State Medicaid “Usual and Customary Charge” Billing Rules

Prepared February 2008

This document sets forth, as of the date this document was prepared, the location of some of the state rules that require pharmacies to bill Medicaid no more than their “usual and customary charge to the general public”:

ALABAMA

ALA. ADMIN. CODE r. 560-X-16-.06 (2007).

ALASKA

ALASKA ADMIN. CODE tit. 7, § 43.950 (SEPT. 2007) and ALASKA ADMIN. CODE tit. 7. § 43.591 (SEPT. 2007).

ARKANSAS

ARKANSAS MEDICAID, ARKANSAS DEPT. OF HUMAN SERVICES, PHARMACY PROVIDER MANUAL, at section II-12, 13 (2004).

CALIFORNIA

CAL. CODE REGS. tit. 22 § 51513 b:1:a (2005).

COLORADO

10 COLO. CODE REGS. § 2505-10 at 8.800.08 (2007).

CONNECTICUT

CONN. AGENCIES REGS. § 17b-262-685 (2007).

CONNECTICUT MEDICAL CARE ADMIN. DIV., CONNECTICUT DEPT. OF SOCIAL SERVICES, PHARMACY PROVIDER MANUAL: PHARMACY SERVICES REGULATION/POLICY, at 3 (2003).

DELAWARE

DELAWARE HEALTH AND SOCIAL SERVICES, DELAWARE DEPT. OF SOCIAL SERVICES, PHARMACY BILLING MANUAL at 16 (2007).

http://www.dmap.state.de.us/downloads/manuals/Pharmacy.Billing.pdf

FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION, FLORIDA MEDICAID PROVIDER GENERAL HANDBOOK, at 1-4 (2003).

AGENCY FOR HEALTH CARE ADMINISTRATION, FLORIDA PRESCRIBED DRUG SERVICES COVERAGE, LIMITATIONS, AND REIMBURSEMENT HANDBOOK, at 6-25 (2001).

GEORGIA

DIVISION OF MEDICAL ASSISTANCE, GEORGIA DEP’T OF COMMUNITY HEALTH, PART II: POLICIES AND PROCEDURES FOR PHARMACY SERVICES, at VI-2, 3 (2007).

HAWAII

MED-QUEST DIVISION, DEP’T OF HUMAN SERVICES, MEDICAID PROVIDER MANUAL: CHAPTER 19 at 23-24, (2002).

MED-QUEST DIVISION, DEP’T OF HUMAN SERVICES, MEDICAID PROVIDER MANUAL: CHAPTER 2 at 3 (2002).

IDAHO

IDAHO ADMIN. CODE § 16.03.09.665 (2005). IDAHO ADMIN. CODE § 16.03.09.03 (2005).

ILLINOIS

ILL. ADMIN. CODE tit. 89 § 140.12 (2005).

INDIANA

INDIANA HEALTH COVERAGE PROGRAMS, PROVIDER MANUAL – CHAPTER 9: PHARMACY SERVICES at 11 (2004).

IOWA

IOWA CODE § 249J.19 (2005). IOWA ADMIN. CODE r. 441-79.1(8) (2005).

KANSAS

KAN. ADMIN. REGS. §30-5-94 (2006).

KENTUCKY

907 KY. ADMIN. REGS. 1:018 (2005).

LOUISIANA

LA. ADMIN. CODE tit. 40, § I.2907 (2006).

LA. REV. STAT. ANN. § 6:437:13 (2006).

MAINE

OFFICE OF MAINECARE SERVICES, DEP’T OF HEALTH AND HUMAN SERVICES, MAINECARE BENEFITS MANUAL: CHAPTER 1 at 6 (2004).

MASSACUSETTS

MASS. REGS. CODE tit. 130 § 406.432-.433 (2005). DIV. OF MEDICAL ASSISTANCE PROVIDER MANUAL SERIES, PHARMACY MANUAL at 4-3 (2005).

MICHIGAN

MICH. COMP. LAWS § 400.111b (2005). MICHIGAN DEP’T OF COMMUNITY HEALTH, MEDICAID PROVIDER MANUAL at 19 and 23 (2005).

MISSISSIPPI

MISSISSIPPI DIVISION OF MEDICAID, PROVIDER POLICY MANUAL, at SECTION 31.04 (2004).

MINNESOTA

MINNESOTA HEALTH CARE PROGRAMS, MINNESOTA DEP’T OF HUMAN SERVICES, PROVIDER MANUAL – CHAPTER 22: PHARMACY SERVICES at 3 (2004).

