Pharmaceutical Benefits Under State Medical Assistance Programs, 1983

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NPC FILE COPY

NATIONAL PHARMACEUTICAL COUNCIL. INC. 1 0 3 0 1 5 T H STREET. N. W.. WI\SHINGTON. D. C. 20005

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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 , Pharmaceut ica l B e n e f i t s Under S t a t e Medical Ass is tance Proqrams, was prepared by t h e N a t i o n a l Pharmaceut ical Counc i l , Inc . t o a s s i s t i n your e v a l u a t i o n o f Medica id program c h a r a c t e r i s t i c s . NPC recognizes Med ica id as an impor tan t h e a l t h c a r e component and, the re fo re , 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 Counc i l shares t h e v iew 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 shou ld r e c e i v e the same qua1 i t y medical 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 con ta ined i n t h i s c o m p i l a t i o n con t inues t o a s s i s t i n t h e development, implementat ion and o p e r a t i o n of respons ive and f i n a n c i a l l y v i a b l e pharmaceut ical programs.

S i 1 c e r e l y ,

a r k R. Knowle

Counc i l , Inc.

MEMBER COMPANIES

Abbott Laboratories Lederle Laboratories Parke Davis Boehringer lngelheim Ltd. Div. of American Cyanamid Co. Div. of Warner-Lamberl Co.

Pfizer inc. Burroughs Wellcome Co. Eli Lilly and Company A. H. Robins Company Ciba-Geigy Carporallon Marlon Laboratories, Inc. Roche Laboratories DuPont Pharmaceuticals Merck Sharp & Dohme Div. of Haffmann-La Roche Inc.

Div. of Merck & Co., Inc. Sandoz Pharmaceuticals Glaxo Inc. Div. of Sandoz. inc. H o e c h ~ t - R O U S S ~ ~ Pharmaceuticals, Inc. Merrell Dow Pharmaceuttcals Inc. Schering Corporation Johnson &Johnson Subsidiary of The Dow Chemical Company Smith Kline & French Laboratories

E. R. Squibb &Sons. Inc. 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.

1030 15rn STREE~, N.W.

WASHINGTON. D.C. 20005

(202) 6592121

TABLE OF CONTENTS

l n t r o d u c t i on

Pharmaceut ical B e n e f i t s Under S t a t e Medical Ass is tance Programs

H e a l t h and Human Serv ices Regional A d m i n i s t r a t o r s

S t a t e Med ica id Drug Program A d m i n i s t r a t o r s

Glossary o f Medica id Terms

Medica id 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

Tables

I . Current S t a t e Medica id Data

I I . Medica id 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 . Misce l laneous

U.S. T o t a l s

Medical Ass is tance 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 )

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NATIONAL PHARMCEUTICAL C W N C I L , INC.

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

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

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

*** Acknowledgements *** NPC acknowledges the cooperation and assistance of the many state program officials and their staffs, state pharmaceutical associations, and others in supplying data for this compilation. Special appreciation is extended to Richard Beisel, HHS-HCFA- ; Sally McCue, La Joila Management Corporation; Harvey Pratt, HHS-HCFA-SBR; and Roland McDevitt, Ph.D., Systemetrics, Inc. T

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 data on S t a t e Medical Ass is tance Programs ( T i t l e X I X ) has been p repared t o p resen t a genera l overv iew 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 together 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 pharmaceut ica l b e n e f i t s p rov ided .

The f o l l o w i n g i n f o r m a t i o n i s p rov ided 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 Medica id 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 loads o r persons e l i g i b l e

t o r e c e i v e h e a l t h c a r e b e n e f i t s i n c l u d i n g r e c i p i e n t s o f pharmaceut ical b e n e f i t s

6. Medica id 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 medical 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 medical a d v i s o r y committees 9 . S t a t e medical and pharmaceut ical a s s o c i a t i o n e x e c u t i v e s

I I . Medica id 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 medical c a r e of low-income Americans. Federa l law governs c e r t a i n aspects 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 medica id coverage. The Federa 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 peop le e l i g i b l e f o r Medica id and t o re imburse 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 ins tances, f l o o r s .

I n many o t h e r respects , t h e s t a t e s have b road 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 Medicaid. T h e i r c o n t r o l over 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 which 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 no 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 Federa l 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 extend Medica id coverage t o a d d i t i o n a l groups o f peop le 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 choosing 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 p r o v i d e r s .

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, rep laced separate F e d e r a l / S t a t e cash 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 inanced and admin is te red by t h e Federa 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 lone f i n a n c e d t h e smal l amount o f p u b l i c l y supported medical ca re a v a i l a b l e t o low income people. I n 1950, t h e Federa 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 medica l s e r v i c e s for p u b l i c ass is tance r e c i p i e n t s . Federa 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 percentage o f cash and i n - k i n d medical b e n e f i t s , up t o maximum d o l l a r amounts.

Federa l involvement i n f i n a n c i n g h e a l t h care f o r low income e l d e r l y people increas57 s i g n i f i c a n t l y i n 1960 w i t h t h e implementat ion 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 owed t o expand t h e i r medica 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 peop le whose incomes, a f t e r s u b t r a c t i n g medical expenses, were below s t a t e standards. 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 "med ica l l y needy". The Federa l government c o n t r i b u t e d open ended matching funds f o r each s t a t e ' s K e r r - M i l l s program. The Federa 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 per c a p i t a income.

I n t h e mid-19605, t h e Federa l r o l e i n p r o v i d i n g medica l s e r v i c e s t o t h e poor expanded markedly w i t h t h e i n t r o d u c t i o n o f Medicaid. 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 we l fa re r e c i p i e n t s who were n o t aged and a l l owed s t a t e s t o ex tend m e d i c a l l y needy coverage t o t h i s new category 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 Medica id program was t o p r o v i d e comprehensive ca re t o a l l those whose incomes were below c e r t a i n s t a t e e s t a b l i s h e d standards, 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 spec 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 superv ise 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)). Genera l l y , 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 umbre l la agency. F i v e s t a t e s have des ignated t h e h e a l t h department, 19 s t a t e s have designated t h e w e l f a r e department, 22 s t a t e s have des ignated an umbre l la agency, and f o u r s t a t e s have des ignated o t h e r agencies t o a d m i n i s t e r t h e Med ica id program. The "o ther" agencies inc luded t h e O f f i c e o f t h e Governor i n Alabama, an independent agency/commission i n Georgia 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 Ass is tance Commission o f Medical Serv i ces 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 ca re f o r low income e l d e r l y persons was named f o r t h e sponsors of the l e g i s l a t i o n t h a t c rea ted i t, Senator Rober t Ker r o f Oklahoma and Represen ta t i ve Wi lbu 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 Robert Stevens and Rosemary Stevens, Wel fare Medic ine i n America (F ree Press, 1974). Source CBO Report - Medicaid: Choices f o r E d beyond. June 1981.

3) L a J o l l a Management Corporat ion, R o c k v i l l e , Maryland, HCFA Con t rac t No. 500-81-0040. ( S e c t i o n I I )

I l l . Medical Care and Serv ices Prov ided

Federa l law p rov ides 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 lan. The reader should 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.

Medica l c a r e se rv i ces t h a t may be p rov ided 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 Serv i ces (excludes: t u b e r c u l o s i s and mental i n s t i t u t i o n s ) (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 ) Rura l h e a l t h c l i n i c se rv i ces , 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 Medica id p lan .

Other Labora to ry and X-Ray S e r v i c e s (A) S k i l l e d Nurs ing F a c i l i t y Serv i ces ( f o r i n d i v i d u a l s

21 o r over ) ( 6 ) E a r l y and P e r i o d i c Screening, Diagnosis, and

Treatment f o r p h y s i c a l and mental de fec ts f o r e l i g i b l e s under 21

(C) Fami ly P lann ing Serv ices P h y s i c i a n s ' Serv ices Medical and Remedial Care recognized under s t a t e law and p rov ided by l i c e n s e d p r a c t i t i o n e r s Home H e a l t h Care Serv ices P r i v a t e Duty Nurs ing Serv ices C l i n i c Serv ices Denta l Serv i ces 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, dentures and p r o s t h e t i c devices, and eyeglasses p resc r ibed by a p h y s i c i a n s k i l l e d i n diseases 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 S e r v i c e s l n p a t i e n t H o s p i t a l , S k i l l e d Nurs ing 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 years o f age o r over 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 iseases l n t e r m e d i a t e Care F a c i l i t y Serv i ces l n p a t i e n t p s y c h i a t r i c h o s p i t a l s e r v i c e s f o r i n d i v i d u a l s under 21 Other Medical o r Remedial Care recognized under s t a t e law and s p e c i f i e d by Secre ta ry , Department o f H e a l t h and Human S e r v i c e s ( HHS)

Serv ices That Must Be Provided: -

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 p r o v i d e t h e b a s i c s e r v i c e s 1 th rough 5, as l i s t e d above.

*"Basic F ive" 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 Med ica id programs.

For t h e M e d i c a l l y Needy ( i f i nc luded 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 "basic 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, as amended.

IV. E l i g i b i l i t y

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 ta tes , 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 Medica id program and t h e AFDC and SSI programs. A t a minimum, s t a t e s must cover a l l persons who r e c e i v e cash payments f rom 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 Medica id 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 Medica id programs must p r o v i d e f o r med ica 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. Genera l ly , these a r e persons 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 as aged, b l i n d , d isab led, 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 depr i ved o f t h e suppor 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 can e l e c t Medica id 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 ass is tance, 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 requirements o r because they do no t w i s h t o r e c e i v e cash ass is tance .

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 cons idered 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 Federa l government mandates e l i g i b i l i t y . F u r t h e r , a Medica id agency t h a t chooses t o cover an o ~ j i o n a l group must p r o v i d e Medica id 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 Con t ro l and Review and Medical Review

a. U t i l i z a t i o n Con t ro l - A s t a t e Medica id p l a n must r e q u i r e t h e medical ass is tance u n i t o f t h e s t a t e Medica id agency t o e s t a b l i s h and implement a s ta te -w ide 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 safeguard 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 covered care 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 covered s e r v i c e s .

4 ) L a J o l l a Management Corpora t ion ( S e c t i o n IV)

5

Federal f inanc ia l p a r t i c i p a t i o n i s ava i l ab le f o r the costs o f u t i l i z a t i o n con t ro l i n accordance w i t h the cond i t ions and a t the r a t e s app l icab le t o Medicaid. There a lso are pena l t i es tha t may be imposed by HHS i f the s ta te does not s a t i s f y HHS t h a t con t ro l o f t h e serv ices has been maintained.

b. U t i l i z a t i o n Review - The Medicaid regu la t ions requ i re t h a t each p a r t i c i p a t i n g hosp i ta l , Mental Hospi ta l , S k i l l e d Nursing F a c i l i t y (SNF), and lntermediate 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 lan f o r use i n reviewing the need fo r i npa t i en t ca re provided. Reviews can be conducted by u t i l i z a t i o n review committees, PSROs, peer review groups or p u b l i c agencies. Medicaid p lans must meet Medicare standards.

c. Medical Review - Medicaid regulat ions requ i re a regular program o f medical review, inc lud ing medical eva lua t ion of each Medicaid SNF p a t i e n t ' s need f o r the care provided.

d. ln termediate Care F a c i l i t i e s (ICFs) have a requirement f o r a regu lar program o f "i ndependant professional review".

, Profess ional Standards Review Orqanizations (PSROs)

PSROs are a review mechanism, establ ished by the Social Secu r i t y Amendments o f 1972, through which physicians assume the r e s p o n s i b i l i t y fo r reviewing the u t i l i z a t i o n o f services provided under Medicaid, T i t l e X I X , and Medicare, - T i t l e XVI I I . PSROs evaluate the appropriateness o f medical determinations as they r e l a t e only t o the medical necessi ty of the serv ices provided, i n accordance w i t h profess ional 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 Equi ty and F i sca l Respons ib i l i t y Act o f 1982, Pub. L. 97-248) repealed the Professional Standards Review Organizat ion (PSRO) program and replaced i t w i t h the U t i l i z a t i o n and Q u a l i t y Control Peer Review Program, commonly re fe r red t o as the PRO Program. This Ac t requi res the Secretary t o enter cont rac ts w i t h p r i v a t e Peer Review Organizat ions (PROS) f o r the review o f the qua l i t y , necessity, and appropriateness of hea l th care serv ices furnished under Medicare.

I t appears t o many observers tha t PSROs, o r i g i n a l l y scheduled t o be phased out a t the end o f 1983, may be funded on an i nd i v idua l basis u n t i l the Peer Review Organizations, (PROS), are establ ished. The t r a n s i t i o n funding remains uncer ta in a t press time (September 1983). P o t e n t i a l PROS are pos i t i on ing themselves t o v i e f o r contracts. Medical soc ie t ies , e x i s t i n g PSROs, and p r i v a t e review cont rac ters appear t o be under considerat ion i n a number o f states. On or a f t e r October 1, 1984, hosp i ta ls rece iv ing payments under the Prospect ive Payment System (Medicare), - are requi red t o cont rac t w i th a PRO. The e f f e c t s tha t the phasing out of PSROs w i l l have on the Medicaid program are unclear a t t h i s time.

V I I . Med ica id 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 Federa l f u n d i n g f o r t h e c o s t s o f design, development, and i n s t a l l a t i o n o f mechanized c la ims ~ r o c e s s i n g and 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 Federa 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 conceptual des ign t h a t can be t a i l o r e d b y s t a t e Medica id agenc ies t o t h e i r own p a r t i c u l a r needs, so long as 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 conceptua l des ign i n c l u d e s s i x subsystems: r e c i p i e n t , p rov ide r , c l a i m processing, re ference 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 review, 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 serve t h e o v e r a l l o b j e c t i v e o f process ing c la ims and pay ing 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 c la ims. The o t h e r two subsystem f u r n i s h data 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 ) V I I I . 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 P rov ided

E a r l y and P e r i o d i c Screeninq, Oiaqnosis and Treatment

E a r l y and p e r i o d i c screening, d iagnos is and t reatment (EPSOT) s e r v i c e s a r e used t o determine 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 care se rv i ces t o c o r r e c t o r a m e l i o r i a t e any de fec ts and c h r o n i c c o n d i t i o n s discovered. There a r e c e r t a i n b a s i c sc reen ing and t reatment s e r v i c e s t h a t each s t a t e must prov ide.

P h y s i c i a n s ' Serv i ces

P h y s i c i a n s ' se rv i ces a r e covered whether p rov ided 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. Phys ic ians ' 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 medic ine o r osteopathy de f ined by s t a t e law, and must be d e l i v e r e d by o r under t h e personal 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 censed under s t a t e law t o p r a c t i c e medic ine o r osteopathy.

Home H e a l t h Serv ices

Home h e a l t h se rv i ces a r e p rov ided 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 residence ( 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 te rmed ia te 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 no t r e q u i r e d t o be p rov ided by t h e f a c i l i t y ) . Serv i ces must be o rdered 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 ca re t h a t i s reviewed b y t h e r e c i p i e n t ' s p h y s i c i a n every 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 nurs ing, home heal t h a ide, and medical 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 therapy, occupa t iona l therapy, speech patho logy, and aud io logy 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 Corporat ion, ( S e c t i o n 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 those under 21 o n l y i f t h e s t a t e p l a n p rov ides SNF s e r v i c e s f o r them.

S k i l l e d N u r s i n q F a c i l i t y Serv ices

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 rov ided 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 d iseases. These se rv i ces must be needed on a d a i l y b a s i s and p rov ided i n an i n p a t i e n t f a c i l i t y . Federa 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 p r o v i d e d 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 requ i rements f o r p a r t i c i p a t i o n and ordered by 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 meet ing l i c e n s u r e requ i rements under s t a t e law t o prov ide, on a r e g u l a r bas is , 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 no t r e q u i r e t h e degree of ca re and t reatment wh ich a h o s p i t a l o r s k i l l e d n u r s i n g f a c i l i t y i s des igned t o p rov ide .

Nurse-Midwife Serv ices

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 nurse-midwi fe 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 nurse-midwi fe 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 nurse-midwife 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 law 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 op t ions . 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 by an o r g a n i z a t i o n recognized b y t h e S e c r e t a r y o r have completed a program o f s tudy and c l i n i c a l exper ience approved by t h e Secretary . Nurse-midwife se rv i ces a r e those concerned w i t h management o f t h e ca re o f mothers and newborns throughout t h e m a t e r n i t y c y c l e .

Fami ly P lann ing Serv ices

Fami ly 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 as a means of e n a b l i n g them t o f r e e l y determine t h e number and spacing of t h e i r c h i l d r e n . A l though the re a r e no Federa 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 can p rov ide , p r o v i s i o n a l r e g u l a t i o n s d e f i n e f a m i l y p l a n n i n g s e r v i c e s t o inc lude: c o n s u l t a t i o n ( i n c l u d i n g counse l ing and p a t i e n t eduat ion) , examinat ion, and t rea tment , 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 by a phys ic ian ; l a b o r a t o r y examinat ion; m e d i c a l l y approved methods, procedures, pharmaceut ical s u p p l i e s and devices t o prevent concept ion; n a t u r a l f a m i l y p lann ing; d iagnos is and t reatment f o r i n f e r t i l i t y ; and v o l u n t a r y s t e r i l i z a t i o n s . 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 se rv i ces , o t h e r than 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 se rv i ces , superv ises 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 medic ines.

Rural Heal th C l i n i c Services

Rural hea l th c l i n i c (RHC) services have been a mandatory serv ice f o r the c a t e g o r i c a l l y needy s ince Ju ly 1978. Each RHC i s requ i red t o have a nurse p r a c t i t i o n e r (NP) or physic ian 's ass is tan t (PA) on i t s s t a f f . Consequently, a c l i n i c can on ly be c e r t i f i e d i f the s ta te permits the d e l i v e r y o f pr imary care 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 provided and furn ished by a phys ic ian or by a PA, NP, nurse-midwife, o r other spec ia l i zed nurse p r a c t i t i o n e r . Services and suppl ies are furn ished i nc iden ta l t o profess ional services. Par t - t ime or i n t e r m i t t e n t v i s i t i n g nurse care and re la ted medical suppl ies are provided i f the c l i n i c i s located i n a Heal th Manpower Shortage Area, the serv ices are furnished by nurses employed by the c l i n i c , and the services are furn ished t o a homebound rec ip ien t under a w r i t t e n p lan of treatment.

Prescribed Druqs

Prescribed drugs includes simple or compound substances or mixtures o f substances prescr ibed by a physic ian or other l icensed p r a c t i t i o n e r of the hea l th a r t s fo r the cure, mi t iga t ion , or prevent ion o f disease. The drugs must be dispensed e i t h e r d i r e c t l y by l icensed authorized p r a c t i t i o n e r s or by a pharmacist ac t i ng on a p r a c t i t i o n e r s prescr ip t ion .

Outpat ient Hospi ta l Services

Outpat ient hosp i ta l services mean prevent ive, d iagnost ic , therapeut ic, 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 services provided t o an ou tpat ien t . There are three Federal l i m i t a t i o n s that are imposed on these services:

0 The services must be provided under the d i r e c t i o n o f a physic ian or d e n t i s t

The f a c i l i t y must be l icensed or fo rmal ly approved as a hosp i ta 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 ta te standard-sett ing; 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

States are f r e e t o spec i fy other l i m i t s on ou tpat ien t hosp i ta l services and 37 states p lus 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 services means prevent ive, d iagnost ic , therapeut ic , 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 or services provided t o an ou tpat ien t , by or under the d i r e c t i o n o f a physic ian or dent is t , on behal f o f a f a c i l i t y t h a t i s not p a r t of a hospi ta bu t i s organized and operated t o prov ide medical care t o outpat ients. b 1

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

Other S e r v i c e s

Other s e r v i c e s p rov ided b u t n o t covered i n t h i s t e x t i nc lude : p r i v a t e du ty nu rs ing , d e n t a l se rv i ces , dentures, p r o s t h e t i c dev ices and eyeglasses, o t h e r d i a g n o s t i c and screen ing and i n p a t i e n t h o s p i t a l se rv i ces .

I X . Vendor Druq Program - (Medica id 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 Medica id 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 Med ica id p l a n f rom any i n s t i t u t i o n , agency, pharmacy, person o r o r g a n i z a t i o n which 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 bas is , and i s q u a l i f i e d t o pe r fo rm such se rv i ces .

I t i s no t requ i red 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 cho ice o f d rug p r o v i d e r if 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 inc ludes pharmaceut ica ls as p a r t o f i t s t o t a l package o f s e r v i c e s .

S e c t i o n 2175 Freedom o f Choice Waivers. S e c t i o n 2175 a t tempts t o inc rease 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 about 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 waivers 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 imary ca re case mangement system f o c u s i n g on p r imary care phys ic ians ;

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 Medica id r e c i p i e n t s i n s e l e c t i n g among compet ing 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 se rv i ces , sav ings r e s u l t i n g f rom 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 medical care; and

R e s t r a i n r e c i p i e n t s t o r e c e i v i n g s e r v i c e s ( o t h e r 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 p r o v i d e r s .

The waivers can be g ran ted f o r a p e r i o d of up t o two years, and a s t a t e may request 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 Serv ices, 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

Requ la t ion 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 Serv ices procedures f o r d e t e r m i n i n g drug c o s t s and, where a p p l i c a b l e , d i spens ing fees which t h e Department w i l l use f o r t h e purpose o f determin ing:

(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 Medicare program;

(2 ) Reimbursement t o s t a t e s under s t a t e admin is te red heal th , wel fare , and s o c i a l s e r v i c e programs; and

( 3 ) A l lowab le c o s t s under p r o j e c t s f o r h e a l t h se rv i ces .

( b ) P o l i c i e s and procedures, which 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 set f o r t h i n t h i s P a r t , w i l l be pub l i shed i n t h e HHS Procurement Regula t ions, T i t l e 41, Chapter 3, Code of Federa l Regula t ions, govern ing t h e d i r e c t purchase of drugs by t h e Department and t h e purchase o r supp ly of drugs by 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 procedures f o r f i x i n g t h e a c t u a l amount o f reimbursement t o which 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 spens ing drugs. Rather, i t e s t a b l i s h e s procedures 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 might o the rw ise prov ide. I f t h e a u t h o r i z i n g 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 issued under t h a t l e g i s l a t i o n , p rov ides f o r a lower r a t e of reimbursement than t h i s r e g u l a t i o n permi ts , t h e n t h e program reimbursement r a t e , be ing 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 which t h e Department w i l l recogn ize 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 desc r ibed i n Sec. 19.1 s h a l l no t exceed t h e lowest o f :

( 1 ) The maximum a l l o w a b l e cos t (MAC) o f t h e drug, if 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 reasonable d i spens ing fee;

(2 ) The a c q u i s i t i o n cos t o f t h e drug p l u s a reasonable d i spens ing fee; o r

7 ) Federal R e g i s t e r , Vo l . 40, 32283, J u l y 31, 1975

8) Federa l R e g i s t e r , Vo l . 40, 32283, J u l y 31, 1975 and c o r r e c t e d i n Federa l Reg is te r , Vo l . 40, 36342, August 20, 1975

( 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; 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 no t app ly t o a brand 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 which 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 rov ided f u r t h e r , tha t : where compensation f o r d rug d ispens ing i s i nc luded i n some o t h e r amount payable t o t h e p r o v i d e r by t h e re imburs ing o r pay ing program agency, a separate d ispens ing f e e w i l l n o t be recognized.

(b ) Each program agency s h a l l es t ima te t h e a c q u i s i t i o n c o s t of each drug 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 drug 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 program 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 des ignated by t h e Pharmaceut ical Reimbursement Board and p u b l i s h e d i n t h e Federa 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 the lower o f :

a. t h e maximum a l l o w a b l e cos t (MAC) e s t a b l i s h e d by t h e Board f o r such drug and pub1 ished i n t h e Federa l R e g i s t e r , o r

b. t h e est imated 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 r e g u l a t i o n s ) .

L i m i t a t i o n t o the 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 by t h e Board s h a l l no 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 brand 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 accep tab le 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 procedure f o r check ing 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 accep tab le c e r t i f i c a t i o n .

For 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 which payment i s made s h a l l be based on t h e lower of t h e c o s t o f t h e drug p l u s a d i spens ing fee o r the p r o v i d e r ' s usual and customary charge t o t h e general pub1 i c .

3 . Pharmaceut ical Reimbursement Board (PRB) 9 Pharmaceut ical Reimbursement S e c t i o n H e a l t h Care F inanc ing 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) Former ly e s t a b l i s h e d i n O f f i c e o f t h e A s s i s t a n t S e c r e t a r y f o r Hea l th , HEW.

Establishment of pharmaceutical reimbursement board.

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

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

(Outline of procedures only - detail omitted)

(a) ldentif ication of drugs to which MAC may be appl ied

(b) Review by the Food and Drug Administration

(c) Initial determination of lowest unit price

(d) Proposed MAC

(e) Notice of Comment

(f) Public Hearing

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

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

HHS will periodically provide each state with product cost data quideline to assist in establishing the estimated acquisition costs 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. Sub jec t : " T i t l e X I X , 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 on Payment o r Reimbursement f o r Drugs: Est imated 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 Medica id r e g u l a t i o n s on d rug reimbursement i s t o have each s t a t e ' s es t ima ted 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 rov ide r . The s t a t e s are, the re fo re , 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 cost . The Department 's a n a l y s i s o f p r i c e data over 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 - t h e 7 0 t h - might a p p r o p r i a t e l y be used as a bench mark i n de te rm in ing t h e degree t o which 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 cos t . Any s t a t e which i s found t o be re imburs ing 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 ev idence 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 than t h e Federal 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 ta tes :

"Each program a d m i n i s t r a t o r should 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 drug program t o assure t h a t drug 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. Fo rmu la r ies i n Medica id Proqrams

Under e x i s t i n g federa 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 drug 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 , " the b a s i c o b j e c t i v e i s t o enable doc to rs and pharmacis ts throughout 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 recognized t h e r a p e u t i c value, produced by r e p u t a b l e manufacturers and broad enough t o cover v i r t u a l l y any s i t u a t i o n " (Medica id Ass is tance Manual SRS-MSA-196 1971).

A drug fo rmu la ry o r l i s t o f pharmaceut ical p roduc ts i s e i t h e r open ( u n r e s t r i c t e d ) o r c losed ( 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 determines i t s own f o r m u l a r y s ta tus . A n o p e n fo rmu la ry 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 by 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 drug t o t r e a t each p a t i e n t . A c losed fo rmu la ry i s a l i m i t e d l i s t of drugs f o r which reimbursement w i l l be g ran ted under t h e s t a t e Medica id program. No drug t h a t i s no t con ta ined i n t h e l i s t i s covered w i t h o u t p r i o r approva l by 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 cho ice o f drugs i n t r e a t i n g Medica id p a t i e n t s .

6 . Implementat ion o f Formulary Guidel ines

Formulary 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 Federa l Regu la t ions as s e t f o r t h be1 ow:

"Drugs. ( i v ) The use o f a fo rmu la ry 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 gener i c drugs. Where e i t h e r i s employed, t h e r e must be standards f o r q u a l i t y , sa fe ty , 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 ou t the above r e g u l a t i o n , s t a t e agencies shou ld c o n s i d e r t h e f o l l o w i n g gu ide l ines :

0 Any med ica t ion inc luded i n a fo rmu la ry s h a l l meet such acceptab le standards f o r drugs as r e q u i r e d under t h e Federal Food, Drug, and Cosmetic Act , as amended, and t h e a p p l i c a b l e requirements 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 reng th , safety, q u a l i t y , p u r i t y , and e f f e c t i v e n e s s .

S t a t e agencies should adopt procedures which w i l l ensure 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 accep tab le s tandards o f i d e n t i t y , s t reng th , safety, q u a l i t y , p u r i t y , and e f fec t i veness .

Any f o r m u l a r y developed f o r a s t a t e ' s Med ica id Drug Program should no t become so 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 i tems 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 impossible. The f o r m u l a r y should have due regard 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 o f p r a c t i t i o n e r s . I t shou ld 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 inso fa 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 formulary committee shou ld be composed o f p r a c t i c i n g phys ic ians, pharmacologists, pharmacists, 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 shou ld be charged w i t h the 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 r e q u i r e d a t s p e c i f i e d i n t e r v a l s .

A p r i n c i p a l purpose of the fo rmu la ry shou ld be t o i d e n t i f y t h e drugs approved f o r reimbursement under t h e program. However, it should 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 tems upon p r o f e s s i o n a l j u s t i f i c a t i o n .

Each i t e m should have an assigned code number ( p r e f e r a b l y , f rom t h e FDA N a t i o n a l Drug Code D i r e c t o r y . ) Tha t code number should lend i t s e l f t o au tomat i c o r e l e c t r o n i c data

process ing 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 cos t . 109

X. R e c i p i e n t Cost Shar ing Under Medica id

F i n a l r e g u l a t i o n s have been issued by 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) which 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 deduc t ib les , co insurance 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 except ions. The r e g u l a t i o n s , which were issued i n f i n a l form e f f e c t i v e February 8, 1983, a r e based on p r o v i s i o n s con ta ined 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) which amended Med ica id cos t s h a r i n g requirements.

Under t h e HCFA's f i n a l r u l e , s t a t e Medica id programs a r e now p e r m i t t e d t o impose cos t shar ing 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 except ions which p r o h i b i t c o s t shar ing 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 years o f age, s e r v i c e s f u r n i s h e d t o pregnant women o r i f t h e se rv i ces a r e r e l a t e d t o t h e pregnancy, emergency se rv i ces , f a m i l y p l a n n i n g se rv i ces , s e r v i c e s f u r n i s h e d by 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 se rv i ces 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 medica 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 Med ica id 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 agree t o accept t h e s t a t e reimbursement and t h e copayment amount p a i d by a b e n e f i c i a r y as payment i n f u l l . However, t h e HCFA r u l e mandates t h a t a p r o v i d e r must agree 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 unable t o pay t h e c o s t s h a r i n g amount. Accord ing 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 assure c o n t i n u e d a v a i l a b i l i t y of se rv i ces 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 Medica id popu la t ion . Because o f these r e v i s i o n s , s t a t e Medica id 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 serv ices. 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 rov ided t o a r e c i p i e n t .

X I . Hea l th and Human Serv ices Department, H e a l t h Care F i n a n c i n q A d m i n i s t r a t i o n - An Overview

The Hea l th 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 major 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 assoc ia ted 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 federa 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 assurance programs.

10) (Reference - Medical Ass is tance 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 deve lo 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 gener i has been inc luded which 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 by pharmacists. See Table #IVB, page

HCFA's m i s s i o n i s to:

Ensure the 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 rder 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 b e n e f i c i a r i e s ;

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 which t h e y a r e e l i g i b l e , t h a t these 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 rov ided i n the most e f f e c t i v e manner, and;

Ensure 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 out by t e n reg iona l o f f i c e s , each of which i s respons ib le 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 geographic 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: m o n i t o r t h e performance o f Medicare c o n t r a c t o r s , Medica id s t a t e agencies, s t a t e survey agencies, and PSROs; i n t e r p r e t Federa 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 these o r g a n i z a t i o n s ; mon i to r t h e expend i tu re o f Federa l funds; oversee 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 .

REG1 ONAL ADM I N I STRATORS H e a l t h and Human Serv ices

Hea l th 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 - Connect icu t , Maine, Massachusetts, New Hampshi re, Rhode I s l a n d , Vermont

John F. Kennedy Federa l B ldg. Government Center, Room 1309 Boston, Massachusetts 02203

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, Federal B u i l d i n g , Room 3811 P u e r t o Rico, V i r g i n 26 Federa l P laza I s l a n d s 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 Columbia, Maryland, Pennsylvania, V i r g i n i a , West V i r g i n i a

(P. 0. Box 7760) 3535 Market S t r e e t P h i l a d e l p h i a , Pennsy lvan ia 19101

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 ryan t

REGION #4 - Alabama, F l o r i d a , Georgia, Kentucky, M i s s i s s i p p i , N o r t h Carol i na, South Caro 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 , Ind iana, Michigan, Minnesota, Ohio, Wisconsin

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

REGION #6 - Arkansas, Lou is iana , New Mexico, Oklahoma, Texas

101 M a r i e t t a S t r e e t S u i t e 701 A t l a n t a , Georgia 30323

175 West Jackson Bou levard 8 t h F l o o r , Room A835 Chicaqo, I 1 l i n o i s 60604

1200 Main Tower B u i l d i n g Room 2400 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 Regional Administrators and ARAs* (con t inued) :

REGION #7 - Iowa, Kansas, M issour i , Nebraska

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

REGION #8 - Colorado, Montana, South Dakota, N o r t h Dakota, Utah, Wyoming

New Federa l O f f i c e B u i l d i n g . 601 East 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

1961 S t o u t S t r e e t Federa l O f f i c e B u i l d i n g , Rm. 628 Denver, Colorado 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. l s h i d a

REGION #9 - Ar izona, 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 ranc isco , 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 : Robert D. O'Connor

REGION #10 - Alaska, Idaho, Oregon, Washington

2901 T h i r d Avenue 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

Sam T. Hard in , P.D. A d m i n i s t r a t o r Pharmaceut ical Program Alabama M e d i c a i d Agency 2500 F a i r l a n e D r i v e Montgomery, Alabama 36130 (205) 277-2710 x310

ALASKA

Bob Ogden A s s i s t a n t D i r e c t o r D i v i s i o n o f P u b l i c Ass is tance Chief o f Medical Ass is tance Pouch H-07 Juneau, A laska 9981 1 (907) 465-3030

ARIZONA

Donald 8. M a t h i s D i r e c t o r A r i zona Department of H e a l t h Serv ices Corpora t ion Commission B u i l d i n g 1200 West Washington, Room 224 Phoenix, A r i zona 85007

ARKANSAS

Tom Brads haw A d m i n i s t r a t o r , Medica l Ass is tance

Sec t ion Arkansas S o c i a l Serv i ces P. 0. Box 1437 L i t t l e Rock, Arkansas 72203 (501) 371-2403

CALIFORNIA

M i l t o n Kuschnere i t , Pharm. Senior 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 Serv ices 714 P. S t r e e t , Room 1253 Sacramento, Cal i f o r n i a 95814 (916) 445-0981

COLORADO

M y r l e A. Myers, R.Ph., M.S. Ch ie f , Pharmacy and Ambulatory

Care Serv ices S e c t i o n D i v i s i o n of Medica l Ass is tance Colorado Department of S o c i a l Serv i ces

1575 Sherman S t r e e t , Room 1010 Denver, Colorado 80203 ( 303) 866-5372

Connect icu t

Meyer Rosenkrantz, R.Ph. Pharmacist Consu l tan t Department o f l ncome Maintenance 110 Bartholomew Avenue H a r t f o r d , Connect icu t 06116 (203) 566-8007 o r 7223 o r 7224

DELAWARE

Roger Anderson, R.Ph. Pharmacist Consul tant Dept. of H e a l t h and S o c i a l Serv i ces Delaware S t a t e H o s p i t a l New Cast le , Delaware 19720 (302) 421-6132

D l STR l CT OF COLUMB l A

James F. H a r r i s , R.Ph. Pharmacist Consu l tan t O f f i c e o f H e a l t h Care F i n a n c i n g Department of Human S e r v i c e s 614 H S t r e e t , NW, Room 708 Washington, D.C. 20001 (202) 727-0753

Rod P r e s n e l l , R.Ph. Pharmacist Consu l tan t Medica id 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 Serv . 1317 Winewood Boulevard, 8-6, R-237 Ta l lahassee, F l o r i d a 32301 (904) 488-9990

GEORGIA l OWA - Frances Lipscomb, R.Ph. Progam Management O f f i c e r Pharmacy S e r v i c e 2 M.L. K ing J r . Dr ive, S.E. James F l o y d Memorial B u i l d i n g West Tower, P.O. Box 38440 A t l a n t a , Georgia 30334 (404) 656-4037

HAWA I I

Omel L. Turk Pharmacist Consul tant P u b l i c We l fa re D i v i s i o n Oept. o f S o c i a l Serv i ces & Housing P.O. Box 339 Honolu lu , Hawai i 96809 (808) 548-8917

l OAHO

Dianne B. Onnen, R.Ph., M.P.A. Pharmacy Consul tant Oept. o f H e a l t h and Welfare Statehouse Boise, Idaho 83720 (208) 334-4323

ILLINOIS

Dawn A t k i ns Pharmacy Program Superv isor Medica l Ass is tance Program I l l i n o i s Oept. of P u b l i c Aid,

2nd F l o o r 931 East 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 (217) 782-0506

INDIANA

Mark S h i r l e y Pharmacy Consul tant Ind iana S t a t e Dept. o f P u b l i c We l fa re 100 Nor th Senate Avenue - Room 701 I n d i a n a p o l i s , Ind iana 46204 (317) 232-4705

Ronald 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 Bureau o f Medical S e r v i c e s Oept. o f S o c i a l S e r v i c e s 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 Oes Moines, Iowa 50319 (515) 281-5755

KANSAS

Gene Hotchkiss, R.Ph. Pharmacist Consu l tan t Dept. o f Soc ia l & R e h a b i l i t a t i o n Serv. S t a t e O f f i c e B u i l d i n g Topeka, Kansas 6661 2 (913) 296-3981

KENTUCKY

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 Bureau of S o c i a l l nsurance 275 East Main S t r e e t , 3 r d F l o o r F r a n k f o r t , Kentucky 40621 (502) 564-4321

LOU l S IANA

Eunice R i t c h i e , R.Ph. Pharmacist Consul tant Medica l Ass is tance Programs O f f i c e o f F a m i l y S e c u r i t y P.O. Box 44065 Baton Rouge, L o u i s i a n a 70804 (504) 342-3889

MAINE - Michael P. O'Oonnel l , R.Ph. Pharmacy Consu l tan t Medica id Drug Program Oept. o f Human S e r v i c e s Statehouse Augusta, Maine 04333 (207) 289-2674

MARYLAND MISSOURI

Leone W. Marks, R.Ph. S t a f f Spec ia l i s t f o r Pharmacy

S e r v i c e s Dept. o f H e a l t h & Mental Hygiene 201 West P r e s t o n S t r e e t Bal t imore, Maryland 21201 ( 301 ) 383-2658

MASSACHUSETTS

Caro lyn Keal y Manager, Med ica id Pharmacy Program Dept. of P u b l i c Wel fare 600 Washington S t r e e t , Room 746 Boston, Massachusetts 02111 (617) 727-8082

MI C H I GAN

Vernon K. Smith, Ph.D. D i r e c t o r Bureau of Med ica id l n fo rmat i on

and Pol i c y Development, Dept. o f S o c i a l Serv i ces 921 West Holmes, P.O. Box 30037 Lansing, Mich igan 48909 (617) 373-7720

MINNESOTA

John T. Bush, R.Ph. Pharmacist Consu l tan t 444 L a f a y e t t e Road S t . Pau l , Minnesota 55164 (612) 296-2363

MISSISSIPPI

James T. Stee le , R.Ph. Pharmacist M i s s i s s i p p i Medica id Commission P.O. Box 16786 4785 i 55 North, P.O. Box 16786 Jackson, M i s s i s s i p p i 39236 (601) 354-7464

R ichard A. R i l e y Pharmaceutical Consul t a n t I I D iv . Fami l y Serv ices, Medica l S e r v i c e s

Sect ion, Dept. S o c i a l Serv i ces Broadway S t a t e O f f i c e Bldg., P.O. Box 88 Je f fe rson C i t y , M i s s o u r i 65103 (314) 751-3399

MONTANA

Gary B l e w e t t A d m i n i s t r a t o r Economic Ass is tance Div . , Dept. o f

Soc ia l and Rehabi l i t a t i o n Serv ices P.O. Box 4210 o r 111 Senders Helena, Montana 59604 (406) 449-3952

NEBRASKA

Tom R. Dolan, R.Ph. Pharmaceut ical Consu l tan t Medical Serv i ces Div., Dept. o f P u b l i c Wei fare 301 Centennia l M a l l South, 5 t h F l o o r P .O. Box 95026 L inco ln , Nebraska 68509 (402) 471-3121, e x t . 360

NEVADA

Steven P. B rad fo rd , Pharm.D. Pharmaceut ical Consu l tan t Nevada Med ica id O f f i c e Welfare D i v i s i o n , Dept. Human Resources S t a t e Capi to1 Complex 251 J e a n e l l D r i v e Carson C i t y , Nevada 89710 (702) 885-4775

NEW HAMPSHIRE

C l i f f o r d A. Z i l c h , R.Ph. Chief , Bureau o f Medica l Claims Review Dept. o f H e a l t h and We l fa re Hazen D r i v e Concord, New Hampshire 03301 (603) 271-4359

NEW JERSEY OHIO - Sanford Luger , R.Ph. Chief , Pharmaceut ica l Serv i ces Div . of Med ica l Ass is tance & H e a l t h

Serv ices, Dept. o f Human Serv ices 324 E a s t S t a t e S t r e e t , P.O. Box 2486 Trenton, New Jersey 08625 (609) 292-3756

NEW HEXI CO

Donald R. Sut ton, R.Ph. Drug Program A d m i n i s t r a t o r Medica l A s s i s t a n c e Bureau Dept. o f Human Serv ices P.O. Box 2348 Santa Fe, New Mexico 87503 (505) 827-5551

NEW YORK

Gera ld F. N e l l i g a n , R.Ph. Assoc ia te S o c i a l Serv ices

Medica l Ass is tance S p e c i a l i s t S t a t e Dept. o f Soc ia l Serv ices 40 N o r t h P e a r l S t r e e t Albany, New York 12243 (518) 474-9261

NORTH CAROL I NA

C. 8. R idou t , R.Ph. Pharmacist Consu l tan t D i v i s i o n of Med ica l Ass is tance Dept. o f Human Resources 410 N. Boy lan Avenue Raleigh, Nor th Carol ina 27603 (919) 733-6775

NORTH DAKOTA

Chuck Gress, R.Ph. Coord ina to r o f Pharmacy Serv ices Department of Human Serv ices S t a t e C a p i t o l B u i l d i n g B i smarck, N o r t h Dakota 58505 (701) 224-2321

R ichard G leck le 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 Med ica id S e r v i c e s D i v i s i o n o f Claims Process ing 30 Eas t Broad S t r e e t - 3 8 t h F l o o r Columbus, Ohio 43215 (614) 466-7814

OKLAHOMA

Howard S tansber ry Pharmacy Program A d m i n i s t r a t o r Dept. of Human S e r v i c e s P.O. Box 25352 Oklahoma C i t y , Oklahoma 73125 (405) 521-3804

OREGON

Charles N. Mortensen, R.Ph. Pharmacists Consu l tan t A d u l t and F a m i l y Serv ices D i v i s i o n Dept. o f Human Resources 203 Publ i c S e r v i c e B u i l d i n g Salem, Oregon 97310 (503) 378-2263

PENNSYLVAN lA

Joseph E. Conci no, R.Ph. Bureau o f P o l i c y and Program Development Dept. o f P u b l i c Welfare, Room 510 H e a l t h and Welfare B u i l d i n g Har r i sburg , Pennsy lvan ia 17120 (717) 787-1170

RHODE ISLAND

John A. P a g l i a r i n i , R.Ph. C h i e f Medica 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 VERMONT

John 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 Serv i ces P. 0. Box 1520, Roan 525 Columbia, South C a r o l i n a 29202

SOUTH DAKOTA

Donald Mahannah, R.Ph. Pharmacist Consu l tan t Department of S o c i a l Serv i ces Medical Serv i ces 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 Serv ices Tennessee Department o f P u b l i c

Heal t h & Envi ronment 283 P l u s Park Boulevard N a s h v i l l e , Tennessee 37217 (615) 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 Ashley, R.Ph. Manager, Program Operat ions and Medica l Determi n a t i o n s

H e a l t h Care F inanc ing U tah Oepartment o f H e a l t h P. 0. Box 2500 S a l t Lake C i t y , Utah 84103 (801 ) 533-6037

Char les P e r r y Chie f o f Po l i c y and E v a l u a t i o n Medica id D i v i s i o n Department o f S o c i a l We l fa re 103 South Main S t r e e t Waterbury, Vermont 05676 (802) 241-2880

VIRGINIA

Mary Ann Johnson, R.Ph. Pharmacist Consu l tan t Medical Ass is tance 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 Consu l tan t O f f i c e Medical P o l i c y & Procedure M a i l Stop LK-11 Olympia, Washington 98504 ( 206) 753-0524

WEST VIRGINIA

Bernard Sch lac t , R.Ph. Pharmacist Consu l tan t D i v i s i o n o f Medical Care West V i r g i n i a Oepartment of Welfare 1900 Washington S t r e e t , E a s t Char leston, West V i r g i n i a 25305 ( 304) 348-8990

WISCONSIN

Ted Col l i n s Pharmacist Consul tant Wisconsin 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 Wi l son S t r e e t , Room 325 Madison, Wisconsin 53702 (608) 266-0722

a C a t e g o r i c a l l y Needy: Under Medicaid, 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 Medica id and who meet f i n a n c i a l e l i g i b i l i t y requirements 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 type o f c o s t - s h a r i n g under Medica id whereby insured o r covered persons pay a s p e c i f i e d f l a t amount per u n i t of s e r v i c e o r u n i t o f t ime, and t h e i n s u r e r pays t h e r e s t of t h e c o s t .

a Covered Serv ices: Covered se rv i ces 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 which Medica id 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 Medica id program c o n s i s t of a combinat ion 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 f u r n i s h i n g a p a r t i c u l a r s e r v i c e o r supp ly 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 iagnos is , and Treatment (EPSDT): The EPSDT program covers screen ing and d i a g n o s t i c s e r v i c e s t o determine 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 reatment , 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 de fec ts and c h r o n i c c o n d i t i o n s discovered.

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 inc luded i n de te rm in ing t h e amount o f cash 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 determined e s s e n t i a l t o t h e i n d i v i d u a l ' s we l l -be ing .

a Expendi tures: Under Medicaid, "expendi tures" 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 covered medica l expenses o f e l i g i b l e p a r t i c i p a n t s .

a Fami ly P lann ing Services: Fami ly 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 iagnos is , t reatment , drugs, s u p p l i e s and devices, and r e l a t e d counse l ing which a r e f u r n i s h e d o r p r e s c r i b 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 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 determine t h e number o r spac ing o f t h e i r c h i l d r e n .

F i s c a l Agent: A f i s c a l agent ( f i s c a l i n te rmed ia ry ) i s a c o n t r a c t o r t h a t processes o r pays vendor c la ims on b e h a l f o f t h e Med ica id agency.

1 1 ) L a J o l l a Management Corporat ion, (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 which 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 which meets c e r t a i n c o n d i t i o n 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 who a r e fu rn ished these s e r v i c e s .

Home H e a l t h Serv ices: Home h e a l t h s e r v i c e s a r e se rv i ces and i tems 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 by a home h e a l t h agency, o r by o t h e r s under arrangements made by 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 by a phys ic ian . 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 inc lude: p a r t - t i m e o r 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 , occupa t iona l , o r speech therapy; medical s o c i a l se rv i ces , medical s u p p l i e s and a p p l i a n c e s ( o t h e r than drugs and b i o l o g i c a l s ) ; home h e a l t h a i d e se rv i ces , and s e r v i c e s o f i n t e r n s and res iden ts .

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 i tems 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 se rv i ces , d i a g n o s t i c and t h e r a p e u t i c se rv i ces , and medical o r s u r g i c a l s e r v i c e s .

In te rmed ia te Care F a c i l i t y : An in te rmed ia te care 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 ca re and s e r v i c e s t o i n d i v i d u a l s who do no t r e q u i r e t h e degree of c a r e p rov ided by 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 as de f ined under T i t l e X I X (Medica id) o f t h e Soc ia l S e c u r i t y Act .

Labora to ry and R a d i o l o g i c a l Serv ices: Labora to ry and r a d i o l o g i c a l se rv i ces 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 ordered by a l i c e n s e d p r a c t i t i o n e r and p rov ided 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 by 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 Medicaid, 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 the rw ise e l i g i b l e f o r Medicaid, and whose income resources 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 as 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 Med ica id s t a t e p lan .

Other P r a c t i t i o n e r s ' Serv ices: 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 se rv i ces o f l i c e n s e d p r a c t i t i o n e r s o t h e r than p h y s i c i a n s and d e n t i s t s .

Ou tpa t ien t H o s p i t a l Serv ices: 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 a r e s e r v i c e s f u r n i s h e d t o o u t p a t i e n t s b y a p a r t i c i p a t i n g h o s p i t a l f o r d iagnos is o r t reatment 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 resc r ibed drugs a r e drugs dispensed b y a l i c e n s e d pharmacist 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 law t o admin is te 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 separab le from h i s o t h e r charges, o r drugs covered by a h o s p i t a l ' s b i l l .

0 Reasonable Charge: I n process ing c la ims f o r Supplementary Medical Insurance 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 reasonable charge f o r se rv i ces rendered. The reasonable charge i s t h e lowest o f : t h e a c t u a l charge b i l l e d by 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 serv i ces , and t h e p r e v a i l i n g charge which most phys ic ians 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 s e r v i c e . Increases i n t h e p h y s i c i a n s ' p r e v a i l i n g charge l e v e l s a r e recognized o n l y t o t h e e x t e n t j u s t i f i e d by 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 general earn ings.

0 Reasonable Cost: I n process ing c la ims f o r H e a l t h 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 determine t h e reasonable cos t i ncu r red 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 en ro l lees . The reasonable 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 serv ices, 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 which 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 covered by t h e insurance program.

0 Rec ip ien t : A r e c i p i e n t o f Medica id i s an i n d i v i d u a l who has been determined t o be e l i g i b l e f o r Medica id and who has used medica l se rv i ces covered under Medicaid.

Rura 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 which 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 medical and h e a l t h se rv i ces , which meets c e r t a i n o t h e r requirements designed t o ensure the 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 served by 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 no t an urban ized area as d e f i n e d by t h e Bureau o f t h e Census and t h a t i s des ignated b y t h e S e c r e t a r y o f DHHS e i t h e r as an area w i t h a shor tage of personal h e a l t h serv ices, o r as a h e a l t h manpower shor tage area, and has f i l e d an agreement w i t h t h e Secre ta ry n o t t o charge any i n d i v i d u a l o r o t h e r person f o r i tems o r s e r v i c e s f o r which 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, except f o r t h e amount o f any d e d u c t i b l e o r co insurance amount app l i c a b l e .

b S k i l l e d Nurs ing 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 which 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 se rv i ces , 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 requ i rements .

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 standards r e q u i r e d by t h e S e c r e t a r y o f DHHS.

a Spend-Down: Under t h e Medica id program, spend-down r e f e r s t o a method b y which an i n d i v i d u a l e s t a b l i s h e s Medica id e l i g i b i l i t y by reduc ing gross income through i n c u r r i n g medica l expenses u n t i l ne t income ( a f t e r medical expenses) meets Medica id 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 which a s t a t e may p r o v i d e Supplementay Medical Insurance coverage f o r i t s needy e l i g i b l e persons through an agreement w i t h t h e Federa l government under which t h e s t a t e pays t h e premiums f o r them.

S t a t e Plan: The Medica id S t a t e P l a n i s a comprehensive w r i t t e n commitment by a Medica id agency t o admin is te r o r superv ise t h e a d m i n i s t r a t i o n of a Medica id program i n accordance w i t h Federa l requ i rements.

Supplemental S e c u r i t y Income (SSI): S S I i s a program o f income suppor t f o r low-income aged, b l i n d , and d i s a b l e d persons e s t a b l i s h e d by T i t l e XVI of t h e Soc ia l S e c u r i t y Act .

0 T h i r d - P a r t y L i a b i l i t y : Under Medicaid, 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 if 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 insurance) which 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 medical 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 o f Medicaid.

Vendor: A medical 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 p rov ides h e a l t h o r medica l se rv i ces .

MEDl CAI D PROGRAM CHARACTERISTICS AND STATIST1 CS

I . C u r r e n t S t a t e Med ica id Data

A. "Medicaid Drug Reimbursement" ( I n c l u d e s d ispens ing fees, copay, i n g r e d i e n t reimbursement bas is , formulary , 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 popu la t ion , 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 medical payments, vendor drug payments.)

I I .

I l l

IV.

Med ica id Trends

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

6. "Rec ip ients o f P r e s c r i b e d Drugs"

C. "Average Expend i tu re pe 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. "Tota l Expendi tures & Drug Expendi tures f o r 1977-1982," t o t a l U.S. f i g u r e s

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. f i g u r e s

F. "Average Expendi tures per 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 Expendi tures per r e c i p i e n t ( f o r drugs) , 1977-1982," t o t a l U.S. f i g u r e s

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

A. "Sta te 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. "State 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 over"

Misce l laneous

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 Regula t ions"

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

------------------ ~ i ~ ~ ~ l year 1983 ------------------ ------------- F i s c a l Year 1982 ------------ I n g r e d i e n t Med ica id Drug Average Number o f

D ispens ing Reimbursement S t a t e Reimbursement P r e s c r i p t i o n P r e s c r i p t i o n s S t a t e Fee Copayment Bas is Formulary MAC M i l l i o n s $ P r i c e Processed

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

A laska No Vendor Drug Program

A r i z o n a 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*

C a l i f o r n i a 3.60 1.00 EAC Yes Yes 231.6 9 - 5 6 28,000,000*

Colorado 3.40 AWP/EAC Yes Yes 14.3 10.22 W

1,401,458 0

Connec t i cu t 3.11 AWP/EAC N o N o 17.4 9.24 2,215,134

Delaware 3.20 AAC N o No 2.5 8.50 293,046"

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

F l o r i d a 3.33 EA C N o No 48.8 8.23 6,192,000

Georgia 3.61 EAC Yes Yes 47.7 10.23 N A

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

I l l i n o i s 2.78 AAC Yes Yes 91.9 7.24 15,052,540

Table IA Page Two

------------------ ~ i ~ ~ ~ l year 1983 ------------------ ------------- F i s c a l Year 1982 ----------- I n g r e d i e n t Medica id Drug Average Number o f

D ispens ing Reimbursement S t a t e Reimbursement P r e s c r i p t i o n P r e s c r i p t i o n s S t a t e Fee Copayment B a s i s Formulary MAC M i l l i o n s $ P r i c e 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

Mich igan 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*

M i s s i s s i p p i 3.17 EAC Yes Yes 28.5 9.06 3,196,542

M issour i 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

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

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

L .- L m u a al w n VI > I E - m.- "7 - r a m m - a m t ,

Table IA Page Four

------------------ F i s c a l year 1983 ------------------ ------------- F i s c a l Year 1982 ----------- I n g r e d i e n t Medica id Drug Average Number of

D ispens ing Reimbursement S t a t e Reimbursement P resc r . P r e s c r i p t i o n s S t a t e Fee Copayment Bas is Formulary MAC M i l 1 ions $ P r i c e 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 A WP No No 3.8 8.61 520, OOO*

V i r g i n i a 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 A WP 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

N A Not a v a i l a b l e * Approximate f i g u r e it* $8.21 r e t a i l - 9.65 N.H. AAC Actua l A c q u i s i t i o n Cost AWP Average Wholesale P r i c e EAC Est imated A c q u i s i t i o n Cost MAC Max imumAl lowab leCos t

In fo rmat ion i n t h i s t a b l e was gathered i n an NPC survey o f S t a t e Medica id Departments

DRU6 RECIPIENTS AND VENDOR PAYMEHTS T a b l e 18 Page One

P o p u l a t i o n T o t a l Drug T o t a l Vendor Vendor Drug Est imates R e c i p i e n t s R e c i p i e n t s Medical Payments Payments

S t a t e 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 $71 1 266,590,253 21,084,674

C a l i f o r n i a 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

F l o r i d a 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

I l l i n o i s 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

Mich igan 9,109,000 1,174,833 742,825 1,292,630,601 71,581,129

Table I B Page Two

Popu la t i on T o t a l Drug T o t a l Vendor Vendor Drug Est imates Rec ip ien ts Rec ip ien ts Medical Payments Payments

S t a t e 1982 1982 1982 1982 1982

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

M i s s i s s i p p i 2,551,000 303,621 232,154 262,866,987 28,456,785

Missour i 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 Caro l ina 6,019,000 353,841 237,621 482,837,674 31,487,710

No r th 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 Caro l ina 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

Tab le IB Page Three

P o p u l a t i o n T o t a l Drug T o t a l Vendor Vendor Drug Est imates Rec ip ien ts R e c i p i e n t s Medical Payments Payments

S t a t e 1982 1982 1982 1982 1982

V i r g i n i a 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 Est imates 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 , compi led by S t a t e Med ica id program o f f i c i a l s . A l though t h e r e p o r t s have been reviewed and e d i t e d by 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 . Despi te these p o t e n t i a l shortcomings t h e 2082 HCFA da ta represent t h e most accura te 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 Med ica id serv ices.

