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National Pharmaceutical Council Pharmaceutical Benefits 2003

TABLE OF CONTENTS

INTRODUCTION......................................................................................................................................v
SECTION 1: THE MEDICARE PRESCRIPTION DRUG, MODERNIZATION,
AND IMPROVEMENT ACT OF 2003, DUAL ELIGIBLES, AND
IMPACT ON STATES .................................................................................................. 1-1

SECTION 2: THE MEDICAID PROGRAM ..................................................................................... 2-1

Medicaid Program Overview.................................................................................................... 2-3


- Total Medicaid Eligibles by Maintenance Assistance Status, 2001........................ 2-11
- Total Medicaid Eligibles by Age Group, 2001........................................................ 2-12
- Total Medicaid Eligibles by Basis of Eligibility, 2001 ........................................... 2-13
- Total Medicaid Eligibles by per 1000 Population, 2001 ........................................ 2-14
- Total Net U.S. Medical Assistance Expenditures by Type of Service ................... 2-15
- Federal Medical Assistance Percentages (FMAP), FY 2004 and FY 2005 ........... 2-16
- Medicaid Total Net Expenditures and Eligibles, 2001 ........................................... 2-17
- Total Medicaid Program Expenditures, 2002 ......................................................... 2-18
- Total SCHIP Expenditures, 2002 ........................................................................... 2-19

Medicaid Managed Care Enrollment ................................................................................... 2-21


- Medicaid Managed Care Enrollment, As of June 30, 2002..................................... 2-23
- Pharmaceutical Benefits Under Managed Care Plans ............................................ 2-24
- Medicaid Managed Care Enrollment Trends, 1998-2002 ....................................... 2-25
- Medicaid Managed Care Plan Type, As of June 30, 2002 ...................................... 2-26
- Medicaid Managed Enrollment by Plan Type, As of June 30, 2002....................... 2-27
- Medicaid Managed Care Enrollment by Payment Arrangement,
As of June 30, 2002 ............................................................................................... 2-28

Medicaid Managed Care Waivers.......................................................................................... 2-29


- Section 1915(b) Waivers, As of June 30, 2002 ....................................................... 2-33
- Section 1115 Research and Demonstration Waivers, As of June 30, 2002............. 2-35
- Pharmacy Plus Demonstrations Program Status, Pharmacy Waivers
Under 115 Authority................................................................................................ 2-36

SECTION 3: STATE CHARACTERISTICS ……………………………………………………….3-1

Sociodemographics
- Age Demographics, 2002 .......................................................................................... 3-5
- Race Demographics, 2002 ......................................................................................... 3-6
- Hispanic Demographics, 2002 .................................................................................. 3-7
- Insurance Status-Populations, 2002 .......................................................................... 3-8
- Insurance Status-Percentages, 2002 ........................................................................ 3-9
- Poverty Status-Populations, 2002 ........................................................................... 3-10

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- Poverty Status-Percentages, 2002............................................................................ 3-11


- Employment Status, 2003........................................................................................ 3-12

Health Care Delivery System


− Medicaid/Medicare Certified Facilities ................................................................... 3-13
− Licensed Pharmacies................................................................................................ 3-14
− Physicians, 2001 ...................................................................................................... 3-16
− Other Providers ........................................................................................................ 3-17

SECTION 4: PHARMACY PROGRAM CHARACTERISTICS..................................................... 4-1

Medicaid Drug Program ........................................................................................................... 4-3


− Drug Expenditures Trends ......................................................................................... 4-5
− Ranking Based on Drug Expenditures....................................................................... 4-6
− Drugs as a Percentage of Total Net Expenditures, 2002 ........................................... 4-7
− Drugs as a Percentage of Total Net Expenditures, 2000-2002 .................................. 4-8
− Share of Drug Expenditures by Category, 2002 ........................................................ 4-9
− Share of Prescriptions Processed, 2002 ................................................................... 4-11
− Medicaid Average Cost per Prescription, 2002 ....................................................... 4-13

Medicaid Drug Rebates ........................................................................................................... 4-15


− Medicaid Drug Rebates, 2002 ................................................................................. 4-17
− Medicaid Drug Rebate Trends, 1998-2002.............................................................. 4-18
− Medicaid Drug Rebate Trends, Annual Percent Change, 1997-2002...................... 4-19
− Rebates As Percent of Drug Expenditures, 2002..................................................... 4-20

Medicaid Drug Coverage ........................................................................................................ 4-21


− Pharmacy Advisory Committees ............................................................................. 4-23
− Pharmacy Benefit Design – Coverage ..................................................................... 4-24
− Coverage of Injectables ........................................................................................... 4-27
− Coverage of Vaccines and Unit Dose ...................................................................... 4-28
− Coverage of Over-the-Counter Medications............................................................ 4-29
− Prior Authorization Process and Procedures ........................................................... 4-31
− Prior Authorization .................................................................................................. 4-34
− Drug Utilization Review.......................................................................................... 4-37
− Prescribing/Dispensing Limits................................................................................. 4-38

Pharmacy Payment and Patient Cost Sharing...................................................................... 4-39


− Pharmacy Payment and Patient Cost Sharing.......................................................... 4-41
− Maximum Allowable Cost (MAC) Programs.......................................................... 4-42
− Mandatory Substitution............................................................................................ 4-43
− Counseling Requirements and Payment for Cognitive Services ............................. 4-44
− Prescription Price Updating ..................................................................................... 4-45

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SECTION 5: STATE PROFILES ........................................................................................................ 5-1

SECTION 6: STATE PHARMACY ASSISTANCE PROGRAMS .................................................. 6-1

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 2003 edition of Pharmaceutical Benefits under State Medical Assistance Programs marks the 38th
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: Reports on the Medicare Modernization Act provisions, the dual eligibles it will
affect, and the overall impact on the States.
• 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 2002.
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 2003
NPC annual survey of State pharmacy program administrators. In addition, this section
provides Medicaid eligibility statistics from CMS for fiscal year 2001 and program
expenditure data for fiscal years 2001 and 2002. 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 2000 and FY 2001 and data on total
number of drug recipients for each State and the nation as a whole for the period 1996-2001.
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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Each year, finding and compiling current, relevant information for inclusion in the Compilation
presents a challenge. For example, each year CMS makes available on its website the Medical
Statistical Information System (MSIS) Statistical Reports for the most recent enrollment and
expenditure data available. The MSIS tables are used throughout several sections as a secondary data
source. This year, CMS released MSIS reports on federal Fiscal Year 2001. However, at the time of
publication, the FY 2001 information for Washington State was not yet available. FY 2000 data have
been substituted in their place. Additionally, Hawaii did not report for FY 2000 and FY 2001,
therefore, their FY 1999 numbers are used.

In addition, updated information for the Medicaid Waivers and Managed Care statistics have not been
released at this time. We believe that this remains an important aspect of State Medical Assistance
Programs and have included last year’s data in its place.

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:

• Eligibility and maintenance assistance status table;


• Eligibility and age table;
• New poverty tables including raw numbers and percentages;
• Enhanced employment tables;
• Additional information on the Pharmacy Plus Demonstration waivers under Section 1115
Authority;
• New listing for brand name products contacts in the State Profiles and Appendix A; and
• A new source for the registered nurses.

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 90 percent response rate to
the 2003 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, 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:
The Medicare Prescription
Drug, Improvement, and
Modernization Act of 2003:
Dual Eligibles and Impact
on the States

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BACKGROUND AND PURPOSE

The Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003
was passed by Congress and signed by the President in December 2003. MMA will have
a significant impact on Medicare beneficiaries and State Medicaid programs through
changes affecting those dually eligible for both Medicare and Medicaid. The purpose of
this section is to:

• Provide a concise summary of the key provisions affecting those dually eligible and the States.

• Provide details of the demographic and Medicaid expenditure characteristics of the dually
eligible, using data from ten states.

THE MEDICARE MODERNIZATION ACT OF 2003

The MMA1 has been described as the most significant expansion of the Medicare program since the
latter was originally enacted in 1965. It affects all aspects of Medicare and related programs. MMA
enacted:

• A new voluntary Medicare Prescription Drug Program, effective January 2006 [Medicare Part
D].

• A new Medicare Prescription Drug Discount Card Program as a transition to the Prescription
Drug Program, available from mid-2004 through December 2005.

• Prescription drug coverage currently provided by Medicaid to individuals who are dually
eligible for Medicaid and Medicare will be available only through Medicare Part D Plan
beginning in 2006, but states will be required to continue contributing toward the cost of this
coverage.

• Revisions to the Medicare provisions for Health Maintenance Organizations (HMOs), now
called the Medicare Advantage (MA) program [Medicare Part C].

• New payment provisions for drugs furnished by physicians [under Medicare


Part B].

• Dozens of other amendments affecting the existing Medicare program, including:


o Enhancements of services furnished in rural areas.
o Coverage of additional preventive screening tests (cardiovascular screening blood
tests; diabetes screening tests; an initial preventive screening examination; payment
improvements for mammography tests).
o Additional demonstration projects and studies, including a demonstration project for
the coverage of certain prescription drugs and biologicals.
o Authority to replace Medicare fiscal intermediaries and carriers with regular
government contractors.

1
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. Law No. 108-173
(December 8, 2003).

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o Detailed procedures for appealing Medicare coverage provisions and other


administrative decisions.
o Establishment of a unified center within CMS for the coordinated administration of
the Medicare HMO, drug, and beneficiary marketing and outreach programs.

• Various amendments to the Medicaid program, including exclusion of inpatient drugs


purchased by certain public hospitals and exclusion of prices negotiated under a Part D Plan,
from the “best price” calculation for the Medicaid drug rebate program.

• Reforms to the Hatch-Waxman patent procedure for introducing new generic drugs.

• Establishment of Health Savings Accounts and other tax amendments.

PROVISIONS OF MMA AFFECTING DUAL ELIGIBLES AND THE STATES

The Prescription Drug Program

A separate Medicare program. The prescription drug program will be a new, separate part of the
Medicare program (Part D). Enrolling in the program, and paying the required premiums, will be a
voluntary choice for most beneficiaries. However, a Medicare beneficiary must first be entitled to
Medicare Part A or enrolled in Medicare Part B in order to be eligible to enroll in a Part D Prescription
Drug Plan (PDP). A full-benefit dual eligible individual who fails to enroll in a drug plan may be
enrolled by CMS into a drug plan whose monthly premium does not exceed the amount of the
premium subsidy. If there is more than one such plan available, CMS will enroll the individual on a
random basis among all plans in the region. However, the individual will remain free to decline or
change this enrollment.

A covered Part D drug is defined as a drug that may be dispensed only with a prescription and that
meets the same tests for safety and efficacy under the Federal Food, Drug, and Cosmetic Act as apply
under the Medicaid drug rebate program. Also covered are approved biologicals, insulin and medical
supplies associated with insulin injections, and approved vaccines. However, drugs excluded from the
Medicaid drug rebate program are also excluded from Medicare Part D, except for smoking cessation
agents, which can be covered.

Enrolling in a Drug Plan. A beneficiary currently in the traditional Medicare fee-for-service program
will be able to enroll in a PDP. A beneficiary enrolled in a Medicare HMO, called a Medicare
Advantage (MA) Plan, will be able to enroll only in that Plan’s drug benefits program if it qualifies
under the new law (“an MA-PD Plan”); such a beneficiary will not be allowed to enroll in a fee-for-
service drug Plan unless the MA-Plan lacks qualified drug coverage.

CMS must ensure that there are at least two Drug Plans available in each area, offered by different
entities, and at least one of the Plans must be a PDP. The other may be an MA-PD Plan.

Premium and Cost-Sharing Subsidies for Low-Income Beneficiaries

The new law defines a subsidy eligible individual as an individual eligible for Medicare Part D drug
benefits who is enrolled in a PDP or an MA-PD Plan; has income below 150% of the Federal poverty
line; and whose resources for 2006 do not exceed three times the maximum amount of resources under
the SSI program (which is $2,000 in countable resources for an individual or $3,000 for a married
couple). Thus, the Part D resources limit would be $6,000 for an individual or $9,000 for a married
couple. These limits will be increased each year in multiples of $10 by the percentage increase in the
Consumer Price Index (“CPI”). For individuals with income below 135% of the Federal poverty level,

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the resources limit for 2006 is $10,000 for an individual, or $20,000 for a married couple, increased
annually in multiples of $10 by the CPI.

The new law defines a full-benefit dual eligible individual as a beneficiary who has qualified for
prescription drug benefits under a Medicare PDP, and who has been determined by the State Medicaid
program to be eligible for any category of full Medicaid benefits. This includes the “medically
needy,” once they have “spent down” their medical expenses to meet the Medicaid income and
resource levels.

When a dually eligible beneficiary has access to drug coverage under both a PDP under Medicare Part
C or D, and under the State’s Medicaid program, Medicare will be the primary payer and no Medicaid
benefits will be available for the drugs themselves or for any cost sharing for them, such as deductibles
and co-payments. However, a State Medicaid Plan may choose to continue to provide Medicaid
coverage in case of a drug that is not covered under a PDP and is covered by the Medicaid Plan.

CMS will notify a PDP of the exact status of each subsidy eligible individual enrolled in the Plan. The
Plan will reduce the beneficiary’s premiums, deductibles, and co-payments appropriately, and CMS
will periodically reimburse the Plan for such reductions.

Individuals with income below 135% of the Federal poverty line will be eligible for a subsidy of
100% of the premium for basic drug coverage. They will be subject to a drug deductible of zero.
Benefits will be payable for drug costs incurred above the initial coverage limit (the “doughnut hole”),
subject to reduced cost sharing, but no co-insurance will be due for full benefit dual eligibles who are
institutionalized. The reduced cost sharing for individuals who are not institutionalized will be $2 for
a generic drug or a multiple source drug and $5 for any other drug. However, individuals with income
not exceeding 100% of the Federal poverty line who are not institutionalized will be subject to a
reduced co-payment of $1 for a generic drug or a preferred multiple source drug, and $3 for any other
drug, increased annually in multiples of 5 cents and 10 cents, respectively, by the percentage increase
in annual aggregate Part D expenditures. There will be no cost sharing for the cost of drugs that
exceeds the out-of-pocket limit ($3600).

Other individuals with income below 150% of the federal poverty line will be entitled to a reduced
deductible of $50 for 2006, increased annually in multiples of $1 by the percentage increase in
aggregate Part D expenditures. They will also be entitled to a premium subsidy based on a sliding
scale ranging from 100% premium subsidy for individuals with income at or below 135% of the
Federal poverty line, to a premium subsidy of 0 for individuals at or above 150% of the Federal
poverty level. These individuals will also be entitled to a reduced annual deductible of $50. Benefits
will be payable for drug costs incurred above the initial coverage limit (the “doughnut hole”), subject
to reduced co-payment of 15% (instead of 25%).

Phased Down State Contribution

The costs States now incur for drugs for dual eligibles will be shifted to Medicare, but States must
continue to pay CMS a portion of those costs. The new law provides that this assumption of costs by
the Federal government be phased in gradually. To accomplish this phase-in, each State must pay to
CMS each month, beginning January 2006, an amount equal to the product of:

• the “Medicaid amount” for the State for that month;


• the total number of full-benefit dual eligible individuals for the State for that month; and
• the phase-in factor.

The “Medicaid amount” is 1/12 of the product of:

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• the base year Medicaid per capita expenditures for full benefit dual-eligibles; and
• a proportion equal to 100% minus the Federal medical assistance percentage (“FMAP”) (“the
matching rate”).

This product is increased each year (beginning with 2004 up to and including the year involved) by the
“growth factor.”

The “base year State Medicaid per capita expenditures” for covered Part D drugs for full-benefit
dual eligible individuals for a State is the weighted average of:

• the gross per capita Medicaid expenditures for prescription drugs for 2003; and
• the estimated actuarial value of prescription drug benefits under a capitated managed care plan
per full-benefit dual eligible individual for 2003.

The “growth factor” for 2004, 2005, and 2006 is the average annual percent change from the previous
year of the per capita amount of prescription drug expenditures as determined based on the most recent
National Health Expenditures for the years involved. For subsequent years, the growth factor is the
percentage change in aggregate annual expenditures for Part D drugs.

The “phase in factor” for a month is 90% in 2006; 88 1/3% in 2007; 86 2/3% in 2008; 85% in 2009;
83 1/3% in 2010; 81 2/3% in 2011; 80% for 2012; 78 1/3% for 2013; 76 2/3% for 2014; and 75%
thereafter.

MMA Medicaid Amendments Requiring State Medicaid Program Actions

A State Medicaid Plan must provide that the State Medicaid program will make eligibility
determinations for low-income beneficiaries who can qualify for premium and cost sharing subsidies
under a PDP Plan, as well as for any Medicare cost sharing, and will offer the individual any available
Medicaid benefit. The State’s administrative costs under this provision are treated as regular Medicaid
administrative costs and the Federal government will match these costs at the rate for Medicaid
administrative costs. The Commissioner of Social Security can also make eligibility determinations
when necessary.

CHARACTERISTICS OF DUALLY ELIGIBLE BENEFICARIES

The following analysis is based on detailed Medicaid Management Information System (MMIS) data
from ten States, for Federal Fiscal Year 2000. Medicaid Statistical Information System (MSIS) data
consists of four claims files and an eligibility file. The claims files are inpatient, long-term care,
prescription drug, and the “other” file. These files contain all claims paid during each fiscal quarter.
A copy of the data dictionary and a detailed overview of the MSIS files can be found at
http://cms.hhs.gov/medicaid/datasources.asp.

The data used in this analysis were obtained under strict confidentiality agreements with the States,
which prohibits their identification. The ten States are both programmatically and geographically
diverse, but comparisons of the ten States to all States using currently available data confirmed that the
ten States are reasonably representative of all States for FFY 2000.

Analytic File Development

Developing the analytical files involved several steps. To begin, we created a research file from the
MSIS data files that would permit us to differentiate dual and non-dual Medicaid eligibles. Next, all

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claims for these beneficiaries were extracted and placed in a temporary file. A list of recipient
identification numbers, which are unique to each individual, was compiled and unduplicated, creating
a single file of all recipients. The final step was to extract all claims for this unduplicated list of
recipients from the four claims files and the eligibility file and created a single record for each
individual. This resulted in a record that contained all Medicaid expenditures for those beneficiaries.
The analysis examines the demographic characteristics and expenditures patterns for dual eligibles and
then contrasts the dual eligibles with those not dually eligible.

The identification of dual eligibles proved challenging. The MSIS data base contains a “flag” for each
person that should indicate whether that person is dual eligible or not. In the process of developing
these estimates, we discovered that the flag in the Medicaid MSIS dataset that identifies dual eligible
beneficiaries is not reliable across all States. Specifically, there is a significant amount of variance in
the accuracy with which the flag in the eligibility dataset is coded by the States. For instance, in one
medium sized Southern State, we found no dual eligibles within the dataset using this indicator.
Knowing this information could not be true, we explored other ways to identify dual eligibles within
the dataset. Given this problem, we analyzed the MSIS data dictionary and datasets to determine other
methods to allow us to impute dual eligible status. This analysis showed that the eligibility file had no
other indicator that would determine if a person was dually eligible. For example, some persons over
65 on Medicaid are not eligible for Medicare, such as those elderly who did not work 40 quarters in
order to obtain Medicare eligibility. However, the claims file contains what are known as “crossover“
claims. These are claims that are filed with Medicaid for Medicare co-pay and deductible amounts.
After considerable exploratory analysis. We decided that the best way to proceed was to treat all those
persons that have cross over claims or have the dual eligible flag as dually eligible. This more
encompassing method is what we used to identify dual eligibles.

Gender and Age

Tables 1 and 2 include total patient counts and expenditures data for males versus females for both
dual and non-dual eligibles.

Table 1. Population by Gender and Eligibility Status*

Dual % Not
All % of All Eligible % Dual Not Dual Dual
Recipients Recipients Population Eligibles Eligibles Eligibles
Total Medicaid
Population 6,647,300 100% 1,002,400 15% 5,644,900 85%

Female 3,890,401 59% 657,562 66% 3,232,839 57%


Male 2,756,899 41% 344,838 34% 2,412,061 43%

*A small number of claims were missing information on gender and have been excluded from Table 1. Therefore, the
column totals for number of beneficiaries may differ slightly with those in other tables.

As shown in Table 1, the dual eligible population is 66 percent female and 34 percent male. By
comparison, the non-dual eligible population is 57 percent female and 43 percent male. In terms of
gender. the total Medicaid population is 59 percent female and 41 percent male, very similar to the
non-dual eligible population. However, even though dual eligibles constitute only 15 percent of the
total Medicaid population, they account for a disproportionate share (42 percent) of Medicaid program
expenditures (Table 2).

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Table 2. Medicaid Expenditures by Gender and Eligibility Status


% Not
% Dual Dual
% of Dual Eligible Eligibles Not Dual Eligibles
Total Paid Total Paid Paid Paid Eligibles Paid Paid
Total Medicaid Paid $21,942,055,818 100% $9,215,082,242 42% $12,726,973,576 58%

Female $13,338,032,842 59% $6,186,874,474 67% $7,151,158,368 56%


Male $8,604,022,976 41% $3,028,207,768 33% $5,575,815,208 44%

Further analysis of the data in Table 2 indicates that the male/female breakouts for expenditures are
virtually identical to the demographic splits (Table 1). Within each of the eligibility categories,
females account for the greatest proportions of Medicaid payments.

Table 3. Payments Per Capita by Gender


Average Per Capita by Gender

Not Dual
Dual Eligible Medicaid Not Dual Eligible
Gender Dual Eligible Per Capita Eligible Per
Paid Medicaid Paid
Capita

Female $6,186,874,474 $9,409 $7,151,158,368 $2,212


Male $3,028,207,768 $8,782 $5,575,815,208 $2,312
Total $9,215,082,242 $9,193 $12,726,973,576 $2,255

Average Medicaid payments per capita by gender are presented in Table 3. For the dual eligible
population, average expenditures per capita expenditure are 400 percent higher than for non-dual
eligibles. Within each group, average per capita spending is fairly similar for males and females.

Table 4. Population Percentages by Age and Eligibility Status


All % of All Dual Eligible % Dual Not Dual % Not Dual
Recipients Recipients Population Eligibles Eligibles Eligibles
Total Medicaid Population 6,558,236 100% 1,002,432 15% 5,555,804 85%

Age
Group 0 to 4 1,318,346 20% 885 0% 1,317,461 23%
5 to 12 1,514,904 23% 3,831 0% 1,511,073 27%
13 to 24 1,377,283 21% 18,579 2% 1,358,704 24%
25 to 44 1,072,332 16% 163,647 16% 908,685 16%
45 to 64 566,877 9% 227,877 23% 339,000 6%
Subtotal 64 5,849,742 88% 414,819 41% 5,434,923 96%
65 plus 708,494 11% 587,613 59% 120,881 2%

Table 4 shows the population distribution by age and eligibility status. For dual eligibles, 59 percent
of the population is 65 years of age or older. More importantly, 41 percent of the dual eligibles are
under 65 years of age. These are overwhelmingly disabled individuals. More interestingly, 17 percent
(120,881 of 708,494 beneficiaries) of the Medicaid population over 65 is not dually eligible. Many
individuals interested in the MMA provisions have incorrectly assumed that all Medicaid recipients
over 65 are dually eligible. Therefore, even if some of these individuals are incorrectly classified by

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Medicaid programs and/or may become eligible for Part D prescription drug coverage, States will
have aged beneficiaries remaining on their rolls. This occurs because many states have expanded their
Medicaid eligibility criteria and/or have elected to cover optional groups whose incomes and assets
exceed the criteria for dual eligibles.

Table 5. Medicaid Expenditures Percentages by Age and Eligibility Status


Not Dual % Not Dual
Total % of Dual Eligible % Dual Eligibles Eligibles
Medicaid Paid Total Paid Medicaid Paid Eligibles Paid Medicaid Paid Paid
Total Medicaid Paid 21,353,868,898 100% 9,215,343,151 43% 12,138,525,747 57%

Age
Group 0 to 4 2,116,168,842 10% 6,096,559 0% 2,110,072,283 17%
5 to 12 1,669,434,562 8% 20,577,970 0% 1,648,856,592 14%
13 to 24 2,809,026,255 13% 121,273,602 1% 2,687,752,653 22%
25 to 44 4,149,276,161 19% 1,317,227,181 14% 2,832,048,980 23%
45 to 64 4,087,134,021 19% 1,885,855,392 20% 2,201,278,629 18%
Subtotal 64 14,831,039,841 69% 3,351,030,704 36% 11,480,009,137 95%
65 plus 6,522,829,057 31% 5,864,312,447 64% 658,516,610 5%
Dual eligibles account for 43 percent of all Medicaid expenditures (Table 5). For dual eligibles, nearly
two-thirds, 64 percent, of Medicaid expenditures are for the elderly and 36 percent are for the
population under 65 years of age. By contrast, among non-dual eligibles, only 5 percent of
expenditures are for beneficiaries 65 years of age and older and 95 percent are for non-elderly
recipients. Of the approximately $6.5 billion in Medicaid program spending for the elderly, $659
million (10.1 percent) was spent on the population 65 and older who are not dually eligible.

Dual Eligible Expenditures by Type of Service


Tables 6 and 7 summarize total patient counts and Medicaid program payments by type of service for
dual and non-dual eligibles. Please note that, because an eligible beneficiary can receive more than
one service, patient counts may be duplicated. However in calculating the percentages, we used the
unduplicated totals (see Table 1).

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Table 6. Summary of Medicaid Data by Service Type and Eligible Status


Patient Count
% Dual Not Dual % Not Dual
Service Type Dual Eligible Eligible Eligible Eligible
Long Term
(NF/ICF/MR) 206,678 21% 54,567 1%
Prescription Drug 822,235 82% 3,213,848 57%
Inpatient 223,978 22% 690,048 12%
Other 652,018 65% 2,318,574 41%
Capitated Payments
HMO/HIO 74,397 7% 1,808,451 32%
Physicians 781,145 78% 3,212,998 57%
Outpatient Hospital 551,116 55% 2,062,036 37%
Clinic 267,253 27% 1,211,036 21%
Personal Care Svcs 68,607 7% 21,769 0%
Dental 125,120 12% 1,278,122 23%
Home Health 42,798 4% 49,310 1%
Targeted Case
Mgmt 27,651 3% 184,342 3%
Emergency Room 175,069 17% 1,194,406 21%
Lab and X-Ray 260,823 26% 1,325,548 23%
Capitated Payments
for PCCM 117,297 12% 1,971,936 35%
Private Duty
Nursing 1072 0% 2,472 0%
Members w/o
Claims 28,566 3% 491,756 9%
Total 1,002,400 100% 5,644,900 100%

Table 6 compares patterns of service utilization for the dual eligible and non-dual eligible populations.
As shown in Table 6, the utilization rates are higher for dual eligibles for almost all of the type of
service categories. The only exceptions are capitated payments, dental services, and use of emergency
rooms.2 Interestingly, prescription drugs are utilized by an overwhelming 82 percent of the dual
eligible population compared to just over half (57 percent) of the non-dual eligibles. Also of interest is
the fact that only 3 percent of dual eligibles did not have service claims compared to 9 percent of the
non-dual eligible population.

2
Please note that persons in capitation arrangements may have used other services, which are reported separately
from their membership in capitation plans. The MMIS reporting system we are using requires that States collect
and report managed care “encounters.” These records appear in the database but do not have the expenditure
fields completed since, by definition, managed care organizations do not charge separately for each service.

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Table 7. Summary of Medicaid Expenditures by Service Type and Eligibility Status


Medicaid Paid
% Dual Not Dual % Not Dual
Service Type Dual Eligible Eligible Eligible Eligible
Long Term
(NF/ICF/MR) $4,375,191,574 47% $1,170,665,993 10%
Prescription Drug $1,914,514,871 21% $1,518,678,388 13%
Inpatient $335,566,759 4% $2,449,561,265 20%
Other $1,035,967,616 11% $1,554,693,387 13%
Capitated Payments
HMO/HIO $193,803,464 2% $2,014,430,322 17%
Physicians $255,046,010 3% $1,013,919,106 8%
Outpatient Hospital $330,030,811 4% $908,154,113 7%
Clinic $174,616,069 2% $517,907,551 4%
Personal Care Svcs $334,877,197 4% $142,456,278 1%
Dental $29,430,515 0% $279,049,989 2%
Home Health $153,738,248 2% $100,913,904 1%
Targeted Case
Mgmt $33,920,739 0% $150,925,649 1%
Emergency Room $19,775,428 0% $127,124,720 1%
Lab and X-Ray $20,006,385 0% $89,964,175 1%
Capitated Payments
for PCCM $7,045,120 0% $68,025,641 1%
Private Duty
Nursing $1,812,345 0% $32,055,266 0%
Members w/o
Claims $0 0% $0 0%
Total $9,215,343,151 100% $12,138,525,747 100%

Table 7 illustrates the distribution of expenditures for both dual and non-dual eligibles. For the dual
eligible population, long-term care (nursing homes and ICFs/MR) and prescription drugs are the two
largest expenditures categories. Long-term care, for example, accounts for 47 percent of the monies
spent on dual eligibles. Prescription drugs comprise an additional 21 percent of the expenditures. By
comparison long-term care is only 10 percent and prescription drugs 13 percent of total expenditures
for the non-dual eligible population. These variations reflect the demographic characteristics of the
dual eligible population and the fact that Medicare is paying for certain sources (i.e., inpatient care) for
dual eligible beneficiaries.

Inpatient care ($2.4 billion) is the most expensive service type for non-dual eligibles. However, while
it accounts for 20 percent of expenditures, only 12 percent of the non-dual eligible population had
claims for inpatient care (Table 6). Conversely, for dual eligibles, 22 percent of the population had
claims for inpatient care but, in terms of expenditures, inpatient care comprised only 4 percent of their
total Medicaid program payments.

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Table 8. Summary of Medicaid Data by Drug Type and Dual Eligible Status
Patient Count Medicaid Paid
% % Not % % Not
Dual Dual Not Dual Dual Dual Not Dual Dual
AHFS 2 digit Eligible Eligible Eligible Eligible Dual Eligible Eligible Eligible Eligible
28 - Central
Nervous System
Drugs 694,111 69% 1,501,358 27% $698,194,103 36% $587,625,205 39%
24 -
Cardiovascular
Drugs 500,805 50% 295,794 5% $289,693,604 15% $109,044,722 7%
56 -
Gastrointestinal
Drugs 415,094 41% 388,738 7% $231,734,451 12% $119,202,951 8%
08 - Anti-
Infective Agents 544,750 54% 2,094,058 37% $122,658,237 6% $207,645,271 14%
68 - Hormones
And Synthetic
Substitutes 407,361 41% 717,795 13% $152,717,579 8% $121,689,014 8%
12 - Autonomic
Drugs 297,568 30% 701,771 12% $81,162,590 4% $59,301,825 4%
92 -
Unclassified
Therapeutic
Agents 120,405 12% 154,685 3% $78,521,356 4% $46,003,044 3%
20 - Blood
Formation And
Coagulation 139,717 14% 172,901 3% $40,782,856 2% $64,052,725 4%
40 - Electrolytic,
Caloric Balance 381,513 38% 229,361 4% $58,678,234 3% $21,098,611 1%
04 -
Antihistamine
Drugs 235,506 23% 908,566 16% $27,477,911 1% $48,917,940 3%
Other 524,159 52% 1,991,217 35% $132,893,950 7% $134,097,080 9%
No Rx Claims 180,197 18% 2,341,956 41% $0 0% $0 0%
Total 1,002,400 100% 5,644,900 100% $1,914,514,871 100% $1,518,678,388 100%

Table 8 summarizes drug utilization and cost data for the dual eligible and non-dual eligible
populations. Analysis of these data yields some interesting results. First, across all of the categories, a
significantly higher proportion of dual eligible beneficiaries compared to non-dual eligibles had drug
claims and a smaller proportion of dual eligible beneficiaries had no drug claims. Furthermore,
although dual eligibles comprise only 15 percent of the beneficiaries in the study, they account for
more than half (56 percent) of total drug expenditures.

For almost every drug category, expenditures for dual eligibles exceed those for non-dual eligible
beneficiaries, even where the actual number of dual eligible recipients is significantly smaller than the
number of non-dual eligible recipients. For example, expenditures for central nervous system (CNS)
drug are the highest expenditure category for both the dual and non-dual eligible population groups.
However, a much higher proportion of dual eligible beneficiaries had claims for CNS drugs than did
non-dual eligibles. Furthermore, despite the fact that more than twice as many non-dual eligible
beneficiaries had claims for CNS drugs, total expenditures for CNS drugs were more than $110
million higher for the dual eligible group.

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Conclusion

Overall, MMA will require that prudent States take a new look at their programs intended to manage
prescription drug spending. Beginning in 2006, states will no longer provide and manage drug
coverage for patients that currently represent, on average, about 50% of the State’s Medicaid spending
for drugs. This significant shift will require that States reassess available resources and the most cost-
efficient ways for employing those resources. Because of the substantial presence of the dual-eligible
population in current spending patterns for drugs, the cost benefit decisions among various strategies
are likely to change dramatically especially for those strategies that rely primarily on reducing drug
costs. The return on investments in efforts to improve care more broadly, such as disease
management, are likely to be increasingly attractive to States.

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Section 2:
The Medicaid Program

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MEDICAID PROGRAM OVERVIEW


Medicaid (Title XIX of the Federal Social Security Act) is a Federal-State funded program of national
health assistance that provides health care coverage to certain individuals and families with low-
incomes and resources. The 50 States, the District of Columbia, and Puerto Rico, Guam, Virgin
Islands, American Samoa, and Northern Mariana Islands each operate medical assistance programs
according to State or territorial rules and criteria that vary within a broad framework of Federal
guidelines.

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 services and any other ambulatory services offered by a
Federally-qualified health center 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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• TB-related services for TB infected persons;


• Prosthetic devices; and
• Dental services.
States may provide home and community-based care waiver services to certain individuals who are
eligible for Medicaid. The services to be provided to these persons may include case management,
personal care services, respite care services, adult day health services, homemaker/home health aide,
habilitation, and other services requested by the State and approved by CMS.

CHARACTERISTICS OF BENEFITS PROVIDED

Inpatient Hospital Services


Inpatient hospital services are those ordinarily furnished in a hospital for the care and treatment of
inpatients. The facility is one maintained primarily for the care and treatment of patients with
disorders other than mental diseases. There are several general Federal limitations on inpatient
hospital services that apply to all States with Medicaid programs (42 CFR 440.10):
• The facility must be licensed or formally approved as a hospital by an officially
designated authority for State standard setting;
• The facility must meet the requirements for participation in Medicare as a hospital;
• The care and treatment of inpatients must be under the direction of a physician or dentist;
and
• The facility must have in effect an approved utilization review plan, applicable to all
Medicaid patients, unless a waiver has been granted by the Secretary of Health and
Human Services, because the State’s own utilization review procedures are adequate.
• A peer review organization (PRO) may satisfy these requirements.
In addition to the Federal limitations, each State may impose further limitations on inpatient hospital
services.

Outpatient Hospital Services


Outpatient hospital services refer to preventive, diagnostic, therapeutic, rehabilitative, or palliative
services provided to an outpatient. Three Federal limitations are imposed on these services, though
States are free to specify other limits on outpatient hospital services and many have chosen to do so.
• The services must be provided under the direction of a physician or dentist;
• The facility must be licensed or formally approved as a hospital by an officially
designated authority for State standard setting; and
• The facility must meet the requirements for participation in Medicare as a hospital.

Rural Health Clinic Services


Rural health clinic (RHC) services are a mandatory service for the categorically needy. Each RHC is
required to have a nurse practitioner (NP) or physician’s assistant (PA) on its staff. Therefore, a
clinic can be certified to participate in the Medicaid program only if State law permits the delivery of
primary care by an NP or PA.
Services in RHCs must be provided by a physician or by a PA, NP, nurse-midwife, or other
specialized nurse practitioner. Services and supplies are furnished as “incident to” the professional
services of such a practitioner are also covered. Part-time or intermittent visiting nurse services and
related medical supplies are provided if the RHC is located in an area which DHHS has determined

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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.

Other Laboratory and X-Ray Services


Other laboratory and X-ray services are professional and technical laboratory and radiological
services. These services must be:
• Ordered and provided by or under the direction of a physician or other licensed
practitioner of the healing arts within the scope of his or her practice, as defined by State
law, or ordered and billed by a physician but provided by an independent laboratory;
• Provided in an office or similar facility other than a hospital inpatient or outpatient
department or clinic; and
• Provided by a laboratory that meets the requirements for participation in Medicare.
• In addition, the States can place limitations on “other laboratory and X-ray services.”

Nursing Facility Services


Nursing facility (NF) services are provided to individuals age 21 or older. They do not include
services provided in institutions for mental diseases. These services must be needed on a daily basis
and must be provided in an inpatient facility. Federal regulations require that the services be:
• Provided by a facility or a distinct part of a facility that is certified to meet the
requirements for participation in the Medicaid program as a NF; and
• Ordered by and furnished under the direction of a physician.

Early and Periodic Screening, Diagnostic and Treatment Services


Early and periodic screening, diagnostic and treatment (EPSDT) refers to screening and diagnostic
services to determine physical or mental defects in recipients under age 21, as well as health care,
treatment and other measures to correct or ameliorate any defects and chronic conditions discovered
(42 CFR 440.40(b)). Certain basic screening and treatment services must be provided by each State
as a minimum (42 CFR 441.56). These services include:
Screening:
• Comprehensive health and developmental history screening;
• Comprehensive unclothed physical examination;
• Appropriate vision testing;
• Appropriate hearing testing;
• Appropriate laboratory tests;
• Dental screening services furnished by direct referral to a dentist for children beginning
at 3 years of age.
Diagnosis and Treatment:
In addition to any diagnostic and treatment services included in the State Medicaid Plan, the State
must provide to eligible EPSDT recipients the following services, the need for which is indicated by
screening, even if the services are not included in the Plan:
• Diagnosis of and treatment for defects in vision and hearing, including eyeglasses and
hearing aids;
• Dental care, at as early an age as necessary, needed for relief of pain and infections,
restoration of teeth and maintenance of dental health; and

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• Appropriate immunizations. (If it is determined at the time of screening that


immunization is needed and appropriate to administer at the time of screening, then
immunization treatment must be provided at that time.)
The State Medicaid agency may provide for any other medical or remedial care specified as a
Medicaid service even if the agency does not otherwise provide for these services to other recipients
or provides for them in a lesser amount, duration, or scope. This is an exception to the general rule
that the amount, duration, and scope of benefits must be the same for all categorically eligible
recipients, and reflects the importance attached to EPSDT services.

Family Planning Services


Federal Requirements: States are required to provide family planning services and supplies to
individuals of childbearing age (including minors who can be considered to be sexually active) who
are eligible under the State Medicaid Plan and who desire such services and supplies. Specifically,
family planning services must be made available to categorically needy Medicaid recipients, and the
State has the option of furnishing these services to the medically needy.
Defined: The term “family planning services” is not defined in the law or in regulations. However,
the Senate Report accompanying the law stresses Congress’ intent of placing emphasis on the
provision of services to “aid those who voluntarily choose not to risk an initial pregnancy,” as well as
those families with children who desire to control family size. In keeping with Congressional intent,
the State may choose to include in its definition of Medicaid family planning services only those
services which either prevent or delay pregnancy, or the State may more broadly define the term to
include services for the treatment of infertility. However, the Medicaid definition must be consistent
with overall State policy and regulation regarding the provision of family planning services.
The State is free to determine the specific services and supplies that will be covered as Medicaid
family planning services as long as those services are sufficient in amount, duration, and scope to
reasonably achieve their purpose. It must also establish procedures for identifying individuals who
are sexually active and eligible for family planning services.
Federal Matching Payments: Federal Financial Participation (FFP) is available at the “enhanced”
rate of 90 percent for the cost of family planning services. These include counseling services and
patient education, examination and treatment by medical professionals in accordance with applicable
State requirements, laboratory examinations and tests, medically approved methods, procedures,
pharmaceutical supplies and devices to prevent conception, and infertility services, including
sterilization reversals.
FFP at the enhanced rate of 90 percent is also available for the cost of a sterilization if a properly
completed sterilization informed consent form, in accordance with the requirements of 42 CFR Part
441, Subpart F, is submitted to the State prior to payment of the claim.
FFP at the 90 percent rate is not available for the cost of a hysterectomy or for the costs related to
other procedures performed for medical reasons, such as removal of an intrauterine device due to
infection. Only items and procedures clearly provided or performed for family planning purposes
may be matched at the 90 percent rate. Transportation to a family planning service is not eligible for
the 90 percent match. Transportation must be claimed as either an administrative cost or a State Plan
service, in accordance with the State’s approved Medicaid State Plan.
Abortions: Abortions may not be claimed as a family planning service. For more than 20 years,
Congressional restrictions have been placed on appropriated funds for DHHS programs that fund
abortions. FFP is available only in expenditures for an abortion when a physician has found, and so
certified in writing to the Medicaid agency, that on the basis of his/her professional judgment, the life
of the mother would be endangered if the fetus were carried to term. The certification must contain
the name and address of the patient. Congress has prohibited the use of Federal funds for victims of
rape or incest.

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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.

Home Health Services


Home health services are provided to a recipient at his or her place of residence. This does not
include a hospital, nursing facility, or (ordinarily) an ICF/MR. Services provided must be on
physicians’ orders as part of a written plan of care that is reviewed by the physician every 60 days.
Home health services include three mandatory services (part-time nursing, home health aide, medical
supplies and equipment) and four optional services (physical therapy, occupational therapy, speech
pathology, and audiology services) (42 CFR 440.70). These services are defined as follows:
• Part-Time Nursing: Nursing that is provided on a part-time or intermittent basis by a
home health agency. If there is no home health agency in the area, services may be
provided by a registered nurse who is currently licensed to practice in the State, receives
written orders from the patient’s physician, documents the care and services provided,
and has had orientation to acceptable clinical and administrative record keeping from a
health department nurse.
• Home Health Aide: Home health aide services provided by a home health agency.
• Medical Supplies and Equipment: Medical supplies, equipment, and appliances that are
suitable for use in the home.
• Physical Therapy (PT), Occupational Therapy (OT), Speech Pathology and Audiology
Services: PT, OT, speech and hearing services provided by a home health agency or a
facility licensed by the State to provide medical rehabilitation.
• Home health services are provided to categorically needy recipients age 21 and over and
to those under 21 only if the State Plan provides SNF services for them.

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. 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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retarded, or institution for mental disease. Services are authorized by a physician in


accordance with a treatment plan, are provided by a qualified individual who is not a
member of the recipient’s family, and are furnished in a home or (at the State’s
option) in another location.
2. Rehabilitative Services: These services include any medical or remedial service
recommended by a physician or other licensed practitioner of the healing arts within
the scope of State law. Services are for the maximum reduction of physical or mental
disability and restoration of a recipient to their best possible functional level.
3. Hospice Services: Hospice services can be received in a hospice facility or elsewhere.
Services are provided to terminally ill individuals by an authorized hospice program
under a written plan established and reviewed by the attending physician, medical
director or physician designee of the program, and an interdisciplinary group.

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.

Pediatric Nurse Practitioner and Family Nurse Practitioner Services


The Omnibus Budget Reconciliation Act of 1989 provides for the availability and accessibility of
services furnished by a certified pediatric nurse practitioner (CPNP) or a certified family nurse
practitioner (CFNP) to Medicaid recipients. These provisions require that services be covered to the
extent that the CPNPs or CFNPs are authorized to practice under State law or regulation, regardless of
whether they are supervised by or associated with a physician or other health care provider. States
are required to offer direct payment to CPNPs and CFNPs as one of their payment options.
CPNP and CFNP certification requirements include a current license to practice as a registered nurse
in the State, meet the applicable state requirements for qualification of pediatric nurse practitioners or
family nurse practitioners, and be currently certified by the American Nurses’ Association as a
pediatric nurse practitioner or a family nurse practitioner.

Federally Qualified Health Center and other Ambulatory Services


Medicaid programs must offer Federally Qualified Health Center (FQHC) services and other
ambulatory services offered by an FQHC under the provisions of the Omnibus Budget Reconciliation
Act of 1989. The definition of FQHC services is the same as that of the services provided by rural
health clinics (RHC). FQHC services include physician services, services provided by physician
assistants, nurse practitioners, clinical psychologists, clinical social workers, and services and
supplies incident to services normally covered if furnished by a physician or if incident to a
physician’s services.
FQHCs are facilities or programs more commonly known as Community Health Centers, Migrant
Health Centers, and Health Care for the Homeless. These centers may qualify as providers of service
under Medicaid, under the following conditions:

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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.

AMOUNT AND DURATION OF SERVICES


Within broad Federal guidelines and certain limitations, States may determine the amount and
duration of services offered under their Medicaid programs. Federal regulations require that the
amount and/or duration of each type of medical and remedial care and services furnished under a
State’s program must be specified in the State Plan, and that these types of care and services must be
sufficient in amount, duration, and scope to “reasonably achieve” their purpose. States are required to
provide Medicaid coverage for comparable amounts, duration, and scope of service to all
“categorically needy” and categorically-related eligible persons.
Each State Plan must include a description of the methods that will be used to assure that the medical
and remedial care and services delivered are of high quality, as well as a description of the standards
established by the State to assure high quality care. The regulations also require that the fee
structures developed must result in participation of a sufficient number of providers so that eligible
persons can receive the medical care and services included in the Plan, at least to the extent that these
are available to the general population. The law further requires that services provided under the Plan
be available throughout the State. Recipients are to have freedom of choice with regard to where they
receive their care, including an option to obtain their care through organizations that provide services
or arrange for their availability on a prepayment basis, such as health maintenance organizations.

MEDICAID PAYMENT FOR SERVICES


The Medicaid program operates on the basis of a division of responsibilities between the Federal
government and the States with the Federal government paying States for a portion of State medical
expenditures and administrative costs. Funding for the program is shared between the two bodies,
with the Federal government matching State health care provider reimbursements at an authorized
rate of between 50% and 72.96%, depending on the State’s per capita income (see the Federal
Medical Assistance Percentage (FMAP) table, page 2-18).
The FMAP is based upon the State’s per capita income; if a State’s per capita income is equal to or
greater than the national average, the Federal share is 50%. If a State’s per capita income is below the
national average, the Federal share is increased, up to a maximum of 76.62%.
The percentages apply to State expenditures for assistance payments and medical services. Federal
statute provides separate Federal matching amounts for administrative costs. Cost sharing for
administrative expenditures vary with the services, i.e., 75% for training, 90% for designing,
developing or installing mechanized claims processing and information retrieval, etc. (Federal
Medicaid Law (Section 1903(a)(2) et seq.)).
In 2000, the Medicaid program enrolled 44.3 million eligible individuals with vendor payments for
medical care services totaling $168.3 billion. The vendor payments reported in the 2000 MSIS
Report do not include Disproportionate Share Hospital (DSH), Medicare premium payments made by
State Medicaid programs, and other Medicaid program expenditures. The CMS-64 Report, which
does include such expenditures, shows total net expenditures for 2000 of $195.2 billion. When
administrative costs are added to total net expenditures, total Medicaid program expenditures in 2000
were $205.7 billion.

2-10
National Pharmaceutical Council Pharmaceutical Benefits 2003

Total Medicaid Eligibles by Maintenance Assistance Status, 20011

Receiving
Total Cash Medically Poverty 1115 MAS
State Eligibles Assistance Needy Related Other Demonstration Unknown
National Total 46,910,257 17,555,319 3,661,252 13,529,154 7,779,041 4,384,730 761
Alabama 780,434 282,756 0 373,733 36,442 87,503 0
Alaska 115,996 52,568 0 54,753 8,663 0 12
Arizona 808,386 380,272 0 241,905 156,460 29,749 0
Arkansas 550,668 147,990 21,122 186,090 53,291 142,162 13
California 8,495,030 3,974,456 863,850 413,616 1,299,265 1,943,842 1
Colorado 410,611 211,229 0 152,356 46,911 0 115
Connecticut 446,326 102,886 35,997 76,751 230,671 0 21
Delaware 133,079 89,121 0 11,384 15,909 16,665 0
District of Columbia 152,597 91,862 27,463 25,617 7,655 0 0
Florida 2,462,171 1,085,854 67,479 815,482 355,620 137,722 14
Georgia 1,328,379 536,171 10,277 541,038 240,893 0 0
Hawaii* 202,912 118,221 2,549 50,790 7,605 23,747 0
Idaho 172,348 26,466 0 96,160 49,722 0 0
Illinois 1,798,723 385,404 427,590 866,708 119,021 0 0
Indiana 825,556 319,863 0 313,072 192,621 0 0
Iowa 331,025 148,544 10,091 95,866 76,524 0 0
Kansas 291,837 94,061 20,127 123,446 54,203 0 0
Kentucky 762,871 334,192 39,893 316,906 71,880 0 0
Louisiana 886,518 345,766 9,498 430,313 100,941 0 0
Maine 277,843 81,088 1,360 75,760 55,759 63,876 0
Maryland 704,628 206,159 83,168 365,212 50,088 0 1
Massachusetts 1,125,607 324,129 22,332 422,318 119,755 237,073 0
Michigan 1,430,246 447,720 125,675 476,446 380,326 0 79
Minnesota 609,856 236,283 10,398 9,261 237,221 116,693 0
Mississippi 681,161 293,225 0 359,329 28,591 0 16
Missouri 1,032,047 390,531 0 299,010 148,868 193,638 0
Montana 101,966 42,887 8,790 22,934 27,334 0 21
Nebraska 249,079 59,977 40,691 117,093 31,069 0 249
Nevada 167,247 62,278 0 60,921 44,048 0 0
New Hampshire 108,562 24,877 10,979 48,437 24,269 0 0
New Jersey 923,697 419,211 5,078 330,854 168,554 0 0
New Mexico 423,543 140,380 0 206,321 67,217 9,625 0
New York 3,548,630 1,395,014 1,368,735 328,866 108,099 347,916 0
North Carolina 1,397,486 632,171 44,066 659,687 61,562 0 0
North Dakota 65,425 28,941 16,008 9,203 11,273 0 0
Ohio 1,660,463 479,253 0 329,421 851,618 0 171
Oklahoma 631,996 108,432 7,887 422,073 93,604 0 0
Oregon 594,679 128,859 8,302 168,341 123,016 166,152 9
Pennsylvania 1,647,440 678,978 116,515 526,543 325,404 0 0
Rhode Island 194,113 84,762 4,453 24,881 41,939 38,077 1
South Carolina 871,675 293,556 0 362,039 216,071 0 9
South Dakota 106,154 39,418 0 43,996 22,740 0 0
Tennessee 1,601,406 441,875 108,363 227,155 172,886 651,105 22
Texas 2,729,660 909,653 57,510 1,263,395 493,704 5,398 0
Utah 214,597 47,043 5,830 122,268 39,456 0 0
Vermont 154,991 32,425 12,064 47,404 14,649 48,445 4
Virginia 700,715 149,660 10,067 383,725 157,263 0 0
Washington** 916,838 257,453 13,421 298,026 347,937 0 1
West Virginia 351,489 141,306 4,916 180,978 24,289 0 0
Wisconsin 673,538 231,211 38,708 123,725 154,550 125,342 2
Wyoming 58,013 18,882 0 27,546 11,585 0 0
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.
*Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 MSIS data are used in this table.
**MSIS data for FY 2001 have not yet been released for Washington. FY 2000 MSIS data are used in this table.

Source: CMS, MSIS Report, FY 2000 and FY 2001.

2-11
National Pharmaceutical Council Pharmaceutical Benefits 2003

Total Medicaid Eligibles by Age Group, 20011


65 Years and
State Total Eligibles <21 Years 21-64 Years Older Age Unknown
National Total 46,910,257 25,798,743 15,947,857 5,060,539 103,118
Alabama 780,434 419,575 249,386 111,473 0
Alaska 115,996 78,373 30,761 6,862 0
Arizona 808,386 487,369 271,499 49,518 0
Arkansas 550,668 324,082 162,083 64,502 1
California 8,495,030 4,094,864 3,647,963 752,203 0
Colorado 410,611 243,120 119,729 47,761 1
Connecticut 446,326 240,064 145,949 60,313 0
Delaware 133,079 69,591 53,394 10,094 0
District of Columbia 152,597 83,343 55,159 14,095 0
Florida 2,462,171 1,375,744 765,418 321,008 1
Georgia 1,328,379 815,970 377,044 135,362 3
Hawaii* 202,912 97,259 85,142 20,511 0
Idaho 172,348 118,848 41,602 11,898 0
Illinois 1,798,723 1,111,280 535,863 151,580 0
Indiana 825,556 524,690 222,095 78,771 0
Iowa 331,025 182,275 107,195 41,555 0
Kansas 291,837 180,124 77,305 34,408 0
Kentucky 762,871 436,215 238,295 88,361 0
Louisiana 886,518 566,259 219,039 101,220 0
Maine 277,843 104,883 110,563 62,379 18
Maryland 704,628 429,301 209,135 66,192 0
Massachusetts 1,125,607 500,383 485,350 139,874 0
Michigan 1,430,246 858,526 441,977 129,743 0
Minnesota 609,856 330,451 212,508 66,888 9
Mississippi 681,161 413,084 174,377 93,700 0
Missouri 1,032,047 605,928 330,815 95,302 2
Montana 101,966 57,001 34,020 10,945 0
Nebraska 249,079 161,809 63,820 23,450 0
Nevada 167,247 96,160 52,107 18,980 0
New Hampshire 108,562 66,824 28,834 12,902 2
New Jersey 923,697 497,761 285,365 140,570 1
New Mexico 423,543 286,567 107,030 29,946 0
New York 3,548,630 1,660,024 1,315,242 470,330 103,034
North Carolina 1,397,486 766,160 449,720 181,606 0
North Dakota 65,425 33,884 21,255 10,286 0
Ohio 1,660,463 951,645 561,249 147,569 0
Oklahoma 631,996 426,288 141,887 63,821 0
Oregon 594,679 275,652 273,893 45,134 0
Pennsylvania 1,647,440 882,484 557,684 207,272 0
Rhode Island 194,113 99,308 71,779 23,023 3
South Carolina 871,675 510,230 281,829 79,582 34
South Dakota 106,154 68,539 25,816 11,799 0
Tennessee 1,601,406 740,012 707,585 153,809 0
Texas 2,729,660 1,743,786 632,870 353,003 1
Utah 214,597 140,676 61,889 12,031 1
Vermont 154,991 74,068 59,926 20,997 0
Virginia 700,715 410,269 189,426 101,020 0
Washington** 916,838 568,245 278,676 69,917 0
West Virginia 351,489 193,628 124,482 33,379 0
Wisconsin 673,538 359,417 235,553 78,568 0
Wyoming 58,013 36,705 16,274 5,027 7
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.
*Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 MSIS data are used in this table.
**MSIS data for FY 2001 have not yet been released for Washington. FY 2000 MSIS data are used in this table.

Source: CMS, MSIS Report, FY 2000 and FY 2001.

2-12
National Pharmaceutical Council Pharmaceutical Benefits 2003

Total Medicaid Eligibles by Basis of Eligibility, 20011

Blind/ Foster Care BOE


State Total Eligibles Aged Disabled Children Adults Children Unknown
National Total 46,910,257 4,400,601 7,657,411 22,438,138 11,546,609 866,692 806
Alabama 780,434 89,484 182,696 377,130 125,448 5,676 0
Alaska 115,996 6,403 11,443 70,446 25,920 1,772 12
Arizona 808,386 37,102 102,909 430,749 229,944 7,682 0
Arkansas 550,668 52,240 104,421 267,241 120,840 5,913 13
California 8,495,030 626,550 959,584 3,169,960 3,598,569 140,366 1
Colorado 410,611 46,708 65,407 202,166 79,337 16,878 115
Connecticut 446,326 59,510 58,579 234,953 84,401 8,862 21
Delaware 133,079 9,613 16,500 59,452 45,580 1,934 0
District of Columbia 152,597 9,957 31,334 71,667 35,007 4,632 0
Florida 2,462,171 248,466 478,847 1,190,510 503,789 40,545 14
Georgia 1,328,379 109,245 229,725 717,007 253,525 18,877 0
Hawaii* 202,912 18,824 21,616 85,074 73,338 4,060 -
Idaho 172,348 11,839 24,701 108,036 25,799 1,973 0
Illinois 1,798,723 112,455 282,956 952,915 368,149 82,248 0
Indiana 825,556 78,267 113,799 484,090 137,344 12,056 0
Iowa 331,025 41,128 57,426 157,333 65,498 9,640 0
Kansas 291,837 31,659 52,513 150,022 44,424 13,219 0
Kentucky 762,871 70,730 207,524 374,318 101,494 8,805 0
Louisiana 886,518 101,002 173,725 499,771 102,480 9,540 0
Maine 277,843 56,942 74,955 91,418 51,163 3,365 0
Maryland 704,628 54,654 114,951 386,346 132,309 16,367 1
Massachusetts 1,125,607 112,994 235,157 453,373 323,473 610 0
Michigan 1,430,246 100,156 288,790 744,902 255,755 40,564 79
Minnesota 609,856 64,108 83,579 309,972 142,313 9,884 0
Mississippi 681,161 74,018 159,306 369,654 74,943 3,224 16
Missouri 1,032,047 95,603 140,938 538,423 233,282 23,801 0
Montana 101,966 9,952 17,757 50,954 19,335 3,947 21
Nebraska 249,079 23,026 28,877 138,980 47,826 10,121 249
Nevada 167,247 17,920 29,993 79,283 35,217 4,834 0
New Hampshire 108,562 12,833 13,507 63,942 15,675 2,605 0
New Jersey 923,697 106,976 164,564 436,335 195,988 19,834 0
New Mexico 423,543 22,605 50,326 268,391 78,634 3,587 0
New York 3,548,630 385,586 684,658 1,573,767 825,201 79,418 0
North Carolina 1,397,486 180,515 234,304 685,285 281,193 16,189 0
North Dakota 65,425 10,242 9,672 29,750 14,026 1,735 0
Ohio 1,660,463 145,324 263,878 861,621 348,936 40,533 171
Oklahoma 631,996 62,350 76,638 397,586 88,507 6,915 0
Oregon 594,679 43,195 64,579 234,692 237,679 14,525 9
Pennsylvania 1,647,440 206,976 364,161 754,343 275,074 46,886 0
Rhode Island 194,113 19,137 36,402 84,191 48,834 5,548 1
South Carolina 871,675 78,673 120,088 444,607 220,606 7,692 9
South Dakota 106,154 9,894 16,042 61,743 16,704 1,771 0
Tennessee 1,601,406 88,350 324,191 682,755 493,266 12,822 22
Texas 2,729,660 362,522 351,509 1,526,365 458,079 31,185 0
Utah 214,597 11,855 26,386 119,196 50,579 6,581 0
Vermont 154,991 19,534 18,529 67,666 46,876 2,382 4
Virginia 700,715 97,093 137,282 359,463 92,498 14,334 45
Washington** 916,838 69,054 121,662 520,323 191,871 13,927 1
West Virginia 351,489 31,183 86,566 168,367 58,889 6,484 0
Wisconsin 673,538 61,165 133,983 299,529 160,354 18,505 2
Wyoming 58,013 4,984 8,476 32,076 10,638 1,839 0
1
Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year.
*Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 data are used in this table.
**MSIS data for FY 2001 have not yet been released for Washington. FY 2000 MSIS data are used in this table.

Source: CMS, MSIS Report, FY 2000 and FY 2001.

2-13
National Pharmaceutical Council Pharmaceutical Benefits 2003

Total Medicaid Eligibles Per 1000 Population, 2001

Total State Total Eligibles per


State Population Eligibles* 1000 Populations
National Total 285,093,813 46,910,257 164.5
Alabama 4,466,440 780,434 174.7
Alaska 632,674 115,996 183.3
Arizona 5,297,684 808,386 152.6
Arkansas 2,692,041 550,668 204.6
California 34,533,054 8,495,030 246.0
Colorado 4,428,786 410,611 92.7
Connecticut 3,432,550 446,326 130.0
Delaware 795,576 133,079 167.3
District of Columbia 572,716 152,597 266.4
Florida 16,355,193 2,462,171 150.5
Georgia 8,394,795 1,328,379 158.2
Hawaii* 1,225,038 202,912 165.6
Idaho 1,321,309 172,348 130.4
Illinois 12,517,168 1,798,723 143.7
Indiana 6,126,470 825,556 134.8
Iowa 2,932,225 331,025 112.9
Kansas 2,700,453 291,837 108.1
Kentucky 4,067,336 762,871 187.6
Louisiana 4,466,001 886,518 198.5
Maine 1,284,691 277,843 216.3
Maryland 5,383,377 704,628 130.9
Massachusetts 6,399,869 1,125,607 175.9
Michigan 10,005,218 1,430,246 143.0
Minnesota 4,985,202 609,856 122.3
Mississippi 2,857,716 681,161 238.4
Missouri 5,636,220 1,032,047 183.1
Montana 905,954 101,966 112.6
Nebraska 1,719,000 249,079 144.9
Nevada 2,094,633 167,247 79.8
New Hampshire 1,258,974 108,562 86.2
New Jersey 8,504,114 923,697 108.6
New Mexico 1,829,110 423,543 231.6
New York 19,074,843 3,548,630 186.0
North Carolina 8,195,249 1,397,486 170.5
North Dakota 636,285 65,425 102.8
Ohio 11,385,833 1,660,463 145.8
Oklahoma 3,467,181 631,996 182.3
Oregon 3,472,629 594,679 171.2
Pennsylvania 12,298,363 1,647,440 134.0
Rhode Island 1,058,992 194,113 183.3
South Carolina 4,059,818 871,675 214.7
South Dakota 758,156 106,154 140.0
Tennessee 5,745,808 1,601,406 278.7
Texas 21,340,598 2,729,660 127.9
Utah 2,279,590 214,597 94.1
Vermont 612,923 154,991 252.9
Virginia 7,192,697 700,715 97.4
Washington** 5,992,760 916,838 153.0
West Virginia 1,801,641 351,489 195.1
Wisconsin 5,405,140 673,538 124.6
Wyoming 493,720 58,013 117.5
*Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 MSIS data are used in this table.
**MSIS data for FY 2001 have not yet been released for Washington. FY 2000 MSIS data are used in this table.

Source: U.S. Department of Commerce, Bureau of the Census, 2003; CMS, MSIS Report, FY 2000 & FY 2001.

2-14
National Pharmaceutical Council Pharmaceutical Benefits 2003

Total Net U.S. Medical Assistance Expenditures


by Type of Service, FY 2001 & FY 2002

Percent Percent Percent


Service FY 2002 FY 2001
of Total of Total Change

Nursing Facility $47,466,264,432 19.3% $43,317,811,704 20.1% +9.6%

Inpatient Acute Care Hospital $43,690,502,629 17.8% $39,586,413,122 18.3% +10.4%

Pharmaceuticals $29,339,050,970 11.9% $24,656,812,921 11.4% +19.0%

HCBS Waivers $17,169,137,673 7.0% $14,864,788,473 6.9% +15.5%

ICF-Mentally Retarded $11,205,483,449 4.6% $10,686,809,919 5.0% +4.9%

Hospital Outpatient $9,245,799,624 3.8% $7,709,540,429 3.6% +19.9%

Physicians $7,559,242,098 3.1% $6,670,379,109 3.1% +13.3%

Clinic* $7,499,886,627 3.1% $6,689,968,278 3.1% +12.1%

Inpatient Mental Health Hospital $7,446,842,170 3.0% $6,862,423,184 3.2% +8.5%

Personal Care Services $6,037,450,986 2.5% $5,251,140,806 2.4% +15.0%

Home Health Care $2,766,480,497 1.1% $2,613,356,673 1.2% +5.9%

Dental $2,630,870,620 1.1% $2,193,475,415 1.0% +19.9%

Other Practitioners $1,413,870,565 0.6% $1,141,272,064 0.5% +23.9%

EPSDT $1,007,637,056 0.4% $935,836,328 0.4% +7.7%

Lab/X-ray $781,820,930 0.3% $660,398,684 0.3% +18.3%

Other** $50,437,280,350 20.5% $41,969,472,522 19.4% +20.2%

Total Expenditures $245,697,620,676 100%‡ $215,809,899,631 100.0%‡ +13.8%


‡ Values may not add to 100% due to rounding. American Samoa, Guam, N. Mariana Islands, Puerto Rico, and Virgin Islands
excluded.
* Clinic includes clinics, FQHCs, and rural health clinics.
** Other includes hospice, other care services, payments to managed care organizations, etc.

Source: CMS, CMS-64 Report, FY 2002 and FY 2001

2-15
National Pharmaceutical Council Pharmaceutical Benefits 2003

Federal Medical Assistance Percentage (FMAP),


FY 2004 and FY 2005
2004 FMAP 2004 Enhanced 2005 Enhanced
State 2004 FMAP (Q1-Q3)* FMAP** 2005 FMAP FMAP**
Alabama 70.75% 73.70% 79.53% 70.83% 79.58%
Alaska*** 58.39% 61.34% 70.87% 57.58% 70.31%
Arizona 67.26% 70.21% 77.08% 67.45% 77.22%
Arkansas 74.67% 77.62% 82.27% 74.75% 82.33%
California 50.00% 52.95% 65.00% 50.00% 65.00%
Colorado 50.00% 52.95% 65.00% 50.00% 65.00%
Connecticut 50.00% 52.95% 65.00% 50.00% 65.00%
Delaware 50.00% 52.95% 65.00% 50.38% 65.27%
District of Columbia*** 70.00% 72.95% 79.00% 70.00% 79.00%
Florida 58.93% 61.88% 71.25% 58.90% 71.23%
Georgia 59.58% 62.55% 71.71% 60.44% 72.31%
Hawaii 58.90% 61.85% 71.23% 58.47% 70.93%
Idaho 70.46% 73.91% 79.32% 70.62% 79.43%
Illinois 50.00% 52.95% 65.00% 50.00% 65.00%
Indiana 62.32% 65.27% 73.62% 62.78% 73.95%
Iowa 63.93% 66.88% 74.75% 63.55% 74.49%
Kansas 60.82% 63.77% 72.57% 61.01% 72.71%
Kentucky 70.09% 73.04% 79.06% 69.60% 78.72%
Louisiana 71.63% 74.58% 80.14% 71.04% 79.73%
Maine 66.01% 69.17% 76.21% 64.89% 75.42%
Maryland 50.00% 52.95% 65.00% 50.00% 65.00%
Massachusetts 50.00% 52.95% 65.00% 50.00% 65.00%
Michigan 55.89% 58.84% 69.12% 56.71% 69.70%
Minnesota 50.00% 52.95% 65.00% 50.00% 65.00%
Mississippi 77.08% 80.03% 83.96% 77.08% 83.96%
Missouri 61.47% 64.42% 73.03% 61.15% 72.81%
Montana 72.85% 75.91% 81.00% 71.90% 80.33%
Nebraska 59.89% 62.84% 71.92% 59.64% 71.75%
Nevada 54.93% 57.88% 68.45% 55.90% 69.13%
New Hampshire 50.00% 52.95% 65.00% 50.00% 65.00%
New Jersey 50.00% 52.95% 65.00% 50.00% 65.00%
New Mexico 74.85% 77.80% 82.40% 74.30% 82.01%
New York 50.00% 52.95% 65.00% 50.00% 65.00%
North Carolina 62.85% 65.80% 74.00% 63.63% 74.54%
North Dakota 68.31% 71.31% 77.82% 67.49% 77.24%
Ohio 59.23% 62.18% 71.46% 59.68% 71.78%
Oklahoma 70.24% 73.51% 79.17% 70.18% 79.13%
Oregon 60.81% 63.76% 72.57% 61.12% 72.78%
Pennsylvania 54.76% 57.71% 68.33% 53.84% 67.69%
Rhode Island 56.03% 58.98% 69.22% 55.38% 68.77%
South Carolina 69.86% 72.81% 78.90% 69.89% 78.92%
South Dakota 65.67% 68.62% 75.97% 66.03% 76.22%
Tennessee 64.40% 67.54% 75.08% 64.81% 75.37%
Texas 60.22% 63.17% 72.15% 60.87% 72.61%
Utah 71.72% 74.67% 80.20% 72.14% 80.50%
Vermont 61.34% 65.36% 72.94% 60.11% 72.08%
Virginia 50.00% 53.48% 65.00% 50.00% 65.00%
Washington 50.00% 52.95% 65.00% 50.00% 65.00%
West Virginia 75.19% 78.14% 82.63% 74.65% 82.26%
Wisconsin 58.41% 61.38% 70.89% 58.32% 70.82%
Wyoming 59.77% 64.27% 71.84% 57.90% 70.53%
* The Jobs and Growth Tax Relief and Reconciliation Act of 2003 (May 28, 2003) provides for a temporary increase in the FMAP. This increase is only
available for the last two quarters of FY 2003 and the first three quarters of FY 2004. More information is available at:
http://aspe.os.DHHS.gov/health/FMAP03-04temporaryincrease.html.
** The “Enhanced Federal Medical Assistance Percentages” are for use in State Children’s Health Insurance Program under Title XXI, and for some or all
of children’s medical assistance under Medicaid sections 1905(u)(2) and 1905(u)(3).
*** The values for Alaska and the District of Columbia were set for the State Plan under Titles XIX and XXI and for capitation payments and DSH
allotments under those titles. For other purposes, including programs remaining in Title IV of the Act, the percentage for Alaska is 52.23% and for the
District of Columbia is 50.00%.
Source: Federal Register, November 15, 2002, Vol. 67, No. 221, pages 69223-69225; June 17, 2003, Vol. 68, No. 116, pages 35889-35890; and December
3, 2003, Vol. 68, No. 232, pages 67676-67678.

2-16
National Pharmaceutical Council Pharmaceutical Benefits 2003

Medicaid Total Net Expenditures and Eligibles, 2001

Total Net Medical Total Average


State Assistance Expenditures Eligibles Per Eligible
National Total $215,809,899,631 46,910,257 $4,000
Alabama $2,875,372,953 780,434 $3,684
Alaska $576,586,201 115,996 $4,971
Arizona $2,665,261,328 808,386 $3,297
Arkansas $1,852,176,546 550,668 $3,364
California $23,870,521,004 8,495,030 $2,810
Colorado $2,142,029,851 410,611 $5,217
Connecticut $3,213,848,086 446,326 $7,201
Delaware $591,974,246 133,079 $4,448
District of Columbia $979,941,105 152,597 $6,422
Florida $8,557,796,303 2,462,171 $3,476
Georgia $5,037,084,881 1,328,379 $3,792
Hawaii* $634,781,970 202,912 $3,128
Idaho $693,205,598 172,348 $4,022
Illinois $7,764,611,352 1,798,723 $4,317
Indiana $4,008,812,857 825,556 $4,856
Iowa $1,666,923,701 331,025 $5,036
Kansas $1,686,410,544 291,837 $5,779
Kentucky $3,304,053,663 762,871 $4,331
Louisiana $4,201,982,590 886,518 $4,740
Maine $1,315,523,163 277,843 $4,735
Maryland $3,256,576,882 704,628 $4,622
Massachusetts $6,619,524,971 1,125,607 $5,881
Michigan $7,218,697,113 1,430,246 $5,047
Minnesota $3,835,870,579 609,856 $6,290
Mississippi $2,438,979,981 681,161 $3,581
Missouri $4,744,963,426 1,032,047 $4,598
Montana $482,357,404 101,966 $4,731
Nebraska $1,187,237,577 249,079 $4,767
Nevada $674,337,888 167,247 $4,032
New Hampshire $873,248,831 108,562 $8,044
New Jersey $7,123,653,988 923,697 $7,712
New Mexico $1,467,417,736 423,543 $3,465
New York $31,367,464,639 3,548,630 $8,839
North Carolina $6,150,681,587 1,397,486 $4,401
North Dakota $406,418,593 65,425 $6,212
Ohio $8,433,412,161 1,660,463 $5,079
Oklahoma $2,021,033,069 631,996 $3,198
Oregon $2,658,358,391 594,679 $4,470
Pennsylvania $10,908,343,146 1,647,440 $6,621
Rhode Island $1,187,880,819 194,113 $6,120
South Carolina $3,019,387,228 871,675 $3,464
South Dakota $464,455,469 106,154 $4,375
Tennessee $5,501,312,153 1,601,406 $3,435
Texas $11,583,679,558 2,729,660 $4,244
Utah $833,720,115 214,597 $3,885
Vermont $601,467,093 154,991 $3,881
Virginia $3,036,846,387 700,715 $4,334
Washington** $4,305,724,247 916,838 $4,696
West Virginia $1,548,398,817 351,489 $4,405
Wisconsin $3,976,142,914 673,538 $5,903
Wyoming $243,408,927 58,013 $4,196
*Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 MSIS data are used in this table.
**MSIS data for FY 2002 have not yet been released for Washington. FY 2000 MSIS data are used in this table.

Source: CMS, CMS-64 Report, FY 2001 and CMS-MSIS Report, FY 2000 & FY 2001.

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Total Medicaid Program Expenditures, 2002

Total Net Medical Administrative Total Program


State Assistance Expenditures Expenditures Expenditures
National Total $245,697,620,676 $11,865,503,019 $257,563,123,695
Alabama $3,093,270,640 $101,262,707 $3,194,533,347
Alaska $685,772,985 $53,525,999 $739,298,984
Arizona $3,541,598,721 $214,483,151 $3,756,081,872
Arkansas $2,237,817,554 $103,472,005 $2,341,289,559
California $26,890,540,967 $2,165,421,909 $29,055,962,876
Colorado $2,323,068,699 $89,593,331 $2,412,662,030
Connecticut $3,456,338,545 $145,108,698 $3,601,447,243
Delaware $634,046,351 $54,177,131 $688,223,482
District of Columbia $1,021,772,693 $60,012,057 $1,081,784,750
Florida $9,871,508,234 $528,381,789 $10,399,890,023
Georgia $6,241,211,454 $302,658,380 $6,543,869,834
Hawaii $740,007,314 $64,472,204 $804,479,518
Idaho $773,534,776 $62,662,990 $836,197,766
Illinois $8,809,060,004 $700,700,368 $9,509,760,372
Indiana $4,448,318,143 $181,277,188 $4,629,595,331
Iowa $2,575,146,342 $79,808,909 $2,654,955,251
Kansas $1,836,717,196 $119,768,351 $1,956,485,547
Kentucky $3,763,204,047 $100,440,133 $3,863,644,180
Louisiana $4,885,971,853 $136,430,738 $5,022,402,591
Maine $1,430,109,134 $59,837,086 $1,489,946,220
Maryland $3,613,476,100 $274,488,455 $3,887,964,555
Massachusetts $8,063,005,258 $317,224,866 $8,380,230,124
Michigan $7,562,053,407 -$163,622,489 $7,398,430,918
Minnesota $4,414,511,470 $247,714,024 $4,662,225,494
Mississippi $2,877,013,521 $87,664,878 $2,964,678,399
Missouri $5,360,607,640 $215,632,683 $5,576,240,323
Montana $571,456,455 $26,886,645 $598,343,100
Nebraska $1,339,132,070 $81,988,159 $1,421,120,229
Nevada $808,198,344 $56,128,326 $864,326,670
New Hampshire $1,016,094,814 $58,564,265 $1,074,659,079
New Jersey $7,745,877,997 $240,847,423 $7,986,725,420
New Mexico $1,776,811,688 $63,569,631 $1,840,381,319
New York $36,295,107,368 $1,181,722,131 $37,476,829,499
North Carolina $6,723,598,560 $302,125,603 $7,025,724,163
North Dakota $461,401,546 $22,525,872 $483,927,418
Ohio $9,658,040,587 $319,681,549 $9,977,722,136
Oklahoma $2,260,403,490 $167,112,579 $2,427,516,069
Oregon $2,571,560,664 $226,191,921 $2,797,752,585
Pennsylvania $12,130,925,035 $556,891,243 $12,687,816,278
Rhode Island $1,358,500,649 $62,877,169 $1,421,377,818
South Carolina $3,292,901,444 $133,484,748 $3,426,386,192
South Dakota $549,884,391 $15,675,093 $565,559,484
Tennessee $5,787,079,096 $245,058,264 $6,032,137,360
Texas $13,523,486,149 $706,759,839 $14,230,245,988
Utah $984,160,785 $78,087,725 $1,062,248,510
Vermont $660,731,979 $55,179,707 $715,911,686
Virginia $3,812,166,436 $187,346,225 $3,999,512,661
Washington $5,168,511,470 $490,873,523 $5,659,384,993
West Virginia $1,584,166,286 $73,009,703 $1,657,175,989
Wisconsin $4,193,175,197 $186,413,731 $4,379,588,928
Wyoming $274,565,128 $23,904,404 $298,469,532
Source: CMS, CMS-64 Report, FY 2002.

