Professional Documents
Culture Documents
2004
Published by the
National Pharmaceutical Council, Inc.
1894 Preston White Drive
Reston, VA 20191-5433
Information for this compilation was acquired from multiple sources, including a survey of Medicaid
prescription drug programs administered for the National Pharmaceutical Council by Muse &
Associates, Washington, DC with assistance from Total Compensation Solutions and StateScape.
While we have checked all secondary data in the book for consistency relative to the original source,
we have not validated the original data reported by the Centers for Medicare and Medicaid Services
(CMS) and other organizations.
The data were compiled and the book prepared for publication by Donald Muse, Ph.D., David
Goldenberg, Ph.D., Anne Marie Hummel, Stanley Weintraub, C.P.A, Daniel B. Gurley, M.P.A.,
Jaclyn S. Kuwada, M.P.P, Steven Heath, M.P.A., Errica Philpott, Liz Segall, and Tiffany Crawford of
Muse & Associates. Paul Gavejian and Matthew Leach of Total Compensation Solutions prepared
and conducted the 2004 survey. James Elliott at StateScape supervised the compilation of information
on State officials, State professional associations, and expanded drug programs for elderly and
disabled beneficiaries. Gary Persinger and Kimberly Westrich of the National Pharmaceutical Council
provided valuable input and support.
National Pharmaceutical Council Pharmaceutical Benefits 2004
TABLE OF CONTENTS
INTRODUCTION......................................................................................................................................v
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Sociodemographics
- Age Demographics, 2003 .......................................................................................... 3-5
- Race Demographics, 2003 ......................................................................................... 3-6
- Hispanic Demographics, 2003 .................................................................................. 3-7
- Insurance Status-Populations, 2003 .......................................................................... 3-8
- Insurance Status-Percentages, 2003 ........................................................................ 3-9
- Poverty Status-Populations, 2003............................................................................ 3-10
- Poverty Status-Percentages, 2003............................................................................ 3-11
- Employment Status, 2004........................................................................................ 3-12
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APPENDIXES
Appendix A: State and Federal Medicaid Contacts.................................................................... A-1
Appendix B: Medicaid Program Statistics – CMS MSIS Tables ................................................B-1
Appendix C: Medicaid Rebate Law.............................................................................................C-1
Appendix D: Federal Upper Limits for Multiple Source Products............................................. D-1
Appendix E: Glossary ..................................................................................................................E-1
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INTRODUCTION
The 2004 edition of Pharmaceutical Benefits under State Medical Assistance Programs marks the 39th
year that the National Pharmaceutical Council (NPC) has compiled and published one of the largest
sources of information on pharmacy programs within the State Medical Assistance Programs (Title
XIX) and expanded pharmacy programs for the elderly and disabled. Due to the hard work of a skilled
team and countless contributors, the “Medicaid Compilation” has become a standard reference and
invaluable resource in government offices, research libraries, consultancies, the pharmaceutical
industry, numerous businesses, and policy organizations.
The data used to create each edition of the Compilation are assembled from numerous sources. The
Compilation incorporates information on each State pharmacy program from an annual NPC survey of
State Medicaid program administrators and pharmacy consultants, statistics from the Centers for
Medicare and Medicaid Services (CMS), and information from other Federal agencies and
organizations.
In order to give a better understanding of the content of the “Medicaid Compilation,” the information
contained in this version of the book is summarized below by section:
• Section 1: Presents estimates of Medicaid expenditures and recipients for FY 2003 to FY
2005 by State.
• Section 2: Contains an overview of the Medicaid program, details about Medicaid managed
care enrollment, including a breakdown by plan type and enrollment by plan type, and a
synopsis of 1915(b) waivers and 1115 demonstrations.
• Section 3: Consists of sociodemographic statistics, by age, race, insurance, income, and
employment, for the fifty States and the District of Columbia for calendar year 2003.
Additionally, a description of the Medicaid certified facilities in each State, including the
number of hospitals, skilled nursing facilities, and intermediate care facilities for the mentally
retarded (ICFs-MR), home health agencies, and rural health clinics are presented.
• Section 4: Provides Medicaid pharmacy program characteristics, drawn largely from the 2004
NPC annual survey of State pharmacy program administrators. In addition, this section
provides Medicaid eligibility statistics from CMS for fiscal year 2002 and program
expenditure data for fiscal years 2002 and 2003. Medicaid pharmacy programs are
characterized by estimates of total expenditures, drug payments, drug benefit design, and
pharmacy payment and patient cost sharing.
• Section 5: Contains detailed profiles of the States’ Medicaid pharmacy programs. This
section contains a description of medical assistance benefits and eligibles, drug payments and
recipients, benefit design, pharmacy payment and patient cost sharing, use of managed care,
and State contacts.
• Section 6: Profiles the “expanded” drug programs in States that are providing pharmaceutical
coverage or discounts to the elderly and/or disabled persons.
The book also contains a series of appendices. Appendix A features a list of State contacts, CMS
regional offices and Medicaid program personnel. Appendix B provides a national level summary on
total Medicaid program recipients by type of service for FY 2001 and FY 2002 and data on total
number of drug recipients for each State and the nation as a whole for the period 1996-2002.
Appendix C provides the current Medicaid drug rebate law. Appendix D contains the list of CMS
upper limits on multiple source products. Appendix E is a glossary and list of acronyms.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Each year, finding and compiling current, relevant information for inclusion in the Compilation
presents a challenge. This year was no exception. For example, CMS makes available on its website
the Medicaid Statistical Information System (MSIS) Statistical Reports for the most recent enrollment
and expenditure data available. MSIS tables are used in several sections of the Compilation as a
secondary data source. This year, CMS released MSIS reports on Federal Fiscal Year 2002.
However, the 2002 MSIS data have been reformatted to appear more like the older Health Care
Financing Administration (HCFA) 2082 reports. Hence, we requested, and CMS provided, a special
version of the 2002 MSIS Report in original MSIS format. This enabled us to compile 2002 data on
pharmaceutical expenditures and recipients for inclusion in each State profile. Also, CMS has yet to
release an update of The CMS 64-Report, a major data source used throughout the Compilation.
However, we were fortunate to obtain a pre-release version of the 2003 CMS 64-Report and thank
CMS for making it available to us.
For the past several years, the Health Resources and Services Administration’s (HRSA) Area
Resource File (ARF) has served as the primary source for statistics on physicians and registered
nurses. Unfortunately, HRSA was not able to obtain updated physician information for the 2004
version of the ARF. Therefore, we have repeated last year’s data on physicians and registered nurses.
As we continue to update and discover data, we are able to improve the Compilation with new tables
and sources that we believe enhance its overall significance to the user. These new tables and sources
include:
NPC gratefully acknowledges the cooperation and assistance of the many State and Federal program
officials and their staffs. With their cooperation, we were able to achieve a 94 percent response rate to
the 2004 Survey. Unfortunately, not all States were able to submit revised/updated information. In
such instances, we have incorporated the most recently available data from other sources. However,
for these States, much of the information may reflect data that have been presented in previous
versions of the Compilation.
We would also like to thank Muse & Associates and their subcontractors, Total Compensation
Solutions, and StateScape, for administering the survey, compiling the information, and analyzing the
data. We hope you continue to find the information contained in this compilation useful and, as
always, we welcome your suggestions and comments.
Gary Persinger
Vice President, Health Care Systems
National Pharmaceutical Council
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Section 1:
Estimates of Medicaid
Total and Prescription
Drug Expenditures and
Recipients: FY 2003
Through FY 2005 by State
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The Centers for Medicare and Medicaid Services (CMS) are responsible for publishing data on the
Medicaid program. The most recent State-by-State statistics on recipients and expenditures for the
Medicaid program, as of the date of preparation of this publication, were for 2002.1 Based on the best
available data from states and CMS, the section provides more recent estimates through 2005 of
Medicaid spending and recipients of prescription drugs. Estimates are presented for each State and for
the nation overall.
The objective of this Section is to estimate total Medicaid expenditures and recipients for FY 2003,
FY 2004, and FY 2005 in the aggregate and by State.2 This will provide interested parties with
estimates of trends more current than estimates available through CMS. The Office of the Actuary at
CMS publishes aggregate estimates of Medicaid expenditures in the National Health Accounts.3 The
Congressional Budget Office (CBO) also publishes aggregate estimates of Medicaid expenditures and
recipients.4 Neither of these organizations has published estimates of State-by-State spending through
FY 2005 in recent years.5 However, these previous estimates document the importance and feasibility
of this chapter’s goals. The aggregate estimates presented in this Section are numerically very similar
in all but one instance, projections of 2005 recipients, to those of CMS and CBO.
SUMMARY
The analysis presented in this Section is based on State reports to CMS. Table 1 contains aggregate
data on total expenditures and number of recipients by fiscal year. Estimates by Muse & Associates
are indicated by the bolded text. All other data are State actual, or estimated by the authors.
Table 1
Total Program Expenditures and Recipients by Source
By Fiscal Year: FY 2000 through FY 2005
1
The most recent estimates can be found at www.cms.hhs.gov/medicaid/msis/mstats.asp.
2
FY stands for Federal Fiscal Year. Federal Fiscal Years are from October 1 to September 30. For example, FY 2003 is
from October 1, 2002 to September 30, 2003.
3
These can be found at www.cms.hhs.gov/statistics/nhe.
4
http://www.cbo.gov/factsheets/2005/Medicaid.pdf
5
Katherine R. Levit, et al, State Health Expenditures Accounts: Building Blocks for State Health Spending Analysis, Health
Care Financing Review, Fall 1995, Vol. 17, No. 1.
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The methodology used for developing the 2003-2005 recipient estimates employed the cube root of
the change over a four year period for each state with outliers trimmed. The trimming procedures are
described later in the paper. The estimation technique we employed is commonly used in statistical
and actuarial estimates and simply means that the fifth point in a curve is estimated by using the rate
of change for the preceding four years. Table 1 shows that expenditures have risen between 6 percent
and 14 percent per year while the number of recipients has increased between 7 percent and 8 percent
per year. We estimate that the accuracy of these estimates is between plus or minus 2.2 percent by
using the methodology to estimate preceding years where the actual data were already available.
DATA
The analysis presented in this Section is based on State data submitted to CMS. We assume that the
States are in the best position to predict the future of their programs. Actual expenditure and recipient
data for FY 2000 through FY 2002 were available from the Medicaid Statistical Information System
(MSIS). Aggregate expenditure data for FY 2003 were available from State reports known as the
CMS-64s. Expenditure estimates for FY 2004 and FY 2005 were compiled from State reports known
as CMS-37s. Aggregate data by type of service and recipient estimates by State were prepared by
Muse & Associates. Each of these sources is discussed below.
MSIS Data
MSIS files are used by CMS to produce data on Medicaid program characteristics and utilization
information by State. The MSIS system collects, manages, analyzes, and disseminates information on
eligibles, beneficiaries, utilization, and payment for services covered by each State Medicaid program.
These data provide CMS with a large-scale database of State eligibles and services for many types of
analyses. States provide CMS with quarterly computer files containing specified data elements for:
(1) eligible persons who received services covered by Medicaid (recipient files); and (2) adjudicated
claims (paid claims files) for medical services reimbursed with Title XIX funds. These data are
furnished on the Federal fiscal year quarterly schedule, which begins October 1 of each year.
Each State recipient file contains one record for each person covered by Medicaid for at least one day
during the reporting quarter. Individual recipient records consist of demographic and monthly
enrollment data. Paid claims files contain information from adjudicated medical service related claims
and capitation payments. Each State submits to CMS four types of claims files representing inpatient,
long-term care, prescription drugs, and non-institutional services. These are claims that have
completed the State's payment processing cycle for which the State has determined it has a liability to
reimburse the provider from Title XIX funds. Claims records contain information on the types of
services provided, providers of services, service dates, costs, types of reimbursement, and
epidemiological variables.
The data files are subjected to quality assurance edits to ensure that the data are within acceptable error
tolerances. A distributional review verifies the reasonableness of the data. Once accepted, valid tape
files are created which serve as the historical source of detailed Medicaid eligibility and paid claims
data maintained by CMS. The individual paid claims and eligible information are used for program
analysis and research and to produce various public use reports that represent national Medicaid
populations and expenditures. After processing, CMS creates the tables and publishes the data. The
MSIS system was our primary source for expenditure and recipient data for FY 2000 through FY
2002.
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The primary source of data for our estimates for FY 2003 through FY 2005 is the CMS-37 Report, a
financial reporting form submitted by the States to CMS. This form is submitted on a quarterly basis
and requires the States to project their expenditures for two fiscal years. The single State agency must
attest to the accuracy of the estimates. The data in the CMS-37s are used by CMS to set the amount
the State may withdraw from the Federal Reserve for Federal Medicaid matching.
The data on this form have known strengths and weaknesses. As with all State submitted data, some
States appear to provide more accurate data than others. Not surprisingly, the States are clearly more
accurate at predicting the present year, at this writing FY 2005, than they are at predicting the
following year, FY 2006. States have, as of this writing, yet to adjust their FY 2006 Medicaid
prescription drug expenditures for the implementation of the Medicare Modernization Act (MMA)
which will transfer the fiscal responsibility for those recipients eligible for both Medicare and
Medicaid to the Federal government. The limitations of the data led us not to attempt to estimate FY
2006.
A third source of data was the CMS-64s, another fiscal reporting form submitted by the States which
contains details of their past expenditures. These reports contain expenditures, reversals,
disallowances, third-party collections and a variety of other adjustments. However, they represent the
most current statement of State-by-State expenditures available for FY 2003. Hence, they were used
for FY 2003 expenditure estimates.
It must be noted that while the data from the three sources (the MSIS, CMS-37, and CMS-64) are
highly correlated, they are not identical. The data do not match for a variety of reasons. Some are
prospective and some are retrospective, some contain adjustments and other do not. Table 2 compares
the three sources at the aggregate expenditure level.
Table 2
Total Program Expenditures by Source
By Fiscal Year: FY 2000 through FY 2005
($ billions)
Source: State data reported to CMS, CMS-37, 64, and MSIS Reports
* CMS 37s as of May 2004.
** N/A is not available
Table 2 clearly shows that the data reported on the CMS-64 reports are higher, until 2003, compared
to the other two data sets. The primary reason for this is that the MSIS reports do not contain
Disproportionate Share (DSH) payments to providers, while the other two reports do contain DSH
data.
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METHODOLOGY
Muse & Associates has accumulated Medicaid data from the CMS-37, CMS-64, MSIS, and the
forerunner to the MSIS, the HCFA 2082, for more than two decades. To create the estimates, we
explored two methodological approaches. The first approach was regression based. Several different
types of regressions were considered, including log-based approaches. The problem we encountered
with regression analysis was that the regression model was over specified.6 This is primarily due to
the fact that the number of States being estimated (fifty-one) is much larger than the small number of
years (three) of data selected for use.7 Five years was selected because of the cyclical nature of the
Medicaid program. CMS published an analysis that clearly shows the trend in drug spending between
the first and second half of the 1990s.8 Their observations and our own analysis show that the
optimum period that State trends appear stable is four years. The regression approach did not yield
results with statistically significant predictability as measured by R2, a measure of the predictive ability
of the regression model. Hence, this approach was abandoned.
The approach that yielded more stable and predictive results was employing the cube root of the
change over a four year period for each state with outliers trimmed.. However, several States had very
significant programmatic changes in recent years that required data trimming. A total of four States
required trimming.9 Outliers were defined as changes of more than 20 percent from year to year for
year to year increase. These were trimmed to 20 percent. Two States, Tennessee and New Mexico
presented special problems. The statistical portions of their data processing systems had considerable
problems over the last five years. The estimates for these States were developed through direct
conversations with State Medicaid officials.
The CMS-37 and CMS-64 reports from States often show significant swings for both total program
and prescription drugs expenditures. State expenditures for Medicaid can have significant swings in
spending for a variety of reasons. For example, all of the Medicaid data systems are on a cash basis
rather than an accrual basis. States often have cash flow concerns that require that they pay claims on
one side or the other at the end of the State fiscal year. Many States have the same Fiscal Year as the
Federal government, which can result in FY data showing decreases followed by substantial increases
in expenditures. In addition, States may incur large settlements with CMS and/or providers in a
particular year. These, and a variety of other factors, lead to real swings in the expenditure data.
DISCUSSION
Presented on the pages that follow are tables showing national and State-level data on Medicaid
expenditures and recipients, including our estimates for the most recent fiscal years. Table 3 shows
national-level data from the CMS-64s for expenditures by type of service for the period FY 2000
through FY 2005. Similarly, Table 4 presents national-level MSIS data on the number of Medicaid
recipients by type of service. Tables 5 through 8 provide national and State-level information on total
6
In non-statistical terms, a regression model becomes over specified when the number of points being estimates
exceeds the number of data points available for the analysis.
7
The District of Columbia was included in the analysis but Puerto Rico and the Trust Territories were excluded.
8
David Baugh, M.A, Penelope I. Pine, Steve Blackwell, Ph.D., J.D. R.Ph. and Gary Ciborowski, M.A..
Medicaid Prescription Drug Spending in the 1990s: A Decade of Change, Health Care Financing Review, Spring
2004, Volume 25, Number 3, page 5 to 23.
9
The States were Connecticut, Delaware, and Nevada. The District of Columbia also required trimming
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Medicaid expenditures, number of recipients, recipients of prescription drugs, and Medicaid program
payments for prescription drugs.
Tables 3 & 4
Table 3 shows the distribution of Medicaid expenditures by service category from the CMS-64s and
the National Health Expenditures Accounts for the period FY 2000 through FY 2005. The data show
that total Medicaid program expenditures have or are expected to increase annually by 6 to 14 percent
per year between FY 2000 and FY 2005, or at an average annual increase of approximately 10 percent
per year. Our estimates indicate that total Medicaid program expenditures will exceed $316 billion in
FY 2005. The data from the CMS-64s indicate that pharmaceuticals are the third highest Medicaid
program expenditure category in each fiscal year, exceeded only by nursing facility expenditures and
payments for inpatient acute care hospital services. For FY 2005, we estimate that Medicaid program
expenditures for pharmaceutical will be $44.3 billion.
Table 4 presents national-level data from the MSIS system on the number of Medicaid recipients by
type of service. Between FY 2000 and FY 2005, the number of Medicaid recipients has or is expected
to increase at annual rates of between 6.4 percent and 7.8 percent, or at an average annual rate of about
seven percent. In FY 2005, it is estimated that 62 million beneficiaries will receive medical services
through the Medicaid program. Aside from capitated payment services (i.e., per capita payments to
managed care organizations), the service category with the highest number of recipients is
pharmaceuticals. It is estimated that 29.9 million Medicaid beneficiaries will receive pharmaceutical
services during FY 2005.
Tables 5 & 6
Presented in Tables 5 and 6 are data on total Medicaid expenditures and number of Medicaid
recipients on a State-by-State basis for the period FY 2000 to FY 2005. The data source for the
expenditures distributions in Table 5 is the CMS-37s. Based on State data submitted to CMS in their
quarterly CMS-37 submissions, Medicaid program expenditures for FY 2005 are expected to total
$315.7 billion, similar to the $316.2 billion FY 2005 estimate derived from the CMS-64s. Also shown
in Table 5 are year-by-year data on total Medicaid expenditures by State for the period. A review of
the State-by-State data indicates that in most States, Medicaid program spending has increased from
one year to the next. There are few instances over the entire period where total Medicaid program
spending has declined from one year to the next.
The MSIS system was the primary source for data on the distribution Medicaid recipients by State
(Table 6). CMS has released MSIS data through FY 2002. FY 2003, FY 2004, and FY 2005 are
estimates, based on the cubed root of change over a 4 year period methodology discussed above. As
shown in Table 6, the total number of Medicaid recipients, like the expenditure data in Table 5, has
increased or is estimated to increase each year between FY 2005 and FY 2006. Likewise, with few
exceptions, the number of Medicaid recipients has increased each year in each State over the period.
Tables 7 & 8
Tables 7 and 8 present MSIS data on State-by-State prescription drug payments and the number of
drug recipients for the period FY 2000-FY 2005. As shown in Table 7, Medicaid program payments
for prescription drugs have more than doubled over the period, from approximately $20 billion in FY
2000 to an estimated $44.3 billion in FY 2005. Few states experienced any declines in prescription
drug payments between one year and the next.
The total number of Medicaid recipients receiving prescription drug services has increased by slightly
more than 50 percent between FY 2000 and FY 2005 (Table 8). For FY 2005, it is estimated that 29.8
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million beneficiaries will receive prescription drug services under the Medicaid program. Most States
are expected to experience increases in the number of Medicaid prescription drug recipients over the
period. However, in a small number of States, including Kansas and Massachusetts, the number of
Medicaid prescription drug recipients are expected to remain relatively constant or even decline
slightly between FY 2000 and FY 2005.
One way to ascertain whether an estimation methodology is accurate is to apply it to earlier years
where the estimated year is known. We chose this methodology as way to address the question of the
probable accuracy of our estimates. We applied the final estimation method to the years FY 1999 to
FY 2002. Specifically, we used FY 1999, FY 2000, and FY 2001 data to predict FY 2002, a year in
which we had actual values for aggregate and State-by-State data. The results were that the actual
aggregate totals were within 0.3 percent of the estimated totals. The State-by-State estimates were less
accurate but still within what we judge as acceptable limits. Forty-two States were within plus or
minus five percent. Seven States were within plus or minus twenty percent, and two States exceeded
twenty percent.
Despite these limitations and the variations inherent in the use of different data systems, we believe
that our estimates provide useful information on Medicaid program expenditures and recipients that is
more up to date than that which is currently available from CMS.
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Table 3
Medicaid Expenditures, by Type of Service: In dollars by Fiscal Year
Table 4
Medicaid Recipients, by Type of Service and Fiscal Year
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Table 5
Total Medicaid Expenditures in thousands of dollars by Fiscal Year by State
S tate FY 2000 FY 2001 FY 2002 FY 2003 FY 2004 FY 2005
National Total $168,307,231 $185,786,851 $213,491,313 $268,496,116 $290,680,584 $315,701,965
Alabama $2,391,195 $2,950,096 $3,204,064 $3,603,097 $3,445,986 $3,850,214
Alaska $470,250 $557,399 $686,795 $774,755 $909,840 $942,281
Arizona $2,111,770 $2,453,184 $2,881,870 $4,253,304 $5,135,647 $5,772,557
Arkansas $1,510,080 $1,684,718 $2,015,437 $2,394,653 $2,762,943 $2,989,172
California $17,060,494 $19,824,989 $23,636,240 $29,897,092 $32,173,749 $36,362,263
Colorado $1,808,569 $1,952,709 $2,166,200 $2,597,187 $2,703,792 $2,902,011
Connecticut $2,839,310 $2,962,088 $3,245,143 $3,691,626 $3,866,361 $4,103,564
Delaware $528,340 $601,182 $651,385 $737,360 $752,775 $855,737
District of Columbia $792,584 $830,258 $1,027,022 $1,072,802 $1,165,242 $1,241,190
Florida $7,350,363 $8,398,160 $9,827,004 $11,041,401 $12,340,063 $13,790,043
Georgia $3,577,903 $3,815,267 $4,796,005 $7,055,152 $7,045,377 $7,154,685
Hawaii $535,163 $535,163 $695,279 $759,731 $846,973 $1,026,277
Idaho $593,751 $713,433 $791,864 $853,256 $905,311 $1,058,487
Illinois $7,807,447 $8,150,021 $9,121,713 $8,954,270 $10,073,437 $11,400,358
Indiana $2,976,177 $3,355,996 $3,725,258 $4,584,428 $4,699,660 $5,563,225
Iowa $1,476,340 $1,660,864 $1,855,817 $2,360,040 $2,196,622 $2,448,931
Kansas $1,226,211 $1,370,248 $1,501,270 $1,789,086 $1,754,285 $2,096,225
Kentucky $2,912,792 $3,235,073 $3,459,366 $3,864,583 $4,075,918 $4,464,305
Louisiana $2,630,563 $2,881,578 $3,234,422 $4,858,435 $4,633,523 $4,990,753
M aine $1,306,809 $1,457,466 $1,716,582 $1,680,703 $1,916,751 $2,072,414
M aryland $3,585,781 $3,855,003 $3,662,090 $4,359,399 $4,494,121 $4,708,992
M assachusetts $5,397,153 $5,765,108 $6,387,100 $8,632,074 $8,987,848 $9,968,515
M ichigan $4,880,769 $5,316,249 $5,918,817 $8,150,661 $8,507,062 $8,850,936
M innesota $3,277,014 $3,766,605 $4,439,494 $5,117,771 $5,225,883 $5,719,244
M ississippi $1,807,392 $2,180,662 $2,499,641 $3,028,552 $3,280,007 $3,658,914
M issouri $3,270,152 $3,626,213 $4,071,544 $5,578,991 $5,966,126 $6,744,680
M ontana $433,208 $482,543 $532,886 $519,065 $601,474 $700,806
Nebraska $958,490 $1,089,788 $1,255,040 $1,351,142 $1,354,239 $1,424,542
Nevada $515,444 $565,300 $723,957 $989,559 $1,053,794 $1,160,591
New Hampshire $650,594 $691,196 $745,754 $1,014,956 $1,180,678 $1,272,117
New Jersey $4,706,929 $5,011,795 $5,497,284 $8,358,844 $7,883,350 $8,416,526
New M exico $1,248,764 $1,476,538 $1,796,901 $2,030,060 $2,230,879 $2,416,959
New York $26,147,613 $27,497,918 $31,488,930 $40,551,353 $49,425,404 $49,312,629
North Carolina $4,830,026 $5,499,094 $6,041,011 $7,139,629 $7,613,812 $8,901,127
North Dakota $356,185 $374,197 $422,745 $463,348 $496,642 $535,293
Ohio $7,090,396 $7,772,738 $9,186,331 $10,601,589 $12,030,919 $12,595,864
Oklahoma $1,603,789 $2,004,799 $2,238,213 $2,402,648 $2,720,199 $2,860,078
Oregon $1,700,409 $1,878,673 $2,136,401 $2,757,488 $2,535,181 $3,057,873
Pennsylvania $6,365,806 $7,634,325 $8,523,928 $13,168,602 $14,422,482 $16,466,731
Rhode Island $1,069,994 $1,095,853 $1,251,440 $1,472,595 $1,533,600 $1,771,549
South Carolina $2,672,146 $3,096,854 $3,382,951 $3,766,709 $3,576,207 $4,097,262
South Dakota $401,175 $426,634 $503,947 $546,789 $579,726 $666,494
Tennessee $3,490,957 $4,059,332 $4,747,550 $6,639,519 $6,735,962 $7,837,560
Texas $9,075,306 $9,644,600 $11,121,020 $15,289,859 $16,621,374 $17,735,949
Utah $959,100 $1,059,730 $1,215,620 $1,123,620 $1,258,360 $1,428,054
Vermont $479,259 $541,283 $607,250 $713,582 $766,279 $862,161
Virginia $2,483,931 $2,715,962 $3,017,870 $3,706,653 $4,156,487 $4,723,322
Washington $2,432,050 $2,432,050 $4,373,171 $5,180,773 $5,304,530 $5,762,663
West Virginia $1,391,731 $1,565,009 $1,577,698 $1,873,502 $1,912,439 $2,157,688
Wisconsin $2,905,599 $3,029,723 $3,605,542 $4,806,489 $4,478,875 $4,403,336
Wyoming $213,958 $241,187 $280,452 $337,334 $342,390 $398,818
Table 6
Total Unduplicated Medicaid Recipients by State by Fiscal Year
State FY 2000* FY 2001* FY 2002* FY 2003** FY 2004** FY 2005**
National Total 42,886,999 46,163,776 49,754,619 53,446,822 57,546,074 61,991,626
Alabama 619,480 882,105 765,328 836,803 925,028 939,796
Alaska 96,432 105,464 109,641 119,836 128,838 137,728
Arizona 681,258 763,422 878,362 976,625 1,101,200 1,244,229
Arkansas 489,325 531,533 579,278 622,674 674,759 730,614
California 7,918,151 8,583,027 9,301,001 10,323,828 11,278,372 12,353,265
Colorado 381,018 393,160 425,878 450,793 476,784 508,439
Connecticut 419,968 685,246 479,051 502,652 533,685 533,685
Delaware 115,267 122,947 167,162 193,885 230,582 276,698
District of Columbia 138,677 140,719 193,494 218,982 255,002 306,002
Florida 2,372,585 2,471,771 2,676,235 2,833,382 3,006,073 3,208,707
Georgia 1,369,006 1,514,398 1,637,329 1,777,775 1,939,549 2,106,303
Hawaii 194,376 191,533 199,966 198,658 200,106 203,048
Idaho 131,077 157,121 176,499 200,665 231,270 263,077
Illinois 1,519,313 1,657,954 1,731,398 1,834,859 1,953,984 2,063,973
Indiana 706,476 777,418 849,427 940,652 1,034,840 1,138,359
Iowa 313,648 319,740 352,635 368,428 388,738 414,900
Kansas 262,557 272,783 289,349 296,359 308,567 321,509
Kentucky 763,587 806,578 808,294 847,565 877,563 902,586
Louisiana 761,252 804,996 898,824 966,003 1,045,831 1,141,171
Maine 193,582 251,511 275,826 316,222 372,421 424,483
Maryland 625,863 656,307 692,539 732,052 771,312 813,962
Massachusetts 1,059,612 1,054,916 1,065,636 1,073,987 1,078,821 1,086,909
Michigan 1,351,852 1,352,610 1,449,915 1,490,027 1,539,155 1,606,888
Minnesota 558,089 600,686 620,652 641,859 672,488 698,281
Mississippi 605,078 707,911 712,457 794,881 870,561 932,694
Missouri 890,338 978,656 1,036,150 1,128,728 1,221,614 1,315,332
Montana 104,354 108,409 103,617 106,048 106,619 106,029
Nebraska 229,379 243,421 255,771 270,822 286,238 302,123
Nevada 138,076 153,777 202,306 231,948 275,728 330,873
New Hampshire 96,935 97,062 104,138 108,072 112,062 117,561
New Jersey 821,579 881,468 954,491 1,002,879 1,071,803 1,143,978
New Mexico 375,585 385,180 798,665 958,398 1,150,078 1,380,093
New York 3,419,983 3,590,999 3,920,718 4,180,420 4,469,771 4,808,120
North Carolina 1,214,174 1,309,810 1,355,269 1,424,834 1,502,884 1,573,372
North Dakota 63,165 63,566 70,132 73,108 76,759 81,739
Ohio 1,304,886 1,498,322 1,656,124 1,805,943 2,012,556 2,220,558
Oklahoma 507,060 589,363 631,498 699,125 778,132 853,644
Oregon 557,809 582,112 621,462 649,472 683,258 720,739
Pennsylvania 1,492,352 1,557,801 1,627,261 1,652,312 1,709,355 1,763,081
Rhode Island 178,859 188,228 199,014 213,572 226,581 241,029
South Carolina 689,159 760,805 809,136 871,535 942,482 1,012,216
South Dakota 102,039 109,516 117,631 130,669 141,898 154,694
T ennessee 1,568,318 1,602,027 1,732,381 1,797,473 1,881,071 1,984,497
T exas 2,633,498 2,659,932 2,952,569 3,113,488 3,292,193 3,534,736
Utah 224,732 232,997 274,707 294,790 322,698 359,703
Vermont 139,351 149,763 153,731 161,978 170,309 177,766
Virginia 626,996 619,727 665,203 680,602 699,471 728,271
Washington 895,567 957,731 1,039,070 1,105,389 1,185,735 1,273,217
West Virginia 342,189 349,229 362,030 367,825 376,790 386,452
Wisconsin 576,636 637,069 716,298 793,773 883,002 984,509
Wyoming 46,451 50,950 59,071 64,164 71,459 79,989
Table 7
Medicaid Prescription Drug Payments, Before Rebates are Deducted
in thousands of dollars by State by Fiscal Year
S tate FY 2000* FY 2001* FY 2002* FY 2003** FY 2004*** FY 2005***
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Table 8
Medicaid Recipients Receiving Prescription Drugs by State by Fiscal Year
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Section 2:
The Medicaid Program
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MEDICAID ELIGIBILITY
Medicaid Eligibility: Medicaid is a “means tested program for low-income individuals.” To qualify,
a Medicaid recipient must not have “income” or “resources” that exceed the applicable limits
prescribed in the law and regulations.
Every State, in order to receive Federal funding under Title XIX, must provide Medicaid benefits to
certain “categorically needy” persons. These are the “mandatory” categorically needy. In addition,
the State has the option of providing Medicaid benefits to certain additional categories of persons.
These are the “optional” categorically needy. An additional category of Medicaid recipients that a
State may choose to include in its program is the “medically needy.”
Mandatory Categorically Needy: There are numerous and detailed categories under which the
“categorically needy” may qualify for Medicaid benefits. The principal categories of the mandatory
categorically needy are:
• Low-income families with children;
• Recipients of Supplemental Security Income (SSI) for the Aged, Blind, and Disabled
(this includes disabled children);
• Individuals qualified for adoption assistance agreements or foster care maintenance
payments under Title IV-E of the Social Security Act;
• Qualified pregnant women;
• Newborn children of Medicaid-eligible women;
• Various categories of low-income children; and
• Certain low-income Medicare beneficiaries.
Optional Categorically Needy: These are groups of individuals who meet the characteristics of the
mandatory groups, but the eligibility criteria are somewhat more liberally defined. For example, in
determining their incomes and resources, they are allowed to exclude certain kinds of income. The
“optional categorically needy” include individuals who are aged, blind, disabled, caretaker relatives,
and pregnant women who meet the SSI income and resources requirements but are not receiving SSI
cash payments.
Medically Needy: The “medically needy” are those individuals who meet the definitional
requirements described above, except that their income or resources exceed the limitations applicable
to the categorically needy. These individuals can “spend down” to qualify. That is, they can deduct
their medical bills from their income and resources until they meet the applicable income and
resources requirements. Their Medicaid benefits can then begin.
Special Categories: The Medicaid statute also authorizes limited Medicaid benefits to special
categories of individuals. In general, these are individuals whose income and resources would
otherwise be too high to qualify for full Medicaid benefits under the regular provisions.
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For example, a “Qualified Medicare Beneficiary” (QMB) is an individual who qualifies for Medicare
Part A, whose income does not exceed 100 percent of the Federal poverty level, and whose resources
do not exceed twice the SSI resource-eligibility standard. Medicaid coverage of QMBs is limited to
payment of their Medicare cost-sharing charges, such as the Medicare premiums, coinsurance, and
co-payment amounts.
Non-Eligibles: A State can include in its Medicaid program individuals who do not meet the statutory
eligibility criteria. However, the State must pay the full costs for these individuals. There are no
Federal matching payments.
MEDICAID SERVICES
Title XIX lists the many types of medical care that a State may select for inclusion into its Medicaid
State Plan, thus qualifying for Federal matching payments. However, the law requires that certain
basic benefits must be available to all “categorically needy” recipients. These services include:
• Inpatient and outpatient hospital services;
• Physician services;
• Medical and surgical dental services;
• Laboratory and X-ray services;
• Nursing facility services (for persons 21 years of age or older);
• Early and periodic screening, diagnostic, and treatment (EPSDT) services for children
under age 21;
• Family planning services and supplies;
• Home health services for persons eligible for nursing facility services;
• Rural health clinic services and any other ambulatory services offered by a rural health
clinic that are otherwise covered under the State Plan;
• Nurse-midwife services (to the extent authorized under State law);
• Pediatric and family nurse practitioners services; and
• Federally-qualified health center (FQHC) services and any other ambulatory services
offered by an FQHC that are otherwise covered under the State Plan.
If a State chooses to include the “medically needy” population, the State Plan must provide, as a
minimum, the following services:
• Prenatal care and delivery services for pregnant women;
• Ambulatory services to individuals under age 18 and individuals entitled to institutional
services;
• Home health services to individuals entitled to nursing facility services; and
• If the State Plan includes services either in institutions for mental diseases or in
intermediate care facilities for the mentally retarded (ICFs/MR), it must offer medically
needy groups certain specified services provided to the categorically needy.
States may also receive Federal funding if they elect to provide other optional services. The most
commonly covered optional services under the Medicaid program include:
• Clinic services;
• Services of ICFs/MR;
• Nursing facility services (children under 21 years old);
• Prescribed drugs;
• Optometrist services and eyeglasses;
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and Human Services (DHHS) has determined has a shortage of home health agencies, the services are
furnished by nurses employed by the RHC, and the services are furnished to a homebound recipient
under a written plan of treatment.
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Voluntary Sterilizations: FFP is available in expenditures for the sterilization of an individual only if
she is at least age 21, has voluntarily given informed consent in accordance with Medicaid
regulations, and is not a mentally incompetent individual.
Physicians’ Services
Physicians’ services are covered, whether provided in the office, the patient’s home, a hospital, a
nursing facility, or elsewhere. Such services must be within the physicians’ scope of practice of
medicine or osteopathy as defined by State law, and by or under the personal supervision of an
individual licensed under State law to practice medicine or osteopathy.
Prescribed Drugs
Prescribed drugs are simple or compound substances or mixtures of substances prescribed for the
cure, mitigation, or prevention of disease, or for health maintenance, which are prescribed by a
physician or other licensed practitioner of the healing arts within the scope of their professional
practice, as defined and limited by Federal and State law (42 CFR 440.120). The drugs must be
dispensed by licensed authorized practitioners on a written prescription that is recorded and
maintained in the pharmacist’s or the practitioner’s records.
Personal support services consist of a variety of services including personal care, targeted case
management, home and community-based care for functionally disabled elderly, rehabilitative
services, hospice services, and nurse-midwife, nurse practitioner, and private duty nursing. Details of
some of these services are provided below:
1. Personal Care Services: Services provided to an individual who is not an inpatient or
resident of a hospital, nursing facility, intermediate care facility for the mentally
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Nurse-Midwife Services
Nurse-midwife services are those concerned with management of the care of mothers and newborns
throughout the maternity cycle. The Omnibus Budget Reconciliation Act of 1980 required that
payment be made providing for nurse-midwife services to categorically needy recipients (42 CFR
440.165). These provisions require States to provide coverage for nurse-midwife services to the
extent that the nurse-midwife is authorized to practice under State law or regulation. The statute also
requires that States offer direct reimbursement to nurse-midwives as one of the payment options.
Nurse-midwives must be registered nurses who are either certified by an organization recognized by
the Secretary of DHHS or who have completed a program of study and clinical experience that has
been approved by the Secretary.
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• The facility receives a grant under sections 329, 330, or 340 of the Public Health Service
Act;
• The Health Resources and Services Administration (HRSA) recommends, and the DHHS
Secretary determines, that the facility meets the requirements of the grant; or
• The Secretary determines that a facility may qualify through waivers of the requirements.
Such a waiver cannot exceed two years.
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Receiving
Total Cash Medically Poverty 1115 MAS
State Eligibles Assistance Needy Related Other Demonstration Unknown
National Total 51,552,491 18,215,830 4,401,790 15,073,035 8,638,035 5,222,626 1,175
Alabama 845,125 285,853 0 415,276 37,583 106,412 1
Alaska 121,400 51,076 0 59,975 10,349 0 0
Arizona 1,053,602 464,480 0 261,509 191,223 136,390 0
Arkansas 608,017 157,551 10,178 240,028 53,153 147,107 0
California 9,336,447 4,248,290 954,214 515,990 1,439,123 2,178,830 0
Colorado 438,670 219,239 0 163,359 56,072 0 0
Connecticut 487,989 90,988 37,438 77,862 281,701 0 0
Delaware 147,197 69,003 0 13,727 42,564 21,903 0
District of Columbia 204,591 121,320 37,458 35,262 10,551 0 0
Florida 2,691,502 1,113,402 73,312 978,702 387,399 138,672 15
Georgia 1,459,631 525,736 11,140 647,738 275,017 0 0
Hawaii 195,684 97,250 2,434 44,997 15,949 35,054 0
Idaho 196,406 27,994 0 112,074 56,338 0 0
Illinois 2,076,146 293,787 464,565 907,285 247,823 162,686 0
Indiana 881,942 346,171 0 334,326 201,445 0 0
Iowa 358,708 153,913 10,470 111,512 82,813 0 0
Kansas 305,110 106,986 20,423 125,774 51,927 0 0
Kentucky 769,826 343,646 34,626 313,097 78,457 0 0
Louisiana 990,286 347,677 12,207 526,815 103,587 0 0
Maine 346,449 75,324 2,281 89,232 63,619 115,993 0
Maryland 752,065 208,927 91,591 396,639 54,907 0 1
Massachusetts 1,204,312 330,017 21,919 444,390 154,005 253,981 0
Michigan 1,527,627 438,127 128,552 524,624 436,113 0 211
Minnesota 680,627 227,569 55,720 47,787 229,354 120,197 0
Mississippi 707,986 305,857 0 380,081 22,009 0 39
Missouri 1,098,525 679,410 0 128,970 170,202 119,943 0
Montana 106,229 45,831 8,812 25,458 26,119 0 9
Nebraska 266,245 62,809 43,608 130,929 28,238 0 661
Nevada 203,251 78,290 0 65,462 59,499 0 0
New Hampshire 115,517 26,064 11,039 53,280 25,134 0 0
New Jersey 982,676 359,040 5,133 373,027 145,072 100,404 0
New Mexico 462,878 184,972 0 206,152 59,022 12,713 19
New York 4,139,898 1,337,584 1,883,373 420,071 100,457 398,413 0
North Carolina 1,389,455 601,045 42,021 678,924 67,465 0 0
North Dakota 71,619 36,148 14,690 5,330 15,451 0 0
Ohio 1,754,379 430,980 0 363,075 960,324 0 0
Oklahoma 677,788 108,330 7,706 463,661 98,091 0 0
Oregon 637,140 146,559 9,472 171,403 129,447 180,084 175
Pennsylvania 1,710,999 699,940 114,369 574,506 322,184 0 0
Rhode Island 204,789 82,419 4,330 29,368 47,524 41,148 0
South Carolina 895,863 295,611 0 382,483 217,753 0 16
South Dakota 113,925 40,732 0 48,892 24,301 0 0
Tennessee 1,700,384 485,216 121,968 252,406 181,966 658,809 19
Texas 3,202,171 930,165 77,768 1,618,830 574,504 904 0
Utah 233,156 85,897 5,558 87,040 54,661 0 0
Vermont 156,958 30,893 13,253 48,162 14,078 50,572 0
Virginia 727,784 141,198 8,395 422,709 155,481 0 1
Washington 1,104,813 260,809 16,819 394,375 361,851 70,959 0
West Virginia 362,264 133,188 5,087 198,667 25,322 0 0
Wisconsin 776,638 263,555 39,861 124,246 177,525 171,443 8
Wyoming 69,802 18,962 0 37,548 13,283 9 0
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.
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American
Indian/
Total Black/African Alaska Hispanic or
State Eligibles White American Native Asian Latino Other
National Total 51,552,491 22,476,575 12,282,148 743,956 1,222,704 10,694,241 4,132,867
Alabama 845,125 386,692 413,920 2,204 3,651 13,566 25,092
Alaska 121,400 51,974 6,275 44,388 5,695 4,449 8,619
Arizona 1,053,602 385,624 62,086 137,230 12,181 436,283 20,198
Arkansas 608,017 378,477 194,146 4,844 5,151 21,159 4,240
California 9,336,447 2,136,678 943,186 43,312 460,010 4,871,320 881,941
Colorado 438,670 203,858 31,916 3,275 4,264 163,887 31,470
Connecticut 487,989 227,213 108,673 946 10,545 140,416 196
Delaware 147,197 63,923 63,337 288 2,042 17,181 426
District of Columbia 204,591 3,166 180,962 25 1,568 11,859 7,011
Florida 2,691,502 1,015,714 807,949 1,271 13,788 552,750 300,030
Georgia 1,459,631 595,614 735,738 1,084 13,586 12,675 100,934
Hawaii 195,684 41,169 2,973 469 57,127 5,882 88,064
Idaho 196,406 158,930 1,547 5,082 861 29,782 204
Illinois 2,076,146 837,072 779,474 3,752 50,926 383,503 21,419
Indiana 881,942 609,861 197,903 579 3,173 60,867 9,559
Iowa 358,708 261,289 27,993 1,874 3,504 8,402 55,646
Kansas 305,110 201,217 51,148 4,073 2,696 36,404 9,572
Kentucky 769,826 626,904 97,351 297 1,913 11,867 31,494
Louisiana 990,286 346,283 574,364 1,780 3,425 5,539 58,895
Maine 346,449 334,640 5,131 3,005 2,274 1,399 0
Maryland 752,065 254,437 397,418 1,284 20,551 51,213 27,162
Massachusetts 1,204,312 592,131 127,243 2,646 39,039 188,078 255,175
Michigan 1,527,627 863,660 520,060 7,779 22,142 79,963 34,023
Minnesota 680,627 413,244 105,466 27,520 44,513 2,140 87,744
Mississippi 707,986 241,923 424,485 2,901 2,786 5,042 30,849
Missouri 1,098,525 773,021 283,495 2,204 7,027 351 32,427
Montana 106,229 78,698 730 23,975 435 2,336 55
Nebraska 266,245 180,346 32,801 9,318 2,845 95 40,840
Nevada 203,251 114,714 37,657 3,362 6,727 40,791 0
New Hampshire 115,517 106,887 2,032 95 832 3,342 2,329
New Jersey 982,676 342,642 306,819 3,263 20,462 200,015 109,475
New Mexico 462,878 116,769 10,384 87,040 2,627 236,470 9,588
New York 4,139,898 1,250,339 898,747 52,389 154,509 648,943 1,134,971
North Carolina 1,389,455 607,557 569,579 23,854 12,478 94,973 81,014
North Dakota 71,619 54,016 1,367 15,907 294 0 35
Ohio 1,754,379 1,142,733 529,489 1,788 8,405 51,314 20,650
Oklahoma 677,788 421,204 111,899 87,341 5,973 51,371 0
Oregon 637,140 469,028 27,287 14,161 17,365 102,107 7,192
Pennsylvania 1,710,999 1,020,844 470,098 1,961 32,235 129,568 56,293
Rhode Island 204,789 92,982 17,997 327 5,046 37,098 51,339
South Carolina 895,863 359,348 480,943 1,294 1,757 13,314 39,207
South Dakota 113,925 68,633 2,346 39,991 651 2,120 184
Tennessee 1,700,384 1,121,661 471,076 3,605 11,783 36,923 55,336
Texas 3,202,171 855,101 606,560 11,602 41,413 1,650,717 36,778
Utah 233,156 163,596 4,815 10,234 9,678 41,538 3,295
Vermont 156,958 92,535 1,023 244 425 302 62,429
Virginia 727,784 333,733 335,288 1,125 18,601 37,338 1,699
Washington 1,104,813 709,195 68,751 29,629 52,419 148,121 96,698
West Virginia 362,264 335,086 18,575 180 719 702 7,002
Wisconsin 776,638 378,877 130,331 11,703 20,320 41,865 193,542
Wyoming 69,802 55,337 1,315 5,456 267 6,901 526
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.
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Total Medicaid Eligibles Per 1000 Population, 2002
Source: U.S. Department of Commerce, Bureau of the Census, Population Estimates, December 18, 2003; CMS, MSIS Report,
FY 2002.
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*The data displayed in this table were compiled from the CMS website at http://www.cms.hhs.gov/schip/enrollment/schip03.pdf.
Column and row values do not always sum to totals.
NR- State has not reported data via the Statistical Enrollment Data System (SEDS).
Source: CMS, SCHIP Enrollment Report, August 5, 2004.
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Not a QMB/
State All Eligibles Dual Eligible QMB Only Medicaid SLMB Only
National Total 51,552,491 40,008,697 461,055 3,946,067 319,072
Alabama 845,125 627,146 24,763 91,387 22,661
Alaska 121,400 99,842 5 7,852 119
Arizona 1,053,602 891,673 918 52,667 114
Arkansas 608,017 421,744 18,403 96,042 2,907
California 9,336,447 7,523,677 7,008 764,249 3,122
Colorado 438,670 336,155 6,320 41,897 3,476
Connecticut 487,989 376,168 6,209 45,416 3,443
Delaware 147,197 118,672 3,935 5,658 3,242
District of Columbia 204,591 173,783 87 11,381 860
Florida 2,691,502 2,072,192 21,989 280,205 19,242
Georgia 1,459,631 1,163,783 50,127 0 46
Hawaii 195,684 156,830 107 21,515 1,262
Idaho 196,406 171,732 2,809 10,706 0
Illinois 2,076,146 1,581,719 10,717 125,373 2,311
Indiana 881,942 706,225 8,787 61,139 5,842
Iowa 358,708 257,128 4,533 29,288 3,574
Kansas 305,110 227,750 4,191 25,299 2,366
Kentucky 769,826 549,992 24,944 83,171 10,805
Louisiana 990,286 787,181 24,420 101,528 12,220
Maine 346,449 242,436 2,524 31,984 5,013
Maryland 752,065 612,534 13,750 53,339 5,475
Massachusetts 1,204,312 887,127 184 67,784 14,098
Michigan 1,527,627 1,217,506 552 78,539 12,687
Minnesota 680,627 504,862 1,705 58,945 6,072
Mississippi 707,986 523,298 603 140,540 1,512
Missouri 1,098,525 899,710 9,149 58,471 4,953
Montana 106,229 78,459 394 10,236 603
Nebraska 266,245 215,554 0 22,551 2,305
Nevada 203,251 150,778 7,223 18,404 5,670
New Hampshire 115,517 90,356 1,838 17,973 0
New Jersey 982,676 715,363 0 111,678 20,333
New Mexico 462,878 408,518 10,191 4,404 0
New York 4,139,898 2,963,226 2,007 224,938 0
North Carolina 1,389,455 1,004,720 720 194,145 27,374
North Dakota 71,619 51,954 724 1,431 598
Ohio 1,754,379 1,450,281 29,749 0 0
Oklahoma 677,788 495,758 22 82,863 8,308
Oregon 637,140 476,725 4,571 29,713 8,937
Pennsylvania 1,710,999 1,294,399 520 205,913 18,831
Rhode Island 204,789 158,661 221 18,337 1,138
South Carolina 895,863 756,869 0 78,482 17
South Dakota 113,925 88,716 2,370 3,010 1,171
Tennessee 1,700,384 1,322,117 36,052 54,344 21,870
Texas 3,202,171 2,471,405 57,996 280,680 30,912
Utah 233,156 194,965 1,084 8,481 492
Vermont 156,958 120,711 159 9,750 361
Virginia 727,784 524,983 32,289 73,502 13,000
Washington 1,104,813 936,178 8,113 76,956 6,089
West Virginia 362,264 286,111 12,924 0 0
Wisconsin 776,638 565,889 1,686 71,103 2,979
Wyoming 69,802 55,136 1,463 2,798 662
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.
QMB Only = Qualified Medicare Beneficiaries Without Other Medicaid
QMB/ Medicaid = QMBs With Full Medicaid
SLMB Only = Specified Low-Income Beneficiaries Without Other Medicaid
SLMB/Medicaid = SLMBs with full Medicaid
QDWI = Qualified Disabled and Working Individuals
QI 1 = Qualifying Individuals (1)
QI 2 = Qualifying Individuals (2)
Other = Other Dual Eligibles, Dual Category Unknown, and Dual Status Unknown
Source: CMS, MSIS Report, FY 2002.
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SLMB/
State Medicaid QDWI QI(1) QI(2) Other
National Total 284,793 3,961 136,263 45,553 6,347,030
Alabama 9,952 0 2,897 62 66,257
Alaska 0 0 0 0 13,582
Arizona 0 0 31 43 108,156
Arkansas 0 3,881 0 0 65,040
California 113,100 4 1,714 1,532 922,041
Colorado 3 1 1,556 767 48,495
Connecticut 6,160 0 4,116 0 46,477
Delaware 0 0 23 0 15,667
District of Columbia 0 0 261 237 17,982
Florida 37,316 0 22,385 0 238,173
Georgia 0 0 0 0 245,675
Hawaii 0 0 0 0 15,970
Idaho 0 0 0 0 11,159
Illinois 17,643 0 10,360 0 328,023
Indiana 14,933 3 3,235 3,278 78,500
Iowa 6,464 0 1,817 1,019 54,885
Kansas 210 0 852 34 44,408
Kentucky 4,315 0 3,979 1,225 91,395
Louisiana 446 0 6,214 4,267 54,010
Maine 1,899 51 1,464 693 60,385
Maryland 0 0 1,833 1,192 63,942
Massachusetts 0 0 2,915 3,267 228,937
Michigan 0 6 5,506 5,628 207,203
Minnesota 10,521 0 2,243 0 96,279
Mississippi 0 0 0 2,840 39,193
Missouri 8,260 0 290 533 117,159
Montana 1,698 0 0 0 14,839
Nebraska 0 0 0 0 25,835
Nevada 0 0 0 0 21,176
New Hampshire 0 0 0 0 5,350
New Jersey 0 0 8,334 0 126,968
New Mexico 0 0 0 0 39,765
New York 0 0 0 0 949,727
North Carolina 5,547 0 12,133 0 144,816
North Dakota 337 0 270 77 16,228
Ohio 0 0 0 0 274,349
Oklahoma 4,688 0 0 0 86,149
Oregon 4 0 4,871 4,647 107,672
Pennsylvania 13,066 0 11,249 4,496 162,525
Rhode Island 0 0 653 564 25,215
South Carolina 0 0 6 2 60,487
South Dakota 934 0 514 152 17,058
Tennessee 0 0 0 0 266,001
Texas 8,073 0 15,658 5,381 332,066
Utah 0 0 223 146 27,765
Vermont 5,266 0 12 0 20,699
Virginia 0 14 4,644 3,218 76,134
Washington 1,923 0 2,700 0 72,854
West Virginia 0 0 0 0 63,229
Wisconsin 8,477 1 969 135 125,399
Wyoming 3,558 0 336 118 5,731
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.
QMB Only = Qualified Medicare Beneficiaries Without Other Medicaid
QMB/ Medicaid = QMBs With Full Medicaid
SLMB Only = Specified Low-Income Beneficiaries Without Other Medicaid
SLMB/Medicaid = SLMBs with full Medicaid
QDWI = Qualified Disabled and Working Individuals
QI 1 = Qualifying Individuals (1)
QI 2 = Qualifying Individuals (2)
Other = Other Dual Eligibles, Dual Category Unknown, and Dual Status Unknown
Source: CMS, MSIS Report, FY 2002.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Total Medicaid Medical Vendor Payments and Dual Eligibility Status, 20021
Not a QMB/
State All Eligibles Dual Eligible QMB Only Medicaid SLMB Only
National Total $213,491,313,278 $106,490,928,726 $1,030,874,920 $42,127,217,095 $380,179,278
Alabama $3,204,063,602 $1,274,232,277 $15,621,507 $776,780,560 $1,742,014
Alaska $686,795,186 $453,075,715 $2,393 $115,089,861 $42,590
Arizona $2,881,870,077 $1,948,997,686 $1,060,033 $434,460,779 $370,784
Arkansas $2,015,436,554 $883,682,774 $33,136,737 $982,685,560 $876,861
California $23,636,239,505 $13,213,780,910 $17,194,733 $5,372,345,733 $8,953,869
Colorado $2,166,199,614 $1,025,390,092 $2,726,907 $539,103,641 $378,910
Connecticut $3,245,142,644 $1,175,956,667 $4,499,349 $1,158,720,879 $932,196
Delaware $651,384,655 $376,621,212 $5,282,458 $96,699,451 $710,727
District of
Columbia $1,027,022,357 $628,363,371 $31,210 $145,262,877 $391,722
Florida $9,827,003,688 $4,874,067,948 $70,370,898 $1,572,827,572 $1,914,956
Georgia $4,796,005,361 $2,604,578,450 $75,123,488 $0 $481,290
Hawaii $695,279,178 $350,981,489 $98,371 $170,361,874 $438,832
Idaho $791,863,699 $574,360,327 $2,988,527 $155,399,823 $0
Illinois $9,121,713,188 $4,462,411,533 $8,884,937 $1,663,359,310 $150,684
Indiana $3,725,257,965 $1,828,126,131 $4,655,964 $965,283,909 $770,567
Iowa $1,855,817,441 $849,122,634 $4,851,165 $514,241,421 $1,118,401
Kansas $1,501,270,019 $641,032,282 $2,589,548 $442,607,105 $623,360
Kentucky $3,459,365,581 $2,024,455,125 $30,181,481 $837,839,353 $5,423,430
Louisiana $3,234,421,939 $1,818,732,605 $15,725,714 $1,129,348,514 $1,891,563
Maine $1,716,581,955 $1,007,751,695 $2,241,357 $402,060,123 $4,571,138
Maryland $3,662,089,984 $2,174,249,468 $42,413,617 $561,303,632 $7,178,292
Massachusetts $6,387,100,271 $2,842,987,095 $1,119,363 $1,276,162,774 $13,833,824
Michigan $5,918,817,382 $2,383,042,311 $239,353 $324,807,789 $12,825,261
Minnesota $4,439,493,794 $1,971,803,574 $1,834,826 $1,269,281,520 $1,576,820
Mississippi $2,499,640,805 $1,244,615,576 $460,562 $1,115,192,344 $529,391
Missouri $4,071,544,403 $2,116,935,133 $13,187,461 $722,404,739 $1,793,555
Montana $532,886,400 $267,585,800 $95,329 $121,091,801 $1,823
Nebraska $1,255,039,718 $597,240,859 $0 $203,777,475 $830,507
Nevada $723,956,752 $393,365,477 $4,139,667 $205,892,296 $1,351,254
New
Hampshire $745,754,084 $322,552,211 $5,726,610 $393,680,976 $0
New Jersey $5,497,284,438 $2,463,309,859 $0 $2,200,468,218 $21,904,790
New Mexico $1,796,901,383 $270,634,581 $2,669,257 $26,751,670 $0
New York $31,488,930,244 $14,675,424,270 $283,178 $4,530,472,744 $0
North
Carolina $6,041,011,008 $3,069,848,793 $476,113 $1,956,224,103 $11,998,085
North Dakota $422,745,114 $141,026,852 $527,092 $11,637,757 $70,489
Ohio $9,186,330,669 $4,505,534,072 $53,754,743 $0 $0
Oklahoma $2,238,213,087 $1,000,843,567 $1,581 $866,098,451 $1,100,816
Oregon $2,136,400,869 $1,197,343,350 $2,454,895 $331,546,311 $104,945,182
Pennsylvania $8,523,928,057 $4,394,947,388 $180,299 $2,006,722,671 $5,704,980
Rhode Island $1,251,440,036 $618,547,690 $29,133 $197,393,826 $650,916
South
Carolina $3,382,950,504 $1,596,815,267 $0 $633,188,504 $332
South Dakota $503,947,234 $245,685,676 $2,324,910 $86,640,920 $486,079
Tennessee $4,747,549,898 $2,989,461,147 $423,736,615 $193,006,651 $148,528,283
Texas $11,121,020,040 $6,226,003,393 $13,230,318 $2,572,622,555 $2,739,277
Utah $1,215,620,497 $597,811,407 $20,665,614 $148,327,002 $617,489
Vermont $607,249,969 $345,763,875 $326,101 $80,741,638 $810,752
Virginia $3,017,869,649 $1,491,183,939 $97,494,303 $840,368,767 $3,077,319
Washington $4,373,171,467 $1,866,732,897 $11,597,264 $725,557,952 $4,353,706
West Virginia $1,577,697,829 $809,141,082 $32,163,017 $0 $0
Wisconsin $3,605,541,906 $1,518,334,992 $1,330,865 $1,025,297,993 $1,423,172
Wyoming $280,451,579 $136,436,202 $1,146,057 $26,025,571 $62,990
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.
