r t h e Pharmacy A s s i s t a n c e Program
remained t h e same as f o r t h e M a r y l a n d M e d i c a l A s s i s t a n c e Program. The f o l l o w i n g
c h a r t shows t h e g r o s s income and a s s e t l e v e l s e f f e c t i v e d u r i n g f i s c a l year 1982.

Gross l ncome
Family Size Standards Assets Standards

1
2
3
4
Each A d d i t i o n a l Person

D u r i n g f i s c a l y e a r 1982, i n c r e a s e s i n S o c i a l S e c u r i t y payments caused many

Pharmacy A s s i s t a n c e r e c i p i e n t s t o l o s e t h e i r e l i g i b i l i t y . I n order t o prevent
t h e reoccurence o f t h i s s i t u a t i o n , t h e General Assembly i n 1982 passed Senate
B i l l 124. T h i s law a l l o w s t h e Program t o i n c r e a s e i t s income s t a n d a r d s each y e a r
a t t h e same r a t e a s S o c i a l S e c u r i t y b e n e f i t s a r e i n c r e a s e d , n o t t o exceed 8%.

I n f i s c a l year 1982, an average of 10,573 i n d i v i d u a l s p e r month were

e n r o l l e d i n t h e Pharmacy A s s i s t a n c e Program. The Program p a i d $2,320,597 f o r
212,611 p r e s c r i p t i o n s , an average of $10.91 p e r p r e s c r i p t i o n . Recipients are
r e s p o n s i b l e f o r a $1.00 copayment f o r each p r e s c r i p t i o n .
 Maryland - 4
1983

Officials, C o n s u l t a n t s and Committees

1. H e a l t h and Mental Hygiene Department O f f i c i a l s :

Adele W i l z a c k Department o f Heal t h and

Secretary Mental Hygiene
201 W. P r e s t o n S t r e e t
B a l t i m o r e , Maryland 21201

K a t h l e e n B. Becker
C h i e f , D i v i s i o n of S p e c i a l i z e d
Health Services

Leone W. Marks, R.Ph.

S t a f f S p e c i a l i s t f o r Pharmacy
Services
301 /383-2658

2. Medicaid/Pharmacy L i a i s o n Committee:

Donald A. Schumer, R.Ph. Adolph Baer, R.Ph.

Penn-Dol Pharmacy F i s h e r ' s Pharmacy
Phone: 669-2424 Phone: 582-2200

*Home: 7 High Stepper C t . , #301 +Home: 1835 Woodburn D r i v e

B a l t i m o r e , MD 21208 Hagerstown, MO 21740
Phone: 733-4116
Murray Polonsky, R.Ph.
A c c r e d i t e d S u r g i c a l Company M e l v i n Rubin, R.Ph.
Phone: 585-7711 P a r a d i s e Pharmacy
Phone: 247-1244
*Home: 415 E . Wayne Avenue
S i l v e r S p r i n g , MD 20901 *Home: 2316 Sugarcone Road
B a l t i m o r e , MO 21209
D a v i d Rombro, R.Ph.
MacGi 1 Ii v r a y ' s Pharmacy M a r t i n M i n t z , R.Ph.
900 N. C h a r l e s S t r e e t N o r t h e r n Pharmacy
B a l t i m o r e , Maryland 21201 N o r t h e r n Parkway and H a r f o r d Road
Phone: 539-0904 B a l t i m o r e , Maryland 21214
685-3272 Phone: 254-2055

Robert M a r t i n , R.Ph. Ronald A. Sanford, R.Ph.

Route 1, Box 75-M D i r e c t o r o f Pharmacy A d m i n i s t r a t i o n
LaVale, Maryland 21502 D a r t Drug Company
Phone: Potomac V a l l e y Pharmacy Phone: 772-6000 341-0616
729-3535 722-2342
*Home: 1336 D e n b r i g h t Road
B a l t i m o r e , MD 21228
Phone: 744-7494
*Represents addresses p r e f e r r e d f o r m a i l i n g s .
 Maryland -5
1983

Medi ca i d/Pharmacy L i a i s o n Cornmi t t e e ( c o n t i nued) :

Ron T e l ak F r a n c i s K. Davis, J r .
M a r y l a n d General H o s p i t a l E a s t e r n F i e l d Manager
Pharmacy Department Government A f f a i r s
827 L i n d e n Avenue Hoechst-Roussel
B a l t i m o r e , MD 21201 P h a r m a c e u t i c a l s , Inc.
2408 F a i r v i e w D r i v e
John J. P a l y a A l e x a n d r i a , VA 22306
A s s i s t a n t t o D i v i s i o n Manger Phone: (703)768-4244
Wyeth L a b o r a t o r i e s
4000 Renaul t P l a c e D a v i d Banta, R.Ph.
A l e x a n d r i a , VA 22309 Maryland Pharmaceutical A s s o c i a t i o n
650 W. Lombard S t r e e t
Tony Warren B a l t i m o r e , MD 21202
P.O. Box 433
B a l t i m o r e , MD 21203

Joseph Stevenson, R.Ph.

A n g e l o V o x a k i s , R.Ph.
Outpat i e n t Pharmacy
University Hospital
22 South Greene S t r e e t , Room 1101
B a l t i m o r e , MD 21201
Phone: 528-5616

3. M e d i c a l A s s i s t a n c e A d v i s o r y Committee:

Lee B e r n h a r d t , D i r e c t o r B l u e Cross/Blue S h i e l d
Government Programs Representative
B l u e C r o s d B l u e S h i e l d of M a r y l a n d
700 E a s t Joppa Road
B a l t i m o r e , M a r y l a n d 21204

Peter Borchardt, Executive D i r e c t o r PSRO R e p r e s e n t a t i v e

Delmarva F o u n d a t i o n f o r M e d i c a l Care
108 N o r t h H a r r i s o n S t r e e t
Easton, Maryland 21601

Joyce Boyd, M.D., Health Officer County H e a l t h O f f i c e r

Howard County H e a l t h Department
3450 Courthouse D r i v e
E l l i c o t t C i t y , M a r y l a n d 21043

John B r a x t o n , J r . , M.D. Monumental C i t y M e d i c a l S o c i e t y

3206 L i b e r t y H e i g h t s Avenue Representative
B a l t i m o r e , Maryland 21215
NP C Maryland -6
1983

M e d i c a l A s s i s t a n c e A d v i s o r y Committee ( c o n t i n u e d ) :

Mildred Bright Consumer R e p r e s e n t a t i v e

2112 J e f f e r s o n S t r e e t
B a l t i m o r e , Maryland 21205

R i c h a r d Buck, E x e c u t i v e D i r e c t o r N u r s i n g Homes R e p r e s e n t a t i v e s
P i c k e r s g i l l Home
615 C h e s t n u t Avenue
B a l t i m o r e , Maryland 21204

G l o r i a Carpeneto Consumer R e p r e s e n t a t i v e
5 B i g Stone Court
B a l t i m o r e , Maryland 21228

Dorothy Council Consumer R e p r e s e n t a t i v e

1100 N o r t h B o l t o n S t r e e t , #210
B a l t i m o r e , Maryland 21201

Carmalyn Dorsey M a r y l a n d Nurses A s s o c i a t i o n

5901 B e l l o n a Avenue Representative
Baltimore, Maryland 21212

D a r r e l l R. Cammack, J r . , A d m i n i s t r a t o r N u r s i n g Home R e p r e s e n t a t i v e
I v y H a l l N u r s i n g Home
19 H a r r i s o n Avenue
B a l t i m o r e , M a r y l a n d 21220

Rev. L o u i s Foxwel I, J r . Consumer R e p r e s e n t a t i v e

Executive D i r e c t o r
Deaf R e f e r r a l S e r v i c e
3312 Elmora Avenue
B a l t i m o r e , Maryland 21213

Rose Goodman Consumer R e p r e s e n t a t i v e

1334 N o r t h Washington S t r e e t
B a l t i m o r e , Maryland 21213

K a t h l e e n Grau, LCSW, D i r e c t o r S o c i a l Worker, Hospital

Department o f S o c i a l Work
N o r t h C h a r l e s General H o s p i t a l
C h a r l e s and 2 8 t h S t r e e t
B a l t i m o r e , M a r y l a n d 21218

E. Jane Hanks Consumer R e p r e s e n t a t i v e

Box 268
Oxford, M a r y l a n d 21654

Ronald H a r r i s Consumer R e p r e s e n t a t i v e
1423 Winston Avenue
Baltimore, Maryland 21239
 Maryland - 7
1983

M e d i c a l A s s i s t a n c e A d v i s o r y Comni t t e e ( c o n t i n u e d ) :

James Harvey Hospital Administrator

Assistant Vice-president
Washington County H o s p i t a l Assoc.
King Street
Hagerstown, Mary l a n d 21740

V e r o n i c a Johnson Consumer R e p r e s e n t a t i v e
620 E a s t 2 7 t h S t r e e t
B a l t i m o r e , Maryland 21218

Benjamin J. Kimbers, Jr., D.D.S. Dentist

Madison Park P r o f e s s i o n a l B u i l d i n g
932 West N o r t h Avenue
Bal t i m o r e , Maryland 21217

H a r r y F. K l i n e f e l t e r , M.O. Doctor, Internist

550 N o r t h Broadway
B a l t i m o r e , M a r y l a n d 21205

Joseph L. LaAsmar, A s s o c i a t e E x e c u t i v e Administrator, HMO

D i rector
Chesapeake P h y s i c i a n s , P.A.
P.O. Box 9048
B a l t i m o r e , Maryland 21222

Adele Wilzack, A s s i s t a n t S e c r e t a r y Department o f H e a l t h and Mental

Medi c a l Care Programs Hygiene R e p r e s e n t a t i v e
201 West P r e s t o n S t r e e t
B a l t i m o r e , Maryland 21201

S h i r l e y Marcus Consumer R e p r e s e n t a t i v e
1101 N o r t h C a l v e r t S t r e e t , Apt. 511
B a l t i m o r e , Maryland 21202

James McCaslin, S e n i o r V i c e P r e s i d e n t Maryland H o s p i t a l A s s o c i a t i o n

Maryland General H o s p i t a l Representative
827 L i n d e n Avenue
B a l t i m o r e , M a r y l a n d 21201

Roberta N e v i t t , D i r e c t o r Consumer R e p r e s e n t a t i v e
N u r s i n g Home Advocacy P r o j e c t
Maryland Conference o f S o c i a l Concern
1301 Park Avenue
B a l t i m o r e , Maryland 21217

E t h e l Pace Consumer R e p r e s e n t a t i v e
1707 Moreland Avenue
B a l t i m o r e , Maryland 21216
NPC Maryland - 8
1983

Medical A s s i s t a n c e A d v i s o r y Comni t t e e ( c o n t i n u e d ) :

P h i l i p Piasecki Administrator, Group H e a l t h P r a c t i c e

E a s t p o i n t Medical Center
1012 N o r t h P o i n t Road
B a l t i m o r e , Maryland 21224

Mary P l a n k Consumer R e p r e s e n t a t i v e
510 East 4 1 s t S t r e e t
B a l t i m o r e , Maryland 21218

Sari Revkin Consumer R e p r e s e n t a t i v e

925 M o n t p e l i e r S t r e e t
B a l t i m o r e , Maryland 21218

M e l v i n Rubin Maryland P h a r m a c e u t i c a l A s s o c i a t i o n
2316 Sugarcone Road Representative
B a l t i m o r e , Maryland 21209

M i l l i e Tyssowski Consumer R e p r e s e n t a t i v e
2500 P i c k w i c k Road
B a l t i m o r e , Maryland 21207

G l o r i a Washington, A c t i n g A s s i s t . Department of Human Resources

Di r e c t o r Representative
Medical Assistance D i v i s i o n
Income Maintenance A d m i n i s t r a t i o n
300 West P r e s t o n S t r e e t , Room 602
B a l t i m o r e , M a r y l a n d 21201

Sheila W i l l e t t Consumer R e p r e s e n t a t i v e
3453 C o t t a g e Avenue
B a l t i m o r e , Maryland 21215

4. E x e c u t i v e O f f i c e r s of S t a t e Medical and P h a r m a c e u t i c a l
Societies:

A. Medical S o c i e t y :

M. E. McGibbon
Medical & C h i r u r g i c a l F a c u l t y
o f Maryland
1121 C a t h e d r a l S t r e e t
B a l t i m o r e 21201
Phone: 30 11539-0872
NPC Maryland - 9
1983

E x e c u t i v e O f f i c e r s o f S t a t e Medical and P h a r m a c e u t i c a l
S o c i e t i e s (continued):

B. Pharmaceutical Association:

D a v i d A. Banta, R.Ph.
Executive O i r e c t o r
Maryland Pharmaceutical Association
650 W. Lombard S t r e e t
B a l t i m o r e 21201
Phone: 301/727-0746

C. Osteopathic Association:

E r n e s t R. MacOonald, 0.0.
Secretary-Treasurer
Maryland Osteopathic Association Inc.
11.5 R i d g e l y Avenue, S u i t e 3
A n n a p o l i s 21401
301/268-1946
NPC Massachusetts - 1
1983

M O I U L ASSISTANCE DRUG PROGRAM (TITLE X I X )

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

*
Type o f B e n e f i t

Prescribed
C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*

Oruqs X X X X X X X X X X
l m a t ient
~ o ; ~t ai l Care X X X X X X X X X
Outnat i
r - - ~
e n t
H o s p i t a l Care X X X X X X X X X
Laboratory &
X-ray S e r v i c e X X X X X X X X X X
S k i l l e d N u r s i n -q
Home S e r v i c e s 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 B e n e f i t s : I n t e r m e d i a t e c a r e f a c i l i t i e s , c l i n i c s , mental h e a l t h s e r v i c e s ,
ambulance and o t h e r m e d i c a l l y necessary t r a n s p o r t a t i o n , s p e c i a l d u t y n u r s i n g , a d u l t
day h e a l t h , a d u l t f o s t e r c a r e , v i s i o n c a r e s e r v i c e s , k i d n e y d i a l y s i s , f a m i l y
p l a n n i n g , c e n t e r s f o r independent l i v i n g , comnunity h e a l t h c e n t e r s e r v i c e s .
*SF0 - S t a t e Funds O n l y

11. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982

1981 1982
Expended R e c i p i e n t Expended Recipient

TOTAL............................... $47,558,758 488,026** $49,793,507 437,710**

CATEGORICALLY NEEDY CASH TOTAL.. .... $32,877,678 373,349

Aged.. .............................. 10,602,183 87,122
Blind............................... 323,839 1,630
Disabled.. .......................... 10,275,243 71,633
C h i l d r e n -Fami l i e s w/Oep C h i l d r e n . . . 3,969,981 97,964
A d u l t s - F a m i l i e s w/Dep Children..... 7,706,432 115,000

CATEGORICALLY NEEDY NON-CASH TOTAL.. $299,440 1,610

Aged ................................ 0 0
Blind............................... 299,440 1,610
Disabled ............................ 0 0
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n . . . 0 0
A d u l t s - F a m i l i e s w/Dep Children.... . 0 0

MEDICALLY NEEDY TOTAL............... $14,381,640 113,067

Aged ................................ 10,415,361 73,571
Blind.............. ................. 229,827 776
Disabled. ........................... 2,288,577 14,520
C h i l d r e n - F a m i l i e s w/Dep Children... 243,805 5,663
A d u l t s - F a m i l i e s w/Dep Children..... 596,897 8,857
Other T i t l e XIX R e c i p i e n t s .......... 607,173 9,680

**Unduplicated T o t a l - HHS r e p o r t HCFA

183
- 2082
 Massachusetts
1983
-2
I l l . Administration:
State Department of Public Welfare.

IV. Provisions Relating to Prescribed Drugs:

A. General Exclusions: Immunizing biologicals available from DPH, legend

vitamins not on Drug List, non-legend drugs not on Drug List.
Restrictions on certain therapeutic classes. Legend cough and cold
medications excluded. Restrictions on propoxyphene containing products.

8. Formulary: No.

C. Prescribing or Dispensing Limitations:

1. Quantity of Medication: Not more than a 6-month supply may be

prescribed.

2. Refills: Prescription may be refilled, as long as total

authorization does not exceed a 6-months' or 5-refills supply from
time of original prescription.

3. Dollar Limits: None.

D. Prescription Charge Formula:

1. Legend Drugs: $2.92 dispensing fee.

2. Compounded prescriptions

a. Compounded prescriptions - $3.92 dispensing fee

b. Suppositories, tablet triturates, capsules - $4.92 dispensing

fee.

3. Payment shall be for the lower of the usual and customary charge or
EAC cost plus dispensing fee, or AWP plus dispensing fee.

4. Non-Legend Drugs: Customary shelf price not to exceed usual and

customary charge to the general public, or 50% markup, or cost plus
fee whichever is lower.
 Massachusetts
1983
- 3

V. Miscellaneous Remarks:

For AB drugs, supplier b i l l s S t a t e Commission f o r the B l i n d d i r e c t l y , which

pays vendor pharmacy through intermediary.

F i s c a l Intermediary:

1982 P i l g r i m Health Applications

1983 Systems Development Corp
P.O. Box 9101
Somervi l l e , Massachusetts 02145
617/625-0120
 Massachusetts -4
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. W e l f a r e Department:

A. Officials

C h a r l e s A t k i ns Department o f P u b l i c W e l f a r e
Commissioner 600 Washington S t r e e t
Boston, Massachusetts 02111

Dennis B e a t r i c e
A s s i s t a n t Commissioner

H e r b e r t B. Hechtman, M.D.
Medical D i r e c t o r

C a r o l y n Kea 1 y
Manager
M e d i c a i d Pharmacy Program

2. E x e c u t i v e O f f i c e r s of S t a t e Medical 'and P h a r m a c e u t i c a l
Soc i e t i es:

A. Medical Society:

W. B. Munier, M.D.
Executive Vice President
Massachusetts M e d i c a l S o c i e t y
22 The Fenway
Boston 02215
Phone: 617/536-8812

B. Pharmaceutical Association:

James H. S t e w a r t
Executive D i r e c t o r
Massachusetts S t a t e
Pharmaceutical A s s o c i a t i o n
210 L i n c o l n S t r e e t
Boston 02111
Phone: 617/423-7222

C. Osteopathic Society:

Mrs. Gladys M, D a v i s
Executive Secretary
Massachusetts O s t e o p a t h i c S o c i e t y I n c .
Box 147
Reading 01867
617/944-5586
 Michigan - 1
1983

l € D I C A l ASSISTANCE DRUG PROGRAM (TITLE X I X )

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e q o r i c a l ly Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFDC OAA AB APT0 AFDC Chi l d r e n < 2 1 (SFO)
Prescribed
Drugs X X X X X X X X X
l ..
~
n rn -a -t .i c n t
H o s p i t a l Care X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X
Laboratory &
X-ray ~ e r ; i c e X X X X X X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X X X X X X
P h v s i -c i a- n
3

Services X X X X X X X X X
Dental
Services (------- ~ i ~ i -------)
t ~ d X
Other B e n e f i t s : T r a n s p o r t a t i o n ; L i m i t e d V i s i o n & H e a r i n g ; L i m i t e d M e d i c a l
S u p p l i e s & ~ ~ u i ~ m e n t ; . F a m iPl lya n n i n g ; A l c o h o l i s m &rug Withdrawal; P s y c h i a t r i c
Services. Special note: There a r e e x c l u s i o n s and l i m i t a t i o n s a p p l i c a b l e t o a l l
s e r v i c e s , and p r i o r a u t h o r i z a t i o n i s r e q u i r e d f o r same.
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982
1981 1982
Expended R e c i p i e n t Expended Recipient

TOTAL...... ......................... $74,525,198 720,848** $71,581,129 742,825**

CATEGORICALLY NEEDY CASH TOTAL...... $45,490,278 594,092

Aged ................................ 3,699,528 18,938
Blind ............................... 101,112 56 3
Disabled ............................ 10,888,704 48,951
C h i l d r e n - F a m i l i e s w/Dep Children... 13,342,563 355,693
.....
A d u l t s - F a m i l i e s w/Dep C h i l d r e n 17,458,371 169,947

CATEGORICALLY NEEDY NON-CASH TOTAL.. $0 0

Aged ................................ 0 0
Blind ............................... 0 0
Disabled ............................ 0 0
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . .. 0 0
A d u l t s -Fami l i e s w/Dep C h i l d r e n . . ... 0 0
Other T i t l e XIX R e c i p i e n t s .......... 0 0

M E D l CALLY NEEDY TOTAL.. ............. $29,034,920 126,756

Aged ................................ 13,763,842 51,493
B l i n d ............................... 122,477 479
Disabled.......... .................. 13,916,607 47,690
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . .. 502,632 16,738
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . . . . 593,268 6,853
Other T i t l e XIX R e c i p i e n t s .......... 136,094 3,503

**Undupl i c a t e d T o t a l - HHS r e p o r t HCFA - 2082

187
 Michigan - 2
1983

I l l . Administration:

M i c h i g a n Department of S o c i a l S e r v i c e s .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s :

. Anorectics Hematinics
. Nonlegend d r u g s / s u p p l i e s , except: Antacids
i n s u l i n , c h r o n i c r e n a l d i s e a s e drugs, A n t i - v e r t i g o Drugs
f a m i l y p l a n n i n g drugs, m e d i c a l s u p p l i e s . Laxatives
and r e a c t i v a t e suppl i e s Cough and C o l d Prepa-
. Analgestics r a t i o n s , except
. A n t i - A n x i e t y Drugs (Benzodiazepines) antihistamines
. V i t a m i n s , except: p r e n a t a l and f l u o r i d e . DESl Drugs
pedo drops

B. Formulary: E f f e c t i v e 2/15/81, c e r t a i n a n t i - a n x i e t y and a n a l g e s i c d r u g s

were e x c l u d e d f r o m coverage. E f f e c t i v e 1/1/82, coverage r e s t r i c t i o n s
were p l a c e d on c o u g h / c o l d p r e p a r a t i o n s , a n t a c i d s , l a x a t i v e s , a n t i -
v e r t i g o drugs, h e m a t i n i c s , and v i t a m i n s . By 4/1/82, t h e DESl d r u g s and
t h e s o - c a l l e d "me, too" drugs were e x c l u d e d from coverage. S t a t e and
F e d e r a l MAC l i m i t s a r e a p p l i e d . However, p h y s i c i a n "DAW" r e q u e s t s w i l l
o v e r - r i d e MAC l i m i t s .

For information regarding the formulary contact:

M r . Bruce Hansen, D i r e c t o r
Medicaid P o l i c y D i v i s i o n
P.O. Box 30037
L a n s i n g , M i c h i g a n 48909
5171373-7720

C. P r e s c r i b i n g o r dispensing l i m i t a t i o n s : P r e s c r i b e d q u a n t i t i e s s h o u l d be
l i m i t e d t o an amount necessary t o keep t h e r e c i p i e n t s u p p l i e d d u r i n g
t h e t h e r a p y regimen. I n c e r t a i n cases and c o n d i t i o n s , more t h a n a
m o n t h ' s s u p p l y w i l l be a p p r o p r i a t e . However, i n no i n s t a n c e may more
t h a n 120 days s u p p l y be dispensed p e r p r e s c r i p t i o n .

D. P r e s c r i p t i o n Charge Formula: Reimbursement i s l i m i t e d t o t h e Lower

of: (See V. M i s c e l l a n e o u s Remarks f o r h i s t o r i c a l fee a d j u s t m e n t s . )

1. A c t u a l a c q u i s i t i o n c o s t , p l u s p r o f e s s i o n a l f e e n o t t o exceed $2.65
p l u s s e l e c t e d $0.50 copay o r

2. The M.A.C." r a t e , p l u s p r o f e s s i o n a l f e e n o t t o exceed $2.65 p l u s

s e l e c t e d $0.50 copay o r

3. The p r o v i d e r ' s u s u a l and customary c h a r g e t o t h e g e n e r a l p u b l i c .

"Maximum A l l o w a b l e Costs
 Michigan - 3
1983

V. Miscellaneous Remarks:

T o t a l Rx claims processed i n FY 1982 - 10,953,406

Average Rx p r i c e during FY 1982 - $7.76
 Michigan -4
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. S o c i a l S e r v i c e s Department O f f i c i a l s :

Agnes M. Mansour, Ph.D. M i c h i g a n Department of S o c i a l

Director Services
P. 0. Box 30037
L a n s i n g , M i c h i g a n 48909

P a u l M. A l l e n Medical Services A d m i n i s t r a t i o n
Director (same as above)

Dennis OuCap, D i r e c t o r
O f f i c e of S u p p o r t S e r v i c e s

V e r n o n K. S m i t h , Ph.D.
D i r e c t o r , Bureau o f Program
Pol i c y

K e i t h F. Cole, D i r e c t o r
Bureau o f M e d i c a i d O p e r a t i o n s

R o b e r t M. L e v i n , D.D.S.
D i r e c t o r , Bureau of H e a l t h
S e r v i c e s Review

R i c h a r d Maharan, D i r e c t o r
Bureau o f M e d i c a i d F i s c a l
Rev i ew

2. S o c i a l S e r v i c e s Department A d v i s o r y Committees:

Consumer Members

Jean Thompson - C i t i z e n s f o r B e t t e r Care

550 C o l l i n g w o o d
East L a n s i n g 48823

Sharon S e b r i g h t - Recipient Representative

R # 2 , 6657 U Avenue, West
S c h o o l c r a f t 49087

Deborah Cheatom - Recipient Representative

1229 Vermont
Lans i ng 48906
 Michigan - 5
1983

S t a t e M e d i c a l Care A d v i s o r y C o u n c i l - Consumer Members ( c o n t i n u e d ) :

C l a r i c e Jones - American A s s o c i a t i o n o f R e t i r e d
2812 Woodruff, Apt. #3 Persons
L a n s i n g 48910

Jan Saxton - Consumer Member a t L a r g e

1309 Reo Road
L a n s i n g 48910

D o r o t h y Walker - UAW R e t i r e d W o r k e r ' s Oept

8731 East J e f f e r s o n Avenue
O e t r o i t 48214

E l l a Bragg - Michigan Welfare R i g h t s

15411 Wabash Organization
O e t r o i t 48238

J a n e t t a Beaumont - M i c h i g a n 4-C C o u n c i l
225 Maple
Alma 48801

William Fairgrieve - M i c h i g a n League f o r Human

200 N. Washington Square, Services
S u i t e 311
L a n s i n g 48933

Samuel L. Davis - Michigan A s s o c i a t i o n f o r

23555 N o r t h w e s t e r n Hwy. Emotionally Disturbed
Southf i e l d 48075 Children

Connie M a r i n - C r i s t o Rey Community Center

C r i s t o Rey Community Center
1314 B a l l a r d S t r e e t
L a n s i n g 48906

P r o v i d e r Members

Raymond E. H u l d i n , 0.0. - Michigan Association o f

3090 Wilson, SW Osteopathic Physicians &
G r a n d v i l l e 49418 Surgeons

R e g i n a l d P. A y a l a - Michigan Hospital
Executive D i r e c t o r Association
S.W. O e t r o i t H o s p i t a l
2401 - 20th Street
D e t r o i t 48216

L l o y d Ganton - H e a l t h Care A s s o c i a t i o n o f
Arbor Manor Care C e n t e r M i c h i g a n (N.H.s)
151 Second S t r e e t
S p r i n g A r b o r 49283
NPC Michigan - 6
1983

S t a t e M e d i c a l Care A d v i s o r y Counci 1 - P r o v i d e r Members ( c o n t i n u e d ) :

G r a n t W i i g , D.P.M. - Michigan State P o d i a t r y

305 N o r t h West Avenue Association
Jackson 4920 1

Dean B a r k e r , R.Ph. - M i c h i g a n Pharmacists

Smith Pharmacy Association
226 E a s t Grand R i v e r
L a n s i n g 48906

Thomas A. V u c h e t i c h - Michigan Dental

712 A b b o t t Road Association
E a s t L a n s i n g 48823

Sandra B i l l i n g s l e a - HMO P r o v i d e r Group

M i c h i g a n HMP Plans, Inc.
660 P l a z a D r i v e
2200 Edison P l a z a
D e t r o i t 48226

L i l o H o e l z e l - S e i p p , RN, - M i c h i g a n Nurses A s s o c i a t i o n
Ph.D.
RR #1, H o l l y D r i v e
Thompsonv i l l e 49683

State O f f i c i a l s

Vernon K. Smith, Ph.D. - M i c h i g a n Department o f

D i r e c t o r , Bureau of Program Social Services
Pol i c y
P. 0. Box 30037
L a n s i n g 48909

V i c t o r Sztengel - Michigan Association of Health

Executive D i r e c t o r System Agencies
Northern Michigan Health
System Agency
325 E a s t Lake S t r e e t
Petoskey 49770

Dominic O'Annunzio - M i c h i g a n Department o f Commerce

7419 Yorktown, Rte. #2 I n s u r a n c e Bureau
L a n s i n g 48917

G l o r i a Smith, Ph.D., M.P.H. - M i c h i g a n Department o f P u b l i c

F.A.A.N., Director Health
M i c h i g a n Dept. P u b l i c H e a l t h
P. 0. Box 30035
L a n s i n g 48909
 Michigan - 7
1983

S t a t e Medical Care A d v i s o r y C o u n c i l - State O f f i c i a l s (continued):

Judy N i l e s - M i c h i g a n Department o f
lngham County Department Social Services
of S o c i a l S e r v i c e s
930 West Holmes Road
L a n s i n g 48910

0. S t a t e Pharmaceutical M e d i c a i d L i a i s o n Committee:

Membership on t h e M e d i c a i d L i a i s o n Comnittee w i t h Pharmacies i s n o t

s t r i c t l y established. P a r t i c i p a t i o n i s open t o a l l p h a r m a c i s t s and
i n t e r e s t e d p a r t i e s t h r o u g h announcements s e n t t o t h e M i c h i g a n
Pharmacists A s s o c i a t i o n and M i c h i g a n Merchants C o u n c i l .

3. E x e c u t i v e O f f i c e r s o f S t a t e Medical, P h a r m a c e u t i c a l , and O s t e o p a t h i c
Associations:

A. Medical S o c i e t y :

Warren T r y l o f f
Director
Michigan State Medical Society
120 West Saginaw
East L a n s i n g 48823

0. Pharmaceutical A s s o c i a t i o n :

L o u i s S e s t i , R.Ph.
Executive D i r e c t o r
Michigan Pharmacists Association
815 N. Washington Avenue
L a n s i n g 48906

C. Osteopathic Association:

0. A. DeShaw
Executive Di r e c t o r
Michigan A s s o c i a t i o n of Osteopathic
P h y s i c i a n s & Surgeons, I n c .
33100 Freedom Road
F a r m i n g t o n 48024
 Minnesota - 1
1983

ME01 W ASS ISTAWCE DRUG PROGRAH (TITLE X I X)

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC Chi ld r e n c 2 1 (SFO)
Prescribed
Drugs X X X X X X X X X
l npat i e n t
~ o s ~ i t a Care
l X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X
Laboratorv &
X-ray S e r v i c e X X X X X X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X X X X X X
Physician
Services X X X X X X X X X
Dental
Services X X X X X X X X X
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

June 30, 1982

1981 1982
Expended Recipient Expended Recipient

TOTAL.. ............................. $27,447,452 207,958** $29,351,971** 206,300**

CATEGORICALLY NEEDY CASH TOTAL. ..... $12,257,528 153,260 $12,453,895 149,132
Aged ................................ 2,868,522 10,468 2,878,054 9,817
B l i n d ............................... 96,854 353 97,648 344
D i s a b l e d . . ..........................
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . ..
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . ...
CATEGORICALLY NEEDY NON-CASH TOTAL..
Aged ................................
Blind ...............................
Disabled.. ..........................
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . .
..
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . .
..........
Other T i t l e X I X R e c i p i e n t s

MEDl CALLY NEEDY TOTAL.. .............

Aged ................................
B l i n d . ..............................
D i s a b l e d ............................
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . .
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . ...
Other T i t l e X I X R e c i p i e n t s ..........
**Undupl i c a t e d T o t a l - HHS r e p o r t HCFA - 2082
194
NPC Minnesota - 2
1983

I l l . Administration:

Minnesota Department o f P u b l i c W e l f a r e , Income Maintenance D i v i s i o n , M e d i c a l

A s s i s t a n c e Program.

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s : C e r t a i n non-legend, c o s m e t i c and n u t r i t i o n a l i t e m s

a r e n o t covered.

B. Formulary: C u r r e n t l y b e i n g developed. Contact:

Thomas A. K e l l e n b e r g e r , Pharm.D.
Minnesota M e d i c a l A s s i s t a n c e Program
H e a l t h Care Programs D i v i s i o n
P.O. Box 43170
S t . Paul, M i n n e s o t a 55164
6 12/296-7850

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Dispensed q u a n t i t i e s must n o t exceed 30-day s u p p l y f o r a c u t e

c o n d i t i o n s , and 100-day s u p p l y f o r maintenance m e d i c a t i o n s .

2. R e f i l l s a r e l i m i t e d t o 5 t i m e s o r 6 months, whichever comes f i r s t .

C o n t r a c e p t i v e s may be f i l l e d t o p r o v i d e a 12-month s u p p l y .

D. P r e s c r i p t i o n Charge Formula: Reimbursement i s based on t h e p h a r m a c i s t ' s

s u b m i t t e d c h a r g e o r t h e S t a t e Department of P u b l i c W e l f a r e ' s maximum
p r i c e , whichever i s lower. V a r i a b l e reimbursement, $1.75-55.00.

V. M i s c e l l a n e o u s Remarks:

Drug u t i l i z a t i o n d a t a :

Drug E x p e n d i t u r e s Rx Claims AverageKla im

1) Minnesota Pharmacist, March 1979

2) Data s u b m i t t e d t o NPC - March 1980
3) Data s u b m i t t e d t o NPC -
March 1981
4) Data s u b m i t t e d t o NPC - March 1982
5) Data s u b m i t t e d t o NPC -
March 1983
 Minnesota - 3
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. W e l f a r e Department O f f i c i a l s :

A r t h u r E . Noot Department o f P u b l i c W e l f a r e
Commissioner Centennial O f f i c e B u i l d i n g
658 Cedar S t r e e t
S t . P a u l , Minnesota 55101

R o b e r t C. Bai r d 444 L a f a y e t t e Road

A s s i s t a n t Commissioner S t . Paul 55164
Bureau o f l ncome Maintenance

Thomas A. Gaylord, R.Ph.

D i rector
Heal t h Care Programs

Thomas A. K e l l e n b e r g e r , Phm.D.
D irector
Drug U t i l i z a t i o n Review Program

John T. Bush, R.Ph.

Pharmacist C o n s u l t a n t

2. W e l f a r e Department A d v i s o r y Committees:

A. P r o f e s s i o n a l M e d i c a l A d v i s o r y Committee:

I r v i n g C. B e r n s t e i n , M.D. L y l e Hay, M.D.

1011 M e d i c a l A r t s B l d g . Route 1, Box 3028
M i nneapol i s 55402 B u f f a l o 55313

D a v i d C r a i g , M.D. L y l e French, M.D.

St. Paul I n t e r n i s t 5620 West B a r a r i a n P a t h
590 Park S t r e e t , S u i t e 408 M i n n e a p o l i s 55432
S t . Paul 55103
Dorothy B e r n s t e i n , M.D.
P e t e r Fehr, M.D. 1011 M e d i c a l A r t s B l d g .
3931 C r y s t a l Lake B l v d . M i nneapol i s 55404
M i nneapol i s 55422
M i l a n d E. Knapp, M.D.
Frank S . Babb, M.D. 21020 Oak Lane
S t . Anthony O r t h o p a e d i c C l i n i c E x c e l s i o r 55331
1661 S t . Anthony, S u i t e 200
S t . Paul 55104
NPC Minnesota - 4
1983

P r o f e s s i o n a l Medical A d v i s o r y C o m i t t e e ( c o n t i n u e d ) :

K a t h l e e n Simo, M.D. John J. Reagan, M.D.

South Medical C l i n i c 1431 Medical A r t s B u i l d i n g
4310 N i c o l l e t Avenue M i n n e a p o l i s 55402
Minneapol i s 55408
Henry B l i s s e n b a c h , Pharm.0.
M e r r i l l Chesler, M.D. 2119 A z t e c
P h y s i c i a n s 6 Surgeons Bldg Mendota H e i g h t s 55120
63 S. 9 t h S t r e e t
M i n n e a p o l i s 55402 S h i r l e y Mink, Ph.D.
110 E. 1 8 t h S t r e e t
John McNeil, M.D. Minneapol i s 55403
1224 Lowry B u i l d i n g
S t . Paul 55102

B. Minnesota S t a t e Pharmaceutical A s s o c i a t i o n Welfare Task

Force:

Donald Gibson - Duluth

M i c h a e l E. O'Toole, R.Ph. - Minneapolis
Roger Vadheim, R.Ph. - Tyler
(Cha i rman)
W i l l i a m F. Appel, R.Ph. - Minneapolis
.Kent F. Olson, R.Ph. - Hopkins
Hugh F. Kabat, R.Ph., Ph.0. - S t . Paul
B a r r y M. K r e l i t z , R.Ph. - Edina
C a r l W. Oberg, R.Ph. - Duluth

3. E x e c u t i v e O f f i c e r s o f S t a t e Medical and P h a r m a c e u t i c a l
Societies:

A. Medical A s s o c i a t i o n :

H a r o l d W. Brunn
Executive Vice-president
Minnesota S t a t e M e d i c a l A s s o c i a t i o n
2221 U n i v e r s i t y Avenue, S.E.
S t . Paul 55414
Phone: 612/222-6366

B. Pharmaceutical Association:

Donald A. Dee, R.Ph.

Executive D i r e c t o r
Minnesota S t a t e Pharmaceutical A s s o c i a t i o n
H e a l t h A s s o c i a t i o n s Center
2221 U n i v e r s i t y Avenue, S.E., S u i t e 326
M i n n e a p o l i s 55414
Phone: 612/378-1414
 Minnesota - 5
1983

E x e c u t i v e O f f i c e r s o f S t a t e Medical and Pharmaceutical

S o c i e t i e s (continued) :

C. Osteopathic Medical S o c i e t y

Robert N. Sampson, D.O.

Executive D i r e c t o r
Minnesota Osteopathic Medical Society
Hoffman C l i n i c
Hoffman 56339
 Mississippi - 1
1983
nlsslsswPl

HEDI CAI. ASSISTANCE DRUG PROGRAM (TITLE X I X)

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l ly Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC C h i l d r e n < Z l (SFD)
Prescribed

Im a t i e n t
~ o s ~ i t a Care
l X X X X
Outoati ent
H o s p i t a l Care X X X X
Laboratory &
X-ray S e r v i c e X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X
Physician
~e;vices x x x x
Dental
Services X X X X
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s by f i s c a l y e a r e n d i n g

June 30, 1982

1981 1982
Expended Recipient Expended Recipient

TOTAL............................... $27,157,381 258,641** $28,456,785 232,154**

CATEGORICALLY NEEDY CASH TOTAL.. .... $9,875,861 168,949
Aged ................................ 3,126,599 25,214
Blind............................... 67,142 629
Disabled. ........................... 2,288,975 16,435
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . .. 1,990,975 91,345
Adults -Families w/DepChildren ..... 2,402,170 35,326
CATEGORICALLY NEEDY NON-CASH TOTAL.. $17,281,520 89,692
Aged ................................ 9,514,922 44,453
Blind........ ....................... 178,024 867
Disabled... ......................... 7,183,036 32,733
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 182,421 8,076
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . . . . 212,568 3,095
Other T i t l e XIX R e c i p i e n t s .......... 10,549 468
MEDICALLY NEEDY TOTAL.. ............. $0 0
Aged ................................ 0 0
Blind............................... 0 0
Disabled ............................ 0 0
...
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n 0 0
.....
A d u l t s - F a m i l i e s w/Dep C h i l d r e n 0 0
..........
Other T i t l e X I X R e c i p i e n t s 0 0
**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082
199
 Mississippi - 2
1983

Ill. Administration:

M i s s i s s i p p i M e d i c a i d Commission.

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs.

A. General E x c l u s i o n s :

1. Reimbursement i s l i m i t e d t o drugs l i s t e d i n t h e f o r m u l a r y .

2. E x c l u s i o n s a r e d i r e c t e d p a r t i c u l a r l y a t amphetamines, o b e s i t y
c o n t r o l drugs, v i t a m i n s , c o l d and cough p r e p a r a t i o n s , c e r t a i n
p e r i p h e r a l v a s o d i l a t o r s , and t h o s e drugs c l a s s i f i e d as m i l d
tranquilizers.

B. Formulary: R e s t r i c t e d formulary. For formulary i n f o r m a t i o n contact:

James T. S t e e l e
M i s s i s s i p p i M e d i c a i d Commission
P.O. Box 16786
Jackson, M i s s i s s i p p i 39236
601/981-4507, E x t . 145

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Q u a n t i t y of M e d i c a t i o n : P r e s c r i p t i o n o r r e f i l l q u a n t i t i e s s h o u l d
n o t exceed t h e amount shown i n t h e maximum u n i t s column of t h e
formulary. P r e s c r i p t i o n s l i m i t e d t o s i x ( 6 ) p e r month p e r
recipient.

2. Refil Is: P r e s c r i p t i o n r e f i l I s a r e l i m i t e d t o t h r e e (31, e x c e p t f o r

maintenance t y p e p r e s c r i p t i o n s w i t h a l i m i t of 5. Authorization i s
required i n w r i t i n g by the prescriber. There a r e no r e f i l l
r e s t r i c t i o n s on i n s u l i n , and no r e f i l l s a r e a l l o w e d on t e l e p h o n e d
prescriptions.

3. Injections: The M e d i c a i d program w i l l n o t r e i m b u r s e d r u g p r o v i d e r s

f o r i n j e c t a b l e m e d i c a t i o n s e x c e p t f o r i n s u l i n and i n j e c t a b l e
m e d i c a t i o n s p r e s c r i b e d f o r r e s i d e n t s of n u r s i n g homes, and f o r those
i n p r i v a t e homes i f t h e i n d i v i d u a l i s r e c e i v i n g Home H e a l t h S e r v i c e s
under an approved p l a n o f t r e a t m e n t . I n j e c t a b l e P r o l i x i n s h a l l be
an e x c e p t i o n .

4. Dollar Limits: None.

 Mississippi - 3
I983

D. P r e s c r i p t i o n Charge Formula:

1. E f f e c t i v e 7/1/81 -
Legend Drugs - reimbursement f o r a l l l e g e n d d r u g
c l a i m s w i l l be based on t h e l o w e r o f :

a. MAC/EAC ( i n g r e d i e n t c o s t ) d e t e r m i n e d f o r t h e d r u g i n t h e
q u a n t i t y d i s p e n s e d , p l u s $3.17 d i s p e n s i n g f e e . Dispensing
p h y s i c i a n s r e c e i v e a f e e o f $2.00.

b. The u s u a l and customary r e t a i l charge.

2. Reimbursement f o r non-legend d r u g s a r e based o n t h e l o w e r of u s u a l

and customary c h a r g e o r t h e maximum o v e r - t h e - c o u n t e r p r i c e s e t f o r
t h a t item l i s t e d i n formulary. Usual and customary of a non-legend
d r u g i s t o be t h e s h e l f p r i c e .

3. Compounded p r e s c r i p t i o n s f o r t o p i c a l use a r e c o v e r e d i f a t l e a s t one

l e g e n d d r u g ( i n t h e r a p e u t i c amounts) i s i n c l u d e d i n t h e i n g r e d i e n t s .

4. Compounded o r a l m e d i c a t i o n s when a l l i n g r e d i e n t s a r e c o v e r e d
s e p a r a t e l y under t h e i r own d r u g codes i n t h e f o r m u l a r y .

V. M i s c e l l a n e o u s Remarks:

M e d i c a i d e l i g i b l e p e r s o n s r e c e i v e d 3,196,542 p r e s c r i p t i o n s d u r i n g F i s c a l
Year 1982. T h i s r e p r e s e n t s a decrease o f 442,434 p r e s c r i p t i o n s o r 12.2%
f r o m F i s c a l Year 1981.

Average Rx p r i c e d u r i n g FY 1982 - $9.06

F i s c a l intermediary:

1982 - B l u e Cross B l u e S h i e l d
1983 - EDS F e d e r a l ( E f f e c t i v e 1 January 1983)
 Mississippi - 4
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. M i s s i s s i p p i M e d i c a i d Commission O f f i c i a l s :

B. F. Simmons M i s s i s s i p p i Medicaid
Director Commission
(P. 0. Box 16786)
4785 1-55 F r o n t a g e Road
Jackson, M i s s i s s i p p i 39236

W i l l Lowery
Associate D i r e c t o r

W. Jack E s t e s
A s s i s t a n t Di r e c t o r
Administration

W i l l i a m R. A l l e n , R.Ph.
Deputy D i r e c t o r

James T. S t e e l e , R.Ph.
Pharmacist

Commission Members ( 7 ) :

Jimmie U. Crane, Chairman - Ful ton

George S . S m i t h - Jackson
C h a r l e s H. Shamburger, I I I - Brandon
Sen. Glen Deweese - Meridian
Sen. Edward E l l i n g t o n - Jackson
Rep. F. Edwi n P e r r y - Oxford
Rep. Don W. R i c h a r d s o n - Jackson

2. T i t l e X I X T e c h n i c a l A d v i s o r y Committee:

There a r e s i x ( 6 ) t e c h n i c a l a d v i s o r y committees. Each c o m m i t t e e c o n s i s t s of

i n d i v i d u a l s who a r e h e a l t h c a r e p r o f e s s i o n a l s i d e n t i f i e d w i t h t h e
r e s p o n s i b i l i t y o f t h e committee t o w h i c h t h e y a r e a p p o i n t e d .