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Total SCHIP Expenditures, 2002

Medicaid SCHIP Non-Medicaid SCHIP


State Expenditures Expenditures Total Expenditure
National Total $1,330,657,305 $4,089,702,326 $5,420,359,631
Alabama $4,628,780 $64,702,498 $69,331,278
Alaska $27,348,249 $2,595,488 $29,943,737
Arizona $0 $167,950,645 $167,950,645
Arkansas $1,828,430 $81,548 $1,909,978
California $41,021,160 $647,354,640 $688,375,800
Colorado $0 $47,971,251 $47,971,251
Connecticut $3,447,029 $21,426,909 $24,873,938
Delaware $0 $4,015,741 $4,015,741
District of Columbia $6,269,076 $654,591 $6,923,667
Florida $65,139,446 $323,338,927 $388,478,373
Georgia $0 $148,512,336 $148,512,336
Hawaii $5,596,585 $20,389 $5,616,974
Idaho $16,772,010 $1,230,699 $18,002,709
Illinois $37,305,573 $18,558,488 $55,864,061
Indiana $66,035,063 $16,226,253 $82,261,316
Iowa $16,277,396 $22,540,225 $38,817,621
Kansas $0 $49,811,709 $49,811,709
Kentucky $60,261,647 $30,841,566 $91,103,213
Louisiana $78,484,723 $3,679,622 $82,164,345
Maine $15,623,419 $7,610,776 $23,234,195
Maryland $166,152,918 $17,228,837 $183,381,755
Massachusetts $72,181,353 $20,491,319 $92,672,672
Michigan $25,640,047 $31,334,653 $56,974,700
Minnesota $50,263 $99,462,784 $99,513,047
Mississippi $5,296,814 $78,458,940 $83,755,754
Missouri $83,252,095 $2,240,727 $85,492,822
Montana $0 $14,935,804 $14,935,804
Nebraska $16,028,217 $594,989 $16,623,206
Nevada $0 $31,433,945 $31,433,945
New Hampshire $276,736 $5,748,840 $6,025,576
New Jersey $44,305,712 $344,167,314 $388,473,026
New Mexico $16,902,487 $223,065 $17,125,552
New York $11,633,119 $560,001,709 $571,634,828
North Carolina $0 $117,820,812 $117,820,812
North Dakota $966,615 $3,880,893 $4,847,508
Ohio $175,369,794 $5,979,799 $181,349,593
Oklahoma $37,014,987 $1,008,907 $38,023,894
Oregon $0 $22,796,830 $22,796,830
Pennsylvania $0 $152,372,663 $152,372,663
Rhode Island $18,831,033 $32,810,550 $51,641,583
South Carolina $47,604,923 $5,289,436 $52,894,359
South Dakota $8,746,215 $2,624,039 $11,370,254
Tennessee $4,877,111 $481,001 $5,358,112
Texas $7,340,202 $735,462,302 $742,802,504
Utah $0 $32,706,432 $32,706,432
Vermont $0 $3,443,510 $3,443,510
Virginia $807,958 $59,375,598 $60,183,556
Washington $0 $12,319,513 $12,319,513
West Virginia $2,773 $32,518,236 $32,521,009
Wisconsin $34,000,865 $79,059,901 $113,060,766
Wyoming $0 $4,304,677 $4,304,677

Source: CMS, CMS-21 (SCHIP) Report, 2002.

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MEDICAID MANAGED CARE ENROLLMENT


Since 1981, when Congress authorized States to implement Section 1915(b) and Section 1115
Medicaid waivers to increase access to managed care and test innovative health care financing and
delivery options, enrollment in Medicaid managed care has grown considerably, although the trend
appears to be leveling off. Over the past ten years, managed care enrollment as a percentage of total
Medicaid enrollment has increased by 310 percent (i.e., from 14.4% to 59.1%). In 2003, 59.1% of all
Medicaid beneficiaries were enrolled in some type of managed care program. As of June 30, 2003, all
but three States (Alaska, Mississippi, and Wyoming) were enrolling Medicaid beneficiaries in some
type of managed care plan.

Figure 2-1: Managed Care Enrollment as a Percentage of Total Medicaid Enrollment

100%

80% 46.4% 44.4% 44.2% 43.2% 42.4% 40.9%


52.2%
59.9%
76.8% 70.6%
60% 85.6%

40%
53.6% 55.6% 55.8% 56.8% 57.6% 59.1%
47.8%
20% 29.4%
40.1%
23.2%
14.4%
0%
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Managed Care Fee for Service

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2003. 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.

TYPES OF MEDICAID MANAGED CARE PLANS

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.

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• Medicaid-only Managed Care Organization (Mcaid-MCO): a MCO that provides


comprehensive services to Medicaid beneficiaries, but not commercial or Medicare
enrollees.
• Prepaid Health Plan (PHP): an entity that provides less than comprehensive
services on an at-risk basis or one that provides any benefit package on a non-risk
basis.
• 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 PHPs
that act as PCCMs.
• “Other” Managed Care Arrangement: An entity where the plan is not considered
a PCCM, PHP, Comprehensive MCO, Medicaid-only MCO, or HIO.
The most utilized of these plans are Comprehensive MCOs and Prepaid Health Plans.

Table 2-1: Medicaid Managed Care Plans

Number of Plans Number of Enrollees


Health Insuring Organization (HIO) 5 531,349
Commercial Managed Care Organization (COM-MCO) 164 9,920,954
Medicaid-only Managed Care Organization (Mcaid-MCO) 120 6,848,585
Primary Care Case Management (PCCM) 42 6,142,646
Prepaid Health Plan (PHP) 136 10,498,301
Other 44 195886
Total 511 34,107,721*
*This table provides duplicated figures by plan type. The total number of enrollees includes 8,844,848 individuals who were
enrolled in more than one managed care plan. It also includes individuals enrolled in State health care reform programs that
expand eligibility beyond traditional Medicaid eligibility standards.

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2003. 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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Medicaid Managed Care Enrollment, As of June 30, 2003

Rank Based on
Medicaid Medicaid Managed Percent in Percent in
State Enrollment Care Enrollment Managed Care Managed Care
National Total 42,740,719 25,262,873 59.11%
Alabama 760,527 404,797 53.23% 37
Alaska 95,335 0 0.00% 50
Arizona 901,655 808,506 89.67% 6
Arkansas 557,074 374,067 67.15% 24
California 6,272,109 3,258,787 51.96% 39
Colorado 330,499 262,263 79.35% 12
Connecticut 405,064 294,331 72.66% 15
Delaware 121,676 86,709 71.26% 17
District of
Columbia 128,185 85,370 66.60% 26
Florida 2,214,058 1,354,025 61.16% 33
Georgia 1,448,645 1,212,639 83.71% 9
Hawaii 179,522 141,399 78.76% 13
Idaho 156,935 101,257 64.52% 31
Illinois 1,580,944 137,682 8.71% 48
Indiana 707,168 502,401 71.04% 18
Iowa 266,737 243,954 91.46% 5
Kansas 246,186 141,119 57.32% 36
Kentucky 663,002 611,878 92.29% 4
Louisiana 861,846 505,434 58.65% 35
Maine 249,738 148,151 59.32% 34
Maryland 681,096 466,688 68.52% 21
Massachusetts 915,114 572,835 62.60% 32
Michigan 1,322,261 1,314,810 99.44% 2
Minnesota 552,779 362,349 65.55% 28
Mississippi 720,304 0 0.00% 50
Missouri 950,694 425,161 44.72% 44
Montana 80,378 55,372 68.89% 20
Nebraska 197,378 142,377 72.13% 16
Nevada 164,033 74,923 45.68% 42
New Hampshire 91,261 13,407 14.69% 47
New Jersey 782,309 525,864 67.22% 23
New Mexico 404,497 261,015 64.53% 30
New York 3,645,834 1,914,794 52.52% 38
North Carolina 1,074,616 749,152 69.71% 19
North Dakota 53,806 35,515 66.01% 27
Ohio 1,515,712 436,146 28.77% 46
Oklahoma 498,031 338,859 68.04% 22
Oregon 425,627 330,874 77.74% 14
Pennsylvania 1,492,095 1,192,031 79.89% 11
Puerto Rico 957,298 857,310 89.56% 7
Rhode Island 178,543 119,257 66.79% 25
South Carolina 862,175 71,195 8.26% 49
South Dakota 93,208 90,733 97.34% 3
Tennessee 1,304,794 1,304,794 100.00% 1
Texas 2,559,248 1,065,945 41.65% 45
Utah 187,823 162,364 86.45% 8
Vermont 131,051 85,751 65.43% 29
Virgin Islands 16,125 0 0.00% 50
Virginia 583,999 262,961 45.03% 43
Washington 1,059,865 854,861 80.66% 10
West Virginia 296,220 151,515 51.15% 40
Wisconsin 739,431 349,246 47.23% 41
Wyoming 56,209 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, 2003. DHHS, CMS, Center for Medicaid & State Operations.

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Pharmaceutical Benefits Under Managed Care Plans


Where do managed care recipients receive Special requirements
pharmacy benefits? for pharmacy benefits
State (State, Managed Care Plan, Both) in managed care?
Alabama N/A N/A
Alaska - -
Arizona* - -
Arkansas State None
California Both Statutes, regulations, guidelines, contractual
Colorado Managed Care Plan Contractual
Connecticut Managed Care Plan Contractual
Delaware State N/A
District of Columbia District of Columbia Government None
Florida Managed Care Plan Contractual
Georgia N/A N/A
Hawaii Both Guidelines
Idaho N/A N/A
Illinois Managed Care Plan Contractual
Indiana Managed Care Plan Statutes
Iowa State None
Kansas Both Statutes, regulations, contractual
Kentucky Both Contractual
Louisiana N/A N/A
Maine State N/A
Maryland Both Regulations
Massachusetts Managed Care Plan Contractual
Michigan Managed Care Plan Contractual
Minnesota Managed Care Plan Contractual
Mississippi State -
Missouri Managed Care Plan Guidelines, contractual
Montana State None
Nebraska State None
Nevada Managed Care Plan None
New Hampshire State None
New Jersey Managed Care Plan Guidelines
New Mexico Managed Care Plan Regulations, contractual
New York State N/A
North Carolina State None
North Dakota State None
Ohio Managed Care Plan Statutes
Oklahoma Both Contractual
Oregon Managed Care Plan Contractual
Pennsylvania Managed Care Plan Contractual
Rhode Island Managed Care Plan Regulations
South Carolina Managed Care Plan Contractual
South Dakota N/A N/A
Tennessee* Managed Care Plan Statutes
Texas State N/A
Utah State Regulations
Vermont State None
Virginia Managed Care Plan Contractual
Washington Both Contractual
West Virginia State N/A
Wisconsin Managed Care Plan Statutes, regulations, guidelines, contractual
Wyoming - -

*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 2003 NPC Survey.

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Medicaid Managed Care Enrollment Trends, 1999-2003


State 1999 2000 2001 2002 2003
National Total 17,756,603 18,786,137 20,773,813 23,117,668 25,262,873
Alabama 377,952 325,059 350,485 405,090 404,797
Alaska 0 0 0 0 0
Arizona 363,662 442,254 527,674 697,171 808,506
Arkansas 232,123 222,261 257,662 336,111 374,067
California 2,540,902 2,525,406 2,870,514 3,191,168 3,258,787
Colorado 216,357 254,232 247,181 278,095 262,263
Connecticut 230,217 229,995 239,829 280,106 294,331
Delaware 68,869 75,535 83,422 87,465 86,709
District of Columbia 75,499 78,864 79,673 80,300 85,370
Florida 912,045 1,016,641 1,184,506 1,267,998 1,354,025
Georgia 638,082 806,009 878,140 1,043,154 1,212,639
Hawaii 120,246 121,581 127,779 132,787 141,399
Idaho 31,184 32,338 37,913 58,284 101,257
Illinois 158,888 137,622 136,497 130,988 137,682
Indiana 331,363 376,066 433,014 484,116 502,401
Iowa 176,487 182,251 206,751 227,495 243,954
Kansas 95,868 108,093 118,209 130,162 141,119
Kentucky 324,447 464,191 489,711 500,987 611,878
Louisiana 44,741 48,802 56,542 206,992 505,434
Maine 23,720 57,151 96,051 110,922 148,151
Maryland 347,937 385,687 421,355 451,307 466,688
Massachusetts 575,186 583,324 616,241 628,832 572,835
Michigan 1,130,608 1,063,557 1,023,264 1,208,803 1,314,810
Minnesota 268,360 291,365 322,640 368,186 362,349
Mississippi* 200,347 218,431 297,916 0 0
Missouri 276,628 304,499 378,771 413,361 425,161
Montana 69,738 42,312 46,995 52,209 55,372
Nebraska 122,006 140,199 150,840 163,772 142,377
Nevada 36,945 37,945 47,518 60,823 74,923
New Hampshire 5,812 4,432 6,200 9,206 13,407
New Jersey 356,956 371,641 459,087 523,904 525,864
New Mexico 208,528 199,297 212,456 243,069 261,015
New York 659,569 691,422 728,709 1,099,900 1,914,794
North Carolina 689,104 598,852 674,133 722,089 749,152
North Dakota 23,886 23,962 25,540 30,808 35,515
Ohio 244,888 239,460 277,617 378,476 436,146
Oklahoma 193,902 279,205 299,272 338,819 338,859
Oregon 308,798 312,064 360,926 378,739 330,874
Pennsylvania 1,004,601 975,211 1,037,374 1,140,211 1,192,031
Puerto Rico 764,068 828,021 898,171 865,285 857,310
Rhode Island 85,900 104,041 111,624 117,024 119,257
South Carolina 23,149 32,149 41,716 64,272 71,195
South Dakota 50,220 67,835 79,641 85,868 90,733
Tennessee 1,312,969 1,323,319 1,426,622 1,430,966 1,304,794
Texas 352,062 606,238 753,613 839,798 1,065,945
Utah 118,601 119,200 128,898 154,784 162,364
Vermont 65,692 55,605 78,181 82,261 85,751
Virgin Islands 0 0 0 0 0
Virginia 292,214 280,978 291,767 323,863 262,961
Washington 706,202 800,481 766,366 829,625 854,861
West Virginia 111,532 90,631 122,230 144,911 151,515
Wisconsin 187,543 210,423 266,577 317,106 349,246
Wyoming 0 0 0 0 0

State Medicaid enrollment includes individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid
eligibility standards.
*As of 2002, HealthMacs no longer participates in the Medicaid program in Mississippi.

Sources: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999; 2000; 2001; 2002 and 2003. DHHS, CMS, Center
for Medicaid & State Operations.

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Medicaid Managed Care Plan Type, As of June 30, 2003


Commercial Medicaid-only
State HIO MCO MCO PCCM PHP Other
National Total 5 164 120 42 136 44
Alabama 0 0 0 2 1 0
Alaska - - - - - -
Arizona 0 2 26 0 1 0
Arkansas 0 0 0 1 1 0
California 5 24 0 2 11 5
Colorado 0 0 1 1 9 1
Connecticut 0 2 2 0 0 0
Delaware 0 1 0 0 0 0
District of Columbia 0 0 4 0 1 0
Florida 0 9 2 1 2 2
Georgia 0 0 0 1 2 0
Hawaii 0 2 1 0 2 1
Idaho 0 0 0 1 0 0
Illinois 0 4 1 0 0 0
Indiana 0 0 3 2 0 0
Iowa 0 3 0 1 1 0
Kansas 0 0 1 1 0 1
Kentucky 0 0 1 1 1 0
Louisiana 0 0 0 1 0 0
Maine 0 0 0 1 0 0
Maryland 0 0 6 0 0 1
Massachusetts 0 2 2 1 1 6
Michigan 0 9 9 0 20 0
Minnesota 0 6 3 0 0 1
Mississippi - - - - - -
Missouri 0 3 4 0 0 1
Montana 0 0 0 1 0 0
Nebraska 0 1 0 1 0 1
Nevada 0 2 0 0 0 0
New Hampshire 0 1 0 0 0 0
New Jersey 0 1 4 0 0 0
New Mexico 0 3 0 0 0 0
New York 0 14 15 6 1 17
North Carolina 0 1 0 2 0 0
North Dakota 0 1 0 1 0 0
Ohio 0 4 2 0 0 2
Oklahoma 0 3 2 0 0
Oregon 0 4 9 1 18 0
Pennsylvania 0 2 9 1 28 1
Puerto Rico 0 3 0 0 2 0
Rhode Island 0 3 0 0 0 0
South Carolina 0 0 1 0 1 0
South Dakota 0 0 0 1 1 0
Tennessee 0 5 3 0 2 1
Texas 0 10 2 2 1 0
Utah 0 0 0 3 13 0
Vermont 0 0 0 1 0 0
Virgin Islands - - - - - -
Virginia 0 6 1 1 0 0
Washington 0 6 2 1 14 1
West Virginia 0 2 0 1 0 0
Wisconsin 0 28 3 0 2 2
Wyoming - - - - - -

HIO=Health Insuring Organization; Commercial MCO=Commercial Managed Care Organization; Medicaid-only MCO=Medicaid-only
Managed Care Organization; PCCM=Primary Care Case Management; PHP=Prepaid Health Plan.

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2003. DHHS, CMS, Center for Medicaid & State
Operations.

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Medicaid Managed Care Enrollment by Plan Type,


As of June 30, 2003
Commercial Medicaid-only
State HIO MCO MCO PCCM PHP Other
National Total 531,349 9,920,954 6,848,585 6,142,646 10,468,301 195,886
Alabama - - - 401,393 391,912 -
Alaska - - - - - -
Arizona - 68,404 740,102 - 64,021 -
Arkansas - - - 325,886 374,067 -
California 531,349 2,676,278 0 28,002 255,281 3,610
Colorado - - 70,150 82,488 274,174 758
Connecticut - 225,057 69,274 - - -
Delaware - 86,709 - - - -
District of Columbia - - 85,370 - 2,898 -
Florida - 463,173 203,728 667,114 90,281 18,268
Georgia - - - 840,630 1,215,029 -
Hawaii - 94,051 45,756 - 550 1,497
Idaho - - - 101,257 - -
Illinois - 119,225 18,457 - - -
Indiana - - 246,488 255,913 - -
Iowa - 64,365 - 73,332 243,954 -
Kansas - - 60,891 80,186 - 61
Kentucky - - 128,679 375,890 611,878 -
Louisiana - - - 505,434 - -
Maine - - - 148,151 - -
Maryland - - 466,542 - - 146
Massachusetts - 103,554 165,162 304,119 324,207 1,195
Michigan - 450,816 374,781 - 1,319,096 -
Minnesota - 345,968 16,381 - - 825
Mississippi - - - - - -
Missouri - 113,616 311,545 - - 168
Montana - - - 55,372 - -
Nebraska - 30,712 - 35,109 - 142,377
Nevada - 74,923 - - - -
New Hampshire - 13,407 - - - -
New Jersey - 43,672 482,192 - - -
New Mexico - 261,015 - - - -
New York - 968,577 875,494 20,961 6,979 18,313
North Carolina - 11,314 - 749,152 - -
North Dakota - 821 - 34,694 - -
Ohio - 151,026 284,662 - - 458
Oklahoma - - 181,451 160,591 - -
Oregon - 45,333 175,469 9,110 550,413 -
Pennsylvania - 230,556 820,601 135,000 970,455 153
Puerto Rico - 857,310 - - 857,310 -
Rhode Island - 119,257 - - - -
South Carolina - - 53,793 - 17,402 -
South Dakota - - - 71,424 90,733 -
Tennessee - 979,682 450,012 - 1,304,794 227
Texas - 450,054 270,931 332,820 277,613 -
Utah - - - 74,422 371,482 -
Vermont - - - 85,751 - -
Virgin Islands - - - - - -
Virginia - 198,288 64,673 80,796 - -
Washington - 392,203 78,752 3,917 853,226 184
West Virginia - 47,783 - 103,732 - -
Wisconsin - 233,805 107,249 - 546 7,646
Wyoming - - - - - -
* This table provides duplicated figures that include enrollees receiving comprehensive and limited benefits. Total number
of enrollees includes those who were enrolled in more than one managed care plan. Figures also include individuals
enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards.

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2003. DHHS, CMS, Center for Medicaid & State
Operations.

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Medicaid Managed Care Enrollment by Payment Arrangement,


As of June 30, 2003
State FEE-FOR-SERVICE (FFS) Fully Capitated (FUL) Partially Capitated (PAR)
National Total 6,188,187 27,704,547 214,987
Alabama 401,393 391,912
Alaska
Arizona 872,527
Arkansas 325,886 374,067
California 28,002 3,466,518
Colorado 82,488 333,171 11,911
Connecticut 294,331
Delaware 86,709
District of Columbia 85,370 2,898
Florida 685,372 757,192
Georgia 840,630 1,215,029
Hawaii 141,854
Idaho 101,257
Illinois 137,682
Indiana 255,913 246,488
Iowa 73,332 308,319
Kansas 80,186 60,952
Kentucky 375,890 740,557
Louisiana 505,434
Maine 148,151
Maryland 466,688
Massachusetts 304,119 594,118
Michigan 2,144,693
Minnesota 825 362,349
Mississippi
Missouri 425,329
Montana 55,372
Nebraska 177,486 30,712
Nevada 74,923
New Hampshire 13,407
New Jersey 525,864
New Mexico 261,015
New York 6,105 1,862,384 21,835
North Carolina 749,152 11,314
North Dakota 34,694 821
Ohio 436,146
Oklahoma 181,451 160,591
Oregon 9,110 771,215
Pennsylvania 135,000 2,021,415 350
Puerto Rico 1,714,620
Rhode Island 119,257
South Carolina 53,793 17,402
South Dakota 71,424 90,733
Tennessee 2,734,715
Texas 332,820 998,598
Utah 133,950 311,954
Vermont 85,751
Virgin Islands
Virginia 80,796 262,961
Washington 3,917 1,324,365
West Virginia 103,732 47,783
Wisconsin 349,246
Wyoming

Individual State totals will not sum to total managed care enrollment (page 2-5) 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, 2003. DHHS, CMS, Center for Medicaid & State
Operations.

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MEDICAID MANAGED CARE WAIVERS


In 1981, Congress authorized States to implement Section 1915(b) and Section 1115 Medicaid
waivers to increase access to managed care and test innovative health care financing and delivery
options. The U.S. Department of Health and Human Services (DHHS) granted these waivers to allow
States to “waive” certain Medicaid requirements in Sections 1902 and 1903 of the Social Security Act
and “mandate” enrollment of Medicaid eligibles in managed care programs.

SECTION 1915(b) “FREEDOM OF CHOICE” WAIVERS

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.

Refer to the table on page 2-33 for a listing of 1915(b) waivers.

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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SECTION 1115 RESEARCH AND DEMONSTRATION WAIVERS

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, Arkansas,
California, Delaware, Hawaii, Kentucky, Maryland, Massachusetts, Minnesota, Missouri, New York,
Oklahoma, Oregon, Rhode Island, Tennessee, Vermont and Wisconsin. Refer to the table on page 2-
33 for a listing of implemented Section 1115 waivers.

PHARMACY PLUS DEMONSTRATIONS UNDER SECTION 1115 AUTHORITY

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 24, 2003, 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.

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) establishes a
new Part D that provides a prescription drug benefit to all Medicare beneficiaries beginning in 2006.
When the new benefit begins, states with Pharmacy Plus waivers may want to eliminate or
substantially revise them because Medicare will be providing prescription drug coverage to seniors
now covered by Pharmacy Plus.

Refer to the table on page 2-36 for a complete status of the Pharmacy Plus Demonstrations Program.

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Section 1915(b) Waivers, As of June 30, 2002

1915(b)
Statutes
State Program(s) Approved Utilized Implemented Expiration
st
Alabama Patient 1 1, 3, 4 01/1/97 12/26/02
Alaska None -- -- --
Arizona None -- -- --
Non-Emergency Transportation 1, 4 3/1/98 8/22/03
Arkansas
Primary Care Physician 1 11/1/96 12/17/04
CALOPTIMA 1, 4 10/1/95 7/29/03
Central Coast Alliance for Health 1, 4 1/1/96 6/2/03
Health Plan of San Mateo 1, 4 11/30/87 8/26/04
Hudman 4 4/24/92 7/15/03
Managed Care Network 1, 2, 4 3/1/97 5/18/03
Medi-Cal Mental Health Care Field Test 4 4/1/95 7/29/03
Medi-Cal Specialty Mental Health Services
4 11/19/02
California Consolidation 3/15/95
Partnership Health Plan of California 1, 4 5/1/94 2/10/03
Primary Care Case Management Program 1, 4 8/1/84 2/4/04
Sacramento Geographic Managed Care 1, 2, 4 4/1/94 11/10/02
San Diego Geographic Managed Care 1, 2, 4 10/17/98 10/10/03
Santa Barbara Health Initiative 1, 4 9/1/83 1/11/03
Selective Provider Contracting Program 4 9/21/82 10/31/02
Two-Plan Model Program 1, 2, 4 1/23/96 11/8/03
Managed Care Program 1, 2 5/1/83 4/14/03
Colorado
Mental Health Capitation Program 1, 3, 4 7/1/95 4/9/03
Connecticut HUSKY A 1, 4 10/1/95 5/30/04
Delaware None -- -- --
District of
DC Medicaid Managed Care Program 1, 2, 4 9/23/03
Columbia 4/1/94
Managed Health Care 1, 2, 4 10/1/92 9/26/04
Florida Prepaid Mental Health Plan 1, 4 3/1/96 6/30/03
Statewide Inpatient Psychiatric Program 4 4/1/99 12/31/03
Georgia Better Health Care 1 10/1/93 3/14/03
Georgia Non-Emergency Transportation Broker Program 4 10/1/97 9/7/03
Preadmission Screening and Annual Resident Review
(PASARR) 1, 4 11/1/94 4/8/03
Hawaii None -- -- --
Idaho Healthy Connections 1, 2 10/1/93 9/21/04
Illinois None -- -- --
Indiana Hoosier Healthwise 1 7/1/94 4/23/03
Iowa Iowa Plan for Behavioral Health 1, 3, 4 1/1/99 2/28/03
KMMC: HealthConnect Kansas 1, 2, 4 1/1/84 10/4/02
Kansas
KMMC: HealthWave 19 1, 2, 4 12/1/95 10/4/02
Kentucky Human Service Transportation 1, 4 6/1/98 3/7/03
Louisiana Community Care 1 6/1/92 3/25/03
Maine None -- -- --
Maryland None -- -- --

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1915(b)
Statutes
State Program(s) Approved Utilized Implemented Expiration
Massachuse None -- -- --
Comprehensive Health Care 1, 2, 4 7/1/97 9/24/04
Michigan
Specialty Community Mental Health Services Programs 1, 4 10/1/98 3/13/03
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
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 10/31/02
Nevada None -- -- --
New None -- -- --
New Jersey New Jersey Care 2000+ 1915(b) 1, 2 10/1/00 9/30/02
New SALUD! 1,4 7/1/97 10/21/02
New York Non-Emergency Transportation 1, 4 7/1/96 11/14/02
ACCESS II /III1915(b) 1 7/1/98 11/08/02
North
Carolina Access 1915(b) 1 4/1/91 11/08/02
Carolina
Health Care Connection 1915(b) 1 7/1/96 11/08/02
North None -- -- --
Ohio PremierCare 1, 2, 4 7/1/01 6/30/03
Oklahoma None -- -- --
Oregon Transportation Program 4 9/1/94 7/25/03
Pennsylvani Family Care Network 1 2/1/94 6/16/04
a HealthChoices 1, 2, 3, 4 2/1/97 6/16/04
Puerto Rico None -- -- --
Rhode None -- -- --
South None -- -- --
South Prime 1 9/1/93 9/28/02
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 11/5/03
11/1/99
STAR 1, 2, 3, 4 8/1/93 8/31/03
STAR Plus 1, 2, 3, 4 1/1/98 8/31/04
Choice of Health Care Delivery 1, 2, 4 7/1/82 7/23/03
Utah Non-Emergency Transportation 1, 4 7/1/01 9/18/04
Prepaid Mental Health Program 4 7/1/91 12/26/03
Vermont None -- -- --
Medallion 1, 2 3/1/92 3/24/04
Virginia
Medallion II 1, 4 1/1/96 12/26/02
Healthy Options 1, 4 10/1/93 2/24/03
Washington
The Integrated Mental Health Services 1, 4 7/1/93 11/4/04
West Mountain Health Trust 1, 4 9/1/96 12/22/04
Virginia Physician Assured Access System 1 6/1/92 4/27/04
Wisconsin None -- -- --
Wyoming None -- -- --

Source: 2002 National Summary of State Medicaid Managed Care Programs. Program Descriptions as of June 30, 2002.
Centers for Medicare and Medicaid Services, Center for Medicaid & State Operations.

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Section 1115 Research and Demonstration Waivers


As of June 30, 2002
State Program Implemented Expiration
Arizona Arizona Health Care Cost Containment System (AHCCCS) 10/1/82 9/30/06
Arkansas ARKids First 9/1/97 9/30/05
Altamed Health Senior Buencare 11/01/98 11/24/02
Center For Elders Independence 4/1/95 11/24/02
California On Lok Senior Health Services 11/1/83 11/24/02
Senior Care Action Network 1/1/85 7/31/03
Sutter Senior Care 5/1/94 11/24/02
Delaware Diamond State Health Plan 1/1/96 3/15/04
Hawaii Hawaii QUEST 8/1/94 3/31/03
Kentucky Kentucky Health Care Partnership Program 11/1/97 11/1/02
Maryland HealthChoice 6/2/97 5/31/05
Massachusetts Mass Health 7/1/97 6/30/05
MinnesotaCare Program for Families and Children 7/1/95 6/30/05
Minnesota
Prepaid Medical Assistance Program 7/1/85 6/30/05
Missouri MC+ Managed Care/1115 9/1/98 3/1/04
Partnership Plan – Family Health Plus 9/04/01 3/31/03
New York
Partnership Plan Medicaid Managed Care Program 10/1/97 3/31/03
Oklahoma SoonerCare 1/1/96 12/31/03
Oregon Oregon Health Plan 2/1/94 1/31/05
Rhode Island Rite Care 8/1/94 7/31/05
Tennessee TennCare 1/1/94 6/30/07
Vermont Vermont Health Access 1/1/96 12/31/03
BadgerCare (SCHIP) 7/01/99 3/31/04
Wisconsin
Wisconsin Partnership Program 1/1/96 12/31/02

Source: 2002 National Summary of State Medicaid Managed Care Programs. Program Descriptions as of June 30, 2002. Centers
for Medicare and Medicaid Services, Center for Medicare & State Operations.

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Pharmacy Plus Demonstrations Program Status

Pharmacy Waivers Under 1115 Authority

STATE PROGRAM NAME STATUS


Arkansas Arkansas RX Senior Care Pending

Connecticut ConnPACE Program Rx Pending

Delaware Delaware Pharmacy Assistance Program Disapproved

Florida Ron Silver Senior Rx Program Approved

Hawaii Prescription Plus Disapproved


Prescription Drug Benefit for Illinois’ Low
Illinois Approved
Income
Pending
Maine Maine Health Prescription Drug Demonstration

Massachusetts Pharmacy Waiver Withdrawn

Michigan EPIC Ex Pending


Pharmaceutical Assistance for the Aged and
New Jersey Pending
Disabled
North Carolina North Carolina Senior Care Pending
Pending
Rhode Island Rhode Island RX+
Prescription Drug Benefit for South Approved
South Carolina
Carolina’s Low Income Seniors
Wisconsin WI Senior Care Approved

Source: CMS Website at www.cms.DHHS.gov/medicaid/1115/pharmplusstatus.asp; last modified on September 24, 2003.

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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 2002 American
Community Survey conducted by the U.S. Bureau of the Census. It is the only 2002 age breakout
on a State-by-State basis that the Bureau had released while data collection for the 2003
Compilation was ongoing. 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 March 2003 Supplement to the Current
Population Survey, 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 The March 2003 Supplement to the
Current Population Survey have been included in this year’s Compilation.

HRSA’s Bureau of Health Professions, Division of Nursing is responsible for conducting the
National Sample Survey of Registered Nurses. This survey is the Nation’s most extensive and
comprehensive source of nursing statistics. The most recent iteration of this survey, which is
conducted every four years, is the 2000 version. Unfortunately, these data are somewhat out-of-
date. We, therefore, turned to another source, The Area Resource File (ARF), for data on the
number of requested nurses. However, as is often the case, data from different sources are not
exactly the same. The Area Resource File, 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. Hence, the nursing numbers included in 2003 Compilation are lower than those
presented last year.

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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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National Pharmaceutical Council Pharmaceutical Benefits 2003

Age Demographics, 2002*


Total Percent Ages Percent Percent Percent
State Population 19 and under Ages 20-44 Ages 45-64 Ages 65+
National Total 280,540,330 28.2% 36.2% 23.6% 12.0%
Alabama 4,370,221 27.8% 35.3% 24.1% 12.9%
Alaska 624,252 33.2% 35.2% 25.6% 6.1%
Arizona 5,346,616 30.0% 35.6% 21.9% 12.6%
Arkansas 2,634,848 28.0% 34.4% 24.2% 13.4%
California 34,292,871 30.0% 38.0% 21.6% 10.3%
Colorado 4,403,659 28.4% 38.2% 24.1% 9.3%
Connecticut 3,350,345 27.9% 34.1% 24.8% 13.1%
Delaware 782,221 26.3% 37.0% 24.0% 12.8%
District of Columbia 535,632 21.5% 42.8% 23.8% 12.0%
Florida 16,318,656 25.8% 33.3% 24.1% 16.8%
Georgia 8,326,251 29.6% 39.1% 22.1% 9.2%
Hawaii 1,208,537 26.7% 35.3% 24.7% 13.3%
Idaho 1,308,320 31.1% 34.4% 23.6% 10.9%
Illinois 12,279,027 28.7% 36.8% 23.0% 11.4%
Indiana 5,980,881 28.7% 36.0% 23.4% 11.9%
Iowa 2,832,392 26.8% 34.5% 24.7% 14.1%
Kansas 2,634,122 28.7% 35.4% 23.2% 12.7%
Kentucky 3,978,103 25.8% 36.9% 25.2% 12.0%
Louisiana 4,347,642 29.9% 35.4% 23.3% 11.3%
Maine 1,259,547 24.3% 34.6% 27.2% 13.8%
Maryland 5,321,993 28.3% 36.3% 24.4% 11.0%
Massachusetts 6,210,578 25.4% 37.3% 24.4% 13.0%
Michigan 9,797,198 28.6% 35.3% 24.1% 11.9%
Minnesota 4,882,303 28.1% 36.7% 23.9% 11.3%
Mississippi 2,775,227 30.0% 35.4% 22.9% 11.7%
Missouri 5,505,963 27.7% 35.4% 24.1% 12.8%
Montana 884,587 27.0% 32.7% 27.2% 13.1%
Nebraska 1,677,978 28.5% 35.3% 23.3% 12.8%
Nevada 2,139,794 28.9% 36.6% 23.6% 10.9%
New Hampshire 1,238,917 26.8% 36.0% 25.7% 11.4%
New Jersey 8,395,357 27.3% 35.6% 24.4% 12.6%
New Mexico 1,818,718 30.1% 34.4% 23.4% 12.1%
New York 18,571,545 26.9% 36.7% 23.9% 12.5%
North Carolina 8,063,874 27.7% 37.0% 23.7% 11.6%
North Dakota 610,245 26.4% 35.3% 24.3% 14.1%
Ohio 11,122,112 28.1% 35.1% 24.0% 12.8%
Oklahoma 3,379,515 28.2% 35.1% 24.0% 12.8%
Oregon 3,444,153 27.0% 35.4% 25.2% 12.3%
Pennsylvania 11,897,522 26.0% 34.0% 25.0% 14.9%
Rhode Island 1,030,762 24.7% 37.1% 24.2% 14.0%
South Carolina 3,971,899 26.8% 36.4% 25.1% 11.7%
South Dakota 731,963 29.0% 33.9% 23.4% 13.7%
Tennessee 5,644,716 27.0% 36.1% 24.8% 12.0%
Texas 21,215,494 31.4% 37.3% 21.8% 9.6%
Utah 2,275,861 34.5% 38.7% 18.4% 8.4%
Vermont 595,826 25.4% 34.8% 27.4% 12.5%
Virginia 7,063,247 27.4% 37.2% 24.5% 10.9%
Washington 5,930,307 27.9% 36.7% 24.5% 10.8%
West Virginia 1,758,096 24.3% 33.4% 27.3% 15.0%
Wisconsin 5,285,604 27.5% 35.7% 24.3% 12.5%
Wyoming 484,833 27.7% 33.9% 26.7% 11.6%
This information was taken from the 2002 American Community Survey conducted by the U.S. Bureau of The Census. The information
provided is limited to the household population and excludes the population living in institutions, college dormitories, and other group
quarters. This accounts for the difference in the estimates of the U.S. population from this source compared to other estimates presented by
the Bureau of the Census. The data are based on a sample and are subject to sampling variability. Data based on twelve monthly samples
during 2002.
*Sum of percentages may not equal 100 percent due to rounding.

Source: U.S. Department of Commerce, Bureau of the Census, 2002 American Community Survey.

3-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Race Demographics, 2002*


Percent
Total Percent Percent Percent Indicated 2
State Population White Black Other** or More Races
National Total 280,540,330 75.8% 12.0% 9.9% 2.9%
Alabama 4,370,221 71.0% 25.6% 1.8% 1.7%
Alaska 624,252 69.3% 3.0% 19.5% 8.5%
Arizona 5,346,616 74.9% 2.8% 18.8% 4.8%
Arkansas 2,634,848 80.0% 15.8% 2.5% 1.9%
California 34,292,871 63.3% 6.1% 26.7% 5.3%
Colorado 4,403,659 82.9% 3.7% 10.9% 3.1%
Connecticut 3,350,345 81.9% 9.2% 7.0% 2.3%
Delaware 782,221 75.2% 18.8% 4.4% 2.0%
District of Columbia 535,632 29.3% 59.6% 9.0% 2.8%
Florida 16,318,656 77.6% 15.1% 5.4% 2.7%
Georgia 8,326,251 65.2% 28.3% 5.2% 1.7%
Hawaii 1,208,537 24.5% 1.8% 48.9% 25.8%
Idaho 1,308,320 91.6% 0.3% 6.0% 2.6%
Illinois 12,279,027 74.7% 14.4% 9.0% 2.4%
Indiana 5,980,881 87.4% 8.1% 2.9% 1.9%
Iowa 2,832,392 93.4% 2.0% 3.1% 1.8%
Kansas 2,634,122 85.9% 5.9% 5.9% 2.6%
Kentucky 3,978,103 89.9% 6.7% 1.8% 1.7%
Louisiana 4,347,642 63.7% 32.3% 3.0% 1.1%
Maine 1,259,547 96.9% 0.4% 1.6% 1.2%
Maryland 5,321,993 64.6% 27.1% 6.3% 2.4%
Massachusetts 6,210,578 84.4% 5.9% 8.2% 2.1%
Michigan 9,797,198 80.2% 13.9% 4.0% 2.2%
Minnesota 4,882,303 88.6% 3.7% 6.3% 1.7%
Mississippi 2,775,227 60.8% 37.0% 1.5% 0.8%
Missouri 5,505,963 84.8% 11.0% 2.4% 1.9%
Montana 884,587 90.2% 0.5% 7.0% 2.6%
Nebraska 1,677,978 89.7% 3.7% 4.5% 2.7%
Nevada 2,139,794 77.8% 6.3% 11.8% 5.8%
New Hampshire 1,238,917 95.8% 0.8% 2.3% 1.4%
New Jersey 8,395,357 72.3% 13.0% 12.9% 2.4%
New Mexico 1,818,718 69.8% 1.6% 24.9% 5.3%
New York 18,571,545 68.6% 15.9% 13.2% 3.3%
North Carolina 8,063,874 71.9% 21.2% 5.2% 1.9%
North Dakota 610,245 91.9% 0.8% 5.9% 1.6%
Ohio 11,122,112 85.0% 11.2% 2.4% 1.6%
Oklahoma 3,379,515 76.5% 7.2% 9.4% 7.4%
Oregon 3,444,153 86.7% 1.5% 8.6% 3.7%
Pennsylvania 11,897,522 85.3% 9.8% 3.6% 1.5%
Rhode Island 1,030,762 84.7% 4.5% 8.7% 2.7%
South Carolina 3,971,899 67.1% 29.6% 2.3% 1.2%
South Dakota 731,963 94.3% 0.7% 3.1% 2.0%
Tennessee 5,644,716 80.1% 16.1% 2.7% 1.3%
Texas 21,215,494 73.1% 10.9% 13.9% 3.2%
Utah 2,275,861 90.2% 0.8% 6.6% 2.9%
Vermont 595,826 96.5% 0.6% 1.7% 1.3%
Virginia 7,063,247 72.7% 19.4% 6.0% 2.4%
Washington 5,930,307 80.9% 3.3% 11.7% 4.8%
West Virginia 1,758,096 95.2% 3.0% 0.8% 1.1%
Wisconsin 5,285,604 88.5% 5.3% 4.6% 1.8%
Wyoming 484,833 92.2% 0.6% 4.7% 3.1%
This information was taken from the 2002 American Community Survey conducted by the U.S. Bureau of The Census. The information provided is limited to the household population and
excludes the population living in institutions, college dormitories, and other group quarters. This accounts for the difference in the estimates of the U.S. population from this source
compared to other estimates presented by U.S. Census. The data are based on a sample and are subject to sampling variability. Data based on twelve monthly samples during 2002.
*Sum of percentages may not equal 100 percent due to rounding.
** Percent Other includes American Indian and Alaska Native, Asian, Native Hawaiian and other Pacific Islander, and other.

Source: U.S. Department of Commerce, Bureau of the Census, 2002 American Community Survey.

3-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

Hispanic Demographics, 2002

State Total Population Hispanic Population Percent Hispanic


National Total 280,540,330 37,872,475 13.5%
Alabama 4,370,221 86,450 2.0%
Alaska 624,252 25,156 4.0%
Arizona 5,346,616 1,452,223 27.2%
Arkansas 2,634,848 92,400 3.5%
California 34,292,871 11,647,324 34.0%
Colorado 4,403,659 801,801 18.2%
Connecticut 3,350,345 334,926 10.0%
Delaware 782,221 40,625 5.2%
District of Columbia 535,632 51,068 9.5%
Florida 16,318,656 2,969,016 18.2%
Georgia 8,326,251 502,157 6.0%
Hawaii 1,208,537 87,769 7.3%
Idaho 1,308,320 111,295 8.5%
Illinois 12,279,027 1,663,514 13.5%
Indiana 5,980,881 231,613 3.9%
Iowa 2,832,392 87,447 3.1%
Kansas 2,634,122 184,148 7.0%
Kentucky 3,978,103 65,532 1.6%
Louisiana 4,347,642 106,445 2.4%
Maine 1,259,547 8,870 0.7%
Maryland 5,321,993 253,012 4.8%
Massachusetts 6,210,578 451,811 7.3%
Michigan 9,797,198 336,104 3.4%
Minnesota 4,882,303 157,540 3.2%
Mississippi 2,775,227 31,985 1.2%
Missouri 5,505,963 112,698 2.0%
Montana 884,587 17,398 2.0%
Nebraska 1,677,978 101,573 6.1%
Nevada 2,139,794 458,223 21.4%
New Hampshire 1,238,917 20,756 1.7%
New Jersey 8,395,357 1,198,470 14.3%
New Mexico 1,818,718 783,315 43.1%
New York 18,571,545 2,997,676 16.1%
North Carolina 8,063,874 434,048 5.4%
North Dakota 610,245 7,403 1.2%
Ohio 11,122,112 225,447 2.0%
Oklahoma 3,379,515 185,361 5.5%
Oregon 3,444,153 306,244 8.9%
Pennsylvania 11,897,522 388,046 3.3%
Rhode Island 1,030,762 96,510 9.4%
South Carolina 3,971,899 104,814 2.6%
South Dakota 731,963 10,404 1.4%
Tennessee 5,644,716 132,687 2.4%
Texas 21,215,494 7,191,546 33.9%
Utah 2,275,861 220,283 9.7%
Vermont 595,826 4,803 0.8%
Virginia 7,063,247 363,544 5.1%
Washington 5,930,307 480,917 8.1%
West Virginia 1,758,096 12,211 0.7%
Wisconsin 5,285,604 205,397 3.9%
Wyoming 484,833 32,470 6.7%
This information was taken from the 2002 American Community Survey conducted by the U.S. Bureau of The Census. The information
provided is limited to the household population and excludes the population living in institutions, college dormitories, and other group
quarters. This accounts for the difference in the estimates of the U.S. population from this source compared to other estimates presented by
the U.S. Census. The data are based on a sample and are subject to sampling variability. Data based on twelve monthly samples during
2002.

Source: U.S. Department of Commerce, Bureau of the Census, 2002 American Community Survey.

3-7
National Pharmaceutical Council Pharmaceutical Benefits 2003

Insurance Status - Populations, 2002*

Total Medicaid Medicare Military Privately Not


State Population Population Population Insurance Insured Insured
National Total 285,933,000 33,246,000 38,448,000 10,063,000 198,973,000 43,574,000
Alabama 4,440,000 459,000 754,000 171,000 3,143,000 564,000
Alaska 635,000 92,000 53,000 81,000 399,000 119,000
Arizona 5,442,000 666,000 792,000 363,000 3,555,000 916,000
Arkansas 2,692,000 396,000 487,000 203,000 1,644,000 440,000
California 35,159,000 4,985,000 3,777,000 1,046,000 22,891,000 6,398,000
Colorado 4,476,000 331,000 501,000 299,000 3,211,000 720,000
Connecticut 3,383,000 314,000 544,000 82,000 2,610,000 356,000
Delaware 798,000 86,000 112,000 30,000 608,000 79,000
District of Columbia 572,000 103,000 75,000 12,000 373,000 74,000
Florida 16,429,000 1,764,000 3,020,000 820,000 10,666,000 2,843,000
Georgia 8,426,000 863,000 869,000 309,000 5,924,000 1,354,000
Hawaii 1,224,000 128,000 173,000 104,000 899,000 123,000
Idaho 1,300,000 136,000 162,000 44,000 903,000 233,000
Illinois 12,504,000 1,180,000 1,618,000 142,000 9,086,000 1,767,000
Indiana 6,100,000 458,000 850,000 98,000 4,628,000 797,000
Iowa 2,903,000 275,000 436,000 75,000 2,314,000 277,000
Kansas 2,684,000 216,000 377,000 194,000 2,084,000 280,000
Kentucky 4,046,000 471,000 641,000 342,000 2,828,000 548,000
Louisiana 4,447,000 694,000 602,000 208,000 2,703,000 820,000
Maine 1,269,000 204,000 229,000 55,000 885,000 144,000
Maryland 5,458,000 355,000 653,000 211,000 4,203,000 730,000
Massachusetts 6,471,000 769,000 890,000 145,000 4,772,000 644,000
Michigan 9,910,000 1,158,000 1,279,000 89,000 7,494,000 1,158,000
Minnesota 5,054,000 489,000 586,000 118,000 4,158,000 397,000
Mississippi 2,787,000 559,000 387,000 108,000 1,703,000 465,000
Missouri 5,585,000 594,000 745,000 192,000 4,253,000 646,000
Montana 906,000 108,000 157,000 62,000 618,000 139,000
Nebraska 1,704,000 167,000 237,000 69,000 1,312,000 174,000
Nevada 2,121,000 127,000 265,000 85,000 1,464,000 418,000
New Hampshire 1,266,000 78,000 164,000 41,000 1,015,000 125,000
New Jersey 8,605,000 789,000 1,241,000 106,000 6,378,000 1,197,000
New Mexico 1,840,000 313,000 294,000 86,000 1,047,000 388,000
New York 19,283,000 2,964,000 2,617,000 278,000 12,635,000 3,042,000
North Carolina 8,162,000 942,000 1,190,000 449,000 5,393,000 1,368,000
North Dakota 633,000 56,000 94,000 35,000 481,000 69,000
Ohio 11,282,000 1,061,000 1,554,000 213,000 8,640,000 1,344,000
Oklahoma 3,477,000 411,000 511,000 205,000 2,280,000 601,000
Oregon 3,510,000 438,000 488,000 126,000 2,475,000 511,000
Pennsylvania 12,189,000 1,187,000 2,033,000 235,000 9,311,000 1,380,000
Rhode Island 1,056,000 165,000 161,000 16,000 763,000 104,000
South Carolina 3,997,000 607,000 678,000 183,000 2,701,000 500,000
South Dakota 744,000 74,000 102,000 38,000 570,000 85,000
Tennessee 5,672,000 1,091,000 734,000 212,000 3,883,000 614,000
Texas 21,529,000 2,425,000 2,339,000 762,000 12,738,000 5,556,000
Utah 2,310,000 219,000 192,000 60,000 1,743,000 310,000
Vermont 619,000 112,000 86,000 14,000 438,000 66,000
Virginia 7,118,000 496,000 891,000 716,000 5,203,000 962,000
Washington 6,001,000 782,000 684,000 301,000 4,214,000 850,000
West Virginia 1,751,000 299,000 360,000 80,000 1,107,000 255,000
Wisconsin 5,476,000 545,000 701,000 124,000 4,298,000 538,000
Wyoming 488,000 45,000 65,000 26,000 334,000 86,000
*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, 2003 Annual Social and Economic Supplement,
March 2003.

3-8
National Pharmaceutical Council Pharmaceutical Benefits 2003

Insurance Status - Percentages, 2002*

% Covered by % Covered by
Total % Covered by % Covered by Military Private
State Population Medicaid Medicare Insurance Insurance % Not Insured
National Total 285,933,000 11.6% 13.4% 3.5% 69.6% 15.2%
Alabama 4,440,000 10.3% 17.0% 3.9% 70.8% 12.7%
Alaska 635,000 14.5% 8.3% 12.8% 62.8% 18.7%
Arizona 5,442,000 12.2% 14.6% 6.7% 65.3% 16.8%
Arkansas 2,692,000 14.7% 18.1% 7.5% 61.1% 16.3%
California 35,159,000 14.2% 10.7% 3.0% 65.1% 18.2%
Colorado 4,476,000 7.4% 11.2% 6.7% 71.7% 16.1%
Connecticut 3,383,000 9.3% 16.1% 2.4% 77.2% 10.5%
Delaware 798,000 10.8% 14.0% 3.8% 76.2% 9.9%
District of Columbia 572,000 18.0% 13.1% 2.1% 65.2% 12.9%
Florida 16,429,000 10.7% 18.4% 5.0% 64.9% 17.3%
Georgia 8,426,000 10.2% 10.3% 3.7% 70.3% 16.1%
Hawaii 1,224,000 10.5% 14.1% 8.5% 73.4% 10.0%
Idaho 1,300,000 10.5% 12.5% 3.4% 69.5% 17.9%
Illinois 12,504,000 9.4% 12.9% 1.1% 72.7% 14.1%
Indiana 6,100,000 7.5% 13.9% 1.6% 75.9% 13.1%
Iowa 2,903,000 9.5% 15.0% 2.6% 79.7% 9.5%
Kansas 2,684,000 8.0% 14.0% 7.2% 77.6% 10.4%
Kentucky 4,046,000 11.6% 15.8% 8.5% 69.9% 13.5%
Louisiana 4,447,000 15.6% 13.5% 4.7% 60.8% 18.4%
Maine 1,269,000 16.1% 18.0% 4.3% 69.7% 11.3%
Maryland 5,458,000 6.5% 12.0% 3.9% 77.0% 13.4%
Massachusetts 6,471,000 11.9% 13.8% 2.2% 73.7% 10.0%
Michigan 9,910,000 11.7% 12.9% 0.9% 75.6% 11.7%
Minnesota 5,054,000 9.7% 11.6% 2.3% 82.3% 7.9%
Mississippi 2,787,000 20.1% 13.9% 3.9% 61.1% 16.7%
Missouri 5,585,000 10.6% 13.3% 3.4% 76.2% 11.6%
Montana 906,000 11.9% 17.3% 6.8% 68.2% 15.3%
Nebraska 1,704,000 9.8% 13.9% 4.0% 77.0% 10.2%
Nevada 2,121,000 6.0% 12.5% 4.0% 69.0% 19.7%
New Hampshire 1,266,000 6.2% 13.0% 3.2% 80.2% 9.9%
New Jersey 8,605,000 9.2% 14.4% 1.2% 74.1% 13.9%
New Mexico 1,840,000 17.0% 16.0% 4.7% 56.9% 21.1%
New York 19,283,000 15.4% 13.6% 1.4% 65.5% 15.8%
North Carolina 8,162,000 11.5% 14.6% 5.5% 66.1% 16.8%
North Dakota 633,000 8.8% 14.8% 5.5% 76.0% 10.9%
Ohio 11,282,000 9.4% 13.8% 1.9% 76.6% 11.9%
Oklahoma 3,477,000 11.8% 14.7% 5.9% 65.6% 17.3%
Oregon 3,510,000 12.5% 13.9% 3.6% 70.5% 14.6%
Pennsylvania 12,189,000 9.7% 16.7% 1.9% 76.4% 11.3%
Rhode Island 1,056,000 15.6% 15.2% 1.5% 72.3% 9.8%
South Carolina 3,997,000 15.2% 17.0% 4.6% 67.6% 12.5%
South Dakota 744,000 9.9% 13.7% 5.1% 76.6% 11.4%
Tennessee 5,672,000 19.2% 12.9% 3.7% 68.5% 10.8%
Texas 21,529,000 11.3% 10.9% 3.5% 59.2% 25.8%
Utah 2,310,000 9.5% 8.3% 2.6% 75.5% 13.4%
Vermont 619,000 18.1% 13.9% 2.3% 70.8% 10.7%
Virginia 7,118,000 7.0% 12.5% 10.1% 73.1% 13.5%
Washington 6,001,000 13.0% 11.4% 5.0% 70.2% 14.2%
West Virginia 1,751,000 17.1% 20.6% 4.6% 63.2% 14.6%
Wisconsin 5,476,000 10.0% 12.8% 2.3% 78.5% 9.8%
Wyoming 488,000 9.2% 13.3% 5.3% 68.4% 17.6%
*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, 2003 Annual Social and Economic Supplement,
March 2003.

3-9
National Pharmaceutical Council Pharmaceutical Benefits 2003

Poverty Status - Populations, 2002

Population Population Population Population


Total Below 100% Below 135% Below 150% Below 200%
State Population FPL* FPL* FPL* FPL*
National Total 285,317,000 34,570,000 52,736,000 61,054,000 87,028,000
Alabama 4,432,000 640,000 979,000 1,094,000 1,490,000
Alaska 632,000 56,000 89,000 106,000 153,000
Arizona 5,424,000 735,000 1,120,000 1,305,000 1,791,000
Arkansas 2,690,000 532,000 695,000 808,000 1,086,000
California 35,068,000 4,605,000 7,092,000 8,406,000 11,563,000
Colorado 4,470,000 436,000 670,000 779,000 1,159,000
Connecticut 3,377,000 279,000 434,000 518,000 763,000
Delaware 796,000 73,000 112,000 130,000 197,000
District of Columbia 570,000 97,000 133,000 149,000 191,000
Florida 16,391,000 2,058,000 3,297,000 3,818,000 5,438,000
Georgia 8,413,000 939,000 1,434,000 1,650,000 2,511,000
Hawaii 1,219,000 138,000 194,000 225,000 330,000
Idaho 1,296,000 147,000 235,000 292,000 437,000
Illinois 12,495,000 1,594,000 2,269,000 2,566,000 3,630,000
Indiana 6,086,000 552,000 908,000 1,097,000 1,730,000
Iowa 2,899,000 267,000 447,000 530,000 783,000
Kansas 2,681,000 269,000 407,000 496,000 725,000
Kentucky 4,033,000 571,000 849,000 976,000 1,370,000
Louisiana 4,445,000 777,000 1,137,000 1,336,000 1,688,000
Maine 1,265,000 170,000 245,000 280,000 408,000
Maryland 5,419,000 400,000 608,000 706,000 1,057,000
Massachusetts 6,469,000 648,000 977,000 1,134,000 1,563,000
Michigan 9,897,000 1,152,000 1,715,000 1,919,000 2,861,000
Minnesota 5,044,000 325,000 540,000 668,000 1,016,000
Mississippi 2,785,000 513,000 780,000 891,000 1,127,000
Missouri 5,581,000 551,000 864,000 1,012,000 1,487,000
Montana 902,000 122,000 202,000 244,000 331,000
Nebraska 1,700,000 181,000 289,000 328,000 474,000
Nevada 2,114,000 188,000 357,000 430,000 657,000
New Hampshire 1,264,000 73,000 117,000 147,000 242,000
New Jersey 8,585,000 681,000 1,060,000 1,237,000 1,862,000
New Mexico 1,837,000 328,000 475,000 540,000 747,000
New York 19,224,000 2,690,000 3,868,000 4,434,000 6,115,000
North Carolina 8,146,000 1,165,000 1,711,000 2,003,000 2,801,000
North Dakota 632,000 73,000 113,000 130,000 194,000
Ohio 11,253,000 1,099,000 1,727,000 2,054,000 3,034,000
Oklahoma 3,473,000 489,000 761,000 875,000 1,232,000
Oregon 3,503,000 380,000 638,000 761,000 1,059,000
Pennsylvania 12,168,000 1,152,000 1,902,000 2,209,000 3,238,000
Rhode Island 1,055,000 116,000 175,000 200,000 276,000
South Carolina 3,989,000 568,000 824,000 963,000 1,290,000
South Dakota 743,000 85,000 131,000 153,000 234,000
Tennessee 5,655,000 839,000 1,236,000 1,368,000 1,934,000
Texas 21,482,000 3,362,000 5,066,000 5,710,000 8,348,000
Utah 2,308,000 228,000 395,000 452,000 655,000
Vermont 616,000 61,000 99,000 115,000 164,000
Virginia 7,108,000 702,000 986,000 1,113,000 1,739,000
Washington 5,988,000 657,000 1,075,000 1,194,000 1,678,000
West Virginia 1,747,000 293,000 438,000 520,000 720,000
Wisconsin 5,463,000 467,000 786,000 893,000 1,300,000
Wyoming 488,000 44,000 72,000 90,000 151,000
*FPL- Federal Poverty Level

Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2003 Annual Social and
Economic Supplement, March 2003.

3-10
National Pharmaceutical Council Pharmaceutical Benefits 2003

Poverty Status - Percentages, 2002

Percent Percent Percent Percent


Total Below 100% Below 135% Below 150% Below 200%
State Population FPL* FPL* FPL* FPL*
National Total 285,317,000 12.1% 22.1% 21.4% 30.5%
Alabama 4,432,000 14.5% 14.1% 24.7% 33.6%
Alaska 632,000 8.8% 20.6% 16.7% 24.2%
Arizona 5,424,000 13.5% 25.8% 24.1% 33.0%
Arkansas 2,690,000 19.8% 20.2% 30.0% 40.4%
California 35,068,000 13.1% 15.0% 24.0% 33.0%
Colorado 4,470,000 9.8% 12.9% 17.4% 25.9%
Connecticut 3,377,000 8.3% 14.0% 15.3% 22.6%
Delaware 796,000 9.1% 23.4% 16.3% 24.7%
District of Columbia 570,000 17.0% 20.1% 26.1% 33.5%
Florida 16,391,000 12.6% 17.0% 23.3% 33.2%
Georgia 8,413,000 11.2% 15.9% 19.6% 29.8%
Hawaii 1,219,000 11.3% 18.2% 18.5% 27.1%
Idaho 1,296,000 11.3% 18.2% 22.5% 33.7%
Illinois 12,495,000 12.8% 14.9% 20.5% 29.1%
Indiana 6,086,000 9.1% 15.4% 18.0% 28.4%
Iowa 2,899,000 9.2% 15.2% 18.3% 27.0%
Kansas 2,681,000 10.1% 21.0% 18.5% 27.0%
Kentucky 4,033,000 14.2% 25.6% 24.2% 34.0%
Louisiana 4,445,000 17.5% 19.4% 30.1% 38.0%
Maine 1,265,000 13.4% 11.2% 22.2% 32.2%
Maryland 5,419,000 7.4% 15.1% 13.0% 19.5%
Massachusetts 6,469,000 10.0% 17.3% 17.5% 24.2%
Michigan 9,897,000 11.6% 10.7% 19.4% 28.9%
Minnesota 5,044,000 6.5% 28.0% 13.2% 20.1%
Mississippi 2,785,000 18.4% 15.5% 32.0% 40.5%
Missouri 5,581,000 9.9% 22.4% 18.1% 26.7%
Montana 902,000 13.5% 17.0% 27.0% 36.7%
Nebraska 1,700,000 10.6% 16.9% 19.3% 27.9%
Nevada 2,114,000 8.9% 9.2% 20.3% 31.1%
New Hampshire 1,264,000 5.8% 12.4% 11.6% 19.1%
New Jersey 8,585,000 7.9% 25.9% 14.4% 21.7%
New Mexico 1,837,000 17.9% 20.1% 29.4% 40.7%
New York 19,224,000 14.0% 21.0% 23.1% 31.8%
North Carolina 8,146,000 14.3% 17.9% 24.6% 34.4%
North Dakota 632,000 11.6% 15.3% 20.6% 30.7%
Ohio 11,253,000 9.8% 21.9% 18.3% 27.0%
Oklahoma 3,473,000 14.1% 18.2% 25.2% 35.5%
Oregon 3,503,000 10.9% 15.6% 21.7% 30.2%
Pennsylvania 12,168,000 9.5% 16.5% 18.2% 26.6%
Rhode Island 1,055,000 11.0% 20.7% 18.9% 26.2%
South Carolina 3,989,000 14.3% 17.6% 24.2% 32.3%
South Dakota 743,000 11.5% 21.9% 20.5% 31.5%
Tennessee 5,655,000 14.8% 23.6% 24.2% 34.2%
Texas 21,482,000 15.6% 17.1% 26.6% 38.9%
Utah 2,308,000 9.9% 16.1% 19.6% 28.4%
Vermont 616,000 9.9% 13.9% 18.7% 26.7%
Virginia 7,108,000 9.9% 17.9% 15.7% 24.5%
Washington 5,988,000 11.0% 25.1% 19.9% 28.0%
West Virginia 1,747,000 16.8% 14.4% 29.8% 41.2%
Wisconsin 5,463,000 8.6% 14.7% 16.3% 23.8%
Wyoming 488,000 9.0% 22.1% 18.4% 30.9%
*FPL- Federal Poverty Level

Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2003 Annual Social and Economic Supplement, March 2003.

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Employment Status, 2003*

Total Civilian Population Unemployment


State Population Labor Force Unemployed Rate
221,168,000
National Total
146,510,000 8,774,000 6.0%
Alabama 3,442,000 2,147,000 125,000 5.8%
Alaska 459,000 332,000 27,000 8.0%
Arizona 4,131,000 2,690,000 151,000 5.6%
Arkansas 2,071,000 1,265,000 78,000 6.2%
California 26,490,000 17,460,000 1,177,000 6.7%
Colorado 3,440,000 2,478,000 150,000 6.0%
Connecticut 2,680,000 1,803,000 99,000 5.5%
Delaware 625,000 417,000 18,000 4.4%
District of Columbia 454,000 302,000 21,000 7.0%
Florida 13,211,000 8,164,000 420,000 5.1%
Georgia 6,431,000 4,414,000 207,000 4.7%
Hawaii 944,000 618,000 27,000 4.3%
Idaho 1,013,000 693,000 37,000 5.4%
Illinois 9,583,000 6,330,000 422,000 6.7%
Indiana 4,679,000 3,188,000 163,000 5.1%
Iowa 2,286,000 1,612,000 72,000 4.5%
Kansas 2,049,000 1,434,000 77,000 5.4%
Kentucky 3,153,000 1,956,000 120,000 6.2%
Louisiana 3,348,000 2,037,000 134,000 6.6%
Maine 1,039,000 693,000 35,000 5.1%
Maryland 4,181,000 2,904,000 131,000 4.5%
Massachusetts 5,028,000 3,416,000 198,000 5.8%
Michigan 7,706,000 5,042,000 368,000 7.3%
Minnesota 3,896,000 2,923,000 145,000 5.0%
Mississippi 2,138,000 1,312,000 83,000 6.3%
Missouri 4,352,000 3,021,000 170,000 5.6%
Montana 714,000 475,000 22,000 4.7%
Nebraska 1,318,000 976,000 39,000 4.0%
Nevada 1,686,000 1,141,000 59,000 5.2%
New Hampshire 1,005,000 719,000 31,000 4.3%
New Jersey 6,619,000 4,375,000 257,000 5.9%
New Mexico 1,401,000 897,000 57,000 6.4%
New York 14,891,000 9,315,000 589,000 6.3%
North Carolina 6,328,000 4,230,000 273,000 6.5%
North Dakota 490,000 346,000 14,000 4.0%
Ohio 8,771,000 5,915,000 363,000 6.1%
Oklahoma 2,646,000 1,696,000 96,000 5.7%
Oregon 2,770,000 1,859,000 152,000 8.2%
Pennsylvania 9,663,000 6,170,000 344,000 5.6%
Rhode Island 844,000 573,000 30,000 5.3%
South Carolina 3,142,000 2,003,000 136,000 6.8%
South Dakota 576,000 425,000 15,000 3.6%
Tennessee 4,501,000 2,909,000 169,000 5.8%
Texas 16,047,000 10,910,000 738,000 6.8%
Utah 1,660,000 1,184,000 67,000 5.6%
Vermont 494,000 351,000 16,000 4.6%
Virginia 5,532,000 3,773,000 154,000 4.1%
Washington 4,697,000 3,140,000 237,000 7.5%
West Virginia 1,442,000 787,000 48,000 6.1%
Wisconsin 4,224,000 3,078,000 174,000 5.6%
Wyoming 387,000 278,000 12,000 4.4%
*This information was compiled from the U.S. Department of Labor, Bureau of Labor Statistics News Release on State and
Regional Unemployment, 2003 Annual Averages, released on February 27, 2004. The table summarizes the employment
status of the civilian noninstitutional population, 16 years of age and over, by state.

Source: U.S. Department of Labor, Bureau of Labor Statistics, February 27, 2004.

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Medicaid/Medicare Certified Facilities, 2003

Skilled Nursing ICF-MR Home Health Rural Health


State Hospitals Facilities Facilities Agencies Clinics
National Total* 5,988 14,926 6,606 7,163 3,401
Alabama 122 225 7 140 61
Alaska 24 14 0 15 6
Arizona 89 134 13 62 6
Arkansas 108 199 41 174 72
California 437 1,256 1,109 604 244
Colorado 84 194 3 129 37
Connecticut 46 252 120 83 0
Delaware 10 37 2 14 0
District of Columbia 14 20 126 15 0
Florida 235 689 107 421 148
Georgia 176 333 13 97 102
Hawaii 27 41 17 14 0
Idaho 47 77 66 49 42
Illinois 216 673 309 298 197
Indiana 157 489 562 161 50
Iowa 119 359 130 180 127
Kansas 150 263 37 131 172
Kentucky 116 296 14 108 105
Louisiana 214 285 480 228 52
Maine 41 120 21 31 46
Maryland 65 233 4 45 0
Massachusetts 112 468 7 114 0
Michigan 176 394 1 212 158
Minnesota 147 404 225 223 68
Mississippi 105 164 13 60 128
Missouri 137 477 20 160 248
Montana 64 100 2 46 40
Nebraska 94 177 4 62 76
Nevada 41 42 19 45 6
New Hampshire 30 70 1 36 19
New Jersey 106 356 9 52 0
New Mexico 53 71 44 58 10
New York 249 669 720 198 9
North Carolina 139 420 330 169 111
North Dakota 50 83 66 30 64
Ohio 211 929 421 351 16
Oklahoma 151 256 68 186 48
Oregon 62 121 1 59 36
Pennsylvania 246 723 194 279 44
Rhode Island 15 95 5 21 1
South Carolina 76 178 132 71 90
South Dakota 67 90 1 47 56
Tennessee 152 305 83 138 37
Texas 499 1,011 909 1,045 338
Utah 48 80 14 47 15
Vermont 16 42 1 12 18
Virginia 109 244 21 156 52
Washington 101 249 14 61 104
West Virginia 66 121 61 65 64
Wisconsin 140 365 37 123 59
Wyoming 29 33 2 38 19
*National total does not include certified facilities in Puerto Rico and U.S. territories.
Source: OSCAR Report 10. Facility Counts: Active Providers. CMS, Center for Medicaid and State Operations, December
9, 2003.

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Licensed Pharmacies (As of June 30, 2003)*

Hospital/ Independent Out-of-State or


Total Institutional Community Chain Pharmacies Non-Resident
State Pharmacies Pharmacies Pharmacies (Four or More) Pharmacies
National Total 78,505 8,729 20,249 15,835 11,756
Alabama 1,873 165 744 578 361
Alaska 158 (G) 17 (H) 264
Arizona 1,872 149 204 1,033 257
Arkansas 745 186 415 330 182
California 6,204 602 202
Colorado 1,083 424
Connecticut 605 (D) 50 (D) 168 (D) 437 (D) 277 (D)
Delaware 165 11 31 134 258
District of Columbia 123 13 27 61 0
Florida 6,567 2,097 4,098 (A) (A) 341
Georgia 3,689 205 (P) (P)
Hawaii 224 162
Idaho 639 69 255 (A, E) 231
Illinois 2,451 342 2,183 (A) (A) 296
Indiana 1,367 205 371
Iowa 1,242 130 (F) 791 (A, F) (A) 301
Kansas 802 172 630 (A) 332
Kentucky 1,514 138 475 749 176
Louisiana 1,818 179 573 541 353
Maine 290 42 187
Maryland 1,425 (I) 66 155 689 296
Massachusetts 1,048 (J) 158 250 740 0
Michigan 2547 150
Minnesota 1,471 138 537 545 280
Mississippi 962 130 220
Missouri 1,543 (K) 173 646 661 371
Montana 317 99 153
Nebraska 487 255 (L)
Nevada 731 268
New Hampshire 269 32 39 177 245
New Jersey 2,489
New Mexico 612 61 298 (A) 283
New York 4,518 493 (Q) 1,993 2,029 91
North Carolina 2,062 (F) 161 561 968 259
North Dakota 530 43 149 32 249
Ohio 2,953 (N) 219 559 1,581 328
Oklahoma 1,304 81 (D) 860 (A) (A) 343
Oregon 1,119 122 310 457 242
Pennsylvania 3,148 291 0
Rhode Island 191 20 41 5 227
South Carolina 1,132 346
South Dakota 507 44 130 89 254
Tennessee 1,852 405 508 822 117
Texas 5,753 (B) 847 1,720 2,430 289
Utah 280 99 415 (A) A 246
Vermont 155 18 139 0
Virginia 1,515 426
Washington 1,588 228 (C) 345 747 268
West Virginia 544 308
Wisconsin 1,286 0
Wyoming 134 (F) 29 276
*Figures reported reflect number of pharmacies licensed by state boards of pharmacy. Individual columns will not sum to
total. Total includes other pharmacies not specified in the four practice settings. Blanks indicate that information was not
available.
Source: 2003-2004 National Association of Boards of Pharmacy, Survey of Pharmacy Law.

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LEGEND

A — Chains included in independent community pharmacies figure.


B — Also licenses 873 nuclear, public health, clinic, ambulatory surgical center, and HMO pharmacies.
C — Includes 121 hospital, 23 nursing home, 18 home infusion, 8 nuclear, 40 HMO, and 18 other pharmacies.
D — Approximately.
E — Plus 22 limited service and 61 parenteral admixture pharmacies.
F — In-state.
G — Includes 21 wholesalers drug distributors.
H — Drug rooms.
I — Total includes other areas not listed: clinic, correctional, HMO, nursing home, IV, nuclear, research, and other.
89 pharmacies have waiver (specialty) permits. Board issued 582 distributor permits.
J — Total also includes home IV and mail-order pharmacies.
K — Includes the following pharmacy categories: 30 long-term care, 17 home health, 8 radiopharmaceutical, 2 renal
dialysis, 1 sterile pharmaceuticals, 2 consultants pharmacies.
L — Nebraska “registers” out-of-state pharmacies.
N — Includes 263 nuclear, clinic, fluid therapy, mail-order, specialty, and pharmacies serving nursing homes only.
P — 2,202 (2,165 independent and chain pharmacies, 14 nuclear pharmacies, 18 prison pharmacies, 5 clinic
pharmacies, and 2 pharmacy schools).
Q — 16 nuclear pharmacies.

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Physicians, 2001

Physicians Office Based Percent Primary Care Percent


State Physicians Per 1,000 Pop. Physicians Office Based Physicians* Primary Care
National Total 820,869 3.0 507,015 61.8% 313,078 38.1%
Alabama 10,009 2.3 6,743 67.4% 4,208 42.0%
Alaska 1,414 2.3 991 70.1% 756 53.5%
Arizona 12,660 2.4 7,872 62.2% 4,511 35.6%
Arkansas 5,856 2.2 3,889 66.4% 2,883 49.2%
California 99,547 3.0 62,387 62.7% 36,298 36.5%
Colorado 12,095 2.8 7,906 65.4% 4,893 40.5%
Connecticut 13,657 4.1 8,016 58.7% 4,227 31.0%
Delaware 2,152 2.8 1,387 64.5% 824 38.3%
District of Columbia 4,490 8.4 2,082 46.4% 1,180 26.3%
Florida 47,299 3.0 30,148 63.7% 15,311 32.4%
Georgia 19,837 2.4 13,015 65.6% 7,448 37.5%
Hawaii 4,044 3.4 2,606 64.4% 1,420 35.1%
Idaho 2,448 1.9 1,812 74.0% 1,181 48.2%
Illinois 36,361 3.0 21,875 60.2% 14,576 40.1%
Indiana 13,887 2.3 9,378 67.5% 6,356 45.8%
Iowa 6,041 2.1 3,727 61.7% 2,891 47.9%
Kansas 6,533 2.5 4,147 63.5% 2,965 45.4%
Kentucky 9,678 2.4 6,641 68.6% 4,076 42.1%
Louisiana 12,439 2.9 7,956 64.0% 4,466 35.9%
Maine 3,708 3.0 2,423 65.3% 1,653 44.6%
Maryland 23,857 4.6 13,018 54.6% 7,092 29.7%
Massachusetts 29,336 4.8 15,944 54.3% 8,752 29.8%
Michigan 25,710 2.6 15,280 59.4% 9,913 38.6%
Minnesota 14,752 3.1 9,283 62.9% 7,352 49.8%
Mississippi 5,544 2.0 3,741 67.5% 2,221 40.1%
Missouri 14,350 2.6 8,799 61.3% 5,209 36.3%
Montana 2,292 2.6 1,642 71.6% 1,013 44.2%
Nebraska 4,399 2.6 2,829 64.3% 2,286 52.0%
Nevada 4,280 2.1 3,050 71.3% 1,599 37.4%
New Hampshire 3,609 2.9 2,310 64.0% 1,423 39.4%
New Jersey 28,179 3.4 17,727 62.9% 9,672 34.3%
New Mexico 4,678 2.6 2,815 60.2% 1,996 42.7%
New York 79,541 4.3 42,839 53.9% 25,738 32.4%
North Carolina 21,899 2.8 13,922 63.6% 8,668 39.6%
North Dakota 1,602 2.6 1,094 68.3% 879 54.9%
Ohio 30,880 2.8 19,072 61.8% 12,208 39.5%
Oklahoma 6,572 2.0 4,278 65.1% 2,794 42.5%
Oregon 9,748 2.9 6,347 65.1% 3,861 39.6%
Pennsylvania 40,063 3.4 23,701 59.2% 14,387 35.9%
Rhode Island 3,942 3.9 2,254 57.2% 1,365 34.6%
South Carolina 9,939 2.5 6,600 66.4% 4,253 42.8%
South Dakota 1,755 2.4 1,220 69.5% 886 50.5%
Tennessee 15,695 2.8 10,437 66.5% 6,179 39.4%
Texas 48,339 2.3 31,647 65.5% 18,647 38.6%
Utah 5,165 2.3 3,337 64.6% 2,036 39.4%
Vermont 2,403 4.1 1,399 58.2% 1,029 42.8%
Virginia 20,880 3.0 13,050 62.5% 8,082 38.7%
Washington 17,404 3.0 11,170 64.2% 7,527 43.2%
West Virginia 4,498 2.6 2,812 62.5% 1,956 43.5%
Wisconsin 14,374 2.7 9,667 67.3% 6,666 46.4%
Wyoming 1,029 2.1 730 70.9% 557 54.1%
*Primary care physicians include General Practice, General Family Practice, General Internal Medicine, and General
Pediatrics.
Source: USDHHS, HRSA, Bureau of Health Professions, National Center for Health Workforce Information & Analysis,
Area Resource File, February 2003.

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Other Providers, 2001/2003

# FTE # FTE
Registered Registered Nurses* Pharmacists** Pharmacists**
State Nurses* per 1,000 population (Licensed by State) per 1,000 population
National Total 962,195 3.4 356,201 1.2
Alabama 17,143 3.8 6,006 1.3
Alaska 2,339 3.7 632 1.0
Arizona 13,058 2.5 7,832 1.4
Arkansas 9,898 3.7 3,680 1.4
California 85,878 2.5 31,133 0.9
Colorado 12,034 2.7 5,586 1.2
Connecticut 9,930 2.9 4,454 1.3
Delaware 2,971 3.7 1,287 1.6
District of Columbia 5,011 8.7 1,564 2.8
Florida 56,078 3.4 20,052 1.2
Georgia 28,447 3.4 10,474 1.2
Hawaii 3,470 2.8 1,556 1.2
Idaho 3,599 2.7 1,569 1.1
Illinois 45,501 3.6 13,151 1.0
Indiana 21,436 3.5 8,480 1.4
Iowa 12,404 4.2 5,034 1.7
Kansas 9,102 3.4 3,584 1.3
Kentucky 16,213 4.0 5,008 1.2
Louisiana 17,274 3.9 5,890 1.3
Maine 5,265 4.1 1,267 1.0
Maryland 16,623 3.1 7,153 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 6,023 1.2
Mississippi 12,356 4.3 3,483 1.2
Missouri 23,650 4.2 7,149 1.3
Montana 3,205 3.5 1,503 1.6
Nebraska 7,249 4.2 2,664 1.5
Nevada 5,084 2.4 8,359 3.7
New Hampshire 4,206 3.3 1,920 1.5
New Jersey 28,082 3.3 16,245 1.9
New Mexico 5,258 2.9 2,434 1.3
New York 72,057 3.8 18,448 1.0
North Carolina 32,695 4.0 9,669 1.2
North Dakota 3,175 5.0 2,132 3.4
Ohio 43,869 3.9 14,476 1.3
Oklahoma 10,827 3.1 4,750 1.4
Oregon 11,674 3.4 4,091 1.1
Pennsylvania 48,786 4.0 17,219 1.4
Rhode Island 2,850 2.7 1,788 1.7
South Carolina 14,942 3.7 5,221 1.3
South Dakota 3,829 5.1 1,429 1.9
Tennessee 20,777 3.6 7,397 1.3
Texas 65,056 3.0 21,245 1.0
Utah 5,446 2.4 2,171 0.9
Vermont 1,656 2.7 830 1.3
Virginia 23,152 3.2 8,605 1.2
Washington 15,440 2.6 6,955 1.1
West Virginia 9,307 5.2 2,973 1.6
Wisconsin 16,878 3.1 5,737 1.0
Wyoming 1,666 3.4 997 2.0
*FTE- Full-time equivalent employees as of 2001
**As of June 30, 2003
Source: USDHHS, HRSA, Bureau of Health Professions, National Center for Health Workforce Information & Analysis,
Area Resource File, February 2003. 2003-2004 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 DRUG PROGRAM

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.