**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 I s l a n d s and P u e r t o Rico.

VENDOR PAYMEWS FOR PRESCRIBED DRUGS

Tab le I I A Page One

(Amounts i n Thousands)

S t a t e 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 l abarna 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

C a l i f o r n i a 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

Connect icu t 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

F l o r i d a 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

I l l i n o i s 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

Mich igan 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

Table I IA Page Two


S t a t e 1977 1978 1979 1980 1981 1982

Miss iss ipp i 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 Carol ina 26,356 26,695 29,131 32,401 34,598 31,488

North 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 Is land 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

V i r g i n i a 15,014 17,490 20,519 23,950 27,121 29,862

Tab le I IA Page Three


S t a t e 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 , compi led by S t a t e Med ica id program o f f i c i a l s . A l 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 some r e p o r t i n g e r r o r s . Desp i te these p o t e n t i a l shortcomings t h e 2082 HCFA data represent t h e most accura te 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 Med ica id se rv i ces . *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 lands and P u e r t o Rico.

RECIPIENTS OF PRESCRIBED DRUGS T a b l e l l B Page One

S t a t e 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

C a l i f o r n i a 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

F l o r i d a 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

I l l i n o i s 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

Table l lB Page Two


S ta te 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

Rhode Is land 69,575 9 86,418 85,7 2 83,946

SouthCaro l ina 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

V i r g i n i a 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


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 the repo r t s have been reviewed and ed i ted by HCFA, they may s t i l l con ta in sane repo r t i ng e r ro rs . Despite these po ten t i a1 shortcomings the 2082 HCFA data represent the most accurate f igures ava i l ab le on u t i l i z a t i o n of s ta te Medicaid services.

AVERAGE EXPENDITURE PER REClP IEHT FOR PRESCRIBED DRUGS

T a b l e I I C Page One

S t a t e 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

C a l i f o r n i a 63.86 63.89 69.82 76.10 87.84 96.62

Col orado 62.70 0 113.02 12 .29 144.13

Connect i cut 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

F l o r i d a 70.36 68.26 101.38 101.82 111.86 125.26

Georgia 1 155.05 144. 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

I l l i n o i s 81 .05 1 114.76 11 .47 114.37

l nd i ana 110.25 121.57 132.07 145.45 156.35 172.03

1 om 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 i ana 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

Mich igan 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

M i s s i s s i p p i 82.89 102.12 96.27 105.95 105.00 122.58

Table I I C Page Two

S t a t e 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

North 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 Is land 91.35 74.19 82.72 93.59 105.63 116.26

South Carol ina 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

V i r g i n i a 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 Three

S t a t e 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 , compi led by S t a t e Medica id program o f f i c i a l s . 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 by HCFA, they 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 . Desp i te these p o t e n t i a l shortcomings t h e 2082 HCFA data rep resen t 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 o f s t a t e Med ica id s e r v i c e s .

EXPENDITURES i n MILLIONS o f DOLLARS

30000

27500

25000

22500

20000

17500

15000

12500

10000

7500

5000

2500

0

Legend:

TOTAL EXPENDITURES C DRUG EXPENDITURES FOR 1977 - 1982

Char t I I D

YEAR

$ - T o t a l Expendi tures D - Drug Expendi tures

RECIPIENTS i n MILLIONS

24

23

22

21

2 0

19

18

17

16

15

14

13

12

Leaend:

TOTAL RECIPIENTS 5 DRUG RECIPIENTS FOR 1977 - 1982

C h a r t I I E

1977 1978 1979 1980 1981 1982

YEAR

< * - T o t a l R e c i p i e n t s 0 - Drugs R e c i p i e n t s

AVERAGE EXPENDITURES

1500

1400

1300

1200

1100

1000

900

800

700

600

500

400

300

200

100

0

AVERAGE EXPENDITURES PER RECIPIENT FOR ALL SERVICES AND FOR DRUGS

Chart I I F

Leaend:

1977 1978 1979 1980 1981 1982

YEAR < * - T o t a l Average Expendi ture for a l l Serv ices

D - Drugs Average Expendi ture f o r Drugs

48

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

Populat ion % o f N a t ' l Compounded Per Capi ta Annual Estimate Population Growth Rate Personal Income Unemployment Rate

S t a t e 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

C a l i f o r n i a 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

F l o r i d a 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

I l l i n o i s 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

Table l l lA Page Two

P o p u l a t i o n % o f N a t ' l Compounded Per Cap i ta Annual E s t i m a t e P o p u l a t i o n Growth Rate Personal Income Unemployment Rate

S t a t e 1982 1982 1977-1982 1982 1982

Mich igan 9,109,000 3.934 -. 11 11,052 15.0

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

M i s s i s s i p p i 2,551,000 1.102 .73 7 792 11.1

M i s s o u r i 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 Jersey 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

Pennsy lvan ia 11,865,000 5.125 -.03 10,943 10.6

Rhode l s land 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

State

Population Estimate

1982

% of Nat' I Compounded Per Capita Annual Population Growth Rate Personal Income Unemployment Rate

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 - 0 3 11.970 6.2 --

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

STATE POPULATION CHARACTERISTICS, AGES 65 AND OVER

T a b l e l l l B Page One

P o p u l a t i o n % of S t a t e Compounded Growth 65 and over P o p u l a t i o n Rate, Ages 65+

1982 65 and over 1977-1982

Alabama 461,000 11.692 2.98

A laska 13,000 2.968 7 -63

Ar izona 340,000 11 .888 6.09

Arkansas 323,000 14.099 2.46

C a l i f o r n i a 2,553,000 10.326 3.18

Colorado 264,000 8.670 3.25

Connect icu t 387,000 12.274 2.68

Delaware 63,000 10.465 3.52

0 . C . 73,000 11.569 .28

F l o r i d a 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

I l l i n o i s 1,313,000 11.469 1.97

Ind iana 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

Lou is iana 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

P o p u l a t i o n % o f S t a t e Compounded Growth 65 and over P o p u l a t i o n Rate, Ages 65+

S t a t e 1982 65 and over 1977-1982

Mich igan 964,000 10.583 2.52

Minnesota 502,000 12.146 1.99

M i s s i s s i p p i 299,000 11.721 2.52

M i s s o u r i 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 Jersey 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 Caro 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

Pennsy lvan ia 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

State

Population 65 and over

1982

% of State Population 65 and over

Compounded Growth Rate, Ages 65+

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 Table IVA Page One

PHARMACIES Nurs ing A l l PHARMA-

STATE Comnunity Chain H o s p i t a l C l i n i c Home Others* T o t a l 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

Ar izona 246 25 1 70 39 4 67 677 2,149""

Arkansas 59 7 111 82 4 4 8 806 1,353

C a l i f o r n i a 3,295 1,139 516 158 5 182 5,295 11,852

Colorado 435 135 51 25 1 53 700 2,189**

Connect icu t 583 126 1 3 0 0 713 1,874

Delaware 46 66 16 2 4 0 134 379**

D.C. 88 7 0 4 1 2 3 168 403

F l o r i d a 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 7 0 32 15 11 0 0 128 274

l daho 198 46 40 6 3 11 304 667

I l l i n o i s 2,143 560 191 82 19 88 3,083 5,658

l nd i ana 705 529 127 21 9 2 1 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**

Lou is iana 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**

Mich igan 1,583 404 215 49 10 109 2,370 6,287

Table IVA Page Two

PHARMACIES Nursing A l l PHARMA-

STATE Comnunity Chain Hospi ta l C l i n i c Home Others* Tota l CISTS

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

Miss iss ipp i 662 144 11 8 27 50 5 1,006 1,789

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

Montana 171 39 6 3 8 3 4 288 702

Nebraska 385 65 14 9 4 15 492 323

Nevada 8 5 68 18 3 0 17 191 521

New Hampshire 121 58 3 2 1 8 1 221 610**

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

New Mexico 183 77 4 1 50 2 9 3 446 871""

New York 3,151 684 316 6 4 68 157 4,440 12,400

North Carol ina 94 1 508 132 23 13 56 1,673 2,245

North Dakota 150 19 47 14 2 4 236 664""

Ohio 1,486 88 0 7 5 3 9 11 136 2,627 7,511""

Oklahoma 714 194 5 2 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 Is land 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 9 1 3 3 9 0 36 396 1,051""

Vermont 90 3 2 18 0 0 1 141 244

Tab le IVA Page Three

PHARMACIES Nurs ing A l l PHARMA-

STATE Comnunity Chain H o s p i t a l C l i n i c Home Others* T o t a l CISTS

V i r g i n i a 576 489 113 38 6 36 1,258 2,989

V i r g i n I s l a n d s 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 2 1 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 I s l a n d s 0 0 0 0 0 0 0 6

APO/FPO, F o r e i g n 1 0 0 0 0 0 1 7

* Inc ludes 1,112 Department S t o r e s and 420 Grocery S t o r e s ** 72,258 Newly Licensed o r Re-Licensed R.Ph.s.

Source: Business 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

Revised 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 P a t i e n t Year Year Formulary RxForm o r Can Be Record Savings N o t i f i c a t i o n

S t a t e Enacted Amended L i m i t a t i o n s P r o v i s i o n s Mandatory Prevented Requi red Pass-on Requi r e d

Alabama 1979 None Yes P A Yes No N o

A laska 1976 None Yes P C N o Yes Yes

Ar i zona 1978 1979 None Yes P A Yes Yes Yes

Arkansas 1975 Nega t i ve No P B No Yes Yes

C a l i f o r n i a 1975 1980 Negat ive N o P B No No Yes

~n Colorado 1976 None No P B No Yes Yes m

Connect icu t 1976 None No P B Yes Yes Yes

Delaware 1976 1981 P o s i t i v e Yes P A Yes Yes Yes

D.C. 1976 P o s i t i v e N o P B Yes N o NO

F l o r i d a 1974 1976 Negat ive N o M(6) B Yes Yes Yes

Georgia 1977 None Yes P A Yes N o N o

Hawa i i 1980 P o s i t i v e N o M(8) B(9) Yes Yes Yes

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

I l l i n o i s 1977 1981 P o s i t i v e N o P B Yes N o N o

"7

"l

"l 0 0

- -

-

m c m .- .- 2 0 2

"l V a l 0 > > Z

a l o a l > Z >

> z >

n m m

L L L P

0 0 0 Z Z Z

O a l a l - > > .-

C) .- h : Z P D

w m r. m -

O L n r . 0 3 r . r . m m m -

" l a - C .- m x

"l

"l 0

.- C) .-

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-

TI C m

> L m x

Table IVB Page Four

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 P a t i e n t Year Year Formulary RxForm o r Can Be Record Savings N o t i f i c a t i o n

S t a t e Enacted Amended L i m i t a t i o n s P r o v i s i o n s Mandatory Prevented - Requi red Pass-on Requi red

V i r g i n i a 1977 1978 P o s i t i v e 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 Nega t i ve Yes ( 2 ) p ( 5 ) A,B ( 2 ) Yes Yes Yes

Wisconsin 1976 P o s i t i v e No P B N o Yes Yes

Wyoming 1979 None Yes P A Yes Yes No

*Some of 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 express p r i o r approval by 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 p lace. Pharmacist i s a u t o m a t i c a l l y au thor i zed t o s u b s t i t u t e un less M.D. i n d i c a t e s express d isapprova l , such as by 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 "Med ica l l y necessary". I n Alaska, M.D. must pe rmi 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 denied 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 the pharmacist i s au thor i zed t o s u b s t i t u t e un less 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 or by p r i n t e d form. Ora l p r e s c r i p t i o n s must be dispensed as t ransc r ibed , 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 pe rmi t ted .

IDAHO: Regu la t ion adopted by 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). A l l p r e s c r i p t i o n s must c o n t a i n two s igna tu res 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 . I f 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 "dispense as w r i t t e n " , i n h i s o r her own h a n d w r i t i n g t o prevent s u b s t i t u t i o n .

Table 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 product t o be s u b s t i t u t e d i s t h e same as t h e manufacturer of the p resc r ibed name brand, M.D. may no t prevent s u b s t i t u t i o n .

WASHINGTON, UTAH: Board o f Pharmacy i s empowered b u t not r e q u i r e d t o adopt nega t i ve o r p o s i t i v e formulary .

WEST VIRGINIA: The pharmacist " s h a l l s u b s t i t u t e . . ., unless i n h i s p ro fess iona l judgement . . . 1 1

FLORIDA: F l o r i d a product s e l e c t i o n law s t a t e s t h a t t h e pharmacist " sha l l " , un less requested o the rw ise by t h e purchaser. I n the absence o f the p r e s c r i b e r s ' "Medica l ly necessary" des ignat ion, t h e pharmacist s h a l l s u b s t i t u t e a l e s s expensive gener i c e q u i v a l e n t drug product f rom a fo rmu la ry o f s u b s t i t u t a b l e drug p roduc ts es tab l i shed by each community pharmacy.

NORTH DAKOTA: Law r e q u i r e s the 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 the p r a c t i t i o n e r s own handwr i t ing , 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 the pharmacist t o o f fe r l e s s expensive gener i c e q u i v a l e n t products when a v a i l a b l e .

HAWAII: Ora 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 Subs t i t u te " statement by t h e p r e s c r i b e r t o p reven t s u b s t i t u t i o n .

LOUISIANA: A pharmacist may s e l e c t o n l y drug products determined by FDA t o be pharmaceu t i ca 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.

O H I O : P a t i e n t n o t i f i c a t i o n i s not requ i red 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 Opin ion s ta tes , "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 the purchaser."

U n i t e d S t a t e s - 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%

F a m i l y P l a n n i n g 134,126 0.4 112,833 0.8

Other Care

C l i n i c 41 1,320 1.4 222,006 1.2

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

Denta l 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 -Pat ient 1,597,801 5.3 821,843 4.5

Phys ic ians 2,107,392 7.0 1,595,399 8.8

H o s p i t a l I n - P a t i e n t 8,853,143 29.6 30.8

T o t a l s $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 found on t h e f i r s t page o f each s t a t e sect ion.

** These t o t a l s do inc lude the V i r g i n I s lands .

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 fFY 1975, 1980, 1982)

NPC U n i t e d S t a t e s . 3 1983

I I . EXPENDITURES FOR DRUGS. 1981 and 1982*

Expend i tu res 1981 1982

R e c i p i e n t s 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 B l i n d . . . . . . . . . . . . . . . . . 9.867. 371 Disab led . . . . . . . . . . . . . . . . 366.528. 602 . . . 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 158.917. 265 . . . . A d u l t s - 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 B l i n d . . . . . . . . . . . . . . . . . 1.617. 713 . . . . . . . . . . . . . . . . m Disab led 47.803. 478

m 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 . . . 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 B l i n d . . . . . . . . . . . . . . . . . 1.007. 429 869. 135 5. 231 3. 569 Disab led . . . . . . . . . . . . 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

M A B A M

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) Presc r ibed

l noat i e n t 7

H o s p i t a l Care X X X X O u t p a t i e n t H o s p i t a l Care X X X X Labora to ry & X-ray Serv ice X X X X S k i l l e d Nurs ing . Home Serv ices X X X X P h y s i c i a n Serv ices X X X X Denta l Serv ices x** Other B e n e f i t s : Optornetr ic se rv i ces ; home h e a l t h care; e a r l y , p e r i o d i c , screen ing, d iagnos is and t reatment; f a m i l y p lann ing; t r a n s p o r t a t i o n . *SF0 - S t a t e Funds Only **Dental Serv i ces EPSDT - under 21 years o l d

I I . EXPENDITURES FOR DRUGS. Payment t o Pharmacists by f i s c a l year end ing September 30, 1982

1981 1982 Expended R e c i p i e n t Expended R e c i p i e n t

T O T M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $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 Disab led ............................ 7,608,117 48,329 9,212,079 48,647 C h i l d r e n -Fami l i es w/Dep Chi ldren. . . 780,397 52,076 888,335 53,145 A d u l t s -Fami l i es 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 Disab led ............................ 452,355 1,942 563,555 1,990 C h i l d r e n -Fami l i es w/Oep Chi ldren. . . 66,583 6,786 27,119 2,408 A d u l t s -Fami l i es 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 ind . . ............................. 0 0 Disabled........ .................... 0 0 Chi l dren -Fami l ies w/Oep Chi ldren. . . 0 0 A d u l t s -Fami l i es w/Oep Chi ldren. . ... 0 0 Other T i t l e X I X R e c i p i e n t s .......... 0 0

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

NPC Alabama - 2 1983

I l l . Adminis t rat ion:

Alabama Medicaid Agency

IV. Provis ions Re la t ing t o Prescribed Drugs:

A. General Exclusions: Vitamins, food supplements, and an t i -obes i t y , cough and co ld preparat ions, c e r t a i n drug products c l a s s i f i e d as lack ing adequate evidence of effect iveness.

0 . Formulary: Alabama Drug Code Index, which spec i f i es those drugs t h a t may be dispensed on p resc r ip t i on only.

C. P rescr ib ing or Dispensing L imi ta t ions :

1. Quant i ty o f Medication: Normal p resc r ip t i ons are 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 prescr ibed by a phys ic ian SHALL NOT be a r b i t r a r i l y changed by a pharmacy except by au tho r i za t i on - of the physician. The pharmacist should contact the p resc r ib ing physic ian fo r au thor iza t ion t o reduce the 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 the 34-day supply l i m i t a t i o n where appropriate. Author iza t ion t o reduce the u n i t s o f a p r e s c r i p t i o n must be noted on the p r e s c r i p t i o n form by the pharmacist. Prescr ip t ions f o r T i t l e X I X nurs ing 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 leas t a minimum t h i r t y (30) day supply.

2. R e f i l l s : When authorized by prescr iber , 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. (sub jec t t o DS/UR). A l l p resc r i p t i ons should be r e f i l l e d only 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 ns t ruc t i ons .

3. L i m i t o f 6 p resc r ip t i ons per r e c i p i e n t per month (E f f . 7/8/83).

D. P resc r ip t i on Charge Formula: Medicaid pays fo r prescr ibed legend and non-legend drugs authorized under the program based upon and s h a l l not exceed the lowest o f :

1 . The Maximum Al lowable Cost (MAC) of the drug p l u s a dispensing fee.

2. The Estimated Acqu is i t i on Cost (EAC) of the drug p lus a dispensing fee, or

3. The p rov ide r ' s Usual and Customary charge t o the p u b l i c f o r the drug.

Alabama - 3 1983

P r e s c r i p t i o n Charge Formula (con t inued) :

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 (county , s t a t e , o r federa l pharmacies)

D ispens ing Phys ic ians .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 by 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 :

Fami ly p l a n n i n g drugs o r supp l ies ; under 21 years o f age,

Drugs used i n t h e t reatment o f c o n d i t i o n s i d e n t i f i e d through t h e EPSDT program; pregnancy cases,

Drugs dispensed t o Medica id 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. Misce l laneous Remarks: FY 1982

COST AND USE DATA

No. o f Drug R e c i p i e n t s % o f E l i g i b l e s 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 R e c i p i e n t s P r i c e per R e c i p i e n t T o t a l Drug Costs Average Rx P r i c e

*Alabama Medica id 1 0 t h Annual Report 10/1/81 - 9/30/82

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

Montgomery, Alabama 36103

NPC Alabama - 4 1983

O f f i c i a l s , Consul tants and Committees

1. O f f i c i a l s :

Faye S. Baggiano A c t i n g Commissioner Alabama Medica id Agency

C lay ton H. Schmidt, M.D. Ch ie f , P r o f e s s i o n a l Serv i ces Div . Alabama Medica id Agency

Sam T. Hardin, P.D. A d m i n i s t r a t o r Pharmaceut ical Program 205/277-2710, Ex t . 300

Alabama Med ica id Agency 2500 F a i r l a n e D r i v e Montgomery, Alabama 36130

2. T i t l e X I X Medical Care Adv iso ry Committee:

C. l v e y Wi l l iamson, M.D. The Medical A s s o c i a t i o n 1555 S p r i n g h i l l Avenue Mob i le 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 Nor th 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 Pharmaceut ical 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 & Nurs ing Home 1616 F o r e s t d a l e P laza Sy I acauga 35150 Birmingham 35214

Alabama Nurs inq Home Assoc. Alabama Optometr ic Assoc.

Ms. M i l d r e d Jobe, A d m i n i s t r a t o r Cra ig R. McNamara Nurs ing 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 Medica id program t r a n s f e r r e d from H e a l t h Oepartment o f Governor 's O f f i c e as S i n g l e S t a t e Agency by Execu t i ve Order.

Alabama - 5 1983

T i t l e X I X Medica l Care Adv iso ry Committee (con t inued) :

American A s s o c i a t i o n Medica l A s s i s t a n t s Consumer Represen ta t i ves

Mrs. Jean Yarbrough Route 1, Box 355 E n t e r p r i s e 36330

Medical A s s o c i a t i o n o f t h e S t a t e o f Alabama

Wheeler A. Gunnels, M.D. 715 B r a n t l e y S t r e e t Opp 37467

C. l v e y Wi l l iamson, M.D. 1555 S p r i n g h i l l Avenue Mob i le 36604

S t a t e Board o f Mental H e a l t h

Mary Ann Darby P. 0. Box 4010 Montgomery 36195

E l l e n Dempsey 1949 Walnut S t r e e t Montgomery 36106

Char les G. S p r a d l i n g 1840 7 t h Avenue N. Birmingham 35203

J u l i a T r a n t P. 0. Box 6406 Dothan 36302 . .

S i s t e r M e r r i l l a c , A d m i n i s t r a t o r Ms. Bess Hatcher 873 O e l c r i s t D r i v e Burmingham 35226

3721 Wares F e r r y Road Montgomery 36109

M r . Mark T h o r n h i l l S t a t e Department o f Pensions O f f i c e o f V o l u n t a r y C i t i z e n

G S e c u r i t y

D r . Leon F r a z i e r Commissioner 64 N o r t h Union S t r e e t Montgomery 36130

P a r t i c i p a t i o n Montgomery 36130

Honorable Thomas A. Snowden P. 0. Box 825 Columbiana 35051

3. Execu t i ve O f f i c e r s o f S t a t e Medical and Pharmaceut ical S o c i e t i e s :

A. Medical Assoc ia t ion : B. Pharmaceut ical Assoc ia t ion :

Lon Conner Jon Barganier Execu t i ve D i r e c t o r Execu t i ve D i r e c t o r Medica l A s s o c i a t i o n o f Alabama Pharmaceut ical

t h e S t a t e o f Alabama A s s o c i a t i o n 19 South Jackson S t r e e t 340 Dexter Avenue Montgomery 36104 Montgomery 36104 Phone: 205/263-6441 Phone: 205/262-0027

C. Osteopath ic Assoc ia t ion :

Kenneth D. McLeod, 0.0. Secre ta ry Alabama Osteopath ic A s s o c i a t i o n 1511 N. McKenzie S t r e e t Fo ley 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 Chi idren<21 (SFO) P r e s c r i b e d Drugs l n p a t i e n t H o s p i t a l Care X X X X X O u t p a t i e n t H o s p i t a l Care X X X X X Labora to ry & X-ray S e r v i c e X X X X X S k i l l e d Nurs ina .. Home Serv ices X X X X X P h y s i c i a n Serv ices X X X X X Dental .......

Serv i ces X , X X X Other B e n e f i t s : In te rmed ia te 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 care; e a r l y and p e r i o d i c screening, d iagnos is and t reatment f o r e l i g i b l e s under 21; f a m i l y p lann ing; i n te rmed ia te care f o r t h e m e n t a l l y re ta rded ; 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 se rv i ces ; eyeglasses; speech and h e a r i n g se rv i ces ; mental h e a l t h c l i n i c . *SF0 - S t a t e Funds Only

I I . EXPENDITURES FOR DRUGS. Payment t o Pharmacis ts b y f i s c a l year end ing September 30, 1982

1981 1982 ~ x ~ e n d e d - 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 ............................... ...... CATEGORICALLY NEEOY CASH TOTAL

Aged ................................ Blind... . . .......................... Disabled.......... ..................

... C h i l d r e n -Fami l i es w/Oep C h i l d r e n A d u l t s -Fami l i es w/Oep Children.....

CATEGORICALLY NEEOY NON-CASH TOTAL.. Aged ................................ Bl ind . . ............................. Disabled............. ............... C h i l d r e n -Fami l i es w/Oep Chi ldren. . . A d u l t s -Fami l i es w/Oep Children..... Other T i t l e XIX R e c i p i e n t s ..........

............... MEDICALLY NEEOY TOTAL Aged ................................ B l i n d . .............................. Disab led ............................ ... C h i l d r e n -Fami l i es 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 Chi ldren. . . . . Other T i t l e X I X R e c i p i e n t s ..........

A l a s k a ' s Med ica id program does n o t i n c l u d e drugs, excep t f a m i l y p l a n n i n g drugs and drugs dispensed t o i n p a t i e n t s of h o s p i t a l s and n u r s i n g homes.

**Undupl icated T o t a l - HHS r e p o r t HCFA - 2082 7 1

NPC Alaska - 2 1983

I I I . A d m i n i s t r a t i o n :

There i s no s t a t e T i t l e XIX vendor drug program. The A laska Medical Ass is tance programs i n c l u d i n g Medica id and General Re l ie f -Med ica l a r e admin is te red by t h e D i v i s i o n o f P u b l i c Ass is tance ( f o r m e r l y t h e D i v i s i o n of Medical Ass is tance) of t h e Alaska Department of H e a l t h and Soc ia l Serv ices. Th is D i v i s i o n a l s o inc ludes 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 de te rm ina t ions .

I V . P r o v i s i o n s R e l a t i n g t o Presc r ibed Drugs:

A l though drugs a r e n o t covered under Medicaid i n Alaska, p r e s c r i p t i o n s a r e p a i d from the General Re l ie f -Med ica l budget f o r Medica id r e c i p i e n t s who have no o t h e r resource f o r o b t a i n i n g p r e s c r i b e d medicat ions.

Alaska - 3 1983

Officials, Consultants and Committees

1. Health and Social Services Department Officials:

Robert Smith, Ph.0. Commissioner

Department of Health and 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 -2556

Fairbanks 99707

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

Ar izona - 1 1983

N£DlCAL ASSISTANCE DRU6 PROGRAH UNDER TITLE X I X

Ar izona H e a l t h Care Cost Containment System (AHCCCS pronounced "ACCESS")

AHCCCS Features:

The Ar izona s t a t e l e g i s l a t u r e set t h e scene f o r i t s exper iemnta l h e a l t h - c a r e program when i t re fused t o accept Medica id fund ing f rom t h e f e d e r a l government. I n 1981 t h e s t a t e bus ied i t s e l f w i t h deve lop ing 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 Ar izona o u t o f t h e t r o u b l e d Med ica id program b u t g e t federa l h e a l t h fund ing i n t o t h e s t a t e .

The Ar izona 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 sess ion 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 years o f debate over c r e a t i n g a s t a t e hea l th -ca re program. Ar i zona 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 tached than t h e Medica id 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 three-year exper iment 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 medica l -care 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 bas is . 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 year. 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 fees f o r v a r i o u s se rv i ces .

A d m i n i s t r a t i o n :

Ar izona H e a l t h Care Containment System (AHCCCS), A r i zona Department of H e a l t h Serv ices. A d m i n i s t r a t o r : MCAUTO Systems.

General In format ion:

The Ar izona H e a l t h Care Cost Containment System (AHCCCS) was developed i n Senate B i l l 1001 which was passed b y t h e L e g i s l a t u r e and s igned b y t h e Governor i n November, 1981. I t c o n t a i n s s i x major 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 t ime, ensur ing 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 care s e r v i c e s a r e p rov ided t o e l i g i b l e persons i n a d i g n i f i e d fash ion. The goal o f these s i x i tems i s t o c o n t r i b u t e t o t h e es tab l i shment 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 less expensive than conven t iona l f e e - f o r - s e r v i c e systems. The s i x mechanisms are:

o Pr imary Care Phys ic ians A c t i n g as Gatekeepers o Prepa id Cap i ta ted F inanc ing o Compet i t ive B i d d i n g Process o Cost Shar ing 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 by t h e Federa 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

Pr imary Care Phys ic ians A c t i n g as Gatekeepers:

Ar izona - 2 1983

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 memb s u p e r v i s i o n ca re phys i ' c i a n who w i l l

e r s mu assume

1st be under t h e ca re and t h e r o l e of case

manager. A s ta tew ide network o f p r imary ca re phys ic ians , a c t i n g as case managers, w i l l thereby be e s t a b l i s h e d t o pe r fo rm a gatekeeping f u n c t i o n f o r t h e system. Because a l l ca re must be approved by t h e p r i m a r y c a r e phys ic ians , t h e p r imary ca re 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 excess ive use o f emergency rooms--both o f which 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 Cap i ta ted 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 t ime. 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 es tab l i shment o f a s ta tew ide 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 rov ided on a county-by-county bas is , and b i d s w i l l be encouraged t o e f f e c t t h a t g o a l . 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 be d e l i v e r e d i n a g iven county. P rov ide rs 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 s e r v i c e s they norma l l y p r o v i d e . For 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 area; h o s p i t a l s may do t h e same; and so on. The law 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 achieve t h e bes t p o s s i b l e system. I n t h e event 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. It i s intended, however, t h a t capped fee- f o r - s e r v i c e w i l l be au thor i zed 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 rep resen t forms of p r e p a i d h e a l t h p lans (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 types o f o rgan ized h e a l t h d e l i v e r y systems. As such, they w i l l charge a f i x e d f e e per 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 broad a r ray of h e a l t h care s e r v i c e s t o members.

Compet i t i ve B i d d i n g Process:

The s ta tew ide c o m p e t i t i v e aspect o f t h e b i d process 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 un ique f e a t u r e o f t h e AHCCCS model. A p r o v i d e r compet i t i on o f t h i s magnitude has never been at tempted i n any o t h e r s ta te . Ar izona 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 ca re s e r v i c e c o n t r a c t s , as opposed t o convent iona 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 ca re 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 Hea l th Serv ices w i l l i ssue 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 se rv i ces , a t l e a s t on a b i e n n i a l bas is , t o b i d t o p r o v i d e se rv i ces 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 serv i ces , o r any a l l o w a b l e p a r t i a l g roup ing of s e r v i c e s , i n one o r more coun t ies .

NPC Ar i zona - 3 1983

Cost Shar ing:

The f o u r t h major dev ice 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 shar ing by members. A s ta tew ide co-payment schedule w i l l be 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 co insurance c o s t shar ing. I t i s expected t h a t t h e i m p o s i t i o n o f nominal copayments w i l l ensure op t ima l e f f e c t i v e n e s s i n t h e area 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 design a co-payment schedule t h a t accomplishes t h r e e o b j e c t i v e s : 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 care.

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

The f i f t h major i t em 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. U n l i k e conven t iona l d e l i v e r y models, A r i zona 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 comp le te ly b lanke ted 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 assigned p lans f o r d e f i n i t e d u r a t i o n s of t ime. 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 which t o e n r o l l , as w e l l as t h e p r i m a r y care 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 covered by p r e p a i d c a p i t a t e d p lans.

C a p i t a t i o n o f t h e S ta te by t h e Federal Government:

The S t a t e o f Ar izona w i l l i t s e l f be c a p i t a t e d by t h e Federal 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 ca re c o s t s . C a p i t a t i o n r a t e s w i l l be e s t a b l i s h e d accord ing 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 rep resen t no more than 95 percen t o f t h e es t ima ted cos t of se rv i ces c u r r e n t l y d e l i v e r e d i n Ar izona under conven t iona l f e e - f o r - s e r v i c e arrangements. C a p i t a t i o n 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 mon i to r h e a l t h care c o s t s on a c a r e f u l and cont inuous bas is .

IMPLEMENTATION OF AHCCCS

AHCCCS i s based on ideas t h a t have been tes ted, i n p a r t , on sma l le r sca les i n d i f f e r e n t areas of t h e coun t ry . By combining a number of key mechanisms on a s ta tew ide bas is , AHCCCS represents a novel h e a l t h c a r e model. The purpose of t h i s s e c t i o n i s t o p resen t a d i s c u s s i o n o f how t h e key concepts 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 rendered o p e r a t i o n a l .

P rov ide r 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 process 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 as e i t h e r f u l l o r p a r t i a l b e n e f i t p r o v i d e r s .

Ar izona - 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 bas is . Here, p r o v i d e r s agree t o accept 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 medica l s e r v i c e s by 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 owed a lmost e x c l u s i v e l y f o r emergency se rv i ces .

Func t ions 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 serve AHCCCS members; and c r e a t e a number of o rgan ized h e a l t h systems through 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 necessary t o complement t h e c a p i t a t e d system.

C o n t r a c t i n g H e a l t h P lans

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 terms of e x p l i c i t groups of p r o v i d e r s organ ized i n t o c o n s o r t i a o r more fo rma l e n t i t i e s . These c o n s o r t i a , o r more formal e n t i t i e s , a r e capable o f p r o v i d i n g t h e f u l l range 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 area f o r a l l AHCCCS members who e l e c t t o j o i n t h e p lans, up t o a predetermined capac i t y . T h i s i s expected 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 compet ing 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 lans a r e d e l i v e r y systems, n o t s imp ly insurance p lans, b u t they need not be H e a l t h Maintenance Organ iza t ions by any l e g a l o r conven t iona 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 organ ized system, b u t i t must be capable 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 ra te .

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 Organized H e a l t h Systems se rve 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 plans, 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 rea 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 cho ice i n those areas covered by 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 Organized P lans must:

o Be prepared 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 ca re d e l i v e r y systems i n any area o f t h e S t a t e no t adequately covered by C o n t r a c t i n g H e a l t h P lans.

o Serve as the mechanism f o r assur ing emergency and u rgen t c a r e f o r t h e "emergent members" o f AHCCCS.

Ar izona - 5 1983

o Serve as back-up systems i n t h e event 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 te rm ina te a c o n t r a c t .

o Operate w i t h i n a f i x e d budget, regard less o f t h e number o f members e n r o l l e d . The C o n t r a c t i n g H e a l t h Plans 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 Role of the Ar izona Department of H e a l t h Serv ices :

The Department o f H e a l t h Serv ices has been charged w i t h t h e genera l implementat ion and m o n i t o r i n g of the 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 zona 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 t h a t r e s p o n s i b i l i t y .

I t w i l l be t h e task of t h e Department to: develop t h e Rules and Regula t ions; conduct the 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 forming 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 mon i to 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 opera te t h e program increases, the r o l e o f t h e D i v i s i o n w i l l become one of general superv is ion , 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 Operat iona l Ro le o f the AHCCCS Admin is t ra to 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 every day opera t ions o f t h e program, sub jec t t o the general 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 Promot ion of AHCCCS o Procurement of Con t rac 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 ions

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. Serv i ces comnenced October 1, 1982. Funding f o r f i r s t year 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 . Serv i ces inc lude: I n p a t i e n t , o u t p a t i e n t , l a b o r a t o r y , x - ray , p r e s c r i p t i o n drugs, medical supp l ies , p r o s t h e t i c devices, emergency den ta 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 dentures, t reatment of eye c o n d i t i o n s and EPSDT.

NPC Ar izona - 6 1983

O f f i c i a l , Consul tants and Committees

1. H e a l t h Services Department O f f i c i a l s :

Donald B. Mathis O i r e c t o r

Ar izona Hea l th Care Cost Containment System

1200 W. Washington, Room 224 Phoenix, Ar izona 85007

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

2 . Execu t i ve O f f i c e r s of S ta te Medical and Pharmaceut ical Sac i e t i e s :

A. Medical Assoc ia t ion :

Bruce E. Robinson Execu t i ve D i r e c t o r Ar izona Medical Assoc ia t ion , Inc. 810 West Bethany Home Road Phoenix 85013 Phone: 602/263-8900

B. Pharmaceutical Assoc ia t ion :

Warren J. E l l ison, R.Ph. Execut ive D i r e c t o r Ar izona Pharmaceutical A s s o c i a t i o n 2202 Nor th 7 S t r e e t Phoenix 85006 Phone: 602/258-8121


M r . S. N. Schul t z Execu t i ve O i r e c t o r Ar izona Osteopath ic Medical A s s o c i a t i o n 5057 E. Thomas Road Phoenix 85018 602/840-0460

NPC

ARKANSAS

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

Arkansas - 1 1983

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)

P r e s c r i b e d 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 p a t i e n t H o s p i t a l Care X X X X X X X X X Labora to rv & 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 Nurs ina

d

Home Serv i ces X X X X X X X X X P h y s i c i a n Serv i ces X X X X X X X X X Dental ......

Serv i ces X X X X X X X X X *SF0 - S t a t e Funds Only

I I . EXPENDITURES FOR DRUGS. Payment t o Pharmacis ts by f i s c a l year end ing September 30, 1982

1981 1982 ~ x ~ e n d e d - R e c i p i e n t ~ x p e n d e d - R e c i p i e n t

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

Aged ................................ B l i n d ............................... Disab led. . .......................... C h i l d r e n -Fami l i es w/Dep Chi ldren. . . A d u l t s -Fami l i es w/Dep C h i l d r e n .....

CATEGORICALLY NEEDY CASH TOTAL...... $18,250,280 142,088 $16,415,811 125,344 8,483,198 40,840 7,558,444 37,671

236,955 1,288 219,279 1,253 6,679,520 31,031 6,525,993 30,416 1,138,285 43,856 804,279 34,710 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 -Fami l i es w/Dep Children... . . Other 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 -Fami l i es w/Dep Chi ldren. . . A d u l t s -Fami l i es w/Dep Children..... Other T i t l e X I X R e c i p i e n t s .......... **Undupl ica ted T o t a l - HHS r e p o r t HCFA - 2082

80

Arkansas - 2 1983

I l l . Administration:

By the Division of Social Services, of the Department of Human Services. The 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 the followinq OTC items are covered: insulin, insulin needles and syringes, analgesics, antacids, calcium lactate, contraceptive foams and jellies, dicalcium phosphate, ferrous fumarate, ferrous gluconate, ferrous sulfate, ferrous cholinate, meclizine HCl, pediatric vitamin drops for children up to three years of age, laxatives and stool softners, nicotinic acid and schedule V narcotics. All other non-legend items are excluded.

8. Formulary: None

C. Prescribing or Dispensing Limitations:

1. Quantity of Medication: 30 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 to the self- paying public, or any other third-party prescription drug program.

V. Miscellaneous Remarks:

The 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


1. Social Services Officials:

Mrs. Dorothy K. Rappeport Commissioner

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.

Roy A. Brinkley, M.D.

Robert E. Richardson, M.D.

Arkansas Dept. of Human Services Division of Social Services P. 0. Box 1437 Little Rock, Arkansas 72203

Baptist Medical Center Medical Education

Department 9600 West 12th Little Rock 72205

Baptist Medical Center 9600 West 12th Little Rock 72205

500 South University Little Rock 72205

Arkansas - 4 1983

3 . Medical Care Advisory Committee

Asa Crow P u r c e l l Smith Jack Burge C.C. Long

M o r r i s s Henry Wal ter O'Neal H. E l v i n S h u f f i e l d

4. Execu t i ve O f f i c e r s of S ta te Medical and Pharmaceut ical S o c i e t i e s :

A. Medical Soc ie ty :

C. C . Long, M.D. Execu t i ve V ice -p res iden t Arkansas Medical S o c i e t y P. 0. Box 1208 F o r t Smi th 72902 Phone: 5011782-8218

B. Pharmaceut ical Assoc ia t ion:

Char les West, P.O. Execu t i ve V ice Pres iden t Arkansas Pharmacists Assoc ia t ion 818 Garland Avenue L i t t l e Rock 72201 Phone: 501/372-5250


Steven W. Wright , D.O. Secre ta ry Arkansas A s s o c i a t i o n o f Osteopath ic Phys ic ians

and Surgeons Route 2, Box 257 F a i r f i e l d Bay 72088

NPC

CALIFORNIA

MEDICAL ASSISTANCE DRUG PROGRAn (TITLE X IX )

C a l i f o r n i a - 1 1983

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) A d u l t s (SSI/SSP) OAA AB APTD AFDC OAA AB APTD AFDC Chi ldrenC21 (SFO)* Presc r ibed 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 O u t p 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 Labora to ry & 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 Nurs ina - Home Serv ices X X X X X X X X X X P h y s i c i a n Serv ices X X X X X X X X X X Dental Serv i ces X X X X X X X X X X *SF0 - S t a t e Funds Only

I I . EXPENDITURES FOR DRUGS. Payment t o Pharmacis ts by f i s c a l year ending June 30, 1982


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 Bl ind. . . .......................... 3,014,462 Disabled... ....................... 73,777,225 C h i l d r e n -Fami l i es w/Dep Chi ldren. 20,784,730 A d u l t s -Fami l i es w/Dep Ch i ld ren . .. 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 -Fami l i es w/Dep Ch i ld ren . 81,738

. A d u l t s -Fami l ies w/Dep Chi ldren. . 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 Bl ind. . . .......................... 202,124 Disabled. . ........................ 10,188,217 C h i l d r e n -Famil i e s w/Dep Ch i ld ren . 2,483,878 A d u l t s -Fami l ies w/Dep Chi ldren. . . 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

**Undupl icated T o t a l - HHS r e p o r t HCFA - 2082 84

California - 2 1983


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.


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 91 6/324-2477


1. Quantity of Medication: This is flexible, but quantities should be consistent with the medical needs of the patient and may not exceed a 100-day supply except under certain circumstances. Many high volume 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 C a l i f o r n i a - 4 1983

m a i l and t o l l f r e e te lephone requests a r e accepted i n t h e San Franc isco 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 . A u t h o r i z a t i o n may on ly be granted f o r t h e lowest cost i t em 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 medical 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 lowest c o s t brand o f a m u l t i p l e source i tem i n s tock meet ing medical needs o f the p a t i e n t .

6. B e n e f i c i a r y P r i o r A u t h o r i z a t i o n : The Department o f H e a l t h Serv ices r e s t r i c t s , th rough t h e requirements 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 abusing 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 o f :

1 . Est imated A c q u i s i t i o n Cost ( E A C ) p l u s $

i s based on t h e

3.60 p r o f e s s i o n a

lowest

1 fee.

2. Federal Maximum A1 lowble 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 ta te Maximum Al lowable 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 usual p r i c e t o general p u b l i c .

V. Misce l laneous Remarks:

Medical Therapeut ics and Drug Adv isory Comnit tee

React ing t o the lead r e s p o n s i b i l i t y of the Pharmaceut ical Standards U n i t i n t h e B e n e f i t s Branch, t h e Medical Therapeut ics and Drug Adv iso ry Conmit tee compares the cost , 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 f rom the fo rmu la ry .

H o s p i t a l Discharge Medicat ions

1. The q u a n t i t i e s f u r n i s h e d as d ischarge medicat ions a r e l i m i t e d t o n o t more than a 10-day supply.

2. The charges a r e inco rpora ted i n t h e h o s p i t a l ' s c la ims f o r i n p a t i e n t se rv i ces .

C a l i f o r n i a - 5 1983

Cancer and DESl Drugs

Any drug approved by FDA f o r t h e t reatment of cancer i s a v a i l a b l e through 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 Al lowable I n g r e d i e n t Cost Program

Sta te MACs are 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 tems. L i s t i s 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 market c o n d i t i o n s .

Numbered Rx Claims Processed i n FY 1982

(Approx imat l y ) 28 m i l l ion .

Average Rx P r i c e FY 1982 ( I n g r e d i e n t Cost P lus Fee)

(Approx imte ly ) $9.56

C a l i f o r n i a - 6 1983

O f f i c i a l s , Consul tants and Comnittees

1. H e a l t h and Welfare Agency

A. H e a l t h and Welfare Agency O f f i c i a l s :

David Swoap Secre ta ry

0. Department of H e a l t h Services:

Peter Rank D i r e c t o r

Robert Fugi na Chief Deputy D i r e c t o r

Ronald Kaldor Deputy D i r e c t o r

Jo Ann Wray ( a c t i n g ) Deputy D i r e c t o r

D o r i s Soderberg C h i e f

W i l l i a m A. White A s s i s t a n t Ch ie f (916) 445-1995

M i l t o n Kuschnere i t , Pharm. Pharmaceutical Program Consul tant (916) 324-2477

C a l i f o r n i a Hea l th and Wel fare 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

Department o f Hea l th Serv ices

714 "P" S t r e e t Sacramento 95814

Departmentof Hea l th Serv ices 714 "P" S t r e e t Sacramento 95814

Med i -Ca l 714 "P" S t r e e t Sacramento 95814

H e a l t h Care P o l i c y and Standards D i v i s i o n


B e n e f i t s Branch 714 "P" S t r e e t Sacramento 95814

NPC C a l i f o r n i a - 7 1983

C. Adv iso ry Committee t o C a l i f o r n i a Oepartment of H e a l t h Services:

1. Medical Therapeut ics and Drug Adv isory Committee:

W i l l i a m A. White Coord inator

David Fung, Pharm. A c t i n g Chairman

C a l i f o r n i a Oepartment o f H e a l t h Serv ices


460 Pol l a s k y Avenue C l o v i s 93612

0. O f f i c e r s o f Computer Sciences Corpora t ion ( t h e F i s c a l In te rmed ia ry ) :

Ross Forncrook Pres iden t of

Governmental Serv ices

Glenn Spaulding, Pharm. Manager o f Pharmacy

R e l a t i o n s

Computer Sciences Corp. P.O. Box 15000 2000 Evergreen S t r e e t Sacramento 95813

2. Execu t i ve Of f i ce rs o f S ta te Medical and Pharmaceut ical Assoc ia t ions:

Medical Assoc ia t ion :

W i l l W. Babb Execut ive 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 ranc isco 94103 Phone: 415/777-2000

Pharmaceut ical Assoc ia t ion :

Robert C. Johnson Execut ive V i c e Pres iden t C a l i f o r n i a Pharmacis ts ' Assoc ia t ion 555 C a p i t o l Mal l , S u i t e 645 Sacramento 95814 Phone: 916/444-7811

Osteopathic Phys ic ians & Surgeons o f C a l i f o r n i a :

Matthew L. Weyuker Execut ive 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

mDICAL ASSISTANCE DRUG PROGRAH (TITLE X I X )

Colorado - 1 1983


Type o f B e n e f i t C a t e g o r i c a l l y Needy Medica l l y Needy (MN) Other* OAA AB APTD AFDC OAA AB APTD AFDC Chi ld ren<21 (SFO)

P r e s c r i b e d Drugs X X X X I n p a t i e n t H o s p i t a l Care X X X X O u t p a t i e n t H o s p i t a l Care X X X X Labora to ry & X-ray S e r v i c e X X X X S k i l l e d Nurs ina

d

Home Serv i ces X X X X P h y s i c i a n Serv i ces X X X X Denta l Serv i ces X *SF0 - S t a t e Funds Only



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 Chi ldren. . . 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 B l i n d ............................... 4,400 Disabled...... ...................... 689,498 C h i l d r e n - F a m i l i e s w/Dep Chi ld ren. . . 20,050 A d u l t s -Fami l i es w/Dep Children... . . 38,950 Other 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 -Fami l i es w/Dep C h i l d r e n ... 0 A d u l t s -Fami l i es 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

**Undupl ica ted T o t a l - HHS r e p o r t HCFA - 2082 9 1

Colorado - 2 1983

I l l . A d m i n i s t r a t i o n :

E l i g i b i l i t y i s determined by 63 County Departments o f S o c i a l Serv ices, and t h e drug program i s admin is te red by t h e Colorado Department o f S o c i a l Serv ices.

IV. P r o v i s i o n s R e l a t i n g t o Presc r ibed Drugs:

A. General Exc lus ions (diseases, drug ca tegor ies , e t c . ) :

R e s t r i c t e d Drug Categor ies:

1. Dextro-Amphetami ne 2. A l l p r e s c r i p t i o n - l e g e n d v i tamins , i n c l u d i n g 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 (Dolophi ne) 4. P r e s c r i p t i o n - l e g e n d drugs no 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 procedures as s e t f o r t h i n t h e Depar tment 's Manual Regula t ions, Volume IV, Supplement "A", S e c t i o n A-4336.53.

5. OTC i tems a r e no t inc luded; excep t ions are: 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 Regu la t ions , Volume IV, Supplement "A", S e c t i o n A-4336.52.

B. Formulary: ColoRv Drug Formulary

Only those drugs p r e s e n t l y assigned drug numbers i n t h e Formulary a r e a b e n e f i t . (Re fe 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 Formulary may be a l l owed as a b e n e f i t . )

C o n t r o l l e d Drug Formulary

Sec t ion I - A l p h a b e t i c a l drug index i n brand name o rder ; i f no brand name assigned, t h e g e n e r i c name i s l i s t e d .

Sec t ion I I - Generic drugs a r e i d e n t i f i e d as hav ing a Maximum A l lowab le Pr i ce , 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 p e r i o d i c a l l y .

Sec t ion I l l - EAC P r i c e L i s t . High volume drugs reimbursed a t g r e a t e r than 100 's s i z e o r d i r e c t manu fac tu re r ' s p r i c e .

NPC Colorado - 3 1983

C. P r e s c r i b i n g or D ispens ing 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 ispens ing by t h e s e l e c t i o n o f t h e l e s s expensive t r a d e name o r gener i c product 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 roduc t i s compat ib le w i t h t h e b e s t i n t e r e s t s o f t h e p a t i e n t .

The ColoR, Drug Formulary w i l l not be used by 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 in fo rmat ion . 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 Medicat ion: 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 acute c o n d i t i o n s , a t t h e d i s c r e t i o n o f t h e phys ic ian . However, reasonable amounts f o r more than a 30-day supply 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 dev ices f o r more than 90 days r e q u i r e new p r e s c r i p t i o n s . Maximum supply i s 100 days.

Except ions t o t h e above are:

A n t i b i o t i c medicat ions and drugs f o r shor t - te rm i l l n e s s e s . N a r c o t i c p r e s c r i p t i o n s . In t ravenous and subcutaneous s o l u t i o n s . P r e s c r i b e d i n j e c t a b l e medicat ions. S h e l f package s i z e o r a l l i q u i d medicat ions, i n p i n t s i z e o n l y , o r sma l le r package s i z e when not packaged i n p i n t s i ze . Shel f package s i z e o r a l t a b l e t and capsu le med ica t ions i n q u a n t i t i e s o f 100 o n l y o r smal ler when n o t a v a i l a b l e i n package s i z e of 100. Analges ics ( p r e s c r i p t i o n - l e g e n d ) . Cough syrups ( 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 decongestants and/or c o l d p r e p a r a t i o n combinat ions ( p r e s c r i p t i o n - l e g e n d ) . 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 ) . A n t h e l m i n t i c s ( p r e s c r i p t i o n - l e g e n d ) .

P r e s c r i p t i o n s f o r l e s s than minimum amounts w i l l be den ied reimbursement of the p ro fess iona l fee un less 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 medical need f o r amounts l e s s than a 30 o r 90-days supply. Medical consul t a t i o n w i l l determine t h e dec is ion .

3. D o l l a r L i m i t s : None.

Colorado - 4 1983

D. P r e s c r i p t i o n Charge Formula:

1 . Community Pharmacist (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 rug 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 fee (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 genera l p u b l i c .

ColoR p r i c e i s determined f rom t h e most c u r r e n t i ssue o f t h e Red - i ts Supplements t o the Red Book, and c u r r e n t e d i t i o n s of t h e Drug Top ics .

S ince t h e Red Book i s no 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 drugs, t h e o rde 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 rug 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 owed i n the ColoR,

i s determined by d i v i d i n g t h e manu fac tu re r ' s d i r e c t p r i c e by .85).

For drugs no t l i s t e d i n Red Book o r i t s Supplements, b u t which 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 rug a l l o w e d w i l l be determined by u s i s manu fac tu re r ' s d i r e c t c o s t t o t h e pharmacy and add ing a 17.6% markup.

Cur ren 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 sma l le r s i z e i f no t 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 5 0 ' s and 5 0 0 ' s

5 oz. and 16 oz Only i n 2 o z .

Spec ia l Note:

100 's 5 0 ' s 16 oz.

2 02.

The Maximum A l l o w a b l e P r i c e s h a l l be determined by t h e D i v i s i o n of Med ica l Ass is tance, 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 roduc 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 rom t h e ColoRV Druq Formulary A d v i s o r y Committee o f the Medical A d v i s o r y Counci l i s cons idered i n d e t e r m i n i n g t h e MAP.


2. Medical I n s t i t u t i o n Pharmacists o r C l i n i c Pharmacists:

Actua l c o s t o f the drug p l u s a p ro fess iona l fee of $1.65. ( n o R 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 Colo x.)

3 . Government-Owned o r Operated C l i n i c s :

Actua l c o s t of t h e drug o n l y (no p r o f e s s i o n a l f e e i s a l l owed) . 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 .- Co lo x.

Inc ludes C i t y o f Denver operated Neighborhood H e a l t h Centers.

4. - Physic ians:

Phys ic ians must b i l l the c o s t o f drugs non-se l f -admin is te red 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 lue 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 ispens ing phys ic ians 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 lowest p r i c e p r e s c r i b e d i n Manual Regu la t ion 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 rom 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 request 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 p r e s c r i p t i o n . Physician-owned pharmacies t h a t have a r e g i s t e r e d pharmacist on duty 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.


Lock- In Review Procedures:

The State Department rece ives computer processed p r i n t o u t s designed t o d i scover 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 ispensed by vendors, and rece ived by e l i g i b l e r e c i p i e n t s .

A Lock-In Review Committee composed o f two phys ic ians , one consumer, and t h r e e pharmacists meets monthly t o rev iew t h e p r i n t o u t s and make recommendations t o the S t a t e regard ing c o r r e c t i v e a c t i o n . I n most cases, the 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 the Committee's recomnendations. Case-workers a r e a l s o con tac ted and informed 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 request t o c o n t a c t the r e c i p i e n t and e x p l a i n l o c k - i n and he lp 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 rev iew o f t h e case i s then 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 should remain locked i n .