3. E x e c u t i v e O f f i c e r s o f S t a t e M e d i c a l and P h a r m a c e u t i c a l
Societies:

A. Medical A s s o c i a t i o n : B. Pharmaceutical A s s o c i a t i o n :

C h a r l e s L. Mathews P h y l l i s s M. M o r e t , R.Ph.
Executive Secretary Executive D i r e c t o r
M i s s i s s i p p i S t a t e M e d i c a l Assoc. M i s s i s s i p p i S t a t e Pharrn. Assoc.
735 R i v e r s i d e D r i v e S u i t e 204 - Barnett Building
Jackson 39216 Jackson 39201
Phone: 601 /354-5433 Phone: 601/944-0416
 Missouri - 1
1983

K O 1 UL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e q o r i c a l ly Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC C h i l d r e w 2 1 (SFO)
Prescribed
Drugs X X X X X
l n ~ ai te n t
~ o ; ~t ai l Care X X X X X
Outpatient
H o s p i t a l Care X X X X X
Laboratory &
X-ray S e r v i c e X X X X X
S k i l l e d Nursin. g
Home S e r v i c e s X X X X X
Physician
Services X X X X X
Dental
Services X X X X xK
*SF0 - S t a t e Funds Only
#Not c o v e r e d f o r General R e l i e f C a t e g o r y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982

1981 1982
Expended R e c i p i e n t Expended Recipient

TOTAL.. ............................. $31,394,520 262,935** $23,010,936 228,673**

CATEGORICALLY NEEDY CASH TOTAL...... $16,973,583 197,748

Aged ................................ 7,550,308 32,042
Blind ............................... 3891593 1,716
Disabled ............................ 3,134,607 12,489
Children-Families w/DepChildren ... 2,039,765 90,065
A d u l t s - F a m i l i e s w/Dep Children..... 3,859,310 61,436

CATEGORICALLY NEEDY NON-CASH TOTAL.. $14,420,937 65,187

Aged.. .............................. 8,050,495 31,482
Blind ............................... 82,544 28 1
Disabled.. .......................... 5,899,327 23,765
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 112,713 4,163
A d u l t s - F a m i l i e s w/Dep Children..... 240,105 3,561
..........
O t h e r T i t l e XIX R e c i p i e n t s 35,753 1,935

ME01 CALLY NEEDY TOTAL.. ............. $0 0

Aged ................................ 0 0
B l i n d ............................... 0 0
Disabled................ ............ 0 0
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n ... 0 0
A d u l t s - F a m i l i e s w/Dep Children..... 0 0
Other T i t l e X I X R e c i p i e n t s .......... 0 0

*nunduplicated T o t a l - HHS r e p o r t HCFA - 2082

203
 Missouri - 2
1983

III. Administration:

D i v i s i o n o f F a m i l y S e r v i c e s o f t h e S t a t e Department o f S o c i a l S e r v i c e s .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

General E x c l u s i o n s :
E x c l u s i o n s governed b y F o r m u l a r y .

Formulary: F o r m u l a r y l i s t s 402 drugs b y g e n e r i c names o r t r a d e

names. F o r i n f o r m a t i o n c o n t a c t :

Susan McCann, P.D.

Pharmacy C o n s u l t a n t
227 M e t r o D r i v e
P.0. Box 88
Jefferson City, Missouri 65103
314/751-3425

S t a t e a l l o w s payment f o r o n l y t h e drugs i n t h e f o r m u l a r y .

P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Q u a n t i t y of M e d i c a t i o n : P h y s i c i a n encouraged t o p r e s c r i b e 34-day
o r 100 doses s u p p l y b u t may, a t h i s own d i s c r e t i o n , p r e s c r i b e up t o
a maximum 90-day s u p p l y .

2. Refills: F e d e r a l r e g u l a t i o n s must be observed f o r a l l drugs on t h e

f o r m u l a r y w h i c h a r e l i s t e d i n BNDD Schedules 2, 3, 4, and 5. A l l
o t h e r p r e s c r i p t i o n s r e f i l l e d s h o u l d be i n accordance w i t h t h e
d i r e c t i o n s g i v e n by t h e p r e s c r i b i n g physician.

3. F i v e Rx l i m i t a t i o n p e r month p e r r e c i p i e n t . C e r t a i n drugs which

a r e comnonly p r e s c r i b e d f o r l o n g - t e r m c h r o n i c m e d i c a l c o n d i t i o n s
a r e exempt f r o m l i m i t a t i o n .

P r e s c r i p t i o n Charge Formula: The l o w e s t of t h e f o l l o w i n g :

F e d e r a l MAC, M i s s o u r i MAC, AWP, o r D i r e c t p l u s $2.50 f e e o r usual and
customary, whichever i s l o w e r .

Co-payment ( v a r i a b l e ) - $0.50 ~ o - ~ a ~ m ewhenn t acquisition

$10.99 o r l e s s
- $1.00 co-payment when a c q u i s i t i o n
$11.00 o r more
- Co-payment r e t a i n e d b y p h a r m a c i s t .

Drug E x c e p t i o n Process:

C e r t a i n n o n s t e r o i d a l a n t i - i n f l a m m a t o r y drugs c o v e r e d on a p r i o r
a u t h o r i z a t i o n b a s i s f o r r e c i p i e n t s w i t h d i a g n o s i s of r h e u m a t o i d
a r t h r i t i s o r j u v e n i l e r h e u m a t o i d a r t h r i t i s who c a n n o t t o l e r a t e a s p i r i n .
NPC Missouri - 3
1983

V. M i s c e l l a n e o u s Remarks:

A l l p r e s c r i p t i o n s must be f i l l e d w i t h drugs t h a t meet USP standards.

P a r t i c i p a t i n g pharmacies s i g n a p a r t i c i p a t i o n agreement w i t h t h e S t a t e
Department. A l l d i s p e n s i n g p h y s i c i a n s p a r t i c i p a t i n g i n t h e program a r e
r e q u i r e d t o keep p r e s c r i p t i o n f i l e s t h e same as pharmacies.

Missouri formulary i s a r e s t r i c t e d formulery, r e s t r i c t i o n being t h a t t h e

S t a t e o n l y pays f o r drugs l i s t e d on t h e f o r m u l a r y , o r d r u g s t h a t a r e
c h e m i c a l l y e q u i v a l e n t t o drugs l i s t e d . Any drug t h a t i s c h e m i c a l l y
e q u i v a l e n t t o a t r a d e name d r u g l i s t e d a s a c c e p t a b l e f o r reimbursement. And
l i k e w i s e any t r a d e name drug t h a t i s n o t l i s t e d , b u t i s e q u i v a l e n t t o a
g e n e r i c d r u g l i s t e d , i s r e i m b u r s a b l e under t h e d r u g program.

Method of reimbursement payment i s based on a c q u i s i t i o n c o s t p l u s a

d i s p e n s i n g f e e o f $2.50 p e r p r e s c r i p t i o n f i l l e d . A c q u i s i t i o n may v a r y
depending whether i t i s based on AWP, D i r e c t P r i c e and F e d e r a l o r M i s s o u r i
MAC. The master d r u g f i l e c o n t a i n s a l l a c c e p t a b l e d r u g s and t h e i r
a p p r o p r i a t e NDC ( N a t i o n a l Drug Code) number.

AWP (Average Wholesale P r i c e ) , any d r u g t h a t i s n o t m a n u f a c t u r e d by A b b o t t ,

L e d e r l e , Merck Sharp & Dohme, Parke-Davis, P f i z e r , R o e r i g , Squibb, Upjohn
and Wyeth, o r i s n o t a F e d e r a l o r M i s s o u r i MAC d r u g w i l l be based on t h e
AW. The m a j o r i t y of drugs l i s t e d a r e based on AWP. The method of p r i c i n g
w i l l be t a k e n from t h e NDC number.

Any drug manufactured b y A b b o t t , L e d e r l e , Merck Sharp & Oohme, P a r k e - D a v i s ,

P f i z e r , R o e r i g , Squibb, Upjohn and Wyeth, a c q u i s i t i o n c o s t w i l l be based o n
the manufacturer's d i r e c t price.

The F e d e r a l Government has 19 drugs 1 i s t e d as MAC (Maximum A l l o w a b l e

C o s t ) . M i s s o u r i has 39 drugs l i s t e d as MAC (Maximum A l l o w a b l e C o s t ) . These
58 d r u g s have a maximum p r i c e t h a t w i l l be p a i d .

A l l p h a r m a c i s t s and p h y s i c i a n s t h a t p a r t i c i p a t e i n t h e M i s s o u r i T i t l e X I X
M e d i c a i d Drug Vendor Program have been i s s u e d a l i s t i n g of a l l MAC drugs, a
l i s t i n g o f t h e manufacturers t h a t t h e D i v i s i o n o f Family Services l i m i t s
price t o direct price.

By f o l l o w i n g t h e s e g u i d e l i n e s t h e D i v i s i o n of F a m i l y S e r v i c e s f e e l s t h a t t h e
p h a r m a c i s t has a freedom o f c h o i c e of p r o d u c t s and package s i z e s i n w h i c h he
o r she may s t o c k t h e i r i n v e n t o r y .

F i s c a l intermediary: General American-Consultec

P.O. Box 1105
J e f f e r s o n C i t y , M i s s o u r i 65102

Number o f d r u g c l a i m s processed i n FY 1982 - 4,959,272

Average p r e s c r i p t i o n p r i c e d u r i n g FY 1982 - $7.76

 Missouri - 4
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. S o c i a l S e r v i c e s Department O f f i c i a l s :

B a r r e t t A. Toan Department o f S o c i a l S e r v i c e s
D i rector Broadway S t a t e O f f i c e B u i l d i n g
J e f f e r s o n C i t y , M i s s o u r i 65103

Sharon Marcum
Deputy D i r e c t o r

Joseph J. O'Hara
Di r e c t o r
D i v i s i o n of F a m i l y S e r v i c e s

Gretchen E n g q u i s t D i v i s i o n of F a m i l y S e r v i c e s
Di r e c t o r , Medical Services 227 M e t r o D r i v e
P . 0. Box 88
J e f f e r s o n C i t y 65103

K a r e n McKenzie, A d m i n i s t r a t o r
Surveillance/Util ization
Review Systems (SURS)

Susan McCann
P h a r m a c i s t Consul t a n t

E v e r e t t H a r r i s , D.O.,
Physician Consultant
M i c h a e l Wilson, D.O.,
Physician Consultant

2. M e d i c a l A d v i s o r y Committee t o t h e S t a t e D i v i s i o n o f F a m i l y
Services:

Robert H o t c h k i s s , M.D. L e s l i e F. Bond, M.D., Chairman

Director 3400 N. Kingshighway
D i v i s i o n of H e a l t h S t . L o u i s 63115
Broadway S t a t e O f f i c e B u i l d i n g
J e f f e r s o n C i t y 65101 James E. Canter, 0.0.
410 N o r t h e a s t S t r e e t
Ms. E d d i e Mae B i n i o n C a l i f o r n i a 65018
S o u t h s i d e Welfare R i g h t s
Organization Senator D a v i d D o c t o r i a n
1400 Park Route 3
S t . L o u i s 63104 Macon 63552
 Missouri - 5
1983

M e d i c a l A d v i s o r v Committee t o t h e S t a t e D i v i s i o n of F a m i l y
Services (continued):

Rep. R u s s e l l Goward Jonathan G. Hanson

4015 F a i r Avenue 1407 Southwest B l v d .
St. L o u i s 63115 J e f f e r s o n C i t y 65101

John H a r t , D.O. George L. McElroy, I l l , M.D.

M e d i c a l D i r e c t o r o f Rehab. Capitol C h i l d r e n ' s C l i n i c s , Inc.
C h a r l e s E. S t i l l H o s p i t a l 1233 S o u t h J e f f e r s o n
1125 Madison J e f f e r s o n C i t y 65101
J e f f e r s o n C i t y 65101
H. D. S p i e r s , B i s h o p
Administrator
B. D a v i d H a r t w i g , V i c e - c h a i r m a n Resthaven N u r s i n g Home
Red Cross Pharmacy 1500 West Truman Road
52 A r r o w S t r e e t l ndependence 64050
Marshal l 65340
Audrey M. Thaman, Ph.D.
Ms. D o r e t t a Henderson D i r e c t o r of S o c i a l Work
1827 East 1 2 t h S t r e e t C i t y of S t . Louis
Kansas C i t y 64127 Department of H e a l t h &
Hospital
Dennis L. Hunter, O.D. 1625 South 1 4 t h S t r e e t
302 West Morgan St. L o u i s 63104
M a r s h a l l 65340
Senator H a r r y Wiggi ns
Erma Cunningham, Exec. D i r e c t o r 7817 T e r r a c e S t r e e t
M i s s o u r i R i v e r Home Heal t h Agency Kansas C i t y 64114
219 E. D u n k l i n
J e f f e r s o n C i t y 65101 Rep. I r e n e T r i p p l e r
House o f R e p r e s e n t a t i v e s
Norman E. McCann, S o c i a l S e r v i c e s Committee
Executive D i r e c t o r 4681 Fuchs Road
Missouri Baptist Hospital S t . L o u i s 63128
3015 N o r t h B a l l a s Road
Kansas C i t y 63131 I r a White, D.O.
1701 S. L a f a y e t t e
Sedal i a 63501

E x - O f f i c i o Members:

Joyne L e e t J a c q u e l i n e Hal I, R.N., M.A.

Grace H i l l H e a l t h Center 800 W. J e f f e r s o n
2500 Hadley S t r e e t K i r k s v i l l e C o l l e g e of O s t e o p a t h i c Med.
S t . L o u i s 63106 K i r k s v i l l e 63501
 Missouri - 6
1983

3. Pharmacy A d v i s o r y Committee:

B . D a v i d H a r t w i g , R.Ph., Jack L i t t r e l l , R.Ph.

C ha i rman B l u e V a l l e y Pharmacy
Red Cross Pharmacy 5811 Truman Road
52 Arrow S t r e e t Kansas C i t y 64126
M a r s h a l l 65340
816/886-5533 James D. Osborn, R.Ph.
Osborn Medical Tower Pharmacy
B i l l F i t z p a t r i c k , R.Ph. 1443 N o r t h Robberson
F i t z p a t r i c k Pharmacy S p r i n g f i e l d 65802
130 Manchester
B a l l w i n 63011

Tom Gibson, R.Ph.

Waverly Pharmacy
K e l l i n g and Broadway
Waver ly 64096

4. E x e c u t i v e O f f i c e r s of S t a t e M e d i c a l and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical A s s o c i a t i o n :

Royal Cooper
Executive Secretary
M i s s o u r i S t a t e Medical A s s o c i a t i o n
113 Madison S t r e e t
P. 0. Box 1028
J e f f e r s o n C i t y 65101
Phone: 314/636-5151

8. Pharmaceutical Association:

John B. Z a t t i , R.Ph.
Chief E x e c u t i v e O f f i c e r
Missouri Pharmaceutical Association
410 Madison S t r e e t
J e f f e r s o n C i t y 65101
Phone: 314/636-7522

C. Osteopathic Association:

Edward Borman
Executive D i r e c t o r
Missouri Association o f Osteopathic
P h y s i c i a n s and Surgeons
325 East McCarty
J e f f e r s o n C i t y 65101
Phone: 314/634-3415
NPC Montana - 1
1983

E D I C A L ASSISTANCE DRUG PROGRAM (TITLE X I X )

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFOC C h i l d r e n Q l (SFO)
Prescribed
Drugs X X X X X X X X X
l noat
r~~
i e n t ~

H o s p i t a l Care X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X
Laboratory &
X-ray S e r v i c e X X X X X X X X X
S k i l l e d Nursina -
Home S e r v i c e s X X X X X X X X X
Physician
Services X X X X X X X X X
Dental
~ ~

Services X X X X X X X X X
*SF0 -
S t a t e Funds Only

II. EXPENDITURES FOR DRUGS. Payment t o Pharmacists b y f i s c a l year e n d i n g

September 30, 1982

Expended Recipient Expended Recipient

TOTAL............................... $3,521,017 32,810**

CATEGORICALLY NEEDY CASH TOTAL...... 1,680,897 22,191

Aged ................................ 375,342 1,930
Blind..... .......................... 13,359 74
Disabled.. .......................... 747,497 3,688
C h i l d r e n - F a m i l i e s w/Dep Children... 189,371 9,506
A d u l t s - F a m i l i e s w/Dep Children..... 355,328 6,993

CATEGORICALLY NEEDY NON-CASH TOTAL.. $1,699,181 9,495

Aged.. .............................. 1,194,388 4,156
Blind............................... 12,749 38 1
Disabled............................ 340,296 1,187
C h i l d r e n - F a m i l i e s w/Dep Children... 35,019 1,708
A d u l t s - F a m i l i e s w/Dep Children..... 60,889 1,200
..........
Other T i t l e XIX R e c i p i e n t s 25,840 863

MEDICALLY NEEDY TOTAL.. ............. $170,939 1,124

Aged ................................ 70,082 425
Blind... ............................ 45 1
D i s a b l e d ............................ 81,214 402
C h i l d r e n - F a m i l i e s w/Dep Children... 0 0
A d u l t s - F a m i l i e s w/Dep Children..... 19,598 296
Other T i t l e XIX R e c i p i e n t s .......... 0 0

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

209
 Montana - 2
1983

I l l . Administration:

State Department of Social and Rehabilitation Services.

IV. Provisions Relating t o Prescribed Drugs:

A. General Exclusions:
Provided are all legend drugs and those non-legend drugs in the
following classes: insulin, laxatives, antacids. They must be
prescribed by a l icensed practitioner (physician, dentist, or
podiatrist).

B. Formulary: None.

C. Prescribing o r Dispensing Limitations:

1. Quantity of Medication: None.

2. Refills: A s directed by licensed practitioner.

3. Dollar Limits: No limit.

Copayment o f $0.50/Rx by recipient o n any prescription unless

exempt from copay by Tefra Act.

D. Prescription Charge Formula: Drugs will be paid at the usual retail

rate or estimated acquisition cost or maximum allowable cost, plus a
dispensing f e e - whichever is lower. Dispensing fees range from $2.00
t o $3.75. Additional $0.75 per R x allowed for unit dose systems.
 Montana - 3
1983

Officials, Consultants and Committees

Social and R e h a b i l i t a t i o n Services Department O f f i c i a l s :

John D. LaFaver ~e~aitmen o ft S o c i a l and

D i rector R e h a b i l i t a t i o n Services
P. 0. Box 4210
Helena, Montana 59604

Lowell Uba
Chief
D i v i s i o n of Economic Assistance

John Larson, Chief

Hed ic a i d F inance Bureau

Montana Medical Care Advisory Council:

Doug l as 0 lson Pat Godbout

James Conway C a l v i n Bohleen
Joan Jacobson, M.D. Gary Blewett
Lowell Uba Gary Walsh

Social and R e h a b i l i t a t i o n Servi ces Econanic Assistance

Division:

Jack E l l e r y K a r l Banschbach
Administrator Medical Care S p e c i a l i s t

Jack Oorner Marie B r a z i e r , R.N.

Medical Care S p e c i a l i s t Nurse Consultant,

Jack Lowney Paul M i l l e r

Management Analyst, Budget Medical Care S p e c i a l i s t

John K a l l , D.D.S. Bob Froisness, Chief

Dental Consultant Medicaid Finance Bureau

Joyce DeCunzo J i m McCabe, Chief

Administrative Assistant E l i g i b i l i t y Bureau
 Montana -4
1983

4. E x e c u t i v e O f f i c e r s o f S t a t e Medical and P h a r m a c e u t i c a l
Societies:

A. Medical Association:

G. B r i a n Z i n s
Executive D i r e c t o r
Montana M e d i c a l A s s o c i a t i o n
2021 1 1 t h Avenue, S u i t e 12
Helena 59601
Phone: 406/443-4000

B. Pharmaceutical Association:

Frank D a v i s
Executive D i r e c t o r
Montana S t a t e P h a r m a c e u t i c a l A s s o c i a t i o n
P.O. Box 6335
G r e a t F a l l s 59406
Phone: 406/452-3201

C. Osteopathic Association:

L e s t e r F. Howard, D.O.
Secretary-Treasurer
Montana O s t e o p a t h i c A s s o c i a t i o n
1116 F i r s t Avenue N o r t h
G r e a t F a l l s 59401
406/452-6353
NPC Nebraska - 1
1983

NEBRASKA

) E O I U L ASSlSTAllCE DRUG PRO- (TITLE X I X )

I. BENEFITS PROVIDED AND GROUPS ELI GlBLE

Type o f B e n e f i t C a t e q o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
O M A0 APT0 AFDC OAA AB APTD AFDC C h i l d r e n Q l (SFO)
Prescribed
Drugs X X X X X X X X X X
l npat i e n t
H o s p i t a l Care X X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X X
Laboratorv 6
X-ray S e r v i c e X X X X X X X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X X X X X X X
Physician
Services X X X X X X X X X X
Dental
Services X X X X X X X X X X
*SF0 - S t a t e Funds Only

II. EXPENDITURES FOR DRUGS. Payment t o Pharmacists by f i s c a l year ending

September 30, 1982

1981 1982
Expended R e c i p i e n t Expended Recipient

CATEGORICALLY NEEDY CASH TOTAL...... $5,074,022 43,340 $5,541,093 44,961

Aged ................................ 1,721,820 5,524 1,852,501 5,201
Blind............................... 35,899 151 40,415 149
Disabled............................ 1,833,819 6,002 2,018,316 6,065
C h i l d r e n - F a m i l i e s w/Dep Children... 568,858 19,141 630,202 20,102
A d u l t s - F a m i l i e s w/Dep Children..... 913,626 12,522 999,659 13,444

CATEGORICALLY NEEDY NON-CASH TOTAL.. $89,202 2,116 $116,260 2,857

Aged ................................ 0 0 0 0
Blind ............................... . o 0 0
0
0
0
Disabled............................ 0 0
C h i l d r e n - F a m i l i e s w/Dep Children... 8,479 38 1 15,017 740
A d u l t s - F a m i l i e s w/Dep Children..... 14,718 28 1 26,215 527
..........
Other T i t l e X I X R e c i p i e n t s 66,005 1,454 75,028 1,590

MEDl CALLY NEEDY TOTAL.. ............. $3,725,235 9,947 $3,912,736 9,449

Aged ................................ 3,152,509 8,395 3,305,323 7 1979
Blind.... ........................... 5,764 18 4,966 16
Disabled. ........................... 550,204 1,344 588,017 1,264
C h i l d r e n - F a m i l i e s w/Dep Children... 1,453 79 1,925 80
A d u l t s - F a m i l i e s w/Dep Children..... 15,101 102 11,930 81
..........
Other T i t l e X I X R e c i p i e n t s 204 9 575 29

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

 Nebraska - 2
1983

I l l . Administration:

S t a t e Department o f P u b l i c W e l f a r e .

1V. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s : E x p e r i m e n t a l drugs; w e i g h t c o n t r o l and a p p e t i t e

depressant drugs, e x c e p t f o r use i n N a r c o l e p s y o r H y p e r k i n e s e s i n
c h i l d r e n w i t h g r a n t e d p r i o r a p p r o v a l ; OTC d r u g s t h a t have n o t been
p r e s c r i b e d by a l i c e n s e d p r a c t i t i o n e r ; drugs t h a t a r e m a r k e t e d w i t h o u t
r e q u i r e d FDA a p p r o v a l ; d r u g s marketed t h a t i n f r i n g e on p a t e n t r i g h t s ;
p r i o r a u t h o r i z a t i o n i s r e q u i r e d f o r c e r t a i n o t h e r items.

8. Formulary: None. The " O f f i c i a l Drug Guide" i s a l i s t o f drugs

t o g e t h e r w i t h i d e n t i f i c a t i o n members f o r b i l l i n g purposes. For Drug
Guide I n f o r m a t i o n , c o n t a c t :

M r . Tom Dolan, R.Ph.

NDPW
P.O. Box 95026
L i n c o l n , Nebraska 68509
402/471-3121

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s : "

1. Q u a n t i t y o f Medication: Maintenance-type d r u g s l i m i t e d t o
purchases o f a t l e a s t a 30-day s u p p l y , u n l e s s an e x c e p t i o n i s
s p e c i f i c a l l y allowed. C a r d i a c g l y c o s i d e s , t h y r o i d , v i t a m i n s and
D i l a n t i n w i l l b e l i m i t e d t o purchases of n o t l e s s t h a n 1 0 0 ' s .

The Department o f P u b l i c W e l f a r e f u r t h e r r e q u i r e s t h a t any o t h e r

maintenance d r u g o r any d r u g used i n a c h r o n i c manner be
PRESCRIBED and DISPENSED i n a minimum o f a one-month s u p p l y .

(Note: P r e s c r i p t i o n s which a r e w r i t t e n f o r q u a n t i t i e s l a r g e r than

a m o n t h ' s s u p p l y a r e n o t t o be reduced t o a m o n t h ' s s u p p l y . The
Nebraska Department o f P u b l i c W e l f a r e w i l l c o n s i d e r any form of
p r e s c r i p t i o n s p l i t t i n g as f r a u d u l e n t . )

Exceptions t o t h e Q u a n t i t y L i m i t a t i o n s :

a. When t h e p r e s c r i b i n g p h y s i c i a n f i r s t i n t r o d u c e s a maintenance
d r u g t o a p a t i e n t ' s c o u r s e of t h e r a p y , t h e p h y s i c i a n i s
a l l o w e d t o p r e s c r i b e as h i s judgment d i c t a t e s . Physicians
-
and P h a r m a c i s t s MUST i n d i c a t e on t h e c l a i m f o r m t h a t t h i s i s
the i n i t i a l f i l l i n g o f t h e medication.

*Medical S e r v i c e s , Department o f P u b l i c W e l f a r e , S t a t e of Nebraska.

Nebraska DPW Program Manual i s s u e d November 24, 1982, as amended.
 Nebraska -3
1983
Q u a n t i t y of M e d i c a t i o n ( c o n t i n u e d ) :

Any subsequent d i s p e n s i n g o f t h i s maintenance drug must be

p r e s c r i b e d and dispensed i n a t l e a s t a m o n t h ' s s u p p l y o r t h e
r e q u i r e d 100 doses.

When t h e p r e s c r i b i n g p h y s i c i a n ' s p r o f e s s i o n a l judgment

i n d i c a t e s t h a t t h e s e q u a n t i t i e s o f m e d i c a t i o n would n o t be i n
t h e p a t i e n t ' s b e s t medical i n t e r e s t , t h e p h y s i c i a n may
p r e s c r i b e as h i s judgment d i r e c t s ; b u t t h e c l a i m f o r m 5
c l e a r l y i n d i c a t e t h a t an e x c e p t i o n t o t h e r e q u i r e m e n t i s
b e i n g made.

I f , i n t h e P h a r m a c i s t ' s p r o f e s s i o n a l judgment, an e x c e p t i o n
t o t h e r e q u i r e m e n t s must be made, t h e P h a r m a c i s t a l s o MUST
c l e a r l y i n d i c a t e t h i s on t h e c l a i m form.

Schedule I I d r u g s a r e e x c e p t i o n s .

O r i g i n a l s h e l f packages: The Department o f P u b l i c W e l f a r e

w i l l a c c e p t CERTAIN o r i g i n a l s h e l f package s i z e s of
medication.

An o r i g i n a l s h e l f package of 16 f l u i d ounces, o r l e s s
when n o t packaged i n t h e p i n t s i z e , w i l l be s u f f i c i e n t
f o r our q u a n t i t y l i m i t a t i o n s r e q u i r e m e n t f o r l i q u i d s ,
b u t w i l l n o t be s u f f i c i e n t , f o r t h e s u p p l e m e n t a l
dispensing fee unless i t ' s a f u l l month's supply.

O r i g i n a l s h e l f packages o f 100 t a b l e t s o r c a p s u l e s o f
ROUTINELY p r e s c r i b e d drugs such as Oarvon, L i b r i u m ,
-
Valium, M e l l a r i l , etc., w i l l NOT be a c c e p t a b l e as
s u f f i c i e n t f o r f u l f i l l m e n t of our q u a n t i t y l i m i t a t i o n s
r e q u i r e m e n t . The f u l l m o n t h ' s s u p p l y must be p r e s c r i b e d
and dispensed.

An o r i g i n a l s h e l f package of 100 t a b l e t s o r c a p s u l e s , o r
l e s s when n o t a v a i l a b l e i n t h e 100 s i z e f o r SELDOM
p r e s c r i b e d s o l i d dosage drugs w i l l be s u f f i c i e n t f o r our
q u a n t i t y l i m i t a t i o n s r e q u i r e m e n t , b u t w i l l n o t be
s u f f i c i e n t f o r t h e supplemental d i s p e n s i n g f e e u n l e s s i t
i s a f u l l month's supply.

Ready-made o i n t m e n t s , creams, e t c . , when used i n a

c h r o n i c o r maintenance manner, may be d i s p e n s e d i n an
o r i g i n a l s h e l f package s i z e p r o v i d e d i t i s t h e o r i g i n a l
s i z e c l o s e s t t o t h e needed amount o f m e d i c a t i o n .
 Nebraska - 4
1983

O r i g i n a l s h e l f packages ( c o n t i n u e d ) :

(5) The d e t e r m i n a t i o n o f whether a c l a i m v i o l a t e s our

r e g u l a t i o n s o r n o t , would, by n e c e s s i t y , have t o be made
by t h e Department o f P u b l i c W e l f a r e ' s p r o f e s s i o n a l
s t a f f . Any c l a i m deemed t o be i n v i o l a t i o n o r n o t an
e x c e p t i o n t o our r u l i n g s , w i l l -
n o t be compensated w i t h
t h e d i s p e n s i n g fee.

Any disagreement w i t h a d e t e r m i n a t i o n may be a r b i t r a t e d

t h r o u g h t h e NEBRASKA PHARMACISTS ASSOCIATION'S WELFARE
ADVISORY COMMITTEE.

3. Refills: As a u t h o r i z e d b y t h e p r e s c r i b i n g p h y s i c i a n .

4. Dollar Limits: None,

D. P r e s c r i p t i o n Charge Formula:

1. R e t a i l Pharmac i e s

a. "Assigned" D ispens i ng fee.

A d i s p e n s i n g f e e w i l l be a s s i g n e d b y t h e Nebraska Department
o f P u b l i c Welfare, t o each i n d i v i d u a l r e t a i l pharmacy. The
f e e w i l l be c a l c u l a t e d f r o m t h e i n f o r m a t i o n o b t a i n e d t h r o u g h
t h e D e p a r t m e n t ' s P r e s c r i p t i o n Survey. Each Pharmacy w i l l be
n o t i f i e d o f i t s d i s p e n s i n g fee.

b. "Mai ntenance Drug-Month Supply"

Supplemental fee.

I n a d d i t i o n t o t h e "assigned" d i s p e n s i n g f e e f o r each
pharmacy, t h e r e i s a maintenance drug-month s u p p l y
supplemental f e e of $1.00. T h i s a d d i t i o n a l f e e may be
charged p r o v i d e d t h a t a MAINTENANCE DRUG o r d r u g used i n a
c h r o n i c manner i s dispensed i n a q u a n t i t y s u f f i c i e n t t o
p r o v i d e an e n t i r e m o n t h ' s t h e r a p y .

V a r i a b l e Pharmacy Fee f o r i n a i v i d u a l pharmacy d e t e r m i n e d from s u r v e y

data submitted t o state:

EAC, SMAC, MAC p l u s d e t e r m i n e d s t o r e f e e (minimum $2.98 t o maximum

$3.35)

o r u s u a l and customary, whichever i s lower.

 Nebraska - 5
1983

Hospital Pharmacies

Hospital Pharmacies are signled a "fixed" fee of $0.80 per

prescription.

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 the lowest cost
at which the drug is widely and consistently available.
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 Public
Welfare will -NOT have authority to adjust 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, DHHS/HCFA, 6401
Security Blvd., Rm. 1-C-5 East Low Rise Bldg., Baltimore,
Maryland 21235.

All pharmacies will be notified by the Nebraska

Department of Public Welfare 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): NDPW designates a

state maximum allowable cost (SMAC) for certain drug
products available from multiple manufacturers. The
SMAC value is the cost at which the multiple-source drug
is widely and consistently available to pharmacy
providers in Nebraska. The determination of which
products are designated SMAC items is the direct
responsibility of the Division of Medical Services in
conjunction with the Nebraska Pharmacists Association's
Welfare Advisory and Formulary Committee. Any
individual or organization may request a revision in a
SMAC value directly from NDPW at any time.

(3) Estimated Acquisition Cost (EAC): All drug products,

including the federally-designated MAC and state-
designated SMAC drugs, are assigned an estimated
acquisition cost (EAC) as required by 42 CFR 447.332 ( a )
NPC Nebraska - 6
1983

E s t i m a t e d A c q u i s i t i o n Cost (EAC) ( c o n t i n u e d ) :

( 2 ) . The EAC o f any p r o d u c t i s t h e c o s t a t w h i c h most

p r o v i d e r s may o b t a i n t h e item. NDPW i s r e s p o n s i b l e f o r
a s s i g n i n g t h e EAC v a l u e s t o a l l drugs. Any i n d i v i d u a l
o r o r g a n i z a t i o n may a t any t i m e r e q u e s t a r e v i s i o n i n an
EAC v a l u e d i r e c t l y f r o m NDPW.

b. Cost L i m i t a t i o n s

The Nebraska M e d i c a i d Drug Program i s r e q u i r e d t o r e i m b u r s e

p r o d u c t c o s t a t t h e LOWEST o f :

(1) t h e M.A.C. o r S.M.A.C. o f t h e drug, if one has been

established, or,

(2) t h e E.A.C. f o r t h a t drug.

The M.A.C. o r S.M.A.C. l i m i t a t i o n w i l l n o t a p p l y when t h e

p r e s c r i b i n g p h y s i c i a n c e r t i f i e s on a Form MC-6 t h a t a
s p e c i f i c b r a n d i s m e d i c a l l y necessary. I n t h e s e cases, t h e
E.A.C. w i l l be t h e maximum a l l o w a b l e c o s t .

4. PHYSICIAN CERTIFICATION

a. General I n f o r m a t i o n .

I f a p h y s i c i a n b e l i e v e s t h a t a c e r t a i n b r a n d name p r o d u c t of
a M.A.C. d e s i g n a t e d d r u g o r c l a s s of d r u g i s m e d i c a l l y
necessary f o r t h e p r o p e r t r e a t m e n t o f t h e p a t i e n t , t h e
p r a c t i t i o n e r may p r e s c r i b e as h i s judgment d i c t a t e s ; the
p h y s i c i a n must complete t h e Nebraska Department of P u b l i c
W e l f a r e ' s MC-6 c e r t i f i c a t i o n form. I f t h i s form (MC-6) i s
NOT completed, t h e Nebraska Department o f P u b l i c W e l f a r e MUST
(by F e d e r a l R e g u l a t i o n ) compensate t h e Pharmacy a t t h e M.E
v a l u e f o r t h a t drug.

5. PRICING INSTRUCTION (DRUGS)

UNDER NO CIRCUMSTANCES, MAY ANY CHARGE EXCEED THE USUAL AND

CUSTOMARY CHARGE TO THE GENE= PUBLI C.

a. Compounded P r e s c r i p t i o n s a n d Legend Drugs

These drugs w i l l be reimbursed a t t h e l e s s e r v a l u e o f e i t h e r :

1. P r o d u c t Cost (M.A.C., S.M.A.C. o r E.A.C.) plus the

appropriate dispensing f e e ( s ) , or
 Nebraska - 7
1983

Compounded P r e s c r i p t i o n s and Legend Drugs ( c o n t i n u e d ) :

2. The usual and customary charge t o t h e g e n e r a l p u b l i c .

b. O v e r - t h e - c o u n t e r Drugs

These items w i l l be reimbursed a t t h e l e s s e r v a l u e of e i t h e r :

1. P r o d u c t Cost (M.A.C., S.M.A.C. o r E.A.C.) plus the

appropriate dispensing f e e ( s ) , or

2. The usual and customary s h e l f p r i c e t o t h e g e n e r a l

public.

S e c t i o n 2500 - PRODUCTS REQUIRING PRIOR APPROVAL

C e r t a i n p r o d u c t s r e q u i r e t h a t a p p r o v a l be g r a n t e d PRIOR t o t h e i r payment.

PHYSICIANS w i s h i n g t o p r e s c r i b e these p r o d u c t s MUST o b t a i n a p p r o v a l from:

The M e d i c a l D i r e c t o r
Medical Services D i v i s i o n
Nebraska Department o f P u b l i c W e l f a r e
301 C e n t e n n i a l M a l l South
F i f t h Floor
L i n c o l n, Nebraska 68509

The Department o f P u b l i c W e l f a r e w i l l n o t i f y t h e p r e s c r i b i n g p h y s i c i a n and t h e

pharmacy o f t h e r e c i p i e n t ' s c h o i c e , whenever t h e s e r e q u e s t s a r e approved.

V. Miscellaneous:

Co-payment - None.

Number o f c l a i m s processed i n FY 1982 - 962,738

Average p r e s c r i p t i o n p r i c e d u r i n g FY 1982 - $9.94

 Nebraska - 8
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. W e l f a r e Department O f f i c i a l s :

Gina C. Dunning Department o f P u b l i c W e l f a r e

D irector 301 C e n t e n n i a l M a l l S o u t h
5th Floor
L i n c o l n , Nebraska 68509

Melvin Clothier
Administrator
D i v i s i o n of M e d i c a l S e r v i c e s

D e r a l d Lembrich
Administrator
Provider Services

Donald F . Hogg
S u r v e i l l a n c e and U t i l i z a t i o n
Review C o n s u l t a n t

Samuel F. Moessner, M.D.

Medical C o n s u l t a n t

Edward J. Smith, M.D.

Medical D i r e c t o r
D i v i s i o n o f Medical Services

Tom R . Dolan, R.Ph.

Pharmaceutical Consultant
D i v i s i o n o f Medical Services
402/471-3121, E x t . 360

Gary J. Cheloha, R.Ph.

Pharmacist
D i v i s i o n of Payment and Data S e r v i c e s
402/471-3121, E x t . 315

2. W e l f a r e Department M e d i c a l Care A d v i s o r y Committee:

D r . Henry Smith, D i r e c t o r Warren B o s l e y , M.D.

Depar tment of Heal t h 418 West D i v i s i o n
301 C e n t e n n i a l M a l l South Grand I s l a n d 68801
3rd F l o o r
L i n c o l n 68509 E s t h e r Buethe, D i r e c t o r
Johnson County D i v i s i o n
Gladysteen Warren o f P u b l i c Welfare
4507 NW 51 s t Tecumseh 68450
L i n c o l n 68524
 Nebraska - 9
1983

W e l f a r e Department Medical Care A d v i s o r y Comni t t e e ( c o n t i n u e d ) :

E v e l y n Runyon Thomas K i e f e r , D.D.S.

885 South 72nd 2602 J S t r e e t
Omaha 68114 Omaha 68107

Edmund Schneider, O.D. Jack S t i 1es

Lincoln Vision C l i n i c S t . E l i z a b e t h Community
810 N o r t h 4 8 t h S t r e e t H e a l t h Center
L i n c o l n 68504 555 South 7 0 t h
L i n c o l n 68510
Robert Marshal 1
Nebraska P h a r m a c i s t s Assoc. Paul Ess
600 S. 1 2 t h S t r e e t 6031 V i n e S t r e e t
L i n c o l n 68508 L i n c o l n 68505

A r d e l l e Boardman Warren Bosley, M.D.

4131 N o r t h 4 4 t h 418 West D i v i s i o n
L i n c o l n 68504 Grand I s l a n d 68801

3. E x e c u t i v e O f f i c e r s o f S t a t e Medical and P h a r m a c e u t i c a l
Societies:

A. Kenneth Neff
Executive Secretary
Nebraska Medical A s s o c i a t i o n
1902 F i r s t N a t i o n a l Bank B u i l d i n g
L i n c o l n 68508
Phone: 402/432-7585

B. Pharmaceutical A s s o c i a t i o n :

Robert Marshal 1
Executive D i r e c t o r
Nebraska Pharmacists A s s o c i a t i o n
600 S. 1 2 t h S t r e e t
L i n c o l n 68508
Phone: 402/475-4274

C. O s t e o p a t h i c P h y s i c i a n s and Surgeons:

A. G. Zuspan, D.O.
Secretary
Nebraska A s s o c i a t i o n O s t e o p a t h i c
P h y s i c i a n s and Surgeons
1210 1 3 t h S t r e e t
A u r o r a 68818
412/694-2525
 Nevada - 1
1983

NEVADA

M D l C A L ASSISTANCE DRUG PROGRAH (TITLE X I X )

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e q o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC Chi l d r e n < 2 1 (SFO)
Prescribed
Drugs X X X X
Inpatient
H o s p i t a l Care X X X X
Outpatient
H o s p i t a l Care X X X X
Laboratory 6
X-ray S e r v i c e X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X
Physician
Services X X X X
Dental
Services X X X X
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982

Expended Recipient Expended Recipient

TOTAL....... ........................ $2,257,989 19,116**

CATEGORICALLY NEEDY CASH TOTAL...... $1,434,434 16,050
Aged ................................ 502,779 2,877
Blind.............................. . 39,816 287
Disabled.... ........................ 537,467 2,580
..
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . 5,906
..
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . . 4,478

CATEGORICALLY NEEDY NON-CASH TOTAL.. 3,721

Aged ................................ 2,102
Blind ............................... 39
Disabled......... ................... 393
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 292
A d u l t s - F a m i l i e s w/Dep C h i l d r e n..... 273
Other T i t l e X I X R e c i p i e n t s .......... 637

MEDl CALLY NEEDY TOTAL.. ............. 0

Aged ................................ 0
Blind... ............................ 0
Disabled ............................ 0
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 0
A d u l t s - F a m i l i e s w/Oep Children..... 0
Other T i t l e X I X R e c i p i e n t s .......... 0

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

222
 Nevada - 2
1983

I l l . Administration:

S t a t e D i v i s i o n o f W e l f a r e o f t h e Department o f Human Resources.

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s :

Excluded. Nevada M e d i c a i d w i l l n o t pay f o r t h e f o l l o w i n g :

1. A n o r e c t i c s used f o r o b e s i t y c o n t r o l .

2. Amphetamine c o m b i n a t i o n s .

3. Pharmaceuticals designated " i n e f f e c t i v e , " o r " l e s s than e f f e c t i v e "

( i n c l u d i n g i d e n t i c a l , r e l a t e d , o r s i m i l a r d r u g s ) b y t h e FDA as t o
substance o r d i a g n o s i s f o r which p r e s c r i b e d .

4. Pharmaceuticals considered "experimental" as t o substance o r

diagnosis f o r which prescribed.

Exceptions: Nevada M e d i c a i d w i l l n o t pay f o r t h e f o l l o w i n g u n l e s s

p r i o r - a u t h o r i z e d by t h e M e d i c a i d O f f i c e on f o r m NMO-3, Treatment
A u t h o r i z a t i o n Request (TAR) :

Vitamins, v i t a m i d m i n e r a l combinations o r hematinics.

Glucose b l o o d t e s t s t r i p s .

F l u o r i d e preparations.

Non-legend p h a r m a c e u t i c a l s .

Appliances, s u n d r i e s and s u p p l i e s ; see 1202.4.

N u t r i t i o n a l supplements o r replacements; see 1202.5 and 1203.3.

N i c o t i n i c a c i d i n o r a l o r i n j e c t i b l e form.

N i t r o g l y c e r i n t r a n s d e r m a l systems, e.g., Nitrodisc, Nitro-Dur,

Transderm-Nitro.

E x c l u s i o n E x c e p t i o n s : A l l p h a r m a c e u t i c a l s must be p r e s c r i b e d by a
licensed physician, p o d i a t r i s t , osteopath o r d e n t i s t . They may b e
dispensed d i r e c t l y b y t h e p r e s c r i b e r o r p h a r m a c i s t , o r i n d i r e c t l y b y
means o f an i n p a t i e n t p h a r m a c e u t i c a l c h a r t o r d e r , i n c o m p l i a n c e w i t h
f e d e r a l and s t a t e laws and r e g u l a t i o n s .
 Nevada - 3
1983

E x c l u s i o n Exceptions ( c o n t i w e d ) :

The Nevada T i t l e X I X drug program rt i l l pay f o r t h e f o l l o w i n g p r e s c r i b

pharmaceuticals:

Legend p h a r m a c e u t i c a l s .

Insulin.

D i a b e t i c u r i n e t e s t tab1 e t s and t e s t tapes.

P r e n a t a l v i t a m i d m i n e r a l supplements, l e g e n d o r non-legend,
intended f o r prenatal care.

M e t h y l p h e n i d a t e HCI when p r e s c r i b e d f o r FDA-approved i n d i c a t i o n s .

Pemoline when p r e s c r i b e d f o r FDA-approved i n d i c a t i o n s .

F a m i l y p l a n n i n g items such as diaphragms, o r a l c o n t r a c e p t i v e s ,

foams and j e l l i e s .