QMB Only = Qualified Medicare Beneficiaries Without Other Medicaid
QMB/ Medicaid = QMBs With Full Medicaid
SLMB Only = Specified Low-Income Beneficiaries Without Other Medicaid
SLMB/Medicaid = SLMBs with full Medicaid
QDWI = Qualified Disabled and Working Individuals
QI 1 = Qualifying Individuals (1)
QI 2 = Qualifying Individuals (2)
Other = Other Dual Eligibles, Dual Category Unknown, and Dual Status Unknown
Source: CMS, MSIS Report, FY 2002
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Total Medicaid Medical Vendor Payments and Dual Eligibility Status, 2002 (Con’t)1
SLMB/
State Medicaid QDWI QI (1) QI (2) Other
National Total $3,559,380,313 $735,149 $178,350,688 $74,882,766 $59,648,764,343
Alabama $112,567,502 $0 $513,112 $92,115 $1,022,514,515
Alaska $0 $0 $0 $0 $118,584,627
Arizona $0 $0 $84,004 $243,720 $496,653,071
Arkansas $0 $672,119 $0 $0 $114,382,503
California $745,947,070 $4,165 $1,162,676 $566,590 $4,276,283,759
Colorado $142 $0 $146,264 $68,737 $598,384,921
Connecticut $197,571,333 $0 $411,137 $0 $707,051,083
Delaware $0 $0 $333,000 $0 $171,737,807
District of Columbia $0 $0 $85,870 $206,988 $252,680,319
Florida $123,645,804 $0 $20,102,739 $0 $3,164,073,771
Georgia $0 $0 $0 $0 $2,115,822,133
Hawaii $0 $0 $0 $0 $173,398,612
Idaho $0 $0 $0 $0 $59,115,022
Illinois $296,069,746 $0 $63,709,153 $0 $2,627,127,825
Indiana $263,277,503 $0 $608,687 $847,483 $661,687,721
Iowa $115,732,538 $0 $615,501 $498,436 $369,637,345
Kansas $1,482,507 $0 $126,091 $0 $412,809,126
Kentucky $105,575,625 $0 $1,404,720 $323,582 $454,162,265
Louisiana $5,298,239 $0 $769,228 $665,812 $261,990,264
Maine $26,664,799 $42,650 $1,479,128 $829,750 $270,941,315
Maryland $0 $0 $676,428 $943,460 $875,325,087
Massachusetts $0 $0 $708,782 $592,059 $2,251,696,374
Michigan $0 $9,474 $5,622,730 $6,009,856 $3,186,260,608
Minnesota $228,125,144 $0 $651,618 $0 $966,220,292
Mississippi $0 $0 $0 $1,279,733 $137,563,199
Missouri $109,503,184 $0 $164,581 $159,402 $1,107,396,348
Montana $23,213,856 $0 $0 $0 $120,897,791
Nebraska $0 $0 $0 $0 $453,190,877
Nevada $0 $0 $0 $0 $119,208,058
New Hampshire $0 $0 $0 $0 $23,794,287
New Jersey $0 $0 $10,312,558 $0 $801,289,013
New Mexico $0 $0 $0 $0 $1,496,845,875
New York $0 $0 $0 $0 $12,282,750,052
North Carolina $145,924,080 $0 $4,503,365 $0 $852,036,469
North Dakota $2,172,957 $0 $28,265 $3,604 $267,278,098
Ohio $0 $0 $0 $0 $4,627,041,854
Oklahoma $80,888,878 $0 $0 $0 $289,279,794
Oregon $20,304 $0 $57,550,344 $58,249,186 $384,291,297
Pennsylvania $418,438,234 $0 $2,601,815 $1,411,225 $1,693,921,445
Rhode Island $0 $0 $121,993 $246,581 $434,449,897
South Carolina $0 $0 $0 $0 $1,152,946,401
South Dakota $22,512,693 $0 $482,607 $95,771 $145,718,578
Tennessee $0 $0 $0 $0 $992,817,202
Texas $150,439,855 $0 $971,338 $0 $2,155,013,304
Utah $0 $0 $158,160 $162,856 $447,877,969
Vermont $129,875,293 $0 $33,049 $0 $49,699,261
Virginia $0 $6,741 $1,129,860 $1,371,915 $583,236,805
Washington $9,357,997 $0 $879,661 $0 $1,754,691,990
West Virginia $0 $0 $0 $0 $736,393,730
Wisconsin $150,448,240 $0 $193,214 $7,787 $908,505,643
Wyoming $94,626,790 $0 $9,010 $6,118 $22,088,741
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.
QMB Only = Qualified Medicare Beneficiaries Without Other Medicaid
QMB/ Medicaid = QMBs With Full Medicaid
SLMB Only = Specified Low-Income Beneficiaries Without Other Medicaid
SLMB/Medicaid = SLMBs with full Medicaid
QDWI = Qualified Disabled and Working Individuals
QI 1 = Qualifying Individuals (1)
QI 2 = Qualifying Individuals (2)
Other = Other Dual Eligibles, Dual Category Unknown, and Dual Status Unknown
Source: CMS, MSIS Report, FY 2002
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100%
40%
55.6% 55.8% 56.8% 57.6% 59.1% 60.7%
47.8% 53.6%
20% 29.4%
40.1%
23.2%
14.4%
0%
19 9 3 19 9 4 19 9 5 19 9 6 19 9 7 19 9 8 19 9 9 2000 2001 2002 2003 2004
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2004. DHHS, CMS, Center for Medicaid
& State Operations. *Approximated numbers for 1995. Total Medicaid population was provided by the Office of the Actuary,
which used CMS 2082 data to calculate average Medicaid enrollees over 1995. The managed care population differs from the
11,619,929 reported in the 1995 report as the number represented enrollment of some beneficiaries in more than one plan.
Medicaid managed care beneficiaries can be enrolled in one of five basic Medicaid managed care
plans:
• Health Insuring Organization (HIO): an entity that provides for or arranges for the
provision of care and contracts on a prepaid capitated risk basis to provide a
comprehensive set of services.
• Commercial Managed Care Organization (Com-MCO): a Com-MCO is a health
maintenance organization with a contract under §1876 or a Medicare+Choice
organization, a provider sponsored organization or any other private or public
organization, which meets the requirements of §1902(w). They provide
comprehensive services to commercial and/or Medicare enrollees, as well as
Medicaid enrollees.
• Medicaid-only Managed Care Organization (Mcaid-MCO): an MCO that
provides comprehensive services to Medicaid beneficiaries, but not commercial or
Medicare enrollees.
• Prepaid Inpatient Health Plan (PIHP): an entity that provides less than
comprehensive services on an at-risk basis or one that provides any benefit package
on a non-risk or other than State reimbursement Plan basis; and provides, arranges
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National Pharmaceutical Council Pharmaceutical Benefits 2004
for or otherwise has responsibility for the provision of any inpatient hospital or
institutional services.
• Prepaid Ambulatory Health Plan (PAHP): a prepaid ambulatory health plan that
provides less than comprehensive services on an at-risk or other than State Plan
reimbursement basis, and does not provide, arranges for, or otherwise has
responsibility for the provision of any inpatient hospital or institutional services.
• Primary Care Case Management (PCCM): a provider (usually a physician,
physician group practice, or an entity employing or having other arrangements with
such physicians, but sometimes also including nurse practitioners, nurse-midwives,
or physician assistants) who contracts to locate, coordinate, and monitor covered
primary care (and sometimes additional services). This category includes those
PIHPs that act as PCCMs.
• Program for All-Inclusive Care for the Elderly (PACE): a program that provides
prepaid, capitated comprehensive health care services to the frail elderly.
• “Other” Managed Care Arrangement: An entity where the plan is not considered
a PCCM, PIHP, PAHP, Comprehensive MCO, Medicaid-only MCO, HIO, or PACE.
The most utilized of these plans are Comprehensive MCOs and Prepaid Health Plans.
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2004. DHHS, CMS, Center for Medicaid
& State Operations.
The following tables provide an overview of Medicaid managed care enrollment at the State level.
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Rank Based on
Medicaid Medicaid Managed Percent in Percent in
State Enrollment Care Enrollment Managed Care Managed Care
National Total 44,355,955 26,913,570 60.68%
Alabama 800,569 439,832 54.94% 39
Alaska 96,630 0 0.00% 50
Arizona 904,658 806,193 89.12% 8
Arkansas 594,264 386,395 65.02% 29
California 6,471,239 3,258,787 50.36% 42
Colorado 378,416 369,270 97.58% 3
Connecticut 402,286 303,404 75.42% 17
Delaware 135,224 99,598 73.65% 18
District of Columbia 138,637 88,452 63.80% 31
Florida 2,207,375 1,450,117 65.69% 27
Georgia 1,323,036 1,273,133 96.23% 5
Hawaii 190,381 145,580 78.04% 15
Idaho 166,088 131,693 79.29% 12
Illinois 1,740,488 158,869 9.13% 48
Indiana 803,786 509,732 63.42% 33
Iowa 284,918 262,487 92.13% 7
Kansas 269,032 153,395 57.02% 38
Kentucky 678,529 625,807 92.23% 6
Louisiana 919,079 723,837 78.76% 14
Maine 258,686 154,785 59.84% 36
Maryland 696,097 469,998 67.52% 24
Massachusetts 947,297 581,520 61.39% 35
Michigan 1,409,832 1,255,067 89.02% 9
Minnesota 568,761 361,381 63.54% 32
Mississippi 637,910 73,445 11.51% 47
Missouri 974,310 432,339 44.37% 44
Montana 86,452 58,030 67.12% 25
Nebraska 206,701 149,405 72.28% 19
Nevada 169,334 89,846 53.06% 40
New Hampshire 96,188 0 0.00% 50
New Jersey 798,132 541,820 67.89% 23
New Mexico 420,935 273,018 64.86% 30
New York 4,022,544 2,341,733 58.22% 37
North Carolina 1,112,341 788,943 70.93% 20
North Dakota 52,458 33,065 63.03% 34
Ohio 1,645,454 507,337 30.83% 46
Oklahoma 518,926 354,110 68.24% 22
Oregon 426,905 345,410 80.91% 11
Pennsylvania 1,599,570 1,265,891 79.14% 13
Puerto Rico 873,211 842,827 96.52% 4
Rhode Island 180,528 124,921 69.20% 21
South Carolina 845,870 69,791 8.25% 49
South Dakota 97,774 95,577 97.75% 2
Tennessee 1,345,131 1,345,131 100.00% 1
Texas 2,692,012 1,150,773 42.75% 45
Utah 188,839 167,338 88.61% 10
Vermont 130,782 86,263 65.96% 26
Virgin Islands 10,900 0 0.00% 50
Virginia 607,493 398,871 65.66% 28
Washington 1,080,738 834,883 77.25% 16
West Virginia 298,093 156,468 52.49% 41
Wisconsin 792,177 374,003 47.21% 43
Wyoming 58,939 0 0.00% 50
State Medicaid enrollment includes individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility
standards. This table provides unduplicated figures for Medicaid Enrollment and Managed Care Enrollment by State for a single point in time. These
values differ significantly (i.e., are lower than) unduplicated annual counts of enrollees over the entire year.
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2004. DHHS, CMS, Center for Medicaid & State Operations.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions.
“-” indicates Not Applicable, “N/A” indicates “No Answer” was received on the Survey.
Sources: As reported by State drug program administrators in the 2004 NPC Survey.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
State Medicaid enrollment includes individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid
eligibility standards.
Sources: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2000; 2001; 2002; 2003and. DHHS, CMS, Center for
Medicaid & State Operations.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
HIO=Health Insuring Organization; Commercial MCO=Commercial Managed Care Organization; Medicaid-only MCO=Medicaid-only
Managed Care Organization; PCCM=Primary Care Case Management; PIHP=Prepaid Inpatient Health Plan; PAHP=Prepaid Ambulatory Health
Plans; PACE=Program for All-Inclusive Care for the Elderly.
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2004. DHHS, CMS, Center for Medicaid & State
Operations.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2004. DHHS, CMS, Center for Medicaid & State
Operations.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Individual State totals may not sum to total managed care enrollment (page 2-29) because State totals include individuals enrolled in more than
one plan type including dental, mental, and long-term care.
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2004. DHHS, CMS, Center for Medicaid & State
Operation
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Section 1915(b) waivers are granted to give States the authority to conduct Medicaid programs
outside of the scope of the Medicaid statute, allowing them to waive freedom of choice, statewide
access to care, and comparability requirements under Section 1902 of the Social Security Act. With a
1915(b) waiver, a State can require mandatory enrollment of Medicaid recipients in managed care
plans. Section 1915(b) waivers can also allow a State to create a “carveout” delivery system for
specialty care, e.g., a Managed Behavioral Health Care Plan. Section 1915(b) waivers cannot
negatively impact beneficiary access or quality of care of services, and must be cost-effective (i.e.,
cost must be less than the Medicaid program would cost without the waiver). Section 1915(b)
waivers are typically limited to a targeted geographical area or population, are approved for an initial
period of two years, and can be renewed on an ongoing basis if the State reapplies.
Four options for 1915(b) waivers exist; each is governed by a different subsection(s) of Section
1915(b);
• Paragraph (b)(1) - Case Management: States are allowed to implement case management
systems which can be as simple as requiring each beneficiary to choose a primary care
provider or as comprehensive as mandating enrollment in a prepaid health plan. The
Balanced Budget Act of 1997 also gave States the option to enroll certain beneficiaries
into managed care via a State Plan Amendment.
• Paragraph (b)(2) - Central Broker: Localities are allowed to act as a central broker in
assisting Medicaid eligibles in selecting among competing health care plans, if such a
restriction does not substantially impair access to medically necessary services of
adequate quality.
• Paragraph (b)(3) - Shared Cost Saving: States are allowed to share (through provision of
additional services) cost savings (resulting from use by the recipient of more cost-
effective medical care) with recipients of medical assistance under the State Plan.
• Paragraph (b)(4) - Restrict Providers: States can limit the number of providers of certain
services. These waivers are sometimes referred to as selective contracting waivers and
are gaining in popularity. For example, some approved 1915(b)(4) waivers include
programs to restrict the number of providers of transportation services, organ transplants,
and inpatient obstetrical care.
Although Section 1915(b) waivers allow States to increase access to managed care plans, States are still
limited under Federal regulations and cannot use them to serve beneficiaries beyond Medicaid State Plan
Eligibility or change their benefits package. In order to expand their Medicaid programs even further
than under Section 1915(b) waivers, States apply for Section 1115 research and demonstration waivers.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Section 1115 research and demonstration waivers release States from standard Medicaid
requirements, allowing them the flexibility to test substantially new ideas of policy merit. Along with
Section 1915(b) waivers, Section 1115 waivers allow States to waive freedom of choice, statewide
access to care, and comparability requirements. However, a Section 1115 waiver also allows States
to provide new and additional services, test new payment methods, offer benefits to new and
expanded populations, and contract with managed care organizations that do not meet the necessary
criteria of Section 1903 of the Social Security Act.
To receive approval of a Section 1115 waiver, States submit a proposal to CMS for discussion and
review. Once operational, States allow formal evaluations of the research and public policy value of
the programs and to demonstrate that their programs do not exceed costs, which would have
otherwise occurred under traditional Medicaid programs (i.e., States must demonstrate budget
neutrality). Section 1115 waivers are usually granted for a five-year period and each State must
submit a request for continuation. For example, Arizona has operated its program under a Section
1115 waiver for over 20 years. The Benefits Improvement and Protection Act (BIPA) of 2000
streamlined the process for States to submit requests for and receive extensions of Section 1115
demonstration waivers.
Currently, there are 17 Medicaid programs with Section 1115 waiver approvals: Arizona, California,
Delaware, Hawaii, Kentucky, Maryland, Massachusetts, Minnesota, Missouri, New York, Oklahoma,
Oregon, Rhode Island, Tennessee, Utah, Vermont and Wisconsin. Refer to the table on page 2-40 for
a listing of implemented Section 1115 waivers.
Section 1115 demonstration authority may be used to extend pharmacy coverage to certain low-
income elderly and disabled individuals who are not otherwise eligible for Medicaid. This type of
Section 1115 waiver program is commonly referred to as “Pharmacy Plus.” Its purpose is to provide
a subsidized pharmacy benefit that is intended to assist individuals in maintaining their healthy status
and avoid spending down to Medicaid income and asset eligibility levels. The waivers will test how
provision of a pharmacy benefit to a non-Medicaid covered population will affect Medicaid costs,
utilization and future eligibility trends.
Pharmacy Plus demonstrations 1) cover an individual’s cost of drugs; 2) cover the individual’s cost
sharing obligation for private prescription programs; and 3) provide wrap-around coverage to bring
private sources of drug coverage up to the level of the Pharmacy Plus benefit. States may construct
their Pharmacy Plus programs to provide eligibility for individuals who are not eligible for full
Medicaid benefits and who have incomes below 200 percent of the Federal Poverty Level. Under a
Pharmacy Plus waiver, States may elect to provide a prescription and over-the-counter drug benefit
that is similar to, or different from, the benefits provided in the Medicaid State Plan. States may
choose to deliver the services via fee-for-service or capitation. Last, States may choose whether to
perform assets tests and income adjustments, and may also choose to enact an enrollment ceiling on
the number of individuals who participate in the demonstration.
Like all 1115 demonstrations, Pharmacy Plus waivers must be budget neutral to the Federal
government. Under the terms and conditions of an approved plan, which is usually granted for a 5-
year period, a ceiling cap is placed on Federal financial payments for services included in the budget
neutrality agreement. States are encouraged to involve the private sector in implementing these
programs and are encouraged to explore the use of pharmacy benefit managers (PBM). Premiums,
cost sharing (deductibles, co-payments and coinsurance), and benefit limitations are all available tools
for providing incentives and cost containment.
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As of September 16, 2004, four States had received Pharmacy Plus demonstration approval: Florida,
Illinois, South Carolina and Wisconsin. Another 8 states had applications pending and one state
withdrew its request.
Refer to the table on page 2-41 for a complete status of the Pharmacy Plus Demonstrations Program.
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1915)
Statutes
State Program(s) Approved Utilized Implemented Expiration
st
Alabama Patient 1 1, 3, 4 01/1/97 2/18/04
Alaska None -- -- --
Arizona None -- -- --
Non-Emergency Transportation 1, 4 3/1/98 11/21/05
Arkansas
Primary Care Physician 1 11/1/96 12/17/04
Caloptima 1, 4 10/1/95 7/10/05
Central Coast Alliance for Health 1, 4 1/1/96 7/10/05
Health Plan of San Mateo 1, 4 11/30/87 8/26/04
Hudman 4 4/24/92 10/14/03
Managed Care Network 1, 2, 4 3/1/97 6/30/03
Medi-Cal Mental Health Care Field Test (San Mateo Co.) 4 4/1/95 7/25/05
Medi-Cal Specialty Mental Health Services Consolidation 4 3/15/95 4/27/05
California
Partnership Health Plan of California 1, 4 5/1/94 2/10/05
Primary Care Case Management Program 1, 4 8/1/84 8/13/03
Sacramento Geographic Managed Care 1, 2, 4 4/1/94 10/8/04
San Diego Geographic Managed Care 1, 2, 4 10/17/98 10/10/03
Santa Barbara Health Initiative 1, 4 9/1/83 1/11/05
Selective Provider Contracting Program 4 9/21/82 12/31/04
Two-Plan Model Program 1, 2, 4 1/23/96 11/8/03
Colorado Mental Health Capitation Program 1, 3, 4 7/1/95 5/4/05
Connecticut HUSKY A 1, 4 10/1/95 5/30/04
Delaware None -- -- --
District of
DC Medicaid Managed Care Program
Columbia 1, 2, 4 4/1/94 6/30/04
Managed Health Care 1, 2, 3, 4 10/1/92 9/26/04
Florida Prepaid Mental Health Plan 1, 4 3/1/96 11/12/03
Statewide Inpatient Psychiatric Program 4 4/1/99 12/31/03
Non-Emergency Transportation Broker Program 4 10/1/97 1/10/04
Georgia Preadmission Screening and Annual Resident Review
(PASARR) 1, 4 11/1/94 10/5/05
Hawaii None -- -- --
Idaho Healthy Connections 1, 2 10/1/93 9/21/04
Illinois None -- -- --
Indiana Hoosier Healthwise 1 7/1/94 9/22/05
Indiana Medicaid Select 1 1/1/03 7/22/05
Iowa Iowa Plan for Behavioral Health 1, 3, 4 1/1/99 6/30/05
Kansas None -- -- --
Kentucky Human Service Transportation 1, 4 6/1/98 6/12/05
Louisiana Community Care 1 6/1/92 2/28/04
Maine None -- -- --
Maryland None -- -- --
Massachusetts None -- -- --
Michigan Comprehensive Health Care 1, 2, 4 7/1/97 4/21/05
Minnesota Consolidated Chemical Dependency Treatment Fund 1, 4 1/1/88 3/23/03
Mississippi None -- -- --
Missouri MC+ Managed Care/1915(b) 1, 2, 4 9/1/95 3/14/04
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1915)
Statutes
State Program(s) Approved Utilized Implemented Expiration
Montana Passport to Health 1, 2 1/1/94 4/24/04
Nebraska Nebraska Health Connection Combined Waiver Program 1, 2, 3, 4 7/1/95 6/30/05
Nevada None -- -- --
New
None
Hampshire -- -- --
New Jersey New Jersey Care 2000+ 1915(b) 1, 2 10/1/00 12/29/04
New Mexico SALUD! 1,4 7/1/97 6/30/04
New York Non-Emergency Transportation 1, 4 7/1/96 11/14/04
ACCESS II/III 1915(b) 1 7/1/98 8/5/03
North Carolina Carolina Access 1915(b) 1 4/1/91 8/5/03
Health Care Connection 1915(b) 1 7/1/96 8/5/03
North Dakota None -- -- --
Ohio PremierCare 1, 2, 4 7/1/01 6/30/05
Oklahoma None -- -- --
Oregon Transportation Program 4 9/1/94 7/25/03
Family Care Network 1 2/1/94 10/26/03
Pennsylvania
HealthChoices 1, 2, 3, 4 2/1/97 6/16/04
Puerto Rico None -- -- --
Rhode Island None -- -- --
South Carolina None
-- -- --
South Dakota None -- -- --
Tennessee None -- -- --
Lonestar Select I 4 9/1/94 9/3/04
Lonestar Select II 4 3/10/95 3/4/04
Texas
NorthSTAR 1, 2, 4 11/1/99 11/5/03
STAR 1, 2, 3, 4 8/1/93 8/31/03
Choice of Health Care Delivery 1, 2, 4 7/1/82 7/23/03
Utah Non-Emergency Transportation 1, 4 7/1/01 10/21/05
Prepaid Mental Health Program 4 7/1/91 12/26/05
Vermont None -- -- --
Medallion 1, 2 3/1/92 3/24/04
Virginia
Medallion II 1, 2, 4 1/1/96 12/25/04
Healthy Options 1, 4 10/1/93 7/1/03
Washington
The Integrated Mental Health Services 1, 4 7/1/93 3/4/04
Mountain Health Trust 1, 4 9/1/96 3/22/04
West Virginia
Physician Assured Access System 1,2 6/1/92 4/27/04
Wisconsin None -- -- --
Wyoming None -- -- --
Source: 2003 National Summary of State Medicaid Managed Care Programs. Program Descriptions as of June 30, 2003.
Centers for Medicare and Medicaid Services, Center for Medicaid & State Operations.
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Source: 2003 National Summary of State Medicaid Managed Care Programs. Program Descriptions as of June 30, 2003. Centers
for Medicare and Medicaid Services, Center for Medicaid & State Operations. Last Modified: 9/16/04.
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Section 3:
State Characteristics
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STATE CHARACTERISTICS
Presented in Section 3 of the Compilation is State-by-State information on several topics. The
Section begins with a series of tables showing select State demographic characteristics including
age composition and racial/Hispanic status. Next, insurance coverage, poverty status,
employment, and income data for each State are presented. The final group of tables show select
components of each State’s health care system including Medicare and Medicaid certified
facilities (hospitals, SNFs, ICFs/MR, home health agencies, and rural health clinics), licensed
pharmacies, and health manpower (physicians, Registered Nurses, and pharmacists).
The data in Section 3 have been compiled from a myriad of sources. These include:
• CMS
• The U.S. Bureau of the Census
• The Bureau of Labor Statistics (BLS)
• The Health Resources and Services Administration (HRSA)
• The National Association of Boards of Pharmacy
Because of the unevenness with which the various government agencies and other organizations
have released updated information, we have carefully reviewed all possible information sources
and made judgments on which data to present. In the final analysis, we have included those data
that, in our opinion, best reflect the factors and characteristics on which we have reported.
However, certain limitations in the different sources have resulted in some inconsistencies among
the tables. The following examples illustrate this problem.
The table showing the age distribution of the population is derived from the 2003 American
Community Survey conducted by the U.S. Bureau of the Census. Unfortunately, the
approximately 5 million individuals residing in “group quarters” were not included. Hence, the
total population figure (and the corresponding figures for each State) presented in this table is
lower than the population total in the table showing insurance status.
The data on insurance status was compiled from the Current Population Survey, 2004 Annual
Social and Economic Supplement, a collaborative effort by the Census Bureau and BLS. Hence,
the estimates on the number of Medicare and Medicaid beneficiaries differ slightly from those
published by CMS. In addition, more detailed data on poverty, also compiled from 2004 Annual
Social and Economic Supplement to the Current Population Survey, have been included in this
year’s Compilation.
HRSA’s Bureau of Health Professions, National Center for Health Workforce Analysis is
responsible for compiling the Area Resource File (ARF), an important annual data file for
researchers, planners, policymakers, and others seeking information on the health professions
workforce, health care facilities, health care utilization and expenditures, etc. at a variety of
geographic levels. The ARF has been our primary source of information on physicians and, for
the past several years, registered nurses. Unfortunately, 2002 physician data provided by the
American Medical Association (AMA) that HRSA had hoped to include in the 2004 ARF were
not able to be included. Instead, HRSA carried over 2001 physician data from the 2003 ARF.
Therefore, since no update information was available, we decided not to acquire the 2004 ARF
and have repeated the 2001 physician data that appeared in last year’s Compilation (see page 3-
16).
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The National Sample Survey of Registered Nurses is the most extensive and comprehensive
source of nursing statistics for the U.S health care system. Conducted every four years by
HRSA’s Bureau of Health Professions, Division of Nursing, the most recent data currently
available from this survey are for 2000. Since these data are somewhat out-of-date, we have, for
the past two years, turned to the ARF for nursing statistics. However, as is often the case, data
from different sources are not exactly the same. The ARF, for example, provides information on
the number of “full-time equivalent registered nurses, not a simple body count of the number of
full-time and part-time RNs. Thus, the number of nurses presented in the ARF may be lower than
those compiled from the National Sample Survey of Registered Nurses. Also, since we did not
obtain the 2004 ARF because of the lack of updated physician data, we also repeated the RN data
that were presented in the 2003 Compilation (see page 3-17).
Despite the limitations confronted while compiling these statistics, we believe that the data
presented in Section 3 provide a useful and meaningful picture of State characteristics. Users of
the Compilation are urged to carefully read the source information and notes at the bottom of each
table in order to understand the limitations of the data contained therein.
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Source: U.S. Department of Commerce, Bureau of the Census, 2003 American Community Survey.
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Source: U.S. Department of Commerce, Bureau of the Census, 2003 American Community Survey.
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Source: U.S. Department of Commerce, Bureau of the Census, 2003 American Community Survey.
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% Covered by % Covered by
Total % Covered by % Covered by Military Private
State Population Medicaid Medicare Insurance Insurance % Not Insured
National Total 288,280,000 12.4% 13.7% 3.5% 68.6% 15.6%
Alabama 4,427,000 13.2% 15.5% 4.1% 67.7% 14.2%
Alaska 645,000 15.1% 8.5% 14.0% 61.5% 18.9%
Arizona 5,576,000 13.3% 13.6% 6.3% 64.0% 17.0%
Arkansas 2,671,000 16.0% 17.0% 7.0% 60.7% 17.4%
California 35,394,000 15.1% 11.7% 2.7% 63.8% 18.4%
Colorado 4,480,000 9.1% 9.9% 5.6% 69.8% 17.2%
Connecticut 3,421,000 10.7% 15.4% 2.1% 75.8% 10.4%
Delaware 820,000 11.2% 13.4% 3.9% 75.7% 11.1%
District of Columbia 554,000 18.2% 12.5% 2.1% 64.6% 14.3%
Florida 16,921,000 11.2% 18.4% 4.7% 64.7% 18.2%
Georgia 8,571,000 11.3% 11.6% 3.3% 69.5% 16.4%
Hawaii 1,253,000 10.6% 14.1% 8.3% 74.0% 10.1%
Idaho 1,360,000 12.3% 12.3% 3.0% 67.1% 18.6%
Illinois 12,628,000 9.5% 13.5% 1.7% 73.2% 14.4%
Indiana 6,149,000 9.2% 13.7% 1.5% 73.7% 13.9%
Iowa 2,921,000 8.0% 15.9% 2.7% 79.3% 11.3%
Kansas 2,683,000 8.8% 12.9% 7.6% 75.4% 11.0%
Kentucky 4,110,000 13.4% 16.1% 6.0% 68.4% 14.0%
Louisiana 4,429,000 13.7% 13.7% 4.4% 61.3% 20.6%
Maine 1,283,000 18.0% 17.3% 4.2% 68.4% 10.4%
Maryland 5,493,000 8.0% 12.3% 3.4% 75.2% 13.9%
Massachusetts 6,367,000 11.9% 14.0% 1.8% 74.4% 10.7%
Michigan 9,918,000 12.7% 14.1% 1.4% 76.2% 10.9%
Minnesota 5,076,000 9.5% 11.3% 2.1% 81.0% 8.7%
Mississippi 2,854,000 18.8% 14.8% 6.6% 59.4% 17.9%
Missouri 5,623,000 12.1% 16.2% 3.4% 74.9% 11.0%
Montana 917,000 12.5% 14.7% 7.4% 64.2% 19.4%
Nebraska 1,727,000 8.8% 12.5% 4.8% 76.2% 11.3%
Nevada 2,250,000 8.3% 12.4% 4.0% 67.5% 18.9%
New Hampshire 1,264,000 6.9% 12.6% 2.4% 79.3% 10.3%
New Jersey 8,579,000 8.3% 12.6% 1.4% 74.2% 14.0%
New Mexico 1,871,000 19.3% 15.0% 4.8% 55.2% 22.1%
New York 18,970,000 16.5% 14.5% 1.2% 66.4% 15.1%
North Carolina 8,253,000 12.8% 14.7% 5.3% 63.9% 17.3%
North Dakota 631,000 8.7% 13.9% 6.8% 76.0% 10.9%
Ohio 11,247,000 10.7% 13.1% 2.0% 74.8% 12.1%
Oklahoma 3,438,000 11.5% 16.1% 6.5% 62.1% 20.4%
Oregon 3,569,000 11.6% 13.3% 3.4% 68.3% 17.2%
Pennsylvania 12,155,000 10.5% 17.1% 2.1% 75.8% 11.4%
Rhode Island 1,053,000 15.2% 15.5% 2.5% 72.7% 10.2%
South Carolina 4,064,000 13.6% 16.3% 5.4% 68.3% 14.4%
South Dakota 751,000 10.8% 15.8% 4.6% 74.6% 12.2%
Tennessee 5,909,000 16.3% 14.5% 4.4% 66.6% 13.2%
Texas 21,858,000 13.3% 10.6% 3.1% 57.9% 24.6%
Utah 2,352,000 8.5% 8.8% 3.6% 77.8% 12.7%
Vermont 611,000 18.4% 15.4% 3.3% 71.1% 9.5%
Virginia 7,386,000 7.8% 13.4% 10.2% 71.8% 13.0%
Washington 6,091,000 13.8% 11.3% 5.2% 68.3% 15.5%
West Virginia 1,787,000 16.6% 19.9% 3.6% 60.9% 16.6%
Wisconsin 5,429,000 12.1% 13.9% 1.6% 75.2% 10.9%
Wyoming 488,000 12.3% 13.1% 7.8% 68.2% 15.9%
*The sum of rows may be greater than the total State population because individuals may have dual coverage and appear in
more than one category.
Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2004 Annual Social and
Economic Supplement.
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Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2004 Annual Social and
Economic Supplement.
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Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2004 Annual Social and
Economic Supplement.
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Source: U.S. Department of Labor, Bureau of Labor Statistics, March 10, 2005.
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LEGEND
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Physicians, 2001
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# FTE # FTE
Registered Registered Nurses* Pharmacists** Pharmacists**
State Nurses* per 1,000 population (Licensed by State) per 1,000 population
National Total 962,195 3.4 352,869 1.2
Alabama 17,143 3.8 6,026 1.3
Alaska 2,339 3.7 616 0.9
Arizona 13,058 2.5 6,884 1.2
Arkansas 9,898 3.7 3,649 1.3
California 85,878 2.5 29,676 0.8
Colorado 12,034 2.7 5,445 1.2
Connecticut 9,930 2.9 4,486 1.3
Delaware 2,971 3.7 1,385 1.7
District of Columbia 5,011 8.7 1,564 2.8
Florida 56,078 3.4 21,540 1.2
Georgia 28,447 3.4 10,474 1.2
Hawaii 3,470 2.8 1,574 1.2
Idaho 3,599 2.7 1,623 1.2
Illinois 45,501 3.6 13,151 1.0
Indiana 21,436 3.5 8,696 1.4
Iowa 12,404 4.2 5,001 1.7
Kansas 9,102 3.4 3,652 1.3
Kentucky 16,213 4.0 5,383 1.3
Louisiana 17,274 3.9 5,970 1.3
Maine 5,265 4.1 1,267 1.0
Maryland 16,623 3.1 7,391 1.3
Massachusetts 24,133 3.8 9,940 1.5
Michigan 35,094 3.5 11,322 1.1
Minnesota 16,122 3.2 6,052 1.2
Mississippi 12,356 4.3 3,483 1.2
Missouri 23,650 4.2 7,123 1.2
Montana 3,205 3.5 1,556 1.7
Nebraska 7,249 4.2 2,722 1.6
Nevada 5,084 2.4 8,386 3.6
New Hampshire 4,206 3.3 1,963 1.5
New Jersey 28,082 3.3 13,100 1.5
New Mexico 5,258 2.9 2,325 1.2
New York 72,057 3.8 19,136 1.0
North Carolina 32,695 4.0 9,864 1.2
North Dakota 3,175 5.0 2,155 3.4
Ohio 43,869 3.9 14,703 1.3
Oklahoma 10,827 3.1 4,785 1.4
Oregon 11,674 3.4 4,189 1.2
Pennsylvania 48,786 4.0 17,991 1.5
Rhode Island 2,850 2.7 1,810 1.7
South Carolina 14,942 3.7 5,256 1.3
South Dakota 3,829 5.1 1,443 1.9
Tennessee 20,777 3.6 7,498 1.3
Texas 65,056 3.0 21,795 1.0
Utah 5,446 2.4 2,266 0.9
Vermont 1,656 2.7 840 1.4
Virginia 23,152 3.2 8,754 1.2
Washington 15,440 2.6 7,146 1.2
West Virginia 9,307 5.2 2,970 1.6
Wisconsin 16,878 3.1 5,836 1.1
Wyoming 1,666 3.4 1,007 2.0
*FTE- Full-time equivalent employees as of 2001
**As of June 30, 2004
Source: USDHHS, HRSA, Bureau of Health Professions, National Center for Health Workforce Information & Analysis,
Area Resource File, February 2003. 2005 National Association of Boards of Pharmacy, Survey of Pharmacy Law.
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Section 4:
Pharmacy Program
Characteristics
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The Medicaid program defines prescribed drugs as simple or compound substances or mixtures of
substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance,
which are prescribed by a physician or other licensed practitioner of the healing arts within the scope
of their professional practice (42 CFR 440.120). The drugs must be dispensed by licensed authorized
practitioners on a written prescription that is recorded and maintained in the pharmacist’s or the
practitioner’s records.
On July 31, 1987, CMS published a notice of the final rule for limits on payments for drugs in the
Medicaid program. The regulations adopted in the rule became effective October 29, 1987 (52 FR
28648). In this final rule, CMS attempted to (1) respond to public comments on the NPRM (51 FR
2956); (2) provide maximum flexibility to the States in their administration of the Medicaid program;
(3) provide responsible but not burdensome Federal oversight of the Medicaid program; and (4) take
advantage of savings in the marketplace for multiple-source drugs.
To accomplish this, CMS adopted a Federal upper limit standard for certain multiple-source drugs,
based on application of a specific formula. The upper limit for other drugs is similar, in that it retains
the estimated acquisition cost (EAC) as the upper limit standard that State agencies must meet.
However, this standard is applied on an aggregate basis rather than on a prescription-specific basis.
State agencies are therefore encouraged to exercise maximum flexibility in establishing their own
payment methods (see the Federal Register, Vol. 52, No. 147, Friday, July 31, 1987, page 28648).
Multiple-Source Drugs
A multiple-source drug is one that is marketed or sold by two or more manufacturers or labelers, or a
drug marketed or sold by the same manufacturer or labeler under two or more different proprietary
names or under a proprietary name and without such a name.
A specific upper limit for a multiple-source drug may be established if the following requirements are
met:
• All of the formulations of the drug approved by the Food and Drug Administration (FDA) have
been evaluated as therapeutically equivalent in the current edition of the publication, Approved
Drug Products with Therapeutically Equivalent Evaluations; and
• At least three suppliers list the drug (which is classified by the FDA as Category A in its
publication) in the current editions of published compendia of cost information for drugs
available for sale nationally.
The upper limit for a multi-source drug for which a specific limit has been established does not apply
if a physician certifies in his or her own handwriting that a specific brand is “medically necessary” for
a particular recipient.
The handwritten phrase “brand necessary,” “medically necessary,” or “brand medically necessary”
must appear on the face of the prescription. The rule specifically states that a check-off box on a
prescription form is not acceptable, but it does not address the use of two-line prescription forms.
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The formula to be used in calculating the aggregate upper limit of payment for certain multiple-source
drugs will be 150% of the least costly therapeutic equivalent that can be purchased by pharmacists in
quantities of 100 tablets or capsules (or if the drug is not commonly available in quantities of 100, the
package size commonly listed), or in the case of liquids, the commonly listed size, plus a reasonable
dispensing fee.
Other Drugs
A drug described as an “other drug” is (1) a brand name drug certified as medically necessary by the
physician, (2) a multiple-source drug not subject to the 150% formula; or (3) a single-source drug.
Payments for these drugs must not exceed, in the aggregate, payment levels determined by applying
the lower of:
Other Requirements
The rule requires States to submit a State plan that describes their payment methods for prescribed
drugs. The rule does not prescribe a preferred payment method, as long as the State’s aggregate
spending in each category is equal to or below the upper limit requirements. States are also required
to submit assurances to CMS that the requirements are met.
The rule does not prescribe a preferred payment method for the States, but gives States the flexibility
to determine how they will pay for prescription drugs under Medicaid. As long as the State’s
aggregate spending is at or below the amount derived from the formula, the State is free to maintain
its current payment program or adopt other methods. States can alter payment rates for individual
drugs, balancing payment increases for certain products with payment decreases for other drugs so
that, in the aggregate, the program does not exceed the established limit. With the establishment of
upper limit payment maximums, some States may alter their current payment methods to comply with
the established limits.
State programs vary, depending upon whether or not State maximum allowable cost (MAC) programs
cover the same drugs listed by CMS. States with established MAC programs may be unaffected if
their MAC rates are already low, or they may have to make certain adjustments in their MAC levels
to meet the Federal aggregate expenditure limits. States without MAC programs may develop a new
payment method to increase the use of lower cost generic drug products in order to stay within the
upper payment limits, or may simply adopt CMS’ formula for listed drug products.
DRUG RECIPIENTS
Drug recipients are defined as individuals who received drugs, not as everyone eligible to receive
drugs. Today, all 50 States and the District of Columbia cover drugs under the Medicaid program.
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% of 2003 National
2003 2003 Medicaid Drug 2002 2002
State Payments Ranking Expenditures Payments Ranking
National Total $33,794,520,738 $29,339,050,970
California $4,219,504,969 1 12.5% $3,591,537,830 2
New York $4,218,811,815 2 12.5% $3,660,427,024 1
Florida $2,018,037,106 3 6.0% $1,717,652,527 3
Texas $1,920,865,985 4 5.7% $1,591,064,713 4
Ohio $1,520,147,470 5 4.5% $1,333,992,298 5
Illinois $1,469,190,682 6 4.3% $1,293,435,797 6
North Carolina $1,291,263,155 7 3.8% $1,100,822,176 7
Tennessee $1,280,129,986 8 3.8% $905,405,421 9
Georgia $1,073,715,230 9 3.2% $873,703,133 10
Massachusetts $946,210,618 10 2.8% $958,972,520 8
Missouri $941,522,305 11 2.8% $790,853,387 11
Louisiana $827,713,132 12 2.4% $714,107,841 13
Pennsylvania $791,053,653 13 2.3% $718,210,352 12
New Jersey $766,995,569 14 2.3% $694,669,924 14
Michigan $758,266,989 15 2.2% $674,222,281 15
Kentucky $685,229,661 16 2.0% $652,904,065 16
Indiana $627,575,345 17 1.9% $631,637,846 17
Washington $592,437,155 18 1.8% $541,963,790 19
Wisconsin $592,295,000 19 1.8% $442,718,195 23
Mississippi $568,007,104 20 1.7% $567,313,801 18
South Carolina $558,129,364 21 1.7% $451,846,044 22
Alabama $536,222,703 22 1.6% $452,269,953 21
Virginia $506,414,352 23 1.5% $458,953,342 20
Maryland $429,589,193 24 1.3% $297,291,733 26
Connecticut $403,802,170 25 1.2% $357,919,257 24
West Virginia $345,831,214 26 1.0% $277,039,990 30
Iowa $331,222,324 27 1.0% $285,467,642 27
Arkansas $310,709,182 28 0.9% $273,257,660 31
Oklahoma $301,294,000 29 0.9% $285,068,869 28
Minnesota $276,731,202 30 0.8% $310,174,144 25
Maine $268,547,563 31 0.8% $220,420,714 32
Oregon $262,335,388 32 0.8% $279,029,096 29
Kansas $228,920,787 33 0.7% $213,778,616 33
Colorado $225,297,507 34 0.7% $189,717,036 35
Nebraska $210,199,726 35 0.6% $207,782,737 34
Utah $163,217,885 36 0.5% $140,275,267 36
Rhode Island $140,686,626 37 0.4% $125,187,888 37
Idaho $132,143,091 38 0.4% $119,177,013 38
Vermont $127,763,857 39 0.4% $114,157,870 39
New Hampshire $112,948,647 40 0.3% $99,682,997 40
Delaware $109,844,743 41 0.3% $97,750,161 41
Nevada $106,821,075 42 0.3% $86,929,536 43
Hawaii $97,386,406 43 0.3% $88,256,904 42
New Mexico $86,408,362 44 0.3% $73,877,785 45
District of Columbia $81,762,504 45 0.2% $66,129,208 47
Montana $79,771,831 46 0.2% $83,587,410 44
South Dakota $71,223,108 47 0.2% $62,382,937 48
Alaska $69,512,220 48 0.2% $70,708,412 46
North Dakota $56,960,417 49 0.2% $52,495,878 49
Wyoming $49,106,118 50 0.1% $39,094,579 50
Arizona $4,744,244 51 0.0% $3,725,371 51
*Rebates have not been subtracted from these figures.
4-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
Total Medicaid
Net Medical Assistance Total Drug % of Total
State Expenditures Expenditures* Net Expenditures
National Total $259,895,896,495 $33,794,520,738 13.0%
Alabama $3,477,832,931 $536,222,703 15.4%
Alaska $563,428,717 $69,512,220 12.3%
Arizona $4,219,253,105 $4,744,244 0.1%
Arkansas $2,329,593,600 $310,709,182 13.3%
California $30,051,769,056 $4,219,504,969 14.0%
Colorado $2,552,159,860 $225,297,507 8.8%
Connecticut $3,506,583,946 $403,802,170 11.5%
Delaware $718,470,271 $109,844,743 15.3%
District of Columbia $1,076,136,978 $81,762,504 7.6%
Florida $10,946,214,986 $2,018,037,106 18.4%
Georgia $6,300,856,479 $1,073,715,230 17.0%
Hawaii $766,109,972 $97,386,406 12.7%
Idaho $809,931,820 $132,143,091 16.3%
Illinois $9,253,097,164 $1,469,190,682 15.9%
Indiana $4,282,435,701 $627,575,345 14.7%
Iowa $2,136,386,901 $331,222,324 15.5%
Kansas $1,764,536,608 $228,920,787 13.0%
Kentucky $3,697,230,708 $685,229,661 18.5%
Louisiana $4,423,174,011 $827,713,132 18.7%
Maine $1,747,306,187 $268,547,563 15.4%
Maryland $4,343,054,613 $429,589,193 9.9%
Massachusetts $7,680,882,159 $946,210,618 12.3%
Michigan $7,967,828,590 $758,266,989 9.5%
Minnesota $3,604,575,049 $276,731,202 7.7%
Mississippi $2,853,086,305 $568,007,104 19.9%
Missouri $5,541,604,705 $941,522,305 17.0%
Montana $511,474,712 $79,771,831 15.6%
Nebraska $1,325,133,485 $210,199,726 15.9%
Nevada $1,015,796,455 $106,821,075 10.5%
New Hampshire $916,422,038 $112,948,647 12.3%
New Jersey $7,858,368,246 $766,995,569 9.8%
New Mexico $2,006,492,205 $86,408,362 4.3%
New York $39,585,134,508 $4,218,811,815 10.7%
North Carolina $7,050,804,888 $1,291,263,155 18.3%
North Dakota $468,522,734 $56,960,417 12.2%
Ohio $10,177,517,569 $1,520,147,470 14.9%
Oklahoma $2,311,939,159 $301,294,000 13.0%
Oregon $2,678,357,318 $262,335,388 9.8%
Pennsylvania $12,772,008,268 $791,053,653 6.2%
Rhode Island $1,436,618,006 $140,686,626 9.8%
South Carolina $3,540,107,364 $558,129,364 15.8%
South Dakota $536,195,894 $71,223,108 13.3%
Tennessee $6,348,265,631 $1,280,129,986 20.2%
Texas $15,420,026,696 $1,920,865,985 12.5%
Utah $1,092,519,199 $163,217,885 14.9%
Vermont $705,028,688 $127,763,857 18.1%
Virginia $3,524,849,814 $506,414,352 14.4%
Washington $5,006,473,801 $592,437,155 11.8%
West Virginia $1,857,747,927 $345,831,214 18.6%
Wisconsin $4,799,267,070 $592,295,000 12.3%
Wyoming $337,284,398 $49,106,118 14.6%
*Rebates have not been subtracted from these figures.
