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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/.