MEDICAID PRESCRIPTION DRUG REIMBURSEMENT

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:

• Estimated acquisition cost (EAC) plus reasonable dispensing fees; or


• The provider’s usual and customary charges to the general public.
States may continue to use their existing EAC program, or adopt another method, as long as their
aggregate expenditures do not exceed what would have been paid under EAC principles.

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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Drug Expenditures Trends*

State 2001 2002 % Change 2001-2002


National Total $24,656,812,921 $29,339,050,970 19.0%
Alabama $386,876,131 $452,269,953 16.9%
Alaska $55,754,050 $70,708,412 26.8%
Arizona $2,573,205 $3,725,371 44.8%
Arkansas $241,558,369 $273,257,660 13.1%
California $2,984,162,770 $3,591,537,830 20.4%
Colorado $166,000,664 $189,717,036 14.3%
Connecticut $304,780,286 $357,919,257 17.4%
Delaware $81,156,928 $97,750,161 20.4%
District of Columbia $63,504,500 $66,129,208 4.1%
Florida $1,475,766,739 $1,717,652,527 16.4%
Georgia $735,944,558 $873,703,133 18.7%
Hawaii $74,869,859 $88,256,904 17.9%
Idaho $102,975,196 $119,177,013 15.7%
Illinois $884,018,166 $1,293,435,797 46.3%
Indiana $561,642,082 $631,637,846 12.5%
Iowa $234,716,795 $285,467,642 21.6%
Kansas $185,017,060 $213,778,616 15.5%
Kentucky $592,096,755 $652,904,065 10.3%
Louisiana $585,388,809 $714,107,841 22.0%
Maine $191,785,942 $220,420,714 14.9%
Maryland $244,203,084 $297,291,733 21.7%
Massachusetts $797,859,072 $958,972,520 20.2%
Michigan $584,670,445 $674,222,281 15.3%
Minnesota $265,726,228 $310,174,144 16.7%
Mississippi $493,177,297 $567,313,801 15.0%
Missouri $675,647,147 $790,853,387 17.1%
Montana $72,577,455 $83,587,410 15.2%
Nebraska $170,897,014 $207,782,737 21.6%
Nevada $61,500,721 $86,929,536 41.3%
New Hampshire $91,703,067 $99,682,997 8.7%
New Jersey $651,442,945 $694,669,924 6.6%
New Mexico $57,995,801 $73,877,785 27.4%
New York $2,986,292,455 $3,660,427,024 22.6%
North Carolina $984,653,306 $1,100,822,176 11.8%
North Dakota $44,067,986 $52,495,878 19.1%
Ohio $1,099,697,768 $1,333,992,298 21.3%
Oklahoma $171,188,873 $285,068,869 66.5%
Oregon $228,670,426 $279,029,096 22.0%
Pennsylvania $692,665,382 $718,210,352 3.7%
Rhode Island $102,708,476 $125,187,888 21.9%
South Carolina $438,897,100 $451,846,044 3.0%
South Dakota $51,748,770 $62,382,937 20.5%
Tennessee $681,454,847 $905,405,421 32.9%
Texas $1,325,987,804 $1,591,064,713 20.0%
Utah $117,170,006 $140,275,267 19.7%
Vermont $104,250,880 $114,157,870 9.5%
Virginia $417,689,526 $458,953,342 9.9%
Washington $458,332,414 $541,963,790 18.2%
West Virginia $259,638,952 $277,039,990 6.7%
Wisconsin $382,272,975 $442,718,195 15.8%
Wyoming $31,435,835 $39,094,579 24.4%
*Rebates have not been subtracted from these figures.

Source: CMS, CMS-64 Report, FY 2001 and FY 2002.

4-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Ranking Based on Drug Expenditures*

% of 2002 National
2002 2002 Medicaid Drug 2001 2001
State Payments Ranking Expenditures Payments Ranking
National Total $29,339,050,970 $24,656,812,921
New York $3,660,427,024 1 12.5% $2,986,292,455 1
California $3,591,537,830 2 12.2% $2,984,162,770 2
Florida $1,717,652,527 3 5.9% $1,475,766,739 3
Texas $1,591,064,713 4 5.4% $1,325,987,804 4
Ohio $1,333,992,298 5 4.5% $1,099,697,768 5
Illinois $1,293,435,797 6 4.4% $884,018,166 7
North Carolina $1,100,822,176 7 3.8% $984,653,306 6
Massachusetts $958,972,520 8 3.3% $797,859,072 8
Tennessee $905,405,421 9 3.1% $681,454,847 11
Georgia $873,703,133 10 3.0% $735,944,558 9
Missouri $790,853,387 11 2.7% $675,647,147 12
Pennsylvania $718,210,352 12 2.4% $692,665,382 10
Louisiana $714,107,841 13 2.4% $585,388,809 15
New Jersey $694,669,924 14 2.4% $651,442,945 13
Michigan $674,222,281 15 2.3% $584,670,445 16
Kentucky $652,904,065 16 2.2% $592,096,755 14
Indiana $631,637,846 17 2.2% $561,642,082 17
Mississippi $567,313,801 18 1.9% $493,177,297 18
Washington $541,963,790 19 1.8% $458,332,414 19
Virginia $458,953,342 20 1.6% $417,689,526 21
Alabama $452,269,953 21 1.5% $386,876,131 22
South Carolina $451,846,044 22 1.5% $438,897,100 20
Wisconsin $442,718,195 23 1.5% $382,272,975 23
Connecticut $357,919,257 24 1.2% $304,780,286 24
Minnesota $310,174,144 25 1.1% $265,726,228 25
Maryland $297,291,733 26 1.0% $244,203,084 27
Iowa $285,467,642 27 1.0% $234,716,795 29
Oklahoma $285,068,869 28 1.0% $171,188,873 33
Oregon $279,029,096 29 1.0% $228,670,426 30
West Virginia $277,039,990 30 0.9% $259,638,952 26
Arkansas $273,257,660 31 0.9% $241,558,369 28
Maine $220,420,714 32 0.8% $191,785,942 31
Kansas $213,778,616 33 0.7% $185,017,060 32
Nebraska $207,782,737 34 0.7% $170,897,014 34
Colorado $189,717,036 35 0.6% $166,000,664 35
Utah $140,275,267 36 0.5% $117,170,006 36
Rhode Island $125,187,888 37 0.4% $102,708,476 39
Idaho $119,177,013 38 0.4% $102,975,196 38
Vermont $114,157,870 39 0.4% $104,250,880 37
New Hampshire $99,682,997 40 0.3% $91,703,067 40
Delaware $97,750,161 41 0.3% $81,156,928 41
Hawaii $88,256,904 42 0.3% $74,869,859 42
Nevada $86,929,536 43 0.3% $61,500,721 45
Montana $83,587,410 44 0.3% $72,577,455 43
New Mexico $73,877,785 45 0.3% $57,995,801 46
Alaska $70,708,412 46 0.2% $55,754,050 47
Dist. of Columbia $66,129,208 47 0.2% $63,504,500 44
South Dakota $62,382,937 48 0.2% $51,748,770 48
North Dakota $52,495,878 49 0.2% $44,067,986 49
Wyoming $39,094,579 50 0.1% $31,435,835 50
Arizona $3,725,371 51 0.0% $2,573,205 51
*Rebates have not been subtracted from these figures.

Source: CMS, HCFA-64 Report, FY 2001 and FY 2002.

4-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

Drugs as a Percentage of Total Net Expenditures, 2002

Total Medicaid
Net Medical Assistance Total Drug % of Total
State Expenditures Expenditures* Net Expenditures
National Total $245,697,620,676 $29,339,050,970 11.9%
Alabama $3,093,270,640 $452,269,953 14.6%
Alaska $685,772,985 $70,708,412 10.3%
Arizona $3,541,598,721 $3,725,371 0.1%
Arkansas $2,237,817,554 $273,257,660 12.2%
California $26,890,540,967 $3,591,537,830 13.4%
Colorado $2,323,068,699 $189,717,036 8.2%
Connecticut $3,456,338,545 $357,919,257 10.4%
Delaware $634,046,351 $97,750,161 15.4%
District of Columbia $1,021,772,693 $66,129,208 6.5%
Florida $9,871,508,234 $1,717,652,527 17.4%
Georgia $6,241,211,454 $873,703,133 14.0%
Hawaii $740,007,314 $88,256,904 11.9%
Idaho $773,534,776 $119,177,013 15.4%
Illinois $8,809,060,004 $1,293,435,797 14.7%
Indiana $4,448,318,143 $631,637,846 14.2%
Iowa $2,575,146,342 $285,467,642 11.1%
Kansas $1,836,717,196 $213,778,616 11.6%
Kentucky $3,763,204,047 $652,904,065 17.3%
Louisiana $4,885,971,853 $714,107,841 14.6%
Maine $1,430,109,134 $220,420,714 15.4%
Maryland $3,613,476,100 $297,291,733 8.2%
Massachusetts $8,063,005,258 $958,972,520 11.9%
Michigan $7,562,053,407 $674,222,281 8.9%
Minnesota $4,414,511,470 $310,174,144 7.0%
Mississippi $2,877,013,521 $567,313,801 19.7%
Missouri $5,360,607,640 $790,853,387 14.8%
Montana $571,456,455 $83,587,410 14.6%
Nebraska $1,339,132,070 $207,782,737 15.5%
Nevada $808,198,344 $86,929,536 10.8%
New Hampshire $1,016,094,814 $99,682,997 9.8%
New Jersey $7,745,877,997 $694,669,924 9.0%
New Mexico $1,776,811,688 $73,877,785 4.2%
New York $36,295,107,368 $3,660,427,024 10.1%
North Carolina $6,723,598,560 $1,100,822,176 16.4%
North Dakota $461,401,546 $52,495,878 11.4%
Ohio $9,658,040,587 $1,333,992,298 13.8%
Oklahoma $2,260,403,490 $285,068,869 12.6%
Oregon $2,571,560,664 $279,029,096 10.9%
Pennsylvania $12,130,925,035 $718,210,352 5.9%
Rhode Island $1,358,500,649 $125,187,888 9.2%
South Carolina $3,292,901,444 $451,846,044 13.7%
South Dakota $549,884,391 $62,382,937 11.3%
Tennessee $5,787,079,096 $905,405,421 15.6%
Texas $13,523,486,149 $1,591,064,713 11.8%
Utah $984,160,785 $140,275,267 14.3%
Vermont $660,731,979 $114,157,870 17.3%
Virginia $3,812,166,436 $458,953,342 12.0%
Washington $5,168,511,470 $541,963,790 10.5%
West Virginia $1,584,166,286 $277,039,990 17.5%
Wisconsin $4,193,175,197 $442,718,195 10.6%
Wyoming $274,565,128 $39,094,579 14.2%
*Rebates have not been subtracted from these figures.

Source: CMS, CMS-64 Report, FY 2002.

4-7
National Pharmaceutical Council Pharmaceutical Benefits 2003

Drugs as a Percentage of Total Net Expenditures, 2000-2002*

State 2000 2001 2002


National Total 10.5% 11.4% 11.9%
Alabama 12.4% 13.5% 14.6%
Alaska 9.3% 9.7% 10.3%
Arizona 0.1% 0.1% 0.1%
Arkansas 13.1% 13.0% 12.2%
California 11.7% 12.5% 13.4%
Colorado 7.4% 7.7% 8.2%
Connecticut 8.5% 9.5% 10.4%
Delaware 12.6% 13.7% 15.4%
District of Columbia 6.7% 6.5% 6.5%
Florida 18.1% 17.2% 17.4%
Georgia 13.4% 14.6% 14.0%
Hawaii 9.6% 11.8% 11.9%
Idaho 14.2% 14.9% 15.4%
Illinois 10.8% 11.4% 14.7%
Indiana 13.3% 14.0% 14.2%
Iowa 12.0% 14.1% 11.1%
Kansas 11.7% 11.0% 11.6%
Kentucky 15.3% 17.9% 17.3%
Louisiana 14.8% 13.9% 14.6%
Maine 14.4% 14.6% 15.4%
Maryland 6.8% 7.5% 8.2%
Massachusetts 11.0% 12.1% 11.9%
Michigan 5.9% 8.1% 8.9%
Minnesota 7.0% 6.9% 7.0%
Mississippi 18.6% 20.2% 19.7%
Missouri 15.1% 14.2% 14.8%
Montana 13.4% 15.0% 14.6%
Nebraska 13.7% 14.4% 15.5%
Nevada 8.4% 9.1% 10.8%
New Hampshire 10.3% 10.5% 9.8%
New Jersey 9.9% 9.1% 9.0%
New Mexico 4.0% 4.0% 4.2%
New York 8.4% 9.5% 10.1%
North Carolina 14.7% 16.0% 16.4%
North Dakota 9.1% 10.8% 11.4%
Ohio 11.8% 13.0% 13.8%
Oklahoma 10.2% 8.5% 12.6%
Oregon 8.0% 8.6% 10.9%
Pennsylvania 5.7% 6.3% 5.9%
Rhode Island 7.8% 8.6% 9.2%
South Carolina 13.1% 14.5% 13.7%
South Dakota 11.2% 11.1% 11.3%
Tennessee 5.5% 12.4% 15.6%
Texas 10.6% 11.4% 11.8%
Utah 12.5% 14.1% 14.3%
Vermont 16.6% 17.3% 17.3%
Virginia 14.2% 13.8% 12.0%
Washington 10.0% 10.6% 10.5%
West Virginia 15.6% 16.8% 17.5%
Wisconsin 10.6% 9.6% 10.6%
Wyoming 12.6% 12.9% 14.2%
*Percentages are based on figures that have not had rebates subtracted from them.

Source: CMS, HCFA-64 Report, FY 2000 - FY 2002.

4-8
National Pharmaceutical Council Pharmaceutical Benefits 2003

Share of Drug Expenditures by Category, 2002

Hormones and
Central Nervous Cardiovascular Anti-Infective Gastrointestinal Synthetic
State System Drugs Drugs Agents Drugs Substitutes
National Total $11,110,878,554 $3,309,235,175 $3,123,794,684 $2,220,293,730 $2,450,336,932
Alabama $162,427,968 $58,939,919 $53,191,197 $19,724,615 $47,715,140
Alaska $40,138,250 $6,871,390 $8,258,256 $8,448,493 $5,749,324
Arizona* - - - - -
Arkansas $104,327,247 $28,178,010 $34,062,548 $17,516,577 $25,063,050
California $1,326,623,035 $496,583,694 $340,238,011 $299,960,881 $408,010,804
Colorado $83,397,713 $18,457,938 $14,225,625 $19,891,233 $15,025,084
Connecticut $160,777,341 $40,992,549 $32,005,763 $30,864,193 $24,067,812
Delaware $33,137,878 $8,754,892 $14,857,621 $7,558,824 $7,523,594
District of Columbia $16,566,443 $8,980,540 $15,878,461 $2,293,635 $4,126,743
Florida $567,979,172 $187,207,113 $287,185,968 $128,405,638 $126,663,957
Georgia $293,303,215 $94,504,922 $116,609,831 $37,372,052 $73,825,742
Hawaii $34,086,249 $13,717,144 $7,463,253 $3,648,598 $8,519,468
Idaho $51,034,605 $7,528,366 $12,505,892 $8,638,278 $8,818,138
Illinois $350,382,552 $122,510,875 $119,743,795 $81,780,842 $91,373,328
Indiana $261,850,680 $56,525,273 $52,568,049 $43,805,799 $49,950,818
Iowa $133,389,066 $26,919,865 $25,133,166 $17,166,772 $23,699,984
Kansas $92,620,891 $18,956,370 $14,404,125 $16,375,484 $16,126,439
Kentucky $246,745,840 $76,276,780 $59,717,916 $47,258,191 $57,303,474
Louisiana $215,776,810 $77,561,164 $98,070,631 $50,354,434 $58,436,886
Maine $102,697,707 $32,706,097 $15,813,854 $20,571,791 $23,502,715
Maryland $155,536,684 $34,300,423 $25,569,033 $22,383,011 $18,483,071
Massachusetts $430,570,903 $92,069,851 $97,049,019 $71,551,884 $65,280,437
Michigan $340,976,049 $73,768,758 $39,031,663 $45,338,916 $48,709,565
Minnesota $168,448,868 $22,183,423 $20,695,558 $24,111,242 $22,047,764
Mississippi $163,971,736 $74,830,740 $57,550,451 $38,835,119 $47,224,420
Missouri $345,195,541 $88,695,064 $76,038,064 $40,234,018 $69,509,901
Montana $34,810,221 $6,010,486 $5,521,773 $7,116,556 $6,146,901
Nebraska $81,936,002 $16,357,515 $16,977,505 $18,138,100 $15,440,716
Nevada $38,425,453 $9,365,878 $9,266,546 $5,789,204 $6,733,244
New Hampshire $50,011,843 $8,064,813 $6,784,686 $7,427,069 $7,511,020
New Jersey $233,071,337 $84,618,207 $76,763,184 $55,305,576 $43,057,935
New Mexico $29,130,298 $9,205,694 $5,923,305 $8,455,563 $9,789,382
New York $1,140,536,063 $421,174,650 $582,777,416 $263,380,736 $292,497,125
North Carolina $378,957,583 $131,377,542 $110,556,228 $122,152,344 $91,412,449
North Dakota $24,261,002 $4,805,781 $3,723,614 $4,123,091 $4,136,352
Ohio $548,273,256 $136,785,856 $117,486,151 $133,074,736 $106,110,103
Oklahoma $104,495,550 $29,741,991 $25,469,725 $16,950,080 $22,005,051
Oregon $167,833,786 $19,501,122 $17,189,123 $12,676,327 $18,126,559
Pennsylvania $277,892,318 $76,953,109 $50,334,104 $66,460,266 $52,304,661
Rhode Island $54,554,473 $15,629,844 $10,756,138 $12,760,847 $9,079,709
South Carolina $166,326,864 $65,363,553 $58,789,210 $26,958,237 $48,429,827
South Dakota $24,744,099 $4,278,404 $5,738,550 $5,566,752 $4,721,494
Tennessee $498,494,118 $126,602,215 $39,685,343 $80,012,408 $63,222,119
Texas $534,365,292 $170,623,922 $188,773,209 $105,134,911 $144,900,535
Utah $66,525,169 $9,033,014 $11,164,654 $10,721,510 $10,004,484
Vermont $15,204,207 $1,996,150 $4,094,728 $1,825,472 $3,386,327
Virginia $169,780,908 $56,516,797 $34,656,425 $49,598,408 $33,627,141
Washington $240,264,995 $52,602,760 $42,461,101 $42,712,396 $44,968,562
West Virginia $114,111,323 $35,490,850 $27,406,002 $15,554,339 $28,201,869
Wisconsin $219,043,257 $46,738,020 $29,955,583 $40,886,751 $34,911,470
Wyoming $15,866,694 $2,375,842 $3,672,631 $3,421,531 $2,854,239
* Data not reported for Arizona. Arizona has an 115 waiver for which special rules apply.

Source: CMS, State Drug Utilization Data, FY 2002

4-9
National Pharmaceutical Council Pharmaceutical Benefits 2003

Share of Drug Expenditures by Category, 2002 (con't.)

Unclassified
Therapeutic Autonomic Blood Formation
State Agents Drugs and Coagulation Other Total
National Average $1,359,408,404 $1,310,216,943 $990,931,837 $3,558,911,926 $29,434,008,185
Alabama $22,738,666 $25,079,219 $14,344,026 $73,878,759 $478,039,509
Alaska $3,581,523 $3,755,322 $5,983,211 $7,629,178 $90,414,947
Arizona* - - - - -
Arkansas $13,863,613 $14,761,594 $12,118,144 $36,775,275 $286,666,058
California $157,970,901 $120,211,219 $209,658,251 $346,042,559 $3,705,299,355
Colorado $10,839,480 $9,701,591 $3,878,876 $20,711,072 $196,128,612
Connecticut $14,860,816 $13,959,149 $9,952,330 $36,195,541 $363,675,494
Delaware $4,793,777 $4,361,417 $2,059,247 $12,024,599 $95,071,849
District of Columbia $2,027,293 $1,757,168 $2,061,662 $8,100,729 $61,792,674
Florida $93,146,712 $79,021,471 $65,139,602 $214,181,262 $1,748,930,895
Georgia $35,344,409 $51,251,712 $23,350,249 $135,189,926 $860,752,058
Hawaii $5,739,678 $3,682,979 $3,725,363 $9,623,486 $90,206,218
Idaho $4,702,849 $4,537,192 $2,090,222 $10,675,638 $110,531,180
Illinois $51,201,123 $49,711,098 $42,312,778 $125,591,419 $1,034,607,810
Indiana $30,428,285 $34,113,121 $30,588,581 $88,424,694 $648,255,300
Iowa $14,503,456 $14,515,299 $4,634,670 $30,708,063 $290,670,341
Kansas $8,882,991 $10,341,541 $2,710,267 $22,665,160 $203,083,268
Kentucky $32,858,754 $44,179,459 $16,546,274 $92,326,826 $673,213,514
Louisiana $28,664,540 $37,300,313 $22,766,784 $126,322,534 $715,254,096
Maine $11,567,546 $13,021,181 $7,032,641 $23,157,560 $250,071,092
Maryland $12,230,384 $9,621,667 $12,500,270 $27,905,071 $318,529,614
Massachusetts $39,070,997 $34,788,062 $25,993,252 $93,515,983 $949,890,388
Michigan $36,673,123 $28,611,197 $21,000,992 $78,003,615 $712,113,878
Minnesota $14,145,281 $12,275,238 $10,275,040 $28,487,965 $322,670,379
Mississippi $26,530,965 $26,109,283 $10,028,232 $71,978,643 $517,059,589
Missouri $39,157,120 $42,009,219 $27,370,560 $107,787,109 $835,996,596
Montana $4,849,421 $3,999,013 $1,873,361 $8,043,097 $78,370,829
Nebraska $8,345,459 $9,248,417 $4,526,460 $26,832,410 $197,802,584
Nevada $4,479,913 $4,540,225 $3,355,258 $10,558,557 $92,514,278
New Hampshire $4,030,559 $5,036,489 $1,726,064 $11,498,389 $102,090,932
New Jersey $33,208,357 $28,777,427 $31,413,603 $82,236,456 $668,452,082
New Mexico $4,858,911 $3,660,437 $2,321,704 $10,427,651 $83,772,945
New York $164,083,098 $144,160,697 $128,216,711 $448,781,131 $3,585,607,627
North Carolina $52,831,364 $47,151,722 $34,051,151 $154,246,658 $1,122,737,041
North Dakota $2,190,494 $2,402,271 $1,200,697 $6,203,497 $53,046,799
Ohio $61,882,420 $73,814,087 $31,269,079 $171,884,121 $1,380,579,809
Oklahoma $15,423,385 $14,719,001 $12,077,645 $32,175,743 $273,058,171
Oregon $11,165,553 $10,626,003 $3,269,333 $17,340,074 $277,727,880
Pennsylvania $36,543,215 $37,155,760 $28,115,340 $81,438,693 $707,197,466
Rhode Island $5,349,865 $4,968,045 $2,243,417 $12,019,287 $127,361,625
South Carolina $23,527,729 $22,180,993 $12,869,914 $73,393,454 $497,839,781
South Dakota $2,662,003 $3,005,290 $2,132,526 $8,156,411 $61,005,529
Tennessee $42,907,863 $35,886,456 $11,623,384 $74,216,876 $972,650,782
Texas $71,446,566 $79,465,180 $47,090,505 $281,968,505 $1,623,768,625
Utah $5,777,363 $5,309,763 $1,236,279 $15,712,079 $135,484,315
Vermont $1,538,173 $1,484,182 $910,603 $4,175,415 $34,615,257
Virginia $21,636,958 $22,121,039 $14,515,501 $57,867,501 $460,320,678
Washington $25,745,981 $22,298,725 $12,901,679 $54,928,168 $538,884,367
West Virginia $14,341,914 $16,315,461 $3,412,406 $35,444,231 $290,278,395
Wisconsin $23,072,206 $21,426,205 $9,215,035 $47,029,239 $472,277,766
Wyoming $1,985,352 $1,787,344 $1,242,658 $4,431,617 $37,637,908
* Data not reported for Arizona. Arizona has an 1115 waiver for which special rules apply.

Source: CMS, State Drug Utilization Data, FY 2002.

4-10
National Pharmaceutical Council Pharmaceutical Benefits 2003

Share of Prescriptions Processed, 2002

Hormones and
Central Nervous Cardiovascular Anti-Infective Gastrointestinal Synthetic
State System Drugs Drugs Agents Drugs Substitutes
National Average 161,232,219 72,443,028 44,093,996 32,548,275 49,926,307
Alabama 2,941,431 1,474,573 1,048,966 502,468 1,071,095
Alaska 538,815 180,198 117,690 97,338 140,539
Arizona* - - - - -
Arkansas 1,603,598 760,062 702,941 271,296 565,683
California 15,214,602 7,876,231 4,083,588 3,385,060 5,529,844
Colorado 1,339,641 511,136 301,986 254,879 446,353
Connecticut 2,021,686 847,007 256,096 352,779 521,491
Delaware 488,341 174,105 163,401 86,189 151,233
District of Columbia 238,638 192,385 75,916 34,750 85,750
Florida 8,038,952 4,449,917 2,573,795 1,684,045 2,578,311
Georgia 4,836,548 2,272,159 2,201,615 798,841 1,726,279
Hawaii 460,387 280,308 85,657 131,081 164,060
Idaho 730,380 186,130 241,834 90,662 219,364
Illinois 5,998,874 3,043,522 2,011,538 1,612,006 2,087,064
Indiana 4,105,446 1,344,857 1,021,660 961,743 1,083,084
Iowa 2,042,876 676,484 526,890 289,881 574,214
Kansas 1,283,667 478,864 292,629 224,830 403,111
Kentucky 3,958,848 1,798,630 1,260,103 1,031,820 1,255,859
Louisiana 3,565,125 1,748,774 1,618,788 627,664 1,234,697
Maine 1,816,121 992,273 346,253 307,138 669,930
Maryland 2,040,489 771,138 235,643 276,028 437,447
Massachusetts 6,184,586 2,193,033 1,121,462 871,999 1,597,184
Michigan 5,334,314 1,975,384 749,240 804,253 1,233,184
Minnesota 2,002,604 505,679 313,581 461,421 449,417
Mississippi 2,383,531 1,565,659 1,009,586 446,750 917,779
Missouri 4,817,043 2,017,339 1,126,028 822,151 1,473,030
Montana 524,752 149,104 123,537 95,044 154,526
Nebraska 1,273,870 419,270 399,375 343,820 369,585
Nevada 506,986 207,748 116,449 70,849 154,274
New Hampshire 782,217 221,431 135,110 168,121 180,316
New Jersey 3,019,679 1,720,151 565,815 618,302 871,468
New Mexico 514,776 232,761 120,054 123,271 264,285
New York 14,908,099 8,342,535 4,737,922 3,717,304 5,014,585
North Carolina 5,676,633 3,110,086 1,789,714 1,261,734 2,123,893
North Dakota 354,179 138,692 90,114 53,653 117,790
Ohio 8,874,351 3,367,729 2,171,902 2,251,991 2,532,337
Oklahoma 1,359,234 619,655 469,747 253,620 454,955
Oregon 2,482,014 536,975 271,375 274,184 497,490
Pennsylvania 4,061,265 1,930,258 844,456 920,012 1,260,625
Rhode Island 759,101 288,310 107,145 155,871 178,022
South Carolina 2,488,867 1,551,714 956,429 414,746 1,121,193
South Dakota 328,166 113,324 132,161 61,797 110,042
Tennessee 8,328,542 3,188,238 663,010 1,211,895 1,650,584
Texas 8,145,506 2,954,622 4,157,104 1,525,126 2,404,342
Utah 985,750 205,220 259,890 170,618 248,371
Vermont 233,990 44,219 73,282 24,002 63,883
Virginia 2,658,974 1,275,731 549,649 755,313 763,085
Washington 3,607,572 1,292,270 681,200 772,019 1,140,120
West Virginia 1,978,691 838,280 608,930 296,680 625,931
Wisconsin 3,167,088 1,321,310 496,952 541,168 945,241
Wyoming 225,374 57,548 85,788 40,063 63,362
*Data not reported for Arizona. Arizona has an 1115 waiver for which special rules apply.

Source: CMS, State Drug Utilization Data, FY 2002.

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Share of Prescriptions Processed, 2002 (con't)

Unclassified
Therapeutic Autonomic Blood Formation
State Agents Drugs and Coagulation Other Total
National Average 12,417,152 28,118,352 8,829,418 109,663,158 519,271,905
Alabama 236,233 593,690 176,967 2,577,154 10,622,577
Alaska 32,981 84,604 21,891 216,774 1,430,830
Arizona* - - - - -
Arkansas 147,559 304,771 78,382 1,211,543 5,645,835
California 1,251,287 2,391,533 1,171,076 9,602,912 50,506,133
Colorado 102,310 246,770 78,758 763,212 4,045,045
Connecticut 123,141 286,590 118,220 953,334 5,480,344
Delaware 39,794 100,817 17,248 332,518 1,553,646
District of Columbia 21,194 39,581 14,437 214,858 917,509
Florida 814,906 1,488,860 462,674 5,505,188 27,596,648
Georgia 386,418 1,116,911 277,778 4,310,917 17,927,466
Hawaii 68,661 80,472 24,987 314,766 1,610,379
Idaho 45,247 110,953 22,090 335,525 1,982,185
Illinois 475,449 1,227,016 444,852 5,101,759 22,002,080
Indiana 265,303 693,573 221,927 2,856,633 12,554,226
Iowa 119,840 312,212 102,265 1,048,931 5,693,593
Kansas 86,239 209,318 62,517 706,425 3,747,600
Kentucky 350,628 828,775 218,980 3,124,789 13,828,432
Louisiana 283,139 799,945 225,964 3,561,044 13,665,140
Maine 139,597 319,159 82,503 836,581 5,509,555
Maryland 120,094 241,386 123,481 845,278 5,090,984
Massachusetts 350,189 882,646 224,809 2,622,424 16,048,332
Michigan 359,466 673,362 278,304 2,470,691 13,878,198
Minnesota 98,300 273,845 73,086 908,532 5,086,465
Mississippi 255,373 450,278 142,959 2,095,665 9,267,580
Missouri 334,079 848,195 263,580 3,036,239 14,737,684
Montana 36,544 92,105 19,000 260,368 1,454,980
Nebraska 84,578 209,544 64,395 978,024 4,142,461
Nevada 46,298 100,059 19,587 262,239 1,484,489
New Hampshire 42,495 110,132 31,078 421,656 2,092,556
New Jersey 303,410 504,862 182,297 2,056,526 9,842,510
New Mexico 42,822 87,788 34,673 415,945 1,836,375
New York 1,383,908 3,156,479 756,500 12,587,023 54,604,355
North Carolina 527,568 1,035,032 280,164 4,328,993 20,133,817
North Dakota 23,616 52,035 19,627 214,883 1,064,589
Ohio 605,376 1,656,240 489,554 6,456,527 28,406,007
Oklahoma 131,804 278,564 51,310 851,206 4,470,095
Oregon 97,919 260,718 65,043 738,907 5,224,625
Pennsylvania 371,915 710,505 424,057 2,555,642 13,078,735
Rhode Island 50,658 111,718 34,459 372,418 2,057,702
South Carolina 228,975 458,400 129,353 2,036,447 9,386,124
South Dakota 25,509 59,709 19,269 243,295 1,093,272
Tennessee 416,508 848,942 296,281 3,008,859 19,612,859
Texas 587,114 1,735,053 384,211 9,091,697 30,984,775
Utah 63,353 132,311 29,355 486,901 2,581,769
Vermont 20,430 35,855 4,869 99,712 600,242
Virginia 215,740 438,542 166,555 1,879,125 8,702,714
Washington 220,230 573,523 157,276 1,919,907 10,364,117
West Virginia 149,046 344,864 70,280 1,116,604 6,029,306
Wisconsin 217,841 480,948 159,848 1,586,155 8,916,551
Wyoming 16,068 39,162 10,642 140,407 678,414
*Data not reported for Arizona. Arizona has an 1115 waiver for which special rules apply.

Source: CMS, State Drug Utilization Data, FY 2002.

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Medicaid Average Cost Per Prescription, 2002*

Drug Prescriptions Average


State Payments Processed Prescription Cost
National Average $29,434,008,185 519,271,905 $56.68
Alabama $478,039,509 10,622,577 $45.00
Alaska $90,414,947 1,430,830 $63.19
Arizona** - - -
Arkansas $286,666,058 5,645,835 $50.77
California $3,705,299,355 50,506,133 $73.36
Colorado $196,128,612 4,045,045 $48.49
Connecticut $363,675,494 5,480,344 $66.36
Delaware $95,071,849 1,553,646 $61.19
District of Columbia $61,792,674 917,509 $67.35
Florida $1,748,930,895 27,596,648 $63.37
Georgia $860,752,058 17,927,466 $48.01
Hawaii $90,206,218 1,610,379 $56.02
Idaho $110,531,180 1,982,185 $55.76
Illinois $1,034,607,810 22,002,080 $47.02
Indiana $648,255,300 12,554,226 $51.64
Iowa $290,670,341 5,693,593 $51.05
Kansas $203,083,268 3,747,600 $54.19
Kentucky $673,213,514 13,828,432 $48.68
Louisiana $715,254,096 13,665,140 $52.34
Maine $250,071,092 5,509,555 $45.39
Maryland $318,529,614 5,090,984 $62.57
Massachusetts $949,890,388 16,048,332 $59.19
Michigan $712,113,878 13,878,198 $51.31
Minnesota $322,670,379 5,086,465 $63.44
Mississippi $517,059,589 9,267,580 $55.79
Missouri $835,996,596 14,737,684 $56.73
Montana $78,370,829 1,454,980 $53.86
Nebraska $197,802,584 4,142,461 $47.75
Nevada $92,514,278 1,484,489 $62.32
New Hampshire $102,090,932 2,092,556 $48.79
New Jersey $668,452,082 9,842,510 $67.91
New Mexico $83,772,945 1,836,375 $45.62
New York $3,585,607,627 54,604,355 $65.67
North Carolina $1,122,737,041 20,133,817 $55.76
North Dakota $53,046,799 1,064,589 $49.83
Ohio $1,380,579,809 28,406,007 $48.60
Oklahoma $273,058,171 4,470,095 $61.09
Oregon $277,727,880 5,224,625 $53.16
Pennsylvania $707,197,466 13,078,735 $54.07
Rhode Island $127,361,625 2,057,702 $61.90
South Carolina $497,839,781 9,386,124 $53.04
South Dakota $61,005,529 1,093,272 $55.80
Tennessee $972,650,782 19,612,859 $49.59
Texas $1,623,768,625 30,984,775 $52.41
Utah $135,484,315 2,581,769 $52.48
Vermont $34,615,257 600,242 $57.67
Virginia $460,320,678 8,702,714 $52.89
Washington $538,884,367 10,364,117 $52.00
West Virginia $290,278,395 6,029,306 $48.14
Wisconsin $472,277,766 8,916,551 $52.97
Wyoming $37,637,908 678,414 $55.48
*Rebates have not been subtracted from these figures.
**Data not reported for Arizona. Arizona has an 1115 waiver for which special rules apply.
Source: CMS, State Drug Utilization Data, FY 2002.

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MEDICAID DRUG REBATES

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 the Department of Health and Human Services (HHS) 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 HHS 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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Medicaid Drug Rebates, 2002

Allocation of
State Drug Rebate Monies1 Total Rebates2 Federal Share2
National Total $5,917,504,760 $3,407,724,441
Alabama Medicaid Drug Budget $84,994,286 $59,956,556
Alaska Medicaid General $14,347,654 $8,232,684
Arizona* - - -
Arkansas Medicaid Drug Budget $56,688,398 $41,263,780
California Medicaid Drug Budget $946,651,118 $501,389,213
Colorado General Fund $39,054,140 $19,757,318
Connecticut General Fund $62,627,160 $31,353,041
Delaware Medicaid General $16,990,455 $8,583,285
District of Columbia Medicaid General $11,445,790 $8,012,876
Florida Medicaid Drug Budget $353,649,807 $200,302,136
Georgia Medicaid General $205,469,531 $121,227,024
Hawaii Medicaid Drug Budget $15,267,796 $8,601,876
Idaho Medicaid General $22,939,130 $16,291,370
Illinois Medicaid Drug Budget $190,316,986 $95,869,844
Indiana General Fund $126,512,101 $78,488,107
Iowa General Fund $50,092,788 $31,591,633
Kansas Medicaid General $29,755,595 $17,938,406
Kentucky General Fund $133,330,557 $93,351,276
Louisiana Medicaid Drug Budget $113,729,749 $80,081,323
Maine Medicaid Drug Budget $47,395,300 $31,642,678
Maryland Medicaid General $54,261,949 $27,263,281
Massachusetts Medicaid General $191,118,385 $95,707,811
Michigan General Fund $172,522,597 $97,412,881
Minnesota General Fund $62,655,474 $31,327,739
Mississippi Medicaid General $115,221,421 $87,844,768
Missouri Medicaid Drug Budget $147,281,505 $90,586,777
Montana General Fund $15,955,235 $11,659,478
Nebraska Medicaid Drug Budget $47,855,128 $28,770,955
Nevada General Fund $13,547,604 $6,803,437
New Hampshire General Fund $20,888,707 $10,500,160
New Jersey Medicaid Drug Budget $127,373,014 $63,850,343
New Mexico General Fund $13,274,387 $9,695,612
New York General Fund $663,973,100 $331,986,551
North Carolina Medicaid General $207,064,443 $127,702,769
North Dakota Medicaid Drug Budget $11,651,682 $8,159,556
Ohio Medicaid General $263,267,258 $154,748,494
Oklahoma Medicaid General $51,471,649 $36,251,483
Oregon General Fund $54,474,938 $32,343,683
Pennsylvania Outpatient Appropriation $154,338,235 $84,595,091
Rhode Island General Fund $26,213,636 $13,749,052
South Carolina Medicaid Drug Budget $98,272,773 $68,818,366
South Dakota Medicaid Drug Budget $12,056,925 $8,004,147
Tennessee Medicaid General $180,613,885 $114,942,676
Texas Medicaid Drug Budget $305,110,523 $184,019,819
Utah General Fund $36,756,960 $25,760,249
Vermont Medicaid General $24,488,863 $15,514,120
Virginia General Fund, Medicaid General $76,776,155 $39,595,957
Washington General Fund $100,874,789 $51,143,700
West Virginia Medicaid General $48,976,536 $36,864,639
Wisconsin Medicaid General $89,226,751 $52,764,907
Wyoming Medicaid Drug Budget $8,681,912 $5,401,514
*Does not apply for Arizona. Arizona has an 1115 waiver for which special rules apply.
Sources: 1As reported by State drug program administrators in the 2003 NPC Survey.
2
CMS, CMS-64 Report, FY 2002, includes reported state supplemental rebates for CA, FL, MD, and MI.

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Medicaid Drug Rebate Trends, 1998-2002

State 1998 1999 2000 2001 2002


National Total $2,469,136,949 $3,338,497,983 $3,980,646,518 $4,948,222,331 $5,917,504,760
Alabama $36,537,095 $49,785,076 $60,984,826 $76,624,463 $84,994,286
Alaska $5,026,624 $7,050,981 $8,594,014 $11,337,883 $14,347,654
Arizona* - - - - -
Arkansas $22,518,230 $37,931,853 $40,814,931 $45,744,406 $56,688,398
California $362,808,597 $539,928,783 $600,895,711 $786,113,991 $946,651,118
Colorado $20,424,896 $25,151,080 $28,832,989 $34,264,574 $39,054,140
Connecticut $32,128,587 $38,656,394 $49,164,014 $61,916,192 $62,627,160
Delaware $7,096,836 $9,787,444 $13,780,359 $17,042,045 $16,990,455
District of Columbia $7,100,983 $8,379,982 $9,215,651 $10,446,499 $11,445,790
Florida $150,733,077 $195,512,719 $248,637,014 $297,362,792 $353,649,807
Georgia $64,320,077 $95,237,778 $91,886,605 $110,087,285 $205,469,531
Hawaii $5,992,722 $8,378,292 $10,947,632 $14,363,603 $15,267,796
Idaho $8,614,444 $11,901,778 $13,984,004 $18,841,154 $22,939,130
Illinois $100,811,862 $121,540,781 $143,590,170 $170,733,612 $190,316,986
Indiana $50,710,861 $62,691,135 $84,453,135 $103,148,144 $126,512,101
Iowa $25,265,390 $32,369,409 $36,040,216 $42,602,101 $50,092,788
Kansas $19,852,439 $26,878,486 $31,022,023 $39,731,568 $29,755,595
Kentucky $57,082,387 $72,676,810 $93,688,165 $104,759,238 $133,330,557
Louisiana $65,994,910 $76,147,317 $84,800,897 $115,254,842 $113,729,749
Maine $19,650,719 $30,032,364 $31,598,262 $41,847,632 $47,395,300
Maryland $25,017,660 $32,311,299 $42,081,781 $34,263,429 $54,261,949
Massachusetts $89,011,664 $140,102,747 $146,225,538 $180,517,139 $191,118,385
Michigan $72,526,027 $75,674,128 $75,687,945 $111,716,756 $172,522,597
Minnesota $31,058,740 $37,389,033 $43,228,324 $54,548,714 $62,655,474
Mississippi $39,983,265 $49,332,307 $61,260,326 $88,481,567 $115,221,421
Missouri $66,460,159 $84,620,799 $110,025,619 $133,927,028 $147,281,505
Montana $7,378,206 $9,290,653 $10,985,923 $13,359,968 $15,955,235
Nebraska $16,545,572 $21,609,490 $31,004,940 $30,219,685 $47,855,128
Nevada $5,143,136 $7,727,267 $4,863,879 $16,330,579 $13,547,604
New Hampshire $9,676,461 $12,956,727 $15,073,211 $13,934,765 $20,888,707
New Jersey $70,992,525 $90,472,488 $105,535,091 $124,127,231 $127,373,014
New Mexico $10,670,766 $7,972,600 $8,901,456 $12,110,896 $13,274,387
New York $251,273,382 $356,088,488 $470,317,992 $543,984,948 $663,973,100
North Carolina $81,211,796 $111,326,116 $140,047,825 $207,551,841 $207,064,443
North Dakota $4,990,065 $5,954,387 $6,503,601 $8,780,182 $11,651,682
Ohio $110,484,575 $148,477,399 $171,685,793 $217,702,350 $263,267,258
Oklahoma $23,329,251 $31,992,100 $37,135,809 $40,177,945 $51,471,649
Oregon $14,433,179 $21,360,688 $32,056,386 $34,991,037 $54,474,938
Pennsylvania $95,692,149 $119,340,064 $118,989,849 $129,265,110 $154,338,235
Rhode Island $11,041,552 $14,440,971 $19,223,034 $21,467,002 $26,213,636
South Carolina $39,156,574 $55,971,288 $73,052,676 $95,438,155 $98,272,773
South Dakota $5,070,643 $5,971,015 $7,198,848 $9,405,933 $12,056,925
Tennessee** $840 $22,434,760 $41,302,450 $102,644,077 $180,613,885
Texas $145,635,499 $185,695,267 $222,314,531 $268,557,241 $305,110,523
Utah $9,988,037 $15,145,126 $21,889,639 $21,949,963 $36,756,960
Vermont $8,868,263 $10,579,999 $17,869,053 $22,045,277 $24,488,863
Virginia $51,079,391 $67,715,512 $75,630,717 $79,484,868 $76,776,155
Washington $39,191,376 $54,331,249 $69,782,396 $91,250,830 $100,874,789
West Virginia $26,753,285 $35,941,495 $46,762,149 $52,402,218 $48,976,536
Wisconsin $40,776,543 $51,869,264 $66,358,433 $79,554,207 $89,226,751
Wyoming $3,025,632 $4,364,795 $4,720,686 $5,809,366 $8,681,912

*Does not apply for Arizona. Arizona has an 1115 waiver for which special rules apply.
Source: CMS, HCFA-64 Report, FY 1998-FY 2002.

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Medicaid Drug Rebate Trends


Annual Percent Change, 1997-2002

% Change % Change % Change % Change % Change


State 97-98 98-99 99-00 00-01 01-02
National Total 11.6% 35.2% 19.2% 24.3% 19.6%
Alabama -22.5% 36.3% 22.5% 25.6% 10.9%
Alaska 2.6% 40.3% 21.9% 31.9% 26.5%
Arizona* - - - - -
Arkansas -8.1% 68.4% 7.6% 12.1% 23.9%
California 17.9% 48.8% 11.3% 30.8% 20.4%
Colorado 20.5% 23.1% 14.6% 18.8% 14.0%
Connecticut 17.6% 20.3% 27.2% 25.9% 1.1%
Delaware 21.3% 37.9% 40.8% 23.7% -0.3%
District of Columbia 6.5% 18.0% 10.0% 13.4% 9.6%
Florida 17.3% 29.7% 27.2% 19.6% 18.9%
Georgia 7.6% 48.1% -3.5% 19.8% 86.6%
Hawaii 28.8% 39.8% 30.7% 31.2% 6.3%
Idaho 2.9% 38.2% 17.5% 34.7% 21.8%
Illinois 18.4% 20.6% 18.1% 18.9% 11.5%
Indiana 16.2% 23.6% 34.7% 22.1% 22.7%
Iowa 16.1% 28.1% 11.3% 18.2% 17.6%
Kansas 68.3% 35.4% 15.4% 28.1% -25.1%
Kentucky -4.7% 27.3% 28.9% 11.8% 27.3%
Louisiana 20.8% 15.4% 11.4% 35.9% -1.3%
Maine 7.7% 52.8% 5.2% 32.4% 13.3%
Maryland -27.6% 29.2% 30.2% -18.6% 58.4%
Massachusetts 21.9% 57.4% 4.4% 23.5% 5.9%
Michigan -2.1% 4.3% 0.0% 47.6% 54.4%
Minnesota -2.6% 20.4% 15.6% 26.2% 14.9%
Mississippi 7.7% 23.4% 24.2% 44.4% 30.2%
Missouri 21.7% 27.3% 30.0% 21.7% 10.0%
Montana 8.9% 25.9% 18.2% 21.6% 19.4%
Nebraska 10.8% 30.6% 43.5% -2.5% 58.4%
Nevada -4.6% 50.2% -37.1% 235.8% -17.0%
New Hampshire 10.1% 33.9% 16.3% -7.6% 49.9%
New Jersey 6.4% 27.4% 16.6% 17.6% 2.6%
New Mexico -20.2% -25.3% 11.7% 36.1% 9.6%
New York 25.5% 41.7% 32.1% 15.7% 22.1%
North Carolina 18.8% 37.1% 25.8% 48.2% -0.2%
North Dakota 7.3% 19.3% 9.2% 35.0% 32.7%
Ohio 31.2% 34.4% 15.6% 26.8% 20.9%
Oklahoma 12.3% 37.1% 16.1% 8.2% 28.1%
Oregon 4.2% 48.0% 50.1% 9.2% 55.7%
Pennsylvania -17.2% 24.7% -0.3% 8.6% 19.4%
Rhode Island 9.1% 30.8% 33.1% 11.7% 22.1%
South Carolina 13.0% 42.9% 30.5% 30.6% 3.0%
South Dakota 2.6% 17.8% 20.6% 30.7% 28.2%
Tennessee** - - 84.1% 148.5% 76.0%
Texas 11.5% 27.5% 19.7% 20.8% 13.6%
Utah 19.3% 51.6% 44.5% 0.3% 67.5%
Vermont 7.4% 19.3% 68.9% 23.4% 11.1%
Virginia 12.9% 32.6% 11.7% 5.1% -3.4%
Washington 2.3% 38.6% 28.4% 30.8% 10.5%
West Virginia 2.6% 34.3% 30.1% 12.1% -6.5%
Wisconsin 9.8% 27.2% 27.9% 19.9% 12.2%
Wyoming 12.9% 44.3% 8.2% 23.1% 49.4%

*Does not apply to Arizona. Arizona has an 1115 waiver for which special rules apply.
**Tennessee did not report data for 1997.
Source: CMS, CMS-64 Report, FY 1997 – FY 2002.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Rebates as Percent Drug Expenditures, 2002

Rebates as % Drug
State Drug Expenditures Rebates Expenditure
National Total $29,339,050,970 $5,917,504,760 20.2%
Alabama $452,269,953 $84,994,286 18.8%
Alaska $70,708,412 $14,347,654 20.3%
Arizona* $3,725,371 - -
Arkansas $273,257,660 $56,688,398 20.7%
California $3,591,537,830 $946,651,118 26.4%
Colorado $189,717,036 $39,054,140 20.6%
Connecticut $357,919,257 $62,627,160 17.5%
Delaware $97,750,161 $16,990,455 17.4%
District of Columbia $66,129,208 $11,445,790 17.3%
Florida $1,717,652,527 $353,649,807 20.6%
Georgia $873,703,133 $205,469,531 23.5%
Hawaii $88,256,904 $15,267,796 17.3%
Idaho $119,177,013 $22,939,130 19.2%
Illinois $1,293,435,797 $190,316,986 14.7%
Indiana $631,637,846 $126,512,101 20.0%
Iowa $285,467,642 $50,092,788 17.5%
Kansas $213,778,616 $29,755,595 13.9%
Kentucky $652,904,065 $133,330,557 20.4%
Louisiana $714,107,841 $113,729,749 15.9%
Maine $220,420,714 $47,395,300 21.5%
Maryland $297,291,733 $54,261,949 18.3%
Massachusetts $958,972,520 $191,118,385 19.9%
Michigan $674,222,281 $172,522,597 25.6%
Minnesota $310,174,144 $62,655,474 20.2%
Mississippi $567,313,801 $115,221,421 20.3%
Missouri $790,853,387 $147,281,505 18.6%
Montana $83,587,410 $15,955,235 19.1%
Nebraska $207,782,737 $47,855,128 23.0%
Nevada $86,929,536 $13,547,604 15.6%
New Hampshire $99,682,997 $20,888,707 21.0%
New Jersey $694,669,924 $127,373,014 18.3%
New Mexico $73,877,785 $13,274,387 18.0%
New York $3,660,427,024 $663,973,100 18.1%
North Carolina $1,100,822,176 $207,064,443 18.8%
North Dakota $52,495,878 $11,651,682 22.2%
Ohio $1,333,992,298 $263,267,258 19.7%
Oklahoma $285,068,869 $51,471,649 18.1%
Oregon $279,029,096 $54,474,938 19.5%
Pennsylvania $718,210,352 $154,338,235 21.5%
Rhode Island $125,187,888 $26,213,636 20.9%
South Carolina $451,846,044 $98,272,773 21.7%
South Dakota $62,382,937 $12,056,925 19.3%
Tennessee $905,405,421 $180,613,885 19.9%
Texas $1,591,064,713 $305,110,523 19.2%
Utah $140,275,267 $36,756,960 26.2%
Vermont $114,157,870 $24,488,863 21.5%
Virginia $458,953,342 $76,776,155 16.7%
Washington $541,963,790 $100,874,789 18.6%
West Virginia $277,039,990 $48,976,536 17.7%
Wisconsin $442,718,195 $89,226,751 20.2%
Wyoming $39,094,579 $8,681,912 22.2%
*Does not apply to Arizona. Arizona has an 1115 waiver for which special rules apply.
Source: CMS, CMS-64 Report, FY 2002

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National Pharmaceutical Council Pharmaceutical Benefits 2003

MEDICAID DRUG COVERAGE

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.

DRUG UTILIZATION REVIEW

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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National Pharmaceutical Council Pharmaceutical Benefits 2003

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 and description of the medication;


• The route of administration, dosage form, dosage, and duration of therapy;
• Special directions and precautions for preparation, administration and use by the patient;
• Common severe side or adverse effects or interactions and therapeutic contraindications that
may be encountered, including their avoidance, and the action required if they occur;
• Techniques for self-monitoring prescription therapy;
• Proper storage;
• Prescription refill information; and
• Action to be taken in the event of a missed dose.
State law must also require pharmacists to make a reasonable effort to obtain, record, and maintain at
least the following information for each Medicaid recipient:

• 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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National Pharmaceutical Council Pharmaceutical Benefits 2003

Pharmacy Advisory Committees


Preferred Product Introduction
State Pharmacy Advisory Committee Meetings
Process
Alabama Pharmacy & Therapeutic Committee Quarterly Introductory letter
Alaska None - Introductory letter
Arizona* - - Inform health plans directly
Arkansas None - Introductory letter
California Medi-Cal Contract Drug Advisory Committee Ad Hoc Petition with specific content requirements
Colorado None - Introductory letter
Connecticut Pharmacy and Therapeutic Committee (2004) Quarterly Introductory letter
Delaware DUR Board advises Bi-Monthly Introductory letter
District of Columbia N/A - Introductory letter
Florida Pharmacy and Therapeutic Committee - Introductory letter
Georgia Yes Quarterly Introductory letter
Hawaii None - Introductory letter, Formulary kit
Idaho Pharmacy Committee Weekly Introductory letter, Formulary kit
Illinois None - Contact First DataBank
Indiana DUR Board advises Monthly Electronic form
Iowa DUR Board advises Monthly Introductory letter
Kansas DUR Board advises Bi-Monthly Introductory letter
Kentucky Pharmacy & Therapeutic Advisory Committee Bi-Monthly Introductory letter, Package insert
Louisiana Pharmacy Advisory Committee Semiannually Introductory letter
Maine DUR Committee Monthly Introductory letter
Maryland None - Introductory letter
Massachusetts DUR Committee Quarterly Introductory letter
Michigan Pharmacy and Therapeutics Committee Quarterly State form, Introductory letter
Minnesota Drug Formulary Committee Quarterly Introductory letter
Mississippi Pharmacy and Therapeutics Committee Bi-Monthly Introductory letter
Missouri DUR Board & Prior Authorization Committee Quarterly AMPC format dossier
Montana DUR Board advises Monthly Introductory letter
Nebraska None - Introductory letter
Nevada DUR Board Quarterly Introductory letter
New Hampshire None - Information packet
New Jersey None - Introductory letter
New Mexico None - Contact First DataBank
New York Pharmacy Advisory Committee Quarterly Introductory letter
North Carolina Medical Care Advisory Committee - Introductory letter, Package insert
North Dakota None - Manufacturer’s preference
Ohio Pharmacy & Therapeutic Committee Quarterly Introductory letter
Oklahoma DUR Board Monthly E-mail to medicaidrx@ohca.state.ok.us
Oregon DUR Board Quarterly Introductory letter
Pennsylvania Medical Assistance Advisory Committee Monthly Introductory letter
Rhode Island None - Introductory letter
South Carolina None - Formulary packet
South Dakota None - Introductory letter
Tennessee* TennCare Pharmacy Advisory Committee Quarterly Introductory letter
Texas None - State form
Utah DUR Board Monthly Introductory letter, FDA information
Vermont DUR Committee Bi-Monthly Introductory letter
Virginia Pharmacy Liaison Committee Quarterly Introductory letter
Washington Pharmacy and Therapeutics Committee Quarterly AMCP format dossier
West Virginia Medical Services Fund Advisory Council Quarterly Introductory product packet
Introductory letter, First DataBank
Wisconsin None -
notification
Wyoming DUR Board Bi-Monthly Introductory letter

*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 2003 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Pharmacy Benefit Design - Coverage


State Cosmetics Fertility Drugs Experimental Drugs
Alabama Not Covered Not Covered Not Covered
Alaska Covered with Restrictions Not Covered Not Covered
Arizona* - - -
Arkansas Not Covered Not Covered Not Covered
California Not Covered Not Covered Not Covered
Colorado Not Covered Not Covered Not Covered
Connecticut Not Covered Not Covered Not Covered
Delaware Not Covered Not Covered Not Covered
District of Columbia Covered with Restrictions Not Covered Not Covered
Florida Not Covered Not Covered Not Covered
Georgia Not Covered Not Covered Not Covered
Hawaii Not Covered Not Covered Not Covered
Idaho Not Covered Not Covered Not Covered
Illinois Not Covered Not Covered Not Covered
Indiana Not Covered Not Covered Not Covered
Iowa Not Covered Not Covered Not Covered
Kansas Not Covered Not Covered Not Covered
Kentucky Not Covered Not Covered Not Covered
Louisiana Not Covered Not Covered Not Covered
Maine Not Covered Not Covered Not Covered
Maryland Not Covered Not Covered Not Covered
Massachusetts Not Covered Not Covered Not Covered
Michigan Not Covered Not Covered Not Covered
Minnesota Not Covered Not Covered Not Covered
Mississippi Not Covered Not Covered Not Covered
Missouri Not Covered Not Covered Not Covered
Montana Not Covered Not Covered Not Covered
Nebraska Not Covered Not Covered Not Covered
Nevada Not Covered Not Covered Not Covered
New Hampshire Not Covered Not Covered Not Covered
New Jersey Not Covered Not Covered Not Covered
New Mexico Not Covered Not Covered Not Covered
New York Not Covered Not Covered Not Covered
North Carolina Not Covered Not Covered Not Covered
North Dakota Not Covered Not Covered Not Covered
Ohio Not Covered Not Covered Not Covered
Oklahoma Not Covered Not Covered Not Covered
Oregon Not Covered Not Covered Not Covered
Pennsylvania Not Covered Not Covered Not Covered
Rhode Island Not Covered Not Covered Not Covered
South Carolina Not Covered Not Covered Not Covered
South Dakota Not Covered Not Covered Not Covered
Tennessee* Not Covered Not Covered Not Covered
Texas Not Covered Not Covered Not Covered
Utah Not Covered Not Covered Not Covered
Vermont Not Covered Not Covered Not Covered
Virginia Not Covered Not Covered Not Covered
Washington Not Covered Not Covered Not Covered
West Virginia Not Covered Not Covered Not Covered
Wisconsin Not Covered Not Covered Not Covered
Wyoming Not Covered Not Covered Not Covered

*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 2003 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Pharmacy Benefit Design - Coverage (con’t)


Disposable Needles for Syringe Combinations Blood Glucose Test
State Prescribed Insulin Insulin Use for Insulin Use Strips
Alabama Covered Covered Covered Covered as DME
Alaska Covered Covered as DME Covered Not Covered
Arizona* - - - -
Arkansas Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
California Covered Covered Covered Covered
Colorado Covered DME DME DME
Connecticut Covered Covered Covered Covered
Delaware Covered Covered Covered Covered
District of Columbia Covered Covered Covered Not Covered
Florida Covered Covered Covered Covered
Georgia Covered Covered Covered Covered with Restrictions
Hawaii Covered Covered as DME Covered as DME Covered as DME
Idaho Covered Covered Covered Covered as DME
Illinois Covered Covered Covered with Restrictions Covered
Indiana Covered Covered Covered Covered
Iowa Covered Not Covered Not Covered Not Covered
Kansas Covered Covered as DME Covered as DME Covered as DME
Kentucky Covered Not Covered Covered Not Covered
Louisiana Covered Covered Covered Covered
Maine Covered Covered Covered with Restrictions Covered
Maryland Covered Covered Covered Covered as DME
Massachusetts Covered Covered with Restrictions Covered with Restrictions Covered with Restrictions
Michigan Covered Covered Covered Covered
Minnesota Covered Not Covered Covered Not Covered
Mississippi Covered Not Covered Not Covered Not Covered
Missouri Covered Covered Covered Covered
Montana Covered Not Covered Not Covered Not Covered
Nebraska Covered, PA Required Covered as DME Covered (med. necess.) Covered as DME
Nevada Covered Covered Covered Covered
New Hampshire Covered Covered Covered Covered
New Jersey Covered Covered Covered Covered
New Mexico Covered Covered Covered Covered
New York Covered Covered Covered Covered
North Carolina Covered Covered as DME Covered as DME Covered as DME
North Dakota Covered Covered Covered Covered
Ohio Covered Covered as DME Covered as DME Covered as DME
Oklahoma Covered Covered as DME Covered as DME Covered as DME
Oregon Covered Covered as DME Covered as DME Covered as DME
Pennsylvania Covered Covered Covered Covered
Rhode Island Covered Covered Covered Covered as DME
South Carolina Covered Covered Covered Covered as DME
South Dakota Covered Covered Covered Covered
Tennessee* Covered Covered Covered Covered
Texas Covered Covered Covered Not Covered
Utah Covered Covered Covered with Restrictions Covered
Vermont Covered Covered Covered Covered
Virginia Covered Covered Covered Covered
Washington Covered Covered Covered Covered
West Virginia Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Wisconsin Covered Covered Covered Covered
Wyoming Covered Covered Covered Covered

*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 2003 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Pharmacy Benefit Design - Coverage (con’t)


Urine Ketone Total Interdialytic Parenteral
State Test Strips Parenteral Nutrition Nutrition
Alabama Covered as DME Covered as DME Covered as DME
Alaska Not Covered Covered Not Covered
Arizona* - - -
Arkansas Not Covered Not Covered Not Covered
California Covered PA Required Not Covered
Colorado DME PA Required Not Covered
Connecticut Covered Covered with Restrictions Covered with Restrictions
Delaware Covered Covered Covered with Restrictions
District of Columbia Not Covered Covered with Restrictions Covered with Restrictions
Florida Covered with Restrictions Covered Not Covered
Georgia Covered with Restrictions Covered with Restrictions Covered with Restrictions
Hawaii Covered as DME Covered, PA Required Covered, PA Required
Idaho Covered as DME Covered Not Covered
Illinois Covered Covered with Restrictions Covered with Restrictions
Indiana Covered Covered Covered
Iowa Not Covered Not Covered Not Covered
Kansas Covered as DME Covered as DME Covered with Restrictions
Kentucky Not Covered Covered, PA Required Covered, PA Required
Louisiana Covered Covered as DME Covered as DME
Maine Covered Not Covered Not Covered
Maryland Covered as DME Covered Covered
Massachusetts Covered with Restrictions Covered with Restrictions Not Covered
Michigan Covered Covered with Restrictions, PA Covered with Restrictions, PA
required required
Minnesota Not Covered Covered Covered
Mississippi Not Covered Covered Covered
Missouri Covered Covered Covered
Montana Not Covered Not Covered Not Covered
Nebraska Covered as DME Covered as DME Covered as DME
Nevada Covered Covered as DME Covered as DME
New Hampshire Covered Covered Covered
New Jersey Covered Covered Covered
New Mexico Covered Covered Covered
New York Covered Covered Covered
North Carolina Covered as DME Covered Covered
North Dakota Not Covered Covered Not Covered
Ohio Covered as DME Covered Covered
Oklahoma Covered as DME Covered with Restrictions N/A
Oregon Covered as DME Covered, PA Required Covered, PA Required
Pennsylvania Covered Covered Covered
Rhode Island Covered Covered as DME, PA required Covered as DME, PA Required
South Carolina Covered as DME Covered as DME Covered as DME
South Dakota Covered Not Covered Not Covered
Tennessee* Covered Covered Covered
Texas Not Covered Not Covered Not Covered
Utah Covered Covered as DME Covered as DME
Vermont Covered Covered Covered
Virginia Covered Covered Covered
Washington Covered Covered Covered
West Virginia Covered with Restrictions Covered as DME Not Covered
Wisconsin Covered Covered Covered
Wyoming Covered Covered as DME Covered as DME

*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 2003 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Coverage of Injectables
Reimbursement for Non Self-Administered Medicines via
the Prescription Drug Program (PDP) or Physician Payment (PP)

State Physicians Office Home Health Care Extended Care Facility


Alabama PDP PDP PDP
Alaska PP PDP PDP
Arizona* - - -
Arkansas PP PDP PDP
California PP PDP PDP
Colorado PP PDP PDP
Connecticut PP PP PP
Delaware PDP PDP PDP
District of Columbia PP PDP PDP
Florida PDP and PP PDP PDP
Georgia PP PDP PDP
Hawaii PDP and PP PDP PDP
Idaho PP PDP PDP
Illinois PDP and PP PDP PDP
Indiana PDP and PP PDP and PP PDP and PP
Iowa PDP and PP - -
Kansas PP PDP PDP
Kentucky PDP and PP PDP PDP
Louisiana PDP and PP - -
Maine PDP PDP PDP
Maryland PDP and PP PDP PDP
Massachusetts PDP and PP PDP PDP
Michigan PP PDP PDP
Minnesota PP PDP and PP PDP
Mississippi PP PDP PDP
Missouri PDP PDP PDP
Montana PP PDP PDP
Nebraska PP PDP PDP
Nevada PP PDP PDP
New Hampshire PP PDP PDP
New Jersey PP PDP PDP
New Mexico PDP and PP PDP and PP PDP and PP
New York PP PDP Included in facility rate
North Carolina PDP and PP PDP PDP
North Dakota PDP and PP PDP and PP PDP and PP
Ohio PP PDP PDP
Oklahoma PP PDP and PP PDP and PP
Oregon PP PP PP
Pennsylvania PDP PDP PDP
Rhode Island PP PDP PDP
South Carolina PP PDP PDP
South Dakota PP PP PP
Tennessee* PP PDP PDP
Texas PP PP PP
Utah PDP and PP PDP PDP
Vermont PP PP PP
Virginia PDP and PP PDP and PP PDP and PP
Washington PP PDP PDP
West Virginia PDP and PP PDP PDP
Wisconsin PDP and PP PDP PDP
Wyoming PP PP 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 2003 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Coverage of Vaccines and Unit Dose


State Method for Vaccine Reimbursement ^ Reimbursement for Unit Dose
Alabama EPSDT, VCP Yes
Alaska EPSDT, CHIP, VCP Yes
Arizona* - -
Arkansas VCP Yes
California VCP Yes
Colorado EPSDT No
Connecticut CHIP No
Delaware VCP No
District of Columbia EPSDT No
Florida VCP Yes
Georgia EPSDT, VCP Yes
Hawaii EPSDT, CHIP, VCP Yes
Idaho ESPDT, CHIP, VCP, State Vaccine Program Yes
Illinois VCP No
Indiana EPSDT, CHIP, VCP Yes
Iowa EPSDT, VCP Yes
Kansas CHIP, VCP No
Kentucky EPSDT, CHIP, VCP, Pharmacy Program Yes
Louisiana EPSDT, VCP Yes
Maine EPSDT, CHIP, VCP No
Maryland VCP No
Massachusetts EPSDT, Department of Public Health No
Michigan EPSDT, CHIP, VCP Yes
Minnesota EPSDT, CHIP, VCP Yes
Mississippi VCP Yes
Missouri VCP Yes
Montana EPSDT, CHIP, VCP Yes
Nebraska EPSDT, CHIP, VCP No
Nevada EPSDT Yes
New Hampshire EPSDT, CHIP, VCP Yes
New Jersey EPSDT, VCP Yes, LTC
New Mexico EPSDT, CHIP, VCP No
New York EPSDT, CHIP, VCP No
North Carolina EPSDT, VCP No
North Dakota EPSDT No
Ohio VCP No
Oklahoma EPSDT, VCP No
Oregon VCP No
Pennsylvania EPSDT, CHIP, VCP, Pharmacy Services No
Rhode Island VCP, Physician Payment (adults) No
South Carolina VCP Yes
South Dakota VCP Yes
Tennessee* EPSDT, VCP No
Texas EPSDT, CHIP, VCP Yes
Utah EPSDT, CHIP, VCP Yes
Vermont EPSDT Yes
Virginia VCP Yes
Washington EPSDT Yes
West Virginia CHIP, VCP Yes
Wisconsin VCP Yes
Wyoming EPSDT, CHIP, VCP No

^ 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 2003 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Coverage of Over-the-Counter Medications


Allergy, Asthma,
State and Sinus Analgesics Cough and Cold Smoking Deterrents
Alabama Covered Covered Covered Not Covered
Alaska Not Covered Not Covered Not Covered Not Covered
Arizona* - - - -
Arkansas Limited Coverage Limited Coverage Limited Coverage Not Covered
California Limited Coverage Limited Coverage Limited Coverage Covered with Restrictions
Colorado Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Connecticut Covered Not Covered Covered Not Covered
Delaware Covered Covered Covered Covered
District of Columbia Not Covered Covered with Restrictions Not Covered Not Covered
Florida Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
Georgia Not Covered Covered with Restrictions Covered with Restrictions Not Covered
Hawaii Covered Covered Limited Coverage Covered with Restrictions
Idaho Not Covered Not Covered Not Covered Not Covered
Illinois PA Required Covered Not Covered Covered
Indiana Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Iowa Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
Kansas Not Covered Covered Limited Coverage Covered with Restrictions
Kentucky Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
Louisiana Not Covered Not Covered Not Covered Not Covered
Maine Covered Covered Not Covered Covered with Restrictions
Maryland Not Covered Not Covered Not Covered Not Covered
Massachusetts Limited Coverage Limited Coverage Limited Coverage Not Covered
Michigan Limited Coverage Limited Coverage Not Covered Limited Coverage
Minnesota Limited Coverage Limited Coverage Limited Coverage Covered
Mississippi Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Missouri Limited Coverage Limited Coverage Limited Coverage Not Covered
Montana Covered with Restrictions Covered with Restrictions Not Covered Covered with Restrictions
Nebraska Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
Nevada Covered Covered Covered Covered
New Hampshire Covered Covered Covered Covered
New Jersey Covered Covered Limited Coverage Limited Coverage
New Mexico Covered Covered Covered Covered
New York Limited Coverage Limited Coverage Limited Coverage Limited Coverage
North Carolina Covered Limited Coverage Limited Coverage Not Covered
North Dakota Covered with Restrictions Covered Not Covered Covered with Restrictions
Ohio Selective Coverage Selective Coverage Selective Coverage Selective Coverage
Oklahoma Limited Coverage Not Covered Not Covered Covered with Restrictions
Oregon Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Pennsylvania Covered with Restrictions Covered Covered with Restrictions Covered
Rhode Island Covered Covered with Restrictions Covered with Restrictions Not Covered
South Carolina Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
South Dakota Not Covered Not Covered Not Covered Not Covered
Tennessee* Covered Covered Not Covered Not Covered
Texas Covered Covered Covered Covered
Utah Limited Coverage Limited Coverage Limited Coverage Not Covered
Vermont PA Required PA Required PA Required PA Required
Virginia Covered Covered Covered Covered
Washington Limited Coverage Limited Coverage Limited Coverage Not Covered
West Virginia Limited Coverage Limited Coverage Limited Coverage PA Required
Wisconsin Covered with Restrictions Covered Covered with Restrictions Not Covered
Wyoming Covered Covered Covered Not Covered
*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 2003 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Coverage of Over-the-Counter Medications (Con’t)


Digestive Products
State (non- H2 antagonists) H2 Antagonists Feminine Products Topical Products
Alabama Covered Covered Not Covered Covered with Restrictions
Alaska Not Covered Not Covered Limited Coverage Limited Coverage
Arizona* - - - -
Arkansas Limited Coverage Covered Limited Coverage Limited Coverage
California Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Colorado Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Connecticut Covered with Restrictions Covered with Restrictions Not Covered Covered
Delaware Covered Covered Not Covered Covered
District of Columbia Covered with Restrictions Not Covered Not Covered Not Covered
Florida Not Covered Covered with Restrictions Covered with Restrictions Covered with Restrictions
Georgia Not Covered Not Covered Not Covered Not Covered
Hawaii Covered Limited Coverage N/A Limited Coverage
Idaho Not Covered Not Covered Not Covered Not Covered
Illinois PA Required Not Covered Not Covered PA Required
Indiana Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Iowa Not Covered Not Covered Not Covered Covered with Restrictions
Kansas Not Covered Covered Not Covered Covered with Restrictions
Kentucky Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Louisiana Not Covered Not Covered Not Covered Not Covered
Maine Covered Covered with Restrictions Covered Covered
Maryland Not Covered Not Covered Limited Coverage Not Covered
Massachusetts Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Michigan Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Minnesota Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Mississippi Limited Coverage Not Covered Limited Coverage Limited Coverage
Missouri Limited Coverage Not Covered Not Covered Limited Coverage
Montana Covered with Restrictions Covered with Restrictions Not Covered Not Covered
Nebraska Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Nevada Covered Covered Not Covered Covered with Restrictions
New Hampshire Covered Covered Covered Covered
New Jersey Not Covered Not Covered Not Covered Covered
New Mexico Covered Covered Not Covered Covered with Restrictions
New York Limited Coverage Not Covered Limited Coverage Limited Coverage
North Carolina Not Covered Not Covered Not Covered Not Covered
North Dakota Covered Covered Not Covered Not Covered
Ohio Selective Coverage Selective Coverage Selective Coverage Selective Coverage
Oklahoma Limited Coverage Not Covered Not Covered Not Covered
Oregon Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Pennsylvania Not covered Covered with Restrictions Covered Covered
Rhode Island Covered Not Covered Not Covered Covered with Restrictions
South Carolina Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
South Dakota Not Covered Not Covered Not Covered Not Covered
Tennessee* Covered Covered Not Covered Covered
Texas Covered Covered Not Covered Covered
Utah Not Covered Not Covered Limited Coverage Limited Coverage
Vermont PA Required PA Required PA Required PA Required
Virginia Covered Covered Covered Covered
Washington Limited Coverage Limited Coverage Limited Coverage Limited Coverage
West Virginia Limited Coverage Not Covered Limited Coverage Limited Coverage
Wisconsin Covered with Restrictions Not Covered Covered with Restrictions Covered with Restrictions
Wyoming Not Covered Covered Covered Covered

*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 2003 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Prior Authorization Process and Procedures


State PA Procedure Prior Authorization Committee Members Meetings
Alabama Yes Pharmacy & Therapeutics 9 Quarterly
Alaska Yes No - -
Arizona* - - - -
Arkansas Yes DUR Board 9 Quarterly
California Yes No - -
Colorado Yes No - -
Connecticut Yes - - -
Delaware Yes No - -
District of Columbia Yes N/A N/A N/A
Florida Yes No - -
Georgia Yes N/A N/A N/A
Hawaii Yes No - -
Idaho Yes Pharmacy Committee 5 Weekly
Illinois Yes Committee on Drugs and Therapeutics Varies Quarterly
Indiana Yes No - -
Iowa Yes DUR Board 10 Monthly
Kansas Yes No - -
Kentucky Yes Pharmacy and Therapeutics Advisory Committee 14 Bi-monthly
Louisiana Yes Pharmaceutical and Therapeutics Committee 21 Quarterly
Maine Yes No - -
Maryland Yes No - -
Massachusetts Yes No - -
Michigan Yes No - -
Minnesota Yes Drug Formulary Committee 9 Quarterly
Mississippi Yes Pharmacy and Therapeutics Committee 12 Bi-monthly
Missouri Yes Prior Authorization Committee 9 Quarterly
Montana Yes DUR Board 5 Monthly
Nebraska Yes No - -
Nevada Yes No - -
New Hampshire Yes Pharmacy and Therapeutics Advisory Committee 12 Quarterly
New Jersey Yes No - -
New Mexico Yes No - -
New York Yes Pharmacy and Therapeutics Committee 11 Quarterly
North Carolina Yes No - -
North Dakota Yes No - -
Ohio Yes No - -
Oklahoma Yes No - -
Oregon Yes DUR Board 12 Quarterly
Pennsylvania Yes No - -
Rhode Island Yes No - -
South Carolina Yes No - -
South Dakota Yes No - -
Tennessee* Yes No - -
Texas Yes No - -
Utah Yes DUR Board 12 Monthly
Vermont Yes No - -
Virginia Yes No - -
Washington Yes Drug Utilization Review Team 16 Daily
West Virginia Yes Pharmaceutical and Therapeutics Committee 11 Quarterly
Wisconsin Yes Pharmacy Prior Authorization Advisory Comm. 9 As needed
Wyoming Yes DUR Board 12 Bi-monthly

*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 2003 NPC Survey.

4-31
National Pharmaceutical Council Pharmaceutical Benefits 2003

Prior Authorization Process and Procedures (Con’t)


State Initiated By: Annual Requests % Approved
Alabama M.D., R.Ph. N/A N/A
Alaska M.D., R.Ph. 1,550 94%
Arizona* - - -
Arkansas M.D. 155,00 72%
California M.D., R.Ph. 2,400,000 90%
Colorado M.D. 32,000 87%
Connecticut M.D., R.Ph. N/A N/A
Delaware M.D. 36,000 90%
District of Columbia M.D., R.Ph. 9,000 70%
Florida M.D., R.Ph., Pharm. Tech. 440,000 78%
Georgia M.D., R.Ph. 104,000 92%
Hawaii M.D., R.Ph. N/A 99%
Idaho M.D., R.Ph. 24,500 77%
Illinois M.D., R.Ph. 500,000 20%
Indiana M.D., Other Providers N/A N/A
Iowa M.D., R.Ph. 56,000 93%
Kansas M.D., R.Ph. N/A N/A
Kentucky M.D., R.Ph. 285,000 58%
Louisiana M.D. 171,000 95%
Maine M.D. 65,000 82%
Maryland M.D., R.Ph 5,300 99%
Massachusetts M.D. 137,000 67%
Michigan M.D. 120,000 95%
Minnesota M.D., R.Ph., Pharm. Tech. N/A N/A
Mississippi M.D. 216,000 90%
Missouri M.D., R.Ph., Physician Extender 35,000 N/A
Montana M.D., R.Ph., Pharm. Tech. 16,000 70%
Nebraska M.D., R.Ph. 24,000 40%
Nevada M.D. - -
New Hampshire M.D. 870 88%
New Jersey R.Ph., DME Supplier 351,000 97%
New Mexico M.D., R.Ph., Pharm. Tech. 1,300 N/A
New York Ordering Provider 180,000 100%
North Carolina M.D. N/A N/A
North Dakota M.D., R.Ph., Pharm. Tech. N/A N/A
Ohio M.D. 120,000 Most
Oklahoma M.D., R.Ph. 117,000 59%
Oregon M.D. 43,000 66%
Pennsylvania M.D., Other Licensed Prescriber N/A N/A
Rhode Island M.D., R.Ph. N/A N/A
South Carolina M.D. 37,700 60%
South Dakota M.D., R.Ph. 28 100%
Tennessee* M.D. 450,000 66%
Texas M.D., R.Ph., Other Licensed Provider 3,000 75%
Utah M.D. 12,000 50%
Vermont M.D. N/A 99%
Virginia M.D., R.Ph. 50,000 64%
Washington R.Ph., Pharm. Tech. N/A 80%
West Virginia M.D., R.Ph. 160,000 78%
Wisconsin R.Ph. 182,000 97%
Wyoming M.D., R.Ph., Pharm. Tech. 8,200 81%

*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 2003 NPC Survey.

