WSR 12-17-028

INTERPRETIVE OR POLICY STATEMENT

HEALTH CARE AUTHORITY


[ Filed August 6, 2012, 3:23 p.m. ]


Notice of Interpretive or Policy Statement


     In accordance with RCW 34.05.230(12), following is a list of policy and interpretive statements issued by the health care authority (HCA).


HCA

Legal and Administrative Services



     Document Title: Provider Notice #12-64.

     Subject: Prescription drug program.

     Effective Date: September 1, 2012.

     Effective for dates of service on and after September 1, 2012 (unless otherwise noted), the medicaid program of the HCA will implement the following changes to maximum allowable costs (MAC) in the prescription drug program.


MAC Additions
Generic Name Strength Form MAC Effective 9/1/12
POTASSIUM CHLORIDE 10MEQ CAPSULE CR $0.66570
MAC Adjustments
Generic Name Strength Form MAC Effective 8/1/12
LATANOPROST 0.005% OPHTH SOLN $7.64800
MAC Effective 9/1/12
ATORVASTATIN 10MG TABLET $0.18838
ATORVASTATIN 20MG TABLET $0.27120
ATORVASTATIN 40MG TABLET $0.27120
ATORVASTATIN 80MG TABLET $0.27120
ENOXAPARIN SODIUM 30MG/0.3ML SOLUTION $27.56250
ENOXAPARIN SODIUM 40MG/0.4ML SOLUTION $27.56250
ENOXAPARIN SODIUM 60MG/0.6ML SOLUTION $27.56250
ENOXAPARIN SODIUM 80MG/0.8ML SOLUTION $27.56250
ENOXAPARIN SODIUM 100MG/ML SOLUTION $27.56250
ENOXAPARIN SODIUM 120MG/0.8ML SOLUTION $41.34380
ENOXAPARIN SODIUM 150MG/ML SOLUTION $80.77550
FLUTICASONE PROPIONATE 50MCG/ACT NASAL SUSP $1.22438
HALOPERIDOL 10MG TABLET $0.77290
HYOSCYAMINE SULFATE 0.125MG TAB SUBL $0.47220
SIMVASTATIN 5MG TABLET $0.05444
SIMVASTATIN 10MG TABLET $0.04068
SIMVASTATIN 20MG TABLET $0.04425
SIMVASTATIN 40MG TABLET $0.06358
SIMVASTATIN 80MG TABLET $0.08466
VALACYCLOVIR HCL 500MG TABLET $1.40000
VALACYCLOVIR HCL 1GM TABLET $2.33620
VENLAFAXINE HCL 25MG TABLET $0.52450
VENLAFAXINE HCL 37.5MG TABLET $0.37760
MAC Deletions
Generic Name Strength Form MAC Effective 8/1/12
PERPHENAZINE 2MG TABLET $0.00000
PERPHENAZINE 8MG TABLET $0.00000
PERPHENAZINE 16MG TABLET $0.00000

     For additional information, contact Amber Dassow, HCA, P.O. Box 45504, phone (360) 725-1349, TDD/TTY 1-800-848-5429, fax (360) 586-9727, e-mail dassoal@hca.wa.gov, web site http://www.hca.wa.gov/.