P r e s c r i p t i o n Data:

Tota l Rxs . . . . . . . . 1,401,458 Average Rx Cost . . . . . $10.22

F i s c a l l n te rmed ia ry

Blue Cross 700 Broadway Denver, CO 80272


O f f i c i a l s , Consu l tants and Committees

1. Soc ia l Serv ices Department O f f i c i a l s :

George A. Golds te in , Ph.D. Execu t i ve D i r e c t o r

Susan C h r i s t i e Assoc ia te D i r e c t o r f o r

Operat i ons

George E. Kawamura Assoc ia te D i r e c t o r f o r Programs

Robert 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 Assoc ia te D i r e c t o r f o r

A d m i n i s t r a t i o n

Garry A. Toerber, Ph.D. D i r e c t o r , D i v i s i o n o f Medical

Ass is tance

M y r l e A. Myers, R.Ph., M.S. Chief , Pharmacy and Ambulatory

Care Serv ices Sec t ion D i v i s i o n of Medical Ass is tance 303/866-5372

James C. Syner, M.D. Medical Consu l tant D i v i s i o n of Medical Ass is tance

M a r j o r i e Jones, A c t i n g Chief H o s p i t a l Serv ices Sec t ion D i v i s i o n o f Medical Ass is tance

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 i ew Sec t ion

2. Soc ia l Serv i ces Department Consu l tant :

Marvin J. Lubeck, M.D. Ophthalmology

Colorado Department o f Soc ia l S e r v i c e s

1575 Sherman S t r e e t Denver, Co lorado 80203

3865 Cherry Creek Nor th D r i v e

Denver 80210


3. Medical Adv isory Committees:

A. Medical Ass is tance and Serv ices Adv isory Counc i l :

Members

Wa l te r B a l l a r d , D.D.S. 1416 C o n s t i t u t i o n Pueblo, Colorado 81001

Represent ing

D e n t i s t

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 A s s o c i a t i o n 1024 Lemay Avenue F o r t C o l l i n s , Colorado 80524

Stephen G i l l , D.P.M. 1410 South Mar ion S t r e e t Denver, Colorado 80210

R ichard L. Haney, D.D. W r i t e r ' s Tower Bldg. 1660 S. A l b i o n Denver, Colorado 80222

Roger A. Lueck, M.D. 4701 South l d a l i a S t r e e t Aurora, Colorado 80015

Helen Madr id 3165 l n g a l l s S t r e e t Wheatridge, Colorado 80214

Mary Lou Parmelee 586 South Gay lord Denver, Colorado 80209

Donald S c h i f f , M.D. 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 lvd. L i t t l e t o n , Colorado 80120

P h y l l i s R. Schu l tz , R.N. 5700 East C o r n e l l Avenue Denver, Colorado 80222

M i l e s Schuman 1920 High S t r e e t Denver, Colorado 80218

Bobbie Cumnings Smith 12120 West C a r o l i n a D r i v e Lakewood, Colorado 80228

P o d i a t r i s t Denver Foot C l i n i c , P.C. 3193 S. Broadway

O p t o m e t r i s t

Doctor of Medic ine

Publ i c

P u b l i c

Doctor of Med ic ine

P r o f e s s i o n a l Nurse (CHAIRWOMAN)

Pharmacist

Nurs ing Homes

Colorado - 8 1983

Medical Ass is tance and Serv i ces Adv isory Counc i l ( c o n t i n u e d ) :

Janet Washburn 1260 South Reed, #4 Lakewood, Colorado 80226

P u b l i c

EX OFFlClO MEMBERS:

George A. Golds te in , Ph.0. 1575 Sherman S t r e e t Oenver, Colorado 80203

Frank T r a y l o r , M.D. 4210 East 11 th Avenue Denver, Colorado 80220

Execu t i ve D i r e c t o r Colorado Department o f

Soc ia l Serv i ces

Execu t i ve D i r e c t o r Colorado Department of

Hea l th

COLORADO BOARD OF SOCIAL SERVICES LIAISON TO THE MEDICAL ADVISORY COUNCIL

F l o Mendez 1665 Grant S t r e e t Denver, Colorado 80203

RECORDING SECRETARY

Ms. Jeane R . Gar r i son 20 B i r d i e Lane L i t t l e t o n , Colorado 80123

Ms. S h e i l a Harper 5630 W. Dakota Oenver, Colorado 80226

B. ColoRx Drug Formulary Adv isory Committee:

R ichard A. Haynes, R.Ph., Duane H. Lambert, R.Ph. Cha i rman 1700 V ine S t r e e t

130 Pear l S t r e e t , # I805 Denver, Co lorado 80206 Oenver, Colorado 80203

Roger R. Pearce, P.Ph., L i l l i a n B i r d , R.Ph. Pharmacy D i v i s i o n 2420 - 71s t S t r e e t K ing Soopers Greeley, Colorado 80631 P.O. Box 5567 (65 Tejon S t r e e t )

Denver, Co lorado 80221 F r a n k l i n L. Connel l , R.Ph. P.O. Box 189 Del Norte, Colorado 81132

Colorado - 9 1983

ColoRx Drug Formulary Adv iso ry Committee (con t inued) :

Gerr i Sormani, R.Ph. Musick Drug 309 East Fontanero S t r e e t Colorado Spr ings, Colorado

80907

Don Asher 2770 W. 5 t h Avenue Denver, Colorado 80204

J e r r y D. Harvey, R.Ph. 2201 San Juan Avenue LaJunta, Colorado 81050

Robert W. Piepho, Ph.O., F.C.P. P ro fessor and Assoc ia te Dean D i v i s i o n o f C l i n i c a l Programs U n i v e r s i t y o f Colorado Medical

Center 4200 East N i n t h St reet -Box C-238 Denver, Colorado 80262

M i l e s Schuman, R.Ph. P r o f e s s i o n a l Pharmacy 1920 H igh S t r e e t Denver, Colorado 80218

Thomas Per ry , M.D. 5440 W . 2 5 t h Avenue Edgewater, Colorado 80214


A. Medica l Soc ie ty :

R.G. Bowman Execu t i ve V ice -p res iden t Colorado Medical S o c i e t y 1601 Eas t N ine teen th Avenue Denver 8021 8 Phone: 303/534-8580

B. Pharmaceut ical Assoc ia t ion :

A r t h u r C. Hassen, J r . Execu t i ve D i r e c t o r Colorado Pharmacal A s s o c i a t i o n 1711 Pennsy lvan ia S t r e e t Denver 80203 Phone: 303/861-0328

C. S o c i e t y of Osteopath ic Medic ine:

Elwyn D. B a t c h e l o r Execu t i ve D i r e c t o r Colorado S o c i e t y o f Osteopath ic Medic ine 4701 E. 9 t h Avenue, Room 304 Denver 80220

NPC Connect icu t - 1 1983

ClMNECTl CUT

M D I U I L ASSISTANCE DRUG PROGRAM (TITLE X I X )


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 ldren<21 (SFD)

P r e s c r i b e d 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 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 Labora to ry & 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 g Home S e r v i c e s X X X X X X X X X X P h y s i c i a n Serv i ces X X X X X X X X X X Dental Serv ices X X X X X X X X X X *SF0 - S t a t e Funds Only

I I . EXPENDITURES FOR DRUGS. Payment t o Pharmacis ts by f i s c a l year end ing June 30, 1982


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 6 5 13,887 58 Disab led ............................ 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 Ch i ld ren . .. 2,097,710 67,574 1,648,580 56,782 A d u l t s -Fami l i es w /DepCh i ld ren ..... 3,187,266 36,843 2,779,983 36,617

CATEGORICALLY NEEDY NON-CASH TOTAL.. $ 0 0 $0 0 Aged ................................ 0 0 0 0 B l i n d ............................... 0 0 0 0 Disab led. ........................... 0 0 0 0 C h i l d r e n -Fami l i es w/Dep Chi ldren. . . 0 0 0 0 A d u l t s -Fami l i es w/Dep Chi ldren. . . . . 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 -Fami l i es w/Dep Chi ldren. . . 189,178 4,516 64,654 2,083 A d u l t s -Fami l i es 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


Directly by the State Welfare Department through seven district offices and one town delegated this special authority.


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

1. Will not pay for experimental drugs, anti-obesity drugs, drugs available free from the Department of Health Services, OESl drugs.

2. Prior authorization required for: non-legend drugs not listed on Connecticut Drug List; Amphetamines except when used for narcolepsy and hyperkenesis; vitamins except prenatal, pediatric prior to 7th birthday and fluoride prior to 14th birthday; nutritional supplements.

3. Nursing home patients: 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


1. Physicians are encouraged to prescribe drugs generically, when possible.

2. Quantity of Medication: Maximum quantity: 30-day supply or 120 tablets or capsules or 1 lb. powder. For chronic conditions, prescription may cover 120 day supply but no more than 120 tablets or capsules or 1 lb. powder.

Oral Contraceptives: 3 months supply may be dispensed at one time.

3. Refills: 6 month refill limit except for oral contraceptives which have a 12 month limit.

4. Dollar Limits: None

D. Prescription Charge Formula: MAC, AWP as listed in Red Book or EAC price set by Department plus fee; or usual and customary if lower.

Fees:

Convalescent and nursing homes - cost plus $2.59 (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 fee of twenty-five cents per prescription, in addition to any other dispensing fee, for substituting a generically equivalent drug product.

NPC Connect icu t - 4 1983


1. Income Maintenance O f f i c i a l s :

Stephen B. H e i n t z Commissioner

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 D i r e c t o r Medical Care A d m i n i s t r a t i o n

Dennis Bothamley Chie f , I n s t i t u t i o n a l Care Medical Care A d m i n i s t r a t i o n

C l a i r Ca l lan , M.D. Assoc ia te Medical D i r e c t o r

Har ry K iernan, D.D.S. Denta l Consul tant

Meyer Rosenkrantz, R.Ph. Pharmacist Consul tant

2. l ncome Maintenance Consu l tan ts (Par t - t ime) :

Department o f Income Maintenance 110 Bartholomew Avenue H a r t f o r d , Connect icu t 06106

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. Kal lman, D.P.M. 0. 0 . H i l l , O.D.

3. T i t l e X I X Adv iso ry Committees:

A. Pharmacy Adv iso ry Committee:

S t a t e Pharmacy Commission Dr. James O 'Br ien Mike W i l l i a m s

Connect icu t Pharmaceut ical Assoc.

Dan Leone W i l l i a m Sumna Edward C. L i s k a

NPC

Pharmacy Adv isory Committee (con t inued)

Connect icu t S t a t e Medical Soc ie ty

D r . E l l i o t t R. Mayo

Connec t i cu t - 5 1983

Income Maintenance Department

Stephen H. Press Meyer Rosenkrantz

(Pharmacis t )

4 . F i s c a l Agent

E l e c t r o n i c Data Systems Corp Farmington, Connect icu t

5. Average Rx P r i c e s FY 1982 $9.24

6. Execu t i ve O f f i c e r s of S t a t e Medical and Pharmaceut ical S o c i e t i e s :


T. B. Norbeck Execu t i ve D i r e c t o r Conn. S ta te Medical Assoc. 160 S t . Ronan S t r e e t New Haven 0651 1 Phone: 203/865-0587

6 . Pharmaceut ical Assoc ia t i on :

Danie l C. Leone, D.O. Execu t i ve D i r e c t o r Connect icu t Pharmaceut ical 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. Soc ie ty o f Osteopath ic Medic ine:

Norman S. Roome. D.O., Sec re ta ry Connect icu t S o c i e t y o f Osteopath ic

Phys ic ians and Surgeons 16 South Main S t r e e t New M i l f o r d 06774

DELAWARE

MEDICAL ASSISTANCE DRUG PROGRAM (TITLE X I X )

Delaware - 1 1983


Type of B e n e f i t C a t e g o r i c a l l y Needy Medica l l y Needy (MN) Other* O M AB APTD AFDC DAA AB APTD AFDC Chi ld ren<21 (SFO)

P r e s c r i b e d Drugs X X X X l npa t i e n t H o s p i t a l Care X X X X O u t p a t i e n t H o s p i t a l Care X X X X L a b o r a t o r y & X-ray S e r v i c e X X X X S k i l l e d Nurs ina

0

Home Serv i ces X X X X P h y s i c i a n Serv i ces X X X X Denta l Serv i ces X *SF0 - S t a t e Funds Only

1 1 . EXPENDITURES FOR DRUGS. Payment t o Pharmacis ts by f i s c a l year end ing September 30, 1982

1981 1982 ~ x ~ e n d e d - R e c i p i e n t ~ x p e n d e d -

.............................. 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 B l i n d ............................... 9,943 69 8,850 D isab led ............................ 582,877 3,202 674,036 C h i l d r e n - F a m i l i e s w/Dep Chi ldren. . . 421,556 16,833 404,926 A d u l t s -Fami l i es w/Dep C h i l d r e n ..... 516,559 10,081 543,485

R e c i p i e n t

CATEGORICALLY NEEDY NON-CASH TOTAL.. $267,559 3,589 5306,106 3,504 Aged ................................ 175,866 808 21 1,323 80 5 B l i n d . .............................. 14 1 0 0 D isab led ............................ 25,820 152 27,170 124 C h i l d r e n -Fami l i es w/Dep Chi ldren. . . 11,142 566 9,692 480 A d u l t s -Fami l i es 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 -Fami l i es w/Dep Chi ldren. . . 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

**Undupl ica ted 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.


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.


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.


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


1. Health and Social Services Department Officials:

Patricia Schram Secretary

Charles Hayward Di rector

Richard J. Cherrin Administrator Medical Assistance Services

Dr. James Salva Medical Consultant

Roger Andersen, R.Ph. (Part-time) Pharmacist Consultant 302/421-6132

2. Medical Advisory Comnittee Members:

Mark Abrams 2501 Northgate Road Wilmington 19810

Roger Andersen 613 Foulkstone Road Wilmington 19803

Anne Bader 1925 Lovering Avenue Wilmington 19806

Dale Bunting Director of Social Services Delaware State Hospital New Castle 19720

Par is Carpenter RD 1 Box 209 Lincoln 19960

Donald B. Cowan, D.D.S. DPH-Bureau of Special ized

Health Services Jesse Cooper Bldg. Dover 1990 1

Department of Health and Social Services

Delaware State Hospital New Castle, Delaware 19720

Division of Economic Services P. 0. Box 906 New Castle 19720

2018 Naamans Road, Suite 1B Wilmington 19810

P. 0. Box 309 Wilmington 19899

Delaware Pharmaceutical Association

Pharmaceutical Consultant Division of Economic Services

Delaware Medical Society

Division of Mental Health

Sussex County-Medicaid Recipient

Division of Public Health Bureau of Special ized Health

Services

Delaware - 4 1983

Medica l Adv iso ry Committee Members (con t inued) :

Bur ton Church S t . F r a n c i s H o s p i t a l 7 t h & C lay ton S t r e e t s W i lm ing ton 19806

B o n i t a DePree 1200 Lancaster Avenue Wi lmington 19805

Gary Ferguson 1925 L o v e r i n g Avenue Wi lmington 19806

Frances Gunner 1625 G i l p i n Avenue L i n c o l n Towers Wi lmington 19806

E l i z a b e t h Henry C.T. B ldg. Delaware S t a t e H o s p i t a l New C a s t l e 19720

David Howard, M.D. P. 0. Box 107 Ocean View 19970

Carol Katz 64 Sussex D r i v e Lewes 19958

David K r i g s t e i n 201 W. 1 4 t h S t r e e t Wi lmington 19801

A l l e n Levine, O.D. 419 N. Market S t r e e t Wi lmington 19803

David L e v i t s k y , M.D. 110 C h r i s t i a n a Medica l Center Newark 19702

Leon Levy, D.D.S. 1905 Delaware Avenue Wi lmington 19803

A s s o c i a t i o n of Delaware H o s p i t a l s

New C a s t l e County-Medicaid R e c i p i e n t

Delaware H e a l t h Counc i l

New C a s t l e County Medica id R e c i p i e n t

D i v i s i o n o f Aging

Delaware Chapter-American Academy o f P e d i a t r i c i a n s

Sussex County Home Serv ices, CHEER PROGRAM Consumer

B l u e Cross B l u e S h i e l d , Inc .

Delaware Optometr ic S o c i e t y

Delaware Medical S o c i e t y

Delaware Denta l S o c i e t y

NPC Delaware - 5 1983

Medical Adv isory Committee Members ( c o n t i n u e d ) :

Caro lyn L i p p 1601 Concord P i k e S u i t e 92-100 W i lm ing ton 19803

Char les Mo l loy # 1 P i k e Creek Center S u i t e 402, Wing 2 W i lm ing ton 19808

M a r t i n Moss, O.D. 702 N. Union S t r e e t W i lm ing ton 19805

Mabel C. Nowland 2713 Lancaster Avenue Wi lmington 19805

P a t r i c i a P u r c e l l , M.O. 1508 Pennsylvania Avenue Wi lmington 19806

Olga Ramirez 1225 M a y f i e l d Road Wi lmington 19803

Rober t Reed Ret i rement f o r L i v i n g T i g a n i B u i l d i n g Fou lk Road W i lm ing ton 19803

James B. Salva, M.D. 601 New C a s t l e Avenue Wi lmington 19801

Frank J. Shannon, Jr., M.O. Jesse Cooper Bui l d i n g Dover 19901

Pat Voshe l le Outreach Worker 63 Sussex D r i v e Lewes 19958

Dar lene Finney 1831 DuPont Highway Dover 19901

Oelaware Review O r g a n i z a t i o n

The Computer Company

C o n s u l t a n t - V i s i o n Care Program Medical Serv i ces

V i s i t i n g Nurse A s s o c i a t i o n

Oelaware Medical S o c i e t y

Consumer-Pub1 i c Task Force

Oelaware H e a l t h Care F a c i l i t i e s

Medica id

D i v i s i o n of P u b l i c H e a l t h

Consumer-Sussex County

Consumer-Kent County

NPC Delaware - 6 1983


A. Medical Society: B. Pharmaceutical Society:

Ann Shane Bader (Mrs.) Executive Director Medical Society of Dela. 1925 Lovering Avenue Wi lmington 19806 Phone: 302/658-7596

C. Osteopathic Society:

Ms. Christine L. Bailey Executive Director Delaware Pharmaceutical

Society 716 Philadelphia Pike Wilmington 19809 Phone: 302/762-6019

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)


Type o f B e n e f i t C a t e g o r i c a l l y Needy Medica l l y Needy (MN) Other* OAA AB APTD AFDC OAA AB APTD AFDC Chi ldren<21 (SFO)

P r e s c r i b e d Drugs X X X X X X X X X l noat i en t ~ o ; ~ i t a l Care X X X X X X X X X O u t p a t i e n t H o s p i t a l Care X X X X X X X X X Labora to ry & X-ray ~ e r ; i c e X X X X X X X X X S k i l l e d Nurs ina Home Serv ices X X X X X X X X X P h y s i c i a n Serv ices X X X X X X X X X Dental Serv ices X X X X *SF0 - S t a t e Funds Only

I I . EXPENDITURES FOR DRUGS. Payments t o Pharmacists by f i s c a l year end ing September 30, 1982

1981 1982 Expended R e c i p i e n t Expended

TOTAL... ............................ 56,124,337

CATEGORICALLY NEEDY CASH TOTAL...... $4,948,464 Aged.. .............................. 850,682 Bl ind. . . ............................ 10,351 Disabled... ......................... 1,613,199 C h i l d r e n -Fami l i es w/Dep C h i l d r e n ... 554,228 A d u l t s -Fami l i es w/Dep C h i l d r e n ..... 1,920,004

CATEGORICALLY NEEDY NDN-CASH TOTAL.. $85,742 Aged ................................ 1,715 Bl ind. . . . ........................... 0 Disab led ............................ 70,566 C h i l d r e n -Fami l i es w/Dep Chi ldren. . . 5,573 A d u l t s -Fami l i es 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 Bl ind. . . . ........................... 1,090 D isab led ............................ 320,499 C h i l d r e n -Fami l i es w/Dep Chi ldren. . . 77,399 A d u l t s -Fami l i es w/Dep Ch i ld ren . .... 147,168 Other T i t l e X I X R e c i p i e n t s .......... 0

R e c i p i e n t

**Undupl icated T o t a l - HHS r e p o r t HCFA - 2082 11 1



The D.C. Department of Human Serv ices (DHS), O f f i c e of H e a l t h Care F inanc ing .


A. General Exc lus ions: A l l legend drugs a r e covered except those drugs 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 tems a r e covered: o r a l ana lges ics , o r a l an tac ids , i n s u l i n , i n s u l i n needles and syr inges, c o n t r a c e p t i v e foams and j e l l i e s , f e r r o u s s u l f a t e , p r e n a t a l v i t a m i n fo rmu la t ions , 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 years 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 years o f age and under. A l l o t h e r non- legend items are excluded.

B. Formulary: None.

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

1. R e f i l l s : I n genera l , amounts dispensed a r e t o be 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 episode 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 dispensed i n amounts up t o a 30-day supp ly 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 medicat ions used i n t reatment of acute i n f e c t i o n s a r e no t t o be dispensed i n excess o f a (10) day supply . B i r t h c o n t r o l t a b l e t s may be dispensed i n 3 -cyc le 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 year.

3. D o l l a r L i m i t s : There i s no present d o l l a r l i m i t a t i o n . P h y s i c i a n s a r e requested t o p r e s c r i b e reasonable amounts.

4. Formulary: No


The lesser o f :

- Maximum a l l o w a b l e charge (MAC) p l u s $3.27" o r - Es t ima ted 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 usual charge 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 usua l charge 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 app ly t o r e c i p i e n t s under 21 years 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 lann ing, n u r s i n g home p a t i e n t s , or pregnancy r e l a t e d .

NPC


F isca 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


1. D e p a r t m e n t o f Human Serv ices O f f i c i a l s :

James A. Buford O i r e c t o r

Department o f Human Serv i ces 801 Nor th 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 Connect icu t Ave., N.W. Commissioner of P u b l i c H e a l t h Room 825

Washington, D. C . 20009

Pe te r 6. Coppola 614 H S t r e e t , N.W., Room 708 Ch ie f , O f f i c e of H e a l t h Washington, D. C. 20001

Care F inanc ing

James H a r r i s , R.Ph. Pharmacist Consu l tant O f f i c e o f H e a l t h Care F inanc ing

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 Pharmaceut ical S o c i e t i e s :


F r a n c i s c o P. F e r r a r a c c i o E x e c u t i v e Sec re ta ry Medical Soc ie ty 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. Pharmaceut ical Assoc ia t i on :

Chauncey I. Cooper, Ph.D. Execu t i ve D i r e c t o r Washington, D.C. Pharmaceut ical A s s o c i a t i o n 5506 Connect icu t Avenue, N.W. Washington, D. C. 20015 Phone: 202/363-0305

C. Osteopath ic Assoc ia t i on :

Har ry Handelsman, D.O. Sec re ta ry Osteopath ic A s s o c i a t i o n o f the 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

rYDl CAL ASS l STANCE DRUG PROGRAM (TITLE X I X)

F l o r i d a - 1 1983


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 Ch i ld ren<21 (SFO)

Prescr i bed Oruqs X X X X l npa t i e n t H o s p i t a l Care X X X X O u t p a t i e n t H o s p i t a l Care X X X X Labora to ry & X-ray S e r v i c e X X X X S k i l l e d Nurs ina ., Home Serv i ces X X X P h y s i c i a n Serv i ces X X X X Denta l Serv i ces X X X X *SF0 - S t a t e Funds Only


1981 1982 ~ x ~ e n d e d - R e c i p i e n t ~ x p e n d e d R e c i p i e n t

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 B l ind . . . ............................ 345,858 2,269 380,371 2 297 Disabled. . . . . . .. . ... ... ..... ...... .. 14,433,266 78,919 16,172,789 78,015 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 ... 3,922,142 132,444 3,790,680 122,826 A d u l t s -Fami l i es w/Dep Chi ldren. . . .. 3,858,493 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 B l i n d . .............................. 6,507 44 7,414 38 Disabled.. .......................... 658,891 3,052 817,648 3,117 C h i l d r e n -Fami l i es w/Oep Chi ldren. . . 200,652 9,724 202,845 9,665 A d u l t s -Fami l i es w/Oep Chi ldren. . . . . 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 B l i n d . .............................. 0 0 0 0 D isab led ............................ 0 0 0 0 C h i l d r e n - F a m i l i e s w/Oep Chi ldren. . . 0 0 0 0 A d u l t s -Fami l i es w/Dep Ch i ld ren . . ... 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

* *Undupl ica ted T o t a l - HHS r e p o r t HCFA - 2082 11 5

F l o r i d a - 3 1983

P r e s c r i b i n g o r D ispens ing L i m i t a t i o n s (con t inued) :

The r e c i p i e n t must present a month ly e l i g i b i l i t y c a r d t o the p r o v i d e r and must then 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 ca lendar month.

Maintenance med ica t ion should be dispensed and b i l l e d f o r a t l e a s t a one-month supp ly 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 by t h e p r e s c r i b e r and can be made f o r up t o one year, except t h a t c o n t r o l l e d substances can 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 ques t ionab le e f f i c a c y , as r a t e d by t h e FDA (OESI), a r e d i s a l l o w e d un less 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 , exper imenta l , b l o o d d e r i v a t i v e (e.g. f o r hemoph i l i a ) , and a p p e t i t e suppressant i tems a r e no 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 than t h e i r approved i n d i c a t i o n s .


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 isce l l aneous Remarks:

A. A l l drugs have an EAC (Est imated A c q u i s i t i o n Cost )

B. Some H igh 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. Federal MAC drug 1 i s t

E. Number o f Rx c la ims processed i n FY 1982 ( I n g r e d i e n t c o s t and fee )

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 fee) $8.23

G. Claims Processor

EDS Federa l C o r p o r a t i o n Pharmacy Serv ices P.O. Box 9030 Tal lahassee, F l o r i d a 32314

F l o r i d a - 3 1983

P r e s c r i b i n g o r D ispens ing L i m i t a t i o n s (con t inued) :

2. The r e c i p i e n t must present a monthly 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 then 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 calendar month.

3. Maintenance med ica t ion should be dispensed and b i l l e d f o r a t l e a s t a one-month supply 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 by t h e p r e s c r i b e r and can be made f o r up t o one year, except t h a t c o n t r o l l e d substances can 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 .

5. Drugs w i t h ques t ionab le 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 sa l lowed un less 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 .

6. I n v e s t i g a t i o n a l , exper imenta l , b lood d e r i v a t i v e (e.g. f o r hemophi l ia) , and a p p e t i t e suppressant i tems a r e n o t covered, no r a r e drugs t h a t a r e p resc r ibed f o r o t h e r than t h e i r approved i n d i c a t i o n s .


Fee - e f f e c t i v e 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


A. A l l drugs have an EAC (Est imated A c q u i s i t i o n Cost)

B. Some High 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. Federal MAC drug l i s t

E. Number of Rx c la ims 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 fee) $8.23

G. Claims Processor

EDS Federa l Corpora t ion Pharmacy Serv ices P.O. Box 9030 Tal lahassee, F l o r i d a 32314

F l o r i d a - 4 1983


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 Serv ices O f f i c i a l s :

David P i ngree Secre ta ry

R ichard T. L u t z Deputy A s s i s t a n t Secre ta ry

f o r Med ica id

Rod P r e s n e l l , R.Ph. Pharmacist Consu l tan t Medica id O f f i c e of Program

Development

J e r r y H i l l , R.Ph. Pharmacist Consul tant Medica id O f f i c e of Program

Development

Oepartment 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

1323 Winewood Boulevard Tal lahassee, F l o r i d a 32301

1309 W i newood Bou levard B u i l d i n g 6, Room 233 Ta l lahassee 32301

1309 Winewood Boulevard B u i l d i n g 6, Room237 Ta l lahassee 32301

1309 W i newood Boulevard B u i l d i n g 6, Room 237 Ta l lahassee 32301

2. Consul tants t o Medical Serv i ces Program: ( P a r t - t ime)

Donald 0. A l f o r d , M.D. Gene L. Davidson, M.D. L a r r y C. Deeb, M.O. I r v i n g J. F l e e t , D.O.S. Char les F. James, M.D. Fred Lindsey, M.D. Ivan B. Roberts, D.D.S. Ms. Janet She l fe 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. Medica id Adv iso ry Counc i l :

Mrs. Maggie Bennett 720 West M y r t l e S t r e e t Lakeland 33801 *Consumer

Ms. P a t r i c i a Bryant Post O f f i c e box 2104 Miami 33143 *Consumer

Medica id O f f i c e 1309 W i newood Boulevard Ta l lahassee 32301

George Browning, R.Ph. 1281 South H ickory S t r e e t Melbourne 32901 * F l o r i d a Pharmacy A s s o c i a t i o n

Mrs. Sus ie Mae Burns 4205 Maxwell Boulevard South Ta l lahassee 32301 *Consumer

F l o r i d a - 5 1983

M e d i c a i d Adv iso ry Counci l ( con t inued) :

Canmissioner Pa t Glass Manatee County Commission Post O f f i c e Box 1000 Bradenton 33506 * 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 .

M r . A r t h u r H a r r i s F l o r i d a Manor 830 West Mich igan Orlando 32804 * 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 Route 1, Box 31 OIBr ien 32071 *Consumer

C h r i s C. Scures, D.D.S. 2122 East Robinson S t r e e t Or lando 32803 * F l o r i d a Dental A s s o c i a t i o n

M r . Leon Zucker V i c e P r e s i d e n t 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 Northwest 12 Avenue Miami 33136 * F l o r i d a H o s p i t a l A s s o c i a t i o n

4. F l o r i d a MAC Adv iso ry Committee:

George Browning, R.Ph. 1281 H i c k o r y S t r e e t Melbourne 32901

Lew Becks 5607 Hamnock Lane L a u d e r h i l l 33319

Lawrence DuBow Lawrence Pharmaceut ical s Post O f f i c e Box 5386 J a c k s o n v i l l e 32207

V i r g i n i a Haggerty, R.N. Pos t O f f i c e Box 6985 Orlando 32803 * F l o r i d a Nurses A s s o c i a t i o n

M r . W i l l i a m Hobson 610 South "K" S t r e e t Lake Worth 33460 *Consumer

Donald G. N iko laus, M.D. Mease H o s p i t a l and C l i n i c Dunedi n 33528 * F l o r i d a Medical A s s o c i a t i o n

M r . Fa tah Wa l l i zada 3656 S t . Johns Avenue J a c k s o n v i l l e 32205 *Consumer

M r . R ichard 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 Medica id 1317 Winewood Boulevard B u i l d i n g 6, Room 233 Ta l lahassee 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 Serv ices

R e t a i l Pharmacy f o r N u r s i n g Homes

Nurs ing Home Pharmacy

Wholesaler

NPC F l o r i d a - 6 1983

F l o r i d a MAC Adv isory Committee ( c o n t i n u e d ) :

Dick Kaplan 3730 Thornwood D r i v e Tampa 33618

J im Powers, R.Ph. 610 Nor th Adams Tal lahassee 32301

Mark S u l l i v a n , R.Ph. 1330 Miccosukee Road Ta l lahassee 32303

Michae l Zagorac, R.Ph. C/O Jack Eckard Corporat i o n p o s t O f f i c e Box 4689 C lea rwa te r 33518

DHRS Med ica id Representa t ives :

D ick Grant, R.Ph. Department o f HRS (PDHERx) 1317 Winewood Boulevard Ta l lahassee 32301

Pharmacy Manager

Secre tary , F l o r i d a Pharmacy A s s o c i a t i o n

Pharmacist

Pharmacy Manager

Rod P r e s n e l l , R.Ph. Department o f HRS (PDDE) 1309 W i newood Bou leva rd Ta l lahassee 32301

J e r r y H i l l , R.Ph. Department o f HRS (PDDE) 1309 Winewood Boulevard Tal lahassee 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 Medical and Pharmaceut ical S o c i e t i e s :

A. Medical Assoc ia t i on : B. Pharmaceut ical A s s o c i a t i o n :

W. Ha ro ld Parham James B. Powers Execu t i ve V ice -p res iden t Execu t i ve D i r e c t o r F l o r i d a Medical Assoc ia t i on , Inc. F l o r i d a Pharmacy A s s o c i a t i o n Post O f f i c e Box 2411 610 Nor th Adams S t r e e t J a c k s o n v i l l e 32203 Tal lahassee 32301 Phone: 904/356-1571 Phone: 904/222-2400

C . Osteopath ic Medical Assoc ia t i on :

Merv in E. Meck, D.O. Secre tary-Treasurer , Execu t i ve D i r e c t o r F l o r i d a Osteopath ic Medical A s s o c i a t i o n 161 N. Causeway New Smyrna Beach 32069

NPC

GEORG l A

HEDICAL ASSISTANCE DRUG PROGRAM (T ITLE X I X )

Georgia - 1 1983

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 Medical l y Needy (MN) ' Other*

O M AB APTD AFDC O M AB APTD AFDC Ch i ld renc21 (SFO) Presc r ibed Druqs X X X X l n p a t i e n t nosp i t a l Care X X X X O u t p a t i e n t H o s p i t a l Care X X X X Labora to rv E X-ray S e r v i c e X X X X S k i l l e d N u r s i n g Home Serv ices X X X X P h y s i c i a n Serv ices X X X X Dental Serv ices X X X X *SF0 - S t a t e Funds Only



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 -Fami l i es w/Dep Chi ldren. . . 2,675,698 111,504 2,509,331 100,649 A d u l t s -Fami l i es w/Dep Ch i ld ren . .... 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 B l i n d ............................... 27,788 87 24,452 9 3 Disabled.. .......................... 1,789,893 4,664 1,465,903 4,424 C h i l d r e n -Fami l i es w/Dep C h i l d r e n ... 196,366 9,133 116,699 6,278 A d u l t s -Fami l i es 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 Disabled. . .......................... 0 0 0 0 C h i l d r e n -Fami l i es w/Oep Chi ldren. . . 0 0 0 0 A d u l t s -Fami l i es 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

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

121

Georgia - 18 1983

1 ) The Georgia Dept. of Medical Ass is tance 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 category . Instead, b e n e f i t s a r e p rov ided t o r e c i p i e n t s under a Maintenance Ass is tance Only C l a s s i f i c a t i o n . Maintenance ( M e d i c a l ) Ass is tance Only i s p r o v i d e d t o those 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 medica l s e r v i c e s b u t who do not , f o r v a r i o u s reasons, r e c e i v e money payments. The MA0 ca tegory d i f f e r s f rom the MN i n terms o f e l i g i b i l i t y requ i rements . MA0 covers t h e same type o f b e n e f i t s f o r each r e l a t e d ca tegory o f r e c i p i e n t s as those checked f o r money payments. Also, p lease no te t h a t the expend i tu res l i s t e d f o r MNs i n Sec t ion I I a r e a c t u a l l y those f o r Georg ia 's MA0 r e c i p i e n t s .

Source: FY-82 N C S S 2082 Repor t FY-82 Annual Repor t

NPC Georgia - 2 1983


By t h e Department o f Medical Assistance.


A. General Exc lus ions: Drugs no t on t h e drug l i s t .

B. Formulary: The C o n t r o l l e d Medical Ass is tance Drug L i s t . For i n f o r m a t i o n con tac t :

Mrs. E a r l i n e D. Jordan 2 M.L. King, J r . D r i v e S.E. F l o y d B u i l d i n g - West Tower A t l a n t a , GA 30334 404/656-4044


1. Q u a n t i t y o f Medicat ion: Phys ic ians a r e encouraged t o p r e s c r i b e a 30 day supply. S i x p r e s c r i p t i o n s per month per r e c i p i e n t except b y p r i o r a u t h o r i z a t i o n .

3. R e f i l l s : According t o s t a t e and f e d e r a l law.


D. P r e s c r i p t i o n Charge Formula: Lower o f , es t ima ted a c q u i s i t i o n cos t (EAC) p l u s fee o f $3.61, o r MAC p l u s fee, o r usual and customary. N o n - p r o f i t i n s t i t u t i o n s - $3.17.

No copayment


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 = Federal MAC P l u s 11 A d d i t i o n a l Drugs



1. Department o f Medical Ass is tance O f f i c i a l s :

Aaron Johnson Commissioner

Russ Toal A s s i s t a n t Comnissioner

Jacque l ine Fos te r , D i r e c t o r 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 Serv ices

Department o f Medica l Ass is tance

James F l o y d Memorial Bldg. (Twin Towers)

P.O. Box 38440 A t l a n t a , Georgia 30334

(Mrs.) Frances Lipscomb, R.Ph. Program Mangement O f f i c e r Pharmacy Serv i ce

T i t l e X I X (Medica id) Medical Ass is tance Adv isory Comnittees:

Represen ta t i ves 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 A t l a n t a Medical A s s o c i a t i o n Georgia H o s p i t a l A s s o c i a t i o n Georgia Pharmaceut ical A s s o c i a t i o n Georgia Hea l th Care A s s o c i a t i o n Georgia Osteopath ic 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

Execu t i ve O f f i c e r s o f S t a t e Medical and Pharmaceut ical S o c i e t i e s :

A. Medical Assoc ia t i on :

J.M. M o f f a t t Execu t i ve 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


Execu t i ve O f f i c e r s o f S t a t e Medical and Pharmaceut ical S o c i e t i e s ( c o n t i n u e d ) :


L a r r y L. Braden Execu t i ve D i r e c t o r Georgia Pharmaceut ical Assoc ia t ion 2520 C a r r o l l Avenue A t l a n t a 30341 Phone: 404/451-1336

C. Osteopath ic Medical Assoc ia t ion:

Ms. Cathy M. G a r r i s Execu t i ve D i r e c t o r Georgia Osteopath ic 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 Medica l l y Needy (MN) Other*

OAA AB APTD AFDC OAA AB APTD AFDC Chi ld ren<21 (SFO) P r e s c r i b e d Drugs 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 O u t p a t i e n t H o s p i t a l Care X X X X X X X X L a b o r a t o r y & X-ray S e r v i c e X X X X X X X X S k i l l e d Nurs ing Home S e r v i c e s X X X X X X X X P h y s i c i a n Serv i ces X X X X X X X X Dental Serv i ces X X X X X X X X "SF0 - S t a t e Funds Only Other B e n e f i t : T r a n s p o r t a t i o n ; pros theses



TOTAL ............................... CATEGORICALLY NEEDY CASH TOTAL...... Aged ................................ B l i n d ............................... Disab led. ...........................

. C h i l d r e n - F a m i l i e s w/Dep Chi ld ren. . A d u l t s -Fami l i es w/Dep Children... . .

CATEGORICALLY NEEDY NON-CASH TOTAL.. Aged ................................ B l i n d ............................... ............................ Disab led C h i l d r e n -Fami l i es w/Dep Chi ldren. . . A d u l t s -Fami l i es w/Dep Chi ld ren. . . .. 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 . Disabled. . ..........................

... C h i l d r e n -Fami l i es w/Dep C h i l d r e n A d u l t s -Fami l i es w/Dep Chi ld ren. . ... Other T i t l e X I X R e c i p i e n t s ..........

No Data A v a i l a b l e

* *Undupl ica ted T o t a l - HHS r e p o r t HCFA - 2082 126

NPC


By the Department o f P u b l i c Hea l th and Soc ia l Serv ices.

Guam - 2 1982

P r o v i s i o n s R e l a t i n g t o Presc r ibed Drugs:

P resc r ibed drugs a r e p rov ided 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 X I X . P rov ide rs 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 operated pharmacies.

D ispens ing fee - AWP p l u s $2.75


A. P u b l i c H e a l t h and Soc ia l Serv ices Department O f f i c i a l s :

F r a n k l i n S. Cruz, Ed.D. D i r e c t o r

Mabel M. F. Chen Supervisor Medical Care Serv ice

Department o f P u b l i c Hea l th and Soc ia l Serv i ces

Government o f Guam Post O f f i c e Box 2816 Agana, Guam 96910

6 . Execut ive O f f i c e r of Pharmaceut ical Assoc ia t ion :

Orencia L. Concepcion Guam Pharmaceut ical A s s o c i a t i o n 626 Western Boulevard Jonestown Tamun i ng, Guam 969 11

WED1 CAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

Hawa i i - 1 1983

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 ld ren<21 (SF()) P r e s c r i b e d 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 O u t p 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 Labora to ry & X-ray ~e r ; i ce X X X X X X X X X X S k i l l e d Nurs ina

<

Home Serv i ces X X X X X X X X X X P h y s i c i a n Serv i ces X X X X X X X X X X Denta 1 - - . . - - . Serv i ces X X X X X X X X X X *SF0 - S t a t e Funds Only


1981 Expended R e c 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 Disabled. . .......................... 553,842 2,951 C h i l d r e n -Fami l i es w/Dep C h i l d r e n . .. 1,235,414 35,718 A d u l t s -Fami l i es 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 D isab led ............................ 47,174 254 C h i l d r e n -Fami l i es w/Dep Chi ldren. . . 41,526 1,555 A d u l t s -Fami l i es 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 3 1 Disabled..... ....................... 295,108 1,715 C h i l d r e n - F a m i l i e s w/Dep Chi ldren. . . 62,687 2,376 A d u l t s -Fami l i es 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

1982 Expended Rec i p i e n t

* *Undupl ica ted T o t a l - HHS r e p o r t HCFA - 2082

128

Hawa i i - 2 1983


By t h e S t a t e Department o f S o c i a l Serv i ces and Housing through i t s P u b l i c We l fa re D i v i s i o n and f o u r county 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 Presc r ibed Drugs

A. Exc lus ions: 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 as 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 by t h e FDA.

0 . Formulary: Yes, Hawaii S t a t e Medica id Drug Formulary

D. P r e s c r i p t i o n Charge Formula: Est imated A c q u i s i t i o n s Cost (EAC) p l u s d ispens ing fee $3.22.

V. F i s c a l In te rmed ia ry

Hawai i Medica l S e r v i c e A s s o c i a t i o n Medica id 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


1. S o c i a l Serv i ces and Housing Department O f f i c i a l s :

F r a n k l i n Y. K. Sunn D i r e c t o r

Department o f S o c i a l Serv i ces and Housing

P. 0. Box 339 Honolulu, Hawai i 96809-0339

A l f r e d K. Suga Deputy D i r e c t o r

Raymond Sato A d m i n i s t r a t i v e S e r v i c e s O f f i c e r

Sh igemi tsu Nakashima P u b l i c Wel fare A d m i n i s t r a t o r

P u b l i c Wel fare D i v i s i o n (same address as above)

E a r l S . Motooka Medical Care A d m i n i s t r a t o r

Wayne S. Hansen, M.D. Medical Consul tant

John A. Sheedy, M.D. Medical Consul tant

F lorance Chinn, M.D. Medical Consul tant

Benjamin Sherman, D.D.S. Dental Consul tant ( p a r t - t i m e )

Omel L . Turk, R.Ph. Pharmaceut ical Consul tant ( 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 Consul tant ( p a r t - t i m e )

2. Soc ia l Serv i ces and Housing Department Medical Care A d v i s o r y Committee:

Y. K. Look, O.D. Chai rman

1441 K a p i o l a n i Blvd. , #517

Honolulu, Hawai i 96814

Roy F. Fuboyama, M.D. Phys ic ian

K a l i h i Medical Center 2055 Nor th K i n g S t r e e t Honolu lu 96819

NPC Hawa i i - 4 1983

S o c i a l Serv i ces and Housing Department Medical Care A d v i s o r y Committee (cont inued) :

Lee Simmons, M.D. P h y s i c i a n

Paul McCal l in , M.D. P h y s i c i a n

R ichard Kato, ACSW S o c i a l Worker

Michael Matsuura H o s ~ i t a l A d m i n i s t r a t o r

C l i f f o r d M i l l e r , J r . Long Term Care A d m i n i s t r a t o r

John Chalmers, M.D Department o f Heal t h

Represen ta t i ve

Saburo F u j i s a k i Labor Represen ta t i ve

Rev. Gera ld G i f f o r d Pastor

James Asato, R.Ph. Pharmacist

Ned W i ederhol t Represen ta t i ve from School

o f P u b l i c H e a l t h

Ms. Roberta Rosea R e c i p i e n t - Maui

Ms. Stephanie T a r l ep R e c i p i e n t - Hawai i

Joyce Dahlberg R e c i p i e n t - Kauai

1380 L u s i t a n a S t r e e t , #407 Hono lu lu 96813

Ka ise r Foundat ion H e a l t h P lan, Inc. 1697 A l a Moana Boulevard Honolu lu 96815

Aloha U n i t e d Way P.O. BOX 1096 Hono lu lu 96808

S t . F r a n c i s H o s p i t a l 2230 L i l i h a S t r e e t Honolu lu 96817

Ann P e a r l Care Home, Inc . 45-181 Waikalua Road Kaneohe 96744

Department o f H e a l t h 1250 Punchbowl S t r e e t Honolu lu 96813

451 Atk inson D r i v e Hono lu lu 96814

S t . E l i z a b e t h Episcopal Church 720 N. K ing S t r e e t Honolu lu 96817

Leahi H o s p i t a l 3675 K i l a u e a Avenue Hono lu lu 96816

855 Aalapapa D r i v e K a i l u a 96734

1993 S. K i h e i Road, Apt . # 403 K i h e i , Maui 96723

1875 S. K i h e i Road, Apt. #I10 H i l o 96720

P.O. box 1824 Lihue, Kauai 96766

Hawa i i - 5 1983

Social Services and Housing Department Medical Care Advisory Committee (continued):

Y.K. Look, 0.0. Optometrist

Walter Fo, Ph.D. Psychologist

Ms. Dorothy K. Nobriga Recipient - Hawaii

Johanna Mokiao Rosie Spesi nger Recipient - Oahu

James L. Watson, D.0.S. Dentist

Patricia K. Osgood, R.N., M.S. Nurse

Henry Miyoi Businessman

1441 Kapiolani Blvd., Room 517 Honolulu 96814

4211 Waialae Avenue Suite 206 Honolulu 96816

69 lpuka Street Hilo 96720

Welfare Recipient Advisory Counc i l

810 N. Vineyard Boulevard Honolulu 96817

Kailua Professional Center 30 Aulike Street, Suite 305 Kailua 96734

Hawaii Nurses Association 677 Ala Moana Boulevard Suite 1014 Honolulu 96813

1932 Kealakai Street, Room 2 Honolulu 96817


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

l OAHO

HEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

Idaho - 1 1983

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 ren<21 (SFO) Prescr i bed Drugs X X X X l n p a t i en t H o s p i t a l Care X X X X O u t p a t i e n t H o s p i t a l Care X X X X Labora to ry & X-ray Serv i ce X X X X S k i l l e d Nurs ing Home Serv i ces X X X X P h v s i c i a n Serv ices X X X X Denta l Serv ices X *SF0 - S t a t e Funds Only



TOTAL.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $2,337,100 28,995**

CATEGORICALLY NEEDY CASH TOTAL...... $1,150,771 21,961 Aged ................................ 262,822 1,658 B l i n d ............................... 2,596 3 3 Disabled... . . . ...................... 326,232 2,098 C h i l d r e n -Fami l i es w/Oep Chi ldren. . . 239,148 11,699 A d u l t s -Fami l i es w/Oep Children... . . 319,973 6,676

CATEGORICALLY NEEOY NON-CASH TOTAL.. $1,186,329 Aged.. .. . .. .. . . .. . ... .... .. . . . .. .. . . 733,041 B l i n d ............................... 4,563 O i s a b l e d . . . . . . . . . . . . . . . . . . . . . . . ..... 420,559 C h i l d r e n -Fami l i es w/Dep Chi ldren. . . 8,634 A d u l t s -Fami l i es w/Dep C h i l d r e n ..... 9,699 Other T i t l e XIX R e c i p i e n t s .......... 9,833

M E O l CALLY NEEDY TOTAL.. . . . . . . . . . . . . . $0 Aged ................................ 0 Blind............................... 0 D isab led ............................ 0 C h i l d r e n - F a m i l i e s w/Dep Chi ld ren. . . 0 A d u l t s -Fami l i es w/Oep Children... . . 0 Other T i t i e XIX R e c i p i e n t s .......... 0


$2,452,372 27.11 4**

1,104,266 19,579 236,543 1 395

2,606 26 314,317 1,838 231,337 10,402 319,463 6,056

$1,348,106 8,471 813,474 4,266

6,619 4 2 488,830 2,823

12,547 637 13,079 421 13,557 339

$0 0 0 0 0 0 0 0 0 0 0 0 0 0


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.

I V . 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

1. H e a l t h and Wel fare Oepartment:

Rose Bowman D i r e c t o r

Pennie B jo rns tad , Chief Bureau o f B e n e f i t Payments

Dianne B. Onnen, R.Ph., M.P.A. Pharmacy Consul tant 208/334-4323

2. Medical Care Adv iso ry Committee:

R ichard 0. Adams D i r e c t o r , H e a l t h O i s t r i c t I l l P. 0. Box 489 Cal dwe l l 83605 208/459-0744

J . Stephen Anderson Regional Serv i ces Manager H e a l t h and Welfare, Region V Box 1509 Twin F a l I s 83301

Howard Bar ton Commission f o r t h e B l i n d Statehouse Boise 83720 208/334-3220

Laura Barton, R.N. Cen t ra l O i s t r i c t H e a l t h Oepartment Home H e a l t h Serv ices 1455 Nor th Orchard Bo ise 83706 208/375-5211

Rober t Berntson ldaho S t a t e Pharmaceut ical Assoc. 145 Mar jacq l daho F a l l s 83401 208/523-1384

Oepartment o f H e a l t h and Welfare Statehouse Boise, ldaho 83720 208/334-4334

Robert Campbell S t , B e n e d i c t ' s H o s p i t a l Jerome 83338 208/324-4301

Ruby Crosby, R.N. S t . B e n e d i c t ' s H o s p i t a l Jerome 83338 208/324-4301

O r . Rodney Heater 827 Center Avenue Paye t te 83664 208/642-4434

J. Char les (Chuck) Holden ldaho A s s o c i a t i o n of Count ies P.O. Box 1623 Bo ise 83701 2081345-91 26

The Honorable E l a i n e Kearnes ldaho House o f Represen ta t i ves 3040 Gustafson C i r c l e l daho Fa l l s 8340 1 208/522-6875

ldaho - 4 1983

Medica l Care A d v i s o r y Committee (con t inued) :

John S. K r i z , D.D.S. ldaho Denta l A s s o c i a t i o n 8424 F a i r v i e w Avenue Bo ise 83704 208/376-7740

The Honorable L a i r d Noh ldaho S t a t e Senate Route No. 1, Box 65 K imber l y 83341 208/733-3617

Dale S h i r k , Execu t i ve V i c e P r e s i d e n t

ldaho H e a l t h F a c i l i t i e s , Inc. P.O. Box 2623 Boise 83701 208/343-9735

Don Sower, Execu t i ve D i r e c t o r ldaho Medical A s s o c i a t i o n 407 W. Bannock Boise 83702 208/344-7888

Mari l yn Leoni ng Sword ldaho Mental H e a l t h Assoc. 3105-1/2 S t a t e S t r e e t Bo ise 83703 208/344-8585

A r l e n e Warner O f f i c e on Aging Statehouse Boise 208/334-3833

Connie W h i t t i n g t o n 792 N o r t h 30 th S t r e e t Bo ise 83703 208/336-4117

Bren t Brocksome Chartham Management 2465 Over land Road, S u i t e A Boise 83705 208/343-7013


A. Medical Assoc ia t ion : B. Pharmaceut ical A s s o c i a t i o n :

D . Sower Rosemary Wel l s Execu t i ve D i r e c t o r Execu t i ve D i r e c t o r l daho Medical A s s o c i a t i o n l daho S t a t e Pharmaceut ical

P. 0. Box 2668 A s s o c i a t i o n Bo ise 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

Bo ise 83704 Phone: 208/376-2273

C. Osteopath ic Medica l Assoc ia t ion :

Harry E. Kale, D.O. Secretary-Treasurer ldaho Osteopath ic Medical 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

I l l i n o i s - 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 Medical l y Needy (MN) Other*

OAA AB APTD AFDC OAA AB APTD AFDC Chi I d r e 6 2 1 (SFO) P r e s c r i b e d 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 Labora to ry & X-ray Serv ice X X X X X X X X X X S k i l l e d Nurs ing Home Serv ices X X X X X X X X X X P h y s i c i a n Serv ices X X X X X X X X X X Denta l Serv i ces X X X X X X X X X X *SF0 - S t a t e Funds Only



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 B l i n d ............................... 71,163 35 1 Disab led ............................ 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 -Fami l i es 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 A d u l t s -Fami l i es w/Dep C h i l d r e n ..... 399,546 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 -Fami l i es w/Dep Chi ldren. . . 486,407 13,448 A d u l t s -Fami l i es 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

**Undupl icated T o t a l - HHS r e p o r t HCFA 137

I l l i n o i s - 2 1983

1 1 1 . A d m i n i s t r a t i o n :

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 Exc lus ions: B i o l o g i c a l s and drugs 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 tock and dispense non- p r o p r i e t a r y drugs o f recogn ized q u a l i t y . I f a d r u g i s l i s t e d i n t h e Oruq Manual by g e n e r i c name and the i d e n t i c a l drug i s p r e s c r i b e d by t r a d e name, t h e pharmacis t may dispense t h e t r a d e name p roduc t ; however, payment w i l l be based on c o s t of the g e n e r i c p roduc t . The pharmacis t may so adv ise 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 ispense t h e g e n e r i c product rvhich does n o t exceed t h e maximum a l l o w a b l e p r i c e .

Fo r fo rmu la ry i n f o r m a t i o n con tac t :

Ms. Dawn A t k i ns P.O. Box 4037 S p r i n g f i e l d , 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 D ispens ing L i m i t a t i o n s :

1. "The pharmacy s h a l l d ispense 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 the pharmacy w i l l be based on t h e p r i c e of a non-p rop r ie ta ry i t e m of recogn ized q u a l i t y . "

I f the pharmacis t d ispenses a t r a d e name p roduc t , t h e charge t o t h e Department of P u b l i c A i d cannot exceed t h a t charge based on t h e maximum a l l o w a b l e charqe o r c o s t i n d i c a t e d i n t h e Drug Manual.

2. Q u a n t i t y : One p r e s c r i p t i o n pe r p a t i e n t pe r d rug pe r month.

3. R e f i l l s : 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 be r e f i l l e d no more than t w i c e and no l a t e r than 3 months f rom 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 . Maintenance RXis may be r e f i l l e d f o r up t o one year.


0. P r e s c r i p t i o n Charge Formula: Lowest of 1) usual 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) Depar tment 's MAC p l u s fee. 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, reduced t o $2.78 on 3/3/83.

NPC

V. M i s c e l l a n e o u s I n f o r m a t i o n :

S t a t e MAC: Yes A p p r o x i m a t e l y 500 drugs

Copayrnent - none 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 - $7.24

F i s c a l I n t e r m e d i a r y - none

I l l i n o i s - 3 1983

I l l i n o i s - 4 1983


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. M i l l e r D i r e c t o r

Betsy S k l o o t A d m i n i s t r a t o r Medica l Ass is tance Program

Department of P u b l i c A i d 316 South 2nd S t r e e t Spr i ngf i e l d 62762

628 Eas t Adams Spr i ngf i e l d 62763

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 Aslaksen Deputy A d m i n i s t r a t o r Medical Ass is tance Program

628 East Adams S p r i n g f i e l d 62763

Norman L. Ryan 216 East Monroe General Serv i ces 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 A d m i n i s t r a t o r Pol i c y and P lann ing

Mark Cami l le , Chief Research & A n a l y s i s

316 South 2nd S t r e e t S p r i n g f i e l d 62762

216 East Monroe S p r i n g f i e l d 62706

B e v e r l y Knous, Chief 216 East Monroe Bureau o f l nformat i on Systems S p r i n g f i e l d 62762

Dawn A t k i n s , Superv isor Drug Program 217/782-0506

Ron G o t t r i c h Pharmacist Consul tant

931 East Washington S p r i n g f i e l d 62763

931 East Washington 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 Medical A d v i s o r y Committee, composed o f phys ic ians appoin ted by t h e D i r e c t o r o f P u b l i c A id . 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 t h e 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. White Cha i rman

723 N o r t h 2nd S t r e e t C h i l l i co the , l l l i n o i s 61523

I l l i n o i s - 5 1983

B . Committee on Drugs and Therapeut ics :

A Committee on Drugs and Therapeut ics, a s tand ing committee appoin ted by t h e I l l i n o i s S t a t e Medical Soc ie ty , serves 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. Cha i rman

Amin N. Oaghestani, M.O.

l g n a c i o Del V a l l e , M.O.

Dorothy Hubler, M.D.

John Hyde, M.D.

Robert Reeder, M.O.

707 Fa i rbanks Cour t Chicago, I l l i n o i s 60611

64 O l d Orchard, S u i t e 205 Skok ie 60077

311 S. Main S t r e e t Tayl o r v i l l e 62568

Casey Medica l Center Casey 62420

603 F o r e s t Avenue Oak Park 60302

970 N. 5 t h Avenue S t . Char les 60174

Consul tants :

A. Samuel Enloe, R.Ph. 251 W. F i r s t D r i v e Decatur 62521

K e r r i s o n Jun ipe r , M.O. SIU School o f Med ic ine P. 0. Box 3926 S p r i n g f i e l d 62708

V incen t A. Costanzo, Jr., 7531 South Stony I s l a n d M.D. Chicago 60649

C. Drug Adv iso ry Committee:

A S t a t e Drug A d v i s o r y Committee, appoin ted 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 adv ise on general 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 ta tew ide 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

Bern ie Evers, R.Ph. Evers Pharmacy 417 West Main Col l i nsv i l l e 62234

Tom Gul ick , R.Ph. Gu l i ck Pharmacy, Inc . 912 N o r t h V e r m i l i o n D a n v i l l e 61832

NPC

Drug Adv isory Connni t t e e (con t inued) :

Don Gronewold, R.Ph. Don's Pharmacy 100 South Main S t r e e t Washington 61571

Rose Mancuso, R.Ph. 1610 Arden P lace J o l i e t 60435

Ed M i l l e r , R.Ph. 400 East Randolph S t r e e t , #I930 # I930 Chicago 60601

Sherwood Thomas, R.Ph. Touhy Pharmacy 7173 N o r t h C l a r k S t r e e t Ch i cago 60626

J e f f r e y Veal, R.Ph. 340 East 8 7 t h P lace Chicago 60619

Execu t i ve O f f i c e r s o f S t a t e Medical and Pharmaceut ical S o c i e t i e s :

A. Medical Soc ie ty : 0. Pharmaceut ical Assoc ia t i on :

Al Lerner Alan L. Granat Execu t i ve A d m i n i s t r a t o r Execu t i ve 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 Pharmaceut ical 55 East Monroe, S u i t e 3510 A s s o c i a t i o n 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. Osteopath ic Medical Assoc ia t i on :

M r . George C. Andrews Execu t i ve 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

Phys ic ians and Surgeons, Inc . 900 East Center S t r e e t Ottawa 61350 815/434-5576

NPC

INDIANA

Ind iana - 1 1983

KDlCAL ASSISTANCE DRUG PROGRAn (TITLE XIX)

I . BENEFITS PROVIDED AN0 GROUPS ELIGIBLE Type o f B e n e f i t Ca tegor i ca l l y Needy Medical l y Needy (MN) Other*

OAA AB APT0 AFOC OAA AB APT0 AFOC Chi ldren<21 (SFO) P r e s c r i b e d Drugs X X X X l npat i e n t H o s p i t a l Care X X X X O u t p a t i e n t H o s p i t a l Care X X X X Labora to ry & X-ray ~er ; ice X X X X S k i l l e d Nurs inq - Home S e r v i c e s X X X X P h y s i c i a n Serv ices X X X X Denta l - ~

Se rv i ces X X X X *SF0 - S t a t e Funds Only

I I . EXPENDITURES FOR DRUGS. Payment t o Pharmacists by f i s c a l year end ing June 30, 1982


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 -Fami l i es w/Dep C h i l d r e n ... 2,310,305 84,397 A d u l t s -Fami l i es 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 -Fami l i es w/Oep Chi ldren. . . 110,047 3,108 A d u l t s -Fami l i es 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 -Fami l ies w/Oep Chi ldren. . . 0 0 A d u l t s -Fami l ies 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



143

l nd iana - 2 1983


The l n d i a n a S t a t e Department of P u b l i c Welfare.