4-32
National Pharmaceutical Council Pharmaceutical Benefits 2003

Prior Authorization Process and Procedures (Con’t)


State Reviewer Review Time Response Vehicle
Alabama R.N., M.D., R.Ph. 24 hours Phone, fax, mail, e-mail
Alaska R.N., R.Ph., Pharm. Tech. 24 hours Phone, fax
Arizona* - - -
Arkansas Voice Response 1-3 minutes Voice response system
California R.Ph. One business day Fax or telephone inquiry system
Colorado Pharm. Tech. 24 hours Phone, fax
Connecticut R.Ph. 2 hours Fax, POS system
Delaware R.Ph. 1 working day Mail
District of Columbia R.Ph., Pharm. Tech. Minutes to 24 hours Phone, fax
Florida R.Ph., Pharm. Tech. 30 minutes-24 hours Phone, fax, mail
Georgia PBM 24 hours or less Phone, mail
Hawaii Pharm. Tech., L.P.N. 24 hours Fax
Idaho M.D., R.Ph., Pharm. Tech. 24 hours or less Phone, fax, mail
Illinois M.D., R.Ph. 4-8 hours Automated phone
Indiana Medicaid Director or designee 10 days Phone, letter
Iowa R.Ph. 24 hours or less Phone, fax
Kansas R.N., R.Ph. 24 hours or less Phone, mail
Kentucky R.N., R.Ph. 4-24 hours Phone, fax
Louisiana R.Ph. 3-5 minutes Phone, fax
Maine M.D. 4 hours Mail
Maryland M.D., R.Ph., Pharm. Tech. 24 hours or less Phone, fax
Massachusetts R.Ph. 24 hours Phone, mail
Michigan M.D., R.Ph., Pharm. Tech. 24 hours or less Phone, fax
Minnesota R.N. Within minutes Phone, mail
Mississippi R.N., R.Ph., Pharm. Tech. 6 hours Phone, fax, mail
Missouri M.D., R.Ph., Pharm. Tech. < 5 minutes Phone, fax, mail
Montana M.D., R.Ph., Pharm. Tech. 24 hours or less Mail
Nebraska M.D., R.Ph., Pharm, Tech. 24 hours Phone, fax, mail
Nevada R.Ph., Pharm. Tech. 24 hours Phone
New Hampshire R.Ph., Pharm. Tech. 24 hours Phone, fax with written follow-up of denials
New Jersey R.N., R.Ph., First Health Minutes Phone
New Mexico R.Ph. 24 hours Phone
New York Voice interactive system Processed during call PA issued to prescriber by phone
North Carolina ACS (PBM) 24 hours Phone, fax, e-mail
North Dakota R.Ph. 24 hours Fax
Ohio R.Ph., Pharm. Tech. Immediate Phone
Oklahoma R.Ph., Pharm. Tech, Pharm. Intern 24 hours Fax, mail
Oregon R.Ph., Pharm. Tech. 24 hours or less Phone, fax
Pennsylvania R.N., M.D. Immediately to 24 hours Phone
Rhode Island R.Ph., Pharm. Tech. Immediately to 24 hours Online adjudication or verbally
South Carolina R.Ph., First Health Per OBRA ‘90 guidelines Phone, fax
South Dakota R.Ph. 24 hours Phone, fax, mail, e-mail
Tennessee* R.Ph. Same day Fax
Texas R.Ph. 72 hours Phone, fax
Utah Nurse 8-12 hours Phone, fax, mail
Vermont R.N. 24 hours Phone, mail
Virginia M.D., R.Ph., Pharm. Tech. Less than 3 minutes Phone, fax, mail
M.D., Drug Utilization Review
Washington <24 hours Phone, fax; denial through mail
Team**
West Virginia R.Ph. 3 minutes to 2 hours Phone, fax
Wisconsin R.Ph., Done electronically Immediate Online
Wyoming ACS Clinical Supervisor 24 hours Phone, fax, mail, e-mail

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
**Reviewer also includes Medical Claims Examiner.
Source: As reported by State drug program administrators in the 2003 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Prior Authorization
Analgesics,
State Anabolic Steroids Antipyretics, NSAIDs Anorectics
Alabama Covered Covered, PA Required 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 Not Covered, PA Required
District of Columbia Not Covered Partial Coverage, PA Required Partial Coverage, PA Required
Florida Covered, PA Required Covered Not Covered
Georgia Covered, PA Required Covered, PA Required Not covered
Hawaii Covered, PA Required Covered, PA Required Covered, PA Required
Idaho Partial Coverage, PA Required Partial Coverage, PA Required Not Covered
Illinois N/A Covered 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 Partial Coverage, PA Required Not Covered
Mississippi Covered Covered, PA Required Not Covered
Missouri Partial Coverage Partial Coverage Not Covered
Montana Covered Partial Coverage, PA Required Partial Coverage, PA Required
Nebraska Covered Partial Coverage, PA Required Not Covered
Nevada Partial Coverage Covered Not Covered
New Hampshire Covered Covered, PA Required Covered, PA Required
New Jersey Partial Coverage Covered PA for ADD Diagnosis
New Mexico Covered Covered Covered, PA Required
New York Covered Covered Not Covered
North Carolina Covered Covered Covered
North Dakota Covered Covered, PA Required Partial Coverage, PA Required
Ohio Not Covered Covered Not Covered
Oklahoma Not Covered Covered, PA Required Partial Coverage, PA Required
Oregon Covered, PA Required Covered Not Covered
Pennsylvania Covered Covered Not Covered
Rhode Island Covered Covered Covered, PA Required
South Carolina Covered Covered Not Covered
South Dakota Covered Covered Covered
Tennessee* Covered Covered, PA Required Covered
Texas Covered Covered Covered
Utah Not Covered Covered, PA Required Not Covered
Vermont Covered Covered Covered
Virginia Covered Covered Covered
Washington Covered, PA Required Covered, PA Required Not Covered
West Virginia Covered Partial Coverage, PA Required 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 = Prior Authorization
Source: As reported by State drug program administrators in the 2003 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Prior Authorization (con’t)


Anxiolytics, Prescribed
State Antihistamines Sedatives, and Hypnotics Cold Medications
Alabama Covered, PA Required Covered Partial Coverage
Alaska Covered Covered Not Covered
Arizona* - - -
Arkansas Partial Coverage, PA Required Covered Partial Coverage
California Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
Colorado Covered Covered Covered, PA Required
Connecticut Covered Covered Covered
Delaware Covered Covered Covered
District of Columbia Covered Covered Covered
Florida Covered Covered Partial Coverage
Georgia Covered Covered, PA Required Partial Coverage
Hawaii Partial Coverage, PA Required Covered N/A
Idaho Partial Coverage, PA Required Covered Partial Coverage
Illinois Partial Coverage Partial Coverage Not Covered
Indiana** N/A N/A N/A
Iowa Covered, PA Required Covered Covered
Kansas Covered Partial Coverage, PA Required Partial Coverage
Kentucky Covered, PA Required Covered, PA Required Covered, PA Required
Louisiana Covered, PA Required Covered, PA Required Partial Coverage
Maine Covered, PA Required Covered, PA Required Not Covered
Maryland Covered Covered Covered
Massachusetts Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage
Michigan Covered Covered Partial Coverage
Minnesota Covered, PA Required Covered Covered
Mississippi Covered, PA Required Covered Partial Coverage
Missouri Partial Coverage Covered, PA Required Partial Coverage
Montana Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage
Nebraska Covered, PA Required Partial Coverage Covered
Nevada Covered Covered Covered
New Hampshire Covered Covered Covered
New Jersey Covered Covered Covered
New Mexico Covered Covered Covered
New York Partial Coverage, PA Required Covered Partial Coverage
North Carolina Covered Covered Covered
North Dakota Covered, PA Required Covered Not Covered
Ohio Partial Coverage, PA Required Covered Partial Coverage, PA Required
Oklahoma Partial Coverage, PA Required Covered, PA Required Not Covered
Oregon Covered, PA Required Covered, PA Required Covered
Pennsylvania Covered Covered Covered
Rhode Island Covered, PA Required Covered Covered
South Carolina Covered Covered Covered
South Dakota Covered Covered Covered
Tennessee* Covered, PA Required Covered Not Covered
Texas Covered Covered Covered
Utah Covered Covered Covered
Vermont Covered Covered Covered
Virginia Covered Covered Covered
Washington Covered, PA Required Covered, PA Required Covered, PA Required
West Virginia Covered Partial Coverage Partial Coverage
Wisconsin Covered, PA Required Covered Covered
Wyoming Covered Covered 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 = Prior Authorization
Source: As reported by State drug program administrators in the 2003 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Prior Authorization (con’t)


Miscellaneous Prescribed
State Growth Hormones GI Products Smoking Deterrents
Alabama Covered, PA Required Covered Not Covered
Alaska Covered, PA Required Covered Not Covered
Arizona* - - -
Arkansas Covered Covered, PA Required Partial Coverage, PA Required
California Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
Colorado Covered, PA Required Covered, PA Required Covered, PA Required
Connecticut Covered Covered Not Covered
Delaware Covered, PA Required Covered Covered, PA Required
District of Columbia Partial Coverage, PA Required Partial Coverage, PA Required Covered
Florida Covered Covered Covered
Georgia Covered, PA Required Covered Not Covered
Hawaii Covered, PA Required Covered Covered, PA Required
Idaho Partial Coverage, PA Required Partial Coverage, PA Required Not Covered
Illinois Covered Covered Covered
Indiana** N/A N/A N/A
Iowa Covered, PA Required Covered, PA Required Not Covered
Kansas Covered, PA Required Covered Partial Coverage
Kentucky Covered, PA Required Covered, PA Required Not Covered
Louisiana Covered, PA Required Covered, PA Required Covered
Maine Covered, PA Required Covered, PA Required Covered, PA Required
Maryland Covered, PA Required Covered Covered
Massachusetts Covered, PA Required Partial Coverage, PA Required Not Covered
Michigan Covered Covered Partial Coverage, PA Required
Minnesota Covered Covered, PA Required Covered
Mississippi Covered Covered, PA Required Covered
Missouri Partial Coverage Partial Coverage, PA Required Not Covered
Montana Partial Coverage, PA Required Covered Partial Coverage, PA Required
Nebraska Covered, PA Required Covered, PA Covered Not Covered
Nevada Partial Coverage, PA Required Covered Covered
New Hampshire Covered Covered, PA Required Covered
New Jersey Partial Coverage Covered Partial Coverage
New Mexico Covered Covered Covered
New York Covered, PA Required Partial Coverage Covered
North Carolina Covered, PA Required Covered Covered, PA Required
North Dakota Covered Covered, PA Required Covered
Ohio Not Covered Partial Coverage, PA Required Partial Coverage, PA Required
Oklahoma Covered, PA Required Covered, PA Required Partial Coverage, PA Required
Oregon Covered, PA Required Covered, PA Required Covered
Pennsylvania Covered Covered Covered
Rhode Island Covered, PA Required Covered, PA Required Not Covered
South Carolina Covered Covered Not Covered
South Dakota Covered, PA Required Covered Partial Coverage
Tennessee* Covered Covered Not Covered
Texas Covered, PA Required Covered Covered
Utah Partial Coverage, PA Required Covered Not Covered
Vermont Covered Covered Covered
Virginia Covered Covered Covered
Washington Covered, PA Required Covered, PA Required Not Covered
West Virginia Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
Wisconsin Covered PA Required Covered Covered
Wyoming Covered Covered, PA Required on PPIs 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 = Prior Authorization
Source: As reported by State drug program administrators in the 2003 NPC Survey.

4-36
National Pharmaceutical Council Pharmaceutical Benefits 2003

Drug Utilization Review


In-House or PRODUR
State State Contact Telephone Contracted Implemented
Alabama Louise Jones 334-242-5039 Contracted Jul-96
Alaska Dave Campana, R.Ph. 907-334-2425 Contracted Jun-95
Arizona* - - - -
Arkansas Pamela Ford, P. D. 501-683-4120 Contracted Mar-97
California Vic Walker, R.Ph., B.C.P.P. 916-552-9500 Contracted Aug-95
Colorado Catherine Traugott 303-866-2468 Contracted Dec-98
Connecticut James Zakszewski, R.Ph. 860-424-4961 Contracted Sep-96
Delaware Cynthia Denemark, R.Ph. 302-453-8453 Contracted Feb-94
District of Columbia Donna Bovell, R.Ph. 202-442-5988 In-House Sep-96
Florida Linda Barnes 850-487-4441 Contracted Jul-93
Georgia Jean Cox, R.Ph. 404-657-7241 In-House Oct-00
Hawaii Kathleen Kang-Kaulupali 808-692-8065 In-House 1997
Idaho Tamara Eide, Pharm.D., B.C.P.S. 208-364-1821 Contracted Jan-98
Illinois Marvin Hazelwood 217-524-5565 In-House Jan-93
Indiana Karen Clifton 317-232-4307 Contracted Mar-96
Iowa Julie Kuhle, R.Ph. 515-270-0713 Contracted Jul-97
Kansas Vicki Schmidt 785-274-4287 Contracted Nov-96
Kentucky Debra Bahr, R.Ph. 502-564-7940 In-House 1987
Louisiana Mary J. Terrebonne, P.D. 225-342-9768 Contracted Apr-66
Maine Jude Walsh 207-287-1815 Contracted Dec-95
Maryland Judith Geisler, P.D. 410-767-1455 Contracted Jan-93
Massachusetts Paul L. Jeffrey 617-210-5319 Contracted Oct-95
Michigan Debera Eggleston, M.D. 517-335-5181 Contracted Jul-00
Minnesota Mary Beth Reinke, Pharm.D., R. Ph. 651-215-1239 In-House Feb-96
Mississippi Judith P. Clark, R.Ph. 601-359-5253 Contracted Oct-93
Missouri Jayne Zemmer 573-751-1612 In-House Feb-93
Montana Mark Eichler, R.Ph. 406-443-4020 Contracted Sep-94
Nebraska Beth Wilson 402-420-1500 Contracted Apr-95
Nevada Dionne Coston, R.N. 702-684-3775 Contracted 2003
New Hampshire Lisè Farrand 603-271-4419 Contracted Jul-95
New Jersey Edward Vaccaro, R.Ph. 609-588-2726 In-House Oct-96
New Mexico Neal Solomon, M.P.H., R.Ph. 505-827-3174 Both Oct-93
New York Lydia Kosinski, R.Ph. 518-474-6866 In-House Mar-95
North Carolina Sharman Leinwand, R.Ph., M.P.H. 919-857-4034 Contracted Oct-96
North Dakota Brendan K. Joyce, Pharm.D., R. Ph. 701-328-1544 In-House Jul-96
Ohio Jan Lawson 614-466-9698 Both Feb-00
Oklahoma Ronald Graham, D.Ph. 405-271-6614 Contracted 2000
Oregon Kathy L. Ketchum, R.Ph., M.P.A 503-494-1589 Contracted Mar-94
Pennsylvania N/A - Contracted Jun-93
Rhode Island Paula Avarista, R.Ph. 401-4642-6390 Contracted Dec-94
South Carolina Caroline Sojourner, R.Ph. 803-898-2876 Contracted Nov-00
South Dakota Michael Jockheck, R.Ph. 605-773-6439 In-House 1996
Tennessee* Jeffrey G. Stockard, D.Ph. 615-532-3107 Contracted Jul-01
Texas Barbara Dean 512-491-1101 In-House Feb-95
Utah Duane Parke 801-538-6452 In-House 1994
Vermont Scott Strenio, M.D. 802-741-7975 Contracted Nov-93
Virginia Javier Menendez, R.Ph. 804-783-2196 Contracted Jul-94
Washington Nicole Nguyen, Pharm.D. 360-725-1757 In-House Mar-96
West Virginia Vicki M. Cunningham, R.Ph. 304-588-1700 Contracted Mar-95
Wisconsin Michael Mergener, R.Ph., Ph.D. 608-258-3348 Contracted 2001
Wyoming Debra Devereuax, R.Ph. 307-766-6750 Contracted Oct-95
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
PRODUR = Prospective Drug Utilization Review System
Source: As reported by State drug program administrators in the 2003 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Prescribing/Dispensing Limits
Limits on
State Rx Limits on Number, Quantity, and Refills of Prescriptions
Alabama Yes 5 refills per Rx, 30 day supply per Rx
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; 100 day supply for maint. meds. Other limits for stadol & oxycontin
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 31 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
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 5 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; 5 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.
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)
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 12 refills per script; Limits on refills by Class
Ohio No -
Oklahoma Yes 3 Rx 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 No -
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
Utah Yes 7 Rx per month, 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; 5 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 2003 NPC Survey.

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PHARMACY PAYMENT AND PATIENT COST SHARING

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.

PATIENT COST SHARING

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:

• Services furnished to individuals under 18 years of age (or up to 21 at State option);


• Pregnancy-related services (or, at State option, any service provided to pregnant women);
• Services provided to certain institutionalized individuals, who are required to spend all of
their income for medical care except for a personal needs allowance;
• Emergency services;
• Family planning services and supplies;
• Services furnished to categorically needy HMO enrollees (or, at State option, services
provided to both categorically needy and medically needy HMO enrollees).
In addition, the law prohibits imposing more than one type of charge on any service.

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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Pharmacy Payment and Patient Cost Sharing


State Dispensing Fee Ingredient Reimbursement Basis Copayment
Alabama $5.40 AWP- 10%; WAC+9.2% $0.50 - $3.00
Alaska $3.45 minimum AWP-5% $2.00
Arizona* - - -
Arkansas $5.51 B; AWP-14%, G; AWP-20% $0.50 - $5.00
California $4.05 AWP-10% $1.00
Colorado $4.00; $1.89 for Institutions AWP-13.5% or WAC+18%, whichever is lowest; $3.00
AWP-35% (for generics)
Connecticut $3.30 AWP-12% $1.50
Delaware $3.65 AWP-14; AWP-16% (LTC)% None
DC $4.50 AWP-10% $1.00
Florida $4.23-$4.73 (LTC) AWP-13.25%; WAC+7% None
Georgia $4.63 + $0.50 (for generics) AWP-10% G/P: $0.50, B/NP: $0.50 - $3.00
Hawaii $4.67 AWP-10.5% None
Idaho $4.94 ($5.54 for unit dose) AWP-12% None
Illinois G: $5.10, B: $4.00 B: AWP-11%, G: AWP-20% $1.00
Indiana $4.90 B: AWP-13.5%, G: AWP-20% $0.50 - $3.00
Iowa $4.26 AWP-12% $0.50-$3.00
Kansas $3.40 B: AWP-15%, G: AWP-27% IV AWP-50%, blood $3.00
AWP-30%
Kentucky $4.51 AWP-12% $1.00
Louisiana $4.45 (avg.) to $5.77 AWP-13.5% (AWP-15% for chains) $0.50 - $3.00
Maine $3.35 - $12.50 AWP-15% $2.50,
Max $25/recipient/pharm./month
Maryland $3.69-$5.65 Lowest of :WAC+9%, direct+9%, AWP-11% $2.00 for Brand not on PDL
Massachusetts $3.50 - $5.00 WAC+6% B: $3.00, G: $1.00
Michigan $3.77 AWP-13.5% (1-4 stores), AWP-15.1% (5+stores) $1.00 (adults)
Minnesota $3.65 AWP-11.5% B: $3.00, G: $1.00
Mississippi $3.91 AWP-12% $1.00 - $3.00
Missouri $4.09 - $8.19 AWP-10.43%, WAC+10% $0.50 - $2.00, $5.00 for some
1115 waiver pop.
Montana $2.00 - $4.70 AWP-15% $1.00 - $5.00
Nebraska $3.27 - $5.00 AWP-11% $2.00
Nevada $4.76 AWP-15% None
New Hampshire $1.75 AWP-16% B: $2.00, G: $1.00
New Jersey $3.73 - $4.07 AWP-10%, WAC+30%, AAC for injectables None
New Mexico $3.65 AWP-12.5% None (except $2.00 for CHIP and
working disabled)
New York B: $3.50 G: $4.50 AWP-12% G: $0.50, B: $2.00
North Carolina B: $4.00 G: $5.60 AWP-10% G: $1.00, B: $3.00
North Dakota $5.10 AWP-10% $3.00 (Brand)
Ohio $3.70 WAC + 9% None
Oklahoma $4.15 AWP-12.0% $1.00 - $2.00
Oregon Retail: $3.50 Inst./NF: $3.80 AWP-15% (retail), AWP-11% (institutional) B: $3.00, G: $2.00
Pennsylvania $4.00 ($5.00 for compounds) AWP-10% $1.00 ($2.00 for General Assist.)
Rhode Island OP: $3.40, LTC: $2.85 WAC+5% None
South Carolina $4.05 AWP-10% $3.00
South Dakota $4.75 ($5.55 for unit dose) AWP-10.5% $2.00
Tennessee* $2.50 AWP-13% Medicaid: None;
Other: $5/$10 Based on Income
Texas (EAC+$5.14)/0.98 & delivery fee AWP-15% or WAC+12%, whichever is lowest None
Utah $3.90 (urban), $4.40 (rural) AWP-15% $3.00
Vermont $4.25 AWP-11.9% B: $3.00, G: $1.00
Virginia $3.75 AWP-10.25% B: $3.00, G: $1.00
Washington $4.20-$5.20 (based on annual # of Rx) AWP-14% None
West Virginia $3.90 (+ extra $1.00 for compounding) AWP-12% $0.50 - $2.00
Wisconsin $4.88 (to a maximum $40.11) AWP-12% $1.00-$3.00, max
$5/recip/pharm/mo
Wyoming $5.00 AWP-11% $2.00
WAC = Wholesalers Acquisition Cost; AWP = Average Wholesale Price; EAC = Estimated Acquisition Cost; AAC= Actual Acquisition Cost;
G = Generic; B = Brand Name; OP = Outpatient; LTC = Long Term Care; P = Preferred; NP = Non-Preferred; PDL= Preferred Drug List
*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 2003 NPC Survey.

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Maximum Allowable Cost (MAC) Programs

Federal State-Specific
State Upper Limits Upper Limits MAC Override Provisions
Alabama Yes Yes Brand medically necessary
Alaska Yes No Brand medically necessary and reason for medical necessity
Arizona* - - -
Arkansas Yes Yes MedWatch form for prior authorization
California Yes Yes Medically necessary and other products unavailable at MAC rate
Colorado Yes Yes Prior authorization with medical necessity
Connecticut No Yes -
Delaware Yes Yes MedWatch form for prior authorization
District of Columbia Yes No Brand medically necessary plus prior authorization
Florida Yes Yes MedWatch form and prior authorization request
Georgia Yes Yes Prior authorization
Hawaii Yes Yes Prior authorization
Idaho Yes Yes Failure of 2 generics plus MedWatch form
Illinois Yes Yes Prior authorization request by M.D. or R.Ph.
Indiana Yes Yes Brand medically necessary, prior authorization
Iowa Yes Yes Brand medically necessary, MedWatch form and prior authorization
Kansas Yes Yes Dispense as written
Kentucky Yes Yes Brand necessary, brand medically necessary, PA on some drugs
Louisiana Yes Yes Brand necessary, brand medically necessary
Maine Yes Yes Prior authorization
Maryland Yes Yes Brand medically necessary and reason for medical necessity
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. No pre-printed DAW allowed.
Mississippi Yes No Brand medically necessary or prior authorization for brand multi-source
Missouri Yes Yes Prior authorization and MedWatch form
Montana Yes No Brand necessary, prior authorization
Nebraska Yes Yes Medically necessary
Nevada No No Brand medically necessary
New Hampshire Yes Yes Brand medically necessary
New Jersey Yes No Brand medically necessary
New Mexico Yes Yes Medically 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
Oregon Yes Yes Brand medically necessary and documentation of generic intolerance
Pennsylvania Yes Yes Brand necessary, brand medically necessary, plus prior authorization
Rhode Island Yes No Brand medically necessary with medical justification
South Carolina Yes Yes Brand medically necessary w/cert. by prescriber and P.A.
South Dakota Yes Yes Brand medically necessary
Tennessee* Yes Yes -
Texas Yes Yes Dispense as written, medically necessary, brand medically necessary
Utah Yes Yes Dispense as written, medically necessary, brand medically necessary
Vermont Yes Yes Dispense as written
Virginia No Yes Dispense as written
Washington Yes Yes Medically necessary, brand medically necessary
West Virginia Yes No Brand medically necessary (hand written by prescriber)
Wisconsin No Yes Brand medically necessary
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 2003 NPC Survey.

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Mandatory Substitution

Incentive Fee for Dispensing of Generic Dispensing of Lowest Cost


State Generic Substitution Multi-Source Required Multi-Source Required
Alabama No No No
Alaska No Yes No
Arizona* - - -
Arkansas $2.00 Yes Yes
California No No Yes
Colorado No No No
Connecticut $0.50 Yes No
Delaware No Yes No
District of Columbia No Yes Yes
Florida No Yes No
Georgia $0.50 Yes (brand PA required) No
Hawaii No - No
Idaho No Yes No
Illinois No No Yes
Indiana No Yes Yes
Iowa No Yes Yes
Kansas No No No
Kentucky No Yes Yes
Louisiana No No No
Maine No Yes No
Maryland Yes Yes Yes
Massachusetts No Yes No
Michigan No No No
Minnesota No Yes Yes
Mississippi No Yes No
Missouri No Yes Yes
Montana No Yes No
Nebraska No No No
Nevada No Yes No
New Hampshire No Yes No
New Jersey No Yes No
New Mexico No No No
New York $1.00 Yes No
North Carolina No Yes Yes
North Dakota No No No
Ohio No No No
Oklahoma No Yes No
Oregon No Yes No
Pennsylvania No Yes No
Rhode Island No Yes No
South Carolina No Yes No
South Dakota $10.00 No No
Tennessee* Yes Yes Yes
Texas No Yes No
Utah No Yes Yes
Vermont No Yes No
Virginia No Yes No
Washington No Yes No
West Virginia No Yes No
Wisconsin No Yes No
Wyoming No Yes No

*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 2003 NPC Survey.

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Counseling Requirements and Payment for Cognitive Services

Medicaid Payment
State Patient Counseling Required1 for Cognitive Services2
Alabama All Yes (Clozaril case management)
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 Yes (HIV, mental health, diabetes, hypertension)
Georgia All No
Hawaii Medicaid Only No
Idaho All No
Illinois All No
Indiana All No
Iowa All No
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 Yes (Clozaril monitoring)
Mississippi All Yes
Yes (diabetes, asthma, heart failure, and depression
Missouri All
education)
Montana All No
Nebraska All No
Nevada All No
New Hampshire All No
New Jersey All Yes
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)
West Virginia All No
Wisconsin All Yes
Wyoming All No

Source: 12002-2003 National Association of Boards of Pharmacy Law, Survey of Pharmacy Law; 2 As reported by State drug
program administrators in the 2003 NPC Survey.

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Prescription Price Updating

State Contact Telephone Updated


Alabama Beverly Churchwell 334-242-5034 Biweekly
Alaska Dave Campana 907-334-2425 Weekly
Arizona* - - -
Arkansas First DataBank 650-588-5454 Weekly
California EDS Federal Corp. 916-636-1000 Monthly
Colorado Martha Warner 303-866-3176 Weekly
Connecticut James Heuschkel 860-424-5347 Weekly
Delaware Dan Cohn 302-453-8453 Weekly
District of Columbia Glenn Sharp 804-965-7447 Monthly
Florida First DataBank 650-588-5454 Weekly
Georgia Express Scripts 952-837-5326 Weekly
Hawaii First DataBank 800-633-3453 Weekly
Idaho Katie Ayad 208-364-1970 Biweekly
Illinois First DataBank 650-588-5454 Weekly
Indiana First DataBank 650-588-5454 Weekly
Iowa Sherry Swanson 515-327-0950 Weekly
Kansas Mary H. Obley 785-296-8406 Weekly
Kentucky Unisys Provider Services 502-226-1140 Weekly
Louisiana Maggie Vick, Unisys Corp. 225-237-3251 Weekly
Maine Jude Walsh 207-287-1815 Weekly
Maryland First DataBank 650-588-5454 Weekly
Massachusetts First DataBank 650-588-5454 Weekly
Michigan First Health Service Corp. 877-864-9014 Weekly
Minnesota First DataBank 650-588-5454 Weekly
Mississippi Judith P. Clark, R.Ph. 601-359-5253 Weekly
Missouri First DataBank 650-588-5454 Weekly
Montana First DataBank 650-588-5454 Weekly
Nebraska First DataBank 650-588-5454 Weekly
Nevada First DataBank 650-588-5454 Monthly
New Hampshire First Health Services Corp. 800-884-2822 Weekly
New Jersey First DataBank 650-588-5454 Weekly
New Mexico Neil Solomon, M.P.H., R.Ph. 505-874-3174 Weekly
New York Carl Cioppa, Pharm.D.. 518-474-9219 Monthly
North Carolina Sharon Greeson, R.Ph.. 919-816-4475 Weekly
North Dakota Brendan K. Joyce, Pharm.D., R.Ph. 701-328-1544 Biweekly
Ohio First DataBank 650-588-5454 Monthly
Oklahoma First DataBank 800-633-3453 Weekly
Oregon First Health Service Corp. 503-391-1980 Biweekly
Pennsylvania First DataBank 800-633-3453 Monthly
Rhode Island Paula Avarista, R.Ph. 401-462-6390 Biweekly
South Carolina First DataBank 650-588-5454 Weekly
South Dakota Mark Petersen, R.Ph. 605-773-3495 Biweekly
Tennessee* First DataBank 650-588-5454 Weekly
Texas Martha McNeill, R.Ph. 512-491-1157 Continuously
Utah RaeDell Ashley, R.Ph. 801-538-6495 Bimonthly
Vermont Christine Dapkiewicz 802-879-4450 Biweekly
Virginia Javier Menendez, R.Ph. 804-786-2196 Weekly
Washington Tom Zuchlewski 360-725-1837 Weekly
West Virginia Becky Garrigan 770-352-8592 Weekly
Wisconsin First DataBank 800-633-3453 Biweekly
Wyoming First DataBank 800-633-3453 Weekly
*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 2003 NPC Survey.

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Section 5:
State Pharmacy Program
Profiles

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Profiles of State Medicaid Drug Programs


In the following State profiles, we present a general overview of the characteristics of State
programs together with detailed information on the pharmaceutical benefits provided. Specifically,
the following information is provided for each State:
A. Benefits Provided and Groups Eligible
B. Expenditures for Drugs
C. Administration
D. Provisions Relating to Drugs, including:
• Drug Benefit Product Coverage
• Over-the-Counter Product Coverage
• Therapeutic Category Coverage
• Coverage of Injectables, Vaccines, and Unit Dosing
• Formulary/Prior Authorization
• Prescribing or Dispensing Limitations
• Drug Utilization Review
• Dispensing Fee
• Ingredient Reimbursement Basis
• Prescription Charge Formula
• Maximum Allowable Cost
• Incentive Fee
• Patient Cost Sharing
• Cognitive Services
E. Use of Managed Care
F. State Contacts

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ALABAMA 1

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 ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $392,482,787 464,695 $452,269,953

RECEIVING CASH ASSISTANCE TOTAL $282,959,267 214,351


Aged $38,349,615 26,574
Blind/Disabled $227,824,175 126,146
Child $9,041,169 45,067
Adult $7,744,308 16,564

MEDICALLY NEEDY, TOTAL $0 -


Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $44,308,667 201,784


Aged $711,972 619
Blind/Disabled $830,003 695
Child $41,406,319 190,910
Adult $1,360,373 9,560

TOTAL OTHER EXPENDITURES/RECIPIENTS* $65,214,853 48,560


*Total other expenditures/recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
** 2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

1
The State of Alabama 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 check with the Alabama Medicaid program to assess the accuracy and currency of the information
included.

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Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.


C. ADMINISTRATION
Formulary/Prior Authorization
Alabama Medicaid Agency.
Formulary: Open formulary with preferred drug list.
D. PROVISIONS RELATING TO DRUGS Prior authorization required for non-preferred drugs.
Anti-psychotics and HIV/AIDs drugs are exempted
from the prior authorization requirements. (For
Benefit Design additional information see: www.medicaid.state.al.us.
Drug Benefit Product Coverage: Products covered:
prescribed insulin, disposable needles used for Prior Authorization: State currently has a formal
insulin; and syringe combinations for insulin prior authorization procedure. Review by Medicaid’s
(considered OTC). Products covered as DME: blood Medical Director required for appeal of prior
glucose test strips; urine ketone test strips; total authorization decisions.
parenteral nutrition; and interdialytic parenteral
nutrition. Prior authorization required for: Retin A, Prescribing or Dispensing Limitations
Accutane, Dipyridamole. Products not covered:
cosmetics; fertility drugs; experimental drugs; drugs Prescription Refill Limit: 30 day supply, maximum of
for anorexia or weight gain; hair growth products; five refills.
and DESI drugs.

Over-the-Counter Product Coverage: Products Drug Utilization Review


covered if prescribed by a physician: allergy, asthma
and sinus products; analgesics; cough and cold PRODUR system implemented in July 1996. State
preparations; digestive products; prenatal vitamins; currently has a DUR Board with a quarterly review.
hemorrhoidal products. Partial coverage for: topical
products. Products not covered: smoking deterrent
Pharmacy Payment and Patient Cost Sharing
products and feminine products.
Dispensing Fee: $5.40.
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; anoretics;
Ingredient Reimbursement Basis: AWP-10%, WAC
antibiotics; anticoagulants; anticonvulsants;
+ 9.2%.
antidepressants; antidiabetic agents; antilipemic
agents; anxiolytics, sedatives, and hypnotics; cardiac
Prescription Charge Formula: Medicaid pays for
drugs; chemotherapy agents; estrogens; hypotensive
prescribed legend and non-legend drugs authorized
agents; misc. GI drugs; sympathominetics
under the program based upon and shall not exceed
(adrenergic) and thyroid agents. Partial coverage for:
the lowest of:
anti-psychotics; prescribed cold medications; and
contraceptives. Prior authorization required for: 1. The Maximum Allowable Cost (MAC) of the
analgesics, antipyretics, and (brand name) NSAIDs; drug plus a dispensing fee,
antihistamine drugs (adult only); ENT anti-
inflammatory agents; growth hormones; and 2. The Estimated Acquisition Cost (EAC) of the
nutritional supplements. Therapeutic categories not drug plus a dispensing fee, or
covered: prescribed smoking deterrents. 3. The provider’s usual and customary charge to
the public for the drug.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program Maximum Allowable Cost: State imposes Federal
when used in physician offices, home health care, Upper Limits as well as State-specific limits on
and extended care facilities. generic drugs. Override requires “Brand Medically
Necessary” in the physician’s own handwriting.
Vaccines: Vaccines reimbursable as part of the
EPSDT service and the Vaccines for Children Incentive Fee: None.
Program. Adult vaccines are available through the
Health Department. Patient Cost Sharing: Tiered copayment.

Unit Dose: Unit dose packaging reimbursable. Drug Ingredient Cost Copayment
$0.00 to $10.00 $0.50
$10.01 to $25.00 $1.00

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$25.01 to $50.00 $2.00


$50.01 or more $3.00
Exemptions: No copayment amount is to be collected
by the pharmacy or paid by the recipient for New Brand Name Products Contact
recipients under age 18, pregnant or living in nursing
Louise F. Jones
facilities.
334/242-5039
Cognitive Services: Clozaril care management fee of
Prescription Price Updating
$3.00.
Beverly R. Churchwell, Administrator
E. USE OF MANAGED CARE Alabama Medicaid Agency
501 Dexter Avenue
Does not use MCOs to deliver services to Medicaid P.O. Box 5624
recipients. Montgomery, AL 36103-5424
T: 334/242-5034
F. STATE CONTACTS F: 334/353-7014
E-mail: bchurchwell@medicaid.state.al.us

State Drug Program Administrator


Medicaid Drug Rebate Contact
Louise F. Jones
Pharmacy Program Manager Gladys Gray, Associate Director
Alabama Medicaid Agency Alabama Medicaid Agency
501 Dexter Avenue 501 Dexter Avenue
P.O. Box 5624 P.O. Box 5624
Montgomery, AL 36103-5624 Montgomery AL 36103-5624
T: 334/242-5039 T: 334/242-2327
F: 334/353-7014 F: 334/353-7014
E-mail: lljones@medicaid.state.al.us E-mail: ggray@medicaid.state.al.us
Internet address: www.medicaid.state.al.us
Claims Submission Contact
Prior Authorization Contact Cyndi Crocket, Supervisor
Louise F. Jones EDS
334/242-5039 301 Technacenter Dr.
Montgomery, AL 36117
334/215-0111
DUR Contact
Louise Jones Medicaid Managed Care Contact
334/242-5039
Kim Davis-Allen, Director
Managed Care
Medicaid DUR Board Alabama Medicaid Agency
John Searcy, M.D. 501 Dexter Avenue
Jimmy Jackson, R.Ph. Montgomery, AL 36103-5624
Johnny Brooklere, R.Ph. 334/242-5011
John E. Brandon, M.D.
Kathy B. Portner, M.D. Mail Order Pharmacy Program
Richard Freeman, M.D.
Gary Magouirk, M.D. None
Roger Lander, Pharm.D. (Vice-chair) Disease Management Program/Initiative
Frank Skinner, R.Ph. Contact
W. Thomas Geary, Jr., M.D. (Chair)
Steven Rostand, M.D. Mary H. Finch
Margaret Thrower, Pharm.D. Associate Medical Director
Rob Colburn, R.Ph. Alabama Medicaid Agency
Jefferson Underwood, III, M.D. 501 Dexter Avenue
Montgomery, AL 36103-5624

Alabama-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

334/242-5610

Alabama-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Alabama Medicaid Agency Officials Medical Association of State of Alabama


Marsha D. Raulerson, M.D.
Mike Lewis
1205 Belleville Avenue
Commissioner
Brewton, AL 36426-1304
Alabama Medicaid Agency
251/867-3609
501 Dexter Avenue
P.O. Box 5624
Wilburn Smith, Jr., M.D.
Montgomery, AL 36103-5624
2023 Normandie Drive
T: 334/242-5600
Montgomery, AL 36111
F: 334/242-0556
334/281-2633
E-mail: Almedicaid@medicaid.state.al.us
Internet address: www.medicaid.state.al.us
Cary J. Kuhlmann, Executive Director
Medical Association of the State of Alabama
John Searcy, M.D.
P.O. Box 1900-C
Medical Director
Montgomery, AL 36104
Alabama Medicaid Agency
334/263-6441
501 Dexter Avenue
P.O. Box 5624
Alabama Nursing Home Association
Montgomery, AL 36103
Mr. Louis E. Cottrell, Jr., Executive Director
334/242-5619
4156 Carmichael Road
Montgomery, AL 36106
Title XIX Medical Care Advisory Committee 334/271-6214
Alabama State Government Representatives Alabama State Medical Association
Dr. Milissa Mauser-Galvin Roosevelt McCorvey, M.D.
Executive Director, Department of Senior Services 3088 Rosa L. Parks Avenue
P.O. Box 301851 Montgomery, AL 36105
Montgomery, AL 36130-1851 334/262-0259
334/242-5743
J.A. Powell, M.D.
Bill Fuller, Commissioner 2212 Mallard Lane SE
Alabama Department of Human Resources Decatur, AL 35602
50 Ripley Street, 2nd Floor 256/340-1068
Montgomery, AL 36130
334/242-1160 Alabama Chap. Am. Academy of Family Physicians
Holly Midgley, Executive Vice President
Kathy Sawyer, Commissioner P.O. Box 1900
Alabama Department of Health and Mental 19 South Jackson Street
Retardation Montgomery, AL 36102-1900
P.O. Box 301410 334/263-6441
Montgomery, AL 36130-1410
334/242-3107 Alabama Pharmacy Association
William S. Eley, II, Executive Director
Donald Williamson, M.D. 1211 Carmichael Road
State Health Officer Montgomery, AL 36106
P.O. Box 303017 334/271-4222
Montgomery, AL 36130-3017 Page Dunlap
334/206-5200 P.O. Box 354
Hartselle, AL 35640
Steve Shivers 256/773-5421
Alabama Department of Rehabilitation Services
2129 East South Boulevard Alabama Chap. American Academy of Pediatrics
Montgomery, AL 36116-2455 Karin Scott, Executive Director
334/281-8780 735 Montgomery Highway, Suite 323
Birmingham, AL 35216
205/824-0888

Alabama-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Alabama Dietetic Association Alabama State Nurses Association


Gayle Mask Karen Pakkala, Executive Director
Alabama Department of Public Health 360 North Hill Street
RSA Tower, Suite 1300 Montgomery, AL 36104-3658
P.O. Box 303017 334/262-8321
Montgomery, AL 36130-3017
334/206-2922 Consumer Representatives
Lawrence F. Gardella
Alabama Hospital Association Senior Staff Attorney
J. Michael Horsley, President Montgomery Regional Office
East Station Legal Services Corporation of Alabama
P.O. Box 210759 600 Bell Building, 207 Montgomery Street
Montgomery, AL 36121 Montgomery, AL 36104
334/272-8781 334/832-4570

Jody Pigg, CEO Bill Chandler


Baptist Health Services General Director
P.O. Box 11010 Montgomery YMCAs
Montgomery, AL 36111-0010 P.O. Box 2336
334/273-4404 Montgomery, AL 36102-2336
334/269-4362
Alabama Optometric Association
Teresa Easterling
Amanda Jones, Executive Director
325 Spigener Road
400 South Union Street, Suite 435
Titus, AL 36080
Montgomery, AL 36104
334/567-5020
334/834-1057
Linda McWilliams
Alabama Association of Home Health Agencies
Top of Alabama Regional Council of Governments
Melane Golson
(TARCOG)
Office of Executive Director
115 Washington Street, SE
P.O. Box 40
Huntsville, AL 35801
Montgomery, AL 36101
205/533-3330
334/395-9949
Rogene W. Parris
Alabama Primary Health Care Association
2061 Fire Pink Court
Al Fox, Executive Director
Birmingham, AL 35244
6008 East Shirley Lane, Suite A
205/987-0338
Montgomery, AL 36117
334/271-7068
Louise Pittman
3355 Lexington Road
Alabama Academy of Ophthalmology
Montgomery, AL 36106
Leigh Jones
334/264-8780
P.O. Box 11455
Montgomery, AL 36111-0455
334/269-9900 Pharmacy and Therapeutics Committee

Assisted Living Association of Alabama A. Z. Holloway, M.D.


Frank Holden, President Richard Freeman, M.D.
400 S. Union Street, Suite 235 Ben Main, R.Ph.
Montgomery, AL 36104 Gary Magouirk, M.D.
334/262-5523 David Herrick, M.D.
Jackie Feldman, M.D.
Alabama Hospice Organization Melanie Smith, R.Ph.
David Stone, Executive Director Mary McIntyre, M.D.
P.O. Box 1835 Jefferson Underwood, III, M.D.
Calera, AL 35040 Rob Colburn, R.Ph.
205/668-0460

Alabama-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

Executive Officers of State Medical and Alabama Independent Drugstore Association (AIDA)
Pharmaceutical Societies Sharon Taylor, Executive Director
400 Interstate Park Drive
Medical Association of the State of Alabama (MASA)
Suite 401
Cary Kuhlmann
Montgomery, AL 36109
Executive Director
T: 334/213-2432
19 S. Jackson Street
F: 334/213-2406
P.O. Box 1900
E-mail: Sharon@aidarx.org
Montgomery, AL 36102-1900
Internet address: www.aidarx.org
T: 334/954-2500
F: 334/269-5200
Alabama Hospital Association
E-mail: cary@masalink.org
Tom Cooper, CEO
Internet address: www.masalink.org
500 North East Blvd.
Montgomery, AL 36117
Alabama Osteopathic Medical Association
T: 334/272-8781
E. Jason Hatfield, D.O.
F: 334/270-9527
Secretary -Treasurer
E-mail: tcooper@alaha.org
P.O. Box 1857
Internet address: www.alaha.org
U.S. Highway 43
Winfield, AL 35594
T: 205/487-7556
F: 205/487-7559
Internet address: www.aloma.org

Alabama State Medical Association


Joel Powell, M.D., President
1408 5th Avenue, SE, Suite 1
Decatur, AL 35601
T: 256/340-9445
F: 256/350-0499

Alabama Pharmacy Association (APA)


William S. Eley, II
Executive Director
1211 Carmichael Way
Montgomery, AL 36106-3672
T: 334/271-4222
F: 334/271-5423
E-mail: aparx@aparx.org
Internet address: www.aparx.org

State Board of Pharmacy


Jerry Moore
Executive Director
1 Perimeter Park South, Suite 425 S
Birmingham, AL 35243
T: 205/967-0130
F: 205/967-1009
E-mail: jmoore@albop.com
Internet address: www.albop.com

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National Pharmaceutical Council Pharmaceutical Benefits 2003

ALASKA

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 ‹ ‹ ‹ ‹

B. DRUG PAYMENTS AND RECIPIENTS


2001 2002**
Expenditure Recipients Expenditure Recipients

TOTAL $64,923,574 65,278 $70,708,412

RECEIVING CASH ASSISTANCE TOTAL $52,946,651 33,640


Aged $9,954,837 4,747
Blind/Disabled $33,634,846 8,964
Child $1,778,759 9,519
Adult $7,578,209 10,410

MEDICALLY NEEDY, TOTAL $0 -


Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $5,303,090 25,775


Aged $6,244 8
Blind/Disabled $368 2
Child $4,319,775 20,919
Adult $976,703 4,846

TOTAL OTHER EXPENDITURES/RECIPTENTS* $6,673,833 5,863

*Total Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Formulary/Prior Authorization


Department of Health and Social Services, Division of Formulary: No formulary. Preferred drug list (PDL)
Medical Assistance. managed by restrictions on use, therapeutic
substitution, preferred products, and physician
D. PROVISIONS RELATING TO DRUGS profiling.

Benefit Design Prior Authorization: State currently has a formal prior


authorization procedure. Request for fair hearing
Drug Benefit Product Coverage: Products covered: required for appealing coverage of an excluded
cosmetics (covered with restrictions); prescribed product and PA decision. Medical necessity form
insulin; disposable needles used for insulin (covered required.
under DME); syringe combinations used for insulin;
and total parental nutrition. Prior authorization Prescribing or Dispensing Limitations
required for: Clorazil; Lupron Depot; ADC infant
vitamins; some DME; Synagis; Pauretin; and Actig Monthly Quantity Limit: Prescriptions are limited to
Naltrexone. Products not covered: fertility drugs; 30-day supplies. Dispensing of generic multi-source
experimental drugs; blood glucose test strips; urine product is required. Maximum number of units for
ketone test strips; and intedialytic parenteral nutrition. about 50 therapeutic classes and 40 narcotic
analgesics.
Over-the Counter Product Coverage: Products
covered with restrictions: feminine products; topical Drug Utilization Review
products (vasatrace ointment). Products not covered:
allergy, asthma, and sinus products; analgesics; cough PRODUR system implemented in June 1995. State
and cold preparations, digestive products; and smoking currently has a DUR Board that meets nine times per
deterrent products. year.

Therapeutic Category Coverage: Categories covered: Pharmacy Payment and Patient Cost Sharing
anabolic steroids; antibiotics; anticoagulants;
anticonvulsants; anti-depressants; antidiabetic agents; Dispensing Fee: No less than $3.45 and no more than
antihistamine drugs; antilipemic agents; anti- the 90th percentile of all dispensing fees determined
psychotics; anxiolytics, sedatives, and hypnotics; under the formula:
cardiac drugs; chemotherapy agents; contraceptives;
ENT anti-inflammatory agents; estrogens; hypotensive 1) $23,192 added to the number resulting from
agents; miscellaneous GI drugs; sympathominetics multiplying total prescriptions filled by that
(adrenergic); and thyroid agents. Prior authorization pharmacy in the previous calendar year by 5.070;
required for: analgesics, antipyretics, and NSAIDs;
growth hormones. Categories not covered: anoretics;
2) to 1), add the result of multiplying total Medicaid
prescribed cold medications; amphetamines (except for
prescriptions filled in the previous calendar year
narcolepsy and hyperactivity); prescribed smoking
by 12.44;
deterrents; cough suppressants; DESI drugs; vitamins
(except prenatal); and vitamins with fluoride.
3) from 2), subtract the result of multiplying the total
floor space volume of the pharmacy in sq. ft. by
Coverage of Injectables: Injectable medicines
2.103;
reimbursable through the Prescription Drug Program
when used in home health care and extended care
4) divide 3) by total prescriptions filled by that
facilities, and through physician payment when used in
pharmacy
physicians’ offices.
5) add $0.73 to 4)
Vaccines: Vaccines reimbursable at cost as part of
EPSDT services, the Children’s Health Insurance
Ingredient Reimbursement Basis: EAC = AWP - 5%.
Program, and the Vaccines for Children Program.
Maximum Allowable Cost: State imposes Federal
Unit Dose: Unit dose packaging reimbursable.
Upper Limits on generic drugs. Override requires
“Brand Medically Necessary” and the reason of
necessity.

Alaska-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Incentive Fee: None. New Brand Name Products Contact


Dave Campana, R.Ph.
Cognitive Services: Does not pay for cognitive
907/334-2425
services.

Patient Cost Sharing: $2.00 copayment for branded Prescription Price Updating
and generic products.
Dave Campana, R.Ph.
907/334-2425
E. USE OF MANAGED CARE
Medicaid Drug Rebate Contact
Does not use MCOs to deliver services to Medicaid Amanda Burger
recipients. Division of Medical Assistance
4501 Business Park Blvd., Suite 24
F. STATE CONTACTS Anchorage, AK 99503
T: 907/334-2409
F: 907/561-1684
Medicaid Drug Program Administrator E-mail: amanda.burger@health.state.ak.us
Dave Campana, R.Ph.
Pharmacy Program Manager Claims Submission Contact
Division of Medical Assistance
Linda Walsh
4501 Business Park Blvd., Suite 24
Systems Administrator
Anchorage, AK 99503
Division of Medical Assistance
T: 907/334-2425
4501 Business Park Blvd, Suite 24
F: 907/561-1684
Anchorage, AK 99503
E-mail: david_campana@health.state.ak.us
T: 907/334-2441
F: 907/561-1684
Health and Social Services Department E-mail: linda_walsh@health.state.ak.us
Officials
Joel Gilbertson, Commissioner Disease Management Program/Initiative
Department of Health and Social Services Contact
P.O. Box 110601
Pam Muth
Juneau, AK 99811-0601
Deputy Director
T: 907/465-3030
Division of Medical Assistance
F: 907/465-3068
4501 Business Park Blvd, Suite 24
E-mail: joel_gilbertson@health.state.ak.us
Anchorage, AK 99503
907/334-2400
Dwayne Peeples, Director
E-mail: pam_muth@health.state.ak.us
Division of Medical Assistance, DHSS
P.O. Box 110660
Juneau, AK 99811-0660 Mail Order Pharmacy Benefit
T: 907/465-3355
Yes, for Medicaid recipients living in rural areas.
F: 907/465-2204
E-mail: dwayne_peeples@health.state.ak.us
Alaska DUR Committee
Prior Authorization Contact Dave Campana, R.Ph.
Anchorage, AK 99503
Dave Campana, R.Ph.
907/334-2425
Richard Reem, M.D.
Fairbanks, AK 99701-3639
DUR Contact
Heide Brainerd, P.H.
Dave Campana, R.Ph.
Anchorage, AK
907/334-2425
Arthur Hansen, D.D.S.
Fairbanks, AK 99712

Alaska-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Greg Polston, M.D.


Fairbanks, AK.

Charlene Hampton, R.Ph.


Anchorage, AK

Alexander von Hafften, M.D.


Anchorage, AK

Executive Officers of State Medical and


Pharmaceutical Societies
Alaska State Medical Association
Jim Jordan, Executive Director
4107 Laurel Street
Anchorage, AK 99508
T: 907/562-0304
F: 907/561-2063
E-mail: asma@alaska.net

Alaska Osteopathic Medical Association


Holly Macriss
AOA Northwest Regional Manager
1900 Point West Way, Suite 188
Sacramento, CA 95815-4705
T: 800/891-0333
F: 916/564-5105
E-mail: hmcriss@osteopathic.org
Internet address: www.do-online.org/aoawesternregion

Alaska Pharmaceutical Association


Nancy Davis, Executive Director
4107 Laurel Street
Anchorage, AK 99508-5334
T: 907/563-8880
F: 907/563-7880
E-mail: akphrmcy@alaska.net
Internet address: www.alaskapharmacy.org

Alaska State Board of Pharmacy


Barbara Roche
Licensing Examiner
P.O. Box 110806
Juneau, AK 99811-0806
T: 907/465-2589
F: 907/465-2974
E-mail: barbara_roche@dced.state.ak.us
Internet address: www.dced.state.ak.us/occ/ppha.htm

Alaska State Hospital and Nursing Home Association


Rod L. Betit
President/CEO
426 Main Street
Juneau, AK 99801
T: 907/586-1790
F: 907/463-3573
E-mail: rbetit@ashnha.com
Internet address: www.ashnha.com

Alaska-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

ARIZONA
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
(AHCCCS - PRONOUNCED "ACCESS")

AHCCCS FEATURES Primary Care Physicians as Gatekeepers


The Arizona Health Care Cost-Containment System AHCCCS legislation provided that all members must
(AHCCCS) is a Title XIX (Medicaid) 1115 Research be under the care and supervision of a primary care
and Demonstration Waiver project, jointly funded by physician who assumed the role of gatekeeper. A
the federal government and the State of Arizona. statewide network of primary care physicians was
Begun in October 1982, it serves as a model for established to perform the gatekeeping function for
providing medical services to the indigent in a the system.
managed care system rather than through fee-for-
service arrangements. Typically, Medicaid programs
have incorporated the traditional hallmarks of the Prepaid Capitated Financing
U.S. health care system: namely, independent
providers and fee-for-service reimbursement. In It was the intent of the AHCCCS legislation that
contrast, organized health plans and capitation mark health plans and their providers offer all covered
the 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. AHCCS
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
Gatekeepers The statewide competitive aspect of the bid process
• Prepaid Capitated Financing for selecting providers and offering prepaid capitated
• Competitive Bidding Process services is the most unique feature of the AHCCCS
• Cost Sharing model. A competition of this magnitude had never
• Limitations on Freedom-of-Choice been attempted in any other State. The AHCCCS
• Capitation of the State by the Federal administration believes competitive bidding for
Government health care service contracts, as opposed to
conventional negotiation processes, provides

Arizona-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

accessible cost-effective delivery of health care for the State to monitor health care costs on a careful
without sacrificing quality performance. and continuous basis.

The AHCCCS administration issues an invitation to IMPLEMENTATION OF AHCCCS


qualified health plans once every five years.
Qualified health plans may bid to offer the full range AHCCCS is based on plans that have been tested, in
of AHCCCS services in one or more counties. part, on smaller scales in different areas of the
country. By combining a number of key mechanisms
Cost Sharing on a statewide basis, AHCCCS represents a novel
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 co-payment schedule was
developed for this purpose, and the medically needy
participate in coinsurance cost sharing. It is expected Provider Participation
that the imposition of nominal co-payments will
ensure optimal effectiveness in the area of service Providers may participate in AHCCCS in 2 different
utilization. The co-payment schedule accomplishes ways. First, they may contract with prepaid capitated
three objectives: curtailment of over-utilization; plans as either full or partial benefit providers.
enhancement of patient dignity; and service
utilization by members for truly needed health care. The second mode of participation is on a capped fee-
There is no co-payment for drugs and medication, for-service basis. Here, providers agree to accept
prenatal care including all obstetrical visits, members capped fee payments as payments in full for services
in long care facilities and for visits scheduled by the provided on a FFS basis.
primary care physician or practitioner, and not at the
request of the member.
Functions of the AHCCCS Administration

Limitations On Freedom-of-Choice The Arizona Health Care Containment System


Administration (AHCCCSA) contracts with full
The fifth major item for containing costs is a benefit capitated health plans to serve AHCCCS
restriction on provider/physician selection by members through a network of providers.
AHCCCS members. Unlike conventional delivery
models, Arizona does not rely on fee-for-service
Contracting Health Plans
arrangements. The goal is to have the State
completely blanketed with prepaid capitated
Under the Contracting Health Plan arrangement,
arrangements. Members are linked to selected or
plans are defined in terms of explicit groups of
assigned plans for definite durations of time.
providers organized as entities that are more formal.
Freedom-of-choice is permitted to the extent
These consortia, or formal entities, are capable of
practicable for members to select the particular group
providing the full range of AHCCCS benefits within
with which to enroll, as well as the primary care
a defined service area for all AHCCCS members who
physician within the selected group. Capped fee-for-
elect to join the plans, up to a predetermined
service health service arrangements are used as a last
capacity. This is the dominant mode of operation
resort, and only in areas not covered by prepaid
within AHCCCS -- with two or more competing
capitated plans.
plans wherever possible.
CAPITATION BY THE FEDERAL The Contracting Health Plans are delivery systems,
GOVERNMENT not simply insurance plans, but they need not be
Health Maintenance Organizations by any legal or
The State of Arizona will itself be capitated by the conventional definition of the term. The AHCCCS
Federal Government and therefore will be at financial legislation provides for the creation of provider
risk for containing health care costs. Capitation rates consortia for the purpose of participation in the
will be established according to sound actuarial program. The Contracting Health Plan may be a
principles, and will represent no more than 95 loosely organized system, but it must be capable of
percent of the estimated cost of services delivered in providing the full range of AHCCCS benefits to a
Arizona under conventional fee-for-service defined population at a capitation rate.
arrangements. Capitation provides a key incentive

Arizona-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

The Organizational Role of AHCCCS (Additional information about AHCCCS can be


Administration found on the agency’s website at
www.ahcccs.state.az.us)
The AHCCCS Administration has been charged with
the general implementation and monitoring of the MEDICAL PLANS AND
AHCCCS program. ADMINISTRATORS
The AHCCCS Administration develops the Rules
and Regulations; manages the health plan bidding AHCCCS Contracted Health Plans
processes; awards the contracts; provides technical Arizona Physicians IPA, Inc.
assistance to providers for the purpose of forming 3141 North 3rd Avenue
consortia to contract with AHCCCS; and monitors Phoenix, AZ 85013
the overall operation of the program. 602/264-1232

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 602/778-1800
operations.
CIGNA Community Choice
The AHCCCS Administration has overall 11001 North Black Canyon Highway
responsibility for the following activity areas: Phoenix, AZ 85029
602/371-2621
• Eligibility Oversight
• Procurement of Health Plans DES/CMDP
• Quality Management CMDP-942-C
• Health Plan Oversight Century Plaza Building, 10th Floor
• Provider, Member Call Center 3225 North Central Avenue
• Grievances and Complaints Phoenix, AZ 85012
• Fee-for-Service for IHS 602/351-2245

AHCCCS became effective December 1, 1981, and Family Health Plan of NE Arizona
services commenced October 1, 1982. Services 258 Justin Drive
include: inpatient, outpatient, laboratory, x-ray, P.O. Box 2069
prescription drugs, medical supplies, prosthetic Cottonwood, AZ 86326
devices, emergency dental care including extractions 928/448-3585
and dentures, treatment of eye conditions and
EPSDT. Health Choice Arizona
Suite 260
Though AHCCCS was a three-year experiment that 1600 West Broadway
was to end in October 1985, the Federal government Tempe, AZ 85282-1136
continues to extend funding for the program. In 480/968-6866
1988, AHCCCS received a five-year extension from
the Federal government and in 1993, it received an Maricopa Health Plan
additional one-year extension. In 1994, AHCCCS 2502 East University Drive
received a three-year extension and in 1998, it Phoenix, AZ 85034
received a one-year extension. Since then, AHCCCS 602/344-8700
has received additional extensions. Currently,
AHCCCS is operating under a five year waiver Mercy Care Plan
extension that will expire on September 30, 2006. Suite 400
Some 20 years after it first began, AHCCCS has 2800 North Central
grown in numbers from the first wave of 180,000 Phoenix, AZ 85004
enrollees to more than 963,000 beneficiaries, (Oct. 602/263-3000
2003) representing 18 percent of Arizona’s
population. AHCCCS has also become a model as
managed care is increasingly by being implemented
in other States’ Medicaid programs.

Arizona-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Phoenix Health Plan/Community Connection Maricopa Long Term Care Plan


1209 South 7th Avenue Suite 125
Phoenix, AZ 85007 2502 East University Drive
602/824-3700 Phoenix, AZ 85034
602/344-8700
Pima Health System
Suite A-200 Mercy Care Plan
5055 East Broadway Suite 400
Tucson, AZ 85711 2800 North Central
602/512-5500 Phoenix, AZ 85004
602/263-3000
University Family Care
575 East River Road Pima Long Term Care
Tucson, AZ 85704 Pima Health System
888/708-2930 Suite A-200, 5055 East Broadway
Tucson, AZ 85711
Phoenix Area Indian Health Services (IHS) 520/512-5500
Two Renaissance Square
40 N. Central Avenue Pinal/Gila LTC
Phoenix, AZ 85004-5036 P.O. Box 2140
602/364-5039 971 North Pinal Parkway
Florence, AZ 85232-2140
Tucson Area Indian Health Services (IHS) 520/868-6775
7900 South J. Stock Road
Tucson, AZ 85746 Yavapai County LTC
520/295-2405 Yavapai County Department of Medical Assistance
595 White Spar Road
Navajo Area Indian Health Services (IHS) Prescott, AZ 86303
P.O. Box 9020 520/771-3560
Window Rock, AZ 86515-9020
928/871-5811 AHCCCS FFS (ALTCS)
Ventilator Dependent
ALTCS Contractor List Office of Medical Management
602/417-4370
Arizona Physicians IPA
Suite A
242 West 28th Street STATE CONTACTS
Yuma, AZ 85364
520/783-5691 AHCCCS Officials

Cochise Health Systems Phyllis Biedess, Director


Cochise County Health & Social Services AHCCCS
1415 West Melody Lane, Building A 801 E. Jefferson Street
Bisbee, AZ 85603-4249 Phoenix, AZ 85034
520/432-9600 T: 602/417-4680
F: 602/252-6536
DES/DDD E-mail: PXBiedess@ahcccs.state.az.us
1789 West Jefferson, 4th Floor Internet address: www.ahcccs.state.az.us
Phoenix, AZ 85007
602/542-0419 Dell Swan
Pharmacy Program Administrator
Evercare Select AHCCCS
314 N. 3rd Avenue 801 East Jefferson Street
Phoenix, AZ 85013 MD 4100
602/331-5100 Phoenix, AZ 85034
612/417-4000
E-mail: dwswan@ahcccs.state.az.us

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Executive Officers of State Medical and


Pharmaceutical Societies
Arizona Medical Association, Inc.
Chic Older
Executive Vice President
810 West Bethany Home Road
Phoenix, AZ 85013
T: 602/246-8901
F: 602/242-6283
E-mail: chicolder@azmedassn.org
Internet address: www.azmedassn.org

Arizona Pharmacy Association


Kathy Boyle
Executive Director
1845 E. Southern Ave.
Tempe, AZ 85282-5831
T: 480/838-3385
F: 480/838-3557
E-mail: azpa@azpharmacy.org
Internet address: www.azpharmacy.org

Arizona Osteopathic Medical Association


Amanda Weaver
Executive Director
5150 N. 16th St., Suite A-122
Phoenix, AZ 85016
T: 602/266-6699
F: 602/266-1393
E-mail: mweaver@az-osteo.org
Internet address: www.az-osteo.org

Arizona Board of Pharmacy


Hal Wand
Executive Director
4425 W. Olive Avenue, Suite 140
Glendale, AZ 85302
T: 623/463-2727
F: 623/934-0583
E-mail: info@azsbp.com
Internet address: www.pharmacy.state.az.us

Arizona Hospital and Healthcare Association


John R. Rivers, FACHE
President/CEO
2901 North Central Avenue
Suite 900
Phoenix, AZ 85012
T: 602/445-4300
F: 602/445-4299
E-mail: jrivers@azha.org
Internet address: www.azha.org

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Arizona-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

ARKANSAS

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expended Recipients Expended Recipients
TOTAL $248,392,084 321,920 $273,257,660

RECEIVING CASH ASSISTANCE, TOTAL $142,811,387 111,016


Aged $18,083,097 13,278
Blind/Disabled $117,036,376 68,665
Child $4,248,875 19,495
Adult $3,443,039 9,578

MEDICALLY NEEDY, TOTAL $7,660,175 13,964


Aged $130,249 203
Blind/Disabled $2,721,983 2,036
Child $1,664,186 5,912
Adult $3,143,757 5,813

POVERTY RELATED, TOTAL $21,594,533 100,643


Aged $370,667 367
Blind/Disabled $917,628 673
Child $18,932,809 88,224
Adult $1,373,429 11,379

TOTAL OTHER EXPENDITURES/RECIPIENTS* $76,325,989 96,297

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Formulary/Prior Authorization


Department of Human Services, Division of Medical Formulary: State covers outpatient drugs whose
Services, Pharmacy Program. manufacturers have signed a rebate agreement with
CMS. General exclusions include:
D. PROVISIONS RELATING TO DRUGS
1. Agents used for hair growth.
Benefit Design 2. Vitamin products except prescription prenatal
vitamins.
Drug Benefit Product Coverage: Products covered
3. Drugs determined by the FDA to be ineffective
with restrictions: prescribed insulin; disposable
(DESI drugs).
needles and syringe combinations used for insulin.
Products not covered: blood glucose test strips; urine 4. Sedatives and hypnotics in the benzodiazepine
ketone test strips; total parenteral nutrition, category (partial coverage).
interdialytic parenteral nutrition; cosmetics; fertility
5. Compounded prescriptions (mixtures of two or
drugs; experimental drugs; and vitamins (other than
more ingredients). States are not allowed to
prenatal vitamins for pregnant women). Prior
have state codes such as 99999-9999-99. All
authorization required for: nitroglycerin patches;
drugs reimbursed by the State must be traced by
agents for impotence; Synagis; Respigam; Xenical-
NDC code and appear on the utilization report.
hyper lipidemia; Remicade; Regranex; Kineret;
Enbrel; Xolair; and Humira. Prior Authorization: State currently has a prior
authorization procedure. Beneficiaries have a right to
Over-the-Counter Product Coverage: Products appeal prior authorization decisions. Physician must
covered: digestive products (H2 antagonist). Limited submit letter explaining medical necessity leading to
coverage for: allergy, asthma and sinus products; the request for the medication.
analgesics; cough and cold preparations (under 21
years and long-term care limited needs); digestive
products (non-H2 antagonist); feminine products; Prescribing or Dispensing Limitations
and topical products. Products not covered: smoking
deterrent products. Prescription Refill Limit: 5 refills within 6 months
are allowed. New Rx required every 6 months.
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; antibiotics; Monthly Quantity Limit: 31-day supply.
anticoagulants; anticonvulsants; anti-depressants;
antidiabetic agents; antilipemic agents; anti- Monthly Prescription Limit: Three prescriptions per
psychotics; anxiolytics, sedatives, and hypnotics; month per recipient, except unlimited for certified
cardiac drugs; chemotherapy agents; contraceptives; LTC recipients and recipients under 21 years old.
ENT anti-inflammatory agents; estrogens; growth Others can receive extension of three more per
hormones; hypotensive agents; sympathominetics month.
(adrenergic); and thyroid agents. Prior authorization
required for: analgesics, antipyretics, NSAIDs; Drug Utilization Review
antihistamine drugs; misc. GI drugs; prescribed
smoking deterrents. Therapeutic categories not PRODUR system implemented in March 1997. State
covered: anorectics. currently has a DUR Board with a quarterly review.

Coverage of Injectables: Injectable medicines are


reimbursable through the Prescription Drug Program Pharmacy Payment and Patient Cost Sharing
when used in home health care and extended care
facilities, and through physician payment when used Dispensing Fee: $5.51 effective 7/1/99. Effective
in physicians offices. 3/1/02, non-MAC generics receive an additional
$2.00 dispensing fee.
Vaccines: Vaccines reimbursable as part of the
Vaccines for Children Program. Ingredient Reimbursement Basis: EAC = AWP-14%
(Brand), AWP-20% (Generic).
Unit Dose: Unit dose packaging reimbursable.
Prescription Charge Formula: Legend drugs: lower
of the EAC plus a dispensing fee or CFA/state upper

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National Pharmaceutical Council Pharmaceutical Benefits 2003

limit plus a dispensing fee. Total charge may not F. STATE CONTACTS
exceed provider’s charge to the self-paying public.

Maximum Allowable Costs: State imposes Federal Medicaid Drug Program Administrator
Upper Limits as well as State-specific limits on Suzette Bridges, P.D., Administrator
generic drugs. State-specific MAC list contains 800 Pharmacy Program
drugs (see www.medicaid.ar.us). Override requires Division of Medical Services
physician documentation on MedWatch form as to Dept. of Human Services
why the generic cannot be dispensed. P.O. Box 1437, Slot S 415
Little Rock, AR 72203-1437
Incentive Fee: $2.00 additional dispensing fee on T: 501/683-4120
non-MAC generics. F: 501/683-4124
E-mail: suzette.bridges@medicaid.state.ar.us
Patient Cost Sharing: Effective 9/1/92, for each
prescription reimbursed, the Medicaid recipient is Prior Authorization Contact
responsible for paying a copayment based on the
following: Suzette Bridges, P.D.
501/683-4120
State Payment Copay
DUR Contact
$10.00 or less $0.50 Pamela Ford, P.D.
Pharmacist II
$10.01 to $25.00 $1.00 Division of Medical Services
Dept. of Human Services
$25.01 to $50.00 $2.00 P.O. Box 1437, Slot S 415
Little Rock, AR 72203-1437
$50.01 or more $3.00 T: 501/683-4120
F: 501/683-4124
ArKids $5.00 E-mail: pamela.ford@medicaid.state.ar.us

Services to individuals under 18, pregnant women,


DUR Board
nursing home residents, emergency services, family
planning services, and services provided by an HMO Steve Bryant, P.D.
to its enrollees are excluded from the Medicaid copay Jason B. Hawkins, P.D.
policy. Benji Post, P.D.
Debbie Hayes
Cognitive Services: Does not pay for cognitive Ann Blaylock, A.P.N.
services. Thomas Lewellen, D.O.
Michael N. Moody, M.D.
Laurence Miller, M.D.
E. USE OF MANAGED CARE
New Brand Name Products Contact
An estimated 275,000 Medicaid recipients are
enrolled with Primary Care Physicians and Suzette Bridges, P.D.
approximately 70,000 children are enrolled in 501/683-4120
ArKids. Pharmaceutical benefits are provided
through the State. Prescription Price Updating
First DataBank
1111 Bay Hill Drive
San Bruno, CA 94066
T: 650/588-5454
F: 650/588-4003

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Medicaid Drug Rebate Contacts Executive Officers of State Medical and


Pharmaceutical Societies
Audits: Suzette Bridges, P.D., 501/683-4120
Arkansas Hospital Association
Dispute Resolution: Dana Boyer James R. Teeter
Rebate Analyst President/CEO
EDS 419 Natural Resources Drive
500 President Clinton Ave, Suite 400 Little Rock, AR 72205
Little Rock, AR 72201 T: 501/224-7878
T: 501/374-6608 F: 501/224-0519
F: 501/372-2971 E-mail: aha@arkhospital.org
E-mail: dana.boyer@mediciad.state.ar.us Internet Address: www.arkhospitals.org

Claims Submission Contact


Arkansas Pharmacists Association
John Herzog, Account Manager Mark Riley
EDS Executive Director
500 President Clinton Ave, Suite 400 417 S. Victory Street
Little Rock, AR 72201 Little Rock, AR 72201-2932
T: 501/374-6608 T: 501/372-5250
F: 501/372-2971 F: 501/372-0546
E-mail: john.herzog@medicaid.state.ar.us E-mail: mriley@arpharmacists.org
Internet address: www.arpharmacists.org
Medicaid Managed Care Contact
Arkansas State Board of Pharmacy
Kellie Phillips Charles S. Campbell
Program Administrator Executive Director
Medical Assistance 101 E. Capitol, Suite 218
Division of Medicaid Services Little Rock, AR 72201
Dept. of Human Services T: 501/682-0190
P.O. Box 1437, Slot 410 F: 501/682-0195
Little Rock, AR 72203 E-mail: charlie.campbell@mail.state.ar.us
T: 501/682-8306 Internet address: www.state.ar.us/asbp
F: 501/682-1197
E-mail: kellie.phillips@medicaid.state.ar.us Arkansas Osteopathic Medical Association
Ed Bullington
Executive Director
Mail Order Pharmacy Benefit 412 Union Station
None 1400 West Markham
Little Rock, AR 72201
Department of Human Services Officials T: 501/374-8900
F: 501/374-8959
Kurt Knickrehm, Director E-mail: osteomed@ipa.net
Department of Human Services Internet address: www.arkosteomed.org
P.O. Box 1437, Slot 201
Little Rock, AR 72203-1437 Arkansas Medical Society
T: 501/682-8650 Ken LaMastus
F: 501/682-6836 Executive Vice President
E-mail: kurt.knickrehm@state.ar.us P.O. Box 55088
Internet Address: www.accessarkansas.org/dhs Little Rock, AR 72215
T: 501/224-8967
Roy Jeffus, Director F: 501/224-6489
Division of Medical Services E-mail: klamastus@arkmed.org
P.O. Box 1437, Slot 1100 Internet address: www.arkmed.org
Little Rock, AR 72203-1437
T: 501/682-1671
F: 501/682-1197
E-mail: roy.jeffus@medicaid.state.ar.us

Arkansas-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

CALIFORNIA

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Note: Certain classifications of aliens in the above categories are eligible only for emergency and pregnancy-related benefits.