4-7
National Pharmaceutical Council Pharmaceutical Benefits 2004
4-8
National Pharmaceutical Council Pharmaceutical Benefits 2004
Hormones and
Central Nervous Cardiovascular Anti-Infective Gastrointestinal Synthetic
State System Drugs Drugs Agents Drugs Substitutes
National Total $12,363,631,847 $3,801,947,569 $3,524,213,631 $2,450,238,097 $3,122,393,794
Alabama $190,945,957 $66,659,877 $60,716,138 $27,223,794 $60,041,745
Alaska $40,923,331 $7,768,953 $8,847,721 $9,310,870 $7,442,275
Arizona* - - - - -
Arkansas $124,140,938 $31,785,881 $36,048,688 $15,032,482 $34,833,265
California $1,289,548,645 $559,177,157 $328,595,843 $332,606,715 $446,647,443
Colorado $103,640,073 $22,017,120 $18,531,371 $14,468,064 $20,563,418
Connecticut $175,996,061 $43,649,610 $33,252,384 $33,724,817 $28,069,637
Delaware $35,648,536 $9,932,451 $15,575,193 $6,274,352 $9,960,540
District of Columbia $22,639,645 $11,118,033 $20,050,510 $2,311,674 $5,808,770
Florida $693,597,564 $226,902,557 $327,894,156 $166,461,633 $169,619,538
Georgia $352,660,702 $106,114,919 $146,354,001 $46,097,696 $101,979,157
Hawaii $38,608,056 $16,570,061 $8,256,539 $4,368,883 $10,537,125
Idaho $60,904,208 $9,756,419 $10,628,384 $4,941,868 $12,181,215
Illinois $495,470,501 $216,632,381 $158,093,371 $120,206,662 $147,429,047
Indiana $285,453,451 $56,722,913 $50,052,280 $38,769,474 $61,546,793
Iowa $157,180,331 $29,475,299 $29,648,480 $20,589,271 $31,129,735
Kansas $108,704,011 $20,129,864 $17,339,561 $19,155,941 $20,852,659
Kentucky $259,250,343 $77,499,804 $65,552,414 $38,423,330 $71,239,832
Louisiana $243,290,866 $80,234,506 $109,817,991 $54,704,705 $72,578,920
Maine $117,977,151 $25,767,867 $18,778,785 $25,943,479 $26,564,709
Maryland $204,973,562 $52,518,379 $37,778,689 $30,695,978 $30,165,832
Massachusetts $426,324,589 $92,542,559 $91,559,817 $65,955,409 $76,059,993
Michigan $361,027,746 $76,602,148 $41,181,543 $46,655,710 $59,556,708
Minnesota $181,317,127 $22,612,381 $21,521,170 $26,666,517 $26,618,045
Mississippi $177,433,416 $84,476,651 $66,031,112 $32,146,980 $57,169,431
Missouri $405,814,288 $102,560,092 $85,327,587 $42,501,845 $91,382,260
Montana $40,552,154 $6,856,348 $5,988,940 $7,054,158 $7,814,615
Nebraska $90,518,087 $18,113,336 $17,825,594 $9,825,208 $19,259,675
Nevada $47,839,070 $11,322,593 $12,500,368 $4,793,034 $9,231,504
New Hampshire $55,511,397 $8,670,264 $6,145,697 $7,987,351 $9,272,731
New Jersey $282,889,997 $100,795,953 $86,862,944 $66,022,618 $59,052,329
New Mexico $33,805,242 $10,254,314 $7,189,377 $9,600,179 $11,525,477
New York $1,289,421,527 $466,736,184 $660,900,621 $298,153,780 $377,655,759
North Carolina $448,996,966 $150,623,341 $133,935,843 $137,251,191 $121,245,082
North Dakota $25,861,471 $4,787,469 $3,856,941 $3,635,205 $4,990,743
Ohio $652,799,378 $157,137,204 $135,588,872 $126,543,046 $143,667,021
Oklahoma $119,561,069 $30,104,381 $28,607,550 $17,356,536 $27,406,868
Oregon $141,970,988 $14,073,890 $12,508,942 $9,146,150 $15,944,333
Pennsylvania $307,075,831 $86,090,827 $51,191,071 $76,369,314 $66,108,211
Rhode Island $62,768,301 $18,136,380 $10,787,026 $12,448,121 $11,563,648
South Carolina $207,810,670 $89,756,227 $70,178,436 $28,189,939 $67,604,062
South Dakota $31,103,276 $5,211,572 $7,244,215 $6,629,496 $6,748,303
Tennessee $519,390,119 $161,820,197 $77,633,377 $114,371,425 $102,886,876
Texas $649,950,752 $197,853,618 $227,126,956 $119,278,242 $196,523,211
Utah $76,262,627 $10,588,695 $13,338,853 $12,287,375 $13,644,567
Vermont $12,190,259 $4,029,933 $2,955,483 $1,274,253 $3,432,229
Virginia $191,563,725 $64,498,544 $41,046,594 $55,067,690 $43,083,321
Washington $264,734,853 $57,092,141 $43,927,432 $50,205,897 $54,915,790
West Virginia $132,548,914 $41,425,874 $31,511,034 $22,586,370 $36,930,892
Wisconsin $106,988,776 $34,076,588 $23,531,062 $26,031,579 $27,907,393
Wyoming $18,045,300 $2,663,814 $4,396,675 $2,891,791 $4,001,062
* Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
4-9
National Pharmaceutical Council Pharmaceutical Benefits 2004
Unclassified
Therapeutic Autonomic Blood Formation
State Agents Drugs and Coagulation Other Total
National Average $1,055,465,025 $1,444,434,327 $1,631,603,922 $4,342,078,576 $33,736,006,788
Alabama $16,933,831 $29,117,413 $24,798,577 $88,291,181 $564,728,513
Alaska $3,017,515 $4,143,870 $6,586,137 $10,045,292 $98,085,964
Arizona* - - - - -
Arkansas $11,391,635 $16,290,279 $20,346,625 $43,386,184 $333,255,977
California $124,486,965 $109,440,799 $277,059,101 $392,418,402 $3,859,981,070
Colorado $8,369,762 $12,209,376 $8,772,382 $28,741,953 $237,313,519
Connecticut $10,845,172 $15,529,027 $15,588,038 $42,629,307 $399,284,053
Delaware $3,080,673 $4,797,072 $4,129,047 $14,564,793 $103,962,657
District of Columbia $1,528,819 $1,881,191 $4,304,599 $11,053,831 $80,697,072
Florida $66,881,733 $92,245,297 $114,802,172 $273,547,974 $2,131,952,624
Georgia $32,931,912 $58,770,316 $47,089,914 $172,266,157 $1,064,264,774
Hawaii $4,528,069 $4,022,621 $6,637,325 $12,070,039 $105,598,718
Idaho $4,314,264 $5,635,849 $2,919,820 $13,229,104 $124,511,131
Illinois $47,769,159 $63,945,423 $85,924,830 $197,901,702 $1,533,373,076
Indiana $23,254,776 $31,028,392 $42,923,482 $102,732,283 $692,483,844
Iowa $9,787,979 $16,730,776 $9,418,099 $39,127,637 $343,087,607
Kansas $7,119,076 $12,062,663 $6,580,327 $28,274,280 $240,218,382
Kentucky $26,072,218 $45,278,547 $30,533,575 $94,528,334 $708,378,397
Louisiana $23,611,873 $38,485,281 $36,873,442 $139,158,070 $798,755,654
Maine $8,040,234 $12,176,814 $10,185,925 $25,153,673 $270,588,637
Maryland $10,075,261 $12,388,585 $21,864,657 $39,448,955 $439,909,898
Massachusetts $25,289,436 $32,901,099 $38,923,231 $105,231,780 $954,787,913
Michigan $24,190,573 $28,593,928 $37,571,523 $85,771,522 $761,151,401
Minnesota $10,553,097 $14,662,898 $13,349,968 $38,123,425 $355,424,628
Mississippi $16,796,656 $27,954,253 $26,440,052 $76,114,896 $564,563,447
Missouri $27,673,946 $51,284,406 $44,879,042 $128,694,744 $980,118,210
Montana $3,539,485 $4,642,139 $2,668,099 $10,979,885 $90,095,823
Nebraska $6,717,962 $9,742,260 $6,302,498 $26,583,522 $204,888,142
Nevada $3,571,056 $5,639,042 $6,116,918 $13,564,994 $114,578,579
New Hampshire $2,992,898 $5,631,726 $2,482,312 $12,988,214 $111,682,590
New Jersey $25,517,275 $33,348,479 $52,697,474 $104,790,316 $811,977,385
New Mexico $3,806,974 $4,222,012 $3,924,480 $13,564,380 $97,892,435
New York $141,742,052 $155,076,486 $197,337,654 $555,046,144 $4,142,070,207
North Carolina $42,606,450 $56,952,033 $60,109,134 $193,389,654 $1,345,109,694
North Dakota $1,697,267 $2,510,695 $1,645,740 $6,675,757 $55,661,288
Ohio $45,200,120 $85,106,203 $57,239,140 $213,194,584 $1,616,475,568
Oklahoma $11,119,046 $14,623,169 $14,922,093 $32,159,087 $295,859,799
Oregon $5,192,257 $8,586,132 $7,653,099 $16,824,128 $231,899,919
Pennsylvania $24,675,241 $44,691,804 $48,107,836 $101,012,127 $805,322,262
Rhode Island $3,880,507 $5,800,930 $4,609,417 $15,825,524 $145,819,854
South Carolina $19,236,343 $28,235,443 $24,643,479 $92,173,886 $627,828,485
South Dakota $2,361,480 $3,460,577 $2,942,659 $10,135,666 $75,837,244
Tennessee $32,266,211 $51,570,846 $37,631,333 $119,158,930 $1,216,729,314
Texas $68,447,771 $95,780,057 $88,073,590 $351,910,677 $1,994,944,874
Utah $4,199,480 $6,240,065 $2,186,777 $19,419,642 $158,168,081
Vermont $1,171,684 $1,460,581 $1,529,437 $4,942,610 $32,986,469
Virginia $15,844,703 $25,131,271 $27,136,311 $71,109,483 $534,481,642
Washington $18,662,019 $24,374,739 $20,421,210 $64,322,622 $598,656,703
West Virginia $11,707,954 $16,987,581 $9,383,374 $43,432,138 $346,514,131
Wisconsin $9,066,980 $10,992,631 $11,481,805 $40,318,584 $290,395,398
Wyoming $1,697,176 $2,051,251 $1,856,163 $6,050,504 $43,653,736
* Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
4-10
National Pharmaceutical Council Pharmaceutical Benefits 2004
Hormones and
Central Nervous Cardiovascular Anti-Infective Gastrointestinal Synthetic
State System Drugs Drugs Agents Drugs Substitutes
National Average 171,087,805 80,839,088 48,001,985 34,302,085 55,890,837
Alabama 3,171,638 1,567,963 1,138,879 553,609 1,127,896
Alaska 548,257 203,519 122,476 103,357 149,034
Arizona* - - - - -
Arkansas 1,731,110 797,550 759,124 263,680 648,832
California 14,259,438 7,954,722 3,977,118 3,317,303 5,721,487
Colorado 1,583,124 593,377 413,553 244,334 520,571
Connecticut 2,072,006 915,787 259,671 362,472 545,336
Delaware 487,968 184,937 162,745 76,266 169,529
District of Columbia 268,419 225,749 84,515 33,064 98,035
Florida 9,307,006 5,172,090 2,831,244 1,902,380 3,047,416
Georgia 5,424,867 2,495,750 2,494,567 898,164 1,998,544
Hawaii 490,672 324,763 92,049 136,203 177,740
Idaho 763,814 214,445 196,731 82,277 238,825
Illinois 8,266,131 5,540,656 2,496,296 2,101,959 3,234,926
Indiana 4,206,893 1,419,140 992,144 932,118 1,112,689
Iowa 2,232,976 746,404 578,027 304,342 638,478
Kansas 1,429,685 544,022 345,553 244,418 448,490
Kentucky 4,209,055 1,901,993 1,308,853 1,002,805 1,352,565
Louisiana 3,653,912 1,731,401 1,710,847 586,044 1,301,839
Maine 1,909,114 708,202 356,938 323,601 580,394
Maryland 2,485,651 1,120,167 313,685 353,731 609,632
Massachusetts 5,852,176 2,326,321 1,039,851 891,682 1,614,601
Michigan 5,348,834 2,085,945 746,226 801,119 1,280,656
Minnesota 2,088,156 559,625 311,226 451,235 485,462
Mississippi 2,572,856 1,769,873 1,137,394 451,414 1,012,463
Missouri 5,202,372 2,282,561 1,195,140 814,529 1,643,419
Montana 563,101 171,791 129,643 96,744 172,580
Nebraska 1,289,900 447,252 390,739 310,048 385,045
Nevada 599,049 256,638 151,055 81,940 183,761
New Hampshire 783,744 217,582 131,413 158,724 181,359
New Jersey 3,444,576 1,981,577 628,802 714,276 1,021,018
New Mexico 595,916 281,797 134,825 143,222 286,371
New York 16,319,688 9,021,907 5,175,402 4,049,862 5,817,384
North Carolina 6,235,662 3,386,484 2,032,839 1,332,424 2,364,568
North Dakota 357,380 143,776 91,286 50,922 120,832
Ohio 9,926,750 3,864,726 2,349,075 2,407,992 2,899,276
Oklahoma 1,395,693 581,302 512,325 232,606 454,827
Oregon 2,004,987 453,103 222,004 224,644 397,877
Pennsylvania 4,198,755 2,036,284 837,861 948,649 1,335,172
Rhode Island 813,442 308,215 116,847 159,760 192,723
South Carolina 2,928,723 2,021,657 1,047,783 475,084 1,339,858
South Dakota 399,558 147,440 158,080 71,747 138,279
Tennessee 8,340,084 3,670,322 1,286,313 1,496,149 2,213,225
Texas 9,092,238 3,169,705 4,802,083 1,600,010 2,757,927
Utah 1,109,740 241,808 297,363 166,672 294,969
Vermont 166,600 74,664 41,811 22,874 57,384
Virginia 2,838,758 1,428,824 603,632 774,924 853,123
Washington 3,872,043 1,467,594 701,236 823,549 1,224,420
West Virginia 2,215,492 928,170 664,115 359,356 691,640
Wisconsin 1,788,091 1,087,096 333,075 329,368 675,631
Wyoming 241,705 62,412 97,526 38,433 72,729
*Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
4-11
National Pharmaceutical Council Pharmaceutical Benefits 2004
Unclassified
Therapeutic Autonomic Blood Formation
State Agents Drugs and Coagulation Other Total
National Average 11,853,860 30,838,002 13,382,215 115,859,862 562,055,739
Alabama 212,576 658,280 265,307 2,704,930 11,401,078
Alaska 28,043 87,848 30,535 233,712 1,506,781
Arizona* - - - - -
Arkansas 121,607 322,711 129,844 1,262,522 6,036,980
California 1,119,181 2,220,821 1,370,538 9,121,332 49,061,940
Colorado 96,895 298,800 100,463 850,026 4,701,143
Connecticut 125,679 292,253 156,958 939,638 5,669,800
Delaware 33,085 107,860 26,206 328,206 1,576,802
District of Columbia 21,565 44,891 24,297 218,812 1,019,347
Florida 835,642 1,831,715 861,701 6,044,048 31,833,242
Georgia 392,437 1,305,010 428,075 4,639,338 20,076,752
Hawaii 63,617 82,552 45,988 330,097 1,743,681
Idaho 44,790 120,381 33,901 347,382 2,042,546
Illinois 656,985 1,573,171 928,489 6,946,150 31,744,763
Indiana 230,548 698,234 310,000 2,781,211 12,682,977
Iowa 114,630 354,809 140,862 1,107,657 6,218,185
Kansas 81,549 245,679 90,475 771,341 4,201,212
Kentucky 313,874 870,152 342,808 3,154,670 14,456,775
Louisiana 281,821 863,458 341,589 3,512,998 13,983,909
Maine 97,307 303,890 83,761 675,526 5,038,733
Maryland 130,618 299,880 189,155 1,013,935 6,516,454
Massachusetts 275,688 813,956 301,360 2,415,517 15,531,152
Michigan 275,857 652,859 409,452 2,342,925 13,943,873
Minnesota 90,260 280,272 95,056 941,083 5,302,375
Mississippi 208,689 476,308 285,945 2,158,653 10,073,595
Missouri 287,390 973,232 386,707 3,028,715 15,814,065
Montana 34,681 99,230 25,941 275,126 1,568,837
Nebraska 77,885 230,919 84,325 951,883 4,167,996
Nevada 39,978 123,670 40,868 325,257 1,802,216
New Hampshire 32,045 114,142 35,577 398,917 2,053,503
New Jersey 294,180 575,191 332,324 2,355,693 11,347,637
New Mexico 41,959 101,590 49,449 459,079 2,094,208
New York 1,610,186 3,409,929 1,192,203 13,543,607 60,140,168
North Carolina 524,687 1,193,010 454,082 4,694,793 22,218,549
North Dakota 22,156 52,161 25,011 206,338 1,069,862
Ohio 561,787 1,914,814 739,909 6,915,185 31,579,514
Oklahoma 96,291 266,844 81,798 746,371 4,368,057
Oregon 52,451 196,722 73,708 579,612 4,205,108
Pennsylvania 274,742 754,046 579,899 2,602,161 13,567,569
Rhode Island 49,480 120,909 51,961 387,406 2,200,743
South Carolina 225,238 569,221 268,378 2,314,061 11,190,003
South Dakota 27,068 70,636 29,357 270,255 1,312,420
Tennessee 396,317 1,173,744 503,537 3,793,613 22,873,304
Texas 617,164 2,146,746 626,793 10,040,023 34,852,689
Utah 45,455 158,015 42,323 539,754 2,896,099
Vermont 10,812 29,345 9,374 96,604 509,468
Virginia 205,807 486,953 245,099 2,043,981 9,481,101
Washington 189,025 608,244 213,822 1,954,869 11,054,802
West Virginia 143,269 377,868 125,592 1,222,582 6,728,084
Wisconsin 125,280 238,879 157,435 1,112,614 5,847,469
Wyoming 15,584 46,152 13,978 159,654 748,173
*Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
4-12
National Pharmaceutical Council Pharmaceutical Benefits 2004
4-13
National Pharmaceutical Council Pharmaceutical Benefits 2004
4-14
National Pharmaceutical Council Pharmaceutical Benefits 2004
In 1990, Congress considered a number of proposals designed to reduce and control Federal and State
expenditures for prescription drug products provided to Medicaid patients (S.2605, the
Pharmaceutical Access and Prudent Purchasing Act; S.3029, the Medicaid Anti-Discriminatory Drug
Act, sponsored by Senator David Pryor; and H.R.5589, the Medicaid Prescription Drug Fair Access
and Pricing Act, sponsored by Representatives Ron Wyden and Jim Cooper). A vigorous
Congressional debate ensued over which of these approaches to pursue. Several pharmaceutical
manufacturers voluntarily offered rebates to the States in exchange for open access for their products,
while the Pharmaceutical Manufacturers Association proposed a set rebate amount in exchange for
open formularies. Numerous public interest groups offered opinions on the proposals and in some
cases proposals of their own.
The Congressional debate ended in both the House and Senate offering somewhat similar proposals.
During the ensuing Conference between the House and Senate, the Office of Management and Budget
(OMB) argued for the inclusion of several proposals into the provisions in budget bill, the Omnibus
Budget Reconciliation Act of 1990 (OBRA ’90). The resulting Public Law 101-508, enacted
November 5, 1990, required a drug manufacturer to enter into and have in effect a national rebate
agreement with the Secretary of DHHS for States to receive Federal funding for outpatient drugs
dispensed to Medicaid patients. (For a detailed account of the debate and genesis of various
provisions see Robert Betz’s analysis of the Medicaid Best Price Law and its effect on pharmaceutical
manufacturers’ pricing policies.∗)
The requirement for rebate agreements does not apply to the dispensing of a single-source or
innovator multiple-source drug if the State has determined that the drug is essential, rated 1-A by the
FDA, and prior authorization is obtained for the exception. Existing rebate agreements qualify under
the law if the State agrees to report all rebates to DHHS and the agreement provides for a minimum
aggregate rebate of 10% of the State’s expenditures for the manufacturer’s products.
OBRA ‘90 was amended by the Veterans Health Care Act of 1992 which also required a drug
manufacturer to enter into discount pricing agreements with the Department of Veterans Affairs and
with covered entities funded by the Public Health Service in order to have its drugs covered by
Medicaid. The Medicaid rebate law, as amended, is included as Appendix C.
The drug rebate program is administered by CMS’ Center for Medicaid and State Operations
(CMSO). Currently, the rebate for covered outpatient drugs is as follows:
• For all innovator products, reimbursement requires: (1) a rebate that is the greater of 15.1
percent of the average manufacturer’s price (AMP) or the difference between the AMP and
the manufacturer’s “best price,” and (2) an additional rebate for any price increase for a
product that exceeds the increase in the Consumer Price Index (CPI-U) for all items since the
fall of 1990. AMP is the average price paid by wholesalers for products distributed to the
retail class of trade. The best price is the lowest price offered to any other customer,
excluding Federal Supply Schedule prices, prices to State pharmaceutical assistance
programs, and prices that are nominal in amount, and includes all discounts and rebates.
• For generic drugs (non-innovator drugs), reimbursement requires: a rebate of 11 percent of
each product’s AMP.
∗
Robert Betz, “The Medicaid Best Price Law and Its Effect on Pharmaceutical Manufacturer’s Pricing Policies and Behavior for
Name Brand, Outpatient Pharmaceutical Products,” unpubl. Ph.D. dissertation, The George Washington University, May 21,
2000.
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Allocation of
State Drug Rebate Monies1 Total Rebates2 Federal Share2
National Total $7,008,382,303 $4,145,168,732
Alabama Medicaid Drug Budget $102,784,110 $74,244,635
Alaska General Fund $15,060,446 $8,946,379
Arizona* - - -
Arkansas Medicaid Drug Budget $58,097,761 $44,058,096
California Medicaid Drug Budget $1,207,800,866 $635,884,565
Colorado Medicaid General $32,446,928 $16,743,775
Connecticut General Fund $81,550,711 $42,156,720
Delaware Medicaid General $28,352,506 $14,871,627
District of Columbia Medicaid Drug Budget $15,120,780 $10,813,162
Florida Medicaid Drug Budget $464,880,949 $281,544,767
Georgia General Fund $219,238,104 $133,880,256
Hawaii General Fund $19,212,047 $11,571,434
Idaho General Fund $31,430,642 $22,834,044
Illinois Drug Rebate Fund $292,630,625 $150,740,652
Indiana General Fund $131,850,261 $83,862,599
Iowa Medicaid Drug Budget $62,173,583 $40,568,073
Kansas General Fund $59,849,370 $36,912,589
Kentucky General Fund $124,919,867 $89,772,191
Louisiana Medicaid Drug Budget $165,904,174 $121,064,068
Maine Medicaid Drug Budget $68,331,107 $46,664,469
Maryland Medicaid General $77,934,401 $40,509,917
Massachusetts Medicaid General $208,146,240 $108,049,289
Michigan General Fund $179,774,542 $103,731,878
Minnesota Medicaid General $54,081,115 $27,643,562
Mississippi Medicaid General $114,233,479 $89,163,417
Missouri Medicaid Drug Budget $178,620,625 $112,813,582
Montana General Fund $17,172,113 $12,822,675
Nebraska Medicaid Drug Budget $42,766,762 $26,291,497
Nevada General Fund $21,078,909 $11,402,018
New Hampshire General Fund $27,628,562 $14,223,879
New Jersey Medicaid Drug Budget $149,040,244 $76,924,905
New Mexico General Fund $19,585,223 $14,894,385
New York General Fund $598,407,083 $305,702,916
North Carolina Medicaid General $260,487,290 $168,077,481
North Dakota Medicaid Drug Budget $11,369,358 $8,067,828
Ohio Medicaid General $325,329,459 $196,899,815
Oklahoma Medicaid General $59,205,487 $42,776,373
Oregon General Fund $65,706,778 $40,630,979
Pennsylvania Outpatient Appropriation $149,563,463 $84,158,389
Rhode Island General Fund $30,477,726 $17,361,117
South Carolina Medicaid Drug Budget $119,101,600 $85,684,428
South Dakota Medicaid Drug Budget $14,808,661 $10,010,329
Tennessee Medicaid General $224,072,761 $148,367,141
Texas Medicaid Drug Budget $392,292,711 $242,560,725
Utah General Fund $25,931,043 $19,597,473
Vermont Health Access Trust Fund $28,595,852 $18,448,953
Virginia Medicaid General $112,854,618 $59,506,765
Washington General Fund $123,683,508 $64,563,377
West Virginia Medicaid General $69,568,029 $53,266,225
Wisconsin Medicaid General $118,267,026 $69,458,066
Wyoming Medicaid Drug Budget $6,962,798 $4,425,247
*Does not apply for Arizona. Arizona has a 1115 waiver for which special rules apply.
Sources: 1As reported by State drug program administrators in the 2004 NPC Survey.
2
CMS, CMS-64 Report, FY 2003, includes reported state supplemental rebates for CA, FL, IL, LA, MI, VT, and WV.
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*Does not apply for Arizona. Arizona has a 1115 waiver for which special rules apply.
**Includes reported State supplemental rebates.
Source: CMS, HCFA-64 Report, FY 1999-FY 2003.
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Rebates as % Drug
State Drug Expenditures Rebates** Expenditure
National Total $33,794,520,738 $7,008,382,303 20.7%
Alabama $536,222,703 $102,784,110 19.2%
Alaska $69,512,220 $15,060,446 21.7%
Arizona* $4,744,244 - -
Arkansas $310,709,182 $58,097,761 18.7%
California $4,219,504,969 $1,207,800,866 28.6%
Colorado $225,297,507 $32,446,928 14.4%
Connecticut $403,802,170 $81,550,711 20.2%
Delaware $109,844,743 $28,352,506 25.8%
District of Columbia $81,762,504 $15,120,780 18.5%
Florida $2,018,037,106 $464,880,949 23.0%
Georgia $1,073,715,230 $219,238,104 20.4%
Hawaii $97,386,406 $19,212,047 19.7%
Idaho $132,143,091 $31,430,642 23.8%
Illinois $1,469,190,682 $292,630,625 19.9%
Indiana $627,575,345 $131,850,261 21.0%
Iowa $331,222,324 $62,173,583 18.8%
Kansas $228,920,787 $59,849,370 26.1%
Kentucky $685,229,661 $124,919,867 18.2%
Louisiana $827,713,132 $165,904,174 20.0%
Maine $268,547,563 $68,331,107 25.4%
Maryland $429,589,193 $77,934,401 18.1%
Massachusetts $946,210,618 $208,146,240 22.0%
Michigan $758,266,989 $179,774,542 23.7%
Minnesota $276,731,202 $54,081,115 19.5%
Mississippi $568,007,104 $114,233,479 20.1%
Missouri $941,522,305 $178,620,625 19.0%
Montana $79,771,831 $17,172,113 21.5%
Nebraska $210,199,726 $42,766,762 20.3%
Nevada $106,821,075 $21,078,909 19.7%
New Hampshire $112,948,647 $27,628,562 24.5%
New Jersey $766,995,569 $149,040,244 19.4%
New Mexico $86,408,362 $19,585,223 22.7%
New York $4,218,811,815 $598,407,083 14.2%
North Carolina $1,291,263,155 $260,487,290 20.2%
North Dakota $56,960,417 $11,369,358 20.0%
Ohio $1,520,147,470 $325,329,459 21.4%
Oklahoma $301,294,000 $59,205,487 19.7%
Oregon $262,335,388 $65,706,778 25.0%
Pennsylvania $791,053,653 $149,563,463 18.9%
Rhode Island $140,686,626 $30,477,726 21.7%
South Carolina $558,129,364 $119,101,600 21.3%
South Dakota $71,223,108 $14,808,661 20.8%
Tennessee $1,280,129,986 $224,072,761 17.5%
Texas $1,920,865,985 $392,292,711 20.4%
Utah $163,217,885 $25,931,043 15.9%
Vermont $127,763,857 $28,595,852 22.4%
Virginia $506,414,352 $112,854,618 22.3%
Washington $592,437,155 $123,683,508 20.9%
West Virginia $345,831,214 $69,568,029 20.1%
Wisconsin $592,295,000 $118,267,026 20.0%
Wyoming $49,106,118 $6,962,798 14.2%
*Does not apply to Arizona. Arizona has a 1115 waiver for which special rules apply.
**Includes reported State supplemental rebates.
Source: CMS, CMS-64 Report, FY 2003.
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In general, all prescription products sold by a manufacturer that has signed a drug rebate agreement
are covered outpatient drugs reimbursable by Medicaid. A State Medicaid program may require prior
approval before dispensing of any drug product and may design and implement a formulary intended
to limit coverage for specific drugs. Drug formularies and prior authorization programs must meet
specific requirements established in Medicaid law.
A State Medicaid program can restrict coverage for a drug product through a formulary, if based on
official labeling or information in designated official medical compendia, “the excluded drug does not
have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness or
clinical outcome of such treatment” over other drug products, and there is a written explanation
(available to the public) of the basis for the exclusion. However, drug products excluded from the
formulary under these conditions, nevertheless, must be available through prior authorization.
Drugs in certain specific classes may be restricted or excluded from coverage without regard to the
formulary conditions and need not be available through prior authorization. These classes include:
• Drugs used for anorexia, weight gain, fertility, hair growth, cosmetic effect, symptomatic
relief of cough or colds, or for cessation of smoking.
• Vitamins and minerals (except prenatal prescription vitamins and fluoride preparations) or
non-prescription drugs.
• Drugs that require tests or monitoring services to be purchased exclusively from the
manufacturer or his designee.
• Barbiturates or benzodiazepines.
PRIOR AUTHORIZATION
Whether or not a drug product is on a formulary, States may require physicians to request and receive
official permission before a particular product can be dispensed. This procedure is called Prior
Authorization or Prior Approval.
States may not operate prior authorization plans unless the State provides for a response within 24
hours of a request and provides for a 72-hour emergency supply of the medication.
The Congressional intent for the prior authorization provision was not to encourage the use of such
programs, but rather to make them available to the States for the purpose of controlling utilization of
products that have very narrow indications or high abuse potential.
The majority of States report the establishment of prior authorization programs and have plans to
apply prior authorization to a select number of drugs. Some States will do so only after their Drug
Utilization Review (DUR) program has identified areas of therapeutic concern.
DUR Program. Each State must establish a Drug Utilization Review (DUR) Program in order to
assure that prescriptions are appropriate, medically necessary, and not likely to result in adverse
medical results. A DUR Program consists of prospective and retrospective components as well as
components to educate physicians and pharmacists on common drug therapy problems.
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Specifically, the program educates physicians and pharmacists how to identify and reduce fraud,
abuse, gross overuse, or inappropriate or medically unnecessary care; potential and actual severe
adverse reactions to drugs, including education on therapeutic appropriateness, overutilization and
underutilization, appropriate use of generic products, therapeutic duplication, drug-disease
contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, drug-
allergy interactions, and clinical abuse or misuse.
The two primary objectives of DUR systems are (1) to improve quality of care; and (2) to assist in
containing health care costs. While there is a general belief that DUR is cost beneficial, it is difficult
to isolate concrete evidence that supports this view. The primary issue facing Medicaid DUR
programs is whether or not the systems currently in place (or envisioned) meet the two objectives
outlined above.
Prospective DUR. Prospective DUR is to be conducted at the point of sale (POS) before delivery of a
medication by the pharmacist to the Medicaid recipient or caregiver. The State is to establish
standards for counseling patients and will require the pharmacist to offer to discuss matters, which, in
the exercise of the pharmacist’s professional judgment are deemed significant, including the
following:
• Name, address, telephone number, date of birth (or age) and gender;
• Individual history where significant, including a disease state or states, known allergies and
drug reactions, and a comprehensive list of medications and relevant devices; and
• Pharmacist comments relevant to the individual’s pharmaceutical therapy.
Retrospective DUR. This activity continuously assesses data on drug use against established
standards, preferably using automated claims processing and information retrieval techniques to
monitor for therapeutic appropriateness, overutilization and underutilization, appropriate use of
generic products, therapeutic duplication, drug-disease contraindications, drug-drug interactions,
incorrect drug dosage or duration of drug treatment, clinical abuse/misuse and, as necessary,
introduce remedial strategies in order to improve the quality of care and to conserve program funds or
personal expenditures. This activity is also intended to identify patterns of fraud, abuse, gross
overuse, or inappropriate of medically unnecessary care among physicians, pharmacists, and
recipients, or with respect to specific drugs or groups of drugs.
State Drug Use Review Board. Each State must provide for the establishment of a DUR board of
health practitioners (one-third to one-half physicians and at least one-third pharmacists) to help
implement the DUR program. Each State must require its DUR board to make annual reports to
DHHS on its activities and on cost savings resulting from the DUR program.
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*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2004 NPC Survey.
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*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
PA = Prior Authorization, DME = Durable Medical Equipment
Source: As reported by State drug program administrators in the 2004 NPC Survey.
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*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
PA = Prior Authorization, DME = Durable Medical Equipment
Source: As reported by State drug program administrators in the 2004 NPC Survey.
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*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
PA= Prior Authorization, DME = Durable Medical Equipment
Source: As reported by State drug program administrators in the 2004 NPC Survey.
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Coverage of Injectables
Reimbursement for Non Self-Administered Medicines via
the Prescription Drug Program (PDP) or Physician Payment (PP)
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2004 NPC Survey.
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^ Early and Periodic Screening, Diagnostic and Treatment (EPSDT), Children Health Insurance Program (CHIP), Vaccines for
Children Program (VCP), or other.
LTC = Long Term Care
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2004 NPC Survey.
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*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
PA= Prior Authorization
Source: As reported by State drug program administrators in the 2004 NPC Survey.
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*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2004 NPC Survey.
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*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2004 NPC Survey.
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*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2004 NPC Survey.
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Prior Authorization
Analgesics,
State Anabolic Steroids Antipyretics, NSAIDs Anorectics
Alabama Covered Covered Covered
Alaska Covered Covered, PA Required Not Covered
Arizona* - - -
Arkansas Covered Covered, PA Required Not Covered
California Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
Colorado Covered, PA Required Covered, PA Required Not Covered
Connecticut Covered Covered Not Covered
Delaware Covered Covered, PA Required Covered, PA Required
District of Columbia Not Covered Covered, PA Required Covered, PA Required
Florida Covered Covered, PA Required Covered
Georgia Covered, PA Required Covered, PA Required Not covered
Hawaii Covered, PA Required Covered Covered, PA Required
Idaho Partial Coverage, PA Required Covered, PA Required Not Covered
Illinois Covered, PA Required Covered, PA Required Not Covered
Indiana** N/A N/A N/A
Iowa Covered Covered, PA Required Not Covered
Kansas Covered Covered Partial Coverage, PA Required
Kentucky Covered, PA Required Covered, PA Required Covered, PA Required
Louisiana Covered Covered, PA Required Partial Coverage
Maine Covered, PA Required Covered, PA Required Covered, PA Required
Maryland*** Covered Covered Not Covered
Massachusetts Covered Partial Coverage, PA Required Not Covered
Michigan Partial Coverage, PA Required Covered Not Covered
Minnesota Covered Covered, PA Required Not Covered
Mississippi Covered Covered, PA Required Not Covered
Missouri Partial Coverage Covered Not Covered
Montana Covered Covered, PA Required Not Covered
Nebraska Not Covered Partial Coverage, PA Required Not Covered
Nevada Partial Coverage Covered Not Covered
New Hampshire Covered Covered, PA Required Covered, PA Required
New Jersey Covered Covered Partial Coverage
New Mexico Covered Covered Covered, PA Required
New York Covered Covered Not Covered
North Carolina Covered Covered, PA Required Not Covered
North Dakota Covered Covered Partial Coverage, PA Required
Ohio Covered, PA Required Covered Not Covered
Oklahoma Not Covered Covered, PA Required Partial Coverage, PA Required
Oregon Covered, PA Required Covered Covered, PA Required
Pennsylvania Covered Covered Not Covered
Rhode Island Covered Covered, PA Required Covered, PA Required
South Carolina Covered Covered Not Covered
South Dakota Covered Covered Covered
Tennessee* Covered Covered, PA Required Not Covered
Texas Covered Covered Covered, PA Required
Utah Covered Covered, PA Required Covered
Vermont Covered, PA Required Covered, PA Required Not Covered
Virginia Covered Covered Partial coverage, PA Required
Washington Covered, PA Required Covered, PA Required Not Covered
West Virginia Covered Covered Not Covered
Wisconsin Covered Covered, PA Required Covered, PA Required
Wyoming Not Covered Covered, Some require PA Not Covered
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
** All coverage in accordance with OBRA'90 and OBRA'93.
***PA required for all drugs not on the preferred drug list.
PA = Prior Authorization
Source: As reported by State drug program administrators in the 2004 NPC Survey.
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Prescribing/Dispensing Limits
Limits on
State Rx Limits on Number, Quantity, and Refills of Prescriptions
Alabama Yes 5 refills per Rx, 34 day supply per Rx, 4 brand limit per month
Alaska Yes 30 day supply per Rx, maximum number units for 50 classes and 40 narcotics
Arizona* - -
Arkansas Yes 31 day supply per Rx; 3 Rx per month (extension to 6); 5 refills per Rx within 6 months
California Yes 6 Rx per month, maximum 100 day supply for most medications
Colorado Yes 30 day quantity supply per Rx; reasonable amts. for maint. meds. Other limits may apply
Connecticut Yes 240 units or 30 day supply, 5 refills per RX except 12 month limit on oral contraceptives
Delaware Yes 34 day supply or 100 unit doses per Rx (whichever is greater)
District of Columbia Yes 30 day supply per Rx, 3 refills per Rx within 4 mths. Max/min quantities for certain meds
Florida Yes 4 brand name Rxs per month (with exceptions)
Georgia Yes 34 day supply per Rx; 5 (adult)/6 (child) Rx per month; Per Rx limit: $2999.99 (potential override)
Hawaii Yes 30 day supply or 100 unit doses per Rx, maximum quantities for some drugs
Idaho Yes 34 day supply per Rx (with exceptions); 3 cycles of birth control; limits on refills/early refills
Illinois Yes Medically appropriate monthly quantity
Indiana No -
Iowa Yes Maximum 30 day supply except select maintenance drugs (90 days)
Kansas Yes 31 day supply per Rx, 5 Rx per month, other limitations specific to certain medications
Kentucky Yes 30 day supply, max. 5 refills in 6 months; one dispensing fee per month for maintenance medication
Louisiana Yes 30 day supply or 100 unit doses (whichever is greater); 5 refills per Rx within 6 mos., max. 8 scripts per
recipient per month
Maine Yes 34 day supply (brand), 90 day supply (generic); Maximum 11 refills per prescription, 5 brand scripts
per month
Maryland Yes 34 day supply per Rx; maximum 11 refills per Rx, refills may not exceed 360 day supply
Massachusetts Yes 30 day supply, maximum 11 refills per prescription
Michigan Yes 100 day supply, quantity limits for selected drugs (e.g., sedative hypnotics)
Minnesota Yes 34 day supply
Mississippi Yes 34 day supply or 100 unit doses (whichever is greater); 5 Rx per month; 11 refills maximum
Missouri No -
Montana Yes 34 day supply
Nebraska Yes 90 day/100 unit doses, 5 refills per Rx 6 mos. for controlled substances, 31 days for injectibles
Nevada Yes 34 day supply per Rx; 100 day supply for maintenance medications. 5 refills within 6 months.
New Hampshire Yes 30 day supply, 90 day supply on maintenance medications
New Jersey Yes 34 day supply or 100 unit doses per Rx, 5 refills within 6 months
New Mexico No 34 day supply, except contraceptives (100 days) and maintenance drugs (90 days)
New York Yes 5 refills per Rx; annual limit on number of Rx and OTC drugs avail. (potential override)
North Carolina Yes 34 day supply per Rx, with exceptions; 6 Rx per month
North Dakota Yes 34 day supply per Rx, max 5 refills per script, limits on refills by Class
Ohio Yes 34 day supply; 102 day supply for maintenance medications; 5 refills per Rx
Oklahoma Yes 6 Rx (incl. 5 brands) per month (21+; under 21 unlimited), 34 day supply or 100 unit doses per Rx
Oregon Yes 34 day supply (15 day supply for initial Rx for chronic conditions), duration limits on selected drugs
Pennsylvania Yes 34 day supply or 100 unit doses per Rx (whichever is greater); 5 refills within 6 mos., 6 Rx per month
Rhode Island Yes 30 day supply per Rx (non-maintenance); 5 refills per Rx
South Carolina Yes 34 day supply w/ unlimited Rx (children); 4 Rx per month (adult), (potential override)
South Dakota Yes Varies by drug
Tennessee* Yes 31 day supply, 1 year for non-controlled medications
Texas Yes 3 Rx per month (unlimited Rxs for nursing home recipients or those < 21), max 5 refills or 6 months
Utah Yes 31 day supply per Rx, max 5 refills, cumulative limit on specific drugs
Vermont Yes 60 day supply for maintenance medications, 5 refills per Rx
Virginia Yes 34 day supply per Rx
Washington Yes 34 day supply per Rx; usually 2 refills per month; 4 refills for antibiotics or scheduled drugs
West Virginia Yes 34 day supply; 11 refills per Rx with quantity limits on some drugs
Wisconsin Yes 34 day supply per Rx with exceptions, maximum 11 refills during 12-month period
Wyoming Yes Quantity limits on some medications as deemed clinically appropriate.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2004 NPC Survey.
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Medicaid Payment for Outpatient Prescription Drugs. Federal Medicaid regulations prescribe the
principles that apply to State Medicaid programs when they pay a pharmacy for outpatient drugs.
These regulations don’t just indicate the FFP cannot be based on amounts that exceed drug costs as
determined under the federal formula; they indicate the actual method for paying for prescription
drugs.
Medicaid Managed Care Organizations (MCOs). If the recipient is enrolled in a Medicaid managed
care organization, payment is made to the MCO in accordance with its contract with the State
Medicaid agency to the extent the contract covers outpatient prescribed drugs.
Medicaid Payment to Pharmacies. Each State’s Medicaid State Plan must comprehensively describe
its payment for prescription drugs. Its aggregate Medicaid expenditures for “multiple-source drugs”
must not exceed the Federal Upper Limits published by CMS (see Appendix D) and its payment level
for other drugs must not exceed, in the aggregate, the lower of (1) EAC plus a reasonable dispensing
fee, or (2) providers’ charges to the general public.
States are permitted to require certain recipients to share some of the costs of Medicaid by imposing
on them such payments as enrollment fees, premiums, deductibles, coinsurance, copayments, or
similar cost-sharing charges (42 CFR 447.50). For States that impose cost-sharing payments, the
regulations specify the standards and conditions under which States may impose cost-sharing, set
forth minimum amounts and the methods for determining maximum amounts, and describe
limitations on availability that relate to cost-sharing requirements.
With the passage of the Social Security Amendments of 1972, States were empowered to impose
“nominal” cost-sharing requirements on optional Medicaid services for cash assistance recipients, and
on any services for the medically needy. Section 131 of the Tax Equity and Fiscal Responsibility Act
(TEFRA) of 1982 introduced major changes to Medicaid cost-sharing requirements. Under this act,
States may impose a nominal deductible, coinsurance, copayment, or similar charge on both
categorically needy and medically needy persons for any service offered under the State Plan. Public
Law 97-248, TEFRA, has been in effect since October 1982; it prohibits imposition of cost-sharing
on the following:
While emergency services are excluded from cost sharing, States may apply for waivers of nominal
amounts for non-emergency services furnished in hospital emergency rooms. Such a waiver allows
States to impose a copayment amount up to twice the current maximum for such services. Approval
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of a waiver request by CMS is based partly on the State’s assurance that recipients will have access to
alternative sources of care.
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Federal State-Specific
State Upper Limits Upper Limits MAC Override Provisions
Alabama Yes Yes Brand medically necessary
Alaska Yes No Medically necessary and reason for medical necessity
Arizona* - - -
Arkansas Yes Yes Brand medically necessary MedWatch indicating why generics cannot
be dispensed
California Yes Yes Medically necessary and product unavailable at MAC rate
Colorado Yes Yes Medically necessary with documentation
Connecticut Yes Yes No physician MAC override
Delaware Yes Yes MedWatch form for prior authorization
District of Columbia No No -
Florida Yes Yes MedWatch form and prior authorization request
Georgia Yes Yes Prior authorization (Brand medically necessary and MedWatch form)
Hawaii Yes Yes Prior authorization
Idaho Yes Yes Prior authorization for brand names
Illinois Yes Yes Prior authorization request by M.D. justifying need for brand
Indiana Yes Yes Brand medically necessary, prior authorization
Iowa Yes Yes Brand medically necessary
Kansas Yes Yes Prior authorization and MedWatch form
Kentucky Yes Yes Brand necessary, brand medically necessary, plus PA on some drugs
Louisiana Yes Yes Brand necessary, brand medically necessary
Maine Yes Yes Prior authorization
Maryland Yes Yes Brand medically necessary and MedWatch form
Massachusetts Yes Yes Dispense as written, brand medically necessary, prior authorization
Michigan Yes Yes Brand medically necessary and prior authorization
Minnesota Yes Yes Dispense as written, brand medically necessary, plus prior authorization
Mississippi Yes No Brand medically necessary or prior authorization for brand multi-source
Missouri Yes Yes Brand medically necessary, prior authorization and MedWatch form
Montana Yes No Brand necessary or brand required
Nebraska Yes Yes Brand medically necessary
Nevada No Yes Brand medically necessary
New Hampshire Yes Yes Brand medically necessary
New Jersey Yes No Dispense as written, medically necessary
New Mexico Yes Yes Brand necessary, brand medically necessary
New York Yes No Prior authorization
North Carolina Yes Yes Brand medically necessary in writing on prescription
North Dakota Yes Yes Dispense as written
Ohio Yes Yes Prior authorization
Oklahoma Yes Yes Brand medically necessary plus prior authorization
Oregon Yes Yes Brand medically necessary and documentation of generic intolerance
Pennsylvania Yes Yes Brand necessary, brand medically necessary, plus prior authorization
Rhode Island No No -
South Carolina Yes Yes Brand medically necessary w/cert. by prescriber and prior authorization
South Dakota Yes Yes Brand necessary, brand medically necessary
Tennessee* Yes Yes Dispense as written
Texas Yes Yes Dispense as written, medically necessary, brand necessary, brand
medically necessary
Utah Yes Yes Brand medically necessary plus prior approval
Vermont Yes Yes Dispense as written, medically necessary, brand necessary, brand
medically necessary or DAW 8 (generic not available)
Virginia Yes Yes Medically necessary
Washington Yes Yes Brand medically necessary
West Virginia Yes No Dispense as written, brand medically necessary
Wisconsin No Yes Brand medically necessary plus prior authorization
Wyoming Yes Yes Brand medically necessary
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2004 NPC Survey.
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Mandatory Substitution
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2004 NPC Survey.
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Medicaid Payment
State Patient Counseling Required1 for Cognitive Services2
Alabama All No
Alaska All No
Arizona All -
Arkansas All No
California All No
Colorado Medicaid Only No
Connecticut Medicaid Only No
Delaware All No
District of Columbia Medicaid Only, New Prescriptions No
Florida All No
Georgia All No
Hawaii Medicaid Only No
Idaho All No
Illinois All No
Indiana All No
Iowa All Yes (pharm. Case management)
Kansas All No
Kentucky All No
Louisiana All No
Maine All No
Maryland Medicaid Only, New Prescriptions No
Massachusetts All No
Michigan All No
Minnesota All No
Mississippi All Yes (diabetes, asthma, coagulation, and lipids)
Missouri All Yes (diabetes, asthma, heart failure, and depression
education)
Montana All No
Nebraska All No
Nevada All No
New Hampshire All No
New Jersey All No
New Mexico All No
New York All No
North Carolina All No
North Dakota All No
Ohio All No
Oklahoma All No
Oregon All No
Pennsylvania All No
Rhode Island All No
South Carolina Medicaid Only No
South Dakota All No
Tennessee All No
Texas All No
Utah All No
Vermont All No
Virginia All No
Washington All Yes (emergency contraceptive counseling, clozaril
case management)
West Virginia All No
Wisconsin All Yes
Wyoming All No
Source: 12003-2004 National Association of Boards of Pharmacy Law, Survey of Pharmacy Law; 2 As reported by State drug
program administrators in the 2004 NPC Survey.
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Source: As reported by State drug program administrators in the 2004 NPC Survey.
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Section 5:
State Pharmacy Program
Profiles
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ALABAMA
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Alabama Medicaid Agency. Formulary: Open formulary with preferred drug list.
Formulary managed through restrictions on use, prior
D. PROVISIONS RELATING TO DRUGS authorization, therapeutic substitution, preferred
products, physician profiling, and voluntary
Benefit Design supplemental rebates. Prior authorization required for
non-preferred drugs. Anti-psychotics and HIV/AIDs
Drug Benefit Product Coverage: Products covered: drugs are exempted from the prior authorization
disposable needles and syringe combinations used for requirements. (For additional information see:
insulin. Products covered with restriction: prescribed www.medicaid.state.al.us.)
insulin. Products covered as DME: blood glucose test
strips; urine ketone test strips. Prior authorization Prior Authorization: State currently has a formal
required for: total parenteral nutrition; interdialytic prior authorization procedure. Prior authorization
parenteral nutrition; Retin A; Accutane; decisions may be appealed by physician submitting
Dipyridamole; and Synagis. Products not covered: written notice along with medical documentation to
cosmetics; fertility drugs; experimental drugs; drugs the administrative services contractor for physician
for anorexia or weight gain; hair growth products; review. The request is forwarded to the Medicaid
and DESI drugs. agency’s Medical Director for review.
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ALASKA
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
*Total Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
Source: CMS, MSIS Report, FY 2002 and Alaska Medicaid Management Information System, FY 2003.
Note: Alaska estimates 2004 drug expenditures of approximately $113.5 million and the number of Medicaid drug recipients to be
75,000.
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David Gilbreath
Soldotna,AK
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ARIZONA
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
(AHCCCS - PRONOUNCED "ACCESS")
• Capitation of the State by the Federal
AHCCCS FEATURES Government.
The Arizona Health Care Cost-Containment System Primary Care Physicians as Gatekeepers
(AHCCCS), Arizona’s Medicaid program, is a Title
XIX (Medicaid) 1115 Research and Demonstration AHCCCS legislation provided that all members must
Waiver project, jointly funded by the federal be under the care and supervision of a primary care
government and the State of Arizona. Begun in physician who assumed the role of gatekeeper. A
October 1982, it serves as a model for providing statewide network of primary care physicians was
medical services to the indigent in a managed care established to perform the gatekeeping function for
system rather than through fee-for-service the system.
arrangements. Typically, Medicaid programs have
incorporated the traditional hallmarks of the U.S. Prepaid Capitated Financing
health care system: namely, independent providers
and fee-for-service reimbursement. In contrast, It was the intent of the AHCCCS legislation that
organized health plans and capitation mark the health plans and their providers offer all covered
AHCCCS model. services to groups of members within a geographical
area for a fixed price, for a definite period. The law
In traditional Medicaid programs, the States assume allowed for the establishment of a statewide bidding
responsibility for contracting with individual process to accomplish this. Services are provided on
pharmacies and reimbursing them. In the AHCCCS a county-by-county basis, by prepaid health plans.
model however, the State contracts, instead, with pre- Providers may bid on a prepaid capitated basis for
paid health plans, HMOs and HMO-like entities. covered services to be provided within a particular
These plans are paid on a capitation basis and are county. The law allows for expansion and
responsible for providing all of the services covered contraction of bids to achieve the best possible
by the program. Thus, with the exception of system. In the event there are insufficient bids for a
behavioral health drugs which are carved out of given area, the legislation permits capped fee-for-
managed care, the delivery of pharmacy services is service arrangements. It is intended, however, that
the responsibility of each prepaid plan. capped fee-for-service will be authorized as a last
resort only.
GENERAL INFORMATION
In essence, AHCCCS prepaid health plans (PHPs),
The Arizona Health Care Cost Containment System health maintenance organizations (HMOs), and other
(AHCCCS), developed in Senate Bill 1001, was types of organized health delivery systems charge a
passed by the Legislature and signed by the Governor fixed fee per individual enrolled (i.e., a capitation
in November 1981. It contained six major rate) and assume responsibility for providing a broad
mechanisms for restraining health care costs at the array of health care services to members. The plan or
same time ensuring that appropriate levels of quality contractor is then “at risk” to deliver the necessary
health care services are provided to eligible persons services within the capitated amount. AHCCCS
in a dignified fashion. The goal of these 6 items was receives Federal, State, and county funds to operate,
to contribute to the establishment of health care plus some monies from Arizona’s tobacco tax.
financing that is less expensive than conventional
fee-for-service systems. The six mechanisms were: Competitive Bidding Process
• Primary Care Physicians Acting as
The statewide competitive aspect of the bid process
Gatekeepers
for selecting providers and offering prepaid capitated
• Prepaid Capitated Financing services is the most unique feature of the AHCCCS
• Competitive Bidding Process model. A competition of this magnitude had never
• Cost Sharing been attempted in any other State. The AHCCCS
• Limitations on Freedom-of-Choice administration believes competitive bidding for
health care service contracts, as opposed to
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conventional negotiation processes, provides for the State to monitor health care costs on a careful
accessible cost-effective delivery of health care and continuous basis.
without sacrificing quality performance.
IMPLEMENTATION OF AHCCCS
The AHCCCS administration issues an invitation to
qualified health plans once every five years. AHCCCS is based on plans that have been tested, in
Qualified health plans may bid to offer the full range part, on smaller scales in different areas of the
of AHCCCS services in one or more counties. country. By combining a number of key mechanisms
on a statewide basis, AHCCCS represents a novel
Cost Sharing health care model. The purpose of this section is to
present a discussion of how the key concepts
The fourth major device for containing costs in the embodied in the AHCCCS legislation will be
AHCCCS model is a provision for cost sharing by implemented and rendered operational.
users. A statewide copayment schedule was
developed for this purpose, and the medically needy Provider Participation
participate in coinsurance cost sharing. It is expected
that the imposition of nominal copayments will Providers may participate in AHCCCS in 2 different
ensure optimal effectiveness in the area of service ways. First, they may contract with prepaid capitated
utilization. The copayment schedule accomplishes plans as either full or partial benefit providers.
three objectives: curtailment of over-utilization;
enhancement of patient dignity; and service The second mode of participation is on a capped fee-
utilization by members for truly needed health care. for-service basis. Here, providers agree to accept
There is no copayment for drugs and medication, capped fee payments as payments in full for services
prenatal care including all obstetrical visits, members provided on a FFS basis.
in long care facilities and for visits scheduled by the
primary care physician or practitioner, and not at the Functions of the AHCCCS Administration
request of the member.
The Arizona Health Care Containment System
Limitations On Freedom-of-Choice Administration (AHCCCSA) contracts with full
benefit capitated health plans to serve AHCCCS
The fifth major item for containing costs is a members through a network of providers.
restriction on provider/physician selection by
AHCCCS members. Unlike conventional delivery Contracting Health Plans
models, Arizona does not rely on fee-for-service
arrangements. The goal is to have the State Under the Contracting Health Plan arrangement,
completely blanketed with prepaid capitated plans are defined in terms of explicit groups of
arrangements. Members are linked to selected or providers organized as entities that are more formal.
assigned plans for definite durations of time. These consortia, or formal entities, are capable of
Freedom-of-choice is permitted to the extent providing the full range of AHCCCS benefits within
practicable for members to select the particular group a defined service area for all AHCCCS members who
with which to enroll, as well as the primary care elect to join the plans, up to a predetermined
physician within the selected group. Capped fee-for- capacity. This is the dominant mode of operation
service health service arrangements are used as a last within AHCCCS -- with two or more competing
resort, and only in areas not covered by prepaid plans wherever possible.
capitated plans.
The Contracting Health Plans are delivery systems,
CAPITATION BY THE FEDERAL not simply insurance plans, but they need not be
GOVERNMENT Health Maintenance Organizations by any legal or
conventional definition of the term. The AHCCCS
The State of Arizona will itself be capitated by the legislation provides for the creation of provider
Federal government and therefore will be at financial consortia for the purpose of participation in the
risk for containing health care costs. Capitation rates program. The Contracting Health Plan may be a
will be established according to sound actuarial loosely organized system, but it must be capable of
principles, and will represent no more than 95 providing the full range of AHCCCS benefits to a
percent of the estimated cost of services delivered in defined population at a capitation rate.
Arizona under conventional fee-for-service
arrangements. Capitation provides a key incentive
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The Operational Role of the AHCCCS Care1st Health Plan of Arizona, Inc.
Administration 2355 E. Camelback Rd.
Suite 300
Organizationally, the AHCCCS Administration Phoenix, AZ 85016
assumes responsibility for the oversight of every day 866/560-4042
operations.
Health Choice Arizona
The AHCCCS Administration has overall Suite 260
responsibility for the following activity areas: 1600 West Broadway
Tempe, AZ 85282-1136
• Eligibility Oversight T: 480/968-6866
• Procurement of Health Plans F: 800/322-8670
• Quality Management
• Health Plan Oversight Maricopa Health Plan
• Provider, Member Call Center 2502 East University Drive
• Grievances and Complaints Phoenix, AZ 85034
• Fee-for-Service for IHS 800/582-8686
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Pinal/Gila LTC
P.O. Box 2140
971 Jason Lopez Circle
Florence, AZ 85232-2140
800/624-3879
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ARKANSAS
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
Source: CMS, MSIS Report, FY 2002 and Arkansas Medical Management Information System, FY 2003.
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Vaccines: Vaccines reimbursable as part of EPSDT Dispensing Fee: $5.51 effective 7/1/99. Effective
services, the Children’s Health Insurance Program, 3/1/02, non-MAC generics receive an additional
and the Vaccines for Children Program. $2.00 dispensing fee. LTC pharmacies generally
receive one dispensing fee per NDC per month.
Unit Dose: Unit dose packaging reimbursable.
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CALIFORNIA
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
Note: Certain classifications of aliens in the above categories are eligible only for emergency and pregnancy-related benefits.
*Total Other Expenditures/ Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
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Under the Health and Human Services Agency with Formulary: The Medi-Cal List of Contract Drugs is a
direct administration by the Department of Health preferred drug list. It contains over 600 drugs, in
Services. differing strengths and dosage forms, listed
generically. Patients can get prior authorization for
The Department of Health Services Pharmaceutical unlisted drugs or for listed drugs that are restricted to
Unit of the Medi-Cal Policy Division monitors the specific use(s), if medically justified. Manufacturers
full scope and quality of pharmaceutical benefits frequently petition Medi-Cal to add drugs to the List
covered under the provisions of the California of Contract Drugs. Based on Medi-Cal’s five criteria
Medical Assistance Program. (safety, efficacy, misuse potential, essential need, and
cost), a drug may be added to the list by contractual
D. PROVISIONS RELATING TO DRUGS agreement with the manufacturer to provide the State
a negotiated rebate. The Medi-Cal website at:
Benefit Design http://www.dhs.ca.gov/mcs/mcpd/MBB/contracting/h
tml/faqpage.htm has details of how the drug
Drug Benefit Product Coverage: The Medi-Cal contracting process works.
pharmacy benefit covers practically all FDA-
approved drugs, including both legend and over-the- Examples of general limitations and exclusions
counter products. There are very few drugs or (other uses require prior authorization):
classes of drugs that are non-benefits. Non-benefits
1. CNS stimulants, e.g., amphetamines and
include common household remedies; non-legend
methylphenidate, are restricted to attention
analgesics and cough/cold medications, except when
deficit disorder in individuals between 4 and 16
specifically listed; multivitamin preparations, except
years of age.
certain pre-natal and pediatric products; cosmetics;
fertility drugs; and experimental drugs. Most other 2. Diazepam is restricted to use in cerebral palsy,
products are potential benefits. athetoid states, and spinal cord degeneration.
3. Most non-steroidal anti-inflammatory agents are
In general, products that are listed on the Medi-Cal
restricted to use for arthritis.
List of Contract Drugs do not require prior
authorization. Those not on the List of Contract 4. Some antibiotics have diagnostic and/or age
Drugs do require prior authorization. restrictions.
5. Acyclovir capsules are restricted to herpes
Physician-administered drugs: The Medi-Cal List of
genitalis, immunocompromised, and herpes
Contract Drugs applies to drugs dispensed from
zoster (shingles) patients.
pharmacies to patients. Drugs administered directly
in a physician's, dentist's, or podiatrist's office are not 6. Codeine Combinations: payment to a pharmacy
bound by the List of Contract Drugs. for ASA or APAP with codeine 30 mg is limited
to a maximum dispensing quantity of 45 tablets
Coverage of Injectables: Injectable medicines are or capsules and a maximum of 3 claims for the
reimbursable through the Prescription Drug Program same beneficiary in any 75-day period.
when used in home health care and extended care
7. Enteral nutritional supplements or replacements
facilities and through physician payment when used
are covered, subject to prior authorization, if
in physician offices.
used as a therapeutic regimen to prevent serious
disability or death in patients with medically
Vaccines: Vaccines are reimbursable by schedule as
diagnosed conditions that preclude the full use of
part of the Vaccines for Children Program. Vaccines
regular foodstuffs.
for adults are covered through the prescription drug
program or as administered in a physician's office. 8. Cancer, AIDS, and DESI Drugs: Any
antineoplastic drug approved by FDA for the
Unit Dose: Unit dose packaging reimbursable. treatment of cancer and any drug approved by
FDA for the treatment of AIDS or AIDS-related
condition is covered through the Medi-Cal List
of Contract Drugs; most DESI drugs rated less-
than-effective by FDA are not covered.
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Prior Authorization: Nearly all drugs not included on Monthly Prescription Limit: Limited to 6 per month
the Medi-Cal list of Contract Drugs require prior without prior authorization. The limit does not apply
authorization. State currently has a formal prior to family planning drugs, patients in nursing
authorization procedure to appeal prior authorization facilities, or to AIDS or cancer drugs.
decisions.
Hospital Discharge Medications: Quantities
The patient’s physician or pharmacist may request furnished as discharge medications are limited to no
prior authorization from the field office Medi-Cal more than a 10-day supply. Charges are incorporated
consultant for approval of unlisted drugs or for listed in the hospital’s claims for inpatient services.
drugs that are restricted to specific use(s). This is
done by completing a Treatment Authorization Drug Utilization Review
Request (TAR) form. Providers may appeal prior
authorization decisions within 60 days of notification Prospective DUR system implemented in August
to the local field office and then to field services 1995. State currently has a DUR Board with a
headquarters if necessary. Beneficiaries also have the quarterly review.
ability to request a hearing to review the denial and
must do so within 90 days of notification. Pharmacy Payment and Patient Cost Sharing
TARs may be approved for: covered items or Dispensing Fee: $7.25 ($8.00 LTC), effective 9/1/04.
services not included on the Medi-Cal List of
Contract Drugs (including special circumstance such Ingredient Reimbursement Basis: EAC = AWP-17%
as the need to override multiple source drug price
ceilings or minimum quantity/ frequency of billing Prescription Charge Formula: Reimbursement is
limitations); and for patients exceeding the 6 Rx per based on the lowest of:
month limit. Statewide mail and fax requests are
accepted in the Stockton and Los Angeles Medi-Cal 1. Estimated Acquisition Cost (EAC) + dispensing
Field Offices. Requests must include adequate fee, less $0.50 for most patients, or less $0.10 for
information and justification. Authorization may nursing home patients.
only be given for the lowest cost item or service that 2. Federal Upper Limit (FUL) + dispensing fee,
meets the patient’s medical needs. less $0.50 for most patients, or less $0.10 for
nursing home patients.
Beneficiary or Prescriber Prior Authorization: On a 3. State Maximum Allowable Ingredient Cost
case by case basis, the Dept. of Health Services (MAIC) + dispensing fee, less $0.50 for most
restricts, through the requirements of prior patients, or less $0.10 for nursing home patients.
authorization, the availability of designated 4. Pharmacy’s usual price to general public, less
prescription drugs to certain beneficiaries or $0.50 for most patients, or less $0.10 for nursing
prescribers found by the Department to abuse those home patients.
benefits. State law requires that reimbursement for blood
factors be by NDC and not exceed 120 percent of the
Prescribing or Dispensing Limitations average selling price during the preceding quarter.
Maximum Allowable Cost: State imposes a
Prescription Refill Limit: A prescription refill can be
combination of Federal and State-specific limits on
dispensed as authorized by prescriber. An exception
generic drugs. Maximum Allowable Ingredient Costs
is allowed for refill of a reasonable quantity when
(MAICs) are established for about 50 multi-source
prescriber is unavailable (pursuant to California law).
items. Override requires “Medically Necessary” or
Fee is to be pro-rated so that total fee (for partial
unavailability of drug products at or below MAC.
quantity and balance of the prescription after
List is periodically revised and price limits changed
prescriber is contacted) does not exceed the fee for
to reflect current market conditions.
the same prescription when refilled as a routine
service.
Incentive Fee: None.
Monthly Quantity Limit: This is flexible, but should
be consistent with the medical needs of the patient. Patient Cost Sharing: $1.00 copayment for branded
Limited to 100 days’ supply on most drugs. Many and generic products.
maintenance drugs are subject to minimum quantity
or maximum frequency of billing controls. Cognitive Services: Does not pay for cognitive
services, but this is under consideration.
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COLORADO
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Prescription Charge Formula: Benefit drugs shall be If a recipient requests a brand name for a prescription
reimbursed at the lesser of the Medicaid allowable that is subject to MAC, then he/she may pay the
reimbursement charge, or the provider’s usual and ingredient cost difference between the MAC and
customary charge or whatever is accepted from any brand name drug. The recipient must sign the
third party, discounts, rebates, etc. prescription stating that he/she is willing to pay the
difference in ingredient cost to the pharmacy. The
The Medicaid allowable reimbursement charge is the pharmacy will be paid MAC plus a dispensing fee or
sum of the ingredient cost of the drug dispensed and reimbursement charges, whichever is lower.
the provider’s dispensing fee.
High volume Estimated Acquisition Cost (EAC):
Ingredient cost for retail pharmacies (estimated Reimbursement for single source drugs or certain
acquisition cost) is the price of the drug actually multiple source drugs which are most frequently
dispensed as defined below or the MAC or the high prescribed will be based upon average wholesale
volume EAC, whichever is less. prices (AWP) minus 13.5%, or direct manufacturers’
prices for package sizes containing quantities greater
The ingredient cost for institutional and government than 100 dosage units or less if not available in
pharmacies is defined as the actual cost of acquisition 100’s.
for the drug dispensed or the MAC, or the high
volume EAC, whichever is less. Basis for inclusion in the high volume estimated
acquisition cost list includes but is not limited to:
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on (1) Single source manufacturers;
generic drugs. Override requires Medically (2) High volume Medicaid recipient utilization;
Necessary with explanation of medical necessity
(MedWatch form). (3) Interchangeability problems with multiple source
drugs;
The State MAC is the maximum ingredient cost
allowed by the Department for certain multiple- (4) Package sizes in excess of 100.
source drugs. The establishment of a MAC is
Drug Pricing: The Department will maintain a drug-
subject, but not limited to, the following
pricing file that will be updated at least monthly. The
considerations:
average wholesale price of a drug as determined by
(1) Multiple manufacturers; the Department, MAC, and high volume EAC, will
be the basis for setting the prices in the drug pricing
(2) Broad wholesale price span; file.