Compounded p r e s c r i p t i o n s , p r o v i d i n g t h a t a t l e a s t one legend

pharmaceutical i s included i n t h e r a p e u t i c q u a n t i t y .

Those v a c c i n e s n o t r e a d i l y a v a i l a b l e f r e e of charge.

Schedule V a n t i - d i a r r h e a l and cough p r e p a r a t i o n s .

Formul a r y : None

P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Prescriptions: E l i g i b l e M e d i c a i d r e c i p i e n t s may r e c e i v e t h r e e
o u t p a t i e n t p r e s c r i p t i o n s p e r month p l u s t h o s e i s s u e d f o r EITHER
p r e n a t a l OR f a m i l y p l a n n i n g purposes.

2. R e f i l l s : A r e f i l l i s a prescription subject t o the limitations i n

p a r a g r a p h 1 above.

a. Authorized r e f i l l s are v a l i d o n l y t o t h e pharmaceutical

provider dispensing the o r i g i n a l p r e s c r i p t i o n .

b. A l l prescriptions containing a class I I controlled

pharmaceutical o r pharmaceuticals r e q u i r i n g p r i o r approval,
w i l l be c o n s i d e r e d n o n - r e f i l l a b l e .

c. R e f i l l i n t e r v a l s must be c o n s i s t e n t w i t h t h e dosage s c h e d u l e
i n d i c a t e d on t h e S A M I - 5 .
 Nevada - 4
1983

P r e s c r i b i n g o r Dispensing L i m i t a t i o n s (continued):

3. Q u a n t i t y o f medication: The q u a n t i t y t o be d i s p e n s e d i s as
p r e s c r i b e d by t h e p h y s i c i a n , n o t t o exceed a m o n t h ' s s u p p l y -or a
q u a n t i t y o f 100, whichever i s g r e a t e r . The minimum q u a n t i t y of
maintenance p h a r m a c e u t i c a l s f o r c h r o n i c c o n d i t i o n s i s a m o n t h ' s
supply. I n no case w i l l more t h a n a 100 day s u p p l y o f m e d i c a t i o n
be p a i d f o r .

a. A maintenance d r u g i s d e f i n e d i n The Drug Manual. The

d e f i n i t i o n i s considered t o include the f o l l c w i n g drug
categories:

Anti-anginals
Ant i - a r r h y t h m i c s
Anti-arthritics
Anti-asthmatics
Ant i - c o n v u l s a n t s
Anti-diabetics
Anti-hypertensives
Cardiac glycosides
Diuretics
Hormones
Thyroid preparations
V i t a m i n s c o v e r e d by t h e program
Anti-parkinsonism agents
Potass ium rep1 acemen t s

b. I n long-term-care f a c i l i t i e s , i f the p r e s c r i b e r f a i l s t o
i n d i c a t e t h e d u r a t i o n o f t h e r a p y f o r a m a i n t e n a n c e drug, t h e
pharmacy must p r o v i d e a t l e a s t a 30-day supply." (For o r a l
l i q u i d m e d i c a t i o n s o n l y , a 1 6 - f l u i d - o u n c e q u a n t i t y w i l l be
c o n s i d e r e d s u f f i c i e n t t o f u l f i l l t h e 30-day s u p p l y
requ i rement ) .
4. I n l o n g - t e r m - c a r e f a c i l i t i e s , d r u g s n o t i n c l u d e d i n t h e above
maintenance c a t e g o r i e s must a l s o be dispensed i n e s t i m a t e d 30-day
q u a n t i t i e s when a r e g u l a r p a t t e r n of usage d e v e l o p s . During the
f i r s t 30-day p e r i o d o f usage f u l l payment f o r t h r e e p r e s c r i p t i o n
c l a i m s f o r t h e same m e d i c a t i o n may be a l l o w e d ; f o r each 60-day
p e r i o d t h e r e a f t e r , f u l l payment f o r t h r e e a d d i t i o n a l r e f i l l s o f
t h e same m e d i c a t i o n may be a l l o w e d . The f o u r t h and e v e r y
subsequent c l a i m f o r t h a t m e d i c a t i o n d u r i n g each 60-day p e r i o d
f o l l o w i n g t h e i n i t i a l 30-day p e r i o d may have t h e d i s p e n s i n g f e e
withdrawn. D e r m a t o l o g i c a l p r o d u c t s w i l l be e x c l u d e d from t h i s
requ i rement .

* E x c e p t i o n s may be based on r e a s o n a b l e s t o p o r d e r s .
 Nevada
1983
-5
Prescribing or Dispensing Limitations (continued):

5. Prescription quantities may be reviewed; justification of less

than minimum amounts may be requested from the prescribing
physician and/or pharmacy. In those cases where less than a 30-
day supply of maintenance drug is dispensed without reasonable
medical justification, the professional fee will be disallowed.

Time limits. Claims and adjustment requests must be submitted within

the following time frames:

1. Claims not involving other third party payments must be received

no later than 9 0 days after the date of service.

2. Claims returned by the Fiscal Agent for additional information or

correction must be resubmitted to the Fiscal Agent within 45 days
of the date the claim was returned or 90 days after the date of
service, whichever is longer.

3. Requests for adjustments to paid claims, including zero-paid

claims, must be received no later than 9 0 days after the date of
payment.
4. Inquiries regardingclaims f o r w h i c h theprovider has received
neither payment nor remittance advice must be received no later
than one year after the date of service.

5. Claims for persons who are determined eligible for Medicaid

retroactively must be received no later thann 90 days after the
date of eligibility determination.

Claims for persons who are determined eligible for Medicaidafter the
date of service must be received within 9 0 days of the eligibility
decision date. Attach to the claim either a copy of the Welfare
Division notification of eiigibility or a note giving the date the
person was determined eligible. Please note that the date of
eliqibility determination and not the date the Welfare District Office
was contacted must be the date specified. Obtain eligibility
information by contacting the patient or calling the local Nevada State
Welfare ~ i s t r i c tOffice.

In order to submit a claim within 90 days of determination, contact the

patient every 30 days until a determination of eligibility is
verified. If the patient is unavailable or cannot verify eligibility,
the appropriate Nevada State Welfare District Off ice may be contacted.
NPC Nevada -6
1983

D. Prescription Charge Formula:

1. Reimbursement: Legend Drugs

Reimbursement for legend pharmaceuticals is the lowest o f ( 1 )

maximum allowable cost (MAC) plus the professional fee, ( 2 )
estimated acquisition cost (EAC) plus the professional fee, o r (3)
that pharmacy's usual charge to the general public. The
professional fee is currently $3.78 per prescription.

For prescriptions with ingredient costs exceeding $30, the

Medicaid program will pay actual acquisition cost (AAC) instead o f
EAC, plus the professional fee.

2. Reimbursement: Non-Legend Drugs

Reimbursement for non-legend pharmaceuticals is t h e lower of ( 1 )

the pharmacy's usual charge to the general pub1 ic, o r (2) EAC plus
the professional fee.

3. Reimbursement: Compounded Drugs

Reimbursement for compounded pharmaceuticals, providing at least

one legend drug is included in therapeutic quantity. However, in
addition to the professional fee, compounding time may be
reimbursed at the rate of $0.20 per minute, subject to review by
the Drug Utilization Review Committee.

4. Reimbursement: Unit Dose

Due t o increased costs involved in supplying medications in unit

dose form, a higher professional f e e (an additional $0.37 per
prescription per month) is allowed for provider prepared unit
dose packaging. The higher A.W.P. is allowed for manufacturer
prepared unit dose packaging. Only those pharmacies supplying
long-term care inpatients with acceptable unit dose delivery
systems may qua1 i fy.

For Medicaid reiembursement purposes, an acceptable unit dose

system is one in which:

a. Pharmacists maintain medication profiles o n each patient and

refer t o these profiles each time a medication order is
filled. The profiles must indicate drug allergies and
current diagnoses.
 Nevada - 7
1983

Reimbursement: U n i t Dose ( c o n t i n u e d )

b. Each p a t i e n t ' s p r e s c r i p t i o n r e q u i r e m e n t s a r e i n d i v i d u a l l y
packaged and l a b e l e d . The p h y s i c a l appearance o f t h e u n i t
dose package w i l l v a r y a c c o r d i n g t o t h e system, b u t always
includes a c l e a r product i d e n t i f i c a t i o n , c l e a r p a t i e n t
i d e n t i f i c a t i o n , and i n s t r u c t i o n s f o r a d m i n i s t r a t i o n of t h e
medication. ( L i q u i d s need n o t be dispensed i n u n i t - o f - u s e
packaging, b u t p h a r m a c i s t s a r e encouraged t o do so.)

c. Doses of m e d i c a t i o n s f o r i n d i v i d u a l p a t i e n t s a r e p l a c e d i n t o
an i n d i v i d u a l p a t i e n t c o n t a i n e r , b i n , compartment o r drawer
and whenever p o s s i b l e , a r e s u b d i v i d e d b y dose and
a d m i n i s t r a t i o n time.

To secure t h i s h i g h e r reimbursement f o r u n i t dose, pharmacies must

r e q u e s t and r e c e i v e a p p r o v a l f r o m t h e M e d i c a l Care S e c t i o n . Such
a p p r o v a l i s s u b j e c t t o immediate c a n c e l l a t i o n a t any t i m e i f t h e
c r i t e r i a above a r e n o t m a i n t a i n e d .

5. Return f o r Credit: U n i t Dose

The Nevada M e d i c a i d program r e c o v e r s 90% o f t h e c o s t of

d i s c o n t i n u e d drugs e l i g i b l e f o r c r e d i t , i.e., c o v e r e d d r u g s i n
m a n u f a c t u r e r u n i t dose packaging. The pharmacy p r o v i d e r i s
a l l o w e d 10% t o cover t h e c o s t of a d d i t i o n a l l a b o r i n c u r r e d i n
c o m p l e t i n g t h e r e t u r n forms. Form 3444-SM must be used b y t h o s e
f a c i l i t i e s w i t h a u n i t dose system which c o n t a i n s m a n u f a c t u r e r
u n i t dose d r u g s .

6. Completing Form 3444-SM

a. The Long Term Care F a c i l i t y i s t o i n i t i a t e t h e 3444-SM,

c o m p l e t i n g t h e t o p s e c t i o n o f t h e form, as much o f t h e t e x t
as can be compeleted, and t h e F a c i l i t y C e r t i f i c a t i o n s e c t i o n
a t t h e b o t t o m o f t h e form. The f a c i l i t y s h o u l d t h e n d e t a c h
and r e t a i n t h e g o l d copy, and f o r w a r d t h e o r i g i n a l , c a n a r y
and p i n k c o p i e s t o t h e pharmacy w i t h t h e r e t u r n e d d r u g s . The
f a c i l i t y copy must be made a v a i l a b l e f o r a u d i t upon r e q u e s t .

b. The pharmacy w i l l complete t h e b a l a n c e o f t h e t e x t , a d d i n g

NDC's and Rx numbers as a p p l i c a b l e , i n d i c a t e t h e payment
source (M = M e d i c a r e , P = P r i v a t e , X = M e d i c a i d ) , and a p l a c e
a check mark i n t h e "COV" column f o r d r u g s e l i g i b l e f o r
credit. The l i s t s h o u l d t h e n be checked a g a i n s t t h e d r u g s
received. I f a d i s c r e p a n c y i s noted, t h e pharmacy s h o u l d
r e c o n c i l e w i t h t h e f a c i l i t y and a d j u s t t h e l i s t a s r e q u i r e d ,
i n i t i a l i n g each a d j u s t m e n t . When t h e pharmacy i s s a t i s f i e d
t h e l i s t i s c o r r e c t , t h e y s h o u l d c o m p l e t e +he Pharmacy
NPC Nevada - 8
1983

Complet i n g Form 3444-SM ( c o n t i n u e d )

Concurrence s e c t i o n a t t h e b o t t o m of t h e form, d e t a c h and r e t a i n

t h e p i n k copy and f o r w a r d t h e o r i g i n a l and c a n a r y c o p i e s t o t h e
Nevada M e d i c a i d O f f i c e f o r r e v i e w .

c. The M e d i c a i d O f f i c e w i l l c a l c u l a t e t h e v a l u e of e l i g i b l e r e t u r n e d
drugs, deduct 10% h a n d l i n g , and e n t e r these amounts on t h e 3444-
SM. The c a n a r y c o p i e s can t h e n be r e t u r n e d t o t h e pharmacy upon
request. The o r i g i n a l c o p i e s a r e r e t a i n e d a t t h e Nevada M e d i c a i d
O f f i c e where an I n p u t -1 form i s c o m p l e t e d and s e n t t o B l u e S h i e l d
o f Nevada f o r p r o c e s s i n g . There an a d j u s t m e n t i s made t o t h e
p r o v i d e r accounts r e c e i v a b l e .

d. F a c i l i t i e s a r e a d v i s e d t o r e t u r n d i s c o n t i n u e d d r u g s on a t l e a s t a
monthly basis.

e. The 3444-SM i s p r i n t e d by t h e Nevada S t a t e W e l f a r e D i v i s i o n and

d i s t r i b u t e d t o f a c i l i t i e s by t h e M e d i c a i d O f f i c e .

V. M i s c e l l a n e o u s Remarks:

D i r e c t payment s h a l l b e made t o a l l Nevada p r o v i d e r s who have s i g n e d

p a r t i c i p a t i n g agreements. O u t - o f - s t a t e p r o v i d e r s , i f any, s h a l l be p a i d on
t h e same f e e s c h e d u l e as p a r t i c i p a t i n g pharmacies and o t h e r Nevada
providers.

P r e s c r i p t i o n Charge Formula f o r E s t i m a t e d A c q u i s i t i o n Cost (EAC) concept:

(Implemented May 10, 1976)

AWP ( l a t e s t AWP l i s t ) Cost

-
*Less 5% (Minus)
Balance
*Note: I f AWP exceeds $30.00, 5% i s not subtracted.

-
PLUS P r o f e s s i o n a l Fee
Balance

-
LESS Co-pay (Minus) - 0.00
Amount p a i d by S t a t e $000.00**

Co-pay Schedule $1.00 p e r R,

* The l e s s e r o f t h i s amount o r usual and customary amount b i l l e d

t o the state.
**Amount reimbursed by s t a t e a f t e r t h e s t a t e deducts t h e
a p p l i c a b l e copay.
 Nevada -9
1983

Miscellaneous Remarks ( c o n t i n u e d ) :

Copayment by R e c i p i e n t

R e c i p i e n t s a r e r e q u i r e d t o pay t h e pharmaceutical p r o v i d e r $1 .OO copayment

f o r each p r e s c r i p t i o n received:

Exemptions from the copayment requi rement are t h e f o l lowi ng:

1. I n p a t i e n t s , except when r e c e i v i n g "take home" p r e s c r i p t i o n s on day

o f discharge.

2. Family p l a n n i n g p r e s c r i p t i o n s ( o r a l c o n t r a c e p t i v e s , diaphragms,
foams and j e l l i e s ) .

3. Those i n d i v i d u a l s k h o s e M e d i c a l C e r t i f i c a t e s a r e p r i n t e d 1 ' E X E M P T
FROM CO-PAYMENT" .
Pharmacies dispensing p r e s c r i p t i o n s t o A d u l t Group o r C h i l d Care
F a c i l i t i e s , SNF, ICF, o r ICF MR p a t i e n t s must check ( ) t h e box and
e n t e r the name o f the f a c i l i t y i n the a p p r o p r i a t e b l o c k on t h e NMO-5.
T h i s w i l l a v o i d computer s u b t r a c t i o n o f t h e copayment amount.

The pharmaceutical p r o v i d e r b i l l s each p r e s c r i p t i o n a t h i s usual and

customary f e e t o t h e p u b l i c . Do n o t s u b t r a c t r e c i p i e n t copay from t h e
"usual charge" when completing t h e invoice. Computer p r o c e s s i n g w i l l
s u b t r a c t copay amounts b e f o r e making payments.

Miscellaneous:

F i s c a l intermediary:

B l u e S h i e l d of Nevada
P.O. Box 10330
Reno, Nevada 89510

Number o f claims processed FY 1982 - 210,614

Average p r e s c r i p i o n p r i c e d u r i n g FY 1982 - $1 1.74

 Nevada - 10
1983

Officials, C o n s u l t a n t s and Committees

1. Human Resources Department O f f i c i a l s :

B a r t o n Jacka Department o f Human Resources

D i rector S t a t e C a p i t a l Complex
Carson C i t y , Nevada 89710

Sharon Murphy, A d m i n i s t r a t o r
S t a t e Welfare D i v i s i o n

K e i t h W. Macdonald, R.Ph.
Chief, Medical Services

Jane Feldman
Statistician Ill

James I . L a i r d , M.D.
Medical Consultant
Nevada M e d i c a i d O f f i c e

Steven P . B r a d f o r d , Pharm.0.
Pharmaceutical Consultant
Nevada M e d i c a i d O f f i c e

2. A d v i s o r y Committees o f t h e W e l f a r e D i v i s i o n :

A. M e d i c a l Care A d v i s o r y Group:

Vacant - Chairman, E x e c u t i v e Committee

Tom C o l l i e r - Chairman, H o s p i t a l Committee

John Megara - Chairman, Long Term Care

Committee

B e r n a r d Feldman, M.D. - Chairman, P h y s i c i a n s Committee

H a r r y P. Massoth, D.D.S. - Chairman, D e n t a l Committee

Vacant - Chairman, Consumer R e c i p i e n t

Committee

Vacant - Chairman, Pharmacy Committee

B. Drug U t i l i z a t i o n Review:

S t e v e n P. B r a d f o r d , Pharm.0.
NPC Nevada - 11
1983

3. E x e c u t i v e O f f i c e r s of S t a t e Medical and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical Association:

R i c h a r d C. Pugh
Executive D i r e c t o r
Nevada S t a t e M e d i c a l A s s o c i a t i o n
3660 Baker Lane
Reno 89509
Phone: 702/825-6788

B. Pharmaceutical Association:

R o b e r t C. Johnson
Executive O f f i c e r
Nevada P h a r m a c e u t i c a l A s s o c i a t i o n
555 C a p i t o l M a l l , S u i t e 645
Sacramento, CA 95814
Phone: 916/444-7811

C. Osteopathic Association:

J e f f r e y E. Brookman, 0.0.
Secretary-Treasurer
Nevada O s t e o p a t h i c M e d i c a l A s s o c i a t i o n
2300 South Rancho
Las Vegas 89102
 New Hampshire -1
1983

M O I U U . ASSISTANCE DRUG PROGRAM (TITLE XIX)

I . BENEFITS PROVIDED AN0 GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFOC OAA AB APTD AFDC Chi l dren<21 (SFO)
Prescribed
Oruqs X X X X X X X X X X
l npat i e n t
H o s p i t a l Care X X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X X
L
--a-h-o r-a-t o
- rv &
8 -

X-ray S e r v i c e X X X X X X X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X X X X X X X
Physician
services X X X X X X X X X X
Dental
Services X X X X X X X X X X
*SF0 - S t a t e Funds Only

11. EXPENDITURES FOR DRUGS. Payment t o Pharmacists b y f i s c a l year ending

June 30, 1982

Expended - R e c i p i e n t ~ x ~ e n d e d -R e c i p i e n t

TOTAL... ............................ $3,725,772 30,304** $3,391,071 29,233**

CATEGORICALLY NEEDY CASH TOTAL...... 1,725,127 23,136 $1,422,705 22,255

Aged ................................ 335,135 1,618 261,966 1,456
Blind. .............................. 24,190 155 22,619 140
Disabled.... ........................ 579,545 2,547 513,085 2,720
C h i l d r e n - F a m i l i e s w/Oep Children... 280,690 10,324 230,047 9,505
A d u l t s - F a m i l i e s w/Dep Children..... 505,567 8,864 394,988 8,781

CATEGORICALLY NEEDY NON-CASH TOTAL.. $1,698,513 6,243 $1,774,358 6,526

Aged ................................ 1,404,863 4,328 1,503,288 4,550
Blind........ ....................... 27,560 95 28,802 96
Disabled..... ....................... 220,396 772 202,176 805
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n . . . 17,505 5 24 15,122 523
A d u l t s - F a m i l i e s w/Oep Children..... 23,773 440 20,228 48 1
..........
Other T i t l e X I X R e c i p i e n t s 4,416 106 4,742 100

ME01 CALLY NEEDY TOTAL.. ............. $302,132 2,613 $194,008 2,043

Aged ................................ 152,859 910 101,910 642
B l i n d . .............................. 2,205 13 3,275 18
D i s a b l e d ............................ 82,468 406 42,005 279
C h i l d r e n - F a m i l i e s w/Dep Children... 17,971 620 14,214 495
A d u l t s - F a m i l i e s w/Dep Children..... 46,526 686 32,502 618
Other T i t l e X I X R e c i p i e n t s .......... 103 6 102 7

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

233
 New Hampshire - 2
1983

I l l . Administration:

O f f i c e o f M e d i c a l S e r v i c e s , Department o f H e a l t h and W e l f a r e .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

General E x c l u s i o n s : A n o r e x i a n t ( s t i m u l a n t s ) e x c e p t f o r t r e a t m e n t of
n a r c o l e p s y and h y p e r k i n e t i c c h i l d r e n ; and v i t a m i n s f o r p a t i e n t s o v e r 7
y e a r s of age.

Formulary: None.

P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Q u a n t i t y o f Medication: P r e s c r i p t i o n s l i m i t e d t o 100 day s u p p l y ;

t h r e e p r e s c r i p t i o n s , i n c l u d i n g r e f i l l s f o r r e c i p i e n t p e r month.

2. Dollar Limits: None.

P r e s c r i p t i o n Charge Formula:

$2.70 f e e p l u s E s t i m a t e d A c q u i s i t i o n Cost (EAC) o r Maximum A l l o w a b l e

Cost (MAC) o r Usual and Customary Charge, whichever i s l e s s .

Maintenance m e d i c a t i o n s a r e reimbursed b y t h e above f o r m u l a once e v e r y

t h i r t y days p e r r e c i p i e n t p e r p r o v i d e r : any r e f i l l s of maintenance
m e d i c a t i o n s w i t h i n 30 days a r e reimbursed a t c o s t o n l y .

Copayment : $1.00, e x c e p t n u r s i n g home p a t i e n t s , under 18 years,

f a m i l y p l a n n i n g and pregnancy p r e s c r i p t i o n s .

V. Misce11aneous Remarks:

Number of P r e s c r i p t i o n c l a i m s processed i n FY 1982 - 519,509

Average p r e s c r i p t i o n p r i c e d u r i n g FY 1982 - $8.60

 New Hampshire - 3
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. H e a l t h and W e l f a r e Department O f f i c i a l s :

Edgar J. Helms, J r . Department o f H e a l t h and

Commi s s i oner Welfare
H e a l t h and W e l f a r e B u i l d i n g
Hazen D r i v e
Concord, New Hampshire 03301

P h i l i p Soule'
Administrator
O f f i c e o f Medical Services
D i v i s i o n o f Welfare

C l i f f o r d A. Z i l c h , P.D.
C h i e f , Bureau o f M e d i c a l C l a i m s
Rev i ew
O f f i c e o f Medical S e r v i c e s
D i v i s i o n of W e l f a r e

Edward J. P i e r c e , P.D.
Pharmaceutical Services S p e c i a l i s t
O f f i c e of Medical S e r v i c e s
D i v i s i o n o f Welfare

2. M e d i c a l Care A d v i s o r y Committee:

T h i s committee c o n s i s t s o f 30 members r e p r e s e n t i n g p r o v i d e r s and consumers o f

h e a l t h care, a s w e l l as t h e v a r i o u s a g e n c i e s i n t e r e s t e d i n h e a l t h c a r e i n t h e
State.

3. E x e c u t i v e O f f i c e r s of S t a t e M e d i c a l and P h a r m a c e u t i c a l S e r v i c e s :

A. Medical Society: B. Pharmaceutical A s s o c i a t i o n :

.
Hami l t o n S Putnam M a u r i c e E. G o u l e t , P.D., M.S.
Executive D i r e c t o r E x e c u t i v e 0 ir e c t o r
New Hampshire M e d i c a l New Hampshire P h a r m a c e u t i c a l
Society Association
4 Park S t r e e t 36 Warren S t r e e t
Concord 0330 1 Concord 03301
Phone: 603/224-1909 Phone: 603/225-2231

C. Osteopathic Association:

W i l l i a m J. Kirmes, D.O.
Secretary-Treasurer
New Hampshire O s t e o p a t h i c A s s o c i a t i o n I n c .
13 N o r t h S t r e e t
Manchester 03104
603/623-6757
 New J e r s e y - 1
1983
NEW JERSEY

E O l CAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e q o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC Chi l d r e n < 2 1 (SFO)
Prescribed

H o s p i t a l Care X X X X
Outpatient
H o s p i t a l Care X X X X
Laboratory &
X-ray S e r v i c e X X X X
S k i l l e d Nursinq -
Home S e r v i c e s X X X X
Physician
Services X X X X
Dental
Services X X X X
Other B e n e f i t s : Home H e a l t h Agency S e r v i c e s , Independent C l i n i c S e r v i c e s ,
P o d i a t r i s t , C h i r o p r a c t o r , O p t o m e t r i s t and O p t i c a l A p p l i a n c e s , Ambulance and I n v a l i d
Coach, M e d i c a l Equipment and P r o s t h e t i c Devices.
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982

1981 1982
Expended Recipient Expended Recipient

TOTAL.. ............................. $48,368,969 525,434** $54,399,078 507,658**

CATEGORICALLY NEEDY CASH TOTAL...... $39,271,329 474,695
Aged.. .............................. 6,039,249 29,205
Blind...... ......................... 157,685 845
Disabled......... ................... 10,333,508 44,891
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 10,262,180 258,156
A d u l t s - F a m i l i e s w/Dep Children..... 12,478,707 141,598
CATEGORICALLY NEEDY NON-CASH TOTAL.. $9,097,640 57,845
Aged ................................ 6,793,451 24,323
Blind ............................... 10,819 54
Disabled....... ..................... 1,184,740 5,168
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 563,617 15,595
A d u l t s - F a m i l i e s w/Dep Children..... 208,067 5,064
..........
Other T i t l e X I X R e c i p i e n t s 336,946 7,641
MEDICALLY NEEDY TOTAL.. ............. $0 0
Aged ................................ 0 0
Blind........... .................... 0 0
D i s a b l e d . . .......................... 0 0
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 0 0
A d u l t s - F a m i l i e s w/Dep Children..... 0 0
Other T i t l e XIX R e c i p i e n t s .......... 0 0
**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082
236
NP C New Jersey - 2
1983

1 1 1 . 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 (New Jersey Drug Utilization Review Council Formulary
applies) to the Medicaid program.

C. Prescribing or Dispensing Limitations:

1. Quantity of Medication: The quantity of medication prescribed

should provide a sufficient amount of medication necessary for the
duration of the illness or an amount sufficient to cover the
interval between visits, but may not exceed a 60-day supply or 100
unit doses whichever is greater.

Exceptions:

a. Oral contraceptives may be prescribed for up to a 3-month

supply.
b. Vitamins and vi tamin-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".
 New J e r s e y - 3
1983

P r e s c r i p t i o n Charge Formula ( c o n t i n u e d ) :

a. Maximum A l l o w a b l e Cost i s d e f i n e d as:

(1) The "Maximum A l l o w a b l e Cost" (MAC) p r i c e p u b l i s h e d b y t h e

P h a r m a c e u t i c a l Reimbursement Board o f t h e Department of
H e a l t h and Human S e r v i c e s f o r l i s t e d m u l t i - s o u r c e d r u g s
o r e s t a b l i s h e d by t h e D i v i s i o n o f M e d i c a l A s s i s t a n c e and
H e a l t h Services; o r

(2) The Average Wholesale P r i c e (AWP) l i s t e d f o r t h e most

f r e q u e n t l y purchased package s i z e ( a s d e f i n e d b y t h e N.J.
M e d i c a i d Program) i n t h e c u r r e n t "Drug T o p i c s Red Book"
( p u b l i s h e d b y M e d i c a l Economics Co., O r a d e l l , New J e r s e y
07649), and supplements; p r i c e changes l i s t e d b y t h e same
p u b l i s h e r i n "Drug T o p i c s Magazine" o r o t h e r a p p r o p r i a t e
sources; o r d e s i g n a t e d p r i c e s d e f i n e d i n s e c t i o n 10:51-
1.6. I n t h e case o f u n l i s t e d o r u n d e s i g n a t e d AWP " c o s t s
o r o f t y p o g r a p h i c a l e r r o r s , t h e known c o r r e c t p r i c e w i l l
be used as maximum.

2. Maximum c o s t f o r each e l i g i b l e p r e s c r i p t i o n c l a i m n o t c o v e r e d b y
s e c t i o n 10:51-1.16(a)l s h a l l be s u b j e c t t o t h e f o l l o w i n g f i s c a l
c o n d i t i o n s based upon s i x c a t e g o r i e s , as d e t e r m i n e d b y t h e N.J.
M e d i c a i d program based on t h e p r e v i o u s y e a r ' s t o t a l p r e s c r i p t i o n
volume f o r each p a r t i c i p a t i n g pharmacy. The c a t e g o r i e s s h a l l be
r e v i e w e d a n n u a l l y and a d j u s t e d as a p p r o p r i a t e .

a. To d e t e r m i n e a p r o v i d e r ' s t o t a l p r e s c r i p t i o n volume, w h i c h
s h a l l i n c l u d e a l l p r e s c r i p t i o n s f i l l e d , b o t h new and r e f i l l s ,
f o r p r i v a t e p a t i e n t s , Medicaid, PAA, and o t h e r t h i r d p a r t y
r e c i p i e n t s f o r t h e p r e v i o u s c a l e n d a r y e a r , each pharmacy
p r o v i d e r s h a l l submit i n w r i t i n g , an annual r e p o r t c e r t i f y i n g
i t s p r e s c r i p t i o n volume. F a i l u r e t o submit t h i s r e p o r t
annually w i l l r e s u l t i n the provider being placed i n the
maximum d i s c o u n t c a t e g o r y ( c a t e g o r y V I ) f o r t h e y e a r of non-
compliance, o r u n t i l t h e r e q u i r e d r e p o r t i s r e c e i v e d .

Note: Those pharmacy p r o v i d e r s who have been i n b u s i n e s s f o r

l e s s t h a n one c a l e n d a r year w i l l have t h e i r p r e s c r i p t i o n
volume p r o j e c t e d f o r t h e e n t i r e y e a r , t o d e t e r m i n e t h e
appropriate category.

b. Category I : Pharmacies whose t o t a l p r e s c r i p t i o n volume i n t h e

p r e c e d i n g c a l e n d a r year was n o t more t h a n 14,999
prescriptions.

(1) Pharmacy p r o v i d e r s i n t h i s c a t e g o r y s h a l l r e c e i v e
reimbursement f o r M e d i c a i d p r e s c r i p t i o n c l a i m s f o r l e g e n d
drugs a t average w h o l e s a l e p r i c e (AWP), as d e f i n e d i n
s e c t i o n 10:51-1.16a., a s t h e maximum.
 New J e r s e y -4
1983

P r e s c r i p t i o n Charge Formula ( c o n t i n u e d ) :

c. Category II: Pharmacies whose t o t a l p r e s c r i p t i o n volume i n

t h e p r e c e d i n g c a l e n d a r y e a r was a t l e a s t 15,000 b u t n o t
g r e a t e r t h a n 19,999 p r e s c r i p t i o n s .

(1) Pharmacy p r o v i d e r s i n t h i s c a t e g o r y s h a l l r e c e i v e
reimbursement f o r M e d i c a i d p r e s c r i p t i o n c l a i m s f o r l e g e n d
d r u g s a t average w h o l e s a l e p r i c e (AWP), as d e f i n e d i n
s e c t i o n 10:51-1.16a, l e s s two p e r c e n t , as t h e maximum.

d. Category I l l : Pharmacies whose t o t a l p r e s c r i p t i o n volume i n

t h e p r e c e d i n g c a l e n d a r year was a t l e a s t 20,000 b u t n o t
g r e a t e r t h a n 29,999 p r e s c r i p t i o n s .

(1) Pharmacy p r o v i d e r s i n t h i s c a t e g o r y s h a l l r e c e i v e
reimbursement f o r M e d i c a i d p r e s c r i p t i o n c l a i m s f o r l e g e n d
drugs a t t h e average w h o l e s a l e p r i c e ( A W ) , as d e f i n e d i n
s e c t i o n 10:51-1.16a, l e s s t h r e e p e r c e n t , as t h e maximum.

e. Category IV: Pharmacies whose t o t a l p r e s c r i p t i o n volume i n

t h e p r e v i o u s c a l e n d a r year was a t l e a s t 30,000 b u t n o t g r e a t e r
t h a n 39,999 p r e s c r i p t ions.

(1) Pharmacy p r o v i d e r s i n t h i s c a t e g o r y s h a l l r e c e i v e
reimbursement f o r M e d i c a i d p r e s c r i p t i o n c l a i m s f o r l e g e n d
d r u g s a t average w h o l e s a l e p r i c e (AWP), a s d e f i n e d i n
s e c t i o n 10:51-l.l6a, l e s s f o u r p e r c e n t , as t h e maximum.

f. Category V: Pharmacies whose t o t a l p r e s c r i p t i o n volume i n t h e

p r e c e d i n g c a l e n d a r year was a t l e a s t 40,000 b u t n o t g r e a t e r
t h a n 49,999 p r e s c r i p t i o n s .

(1) Pharmacy p r o v i d e r s i n t h i s c a t e o g r y s h a l l r e c e i v e
reimbursement f o r M e d i c a i d p r e s c r i p t i o n c l a i m s f o r l e g e n d
drugs a t average w h o l e s a l e p r i c e ( A W ) , as d e f i n e d i n
s e c t i o n lO:51-l.l6a, l e s s f i v e p e r c e n t , as t h e maximum.

g. Category V I : Pharmacies whose t o t a l p r e s c r i p t i o n volume i n

t h e p r e c e d i n g c a l e n d a r y e a r was 50,000 p r e s c r i p t i o n s o r more.

(1) Pharmacy p r o v i d e r s i n t h i s c a t e g o r y s h a l l r e c e i v e
reimbursement f o r M e d i c a i d p r e s c r i p t i o n c l a i m s f o r l e g e n d
drugs a t average w h o l e s a l e p r i c e ( A W ) , as d e f i n e d i n
s e c t i o n 10:51-1.16a, l e s s s i x p e r c e n t , a s t h e maximum.

Notes: ( 1 ) I f t h e p u b l i s h e d MAC p r i c e as d e f i n e d i n s e c t i o n
10:51-1.16(a)li i s h i g h e r t h a n t h e p r i c e w h i c h would be p a i d
under s e c t i o n 1 0 : 5 1 - 1 . 1 6 ( a ) l i i , then s e c t i o n 10:51-1.16(a)lii,
w i l l apply.
 New J e r s e y - 5
1983

Notes ( c o n t i n u e d ) :

(2) The a p p r o p r i a t e c a l c u l a t e d d i s c o u n t w i l l be
a u t o m t i c a l l y deducted ( b y B l u e Cross o f New J e r s e y )
f r o m each e l i g i b l e legend drug c l a i m d u r i n g t h e
c l a i m p r o c e s s i n g procedures.

(3) F o r p r e s c r i p t i o n drugs c o s t i n g more t h a n $24.99

t h e r e w i l l be no d i s c o u n t from t h e a v e r a g e w h o l e s a l e
p r i c e (AWP).

D i s p e n s i n g Fee

The d i s p e n s i n g and s e r v i c e s fee ranges f r o m $2.58 t o a maximum of $2.80 depending

upon t h e number and t y p e s of s e r v i c e s agreed t o b y t h e p r o v i d e r .

Service

l NCRE ME NT
1. 24 hour,emergency s e r v i c e a v a i l a b i l i t y $0.05
2. Patient Consultation $0.08
3. Impact A l l o w a n c e $0.09

Any p r o v i d e r who f a i l s t o r e t u r n t h e completed Form FD-70 w i l l r e c e i v e a f e e o f

$2.58.

I n c o m p l e t i n g t h e Pharmacy P r o v i d e r S e r v i c e Agreement t h e p r o v i d e r agrees t o

p r o v i d e a l l s e r v i c e s a t no a d d i t i o n a l c h a r g e t o t h e M e d i c a i d o r PAA r e c i p i e n t .
Under no c i r c u m s t a n c e s a r e any a d d i t i o n a l a d m i n i s t r a t i v e charges a l l o w e d .

The Pharmacy Manual f u r t h e r s t a t e s t h e f o l l o w i n g : The maximum c h a r g e t o t h e New

J e r s e y H e a l t h S e r v i c e s Program f o r a legend drug may n o t exceed t h e l o w e s t of t h e
following:

a. Cost p l u s d i s p e n s i n g f e e as o u t l i n e d h e r e i n .

b. Usual and customary charges and/or p o s t e d o r a d v e r t i s e d charges.

c. Other t h i r d p a r t y p r e s c r i p t i o n p l a n charges, when c o n t r a c t s o r

agreements t o p a r t i c i p a t e have been e n t e r e d i n t o subsequent t o t h e
a d o p t i o n of t h i s r e g u l a t i o n .

V. M i s c e l l a n e o u s Remarks:

F i s c a l Intermediary:

B l u e Cross of New J e r s e y
33 Washington S t r e e t
Newark, New J e r s e y 07101

Number o f R x c l a i m s processed i n FY 1982 - 6,473,198

 New Jersey - 6
1983

Miscellaneous Remarks (continued):

Average Rx price during FY 1982 - Retail: $8.21

Nursing Home: $9.65

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 or scope of care provided. This concept of the Physician Case Manager
controlling costs has received wide support throughout the country since this
role negates the need for increased government regulation and harsh budget caps.

The MP Plan will be phased in throughout the State over a four-year period, or
sooner if feasible. It will be implemented first in Morris, Sussex and Warren
counties. Participating providers may be in solo practice; group practice;
professional corporation or association; health maintenance organization (HMO);
independent, free-standing clinic; or in a hospital affiliated entity which
allows for primary care services and is not subject to DRG reimbursement
principles.
NPC New Jersey - 7
1983

Miscellaneous Remarks (continued):

The participation ofphysicians 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.

(For additional details consult New Jersey Health Services Newsletter, July 15,
1983 BC-260)
NPC New J e r s e y - 8
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. Department o f Human Resources O f f i c i a l s :

George J. Albanese Department o f Human S e r v i c e s

Commissioner D i v i s i o n o f A s s i s t a n c e and
Heal t h S e r v i c e s
324 E a s t S t a t e S t r e e t
P. 0. Box 2486
T r e n t o n , New J e r s e y 08625

Thomas M. Russo D i v i s i o n o f Medical Assistance

Director and H e a l t h S e r v i c e s
(same address as above)

S . Eugene Y u l i a n o , M.D.
Medical D i r e c t o r

S a n f o r d Luger, R.Ph., Chief

Pharmaceutical S e r v i c e s
609/292-3756

2. Medical Assistance A d v i s o r y Council:

Edward V. Lipman Ex-Officio

Cha i rman
R i c h a r d G o l d s t e i n, M.D.
Eugene Freidman Commissioner
V i c e Chairman S t a t e Department of H e a l t h

Consumers D o r i s Dealaman, Chairman

Board o f P u b l i c W e l f a r e
Howard Langan
B e t t y J. P h i l l i p s G. Thomas R i t i , D i r e c t o r
W i l l i a m F. Ward D i v i s i o n o f Public Welfare
Juanita Joiner
L o u i s Weissman

Providers

A. Guy Campo, M.D., F.A.A.F.P.

Anthony P. De S p i r i t o , M.D.,
F.A.A.P.
R o b e r t Kaplan, D.D.S.
W i l l iam K. Hogan
H e r b e r t E. H o r w i t z , R.P.
NPC New Jersey - 9
1983

3. E x e c u t i v e O f f i c e r s o f S t a t e Medical and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical S o c i e t y :

V i n c e n t A. Maressa
Executive D i r e c t o r
Medical S o c i e t y o f New J e r s e y
2 P r i n c e s s Road
Lawrence 08648
Phone: 609/394-3154

0. Pharmaceutical A s s o c i a t i o n :

A l v i n N. Geser
Executive Officer
New J e r s e y P h a r m a c e u t i c a l A s s o c i a t i o n
118 W. S t a t e S t r e e t
T r e n t o n 08608
Phone: 609/394-5596

C. O s t e o p a t h i c P h y s i c i a n s and Surgeons A s s o c i a t i o n :

Eleanore F a r l e y
Executive D i r e c t o r
New Jersey A s s o c i a t i o n O s t e o p a t h i c P h y s i c i a n s and Surgeons
1212 Stuyvesant Avenue
T r e n t o n 08618
609/393-8114
 New Mexico - 1
1983
N E W EEXICO

E D 1 CAL ASS ISTAWCE DRUG PROGRAM ( T I T L E X I X)

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC C h i l d r e n < 2 1 (SFO)
Prescribed
Druqs X X X X X
l npat i e n t
H o s p i t a l Care X X X X X
O u t ~ aite n t
H o s p i t a l Care X X X X X
Laboratory &
X-ray S e r v i c e X X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X X
Physician
~ e ; v i ces X X X X X
Dental
Services X X X X X
Other B e n e f i t s : P r i v a t e D u t y N u r s i n g , Home H e a l t h S e r v i c e s , O r t h o t i c a p p l i a n c e s and
P r o s t h e s i s , F a m i l y P l a n n i n g S e r v i c e s , T r a n s p o r t a t i o n and Maintenance, P s y c h i a t r i c
and P s y c h o l o g i c a l S e r v i c e s , Optometry, P o d i a t r y .
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982

1981 1982
Expended Recipient Expended Recipient

TOTAL............................... $6,140,811 62,966** $6,816,777 60,507**

CATEGORI CALLY NEEDY CASH TOTAL.. .... $5,483,800

Aged ................................ 1,218,881
Blind.. ............................. 52,048
Disabled ............................ 2,575,909
...
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n 650,089
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . . . . 986,873

CATEGORICALLY NEEDY NON-CASH TOTAL.. $675,011

Aged. ..... ........ .................. 530,148
Blind...... ......................... 668
Disabled.. .......................... 69,698
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 13,481
A d u l t s - F a m i l i e s w/Dep Children..... 22,402
..........
Other T i t l e XIX R e c i p i e n t s 20,614

MEDICALLY NEEDY TOTAL.. ............. $0 0 $0 0

Aged ................................ 0 0 0 0
Blind............................... 0 0 0 0
Disabled ............................ 0 0 0 0
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n . . . 0 0 0 0
A d u l t s - F a m i l i e s w/Dep C h i l d r e n ..... 0 0 0 0
Other T i t l e XIX R e c i p i e n t s .......... 0 0 0 0

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

245
 New Mexico - 2
1983

I1I. A d m i n i s t r a t i o n :

Department o f Human S e r v i c e s

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b i n g Drugs:

A. General E x c l u s i o n s :

1. Drugs f o r t r e a t m e n t o f t u b e r c u l o s i s a r e n o t i n c l u d e d .

2. M e d i c a t i o n s s u p p l i e d by t h e New Mexico S t a t e H o s p i t a l t o c l i e n t s
on c o n v a l e s c e n t l e a v e f r o m h o s p i t a l a r e n o t i n c l u d e d .

3. Drugs and i m m u n i z a t i o n s a v a i l a b l e f r o m any o t h e r s o u r c e a r e n o t

included.

4. Legend m u l t i p l e v i t a m i n s , t o n i c p r e p a r a t i o n s and c o m b i n a t i o n s
t h e r e o f w i t h m i n e r a l s , hormones, s t i m u l a n t s o r o t h e r compounds
w h i c h a r e a v a i l a b l e as s e p a r a t e e n t i t i e s f o r t r e a t m e n t o f s p e c i f i c
conditions.

5. H e m a t i n i c s e x c e p t n o n - s u s t a i n e d r e l e a s e forms o f F e r r o u s S u l f a t e ,
F e r r o u s G I uconate, F e r r o u s Fumarate.

6. Amphetamines and c o m b i n a t i o n s o f amphetamines w i t h o t h e r

t h e r a p e u t i c agents; a m p h e t a m i n e - l i k e sympathomimetic compounds
used f o r o b e s i t y c o n t r o l i n c l u d i n g any c o m b i n a t i o n of such
compounds w i t h o t h e r t h e r a p e u t i c agents.

7. Drugs c l a s s i f i e d by FDA a s " I n e f f e c t i v e " o r "Possibly Effective".

8. Hypnotic drugs.

9. OTC items w i t h t h e f o l l o w i n g e x c e p t i o n s ( t h e e x c e p t i o n s a r e
c o v e r e d by t h e p r o g r a m ) :

a. Insulin

b. A n t a c i d s f o r a c t i v e g a s t r i c and duodenal u l c e r s .

c. I n f a n t v i t a m i n d r o p s f o r c h i l d r e n up t o one y e a r o f age.

d. S a l i c y l a t e s and acetaminophen.

e. N o n - s u s t a i n e d r e l e a s e forms o f F e r r o u s S u l f a t e , Ferrous
G I uconate, F e r r o u s Fumarate.
 New Mexico - 3
1983

P r o v i s i o n s R e l a t i n g t o P r e s c r i b i n g Drugs ( c o n t i n u e d ) :

B. Formulary: Open f o r m u l a r y s u b j e c t t o a b o v e - s t a t e d l i m i t a t i o n s . For

formulary information contact:

S h i r l e y Hollandsworth
M e d i c a l A s s i s t a n c e Bureau
P.O. Box 2348
Santa Fe, New Mexico 87503
505/827-4315

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Q u a n t i t y of M e d i c a t i o n : 6 months s u p p l y maximum.