A. General Exc lus ions : None.

8 . Formulary : None.


1. Q u a n t i t y o f Medicat ion: None.

2. R e f i l l s : Al lowed as a u t h o r i z e d by p h y s i c i a n .



1. The lowest of the :

a. MAC p l u s t h e d i spens ing f e e of $2.50.

b. EAC (Es t ima ted A c q u i s i t i o n Cost) p l u s t h e d i spens ing fee o f $2.50. (EAC i s 3% l e s s than AWP r e p o r t e d by Drug Top ics Red Book)

c . Pharmacy's usual and customary charge t o t h e genera l p u b l i c .

V. M isce l l anous In fo rmat ion :

F i s c a l In te rmed ia ry :

EDS Federa l Corp 120 W. Market S t r e e t I n d i a n a p o l i s , l nd iana 46240

l nd iana - 3 1983


1. We l fa re Department O f f i c i a l s :

Donald L . B l i n z i n g e r A d m i n i s t r a t o r

James H. C w k A s s i s t a n t A d m i n i s t r a t o r - A d m i n i s t r a t i o n

Robert F . Smith A s s i s t a n t A d m i n i s t r a t o r - Med ica id

W i l l i a m Hard ing D i r e c t o r D i v i s i o n of A d m i n i s t r a t i v e

Serv ices

Mrs. Nary Kapur A s s i s t a n t A d m i n i s t r a t o r Loca l Operat ions D i v i s i o n

Mark S h i r l e y Pharmacy Consul tant

Department o f P u b l i c Welfare 100 N. Senate Avenue Room 701 I n d i a n a p o l i s , l nd iana 46204

2. Adv iso ry Committee f o r Medical Ass is tance (Medica id)

Hon. W i l l i a m Dunbar 219 West 11 th S t r e e t Anderson 46016

John Cervenka R.R. 1, Box 121 Nor th Judson

Hon. J e f f e r y K. Esp ich Box 158 Uni ondal e 46791

Demetri us Ewi ng 513 South 1 5 t h S t r e e t T e r r e Haute 47801

Lowel l G. Fos te r , M.D. 3500 L a f a y e t t e Road, S u i t e 103 l nd i anapol i s 46222

- lnd iana S t a t e Senate

- S ta tew ide Taxpayer

- House of Represen ta t i ves

- C i t i z e n r y of l n d i a n a

- lnd iana P s y c h i a t r i c Assoc.

l nd iana - 4 1983

A d v i s o r y Committee f o r Medical Ass is tance (con t inued) :

Newel l J. Hal I, V i c e P r e s d i e n t - Ind iana Pharmaceut ical D i r e c t o r , P r o f e s s i o n a l Serv i ces Assoc ia t ion , Inc . Hook Drug, I nc. 2800 E n t e r p r i s e S t r e e t l nd i anapol i s 46226

Car l 0. H icks 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 Sycamore V i l l a g e H e a l t h

Care Center 2905 West Sycamore Road Kokomo 46901

- A g r i c u l t u r a l l n t e r e s t s

- lnd iana H e a l t h Care Assoc.

Edward W. James 3150 West 19 th P l a c e Gary 46402

- Labor l n t e r e s t s

George H. James, A d m i n i s t r a t o r - Ind iana 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

Jo Haynes Books, R.N. - Ind iana S t a t e Nurses' Assoc. Assoc ia te Pro fessor , Nurs ing Purdue U n i v e r s i t y School o f Nurs ing West L a f a y e t t e 47907

A l b e r t F. K u l l , 0.0. 203 South Ironwood D r i v e P. 0. Box 6172 South Bend 46615

Mrs. F r a n c i s Mitcham 3436 N o r t h L a S a l l e I n d i a n a p o l i s 46218

George F. Parker , M.O. 1502 Nor th Emerson Avenue l ndianapol i s 46219

- lnd iana A s s o c i a t i o n of Osteopath ic P h y s i c i a n s and Surgeons

- lnd iana S t a t e L icensed P r a c t i c a l Nurses' Assoc ia t ion , Inc .

- l n d i a n a Chapter American Academy o f P e d i a t r i c s

C l i f f o r d A. Bey len - E x - O f f i c i o - Represent ing D i v i s i o n of Medical Care S t a t e H e a l t h Commissioner

A d m i n i s t r a t i o n lnd iana S t a t e Board o f H e a l t h 1330 West Mich igan S t r e e t I n d i a n a p o l i s 46202

NPC l n d i a n a - 5 1983

Adv iso ry Comni tee f o r Medical Ass is tance ( c o n t i n u e d ) :

Mrs. M a r i e Peacock, R.N. 2300 E x e c u t i v e D r i v e Kokomo 46901

Rober t Sh i rey , D.O.S., Chairman

l n d i a n a S t a t e Dental Assoc. 1121 West Michigan S t r e e t l n d i a n a p o l i s 46202

Rober t Spauld ing

A l b e r t 0. Stroud, 0.0. 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. 5921 East Washington S t r e e t l n d i a n a p o l i s 46219

Char les Watkins, O.C. 5117 East Washington S t r e e t l n d i a n a p o l i s 46219

A r v i n e G. Popplewel l , M.D. 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

- C i t i z e n r y o f l nd iana

- lnd iana S t a t e Denta l Assoc.

- lnd iana O ~ t o m e t r i c Assoc.

- lnd iana S t a t e P o d i a t r y

- lnd iana S t a t e C h i r o p r a c t i c A s s o c i a t i o n

- S t a t e Medica l A s s o c i a t i o n

3 . Execu t i ve O f f i c e r s of S t a t e Medical and Pharmaceut ical S o c i e t i e s :


Donald F. Foy Execu t i ve D i r e c t o r l nd iana S t a t e Medical A s s o c i a t i o n 3936 Nor th 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


Dav id A. C l a r k Execu t i ve D i r e c t o r l nd iana 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


Central administration by the State Department of Social Services.


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.


1. Terminology: None.

2. Quantity of Medication: Prescriptions should be limited to a 30-day supply. Maintenance drugs may be supplied in 90-day quantities.

3. Refills: Permitted.


D. Prescription Charge Formula: Payment will be based on the pharmacist's usual, custmary 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 !


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: Statistics Section, Division of Administration.

1 ) $0.50 copay (Federal Exclusions) fee. $3.74 fee effective July 1, 1983.

lowa - 3 1983


1. Soc ia l Serv ices Department O f f i c i a l s :

Michae l V. Reagen, Ph.D. Commissioner

Donald L. Kassar C h i e f Bureau o f Medical Serv ices

Ronald J. Mahrenholz, R.Ph., M.S. Manager U t i l i z a t i o n Review Sec t ion

Department o f S o c i a l Serv ices Hoover S t a t e O f f i c e B u i l d i n g Des Moines, lowa 50319

2. Soc ia l Serv ices Department Adv isory Committees:

A. T i t l e XIX Medical Ass is tance Counc i l :

Co l lege of Medic ine Paul Seebohm. M.D. Assoc ia te Dean Co l lege of Medic ine U n i v e r s i t y H o s p i t a l s lowa C i t y 52240

House o f Represen ta t i ves Rep. Andy McKean Morley 52312

Rep. Rodney Halvorson 1030 Nor th 7 t h S t . F o r t Dodge 50501

lowa Dental A s s o c i a t i o n C. E. O'Meara 530 39th S t r e e t Des Moines 50309

O p t i c i a n s Assoc. o f lowa, I nc. . . -

E v e r e t t H a i n l i n e 1460 75 th S t r e e t Des Moines 50311

lowa H o s p i t a l A s s o c i a t i o n Inc. Donald Dunn S u i t e R, 600 5 t h Avenue Des Moines 50309

lowa Medical S o c i e t y Donald C. Younq, M.O. 1301 10 th s t r e e t , S u i t e 119 Des Moines 50316

lowa Nurses A s s o c i a t i o n M a r i l v n R u s s e l l (Mrs.) P u b l i c H e a l t h Nurs ing Assoc. Armory B u i l d i n g East 1 s t & Des Moines S t r e e t Oes Moines 50309

H e a l t h F a c i l i t i e s Assoc. o f l owa -

R. Buckman Brock P. 0. Box 677 2137 Sunset Road Des Moines 50303

lowa - 4 1983

T i t l e XIX Medical Ass is tance Counci l (cont inued) :

Iowa S o c i e t y o f Osteopath ic Iowa Senate Phys ic ians and Surgeons Senator Dale L. T ieden

Dante R. T o r i e l l o , D.O. E lkader 52043 623 E. 12 th 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. Pat M i t c h e l l Iowa Optometr ic 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

lowa Osteopath ic H o s p i t a l A s s o c i a t i o n

James Kinasburv 603 E. 12 th ~ t k e e t Oes Moines 50316

lowa Pharmacists Assoc. Thomas R. Temple 8515 Douglas, S u i t e 24 Oes Moines 50322

lowa P o d i a t r y S o c i e t y Tom Anderson, D.P.M. Box 430 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. Pharmaceut ical Adv iso ry Committee:

Mark Richards, Oes Moines B i l l Robinson, A t l a n t i c P h i l Weider, Des Moines Dan Keck ler , 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, Urbandale Duane Haber i ch te r , Oskaloosa Mar ion Reis, S ioux C i t y Roger Zobel, West Oes Moines Lonnie Col t r a i n , E ldon

P u b l i c Represenat ives Mary E l l e n Evans (Mrs.) 2503 Fu l t o n Avenue Davenport 52803

Sharon L. Geers 1200 3 5 t h S t r e e t , S u i t e 120 West Oes Moines 50265

De id ra R e i l l y 1332 23rd S t r e e t , Apt. 8 Des Moines 50311

Robert L. Bray 4129 F o r e s t Avenue Oes Moines 50311

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 Pharmceut ica l S o c i e t i e s :


E ldon Huston E x e c u t i v e V i c e - p r e s i d e n t lowa Medical S o c i e t y 1001 Grand Avenue West Des Moines 50265 Phone: 515/223-1401

B. Pharmacists Assoc ia t i on :

Thomas R. Temple, R.Ph., M.S. E x e c u t i v e D i r e c t o r lowa Pharmacists 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

mOICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

Kansas - 1 1983

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) Presc r ibed Oruqs X X X X X X X X X X l npat i en t H o s p i t a l Care X X X X X X X X X X O u t p a t i e n t Hosp i t a 1 Care - X X X X X X X X X X Labora to ry & 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 Nurs ing Home S e r v i c e s X X X X X X X X X X P h y s i c i a n Serv ices X X X X X X X X X X Dental Serv i ces 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 Services; R e h a b i l i t a t i v e Serv ices; Prostheses; P r e v e n t i v e Serv ices; Fami ly P lann ing Serv ices; C h i r o p r a c t i c Serv i ces ; Optometr ic Serv ices; and Community Based A l t e r n a t e Services. *SF0 - S t a t e Funds Only

I I . EXPENDITURES FOR DRUGS. Payment t o Pharmacists by f i s c a l year end ing June 30, 1982


............................... 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 Disabled. ........................... 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 -Fami l ies 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 -Fami l i es w/Dep C h i l d r e n ... 43,876 2,932 84,060 2,118 A d u l t s -Fami l ies w/Dep Ch i ld ren . .... 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 6 1 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 Disab led. ........................... 1,422,650 4,497 1,495,734 4,163 C h i l d r e n -Fami l i es w/Dep Chi ldren. . . 123,347 4,530 76,850 3,314 A d u l t s -Fami l ies 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


Kansas - 2 1983


State Department of Social and Rehabilitation Services.


A . Prescribed drugs. Covered are: (a) legend drugs in a formulary approved by the state Medicaid agency, excluding drugs that the agency finds ineffective or possibly effective; and (b) seleted nonlegend drugs, devices, and supplies when prescribed for diseases and conditions specified in the state's Medicaid regulations.

B. Formulary: None.


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 Secretary

S a l l y Anderson, D i rec to r l ncome Ma i ntenance

Robin Smith, D i rec to r Pub l ic Assistance Sect ion

L. Kathryn Klassen, R.N., M.S. D i rec tor D i v i s i o n o f Medical Programs

Lynn Muchmore, Budget D i rec to r Department o f Admin is t ra t ion

Joyce Sugrue, R.N. Coordinator o f Medical Services

E la ine Hacker, M.D. U t i l i z a t i o n Review Adminis t rator

Gene Hotchkiss, R.Ph. Pharmacist Consultant

2. Governor's Medical Advisory Committee:

C l i n t W i l l s i e , D i rec tor Sedgwick County Development of

Mental Heal th 1801 East Tenth S t ree t Wichita 67214

Dean Co l l ins , M.D. Menni nger Foundation P. 0. Box 829 Topeka 66601

Theodore Young, M.D. 107 Medical A r t s B u i l d i n g Topeka 66604

Department o f Socia l and R e h a b i l i t a t i o n Services

State O f f i ce Bu i l d ing Topeka, Kansas 66612

Daniel A. Shea, O.D. 2720 East 21st S t ree t Wichita, Kansas 67214

Helen Jones Department o f Aging 2700 West S i x t h S t r e e t Topeka 66606

James Hawk i ns C l i n i c a r e Family Hea l th Services 510 Southwest Boulevard Kansas C i t y 66103

Kansas - 4 1983

Governor 's Medical Adv iso ry Committee (cont inued) :

Warren W. Abbot t , D.P.M. 1919 West 1 0 t h S t r e e t Topeka 66604

A l i c e F i s h e r 226 Woodruff Topeka

Joseph Ho l lowel I, M.D. 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 Blvd. Topeka 66620

Thomas McEvoy, A d m i n i s t r a t o r Leavenworth County Convelescent

l n f i rmary Broadway & Rees Leavenworth 66048

W i l l i a m J. Ciskey, M.D. 1602 N o r t h Elm Eureka 67048

Department Represen ta t i ves

Dr. Robert C. Harder H a r l e y R u s s e l l , R.Ph., Chairman Russe l l Drugs, Inc. L. Ka th ryn Klassen, R.N., M.S. 3400 South F o u r t h

Robert O 'Br ien Senior V i c e P r e s i dent Wesley Medica l Center 550 Nor th H i l l s i d e W i c h i t a 67214

E l a i n e Hacker, M.D.

Gene Hotchk iss , R.Ph.

Robert E. Johnson Admini s t r a t o r Miama County H o s p i t a l 501 South H o s p i t a l D r i v e Paolo 66071

Kansas - 5 1983

3. Execu t i ve O f f i c e r s o f S ta te Medical and Pharmaceut ical S o c i e t i e s :

A. Medical Society:

Steve C a r t e r Execu t i ve D i r e c t o r Kansas Medical Soc ie ty 1300 Topeka Boulevard Topeka 66612 Phone: 913/235-2383

8. Pharmaceut ical Assoc ia t ion:

Kenneth W. Schafermeyer Execu t i ve D i r e c t o r Kansas Pharmaceut ical 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. Osteopath ic Medical Assoc ia t ion :

M r . Haro ld Reihm Execu t i ve D i r e c t o r Kansas A s s o c i a t i o n o f Osteopath ic Medic ine F i r s t Na t iona l Bank Tower - 1425 Topeka 66603

KENTUCKY

Kentucky - 1 1983


OAA AB APT0 AFOC OAA AB APT0 AFOC C h i l d r e n Q l (SFO) Presc r ibed Druqs X X X X X X X X X l m a t i en t ~ o i ~ i t a l Care X X X X X X X X X Outoat i en t H o s p i t a l Care X X X X X X X X X Labora to ry & X-ray Serv ice X X X X X X X X X S k i l l e d N u r s i n g Home Serv ices X X X X X X X X X P h y s i c i a n Serv ices X X X X X X X X X Dental Serv ices X X X X X X X X X *SF0 - S t a t e Funds Only



............................... TOTAL $16,615,252 263,380** $15,665,394

CATEGORICALLY NEEDY CASH TOTAL ...... $14,898,408 212,561 Aged ................................ 4,460,087 35,991 B l i n d . .............................. 188,449 1,555 Disab led ............................ 6,457,132 43,466

. C h i l d r e n - F a m i l i e s w/Oep Chi ldren. . 1,734,152 85,213 A d u l t s -Fami l i es w/OepChi ldren ..... 2,058,588 47,524

CATEGORICALLY NEEDY NON-CASH TOTAL.. $0 0 Aged ................................ 0 0 B l i n d ............................... 0 0 Disabled....... ..................... 0 0 C h i l d r e n -Fami l i es w/Oep Children... 0 0 A d u l t s -Fami l i es 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 -Fami l i es w/Oep Chi ldren. . . 486,889 25,272 A d u l t s -Fami l i es 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

**Undupl ica ted T o t a l - HHS r e p o r t HCFA - 2082

Kentucky - 2 1983


By t h e D i v i s i o n f o r Medical Ass is tance w i t h i n t h e Department f o r Soc ia l Insurance, w i t h i n t h e Cabinet f o r Human Resources.


A. General Exc lus ions (d iseases, drug ca tegor ies , e tc . ) : The f o l l o w i n g a r e i tems which a r e n o t covered under t h e pharmacy b e n e f i t s area o f t h e program:

1. Most medical supply i tems 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 sy r inges a r e covered.)

2. Medic ine c a b i n e t s u p p l i e s and drug s tap les .

3 . Drugs a v a i l a b l e through o t h e r programs o r agencies.

4. Drugs n o t i nc luded on t h e Kentucky Medical Ass is tance Program Drug L i s t ( u n l e s s p re -au thor i zed accord ing t o e s t a b l i s h e d g u i d e l i n e s and c r i t e r i a ) .

5. Medicat ions 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 (over - the -coun te r ) drugs except those used t o t r e a t d iabetes and i r o n d e f i c i e n c y anemia and e n t e r i c coa ted a s p i r i n .

B . Formulary: Yes. Th is 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 Formulary Subcommittee and i n accordance w i t h a v a i l a b l e funds.


1. Q u a n t i t y of Medicat ions: None.

2. R e f i l l s : 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 than 5 t imes o r more than 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 .


D. P r e s c r i p t i o n Charge -- Reimbursement Formula:

1 . A l l covered 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 Kentucky Medical Ass is tance Program r e c i p i e n t s a r e t o be b i l l e d t o t h e Program a t t h e usual charge t o t h e genera l p u b l i c f o r t h e same p roduc 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 lowest o f : ( 1 ) t h e usual and customary charge; (2 ) t h e MAC, i f any, p l u s d i spens ing fee; o r ( 3 ) t h e EAC p l u s d ispens ing fee.

2. The d ispens ing fee i s $2.35.

3. Co-payment - none.


Payment f o r drugs i s l i m i t e d t o those pharmacies which a f f i l i a t e themselves w i t h t h e Medical Ass is tance Program by comp le t ing t h e "Agreement o f P a r t i c i p a t i n g Pharmacies."

F i s c a l In termediary :

E l e c t r o n i c Data Systems Corp Da l las , Texas




Buddy H. Adams Secretary

John Cubine Commissioner

James B. Gooding, D i rec to 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

Cabinet fo r Human Resources 4 th F loor , DHR Bu i l d ing 275 East Maln S t ree t Frankfor t , Kentucky 40621

Department f o r Socia l Insurance 3rd Floor, DHR B u i l d i n g 275 East Main S t r e e t Frankfor t 40621

State Advisory Council on Medical Assistance appointed by the Governor, i s composed of members represent ing pharmacy, hosp i ta ls , reg is te red nurses, medical doctors, dent is ts , nursing homes, optometr ists, p o d i a t r i s t s ; meet qua r te r l y or more often.

A. Advisory Council f o r Medical Assistance:

Howard L. Bost, Ph.D. (Chrmn) Assis tant Vice President fo r

Program G P o l i c y Planning Un ive rs i t y of Kentucky Medical Center Lexington 40506

Theodore E. Logan, Jr., D.M.D.

4229 Bardstown Road L o u i s v i l l e 40218

Nawanda Daniel s 801 South 35th St ree t L o u i s v i l l e 40211

Robert N. McLeod, M.O. 500 Bourne Avenue Somerset 42501

Ms. A l i c e LeMaster 227 Douglas Avenue Frank for t 40601

La r ry H. Spears, R.Ph. C/O Grant County Drugs Dry Ridge 41035

Ms. Wanda Humphreys North Race S t ree t Glasgow 42141

E.P. H i l t o n 219 Lyons Dr ive Frank for t 40601

Suzanne Vance 12708 S t . C l a i r D r i ve Middletown 40243

Kentucky - 5 1983

Adv isory Counci l f o r Medical Ass is tance (con t inued) :

C. A. Nava, D.P.M. Secre ta ry Kentucky S t a t e Board

o f P o d i a t r y 110 N o r t h Hubbard Lane L o u i s v i l l e 40207

Nedra Dav i ne A d m i n i s t r a t r i x Dover Manor Scot land Wood D r i v e Georgetown 40324

Wayne Helderman, O.D. 20 Broadway M t . S t e r l i n g 40353

Frances Johnson 308 S t . Johns Court, Apt. C F r a n k f o r t 40601

E l l e n Buchart , R.N. Je f fe rson County H e a l t h Department 400 East Gray S t r e e t L o u i s v i l l e 40202

J e r r y Rogers 550 High S t r e e t Bowl ing Green 42101

Thomas W. Grant Good Samaritan H o s p i t a l 310 South Limestone S t r e e t Lex ing ton 40503

John Cubine ( e x o f f i c i o ) Comm i 55 i oner Department f o r S o c i a l Insurance DHR B u i l d i n g , 3 r d F l o o r F r a n k f o r t 40621

Buddy H. Adams ( e x o f f i c i o ) Secretary Cabinet 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

Formulary Subcommittee

Robert N. McLeod, M.D. Cha i rman 500 Bourne Avenue Somerset 42501

James Sieg, Ph.D. U n i v e r s i t y o f Kentucky Col lege of Pharmacy Lex ing ton 40506

John M. Ba i rd , M.0 216 Maple Avenue D a n v i l l e 40422

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

Department 400 East Gray S t r e e t L o u i s v i l l e 40202

R. N. Smith Smith 's Pharmacy Burkesvi l l e 42717

Samuel R. S c o t t , M.D. 1302 Richmond Road Lex ing ton 40508

Thomas G. Scharf f , Ph.0. Department o f Pharmacology Hea l th Sciences Center U n i v e r s i t y o f L o u i s v i l l e Post O f f i c e Box 1055 L o u i s v i l l e 40201

Chester L. Parker , Pharrn.0. 1816 Dar ien D r i v e Lex ing ton 40201

NPC Kentucky - 6 1983

B. Pharmacy Technica l Adv isory Comnittee:

Or. Condi 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 i n i c 211 Ger i Lane Mad i sonv i l l e 42431 Richmond 40475

Michael Sheets, R.Ph. 903 Lyndon Lane L o u i s v i l l e 40222

B i l l Sh ink le , R.Ph. 621 Cherrywood O r i v e El izabeth town 42701

Dav id Hancock, R.Ph. 401 Park Row Bowl ing Green 42101

3. Execu t i ve O f f i c e r s o f S ta te Medical and Pharmaceut ical S o c i e t i e s :


Robert K l i n g l e s m i t h Execu t i ve 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 1 e 40205 Phone: 502/459-9790

8. Pharmaceut ical Assoc ia t ion :

Paul Davis, R.Ph. Execu t i ve 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. Dsteopath ic Medical Assoc ia t ion :

Lewis C. Cheatham Execu t i ve D i r e c t o r Kentucky Dsteopath ic 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

HEOICAL ASSISTANCE DRUG PROGRAM (TITLE X I X )

L o u i s i a n a - 1 1983

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 Chi ldrenc21 (SFO) P r e s c r i b e d Drugs X X X X X X X X X X l noat i en t H o s p i t a l Care X X X X X X X X X X O u t p 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 Labora to ry & 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 Nurs inq - Home Serv ices X X X X X X X X X X P h y s i c i a n Serv ices X X X X X X X X X X Dental Serv i ces X X X X X X X X X X *SF0 - S t a t e Funds Only

I I . EXPENDITURES FOR DRUGS. Payments t o Pharmacists by f i s c a l year end ing June 30, 1982


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 -Fami l i es w/Dep Children... A d u l t s -Fami l i es w/Dep C h i l d r e n ..... CATEGORICALLY NEEOY NON-CASH TOTAL.. Aged ................................ Bl ind. . . . ........................... Disabled..... ....................... C h i l d r e n -Fami l i es w/Dep C h i l d r e n . .. A d u l t s -Fami l i es w/Dep Chi ldren. . . . . 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 isab led ............................ 222,674 1,191 308,058 1,771 C h i l d r e n -Fami l i es w/Dep Ch i ld ren . . . 40,141 1,298 42,013 1,455 A d u l t s -Fami l i es w/Dep Chi ldren. . . .. 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


164

NP C

I l l . Adminis t rat ion:

Pub l ic assistance programs are admi Secur i ty , Department o f Heal th and

Louisiana - 2 1983

n is te red by the Sta te O f f i c e o f Family Services. Human

IV. Prov is ions Re la t ing t o Prescribed Drugs:

A. Prescribed legend and non-legend drugs (OTC) are reimbursed.

B. Prescr ib ing or Dispensing L imi ta t ions :

1. Quan 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 iven on a cont inuing basis, a f t e r 5 r e f i l l s or a f t e r 6 months.

Maximum payment quant i ty f o r p resc r ip t i ons sha l l be e i t h e r one nwnth's treatment or 100 u n i t doses.

2. R e f i l l s : Permi t ted as ind ica ted by physic ian w i t h i n 6 months and not t o exceed 5 r e f i l l s .

3. D o l l a r L imi ts : None.

C. P resc r ip t i on Charge Formula:

1. The maximum payment f o r a p resc r ip t i on i s estimated a c q u i s i t i o n cost p lus $3.67 dispensing fee.

D. F isca l Intermediary:

The Computer Company P.O. Box 4169 Baton Rouge, Louisiana 70821

E . Number o f Rx claims processed i n FY 1982 - 5,010,988

Average Rx p r i c e FY 1982 - $10.44

Lou is iana - 3 1983

O f f i c i a l s , Consu l tan ts 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 i ss i nger S e c r e t a r y

R. K. Banks A s s i s t a n t Secre ta ry

Jake Canova Deputy A s s i s t a n t Secre ta ry

Wa l te r S. McLean, Jr. A s s i s t a n t D i r e c t o r f o r Operat ions Medica l Ass is tance Programs

Caro lyn Maggio (Mrs.) D i r e c t o r Medical Ass is tance Programs

Eunice R i t c h i e , R.Ph. Pharmacist Consul tant Medica 1 Ass is tance Programs

Department o f H e a l t h and Human Resources

P. 0. Box 3776 Baton Rouge, L o u i s i a n a 70804

O f f i c e o f Fami l y S e c u r i t y 755 R i v e r s i d e N o r t h P.O. Box 44065 Baton Rouge, L o u i s i a n a 70804

2. O f f i c e o f Fami ly S e c u r i t y Adv iso ry Committees:

A. Medica l Adv iso ry Committee:

(To be appoin ted)

B. Pharmacy Program Adv iso ry Committee:

(Ad Hoc B a s i s On1 y)

L o u i s i a n a - 4 1983


A. Medical Society:

James Stewart , M.D. Execu t i ve V ice Pres iden t Lou is iana S ta te Medical Soc ie ty 1700 Josephine S t r e e t New Orleans 70113 Phone: 504/561-1033


Peter Caldwel l Execu t i ve V ice Pres iden t Lou is iana S t a t e Pharmacists A s s o c i a t i o n 2337 S t . Claude Avenue New Orleans 70117 Phone: 504/949-7545


Char les S. Wyckoff, 0.0. Sec re ta ry -T reasure r Lou is iana A s s o c i a t i o n o f Osteopath ic Phys ic ians 333 S t . Charles Avenue - 412 New Orleans 70115

EDICAL ASSISTANCE DRUG PROGRAH (TITLE X I X )

Maine - 1 1983

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 Medical l y Needy (MN) Other*

OAAABAPTDAFDC OAAABAPTDAFDC Chi ldrenc21 (SFO) Presc r ibed Drugs X X X X X X X X X l npat i en t H o s p i t a l Care X X X X X X X X X Ou tpa t ien t H o s p i t a l Care X X X X X X X X X Labora to ry & X-ray Serv ice X X X X X X X X X S k i l l e d Nurs ing Home Serv ices X X X X X X X X X P h y s i c i a n Serv ices X X X X X X X X X Dental Serv ices X X X X X X X X X *SF0 - S t a t e Funds Only

I I . EXPENDITURES FOR DRUGS. Payment t o Pharmacists by f i s c a l year ending September 30, 1982


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 B l i n d ............................... 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 -Fami l i es w/Dep Ch i ld ren . .. 542,583 26,299 514,401 24,322 A d u l t s -Fami l i es 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 B l ind . . ............................. 1,888 7 2,090 11 Disabled..... ....................... 596,833 2,095 671,315 2,744 C h i l d r e n -Fami l i es w/Dep C h i l d r e n ... 194,856 7,098 271,384 8,530 ..... A d u l t s -Fami l i es 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 Bl ind. . . . . .......................... 414 2 8 1 D isab led ............................ 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 -Fami l i es 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


168

Maine - 2 1983

I II. Administration:

State Department of Human Services.


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:


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.


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

Misce l laneous Remarks (con t inued) :

The Department of Human Serv ices 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 drugs i n gener i c terms whenever p o s s i b l e . The pharmacis t i s expected t o supply such gener i c p repara t ions a t a reasonable c o s t which does no t s a c r i f i c e q u a l i t y . A drug dispensed by a pharmacist on 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 Serv ices b y i t s n o n - p r o p r i e t a r y name must be equal 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 c o u n t e r p a r t .

The S t a t e processes c la ims under t h e M M l S Program.

Druqs f o r t h e E l d e r l y Program (Pharmaceut ical Ass is tance 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 p r e s c r i p t i o n .

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 no t remarr ied, o r a r e 62 years 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 determined e l i g i b l e by 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 des ignated by t h e Bureau o f T a x a t i o n as meet ing t h e f i n a n c i a l guide1 ines f o r t h e Tax and Rent Refund Program.

4. Persons e l i g i b l e f o r Medica id 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 no 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.

Ca tas t roph ic l l lness Proqram (Maine Publ i c Law 768 - (l974), e f f . 7/1/74)

1. Prov ides 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 by s t a t e funds on ly .

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 ca re when i n d i v i d u a l s cannot pay f o r such ca re f r o m t h e i r own o r o t h e r resources.

4. E l i g i b i l i t y : ( i n d i v i d u a l b a s i s - 1 y e a r )

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 ne t income be fo re taxes.

NPC Maine - 4 1983

Miscellaneous Remarks (continued):

c . 10% o f net worth exceeding $20,000 and $1,000 deductible.

d. Payments a r e made only t o vendors or providers of care.

Maine - 5 1983


1. Human S e r v i c e s Department O f f i c i a l s :

Michael R. P e t i t Commissioner

Frances G. McGinty Deputy Commissioner

James H. Lewis, M.P.H. D i r e c t o r Bureau o f Medical Serv ices

B e v e r l y Johnson, R.N. A s s i s t a n t D i r e c t o r Bureau o f Medica l Serv i ces

E. Raymond Dow D i r e c t o r Medica id Plans and P o l i c y

Michael D. O'Oonnel l , R.Ph. Pharmacist Consul tant 207/289-2674

P r i s c i l l a Carney D i r e c t o r Medica id 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 Consul tants:

A l l e n E l k i n s , M.D. P s y c h i a t r i c

D. K. McFadden, D.O. Osteopath ic

Donald E l l i s , O.D. Optometr ic

Kev in H i l l , M.D. Ophtha lmolog is t

J. D. Reeder, D.C. C h i r o p r a c t i c

Department o f Human Serv ices S t a t e House Augusta, Maine 04333

H e a l t h and Medica l S e r v i c e s (address same as above)

NPC Maine - 6 1983

2. Medical Ass is tance Adv isory Comnittee:

A. Dewey Richards, M.D. Cha i rman

11 Gage S t r e e t B r i d g t o n 04009



Frank 0. S t r e d Execut ive 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 Assoc ia t ion :

Har land Goodwin, J r . Execut ive Secre ta ry Maine Pharmaceut ical Assoc ia t ion P. 0. Sox 189 South Berwick 03908 Phone: 207/384-5653


Ph i 1 i p N. Johnson Execut ive D i r e c t o r Maine Osteopath ic 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

MRYLAWD

MEDICAL ASSISTANCE DRUG PROGRAM ( T I T L E X I X )

Maryland - 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 Medica l l y Needy (MN) Other*

OAA AB APTD AFDC OAA AB APTD AFDC C h i l d r e n Q l P r e s c r i b e d

(SFO)

Druqs 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 O u t p 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 Labora to rv 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 Nurs ina

2

Home Serv i ces X X X X X X X X X X P h v s i c i a n Serv i ces X X X X X X X X X X Dental - ~-

Serv i ces X X X X X X X X X X "SF0 - S t a t e Funds Only


-

1981 f i82 Expended R e c i p i e n t Expended R e c i p i e n t

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 B l i n d ............................... 48,129 269 51,839 260 D isab led ............................ 4,449,979 24,042 5,358,725 23,987 C h i l d r e n -Fami l i es w/Dep Chi ld ren. . . 2,348,799 93,199 2,553,256 90,208 A d u l t s -Fami l i es w/Dep Chi ld ren. . ... 3,679,447 59,126 4,326,318 59,921

CATEGORICALLY NEEDY NDN-CASH TOTAL.. Aged ................................ B l i n d . . ............................. Disab led ............................ C h i l d r e n - F a m i l i e s w/Dep Chi ld ren. . . A d u l t s - F a m i l i e s w/Dep Chi ld ren. . ... 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 ind . . ............................. Disabled... ......................... C h i l d r e n -Famil i e s w/Dep Chi ldren. . . 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 .......... +*Undupl ica ted 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.


A. General Exclusions: (a) experimental or investigational drugs; (b) food supplements or infant formulas; (c) prescriptions and injections for central nervous system stimulants and anorectic agents used for weight control ; (d) "less-than-effective" drugs under federal regulations; and (e) certain other items as specified in the state's Medicaid plan.

B. Coverage of nonlegend drugs is limited t o insulin and Schedule V cough preparations.

1. Quantity of Medication: The prescriber may order up t o a 100-day supply of the medication on a single prescription, except for birth control pills h i c h are limited to 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 charge exceeds $40.

4. Formulary: Yes. For information contact:

Mr. Charles Tregoe 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 are provided with a list of therapeutically equivalent drug products. The Program also maintains a list of drugs with maximum allowable cost (MAC) limits. This list, which contained 46 price controlled drugs in fiscal year 1982, is continually updated to reflect deletions and additions made by the 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 Es t ima ted A c q u i s i t i o n Cost (EAC) f o r s i n g l e source drugs 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 lower o f : - A l lowab le c o s t p l u s $3.25 d ispens ing fee, o r - Usual and customary

V. Misce l laneous:

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 ass is tance . No copayment f o r r e c i p i e n t s i n Federa l c a t e g o r i e s , o r those r e c e i v i n g EPSDT and Fami ly P lann ing r e l a t e d s e r v i c e s .

Maryland Pharmacy Ass is tance Program

The Maryland Pharmacy Ass is tance Program, e s t a b l i s h e d by t h e Maryland General Assembly i n 1978, i s admin is te red by t h e A s s i s t a n t S e c r e t a r y f o r Medica l Care Programs and suppor ted e n t i r e l y by s t a t e funds. The purpose of t h i s program 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 no t e l i g i b l e f o r Medical Ass is tance 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 medica l s u p p l i e s .

E l i g i b i l i t y f o r Pharmacy Ass is tance i s based on t h e f i n a n c i a l resources a v a i l a b l e t o t h e f a m i l y u n i t . 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 increased by $200, making t h e gross income s tandard $1,700 above t h e Medical Ass is tance sca le . The asse t standard f o r t h e Pharmacy Ass is tance Program remained t h e same as f o r t h e Maryland Medical Ass is tance Program. The f o l l o w i n g c h a r t shows t h e gross income and asse 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.

Fami ly S i z e

1 2 3 4

Each A d d i t i o n a l Person

Gross l ncome Standards Assets Standards

Dur ing f i s c a l year 1982, increases i n S o c i a l S e c u r i t y payments caused many Pharmacy Ass is tance r e c i p i e n t s t o lose t h e i r e l i g i b i l i t y . I n o r d e r t o p reven t 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 increase i t s income standards each year a t t h e same r a t e as 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 increased, no 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 per month were e n r o l l e d i n t h e Pharmacy Ass is tance 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 per p r e s c r i p t i o n . R e c i p i e n t s a r e respons ib le 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


1. H e a l t h and Mental Hygiene Department O f f i c i a l s :

Adele W i l zack S e c r e t a r y

Ka th leen B. Becker Chie f , D i v i s i o n of S p e c i a l i z e d

H e a l t h Serv ices

Leone W. Marks, R.Ph. S t a f f Spec ia l i s t f o r Pharmacy

Serv ices 301 /383-2658

2. Medicaid/Pharmacy L i a i s o n Committee:

Donald A. Schumer, R.Ph. Penn-Dol Pharmacy Phone: 669-2424

*Home: 7 High Stepper C t . , #301 Ba l t imore , MD 21208

Murray Polonsky, R.Ph. Acc red i ted S u r g i c a l Company Phone: 585-7711

*Home: 415 E . Wayne Avenue S i l v e r Spr ing, MD 20901

Dav id Rombro, R.Ph. MacGi 1 I i v r a y ' s Pharmacy 900 N. Char les S t r e e t Ba l t imore, Maryland 21201 Phone: 539-0904

685-3272

Department o f Heal t h and Mental Hygiene

201 W. P r e s t o n S t r e e t Ba l t imore , Maryland 21201

Adolph Baer, R.Ph. F i s h e r ' s Pharmacy Phone: 582-2200

+Home: 1835 Woodburn D r i v e Hagerstown, MO 21740 Phone: 733-4116

M e l v i n Rubin, R.Ph. Parad ise Pharmacy Phone: 247-1244

*Home: 2316 Sugarcone Road Ba l t imore , MO 21209

M a r t i n M in tz , R.Ph. N o r t h e r n Pharmacy Nor the rn Parkway and Har fo rd Road Ba l t imore , Maryland 21214 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 Denbr ight Road

Ba l t imore , 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 (con t i nued) :

Ron T e l ak Maryland General H o s p i t a l Pharmacy Department 827 L i n d e n Avenue Ba l t imore , MD 21201

John J. Pa lya A s s i s t a n t t o D i v i s i o n Manger Wyeth L a b o r a t o r i e s 4000 Renaul t P lace A lexandr ia , VA 22309

Tony Warren P.O. Box 433 Ba l t imore , MD 21203

F r a n c i s K. Davis, J r . E a s t e r n F i e l d Manager Government A f f a i r s Hoechst-Roussel Pharmaceut icals, Inc. 2408 F a i r v i e w D r i v e A lexandr ia , VA 22306 Phone: (703)768-4244

Dav id Banta, R.Ph. Maryland Pharmaceut ical A s s o c i a t i o n 650 W. Lombard S t r e e t B a l t i m o r e , MD 21202

Joseph Stevenson, R.Ph. Angelo Voxakis, R.Ph. Outpat i ent Pharmacy U n i v e r s i t y H o s p i t a l 22 South Greene S t r e e t , Room 1101 Ba l t imore , MD 21201 Phone: 528-5616

3. Medical Ass is tance Adv iso ry Committee:

Lee Bernhardt , D i r e c t o r B l u e Cross/Blue S h i e l d

Government Programs Represen ta t i ve B l u e C r o s d B l u e S h i e l d of Maryland 700 East Joppa Road Ba l t imore , Maryland 21204

Pe te r Borchardt , Execu t i ve D i r e c t o r PSRO Represen ta t i ve Delmarva Foundat ion f o r Medical Care 108 Nor th H a r r i s o n S t r e e t Easton, Maryland 21601

Joyce Boyd, M.D., H e a l t h O f f i c e r 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 , Maryland 21043

John Braxton, Jr . , M.D. 3206 L i b e r t y H e i g h t s Avenue Ba l t imore , Maryland 21215

Monumental C i t y Medica l S o c i e t y Represen ta t i ve

NP C

Medica l Ass is tance Adv iso ry Committee (con t inued) :

M i l d r e d B r i g h t 2112 J e f f e r s o n S t r e e t Ba l t imore , Maryland 21205

R ichard Buck, Execu t i ve D i r e c t o r P i c k e r s g i l l Home 615 Chestnut Avenue Ba l t imore , Maryland 21204

G l o r i a Carpeneto 5 B i g Stone Cour t Ba l t imore , Maryland 21228

Dorothy Counc i l 1100 N o r t h B o l t o n S t r e e t , #210 Ba l t imore , Maryland 21201

Carmalyn Dorsey 5901 Bel lona Avenue Ba l t imore , Maryland 21212

D a r r e l l R. Cammack, Jr . , A d m i n i s t r a t o r I v y H a l l Nurs ing Home 19 H a r r i s o n Avenue Ba l t imore , Maryland 21220

Rev. L o u i s Foxwel I, J r . Execu t i ve D i r e c t o r Deaf R e f e r r a l Serv i ce 3312 Elmora Avenue Ba l t imore , Maryland 21213

Rose Goodman 1334 N o r t h Washington S t r e e t Ba l t imore , Maryland 21213

Kath leen Grau, LCSW, D i r e c t o r Department o f S o c i a l Work Nor th Char les General H o s p i t a l Char les and 2 8 t h S t r e e t Ba l t imore , Maryland 21218

E. Jane Hanks Box 268 Oxford, Maryland 21654

Ronald H a r r i s 1423 Winston Avenue Ba l t imore , Maryland 21239

Maryland - 6 1983

Consumer Represen ta t i ve

Nurs ing Homes Representat ives



Maryland Nurses A s s o c i a t i o n Represen ta t i ve

Nurs ing Home Represen ta t i ve



Soc ia l Worker, H o s p i t a l



Maryland - 7 1983

Medical Ass is tance Adv isory Comni t t e e (con t inued) :

James Harvey A s s i s t a n t V ice -p res iden t Washington County H o s p i t a l Assoc. K i n g S t r e e t Hagerstown, Mary land 21740

Veron ica Johnson 620 East 27th S t r e e t Ba l t imore , Maryland 21218

Benjamin J. Kimbers, Jr., D.D.S. Madison Park Pro fess iona l B u i l d i n g 932 West Nor th Avenue Bal t imore, Maryland 21217

Har ry F. K l i n e f e l t e r , M.O. 550 N o r t h Broadway Bal t imore, Maryland 21205

Joseph L. LaAsmar, Assoc ia te Execu t i ve D i r e c t o r

Chesapeake Phys ic ians, P.A. P.O. Box 9048 Bal t imore, Maryland 21222

Adele Wilzack, A s s i s t a n t Secretary Medi c a l Care Programs 201 West Preston S t r e e t Ba l t imore, Maryland 21201

S h i r l e y Marcus 1101 Nor th C a l v e r t S t r e e t , Apt. 511 Ba l t imore , Maryland 21202

James McCaslin, Senior V ice Pres iden t Maryland General H o s p i t a l 827 L inden Avenue Bal t imore, Maryland 21201

Roberta N e v i t t , D i r e c t o r Nurs ing Home Advocacy P r o j e c t Maryland Conference o f Soc ia l Concern 1301 Park Avenue Bal t imore, Maryland 21217

E t h e l Pace 1707 Moreland Avenue Bal t imore, Maryland 21216

H o s p i t a l A d m i n i s t r a t o r


D e n t i s t

Doctor, I n t e r n i s t

A d m i n i s t r a t o r , HMO

Department o f Hea l th and Mental Hygiene Represen ta t i ve


Maryland H o s p i t a l A s s o c i a t i o n Represen ta t i ve



NPC Maryland - 8 1983

Medical Ass is tance Adv isory Comni t t e e (con t inued) :

P h i l i p P iaseck i Eas tpo in t Medical Center 1012 N o r t h P o i n t Road Bal t imore, Maryland 21224

Mary Plank 510 East 41st S t r e e t Ba l t imore, Maryland 21218

S a r i Revk in 925 Montpe l ie r S t r e e t Ba l t imore, Maryland 21218

M e l v i n Rubin 2316 Sugarcone Road Bal t imore, Maryland 21209

M i l l i e Tyssowski 2500 Pickwick Road Bal t imore, Maryland 21207

A d m i n i s t r a t o r , Group H e a l t h P r a c t i c e



Maryland Pharmaceut ical A s s o c i a t i o n Represen ta t i ve


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 Represen ta t i ve

Medical Ass is tance 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 Preston S t r e e t , Room 602 Bal t imore, Maryland 21201

S h e i l a W i l l e t t 3453 Cottage Avenue Bal t imore, Maryland 21215


4 . Execut ive O f f i c e r s of S t a t e Medical and Pharmaceut ical S o c i e t i e s :


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 Cathedral S t r e e t Ba l t imore 21201 Phone: 30 11539-0872

NPC Maryland - 9 1983

Execu t i ve O f f i c e r s o f S t a t e Medical and Pharmaceut ical S o c i e t i e s (cont inued) :


David A. Banta, R.Ph. Execu t i ve O i r e c t o r Maryland Pharmaceut ical Assoc ia t ion 650 W. Lombard S t r e e t B a l t i m o r e 21201 Phone: 301/727-0746


Ernest R. MacOonald, 0.0. Secretary-Treasurer Maryland Osteopath ic Assoc ia t ion Inc. 11.5 R i d g e l y Avenue, S u i t e 3 Annapol is 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 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* * Prescribed Oruqs X X X X X X X X X X l m a t i en t ~ o ; ~ i t a l Care X X X X X X X X X Outnat i ent r - - ~

H o s p i t a l Care X X X X X X X X X Labora to ry & X-ray Serv ice X X X X X X X X X X S k i l l e d Nurs inq - Home Serv ices X X X X X X X X X P h y s i c i a n Serv ices X X X X X X X X X X Dental Serv ices X X X X X X X X X X Other Bene f i t s : In te rmed ia te ca re 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 nu rs ing , a d u l t day hea l th , a d u l t f o s t e r care, v i s i o n care se rv i ces , k idney d i a l y s i s , f a m i l y p lann ing , cen te rs 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 Only

1 1 . EXPENDITURES FOR DRUGS. Payment t o Pharmacis ts by f i s c a l year end ing September 30, 1982


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 Chi ldren. . . 3,969,981 97,964 A d u l t s -Fami l i es 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 Disab led ............................ 0 0 C h i l d r e n -Fami l i es w/Oep Chi ldren. . . 0 0 A d u l t s -Fami l i es 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 -Fami l i es w/Dep Children... 243,805 5,663 A d u l t s -Fami l i es 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


Massachusetts - 2 1983


State Department of Public Welfare.


A. General Exclusions: Immunizing biologicals available from DPH, legend vitamins not on Drug List, non-legend drugs not on Drug List. Restrictions on certain therapeutic classes. Legend cough and cold medications excluded. Restrictions on propoxyphene containing products.

8. Formulary: No.


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.


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.


V . Miscel laneous 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 isca l Intermediary:

1982 P i l g r i m Hea l th Appl icat ions 1983 Systems Development Corp

P.O. Box 9101 Somervi l l e , Massachusetts 02145 617/625-0120


1. We l fa re Department:

A. O f f i c i a l s

Char les A t k i ns Commissioner

Dennis B e a t r i c e A s s i s t a n t Commissioner

Herber t B. Hechtman, M.D. Medical D i r e c t o r

Caro lyn Kea 1 y Manager Medica id Pharmacy Program


Department o f P u b l i c Wel fare 600 Washington S t r e e t Boston, Massachusetts 02111

2. Execu t i ve O f f i c e r s of S t a t e Medical 'and Pharmaceut ical Soc i e t i es:


W. B. Munier, M.D. Execu t i ve V i c e P r e s i d e n t Massachusetts Medical S o c i e t y 22 The Fenway Boston 02215 Phone: 617/536-8812


James H. S tewar t Execu t i ve D i r e c t o r Massachusetts S t a t e

Pharmaceut ical 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. Osteopath ic Soc ie ty :

Mrs. Gladys M, Dav is Execu t i ve Secre ta ry Massachusetts Osteopath ic S o c i e t y Inc . Box 147 Reading 01867 617/944-5586

Mich igan - 1 1983

l €D ICAl 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 AFDC OAA AB APT0 AFDC Chi ld ren<21 (SFO) P r e s c r i b e d Drugs X X X X X X X X X l n n a t i c n t ~ .. r - - .

H o s p i t a l Care X X X X X X X X X O u t p a t i e 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 y & X-ray ~ e r ; i ce X X X X X X X X X S k i l l e d Nurs ing Home Serv i ces X X X X X X X X X P h v s i c i a n

3 - - Serv i ces X X X X X X X X X Dental Serv i ces (------- ~ 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 & Hear ing; L i m i t e d Medical Supp l ies & ~ ~ u i ~ m e n t ; . F a m i l y P lann ing; A l c o h o l i s m & rug Wi thdrawal ; P s y c h i a t r i c Serv ices. Spec ia l note: There a re exc lus ions 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 se rv i ces , 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 Only



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 B l i n d ............................... 101,112 56 3 D isab led ............................ 10,888,704 48,951 C h i l d r e n -Fami l i es w/Dep Children... 13,342,563 355,693 A d u l t s -Fami l i es 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 B l i n d ............................... 0 0 D isab led ............................ 0 0 C h i l d r e n -Fami l i es 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 Chi ld ren. . ... 0 0 Other T i t l e XIX R e c i p i e n t s .......... 0 0

MEDl 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 -Fami l i es w/Dep C h i l d r e n . .. 502,632 16,738 A d u l t s -Fami l i es w/Dep Chi ldren. . . . . 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


Mich igan - 2 1983


M ich igan Department of S o c i a l Services.


A. General Exc lus ions:

. Anorec t i cs . Nonlegend drugs/suppl ies , except: i n s u l i n , c h r o n i c rena l d isease drugs, f a m i l y p l a n n i n g drugs, medical s u p p l i e s . and r e a c t i v a t e suppl i e s . A n a l g e s t i c s . A n t i - A n x i e t y Drugs (Benzodiazepines) . Vi tamins, except: p rena ta l and f l u o r i d e . pedo drops

Hemat in ics A n t a c i d s Ant i - v e r t i g o Drugs L a x a t i v e s Cough and Cold Prepa- r a t i o n s , except a n t i h i s t a m i n e s DESl Drugs

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 ana lges ic drugs were excluded f rom 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 laced on cough/cold p repara t ions , an tac ids , l a x a t i v e s , a n t i - v e r t i g o drugs, hemat in ics , and v i tamins . By 4/1/82, t h e DESl drugs and t h e s o - c a l l e d "me, too" drugs were excluded from coverage. S t a t e and Federa 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" reques ts w i l l o v e r - r i d e MAC l i m i t s .

Fo r i n fo rmat ion regard ing t h e f o r m u l a r y con tac t :

M r . Bruce Hansen, D i r e c t o r Medica id P o l i c y D i v i s i o n P.O. Box 30037 Lansing, Mich igan 48909 5171373-7720

C. P r e s c r i b i n g o r d i spens ing l i m i t a t i o n s : P resc r ibed q u a n t i t i e s should 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 therapy regimen. I n c e r t a i n cases and c o n d i t i o n s , more than a month 's supply 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 than 120 days supply be dispensed per 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 o f : (See V. Misce l laneous Remarks f o r h i s t o r i c a l fee adjustments.)

1. A c t u a l a c q u i s i t i o n cos t , p l u s p r o f e s s i o n a l fee n o t t o exceed $2.65 p l u s se lec ted $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 fee no t t o exceed $2.65 p l u s se lec ted $0.50 copay o r

3. The p r o v i d e r ' s usual and customary charge t o t h e genera l p u b l i c .

"Maximum A l l o w a b l e Costs


Tota l Rx claims processed i n FY 1982 - 10,953,406 Average Rx p r i c e during FY 1982 - $7.76

Michigan - 3 1983

Mich igan - 4 1983


1. S o c i a l Serv i ces Department O f f i c i a l s :

Agnes M. Mansour, Ph.D. D i r e c t o r

Paul M. A l l e n D i r e c t o r

Dennis OuCap, D i r e c t o r O f f i c e of Support Serv ices

Vernon K. Smith, Ph.D. D i r e c t o r , Bureau o f Program

P o l i c y

K e i t h F. Cole, D i r e c t o r Bureau o f Medica id Operat ions

Robert M. Lev in , D.D.S. D i r e c t o r , Bureau of H e a l t h

Serv ices Review

R ichard Maharan, D i r e c t o r Bureau o f Med ica id F i s c a l

Rev i ew

Mich igan Department of S o c i a l Serv i ces

P. 0. Box 30037 Lansing, Mich igan 48909

Medica l S e r v i c e s A d m i n i s t r a t i o n (same as above)

2. Soc ia l Serv i ces Department Adv iso ry Committees:

Consumer Members

Jean Thompson 550 Col l ingwood East Lans ing 48823

- C i t i z e n s f o r B e t t e r Care

Sharon S e b r i g h t - R e c i p i e n t Represen ta t i ve R # 2 , 6657 U Avenue, West S c h o o l c r a f t 49087

Deborah Cheatom 1229 Vermont Lans i ng 48906

- R e c i p i e n t Represen ta t i ve

Mich igan - 5 1983

S t a t e Medical Care Adv isory Counci 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 Lans ing 48910

Jan Saxton - Consumer Member a t Large 1309 Reo Road Lansing 48910

Dorothy Walker - UAW R e t i r e d Worker '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 - Mich igan Wel fare R i g h t s 15411 Wabash Organ iza t ion O e t r o i t 48238

Janet ta Beaumont - Mich igan 4-C Counc i l 225 Maple Alma 48801

W i l l i a m F a i r g r i e v e - Mich igan League f o r Human 200 N. Washington Square, Serv ices S u i t e 311 Lansing 48933

Samuel L. Davis - Mich igan A s s o c i a t i o n f o r 23555 Northwestern Hwy. Emot iona l l y D i s t u r b e d Southf i e l d 48075 C h i l d r e n

Connie Mar in - 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 Lansing 48906

Prov ide r Members

Raymond E. Hu ld in , 0.0. 3090 Wilson, SW G r a n d v i l l e 49418

Regina ld P. Ayala Execut ive D i r e c t o r S.W. O e t r o i t H o s p i t a l 2401 - 20th S t r e e t D e t r o i t 48216

L l o y d Ganton Arbor Manor Care Center 151 Second S t r e e t Spr ing Arbor 49283

- Mich igan A s s o c i a t i o n o f Osteopath ic P h y s i c i a n s & Surgeons

- Mich igan H o s p i t a l A s s o c i a t i o n

- H e a l t h Care A s s o c i a t i o n o f Mich igan (N.H.s)

NPC Mich igan - 6 1983

S t a t e Medical Care Advisory Counci 1 - Prov ide r Members ( c o n t i n u e d ) :

Grant W i i g , D.P.M. 305 Nor th West Avenue Jackson 4920 1

- Mich igan S ta te P o d i a t r y A s s o c i a t i o n

Dean Barker, R.Ph. - Michigan Pharmacists Smith Pharmacy A s s o c i a t i o n 226 East Grand R i v e r Lans ing 48906

Thomas A. Vuchet ich 712 Abbott Road East Lansing 48823

- Mich igan Dental A s s o c i a t i o n

Sandra B i l l i n g s l e a - HMO Prov ide r Group Mich igan HMP Plans, Inc. 660 P laza D r i v e 2200 Edison Plaza D e t r o i t 48226

L i l o Hoelzel-Seipp, RN, - Mich igan 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

S ta te O f f i c i a l s

Vernon K. Smith, Ph.D. - Mich igan Department o f D i r e c t o r , Bureau of Program Soc ia l Serv ices

Pol i c y P. 0. Box 30037 Lansing 48909

V i c t o r Sztengel Execu t i ve D i r e c t o r Nor thern Mich igan Hea l th

System Agency 325 East Lake S t r e e t Petoskey 49770

- Mich igan A s s o c i a t i o n o f Hea l th System Agencies

Dominic O'Annunzio - Mich igan Department o f Commerce 7419 Yorktown, Rte. #2 Insurance Bureau Lansing 48917

G l o r i a Smith, Ph.D., M.P.H. - Mich igan Department o f P u b l i c F.A.A.N., D i r e c t o r H e a l t h

Michigan Dept. P u b l i c Hea l th P. 0. Box 30035 Lansing 48909

Mich igan - 7 1983

S t a t e Medical Care Adv isory Counci l - S t a t e O f f i c i a l s ( c o n t i n u e d ) :

Judy N i l e s - Mich igan Department o f lngham County Department Soc ia l Serv i ces

of Soc ia l Serv ices 930 West Holmes Road Lansing 48910

0. Sta te Pharmaceutical Medica id L i a i s o n Committee:

Membership on t h e Medica id 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 es tab l i shed . P a r t i c i p a t i o n i s open t o a l l pharmacis ts and i n t e r e s t e d p a r t i e s through announcements sent t o t h e Mich igan Pharmacists A s s o c i a t i o n and Michigan Merchants Counc i l .