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $2,808,298,437 2,486,910 $3,591,537,830

RECEIVING ASSISTANCE, TOTAL $2,143,413,178 1,334,480


Aged $479,791,420 266,911
Blind/Disabled $1,547,024,854 579,572
Children $39,100,804 299,830
Adult $77,496,100 188,167

MEDICALLY NEEDY, TOTAL $423,154,155 279,326


Aged $198,544,758 120,346
Blind/Disabled $198,371,267 53,459
Children $11,503,750 68,297
Adults $14,734,380 37,224

POVERTY RELATED, TOTAL $54,387,618 103,247


Aged $14,257,426 11,923
Disabled $32,358,484 10,485
Children $5,572,729 51,243
Adults $2,198,979 29,596

TOTAL OTHER EXPENDITURES/RECIPIENTS* $187,343,486 769,857

*Total Other Expenditures/ Recipients include foster care children, demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001and CMS-64 Report, FY 2002.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Formulary/Prior Authorization

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:
http://www.dhs.ca.gov/mcs/mcpd/MBB/contracting/h
Benefit Design tml/faqpage.htm has details of how the drug
contracting process works.
Drug Benefit Product Coverage: The Medi-Cal
pharmacy benefit covers practically all FDA- Examples of general limitations and exclusions
approved drugs, including both legend and over-the- (other uses require prior authorization):
counter products. There are very few drugs or
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;
2. Diazepam is restricted to use in cerebral palsy,
fertility drugs; and experimental drugs. Most other
athetoid states, and spinal cord degeneration.
products are potential benefits.
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
4. Some antibiotics have diagnostic and/or age
authorization. Those not on the List of Contract
restrictions.
Drugs do require prior authorization.
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
6. Codeine Combinations: payment to a pharmacy
in a physician's, dentist's, or podiatrist's office are not
for ASA or APAP with codeine 30 mg is limited
bound by the List of Contract Drugs.
to a maximum dispensing quantity of 45 tablets
or capsules and a maximum of 3 claims for the
Coverage of Injectables: Injectable medicines are
same beneficiary in any 75-day period.
reimbursable through the Prescription Drug Program
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
8. Cancer, AIDS, and DESI Drugs: Any
program or as administered in a physician's office.
antineoplastic drug approved by FDA for the
treatment of cancer and any drug approved by
Unit Dose: Unit dose packaging reimbursable.
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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National Pharmaceutical Council Pharmaceutical Benefits 2003

Prior Authorization: State currently has a formal Hospital Discharge Medications: Quantities
prior authorization procedure. furnished as discharge medications are limited to no
more than a 10-day supply. Charges are incorporated
The patient’s physician or pharmacist may request in the hospital’s claims for inpatient services.
prior authorization from the field office Medi-Cal
consultant for approval of unlisted drugs or for listed
Drug Utilization Review
drugs that are restricted to specific use(s). This is
done by completing a Treatment Authorization
Prospective DUR system implemented in August
Request (TAR) form. Providers may appeal prior
1995. State currently has a DUR Board with a
authorization decisions within 60 days of notification
quarterly review.
to the local field office and then to field services
headquarters if necessary. Beneficiaries also have the
ability to request a hearing to review the denial and Pharmacy Payment and Patient Cost Sharing
must do so within 90 days of notification.
Dispensing Fee: $4.05, effective 8/85.
TARs may be approved for: covered items or
services not included on the Medi-Cal List of Ingredient Reimbursement Basis: EAC = AWP-10%
Contract Drugs (including special circumstance such
as the need to override multiple source drug price Prescription Charge Formula: Reimbursement is
ceilings or minimum quantity/ frequency of billing based on the lowest of:
limitations); and for patients exceeding the 6 Rx per
month limit. Statewide mail and fax requests are 1. Estimated Acquisition Cost (EAC) + dispensing
accepted in the Stockton and Los Angeles Medi-Cal fee, less $0.50 for most patients, or less $0.10 for
Field Offices. Requests must include adequate nursing home patients.
information and justification. Authorization may 2. Federal Upper Limit (FUL) + dispensing fee,
only be given for the lowest cost item or service that less $0.50 for most patients, or less $0.10 for
meets the patient’s medical needs. nursing home patients.
3. State Maximum Allowable Ingredient Cost
Beneficiary or Prescriber Prior Authorization: On a (MAIC) + dispensing fee, less $0.50 for most
case by case basis, the Dept. of Health Services patients, or less $0.10 for nursing home patients.
restricts, through the requirements of prior 4. Pharmacy’s usual price to general public, less
authorization, the availability of designated $0.50 for most patients, or less $0.10 for nursing
prescription drugs to certain beneficiaries or home patients.
prescribers found by the Department to abuse those
benefits. Maximum Allowable Cost: State Maximum
Allowable Ingredient Costs (MAICs) are established
Prescribing or Dispensing Limitations for about 50 multi-source items. Override requires
“Medically Necessary” or unavailability of drug
Prescription Refill Limit: A prescription refill can be products at or below MAC. List is periodically
dispensed as authorized by prescriber. An exception revised and price limits changed to reflect current
is allowed for refill of a reasonable quantity when market conditions.
prescriber is unavailable (pursuant to California law).
Fee is to be pro-rated so that total fee (for partial Incentive Fee: None.
quantity and balance of the prescription after
prescriber is contacted) does not exceed the fee for Patient Cost Sharing: $1.00 copayment for branded
the same prescription when refilled as a routine and generic products.
service.
Cognitive Services: Does not pay for cognitive
Monthly Quantity Limit: This is flexible, but should services, but this is under consideration.
be consistent with the medical needs of the patient.
Limited to 100 days’ supply on most drugs. Many
maintenance drugs are subject to minimum quantity
or maximum frequency of billing controls.
Monthly Prescription Limit: Limited to 6 per month
without prior authorization. The limit does not apply
to family planning drugs, patients in nursing
facilities, or to AIDS or cancer drugs.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

E. USE OF MANAGED CARE Health Net of California


3400 Data Drive, 1st Floor West
Approximately 3,300,000 Medicaid recipients were Rancho Cordova, CA 95670
enrolled in MCOs in FY 2001. Recipients receive
pharmaceutical benefits through the State and Health Plan of San Joaquin
managed care plans. Certain psychiatric drugs 1550 W. Fremont Street, Suite 200
(antipsychotics, lithium, MAO inhibitors) and some Stockton, CA 95203-2643
anti-parkinson drugs are carved out of managed care.
Most AIDS drugs are no longer carved out of Inland Empire Health Plan
managed care. PO Box 19026
San Bernardino, CA 92423-9026
Access Dental Plan, Inc. Kern Health Systems
555 University Ave, Suite 182 Kern Family Health Care
Sacramento, CA 95825 1600 Norris Road
Bakersfield, CA 93308
AIDS Healthcare Foundation
6255 W. Sunset Blvd., 16th Floor Kaiser Foundation Health Plan, Inc.
Los Angeles, CA 90028-7403 393 E. Walnut, 5th Floor
Pasadena, CA 91188-8324
Alameda Alliance for Health
1240 South Loop Road Kaiser Foundation
Alameda, CA 94502 Health Plan, Inc.
Northern California Region
Altamed Health Services Corp. 1800 Harrison Street, 9th Floor
512 South Indiana Street P.O. Box 12916
Los Angeles, CA 90063 Oakland, CA 94612-2998
American Health Guard LA Care Health Plan
30 East Santa Clara, Suite D 555 W. Fifth Street, 19th Floor
Arcadia, CA 91006 Los Angeles, CA 90013-3036
Blue Cross of California Molina Healthcare Inc
5151-A Camino Ruiz A Professional Corporation
Camarillo, CA 93012 One Golden Shore Drive
Long Beach, CA 90802
Center for Elders Independence
1955 San Pablo Ave On Lok Senior Health Services
Oakland, CA 94612 1333 Bush Street
San Francisco, CA 94109
Community Health Group
740 Bay Blvd. Orange County Organized Health System
Chula Vista, CA 91910 Cal Optima
1120 West La Veta Ave., 5th Floor
County of Contra Costa Orange, CA 92868-4220
Contra Costa Health Plan
595 Center Avenue, Suite 100 San Francisco Health Authority
Martinez, CA 94553 San Francisco Health Plan
568 Howard Street, Fifth Floor
Delta Dental Plan of CA San Francisco, CA 94105
1115 International Drive, Bldg. C
Rancho Cordova, CA 95670 San Francisco City & County Public Health
Family Mosaic Project
Health Net Dental, Inc. 1309 Evans Avenue
125 Technology Drive, Suite 100 San Francisco, CA 94124
Irvine, CA 92618

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National Pharmaceutical Council Pharmaceutical Benefits 2003

San Mateo Health Commission F. STATE CONTACTS


Health Plan of San Mateo
701 Gateway Blvd., Suite 400
South San Francisco, CA 94080 State Drug Program Administrator
J. Kevin Gorospe, Pharm.D.
Santa Barbara Regional Health Authority Chief, Medi-Cal Pharmacy Policy Unit
Santa Barbara Health Initiative California Department of Health Services
110 Castilian Drive Medi-Cal Policy Division
Goleta, CA 93117-3028 1501 Capitol Ave.
P.O. Box 997413, MS 4604
Santa Clara Family Health Plan Sacramento, CA 95899-7413
210 E Hacienda Ave T: 916/552-9500
Campbell, CA 95008-6617 F: 916/552-9563
E-mail: kgorospe@dhs.ca.gov
Santa Cruz -Monterey Internet Address: http://www.dhs.ca.gov
Managed Care Commission
Central Coast Alliance for Health New Brand Name Products Contact
375 Encinal Street, Suite A
Santa Cruz, CA 95060 J. Kevin Gorospe, Pharm.D.
916/552-9500
Scan Health Plan
Senior Care Action Network Prior Authorization Contact
3780 Kilroy Airport Way, Suite 100 J. Kevin Gorospe, Pharm.D.
Long Beach, CA 90806-2460 916/552-9500

Sharp Health Plan DUR Contact


4305 University Avenue, Suite 200
San Diego, CA 92105 Vic Walker, R.Ph. B.C.P.P
Senior Consulting Pharmacist
Solano-Napa County Commission on Medical Care Medi-Cal Policy Division
Partnership Health Plan of California 1501 Capitol Ave.
360 Campus Lane, Suite 100 P.O. Box 997413, MS 4604
Suisun City, CA 94585 Sacramento, CA 95899-7413
T: 916/552-9500
Sutter Senior Care F: 916/552-9563
1234 U Street E-mail: vwalker@dhs.ca.gov
Sacramento, CA 95818
Medi-Cal Drug Utilization Review Board (DUR
UCSD Healthcare Board)
200 West Arbor Dr.
San Diego, CA 92103-8501 Timothy E. Albertson, M.D., Ph.D.
University of California-Davis
Universal Care Pulmonary/Critical Care Medicine
1600 E. Hill Street 4301 X Street, Professional Bldg., Room 2120
Signal Hill, CA 90755-3612 Sacramento, CA 95817

Watts Health Foundation, Inc. Craig Jones, M.D.


United Health Plan Director, Division of Allergy/Immunology
3405 West Imperial Highway, Suite 628 Department of Pediatrics
Inglewood, CA 90303 LA County/USC Medical Center
24725 Avenida Asoleada
Western Dental Services Calabasas, CA 91302
530 South Main Street, 6th Floor
Orange, CA 92863 Janeen G. McBride, R.Ph.
Rx America
Western Health Advantage 1500 South Anaheim Blvd.
1331 Garden Highway Suite 100 Anaheim, CA 92815-0017
Sacramento, CA 95833-97543

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Kenneth Schell, Pharm.D. Disease Management Program/Initiative


Pharmacy Services Contact
Clinical Operations Manager
Kaiser Permanente Vic Walker, R.Ph., B.C.P.P., 916/552-9500
10990 San Diego Mission Road
San Diego, CA 92108
Mail Order Drug Benefit
Stephen M. Stahl, M.D., Ph.D. State currently has a mail order pharmacy capability
Clinical Neuroscience Research Center in the Medi-Cal program. All fee-for-service
8899 University Center Lane, Ste. 130 beneficiaries are entitled to participate.
San Diego, CA 92122

Andrew L. Wong, M.D. Health and Welfare Agency Officials


Chief of Rheumatology S. Kimberly Belshé
University of California - Los Angeles Secretary
14445 Olive View - UCLA Medical Center California Health and Human Services Agency
Sylmar, CA 91342 1600 9th Street, Suite 460
Sacramento, CA 95814
Prescription Price Updating T: 916/654-3454
F: 916/654-3343
EDS Federal Corp. E-mail address: www.chhs.ca.gov
P. O. Box 13029
Sacramento, CA 95813-4029 Stan Rosenstein
916/636-1000 Deputy Director
Medical Care Services
California Department of Health Services
Medicaid Drug Rebate Contact
1501 Capitol Ave., P.O. Box 997413, MS 4000
Craig Miller Sacramento, CA 95899-7413
Chief, Medi-Cal Rebate and Vision Section T: 916/ 440-7800
Medi-Cal Policy Division F: 916/ 440-7805
1501 Capitol Ave. E-mail: srosenst.dhs.ca.gov
P.O. Box 997413, MS 4604
Sacramento, CA 95899-7413
T: 916/552-9500 Medi-Cal Contract Drug Advisory Committee
F: 916/552-9563 William B. Ness, M.D.
E-mail: cmiller2@dhs.ca.gov 65 North 14th Street
San Jose, CA 95112
Claims Submission Contact
Bruce K. Uyeda, Pharm.D.
EDS Federal Corp. 1076 Mercy Street
P.O. Box 13029 Mountain View, CA 94041-1915
Sacramento, CA 95813-4029
916/636-1000 Adrian M. Wong, Pharm.D.
Internet Address: www.medi-cal.ca.gov 17 Warren Drive
San Francisco, CA 94131
Medicaid Managed Care Contact
Richard H. White, M.D.
Ronald Sanui, Pharm D. U.C. Davis Medical Center
Pharmaceutical Consultant II Division of General Medicine
Medi-Cal Managed Care Division Primary Care Center, Room 3107
1501 Capitol Ave. 2221 Stockton Blvd.
P.O. Box 997413, MS 4404 Sacramento, CA 95817
Sacramento, CA 95899-7413
916-449-5138 Shirley Ann Floyd
E-mail: rsanui@dhs.ca.gov Blue Cross of California
131 Chester Ave., Suite A
Bakersfield, CA 93301

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Executive Officers of State Medical and


Pharmaceutical Associations/Boards
California Medical Association
Jack C. Lewin, M.D.
CEO and Executive Vice-President
1201 J Street
Sacramento, CA 95814
916/444-5532
Internet address: www.cmanet.org

Osteopathic Physicians & Surgeons of California


Kathleen S. Creason
Executive Director
1900 Point West Way, Suite 188
Sacramento, CA 95815-4703
T: 916/561-0724
F: 916/561-0728
E-mail: opsc@opsc.org

California Pharmacists’ Association


Carlo Michelotti, R.Ph., M.P.H.
Chief Executive Officer
1112 I Street, Suite 300
Sacramento, CA 95814-2865
T: 916/444-7811
F: 916/444-7929
E-mail: cpha@cpha.com
Internet address: www.calpharm.com

State Board of Pharmacy


Patricia F. Harris
Executive Officer
400 R Street, Suite 4070
Sacramento, CA 95814
T: 916/445-5014
F: 916/327-6308
Internet address: www.pharmacy.ca.gov

California Healthcare Association


C. Duane Dauner
President
1215 K Street, Suite 800
Sacramento, CA 95814
T: 916/443-7401
F: 916/552-7596
E-mail: info@calhealth.org
Internet address: www.calhealth.org

California-7
National Pharmaceutical Council Pharmaceutical Benefits 2003

California-8
National Pharmaceutical Council Pharmaceutical Benefits 2003

COLORADO

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 ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients
TOTAL $177,115,553 143,169 $189,717,036

RECEIVING CASH ASSISTANCE, TOTAL $117,978,722 76,243


Aged $38,858,494 18,832
Blind/Disabled $71,297,760 26,703
Child $2,406,437 15,586
Adult $5,416,031 15,092

MEDICALLY NEEDY, TOTAL $0 -


Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $20,438,343 41,156


Aged $101,358 129
Blind/Disabled $15,354,288 3,802
Child $3,695,461 27,041
Adult $1,287,236 10,184

TOTAL OTHER EXPENDITURES/RECIPIENTS* $38,698,488 25,770


*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Colorado-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Vaccines: Vaccines reimbursable as part of the


EPSDT Program.
Colorado Department of Health Care Policy and
Financing administers the drug program. Eligibility Unit Dose: Unit dose packaging not reimbursable.
is determined by 63 County Departments of Social
Services, and the Department.
Formulary/Prior Authorization
D. PROVISIONS RELATING TO DRUGS Formulary: Open formulary.

Benefit Design Prior Authorization: State currently has a formal


prior authorization procedure. There is an appeal
Drug Benefit Product Coverage: Products covered: process and re-review when appealing coverage of an
prescribed insulin. Products covered with restriction: excluded product and prior authorization decisions.
total parenteral nutrition (prior authorization).
Products not covered: cosmetics; DESI drugs; Prescribing or Dispensing Limitations
fertility drugs; prescribed vitamins (except prenatal);
interdialytic parental nutrition products; and Monthly Quantity Limit: New prescriptions for
experimental drugs. Disposable needles and syringe chronic or acute conditions are prescribed at the
combinations used for insulin; blood glucose test discretion of the physician. Normal quantity limit is
strips; and urine ketone test strips are considered a 30-day supply. However, reasonable amounts for
DME and do not fall under the State’s drug benefit. more than a 30-day supply for chronic conditions are
recommended. Maximum supply is 100 days for
Over-the-Counter Product Coverage: Products maintenance medication.
covered with restriction (i.e., must be deemed
medically necessary): allergy, asthma, and sinus Other Limits: Stadol: limit of 4 bottles per month.
products; analgesics; cough and cold preparations; Oxycontin: 2 tablet (any strength) per day limit
digestive products; feminine products; topical without prior authorization.
products; and smoking deterrent products (prior
authorization).
Drug Utilization Review
Therapeutic Category Coverage: Therapeutic
categories covered: antibiotics; anticoagulants; PRODUR system implemented in December 1998.
anticonvulsants; antidepressants; antidiabetic agents; DUR Board meets semiannually.
antilipemic agents; antihistamines; anxiolytics,
sedatives, and hypnotics; cardiac drugs; Lock-In Review Procedures: The Department
chemotherapy agents (given in home); receives computer processed printouts designed to
contraceptives; ENT anti-inflammatory agents; discover over-utilization of drugs prescribed by
estrogens; hypotensive agents; and thyroid agents. physicians, dispensed by vendors, and received by
Prior authorization required for: anabolic steroids; eligible recipients.
analgesics, antipyretics, NSAIDs; anti-psychotics
(prior authorization required for clozoril); prescribed
Pharmacy Payment and Patient Cost Sharing
cough and cold medications; growth hormones; misc.
GI drugs; sympathominetics (adrenergic); vitamins;
Dispensing fee: $4.00 as of July 1, 2001.
acne products; leukocyte stimulants; LHRH/GnRH;
Institutional pharmacies receive a dispensing fee
injectables; plasma products; Epoetin; fluoride
equal to $1.89. Dispensing physicians shall not
preparations; antisera; Oxycontin; erectile
receive a dispensing fee unless their offices or sites
dysfunction; sympathominetics (adrenergie); and
of practice are located more than 25 miles from the
prescribed smoking deterrents. Products not
nearest participating pharmacy. In the latter case,
covered: anoretics.
physicians receive a fee equal to $1.89.
Coverage of Injectables: Injectable medicines
Ingredient Reimbursement Basis: EAC = AWP-
reimbursable through the Prescription Drug Program
13.5% or WAC (wholesaler acquisition cost) + 18%.
when used in home health care and extended care
AWP-35% for generics. Other: FUL, State Mac,
facilities, and through physician payment when used
usual and customary.
in physician offices. Prior authorization is required
for self-administration at home.
Prescription Charge Formula: Benefit drugs shall be
reimbursed at the lesser of the Medicaid allowable

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National Pharmaceutical Council Pharmaceutical Benefits 2003

reimbursement charge, or the provider’s usual and difference in ingredient cost to the pharmacy. The
customary charge or whatever is accepted from any pharmacy will be paid MAC plus a dispensing fee or
third party, discounts, rebates, etc. reimbursement charges, whichever is lower.

The Medicaid allowable reimbursement charge is the High volume Estimated Acquisition Cost (EAC):
sum of the ingredient cost of the drug dispensed and Reimbursement for single source drugs or certain
the provider’s dispensing fee. multiple source drugs which are most frequently
prescribed will be based upon average wholesale
Ingredient cost for retail pharmacies (estimated prices (AWP) minus 13.5%, or direct manufacturers’
acquisition cost) is the price of the drug actually prices for package sizes containing quantities greater
dispensed as defined below or the MAC or the high than 100 dosage units or less if not available in
volume EAC, whichever is less. 100’s.

The ingredient cost for institutional and government Basis for inclusion in the high volume estimated
pharmacies is defined as the actual cost of acquisition acquisition cost list includes but is not limited to:
for the drug dispensed or the MAC, or the high
volume EAC, whichever is less. (1) Single source manufacturers;
(2) High volume Medicaid recipient utilization;
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on (3) Interchangeability problems with multiple source
generic drugs. Override requires prior authorization drugs;
with explanation of medical necessity (Med Watch
form). (4) Package sizes in excess of 100.

Drug Pricing: The Department will maintain a drug-


The State MAC is the maximum ingredient cost
pricing file that will be updated at least monthly. The
allowed by the Department for certain multiple-
average wholesale price of a drug as determined by
source drugs. The establishment of a MAC is
the Department, MAC, and high volume EAC, will
subject, but not limited to, the following
be the basis for setting the prices in the drug pricing
considerations:
file.
(1) Multiple manufacturers;
The Department will determine the average
(2) Broad wholesale price span; wholesale price that will be placed in the drug-
(3) Availability of drugs to retailers at the selected pricing file as follows:
cost;
(1) The average wholesale price as it appears in the
(4) High volume of Medicaid recipient utilization; Red Book, its supplements, and Medi-Span will be
(5) Bioequivalence or interchangeability. the first source. However, if there is a difference
between the two published average wholesale prices,
When Federal MAC limits for multiple source drugs the Department will set the price as the published
are announced, they will be adopted if they are less amount which is the closest to the lowest average
than State MACs or if no State MACs exist. price charged by two drug wholesalers doing
business in Colorado.
The ingredient cost of any drug subject to MAC shall
be limited to MAC or wholesale price as determined (2) If there is a price change which does not appear
by the Department, whichever is less. Exceptions immediately in the Red Book, its supplements, or in
that will allow reimbursement greater than MAC for Medi-Span, then the Department will set the average
a drug entity are obtained through a prior wholesale price by averaging the wholesale prices of
authorization mechanism. An exception will be three drug wholesalers doing business in Colorado,
granted if the patient’s response to the generic drug is until the price is published in the Red Book, its
not therapeutic, an allergic reaction is involved, or supplements, or in Medi-Span.
any similar situation exists.
(3) If the prices or changes do not appear in the
If a recipient requests a brand name for a prescription publications or the wholesalers’ records, then the
that is subject to MAC, then he/she may pay the distributors’ or manufacturers’ prices will be adjusted
ingredient cost difference between the MAC and to the wholesale pricing level and used in the drug
brand name drug. The recipient must sign the pricing file as the price of the drug.
prescription stating that he/she is willing to pay the

Colorado-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

If the difference between the pharmacist’s invoice 600 South Cherry Street, Suite 800
purchase price and the average wholesale price which Denver, CO 80222
appears in the Red Book, its supplements, or Medi- 303/355-6707
Span exceeds 18%, then the Department may adopt a
lower price after a survey is conducted to determine Community Health Plan of the Rockies
the validity of the published prices. The price from 400 South Colorado Boulevard, Suite 300
the distributor or manufacturer will be adjusted the Denver, CO 80222
same as in 3 above. 303/355-3220
Special Note: The Maximum Allowable Cost shall be
United Healthcare
determined by the Division of Medical Assistance,
6251 Greenwood Plaza Boulevard, Suite 200
based upon professional determination of a quality
Englewood, CO 80111-4910
product available at the least expense possible.
303/267/3594
Exceptions to the above are:
- Shelf package size oral liquid medications, in pint F. STATE CONTACTS
size only, or smaller package size when not packaged
in pint size.
Medicaid Drug Program Administrator
- Shelf package size oral tablet and capsule
medications in quantities of 100 only or smaller Martha Warner
when not available in package size of 100. Pharmacy Supervisor
Department of Health Care Policy and Financing
- Prescriptions for less than minimum amounts will 1570 Grant Street
be denied reimbursement of the professional fee Denver, CO 80203
unless the physician notified the Department in T: 303/866-3176
writing of the medical need for amounts less than a F: 303/866-2573
30-day supply. Medical consultation determines the E-mail: martha.warner@state.co.us
decision.

Incentive Fee: None. DUR Contact

Patient Cost Sharing: $3.00 Catherine Travgott


Pharmacist
Cognitive Services: Does not pay for cognitive Department of Health Care Policy and Financing
services. 1570 Grant Street
Denver, CO 80203
T: 303/866-2468
E. USE OF MANAGED CARE F: 303/866-2578
E-mail: Catherine.travgott@state.co.us
Over 260,000 Medicaid recipients were enrolled in
managed care in FY 2001. Recipients receive
New Brand Names Products Contact
pharmaceutical benefits through the Managed Care
Organization. Catherine Travgott
303/866-2468
Managed Care Organizations
Total Long-Term Care Prescription Price Updating
303 East 17th Avenue, Suite 650
Martha Warner
Denver, CO 80203
303/866-3176
303/896-4664
Kaiser Permanente
10350 East Dakota Avenue
Denver, CO 80905
303/344-7250
Rocky Mountain HMO
2775 Crossroads Boulevard
Grand Junction, CO 81506
800/843-0719
Colorado Access

Colorado-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Medicaid Drug Rebate Contacts Health Care Policy & Financing Department
Officials
Vince Sherry
Drug Rebate Manager Karen K. Reinertson
Department of Health Care Policy and Financing Executive Director
1570 Grant Street Department of Health Care Policy and Financing
Denver, CO 80203 1570 Grant Street
T: 303/866-5408 Denver, CO 80203-1818
F: 303/866-2573 T: 303/866-2993
E-mail: vince.sherry@state.co.us F: 303/866-4411
E-mail: Karen.reinertson@state.co.us
Internet Address: www.chcpf.state.co.us
Claims Submission Contact
ACS, Inc. Vivianne M. Chavmont, Director
600 17th Street Medical Assistance Office
Suite 600 North Department of Healthcare Policy and Financing
Denver, CO 80202 1570 Grant Street
T: 800/237-0757 Denver, CO 80203
F: 303/534-0439 303/866-3058

Medicaid Managed Care Contact Medical Services Board


Katie Brookler Michael Oliva, President
Managed Care Manager Julie Reiskin, Vice President
Department of Health Care Policy and Financing Mary Ellen Faules
1570 Grant Street Joan M. Johnson
Denver, CO 80203 Wendal Phillips
T: 303/866-2416 Joe Rall
F: 303/866-2573 Maguerite Salazar
E-mail: katie.brookler@state.co.us Steve Tool
Mathew Dunn, M.D.
Jeremy Schupbach, Coordinator
Disease Management/Patient Education
Programs
Medical Advisory Council
Disease/Medical State: Schizophrenia
Program Name: Schizophrenia with Co-Morbid Donald W. Schiff, M.D.
Conditions Pilot Program 600 Front Range Road
Program Manager: Gloria Johnson Littleton, CO 80120
Sponsor: Eli Lilly and Company 303/837-2745

Disease/Medical State: Diabetes Molly A. Markert


Program Name: Diabetes Disease Management Pilot 11060 E. Wesley Pl.
Program Aurora, CO 80014
Program Manager: Gloria Johnson 303/756-7234
Sponsor: Eli Lilly and Company
Mary Jo Jacobs, M.D.
7425 E. Kenyon Ave.
Disease Management/Patient Education Denver, CO 80237
Contact 303/694-2878
Katie Brookler, 303/866-2416 Walter Daniels, D.D.S.
1633 Filmore Street
Mail Order Pharmacy Program Denver, CO 80206
303/388-0989
None
Rodney Fair, O.D.
105 Bridge Street
Brighton, CO 80601
303/659-3036
Douglas Clinkscales

Colorado-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Denver Health and Hospitals Val Kalnins, R.Ph., Executive Director


777 Bannock Street 6825 E. Tennessee Avenue, Suite 440
Denver, CO 80204 Denver, CO 80224-1662
303/426-7253 T: 303/756-3069
F: 303/756-3649
Cathy Corcoran E-mail: val@copharm.org
15920 W. 66th Place Internet address: www.copharm.org
Golden, CO 80403
303/861-6256 Colorado Society of Osteopathic Medicine
Marie Kowalsky
Ernestine Kotthoff-Burrell Executive Director
6098 S. Iola Ct. 650 South Cherry Street, Suite 440
Englewood, CO 80111 Denver, CO 80246
303/270-8974 T: 303/322-1752
F: 303/332-1956
Carol Bartley E-mail: coloradodo@aol.com
Denver VNA Internet address: www.coloradodo.org
3801 E. Florida Ave., Suite 800
Denver, CO 80201 Colorado State Board of Pharmacy
303/753-7312 Susan L. Warren
Program Administration
Mary Ellen Kuhlman, MSW 1560 Broadway, Suite 1310
St. Mary’s Hospital & Medical Center Denver, CO 80202-5146
P.O. Box 1628 T: 303/894-7750
Grand Junction, CO 81502 F: 303/894-7764
970/244-2273 E-mail: pharmacy@dora.state.co.us
Internet address: www.dora.state.co.us/pharmacy
Dan Stenerson
Shalom Park Colorado Health and Hospital Association
14800 E. Belleview Larry H. Wall
Aurora, CO 80015 President
303/680-5000 7335 East Orchard Road, Suite 100
Greenwood Village, CO 80111-2512
Mark Kunart, D.O. T: 720/489-1630
17200 E. Iliff Avenue F: 720/489-9400
Aurora, CO 80013 Internet address: www.cha.com
303/755-4111

Robert Slay
Jefferson Co. CCB
7456 W. 5th Avenue
Lakewood, CO 80226
303/233-3363 x366

Executive Officers of State Medical and


Pharmaceutical Societies
Colorado Medical Society
Sandra L. Maloney
Executive Director
7351 Lowry Boulevard
Denver, CO 80230
T: 720/859-1001
F: 303/771-8659
E-mail: sandi_maloney@cms.org
Internet address: www.cms.org

Colorado Pharmacists Society

Colorado-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

CONNECTICUT

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002*
Expenditures Recipients Expenditures Recipients
TOTAL $304,470,534 116,755 $357,919,257

RECEIVING CASH ASSISTANCE, TOTAL $85,509,574 29,004


Aged $14,661,696 6,146
Blind/Disabled $70,113,706 17,814
Child $176,052 2,598
Adult $558,120 2,446

MEDICALLY NEEDY, TOTAL $89,643,018 29,417


Aged $21,970,885 10,353
Blind/Disabled $67,436,637 18,548
Child $91,458 283
Adult $144,038 233

POVERTY RELATED, TOTAL $3,750,393 5,721


Aged $644,493 700
Blind/Disabled $2,152,958 1,089
Child $877,998 2,974
Adult $74,944 958

TOTAL OTHER EXPENDITURES/RECIPIENTS* $125,567,549 52,613

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable
Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Connecticut-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Formulary/Prior Authorization

State of Connecticut Department of Social Services Formulary: Open formulary, however, the following
through three regional offices and twelve sub-offices. products are excluded from Medicaid prescription
coverage: experimental drugs, cosmetics, fertility
D. PROVISIONS RELATING TO DRUGS drugs; smoking cessation products; DESI drugs, and
drugs available free from the Department of Health
Benefit Design Services.

Drug Benefit Product Coverage: Products covered: Prior Authorization: State does not currently have a
prescribed insulin, disposable needles and syringe prior authorization procedure.
combinations for insulin; blood glucose test strips;
urine ketone test strips; total parenteral nutrition
(except in NH); and interdialytic parenteral nutrition Prescribing or Dispensing Limitations
(except in NH). Products not covered: cosmetics; Prescription Refill Limit: 5 refills per prescription
fertility drugs; experimental drugs; and weight loss except for oral contraceptives, which have a 12-
products. month limit.
Over-the-Counter Product Coverage: Products Monthly Quantity Limit: Maximum 240 tablets or
covered: cough and cold preparations (children < 19 capsules/30 day supply. Oral contraceptives: 3
years) and topical products. Products covered with months supply may be dispensed at one time.
restrictions: digestive products (non H2 antagonists)
– liquid generics only; and digestive products (H2 Physicians are encouraged to prescribe drugs
antagonists) – legend drugs not covered; birth control generically, when possible.
products; antihistamines; and decongestants.
Products not covered: smoking deterrent products; Drug Utilization Review
allergy, asthma and sinus products; analgesics;
feminine products; iron; calcium; and some trace Pro-DUR system implemented September 1996.
elements. For nursing home patients, the department Retro-DUR since September 1991; the State
will not pay for OTC drugs used in nursing facilities currently has a 9 member DUR Board with a
(such drugs are covered in the per diem rate). Some quarterly review.
drugs require diagnosis for reimbursement such as
CNS stimulants for ADD and narcolepsy. Pharmacy Payment and Patient Cost Sharing
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; analgesics, Dispensing Fee: $3.30, effective 10/1/03.
antipyretics, NSAIDs; antibiotics; anticoagulants; Ingredient Reimbursement Basis: EAC = AWP-12%.
anticonvulsants; antidepressants; antidiabetic agents; Special rules for Factor VIII (AAC + 8%), OTCs
antihistamine drugs; antilipemic agents; anti- (AWP x # units x 1.15), and neutral and parenteral
psychotics; anxiolytics, sedatives, and hypnotics; nutritionals (AWP x # units x 1.15).
cardiac drugs; chemotherapy agents; prescribed cold
medications; contraceptives; ENT anti-inflammatory Prescription Charge Formula: Federal MAC or EAC
agents; estrogens; hypotensive agents; misc. GI plus dispensing fee; or usual and customary if lower.
drugs; sympathominetics (adrenergic); thyroid Special rules for blood factor VIII and
agents; and growth hormones. Therapeutic enteral/parenteral nutrition products.
categories not covered: anorectics and prescribed
smoking deterrents. Maximum Allowable Cost: State imposes Federal
Upper Limits on generic drugs. Effective 1/1/2003,
Coverage of Injectables: Injectable medicines the Department implemented a state MAC to include
reimbursable through physician payment when used in additional multi-source generic products that are not
home health care, extended care facilities, and in on the FUL list. The State MAC reimbursement is
physicians offices. AWP-40%.

Vaccines: Vaccines reimbursable as part of the Patient Cost Sharing: None.


Children Health Insurance Program.
Cognitive Services: Does not pay for cognitive
Unit Dose: Unit dose packaging not reimbursable. services.

Connecticut-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

E. USE OF MANAGED CARE Department of Social Services


Administrative Officials
Connecticut has approximately 290,000 Medicaid Patricia A. Wilson-Coker
recipients enrolled in managed care. Pharmaceutical Commissioner
benefits received through the managed care plan. Department of Social Services
25 Sigourney Street
Managed Care Organizations Hartford, CT 06016-5033
T: 860/424-5008
Anthem Blue Cross/Blue Shield of CT F: 860/566-2022
Blue Care Family Plan E-mail: pat.wilson-coker@po.state.ct.us
Paula Smyth, Director
Medicaid Managed Care Claudette Beaulieu, Deputy Commissioner
370 Bassett Road 860/424-5010
North Haven, CT 06473-4201
T: 203/654-3506 Michael Starkowski, Deputy Commissioner
F: 203/234-5310 860/424-5053
Community Health Network of CT David Parrella, Director
Sylvia Kelly, CEO Medical Care Administration
290 Pratt - 2nd Floor 860/424-5177
Meriden, CT 06450
T: 203/237-4000 Rose Ciarcia, Director
F: 203/634-8411 25 Sigourney Street
Hartford, CT 06106
Health Net 860-424-5139
Janice Perkins, Vice President E-mail: rose.ciarcia@po.state.ct.us
One Far Mill Crossing, Box 904
Shelton, CT 06484-0944 Michelle Parsons, Manager
T: 203/225-8630 Alternate Care Unit
F: 203/225-4175 860/424-5177
First Choice of CT, Preferred One Marcia Mains, Director
Douglas Hayward, Chief Operating Officer Medical Operations
23 Maiden Lane 860/424-5219
North Haven, CT 06473
T: 203/239-7444 Evelyn Dudley
F: 203/239-3381 Pharmacy Program Manager
860/424-5654

F. STATE CONTACTS
DUR Contact

Medicaid Drug Program Administrator James Zakszewski, R.Ph.


Pharmacy Consultant
Evelyn A. Dudley Department of Social Services
Pharmacy Program Manager 25 Sigourney Street
Department of Social Services Hartford, CT 06106
Medical Operations Unit #4 T: 860/424-5150
25 Sigourney Street F: 860/424-5206
Hartford, CT 06106 E-mail: james.zakszewski@po.state.ct.us
T: 860/424-5654
F: 860/424-5206
E-mail: evelyn.dudley@po.state.ct.us
Internet address: www.ctmedicalprogram.com

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Connecticut DUR Board Medicaid Managed Care Contact


Kenneth Fisher, R.Ph. Rose Ciarcia
Brooks Pharmacy 860/424-5139

Arturo Morales, M.D.


Mail Order Pharmacy Program
St. Francis Hospital
None
Lori Jane Duntz Lord, R.Ph.
Greenville Drug Elderly Drug Coverage Program Contact

Dennis J. Chapron, R.Ph. Evelyn Dudley


Pharmokinetics Lab 860/424-5654

Keith Lyke, R.Ph. Physician-Administered Drug Program


Pelton’s Pharmacy Contact

Frederick N. Rowland, M.D. Timothy Bowles, Medical Policy


St. Francis Hospital and Medical Center 25 Sigourney Street
Hartford, CT 06106
Richard Gannon, Pharm.D. 860/424-4984
Hartford Hospital
State Pharmacy Commission
Kathryn Mashey, DPM
Community Health Services William Summa, P.D., Chairman

Michael Moore, R.Ph. Executive Officers of State Medical and


Hebrew Home Hospital Pharmaceutical Societies
State Medical Society
Prescription Price Updating Timothy B. Norbeck, Executive Director
Ellen Arce, R.Ph. 160 St. Ronan Street
Pharmacy Manager New Haven, CT 06511-2390
Electronic Data Systems T: 203/865-0587
100 Stanley Street F: 203/865-4997
New Britain, CT 06053 E-mail: tnorbeck@csms.org
860/832-5885 Internet address: www.csms.org

Connecticut Pharmacists Association


Medicaid Drug Rebate Contacts Margherita R. Guiliano, R.Ph. Executive V.P.
Mark Heuschkel 35 Cold Spring Road, Suite 124
Lead Planning Analyst - Pharmacy Rocky Hill, CT 06067-3161
Department of Social Services T: 860/563-4619
Medical Operations Unit #4 F: 860/257-8241
25 Sigourney Street E-mail: mguiliano@ctpharmacists.org
Hartford, CT 06106 Internet address: www.ctpharmacists.org
T: 860/424-5347
F: 860/424-5206 Connecticut Osteopathic Medical Society
E-mail: mark.heuschkel@po.state.ct.us Donald Halpin, Executive Director
P.O. Box 487
Ellen Arce, R.Ph. (Rebates & Disputes) Winchester, MA 01800-0487
860/832-5885 T: 781/721-9900
F: 781/721-4400
E-mail: don@northeastosteo.org
Claims Submission Contact Internet address: www.northeastosteo.org
Ellen Arce, R.Ph.
860/832-5858

Connecticut-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Pharmacy Commission & Drug Control Division


Michelle Sylvestre, R.Ph.
Board Administrator
State Office Building
165 Capitol Avenue, Room 147
Hartford, CT 06106
T: 860/713-6070
F: 860/713-7242
E-mail: michelle.sylvestre@po.state.ct.us
Internet address:
www.ctdrugcontrol.com/rxcommission.htm

Connecticut Hospital Association, Inc.


Jennifer Jackson
President and CEO
110 Barnes Road
P.O. Box 90
Wallingford, CT 06492-0090
T: 203/265-7611
F: 203/284-9318
Internet address: www.chime.org

Connecticut-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Connecticut-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

DELAWARE

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 ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients
TOTAL $81,623,058 85,351 $97,750,161

RECEIVING CASH ASSISTANCE, TOTAL $52,023,939 62,035


Aged $5,833,794 2,470
Blind/Disabled $27,480,662 9,724
Child $7,259,311 31,503
Adult $11,450,172 18,338

MEDICALLY NEEDY, TOTAL $0 -


Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $1,423,154 3,654


Aged $145,083 132
Blind/Disabled $533,696 282
Child $718,597 3,103
Adults $25,778 137

TOTAL OTHER EXPENDITURES/RECIPIENTS* $28,175,965 19,662


*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Delaware-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Prior Authorization: State currently has a formal


prior authorization procedure. Standard procedures
Division of Social Services, Department of Health for clients to request a fair hearing to appeal prior
and Social Services, through three county offices of authorization decisions.
the State agency.
Prescribing or Dispensing Limitations
D. PROVISIONS RELATING TO DRUGS Prescription Refills: Prescription blank has space for
physician to authorize renewals.
Benefit Design
Monthly Quantity Limit: Greater of 34-day supply or
Drug Benefit Product Coverage: Products covered: 100 dosing units.
prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test Monthly Dollar Limits: None.
strips; urine ketone test strips; and total parenteral
nutrition. Products covered with restrictions: Drug Utilization Review
interdialytic parenteral nutrition. Products not
covered: cosmetics; fertility drugs; and experimental PRODUR system implemented in August 1994. State
drugs. has a DUR Board that meets bimonthly.

Over-the-Counter Product Coverage: Products Pharmacy Payment and Patient Cost Sharing
covered: allergy, asthma and sinus products;
analgesics; cough and cold preparations; digestive Dispensing Fee: $3.65.
products; and topical products. Products covered
with restrictions: smoking deterrent products (prior Ingredient Reimbursement Basis: EAC = AWP-
authorization and quantity limits). Products not 14.0%. (AWP-16% for LTC)
covered: feminine products.
Prescription Charge Formula: Payment is based on
Therapeutic Category Coverage: Therapeutic AWP-14.0% or maximum allowable cost (MAC)
categories covered: anabolic steroids; anticoagulants; plus a dispensing fee, or the usual and customary cost
anticonvulsants; antidepressants; antidiabetic agents; to the general public, whichever is lower.
antihistamine drugs; antilipemic agents; anxiolytics,
sedatives, and hypnotics; cardiac drugs; Maximum Allowable Cost: State imposes Federal
chemotherapy agents; prescribed cold medications; Upper Limits as well as State-specific limits on
contraceptives; ENT anti-inflammatory agents; generic drugs. Override requires completion of an
estrogens; hypotensive agents; misc. GI drugs; FDA MedWatch form.
sympathominetics (adrenergic); and thyroid agents.
Prior authorization required for: analgesics, Incentive Fee: None.
antipyretics, and NSAIDs; anoretics; antibiotics; anti-
psychotics; growth hormones; prescribed smoking Patient Cost Sharing: None.
deterrents; Regranex; Zyvox; Soma Accutane Cipro;
Cholinesterase inhibitors; Modafanil; and Epoetin. Cognitive Services: Does not pay for cognitive
services.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program
when used in home health care and extended care
facilities, and through physician payment when used
in physicians’ offices.

Vaccines: Vaccines reimbursable under the Vaccines


for Children program.

Unit Dose: Unit dose packaging not reimbursable.


Formulary/Prior Authorization
Formulary: Open formulary.

Delaware-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

E. USE OF MANAGED CARE Prescription Price Updating


Dan Cohn
Approximately 90,000 Medicaid recipients were DSS/EDS
enrolled in MCOs in FY 2002. Recipients receive 248 Chapman Road, Suite 100
pharmaceutical benefits through the State. Newark, DE 19702
T: 302/453-8453
Managed Care Organizations F: 302/454-0224
DelawareCare
2751 Centerville Road, Suite 400 Medicaid Drug Rebate Contacts
Wilmington, DE 19808 Frank Long
215/937-8285 Contracts Manager
DSS
First State Health Plan Herman Holloway Campus
1801 Rockland Road, Suite 300 Lewis Building
Wilmington, DE 19803 1901 North DuPont Highway
302/576-7603 New Castle, DE 19720
T: 302/255-9624
F. STATE CONTACTS F: 302/255-4425

State Drug Program Administrator Medicaid Drug Rebate Contact

Cynthia R. Denemark, R.Ph. Audits:


Director of Pharmacy Services Frank Long
DSS/EDS 302/255-9624
248 Chapman Road, Suite 100
Newark, DE 19702 Disputes:
T: 302/453-8453 Lynessa Tejeda
F: 302/454-0224 Rebate Analyst
E-mail: cynthia.denemark@eds.com EDS
Internet address: www.dmap.state.de.us 248 Chapman Road, Suite 100
Newark, DE 19702
T: 302/456-8453
Prior Authorization Contact F: 302/454-0224
Cynthia R. Denemark, R.Ph.
302/453-8453 Claims Submission Contact
Jose Tieso
DUR Contact System Manager
Cynthia R. Denemark, R.Ph. EDS
302/453-8453 248 Chapman Rd, Suite 100
Newark, DE 19702
T: 302/453-8453
DUR Board F: 302/454-0224
Calvin Freedman, R.Ph.
Marvin H. Dorph, M.D. Medicaid Managed Care Contact
Richard Steele, R.Ph. Glynne Williams
Sharon Wisneski, R.N., M.S. Health Care Cost Containment Specialist
Mark Borer, M.D. DSS
Nadia Zalusky, R.Ph. Herman Holloway Campus
Chris Sual, R.Ph. Lewis Building
Frank Falco, M.D. 1901 North DuPont Highway
New Castle, DE 19720
New Brand Name Products T: 302/255-9628
Cynthia R. Denemark, R.Ph. F: 302/255-4425
302/453-8453

Delaware-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Mail Order Pharmacy Benefit Executive Officers of State Medical and


Pharmaceutical Societies
None
Medical Society of Delaware
Mark Meister, Sr.
Health and Social Services Department
Executive Director
Officials
131 Continental Drive, Suite 405
Vincent P. Meconi Wilmington, DE 19713
Secretary T: 302/658-7596
Dept. of Health & Social Services F: 302/658-9669
1901 North DuPont Highway E-mail: mama@medsocdel.org
New Castle, DE 19720 Internet address: www.medsocdel.org
T: 302/255-9040
F: 302/255-4429 Delaware Pharmacists Society
E-mail: vmeconi@state.de.us Patricia Carroll-Grant, R.Ph., CDE
Executive Director
Philip P. Soulé P.O. Box 454
Deputy Director Smyrna, DE 19977-0454
Medicaid Division T: 302/659-3088
Dept. of Health & Social Services F: 302/659-3089
1901 North DuPont Highway E-mail: questions@depharmacy.net
New Castle, DE 19720 Internet address: www.depharmacy.net
T: 302/255-9501
F: 302/255-4425 Osteopathic Medical Society
E-mail: psoule@state.de.us Edward Sobel, D.O.
Executive Director
P.O. Box 8177
Medical Advisory Committee Members Talleyville, DE 19803-8177
Susan Ebner T: 302/764-1198
Anne Aldridge, M.D. F: 302/764-1322
Caroline Vecchiolla E-mail: info@deosteopathic.org
Neil McLaughlin Internet address: www.deosteopathic.org
Richard Cherrin
Kevin Sheahan State Board of Pharmacy
Bob Welch David W. Dryden, R.Ph., J.D.
John A. Forrest, Jr., M.D. Executive Secretary
Mark Meister P.O. Box 637
Olga Ramirez Dover, DE 19903
Penny D. Chelucci T: 302/744-4547
Joseph Letnaunchyn F: 302/739-3071
Al Pilong E-mail: david.dryden@state.de.us
George English Internet address:
Michael Glacken, M.D. www.professionallicensing.state.de.us
Daniese McMullin-Powell
Leonard Nitowski, M.D. Delaware Healthcare Association
Julia M. Pillsbury, D.O. Joseph M. Letnaunchyn
Ulder Jane Tillman, M.D. President & CEO
Yrene E. Waldron 1280 South Governors Avenue
Anne M. Allen Dover, DE 19904-4802
Theodore Gregory T: 302/674-2853
Ellen M. Steele F: 302/734-2731
Kim L. Carpenter, M.D. E-mail: joelet@deha.org
Internet address: www.deha.org

Delaware-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

DISTRICT OF COLUMBIA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/ Child Adult Aged Blind/ Child Adult
Disable Disabled
d
Prescribed Drugs ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Inpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Outpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Laboratory & X-ray Service ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Nursing Facility Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Physician Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Dental Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $62,292,004 35,324 $66,129,208

RECEIVING CASH ASSISTANCE TOTAL $42,750,082 22,033


Aged $3,745,744 2,262
Blind/Disabled $37,256,814 14,440
Child $358,540 2,063
Adult $1,388,984 3,268

MEDICALLY NEEDY, TOTAL $7,930,965 4,980


Aged $1,637,536 819
Blind/Disabled $5,639,520 2,399
Child $128,355 853
Adult $525,554 909

POVERTY RELATED, TOTAL $8,495,578 5,135


Aged $2,772,481 1,513
Blind/Disabled $5,511,608 1,858
Child $195,736 1,575
Adult $15,753 189

TOTAL OTHER EXPENDITURE/RECIPIENTS $3,115,379 3,176

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2000 and CMS-64 Report, FY 2002.

District of Columbia-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Vaccines: Vaccines reimbursable at cost as part of


the EPSDT service.
The District of Columbia Department of Health
(DOH), Medical Assistance Administration. Unit Dose: Unit dose packaging not reimbursable

D. PROVISIONS RELATING TO DRUGS Formulary/Prior Authorization

Benefit Design Formulary: Open formulary with restrictions on use,


prior authorization, and therapeutic substitution.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Prescribing or Dispensing Limitations
combinations used for insulin; and ferrous sulfate.
Products covered with restrictions: (e.g., long-term Monthly Quantity Limit: In general, amounts
care only): total parenteral nutrition; (greater flow) dispensed are to be limited to quantities sufficient to
Prior authorization required for: cosmetics (25 years treat an episode of illness. Maintenance drugs such
of age); injectable drugs administered on an as thyroid, digitalis, etc. may be dispensed in
outpatient basis; anorexic drugs for treatment of amounts up to a 30-day supply with 3 refills that
narcolepsy and minimal brain dysfunction in must be dispensed within 4 months. Antibiotic
children; acute anti-ulcer drugs, and brand NSAIDs. medications used in treatment of acute infections are
Products not covered: anesthetics; infant formulas; not to be dispensed in excess of a 10-day supply.
cold tar preparations; ostomy products; diagnostic Birth control tablets may be dispensed in 3-cycle
products; reusable needles/syringes (non-insulin); units with a maximum of 3 refills within one year.
and all other non-legend items. Monthly Dollar Limits: $1,500 limit. Physicians are
to request prior authorization for prescriptions that
Over-the-Counter Product Coverage: Products exceed this amount.
covered with restrictions: oral analgesics; oral
antacids; contraceptive foams and jellies; prenatal,
pediatric and geriatric vitamins; and bowel Drug Utilization Review
preparation kits. Products not covered: allergy,
asthma, and sinus products; cough and cold PRODUR system implemented in September 1996.
preparations; digestive products (H2 antagonists); Provider/subscriber may appeal denials by writing to
feminine products; topical products; and smoking the District of Columbia Medicaid Program.
deterrent products.
Pharmacy Payment and Patient Cost Sharing
Therapeutic Category Coverage: Therapeutic
categories covered: antibiotics; anticoagulants; Dispensing Fee: $4.50.
anticonvulsants; anti-depressants; antidiabetic agents;
antihistamines; antilipemic agents; anti-psychotics; Ingredient Reimbursement Basis: AWP-10%.
anxiolytics; sedatives; and hypnotics; cardiac drugs;
chemotherapy agents; prescribed cold medications; Prescription Charge Formula: The lesser of: FUL or
contraceptives; ENT anti-inflammatory agents; the AWP-10% plus the dispensing fee or usual and
estrogens; hypotensive agents; prescribed smoking customary to the public.
deterrents; and thyroid agents. Prior authorization
required for: analgesics, antipyretics, and NSAIDs; Maximum Allowable Cost: State imposes Federal
anoretics; growth hormones; misc. GI drugs; Upper Limits on generic drugs. Override requires
sympathominetics (adrenergic); erectile dysfunction “Brand Medically Necessary” plus prior
products; multisource brands; Medicare-covered authorization.
drugs; Levocamitine; Hepatitis C; and Synagis.
Incentive Fee: None.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program Patient Cost Sharing: $1.00 copay by recipient.
when used in home health care and extended care Does not apply to recipients under 18, prescriptions
facilities, and through physician payment when used for family planning, nursing home patients, or
in physicians offices’. pregnancy related.

Cognitive Services: Does not pay for cognitive


services.

District of Columbia-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

E. USE OF MANAGED CARE DUR Contact


Donna Bovell, R.Ph.
Approximately 80,000 Medicaid recipients were 202/442-5988
enrolled in managed care in 2002. Recipients
enrolled in managed care receive pharmaceutical
benefits through managed care plans. District of Columbia DUR Board
Christopher Keeyes, Pharm.D. (Chair)
Managed Care Organizations President, Clinical Pharmacy Associates
11710 Beltsville Drive, Suite 510
Advantage Health Plan, Inc. Calverton, MD 20705
P.O. Box 9596 301/572-1616
Washington, DC 20016
202/686-8555 Martin Dillard, M.D. (Vice Chair)
Assistant Dean for Clinical Affairs
American Preferred Provider Plan Mid-Atlantic, Inc. Chief, Division of Nephrology
1501 M Street, NW, Suite 500 Howard University Hospital
Washington, DC 20002 2041 Georgia Avenue, NW, Suite 5C02
202/408-0460 Washington, DC 20060
202/865-1191
D.C. Chartered Health Plan
820 First Street, NE, Suite LL100 Howard Robinson, R.Ph.
Washington, DC 20002 Manager, Central Pharmacy
202/408-4710 Greater Community Hospital
1310 Southern Avenue, SE
Capitol Community Health Plan Washington, DC 20032
750 First Street, NE, Suite 1120
Washington, DC 20002 Dr. Kim Bullock
202/408-0460 Providence Hospital
Emergency Room
George Washington University Health Plan 1150 Varnum St., NE
4550 Montgomery Avenue Washington, DC 20017
Bethesda, MD 20814 202/269-7863
301/941-2044

Health Right, Inc. Prior Authorization Contacts


3020 14th Street, NW
Donna Bovell, R.Ph.
Washington, DC 20009
202/442-5988
202/518-2370

Prudential Health Care Plan Medicaid Drug Rebate Contacts


2800 N. Charles Street
Technical: Ken Boni
Baltimore, MD 21218
202/965-7400
410/554-7224
Policy: Donna Bovell, R.Ph.
F. STATE CONTACTS 202/442-5988

State Drug Program Administrator DUR: Donna Bovell, R.Ph.


202/442-5988
Donna Bovell, R.Ph.
Pharmacist Consultant
Medical Assistance Administration New Brand Name Products Contact
Department of Health Donna Bovell, R.Ph.
825 North Capitol Street, NE 202/442-5988
Washington, DC 20002
T: 202/442-5988
F: 202/442-4790
E-mail: donna.bovell@dcgov.org

District of Columbia-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Prescription Price Updating Contact Executive Officers of District Medical and


Pharmaceutical Societies
Glenn Sharp
Clinical Account Manager Medical Society of the District of Columbia
First Health Service Corporation K. Edward Shanbacker
4300 Cox Road 2175 K Street, NW, Suite 200
Glen Allen, VA 23060 Washington, DC 20037
T: 804/965-7447 T: 202/466-1800
F: 804/273-6961 F: 202/452-1542
E-mail: sharpgl@fhsc.com E-mail: shanbacker@msdc.org
Internet address: www.msdc.org
Claims Submission Contact
Washington D.C. Pharmacy Association
Anita Martin Herbert Kwash, R.Ph., President
Manager-Plan Administration 908 Caddington Avenue
First Health Service Corporation Silver Spring, MD 20901-1109
4300 Cox Road T: 301/539-3292
Glen Allen, VA 23060 F: 301/539-7215
T: 804/965-7425 E-mail: mldpharm@aol.com
F: 804/273-6961
E-mail: camartin@fhsc.com Osteopathic Association of the District of Columbia
K. Joseph Heaton, D.O., President
2517 North Glebe Road
Medicaid Managed Care Contact Arlington, VA 22207
Donna Bovell, R.Ph. T: 703/522-8404
202/442-5988 F: 703/522-2692

DC Board of Pharmacy
Mail Order Pharmacy Program Graphelia Ramseur
None Health Licensing Specialist
825 North Capitol Street, NE, Room 224
Washington, DC 20002
Department of Human Services Officials T: 202/442-4776
James A. Buford F: 202/442-9431
Director E-mail: gramseur@dchealth .com
Department of Health Internet address: www.dchealth.dc.gov/prof_license
825 North Capitol Street, NE
Fourth Floor District of Columbia Hospital Association
Washington, DC 20002 Robert Malson, President
T: 202/442-5999 1250 Eye Street, NW, Suite 700
F: 202/442-4788 Washington, DC 20005-3980
E-mail: james.buford@dc.gov T: 202/682-1581
F: 202/371-8151
Robert Maruca E-mail: rmalson@dcha.org
Senior Deputy Director Internet address: www.dcha.org
Medical Assistance Administration
Department of Health
825 North Capitol Street, NE
Fifth Floor
Washington, DC 20002
T: 202/442-5988
F: 202/442-4790
E-mail: robert.maruca@dc.gov
Internet address: www.dchealth.dc.gov

District of Columbia-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

FLORIDA

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $1,487,935,645 1,159,155 $1,714,883,612 1,179,944

RECEIVING CASH ASSISTANCE TOTAL $893,222,135 552,401 $1,026,862,696 576,092


Aged $152,426,910 78,408 $170,850,446 79,748
Blind/Disabled $661,129,209 231,074 $750,274,442 235,685
Child $34,626,972 154,340 $46,013,540 170,004
Adult $45,039,044 88,579 $59,724,268 90,655

MEDICALLY NEEDY, TOTAL $62,753,603 24,089 $118,805,473 33,216


Aged $3,522 5 $31,545 21
Blind/Disabled $50,596,537 8,873 $120,427,359 16,970
Child $2,620,115 3,179 $2,360,440 2,997
Adult $9,533,429 12,032 $15,986,129 13,228

POVERTY RELATED, TOTAL $312,171,444 350,262 $336,992,042 397,152


Aged $116,037,164 63,790 $100,463,428 56,777
Blind/Disabled $143,969,419 43,100 $145,453,276 41,099
Child $48,125,864 217,570 $60,847,477 230,119
Adult $4,038,997 25,802 $10,227,861 69,157

TOTAL OTHER EXPENDITURE/RECIPIENTS $219,788,463 232,403 $232,223,401 173,484

*Total other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data provided by the Florida Agency for Health Care Administration.
Source: CMS, MSIS Report, FY 2001 and Florida Medicaid Statistical Information System, FY 2002.

Florida-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Vaccines: Vaccines reimbursable as part of the


Vaccines for Children Program.
Agency for Health Care Administration. Claims
processing and payment by contract with fiscal agent. Unit Dose: Unit dose packaging reimbursable.

D. PROVISIONS RELATING TO DRUGS Formulary/Prior Authorization

Benefit Design Formulary: Preferred Drug List (PDL) with


mandatory limits and exclusions. All covered drugs
Drug Benefit Product Coverage: Products covered: are available through the preferred drug process.
prescribed insulin; disposable needles and syringe General exclusions include excluding products based
combinations used for insulin; blood glucose test on contracting issues, restrictions on use, prior
strips; total parenteral nutrition; and urine ketone test authorization and physician profiling. Specific limits
strips (children under age 21only). Prior and exclusions include:
authorization required for: Cytogam; Proleukin; 1. Vitamins and phosphate binders only for dialysis
Serostim; Albumin; Neutrexin; Provigil; Zoloft patients.
50mg; Paxil 10mg; Panretin gel; Regranex (long term 2. Prostheses; appliances; devices; and personal
care); Botox; and nutritional supplements and non- care items.
preferred items. Products not covered: cosmetics; 3. Non-legend drugs (except for prescribed insulin,
fertility drugs; experimental drugs; and interdialytic pancreatic enzymes, buffered and enteric coated
parenteral nutrition. aspirin when prescribed as an anti-inflammatory
agent only, and single entity hematinics).
Over-the-Counter Product Coverage: Products 4. Anorexants unless the drug is prescribed for an
covered with restrictions: allergy, asthma, and sinus indication other than obesity (i.e., narcolepsy,
products (select products); analgesics (Tylenol); hyperkinesis).
cough and cold preparations (select products); 5. Drugs with questionable efficacy as rated by
digestive products (H2 anatgonists-Prilosec OTC FDA (DESI).
only); topical products (select products); and 6. Investigational and experimental items.
feminine products. Products not covered: digestive 7. Oral vitamins with exception of fluorinated
products (non-H2 antagonists) and smoking deterrent pediatric vitamins prescribed for pediatric
products. patients, vitamins for dialysis patients, prenatal
vitamins.
Therapeutic Category Coverage: Therapeutic 8. Nursing home floor stock drugs.
categories covered: analgesics, antipyretics, NSAIDs;
antibiotics; anticoagulants; anticonvulsants; anti- Prior Authorization: State currently has a formal
depressants; antidiabetic agents; antihistamines; prior authorization procedure. Direct appeal to
antilipemic agents; antipsychotics; anxiolytics, AHCA and/or formal request for administrative
sedatives, and hypnotics; cardiac drugs; hearing required to appeal prior authorization
chemotherapy agents; contraceptives; ENT anti- decisions.
inflammatory agents; estrogens; growth hormones;
hypotensive agents; misc. GI drugs; prescribed
smoking deterrents; sympathominetics (adrenergic); Prescribing or Dispensing Limitations
and thyroid agents. Partial coverage for: anoretics;
prescribed cold medications. Prior authorization Prescription Refill Limit:
required for: anabolic steroids; drugs not included on 1. Limited to four brand name RX’s per month with
the Medicaid preferred drug list; and brand name exceptions for specific therapeutic groups.
prescriptions beyond the four brand cap unless Exemptions are: Anti-Retrovirals for HIV, Anti-
exempted. Therapeutic categories not covered: Psychotics, Depressants and Convulsants,
anoretics. Family Planning, and Diabetic supplies and
insulin, unlimited generic prescriptions.
Coverage of Injectables: Injectable medicines 2. Drugs not included in the Preferred Drug list
reimbursable through the Prescription Drug Program (PDL) require PA. Anti-retrovirals and mental
when used in home health care and extended care health are exempted.
facilities, and through both the Prescription Drug 3. Maintenance medication should be dispensed
Program and physician payment when used in and billed for at least a one-month supply.
physicians’ offices.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

4. Refills must be authorized by the prescriber E. USE OF MANAGED CARE


andcan be made for up to one year, except that
controlled substances can be refilled only in Approximately 600,000 Medicaid recipients (30% of
accordance with Federal and State regulations. all recipients) received pharmaceutical benefits
5. Nutritional supplements are covered with prior through managed care plans (inclusion of such
authorization when the patient is otherwise at benefits is mandated under State law) in 2002.
risk of hospitalization.
6. Other third parties, including Medicare, must be
billed first. Managed Care Organizations
Amerigroup Florida, Inc.
Drug Utilization Review (FKA Physicians Health Care Plans, Inc.)
4200 W. Cypress Street, Suite 900
PRODUR system implemented in July 1993. State Tampa, Fl 33607-4173
currently has a DUR board with a quarterly review. 800/600-4441
Retrospective Drug Utilization Review has been in
place since 1982. The State Medicaid agency and the Buena Vista Medicaid
Florida Pharmacy Association, which performs the Vista Health Plan, Inc.
reviews, share the administration of the program. (FKA Beacon and Discovery)
300 South Park Road
Heritage information systems contracts to provide Hollywood, FL 33021
DUR and prescriber pattern profiling and clinical 866/441-5501
review assistance.
Healthease of Florida, Inc.
6800 N. Dale Mabry Hwy., Suite 168
Pharmacy Payment and Patient Cost Sharing Tampa, FL 33614-3988
800/278-0656
Dispensing Fee: $4.23, effective 3/11/86.
Humana Family
Nursing Home Fee $4.73, effective 7/1/01 c/o Humana Medical Plan, Inc.
3501 SW 160th Street
Ingredient Reimbursement Basis: AWP-13.25 % or Miramar, FL 33027
WAC + 7%. 800/533-5001

Prescription Charge Formula: Lower of: Jackson Memorial Health Plan


1801 NW 9th Ave., Suite 700
1. FUL (Federal Upper Limits or State MAC) plus
Miami, FL 33136
dispensing fee.
800/721-2993
2. EAC plus dispensing fee.
3. Usual and customary charge.
Neighborhood Health Partnership, Inc.
4. In-house unit dose diff. + 0.015/dose.
7600 Corporate Center Dr., 2nd Floor
Maximum Allowable Cost: State imposes Federal Miami, Fl 33126-1216
Upper Limits as well as State-specific limits on 800/354-0222
generic drugs. MAC override by physicians requires
completed MedWatch form and prior authorization. Personal Health Plan
324 Datura Street, Suite 401
Incentive Fee: No incentive fee. West Palm Beach, FL 33401
561/659-1270
Patient Cost Sharing: No copayment
Preferred Medical Plan, Inc.
Cognitive Services: States pay for DUR and disease 4950 SW 8th Street
management counseling for HIV, mental health, Coral Gables, FL 33134
diabetes, and hypertension services. 305/447-8373

StayWell Health Plan of Florida, Inc.


6800 N. Dale Mabry Hwy., Suite 168
Tampa, FL 33614
813/935-5227

Florida-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

United Healthcare of Florida, Inc. DUR Contact


13621 N.W. 12th Street
Linda G. Barnes
Sunrise, FL 33323
Senior Pharmacist
800/910-3224
Agency for Health Care Administration
2727 Mahan Drive, MS 38
Vista South Florida
Tallahassee, FL 32308
(FKA Foundation Health Plan)
T: 850/487-4441
300 South Park Road
F: 850/922-0685
Hollywood, FL 33021
E-mail: barnesl@fdhc.state.fl.us
800/441-5501

Medicaid DUR Board


F. STATE CONTACTS
Arijit Aichbhaumik
Plant City, FL
State Drug Program Administrator
Jerry F. Wells Lois Adams, R.Ph.
Pharmacy Program Manager Orlando, FL
Agency for Health Care Administration
2727 Mahan Drive, MS 38 Bryan Bognar, M.D.
Tallahassee, FL 32308 Lutz, FL
T: 850/487-4441
F: 850/922-0685 Leanne Lai, Ph.D.
E-mail: wellsj@fdhc.state.fl.us Ft. Lauderdale, FL
Internet address: www.fdhc.state.fl.us
David Levine, DPM, D.O.
Ft. Lauderdale, FL
Agency for Health Care Administration
Officials Earlene Lipowski, Ph.D., R.Ph.
Vacant Gainesville, FL
Secretary
Agency for Health Care Administration Larry Mattingly, D.O.
2727 Mahan Drive, MS 1 Orange Park, FL
Tallahassee, FL 32308
T: 850/922-3809 Jeane McCarthy, M.D., Ph.D.
F: 850/488-0043 St. Petersburg, FL
E-mail: AHCAcontact@fdhc.state.fl.us
Richard Roberts, Pharm.D.
Bob Sharpe Jacksonville, FL
Deputy Secretary
Agency for Health Care Administration Robert Taymans, R.Ph.
2727 Mahan Drive, MS 8 Safety Harbor, FL
Tallahassee, FL 32308
T: 850/488-3560 Pharmaceutical and Therapeutics Committee
F: 850/488-2520
E-mail: AHCAcontact@fdhc.state.fl.us Robert Blackburn, D.O. (Chair)
Spring Hill, FL
Prior Authorization Contact James Brookins, M.D.
Bruce McCall, Pharm.D. Tampa, FL
Pharmacy Program Manager
Agency for Health Care Administration Leanne Lai, Ph.D.
2727 Mahan Drive, MS 38 Ft. Lauderdale, FL
Tallahassee, FL 32308
T: 850/487-4441 Jeane McCarthy, M.D., Ph.D.
F: 850/922-0685 St. Petersburg, FL
E-mail: mccallb@fdhc.state.fl.us

Florida-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Lorianne McElheney, R.Ph. Mail Order Pharmacy Program


Palmetto, FL
State has a mail order pharmacy benefit under its
diabetes demonstration waiver.
Douglas Nee, Pharm.D.
Fort Meyers, FL
Disease Management Program/Initiative
Dorinda Segovia, Pharm.D. Contact
Hialeah, FL
Melanie Brown-Woofter
Program Administrator
Jerry Jean Stambaugh, Pharm.D.
Agency for Health Care Administration
Lantana, FL
2727 Mahan Drive, MS 50
Tallahassee,FL 32308
Craig A. Trigueiro, M.D.
T: 850/487-2355
Bradenton, FL
F: 850/410-1676
E-mail: brownme@fdhc.state.fl.us
New Brand Name Products Contact
Disease Management /Patient Education
Jerry F. Wells
850/487-4441 AIDS:
Peter D. Reis
Director of Business Development
Prescription Price Updating
AIDS Healthcare Foundation
First DataBank 6255 West Sunset Blvd, 16th Fl.
1111 Bayhill Drive, Suite 350 Los Angeles, CA 90028
San Bruno, CA 94066 T: 213/860-5200
T: 650/588-5454 F: 213/860-5235
F: 650/827-4578 E-mail: pdreisjr@aol.com

Medicaid Drug Rebate Contacts Executive Officers of State Medical and


Pharmaceutical Societies
Jason Ottinger
Rebate Coordinator Florida Medical Association, Inc.
Agency for Health Care Administration Sandra B. Mortham
2727 Mahan Drive, MS 38 CEO
Tallahassee, FL 32308 113 East College Avenue
T: 850/922-7794 Tallahassee, FL 32301
F: 850/922-0685 T: 850/224-6496
E-mail: ottingej@fdhc.state.fl.us F: 850/222-8030
E-mail: smortham@medone.org
Internet address: www.fmaonline.org
Claims Submission Contact
Kevin Whittington Florida Pharmacy Association
Clinical Program Coordinator Michael Jackson, R.Ph.
ACS Executive Director
9040 Roswell Road 610 North Adams Street
Roswell, GA Tallahassee, FL 32301-1114
850/201-1418 T: 850/222-2400
F: 850/561-6758
E-mail: fpa@pharmview.com
Medicaid Managed Care Contact Internet address: www.pharmview.com
Christina Lopez
Manager, Health Systems Development
Agency for Health Care Administration
2727 Mahan Drive, MS 8
Tallahassee, FL 32308
850/487-2355
E-mail: lopezc@fdhc.state.fl.us
Florida Osteopathic Medical Association

Florida-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Stephen R. Winn
Executive Director
The Hull Building
2007 Apalachee Parkway
Tallahassee, FL 32301
T: 850/878-7364
F: 850/942-7538
E-mail: admin@foma.org
Internet address: www.foma.org

State Board of Pharmacy


John D. Taylor
Executive Director
4052 Bald Cypress Way, Bin C04
Tallahassee, FL 32399-3254
T: 850/487-1257
F: 850/413-6982
E-mail: mqa_pharmacy@doh.state.fl.us
Internet address: www.doh.state.fl.us/mga

Florida Hospital Association


Wayne N. Smith
President
306 East College Avenue
Tallahassee, FL 32301-1522
T: 850/222-9800
F: 850/561-6230
E-mail: wayne@fha.org
Internet address: www.fha.org

Florida-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

GEORGIA

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients
TOTAL $655,515,772 856,797 $873,703,133

RECEIVING CASH ASSISTANCE, TOTAL $422,797,389 368,161


Aged $49,961,732 31,775
Blind/Disabled $323,103,058 156,568
Child $22,633,229 112,507
Adults $27,099,370 67,311

MEDICALLY NEEDY, TOTAL $15,484,179 8,446


Aged $5,802,403 3,606
Blind/Disabled $9,681,639 4,837
Child $137 3
Adults $0 -

POVERTY RELATED, TOTAL $63,048,028 309,147


Aged $3,524,685 2,335
Blind/Disabled $3,102,251 2,047
Child $44,949,926 230,198
Adults $11,471,166 74,567

TOTAL OTHER EXPENDITURES/RECIPIENTS* $154,186,176 171,043

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Georgia-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Coverage of Injectables: Injectable medicines


reimbursable through the Prescription Drug Program
Department of Community Health, Division of when used in home health care and extended care
Medicaid facilities, and through physician payment when used
in physicians offices.
D. PROVISIONS RELATING TO DRUGS
Vaccines: Vaccines reimbursable as part of the
EPSDT service and as part of the Vaccines for
Benefit Design Children Program.
Drug Benefit Product Coverage: Products covered:
prescribed insulin and disposable needles and syringe Unit Dose: Unit dose packaging reimbursable.
combinations used for insulin. Products covered with
restrictions: blood glucose test strips (Roche products Formulary/Prior Authorization
only); urine ketone test strips (total parenteral
nutrition (21 and younger) and interdialytic Formulary: Closed formulary with restrictions on use
parenteral nutrition (21 and younger). Products (quantity level limits), PA, preferred products, and
requiring prior authorization: Marinol; Betaseron, physician profiling.
Avonex, Rebif, Leukine, Crinone 8%, Forteo, growth
hormone, immune globulin, Fuzeon, Penlac, Epoetin; Prior Authorization: State currently has a formal
interferons; lactulose; Neupogen; top.vit.A prior authorization procedure
derivatives; Toradol; Regranex; Viagra; Cialis,
Levitra, Oral Diflucan 50mg, 100mg & 200mg , Prescribing or Dispensing Limitations:
Panretin Gel,, Vfend, Zetia, topical testosterone, Prescription Refill Limit: Maximum of five refills for
Insulin Pen Delivery Systems and Cartridges for adults, six for children. May be overridden at POS by
adults, PPIs; Oral Lamisil; ESRD drugs; Oral the pharmacist for certain maintenance drugs.
Sporanox; Botox; Oxycontin; brand-names and
multi-source. Products not covered: cosmetics; Monthly Quantity Limit: Physicians are encouraged
fertility drugs; experimental drugs; prescription to prescribe a 31-day supply. Some exceptions exist.
vitamins and minerals (except for prenatal and
fluorides not in combination with other vitamins); Monthly Dollar Limit: $2,999.99 requires an
barbituates (except Seconal & Mebaral ); DESI override; >$9,999.99 requires paper claim and a copy
drugs; and Miralax;( covered for 21 and younger) of the prescription.
and smoking cessation products.
Drug Utilization Review
Over-the-Counter Product Coverage: Products
covered: analgesics (Ibuprofen suspension) covered On-line PRODUR system implemented in October
with restriction for ages less than 21; cough and cold 2000. State has a 20 member DUR Board (4
preparations; topical products; PIN-X; NIX; Lice-B- meetings per year).
Gone OTC iron and multivitamins; klout; and
meclizine. Products not covered: allergy, asthma,
Pharmacy Payment and Patient Cost Sharing
and sinus products; digestive products; feminine
products; and smoking deterrent products.
Dispensing Fee: $4.63, effective 7/1/98
Therapeutic Category Coverage: Therapeutic
Ingredient Reimbursement Basis: EAC = AWP -
categories covered: antibiotics; anticoagulants;
10% or MFN price.
anticonvulsants; antidepressants; antidiabetic agents;
antihistamines; antilipemic agents; antipsychotics;
Prescription Charge Formula: Lower of average
cardiac drugs; chemotherapy agents; prescribed cold
wholesale price (AWP) minus 10% plus dispensing
medications (partial coverage); contraceptives; ENT
fee, MAC plus fee, or usual and customary.
anti-inflammatory agents; estrogens; hypotensive
agents; misc. GI drugs; sympathominetics
Maximum Allowable Cost: State imposes a
(andrenergic); and thyroid agents. Prior
combination of Federal Upper Limits as well as
authorization required for: anabolic steroids;
State- Specific Limits on generic drugs. Override
analgesics, antipyretics, NSAIDS for single source;
requires Prior Approval. Approximately 800 drugs
anxiolytics, sedatives, and hypnotics; growth
on the State-specific MAC list.
hormones; and immunoglobulins. Therapeutic
categories not covered: anoretics and prescribed
Incentive Fee: $0.50 for generic drug.
smoking deterrents.

Georgia-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Patient Cost Sharing: $0.50 per prescription for DUR Contact


generics or preferred drugs. $0.50 - $3.00 for non-
preferred and brand drugs, dependent on the cost of Pat Zeigler-Jeter, M.P.A., R.Ph.
the drug. 404-657-9181

Cognitive Services: Does not pay for cognitive Medicaid DUR Board
services.
John Stephen Antalis, M.D.
Dalton Family Practice, P.C.
E. USE OF MANAGED CARE 1114 Professional Blvd.
Dalton, GA 30720
Does not use MCOs to deliver services to Medicaid
recipients. Frank W. Brown, M.D., M.B.A.
Wesley Woods Center
F. STATE CONTACTS 1841 Clifton Road, NE
Atlanta, GA 30329

State Drug Program Administrator Catherine E. Burley, M.D.


Jerry Dubberly, RPh 7365 Old National Hwy, Suite A
Director, Pharmacy Services Riverdale, GA 30296
Department of Community Health-Medicaid Division
2 Peachtree Street, NW, 37th Floor J. Russell May, Pharm.D. , Chairperson
Atlanta, GA 30303-3159 Director of Pharmacy Services
T: 404/656-4044 Department of Pharmacy
F: 404/656-8366 Medical College of Georgia
E-mail: jdubberly@dch.state.ga.us Hospital and Clinics
Internet address: www.dch.state.ga.us 1120 15th Street
Augusta, GA 30912-5600

Department of Community Health Harry Strothers III, M.D., M.M.M.


Tim Burgess, Commissioner Professor, Family Medicine
Department of Community Health Morehouse School of Medicine
2 Peachtree Street, NW, Suite 4043 Department of Family Medicine
Atlanta, GA 30303-3159 505 Fairburn Rd. S.W.
T: 404/656-4507 Atlanta, GA 30331
F: 404/651-6880
E-mail: tburgess@dch.state.ga.us L. Dianne Bradford, Ph.D.
Morehouse School of Medicine
Mark Trail, Medicaid Director Departments of Psychiatry and Medicine
Department of Community Health 720 Westview Drive, SW
2 Peachtree Street, NW, Suite 4043 Atlanta, GA 30310-1495
Atlanta, GA 30303-3159
T: 404/656-4496 Daniel Gallina, M.D.
F: 404/651-6880 Emory University School of Medicine
E-mail: mtrail@dma.state.ga.us Grady Health System
Diabetes Unit
69 Butler Street
Prior Authorization Contact Atlanta, GA 30303-3033
Patricia Zeigler Jeter, M.P.A., R.Ph.
Pharmacist Phyllis A. Johnson, R.N., Ph.D.
Pharmacy Services Unit, Program Policy Section 1010 Forest Overlook Trail, SW
Division of Medical Assistance Atlanta, GA 30331
2 Peachtree Street, NW 37th Floor
Atlanta, GA 30303 Robyn Anderson Lorys, Pharm.D.
T: 404/657-9181 2430 Laurelwood Road
F: 404/656-8366 Atlanta, GA 30360
E-mail: pjeter@dch.state.ga.us

Georgia-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Calvin W. McLarin, M.D.


Medicaid Drug Rebate Contact
Metropolitan Atlanta Cardiology Consultants
999 Peachtree Street, NE Pat Zeigler-Jeter, M.P.A., R.Ph.
Suite 850 404-657-9181
Atlanta, GA 30309

Mathew Perri III, R.Ph., Ph.D. Claims Submission Contact


Department of Clinical and Administrative Sciences Scott Percival
University of Georgia College of Pharmacy Account Manager
DW Brooks Drive, Room 250G Express Scripts, Inc.
Athens, GA 30602 6625 W. 78th St., BL-0420
Bloomington, MN 55439
Cynthia O’Steen-Piela, R.Ph. T: 952/837-7744
District Manager F: 952/837-7741
Wal-Mart Pharmacy E-mail: scott.percival@express-scripts.com
1350 Arborwood Ridge
Bishop, GA 30621
Medicaid Managed Care Contact
Kimberly Rogan, R.Ph. Kathy Driggers
District Manager, South Region Director, Managed Care
Ekcerd Drugs Department of Community Health
3549 Chamblee Tucker Road 2 Peachtree Street, NW
Tucker, GA 30341 Atlanta, GA 30303
T: 404/657-7793
Joseph Rosenfeld, M.D. F: 404/656-8366
Snapfinger Woods Pediatric E-mail: kdriggers@dch.state.ga.us
5008 Snapfinger Woods Drive
Decatur, GA 30035
Disease Management Program/Initiative
William Dennis Taylor, M.D. Contact
Green Acres Nursing Home Charmaine Heard, M.D.
313 Allen Memorial Drive Medical Director
Milledgeville, GA 31061 Department of Community Health
2 Peachtree Street, NW, 37th Floor
Cynthia Wainscott Atlanta, GA 30303
2274 Camden Drive T: 404/463-7638
Marietta, GA 30064 F: 404/656-8366
E-mail: cheard@dch.state.ga.us
Andrew D. Weinberg, M.D., FACP
1647 Brookhaven Close, NE
Atlanta, GA 30319 Mail Order Pharmacy Benefits
None
New Brand Name Products Contact
Etta L. Hawkins, R. Ph. Medical Assistance Advisory Committee
404/656-4044 Representatives from each of the following groups:
Medical Association of Georgia
Prescription Price Updating Georgia Pharmaceutical Association
Andrew Shim, Pharm.D. Atlanta Medical Association
Clinical Program Manager Georgia Health Care Association
Express Scripts, Inc. Georgia Hospital Association
6625 W. 78th Street, BL-0420 Georgia Dental Association
Bloomington, MN 55439 Georgia Osteopathic Medical Association
T: 952/837-5326 National Pharmaceutical Association
F: 952/837-7184
E-mail: andrew.shim@express-scripts.com

Georgia-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Pharmacy Advisory Committee Timara Faulkner Rembert, Pharm.D.