2. Refills: Payment w i l l be made t o a p a r t i c u l a r pharmacy o n l y t h r e e

t i m e s f o r t h e same d r u g f o r t h e same c l i e n t i n any 90-day p e r i o d .

D. P r e s c r i p t i o n Charge Formula:

1. P r e s c r i p t i o n s reimbursed a t t h e l e s s e r o f t h e f o l l o w i n g l e s s a
$0.25 co-payment from r e c i p i e n t :

a. Cost (MAC o r EAC) dispensed p l u s fee ($3.15) or,

b. The usual and c u s t a n a r y charge b y t h e pharmacy t o t h e g e n e r a l

pub1 i c .

V. M i s c e l l a n e o u s Remarks:

Fiscal Intermediary:

EDS F e d e r a l C o r p o r a t i o n
4665 I n d i a n School Road, N.E., S u i t e A-114
Albuquerque, New Mexico 87110

Number o f Rx c l a i m s processed i n FY 1982 - 679,054

Average Rx p r i c e d u r i n g FY 1982 - $9.96

 New Mexico - 4
1983

Officials, C o n s u l t a n t s and Committees

1. Department o f Human S e r v i c e s :

Joseph Gol dberg Department o f Human S e r v i c e s

Secretary P. 0. Box 2348
Santa Fe, New Mexico 87503

C h a r l e s Lopez
A c t i n g Deputy D i r e c t o r
Income S u p p o r t D i v i s i o n

James Kogl i n
Bureau C h i e f
Medical A s s i s t a n c e Bureau

F. R i c h a r d A t k i n s o n
Administrator
M e d i c a l A s s i s t a n c e Bureau

S h i r l e y H o l l a n d s w o r t h , R.Ph.
Drug Program A d m i n i s t r a t o r
Medical A s s i s t a n c e Bureau

2. ISD P o l i c y A d v i s o r y Committee Members:

(pend i ng)

3. D e n t a l A d v i s o r y Committee:

L a r r y Lubar, D.D.S. Bruce V o l k e r d i n g

1418 San Pedro, N.E. 708 East 2 0 t h
Albuquerque 87110 F a r m i n g t o n 87401

Rudolph Woolf Gene Walker

1308 C h i c o 921 E a s t 2 1 s t S t r e e t
C a r l sbad 88220 C l o v i s 88001

M i c h a e l Parey, D.D.S. L a r r y Cook, D.D.S

8400 Osuna NE Box 1885
Albuquerque 87111 Taos 87571

Edmond M i t c h e l l
2801 M i s s o u r i
Las Cruces 88001
 New Mexico - 5
1983

4. NMPHA Committee T h i r d P a r t y Payments:

L i a i s o n Committee f o r NM P h a r m a c e u t i c a l A s s o c i a t i o n meets each month.

R o b e r t Ghattas, R.Ph. N e i l Johnon, R.Ph.

Durans Pharmacy C l i n i c a l Pharmacy
1815 C e n t r a l , N.W. 5002 Gibson, S.E.
Albuquerque 87104 Albuquerque 87108
505/247-4141
V i c t o r C a s t i l l o , R.Ph
R o b e r t Lee, R.Ph. V i c t o r ' s Pharmacy
L e e ' s Pharmacy 1643 l s l e t a , S.W.
4403 4 t h S t r e e t , N.W. Albuquerque 87105
Albuquerque 87107
505/345-3533

Jack E. H i l l i g o s s
E x e c u t i v e D i r e c t o r , NMPHA
4800 Zuni, S.E.
Albuquerque 87108

6. E x e c u t i v e O f f i c e r s of S t a t e M e d i c a l and P h a r m a c e u t i c a l S o c i e t i e s :

Medical Society:

Ralph R. M a r s h a l l
Executive D i r e c t o r
New Mexico M e d i c a l S o c i e t y
2650 Y a l e B o u l e v a r d , S.E.
Albuquerque 87106
Phone: 505/247-0530

Pharmaceutical Association:

Jack E. H i l l i g o s s
Executive D i r e c t o r
New Mexico P h a r m a c e u t i c a l A s s o c i a t i o n
4800 Zuni, S.E.
Albuquerque 87108
Phone: 505/265-8720

Osteopathic Medical Association:

Joseph J . Helak, 0.0.

Executive D i r e c t o r
New Mexico O s t e o p a t h i c M e d i c a l
Association
3911 4 t h S t r e e t , N.W.
Albuquerque 87107
NPC New York - 1
1983
NEW YORK

&Dl CAI. ASSISTANCE DRUG PROGRAM (TITLE X I X)

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFbC OAA AB APTD AFDC C h i l d r e n i 2 1 (SFO)
Prescribed
Drugs X X X X X X X X X X
l npat i e n t
H o s p i t a l Care X X X X X X X X X X
Otltnat i m t
H o s p i t a l Care X X X X X X X X X X
Laboratory &
X-ray S e r v i c e X X X X X X X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X X X X X X X
Physician
Services X X X X X X X X X X
Dental
Services X X X X X X X X X X
Other B e n e f i t s : P r o s t h e t i c and O r t h o t i c d e v i c e s / s u p p l i e s ; eye s e r v i c e s ; p o d i a t r y
s e r v i c e s ; f a m i l y p l a n n i n g ; EPSDT (CHAP); c l i n i c s ; p r i v a t e d u t y n u r s i n g i n h o s p i t a l
s e t t i n g ; home c a r e ; t r a n s p o r t a t i o n ; r e h a b i l i t a t i o n t h e r a p i e s
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982

igai 19112
Expended Recipient Expended Recipient

TOTAL.. ............................ $122,648,000 1,401,768** $142,259,415 1,471,856**

CATEGORICALLY NEEDY CASH TOTAL.... . $106,706,299 1,155,276 $123,768,636 1,213,040
Aged ............................... 22,978,483 36,826 26,652,742 38,667
B l i n d . . ............................ 341,244 1,096 395,809 1,151
Disabled.. ......................... 33,540,401 95,188 38,903,511 99,947
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n . . 22,199,153 691,683 25,748,798 726,267
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . ... 27,647,018 330,481 32,067,776 347,005
CATEGORICALLY NEEDY NON-CASH TOTAL.
Aged ...............................
Blind ..............................
Disabled....... ....................
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . .
...
A d u l t s - F a m i l i e s w/Dep C h i l d r e n .
.........
O t h e r T i t l e XIX R e c i p i e n t s

ME01 CALLY NEEDY TOTAL.. ...........

Aged ..............................
Blind...... .......................
Disabled ..........................
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n .
A d u l t s - F a m i l i e s w/Oep C h i l d r e n ...
Other T i t l e XIX R e c i p i e n t s ........
*Wnduplicated Total - HHS r e p o r t HCFA - 2082
250
 New York - 2
1983

III. Administration:

S t a t e Department o f S o c i a l S e r v i c e s .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s : No r e s t r i c t i o n s e x c e p t : (See V. Miscellaneous

Remarks)

1. P r e s c r i b e d v i t a m i n s and m i n e r a l s n o t p r e s c r i b e d f o r m e d i c a l
necessity.

2. Amphetamines and o t h e r drugs whose s o l e c l i n i c a l use i s f o r

r e d u c t i o n o f weight.

3. L i m i t e d coverage of n o n - p r e s c r i p t i o n drugs.

6. Formulary: Coverage o f p r e s c r i p t i o n d r u g s i s l i m i t e d t o l i s t o f
M e d i c a i d Reimbursable P r e s c r i p t i o n Druqs. For i n f o r m a t i o n contact:

Michael R a v a l l i
40 N o r t h P e a r l S t r e e t
A l b a n y , New York 12243
518/474-7442

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Q u a n t i t y o f Medication: Drugs and s i c k r o o m s u p p l i e s s h a l l b e

p r e s c r i b e d i n s u f f i c i e n t q u a n t i t y c o n s i s t e n t w i t h t h e h e a l t h needs
of t h e p a t i e n t and sound m e d i c a l p r a c t i c e .

2. Refills: R e f i l l s c a n n o t exceed 5, and t h e l i f e of a p r e s c r i p t i o n

c a n n o t exceed 6 months.

3. Dollar Limits: None.

D. P r e s c r i p t i o n Charge Formula:

1. Maximum Reimbursable P r i c i n q Schedule

Maximum reimbursement s h a l l be based on t h e l o w e s t o f :

a. t h e maximum a l l o w a b l e c o s t (MAC) p l u s a p p l i c a b l e d i s p e n s i n g
fee; o r

b. t h e e s t i m a t e d a c q u i s i t i o n c o s t (EAC) e s t a b l i s h e d b y t h e S t a t e ,
p l u s a p p l i c a b l e d i s p e n s i n g fee; o r

c. t h e u s u a l and customary p r i c e c h a r g e d b y t h e pharmacy p r o v i d e r

t o t h e g e n e r a l p u b l i c , i n c l u d i n g any s a l e p r i c e w h i c h may b e
i n e f f e c t on t h e d a t e of s e r v i c e .
NPC New York - 3
1983

2. D i s p e n s i n g Fee, $2.60

V. M i s c e l l a n e o u s Remarks:

The l i s t a p p l i e s o n l y t o p r e s c r i p t i o n and/or f i s c a l o r d e r s f i l l e d i n
comnunity pharmacies.

Based on mandated payment c r i t e r i a f o r p r e s c r i p t i o n drugs, many non-

e s s e n t i a l and h i g h p r i c e d d r u g p r o d u c t s a r e excluded, e.g., those not
e s s e n t i a l t o s u s t a i n l i f e , r e 1 i e v e o r p r e v e n t severe p a i n , o r p r e v e n t
disease o r c o n t i n u i n g d i s a b i l i t y ; sustained r e l e a s e medications; a n t i -
f l a t u l e n c e p r o d u c t s ; cough enzymes; muscle r e l a x a n t s ; v i t a m i n s and
v i t a m i d m i n e r a l p r e p a r a t i o n s ; and d e r m a t o i o g i c a l s . Many c o m b i n a t i o n d r u g s
and c o m f o r t p r o d u c t s a r e a l s o excluded.

The Commissioner of H e a l t h , w i t h t h e a d v i c e o f t h e Ad Hoc T e c h n i c a l Pharmacy

A d v i s o r y Committee and o t h e r c o n s u l t a n t s as a p p r o p r i a t e , s h a l l c o n s i d e r
amendments t o t h e l i s t s t h a t a r e proposed v i a w r i t t e n p e t i t i o n . Address a l l
i n q u r i e s c o n c e r n i n g changes t o t h e l i s t t o t h e f o l l o w i n g address:

D a v i d G. S t a r k s Deputy D i r e c t o r
Division of Health F a c i l i t i e s
Standards and C o n t r o l
NYS Department o f H e a l t h ,
Medicaid
Reimbursable Drug L i s t s
Room 2019
Empire S t a t e P l a z a
Tower B u i l d i n g
Albany, New York 12237

F i s c a l Intermediary:

McAuto Systems Group, I n c .

800 N o r t h P e a r l S t r e e t
Albany, New York 12204

Copayment: None

Number Rx c l a i m s processed i n FY 1982 - 14,187,189 (1/82-12/82)

Average Rx p r i c e d u r i n g FY 1982 - $9.31

 New York - 4
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

S o c i a l S e r v i c e s Department O f f i c i a l s :

Cesar A. P e r a l e s Department o f S o c i a l S e r v i c e s
Commi s s i oner 40 N o r t h P e a r l S t r e e t
Albany, New York 12243

A r t h u r Y. Webb
E x e c u t i v e Deputy Commissioner

R o b e r t Osborne
Deputy Commissioner
D i v i s i o n o f Medical Assistance

Robert J. Dowling, J r .
A s s o c i a t e Commissioner
D i v i s i o n o f Medical Assistance

R i c h a r d T. Cody
A s s i s t a n t Commissioner f o r
Eligibility
D i v i s i o n o f Medical Assistance

Gerard F. N e l l i g a n , R.Ph.
Associate Social Services
Medical Assistance S p e c i a l i s t

M a r t i n Roysher
A s s o c i a t e Commissioner
Program A n a l y s i s and U t i l i z a t i o n
Rev i ew

S o c i a l S e r v i c e s A d v i s o r y Committees:

A. M e d i c a l A d v i s o r y Committee:

G i l b e r t Simon, D.Sc. Ms. B e v e r l y H a r t

D i r e c t o r of Pharmacy Chi I d Development A s s o c i a t e
Lenox H i l l H o s p i t a l Comprehensive I n t e r d i s c i p l i n a r y
100 E a s t 7 7 t h S t r e e t Development S e r v i c e s
New York 10021 318 Madison
E l m i r a 14901
D a v i d A x e l r o d , M.D.
Commissioner C h a r l e s B a r r , D.D.S.
New York S t a t e Department of H e a l t h Director of Dentistry
Emoire S t a t e P l a z a B e t h l s r e a l M e d i c a l Center
~o;er B u i l d i n a 10 Nathan D. Perlman P l a c e
~ l b a n 12237-
~ New York 10003
NPC New York - 5
1983

M e d i c a l A d v i s o r y Committee ( c o n t i n u e d ) :

S. D a v i d Panrinse, M.D. B e a t r i c e Kresky, M.D., M.P.H.,

President Chairman
G r e a t e r New York H o s p i t a l Assoc. Department o f A m b u l a t o r y Care
3 East 54th S t r e e t Jamaica H o s p i t a l
New York C i t y 10022 Jamaica 11418

L u d w i g Jaffee, M.D. E l e n a P a d i l l a , Ph.D.

Research D i r e c t o r H e a l t h P o l i c y P l a n n i n g and
New York S t a t e AFL-CIO A d m i n i s t r a t i o n Program
451 Park Avenue T i s c h Roan 738
New York 10016 New York U n i v e r s i t y
40 West 4 t h S t r e e t
Ms. K a t h e r i n e Simnons New York 10003
Executive D i r e c t o r
V i s i t i n g Nurse A s s o c i a t i o n H a r o l d Rakov, P r o f e s s o r
o f Staten lsland 26 Coleman Creek Road
400 Lake Avenue -
M a r i n e r s Harbor B r o c k p o r t 14420
S t a t e n I s l a n d 10303
R o b e r t H. Randles, M.D.
M r . Ebun Adelona Medical D i r e c t o r
P.O. Box 1405 S t . Peter's Hospital
New York 10027 315 South Manning B o u l e v a r d
Albany 12208
A r c y Degni, S e c r e t a r y T r e a s u r e r
New York S t a t e B u i l d i n g and Ms. I s a b e l A p p e l l a n i z
C o n s t r u c t i o n Trades C o u n c i l Ridgewood Bushwick S e n i o r
AFL-C I 0 C i t i z e n Council
17 J e w e t t P l a c e 319 Stanhope S t r e e t
U t i c a 13501 B r o o k l y n 11237

Peggy Hanson, M.D. Mrs. G l e n i s s Schonholz

A s s o c i a t e P r o f e s s o r of N e u r o l o g y Administrator
and P e d i a t r i c s Long I s l a n d J e w i s h H i l l s i d e
Albany Medical College M e d i c a l Center
A l b a n y 12208 New Hyde Park 11042

M r . E b i e Brown Rufus N i c h o l s , M.D.

115 Woodlawn Avenue, #2N 736 E a s t e r n Parkway
Saratoga S p r i n g s 12866 B r o o k l y n 11213

James G. L i o n e , M.D. Ms. M a r i l y n S a v i o l a

New York S t a t e Chairman Apt. 11-H
American Academy o f P e d i a t r i c s 175 W i l l o u g h b y S t r e e t
251-25 Hand Road B r o o k l y n 11201
L i t t l e Neck 11362
 New York - 6
1983

3. P u b l i c H e a l t h Department:

D a v i d Axel rod, M.D. Department of Heal t h

Commissioner Tower B u i l d i n g
Empire S t a t e P l a z a
A l b a n y 12237

4. E x e c u t i v e O f f i c e r s o f S t a t e Medical and Pha r m a c e u t i c a l S o c i e t i e s :

A. Medical Society:

Edward S i e g e l , M.D.
E x e c u t i v e V i c e P r e s i dent
M e d i c a l S o c i e t y of t h e S t a t e
of New York
420 L a k e v i l l e Road
Lake Success 11042
Phone: 526/488-6100

B. Pharmaceutical Association:

John S c h r e i b e r
Executive D i r e c t o r
Pharmaceutical S o c i e t y of t h e
S t a t e of New York
1975 L i n d e n B o u l e v a r d
Elmont 11003
Phone: 516/285-8822

C. B. C. S c h a r f , 0.0. S e c r e t a r y
New York S t a t e O s t e o p a t h i c
Medical Society, Inc.
1973 M o r r i s Gate
Seaford 11783
516/826-2212
 N o r t h Carol ina - 1
1983

NORTH CAROL INR

MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC C h i l d r e n c 2 1 (SFO)
Prescribed
Drugs X X X X X X X X X
l noat i e n t
H o s p i t a l Care X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X
Laboratory &
X-ray S e r v i c e X X X X X X X X X
S k i l led Nursing
Home S e r v i c e s X X X X X X X X X
Physician
~e;v i ces X X X X X X X X X
Dental
Services X X X X X X X X X
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l year e n d i n g

September 30, 1982

1981 1982
Expended Recipient Expended Recipient

$34,598,362 268,799** $31,487,710

CATEGORICALLY NEEOY CASH TOTAL...... $25,917,909 218,660

Aged ................................ 11,661,284 48,357
Blind ............................... 416,024 1,983
Disabled ............................ 8,589,747 36,830
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 1,717,237 81,767
Adults-FamiIiesw/DepChildren ..... 3,533,617 56,389

CATEGORICALLY NEEDY NON-CASH TOTAL.. $1,285,574 13,490

Aged ................................ 664,594 2,366
Blind. .............................. 10,594 36
Disabled ............................ 219,263 1,169
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 131,146 6,161
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . . .. 196,447 3,512
..........
Other T i t l e X I X R e c i p i e n t s 63,530 2,040

MEDI CALLY NEEDY TOTAL.. ............. $7,394,879 36,649

Aged.. .............................. 5,267,883 19,709
B l i n d ............................... 52,810 200
D i s a b l e d ............................ 1,399,938 5,924
C h i l d r e n -Fami l i e s w/Dep C h i l d r e n . . . 156,313 7,020
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . . . . 481,491 6,201
Other T i t l e X I X R e c i p i e n t s . ......... 36,444 651

**Undupl i c a t e d T o t a l - HHS r e p o r t HCFA - 2082

 North Carolina - 2
1983

I l l . Administration:

D i v i s i o n of M e d i c a l A s s i s t a n c e , Department of Human Resources.

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s : No payment made f o r non-legend drugs, e x c e p t

insulin. Payment made f o r a l l l e g e n d drugs. Non-legend v i t a m i n s a r e
exc l uded.

B. Formulary: None.

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Q u a n t i t y of M e d i c a t i o n : None.

2. Number of P r e s c r i p t i o n s :

a. S i x p e r month p e r r e c i p i e n t .

b. P r e s c r i p t i o n L i m i t Exemptions f o r C e r t a i n R e c i p i e n t s

The General Assembly has d e t e r m i n e d t h a t exemptions t o t h e s i x

( 6 ) p r e s c r i p t i o n l i m i t p e r month may be a u t h o r i z e d b y t h e
Department o f Human Resources "where t h e l i f e of t h e p a t i e n t
would be t h r e a t e n e d w i t h o u t a d d i t i o n a l care." Therefore,
p a t i e n t s b e i n g t r e a t e d f o r t h e f o l l o w i n g i l l n e s s s h o u l d be
excluded from t h e p r e s c r i p t i o n l i m i t a t i o n :

(1) End S t a t e Renal Diseases

(2) Chemotherapy and R a d i a t i o n Therapy f o r M a l i g n a n c y

(3) Acute S i c k l e C e l l Disease

(4) Hemophilia

(5) End S t a t e Lung Diseases

(6) Unstable Diabetes

(7) T e r m i n a l Stage - any i l l n e s s - life-threatening

3. Dollar Limits: None.

4. Generic S u b s t i t u t i o n : P h a r m a c i s t s must s u b s t i t u t e g e n e r i c a l l y i f
t h e y have a g e n e r i c a l l y e q u i v a l e n t p r o d u c t a v a i l a b l e i n s t o c k .
The s u b s t i t u t e d p r o d u c t must be a l o w e r c o s t p r o d u c t t h a n t h e one
o r i g i n a l l y prescribed.
NPC North Carolina - 3
1983

5. Lock-In: Each r e c i p i e n t i s l o c k e d i n t o one pharmacy o f h i s c h o i c e

f o r one month, e x c e p t i n emergencies.

D. P r e s c r i p t i o n Charge Formula: The l o w e s t p r i c e o f MAC, EAC o r AWP, p l u s

$3.22 d i s p e n s i n g f e e f o r each d i f f e r e n t d r u g d i s p e n s e d d u r i n g a month,
o r t h e p h a r m a c i s t ' s u s u a l and customary charge. The p h a r m a c i s t f i l l i n g
t h e o r i g i n a l p r e s c r i p t i o n w i l l n o t be r e i m b u r s e d f o r r e f i l l s f o r t h e
same d r u g w i t h i n a c a l e n d a r month. $0.50 co-payment/Rx ( i n c l u d e s
refills).

V. Miscellaneous

F i s c a l Agent:

EDS F e d e r a l
Subconrrac t e d t o :

The Computer Company (TCC)

1905 Westmoreland S t r e e t
Richmond, V i r g i n i a 23230

Number o f c l a i m s processed i n f i s c a l y e a r 1982 - 2,836,025

Average p r e s c r i p t i o n p r i c e d u r i n g f i s c a l y e a r 1982 - $10.25

 North Carolina - 4
1983

Officials, C o n s u l t a n t s and Comnittees

1. Department of Human Resources O f f i c i a l s :

Sarah T. Morrow, M.D., M.P.H. Department o f Human Resources

Secretary Albermarle B u i l d i n g
325 N. S a l i s b u r y S t r e e t
R a l e i g h , N o r t h C a r o l i n a 27611

B a r b a r a D. M a t u l a D i v i s i o n o f Medical A s s i s t a n c e
Di r e c t o r 410 N. B o y l a n Avenue
R a l e i g h , N o r t h C a r o l i n a 27603

Paul R. P e r r u z z i
Deputy D i r e c t o r

J e r r y W. Wiley, M.D.
C h i e f Medical C o n s u l t a n t

C . Benny R i d o u t , R.Ph.
Pharmacist C o n s u l t a n t

L i l l i a n J. Todd, R.N.
Nurse C o n s u l t a n t

B e t t y King-Sutton, D.M.D.
Dental Consultant

2. Department o f Human Resources A d v i s o r y Committees:

A. Pharmaceutical A s s o c i a t i o n Committee on P u b l i c H e a l t h and

Welfare:

Fred Eckel C h a r l e s D. Reed

Chai m a n 5832 Whitebud D r i v e
UNC School o f Pharmacy R a l e i g h 27609
Beard Hal I, 200-H
Chapel H i l l 27514 C h a r l e s Rhoden, J r .
901 Montrose C i r c l e
John B a r r i nger Shelby 28150
P.O. Box 382
Carthage 28327 Jack Watts
444 T a r l e t o n Avenue
Evelyn L l o y d B u r l i n g t o n 27215
111 N o r t h Churton S t r e e t
Hi 1 l sborough 27278 Frank W e l l s
604 West H a r n e t t S t r e e t
John Myhre Benson 27504
1005 Park Avenue
Garner 27529
NPC North Carolina - 5
1983

8. M e d i c a l S o c i e t y Comnittee on S o c i a l S e r v i c e Programs ( i n c l u d i n g ~ e d i c a i d )
(2 Consultants) :

H e c t o r H. Henry, II, M.D. (U) Joseph D. Russel I, M.D. ( IM)

Cha irman
102 Lake Concord Rd., N.E.
Concord 28607
R i c h a r d W. Furman,
S t a t e Farm Road
Boone 28607
Edna M. Hoffman, M.D.
348 V a l ley Road
F a y e t t e v i l l e 28305
C h a r l e s R. M a r t i n , M.D.
(PD)
120 Memorial D r i v e
Jacksonv i l le 28540
Campbell W. M c M i l l a n , M.D.
(PHO)
N.C. Memorial H o s p i t a l
Chapel H i l l 27514
James S. M i t c h e n e r ,
(GS)
P.O. Box 1808
L a u r i n b u r g 28352
Carolina C l i n i c
W i l s o n 27893
B e t t y L. Smith, M.D. (P)
M.D. (TS) P.O. Box 925
E l l e n b o r o 28040
W. Samuel Yancy, M.D. (PD)
306 S. Gregson S t r e e t
Durham 27701
CONSULTANTS
Barbara 0. Matula, D i r e c t o r
D i v i s i o n o f Medical A s s i s t a n c e
410 N. B o y l a n Avenue
R a l e i g h 27603
L i l l i a n J. Todd, R.N.
Nursing Consultant
D i v i s i o n of M e d i c a l A s s i s t a n c e
410 N. Bovlan Avenue
Jr., M.D. R a l e i g h 27603

Sarah T. Morrow, M.D. (PH)

Dept. o f Human Resources
325 N. S a l i s b u r y S t r e e t
R a l e i g h 27611

3. E x e c u t i v e O f f i c e r s of S t a t e M e d i c a l and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical S o c i e t y :

W i l l i a m N. H i l l i a r d
Executive D i r e c t o r
N.C. Medical S o c i e t y
P.O. Box 27167
222 N o r t h Person S t r e e t
R a l e i g h 27611
Phone: 919/833-3836
 North Carol i na -6
1983

E x e c u t i v e O f f i c e r s o f S t a t e Medical and Pharmaceutical S o c i e t i e s

(continued):

B. Pharmaceutical Association:

A. H . Mebane, I l l
Executive Director
N.C. Pharmaceutical Assoc.
Box 151
Chapel H i l l 27514
Phone: 919/967-2237

C. Osteopathic Society:

Guy T . Funk, D . O .
Secretary-Treasurer
N o r t h C a r o l i n a Osteopathic S o c i e t y , I n c .
Box 667
Advance 27006
 N o r t h Dakota - 1
1983
NORTH DAKOTA

E D 1 CAI. ASSISTANCE DRUG P R O W (TITLE X I X)

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC C h i l d r e n i Z l (SFO)
Prescribed
Drugs X X X X X X X X X
l npat i e n t
H o s p i t a l Care X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X
Laboratory &
X-ray S e r v i c e X X X X X X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X X X X X X
Physician
Services X X X X X X X X X
Dental
Services X X X X X X X X X
*SF0 - S t a t e Funds Only

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982

1981 1982
Expended Recipient Expended Recipient

TOTAL.. ............................. $3,309,592 21,542** $3,442,360 20,138**

CATEGORICALLY NEEDY CASH TOTAL...... $1,597,258 14,237 $1,870,974 12,951

Aged ................................ 660,404 2,558 491,404 2,388
Blind...... ......................... 2,939 23 1,937 17
Disabled. ........................... 430,918 1,570 335,624 1,559
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n ... 185,626 6,266 621,242 5,454
A d u l t s - F a m i l i e s w/Dep Children..... 317,371 4,000 420,767 3,694
CATEGORICALLY NEEDY NON-CASH TOTAL.. $1 78,707 2,276 $168,124 1,467
Aged ................................ 118,987 882 74,950 658
Blind. .............................. 105 6 114 1
Disabled ............................ 27,461 313 26,995 237
... 13,081
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n 593 33,716 296
... 19,073
Adul t s -Fami l i e s w/Dep C h i l d r e n . . 482 30,185 265
..........
Other T i t l e X I X R e c i p i e n t s 0 0 2,164 19
M E D I CALLY NEEDY TOTAL.. ............. $1,533,627 6,875 $1,403,262 7,162
Aged ................................ 1,222,552 4,306 986,930 4,355
Blind....... ........................ 2,561 13 2,144 12
D i s a b l e d ............................ 228,217 866 191,616 893
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 20,093 645 80,645 708
A d u l t s - F a m i l i e s w/Dep C h i l d r e n ..... 40,728 464 67,546 593
Other T i t l e XIX R e c i p i e n t s .......... 19,476 637 74,381 653
**Undupl i c a t e d T o t a l - HHS r e p o r t HCFA - 2082
262
 N o r t h Dakota - 2
1983

1iI. A d m i n i s t r a t i o n :

N o r t h Dakota Department of Human S e r v i c e s .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s :

1. Anorectics
2. H i g h p r o t e i n w e i g h t r e d u c t i o n supplements
3. i n v e s t i g a t i o n a l drugs
4. Drugs w h i c h have q u e s t i o n a b l e t h e r a p e u t i c v a l u e
5. Drugs w h i c h a r e n o t i n d i c a t e d f o r t h e d i a g n o s i s
6. DESl (Less-Than E f f e c t i v e ) d r u g s

B. Formulary: None

C. P r e s c r i b i n g o r Dispensing Limitations:

1. Q u a n t i t y of M e d i c a t i o n : None

2. Refills: A p r e s c r i p t i o n drug may be r e f i l l e d up t o 5 t i m e s o r f o r

12 months a f t e r t h e d a t e of t h e o r i g i n a l p r e s c r i n t i o n , w h i c h e v e r
o c c u r s f i r s t , and p r o v i d e d t h a t such r e f i l l s have been a u t h o r i z e d
by t h e physician.

3. Dollar Limits: None.

D. PrescriptionChargeFormula: A c q u i s i t i o n c o s t plus$3.75 dispensing

f e e p e r p r e s c r i p t i o n o r u s u a l and customary r e t a i l charge, w h i c h e v e r i s
lower.

A c q u i s i t i o n Cost: EAC o r MAC. EAC i n N o r t h D a k o t a i s AWP.

V. M i s c e l l a n e o u s Remarks:

Copayment - No.

Number of Rx c l a i m s processed i n FY 1982 - 364,726

Average Rx p r i c e d u r i n g FY 1982 - $9.56

 N o r t h Dakota - 3
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. S o c i a l S e r v i c e Broad O f f i c i a l s :

D a l e Moug N o r t h Dakota Department

Executive Director o f Human S e r v i c e s
Capitol B u i l d i n g
Bismarck, N o r t h Dakota
58505

LeRoy B o l l i n g e r , A d m i n i s t r a t o r
Research and S t a t i s t i c s

Richard Myatt, D i r e c t o r
Medical Services

Chuck Gress, R.Ph.

Coordinator
Pharmacy S e r v i c e s
701 /224-2321

2. S o c i a l S e r v i c e s Department A d v i s o r y Committees:

A. M e d i c a l Care A d v i s o r y Committee:

Joe P r a t s c h n e r B e r t h a Gipp, R.N.

( H e a l t h Dept. Designee) M a t e r n a l and C h i l d H e a l t h
D i r e c t o r of H e a l t h F a c i l i t i e s Division
S t a t e Department of H e a l t h S t a t e Department o f H e a l t h
1200 M i s s o u r i Avenue Bismarck 58502
B i smarck 58505 701 /224-2493
701/224-2352
P a t r i c i a Kramer, R.Ph.
B r u c e H e t l a n d , M.D. Bismarck H o s p i t a l
Mid-Dakota C l i n i c 300 N o r t h Seventh
N i n t h and Rosser Bismarck 58501
Bismarck 58505 701 /224-6000
701 /223-0150
Val R i e d e r
Bernice Englehorn New R o c k f o r d 58356
801 1/2 Col l i n s Avenue 701 /947-2936
Mandan 55401
701/663-2181 Ron Row, M.S.W.
S o c i a l Work Department
Fred H u l e t S t . Alexius Hospital
116 W. Thayer Avenue N i n t h and Rosser
Bismarck 58501 Bismarck 58501
701/223-4131 701/224-7000
 N o r t h Dakota - 4
1983

M e d i c a l Care A d v i s o r y Committee ( c o n t i n u e d ) :

B i l l Congdon, D.D.S. Jack Heyne

810 E. Rosser Avenue C e n t e r f o r Independent L i v i n g
B ismarck 58501 109 F i r s t S t r e e t , N.W.
701 /258-1321 S u i t e l O l B MSB B l d g .
Manden 58554
J o n Thomas 701 /663-0376
Canmuni t y A c t i o n Program
Region V I I C a r t e r Pendergast
2105 Lee Avenue N.D. Group Management Assoc.
B ismarck 58501 Q u a i n & Ramstad C l i n i c
701 /258-2240 221 N o r t h F i f t h
B i s m a r c k 58501
701 /222-5200

8. Commission on Socio-Economic A f f a i r s :

D. L. Lamb, M.D. B. L . D a h l , M.D.

Chairman West F a r g o M e d i c a l C e n t e r
#504 P r o f e s s i o n a l B l d g . West F a r g o 58078
F a r g o 58103
M. M. F i e c h t n e r , M.D.
R . S . L a r s o n , M.D. Q u a i n & Ramstad C l i n i c
V ice-Cha i rman Bismarck 58502
V e l v a 58790
C. S. H a m i l t o n , J r . , M.D.
R. 0. Anderson, M.D. Fargo C l i n i c
1605 E. C a p i t o l Avenue F a r g o 58123
B i s m a r c k 58501
K. S. H e l e n b o l t, M.D.
J . J. B a l d w i n , M.D. B l u e Shield-ND
Fargo C l i n i c 4510 1 3 t h Avenue, SW
F a r g o 58123 F a r g o 58121

N. E. B y s t o l , M.D. J. R. H e r r , Jr., M.D.

Dakota C l i n i c , L t d . 1213 - 1 5 t h Avenue, W.
F a r g o 58108 W i l l i s t o n 58801

F. M. C a r t e r , M.D. 0. V. L i n d e l o w , M.D.
Grand F o r k s C l i n i c , L t d . Mid-Dakota C l i n i c
Grand F o r k s 58201 B i s m a r c k 58502

J. H. Coffey, M.D. J. J . McLeod, J r . , M.D.

Fargo C l i n i c O r t h o p a e d i c C l i n i c , P.C.
F a r g o 58123 Grand F o r k s 58201

H. B. Cowan, M.D. R. F. M i l l e r , M.D.

Dickinson C l i n i c Medical A r t s B u i l d i n g
D i c k i n s o n 58601 B i s m a r c k 58501
 N o r t h Dakota - 5
1983

Commission on Socio-Economic A f f a i r s ( c o n t i n u e d ) :

R. F. Morgan, M.D. M e d i c a l S t u d e n t Members :

316 N. 1 0 t h S t r e e t
Bismarck 58501
W. J. Norberg, J r . ,
Fargo C l i n i c
F a r g o 58123
N. B. D r d a h l , M.D.
P. 0. Box 1348
D i c k i nson 58601
T e r r y Block
P.D. Box 332
M.D. Thompson 58278
P a t r i c i a Burger
2009 1 0 t h Avenue N.
Grand F o r k s 58201
Counci 1 l o r s Assiqned:

D. M. P f e i f l e , M.D. J . A. Lambie, M.D.

Q u a i n & Ramstad C l i n i c Grand F o r k s C l i n i c , L t d .
B i smarck 58502 Grand F o r k s 58201

T. M. P o l o v i t z , M.D. T. 0. Langager, M.D.

V a l l e y Medical Associates Medical A r t s C l i n i c
Grand F o r k s 58201 M i n o t 58701

Ex-Officio:
D. A . R i n n , M.D.
UND F a m i l y P r a c t i c e C e n t e r D. E. Wolf, M.D.
PO Box 1967 R o d g e r ' s & Gumper C l i n i c
M i n o t 58701 D i c k i nson 58601

H. W. Evans, M.D. C l i n i c Administrator:

Grand F o r k s C l i n i c , L t d .
Grand F o r k s 58201 M r . Ray K u n t z
Johnson C l i n i c
R e s i d e n t Member: Rugby 58368

Roger W. K u l a s , M.D.
UND F a m i l y P r a c t i c e C e n t e r
Grand F o r k s 58201

C. Pharmacy A d v i s o r y Committee:

John Lee, Chairman Marv Tokach

Forman 58032 #1 R i v e r v i e w Lane
Jamestown 58401
Gordon Mayer
708 B i r c h Avenue Tony Welder
Harvey 58341 Box 6 3
Napol eon 58 761
 N o r t h Dakota - 6
1983

Pharmacy A d v i s o r y Committee ( c o n t i n u e d ) :

Duane McCul lough G e r a l d Johnson

422 Main Box 95
Oakes 58474 Fessenden 58438

E r v i n Reuther R o b e r t a Southam ( E x - O f f i c i o )
701 T h i r d S t r e e t Box 158
Langdon 58249 Mohal l 58761

LLoyd S c h n a i d t John S c h u l d (Ex-Off i c i o )

Box 1054 Box 148
O i c k i n s o n 58601 D i c k i n s m 58601

M i c h a e l Berg Tom P e t t i nger

1308 S.W. 1 1 t h S t r e e t 214 F o r e s t Avenue N.
M i n o t 58201 F a r g o 58102

3. E x e c u t i v e O f f i c e r s o f S t a t e M e d i c a l and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical Association:

Vern Wagner
Executive Vice President
N o r t h Dakota M e d i c a l
Association
810 East Rosser Avenue
Box 1198
Bismarck 58501
Phone: 701/223-9475

8. Pharmaceutical Association:

John S c h u l d
Secretary-Treasurer
N o r t h Dakota P h a r m a c e u t i c a l
Association
P. 0. Box 148
O i c k i n s o n 58601
Phone: 701 /225-8650

C. Osteopathic Association:

H a r r y Homewood, D.O.
Secretary-Treasurer
N o r t h Dakota S t a t e O s t e o p a t h i c A s s o c i a t i o n
Box 516
Val l e y C i t y 58072
 Ohio - 1
1983

K D l CAL ASSISTANCE DRUG PROGRAM (TITLE X I X)

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC Chi I d r e n i 2 1 (SFO)
Prescribed
Drugs X X X X
l npatient
H o s p i t a l Care X X X X
Outpatient
H o s p i t a l Care X X X X
Laboratory E
X-ray S e r v i c e X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X
Physician
Services X X X X
Dental
Services X X X X
*SF0 - S t a t e Funds O n l y

11. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l year e n d i n g

September 30, 1982

1981 1982
Expended Recipient Expended Recipient

TMM ............................... $92,147,128 606,702** $96,680,851 612,386**

CATEGORICALLY NEEDY CASH TOTAL ...... $47,432,132 543,394 $52,378,592 545,034

Aged. ............................... 9,386,644 26,420 91170,107 25,348
Blind.. ............................. 370,568 1,230 368,522 1,163
Disabled.. .......................... 16,421,016 52,875 18,350,950 51,835
...
C h i l d r e n - F a m i l i e s w/DepChildren 6,696,437 265,310 7,112,651 263,261
A d u l t s - F a m i l i e s w/Dep Children..... 14,557,467 198,147 17,376,362 204,059
CATEGORICALLY NEEDY NON-CASH TOTAL.. $44,714,996 86,369 $44,302,259 82,991
Aged ................................ 35,785,468 44,142 33,575,941 46,803
Blind......... ...................... 208,060 426 189,486 356
Disabled.. .......................... 8,218,367 19,928 10,142,096 19,324
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 158,361 10,301 119,743 7,308
A d u l t s - F a m i l i e s w/Dep Children..... 344,740 11,784 274,993 9,756
..........
Other T i t l e X I X R e c i p i e n t s 0 0 0 0

MEDICALLY NEEDY TOTAL.. ............. $0 0 $0 0

Aged ................................ 0 0 0 0
B l i n d ............................... 0 0 0 0
Disabled..... ....................... 0 0 0 0
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 0 0 0 0
A d u l t s - F a m i l i e s w/Dep Children..... 0 0 0 0
Other T i t l e X I X R e c i p i e n t s .......... 0 0 0 0

**Unduplicated T o t a l - HHS r e p o r t HCFA

268
- 2082
 Ohio - 2
1983

Ill. Administration:

S t a t e Department o f P u b l i c W e l f a r e .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s : For p r e s c r i p t i o n legend and/or OTC d r u g s n o t

l i s t e d i n the formulary, pharmacist should o b t a i n a u t h o r i z a t i o n b e f o r e
f i l i n g c l a i m f o r payment.

6. Formulary: Yes. 4050 d r u g p r o d u c t s .

To promote economies i n t h e d r u g program, p r a c t i t i o n e r s a r e encouraged

t o p r e s c r i b e by g e n e r i c name t h o s e d r u g s w h i c h c o n s i s t e n t l y d e m o n s t r a t e
t h e r a p e u t i c e f f e c t i v e n e s s and a r e produced by p h a r m a c e u t i c a l
manufacturers w i t h s t r i c t q u a l i t y c o n t r o l s . I n f i l l i n g such g e n e r i c
p r e s c r i p t i o n s t h e pharmacist i s expected t o dispense t h e l e a s t
expensive drug a v a i l a b l e i n h i s stock. The maximum p r i c e a l l o w e d f o r
such g e n e r i c s w i l l b e an amount c l o s e l y r e l a t e d t o i t e m s o b t a i n e d from
g e n e r i c m a n u f a c t u r e r s u s u a l l y a s s o c i a t e d w i t h w h o l e s a l e d r u g houses.

A d r u g code i s l i s t e d i n t h e O h i o W e l f a r e Drug F o r m u l a r y f o r each form

o f g e n e r i c drug. Trade names f o r t h e s e 564 d r u g i t e m s a r e a l s o
contained i n t h e formulary.

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Q u a n t i t y of M e d i c a t i o n :

a. 34-day s u p p l y o r 100-dosage u n i t s ( w h i c h e v e r i s g r e a t e r ) .

b. Amount d e s i g n a t e d i n Ohio W e l f a r e F o r m u l a r y .

2. Refills: Up t o 5 r e f i l l s . After 5 r e f i l l s or 6 months ( w h i c h e v e r

i s f i r s t ) a new p r e s c r i p t i o n i s necessary.

D. P r e s c r i p t i o n Charge Formula:

1. Legend d r u g s i n community pharmacies. - Reimbursement i s based o n

the lowest o f :

a. t h e p r o v i d e r ' s r e a s o n a b l e and c u s t o m a r y c h a r g e t o t h e p u b l i c ;

b. t h e D e p a r t m e n t ' s E s t i m a t e d A c q u i s i t i o n Cost ( E A C ) , p l u s a
d i s p e n s i n g fee; o r

c. t h e l o w e s t f e d e r a l - o r s t a t e - e s t a b l i s h e d Maximum A l l o w a b l e
Cost (MAC), f o r s p e c i f i c a l l y d e s g i n a t e d g e n e r i c a l l y e q u i v a l e n t
drugs p l u s a d i s p e n s i n g fee.
NPC Ohio - 3
1983

Prescription Charge Formula (continued):

2. Nonlegend drugs in community pharmacies. - Reimbursement is based

on the lowest of:

a. EAC plus 50% markup; or

b. EAC plus a dispensing fee.

Dispensing Fee: $2.60 temporarily reduced to $2.21 for the balance of

fiscal year 1983.
NPC Ohio - 4
1983

Officials, C o n s u l t a n t s and C o m i t t e e s

1. W e l f a r e Department O f f i c i a l s :

Kenneth 6. Creasy Department o f P u b l i c W e l f a r e

Director 30 East Broad S t r e e t , 32nd f l r .
Columbus, Ohio 43215

C h a r l e s E. Noggle
Asistant Director

Mary Turney
Deputy D i r e c t o r f o r
Program Development

D i v i s i o n o f Medical A s s i s t a n c e

S t a n l e y 0. S e l l s Department of P u b l i c W e l f a r e
D i v i s i o n Chief 30 E a s t Broad S t r e e t , 3 1 s t f l r .
614/466-2365 Columbus, O h i o 43215

Kathryn Taylor
Bureau C h i e f
Bureau o f Medical Programs

R o b e r t DuPont
Pharmacist Consultant
Bureau o f M e d i c a l O p e r a t i o n s

Robert R e i d
Pharmacist C o n s u l t a n t
Bureau o f Medical O p e r a t i o n s

D i v i s i o n of Data P r o c e s s i n g

R i c h a r d G l e c k e r . R.Ph. Oeoartment o f PI 1b1ic W e l f a r e

Provider Assistance 3 0 ' E a s t Broad S t r e e t , 3 8 t h f l r .
614/466-7814 Columbus, O h i o 43215

2. Ohio M e d i c a l Care A d v i s o r y Committee

Ronald Becker Luke B i g g s

Ohio Department o f Mental H e a l t h Route 2
30 East Broad S t r e e t , 1 3 t h F l o o r 9217 Green V a l l e y Road
Columbus, O h i o 43215 M t . Vernon, O h i o 43050
( 6 1 4 ) 466-7450 ( 6 1 4 ) 397-0656
NPC Ohio - 5
1983

Ohio M e d i c a l Care A d v i s o r y Committee ( c o n t i n u e d ) :

Ms. M i c h e l l e B r e u l e u x W i l l i a m Herbein
Ohio Commission on A g i n g Ohio R e h a b i l i t a t i o n S e r v i c e s
50 West Broad S t r e e t , 9 t h f l r Commission
Columbus, O h i o 43215 4656 Heaton Road
( 6 1 4 ) 466-6597 Columbus, O h i o 43229
(614) 438-1290
Rev. James Couts
1821 Wyton C o u r t Ms. Jane Hersch
Columbus, O h i o 43227 Executive D i r e c t o r
( 6 1 4 ) 235-7388 Ohio S t a t e w i d e P r o f e s s i o n a l
Standards Review C o u n c i l
D r . M o r r i s Oixon 6400 East Main S t r e e t
2224 C h e s t n u t H i l l Reynoldsburg, O h i o 43068
C l e v e l a n d , O h i o 44106
( 2 1 6 ) 444-1517 Ed H i n t o n
U n i t e d Auto Workers' Community
James Eden, R.Ph. Act i o n Program Counc i l
235 N o r t h e a s t Avenue 133 East L i v i n g s t o n Avenue
Ta lmadge, O h i o 44278 Colunibus, Ohio 43215
( 2 1 6 ) 633-9411 (614) 464-2055

Henry S. F i s h e r , D i r e c t o r C l a r e n c e Huggins, M.O.

