Bt200314 - february 18, 2003

I n d i a n a H e a l t h C o v e r a g e P r o g r a m s
P R O V I D E R B U L L E T I N
All Pharmacy and Prescribing Practitioners
Subject: State Maximum Allowable Cost Fee Schedule Update
Note: The information in this bulletin is not directed to those providers rendering services in the risk-based managed care (RBMC) delivery system. Overview
Effective July 1, 2002, the Indiana Health Coverage Programs (IHCP) adopted a state maximum allowable cost (MAC) rate schedule for certain multiple-source generic drug products, blood factors, and blood derivatives, in response to Section 155 of Public Law 291-2001. The state MAC supplements, and adds to, the existing federal upper limit (FUL) program as determined by the Centers for Medicare and Medicaid Services (CMS) under 42 CFR 447.332. Indiana Administrative Code (IAC), 405 IAC 5-24-4, requires that the Office of Medicaid Policy and Planning (OMPP) periodically review the state MAC rates and adjust the rates as necessary to reflect prevailing market conditions. This bulletin advises IHCP providers that effective April 4, 2003, State MAC rates will be adjusted as indicated in Table 1. Direct questions about the state MAC program, including product availability, the state MAC rates, or other related aspects, to the Myers and Stauffer LC Pharmacy Unit at (317) 846-9521 in the Indianapolis local area or 1-800-877-6927, Monday through Friday, from 8 a.m. to 5 p.m. Table 1 – Indiana Health Coverage Programs State MAC Rates Brand Name
Generic Name
P. O. Box 7263 Indianapolis, IN 46207-7263 For more information visit www.indianamedicaid.com Table 1 – Indiana Health Coverage Programs State MAC Rates Brand Name
Generic Name
P. O. Box 7263 Indianapolis, IN 46207-7263 For more information visit www.indianamedicaid.com Table 1 – Indiana Health Coverage Programs State MAC Rates Brand Name
Generic Name
D5W 1/2 NS (Dextrose 5% in water w/ D5W 1/2 NS (Dextrose 5% in water w/ Tylenol with COD #4 60mg/300mg Tab COD/APAP 60mg/300mg Tab P. O. Box 7263 Indianapolis, IN 46207-7263 For more information visit www.indianamedicaid.com Table 1 – Indiana Health Coverage Programs State MAC Rates Brand Name
Generic Name
P. O. Box 7263 Indianapolis, IN 46207-7263 For more information visit www.indianamedicaid.com Table 1 – Indiana Health Coverage Programs State MAC Rates Brand Name
Generic Name
DW, 5%, Solution (Dextrose in water) 0.05 P. O. Box 7263 Indianapolis, IN 46207-7263 For more information visit www.indianamedicaid.com Table 1 – Indiana Health Coverage Programs State MAC Rates Brand Name
Generic Name
P. O. Box 7263 Indianapolis, IN 46207-7263 For more information visit www.indianamedicaid.com Table 1 – Indiana Health Coverage Programs State MAC Rates Brand Name
Generic Name
Note: 3 indicates the rate has changed for this drug group. CDT-3/2000 (including procedure codes, definitions (descriptions) and other data) is copyrighted by the American Dental Association. 1999 American Dental Association. All rights reserved. Applicable Federal Acquisition Regulation System/Department of Defense Acquisition Regulation System (FARS/DFARS) Apply. CPT codes, descriptions and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply. P. O. Box 7263 Indianapolis, IN 46207-7263 For more information visit www.indianamedicaid.com

Source: http://www.indianamedicaid.com/ihcp/bulletins/bt200314.pdf