(3) Availability of drugs to retailers at the selected
cost; The Department will determine the average
wholesale price that will be placed in the drug-
(4) High volume of Medicaid recipient utilization; pricing file as follows:
(5) Bioequivalence or interchangeability.
(1) The average wholesale price as it appears in the
When Federal MAC limits for multiple source drugs Red Book, its supplements, and Medi-Span will be
are announced, they will be adopted if they are less the first source. However, if there is a difference
than State MACs or if no State MACs exist. between the two published average wholesale prices,
the Department will set the price as the published
The ingredient cost of any drug subject to MAC shall amount which is the closest to the lowest average
be limited to MAC or wholesale price as determined price charged by two drug wholesalers doing
by the Department, whichever is less. Exceptions business in Colorado.
that will allow reimbursement greater than MAC for
a drug entity are obtained through a prior (2) If there is a price change which does not appear
authorization mechanism. An exception will be immediately in the Red Book, its supplements, or in
granted if the patient’s response to the generic drug is Medi-Span, then the Department will set the average
not therapeutic, an allergic reaction is involved, or wholesale price by averaging the wholesale prices of
any similar situation exists. three drug wholesalers doing business in Colorado,
until the price is published in the Red Book, its
supplements, or in Medi-Span.
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(3) If the prices or changes do not appear in the 10350 East Dakota Avenue
publications or the wholesalers’ records, then the Denver, CO 80905
distributors’ or manufacturers’ prices will be adjusted 303/344-7250
to the wholesale pricing level and used in the drug
Rocky Mountain HMO
pricing file as the price of the drug.
2775 Crossroads Boulevard
Grand Junction, CO 81506
If the difference between the pharmacist’s invoice
800/843-0719
purchase price and the average wholesale price which
Colorado Access
appears in the Red Book, its supplements, or Medi-
600 South Cherry Street, Suite 800
Span exceeds 18%, then the Department may adopt a
Denver, CO 80222
lower price after a survey is conducted to determine
303/355-6707
the validity of the published prices. The price from
the distributor or manufacturer will be adjusted the
Community Health Plan of the Rockies
same as in 3 above.
400 South Colorado Boulevard, Suite 300
Special Note: The Maximum Allowable Cost shall be Denver, CO 80222
determined by the Division of Medical Assistance, 303/355-3220
based upon professional determination of a quality
product available at the least expense possible. United Healthcare
6251 Greenwood Plaza Boulevard, Suite 200
Exceptions to the above are:
Englewood, CO 80111-4910
- Shelf package size oral liquid medications, in pint 303/267/3594
size only, or smaller package size when not packaged
in pint size.
F. STATE CONTACTS
- Shelf package size oral tablet and capsule
medications in quantities of 100 only or smaller Medicaid Drug Program Administrator
when not available in package size of 100.
Martha Warner
- Prescriptions for less than minimum amounts will Pharmacy Supervisor
be denied reimbursement of the professional fee Department of Health Care Policy and Financing
unless the physician notified the Department in 1570 Grant Street
writing of the medical need for amounts less than a Denver, CO 80203
30-day supply. Medical consultation determines the T: 303/866-3176
decision. F: 303/866-2573
Incentive Fee: None. E-mail: martha.warner@state.co.us
Colorado-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Colorado-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Dan Stenerson
Aurora, CO
Robert Slay
Lakewood, CO
Executive Officers of State Medical and
Pharmaceutical Societies
Colorado Medical Society
Alfred Gilchrist
Executive Director
7351 Lowry Boulevard
Denver, CO 80230
T: 720/859-1001
F: 303/771-8659
E-mail: alfred_gilchrist@cms.org
Internet address: www.cms.org
Colorado-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
CONNECTICUT
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable
Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.
Connecticut-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Connecticut-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Connecticut-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Connecticut-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
F: 781/721-4400
E-mail: nocdos@shore.net
Connecticut-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Connecticut-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
DELAWARE
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Delaware-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Delaware-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Delaware-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Delaware-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
DISTRICT OF COLUMBIA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
District of Columbia-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
District of Columbia-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Cognitive Services: Does not pay for cognitive District of Columbia DUR Board
services.
Christopher Keeyes, Pharm.D. (Chair)
Chairman, Clinical Pharmacy Associates
E. USE OF MANAGED CARE 316 Talbott Avenue
Laurel, MD 20707
Approximately 90,000 Medicaid recipients were 301/617-0555
enrolled in managed care in 2003. Recipients
enrolled in managed care receive pharmaceutical Martin Dillard, M.D. (Vice Chair)
benefits through managed care plans. Assistant Dean for Clinical Affairs
Chief, Division of Nephrology
Managed Care Organizations Howard University Hospital
2041 Georgia Avenue, NW, Suite 5C02
D.C. Chartered Health Plan Washington, DC 20060
1025 15th Street, N.W. 202/865-1191
Washington, DC 20005
202/408-4720 Howard Robinson, R.Ph.
Manager, Central Pharmacy
Amerigroup Greater Community Hospital
750 First Street, NE, Suite 1120 1310 Southern Avenue, SE
Washington, DC 20002 Washington, DC 20032
800/600-4441
Dr. Kim Bullock
Health Right, Inc. Providence Hospital
1101 14th Street, NW, Suite 900 Emergency Room
Washington, DC 20005 1150 Varnum St., NE
202/418-0380 Washington, DC 20017
202/269-7863
District of Columbia-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
District of Columbia-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
District of Columbia-5
National Pharmaceutical Council Pharmaceutical Benefits 2003
Source: CMS, MSIS Report, FY 2002 and Florida Medicaid Statistical Information System, FY 200
C. ADMINISTRATION Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program
Agency for Health Care Administration. Claims when used in home health care and extended care
processing and payment by contract with fiscal agent. facilities, and through physician payment when used
in physicians’ offices.
D. PROVISIONS RELATING TO DRUGS
Vaccines: Vaccines reimbursable as part of the
Benefit Design Vaccines for Children Program.
Drug Benefit Product Coverage: Products covered: Unit Dose: Unit dose packaging reimbursable.
prescribed insulin; total parenteral nutrition;
interdialytic parenteral nutrition; and urine ketone Formulary/Prior Authorization
test strips (children under age 21only). Products
covered with restrictions (non-PDL products require Formulary: Preferred Drug List (PDL) with
prior authorization): disposable needles and syringe mandatory limits and exclusions. All covered drugs
combinations used for insulin; blood glucose test are available through the preferred drug process.
strips. Prior authorization required for: Actiq; General exclusions include excluding products based
Albumin; Aranesp; Procrit; Botox; Cytogam; on contracting issues, restrictions on use, prior
Fuzeon; growth hormone for adults; Intravenous authorization, therapeutic substitution, preferred
Immune Globulin (IVIG); Neupogen; Leukine; products, physician profiling and supplemental
Neulasta; Neurontin; Neutrexin; Panretin; Orfadin; rebates. Specific limits and exclusions include:
Oxycontin; Proleukin; Provigil; Targretin; Valcyte;
Venofer; Vfend; Xenical; Regranex (long-term care); 1. Vitamins and phosphate binders only for dialysis
and nutritional supplements and non-preferred patients.
products. Products not covered: cosmetics; fertility 2. Prostheses; appliances; devices; and personal
drugs; and experimental drugs. care items.
3. Non-legend drugs (except for prescribed insulin,
Over-the-Counter Product Coverage: Products pancreatic enzymes, buffered and enteric coated
covered with restrictions: analgesics (selected aspirin aspirin when prescribed as an anti-inflammatory
and Tylenol products); cough and cold preparations agent only, and single entity hematinics).
(select products); digestive products (non-H2 4. Anorexants unless the drug is prescribed for an
antagonists); feminine products; and smoking indication other than obesity (i.e., narcolepsy,
deterrent products. Products not covered: allergy, hyperkinesis).
asthma, and sinus products; digestive products (H2 5. Drugs with questionable efficacy as rated by
antagonists); and topical products. FDA (DESI).
6. Investigational and experimental items.
Therapeutic Category Coverage: Therapeutic 7. Oral vitamins with exception of fluorinated
categories covered: anaboilic steroids; antibiotics; pediatric vitamins prescribed for pediatric
anticoagulants; anticonvulsants; anti-depressants; patients, vitamins for dialysis patients, prenatal
antidiabetic agents; antihistamines; antilipemic vitamins.
agents; antipsychotics; anxiolytics, sedatives, and 8. Nursing home floor stock drugs.
hypnotics; cardiac drugs; chemotherapy agents;
contraceptives; ENT anti-inflammatory agents; Prior Authorization: State currently has a formal
estrogens; hypotensive agents; misc. GI drugs; prior authorization procedure. Direct appeal to
prescribed smoking deterrents; sympathominetics AHCA and/or formal request for administrative
(adrenergic); and thyroid agents. Partial coverage for: hearing required to appeal prior authorization
prescribed cold medications. Prior authorization decisions.
required for: analgesics, antipyretics, and NSAIDs;
growth hormones; mental health drugs; anti- Prescribing or Dispensing Limitation
retrovirals for HIV; drugs not included on the
Medicaid preferred drug list; and brand name Prescription Refill Limit:
prescriptions beyond the four brand cap unless 1. Limited to four brand name RXs per month with
exempted. Therapeutic categories not covered: exceptions for specific therapeutic groups.
anoretics. Exemptions are: Anti-Retrovirals for HIV, Anti-
Psychotics, Depressants and Convulsants,
Florida-6
National Pharmaceutical Council Pharmaceutical Benefits 2003
Florida-7
National Pharmaceutical Council Pharmaceutical Benefits 2003
Florida-8
National Pharmaceutical Council Pharmaceutical Benefits 2003
Florida-9
National Pharmaceutical Council Pharmaceutical Benefits 2003
Florida-10
National Pharmaceutical Council Pharmaceutical Benefits 2004
GEORGIA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.
Georgia-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Georgia-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Georgia-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Georgia-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Georgia-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Georgia-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
HAWAII
*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Hawaii-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Hawaii-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Hawaii-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Hawaii-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
IDAHO
*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Idaho-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Idaho-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Board Members:
Cognitive Services: Does not pay for cognitive Gary Wilburn, R.Ph.
services. Don Smith, R.Ph.
Kent Jensen, R.Ph.
E. USE OF MANAGED CARE Joseph Steiner, Pharm. D.
Nancy Mann, M.D.
Does not use MCOs to deliver services to Medicaid Kevin Clifford, M.D.
recipients. Robert Ting, M.D.
Idaho-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Linda Johann
Individual
Idaho-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Idaho-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Idaho-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
ILLINOIS
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration partictipants, other
recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are
unavailable.
Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.
Illinois-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Illinois-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Illinois-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Illinois-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Illinois-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Illinois-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
INDIANA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/ Child Adult Aged Blind/ Child Adult
Disabled Disabled
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable..
Indiana-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Indiana-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Indiana-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Indiana-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Indiana Division of Mental Health and Addiction Indiana Hospital and Health Association
Representatitve Kenneth G. Stella
Katy Howard (ex-officio) President
One American Square
Indiana Therapeutics Committee Suite 1900
Indianapolis, IN 46282
Judith Ann Monroe, M.D.
T: 317/633-4870
Nancy F. Stater, M.D.
F: 317/633-4875
Michael C. Sha, M.D. (Chair)
E-mail: kstella@inhha.org
Stephen Dunlop, M.D. (Vice Chair)
Internet address: www.inha.org
James T. Poulos, M.D.
Bill Malloy, M.S., Pharm.D., B.C.P.S.
Bruce G. Hancock, M.S., R.Ph.
Indiana-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Indiana-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
IOWA
*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Iowa-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Drug Benefit Product Coverage: Products covered: Unit Dose: Unit dose packaging reimbursable.
prescribed insulin; total parenteral nutrition; and
interdialytic parenteral nutrition. Products covered
Formulary/Prior Authorization
requiring prior authorization: PPIs; dipyridamole;
epoetin; filgrastim; vitamins and minerals;
ergotamine derivatives; narcotic agonist-antagonist Formulary: No formulary. Preferred drug list
nasal sprays; isotretinoin; oral antifungals; non- managed through prior authorization.
parenteral vasopressin derivatives; and Serotonin 5-
HT1 receptor agonists. Products not covered: fertility Prior Authorization: State currently has a formal
drugs; experimental drugs; cosmetics; disposable prior authorization procedure. State appeals and a
needles and syringe combinations for insulin; blood fair hearing procedure required for appeal of prior
glucose test strips; urine ketone test strips; and DESI authorization decisions and coverage of an excluded
drugs. For additional information on drug product product.
coverage, see www.iowamedicaidpdl.com.
Prescribing and Dispensing Limitations:
Over-the-Counter Product Coverage: Products
covered with restriction (selected products): allergy,
asthma, and sinus products; analgesics; cough and Prescribing or Dispensing Limitations: Maximum 30
cold preparations; and topical products. Products not day supply except select maintenance drugs (90 days)
covered: digestive products (non-H2 antagonists and including oral contraceptives, cardiac drugs,
H2 antagonists); feminine products; and smoking hypotensive agents, antidiabetic agents, diuretics,
deterrent products. anticonvulsants and thyroid/antithyroid agents.
Iowa-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Iowa-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Iowa-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Iowa-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Iowa-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
KANSAS
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Kansas-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
State Department of Social and Rehabilitation Formulary: State currently maintains a formulary
Services, Health Care Policy Division. along with a Preferred Drug List (PDL). (See
www.srskansas.org/hcp/medicalpolicy/pharma for a
D. PROVISIONS RELATING TO DRUGS listing of PDL categories.) The formulary/ PDL is
managed through restrictions on use, preferred
Benefit Design products, and physician profiling. Prior authorization
required for non-PDL products.
Drug Benefit Product Coverage: Products covered:
prescribed insulin and syringe combinatios used for Prior Authorization: State currently has a formal
insulin. Products covered under DME: disposable prior authorization procedure. The individual
needles used for insuline (prior authorization appealing may request an administrative hearing to
required); blood glucose test strips; urine ketone test appeal a prior authorization decision by sending a
strips; total parenteral nutrition; and interdialytic request in writing to:
parenteral nutrition. Products not covered: cosmetics;
fertility drugs; experimental drugs; DESI drugs; and Administrative Hearing Office
drugs not rebated by the manufacturer. 610 S.W. 10th Ave, 2nd Floor
Topeka, KS 66612-1616
Over-the-Counter Product Coverage: Products
covered: analgesics; digestive products; feminine Prescribing or Dispensing Limitations
products; and topical products. Products covered with
restrictions: allergy, asthma, and sinus products Monthly Prescription Limit: 5 single source
(some-for children); cough and cold preparations; and scripts/month.
smoking deterrent products (patches covered for
limited time period). Products not covered: OTC Prescription Refill Limit: As authorized by the
nutritional supplements. prescriber and allowed by statute up to a one-year
period from the date of issuance of the prescription
Therapeutic Category Coverage: Therapeutic for non-controlled drugs. No early refills (<75% Rx
categories covered: anabolic steroids; analgesics (for utilized).
children), antipyretics (for children), NSAIDs;
antibiotics; anticoagulants; anticonvulsants; Monthly Quantity Limit: 31-day supply.
antidepressants; antidiabetic agents; antihistamine
drugs; anti-psychotics; antilipemic agents; Other: Narcotics, Viagra, Cialis, Levitra, Ketorolac,
anxiolytics, sedatives, and hypnotics; cardiac drugs; Toradol Relenza and triptans have other specific
chemotherapy agents; contraceptives; ENT anti- limits.
inflammatory agents; estrogens; hypotensive agents; Drug Utilization Review
misc. GI drugs; sympathominetics (adrenergic); and
thyroid agents. Partial coverage for: prescribed cold PRODUR system implemented in November 1996.
medications; prescribed smoking deterrents. Prior State currently has a DUR Board that meets every
authorization required for: anorectics; growth two months.
hormones; triptans; nasal steroids; PPIs, statins; cox-
II inhibitors; wound products; brand name drugs with Pharmacy Payment and Patient Cost
bioequivalent generics; and all non-preferred drugs. Sharing
Dispensing Fee: $3.40, effective 7/1/02.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program Ingredient Reimbursement Basis: EAC Brand, =
when used in home health care and extended care AWP-13%. Generics, AWP-27%. IV fluids, AWP-
facilities, and through physician payment program 50%. Blood fraction products, AWP-30%.
when used in physician offices.
Prescription Charge Formula: Pharmacies are
Vaccines: Vaccines reimbursed as part of the reimbursed the lesser of usual and customary, MAC,
Vaccines for Children Program. FUL, or acquisition cost (EAC) plus a dispensing
fee.
Unit Dose: Unit dose packaging not reimbursable.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific maximum
allowable cost (MAC) limits on generic drugs.
Kansas-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Kansas-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Kansas-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
KENTUCKY 1
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
1 The State of Kentucky did not respond to the 2004 NPC Survey. Using CMS data and other source materials, we have, to the extent possible,
updated the Profile and the tables in the other sections of the Compilation. Users should contact the Kentucky Medicaid program to assess the
accuracy and currency of the information included.
Kentucky-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Drug Benefit Product Coverage: Products covered: Formulary: Closed Formulary. The Kentucky
prescribed insulin; syringe combinations used for Medicaid Program maintains a closed formulary and
insulin. Products covered with restrictions (i.e., covers all rebated products. The State manages the
require prior authorization): total parenteral nutrition; formulary through a variety of techniques including
and interdialytic parenteral nutrition. Products not the exclusion of products based on contracting issues,
covered: cosmetics; fertility drugs; experimental restrictions on use, prior authorization, algorithms,
drugs; disposable needles used for insulin; blood and preferred products. Prior authorization required
glucose test strips; and urine ketone test strips. for many brand name products with generic
equivalents.
Over-the-Counter Product Coverage: Products
covered with restrictions (i.e., require prior Prior Authorization: State currently has a prior
authorization): allergy, asthma and sinus products; authorization procedure. A formal appeals process is
analgesics; cough and cold preparations; digestive available if a request is denied.
products (H2 and non-H2 antagonists); feminine
products and topical products. Products not covered: Prescribing or Dispensing Limitations
smoking deterrent products.
Prescription Refill Limit: (1) No prescriptions may be
refilled more than 5 times or more than 6 months
Therapeutic Category Coverage: Therapeutic
after the prescription is written. (2) After initial
categories covered: antibiotics; anticoagulants;
filling, one dispensing fee per 30-day period for
anticonvulsants; antidepressants; antidiabetic agents;
designated maintenance drugs.
chemotherapy agents; contraceptives; ENT anti-
inflammatory agents; estrogens; and thyroid agents. Monthly Quantity Limit: For designated classes of
Prior authorization required for: anabolic steroids; maintenance drugs, refills of the original prescription
analgesics, antipyretics, NSAIDs; anoretics; and subsequent prescriptions for these drugs must be
antihistamine drugs; antilipemic agents; anti- prescribed and dispensed in quantities of not less
psychotics; anxiolytics, sedatives, and hypnotics; than a 30 day supply unless the prescriber requests an
cardiac drugs; prescribed cold medications; growth exception to his policy.
hormones; hypotensive agents; misc. GI drugs;
topical steroids; erectile dysfunction products; Drug Utilization Review
Leukotriene inhibitors; Synagis; Respigam; Zetia;
CNS stimulants for ADHD and other disorders;
Avodart; Proscar; anti-fungals for nails; Serotonin PRODUR system implemented in 1987. State
5HT1 Receptor Agonosts; GCSF products; currently has a DUR Board with a quarterly review.
Recombinant Human Erythropoietin agents; and Pharmacy Payment and Patient Cost Sharing
Xolair. Therapeutic categories not covered:
prescribed smoking deterrents; agents for cosmetic
purposes or hair growth and agents to promote Dispensing Fee: $4.51, effective 1/16/01.
fertility.
Ingredient Reimbursement Basis: EAC = AWP-12%.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program Prescription Charge Formula: Reimbursement
when used in home health care and extended care consists of the lowest of: (1) the usual and customary
facilities, and through both the Prescription Drug charge; (2) the FMAC, if any, plus a dispensing fee;
Program and physician payment when used in or (3) the EAC plus a dispensing fee, or (4), SMAC
physician offices. Reimbursement is limited to if any, plus a dispensing fee.
antineoplastic drugs with “J” codes in physician
offices, several antibiotics, Depo-Provera for birth
control.
Kentucky-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Kentucky-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Kentucky-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Kentucky-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Kentucky-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
LOUISIANA
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Louisiana-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Louisiana-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Cognitive Services: Does not pay for cognitive Richard A. Soileu, Pharm.D.
services New Iberia, LA
Louisiana-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Louisiana-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Louisiana-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Louisiana-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
MAINE 1
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
1
The State of Maine did not respond to the 2004 NPC Survey. Using CMS data and other source materials, we have, to the
extent possible, updated the profile and the tables in the other sections of the Compilation. Users should contact the Maine
Medicaid Program to assess the accuracy and currency of the information included.
Maine-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Maine-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Maine-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Maine-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
MARYLAND
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Maryland-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Maryland-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Maryland-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Maryland-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Maryland-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Maryland-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
MASSACHUSETTS
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Massachusetts-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Drug Benefit Product Coverage: Products covered: Unit Dose: Unit dose packaging not reimbursable.
prescribed insulin. Products covered (except in
LTC facilities): disposable needles and syringe Formulary/Prior Authorization
combinations used for insulin; blood glucose test
strips; urine ketone test strips. Products covered Formulary: Open formulary managed through
with restrictions: total parenteral nutrition (prior restrictions on use, prior authorization, and
authorization required). Products not covered: physician profiling.
cosmetics; fertility drugs; experimental drugs; Prior Authorization: State currently has a prior
interdialytic parenteral nutrition; DESI drugs; authorization procedure. A recipient may file a
legend vitamins not on Drug List, non-legend drugs request for a fair hearing to appeal a prior
not on Drug List; propoxyphene-containing authorization decision.
products and products rated by the FDA as less-
than-effective. Prescribing or Dispensing Limitations
Over-the-Counter Product Coverage: Products Prescription Refill Limit: Prescription may be
covered with restrictions (limited OTC list-generics refilled, as authorized, with a limit of up to 11
only- not covered in LTC facilities): allergy, refills from the filling of the original prescription
asthma and sinus products; analgesics; cough and Monthly Quantity Limit: Schedule II and III drugs
cold preparations; digestive products; feminine are limited to a 30-day supply, except Ritalin and
products and topical products. Products not Dexedrine, which may be dispensed up to a 60-day
covered: smoking deterrent products. supply.
Therapeutic Category Coverage: Therapeutic Monthly Dollar Limits: None.
categories covered: anabolic steroids; antibiotics;
anticoagulants; chemotherapy agents; Drug Utilization Review
contraceptives; estrogens, and thyroid agents. Prior PRODUR system implemented in October 1995.
authorization required for: growth hormones; State currently has a DUR Board with a quarterly
Erythropoeitin; and selected biotech drugs. Partial review.
coverage for: prescribed cold medications. Partial
coverage with prior authorization required for: Pharmacy Payment and Patient Cost
analgesic, antipyretics, and NSAIDs; Sharing
anticonvulsants; anti-depressants; antidiabetic
agents; antihistamines; antilipemic agents; anti- Dispensing Fee: $3.00 (basic) plus $1.00-$2.00
psychotics; anxiolytics, sedatives, and hypnotics; additional for compounded Rx’s, effective
cardiac drugs; ENT anti-inflammatory agents; 1/1/2004.
hypotensive agents; misc. GI drugs; and
sympathominetics (adrenergic). Therapeutic Ingredient Reimbursement Basis: EAC = WAC +
categories not covered: anoretics; prescribed 5%.
smoking deterrents; weight loss or gain
medications; medications to treat sexual
dysfunction; experimental or investigational drugs;
and less than effective drugs.
Massachusetts-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Massachusetts-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Massachusetts-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
MICHIGAN
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/ Child Adult Aged Blind/ Child Adult
Disabled Disabled
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Michigan-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Michigan-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Michigan-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Michigan-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Michigan-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Michigan-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
MINNESOTA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Minnesota-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Drug Benefit Product Coverage: Products covered: Vaccines: Vaccines reimbursable when billed as
prescribed insulin; disposable needles and syringe part of the Vaccines for Children Program.
combinations used for insulin; blood glucose test
strips; urine ketone test strips; total parenteral Unit Dose: Unit dose packaging reimbursable.
nutrition; and interdialytic parenteral nutrition.
Products not covered: drugs used for cosmetic Formulary/ Prior Authorization
purposes; drugs used for hair growth; fertility Formulary: Open formulary with general
drugs; appetite supressants; and experimental exclusions, restrictions, prior authorization, and
drugs. Products covered with limitations: sildenafil; preferred products.
methylphenidate (including d-methylphenidate);
Adderall; pemoline; dextroamphetamine; vitamins; Prior Authorization: State currently has a prior
and cough and cold preparations. Prior authorization procedure and a Drug Formulary
authorization required for: alglucerase; Interferon Committee. Recipient has the right to appeal prior
Alfa N-3; Interferon Gamma-1B; Ondansetron; authorization decisions and coverage of an
Granisetron; omeprazole (including s-omeprazole); excluded product by appeals referee followed by an
sertraline 25mg and 50mg tablets; Butulinum Toxin appeal in court.
Types A & B; valdecoxib; Esomeprazole;
dolasetron; celecoxib; rofecoxib; escitalopram Prescribing or Dispensing Limitations
10mg; citalopram 10mg and 20mg; paroxetine
10mg; modafinil 100mg; trandolapril; Monthly Quantity Limit: 3 month supply. Minimum
trandolapril/verapamil combination; quinapril; 34-days for maintenance drugs. Contraceptives may
quinapril/HCTZ; amlodipine/benazepril; be filled to provide a 3-month supply.
benazepril/HCTZ; benazepril; fosinopril; and
fosinopril/HCTZ. (For a complete list of products Drug Utilization Review
requiring prior authorization, contact the Pharmacy
PRODUR system implemented in February 1996.
Program at The Minnesota Department of Human
State currently has a DUR Board with a quarterly
Services, Health Care Management Division,
review.
Medical Assistance Program at
http://www.dhs.state.mn.us/provider/pharm/.)
Pharmacy Payment and Patient Cost
Sharing
Over-the-Counter Product Coverage: Products
covered: allergy, asthma and sinus products; Dispensing Fee: $3.65, effective 7/1/99.
analgesics; cough and cold preparations; digestive Pharmacies that dispense drugs that they package
products; feminine products (antifungals covered); into unit packaging receive an additional $0.30 per
topical products; and smoking deterrent products. prescription.
Products covered with limitations: vitamins; ocular
lubricants; pediculocides; and activated charcoal Ingredient Reimbursement Basis: EAC = AWP-
and ipecac. 11.5%.
Minnesota-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Minnesota-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Minnesota-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Minnesota-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Minnesota-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
MISSISSIPPI
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Nursing Facility Services
Skilled Nursing Home Services
Physician Services
Dental Services
**Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Mississippi-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Mississippi-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Mississippi-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Mississippi-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Mississippi-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Mississippi-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
MISSOURI
**Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Missouri-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Missouri-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Missouri-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Missouri-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Missouri-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Missouri-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
MONTANA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are
unavailable.
Montana-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Montana-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Montana-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Montana-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
NEBRASKA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data provided by the Nebraska Department of Health and Human Services, Finance and Support, Medicaid Division.
Source: CMS, MSIS Report, FY 2002 and Nebraska Medicaid Statistical Information System, FY 2003
Note: Nebraska estimates 2004 drug expenditures to be approximately $216.5 million and the number of Medicaid drug
recipients to be 192,000.
Nebraska-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Therapeutic Category Coverage: Therapeutic 7. Medical supplies and certain drugs for nursing
categories covered: anticoagulants; anticonvulsants; facility and intermediate care facility for the
antilipemic agents; anti-psychotics; cardiac drugs; mentally retarded (ICF/MR) patients;
prescribed cold medications; contraceptives; ENT 8. Over-the-counter (OTC) drugs not listed on the
anti-inflammatory agents; estrogens; hypotensive Department’s Drug Name/License Number
agents; sympathominetics (adrenergic); antibiotics; Listing microfiche;
anti-depressants; antidiabetic agents; and thyroid
agents. Prior authorization required for: 9. Baby foods or metabolic agents (Lofenalac,
sunscreens; Erythropoetin (e.g., Epogen, Procrit); etc.,) normally supplied by the Nebraska
modified versions of FUL or SMAC drugs; Department of Health;
convenience packaged drugs (e.g., Refresh 10. Drugs distributed or manufactured by certain
Ophthalmic 0.3 ml and Novalin penfil insulin); drug manufacturers or labelers that have not
drugs to prevent or treat Respiratory Syncytial agreed to participate in the drug rebate
Virus Immune Globulin (e.g., Palivizumab, RSV- program.
IG); and drugs for sexual dysfunction (e.g.,
Sildenafil, Alprostadil). Partial coverage (PA Drugs, items, or manufacturers that are identifiable
required) for: analgesics, antipyretics, NSAIDs; as non-covered are so designated on the NE-POP
antihistamines; anxiolytics, sedatives, and system, and on the Department’s Drug
hypnotics; chemotherapy agents; growth hormones; Name/License Number Listing microfiche or
and misc. GI drugs. Therapeutic categories not website.
covered: anabolic steroids; anorectics; and
prescribed smoking deterrents.
Nebraska-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Prior Authorization: State currently has a formal Maximum Allowable Cost: State imposes Federal
prior authorization procedure. Prescriber must Upper Limits as well as State-specific limits on
submit a letter of medical necessity with generic drugs. More than 1,500 drugs are listed on
documentation. The Department requires that the State-specific MAC list. Override requires a
authorization be granted prior to payment for “Brand Medically Necessary” form signed by the
certain products. Prior authorization can be physician.
verified through the NE-POP System, or by
contacting the Department. (or its designated Incentive Fee: None.
contractor) if authorization is not verified through
the NE-POP System. Patient Cost Sharing: Copayment = $2.00.
Nebraska-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Nebraska-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Nebraska-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Nebraska-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
Nevada-0
National Pharmaceutical Council Pharmaceutical Benefits 2004
2002 2003**
Expenditures Recipients Expenditures Recipients
Nevada-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Coverage of Injectables: Injectable medicines Monthly Quantity Limit: 5 refills within 6 months
reimbursable through the Prescription Drug for controlled drugs. Up to 11 refills for non-
Program when used in home health care and controlled drugs.
extended care facilities, and through physician
payment when used in physicians’ office
Nevada-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Nevada-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Nevada-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Nevada-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Nevada-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
Nevada-7
National Pharmaceutical Council Pharmaceutical Benefits 2004
New Hampshire-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Cognitive Services: Does not pay for cognitive Medicaid DUR Board
services.
Paul S. Collins, M.D.
Mark Henschke, D.O.
E. USE OF MANAGED CARE Emory Kaplan, M.D.
Steve Lawrence, M.D.
None as of June 2003. Thomas Mellman, M.D.
Elizabeth Gower, R.Ph.
Helen Pervanas, R.Ph.
F. STATE CONTACTS Michael Smith, R.Ph.
John Zinka, R.Ph.
State Drug Program Administrator
Margaret A. Clifford New Brand Name Products Contact
Pharmacy Administrator Lise C. Farrand, R.Ph.
Office of Medicaid Business and Policy Pharmaceautical Services Specialist
129 Pleasant Street, Annex 1 Office of Medicaid Business and Policy
Concord, NH 03301 129 Pleasant Street, Annex 1
T: 603/271-4210 Concord, NH 03301
F: 603/271-8701 T: 603/271-4419
E-mail: mclifford@dhhs.state.nh.us F: 603/271-8701
Internet address: E-mail: lfarrand@dhhs.state.nh.us
www.dhhs.state.nh.gov/dhhs/medicaidprogram
New Hampshire-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
New Hampshire-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
NEW JERSEY
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
1 The State of New Jersey did not respond to the 2002 or 2003 NPC Surveys. Using CMS data and other source materials, we have, to the
extent possible, updated the Profile and the tables in other sections of the Compilation. Users should contact the New Jersey Medicaid
program to assess the accuracy and currency of the information included.
New Jersey-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
New Jersey-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Over-the-Counter Product Coverage: Products Monthly Quantity Limit: Original, 34-day supply.
covered: digestive products (non-H2 antagonists); Refills, 34 days or 100 units, whichever is more.
smoking deterrent products (inhalers or nasal
spray); contraceptive devices and supplies; and Drug Utilization Review
family planning supplies (e.g., pregnancy test kits). PRODUR system implemented in October 1996.
Products covered with restrictions (for children State currently has a DUR Board with a quarterly
under age 21 only): allergy, asthma, and sinus review.
products; analgesics; topical products; and cough
and cold preparations. Products not covered: Pharmacy Payment and Patient Cost
digestive products; (H2 antagonists); feminine Sharing
products; contraceptives; inhalation drugs; and
antacids. Dispensing Fee: $3.73 for legend drugs.
Additional add-ons per/Rx shall be given to
Therapeutic Category Coverage: Therapeutic pharmacy providers who provide the following:
categories covered: anabolic steroids; analgesics,
antipyretics, NSAIDs; antibiotics; anticoagulants; 1. 24-hr. Emergency Service: add $0.11
anticonvulsants; anti-depressants; antidiabetic 2. Patient Consultation: add $0.08
agents; antihistamines; antilipemic agents; anti-
psychotics; anxiolytics, sedatives, and hypnotics; 3. Impact Area Location: add $0.15 (provider
cardiac drugs; chemotherapy agents; prescribed shall have a combined Medicaid, NJ KidCare
cold medications; ENT anti-inflammatory agents; and PAAD prescription volume equal to or
estrogens; hypotensive agents; prescribed smoking greater than 50% of total prescription volume.
deterrents; sympathominetics (adrenergic); and
Ingredient Reimbursement Basis: EAC = AWP-
thyroid agents. Partial coverage for: anorectics (for
12.5%. AAC for injectables, effective 5/1/00.
ADD); contraceptives; growth hormones; and misc.
GI drugs.
Prescription Charge Formula: “Maximum
Allowable Cost,” or Average Wholesale Price-
Coverage of Injectables: Injectable medicines
12.5% (reduction from AWP is pharmacy specific)
reimbursable through both the Prescription Drug
plus a dispensing fee or the provider’s usual and
Program and through physician payment when used
customary charge, whichever is lower.
in home health care, extended care facilities, and
physician offices.
Maximum Allowable Cost: State imposes Federal
Upper Limits on generic drugs. Override requires
Vaccines: Vaccines reimbursable at AWP as part of
“Dispense as Written” or “Medically Necessary.”
the Vaccines for Children Program.
Incentive Fee: None.
Unit Dose: Unit dose packaging reimbursable in
Patient Cost Sharing: None.
long-term care facilities only, not in retail settings
(unless u/d is only way item is packaged).
New Jersey-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Cognitive Services: Does not pay for cognative Department of Human Services Officials
services.
James M. Davy, Commissioner
Department of Human Services
E. USE OF MANAGED CARE Capitol Place One CN-700, 5th Floor
P.O. Box 700
Approximately 640,000 Medicaid recipients Trenton, NJ 08625
received pharmacy benefits through managed care T: 609/292-3717
in 2003. Beneficiaries receive pharmaceutical F: 609/292-3824
benefits through the State and through MCOs. E-mail: james.davy@dhs.state.nj.us
Mental health drugs and prescriptions for the aged,
blind, and disabled (ABD) population are carved Ann Clemency Kohler, Director
out of managed care. Division of Medical Assistance and Health Services
Department of Human Services
Managed Care Organizations P.O. Box 712
Trenton, NJ 08625-0712
AMERIGROUP New Jersey, Inc T: 609/588-2600
399 Thornall Street, 9th Floor F: 609/588-3583
Edison, NJ 08837 E-mail: ann.kohler@dhs.state.nj.us
800/600-4441
DUR Contact
Health Net of New Jersey, Inc.
CNA Building Kaye Morrow
3501 State Highway 66 Assistant Director
Neptune, NJ 07754 Department of Human Services
800/555-2604 Division of Medical Assistance and Health Services
Office of Provider Relations
AmeriChoice of New Jersey, Inc. P.O. Box 712
Two Gateway Center, 13th Floor Trenton, NJ 08619
Newark, NJ 07102 T: 609/631-2396
800/941-4647 F: 609/588-3889
E-mail: kaye.s.morrow@dhs.state.nj.us
Horizon NJ Health Medicaid DUR Board
210 Silvia Street
Trenton, NJ 08628 Christopher A. Cella, R.Ph.
800/765-4325 Judith Martinez Rodriguez, R.Ph.
Joseph Nicholas Micale, M.D.
University Health Plans, Inc. Rochelle Dallago, R. Ph.
550 Broad Street, 17th Floor Linda Gooen, Pharm D., R.Ph.
Newark, NJ 07102 Eileen Moynihan, M.D.
800/564-6847 David Ethan Swee, M.D.
New Jersey-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
New Jersey-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
NEW MEXICO
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
New Mexico-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
New Mexico-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
New Mexico-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
New Mexico-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
New Mexico-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
New Mexico-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
NEW YORK
* Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.
New York-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
New York-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
New York-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
New York-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
New York-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Executive Officers of State Medical and Greater New York Hospital Association
Pharmaceutical Societies Kenneth E. Raske
President
Medical Society of the State of New York
555 W. 57th Street
William R. Abrams
15th Floor
Executive Vice President
New York, NY 10019
420 Lakeville Road
T: 212/246-7100
P.O. Box 5404
F: 212/262-6350
Lake Success, NY 11042-5404
E-mail: raske@gnyha.org
T: 516/488-6100
Internet address: www.gnyha.org
F: 516-488-6136
E-mail: mssny@mssny.org
Internet address: www.mssny.org
New York-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
NORTH CAROLINA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
North Carolina-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Therapeutic Category Coverage: North Carolina Pharmacy Payment and Patient Cost
provides coverage for all therapeutic categories Sharing
except anoretics; products used for cosmetic Dispensing Fee: B: $4.00; G: $5.60, effective 2002.
purposes; fertility drugs; diaphragms; IV fluids
(Dextrose 500ml or greater) and irrigations fluids Ingredient Reimbursement Basis: EAC = AWP-
used in an inpatient facility; drugs on the DESI list; 10%.
any drug manufactured by a company who has not
signed the Federal rebate agreement; and Prescription Charge Formula: The lowest price of
experimental drugs. Prior authorization required AWP minus 10%, State MAC or Federal MAC plus
for: analgesics, antipyretics, and NSAIDs; drugs a dispensing fee or usual and customary, whichever
used to treat ADHD; Procrit/Epogen; Neupogen; is lowest. The pharmacist filling the original
Aransep; OxyContin; Growth Hormones;Provigil; prescription will not be reimbursed for refills for
Rebetron; Vioxx; Celebrex; Bextra; Botox; the same drug within a calendar month.
Mybloc; Zyban, Nicotrol, Nicotine Patch; Synagis;
and RespiGam. (See www.ncmedicaidpbm.com for
Maximum Allowable Cost: State imposes Federal
additional information.)
Upper Limits as well as State-specific maximum
allowable cost (MAC) limits generic drugs. 433
Coverage of Injectables: Injectable medicines drugs are listed on the State-specific MAC list.
reimbursable through the Prescription Drug Override requires “Brand Medically Necessary”
Program when used in home health care and written on the face of the prescription by the
extended care facility, and through physician prescriber.
payment when used in physician offices.
Incentive Fee: $1.60 to dispense a lower cost
Vaccines: Vaccines reimbursable as part of the multisource product.
ESPDT service and The Vaccines for Children
Program.
Patient Cost Sharing: $1.00 copayment/Rx
(includes refills) for generic prescriptions; $3.00
Unit Dose: Unit dose packaging not reimbursable. copayment/Rx for brand name prescriptions.
Formulary/Prior Authorization Cognitive Services: Does not pay for cognitive
Formulary: Open formulary. services.
North Carolina-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
North Carolina-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
North Carolina-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
NORTH DAKOTA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
North Dakota-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Coverage of Injectables: Injectable medicines Cognitive Services: Does not pay for cognitive
reimbursable through the Prescription Drug services
Program when used in home health care, and
extended care facilities, and through both the E. USE OF MANAGED CARE
Prescription drug program and physician payment
when used in physician offices. Approximately 3,500 Medicaid recipients were
enrolled in managed care organizations in 2003.
Vaccines: Vaccines reimbursable as part of the Recipients enrolled in MCO’s receive pharmacy
EPSDT service. benefits through the State.
North Dakota-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
North Dakota-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
North Dakota-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
OHIO
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Ohio-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Ohio-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Ohio-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Ohio-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Ohio-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Ohio-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
OKLAHOMA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
1
Note: As of January 1, 2004, (after the survey was conducted) the Oklahoma Medicaid program, according to its website,
underwent changes regarding managed care. These changes will be reflected in the 2004 compilation. Please contact the State for
information on the changes in managed care.
Oklahoma-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Oklahoma-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Oklahoma-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Oklahoma-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Oklahoma-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
OREGON
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
** 2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Oregon-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Over-the-Counter Product Coverage: Products Pharmacy Payment and Patient Cost Sharing
covered: allergy, asthma, and sinus products; Dispensing Fee: effective 2/1/03.
analgesics; cough and cold preparations; digestive
products; feminine products; and topical products. 1) $3.50 (retail);
Products not covered: topical products (cosmetics,
acne medications, and psoriasis products). 2) $3.91 (institutional/SNF: providers operating a
True or Modified Dose Delivery System).
Therapeutic Category Coverage: Therapeutic
categories covered: analgesics, antipyretics, and Ingredient Reimbursement Basis: EAC = AWP-15%
NSAIDs; antibiotics; anticoagulants; anti- (Retail), AWP-11% (Institutional)
depressants; antidiabetic drugs; antilipemic agents;
antipsychotics; cardiac drugs; chemotherapy agents; Prescription Charge Formula: Estimated acquisition
prescribed cold medications; contraceptives; cost (EAC) defined as the lesser of: (1) AWP-15%
estrogens; hypotensive agents; prescribed smoking (2) Federal Upper Limits for multiple source drugs or
deterrents; sympathominetics (andrenergic); and (3) State MAC, or (4) the usual and customary charge
thyroid agents. Therapeutic categories requiring prior plus a dispensing fee.
authorization: anabolic steroids; anoretics;
anticonvulsants; antihistamine drugs; anxiolytics, Maximum Allowable Cost: State imposes Federal
sedatives, and hypnotics; ENT anti-inflammatory Upper Limits as well as State-specific maximum
agents; growth hormones; misc. GI drugs; allowable cost (MAC) limits on generic drugs.
antifungals; legend laxatives; oral nutrionals; topical Override requires or “Brand Medically Necessary”
antibiotics; topical antivirals; weight reduction drugs; plus documentation of patient intolerance to generic.
and any other drug products for which the only
indication is for a non-funded condition. (The Oregon Incentive Fee: None.
Health Plan coverages are limited to conditions
which appear on the HSC prioritized list.) Patient Cost Sharing: $2.00 (generic); $3.00 (brand)
Coverage of Injectables: Injectable medicines Cognitive Services: Does not pay for cognitive
reimbursable through physician payment when used services.
in physician offices, home health care, and extended
care facilities.
Oregon-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Oregon-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Oregon-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Oregon-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Oregon-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
PENNSYLVANIA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Pennsylvania-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Pennsylvania-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Pennsylvania-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Pennsylvania-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Pennsylvania-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Executive Officers of State Medical and The Hospital and Healthsystem Association of
Pharmaceutical Associations Pennsylvania
Carolyn F. Scanlan
Pennsylvania Medical Society
President and CEO
Roger F. Mecum
4750 Lindle Road
Executive Vice President
P.O. Box 8600
777 E. Park Drive
Harrisburg, PA 17105-8600
P.O. Box 8820
T: 717/564-9200
Harrisburg, PA 17105-8820
F: 717/561-5334
T: 717/558-7750
E-mail: cscanlan@haponline.org
F: 717/558-7840
Internet address: www.haponline.org
E-mail: rmecum@pamedsoc.org
Internet address: www.pamedsoc.org
Pennsylvania-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
RHODE ISLAND
*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Rhode Island-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Rhode Island-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Rhode Island-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Rhode Island-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
SOUTH CAROLINA
*Total Other Expenditures/ Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data provided by the South Carolina Department of Health and Human Services. 2003 data on number of recipients by
maintenance assistance status and basis of eligibility are unavailable.
Source: CMS, MSIS Report, FY 2002, and South Carolina Medicaid Statistical Information System, FY 2003.
South Carolina-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
South Carolina-2
National Pharmaceutical Council Pharmaceutical Benefits 2004
Monthly Quantity Limit: Children (birth to age 21) Patricia Marquis, Chief Operating Officer
are allowed unlimited prescriptions per month. P.O. Box 40024
Beneficiaries over the age of 21 are limited to a Charleston, SC 29403
maximum of four prescriptions per month; however, 843/569-1759
pharmacists may override the monthly prescription
limit for adult Medicaid beneficiaries if the Better Health Care Plans
prescription meets certain specified override criteria. Dan Gallagher
Vice President and Executive Director
Quantity Limit per Prescription: 34-day supply per 250 Berryhill Road, Suite 514
prescription. Maximum quantity limitations have Columbia, SC 29210
been established for certain pharmaceuticals. 803/798-8210
South Carolina-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
South Carolina-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
South Carolina-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
South Carolina-6
National Pharmaceutical Council Pharmaceutical Benefits 2004
SOUTH DAKOTA
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
*Total Other Expenditures/recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
South Dakota-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
Drug Benefit Product Coverage: Products covered: Monthly Quantity Limit: Varies by drug.
prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test Monthly Prescription Limit: None
strips; and urine ketone test strips. Prior authorization
required for: total parenteral nutrition and
interdialytic parenteral nutrition. Products not Drug Utilization Review
covered: cosmetics; DESI drugs; fertility drugs;
experimental drugs; and drugs for impotence. PRODUR system implemented in 1996.
Pharmacy Payment and Patient Cost Sharing
Over-the-Counter Product Coverage: Product Dispensing Fee: $4.75 to $5.55 (with unit dose fee
covered with restrictions: allergy, asthma, and sinus applied), effective 7/1/1991
products (OTC loratadine only) and digestive
products (non-H2 antagonists-OTC omeprazole Ingredient Reimbursement Basis: EAC = AWP-
only). Products not covered: analgesics; cough and 10.5%.
cold preparations; digestive products; (H2
antagonists); feminine products; topical products; and Prescription Charge Formula: Payment is the lower
smoking deterrents. of:
Therapeutic Category Coverage: Therapeutic 1. FUL, State MAC plus a dispensing fee, or
categories covered: anabolic steroids; analgesics, 2. EAC plus a dispensing fee, or usual and
antipyretics, NSAIDs; anoretics; antibiotics; customary charge to the general public.
anticoagulants; anticonvulsants; antidepressants;
antidiabetic agents; antihistamine drugs; antilipemic Maximum Allowable Cost: State imposes Federal
agents; anti-psychotics; anxiolytics, sedatives, and Upper Limits as well as State-specific limits on
hypnotics; cardiac drugs; chemotherapy agents; generic drugs. Approximately 1,000 drugs are listed
contraceptives; ENT anti-inflammatory agents; on the State-specific MAC list. Override requires
estrogens; hypotensive agents; misc. GI drugs; “Brand Necessary” or “Brand Medically Necessary.”
sympathominetics (adrenergic); prescribed cold
medications and thyroid agents. Prior authorization Incentive Fee: None
required for: growth hormones. Partial coverage for:
prescribed smoking deterrents. Therapeutic Patient Cost Sharing: Copayment is $2.00.
categories not covered: nutritional supplements;
clozapine. Cognitive Services: Does not pay for cognitive
services.
Coverage of Injectables: Injectable medicines
reimbursable through both the Prescription Drug E. USE OF MANAGED CARE
Program and physician payment when used in
physician offices, home health care, and extended
Does not use MCOs to deliver pharmacy services to
care facilities.
Medicaid recipients.
Vaccines: Vaccines reimbursable with HCPC code as
part of EPSDT services, The Children’s Health
Insurance Program, and the Vaccines for Children
Program.
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TENNESSEE -- TennCare
On January 1, 1994, Tennessee made history by demonstration project ended December 31, 1998.
withdrawing from the Medicaid Program and HCFA approved a waiver extension for three years
implementing an innovative new health care reform beginning January 1, 1999 through December 31,
plan called TennCare. In order to implement 2001. On July 1, 2002, Tennessee reached a new
TennCare, Tennessee was granted a Section 1115 five-year agreement with the federal government to
demonstration waiver by the Federal government. continue TennCare.
TennCare replaced the existing Medicaid Program
with a program of managed health care. TennCare TennCare services are offered through managed
receives about 66 percent of its annual budget from care organizations (MCOs) and behavioral health
the Federal government. Approximately one-third organizations (BHOs) under contract with the State.
of the TennCare budget consists of State funds. These MCOs, spread out over the twelve regions of
TennCare required no new taxes and extended Tennessee, are paid a fixed amount. The MCOs and
health coverage not only to the nearly 800,000 BHOs negotiate payment rates with individual
Tennesseans in the Medicaid population, but also to providers. Enrollees have a choice of MCOs (and
an approximately 400,000 uninsured or uninsurable their corresponding BHO partner plan) from those
persons using a system of managed care. available in their geographic area. Effective January
Enrollment was open in 1994 to eligible persons in 1, 1997, all services are delivered within a strict
the uninsured, uninsurable, and Medicaid-eligible "gatekeeper" model system requiring primary care
categories. providers to manage enrollees' health care.
On January 1, 1995, TennCare reached 90% of its TennCare services, as determined medically
target enrollment and closed enrollment in the necessary by the MCO, cover inpatient and
uninsured category. However, on April 1, 1997, outpatient hospital care, physician services,
enrollment in the uninsured category re-opened to prescription drugs, lab and x-ray services, medical
children under the age of 18 who do not have supplies, home health care, hospice care, and
access to health insurance through a parent or ambulance transportation. Excluded from TennCare
guardian. On May 21, 1997, TennCare enrollment managed care services are long-term care services
became available for eligible dislocated workers. In and Medicare cross-over payments which are
an effort to expand coverage to more of Tennessee's continuing as they were under the former Medicaid
uninsured children, the Bureau of TennCare opened system.
enrollment on January 1, 1998 to uninsured
Tennesseans under the age of nineteen (19) with TennCare is financed by pooling current Federal,
access to health insurance whose individual family State, and local expenditures for indigent health
incomes are below 200% of the poverty level. care. Pooled resources totaled $5.5 billion in FY
Effective January 1, 1998, uninsured children under 2001. In the future, competition among managed
age nineteen (19) who meet the TennCare criteria care networks, combined with the enrollment cap,
for uninsured are being allowed to enroll in should enable TennCare to grow at a predictable
TennCare indefinitely. The Bureau of TennCare rate not exceeding the annual rate of growth in
eliminated deductibles and limited co-payments to State spending.
$5 and $10 for these new eligibility populations and
all uninsured children under eighteen (18) years of
ELIGIBILITY FOR TENNCARE COVERAGE
age who enrolled in TennCare during previous open
enrollment periods. Enrollment remains open to The current federal waiver separates TennCare into
persons who are Medicaid-eligible or who are Two products: TennCare Medicaid and TennCare
uninsurable. Current enrollment (1/23/04) is Standard. Tenncare Medicaid is a continuation of
approximately 1.3 million of which 1 million are the basic TennCare Medicaid program with a few
Medicaid eligibles and 300,000 are in the minor changes in benefits. TennCare Medicaid adds
uninsured/uninsurable categories. a new eligibility category: woman under 65 who
have been screened by The Centers for Disease
The State of Tennessee was granted approval by the Control and are in need of treatment for breast or
Health Care Financing Administration (now CMS) cervical cancer.
for a five-year demonstration project under Section
1115 of the Social Security Act. State rules were
promulgated to assist in administering the statewide
program (TSOP). The initial five-year
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TennCare Standard is similar to a commercial Accordingly, the State has proposed terminating
HMO package. People eligible for TennCare coverage for the adult demonstration population as
standard are adults below the 100 percent of the well as for the adult non-pregnant Medically Needy
federal poverty level, children below 200 percent of population. As a result, approximately 396,000
the poverty level, and people who are “medically Medicaid eligible adults will retain a “reasonable”
eligible” a new term to describe what the state level of coverage while another 323,000 adults who
previously referred to as “uninsurables.” The are not elegible for Medicaid but who are covered
difference is that “Medical eligibility” will be under TennCare via a Federal waiver will lose
determined by a State-appointed health insurance coverage.
underwriter. Under the previous TennCare system,
In addition, some types of coverage would be
a denial letter from an insurance company defined
eliminated and certain limits or restrictions will be
“uninsurability.”
imposed on other programs, including pharmacy.
Managed care organizations participating in
The five-year waiver that TennCare began on July
TennCare would be asked to assume greater
1, 2002 also includes an annual “open enrollment”
financial risk.
period, which would allow people who are
uninsured or medically eligible above poverty to The TennCare Plan amendments are being
enroll in TennCare. The current fiscal year’s budget reviewed by CMS.
does not allow for an open enrollment period, at
least through the end of the current fiscal year, June
30, 2003. However, if an applicant is both below A. ADMINISTRATION
100 percent of the poverty level and medically
eligible, enrollment will be allowed at any time Tennessee Department of Finance and
during the year. Administration, Bureau of TennCare
Persons wanting to apply for TennCare must visit B. PROVISIONS RELATING TO DRUGS
the local Tennessee Department of Human Services
(DHS) office. There is a local DHS office in every Benefit Design
Tennessee County. For the applicants' convenience,
Pharmacy services are provided by the managed
DHS will make a copy of the application, date
care organizations. Within Federal and State
stamp it, and process the application.
guidelines, each individual managed care and
Recent Proposed Changes to TennCare pharmacy benefit management organization makes
formulary/drug decisions. Pharmacy services are
The TennCare program is currently undergoing a to be covered as medically necessary, excluding
major restructuring as a result of rapidly escalating DESI, less than effective and IRS drugs and some
program costs, Tennessee, during 2004, developed drugs for which TennCare does not mandate
a plan to restructure TennCare in a manner that coverage (e.g., drugs for infertility, weight
would allow the State to maintain coverage while reduction, cosmetic purposes, hair growth products,
reining in the unstainable increase in program costs. products for symptomatic relief of cough and colds,
In September 2004, Tennessee submitted a proposal experimental drugs; smoking cessation products,
to CMS to amend the TennCare program. experimental drugs; and OTCs). Starting in July 1,
While continuing to engage in decisions with 2003 all eligible products dispensed through
various stakeholders regarding the proposed ambulatory pharmacies are invoiced through the
changes, numerous legal objections and possible CMS rebate program.
law suits have made it more difficult to implement
many of the proposed changes. While still hoping Formulary/Prior Authorization
to implement many of the reforms that were Formulary: Preferred Drug List (PDL) was phased
previously announced, because of the rapidly in from October 15th through December 15th in 3
deteriorating budget outlook, the State has had to phases (see http://tennessee.fhsc.com). The PDL is
contemplate more drastic reform measures in order managed through preferred products and prior
to stabilize the program. The proposed revisions, authorization.
which the State has submitted to CMS for approval,
are designed to reduce TennCare enrollment trim Prior Authorization: State currently has a formal
benefits without returning to a traditional Medicaid prior authorization procedure. Recipient may
program. appeal coverage and prior authorization decisions
The State’s objective is to maintain current levels to the TennCare Solutions Unit.
of coverage for the more than 600,000 children who
rely on the TennCare program for their care.
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TEXAS
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
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UTAH
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data provided by the Utah Department of Health Division of Health Care Financing.
Source: CMS, MSIS Report, FY 2002 and Utah Medicaid Statistical Information System, FY 2003.
Note: Utah estimates 2004 drug expenditures to be approximately $177.5 million and the number of Medicaid drug recipients to
be 212,000.
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VERMONT
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
1 The State of Vermont did not respond to the 2001, 2002, or 2003 NPC Surveys. Using CMS data and other source materials, we have, to
the extent possible, updated the Profile and the tables in other sections of the Compilation. Users should contact The Vermont Medicaid
program to assess the accuracy and currency of the information included.
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VIRGINIA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
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WASHINGTON
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Drug Benefit Product Coverage: Products covered: Unit Dose: Unit dose packaging is reimbursable.
prescribed insulin; disposable needles and syringe
combinations for insulin; blood glucose test strips; Formulary/Prior Authorization
urine ketone test strips; total parenteral nutrition; and Formulary: Open formulary with preferred drug list
interdialytic parenteral nutrition. Products not (PDL). Managed through excluding products based
covered: cosmetics; fertility drugs; DESI drugs; and on contracting issues; prior authorization,
experimental drugs. therapeutic substitution; preferred products, and
physician profiling.
Over-the-Counter Product Coverage: Products
covered with restrictions: allergy, asthma and sinus Prior Authorization: State currently has a prior
products (selected items); analgesics (ASA and authorization program and a Drug Utilization
acetaminophen); cough and cold preparations Review Team and a Drug Evaluation Matrix Team.