Summit County Welfare S u i t e 102
Department 13944 E u c l i d Avenue
47 N o r t h Main S t r e e t Cleveland, O h i o 44112
Akron, Ohio 44308 (216) 451-1600
(216) 384-1681
Ralph Jordan, V i c e P r e s i d e n t
Samuel F r a ley H e a l t h Care S e r v i c e s
O h i o Department of H e a l t h N a t i o n w i d e I n s u r a n c e Company
246 N o r t h High S t r e e t 1 Nationwide Plaza
Columbus, Ohio 43215 Columbus, Ohio 43216
(614) 466-7857
Ned Kramer, D.O.S.
Ted F r y Chi l d r e n s H o s p i t a l
Ohio Department o f Mental 561 South 1 7 t h S t r e e t
R e t a r d a t i o n and Developmental Columbus, O h i o 43205
Disabilities (614) 461-2000
30 East Broad S t r e e t , 1 2 t h f l r .
Columbus, Ohio 43215 Edward A. L e n t z
(614) 466-7596 The Hawkes H o s p i t a l o f M t .
Carmel
Owain L. Harper, D.O. 739 West S t a t e S t r e e t
Regional A s s i s t a n t Dean Columbus, Ohio 43222
Ohio U n i v e r s i t y C o l l e g e o f ( 6 14) 225-5876
Osteopathic Medicine
5125 Beacon H i l l Road
Columbus, Ohio 43228
(614) 868-6415
 Ohio - 6
1983

O h i o M e d i c a l Care A d v i s o r y Committee ( c o n t i n u e d ) :

L. Bruce L e v e r i n g Burton Schildhouse

Route 4 407 E a s t L i v i n g s t o n Avenue
F r e d e r i c k t o w n , O h i o 43019 Columbus, O h i o 43215
(614) 886-3931 o r 397-4125 ( 6 1 4 ) 224-1980

R o b e r t C. L i n s t r o m Dora Thomas
H e a l t h P l a n n i n g and 617 E z z a r d C h a r l e s D r i v e
Development Counc i l C i n c i n n a t i , O h i o 45203
405 West L i b e r t y S t r e e t ( 5 1 3 ) 241-5062
Wooster, O h i o 44691
R o b e r t Wade
A n i t a McCormick, Ph.0. Community R e l a t i o n s O f f i c e r
A s s i s t a n t S t a t e Leader Columbus Urban League
O.S.U. School of Home 700 Bryden Road, S u i t e 230
Economics Columbus, O h i o 43215
Ex. N u t r i t i o n Program
1787 N e i l Avenue
Columbus, O h i o 43210
( 6 1 4 ) 422-1935

Mrs. Bobbe Nolan, R.N.

1216 Amherst P l a c e
Dayton, O h i o 45406
( 5 1 3 ) 435-6500

3. E x e c u t i v e O f f i c e r s o f S t a t e M e d i c a l and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical A s s o c i a t i o n B. Pharmaceutical A s s o c i a t i o n

H a r t F. Page P h i l i p W. Cramer
Executive D i r e c t o r Executive D i r e c t o r
Ohio State Medical A s s o c i a t i o n Ohio State Pharmaceutical A s s o c i a t i o n
600 South H i g h S t r e e t 395 E. Broad S t r e e t , S u i t e 320
Columbus 43215 Columbus 43215
Phone: 614/228-6971 Phone: 614/221-2391

C. Ohio Osteopathic Association

Jon F. W i l l s
53 W. 3 r d Avenue
Columbus 43201
Phone: 614/299-2107
 Oklahoma 1 -
1983

WED1 CAL ASSISTANCE DRUG PROGRAM (TITLE X I X )

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l 1y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC Chi I d r e n Q 1 (SFO)
Prescribed
Druqs X X X X X X X X X
Inpatient
H o s p i t a l Care X X X X X X X X X
- -r - - ie
Outaat - n t
H o s p i t a l Care X X X X X X X X X
Laboratory &
X-ray S e r v i c e X X X X X X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X X X X X X
Physician
Services X X X X X X X X X
Dental
Services X X X X X X X X X
Other B e n e f i t s : M e d i c a l l y Needy (MN) a r e e l i g i b l e i f w i t h i n c a t a s t r o p h i c il l n e s s
d e t e r m i n a t i o n a c c o r d i n g t o Department d e f i n i t i o n and i f o t h e r w i s e e l i g i b l e .
*SF0 - S t a t e Funds O n l y

11. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

June 30, 1982

1981 1982
Expended Recipient Expended Recipient

CATEGORICALLY NEEDY CASH TOTAL...... $10,512,683 108,903

Aged ................................ 32,105
Blind ............................... 316
Disabled...... ...................... 14,924
..
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . 40,577
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . . . . 20,981

CATEGORICALLY NEEDY NON-CASH TOTAL..

Aged ................................
Blind......... ......................
Disabled ............................
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . .
A d u l t s - F a m i l i e s w/Dep Children.....
..........
O t h e r T i t l e XIX R e c i p i e n t s

MEDl CALLY NEEDY TOTAL.. .............

Aged ................................
B l i n d ...............................
Disabled ............................
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n ...
A d u l t s -Fami l i e s w/Dep C h i l d r e n . . ...
Other T i t l e X I X R e c i p i e n t s ..........
**Undupl i c a t e d T o t a l - HHS r e p o r t HCFA - 2082
274
NPC Oklahoma - 2
1983

I l l . Administration:

Oklahoma Department of Human S e r v i c e s (DHS).

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

Formulary: Yes, Oklahoma L i s t o f Covered Drugs

Contact: H. W. S t a n s b e r r y
Box 53034
Oklahome C i t y , Oklahoma 73152
405/521-3804

Provider P a r t i c i p a t i o n :

Pharmacy o r Pharmacist:

Any pharmacy o r p h a r m a c i s t who has c u r r e n t l i c e n s e w i t h t h e Oklahoma

S t a t e Board o f Pharmacy and i s f r e e from any Pharmacy Board
r e s t r i c t i o n s s h a l l b e e n t i t l e d t o b e a p a r t i c i p a t i n g p r o v i d e r under
t h i s program.

Prescribing Practitioners:

P r e s c r i b i n g p r a c t i t i o n e r s , a u t h o r i z e d and l i c e n s e d t o p r a c t i c e t h e
h e a l i n g a r t a s d e f i n e d and l i m i t e d by F e d e r a l and s t a t e laws who choose
t o p r o v i d e t h e i r own p h a r m a c e u t i c a l s , may n o t be p a r t i c i p a t i n g
p r o v i d e r s a t t h e present time.

Reimbursement Fee:

E s t i m a t e d A c q u i s i t i o n Cost (EAC) p l u s maximum d i s p e n s i n g f e e of $3.55

e f f e c t i v e 11/1/81. I n no event s h a l l charges t o t h e W e l f a r e Department
exceed charges made t o t h e general p u b l i c f o r t h e same p r e s c r i p t i o n o r
i tem.

C a t e g o r i e s o f Drug Coverage (Revised 1/1/80)

Those drugs t h a t a r e compensable under each c a t e g o r y a r e s p e c i f i e d

i n d i v i d u a l l y b y t r a d e name; o t h e r w i s e b y g e n e r i c name o n l y .

Antidiarrheals
Antiparkinsonism
Antidepressants
B r o n c h o - D i l a t o r s and A n t i a s t h m a t i c s
Opthalmic
Antiarthr i t i c s
A n t i b i o t i c s ( O r a l and i n j e c t i o n )
A n t i b a c t e r i a l s ( O r a l and I n j e c t i o n )
Gl aucoma Drugs
NPC Oklahoma - 3
1983

C a t e g o r i e s o f Drug Coverage ( c o n t i n u e d ) :

O t ic
Ant i g o u t
A n t i n e o p l a s t i c s ( O r a l and I n j e c t i o n )
B i r t h Control
Analgesics
Ant i c o n v u l s a n t s
Antinauseants, A n t i v e r t i g o / A n t i e m e t i c
I n s u l i n and A n t i d i a b e t i c s Drugs
C a r d i o v a s c u l a r - B r o a d and Potassium P r e p a r a t i o n
Antifungal
Specialized Preparations

Prescription Limitations:

Three p r e s c r i p t i o n s p e r m o n t h / r e c i p i e n t .

Quantities:

34-day supply o r 100 dosage u n i t s , w h i c h e v e r i s g r e a t e r .

Legend, Non-Legend and Generic Drugs:

O n l y legend drugs i n t h e d e s i g n a t e d c a t e g o r i e s and i n s u l i n a r e c o v e r e d

i n t h e program.

R e f i 11s:

R e f i l l s s h a l l b e p r o v i d e d o n l y i f a u t h o r i z e d by t h e p r e s c r i b e r , no more
t h a n f i v e t i m e s w i t h i n a 6-month p e r i o d .

V. Miscellaneous:

Number o f Rx c l a i m s processed i n FY 1982 - 1,046,449

Average Rx p r i c e d u r i n g FY 1982 - $11.93

 Oklahoma -4
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. Oepartment o f Human S e r v i c e s O f f i c i a l s :

Robert F u l ton Oepartment o f Human S e r v i c e s

D i rector Sequoyah Memorial O f f i c e
Bldg.
(P. 0. Box 25352)
Oklahoma C i t y , Okl ahoma

B e r t h a M. Levy, M.D.
Assistant Director
M e d i c a l S e r v i c e s Admini s t r a t i o n

Wes W h i t t l e s e y , M.D.
Administrative Assistant
A s s i s t a n t Supervisor,
Medical U n i t s

J. C. Cobb, R.Ph.
Pharmacist Consultant

Howard S t a n s b e r r y
Pharmacy Program Admi n i s t r a t o r
Program C o o r d i n a t o r
405/521-3804

2. A d v i s o r y Committee on M e d i c a l Care f o r P u b l i c A s s i s t a n c e
Recipients:

W a l t e r E. Brown, M.O. - Chai rman

4439 S. B i rmingham
T u l s a 74105

3. Executive O f f i c e r s o f S t a t e Medical, Pharmaceutical, and O s t e o p a t h i c

Societies:

A. Medical A s s o c i a t i o n :

D a v i d Bickham
Executive D i r e c t o r
Oklahoma S t a t e M e d i c a l A s s o c i a t i o n
601 N. W. Expressway
Oklahoma C i t y 73118
Phone: 405/842-3361
NPC Oklahoma - 5
1983

Executive Officers of State Medical, Pharmaceutical, and Osteopathic

Societies (continued):

B. Pharmaceutical Association:

John D. Donner
Executive Di rector
Oklahoma Pharmaceutical Association
Box 18731
Oklahoma City 73154
Phone: 405/528-3338

C. Osteopathic Association:

Bob E. Jones
Executive Director
Oklahoma Osteopathic Association
Citizens Bank Tower Building
1310 Classen Boulevard
Oklahoma City 73106
Phone: 405/528-7095
 Oregon - 1
1983

K D I C A L ASSISTANCE DRUG PROGRAM (TITLE X I X )

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e q o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFOC OAA AB APTD AFDC C h i l d r e n < 2 1 (SFO)
Prescribed

Inpatient
H o s p i t a l Care X X X X
Outpatient
H o s p i t a l Care X X X X
Laboratory E
X-ray S e r v i c e X X X X
S k i l l e d Nursin. g
Home S e r v i c e s X X X X
Physician
Services X X X X
Dental
Services X X X X
Other Benefits: V i s u a l Care, M e d i c a l T r a n s p o r t a t i o n , M e d i c a l S u p p l i e s / E q u i p m e n t ,
P h y s i c a l Therapy, P o d i a t r i s t , C h i r o p r a c t o r , N a t u r o p a t h , ICF, F a m i l y P l a n n i n g ,
A b o r t i o n s , home h e a l t h agency, P r i v a t e d u t y nurse, EPSDT.
*SF0 - S t a t e Funds Only

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

June 30, 1982

1981 1982
Expended Recipient Expended Recipient

TOTAL ............................... $10,215,432 111,912** $11,408,358 102,258+*

CATEGORICALLY NEEDY CASH TOTAL ...... $5,964,414 84,386 $9,190,679 82,380

Aged. ............................... 1,072,057 4,467 486,420 4,360
Blind..... .......................... 112,434 537 58,573 5 25
D i s a b l e d . . .......................... 1,796,320 7,518 818,771 7,339
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n ... 927,094 39,477 4,299,582 38,539
A d u l t s - F a m i l i e s w/Dep Children..... 2,056,509 32,387 3,527,333 31,617
CATEGORICALLY NEEDY NON-CASH TOTAL.. $4,251,018 27,526 $2,217,679 19,878
Aged ................................ 2,967,432 11,299 910,366 8,160
Blind ............................... 52,195 193 15,733 141
Disabled. ........................... 871,226 3,858 310,818 2,786
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 15,216 1,015 81,665 732
A d u l t s - F a m i l i e s w/Dep Children.... . 13,418 549 44,179 396
..........
Other T i t l e X I X R e c i p i e n t s 331,531 10,612 854,918 7,663
MEDICALLY NEEDY TOTAL.. ............. $0 0
Aged ................................ 0 0
B l i n d ............................... 0 0
Disabled... ......................... 0 0
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 0 0
A d u l t s - F a m i l i e s w/Dep Children.... . 0 0
Other T i t l e XIX R e c i p i e n t s .......... 0 0
**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082
279
NPC Oregon - 2
1983

I l l . Administration:

A d u l t and F a m i l y S e r v i c e s D i v i s i o n , Department o f Human Resources.

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. F o r m u l a r y : An open " f o r m u l a r y " e x c e p t f o r m i n o r t r a n q u i l i z e r s and

amphetamines.

B. Non-Formulary: P r i o r a p p r o v a l f r o m s t a t e r e v i e w i n g p h y s i c i a n must be
o b t a i n e d f o r m i n o r t r a n q u i l i z e r s o t h e r t h e n ( g e n e r i c ) meprobamate o r
c h l o r d i a z e p o x i d e , and amphetamines and amphetamine d e r i v a t i v e s , and f o r
c e r t a i n non legend items.

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Q u a n t i t y o f Medication: Not t o exceed 34 days s u p p l y , e x c e p t t o p i c a l

p r e p a r a t i o n s , sprays, a e r o s o l i n h a l e r s , and s i m i l a r p r e p a r a t i o n s .

2. Refills - Schedule 3, 4, o r 5 drugs a r e l i m i t e d t o 5 r e f i l l s .

3. Dollar Limits: None.

D. P r e s c r i p t i o n Charge Formula:

Payment i s t h e l o w e s t of: ( a ) u s u a l and customary c h a r g e s t o g e n e r a l

p u b l i c , ( b ) Maximum A l l o w a b l e Cost (MAC) p l u s d i s p e n s i n g f e e of $3.27, (c)
E s t i m a t e d A c q u i s i t i o n Cost (EAC) p l u s d i s p e n s i n g f e e o f $3.27.

N u r s i n g home d r u g reimbursement i s based upon a c a p i t a t e d f e e of $0.53 p e r

day p e r e l i g i b l e .

V. M i s c e l l a n e o u s Remarks:

Number of Rx c l a i m s processed i n FY 1982 - 1,502,174

Average Rx p r i c e d u r i n g FY 1982 - $8.29

S t a t e MAC program f o r a p p r o x i m a t e l y 150 drugs.
NPC Oregon - 3
1983

Officials, C o n s u l t a n t s and Cormnittees

1. Leo T. Hegstrom Department o f Human Resources

Director 318 P u b l i c S e r v i c e s B u i l d i n g
Salem, Oregon 97310

K e i t h Putnam, A d m i n i s t r a t o r
A d u l t and F a m i l y S e r v i c e s D i v .

Byron C a r p e n t e r
Assistant Administrator
H e a l t h and S o c i a l S e r v i c e s S e c t i o n

Kim S c r a n t o n
Assistant Administrator
F i e l d Operations Section

Leonard T. Sytsma
Assistant Administrator
Support S e r v i c e s Sect i o n

Michael Kane
Assistant Administrator
Income Maintenance S e c t i o n

Vern F i s h e r
Assistant Administrator
Business S e r v i c e s Sect i o n

2. C o n s u l t a n t s t o H e a l t h and S o c i a l S e r v i c e s S e c t i o n :

R i c h a r d J. Cook, D.D.S. A l f r e d S c h e f f , M.D.

Rob i nhood P r o f . B l dg . (Psychiatric)
18603 P a c i f i c Highway 1625 Commercial S t . , SE
West L i n n 97068 Salem 97302

W i 1 1 iam D e t t w y l e r , M.T. O t t o F. Kraushaar, H.D.

5555 Sunnyview Road, NE ( C h i e f Medical Advisor)
Salem 97303 203 P u b l i c S e r v i c e B l d g .
Salem 97310
W i l l i a m Henry, ND
(Naturopath) R o b e r t W. S t a l e y , D.D.S.
1920 N o r t h K i l p a t r i c k 1075 Hansen Avenue S.
P o r t l a n d 97217 Salem 97302
 Oregon - 4
1983

C o n s u l t a n t s t o H e a l t h and S o c i a l S e r v i c e s S e c t i o n ( c o n t i n u e d ) :

Donald C h a r l t o n , DMD D r . Jan lsselman

(Dental) 1320 Lewis S t r e e t , SE
943 L i b e r t y S t r e e t , SE Salem 97302
Salem 97302
R a n v i r Sinanan, M.D.
M e r l e B e r r y , O.D. 203 P u b l i c S e r v i c e B l d g .
(Optometr i c ) Salem 97310
Albany Optometr i c Center
225 W. 2nd Chuck Mortensen
Albany 97321 (Pharmacist Consultant)
203 P u b l i c S e r v i c e B l d g .
Dan Campbell, D.D.S. Salem 97310
C/O Lebanon Branch, AFS 503/378-2263
P. 0. Box 456
Lebanon 97355

3. D i v i s i o n A d v i s o r y Committees:

G o v e r n o r ' s A d v i s o r y Comnittees on Medical A s s i s t a n c e

for the Underprivileged

MEMBERS

C h a r l e s Ross Anthony Public - economics 344-1982

2590 Van Ness 484-0709
Eugene 97403 (home)

D a n i e l B i l l m e y e r , MD Physician
406 7 t h S t r e e t
Oregon C i t y 97045

Kay Breeden Public - recipient

2506 C a n t e r b u r y
Eugene 97404

Roderick Bunnell tndustry

P.D. Box 1071
P o r t l a n d 97207

James E. Creswel I, DMD Dentist

Route 3, Box 428
Klamath F a l l s 97601

S i s t e r Monica Heeran Hospital Administrator

Sacred H e a r t H o s p i t a l
P.O. Box 10905
Eugene 97440
NPC Oregon - 5
1983

G o v e r n o r ' s A d v i s o r y Committee on M e d i c a l A s s i s t a n c e
f o r the Underprivileged (continued)

Joan E. Krahmer Public - Mental H e a l t h 648-8636

614 E a s t M a i n
H i l l s b o r o 97123

F r a n k McBarron Physician 284-1174

2225 Loyd Center
P o r t l a n d 97232

Dennis Marsh Medical P r o f e s s i o n - Other

1015 C o r n e l l Avenue Ambulance
G l a d s t o n e 97027

L a r r i e Noble, R.N. Nursing Profession

11750 SW 72nd
T i g a r d 97223

Rhese Penn, MD D i r e c t o r , Maternal

Health Division and C h i l d H e a l t h
1400 SW F i f t h Avenue
P o r t l a n d 97201

Ruth S l i c k , RN N u r s i n g Home
221 Q u a r r y S t r e e t Administrator
Oregon C i t y 97045

B e v e r l e y C. T r a g l i o Public - Recipient
l o l l NE 6 9 t h
P o r t l a n d 97213

Barbara Watson, R.Ph. Pharmacist 636-5697

4250 SW Upper D r i v e
Lake Oswego 97034

4. E x e c u t i v e O f f i c e r s o f S t a t e M e d i c a l , P h a r m a c e u t i c a l and O s t e o p a t h i c
Associations:

A. Medical A s s o c i a t i o n :

R o b e r t L. Dernedde
Executive D i r e c t o r
Oregon M e d i c a l A s s o c i a t i o n
5210.SW C o r b e t t S t r e e t
P o r t l a n d 97201
Phone: 503/226-1555
NPC Oregon -6
1983

E x e c u t i v e O f f i c e r s of S t a t e M e d i c a l , P h a r m a c e u t i c a l and O s t e o p a t h i c
Associations (continued):

0. Pharmaceutical Association:

Henry A. Speckman
Executive Secretary
Oregon S t a t e P h a r m a c e u t i c a l A s s o c i a t i o n
1460 S t a t e S t r e e t
Salem 97301
Phone: 503/585-4887

C. Osteopathic Association:

J e f f Heatherington
Executive D i r e c t o r
Oregon O s t e o p a t h i c A s s o c i a t i o n
9221 SW Barbur, S u i t e 301
P o r t l a n d 97219
Phone: 503/244-7592
 Pennsylvania - 1
1983
PENNSYLVANIA

l Y D l CAI. ASSISTANCE DRUG PROGRAM (TITLE X I X)

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC C h i I d r e w 2 1 (SF01
Prescribed
Druqs X X X X X
l npat i e n t
H o s p i t a l Care X X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X X
Laboratory &
X-ray S e r v i c e X X X X X X X X X X
Ski1 led Nursing
Home S e r v i c e s X X X X X X X X X X
Physician
Services X X X X X X X X X X
Dental
Services X X X X X X
Other B e n e f i t s : F a m i l y P l a n n i n g , Home H e a l t h Care, Ambulance, C l i n i c s ICF S e r v i c e ,
H o s p i t a l Hane Care, D u r a b l e M e d i c a l Equipment, P r o s t h e t i c s , I n p a t i e n t P s y c h i a t r i c
Care, School Medical.
*SF0 - S t a t e Funds O n l y

11. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l year e n d i n g

June 30, 1982

Expended Recipient Expended Recipient

TOTAL.. ............................ $64,523,915 763,219** $75,910,783 590,176**

CATEGORICALLY NEEDY CASH TOTAL.. .... $54,069,771 661,647 $58,037,226 503,546

Aged ................................ 10,568,777 48,521 11,329,059 37,418
Blind...... ......................... 348,416 1,867 365,647 1,314
Disabled.. .......................... 19,297,461 84,403 22,082,604 67,760
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 9,810,062 342,641 8,694,432 242,800
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . ... 14,045,055 184,215 15,565,484 163,537

CATEGORICALLY NEEOY NON-CASH TOTAL.. $10,174,567 95,439 $17,845,586 94,018

Aged.. .............................. 5,864,924 30,897 12,709,811 36,190
Blind ............................... 286 20 511 2
Disabled. ........................... 2,341,493 8,206 3,243,174 8,570
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 314,978 12,002 241,566 8,690
A d u l t s - F a m i l i e s w/Dep Children.... . 517,600 8,432 567,791 9,827
..........
Other T i t l e XIX R e c i p i e n t s 1,135,286 35,882 1,082,733 31,093

MEDl CALLV NEEDY TOTAL.. ............. $279,577 6,133 27,971 71 4

Aged ................................ 110,487 1,109 308 5
B l i n d ............................... 15,807 20 0 0
Disabled...... ...................... 26,600 410 28 1
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . .. 71,181 3,221 16,919 46 0
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . .... 55,024 1,292 10,593 249
Other T i t l e XIX R e c i p i e n t s .......... 478 81 123 2

**Unduplicated T o t a l - 2[f
HHS r e p o r t HC - 2082
NPC Pennsylvania - 2
1983

111. Administration:

O f f i c e of M e d i c a l A s s i s t a n c e , Department o f P u b l i c W e l f a r e .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s : Payment w i l l n o t b e made t o any pharmacy f o r t h e

f o l l o w i n g s e r v i c e s and items:

1. Methadone f o r any use.

2. Drugs f o r t r e a t m e n t o f pulmonary t u b e r c u l o s i s , d r u g s c o n t a i n i n g
f l u o r i d e s , and any b i o l o g i c a l s o r v a c c i n e s t h a t a p h y s i c i a n can
o b t a i n w i t h o u t c h a r g e f r o m any o t h e r s t a t e o r l o c a l agency.
Pharmacies may be p a i d f o r t h e s e i t e m s i n an emergency i f t h e y a r e
n o t a v a i l a b l e f r o m t h e s t a t e o r l o c a l agency and i f t h e p h y s i c i a n
makes t h i s n o t a t i o n on t h e p r e s c r i p t i o n .

3. Drugs and o t h e r items p r e s c r i b e d f o r o b e s i t y o r a p p e t i t e

control. However, d r u g s w h i c h have been c l e a r e d f o r use i n t h e
t r e a t m e n t o f h y p e r k i n e s i s i n c h i l d r e n and p r i m a r y and secondary
n a r c o l e p s y due t o s t r u c t u r a l damage o f t h e b r a i n a r e
compensable. The p h y s i c i a n must i n d i c a t e t h e d i a g n o s i s on t h e
original prescription.

4. A n t i b i o t i c s , a n t i b a c t e r i a l , a n a l g e s i c , a n e s t h e t i c , and a n t i t u s s i v e
a g e n t s i n t h e f o r m of t r o c h e s , lozenges, t h r o a t t a b l e t s , cough
drops, chewing gum, mouth washes and s i m i l a r items t h a t a r e
p r e s c r i b e d f o r t h e l o c a l t r e a t m e n t of d i s o r d e r s o f t h e mouth and
throat. However, s i n g l e e n t i t y legend a n e s t h e t i c s o l u t i o n s a r e
compensable.

5. P h a r m a c e u t i c a l s e r v i c e s p r o v i d e d t o a h o s p i t a l i z e d p e r s o n or a
person r e c e i v i n g hospital-home care.

6. A11 v i t a m i n s alone o r i n combination w i t h another v i t a m i n , except

f o r the following:

a. S i n g l e e n t i t y and m u l t i p l e v i t a m i n p r e p a r a t i o n s w i t h o r
w i t h o u t f l u o r i d e s f o r c h i l d r e n under t h r e e ( 3 ) y e a r s of age.

b. A p r e s c r i p t i o n drug p r o d u c t w h i c h c o n t a i n s a s i n g l e e n t i t y
v i t a m i n combined w i t h a l e g e n d d r u g .

c. Vitamin D and i t s analogs.

d.
. ..
N i c o t i r ~ i ca c i d aim r c s amides.

e. V i - a m i r i I< and i t s tirlalogs.

 Pennsylvania - 3
1983

General E x c l u s i o n s ( c o n t i n u e d ) :

f. Folic Acid

g. S i n g l e e n t i t y and m u l t i p l e v i t a m i n p r e p a r a t i o n s when
p r e s c r i b e d f o r p r e n a t a l use.

7. Drugs and d e v i c e s c l a s s i f i e d as e x p e r i m e n t a l b y t h e FDA.

8. Drugs and d e v i c e s n o t approved f o r use by t h e FDA.

9. Placebos

10. Legend and nonlegend soaps, c l e a n s i n g a g e n t s , d e n t i f r i c e s , mouth

washes, douche s o l u t i o n s , ear wax removal a g e n t s , deodorants,
l i n i m e n t s , a n t i s e p t i c s , e m o l l i e n t s , and o t h e r p e r s o n a l c a r e and
medicine chest items.

11. Legend and nonlegend agueous s a l i n e s o l u t i o n s f o r use o t h e r t h a n

f o r intravenous administration.

12. Legend and nonlegend w a t e r p r e p a r a t i o n s such as d i s t i l l e d w a t e r ,

water f o r i n j e c t i o n , e t c .

13. Food supplements and s u b s t i t u t e s .

14. Compounded p r e s c r i p t i o n s when:

a. Compensable items a r e used i n l e s s t h a n t h e r a p e u t i c

quantities, or

b. Noncompensable items a r e compounded.

15. Nonlegend d r u g s n o t l i s t e d i n t h e Appendix t o C h a p t e r 1121.

16. Drugs p r e s c r i b e d i n c o n j u n c t i o n w i t h sex r e a s s i g n m e n t p r o c e d u r e s

o r o t h e r noncompensable s u r g i c a l p r o c e d u r e s .

17. The f o l l o w i n g items when p r e s c r i b e d f o r r e c i p i e n t s r e c e i v i n g

s k i l l e d n u r s i n g and i n t e r m e d i a t e c a r e f a c i l i t y s e r v i c e s :

a. Intravenous solutions.

b. , Those noncompensable d r u g s and i t e m s a s s p e c i f i e d i n t h i s

section.

c. Those nonlegend drugs i n d i c a t e d as b e i n g non-compensable f o r

t h e s e r e c i p i e n t s as s p e c i f i e d i n t h e Appendix t o Chapter 1121.
 Pennsylvania -4
1983

General E x c l u s i o n s ( c o n t i n u e d ) :

18. l tems p r e s c r i b e d o r o r d e r e d b y a p r e s c r i b e r who has been b a r r e d o r

suspended from p a r t i c i p a t i o n i n t h e M e d i c a l A s s i s t a n c e Program.
The Department w i l l p e r i o d i c a l l y send pharmacies a l i s t of t h e
names o f suspended, t e r m i n a t e d o r r e i n s t a t e d p r a c t i t i o n e r s and t h e
dates o f t h e various actions. Pharmacies a r e r e s p o n s i b l e f o r
checking t h i s l i s t before f i l l i n g p r e s c r i p t i o n s .

19. P r e s c r i p t i o n s o r o r d e r s f i l l e d by a pharmacy o t h e r t h a n t h e one t o

w h i c h a r e c i p i e n t has been r e s t r i c t e d . Pharmacies a r e r e s p o n s i b l e
f o r c h e c k i n g b o t h t h e l i s t and t h e r e c i p i e n t ' s M e d i c a l S e r v i c e s
E l i g i b i l i t y Card b e f o r e f i l l i n g t h e p r e s c r i p t i o n .

20. DESl Drugs.

Formulary: None

P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Q u a n t i t y of M e d i c a t i o n : t h e q u a n t i t y t o be d i s p e n s e d i s as
p r e s c r i b e d b y t h e p h y s i c i a n , n o t t o exceed a 34 day s u p p l y o r 100
u n i t s , whichever i s g r e a t e r .

2. Ref i l l s : P r e s c r i p t i o n s may be r e f i l l e d , as l o n g a s t o t a l
a u t h o r i z a t i o n does n o t exceed a 6 months' o r 5 - r e f i l l s u p p l y from
t h e time o f o r i g i n a l p r e s c r i p t i o n .

3. Dollar Limits: P r e s c r i p t i o n s f o r m e d i c a t i o n s c o s t i n g more t h a n

$15.00 r e q u i r e p r i o r a u t h o r i z a t i o n f r o m t h e County A s s i s t a n c e
Office.

Drug Cost D e t e r m i n a t i o n :

1. Payment f o r compensable legend drugs i s based on t h e c u r r e n t

E s t i m a t e d A c q u i s i t i o n Cost (EAC) e s t a b l i s h e d b y t h e Department.
The EAC f o r each m e d i c a t i o n i s computed b y t a k i n g t h e a r i t h m e t i c
average o f t h e w h o l e s a l e p r i c e s charged f o r t h e d r u g i n t h e most
common package s i z e b y s i x ( 6 ) of t h e m a j o r P e n n s y l v a n i a drug
w h o l e s a l e r s who a r e w i l l i n g t o p r o v i d e m i c r o f i c h e d a t a t o t h e
Department. The "most common package size", f o r t h e purposes of
computing t h e EAC, i s t h e same as t h a t used b y t h e Department of
H e a l t h and Human S e r v i c e s . I f more t h a n s i x ( 6 ) P e n n s y l v a n i a drug
w h o l e s a l e r s a r e w i l l i n g t o p r o v i d e such p r i c e d a t a , t h e EAC i s
computed based on t h e data o b t a i n e d f r o m t h e s i x (6) w h o l e s a l e r s
that are the largest.
 Pennsylvania - 5
1983

Drug Cost D e t e r m i n a t i o n ( c o n t i n u e d ) :

The Department implemented t h e p r e s e n t EAC system on J a n u a r y 1,

1980 by i n i t i a l l y i s s u i n g EAC's f o r t h e 300 most comnonly used
drugs. I f and when i t was r e p o r t e d b y t h e P e n n s y l v a n i a
w h o l e s a l e r s t h a t p r i c e change o c c u r s w i t h o t h e r drugs, t h e n t h e s e
drugs were assigned EAC's and added t o t h e l i s t . U n t i l a drug's
EAC i s e s t a b l ished, t h e d r u g ' s Average Wholesale P r i c e (AMP) a s
p u b l i s h e d i n t h e c u r r e n t Drug T o p i c s Red Book o r i t s supplement i s
used and updated as t h i s AW i s changed. I n absence of a S t a t e
EAC o r an A W , t h e m a n u f a c t u r e r ' s d i r e c t p r i c e i s used. The EAC
f o r i n d i v i d u a l drugs a r e recomputed on a m o n t h l y b a s i s i f any of
t h e w h o l e s a l e r s which a r e s u p p l y i n g p r i c e d a t a a d v i s e s t h e
Department o f a change i n t h e w h o l e s a l e c o s t o f t h e drug. In
cases where t h e EAC exceeds t h e Maximum A l l o w a b l e Cost (MAC), t h e
MAC w i l l a p p l y .

2. Payment f o r t h e c o s t o f comparable nonlegend d r u g s i s based on t h e

c u r r e n t AWP a p p e a r i n g i n t h e Drug T o p i c s Red Book o r i t s b i -
m o n t h l y and q u a r t e r l y supplements. I f t h e AWP f o r a nonlegend
d r u g does n o t appear i n t h e Red Book o r i t s supplement, t h e n t h e
c o s t i s based on t h e m a n u f a c t u r e r ' s d i r e c t p r i c e l i s t e d i n t h e Red
Book o r i t s supplement o r t h e p r i c e l i s t e d i n a p u b l i c a t i o n
s u p p l i e d by t h e manufacture. The Appendix t o Chapter 1121 l i s t s
t h e nonlegend drugs f o r which payment i s made under t h e M e d i c a l
A s s i s t a n c e Program.

P r e s c r i p t i o n Charge Formula:

1. On May 16, 1981, P e n n s y l v a n i a r e v i s e d i t s payment methodology t o

pharmacies. T h i s r e v i s e d payment methodology, w h i c h has been
approved b y t h e f e d e r a l government as p a r t of t h e S t a t e ' s approved
S t a t e P l a n , r e c o g n i z e s a d i f f e r e n c e between a pharmacy's u s u a l and
customary charge t o t h e s e l f - p a y i n g p u b l i c and t h e pharmacy's
usual and customary charge t o t h i r d p a r t y p a y o r s . The " s e l f -
p a y i n g pub1 i c " i s d e f i n e d as a l l p e r s o n s whose c o s t s f o r
p r e s c r i b e d d r u g s a r e n o t c o v e r e d by a t h i r d p a r t y p a y o r . "Third
p a r t y payors" a r e d e f i n e d as p u b l i c o r p r i v a t e h e a l t h i n s u r a n c e
p l a n s o r programs w h i c h make payments t o pharmacies on b e h a l f of
e l i g i b l e recipients or beneficiaries. As a r e s u l t o f t h i s r e v i s e d
payment methodology, pharmacies a r e r e i m b u r s e d an a d d i t i o n a l
amount n o t t o exceed 25 c e n t s f o r each w e l f a r e p r e s c r i p t i o n t h a t
would o r d i n a r i l y be p a i d on a u s u a l and customary b a s i s . The
amount o f t h e t o t a l payment w i l l n o t exceed t h e c o s t of t h e drug
p l u s t h e d i s p e n s i n g fee.
NPC Pennsylvania -6
1983

P r e s c r i p t i o n Charge Formula ( c o n t i n u e d ) :

2. A l i c e n s e d r e t a i l pharmacy's maximum reimbursement f o r a l l

compensable l e g e n d and nonlegend d r u g s s h a l l be t h e c o s t o f t h e
d r u g p l u s a $2.25 d i s p e n s i n q f e e o r t h e pharmacy's u s u a l and
customary c h a r g e t o t h i r d p a r t y payors, whichever i s l o w e r . F o r
purposes of Medical A s s i s t a n c e reimbursement, t h e u s u a l and
customary c h a r g e t o t h i r d p a r t y p a y o r s may n o t exceed 25 c e n t s p e r
p r e s c r i p t i o n h i g h e r t h a n t h e usual and customary c h a r g e t o t h e
s e l f - p a y i n g p u b l i c . The c o s t of t h e d r u g s h a l l b e e i t h e r t h e M A C ,
EAC, o r AWP. A l t h o u g h payment s h a l l be made i n accordance w i t h
t h i s method o f payment, t h e pharmacy i s r e q u i r e d t o b i l l t h e
Department a t i t s u s u a l and customary c h a r g e t o t h e s e l f - p a y i n g
pub1 i c .

3. An o u t p a t i e n t h o s p i t a l , s k i l l e d n u r s i n g f a c i l i t y o r i n t e r m e d i a t e
c a r e f a c i l i t y l i c e n s e d pharmacy's maximum reimbursement f o r a l l
compensable legend and non-legend drugs s h a l l be t h e c o s t of t h e
d r u g p l u s a $1.55 d i s p e n s i n q f e e o r t h e pharmacy's usual and
customary charge t o t h i r d p a r t y payors, whichever i s lower. For
purposes o f M e d i c a l A s s i s t a n c e reimbursement, t h e usual and
customary charge t o t h i r d p a r t y p a y o r s may n o t exceed 25 c e n t s per
p r e s c r i p t i o n h i g h e r t h a n t h e usual and c u s t a n a r y c h a r g e t o t h e
s e l f - p a y i n g p u b l i c . The c o s t o f t h e drug s h a l l be e i t h e r t h e MAC,
EAC, o r AWP. A l t h o u g h payment s h a l l be made i n accordance w i t h
t h i s method o f payment, t h e pharmacy i s r e q u i r e d t o b i l l t h e
Department a t i t s u s u a l and customary c h a r g e t o t h e s e l f - p a y i n g
public.

4. F o r compound p r e s c r i p t i o n s , an a d d i t i o n a l fee of $1.00 i s a l l o w e d

t o r e t a i l pharmacies and t o i n s t i t u t i o n a l pharmacies, b r i n g i n g t h e
t o t a l d i s p e n s i n g fees t o $3.25 and $2.55 r e s p e c t i v e l y . A compound
p r e s c r i p t i o n f o r t h e purposes o f M e d i c a l A s s i s t a n c e payment, i s
one which i s p r e p a r e d a t t h e t i m e of d i s p e n s i n g and i n v o l v e s t h e
w e i g h i n g of a t l e a s t one s o l i d i n g r e d i e n t . A t l e a s t one
i n g r e d i e n t must be a legend drug i n a t h e r a p e u t i c amount. The
a d d i t i o n a l $1.00 f e e w i l l n o t be p a i d f o r p r e s c r i p t i o n s p r e p a r e d
i n b u l k p r i o r t o dispensing.

V. Miscellaneous:

R e c i p i e n t L o c k - l n Proqram.

A. A p p r o x i m a t e l y 2,394 r e c i p i e n t s were r e s t r i c t e d t o a pharmacy as of June

30, 1982.

B. Savings per r e c i p i e n t i s $42.00 p e r month f o r reduced u t i l i z a t i o n o f

drug s e r v i c e s .

C. Parameters used f o r t h e p r o f i l e s are:

1. $250 f o r d r u g s e r v i c e s f o r a t h r e e month p e r i o d ;
2. 25 p r e s c r i p t i o n s i n t h r e e months; and
3. s i x o r more pharmacies.
NPC Pennsylvania - 7
1983

Miscellaneous (continued):

D. Copayment - No.

E. Fiscal Intermediary

The Computer Company

5101 Jonestown Road
Harrisburg, Pennsylvania 17112

F. Number of Rx c l a i m s processed i n FY 1982 - 12,346,694

G. Average p r e s c r i p t i o n p r i c e d u r i n g FY 1982 - $7.46

NPC Pennsylvania - 8
1983

Officials, C o n s u l t a n t s and Committees

1. W e l f a r e Department O f f i c i a l s :

W a l t e r W. Cohen Department o f P u b l i c W e l f a r e
Secretary H e a l t h and W e l f a r e B u i l d i n g
H a r r i s b u r g , P e n n s y l v a n i a 17120

B r i a n T. B a x t e r
E x e c u t i v e Deputy S e c r e t a r y

G e r a l d F. Radke
Deputy S e c r e t a r y f o r M e d i c a l
Assistance

David S. Feinberg
D irector
Bureau of Pol i c y and Program
Deve 1 opmen t

R i c h a r d H. Lee
D i r e c t o r , Bureau o f
Reimbursement Methods

R o b e r t B. K e l l y
D i r e c t o r , Bureau o f M e d i c a l
Assistance Operations

Glenn Johnson
O i r e c t o r , Bureau o f
U t i l i z a t i o n Review

E i l e e n M. Schoen
Director
Bureau o f P r o v i d e r R e l a t i o n s

2. Consultant Pharmacists:

Joseph E. Concino, R.Ph.

Bureau of P o l i c y and Program
Deve 1 opmen t
7171787- 1170

M i c h a e l A. R i m l e r , R.Ph.
Bureau o f Reimbursement Methods
 Pennsylvania - 9
1983

Consultant Pharmacists (continued):

W i l l i a m M. P e i f e r , R.Ph. Department o f P u b l i c W e l f a r e
Bureau of M e d i c a l A s s i s t a n c e Park Penn B u i l d i n g
Operations H a r r i s b u r g 17112

R o b e r t G . D i s s i n g e r , R.Ph.
Bureau of M e d i c a l A s s i s t a n c e
Operations

S . C h a r l e s Modica, R.Ph.
Bureau o f M e d i c a l A s s i s t a n c e
Operations

John F e r r a r a , R.Ph. Department of P u b l i c W e l f a r e

Bureau of U t i l i z a t i o n Review 25 N o r t h 32nd S t r e e t
Camp H i l l 17011

F r a n k Cwynar, R.Ph.
Bureau of U t i l i z a t i o n Review

John Hocker, R.Ph.

Bureau of U t i l i z a t i o n Review

J u l i u s R. Katzman, R.Ph.
Bureau of U t i l i z a t i o n Review

P a u l B u r k h o l d e r , R.Ph.
Bureau of U t i l i z a t i o n Review

3. M e d i c a l A s s i s t a n c e A d v i s o r y Committee:

Member Orqanization

James M. Redmond H o s p i t a l A s s o c i a t i o n of Pa.

Vice President, Hospital Services
H o s p i t a l A s s o c i a t i o n o f Pa.
P .O. Box 608
Camp H i l l 17011

H. W i l l i a m Gross, O.D.S. Pa. D e n t a l A s s o c i a t i o n

1414 F a i rmont S t r e e t
A l l e n t o w n 18102

W a l t e r M. G r e i s s i nger, M.D. Pa. M e d i c a l S o c i e t y

Central Medical P a v i l i o n
1400 Center Avenue
P i t t s b u r g h 15219
 Pennsylvania - 10
1983

M e d i c a l A s s i s t a n c e A d v i s o r y Committee ( c o n t i n u e d ) :

Thomas W. C l a r k , M.D. The C o a l i t i o n o f Advocates f o r

44 West H i g h l a n d Avenue t h e R i g h t s of t h e l n f i r m e d E l d e r l y
P h i l a d e l p h i a 19118

John J . Sheehy I n s u r a n c e Commission

Deputy l n s u r a n c e Commissioner
S t r a w b e r r y Square
H a r r i s b u r g 17120

Harry Stacks Southeast C e n t r a l R e g i o n a l

2411 C h e s t n u t V i e w D r i v e C o u n c i l on A g i n g
L a n c a s t e r 17603

James F e r l o Cmmun i t y Heal t h Advocacy

139 C a r v e r S t r e e t Network
P i t t s b u r g h 15206

Thomas W. B l a c k , M.D. The Coal i t i on of Advocates

44 West H i g h l a n d Avenue f o r t h e R i g h t s of t h e
P h i l a d e l p h i a 19118 Infirm Elderly

W i l l i a m L. Greene, R.Ph. Pa. P h a r m a c e u t i c a l Assn.

G r e e n ' s Pharmacy
2020 U n i o n B o u l e v a r d
A l l e n t o w n 18103

NOTE: M r . M i l t o n Jacobs i s c u r r e n t l y s e r v i n g as Chairman of

t h e M e d i c a l A s s i s t a n c e A d v i s o r y Committee.

4. Pharmacy Subcommittee t o t h e M e d i c a l A s s i s t a n c e A d v i s o r y
Committee:

W i l l i a m L. Greene, R.Ph. A l a n J . Vogenberg, R.Ph.