MONTANA

MONTANA DEPARTMENT OF PUBLIC HEALTH & HUMAN SERVICES, PRESCRIPTION DRUG PROGRAM MANUAL, at 6.1 (2004).

MISSOURI

MO. CODE REGS. tit. 13, § 70-20.070 (2006).

NEBRASKA

NEBRASKA MEDICAL ASSISTANCE PROGRAM, NEBRASKA DEP’T OF HEALTH & HUMAN SERVICES, NEBRASKA HHS FINANCE AND SUPPORT MANUAL, at 16-005.03 (2002).

NEVADA

DIVISION OF HEALTH CARE FINANCING AND POLICY, MEDICAID SERVICES MANUAL at 2 and 6 (sections 1202.10 and 1202.29) (2005).

NEW HAMPSHIRE

N.H. REV. STA. ANN. § 126-A:3 (2006).

NEW JERSEY

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES, NEW JERSEY DEP’T OF HUMAN SERVICES, PHARMACUETICAL SERVICES MANUAL (N.J.A.C. 10-51), at 11-12 (2004).

NEW MEXICO

NEW MEXICO ADMIN. CODE tit. 8 § 324.4.16 (2006).

NEW YORK

NEW YORK MEDICAID PROGRAM, NEW YORK STATE DEP’T OF HEALTH, PHARMACY MANUAL: POLICY GUIDELINES at 26, 40 and 44 (2007).

NORTH CAROLINA

N.C. ADMIN. CODE tit. 10A, r. 39A.1307 (2006).

NORTH DAKOTA

MEDICAL SERVICES, NORTH DAKOTA DEP’T OF HUMAN SERVICES, PROVIDER MANUAL FOR PHARMACIES, at 23 (2006).

OHIO

OHIO ADMIN. CODE § 5101:3-1-60 (Anderson 2005).

OKLAHOMA

OKLAHOMA HEALTH CARE AUTHORITY, MEDICAL PROVIDERS – FEE FOR SERVICE at section 317:30-5-78. (2002).

OREGON

OFFICE OF MEDICAL ASSISTANCE PROGRAMS, OREGON DEP’T OF HUMAN SERVICES, PHARMACEUTICAL SERVICES RULEBOOK, at 1 (2004).

PENNSYLVANIA

55 PA. CODE § 1121.2 (2005).

RHODE ISLAND

RHODE ISLAND DEP’T OF HUMAN SERVICES, PHARMACY COVERAGE POLICY (no page indicated) (2007).

SOUTH CAROLINA

SOUTH CAROLINA DEP’T OF HEALTH AND HUMAN SERVICES, MEDICAID PROVIDER MANUAL: PHARMACY SERVICES, at 1-17 and 2-41 (2007).

SOUTH DAKOTA

S.D. ADMIN. R. 67:16:14:06 (2006).

TENNESSEE

BUREAU OF TENNCARE, TENNESSEE DEP’T OF FINANCE AND ADMINSTRATION, RULES OF TENNESSEE DEP’T OF FINANCE AND ADMINSTRATION: GENERAL RULES at 3 (2004 Revised).

TEXAS

TEXAS HEALTH AND HUMAN SERVICES COMMISSION, VENDOR DRUG PROGRAM PHARMACY PROVIDER HANDBOOK, at 17 (2004).

UTAH

DIVISION OF HEALTH CARE FINANCING, UTAH DEP’T OF HEALTH, UTAH MEDICAID PROVIDER MANUAL at 22 (2004).

VERMONT

OFFICE OF VERMONT HEALTH ACCESS, VERMONT AGENCY OF HUMAN SERVICES, PROVIDER MANUAL, at 9 (2006).

VIRGINIA

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES, VIRGINIA PHARMACY MANUAL, at 2 (2004).

WASHINGTON

WASH. ADMIN. CODE § 388-530-1050 (2006).

WEST VIRGINIA

BUREAU OF MEDICAL SERVICES, WEST VIRGINIA DEP’T OF HEALTH AND HUMAN SERVICES, W.V. PROVIDER MANUALS, at Chapter 200-29 and Chapter 500-24 (2003).

WISCONSIN

DEP’T OF HEALTH AND FAMILY SERVICES. WISCONSIN PHARMACY HANDBOOK-COVERED SERVICES AND REIMBURSEMENT, at 17 (2001).

WYOMING

EQUALITYCARE, WYOMING DEP’T OF HEALTH, EQUALITYCARE GENERAL PROVIDER MANUAL, at 3-7 (2003).