3. Execu t i ve O f f i c e r s o f S t a t e Medical, Pharmaceut ical , and Osteopath ic Assoc ia t ions :


Warren T r y l o f f D i r e c t o r Mich igan S ta te Medical Soc ie ty 120 West Saginaw East Lansing 48823

0. Pharmaceutical Assoc ia t ion :

Louis S e s t i , R.Ph. Execu t i ve D i r e c t o r Mich igan Pharmacists Assoc ia t ion 815 N. Washington Avenue Lansing 48906

C . Osteopath ic Assoc ia t ion :

0. A. DeShaw Execu t i ve Di r e c t o r Michigan A s s o c i a t i o n o f Osteopath ic

Phys ic ians & Surgeons, Inc . 33100 Freedom Road Farmington 48024

ME01 W ASS ISTAWCE DRUG PROGRAH (TITLE X I X)

Minnesota - 1 1983


OAA AB APTD AFDC OAA AB APTD AFDC Chi l drenc2 1 (SFO) P r e s c r i b e d Drugs X X X X X X X X X l npat i ent ~ o s ~ i t a l Care X X X X X X X X X O u t p a t i e 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 Nurs ing Home Serv i ces X X X X X X X X X P h y s i c i a n Serv i ces X X X X X X X X X Denta l Serv i ces X X X X X X X X X *SF0 - S t a t e Funds Only



TOTAL.. ............................. $27,447,452 207,958** $29,351,971** 206,300**

Aged ................................ B l i n d ............................... Disab led. . ..........................

.. 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 Ch i ld ren . . ...

CATEGORICALLY NEEDY CASH TOTAL. ..... $12,257,528 153,260 $12,453,895 149,132 2,868,522 10,468 2,878,054 9,817

96,854 353 97,648 344

CATEGORICALLY NEEDY NON-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 Chi ldren. . . A d u l t s -Fami l i es w/Dep Chi ldren. . . .. 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 -Fami l i es w/Dep Chi ldren. . . A d u l t s -Fami l i es w/Dep Ch i ld ren . . ... 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


Minnesota Department o f P u b l i c Welfare, Income Maintenance D i v i s i o n , Medica l Ass is tance Program.


A. General Exc lus ions: C e r t a i n non-legend, cosmet ic and n u t r i t i o n a l i tems a r e n o t covered.

B. Formulary: C u r r e n t l y be ing developed. Contact:

Thomas A. Ke l lenberger , Pharm.D. Minnesota Medical Ass is tance Program Hea l th Care Programs D i v i s i o n P.O. Box 43170 S t . Paul, Minnesota 55164 6 12/296-7850


1. Dispensed q u a n t i t i e s must no t exceed 30-day supply f o r acu te c o n d i t i o n s , and 100-day supply f o r maintenance med ica t ions .

2. R e f i l l s are l i m i t e d t o 5 t imes o r 6 months, whichever comes f i r s t . Cont racept ives may be f i l l e d t o p r o v i d e a 12-month supply .

D. P r e s c r i p t i o n Charge Formula: Reimbursement i s based on t h e pharmac is t ' s submi t ted charge o r t h e S ta te Department of P u b l i c We l fa re ' s maximum p r i c e , whichever i s lower. V a r i a b l e reimbursement, $1.75-55.00.


Drug u t i l i z a t i o n data:

Drug Expendi tures Rx Claims A v e r a g e K l a i m

1 ) Minnesota Pharmacist, March 1979 2) Data submi t ted t o NPC - March 1980 3 ) Data submi t ted t o NPC - March 1981 4) Data submi t ted t o NPC - March 1982 5 ) Data submi t ted t o NPC - March 1983

Minnesota - 3 1983


1. Wel fare Department O f f i c i a l s :

A r t h u r E . Noot Commissioner

Robert C. Bai r d A s s i s t a n t Commissioner Bureau o f l ncome Maintenance

Thomas A. Gaylord, R.Ph. D i r e c t o r Heal t h Care Programs

Thomas A. Ke l lenberger , Phm.D. D i r e c t o r Drug U t i l i z a t i o n Review Program

John T. Bush, R.Ph. Pharmacist Consul tant

Department o f P u b l i c We l fa re Centennia l O f f i c e B u i l d i n g 658 Cedar S t r e e t S t . Paul , Minnesota 55101

444 L a f a y e t t e Road S t . Paul 55164

2. Wel fare Department A d v i s o r y Committees:

A. P r o f e s s i o n a l Medical Adv iso ry Committee:

I r v i n g C. Berns te in , M.D. L y l e Hay, M.D. 1011 Medical A r t s Bldg. Route 1, Box 3028 M i nneapol i s 55402 Bu f fa lo 55313

David Craig, M.D. S t . Paul I n t e r n i s t 590 Park S t r e e t , S u i t e 408 S t . Paul 55103

P e t e r Fehr, M.D. 3931 C r y s t a l Lake Blvd. M i nneapol i s 55422

Frank S . Babb, M.D. S t . Anthony Or thopaedic C l i n i c 1661 S t . Anthony, S u i t e 200 S t . Paul 55104

L y l e French, M.D. 5620 West B a r a r i a n Path Minneapol is 55432

Dorothy Berns te in , M.D. 1011 Medical A r t s B ldg. M i nneapol i s 55404

Mi land E. Knapp, M.D. 21020 Oak Lane E x c e l s i o r 55331

NPC Minnesota - 4 1983

P r o f e s s i o n a l Medical Advisory C o m i t t e e (con t inued) :

Kath leen Simo, M.D. South Medical C l i n i c 4310 N i c o l l e t Avenue Minneapol i s 55408

M e r r i l l Chesler, M.D. Phys ic ians 6 Surgeons Bldg 63 S. 9 t h S t r e e t M inneapo l i s 55402

John McNeil, M.D. 1224 Lowry B u i l d i n g S t . Paul 55102

John J. Reagan, M.D. 1431 Medical A r t s B u i l d i n g Minneapol is 55402

Henry Bl issenbach, Pharm.0. 2119 Aztec Mendota He igh ts 55120

S h i r l e y Mink, Ph.D. 110 E. 18 th S t r e e t Minneapol i s 55403

B. Minnesota S ta te Pharmaceutical Assoc ia t ion Welfare Task Force:

Donald Gibson - Du lu th Michael E. O'Toole, R.Ph. - Minneapo l i s Roger Vadheim, R.Ph. - T y l e r

(Cha i rman) W i l l i a m F. Appel, R.Ph. - Minneapol is

.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 Car l W. Oberg, R.Ph. - Du lu th

3 . Execu t i ve O f f i c e r s o f S t a t e Medical and Pharmaceut ical S o c i e t i e s :


Haro ld W. Brunn Execu t i ve V ice -p res iden t Minnesota S t a t e Medical Assoc ia t ion 2221 U n i v e r s i t y Avenue, S.E. S t . Paul 55414 Phone: 612/222-6366


Donald A. Dee, R.Ph. Execut ive 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 Hea l th Assoc ia t ions Center 2221 U n i v e r s i t y Avenue, S.E., S u i t e 326 Minneapol is 55414 Phone: 612/378-1414

Minnesota - 5 1983

Executive O f f i c e r s o f State Medical and Pharmaceutical Societ ies (continued) :

C . Osteopathic Medical Society

Robert N. Sampson, D.O. Executive D i rector Minnesota Osteopathic Medical Society Hoffman C l i n i c Hoffman 56339

M i s s i s s i p p i - 1 1983

n l s s l s s w P l

HEDI CAI. ASSISTANCE DRUG PROGRAM (TITLE XI 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 Medica l l y Needy (MN) Other*

OAA AB APTD AFDC OAA AB APTD AFDC Ch i ld ren<Z l (SFD) P r e s c r i b e d

I m a t i e n t ~ o s ~ i t a l Care 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 L a b o r a t o r y & X-ray S e r v i c e X X X X S k i l l e d N u r s i n g Home Serv i ces X X X X P h y s i c i a n ~ e ; v i c e s x x x x Denta l Serv ices X X X X *SF0 - S t a t e Funds Only



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 -Fami l i es w/Dep C h i l d r e n . .. 1,990,975 91,345 A d u l t s -Fami l i es w / D e p C h i l d r e n ..... 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 -Fami l i es w/Dep Chi ld ren. . . 182,421 8,076 A d u l t s - F a m i l i e s w/Dep Chi ldren. . . . . 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 Disab led ............................ 0 0 C h i l d r e n -Fami l i es w/Dep C h i l d r e n ... 0 0 A d u l t s -Fami l i es 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


M i s s i s s i p p i - 2 1983


M i s s i s s i p p i Medica id 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 Exc lus ions:

1. Reimbursement i s l i m i t e d t o drugs l i s t e d i n the fo rmu la ry .

2. Exc lus ions 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 tamins , c o l d and cough p repara t ions , 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 those drugs c l a s s i f i e d as m i l d t r a n q u i l i z e r s .

B. Formulary: R e s t r i c t e d formulary . For fo rmu la ry i n f o r m a t i o n con tac t :

James T. S t e e l e M i s s i s s i p p i Medica id Commission P.O. Box 16786 Jackson, M i s s i s s i p p i 39236 601/981-4507, Ext . 145


1. Q u a n t i t y of Medicat ion: 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 shou ld n o t exceed the amount shown i n t h e maximum u n i t s column of t h e fo rmu la ry . 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 ) per month per r e c i p i e n t .

2. R e f i l I s : P r e s c r i p t i o n r e f i l I s are l i m i t e d t o t h r e e (31, except f o r maintenance t ype 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. A u t h o r i z a t i o n i s r e q u i r e d i n w r i t i n g by t h e p r e s c r i b e r . 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 owed on te lephoned p r e s c r i p t i o n s .

3. I n j e c t i o n s : The Med ica id program w i l l n o t re imburse drug p r o v i d e r s f o r i n j e c t a b l e medicat ions except f o r i n s u l i n and i n j e c t a b l e medicat ions 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 reatment . 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 excep t ion .


M i s s i s s i p p i - 3 I983


1. E f f e c t i v e 7/1/81 - Legend Drugs - reimbursement f o r a l l legend drug c l a i m s w i l l be based on the lower o f :

a. MAC/EAC ( i n g r e d i e n t c o s t ) determined f o r t h e d rug i n t h e q u a n t i t y d ispensed, p l u s $3.17 d i spens ing fee . D ispens ing p h y s i c i a n s r e c e i v e a fee o f $2.00.

b. The usual and customary r e t a i l charge.

2. Reimbursement f o r non-legend drugs a re based on t h e lower of usua l and customary charge o r the maximum over - the -coun te r p r i c e s e t f o r t h a t i t e m l i s t e d i n fo rmu la ry . Usual and customary of a non-legend drug 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 covered i f a t l e a s t one legend drug ( 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 med ica t ions when a l l i n g r e d i e n t s a r e covered s e p a r a t e l y under t h e i r own d rug codes i n t h e fo rmu la ry .


Medica id e l i g i b l e persons 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 rep resen ts a decrease o f 442,434 p r e s c r i p t i o n s o r 12.2% from F i s c a l Year 1981.


F i s c a l i n te rmed ia ry :

1982 - Blue Cross Blue S h i e l d 1983 - EDS Federal ( E f f e c t i v e 1 January 1983)

M i s s i s s i p p i - 4 1983


1. M i s s i s s i p p i Medica id Commission O f f i c i a l s :

B. F. Simmons D i r e c t o r

W i l l Lowery Assoc ia te D i r e c t o r

W. Jack Estes A s s i s t a n t D i r e c t o r A d m i n i s t r a t i o n

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 tee le , R.Ph. Pharmacist

M i s s i s s i p p i Medica id Commission

(P. 0. Box 16786) 4785 1-55 F ron tage Road Jackson, M i s s i s s i p p i 39236

Commission Members ( 7 ) :

Jimmie U. Crane, Chairman - Fu l t o n George S . Smi th - Jackson Char les H. Shamburger, I I I - Brandon Sen. Glen Deweese - M e r i d i a n 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 ichardson - Jackson

2. T i t l e X I X Techn ica 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 commit tee 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 care 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 which they a r e appoin ted.



Char les L. Mathews P h y l l i s s M. Moret , R.Ph. Execut ive S e c r e t a r y Execu t i ve D i r e c t o r M i s s i s s i p p i S t a t e Medica 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 - B a r n e t t B u i l d i n g Jackson 39216 Jackson 39201 Phone: 601 /354-5433 Phone: 601/944-0416

K O 1 UL ASSISTANCE DRUG PROGRAM (TITLE XIX)

M i s s o u r i - 1 1983


OAA AB APTD AFDC OAA AB APTD AFDC C h i l d r e w 2 1 (SFO) P r e s c r i b e d Drugs X X X X X l n ~ a t i e n t ~ o ; ~ i t a l Care X X X X X O u t p a t i e n t H o s p i t a l Care X X X X X L a b o r a t o r y & X-ray S e r v i c e X X X X X S k i l l e d N u r s i n g . Home S e r v i c e s X X X X X P h y s i c i a n Serv i ces X X X X X Denta l Serv i ces X X X X xK *SF0 - S t a t e Funds Only #Not covered f o r General R e l i e f Category



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 B l i n d ............................... 3891593 1,716 D isab led ............................ 3,134,607 12,489 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 ... 2,039,765 90,065 A d u l t s -Fami l i es w/Dep Children..... 3,859,310 61,436

CATEGORICALLY NEEDY NON-CASH TOTAL.. $14,420,937 65,187 Aged.. .............................. 8,050,495 31,482 B l i n d ............................... 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 Chi ldren. . . 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 .......... Other 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 -Fami l i es 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

*nundup l i ca ted T o t a l - HHS r e p o r t HCFA - 2082 203

Missour i - 2 1983


D i v i s i o n o f Fami ly Serv ices o f t h e S t a t e Department o f S o c i a l Serv ices.

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

General Exc lus ions: Exc lus ions governed by Formulary.

Formulary: Formulary l i s t s 402 drugs by gener 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 contact :

Susan McCann, P.D. Pharmacy Consul tant 227 Metro D r i v e P.0. Box 88 J e f f e r s o n C i t y , M issour i 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 fo rmu la ry .

P r e s c r i b i n g o r D ispens ing L i m i t a t i o n s :

1. Q u a n t i t y of Medicat ion: Phys ic ian encouraged t o p r e s c r i b e 34-day o r 100 doses supply 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 supply.

2. R e f i l l s : Federal 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 fo rmu la ry which 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 should 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 phys ic ian .

3. F i v e Rx l i m i t a t i o n per month per 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 long- term c h r o n i c medica l c o n d i t i o n s are exempt f rom 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 lowest of t h e f o l l o w i n g : Federal MAC, M issour 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 lower.

Co-payment ( v a r i a b l e ) - $0.50 ~ o - ~ a ~ m e n t when a c q u i s i t i o n $10.99 or 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 pharmacis t .

Drug Excep t ion 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 covered 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 rheumato id a r t h r i t i s o r j u v e n i l e rheumatoid a r t h r i t i s who cannot t o l e r a t e a s p i r i n .

NPC Missour i - 3 1983

V. M isce l laneous 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 spens ing phys ic ians 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.

M i s s o u r i fo rmulary i s a r e s t r i c t e d fo rmu le ry , r e s t r i c t i o n be ing 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 fo rmu la ry , o r drugs 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 drug l i s t e d as acceptab le 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 gener i c drug l i s t e d , i s re imbursab le under t h e drug 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 spens ing f e e o f $2.50 per 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 Federa l o r M i s s o u r i MAC. The master drug f i l e c o n t a i n s a l l accep tab le drugs and t h e i r a p p r o p r i a t e NDC (Na t iona l Drug Code) number.

AWP (Average Wholesale P r i c e ) , any drug t h a t i s n o t manufactured by Abbo t t , Leder le , Merck Sharp & Dohme, Parke-Davis, P f i z e r , Roer ig, Squibb, Upjohn and Wyeth, o r i s no t a Federa l o r M i s s o u r i MAC drug 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 taken from t h e NDC number.

Any drug manufactured by Abbott , Leder le , Merck Sharp & Oohme, Parke-Davis, P f i z e r , Roer ig, 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 on t h e manu fac tu re r ' s d i r e c t p r i c e .

The Federa l Government has 19 drugs 1 i s t e d as MAC (Maximum A l l o w a b l e Cost ) . M issour i has 39 drugs l i s t e d as MAC (Maximum A l l o w a b l e Cost) . These 58 drugs have a maximum p r i c e t h a t w i l l be pa id .

A l l pharmacis ts 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 Medica id Drug Vendor Program have been issued 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 Fami l y S e r v i c e s l i m i t s p r i c e t o d i r e c t p r i c e .

By f o l l o w i n g these g u i d e l i n e s t h e D i v i s i o n of Fami l y Serv ices f e e l s t h a t t h e pharmacist has a freedom o f cho ice of p roduc ts and package s i z e s i n which he o r she may s tock t h e i r inventory .

F i s c a l i n te rmed ia ry : 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 drug c la ims 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

Missour i - 4 1983



B a r r e t t A. Toan D i r e c t o r

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 Fami ly Serv ices

Department o f 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 B u i l d i n g J e f f e r s o n C i t y , M issour i 65103

Gretchen Engquis t D i v i s i o n of Fami ly Serv ices Di r e c t o r , Medical Serv i ces 227 Met ro D r i v e

P . 0. Box 88 J e f f e r s o n C i t y 65103

Karen McKenzie, A d m i n i s t r a t o r S u r v e i l l a n c e / U t i l i z a t i o n

Review Systems (SURS)

Susan McCann Pharmacist Consul t a n t

E v e r e t t H a r r i s , D.O., P h y s i c i a n Consul tant

Michael Wilson, D.O., P h y s i c i a n Consul tant

2. Medical Adv iso ry 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 Hotchk iss , M.D. D i r e c t o r D i v i s i o n of H e a l t h 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

Ms. Eddie Mae B i n i o n Souths ide Welfare R i g h t s

Organ iza t ion 1400 Park S t . L o u i s 63104

L e s l i e F. Bond, M.D., Chairman 3400 N. Kingshighway S t . L o u i s 63115

James E. Canter, 0.0. 410 Nor theas t S t r e e t C a l i f o r n i a 65018

Senator Dav id D o c t o r i a n Route 3 Macon 63552

Missour i - 5 1983

Medica l Adv iso rv 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 Serv ices (cont inued) :

Rep. Russe l l Goward 4015 F a i r Avenue St. L o u i s 63115

John H a r t , D.O. Medical D i r e c t o r o f Rehab. Char les E. S t i l l H o s p i t a l 1125 Madison J e f f e r s o n C i t y 65101

B. Dav id Har twig , Vice-chairman Red Cross Pharmacy 52 Arrow S t r e e t Marshal l 65340

Ms. D o r e t t a Henderson 1827 East 12th S t r e e t Kansas C i t y 64127

Dennis L. Hunter, O.D. 302 West Morgan Marsha l l 65340

Erma Cunningham, Exec. D i r e c t o r M issour i R i v e r Home Heal t h Agency 219 E. D u n k l i n Je f fe rson C i t y 65101

Norman E. McCann, Execu t i ve D i r e c t o r M i s s o u r i B a p t i s t H o s p i t a l 3015 Nor th B a l l a s Road Kansas C i t y 63131

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

Joyne Leet Grace H i l l H e a l t h Center 2500 Hadley S t r e e t S t . Lou is 63106

Jonathan G. Hanson 1407 Southwest B l v d . J e f f e r s o n C i t y 65101

George L. McElroy, I l l , M.D. C a p i t o l C h i l d r e n ' s C l i n i c s , Inc . 1233 South J e f f e r s o n J e f f e r s o n C i t y 65101

H. D. Sp ie rs , B ishop A d m i n i s t r a t o r Resthaven N u r s i n g Home 1500 West Truman Road l ndependence 64050

Audrey M. Thaman, Ph.D. D i r e c t o r of S o c i a l Work C i t y o f S t . L o u i s Department of H e a l t h &

H o s p i t a l 1625 South 1 4 t h S t r e e t St. L o u i s 63104

Senator H a r r y Wiggi ns 7817 T e r r a c e S t r e e t Kansas C i t y 64114

Rep. I r e n e T r i p p l e r House o f Represen ta t i ves S o c i a l S e r v i c e s Committee 4681 Fuchs Road S t . L o u i s 63128

I r a White, D.O. 1701 S. L a f a y e t t e Sedal i a 63501

Jacquel ine Hal I, R.N., M.A. 800 W. J e f f e r s o n K i r k s v i l l e Co l lege of Osteopath ic Med. K i r k s v i l l e 63501

Missour i - 6 1983

3. Pharmacy Adv isory Committee:

B. Dav id Har twig , R.Ph., C ha i rman Red Cross Pharmacy 52 Arrow S t r e e t Marsha l l 65340 816/886-5533

B i l l F i t z p a t r i c k , R.Ph. F i t z p a t r i c k Pharmacy 130 Manchester B a l l w i n 63011

Jack L i t t r e l l , R.Ph. B lue V a l l e y Pharmacy 5811 Truman Road Kansas C i t y 64126

James D. Osborn, R.Ph. Osborn Medical Tower Pharmacy 1443 N o r t h Robberson S p r i n g f i e l d 65802

Tom Gibson, R.Ph. Waverly Pharmacy K e l l i n g and Broadway Waver l y 64096

4. Execu t i ve O f f i c e r s of Sta te Medical and Pharmaceut ical S o c i e t i e s :


Royal Cooper Execu t i ve Secre ta ry M issour i S ta te Medical Assoc ia t ion 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


John B. Z a t t i , R.Ph. Chief Execu t i ve O f f i c e r M issour i Pharmaceut ical Assoc ia t ion 410 Madison S t r e e t Jef ferson C i t y 65101 Phone: 314/636-7522


Edward Borman Execu t i ve D i r e c t o r M issour i A s s o c i a t i o n o f Osteopath ic

Phys ic ians and Surgeons 325 East McCarty J e f f e r s o n C i t y 65101 Phone: 314/634-3415

NPC

EDICAL ASSISTANCE DRUG PROGRAM (TITLE X I X )

Montana - 1 1983


OAA AB APTD AFDC OAA AB APTD AFOC C h i l d r e n Q l (SFO) Presc r ibed Drugs X X X X X X X X X l noat i en t r~~ ~

H o s p i t a l Care X X X X X X X X X O u t p a t i e n t H o s p i t a l Care X X X X X X X X X Labora to ry & X-ray Serv ice X X X X X X X X X S k i l l e d Nurs ina - Home Serv ices X X X X X X X X X P h y s i c i a n Serv ices X X X X X X X X X Dental ~ ~

Se rv i ces 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 end ing September 30, 1982

Expended R e c i p i e n t Expended

TOTAL............................... $3,521,017

CATEGORICALLY NEEDY CASH TOTAL...... 1,680,897 Aged ................................ 375,342 Blind..... .......................... 13,359 Disabled.. .......................... 747,497 C h i l d r e n -Fami l i es w/Dep Chi ldren. . . 189,371 A d u l t s -Fami l ies w/Dep Children..... 355,328

CATEGORICALLY NEEDY NON-CASH TOTAL.. $1,699,181 Aged.. .............................. 1,194,388 Blind............................... 12,749 Disabled............................ 340,296 C h i l d r e n -Fami l i es w/Dep Children... 35,019 A d u l t s -Fami l ies w/Dep Children..... 60,889 Other T i t l e XIX R e c i p i e n t s .......... 25,840

MEDICALLY NEEDY TOTAL.. ............. $170,939 Aged ................................ 70,082 Bl ind. . . ............................ 45 D isab led ............................ 81,214 C h i l d r e n -Fami l i es w/Dep Children... 0 A d u l t s -Fami l ies w/Dep Children..... 19,598 Other T i t l e XIX R e c i p i e n t s .......... 0

R e c i p i e n t

32,810**

22,191 1,930

74 3,688 9,506 6,993

9,495 4,156

38 1 1,187 1,708 1,200

863

1,124 425

1 402

0 296

0


209

Montana - 2 1983


State Department of Social and Rehabilitation Services.


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.


1. Quantity of Medication: None.

2. Refills: As directed by licensed practitioner.

3. Dollar Limits: No limit.

Copayment of $0.50/Rx by recipient on 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 fee - whichever is lower. Dispensing fees range from $2.00 to $3.75. Additional $0.75 per Rx allowed for unit dose systems.

Montana - 3 1983


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 ~ a i t m e n t o f Soc ia l and D i r ec to r R e h a b i l i t a t i o n Services

P. 0. Box 4210 Helena, Montana 59604

Lowel l Uba Chief D i v i s i o n of Economic Assistance

John Larson, Chief Hed i ca i d F i nance Bureau

Montana Medical Care Advisory Council:

Doug l as 0 l son James Conway Joan Jacobson, M.D. Lowel l Uba

Jack E l l e r y Adminis t rator

Jack Oorner Medical Care Spec ia l i s t

Jack Lowney Management Analyst, Budget

John K a l l , D.D.S. Dental Consultant

Social and Rehab i l i t a t i on Servi D iv is ion :

Joyce DeCunzo Admin is t ra t i ve Ass is tan t

Pat Godbout Ca lv in Bohleen Gary Blewett Gary Walsh

ces Econanic Assistance

Kar l Banschbach Medical Care S p e c i a l i s t

Marie Brazier , R.N. Nurse Consultant,

Paul M i l l e r Medical Care S p e c i a l i s t

Bob Froisness, Chief Medicaid Finance Bureau

J im McCabe, Chief E l i g i b i l i t y Bureau

Montana - 4 1983



G. B r i a n Z i n s Execu t i ve D i r e c t o r Montana Medical A s s o c i a t i o n 2021 11th Avenue, S u i t e 12 Helena 59601 Phone: 406/443-4000


Frank Davis Execu t i ve D i r e c t o r Montana S t a t e Pharmaceut ical A s s o c i a t i o n P.O. Box 6335 Great F a l l s 59406 Phone: 406/452-3201


L e s t e r F. Howard, D.O. Secre tary-Treasurer Montana Osteopath ic A s s o c i a t i o n 1116 F i r s t Avenue N o r t h Great 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 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*

O M A0 APT0 AFDC OAA AB APTD AFDC C h i l d r e n Q l (SFO) Presc r ibed Drugs X X X X X X X X X X l npat i ent Hosp i t a l Care X X X X X X X X X X Outpa t ien t Hosp i t a l Care X X X X X X X X X X Labora to rv 6 X-ray Serv ice X X X X X X X X X X S k i l l e d Nurs ing Home Serv ices X X X X X X X X X X Phys i c i an Serv ices X X X X X X X X X X Dental Serv ices 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 Rec ip i en t Expended R e c i p i e n t

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 Ch i l d ren -Fami l ies w/Dep Children... 568,858 19,141 630,202 20,102 Adu l t s -Fami l ies 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 B l i n d ............................... . o 0 0 0 Disabled............................ 0 0 0 0 Ch i l d ren -Fami l ies w/Dep Children... 8,479 38 1 15,017 740 Adu l t s -Fami l ies w/Dep Children..... 14,718 28 1 26,215 527 .......... Other T i t l e X I X Rec ip i en 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 Ch i ld ren -Fami l ies w/Dep Chi ldren.. . 1,453 79 1,925 80 Adu l t s -Fami l ies w/Dep Children..... 15,101 102 11,930 8 1 Other T i t l e X I X Rec ip i en t s .......... 204 9 575 29


Nebraska - 2 1983


S ta te Department o f P u b l i c Welfare.

1V. P r o v i s i o n s R e l a t i n g t o Presc r ibed Drugs:

A. General Exc lus ions: Exper imental drugs; we igh t c o n t r o l and a p p e t i t e depressant drugs, except f o r use i n Narcolepsy o r Hyperkineses i n c h i l d r e n w i t h granted p r i o r approva l ; OTC drugs 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 marketed w i t h o u t r e q u i r e d FDA approva l ; drugs 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 i tems.

8. Formulary: None. The " O f f i c i a l Drug Guide" i s a l i s t o f drugs toge ther 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 In fo rmat ion , c o n t a c t :

M r . Tom Dolan, R.Ph. NDPW P.O. Box 95026 L inco ln , Nebraska 68509 402/471-3121

C. P r e s c r i b i n g o r D ispens ing L i m i t a t i o n s : "

1. Q u a n t i t y o f Medicat ion: Maintenance-type drugs l i m i t e d t o purchases o f a t l e a s t a 30-day supply, un less an excep t ion i s s p e c i f i c a l l y a l lowed. Cardiac g lycos ides , 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 be l i m i t e d t o purchases of n o t l e s s than 100 's .

The Department o f P u b l i c Wel fare 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 drug o r any drug 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 supply .

(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 month's supply a r e n o t t o be reduced t o a month 's supply. The Nebraska Department o f P u b l i c Wel fare 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 . )

Except ions 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 roduces a maintenance drug t o a p a t i e n t ' s course of therapy, t h e p h y s i c i a n i s a l l owed t o p r e s c r i b e as h i s judgment d i c t a t e s . Phys ic ians and Pharmacists 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 - t h e i n i t i a l f i l l i n g o f t h e medicat ion.

*Medical Services, Department o f P u b l i c Welfare, S ta te of Nebraska. Nebraska DPW Program Manual issued November 24, 1982, as amended.

Nebraska - 3 1983

Q u a n t i t y of Med ica t ion (con t inued) :

Any subsequent d ispens ing 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 month 's supp ly 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 these q u a n t i t i e s o f m e d i c a t i o n would no t be i n t h e p a t i e n t ' s bes 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 excep t ion t o t h e requirement i s be ing made.

I f , i n t h e Pharmac is t ' s p r o f e s s i o n a l judgment, an excep t ion t o t h e requirements must be made, t h e Pharmacis 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 drugs a r e except ions.

O r i g i n a l s h e l f packages: The Department o f P u b l i c Welfare w i l l accept CERTAIN o r i g i n a l she l f package s i z e s of medicat ion.

An o r i g i n a l she l f package of 16 f l u i d ounces, o r l e s s when no t packaged i n t h e p i n t s i ze , 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 requirement f o r l i q u i d s , b u t w i l l no t be s u f f i c i e n t , f o r t h e supplemental d i spens ing fee un less 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 capsules o f ROUTINELY p r e s c r i b e d drugs such as Oarvon, L ib r ium, Valium, M e l l a r i l , etc., w i l l - NOT be accep tab le 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 requirement. The f u l l month 's supp ly must be p r e s c r i b e d and dispensed.

An o r i g i n a l she l f package of 100 t a b l e t s o r capsules, 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 requirement, b u t w i l l no t be s u f f i c i e n t f o r the supplemental d i spens ing fee un less i t i s a f u l l month 's supply .

Ready-made ointments, creams, etc. , when used i n a c h r o n i c o r maintenance manner, may be dispensed i n an o r i g i n a l she 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 med ica t ion .

Nebraska - 4 1983

O r i g i n a l she l f packages (con t inued) :

(5) The de te rm ina t ion 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 not , would, by necess 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 excep t ion 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 ispens ing fee.

Any disagreement w i t h a de te rm ina t ion may be a r b i t r a t e d through t h e NEBRASKA PHARMACISTS ASSOCIATION'S WELFARE ADVISORY COMMITTEE.

3. R e f i l l s : As 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 .

4. D o l l a r L i m i t s : None,


1. Reta i l Pharmac i e s

a. "Assigned" D i spens i ng fee.

A d ispens ing fee w i l l be ass igned by 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 rom t h e i n f o r m a t i o n o b t a i n e d th rough t h e Department '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 ispens ing fee.

b. "Mai ntenance Drug-Month Supply" Supplemental fee.

I n a d d i t i o n t o the "assigned" d i spens ing fee f o r each pharmacy, t h e r e i s a maintenance drug-month supp ly 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 rov ided t h a t a MAINTENANCE DRUG o r drug 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 month's therapy.

V a r i a b l e Pharmacy Fee f o r i n a i v i d u a l pharmacy determined from survey data submi t ted t o s t a t e :

EAC, SMAC, MAC p l u s determined s t o r e f e e (minimum $2.98 t o maximum $3.35)

o r usua l and customary, whichever i s lower.

Nebraska - 5 1983

Hospital Pharmacies

Hospital Pharmacies prescription.

are sign led a "fixed" fee

DETERMINING DRUG OR INGREDIENT COST

a. General Information

( 1 ) Maximum Allowable Cost (M.A.C.)

of $0.80 per

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

Es t ima ted A c q u i s i t i o n Cost (EAC) (con t inued) :

( 2 ) . The EAC o f any p r o d u c t i s t h e c o s t a t which most p r o v i d e r s may o b t a i n t h e i tem. NDPW i s respons ib le f o r ass ign ing t h e EAC va lues 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 ime request a r e v i s i o n i n an EAC va lue d i r e c t l y f rom NDPW.

b. Cost L i m i t a t i o n s

The Nebraska Medica id Drug Program i s r e q u i r e d t o re imburse p roduc t c o s t a t t h e LOWEST of :

(1 ) t h e M.A.C. o r S.M.A.C. o f t h e drug, if one has been es tab l i shed , 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 app ly 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 brand i s m e d i c a l l y necessary. I n these 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 In fo rmat ion .

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 brand name p roduc t of a M.A.C. des ignated drug o r c l a s s of drug i s m e d i c a l l y necessary f o r t h e proper t reatment 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 ; t h e 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, the Nebraska Department o f P u b l i c Welfare MUST (by Federa l Regu la t ion ) compensate t h e Pharmacy a t t h e M.E value 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 the l e s s e r v a l u e o f e i t h e r :

1. Product Cost (M.A.C., S.M.A.C. o r E.A.C.) p l u s t h e a p p r o p r i a t e d ispens ing f e e ( s ) , o r

Nebraska - 7 1983

Compounded P r e s c r i p t i o n s and Legend Drugs (con t inued) :

2. The usual and customary charge t o the genera l p u b l i c .

b . Over- the-counter Drugs

These items w i l l be reimbursed a t t h e lesser va lue of e i t h e r :

1. Product Cost (M.A.C., S.M.A.C. o r E.A.C.) p l u s t h e a p p r o p r i a t e d ispens ing f e e ( s ) , o r

2. The usual and customary s h e l f p r i c e t o t h e genera l p u b l i c .

Sect i o n 2500 - PRODUCTS REQUIRING PRIOR APPROVAL

C e r t a i n p roduc ts r e q u i r e t h a t approva l be granted PRIOR t o t h e i r payment.

PHYSICIANS w ish ing t o p r e s c r i b e these products MUST o b t a i n approval from:

The Medical D i r e c t o r Medica l Serv i ces D i v i s i o n

Nebraska Department o f P u b l i c Welfare 301 Centennial M a l l South

F i f t h F l o o r L i nco l n, Nebraska 68509

The Department o f P u b l i c Wel fare 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 cho ice, whenever these requests a r e approved.

V. Miscel laneous:

Co-payment - None.

Number o f c la ims processed i n FY 1982 - 962,738


Nebraska - 8 1983



Gina C. Dunning D i r e c t o r

M e l v i n C l o t h i e r A d m i n i s t r a t o r D i v i s i o n of Medica l Serv i ces

Dera ld Lembrich A d m i n i s t r a t o r P r o v i d e r Serv ices

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 Consul tant

Samuel F. Moessner, M.D. Medical Consul tant

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 Serv i ces

Tom R . Dolan, R.Ph. Pharmaceut ical Consul tant D i v i s i o n o f Medica l S e r v i c e s 402/471-3121, Ex t . 360

Gary J. Cheloha, R.Ph. Pharmacist D i v i s i o n of Payment and Data Serv ices 402/471-3121, Ex t . 315

Department o f P u b l i c Wel fare 301 Centennia l M a l l South 5 t h F l o o r L i n c o l n , Nebraska 68509

2. Welfare Department Medical Care Adv iso ry Committee:

D r . Henry Smith, D i r e c t o r Warren Bos ley, M.D. Depar tment of Heal t h 418 West D i v i s i o n 301 Centennia l M a l l South Grand I s l a n d 68801 3rd F l o o r L i ncol n 68509 Esther 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 Wel fare 4507 NW 51 s t Tecumseh 68450 L i n c o l n 68524

Nebraska - 9 1983

We l fa re Department Medical Care Adv isory Comni t t e e (con t inued) :

Evelyn Runyon 885 South 72nd Omaha 68114

Edmund Schneider, O.D. L i n c o l n V i s i o n C l i n i c 810 N o r t h 48th S t r e e t L i n c o l n 68504

Robert Marshal 1 Nebraska Pharmacists Assoc. 600 S. 12th S t r e e t L i n c o l n 68508

Arde l l e Boardman 4131 N o r t h 44 th L i n c o l n 68504

Thomas K i e f e r , D.D.S. 2602 J S t r e e t Omaha 68107

Jack S t i 1 es S t . E l i z a b e t h Community

Hea l th Center 555 South 7 0 t h L i n c o l n 68510

Paul Ess 6031 Vine S t r e e t L i n c o l n 68505

Warren Bosley, M.D. 418 West D i v i s i o n Grand I s l a n d 68801

3. Execu t i ve O f f i c e r s o f Sta te Medical and Pharmaceut ical S o c i e t i e s :

A. Kenneth Neff Execu t i ve Secre ta ry Nebraska Medical Assoc ia t ion 1902 F i r s t Na t iona l Bank B u i l d i n g L i n c o l n 68508 Phone: 402/432-7585

B. Pharmaceutical Assoc ia t ion:

Robert Marshal 1 Execut ive D i r e c t o r Nebraska Pharmacists Assoc ia t ion 600 S. 12 th S t r e e t L i n c o l n 68508 Phone: 402/475-4274

C. Osteopath ic Phys ic ians and Surgeons:

A. G. Zuspan, D.O. Sec re ta ry Nebraska Assoc ia t ion Osteopathic

Phys ic ians and Surgeons 1210 13th S t r e e t Aurora 68818 412/694-2525

NEVADA

M D l C A L ASSISTANCE DRUG PROGRAH (TITLE X I X )

Nevada - 1 1983


OAA AB APTD AFDC OAA AB APTD AFDC Chi ldren<21 (SFO) P r e s c r i b e d Drugs X X X X I n p a t i e n t H o s p i t a l Care X X X X O u t p a t i e n t H o s p i t a l Care X X X X L a b o r a t o r y 6 X-ray Serv i ce X X X X S k i l l e d N u r s i n g Home S e r v i c e s X X X X P h y s i c i a n Serv i ces X X X X Denta l Serv i ces X X X X *SF0 - S t a t e Funds Only


Expended

TOTAL....... ........................ $2,257,989

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 -Fami l i es w/Dep Chi ldren. . . ..

CATEGORICALLY NEEDY CASH TOTAL...... $1,434,434 502,779

39,816 537,467

CATEGORICALLY NEEDY NON-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 Chi ldren. . . A d u l t s -Fami l i es 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 ................................ Bl ind. . . ............................ Disab led ............................ C h i l d r e n - F a m i l i e s w/Dep Chi ldren. . . A d u l t s -Fami l i es w/Oep Children... . . Other T i t l e X I X R e c i p i e n t s ..........

R e c i p i e n t Expended R e c i p i e n t

19,116**

16,050 2,877

287 2,580 5,906 4,478

3,721 2,102

39 393 292 273 637

0 0 0 0 0 0 0


Nevada - 2 1983


S t a t e D i v i s i o n o f Welfare o f t h e Department o f Human Resources.



Excluded. Nevada Medica id 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 combinat ions.

3 . Pharmaceut ica ls 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 drugs) b y t h e FDA as t o substance o r d iagnos is f o r which p resc r ibed .

4. Pharmaceut icals cons idered "exper imental" as t o substance o r d iagnos is f o r which prescr ibed.

Except ions: Nevada Medica id w i l l no 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 Medica id O f f i c e on fo rm NMO-3, Treatment A u t h o r i z a t i o n Request (TAR) :

Vi tamins, v i t a m i d m i n e r a l combinat ions o r hemat in ics .

Glucose b l o o d t e s t s t r i p s .

F l u o r i d e p repara t ions .

Non-legend pharmaceut icals.

Appl iances, sundr ies and suppl ies ; 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 ransdermal systems, e.g., N i t r o d i s c , N i t r o - D u r , Transderm-Nitro.

E x c l u s i o n Except ions: A l l pharmaceut ica ls must be p r e s c r i b e d by a l i c e n s e d phys ic ian , p o d i a t r i s t , os teopath o r d e n t i s t . They may be dispensed d i r e c t l y by t h e p r e s c r i b e r o r pharmacis t , o r i n d i r e c t l y by means o f an i n p a t i e n t pharmaceut ical c h a r t order , i n compl iance w i t h federa 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 Except ions ( c o n t i w e d ) :

The Nevada T i t l e X I X drug program r pharmaceut ica ls :

Legend pharmaceut icals.

I n s u l i n .

t 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

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 rena ta l v i t a m i d m i n e r a l supplements, legend o r non-legend, intended f o r p rena ta l care.

Methy lphenidate 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 resc r ibed f o r FDA-approved i n d i c a t i o n s .

Fami l y p l a n n i n g i tems 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 pharmaceut ical i s i nc luded i n t h e r a p e u t i c q u a n t i t y .

Those vaccines no 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 ary : None


1. P r e s c r i p t i o n s : E l i g i b l e Medica id 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 per month p l u s those issued 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 p r e s c r i p t i o n s u b j e c t t o t h e l i m i t a t i o n s i n paragraph 1 above.

a. Au thor i zed r e f i l l s are v a l i d o n l y t o t h e pharmaceut ical p r o v i d e r d i spens ing t h e o r i g i n a l p r e s c r i p t i o n .

b. A l l p r e s c r i p t i o n s c o n t a i n i n g a c l a s s I I c o n t r o l l e d pharmaceut ical o r pharmaceut ica ls r e q u i r i n g p r i o r approva l , w i l l be cons idered 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 schedule 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 (con t inued) :

3. Q u a n t i t y o f medicat ion: The q u a n t i t y t o be dispensed i s as p r e s c r i b e d by t h e phys ic ian , n o t t o exceed a month 's supply - o r a q u a n t i t y o f 100, whichever i s g rea te r . The minimum q u a n t i t y of maintenance pharmaceut ica ls f o r c h r o n i c c o n d i t i o n s i s a month 's supply. I n no case w i l l more than a 100 day supply o f med ica t ion be p a i d f o r .

a. A maintenance drug i s de f ined i n The Drug Manual. The d e f i n i t i o n i s cons idered t o i n c l u d e t h e f o l l c w i n g d rug ca tegor ies :

A n t i - a n g i n a l s Ant i - a r r h y t h m i c s A n t i - a r t h r i t i c s An t i -as thmat i cs Ant i -convu l sants A n t i - d i a b e t i c s An t i -hyper tens ives Cardiac g lycos ides D i u r e t i c s Hormones Thyro id p repara t ions V i tamins covered by t h e program An t i -pa rk inson ism 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 therapy f o r a maintenance 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 medicat ions on ly , a 16- f lu id-ounce q u a n t i t y w i l l be cons idered s u f f i c i e n t t o f u l f i l l t h e 30-day supply requ i rement . )

4. I n long-term-care f a c i l i t i e s , drugs 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 develops. Dur ing t h e 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 la ims f o r t h e same med ica t ion may be al lowed; 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 med ica t ion may be al lowed. The f o u r t h and every subsequent c l a i m f o r t h a t med ica t ion 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 ispens ing fee withdrawn. Dermato log ica l p roduc ts w i l l be exc luded from t h i s requ i rement .

*Except ions may be based on reasonable s t o p orders .

Nevada - 5 1983

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 90 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 90 days after the date of payment .

4. Inquiries regardingclaims forwhich 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 90 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 ~istrict Office.

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


1. Reimbursement: Legend Drugs

Reimbursement for legend pharmaceuticals is the lowest of ( 1 ) maximum allowable cost (MAC) plus the professional fee, (2) estimated acquisition cost (EAC) plus the professional fee, or (3) that pharmacy's usual charge to the general public. The professional fee is currently $3.78 per prescription.

For prescriptions with ingredient costs exceeding $30, the Medicaid program will pay actual acquisition cost (AAC) instead of EAC, plus the professional fee.

2. Reimbursement: Non-Legend Drugs

Reimbursement for non-legend pharmaceuticals is the lower of ( 1 ) the pharmacy's usual charge to the general pub1 ic, or (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 to increased costs involved in supplying medications in unit dose form, a higher professional fee (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 on each patient and refer to 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 (con t inued)

b. Each p a t i e n t ' s p r e s c r i p t i o n requ i rements a r e i n d i v i d u a l l y packaged and labe led . 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 accord ing t o t h e system, b u t always inc ludes 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 medicat ion. ( L i q u i d s need no t be dispensed i n u n i t - o f - u s e packaging, b u t pharmacists a r e encouraged t o do so.)

c. Doses of medicat ions 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 laced i n t o an i n d i v i d u a l p a t i e n t con ta ine r , b i n , compartment o r drawer and whenever p o s s i b l e , a r e subd iv ided by dose and a d m i n i s t r a t i o n t ime.

To secure t h i s h igher reimbursement f o r u n i t dose, pharmacies must request and r e c e i v e approva l f rom t h e Medical Care Sec t ion . Such approval i s sub jec 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 main ta ined.

5 . Return f o r Cred i t : U n i t Dose

The Nevada Medica id program recovers 90% o f t h e c o s t of d i scon t inued drugs e l i g i b l e f o r c r e d i t , i.e., covered drugs i n manufacturer u n i t dose packaging. The pharmacy p r o v i d e r i s a l lowed 10% t o cover t h e cost 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 complet ing t h e r e t u r n forms. Form 3444-SM must be used by those 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 manufacturer u n i t dose drugs.

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, comp le t ing t h e t o p s e c t i o n o f t h e form, as much of 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 bot tom o f t h e form. The f a c i l i t y shou ld t h e n detach and r e t a i n t h e g o l d copy, and forward t h e o r i g i n a l , canary and p i n k cop ies t o t h e pharmacy w i t h t h e r e t u r n e d drugs. 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 request.

b. The pharmacy w i l l complete t h e ba lance o f t h e t e x t , adding NDC's and Rx numbers as a p p l i c a b l e , i n d i c a t e the payment source (M = Medicare, P = P r i v a t e , X = Med ica id ) , and a p l a c e a check mark i n t h e "COV" column f o r drugs e l i g i b l e f o r c r e d i t . The l i s t should then be checked a g a i n s t t h e drugs rece ived. I f a discrepancy i s noted, t h e pharmacy shou ld 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 adjustment. 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 , they should complete +he Pharmacy

NPC Nevada - 8 1983

Complet i n g Form 3444-SM (con t inued)

Concurrence s e c t i o n a t t h e bot tom of t h e form, detach and r e t a i n t h e p i n k copy and fo rward t h e o r i g i n a l and canary c o p i e s t o t h e Nevada Medicaid O f f i c e f o r rev iew.

c . The Medicaid O f f i c e w i l l c a l c u l a t e the 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% handl ing, and e n t e r these amounts on t h e 3444- SM. The canary cop ies can then 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 cop ies a r e r e t a i n e d a t t h e Nevada Medica id O f f i c e where an Inpu t -1 form i s completed and sent t o B lue S h i e l d o f Nevada f o r processing. There an adjustment i s made t o t h e p r o v i d e r accounts rece ivab le .

d. F a c i l i t i e s are adv ised t o r e t u r n d i s c o n t i n u e d drugs on a t l e a s t a month ly bas is .

e. The 3444-SM i s p r i n t e d by t h e Nevada S ta te Welfare 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 Medica id O f f i c e .


D i r e c t payment s h a l l be made t o a l l Nevada p r o v i d e r s who have s igned p a r t i c i p a t i n g agreements. Out -o f -s ta te 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 schedule as p a r t i c i p a t i n g pharmacies and o t h e r Nevada p r o v i d e r s .

P r e s c r i p t i o n Charge Formula f o r Est imated 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 n o t sub t rac ted .

PLUS - Profess iona 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 per R,

* The lesser o f t h i s amount o r usual and customary amount b i l l e d t o t h e s t a t e .

**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 app l i c a b l e copay.

Nevada - 9 1983

Miscellaneous Remarks (cont inued) :

Copayment by Recipient

Recip ients are required t o pay the pharmaceutical p rov ider $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 the f o l lowi ng:

1. Inpat ients, except when rece iv ing "take home" p resc r ip t i ons on day o f discharge.

2. Family planning p resc r ip t i ons ( o r a l contracept ives, diaphragms, foams and j e l l i e s ) .

3. Those i nd i v idua lskhoseMed ica l C e r t i f i c a t e s areprinted1'EXEMPT FROM CO-PAYMENT" .

Pharmacies dispensing p resc r ip t i ons t o Adu l t Group or C h i l d Care F a c i l i t i e s , SNF, ICF, o r ICF MR pa t i en ts must check ( ) the box and enter the name o f the f a c i l i t y i n the appropr iate block on the NMO-5. Th is w i l l avoid computer sub t rac t i on o f the copayment amount.

The pharmaceutical p rov ider 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 fee t o the pub l ic . Do not subtract r e c i p i e n t copay from the "usual charge" when completing the invoice. Computer processing w i l l sub t rac t copay amounts before making payments.

Miscellaneous:

F i sca l intermediary:

Blue Sh ie ld of Nevada P.O. Box 10330 Reno, Nevada 89510

Number o f claims processed FY 1982 - 210,614

Average prescr ip ion p r i c e during FY 1982 - $1 1.74

Nevada - 10 1983


1. Human Resources Department O f f i c i a l s :

Bar ton Jacka D i r e c t o r

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. Ch ie f , Medica l Serv i ces

Jane Feldman S t a t i s t i c i a n I l l

James I . L a i r d , M.D. Medical Consul tant Nevada Med ica id O f f i c e

Steven P . Bradford, Pharm.0. Pharmaceut ical Consu l tan t Nevada Med ica id O f f i c e

Department o f Human Resources S t a t e C a p i t a l Complex Carson C i t y , Nevada 89710

2 . Adv iso ry Committees o f t h e Wel fare D i v i s i o n :

A. Medical Care Adv iso ry Group:

Vacant

Tom C o l l i e r

John Megara

Bernard Feldman, M.D.

Har ry P. Massoth, D.D.S.

Vacant

Vacant

B. Drug U t i l i z a t i o n Review:

Steven P. Bradford, Pharm.0.

- Chairman, Execu t i ve Committee

- Chairman, H o s p i t a l Committee

- Chairman, Long Term Care Committee

- Chairman, P h y s i c i a n s Committee

- Chairman, Dental Committee

- Chairman, Consumer R e c i p i e n t Committee

- Chairman, Pharmacy Committee

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 Pharmaceut ical S o c i e t i e s :


R i c h a r d C. Pugh Execu t i ve D i r e c t o r Nevada S t a t e Medical A s s o c i a t i o n 3660 Baker Lane Reno 89509 Phone: 702/825-6788

B . Pharmaceut ical Assoc ia t ion :

Robert C. Johnson Execu t i ve O f f i c e r Nevada Pharmaceut ical 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


J e f f r e y E. Brookman, 0.0. Secretary-Treasurer Nevada Osteopath ic Medical A s s o c i a t i o n 2300 South Rancho Las Vegas 89102

M O I U U . ASSISTANCE DRUG PROGRAM (TITLE XIX)

New Hampshire - 1 1983

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) Presc r ibed Oruqs X X X X X X X X X X l npat i en t H o s p i t a l Care X X X X X X X X X X O u t p 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 Lahora to rv & - - - - - - -

8 -

X-ray Serv ice X X X X X X X X X X S k i l l e d Nurs ing Home Serv ices X X X X X X X X X X P h y s i c i a n s e r v i c e s X X X X X X X X X X Dental Serv ices X X X X X X X X X X *SF0 - S t a t e Funds Only

1 1 . EXPENDITURES FOR DRUGS. Payment t o Pharmacists by 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 B l i n d . .............................. 24,190 155 22,619 140 Disabled.... ........................ 579,545 2,547 513,085 2,720 C h i l d r e n -Fami l i es w/Oep Chi ldren. . . 280,690 10,324 230,047 9,505 A d u l t s -Fami l i es 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 9 5 28,802 96 Disabled..... ....................... 220,396 772 202,176 805 C h i l d r e n -Fami l ies w/Oep Chi ldren. . . 17,505 5 24 15,122 523 A d u l t s -Fami l i es 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 isab led ............................ 82,468 406 42,005 279 C h i l d r e n -Fami l i es w/Dep Chi ldren. . . 17,971 620 14,214 495 A d u l t s -Fami l i es 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


233



O f f i c e o f Medical Serv ices, Department o f H e a l t h and Welfare.


General Exc lus ions: Anorex iant ( s t i m u l a n t s ) except f o r t reatment of narco lepsy 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 over 7 years of age.

Formulary: None.


1. Q u a n t i t y o f Medicat ion: P r e s c r i p t i o n s l i m i t e d t o 100 day supply ; 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 pe r month.


P r e s c r i p t i o n Charge Formula:

$2.70 f e e p l u s Es t ima ted 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 ess .

Maintenance medicat ions a r e reimbursed by t h e above formula once every t h i r t y days per r e c i p i e n t pe r p rov ide r : any r e f i l l s of maintenance medicat ions w i t h i n 30 days are reimbursed a t c o s t on ly .

Copayment : $1.00, except 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 la ims processed i n FY 1982 - 519,509




1. H e a l t h and We l fa re Department O f f i c i a l s :

Edgar J. Helms, J r . Commi s s i oner

P h i l i p Sou le ' A d m i n i s t r a t o r O f f i c e o f Medical Serv i ces 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. Ch ie f , Bureau o f Medical Claims

Rev i ew O f f i c e o f Medical Serv ices D i v i s i o n of Welfare

Edward J. P ie rce , P.D. Pharmaceut ical Serv i ces S p e c i a l i s t O f f i c e of Medical Serv i ces D i v i s i o n o f We l fa re

Department o f H e a l t h and We l fa re

H e a l t h and Wel fare B u i l d i n g Hazen D r i v e Concord, New Hampshire 03301

2. Medical Care Adv iso ry 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, as w e l l as t h e v a r i o u s agencies 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 Sta te .