(selected items); digestive products (selected items); Recipients can request a fair hearing and exception
feminine products (selected items); and topical to policy to appeal an excluded product or prior
products (selected items). Products not covered: authorization decision.
smoking deterrent products. (Note: Zyban only
covered for pregnant women in smoking cessation Prescribing or Dispensing Limitations
program). Prescription Refill Limit: Two (2) refills in 30-day
period except for antibiotics, anti-asthmatics,
Therapeutic Category Coverage: Therapeutic Schedule II and III drugs, anti-neoplastic, topicals,
categories covered: antibiotics; anticoagulants; and any propoxyphene, which may have 4 refills.
anticonvulsants; anti-depressants; cardiac drugs;
chemotherapy agents; contraceptives; ENT anti- Monthly Prescription Limit: Review of client drug
inflammatory agents; hypotensive agents; profile by a clinical pharmacist when request for 5th
sympathominetics (adrenergic); and thyroid agents. brand name prescription in any one-month period.
Therapeutic categories requiring prior authorization:
anabolic steroids; analgesics, antipyretics, and Monthly Quantity Limit: Maximum 34-day supply
NSAIDs; antidiabetic agents; antihistamines; (90 days on select items).
antilipemic agents; anti-psychotics; anxiolytics,
sedatives, and hypnotics; prescribed cold Drug Utilization Review
medications; estrogens; growth hormones; misc. GI PRODUR system implemented in March 1996.
drugs; and non-preferred drugs*. Therapeutic State currently has a P&T Committee/DUR Board
categories not covered: anoretics; prescribed with a quarterly review.
smoking deterrents (except Zyban for pregnant
women enrolled in a smoking cessation program); Pharmacy Payment and Patient Cost
weight loss drugs; products for hair growth; drugs Sharing
for infertility, and frigidity, impotency, or sexual Dispensing Fee: $4.20 to $5.20, effective 7/1/02.
dysfunction. − $4.20 - Retail pharmacies, filling over 35,000
Rxs annually.
*Drugs considered for prior authorization are drugs − $4.51 - Retail pharmacies, filling 15,001-
with high risk/benefit ratio, high potential for 35,000 Rxs annually.
abuse/misuse, narrow therapeutic indication, and − $5.20 - Retail pharmacies, filling 15,000 or less
high cost. A complete list of drugs requiring prior Rxs annually.
authorization may be found on the Medical − $5.20 - Unit dose systems (nursing home Rxs).
Assistance Administration’s web site:
http://maa.dshs.wa.gov/pharmacy Ingredient Reimbursement Basis: EAC = AWP-
14%, except drugs on the MAC list with 5 or more
labelers/manufacturers are reimbursed at AWP-
50%.
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Prescription Charge Formula: The amount shall not Molina Healthcare of Washington, Inc. (MHC)
exceed the usual and customary charge to the public P.O. Box 1469
or EAC plus a dispensing fee. Any drug with more Bothell, WA 98041
than 3 labelers will be reimbursed according to the 800/869-7165
Maximum Allowable Cost.
Regence Blue Shield
Maximum Allowable Cost: State imposes Federal P.O. Box 21267
Upper Limits as well as State-specific limits on Mail Stop BR 390
generic drugs. Override requires “Brand Medically Seattle, WA 98111-3267
Necessary.” 800/689-8791
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WEST VIRGINIA
1 The State of West Virginia did not respond to the 2003 NPC Survey. Using CMS data and other source materials, we have, to the extent
possible, updated the profile and the tables in other sections of the Compilation. Users should contact the West Virginia Medicaid program to
assess the accuracy and currency of the information included.
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Note: West Virginia estimates 2004 drug expenditures to be approximately $360 million and the number of Medicaid drug
recipients to be 364,000.
C. ADMINISTRATION
Unit Dose: Unit dose packaging reimbursable.
Bureau for Medical Services, Department of Health Formulary/Prior Authorization
& Human Resources.
Formulary: Closed formulary (as of 1/17/03) with
preferred drug list. Restrictions include preferred
D. PROVISIONS RELATING TO DRUGS products and prior authorization through the Rational
Benefit Design Drug Therapy Program. General exclusions include:
legend agents used for cosmetics purposes or hair
Drug Benefit Product Coverage: Products covered: growth; DESI drugs; fertility drugs; and products
prescribed insulin; disposable needles and syringe used for anorexia or weight gain.
combinations used for insulin; blood glucose test
strips; and urine ketone test strips. Products not Prior Authorization: State currently has a prior
covered: cosmetics; fertility drugs; experimental authorization screening procedure for drug classes
drugs; total parenteral nutrition; and interdialytic and home health care. Written appeal to the Medical
parenternal nutrition. Director by the prescriber required to appeal a prior
authorization decision. P&T Committee and DUR
Over-the-Counter Product Coverage: Products Board make prior authorization recommendations.
covered with restrictions (i.e., limited
formulary/prescription required): feminine products; Prescribing or Dispensing Limitations
topical products; allergy, asthma, and sinus products; All covered outpatient drugs are reimbursed up to a
analgesics; cough and cold preparations; and 34-day supply and eleven refills.
digestive products (non-H2 antagonist). Prior
Exceptions include:
authorization for: smoking deterrent products.
Products not covered: digestive products (H2 1. Antibiotics are covered for a 14-day supply and
antagonists). one refill.
2. Opiate agonists (excluding Schedule II drugs),
Therapeutic Category Coverage: Therapeutic analgesics and miscellaneous antipyretics are
categories covered: anabolic steroids; analgesics, covered for 30 days and five refills, in
antipyretics, and NSAIDs; antibiotics; accordance with Federal law.
anticoagulants; anti-depressants; antidiabetic drugs; 3. Sedatives and hypnotics are covered for a 30-
antilipemic agents; antihistamine drugs; day supply and five refills, in accordance with
antipsychotics; anxiolytics, sedatives, and hypnotics Federal law.
(partial coverage); cardiac drugs; chemotherapy Drug Utilization Review
agents; contraceptives; prescribed cold mediation
(partial coverage); ENT anti-inflammatory agents; PRODUR system implemented in March 1995.
estrogens; hypotensive agents; misc. GI drugs; State currently has a DUR Board with a quarterly
sympathominetics (adrenergic); and thyroid agents. review.
Therapeutic categories requiring prior authorization: Pharmacy Payment and Patient Cost
growth hormones; prescribed smoking deterrents; Sharing
and all stimulants except strattera (for beneficiaries >
18 yrs. of age). Therapeutic categories not covered: Dispensing Fee: $3.90, effective 1/1/96. For a
anorectics; agents for cosmetic use; and weight loss compounded prescription, an additional $1.00 will
products. be added to the dispensing fee. A compound
prescription is defined as any legend medication
Coverage of Injectables: Injectable medicines requiring a combination of any two or more
reimbursable under the Prescription Drug Program substances to exclude normal reconstitution
when used in home health care and extended care operations.
facilities, and through physician payment in
physician offices. All injectable medications Ingredient Reimbursement Basis: EAC = AWP-
dispensed through outpatient pharmacies require 12%.
prior authorization.
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WISCONSIN
*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
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C. ADMINISTRATION
Vaccines: Vaccines provided plus reimbursement
State Department of Health and Family Services, for administrative fee as part of the Vaccines for
Division of Health Care Financing. Children Program.
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WYOMING
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
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D. PROVISIONS RELATING TO DRUGS Unit Dose: Unit dose packaging not reimbursable.
Benefit Design
Drug Benefit Product Coverage: Products covered: Formulary/Prior Authorization
prescribed insulin, syringe combinations and Formulary: Open formulary with preferred drug list
disposable needles used for insulin; blood glucose (PDL). PDL managed through preferred products
test strips; and urine ketone test strips. Products and prior authorization. General exclusions include
covered under DME: total parenteral nutrition; and anorexants, except amphetamines and derivatives
interdialytic parenteral nutrition. Products not which are used for narcolepsy and hyperkinetic
covered: cosmetics; fertility drugs; tobacco states; products to stimulate hair growth. Prior
cessation products; weight loss products; hair authorization implemented 10/1/02.
growth products; IQ enhancers; DESI drugs; and
experimental drugs. Prior Authorization: State currently has a formal
prior authorization procedure with review/appeal
Over-the-Counter Product Coverage: Products process to the Department of Health Pharmacy
covered (must be ordered by a licensed prescribing Unit.
practitioner, furnished to a client who is not
residing in a nursing facility, is listed in State’s Prescribing or Dispensing Limitations
system, and filed with First DataBank): allergy, Monthly Quantity Limits: Quantity limits on some
asthma, and sinus products; analgesics; cough and medications as deemed clinically appropriate.
cold products; digestive products (H2 antagonists);
topical agents; food thickeners; nutrition products; Drug Utilization Review
pediatric and prenatal vitamins; and artificial tears. PRODUR system implemented in October 1995.
Products covered with reatrictions: non-H2 State currently has a DUR Board with 12 members
antagonists (antacids, antidiarrheals and laxatives) that meet bimonthly.
and feminine products (vaginal anti-infective agents
and contraceptives). Products not covered: smoking Pharmacy Payment and Patient Cost
deterrent products. Sharing
Dispensing Fee: $5.00 and 50% of AWP for OTCs,
Therapeutic Category Coverage: Products covered: effective 7/01.
analgesics, antipyretics, and NSAIDs (prior
authorization for COX 2s and oxycontin); Ingredient Reimbursement Basis: EAC = AWP-
antibiotics; anticoagulants; anticonvulsants; anti- 11%.
depressants; antidiabetic agents; antihistamines;
antilipemic agents (prior authorization for statins); Prescription Charge Formula: Payments shall be
anti-psychotics; anxiolytics, sedatives, and the lowest of:
hypnotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives; ENT 1. The Estimated Acquisition Cost (AWP-11%)
anti-inflammatory agents; estrogens; hypotensive of the ingredient, plus a dispensing fee.
agents; (prior authorization for ACE Inhibitors); 2. Usual and customary charge.
misc. GI drugs (prior authorization for PPIs); 3. The upper limit established by CMS for
sympathominetics (adrenergic); thyroid agents; multiple source drugs or State MAC.
antifungals; antiparasitic products; and
bronchodilators. Partial coverage for: growth Maximum Allowable Cost: State imposes Federal
hormones. Products not covered; anabolic steroids; Upper Limits as well as State-specific limits on
anoretics; and prescribed smoking deterrents. generic drugs. Override requires “Brand Medically
Necessary.” Currently, 1,226 drugs are included on
Coverage of Injectables: Injectable medicines the State’s MAC list.
reimbursable through physician payment when used
in home health care, extended care facilities, and Incentive Fee: None.
physician offices.
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Section 6:
State Pharmacy Assistance
Programs
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The Federal Medicare Prescription Drug, Improvement, and Modernization Act of 2004 (P.L
108-173, commonly known as the Medicare Modernization Act) will impact every State,
whether or not they have a pharmacy assistance program. State pharmacy assistance programs
(SPAPs) are not required to coordinate or provide any financial assistance with respect to a
Medicare Part D plan, but many are either planning to sunset current pharmacy assistance
programs, use the SPAP as a “wrap-around” program, or develop some other coordination, yet
to be determined. Currently, four States have indicated that their respective pharmacy assistance
plans will end, barring State legislative action to modify and/or coordinate these programs with
the Medicare Part D program.
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The following programs were legislatively approved, but have yet to be implemented:
• Arkansas’ ARx Senior Program, a Federal §1115 waiver program, has not received
approval from CMS. Program officials indicate that it is unlikely that the program
will be implemented given the Medicare Part D prescription drug program beginning
in 2006.
• Arkansas Rx Program: HB1241 was signed into law March 3, 2005. It establishes a
discount program for residents without prescription coverage. There are no income
limits for those 65 and over, while those under 65 and below 350% of the FPL are
eligible. Medicaid and Medicare Part D enrollees will not be eligible.
• Kentucky Pharmaceutical Assistance Program: SB23 was signed into law March
18, 2005. It is designed to wrap around Medicare Part D for seniors over 65 and
under 150% of the FPL. Enrollment is scheduled to begin October 1, 2005 with the
program beginning January 1, 2006.
• Oklahoma Prescription Drug Discount Program: SB547 was signed into law June
6, 2005. The law establishes a discount program for uninsured residents, with an
enrollment fee only for those above 150 percent of the FPL.
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• Texas Prescription Drug Program: State funding for the program was not
established for 2004-2005.
• South Dakota Senior Prescription Drug Benefit Program: Under South Dakota HB
1312, the Senior Prescription Drug Benefit Program was repealed by legislation,
effective September 1, 2004.
The following pharmacy assistance programs are scheduled to sunset during 2005, barring
legislative action to operate the programs in conjunction with, or in addition to, the Medicare
Part D program: Maryland Senior Prescription Drug Program, Minnesota Prescription Drug
Program, Missouri SenioRx Program, and North Carolina Senior Care. There are 14 States
that are reviewing current pharmacy assistance programs in an effort to coordinate benefits
with the Medicare Part D program. (These States are noted throughout this section.)
• District of Columbia AccessRx Program: B 569, effective May 18, 2004, established
the AccessRx program, requiring drug manufacturers and labelers that sell
prescription drugs in the District through a publicly funded pharmaceutical assistance
program to enter into rebate agreements with the District. The rebates are used to
fund the AccessRx program for low-income elderly District of Columbia residents.
• Rhode Island Prescription Drug Discount Program for the Uninsured: HB7374
(SB 2886), effective July 2, 2004, established the Rhode Island Prescription Drug
Discount Program for the Uninsured. The program requires the Departments of
Human Services and Elderly Affairs to develop a prescription drug discount program
for uninsured State residents between 18 years and 65 years of age, with family
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incomes at or below 200 percent of the Federal poverty level (FPL). The State is
currently developing the program and reviewing RFP bids from interested pharmacy
benefit managers (PBMs). The program implementation date is slated for May 2005.
The following pages provide profiles of the States that provided pharmacy assistance in 2004,
as well as profiles of the new State programs. Details were provided by State contacts on
program characteristics, including eligibility criteria, funding and reimbursement information,
and drug coverage. Supplemental information was obtained from special surveys of State
programs, including the National Conference of State Legislatures’ internet site
(www.ncsl.org/programs/health/drugaid.htm), which is a good source for the most up-to-date
information.
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Alabama
Alabama SenioRx Program*
Program Type: Coordinate Assistance Between Elderly and Manufacturers’
Pharmaceutical Programs
Year Operational: 2002
Number of Recipients (January 2005): 16,769
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: Based on a manufacturer’s charitable program criteria.
Drug Coverage Restrictions: Not available
Notes: Enrollees must have chronic health care conditions to participate
in the program, e.g., maintenance medications for long-term
problems like hypertension. Participants with short-term illnesses
are not eligible for the program.
*
The Alabama SenioRx Program assists eligible State residents in coordinating services from various manufacturers’
charitable prescription assistance programs. The State does not contribute any money for the direct purchase of
prescription drugs.
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PROGRAM CONTACT
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Alaska
SeniorCare Rx
Program Type: Direct Assistance
Year Operational: 2004
Number of Recipients (January 2005): 7,000∗
ELIGIBILITY CRITERIA
DRUGS COVERAGE
∗
Currently, only 50 beneficiaries are using a direct pharmaceutical benefit provided by the program.
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PROGRAM CONTACT
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Arizona
Prescription Discount Program (CoppeRx Card)
Program Type: Discount
Law Enacted: 2001
Estimated Number of Recipients (January 2005): 17,000*
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: All FDA-approved drugs
Drug Coverage Restrictions: None
Notes: The State is discussing the impact of the Medicare Part D program on
the CoppeRx program and future reforms. Preliminary discussions
only at this time.
*
967,061 eligible residents sent program information, as of January 2005.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
PROGRAM CONTACT
6-14
National Pharmaceutical Council Pharmaceutical Benefits 2004
Arkansas
ARx Senior Program
Program Type: Direct Assistance (1115 Waiver)
Law Enacted: 2001∗
Projected Number of Recipients: Not Available
ELIGIBILITY CRITERIA
Funding Source: State General Revenue Fund and Federal matching funds
Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: Medicaid reimbursement rate
Enrollment Fee: $25.00 per year
Deductible Amount: $5.00
Copayment Amount: $10.00 for generic drugs and $20.00 for brand name drugs
Dispensing Fee: Not available
Notes: The program has not received approval from CMS, as the State has
been unable to design a program with budget neutrality. Arkansas
will likely withdraw its 1115 waiver request depending on the
success of the Medicare Part D program.
DRUGS COVERAGE
PROGRAM CONTACT
6-15
National Pharmaceutical Council Pharmaceutical Benefits 2004
Arkansas
Arkansas Rx Program
Program Type: Discount
Law Enacted: 2005∗
Projected Number of Recipients: Not Available
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): See notes Eligibility Age (Disabled): See notes
Eligible Income Level (Single): See notes Eligible Income Level (Married): See notes
Other Eligibility Notes: No income limit for 65+, under 65 < 350% FPL. Medicaid and
Medicare Part D enrollees not eligible.
DRUGS COVERAGE
PROGRAM CONTACT
Not available
∗
Program is not yet operational.
6-16
National Pharmaceutical Council Pharmaceutical Benefits 2004
California
Prescription Drug Discount for Medicare Recipients Program
Program Type: Discount
Year Operational: 2000
Number of Recipients (January 2005): 1,595,434
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): All Medicare Eligibility Age (Disabled): All Medicare
eligible eligible
Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: Must be a Medicare beneficiary not on Medicaid.
DRUGS COVERAGE
Formulary: No formulary
Drugs Covered: Almost all prescription drugs
Drug Coverage Restrictions: Over-the-counter drugs and compound drugs not covered.
PROGRAM CONTACT
∗
Price inquires do not always result in sales, because customers may elect not to purchase a pharmaceutical once its
price has been quoted.
6-17
National Pharmaceutical Council Pharmaceutical Benefits 2004
California
Golden Bear State Pharmacy Assistance Program
Program Type: State-Negotiated Discounts
Projected Operational Date: Not Available
Estimated Eligibles (November 2002): 1 to 3 million
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): See notes Eligibility Age (Disabled): See notes
Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: Program covers pharmaceuticals not covered by a private insurer or
other State program. Anyone who has a Medicare card is eligible;
however, unlike the California Discount Prescription Medication
Program, enrollment is required to receive services.
DRUGS COVERAGE
Formulary: No formulary
Drugs Covered: Prescription drugs for which the State has negotiated manufacturer
discounts that supplement the Medi-Cal discount already mandated
under the California Discount Prescription Medication Program.
Drug Coverage Restrictions: Only prescription drugs with manufacturer-negotiated discounts.
PROGRAM CONTACT
6-18
National Pharmaceutical Council Pharmaceutical Benefits 2004
Connecticut
Pharmaceutical Assistance Contract to the Elderly and
Disabled (ConnPACE)
Program Type: Direct Assistance
Year Operational: 1986
Number of Recipients (January 2005): 49,138
ELIGIBILITY CRITERIA
DRUGS COVERAGE
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Drug Coverage Restrictions: ConnPACE does not cover drugs prescribed for cosmetic purposes,
experimental drugs, drugs FDA has determined are ineffective,
antihistamines, contraceptives, cough preparations, anti-obesity drugs,
multi-vitamin combinations, smoking cessation gum, vaccines
obtained free of charge from the Department of Health Services,
prescription drugs in excess of manufacturer’s recommendations with
documented legal justification, drugs for lock-in clients from other
than lock-in pharmacy, and over-the-counter drugs (with certain
exceptions). Other drugs may not be covered if pharmaceutical
manufacturers opt not to participate in the Drug Rebate Program.
ConnPACE restricts beneficiaries to 120 units or a 30-day supply,
whichever is greater.
Notes: Generic drugs must be substituted for brand name drugs, unless
otherwise indicated by the prescribing physician (prior authorization
required). Prior authorization is required for early refills, drug product
costs over $500, physician request for a brand name product. Under
statutory authority, State is completing implementation of a preferred
drug list (PDL). PDL will start after appropriate training and outreach
with providers.
PROGRAM CONTACT
6-20
National Pharmaceutical Council Pharmaceutical Benefits 2004
Delaware
Nemours Pharmacy Assistance
Program Type: Private Discount
Year Operational: 1981
Number of Enrollees (January 2005): 9,000
ELIGIBILITY CRITERIA
Funding Source: This program is a privately funded program; no State funds are used.
Budget: Not available
Cost per Enrollee: Not available
# of Rx’s Per Enrollee (2003): 18
Manufacturer Rebate Type: None
Ingredient Cost Calculation: Not available
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: 20% of drug cost
Dispensing Fee: $5.00
Notes: Maximum annual benefit is $2,000.00 per enrollee.
DRUGS COVERAGE
Formulary: None
Drugs Covered: Due to severe budgetary constraints, covered drugs are chosen
individually, based on physician recommendations.
Drug Coverage Restrictions: As many recommended drugs as allowed by the budget are purchased
and made available to enrollees.
Notes: One central pharmacy distributes all drugs by courier to branch
locations where citizens can pick up a 2-3 month supply.
PROGRAM CONTACT
6-21
National Pharmaceutical Council Pharmaceutical Benefits 2004
Delaware
Prescription Assistance Program (DPAP)
Program Type: Direct Assistance
Year Operational: 2000
Number of Recipients (January 2005): 7,206
ELIGIBILITY CRITERIA
DRUGS COVERAGE
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National Pharmaceutical Council Pharmaceutical Benefits 2004
PROGRAM CONTACT
6-23
National Pharmaceutical Council Pharmaceutical Benefits 2004
District of Columbia
Access Rx
Program Type: Manufacturer Rebates
Law Enacted: March 2004
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
6-24
National Pharmaceutical Council Pharmaceutical Benefits 2004
Florida
Silver SaveRx Program
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 2002
Number of Enrollees (January 2005): 55,036
ELIGIBILITY CRITERIA
Funding Source: State General Revenue Fund, Federal matching funds, and manufacturer
rebates
Budget (FY 05): $100 million
Cost per Enrollee (FY 05): $160 per month maximum benefit per user, per month
# of Rx’s Per Enrollee (FY 05): Between 2.77 and 3.67 per user/per month
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: The lesser of AWP-13.25%, Wholesalers Acquisition Cost (WAC)+7%, or
the usual and customary
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $2.00 for generic drugs, $5.00 for brand name drugs on the preferred drug
list, and $15.00 for brand name drugs not on the preferred drug list
Dispensing Fee: $4.23
Notes: Enrollees will have $160 deposited in a Silver Saver account that is
maintained by the Medicaid program. Eligibility is determined on a
monthly basis. During Calendar Year 2004, an average of 23% of
beneficiaries used the maximum allowed benefit of $160 per month.
DRUGS COVERAGE
PROGRAM CONTACT
6-25
National Pharmaceutical Council Pharmaceutical Benefits 2004
Florida
Medicare Prescription Discount Program∗
Program Type: Discount
Year Operational: 2000
Estimated Participants: Not Available
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): See notes Eligibility Age (Disabled): See notes
Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: Anyone who has a Medicare card is eligible.
DRUGS COVERAGE
Formulary: None
Drugs Covered: All prescription drugs
Drug Coverage Restrictions: None
PROGRAM CONTACT
∗
By law Florida pharmacies are required to provide this discount in order to participate in Medicaid.
6-26
National Pharmaceutical Council Pharmaceutical Benefits 2004
Georgia
Georgia Cares Program*
Program Type: Coordinate Assistance Between Elderly and Charitable
Pharmaceutical Programs
Year Operational: 2002
Number of Recipients (January 2005): 24,739
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: Based on a manufacturer’s charitable program criteria
Drug Coverage Restrictions: Not available
PROGRAM CONTACT
*
The Georgia Cares Program assists eligible State residents in health care insurance counseling and in coordinating
services from various manufacturers’ charitable prescription assistance programs. The State does not contribute any
money for the direct purchase of prescription drugs.
6-27
National Pharmaceutical Council Pharmaceutical Benefits 2004
Hawaii
Hawaii Rx Plus
Program Type: Direct Discount
Operational Date: 2004
Number of Recipients (January 2005): 147,685
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages
Eligible Income Level (Single): $38,000 Eligible Income Level (Married): $51,000
Other Eligibility Notes: Open to all Hawaii residents, providing that they have no other
prescription drug coverage.
DRUGS COVERAGE
Formulary: None
Drugs Covered: All FDA approved drugs
Drug Coverage Restrictions: None
Notes: Each pharmacy participating in the program discounts the price of
drugs covered by the program and sold to program participants.
Participating pharmacies submit claims to the Department of Human
Services and are reimbursed for the discounted drugs. Legislation is
being considered to restructure this program in order to “wrap-around”
the Medicare Part D program. The legislation would provide benefits
for dual eligibles to pay co-payments.
PROGRAM CONTACT
6-28
National Pharmaceutical Council Pharmaceutical Benefits 2004
Illinois
Pharmaceutical Assistance Program (PAP)
“Circuit Breaker”
Program Type: Direct Assistance
Year Operational: 1985
Number of Recipients (January 2005): 45,394
ELIGIBILITY CRITERIA
Funding Source: State General Revenue Fund and Tobacco Settlement Fund
Budget (FY 04): $83 million
Cost per Participant (FY 03): $1,255.66
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type Negotiated by State
Ingredient Cost Calculation: AWP-14%
Enrollment Fee: $5.00 if income is below 100% of FPL and $25.00 if income is at or
above 100% of FPL
Deductible Amount: None
Copayment Amount: For income less than 100% of FPL, there is no copayment until annual
drug cost exceeds $2,000; then copayment is 20% of drug cost. For
income at 100% of FPL or greater, there is a $3.00 copayment until
annual drug cost exceeds $2,000.00; then copayment is 20% of drug
cost.
Dispensing Fee: $2.55
DRUGS COVERAGE
Formulary: Some drugs covered by preferred drug list (PDL); prior authorization.
Drugs Covered: Prescription medication used for cancer, Alzheimer’s disease,
Parkinson’s disease, glaucoma, lung disease and smoking-related
diseases, cardiovascular, arthritis, diabetes, and osteoporosis, heart and
blood pressure problems, multiple sclerosis, and osteoporosis.
Drug Coverage Restrictions Some classes of drugs covered by preferred drug list (PDL); prior
authorization.
6-29
National Pharmaceutical Council Pharmaceutical Benefits 2004
PROGRAM CONTACT
6-30
National Pharmaceutical Council Pharmaceutical Benefits 2004
Illinois
Illinois SeniorCare
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 2002
Number of Recipients (January 2005): 195,746
ELIGIBILITY CRITERIA
Funding Source: State General Revenue Fund and Tobacco Settlement Fund
Budget (FY 03): $102 million
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type Negotiated by State
Ingredient Cost Calculation: AWP-14% or MAC if generic is available
Enrollment Fee: None, but participants must reapply every year.
Deductible Amount: None
Copayment Amount: If the participant is single with income of no more than $9,569 a year, or if
participant lives with his/her spouse and together the income is no more
than $12,829, SeniorCare pays up to $1,750 per person in a year at no cost.
After $1,750, participant pays 20% of each prescription.
If the participant is a single individual with an income of $9,750 to $19,140
a year, or if the participants are a married and living together with a total
household income of $12,830 to $25,600 a year, SeniorCare pays for the
first $1,750 per person. The participants are also required to pay $1 for a
generic drug and $4 for each brand name drug. After the $1,750 limit is
met, the participants continue to pay $1 for a generic drug and $4 for each
brand name drug plus 20% of the cost of each prescription.
If a generic drug is available but the participant requests a brand name drug,
participants must pay $4 for each prescription plus the difference in price
between the generic and the brand name drug.
Dispensing Fee: $2.25
DRUGS COVERAGE
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Drug Coverage Restrictions Some classes of drugs covered by the preferred drug list (PDL) or prior
authorization.
PROGRAM CONTACT
6-32
National Pharmaceutical Council Pharmaceutical Benefits 2004
Illinois
Illinois Rx Buying Club
Program Type: Direct Discount
Year Operational: 2004
Number of Eligible Recipients: 1.5 million
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
6-33
National Pharmaceutical Council Pharmaceutical Benefits 2004
Indiana
Indiana Prescription Drug Program
“HoosierRx”
Program Type: Discount
Year Operational: 2000
Number of Recipients (January 2005): 26,800
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: All prescription drugs, as well as insulin
6-34
National Pharmaceutical Council Pharmaceutical Benefits 2004
PROGRAM CONTACT
6-35
National Pharmaceutical Council Pharmaceutical Benefits 2004
Iowa
Iowa Priority Prescription Savings Program
Program Type: Negotiated Discount
Year Operational: 2002
Number of Enrollees (January 2005): 50,000
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): All Medicare eligibles Eligibility Age (Disabled): All Medicare
eligibles
Eligible Income Level (Single): All income levels Eligible Income Level All income levels
(Married):
Other Eligibility Notes: Medicaid recipients are not eligible. Novartis has an income requirement:
only a couple with an income of more than $16,862 and less than $24,000,
or individuals with an income of more than $12,569 and less than $18,000,
qualifies for medications at a flat-fee of $12.
6-36
National Pharmaceutical Council Pharmaceutical Benefits 2004
DRUGS COVERAGE
PROGRAM CONTACT
6-37
National Pharmaceutical Council Pharmaceutical Benefits 2004
Kansas
Kansas Senior Pharmacy Assistance Program
Program Type: Reimbursement
Year Operational: 2001
Number of Enrollees (January 2005): 2,416
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: Legend drugs, diabetic supplies not covered by Medicare
Drug Coverage Restrictions: Program does not cover over-the-counter or lifestyle drugs.
Notes: Kansas Senior Pharmacy Assistance Program will be terminated once
the Medicare Part D program begins.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
PROGRAM CONTACT
6-39
National Pharmaceutical Council Pharmaceutical Benefits 2004
Kentucky
Kentucky Pharmaceutical Assistance Program
Program Type: Direct Assistance
Year Operational: Begins 1/1/2006
Projected Number of Enrollees: not available
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Not available
6-40
National Pharmaceutical Council Pharmaceutical Benefits 2004
Louisiana
Louisiana SenioRx Program*
Program Type: Coordinate Assistance between Elderly and Charitable
Pharmaceutical Programs
Year Operational: 2003
Number of Enrollees (January 2005): 7,182
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: Based on a manufacturer’s charitable program criteria.
Drug Coverage Restrictions: Not available
PROGRAM CONTACT
*
The Louisiana SeniorRx Program assists eligible State residents in coordinating services from various manufacturers’
charitable prescription assistance programs. State does not contribute money for direct purchase of prescription drugs.
6-41
National Pharmaceutical Council Pharmaceutical Benefits 2004
Maine
Maine Rx Plus*
Program Type: Subsidy and Discount
Law Enacted: 2003
Number of Enrollees (Fiscal Year 2005): 275,000
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages
Eligible Income Level (Single): 350% of FPL Eligible Income Level (Married): 350% of FPL
Other Eligibility Notes: Any person who incurs unreimbursed expenses for prescription drugs
equaling 5% or more of family income, or who incurs unreimbursed
expenses for all medical care equaling 15% or more of family income, is
eligible for the remainder of the eligibility period.
DRUGS COVERAGE
PROGRAM CONTACT
*
This program replaces the Maine Rx Program, which faced significant legal challenges and was never implemented.
Additionally, beneficiaries from the former Healthy Maine Prescription Program were immediately eligible for the
Maine Rx Plus program. Program includes a pharmacy incentive program, in which Maine Rx Plus sends out over
$50,000 per year to pharmacies that qualify.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Maine
Low Cost Drugs for the Elderly and Disabled Program
(DEL)*
Program Type: Subsidy and Discount
Year Operational: 1975
Number of Recipients (January 2005): 41,200
ELIGIBILITY CRITERIA
DRUGS COVERAGE
*
The Low Cost Drugs for the Elderly and Disabled (DEL) Program is also run under the Maine Rx Plus umbrella,
distinguished by the eligibility criteria differences. Program includes a pharmacy incentive program, in which the DEL
program sends out over $200,000 per year to pharmacies that qualify.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
PROGRAM CONTACT
6-44
National Pharmaceutical Council Pharmaceutical Benefits 2004
Maryland
Maryland Pharmacy Assistance Program
Program Type: Direct Assistance
Year Operational: 1979
Number of Recipients (January 2005): 62,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
6-45
National Pharmaceutical Council Pharmaceutical Benefits 2004
PROGRAM CONTACT
6-46
National Pharmaceutical Council Pharmaceutical Benefits 2004
Maryland
Senior Prescription Drug Program
Program Type: Direct Assistance
Year Operational: 2001
Number of Recipients (January 2005): 35,500
ELIGIBILITY CRITERIA
DRUGS COVERAGE
6-47
National Pharmaceutical Council Pharmaceutical Benefits 2004
PROGRAM CONTACT
6-48
National Pharmaceutical Council Pharmaceutical Benefits 2004
Maryland
Maryland Pharmacy Discount Program
Program Type: Discount (1115 Waiver)
Operational Date: July 1, 2003
Number of Recipients (January 2005): 3,965
ELIGIBILITY CRITERIA
Funding Source: State General Revenue funds and Federal matching funds
Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid guidelines
Ingredient Cost Calculation: For brand name drugs, lower of AWP-11%, WAC+9%, Direct
Manufacturer’s Cost (DMC)+10%, or Direct Cost (DC)+10%. For
generic drugs, lower of EAC, State MAC, or Federal MAC.
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: 65% of the State’s reduced cost
Dispensing Fee: $1.00 per prescription
DRUGS COVERAGE
PROGRAM CONTACT
6-49
National Pharmaceutical Council Pharmaceutical Benefits 2004
Massachusetts
Prescription Advantage
Program Type: Direct Assistance
Year Operational: 2001
Number of Recipients (January 2005): 84,880
ELIGIBILITY CRITERIA
6-50
National Pharmaceutical Council Pharmaceutical Benefits 2004
DRUGS COVERAGE
PROGRAM CONTACT
6-51
National Pharmaceutical Council Pharmaceutical Benefits 2004
Michigan
Elder Prescription Insurance Coverage (EPIC) Program
Program Type: Direct Assistance
Year Operational: 2001
Number of Enrollees (February 2005): 10,900
ELIGIBILITY CRITERIA
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National Pharmaceutical Council Pharmaceutical Benefits 2004
DRUGS COVERAGE
Formulary: Drugs not on the Michigan Pharmaceutical Products List (MPPL) may
require prior authorization before they are paid for by EPIC. The use
of generic drugs is encouraged.
Drugs Covered: Most prescription drugs plus insulin and syringes for diabetics, with
some exceptions.
Drug Coverage Restrictions: The EPIC program does not cover the following types of drugs:
products used for weight loss or weight gain; fertility or infertility
drugs; drugs used to treat erectile dysfunction; drugs or products used
for contraception; products used to promote hair growth or for other
cosmetic purposes; drugs used to treat the skin aging process; smoking
cessation products; cold and cough preparations; fluoride preparations;
experimental and investigational drugs; Drug Efficacy Study
Implementation program (DESI) drugs; vitamins/minerals, alone or in
combination; dietary formulas or nutritional supplements; central
nervous system (CNS) stimulants; Acquired Immunodeficiency
Syndrome (AIDS) drugs/injectables and orals; injectable drugs; allergy
serums; compounds; over-the-counter (OTC) drugs except for
prescription insulin and OTC drugs with prescriptions used for
approved step therapy programs; miscellaneous products associated
with a specific drug administration, except for diabetes needles and
syringes; drugs produced by manufacturers not participating in the
rebate program; non-Food and Drug Administration (FDA) approved
drugs; and drugs for which the manufacturer seeks to require as a
condition of sale that associated tests or monitoring services be
purchased exclusively from the manufacturer or its designee.
Notes: Most prescription drugs have a 30-day supply; however, covered
maintenance drugs may be filled for 100-day supply.
PROGRAM CONTACT
6-53
National Pharmaceutical Council Pharmaceutical Benefits 2004
Michigan
MI Rx Prescription Savings Program
Program Type: Discount
Operational Date: September 2004
Number of Recipients: Est: 50,000 – 200,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
6-54
National Pharmaceutical Council Pharmaceutical Benefits 2004
Minnesota
Prescription Drug Program∗
Program Type: Direct Assistance
Year Operational: 1999
Number of Enrollees (January 2005): 7,500
ELIGIBILITY CRITERIA
∗
Formerly the Senior Citizen Drug Program.
6-55
National Pharmaceutical Council Pharmaceutical Benefits 2004
DRUGS COVERAGE
PROGRAM CONTACT
6-56
National Pharmaceutical Council Pharmaceutical Benefits 2004
Mississippi
Mississippi Seniors and Indigents Rx Program
Program Type: Coordinate Assistance Between Eligibles and Manufacturers’
Charitable Pharmaceutical Programs
Law enacted: July 2004
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): Not available Eligibility Age (Disabled): Not available
Eligible Income Level (Single): Not available Eligible Income Level (Married): Not available
Other Eligibility Notes: The program awaits implementation.
Funding Source: Federal funds and gifts, voluntary funding in the form of grants
available to build community, public sector and private sector
partnerships.
Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Not available
Ingredient Cost Calculation: Not available
Enrollment Fee: Not available
Deductible Amount: Not available
Copayment Amount: Not available
Dispensing Fee: Not available
Notes: The purpose of the program is to help seniors and qualified indigents
in accessing pharmaceutical manufacturers’ discount cards and
pharmaceutical assistance programs and to provide seniors and
qualified indigents with applications for those programs.
DRUGS COVERAGE
PROGRAM CONTACT
6-57
National Pharmaceutical Council Pharmaceutical Benefits 2004
Missouri
SenioRx Program
Program Type: Direct Assistance
Year Operational: 2002
Number of Enrollees (January 2005): 17,500
ELIGIBILITY CRITERIA
Funding Source: Funding comes from the Missouri Senior Rx Fund, consisting of
enrollment fees and manufacturer rebates, and funds appropriated by
the General Assembly.
Budget (FY 05): $26.7 million
Cost Per Enrollee (FY 05): $800 per year
# of Rx’s Per Enrollee (FY 05): 32.4
Manufacturer Rebate Type: 15% for brand drugs; 11% for generic drugs
Ingredient Cost Calculation: AWP-10.43%
Enrollment Fee: $25.00 or $35.00, depending on income level
Deductible Amount: $250.00 or $500.00, depending on income level
Copayment Amount: 40% of prescription cost
Dispensing Fee: $4.09
Notes: Maximum annual benefit of $5,000.00
If an enrollee has already met the deductible and a brand name drug is
needed, the enrollee must pay: 1) the cost difference between the brand
name and generic drug and 2) 40% of the generic drug price.
If the enrollee has not met the deductible, the enrollee pays the full
cost of the brand name drug and the cost of the generic drug will be
applied to the deductible.
DRUGS COVERAGE
Formulary: None
Drugs Covered: Medicaid guidelines.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Drug Coverage Restrictions: The following drugs are not covered: drugs manufactured by
companies that do not participate in the Missouri SenioRx rebate
program; over-the-counter (OTC) products; drugs used for weight gain
or anorexia; drugs used to promote fertility; cosmetic and hair growth
agents; cough and cold preparations; prescription strength vitamins;
barbiturates; benzodiazepines; insulin syringes and diabetic supplies;
food supplements; and medical equipment, devices and supplies. Use
of generics is encouraged.
Notes: The program requires the use of generic drugs whenever available. If
a drug is available in generic form, the program covers the brand name
drug only if the doctor determines it is necessary.
Discount cards cannot be used in conjunction with the program.
The program is to sunset, effective 12/13/05. There are, however,
several measures in the General Assembly to enable the Senior Rx
program to continue as a “wrap-around” program in conjunction with
the Medicare Part D program.
PROGRAM CONTACT
6-59
National Pharmaceutical Council Pharmaceutical Benefits 2004
Montana
Prescription Drug Expansion Program
Program Type: Discount (CMS Pharmacy Plus Program Waiver)
Law Enacted: 2003*
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: Based on participating manufacturers’ pharmaceutical products
Drug Coverage Restrictions: None
PROGRAM CONTACT
*
The program will not be implemented given the passage of the Federal Medicare prescription drug program.
6-60
National Pharmaceutical Council Pharmaceutical Benefits 2004
Montana
Pharmacy Access Prescription Drug Benefit Program
Program Type: Direct Assistance
Law Enacted: 2005*
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Not available
*
The program is not yet operational.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Montana
Prescription Drug Plus Program
Program Type: Discount
Law Enacted: 2005*
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): See notes Eligibility Age (Disabled): See notes
Eligible Income Level (Single): 250% of FPL Eligible Income Level (Married): 250% of FPL
Other Eligibility Notes: No age limit. Must lack Rx coverage or have exhausted benefit.
DRUGS COVERAGE
PROGRAM CONTACT
Not available
*
The program is not yet operational.
6-62
National Pharmaceutical Council Pharmaceutical Benefits 2004
Nevada
Senior Rx Insurance Subsidy for Prescription Drugs∗
Program Type: Subsidy
Year Operational: 2001
Number of Recipients (January 2005): 9,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
∗
Formerly the Nevada Senior Rx.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Drug Coverage Restrictions: Coverage for generic and preferred brand name drugs is provided under
the Senior Rx Prescription Drug Program for the co-pay options
outlined above. If the prescription is for a non-preferred brand name
drug, coverage is available if the drug is determined to be medically
necessary. The copay for medically necessary non-preferred drugs is
$25.00. If the non-preferred drug is not medically necessary, or is
specifically excluded by the policy, it will cost 100% of the pharmacy
discount rate.
General exclusions for over-the-counter drugs; blood glucose meters;
insulin injecting devices; biologicals; durable medical equipment;
nutritional supplements; and cosmetic drugs.
PROGRAM CONTACT
6-64
National Pharmaceutical Council Pharmaceutical Benefits 2004
New Hampshire
Senior Prescription Drug Discount Program*
Program Type: Discount
Year Operational: 2000
Number of Enrollees (January 2005): 70,000†
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: No formulary
Drugs Covered: All prescription drugs
Drug Coverage Restrictions: Over-the-counter drugs are not covered.
Notes: The State will likely offer some type of additional “wrap-around”
program to better integrate options with the Medicare Part D program.
Legislation is pending in the Legislature and very early discussions
have begun on a program framework and implementation.
*
The program is offered by Express Scripts and has no State funding.
†
Active number of participants about 12,000.
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PROGRAM CONTACT
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New Jersey
Pharmaceutical Assistance to the Aged and Disabled
(PAAD)
Program Type: Direct Assistance
Year Operational: 1975
Estimated Number of Recipients (January 2005): 191,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: No formulary
Drugs Covered: Legend drugs, insulin, syringes, insulin needles, certain diabetic testing
materials and syringes, and injectables used in treatment of multiple
sclerosis
Drug Coverage Restrictions: Drugs must be purchased in New Jersey, and must be covered by a
Manufacturer’s Rebate Agreement. Drug Efficacy Study
Implementation program (DESI) drugs are not covered. Generic drugs
must be dispensed unless physician requires brand name drug.
(Medical justification required in obtaining authorization for brand
version of multi-source drugs.)
All first-time prescriptions are limited to a 34-day supply. PAAD
allows for refills up to a 34-day supply or 100 unit doses, whichever is
greater. Program mandates an enhanced Drug Utilization Review
(DUR).
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Notes: The program will likely be restructured to better integrate options with
the Medicare Part D program. Preliminary changes are under
consideration but formal discussions have not started.
PROGRAM CONTACT
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New Jersey
Senior Gold Prescription Discount Program
Program Type: Direct Assistance
Year Operational: 2001
Estimated Number of Recipients (January 2005): 29,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: No formulary
Drugs Covered: Legend drugs, insulin, syringes, insulin needles, certain diabetic testing
materials and syringes, and injectables used in treatment of multiple
sclerosis
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Drug Coverage Restrictions: Drugs must be purchased in New Jersey, and must be covered by a
Manufacturer’s Rebate Agreement. Drug Efficacy Study
Implementation program (DESI) drugs are not covered. Generic drugs
must be dispensed unless physician requires dispensing of brand name
drug. (Medical justification required in obtaining authorization for
brand version of multi-source drugs.)
PROGRAM CONTACT
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New Mexico
Senior Prescription Drug Program
Program Type: Discount
Operational Date: 2003
Number of Recipients (January 2005): 4,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: Manufacturers’ participating prescription drug products
Drug Coverage Restrictions: None
Notes:
PROGRAM CONTACT
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New York
Elderly Pharmaceutical Insurance Coverage (EPIC)
Program
Program Type: Direct Assistance
Year Operational: 1987
Number of Recipients (January 2005): 348,269
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: All legend drugs, insulin and insulin syringes and needles
Drug Coverage Restrictions: Drug Efficacy Study and Implementation program (DESI) drugs and non-
participating manufacturers excluded
Notes: There are several measures in the legislation to enable the EPIC program to
fully wraparound Part D if a senior joins Part D, and would waive EPIC
enrollment fees for participants that join Part D as a full subsidy individual.
PROGRAM CONTACT
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North Carolina
Senior Care∗
Program Type: Direct Assistance
Year Operational: 2002
Number of Recipients (January 2005): 113,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: All prescription drugs
Drug Coverage Restrictions: This program will not pay for over-the-counter drugs or potassium
supplements. Identical restrictions as those for the Medicare Discount Card.
Notes: Sunset date for this program is on December 31, 2005. There are no plans
addressing the Medicare Part D program as of yet, however legislation is
being considered.
PROGRAM CONTACT
∗
Previously referred to as Carolina CaRxes in State legislation.
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Ohio
Golden Buckeye Prescription Drug Program
Program Type: Negotiated Discounts
Operational Date: 2003
Estimated Eligibles: 2 million
ELIGIBILITY CRITERIA
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DRUGS COVERAGE
PROGRAM CONTACT
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Ohio
Ohio’s Best Rx Program
Program Type: Negotiated Discounts
Year Operational: 2005
Number of Recipients (January 2005): 14,934
ELIGIBILITY CRITERIA
Funding Source: Initially State funded; however, by January 2006 this program is expected
to be self-funded by obtaining rebates from drug manufacturers and
collecting a small administrative fee from participants.
Budget (FY 05): $10 million for start-up costs from the State
Cost per Participant (FY 05): $34.78
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Negotiated with each individual manufacturer. Estimated discounts range
between 20% and 40%.
Ingredient Cost Calculation: Based on contractual arrangements with participating manufacturers
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $1 transaction cost
Dispensing Fee: $3.00
Notes: Discounts are calculated from the average rebate paid by drug
manufacturers to State retirement and employees benefit plans. Up to 5%
of the money collected through manufacturers’ rebates may be used for the
contract with the PBM program administrator, MemberHealth.
DRUGS COVERAGE
Formulary: Open
Drugs Covered: Based on pharmaceutical manufacturers participating in the program.
Drug Coverage Restrictions: None
Notes:
PROGRAM CONTACT
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Oklahoma
Pharmacy Connection Council Program*
Program Type: Coordinate Assistance Between Elderly and Manufacturers’
Pharmaceutical Programs
Year Operational: 2003
Number of Recipients: Not Available
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: Based on a manufacturer’s charitable program criteria.
Drug Coverage Restrictions: Not available
*
The Pharmacy Connection Council program assists eligible State residents in coordinating services from various
manufacturers’ charitable prescription assistance programs. The State does not contribute any money for the direct
purchase of prescription drugs.
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PROGRAM CONTACT
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Oklahoma
Oklahoma Prescription Drug Assistance Program*
Program Type: Discount
Law Enacted: 2005
Projected Number of Recipients: Not Available
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): See notes Eligibility Age (Disabled): See notes
Eligible Income Level (Single): See notes Eligible Income Level (Married): See notes
Other Eligibility Notes: No age limit, all uninsured residents are eligible. No income limit, but
enrollment fee for those above 150% FPL.
DRUGS COVERAGE
PROGRAM CONTACT
Not available
*
The program is not yet operational.
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Oregon
Senior Prescription Drug Assistance Program*
Program Type: Discount
Operational Date: 2003
Number of Recipients (January 2005): 100
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: All legend drugs
Drug Coverage Restrictions OTC drugs and medical supplies and medical equipment are not
covered.
*
Legislation was enacted in 2003 seeking a CMS waiver for the creation of the Medication Expansion for Disabled
Persons and Seniors (MEDS) program. MEDS would have expanded drug coverage for additional seniors’ 65 years of
age and older using a sliding scale, cost-share and co-insurance matrix based on income levels. The waiver has not
been approved to date. Oregon officials may not seek implementation of the program given the Medicare prescription
drug benefit enacted by Congress in 2003.
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PROGRAM CONTACT
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Pennsylvania
Pharmaceutical Assistance Contract for the Elderly
(PACE)
Type of Program: Direct Assistance
Year Operational: 1984
Number of Recipients (January 2005): 194,717
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: All Federal legend drugs and insulin, insulin syringes and needles
Drug Coverage Restrictions: 30-day supply or 100 units, whichever is less. No experimental
drugs, drugs for baldness and wrinkles, over-the-counter drugs, or
most off-label uses. Mandatory generic substitution for A-rated
(therapeutically equivalent) products. Drug Efficacy Study and
Implementation program (DESI) drugs require documentation of
medical necessity.
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PROGRAM CONTACT
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Pennsylvania
PACE Needs Enhancement Tier (PACENET)
Program Type: Direct Assistance
Year Operational: 1996
Number of Recipients (January 2005): 104,178
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: All Federal legend drugs and insulin, insulin syringes and needles
Drug Coverage Restrictions: 30-day supply or 100 units, whichever is less. No experimental drugs,
drugs for baldness and wrinkles, over-the-counter drugs, or most off-
label uses. Mandatory generic substitution for A-rated (therapeutically
equivalent) products. Drug Efficacy Study and Implementation
program (DESI) drugs require documentation of medical necessity.
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PROGRAM CONTACT
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Rhode Island
Rhode Island Pharmaceutical Assistance to the Elderly
(RIPAE)
Program Type: Direct Assistance, Discount
Year Operational: 1985
Number of Enrollees (January 2005): 38,500
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 55-65
Eligible Income Level (Single): See notes Eligible Income Level (Married): See notes
Other Eligibility Notes: Income levels exclude income spent on medical expenses if greater
than 3% of total income.
FUNDING AND REIMBURSEMENT
Funding Source: State General Revenue Fund
Budget (FY 05): Not available
Cost per Enrollee (FY 05): Not available
# of Rx’s Per Enrollee (FY 05): Not available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP-13% for brand name drugs; MAC for generics
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: Participant pays co-pay of 40%, 70%, or 85% of prescription cost
depending on income levels. For members in the lowest income class,
the program will pay 100% of the cost of covered medications after the
member has paid $1,500.00 in copayments.
Dispensing Fee: $2.75
Notes: Participating pharmaceutical manufacturers must sign a rebate
agreement with the State for covered products.
DRUGS COVERAGE
Formulary: Open formulary
Drugs Covered: Drugs for Alzheimer’s disease, anti-infectives, arthritis, asthma and
other chronic respiratory conditions, cancer, circulatory insufficiency,
depression, diabetes (including insulin syringes), glaucoma, heart
problems, high cholesterol, hypertension, osteoporosis, Parkinson’s
disease, prescription mineral and vitamin supplements for renal
patients, and urinary incontinence.
Drug Coverage Restrictions: Non-cosmetic Food and Drug Administration approved drugs that
were not previously listed are covered at the program’s discount price
or at the Federal MAC price, whichever is lower.
Notes: Program officials have begun preliminary discussions on using the
RIPAE program as a “wrap-around” program once the Medicare
Prescription Drug Program (Part D) is operational. Specific criteria
have yet to be determined.
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PROGRAM CONTACT
Kristin Pono Phone: 401/462-0510
Rhode Island Dept. of Elderly Affairs Fax: 401/462-0586
Benjamin Rush Building #55
35 Howard Avenue
Cranston, RI 02920
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Rhode Island
Rhode Island Pharmacy Prescription Drug Discount
Program for the Uninsured
Program Type: Cash Discount
Year Operational: 2005∗
Number of Enrollees: Not Available
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): 19-65 Eligibility Age (Disabled): 19-65
Eligible Income Level (Single): 200% (FPL) Eligible Income Level (Married): 200% (FPL)
Other Eligibility Notes: Must be uninsured with no prescription drug coverage. Family income
may not exceed 200 percent of the Federal poverty level (FPL).
FUNDING AND REIMBURSEMENT
Funding Source: PBM negotiated contracts with manufacturers
Budget (FY 05): Not available
Cost per Enrollee (FY 05): Not available
# of Rx’s Per Enrollee (FY 05): Not available
Manufacturer Rebate Type: PBM negotiated contracts with pharmaceutical manufacturers
Ingredient Cost Calculation: Criteria based on the lower of the usual and customary or:
AWP-15% (retail –brand); AWP-17% (retail – mail); Retail generic:
CMS MAC rate or AWP-40%; Mail-order generic: CMS MAC rate or
AWP-50%.
Enrollment Fee: Annual, non-refundable enrollment fee, up to $30, may be charged.
Deductible Amount: Not available
Copayment Amount: Not available
Dispensing Fee: Not available
Notes: Request for Proposal (RFP) is under evaluation. Specific funding and
reimbursement criteria will be determined based on the winning
vendor bid from pharmacy benefits manager (PBM).
DRUGS COVERAGE
Formulary: To be determined based on winning RFP bid.
Drugs Covered: To be determined based on winning RFP bid.
∗
Program is scheduled to begin May 2005; however, the Request For Proposal (RFP) is still under evaluation, as of
April 1, 2005.
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PROGRAM CONTACT
Kristin Pono Phone: 401/462-0510
Rhode Island Dept. of Elderly Affairs Fax: 401/462-0586
Benjamin Rush Building #55
35 Howard Avenue
Cranston, RI 02920
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National Pharmaceutical Council Pharmaceutical Benefits 2004
South Carolina
SilveRxCard Senior Prescription Drug Program
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 2003
Number of Enrollees (January 2005): 53,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
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Notes: Brand name drugs are dispensed when generic drugs are not available.
Over-the-counter drugs are paid for when authorized with a
prescription. Insulin syringes, insulin, or other injectable products that
are either administered at home or self-administered are also covered.
Diabetic supplies such as alcohol wipes and test strips; smoking
cessation products; certain lifestyle drugs; and, injectable products
administered in a physician’s office or clinic are not covered.
The program will likely be restructured to better integrate options with
the Medicare Part D program. Legislation is being discussed but
specific details have yet to be announced. An effort to expand drug
coverage through the South Carolina Retirees and Individuals Pooling
Together for Savings (SCRIPTS) Program has been postponed due to
the Federal Medicare prescription drug coverage program.
PROGRAM CONTACT
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South Dakota
Senior Citizen Prescription Drug Benefit Program
Program Type: Negotiated Discount
Year Operational: 2003*
Number of Enrollees (December 2003): 36,361
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): All Medicare Eligibility Age (Disabled): All Medicare
eligibles eligibles
Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: Must be a resident of South Dakota. Medicaid recipients are not
eligible.
DRUGS COVERAGE
Formulary: None
Drugs Covered: All prescription drugs
Drug Coverage Restrictions: None
PROGRAM CONTACT
*
This program was repealed by legislation, effective September 1, 2004.
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Tennessee
TennCare Rx
Program Type: Direct Assistance (1115 Waiver)
Law Enacted: 2003*
Number of Recipients: None
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
*
This program has not yet been implemented.
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Texas
Kidney Health Care Program (KHC)
Program Type: Direct Assistance
Year Operational: 1999
Number of Recipients (January 2005): 17,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
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Texas
State Prescription Drug Program
Program Type: Subsidy
Law Enacted: 2001∗
Estimated Eligibles: None
ELIGIBILITY CRITERIA
Funding Source: State General Revenue Fund, unless funds are available under Federal law
to fund all or part of the program
Budget: None
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Not available
Ingredient Cost Calculation: Not available
Enrollment Fee: Not available
Deductible Amount: Not available
Copayment Amount: Not available
Dispensing Fee: Not available
Notes: According to statute, the Health and Human Services Commission may
require a cost-sharing payment.
DRUGS COVERAGE
PROGRAM CONTACT
∗
This program has not been implemented due to the fact that no funding has been budgeted.
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Vermont
VSCRIPT
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 1989∗
Number of Eligibles (February 2005): 2,752
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
∗
This program was integrated into the VHAP (1115 waiver) program in 1999.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Vermont
VSCRIPT Expanded
Program Type: Direct Assistance
Year Operational: 2000
Number of Recipients (February 2005): 2,665
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Vermont
Vermont Health Access Plan (VHAP) Pharmacy
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 1996
Number of Recipients (February 2005): 8,465
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Vermont
Healthy Vermonters Program
Program Type: Direct Assistance (1115 Waiver)
Year Operational: July 1, 2002
Eligible Recipients (February 2005): 13,469
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Washington
Pharmacy Connections
Program Type: Coordinate Assistance Between Elderly and Manufacturers’
Pharmaceutical Programs
Year Operational: 2003
Number of Individuals Assisted (2004): 26,000∗
ELIGIBILITY CRITERIA
DRUGS COVERAGE
∗
The program provided 15,000 individuals with referral information for drug manufacturer-sponsored patient assistance
programs and drug discount cards. The program also helped 11,000 individuals complete applications. These numbers
are expected to increase dramatically based on confusion surrounding implementation of the Medicare prescription drug
benefit in 2006.
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PROGRAM CONTACT
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Washington
Rx Washington Card
Program Type: Direct Discounts
Year Operational: 2004
Number of Recipients (February 2005): 50∗
ELIGIBILITY CRITERIA
DRUGS COVERAGE
∗
Enrollment in Rx Washington has remained low due to a variety of factors, including: (1) availability of the Medicare
drug discount card; (2) provisions in law preventing negotiated discounts from hurt retail pharmacies; (3) the existence
of programs offered by drug manufacturers; and (4) the fact that the program is mail order only.
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PROGRAM CONTACT
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Washington
Medicaid Prescription Drug Assistance Program
Program Type: Direct Assistance (1115 Waiver)
Law Enacted: 2003∗
Number of Recipients: None
ELIGIBILITY CRITERIA
DRUGS COVERAGE
∗
The program has not been implemented. The State decided not to pursue the requisite 1115 demonstration waiver
after passage of the Medicare Prescription Drug Improvements and Modernization Act of 2003.