87 Buckeye Loop
Ifeanyi J. Anikpe, Pharm.D.
Midland, GA 31820
Washington Road Pharmacy
3518 Washington Road
East Point, GA 30344 Executive Officers of State Medical and
Pharmaceutical Societies
Anthony Compton, Pharm.D.
Medical Association of Georgia
Pharmacy Manager
David Cook, Executive Director
Saint Joseph’s Hospital of Atlanta
1330 W. Peachtree Street, NW, Suite 500
2783 Harvest Drive
Atlant, GA 30309
Conyers, GA 30013
T: 404/876-7535
F: 404/881-5021
Amanda R. Gaddy, R.Ph.
E-mail: dcook@mag.org
Kroger
Internet address: www.mag.org
131 Windsong Drive
Stockbridge, GA 30281
Georgia Pharmacy Association
Oren “Buddy” Harden, Jr.
Ted M. Hunt, R.Ph.
Chief Executive Officer
General Manger
50 Lenox Pointe, NE
PharMerica
Atlanta, GA 30324-3170
1100 Wilson Way, Suite 500
T: 404/231-5074
Smyrna, GA 30082
F: 404/237-8435
E-mail: bharden@gpha.org
Leslie M. Litton
Internet address: www.gpha.org
Executive Director
Kaiser Permanente
Osteopathic Medical Association
9 Piedmont Center
Sheila J. Smith, D.O.
3495 Piedmont Rd. NE
President
Atlanta, GA 30082
2037 Grayson Highway, Suite 200
Grayson, GA 30017
Scott Moody, Pharm.D.
T: 770/493-9278
Regional Manager, Pro
F: 770/908-3210
Glaxo Wellcome, Inc.
E-mail: exdir@goma.org
9306 Fall Court West
Internet address: www.goma.org
Brentwood, TN 37027
State Board of Pharmacy
Malcolm “Mickey” Tatum, R.Ph.
Sandy Bond
Dinglewood Pharmacy
Executive Director
1819 Wynnton Road
237 Coliseum Drive
Columbus, GA 31902
Macon, GA 31217-3858
T: 478/207-1686
Homer L. Whelchel, R.Ph.
F: 404/656-0513
President, CEO
E-mail: sosweb@sos.state.ga.us
Berrien Health Center
Internet address: www.sos.state.ga.us/plb/pharmacy/
P.O. Box 866
Nashville, GA 31639-0866
Georgia State Medical Association
Julie M. Wickman, Pharm.D.
Katherine Daniels
Mercer University
Executive Director
593 Cantebury Lane
Morehouse School of Medicine
Winder, GA 30680
720 Westview Drive, SW
Atlanta, GA 30310-1495
Ellen Whipple Guthrie, Pharm.D.
T: 404/752-1564
Pharmacy Manager
F: 404/752-1024
The Shepard Center
Internet address: www.gastatemedicalassoc.org
2020 Peachtree Rd., NW
Atlanta, GA 30309

Georgia-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Georgia Hospital Association


Joseph A. Parker
President
1675 Terrell Mill Road
Marietta, GA 30067
T: 770/249-4522
F: 770/955-5801
E-mail: jparker@gha.org
Internet address: www.gha.org

Georgia-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

HAWAII

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001* 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $74,869,859 $88,256,904

RECEIVING CASH ASSISTANCE TOTAL


Aged
Blind/Disabled
Child
Adult

MEDICALLY NEEDY, TOTAL


Aged
Blind/Disabled
Child
Adult

POVERTY RELATED, TOTAL


Aged
Blind/Disabled
Child
Adult

TOTAL OTHER EXPENDITURES/RECIPIENTS*

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2001 and 2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are
unavailable.

Source: CMS, CMS-64 Report, FY 2001 and FY 2002.

Hawaii-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Unit Dose: Unit dose packaging reimbursable

Hawaii Department of Human Services through its


Formulary/Prior Authorization
Med-Quest Division and four county branch offices.
Formulary: Open formulary managed through prior
authorization. Preferred drug list to be implemented
D. PROVISIONS RELATING TO DRUGS in 2004.

Benefit Design Prior Authorization: State currently has a formal


prior authorization procedure. A fair hearing may be
Drug Benefit Product Coverage: Products covered: requested for appeal of prior authorization decisions.
prescribed insulin. Products covered as DME:
disposable needles and syringe combinations used for Prescribing or Dispensing Limitations
insulin; blood glucose test strips; and urine ketone
test strips. Products requiring prior authorization: Monthly Quantity Limit: Physicians are encouraged
total parenteral nutrition (for home infusion); to prescribe a 30-day supply or 100 units. State has
interdialytic parenteral nutrition (for home infusion); implemented maximum doses for certain drugs,
Clorazil; Procardia XL; Norvasc; brand products on including Epogen, Liptor, Zofran, and Zomig.
FUL price list; Betaseron; and Oxycontin. Products
not covered: cosmetics; fertility drugs; and Drug Utilization Review
experimental drugs. PRODUR system implemented in September 1997.
State currently has a DUR board with a quarterly
Over-the-Counter Product Coverage: Products review.
covered: allergy, asthma, and sinus products;
analgesics; and digestive products (non-H2
antagonists). Products covered with restrictions; Pharmacy Payment and Patient Cost Sharing
cough and cold preparations (select products, others Dispensing Fee: $4.67, effective May 9, 1990.
require prior authorization); digestive products (H2
antagonists-cimatidine and ranitidine, others require Ingredient Reimbursement Basis: EAC = AWP-
prior authorization); topical products (for non- 10.5%.
cosmetic purposes only); and smoking deterrent
products (Xyban only, others require prior Prescription Charge Formula: Payment for
authorization). prescription and OTC drugs listed in the formulary is
limited to the State or Federally established MAC
Therapeutic Category Coverage: Products covered: price, or Estimated Acquisition Cost (EAC) or AWP-
analgesics, antipyretics, and NSAIDs; antibiotics; 10.5% when equal to average selling price plus
anticoagulants; anticonvulsants; anti-depressants; dispensing fee, or billed amount, whichever is
antidiabetic agents; antilipemic agents; anxiolytics; lowest.
sedatives; and hypnotics; cardiac drugs;
chemotherapy agents; contraceptives; estrogens; Maximum Allowable Cost: State imposed Federal
hypotensive agents; misc. GI drugs; Upper Limits and State-specific limits on generic
sympathominetics (adrenergic); and thyroid agents drugs. Override requires prior authorization.
Prior authorization required for: anabolic steroids;
anorectics; non-sedating antihistamine drugs; atypical
Incentive Fee: None.
anti-psychotics; prescribed cold medications; proton
pump inhibitors; growth hormones; and prescribed
Patient Cost Sharing: No copayment.
smoking deterrents.
Cognitive Services: Does not pay for cognitive
Coverage of Injectables: Injectable medicines
services.
reimbursable through the Prescription Drug Program
when used in home health care and extended care
facilities, and through both the Prescription Drug
Program and physician payment when used in
physicians’ offices.

Vaccines: Vaccines reimbursable as part of EPSDT


service, CHIP, and the Vaccines for Children
Program.

Hawaii-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

E. USE OF MANAGED CARE DUR Contact


Kathleen Kang-Kaulupali
Approximately 135,000 Medicaid recipients were Pharmacy Consultant
enrolled in MCOs in FY 2002. Recipients receive Department of Human Services
most of their pharmaceutical benefits through Med-Quest Division
managed care plans. State has specific guidelines for 601 Kanokila Blvd., Room 506-B
the pharmacy benefit for Medicaid recipients enrolled Kapolei, HI 96707
in managed care plans. Drugs prescribed by dentists T: 808/692-8065
are “carved out” of managed care and provided F: 808/692-8131
through the State.

Medicaid DUR Board


Managed Care Organizations
Myron Shirasu, M.D. (Internal Medicine)
AlohaCare, Inc. 321 North Kuakini Street, Suite 200
Mr. John McComas Honolulu, HI 96817
1357 Kapiolani Blvd., Suite 1250 808/523-8611
Honolulu, HI 96814
808/973-1650 Gregory E.M. Yuen, M.D. (Psychiatry)
1188 Bishop Street, Suite 806
Hawaii Medical Service Association (HMSA) Honolulu, HI 96813
QUEST Administration 808/599-5050
818 Keeaumoku Street Linda Tom MD (Geriatric Medicine), Vice-Chair
Honolulu, HI 96808 347 N. Kuakini Street, HPM-9
808/948-5250 Honolulu, HI 96817
808/523-8461
Kaiser Foundation Health Plan, Inc.
Ms. Virginia Vierra James Lumeng, M.D. (Medicine/Pathology)
1441 Kapiolani Blvd, Suite 1600 850 West Hind Drive, #114
Honolulu, HI 96814 Honolulu, HI 96821
808/944-0261 808/377-5485
Brian Matsuura (Medical Services Rep.)
Behavioral Health Services
DHS/MQD/MSB
Andreas Carvalho
P.O. Box 700190
Community Care Services (CCS)
Kapolei, HI 96709-0190
810 N. Vineyard Blvd.
808/692-8065
Honolulu, HI 96817
808/948-5250 Joy Higa, R.Ph. (Long Term Care), Chair
DHS/MQD/MSB
P.O. Box 700190
F. STATE CONTACTS Kapolei, HI 96709-0190
808/692-8065
Medicaid Drug Program Administrator Jerry Smead, R.Ph. (Ambulatory Care)
Lynn S. Donovan, R.Ph. Kaiser Parmanente Hawaii Region
Pharmacy Consultant 201 Hamakua Drive, Building B
Department of Human Services Kailua, HI 96734
Med-Quest Division 808/432-3454
601 Kanokila Boulevard, Suite 506B Kerry Kitsu, R.Ph. (Community, chain)
Kapolei, HI 96707 DHS/MQD/MSB
T: 808/692-8116 P.O. Box 700190
F: 808/692-8131 Kapolei, HI 96709-0190
Internet address: www.med-quest.us 808/692-8065
Carl Mudrick, R.Ph. (Community, independent)
Prior Authorization Contact 750 Palani Avenue
Lynn S. Donovan, R.Ph. Honolulu, HI 96816
808/692-8116 808/739-1188

Hawaii-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

New Brand Name Products Contact Aileen Hiramatsu


Administrator, Med-Quest Division
Lynn S. Donovan, R.Ph.
Department of Human Services
808/692-8116
P.O. Box 399
Kapolei, HI 96809-0339
Prescription Price Updating
T: 808/692-8050
First Data Bank F: 808/586-4890
111 Bayhill Drive E-mail: AHiramatsu@medicaid.dhs.state.hi.us
San Bruno, CA 94066
800/633-3453 Executive Officers of State Medical and
Pharmaceutical Societies
Medicaid Drug Rebate Contacts Hawaii Medical Association
Paula Arcena
Policy: Lynn S. Donovan, R.Ph.
Executive Director
808/692-8116
1360 S. Beretania Street, Suite 200
Honolulu, HI 96814-1520
Audits: Martha Kessinich
T: 808/536-7702
Drug Rebate Manager
F: 808/528-2376
ACS State Healthcare
E-mail: paula_arcena@hma-assn.org
365 Northridge Road, Suite 400
Internet address: www.hmaonline.net
Atlanta, GA 30350
800/358-2381
Hawaii Pharmacist Association
Les Krenk
Claims Submission Contact President
Heather Bodiford P.O. Box 1198
Account Manager Honolulu, HI 96807-1198
ACS State Healthcare T: 808/877-6222
365 Northridge Road, Suite 400 F: 808/432-5535
Attn: Hawaii Medicaid E-mail: tkiammc@aol.com
T: 800/358-2381
F: 770/730-5198 Association of Osteopathic Physicians and Surgeons
E-mail: heather.bodiford@acs-inc.com Brenda Dela Cruz
545 Ohohia Street
Honolulu, HI 96819
Disease Management/Patient Education T: 808/831-3000
Contact F: 808/834-5763
Lynn S. Donovan, R.Ph.
808/692-8116 State Board of Pharmacy
Lee Ann Teshima
Executive Officer
Mail Order Pharmacy Benefit P.O. Box 3469
None Honolulu, HI 96801
T: 808/586-2694
F: 808/586-2689
Department of Human Services Officials E-mail: pharmacy@dcca.state.hi.us
Lillian Koller Internet address: www.state.hi.us/dcca/pvl
Director
Department of Human Services Healthcare Association of Hawaii
1390 Miller Street, Room 209 Richard E. Meiers
Honolulu, HI 96813 President/CEO
T: 808/586-4997 932 Ward Avenue, Suite 430
F: 808/586-4890 Honolulu, HI 96814-2126
E-mail: lillian.b.koller@hawaii.gov T: 808/521-8961
F: 808/599-2879
E-mail: postmaster@hah.org
Internet address: www.hah.org

Hawaii-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

IDAHO

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 ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $105,473,425 112,357 $119,177,013

RECEIVING CASH ASSISTANCE, TOTAL $64,871,126 22,489


Aged $4,947,969 2,016
Blind/Disabled $59,411,640 19,271
Child $280,234 963
Adult $231,283 239

MEDICALLY NEEDY, TOTAL $0 -


Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $10,152,018 55,312


Aged $139,939 93
Blind/Disabled $160,823 132
Child $8,806,102 48,702
Adult $1,045,154 6,385

TOTAL OTHER EXPENDITURES/RECIPIENTS* $30,450,281 34,556

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report FY 2002.

Idaho-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Unit Dose: Unit dose packaging reimbursable when


used in unit dose systems.
Division of Medicaid
Idaho Department of Health & Welfare
Formulary Authorization
By the State Department of Health and Welfare
through seven regional offices, each serves five or Formulary: Open formulary. Pharmacy program is
more of the State’s 44 counties. managed through an enhanced prior authorization
program, therapeutic substitution, preferred products,
physician profiling, and generic substitution for
D. PROVISIONS RELATING TO DRUGS multi-source products.

Benefit Design Prior Authorization: State currently has a formal


prior authorization procedure and a prior
Drug Benefit Product Coverage: Products covered: authorization committee. Informal reconsideration of
prescribed insulin; disposable needles and syringe denied prior authorization requests followed by a
combinations for insulin and total parenteral formal appeal process Written “notice of appeal”
nutrition. Products not covered: cosmetics; fertility required for fair hearing.
drugs; experimental drugs; and interdialytic
parenteral nutrition. Note: blood glucose test strips
and urine ketone test strips are DME items and do Prescribing or Dispensing Limitations
not fall under the pharmacy program. Monthly Quantity Limit: Prescription drugs are
limited to a 34-day supply. Limits on the number of
OTC Coverage: Products covered: permethrin; oral refills per script and early refills. The following drugs
iron salts; insulin and insulin syringes. Products not are limited to a 100-day supply: Digoxin, thyroids,
covered: allergy, asthma, and sinus; analgesics, prenatal vitamins, nitroglycerin, fluoride, fluoride
cough and cold preparations; digestive products; and vitamin combinations, non-legend oral iron salts
feminine products; topical products; and smoking and 3 cycles of birth control.
deterrent products.
Drug Utilization Review
Therapeutic Category Coverage: Therapeutic
categories covered: antibiotics; anticoagulants; Contracted DUR through Idaho State University.
anticonvulsants; antidepressants; antidiabetic agents; PRODUR system implemented January 1998. State
antilipemic agents; anti-psychotics; anxiolytics, currently has a DUR board with a quarterly review.
sedatives, and hypnotics; cardiac drugs;
chemotherapy agents; contraceptives; ENT anti- Pharmacy Payment and Patient Cost Sharing
inflammatory agents; estrogens; hypotensive
agents;sympathominetics (adrenergic); and thyroid Dispensing Fee: $4.94 ($5.54 for unit dose),
agents. Prior authorization required for: anabolic effective March 1999.
steroids; analgesics; antipyretics, and NSAIDs;
antihistamines; prescribed cold medications; growth Ingredient Reimbursement Basis: EAC = AWP-12%
hormones misc. GI drugs; amphetamines; Provigil; as determined by First DataBank Data File Service or
Aldara; Synagis; Regranex; Retinoids; Androgel; manufacturer direct price for selected manufacturers.
Prolastin; Klonopin Wafer; Zetia; Xanax XR; and
brand names of FUL and SMAC drugs. Therapeutic Prescription Charge Formula: Lower of FUL,
categories not covered: anorectics and prescribed SMAC or EAC plus a dispensing fee or provider’s
smoking deterrents. usual and customary price to the general public.

Coverage of Injectables: Injectable medicines Maximum Allowable Cost: State imposes Federal
reimbursable through the Prescription Drug Program Upper Limits as well as State-specific limits on
when used in home health care and extended care generic drugs. Override requires failure of two
facilities, and through physician payment when used generic formulations and submission of a MedWatch
in physicians offices. form.

Vaccines: Vaccines reimbursable as part of the Incentive Fee: None.


EPSDT service, The Children’s Health Insurance
Program, the Vaccines for Children Program, and the Patient Cost Sharing: No copayment.
State Vaccine Program.

Idaho-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Cognitive Services: Does not pay for cognitive New Brand Name Products Contact
services.
Shawna Kittridge, R.Ph., M.H.S.
E. USE OF MANAGED CARE 208/364-1956

Does not use MCOs to deliver services to Medicaid Prescription Price Updating
recipients. Some Medicaid recipients are enrolled in
primary care case management and receive their Katie Ayad
benefits from the state. Technical Records II
Department of Health and Welfare
Division of Medicaid
F. STATE CONTACTS 3232 Elder
Boise, ID 83705
Medicaid Drug Program Administrator T: 208/364-1970
F: 208/364-1864
Shawna L. Kittridge, R.Ph., M.H.S. E-mail: ayadk@idhw.state.id.us
Pharmacy Services Supervisor
Department of Health and Welfare
Division of Medicaid Medicaid Drug Rebate Contact
3232 Elder Mary Wheatly
Boise, ID 83705 Pharmacy Services Specialist
T: 208/364-1956 Department of Health and Welfare
F: 208/364-1864 Division of Medicaid
E-mail: kttrids@idhw.state.id.us 3232 Elder
Internet address: www.idahohealth.org Boise, ID 83705
T: 208/364-1832
Prior Authorization Contact F: 208/364-1864
E-mail: wheatlem@idhw.state.id.us
Shawna L. Kittridge, R.Ph., M.H.S.
208/364-1956 Claims Submission Contact
EDS
DUR Contact P.O. Box 23
Tamara Eide, Pharm.D., BCPS, FASHP Boise, ID 83707
Pharmacy Service Specialist T: 208/395-2000
Department of Health and Welfare F: 208/395-2030
Division of Medicaid
3232 Elder Medicaid Managed Care Contact
Boise, ID 83705 Shawna Kittridge, R.Ph., M.H.S.
T: 208/364-1821 208/364-1956
F: 208/364-1864
E-mail: eidet@idhw.state.id.us
Mail Order Pharmacy Program
Medicaid DUR Board State currently has a mail order pharmacy program.
Board Members: Pharmacy must be a registered Idaho Medicaid
Gary Wilburn, R.Ph. provider.
Don Smith, R.Ph.
Kent Jensen, R.Ph. Health and Welfare Department Officials
Joseph Steiner, Pharm. D.
Nancy Mann, M.D. Karl Kurtz, Director
E. Gregory Thompson, M.D. Dept. of Health & Welfare
Robert Ting, M.D. 450 West State Street
PO Box 83720
Staff: Boise, ID 83720-0036
Tamara Eide, Pharm. D., Dept. Contact T: 208/334-5500
Vaughn Culbertson, Pharm.D. Project Dir. F: 208/334-6558
E-mail: dhwinfo@idhw.state.id.us

Idaho-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Joe Brunson, Administrator Executive Officers of State Medical and


Department of Health and Welfare Pharmaceutical Societies
Division of Medicaid
Idaho Medical Association
Americana Building
Robert Seehusen, CEO
P.O. Box 83720
P.O. Box 2668
Boise, ID 83720-0036
305 West Jefferson
T: 208/364-5747
Boise, ID 83701
F: 208/334-1811
T: 208/344-7888
E-mail: allynkp@mmis.state.id.us
F: 208/344-7903
E-mail: mail@idmed.org
Title XIX Medical Care Advisory Committee
Internet address: www.idmed.org
JoAn Condie
Idaho State Pharmacy Association Idaho State Pharmacy Association
JoAn Condie
Greg Dickerson Executive Director
Mental Health Providers Association P.O. Box 140117
Boise, ID 83714-0117
Bill Foxcroft T: 208/424-1107
Idaho Primary Care Association F: 208/376-3131
E-mail: condie@velocitus.net
Bonnie Haines Internet address: www.idahopharmacy.org
Idaho Hospital Association
State Board of Pharmacy
Linda Johnson Richard K. Markuson
(Individual) Executive Director
P.O. Box 83720
Deedra Kucera Boise, ID 83720-0067
(Aged Community) T: 208/334-2356
F: 208/334-3536
Mark Leeper E-mail: rmarkuson@bop.state.id.us
(Disabled Community) Internet address: www.state.id.us.bop

Marla Lewis Idaho Hospital Association


Kootenai County Welfare Department Steven A. Millard
President
Randy Robinson 615 North Seventh Street
Legal Aid-Lewiston P.O. Box 1278
Boise, ID 83701
Robert VandeMerwe T: 208/338-5100
Idaho HealthCare Association F: 208/338-7800
E-mail: info@teamiha.org
Bob Seehusen Internet address: www.teamiha.org
Idaho Medical Association

Mitzi Smith
St. Luke’s Hospital

Gene Wiggers (Chairperson)


AARP

Idaho-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

1
ILLINOIS

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $934,241,252 1,068,535 $1,293,435,797

RECEIVING CASH ASSISTANCE TOTAL $330,543,572 241,552


Aged $39,704,574 19,211
Blind/Disabled $270,163,357 120,773
Child $9,670,272 71,473
Adult $11,005,369 30,095

MEDICALLY NEEDY, TOTAL $458,879,265 294,472


Aged $128,710,263 61,247
Blind/Disabled $271,010,968 93,079
Child $620,940 784
Adult $58,537,094 139,362

POVERTY RELATED, TOTAL $84,314,675 456,821


Aged $3,621,119 2,432
Blind/Disabled $9,302,549 3,668
Child $64,771,300 404,568
Adult $6,619,707 46,153

OTHER EXPENDITURES/RECIPIENTS* $60,503,740 75,690

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Source: CMS, MSIS Report, FY 2001and CMS-64 Report, FY 2002.

1 The State of Illinois 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 Illinois Medicaid program to
assess the accuracy and currency of the information included.

Illinois-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Prior Authorization: State currently has a formal


prior authorization procedure and a Committee on
Illinois Department of Public Aid, Division of Drugs and Therapeutics. Recipient must file an
Medical Assistance. appeal with their local office in order to appeal prior
authorization decisions. To appeal the coverage of an
D. PROVISIONS RELATING TO DRUGS excluded product, the recipient can request the
opportunity to appear before the Committee on Drugs
and Therapeutics.
Benefit Design
Drug Benefit Product Coverage: Products covered: Prescribing or Dispensing Limitations
prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test Prescription Refill Limit: Maximum of eleven refills.
strips; and urine ketone test strips. Prior
authorization required: syringe combinations used for Monthly Quantity Limit: As medically appropriate.
insulin. Products covered with restrictions: total Also edit for maximum daily quantities.
parenteral nutrition and interdialytic parenteral
nutrition. Products not covered: cosmetics; DESI- Drug Utilization Review
ineffectives; fertility drugs; and experimental drugs.
PRODUR system implemented in January 1993.
OTC Coverage: Products covered: analgesics and State currently has a DUR board which meets as
smoking deterrent products. Products requiring prior needed.
authorization: allergy, asthma, and sinus products;
digestive products (non-H2 antagonist); and topical Pharmacy Payment and Patient Cost Sharing
products. Products not covered: cough and cold
preparations; digestive products (H2 antagonists) and Dispensing Fee: $4.00 for branded drugs; $5.10 for
feminine products. generics. Effective 7/1/00.

Therapeutic Category Coverage: Categories Ingredient Reimbursement Basis: EAC = B: AWP-


covered: analgesics, antipyretics, and NSAIDs; 11%; G: AWP-20%.
antibiotics; anticogulants; anticonvulsants; anti-
depressants; antidiabetic agents; antilipemic agents; Prescription Charge Formula: Lowest of 1) usual
anti-psychotics; cardiac drugs; chemotherapy agents; and customary, 2) Department's MAC plus fee.
contraceptives; hypotensive agents; misc. GI drugs; Professional fee: $3.58 up to EAC of $35.80; above
prescribed smoking deterrents; sympathominetics EAC of $35.80, fee is 10% of EAC.
(adrenergic); and thyroid agents. Partial coverage:
antihistamines; anxiolytics, sedatives, and hypnotics; Maximum Allowable Cost: State imposes Federal
and estrogens. Prior authorization required: ENT Upper Limits as well as State-specific limits on
anti-inflammatory agents; growth hormones; and Cox generic drugs. Generics priced at the lower of the
II’s. Products not covered: anoretics and prescribed NDC, FUL, state MAC, or AWP-20%. Override
cold medications. requires prior authorization.

Coverage of Injectables: Injectable medicines Incentive Fee: None.


reimbursable through the Prescription Drug Program
when used in home health care and extended care Patient Cost Sharing: $1.00 for both branded drugs
facilities and through both the Prescription Drug and generics.
Program and physician payment when used in
physician offices. Cognitive Services: Does not pay for cognitive
services.
Vaccines: Vaccines are reimbursable as part of the
Vaccines for Children Program.
E. USE OF MANAGED CARE
Unit Dose: Unit dose packaging not reimbursable. Approximately 140,000 Medicaid recipients were
voluntarily enrolled in MCOs in 2003. Recipients
receive pharmaceutical benefits through managed
Formulary/Prior Authorization
care plans.
Formulary: Open formulary.

Illinois-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Managed Care Organizations 217/524-5565


Amerigroup Illinois
211 Wacker Drive Prescription Price Updating
Suite 1350
First DataBank
Chicago, IL 60606-3101
111 Bayhill Dr.
San Bruno, CA 94066
United Health Care of IL
650/588-5454
233 N. Michigan Ave. 8th Fl-12th Fl.
Chicago, IL 60601
Medicaid Drug Rebate Contact
Harmony Health Plan of Illinois
125 South Wacker Drive Brandley Wallner, Manager
Suite 2600 Illinois Department of Public Aid
Chicago, IL 60606-4402 2200 Churchill Road
Springfield, IL 62704
Harmony Health Plan 217/785-6114
23 Public Square, Suite 340 E-mail: cpa_webmaster@state.il.us
Belleville, IL 62220
Medicaid Managed Care Contact
Humana Health Plan
30 South Wacker Drive Bureau of Managed Care
Suite 3100 Illinois Department of Public Aid
Chicago, IL 60606 201 S. Grand Avenue East
Springfield, IL 62763
Family Health Network T: 217/524-7478
910 West Van Buren F: 217/524-7535
6th Floor E-mail: dpa_webmaster@state.il.us
Chicago, IL 60607-3523
Mail Order Pharmacy Benefit
F. STATE CONTACTS None

State Drug Program Administrator Elderly Expanded Drug Coverage Program


Marvin L. Hazelwood, Manager Susan Coombe, Supervisor, Circuit Breaker Program
Pharmacy and Ancillary Services Programs Illinois Department of Revenue
Illinois Department of Public Aid 101 W. Jefferson, Level 3 - 250
Division of Medical Assistance Springfield, IL 62794
1001 N. Walnut St. 217/785-2097
Springfield, IL 62702
T: 217/524-5565
F: 217/524-7194 Physician-Administered Drug Program
E-mail: dpa_webmaster@state.il.us Contact
Internet address: http://www.state.il.us/dpa/ Cheryl Bechner
217/782-5565
Prior Authorization Contact
Pharmacy Unit Staff Illinois Medicaid Agency Officials
217/782-5565 Barry Maram, Director
Illinois Department of Public Aid
DUR Contact 201 South Grand Avenue, East, Third Floor
Springfield, IL 62794
Marvin L. Hazelwood T: 217/782-1200
217/524-5565 F: 217/524-7120
E-mail: directordpa@mail.idpa.state.il.us
New Brand Name Products Contact
Marvin L. Hazelwood

Illinois-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

A. George Hovanec, Administrator Joan E. Cummings, M.D.


Division of Medicaid Programs Extended Care
Illinois Department of Public Aid 181 Hines VA Hospital
201 South Grand Avenue, East, Third Floor Building 1, Room C-124D
Springfield, IL 62763-0001 Hines, IL 60141
T: 217/782-1200 708/343-7200 ext. 5057
F: 217/524-7979
David B. Littman, M.D.
1030 Old Elm Road
Title XIX Medical Care Advisory Committees
Highland Park, IL 60035
State Medical Advisory Committee 708/433-3900
Arthur Traugott, M.D.
32207 Weisiger Way Richard P. Snodgrass, M.D.
Urbana, IL 61801 550 30th Avenue
Moline, IL 61265
Committee on Drugs and Therapeutics 309/764-1910
Marshall Blankenship, M.D., Chairman
1555 Astor Avenue IDPA Representative
Chicago, IL 60610 Marvin Hazelwood
708/636-3757 Illinois Department of Public Aid
1001 N. Walnut Street
Nicholas C. Bellios, M.D. Springfield, IL 62702
2504 Washington 217/524-7112
Waukegan, IL 60085
708/249-3660 Illinois State Medical Society
Kenneth E. Ryan
Armand Littman, M.D. Director, Department of Economics
Medical Services 20 N. Michigan Avenue, Suite 700
Hines VA Hospital Chicago, IL 60602
Hines, IL 60141 312/782-1654
708/216-2006
IDPH Representative:
Vincent A. Costanzo, Jr., M.D. Ron Gottrich, R.Ph
7501 South Stony Island Avenue Illinois Department of Public Health
Chicago, IL 60649 525 W. Jefferson
312/995-1075 Springfield, IL 62761
217/782-7532
Theodore M. Kanellakes, M.D.
229 N. Hammes Avenue Executive Officers of State Medical and
Joliet, IL 60435 Pharmaceutical Societies
815/744-2300
Illinois State Medical Society
William E. Kobler, M.D.
Patrick R. Staunton, M.D.
President
156 N. Oak Park Avenue
20 N. Michigan Avenue, Suite 700
Oak Park, IL 60301
Chicago, IL 60602
708/696-5887
T: 312/782-1654
F: 312/782-2023
Board of Trustees
E-mail: info@isms.org
Phillip D. Boren, M.D.
Internet address: www.isms.org
Doctor's Clinic
S. Plum Street
Carmi, IL 62821
618/382-4193

Illinois-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Illinois Pharmacists Association


Terri McEntaffer, R.Ph., CAE
Executive Director
204 West Cook Street
Springfield, IL 62704-2526
T: 217/522-7300
F: 217/522-7349
E-mail: terrim@ipha.org
Internet address: www.ipha.org

Illinois Osteopathic Medical Society


Gary Knepp
President
142 East Ontario Avenue, Suite 1023
Chicago, IL 60611-2854
T: 312/202-8174
F: 312/202-8224
E-mail: ioms@ioms.org
Internet address: www.ioms.org

State Board of Pharmacy


Judy Cullen
Pharmacy Coordinator
Illinois Department of Professional Regulation
Pharmacy Section
320 West Washington Street, 3rd Floor
Springfield, IL 62786
T: 217/782-8556
F: 217/782-7645
Internet address: www.dpr.state.il.us

Illinois Hospital and Health Systems Association


Kenneth C. Robbins
President
Center for Health Affairs
1151 East Warrenville Road
P.O. Box 3015
Naperville, IL 60566-7015
T: 630/505-7777
F: 630/505-9457
E-mail: krobbins@ihha.org
Internet address: www.ihatoday.org

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Illinois-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

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 ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients
TOTAL $562,120,344 464,879 $636,346,098 490,260

RECEIVING CASH ASSISTANCE, TOTAL $277,174,243 188,399 $315,484,522 200,489


Aged $47,951,486 16,531 $52,184,587 16,691
Blind/Disabled $190,763,506 56,296 $217,167,920 59,727
Child $15,067,039 69,054 $17,736,334 70,416
Adult $23,392,212 46,518 $28,395,681 53,655

MEDICALLY NEEDY, TOTAL $0 - $0 -


Aged $0 - $0 -
Blind/Disabled $0 - $0 -
Child $0 - $0 -
Adult $0 - $0 -

POVERTY RELATED, TOTAL $48,080,747 146,488 $55,897,050 155,896


Aged $304,966 378 $400,906 482
Blind/Disabled $535,916 566 $1,018,867 777
Child $46,038,486 136,278 $53,085,594 145,439
Adult $1,201,379 9,266 $1,391,683 9,198

TOTAL OTHER EXPENDITURES/RECIPENTS* $236,865,354 129,992 $264,964,526 133,875

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data provided by the Indiana Medicaid Program’s Office of Medicaid Policy and Planning.

Source: CMS, MSIS Report, FY 2001 and Indiana Medicaid Statistical Information System, FY 2002.

Indiana-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Legend Drug Reimbursement Methodology:


Office of Medicaid Policy and Planning Lower/Lowest of:
1. Federal MAC, if applicable, plus a dispensing
*NOTE WELL—All requests for information by,
fee.
or on behalf of, drug manufacturers must
2. State MAC, if applicable, plus a dispensing fee.
be made ONLY to: PDL@FSSA.state.in.us
3. EAC plus a dispensing fee.
Phone requests will not be accepted. 4. Pharmacy’s usual and customary charge to the
general public.
D. PROVISIONS RELATING TO DRUGS Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
Benefit Design generic drugs. “Brand Medically Necessary” requires
prior authorization as of September 2001.
Drug Benefit Product Coverage: Products covered:
All FDA-approved legend drugs from rebating
Incentive Fee: None.
labelers, excluding those products specifically non-
covered by State law (e.g., cosmetics; enhancement
Patient Cost Sharing: Copayment varies from $0.50
drugs; and experimental drugs).
to $3.00 for branded drugs and is $0.50 for generic
drugs.
Over-the-Counter Product Coverage: Indiana has a
Medicaid OTC drug formulary. Listed drugs are Cognitive Services: None.
reimbursed based on State MAC.

Therapeutic Category Coverage: All coverage in


E. USE OF MANAGED CARE
accordance with OBRA ’90 & ’93.
Approximately 105,000 Medicaid recipients were
enrolled in MCOs in FY 2001. Recipients receive
Coverage of Injectables: Covered.
pharmaceutical benefits through managed care plans.
Vaccines: Covered.
Managed Care Organizations
Unit Dose: In accordance with OBRA 1990
Harmony Health Management, Inc.
Requirements. MCFA policy only.
504 Broadway, Suite 200
Gary, IN 46404-4300
Formulary/Prior Authorization
Formulary: Preferred Drug List Managed Health Services
1099 N. Meridian Street, Suite 400
Prior Authorization: State has a prior authorization Indianapolis, IN 46204
program with formal appeal process.
MDwise
Prescribing or Dispensing Limitations 1099 N. Meridian Street, Suite 320
Indianapolis, IN 46204
Monthly Quantity Limit: None.
AmeriChoice
Drug Utilization Review 333 N. Alabama
Suite 350
PRODUR system implemented in March 1996. State Indianapolis, IN 46204
currently has a DUR Board with a monthly review.

Pharmacy Payment and Patient Cost Sharing

Dispensing Fee: $4.90, effective 05/30/02.

Ingredient Reimbursement Basis:

EAC = Brand: AWP-13.5%


Generic: AWP-20%

Indiana-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

F. STATE CONTACTS Prescription Pricing Updating


First DataBank
State Drug Program* 1111 Bay Hill Drive
San Bruno, CA 94066
Marc Shirley, R.Ph. 650/588-5454
Pharmacy Program Director
Office of Medicaid Policy and Planning
Room W382 Medicaid Drug Rebate Contact
Indiana State Government Center South Martha Kessenich
402 W. Washington Street Rebate Accounting Manager
Indianapolis, IN 46204-2739 365 Northridge Road, Suite 400
T: 317/232-4307 Atlanta, GA 30350
F: 317/232-7382 T: 770/730-3292
E-mail: mshirley@fssa.state.in.us F: 866/759-4100
E-mail: martha.kessenich@acs-inc.com
*NOTE WELL—All requests for information by,
or on behalf of, drug manufacturers must
be made ONLY to: PDL@FSSA.state.in.us Claims Submission Contact
Phone requests will not be accepted. Ulka Pandya
365 Northridge Road, Suite 400
DUR Contact Atlanta, GA 30350
T: 866-322-5960 x4032
Karen Clifton F: 866/759-4100
DUR Board Secretary E-mail: ulka.pandya@acs-inc.com
Office of Medicaid Policy & Planning
Room W382, Indiana Sate Government Center Medicaid Managed Care Contact
South, 402 West Washington Street
Indianapolis, IN 46204 John Barth
T: 317/232-4307 Managed Care Director
F: 317/232-7382 Office of Medicaid Policy and Planning
E-mail: kclifton@fssa.state.in.us 402 W. Washington Street
Room W382, MS07
Indianapolis, IN 46204
Medicaid DUR Board T: 317/233-0237
Physicians F: 317/232-7382
Neil Irick, M.D. E-mail: jbarth@fssa.state.in.us
Patricia Treadwell, M.D.
John J. Wernert, M.D. Mail Order Pharmacy Program
Philip N. Eskew, Jr., M.D.
None
Pharmacists
Paula Ceh, Pharm.D.
Administration Officials
Brian Musial, R.Ph.
Thomas A. Smith, P.D., M.S. Melanie Bella
G. Thomas Wilson, B.S. Pharm., J.D. Assistant Secretary
Medicaid Policy & Planning
Health Care Economist Indiana Family & Social Services Administration
Marko Mychaskiw, R.Ph., Ph.D. 402 W. Washington Street, Room W382
Indianapolis, IN 46204
Pharmacologist T: 317/234-2407
Terry Lindstrom, Ph.D. F: 317/232-7382

Representative from HMO John Barth


Vicki Perry Managed Care Director
317/233-4697

Pat Nolting, Director

Indiana-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Medicaid Program Operations – Acute Care Executive Officers of State Medical and
317/232-4318 Pharmaceutical Societies
Indiana State Medical Association
Medicaid Advisory Committee Richard R. King, J.D.
Executive Director
Indiana Council of Community Mental Health
322 Canal Walk, Canal Level
Centers
Indianapolis, IN 46202-3268
James F. Jones
T: 317/261-2060
F: 317/261-2076
Indiana Hospital Association
E-mail: rking@ismanet.org
L. Richard Gohman
Internet address: www.ismanet.org
Indiana Dental Association
Indiana Pharmacists Alliance
Ed Popcheff
Lawrence J. Sage
Executive Vice President
Indiana State Osteopathic Association
729 N. Pennsylvania, Suite 1171
Edward A. White, D.O.
Indianapolis, IN 46204-1171
T: 317/634-4968
Indiana State Nurses Association
F: 317/632-1219
Ernest C. Klein
Email: inpharm@indianapharmacists.org
Internet address: www.indianapharmacists.org
Indiana State Podiatry Association
Kirk S. Holston, D.P.M.
Indiana Osteopathic Association
Terry Iwasko, D.O.
Indiana Optometric Association
President
Marjorie Knotts, O.D.
3520 Guion Road, Suite 202
Indianapolis, IN 46222-1672
Indiana Pharmaceutical Association
T: 317/926-3009
Monica Foye
F: 317/926-3984
Email: info@inosteo.org
Indiana Psychological Association
Internet address: www.inosteo.org
Paul Schneider, Ph.D.
State Board of Pharmacy
Indiana State Chiropractic Association
Joshua Bolin
Michael Gallagher
Director
402 W. Washington Street, Room 041
Indiana Association for Home Care
Indianapolis, IN 46204-2739
Todd Stallings
T: 317/234-2067
F: 317/233-4236
Indiana Academy of Ophthalmology
Email: jbolin@hpb.state.in.us
Kim Williams
Internet address: www.in.gov/hpb/boards/isbp
Indiana Speech and Hearing Association
Indiana Hospital and Health Association
Susan Holbert
Kenneth G. Stella
President
Business and Industrial Interests
One American Square
Lula E. Baxter
P.O. Box 82063
Indianapolis, IN 46282
Labor Interests
T: 317/633-4870
Donald Mulligan, Sr.
F: 317/633-4875
E-mail: kstella@inhha.org
Internet address: www.inha.org

Indiana-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

IOWA

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $230,430,967 221,691 $285,467,642

RECEIVING CASH ASSISTANCE TOTAL $114,379,584 106,099


Aged $14,750,173 6,734
Blind/Disabled $81,135,611 32,484
Child $7,586,771 39,126
Adult $10,907,029 27,755

MEDICALLY NEEDY, TOTAL $13,202,042 6,191


Aged $3,922,542 2,287
Blind/Disabled $7,976,548 2,034
Child $154,791 278
Adult $1,148,161 1,592

POVERTY RELATED, TOTAL $8,996,176 46,728


Aged $513,385 843
Blind/Disabled $740,862 756
Child $6,629,188 37,819
Adult $1,112,741 7,310

TOTAL OTHER EXPENDITURES/RECIPIENTS* $93,853,165 62,673

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and Iowa Medicaid Statistical Information System, FY 2002.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION − Nicotinic Acid (Niacin) Tablets:


25/50/100/250/500 mg
State Department of Human Services, Bureau of − Pediatric Oral Electrolyte Solutions
Long Term Care. − Permethrin Liquid 1%
− Pseudoephedrine Hydrochloride: 30/60 mg
D. PROVISIONS RELATING TO DRUGS Tablets; 30mg/5mg Liquid
− Salicylic Acid Liquid 17%
− Senokot: 326 mg/tsp Granules for children aged
Benefit Design
20 and under; 187 mg Tablets for children aged
20 and under
Drug Benefit Product Coverage: Products covered:
prescribed insulin. Products covered requiring prior − Sodium Chloride Solution 0.9% for inhalation,
authorization: PPIs; dipyridamole; epoetin; with metered dispensing valve 90 ml, 240 ml
filgrastim; vitamins and minerals; ergotamine − Tolnaftate 1% Cream, Solution, Powder
derivatives; narcotic agonist-antagonist nasal sprays; − Nonprescription multiple vitamin and mineral
isotretinoin; oral antifungals; non-parenteral products specifically formulated and
vasopressin derivatives; and Serotonin 5-HT1 recommended for use as a dietary supplement
receptor agonists. Products not covered: fertility during pregnancy and lactation
drugs; experimental drugs; cosmetics; disposable − With prior authorization, nonprescription multiple
needles and syringe combinations for insulin; blood vitamins and minerals under the conditions
glucose test strips; urine ketone test strips; total specified in subparagraph 78.1(2) “a” (3)
parenteral nutrition; and interdialytic parenteral − Insulin
nutrition. − Oral solid forms of the above-covered items shall
be prescribed and dispensed in a minimum
Over-the-Counter Product Coverage: Products quantity of 100 units per prescription or the
covered with restriction (selected products): allergy, currently available consumer package size except
asthma and sinus products; analgesics; cough and when dispensed via a unit dose system. When
cold preparations; and topical products. Products not used for maintenance therapy, all of the above-
covered: digestive products (non-H2 antagonists and listed items may be prescribed and dispensed in
H2 antagonists); feminine products; and smoking 90-day quantities
deterrent products.
Therapeutic Category Coverage: Therapeutic
The Iowa Department of Human Services adopted an categories covered: anabolic steroids; antibiotics;
administrative rule that permits coverage for these anticoagulants; anticonvulsants; antidepressants;
non-prescription drugs: antidiabetic agents; antilipemic agents; anti-
psychotics; anxiolytics, sedatives, and hypnotics;
− Aspirin: 325/650 mg Tabs; 81mg Chewable; cardiac drugs; chemotherapy agents; prescribed cold
Aspirin Enteric Coated: 325/650mg Tabs; 81mg medications; contraceptives; ENT anti-inflammatory
Chewable; Aspirin Tablets Buffered, 325 mg agents; estrogens; hypotensive agents;
− Acetaminophen: 325/500mg Tablets; 120mg/5ml sympathominetics (adrenergic); and thyroid agents.
and 160mg/5mL Elixir; 100 mg/ml Solution; Prior authorization required for: analgesics,
120mg Suppositories antipyretics, NSAIDs; amphetamines; antihistamine
− Bacitracin Ointment 500 units/gm drugs; growth hormones; and misc. GI drugs.
− Benzoyl Peroxide 5% and 10%, Cleanser, Lotion, Therapeutic categories not covered: anorectics;
Cream, Gel prescribed smoking deterrents; drugs for strictly
− Chlorpheniramine Maleate Tablets 4 mg cosmetic purposes and hair growth; fertility drugs;
− Diphenhydramine Hydrochloride: 25 mg and drugs without signed Medicaid rebate
Capsules; 6.25mg/5mL and 12.5mg/5ml Liquid agreements.
− Ferrous Sulfate: 300/325mg Tablets; 220mg/5ml
Coverage of Injectables: Injectable medicines
Elixir; 75 mg/0.6 ml Drops
reimbursable through the Prescription Drug Program
− Ferrous Gluconate: 300/325mg Tablets; and physician payment when used in physicians
300mg/5ml Elixir offices.
− Ferrous Fumarate Tablets 300 mg, 325 mg
− Guafenesin 100 mg/5 ml with Dextromethorphan Vaccines: Vaccines reimbursable as part of the
10 mg/5 ml liquid EPSDT service and the Vaccines for Children
− Meclizine Hydrochloride Tablets 15.5 mg, 25 mg Program.
− Miconazole Nitrate: Topical and Vaginal Cream
2%, Vaginal Suppositories, 100mg Unit Dose: Unit dose packaging reimbursable.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Formulary/Prior Authorization
Managed Care Organizations
Formulary: No formulary.
John Deere Health Care, Inc.
Kristine Klaver
Prior Authorization: State currently has a formal
1300 River Drive, Suite 200
prior authorization procedure. State appeals and a
Moline, IL 61265-1368
fair hearing procedure required for appeal of prior
309/765-1482
authorization decisions and coverage of an excluded
product.
Timothy J. Gibson
Area Manager, Central Iowa
Prescribing and Dispensing Limitations:
4201 Westown Parkway, Suite 325
Prescribing or Dispensing Limitations: Maximum 30 West DesMoines, IA 50266-6270
day supply except select maintenance drugs (90 days) 515/327-2004
including oral contraceptives, cardiac drugs,
hypotensive agents, antidiabetic agents, diuretics, Coventry Health Care of Iowa
anticonvulsants and thyroid/antithyroid agents. Jennifer Goodell
Account Manager
4600 Westown Parkway, Suite 301
Drug Utilization Review
Des Moines, IA 50266
PRODUR system implemented in July 1997. State 515/225-1234
currently has a DUR Board with a monthly review.
Iowa Health Solutions
Bob Wilcox
Pharmacy Payment and Patient Cost Sharing Vice President
2550 Middle Road, Suite 405
Dispensing Fee: $4.26, effective 7/1/03. Bettendorf, IA 52722
319/359-8999
Ingredient Reimbursement Basis: EAC = AWP-12%.
F. STATE CONTACTS
Prescription Charge Formula: Payment will be
based on the pharmacist's usual, customary and
reasonable charge, but payment may not exceed EAC State Drug Program Administrator
plus a dispensing fee.
Susan L. Parker, Pharm.D.
Pharmacy Consultant
Maximum Allowable Cost: State imposes Federal
Division of Medical Services
Upper Limits as well as State-specific limits on
Bureau of Long Term Care
generic drugs. Override requires “Brand Medically
Hoover State Office Bldg.
Necessary,” completion of a MedWatch form, and
Des Moines, IA 50319
prior authorization.
T: 515/281-3002
F: 515/281-8512
Incentive Fee: None.
E-mail: sparker2@dhs.state.ia.us
Patient Cost Sharing: Copayment of $0.50-$3.00 for
brand products, depending on the cost of the drug. Prior Authorization Contact
Sandy Pranger, R.Ph.
Cognitive Services: Does not pay for cognitive
ACS
services.
P.O. Box 14422
Des Moines, IA 50306-3422
E. USE OF MANAGED CARE T: 515/327-0950 ext. 1329
F: 515/327-0945
Approximately 285,000 Medicaid beneficiaries were
enrolled in managed care organizations in 2002.
Iowa Medicaid recipients enrolled in managed care
receive pharmaceutical benefits through the State.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Medicaid Managed Care Contact


DUR Contact
Dennis Janssen
Julie Kuhle, R.Ph.
MHC Program Manager
DUR Coordinator
Bureau of Managed Care and Clinical Services
Iowa Pharmacy Association
Hoover Building, 5th Floor
8515 Douglas Ave, Suite 16
T: 515/281-8747
Des Moines, IA 50322
F: 515/281-8512
T: 515/270-0713
E-mail: djansse@dhs.state.ia.us
F: 515/270-2979

Mail Order Pharmacy Program


Medicaid DUR Board
State currently has a mail order pharmacy program.
Richard Rinehart, M.D. Participating pharmacies must be enrolled as an Iowa
Connie Connolly, R.Ph. Medicaid provider.
Ronald Miller, M.D., M.B.A.
Bruce Alexander, R.Ph., Pharm. D.
Iowa Pharmacy Association Medicaid
Sandi Birchem, D.O.
Pharmacy Advisory Committee
George Kappos, M.D.
Dan Murphy, R.Ph. Tim Becker (Chair)
Julie Kuhle, R.Ph., Project Coordinator Mason City, IA
Cheryl Clark, R.Ph. 641/422-6100
Janalyn Phillips, R.Ph.
Susan Parker, Pharm.D. David Brotherson (Vice Chair)
Davenport, IA
563/388-1887
New Brand Name Products Contact
Susan L. Parker, Pharm.D. Hal Jackson
515/281-3002 Winterset, IA
515/462-2479
Prescription Price Updating
Russ Wiesley
Sherry Swanson Waukee, IA
Deputy Account Manager 515/987-8111
ACS
P.O. Box 14422 Matthew Shivers
Des Moines, IA 50306-3422 Burlington, IA
T: 515/327-0950 ext. 1107 319/753-0112
F: 515/327-0945
Jerry Hartleip
Waterloo, IA
Medicaid Drug Rebate Contacts 319/234-1589
Technical: Rocco Russo, 515/327-0950 ext. 1114
Audits: Rocco Russo, 515/327-0950 ext. 1114 Mary Tasler
DUR: Julie Kuhle 515/270-0713 LaPorte City, IA
PA: Sandy Pranger, 515/327-0950 ext. 1329 319/272-5700

Joe Mahrenholz
Claims Submission Contact Panora, IA
Mindy Ruby 641/755-3052
Claims Manager
ACS Marilyn Aldrich
P.O. Box 14422 DSM
Des Moines, IA 50306-3422 515/255-8642
T: 515/327-0950 ext. 1108
F: 515/327-0945 Larry Costello
Mason City, IA
641/424-1343

Iowa-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Wally Tschopp Iowa Human Services Department Officials


Hartley, IA
Kevin W. Concannon, Director
712/728-2165
Dept. of Human Services
Hoover State Office Bldg., 5th Floor
Joe Cunningham
Des Moines, IA 50319-0014
Waukon, IA
T: 515/281-5452
563/568-6315
F: 515/281-7791
E-mail: kconcan@dhs.state.ia.us
Robert Dean
Sioux City, IA
Eugene Gessow
712/252-2761
Medicaid Director
Department of Human Services
Sue Testroet
Hoover State Office Building, 5th Floor
Bettendorf, IA
Des Moines, IA 50319-6242
563/324-5004
T: 515/281-6249
F: 515/281-8512
Sally Horst
E-mail: egessow@dhs.state.ia.us
Maquoketa, IA
563/652-5611
Title XIX Medical Assistance Advisory
Dennis Killion Council
Red Oak, IA
College of Medicine
712/623-3370
Stacey T. Cyphert, Ph.D.
Assistant Vice President-Statewide Health Services
Steve Firman
Senior Assistant Director of University Hospitals and
Cedar Falls, IA
Clinics
319/352-4440
The University of Iowa
Iowa City, IA 52242-1009
Leman Olson
Mason City, IA
House of Representatives
641/422-7917
Andra Attenberry
1034 Sherman Avenue
David Gavin
Manchester, IA 52057
Indianola, IA
515/961-2191
Brad Hansen
1015 Shoal Pointe Dr.
Alan Shepley
Carter Lake, IA 51510
Mount Vernon, IA
319/895-6248
Iowa Nurses Association
Linda Goeldner
Matt Osterhaus
1501 42nd Street, Suite 471
Maquoketa, IA
West Des Moines, IA 50266
563/652-5611
Iowa Medical Society
Gene Lutz
Angela Dorsey
Altoona, IA
Manager of Legislative Affairs
515/967-4213
1001 Grand Avenue
West Des Moines, IA 50265
Cora Lynn Becker
West Des Moines, IA
Opticians Assn. of Iowa
515/360-0065
Vacant
Jim Wallace
Iowa Senate
Davenport, IA
Sen. Maggie Tinsman
3541 E. Kimberly Road
Davenport, IA 52807

Iowa-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Senator Jack Holveck


Iowa Pharmacy Association
2007 47th Street
Jerry Karbeling
Des Moines, IA 50310
8515 Douglas, Suite 16
Des Moines, IA 50322
Iowa Dept. of Public Health
Anne Kinzel
Iowa Assn. of Homes and Services for the Aging
State Planning Grant Project Director
Dana Petrowsky
Lucas State Office Bldg., 5th Floor
President
DesMoines, IA 50319-0075
1701 48th Street, Suite 203
West Des Moines, IA 50266-6723
Public Representatives
Vacant
Iowa Association of Community Providers
Michelle Wray
Mary Ann Weber
Abbe Inc.
565 Greenwood Court
800 First Street, NW
Dubuque, IA 52001
Cedar Rapids, IA 52405
Orvil Nelson
Iowa Dental Association
1534 Second Street
Larry Carl
Boone, IA 50036
Executive Director
505 5th Avenue, Suite 333
Jodi Tomlonovic
Des Moines, IA 50309
Executive Director
Family Planning Council of Iowa
Iowa Council of Health Care Centers
108 Third Street, Suite 220
George W. Appleby
Des Moines, IA 50309
Carney, Appleby, Neilson and Skinner PLC
303 Locust Street, 400 Homestead Building
Iowa Speech & Hearing Association
Des Moines, IA 50309
Barbara Vogen
Central Rehabilitation, Ltd.
Iowa Osteopathic Medical Association
950 Office Park Road, Suite 100
Leah McWilliams
West Des Moines, IA 50265
Executive Director
950 12th Street
Iowa Hospital Association
Des Moines, IA 50309-1001
Tracy Warner
100 E. Grand Avenue, Suite 100
Iowa Optometric Association
Des Moines, IA 50309-1835
Gary Ellis
1454 30th Street, Suite 204
Iowa Health Care Association
West Des Moines, IA 50266-1312
Steve Ackerson
Executive Director
Iowa Podiatric Medical Association
6750 Westown Parkway, Suite 100
Dr. Richard Spencer
West Des Moines, IA 50266-7726
Spencer Foot & Ankle Clinics
110 East McLane
Iowa Assn. for Home Care
Osceola, IA 50213
Larry L. Breeding
Executive Director
Iowa Psychological Society
1520 High Street, Suite 203-B
Mark Peltan, Ph.D.
Des Moines, IA 50309
Mercy Medical Center-North Iowa
1000 4th Street, SW
Iowa Chiropractic Society
Mason City, IA 50401-2921
Dr. Terry Burk
P.O. Box 370
Iowa Association of Hearing Health Professionals
Huxley, IA 50124
Bev Thomas, Executive Director
1001 Office Park Road, Suite 105
West DesMoines, IA 50265

Iowa-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

Alliance for the Mentally Ill of Iowa Iowa Chapter-Nat’l. Association of Social Workers
Margaret Stout Jay J. Cayner, A.C.S.W., L.I.S.W.
5911 Meredith Drive, Suite E Assistant Hospital Director and Director, Social,
Urbandale, IA 50322 Patient, and Family Services
University of Iowa Hospitals and Clinics
Iowa Psychiatric Society 200 Hawkins Drive
Karen Loihl Iowa City, IA 52242
2643 Beaver, Suite 338
Des Moines, IA 50310 Iowa Chapter-Am. Academy of Pediatrics
Rizwan Z. Shah, M.D.
Iowa Governor’s Developmental Disabilities Council Children’s Health Center
Rick Shannon 1212 Pleasant Street
617 E. 2nd Street Des Moines, IA 50309
Des Moines, IA 50309
Executive Officers of State Medical and
Iowa Academy of Family Physicians
Pharmaceutical Societies
Dr. Dave Carlyle
1215 Duff Avenue Iowa Medical Society
Ames, IA 50010 Michael Abrams
Executive Vice President
Iowa Physical Therapy Association 1000 Grand Avenue West
Michael Mandel Des Moines, IA 50265
1228 8th Street, Suite 106 T: 515/223-1401
West Des Moines, IA 50265-2624 F: 515/223-0590
E-mail: mambrams@iowamedical.org
Iowa Physician Assistant Society Internet address: www.iowamedical.org
Michael Farley
4524 Boulevard Pl. Iowa Pharmacy Association
Des Moines, IA 50311 Thomas R. Temple, R.Ph., M.S.
Executive Vice President & CEO
Iowa Association of Nurse Practitioners 8515 Douglas, Suite 16
Wanda Marshall Des Moines, IA 50322-2927
Children’s Health Center T: 515/270-0713
1212 Pleasant Avenue, Suite 300 F: 515/270-2979
Des Moines, IA 50309 E-mail: ipa@iarx.org
Internet address: www.iarx.org
Iowa Association of Rural Health Clinics
Ed Friedmann Iowa Osteopathic Medical Association
1013 1st Street, Box C Leah McWilliams
Redfield, IA 50233 Executive Director
950 12th Street
Iowa Occupational Therapy Association Des Moines, IA 50309-1001
Angela Hansen-Abbas T: 515/283-0002
161 315th Street F: 515/283-0355
Perry, IA 50220 E-mail: leah@ioma.org
Internet address: www.ioma.org
The ARC of Iowa
Vacant State Board of Pharmacy Examiners
Lloyd K. Jessen
Des Moines University-Osteopathic Medical Center Executive Secretary/Director
Howard S. Teitelbaum, D.O., Ph.D., M.P.H. 400 SW 8th Street, Suite E
Dean of OMS Des Moines, IA 50309-4688
3200 Grand Avenue T: 515/281-5944
Des Moines, IA 50312 F: 515/281-4609
E-mail: debbie.jorgenson@ibpe.state.ia.us
Internet address: www.state.ia.us/ibpe

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National Pharmaceutical Council Pharmaceutical Benefits 2003

The Association of Iowa Hospitals and Health


Systems
J. Kirk Norris
President
100 East Grand Avenue, Suite 100
Des Moines, IA 50309-1835
T: 515/288-1955
F: 515/283-9366
E-mail: norrisk@ihaonline.org
Internet address: www.ihaonline.org

Iowa-8
National Pharmaceutical Council Pharmaceutical Benefits 2003

KANSAS

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $189,290,260 158,515 $213,145,382 156,832

RECEIVING CASH ASSISTANCE TOTAL $85,089,631 58,792 $91,842,893 34,917


Aged $8,618,107 4,187 $14,301,443 6,006
Blind/Disabled $70,087,687 29,828 $68,219,151 22,560
Child $2,774,647 14,115 $9,322,299 6,405
Adult $3,609,190 10,662 $0 -

MEDICALLY NEEDY, TOTAL $11,665,933 8,314 $94,149,457 30,715


Aged $2,421,349 1,362 $56,071,896 19,501
Blind/Disabled $8,335,032 2,898 $37,779,501 9,870
Child $331,900 1,946 $146,766 829
Adult $577,652 2,108 $151,294 515

POVERTY RELATED, TOTAL $10,333,897 49,242 $9,970,767 77,451


Aged $484,846 470 $248 1
Blind/Disabled $1,460,600 867 $0 -
Child $7,711,591 41,266 $9,415,709 72,996
Adult $676,860 6,639 $554,810 4,454

TOTAL OTHER EXPENDITURES/RECIPIENTS* $82,200,799 42,167 $17,182,265 13,695

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients and unknown.
**2002 data provided by the Health Care Policy Division, Kansas Department of Social and Rehabilitation Services.

Source: CMS, MSIS Report, FY 2001 and Kansas Medicaid Statistical Information System, FY 2002.

Note: Kansas estimates 2003 drug expenditures to be approximately $237 million and the number of Medicaid drug recipients to
be 200,000.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Formulary/Prior Authorization

State Department of Social and Rehabilitation Formulary: State currently maintains a formulary
Services. 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.) Prior authorization
required for non-PDL products.

Benefit Design Prior Authorization: State currently has a formal


prior authorization procedure. The individual
Drug Benefit Product Coverage: Products covered: appealing may request an administrative hearing to
prescribed insulin: Products covered under DME: appeal a prior authorization hearing by sending a
disposable needles and syringe combinations used for request in writing to:
insulin; blood glucose test strips; urine ketone test
strips; and total parenteral nutrition. Products covered Administrative Hearing Office
with restriction: interdialytic parenteral nutrition. 610 S.W. 10th Ave, 2nd Floor
Products not covered: cosmetics; fertility drugs; Topeka, KS 66612-1616
experimental drugs; DESI drugs; and drugs not
rebated by the manufacturer.
Prescribing or Dispensing Limitations
Over-the-Counter Product Coverage: Products
covered: analgesics (for adults); digestive products Monthly Prescription Limit: 5 single source
(H2 antagonist); and antifungals. Products covered scripts/month.
with restrictions: cough and cold preparations (for
children), smoking deterrent products (patches Prescription Refill Limit: As authorized by the
covered for limited time period); and topical products prescriber and allowed by statute up to a one-year
Products not covered: allergy, asthma and sinus period from the date of issuance of the prescription
products; digestive products (non-H2 antagonists); for non-controlled drugs. No early refills (<75% Rx
feminine products; and nutritional supplements. utilized).

Therapeutic Category Coverage: Therapeutic Monthly Quantity Limit: 31-day supply.


categories covered: anabolic steroids; analgesics (for
children), antipyretics (for children), NSAIDs; Other: Narcotics, Viagra, Cialis, Levitra, Ketorolac,
antibiotics; anticoagulants; anticonvulsants; Toradol and Relenza have other specific limits.
antidepressants; antidiabetic agents; antihistamine
drugs; anti-psychotics antilipemic agents; cardiac Drug Utilization Review
drugs; chemotherapy agents; contraceptives; ENT
anti-inflammatory agents; estrogens; hypotensive PRODUR system implemented in November 1996.
agents; misc. GI drugs; sympathominetics State currently has a DUR Board that meets every
(adrenergic); and thyroid agents. Partial coverage for: two months.
prescribed cold medications; prescribed smoking
deterrents. Prior authorization required for:
anxiolytics, sedatives, and hypnotics; anorectics; Pharmacy Payment and Patient Cost
growth hormones; triptans; nasal steroids; PPIs, Sharing
statins; H2 antagonists; and non-preferred drugs.
Dispensing Fee: $3.40, effective 7/1/02.
Coverage of Injectables: Injectable medicines Ingredient Reimbursement Basis: EAC Brand, =
reimbursable through the Prescription Drug Program AWP - 13%. Generics, AWP-27%. IV fluids, AWP-
when used in home health care and extended care 50%. Blood fraction products, AWP-30%.
facilities, and through physician payment program
when used in physician offices. Prescription Charge Formula: Pharmacies are
reimbursed the lesser of usual and customary, MAC,
Vaccines: Vaccines reimbursed as part of the FUL, or acquisition cost (EAC) plus a dispensing
Children Health Insurance Program and the Vaccines fee.
for Children Program.
Maximum Allowable Cost: State imposes Federal
Unit Dose: Unit dose packaging not reimbursable. Upper Limits as well as State-specific maximum

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National Pharmaceutical Council Pharmaceutical Benefits 2003

allowable cost (MAC) limits on generic drugs.


Override requires “Dispense as Written.” DUR Contact
Vicki L. Schmidt, Pharmacist
Incentive Fee: None.
Health Care Policy Division
Department of Social and Rehabilitation Services
Patient Cost Sharing: A recipient copay charge of
915 SW Harrison, Rm. 651-S
$3.00 (effective 7/02) applies to each new and refill
Topeka, KS 66612-1570
prescription not specifically exempted under Federal
T: 785/274-4287
regulations.
F: 785/296-4813
E-mail: vixs@srskansas.org
Cognitive Services: Does not pay for cognitive
services.
DUR Board
E. USE OF MANAGED CARE Michael Burke, M.D., Ph.D.
Barry Sarvis, R.Ph.
Approximately 45,000 Medicaid Recipients were Kevin Waite. Pharm.D.
enrolled in MCOs in FY 2002. Recipients receive John Lowdermilk, R.Ph.
pharmaceutical benefits through both the State and R. Kevin Bryant, M.D., C.M.D
managed care plans. Hemophilia drugs and certain Brenda Shewe, M.D.
other specific compounds are carved out of managed John Whitehead, D.O.
care. Linda Kroeger, ARNP, FNP

Managed Care Organizations Prescription Price Updating


First Guard Mary H.Obley, Pharmacist
3801 Blue Pkwy 785/296-8406
Kansas City, MO 64130
Medicaid Drug Rebate Contacts
F. STATE CONTACTS Policy: Mary H. Obley, Pharmacist
Pharmacy Program Manager
State Drug Program Administrator 785/296-8406

Mary H. Obley, Pharmacist Technical: Cindy LaClair


Pharmacy Program Manager Drug Rebate Specialist, EDS
Health Care Policy Division 3600 SW Topeka Boulevard, Suite 204
Department of Social and Rehabilitation Services Topeka, KS 66611
915 SW Harrison, Rm. 651-S 785/274-5987
Topeka, KS 66612-1570 E-mail: cindy.laclair@ksxix.hcg.eds.com
T: 785/296-8406
F: 785/296-4813 Claims Submission Contact
E-mail: mho@srskansas.org
Internet address: www.srskansas.eds.com EDS
3600 SW Topeka Boulevard, Suite 204
Topeka, KS 66611
New Brand Name Products Contact 785/274-4200
Mary H. Obley, Pharmacist
785/296-8406 Medicaid Managed Care Contact
Debra Bachmann, R.N. IV
Prior Authorization Contact Manager, Health Wave XIX
Mary H. Obley, Pharmacist Health Care Policy Division, Kansas Dept. of SRS
785/296-8406 915 SW Harrison, Rm. 651-S
Topeka, KS 66612-1570
T: 785/296-3667
F: 785/296-4813
E-mail: djzb@srskansas.org

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Mail Order Pharmacy Program Kansas Association of Osteopathic Medicine


Charles Wheeler, Executive Director
None
1260 SW Topeka Boulevard
Topeka, KS 66612
Social and Rehabilitation Services T: 785/234-5563
Department Officials F: 785/234-5564
E-mail: kansasdo@aol.com
Janet Schalansky, Secretary
Department of Social and Rehabilitation Services
State Board of Pharmacy
Docking State Office Bldg.
Debra Billingsley, Secretary
915 SW Harrison
Landon State Office Building
Topeka, KS 66612-1570
900 Jackson, Room 560
T: 785/296-3271
Topeka, KS 66612-1231
F: 785/296-2173
T: 785/296-4056
E-mail: JKS@srskansas.org
F: 785/296-8420
E-mail: pharmacy@ink.org
Robert Day, Ph.D., Director
Internet address: www.accesskansas.org
Adult and Medical Services
Department of Social and Rehabilitation Services
Kansas Hospital Association
915 SW Harrison
Don Wilson
Topeka, KS 66612-1570
President
T: 785/296-3981
215 Southeast Eighth Street
F: 785/296-4813
Topeka, KS 66603
E-mail: rmd@srskansas.org
T: 785/233-7436
F: 785/233-6955
Medical Care Advisory Committee Contact E-mail: cyelkin@kha-net.org
Nialson Lee, B.S.N., M.H.A Internet address: www.kha-net.org
Administrator, Health Care Systems and Policy/
Medical
Department of Social and Rehabilitation Services
915 SW Harrison, Rm. 651-S
Topeka, KS 66612-1570
T: 785/296-4753
F: 785/2964813
E-mail: nxl@srskansas.org

Executive Officers of State Medical and


Pharmaceutical Societies
Kansas Medical Society
Dan Suiter, President
623 SW 10th Avenue
Topeka, KS 66612
T: 785/235-2383
F: 785/235-5114
E-mail: apeterson@kmsonline.org
Internet address: www.kmsonline.org

Kansas Pharmacists Association


Sherry Denton, Interim Executive Director
1020 SW Fairlawn Road
Topeka, KS 66604-2275
T: 785/228-2327
F: 785/228-9147
E-mail: info@kansaspharmacy.org
Internet address: www.kansaspharmacy.org

Kansas-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

KENTUCKY

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients
TOTAL $598,093,343 475,365 $652,904,065

RECEIVING CASH ASSISTANCE, TOTAL $424,804,782 235,058


Aged $37,547,483 16,692
Blind / Disabled $355,245,438 137,989
Child $12,748,175 51,834
Adult $19,263,686 28,543

MEDICALLY NEEDY, TOTAL $19,756,137 24,343


Aged $4,859,165 2,018
Blind / Disabled $3,736,659 1,645
Child $3,032,751 11,256
Adult $8,127,562 9,424

POVERTY RELATED, TOTAL $40,038,880 160,513


Aged $557,666 595
Blind / Disabled $1,299,771 941
Child $35,140,791 140,715
Adult $3,040,652 18,262

TOTAL OTHER EXPENDITURES/RECIPIENTS* $113,493,544 55,451

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Kentucky-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Vaccines: Vaccines reimbursable in the cost of the


physician visit as part of EPSDT service, Children’s
Department for Medicaid Services, within the Health Insurance Program, Vaccines for Children
Cabinet for Health Services. Program and through the Pharmacy Program.

D. PROVISIONS RELATING TO DRUGS Unit Dose: Unit dose packaging reimbursable.

Formulary/Prior Authorization
Benefit Design
Formulary: Closed Formulary. The Kentucky
Drug Benefit Product Coverage: Products covered: Medicaid Program maintains a closed formulary and
prescribed insulin; syringe combinations used for covers all rebated products. The State manages the
insulin. Products covered with restrictions (i.e., formulary through a variety of techniques including
require prior authorization): total parenteral nutrition; the exclusion of products based on contracting issues,
and interdialytic parenteral nutrition. Products not restrictions on use, prior authorization, algorithms,
covered: cosmetics; fertility drugs; experimental and preferred products. Prior authorization required
drugs; disposable needles used for insulin; blood for many brand name products with generic
glucose test strips; and urine ketone test strips. equivalents.

Over-the-Counter Product Coverage: Products Prior Authorization: State currently has a prior
covered with restrictions (i.e., require prior authorization procedure. A formal appeals process is
authorization): allergy, asthma and sinus products; available if a request is denied.
analgesics; cough and cold preparations; digestive
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;
Leukotriene inhibitors; Synagis; Respigam; Zetia; Drug Utilization Review
CNS stimulants for ADHD and other disorders; PRODUR system implemented in 1987. State
Avodart; Proscar; anti-fungals for nails; Serotonin currently has a DUR Board with a quarterly review.
5HT1 Receptor Agonosts; GCSF products;
Recombinant Human Erythropoietin agents; and
Xolair. Therapeutic categories not covered: Pharmacy Payment and Patient Cost Sharing
prescribed smoking deterrents; agents for cosmetic Dispensing Fee: $4.51, effective 1/16/01.
purposes or hair growth and agents to promote
fertility.
Ingredient Reimbursement Basis: EAC = AWP-12%.
Coverage of Injectables: Injectable medicines
Prescription Charge Formula: Reimbursement
reimbursable through the Prescription Drug Program
consists of the lowest of: (1) the usual and customary
when used in home health care and extended care
charge; (2) the FMAC, if any, plus a dispensing fee;
facilities, and through both the Prescription Drug
or (3) the EAC plus a dispensing fee, or (4), SMAC
Program and physician payment when used in
if any, plus a dispensing fee.
physician offices. Reimbursement is limited to
antineoplastic drugs with “J” codes in physician
Maximum Allowable Cost: State imposes Federal
offices, several antibiotics, Depo-Provera for birth
Upper Limits as well as State-specific limits on
control.
generic drugs. Override requires “Brand Necessary,”

Kentucky-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

“Brand Medically Necessary,” or Prior Janet Poe Wright, Pharm.D.


Authorization. R. Michael Cayce, R.Ph.
Garry A. Hamm. R.Ph.
Incentive Fee: None. Dan Yeager, R.Ph. (non-voting)

Patient Cost Sharing: $1.00


DUR Contact
Cognitive Services: Does not pay for cognitive Debra Bahr, R.Ph.
services. Pharmacy Services Program Manager
Department for Medicaid Services
CHR Building, 6 W-A
E. USE OF MANAGED CARE 275 East Main Street
Frankfort, KY 40621
Approximately 153,000 Medicaid recipients were T: 502/564-7940
enrolled in MCOs in FY 2002. Recipients receive F: 502/564-0509
pharmaceutical benefits through both the State and E-mail: Debra.Bahr@ky.gov
managed care plans. Medications prescribed by a
board certified psychiatrist are carved out of
managed care. Drug Management Review Advisory Board
Richard Arnold, M.D. (Chair)
Managed Care Organization Phillip Bressoud, M.D.
Phillip Baier, O.D.
Passport Health Plan Patricia Freeman, R.Ph., Ph.D.
Joyce Schifano, Executive Director James S. Davis, M.D.
Karen Barnes, M.D.
F. STATE CONTACTS Janice Sullivan, M.D.
Madonna H. Ringswald, D.O.
John Spencer, Pharm.D.
Medicaid Drug Program Administrator Sandra Thornbury
Dan Yeager, R.Ph. Jacob Hutti, Pharm.D.
Interim Pharmacy Director Misha Glendening, A.R.N.P.
Department for Medicaid Services Pam Koob, Ph.D. A.R.N.P.
CHR Building, 6 W-A Scott Moody, Pharm.D. (non-voting)
275 East Main Street
Frankfort, KY 40621 New Brand Name Products Contact
T: 502/564-7940 Debra Bahr, R.Ph.
F: 502/564-0509 502/564-7940
E-mail: dan.yeager@ky.gov
Internet address: www.chs.ky.us/dms
Prescription Price Updating

Prior Authorization Contact UNYSIS Provider Services


P.O. Box 2106
Dan Yeager, R.Ph. Frankfort, KY 40602
502/564-7940 T: 502/226-1140
F: 502/226-1860
Pharmacy and Therapeutics Advisory
Committee Medicaid Drug Rebate Contact
Robert C. Hughes, M.D. (Chair) Betsy Scott
Truman Perry, M.D. Department for Medicaid Services
Dale E. Toney, M.D. CHR Building, 6 E-B
Christopher A. Cunha, M.D. 275 East Main Street
Carol Lee Steltenkamp, M.D., M.B.A. Frankfort, KY 40621
Connie Gayle White, M.D. (Vice-Chair) T: 502/564-5472
Naren N. James, M.D. F: 502/564-3232
Carmel Wallace, M.D. E-mail: Betsy.Scott@ky.gov
Andrew T. Cooley, M.D.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Claims Submission Contact Nancy Steele


Suzanne Watkins, O.D.
Unisys Provider Services
William T. Watkins, M.D.
P.O. Box 2106
Bettie Speicher Weyler
Frankfort, KY 40602
Donnie Wilhite
T: 502/226-1140
John Withrow
F: 502/226-1860

Executive Officers of State Medical and


Medicaid Managed Care Contact
Pharmaceutical Societies
Lorraine Dumas
Kentucky Medical Association
Department of Medicaid Services
William T. Applegate
CHR Building, 6 E-C
4965 U.S. Highway 42, Suite 2000
275 E. Main St
Louisville, KY 40222-6301
Frankfort, KY 40621
T: 502/426-6200
T: 502/564-4923
F: 502/426-6877
F: 502/564-0223
E-mail: member@kyma.org
E-mail: Lorraine.Dumas@ky.gov
Internet address: www.kyma.org

Mail Order Pharmacy Program Kentucky Pharmacists Association


Mike Mayes, FACHE
Sate currently has a mail order pharmacy program.
Executive Director
Mail order pharmacy program is open to all Medicaid
1228 U.S. Highway 127 South
recipients. Must use a pharmacy that participates in
Frankfort, KY 40601
the Kentucky Medicaid Program.
T: 502/227-2302
F: 502/227-2854
Department for Medicaid Services Officials E-mail: kyphassoc@aol.com
Internet address: www.kphanet.org
James W. Holsinger, Jr., M.D., Secretary
Cabinet for Health and Family Services State Board of Pharmacy
CHR Building, 5 W-A Michael A. Mone
275 East Main Street Executive Director
Frankfort, KY 40621 23 Millcreek Park
T: 502/564-6786 Frankfort, KY 40601-9230
F: 502/564-0274 T: 502/573-1580
F: 502/573-1582
Mike Robinson, Commissioner E-mail: pharmacy.board@mail.state.ky.us
Department for Medicaid Services Internet address: www.state.ky.us/boards/pharmacy
Sixth Floor
275 East Main Street Kentucky Society of Health-System Pharmacists
Frankfort, KY 40621 Dwaine K. Green
T: 502/564-4321 Executive Vice President
F: 502/564-0509 One Quality Street
Lexington, KY 40507-1428
State Advisory Council on Medical T: 859/433-3641
Assistance F: 859/257-7297
E-mail: dgree1@uky.edu
Frank Butler Internet address: www.kshp.org
Elvin E. Dodson
Bob Gray Kentucky Osteopathic Medical Association
William P. Mattingly Tom Underwood, Executive Director
Marsha Mercer 1501 Twilight Trail
Marcia Morgan Frankfort, KY 40601
Chester A. Nava Jr., D.P.M. (chair) T: 502/223-5322
Kristin V. Paul, R.N. F: 502/223-4937
Vickie L. Prichard E-mail: tunderwood@koma.org
William K. Rich, D.M.D Internet address: www.koma.org
Leslie Rogers

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Kentucky Hospital Association


Michael T. Rust
President
2501 Nelson Miller Parkway
Louisville, KY 40223
T: 502/426-6220
F: 502/426-6226
Internet address: www.kyha.com

Kentucky Association of Health Care Facilities


Rich Miller, President
9403 Mill Brook Road
Louisville, KY 40223
T: 502/425-5000
F: 502/425-3431
E-mail: rmiller@kahcf.org
Internet address: www.kahcf.org

Kentucky-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

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National Pharmaceutical Council Pharmaceutical Benefits 2003

LOUISIANA

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $554,670,701 628,571 $714,107,841

RECEIVING CASH ASSISTANCE, TOTAL $351,387,693 259,405


Aged $91,902,271 41,683
Blind/Disabled $227,169,789 114,935
Child $15,071,139 64,596
Adult $17,244,494 38,191

MEDICALLY NEEDY, TOTAL $7,085,668 5,470


Aged $2,977,860 1,238
Blind/Disabled $2,574,449 1,411
Child $61,884 215
Adult $1,471,475 2,606

POVERTY RELATED, TOTAL $67,020,934 260,160


Aged $1,987,183 1,371
Blind/Disabled $1,481,920 1,336
Child $59,094,838 228,683
Adult $4,456,993 28,770

TOTAL OTHER EXPENDITURES/RECIPIENTS* $129,176,406 103,536

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Louisiana-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Prescribing or Dispensing Limitations

Department of Health and Hospitals. Prescription Refill Limit: Permitted as indicated by


physician within 6 months and not to exceed 5 refills.