Chai rman 10 F r u i t r e e Road
780 West Macada L e v i t t o w n 19056
Bethleham 18017

Samuel D. Brog, R.Ph. John A. Paone, R.Ph.

102 B u c k l e y D r i v e Wyman Pharmacy
P h i l a d e l p h i a 19115 524 E a s t O h i o S t r e e t
P i t t s b u r g h 15212

D a v i d D a l t o n , R.Ph. N.E. M o n t i c e i l i , R.Ph

Rite A i d Corporation 669 B u r c l a y Lane
P.O. Box 3165 B r o m a l l 19008
H a r r i s b u r g 17105
NPC Pennsylvania - 11
1983

Pharmacy Subcommittee t o t h e Medical A s s i s t a n c e A d v i s o r y Committee

(continued) :

R o b e r t Peyakovich, R.Ph. Donald E. S c h e l l , R.Ph.

1921 H a r v a r d Avenue 129 B l a c k s m i t h Road
P o t t s v i l l e 17901 Camp H i l l 17011

Laraine Forry Benjamin P u l i z z i , R.Ph.

Pennsy:vania A s s o c i a t i o n W i l l i a m s p o r t Orthopedic
of Medical S u p p l i e r s and P r o s t h e t i c Co.
C / O H a r r i s b u r g S u r g i c a l Co. 138 E a s t 4 t h S t r e e t
P.O. Box 2227 W i l l i a m s p o r t 17701
H a r r i s b u r g i7108

4. Executive O f f i c e r s o f S t a t e Medical, Pharmaceutical, Podiatry,

and O s t e o p a t h i c Medical A s s o c i a t i o n s :

A. Medical Society: B. P h a r m a c e u t i c a l A s s o c i a t i o n :

John F. Rineman Carmen A. O i C e l l o , R.Ph.

Executive Vice President Executive D i r e c t o r
Pa. Medical S o c i e t y Pennsylvania Pharmaceutical
20 E r f o r d Road Assoc .
Lemoyne 17043 508 N o r t h T h i r d S t r e e t
Phone: 717/763-7151 H a r r i s b u r g 17101
Phone: 717/234-6151

C. Podiatry Association: D. O s t e o p a t h i c M e d i c a l A s s o c i a t i o n :

Matthew M. Shook, J r . Marianne F i e l d s

Executive O i r e c t o r
Pennsylvania P o d i a t r y
Association
737 P o p l a r Church Road
Camp H i l l 17011
Executive D i r e c t o r
Pennsylvania Osteopathic
Medical A s s o c i a t i o n
1330 Eisenhower B o u l e v a r d
H a r r i s b u r g 17111
Phone: 717/939-9318
 Puerto Rico - 1
1983

PUERTO RICO

E O I C A L ASSISTANCE DRUG P R O M ( T I T L E X I X )

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFDC DAA AB APTD AFDC C h i l d r e M 2 1 (SFD)
Prescribed
Drugs X X X X X X X X X X
l npat i e n t
H o s p i t a l Care X X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X X
Laboratorv &
X-ray S e r v i c e X X X X X X X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X X X X X X X
Physician
Services X X X X X X X X X X
Dental
Services X X X X X X X X X X
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982

1981 1982
Expended Recipient Expended Recipient

TOTAL..... ..........................
CATEGORICALLY NEEDY CASH TOTAL.... ..
Aged ................................
Blind ...............................
Disabled... .........................
.
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . .
A d u l t s - F a m i l i e s w/Dep Children.....

CATEGORICALLY NEEDY NDN-CASH TOTAL.

Aged ................................
Blind.... ...........................
Disabled... .........................
..
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . No D a t a S u b m i t t e d
....
A d u l t s - F a m i l i e s w/Dep C h i l d r e n .
-
..........
Other T i t l e X I X R e c i p i e n t s

MEDICALLY NEEDY TOTAL ...............

Aged ................................
B l i n d ...............................
D i s a b l e d ............................
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . .
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . . . .
Other T i t l e XIX R e c i p i e n t s ..........
HHS r e p o r t HCFA - 2082

296
 Puerto Rico - 2
1983

I I I . Administration:
By the Department of Health through the existing regionalized health care
system operated by the Comnonwealth and municipal government.

IV. Provisions Relating to Prescribed Drugs:

Prescribed drugs and biologicals are provided to both inpatients and

outpatients in municipal hospitals, health centers, regional hospitals,
special hospitals, and rehabilitation centers. All drugs and biologicals
provided are approved by the medical staff and included in all regional
hospitals and health centers.

Drugs are prescribed by general practitioners without a formulary.

Designated hospital pharmacies are the primary source of all prescription

drugs. Retail pharmacies are used only when necessary.
NPC Puerto Rico - 3
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. H e a l t h Department O f f i c i a l s :

D r . Jaime R i v e r a Dueno Department of H e a l t h

Secretary C a l l Box 70 184
San Juan, P u e r t o R i c o 00936

Medical A s s i s t a n c e Program:

E m i l i a Hoyos Rucabado, M.S.

Pharmacist Consultant

J u l i o Cesar G a l a r c e P. 0. Box 10037

D i rector Caparra H e i g h t s S t a t i o n
H e a l t h Economy O f f i c e San Juan 00922

Irma R e v i l l e De F e r r e r
Director
M e d i c a l A s s i s t a n c e Program

2. Medical A s s i s t a n c e A d v i s o r y Cornnittee:

The a d v i s o r y c o m m i t t e e c o n s i s t s of e l e v e n members a p p o i n t e d by t h e Governor.

3. E x e c u t i v e O f f i c e r s of P u e r t o R i c o Medical and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical A s s o c i a t i o n :

G. T. Oiaz
Executive D i r e c t o r
P u e r t o R i c o Medical A s s o c i a t i o n
P. 0. Box 9387
S a n t u r c e 00908
Phone: 809/725-6969

B. Pharmaceutical Association:

Luz C e l e s t e R i v e r a
Executive Secretary
BOX 206, G.P.O.
San Juan 00936
Phone: 809/753-7157
 Rhode l s l a n d - 1
1983

RHODE ISLAND

r Y D l CAL ASSISTANCE DRUG P R O G W (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of B e n e f i t C a t e q o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*

OAA AB APTD AFDC OAA AB APTD AFDC Chi I d r e 6 2 1 (SFO)
Prescribed
Drugs X X X X X X X X X
l npat i e n t
H o s p i t a l Care X X X X X X X X X
O u t ~ aite n t
H o s p i t a l Care X X X X X X X X X
L a-b o r a t o r v &
X-ray S e r v i c e X X X X X X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X X X X X X
Physician
Services X X X X X X X X X
Dental
Services X X X X X X X X X
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s by f i s c a l y e a r e n d i n g

September 30, 1982
1981 1982
Expended R e c i p i e n t Expended Recipient

TOTAL ............................... $9,060,921

CATEGORICALLY NEEDY CASH TOTAL. ..... $4,502,699
Aged ................................ 787,237
B l i n d ............................... 21,738
D i s a b l e d . . .......................... 1,775,840
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 730,714
A d u l t s -Famil i e s w/Dep C h i l d r e n . .... 1,187,170

CATEGORICALLY NEEDY NON-CASH TOTAL.. $2,273,220

Aged ................................ 1,760,454
Blind. .............................. 8,965
Disabled ............................ 503,801
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 0
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . . . . 0
Other T i t l e X I X R e c i p i e n t s .......... 0

MEDl CALLY NEEDY TOTAL.. ............. $2,285,002

Aged ................................ 1,685,774
Blind ............................... 4,495
Disabled ............................ 512,475
C h i l d r e n -Famil i e s w/Dep C h i l d r e n . . . 29,220
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . . . . 15,734
Other T i t l e X I X R e c i p i e n t s .......... 37,304

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

299
 Rhode l s l and - 2
1983

I I I. A d m i n i s t r a t i o n :

S t a t e Department of S o c i a l and R e h a b i l i t a t i v e S e r v i c e s .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s :
DTC and c e r t a i n M e d i c i n e Chest Items and l n j e c t a b l e s :

P r i o r authorization i s required f o r a l l injectables (excluding

i n s u l i n and a d r e n a l i n ) , a p p e t i t e depressant drugs, c e n t r a l nervous
system s t i m u l a n t s , e x p e n s i v e v i t a m i n s , h e m a t i n i c s and l i p o t r o p i c
p r e p a r a t i o n s ( s e l l i n g f o r over $10 p e r 100 t a b l e t s / c a p s u l e s o r ~ i n t ) ,
e x p e n s i v e and/or new p r e p a r a t i o n s .

P r e s c r i b e d drugs r e q u i r i n g p r i o r a u t h o r i z a t i o n may be r e f i l l e d i f
r e q u e s t e d b y t h e a t t e n d i n g p h y s i c i a n and approved b y t h e D i v i s i o n o f
Medical Services.

0. Formulary: None

C. P r e s c r i b i n g or D i s p e n s i n g L i m i t a t i o n s :

1. Quantity o f Medication: One m o n t h ' s s u p p l y o f d r u g s

2. Maintenance M e d i c a t i o n : The a t t e n d i n g p h y s i c i a n may p r e s c r i b e

c e r t a i n maintenance drugs up t o a maximum o f 100 t a b l e t s , c a p s u l e s o r
p i n t of l i q u i d or a 30-days' s u p p l y of these d r u g s --
whichever i s
greater.

3. Refills: R e f i l l s t o a maximum o f f i v e a r e a l l o w e d f o r s p e c i f i e d
drugs: anti-hypertensives, d i u r e t i c s , anti-convulsants, coronary
v a s o d i l a t o r s , t r a n q u i l i z e r s , a n t i d e p r e s s a n t s , hormones, e t c .

R e f i l l s a r e n o t a l l o w e d f o r s p e c i f i e d drugs, e.g., antibiotics,

c e n t r a l nervous system s t i m u l a n t s , n a r c o t i c s ( S c h e d u l e I I , I I I ) ,
C o r t i c o s t e r o i d s and a p p e t i t e depressants, b e n z o d i a z e p i n e s .

4. Dollar Limits: None

D. P r e s c r i p t i o n Charge Formula:

1. P r e s c r i p t i o n Drugs Dispensed t o E l i q i b l e R e c i p i e n t s
Res i d i nq i n T h e i r Own H m e s

A P r o f e s s i o n a l Fee f o r S e r v i c e o f $3.10 w i l l be a l l o w e d f o r a l l
p r e s c r i p t i o n s i n a d d i t i o n t o t h e c o s t o f t h e drug.
 Rhode I s l a n d - 3
1983

P r e s c r i p t i o n Charge Formula ( c o n t i n u e d ) :

I n accordance w i t h f e d e r a l r e g u l a t i o n t h e upper l i m i t f o r payment f o r

p r e s c r i b e d d r u g s w i l l be based upon t h e u n i t c o s t o f t h e d r u g p l u s a
d i s p e n s i n g f e e o r t h e u s u a l and customary c h a r g e t o t h e g e n e r a l
p u b l i c , whichever i s lower.

Payment f o r o v e r - t h e - c o u n t e r drugs ( n o n - l e g e n d d r u g s ) wi l l be based

upon t h e l o w e r of e i t h e r t h e u n i t c o s t of t h e d r u g p l u s 50 p e r c e n t ,
t h e u s u a l and customary charge t o t h e g e n e r a l p u b l i c , o r t h e u n i t
c o s t p l u s t h e P r o f e s s i o n a l Fee f o r S e r v i c e .

P r e s c r i p t i o n Druqs Dispensed t o R e c i p i e n t s R e s i d i n q i n S k i l l e d
N u r s i n q o r I n t e r m e d i a t e Care F a c i l i t i e s :

A S p e c i a l P r o f e s s i o n a l Fee f o r S e r v i c e o f $2.60 w i l l be a l l o w e d f o r
these p r e s c r i p t i o n s i n a d d i t i o n t o t h e c o s t o f t h e drug t o t h e
pharmacist.

I n accordance w i t h f e d e r a l r e g u l a t i o n t h e upper l i m i t f o r payment f o r

p r e s c r i b e d d r u g s w i l l be based upon t h e u n i t c o s t o f t h e d r u g p l u s a
d i s p e n s i n g f e e o r t h e usual and customary c h a r g e t o t h e g e n e r a l
p u b l i c , whichever i s lower.

Payment f o r o v e r - t h e - c o u n t e r drugs ( n o n - l e g e n d d r u g s ) w i l l be based

upon t h e l o w e r of e i t h e r t h e u n i t c o s t o f t h e d r u g p l u s 50 p e r c e n t ,
t h e u s u a l and customary charge t o t h e g e n e r a l p u b l i c , o r t h e u n i t
c o s t p l u s t h e P r o f e s s i o n a l Fee f o r S e r v i c e .

The c o s t o f t h e drug t o t h e p h a r m a c i s t i n t h i s p r o f e s s i o n a l f e e - f o r -
s e r v i c e method o f payment w i l l b e based upon t h e AWP l i s t i n g s i n t h e
Red Book, p e r 100 t a b l e t s / c a p s u l e s o r p i n t of l i q u i d e x c e p t f o r
d i r e c t purchases from t h e f o l l o w i n g manufacturers:

Abbott-Ross Pfipharmics
Lederle P f izer-Roerig
Merck Sharp & Dohme Squ i bb
Parke-Davis & Co. Upjohn
Warner-Chilcott Wyeth

The q u a n t i t y of t h e d r u g d i s p e n s e d on t h e o r i g i n a l p r e s c r i p t i o n w o u l d
be d e t e r m i n e d on t h e b a s i s of a 30-day s u p p l y t o t h e p a t i e n t . A
maximum of 5 r e f i l l s i n a d d i t i o n t o t h e o r i g i n a l p r e s c r i p t i o n w i l l be
a l l o w e d when so i n d i c a t e d b y t h e p h y s i c i a n .

The a t t e n d i n g p h y s i c i a n may p r e s c r i b e c e r t a i n m a i n t e n a n c e d r u g s up t o
a maximum of 100 t a b l e t s , c a p s u l e s o r e q u i v a l e n t , o r a 30 d a y s '
s u p p l y of t h e s e d r u g s -- w h i c h e v e r i s g r e a t e r .
NPC Rhode I s l a n d - 4
1983

P r e s c r i p t i o n Charge Formula ( c o n t i n u e d ) :

The f o l l o w i n g c l a s s e s of drugs a r e c o n s i d e r e d as maintenance drugs:

a. Anti-diabetic preparations

b. Anticonvulsants

c. Antihypertensives

d. C a r d i o v a s c u l a r p r e p a r a t i o n s , namely:

(1) Anti-anginal
(2) D i g i t a l i s and t h e c a r d i a c g l y c o s i d e s

e. Diuretics

f. Hormones, including thyroid preparations

g. V i t a m i n s , h e m a t i n i c s and l i p o t r o p i c p r e p a r a t i o n s f o r w h i c h t h e
t o t a l c h a r g e t o t h e Medical A s s i s t a n c e Program does n o t exceed
$10 p e r p i n t of l i q u i d o r 100 t a b l e t s o r c a p s u l e s .

V. M i s c e l l a n e o u s Remarks:

Copayment - No

Number o f Rx c l a i m s processed i n FY 1982 - 1,088,372

Average Rx p r i c e d u r i n g FY 1982 - $8.92

 Rhode I s l a n d - 5
1983

Officials, C o n s u l t a n t s and C o m n i t t e e s

1. S o c i a l and R e h a b i l i t a t i v e S e r v i c e s Department O f f i c i a l s :

John J. A f f l e c k Department o f S o c i a l and

Director R e h a b i l i t a t i v e Services
600 New London Avenue
Cranston, Rhode I s l a n d 02920

Anthony B a r i l e , M.P.A.
Assistant Director
Medical Services

John A. P a g l i a r i n i , R.Ph.
C h i e f M e d i c a l Care S p e c i a l i s t

A l b e r t LaMarra, R.Ph.
M e d i c a l Care Program Pharmac i s t

Cosmo F r a n c h e t t i , R.Ph.
Senior Pharmacist

2. S o c i a l and R e h a b i l i t a t i v e S e r v i c e s Department A d v i s o r y Committees:

A. Medical A s s i s t a n c e Comnittees:

(1) M e d i c a l A d v i s o r y Committee on Pharmacy:

Dr. Heber W. Youngken, Jr., Chairman

Joan Abar, D.O. P e t e r Mathieu, M.D.

V i n c e n t A l i a n i e l l o , R.Ph. Joseph Navach, R.Ph.
W a l t e r Carnevale, R.Ph. Hon. Anthony Soloman,
John DeFeo, Ph.0. State Treasurer
John DePasquale, R.Ph. I r a W e l l i n s , R.Ph.
Joseph G a l i n a R i c h a r d Yacino, R.Ph.
L o u i s J e f f r e y , R.Ph.

(2) Rhode l s l a n d P h a r m a c e u t i c a l A s s o c i a t i o n :

D a v i d P. Feeney, R.Ph., President

NPC
Rhode l s l a n d - 6
1983

3. E x e c u t i v e O f f i c e r s of S t a t e Medical and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical Society:

Norman A. B a x t e r , Ph.D.
Executive D i r e c t o r
Rhode l s l a n d Medical S o c i e t y
106 F r a n c i s S t r e e t
P r o v i d e n c e 02903
Phone: 401/331-3207

B. Pharmaceutical Association:

Judge J. S. Gendron (R.Ph.)

Executive D i r e c t o r
Rhode l s l a n d P h a r m a c e u t i c a l A s s o c i a t i o n
23 Broad S t r e e t
Pawtucket 02860
Phone: 401/725-4141

C. Osteopathic Association:

Reuben L. Alexander, 0.0.

Secretary
Rhode l s l a n d O s t e o p a t h i c P h y s i c i a n s
and Surgeons
849 Post Road
Warwick 02888
Phone: 401/781-3940
 South C a r o l i na - 1
1983
SOUTH CAROLINA

FEDICAL ASSISTANCE DRUG PROGRAM (TITLE X I X )

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFOC Chi l d r e n < 2 1 (SFO)

Prescribed
Druqs X X X X X
lnpat i e n t
H o s p i t a l Care X X X X X
Outpatient
H o s p i t a l Care X X X X X
Laboratory &
X-ray S e r v i c e X X X X X
S k i l l e d fiursing
Home S e r v i c e s X X X X X
Physician
Services X X X X X
D-e n-t-a l
Services X X X X X
Other B e n e f i t s : Home H e a l t h S e r v i c e s , R u r a l H e a l t h C l i n i c S e r v i c e s , M e d i c a l
Transportation, P o d i a t r i s t Services, Optometrists Services, C h i r o p r a c t i c Services,
D u r a b l e M e d i c a l Equipment, I n t e r m e d i a t e Care F a c i l i t i e s S e r v i c e s .
+SF0 - S t a t e Funds O n l y

ll. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

June 30, 1982
1981 1982
~ x ~ e n d e dR- e c i p i e n t ~ x ~ e n d e d -R e c i p i e n t

TOTAL ............................... $21,756,962 191,196** $16,866,105 168,535**

CATEGORICALLY NEEDY CASH TOTAL.. .... $17,301,439 167,531 $14,797,469 155,278

Aged ................................ 6,645,962 34,844 5,458,698 31,679
B l i n d ............................... 241,933 1,269 194,291 1,178
Disabled.. .......................... 7,953,788 39,434 6,794,679 37,552
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n . . . 726,827 51,792 713,519 47,114
A d u l t s -Famil i e s w/Oep Chi I d r e n . . ... 1,732,929 40,192 1,636,282 37,755
CATEGORICALLY NEEDY NON-CASH TOTAL.. $4,455,523
Aged ................................ 2,745,558
Blind ............................... 13,389
Disabled..... ....................... 637,362
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 339,688
A d u l t s - F a m i l i e s w/Oep C h i l d r e n ..... 716,046
..........
O t h e r T i t l e XIX R e c i p i e n t s 3,480
MEDICALLY NEEDY TOTAL.. ............. $0
Aged ................................ 0
B l i n d ............................... 0
D i s a b l e d ............................ 0
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n ... 0
A d u l t s - F a m i l i e s w/Dep C h i l d r e n ..... 0
Other T i t l e X I X R e c i p i e n t s .......... 0

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

305
NPC South C a r o l i n a - 2
1983

I I I. A d m i n i s t r a t i o n :

South C a r o l i n a Department o f S o c i a l S e r v i c e s .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. Exclusions:

P r i o r a u t h o r i z a t i o n i s r e q u i r e d f o r legend d r u g s n o t l i s t e d i n t h e
s t a t e ' s M e d i c a i d F o r m u l a r y , as w e l l as decongestant - a n t i h i s t a m i n e
c o m b i n a t i o n s , muscle r e l a x a n t s , p s y c o t h e r a p e u t i c drugs, c i r c u l a t o r y
s t i m u l a n t s , p e r i p h e r a l v a s o d i a l a t o r s , a n o r e c t i c s , f o o d supplements,
v i t a m i n s , a n a l g e s t i c s and m i n o r t r a n q u i l i z e r s . OTC i t e m s a r e l i m i t e d
t o i n s u l i n , a n a l g e s i c s and m i n o r t r a n q u i l i z e r s , OTC i t e m s a r e l i m i t e d
t o i n s u l i n , i n s u l i n s y r i n g e s , and f a m i l y p l a n n i n g d r u g s and s u p p l i e s .

B. Formulary:

A c l o s e d - e n d f o r m u l a r y i s u t i l i z e d w i t h d r u g code, s t r e n g t h , and
dispensing u n i t . For d r u g s n o t on t h e f o r m u l a r y , s p e c i a l a u t h o r i z a t i o n
on i n d i v i d u a l b a s i s when r e q u e s t e d by a t t e n d i n g p h y s i c i a n w i t h m e d i c a l
justification.

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

Q u a n t i t y of Medication:

I n acute c o n d i t i o n s , p h y s i c i a n requested t o l i m i t supply t o a

minimum o f t e n ( 1 0 ) days. I n c h r o n i c c o n d i t i o n s and f o r
maintenance drugs, a n i n e t y ( 9 0 ) days s u p p l y i s a l l o w e d and
encouraged.

Refills:

The p r e s c r i b e r a u t h o r i z e s t h e number of r e f i l l s .

Dollar Limits: None

R e c i p i e n t s a r e l i m i t e d t o t h r e e ( 3 ) p r e s c r i p t i o n s p e r month.

D. P r e s c r i p t i o n Charge Formula:

M e d i c a i d reimbursement f o r pharmacy s e r v i c e s w i l l b e based o n t h e lower

of: t h e South C a r o l i n a E s t i m a t e d A c q u i s i t i o n Cost (SCEAC); f e d e r a l
maximum a l l o w a b l e c o s t (MAC) o r s t a t e maximum a l l o w a b l e c o s t (SMAC) as
e s t a b l i s h e d by t h e Department o f S o c i a l S e r v i c e s ; t h e p r o v i d e r ' s
s u b m i t t e d u s u a l and customary charge.

Dispensing fee i s $ 3 . 0 3 .
 South C a r o l i n a - 3
1983

P r e s c r i p t i o n Charge Formula ( c o n t i n u e d ) :

Copayment - P r o v i d e r s a r e a u t h o r i z e d t o c o l l e c t a CO-PAY of f i f t y c e n t s
($0.50) p e r p r e s c r i p t i o n f r o m t h e c l i e n t , e x c e p t f o r c l i e n t s i n l o n g t e r m
c a r e f a c i l i t i e s , f a m i l y p l a n n i n g , EPSDT, and pregnancy r e l a t e d
prescriptions.

V. M i s c e l l a n e o u s Remarks:

I t i s r e q u i r e d t h a t each r e c i p i e n t choose one pharmacy f o r a month.

R e v i s i o n s i n t h e f o r m u l a r y w i l l occur p e r i o d i c a l l y w i t h no d e s i g n a t e d t i m e
element. The Drug F o r m u l a r y Committee, composed of members a p p o i n t e d by t h e
South C a r o l i n a Board o f S o c i a l S e r v i c e s upon recommendations s u b m i t t e d b y
a p p r o p r i a t e p r o f e s s i o n a l m e d i c a l and p h a r m a c e u t i c a l a s s o c i a t i o n s , i s
r e s p o n s i b l e f o r any r e v i s i o n s .
NPC South C a r o l i n a - 4
1983

O f f i c i a l , C o n s u l t a n t s and Committees

1. S o c i a l S e r v i c e s Department O f f i c i a l s :

John A. Crosscope, J r . Department o f S o c i a l

I n t e r i m Commissioner Services
P. 0. Box 1520
Columbia, South C a r o l i n a 29202

J. Kenneth Shealy
E x e c u t i v e Manager,
O f f i c e o f Management

Raymond G. H a l f o r d
Deputy A t t o r n e y General,
O f f i c e o f t h e General Counsel

P a u l H. Bjorkman
E x e c u t i v e Manager,
O f f i c e of Systems and I n f o r m a t i o n

John P. Soloman
E x e c u t i v e Manager,
O f f i c e o f Program O p e r a t i o n s

Robert D. F l o y d
E x e c u t i v e Manager,
O f f i c e of S u p p o r t S e r v i c e s

John D. M i d d l e b r o o k
Comptroller

Thomas E. Brown, J r .
Director,
O f f i c e of Community Long Term Care

2. S o c i a l S e r v i c e s Department C o n s u l t a n t s :

A. Physicians (Part-time):

B e r n a r d Frank, O.D. Columbia

James C . B e a l l , D.D.S. Charleston

Paul Hopkins, M.O. Columbia

B. Pharmacists ( P a r t - t i m e ) :

P o s i t i o n Vacant (August 1983)

NPC South C a r o l i n a - 5
1983

3. M e d i c a l Care A d v i s o r y Committee t o T i t l e X I X :

O ~ q a n i z aito n Member

Commissioner, S.C. Department Robert Jackson, M.D.

o f H e a l t h and E n v i r o n m e n t a l Conunissioner
Control S.C. Department o f H e a l t h and
Environmental Control
2600 B u l l S t r e e t
J. M a r i o n Sims B u i l d i n g
Columbia 29201

S.C. Department of Mental M r . W i l l i a m B. F l o y d

Health Deputy Commissioner
D i v i s i o n o f F i n a n c i a l Services
Department o f M e n t a l H e a l t h
2414 B u l l S t r e e t
Columbia 29201

S.C. Department o f M e n t a l M r . James M. K i r b y

Retardat i o n S.C. Dept. o f
Mental R e t a r d a t i o n
P. 0. Box 4706
Columbia 29240

S.C. Department of V o c a t i o n a l M r . P e t e Howel 1

Rehabilitation Program S p e c i a l i s t
Vocational R e h a b i l i t a t i o n
Department
301 Landmark Center
P. 0. Box 4945
Columbia 29240

S.C. Human A f f a i r s Commission M r . John D. R. Jones

S t a t e Human A f f a i r s Commission
P. 0. Box 11300
Columbia 29211

S.C. Commission on A g i n g M r . J i m Dubs

Deputy D i r e c t o r
S.C. Commission on A g i n g
915 Main S t r e e t
Columbia 29201

R e p r e s e n t a t i v e o f H e a l t h Care Representative Parker E v a t t

P l a n n i n g O v e r s i g h t Committee H e a l t h Care P l a n n i n a
< &

O v e r s i g h t Committee
S u i t e 107
Blatt Building
Col umbia 29201
 South Carolina -6
1983

Medical Care Advisory Committee to Title X I X (continued):

Practicing Physician Gerald Anthony Wilson, M.D.

Midlands Surgical Association
2226 Hampton Street
Columbia 29204

Practicing Physician John H. Cathcart, Jr., M.O.

P.O. Box 130
Gaffney 29340

Practicing Dentist Richard M. Sasnett, O.D.S.

3518 Medical Drive
Columbia 29203

Practicing Pharmacist W. Carroll Watkins, P.D.

Florence Pharmacy
123 S. Dargan Street
Florence 2950 1

Practicing Optometrist Dr. Wayne Cannon

3519 Medical Drive
Columbia 29203

Practicing Pediatrician 0. Martin Burton, M.D.

Fant at Calhoun
Anderson 29621

Hospital Administrator Mr. W. H. Hudson,

Administrator
Oconee Memorial Hospital
P. 0. Box 857
Seneca 29678

Nursing Home Administrator Mr. Harry Branton

Administrator
Dundee Nursing Home
401 By Pass
Bennettsville 29412

Representative from Civil Mrs. Alberta Rowe

Rights Organization 1506 Holrnes Street
West Columbia 29169

Home Health Agency Edith A. Smith, R.N., M.P.H.

Representative OHEC
Bureau of Home Health
Services
2600 Bull Street
Col umb i a 2920 1
NP C South C a r o l i n a - 7
1983

M e d i c a l Care A d v i s o r y Committee t o T i t l e XIX ( c o n t i n u e d ) :

Consumer Ms. A d d i e L o u i s e S t o r y
6814 W a k e f i e l d Road
Columbia 29203

M r . M i k e Caughman
206 F i e l d s Lane
L e x i n g t o n 29072

Consumer Mrs. Josephine C r a f t

4412 Ryan S t r e e t
Columbia 29203

Consumer M r . R o b e r t Jackson
Route 2, Box 65
B l a i r 29015

Consumer R e p r e s e n t a t i v e M r . Roy C. Harms

Deputy A d m i n i s t r a t o r
S.C. Department o f Consumer
Affairs
P.O. Box 5757
2221 Devine S t r e e t
Columbia 29250

Practicing Podiatrist Edward W. Warcholak, D.P.M.

6961 S t . Andrews Road
Columbia 29210

S t a t e N u r s i n g Home Ombudsman W i l l i a m V. B r a d l e y , NHA

(Governor's O f f ice) S t a t e Ombudsman
S t a t e o f South C a r o l i n a
O f f i c e o f t h e Governor
Edgar A. Brown B u i l d i n g
1205 P e n d l e t o n S t r e e t
Columbia 29201

4. E x e c u t i v e O f f i c e r s of S t a t e M e d i c a l and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical Association:

J. C. Johnson
Executive Vice President
South C a r o l i n a M e d i c a l A s s o c i a t i o n
3325 Medical P a r k Road
Columbia 29211
Phone: 803/242-6311
NPC South C a r o l i n a -8
1983

E x e c u t i v e O f f i c e r s o f S t a t e Medical and Pharmaceutical

Societies (continued):

Pharmaceutical Association:

Sharon Fennel l
Executive Director
South C a r o l i n a Pharmaceutical Association
2026 Assembley S t r e e t , S u i t e 200
Columbia 29201
Phone: 803/254-1065

Osteopathic Association:

J . W. N i c h o l s , D . O .
Secretary-Treasurer
South C a r o l i n a Osteopathic Association
3321 Medical Park Road
S u i t e 401
Columbia 29203
Phone: 803/252-3301
 South D a k o t a - 1
1983
SOUTH DAKOTA

E D I C A L ASSISTANCE DRUG P R O W (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*

OAA AB APTD AFDC OAA AB APTD AFDC Chi l d r e n < 2 1 (SFO)
Prescribed Renal
Drugs X X X X Disease
lnpatient Renal
H o s p i t a l Care X X X X Disease
Outpatient Renal
H o s p i t a l Care X X X X Disease
Laboratory & Renal
X-ray S e r v i c e X X X X Disease
S k i l l e d Nursing
Home S e r v i c e s X X X X
Physician Renal
Services X X X X Disease
Dental
Services X X X X X X X X X
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payments t o P h a r m a c i s t s b y f i s c a l .year e n d i n g

September 30, 1982
1981 1982
Expended Recipient Expended Recipient

TOTAL.. ............................. $2,177,466

CATEGDRI CALLY NEEDY CASH TOTAL.. .... $1,133,961
Aged ................................ 459,500
B l i n d ............................... 10,271
D i s a b l e d . . .......................... 442,790
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 94,610
A d u l t s - F a m i l i e s w/Dep Children..... 126,790
CATEGORICALLY NEEDY NON-CASH TOTAL.. $1,043,505
Aged..
Blind......
...............................
........................ 923,756
1,404
Disabled.. .......................... 90,274
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 6,446
A d u l t s - F a m i l i e s w/Dep C h i l d r e n ..... 11,028
Other T i t l e X I X R e c i p i e n t s .......... 10,597
MEDICALLY NEEDY TOTAL.. ..... ........ $0
Aged ................................ 0
Blind...... ......................... 0
Disabled.. .......................... 0
C h i l d r e n -Famil i e s w/Dep C h i l d r e n . .. 0
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . ... 0
Other T i t l e XIX R e c i p i e n t s .......... 0

**Undupl i c a t e d T o t a l - HHS r e p o r t HCFA - 2082

31 3
 S o u t h Dakota - 2
1983

Ill. Administration:

S t a t e Department o f S o c i a l S e r v i c e s , O f f i c e o f M e d i c a l S e r v i c e s .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. Exclusions: The program i s l i m i t e d t o l e g e n d p r e s c r i p t i o n drugs as

s p e c i f i e d i n t h e s t a t e ' s M e d i c a i d r e g u l a t i o n s , and t o i n s u l i n .

B. Formulary: None (See V.A)

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Quantity: Maintenance drugs r e q u i r i n g more t h a n one dose p e r day

must be d i s p e n s e d i n u n i t s of a t l e a s t 100 o r a 30 day s u p p l y , i f
more t h a n 100 u n i t a r e r e q u i r e d p e r month. Maintenance p r e s c r i p t i o n s
f o r f a m i l y p l a n n i n g i t e m s must be d i s p e n s e d i n a t l e a s t a 3 month
supply. (New f a m i l y p l a n n i n g p r e s c r i p t i o n s c a n b e i n s m a l l e r u n i t s . )

2. Refills: R e f i l l s of maintenance d r u g s c o s t i n g l e s s t h a n $4.25 per

100 a r e l i m i t e d t o t h e g r e a t e r o f 100 o r a 30 day s u p p l y .

3. Dollar limits: None.

0. P r e s c r i p t i o n charge formula: Payment i s t h e l o w e r o f : ( a ) MAC p l u s

d i s p e n s i n g f e e of $3.00, ( b ) EAC p l u s d i s p e n s i n g f e e o f $3.00, o r u s u a l
and customary charge t o t h e g e n e r a l p u b l i c .

V. Miscellaneous

A. A d m i n i s t r a t i v e Rule, adopted J u l y 1, 1983 s t a t e s :

" C e r t a i n d r u g payments l i m i t e d t o g e n e r i c d r u g form. Payment f o r t h e

b r a n d name drugs s h a l l b e l i m i t e d t o t h e g e n e r i c d r u g f o r m , u n l e s s t h e
p r e s c r i b e r i n d i c a t e s i n w r i t i n g on t h e p r e s c r i p t i o n a m e d i c a l r e a s o n why
t h e g e n e r i c drug may n o t be used. I f t h e p r e s c r i p t i o n i s an o r a l o r c a l l -
back p r e s c r i p t i o n , t h e p h a r m a c i s t may document t h e p r e s c r i b e r ' s r e a s o n f o r
r e q u i r i n g t h e b r a n d name drug." ( 9 6 d r u g s and d r u g dosage forms a r e
affected)

B. A d m i n i s t r a t i v e Rule, adopted J u l y 1, 1983 s t a t e s :

"Cost s h a r i n g f o r p r e s c r i p t i o n s i s $1.00 f o r each p r e s c r i p t i o n and $1.00

f o r each p r e s c r i p t i o n r e f i l l e d . " (Exemptions i n c l u d e p a t i e n t s under 18
y e a r s , r e s i d e n t s of home o r comnunity-based s e r v i c e s , s e r v i c e s r e l a t e d t o
pregnancy, f a m i l y p l a n n i n g and emergency h o s p i t a l s e r v i c e s . )

C. Number o f c l a i m s p r o c e s s e d i n FY 1982 - 286,130

0. Average Rx p r i c e d u r i n g FY 1982 - $9.94

 South Dakota - 3
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. James E l Ienbecker Department o f S o c i a l S e r v i c e s

Secretary P i e r r e , S o u t h Dakota 57501
Department of S o c i a l S e r v i c e s

E r v i n Schumacher
Program A d m i n i s t r a t o r
Medical Services

Donald Mahannah, R.Ph.

Pharmacist Consultant
Medical Services
605/773-3495

2. Medical A d v i s o r y Committee (MAC):

L l o y d Jones, P h a r m a c i s t
Jones Drug
609 S i x t h Avenue
Aberdeen 57401

Paul I . Engbrecht, N u r s i n g Home A d m i n i s t r a t o r

Administrator
The T i e s z e n Memorial Home
437 S t a t e S t r e e t
M a r i o n 57043

Dennis Johnson, M.D., Physician

1301 South N i n t h , #700
S i o u x F a l l s 57105

Glenn W. Robeson, D.D., Optometrist

34 T h i r d S t r e e t , SE
Huron 57350

James D. M. R u s s e l l , H o s p i t a l A d m i n i s t r a t o r
Administrator
S t . Mary's H o s p i t a l
P i e r r e 57501

A l v i n A. B u e c h l e r , DDS, D e n t i s t
Box L
Get t y s b u r g 57442
 South Dakota -4
1983

3. E x e c u t i v e O f f i c e r s o f S t a t e Medical and Pharmaceutical S o c i e t i e s :

A. Medical A s s o c i a t i o n :

R o b e r t D. Johnson
Executive Secretary
S o u t h Dakota S t a t e M e d i c a l A s s o c i a t i o n
608 West Avenue N o r t h
S i o u x F a l l s 57104
605/336-1965

B. Pharmaceutical A s s o c i a t i o n :

H a r o l d H. Schuler
Secretary
South Dakota Pharmaceut i c a l A s s o c i a t i o n
222 E a s t C a p i t o l
(Box 518)
P i e r r e 57501
605/224-2338

C. Osteopathic Association:

G. Thompson, D.O.
Secretary-Treasurer
South Dakota S o c i e t y o f O s t e o p a t h i c
P h y s i c i a n s & Surgeons
C/O C l i n i c
Gregory 57533
605/835-9611
 Tennessee 1-
1983
TENNESSEE

K D l U L ASSISTANCE DRUG PROGRAM (TITLE XIX)

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l ly Needy (MN) Other*
OAA AB APTD AFOC OAA AB APT0 AFOC Chi l d r e n < 2 1 (SFO)
Prescribed
Druqs X X X X **
*?c ** **
lnpat i ent
~ o ; ~t ai l Care X X X X *1 ** ** **.
Outpatient
H o s p i t a l Care X X X X **
)i* ** **
Laboratory &
X-ray S e r v i c e X X X X ** ** *I ;c*
S k i l l e d Nursing
Home S e r v i c e s X X X X ** ** fi* NO
Physician
Services X X X X ** ** ?A **
Dental
Services Covered o n l y i f EPSDT o r under 21
Other B e n e f i t s : Home h e a l t h s e r v i c e s ; community h e a l t h c l i n i c s ; i n t e r m e d i a t e h e a l t h
care f a c i l i t i e s ; family planning services, r u r e l h e a l t h c l i n i c k ; e a r l y p e r i o d i c
s c r e e n i n g and t r e a t m e n t (EPSD&T)
*SF0 - S t a t e Funds O n l y
::*Caretaker over 21

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982
1981 1982
Expended R e c i p i e n t Expended Recipient

TOTAL.. ............................. $44,003,286 272,418*** $48,240,804 271,519***

CATEGORICALLY NEEDY CASH TOTAL...... $34,450,368 231,361 $37,767,938 230,598

Aged.. .............................. $12,827,217 53,601 14,062,478 53,424
Blind ............................... 307,272 1,547 336,862 1,542
Disabled ............................ 15,790,652 60,244 17,311,292 60,045
C h i l d r e n - F a m i l i e s w/Dep Children... 2,301,570 77,954 2,523,211 77,697
A d u l t s - F a m i l i e s w/Oep Children..... 3,223,657 38,015 3,534,095 37,890

CATEGORICALLY NEEDY NON-CASH TOTAL.. $883,494 10,840 $968,575 10,804

Aged ................................ 171,861 409 188,411 408
Blind......... ...................... 427,289 2,287 468,437 2,279
Disabled ............................ 29,788 50 32,657 50
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n . . . 133,128 5,358 145,948 5,340
A d u l t s - F a m i l i e s w/Dep Children..... 121,428 2,736 133,122 2,727
..........
Other T i t l e X I X R e c i p i e n t s 0 0 0 0

ME01 CALLY NEEDY TOTAL.. ............. $8,669,424 30,217 $9,504,291 30,117

Aged ................................ 6,849,860 17,872 7,509,502 17,813
Blind...... ......................... 3,610 24 3,958 24
Disabled ............................ 1,468,065 6,206 1,609,440 6,186
...
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n 114,133 3,670 125,124 3,658
A d u l t s - F a m i l i e s w/Dep Children..... 233,075 2,436 255,520 2,428
Other T i t l e XIX R e c i p i e n t s .......... 68 1 9 747 9
.
La,
.
---Unduplicated T o t a l - HHS r e p o r t HCFA - 2082
31 7
 Tennessee - 2
1983

I l l . Administration:

Tennessee Department o f P u b l i c H e a l t h .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s : OTC drugs ( e x c e p t i n s u l i n ) , a n o r e t i c drugs ( e x c e p t

f o r amphetamines and d e r i v a t i v e s f o r o n l y s p e c i f i c i n d i c a t i o n s of
n a r c o l e p s y and t h e h y p e r k i n e t i c c h i l d ) .

B. Formulary: "Tennessee M e d i c a i d Drug Formulary", Closed/Restricted

Formulary. For i n f o r m a t i o n c o n t a c t :

M a r i l y n 8 . Ekstam, D.Ph.
D i r e c t o r o f Pharmacy S e r v i c e s
Medicaid A d m i n i s t r a t i o n
283 P l u s P a r k B o u l e v a r d
N a s h v i l l e , Tennessee 37217
615/361-6705

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Terminology: May p r e s c r i b e and d i s p e n s e b r a n d name d r u g s b u t

encourage usage o f g e n e r i c drugs f o r p o t e n t i a l c o s t s a v i n g s .

2. Q u a n t i t y o f Medication:

a. One m o n t h ' s supply.

b. L i m i t o f 7 p r e s c r i p t i o n and/or r e f i l l s p e r month.

3. Refills: Covered o n l y i f s p e c i f i c a l l y a u t h o r i z e d by t h e
p r e s c r i b i n g p h y s i c i a n on t h e o r i g i n a l p r e s c r i p t i o n . F i v e r e f i l l s
w i t h i n 6 months.

4. Dollar Limits: None.

5. MAC (Maximum A l l o w a b l e C o s t ) d r u g s i n a d d i t i o n t o f e d e r a l M A C
drugs. Approved M a n u f a c t u r e r ' s L i s t e s t a b l i s h e d based upon
b i o e q u i v a l ence.

D. P r e s c r i p t i o n Charge Formula: A c q u i s i t i o n c o s t p l u s p r o f e s s i o n a l f e e of
$3.25 maximum, o r u s u a l and customary -
whichever i s lower ( e f f e c t i v e
7/1/82).
 Tennessee - 5
1983

M e d i c a i d M e d i c a l Care A d v i s o r y Committee ( c o n t i n u e d ) :

Hays M i t c h e l l , M.O. Physician (Rural)

B r a d l e y M e d i c a l Center
C l e v e l a n d , TN 37311
(472-6551)

David L i l l a r d Pharmacist
L i l l a r d ' s Pharmacy
81 N o r t h T i l lman S t r e e t
Memphis, TN 38111

B i l l McCaskel l Administrator
Trevecca H e a l t h Care Center
329 Murf r e e s b o r o Road
N a s h v i l l e , TN 37210
(244-6900)

Imogene Kaserman, R.N. Nurse

Lakeshore Mental H e a l t h
5908 Lyons View D r i v e
K n o x v i l l e , TN 38301
(584-1561)

B e t t y J. Thompson Nurse
F a m i l y Nurse C l i n i c a n
M e t r o H e a l t h Department
East S t a t i o n
1015 E. T r i n i t y Lane
N a s h v i l l e , TN 37216
(227-8140)

J e r r e Hale, O.O.S. Dentist

300 B r y a n t S t .
S m i t h v i l l e , TN 37166
(597-4737)

Thomas L. Adams Consumer

R e t a i l C l e r k s Union,
L o c a l 1557
203 N o r t h 1 1 t h S t r e e t
N a s h v i l l e , TN 37206

E l i z a b e t h Marbury Consumer ( M e d i c a i d
2300 W i l s o n S t r e e t recipient)
Apt. 6-A
Chattanooga, TN 37406
(629-0765)
 Tennessee -4
1983

O f f i c i a l s , C o n s u l t a n t s and Cornnittees

1. H e a l t h Department:

A. Officials:

James E . Word, M.P.H. Tennessee Department o f

Comnissioner H e a l t h and Environment
344 C o r d e l l H u l l B u i l d i n g
Nashvi l l e , Tennessee 37219

M a r i l y n 6. Ekstam, D.Ph. Medicaid A d m i n i s t r a t i o n

D i r e c t o r o f Pharmacy 283 P l u s Park B o u l e v a r d
Services N a s h v i l l e 37217
615/361-6705

Sandra J. D a n i e l
Director

B i l l y W. H u f f i n e s
D i r e c t o r , D i v i s i o n of
Medical A s s i s t a n c e -
Medicaid

Peggy A. Alsup, M.D.,

Bureau Medical
D i rector

B. M e d i c a i d M e d i c a l Care A d v i s o r y Committee:

F i f t e e n members a p p o i n t e d by t h e Governor f o r t h r e e - y e a r terms ( e x c e p t

i n i t i a l appointments). One member s h a l l be t h e Commissioner of t h e
Department o f Human S e r v i c e s ; seven members s h a l l be r e p r e s e n t a t i v e s o f
consumer groups and o r g a n i z a t i o n s ( i n c l u d i n g M e d i c a i d r e c i p i e n t s , l a b o r
unions, HMO's, e t c . ) ; and seven members s h a l l be M e d i c a i d p r o v i d e r s
(one p h y s i c i a n from a r u r a l area, one p h y s i c i a n f r o m an u r b a n area, one
nurse, one d e n t i s t , one p h a r m a c i s t , one n u r s i n g home a d m i n i s t r a t o r , and
one h o s p i t a l a d m i n i s t r a t o r ) .