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PROGRAM CONTACT
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West Virginia
Golden Mountaineer Card Program
Program Type: Direct Assistance
Year Operational: 2001
Number of Recipients (2004): 14,000-16,000/month*
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: All FDA Federal legend pharmaceuticals and diabetic supplies
Drug Coverage Restrictions: None
PROGRAM CONTACT
*
There are a total of 360,000 eligible seniors for the Gold Mountaineer Card Program. Monthly card usage varies.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
West Virginia
West Virginia Prescription Drug Assistance Clearinghouse
Program
Program Type: Coordinate Assistance Between Elderly and Manufacturers’
Pharmaceutical Programs
Law Enacted: April 2004
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): Not available Eligibility Age (Disabled): Not available
Eligible Income Level (Single): 200% FPL Eligible Income Level (Married): 200% FPL
Other Eligibility Notes: Uninsured West Virginia residents who have had no coverage for at
least 6 months.
DRUGS COVERAGE
Formulary: None
Drugs Covered: None
Drug Coverage Restrictions: None
Notes: The clearinghouse portion of the program assists low-income State residents or uninsured to gain
access to existing manufacturers’ private and public sector prescription drug assistance programs
offered by manufacturers. The discount drug program provides low-income, uninsured individuals
prescription drugs from participating brand pharmaceutical companies and pharmacists through
either a State-sponsored discount card program or a program extending current brand
pharmaceutical manufacturer prescription drug assistance programs.
PROGRAM CONTACT
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Wisconsin
SeniorCare Prescription Drug Assistance Program
Program Type: Direct Assistance
Year Operational: 2002
Estimated Enrollment (March 2005): 88,000
ELIGIBILITY CRITERIA
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Copayment Amount: Level 1: $15 co-pay for covered brand name drugs, $5 co-pay
for covered generics
Level 2a: After $500 deductible, $15 co-pay for covered brand
name drugs, $5 co-pay for covered generics
Level 2b: After $850 deductible, $15 co-pay for covered brand
name drugs, $5 co-pay for covered generics
Level 3: After spenddown and an $850 deductible are met, $15
co-pay for covered brand name drugs, $5 co-pay for
covered generics
Dispensing Fee: $4.88
DRUGS COVERAGE
Formulary: PDL
Drugs Covered: Manufacturers’ products that have a signed SeniorCare rebate
agreement
Drug Coverage Restrictions: Reimbursement for most drugs is limited to a 34-day supply. Some
maintenance drugs may be provided in a 100-day supply.
A preferred drug list (PDL) has been implemented.
PROGRAM CONTACT
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Wyoming
Prescription Drug Assistance Program
Program Type: Direct Assistance
Year Operational: 2003
Number of Recipients (FY 2004): 1,066 (monthly average)*
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages
Eligible Income Level (Single): 100% of FPL Eligible Income Level (Married): 100% of FPL
Other Eligibility Notes: Medicaid enrollees are not eligible for this program. Also, an asset
test was implemented effective July 1, 2004. The asset test takes into
account motor vehicles worth more than $15,000 and resources in
excess of $2,500. Homes are exempt.
DRUGS COVERAGE
*
Program closed to new enrollment effective July 1, 2003.
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PROGRAM CONTACT
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Appendix A:
State and Federal
Medicaid Contacts
A-1
National Pharmaceutical Council Pharmaceutical Benefits 2004
ALABAMA CALIFORNIA
Louise F. Jones J. Kevin Gorospe, Pharm.D.
Director Chief, Pharmacy Policy Unit
Pharmacy Services California Department of Health Services
Alabama Medicaid Agency Medi-Cal Policy Division
501 Dexter Avenue Pharmacy Contracting and Policy Section
P.O. Box 5624 1501 Capitol Avenue
Montgomery, AL 36103-5624 P.O. Box 997413, MS 4604
T: 334/242-5039 Sacramento, CA 95814
F: 334/353-7014 T: 916/552-9500
E-mail: lljones@Medicaid.state.al.us F: 916/552-9563
Internet address: www.medicaid.state.al.us E-mail: jgorospe@dhs.ca.gov
Internet address: http://www.medi-cal.ca.gov
ALASKA
COLORADO
Dave Campana, R.Ph.
Pharmacy Program Manager Martha Warner
Division of Health Care Services Pharmacy Supervisor
4501 Business Park Blvd., Suite 24 Department of Health Care Policy and Financing
Anchorage, AK 99503 1570 Grant Street
T: 907/334-2425 Denver, CO 80203
F: 907/561-1684 T: 303/866-3176
E-mail: david_campana@health.state.ak.us F: 303/866-2573
Internet address: www.hss.state.ak.us/dhcs E-mail: martha.warner@state.co.us
CONNECTICUT
ARIZONA
Evelyn A. Dudley
Dell Swan
Manager, Pharmacy Unit
Pharmacy Program Administrator
Department of Social Services, Medical Operations
AHCCCS
25 Sigourney Street
701 East Jefferson Street
Hartford, CT 06106-5033
MD 8000
T: 860/424-5654
Phoenix, AZ 85034
F: 860/424-5206
T: 612/417-4726
E-mail: evelyn.dudley@po.state.ct.us
E-mail: dwswan@ahcccs.state.az.us
Internet address: www.dss.state.ct.us
Internet address: www.ahcccs.state.az.us
DELAWARE
ARKANSAS
Cynthia R. Denemark, R.Ph.
Suzette Bridges, P.D., Administrator
Director of Pharmacy Services
Pharmacy Program
DSS/EDS
Department of Human Services
248 Chapman Road, Suite 100
Division of Medical Services
Newark, DE 19702
P.O. Box 1437, Slot 415
T: 302/453-8453
Little Rock, AR 72203-1437
F: 302/454-0224
T: 501/683-4120
E-mail: Cynthia.denemark@eds.com
F: 501/683-4124
Internet address: www.dmap.state.de.us
E-mail: suzette.bridges@medicaid.state.ar.us
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National Pharmaceutical Council Pharmaceutical Benefits 2004
GEORGIA INDIANA
Jerry L. Dubberly, R.Ph., M.B.A. Marc Shirley, R.Ph.
Director, Pharmacy Services Pharmacist
Department of Community Health Office of Medicaid Policy and Planning
Division of Medical Assistance Indiana State Government Center South-Rm. W382
2 Peachtree Street, N.W., 37th Floor 402 West Washington Street
Atlanta, GA 30303-3159 Indianapolis, IN 46204-2739
T: 404/657-4044 T: 317/232-4343
F: 404/657-5461 F: 317/232-7382
E-mail: jdubberly@dch.state.ga.us E-mail: mshirley@fssa.state.in.us
Internet address: www.dch.state.ga.us
Note: All requests for information by, or on behalf of drug
manufacturers must be made ONLY to: PDL@FSSA.state.in.us.
HAWAII Phone requests will not be accepted.
A-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
KANSAS MARYLAND
Mary H. Obley, Pharmacist Joseph L. Fine
Pharmacy Program Manager Director
Health Care Policy Division Maryland Pharmacy Program
Department of Social and Rehabilitation Services DHMH, Office of Operations and Eligibility, and
Docking State Office Building Pharmacy
915 SW Harrison, Room 651-South 201 West Preston Street, Room 407
Topeka, KS 66612-1570 Baltimore, MD 21201
T: 785/296-3981 T: 410/767-1455
F: 785/296-4813 F: 410/333-5398
E-mail: mho@srskansas.org E-mail: jfine@dhmh.state.md.us
Internet address: www.srskansas.org/hcp Internet address: www.dhmh.state.md.us/mma/mpap
KENTUCKY MASSACHUSETTS
Dan Yeager, R.Ph. Paul L. Jeffrey
Interim Pharmacy Director Director of Pharmacy
Department for Medicaid Services Office of Medicaid
CHR Building, 6 W-A 600 Washington Street, 5th Floor
275 East Main Street Boston, MA 02111
Frankfort, KY 40621 T: 617/210-5319
T: 502/564-7940 F: 617/210/5865
F: 502/564-0509 E-mail: pjeffrey@MassMail.state.ma.us
E-mail: dan.yeager@ky.gov Internet address: www.state.ma.us/dma
LOUISIANA MICHIGAN
Mary J. Terrebonne, Pharm.D. Giovannino A. Perri, M.D.
Pharmacy Director Chief Medical Consultant
Department of Health and Hospitals MDCH/Medical Services Administration
1201 Capitol Access Road, 6th Floor 400 South Pine Street
P.O. Box 91030 P.O. Box 30479
Baton Rouge, LA 70821 Lansing, MI 48909-7979
T: 225/342-9768 T: 517/335-5181
F: 225/342-1980 F: 517/241-8135
E-mail: mterrebo@dhh.la.gov E-mail: perrig@michigan.gov
Internet address: www.lamedicaid.com Internet address: www.michigan.gov/mdch
MAINE MINNESOTA
Bruce McClanahan Cody C. Wiberg, Pharm.D., R.Ph.
Pharmacy Unit Manager Pharmacy Program Manager
Department of Human Services Department of Human Services
Bureau of Medical Services 444 Lafayette Road North
11 SHS, 442 Civic Center Drive St. Paul, MN 55155-3853
Augusta, ME 04333 T: 651/296-8515
T: 886/796-2463 F: 651/282-6744
F: 207/287-8601 E-mail: cody.c.wiberg@state.mn.us
E-mail: bruce.mcclanahan@maine.gov Internet address: www.dhs.mn.us/provider/pharm
Internet address: www.maine.gov/bms
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National Pharmaceutical Council Pharmaceutical Benefits 2004
MISSISSIPPI NEVADA
Judith P. Clark, R.Ph. Dionne Coston, R.N.
Pharmacy Director Medicaid Services Specialist
Division of Medicaid Division of Health Care Financing and Policy
Robert E. Lee Building Pharmacy Program
239 North Lamar Street, Suite 801 1100 E. Williams Street
Jackson, MS 39201 Carson City, NV 89701
T: 601/359-5253 T: 775/684-3775
F: 601/359-9555 F: 775/684-3762
E-mail: phipc@medicaid.state.ms.us E-mail: dcpstpm@dhcfp.state.nv.us
Internet address: www.dom.state.ms.us Internet address: www.dhcfp.state.nv.us
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National Pharmaceutical Council Pharmaceutical Benefits 2004
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National Pharmaceutical Council Pharmaceutical Benefits 2004
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National Pharmaceutical Council Pharmaceutical Benefits 2004
WEST VIRGINIA
Peggy A. King, R.Ph.
Director, Office of Pharmacy Services
Department of Health and Human Resources
Bureau for Medical Services
350 Capitol St., Room 251
Charleston, WV 25301-3707
T: 304/558-1700
F: 304/558-1542
E-mail: pking@wvdhhr.org
Internet address: www.wvhhhr.org/bms/pharmacy
WISCONSIN
Mark Moody
Administrator
Division of Health Care Financing
Department of Health and Family Services
One West Wilson Street
P.O. Box 309
Madison, WI 53701-0309
T: 608/266-8922
F: 608/266-1096
E-mail: webmaster@dhfs.state.wi.us
Internet address: www.dhfs.state.wi.us
WYOMING
Antoinette K. Brown, R.Ph.
Medicaid Pharmacist
Department of Health-Pharmacy Unit
2300 Capitol Avenue, Suite 147
Cheyenne, WY 82002
T: 307/777-6016
F: 307/777-8623
E-mail: abrown@state.wy.us
Internet address: www.pharmacy.state.wy.us
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National Pharmaceutical Council Pharmaceutical Benefits 2004
ALABAMA CALIFORNIA
Louise F. Jones J. Kevin Gorospe, Pharm.D.
Director Chief, Pharmacy Policy Unit
Pharmacy Services California Department of Health Services
Alabama Medicaid Agency Medi-Cal Policy Division
501 Dexter Avenue Pharmacy Contracting and Policy Section
P.O. Box 5624 1501 Capitol Avenue
Montgomery, AL 36103-5624 P.O. Box 997413, MS 4604
T: 334/242-5039 Sacramento, CA 95814
F: 334/353-7014 T: 916/552-9500
E-mail: lljones@Medicaid.state.al.us F: 916/552-9563
E-mail: jgorospe@dhs.ca.gov
ALASKA
Dave Campana, R.Ph.
COLORADO
Pharmacy Program Manager
Division of Health Care Services Martha Warner
4501 Business Park Blvd., Suite 24 Pharmacy Supervisor
Anchorage, AK 99503 Department of Health Care Policy and Financing
T: 907/334-2425 1570 Grant Street
F: 907/561-1684 Denver, CO 80203
E-mail: david_campana@health.state.ak.us T: 303/866-3176
F: 303/866-2573
E-mail: martha.warner@state.co.us
ARIZONA
Contact health plans directly.
CONNECTICUT
Evelyn A. Dudley
ARKANSAS Manager, Pharmacy Unit
Suzette Bridges, P.D., Administrator Department of Social Services, Medical Operations
Pharmacy Program 25 Sigourney Street
Department of Human Services Hartford, CT 06106-5033
Division of Medical Services T: 860/424-5654
P.O. Box 1437, Slot S 415 F: 860/424-5206
Little Rock, AR 72203-1437 E-mail: evelyn.dudley@po.state.ct.us
T: 501/683-4120
F: 501/683-4124
E-mail: suzette.bridges@medicaid.state.ar.us DELAWARE
Joli Martini
Pharmacist Consultant – Clinical Reviews
DSS/EDS
248 Chapman Road, Suite 100
Newark, DE 19702
T: 302/453-8453
F: 302/454-0224
E-mail: Joli.martini@eds.com
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National Pharmaceutical Council Pharmaceutical Benefits 2004
DISTRICT OF COLUMBIA
IDAHO
Cheryl S. Wilson
Risk Manager – Pharmacy/DME Mary Wheatley, R.Ph.
Department of Health Pharmacy Services Specialist
Medical Assistance Administration Department of Health and Welfare
825 North Capitol Street, NE Division of Medicaid
Suite 5135 3232 Elder
Washington, DC 20002 Boise, ID 83705
T: 202/442-9078 T: 208/364-1832
F: 202/442-4790 F: 208/364-1864
E-mail: cheryl.wilson@dcgov.org E-mail: wheatlem@idhw.state.id.us
FLORIDA ILLINOIS
Jerry F. Wells Lisa Voils
Bureau Chief Special Assistant to the Medicaid Deputy
Medicaid Pharmacy Services Adminstrator
Agency for Health Care Administration Illinois Department of Public Aid
2727 Mahan Drive, MS 38 201 S. Grand Avenue East
Tallahassee, FL 32308 Springfield, IL 62763
T: 850/487-4441 T: 217/782-2570
F: 850/922-0685 F: 217/782-5672
E-mail: wellsj@ahca.myflorida.com E-mail: lisa.voils@idpa.state.il.us
GEORGIA INDIANA
Etta L. Hawkins, R.Ph. Marc Shirley, R.Ph.
Medicaid Program Pharmacy Manager Pharmacist
Department of Community Health Office of Medicaid Policy and Planning
Division of Medical Assistance Room W382
2 Peachtree Street, NW, 37th Floor Indiana State Government Center South
Atlanta, GA 30303-3159 402 West Washington Street
T: 404/657-4044 Indianapolis, IN 46204-2739
F: 404/657-5461 T: 317/232-4343
E-mail: ehawkins@dch.state.ga.us F: 317/232-7382
Note: All manufacturer inquiries and/or submissions must be in
electronic format and sent to PDL@fssa.state.in.us. Paper copies
HAWAII will not be accepted and should not be mailed to any of the involved
parties, including OMPP, ACS, or the Therapeutic Committee.
Lynn S. Donovan, R.Ph. Visit: http://indianapbm.com/downloads/T-
committe%20PDL%20submission%20Form1-5-04.pdf for
Pharmacy Consultant necessary forms.
Department of Human Services
Med-Quest Division
601 Kamokila Boulevard, Suite 506B
Kapolei, HI 96707
T: 808/692-8116
F: 808/692-8131
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National Pharmaceutical Council Pharmaceutical Benefits 2004
IOWA MAINE
Susan L. Parker, Pharm.D. Bruce McClanahan
Pharmacy Consultant Pharmacy Unit Manager
Iowa Medicaid Enterprise Department of Human Services
100 Army Post Road Bureau of Medical Services
Des Moines, IA 50315 11 SHS, 442 Civic Center Drive
T: 515/725-1226 Augusta, ME 04333
F: 515/725-1010 T: 886/796-2463
E-mail: sparker2@dhs.state.ia. F: 207/287-8601
E-mail: bruce.mcclanahan@maine.gov
KANSAS
MARYLAND
Mary H. Obley
Pharmacist Frank Tetkoski, P.D
Pharmacy Program Manager Pharmacist Consultant
Health Care Policy Division Maryland Pharmacy Program
Department of Social and Rehabilitation Services DHMH
Docking State Office Building Division of Pharmacy Services
915 SW Harrison, Room 651-South 201 W. Preston Street, Room 409
Topeka, KS 66612-1570 Baltimore, MD 21201
T: 785-296-3981 T: 410/767-1460
F: 785/296-4813 F: 410/333-5398
E-mail: mho@srskansas.org E-mail: tetkoskif@dhmh.state.md.us
KENTUCKY MASSASCHUSETTS
Debra Bahr, R.Ph. Christopher T. Burke
Pharmacy Services Program Manager Policy Analyst
Department for Medicaid Services Office of Medicaid
CHR Building, 6 W-A 600 Washington Street, 5th Floor
275 East Main Street Boston, MA 02111
Frankfort, KY 40621 T: 617/210-5592
T: 502/564-7940 F: 617/210-5597
F: 502/564-0509 E-mail: christopher.burke@MassMail.state.ma.us
E-mail: Debra.Bahr@ky.go
MICHIGAN
LOUISIANA Donna Hammel
Mary J. Terrebonne, Pharm.D. Office of Medical Affairs
Pharmacy Director MDCH/Medical Services Administration
Department of Health & Hospitals 400 South Pine Street
1201 Capitol Access Road, 6th Floor P.O. Box 30479
P.O. Box 91030 Lansing, MI 48909-7979
Baton Rouge, LA 70821 T: 517/335-5181
T: 225/342-9768 F: 517/241-8135
F: 225/342-1980 E-mail: hammeld@michigan.gov
E-mail: mterrebo@dhh.la.gov
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National Pharmaceutical Council Pharmaceutical Benefits 2004
MINNESOTA
NEBRASKA
Cody C. Wiberg, Pharm.D., R.Ph.
Dyke Anderson, R.Ph
Pharmacy Program Manager
Pharmacy Consultant
Department of Human Services
Department of Health and Human Services
444 Lafayette Road North
Finance and Support/Medicaid Division
St. Paul, MN 55155-3853
301 Centennial Mall South
T: 651/296-8515
5th Floor-NSOB
F: 651/282-6744
P.O. Box 95026
E-mail: cody.c.wiberg@state.mn.us
Lincoln, NE 68509-5026
T: 402/471-9379
F: 402/471-9092
MISSISSIPPI
E-mail: dyke.anderson@hhss.ne.gov
Judith P. Clark, R.Ph.
Pharmacy Director
Division of Medicaid NEVADA
Robert E. Lee Building
Dionne Coston, R.N.
239 North Lamar Street, Suite 801
Medical Services Specialist
Jackson, MS 39201
T: 601/359-5253 Division of Health Care Financing and Policy
Pharmacy Program
F: 601/359-9555
1100 E. Williams Street
E-mail: phipc@medicaid.state.ms.us
Carson City, NV 89701
T: 775/684-3775
F: 775/684-3762
MISSOURI
E-mail: dcpstpm@dhcfp.state.nv.us
Rhonda A. Driver
Clinical Pharmacist
Department of Social Services NEW HAMPSHIRE
Division of Medical Services
2023 St. Mary’s Boulevard Lisè C. Farrand, R.Ph.
P.O. Box 6500 Pharmaceutical Services Specialist
Office of Medicaid Business and Policy
Jefferson City, MO 65102- 6500
129 Pleasant Street, Annex 1
T: 573/751-6961
Concord, NH 03301
F: 573/522-8514
T: 603/271-4419
E-mail: Rhonda.Driver@dss.mo.gov
F: 603/271-8701
E-mail: lfarrand@dhhs.state.nh.us
MONTANA
Dan Peterson NEW JERSEY
Pharmacy Program Officer
Department of Public Health and Human Services Joseph B. Martinez
Medicaid Services Bureau Chief, Pharmaceutical Services
1400 Broadway Department of Medical Assistance and Human
P.O. Box 202951 Services
Helena, MT 59620-2951 Office of Utilization Management
T: 406/444-2738 P.O. Box 712
F: 406/444-1861 Trenton, NJ 08619
E-mail: danpeterson@mt.gov T: 609/588-2774
F: 609/588-3889
E-mail: joseph.b.martinez@dhs.state.nj.us
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National Pharmaceutical Council Pharmaceutical Benefits 2004
OREGON
NORTH CAROLINA
Kathy L. Ketchum, R.Ph., M.P.A.-H.A.
Tom D’Andrea, R.Ph., M.B.A. Medicaid Program Coordinator
Chief of Pharmacy and Ancillary Services Oregon State University College of Pharmacy
Department of Health and Human Services 840 SW Gaines Road, MC 212
Division of Medical Assistance Portland, OR 97239-3098
1985 Umstead Drive, 2501 Mail Service Center T: 503/494-1589
Raleigh, NC 27699 F: 503/494-8797
T: 919/855-4300 E-mail: ketchumk@ohsu.edu
F: 919/715-1255
E-mail: Tom.Dandrea@ncmail.net
PENNSYLVANIA
Terri Cathers
NORTH DAKOTA
Director of Pharmacy
Brendan K. Joyce, Pharm.D., R.Ph. Department of Public Welfare
Administrator, Pharmacy Services P.O. Box 2675
Department of Human Services Harrisburg, PA 17105
600 East Boulevard Avenue T: 717/772-6195
Department 325 F: 717/705-8391
Bismarck, ND 58505-0250 E-mail: c-tcathers@state.pa.us
T: 701/328-4023
F: 701/328-1544
E-mail: sojoyb@state.nd.us
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National Pharmaceutical Council Pharmaceutical Benefits 2004
RHODE ISLAND
TEXAS
Paula J. Avarista, R.Ph., M.B.A.
Martha McNeil, R.Ph.
Chief of Pharmacy
Product and Prescriber Manager
Department of Human Services
Texas Health and Human Services Commission
600 New London Avenue
11209 Metric Boulevard, Building H
Cranston, RI 02920
Austin, TX 78758
T: 401/462-6390
T: 512/491-1157
F: 401/462-6836
F: 512/491-1961
E-mail: pavarista@dhs.state.ri.us
E-mail: Martha.Mcneil@hhsc.state.tx.us
SOUTH CAROLINA
UTAH
James M. Assey, R.Ph., Division Director
Division of Pharmaceutical Services and DME RaeDell Ashley, R.Ph.
Pharmacy Director
Department of Health & Human Services
Medicaid Program
P.O. Box 8206
Division of Health Care Financing
Columbia, SC 29202-8206
Department of Health
T: 803/898-2876
F: 803/255-8353 288 North 1460 West
P.O. Box 143102
E-mail: asseyj@dhhs.state.sc.us
Salt Lake City, UT 84114-3102
T: 801/538-6495
F: 801/538-6099
SOUTH DAKOTA
E-mail: rashley@utah.gov
Mark E. Petersen, R.Ph.
Pharmacy Consultant
Department of Social Services VERMONT
Office of Medical Services
Felicia Montineri
700 Governors Drive
Clinical Pharmacist
Pierre, SD 57501
First Health Services Corporation
T: 605/773-3498
312 Hurricane Lane, Suite 200
F: 605/773-5246
Williston, VT 05495
E-mail: Mark.Petersen@state.sd.us
T: 802/879-5900
F: 802/879-5919
E-mail: MontinFe@fhsc.com
TENNESSEE
Jeffrey G. Stockard, D.Ph.
Associate Pharmacy Director VIRGINIA
Bureau of TennCare
Keith T. Hayashi
729 Church Street
Pharmacist I
Nashville, TN 37247-6501
Department of Medical Assistance Services
T: 615/532-3107
600 East Broad Street, Suite 1300
F: 615/253-5481
Richmond, VA 23219
E-mail: jeff.stockard@state.tn.us
T: 804/225-2773
F: 804/786-0973
E-mail: Keith.Hayashi@dmas.virginia.gov
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National Pharmaceutical Council Pharmaceutical Benefits 2004
WASHINGTON
Siri A. Childs, Pharm D.
Pharmacy Policy Manager
Medical Assistance Administration, DSHS
805 Plum Street, SE
P.O. Box 45506
Olympia, WA 98504-5506
T: 360/725-1564
F: 360/586-8827
E-mail: childsa@dshs.wa.gov
WEST VIRGINIA
Peggy A. King, R.Ph.
Director, Office of Pharmacy Services
Department of Health and Human Resources
Bureau for Medical Services
350 Capitol Street, Room 251
Charleston, WV 25301-3707
T: 304/558-1700
F: 304/558-1542
E-mail: pking@wvdhhr.org
WISCONSIN
Carol Neeno
Pharmacy Assistant
Division of Health Care Financing
Department of Health and Family Services
One West Wilson Street
P.O. Box 309
Madison, WI 53701-0309
T: 608/266-1203
F: 608/267-3380
E-mail: neenocj@dhfs.state.wi.us
WYOMING
Antoinette K. Brown, R.Ph.
Medicaid Pharmacist
Department of Health
Pharmacy Unit
2300 Capitol Avenue, Suite 147
Cheyenne, WY 82002
T: 307/777-6016
F: 307/777-8623
E-mail: abrown@state.wy.us
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National Pharmaceutical Council Pharmaceutical Benefits 2004
State Contact
Dave Campana, R.Ph.
Pharmacy Program Manager
Division of Health Care Services
ALASKA 4501 Business Park Blvd., Ste. 24
In-House DUR Anchorage, AK 99503
T: 907/334-2425
F: 907/561-1684
E-mail: david_campana@health.state.ak.us
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National Pharmaceutical Council Pharmaceutical Benefits 2004
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National Pharmaceutical Council Pharmaceutical Benefits 2004
State Contact
Patricia Zeigler Jeter, R.Ph., M.P.A.
DUR Coordinator-Rebate Pharmacist
Department of Community Health
GEORGIA Division of Medical Assistance
In-House DUR 2 Peachtree St. NW, 37th Floor
Atlanta, GA 30303-3159
T: 404/657-9181
F: 404/657-5461
E-mail: pjeter@dch.state.ga.us
State Contact
Kathleen Kang-Kaulupali
Pharmacy Consultant
Department of Human Services
HAWAII
Med-Quest Division
In-House DUR
601 Kamokila Boulevard, Room 506-B
Kapolei, HI 90707
T: 808/692-8065
F: 808/692-8131
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National Pharmaceutical Council Pharmaceutical Benefits 2004
State Contact
Pamela Bunch
Medicaid Pharmacy Manager
Illinois Department of Public Aid
ILLINOIS
201 S. Grand Avenue East
In-House DUR
Springfield, IL 62763
T: 217/524-7478
F: 217/524-7535
E-mail: pam.bunch@idpa.state.il.us
State Contact
Debra Bahr, R.Ph.
Pharmacy Services Program Manager
Department for Medicaid Services
KENTUCKY CHR Building, 6 W-A
In-House DUR 275 East Main Street
Frankfort, KY 40621
T: 502/564-7940
F: 502/564-0509
E-mail: Debra.Bahr@ky.gov.us
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National Pharmaceutical Council Pharmaceutical Benefits 2004
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National Pharmaceutical Council Pharmaceutical Benefits 2004
State Contact
Mary Beth Reinke, Pharm.D., M.S.A.
DUR Coordinator
Minnesota Dept. of Human Services
MINNESOTA
444 Lafayette Rd. North
In-House DUR
St. Paul, MN 55155-3853
T: 651/215-1239
F: 651/282-6744
E-mail: mary.beth.reinke@state.mn.us
State Contact
Tisha A. Pomering
DUR Coordinator
Div. of Medical Services
MISSOURI 2023 St. Mary’s Boulevard
In-House DUR P.O. Box 6500
Jefferson City, MO 65102-6500
T: 573/751-6961
F: 573/522-8514
E-mail: Tisha.A.Pomering@dss.mo.gov
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National Pharmaceutical Council Pharmaceutical Benefits 2004
State Contact
Kaye S. Morrow
Assistant Director
Department of Medical Assistance and
Human Services
NEW JERSEY
Office of Provider Relations
In-House DUR
P.O Box 712
Trenton, NJ 08619
T: 609/631-2396
F: 609/588-3889
E-mail: kaye.s.morrow@dhs.state.nj.us
State Contact
Neal Solomon, M.P.H., R. Ph.
Pharmacist
Human Services Department
NEW MEXICO Medical Assistance Division
In-House DUR P.O. Box 2348
Sante Fe, NM 87504-2348
T: 505/827-3174
F: 505/827-3196
E-mail: neal.solomon@state.nm.us
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National Pharmaceutical Council Pharmaceutical Benefits 2004
State Contact
Lydia J. Kosinski, R.Ph., Manager
Recipient Activities and Utilization Review
Office of Medicaid Management
NEW YORK NYS Dept. of Health
In-House DUR 800 North Pearl Street
Albany, NY 12204
T: 518/474-6866
F: 518/473-5332
E-mail: ljk02@health.state.ny.us
State Contact
Brendan K. Joyce, Pharm.D., R.Ph.
Administrator, Pharmacy Services
North Dakota Department of Human Services
NORTH DAKOTA
600 E. Boulevard Avenue, Dept. 325
In-House DUR
Bismarck, ND 58505-0250
T: 701/328-4023
F: 701/328-1544
E-mail: sojoyb@state.nd.us
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National Pharmaceutical Council Pharmaceutical Benefits 2004
State Contact
Teddi Martell
Rebate Coordinator
SOUTH DAKOTA Department of Social Services
In-House DUR 700 Governors Drive
Pierre, SD 57501
T: 605/773-3653
E-mail: Teddi.Martell@state.sd.us
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Within Federal and State guidelines, individual managed care and pharmacy benefit
management organizations make formulary/drug decisions.
State Contact
Barbara Dean, R.Ph.
Acting Director, Vendor Drug Program
Texas Health and Human Services
TEXAS Commision
In-House DUR 11209 Metric Boulevard, Building H
Austin, TX 78758
T: 512/491-1101
F: 512/491-1962
E-mail: Barbara.Dean@hhsc.state.tx.us
State Contact
Duane Parke
DUR Director
Medicaid Program
Division of Health Care Financing
UTAH
Department of Health
In-House DUR
P.O. Box 143102
Salt Lake City, UT 84114-3102
T: 801/538-6452
F: 801/538-6099
E-mail: dpark@utah.gov
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National Pharmaceutical Council Pharmaceutical Benefits 2004
State Contact
Nicole N. Nguyen, Pharm.D.
Clinical Pharmacist
Medical Assistance Administration, DSHS
WASHINGTON 805 Plum Street, SE
In-House DUR P.O. Box 45506
Olympia, WA 98504-5506
T: 360/725-1757
F: 360/586-8827
E-mail: nguyen@dshs.wa.gov
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National Pharmaceutical Council Pharmaceutical Benefits 2004
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National Pharmaceutical Council Pharmaceutical Benefits 2004
COLORADO
ALABAMA
ACS State Healthcare
Cyndi Crockett
600 17th Street
Supervisor
Suite 600 North
EDS
Denver, CO 80202
301 Technacenter Dr.
T: 800/237-0757
Montgomery, AL 36117
F: 303/534-0439
T: 334/215-0111
CONNECTICUT
ALASKA
Ellen Arce, R.Ph.
Dave Campana, R.Ph.
Pharmacy Manager
Pharmacy Program Manager
EDS
Division of Health Care Services
1000 Stanley Drive
4501 Business Park Blvd., Suite 24
New Britain, CT 06053
Anchorage, AK 99503
T: 860/832-5885
T: 907/334-2425
F: 860/832-5921
F: 901/561-1684
E-mail: ellen.arce@eds.com
E-mail: david_campana@health.state.ak.us
DELAWARE
ARIZONA
Cynthia R. Denemark, R.Ph.
Dell Swan
Director of Pharmacy Services
Pharmacy Program Administrator
DSS/EDS
AHCCCS
248 Chapman Rd, Suite 100
701 East Jefferson Street
Newark, DE 19702
MD 8000
T: 302/453-8453
Phoenix, AZ 85034
F: 302/454-0224
T: 612/417-4726
E-mail: Cynthia.denemark@eds.com
E-mail: dwswan@ahcccs.state.az.us
DISTRICT OF COLUMBIA
ARKANSAS
Jacqueline Bonner
John Herzog
Clinical Manager
Account Manager
First Health Services Corporation
EDS
4300 Cox Road
500 President Clinton Ave., Suite 400
Glen Allen, VA 23060
Little Rock, AR 72201
T: 800/884-2822
T: 501/374-6608
F: 804/273-6961
F: 501/372-2971
E-mail: bonner.ja@fhsc.com
E-mail: john.herzog@medicaid.state.ar.us
CALIFORNIA
EDS
P.O. Box 13029
Sacramento, CA 95813-4029
T: 916/636-1000
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National Pharmaceutical Council Pharmaceutical Benefits 2004
FLORIDA INDIANA
Kevin Whittington ACS State Healthcare
Clinical Program Coordinator 365 Northridge Rd., Suite 400
ACS State Healthcare Atlanta, GA 30350
9040 Roswell Road T: 866-322-5960
Roswell, GA F: 866/759-4100
T: 850/201-1418
IOWA
GEORGIA
Patrick Danlen
Mary K. Kruchten POS Account Manager
Senior Account Manager Iowa Medicaid Enterprise
Express Scripts, Inc. 100 Army Post Road
6625 W. 78th St., BL-0440 Des Moines, IA 50315
Bloomington, MN 55439 T: 515/725-1226
T: 952/837-7401 F: 515/725-1010
F: 952/837-7184
E-mail: kruchtem@express-scripts.com
KANSAS
EDS
HAWAII
3600 SW Topeka Boulevard
Becky Garrigan Suite 204
Account Manager Topeka, KS 66611
ACS State Healthcare T: 785/274-4200
365 Northridge Road, Suite 400 F: 785/267-7687
Atlanta, GA 30350
Attn: Hawaii Medicaid
KENTUCKY
T: 866/322-5960
F: 866/759-4100 Unisys Provider Services
P.O. Box 2106
Frankfort, KY 40602
IDAHO
T: 502/226-1140
EDS F: 502/226-1860
P.O. Box 23
Boise, ID 83707
LOUISIANA
T: 208/395-2000
F: 208/395-2030 Doug Hasty
Project Manager
Unisys
ILLINOIS
8591 United Plaza Blvd., Ste. 300
Illinois Dept. of Public Aid Baton Rouge, LA 70809
201 S. Grand Avenue East T: 225/237-3391
Springfield, IL 62763 F: 225/237-3334
T: 217/782-2570 E-mail: doug.hasty@unisys.com
F: 217/782-5672
E-mail: dpa_webmaster@state.il.us
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MAINE MISSISSIPPI
Marcia Pykare Robert Reedy, C.Ph.T.
Manager of Data Processing PBM Account Manager
Goold Health Systems ACS State Healthcare
P.O. Box 1090 385-B Highland Colony Parkway
Augusta, ME 04332-1090 Ridgeland, MS 39157
T: 207/622-7153 T: 601/296-2936
F: 207/623-5125 F: 601/296-3119
E-mail: movkare@ghsinc.com E-mail: robert.reedy@acs-inc.com
MARYLAND MISSOURI
James Demery Diane Twehous
Manager, Pharmacy Services Account Manager
First Health Services Corporation Infocrossing Health Care Services, Inc.
Division of Claims Processing 905 Weathered Rock Rd.
201 W. Preston St. Jefferson City, MO 65109
Baltimore, MD 21201 T: 573/635-2434
T: 401/767-6028
F: 410/333-5398 MONTANA
E-mail: demeryj@dhmh.state.md.us
Brett Jakovac
Executive Account Manager
MASSACHUSETTS
ACS State Healthcare
ACS State Healthcare 34 N. Last Chance Gulch, Suite 200
365 Northridge Road Helena, MT 59601
Northridge Center One, Suite 400 T: 406/457-9555
Atlanta, GA 30350 F: 406/442-2819
T: 800/358-2381 E-mail: brett.jakovac@acs-inc.com
F: 770/730-5198
NEBRASKA
MICHIGAN
Barbara Pavolony
First Health Services Corp. Account Manager
4300 Cox Rd. ACS State Healthcare
Glen Allen, VA 23060 365 Northridge Road
T: 877/864-9014 Northridge Center One, Suite 400
F: 888/603-7696 Atlanta, GA 30350
T: 770/352-8536
MINNESOTA F: 770/730-5198
E-mail: barbara.pavolony@acs-inc.com
Dwaine Voas
MMIS Unit Supervisor
NEVADA
Minnesota Dept. of Human Services
800 Minnehaha Avenue First Health Services Corp.
St. Paul, MN 51555 4300 Cox Road
Glen Allen, VA 23060
T: 800/884-3238
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TENNESSEE WASHINGTON
Maria P. Hogan Chris Johnson
Plan Administrator Claims Processing Manager
First Health Services Corporation Medical Assistance Administrator, DSHS
4300 Cox Road P.O. Box 45509
Glen Allen, VA 23060 Olympia, WA 98504-5509
T: 804/965-7400 T: 360/725-1239
E-mail: mphogan@fhsc.com E-mail: johnsc2@dshs.wa.gov
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WISCONSIN
Mark Gajewski
Account Director
EDS
6406 Bridge Road
Madison, WI 53784-0014
T: 608/221-4746
F: 608/221-4567
WYOMING
ACS State Healthcare
Northridge Center One, Suite 400
365 Northridge Road
Atlanta, GA 30350
T: 866/322-5960
F: 888/335-8459
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ARKANSAS
DISTRICT OF COLUMBIA
First DataBank
Christine Quinn
1111 Bayhill Drive, Suite 350
Account Manager
San Bruno, CA 94066
ACS State Healthcare
T: 650/588-5454
750 First Street, NE
F: 650/588-4003
Washingotn, DC 20002
T: 202/906-8304
CALIFORNIA F: 202/906-8378
EDS Federal Corporation E-mail: christine.quinn@acs-inc.com
P.O. Box 13029
Sacramento, CA 95813-4029
T: 916/636-1000
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FLORIDA INDIANA
First DataBank First DataBank
1111 Bayhill Drive, Suite 350 1111 Bayhill Drive, Suite 350
San Bruno, CA 94066 San Bruno, CA 94066
T: 650/588-5454 T: 650/588-5454
F: 650/827-4578 F: 650/588-4003
GEORGIA IOWA
Manny Conduah, Pharm.D. Patrick Danlen
Clinical Program Manager POS Account Manager
Express Scripts, Inc. Iowa Medicaid Enterprise
300 Colonial Center Parkway 100 Army Post Road
Roswell, GA 30076 Des Moines, IA 50315
T: 770/552-3793 T: 515/725-1226
F: 770/992-8949 F: 515/725-1010
E-mail: mconduah@express-scripts.com
KANSAS
HAWAII
Mary H. Obley
ACS State Healthcare Pharmacist
365 Northridge Road, Suite 400 Pharmacy Program Manager
Atlanta, GA 30350 Health Care Policy Division
Attn: Hawaii Medicaid Department of Social and Rehabilitation Services
T: 800/358-2381 Docking State Office Building
F: 770/730-5198 915 SW Harrison, Room 651-South
Topeka, KS 66612-1570
IDAHO T: 785/296-3981
F: 785/296-4813
Katie Ayad, C.Ph.T. E-mail: mho@srskansas.org
Technical Records II
Department of Health and Welfare
KENTUCKY
Division of Medicaid
3232 Elder Unisys Provider Services
Boise, ID 83705 P.O. Box 2106
T: 208/364-1970 Frankfort, KY 40602
F: 208/364-1864 T: 502/226-1140
E-mail: ayadk@idhw.state.id.us F: 502/226-1860
ILLINOIS LOUISIANA
First DataBank Maggie Vick
1111 Bayhill Drive, Suite 350 Unisys
San Bruno, CA 94066 8591 United Plaza Blvd., Ste. 300
T: 650/588-5454 Baton Rouge, LA 70809
F: 650/588-4003 T: 225/237-3251
F: 225/237-3334
E-mail: margaret.vick@unisys.com
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MAINE MISSISSIPPI
Bruce McClanahan Terri R. Kirby, R.Ph.
Pharmacy Unit Manager Pharmacist
Department of Human Services Division of Medicaid
Bureau of Medical Services Robert E. Lee Building
11 SHS, 442 Civic Center Drive 239 North Lamar St., Suite 801
Augusta, ME 04333 Jackson, MS 39201
T: 886/796-2463 T: 601/359-5253
F: 207/287-8601 F: 601/359-9555
E-mail: bruce.mcclanahan@maine.gov E-mail: phtrk@medicaid.state.ms.us
Internet address: www.maine.gov/bms
MISSOURI
MARYLAND
First DataBank
First DataBank 1111 Bayhill Drive, Suite 350
1111 Bayhill Drive, Suite 350 San Bruno, CA 94066
San Bruno, CA 94066 T: 650/588-5454
T: 415/588-5454 F: 650/827-4510
F: 415/827-4578
MONTANA
MASSACHUSETTS
First DataBank
First DataBank 1111 Bayhill Drive, Suite 350
1111 Bayhill Drive, Suite 350 San Bruno, CA 94066
San Bruno, CA 94066 T: 650/588-5454
T: 650/588-5454 F: 650/827-4578
F: 650/827-4578
NEBRASKA
MICHIGAN
Dyke Anderson, R.Ph.
First Health Services Corporation Pharmacy Consultant
4300 Cox Road Department of Health and Human Services
Glen Allen, VA 23060 Finance and Support/Medicaid Division
T: 877/864-9014 301 Centennial Mall South, 5th Floor-NSOB
F: 888/603-7696 P.O. Box 95026
Lincoln, NE 68509-5026
T: 402/471-9379
MINNESOTA
F: 402/471-9092
First DataBank E-mail: dyke.anderson@hhss.ne.gov
1111 Bay Hill Drive, Suite 350
San Bruno, CA 94066
NEVADA
T: 650/588-5454
F: 650/588-4003 First DataBank
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
T: 650/588-5454
F: 650/827-4578
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NEW HAMPSHIRE
Sherrill Bryant NORTH DAKOTA
Plan Administrator
Brendan K. Joyce, Pharm.D., R.Ph.
First Health Services Corp.
Administrator, Pharmacy Services
4300 Cox Road
North Dakota Department of Human Services
Glen Allen, VA 23060
600 East Boulevard Avenue
T: 800/884-2822
Dept. 325
F: 804/965-7647
Bismark, ND 58505-0250
E-mail: bryantsh@fhsc.com
T: 701/328-4023
F: 701/328-1544
NEW JERSEY E-mail: sojoyb.@state.nd.us
First DataBank
1111 Bayhill Drive, Suite 350 OHIO
San Bruno, CA 94066
First DataBank
T: 650/588-5454
1111 Bayhill Drive, Suite 350
F: 650/827-4578
San Bruno, CA 94066
T: 650/588-5454
NEW MEXICO F: 650/827-4578
First DataBank
1111 Bayhill Drive, Suite 350 OKLAHOMA
San Bruno, CA 94066
First DataBank
T: 800/633-3453
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
NEW YORK T: 800/633-3453
Carl T. Cioppa, Pharm.D.
Pharmacy Operations Manager OREGON
Department of Health
Jim Rowland
Office of Medicaid Management
Account Manager
99 Washington Avenue
First Health Sevices Corporation
Albany, NY 12210
925 Commercial Street SE
T: 518/474-9219
Salem, OR 97302
F: 518/473-5508
T: 503/391-1980
E-mail: ctc02@health.state.ny.us
F: 503/391-1979
E-mail: rowlanji@fhsc.com
NORTH CAROLINA
Tom D’Andrea, R.Ph., M.B.A. PENNSYLVANIA
Chief of Pharmacy and Ancillary Services
First DataBank, Inc.
Department of Health and Human Services
1111 Bayhill Drive, Suite 350
Division of Medical Assistance
San Bruno, CA 94066
1985 Umstead Drive
T: 800/633-3453
2501 Mail Service Center
Raleigh, NC 27699
T: 919/855-4300
F: 919/715-1255
E-mail: Tom.Dandrea@ncmail.net
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First DataBank
VERMONT
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066 Cathy England, Manager
T: 650/588-5454 Rebate Administration
F: 650/588-4003 First Health Services Corporation
4300 Cox Road
SOUTH DAKOTA Glen Allen, VA 23060
T: 804/965-7717
Mark E. Petersen, R.Ph.
Pharmacy Consultant
VIRGINIA
Department of Social Services
Office of Medical Services Keith T. Hayashi
700 Governors Drive Pharmacist I
Pierre, SD 57501 Department of Medical Assistance Services
T: 605/773-3498 600 East Broad Street, Suite 1300
F: 605/773-5246 Richmond, VA 23219
E-mail: Mark.Petersen@state.sd.us T: 804/225-2773
F: 804/786-0973
TENNESSEE E-mail: Keith.Hayashi@virginia.gov
First DataBank
WASHINGTON
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066 Tom Zuchlewski
T: 650/588-5454 Pharmacy Rates Manager
F: 650/588/6867 Medical Assistance Administration, DSHS
P.O. Box 45510
TEXAS Olympia, WA 98504-5510
T: 360/725-1837
Martha McNeill, R.Ph. F: 360/753-9152
Product and Prescriber Manager E-mail: zuchltm@dshs.wa.gov
Texas Health and Human Services Commission
11209 Metric Boulevard, Building H
Austin, TX 78758
T: 512/491-1157
F: 512/491-1961
E-mail: Martha.Mcneill@hhsc.state.tx.us
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WEST VIRGINIA
Heather Bodiford
PBM Account Manager
ACS State Healthcare
365 Northridge Road
Northridge Center, Suite 400
Atlanta, GA 30350
T: 866/322-5960
F: 770/730-5198
E-mail: Heather.Bodiford@acs-inc.com
WISCONSIN
First DataBank
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
T: 800/633-3453
F: 650/588-6867
WYOMING
First DataBank
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
T: 800/633-3453
F: 650/588-4003
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ALABAMA
CALIFORNIA
Cyndi Crocket, Supervisor
EDS Craig Miller
301 Technacenter Drive Chief, Drug Rebate and Vision Section
Montgomery, AL 36117 Department of Health Services
T: 334/215-0111 Medi-Cal Policy Division
Pharmacy Contracting and Policy Section
1501 Capitol Avenue
ALASKA
P.O. Box 997413, MS 4604
Amanda Burger Sacramento, CA 95814
Division of Medical Assistance T: 916/552-9500
4501 Business Park Blvd., Suite 24 F: 916/552-9563
Anchorage, AK 99503 E-mail: cmiller2@dhs.ca.gov
T: 907/334-2409
F: 907/561-1684
COLORADO
E-mail: amanda.burger@health.state.ak.us
Vince Sherry
Drug Rebate Manager
ARIZONA
Department of Health Care Policy and Financing
Dell Swan 1570 Grant Street
Pharmacy Program Administrator Denver, CO 80203
AHCCCS T: 303/866-5408
701 East Jefferson Street F: 303/866-2573
MD 8000 E-mail: vince.sherry@state.co.us
Phoenix, AZ 85034
T: 612/417-4726
CONNECTICUT
E-mail: dwswan@ahcccs.state.az.us
Afrika Hinds-Ayala
Health Program Associate
ARKANSAS
Department of Social Services
Suzette Bridges, P.D., Administrator Medical Operations Unit #4
Pharmacy Program 25 Sigourney Street
Department of Human Services Hartford, CT 06106-5033
Division of Medical Services T: 860/424-5150
Pharmacy Program F: 860/424-5206
P.O. Box 1437, Slot 415 E-mail: afrika.hinds-ayala@po.state.ct.us
Little Rock, AR 72203-1437
T: 501/683-4120
DELAWARE
F: 501/683-4124
E-mail: suzette.bridges@medicaid.state.ar.us Cynthia R. Denemark, R.Ph.
Director of Pharmacy Services
DSS/EDS
248 Chapman Road, Suite 100
Newark, DE 19702
T: 302/453-8453
F: 302/454-0224
E-mail: Cynthia.denemark@eds.com
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KANSAS MARYLAND
Mary H. Obley Barry Pope
Pharmacist Rebate Pharmacist
Pharmacy Program Manager First Health Services Corporation
Health Care Policy Division Montgomery Park Business Center
Dept. of Social and Rehabilitation Services 1800 Washington Boulevard, Suite 420
Docking State Office Building Baltimore, MD 21230
915 SW Harrison, Room 651-South T: 410/263-7048
Topeka, KS 66612-1570 F: 410/263-7062
T: 785/296-3981
F: 785/296-4813 MASSACHUSETTS
E-mail: mho@srskansas.org
Martha Kessenich
Rebate Analyst
KENTUCKY
ACS State Healthcare
Betsy Scott 365 Northridge Road, Suite 400
Department for Medicaid Services Atlanta, GA 30350
CHR Building, 6 E-B T: 800/358-2381
275 E. Main Street F: 770/730-5198
Frankfort, KY 40621 E-mail: martha.kessenich@acs-inc.com
T: 502/564-5472
F: 502/564-0223
MICHIGAN
E-mail: Betsy.Scott@ky.gov
Dawn Parsons
Pharmacy Consultant
LOUISIANA
MDCH/ Medical Services Administration
Timothy T. Williams 400 South Pine Street
Health Services Financing P.O. Box 30479
Program Director Lansing, MI 48909-7979
Department of Health and Hospitals T: 517/335-5181
1201 Capitol Access Road, 6th Floor F: 517/241-8135
P.O. Box 91030 E-mail: parsonsd@michigan.gov
Baton Rouge, LA 70821
T: 225/342-5194
F: 225/342-1980 MINNESOTA
E-mail: ttwilliams@dhh.la.gov Jarvis P. Jackson, R.Ph.
Drug Rebate Coordinator
Department of Human Services
MAINE 444 Lafayette Rd. North
Rossi Rowe St. Paul, MN 55155-3853
Insurance Recovery/ Drug Rebate Manager T: 651/282-5881
Department of Human Services F: 651/282-6744
Bureau of Medical Services E-mail: jarvisp.jackson@state.mn.us
11 SHS, 442 Civic Center Drive
Augusta, ME 04333
T: 207/287-1838
F: 207/287-1788
E-mail: rossi.rowe@maine.gov
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NEVADA
MISSISSIPPI
Dionne Coston, R.N.
Robert Reedy, C.Ph.T.
Medicaid Services Specialist
DRAMS Business Analyst
Nevada Medicaid Office
ACS State Healthcare
Pharmacy Program
385-B Highland Colony Parkway
1100 E. Williams Street
Ridgeland, MS 39157
Carson City, NV 89701
T: 601/206-2936
T: 775/684-3775
F: 601/206-3119
F: 775/684-3762
E-mail: robert.reedy@acs-inc.com
E-mail: dcpstpm@dhcfp.state.nv.us
MISSOURI
NEW HAMPHSHIRE
Vickie L. Harper
John Cox
Medicaid Unit Supervisor
Rebate Pharmacist
Division of Medical Services
First Health Services Corp.
Drug Rebate Unit
4300 Cox Road
2023 St. Mary’s Boulevard
Glen Allen, VA 23060
P.O. Box 6500
T: 800/884-2822
Jefferson City, MO 65102
F: 804/965-7647
T: 573/526-5664
E-mail: coxjo@fhsc.com
F: 573/522-4650
E-mail: Vicki.L.Harper@dss.mo.gov
NEW JERSEY
MONTANA Joseph B. Martinez, R.Ph.
Chief, Pharmaceutical Services
Betty DeVaney
Department of Medical Assistance and Human
Drug Rebate Coordinator
Services
Dept. of Public Health and Human Services
Office of Utilization Management
Medicaid Services Bureau
P.O. Box 712
1400 Broadway
Trenton, NJ 08619
P.O. Box 202951
T: 609/588-2774
Helena, MT 59620-2951
F: 609/588-3889
T: 406/444-3457
E-mail: joseph.b.martinez@dhs.state.nj.us
F: 406/444-1861
E-mail: bdevaney@state.mt.us
NEW MEXICO
NEBRASKA Sherry Montoya, Pharmacist
Human Services Department
Karen Jaques
Medical Assistance Division
Accountant II
P.O. Box 2348
HHSS-Finance and Support
Santa Fe, NM 87504-2348
301 Centennial Mall South
T: 505/827-7777
NSOB, 5th Floor
F: 505/827-3196
P.O. Box 95026
E-mail: sherry.montoya@state.nm.us
Lincoln, NE 68509-5026
F: 402/471-9397
E-mail: karen.jaques@hhss.ne.gov
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UTAH WISCONSIN
Raedell Ashley, R.Ph. Ellen Orsburne
Pharmacy Director Medicaid Systems Analyst
Medicaid Program Division of Health Care Financing
Division of Health Care Financing Department of Health and Family Services
P.O. Box 143102 One West Wilson Street
Salt Lake City, UT 84114-3102 P.O. Box 309
T: 801/538-6495 Madison, WI 53701-0309
F: 801/538-6099 T: 608/267-7939
E-mail: rashley@utah.gov E-mail: orsbuer@dhfs.state.wi.us
VERMONT WYOMING
Christine Dapkiewicz Sheila McInerney
Drug Rebate Coordinator TPL Manager
EDS ACS State Healthcare
312 Hurricane Lane, Suite 100 P.O. Box 667
Williston, VT 05495 Cheyenne, WY 82003
T: 802/879-4450 T: 307/772-8400
F: 802/878-3440 F: 307/772-8405
E-mail: sheila.mcinerney@acs-inc.com
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WYOMING
Governor
Honorable Dave Freudenthal
State Capitol, Room 124
Cheyenne, WY 82002-0010
T: 307/777-7434
F: 307/632-3909
E-mail:
governor@missc.state.wy.us
Internet address: www.state.wy.us
Medicaid Director
Ms. Iris Oleske,
State Medicaid Agent
Department of Health
147 Hathaway Building
Cheyenne, WY 82002
T: 307/777-7531
F: 307/777-6964
E-mail: iolesk@state.wy.us
Internet address: wdhfs.state.wy.us
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Source: CMS, Central Office, Centers for Medicaid and State Operations, as of April 2005.
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Source: CMS Website at www.cms.hhs.gov/states/natreps.pdf Central Office CMSO staff: Information as of April 2005.
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Appendix B:
Medicaid Program Statistics -
CMS MSIS Tables
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The CMS MSIS Report is an annual report designed to collect State-reported statistical summary data
on eligibles, recipients, services, and expenditures during a Federal fiscal year (i.e., October l through
September 30). The data reported for a given year represent recipients of service and the amount of
payments for claims adjudicated during the year. The data reflect bills adjudicated during the year
rather than the services used during the year.
Historically, States summarized and reported the data processed through their Medicaid claims
processing and payment operations unless they opted to participate in the Medicaid Statistical
Information System (MSIS) project. Prior to Federal fiscal year 1999, MSIS was a voluntary
program and those States participating in the MSIS project provide data tapes from their claims
processing systems to HCFA in lieu of HCFA-2082 tables. However, in accordance with the
Balanced Budget Act of 1997, all claims processed on or after January 1, 1999, must be submitted
electronically in the MSIS format.
The MSIS Report is the primary CMS source on recipients’ use of services and the associated
payments for these services. However, the new reporting requirements have resulted in a lag in the
timely release of MSIS summary tables. The most recent MSIS service utilization information
available from CMS is for FY 2002. In addition, Puerto Rico and the U.S. territories have been
excluded from the tables and the National totals.
In an effort to provide more recent recipient information as well as to maintain continuity with
previous version of the Compilation, we have compiled ten tables from the MSIS data system for
inclusion in this Appendix. The first two tables provide national level summary information on total
expenditures and total number of recipients by type of service for FY 2001 and FY 2002. The
remaining tables present State-by-State and national level data, including some trend information, on
total Medicaid recipients, total Medicaid payments, number of prescription drug recipients, and
Medicaid prescription drug payments. Additionally, there are three tables at the end of the Appendix
that correspond to FY 2002 tables presented in Section 2.
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*Sum of percentages will exceed 100% due to recipients' use of multiple services. Puerto Rico and the U.S. Territories are not included in these
national totals.
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*Sum of percentages will exceed 100% due to recipients' use of multiple services. Puerto Rico and the U.S. Territories are not included in these
national totals.
