117 
number of medically underserved individuals, of pop-
ulations served by the organization. 
(3) ADJUSTMENT
FOR
SERVICES
NOT
PRO-
VIDED.—The State health security program shall ad-
just such average amounts to take into account the 
cost of covered health care services that are not pro-
vided by the comprehensive health service organiza-
tion under section 303(a). 
SEC. 614. PAYMENTS FOR COMMUNITY-BASED PRIMARY 
HEALTH SERVICES. 
(a) IN GENERAL.—In the case of community-based 
primary health services, subject to subsection (b), pay-
ments under a State health security program shall— 
(1) be based on a global budget described in 
section 611; 
(2) be based on the basic primary care capita-
tion amount described in subsection (c) for each in-
dividual enrolled with the provider of such services; 
or 
(3) be made on a fee-for-service basis under 
section 612. 
(b) PAYMENT ADJUSTMENT.—Payments under sub-
section (a) may include, consistent with the budgets devel-
oped under this title— 
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118 
(1) an additional amount, as set by the State 
health security program, to cover the costs incurred 
by a provider which serves persons not covered by 
this Act whose health care is essential to overall 
community health and the control of communicable 
disease, and for whom the cost of such care is other-
wise uncompensated; 
(2) an additional amount, as set by the State 
health security program, to cover the reasonable 
costs incurred by a provider that furnishes case 
management 
services 
(as 
defined 
in 
section 
1915(g)(2) of the Social Security Act), transpor-
tation services, and translation services; and 
(3) an additional amount, as set by the State 
health security program, to cover the costs incurred 
by a provider in conducting health professional edu-
cation programs in connection with the provision of 
such services. 
(c) BASIC PRIMARY CARE CAPITATION AMOUNT.— 
(1) IN GENERAL.—The basic primary care capi-
tation amount described in this subsection for an en-
rollee with a provider of community-based primary 
health services shall be determined by the State 
health security program on the basis of the average 
amount of expenditures that is estimated would be 
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made under the State health security program for 
such an enrollee, based on actuarial characteristics 
(as defined by the State health security program). 
(2) 
ADJUSTMENT
FOR
SPECIAL
HEALTH 
NEEDS.—The State health security program shall 
adjust such average amounts to take into account 
the special health needs, including a disproportionate 
number of medically underserved individuals, of pop-
ulations served by the provider. 
(3) ADJUSTMENT
FOR
SERVICES
NOT
PRO-
VIDED.—The State health security program shall ad-
just such average amounts to take into account the 
cost of community-based primary health services 
that are not provided by the provider. 
(d) COMMUNITY-BASED PRIMARY HEALTH SERVICES 
DEFINED.—In this section, the term ‘‘community-based 
primary health services’’ has the meaning given such term 
in section 202(a). 
SEC. 615. PAYMENTS FOR PRESCRIPTION DRUGS. 
(a) ESTABLISHMENT OF LIST.— 
(1) IN GENERAL.—The Board shall establish a 
list of approved prescription drugs and biologicals 
that the Board determines are necessary for the 
maintenance or restoration of health or of employ-
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ability or self-management and eligible for coverage 
under this Act. 
(2) EXCLUSIONS.—The Board may exclude re-
imbursement under this Act for ineffective, unsafe, 
or over-priced products where better alternatives are 
determined to be available. 
(b) PRICES.—For each such listed prescription drug 
or biological covered under this Act, for insulin, and for 
medical foods, the Board shall from time to time deter-
mine a product price or prices which shall constitute the 
maximum to be recognized under this Act as the cost of 
a drug to a provider thereof. The Board may conduct ne-
gotiations, on behalf of State health security programs, 
with product manufacturers and distributors in deter-
mining the applicable product price or prices. 
(c) CHARGES
BY INDEPENDENT PHARMACIES.— 
Each State health security program shall provide for pay-
ment for a prescription drug or biological or insulin fur-
nished by an independent pharmacy based on the drug’s 
cost to the pharmacy (not in excess of the applicable prod-
uct price established under subsection (b)) plus a dis-
pensing fee. In accordance with standards established by 
the Board, each State health security program, after con-
sultation with representatives of the pharmaceutical pro-
fession, shall establish schedules of dispensing fees, de-
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