3. Execut ive O f f i c e r s of S t a t e Medical and Pharmaceut ical Serv ices:

A. Medical Soc ie ty : B. Pharmaceut ical A s s o c i a t i o n :

Hami l t o n S . Putnam Execu t i ve D i r e c t o r New Hampshire Medical

S o c i e t y 4 Park S t r e e t Concord 0330 1 Phone: 603/224-1909


Maur ice E. Goulet , P.D., M.S. Execu t i ve 0 i r e c t o r New Hampshire Pharmaceut ical

A s s o c i a t i o n 36 Warren S t r e e t Concord 03301 Phone: 603/225-2231

W i l l i a m J. Kirmes, D.O. Secretary-Treasurer New Hampshire Osteopath ic A s s o c i a t i o n Inc . 13 N o r t h S t r e e t Manchester 03104 603/623-6757

New Jersey - 1 1983

NEW JERSEY

E O l CAL ASSISTANCE DRUG PROGRAM (TITLE XIX)


OAA AB APTD AFDC OAA AB APTD AFDC Chi ld ren<21 (SFO) Presc r ibed

H o s p i t a l Care X X X X O u t p a t i e n t H o s p i t a l Care X X X X Labora to ry & X-ray Serv ice X X X X S k i l l e d Nurs inq - Home Serv ices X X X X P h y s i c i a n Serv ices X X X X Denta l Serv ices X X X X Other B e n e f i t s : Home H e a l t h Agency Serv ices, Independent C l i n i c Serv ices , P o d i a t r i s t , Ch i rop rac to r , Op tomet r i s t and O p t i c a l Appl iances, Ambulance and I n v a l i d Coach, Medica l Equipment and P r o s t h e t i c Devices. *SF0 - S t a t e Funds Only



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 -Fami l i es w/Dep Chi ldren. . . 10,262,180 258,156 A d u l t s -Fami l i es w/Dep Children..... 12,478,707 141,598

CATEGORICALLY NEEDY NON-CASH TOTAL.. $9,097,640 57,845 Aged ................................ 6,793,451 24,323 B l i n d ............................... 10,819 54 Disabled....... ..................... 1,184,740 5,168 C h i l d r e n -Fami l i es w/Dep Chi ldren. . . 563,617 15,595 A d u l t s -Fami l i es 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 Disab led. . .......................... 0 0

. C h i l d r e n -Fami l i es w/Dep Chi ldren. . 0 0 A d u l t s -Fami l ies w/Dep Children... . . 0 0 Other T i t l e XIX R e c i p i e n t s .......... 0 0


NP C

1 1 1 . Administration:

Division of Medical Assistance and Health Services, Services.

New Jersey - 2 1983

Department o f Health


A. General Exclusions: Experimental drugs, antiobesics and anorexiants.

B . Formulary: None (New Jersey Drug Utilization Review Council Formulary applies) to the Medicaid program.


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.


1. Payment for legend drugs, contraceptive diaphragms and reimbursable devices shall be based upon "Maximum Allowable Cost".

New Jersey - 3 1983


a. Maximum A l l o w a b l e Cost i s de f ined 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 by t h e Pharmaceut ical Reimbursement Board o f t h e Department of H e a l t h and Human Serv ices f o r l i s t e d m u l t i - s o u r c e drugs 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 Medical Ass is tance 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 by t h e N.J. Medica id Program) i n t h e c u r r e n t "Drug Top ics Red Book" ( p u b l i s h e d b y Medical Economics Co., O r a d e l l , New Jersey 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 Top ics Magazine" o r o t h e r a p p r o p r i a t e sources; o r designated 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 undesignated AWP "cos ts o r o f t ypograph ica 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 covered by 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 ca tegor ies , as determined by t h e N.J. Medica id program based on t h e p rev ious 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 reviewed a n n u a l l y and ad jus ted as a p p r o p r i a t e .

a. To determine 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, which 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 rev ious ca lendar year, 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 a n n u a l l y w i l l r e s u l t i n t h e p r o v i d e r be ing p laced i n t h e maximum d i s c o u n t ca tegory (ca tegory V I ) f o r t h e year of non- compliance, o r u n t i l the r e q u i r e d r e p o r t i s rece ived.

Note: Those pharmacy p r o v i d e r s who have been i n bus iness f o r l ess than one ca lendar 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 year, t o determine t h e a p p r o p r i a t e 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 preceding ca lendar year was n o t more than 14,999 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 ca tegory s h a l l r e c e i v e reimbursement f o r Medica id p r e s c r i p t i o n c l a i m s f o r legend drugs a t average wholesa le p r i c e (AWP), as de f ined i n s e c t i o n 10:51-1.16a., as t h e maximum.

New Jersey - 4 1983


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 preceding calendar year was a t l e a s t 15,000 b u t no t g r e a t e r than 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 ca tegory s h a l l r e c e i v e reimbursement f o r Medica id p r e s c r i p t i o n c la ims f o r legend drugs a t average wholesa le p r i c e (AWP), as def ined i n s e c t i o n 10:51-1.16a, l ess two per cent, 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 preceding calendar year was a t l e a s t 20,000 b u t no t g r e a t e r than 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 ca tegory s h a l l r e c e i v e reimbursement f o r Medica id p r e s c r i p t i o n c l a i m s f o r legend drugs a t t h e average wholesale p r i c e (AW) , as def ined 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 cent , 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 rev ious calendar year was a t l e a s t 30,000 b u t n o t g r e a t e r than 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 ca tegory s h a l l r e c e i v e reimbursement f o r Medica id p r e s c r i p t i o n c l a i m s f o r legend drugs a t average wholesa le 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-l.l6a, less four pe r cent , 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 preceding calendar year was a t l e a s t 40,000 b u t n o t g r e a t e r than 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 Medica id p r e s c r i p t i o n c l a i m s f o r legend drugs a t average wholesale p r i c e ( A W ) , as def ined i n s e c t i o n lO:51-l. l6a, l e s s f i v e pe r cen 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 reced ing ca lendar year 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 Medica id p r e s c r i p t i o n c l a i m s f o r legend drugs a t average wholesa le p r i c e ( A W ) , as def ined i n s e c t i o n 10:51-1.16a, l e s s s i x p e r cen t , as t h e maximum.

Notes: ( 1 ) I f t h e pub l i shed 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) l i i s h igher than t h e p r i c e which would be p a i d under s e c t i o n 10:51-1.16(a) l i i , then s e c t i o n 10:51-1.16(a) l i i , w i l l app ly .

New Jersey - 5 1983

Notes (cont inued) :

(2) The a p p r o p r i a t e c a l c u l a t e d d iscoun t w i l l be a u t o m t i c a l l y deducted (by B l u e Cross o f New Jersey) f rom 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 process ing procedures.

(3) For p r e s c r i p t i o n drugs c o s t i n g more than $24.99 t h e r e w i l l be no d iscoun t from t h e average who lesa le p r i c e (AWP).

D ispens ing Fee

The d ispens ing and se rv i ces fee ranges f rom $2.58 t o a maximum of $2.80 depending upon t h e number and types of s e r v i c e s agreed t o by t h e p r o v i d e r .

Serv i ce

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 . P a t i e n t C o n s u l t a t i o n $0.08 3. Impact Al lowance $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 the completed Form FD-70 w i l l r e c e i v e a fee o f $2.58.

I n comp le t ing t h e Pharmacy P r o v i d e r Serv ice 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 charge t o t h e Med ica id o r PAA r e c i p i e n t . Under no c i rcumstances are 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 lowed.

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 charge t o t h e New Jersey H e a l t h Serv ices Program f o r a legend drug may n o t exceed t h e lowest of t h e f o l l o w i n g :

a. Cost p l u s d i spens ing fee as o u t l i n e d here in .

b. Usual and customary charges and/or posted 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 en te red i n t o subsequent t o t h e adop t ion of t h i s r e g u l a t i o n .

V . Misce l laneous Remarks:


B l u e Cross of New Jersey 33 Washington S t r e e t Newark, New Jersey 07101

Number o f R x c la ims processed i n FY 1982 - 6,473,198

New Jersey - 6 1983


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


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)



1 . Department o f Human Resources O f f i c i a l s :

George J. Albanese Commissioner

Thomas M. Russo D i r e c t o r

S . Eugene Yul iano, M.D. Medical D i r e c t o r

Sanford Luger, R.Ph., Chief Pharmaceut ical S e r v i c e s 609/292-3756

2. Medical Ass is tance A d v i s o r y Counc i l :

Department o f Human Serv ices D i v i s i o n o f Ass is tance and

Heal t h Serv ices 324 E a s t S t a t e S t r e e t P. 0. Box 2486 Trenton, New Jersey 08625

Edward V. Lipman Cha i rman

Eugene Freidman V ice Chairman

Consumers

Howard Langan B e t t y J. P h i l l i p s W i l l i a m F. Ward J u a n i t a J o i n e r L o u i s Weissman

P r o v i d e r s

D i v i s i o n o f Medica l Ass is tance and H e a l t h Serv ices

(same address as above)

E x - O f f i c i o

Richard Go lds te i n, M.D. Commissioner S t a t e Department of H e a l t h

D o r i s Dealaman, Chairman Board o f P u b l i c Welfare

G. Thomas R i t i , D i r e c t o r D i v i s i o n o f P u b l i c We l fa re

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. Robert Kaplan, D.D.S. W i l l iam K. Hogan Herber t E. Horwi tz , R.P.


3 . Execu t i ve O f f i c e r s o f S t a t e Medical and Pharmaceut ical S o c i e t i e s :


V incent A. Maressa Execut ive D i r e c t o r Medical Soc ie ty o f New Jersey 2 Pr incess Road Lawrence 08648 Phone: 609/394-3154

0 . Pharmaceutical Assoc ia t ion :

A l v i n N. Geser Execu t i ve O f f i c e r New Jersey Pharmaceut ical Assoc ia t ion 118 W. S t a t e S t r e e t Trenton 08608 Phone: 609/394-5596

C. Osteopath ic Phys ic ians and Surgeons Assoc ia t ion :

Eleanore F a r l e y Execut ive D i r e c t o r New Jersey A s s o c i a t i o n Osteopath ic Phys ic ians and Surgeons 1212 Stuyvesant Avenue Trenton 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)


OAA AB APTD AFDC OAA AB APTD AFDC Chi ld ren<21 (SFO) P r e s c r i b e d Druqs X X X X X l npat i ent H o s p i t a l Care X X X X X O u t ~ a t i e n t H o s p i t a l Care X X X X X Labora to ry & X-ray S e r v i c e X X X X X S k i l l e d N u r s i n g Home Serv i ces X X X X X P h y s i c i a n ~e ;v i ces X X X X X Dental Serv ices X X X X X Other B e n e f i t s : P r i v a t e Duty Nursing, Home H e a l t h Serv ices, O r t h o t i c app l iances and P r o s t h e s i s , Fami l y P lann ing Serv i ces , 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 Psycho log ica l Serv i ces , Optometry, P o d i a t r y . *SF0 - S t a t e Funds Only



TOTAL............................... $6,140,811 62,966** $6,816,777 60,507**

CATEGORI CALLY NEEDY CASH TOTAL.. . . . . $5,483,800 Aged ................................ 1,218,881 B l i n d . . ............................. 52,048 D isab led ............................ 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 Chi ldren. . . . . 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 Chi ldren. . . 13,481 A d u l t s -Fami l i es 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 D isab led ............................ 0 0 0 0 C h i l d r e n - F a m i l i e s w/Oep Chi ld ren. . . 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


New Mexico - 2 1983

I1 I. A d m i n i s t r a t i o n :

Department o f Human Serv ices

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:


1. Drugs f o r t reatment o f t u b e r c u l o s i s a re n o t i nc luded .

2. Medicat ions 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 conva lescent l eave f rom h o s p i t a l a r e n o t i nc luded .

3 . Drugs and immunizat ions a v a i l a b l e f rom any o t h e r source a r e n o t inc luded.

4 . Legend m u l t i p l e v i tam ins , t o n i c p r e p a r a t i o n s and combinat ions thereof w i t h m ine ra ls , hormones, s t i m u l a n t s o r o t h e r compounds which a r e a v a i l a b l e as separate e n t i t i e s f o r t rea tmen t o f s p e c i f i c c o n d i t i o n s .

5 . Hemat in ics except non-susta ined r e l e a s e forms o f Fe r rous S u l f a t e , Ferrous G I uconate, Ferrous Fumarate.

6. Amphetamines and combinat ions o f amphetamines w i t h o t h e r t h e r a p e u t i c agents; amphetamine- l ike 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 combinat ion 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 as " I n e f f e c t i v e " o r "Poss ib l y E f fec t i ve " .

8. Hypnot ic drugs.

9. OTC i tems w i t h t h e f o l l o w i n g excep t ions ( t h e excep t ions a r e covered by t h e program):

a. I n s u l i n

b. Antac ids 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 drops f o r c h i l d r e n up t o one year o f age.

d. S a l i c y l a t e s and acetaminophen.

e. Non-sustained re lease forms o f Ferrous S u l f a t e , Fe r rous G I uconate, Fe r rous 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 (con t inued) :

B. Formulary: Open fo rmu la ry sub jec t t o above-stated l i m i t a t i o n s . For fo rmu la ry i n f o r m a t i o n contact :

S h i r l e y Hol landswor th Medica l Ass is tance Bureau P.O. Box 2348 Santa Fe, New Mexico 87503 505/827-4315


1. Q u a n t i t y of Medicat ion: 6 months supply maximum.

2. R e f i l l s : 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 imes f o r t h e same drug f o r t h e same c l i e n t i n any 90-day per iod .


1. P r e s c r i p t i o n s reimbursed a t t h e lesser 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) o r ,

b. The usual and custanary charge by t h e pharmacy t o t h e genera l pub1 i c .



EDS Federa 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 la ims processed i n FY 1982 - 679,054


New Mexico - 4 1983


1. Department o f Human Serv ices:

Joseph Gol dberg Secre ta ry

Char les Lopez A c t i n g Deputy D i r e c t o r Income Support D i v i s i o n

James Kogl i n Bureau Chief Medical Ass is tance Bureau

F. R ichard A tk inson A d m i n i s t r a t o r Medical Ass is tance Bureau

S h i r l e y Hol landsworth, R.Ph. Drug Program A d m i n i s t r a t o r Medical Ass is tance Bureau

2. ISD P o l i c y Adv iso ry Committee Members:

(pend i ng)

3. Dental A d v i s o r y Committee:

L a r r y Lubar, D.D.S. 1418 San Pedro, N.E. Albuquerque 87110

Rudolph Woolf 1308 Chico Car l sbad 88220

Michael Parey, D.D.S. 8400 Osuna NE Albuquerque 87111

Department o f Human Serv ices P. 0. Box 2348 Santa Fe, New Mexico 87503

Bruce V o l k e r d i n g 708 East 2 0 t h Farmington 87401

Gene Walker 921 East 2 1 s t S t r e e t C l o v i s 88001

L a r r y Cook, D.D.S Box 1885 Taos 87571

Edmond M i t c h e l l 2801 M issour 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 Pharmaceut ical A s s o c i a t i o n meets each month.

Robert Ghattas, R.Ph. Durans Pharmacy 1815 Cen t ra l , N.W. Albuquerque 87104 505/247-4141

Robert Lee, R.Ph. Lee 's Pharmacy 4403 4 t h S t r e e t , N.W. Albuquerque 87107 505/345-3533

N e i l Johnon, R.Ph. C l i n i c a l Pharmacy 5002 Gibson, S.E. Albuquerque 87108

V i c t o r Cas t i l l o , R.Ph V i c t o r ' s Pharmacy 1643 l s l e t a , S.W. Albuquerque 87105

Jack E. H i l l i g o s s Execu t i ve Di r e c t o r , NMPHA 4800 Zuni, S.E. Albuquerque 87108

6. Execut ive O f f i c e r s of S t a t e Medical and Pharmaceut ical S o c i e t i e s :

Medical Soc ie ty :

Ralph R. Marsha l l Execu t i ve D i r e c t o r New Mexico Medical S o c i e t y 2650 Yale Boulevard, S.E. Albuquerque 87106 Phone: 505/247-0530

Pharmaceut ical Assoc ia t ion :

Jack E. H i l l i g o s s Execu t i ve D i r e c t o r New Mexico Pharmaceut ical A s s o c i a t i o n 4800 Zuni, S.E. Albuquerque 87108 Phone: 505/265-8720

Osteopath ic Medica l Assoc ia t ion :

Joseph J . Helak, 0.0. Execu t i ve D i r e c t o r New Mexico Osteopath ic Medical

A s s o c i a t i o n 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)


OAA AB APTD AFbC OAA AB APTD AFDC C h i l d r e n i 2 1 (SFO) P r e s c r i b e d 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 mt H o s p i t a l Care X X X X X X X X X X Labora to ry & X-ray Serv i ce X X X X X X X X X X S k i l l e d Nurs ing Home Serv i ces X X X X X X X X X X P h y s i c i a n Serv i ces X X X X X X X X X X Dental Serv i ces 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 dev ices /supp l ies ; eye se rv i ces ; p o d i a t r y se rv i ces ; f a m i l y p lann ing ; EPSDT (CHAP); c l i n i c s ; p r i v a t e du ty 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 care; 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 Only


igai 19112 Expended R e c i p i e n t Expended R e c i p i e n t

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 Chi ldren. . 22,199,153 691,683 25,748,798 726,267 ... A d u l t s -Fami l i es w/Dep Ch i ld ren . 27,647,018 330,481 32,067,776 347,005

CATEGORICALLY NEEDY NON-CASH TOTAL. Aged ............................... B l i n d .............................. Disabled....... .................... C h i l d r e n -Fami l i es w/Dep Ch i ld ren . . ... A d u l t s -Fami l i es 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

ME01 CALLY NEEDY TOTAL.. ........... Aged .............................. Blind...... ....................... Disab led .......................... C h i l d r e n -Fami l i es w/Dep C h i l d r e n . A d u l t s -Fami l i es 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 ........ * W n d u p l i c a t e d T o t a l - HHS r e p o r t HCFA - 2082

250

New York - 2 1983


S t a t e Department o f S o c i a l Serv i ces .


A. General Exc lus ions: No r e s t r i c t i o n s except: (See V. M isce l l aneous 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 medical necess i t y .

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 drugs i s l i m i t e d t o l i s t o f Med ica id 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 c o n t a c t :

Michae l R a v a l l i 40 Nor th Pear l S t r e e t Albany, New York 12243 518/474-7442


1 . Q u a n t i t y o f Medicat ion: Drugs and s ickroom s u p p l i e s s h a l l be 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 medica l p r a c t i c e .

2. R e f i l l s : R e f i l l s cannot exceed 5, and t h e l i f e of a p r e s c r i p t i o n cannot exceed 6 months.



1 . Maximum Reimbursable P r i c i n q Schedule

Maximum reimbursement s h a l l be based on t h e lowest 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. the es t ima ted 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 by t h e S t a t e , p l u s a p p l i c a b l e d i spens ing fee; o r

c. t he usual and customary p r i c e charged by t h e pharmacy p r o v i d e r t o t h e genera 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 which may be i n e f f e c t on t h e da te of s e r v i c e .


2. D ispens ing Fee, $2.60


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 rders 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 rug p roduc ts a r e excluded, e.g., those n o t e s s e n t i a l t o s u s t a i n l i f e , re1 ieve o r prevent severe pa in , o r prevent d isease o r c o n t i n u i n g d i s a b i l i t y ; sus ta ined r e l e a s e medicat ions; a n t i - f l a t u l e n c e products ; cough enzymes; muscle re laxan ts ; v i t a m i n s and v i t a m i d m i n e r a l p repara t ions ; and dermato iog ica ls . Many combinat ion drugs and comfor t p roduc ts a r e a l s o excluded.

The Commissioner of Heal th , w i t h t h e adv ice o f t h e Ad Hoc Techn ica l Pharmacy Adv iso ry Committee and o t h e r c o n s u l t a n t s as appropr ia te , s h a l l cons ide 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 concern ing changes t o t h e l i s t t o the f o l l o w i n g address:

Dav id G. S t a r k s Deputy D i r e c t o r D i v i s i o n o f H e a l t h 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 ,

Medica id 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


McAuto Systems Group, Inc . 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 la ims processed i n FY 1982 - 14,187,189 (1/82-12/82)


New York - 4 1983


S o c i a l Serv i ces Department O f f i c i a l s :

Cesar A. Pera les Commi s s i oner

A r t h u r Y. Webb Execut ive Deputy Commissioner

Robert Osborne Deputy Commissioner D i v i s i o n o f Medica l Ass is tance

Robert J. Dowling, J r . Assoc ia te Commissioner D i v i s i o n o f Medical Ass is tance

R ichard T. Cody A s s i s t a n t Commissioner f o r

E l i g i b i l i t y D i v i s i o n o f Medical Ass is tance

Gerard F. N e l l i g a n , R.Ph. Assoc ia te S o c i a l Serv i ces

Medical Ass is tance S p e c i a l i s t

M a r t i n Roysher Assoc ia te 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

Soc ia l Serv i ces A d v i s o r y Committees:

Department o f S o c i a l Serv i ces 40 N o r t h P e a r l S t r e e t Albany, New York 12243

A. Medica l A d v i s o r y Committee:

G i l b e r t Simon, D.Sc. D i r e c t o r of Pharmacy Lenox H i l l H o s p i t a l 100 East 7 7 t h S t r e e t New York 10021

Dav id Axe l rod, M.D. Commissioner New York S t a t e Department Emoire S t a t e P laza

Ms. B e v e r l y H a r t Chi I d Development A s s o c i a t e Comprehensive I n t e r d i s c i p l i n a r y

Development S e r v i c e s 318 Madison E l m i r a 14901

Char les B a r r , D.D.S. of H e a l t h D i r e c t o r o f D e n t i s t r y

Beth l s r e a l Medical 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


Medica l Adv iso ry Committee (cont inued) :

S. Dav id Panrinse, M.D. P r e s i d e n t Greater New York H o s p i t a l Assoc. 3 Eas t 5 4 t h S t r e e t New York C i t y 10022

Ludwig Jaffee, M.D. Research D i r e c t o r New York S t a t e AFL-CIO 451 Park Avenue New York 10016

Ms. K a t h e r i n e Simnons Execu t i ve 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

o f S t a t e n l s l a n d 400 Lake Avenue - Mar iners Harbor S t a t e n I s l a n d 10303

M r . Ebun Adelona P.O. Box 1405 New York 10027

Arcy Degni, S e c r e t a r y Treasurer New York S t a t e B u i l d i n g and

C o n s t r u c t i o n Trades Counc i l AFL-C I 0 17 Jewet t P lace U t i c a 13501

Peggy Hanson, M.D. Assoc ia te Professor of Neurology

and P e d i a t r i c s Albany Medical Col lege Albany 12208

M r . E b i e Brown 115 Woodlawn Avenue, #2N Saratoga Spr ings 12866

James G. L ione, M.D. New York S t a t e Chairman American Academy o f P e d i a t r i c s 251-25 Hand Road L i t t l e Neck 11362

B e a t r i c e Kresky, M.D., M.P.H., Chairman

Department o f Ambulatory Care Jamaica H o s p i t a l Jamaica 11418

Elena P a d i l l a , Ph.D. H e a l t h P o l i c y P lann ing and

A d m i n i s t r a t i o n Program T i s c h Roan 738 New York U n i v e r s i t y 40 West 4 t h S t r e e t New York 10003

Haro ld Rakov, P ro fessor 26 Coleman Creek Road Brockpor t 14420

Robert H. Randles, M.D. Medica l D i r e c t o r S t . P e t e r ' s H o s p i t a l 315 South Manning Boulevard Albany 12208

Ms. I sabe l A p p e l l a n i z Ridgewood Bushwick Sen io r

C i t i z e n Counc i l 319 Stanhope S t r e e t B rook lyn 11237

Mrs. Glen iss Schonholz A d m i n i s t r a t o r Long I s l a n d Jewish H i l l s i d e

Medical Center New Hyde Park 11042

Rufus N icho ls , M.D. 736 Eas te rn Parkway Brook lyn 11213

Ms. M a r i l y n S a v i o l a Apt. 11-H 175 Wi l loughby S t r e e t Brook lyn 11201

New York - 6 1983

3. P u b l i c H e a l t h Department:

David Axel rod, M.D. Commissioner

4. Execu t i ve O f f i c e r s o f S t a t e Medical and Ph


Edward S i e g e l , M.D. Execu t i ve V i c e P res i dent Medica l S o c i e t y of t h e S t a t e

of New York 420 Lakev i l l e Road Lake Success 11042 Phone: 526/488-6100


John Schre ibe r Execu t i ve D i r e c t o r Pharmaceut ical S o c i e t y o f t h e

S t a t e of New York 1975 L inden Boulevard Elmont 11003 Phone: 516/285-8822

Department of Heal t h Tower B u i l d i n g Empire S t a t e P laza Albany 12237

a r m a c e u t i c a l S o c i e t i e s :

C. B. C. Schar f , 0.0. Secre ta ry New York S t a t e Osteopath ic

Medical Soc ie ty , Inc. 1973 M o r r i s Gate Seaford 11783 516/826-2212

NORTH CAROL I NR

MEDICAL ASSISTANCE DRUG PROGRAM (TITLE XIX)

N o r t h Carol i na - 1 1983


OAA AB APTD AFDC OAA AB APTD AFDC Chi ldrenc21 (SFO) Presc r ibed Drugs X X X X X X X X X l noat i ent H o s p i t a l Care X X X X X X X X X Ou tpa t ien t H o s p i t a l Care X X X X X X X X X Labora to ry & X-ray Serv ice X X X X X X X X X S k i l l ed Nurs ing Home Serv ices X X X X X X X X X Phys ic ian ~e;v i ces X X X X X X X X X Dental Serv ices X X X X X X X X X *SF0 - S t a t e Funds Only


1981 1982 R e c i p i e n t Expended R e c i p i e n t Expended

$34,598,362 268,799** $31,487,710

CATEGORICALLY NEEOY CASH TOTAL...... $25,917,909 218,660 Aged ................................ 11,661,284 48,357 B l i n d ............................... 416,024 1,983 Disab led ............................ 8,589,747 36,830 C h i l d r e n -Fami l i es w/Dep Chi ldren. . . 1,717,237 81,767 A d u l t s - F a m i I i e s w / D e p C h i l d r e n ..... 3,533,617 56,389

CATEGORICALLY NEEDY NON-CASH TOTAL.. $1,285,574 13,490 Aged ................................ 664,594 2,366 B l i n d . .............................. 10,594 36 ............................ Disab led 219,263 1,169 C h i l d r e n - F a m i l i e s w/Dep Chi ldren. . . 131,146 6,161 A d u l t s -Fami l i es w/Dep Chi ldren. . . .. 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 isab led ............................ 1,399,938 5,924 C h i l d r e n -Fami l i e s w/Dep Ch i ld ren . . . 156,313 7,020 A d u l t s -Fami l i es w/Dep Chi ldren. . . . . 481,491 6,201 Other T i t l e X I X Rec ip ien ts . ......... 36,444 651

**Undupl i c a t e d T o t a l - HHS r e p o r t HCFA - 2082

Nor th C a r o l i n a - 2 1983


D i v i s i o n of Medical Assistance, Department of Human Resources.

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. General Exc lus ions: No payment made f o r non-legend drugs, except i n s u l i n . Payment made f o r a l l legend drugs. Non-legend v i t a m i n s a r e exc l uded.

B. Formulary: None.


1 . Q u a n t i t y of Medicat ion: None.

2. Number of P r e s c r i p t i o n s :

a. S i x per month per 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 determined 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 pe r month may be a u t h o r i z e d by 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 th rea tened 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 be ing 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 should be exc luded f rom 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 Mal ignancy

( 3 ) Acute S i c k l e C e l l Disease

( 4 ) Hemophi l ia

(5) End S t a t e Lung Diseases

( 6 ) Uns tab le Diabetes

(7 ) Terminal Stage - any i l l n e s s - l i f e - t h r e a t e n i n g


4. Gener ic S u b s t i t u t i o n : Pharmacists must s u b s t i t u t e g e n e r i c a l l y i f they have a g e n e r i c a l l y e q u i v a l e n t p roduc t a v a i l a b l e i n s tock. The s u b s t i t u t e d product must be a lower c o s t p roduc t than t h e one o r i g i n a l l y p resc r ibed .

NPC N o r t h C a r o l i n a - 3 1983

5. Lock-In: Each r e c i p i e n t i s locked i n t o one pharmacy o f h i s c h o i c e f o r one month, except i n emergencies.

D. P r e s c r i p t i o n Charge Formula: The lowest p r i c e o f MAC, EAC o r AWP, p l u s $3.22 d i spens ing f e e f o r each d i f f e r e n t drug dispensed d u r i n g a month, o r t h e p h a r m a c i s t ' s usual and customary charge. The pharmac is 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 re imbursed f o r r e f i l l s f o r t h e same drug w i t h i n a ca lendar month. $0.50 co-payment/Rx ( i n c l u d e s r e f i l l s ) .

V. M isce l l aneous

F i s c a l Agent:

EDS Federa l Subconrrac t e d to :

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 la ims processed i n f i s c a l yea 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 yea r 1982 - $10.25

N o r t h Caro l ina - 4 1983


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 Secre ta ry A lbermar le 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 Raleigh, Nor th C a r o l i n a 27611

Barbara D. Matula Di r e c t o r

Paul R. Per ruzz i Deputy D i r e c t o r

J e r r y W. Wiley, M.D. Ch ie f Medical Consul tant

C . Benny Ridout , R.Ph. Pharmacist Consul tant

L i l l i a n J. Todd, R.N. Nurse Consul tant

B e t t y King-Sutton, D.M.D. Dental Consul tant

D i v i s i o n o f Medical Ass is tance 410 N. Boylan Avenue Raleigh, Nor th C a r o l i n a 27603

2. Department o f Human Resources Adv isory 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 Chai m a n UNC School o f Pharmacy Beard Hal I, 200-H Chapel H i l l 27514

John Bar r i nger P.O. Box 382 Carthage 28327

Evelyn L l o y d 111 N o r t h Churton S t r e e t Hi 1 l sborough 27278

John Myhre 1005 Park Avenue Garner 27529

Char les D. Reed 5832 Whitebud D r i v e Ra le igh 27609

Char les Rhoden, J r . 901 Montrose C i r c l e Shelby 28150

Jack Watts 444 T a r l e t o n Avenue B u r l i n g t o n 27215

Frank Wel ls 604 West H a r n e t t S t r e e t Benson 27504

NPC N o r t h C a r o l i n a - 5 1983

8. Medical Soc ie ty Comnittee on Soc ia l Serv i ce Programs ( i n c l u d i n g ~ e d i c a i d ) ( 2 Consu l tan ts ) :

Hector H. Henry, II, M.D. (U) Cha i rman 102 Lake Concord Rd., N.E. Concord 28607

R ichard W. Furman, M.D. (TS) S ta te Farm Road Boone 28607

Edna M. Hoffman, M.D. 348 Val l ey Road F a y e t t e v i l l e 28305

Char les R. Mar t in , M.D. (PD)

120 Memorial D r i v e Jacksonv i l l e 28540

Campbell W. McMi l lan, M.D. (PHO)

N.C. Memorial H o s p i t a l Chapel H i l l 27514

Joseph D. Russel I, M.D. ( I M ) Caro l ina C l i n i c W i l s o n 27893

B e t t y L. Smith, M.D. ( P ) P.O. Box 925 El l enboro 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 Ass is tance 410 N. Boylan Avenue Ra le igh 27603

L i l l i a n J. Todd, R.N. Nurs ing Consul tant D i v i s i o n of Medical Ass is tance 410 N. Bovlan Avenue

James S. Mi tchener, Jr., M.D. Ra le igh 27603 (GS)

P.O. Box 1808 Laur inburg 28352

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 Ra le igh 27611

3. Execut ive O f f i c e r s of S ta te Medical and Pharmaceut ical S o c i e t i e s :


W i l l i a m N. H i l l i a r d Execu t i ve D i r e c t o r N.C. Medical S o c i e t y P.O. Box 27167 222 Nor th Person S t r e e t Ra le igh 27611 Phone: 919/833-3836

North Carol i na - 6 1983

Execut ive O f f i c e r s of 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 D i rec tor 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 North Carol ina Osteopathic Society , Inc. Box 667 Advance 27006

NORTH DAKOTA

E D 1 CAI. ASSISTANCE DRUG P R O W (TITLE X I X)

Nor th Dakota - 1 1983

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 Medical 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) P r e s c r i b e d Drugs X X X X X X X X X l npat i ent H o s p i t a l Care X X X X X X X X X O u t p a t i e n t H o s p i t a l Care X X X X X X X X X Labora to ry & X-ray Serv i ce X X X X X X X X X S k i l l e d Nurs ing Home Serv i ces X X X X X X X X X P h y s i c i a n Serv i ces X X X X X X X X X Dental Serv i ces X X X X X X X X X *SF0 - S t a t e Funds Only



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 2 3 1,937 17 Disab led. ........................... 430,918 1,570 335,624 1,559 C h i l d r e n -Fami l i es w/Dep C h i l d r e n ... 185,626 6,266 621,242 5,454 A d u l t s -Fami l i es 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 B l i n d . .............................. 105 6 114 1 Disab led ............................ 27,461 313 26,995 237 C h i l d r e n -Fami l i es w/Oep C h i l d r e n ... 13,081 593 33,716 296 Adul t s -Fami l ies w/Dep Ch i ld ren . . ... 19,073 482 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

............. MEDI 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 Disab led ............................ 228,217 866 191,616 893 C h i l d r e n -Fami l i es w/Dep Chi ld ren. . . 20,093 645 80,645 708

..... A d u l t s -Fami l i es w/Dep C h i l d r e n 40,728 46 4 67,546 59 3 .......... Other T i t l e XIX R e c i p i e n t s 19,476 637 74,381 653


N o r t h Dakota - 2 1983

1iI. A d m i n i s t r a t i o n :

Nor th Dakota Department of Human Serv ices.


A. General Exc lus ions :

1. A n o r e c t i c s 2. H igh p r o t e i n weight 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 which have ques t ionab le t h e r a p e u t i c va lue 5. Drugs which a r e no 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 ) drugs

B . Formulary: None


1. Q u a n t i t y of Med ica t ion : None

2. R e f i l l s : 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 imes o r f o r 12 months a f t e r t h e da te of t h e o r i g i n a l p r e s c r i n t i o n , whichever occurs 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 p h y s i c i a n .


D. P r e s c r i p t i o n C h a r g e F o r m u l a : A c q u i s i t i o n c o s t p l u s $ 3 . 7 5 d i s p e n s i n g fee per p r e s c r i p t i o n o r usual and customary r e t a i l charge, whichever 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 Dakota i s AWP.

V. M isce l l aneous Remarks:

Copayment - No.

Number of Rx c la ims processed i n FY 1982 - 364,726




1. S o c i a l S e r v i c e Broad O f f i c i a l s :

Dale Moug Execu t i ve D i r e c t o r

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 Myat t , D i r e c t o r Medica l Serv i ces

Chuck Gress, R.Ph. Coord ina to r Pharmacy Serv ices 701 /224-2321

Nor th Dakota Department o f Human S e r v i c e s

Cap i to l B u i l d i n g Bismarck, N o r t h Dakota

58505

2. Soc ia l Serv i ces Department Adv iso ry Committees:

A. Medical Care A d v i s o r y Committee:

Joe Pratschner ( H e a l t h Dept. Designee) 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 S t a t e Department of H e a l t h 1200 M issour i Avenue B i smarck 58505 701/224-2352

Bruce Het land, M.D. Mid-Dakota C l i n i c N i n t h and Rosser Bismarck 58505 701 /223-0150

Bern ice Englehorn 801 1/2 Col l i n s Avenue Mandan 55401 701/663-2181

Fred H u l e t 116 W. Thayer Avenue Bismarck 58501 701/223-4131

Ber tha Gipp, R.N. Maternal and C h i l d H e a l t h

D i v i s i o n S t a t e Department o f H e a l t h Bismarck 58502 701 /224-2493

P a t r i c i a Kramer, R.Ph. Bismarck H o s p i t a l 300 Nor th Seventh Bismarck 58501 701 /224-6000

Val R ieder New Rockford 58356 701 /947-2936

Ron Row, M.S.W. Soc ia l Work Department S t . A l e x i u s H o s p i t a l N i n t h and Rosser Bismarck 58501 701/224-7000


Med ica l Care Adv iso ry Committee ( c o n t i n u e d ) :

B i l l Congdon, D.D.S. 810 E. Rosser Avenue B ismarck 58501 701 /258-1321

Jon Thomas Canmuni t y A c t i o n Program

Region V I I 2105 Lee Avenue B ismarck 58501 701 /258-2240

Jack Heyne Center f o r Independent L i v i n g 109 F i r s t S t r e e t , N.W. S u i t e lO lB MSB Bldg. Manden 58554 701 /663-0376

C a r t e r Pendergast N.D. Group Management Assoc. Qua in & Ramstad C l i n i c 221 Nor th F i f t h Bismarck 58501 701 /222-5200

8. Commission on Socio-Economic A f f a i r s :

D. L. Lamb, M.D. Chairman #504 Pro fess iona l B ldg. Fargo 58103

R . S . Larson, M.D. V ice-Cha i rman Ve lva 58790

R. 0. Anderson, M.D. 1605 E. C a p i t o l Avenue Bismarck 58501

J. J. Baldwin, M.D. Fargo C l i n i c Fargo 58123

N. E. B y s t o l , M.D. Dakota C l i n i c , L t d . Fargo 58108

B. L . Dahl , M.D. West Fa rgo Medica l Center West Fa rgo 58078

M. M. F i e c h t n e r , M.D. Qua in & Ramstad C l i n i c Bismarck 58502

C. S. Hami l ton, J r . , M.D. Fargo C l i n i c Fargo 58123

K. S. Helenbol t, M.D. B l u e Shield-ND 4510 1 3 t h Avenue, SW Fargo 58121

J. R. Her r , Jr., M.D. 1213 - 1 5 t h Avenue, W. W i l l i s t o n 58801

F. M. C a r t e r , M.D. 0. V. L indelow, M.D. Grand Forks C l i n i c , L t d . Mid-Dakota C l i n i c Grand Forks 58201 Bismarck 58502

J. H. Coffey, M.D. Fargo C l i n i c Fargo 58123

H. B. Cowan, M.D. D ick inson C l i n i c D ick inson 58601

J. J . McLeod, J r . , M.D. Or thopaedic C l i n i c , P.C. Grand Forks 58201

R. F. M i l l e r , M.D. Medical A r t s B u i l d i n g Bismarck 58501


Commission on Socio-Economic A f f a i r s ( con t inued) :

R. F. Morgan, M.D. 316 N. 1 0 t h S t r e e t Bismarck 58501

W. J. Norberg, J r . , M.D. Fa rgo C l i n i c Fargo 58123

N. B. Drdah l , M.D. P. 0. Box 1348 D ick i nson 58601

D. M. P f e i f l e , M.D. Qua in & Ramstad C l i n i c B i smarck 58502

Medical Student Members :

T e r r y B lock P.D. Box 332 Thompson 58278

P a t r i c i a Burger 2009 1 0 t h Avenue N. Grand Forks 58201

Counci 1 l o r s Assiqned:

J. A. Lambie, M.D. Grand Forks C l i n i c , L t d . Grand Forks 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 Assoc ia tes Medica l A r t s C l i n i c Grand Forks 58201 Minot 58701

D. A . Rinn, M.D. E x - O f f i c i o :

UND F a m i l y P r a c t i c e Center D. E. Wolf, M.D. PO Box 1967 Rodger '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 A d m i n i s t r a t o r : Grand Forks C l i n i c , L t d . Grand Forks 58201 M r . Ray Kuntz

Johnson C l i n i c Res ident Member: Rugby 58368

Roger W. Kulas, M.D. UND Fami l y P r a c t i c e Center Grand Forks 58201

C. Pharmacy A d v i s o r y Committee:

John Lee, Chairman Forman 58032

Gordon Mayer 708 B i r c h Avenue Harvey 58341

Marv Tokach #1 R i v e r v i e w Lane Jamestown 58401

Tony Welder Box 63 Napol eon 58 761

North Dakota - 6 1983

Pharmacy Adv iso ry Committee (con t inued) :

Duane McCul lough 422 Main Oakes 58474

E r v i n Reuther 701 T h i r d S t r e e t Langdon 58249

LLoyd Schnaid t Box 1054 Oick inson 58601

Gera ld Johnson Box 95 Fessenden 58438

Roberta Southam ( E x - O f f i c i o ) Box 158 Mohal l 58761

John Schuld (Ex-Off i c i o ) Box 148 D i c k i n s m 58601

Michael Berg Tom P e t t i nger 1308 S.W. 11th S t r e e t 214 Fores t Avenue N. M i not 58201 Fargo 58102



Vern Wagner Execu t i ve V i c e P r e s i d e n t North Dakota Medical

A s s o c i a t i o n 810 East Rosser Avenue Box 1198 Bismarck 58501 Phone: 701/223-9475


John Schuld Secretary-Treasurer N o r t h Dakota Pharmaceut ical

A s s o c i a t i o n P. 0. Box 148 Oick inson 58601 Phone: 701 /225-8650


Harry Homewood, D.O. Secretary-Treasurer Nor th Dakota S t a t e Osteopath ic A s s o c i a t i o n Box 516 Val l e y C i t y 58072

K D l CAL ASSISTANCE DRUG PROGRAM (TITLE XI X)

Ohio - 1 1983


OAA AB APTD AFDC OAA AB APTD AFDC Chi I d r e n i 2 1 (SFO) Presc r ibed Drugs X X X X l n p a t i e n t H o s p i t a l Care X X X X O u t p a t i e n t H o s p i t a l Care X X X X Labora to ry E X-ray Serv ice X X X X S k i l l e d Nurs ing Home Serv ices X X X X Phys ic ian Serv ices X X X X Dental Serv ices X X X X *SF0 - S t a t e Funds Only

1 1 . EXPENDITURES FOR DRUGS. Payment t o Pharmacists by f i s c a l year end ing September 30, 1982


T M M ............................... $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 B l ind . . ............................. 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 /DepCh i ld ren ... 6,696,437 265,310 7,112,651 263,261 A d u l t s -Fami l i es 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 -Fami l i es w/Dep Chi ldren. . . 158,361 10,301 119,743 7,308 A d u l t s -Fami l i es 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 -Fami l i es w/Dep Chi ldren. . 0 0 0 0 A d u l t s -Fami l i es 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


Ohio - 2 1983


S t a t e Department o f P u b l i c Welfare.

IV. P r o v i s i o n s R e l a t i n g t o P resc r ibed Drugs:

A. General Exc lus ions: For p r e s c r i p t i o n legend and/or OTC drugs n o t l i s t e d i n the fo rmu la ry , pharmac is t shou ld 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 rug p roduc ts .

To promote economies i n t h e drug 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 those drugs which c o n s i s t e n t l y demonst ra te t h e r a p e u t i c e f fec t i veness and a r e produced by pharmaceut ica 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 pharmacis t i s expected t o d ispense t h e l e a s t expens ive d rug a v a i l a b l e i n h i s s tock . The maximum p r i c e a l l o w e d f o r such gener i cs 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 tems o b t a i n e d from g e n e r i c manufacturers u s u a l l y a s s o c i a t e d w i t h who lesa le d r u g houses.

A drug code i s l i s t e d i n t h e Ohio Welfare Drug Formulary f o r each form o f g e n e r i c drug. Trade names f o r these 564 drug i tems a r e a l s o con ta ined i n t h e formulary .


1. Q u a n t i t y of Medicat ion:

a. 34-day supply o r 100-dosage u n i t s (wh ichever i s g r e a t e r ) .

b. Amount des ignated i n Ohio We l fa re Formulary.

2. R e f i l l s : Up t o 5 r e f i l l s . A f t e r 5 r e f i l l s o r 6 months (wh ichever i s f i r s t ) a new p r e s c r i p t i o n i s necessary.


1. Legend drugs i n community pharmacies. - Reimbursement i s based on the lowest o f :

a. t h e p r o v i d e r ' s reasonable and customary charge t o t h e p u b l i c ;

b. t h e Department 's Est imated A c q u i s i t i o n Cost (EAC) , p l u s a d i spens ing fee; o r

c. t h e lowest federa 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 desg inated 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 spens ing 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

O f f i c i a l s , Consu l tants and C o m i t t e e s


Kenneth 6. Creasy D i r e c t o r

Char les E. Noggle A s i s t a n t D i r e c t o r

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 Ass is tance

Stan ley 0. S e l l s D i v i s i o n Chief 614/466-2365

Ka th ryn T a y l o r Bureau Ch ie f Bureau o f Medical Programs

Rober t DuPont Pharmacist Consu l tan t Bureau o f Medical Operat ions

Robert R e i d Pharmacist Consu l tant Bureau o f Medical Operat ions

D i v i s i o n of Data Process ing

Department o f P u b l i c We l fa re 30 East Broad S t r e e t , 32nd f l r . Columbus, Ohio 43215

Department of P u b l i c We l fa re 30 East Broad S t r e e t , 3 1 s t f l r . Columbus, Ohio 43215

R ichard Glecker . R.Ph. Oeoartment o f PI P rov ide r Ass is tance 614/466-7814

2. Ohio Medical Care Adv iso ry Committee

1b1ic We l fa re 30 'East Broad S t r e e t , 38 th f l r . Columbus, Ohio 43215

Ronald Becker Luke B iggs 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, Ohio 43215 M t . Vernon, Ohio 43050 (614) 466-7450 (614) 397-0656

NPC Ohio - 5 1983

Ohio Medical Care Adv isory Committee (cont inued) :

Ms. M i c h e l l e Breuleux Ohio Commission on Aging 50 West Broad S t r e e t , 9 t h f l r Columbus, Ohio 43215 (614) 466-6597

Rev. James Couts 1821 Wyton Cour t Columbus, Ohio 43227 (614) 235-7388

D r . M o r r i s Oixon 2224 Chestnut H i l l Cleveland, Ohio 44106 (216) 444-1517

James Eden, R.Ph. 235 Nor theast Avenue Ta lmadge, Ohio 44278 (216) 633-9411

Henry S. F i sher , D i r e c t o r Summit County Welfare

Department 47 Nor th Main S t r e e t Akron, Ohio 44308 (216) 384-1681

Samuel Fra l ey Ohio Department of Hea l th 246 Nor th High S t r e e t Columbus, Ohio 43215 (614) 466-7857

Ted Fry Ohio Department o f Mental

R e t a r d a t i o n and Developmental D i s a b i l i t i e s

30 East Broad S t r e e t , 12th f l r . Columbus, Ohio 43215 (614) 466-7596

Owain L. Harper, D.O. Regional A s s i s t a n t Dean Ohio U n i v e r s i t y Co l lege o f

Osteopathic Medic ine 5125 Beacon H i l l Road Columbus, Ohio 43228 (614) 868-6415

W i l l i a m Herbein Ohio R e h a b i l i t a t i o n Serv ices

Commission 4656 Heaton Road Columbus, Ohio 43229 (614) 438-1290

Ms. Jane Hersch Execut ive D i r e c t o r Ohio Sta tewide P r o f e s s i o n a l

Standards Review Counc i l 6400 East Main S t r e e t Reynoldsburg, Ohio 43068

Ed H in ton U n i t e d Auto Workers' Community

Act i o n Program Counc i l 133 East L i v i n g s t o n Avenue Colunibus, Ohio 43215 (614) 464-2055

Clarence Huggins, M.O. S u i t e 102 13944 E u c l i d Avenue Cleveland, Ohio 44112 (216) 451-1600

Ralph Jordan, V ice P r e s i d e n t Hea l th Care Serv ices Nat ionwide Insurance Company 1 Nat ionwide Plaza Columbus, Ohio 43216

Ned Kramer, D.O.S. Chi l d rens H o s p i t a l 561 South 1 7 t h S t r e e t Columbus, Ohio 43205 (614) 461-2000

Edward A. Lentz The Hawkes H o s p i t a l o f M t .

Carmel 739 West S t a t e S t r e e t Columbus, Ohio 43222 (6 14) 225-5876

Ohio - 6 1983

Ohio Medica l Care Adv isory Committee (con t inued) :

L. Bruce Lever ing Bur ton Schi ldhouse Route 4 407 East L i v i n g s t o n Avenue Freder ick town, Ohio 43019 Columbus, Ohio 43215 (614) 886-3931 o r 397-4125 (614) 224-1980

Rober t C. L i n s t r o m H e a l t h P lann ing and

Development Counc i l 405 West L i b e r t y S t r e e t Wooster, Ohio 44691

A n i t a McCormick, Ph.0. A s s i s t a n t S t a t e Leader O.S.U. School of Home

Economics Ex. N u t r i t i o n Program 1787 N e i l Avenue Columbus, Ohio 43210 (614) 422-1935

Dora Thomas 617 Ezzard Char les D r i v e C i n c i n n a t i , Ohio 45203 (513) 241-5062

Rober t Wade Community R e l a t i o n s O f f i c e r Columbus Urban League 700 Bryden Road, S u i t e 230 Columbus, Ohio 43215

Mrs. Bobbe Nolan, R.N. 1216 Amherst P lace Dayton, Ohio 45406 (513) 435-6500

3. Execu t i ve O f f i c e r s o f S ta te Medical and Pharmaceut ica l S o c i e t i e s :

A. Medical A s s o c i a t i o n B. Pharmaceut ica l 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 Execu t i ve D i r e c t o r E x e c u t i v e D i r e c t o r Ohio S ta te Medical A s s o c i a t i o n Ohio S t a t e Pharmaceut ica l A s s o c i a t i o n 600 South High 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. Oh io Osteopath ic A s s o c i a t i o n

Jon F. W i l l s 53 W. 3 r d Avenue Columbus 43201 Phone: 614/299-2107

WED1 CAL ASSISTANCE DRUG PROGRAM (TITLE X I X )

Oklahoma - 1 1983

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 1 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 Q 1 (SFO) P r e s c r i b e d Druqs X X X X X X X X X I n p a t i e n t H o s p i t a l Care X X X X X X X X X Outaat i ent - - r - - - 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 y & X-ray Serv i ce X X X X X X X X X S k i l l e d Nurs ing Home Serv i ces X X X X X X X X X P h y s i c i a n Serv i ces X X X X X X X X X Denta l Serv i ces 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 lness d e t e r m i n a t i o n accord ing 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 Only

1 1 . EXPENDITURES FOR DRUGS. Payment t o Pharmacis ts by f i s c a l year end ing June 30, 1982


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 - F a m i l i e s w/Dep Chi ldren. . . . .

CATEGORICALLY NEEDY CASH TOTAL...... $10,512,683 108,903 32,105

316 14,924 40,577 20,981

CATEGORICALLY NEEDY NON-CASH TOTAL.. Aged ................................ Blind......... ...................... Disab led ............................ C h i l d r e n - F a m i l i e s w/Dep Chi ldren. . . A d u l t s - F a m i l i e s w/Dep Children... . . Other 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 ............................... Disab led ............................

... C h i l d r e n -Fami l i es w/Dep C h i l d r e n ... A d u l t s -Fami l i e s w/Dep Ch i ld ren . . .......... Other T i t l e X I X R e c i p i e n t s


NPC Oklahoma - 2 1983


Oklahoma Department of Human Serv ices (DHS).

IV. P r o v i s i o n s R e l a t i n g t o Prescr ibed Drugs:

Formulary: Yes, Oklahoma L i s t o f Covered Drugs

Contact : H. W. S tansberry Box 53034 Oklahome C i t y , Oklahoma 73152 405/521-3804

Prov ide r P a r t i c i p a t i o n :

Pharmacy or Pharmacist:

Any pharmacy o r pharmacist 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 be e n t i t l e d t o be 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.

P r e s c r i b i n g P r a c t i t i o n e r s :

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 as d e f i n e d and l i m i t e d by Federa 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 pharmaceut icals, 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 p resen t t ime.

Reimbursement Fee:

Est imated A c q u i s i t i o n Cost (EAC) p l u s maximum d ispens ing 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 Welfare 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.

Categor ies 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 by t r a d e name; o therwise by gener i c name o n l y .

A n t i d i a r r h e a l s An t ipa rk inson ism Ant idepressants Broncho-Di la tors and An t ias thmat i cs Opthalmic A n t i a r t h r i t i c s A n t i b i o t i c s (Ora 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 (Ora l and I n j e c t i o n ) Gl aucoma Drugs


Categor ies o f Drug Coverage (con t inued) :

O t i c Ant i g o u t A n t i n e o p l a s t i c s (Ora l and I n j e c t i o n ) B i r t h Con t ro l Analges ics Ant i convu lsan ts Ant inauseants, 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 Cardiovascular-Broad and Potassium P r e p a r a t i o n A n t i f u n g a l Spec ia l i zed Prepara t ions

P r e s c r i p t i o n L i m i t a t i o n s :

Three p r e s c r i p t i o n s per mon th / rec ip ien t .

Q u a n t i t i e s :

34-day supply o r 100 dosage u n i t s , whichever i s g r e a t e r .

Legend, Non-Legend and Generic Drugs:

Only legend drugs i n t h e des ignated c a t e g o r i e s and i n s u l i n a r e covered i n t h e program.

R e f i 11s:

R e f i l l s s h a l l be 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 than f i v e t imes w i t h i n a 6-month p e r i o d .

V. Miscel laneous:

Number o f Rx c la ims processed i n FY 1982 - 1,046,449


Oklahoma - 4 1983


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 D i r e c t o r

Ber tha M. Levy, M.D. A s s i s t a n t D i r e c t o r Medica l Serv i ces Admini s t r a t i o n

Wes Wh i t t l esey , M.D. A d m i n i s t r a t i v e A s s i s t a n t A s s i s t a n t Superv isor ,

Medical U n i t s

J. C. Cobb, R.Ph. Pharmacist Consu l tan t

Howard S tansber ry Pharmacy Program Admi n i s t r a t o r Program Coord ina to r 405/521-3804

Oepartment o f Human Serv ices Sequoyah Memorial O f f i c e

Bldg. (P. 0. Box 25352) Oklahoma C i t y , Okl ahoma

2. Adv iso ry Committee on Medical Care f o r P u b l i c Ass is tance Rec ip ien ts :

Walter E. Brown, M.O. 4439 S. B i rmingham Tulsa 74105

- Chai rman

3. Execut ive O f f i c e r s o f S t a t e Medical , Pharmaceut ical , and Osteopath ic S o c i e t i e s :


David Bickham Execu t i ve D i r e c t o r Oklahoma S t a t e Medica 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


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 )


OAA AB APTD AFOC OAA AB APTD AFDC Chi ld ren<21 (SFO) P r e s c r i b e d

I n p a t i e n t H o s p i t a l Care X X X X O u t p a t i e n t H o s p i t a l Care X X X X L a b o r a t o r y E X-ray Serv i ce X X X X S k i l l e d Nurs ing . Home Serv i ces X X X X P h y s i c i a n Serv i ces X X X X Denta l Serv i ces X X X X Other Bene f i t s : V i s u a l Care, Medica l T r a n s p o r t a t i o n , Medica l Suppl ies/Equipment, P h y s i c a l Therapy, P o d i a t r i s t , Ch i rop rac to r , Naturopath , ICF, F a m i l y P lann ing , Abor t i ons , home h e a l t h agency, P r i v a t e du ty nurse, EPSDT. *SF0 - S t a t e Funds Only



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 Bl ind... . . .......................... 112,434 537 58,573 5 25 Disab led. . .......................... 1,796,320 7,518 818,771 7,339 C h i l d r e n -Fami l i es 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 -Fami l i es 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 B l i n d ............................... 52,195 193 15,733 141 Disab led. ........................... 871,226 3,858 310,818 2,786 C h i l d r e n -Fami l i es w/Dep Chi ld ren. . . 15,216 1,015 81,665 732

. A d u l t s -Fami l i es 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 -Fami l i es w/Dep Chi ld ren. . . 0 0 A d u l t s -Fami l i es w/Dep Children... . . 0 0 Other T i t l e XIX R e c i p i e n t s .......... 0 0


NPC Oregon - 2 1983


A d u l t and Fami ly Serv ices D i v i s i o n , Department o f Human Resources.

I V . P r o v i s i o n s R e l a t i n g t o Presc r ibed Drugs:

A. Formulary: An open " formulary" except f o r minor t r a n q u i l i z e r s and amphetamines.

B. Non-Formulary: P r i o r approval f rom 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 ob ta ined f o r minor t r a n q u i l i z e r s o t h e r then ( g e n e r i c ) meprobamate o r ch lo rd iazepox ide , 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.


1. Q u a n t i t y o f Medicat ion: Not t o exceed 34 days supply , except t o p i c a l p r e p a r a t i o n s , sprays, ae roso l i nha le rs , and s i m i l a r p r e p a r a t i o n s .