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State Total Drug Payments Total Drug Recipients Drug Payments Per Recipient
National Total $28,408,181,719 24,424,493 $1,163
Alabama $454,370,478 500,789 $907
Alaska $83,324,085 70,550 $1,181
Arizona $4,338,712 7,805 $556
Arkansas $279,644,642 356,233 $785
California $3,402,508,001 2,651,229 $1,283
Colorado $202,286,461 153,520 $1,318
Connecticut $356,980,484 123,704 $2,886
Delaware $100,112,623 125,461 $798
District of Columbia $68,050,981 45,216 $1,505
Florida $1,736,991,594 1,245,841 $1,394
Georgia $749,552,199 1,076,904 $696
Hawaii $81,453,811 39,320 $2,072
Idaho $121,780,793 125,537 $970
Illinois $1,222,947,241 1,199,933 $1,019
Indiana $636,357,519 490,386 $1,298
Iowa $277,753,942 245,711 $1,130
Kansas $220,800,602 157,618 $1,401
Kentucky $661,409,737 489,416 $1,351
Louisiana $682,557,080 689,973 $989
Maine $250,331,526 224,664 $1,114
Maryland $320,313,995 181,101 $1,769
Massachusetts $952,790,939 659,626 $1,444
Michigan $674,898,273 577,785 $1,168
Minnesota $294,838,630 190,577 $1,547
Mississippi $568,084,274 526,923 $1,078
Missouri $799,910,014 493,230 $1,622
Montana $77,980,883 67,365 $1,158
Nebraska $196,526,107 194,889 $1,008
Nevada $90,134,969 71,950 $1,253
New Hampshire $98,836,636 78,861 $1,253
New Jersey $686,301,522 296,059 $2,318
New Mexico $92,674,018 122,098 $759
New York $3,413,404,507 2,567,595 $1,329
North Carolina $1,069,140,895 949,795 $1,126
North Dakota $51,749,961 44,428 $1,165
Ohio $1,330,569,382 997,246 $1,334
Oklahoma $267,549,002 276,111 $969
Oregon $269,936,847 242,865 $1,111
Pennsylvania $719,243,402 464,848 $1,547
Rhode Island $126,331,040 53,729 $2,351
South Carolina $456,976,916 576,136 $793
South Dakota $63,654,623 64,948 $980
Tennessee $573,588,021 916,968 $626
Texas $1,591,828,224 2,153,316 $739
Utah $140,520,420 152,268 $923
Vermont $115,623,970 112,227 $1,030
Virginia $453,663,058 319,196 $1,421
Washington $549,216,380 423,758 $1,296
West Virginia $274,613,136 276,338 $994
Wisconsin $455,720,622 309,795 $1,471
Wyoming $38,008,542 42,652 $891
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*Hawaii did not report on time for FY 1997 and FY 1999 and was excluded from the national totals for those years. Hawaii also did not report
for FY 2000. CMS included their FY 1999 data in the FY 2000 MSIS Report. Oklahoma did not report for FY 1998 and was excluded from the
national total for that year.
Source: CMS, HCFA-2082 Reports, FY 1996 - FY 1998 and MSIS Reports, FY 1999 – FY 2002.
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Note: Recipients are defined as individuals who received drugs, not as everyone eligible to receive drugs.
*Hawaii did not report on time for FY 1997. They are excluded from the national total for that year. Oklahoma did not report for FY 1998. They are
excluded from the national total for that year.
^Until 2002, Tennessee did not report drug recipients because beneficiaries are enrolled in managed care & receive pharmaceutical benefits through these
plans.
Source: CMS, HCFA-2082 Report, FY 1996 - FY1998 and MSIS Report, FY 1999 – FY 2002.
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Note: Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year.
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Note: Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year.
Source: U.S. Department of Commerce, Bureau of the Census, 2003; CMS, MSIS Report, FY 2002.
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Note: Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year.
Source: CMS, CMS-64 Report, FY 2002 and CMS-MSIS Report, 2002.
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Appendix C:
Medicaid Rebate Law
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(1) In general
In order for payment to be available under section 1396b(a) of this title or under part B of title XVIII
for covered outpatient drugs of a manufacturer, the manufacturer must have entered into and have in
effect a rebate agreement described in subsection (b) of this section with the Secretary, on behalf of
States (except that, the Secretary may authorize a State to enter directly into agreements with a
manufacturer), and must meet the requirements of paragraph (5)(with respect to drugs purchased by a
covered entity on or after the first day of the first month that begins after November 4, 1992) and
paragraph (6). Any agreement between a State and a manufacturer prior to April 1, 1991, shall be
deemed to have been entered into on January 1, 1991, and payment to such manufacturer shall be
retroactively calculated as if the agreement between the manufacturer and the State had been entered
into on January 1, 1991. If a manufacturer has not entered into such an agreement before March 1,
1991, such an agreement, subsequently entered into, shall become effective as of the date on which the
agreement is entered into or, at State option, on any date thereafter on or before the first day of the
calendar quarter that begins more than 60 days after the date of the agreement is entered into.
(3) Authorizing payment for drugs not covered under rebate agreements
Paragraph (1), and section 1396b(i)(10)(A) of this title, shall not apply to the dispensing of a single
source drug or innovator multiple source drug if (A)(i) the State has made a determination that the
availability of the drug is essential to the health of beneficiaries under the State Plan for medical
assistance; (ii) such drug has been given a rating of 1-A by the Food and Drug Administration; and
(iii)(I) the physician has obtained approval for use of the drug in advance of its dispensing in
accordance with a prior authorization program described in subsection (d) of this section, or (II) the
Secretary has reviewed and approved the State’s determination under subparagraph (A); or (B) the
Secretary determines that in the first calendar quarter of 1991, there were extenuating circumstances.
1
This is section 1927 of the Social Security Act. It is codified as Section 1396r-8 of Title 42 of the United States Code.
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A manufacturer meets the requirements of this paragraph if the manufacturer has entered into
an agreement with the Secretary that meets the requirements of section 256b of this title with
respect to covered outpatient drugs purchased by a covered entity on or after the first day of
the first month that begins after November 4, 1992.
(6) Requirements relating to master agreements for drugs procured by Department of Veterans Affairs
and certain other Federal agencies
(A) In general
A manufacturer meets the requirements of this paragraph if the manufacturer complies with
the provisions of section 8126 of title 38, including the requirement of entering into a master
agreement with the Secretary of Veterans Affairs under such section.
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after November 4, 1992) and would have entered into an agreement under such section (as
such section was in effect at such time), but for a legislative change in such section after
November 4, 1992.
(A) In general
A rebate agreement under this subsection shall require the manufacturer to provide, to each
State Plan approved under this subchapter, a rebate for a rebate period in an amount specified
in subsection (c) of this section for covered outpatient drugs of the manufacturer dispensed
after December 31, 1990, for which payment was made under the State Plan for such period.
Such rebate shall be paid by the manufacturer not later than 30 days after the date of receipt of
the information described in paragraph (2) for the period involved.
(B) Audits
A manufacturer may audit the information provided (or required to be provided) under
subparagraph (A). Adjustments to rebates shall be made to the extent that information
indicates that utilization was greater or less than the amount previously specified.
(A) In general. -- Each manufacturer with an agreement in effect under this section shall report
to the Secretary –
(i) not later than 30 days after the last day of each rebate period under the agreement
(beginning on or after January 1, 1991), on the average manufacturer price (as defined in
subsection (k)(1) of this section) and, (for single source drugs and innovator multiple source
drugs), the manufacturer’s best price (as defined in subsection (c)(2)(B) of this section) for
covered outpatient drugs for the rebate period under the agreement;
(ii) not later than 30 days after the date of entering into an agreement under this section on
the average manufacturer price (as defined in subsection (k)(1) of this section) as of October
1, 1990 for each of the manufacturer’s covered outpatient drugs; and
(iii) for calendar quarters beginning on or after January 1, 2004, in conjunction with
reporting required under clause (i) and by National Drug Code (including package size)—
(I) the manufacturer’s average sales price (as defined in section 1847A(c)) and the
total number of units specified under section 1847A(b)(2)(A);
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(II) if required to make payment under section 1847A, the manufacturer’s wholesale
acquisition cost, as defined in subsection (c)(6) of such section; and
(III) information on those sales that were made at a nominal price or otherwise
described in section 1847A(c)(2)(B);
for a drug or biological described in subparagraph (C), (D), (E), or (G) of section 1842 (o)(1)
or section 1881(b)(13)(A)(ii).
Information reported under this subparagraph is subject to audit by the Inspector General of
the Department of Health and Human Services.
(B) Verification surveys of average manufacturer price and manufacturer’s average sales price
The Secretary may survey wholesalers and manufacturers that directly distribute their covered
outpatient drugs, when necessary, to verify manufacturer prices and manufacturer’s average
sales prices (including wholesale acquisition cost) if required to make payment reported under
subparagraph (A). The Secretary may impose a civil monetary penalty in an amount not to
exceed $100,000 on a wholesaler, manufacturer, or direct seller, if the wholesaler,
manufacturer, or direct seller of a covered outpatient drug refuses a request for information
about charges or prices by the Secretary in connection with a survey under this subparagraph
or knowingly provides false information. The provisions of section 1320a-7a of this title
(other than subsections (a) (with respect to amounts of penalties or additional assessments)
and (b)) shall apply to a civil money penalty under this subparagraph in the same manner as
such provisions apply to a penalty or proceeding under section 1320a-7a(a) of this title.
(C) Penalties
(i) Failure to provide timely information
In the case of a manufacturer with an agreement under this section that fails to provide
information required under subparagraph (A) on a timely basis, the amount of the penalty
shall be increased by $10,000 for each day in which such information has not been
provided and such amount shall be paid to the Treasury, and, if such information is not
reported within 90 days of the deadline imposed, the agreement shall be suspended for
services furnished after the end of such 90-day period and until the date such information
is reported (but in no case shall such suspension be for a period of less than 30 days).
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(ii) to permit the Comptroller General to review the information provided, and
(iii) to permit the Director of the Congressional Budget Office to review the information
provided.
The previous sentence shall also apply to information disclosed under section 1860D-2(d)(2)
or 1860D-4(c)(2)(E) and drug pricing data reported under the first sentence of section 1860D-
31(i)(1).
(A) In general
A rebate agreement shall be effective for an initial period of not less than 1 year and shall be
automatically renewed for a period of not less than one year unless terminated under
subparagraph (B).
(B) Termination
(i) By the Secretary
The Secretary may provide for termination of a rebate agreement for violation of the
requirements of the agreement or other good cause shown. Such termination shall not be
effective earlier than 60 days after the date of notice of such termination. The Secretary
shall provide, upon request, a manufacturer with a hearing concerning such a termination,
but such hearing shall not delay the effective date of the termination.
(ii) By a manufacturer
A manufacturer may terminate a rebate agreement under this section for any reason. Any
such termination shall not be effective until the calendar quarter beginning at least 60 days
after the date the manufacturer provides notice to the Secretary.
(iii) Effectiveness of termination
Any termination under this subparagraph shall not affect rebates due under the agreement
before the effective date of its termination.
(iv) Notice to States
In the case of a termination under this subparagraph, the Secretary shall provide notice of
such termination to the States within not less than 30 days before the effective date of such
termination.
(v) Application to terminations of other agreements
The provisions of this subparagraph shall apply to the terminations of agreements described
in section 256b(a)(1) of this title and master agreements described in section 8126(a) of title
38.
(c) In the case of any rebate agreement with a manufacturer under this section which is terminated,
another such agreement with the manufacturer (or a successor manufacturer) may not be entered
into until a period of 1 calendar quarter has elapsed since the date of the termination, unless the
Secretary finds good cause for an earlier reinstatement of such an agreement.
(1) Basic rebate for single source drugs and innovator multiple source drugs
(A) In general
Except as provided in paragraph (2), the amount of the rebate specified in this subsection for a
rebate period (as defined in subsection (k)(8) of this section) with respect to each dosage form
and strength of a single source drug or an innovator multiple source drug shall be equal to the
product of -
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(i) the total number of units of each dosage form and strength paid for under the State Plan
in the rebate period (as reported by the State); and
(ii) subject to subparagraph (B)(ii), the greater of -
(I) the difference between the average manufacturer price and the best price (as defined
in subparagraph (C)) for the dosage form and strength of the drug, or
(II) the minimum rebate percentage (specified in subparagraph (B)(i)) of such average
manufacturer price, for the rebate period.
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(III) shall not take into account prices that are merely nominal in amount.
(iii) Application of auditing and recordkeeping requirements
With respect to a covered entity described in section 340B(a)(4)(L) of the Public Health
Service Act, any drug purchased for inpatient use shall be subject to the auditing and
recordkeeping requirements described in section 340B(a)(5)(C) of the Public Health
Service Act.
(2) Additional rebate for single source and innovator multiple source drugs
(A) In general
The amount of the rebate specified in this subsection for a rebate period, with respect to each
dosage form and strength of a single source drug or an innovator multiple source drug, shall be
increased by an amount equal to the product of -
(i) the total number of units of such dosage form and strength dispensed after December 31,
1990, for which payment was made under the State Plan for the rebate period; and
(ii) the amount (if any) by which -
(I) the average manufacturer price for the dosage form and strength of the drug for the
period, exceeds
(II) the average manufacturer price for such dosage form and strength for the calendar
quarter beginning July 1, 1990 (without regard to whether or not the drug has been sold
or transferred to an entity, including a division or subsidiary of the manufacturer, after
the first day of such quarter), increased by the percentage by which the consumer price
index for all urban consumers (United States city average) for the month before the
month in which the rebate period begins exceeds such index for September 1990.
.
(B) Treatment of subsequently approved drugs
In the case of a covered outpatient drug approved by the Food and Drug Administration after
October 1, 1990, clause (ii)(II) of subparagraph (A) shall be applied by substituting “the first
full calendar quarter after the day on which the drug was first marketed” for “the calendar
quarter beginning July 1, 1990” and “the month prior to the first month of the first full
calendar quarter after the day on which the drug was first marketed” for “September 1990.”
(A) In general
The amount of the rebate paid to a State for a rebate period with respect to each dosage form
and strength of covered outpatient drugs (other than single source drugs and innovator
multiple source drugs) shall be equal to the product of -
(i) the applicable percentage (as described in subparagraph (B)) of the average
manufacturer price for the dosage form and strength for the rebate period, and
(ii) the total number of units of such dosage form and strength dispensed after December
31, 1990, for which payment was made under the State Plan for the rebate period.
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(A) A State may subject to prior authorization any covered outpatient drug. Any such prior
authorization program shall comply with the requirements of paragraph (5).
(B) A State may exclude or otherwise restrict coverage of a covered outpatient drug if -
(i) the prescribed use is not for a medically accepted indication (as defined in subsection
(k)(6) of this section);
(ii) the drug is contained in the list referred to in paragraph (2);
(iii) the drug is subject to such restrictions pursuant to an agreement between a
manufacturer and a State authorized by the Secretary under subsection (a)(1) of this section
or in effect pursuant to subsection (a)(4) of this section; or
(iv) the State has excluded coverage of the drug from its formulary established in
accordance with paragraph (4).
(A) Agents when used for anorexia, weight loss, or weight gain.
(B) Agents when used to promote fertility.
(C) Agents when used for cosmetic purposes or hair growth.
(D) Agents when used for the symptomatic relief of cough and colds.
(E) Agents when used to promote smoking cessation.
(F) Prescription vitamins and mineral products, except prenatal vitamins and fluoride
preparations.
(G) Nonprescription drugs.
(H) Covered outpatient drugs which the manufacturer seeks to require as a condition of sale
that associated tests or monitoring services be purchased exclusively from the manufacturer or
its designee.
(I) Barbiturates.
(J) Benzodiazepines.
(B) Except as provided in subparagraph (C), the formulary includes the covered outpatient
drugs of any manufacturer which has entered into and complies with an agreement under
subsection (a) of this section (other than any drug excluded from coverage or otherwise
restricted under paragraph (2)).
(C) A covered outpatient drug may be excluded with respect to the treatment of a specific
disease or condition for an identified population (if any) only if, based on the drug’s labeling
(or, in the case of a drug the prescribed use of which is not approved under the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 301 et seq.) but is a medically accepted indication, based
on information from the appropriate compendia described in subsection (k)(6) of this section),
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the excluded drug does not have a significant, clinically meaningful therapeutic advantage in
terms of safety, effectiveness, or clinical outcome of such treatment for such population over
other drugs included in the formulary and there is a written explanation (available to the
public) of the basis for the exclusion.
(D) The State Plan permits coverage of a drug excluded from the formulary (other than any
drug excluded from coverage or otherwise restricted under paragraph (2)) pursuant to a prior
authorization program that is consistent with paragraph (5).
(E) The formulary meets such other requirements as the Secretary may impose in order to
achieve program savings consistent with protecting the health of program beneficiaries. A
prior authorization program established by a State under paragraph (5) is not a formulary
subject to the requirements of this paragraph.
(B) except with respect to the drugs on the list referred to in paragraph (2), provides for the
dispensing of at least 72-hour supply of a covered outpatient prescription drug in an
emergency situation (as defined by the Secretary).
(1) In general
During the period beginning on January 1, 1991, and ending on
December 31, 1994 –
(A) a State may not reduce the payment limits established by regulation under this subchapter
or any limitation described in paragraph (3) with respect to the ingredient cost of a covered
outpatient drug or the dispensing fee for such a drug below the limits in effect as of January 1,
1991, and
(B) except as provided in paragraph (2), the Secretary may not modify by regulation the
formula established under sections 447.331 through 447.334 of title 42, Code of Federal
Regulations, in effect on November 5, 1990, to reduce the limits described in subparagraph
(A).
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(1) In general
(A) In order to meet the requirement of section 1396b(i)(10)(B) of this title, a State shall
provide, by not later than January 1, 1993, for a drug use review program described in
paragraph (2) for covered outpatient drugs in order to assure that prescriptions (i) are
appropriate, (ii) are medically necessary, and (iii) are not likely to result in adverse medical
results. The program shall be designed to educate physicians and pharmacists to identify and
reduce the frequency of patterns of fraud, abuse, gross overuse, or inappropriate or medically
unnecessary care, among physicians, pharmacists, and patients, or associated with specific
drugs or groups of drugs, as well as potential and actual severe adverse reactions to drugs
including education on therapeutic appropriateness, overutilization and underutilization,
appropriate use of generic products, therapeutic duplication, drug-disease contraindications,
drug-drug interactions, incorrect drug dosage or duration of drug treatment, drug-allergy
interactions, and clinical abuse/misuse.
(B) The program shall assess data on drug use against predetermined standards, consistent
with the following:
(i) compendia which shall consist of the following:
(I) American Hospital Formulary Service Drug Information;
(II) United States Pharmacopeia-Drug Information; and
(III) the DRUGDex information System.
(ii) the peer-reviewed medical literature.
(C) The Secretary, under the procedures established in section 1396b of this title, shall pay to
each State an amount equal to 75 per centum of so much of the sums expended by the State
Plan during calendar years 1991 through 1993 as the Secretary determines is attributable to the
statewide adoption of a drug use review program which conforms to the requirements of this
subsection.
(D) States shall not be required to perform additional drug use reviews with respect to drugs
dispensed to residents of nursing facilities which are in compliance with the drug regimen
review procedures prescribed by the Secretary for such facilities in regulations implementing
section 1396r of this title, currently at section 483.60 of title 42, Code of Federal Regulations.
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(A) Establishment
Each State shall provide for the establishment of a drug use review board (hereinafter referred
to as the “DUR Board”) either directly or through a contract with a private organization.
(B) Membership
The membership of the DUR Board shall include health care professionals who have
recognized knowledge and expertise in one or more of the following:
(i) The clinically appropriate prescribing of covered outpatient drugs.
(ii) The clinically appropriate dispensing and monitoring of covered outpatient drugs.
(iii) Drug use review, evaluation, and intervention.
(iv) Medical quality assurance.
The membership of the DUR Board shall be made up at least 1/3 but no more than 51
percent licensed and actively practicing physicians and at least 1/3 licensed and actively
practicing pharmacists.
(C) Activities
The activities of the DUR Board shall include but not be limited to the following:
(i) Retrospective DUR as defined in section.
(ii) Application of standards as defined in paragraph (2)(C).
(iii) Ongoing interventions for physicians and pharmacists, targeted toward therapy
problems or individuals identified in the course of retrospective drug use reviews
performed under this subsection. Intervention programs shall include, in appropriate
instances, at least:
(I) information dissemination sufficient to ensure the ready availability to physicians and
pharmacists in the State of information concerning its duties, powers, and basis for its
standards;
(II) written, oral, or electronic reminders containing patient-specific or drug-specific (or
both) information and suggested changes in prescribing or dispensing practices,
communicated in a manner designed to ensure the privacy of patient-related information;
(III) use of face-to-face discussions between health care professionals who are experts in
rational drug therapy and selected prescribers and pharmacists who have been targeted
for educational intervention, including discussion of optimal prescribing, dispensing, or
pharmacy care practices, and follow-up face-to-face discussions; and
(IV) intensified review or monitoring of selected prescribers or dispensers. The Board
shall re-evaluate interventions after an appropriate period of time to determine if the
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intervention improved the quality of drug therapy, to evaluate the success of the
interventions and make modifications as necessary.
(1) In general
In accordance with chapter 35 of title 44 (relating to coordination of Federal information policy), the
Secretary shall encourage each State agency to establish, as its principal means of processing claims
for covered outpatient drugs under this subchapter, a point-of-sale electronic claims management
system, for the purpose of performing on-line, real time eligibility verifications, claims data capture,
adjudication of claims, and assisting pharmacists (and other authorized persons) in applying for and
receiving payment.
(2) Encouragement
In order to carry out paragraph (1) -
(A) for calendar quarters during fiscal years 1991 and 1992, expenditures under the State Plan
attributable to development of a system described in paragraph (1) shall receive Federal
financial participation under section 1396b(a)(3)(A)(i) of this title (at a matching rate of 90
percent) if the State acquires, through applicable competitive procurement process in the State,
the most cost-effective telecommunications network and automatic data processing services
and equipment; and
(B) the Secretary may permit, in the procurement described in subparagraph (A) in the
application of part 433 of title 42, Code of Federal Regulations, and parts 95, 205, and 307 of
title 45, Code of Federal Regulations, the substitution of the State’s request for proposal in
competitive procurement for advance planning and implementation documents otherwise
required.
(1) In general
Not later than May 1 of each year the Secretary shall transmit to the Committee on Finance of the
Senate, the Committee on Energy and Commerce of the House of Representatives, and the
Committees on Aging of the Senate and the House of Representatives a report on the operation of this
section in the preceding fiscal year.
(2) Details
Each report shall include information on –
(A) ingredient costs paid under this subchapter for single source drugs, multiple source drugs,
and nonprescription covered outpatient drugs;
(B) the total value of rebates received and number of manufacturers providing such rebates;
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(C) how the size of such rebates compare with the size of rebates offered to other purchasers
of covered outpatient drugs;
(D) the effect of inflation on the value of rebates required under this section;
(E) trends in prices paid under this subchapter for covered outpatient drugs; and
(F) Federal and State administrative costs associated with compliance with the provisions of
this subchapter.
(1) Covered outpatient drugs dispensed by health maintenance organizations, including Medicaid
managed care organizations that contract under section 1396b(m) of this title, are not subject to the
requirements of this section.
(2) The State Plan shall provide that a hospital (providing medical assistance under such Plan) that
dispenses covered outpatient drugs using drug formulary systems, and bills the Plan no more than the
hospital’s purchasing costs for covered outpatient drugs (as determined under the State Plan) shall not
be subject to the requirements of this section.
(3) Nothing in this subsection shall be construed as providing that amounts for covered outpatient
drugs paid by the institutions described in this subsection should not be taken into account for
purposes of determining the best price as described in subsection (c) of this section.
(k) Definitions
In this section -
(A) of those drugs which are treated as prescribed drugs for purposes of section 1396d(a)(12)
of this title, a drug which may be dispensed only upon prescription (except as provided in
paragraph (5)), and -
(i) which is approved for safety and effectiveness as a prescription drug under section 505
or 507 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355, 357) or which is
approved under section 505(j) of such Act (21 U.S.C. 355(j));
(ii)(I) which was commercially used or sold in the United States before October 10, 1962,
or which is identical, similar, or related (within the meaning of section 310.6(b)(1) of title
21 of the Code of Federal Regulations) to such a drug, and (II) which has not been the
subject of a final determination by the Secretary that it is a “new drug” (within the meaning
of section 201(p) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 321(p))) or an
action brought by the Secretary under section 301, 302(a), or 304(a) of such Act (21 U.S.C.
331, 332(a), 334(a)) to enforce section 502(f) or 505(a) of such Act (21 U.S.C. 352(f),
355(a)); or
(iii)(I) which is described in section 107(c)(3) of the Drug Amendments of 1962 and for
which the Secretary has determined there is a compelling justification for its medical need,
or is identical, similar, or related (within the meaning of section 310.6(b)(1) of title 21 of
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the Code of Federal Regulations) to such a drug, and (II) for which the Secretary has not
issued a notice of an opportunity for a hearing under section 505(e) of the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 355(e)) on a proposed order of the Secretary to
withdraw approval of an application for such drug under such section because the Secretary
has determined that the drug is less than effective for some or all conditions of use
prescribed, recommended, or suggested in its labeling; and
(C) insulin certified under section 506 of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 356).
(C) Dental services, except that drugs for which the State Plan authorizes direct
reimbursement to the dispensing dentist are covered outpatient drugs.
(F) Nursing facility services and services provided by an intermediate care facility for the
mentally retarded.
(5) Manufacturer
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(7) Multiple source drug; innovator multiple source drug; noninnovator multiple source drug; single
source drug
(A) Defined
(i) Multiple source drug
The term “multiple source drug” means, with respect to a rebate period, a covered
outpatient drug (not including any drug described in paragraph (5)) for which there are 2 or
more drug products which -
(I) are rated as therapeutically equivalent (under the Food and Drug Administration’s
most recent publication of “Approved Drug Products with Therapeutic Equivalence
Evaluations”),
(II) except as provided in subparagraph (B), are pharmaceutically equivalent and
bioequivalent, as defined in subparagraph (C) and as determined by the Food and Drug
Administration, and
(III) are sold or marketed in the State during the period.
(ii) Innovator multiple source drug The term “innovator multiple source drug” means a
multiple source drug that was originally marketed under an original new drug application
approved by the Food and Drug Administration.
(iii) Noninnovator multiple source drug
The term “noninnovator multiple source drug” means a multiple source drug that is not an
innovator multiple source drug.
(iv) Single source drug
The term “single source drug” means a covered outpatient drug which is produced or
distributed under an original new drug application approved by the Food and Drug
Administration, including a drug product marketed by any cross-licensed producers or
distributors operating under the new drug application.
(B) Exception
Subparagraph (A)(i)(II) shall not apply if the Food and Drug Administration changes by
regulation the requirement that, for purposes of the publication described in subparagraph
(A)(i)(I), in order for drug products to be rated as therapeutically equivalent, they must be
pharmaceutically equivalent and bioequivalent, as defined in subparagraph (C).
(C) Definitions
For purposes of this paragraph -
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(i) drug products are pharmaceutically equivalent if the products contain identical amounts
of the same active drug ingredient in the same dosage form and meet compendial or other
applicable standards of strength, quality, purity, and identity;
So in original. Probably should be “pharmaceutically”.
(ii) drugs are bioequivalent if they do not present a known or potential bioequivalence
problem, or, if they do present such a problem, they are shown to meet an appropriate
standard of bioequivalence; and
(iii) a drug product is considered to be sold or marketed in a State if it appears in a
published national listing of average wholesale prices selected by the Secretary, provided
that the listed product is generally available to the public through retail pharmacies in that
State.
C-19
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C-20
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Appendix D:
Federal Upper Limits for
Multiple Source Products
D-1
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D-2
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The following list of multiple source drugs meets the criteria set forth in 42 CFR 447.332 and
§1927(e) of the Social Security Act, as amended by OBRA 1993. The development of the current
Federal Upper Limit (FUL) listing has been accomplished by computer. Payments for multiple source
drugs identified and listed in the accompanying addendum must not exceed, in the aggregate, payment
levels determined by applying to each drug entity a reasonable dispensing fee (established by the State
and specified in the State Plan), plus an amount based on the limit per unit which CMS has determined
to be equal to a 150 percent applied to the lowest price listed (in package sizes of 100 units, unless
otherwise noted) in any of the published compendia of cost information of drugs. Issued by CMS on
November 20, 2001 the initial listing was based on data current as of April 2001 from the First Data
Bank (Blue Book), Medi-Span, and the Red Book. The listing was revised to reflect additional
changes (i.e., additions, deletions, pricing changes) through January 14, 2005. The list does not
reference the commonly known brand names. However, the brand names are included in the FUL
listing provided to the State agencies in electronic media format. The FUL price list is in Microsoft
Word format at http://www.cms.hhs.gov/Medicaid/drugs/drug10.asp.
In accordance with current policy, Federal financial participation will not be provided for any drug on
the FUL listing for which the Food and Drug Administration (FDA) has issued a notice of an
opportunity for a hearing as a result of the Drug Efficacy Study and Implementation (DESI) program
and which has been found to be less than effective or is identical, related, or similar (IRS) to the DESI
drug. The DESI drug is identified by the FDA or reported by the drug manufacturer for purposes of
the Medicaid drug rebate program.
The November 20, 2001 list has been amended with all changes to be implemented no later than
February 14, 2005.
Acebutolol Hydrochloride
Eq 200 mg base, Capsule, Oral 100 $0.4612 B
Eq 400 mg base, Capsule, Oral 100 0.6713 B
D-3
National Pharmaceutical Council Pharmaceutical Benefits 2004
Acetazolamide
250 mg, Tablet, Oral 100 0.2454 R
Acyclovir
200 mg, Capsule, Oral 100 0.1478 B
400 mg, Tablet, Oral 100 0.4425 B
800 mg, Tablet, Oral 100 0.8700 B
Albuterol
0.09 mg/inh, Aerosol, Metered, Inhalation, 17 gm 0.8823 B
Albuterol Sulfate
Eq 0.083% base, Solution, Inhalation 3ml 0.1450 B
Eq 0.5% base, Solution, Inhalation 20 ml 0.3360 B
4 mg, Tablet, Oral 100 0.1425 B
Allopurinol
100 mg, Tablet, Oral 100 0.0784 B
300 mg, Tablet, Oral 100 0.1671 B
Alprazolam
0.25 mg, Tablet, Oral 100 0.0614 R
0.5 mg, Tablet, Oral 100 0.0698 B
1 mg, Tablet, Oral 100 0.0885 B
2 mg, Tablet, Oral 100 0.1745 R
Amantadine Hydrochloride
50 mg/5 ml, Syrup, Oral 480 ml 0.0656 M
Amiodarone Hydrochloride
200 mg, Tablet, Oral 60 1.6875 B
D-4
National Pharmaceutical Council Pharmaceutical Benefits 2004
Amitriptyline Hydrochloride
10 mg, Tablet, Oral 100 0.0608 B
25 mg, Tablet, Oral 100 0.0653 B
50 mg, Tablet, Oral 100 0.0666 B
75 mg, Tablet, Oral 100 0.1425 B
100 mg, Tablet, Oral 100 0.1500 R
150 mg, Tablet, Oral 100 0.2430 B
Amoxapine
50 mg, Tablet, Oral 100 0.5425 R
Amoxicillin
250 mg, Capsule, Oral 100 0.0675 B
500 mg, Capsule, Oral 100 0.1302 R
125 mg/5 ml, Powder for Reconstitution, Oral 150 0.0201 B
250 mg/5 ml, Powder for Reconstitution, Oral 100 0.0281 B
Ampicillin/Ampicillin Trihydrate
250 mg, Capsule, Oral 100 0.1736 B
500 mg, Capsule, Oral 100 0.2991 B
Aspirin; Carisoprodol
325 mg; 200 mg, Tablet, Oral 100 0.3522 B
Atenolol
25 mg, Tablet, Oral 100 0.0975 B
50 mg, Tablet, Oral 100 0.1058 B
100 mg, Tablet, Oral 100 0.1943 B
Atenolol; Chlorthalidone
50 mg; 25 mg, Tablet, Oral 100 0.1762 B
100 mg; 25 mg, Tablet, Oral 100 0.2549 B
Baclofen
10 mg, Tablet, Oral, 100 0.4492 B
20 mg, Tablet, Oral, 100 0.8438 B
D-5
National Pharmaceutical Council Pharmaceutical Benefits 2004
Benazepril Hydrochloride
5 mg, Tablet, Oral, 100 0.4905 R
10 mg, Tablet, Oral, 100 0.4905 R
20 mg, Tablet, Oral, 100 0.4905 R
40 mg, Tablet, Oral, 100 0.4905 R
Benzonatate
100 mg, Capsule, Oral 100 0.4387 B
Benztropine Mesylate
0.5 mg, Tablet, Oral 100 0.1227 B
1 mg, Tablet, Oral 100 0.1502 B
2 mg, Tablet, Oral 100 0.1930 B
Betamethasone Dipropionate
Eq 0.05% base, Cream, Topical 15 gm 0.2330 B
Eq 0.05% base, Lotion, Topical 60 ml 0.1500 B
Betamethasone Valerate
Eq 0.1% base, Cream, Topical 45 gm 0.1197 B
Bumetanide
0.5 mg, Tablet, Oral 100 0.1743 B
1 mg, Tablet, Oral 100 0.2814 B
2 mg, Tablet, Oral 100 0.4708 B
Buspirone Hydrochloride
5 mg, Tablet, Oral 100 0.2964 B
10 mg, Tablet, Oral 100 0.3942 B
15 mg, Tablet, Oral 60 0.4470 B
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Captopril
12.5 mg, Tablet, Oral 100 0.0232 B
50 mg, Tablet, Oral, 100 0.0390 B
100 mg, Tablet, Oral 100 0.1080 B
Captopril; Hydrochlorothiazide
25 mg; 15 mg, Tablet, Oral 100 0.2360 B
50 mg; 25 mg, Tablet, Oral 100 0.3702 B
Carbamazepine
200 mg, Tablet, Oral 100 0.1388 R
Carbidopa; Levodopa
10 mg; 100 mg, Tablet, Oral 100 0.3644 B
25 mg; 100 mg, Tablet, Oral 100 0.4455 B
25 mg; 250 mg, Tablet, Oral 100 0.5145 B
Carisoprodol
350 mg, Tablet, Oral 100 0.3743 B
Carteolol Hydrochloride
1%, Solution/Drops, Ophthalmic 10 ml 3.6775 R
Cefaclor
Eq 250 mg base, Capsule, Oral 100 0.6600 B
Eq 500 mg base, Capsule, Oral 100 1.2900 B
Eq 125 mg base/5 ml,
Powder for reconstitution, Oral 150 0.0980 B
Eq 187 mg base/5 ml,
Powder for reconstitution, Oral 100 0.1470 B
Eq 250 mg base/5 ml,
Powder for reconstitution, Oral 150 0.2995 B
Eq 375 mg base/5 ml,
Powder for reconstitution, Oral 100 0.4492 B
Cefadroxil/Cefadroxil Hemihydrate
Eq 500 mg base, Capsule, Oral 50 2.4837 B
Cephalexin
Eq 250 mg base, Capsule, Oral 100 0.1835 R
Eq 500 mg base, Capsule, Oral 100 0.3641 R
Chlordiazepoxide Hydrochloride
5 mg, Capsule, Oral 100 0.1140 B
10 mg, Capsule, Oral 100 0.0877 B
Chlorhexidine Gluconate
0.12%, Solution, Dental 480 ml 0.0109 B
D-7
National Pharmaceutical Council Pharmaceutical Benefits 2004
Chlorpropamide
100 mg, Tablet, Oral 100 0.1837 B
250 mg, Tablet, Oral 100 0.3885 B
Chlorzoxazone
500 mg, Tablet, Oral 100 0.0757 B
Cholestyramine
Eq 4 gm Resin/Packet, Powder, Oral 60 1.2767 B
Cimetidine
200 mg, Tablet, Oral 100 0.1313 B
300 mg, Tablet, Oral 100 0.1313 B
400 mg, Tablet, Oral 100 0.1071 R
800 mg, Tablet, Oral 100 0.2775 B
Cimetidine Hydrochloride
Eq 300 mg base/ 5 ml Solution, Oral , 240 ml 0.1139 B
Ciprofloxacin Hydrochloride
0.3%, Solution/Drops, Ophthalmic, 5ml 7.5690 B
250 mg, Tablet, Oral, 100 0.3750 B
500 mg, Tablet, Oral, 100 0.4500 B
750 mg, Tablet, Oral, 100 0.4800 B
Clindamycin Hydrochloride
Eq 150 mg base, Capsule, Oral 100 0.9180 R
Clindamycin Phosphate
Eq 1% base, Solution, Topical 60 ml 0.2060 R
Clobetasol Propionate
0.05%, Cream, Topical 30 gm 0.8315 B
Clomipramine Hydrochloride
25 mg, Capsule, Oral 100 0.3322 R
50 mg, Capsule, Oral 100 0.5138 B
75 mg, Capsule, Oral 100 0.6623 B
Clonazepam
0.5 mg, Tablet, Oral 100 0.2455 B
1 mg, Tablet, Oral 100 0.2852 B
2 mg, Tablet, Oral 100 0.3903 B
Clonidine Hydrochloride
0.1 mg, Tablet, Oral 100 0.0968 B
0.2 mg, Tablet, Oral 100 0.1350 B
0.3 mg, Tablet, Oral 100 0.1830 B
D-8
National Pharmaceutical Council Pharmaceutical Benefits 2004
Clorazepate Dipotassium
3.75 mg, Tablet, Oral 100 0.8350 B
7.5 mg, Tablet, Oral 100 1.0388 B
15 mg, Tablet, Oral 100 1.4094 B
Cromolyn Sodium
4%, Solution/ Drops, Ophthalmic 10 ml 3.3750 B
Cyclobenzaprine Hydrochloride
10 mg, Tablet, Oral 100 0.2728 B
Desonide
0.05%, Ointment, Topical 60 gm 0.4077 B
0.05%, Cream, Topical 100 0.2337 B
Dextroamphetamine Sulfate
10 mg, Tablet, Oral, 100 0.3435 B
Diazepam
2 mg, Tablet, Oral 100 0.0423 B
5 mg, Tablet, Oral 100 0.0718 B
10 mg, Tablet, Oral 100 0.0573 B
Diclofenac Potassiuim
50 mg, Tablet, Oral 100 0.8625 B
Diclofenac Sodium
50 mg, Tablet, Delayed Release, Oral 100 0.4748 R
75 mg, Tablet, Delayed Release, Oral 100 0.5850 R
Dicyclomine Hydrochloride
10 mg, Capsule, Oral 100 0.1222 B
20 mg, Tablet, Oral 100 0.1185 B
Diltiazem Hydrochloride
30 mg, Tablet, Oral 100 0.1019 B
60 mg, Tablet, Oral 100 0.1114 B
90 mg, Tablet, Oral 100 0.2312 B
120 mg, Tablet, Oral 100 0.2331 B
Diphenhydramine Hydrochloride
12.5 mg/5 ml, Elixir, Oral 120 ml 0.0137 B
Dipivefrin Hydrochloride
0.1%, Solution/Drops, Ophthalmic 5 ml 0.8700 B
D-9
National Pharmaceutical Council Pharmaceutical Benefits 2004
Doxazosin Mesylate
1 mg, Tablet, Oral 100 0.5918 B
2 mg, Tablet, Oral 100 0.5918 B
4 mg, Tablet, Oral 100 0.6210 B
8 mg, Tablet, Oral 100 0.6518 B
Doxepin Hydrochloride
Eq 10 mg base, Capsule, Oral 100 0.0891 R
Eq 25 mg base, Capsule, Oral 100 0.1822 B
Eq 50 mg base, Capsule, Oral 100 0.1447 R
Eq 75 mg base, Capsule, Oral 100 0.2052 R
Eq 100 mg base, Capsule, Oral 100 0.4174 B
Eq 10 mg base/ml, Concentrate, Oral 120 ml 0.1145 R
Doxycycline Hyclate
Eq 50 mg base, Capsule, Oral 50 0.1317 B
Eq 100 mg base, Capsule, Oral 50 0.1491 B
Eq 100 mg base, Tablet, Oral 50 0.1287 B
Doxycycline Hydrochloride
Eq 50 mg base, Capsule, Oral 50 0.0945 R
Eq 100 mg base, Capsule, Oral 50 0.1215 R
Enalapril Maleate
2.5 mg, Tablet, Oral, 100 0.4334 B
5 mg, Tablet, Oral, 100 0.5490 B
10 mg, Tablet, Oral, 100 0.6863 B
20 mg, Tablet, Oral, 100 0.9150 B
Erythromycin
2%, Solution, Topical 60 ml 0.0687 B
2%, Gel, Topical, 30 gm 0.6250 B
0.5%, Ointment, Ophthalmic, 3 gm 1.0714 B
Estazolam
1 mg, Tablet, Oral 100 0.5925 R
2 mg, Tablet, Oral 100 0.6449 R
Estradiol
0.5 mg, Tablet, Oral 100 0.1791 B
1 mg, Tablet, Oral 100 0.2175 B
2 mg, Tablet, Oral 100 0.3060 B
Estropipate
0.75 mg, Tablet, Oral 100 0.2754 B
1.5 mg, Tablet, Oral 100 0.3450 B
3 mg, Tablet, Oral 100 0.8622 B
Etodolac
D-10
National Pharmaceutical Council Pharmaceutical Benefits 2004
Famotidine
20 mg, Tablet, Oral 100 0.1500 B
40 mg, Tablet, Oral 100 0.3000 B
Fenoprofen Calcium
Eq 600 mg base, Tablet, Oral 100 0.2400 R
Flecainide Acetate
50 mg, Tablet, Oral, 100 0.8610 B
100 mg, Tablet, Oral, 100 1.4070 B
150 mg, Tablet, Oral, 100 1.9328 B
Fluocinonide
0.05%, Cream, Topical 60 gm 0.0790 R
0.05%, Gel, Topical 60 gm 0.4965 R
0.05%, Solution, Topical 60 ml 0.2483 R
Fluorometholone
0.1%, Suspension/Drops, Ophthalmic 5 ml 1.6590 B
Fluoxetine Hydrochloride
10 mg, Capsule, Oral 100 0.5850 B
20 mg, Capsule, Oral 100 0.2520 B
40 mg Capsule, Oral 30 4.0125 B
20 mg/5ml, Solution, Oral 120 ml 0.7500 R
10 mg, Tablets, Oral 30 0.6000 B
Fluphenazine Hydrochloride
1 mg, Tablet, Oral 100 0.2273 B
2.5 mg, Tablet, Oral 100 0.2775 B
5 mg, Tablet, Oral 100 0.3546 B
10 mg, Tablet, Oral 100 0.5099 R
Flurazepam Hydrochloride
15 mg, Capsule, Oral 100 0.0975 B
30 mg, Capsule, Oral 100 0.1148 B
Flurbiprofen
100 mg, Tablet, Oral 100 0.2438 B
Flurbiprofen Sodium
0.03%, Solution/Drops, Ophthalmic 2ml 4.0679 B
D-11
National Pharmaceutical Council Pharmaceutical Benefits 2004
Furosemide
10 mg/ml, Solution, Oral 60 ml 0.1300 B
20 mg, Tablet, Oral 100 0.0563 B
40 mg, Tablet, Oral 100 0.0599 B
80 mg, Tablet, Oral 100 0.1043 B
Gemfibrozil
600 mg, Tablet, Oral 500 0.3800 B
Gentamicin Sulfate
Eq 0.3% Base, Solution/Drops, Ophthalmic 5 ml 0.5700 B
Glipizide
5 mg, Tablet, Oral 100 0.0699 B
10 mg, Tablet, Oral 100 0.1192 B
Glyburide
1.5 mg, Tablet, Oral 100 0.2549 R
3 mg, Tablet, Oral 100 0.3202 R
Guanfacine Hydrochloride
Eq 1 mg base, Tablet, Oral 100 0.5250 B
Eq 2 mg base, Tablet, Oral 100 0.7200 B
Haloperidol Lactate
Eq 2 mg base/ml, Concentrate, Oral 120 ml 0.1369 B
Hydrochlorothiazide
25 mg, Tablet, Oral, 1000 0.0577 R
50 mg, Tablet, Oral, 1000 0.1019 R
Hydrochlorothiazide; Spironolactone
25 mg; 25 mg, Tablet, Oral 100 0.3463 B
Hydrochlorothiazide; Triamterene
25 mg; 37.5 mg, Capsule, Oral 100 0.3177 B
25 mg; 37.5 mg, Tablet, Oral 100 0.1683 R
50 mg; 75 mg, Tablet, Oral 100 0.0488 B
Generic Name Upper Limit per Unit (Source)
Hydrocortisone
0.5%, Cream, Topical, 30 gm 0.0510 M
1%, Cream, Topical 30 gm 0.0572 B
2.5%, Cream, Topical 30 gm 0.1820 B
D-12
National Pharmaceutical Council Pharmaceutical Benefits 2004
Hydroxychloroquine Sulfate
200 mg, Tablet, Oral 100 0.8535 B
Hydroxyzine Hydrochloride
10 mg/5 ml, Syrup, Oral 480 ml 0.0367 B
25 mg, Tablet, Oral 100 0.7134 B
Hydroxyzine Pamoate
Eq 25 mg HCL, Capsule, Oral 100 0.0892 B
Eq 50 mg HCL, Capsule, Oral 100 0.1013 B
Ibuprofen
400 mg, Tablet, Oral 100 0.0493 B
600 mg, Tablet, Oral 100 0.0573 B
800 mg, Tablet, Oral 100 0.1065 B
Imipramine Hydrochloride
10 mg, Tablet, Oral 100 0.2643 B
25 mg, Tablet, Oral 100 0.3551 B
50 mg, Tablet, Oral 100 0.4604 B
Indapamide
1.25 mg, Tablet, Oral 100 0.1035 B
2.5 mg, Tablet, Oral 100 0.1125 B
Ipratropium Bromide
0.02%, Solution for Inhalation, 2.500 ml, 25s 0.1080 R
Isoniazid
300 mg, Tablet, Oral 100 0.0890 B
Isosorbide Dinitrate
5 mg, Tablet, Oral 100 0.0217 R
10 mg, Tablet, Oral 100 0.0228R
20 mg, Tablet, Oral 100 0.0558B
Isosorbide Mononitrate
10 mg, Tablet, Oral 100 0.6110 R
20 mg, Tablet, Oral 100 0.4950 B
60 mg, Tablet, Extended Release, Oral 100 0.7492 B
Ketoconazole
200 mg, Tablet, Oral 100 2.2500 R
Ketorolac Tromethamine
10 mg, Tablet, Oral 100 0.6773 M
D-13
National Pharmaceutical Council Pharmaceutical Benefits 2004
Labetalol Hydrochloride
100 mg, Tablet, Oral 100 0.2157 B
200 mg, Tablet, Oral 100 0.3582 B
300 mg, Tablet, Oral 100 0.5363 B
Lactulose
10 gm/15 ml, Solution, Oral 480 ml 0.0219 B
Levobunolol Hydrochloride
0.25%, Solution/Drops, Ophthalmic 10 ml 1.2749 B
0.5%, Solution/Drops, Ophthalmic 10 ml 1.4925 B
Lidocaine Hydrochloride
2%, Solution, Oral 100 ml 0.0315 R
Lisinopril
2.5 mg, Tablet, Oral, 100 0.3855 B
5 mg, Tablet, Oral, 100 0.5783 B
10 mg, Tablet, Oral, 100 0.5970 B
20 mg, Tablet, Oral, 100 0.6390 B
30 mg, Tablet, Oral, 100 0.9038 B
40 mg, Tablet, Oral, 100 0.9345 B
Lisinopril ; Hydrochlorothiazide
10 mg ; 12.5 mg, Tablet, Oral, 100 0.6450 B
20 mg ; 12.5 mg, Tablet, Oral, 100 0.6983 B
20 mg ; 25 mg, Tablet, Oral, 100 0.7065 B
Lithium Carbonate
300 mg, Capsule, Oral, 1000 0.1350 B
Lorazepam
0.5 mg, Tablet, Oral 100 0.4350 B
1 mg, Tablet, Oral 100 0.5718 B
2 mg, Tablet, Oral 100 0.5698 B
Lovastatin
10 mg, Tablet, Oral 60 0.7487 B
20 mg, Tablet, Oral 60 1.2488 B
40 mg, Tablet, Oral 60 3.2012 B
Meclizine Hydrochloride
12.5 mg, Tablet, Oral 100 0.0599 B
25 mg, Tablet, Oral 100 0.0420 B
Medroxyprogesterone Acetate
2.5 mg, Tablet, Oral 100 0.2025 B
D-14
National Pharmaceutical Council Pharmaceutical Benefits 2004
Megestrol Acetate
20 mg, Tablet, Oral 100 0.3489 B
40 mg, Tablet, Oral 100 0.6755 B
Meperidine Hydrochloride
50 mg, Tablet, Oral 100 0.5370 B
100 mg, Tablet, Oral 100 1.0347 B
Metformin Hydrochloride
500 mg, Tablet, Oral 100 0.3557 B
850 mg, Tablet, Oral 100 0.3863 B
1000 mg, Tablet, Oral, 100 0.4597 B
Methazolamide
25 mg, Tablet, Oral 100 0.3150 R
50 mg, Tablet, Oral 100 0.4650 R
Methenamine Mandelate
1 gm, Tablet, Oral 100 0.2923 B
Methocarbamol
500 mg, Tablet, Oral 100 0.1463 B
750 mg. Tablet, Oral 100 0.1792 B
Methotrexate Sodium
Eq 2.5 mg base, Tablet, Oral 100 1.2637 B
Methylphenidate Hydrochloride
5 mg, Tablet, Oral 100 0.3020 B
10 mg, Tablet, Oral 100 0.4224 B
20 mg, Tablet, Oral 100 0.6180 B
Methylprednisolone
4 mg, Tablet, Oral 100 0.2849 B
Metoclopramide
10 mg, Tablet, Oral 100 0.1095 B
Metoclopramide Hydrochloride
Eq 5 mg base/5 ml, Solution, Oral 480 ml 0.0155 B
Eq 5 mg base, Tablet, Oral 100 0.1842 B
Eq 10 mg base, Tablet, Oral 100 0.1089 B
Metoprolol Tartrate
50 mg, Tablet, Oral 100 0.0500 B
D-15
National Pharmaceutical Council Pharmaceutical Benefits 2004
Metronidazole
250 mg, Tablet, Oral 100 0.0849 B
500 mg, Tablet, Oral 100 0.2184 B
Mexiletine Hydrochloride
200 mg, Capsule, Oral 100 0.9712 R
Minocycline Hydrochloride
Eq 50 mg base, Capsule, Oral 100 0.9000 B
Eq 100 mg base, Capsule, Oral 50 1.8000 B
Minoxidil
2.5 mg, Tablet, Oral 100 0.3170 B
10 mg, Tablet, Oral 100 0.6965 B
Mirtazapine
15 mg, Tablet, Oral, 30 1.6300 B
30 mg, Tablet, Oral, 30 1.6775 B
45 mg, Tablet, Oral, 30 1.7100 B
Nadolol
20 mg, Tablet, Oral 100 0.4650 B
40 mg, Tablet, Oral 100 0.4289 B
80 mg, Tablet, Oral 100 0.8025 B
Naltrexone Sodium
50 mg, Tablet, Oral 100 4.0400 B
Naphazoline Hydrochloride
0.1%, Solution/Drops, Ophthalmic 15 ml 0.3140 R
Naproxen
250 mg, Tablet, Oral 100 0.1044 R
375 mg, Tablet, Oral 100 0.1383 R
500 mg, Tablet, Oral 100 0.1805 B
Niacin
500 mg, Tablet, Oral 100 0.0390 B
Nicardipine Hydrochloride
20 mg, Capsule, Oral 100 0.3375 B
30 mg, Capsule, Oral 100 0.4050 B
Nizatidine
150 mg, Capsule, Oral, 60 1.8307 B
300 mg, Capsule, Oral, 30 3.6615 B
D-16
National Pharmaceutical Council Pharmaceutical Benefits 2004
Nortriptyline Hydrochloride
Eq 10 mg base, Capsule, Oral 100 0.1019 B
Eq 25 mg base, Capsule, Oral 100 0.1406 B
Eq 50 mg base, Capsule, Oral 100 0.1722 B
Eq 75 mg base, Capsule, Oral 100 0.2203 B
Nystatin
100,000 units/gm, Cream, Topical 30 gm 0.0755 B
100,000 units/gm, Ointment, Topical 15 gm 0.1019 B
Oxaprozin
600 mg, Tablet, Oral 100 0.6758 B
Oxazepam
10 mg, Capsule, Oral 100 0.5363 B
15 mg, Capsule, Oral 100 0.5709 B
30 mg, Capsule, Oral 100 1.2337 R
Oxybutynin Chloride
5 mg, Tablet, Oral 100 0.1260 R
Oxycodone Hydrochloride
5 mg, Capsule, Oral, 100 0.2138 B
20 mg/ml, Concentrate, Oral, 30 ml 0.9500 B
5 mg, Tablet, Oral, 100 0.2399 B
15 mg, Tablet, Oral, 100 0.6695 M
30 mg, Tablet, Oral, 100 1.3094 M
Paroxetine Hydrochloride
10 mg, Tablet, Oral, 30 2.4300 R
20 mg, Tablet, Oral, 30 2.5200 R
30 mg, Tablet, Oral, 30 2.6100 R
40 mg, Tablet, Oral, 30 2.7000 R
Pentoxifylline
400 mg, Tablet, Extended Release, Oral 100 0.3147 B
Perphenazine
2 mg, Tablet, Oral 100 0.3473 R
16 mg, Tablet, Oral 100 1.3833 B
Piroxicam
10 mg, Capsule, Oral 100 0.0891 B
20 mg, Capsule, Oral 100 0.1131 B
D-17
National Pharmaceutical Council Pharmaceutical Benefits 2004
Potassium Chloride
8 MEQ, Tablet, Extended Release, Oral 100 0.0893 B
Prednisolone
15 mg/5 ml, Syrup, Oral 480 ml 0.2081 B
Prednisolone Acetate
1%, Suspension/Drops, Ophthalmic 10 ml 1.6950 B
Primidone
250 mg, Tablet, Oral 100 0.6956 R
Probenecid
500 mg, Tablet, Oral 100 0.7059 B
Prochlorperazine Maleate
Eq 5 mg base, Tablet, Oral 100 0.3986 B
Eq 10 mg base, Tablet, Oral 100 0.5766 B
Propafenone Hydrochloride
150 mg, Tablet, Oral 100 1.1049 B
225 mg, Tablet, Oral 100 1.5624 B
Propranolol Hydrochloride
10 mg, Tablet, Oral 100 0.0585 B
20 mg, Tablet, Oral 100 0.0705 B
40 mg, Tablet, Oral 100 0.0848 B
80 mg, Tablet, Oral 100 0.1140 B
Ranitidine Hydrochloride
Eq 150 mg base, Tablet, Oral, 100 0.3411 R
Eq 300 mg base, Tablet, Oral 100 0.3180 B
Rimantadine Hydrochloride
100 mg, Tablet, Oral, 100 1.5120 B
Generic Name Upper Limit per Unit (Source)
Selegiline Hydrochloride
5 mg, Tablet, Oral 60 0.7658 R
Selenium Sulfide
2.5%, Lotion/Shampoo, Topical 120 ml 0.0750 B
D-18
National Pharmaceutical Council Pharmaceutical Benefits 2004
Spironolactone
25 mg, Tablet, Oral 100 0.3000 B
Sucralfate
1 gm, Tablet, Oral 100 0.3690 B
Sulfacetamide Sodium
10%, Solution/Drops, Opthalmic 15 ml 0.1530 B
Sulfamethoxazole; Trimethoprim
400 mg; 80 mg, Tablet, Oral 100 0.1325 B
800 mg; 160 mg, Tablet, Oral 100 0.1454 R
Sulfasalazine
500 mg, Tablet, Oral 100 0.1565 B
Sulindac
150 mg, Tablet, Oral 100 0.3317 B
200 mg, Tablet, Oral 100 0.4289 B
Tamoxifen Citrate
10 mg, Tablet, Oral, 60 0.9713 B
20 mg, Tablet, Oral, 30 1.9425 B
Temazepam
15 mg, Capsule, Oral 100 0.1365 B
30 mg, Capsule, Oral 100 0.1748 B
Terazosin Hydrochloride
Eq 1 mg base, Capsule, Oral 100 1.5413 B
Eq 2 mg base, Capsule, Oral 100 1.5413 B
Eq 5 mg base, Capsule, Oral 100 1.5413 B
Eq 10 mg base, Capsule, Oral 100 1.5413 B
Tetracycline Hydrochloride
500 mg, Capsule, Oral 100 0.0975 B
Thioridazine Hydrochloride
10 mg, Tablet, Oral 100 0.2190 B
25 mg, Tablet, Oral 100 0.3030 B
50 mg, Tablet, Oral 100 0.3885 R
100 mg, Tablet, Oral 100 0.4941 B
Thiothixene
1 mg, Capsule, Oral 100 0.1388 B
2 mg, Capsule, Oral 100 0.1860 B
5 mg, Capsule, Oral 100 0.2963 B
10 mg, Capsule, Oral 100 0.4065 B
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Ticlopidine Hydrochloride
250 mg, Tablet, Oral 60 0.2732 B
Timolol Maleate
Eq 0.25% base, Solution/Drops, Ophthalmic 10 ml 0.6975 B
Eq 0.5% base, Solution/Drops, Ophthalmic 15 ml 0.9000 B
Tizanidine Hydrochloride
2 mg, Tablet, Oral, 150 0.6499 B
4 mg, Tablet, Oral, 150 0.7899 B
Tobramycin
0.3%, Solution/Drops, Ophthalmic 5 ml 0.6720 B
Tolazamide
250 mg, Tablet, Oral 100 0.4005 B
Tramadol Hydrochloride
50 mg, Tablet, Oral, 100 0.3068 B
Trazodone Hydrochloride
50 mg, Tablet, Oral 100 0.0742 R
100 mg, Tablet, Oral 100 0.1140 B
150 mg, Tablet, Oral 100 0.3113 B
Triamcinolone Acetonide
0.1%, Cream, Topical 80 gm 0.0469 B
0.5%, Cream, Topical 15 gm 0.2370 B
0.1%, Ointment, Topical 80 gm 0.0502 B
Triazolam
0.125 mg, Tablet, Oral 100 0.4041 B
Trihexyphenidyl Hydrochloride
2 mg, Tablet, Oral 100 0.1275 B
5 mg, Tablet, Oral 100 0.2295 B
Tropicamide
0.5%, Solution/Drops, Ophthalmic 15 ml 0.6550 B
1%, Solution/Drops, Ophthalmic 15 ml 0.7000 B
Valproic Acid
250 mg, Capsule, Oral 100 0.5250 B
250 mg/5 ml, Syrup, Oral 480 ml 0.0594 M
Verapamil Hydrochloride
120 mg, Capsule, Extended Release, Oral 100 0.8250 B
180 mg, Capsule, Extended Release, Oral 100 0.8700 B
240 mg, Capsule, Extended Release, Oral 100 0.4350 B
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Appendix E:
Glossary
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Access A patient’s ability to obtain medical care. The ease of access is determined
by components such as the availability of medical services and their
acceptability to the patient, the location of health care facilities,
transportation, hours of operation and affordability of care.