MEMBERS REPRESENTATION

Edward W. Reed, M.O. Chrmn. P h y s i c i a n (Urban)

975 Thomas S t r e e t
Memphis, TN 38107
(527-4484)

Sammie Lynn P u e t t Commissioner

11 1 Seventh Avenue, N o r t h Tennessee Department o f
N a s h v i l l e , TN 37203 Human S e r v i c e s
(741-3241)
 Tennessee - 5
1983

M e d i c a i d M e d i c a l Care A d v i s r y Committee ( c o n t i n u e d ) :

Hays M i t c h e l l , M.D. Physician (Rural)

B r a d l e y M e d i c a l Center
C l e v e l a n d , TN 37311
(472-6551 )

David L i l l a r d Pharmacist
L i l l a r d ' s Pharmacy
81 N o r t h T i l l m a n S t r e e t
Memphis, TN 38111

B i l l McCaskell Administrator
T r e v e c c a H e a l t h Care Center
329 M u r f r e e s b o r o Road
N a s h v i l l e , TN 37210
(244-6900)

Imogene Kaserman, R.N. Nurse

Lakeshore M e n t a l H e a l t h
5908 Lyons V i e w D r i v e
K n o x v i l l e , TN 38301
(584-1561)

B e t t y J. Thompson Nurse
F a m i l y Nurse C l i n i c a n
M e t r o H e a l t h Department
East Station
1015 E. T r i n i t v Lane

J e r r e Hale, D.D.S. Dentist

300 B r y a n t S t .
S m i t h v i l l e , TN 37166
(597-4737)

Thomas L. Adams Consumer

R e t a i l C l e r k s Union,
L o c a l 1557
203 N o r t h 1 1 t h S t r e e t
N a s h v i l l e , TN 37206

E l i z a b e t h Marbury Consumer ( M e d i c a i d
2300 W i l s o n S t r e e t recipient)
Apt. 6-A
Chattanooga, TN 37406
(629-0765)
 Tennessee - 6
1983

M e d i c a i d Medical Care A d v i s o r y Comni t t e e ( c o n t i n u e d ) :

B e t t y R. Tenpenoy Consumer R e p r e s e n t a t i v e
1007 West Parkway
K n o x v i l l e , TN 37912

John G. Green
1015 M i t c h e l l
Cookevi l l e , TN 38501

John L. Brown Consumer

Director, Benefits (HMO R e p r e s e n t a t i v e )
N o r t h e r n Telecom, I n c .
259 Cumberland Bend
Metro Center
N a s h v i l l e , TN 37228
(256-5900)

John Watson Consumer

U n i t e d Way o f G r e a t e r (Labor Represen t a t i v e )
Memph i s
3489 P o p l a r Ave.
Su i t e One
Memphis, TN 38111

2. M e d i c a i d Formulary A d v i s o r y Comnittee:

E i g h t members a p p o i n t e d by t h e Commissioner f o r t h r e e - y e a r terms ( i n i t i a l

terms w i l l be s t a g g e r e d ) . F i v e members w i l l be p h a r m a c i s t s . Each
~ h a r m a c i s tmember w i l l be s e l e c t e d f r o m n o m i n a t i o n s s u b m i t t e d bv t h e
Tennessee P h a r m a c e u t i c a l A s s o c i a t i o n . Three members w i l l be p h y s i c i a n s .
Each p h y s i c i a n member w i l l be s e l e c t e d from n o m i n a t i o n s s u b m i t t e d by t h e
Tennessee Medical A s s o c i a t i o n . Members s h o u l d be f a m i l i a r w i t h t h e M e d i c a i d
program - preferably e n r o l l e d providers.

MEMBERS OCCUPATION

H o r t o n Jones Community P h a r m a c i s t
Jones Pharmacy
1 4 t h and Buchanan S t r e e t
N a s h v i l l e , TN 37208

T e r r y B r i m e r , Pharm.D. C l i n i c a l and l n s t i t u t i o n a l
D o c t o r ' s H o s p i t a l Pharmacy Pharmacist
726 McFarland Avenue
M o r r i s t o w n , TN 37813

J a n i e Robbins, D.Ph. I n s t i t u t i o n a l Pharmacist

H a m i l t o n County N u r s i n g Home
2626 Walker Road
Chattanooga, TN 37421
NPC Tennessee - 7
1983

M e d i c a i d F o r m u l a r y A d v i s o r y Connni t t e e ( c o n t i n u e d ) :

Ray Marcrom, Pharm.D. Community P h a r m a c i s t

Marcrom's Pharmacy
1277 McArthur S t r e e t
Manchester, TN 37355

E a r l M a r s h a l l , D.Ph. Community P h a r m a c i s t
Hollywood Pharmacy Mart, Inc.
903 Hollywood
Jackson, TN 38301

Stephen S c h i l l i g , M.D. Physician

M e t r o p o l i t a n Board o f H o s p i t a l s M i d d l e TN
72 Hermitage Avenue
Nashvi I l e , TN 37210

C h a r l e s W. White, M.D. Physician

14 H o s p i t a l D r i v e West TN
L e x i n g t o n , TN 38351

C e c i l E. R u s s e l l , Jr., M.D. Physician

Route 5, Emory Road
Powe 11, TN 37849

3. E x e c u t i v e O f f i c e r s of S t a t e Medical and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical A s s o c i a t i o n : 8. Pharmaceutical Association:

L. H. W i l l i a m Tom C. Sharp, J r .
Executive D i r e c t o r Executive Secretary
TN Medical A s s o c i a t i o n TN P h a r m a c e u t i c a l Assoc.
112 L o u i s e Avenue 226 C a p i t o l Blvd.,
N a s h v i l l e 37203 S u i t e 308
Phone: 615/327-1451 N a s h v i l l e 37219
Phone: 615/256-3023

C. Osteopathic Association:

P. G . Smith, D.O.
Secretary-Treasurer
Tennessee O s t e o p a t h i c Medical A s s o c i a t i o n
Box 390
P i k e v i l l e 37367
6 15/447-2606
 lexas 1-
1983

TEXAS

E D I C A L ATSISTANCE DRUG PRDGRAn (TITLE X I X )

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e q o r i c a l l y Needy M e d i c a l ly Needy (MN) Other*

OAA AB APTD AFDC OAA AB APTD AFDC C h i l d r e n t 2 1 (SFO)
Prescribed

l n p a t ie n t
H o s p i t a l Care X X X X
Outoatient
H o s p i t a l Care X X X X
Laboratorv &
X-ray S e r v i c e X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X
Physician
Services X X X X
Dental
Services X X X
O t h e r B e n e f i t s : Eye r e f r a c t i o n s , p r o s t h e t i c l e n s ; home h e a l t h s e r v i c e s ; ambulance,
c h i r o p r a c t o r ; p o d i a t r i s t ; eye g l a s s e s ; h e a r i n g a i d s .
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s by f i s c a l y e a r e n d i n g

Auqust 31, 1982
1981 1982
Expended R e c i p i e n t Expended Recipient

TOTAL ............................... $74,124,421 565,757'"

CATEGORICALLY NEEDY CASH TOTAL. ..... $54,441,647 493,464
Aged ................................ 29,720,464 150,763
Blind ............................... 536,463 3,237
Disabled ............................ 13,334,311 77,281
... 4,852,586
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n 174,816
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . . . . 5,997,823 90,915

CATEGORICALLY NEEDY NON-CASH TOTAL.. $19,682,774 87,823

Aged ................................ 17,760,135 64,322
Blind ............................... 20,491 80
Disabled ............................ 1,514,513 5,985
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 184,868 10,425
A d u l t s - F a m i l i e s w/Dep C h i l d r e n ..... 202,767 7,368
Other T i t l e XIX R e c i p i e n t s .......... 0 0

MEDl CALLY NEEDY TOTAL.. ............. $0 0

Aged ................................ 0 0
Blind ............................... 0 0
Disabled ............................ 0 0
...
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n 0 0
.....
A d u l t s - F a m i l i e s w/Dep C h i l d r e n 0 0
..........
Other T i t l e XIX R e c i p i e n t s 0 0

**Unduplicated T o t a l - HHS r e p o r t HCFA

324
- 2082
 Texas - 2
1983

Ill. Administration:

Vendor d r u g program was implemented September 1, 1971.

Texas Department o f Human Resources.

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

Pharmacy s e r v i c e s under t h e vendor d r u g program i n c l u d e t h e d i s p e n s i n g o f

most l e g e n d drugs and c e r t a i n non-legend d r u g s t o e l i g i b l e r e c i p i e n t s . Only
p h a r m a c e u t i c a l s w h i c h meet t h e FDA r e q u i r e m e n t s , a r e a p p r o v e d f o r m a r k e t i n g
and a r e approved by t h e Texas Department o f Human Resources f o r use i n t h e
vendor d r u g program, may be s u p p l i e d .

C e r t a i n OTC d r u g s a r e covered on a p r e s c r i p t i o n b a s i s e x c e p t as o t h e r w i s e
p r o v i d e d i n t h e reimbursement f o r m u l a and v e n d o r payment t o h o s p i t a l s ,
n u r s i n g homes and i n s t i t u t i o n s .

A. General E x c l u s i o n s ( d i s e a s e s , d r u g c a t e g o r i e s , e t c . ) :
A d u l t v i t a m i n s and a d u l t v i t a m i n c o m b i n a t i o n s , amphetamines and o b e s i t y
c o n t r o l drugs, a p p l i a n c e s , d u r a b l e m e d i c a l equipment (bedpans, e t c . -
e i t h e r r e n t a l o r p u r c h a s e ) , e l a s t i c s t o c k i n g s , e x p e r i m e n t a l drugs,
f e r t i l i t y agents, f i r s t a i d s u p p l i e s , f o o d s , f o o d supplements o r
a d d i t i v e s , immunizing agents, m e d i c a l s u p p l i e s , oxygen, s u p p o r t s and
s u s p e n s o r i e s , s y r i n g e s , needles and t r u s s e s .

6. Formulary: None. However, t h e Texas Drug Code I n d e x i s u t i l i z e d f o r

p r o d u c t i d e n t i f i c a t i o n and c l a i m s p r o c e s s i n g and c o n t a i n s t h o s e d r u g s
w h i c h a r e c o v e r e d under t h e program.

For i n f o r m a t i o n c o n t a c t :

Raul M a r t i n e z , J r . , R.Ph.
D i r e c t o r , P r o d u c t E n r o l l m e n t , Vendor Drugs
Texas Department of Human Resources
P.O. Box 2960 (541-A)
A u s t i n , Texas 78769
512/835-0440, e x t . 2595

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Q u a n t i t y o f Medication: P r e s c r i b e d q u a n t i t y c a n n o t exceed a s i x
month s u p p l y .

2. Refills: F i v e r e f i l l s , b u t t o t a l amount may n o t exceed 6 months'

supply.
NPC Texas - 3
1983

0. P r e s c r i p t i o n Charge Formula:

1. For p r e s c r i p t i o n legend m e d i c a t i o n :

A c q u i s i t i o n c o s t p l u s a v a r i a b l e d i s p e n s i n g f e e up t o a maximum o f
$3.73 p e r p r e s c r i p t i o n ( r a n g e $3.45-$3.73*) based on a p o i n t
system of s e r v i c e s rendered, o r u s u a l and customoary t o t a l p r i c e ,
w h i c h e v e r i s lower.

A c q u i s i t i o n Cost: C u r r e n t Red Book c o s t o f d i r e c t c o s t o r i n v o i c e

c o s t . MAC based on w h o l e s a l e o r d i r e c t c o s t a s i n d i c a t e d by t h e
provider.

2. I n s u l i n and approved non-legend d r u g s on p r e s c r i p t i o n :

p h a r m a c i s t s and d i s p e n s i n g p h y s i c i a n s w i l l be r e i m b u r s e d on t h e
b a s i s o f u s u a l charges t o t h e g e n e r a l p u b l i c o r c o s t p l u s 50% of
c o s t , w h i c h e v e r i s l o w e r ; 50% o f c o s t n o t t o exceed a s s i g n e d
v a r i a b l e dispensing fee.

V. M i s c e l l a n e o u s Remarks:

The d i s p e n s i n g fee, w h i c h i n c l u d e s a l l c o s t s o f f i l l i n g a p r e s c r i p t i o n , was

e s t a b l i s h e d by c o s t a c c o u n t i n g and s e r v i c e e v a l u a t i o n o f t h e expenses
involved i n dispensing a p r e s c r i p t i o n . Therefore, fees p a i d t o p r o v i d e r s
who do n o t e x p e r i e n c e a l l c o s t and s e r v i c e f a c t o r s c o n s i d e r e d i n a r r i v i n g a t
t h e f e e , may be l e s s t h a n t h e maximum a l l o w a b l e f e e .

Copayment - None.

Number of c l a i m s p r o c e s s e d i n FY 1982 - 6.5 m i l l i o n

Average Rx p r i c e d u r i n g FY 1982 - $12.09

*Plus S.06 i f on t a p e .
Plus $.08 patient profits
Plus S.08 delivery service
Plus S.03 emergency s e r v i c e
Plus S.03 c o n t i n u i n g education
NPC Texas -4
1983

Officials, C o n s u l t a n t s and Comnittees

1 . Department of Human Resources O f f i c i a l s :

M a r l i n W. Johnston Texas Department of Human

Comm iss ioner Resources
Post O f f i c e Box 2960
A u s t i n , Texas 78769

M e r l e E. S p r i n g e r
Deputy Commissioner

Jack B l a n t o n
Executive Assistant

R. K. Pendergrass, H.D.
Special A s s i s t a n t f o r Health
Affairs

M a r t i n Dukler
Deputy Comnissioner f o r Programs

H i l l a r y Connor, M.D.
Deputy Commissioner f o r
Medical S p e c i a l t i e s

Dr. Janice Caldwell

A s s o c i a t e Comnissioner
S e r v i c e s t o Aged & D i s a b l e d

Roy E. W e s t e r f i e l d
A s s i s t a n t Deputy Commissioner
f o r Programs
S e r v i c e s t o Aged and D i s a b l e d

Claims Department (Vendor Drug Program) :

W. B. Barner, R.Ph., D.Ph.

Program S p e c i a l i s t
512/835-0440, e x t . 2594

Raul M a r t i n e z , Jr., R.Ph.

Staff Specialist
512/835-0440, e x t . 2595
NPC Texas - 5
1983

2. E x e c u t i v e O f f i c e r s o f S t a t e Medical and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical Association:

C. L i n c o l n W i l l i s t o n
Executive D i r e c t o r
Texas Medical A s s o c i a t i o n
1801 N. Lamar B o u l e v a r d
A u s t i n 78701
Phone: 512/477-6704
8. Pharmaceutical Association:

L u t h e r R. P a r k e r
Executive O i r e c t o r
Texas P h a r m a c e u t i c a l Assoc.
P. 0. Box 14706
1624 East Anderson Lane
A u s t i n 78761
Phone: 512/836-8350
C. Osteopathic Association:

Tex R o b e r t s
Executive D i r e c t o r
Texas O s t e o p a t h i c Medical A s s o c i a t i o n
226 B a i l e y Avenue
F o r t Worth 76107
8 l7/336-05'+9
 Utah - 1
1983
UTAH

EDlCAL ASSISTANCE DRUG PROGRAH (TITLE XIX)

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l 1y Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC C h i l d r e n < 2 1 (SFD)
Prescribed
Druqs X X X X X X X X X X
l npat i e n t
~ o it a~l Care i X X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X X
Laboratorv &
X-ray S e r v i c e X X X X X X X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X X X X X X X
Physician
services X X X X X X X X X X
Dental
Services X X X X X X X X X X
Other B e n e f i t s : Home h e a l t h , c l i n i c s e r v i c e s , t r a n s p o r t a t i o n , f a m i l y p l a n n i n g ;
medical supplies, E a r l y P e r i o d i c Screening f o r Children; s e r v i c e s o f p s y c h o l o g i s t s ,
p h y s i c a l t h e r a p i s t s , speech t h e r a p i s t s , p o d i a t r i s t s , o s t e o p a t h s , o p t o m e t r i s t s and
audiologists.
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l year e n d i n g

September 30, 1982
1981 1982
Expended R e c i p i e n t Expended Recipient

TOTAL........................ ....... $4,483,602

CATEGORICALLY NEEDY CASH TOTAL...... $2,517,744
Aged ................................ 528,423
Blind................... ............ 8,000
Disabled................... ......... 867,685
C h i l d r e n -Famil i e s w/Dep C h i l d r e n . .. 393,829
A d u l t s - F a m i l i e s w/Dep Children..... 719,807

CATEGORICALLY NEEDY NON-CASH TOTAL.. $717,176

Aged ................................ 394,046
Blind.. ............................. 4,206
Disabled............................ 230,776
...
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n 35,742
A d u l t s - F a m i l i e s w/Dep Children..... 52,406
Other T i t l e XIX R e c i p i e n t s .......... 0

MEDICALLY NEEDY TOTAL.. .............$1,248,682

Aged ................................ 850,776
Blind.... ........................... 614
Disabled...................... ...... 284,984
.. 15,118
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n .
.... 45,360
A d u l t s - F a m i l i e s w/Dep C h i l d r e n .
.......... 51,830
Other T i t l e X I X R e c i p i e n t s

**Unduplicated T o t a l - HHS r e p o r t H
$59
A - 2082
NPC Utah - 2
1983

Ill. Administration:

D i v i s i o n o f H e a l t h Care F i n a n c i n g , S t a t e Department of H e a l t h .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

General E x c l u s i o n s :
V i t a m i n s , ( e x c e p t f o r e x p e c t a n t m o t h e r s and c h i l d r e n t o age 51,
a n o r e c t i c s ; ( e x c e p t f o r amphetamines and d e r i v a t i v e s o n l y f o r
s p e c i f i c i n d i c a t i o n s of n a r c o l e p s y and t h e h y p e r k i n e s i s . ) Other
categories - m i n o r t r a n q u i l i z e r s and a n t i a r t h r i t i c s r e q u i r e p r i o r
approval .
Formulary: R e s t r i c t e d formulary. Use o f p r i o r a u t h o r i z a t i o n t o
a l l o w p h y s i c i a n s t o use, o t h e r m e d i c a l l y necessary, n o n - f o r m u l a r y
drugs.

P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Q u a n t i t y o f Medication: I n general, the q u a n t i t y of medication

s h a l l b e l i m i t e d t o a supply n o t t o exceed 30 days e x c e p t f o r
9Dsustaining" drugs, f o r w h i c h a 100-day s u p p l y i s a u t h o r i z e d .

P r e s c r i p t i o n Charge Formula:

1. Lowest o f : EAC/MAC Cost p l u s p r o f e s s i o n a l f e e of $3.25, or

u s u a l and customary charges t o t h e p r i v a t e s e c t o r .

2. Reduced Fee: F o r b i r t h c o n t r o l p i l l s and i n s u l i n t h e

p h a r m a c i s t w i l l be reimbursed a t t h e MAC/EAC p r i c e p l u s $1.00
p r o f e s s i o n a l f e e n o t t o exceed charges i n t h e p r i v a t e s e c t o r .

3. Generic Drugs: A s e l e c t e d g e n e r i c l i s t i n g of a p p r o x i m a t e l y 500

dosage forms o f d r u g s f o r w h i c h t h e program has s e t t h e
r e i m b u r s a b l e p r i c e i s i n c l u d e d i n t h e Utah T o t a l Drug Index.
 Utah - 3
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. Department o f H e a l t h O f f i c i a l s :

James 0. Mason, M.D., Department of H e a l t h

Director 150 West N o r t h Temple
S a l t Lake C i t y , U t a h 84103

M e l v i n M. Owens, Deputy D i r e c t o r
Department o f H e a l t h

Sharon Wasek, D i r e c t o r
D i v i s i o n o f H e a l t h Care F i n a n c i n g

RaeDell Ashley
Manager, Program O p e r a t i o n s
and M e d i c a l D e t e r m i n a t i o n

2. Department o f S o c i a l S e r v i c e s O f f i c i a l s :

Norman G. Angus, Deputy D i r e c t o r Department of S o c i a l S e r v i c e s

Entitlements 150 West N o r t h Temple
S a l t Lake C i t y 84103

K e i t h Oram, D i r e c t o r
O f f i c e o f A s s i s t a n c e Payments

3. H e a l t h Department c o n s u l t a n t s :

A. Physicians:

H a r o l d E. Merkley, M.D. 2020 South 1 3 t h East

S a l t Lake C i t y 84105

C h a r l e s P a r k i n , DMD Department o f H e a l t h
150 West N o r t h Temple
S a l t Lake C i t y 84103

C a r l o s Madsen, M.D. 1445 E a s t 3 3 r d South

S a l t Lake C i t y 84106

Joseph H a l g r e n , M.D.
 Utah - 4
1983

4. E x e c u t i v e O f f i c e r s o f S t a t e M e d i c a l and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical A s s o c i a t i o n :

J. Leon Sorenson
Executive D i r e c t o r
Utah S t a t e M e d i c a l Assoc.
540 East 5 t h South
S a l t Lake C i t y 84102
Phone: 801 /355-7477

0. Pharmaceutical Association:

C. N e i l Jensen
Executive D i r e c t o r
Utah Pharmaceutical Assoc.
1062 E a s t 2 1 s t South, S u i t e 212
S a l t Lake C i t y 84106
Phone: 801 /484-9141

C. Osteopathic Association:

K a t h e r i n e V. Greenwood, D.O.
S u i t e 201
750 N. 200 N .
Provo 84601
Phone: 801 1377-3871
NPC Vermont - 2
1983

I l l . 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: For prescribed legend or non-legend
drugs: Average wholesale price, based upon Drug Topics Red Book plus
professional fee of $2.50. Charge must not exceed usual and customary
charges.

E. Co-pay of $1.00 per dispensation required effective 2/1/82. Excludes

family planning items; exempts nursing home patients.

V. Miscellaneous

Fiscal Intermediary:

EDS Federal
35 Green Mt. Drive
South Burlington, Vermont 05402
 Vermont - 3
1983

Officials, C o n s u l t a n t s and Committees

Agency of Human S e r v i c e s :

L l o y d Novick Agency o f Human S e r v i c e s

Secretary 103 S. M a i n S t r e e t
Waterbury 05676

S o c i a l W e l f a r e Department:

David Wilson ~ e ~ a r t m e no tf S o c i a l W e l f a r e
Commissioner 103 S. M a i n S t r e e t
Waterbury 05676

Paul Ohlson
Deputy Commissioner

Elmo A. S a s s o r o s s i
Director
Medicaid D i v i s i o n

James B a r r e
Assistant Director
Medicaid D i v i s i o n

Charles P e r r y
Chief o f P o l i c y E Evaluation
802/241-2880

M e d i c a i d Pharmacy Peer Review Committee:

M i c h a e l S c o l l i n s , M.D., Chairman Department of S o c i a l W e l f a r e

Medicaid D i v i s i o n
103 South M a i n S t r e e t
Waterbury 05676

James Craddock, R.Ph.

Edgar Hyde, M.D.

James L i l l , R.Ph.

John Low, R.Ph.

 Vermont - 4
1983

4. E x e c u t i v e O f f i c e r s o f S t a t e Medical and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical Society:

R o b e r t Vaut i e r
Executive Director
Vermont Medical S o c i e t y
136 Main S t r e e t
M o n t p e l i e r 05602
Phone: 802/223-7898

8. Pharmaceutical Association:

P h i l i p J. O ' N e i l l
Executive Secretary
Vermont P h a r m a c e u t i c a l A s s o c i a t i o n
P. 0. Box 926
Benn i n g t o n 05201
Phone: 802/442-5943

C. Osteopathic Association:

L e s t e r H. L o v e l l , D.O.
Secretary-Treasurer
Vermont S t a t e A s s o c i a t i o n O s t e o p a t h i c
P h y s i c i a n s and Surgeons, I n c .
R.F.D. #3
B r a t t l e b o r o 05301
802/254-2944
 V i r g i n Islands -1
1983

VIRGIN ISLANDS

E D I C A L ASSISTANCE DRU6 PROGRAH (TITLE X I X )

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*

OAA AB APTD AFDC OAA AB APTD AFDC Chi l d r e n c 2 1 (SFO)
Prescribed
Drugs X X X X X X X X X X
l npat i e n t
H o s p i t a l Care X X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X X
Laboratory E
X-ray S e r v i c e X X X X X X X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X X X X X X X
Physician
Services X X X X X X X X X X
Dental
Services X X X X X X X X X X
Other B e n e f i t s : Home h e a l t h s e r v i c e s ; EPSDT; c l i n i c s e r v i c e s , p r o s t h e t i c d e v i c e s
and d e n t u r e s ; eyeglasses; ambulance s e r v i c e and o t h e r t r a n s p o r t a t i o n .
*SF0 -
S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l year e n d i n g

September 30, 1982
1981 1982
~ x ~ e n d e dR- e c i p i e n t ~ x ~ e n d e d -R e c i p i e n t

TOTAL...............................

CATEGORICALLY NEEDY CASH TOTAL......

Aged ................................
Blind...... .........................
Disabled.. ..........................
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n . ..
A d u l t s - F a m i l i e s w/Dep Children.....

CATEGORI CALLY NEEDY NON-CASH TOTAL..

Aged ................................
Blind.. .............................
Disabled............ ................
C h i l d r e n - F a m i l i e s w/Dep Children... Not A p p l i c a b l e
A d u l t s - F a m i l i e s w/Dep Children.....
Other T i t l e X I X R e c i p i e n t s ..........
MEDICALLY NEEDY TOTAL.. .............
Aged ................................
Blind..... ..........................
Disabled.............. ..............
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . ..
A d u l t s -Famil i c s w/Dep C h i l d r e n . ....
Other T i t l e XIX R e c i p i e n t s ..........
337
 V i r g i n Islands - 2
1983

I I I. A d m i n i s t r a t i o n :

Department o f H e a l t h .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

Broad coverage as p r o v i d e d b y p u b l i c m e d i c a l f a c i l i t i e s .

P r i v a t e f a c i l i t i e s a r e used when t h e p r e s c r i b e d d r u g i s n o t a v a i l a b l e a t t h e
p u b l i c m e d i c a l f a c i l i t y o r d e s i g n a t e d h o s p i t a l pharmacy. However, such
p r i v a t e pharmacies used must have signed a p r o v i d e r ' s agreement w i t h t h e
agency.

P r e s c r i p t i o n Charge Formula: The p h a r m a c i s t s a c t u a l c o s t p l u s a $2.40

d i s p e n s i n g fee, e x c e p t i n i n s t i t u t i o n s where d r u g s a r e i n c l u d e d i n t h e
reimbursement formula, o r e x c e p t where a p u b l i c agency makes b u l k purchases
o f d r u g s i n accordance w i t h s t a t u t e s o r r e g u l a t i o n s g o v e r n i n g such
purchases.
NPC V i r g i n lslands - 3
1983

Officials, C o n s u l t a n t s and Committees

A. H e a l t h Department:

1. Officials:

Roy L. Schneider, H.D., Department of H e a l t h

Commissioner P. 0. Box 7309
C h a r l o t t e Amalie
S t . Thomas
V i r g i n l s l a n d s 00801

J e a n n e t t e A. Mahoney,
A.C.S.W., M.P.H.
D i r e c t o r , Health lnsurance
and M e d i c a l A s s i s t a n c e

2. M e d i c a l Care A d v i s o r y Committee:

Roy L. Schneider, M.D., - Commissioner o f H e a l t h

(ex o f f i c i o )

J e a n n e t t e A. Mahoney, - D i r e c t o r , H e a l t h lnsurance
and M e d i c a l A s s i s t a n c e
(ex o f f i c i o )

B. S o c i a l W e l f a r e Department O f f i c i a l :

Gwendolyn C. B l a k e (Mrs.) Department of S o c i a l W e l f a r e

Commissioner C h a r l o t t e Amalie
S t . Thomas 00801

C. Executive O f f i c e r o f V i r g i n l s l a n d s Medical S o c i e t y :

I nformat i o n :

A. L i t t e l l
V i r g i n l s l a n d s Medical S o c i e t y
P. 0. Box 9626
C h a r l o t t e Amal i e
S t . Thomas, V i r g i n l s l a n d s 00801
 Virginia - 1
1983
VIRGINIA
E D 1 CIU ASSISTAWE DRUG PROGRAM (TITLE XIX)

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e q o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*

DAA AB APTD AFDC DAA AB APTD AFDC Chi l d r e n < 2 1 (SFO)
Prescribed
Druqs X X X X X X X X X
l noat
r
i e n t
H o s p i t a l Care X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X
Laboratory G
X-ray S e r v i c e X X X X X X X X X
Ski l led Nursing
Home S e r v i c e s X X X X X X X X X
Physician
Services X X X X X X X X X
Dental
Services A l l e l i q i b l e r e c i p i e n t s under age 21
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982
1981 1982
Expended Recipient Expended Recipient

TOTAL.. ............................. $27,120,542 243,711** $29,861,646 225,290**

CATEGORICALLY NEEDY CASH TOTAL...... $18,465,743 197,526 $20,625,819 190,715
Aged.. .............................. 6,623,796 31,269 7,371,906 30,481
Blind.. ............................. 166,850 900 193,151 842
Disabled. ........................... 5,883,365 28,262 7,038,910 28,926
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 2,099,860 82,714 2,071,692 78,037
....
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . 3,691,872 54,381 3,950,160 53,351
CATEGORICALLY NEEDY NON-CASH TOTAL.. $1,443,674 5,675 $1,759,381 6,398
Aged ................................ 1,190,326 3,216 1,436,260 3,668
Blind.......................... ..... 4,096 20 5,311 22
Disabled.. .......................... 188,227 626 227,513 645
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 17,726 859 25,593 1,046
A d u l t s - F a m i l i e s w/Oep Children..... 39,328 793 60,676 869
Other T i t l e XIX R e c i p i e n t s .......... 3,971 161 4,028 174
MEDICALLY NEEDY TOTAL ............... $7,211,125 40,510 $7,476,446 36,562
Aged ................................ 5,027,303 18,009 5,234,673 15,613
B l i n d . .............................. 42,978 219 43,885 174
D i s a b l e d ............................ 1,482,888 6,615 1,456,921 5,288
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 177,875 6,874 199,944 7,466
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . ... 380,330 5,526 428,300 5,304
Other T i t l e X I X R e c i p i e n t s .......... 99,751 3,267 112,723 2,887

**Undupl i c a t e d T o t a l - HHS r e p o r t HCFA

340
- 2082
 Virginia - 2
1983

I I I. A d m i n i s t r a t i o n :

By t h e D i v i s i o n o f M e d i c a l A s s i s t a n c e , S t a t e H e a l t h Department. Eligibility
d e t e r m i n a t i o n by t h e Department o f S o c i a l S e r v i c e s .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s ( d i s e a s e s , d r u g c a t e g o r i e s , e t c . ) :
Non-legend drugs e x c e p t f a m i l y p l a n n i n g d r u g s and s u p p l i e s , i n s u l i n ,
and i n s u l i n s y r i n g e s and needles. A n o r e c t i c d r u g s . ( A l l drugs covered
f o r n u r s i n g home r e c i p i e n t s . )

8. Formulary: None. P r e s c r i b e r s a r e urged t o p e r m i t use o f drugs

appearing i n t h e V i r g i n i a Voluntary Formulary.

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Q u a n t i t y of M e d i c a t i o n : Physicians requested t o p r e s c r i b e
maintenance d r u g s i n q u a n t i t i e s r e f l e c t i n g a 30-day s u p p l y , o r 100
un i t s o r doses.

2. Refills: P h y s i c i a n s may a u t h o r i z e r e f i l l s a c c o r d i n g t o l e g a l
r e q u i rements.

0. P r e s c r i p t i o n Charge Formula:

S t a t e Reimbursement - E f f e c t i v e J u l y 1, 1982, based upon t h e l o w e r o f :

E s t i m a t e d A c q u i s i t i o n Cost ( E A C ) p l u s $2.85
-
minus a p p l i cab1 e co-pay/Rx

Maximum A l l o w a b l e Cost ( M A C ) p l u s $2.85

-minus a p p l i c a b l e co-pay/Rx

to-payment

$0.5D/Rx f o r w h i c h t h e S t a t e pays $10 o r l e s s

$l.OO/Rx f o r w h i c h t h e S t a t e pays more t h a n $10
( E x c l u s i o n s , u n d e r 21, pregnancy r e l a t e d , and n u r s i n g home p a t i e n t s )

Unit-Dose

Usual and c u s t o m a r y n o t t o exceed a c q u i s i t i o n c o s t p l u s $2.85 fee.

NPC Virginia - 3
1983

P r e s c r i p t i o n Charge Formula ( c o n t i n u e d ) :

-
Note: 1. A l l p r o v i d e r s o f u n i t - d o s e must be c e r t i f i e d b y M e d i c a i d
program - f o r computer purposes.

2. U n i t - d o s e a p p l i e s o n l y t o t a b l e t s and c a p s u l e s dosage forms.

On o r about October 1, 1982

( F o r N u r s i n g Home P a t i e n t s )
Each t a b l e t o r c a p s u l e repackaged:*
Packaging . . allowance ......... $1.57/dose
P l u s an a d d i t i o n a l ........ .$l.OO/dose
- t h e dose)
(Whether o r n o t p h a r m a c i s t repackaqed
*Liquids, etc. are - not included

N u r s i n g Homes

EAC/MAC p l u s $2.85 f e e (Copay does n o t a p p l y )

0-T-CS

Lower of c o s t and markup ( u s u a l l y 50%) o r u s u a l and customary p r i c e .

Maximum A l l o w a b l e Cost Drugs

( S t a t e MACed - -
Non-leqend 0-T-CS)
Acetaminophen T a b l e t s , Acetaminophen E l i x i r , O i m e n h y d r i n a t e T a b l e t s ,
Oocusate Sodium Capsules, Oocusate Sodium Syrup, Docusate Sodium
w/Casanthranol c a p s u l e s and F e r r o u s S u l f a t e T a b l e t s .

P r e s c r i p t i o n Payment L i m i t a t i o n

One m o n t h l y p r e s c r i p t i o n fee p e r legend d r u g dispensed.

V. Miscellaneous

S t a t e MAC Program - Yes, 42 drugs.

Number of c l a i m s processed i n FY 1982 - 3,515,863

Average Rx p r i c e d u r i n g FY 1982 - $8.49

F i s c a l Intermediary:

The Computer Company ( T C C )

P.O. Box 6987
Richmond, V i r g i n i a 23230
 Virginia - 4
1983

Officials, C o n s u l t a n t s and Committees

1. H e a l t h Department O f f i c i a l s :

James B. Kenley, M.D. S t a t e Department o f H e a l t h

Commissioner Richmond, V i r g i n i a 23219

Bruce U. Kozlowski
A s s i s t a n t Commissioner
O f f i c e of Medical A s s i s t a n c e

Mary Ann Johnson, R.Ph. (Mrs.) 109 Governor S t r e e t , 8 t h F l o o r

Pharmaceutical Consultant Richmond 23219

Malcolm 0. P e r k i n s
Manager, P r o v i d e r R e l a t i o n s
D i v i s i o n of O p e r a t i o n s &
Provider Services
O f f i c e o f Medical A s s i s t a n c e
804/786-778 1

2. G o v e r n o r ' s A d v i s o r y Committee on Medicaid:

Medical S o c i e t y o f V i r q i n i a
C. B a r r i e Cook, M.D.
Frank S. Royal, M.D.

B l u e Cross/Blue S h i e l d o f VA V i r q i n i a Academy o f General

Ronald H. B a r g a t z e Practice
A. Epes H a r r i s , J r . , M.D.

V i r q i n i a S t a t e D e n t a l Assoc. V i r q i n i a S t a t e H o s p i t a l Assoc.
Byard S. Deputy, D.D.S. C r a i g R. Cudworth
H a r r y L. Hodges, D.D.S.
B a r r y Shipman, D.M.D.

P r i v a t e Insurance C a r r i e r s V i r q i n i a P h a r m a c e u t i c a l Assoc.
John L. T u t t l e Thomas A. A b b o t t , R.Ph.
James V. Morgan, R.Ph.

M e d i c a l School R e p r e s e n t a t i v e P a r t i c i p a n t s ' Advisory Council

Gary G. S u t e r , M.D. Mary 6 . Evans
Grace Johnson
Mamie K i n g
Jane M e l g a r d

V i r g i n i a H e a l t h Care Assoc. V i r g i n i a Nurses A s s o c i a t i o n

James K. Meharg, J r . Lucy H. W o h l f o r d
 Virginia - 5
1983

Governor's Advisory Comrni ttee on Medicaid (continued):

Ex Off icio

William L. Lukhard State Department of Welfare

Commissioner

Joseph J. Bevilacqua, Ph.D. State Department of Mental

Corn i ss i oner Health and Mental Retardation

James 0 . Kenley, M.D. State De~artmentof Health

Connnissioner

Social Services Department Officials:

Wi I 1 iam L. Lukhard State Department of Welfare

Commissioner 8007 Discovery Drive
Blair Building
Richmond 23288

Executive Officers of State Medical and Pharmaceutical Societies:

Medical Society:

James L. Moore
Executive Vice-Presdient
Medical Society of Virginia
4205 Dover Road
Richmond 23221
Phone: 804/353-2721

Pharmaceutical Association:

Paul Galanti
Executive Director
Virginia Pharmaceutical Association
3119 West Clay Street
Richmond 23230
Phone: 804/355-7941

Osteopathic Association:

Wellden Pyle, Jr., 0.0.

Secretary-Treasurer
Virginia Osteopathic Medical Association
4312 Greenleaf Drive
Chesapeake 23321
804/484-0642
 Washington - 1
1983
WASHINGTON

K O 1 CM ASSISTANCE DRUG PROGRAM (TITLE X I X )

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFDC a OAA AB APTD AFDC C h i l d r e n < 2 1 # (SFO)
Prescribed
Drugs X X X X X X X X X X X
l n ~ ai te n t -
~ o &t a ~l Care i X X X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X X X
Laboratorv &
X-ray S e r v i c e X X X X X X X X X X X
S k i l l e d Nursing
Home S e r v i c e s X X X X X X X X X X X
Physician
~ e ; v i ces X X X X X X X X X X X
Dental
Services x0 x0
a - C h i l d r e n under 21
o - C h i l d r e n (EPSDT) o n l y
# - L i m i t e d t o c h i l d r e n i n f o s t e r c a r e , s u b s i d i z e d a d o p t i o n , SNH, IFC, I C M R o r
inpatient psychiatric f a c i l i t y .
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l y e a r e n d i n g

September 30, 1982
1981 1982
Expended R e c i p i e n t Expended Recipient

TOTAL ............................... $19,380,214 209,566**

CATEGORICALLY NEEDY CASH TOTAL...... $12,059,486 171,422

Aged ................................ 3,264,070 18,201
Blind.... ........................... 48,361 304
Disabled ............................ 4,402,004 22,702
...
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n 1,840,817 80,508
A d u l t s - F a m i l i e s w/Dep Children..... 2,504,234 51,188

CATEGORICALLY NEEDY NON-CASH TOTAL.. $5,398,512 22,360

Aged ................................ 4,330,768 17,710
Blind ............................... 12,277 59
Disabled.... ........................ 1,051,810 4,570
C h i l d r e n - F a m i l i e s w/Oep C h i l d r e n . .. 1,211 93
A d u l t s - F a m i l i e s w/Oep C h i l d r e n . .... 2,446 85
Other T i t l e XIX R e c i p i e n t s .......... 0 0

MEDICALLY NEEDY TOTAL.. ............. $1,922,216 28,492

Aged ................................ 903,703 5,308
B l i n d ............................... 5,248 25
D i s a b l e d . . .......................... 547,608 3,064
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . . 331,503 17,101
A d u l t s -Fami 1 i e s w/Dep C h i l d r e n . . ... 134,154 3,661
Other T i t l e XIX R e c i p i e n t s .......... 0 0

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

345
NPC Washington -2
1983

I l l . Administration:

By D i v i s i o n o f M e d i c a l A s s i s t a n c e , Department o f S o c i a l and H e a l t h S e r v i c e s .
The l o c a l M e d i c a l C o n s u l t a n t s r e v i e w t h e need f o r n o n - f o r m u l a r y drugs.

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s :
M e d i c i n e c h e s t drugs a r e n o t p r o v i d e d . Non-formulary drugs a r e
p r o v i d e d i n an emergent l i f e - e n d a n g e r i n g s i t u a t i o n and/or m e d i c a l l y
mandatory.

B. Formulary: I n c l u d e s 2,800 l i s t i n g s b y drug p r o d u c t name, q u a n t i t y ,

dosage form and s t r e n g t h . Formulary i s r e v i s e d 2 t o 3 times annually.

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Quantity o f Medication: Some minimums and maximums s t i p u l a t e d .

2. Refills: No more t h a n 2 r e f i l l s i n any 30-day p e r i o d u n l e s s

p r e s c r i p t i o n and r e f i l l s a r e i n amount of 1 0 0 ' s .

3. Dollar Limits: S t a t e and F e d e r a l MAC where l i s t e d .

D. P r e s c r i p t i o n Charge Formula: The amount s h a l l n o t exceed t h e usual and

customary charge t o t h e p u b l i c o r t h e maximum a l l o w e d b y t h e
department.

The maximum charge t o t h e department i s t o be e s t i m a t e d a c q u i s i t i o n

c o s t (EAC) ( a s d e t e r m i n e d by t h e D i v i s i o n of M e d i c a l A s s i s t a n c e ) p l u s a
d i s p e n s i n g fee f o r s e r v i c e .

$3.33 - U n i t dose systems ( N u r s i n g Home Rxs)

3.04 - R e t a i l pharmacies, f i l l i n g over 35,000 Rxs a n n u a l l y
3.33 - R e t a i l pharmacies, f i l l i n g 35,000 o r l e s s Rxs a n n u a l l y

V. Miscellaneous

Copayment -
None.
S t a t e MAC -
120 d r u g s ( e x c l u d i n g f e d e r a l MAC)
Claims p r o c e s s i n g agent: Consultec, I n c .
P.O. Box 9245
M a i l S t o p LG-11
A i r d u s t r i a l Park
Tumwater, Washington 98504

Number of Rx c l a i m s processed i n FY 1982 - 2,223,062

Average Rx p r i c e d u r i n g FY 1982 - $8.72

 Washington - 3
1983

Officials, C o n s u l t a n t s and Committees

1. S o c i a l and H e a l t h S e r v i c e s Department O f f i c i a l s :

A l a n J. Gibbs Department o f S o c i a l and

Secretary Health Services
08-44
Olympia, Washington 98504

G e r a l d J. Rei l l y D i v i s i o n o f Medical
Director Assistance
LK-11
Olympi a 98504

Wesley M. Brock, M.D. O f f i c e o f M e d i c a l P o l i c y and

A c t i n g Medical D i r e c t o r Procedure
LK-11
Olympia 98504

W i l l i a m P. Pace, R.Ph. O f f i c e o f M e d i c a l P o l i c y and

Pharmacist Consultant Procedure
LK-11
Olympia 98504

2. S o c i a l and H e a l t h S e r v i c e s Department M e d i c a l C o n s u l t a n t s
( a t county l e v e l ) :

A. F u l l - t ime: Local O f f i c e

Norman M e c k s t r o t h , M.D. Spokane

Edward P. Palmason, M.D. RMU - Seattle

P o r t Angeles
P o r t Townsend

Joseph F. Powers, M.D. Pierce Central

B. Part-time

W a l t e r A. Boyle, M.O. K e l so
Robert B r i g h t , M.D. Bremerton
Raymond J. Bunker, M.D. Wenatchee
Cary H. Coppock, M.D. Pierce Central
L y l e J. Cowan, M.D. Omak/Okanogan
L o w e l l L. Eddy, M.D. RMU - Seattle
Lawrence N. E t t e l s o n , M.O. RMU - S e a t t l e
E r n e s t E y t i n g e , M.D. Everett
B u r t o n A. F o o t e , M.D. E l 1ensburg
Mark G a b r i e l s o n , M.D. Be1 l ingham
Mark G a b r i e l s o n , M.D. Mount Vernon
 Washington -4
1983

S o c i a l and H e a l t h S e r v i c e s Department M e d i c a l C o n s u l t a n t s P a r t - t i m e
( c o n t i nued:

A r n o l d J. Herrmann, M.D. P ie r c e C e n t r a l
M i c h a e l H. H i g g i n s , M.D. Spokane
Paul Johnson, M.D. RMU - Seattle
Kenneth H. K i n a r d , M.D. Everett
J e f f e r s o n D. Kyle, M.D. Spokane
A l b e r t V. M i l l s , M.D. Pasco
A l b e r t V. M i l l s , M.D. Walla Walla
James A. Moore, M.D. Aberdeen
James A. Moore, M.D. South Bend
C l a r e n c e Olson, M.D. RMU - Seattle
Glen L. Shearer, M.D. Olympia
Glen L. Shearer, M.D. Chehal i s
Glen L. Shearer, M.D. Shel t o n
C a r l C. W a l t e r s , M.D. Yakima
John A. Walz, M.D. Vancouver

(Dental )
Howard 0 . Henderson, D.M.D. O f f i c e of M e d i c a l D i r e c t o r , Olympia
C u r t i s C. Sapp, D.D.S. O f f i c e o f M e d i c a l D i r e c t o r , Olympia

(Podiatry)
Robert E. Wendel, D.P.M. RMU - Seattle

3. Department of S o c i a l and H e a l t h S e r v i c e s T i t l e X I X A d v i s o r y Committee:

Members:

C a r o l i n e S. MacCol I, ( C h a i r p e r s o n )
V i s i t i n g Nurse S e r v i c e
909 U n i v e r s i t y S t r e e t
S e a t t l e , 98101
( 2 0 6 ) 382-9800
Term E x p i r e s : 9/30/83

John A. Beare, M.D. Mary E. Coyne

D irector Seattle
DSHS-Division o f H e a l t h Term E x p i r e s : 9/30/83
M a i l Stop ET-21
O l yrnpia 98504 H a r r i e t J. Greenwood
Seattle
D a v i d A. Cox, R.Ph. Term E x p i r e s : 7/30/85
South Bend
Term E x p i r e s : 7/30/84 Robert A. Jacobs, D.D.S
Edmonds
Term E x p i r e s : 7/30/86
NPC Washington - 5
1983

Department o f S o c i a l and H e a l t h S e r v i c e s T i t l e X I X A d v i s o r y
Committee ( c o n t i n u e d ) :

R o b e r t I. J e t l a n d Gary McFaddon, M.D.