2. R e f i l l s - 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 .



Payment i s t h e lowest of: (a) usual and customary charges t o general p u b l i c , ( b ) Maximum Al lowable Cost (MAC) p l u s d ispens ing fee of $3.27, ( c ) Est imated A c q u i s i t i o n Cost (EAC) p l u s d ispens ing f e e o f $3.27.

Nurs ing home drug 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 per e l i g i b l e .

V . Misce l laneous Remarks:

Number of Rx c la ims processed i n FY 1982 - 1,502,174


S ta te MAC program f o r approx imate ly 150 drugs.

NPC Oregon - 3 1983

1. Leo T. Hegstrom D i r e c t o r

O f f i c i a l s , Consul tants and Cormnittees

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 Fami ly Serv ices Div .

Byron Carpenter A s s i s t a n t A d m i n i s t r a t o r H e a l t h and Soc ia l Serv ices Sec t ion

Kim Scranton A s s i s t a n t A d m i n i s t r a t o r F i e l d Operat ions Sec t ion

Leonard T. Sytsma A s s i s t a n t A d m i n i s t r a t o r Support Serv ices Sect i o n

Michael Kane A s s i s t a n t A d m i n i s t r a t o r Income Maintenance Sec t ion

Vern F i s h e r A s s i s t a n t A d m i n i s t r a t o r Business Serv ices Sect i o n

Department o f Human Resources 318 P u b l i c Serv ices B u i l d i n g Salem, Oregon 97310

2. Consu l tan ts t o Hea l th and Soc ia l Serv ices Sect ion:

R ichard J. Cook, D.D.S. Rob i nhood Prof . B l dg . 18603 P a c i f i c Highway West L i n n 97068

W i 1 1 iam Det twy le r , M.T. 5555 Sunnyview Road, NE Salem 97303

W i l l i a m Henry, ND (Naturopath)

1920 Nor th K i l p a t r i c k Por t land 97217

A l f r e d Schef f , M.D. ( P s y c h i a t r i c )

1625 Commercial S t . , SE Salem 97302

O t t o F. Kraushaar, H.D. ( C h i e f Medical Adv iso r )

203 P u b l i c Serv i ce Bldg. Salem 97310

Robert W. S ta ley , D.D.S. 1075 Hansen Avenue S. Salem 97302

Oregon - 4 1983

Consul tants t o Hea l th and Soc ia l Serv ices Sec t ion (con t inued) :

Donald Char l ton, DMD ( D e n t a l )

943 L i b e r t y S t r e e t , SE Salem 97302

Mer le Berry , O.D. (Optometr i c )

Albany Optometr i c Center 225 W. 2nd Albany 97321

Dan Campbell, D.D.S. C /O Lebanon Branch, AFS P. 0. Box 456 Lebanon 97355

D r . Jan lsselman 1320 Lewis S t r e e t , SE Salem 97302

Ranv i r Sinanan, M.D. 203 P u b l i c Serv i ce Bldg. Salem 97310

Chuck Mortensen (Pharmacist Consu l tan t )

203 P u b l i c Serv i ce B ldg. Salem 97310 503/378-2263

3. D i v i s i o n Adv isory Committees:

Governor 's Adv isory Comnittees on Medical Ass is tance f o r t h e U n d e r p r i v i l e g e d

MEMBERS

Char les Ross Anthony P u b l i c - economics 344-1982 2590 Van Ness 484-0709 Eugene 97403 (home)

Danie l B i l lmeyer , MD Phys ic ian 406 7 t h S t r e e t Oregon C i t y 97045

Kay Breeden P u b l i c - r e c i p i e n t 2506 Canterbury Eugene 97404

Roder ick Bunnel l t ndus t ry P.D. Box 1071 P o r t land 97207

James E. Creswel I, DMD D e n t i s t Route 3, Box 428 Klamath F a l l s 97601

S i s t e r Monica Heeran H o s p i t a l A d m i n i s t r a t o r Sacred Heart H o s p i t a l P.O. Box 10905 Eugene 97440

NPC Oregon - 5 1983

Governor 's Adv iso ry Committee on Medica l Ass is tance f o r t h e U n d e r p r i v i l e g e d (con t inued)

Joan E. Krahmer 614 East Main H i l l s b o r o 97123

Frank McBarron 2225 Loyd Center P o r t l a n d 97232

Dennis Marsh 1015 C o r n e l l Avenue Gladstone 97027

L a r r i e Noble, R.N. 11750 SW 72nd T i g a r d 97223

Rhese Penn, MD H e a l t h D i v i s i o n 1400 SW F i f t h Avenue P o r t l a n d 97201

Ruth S l i c k , RN 221 Quarry S t r e e t Oregon C i t y 97045

Bever ley C. T r a g l i o l o l l NE 69 th P o r t l a n d 97213

Barbara Watson, R.Ph. 4250 SW Upper D r i v e Lake Oswego 97034

P u b l i c - Mental H e a l t h 648-8636

Phys ic ian 284-1174

Medical P r o f e s s i o n - Other Ambulance

Nurs ing Pro fess ion

D i r e c t o r , Maternal and C h i l d H e a l t h

Nurs ing Home A d m i n i s t r a t o r

P u b l i c - Rec ip ien t

Pharmacist 636-5697

4. Execu t i ve O f f i c e r s o f S t a t e Medica l , Pharmaceut ical and Osteopath ic Assoc ia t ions :


Robert L. Dernedde Execu t i ve D i r e c t o r Oregon Medica l A s s o c i a t i o n 5210.SW Corbe 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 Medical , Pharmaceut ical and Os teopa th i c A s s o c i a t i o n s (con t inued) :

0. Pharmaceut ical Assoc ia t i on :

Henry A. Speckman E x e c u t i v e Sec re ta ry Oregon S ta te Pharmaceut ical 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


J e f f Hea the r ing ton Execu t i ve D i r e c t o r Oregon Osteopath ic 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

l Y D l CAI. ASSISTANCE DRUG PROGRAM (TITLE X I X)

Pennsy lvan ia - 1 1983

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 Presc r ibed Druqs X X X X X l npat i en t H o s p i t a l Care X X X X X X X X X X Ou tpa t ien t H o s p i t a l Care X X X X X X X X X X Labora to ry & X-ray Serv ice X X X X X X X X X X Ski1 led Nurs ing Home Serv ices X X X X X X X X X X Phys ic ian Serv ices X X X X X X X X X X Dental Serv ices X X X X X X Other B e n e f i t s : Fami ly Planning, Home H e a l t h Care, Ambulance, C l i n i c s ICF Serv ice, H o s p i t a l Hane Care, Durab le Medica 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 Only

1 1 . EXPENDITURES FOR DRUGS. Payment t o Pharmacists by f i s c a l year ending June 30, 1982

Expended R e c i p i e n t Expended R e c i p i e n t

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 -Fami l i es w/Dep Chi ldren. . . 9,810,062 342,641 8,694,432 242,800 ... A d u l t s -Fami l i es w/Dep Chi ldren. . 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 B l i n d ............................... 286 20 511 2

........................... Disabled. 2,341,493 8,206 3,243,174 8,570 . C h i l d r e n -Fami l i es w/Dep Chi ldren. . 314,978 12,002 241,566 8,690 . A d u l t s -Fami l ies 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 2 8 1 C h i l d r e n -Fami l i es w/Dep Ch i ld ren . .. 71,181 3,221 16,919 46 0

.... A d u l t s -Fami l ies 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 8 1 123 2

2[f - 2082 **Undupl icated T o t a l - HHS r e p o r t HC

NPC Pennsy lvan ia - 2 1983

1 1 1 . A d m i n i s t r a t i o n :

O f f i c e of Medical Assistance, Department o f P u b l i c We l fa re .

IV . P r o v i s i o n s R e l a t i n g t o P resc r ibed Drugs:

A. General Exc lus ions: 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 reatment o f pulmonary t u b e r c u l o s i s , d rugs 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 vacc ines 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 charge f rom 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 these i tems i n an emergency i f they a r e n o t a v a i l a b l e f rom the 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 i tems 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 c o n t r o l . However, drugs which have been c l e a r e d f o r use i n t h e t rea tmen 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 narco lepsy 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 o r i g i n a l p r e s c r i p t i o n .

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 , ana lges ic , a n e s t h e t i c , and a n t i t u s s i v e agents i n t h e fo rm of t roches, 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 i tems t h a t a re p r e s c r i b e d f o r the l o c a l t rea tmen t of d i s o r d e r s o f t h e mouth and t h r o a t . 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 re compensable.

5. Pharmaceut ical 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 person or a person r e c e i v i n g hosp i ta l -home care.

6. A 1 1 v i t a m i n s a l o n e o r i n combinat ion w i t h another v i t a m i n , except f o r the f o l l o w i n g :

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 ) yea rs of age.

b. A p r e s c r i p t i o n drug p roduc t which 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 legend drug.

c . V i t a m i n D and i t s analogs.

. . . d. N i c o t i r ~ i c a c i d aim r c s amides.

e . Vi-amir i I< and i t s tirlalogs.

Pennsylvania - 3 1983

General E x c l u s i o n s (con t inued) :

f . F o l i c A c i d

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 dev ices c l a s s i f i e d as exper imenta l b y t h e FDA.

8. Drugs and dev ices no 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 agents, 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 agents, 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 pe rsona l c a r e and medic ine ches t i tems.

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 than f o r i n t ravenous a d m i n i s t r a t i o n .

12. Legend and nonlegend water p r e p a r a t i o n s such as d i s t i l l e d water, 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 i tems a r e used i n l e s s than t h e r a p e u t i c q u a n t i t i e s , o r

b. Noncompensable items a r e compounded.

15. Nonlegend drugs no t l i s t e d i n t h e Appendix t o Chapter 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 reassignment procedures o r o t h e r noncompensable s u r g i c a l procedures.

17. The f o l l o w i n g i tems 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. In t ravenous s o l u t i o n s .

b. , Those noncompensable drugs and i tems as s p e c i f i e d i n t h i s s e c t i o n .

c . Those nonlegend drugs i n d i c a t e d as be ing non-compensable f o r these 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.


General Exc lus ions (cont inued) :

18. l tems p resc r ibed o r ordered by a p r e s c r i b e r who has been bar red o r suspended from p a r t i c i p a t i o n i n t h e Medica l Ass is tance 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, te rm ina ted 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 va r ious ac t ions . Pharmacies a r e r e s p o n s i b l e f o r check ing t h i s l i s t b e f o r e 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 rders f i l l e d by a pharmacy o t h e r than t h e one t o which 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 check ing 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 Medical Serv i ces 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


1. Q u a n t i t y of Medicat ion: t h e q u a n t i t y t o be dispensed i s as p r e s c r i b e d by t h e phys ic ian , no t t o exceed a 34 day supp ly o r 100 u n i t s , whichever i s g rea te 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 as t o t a l a u t h o r i z a t i o n does no t exceed a 6 months' o r 5 - r e f i l l supply from t h e t ime o f o r i g i n a l p r e s c r i p t i o n .

3. D o l l a r L i m i t s : P r e s c r i p t i o n s f o r medicat ions c o s t i n g more than $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 Ass is tance O f f i c e .

Drug Cost Determinat ion:

1. Payment f o r compensable legend drugs i s based on t h e c u r r e n t Es t ima ted 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 med ica t ion i s computed by 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 wholesa le p r i c e s charged f o r t h e d rug i n t h e most common package s i z e by s i x (6 ) of t h e major Pennsy lvan ia drug wholesa lers 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 by t h e Department of H e a l t h and Human Serv ices. I f more than s i x ( 6 ) Pennsy lvan ia drug wholesa lers 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 data , t h e EAC i s computed based on t h e data ob ta ined f rom t h e s i x (6) who lesa le rs t h a t a r e t h e l a r g e s t .


Drug Cost Determinat ion (con t inued) :

The Department implemented the p resen t EAC system on January 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 repor ted by t h e Pennsy lvan ia wholesa lers t h a t p r i c e change occurs w i t h o t h e r drugs, then these drugs were assigned EAC's and added t o t h e l i s t . U n t i l a d r u g ' 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) as pub l i shed i n the c u r r e n t Drug Top ics 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 AW, t h e manufacturer '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 month ly b a s i s if any of t h e wholesa lers which a r e supp ly ing p r i c e data adv ises t h e Department o f a change i n t h e wholesa le c o s t o f t h e drug. I n cases where the EAC exceeds the Maximum A l l o w a b l e Cost (MAC), t h e MAC w i l l app ly .

2. Payment f o r t h e c o s t o f comparable nonlegend drugs i s based on t h e c u r r e n t AWP appear ing i n t h e Drug Top ics Red Book o r i t s b i - month ly and q u a r t e r l y supplements. I f t h e AWP f o r a nonlegend drug does n o t appear i n t h e Red Book o r i t s supplement, then t h e c o s t i s based on the manu fac tu re 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 supp l ied 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 Medica l Ass is tance Program.


1. On May 16, 1981, Pennsy lvan ia 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, which has been approved by t h e federa l government as p a r t of t h e S t a t e ' s approved S t a t e Plan, recognizes a d i f f e r e n c e between a pharmacy's usual 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 payors. The " s e l f - pay ing pub1 i c " i s def ined as a l l persons whose c o s t s f o r p r e s c r i b e d drugs a r e n o t covered by a t h i r d p a r t y payor. " T h i r d p a r t y payors" a r e de f ined as p u b l i c o r p r i v a t e h e a l t h insurance p lans o r programs which make payments t o pharmacies on beha l f of e l i g i b l e r e c i p i e n t s o r b e n e f i c i a r i e s . 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 reimbursed an a d d i t i o n a l amount no t t o exceed 25 cen ts 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 usual and customary bas is . 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 ispens ing fee.


P r e s c r i p t i o n Charge Formula (cont inued) :

2. A l i censed r e t a i l pharmacy's maximum reimbursement f o r a l l compensable legend and nonlegend drugs s h a l l be t h e c o s t o f t h e drug p l u s a $2.25 d ispens inq fee o r t h e pharmacy's usua l and customary charge t o t h i r d p a r t y payors, whichever i s lower. Fo r purposes of Medical Ass is tance reimbursement, t h e usual and customary charge t o t h i r d p a r t y payors may n o t exceed 25 cents per p r e s c r i p t i o n h igher than t h e usual and customary charge 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 drug s h a l l be e i t h e r t h e M A C , EAC, o r AWP. A l though 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 to b i l l t h e Department a t i t s usual and customary charge 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 ca re 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 drug p l u s a $1.55 d ispens inq 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 Medica l Ass is tance reimbursement, t h e usual and customary charge t o t h i r d p a r t y payors may no t exceed 25 c e n t s per p r e s c r i p t i o n h igher than t h e usual and custanary charge 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 though 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 usual and customary charge t o t h e s e l f - p a y i n g p u b l i c .

4. For 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 lowed 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 spens ing 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 Medica l Ass is tance payment, i s one which i s prepared a t t h e t ime of d i spens ing and i n v o l v e s t h e weighing 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 not be p a i d f o r p r e s c r i p t i o n s prepared i n b u l k p r i o r t o d ispens ing.

V . Miscel laneous:

Rec ip ien t Lock- l n Proqram.

A. Approx imate ly 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 per month f o r reduced u t i l i z a t i o n o f drug se rv i ces .

C. Parameters used f o r t h e p r o f i l e s are: 1. $250 f o r drug s e r v i c e s f o r a t h r e e month per iod ; 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

M isce l laneous ( c o n t i n u e d ) :

D. Copayment - No.

E. F i s c a l In te rmed ia ry

The Computer Company 5101 Jonestown Road Har r i sburg , 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



Wal ter W. Cohen Secre ta ry

B r i a n T. Baxter Execu t i ve Deputy Sec re ta ry

Gera ld F. Radke Deputy Sec re ta ry f o r Medical

Ass is tance

David S . Feinberg D i r e c t o r Bureau of Pol i c y and Program

Deve 1 opmen t

R ichard H. Lee D i r e c t o r , Bureau o f

Reimbursement Methods

Rober t B. K e l l y D i r e c t o r , Bureau o f Medical

Ass is tance Operat ions

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 D i r e c t o r Bureau o f P r o v i d e r R e l a t i o n s

2. Consu l tan t Pharmacists:

Joseph E. Concino, R.Ph. Bureau of Pol i c y and Program

Deve 1 opmen t 7171787- 1170

Michael A. R imler , R.Ph. Bureau o f Reimbursement Methods

Department o f P u b l i c We l fa re H e a l t h and We l fa re B u i l d i n g Har r i sbu rg , Pennsy lvan ia 17120


Consu l tan t Pharmacists ( con t inued) :

W i l l i a m M. P e i f e r , R.Ph. Bureau of Medica l Ass is tance

Operat ions

Rober t G . D i s s i n g e r , R.Ph. Bureau of Medical Ass is tance

Opera t ions

S . Char les Modica, R.Ph. Bureau o f Medica l Ass is tance

Operat ions

John F e r r a r a , R.Ph. Bureau of U t i l i z a t i o n Review

Frank 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

Paul Burkho lder , R.Ph. Bureau of U t i l i z a t i o n Review

Department o f P u b l i c We l fa re Park Penn B u i l d i n g H a r r i s b u r g 17112

Department of P u b l i c We l fa re 25 N o r t h 32nd S t r e e t Camp H i l l 17011

3. Medica l Ass is tance A d v i s o r y Committee:

Member O r q a n i z a t i o n

James M. Redmond H o s p i t a l A s s o c i a t i o n of Pa.

V i c e Pres iden t , H o s p i t a l Se rv i ces 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. 1414 Fa i rmont S t r e e t A l l en town 18102

Wal ter M. G r e i s s i nger, M.D. Cen t ra l Medica l P a v i l i o n 1400 Center Avenue P i t t s b u r g h 15219

Pa. Dental A s s o c i a t i o n

Pa. Medical S o c i e t y


Medica l Ass is tance Adv iso ry Committee ( c o n t i n u e d ) :

Thomas W. C la rk , M.D. The C o a l i t i o n o f Advocates f o r 44 West H igh land 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 Insurance Commission Deputy lnsurance Commissioner S t rawber ry Square H a r r i s b u r g 17120

Har ry Stacks 2411 Chestnut View D r i v e Lancaster 17603

James F e r l o 139 Carver S t r e e t P i t t s b u r g h 15206

Thomas W. B lack , M.D. 44 West H igh land Avenue P h i l a d e l p h i a 19118

W i l l i a m L. Greene, R.Ph. Green's Pharmacy 2020 Union Bou leva rd A l l en town 18103

Southeast Cen t ra l Reg iona l Counc i l on Ag ing

Cmmun i t y Heal t h Advocacy Network

The Coal i t i on of Advocates f o r t h e R i g h t s of t h e I n f i r m E l d e r l y

Pa. Pharmaceut ica l Assn.

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 Medica l Ass is tance Adv iso ry Committee.

4. Pharmacy Subcommittee t o the Medical Ass is tance A d v i s o r y Committee:

W i l l i a m L. Greene, R.Ph. Chai rman 780 West Macada Bethleham 18017

Samuel D. Brog, R.Ph. 102 Buck ley D r i v e P h i l a d e l p h i a 19115

Dav id Da l ton , R.Ph. R i t e A i d C o r p o r a t i o n P.O. Box 3165 H a r r i s b u r g 17105

A lan J . Vogenberg, R.Ph. 10 F r u i t r e e Road L e v i t t own 19056

John A. Paone, R.Ph. Wyman Pharmacy 524 East Ohio S t r e e t P i t t s b u r g h 15212

N.E. M o n t i c e i l i , R.Ph 669 B u r c l a y Lane B r o m a l l 19008


Pharmacy Subcommittee t o t h e Medical Ass is tance Adv isory Committee (con t inued) :

Rober t Peyakovich, R.Ph. 1921 Harvard Avenue P o t t s v i l l e 17901

Donald E. Sche l l , R.Ph. 129 B lacksmi th Road Camp H i l l 17011

L a r a i n e F o r r y 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 Or thopedic

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 East 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. Execu t i ve O f f i c e r s o f S t a t e Medical , Pharmaceut ical , P o d i a t r y , and Osteopath ic Medical Assoc ia t i ons :


John F. Rineman Carmen A. OiCe l lo , R.Ph. Execu t i ve V i c e P r e s i d e n t Execu t i ve D i r e c t o r Pa. Medical Soc ie ty Pennsy lvan ia Pharmaceut ica l 20 E r f o r d Road Assoc . Lemoyne 17043 508 Nor th 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. P o d i a t r y Assoc ia t i on : D. Osteopath ic Medical A s s o c i a t i o n :

Matthew M. Shook, J r . Marianne F i e l d s Execu t i ve O i r e c t o r Execu t i ve D i r e c t o r Pennsy lvan ia P o d i a t r y Pennsy lvan ia Os teopa th i c

A s s o c i a t i o n Medical A s s o c i a t i o n 737 Pop la r Church Road 1330 Eisenhower Boulevard Camp H i l l 17011 H a r r i s b u r g 17111

Phone: 717/939-9318

PUERTO RICO

P u e r t o R i c o - 1 1983

E O I C A L ASSISTANCE DRUG P R O M ( T I T L E X I X )


OAA AB APTD AFDC DAA AB APTD AFDC C h i l d r e M 2 1 (SFD) P r e s c r i b e d Drugs X X X X X X X X X X l npat i ent H o s p i t a l Care X X X X X X X X X X O u t p 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 Labora to rv & X-ray Serv i ce X X X X X X X X X X S k i l l e d Nurs ing Home Serv i ces X X X X X X X X X X P h y s i c i a n Serv ices X X X X X X X X X X Dental Serv ices X X X X X X X X X X *SF0 - S t a t e Funds Only



TOTAL..... .......................... .. CATEGORICALLY 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 Ch i ld ren . . A d u l t s -Fami l i es w/Dep Children.....

CATEGORICALLY NEEDY NDN-CASH TOTAL. Aged ................................ Bl ind. . . . ........................... Disabled... ......................... .. C h i l d r e n -Fami l i es 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 ............................... Disab led ............................

. C h i l d r e n -Fami l i es w/Dep Ch i ld ren . .

. A d u l t s -Fami l i es w/Dep Chi ldren. . . . .......... Other T i t l e XIX R e c i p i e n t s

No Data Submi t ted

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.


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 Puer to R i c o - 3 1983


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

D r . Jaime R ive ra Dueno Secre ta ry

Medical Ass is tance Program:

E m i l i a Hoyos Rucabado, M.S. Pharmacist Consu l tan t

J u l i o Cesar Galarce D i r e c t o r H e a l t h Economy O f f i c e

Irma R e v i l l e De F e r r e r D i r e c t o r Medical Ass is tance Program

Department of H e a l t h C a l l Box 70 184 San Juan, Puer to R i c o 00936

P. 0. Box 10037 Caparra He igh ts S t a t i o n San Juan 00922

2. Medical Ass is tance Adv isory Cornnittee:

The a d v i s o r y commit tee c o n s i s t s of e leven members appo in ted by t h e Governor.

3 . Execu t i ve O f f i c e r s of P u e r t o R i c o Medical and Pharmaceut ical S o c i e t i e s :


G. T. Oiaz Execu t i ve D i r e c t o r Puer to R i c o Medical A s s o c i a t i o n P. 0. Box 9387 Santurce 00908 Phone: 809/725-6969


Luz Celes te R i v e r a Execu t i ve Sec re ta ry BOX 206, G.P.O. San Juan 00936 Phone: 809/753-7157

RHODE ISLAND

rYDl CAL ASSISTANCE DRUG PROGW (TITLE XIX)

Rhode l s l a n d - 1 1983


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)

P r e s c r i b e d Drugs X X X X X X X X X l npat i ent H o s p i t a l Care X X X X X X X X X O u t ~ a t i ent H o s p i t a l Care X X X X X X X X X Labora to rv & -

X-ray Serv i ce X X X X X X X X X S k i l l e d Nurs ing Home Serv i ces X X X X X X X X X P h y s i c i a n Serv ices X X X X X X X X X Dental Serv ices X X X X X X X X X *SF0 - S t a t e Funds Only



TOTAL ............................... $9,060,921

CATEGORICALLY NEEDY CASH TOTAL. ..... $4,502,699 Aged ................................ 787,237 B l i n d ............................... 21,738 Disabled. . .......................... 1,775,840 C h i l d r e n - F a m i l i e s w/Dep Chi ldren. . . 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 B l i n d . .............................. 8,965 Disab led ............................ 503,801 C h i l d r e n - F a m i l i e s w/Dep Chi ldren. . . 0 A d u l t s -Fami l i es w/Dep Chi ldren. . . . . 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 B l i n d ............................... 4,495 D isab led ............................ 512,475 C h i l d r e n -Famil i e s w/Dep Ch i ld ren . . . 29,220 A d u l t s - F a m i l i e s w/Dep Chi ldren. . . . . 15,734 Other T i t l e X I X R e c i p i e n t s .......... 37,304


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 Serv ices .


A. General Exc lus ions: DTC and c e r t a i n Medic ine Chest I tems and l n j e c t a b l e 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 a l l i n j e c t a b l e s ( e x c l u d i n g i n s u l i n and adrenal i n ) , a p p e t i t e depressant drugs, c e n t r a l nervous system s t imu lan ts , expensive v i tamins , hemat in i cs 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 per 100 t a b l e t s / c a p s u l e s o r ~ i n t ) , expensive and/or new p repara t ions .

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 requested by t h e a t t e n d i n g p h y s i c i a n and approved by t h e D i v i s i o n o f Medical Serv ices.

0 . Formulary: None

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

1. Q u a n t i t y o f Medicat ion: One month's supp ly o f drugs

2. Maintenance Medicat ion: 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 , capsu les o r p i n t of l i q u i d or a 30-days' supply of these drugs -- whichever i s g r e a t e r .

3. R e f i l l s : R e f i l l s t o a maximum o f f i v e a r e a l lowed f o r s p e c i f i e d drugs: an t i -hyper tens ives , d i u r e t i c s , an t i - convu lsan ts , 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 , ant idepressants , hormones, e tc .

R e f i l l s a r e n o t a l lowed f o r s p e c i f i e d drugs, e.g., a n t i b i o t i c s , c e n t r a l nervous system s t imu lan ts , n a r c o t i c s (Schedule 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, benzodiazepines.

4. D o l l a r L i m i t s : None


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 Hmes

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 owed 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


I n accordance w i t h federa 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 drugs w i l l be based upon t h e u n i t c o s t o f t h e d rug p l u s a d i spens ing fee o r the usual and customary charge t o t h e genera l p u b l i c , wh ichever i s lower .

Payment f o r over - the-counter drugs (non- legend drugs) wi l l be based upon t h e lower of e i t h e r t h e u n i t c o s t of t h e d rug p l u s 50 pe r cen t , t he usual and customary charge t o t h e genera l p u b l i c , o r t h e u n i t cos t p l u s t h e P r o f e s s i o n a l Fee f o r Serv i ce .

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 Nurs inq 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 Spec ia 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 owed 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 the upper l i m i t f o r payment f o r p r e s c r i b e d drugs w i l l be based upon t h e u n i t c o s t o f t h e d rug p l u s a d i spens ing fee o r t h e usual and customary charge t o t h e genera l p u b l i c , wh ichever i s lower.

Payment f o r over - the-counter drugs (non- legend d rugs ) w i l l be based upon t h e lower of e i t h e r t h e u n i t c o s t o f t h e d rug p l u s 50 pe r c e n t , t h e usual and customary charge t o t h e genera l p u b l i c , o r t h e u n i t cos t p l u s t h e P r o f e s s i o n a l Fee f o r Serv i ce .

The c o s t o f t h e drug t o the pharmacist 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 be based upon t h e AWP l i s t i n g s i n t h e Red Book, per 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 except f o r d i r e c t purchases f rom t h e f o l l o w i n g manufacturers :

Abbott-Ross P f i p h a r m i c s L e d e r l e P f i z e r - R o e r i g Merck Sharp & Dohme Squ i bb Parke-Davis & Co. Upjohn Warner -Ch i l co t t Wyeth

The q u a n t i t y of t h e drug dispensed on t h e o r i g i n a l p r e s c r i p t i o n would be determined on t h e b a s i s of a 30-day supp ly 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 lowed when so i n d i c a t e d by 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 maintenance drugs up t o a maximum of 100 t a b l e t s , capsules o r e q u i v a l e n t , o r a 30 days' supp ly of these drugs -- whichever i s g r e a t e r .

NPC Rhode I s l a n d - 4 1983


The f o l l o w i n g c lasses of drugs a r e cons idered as maintenance drugs:

a. A n t i - d i a b e t i c p r e p a r a t i o n s

b. An t i convu lsan ts

c . An t ihyper tens ives

d. Card iovascu lar p repara t ions , namely:

(1 ) An t i -ang ina l ( 2 ) D i g i t a l i s and t h e c a r d i a c g lycos ides

e. D i u r e t i c s

f. Hormones, i n c l u d i n g t h y r o i d p r e p a r a t i o n s

g. V i tamins, hemat in ics 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 which t h e t o t a l charge t o t h e Medical Ass is tance 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 capsules.


Copayment - No

Number o f Rx c la ims processed i n FY 1982 - 1,088,372


Rhode I s l a n d - 5 1983

O f f i c i a l s , Consu l tants and Comnit tees

1. Soc ia l and R e h a b i l i t a t i v e Serv ices Department O f f i c i a l s :

John J. A f f l e c k D i r e c t o r

Anthony B a r i l e , M.P.A. A s s i s t a n t D i r e c t o r Medical Serv i ces

John A. P a g l i a r i n i , R.Ph. C h i e f Medical Care S p e c i a l i s t

A l b e r t LaMarra, R.Ph. Medical Care Program Pharmac i s t

Cosmo F r a n c h e t t i , R.Ph. Sen ior Pharmacist

Department o f S o c i a l and R e h a b i l i t a t i v e Serv i ces

600 New London Avenue Cranston, Rhode I s l a n d 02920

2. Soc ia l and R e h a b i l i t a t i v e Serv ices Department Adv iso ry Committees:

A. Medical Ass is tance Comnittees:

( 1 ) Medical Adv iso ry Committee on Pharmacy:

D r . Heber W. Youngken, Jr., Chairman

Joan Abar, D.O. Pe te r Mathieu, M.D. V incent A l i a n i e l l o , R.Ph. Joseph Navach, R.Ph. Wal ter Carnevale, R.Ph. Hon. Anthony Soloman, John DeFeo, Ph.0. S t a t e T reasure r John DePasquale, R.Ph. I r a W e l l i n s , R.Ph. Joseph G a l i n a R ichard Yacino, R.Ph. Lou is J e f f r e y , R.Ph.

(2) Rhode l s l a n d Pharmaceut ical A s s o c i a t i o n :

Dav id P. Feeney, R.Ph., P r e s i d e n t

NPC Rhode l s l a n d - 6 1983

3 . Execu t i ve O f f i c e r s of S t a t e Medical and Pharmaceut ical S o c i e t i e s :


Norman A. Baxter , Ph.D. Execu t i ve D i r e c t o r Rhode l s l a n d Medical Soc ie ty 106 F r a n c i s S t r e e t Providence 02903 Phone: 401/331-3207

B. Pharmaceut ical Assoc ia t ion:

Judge J. S. Gendron (R.Ph.) Execu t i ve D i r e c t o r Rhode l s l a n d Pharmaceut ical Assoc ia t ion 23 Broad S t r e e t Pawtucket 02860 Phone: 401/725-4141

C. Osteopath ic Assoc ia t ion:

Reuben L. Alexander, 0.0. Secretary Rhode l s l a n d Osteopath ic Phys ic ians

and Surgeons 849 Post Road Warwick 02888 Phone: 401/781-3940

South Caro l i na - 1 1983

SOUTH CAROLINA

FEDICAL ASSISTANCE DRUG PROGRAM (TITLE X I X )


OAA AB APTD AFDC OAA AB APTD AFOC Chi ldren<21 (SFO)

P r e s c r i b e d 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 p a t i e n t H o s p i t a l Care X X X X X L a b o r a t o r y & X-ray S e r v i c e X X X X X S k i l l e d f i u rs ing Home S e r v i c e s X X X X X P h y s i c i a n Serv ices X X X X X Dental - - -

Se rv i ces X X X X X Other B e n e f i t s : Home H e a l t h Serv ices, Rura l H e a l t h C l i n i c Serv i ces , Medical T r a n s p o r t a t i o n , P o d i a t r i s t Se rv i ces , O p t o m e t r i s t s Serv i ces , C h i r o p r a c t i c S e r v i c e s , Durab le Medica l Equipment, I n te rmed ia te Care F a c i l i t i e s Serv i ces . +SF0 - S t a t e Funds Only

l l . EXPENDITURES FOR DRUGS. Payment t o Pharmacis ts by f i s c a l year end ing June 30, 1982

1981 1982 ~ x ~ e n d e d - 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 ............................... $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 Chi ld ren. . . 726,827 51,792 713,519 47,114 A d u l t s -Famil i es w/Oep Chi Idren. . ... 1,732,929 40,192 1,636,282 37,755

CATEGORICALLY NEEDY NON-CASH TOTAL.. $4,455,523 Aged ................................ 2,745,558 B l i n d ............................... 13,389 Disabled... . . ....................... 637,362 C h i l d r e n -Fami l i es w/Dep Chi ldren. . . 339,688 A d u l t s -Fami l i es w/Oep C h i l d r e n ..... 716,046 Other 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 isab led ............................ 0 C h i l d r e n -Fami l i es w/Dep C h i l d r e n ... 0 A d u l t s -Fami l i es 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


NPC South C a r o l i n a - 2 1983

II 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 Soc ia l Serv ices.


A. Exc lus ions:

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 drugs n o t l i s t e d i n t h e s t a t e ' s Medica id Formulary, as w e l l as decongestant - a n t i h i s t a m i n e combinat ions, muscle r e l a x a n t s , psyco the rapeu 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 , food supplements, v i t a m i n s , a n a l g e s t i c s and minor t r a n q u i l i z e r s . OTC i tems a re l i m i t e d t o i n s u l i n , ana lges ics and minor t r a n q u i l i z e r s , OTC i tems 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 sy r inges , and f a m i l y p l a n n i n g drugs and supp l ies .

B. Formulary:

A c losed-end fo rmu la ry i s u t i l i z e d w i t h drug code, s t r e n g t h , and d i spens ing u n i t . For drugs no t on t h e formulary , 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 requested by a t t e n d i n g p h y s i c i a n w i t h medical j u s t i f i c a t i o n .


Q u a n t i t y o f Medicat ion:

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 supp ly t o a minimum o f t e n (10) 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 (90) days supp ly i s a l l owed and encouraged.

R e f i l l s :

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 .

D o l l a r L i m i t s : None

R e c i p i e n t s a re 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 pe r month.


Medicaid reimbursement f o r pharmacy s e r v i c e s w i l l be based on t h e lower o f : t h e South C a r o l i n a Est imated 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 Soc ia l Serv ices; t h e p r o v i d e r ' s submi t ted usual 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 (cont inued) :

Copayment - Prov ide rs are au thor i zed t o c o l l e c t a CO-PAY of f i f t y cen ts ($0.50) p e r p r e s c r i p t i o n f rom the c l i e n t , except f o r c l i e n t s i n long term care f a c i l i t i e s , f a m i l y p lann ing, EPSDT, and pregnancy r e l a t e d p r e s c r i p t i o n s .


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.

Rev is ions i n t h e fo rmu la ry w i l l occur p e r i o d i c a l l y w i t h no des ignated t i m e element. The Drug Formulary Committee, composed of members appoin ted by t h e South C a r o l i n a Board o f Soc ia l Serv ices upon recommendations submi t ted by a p p r o p r i a t e p r o f e s s i o n a l medical and pharmaceut ical a s s o c i a t i o n s , i s respons ib le 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 , Consul tants and Committees


John A. Crosscope, J r . I n t e r i m Commissioner

J. Kenneth Shealy Execu t i ve 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

Paul H. Bjorkman Execu t i ve Manager, O f f i ce of Systems and In fo rmat ion

John P. Soloman Execu t i ve Manager, O f f i c e o f Program Operat ions

Robert D. F l o y d Execu t i ve Manager, O f f i c e of Support Serv ices

John D. Middlebrook Compt ro l l e r

Thomas E. Brown, J r . D i r e c t o r , O f f i c e of Community Long Term Care

Department o f Soc ia l Serv i ces

P. 0. Box 1520 Columbia, South C a r o l i n a 29202

2. S o c i a l Serv i ces Department Consul tants:

A. Phys ic ians ( P a r t - t i m e ) :

Bernard Frank, O.D. Columbia

James C . B e a l l , D.D.S. Char les ton

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 Caro l ina - 5 1983

3. Medical Care Adv iso ry Committee t o T i t l e X I X :

O ~ q a n i z a t i o n

Commissioner, S.C. Department o f H e a l t h and Environmental Con t ro l

S.C. Department of Mental H e a l t h

S.C. Department o f Mental Retardat i o n

S.C. Department of Voca t iona l R e h a b i l i t a t i o n

S.C. Human A f f a i r s Commission

S.C. Commission on Aging

Represen ta t i ve o f H e a l t h Care P lann ing Overs ight Committee

Member

Robert Jackson, M.D. Conunissioner S.C. Department o f H e a l t h and

Environmental Con t ro l 2600 B u l l S t r e e t J. Mar ion Sims B u i l d i n g Columbia 29201

M r . W i l l i a m B. F l o y d Deputy Commissioner D i v i s i o n o f F i n a n c i a l Serv i ces Department o f Mental H e a l t h 2414 B u l l S t r e e t Columbia 29201

M r . James M. K i r b y S.C. Dept. o f

Mental R e t a r d a t i o n P. 0. Box 4706 Columbia 29240

M r . Pete Howel 1 Program S p e c i a l i s t Voca t iona l R e h a b i l i t a t i o n

Department 301 Landmark Center P. 0. Box 4945 Columbia 29240

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

M r . J im Dubs Deputy D i r e c t o r S.C. Commission on Ag ing 915 Main S t r e e t Columbia 29201

Represen ta t i ve Parker E v a t t Hea l th Care P lann ina & <

Overs ight Committee S u i t e 107 B l a t t B u i l d i n g Col umbia 29201

South Carolina - 6 1983

Medical Care Advisory Committee to Title X I X (continued):

Practicing Physician

Practicing Physician

Practicing Dentist

Practicing Pharmacist

Practicing Optometrist

Practicing Pediatrician

Hospital Administrator

Nursing Home Administrator

Representative from Civil Rights Organization

Home Health Agency Representative

Gerald Anthony Wilson, M.D. Midlands Surgical Association 2226 Hampton Street Columbia 29204

John H. Cathcart, Jr., M.O. P.O. Box 130 Gaffney 29340

Richard M. Sasnett, O.D.S. 3518 Medical Drive Columbia 29203

W. Carroll Watkins, P.D. Florence Pharmacy 123 S. Dargan Street Florence 2950 1

Dr. Wayne Cannon 3519 Medical Drive Columbia 29203

0. Martin Burton, M.D. Fant at Calhoun Anderson 29621

Mr. W. H. Hudson, Administrator Oconee Memorial Hospital P. 0. Box 857 Seneca 29678

Mr. Harry Branton Administrator Dundee Nursing Home 401 By Pass Bennettsville 29412

Mrs. Alberta Rowe 1506 Holrnes Street West Columbia 29169

Edith A. Smith, R.N., M.P.H. 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

Medica l Care Adv isory Committee t o T i t l e XIX (con t inued) :

Consumer Ms. Addie Lou ise S t o r y 6814 Wakef ie ld Road Columbia 29203

Consumer

Consumer

Consumer Representat ive

P r a c t i c i n g P o d i a t r i s t

S t a t e Nurs ing Home Ombudsman (Governor 's O f f i ce )

M r . Mike Caughman 206 F i e l d s Lane Lex ing ton 29072

Mrs. Josephine C r a f t 4412 Ryan S t r e e t Columbia 29203

M r . Robert Jackson Route 2, Box 65 B l a i r 29015

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

A f f a i r s P.O. Box 5757 2221 Devine S t r e e t Columbia 29250

Edward W. Warcholak, D.P.M. 6961 S t . Andrews Road Columbia 29210

W i l l i a m V. Brad ley, NHA 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 Pendle ton S t r e e t Columbia 29201

4. Execu t i ve O f f i c e r s of S t a t e Medical and Pharmaceut ical S o c i e t i e s :


J. C. Johnson Execu t i ve V i c e Pres iden t South C a r o l i n a Medical A s s o c i a t i o n 3325 Medical Park Road Columbia 29211 Phone: 803/242-6311

NPC

Execut ive O f f i c e r s of S t a t e Medical and Pharmaceutical Soc ie t ies (continued):

Pharmaceutical Association:

Sharon Fennel l Execut ive D i r e c t o r South Carol ina Pharmaceutical Association 2026 Assembley S t r e e t , Su i te 200 Columbia 29201 Phone: 803/254-1065

Osteopathic Association:

J. W. Nichols, D . O . Secretary-Treasurer South Carol ina Osteopathic Association 3321 Medical Park Road S u i t e 401 Columbia 29203 Phone: 803/252-3301

South Carol ina - 8 1983

SOUTH DAKOTA

EDICAL ASSISTANCE DRUG P R O W (TITLE XIX)

South Dakota - 1 1983


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 ren<21 (SFO)

P r e s c r i b e d Renal Drugs X X X X D isease l n p a t i e n t Renal H o s p i t a l Care X X X X Disease O u t p a t i e n t Renal H o s p i t a l Care X X X X Disease L a b o r a t o r y & Renal X-ray S e r v i c e X X X X Disease S k i l l e d N u r s i n g Home S e r v i c e s X X X X P h y s i c i a n Renal Serv ices X X X X Disease Denta l Serv ices X X X X X X X X X *SF0 - S t a t e Funds Only

I I . EXPENDITURES FOR DRUGS. Payments t o Pharmacis ts by f i s c a l .year end ing September 30, 1982

1981 1982 Expended R e c i p i e n t

TOTAL.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $2,177,466

CATEGDRI CALLY NEEDY CASH TOTAL.. . . .. $1,133,961 Aged ................................ 459,500 B l i n d ............................... 10,271 Disabled. . .......................... 442,790 C h i l d r e n - F a m i l i e s w/Dep Chi ldren. . . 94,610 A d u l t s -Fami l i es w/Dep Children... . . 126,790

CATEGORICALLY NEEDY NON-CASH TOTAL.. $1,043,505 Aged.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 923,756 Blind...... ......................... 1,404 Disabled. . .......................... 90,274 C h i l d r e n -Fami l i es w/Dep Chi ld ren. . . 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 -Fami l i es w/Dep Chi ld ren. . . . . 0 Other T i t l e XIX R e c i p i e n t s .......... 0

Expended R e c i p i e n t

**Undupl i c a t e d T o t a l - HHS r e p o r t HCFA - 2082 31 3



S t a t e Department o f S o c i a l Serv i ces , O f f i c e o f Medical S e r v i c e s .


A. Exc lus ions: The program i s l i m i t e d t o legend 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 Med ica id 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)


1. Quan t i t y : Maintenance drugs r e q u i r i n g more than one dose per day must be dispensed i n u n i t s of a t l e a s t 100 o r a 30 day supp ly , i f more than 100 u n i t a re r e q u i r e d per 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 tems must be dispensed 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 can be i n sma l le r u n i t s . )

2. R e f i l l s : R e f i l l s of maintenance drugs c o s t i n g l e s s than $4.25 per 100 a r e l i m i t e d t o the g r e a t e r o f 100 o r a 30 day supp ly .

3. D o l l a r l i m i t s : None.

0. P r e s c r i p t i o n charge formula: Payment i s t h e lower of : ( a ) MAC p l u s d i spens ing fee of $3.00, ( b ) EAC p l u s d i spens ing fee o f $3.00, o r usua l and customary charge t o t h e genera l p u b l i c .

V. M isce l l aneous

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 :

"Cer ta in drug payments l i m i t e d t o g e n e r i c d rug form. Payment f o r t h e brand name drugs s h a l l be l i m i t e d t o the g e n e r i c drug form, un less 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 medica l reason why t h e g e n e r i c drug may n o t be used. I f t he 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 pharmacis t may document t h e p r e s c r i b e r ' s reason f o r r e q u i r i n g t h e brand name drug." (96 drugs and drug dosage forms a r e a f f e c t e d )

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 years, 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 se rv i ces . )

C. Number o f c la ims processed i n FY 1982 - 286,130

0. Average Rx p r i c e d u r i n g FY 1982 - $9.94



1. James E l I enbecker Department o f S o c i a l S e r v i c e s S e c r e t a r y P i e r r e , South Dakota 57501 Department of S o c i a l Serv i ces

E r v i n Schumacher Program A d m i n i s t r a t o r Medical Serv i ces

Donald Mahannah, R.Ph. Pharmacist Consul tant Medical Serv i ces 605/773-3495

2. Medical A d v i s o r y Committee (MAC):

L l o y d Jones, Pharmacist Jones Drug 609 S i x t h Avenue Aberdeen 57401

Paul I . Engbrecht, Nurs ing Home A d m i n i s t r a t o r A d m i n i s t r a t o r The T ieszen Memorial Home 437 S t a t e S t r e e t Mar ion 57043

Dennis Johnson, M.D., P h y s i c i a n 1301 South N i n t h , #700 Sioux F a l l s 57105

Glenn W. Robeson, D.D., Op tomet r i s t 34 T h i r d S t r e e t , SE Huron 57350

James D. M. Russe l l , H o s p i t a l A d m i n i s t r a t o r A d m i n i s t r a t o r 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. Buechler , DDS, D e n t i s t Box L Get t ysburg 57442




Rober t D. Johnson Execu t i ve Secre ta ry South Dakota S t a t e Medica l A s s o c i a t i o n 608 West Avenue Nor th S ioux F a l l s 57104 605/336-1965


Haro ld H. Schuler S e c r e t a r y South Dakota Pharmaceut i c a l A s s o c i a t i o n 222 Eas t C a p i t o l (Box 518) P i e r r e 57501 605/224-2338


G. Thompson, D.O. Secretary-Treasurer South Dakota S o c i e t y o f Osteopath ic

Phys ic ians & 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 Medica l l y Needy (MN) Other*

OAA AB APTD AFOC OAA AB APT0 AFOC Chi ldren<21 (SFO) P r e s c r i b e d Druqs X X X X ** *?c ** ** l npat i ent ~ o ; ~ i t a l Care X X X X *1 ** ** **. O u t p a t i e n t H o s p i t a l Care X X X X ** )i* ** ** L a b o r a t o r y & X-ray Serv i ce X X X X ** ** *I ;c*

S k i l l e d Nurs ing Home Serv i ces X X X X ** ** fi* NO P h y s i c i a n Serv i ces X X X X ** ** ?A ** Dental Serv i ces 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 se rv i ces ; 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 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 se rv i ces , 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 sc reen ing and t reatment (EPSD&T) *SF0 - S t a t e Funds Only ::*Caretaker over 21



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 B l i n d ............................... 307,272 1,547 336,862 1,542 ............................ Disab led 15,790,652 60,244 17,311,292 60,045 C h i l d r e n -Fami l i es w/Dep Children... 2,301,570 77,954 2,523,211 77,697 A d u l t s -Fami l i es 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 D isab led ............................ 29,788 5 0 32,657 5 0 C h i l d r e n -Fami l i es w/Oep Chi ld ren. . . 133,128 5,358 145,948 5,340 A d u l t s -Fami l i es 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 D isab led ............................ 1,468,065 6,206 1,609,440 6,186 C h i l d r e n -Fami l i es w/Dep C h i l d r e n ... 114,133 3,670 125,124 3,658 A d u l t s -Fami l i es 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,. - - -Undupl ica ted T o t a l - HHS r e p o r t HCFA - 2082 31 7

Tennessee - 2 1983


Tennessee Department o f P u b l i c Heal th .


A. General Exc lus ions: OTC drugs (except i n s u l i n ) , a n o r e t i c drugs (excep 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 narco lepsy and t h e h y p e r k i n e t i c c h i l d ) .

B . Formulary: "Tennessee Med ica id Drug Formulary", C losed /Res t r i c ted Formulary. For i n f o r m a t i o n con tac t :

M a r i l y n 8 . Ekstam, D.Ph. D i r e c t o r o f Pharmacy Serv ices Med ica id A d m i n i s t r a t i o n 283 P l u s Park Boulevard N a s h v i l l e , Tennessee 37217 615/361-6705


1. Terminology: May p r e s c r i b e and d ispense brand name drugs b u t encourage usage o f gener i c drugs f o r p o t e n t i a l c o s t savings.

2. Q u a n t i t y o f Med ica t ion :

a. One month '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 pe r month.

3. R e f i l l s : 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.


5. MAC (Maximum A l l o w a b l e Cost) drugs i n a d d i t i o n t o federa l M A C drugs. Approved Manu fac tu re 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 fee of $3.25 maximum, o r usual and customary - whichever i s lower ( e f f e c t i v e 7/1/82).

Tennessee - 5 1983

Med ica id Medical Care Adv iso ry Committee (con t inued) :

Hays M i t c h e l l , M.O. B r a d l e y Medical Center Cleveland, TN 37311 (472-6551)

Dav id L i l l a r d L i l l a r d ' s Pharmacy 81 Nor th T i l lman S t r e e t Memphis, TN 38111

B i l l McCaskel l Trevecca H e a l t h Care Center 329 Murf reesboro Road N a s h v i l l e , TN 37210 (244-6900)

Imogene Kaserman, R.N. 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 Fami l y Nurse C l i n i c a n Metro 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. 300 Bryan t S t . S m i t h v i l l e , TN 37166 (597-4737)

Thomas L. Adams R e t a i l C le rks Union,

Loca l 1557 203 N o r t h 11 th 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 2300 Wi lson S t r e e t Apt. 6-A Chattanooga, TN 37406 (629-0765)

P h y s i c i a n ( R u r a l )

Pharmacist

A d m i n i s t r a t o r

Nurse

Nurse

D e n t i s t

Consumer

Consumer (Med ica id r e c i p i e n t )

Tennessee - 4 1983

O f f i c i a l s , Consul tants and Cornnittees

1. H e a l t h Department:

A. O f f i c i a l s :

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 le , Tennessee 37219

M a r i l y n 6. Ekstam, D.Ph. Medica id 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 Boulevard

Serv ices N a s h v i l l e 37217 615/361-6705

Sandra J. Danie l D i r e c t o r

B i l l y W . Huf f ines D i r e c t o r , D i v i s i o n of

Medical Ass is tance - Medica id

Peggy A. Alsup, M.D., Bureau Medical D i r e c t o r

B. Medica id Medical Care Adv isory Committee:

F i f t e e n members appo in ted by the Governor f o r three-year terms (excep 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 Services; seven members s h a l l be rep resen ta t i ves 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 Medica id r e c i p i e n t s , l abor unions, HMO's, e tc . ) ; and seven members s h a l l be Medica id 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 rom an urban area, one nurse, one d e n t i s t , one pharmacist , 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

Edward W. Reed, M.O. Chrmn. 975 Thomas S t r e e t Memphis, TN 38107 (527-4484)

Sammie Lynn Puet t 11 1 Seventh Avenue, N o r t h N a s h v i l l e , TN 37203 (741-3241)

REPRESENTATION

P h y s i c i a n (Urban)

Commissioner Tennessee Department o f

Human Serv ices

Tennessee - 5 1983

Med ica id Medica l Care A d v i s r y Committee (con t inued) :

Hays M i t c h e l l , M.D. B r a d l e y Medica l Center C leve land, TN 37311 (472-6551 )

D a v i d L i l l a r d L i l l a r d ' s Pharmacy 81 Nor th T i l l m a n S t r e e t Memphis, TN 38111

P h y s i c i a n ( R u r a l )

Pharmacist

B i l l McCaskell A d m i n i s t r a t o r Trevecca H e a l t h Care Center 329 Murfreesboro Road N a s h v i l l e , TN 37210 (244-6900)

Imogene Kaserman, R.N. 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 F a m i l y Nurse C l i n i c a n Met ro H e a l t h Department E a s t S t a t i o n 1015 E. T r i n i t v Lane

J e r r e Hale, D.D.S. 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 R e t a i l C l e r k s Union,

Local 1557 203 Nor th 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 2300 Wi lson S t r e e t Apt. 6-A Chattanooga, TN 37406 (629-0765)

Nurse

Nurse

D e n t i s t

Consumer

Consumer (Med ica id r e c i p i e n t )

Tennessee - 6 1983

Medica id Medical Care Adv isory Comni t t e e (con t inued) :

B e t t y R. Tenpenoy 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 D i r e c t o r , B e n e f i t s Nor the rn Telecom, Inc. 259 Cumberland Bend Met ro Center N a s h v i l l e , TN 37228 (256-5900)

John Watson U n i t e d Way o f Greater

Memph i s 3489 Poplar Ave. Su i t e One Memphis, TN 38111


Consumer (HMO Represen ta t i ve )

Consumer (Labor Represen t a t i v e )

2. Medica id Formulary Adv isory Comnittee:

E i g h t members appoin ted by t h e Commissioner f o r three-year terms ( i n i t i a l terms w i l l be staggered). F i v e members w i l l be pharmacis ts . Each ~ h a r m a c i s t member w i l l be s e l e c t e d f rom nominat ions submi t ted bv t h e Tennessee Pharmaceut ical Assoc ia t ion. 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 nominat ions submi t ted by t h e Tennessee Medical Assoc ia t ion . Members should be f a m i l i a r w i t h t h e Medica id program - p r e f e r a b l y e n r o l l e d p rov ide rs .

MEMBERS OCCUPATION

Hor ton Jones Jones Pharmacy 14th and Buchanan S t r e e t N a s h v i l l e , TN 37208

T e r r y Br imer , Pharm.D. D o c t o r ' s H o s p i t a l Pharmacy 726 McFarland Avenue Morr istown, TN 37813

Jan ie Robbins, D.Ph. Hami l ton County Nurs ing Home 2626 Walker Road Chattanooga, TN 37421

Community Pharmacist

C l i n i c a l and l n s t i t u t i o n a l Pharmacist

I n s t i t u t i o n a l Pharmacist

NPC Tennessee - 7 1983

Medica id Formulary Advisory Connni t t e e (con t inued) :

Ray Marcrom, Pharm.D. Marcrom's Pharmacy 1277 McArthur S t r e e t Manchester, TN 37355

E a r l Marsha l l , D.Ph. Hollywood Pharmacy Mart, Inc. 903 Hollywood Jackson, TN 38301

Stephen S c h i l l i g , M.D. M e t r o p o l i t a n Board o f H o s p i t a l s 72 Hermitage Avenue Nashvi I l e , TN 37210

Char les W. White, M.D. 14 H o s p i t a l D r i v e Lexington, TN 38351

C e c i l E. Russe l l , Jr., M.D. Route 5, Emory Road Powe 11, TN 37849



Phys ic ian M idd le TN

Phys ic ian West TN

Phys ic ian

3. Execut ive O f f i c e r s of S ta te Medical and Pharmaceut ical S o c i e t i e s :

A. Medical Assoc ia t ion : 8. Pharmaceut ical Assoc ia t ion :

L. H. W i l l i a m Execut ive D i r e c t o r TN Medical A s s o c i a t i o n 112 Lou ise Avenue N a s h v i l l e 37203 Phone: 615/327-1451

C . Osteopath ic Assoc ia t ion :

Tom C. Sharp, J r . Execu t i ve Secre ta ry TN Pharmaceut ical Assoc. 226 C a p i t o l Blvd.,

S u i t e 308 N a s h v i l l e 37219 Phone: 615/256-3023

P. G . Smith, D.O. Secretary-Treasurer Tennessee Osteopath ic Medical Assoc ia t ion 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 )


Type o f B e n e f i t C a t e q o r i c a l l y Needy Medica l l y Needy (MN) Other* OAA AB APTD AFDC OAA AB APTD AFDC C h i l d r e n t 2 1 (SFO)

P r e s c r i b e d

l npa t i e n t H o s p i t a l Care 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 L a b o r a t o r v & X-ray S e r v i c e X X X X S k i l l e d N u r s i n g Home S e r v i c e s X X X X P h y s i c i a n Serv ices X X X X Denta l Serv ices X X X Other 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 lens; 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 glasses; h e a r i n g a i d s . *SF0 - S t a t e Funds Only

I I . EXPENDITURES FOR DRUGS. Payment t o Pharmacis ts by f i s c a l year end ing Auqust 31, 1982



TOTAL ............................... $74,124,421 565,757'"

..... CATEGORICALLY NEEDY CASH TOTAL. $54,441,647 493,464 Aged ................................ 29,720,464 150,763 B l i n d ............................... 536,463 3,237 D isab led ............................ 13,334,311 77,281 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 ... 4,852,586 174,816 A d u l t s - F a m i l i e s w/Dep Chi ldren. . . . . 5,997,823 90,915

CATEGORICALLY NEEDY NON-CASH TOTAL.. $19,682,774 87,823 Aged ................................ 17,760,135 64,322 B l i n d ............................... 20,491 8 0 D isab led ............................ 1,514,513 5,985 C h i l d r e n - F a m i l i e s w/Dep Ch i ld ren . . . 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 B l i n d ............................... 0 0 D isab led ............................ 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 es 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


Texas - 2 1983


Vendor drug program was implemented September 1, 1971.