Actual Acquisition Cost (AAC) The pharmacist’s net payment made to purchase a drug product, after
taking into account such items as purchasing allowances, discounts, and
rebates.
Actual Charge The amount a physician or other provider actually bills a patient for a
particular medical service, procedure or supply in a specific instance. The
actual charge may differ from the usual, customary, prevailing, and/or
reasonable charge.
Additional Drug Benefit List A list of pharmaceutical products approved by a health plan and employer
for dispensing in larger quantities than the standards covered under a
benefit package in order to facilitate long-term patient use. The list is
subject to periodic review and modification by the health plan. Also called
“drug maintenance list.”
Administrative Costs The costs incurred by a carrier, such as an insurance company or HMO,
for services such as claims processing, billing and enrollment, and
overhead costs. Administrative costs can be expressed as a percentage of
premiums or on a per member per month basis. Additional costs that are
often expressed as administrative include those related to utilization
review, insurance marketing, medical underwriting, agents’ commissions,
premium collection, claims processing, insurer profit, quality assurance
activities, medical libraries and risk management.
Administrative Services Only An insurance arrangement requiring the employer to be at risk for the cost
(ASO) of health care services provided, while a separate company delivers
administrative services. This is a common arrangement when an employer
sponsors a self-funded health care program.
Adverse Selection A term used to describe a situation in which a health plan disproportionally
enrolls a population that is prone to higher than average utilization of
benefits, thereby driving up costs and increasing financial risk.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Aged For purposes of Medicare enrollment, persons 65 years of age or over are
considered to be aged. Medicaid eligibility is determined on the basis of
financial need for people who meet Supplemental Security Income (SSI)
eligibility criteria (aged, blind, or disabled individuals) and Temporary
Assistance for Needy Families (TANF) criteria (adults and children).
Eligibility determinations are made for an entire economic unit or “case”
(sometimes a family) based on whether or not one member of a case meets
the criteria. For example, an “aged” case could consist of a 66 year old
male and his 63 year old wife. In contrast, a disabled enrollee could be
over 65 years of age. May also be defined as “Elderly.”
Agency for Healthcare A Federal agency under Health and Human Services (HHS) whose
Research and Quality (AHRQ) purpose is to enhance the quality and effectiveness of health care by
funding healthcare services research, conducting health technology
assessments and outcomes studies, and developing and disseminating
clinical practice guidelines.
Aid to Families with Dependent A State-based Federal cash assistance program for low-income families. In
Children (AFDC) all States, AFDC recipiency may be used to establish Medicaid eligibility.
Now known as Temporary Assistance for Needy Families (TANF).
Allied Health Personnel Specially trained and licensed (when necessary) health workers other than
physicians, dentists, optometrists, chiropractors, podiatrists and nurses.
The term is sometimes used synonymously with paramedical personnel, all
health workers who perform tasks that must otherwise be performed by a
physician, or health workers who do not usually engage in independent
practice.
Allowable Charge The maximum fee that a third party will reimburse a provider for a given
service. An allowable charge may not be the same amount as either a
reasonable or customary charge.
Allowable Costs Charges for services rendered or supplies furnished by a health provider,
which qualify for an insurance reimbursement.
Ambulatory Care All types of health services that are provided on an outpatient basis, in
contrast to services provided in the home or to persons who are inpatients.
While many inpatients may be ambulatory, the term ambulatory care
usually implies that the patient must travel to a location to receive services
which do not require an overnight stay.
Ambulatory Surgery Any minor surgical procedures that can be performed at any type of
medical facility on an outpatient basis, i.e., not requiring an overnight stay.
American National Standards A nonprofit organization that coordinates the development of voluntary
Institute (ANSI) national standards in both the public and private sectors.
Ancillary Charge (1) The fee associated with additional service performed prior to and/or
secondary to a significant procedure. (2) Also referred to as hospital
“extras” or miscellaneous hospital charges. They are supplementary to a
hospital’s daily room and board charge. They include such items as
charges for drugs, medicines and dressings, lab services, X-ray
examinations, and use of the operating room.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Ancillary Services Hospital services other than room, board, and professional services. They
may include X-rays, lab tests, or anesthesia.
Any Willing Provider A requirement that a health insurance plan or a health maintenance
organization (HMO) must sign a contract for the delivery of health care
services with any provider in the area that would like to provide such
services to the plan’s or HMO’s enrollees, and can meet the terms of a
contract.
Assignee The person to whom the rights to a health insurance policy are assigned,
either in part or in whole, by the original policyholder.
Assignment of Benefits A method under which a claimant requests that his/her benefits under a
claim be paid to some designated person or institution, usually a physician
or hospital.
Average Cost Per Claim The average dollar amount of administrative and/or medical services
rendered for the unit of measure within each expenditure category. The
calculation is $amount / #of units.
Average Manufacturer Price The average price paid by wholesalers for products distributed to the retail
(AMP) class of trade.
Average Wholesale Price The published suggested wholesale price of a drug. It is often used by
(AWP) pharmacies as a cost basis for pricing prescriptions.
Behavioral Health Care Assessment and treatment of mental and/or psychoactive substance abuse
disorders.
Benefit Maximum Specifies a dollar limit for the total reimbursement of health care costs
during a benefit period.
Benefit Package Services an insurer, government agency, or health plan offers to a group or
individual under the terms of a contract.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Best Price For purposes of Medicaid rebate calculations, lowest price paid for a
product by any purchaser other than Federal agencies and State
pharmaceutical assistance programs.
Biological Equivalents Those chemical equivalents which, when administered in the same amounts,
will provide the same biological or physiological availability, as measured
by blood levels, urine levels, etc.
Blue Book (MDBT) The generic name for a widely used pricing guide entitled the American
Druggist First Databank Annual Directory of Pharmaceuticals. Brand
name and generic drugs are listed by product, manufacturer, National Drug
or Universal Price Codes, direct price and average wholesale price (AWP).
Other pricing guides are the Red Book and Medispan’s Pricing Guide.
Cafeteria Plan An employee benefit plan under which all participants are permitted to
choose among two or more benefit options according to their needs and/or
ability to pay. Also called a flexible benefit plan of “flex plan.”
Capitation Fund A fund based on the number of members multiplied by the budgeted or
capitated amount each member pays. Some HMOs, in lieu of reimbursing
physicians on a direct capitation basis, may establish such a fund.
Physicians are then reimbursed on a fee-for-service basis from the
capitation fund. The HMO monitors patient visits for over-utilization;
patients exceeding the norm are notified.
Card Programs The use of a drug benefit identification card which, when presented to a
participating pharmacy by employees or their dependents, usually entitles
them to receive the medication for a copay.
Care Coordinator A primary health care practitioner: (1) who provides primary care services
to an enrollee, (2) who is generally responsible for coordinating the
enrollee’s health care, and (3) with whom, other than in an emergency, a
patient must consult to obtain a referral to a specialist provider in order to
obtain the highest level of benefits available under a health plan. Care
coordinators are sometimes called “gatekeepers.”
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Case Management (1) A process whereby covered persons with specific health care needs are
identified and a plan designed to efficiently utilize health care resources is
formulated and implemented to achieve the optimum patient outcome in the
most cost-effective manner. (2) A utilization management program that
assists the patient in determining the most appropriate and cost-effective
treatment plan. It is used for patients who have prolonged expensive or
chronic conditions, helps determine the treatment location (hospital, or
other institution, or home), and authorizes payment for such care if it is not
covered under the patient’s benefit agreement.
Case Manager An experienced professional (e.g., nurse, doctor or social worker) who
works with patients, providers and insurers to coordinate all services
deemed necessary to provide the patient with a plan of medically necessary
and appropriate health care.
Categorically Needy Under Medicaid, categorically needy are aged, blind, or disabled
individuals or families and children who meet financial eligibility
requirements for TANF, Supplemental Security Income, or an optional
State supplement.
Center for Medicaid and State The agency within the Centers for Medicare and Medicaid Services (CMS)
Operations (CMSO) with responsibility for administering the Medicaid and The Children’s
Health Insurance Program (SCHIP).
Centers for Medicare and The government agency within the Department of Health and Human
Medicaid Services (CMS) Services which directs the Medicare and Medicaid programs (Titles XVIII
and XIX of the Social Security Act) and conducts research to support those
programs. Formerly known as the Health Care Financing Administration
(HCFA).
Chain Pharmacy One of a group of pharmacies, usually three or more, under the same
management or ownership.
Charity Care Pools The assets of several funds combined to cover health care costs to the poor
and uninsured. The pools are established by organizations such as
hospitals and insurance companies to offset a portion of the cost for
providing health care to the indigent.
Chemical Equivalents Those multiple-source drug products containing identical amounts of the
same active ingredients, in equivalent dosage forms, and meeting existing
physical/chemical standards.
Chronic Care Care and treatment rendered to individuals whose health problems are of a
long-term and continuing nature. Rehabilitation facilities, nursing homes,
and mental hospitals may be considered chronic care facilities.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Claims Administration A carrier function involving the review of health insurance claims
submitted for payment, by individual claim or in the aggregate. Claims
administration, as it relates to professional review programs, is an
identification procedure, screening treatment or charge pattern, for
subsequent peer review and adjudication.
Claims Clearinghouse System A system which allows electronic claims submission through a single
source.
Claims Review The method by which an enrollee’s health care service claims are reviewed
before reimbursement is made. The purpose of this monitoring system is to
validate the medical appropriateness of the provided services and to be
sure the cost of the service is not excessive.
Clearinghouse Capability A company capable of submitting electronic and/or paper claims to several
third-party payers.
Clinical Indicator A tool or marker used to monitor and evaluate care to assure desirable
outcomes and to explain or prevent undesirable outcomes.
Clinical Outcome The status of the patient’s health, especially after receipt of medical care
services. Assessment of outcomes may be dependent upon targeted goals,
clinical markers, and the ability to provide objective measurements.
Clinical Practice Guidelines Guidelines that specify the appropriate course(s) of treatment for specified
health conditions.
Closed-Panel HMO Generally offers the services of a relatively limited number of health care
providers, e.g., physicians employed by the HMO. Staff- and group-model
HMOs are usually referred to as being in this category.
CMS MSIS Report The CMS MSIS Report, formerly the HCFA-2082 Report, is the basic
source of State-reported eligibility and claims data on the Medicaid
population, their characteristics, utilization, and payments. Through FY
1998, the HCFA-2082 was an annual State submitted report designed to
collect aggregate statistical data on Medicaid eligibles, recipients, services,
and expenditures during each federal fiscal year. States summarized and
reported the data processed through their own Medicaid claims processing
and payment systems unless they opted to participate in the Medicaid
Statistical Information System (MSIS) where the 2082 Report was
produced by CMS. State-by-State national summary tables were developed
based on the 2082 Reports. As a result of legislation enacted by The
Balanced Budget Act of 1997, States, beginning in FY 1999, are required
to submit all of their eligibility and claims data on a quarterly basis
through MSIS. The State requirement for completing the HCFA-2082
Report has been eliminated.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
CMS-64 Report The CMS-64 Report is a product of the financial budget and grant system.
It is a statement of expenditures for the Medicaid program that States
submit to CMS 30 days after each quarter. The Report is an accounting
statement of actual expenditures made by the States for which they are
entitled to receive Federal reimbursement under Title XIX for that quarter.
Along with The CMS MSIS Report, it is one of the primary sources for
Medicaid statistical data.
Coinsurance The portion of covered health care costs for which the covered person has
a financial responsibility, usually according to a fixed percentage. Often
coinsurance applies after first meeting a deductible requirement.
Commercial Managed Care A health maintenance organization with a contract §1876 or a Medicare +
Organization (Comp-MCO) Choice organization, a provider sponsored organization, or any private or
public organization which meets the requirements of §1902(w). They
provide comprehensive services to commercial and/or Medicare, as well as
Medicaid enrollees.
Community Rating A method of determining a premium structure that is influenced not by the
expected level of benefit utilization by specific groups, but by expected
utilization by the population as a whole. Most often based on the entire
population of a metropolitan statistical area (MSA). The intent is to spread
risk over a large number of covered lives.
Competitive Medical Plan A status granted by the Federal government to an organization meeting
(CMP) specified criteria, enabling that organization to obtain a Medicare risk
contract.
Comprehensive Benefits Plan A variation of the major medical plan which carries copayment
requirements, usually 10-20 percent of all health expenses and deductibles
ranging from $100 to $1,000.
Concurrent Drug Evaluation An electronic assessment of claims at the point of service to detect potential
problems that should be addressed prior to dispensing drugs to patients.
Consolidated Omnibus A Federal law that, among other things, requires employers to offer
Reconciliation Act (COBRA) continued health insurance coverage to certain employees and their
beneficiaries whose group health insurance coverage has been terminated.
Consumer Price Index (CPI) A price index constructed monthly by the U.S. Department of Labor using
retail prices of goods and services sold in large cities across the country.
Continuous Quality A formal process of constantly seeking better ways to achieve stated goals.
Improvement (CQI)
Continuum of Care A range of clinical services provided to an individual or group, which may
reflect treatment rendered during a single inpatient hospitalization, or care
for multiple conditions over a lifetime. The continuum provides a basis
for analyzing quality, cost and utilization over the long term.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Contract Pharmacy System Pharmaceutical benefit delivery arrangement in which an HMO contracts
with community pharmacies (chain or selected independents) to provide
medications to members. Reimbursement may be by fee-for-service,
capitation, or some other arrangement.
Contributory Program A method of payment for group coverage in which part of the premium is
paid by the employee and part is paid by the employer or union.
Cosmetic Procedures Those procedures which involve physical appearance, but which do not
correct or materially improve a physiological function and are not deemed
medically necessary.
Cost Sharing Any provision of a health insurance policy that requires the insured to pay
some portion of medical expenses. The general term includes deductibles,
copayments, and coinsurance.
Cost Shifting The redistribution of payment sources. Typically, cost shifting occurs
when one payer obtains a discount on provider services, and the providers
increase costs to another payer to make up the difference.
Cost-Based Reimbursement Payment by third-party insurers in which the amount is based on the cost to
the provider of delivering services.
Covered Expenses Medical and related costs, experienced by those covered under the policy,
that qualify for reimbursement under terms of the insurance contract.
Covered Services The specific services and supplies for which Medicaid will provide
reimbursement. Covered services under Medicaid consist of a
combination of mandatory and optional services within each State.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Customary Charge The charge a physician or supplier usually bills his patients for furnishing
a particular service or supply is called the customary charge.
Customary, Prevailing, and Method of reimbursement which limits payment to the lowest of the
Reasonable Charges following: physician’s actual charge, physician’s median charge in a recent
prior period (customary), or the 75th percentile of charges in the same time
period (prevailing).
Day Supply Maximum The maximum amount of medication a person may receive at one time,
usually the amount needed for 30 (acute) or 90 (maintenance) days of
therapy, as defined by the drug benefit.
Deductible An amount the insured person must pay before payments for covered
services begin. For example, an insurance plan might require the insured to
pay the first $250 of covered expenses during a calendar year before the
insurance company will begin payment.
Demand The amount of care a population seeks to obtain through the health delivery
system.
Depot Price The price(s) available to any depot of the Federal government, for
purchase of drugs from the manufacturer through the depot system of
procurement.
Diagnosis Related Group A system of classification for inpatient hospital services based on principal
(DRG) diagnosis, secondary diagnosis, surgical procedures, age, sex and presence
of complications. This system of classification is used as a financing
mechanism to reimburse hospital and selected other providers for services
rendered.
Disability (1) Any condition that results in functional limitations that interfere with
an individual’s ability to perform his/her customary work and which
results in substantial limitation in one of more major life activities. (2)
Condition(s) that prevent or limit an individual’s ability to engage in
normal activities. These may be temporary.
Disability Income Insurance Type of health insurance that periodically pays a disabled subscriber to
replace income lost during the period of disability.
Disease Management An effort to improve patient outcomes and lower costs by organizing
managed care initiatives around patients with a particular disease or
condition.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Dispense As Written (DAW) A prescribing directive issued by physicians to indicate that the pharmacy
should not in any way alter a prescription. Such alterations are usually done
in order to substitute a generic drug for the brand name drug ordered.
Dispensing, Fill or Professional The amount paid to a pharmacy for each prescription, in addition to the
Fee negotiated formula for reimbursing ingredient cost.
Dispensing or Prescribing Limitations on the number of prescriptions per month, or the amount of
Limits medication that may be prescribed in a given time frame.
Drug Detailing Presenting information about a brand name drug product to prescribers to
educate them about its activity, uses, side effects, proper dosage and
administration, etc.
Drug Formulary A listing of prescription medications which are preferred for use by a health
plan and which may be dispensed through participating pharmacies to
covered persons. This list is subject to periodic review and modification by
the health plan. A plan that has adopted an “open or voluntary” formulary
allows coverage for both formulary and non-formulary medications. A plan
that has adopted a “closed, select or mandatory” formulary limits coverage
to those drugs in the formulary.
Drug Use Evaluation (DUE) Evaluations of prescribing patterns of prescribers to specifically determine
the appropriateness of drug therapy. There are three forms of DUE:
prospective (before or at the time of prescription dispensing), concurrent
(during the course of drug therapy), and retrospective (after the therapy has
been completed). Same as “Drug Utilization Review.”
Drug Utilization Review (DUR) A quantitative evaluation of prescription drug use, physician prescribing
patterns or patient drug utilization to determine the appropriateness of drug
therapy. Most often focuses on over-utilization.
Dual Eligibles The term describes a population of low-income elderly and individuals
with disabilities who qualify for both Medicare and Medicaid coverage.
While Medicare covers basic health services, including physician and
hospital care, dual eligibles rely on Medicaid to pay Medicare premiums
and cost-sharing and to cover critical benefits Medicare does not cover,
such as long-term care and prescription drugs. However starting in 2006,
coverage of prescription drugs for dual eligibles will shift from Medicaid
to Medicare.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Early and Periodic Screening, The EPSDT program covers screening and diagnostic services to
Diagnostic, and Treatment determine physical or mental defects in recipients under age 21, as well as
(EPSDT) health care and other measures to correct or ameliorate any defects and
chronic conditions discovered.
Electronic Data Interchange The computer-to-computer exchange of business or other information. The
(EDI) data may be in either a standardized or priority format.
Employee Benefits Program Health insurance and other benefits, beyond salaries, offered to employees
at their place of work. The employer typically picks up all or part of the
cost of these benefits.
Employee Retirement Income A Federal Act passed in 1974, that established new standards and
Security Act of 1974, Public reporting/disclosure requirements for employer-funded pension and health
Law 93-406 (ERISA) benefit programs. To date, self-funded health benefit plans operating under
ERISA have been held to be exempt from State insurance laws.
Enrollment The total number of covered persons in a health plan. Also refers to the
process by which a health plan signs up groups and individuals for
membership, or the number of enrollees who sign up in any one group.
Estimated Acquisition Cost An estimate of the price generally, and currently, paid by providers for a
(EAC) drug marketed or sold by a particular manufacturer or labeler in the
package size most frequently purchased by providers.
Exclusivity Clause A part of a contract which prohibits physicians from contracting with more
than one health maintenance organization or preferred provider
organization.
Experience Rating The process of setting rates based partially or in whole on previous claims
experience and projected required revenues for a future policy year for a
specific group or pool of groups.
Experimental, Investigational Medical, surgical, psychiatric, substance abuse or other health care services,
or Unproven Procedures supplies, treatments, procedures, drug therapies or devices that are
determined by the health plan (at the time it makes a determination
regarding coverage in a particular case) to be either: not generally accepted
by informed health care professionals in the U.S. as effective in treating the
condition, illness or diagnosis for which their use is proposed; or not proven
by scientific evidence to be effective in treating the condition, illness or
diagnosis for which their use is proposed.
Extended Care Long-term care, ranging from routine assistance for daily activities to
sophisticated medical and nursing care for those needing it. The care,
covered under certain insurance policies, can be provided in homes, day-
care centers or other facilities.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Family Planning Services Any medically approved means, including diagnosis, treatment, drugs,
supplies and devices, and related counseling which are furnished or
prescribed by or under the supervision of a physician for individuals of
childbearing age for purposes of enabling such individuals freely to
determine the number or spacing of their children.
Federal Financial Participation The technical term for Federal Medicaid matching funds paid to States for
allowable expenditures for Medicaid services or administrative costs.
Federal Medical Assistance The Federal Medical Assistance Percentage (FMAP) determines that
Percentage (FMAP) Federal government’s share of medical assistance expenditures under each
State’s Medicaid program. Each year, the FMAP is established by a
formula that compares the State's average per capita income level with the
national income average. States with a higher per capita income level are
reimbursed a smaller share of their costs. By law, the FMAP cannot be
lower than 50 percent or higher than 83 percent. The FMAP is defined in
Section 1933(d) of the Social Security Act.
Federal Poverty Level (FPL) The Federal government’s working definition of poverty is used as the
reference point for the income standard for Medicaid eligibility for certain
categories of beneficiaries. The Federal Poverty Level is the
administrative version of the poverty measure and is issued by the
Department of Health and Human Services (HHS). It is a simplification of
the poverty thresholds and is used in determining financial eligibility for
certain Federal programs. The FPL is also referred to as the Federal
poverty guidelines.
Federal Upper Limits (FUL) The upper limit amount that Medicaid can reimburse for a drug product if
there are three or more generic versions of the product rated
therapeutically equivalent and at least three suppliers listed in the current
editions of published national compendia. These limits are intended to
assure that the Federal government acts as a prudent buyer of drugs. The
upper limits program seeks to achieve savings by taking advantage of
current market prices.
Federally Qualified Health Federally Qualified Health Centers are facilities or programs more
Center (FQHC) commonly known as Community Health Centers, Migrant Health Centers,
and Health Care for The Homeless. These centers may qualify as Medicaid
providers of services if: 1) The facility receives a grant under sections 329,
330, or 340 of The Public Health Services Act; 2) HRSA recommends,
and the HHS Secretary determines, that the facility meets the requirements
of the grant; or 3) The Secretary determines that a facility may qualify
through waivers of the requirements (such a waiver cannot exceed two
years).
Federally Qualified HMOs HMOs that meet certain Federally stipulated provisions aimed at
protecting consumers: e.g., providing a broad range of basic health
services, assuring financial solvency, and monitoring the quality of care.
HMOs must apply to the Federal government for qualification. The Office
of Prepaid Health Care of CMS administers the process.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Fee Maximum The maximum amount a participating provider may be paid for a specific
health care service provided to a covered person under a specific contract.
Sometimes called “fee max.”
Fee Schedule A listing of codes and related services with pre-established payment
amounts that could be percentages of billed charges, flat rates or maximum
allowable amounts.
Fee-for-Service The traditional health care payment system, under which physicians and
Reimbursement other providers receive a payment that does not exceed their billed charge
for each unit of service provided. Fees are paid as care is rendered.
First-Dollar Coverage Health policies that pay all or a portion of medical expenses upon
enrollment, without a deductible charge.
Fiscal Agent A contractor that processes or pays vendor claims on behalf of a Medicaid
agency.
Fiscal Intermediary The agent that has contracted with providers of service to process claims
for reimbursement under health care coverage. In addition to handling
financial matters, it may perform other functions such as providing
consultative services or serving as a center for communication with
providers and making audits of providers’ records.
Fiscal Year Any predetermined set of 12 months for which annual accounts are kept.
The Federal government’s fiscal year extends from Oct. 1 to the following
Sept. 30.
Fixed Fee An established “fee” schedule for pharmacy services allowed by certain
government and private third-party programs in lieu of cost-of-doing
business markups.
Free-Standing Hospital Any hospital that is not affiliated with a multihospital system.
Generic Drug A chemically equivalent copy of a brand name drug whose patent has
expired. Drug formulations must be of identical composition with respect
to the active ingredient (i.e., meet official standards of identity, purity, and
quality of active ingredient). Also called generic equivalent or non-
innovator multiple source drug.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
HCFA 1500 A universal form developed by the government agency previously known
as the Health Care Financing Administration (HCFA, now CMS), for
providers of services to bill professional fees to health carriers.
HCFA Common Procedural A listing of services, procedures and supplies offered by physicians and
Coding System (HCPCS) other providers. HCPCS includes current procedural terminology (CPT)
codes, national alphanumeric codes and local alphanumeric codes. The
national codes are developed by CMS in order to supplement CPT codes.
They include physician services not included in CPT as well as non-
physician services such as ambulance, physical therapy and durable medical
equipment. The local codes are developed by local Medicare carriers in
order to supplement the national codes. HCPCS codes are 5-digit codes, the
first digit a letter followed by four numbers. HCPCS codes beginning with
A through V are national; those beginning with W through Z are local.
Health Care Financing See “Centers for Medicare and Medicaid Services.”
Administration (HCFA)
Health Care Prepayment Plan A cost contract with the CMS that prepays a health plan a flat amount per
(HCPP) month to provide Medicare-eligible Part B medical services to enrolled
members. Members pay premiums to cover the Medicare coinsurance,
deductibles and copayments, plus any additional non-Medicare covered
services that the plan provides. The HCPP does not arrange for Part A
services.
Health Insurance Financial protection against the medical care costs arising from disease or
accidental bodily injury. Such insurance usually covers all or part of the
medical costs of treating the disease or injury. Insurance may be obtained
on either an individual or a group basis.
Health Insurance Flexibility A Medicaid and State Children’s Health Insurance Program (SCHIP)
and Accountability (HIFA) demonstration waiver, using Section 1115 waiver authority, that offers
Waiver States greater flexibility in setting benefits and cost-sharing for some
groups of Medicaid beneficiaries. States can use the waiver to cut benefits
and /or increase cost-sharing for certain Medicaid beneficiaries and invest
resulting savings into expanding coverage of uninsured individuals
through Medicaid and SCHIP.
Health Insurance Portability Public Law 104-191, a law which requires each State’s Medicaid
and Accountability Act of 1996 Management Information System (MMIS) to have the capacity to exchange
(HIPAA) data with the Medicare program and contains “administrative
simplification” provisions that require State Medicaid Programs to use
standard codes for electronic transactions relating to the processing of
health claims.
Health Insuring Organization An entity that provides for or arranges for the provision of care and
(HIO) contracts on a prepaid capitated risk basis to provide a comprehensive set of
services.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Health Maintenance (1) An entity that provides, offers or arranges for coverage of designated
Organizations (HMO’s) health services needed by plan members for a fixed, prepaid premium.
There are four basic models of HMOs: staff model, group model, network
model and individual practice association; (2) Under the Federal HMO Act,
an entity must have three characteristics to call itself an HMO: (a) An
organized system for providing health care or otherwise assuring health care
delivery in a geographic area, (b) An agreed upon set of basic and
supplemental health maintenance and treatment services, and (c) A
voluntary enrolled group of people.
Health Plan An organization that provides a defined set of benefits; this term usually
refers to an HMO-like entity, as opposed to an indemnity insurer.
Health Plan Employer Data and A core set of performance measures to assist employers and other health
Information Set (HEDIS) purchasers in understanding the value of health care purchases and
evaluating health plan performance. HEDIS 2005 is currently used and
distributed by NCQA (National Committee for Quality Assurance).
HMO - Group Model A health care model involving contracts with physicians organized as a
partnership, professional corporation, or other association. The health plan
compensates the medical group for contracted services at a negotiated rate,
and that group is responsible for compensating its physicians and
contracting with hospitals for care of their patients.
HMO - Individual Practice A health care model that contracts with physicians and other community
Association (IPA) health care providers, to provide services in return for a negotiated fee.
Physicians continue in their existing individual or group practices and are
compensated on a per capita, fee schedule, or fee-for-service basis.
HMO - Network Model An HMO type in which the HMO contracts with more than one physician
group, and may contract with single- and multi-specialty groups. The
physician works out of his/her own office. The physician may share in
utilization savings, but does not necessarily provide care exclusively for
HMO members.
HMO - Staff Model A health care model that employs physicians to provide health care to its
members. All premiums and other revenues accrue to the HMO, which
compensates physicians by salary and incentive programs.
Home Health Agency (HHA) A facility or program licensed, certified or otherwise authorized pursuant
to State and Federal laws to provide health care services in the home.
Home Health Services Services and items furnished to an individual who is under the care of a
physician by a home health agency or by others under arrangements made
by such agency. Services are furnished under a plan established and
periodically reviewed by a physician. They are provided on a visiting basis
in an individual’s home and include: nursing, physical therapy, dietary,
counseling, and social services; part-time or intermittent skilled nursing
care; physical, occupational, or speech therapy; medical social services,
medical supplies and appliances (other than drugs and biologicals); home
health aide services; and services of interns and residents.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Hospice A program that provides palliative and supportive care for terminally ill
patients and their families, either directly or on a consulting basis with the
patient's physician or another community agency. Originally a medieval
name for a way station for crusaders where they could be replenished,
refreshed, and cared for, hospice is used here for an organized program of
care for people going through life's "last station." The whole family is
considered the unit of care, and care extends through their period of
mourning.
Indemnity Insurance An insurance program in which the insured person is reimbursed or the
provider is paid for covered expenses after services are rendered.
Innovator Multiple-Source An innovator multiple-source drug is a multiple source drug that was
Drug originally marketed under an original new drug application approved by
the FDA.
Inpatient Hospital Services Items and services furnished to a resident patient of a hospital by the
hospital. May include such items as: bed and board; nursing and related
services; diagnostic and therapeutic services; and medical or surgical
services.
Integrated Behavioral Health A carve-out benefit plan that combines independent managed care services
into what is designed as a seamless delivery system for behavioral health
concerns. Components could include employee assistance services, a
telephone counseling triage, utilization management, behavioral health
treatment networks, claims payment, and data management.
Integrated Delivery System A generic term referring to a joint effort of physician/hospital integration
for a variety of purposes. Some models of integration include physician-
hospital organization, group practice without walls, integrated provider
organization and medical foundation.
Intergovernmental Transfer The transfer of non-Federal public funds from a local government (or
(IGT) locally owned hospital or nursing facility) to the State Medicaid agency, or
from another State agency (or State-owned hospital) to the State Medicaid
agency, usually for the purpose of providing the State share of a Medicaid
expenditure in order to draw down Federal matching funds.
Intermediate Care Facility for The ICF/MR benefit is an optional Medicaid benefit for States. Section
the Mentally Retarded 1905(d) of the Social Security Act created this benefit to fund
(ICF/MR) "institutions" (4 or more beds) for people with mental retardation, and
specifies that these institutions must provide health and/or rehabilitative
services.
International Classification of A listing of diagnoses and identifying codes used by physicians for
Diseases, 9th Edition (Clinical reporting diagnoses of health plan enrollees. The coding and terminology
Modification) (ICD-9-CM) provide a uniform language that can accurately designate primary and
secondary diagnoses and provide for reliable, consistent communications on
claim forms.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Investigational Treatments Medical treatments, including drugs waiting for FDA approval, that are
considered experimental and, therefore, may not be covered by insurance
plans. The definition of experimental currently varies from plan to plan.
Laboratory and Radiological Professional and technical laboratory and radiological services ordered by
Services a licensed practitioner, provided in an office or similar facility (other than
a hospital outpatient department or clinic) or by a qualified lab.
Legend Drug A drug that, by law, can be obtained only by prescription and bears the
label, “Caution: Federal law prohibits dispensing without a prescription.”
See “Prescription Medication.”
Lifetime Maximum Benefit A limitation on financial coverage for health care for an individual stated by
an insurer. This amount serves as a cap on contractual liability and can be
exceeded only in rare and unusual circumstances.
Long-Term Care A set of health care, personal care and social services required by persons
who have lost, or never acquired, some degree of functional capacity (e.g.,
the chronically ill, aged, disabled, or retarded) in an institution or at home,
on a long-term basis. The term is often used more narrowly to refer only to
long-term institutional care such as that provided in nursing homes, homes
for the retarded and mental hospitals. Ambulatory services such home
health care, which can also be provided on a long-term basis, are seen as
alternatives to long-term institutional care.
Magnetic Resonance Imaging State-of-the-art machine used as a diagnostic tool, using magnetic fields to
produce comprehensive pictures of the anatomy.
Managed Care (1) A system of health care delivery that influences utilization and cost of
services and measures performance. The goal is a system that delivers
value by giving people access to high quality, cost-effective health care;
(2) A systemized approach which seeks to ensure the provision of the right
health care at the right time, place and cost.
Managed Care Organization Broad term that encompasses various types of health plans, including
(MCO) Health Maintenance Organizations (HMOs), Preferred Provider
Organizations (PPOs), Point-of-Service plans (POSs) and Provider-
Sponsored Organizations (PSOs). Often used to refer to a health plan that
is similar to an HMO but which does not have an HMO license and serves
only Medicaid beneficiaries.
Mandated Benefits Those benefits which health plans are required by State or Federal law to
provide to policyholders and eligible dependents.
Maximum Allowable Cost, or A fixed maximum cost for which the pharmacist can be reimbursed for
“Reasonable Cost Range” selected products, as identified in a “formulary.”
Maximum Out-of-Pocket Costs The limit on total member copayments, deductibles and coinsurance under a
benefit contract.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Means Testing The policy of basing eligibility for benefits upon an individual’s lack of
means, as measured by his or her income or resources. Means testing, by
definition, requires the disclosure of personal financial information by an
applicant as a condition of eligibility. Medicaid and SCHIP are means
tested programs.
Medicaid A Federally aided State-operated and administered program that provides
medical benefits for certain indigent or low-income persons in need of
health and medical care. The program, authorized by Title XIX of the
Social Security Act, is basically for the poor. It does not cover all of the
poor, however, but only persons who meet specified eligibility criteria.
Subject to broad Federal guidelines, States determine the benefits covered,
program eligibility, rates of payment for providers, and methods of
administering the program. Also referred to as State Medical Assistance
Programs.
Medicaid Buy-In A provision in certain health reform proposals whereby the uninsured
would be allowed to purchase Medicaid coverage by paying premiums on
a sliding scale based on income.
Medicaid Management Federally developed guidelines for a computer system designed to achieve
Information System (MMIS) national standardization of Medicaid claims processing, payment, review
and reporting for all health care claims.
Medicaid-only Managed Care An MCO that provides comprehensive services to Medicaid beneficiaries
Organization (Mcaid-MCO) but not commercial or Medicare enrollees.
Medicaid Statistical The information system developed by CMS to collect detailed data on
Information System (MSIS) eligibility, utilization, and payments for services covered by State Medicaid
programs.
Medical Assistance The term used in the Federal Medicaid statute (Title XIX of the Social
Security Act) to refer to payment for items and services covered under a
State’s Medicaid program.
Medical Care Advisory Committee A committee, consisting of physicians, other health professionals,
(MCAC)
Medicaid beneficiaries, and the director of the public health or welfare
agency, appointed by the Medicaid agency director to participate in policy
development and administration of a State’s Medicaid program.
Medical Necessity
The evaluation of health care services to determine if they are: medically
appropriate and required to meet basic health needs; consistent with the
diagnosis or condition and rendered in a cost-effective manner; and
consistent with national medical practice guidelines regarding type,
frequency and duration of treatment.
Medical Savings Account A non-taxable savings account used to cover medical expenses. Based
(MSA) loosely on the idea of individual retirement accounts.
Medically Needy Under Medicaid, medically needy cases are aged, blind, or disabled
individuals or families and children who are not otherwise eligible for
Medicaid, and whose income resources are above the limits for eligibility
as categorically needy (TANF or SSI) but are within limits set under the
Medicaid State Plan.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Medicare A U.S. health insurance program for people aged 65 and over, for persons
eligible for social security disability payments for two years or longer, and
for certain workers and their dependents who need kidney transplantation
or dialysis. Monies from payroll taxes and premiums from beneficiaries
are deposited in special trust funds for use in meeting the expenses
incurred by the insured. It consists of two separate but coordinated
programs: hospital insurance (Part A) and supplementary medical
insurance (Part B). Recent legislation has expanded the Medicare program
to include an HMO option (Part C) and a prescription drug benefit (Part
D). See “Medicare Prescription Drug, Improvement and Modernization
Act of 2003.”
Medicare Payment Advisory A Federal commission established under the Balanced Budget Act of 1997
Commission (MedPAC) to advise and assist Congress and the Department of Health and Human
Services in maintaining and updating the Medicare prospective payment
system. MedPAC replaces and assumes the responsibilities of the
Physician Payment Review Commission (PPRC) and the Prospective
Payment Assessment Commission (ProPAC).
Medicare Prescription Drug, The Medicare Prescription Drug, Improvement, and Modernization Act
Improvement, and (Public Law 108-173), also known as the Medicare Modernization Act
Modernization Act of 2003 (MMA) was enacted December 8, 2003. It enacted the Prescription Drug
(MMA) Program (Medicare Part D) effective January 2006, under which Medicare
will assume responsibility for the prescription drug needs of beneficiaries
eligible for both Medicare and Medicaid. It also enacted the temporary
Medicare Prescription Drug Discount Card Program, effective June 2004-
December 2005. Many other amendments to the Medicare and Medicaid
programs were also enacted, including coverage of an initial preventive
physical examination, cardiovascular screening blood tests, and diabetes
screening tests. Health Savings Accounts were also authorized. Medicare
payment limits were established for certain hospital outpatient
departments.
Medicare Supplemental
Insurance A policy guaranteeing that a health plan will pay a policyholder’s
coinsurance, deductible and copayments and will provide additional health
plan or non-Medicare coverage for services up to a predefined benefit
limit. In essence, the product pays for the portion of the cost of services
not covered by Medicare. Also called “Medigap” or “Medicare wrap.”
Medigap (Medicare See “Medicare Supplemental Insurance.”
Supplemental Insurance)
Members A participant in a health plan (member or eligible dependent). Also used to
describe an individual specified within a subscriber contract that may
receive health care services according to the terms of the subscriber
policy. Also known as "beneficiary," "enrollee," "subscriber," or
"insured."
Modified Fee-for-Service A system in which providers are paid on a fee-for-service basis, with certain
fee maximums for each procedure.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Most Favored Nations Discount A contractual agreement that stipulates that a vendor must provide to a
or Clause particular payor the lowest prices that would be available to any purchaser.
The Federal government often invokes most favored nation clauses for
health care contracts.
Multiple-Source Drug A multiple-source drug is one that is marketed or sold by two or more
manufacturers or labelers, or a drug marketed or sold by the same
manufacturer or labeler under two or more different proprietary names or
under a proprietary name and without such a name.
National Committee for Quality A national organization founded in 1979 composed of 14 directors
Assurance (NCQA) representing consumers, purchasers, and providers of managed health care.
It accredits quality assurance programs in prepaid managed health care
organizations, and develops and coordinates programs for assessing the
quality of care and service in the managed care industry, including the
HEDIS quality measures.
National Drug Code (NDC) A national classification system for identification of drugs. Similar to the
Universal Product Code (UPC).
Network Plan A phrase that generally refers to arrangements where providers contract
with payers or a managed care plan to provide services for patients
enrolled in the managed care plan. See “Managed Care.”
Nurse-Midwife Services Nurse-midwife services are those concerned with the management of care
of mothers and newborns throughout the maternity cycle. OBRA 1980
required that payment be made for providing nurse-midwife services to
categorically needy recipients to the extent that the nurse-midwife is
authorized to practice under State law or regulation. States are also
required to offer direct reimbursement to nurse-midwives as one of the
payment options. Nurse-midwives must be registered nurses who are either
certified by an organization recognized by the Secretary of HHS or who
have completed a program of study and clinical experience that has been
approved by the Secretary.
Nursing Facility (NF) A facility in either freestanding or part of a hospital, that accepts patients
in need of rehabilitation and medical care that is of a lesser intensity than
that received in a hospital.
Nursing Facility Services All services furnished to inpatients of, and billed for by, a formally
certified nursing facility that meets standards set by Secretary of DHHS.
Other Practitioners’ Services Health care services of licensed practitioners other than physicians and
dentists.
Out-of-Pocket Costs/Expenses The portion of payments for health services required to be paid by the
(OOPs) enrollee, including copayments, coinsurance and deductibles.
Out-of-Pocket Limit The total payments toward eligible expenses that a covered person funds for
him/herself and/or dependents: i.e., deductibles, copays and coinsurance -
as defined per the contract. Once this limit is reached, benefits will increase
to 100% for health services received during the rest of that calendar year.
Some out-of-pocket costs (e.g., mental health, penalties for non-
precertification, etc.) are not eligible for out-of-pocket limits.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Outcome Measures Assessments which gauge the effect or results of treatment for a particular
disease or condition. Outcome measures include such parameters as: the
patient’s perception of restoration of function, quality of life and functional
status, as well as objective measures of mortality, morbidity and health
status.
Outcomes Research Studies aimed at measuring the effect of a given product, procedure, or
medical technology on health or costs.
Outpatient Services Outpatient services are medical and other services provided on a non-
resident basis (patients are not admitted to the facility) by a hospital or
other qualified facility, such as a mental health clinic, rural health clinic,
mobile X-ray unit, or freestanding dialysis unit. Such services include
outpatient physical therapy services, diagnostic X-ray and laboratory tests,
and X-ray and other radiation therapy.
Over-the-Counter (OTC) A drug product that does not require a prescription under Federal or State
law.
Participating Provider A provider who has contracted with the health plan to provide medical
services to covered persons. The provider may be a hospital, pharmacy,
other facility or a physician who has contractually accepted the terms and
conditions as set forth by the health plan.
Patient Health Status Survey Questionnaire used to solicit patient perceptions regarding the state of their
health. Questions may be general and address overall health status with
regard to a specific condition (e.g., an arthritic patient’s ability to make a
fist or an asthmatic patient’s ability to climb a flight of stairs).
Patient Satisfaction Survey Questionnaire used to solicit the perceptions the plan enrollees or patients
have regarding how a health plan meets their medical needs and how the
delivery of care is handled, (e.g., waiting time, access to treatments).
Payer A general term indicating the responsible party for the payment of medical
care service expenses. Payers may be patients, insurance companies,
government agencies, or a combination of these.
Pediatric Nurse Practitioner Services furnished as authorized under State law by a registered
and Family Nurse Practitioner professional nurse who meets a State’s advanced educational and clinical
Services practice requirements, whether or not the practitioner is under the
supervision of or associated with a physician or other health care provider.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Peer Review The evaluation of quality of total health care provided, by medical staff
with equivalent training.
Peer Review Organization An entity established by the Tax Equity and Fiscal Responsibility Act of
(PRO) 1982 (TERFA) to review quality of care and appropriateness of
admissions, readmissions and discharges for Medicare and Medicaid.
These organizations are held responsible for maintaining and lowering
admission rates, and reducing lengths of stay while insuring against
inadequate treatment. Also known as “Professional Standards Review
Organization.”
Personal Support Services Personal support services consist of a variety of services including personal
care, targeted case management, home and community-based care for
functionally disabled elderly, rehabilitative services, hospice services, and
nurse-midwife, nurse practitioner, and private duty nursing services.
Pharmacy And Therapeutics An organized panel of physicians and pharmacists from varying practice
(P&T) Committee specialties, who function as an advisory panel to the plan regarding the safe
and effective use of prescription medications. Often comprises the official
organizational line of communication between the medical and pharmacy
components of the health plan. A major function of such a committee is to
develop, manage and administer a drug formulary.
Physician Any doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who is duly
licensed and qualified under the law of jurisdiction in which treatment is
received.
Point-Of-Service (POS) Plan A health plan allowing the covered person to choose to receive a service
from a participating or non-participating provider, with different benefit
levels associated with the use of participating providers. POS can be
provided in several ways: an HMO may allow members to obtain limited
services from non-participating providers; an HMO may provide non-
participating benefits through a supplemental major medical policy; a PPO
may be used to provide both participating and non-participating levels of
coverage and access; or various combinations of the above may be used.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Pre-Existing Condition (PEC) Any medical condition that has been diagnosed or treated within a
specified period immediately preceding the covered person’s effective date
of coverage under the master group contract.
Preferred Provider A program in which contracts are established with providers of medical
Organization (PPO) care. Providers under such contracts are referred to as preferred providers.
Usually, the benefit contract provides significantly better benefits (fewer
copayments) for services received from preferred providers, thus
encouraging covered persons to use these providers. Covered persons are
generally allowed benefits for non-participating providers’ services,
usually on an indemnity basis with significantly higher copayments. A
PPO arrangement can be insured or self-funded. Providers may be, but are
not necessarily, paid on a discounted fee-for-service basis.
Prepaid Group Practice Plans Organized medical groups of essentially full-time physicians in
appropriate specialties, as well as other professional and subprofessional
personnel, who, for regular compensation, undertake to provide
comprehensive care to an enrolled population for premium payments that
are made in advance by the consumer and/or their employers.
Prepaid Health Plan (PHP) An entity that provides a non-comprehensive set of services on either
capitated risk or non-risk basis or the entity provides comprehensive
services on a non-risk basis.
Prescribed Drugs Prescribed drugs are drugs dispensed by a licensed pharmacist on the
prescription of a practitioner licensed by law to administer such drugs, and
drugs dispensed by a licensed practitioner to his own patients. This item
does not include a practitioner’s drug charges that are not separable from
his other charges, or drugs covered by a hospital bill.
Prescription Medication A drug which has been approved by the Food and Drug Administration and
which can, under Federal and State law, be dispensed only pursuant to a
prescription order from a duly licensed prescriber, usually a physician.
Preventive Care Comprehensive care emphasizing priorities for prevention, early detection
and early treatment of conditions, generally including routine physical
examinations, immunization and well person care.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Primary Care Basic or general health care traditionally provided by family practice,
pediatrics and internal medicine. See also “Secondary Care.”
Primary Care Case Managed care arrangements where primary care providers receive a per
Management (PCCM) capita management fee to coordinate a patient's care in addition to
reimbursement (fee-for-service or capitation) for the medical services they
provide.
Primary Care Physician (PCP) The primary care practitioner (e.g., internist, family/general practitioner,
pediatrician, and in some cases, OB/Gyn) in managed care organizations
who determines whether the presenting patient needs to see a specialist or
requires other non-routine services. See Care Coordinator.
Prospective Financing Financing for health care services based on prices or budgets determined
prior to the delivery of service. Payments can be per unit of service, per
member, or per time period. In all its forms prospective financing differs
from cost-based reimbursement, under which a provider is paid for costs
incurred.
Qualified Medicare Beneficiary An individual who qualifies for Medicare Part A, whose income does not
(QMB) exceed 100 percent of the Federal poverty level, and whose resources do
not exceed twice the SSI resource-eligibility standard. Medicaid coverage
of QMBs is limited to payments of their Medicare cost-sharing charges,
such as Medicare premiums, coinsurance, and copayment amounts.
Quality Assurance (QA) or A formal set of activities to review and affect the quality of services
Quality Improvement (QI) provided. Quality assurance includes assessment and corrective actions to
remedy any deficiencies identified in the quality of direct patient,
administrative and support services.
Rate Setting A form of financing under which hospitals or nursing homes are paid
prices that are prospectively determined, generally by a State agency.
Prospectively determined prices may be paid by all payers for all covered
services, as in all payer systems, or by only some payers. The unit of
payment can be service, patient, or time period. See “Prospective
Financing.”
Rational Drug Therapy Prescribing the right drug for the right patient, at the right time, in the right
amount, and with due consideration of relative cost.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Reasonable Cost In processing claims for health insurance benefits, intermediaries use CMS
guidelines to determine the reasonable cost incurred by the individual
providers in furnishing covered services to enrollees. The reasonable cost
is based on the actual cost of providing such services, including direct and
indirect costs of providers, excluding any costs that are unnecessary in the
efficient delivery of services covered by the insurance program.
Referral The process of sending a patient from one practitioner to another for health
care services. Health plans may require that designated primary care
providers authorize a referral for coverage of specialty services.
Restrictive Formulary A term often used synonymously with closed formulary. See “Drug
Formulary.”
Retrospective Review Determination of medical necessity and/or appropriate billing practice for
services already rendered.
Risk Responsibility for paying for or otherwise providing a level of health care
services based on an unpredictable need for these services.
Risk Contract (1) An agreement between a State Medicaid program and an HMO or
competitive medical plan requiring the HMO to furnish at a minimum all
Medicaid covered services to Medicaid eligible enrollees for an annually
determined, fixed monthly payment rate from the State government. The
HMO is then liable for services regardless of their extent, expense or
degree. (2) An agreement between a provider and payer, or intermediary,
on behalf of a payer, that requires the provider to furnish all specified
services for a specified enrollee for a set fee, usually prepaid, and for a set
period of time (usually one year). The provider is then liable for services
regardless of their extent, expense or degree. Such stated limitations for
such liability are stated in advance and may be subject to reinsurance.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Rural Health Clinic A rural health clinic is an outpatient facility which is primarily engaged in
furnishing physician and other medical and health services, which meets
certain other requirements designed to ensure the health and safety of the
individuals served by the clinic. The clinic must be located in an area that
is not urbanized as defined by the Census Bureau and that is designated by
the Secretary of DHHS either as an area with a shortage of personal health
services, or as a health manpower shortage area, and has filed an
agreement with the Secretary not to charge any individual or other person
for items or services for which such individual is entitled to have payment
made by Medicare, except for the amount of any deductible or coinsurance
amount applicable.
Section 1115 Waivers Section 1115 of the Social Security Act grants the Secretary of Health and
Human Services broad authority to waive certain laws relating to Medicaid
for the purpose of conducting pilot, experimental or demonstration
projects. Section 1115 demonstration waivers allow States to change
provisions of their Medicaid programs, including: eligibility requirements,
the scope of services available, the freedom to choose a provider, a
provider’s choice to participate in a plan, the method of reimbursing
providers, and the statewide application of the program. Projects typically
run three to five years.
Section 1915(b) of the Social Security Act authorizes the Secretary of
Section 1915(b) Waivers
Health and Human Services to waive compliance with certain portions of
the Medicaid statute that prevent a State from mandating Medicaid
beneficiaries obtain their care from a single provider or health plan.
Section 1915(b) waivers allow States to operate mandatory managed care
programs in all or portions of the State while continuing to receive Federal
Medicaid matching funds. Waivers must be approved by the Centers for
Medicare & Medicaid Services (CMS).
Section 1915(c) Waivers Section 1915(c) of the Social Security Act authorizes the Secretary of
Health and Human Services to allow State Medicaid programs to offer
special services to beneficiaries at risk of institutionalization in a nursing
facility or facility for the mentally retarded. These services, which would
otherwise not qualify for Federal matching funds, include case
management, homemaker/home health aide services, rehabilitation
services, and respite care. They also include, in the case of individuals,
with chronic mental illness, day treatment and partial hospitalization,
psychosocial rehabilitation, and clinic services. Also know as home and
community-based (HCBS) waivers.
Sin Taxes Taxes imposed on items considered harmful to public health interests, such
as tobacco and alcohol.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
Specified Low-Income These individuals are entitled to Medicare Part A, have income of greater
Medicare Beneficiary (SLMB) than 100% FPL, but less than 120% FPL and resources that do not exceed
Program twice the limit for SSI eligibility, and are not otherwise eligible for
Medicaid as a dual eligible. Medicaid pays their Medicare Part B
premiums only, but they are not eligible for Medicaid payment for their
Medicare cost-sharing obligations.
State Buy-In The term given to the process by which a State may provide
Supplementary Medical Insurance coverage for its needy eligible persons
through an agreement with the Federal government under which the State
pays the premiums for them.
State Children’s Health As part of the Balanced Budget Act of 1997, Congress created SCHIP as a
Insurance Program (SCHIP) Federal/State partnership with the goal of expanding health insurance to
children whose families earn too much money to be eligible for Medicaid,
but not enough money to purchase private insurance. SCHIP is designed
to provide coverage to "targeted low-income children." A "targeted low-
income child" is one who resides in a family with income below 200% of
the Federal Poverty Level (FPL) or whose family has an income 50%
higher than the State's Medicaid eligibility threshold. Unlike Medicaid,
SCHIP is a block grant awarded to the States each year. Children who are
eligible for Medicaid are not eligible for SCHIP.
State Mandated Benefits Laws State laws requiring insurance contracts to provide coverage for certain
health services (e.g., in vitro fertilization) or services provided by certain
health care providers (e.g., audiologists). Self-insureds are exempt from
these requirements.
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National Pharmaceutical Council Pharmaceutical Benefits 2004
Term Definition
State Plan Amendment A State that wishes to change its Medicaid eligibility criteria or its covered
benefits or its provider reimbursement rates must amend its State Medicaid
Plan to reflect the proposed change. The State must submit the State Plan
Amendment to CMS for approval.
Stop Loss
That point at which a third party has reinsurance to protect against the
overly large single claim or the excessively high aggregate claim during a
given period of time. Large employers, who are self-insured, may also
purchase “reinsurance” for stop-loss purposes.
Supplemental Security Income A Federal cash assistance program for low-income aged, blind and
(SSI) disabled individuals established by Title XVI of the Social Security Act.
States may use SSI income limits to establish Medicaid eligibility.
Tax Equity and Fiscal The Federal law which created the current risk and cost contract provisions
Responsibility Act of 1982 under which health plans contract with CMS and which defined the primary
(TEFRA) and secondary coverage responsibilities of the Medicare program.
Temporary Assistance to Needy Federal-State welfare program which replaces Aid to Families with
Families (TANF) Dependent Children. Authorized by the 1996 Welfare Reform Act. States
may use TANF to establish Medicaid eligibility.
Therapeutic Alternatives Drug products containing different chemical entities but which should
provide similar treatment effects, the same pharmacological action or
chemical effect when administered to patients in therapeutically equivalent
doses.
Therapeutic Substitution Dispensing by a pharmacist of a product different from that which was
prescribed, but which is deemed to be therapeutically equivalent. In most
States such a practice requires the prescribing physician’s authorization
before the substitution may occur. A pharmacy and therapeutics committee
(P&T) most often approves the rationale for therapeutic equivalency prior
to such practice.
Third-Party Administrator An independent person or corporate entity (third party) that administers
(TPA) group benefits, claims and administration for a self-insured company/group.
A TPA does not underwrite the risk.
Third-Party Liability Under Medicaid, third-party liability exists if there is any entity (i.e., other
government programs or insurance) which is or may be liable to pay all or
part of the medical cost or injury, disease, or disability of an applicant or
recipient of Medicaid.
Universal Access The availability of affordable public or private insurance coverage for
every United States citizen or legal resident. There is no guarantee,
however, that all individuals will actually choose to purchase or have the
funds to purchase coverage. See “Universal Coverage.”
Universal Coverage The guaranteed provision of at least basic health care services to every
United States citizen or legal resident. See “Universal Access.”
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Term Definition
Usual, Customary and A term used to refer to the commonly charged or prevailing fees for health
Reasonable Charges services within a geographic area. A fee is considered to be reasonable if
it falls within the parameters of the average or commonly charged fee for
the particular service within that specific community.
Utilization The extent to which the members of a covered group use a program or
obtain a particular service, or category of procedures, over a given period of
time. Usually expressed as the number of services used per year or per 100
or 1,000 persons eligible for the service.
Utilization Management (UM) A process of integrating review and case management of services in a
cooperative effort with other parties, including patients, providers, and
payers.
Vaccines for Children Program A program under which the Federal government, through the Centers for
(VCF) Disease Control and Prevention, purchases and distributes pediatric
vaccines to States at no charge and the State, in turn, arranges for the
immunization of Medicaid-eligible and uninsured children through public
and private physicians or other authorized providers.
Vendor Payments In welfare programs, direct payments are made by the State to providers
such as physicians, pharmacists and health care institutions rather than to
the welfare recipient himself.
Withhold “At-risk” portion of a claim deducted and withheld by the health plan
before payment is made to a participating physician as an incentive for
appropriate utilization and quality of care. This amount – for example,
20% of the claim – remains within the plan and is credited to the doctor’s
account. Can be used where the plan needs additional funds to pay for
claims. The withhold may be returned to the physician in varying levels
which are determined based on analysis of his/her performance or
productivity compared against his/her peers. Also called “physician
contingency reserve (PCR).”
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ACRONYMS
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NP Nurse Practitioner
OACT Office of the Actuary
OASDI Old Age, Survivors, and Disability Insurance
OBRA Omnibus Budget Reconciliation Act
OHS Outpatient Hospital Services
OMB Office of Management and Budget
ORD Office of Research and Demonstrations
OT Occupational Therapy
OTC Over-the-Counter (drugs)
P&T Pharmacy and Therapeutics Committee
PA Physician’s Assistant or Prior Authorization
PBM Pharmaceutical Benefits Manager
PCCM Primary Care Case Management
PCF Program Characteristics File
PCP Primary Care Physician
PHP Prepaid Health Plan
PMPM Per Member Per Month
PHO Physician-Hospital Organization
POS Point-of-Service
PPO Preferred Provider Organization
PRO Peer Review Organization
ProPAC Prospective Payment Assessment Commission
PT Physical Therapy
QA/QI Quality Assurance/Quality Improvement
QMB Qualified Medicare Beneficiary
RHC Rural Health Clinic
RPH Registered Pharmacist
Rx Pharmaceutical
SCHIP State Children’s Health Insurance Program
SFO State Funds Only
SLMB Specified Low-Income Medicare Beneficiary
SSA Social Security Administration
SSI Supplemental Security Income
SSP State Supplemental Payments
TANF Temporary Assistance for Needy Families
TDOC Total Days of Care
TEFRA Tax Equity & Fiscal Responsibility Act
Title XIX Title XIX of The Social Security Act (See Medicaid)
TPA Third-Party Administrator
TQM Total Quality Management
UCR Usual, Customary and Reasonable
UM Utilization Management
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UR Utilization Review
VCF Vaccines for Children Program
WAC Weighted Average Cost or Wholesale Acquisition Cost
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