D. PROVISIONS RELATING TO DRUGS Monthly Quantity Limit: New prescription must be


issued for drugs given on a continuing basis, after 5
Benefit Design refills or after 6 months. Maximum quantity for
prescriptions shall be either 30-day supply or 100
Drug Benefit Product Coverage: Products covered: unit doses, whichever is greater. Monthly limit of 8
prescribed insulin; disposable needles and syringe prescriptions per recipient.
combinations used for insulin; blood glucose test
strips; and urine ketone test strips. Products covered Other: Viagra and other drugs to treat impotence are
as DME: total parenteral nutrition and interdialytic limited to a quantity of 6 pills per month.
parenteral nutrition. Products not covered:
cosmetics; DESI drugs; fertility drugs; experimental Drug Utilization Review
drugs; and cough and cold preparation.
PRODUR system implemented in April 1996. State
Over-the-Counter Product Coverage: Products not has a DUR Board that meets quarterly.
covered (with limited exceptions): allergy, asthma,
and sinus products; analgesics; cough and cold
preparations; digestive products; feminine products; Pharmacy Payment and Patient Cost Sharing
topical products; and smoking deterrent products.
Dispensing Fee: $4.45 on average to $5.77
Therapeutic Category Coverage: Therapeutic maximum, effective 7/1/94.
categories/ products covered: all except cosmetics,
cough and cold preparations, DESI drugs and Ingredient Reimbursement Basis: EAC = AWP-
experimental drugs. Prior authorization required for: 13.5% for Independent Pharmacies. AWP - 15% for
analgesics, antipyretics, and NSAIDs; antibiotics; chain pharmacies. (Chain pharmacies are defined as
anticoagulants; anti-depressants; antidiabetic agents; ownership of more than fifteen (15) Medicaid
antihistamines; antilipemic agents; anxiolytics, enrolled pharmacies under common ownership.)
sedatives, and hypnotics; cardiac drugs;
contraceptives; ENT anti-inflammatory agents; Prescription Charge Formula: Medicaid
estrogens; growth hormones; hypotensive agents; reimbursement for pharmacy services will be based
misc. GI drugs; and sympathominetics (adrenergic). on the lower of:
Partial coverage for: anoretics. 1. AWP minus 13.5% for independent pharmacies
and AWP minus 15% for chain pharmacies plus
Coverage of Injectables: Injectable medicines a dispensing fee for single source products or
reimbursable under the Prescription Drug Program multiple source products with no maximum
and through physician payment when used in allowable cost limitations or when physician
physician offices. authorizes “Brand Medically Necessary” for a
brand name product which has a State MAC or
Vaccines: Vaccines reimbursable at cost as part of FUL.
EPSDT service and Vaccines for Children Program.
2. Louisiana Maximum Allowable Costs (LMAC)
or the Federal Upper Limit plus the dispensing
Unit Dose: Unit dose packaging reimbursable.
fee.
3. AWP for multi-source drugs when lower than
Formulary/Prior Authorization FUL or LMAC.
4. The provider’s usual and customary charge to
Formulary: Open formulary. General management
other payors.
techniques include restrictions on use, prior
authorization, preferred products, and physician Maximum Allowable Cost: State imposes Federal
profiling. Upper Limits as well as State-specific limits on
generic drugs. Approximately 800 drugs are listed on
Prior Authorization: State currently has a formal the State-specific MAC list. Override requires
prior authorization procedure but no method of “Brand Necessary” or “Brand Medically Necessary.”
appealing a prior authorization decision.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Incentive Fee: None.


DUR Board
Patient Cost Sharing: $ 0.50 - $3.00 copayment
Edwin Adams
depending of the cost of the prescription, effective
120 Dove Drive
7/13/95.
West Monroe, LA 71291
318/343-3562
Cognitive Services: Does not pay for cognitive
services
Ken Ardoin, Senior Manager
State Government Relations
E. USE OF MANAGED CARE Pfizer, Inc.
7 Village Circle, Suite 400
Does not use MCOs to deliver services to Medicaid Westlake, TX 76262
recipients. 817/491-8410

Brad Belding, P.D.


F. STATE CONTACTS Director of Pharmacy
Thibodaux Hospital
State Drug Program Administrator 402 Easy Street
Thibodaux, LA 70301
Mary J. Terrebonne, P.D. 504/493-4786
Pharmacy Director
Department of Health & Hospitals Sylvia Heidingsfelder, M.D.
1201 Capital Access Road, 6th Floor 5805 Highland Road
P.O. Box 91030 Baton Rouge, LA 70808
Baton Rouge, LA 70821 225/358-1069
T: 225/342-9768
F: 225/342-1980 Susan Hinton, Pharm.D.
E-mail: mterrebo@dhh.la.gov 7680 Dune Drive
Internet address: www.lamedicaid.com New Orleans, LA 70128
504/483-7570
Department of Health and Hospital
Richard Soileau
Administration Officials
401½ St Peters Street
Frederick P. Cerise, Secretary New Iberia, LA 70560
Department of Health and Hospitals 337/365-6721
P.O. Box 629, Bin #2
Baton Rouge, LA 70821 Paul Staab, M.D.
T: 225/342-9500 5216 Lapalco Boulevard
F: 225/342-9508 Marrero, LA 70072
E-mail: fcerise@dhh.state.la.us 504/348-4357
Ben A. Bearden, Director
Charmaine Venters, M.D.
Bureau of Health Services Financing
Earl K. Long Hospital
Department of Health and Hospitals
5825 Airline Highway
P.O. Box 91030
Baton Rouge, LA 70805
Baton Rouge, LA 70821
225/358-1063
T: 225/342-3891
F: 225/342-9508
E-mail: bbearden@dhhmail.dhh-state.la.us New Brand Name Products Contact
Mary J. Terrebonne, P.D.
DUR Contact 225/342-9768
Mary J. Terrebonne, P.D.
225/342-9768

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Prescription Price Updating Dr. Robert L. Marier


June Peach
Maggie Vick
Dr. Keith M. Perrin
Unisys
Ms. Bea Piker
8591 United Plaza Boulevard, Suite 300
Tawana Pounders
Baton Rouge, LA 70809
Sean Prados
T:225/237-3251
Willa Rawls
F: 225/237-3334
Sen. J. “Tom” Schedler
E-mail: margaret.vick@unisys.com
Greg Scott
Mary Scott
Medicaid Drug Rebate Contacts Richard “Andy” Soileau
Mary Tonore
Technical: Timothy Williams, 225/342-5194
Dr. Leonard Weather, Jr.
Policy: Mary J. Terrebonne, 225/342-9768
Linda Welch
Disputes: Katie Landry, 225/342-0427
Ms. Ann Williamson

Claims Submission Contact


Medicaid Pharmaceutical and Therapeutics
Doug Hasty Committee
Project Manager
Mr. Joe Adams
Unisys
Mandeville, LA
8591 United Plaza Blvd., Suite 300
Baton Rouge, LA 70809
State Representative Rodney Alexander
T: 225/237-3391
Jonesboro, LA
F: 225/237-3334
E-mail: doug.hasty@unisys.com
Dr. Donnie Batie
Baton Rouge, LA
Mail Order Pharmacy Program
Mr. Ben Bearden
State has a voluntary mail order pharmacy program Baton Rouge, LA
open to all Medicaid recipients.
Dr. Vincent Culotta
Medical Managed Care Contact Metairie, LA
Mary J. Terrebonne, P.D. Dr. Richard Doskey
225/342-9768 River Ridge, LA

Medical Care Advisory Committee Dr. Blackwell B. Evans, Jr.


New Orleans, LA
Sandra C. Adams (Chairperson)
Brenda Armstrong Dr. Conchetta Fulton
Ralph D. Balentine New Orleans, LA
Dr. Donnie Batie
Francine Boyles Mr. David Hood
Dr. Floyd A. Buras Baton Rouge, LA
Jennifer Canaday
Marcia Daigle Charles Jastram
Sen. John L. “Jay” Dardenne, Jr. New Orleans, LA
Partricia DeMichele
Daily Dupre, Jr. Dr. Ernest Kinchen
Wanda Ellis Lafayette, LA
Warren Hebert
Paul Hildreth Dr. Michael Kudla
Robert D. Horneman Lake Charles, LA
Amelia Lafont
Rep. Jerry L. “Luke” LeBlane Dr. W. Chapman Lee
Dr. Charles Clinton Lewis Baton Rouge, LA
Kay Marcel

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National Pharmaceutical Council Pharmaceutical Benefits 2003

James Lowery Executive Officers of State Medical and


Pineville, LA Pharmaceutical Societies
Dr. Brobson Lutz
New Orleans, LA
Louisiana State Medical Society
Dave L. Tarver
Dr. Catherine A. McDonald
Executive Vice President
Lafayette, LA
6767 Perkins Road, Suite 100
Baton Rouge, LA 70808
Mr. Marty McKay
T: 225/763-8500
Alexandria, LA
F: 225/763-6122
E-mail: executive@lsms.org
Dr. Phillip J. Medon
Internet address: www.lsms.org
Monroe, LA
Louisiana Osteopathic Medical Association
Dr. John B. Pope
(Inactive)
Shreveport, LA
Nancy Bellemare, D.O.
President
Ms. Carolyn Tackett
215 Friedrichs Avenue
Hammond, LA
Metairie, LA 70005-4516
800/621-1773, ext. 8188
Dr. Henderson Tilton
E-mail: info@loma-net.org
New Orleans, LA
Internet address: www.loma-net.org
Dr. Leonard Weather
State Board of Pharmacy
New Orleans, LA
Malcolm J. Broussard
Executive Director
Dr. Lolie C. Yu
5615 Corporate Boulevard, Suite 8E
New Orleans, LA
Baton Rouge, LA 70808-2537
T: 225/925-6496
Pharmacy Advisory Committee F: 225/925-6499
E-mail: labp@labp.com
Ken Ardoin
Internet address: www.labp.com
Michelle Wolf-Selfo
Scott Napoli
Louisiana State Pharmacists Association
William Bouren
Doug Cheramie
Allan Brinkhaus
Executive Director
Clovis Burch
4744 Jamestown, Suite 101
Horace Bynum
Building 7-B
Wayne T. Harris
Baton Rouge, LA 70808
Tim Jacks
T: 225/926-2666
Ruth “Cookie” Jean
F: 225/926-1020
Ricky Guidry
E-mail: lpa2000@tlxnet.net
Carl Aron
Internet address: www.louisianapharmacists.org
Amy Soileau
Marty McKay
Louisiana Society of Health-System Pharmacists
Jerry Wallace
David Lofton
Kirt Soileau
President
8550 United Plaza Boulevard, Suite 1001
Baton Rouge, LA 70809
T: 225/922-4520
F: 225/922-4611
E-mail: lshp@pncpa.com
Internet address: www.lshp.org

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Louisiana Hospital Association


Lynn B. Nicholas
President & CEO
9521 Brookline Avenue
Baton Rouge, LA 70898-0720
T: 504/928-0026
F: 225/923-1004
E-mail: lnicholas@lhaonline.org
Internet address: www.laha.org

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National Pharmaceutical Council Pharmaceutical Benefits 2003

MAINE

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients
TOTAL $203,693,259 192,833 $220,420,714

RECEIVING CASH ASSISTANCE, TOTAL $99,156,442 63,650


Aged $9,742,927 4,469
Blind/Disabled $75,144,561 28,041
Child $3,038,840 13,637
Adults $11,230,114 17,503

MEDICALLY NEEDY, TOTAL $3,381,341 1,253


Aged $2,428,720 912
Blind/Disabled $916,215 281
Child $8,041 24
Adults $28,365 36

POVERTY RELATED, TOTAL $42,571,202 49,911


Aged $10,445,319 5,441
Blind/Disabled $22,747,950 7,758
Child $9,021,432 34,767
Adult $356,501 1,945

TOTAL OTHER EXPENDITURES/RECIPIENTS* $58,584,274 78,019

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report FY 2001 and CMS-64 Report, FY 2002.

Maine-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Formulary/Prior Authorization


State Department of Human Services, Bureau of Formulary: Closed formulary with restrictions on
Medical Services. use, prior authorization, and preferred products.
(The Maine Care Preferred Drug List can be seen at
www.ghsinc.com.)
D. PROVISIONS RELATING TO DRUGS
Prior Authorization: State currently has a formal
Benefit Design prior authorization procedure. Prior authorization
Drug Benefit Product Coverage: Products covered: may be obtained in the case of necessary
prescribed insulin; disposable needles and syringe exceptions. Fair hearing appeal of denials through
combinations used for insulin (not covered for the Office of Administrative Hearings. State has no
nursing home patients); blood glucose test strips formal prior authorization committee.
(with HbA1e values); urine ketone test strips.
Products not covered: cosmetics; fertility drugs; Prescribing or Dispensing Limitations
experimental drugs; total parenteral nutrition; Monthly Quantity Limit: 34 day for brand-name
interdialytic parenteral nutrition (part of procedure); drugs and 90 days for generic drugs per month.
vitamin and vitamin preparations (except
pregnancy); and injectables when oral medication is Prescription Refill Limit: maximum of 11 refills
available for equally effective treatment. per prescription.

Over-the-Counter Product Coverage: Products Drug Utilization Review


covered: allergy, asthma, and sinus products;
analgesics; digestive products (non H2 antagonists); PRODUR system implemented in 1995. State
topical products; and feminine products. Products currently has a DUR Board that meets 12 times per
covered with restrictions: H2 antagonists (limited year.
coverage after 1/1/01); smoking deterrent products
(by Rx only). Products not covered: cough and cold Pharmacy Payment and Patient Cost
preparations. Sharing
Dispensing Fee: $3.35 - $12.50 (Effective
Therapeutic Category Coverage: Therapeutic 1/20/2004)
categories covered: (prior authorization required):
anabolic steroids; analgesics, antipyretics, and Ingredient Reimbursement Basis: EAC = AWP -
NSAIDs; anoretics; antibiotics anticoagulants; 15%.
anticonvulsants; anti-depressants; antidiabetic Prescription Charge Formula: Lowest of usual and
agents; antihistamine drugs; antilipemic agents; customary, FUL, AWP-15%, or Maine MAC.
anti-psychotics; anxiolytics, sedatives, and Maine MAC includes 1,232 drug products in
hypnotics; cardiac drugs; chemotherapy agents; addition to FUL products.
contraceptives; ENT anti-inflammatory agents;
estrogens; growth hormones; hypotensive agents; Maximum Allowable Cost: State imposes Federal
misc. GI drugs; prescribed smoking deterrents; Upper Limits as well as State-specific limits on
sympathominetics (adrenergic); thyroid agents; generic drugs. Override requires prior
injectable arthritis medications; acute migraine authorization.
medications; Synvisc; antifungals; EPO; Synagis, Incentive Fee: None.
and erectile dysfunction products.
Patient Cost Sharing: $2.50 per script up to a
Coverage of Injectables: Injectable medicines maximum of $25.00 per month.
reimbursable through the Prescription Drug Cognitive Services: State does not pay for cognitive
Program when used in home health care and services.
extended care facilities and in physician offices.

Vaccines: Vaccines reimbursable based on cost as E. USE OF MANAGED CARE


part of the EPSDT service (admin. fees), as part of
About 110,000 Medicaid recipients are enrolled in
the Children’s Health Insurance Program, and as
managed care in 2002. Medicaid recipients
part of the Vaccines for Children Program.
enrolled in managed care receive pharmaceutical
benefits through the State.
Unit Dose: Unit dose packaging not reimbursable.

Maine-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

F. STATE CONTACTS Cheryl Blaisdell, R.Ph.


94 Marston Road
State Drug Program Administrator Waterville, ME 04901
Jude Walsh, Director Paula Knight, R.Ph.
Health Care Management Division 31 Birch Circle
Department of Human Services Sidney, ME 04330
Bureau of Medical Services 207/547-3681
11 SHS, 442 Civic Center Drive
Augusta, ME 04333 Stephen McPike, R.Ph.
T: 207/287-1815 15 Wildwood Lane
F: 207/287-6533 Gray, ME 04039
E-mail: jude.c.walsh@maine.gov 207/822-7627
Internet address: www.maine.gov/bms
Michael Ouellette, R.
Prior Authorization Contact 4235 Bassett Road
Jude Walsh Winslow, ME 04901
207/287-1815 207/281-2727

Pharmacy Advisory Group Robert Weiss, M.D.


2 Great Falls Plaza
Alroy Chow, M.D. Auburn, ME 04210
Tim Clifford, M.D.
Edward Ervin, M.D. Jabbar Fazeli, M.D.
Jabbar Fazeli, M.D. 100 Campus Avenue
Thomas Hayward, M.D. Lewiston, ME 04240
Lawrence Losey, M.D.
James Raczek. M.D. Non-voting:
John Grotton, R.Ph.
Paula Knight, R.Ph. Joe Bruno (President)
Dennis Lyons, R.Ph. Goold Health Systems
Steve McPike, R.Ph. P.O. Box 708
Gary Roy, R.Ph. Augusta, ME 04332
207/622-7153
DUR Contact
Dennis G. Lyons, R.Ph.
Jude Walsh 255 Bear Hill Rd., 2nd Fl.
207/287-1815 Waltham, MA 02451

Maine DUR Board New Brand Name Products Contact


Timothy Clifford, M.D. Jude Walsh
Pharmacy Consultant 207/287-1815
P.O. Box 708
Augusta, ME 04332 Prescription Price Updating
207/622-7153
Jude Walsh
William Alto, M.D. 207/287-1815
Maine Dartmouth Family Practice
4 Sheridan Drive Medicaid Drug Rebate Contact
Fairfield, ME 04937 Rossi Rowe
207/861-5000 Insurance Recovery/ Drug Rebate Manager
Department of Human Services
John Grotton, R.Ph. Bureau of Medical Services
Goold Health Systems 11 SHS, 442 Civic Center Drive
P.O. Box 708 Augusta, ME 04333
Augusta, ME 04332 T: 207/287-1838
207/622-7153 F: 207/287-1788
E-mail: rossi.rowe@maine.gov

Maine-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Claims Submission Contact Maine Pharmacy Association


Christopher R. Gauthier, President
Marcia Pykare
127 Pleasant Hill Road
Manager of Data Processing
Scarborough, ME 040704
Goold Health Systems
T: 207/396-5340
P.O. Box 1090
F: 207/396-5341
Augusta, ME 04332-1090
E-mail: cgauthierrph@adelphia.net
T: 207/622-7153
Internet address: www.mparx.com
F: 207/623-5125
E-mail: movkare@ghsinc.com
Maine Osteopathic Association
Kellie Miller, M.S.
Medicaid Managed Care Contact Executive Director
Jude Walsh 693 Western Avenue, #1
207/287-1815 Manchester, ME 04351
T: 207/623-1101
Mail Order Pharmacy Program F: 207/623-4228
E-mail: kmiller@mainedo.org
State has a mail order Medical Assistance Internet address: www.mainedo.org
pharmacy program.
Maine Board of Pharmacy
Disease Management Program/Initiative Geraldine “Jeri” Betts, Board Administrator
Contact 35 State House Station
Jude Walsh Augusta, ME 04333
207/287-1815 T: 207/624-8620
F: 207/624-8637
Human Services Department Officials E-mail: geraldine.l.betts@maine.gov
Internet address: www.maine.gov/prf/olr/
Peter Walsh, Acting Commissioner
Department of Human Services Maine Society of Health-System Pharmacists
State House Station 11 Carl Grove, President
Augusta, ME 04333-0011 25 June Street
T: 207/287-2736 Sanford, ME 04073
F: 207/287-3005 207/324-4310
E-mail: peter.e.walsh@maine.gov E-mail: cgrove@goodallhosp.org
Internet address: www.maine.gov/dhs
Maine Hospital Association
Chris Zukus Lessard, Director Steve Michaud
Bureau of Medical Services President
Department of Human Services 33 Fuller Road
State House Station 11 Augusta, ME 04330
Augusta,ME 04333-0011 T: 207/622-4794
T: 207/287-2674 F: 207/622-3073
F: 207/287-2675 E-mail: smichaud@themha.org
E-mail: chris.zukas.lessard@maine.gov Internet address: www.themha.org
Internet address: www.maine.gov/bms
Maine Health Care Association
Executive Officers of State Medical and Richard A. Erb
Pharmaceutical Societies President and CEO
Maine Medical Association 317 State Street
Gordon Smith, Esq. Augusta, ME 04330
Executive Vice President T: 207/623-1146
Frank O. Stred Building F: 207/623-4080
P. O. Box 190 E-mail: rerb@mehca.org
Manchester, ME 04351-0190 Internet address: www.mehca.org
T: 207/622-3374
F: 207/622-3332
E-mail: info@mainemed.com
Internet address: www.mainemed.com

Maine-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

MARYLAND

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $417,080,496 413,755 $297,291,733

RECEIVING CASH ASSISTANCE, TOTAL $250,086,652 146,902


Aged $32,434,284 16,402
Blind / Disabled $195,329,917 69,078
Child $8,287,280 40,807
Adult $14,035,171 20,615

MEDICALLY NEEDY, TOTAL $86,459,198 53,223


Aged $46,136,023 18,138
Blind / Disabled $29,821,999 11,626
Child $4,769,778 13,221
Adult $5,731,398 10,238

POVERTY RELATED, TOTAL $59,823,561 186,809


Aged $11,344,463 7,589
Blind / Disabled $14,225,876 5,162
Child $31,413,643 154,271
Adult $2,839,579 19,787

TOTAL OTHER EXPENDITURES/RECIPIENTS* $20,711,085 26,821

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Maryland-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Unit Dose: Unit dose packaging not reimbursable.


State Department of Health and Mental Hygiene.
Formulary/Prior Authorization
D. PROVISIONS RELATING TO DRUGS Formulary: Open formulary with a preferred drug
list (PDL). Prior authorization required for non-
Benefit Design PDL products.

Drug Benefit Product Coverage: Products covered: Prior Authorization: State currently has a Prior
legend drugs; prescribed insulin; disposable needles Authorization procedure. A general appeals
and syringe combinations used for insulin. Covered procedure is available when a physician can
under DME: blood glucose test strips; urine ketone provide additional information to justify the
test strips total parenteral nutrition; and interdialytic medical necessity of a particular product.
parenteral nutrition. Products not covered:
cosmetics; fertility drugs; experimental drugs; Preauthorization is needed for any prescription with
DESI drugs; prescriptions and injections for central a usual and customary charge exceeding $400.
nervous system stimulants; food supplements or Prior authorization is also needed for early refills,
infant formulas; products for which Federal nutritional supplements, brand medically necessary
Financial Participation is not allowed, i.e., "less and excessive quantities.
than effective" drugs and products whose
manufacturers have not signed rebate agreements;
and certain other items as specified in The State's Prescribing or Dispensing Limitations
Medicaid Plan.
Prescription Refill Limit: Maximum of eleven
Over-the-Counter Product Coverage: Products refills. The original prescription and its refills may
covered: contraceptives; oral ferrous sulfate; and not exceed a 360-day supply.
aspirin for arthritis. Products not covered: allergy,
asthma and sinus products; analgesics; cough and Monthly Quantity Limit: The amount of medication
cold preparations; digestive products (H2 and non- to be dispensed on a prescription at one time is
H2 antagonists); feminine products (except limited to a less than 34-day supply except for
contraceptives); topical products; and smoking specific maintenance drugs for chronic conditions,
deterrent products. where up to a 100-day supply may be dispensed at
one time.
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; analgesics, Drug Utilization Review
antipyretics, NSAIDs; antibiotics; anticoagulants;
anticonvulsants; antidepressants; antidiabetic PRODUR system implemented January 1993. State
agents; antihistamine drugs; antilipemic agents; currently has a DUR Board with a quarterly review.
anti-psychotics; anxiolytics, sedatives, and
hypnotics; cardiac drugs; chemotherapy agents;
Pharmacy Payment and Patient Cost
prescribed cold medications; contraceptives; ENT
Sharing
anti-inflammatory agents; estrogens; hypotensive
agents; misc. GI drugs; prescribed smoking Dispensing Fee: $3.69 - $5.65 as of November
deterrents; sympathominetics (adrenergic); and 2002.
thyroid agents. Prior authorization required for: $3.69 - non-PDL Brand.
growth hormones; synagis; and nutritional $4.69 - PDL Generic
supplements for tube-fed recipients. Therapeutic $4.65-Nursing Home non-PDL
categories not covered: anorectics. Brand
$5.65 - Nursing Home PDL or
Coverage of Injectables: Injectable medicines Generic
reimbursable through the Prescription Drug
Program when used in home health care and Ingredient Reimbursement Basis: Estimated
extended care facilities, and through both the Acquisition Cost (EAC) equals/lowest of:
Prescription Drug Program and physician payment 1. Wholesale Acquisition Cost (WAC) plus 9%.
when used in physician offices.
2. Direct cost plus 9%.
Vaccines: Vaccines reimbursable as part of the 3. Distributor's price plus 9%.
Vaccines for Children Program.
4. Average Wholesale Price (AWP) minus 11%.

Maryland-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Prescription Charge Formula: Reimbursement will Priority Partners MCO


be the lower of: (1) the calculated ingredient cost Bay Meadow Industrial Park
plus a dispensing fee; (2) the usual and customary 6704 Curtis Court
fee. Glen Burnie, MD 21060
410/424-4400
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
Ameri Group
generic drugs. Approximately 1,000 drugs are
857 Elkridge Landing Road, #300
listed on the State-specific MAC list. Override
Linthicum, MD 21090
requires “Brand Medically Necessary” and a
410/859-5800
reason.
Incentive Fee: $1.00 higher for dispensing a lower
cost multisource product. F. STATE CONTACTS

Patient Cost Sharing: Copayment = $2.00 for State Drug Program Administrator
Brands not on the PDL. Does not apply to
managed care, family planning, nursing home Mr. Joseph L. Fine
residents, recipients under 21 years old, or generic Director
drugs. Maryland Pharmacy Program
DHMH, Office of Operation and Eligibility
Cognitive Services: Does not pay for cognitive 201 West Preston Street
services. Baltimore, MD 21201
T: 410/767-1455
F: 410/333-5398
E. USE OF MANAGED CARE E-mail: jfine@dhmh.state.md.us
Internet address: www.dhmh.state.md.us
Approximately 444,000 Medicaid recipients were
enrolled in MCOs in FY 2002. Recipients receive
New Brand Name Products Contact
pharmaceutical benefits through the State and
managed care plans. (Mental health drugs are Frank T. Tetkoski
“carved out” of managed care.) Manager
Services and Preauthorization
DHMH, Division of Pharmacy Services
Managed Care Organizations 201 West Preston Street, Room 409
United Healthcare Family First Baltimore, MD 21201
Lyndwood Executive Center T: 410/767-1460
6095 Marshalee Drive F: 410/333-5398
Elkridge, MD 21075 E-mail: tetkoskif@dhmh.state.md.us
410/277-6000
Prior Authorization Contact
Helix Family Choice, Inc.
8094 Sandpiper Circle Tuong Nguyen, P.D.
Baltimore, MD 21236 Pharmacist Consultant
410/933-3021 DHMH-Office of Operations and Eligibility
Division of Pharmacy Services
Jai Medical Systems, Inc. 201 W. Preston St.
5010 York Road Baltimore, MD 21201
Baltimore, MD 21212 T: 410/767-8701
410/433-2200 F: 410/333-5398
E-mail: nguyent@dhmh.md.us
Maryland Physicians Care MCO
7104 Ambassador Road
Suite 100
Baltimore, MD 21244
410/277-9710

Maryland-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

DUR Contact Mail Order Pharmacy Benefit


Judy Geisler, P.D. None
Pharmacist Consultant
DHMH-Office of Operations and Eligibility
Division of Pharmacy Services Expanded Drug Coverage Program
201 W. Preston Street Paul Roeger, Chief
Baltimore, MD 21201 Division of Eligibility Services
T: 410/767-1455 Montgomery Park Business Center
F: 410/333-5398 1800 Washington Boulevard, Suite 400
E-mail: geislerj@dhmh.state.md.us Baltimore, MD 21230
T: 443/263-7031
F: 443/263-7065
DUR Board
E-mail: roegerp@dhmh.state.md.us
Deneen Pieri, M.D.
John Boronow, M.D.
Michelle A. Forrest-Smith, Pharm.D. Health and Mental Hygiene Department
Myron Miller, M.D. (Chair) Officials
Lori Fantry, M.D., M.P.H. Nelson J. Sabatini, Secretary
Vincent Ferrari, R.Ph. Department of Health and Mental Hygiene
Steve A. Anifowshe, R.Ph. 201 W. Preston Street
Elliot S. Gottlieb, R.Ph. Baltimore, MD 21201
Bernard J. Lechman, R.Ph. T: 410/225-6500
F: 410/161-6489
E-mail: nsabatini@dhmh.state.md.us
Prescription Price Updating
First DataBank Joseph Davis
1111 Bayhill Dr. Executive Director
San Bruno, CA 94066 Office of Operations and Eligibility
T: 415/588-5454 201 W. Preston Street
F: 415/827-4578 Baltimore, MD 21201

Joseph Fine
Medicaid Drug Rebate Contacts Director
Technical: Ed Ellis, 410/767-1455 Maryland Pharmacy Program
Policy: Jeffrey Gruel, 410/767-1455 201 W. Preston Street
Disputes: Alex Taylor, 410/263-7048 Baltimore, MD 21201

Jeffrey Gruel,Chief
Claims Submission Contact Division of Pharmacy Services
First Health Services Corporation Office of Operations and Eligibility
Division of Claims Processing 201 W. Preston Street
James Demery Baltimore, MD 21201
Manager, Pharmacy Services 410/767-1455
201 W. Preston St.
Baltimore, MD 21201 Paul Roeger
T: 410/767-1460 Program Manager - Eligibility
F: 410/333-5398 Pharmacy Assistance Program
E-mail: demeryj@dhmh.state.md.us PO Box 386
Baltimore, MD 21203
Medicare Managed Care Contact
Medical Assistance Staff Committee
Jim Gardner Members
Chief
Division of Health Choice Management Judy Geisler, P.D.
201 W. Preston St., Room 208 Division of Pharmacy Services
Baltimore, MD 21201 201 W. Preston Street
410/767-1482 Baltimore, MD 21201

Maryland-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Mr. Frank Tetkoski, P.D., Manager State Board of Pharmacy


Services and Preauthorization LaVerne G. Naesea
Division of Pharmacy Services Executive Director
201 W. Preston Street, Room 409 4201 Patterson Avenue
Baltimore, MD 21201 Baltimore, MD 21215-2299
T: 410/764-4794
Phil Cogan F: 410/358-6207
Preferred Drug List E-mail: mdbop@dhmh.state.md.us
Division of Pharmacy Services Internet address:
201 W. Preston Street www.dhmh.state.md.us/pharmacyboard
Baltimore, MD 21201
Association of Maryland Hospitals and Health
Tuong Nguyen, P.D. Systems
Division of Pharmacy Services Calvin M. Pierson, President
201 W. Preston St. 6820 Deerpath Road
Baltimore, MD 21201 Elkridge, MD 21075-6234
T: 410/379-6200
F: 410/379-8239
Executive Officers of State Medical and
E-mail: cpierson@mhaonline.org
Pharmaceutical Societies
Internet address: www.mhaonline.org
Maryland State Medical Society
T. Michael Preston Health Facilities Association of Maryland
Executive Director Adele Wilzack, President
1211 Cathedral Street 7060 Oakland Mills Road, Suite M
Baltimore, MD 21201 Columbia, MD 21046
T: 410/539-0872 T: 410/792-4390
F: 410/547-0915 T: 301/490-8413
E-mail: mpreston@medchi.org F: 410/792-4617
Internet address: www.medchi.org E-mail: awilzack@hfam.org
Internet address: www.hfam.org
Maryland Association of Osteopathic Physicians
John Kylan Lynch, D.O.
President
3603 Southside Drive
Phoenix, MD 21131
T: 410/683-8100
F: 410/683-8200
E-mail: lynchj@ninds.nih.gov
Internet address: www.maops.com

Maryland Pharmacists Association


Howard Schiff
Executive Director
650 West Lombard Street
Baltimore, MD 21201-1572
T: 410/727-0746
F: 410/727-2253
E-mail: MPHA@erols.com
Internet address: www.marylandpharmac.street.org

Maryland Society of Health-System Pharmacists


David A. Kotzin, President
8480-M Baltimore National Pike, Ste. 252
Ellicott City, MD 21042
T: 410/465-9975
F: 410/465-7073
E-mail: dkotzin@gbmc.org
Internet address: www.mshp.org

Maryland-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Maryland-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

MASSACHUSETTS

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $795,309,302 664,891 $958,972,520

RECEIVING CASH ASSISTANCE TOTAL $398,769,692 233,547


Aged $43,882,222 27,199
Blind/Disabled $325,512,115 126,497
Child $9,394,346 50,397
Adult $19,981,009 29,454

MEDICALLY NEEDY, TOTAL $33,106,079 16,380


Aged $13,532,409 8,577
Blind/Disabled $19,573,670 7,823
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $222,673,963 225,206


Aged $57,479,842 29,452
Blind/Disabled $133,146,461 46,414
Child $30,025,642 144,510
Adult $2,022,018 4,830

TOTAL OTHER EXPENDITURES/RECIPIENTS* $140,759,568 189,758

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Massachusetts-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Coverage of Injectables: Injectable medicines


reimbursable through the Prescription Drug
Executive Offices of Health and Human Services, Program when used in home health care and
Division of Medical Assistance, Office of extended care facilities and through both the
Medicaid. Prescription Drug Program and physician payment
when used in physician offices.

D. PROVISIONS RELATING TO DRUGS Vaccines: Vaccines reimbursable as part of the


EPSDT service if not provided by the Department
Benefit Design of Public Health.

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). Ritalin and amphetamines physician profiling.
are limited to treatment of hyperkinesis for children Prior Authorization: State currently has a prior
under age 17, except by prior authorization; and authorization procedure. A fair hearing process by
ADD by prior authorization (not covered for the recipient on an individual basis is required for
appetite control). Products not covered: cosmetics; appealing a prior authorization decision.
fertility drugs; experimental drugs; interdialytic
parenteral nutrition; DESI drugs; legend vitamins Prescribing or Dispensing Limitations
not on Drug List, non-legend drugs not on Drug
List; propoxyphene-containing products and Prescription Refill Limit: Prescription may be
products rated by the FDA as less-than-effective. refilled, as authorized, with a limit of up to 5 refills
from the filling of the original prescription
Over-the-Counter Product Coverage: Products Monthly Quantity Limit: Schedule II and III drugs
covered with restrictions (limited OTC list-generics are limited to a 30-day supply, except Ritalin and
only- not covered in LTC facilities): allergy, Dexedrine, which may be dispensed up to a 60-day
asthma and sinus products; analgesics; cough and supply.
cold preparations; digestive products; feminine
products and topical products. Products not Monthly Dollar Limits: None.
covered: smoking deterrent products.
Drug Utilization Review
Therapeutic Category Coverage: Therapeutic PRODUR system implemented in October 1995.
categories covered: anabolic steroids; antibiotics; State currently has a DUR Board with a quarterly
chemotherapy agents; contraceptives; and thyroid review.
agents. Prior authorization required for: growth
hormones; Erythropoeitin; and selected biotech Pharmacy Payment and Patient Cost
drugs. Partial coverage for: prescribed cold Sharing
medications. Partial coverage with prior
authorization required for: analgesic, antipyretics, Dispensing Fee: Brand: $3.00 (basic) plus $1.00-
and NSAIDs; anticonvulsants; anti-depressants; $2.00 additional for compounded Rx’s, effective
antidiabetic agents; antihistamines; antilipemic 1/1/2004.
agents; anti-psychotics; anxiolytics, sedatives, and
hypnotics; cardiac drugs; ENT anti-inflammatory Ingredient Reimbursement Basis: EAC = WAC +
agents; hypotensive agents; misc. GI drugs; 6%.
andsympathominetics (adrenergic). Therapeutic
categories not covered: anoretics; prescribed Prescription Charge Formula: Payment shall be for
smoking deterrents; weight loss or gain the lowest of:
medications; medications to treat sexual
dysfunction; experimental or investigational drugs; 1. EAC plus dispensing fee;
and less than effective drugs.
2. The usual and customary charge defined as
the lowest price charged or accepted by a
provider for any payor; or
3. FULP plus a dispensing fee.

Massachusetts-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Maximum Allowable Cost: State imposes Federal DUR Contact


Upper Limits as well as State-specific limits on
Paul L. Jeffrey
generic drugs. Override requires “Dispense as
617/210-5319
Written,” and/or “Brand Medically Necessary” plus
prior authorization.
Medicaid DUR Board
Patient Cost Sharing: Copayment = $3.00 (Brands) Spencer Wilking, MD (Chairman)
and $1.00 (Generics), effective 2/1/2004. C. Michael Bliss, MD
Sarah Cheeseman, MD
Institutionalized patients Thomas Hewitt, MD
Anne Marie McCloskey, R.Ph.
− Children under age 19 Leo McKenna, R.Ph.
− Pregnant and postpartum women Dave Morgan, R.Ph.
Robert Portney, MD
− Hospice care James Scanlon, R.Ph.
− Family planning items David Kosegarten, Ph.D.
Gerry Longnecker, Pharm.D.
Incentive Fee: None.
New Brand Name Products Contact
Cognitive Services: Does not pay for cognitive
services. Christopher T. Burke
Policy Analyst
Office of Medicaid
E. USE OF MANAGED CARE 600 Washington Street, 5th Floor
Approximately 238,000 Medicaid recipients in Boston, MA 02111
MCOs were enrolled in MCOs in FY 2002 with T: 617/210-5592
another 411,000 enrolled in pre-paid health plans F: 617/210-5597
(PHPs). Recipients receive pharmaceutical benefits E-mail: cburke@nt.dma.state.ma.us
through managed care plans. Enrollees in the
PCCM program receive pharmaceutical benefits Prescription Price Updating
from the State. First Data Bank
111 Bayhill Drive, Suite 350
Managed Care Organization San Bruno, CA 94066
T: 650/588-5454
Primary Care Clinician Plan F: 650/827-4578
Boston Medical Center HealthNet Plan
Fallon Community Health Plan Medicaid Drug Rebate Contacts
Neighborhood Health Plan
Network Health Martha Kessenich
Rebate Analyst
ACS State Health Care
F. STATE CONTACTS 365 North Ridge Road, Suite 400
Atlanta, GA 30350
State Drug Program Administrator 800/358-2381
Paul L. Jeffrey
Director of Pharmacy Claims Submission Contact
Office of Medicaid ACS State Health Care
600 Washington Street, 5th Floor 365 North Ridge Road, Suite 400
Boston, MA 02111 Atlanta, GA 30350
T: 617/210-5319 800/358-2381
F: 617/210-5865
E-mail: pjeffrey@nt.dma.state.ma.us
Internet Address: www.state.ma.us/dma

Prior Authorization Contact


Paul L. Jeffrey
617/210-5319

Massachusetts-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Medicaid Managed Care Contact Massachusetts Pharmacists Association


Alan J. Shubin, R.Ph.
Kate Willrich-Nordahl, Director
President
Massachusetts Health MCO Program
681 Main Street, Suite 3-32
Department of Public Health
Waltham, MA 02451
250 Washinton Street, 6th Floor
T: 781/736-0101
Boston, MA 02108
F: 781/736-0080
T: 617/624-5693
Internet address: www.maspharmacists.org
F: 617/624-5698
E-mail: kate.willrich-nordahl@state.ma.us
Massachusetts Osteopathic Society, Inc.
William Seeglitz
Mail Order Pharmacy Benefit President
None P.O. Box 487
Winchester, MA 01890
Disease Management Program/Initiative 781/721-9900
Contact E-mail: nocdos@shore.net
Internet address: www.northeastosteo.org
N/A
Massachusetts Board of Registration in Pharmacy
Executive Offices of Health and Human Charles R. Young
Services Executive Director
Ronald Preston, Secretary 239 Causeway Street, Suite 500
Executive Office of Health and Human Services Boston, MA 02114
One Ashburton Place, Room 1109 T: 617/727-9953
Boston, MA 02108 F: 617/727-2197
T: 617/727-0077 E-mail: charles.r.young@state.ma.us
F: 617/727-5134 Internet address: www.state.ma.us/reg/boards/ph
E-mail: ronald.preston@state.ma.us
Internet address: www.masscares.org Massachusetts Society of Health-Systems
Pharmacists
Beth Waldman, Director Martin Goldberg
Office of Medicaid President
One Ashburton Place, Room 1109 500 West Commings Park, Suite 3475
Boston, MA 02108 Woburn, MA 01801
T: 617/573-1770 T: 781/937-0175
F: 617/573-1894 F: 781/937-0176
E-mail: bwaldman@nt.dma.state.ma.us E-mail: admin@mashp.org
Internet address: www.state.ma.us/dma Internet address: www.mashp.org

Executive Officers of State Medical and Massachusetts Hospital Association


Pharmaceutical Societies Ronald M. Hollander
President
Massachusetts Medical Society Five New England Executive Park
Corrine Broderick Burlington, MA 01803
Executive Vice President T: 617/272-8000
860 Winter Street F: 781/272-8000
Waltham Woods Corporate Center E-mail: info@mhalink.org
Waltham, MA 02451-1411 Internet address: www.mhalink.org
T: 781/893-4610
F: 781/893-9136 Massachusetts Extended Care Federation
E-mail: broderick@massmed.org Abraham E. Morse
Internet address: www.massmed.org President
2310 Washington Street, Suite 300
Newton, MA 02462
T: 617/558-0202
F : 617/558-3546
E-mail: amorse@mecf.org
Internet address: www.mecf.org

Massachusetts-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $604,759,491 551,593 $674,222,281

RECEIVING CASH ASSISTANCE TOTAL $278,471,171 199,600


Aged $34,781,401 18,971
Blind/Disabled $232,639,786 127,875
Child $3,532,094 24,915
Adult $7,517,890 27,839

MEDICALLY NEEDY, TOTAL $33,663,061 48,285


Aged $8,419,629 5,074
Blind/Disabled $14,322,748 5,269
Child $2,043,913 10,523
Adult $8,876,771 27,419

POVERTY RELATED, TOTAL $33,072,967 114,030


Aged $1,984,861 1,503
Blind/Disabled $14,408,432 5,343
Child $13,531,563 85,310
Adult $3,148,111 21,874

TOTAL OTHER EXPENDITURES/RECIPIENTS* $259,552,292 189,678

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Michigan-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Coverage of Injectables: Injectable medicines


reimbursable through the Prescription Drug
Michigan Department of Community Health, Program when used in home health care and
Medical Services Administration. extended care facilities, and through physician
payment when used in physician offices.

D. PROVISIONS RELATING TO DRUGS Vaccines: Vaccines reimbursable at cost plus a


fee/or vaccine replacement as part of the EPSDT
Benefit Design service the Children Health Insurance Program,
and the Vaccines for Children Program.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Unit Dose: Unit dose packaging reimbursable.
combinations used for insulin; blood glucose test
strips; and urine ketone test strips. Products covered Formulary/Prior Authorization
with restrictions: total parenteral nutrition (prior
authorization for equipment and supplies) and Formulary: Closed formulary and a preferred drug
interdialytic parenteral nutrition (prior authorization list (PDL). (See www.michigan.fhsc.com for
required for self administration). Prior authorization listing of drugs on the PDL.) Formulary managed
required for: brand name products equivalent to through restrictions on use, prior authorization
MACs; Accutane & Retin-A; Dexedrine and requirements, age/gender editing; and clinical
Adderall; Persantine; Lactulose (Cephulac); editing for “first line” therapy.
Methylphenidate (selected ages); selected
benzodiazepines; Epogen administered in the home Prior Authorization: State currently has a formal
setting; dietary formulas; and drugs not listed on the prior authorization procedure. Beneficiaries have a
formulary. Products not covered: cosmetics; right to appeal prior authorization decisions on the
fertility drugs; and experimental drugs. basis of medical necessity. Informal review of
additional information can be conducted at any
Over-the-Counter Product Coverage: Products time. Beneficiaries also have fair hearing rights to
covered with restrictions (only selected products in appeal denial of coverage for an excluded product.
each category): allergy, asthma and sinus products
(antihistamines); analgesics (payment limits, Prescribing or Dispensing Limitations
considered part of nursing home per diem Prescription Refill Limit: None
reimbursement); non-H2 antagonists (payment
limits, considered part of nursing home per diem Monthly Quantity Limit: Prescribed quantities
reimbursement); H2 antagonist (payment limits); should be limited to an amount necessary to keep
feminine products (payment limits); topical the recipient supplied during the therapy regimen.
products; and smoking deterrent products (tablets, Quanity limits for selected pharmaceuticals (e.g.,
patches and gum-quanity limits per beneficiary per sedative hypnotics). In certain cases and
year). Products not covered: cough and cold conditions, more than a month’s supply will be
preparations. appropriate. However, in no instance may more
than 100 days supply be dispensed per
Therapeutic Category Coverage: Therapeutic prescription.
categories covered: analgesics, antipyretics,
NSAIDs; antibiotics; anticoagulants; Drug Utilization Review
anticonvulsants; antidepressants; antidiabetic
agents; antihistamine drugs; antilipemic agents; PRODUR system implemented in July 2000. State
anti-psychotics; anxiolytics, sedatives, and currently has a DUR Board with a quarterly
hypnotics; cardiac drugs; chemotherapy agents; review.
contraceptives; ENT anti-inflammatory agents;
estrogens; growth hormones; hypotensive agents; Pharmacy Payment and Patient Cost
misc. GI drugs; sympathominetics (adrenergic); and Sharing
thyroid agents. Partial coverage for: anabolic
Dispensing Fee: $3.77, (included in annual
steroids (prior authorization required); prescribed
Appropriations Act.)
cold medications; and prescribed smoking deterrents
(prior authorization required). Therapeutic
Ingredient Reimbursement Basis: 1-4 stores =
categories not covered: anoretics.
AWP-13.5%, 5 or more stores = AWP-15.1%.

Michigan-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Prescription Charge Formula: Reimbursement for Managed Care Organizations


legend drugs is limited to the lower of:
Botsford Health Plan
1. AWP-13.5% for 1 to 4 stores & AWP-15.1% 28050 Grand River
for 5 or more stores or LTC, plus dispensing Farmington Hills, MI 48336
fee minus selected $1.00 patient copay, or 800/479-5122
Internet address: www.botsfordhealthplan.org
2. The MAC rate, plus dispensing fee, or
3. The provider’s usual and customary charge to Cape Health Plan
the general public. 26711 Northwestern Highway, Suite 300
Southfield, MI 48034
Maximum Allowable Cost: State imposes Federal 248/386-3000
Upper Limits as well as State-specific limits on 888/354-2273
generic drugs. Override requires “Brand Medically Internet address: www.capehealth.com
Necessary” and prior authorization.
Community Choice Michigan
Incentive Fee: None. 2369 Woodlake Drive
Okemos, MI 48864
Patient Cost Sharing: Ambulatory recipients age 21 517/349-9922
and older are required to pay a $1.00 copayment for 800/390-7102
most legend drugs. If the recipient is unable to pay Internet address: www.ccmhmo.org
a required copayment on the date of service, the
pharmacy cannot refuse to render the service. Great Lakes Health Plan, Inc.
However, the pharmacy may bill the recipient for 17117 W. Nine Mile, Suite 1600
the copayment amount, and he/she is responsible for Southfield, MI 48075
paying it. If the recipient fails to pay a copayment, 248/559-5656
the pharmacy could, in the future, refuse to serve the 800/903-5253
recipient as a Medicaid recipient. Internet address: www.glhp.com
Drugs not requiring a co-payment include Health Plan of Michigan, Inc.
pregnancy-related and family planning products. 17515 W. Nine Mile, Suite 650
Southfield, MI 48075
Recipients are not required to make a copayment if: 248/557-3700
888/437-0606
− They are under age 21, or
Internet address: hpmich.com
− They reside in a long-term care facility (nursing
home, hospital long-term care facility, or HealthPlus Partners, Inc.
medical care facility), or 2050 S. Linden Road
P.O. Box 1700
− Health Maintenance Organization (HMO), or a
Flint, MI 48501-1700
capitated Clinic Plan.
810/230-2132
Cognitive Services: Does not pay for cognitive 800/322-9161
services. Internet address: www.healthplus.com

M-Caid
E. USE OF MANAGED CARE 2301 Commonwealth Blvd.
Ann Arbor, MI 48105-1573
Approximately 800,000 Medicaid recipients were 800/527-5549
enrolled in MCOs in FY 2002. Recipients receive Internet address: www.mcare.org
pharmaceutical benefits through managed care
plans. Psychotropics, antidepressants, anti-mania, McLaren Health Plan
central nervous system stimulants, and other select G 3245 Beacher Road, Suite 200
classes of drugs are administered by managed care Flint, MI 48532
organizations but paid for by the State. 888/327-0671
Internet address: www.mclaren.org

Michigan-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Midwest Health Plan The Wellness Plan


5050 Schaefer Road 7700 Second Avenue
Dearborn, MI 48126 Detroit, MI 48202
313/581-3700 313/202-8500
888/654-2200 800/875-9355
Internet address: www.midwesthealthplan.com Internet address: www.wellplan.com

Molina Healthcare of Michigan


100 W. Big Beaver Road, Suite 600 F. STATE CONTACTS
Troy, MI 48084
248/925-1700 State Drug Program Administrator
888/898-7969 Giovannino A. Perri, M.D.
Internet address: www.molinahealthcare.com Chief Medical Consultant
MDCH/Medical Services Administration
OmniCare Health Plan 400 South Pine Street
1155 Brewery Park Blvd. P.O. Box 30479
Suite 250 Lansing, MI 48909-7979
Detroit, MI 48207 T: 517/335-5181
313/259-4000 F: 517/241-8135
800/955-4578 E-mail: perrig@michigan.gov
Internet address: www.ochp.com Internet address: www.michigan.gov/mdhc

PHP of Mid-Michigan, Inc.


P.O. Box 30377 New Brand Names Products Contact
Lansing, MI 48909-7877 Donna Hammel
517/364-8400 Office of Medical Affairs
800/661-8299 MDCH/ Medical Services Administration
Internet address: www.phpmm.org 400 South Pine Street
P.O. Box 30479
PHP of Southwest Michigan, Inc. Lansing, MI 48909-7979
106 Farmers Alley, Suite 300 T: 517/335-5181
Kalamazoo, MI 49007 F: 517/241-8135
269/341-7200 E-mail: hammeld@michigan.gov
800/261-0084
Internet address: www.ibahealthplans.com
Prior Authorization Contact
Priority Health, Government Programs, Inc. First Health Service Corporation
1231 E. Beltline, NE 4300 Cox Road
Grand Rapids, MI 49525-4501 Glen Allen, VA 23060
616/942-0954 T: 877/864-9014
888/975-8102 F: 888/603-7696
Internet address: www.priority-health.com

Total Health Care DUR Contact


3011 W. Grand Blvd., Suite 1600
Deberah Eggleston, M.D.
Detroit, MI 48202
MDCH- Medical Services Administration
313/871-2000
400 S. Pine St.
800/826-2862
P.O. Box 30479
Internet address: totalhealthcareonline.com
Lansing, MI 48909-7979
T: 517/335-5181
Upper Peninsula Health Plan
F: 517/241-8135
228 W. Washington Street
E-mail: egglestond@michigan.gov
Marquette, MI 49855
906/225-7500
800/835-2556
Internet address: www.uphp.com

Michigan-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Medicaid DUR Board Medicaid Drug Rebate Contacts


Richard Henderson, M.D. Technical: Dawn Parsons
34650 Versailles Court Pharmacy Consultant
Farmington Hills, MI 48331 MDCH/ Medical Services
810/474-1397 Administration
400 South Pine Street
Frank Check, M.D. P.O. Box 30479
St. Joseph Mercy Hospital Lansing, MI 48909-7979
900 Woodward Avenue T: 517/335-5181
Pontiac, MI 48341 F: 517/241-8135
313/858-3233 E-mail: parsonsd@michigan.gov

Duane Kirking, Ph.D. Audits: First Health Services Corporation


College of Pharmacy 877/864-9014
University of Michigan
Ann Arbor, MI 48109-1065 Claims Submission Contact
313/764-4483
313/764-7312 First Health Services Corp
T: 877/864-9014
William Overkamp F: 888/603-7696
2929 Walker, N.W.
Grand Rapids, MI 49544 Medicaid Managed Care Contact
Sue Moran, Chief
Karen Jonas, R.Ph. Bureau of Medicaid Operations and Quality
13121 Willow Grove Road MDCH- Medical Services Administration
Dewitt, MI 48820 400 S. Pine Street
517/315-1243 P.O. Box 30479
Lansing, MI 48909-7979
James Kenyon, R.Ph. T: 517/335-5181
Michigan Department of Community Health F: 517/241-8135
Medical Services Administration E-mail: morans@michigan.gov
P.O. Box 30479
Lansing, MI 48909 Disease Management Program/Initiative
Contact
Otto Graesser, DO
1421 W. Mt. Hope Giovannino A. Perri, M.D.
Lansing, MI 48910 517/335-5181

Prescription Price Updating Mail Order Pharmacy Program

First Health Services Corporation None


4300 Cox Road
Glen Allen, VA 23060 Elderly Expanded Drug Coverage Contact
T: 877/864-9014
F: 888/603-7696 Thomas Chisnell
MDCH/ Medical Services Administration
400 South Pine Street
P.O. Box 30479
Lansing, MI 48909-7979
T: 517/335-5181
F: 517/241-8135
E-mail: chisnellt@michigan.gov

Michigan-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Michigan Dept. of Community Health Michigan Pharmacists Association


(MDCH) Larry D. Wagenknecht, CEO
815 N. Washington Avenue
Janet Olszewski, Director
Lansing, MI 48906-5198
MCDH/ Lewis Cass Building
T: 517/484-1466
320 South Walnut Street
F: 517/484-4893
Lansing, MI 48913
E-mail: larry@michiganpharmacists.org
T: 517/335-0267
Internet address: www.michigan pharmacists.org
F: 517-373-4288
E-mail: norris@michigan.gov
Michigan Osteopathic Association
Dennis Paradis, Executive Director
Patrick Barrie, Deputy Director
2445 Woodlake Circle
Health Programs Administration
Okemos, MI 48864
Michigan Department of Community Health
T: 800/657-1556
400 South Pine Street
F: 517/347-1566
Lansing, MI 48909
E-mail: dennis@moa-do.com
T: 517/335-5001
Internet address: www.moa-do.com
F: 517/335-5007
E-mail: barriep@michigan.gov
State Board of Pharmacy
Roberta Armstrong, Chairperson
Formulary Review Committee Licensing Manager
611 W. Ottawa, First Floor
James Kenyon, R.Ph. P.O. Box 30670
Giovannino Perri, M.D. Lansing, MI 48909-8170
Debera Eggleston, M.D. 517/335-0918
Max Robins, D.O. Internet address: www.michigan.gov/cis/
Lawerence Nagel, D.D.S.
Chris Farrell Michigan Health and Hospital Association
Robert Pheteplace, R.Ph. (Alternate) Spencer C. Johnson, President
6215 West St. Joseph Highway
Addresses for all members: Lansing, MI 48917
Medical Services Administration T: 517/323-3443
Michigan Department of Community Health F: 517/323-0946
400 S. Pine Street E-mail: sjohnson@lans.mha.org
Lansing, MI 48933 Internet address: www.mha.org

Michigan Pharmacy and Therapeutics Health Care Association of Michigan


Committee Reginald Carter, Ph.D.
President & CEO
David R. Johnson, M.D., M.Ph. (Chair) P.O. Box 80050
Robert P. Coffey, Pharm.D. Lansing, MI 48908
Debera Hayes Eggleston, M.D. T: 517/627-1561
Robert Ernst, M.D. F: 517/627-3016
Jonathan G.A. Henry, M.D. E-mail: recarter@hcam.org
Edward J. Keating, R.Ph. Internet address: www.hcam.org
Giovannino A. Perri, M.D.
Max Robins, D.O.
Sandra Campbell, Pharm.D.

Executive Officers of State Medical and


Pharmaceutical Societies
Michigan State Medical Society
William E. Madigan, Executive Director
120 West Saginaw Street
East Lansing, MI 48823
T: 517/337-1315
F: 517/337-2490
E-mail: wmadigan@msms.org
Internet address: www.msms.org

Michigan-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

MINNESOTA

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $265,240,353 188,566 $310,174,144

RECEIVING CASH ASSISTANCE, TOTAL $148,264,320 78,475


Aged $7,108,479 4,018
Blind / Disabled $129,186,438 46,033
Child $5,008,680 16,345
Adult $6,960,723 12,079

MEDICALLY NEEDY, TOTAL $17,151,129 6,590


Aged $4,624,706 2,823
Blind / Disabled $12,502,998 3,665
Child $22,225 92
Adult $1,200 10

POVERTY RELATED, TOTAL $1,456,490 1,725


Aged $695,335 1,177
Blind / Disabled $753,128 472
Child $7,795 61
Adult $232 15

TOTAL OTHER EXPENDITURES/RECIPIENTS* $98,368,414 101,776

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Minnesota-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION deterrents; sympathominetics (adrenergic); thyroid


agents; and prescribed cold medications. Prior
Minnesota Department of Human Services, Health authorization required for: analgesics, antipyretics,
Care Management Division, Medical Assistance and NSAIDS; antidepressants; cardiac drugs; and
Program. misc. GI drugs. Therapeutic categories not covered:
anoretics; DESI drugs.
D. PROVISIONS RELATING TO DRUGS
Coverage of Injectables: Injectable medicines
Benefit Design reimbursable through the pharmacy benefit when
dispensed by a pharmacy and through physician
Drug Benefit Product Coverage: Products covered: payment when used in physician offices.
prescribed insulin; syringe combinations used for
insulin; total parenteral nutrition; and interdialytic Vaccines: Vaccines reimbursable when billed as
parenteral nutrition. Products not covered: drugs part of EPSDT services, the Children’s Health
used for cosmetic purposes; drugs used for hair Insurance Program, and the Vaccines for Children
growth; fertility drugs; appetite supressants; and Program.
experimental drugs; disposable needles used for
insulin; blood glucose test strips; and urine ketone Unit Dose: Unit dose packaging reimbursable.
test strips. Products covered with limitations:
sildenafil, methylphenidate (including d- Formulary/ Prior Authorization
methylphenidate), Adderall, pemoline, Formulary: Open formulary with general
dextroamphetamine, vitamins, and cough and cold exclusions, restrictions, and preferred products.
preparations. Prior authorization required for:
alglucerase; Interferon Alfa N-3; Interferon Prior Authorization: State currently has a prior
Gamma-1B; Ondansetron; Granisetron; omeprazole authorization procedure and a Drug Formulary
(including s-omeprazole); sertraline 25mg and Committee. Recipient has the right to appeal prior
50mg tablets; Butulinum Toxin Types A & B; authorization decisions and coverage of an
valdecoxib; Esomeprazole; dolasetron; celecoxib; excluded product by appeals referee followed by an
rofecoxib; escitalopram 10mg; citalopram 10mg appeal in court.
and 20mg; paroxetine 10mg; modafinil 100mg;
trandolapril; trandolapril/verapamil combination; Prescribing or Dispensing Limitations
quinapril; quinapril/HCTZ; amlodipine/benazepril;
benazepril/HCTZ; benazepril; fosinopril; and Monthly Quantity Limit: 3 month supply. Minimum
fosinopril/HCTZ. (For a complete list of products 30-days for maintenance drugs. Contraceptives may
requiring prior authorization, contact the Pharmacy be filled to provide a 3-month supply.
Program at The Minnesota Department of Human
Services, Health Care Management Division, Drug Utilization Review
Medical Assistance Program.)
PRODUR system implemented in February 1996.
State currently has a DUR Board with a quarterly
Over-the-Counter Product Coverage: Products
review. Heritage Information Systems provides
covered: smoking deterrent products. Products
software and assistance with RetroDUR.
covered with limitations: allergy, asthma and sinus
products; analgesics; cough and cold preparations;
Pharmacy Payment and Patient Cost
digestive products (H2 and antagonist); feminine
Sharing
products (antifungals covered); topical products;
and smoking deterrent products; vitamins; ocular Dispensing Fee: $3.65, effective 7/1/99.
lubricants; pediculocides; and activated charcoal
and ipecac. Ingredient Reimbursement Basis: EAC = AWP –
11.5%.
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; antibiotics; Prescription Charge Formula: Reimbursement is
anticoagulants; anticonvulsants; antidiabetic agents; based on the lesser of submitted AWP minus 11.5%
antihistamine drugs (OTC loratadine products are plus a dispensing fee, MAC plus a dispensing fee,
preferred second generation antihistamines, all or usual and customary. Special rules for IV
other require prior authorization); antilipemic admixtures.
agents; anti-psychotics; anxiolytics, sedatives, and
hypnotics; chemotherapy agents; contraceptives;
ENT anti-inflammatory agents; estrogens; growth
hormones; hypotensive agents; prescribed smoking

Minnesota-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Maximum Allowable Cost: State imposes a UCare Minnesota


combination of Federal Upper Limits and State- P.O. Box 52
specific MAC on generic drugs. Override requires Minneapolis, MN 55440-0052
or “dispense as written.” No pre-printed DAW T: 612/626-3300
allowed. F: 612/676-6555

Incentive Fee: None. South County Health Alliance


303 South Cedar Street
Patient Cost Sharing: Brand: $3.00
Owatonna, MN 55060
Generic: $1.00
T: 507/444-7770
Cognitive Services: State pays for professional F: 507/444-7774
services (e.g., clozaril monitoring).
F. STATE CONTACTS
E. USE OF MANAGED CARE
State Drug Program Administrator
Approximately 370,000 Medicaid recipients were
Cody C. Wiberg, Pharm.D., R.Ph.
enrolled in MCOs in FY 2002. Recipients receive Pharmacy Program Manager
pharmaceutical benefits through managed care Minnesota Department of Human Services
plans.
444 Lafayette Road North
St. Paul, MN 55155-3853
Managed Care Organizations T: 651/296-8515
F: 651/282-6744
Itasca Medical Care E-mail: cody.c.wiberg@state.mn.us
Itasca Resource Center Internet address: www.dhs.state.mn.us
1209 SE 2nd Ave.
Grand Rapids, MN 55744-3983
T: 218/327-6133 Prior Authorization Contact
F: 218/327-5545 Cody C. Wiberg, Pharm.D., R.Ph.
651/296-8515
Blue Plus
P.O. Box 64179
St. Paul, MN 55164-0179 DUR Contact
651/662-5200
Mary Beth Reinke, Pharm.D., R.Ph.
DUR Coordinator
First Plan Blue
444 Lafayette Road North
1601 London Road
St. Paul, MN 55155-3853
Duluth, MN 55812
T: 651/215-1239
T: 218/728-6706
F: 651/282-6744
F: 218/724-9176
E-mail: mary.beth.reinke@state.mn.us
HealthPartners
8100 34th Avenue South Medicaid DUR Board
P.O. Box 1309
Minneapolis, MN 55414-1309 Physicians
T: 952/967-6633 Michael F. Koch, M.D.
Director, Child Psychiatry
Medica Hennepin County Medical Center
P.O. Box 9310 701 Park Avenue South
Mail Route 80920 Minneapolis, MN 55402
Minneapolis, MN 55440-9310 Andrew R. Baron, M.D.
T: 952/992-3200 1930 17th Street South
F: 952/992-3198 St. Cloud, MN 56301

Metropolitan Health Plan Roger E. Hofer, M.D.


822 South 3rd Street, Suite 140 Mayo Clinic
Minneapolis, MN 55415 200 SW First Street
T: 612/347-8584 Rochester, MN 55905
F: 612/904-4493

Minnesota-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Health Care Professional Medicaid Drug Rebate Contacts


Marilyn M. Ulseth, MS., RN., CNP.
Jarvis Jackson, R.Ph.
2909-33rd Ave South
Drug Rebate Coordinator
Minneapolis, MN 55406
Minnesota Department of Human Services
444 Lafayette Road North
Pharmacists
St. Paul, MN 55155-3853
Lynne M. Schneider, R.Ph.
T: 651/282-5881
12910 37th Avenue North
F: 651/282-6744
Plymouth, MN 55441
E-mail: jarvis.p.jackson@state.mn.us
Ron Johnson, R.Ph.
Lloyd’s Pharmacy Disease Management Program/Initiative
720 North Snelling Contact
St. Paul, MN 55104 Mary Claire Wohtetz
Clinical Pharmacist
Peter Marshall, Pharm. D. Minnesota Department of Human Services
HealthPartners Pharmacy Services 444 Lafayette Road North
P.O. Box 1309 St. Paul, MN 55155-3853
8100 - 34th Avenue South T: 651/215-1632
Minneapolis, MN 55440-1309 F: 651/282-6744
E-mail: mary.c.whohetz@state.mn.us
Wendy L. St. Peter, Pharm.D.
Hennepin County Medical Center Mail Order Pharmacy Benefit
Nephrology Analytical Services
USRDS Coordinating Center None
914 Eighth Avenue South
Minneapolis, MN 55404 Elderly Expanded Drug Coverage Program
Contact
Consumers Representative Cody C. Wiberg, Pharm.D., R.Ph.
Vacant 651/296-8515

DHS Staff Department of Human Services Officials


Cody C. Wiberg, Pharm.D., R.Ph.
Pharmacy Program Manager Kevin Goodno
Commissioner
Mary Beth Reinke, Pharm.D., R.Ph. Department of Human Services
DUR Coordinator 444 Lafayette Road North
St. Paul, MN 55155-3815
New Brand Names Product Contact T: 651/297-7515
F: 651/297-3230
Cody C. Wiberg, Pharm.D., R.Ph. E-mail: commissioner.dhs@state.mn.us
651/296-8515
Mary Kennedy
Prescription Drug Updating Medicaid Director
First DataBank Department of Human Services
1111 Bayhill Drive, Suite 350 444 Lafayette Road
San Bruno, CA 94066 St. Paul, MN 55155-3852
T: 650/588-5454 T: 651/297-7515
F: 650/588/4003 F: 651/297-3230
E-mail: mary.kennedy@state.mn.us
Claims Submission Contact
Dwaine Voas Drug Formulary Committee
MMIS Unit Supervisor Al Heaton, Pharm.D., R.Ph.
Minnesota Department of Human Services Senior Director
800 Minnehaha Avenue Prime Therapeutics
St. Paul, MN 55155 1020 Discovery Road, No. 100
Eagan, MN 55121

Minnesota-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Charlene Nusman, Consumer Representative Minnesota Pharmacists Association


2534 Lynn Avenue So. Julie K. Johnson, R.Ph.
St. Louis Park, MN 55416 Executive Vice-President
1935 W. County Road, B2 #450
William P. Korchik, M.D. Roseville, MN 55113
Veterans Affairs Medical Center T: 651/697-1771
One Veteran Drive (11L) F: 651/697-1776
Minneapolis, MN 55417 E-mail: julie@mpha.org
Internet address: www.mpha.org
Jack Alexander, M.D.
Chief Medical Officer Minnesota Osteopathic Medical Society
Fairview Red Wing Clinic Colleen Jensen
2835 South Service Clinic Executive Director
Red Wing, MN 55066-0095 P.O. Box 314
Lakeland , MN 55043-0314
Paul Johnson, M.D. T: 612/623-3268
Metropolitan Health Plan F: 612/677-3200
822 South 3rd Street, Suite 140 Internet address: www.mndo.org
Minneapolis, MN 55415
State Board of Pharmacy
Kim Allan Macnab, M.D., Pharm.D., CCFP (EM) David E. Holmstrom
714 Barton Ave, N.W. Executive Director
Buffalo, MN 55313 2829 University Avenue SE, #530
Minneapolis, MN 55414-3251
Lynne M. Schneider, R.Ph. T: 612/617-2201
12910-37th Avenue North F: 612/617-2212
Plymouth, MN 55441 E-mail: David.Holstrom@state.mn.us
Internet address: www.phcybrd.state.mn.us
Robert Straka, Pharm.D.
University of Minnesota College of Pharmacy Minnesota Hospital and Healthcare Partnership
7-148 Weaver-Densford Hall Bruce Rueben
308 Harvard Street, S.E. President
Minneapolis, MN 55455 2550 University Avenue West, Suite 350S
St. Paul, MN 55114-1900
DHS Staff T: 651/641-1121
Cody Wiberg, Pharm.D., R.Ph. F: 651/659-1477
Pharmacy Program Manager E-mail: brueben@mnhospitals.org
Internet address: www.mhlp.com
Mary Beth Reinke, Pharm.D., R.Ph.
DUR Coordinator Minnesota Society of Health System-Pharmacists
Scott Marin
Executive Officers of State Medical and Executive Director
Pharmaceutical Societies 13911 Ridgedale Drive, Suite 260
Minnesota Medical Association Minnetonka, MN 55305
Robert K. Meiches T: 952/541-9499
Chief Executive Officer F: 952/541-9684
1300 Godward Street, NE, Suite 2500 E-mail: dstanton@mnshp.org
Minneapolis, MN 55413-1878 Internet address: www.mnshp.org
T: 612/378-1875
F: 612/378-3875 Care Providers of Minnesota
E-mail: rmeiches@mnmed.org Rick E. Carter
Internet address: www.mnmed.org President & CEO
7851 Metro Parkway
Suite 200
Bloomington, MN 55425
T: 612/854-2844
F: 612/854-6214
E-mail: rcarter@careproviders.org
Internet address: www.careproviders.org

Minnesota-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Minnesota-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

MISSISSIPPI

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 ‹ ‹ ‹ ‹
Nursing Facility Services ‹ ‹ ‹ ‹
Skilled Nursing Home Services ‹ ‹ ‹ ‹
Physician Services ‹ ‹ ‹ ‹
Dental Services ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $494,805,247 478,404 $567,313,801

RECEIVING CASH ASSISTANCE TOTAL $273,269,878 214,993


Aged $40,460,923 21,661
Blind/Disabled $206,625,503 105,509
Child $12,577,330 59,540
Adult $13,606,122 28,283

MEDICALLY NEEDY, TOTAL $0 -


Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $163,081,425 238,963


Aged $57,308,548 28,431
Blind/Disabled $65,540,551 24,427
Child $35,839,110 161,784
Adult $4,393,216 24,321

TOTAL OTHER EXPENDITURES/RECIPIENTS* $58,453,944 24,448

**Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Mississippi-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION weight loss drugs; fertility drugs; vitamins and


minerals (except prenatal); and DESI drugs.
Division of Medicaid, Office of the Governor.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug
D. PROVISIONS RELATING TO DRUGS Program when used in home health care and
extended care facilities, and through physician
Benefit Design payment when used in physicians’ offices.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; total parenteral nutrition; and Unit Dose: Unit dose packaging is reimbursable.
interdialytic parenteral nutrition. Prior
authorization required for: brand name multisource Vaccines: Vaccines reimbursable as part of the
products; Sandimmune; oral erectile dysfunction Vaccine for Children Program.
agents; enteral feeding products; nutritional
products; immunosuppressant agents; Clozaril Formulary/Prior Authorization
(must be prescribed by Board Certified or Board Formulary: Open formulary with preferred drug list
Eligible Psychiatrist); * Xenical, Benzodiazepines, (PDL). General exclusions include:
NSAD, Protropin and Humatrope; * all
Antihemophilic Factors including VIII and IX; * 1. Drugs used for anorexia or weight gain.
Synagis; Enbrel; Brand SR opioid agonists; and all
Home IV drug therapies. Products not covered: 2. Drugs when used for the symptomatic relief of
cosmetics; fertility drugs; experimental drugs; cough and colds (except quaifenesin syrup 100
disposable needles and syringe combinations used mg/5 ml, iodinated glycerol tablets 30 mg,
for insulin; blood glucose test strips; and urine which are covered).
ketone test strips. 3. Prescription vitamins and mineral products
(except prenatal vitamins and fluoride
* These products are covered only for children ages preparations, which are covered).
0-21 years through the Early and Periodic
Screening, Diagnosis and Treatment Program 4. Covered outpatient drugs for which the
(EPSDT). manufacturer requires (as a condition of sale)
that associated tests or monitoring services be
Over-the-Counter Product Coverage: Products purchased exclusively from the manufacturer
covered with restrictions; (i.e.must be on limited or its designee.
formulary, requires a prescription, and counts 5. Barbiturates (except amobarbital, butabarbital,
against monthly service limits): allergy, asthma, mephobarbital, pentobarbital, phenobarbital,
and sinus products (Benadryl); analgesics (ASA, secobarbital, which are covered).
generic Tylenol); cough and cold preparations
(generic Robitussin); digestive products (non-H2 6. Benzodiazepines (except Klonopin,
antagonist); feminine products; topical products; Lorazapam, Diazepam and Temazepam which
smoking deterrent products; certain vitamins are covered).
(prenatal and dialysis). Products not covered: H2 7. DESI drugs (those drugs that are designated
antagonists. less than effective by the FDA).

Therapeutic Category Coverage: Therapeutic Prior Authorization: State currently has a prior
categories covered: anabolic steroids; antibiotics; authorization procedure. A written request
anticoagulants; anticonvulsants; antidepressants; (including medical justification for beneficiaries
antidiabetic agents; anti-psychotics; anxiolytics, under age 21) must be made within 30 days of
sedatives, and hypnotics; cardiac drugs; denial to appeal a prior authorization decision.
contraceptives; ENT anti-inflammatory agents; Review and determination made within 3 days of
estrogens; growth hormones; hypotensive agents; receipt. All parties notified in writing within 24
prescribed smoking deterrents, antilipemic agents hours of decision.
(PA required for xenical); sympathominetics
(adrenergic); and thyroid agents. Prior Prescribing or Dispensing Limitations
authorization required for: analgesics, antipyretics,
Prescription Refill Limit: Limited to five (5).
NSAIDs; antihistamines; chemotherapy agents; and
misc. GI drugs. Partial coverage for: prescribed Monthly Quantities Limit: 34-day supply or 100
cold medications. Products not covered: anoretics; units or doses, whichever is greater. Birth control
pills may be supplied in 3-month quantities.

Mississippi-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Monthly Prescription Limit: Total prescriptions F. STATE CONTACTS


dispensed per month per recipient are limited to 5.
Two additional prescriptions per month may be State Drug Program Administrator
allowed with prior authorization. Beneficiaries
under age 21 years old or in long term care Judith P. Clark, R.Ph.
facilities are exempt from monthly prescription Pharmacy Director
limits. Division of Medicaid
Robert E. Lee Building
Drug Utilization Review 239 North Lamar Street, Suite 801
Jackson, MS 39201
PRODUR system implemented in 1993. State has a T: 601/359-5253
12 member DUR Board that meets quarterly. F: 601/359-9555
E-mail: phipc@medicaid.state.ms.us
Pharmacy Payment and Patient Cost Internet address: www.dom.state.ms.us
Sharing
Dispensing Fee: $3.91 (effective 4/1/02). IV Division of Medicaid Official
mixtures can receive up to a $30 per liter Warren A. Jones, M.D., Executive Director
dispensing fee. Division of Medicaid
Suite 801, Robert E. Lee Building
Ingredient Reimbursement Basis: EAC = AWP- 239 North Lamar Street
12%, effective July 1, 1990. Jackson, MS 39201
T: 601/359-6050
Prescription Charge Formula: Reimbursement for
F: 601/359-6048
legend drugs will be at the lessor of AWP-12% plus
E-mail: exfmp@medicaid.state.ms.us
a dispensing fee or usual and customary charge.
OTC drugs will be paid at lessor of AWP plus a
DUR Contact
dispensing fee, usual and customary price, or
estimated shelf price plus a dispense fee. Judith P. Clark, R.Ph.
601/359-5253
Maximum Allowable Cost: State imposes Federal
Upper Limits on generic drugs. Override requires Mississippi DUR Board
“Brand Medically Necessary” or prior authorization
for brand multi-source drugs. Sara Weisenberger, M.D.
UMC-Department of Pediatrics
Incentive Fee: None. 2500 North State Street
Jackson, MS 39216
Patient Cost Sharing: Tiered copayment of $1.00-
$3.00. Tim Alford, M.D. (Chair)
$1.00 - preferred generic Kosciusko Medicaid Clinic
$2.00 - preferred brand Highway 12
$3.00 - non-preferred brand Kosciusko, MS 39090
Cognitive Services: Pays for Disease Management
Services for diabetes, hyperlipidemia, asthma, and John R. Mitchell, M.D.
coagulatory disorders (effective 8/1/98). Pays $20 Tupelo Family Medicine Residency Center
for average 30-minute encounter. 1665 South Green Street
Tupelo, MS 38804

E. USE OF MANAGED CARE Cynthia Undesser, M.D.


P.O. Box 5102
No Medicaid recipients receive health benefits Brandon, MS 39047
through MCOs.
Andrea Phillips, M.D.
Phillips Medical Services
P.O. Box 21214
Jackson, MS 39289

Joe McGuffee, R.Ph.