Texas Department o f Human Resources.


Pharmacy s e r v i c e s under t h e vendor drug program i n c l u d e t h e d i spens ing o f most legend drugs and c e r t a i n non-legend drugs t o e l i g i b l e r e c i p i e n t s . Only pharmaceut ica ls wh ich meet t h e FDA requirements, a r e approved 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 rug program, may be supp l ied.

C e r t a i n OTC drugs a r e covered on a p r e s c r i p t i o n b a s i s except as o t h e r w i s e p r o v i d e d i n t h e reimbursement fo rmula and vendor 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 Exc lus ions (d iseases, drug c a t e g o r i e s , e tc . ) : 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 combinat ions, amphetamines and o b e s i t y c o n t r o l drugs, app l i ances , du rab le medica l equipment (bedpans, e t c . - e i t h e r r e n t a l o r purchase), e l a s t i c s tock ings , exper imen ta l drugs, f e r t i l i t y agents, f i r s t a i d supp l ies , foods, f o o d supplements o r a d d i t i v e s , immunizing agents, medical supp l ies , oxygen, suppor ts and suspensor ies, syr inges, needles and t russes .

6 . Formulary: None. However, t h e Texas Drug Code Index i s u t i l i z e d f o r p roduc 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 those drugs which a r e covered 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 Mar t i nez , Jr . , R.Ph. D i r e c t o r , Product Enro l lment , Vendor Drugs Texas Department of Human Resources P.O. Box 2960 (541-A) Aus t in , Texas 78769 512/835-0440, e x t . 2595


1. Q u a n t i t y o f Medicat ion: P r e s c r i b e d q u a n t i t y cannot exceed a s i x month supp ly .

2. R e f i l l s : 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' supp ly .

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 medicat ion:

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 spens ing fee up t o a maximum o f $3.73 per p r e s c r i p t i o n ( range $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 usual and customoary t o t a l p r i c e , whichever i s lower.

A c q u i s i t i o n Cost: Cur ren t Red Book cos 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 wholesa le o r d i r e c t c o s t as i n d i c a t e d by t h e p r o v i d e r .

2 . I n s u l i n and approved non-legend drugs on p r e s c r i p t i o n : pharmac is ts and d i spens ing p h y s i c i a n s w i l l be re imbursed on t h e bas is o f usual charges t o t h e general p u b l i c o r c o s t p l u s 50% of c o s t , whichever i s lower; 50% o f c o s t no t t o exceed ass igned v a r i a b l e d i spens ing fee.

V. M isce l l aneous Remarks:

The d i spens ing fee, which inc ludes 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 account ing and s e r v i c e e v a l u a t i o n o f t h e expenses i n v o l v e d i n d i spens ing 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 no t exper ience a l l c o s t and s e r v i c e f a c t o r s cons ide red i n a r r i v i n g a t t h e fee , may be l e s s than t h e maximum a l l o w a b l e fee.

Copayment - None.

Number of c la ims processed i n FY 1982 - 6.5 m i l l i o n


*Plus S.06 i f on tape. P l u s $.08 p a t i e n t p r o f i t s P lus S.08 d e l i v e r y s e r v i c e P lus S.03 emergency s e r v i c e P lus S.03 c o n t i n u i n g educa t ion

NPC Texas - 4 1983


1 . Department of Human Resources O f f i c i a l s :

M a r l i n W. Johnston Comm i ss i oner

Mer le E. Spr inger Deputy Commissioner

Jack B lan ton Execut ive A s s i s t a n t

R. K. Pendergrass, H.D. Spec ia l A s s i s t a n t f o r H e a l t h

A f f a i r s

M a r t i n Duk ler 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

D r . Jan ice Caldwel l Assoc ia te Comnissioner

Serv ices t o Aged & D isab led

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 Serv ices t o Aged and D isab led

Claims Department (Vendor Drug Program) :

Texas Department of Human Resources

Post O f f i c e Box 2960 Aust in , Texas 78769

W. B. Barner, R.Ph., D.Ph. Program S p e c i a l i s t 512/835-0440, ex t . 2594

Raul Mar t inez, Jr., R.Ph. S t a f f S p e c i a l i s t 512/835-0440, e x t . 2595

NPC Texas - 5 1983

2 . Execu t i ve O f f i c e r s o f S ta te Medical and Pharmaceut ical S o c i e t i e s :


C. L i n c o l n W i l l i s t o n Execu t i ve D i r e c t o r Texas Medical A s s o c i a t i o n 1801 N. Lamar Boulevard A u s t i n 78701 Phone: 512/477-6704


Lu ther R. Parker Execu t i ve O i r e c t o r Texas Pharmaceut ical Assoc. P. 0. Box 14706 1624 East Anderson Lane A u s t i n 78761 Phone: 512/836-8350


Tex Rober ts Execu t i ve D i r e c t o r Texas Osteopath ic Medical Assoc ia t ion 226 B a i l e y Avenue F o r t Worth 76107 8 l7/336-05'+9

UTAH

Utah - 1 1983

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 Medical 1 y Needy (MN) Other*

OAA AB APTD AFDC OAA AB APTD AFDC Chi ldren<21 (SFD) P r e s c r i b e d Druqs X X X X X X X X X X l npat i en t ~ o i ~ i t a l Care X X X X X X X X X X O u t p 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 Labora to rv & X-ray Serv ice X X X X X X X X X X S k i l l e d Nurs ing Home Serv ices X X X X X X X X X X P h y s i c i a n s e r v i c e s X X X X X X X X X X Dental Serv i ces X X X X X X X X X X Other Bene f i t s : Home heal th , c l i n i c se rv i ces , t r a n s p o r t a t i o n , f a m i l y p lann ing; medical supp l ies , E a r l y P e r i o d i c Screening f o r Ch i ld ren ; 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 , osteopaths, o p t o m e t r i s t s and a u d i o l o g i s t s . *SF0 - S t a t e Funds Only

I I . EXPENDITURES FOR DRUGS. Payment t o Pharmacists b y f i s c a l year end ing September 30, 1982

1981 1982 Expended

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 Ch i ld ren . .. 393,829 A d u l t s -Fami l i es w/Dep Children..... 719,807

CATEGORICALLY NEEDY NON-CASH TOTAL.. $717,176 Aged ................................ 394,046 B l ind . . ............................. 4,206 Disabled............................ 230,776 C h i l d r e n -Fami l i es w/Dep C h i l d r e n ... 35,742 A d u l t s -Fami l i es 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 Bl ind. . . . ........................... 614 Disabled...................... ...... 284,984 C h i l d r e n -Fami l i es w/Dep C h i l d r e n . .. 15,118 A d u l t s -Fami l i es w/Dep C h i l d r e n . .... 45,360 Other T i t l e X I X R e c i p i e n t s .......... 51,830

R e c i p i e n t Expended R e c i p i e n t

**Undupl icated T o t a l - HHS r e p o r t H A - 2082 $59

NPC Utah - 2 1983


D i v i s i o n o f H e a l t h Care Financing, S ta te Department of Heal th .


General Exc lus ions: V i tamins, (except f o r expectant mothers and c h i l d r e n t o age 51, anorec t i cs ; (except 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 narco lepsy and t h e hyperk ines is . ) Other c a t e g o r i e s - minor 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, non- formulary drugs.


1. Q u a n t i t y o f Medicat ion: I n genera l , t h e q u a n t i t y o f med ica t ion s h a l l be l i m i t e d t o a supply n o t t o exceed 30 days except f o r 9 D s u s t a i n i n g " drugs, f o r which a 100-day supply i s au thor i zed .


1 . Lowest o f : EAC/MAC Cost p l u s p r o f e s s i o n a l fee of $3.25, or usual and customary charges t o t h e p r i v a t e sec to r .

2. Reduced Fee: For 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 pharmacist 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 no 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 se lec ted gener i c l i s t i n g of approx imate ly 500 dosage forms o f drugs f o r which t h e program has s e t t h e re imbursab le p r i c e i s i nc luded i n t h e Utah T o t a l Drug Index.

Utah - 3 1983


1. Department o f Hea l th O f f i c i a l s :

James 0. Mason, M.D., D i r e c t o r

M e l v i n M. Owens, Deputy D i r e c t o r Department o f Hea l th

Sharon Wasek, D i r e c t o r D i v i s i o n o f Hea l th Care F inanc ing

RaeDell Ashley Manager, Program Operat ions

and Medical De te rm ina t ion

Department of Hea l th 150 West N o r t h Temple S a l t Lake C i t y , Utah 84103

2. Department o f Soc ia l Serv ices 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 Serv i ces E n t i t l e m e n t s 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 Ass is tance Payments

3. H e a l t h Department c o n s u l t a n t s :

A. Phys ic ians:

Haro ld E. Merkley, M.D.

Char les Park in , DMD

Car los Madsen, M.D.

2020 South 13 th East S a l t Lake C i t y 84105

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

1445 East 33 rd South S a l t Lake C i t y 84106

Joseph Halgren, M.D.

Utah - 4 1983



J. Leon Sorenson Execut ive D i r e c t o r Utah S t a t e Medical Assoc. 540 East 5 t h South S a l t Lake C i t y 84102 Phone: 801 /355-7477

0 . Pharmaceut ical Assoc ia t ion :

C. N e i l Jensen Execu t i ve D i r e c t o r Utah Pharmaceutical Assoc. 1062 East 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


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


Agency of Human Services.


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.


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


Agency of Human Serv ices:

L l o y d Nov ick S e c r e t a r y

S o c i a l Wel fare Department:

Dav id Wi lson Commissioner

Paul Ohlson Deputy Commissioner

Elmo A. Sassorossi D i r e c t o r Medica id D i v i s i o n

James B a r r e A s s i s t a n t D i r e c t o r Medica id D i v i s i o n

Char les P e r r y Ch ie f o f P o l i c y E E v a l u a t i o n 802/241-2880

Agency o f Human Serv ices 103 S. Main S t r e e t Waterbury 05676

Medica id Pharmacy Peer Review Committee:

~ e ~ a r t m e n t o f S o c i a l Wel fare 103 S. Main S t r e e t Waterbury 05676

Michael S c o l l i n s , M.D., Chairman Department of S o c i a l Wel fare Medica id D i v i s i o n 103 South Main 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



Rober t Vaut i e r Execu t i ve D i r e c t o r 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


P h i l i p J. O ' N e i l l Execu t i ve Secre ta ry Vermont Pharmaceut ical Assoc ia t ion P. 0. Box 926 Benn i n g t o n 05201 Phone: 802/442-5943


Les te r H. L o v e l l , D.O. Secretary-Treasurer Vermont S ta te A s s o c i a t i o n Osteopath ic

Phys ic ians and Surgeons, Inc. R.F.D. #3 B r a t t l e b o r o 05301 802/254-2944

VIRGIN ISLANDS

V i r g i n I s l a n d s - 1 1983

EDICAL ASSISTANCE DRU6 PROGRAH (TITLE X I X )


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 renc21 (SFO)

P r e s c r i b e d Drugs X X X X X X X X X X l npat i en t H o s p i t a l Care X X X X X X X X X X O u t p 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 Labora to ry 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 Nurs ing Home Serv ices X X X X X X X X X X P h y s i c i a n Serv ices X X X X X X X X X X Dental Serv i ces 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 serv ices; EPSDT; c l i n i c se rv i ces , p r o s t h e t i c dev ices and dentures; 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 Only

I I . EXPENDITURES FOR DRUGS. Payment t o Pharmacis ts by f i s c a l year ending September 30, 1982

1981 1982 ~ x ~ e n d e d - 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...............................

CATEGORICALLY NEEDY CASH TOTAL...... Aged ................................ Blind...... ......................... Disabled.. ..........................

.. C h i l d r e n -Fami l i es w/Oep Ch i ld ren . A d u l t s -Fami l ies w/Dep Children.....

CATEGORI CALLY NEEDY NON-CASH TOTAL.. Aged ................................ B l i n d . . ............................. Disabled............ ................ C h i l d r e n -Fami l i es w/Dep Children... A d u l t s -Fami l ies 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 -Fami l ies w/Dep Ch i ld ren . .. .... A d u l t s -Famil i c s w/Dep Ch i ld ren . .......... Other T i t l e XIX R e c i p i e n t s

337

Not A p p l i c a b l e

V i r g i n I s l a n d s - 2 1983


Department o f Heal th .


Broad coverage as p rov ided by p u b l i c medical 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 rug i s no t a v a i l a b l e a t t h e p u b l i c medical f a c i l i t y o r designated 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 pharmacists a c t u a l c o s t p l u s a $2.40 d ispens ing fee, except i n i n s t i t u t i o n s where drugs a r e inc luded i n t h e reimbursement formula, o r except where a p u b l i c agency makes b u l k purchases o f drugs i n accordance w i t h s t a t u t e s or r e g u l a t i o n s govern ing such purchases.

NPC V i r g i n l s l a n d s - 3 1983


A. H e a l t h Department:


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 Amal ie S t . Thomas V i r g i n l s l a n d s 00801

Jeanne t te A. Mahoney, A.C.S.W., M.P.H.

D i r e c t o r , H e a l t h lnsurance and Medica l Ass is tance

2. Medica l Care Adv iso ry Committee:

Roy L. Schneider, M.D., - Commissioner o f H e a l t h (ex o f f i c i o )

Jeanne t te A. Mahoney,

B. S o c i a l We l fa re Department O f f i c i a l :

Gwendolyn C. B lake (Mrs.) Commissioner

- D i r e c t o r , H e a l t h lnsurance and Medica l Ass is tance ( e x o f f i c i o )

Department of S o c i a l Welfare C h a r l o t t e Amal ie S t . Thomas 00801

C. Execu t i ve 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 ion :

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

E D 1 CIU ASSISTAWE DRUG PROGRAM (TITLE XIX)

V i r g i n i a - 1 1983


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 ldren<21 (SFO)

P r e s c r i b e d Druqs X X X X X X X X X l noat i en t r

H o s p i t a l Care X X X X X X X X X O u t p a t i e n t H o s p i t a l Care X X X X X X X X X Labora to ry G X-ray S e r v i c e X X X X X X X X X Sk i l l e d N u r s i n g Home Serv ices X X X X X X X X X P h y s i c i a n Serv ices X X X X X X X X X Dental Serv ices 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 Only

I I . EXPENDITURES FOR DRUGS. Payment t o Pharmacists by f i s c a l year ending September 30, 1982


............................. 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 B l i n d . . ............................. 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 -Fami l i es w/Dep Chi ldren. . . 2,099,860 82,714 2,071,692 78,037 .... A d u l t s -Fami l ies w/Dep Chi ldren. 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 2 2 Disabled.. .......................... 188,227 626 227,513 645 C h i l d r e n -Fami l i es w/Dep Chi ldren. . . 17,726 859 25,593 1,046 A d u l t s -Fami l ies 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 -Fami l i es w/Dep Chi ldren. . 177,875 6,874 199,944 7,466 ... A d u l t s -Fami l i es w/Dep Chi ldren. . 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


V i r g i n i a - 2 1983


By t h e D i v i s i o n o f Medical Assistance, S t a t e H e a l t h Department. E l i g i b i l i t y d e t e r m i n a t i o n by the Department o f Soc ia l Serv i ces .


A. General Exc lus ions (d iseases, drug ca tegor ies , e t c . ) : Non-legend drugs except f a m i l y p l a n n i n g drugs 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 drugs. ( A l l d rugs 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 u rged t o p e r m i t use o f drugs appear ing i n t h e V i r g i n i a Vo lun ta ry Formulary.


1. Q u a n t i t y of Medicat ion: Phys ic ians requested t o p r e s c r i b e maintenance drugs 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 supply, o r 100 un i t s o r doses.

2. R e f i l l s : Phys ic ians 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 requ i rements.

0. P r e s c r i p t i o n Charge Formula:

S ta te Reimbursement - E f f e c t i v e J u l y 1, 1982, based upon t h e lower o f :

Est imated A c q u i s i t i o n Cost (EAC) p l u s $2.85 minus app l i cab1 e co-pay/Rx - Maximum A l lowab le Cost (MAC) p l u s $2.85 minus app l i c a b l e co-pay/Rx -

to-payment

$0.5D/Rx f o r wh ich t h e S ta te pays $10 o r l e s s $l.OO/Rx f o r wh ich t h e S t a t e pays more than $10 (Exc lus ions , under 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 )

Uni t -Dose

Usual and customary 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 V i r g i n i a - 3 1983


Note: 1. A l l p r o v i d e r s o f un i t -dose must be c e r t i f i e d by Medica id - program - f o r computer purposes.

2. Uni t -dose a p p l i e s on ly t o t a b l e t s and capsules dosage forms.

On o r about October 1, 1982 (For Nurs ing Home P a t i e n t s )

Each t a b l e t o r capsule repackaged:* ......... Packaging al lowance $1.57/dose . . P l u s an a d d i t i o n a l ........ .$l.OO/dose

(Whether o r no t pharmacist repackaqed t h e dose) - *L iqu ids , e tc . a r e - n o t inc luded

Nurs ing Homes

EAC/MAC p l u s $2.85 fee (Copay does n o t app ly)

0-T-CS

Lower of cos t and markup ( u s u a l l y 50%) o r usual

Maximum Al lowable Cost Drugs

and customary p r i c e .

( S t a t e MACed - Non-leqend 0-T-CS) - Acetaminophen Table ts , Acetaminophen E l i x i r , Oimenhydr inate Table ts , Oocusate Sodium Capsules, Oocusate Sodium Syrup, Docusate Sodium w/Casanthranol capsules and Ferrous S u l f a t e Table ts .

P r e s c r i p t i o n Payment L i m i t a t i o n

One monthly p r e s c r i p t i o n fee per legend drug dispensed.

V. Misce l laneous

S ta te MAC Program - Yes, 42 drugs.

Number of c la ims processed i n FY 1982 - 3,515,863



The Computer Company (TCC) P.O. Box 6987 Richmond, V i r g i n i a 23230

V i r g i n i a - 4 1983


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

James B. Kenley, M.D. Commissioner

Bruce U. Kozlowski A s s i s t a n t Commissioner Of f i ce of Medical Ass is tance

Mary Ann Johnson, R.Ph. (Mrs.) Pharmaceut ical Consul tant

Malcolm 0. Perk ins 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 Operat ions &

P r o v i d e r Serv ices O f f i c e o f Medical Ass is tance 804/786-778 1

S t a t e Department o f H e a l t h Richmond, V i r g i n i a 23219

2. Governor 's Adv iso ry Committee on Medicaid:

Medica l 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.

109 Governor S t r e e t , 8 t h F l o o r Richmond 23219

Blue 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. Bargatze P r a c t i c e

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 Denta 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 Harry L. Hodges, D.D.S. Bar ry Shipman, D.M.D.

P r i v a t e Insurance C a r r i e r s John L. T u t t l e

Medical School Represen ta t i ve Gary G. Suter , M.D.

V i r g i n i a H e a l t h Care Assoc. James K. Meharg, J r .

V i r q i n i a Pharmaceut ical Assoc. Thomas A. Abbot t , R.Ph. James V. Morgan, R.Ph.

P a r t i c i p a n t s ' A d v i s o r y Counc i l Mary 6 . Evans Grace Johnson Mamie K ing Jane Melgard

V i r g i n i a Nurses A s s o c i a t i o n Lucy H. Woh l fo rd

Virginia - 5 1983

Governor's Advisory Comrni ttee on Medicaid (continued):

Ex Off icio

William L. Lukhard Commissioner

Joseph J. Bevilacqua, Ph.D. Corn i ss i oner

James 0 . Kenley, M.D. Connnissioner

Social Services Department Officials:

Wi I 1 iam L. Lukhard Commissioner

State Department of Welfare

State Department of Mental Health and Mental Retardation

State De~artment of Health

State Department of Welfare 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

Washington - 1 1983

K O 1 CM ASSISTANCE DRUG PROGRAM (TITLE X I X )


OAA AB APTD AFDC a OAA AB APTD AFDC Chi ldren<21# (SFO) Presc r ibed Drugs X X X X X X X X X X X l n ~ a t i en t - ~ o & ~ i t a l Care X X X X X X X X X X X O u t p 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 X Labora to rv & X-ray Serv ice X X X X X X X X X X X S k i l l e d Nurs ing Home Serv ices X X X X X X X X X X X P h y s i c i a n ~e;v i ces X X X X X X X X X X X Dental Serv ices 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 fos te rca re , subs id i zed adopt ion, SNH, IFC, ICMR o r i n p a t i e n t p s y c h i a t r i c f a c i l i t y . *SF0 - S t a t e Funds Only


1981 1982 Expended R e c i p i e n t

TOTAL ............................... $19,380,214 209,566**

CATEGORICALLY NEEDY CASH TOTAL...... $12,059,486 171,422 Aged ................................ 3,264,070 18,201 B l ind. . . . ........................... 48,361 304 Disab led ............................ 4,402,004 22,702 C h i l d r e n -Fami l i es w/Dep C h i l d r e n ... 1,840,817 80,508 A d u l t s -Fami l i es w/Dep Children... . . 2,504,234 51,188

CATEGORICALLY NEEDY NON-CASH TOTAL.. $5,398,512 22,360 Aged ................................ 4,330,768 17,710 B l i n d ............................... 12,277 59 Disabled.... ........................ 1,051,810 4,570 C h i l d r e n -Fami l i es w/Oep Ch i ld ren . .. 1,211 9 3 A d u l t s -Fami l i es w/Oep Ch i ld ren . .... 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 Disabled. . .......................... 547,608 3,064 C h i l d r e n -Fami l i es w/Dep Chi ldren. . . 331,503 17,101

... A d u l t s -Fami 1 i e s w/Dep Chi ldren. . 134,154 3,661 .......... Other T i t l e XIX R e c i p i e n t s 0 0

Expended R e c i p i e n t


NPC Washington - 2 1983


By D i v i s i o n o f Medical Ass is tance, Department o f S o c i a l and H e a l t h Serv ices. The l o c a l Medical Consul tants rev iew t h e need f o r non- formulary drugs.

IV . P r o v i s i o n s R e l a t i n g t o Presc r ibed Drugs:

A. General Exc lus ions: Medic ine chest drugs a r e n o t provided. Non-formulary drugs are p rov ided i n an emergent l i f e -endanger ing s i t u a t i o n and/or m e d i c a l l y mandatory.

B. Formulary: Inc ludes 2,800 l i s t i n g s by drug product name, q u a n t i t y , dosage form and s t reng th . Formulary i s r e v i s e d 2 t o 3 t imes annua l l y .


1. Q u a n t i t y o f Medicat ion: Some minimums and maximums s t i p u l a t e d .

2. R e f i l l s : No more than 2 r e f i l l s i n any 30-day p e r i o d un less 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 100 's .

3. D o l l a r L i m i t s : S t a t e and Federal 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 no t exceed t h e usual and customary charge t o t h e p u b l i c o r the maximum a l lowed by t h e department.

The maximum charge t o t h e department i s t o be es t ima ted a c q u i s i t i o n cos t (EAC) ( a s determined by t h e D i v i s i o n of Medica l Ass is tance) p l u s a d ispens ing fee f o r se rv i ce .

$3.33 - U n i t dose systems (Nurs ing 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. Misce l laneous

Copayment - None. S t a t e MAC - 120 drugs ( e x c l u d i n g federa l MAC) Claims process ing agent: Consultec, Inc .

P.O. Box 9245 M a i l Stop LG-11 A i r d u s t r i a l Park Tumwater, Washington 98504

Number of Rx c la ims processed i n FY 1982 - 2,223,062


Washington - 3 1983


1. S o c i a l and H e a l t h Serv ices Department O f f i c i a l s :

A lan J. Gibbs Sec re ta ry

Gera ld J. Rei l l y D i r e c t o r

Wesley M. Brock, M.D. A c t i n g Medical D i r e c t o r

W i l l i a m P. Pace, R.Ph. Pharmacist Consu l tan t

Department o f Soc ia l and H e a l t h Serv i ces

08-44 Olympia, Washington 98504

D i v i s i o n o f Medical Ass is tance

LK-11 Olympi a 98504

O f f i c e o f Medical P o l i c y and Procedure

LK-11 Olympia 98504

O f f i c e o f Medical P o l i c y and Procedure

LK-11 Olympia 98504

2. Soc ia l and H e a l t h Serv ices Department Medical Consu l tan ts ( a t county l e v e l ) :

A. F u l l - t ime: Loca l O f f i c e

Norman Meckst ro th , M.D. Spokane

Edward P. Palmason, M.D. RMU - S e a t t l e P o r t Angeles P o r t Townsend

Joseph F. Powers, M.D. P i e r c e Cen t ra l

B. P a r t - t i m e

Wal ter A . Boyle, M.O. Robert B r i g h t , M.D. Raymond J. Bunker, M.D. Cary H. Coppock, M.D. L y l e J. Cowan, M.D. Lowel l L. Eddy, M.D. Lawrence N. E t t e l s o n , M.O. Ernest Ey t inge , M.D. Bur ton A. Foote, M.D. Mark Gabr ie lson, M.D. Mark Gabr ie lson, M.D.

Kel so Bremerton Wenatchee P i e r c e C e n t r a l Omak/Okanogan RMU - S e a t t l e RMU - S e a t t l e E v e r e t t E l 1 ensburg Be1 l ingham Mount Vernon

Washington - 4 1983

S o c i a l and H e a l t h Serv ices Department Medical Consu l tan ts P a r t - t i m e ( c o n t i nued:

A r n o l d J. Herrmann, M.D. Michael H. H igg ins , M.D. Paul Johnson, M.D. Kenneth H. K inard, M.D. Je f ferson D. Kyle, M.D. A l b e r t V. M i l l s , M.D. A l b e r t V. M i l l s , M.D. James A. Moore, M.D. James A. Moore, M.D. Clarence Olson, M.D. Glen L. Shearer, M.D. Glen L. Shearer, M.D. Glen L. Shearer, M.D. Car l C. Wal ters , M.D. John A. Walz, M.D.

P i erce Cen t ra l Spokane RMU - S e a t t l e E v e r e t t Spokane Pasco Wal la Wal la Aberdeen South Bend RMU - S e a t t l e Olympia Chehal i s Shel ton Yakima Vancouver

(Denta l ) Howard 0 . Henderson, D.M.D. O f f i c e of Medical 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 Medica l D i r e c t o r , Olympia

( P o d i a t r y ) Robert E. Wendel, D.P.M. RMU - S e a t t l e

3. Department of S o c i a l and H e a l t h Serv ices 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, (Chai rperson) 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 (206) 382-9800 Term Expi res : 9/30/83

John A. Beare, M.D. D i r e c t o r DSHS-Division o f H e a l t h M a i l Stop ET-21 O l yrnpia 98504

David A. Cox, R.Ph. South Bend Term Expi res : 7/30/84

Mary E. Coyne S e a t t l e Term Expi res: 9/30/83

H a r r i e t J. Greenwood S e a t t l e Term Expi res : 7/30/85

Robert A. Jacobs, D.D.S Edmonds Term Expi res : 7/30/86


Department o f Soc ia l and Hea l th Serv ices T i t l e X I X Adv iso ry Committee (con t inued) :

Robert I. J e t l a n d Gary McFaddon, M.D. A d m i n i s t r a t o r S e a t t l e Harborview Medical Center Term Expi res : 7/1/84 S e a t t l e Term Expi res : 7/30/85 Chr is G. Stevenson

Richmond James Johnson Term Expi res : 7/30/84 Pasco Term Expi res : 7/30/84

Ivan C. LeCompte, M.D. Pasco Term E x ~ i r e s : 7/30/84

Andrade Man

Lewis 0. Stewart Olympia Term Expi res : 7/30/85

Ray Westeren S e a t t l e Term Expi res : 7/30/85

C h i l d r e n ' s Or thopedic H o s p i t a l S e a t t l e Dwain H. Whi te Term Expi res : 7/30/86 Spokane

Term Expi res: 9/30/83 Susan McCroskey Group Hea l th Co-op S e a t t l e Term Expi res : 7/30/85

DSHS S t a f f Members:

Gerald J. R e i l l y , D i r e c t o r D i v i s i o n o f Medical Ass is tance LK-11 Olympia

Peggy Flemer, Secre ta ry D i v i s i o n o f Medical Ass is tance LK- 11 Olympia

James Peterson, Chief O f f i c e o f Ana lys is and Medical

Review LE-11 Olympia

Mike Stewart , Chief O f f i c e o f P rov ide r Serv ices 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


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 Pharmaceut ical S o c i e t i e s :


H. R. Knudson Execu t i ve 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. Pharmaceut ical Assoc ia t i on :

Raymond A. O l son Execu t i ve D i r e c t o r Washington S t a t e Pharmaceut ical 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 . Osteopath ic Assoc ia t i on :

M r . W. Lawless Execu t i ve D i r e c t o r Washington Osteopath ic Medical Assoc ia t i on , Inc . 4210 S.W. Oregon S e a t t l e 98116 206/937-5358

=ST VIRGINIA

West V i r g i n i a - 1 1983


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)

Presc r ibed Druqs X X X X X X X X l npat i en t H o s p i t a l Care X X X X X X X X O u t p a t i e n t H o s p i t a l Care X X X X X X X X Labora to ry & X-ray Serv ice X X X X X X X X S k i l l e d Nurs ing H m e Serv ices X X X X X X X X P h y s i c i a n Serv ices X X X X X X X X Dental Serv ices X X X X X X X X Other B e n e f i t s : In te rmed ia te Nurs ing Services, Rura l H e a l t h C l i n i c s , Durab le Medica l Equipment and Medical Suppl ies , 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 Only


1981 1982 ~ x ~ e n d e d - R e c i p i e n t ~xpended- R e c i p i e n t

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 B l i n d . . ............................. 53,167 387 38,363 287 0 i sabl 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 Chi ldren. . . 1,046,922 48,078 640,447 36,370 A d u l t s -Fami l ies w/Dep Children..... 1,511,683 31,302 1,071,235 25,512

CATEGORICALLY NEEDY NON-CASH TOTAL.. $1,085,598 Aged.. .............................. 683,862 B l i n d . . ............................. 1,086 Disab led ............................ 176,303 . C h i l d r e n -Fami l i es w/Dep Chi ldren. . 73,475 A d u l t s -Fami l ies 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 Bl ind. . . ............................ 1,399 Disabled... ......................... 222,096 C h i l d r e n -Famil i e s w/Dep Chi ldren. . . 59,857 A d u l t s -Fami l ies 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


NPC West V i r g i n i a - 2 1983


The D i v i s i o n o f Medical Care, Department o f Wel fare , i s t h e medica 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 determined by t h e l o c a l We l fa re 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 . I n d i v i d u a l s e l i g i b l e f o r S S I b e n e f i t s a re covered f o r Med ica id 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 .


PROGRAM COVERAGE

A. A l l covered 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 Federal law govern ing d i spens ing o f drugs and b i o l o g i s t s must be fo l lowed:

Drugs i d e n t i f i e d i n t h e Medica id Drug Formulary, l i s t e d by p roduc 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 drugs i n c l u d i n g i n j e c t a b l e s a re covered un less 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 re covered:

( a ) Fami ly p l a n n i n g supp l ies . ( b ) I n s u l i n . ( c ) D i a b e t i c syr inges, needles, 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 ine ra l p r e p a r a t i o n s , and o t h e r

med ica t ions r e l a t e d t o End Stage Renal Disease s e r v i c e s .

Except ion:

Non-legend drug coverage does n o t app ly f o r c l i e n t s r e s i d i n g i n long- term c a r e f a c i l i t i e s (SNF/ICF).

COVERAGE WITH PRIOR AUTHORIZATION

Cons ide ra t ion may be g i v e n on s p e c i a l d rug needs of a c l i e n t b y t h e Medical 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 medica 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 format s p e c i f i e d by t h e S ta te .


S p e c i f i c i tems covered by 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 ana lges ics f o r c h r o n i c usage; i.e., over t e n days.

2. Medical s u p p l i e s and equipment. Medica l supp l ies ; i.e., bandages, colostomy bags, underpads, and o t h e r i tems r e q u i r e d f o r home care, and covered by t h e Department based on a t reatment p l a n developed f o r t h e i n d i v i d u a l c l i e n t .

3. V i tami n /v i tamin minera l p r e p a r a t i o n s f o r End-State Renal D isease p a t i e n t s and o t h e r medicat ions r e l a t e d t o End-Stage Renal Disease serv ices.

4. L i f e sus ta in ing , c r i t i c a l , o r necessary drugs n o t i nc luded 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 drug i s needed f o r h i s p a t i e n t which i s no t i nc luded on t h e f o r m u l a r y l i s t , and i s no t exc luded from progrm 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 so 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 igna tu re . 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' supp ly w i t h no r e f i l l . Continuous therapy, 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 roduc ts a r e n o t payable:

1 . Non-legend drugs except f o r those i d e n t i f i e d i n I V . A.2.

2. Legend drugs and drug p roduc ts as f o l lows:

(a ) A p p e t i t e depressants and/or drug p roduc ts f o r we igh t c o n t r o l . ( b ) Fecal so f ten ing agents; l a x a t i v e s . ( c ) Food, food products-as l a b e l e d by F.D.A. ( d ) Exper imental 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 be ing f u l l y approved by t h e F.D.A.

( e ) Oral v i tamins , v i t a m i n and m inera l combinat ions, g e r i a t r i c t o n i c s .

( 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 determined by t h e F.D.A. o f t h e Department of H e a l t h and Human Serv ices t o l a c k s u b s t a n t i a l evidence 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 Federa l R e g i s t e r , Volume 46, Number 210, dated F r i d a y , October 30, 1981. Also, 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 inc luded.


3. Except ions:

The f o l l ow ing except ions 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 minera 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 med ica t ions r e l a t e d t o End Stage Renal Disease serv ices.

HAND1 CAPPED CHILDREN'S SERVl CES PROGRAM

Pharmacy Serv ices

Serv ices 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 years of age r e c e i v i n g medical ca re 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 Serv ices. These se rv i ces a r e no 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 ran ts .

Scope of Serv i ces

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 supp ly w i t h maximum of f i v e month ly 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 Medica id Drug Formulary L i s t

Fo r i n f o r m a t i o n con tac t : 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 Medical Care 1900 Washington S t r e e t , E. Char leston, West V i r g i n i a 25305 304/348-8990


QUANTITY AND FREQUENCY

Covered legend and non-legend drugs a r e payable as 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 up t o a 30-day supp ly w i t h a maximum o f f i v e r e f i l l s .

Except ion:

1. A n t i b i o t i c s and ana lges ics 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. Exc lud ing phenobarb i ta l , sedat ives 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 .



1 . Maximum reimbursement f o r each d rug c l a im processed w i l l be based on t h e lowest o f :

The maximum a l l o w a b l e cos t (MAC) f o r each m u l t i p l e - s o u r c e d rug as d e f i n e d by t h e Pharmaceut ical 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 d i spens ing fee. See Appendix G f o r l i s t i n g o f MAC drugs.

Except ion:

The MAC s h a l l n o t app ly 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 medica l judgement a s p e c i f i c brand i s m e d i c a l l y necessary f o r a p a r t i c u l a r p a t i e n t . A n o t a t i o n l i k e "brand necessary" w r i t t e n by 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 acceptab le c e r t i f i c a t i o n . A procedure f o r checking a box on a form w i l l n o t c o n s t i t u t e an acceptab le 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 Serv i ces and t h e Department o f Welfare.

The es t ima ted 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 fee.

The a c q u i s i t i o n cos t o r average wholesa le 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 drugs p l u s a d i spens ing fee.

The usual and customary p r i c e charged by t h e pharmacy t o t h e genera 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 which may be i n e f f e c t on t h e date o f se rv i ce .

APPLICATION OF DISPENSING FEE

A. For covered legend and non-legend drugs, a p r o f e s s i o n a l d i spens ing fee o f $2.75 w i l l be 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 be added t o t h e d i spens ing 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 legend medicament r e q u i r i n g a comb ina t ion o f any two o r more substances t o exc lude 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 .


C. U n i t dose drug d e l i v e r y systems a r e reimbursed under t h e same p r o v i s i o n s as o t h e r legend drug s e r v i c e s t o Medica id p a t i e n t s . Legend drugs a r e reimbursed on a 30-day b a s i s r e g a r d l e s s o f drug d e l i v e r y system o r how the pharmacist 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 those i tems s p e c i f i c a l l y exc luded f r o m t h e copay requirement. The r e c i p i e n t co-payment pe 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 formula) t o determine the amount payable 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 deduc t ion w i l l a p p l y as 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 per 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, t h e r e d u c t i o n w i l l be $1.00 per p r e s c r i p t i o n .

Excluded from t h e Co-Pay Requirement:

( a ) Fami ly P lann ing S e r v i c e s and Suppl ies .

( 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 Screening, D iagnos is and Treatment Program (EPSDT).

Misce l laneous

Claims processor:

The Computer Company Richmond, V i r g i n i a

Number of c la ims processed i n FY i982 - 995,580





Leon H. Ginsberg, Ph.0. Commissioner

David W. Fo r inash A s s i s t a n t Cornmissioner Medical Serv ices

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 Medical Care

(Mrs.) Helen M. Condry, D i r e c t o r D i v i s i o n o f Medical Care

Auburn A. Cooper A d m i n i s t r a t i v e A s s i s t a n t D i v i s i o n of Medical Care . W i l l i a m 6 . Rossman, M.D. P s y c h i a t r i s t Consu l tan t

Bernard Sch lac t , R.Ph. Pharmaceut ical Coord ina to r 304/348-8990

B e r t Bradford, Jr., M.D. Medical Consu l tan t ( P a r t - t i m e )

Rober t Crawford, M.D. Medical Consu l tan t ( P a r t - t i m e )

F. A. Sines, D.D.S. Denta l Consu l tant ( P a r t - t i m e )

Dav id Heitmeyer, Sec t ion 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 Department of We l fa re

1900 Washington S t r e e t , East Char les ton, W. Va. 25305


2. W e l f a r e Oepartment Medical S e r v i c e s Adv iso ry Counc i l :

A. Medical S e r v i c e Fund (MSF) Adv iso ry Counci l Members:

Reqular Members

M r . Fred B l a i r , Execu t i ve D i r e c t o r Mrs. Caro l J. M i l l e r , O i r e c t o r Ohio 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 B u i l d i n g

Beck ley 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, East R.O. 2, Box 44 Apartment 719 We1 l s b u r g 26070 Char les ton 2531 1

Jack E. F r u t h , R.Ph. F r u t h Pharmacy 2501 Jackson Avenue P t . P leasan t 25550

Har ry Shannon, M.0. P.O. Box 659 Parkersburg 26101

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) Hur r i cane 25526 501 Broad S t r e e t Char les ton 25311

M r . Danie l W. Fa r ley , 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 Method is 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., O i r e c t o r 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 Lou ise Avenue 1800 Washington S t r e e t , East Morgantown 26505 Char les ton 25305

A l t e r n a t e Members

Thomas L. Carson, R.Ph. Col lege Drug Store, Inc . Drawer 510 Montgomery 25136

Ms. Nancy W. Comer 360 Laure l S t r e e t Morgantown 26505

Ms. Sarah M. Kerns 1546 Kanawha Boulevard, East Apartment #305 Char les ton 25311

M r . Jack R. McComas, Secre ta ry /T reasure r

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 Char les ton 25301


Medica l S e r v i c e Fund (MSF) Adv iso ry Counc i l Members (con t inued) :

M r . Robert Eakin, P res iden t Memorial General H o s p i t a l 1200 H a r r i s o n Avenue E l k i n s 26241

M r . Mark Nesselroad, General Manager

West V i r g i n i a Operat ions Crossgates, Inc . 3555 Washington Road McMurray, Pennsy lvan ia

L inda R . Hickrnan, R.N. Operat ions Superv iso r Heal thwise, Inc . (HMO) S u i t e 313, R a l e i g h t County Bank B u i l d i n g Beck ley 25801

Mrs. E d i t h Sanderson C/O Beck ley Farmer 's Market Box 117 Skel ton 25955

B. Welfare Committee Members of t h e West V i r g i n i a Pharmaceut ical Assoc ia t ion :

M r . A r l i e Winters, Jr . , Chairman Benjamin Carson P. 0. Box 96 409 Monroe S t r e e t Berke ley Spr ings 25411 Montgomery 25136

S. Ewood Bare 1002 Greenbr iar Avenue Ronceverte 24970

Ann Bond Smi th P.O. Box 225 Clendeni n 25036

David Oowyer, Student Representat ive 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. Execut ive O f f i c e r s o f S t a t e Medical and Pharmaceut ical S o c i e t i e s :


Charles R. Lewis Richard D. Stevens Execu t i ve Secre ta ry Execu t i ve 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 Pharmacis ts A s s o c i a t i o n

Medica l A s s o c i a t i o n S u i t e 4 Box 1031 4004 MacCorkle Avenue, SE Char les ton 25324 Char les ton 25304 Phone: 304/346-0551 Phone: 304/925-7204

C. Osteopath ic Medic ine:

A. Robert Ozmura, 0.0. 4850 Eo 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 )


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 ldren<21 (SFO)

Presc r ibed Drugs X X X X X X X X X X l npat i en t H o s p i t a l Care X X X X X X X X X X Outpa t ien t H o s p i t a l Care X X X X X X X X X X Labora to ry & X-ray Serv ice X X X X X X X X X X S k i l l e d Nurs ing Hane Serv ices X X X X X X X X X X P h y s i c i a n Serv ices X X X X X X X X X X Dental Serv ices X X X X X *SF0 - S t a t e Funds Only


1981 1982 ~ x ~ e n d e d - R e c i p i e n t ~xpended- R e c i p i e n t

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 B l i n d . .............................. 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 -Fami l i es w/Dep Children... 2,984,470 113,915 2,617,155 105,109 A d u l t s -Fami l ies 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 Bl ind . . ............................. 5,558 Disabled............................ 3,008,923 C h i l d r e n -Fami l i es w/Dep Chi ldren. . . 652,305 A d u l t s -Fami l ies 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 -Fami l i es w/Dep Chi ldren. . . 102,048

... A d u l t s -Fami l i es w/Dep Chi ldren. . 93,192 .......... Other T i t l e X I X R e c i p i e n t s 583,983


Wisconsin - 2 1983


The S t a t e Department o f H e a l t h and Soc ia l Serv ices.

I V . P r o v i s i o n s R e l a t i n g t o P resc r ibed Drugs:


1. Legend l a x a t i v e s and nonprenata l v i t a m i n s .

2. A l l non-legend pharmaceut ica ls except I n s u l i n , a n t a c i d s and ana lges ics .

B. Formulary: None.


1 . Q u a n t i t y o f Medicat ion: Pharmacists may not d ispense more t h a n 34- day supply o f a legend drug.

2. R e f i l l s : 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 medicat ions.

3 . D o l l a r L i m i t s : None.


1. T r a d i t i o n a l (non-un i t dose) d i spens ing re imbursed a t t h e lowest o f : Est imated 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 lowab le 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 usua l and customary.

2. U n i t Dose Dispensing:

Reimbursement a t t h e lowest of : Est imated 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 lowab le Cost (MAC) 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 usua 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 per d r u g p e r month.


A. P r i o r A u t h o r i z a t i o n Requi red on t h e F o l l o w i n g Drugs:

1. A l l a n o r e c t i c s 2. Methaqualone 3 . Debr isan

4. D e r i f i l 5 . Decubi tex

NPC

M i s c e I Ianeous Remarks (cont inued) :

Wisconsin - 3 1983

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 Nurs ing F a c i l i t y (SNF) o r l n te rmed ia te 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. A n t i b i o t i c s 2. An t i convu lsan ts 3. Musc leRe laxan ts

4. . Psycho t rop ics 5. Fami ly P lann ing Drugs

Copayment

A l l legend and over- the-counter drugs except f a m i l y p l a n n i n g drugs a r e sub jec 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 te rmed ia te Care Fac i 1 i t i e s ( ICF), subs id i zed adop t ion 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 rom t h e copayment.

Sta te MAC Program - Yes


ED5 - Federal 6406 Br idge Road Madison, Wisconsin 53784

Number o f c la ims processed i n FY 1982 - 2,463,015


Wisconsin - 4 1983


1. H e a l t h and Soc ia l Serv ices Department O f f i c i a l s :

L inda R e i v i t z Secre ta ry

K a t i e Mor r i son A d m i n i s t r a t o r D i v i s i o n o f H e a l t h

Vacant D i r e c t o r Bureau o f H e a l t h Care F inanc ing (Medica id)

A l f r e d D a l l y , M.D. Phys ic ian Consul tant

Ted C o l l i n s Pharmacy P r a c t i c e s Consu l tan t 608/266-0722

Oepartment o f Hea l th and Soc ia l Serv i ces

S ta te O f f i c e B u i l d i n g One West Wi lson S t r e e t Madison,.Wisconsin 53702

2. Hea l th and Soc ia l Serv ices Oepartment Adv isory Committee - Medical Ass is tance Adv isory Comnittee:

P u b l i c Hea l th Nurs ing Anne Adams

H o s p i t a l s Danie l Kane, A d m i n i s t r a t o r

D i r e c t o r , J a n e s v i l l e V i s i t i n g M t . S i n a i Medical Center Nurse A s s o c i a t i o n 950 N. Twel th S t r e e t

Route 3, Box 107 P.O. Box 342 F o r t A tk inson 53583 Milwaukee 53201

M i n o r i t i e s Phys ic ians D r . Leonardo Aponte, D i r e c t o r Gerald Kempthorne, M.D. C l i n i c a L a t i n a 153 E. J e f f e r s o n Avenue 1302 S. 16 th S t r e e t Spr ing Green 53588 M i 1 waukee 53504

(414)645-6665

W i scons i n - 5 1983

Med ica l Ass is tance Adv iso ry Commi t t e e Members (con t inued) :

Consumer-Rec i p i en t Randy B a r t e l s 201 S. Park S t r e e t Madison 53715

Consumers Timothy Charek Execu t i ve D i r e c t o r Wel fare Advocacy Center 2014 W. McKinley, Rm 109 M i l waukee 53205 (414)931-8330

Pharmacists P a t r i c k C o l l i n s , R.Ph. P.O. Box 285 Reedsburg 53959 (608)524-6474(h)

524-3515(0)

R e c i p i e n t Sandra Gaulke 1 N. Bedford #302 Mad i son 53703

Nurs inq Homes Dennis Gra l i n s k i , A d m i n i s t r a t o r S t . Johns Home of Milwaukee 1840 N. Prospect Avenue Milwaukee 53202

R e c i p i e n t R i q h t s Don Hermanson, Esqui re,

V ice Chai rperson 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 Wausau 54401

Consumers J im K u ~ e r b e r q - Chai rperson ~ s s o c i e t e p r o f e s s o r '

Cont inu ing Educa t ion i n Admin. 307 S. H a l l 929 N. 6 t h S t r e e t Milwaukee 53203

(414)224-1972 ( 0 ) 244-1987 ( h )

D e n t i s t s Or. P e t e r M u r r e l l ODs 2545 N. Teu ton ia Avenue M i l waukee 53206 (414) 562-7460

51.52 Boards Diane Nelsom, D i r e c t o r U n i f i e d Board Buffalo/Trempealeau/Jackson Count ies 112 1/2 Washington Box 45 l ndependence 54747

Consumers V i c k i P l e v i n Program Coord ina to r Un i ted Cerebra l P a l s y of S.E.WI 152 W. Wisconsin Avenue Milwaukee 53203

R e c i p i e n t C h r i s Rober ts 333 W. Dayton, Apt. 616 Madison 53703

Handicapped R i q h t s

Sara Rober ts Support Serv i ces Coord ina to r Access t o Independence 1954 E. Washington Avenue Madison 53704

Wisconsin - 6 1983

Medica l Ass is tance Adv iso ry Committee (con t inued) :

Consumers

Dorothy Seel y, P r e s i d e n t A l l i e d Counci l

4860 S. 9 4 t h S t r e e t Milwaukee 53228

R e h a b i l i t a t i o n Therap ies

E l d e r l y

Joseph Tvaruzka Board on Aging & Long Term Care 101 S. Webster Madison 53702

Gregory Thompson Community H e a l t h D i r e c t o r , Human Resources

& Personnel Stephanie Wi l l iamson, M.D. Sacred Hear t R e h a b i l i t a t i o n Coggs Comnunity H e a l t h Center

H o s p i t a l 2770 N . 5 t h S t r e e t 1545 S. Layton B lvd. Milwaukee 53212 M i l awukee 53215

(414)265-7500 (414)383-4490

R e c i p i e n t Chr i s Rober ts 333 W. Dayon, Apt. 616 Madison 53703



E a r l Thayer ' W. A l l e n Dan ie ls , R.Ph. Secretary-General Manager Execu t i ve D i r e c t o r S t a t e Medical S o c i e t y o f Wisconsin Wisconsin Pharmaceut ical Assoc. 330 East Lakes ide 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


M r . Robert J. Finnegan Execu t i ve D i r e c t o r Wisconsin A s s o c i a t i o n o f Osteopath ic

Phys ic ians and Surgeons 34615 Road E. Oconomowoc 53066 Phone: 414/567-0520

Wyoming - 1 1983

E D I U L ASSISTANCE DRUG PROGRAn (TITLE XIX)


OAA AB APTD AFDC OAA AB APTD AFDC Chi ldren<21 (SFO) Presc r ibed Druqs I n p a t i e n t H o s p i t a l Care X X X X O u t p a t i e n t H o s p i t a l Care X X X X Labora to ry 6 X-ray Serv ice X X X X S k i l l e d Nurs ing H m e Serv ices X X X X P h y s i c i a n Serv ices X X X X Denta l Serv ices Other B e n e f i t s : Dental and o p t m e t r i c se rv i ces , 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 years o f age, home serv i ces . *SF0 - S t a t e Funds Only

I I . EXPENDITURES FOR DRUGS. Payment t o Pharmacists b y f i s c a l year ending September 30, 1982


TOTAL...............................

CATEGORICALLY NEEDY CASH TOTAL.. .... Aged ................................ Bl ind. . . ............................ Disabled....... ..................... C h i l d r e n -Fami l i es w/Dep Chi ldren. . . A d u l t s -Fami l i es w/Dep Children.....

CATEGORICALLY NEEDY NON-CASH TOTAL.. Aged ................................ Blind...... ......................... Disabled............................ C h i l d r e n -Fami l i es w/Dep Chi ldren. . . A d u l t s -Fami l i es 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 ................................ ............................ Bl ind. . . ............................ Disab led C h i l d r e n -Fami l i es w/Dep Chi ldren. . .

... 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 ..........

No vendor drug program


Wyoming - 2 1983


There i s no s t a t e vendor drug program. The Medical Ass is tance Program i s admin is te red by t h e D i v i s i o n o f Medical Serv ices o f t h e Department of H e a l t h and Soc ia l Serv ices.


No s t a t e vendor drug program.

The cost 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 Ass is tance and Soc ia l Serv ices and payment i s made from county funds.

Wyoming - 3 1983


1. H e a l t h and Soc ia l Serv ices Department O f f i c i a l s :

Stan T o r v i c D i r e c t o r

Lawrence J. Cohen, M.D., M.P.H. A d m i n i s t r a t o r

Ernest A. Rumpf, J r . D i r e c t o r Medical Ass is tance Serv ices

J e r r v Brvan t A c t i n g A d m i n i s t r a t o r 307/777-7531

2. Medical Advisory Comnittee:

John Yale Donald Hunton, M.D. Lawrence J. Cohen, M.D.

John J. Corbet t , M.D. Joan Beachler

Gerald Palmer Frank Shaw James N o r r i s Warren J. Hickman, D.D.S.,

Chairman J e r r y Bryant

Mrs. J. J. H ickey Steve Cranf i l l John V i n i c h Ray Ring

Henry Stephenson, M.D. Mrs. Joyce F i t z h u g h

Department o f H e a l t h and Soc ia l Serv ices

317 Hathaway B u i l d i n g Cheyenne, Wyoming 82002

D i v i s i o n o f H e a l t h and Medical Serv ices

D i v i s i o n o f P u b l i c Ass is tance and Soc ia l Serv i ces

- H o s p i t a l A d m i n i s t r a t o r - P h y s i c i a n - A d m i n i s t r a t o r , D i v i s i o n o f

H e a l t h & Medical Serv i ces - P h y s i c i a n - County D i r e c t o r o f P u b l i c

Ass is tance & Soc ia l Serv ices - Pharmacist - Nurs ing Home A d m i n i s t r a t o r - S t a t e Senator - D e n t i s t

- A c t i n g A d m i n i s t r a t o r , D iv . o f P u b l i c Ass is tance & Soc ia l Serv ices

- County Commissioner - S ta te Represen ta t i ve - S t a t e Represen ta t i ve - County D i r e c t o r of P u b l i c

Ass is tance & Soc ia l Serv ices - Phys ic ian - 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 Pharmaceut ical S o c i e t i e s :


Roger Brown Execu t i ve Secre ta ry Wyoming S t a t e Medical S o c i e t y 1920 Evans P. 0. Drawer 4009 Cheyenne 82001 Phone: 307/635-2424


Oscar M. Ray Secretary-Treasurer Wyoming Pharmaceutical A s s o c i a t i o n 1812 South M i t c h e l l (Residence) Casper 82601 Phone: 307/237-9393 ( S t o r e ) (4080 South Poplar S t r e e t )


David A. V ick , 0.0. Secretary-Treasurer Wyoming A s s o c i a t i o n of Osteopath ic

Phys ic ians and Surgeons Box 1298 Worland 82401

MEMBERS OF THE NATIONAL PHARMACEUTICAL COUNCIL, INC.

ABBOTT LABORATORIES Abbott Park North Chicago, Illinois 60064

BOEHRINGER INGELHEIM LTD. 90 East Ridge Ridgefield, C T 06877

BURROUGHS WELLCOME CO. 3030 Cornwallis Road Research Triangle Park, NC 27709

CIBA-GEIGY CORPORATION 556 Morris Avenue Summit, New Jersey 07901

DUPONT PHARMACEUTICALS One Rodney Square Wilmington, DE 19898

GLAXO, INC. 1900 West Commercial Blvd. Fort Lauderdale, FL 33309

HOECHST-ROUSSEL INC. Route 202-206 North Somerville, NJ 08876

JOHNSON & JOHNSON 501 George Street New Brunswick, NJ 08903

LEDERLE LABORATORIES Berdan Avenue Wayne, New Jersey 07470

ELI LILLY AND COMPANY 307 East McCarty Street Indianapolis, Indiana 462"5

MARION LABORATORIES, INC. 10236 Bunker Ridge Road Kansas City, MO 64137

MERCK SHARP & DOHME Division of Merck & Co., Inc. West Point, PA 19486

MERRELL DOW PHARMACEUTICALS 2110 East Galbraith Road Cincinnati, Ohio 45215

PARKE-DAVIS 201 Tabor Road Morris Plains, New Jersey 07950

PFIZER, INC. 235 East 42nd Street New York, New York 10017

A.H. ROBINS COMPANY 1407 Cummings Drive Richmond, VA 23220

ROCHE LABORATORIES 340 Kingsland Street Nutley, New Jersey 07110

SAND02 PHARMACEUTICALS Route 10 East Hanover, New Jersey 07936

SCHEKING CORPORATION 2000 Galloping Hill Road Kenilworth, New Jersey 07033

SMITH KLINE 8r FRENCH 1500 Spring Garden Street Philadelphia, PA 19101

E.R. SQUIBB ck SONS, INC. P.O. Box 4000 Princeton, New Jersey 08540

STUART PHARMACEUTICALS Division of ICI Americas, Inc. Wilmington, DE 19897

SYNTEX LABORATORIES 3401 Hillview Avenue Palo Alto, CA 94304

THE UPJOHN COMPANY 7000 Portage Road Kalamazoo, MI 49001

USV LABORATORIES 303 South Broadway Tarrytown, New York 10591

WINTHROP LABORATORIES Division of Sterling Drug Inc. 90 Park Avenue New York, New York 10016

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Pharmaceutical Benefits Under State Medical Assistance Programs, 1983

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