Administrator Seattle
Harborview Medical Center Term E x p i r e s : 7/1/84
Seattle
Term E x p i r e s : 7/30/85 C h r i s G. Stevenson
Richmond
James Johnson Term E x p i r e s : 7/30/84
Pasco
Term E x p i r e s : 7/30/84 Lewis 0. S t e w a r t
Olympia
I v a n C. LeCompte, M.D. Term E x p i r e s : 7/30/85
Pasco
Term E x ~ i r e s : 7/30/84 Ray Westeren
Seattle
Andrade Man Term E x p i r e s : 7/30/85
C h i l d r e n ' s Orthopedic Hospital
Seattle Dwain H. W h i t e
Term E x p i r e s : 7/30/86 Spokane
Term Expi r e s : 9/30/83
Susan McCroskey
Group H e a l t h Co-op
Seattle
Term E x p i r e s : 7/30/85

DSHS S t a f f Members:

G e r a l d J. R e i l l y , D i r e c t o r James Peterson, Chief

D i v i s i o n o f Medical Assistance O f f i c e o f A n a l y s i s and Medical
LK-11 Review
Olympia LE-11
Olympia
Peggy Flemer, S e c r e t a r y
D i v i s i o n o f Medical Assistance Mike S t e w a r t , C h i e f
LK- 11 O f f i c e o f Provider Services
Olympia LG-11
Olympia
Wesley M. Brock, M.D.
A c t i n g Medical D i r e c t o r
O f f i c e o f Medical P o l i c y and
Procedure
LK-11
Olympia
NPC Washington - 6
1983

4. E x e c u t i v e O f f i c e r s o f S t a t e Medical and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical Association:

H. R. Knudson
Executive D i r e c t o r
Washington S t a t e Medical A s s o c i a t i o n
900 U n i t e d A i r l i n e s B u i l d i n g
2033 S i x t h Avenue, S u i t e 900
S e a t t l e 98121
Phone: ZO6/623-480 1

8. Pharmaceutical Association:

Raymond A. O l son
Executive D i r e c t o r
Washington S t a t e P h a r m a c e u t i c a l A s s o c i a t i o n
1415 Seneca SW, S u i t e 200
Renton 98055
Phone: 206/228-7171

C. Osteopathic Association:

M r . W. Lawless
Executive D i r e c t o r
Washington O s t e o p a t h i c Medical A s s o c i a t i o n , Inc.
4210 S.W. Oregon
S e a t t l e 98116
206/937-5358
 West V i r g i n i a -1
1983

=ST VIRGINIA

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*

OAA AB APT0 AFDC OAA AB APTD AFDC Chi I d r e n Q l (SFO)
Prescribed
Druqs X X X X X X X X
l npat i e n t
H o s p i t a l Care X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X
Laboratory &
X-ray S e r v i c e X X X X X X X X
S k i l l e d Nursing
Hme Services X X X X X X X X
Physician
Services X X X X X X X X
Dental
Services X X X X X X X X
Other B e n e f i t s : I n t e r m e d i a t e N u r s i n g S e r v i c e s , R u r a l H e a l t h C l i n i c s , D u r a b l e M e d i c a l
Equipment and M e d i c a l S u p p l i e s , P r o s t h e t i c s and O r t h o t i c s , V i s i o n Care.
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l year e n d i n g

September 30, 1982
1981 1982
~ x ~ e n d e dR- e c i p i e n t ~xpended- Recipient

TOTAL ...............................$ 10,867,716 144,221** $8,400,067 112,497**

CATEGORICALLY NEEDY CASH TOTAL...... $9,042,522 122,610 56,960,103 94,952

Aged. ............................... 3,024,223 19,188 2,419,218 14,999
Blind.. ............................. 53,167 387 38,363 287
..........................
0 is a b l ed.. 3,406,527 23,655 2,790,840 18,445
.
C h i l d r e n -Fami l i e s w/Dep C h i l d r e n . . 1,046,922 48,078 640,447 36,370
A d u l t s - F a m i l i e s w/Dep Children..... 1,511,683 31,302 1,071,235 25,512

CATEGORICALLY NEEDY NON-CASH TOTAL.. $1,085,598

Aged.. .............................. 683,862
Blind.. ............................. 1,086
Disabled ............................ 176,303
.
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . . 73,475
A d u l t s - F a m i l i e s w/Dep C h i l d r e n ..... 150,872
Other T i t l e X I X R e c i p i e n t s .......... 0

MEDICALLY NEEDY TOTAL.. ............. $739,596

Aged ................................ 318,067
B l i n d . . . ............................ 1,399
Disabled... ......................... 222,096
C h i l d r e n -Famil i e s w/Dep C h i l d r e n . . . 59,857
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . .... 138,177
Other T i t l e X I X R e c i p i e n t s .......... 0

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

351
NPC West V i r g i n i a - 2
1983

I l l . Administration:

The D i v i s i o n o f M e d i c a l Care, Department o f W e l f a r e , i s t h e m e d i c a l

a s s i s t a n c e u n i t r e p o n s i b l e f o r t h e a d m i n i s t r a t i o n o f t h e T i t l e XIX
program. E l i g i b i l i t y f o r program b e n e f i t s i s d e t e r m i n e d b y t h e l o c a l
W e l f a r e o f f i c e s f o r AFDC and m e d i c a l l y needy i n d i v i d u a l s . Individuals
e l i g i b l e f o r S S I b e n e f i t s a r e covered f o r M e d i c a i d as c a t e g o r i c a l l y needy,
aged and d i s a b l e d .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

PROGRAM COVERAGE

A. A l l c o v e r e d drugs, whether legend o r non-legend, must b e p r e s c r i b e d by

a p h y s i c i a n o r o t h e r p r a c t i t i o n e r q u a l i f i e d under S t a t e law.
A p p l i c a b l e S t a t e and F e d e r a l law g o v e r n i n g d i s p e n s i n g o f d r u g s and
b i o l o g i s t s must be f o l l o w e d :

Drugs i d e n t i f i e d i n t h e M e d i c a i d Drug F o r m u l a r y , l i s t e d b y p r o d u c t o r
t h e r a p e u t i c c l a s s , a r e covered w i t h o u t p r i o r a u t h o r i z a t i o n .

COVERED SERVICES

1. Legend Drugs

Legend d r u g s i n c l u d i n g i n j e c t a b l e s a r e c o v e r e d u n l e s s s p e c i f i c a l l y
excluded.

2. Non-Legend Drugs

The f o l l o w i n g non-legend drugs a r e covered:

(a) Family planning supplies.

(b) Insulin.
(c) D i a b e t i c s y r i n g e s , n e e d l e s , and t e s t i n g k i t s .
(d) ESRD v i t a m i d v i t a m i n m i n e r a l p r e p a r a t i o n s , and o t h e r
m e d i c a t i o n s r e l a t e d t o End Stage Renal Disease s e r v i c e s .

Exception:

Non-legend d r u g coverage does n o t a p p l y f o r c l i e n t s r e s i d i n g i n

l o n g - t e r m c a r e f a c i l i t i e s (SNF/ICF).

COVERAGE WITH PRIOR AUTHORIZATION

C o n s i d e r a t i o n may be g i v e n on s p e c i a l d r u g needs of a c l i e n t b y t h e M e d i c a l
D i r e c t o r on an i n d i v i d u a l b a s i s based on m e d i c a l i n f o r m a t i o n s u p p l i e d by t h e
a t t e n d i n g p h y s i c i a n i n t h e f o r m a t s p e c i f i e d by t h e S t a t e .
 West V i r g i n i a - 3
1983

S p e c i f i c i t e m s c o v e r e d b y p r i o r a u t h o r i z a t i o n are:

1. A n t i b i o t i c s and a n a l g e s i c s f o r c h r o n i c usage; i.e., o v e r t e n days.

2. M e d i c a l s u p p l i e s and equipment. M e d i c a l s u p p l i e s ; i.e., bandages,

colostomy bags, underpads, and o t h e r items r e q u i r e d f o r home c a r e ,
and c o v e r e d b y t h e Department based on a t r e a t m e n t p l a n d e v e l o p e d
for the individual c l i e n t .

3. V i t a m i n / v i t a m i n m i n e r a l p r e p a r a t i o n s f o r E n d - S t a t e Renal D i s e a s e
p a t i e n t s and o t h e r m e d i c a t i o n s r e l a t e d t o End-Stage Renal D i s e a s e
services.

4. L i f e s u s t a i n i n g , c r i t i c a l , o r necessary drugs n o t i n c l u d e d i n t h e
formulary.

EMERGENCY COVERAGE

I f a p h y s i c i a n determines t h a t a p a r t i c u l a r d r u g i s needed f o r h i s p a t i e n t
w h i c h i s n o t i n c l u d e d on t h e f o r m u l a r y l i s t , and i s n o t e x c l u d e d from p r o g r m
coverage, and t h a t an emergency s i t u a t i o n s e x i s t s , he may s o i n d i c a t e b y
w r i t i n g "emergency" on t h e p r e s c r i p t i o n above h i s s i g n a t u r e . These
p r e s c r i p t i o n s w i l l be covered up t o a ten-day' s u p p l y w i t h no r e f i l l .
Continuous t h e r a p y , if needed, w i l l r e q u i r e p r i o r a u t h o r i z a t i o n .

NON-COVERED SERVICES

The f o l l o w i n g drugs and drug p r o d u c t s a r e n o t payable:

1. Non-legend drugs e x c e p t f o r t h o s e i d e n t i f i e d i n I V . A.2.

2. Legend drugs and drug p r o d u c t s as f o l lows:

(a) A p p e t i t e d e p r e s s a n t s and/or d r u g p r o d u c t s f o r w e i g h t c o n t r o l .
(b) Fecal s o f t e n i n g agents; l a x a t i v e s .
(c) Food, f o o d p r o d u c t s - a s l a b e l e d b y F.D.A.
(d) E x p e r i m e n t a l drugs; i .e., drugs under development, i n
c l i n i c a l t e s t i n g , o r o t h e r processes s h o r t o f b e i n g f u l l y
approved b y t h e F.D.A.
(e) O r a l v i t a m i n s , v i t a m i n and m i n e r a l c o m b i n a t i o n s , g e r i a t r i c
tonics.
(f) "Minor t r a n q u i l i z e r s " i d e n t i f i e d by t h e Department.
(g) Drugs d e t e r m i n e d b y t h e F.D.A. o f t h e Department of H e a l t h
and Human S e r v i c e s t o l a c k s u b s t a n t i a l e v i d e n c e of
e f f e c t i v e n e s s p u b l i s h e d i n t h e F e d e r a l R e g i s t e r , Volume 46,
Number 210, dated F r i d a y , October 30, 1981. A l s o , i d e n t i c a l ,
r e l a t e d o r s i m i l a r drugs a r e i n c l u d e d .
 West V i r g i n i a - 4
1983

3. Exceptions:

The f o l l o w i n g e x c e p t i o n s a r e made:

(a) V i t a m i n s A, K, and D.
(b) V i t a m i d v i t a m i n and m i n e r a l p r e p a r a t i o n s f o r End-Stage Renal
Disease p a t i e n t s , and o t h e r m e d i c a t i o n s r e l a t e d t o End S t a g e
Renal Disease s e r v i c e s .

HAND1 CAPPED CHILDREN'S SERVl CES PROGRAM

Pharmacy S e r v i c e s

S e r v i c e s a r e a v a i l a b l e f o r c e r t a i n c h i l d r e n under 21 y e a r s of age
r e c e i v i n g m e d i c a l c a r e w i t h i n t h e D i v i s i o n of Handicapped
C h i l d r e n ' s Services. These s e r v i c e s a r e n o t l i m i t e d t o c h i l d r e n
of f a m i l i e s r e c e i v i n g p u b l i c a s s i s t a n c e g r a n t s .

Scope of S e r v i c e s

P r e s c r i p t i o n s a r e l i m i t e d t o a one-month s u p p l y w i t h maximum of
f i v e m o n t h l y r e f i l l s i n any six-month p e r i o d .

Formulary: West V i r g i n i a M e d i c a i d Drug F o r m u l a r y L i s t

For information contact: J. L. Mangus, M.D.

Medical D i r e c t o r
W.V. Department o f Human S e r v i c e s
D i v i s i o n o f M e d i c a l Care
1900 Washington S t r e e t , E.
C h a r l e s t o n , West V i r g i n i a 25305
304/348-8990

P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

QUANTITY AND FREQUENCY

Covered legend and non-legend drugs a r e p a y a b l e as p r e s c r i b e d b y a l i c e n s e d

p r a c t i t i o n e r up t o a 30-day s u p p l y w i t h a maximum o f f i v e r e f i l l s .

Exception:

1. A n t i b i o t i c s and a n a l g e s i c s a r e l i m i t e d t o a maximum o f t e n days

w i t h no r e f i l l s . (See p r i o r a u t h o r i z a t i o n . )

2. E x c l u d i n g p h e n o b a r b i t a l , s e d a t i v e s and h y p n o t i c s a r e l i m i t e d t o a
maximum o f 30 days w i t h no r e f i l l s .
 West V i r g i n i a - 5
1983

D. P r e s c r i p t i o n Charge Formula:

1. Maximum reimbursement f o r each d r u g c l a im p r o c e s s e d w i l l be based

on t h e l o w e s t o f :

The maximum a l l o w a b l e c o s t (MAC) f o r each m u l t i p l e - s o u r c e

d r u g a s d e f i n e d by t h e P h a r m a c e u t i c a l Reimbursement Board and
p u b l i s h e d i n t h e Federal R e g i s t e r p l u s a dispensing fee. See
Appendix G f o r l i s t i n g o f MAC d r u g s .

Exception:

The MAC s h a l l n o t a p p l y i n any case where a p h y s i c i a n

c e r t i f i e s i n h i s own h a n d w r i t i n g t h a t i n h i s m e d i c a l
judgement a s p e c i f i c brand i s m e d i c a l l y n e c e s s a r y f o r a
particular patient. A n o t a t i o n l i k e "brand necessary"
w r i t t e n b y t h e p h y s i c i a n on t h e p r e s c r i p t i o n above t h e
p h y s i c i a n ' s s i g n a t u r e i s an a c c e p t a b l e c e r t i f i c a t i o n . A
p r o c e d u r e f o r c h e c k i n g a box on a form w i l l n o t c o n s t i t u t e a n
acceptable c e r t i f i c a t i o n .

A l l such c e r t i f i e d p r e s c r i p t i o n s must be m a i n t a i n e d i n t h e
pharmgcy f i l e s and made a v a i l a b l e f o r i n s p e c t i o n by t h e
Department o f H e a l t h and Human S e r v i c e s and t h e Department o f
Welfare.

The e s t i m a t e d a c q u i s i t i o n c o s t (EAC) f o r each m u l t i p l e - s o u r c e

d r u g as d e f i n e d by t h e S t a t e p l u s a d i s p e n s i n g f e e .

The a c q u i s i t i o n c o s t o r a v e r a g e w h o l e s a l e p r i c e (AWP) f o r a l l
o t h e r p r e s c r i b e d d r u g s p l u s a d i s p e n s i n g fee.

The u s u a l and customary p r i c e c h a r g e d b y t h e pharmacy t o t h e

g e n e r a l p u b l i c i n c l u d i n g any s a l e p r i c e w h i c h may be i n
e f f e c t on t h e d a t e o f s e r v i c e .

APPLICATION OF DISPENSING FEE

A. For c o v e r e d legend and non-legend d r u g s , a p r o f e s s i o n a l d i s p e n s i n g

f e e o f $2.75 w i l l b e added t o t h e F e d e r a l l y e s t a b l i s h e d MAC o r
S t a t e - e s t a b l i s h e d a c q u i s i t i o n c o s t p r i c e o f each p r e s c r i b e d drug.

8. For a compounded p r e s c r i p t i o n , an a d d i t i o n a l $1.00 w i l l b e added

t o t h e d i s p e n s i n g fee. A compound p r e s c r i p t i o n i s d e f i n e d as any
l e g e n d medicament r e q u i r i n g a c o m b i n a t i o n o f any t w o o r more
substances t o e x c l u d e normal r e c o n s t i t u t i o n o p e r a t i o n s .
 West V i r g i n i a - 6
1983

C. U n i t dose d r u g d e l i v e r y systems a r e r e i m b u r s e d under t h e same

p r o v i s i o n s as o t h e r l e g e n d drug s e r v i c e s t o M e d i c a i d p a t i e n t s .
Legend d r u g s a r e r e i m b u r s e d on a 30-day b a s i s r e g a r d l e s s o f d r u g
d e l i v e r y system o r how t h e p h a r m a c i s t may choose t o dispense.

A co-payment i s r e q u i r e d f o r each p r e s c r i p t i o n f i l l e d on and a f t e r March 10,

1981, w i t h t h e e x c e p t i o n o f t h o s e i t e m s s p e c i f i c a l l y e x c l u d e d f r o m t h e co-
pay r e q u i r e m e n t . The r e c i p i e n t co-payment p e r p r e s c r i p t i o n w i l l be deducted
f r o m t h e maximum a l l o w a b l e payment ( p r e s c r i p t i o n charge f o r m u l a ) t o
d e t e r m i n e t h e amount p a y a b l e f o r each p r e s c r i p t i o n b i l l e d t o t h e programs.

The d e d u c t i o n w i l l a p p l y a s f o l l o w s :

1. I f t h e maximum a l l o w a b l e payment i s under $10.99, t h e r e d u c t i o n w i l l be

$0.50 p e r p r e s c r i p t i o n .

2. If t h e maximum a l l o w a b l e payment i s $11.00 o r more, the reduction w i l l

be $1.00 p e r p r e s c r i p t i o n .

E x c l u d e d from t h e Co-Pay Requirement:

(a) F a m i l y P l a n n i n g S e r v i c e s and S u p p l i e s .

(b) P r e s c r i p t i o n s o r i g i n a t i n g w i t h t h e E a r l y and P e r i o d i c S c r e e n i n g ,
D i a g n o s i s and T r e a t m e n t Program (EPSDT).

Miscellaneous

Claims p r o c e s s o r :

The Computer Company

Richmond, V i r g i n i a

Number of c l a i m s processed i n FY i 9 8 2 - 995,580

Average Rx p r i c e d u r i n g FY 1982 - $7.94

 West V i r g i n i a - 7
1983

Officials, C o n s u l t a n t s and Committees

1. W e l f a r e Department O f f i c i a l s :

Leon H. Ginsberg, Ph.0. West V i r g i n i a Department of

Commissioner Welfare
1900 Washington S t r e e t , East
C h a r l e s t o n , W. Va. 25305

D a v i d W. F o r i n a s h
A s s i s t a n t Cornmissioner
Medical Services

J. L. Mangus, M.D.
Medical D i r e c t o r ( H a l f - t i m e )
D i v i s i o n o f M e d i c a l Care

(Mrs.) Helen M. Condry, D i r e c t o r

D i v i s i o n o f M e d i c a l Care

Auburn A. Cooper
Administrative Assistant
. D i v i s i o n of M e d i c a l Care

W i l l i a m 6 . Rossman, M.D.
P s y c h i a t r i s t Consultant

B e r n a r d S c h l a c t , R.Ph.
Pharmaceutical Coordinator
304/348-8990

B e r t Bradford, Jr., M.D.

Medical Consultant ( P a r t - t i m e )

R o b e r t Crawford, M.D.
Medical Consultant ( P a r t - t i m e )

F. A. Sines, D.D.S.
Dental Consultant ( P a r t - t i m e )

D a v i d Heitmeyer, S e c t i o n C h i e f
Research & S t a t i s t i c s U n i t
 West V i r g i n i a - 8
1983

2. W e l f a r e Oepartment Medical S e r v i c e s A d v i s o r y C o u n c i l :

A. Medical S e r v i c e Fund (MSF) A d v i s o r y Counci l Members:

Reqular Members

M r . Fred B l a i r , Executive D i r e c t o r Mrs. C a r o l J. M i l l e r , O i r e c t o r

O h i o V a l l e y Medical Center, Inc. Heal thwi se, I nc. (HMO)
2000 E o f f S t r e e t S u i t e 313 - R a l e i g h County Bank
Wheel i ng 26003 Building
B e c k l e y 25801

Mrs. A l i c e M. Couch, A d m i n i s t r a t o r Mrs. Opal R i l i n g

Val l e y Haven Rest Home, I nc. 1546 Kanawha Boulevard, E a s t
R.O. 2, Box 44 Apartment 719
We1 l s b u r g 26070 C h a r l e s t o n 2531 1

Jack E. F r u t h , R.Ph. H a r r y Shannon, M.0.

F r u t h Pharmacy P.O. Box 659
2501 Jackson Avenue P a r k e r s b u r g 26101
P t . P l e a s a n t 25550

M r . Joseph Powel I, P r e s i d e n t Ms.. P a t r i c i a Sumner

West V i r g i n i a Labor F e d e r a t i o n Route 2, Box 214
(AFL-CIO) H u r r i c a n e 25526
501 Broad S t r e e t
C h a r l e s t o n 25311

M r . D a n i e l W. F a r l e y , A d m i n i s t r a t o r Mrs. J a c k i e Withrow
Glenwood Park U n i t e d M e t h o d i s t Home 1301 Maxwell H i l l Road
Route 1, Box 464 Beckl ey 25801
P r i n c e t o n 24740

L. C l a r k Hansbarger, M.O., Oirector Mrs. R i t a Tanner

West V i r g i n i a Oepartment o f H e a l t h 1100 L o u i s e Avenue
1800 Washington S t r e e t , E a s t Morgantown 26505
C h a r l e s t o n 25305

A l t e r n a t e Members

Thomas L . Carson, R.Ph. Ms. Sarah M. Kerns

C o l l e g e Drug S t o r e , I n c . 1546 Kanawha Boulevard, E a s t
Drawer 510 Apartment #305
Montgomery 25136 C h a r l e s t o n 25311

Ms. Nancy W. Comer M r . Jack R. McComas,

360 L a u r e l S t r e e t Secretary/Treasurer
Morgantown 26505 West V i r g i n i a Labor F e d e r a t i o n
AFL-CIO
501 Broad S t r e e t
C h a r l e s t o n 25301
 West V i r g i n i a - 9
1983

M e d i c a l S e r v i c e Fund (MSF) A d v i s o r y C o u n c i l Members ( c o n t i n u e d ) :

Mr. Robert Eakin, President L i n d a R . Hickrnan, R.N.

Memorial General H o s p i t a l Operations Supervisor
1200 H a r r i s o n Avenue H e a l t h w i s e , I n c . (HMO)
E l k i n s 26241 S u i t e 313,
R a l e i g h t County Bank B u i l d i n g
M r . Mark Nesselroad, B e c k l e y 25801
General Manager
West V i r g i n i a O p e r a t i o n s Mrs. E d i t h Sanderson
Crossgates, I n c . C/O Beckley Farmer's Market
3555 Washington Road Box 117
McMurray, P e n n s y l v a n i a Skel t o n 25955

B. W e l f a r e Committee Members of t h e West V i r g i n i a P h a r m a c e u t i c a l

Association:

M r . A r l i e W i n t e r s , J r . , Chairman Benjamin Carson

P. 0. Box 96 409 Monroe S t r e e t
B e r k e l e y S p r i n g s 25411 Montgomery 25136

S. Ewood Bare Ann Bond S m i t h

1002 G r e e n b r i a r Avenue P.O. Box 225
Ronceverte 24970 Clendeni n 25036

D a v i d Oowyer, S t u d e n t R e p r e s e n t a t i v e
West V i r g i n i a U n i v e r s i t y
School o f Pharmacy
Morgantown 26506

3. E x e c u t i v e O f f i c e r s o f S t a t e M e d i c a l and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical Association: B. Pharmaceutical A s s o c i a t i o n :

Charles R. L e w i s R i c h a r d D. Stevens
Executive Secretary Executive D i r e c t o r
West V i r g i n i a S t a t e West V i r g i n i a P h a r m a c i s t s A s s o c i a t i o n
Medical A s s o c i a t i o n Suite 4
Box 1031 4004 MacCorkle Avenue, SE
C h a r l e s t o n 25324 C h a r l e s t o n 25304
Phone: 304/346-0551 Phone: 304/925-7204

C. Osteopathic Medicine:

A. R o b e r t Ozmura, 0.0.
4850 E o f f S t r e e t
Benwood 26031
Phone: 304/233-1656
 Wisconsin - 1
1983
WISCONSIN

K D l C M ASSISTANCE DRUG PROGRAH (TITLE X I X )

I. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e q o r i c a l ly Needy M e d i c a l l y Needy (MN) Other*

OAA AB APTD AFDC OAA AB APTD AFDC C h i l d r e n < 2 1 (SFO)
Prescribed
Drugs X X X X X X X X X X
lnpat i e n t
H o s p i t a l Care X X X X X X X X X X
Outpatient
H o s p i t a l Care X X X X X X X X X X
Laboratory &
X-ray S e r v i c e X X X X X X X X X X
S k i l l e d Nursing
Hane S e r v i c e s X X X X X X X X X X
Physician
Services X X X X X X X X X X
Dental
Services X X X X X
*SF0 - S t a t e Funds O n l y

II. EXPENDITURES FOR DRUGS. Payment t o P h a r m a c i s t s b y f i s c a l year ending

September 30, 1982
1981 1982
~ x ~ e n d e dR- e c i p i e n t ~xpended- Recipient

CATEGORICALLY NEEDY CASH TOTAL...... $21,081,836 240,149 $19,743,234 228,228

Aged ................................ 5,683,314 28,010 4,984,298 22,889
Blind. .............................. 143,520 70 1 148,637 658
Disabled ............................ 7,859,694 30,980 7,652,795 28,875
C h i l d r e n - F a m i l i e s w/Dep Children... 2,984,470 113,915 2,617,155 105,109
A d u l t s - F a m i l i e s w/Dep Children..... 4,410,838 66,543 4,340,349 67,697
CATEGORICALLY NEEDY NON-CASH TOTAL.. $17,472,128
Aged ................................ 13,328,991
Blind.. ............................. 5,558
Disabled............................ 3,008,923
C h i l d r e n - F a m i l i e s w/Dep Children... 652,305
A d u l t s - F a m i l i e s w/Dep Children..... 285,611
Other T i t l e X I X R e c i p i e n t s . ......... 190,740
MEDICALLY NEEDY TOTAL.. .............. $2,092,090
Aged ................................ 691,843
Blind........... .................... 647
Disabled.......... .................. 620,377
C h i l d r e n - F a m i l i e s w/Dep Children... 102,048
A d u l t s - F a m i l i e s w/Dep C h i l d r e n . . ... 93,192
Other T i t l e X I X R e c i p i e n t s .......... 583,983

**Unduplicated T o t a l - HHS r e p o r t HCFA - 2082

360
 Wisconsin - 2
1983

I l l . Administration:

The S t a t e Department o f H e a l t h and S o c i a l S e r v i c e s .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

A. General E x c l u s i o n s :

1. Legend l a x a t i v e s and n o n p r e n a t a l v i t a m i n s .

2. A l l non-legend p h a r m a c e u t i c a l s e x c e p t I n s u l i n , a n t a c i d s and
analgesics.

B. Formulary: None.

C. P r e s c r i b i n g o r Dispensing L i m i t a t i o n s :

1. Q u a n t i t y o f Medication: P h a r m a c i s t s may n o t d i s p e n s e more t h a n 34-

day s u p p l y o f a legend drug.

2. Refills: Maximum o f 11 r e f i l l s d u r i n g a 12-month p e r i o d f o r non-

scheduled m e d i c a t i o n s .

3. Dollar Limits: None.

D. P r e s c r i p t i o n Charge Formula:

1. T r a d i t i o n a l ( n o n - u n i t dose) d i s p e n s i n g r e i m b u r s e d a t t h e l o w e s t o f :
E s t i m a t e d A c q u i s i t i o n Cost (EAC) p l u s $3.40 p r o f e s s i o n a l fee; Maximum
A l l o w a b l e Cost (MAC) p l u s $3.40 p r o f e s s i o n a l f e e ; o r p r o v i d e r s u s u a l
and customary.

2. U n i t Dose D i s p e n s i n g :

Reimbursement a t t h e l o w e s t o f : E s t i m a t e d A c q u i s i t i o n Cost ( E A C )
p l u s $5.25 p r o f e s s i o n a l fee; Maximum A l l o w a b l e Cost ( M A C ) p l u s $5.00
p r o f e s s i o n a l fee; o r p r o v i d e r s u s u a l and customary.

Reimbursement l i m i t e d t o one u n i t dose p r o f e s s i o n a l f e e p e r d r u g p e r

month.

V. M i s c e l l a n e o u s Remarks:

A. P r i o r A u t h o r i z a t i o n R e q u i r e d o n t h e F o l l o w i n g Drugs:

1. A l l anorectics 4. Derifil
2. Methaqualone 5. Decubitex
3. Debr i s a n
NPC Wisconsin - 3
1983

M i s c e I Ianeous Remarks ( c o n t i n u e d ) :

M e d i c a l l y Needy R e c i p i e n t s

M e d i c a l l y Needy r e c i p i e n t s who do n o t r e s i d e i n a S k i l l e d N u r s i n g F a c i l i t y
(SNF) o r l n t e r m e d i a t e Care F a c i l i t y (ICF) a r e e l i g i b l e f o r o n l y f i v e
c a t e g o r i e s of legend drug:

1. Antibiotics 4. . Psychotropics
2. Anticonvulsants 5. F a m i l y P l a n n i n g Drugs
3. MuscleRelaxants

Copayment

A l l legend and o v e r - t h e - c o u n t e r drugs except f a m i l y p l a n n i n g d r u g s a r e

s u b j e c t t o a $.SO copayment. Residents o f S k i l l e d N u r s i n g F a c i l i t i e s
(SNF) o r l n t e r m e d i a t e Care F a c i 1i t i e s ( ICF), s u b s i d i z e d a d o p t i o n
r e c i p i e n t s , and HMO e n r o l l e e s a r e exempt f r o m t h e copayment.

S t a t e MAC Program - Yes

Fiscal Intermediary:

ED5 -
Federal
6406 B r i d g e Road
Madison, Wisconsin 53784

Number o f c l a i m s p r o c e s s e d i n FY 1982 - 2,463,015

Average Rx p r i c e d u r i n g FY 1982 - $9.59

 Wisconsin - 4
1983

O f f i c i a l s , C o n s u l t a n t s and Committees

1. H e a l t h and S o c i a l S e r v i c e s Department O f f i c i a l s :

Linda R e i v i t z Oepartment o f H e a l t h and

Secretary Social Services
State O f f i c e B u i l d i n g
One West W i l s o n S t r e e t
Madison,.Wisconsin 53702

K a t i e Morrison
Administrator
Division o f Health

Vacant
D i rector
Bureau o f H e a l t h Care F i n a n c i n g
(Medicaid)

A l f r e d D a l l y , M.D.
Physician Consultant

Ted C o l l i n s
Pharmacy P r a c t i c e s C o n s u l t a n t
608/266-0722

2. H e a l t h and S o c i a l S e r v i c e s Oepartment A d v i s o r y Committee -

Medical A s s i s t a n c e A d v i s o r y Comnittee:

Public Health Nursing Hospitals

Anne Adams D a n i e l Kane, A d m i n i s t r a t o r
Director, Janesville V i s i t i n g M t . S i n a i M e d i c a l Center
Nurse A s s o c i a t i o n 950 N. T w e l t h S t r e e t
Route 3, Box 107 P.O. Box 342
F o r t A t k i n s o n 53583 Milwaukee 53201

Minorities
D r . Leonardo Aponte,
Clinica Latina
1302 S. 1 6 t h S t r e e t
M i 1 waukee 53504
Physicians
Director G e r a l d Kempthorne, M.D.
153 E. J e f f e r s o n Avenue
S p r i n g Green 53588

(414)645-6665
 W i scons i n -5
1983

M e d i c a l A s s i s t a n c e A d v i s o r y Commi t t e e Members ( c o n t i n u e d ) :

Consumer-Rec ip i e n t Consumers
Randy B a r t e l s -
Jim K u ~ e r b e r q Chairperson
201 S. P a r k S t r e e t ~ s s o c i e t ep r o f e s s o r '
Madison 53715 C o n t i n u i n g E d u c a t i o n i n Admin.
307 S. H a l l
929 N. 6 t h S t r e e t
Milwaukee 53203
Consumers
Timothy Charek (414)224-1972 ( 0 )
Executive D i r e c t o r 244-1987 ( h )
W e l f a r e Advocacy Center
2014 W. McKinley, Rm 109 Dentists
M i l waukee 53205 Or. P e t e r M u r r e l l
(414)931-8330 ODs
2545 N. T e u t o n i a Avenue
Pharmacists M i lwaukee 53206
P a t r i c k C o l l i n s , R.Ph. (414) 562-7460
P.O. Box 285
Reedsburg 53959
(608)524-6474(h) 51.52 Boards
524-3515(0) Diane Nelsom, D i r e c t o r
U n i f i e d Board
Recipient Buffalo/Trempealeau/Jackson C o u n t i e s
Sandra Gaulke 112 1/2 Washington
1 N. B e d f o r d #302 Box 45
Mad i son 53703 l ndependence 54747

Consumers
Vicki Plevin
N u r s i n q Homes Program C o o r d i n a t o r
Dennis G r a l i n s k i , A d m i n i s t r a t o r U n i t e d C e r e b r a l P a l s y of S.E.WI
S t . Johns Home of Milwaukee 152 W. Wisconsin Avenue
1840 N. P r o s p e c t Avenue Milwaukee 53203
Milwaukee 53202
Recipient
Chris Roberts
333 W. Dayton, Apt. 616
Recipient Riqhts Madison 53703
Don Hermanson, Esqui re,
Vice Chairperson
Wisconsin J u d i c a r e Inc.
408 T h i r d S t r e e t , S u i t e 408 Handicapped R i q h t s
Wausau 54401
Sara R o b e r t s
Support S e r v i c e s C o o r d i n a t o r
Access t o Independence
1954 E. Washington Avenue
Madison 53704
 Wisconsin - 6
1983

M e d i c a l A s s i s t a n c e A d v i s o r y Committee ( c o n t i n u e d ) :

Consumers Elderly

D o r o t h y Seel y, P r e s i d e n t Joseph T v a r u z k a
A l l i e d Council Board on A g i n g & Long Term Care
4860 S. 9 4 t h S t r e e t 101 S. Webster
Milwaukee 53228 Madison 53702

R e h a b i l i t a t i o n Therapies

Gregory Thompson Community H e a l t h

D i r e c t o r , Human Resources
& Personnel S t e p h a n i e W i l l i a m s o n , M.D.
Sacred H e a r t R e h a b i l i t a t i o n Coggs Comnunity H e a l t h Center
Hospital 2770 N . 5 t h S t r e e t
1545 S. L a y t o n B l v d . Milwaukee 53212
M i l awukee 53215
(414)265-7500
(414)383-4490

Recipient
Chris Roberts
333 W. Dayon, Apt. 616
Madison 53703

3. E x e c u t i v e O f f i c e r s o f S t a t e M e d i c a l and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical Society: B. Pharmaceutical A s s o c i a t i o n :

E a r l Thayer ' W. A l l e n D a n i e l s , R.Ph.

S e c r e t a r y - G e n e r a l Manager Executive D i r e c t o r
S t a t e M e d i c a l S o c i e t y o f Wisconsin W i s c o n s i n P h a r m a c e u t i c a l Assoc.
330 E a s t L a k e s i d e 202 P r i c e P l a c e
Box 1109 Madison 53705
Madison 53701 Phone: 608/238-5515
Phone: 608/257-6781

C. Osteopathic Association:

M r . Robert J. F i n n e g a n
Executive Di r e c t o r
Wisconsin A s s o c i a t i o n o f Osteopathic
P h y s i c i a n s and Surgeons
34615 Road E.
Oconomowoc 53066
Phone: 414/567-0520
 Wyoming - 1
1983

E D I U L ASSISTANCE DRUG PROGRAn (TITLE XIX)

I . BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type o f B e n e f i t C a t e g o r i c a l l y Needy M e d i c a l l y Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC Chi ldren<21 (SFO)
Prescribed
Druqs
Inpatient
H o s p i t a l Care X X X X
Outpatient
H o s p i t a l Care X X X X
Laboratory 6
X-ray S e r v i c e X X X X
S k i l l e d Nursing
Hme Services X X X X
Physician
Services X X X X
Dental
Services
Other B e n e f i t s : Dental and o p t m e t r i c s e r v i c e s , eyeglasses and h e a r i n g a i d s f o r
e l i g i b l e p a t i e n t s under 21 y e a r s o f age, home s e r v i c e s .
*SF0 - S t a t e Funds Only

II. EXPENDITURES FOR DRUGS. Payment t o Pharmacists b y f i s c a l year ending

September 30, 1982
1981 1982
Expended R e c i p i e n t Expended Recipient

TOTAL...............................

CATEGORICALLY NEEDY CASH TOTAL.. ....

Aged ................................
Blind... ............................
Disabled....... .....................
.
C h i l d r e n - F a m i l i e s w/Dep C h i l d r e n . .
A d u l t s - F a m i l i e s w/Dep Children.....

CATEGORICALLY NEEDY NON-CASH TOTAL..

Aged ................................
Blind...... ......................... No vendor drug program
Disabled............................
C h i l d r e n - F a m i l i e s w/Dep Children...
A d u l t s - F a m i l i e s w/Dep Children.....
..........
Other T i t l e X I X R e c i p i e n t s

MEDICALLY NEEDY TOTAL.. .............

Aged ................................
Blind... ............................
D i s a b l e d ............................
C h i l d r e n - F a m i l i e s w/Dep Children...
Adul t s -Fami l i e s w/Oep Chi 1 dren.. ...
Other T i t l e X I X R e c i p i e n t s ..........
**Unduplicated T o t a l - HHS r e p o r t HCFA
366
- 2082
 Wyoming - 2
1983

I l l . Administration:

There i s no s t a t e vendor drug program. The M e d i c a l A s s i s t a n c e Program i s

a d m i n i s t e r e d by t h e D i v i s i o n o f Medical S e r v i c e s o f t h e Department of H e a l t h
and S o c i a l S e r v i c e s .

IV. P r o v i s i o n s R e l a t i n g t o P r e s c r i b e d Drugs:

No s t a t e vendor drug program.

The c o s t of p r e s c r i p t i o n drugs i s t h e r e s p o n s i b i l i t y of County D i v i s i o n of

P u b l i c A s s i s t a n c e and S o c i a l S e r v i c e s and payment i s made from c o u n t y funds.
 Wyoming - 3
1983

Officials, C o n s u l t a n t s and Committees

1. H e a l t h and S o c i a l S e r v i c e s Department O f f i c i a l s :

Stan T o r v i c Department o f H e a l t h and

D i rector Social Services
317 Hathaway B u i l d i n g
Cheyenne, Wyoming 82002

Lawrence J. Cohen, M.D., M.P.H. D i v i s i o n o f H e a l t h and M e d i c a l

Administrator Services

E r n e s t A. Rumpf, J r .
Director
Medical Assistance Services

Jerrv Brvant D i v i s i o n o f Public Assistance

Acting Administrator and S o c i a l S e r v i c e s
307/777-7531

2. Medical A d v i s o r y Comnittee:

John Y a l e - Hospital Administrator

Donald Hunton, M.D. - Physician
Lawrence J. Cohen, M.D. - Administrator, D i v i s i o n o f
H e a l t h & Medical Services
John J. C o r b e t t , M.D. - Physician
Joan B e a c h l e r - County D i r e c t o r o f P u b l i c
Assistance & Social Services
G e r a l d Palmer - Pharmacist
Frank Shaw - N u r s i n g Home A d m i n i s t r a t o r
James N o r r i s - S t a t e Senator
Warren J. Hickman, D.D.S., - Dentist
Chairman
J e r r y Bryant - Acting Administrator, Div. o f P u b l i c
Assistance & Social Services
Mrs. J. J. H i c k e y - County Commissioner
Steve C r a n f i l l - State Representative
John V i n i c h - State Representative
Ray R i n g - County D i r e c t o r of P u b l i c
Assistance & Social Services
Henry Stephenson, M.D. - Physician
Mrs. Joyce F i t z h u g h - Consumer
 Wyoming - 4
1983

3. E x e c u t i v e O f f i c e r s of S t a t e Medical and P h a r m a c e u t i c a l S o c i e t i e s :

A. Medical Society:

Roger Brown
Executive Secretary
Wyoming S t a t e M e d i c a l S o c i e t y
1920 Evans
P. 0. Drawer 4009
Cheyenne 82001
Phone: 307/635-2424

B. Pharmaceutical Association:

Oscar M. Ray
Secretary-Treasurer
Wyoming Pharmaceutical A s s o c i a t i o n
1812 S o u t h M i t c h e l l (Residence)
Casper 82601
Phone: 307/237-9393 ( S t o r e )
(4080 South P o p l a r S t r e e t )

C. Osteopathic Association:

D a v i d A. V i c k , 0.0.
Secretary-Treasurer
Wyoming A s s o c i a t i o n of O s t e o p a t h i c
P h y s i c i a n s and Surgeons
Box 1298
Worland 82401
 MEMBERS OF THE
NATIONAL PHARMACEUTICAL COUNCIL, INC.

ABBOTT LABORATORIES PARKE-DAVIS

Abbott P a r k 201 Tabor Road
North Chicago, Illinois 60064 Morris Plains, New J e r s e y 07950

BOEHRINGER INGELHEIM LTD. PFIZER, INC.

90 East Ridge 235 East 42nd S t r e e t
Ridgefield, C T 06877 New York, New York 10017

BURROUGHS WELLCOME CO. A.H. ROBINS COMPANY

3030 Cornwallis Road 1407 Cummings Drive
Research Triangle Park, NC 27709 Richmond, VA 23220

CIBA-GEIGY CORPORATION ROCHE LABORATORIES

556 Morris Avenue 340 Kingsland S t r e e t
Summit, New Jersey 07901 Nutley, New Jersey 07110

DUPONT PHARMACEUTICALS SAND02 PHARMACEUTICALS

One Rodney Square Route 10
Wilmington, DE 19898 East Hanover, New J e r s e y 07936

GLAXO, INC. SCHEKING CORPORATION

1900 West Commercial Blvd. 2000 Galloping Hill Road
Fort Lauderdale, FL 33309 Kenilworth, New Jersey 07033

HOECHST-ROUSSEL INC. SMITH KLINE 8r FRENCH

Route 202-206 North 1500 Spring Garden S t r e e t
Somerville, NJ 08876 Philadelphia, PA 19101

JOHNSON & JOHNSON E.R. SQUIBB ck SONS, INC.

501 George S t r e e t P.O. Box 4000
New Brunswick, NJ 08903 Princeton, New Jersey 08540

LEDERLE LABORATORIES STUART PHARMACEUTICALS

Berdan Avenue Division of ICI Americas, Inc.
Wayne, New Jersey 07470 Wilmington, DE 19897

ELI LILLY AND COMPANY SYNTEX LABORATORIES

307 East McCarty S t r e e t 3401 Hillview Avenue
Indianapolis, Indiana 462"5 Palo Alto, CA 94304

MARION LABORATORIES, INC. THE UPJOHN COMPANY

10236 Bunker Ridge Road 7000 Portage Road
Kansas City, MO 64137 Kalamazoo, MI 49001

MERCK SHARP & DOHME USV LABORATORIES

Division of Merck & Co., Inc. 303 South Broadway
West Point, PA 19486 Tarrytown, New York 10591

MERRELL DOW PHARMACEUTICALS WINTHROP LABORATORIES

2110 East Galbraith Road Division of Sterling Drug Inc.
Cincinnati, Ohio 45215 90 Park Avenue
New York, New York 10016