McGuffee Drugs
102 North Main Street
Mendenhall, MS 39114

Mississippi-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

D. Montez Carter, Pharm.D. Disease/Medical State: Diabetes


P.O. Box 1414 Program Name: Diabetes Disease Management
Greenwood, MS 38935 (eff. 2/03)
Program Manager: Mckesson
Leigh Ann Ramsey, Pharm.D.
231 Winged Foot Circle Disease/Medical State: Hypertension
Jackson, MS 39211 Program Name: Hypertension Disease
Management (eff. 2/03)
Diana McGowan, R.Ph., M.B.A Program Manager: Mckesson
328 Dover Lane
Madison, MS 39110 Disease Management/Patient Education
Contact
Clarence DuBose, R.Ph. (Vice-Chair)
Medi-Mart Pharmacy Alicia K. Crowder, R.N., M.P.H.
3737 Main Street Director of Medical Services
Moss Point, MS 39563 Division of Medicaid
Robert E. Lee Building
Bob Broadus, R.Ph. 239 North Lamar Street
7147 Creekwood Drive Jackson, MS 39201
Mandeville, LA 70471 T: 601/359-5243
F: 601/359-5252
E-mail: maskc@medicaid.state.ms.us
New Brand Names Product Contact
Judith P. Clark, R.Ph. Mail Order Pharmacy Program
601/359-5253
Pilot Program
Prescription Price Updating
Medicaid Managed Care Contact
Judith P. Clark, R.Ph.
601/359-5253 Melzana Fuller
Director of Provider and Beneficiary Relations
Division of Medicaid
Medicaid Drug Rebate Contact
Robert E. Lee Building
Robert Reedy, C.Ph.T. 239 North Lamar Street,
DRAMS Business Analyst Jackson, MS 39201
ACS State Healthcare T: 601/359-6063
385-B Highland Colony Parkway F: 601/359-4185
Ridgeland, MS 39157 E-mail: mcmmf@medicaid.state.ms.us
T: 601/206-2936
F: 601/206-3119 Pharmacy and Therapeutics Committee
E-mail: robert.reedy@acs-inc.com
Craig Dawkins, M.D.
1213 Broad Avenue
Claims Submission Contact
Gulfport, MS 39501
Bob Parenteu, PBM Account Manager
ACS State Healthcare Yolanda Wilson, M.D.
385-B Highland Colony Parkway 1600 North State Street, Suite 301
Ridgeland, MS 39157 Jackson, MS 39202
T: 601/296-2934
F: 601/296-3119 Shannon Johnson, M.D.
E-mail: bob-parenteau@acs-inc.com South Mississippi Psychiatric Group
1101 B. South 28th Avenue
Disease Management/Patient Education Hattiesburg, MS 39402
Programs
Gary Davis, M.D.
Disease/Medical State: Asthma 571 East Beasley Road, Suite D
Program Name: Asthma Disease Management (eff. Jackson, MS 39206
2/03)
Program Manager: Mckesson Charles Brock, M.D.
498 Hillcrest
Cleveland, MS 38732

Mississippi-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Myrna Alexander, M.D. Mississippi State Board of Pharmacy


971 Lakeland Drive, Suite 850 Leland “Mac” McDivitt
Jackson, MS 39216 Executive Director
625 North State Street
Betsy Commings, C.F.N.P Jackson, MS 39202
1740 McClain Street T: 601/354-6750
Greenville, MS 38701 F: 601/354-6071
E-mail: lmcdivitt@mbp.state.ms.us
Guy Phillips, R.Ph. Internet address: www.mbp.state.ms.us
903 Highway 82 East
Indianola, MS 38751 Mississippi Osteopathic Medical Association
Jeffrey J. LeBoeuf
David Hudson, R.Ph. Executive Director
389 NW Depot Street P.O. Box 16890
Durant, MS 39063 Jackson, MS 39236
T: 601/366-3105
Todd Barrett, R.Ph. F: 601/366-2868
Covenant Pharmacy E-mail: info@moma-net.org
2506 Lakeland Drive, Suite 101 Internet address: www.moma-net.org
Flowood, MS 39232
Mississippi Hospital Association
Jeff Jones, R.Ph. Sam W. Cameron
Carthage Discount Drugs President/CEO
602 Highway 16E P.O. Box 16444
Carthage, MS 39051-4212 6425 Lakeover Road
Jackson, MS 39236-6444
Larry Calvert, R.Ph. T: 800/289-8884
720 Sarazen Drive F: 601/368-3200
Gulfport, MS 39507 E-mail: scameron@mhanet.org
Internet address: www.mhanet.org
Executive Officers of State Medical and
Pharmaceutical Societies Mississippi Society of Health-System Pharmacists
Dianna McGowan
Mississippi State Medical Association
Association Manager
William F. Roberts
328 Dover Lane
Executive Director
Madison, MS 39110
P.O. Box 2548
T: 601/856-9273
Ridgeland, MS 39158-2548
F: 601/856-8539
601/853-6733
E-mail: johnnymcg@msn.com
E-mail: wroberts@msmaonline.com
Internet address: www.pharmd.org/mshp
Internet address: www.msmaonline.com
Mississippi Health Care Association
Mississippi Pharmacists Association
Vanessa P. Henderson
Bo Dalton, R.Ph.
Executive Director
Executive Director
114 Marketridge Drive
341 Edgewood Terrace Drive
Ridgeland, MS 39157
Jackson, MS 39206-6217
T: 601/956-3472
601/981-0416
F: 601/977-0273
E-mail: mpha@bellsouth.net
E-mail: vanessa@mshca.com
Internet address: www.mspharm.org
Internet address: www.mshca.com

Mississippi-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Mississippi-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

MISSOURI

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 ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $680,574,899 472,624 $790,853,387

RECEIVING CASH ASSISTANCE TOTAL $302,169,328 173,944


Aged $52,969,010 21,219
Blind/Disabled $220,471,969 71,356
Child $12,427,726 46,893
Adult $16,300,623 34,476

MEDICALLY NEEDY, TOTAL $0 -


Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $46,561,919 108,561


Aged $6,632,609 3,988
Blind/Disabled $14,729,020 4,105
Child $23,680,913 87,976
Adult $1,519,377 12,492

TOTAL OTHER EXPENDITURES/RECIPIENTS* $331,843,652 190,119

**Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Missouri-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Formulary/Prior Authorization


Formulary: Open formulary with exclusions and
Division of Medical Services, Missouri Department restrictions, including preferred products, physician
of Social Services. profiling, prior authorization, clinical edits, and step
therapy.
D. PROVISIONS RELATING TO DRUGS
Prior Authorization: State currently has a prior
Benefit Design authorization procedure and a Drug Prior
Authorization Committee composed of 9 members
Drug Benefit Product Coverage: Categories or who meet quarterly. Fair hearing process to appeal
drugs that are covered: prescribed insulin; prior authorization decisions.
disposable needles and syringe combinations used
for insulin; blood glucose test strips; urine ketone Prescribing or Dispensing Limitations
test strips; total parenteral nutrition; and
interdialytic parenteral nutrition. Limited coverage Prescription Refill Limit: None
(limited to OTC formulary) for: allergy, asthma,
and sinus products; analgesics; cough and cold Monthly Quantity Limit: Physician encouraged to
preparations; digestive products (non-H2 prescribe 34-day or 100 dose supply but may, at
antagonists); and topical products. Prior own discretion, prescribe up to a maximum 90-day
authorization required for: amphetamines; supply.
barbiturates; Isotretinoin; and Retinoic Acid.
Products not covered: cosmetics; fertility drugs; Dose Limit: Prescriptions for the following must be
experimental drugs; smoking deterrent products and dispensed for at least 200 units per prescriptions:
feminine products. Aspirin 5 gr.; Aspirin buffered 5 gr.; Aspirin
enteric-coated 5 gr.; Acetaminophen 5 gr. Prenatal
Therapeutic Catogory Coverage: Therapeutic vitamins must be dispensed in a quantity of at least
categories covered: antibiotics; anticoagulants; 100.
anticonsulants; anti-depressants; antidiabetic
agents; anti-psychotics; cardiac drugs; Drug Utilization Review
chemotherapy agents; contraceptives; ENT anti- PRODUR system implemented in 1993. State
inflammatory agents; estrogens; hypotensive currently has a 13 member DUR Board with a
agents; sympathominetics (adrenergic); thyroid quarterly review.
agents; and anxiolytics, sedatives, and hypnotics
(PA required). Partial coverage for: anabolic Pharmacy Payment and Patient Cost
steroids; analgesics, antipyretics, and NSAIDs; Sharing
antihistamines; antilipemic agents; prescribed cold
medications; growth hormones; and misc. GI drugs Dispensing Fee: $4.09 (out-of-state), $8.04 (in-
(PA required). Categories not covered: anoretics; state), $8.19 (long-term care pharmacies).
prescribed smoking deterrents.
Ingredient Reimbursement Rate: EAC = AWP-
(For additional information on products and/or 10.43% or WAC+10%.
category coverage, see the pharmacy provider
bulletin at www.medicaid.state.mo.us.) Prescription Charge Formula:
1. Method of reimbursement payment is based on
Coverage of Injectables: Injectable medicines
acquisition cost plus a dispensing fee per
reimbursable through the Prescription Drug
prescription filled. Acquisition may vary
Program when used in physician offices, home
depending whether it is based on AWP and
health care settings, and extended care facilities.
Federal or Missouri MAC.
Vaccines: Vaccines reimbursable as part of the 2. Any drug that is not a Federal or Missouri
Vaccines for Children Program. MAC drug will be based on the AWP-10.43%
or the WAC+10%. The majority of drugs listed
Unit Dose: Unit dose packaging reimbursable. are based on AWP. The method of pricing will
be taken from the NDC number.

Missouri-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Maximum Allowable Cost: State imposes Federal Community Care Plus Health Plan
Upper Limits as well as State-specific limits on 5615 Pershing Avenue, Suite 29
generic drugs. 910 drugs are listed on the State- St. Louis, MO 63112
specific MAC list. Override requires prior 314/454-0055 ext. 234
authorization and a MedWatch form.
HealthNet Health Plan
Incentive Fee: None. 2300 Main Street, Suite 700
Kansas City, MO 64108
Patient Cost Sharing: Variable copayment: 816/221-8400

Drug Ingredient Cost Copayment FirstGuard Health Plan


3801 Blue Parkway
$0.00 to $10.00 $0.50 Kansas City, MO 64130
816/922-7250
$10.01 to $25.00 $1.00
Family Health Partners Health Plan
$25.01 or more $2.00 215 W. Pershing Road, Suite 310
P.O. Box 411806
($5.00 copayment for certain 1115 waiver Kansas City, MO 64141
populations (see Pharmacy Bulletin).) 816/855-1871

Copayment retained by pharmacist. Missouri Care Health Plan


2404 Forum Boulevard
Cognitive Services: Payment for cognitive services Columbia, MO 65203
is provided to qualified pharmacies who enroll to 573/441-2100
provide asthma, diabetes, heart failure, and
depression education.
F. STATE CONTACTS
E. USE OF MANAGED CARE State Drug Program Administrator

Approximately 402,000 Medicaid recipients are George L. Oestreich, Pharmacy Program Director
enrolled in managed care organizations in 2002. Department of Social Services
All receive pharmacy services through managed Division of Medical Services
care. Protease inhibitors are carved out of managed P.O. Box 6500
care. Jefferson City, MO 65102-6500
T: 573/751-6961
Managed Care Organizations F: 573/522-8514
E-mail: George.L.Oestreich@dds.mo.gov
Healthcare USA Internet address: www.dss.mo.gov/dms
100 South 4th Street, Suite 1100
St. Louis, MO 63102 Social Services Department Officials
314/444-7239
Steve Roling, Director
Blue Advantage Plus Health Plan Department of Social Services
P.O. Box 419130 Broadway State Office Building
2301 Main St. 221 West High Street
Kansas City, MO 64141 P.O. Box 1527
816/395-3891 Jefferson City, MO 65102
T: 573/751-4815
Mercy Health Plan F: 573/751-3203
425 S. Woods Mill Road E-mail: dorisia.lorts@dss.mo.gov
Chesterfield, MO 63017
314/214-8000

Care Partners Health Plan


The Clayton Center
120 S. Central, 8th Floor
St. Louis, MO 63105
314/505-5400

Missouri-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Christine Rackers, Director Joseph M. Yasso, D.O.


Department of Social Services 3513 NW Primrose Lane
Division of Medical Services Lee’s Summit, MO 64064
615 Howerton Court, P.O. Box 6500
Jefferson City, MO 65102-6500 Harold Lurie, M.D.
T: 573/751-3425 Springfield, MO
F: 573/751-6564
E-mail: crackers@dss.state.mo.us Karla Dwyer, R.Ph.
901 Cherry Lane
New Brand Name Products Contact Kirksville, MO 63501
Rhonda A. Driver
Susan Abdel-Rahman, Pharm.D.
Clinical Pharmacist
Division of Clinical Pharmacology
Department of Social Services
Children’s Mercy Hospital
Division of Medical Services
2401 Gillham Road, Suite 0411
P.O. Box 6500
Kansas City, MO 64108
Jefferson City, MO 65102- 6500
T: 573/751-6961
Peggy Wanner-Barjenbrunch, M.D.
F: 573/522-8514
Mexico Health Services
E-mail: Rhonda.Driver@dss.mo.gov
809 Medical Park Drive, Suite 104
Mexico, MO 65265
Prior Authorization Contact
Rhonda A. Driver Sandra Bollinger, Pharm.D.
573/751-6961 Health Priorities, Inc.
707 Specialty Drive
DUR Contact Dexter, MO 63841
Jayne Zemmer Stephen Calloway, Pharm.D.
DUR Coordinator Columbia, MO
Division of Medical Services
P.O. Box 6500 Robert Dale Potter, R.N.
Jefferson City, MO 65102-6500 422 West Robin Ridge Road
T: 573/751-1612 Columbia, MO 65203
F: 573/526-4650
E-mail: Jayne.A.Zemmer@dss.mo.gov Drug Prior Authorization Committee
DUR Board Patrick J. Bryant, Pharm.D.
Drug Information Center
John W. Newcomer, M.D. (Chair) School of Pharmacy
Associate Professor of Psychiatry University of Missouri - Kansas City
Washington University, School of Medicine MG-200 Medical School Building
Campus Box 8134 2411 Holmes Street
660 S. Euclid Kansas City, MO 64108-2792
St. Louis, MO 63110
M. Dale Terrell, M.D.
Ronald Graham, Pharm.D. Washington University School of Medicine
Government Relations Manager Division of Geriatric Medicine
Novartis Corporation Room M238
1311 Granite Creek Drive 1402 South Grand Blvd.
Blue Springs, MO 64015 St. Louis, MO 63104
Randall Huss, M.D. Gene Forrester, R.Ph.
Rolla Family Practice 2400 S. Blackthorne
910 W. 10th Street Columbia, MO 65201
Rolla, MO 65401
Henry Petry, D.O.
Joy S. Gronstedt, D.O. Laurie Clinic
30580 Summers Drive P.O. Box 1277
Sedalia, MO 65301 Laurie, MO 65038

Missouri-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

James E. Edwards, M.D. Disease Management/ Patient Education


1000 Executive Pkwy, Suite 103 Programs
St. Louis, MO 63141
Disease Medical States: Asthma
Cardiovascular Disease
Lorraine C. Brown, D.O.
Depression
Rt. 2, Box 247C
Diabetes
Camdenton, MO 65020
Program Manager: Jennifer Cornelious
Program Sponsor: State of Missouri
Conrad S. Balcer, D.O.
1241 W. Stadium Boulevard
Jefferson City, MO 65109 Disease Management Initiatives Contact
George Oestreich
573/781-6961
Prescription Price Updating
First DataBank Pharmacy Subcommittee Roster
1111 Bayhill Drive
San Bruno, CA 94066 Bill Fitzpatrick, R.Ph.
T: 650/588-5454 Interlock Pharmacy Systems
F: 650/872-4510 2292 Weldon Parkway
St. Louis, MO 63146

Medicaid Drug Rebate Contact Philip A. Bangert, R.Ph.


Bangert Pharmacy, Ltd.
Lynn Hebenheimer
13300 New Halls Ferry
Medicaid Unit Supervisor
Florissant, MO 63033
Division of Medicaid Services
Drug Rebate Unit
Tom Beetem, R.Ph., Chairman
P.O. Box 6500
1425 Eastview Drive
Jefferson City, MO 65102-6500
Holts Summit, MO 65043
T: 573/526-5664
F: 573/522-2594
Robert D. Hurley, R.Ph.
E-mail: Lynn.Hebenheimer@dss.mo.gov
Walgreens
440 N. Highway 67
Claims Submission Contact Florissant, MO 63031
Diane Twehous Craig Leonard, R.Ph.
Claims Process Administrator Lee’s Summit Pharmacy
Verizon Data Services 615 W. 3rd Street
905 Weathered Rock Road Lee’s Summit, MO 64063
Jefferson City, MO 65109
573/635-2434
Executive Officers of State Medical and
Pharmaceutical Societies
Medicaid Managed Care Contact
Missouri State Medical Association
Judy Muck C. C. Swarens
Assistant Deputy Director Executive Secretary
Division of Medical Services 113 Madison Street, P.O. Box 1028
Managed Care Unit Jefferson City, MO 65102
P.O. Box 6500 T:573/636-5151
Jefferson City, MO 65102-6500 F: 573/636-8552
T: 573/526-2886 E-mail: cswarens@msma.org
F: 573/526-3946 Internet address:
E-mail: Judy.Muck@dss.mo.gov www.momed.net/momed/index.htm
Mail Order Pharmacy Program
None

Missouri-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Missouri Pharmacy Association


Ron Fitzwater
Chief Executive Officer
211 East Capitol Avenue
Jefferson City, MO 65101-3001
T: 573/636-7522
F: 573-636-7485
E-mail: ron@morx.com
Internet address: www.morx.com

Missouri Assoc. of Osteopathic


Physicians/Surgeons, Inc.
Bonnie M. Bowles
Executive Director
1423 Randy Lane - P.O. Box 748
Jefferson City, MO 65102
T: 573/634-3415
F: 573/634-5635
E-mail: maopsemail@cs.com
Internet address: www.maops.com

State Board of Pharmacy


Kevin E. Kinkade
Executive Director
3605 Missouri Boulevard
P. O. Box 625
Jefferson City, MO 65102
T: 573/751-0091
F: 573/526-3464
E-mail: pharmacy@mail.state.mo.us
Internet address:
www.ecodev.state.mo.us/pr/pharmacy

Missouri Hospital Association


Marc Smith
President
4712 Country Club Drive
P.O. Box 60
T: 573/893-3700
F: 573/893-2809
E-mail: msmith@mail.mhanet.com
Internet address: www.mhanet.com

Missouri-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

MONTANA

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $69,552,397 63,338 $77,845,461 67,341

RECEIVING CASH ASSISTANCE, TOTAL $33,656,590 25,847 $37,412,054 28,190


Aged $2,737,151 1,546 $2,999,604 1,524
Blind / Disabled $26,502,817 10,510 $28,765,236 10,729
Child $1,528,685 8,838 $2,074,230 9,751
Adult $2,887,937 4,953 $3,572,984 6,186

MEDICALLY NEEDY, TOTAL $19,932,987 7,701 $22,229,084 7,821


Aged $11,577,514 5,327 $12,853,926 5,336
Blind / Disabled $8,337,077 2,318 $9,364,165 2,449
Child $18,336 55 $10,665 34
Adult $60 1 $328 2

POVERTY RELATED, TOTAL $1,798,235 11,913 $2,534,084 13,561


Aged $0 - $14 1
Blind / Disabled $0 - $0 -
Child $1,509,510 9,980 $2,079,724 11,322
Adult $288,725 1,933 $454,346 2,238

TOTAL OTHER EXPENDITURES/RECIPIENTS* $14,164,585 17,877 $15,670,239 17,769

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data provided by Montana Department of Public Health and Human Services, Medicaid Services Bureau.

Source: CMS, MSIS Report, FY 2001 Montana Medicaid Statistical Information System, FY 2002.

Montana-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Coverage of Injectables: Injectable medicines


reimbursable through the Prescription Drug
Department of Public Health and Human Services, Program when used in home health care and
Medicaid Services Bureau. extended care facilities, and through physician
payment when used in physician offices.

D. PROVISIONS RELATING TO DRUGS Vaccines: Vaccines reimbursable as part of the


EPSDT service, the Children Health Insurance
Benefit Design Program, and the Vaccines for Children Program.
Drug Benefit Product Coverage: Products covered:
legend drugs, prescribed insulin; certain prescribed Unit Dose: Unit dose packaging reimbursable.
over-the-counter products, vaccines except children
18 and under and clients with Medicare Part B Formulary/Prior Authorization
coverage; compounded prescriptions; contraceptive Formulary: Open formulary. Drugs classified as
supplies and devices. Products not covered: less-than-effective (LTE) by the FDA are not
cosmetics; fertility drugs; experimental drugs; covered. Drugs with no manufacturer rebate are
disposable needles used for insulin, syringe not covered.
combinations for insulin use; blood glucose test
strips; urine ketone test strips; total parenteral Prior Authorization: State has a formal prior
nutrition; and interdialytic parenteral nutrition. authorization procedure. Prescriber letter
Prior authorization required for non-steroidal anti- documenting evidence for use of prescribed
inflammatory drugs; all single source NSAIDs; medication in treatment of disease is reviewed by
Celebrex, Vioxx; disease-modifying anti-rheumatic DUR Board for appeal of excluded product. An
drugs (Arava, Enbrel, Remicade); growth appeal procedure through the Department possible
hormones; single-source benzodiazepines; gastro- for PA decisions.
intestinal drugs (including H2 antagonists, proton
pump inhibitors, Carafate and Cytotec); migraine Prescribing or Dispensing Limitations
headache drugs for certain monthly quantities on
Imitrex, Maxalt, Zomig, Migranal, Amerge; weight Prescription Refill Limit: 25% grace period over a
reduction drugs (Fastin, Ionamin, Meridia, 3-month period is allowed.
Xenical); smoking-cessation drugs; Toradoloral;
Dipyridamole; Aggrenox; Trental, Pletal; Ambien Monthly Quantity Limit: 34-day supply.
and Sonata; Viagra; Thalomid; Zyvox; Tretinoin;
Zoloft; Hismanal; Bextra; Kineret; Stadol; Drug Utilization Review
Isoetherine; and Isoproterenol.
PRODUR system implemented in September 1994.
State DUR Board (DUE Care Program) has 6
Over-the-Counter Product Coverage: Products members and meets monthly.
covered with restrictions (i.e., when prescribed):
analgesics (aspirin only); allergy, asthma, and sinus
Pharmacy Payment and Patient Cost
products (Loratadine only); insulin; laxatives;
Sharing
antacids; head lice treatment; H2 antagonist GI
products; bronchosaline; and smoking deterrent Dispensing Fee: $2.00-$4.70; effective 7/1/02.
products. Products not covered: cold and cough Pharmacies submit documentation showing their
preparations; feminine products; and topical costs. Dispensing fee is based on their cost up to a
products. maximum of $4.70. Pharmacies that do not submit
documentation receive a dispensing fee of $2.00.
Therapeutic Category Coverage: Therapeutic
Ingredient Reimbursement Basis: EAC = AWP -
categories covered: anabolic steroids; antibiotics;
15%.
anticoagulants; anticonvulsants; antidepressants;
antidiabetic agents; antilipemic agents; anti- Prescription Charge Formula: The lower of EAC,
psychotics; cardiac drugs; chemotherapy agents; the Federal MAC (plus a dispensing fee), or the
contraceptives; ENT anti-inflammatory agents; provider usual and customary charge.
estrogens; hypotensive agents; misc. GI drugs;
Maximum Allowable Cost: State imposes Federal
sympathominetics (adrenergic); and thyroid agents.
Upper Limits on generic drugs. Override requires
Partial coverage for: prescribed cold medications.
“Brand Necessary” or prior authorization.
Prior authorization required for: anorectics;
antihistamines; anxiolytics, sedatives, and Incentive Fee: None.
hypnotics; analgesics, antipyretics, NSAIDs; and
growth hormones.

Montana-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Patient Cost Sharing: Copayment of $1.00 - $5.00. Mary Angela Collins, Bureau Chief
Recipient pays 5% of Medicaid allowable cost Managed Care Section
between $1.00 and $5.00. $5.00 copayment cap per 406/444-4146
prescription. $25.00 copayment cap per month.
Brett Williams, Bureau Chief
Cognitive Services: Does not pay for cognitive
Hospital and Clinic Section
services.
406/444-9614

E. USE OF MANAGED CARE Prior Authorization Contact


Mark Eichler, R.Ph., FASCP
HMO availability began November 1995, to FAIM DUR Coordinator
recipients. SSI and SSI-related clients were eligible Mountain-Pacific Quality Health Foundation
to enroll October 1, 1997. HMO coverage ended 3404 Cooney Drive
June 30, 2000. Helena, MT 59602
T: 406/443-4020
F. STATE CONTACTS F: 406/443-4585
E-mail: meichler@mpqhf.org
State Drug Program Administrator
DUR Contact
Dan Peterson Pharmacy Program Officer
Department of Public Health and Human Services Mark Eichler, R.Ph., FASCP
Medicaid Services Bureau T: 406/443-4020
P.O. Box 202951
1400 Broadway Montana DUR Board
Helena, MT 59620-2951 Mark Eichler, R.Ph., FASCP
T: 406/444-2738 DUR Coordinator
F: 406/444-1861
E-mail: danpeterson@state.mt.us V. Lee Harrison, M.D.
Internet address: www.dphhs.state.mt.us Richard Sargent, M.D.
Marcella Barnhill, R.Ph.
Public Health and Human Services Officials Lori Fitzgerald, Pharm. D.

Dr. Gail Gray, Director Prescription Price Updating


Department of Public Health and Human Services
P.O. Box 4210 First DataBank
111 N. Sauders 1111 Bayhill Dr.
Helena, MT 59604 San Bruno, CA 94066
T:406/444-5622 T: 650/588-5454
F: 406/444-1970 F: 650/827-4578
E-mail: ggray@state.mt.us
Medicaid Drug Rebate Contacts
Chuck Hunter, Administrator Betty DeVaney, Drug Rebate Coordinator
Division of Health Policy and Services Department of Public Health & Human Services
Department of Public Health and Human Services Medicaid Services Bureau
1400 Broadway P.O. Box 202951
Helena, MT 59601 1400 Broadway
T: 406/444-4458 Helena, MT 59620-2591
F: 406/444-1861 T: 406/444-3457
E-mail: chunter@state.mt.us F: 406/444-1861
E-mail: bdevaney@state.mt.us
John Chappuis
Medicaid Director
406/444-4084

Duane Pershinger, Bureau Chief


Acute Services Section
406/444-4144

Montana-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Claims Submission Contact Executive Officers of State Medical and


Pharmaceutical Societies
Kevin Quinn, Executive Account Manager
ACS, Inc. Montana Medical Association
34 N. Last Chance Gulch, Suite 200 G. Brian Zins
Helena, MT 59601 Executive Vice President/CEO
T: 406/442-7693 2021 11th Avenue, Suite 1
F: 406/442-2819 Helena, MT 59601-4890
E-mail: kevin.quinn@acs-inc.com T: 406/443-4000
F: 406/443-4042
Medicaid Managed Care Contact E-mail: brian@mmaoffice.com
Internet address: www.mmaoffice.com
Jo Thompson, Program Officer
Dept. of Public Health and Human Services
Montana Pharmacy Association
Medicaid Services Bureau
Jim E. Smith
P.O. Box 202951
Executive Director
1400 Broadway
P. O. Box 1569
Helena, MT 59620-2951
34 West 6th Avenue, Suite 2E
T: 406/444-4148 Helena, MT 59601-5074
F: 406/444-1861
T: 406/449-3843
E-mail: jothompson@state.mt.us F: 406/443-1592
E-mail: jimesmith@qwestreet.net
Disease Management/Patient Education Internet address: www.rxmt.org
Programs
Disease/Medical State: Asthma State Board of Pharmacy
Program Name: Nurse First Asthma Program Rebecca Deschamps, R.Ph.
Program Manager: Ted Weldon Executive Director
Program Sponsor: Mckesson Health Solutions P.O. Box 200513
301 South Park, 4th Floor
Disease/Medical State: Cardiovascular disease Helena, MT 59620-0513
Program Name: Nurse First Asthma Program T: 406/841-2355
Program Manager: Ted Weldon F: 406/841-2343
Program Sponsor: Mckesson Health Solutions E-mail: dlibspdha@state.mt.us
Internet address:
Disease/Medical State: Diabetes discoveringmontana.com/dli/bsd/license/bsd_board
Program Name: Nurse First Asthma Program s/pha_board/board_page.htm
Program Manager: Ted Weldon
Program Sponsor: Mckesson Health Solutions Montana Osteopathic Medical Association
Carmen Bell
Disease/Medical State: Chronic Pain Executive Director
Program Name: Nurse First Asthma Program 1600 2nd Avenue, SW, Suite 120
Program Manager: Ted Weldon Minot, ND 58701
Program Sponsor: Mckesson Health Solutions 701/852-8789
E-mail: drbillmunro@macn.net
Disease Management Program/Initiative
Contact Montana Hospital Association
Dick Brown
Jacklynn Thiel, Quality Assurance Program Officer Sr. Vice President/Executive Director
Dept. of Public Health and Human Services P.O. Box 5119
Medicaid Services Bureau Helena, MT 59604
P.O. Box 202951 406/442-1911, Ext. 26
1400 Broadway E-mail: dick@mtha.org
Helena, MT 59620-2951 Internet address: www.medassets.com/mtha.htm
T: 406/444-1834
F: 406/444-1861
E-mail: jthiel@state.mt.us

Mail Order Pharmacy Benefit


None

Montana-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

NEBRASKA

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients
TOTAL $161,577,499 178,365 $196,409,250 194,714

RECEIVING CASH ASSISTANCE TOTAL $58,978,402 45,490 $69,279,614 48,501


Aged $8,756,182 3,959 $9,843,626 3,983
Blind/Disabled $42,225,001 15,234 $49,388,569 15,517
Child $3,734,776 17,651 $4,534,213 19,350
Adult $4,262,443 8,646 $5,513,206 9,651

MEDICALLY NEEDY, TOTAL $40,152,899 30,671 $48,643,338 33,381


Aged $25,640,472 9,676 $29,632,049 9,808
Blind/Disabled $5,365,283 1,463 $6,684,567 1,527
Child $1,810,841 6,569 $2,260,713 6,761
Adult $7,336,303 12,963 $10,066,009 15,285

POVERTY RELATED, TOTAL $50,564,381 78,571 $65,092,478 90,996


Aged $13,567,579 6,293 $15,871,572 6,505
Blind/Disabled $22,577,439 7,496 $29,727,730 8,077
Child $13,960,793 60,808 $18,756,628 71,240
Adult $458,570 3,974 $736,548 5,174

TOTAL OTHER EXPENDITURES/RECIPIENTS* $11,881,817 23,633 $13,393,820 21,836

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data provided by the Nebraska Department of Health and Human Services, Finance and Support, Medicaid Division.

Source: CMS, MSIS Report, FY 2001 and Nebraska Medicaid Statistical Information System, FY 2002.

Nebraska-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Vaccines: Vaccines reimbursable by Medicaid for


individuals under 21 years of age as part of EPSDT
State Department of Health and Human Services, services, through the Children’s Health Insurance
Finance and Support, Medicaid Division. Program, and through the Vaccines for Children
Program.
D. PROVISIONS RELATING TO DRUGS
Unit Dose: Unit dose packaging not reimbursable.
Benefit Design
Formulary/Prior Authorization
Drug Benefit Product Coverage: Products covered:
legend drugs, compound prescriptions, prescribed Formulary: Open formulary. General exclusions
insulin with prior approval (i.e., must be medically include:
necessary on pre-filled syringes). Products covered
1. More than a three-month supply of birth
under the supplier program: disposable needles
control tablets;
used for insulin; blood glucose test strips; urine
ketone test strips; total parenteral nutrition; and 2. Experimental drugs or non-FDA approved
interdialytic parenteral nutrition. Products not drugs;
covered: DESI drugs, drugs for weight control;
cosmetics; fertility drugs; and experimental drugs. 3. Drugs or items when the prescribed use is not
Prior authorization required for: methadone; IV for a medically accepted indication;
infusions; and protein replacement supplements. 4. Liquors (any alcoholic beverages);

Over-the-Counter Product Coverage: Products 5. DESI drugs and all identical, related, or similar
covered: (must be prescribed and subject to rebate) drugs;
allergy, asthma, and sinus products; analgesics; 6. Personal care items (e.g. non-medical
topical products; cough and cold preparations; mouthwashes, deodorants, talcum powders,
digestive products; and feminine products. bath powders, soaps, dentrifices, eye washes,
Products not covered: smoking deterrent products. and contact solutions);

Therapeutic Category Coverage: Therapeutic 7. Medical supplies and certain drugs for nursing
categories covered: anabolic steroids; facility and intermediate care facility for the
anticoagulants; anticonvulsants; antilipemic agents; mentally retarded (ICF/MR) patients;
anti-psychotics; anxiolytics, sedatives, and 8. Over-the-counter (OTC) drugs not listed on the
hypnotics; cardiac drugs; chemotherapy agents; Department’s Drug Name/License Number
prescribed cold medications; contraceptives; ENT Listing microfiche;
anti-inflammatory agents; estrogens; hypotensive
agents; sympathominetics (adrenergic); and thyroid 9. Baby foods or metabolic agents (Lofenalac,
agents. Prior authorization required for: analgesics, etc.,) normally supplied by the Nebraska
antipyretics, NSAIDs; antibiotics (Zyvox); anti- Department of Health;
depressants (Zoloft 25+ 50mg); antidiabetic agents 10. Drugs distributed or manufactured by certain
(Glucovance); antihistamine (low sedating); growth drug manufacturers or labelers that have not
hormones; misc. GI drugs (PPIs); sunscreens; agreed to participate in the drug rebate
Erythropoetin (e.g., Epogen, Procrit); modified program.
versions of FUL or SMAC drugs; convenience
packaged drugs (e.g., Refresh Ophthalmic 0.3 ml Drugs, items, or manufacturers that are identifiable
and Novalin penfil insulin); drugs to prevent or as non-covered are so designated on the NE-POP
treat Respiratory Syncytial Virus Immune Globulin system, and on the Department’s Drug
(e.g., Palivizumab, RSV-IG); and drugs for sexual Name/License Number Listing microfiche or
dysfunction (e.g., Sildenafil, Alprostadil). Partial website.
coverage for: anxiolytics, sedatives, and hypnotics.
Therapeutic categories not covered: anorectics and Prior Authorization: State currently has a formal
prescribed smoking deterrents. prior authorization procedure. The Department
requires that authorization be granted prior to
Coverage of Injectables: Injectables reimbursable payment for certain products. Prior authorization
through the Pharmacy program when used in home can be verified through the NE-POP System, or by
health care and extended care facilities, and through contacting the Department. (or its designated
physician payment when used in physician offices. contractor) if authorization is not verified through
the NE-POP System.

Nebraska-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Prescribing or Dispensing Limitations E. USE OF MANAGED CARE


Prescription Refill Limit: As authorized by the
prescribing physician. For controlled substances, Approximately 156,000 unduplicated Medicaid
maximum 5 refills every 6 months. recipients were enrolled in managed care in 2002.
Recipient enrolled in MCOs receive pharmaceutical
Monthly Quantity Limit: 90-day supply or 100 services through the State.
dosage units, whichever is greater. 31-days for
injectables. Managed Care Organizations

Drug Utilization Review Share Advantage


United HealthPlans of the Midlands
PRODUR system implemented in April 1995. 2717 North 118th Circle
State currently has a DUR Board with a monthly Omaha, NE 68164
review.
Primary Care +
Pharmacy Payment and Patient Cost Blue Cross/Blue Shield of Nebraska
Sharing P.O. Box 241739
Omaha, NE 68124
Dispensing Fee: $3.27 - $5.00. The Nebraska
Department of Health and Human Services assigns
Value Options Mental Health
a dispensing fee to each individual pharmacy based
10330 Regency Parkway
on location, services, volume, and other third-party
Omaha, NE 68114
participation. The fee is calculated from
information obtained through the Department’s
Prescription Survey. F. STATE OFFICIALS
Ingredient Reimbursement Basis: EAC = AWP - State Drug Program Administrator
11%.
Dyke Anderson, R.Ph
Prescription Charge Formula: Lower of: Pharmacy Consultant
Department of Health and Human Services
1. Product cost (EAC, SMAC, or FUL) plus a Finance and Support Medicaid Division
dispensing fee, or 301 Centennial Mall South, 5th Floor-NSOB
P.O. Box 95026
2. The usual and customary price to the general Lincoln, NE 68509-5026
public. T: 402/471-9379
Listed OTCs are reimbursed at the lower of: F: 402/471-9092
E-mail: dyke.anderson@hhss.state.ne.us
1. Product cost (EAC, SMAC, or FUL) plus a Internet address: www.hhs.state.ne.us
dispensing fee,
2. The usual and customary shelf price to the Health and Human Services Department
general public, or Officials
3. Product cost (EAC, SMAC, or FUL) plus a Stephen Curtiss, Director
50% mark-up. Department of Health and Human Services
Finance and Support
Maximum Allowable Cost: State imposes Federal P.O. Box 95026
Upper Limits as well as State-specific limits on Lincoln, NE 68509-5026
generic drugs. Approximately 1,400 drugs are T: 402/471-8553
listed on the State-specific MAC list. Override F: 402/471-9449
requires a “Medically Necessary” form signed by E-mail: kelly.ostrander@hhss.state.ne.us
the physician.

Incentive Fee: None.

Patient Cost Sharing: Copayment = $2.00.

Cognitive Services: Does not pay for cognitive


services.

Nebraska-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Robert J. Seiffert, Administrator Physician Members:


Medicaid Division Kay Anderson, M.D.
Department of Health and Human Services Fred Ayers, M.D.
Finance and Support Kirk Muffly, M.D.
P.O. Box 95026 Thomas B. Murray, M.D.
301 Centennial Mall South, 5th Floor Sam Perry, M.D.
Lincoln, NE 68509-5026
T: 402/471-9223 New Brand Name Products Contact
F: 402/471-9092
E-mail: bob.seiffert@hhs.state.ne.us Dyke Anderson, R.Ph.
402/471-9379
Richard Raymond, M.D., Chief Medical Official
Department of Health and Human Services Prescription Price Updating
402/471-9105 First DataBank
1111 Bayhill Dr.
Kris Azimi San Bruno, CA 94066
Utilization Review Consultant T: 650/588-5454
402/471-7620 F: 650/827-4578

Christine Wright, M.D., Medical Director Medicaid Drug Rebate Contacts


Medicaid Division
402/471-9136 Technical
Karen Jaques
Prior Authorization Contacts Accountant II
Health and Human Services – Finance and Support
Dyke Anderson, R.Ph. 301 Centennial Mall South
402/471-9379 5th Floor – NSOB
Barbara Mart P.O. Box 95026
Clinical Pharamacist Lincoln, NE 68509-5026
Health and Human Services F: 402/471-9397
301 Centennial Mall South E-mail: karen.jaques@hhss.state.ne.us
5th Floor-NSOB
P.O. Box 95026 Policy
Lincoln, NE 68509-5026 Dyke Anderson, R.Ph.
T: 402/471-9301 402/471-9379
F: 402/471-9092
E-mail: barb.mart@hhhs.state.ne.us Claims Submission Contact
Steve Smith
DUR Contact Account Representative
Beth Wilson ACS State Healthcare
DUR Director 365 Northridge Road
Nebraska Pharmacists Association Northridge Center One, Suite 400
6221 South 58th, Suite A Atlanta, GA 30350
Lincoln, NE 68516 T: 770/901-5002
T: 402/420-1500 F: 770/730-5198
F: 402/420-1406 E-mail: stephen.m.smith@acs-inc.com
E-mail: beth@npharm.org
Medicaid Managed Care Contact
Nebraska DUR Board David Cygan
Pharmacist Members: Managed Care Program Administrator
Kevin Borcher, R.Ph. HHSS-Finance & Support-Medicaid
Elissa Carney, R.Ph. 301 Centennial Mall South
Patty Gollner, R.Ph. Lincoln, NE 68509
David Hutsell, R.Ph. T: 402/471-9050
John Franklin, R.Ph. F: 402/471-9455
Kim Hamik, R.Ph. E-mail: David.Cygan@hhss.state.ne.us
Shannon Nelson, R.Ph.
Phillip Vuchetich, R.Ph.

Nebraska-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Mail Order Pharmacy Program Sandy Johnson


Executive Secretary
None
Nebraska Medical Association
First Bank Bldg., Suite 1512
Medical Advisory Committee Lincoln, NE 68508
Marlene Brondel
League of Human Dignity Pat Snyder
1701 P Street Executive Director
Lincoln, NE 68508 Nebraska Health Care Association
421 South 9th Street, Suite 137
Tim Bruner Lincoln, NE 68508
Director of Fiscal Services
Lincoln General Hospital James Walker, D.D.S.
2300 South 16th Street 1640 South 70th, Suite 200
Lincoln, NE 68502 Lincoln, NE 68506

Joni Cover, J.D. Executive Officers of State Medical and


Executive Vice President Pharmaceutical Societies
Nebraska Pharmacists Association
Nebraska Medical Association
6221 South 58th Street, Suite A
Sandra Johnson
Lincoln, NE 68502
Executive Vice President
233 S. 13th Street, Suite 1512
Karen Miller
Lincoln, NE 68508-2091
Health Insurance Specialist
402/474-4472
Room 227, Federal Building
E-mail: nebmed@nebmed.org
601 East 12th Street
Internet address: www.nebmed.org
Kansas City, MO 64106
Nebraska Pharmacists Association
Edmund A. Schneider, O.D.
Joni Cover, J.D.
Lincoln Vision Clinic
Executive Vice President
810 North 48th Street
6221 South 58th, Suite A
Lincoln, NE 68504
Lincoln, NE 68516-3679
T: 402/420-1500
Steven Lorenzen
F: 402/420-1406
Director, Federal Programs
E-mail: joni@npharm.org
Blue Cross/Blue Shield of NE
Internet address: www.npharm.org
Main P.O. Station Box 3248
Omaha, NE 68180
Nebraska Assn. of Osteopathic Physicians &
Surgeons
John Milligan
Arthur A. Weaver, D.O.
Legal Services of Southeast Nebraska
Secretary
825 Terminal Building
16556 Dorcas Street
Lincoln, NE 68508
Omaha, NE 68130
402/554-2374
Joan Penrod, Ph.D.
Department of Preventive and Social Medicine
State Board of Pharmacy
UNMC
Becky Wisell
Box 984350, 600 S. 42nd Street
Executive Secretary
Omaha, NE 68198
P. O. Box 94986
Lincoln, NE 68509
Larry Rennecker
T: 402/471-2115
NAHHS
F: 402/471-3577
1640 L Street, Suite D
E-mail: becky.wisell@hhss.state.ne.us
Lincoln, NE 68508
Internet address: www.hhs.state.ne.us/lis/lis.asp

Nebraska-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Nebraska Association of Hospitals and Health


Systems
Laura J. Redoutey, FACHE
President
1640 L Street, Suite D
Lincoln, NE 68508-2509
T: 402/458-4900
F: 402/475-4091
E-mail: lredoutey@nhanet.org
Internet address: www.nhanet.org

Nebraska-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

NEVADA

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 ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $62,849,319 55,580 $86,929,536

RECEIVING CASH ASSISTANCE TOTAL $45,602,458 29,090


Aged $9,830,256 5,917
Blind/Disabled $34,597,803 16,240
Child $588,847 4,156
Adult $585,552 2,777

MEDICALLY NEEDY, TOTAL $0 -


Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $1,863,191 10,403


Aged $97,513 157
Blind/Disabled $259,384 255
Child $806,164 5,859
Adult $700,130 4,132

TOTAL OTHER EXPENDITURES/RECIPIENTS* $15,383,670 16,087

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Note: Nevada estimates 2003 drug expenditures to be approximately $102.8 million.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Nevada-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Vaccines: Vaccines reimbursable at cost plus an


administration fee ($3.83) as part of the EPSDT
Division of Health Care Financing and Policy of service.
the Department of Human Resources. Unit Dose: Unit dose packaging reimbursable.

D. PROVISIONS RELATING TO DRUGS Formulary/Prior Authorization


Formulary: Open formulary. General exclusions
Benefit Design include:
Drug Benefit Product Coverage: Products covered: 1. Agents used for cosmetic purposes or hair
prescribed insulin; disposable needles and syringe growth.
combinations used for insulin; blood glucose test
2. Yohimbine (e.g., Yocon).
strips; and urine ketone test strips. Products covered
under DME: total parental nutrition; interdialytic 3. Radiopaque agents (e.g., Telepaque, Hypaque,
parenteral nutrition. Products not covered: Barium Sulfate).
cosmetics; fertility drugs; and experimental drugs. 4. Radiographic adjuncts (e.g., Perchloracap).
5. Pharmaceuticals designed “ineffective,” or
Over-the-Counter Product Coverage: Products “less than effective” (including identical,
covered: allergy, asthma, and sinus products; related, or similar drugs) by the FDA.
analgesics; cough and cold preparations; digestive
6. Non-rebated medications.
products; and smoking deterrent products. Products
covered with restrictions: topical products. OTC Prior Authorization: State currently has a prior
drugs are reimbursed at EAC+$4.76 or the usual authorization procedure with appeals process. Prior
and customary amount, whichever is less, and authorization procedure screening for individual
require prior authorization. Products not covered: drugs. Drugs requiring PA include:
feminine products. 1. Amphetamine (e.g., Dexedrine)
2. Chorionic Gonadotropin (HCG)
Therapeutic Category Coverage: Therapeutic
categories covered: analgesics, antipyretics, and 3. Dipyridamole (e.g., Persantine)
NSAIDs; antibiotics; anticoagulants; 4. Erythropoietin (e.g., Epogen, Procrit)
anticonvulsants; anti-depressants; antidiabetic 5. Gonadotropin releasing hormone analog (e.g.,
agents; antihistamine drugs; antilipemic agents; Lupron, Zoladex)
anti-psychotics; anxiolytics, sedatives, and
6. Growth hormone (e.g., Protropin, Nutropin)
hypnotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives; ENT 7. Interferon (all combinations manufactured by
anti-inflammatory agents; hypotensive agents; recombinant DNA technology)
misc. GI products; prescribed smoking deterrents; 8. Intravenous antibiotic therapy
sympathominetics (adrenergic); and thyroid agents. 9. Methylphenidate (e.g., Ritalin)
Prior authorization required for: CNS stimulants;
Hemapopoiletic; PPIs; Cox2 inhibitors; erectile 10. Non-legend pharmaceuticals
dysfunction medications; duragisic patches; HCG; 11. Nutritional supplements or replacements
Gonadotropin, Gonadotropin releasing hormone 12. Pemoline (e.g., Cylert)
analog; Erythropoetin; Interferon; IV antibiotic; 13. Pulmozyme
Methylpenidate, Peomoline; vitamins; and
Remicade. Partial coverage for: growth hormones 14. Vitamins, vitamin/mineral combinations or
(prior authorization required); estrogens; and hematinics
anabolic steroids. Therapeutic categories not Prescribing or Dispensing Limitations
covered: anorectics; amphetamine combinations;
radiopague and radiographic products; DESI drugs; Monthly Quantity Limit: The maximum dispensable
yohimbine; and drugs not participating in the drug quantity is limited to a 34-day supply. Maintenance
rebate program. medications limited to a 100 day supply.

Coverage of Injectables: Injectable medicines Drug Utilization Review


reimbursable through the Prescription Drug
State currently has a DUR Board with a quarterly
Program when used in home health care and
review by a PRODUR contractor. PRODUR system
extended care facilities, and through physician
implemented in 2003.
payment when used in physicians’ offices.

Nevada-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Pharmacy Payment and Patient Cost Human Resources Department Officials


Sharing
Michael J. Willden, Director
Dispensing Fee: $4.76, effective 10/1/98. IV Department of Human Resources
dispensing fee is $16.80 for first ingredient; $5.60 State Capital Complex
for other ingredients. 505 East King Street, Room 600
Carson City, NV 89710
Ingredient Reimbursement Basis: EAC = AWP- T: 775/684-4000
15%. F: 775/684-4010
E-mail: slindsey@dhr.state.nv.us
Prescription Charge Formula: The lowest of (1)
specific upper limit (SUL) plus a dispensing fee, (2) Chuck Duarte
estimated acquisition cost (EAC) plus a dispensing Administrator
fee, or (3) the pharmacy's usual charge to the Division of Health Care Financing and Policy
general public. 1100 E. Williams Street, Suite 116
Carson City, NV 89710
Maximum Allowable Cost: State does not impose T: 775/684-3676
Upper Limits on generic drugs. F: 775/684-8792
E-mail: cduarte@govmail.state.nv.us
Incentive Fee: None.
Prior Authorization Contact
Patient Cost Sharing: None.
Dionne Coston, R.N.
Cognitive Services: Does not pay for cognitive 775/684-3775
services. Steve Espy, R.Ph.
Director of Drug Utilization
E. USE OF MANAGED CARE Health Information Design, Inc.
1550 Pumphrey Avenue
Approximately 61,000 Medicaid recipients are Auburn, AL 36832
enrolled in MCOs in 2002; all receive pharmacy T: 205/402-9530
benefits through their managed care plan. F: 205/402-9531

Managed Care Organizations DUR Contact

Health Plan of Nevada Dionne Coston, R.N.


P.O. Box 15645 775/684-3775
Las Vegas, NV 89114
DUR Board
NevadaCare, Inc. Joseph W. Johnson, M.D.
1701 W. Charleston Blvd. 110 E. Lake Mead Boulevard, #201
Suite 420 Henderson, NV 89015
Las Vegas, NV 89102
Steven W. Parker, M.D.
75 Pringle Way, #603
F. STATE CONTACTS
Reno, NV 89503
State Drug Program Administrator
David England, R.Ph.
Dionne Coston, R.N. University Medical Center Pharmacy
Medical Services Specialist 1800 W. Charleston Boulevard
Division of Health Care Financing and Policy Las Vegas, NV 89102
Pharmacy Program
1100 E. Williams Street Lori Winchell, R.N.
Carson City, NV 89701 341 Pinnacle Court
T: 775/684-3775 Henderson, NV 89014
F: 775/684-3762
Email: dcpstpm@dhcfp.state.nv.us Vanetta Christopherson
Internet address: www.dhcfp.state.nv.us 2149 Hidden Ranch Terrace
Henderson, NV 89052

Nevada-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

New Brand Name Products Contact Mary Guinan, M.D., Nevada State Health officer,
Health Division
Dionne Coston, R.N.
775/684-3775 Executive Officers of State Medical and
Pharmaceutical Societies
Prescription Price Updating
Nevada State Medical Association
First DataBank Lawrence P. Matheis
1111 Bayhill Drive, Suite 350 Executive Director
San Bruno, CA 94066 3660 Baker Lane, Suite 101
T: 650/588-5454 Reno, NV 89509
F: 650/827-4578 T: 775/825-6788
F: 775/825-3202
Medicaid Drug Rebate Contacts E-mail: nsma@nsmadocs.org
Technical: Anita Sheard, 775/684-3749 Internet address: www.nsmadocs.org
Policy: Dionne Coston, R.N., 775/684-3755
Rebate: Anita Sheard, 775/684-3749 Nevada Pharmacy Alliance
Mary Grear, R.Ph.
Claims Submission Contact Executive Vice President
c/o Nevada College of Pharmacy
First Health Services Corp. 5740 S. Eastern Avenue, Suite 240
4300 Cox Road 702/990-4433
Glen Allen, VA 23060 E-mail: nvphall@ludi.net
800/884-3238 Internet address: www.nvphall.org

Medicaid Managed Care Contact Nevada Osteopathic Medical Association


Denise Selleck Davis
Hilary Jones, R.N.
Executive Director
Medicaid Services Specialist III
2920 N. Green Valley Parkway, Suite 527
1100 E. Williams Street, Suite 204
Las Vegas, NV 89014
Carson City, NV 89701
T: 702/434-7112
775/684-3697
F: 702/434-7110
E-mail: hjones@dhcfp.state.nv.us
E-mail: nvoma@aol.com
Internet address: www.nevadaosteopathic.com
Mail Order Pharmacy Program
None State Board of Pharmacy
Keith W. MacDonald, R.Ph.
Physician-Administered Drug Program Executive Secretary
Contact 555 Double Eagle Court, Suite 1100
Reno, NV 89511-8991
Coleen Lawrence, 775-684-3744 T: 775/850-1440
F: 775/850-1444
Medical Care Advisory Group E-mail: pharmacy@govmail.state.nv.us
David England, Pharm.D. Internet address: www.state.nv.gov/pharmacy
Trudy Larson, M.D.
Nevada Hospital Association
Dr. William Bannen, Medical Director, Anthem Bill M. Welch
BC/BS President/CEO
Mr. Paul Boyar, Administrator, Plaza Regency at 5250 Neil Road
Sun Mountain Suite 302
Patricia Craddock, D.D.S. Reno, NV 89502
T: 775/827-0184
Ms. Jessie Harris
F: 775/827-0190
Mr. Keith MacDonald, RPh. E-mail: bill@nvha.net
Mr. Ken Richardson, Clinic Director, Walker River Internet address: www.nvha.net
Tribal Health Clinic
Ms. Linda Sheldon, State Coordinator, Nevada
Covering Kids Coalition

Nevada-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

NEW HAMPSHIRE

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $90,927,579 73,489 $99,682,997

RECEIVING CASH ASSISTANCE, TOTAL $25,669,473 18,137


Aged $3,216,921 1,436
Blind/Disabled $18,263,975 5,335
Child $1,567,158 7,533
Adult $2,621,419 3,833

MEDICALLY NEEDY, TOTAL $24,027,775 9,047


Aged $10,097,853 4,233
Blind/Disabled $11,643,790 2,676
Child $328,662 819
Adult $1,957,470 1,319

POVERTY RELATED, TOTAL $6,948,883 26,834


Aged $421,825 293
Blind/Disabled $437,532 257
Child $5,787,235 24,563
Adult $302,291 1,721

TOTAL OTHER EXPENDITURES/ RECIPIENTS* $34,281,448 19,471

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

New Hampshire-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Formulary/Prior Authorization


Office of Health Planning and Medicaid, Formulary: Open formulary. General exclusions
Department of Health and Human Services. include cosmetic agents for hair growth,
experimental and fertility drugs. Management of
formulary includes prior authorization and quantity
D. PROVISIONS RELATING TO DRUGS limits on certain products (e.g., anti-emetics, anti-
migraine agents, etc.).
Benefit Design
Drug Benefit Product Coverage: Products covered: Prior Authorization: State currently has a formal
prescribed insulin; disposable needles and syringe prior authorization procedure with an associated
combinations for insulin; blood glucose test strips; grievance and appeal procedure.
urine ketone test strips; total parenteral nutrition;
and interdialytic parenteral nutrition. Products not Prescribing or Dispensing Limitations
covered: cosmetics; fertility drugs; and Monthly Quantity Limit: Limited to 30-day supply
experimental drugs. Maintenance Medications: Limited to 90-day
Supply
Over-the-Counter Product Coverage: Products
covered: allergy, asthma, and sinus products; Monthly Dollar Limits: None.
analgesics; cough and cold preparations; digestive
products (including H2 antagonists); feminine Drug Utilization Review
products smoking deterrents; and topical products.
PRODUR system implemented in July 1995. State
Therapeutic Category Coverage: Therapeutic currently has a DUR Board with a quarterly review.
categories covered: anabolic steroids; antibiotics;
anticoagulants; anticonvulsants; anti-depressants; Pharmacy Payment and Patient Cost
antidiabetic agents; antihistamine drugs; Sharing
antilipemic agents; anti-psychotics; anxiolytics, Dispensing Fee: $1.75, effective 1/24/2004.
sedatives, and hypnotics; cardiac drugs;
chemotherapy agents; prescribed cold medications; Ingredient Reimbursement Basis: EAC = AWP-
contraceptives; ENT anti-inflammatory agents; 16%.
estrogens; growth hormones; hypotensive agents;
sympathominetics (adrenergic); thyroid agents; and
Prescription Charge Formula: Lesser of usual and
prescribed smoking deterrents. Therapeutic
customary charge or AWP-16%, Federal Upper
categories/products requiring prior authorization:
Limit; State MAC; or DOJ pricing, plus a
anorectics; erectile dyfunction products; PPIs; Cox
dispensing fee.
IIs; Oxycontin; CNS stimulants; anti-fungals for
nail fungus; and rheumatoid arthritis agents. Brand
Maximum Allowable Cost: State imposes Federal
approval overrides required for NSAIDs, controlled
Upper Limits as well as State-specific limits on
substances, and GI drugs for which there are
generic drugs. Override requires “Brand Medically
therapeutically equivalent (A-rated) generics
Necessary.”
available.
Incentive Fee: None.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug
Patient Cost Sharing: Copayment – Generics:
Program when used in home healthcare and
$1.00; Brand: $2.00, effective 3/1/04. Copayments
extended care facilities, and through physician
apply to all recipients except nursing home patients
payment when used in physicians’ offices.
in SNF or ICF facilities; home and community
based care waived recipients holding form 949;
Vaccines: Vaccines reimbursable as part of the
pregnant women; children under 18 years; and
EPSDT, CHIP, and VCP service. Childhood
prescriptions for family planning drugs.
immunization vaccine is provided to all children
through the Division of Public Health Services.
Cognitive Services: Does not pay for cognitive
The Medicaid program does not reimburse
services.
providers for routine vaccines, although an
administration fee is allowed.
E. USE OF MANAGED CARE
Unit Dose: Unit dose packaging reimbursable.
None as of June 2003.

New Hampshire-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

F. STATE CONTACTS Prescription Price Updating


Sherrill Bryant
State Drug Program Administrator Plan Administrator
Margaret A. Clifford First Health Services Corp.
Pharmacy Administrator 4300 Cox Road
Office of Health Planning & Medicaid Glen Allen, VA 23060
129 Pleasant Street, Annex 1 T: 800/884-2822
Concord, NH 03301 F: 804/965-7647
T: 603/271-4210 E-mail: bryantsh@fhsc.com
F: 603/271-8701
E-mail: mclifford@dhhs.state.nh.us Medicaid Drug Rebate Contacts
Internet address: www.dhhs.state.nh.us John Cox
Rebate Pharmacist
Department of Health and Human Services First Health Services Corp.
Officials 4300 Cox Road
John Stephen Glen Allen, VA 23060
Commissioner T: 800/884-2822
Department of Health and Human Services F: 804/965/7647
129 Pleasant Street E-mail: coxjo@fhsc.com
Concord, NH 03301-3857
T: 603/271-4331 Claims Submission Contact
F: 603/271-4912 Sherrill Bryant
E-mail: jstephen@dhhs.state.nh.us 800/884-2822
Stephen Norton
Acting Director Medicaid Managed Care Contact
Office of Health Planning & Medicaid
Margaret A. Clifford
129 Pleasant Street
603/271-4210
Concord, NH 03301
603/271-4297
Mail Order Pharmacy Benefit
snorton@dhhs.state.nh.us
None
DUR Contact
Disease Management/Patient Education
Lisè Farrand, R.Ph.
Contact
Pharmaceutical Services Specialist
Office of Health Planning & Medicaid Doris Lotz, M.D.
129 Pleasant Street, Annex 1 Medicaid Medical Director
Concord, NH 03301 Office of Health Planning & Medicaid
T: 603/271-4419 129 Pleasant Street, Annex 1
F: 603/271-8701 Concord, NH 03301
E-mail: lfarrand@dhhs.state.nh.us T: 603/271-8166
F: 603/271-8701
Medicaid DUR Board E-mail: dlotz@dhhs.state.nh.us
Paul S. Collins, M.D.
Mark Henschke, D.O.
Emory Kaplan, M.D.
Steve Lawrence, M.D.
Thomas Mellman, M.D.
Elizabeth Gower, R.Ph.
Helen Pervanas, R.Ph.
Michael Smith, R.Ph.
John Zinka, R.Ph.

New Brand Name Products Contact


Lisé Farrand, R.Ph.
603/271-4419

New Hampshire-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Pharmacy & Therapeutics Advisory New Hampshire Hospital Association


Committee Michael J. Hill, C.H.E.
President
William Kassler, M.D., M.P.H.
125 Airport Road
Stephen Bartels, M.D.
Concord, NH 03301-7300
Doris Lotz, M.D.
T: 603/225-0900
Bryan King, M.D.
F: 603/225/4346
Steven Paris, M.D.
E-mail: mhill@nhh.org
Richard Lafleur, M.D.
Internet address: www.nhha.org
Eric Pollak, M.D., M.P.H.Lenny Parker, R.Ph.
Margaret Clifford, R.Ph.
Roger Hebert, R.Ph.
Paul Santos, Pharm.D.
Robert Lenza, R.Ph.

Executive Officers of State Medical and


Pharmaceutical Services
New Hampshire Medical Society
Palmer P. Jones
Executive Vice President
7 N. State Street
Concord, NH 03301-4018
T: 603/224-1909
F: 603/226-2432
E-mail: nhmsppj@aol.com
Internet address: www.nhms.org

New Hampshire Pharmacists Association


David Minnis
Executive Director
2 Eagle Square, Suite 400
Concord, NH 03301-8905
T: 603/229-0292
F: 603/224-7769
E-mail: mms@worldpath.net
Internet address:
www.newhampshirepharmacistree.org
New Hampshire Osteopathic Association, Inc.
Robert Soucy, D.O.
President
7 North State Street
Concord, NH 03301
603/224-1909
E-mail: osteo@worldpath.net
Internet address: www.nh-osteopath.org

State Board of Pharmacy


Paul G. Boisseau
Executive Secretary
57 Regional Drive
Concord, NH 03301-8518
603/271-2350
E-mail: nhpharmacy@nhsa.state.nh.us
Internet address: www.state.nh.us/pharmacy

New Hampshire-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

NEW JERSEY 1

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients
TOTAL $649,274,352 307,798 $694,669,924

RECEIVING CASH ASSISTANCE, TOTAL $364,861,677 165,644


Aged $66,082,464 30,760
Blind / Disabled $291,316,345 96,878
Child $1,682,939 14,742
Adult $5,779,929 23,264

MEDICALLY NEEDY, TOTAL $8,848,818 3,531


Aged $7,865,157 3,213
Blind / Disabled $948,839 230
Child $34,822 88
Adult $0 -

POVERTY RELATED, TOTAL $100,274,542 57,346


Aged $32,401,984 14,695
Blind / Disabled $64,930,600 16,665
Child $2,513,691 20,113
Adult $428,267 5,873

TOTAL OTHER EXPENDITURES/RECIPIENTS* $175,289,315 81,277

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

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 2003

C. ADMINISTRATION Unit Dose: Unit dose packaging reimbursable in


long-term care facilities only, not in retail settings
Division of Medical Assistance and Health (unless u/d is only way item is packaged).
Services, Department of Health and Human
Services. Formulary/Prior Authorization
Formulary: Open formulary. General exclusions
D. PROVISIONS RELATING TO DRUGS include experimental drugs, cosmetics, fertility
drugs, DESI drugs, and drugs for which FFP is not
Benefit Design available (OBRA '90).

Drug Benefit Product Coverage: Products covered: Prior Authorization: State currently has a formal
prescribed insulin; disposable needles and syringe prior authorization procedure. Periodic review for
combinations for insulin use; blood glucose test reconsideration possible for excluded product from
strips; urine ketone test strips; total parenteral formulary. Fair hearings possible for appealing
nutrition; and interdialytic parenteral nutrition. prior authorization decisions.
Products not covered: cosmetics; fertility drugs;
and experimental drugs, and DESI drugs. Prior Prescribing or Dispensing Limitations
authorization required for: methadone; IV
infusions; and protein replacement supplements. Prescription Refill Limit: 5 times within a 6-month
period.
Over-the-Counter Product Coverage: Products
covered: allergy, asthma, and sinus products; Monthly Quantity Limit: Original, 34-day supply.
analgesics; topical products; cough and cold Refills, 34 days or 100 units, whichever is more.
preparations for children under age 21;
contraceptive devices and supplies; family planning Drug Utilization Review
supplies (e.g., pregnancy test kits); and smoking PRODUR system implemented in October 1996.
deterrent products (inhaler or nasal spray). State currently has a DUR Board with a quarterly
Products not covered: digestive products; feminine review.
products; contraceptives; pregnancy test kits;
inhalation drugs; and antacids. Pharmacy Payment and Patient Cost
Sharing
Therapeutic Category Coverage: Therapeutic
categories covered: analgesics, antipyretics, Dispensing Fee: $3.73 for legend drugs.
NSAIDs; antibiotics; anticoagulants; Additional add-ons per/Rx shall be given to
anticonvulsants; anti-depressants; antidiabetic pharmacy providers who provide the following:
agents; antihistamine drugs; anti-psychotics;
anxiolytics, sedatives, and hypnotics; cardiac drugs; 1. 24-hr Emergency Service: add $0.11
chemotherapy agents; prescribed cold medications; 2. Patient Consultation: add $0.08
contraceptives; ENT anti-inflammatory agents;
estrogens; hypotensive agents; misc. GI drugs; 3. Impact Area Location: add $0.15 (provider
sympathominetics (adrenergic); and thyroid agents. shall have a combined Medicaid, NJ KidCare
Prior authorization required for: antilipemic agents. and PAAD prescription volume equal to or
Partial coverage for: anabolic steroids; anorectics greater than 50% of total prescription volume.
(for ADD); growth hormones; and prescribed
Ingredient Reimbursement Basis: EAC = AWP-
smoking deterrents.
10%, WAC + 30%. AAC for injectables, effective
5/1/00.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug
Prescription Charge Formula: “Maximum
Program when used in home health care and
Allowable Cost,” or Average Wholesale Price-10%
extended care facilities and through physician
(reduction from AWP is pharmacy specific) plus a
payment when used in physician offices.
dispensing fee or the provider’s usual and
customary charge, whichever is lower.
Vaccines: Vaccines reimbursable at AWP as part of
the EPSDT program and the Vaccines for Children
Maximum Allowable Cost: State imposes Federal
Program.
Upper Limits on generic drugs. Override requires
“Brand Medically Necessary”.
Incentive Fee: None.

New Jersey-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Patient Cost Sharing: None. Department of Human Services Officials


Cognitive Services: State pays for cognitive Gwendolyn L. Harris, Commissioner
services. Department of Human Services
Capitol Place One CN-700, 5th Floor
P.O. Box 700
E. USE OF MANAGED CARE Trenton, NJ 08625
T: 609/292-3717
Approximately 460,000 Medicaid recipients F: 609/292-3824
received pharmacy benefits through managed care E-mail: webmaster@dhs.state.nj.us
in 2001. All receive pharmaceutical benefits from
MCOs. Ann Clemency Kohler, Director
Division of Medical Assistance and Health Services
Managed Care Organizations Department of Human Services
AMERIGROUP New Jersey, Inc P.O. Box 712
399 Thornall Street, 9th Floor Trenton, NJ 08625-0712
Edison, NJ 08837 T: 609/588-2600
800/600-4441 F: 609/588-3583
E-mail: ann.kohler@dhs.state.nj.us
Health Net of New Jersey, Inc.
CNA Building DUR Contact
3501 State Highway 66 Edward J. Vaccaro, R.Ph.
Neptune, NJ 07754 T: 609/588-2726
800/555-2604
Medicaid DUR Board
AmeriChoice of New Jersey, Inc.
Two Gateway Center, 13th Floor Christopher A. Cella, R.Ph.
Newark, NJ 07102 Alfred F. Sorbelo, D.O.
800/941-4647 Edith Kessler-Feinstein, R.Ph.
Joseph Nicholas Micale, M.D.
Horizon Mercy Rochelle Dallago, R. Ph..
275 Phillips Boulevard Thomas A. Cavalieri, D.O.
Trenton, NJ 08618-1426 Linda Gooen, R.Ph.
800/656-3729 Mary E Petit, Pharm.D.
David Ethan Swee, M.D.
University Health Plans, Inc.
550 Broad Street, 17th Floor New Brand Name Products Contact
Newark, NJ 07102 Edward J. Vaccaro, R.Ph.
800/564-6847 T: 609/588-2726

F. STATE CONTACTS Prescription Price Updating


First DataBank
State Drug Program Administrator 1111 Bayhill Dr.
Edward J. Vaccaro, R.Ph. San Bruno, CA 94066
Assistant Director, Office of Utilization 415/588-5454
Management
Department of Human Services Medicaid Drug Rebate Contacts
Division of Medical Assistance and Health Services Technical: Daniel Upright, 609/588-2792
P.O. Box 712, Bldg. 11-A Policy: Edward J. Vaccaro, 609/588-2726
Trenton, NJ 08625 PA: Carl Tepper, 609/588-2744
T: 609/588-2726
F: 609/588-3889
E-mail: ejvaccaro@dhs.state.nj.us

New Jersey-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Claims Submission Contact New Jersey Association of Osteopathic Physicians


& Surgeons
Peter Ringel
Frank Cagliari
Deputy Project Director
President
Unisys
1 Distribution Way, Suite 201
3705 Quakerbridge Road, Suite 101
Monmouth Junction, NJ 08852
Trenton, NJ 08619
T: 732/940-9000
T:609/588-6000
F: 732/940-8899
F: 609/584-8270
E-mail: frank@njosteo.com
E-mail: ringelp@nipo1.him.unisys.com
Internet address: www.njosteo.org
Medicaid Managed Care Contact State Board of Pharmacy
Edward J. Vaccaro Remi Erdos
609/588-2726 Executive Director
P.O. Box 45013
Mail Order Benefit Program Newark, NJ 07101
973/504-6450
State currently has a mail order benefit program. E-mail: askconsumeraffairs@dca.lps.state.nj.us
All Medicaid recipients are entitled to participate. Internet address:
www.state.nj.us/lps/ca/brief/pharm.htm
Elderly Expanded Drug Coverage Contact
New Jersey Hospital Association
Kathleen Mason Gary S. Carter, FACHE
Assistant Commissioner, Benefits and Utilization President & CEO
Management 760 Alexander Road, P.O. Box 1
Dept. of Health and Senior Services Princeton, NJ 08543-0001
P.O. Box 715 609/275-4000
Trenton, NJ 08625 E-mail: gcarter@njha.com
T: 609/588-7032 Internet address: www.njha.com
F: 609/584-7037

Physician-Administered Drug Program


Contact
Edward J. Vaccaro
609/588-2726

Executive Officers of State Medical and


Pharmaceutical Societies
Medical Society of New Jersey
Vincent A. Maressa
Executive Director
2 Princess Road
Lawrenceville, NJ 08648-2302
T: 609/896-1766
F: 609/896-1368
E-mail: vamaress@msnj.org
Internet address: www.msnj.org

New Jersey Pharmacists Association


Joseph V. Roney, R.Ph.
Chief Executive Officer
760 Alexander Road, P.O. Box 1
Princeton, NJ 08543-0001
T: 609/275-4246
F: 609/275-4066
E-mail: joeroney@njaj.com
Internet address: www.njpharma.org

New Jersey-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

NEW MEXICO

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 ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002*
Expenditures Recipients Expenditures Recipients

TOTAL $70,147,344 75,669 $73,877,785

RECEIVING CASH ASSISTANCE TOTAL $38,536,342 33,554


Aged $7,975,843 6,366
Blind/Disabled $29,447,155 15,664
Disabled $350,900 5,397
Child $762,444 6,127
Adult
$0 -
MEDICALLY NEEDY, TOTAL $0 -
Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult
$2,087,207 23,345
MEDICALLY NEEDY, TOTAL $96,973 176
Aged $342,469 425
Blind/Disabled $1,478,634 19,624
Child $169,131 3,120
Adult

TOTAL OTHER EXPENDITURES/RECIPIENTS* $29,523,795 18,770

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001and CMS-64 Report, FY 2002.

New Mexico-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION physician offices, home health care, and extended


care facilities.
Human Services Department (HSD), Medical Vaccines: Vaccines reimbursable as part of the
Assistance Division. EPSDT service, the Children’s Health Insurance
Program, and the Vaccine for Children Program.
D. PROVISIONS RELATING TO DRUGS Unit Dose: Does not reimburse for unit dose
packaging.
Benefit Design
Formulary/Prior Authorization
Drug Benefit Product Coverage: Products covered:
Formulary: Open formulary
prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test
strips; urine ketone test strips; total parenteral Prior Authorization: State currently has a formal
nutrition; and interdialytic parenteral nutrition. Prior prior authorization procedure screening for drug
Authorization required for: amphetamines and classes.
stimulants for ADD (adults only); nutritional
supplements. Products not covered: drugs for Prescribing or Dispensing Limitations
treatment of tuberculosis; cosmetics; experimental Monthly Quantity Limit: 34-day supply maximum,
drugs; fertility drugs; drugs and immunizations excluding birth control pills (1 year). Number of
available from any other source; medications refills must conform to applicable State and Federal
supplied by the New Mexico State Hospital to laws.
clients on convalescent leave from hospital;
hormones; stimulants; drugs classified by FDA as Drug Utilization Review
“ineffective;” hypnotic drugs (barbiturates); and
drugs without Medicaid rebate participation PRODUR system implemented in October 1993.
agreement.
Pharmacy Payment and Patient Cost Sharing
Over-the-Counter Product Coverage: Products
Covered: insulin; antacids for active gastric and Dispensing Fee: $3.65, effective 6/12/02. State
duodenal ulcers; infant vitamin drops for up to 1 currently has a DUR Board that meets at least
year; Salicylates and acetaminophen; vitamins; iron; quarterly.
minerals; and pediculocides; laxatives, stool
softeners, calcium, nicotine replacement, ibuprofen, Ingredient Reimbursement Basis: EAC = AWP-
antihistamines, decongestants, expectorants, cough 12.5%, effective 7/1/97.
suppressants, anti-candida, and antifungals.
Products covered with restriction: topical products Prescription Charge Formula: Prescriptions
(specific therapeutic categories). Products not reimbursed at the lesser of the following:
covered: personal care items (i.e., over-the-counter 1. Cost (EAC or MAC) dispensed plus a
shampoo and soap); feminie products. dispensing fee or,
2. The usual and customary charge by the
Therapeutic Category Coverage: Products Covered: pharmacy to the general public.
anabolic steroids; analgesics; antipyretics; and
NSAIDs (prior authorization required); antibiotics; Maximum Allowable Cost: State imposes Federal
anticoagulants; anticonvulsants; antidepressants; Upper Limits as well as State-specific limits on
antidiabetic agents, antihistamines; antilipemic generic drugs. Override requires “Medically
agents; anti-psychotics; anxyolitics, sedatives, and Necessary” or “Brand Necessary.” Also prescriber
hypnotics; cardiac drugs; chemotherapy agents; is not prohibited from generic substitution and, if
prescribed cold medications; contraceptives; ENT due to drug shortage, requesting reimbursement at
anti-inflammatory agents; estrogens; growth the brand level.
hormones; hypotensive agents; misc. GI drugs;
prescribed smoking deterrents; and Incentive Fee: None.
sympathominetics (adrenergic-prior authorization
required for adults); and thyroid agents. Partial Patient Cost Sharing: No copayment, except $2.00
coverage for: Viagra (prior authorization required). for CHIP clients and working disabled clients.

Coverage of Injectables: Injectable medicines Cognitive Services: Does not pay for cognitive
reimbursable through both the Prescription Drug services.
Program and physician payment when used in

New Mexico-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

E. USE OF MANAGED CARE Prescription Price Updating Contact


Neal Solomon, M.P.H., R.Ph.
Approximately 250,000 Medicaid recipients 505/874-3174
enrolled in are MCOs in FY 2002. Recipients
receive pharmaceutical benefits through managed Claims Submission
care plans.
ACS, Inc.
365 Northridge Road
F. STATE CONTACTS Northridge Center One, Suite 400
Atlanta, GA 30350
State Drug Program Administrator T: 770/352-8592
F: 770/730-5198
Neal Solomon, M.P.H., R.Ph.
Pharmacist, Human Services Department Medicaid Managed Care Contact
Medical Assistance Division
P.O. Box 2348 Alana Reeves
Santa Fe, NM 87504-2348 Human Services Department
T: 505/827-3174 P.O. Box 2348
F: 505/827-3185 Santa Fe, NM 85705-2348
E-mail: neal.solomon@state.nm.us T: 505/827-3131
F: 505/827-3185
DUR Contact E-mail: alana.reeves@state.nm.us

Neal Solomon, M.P.H., R.Ph. Mail Order Pharmacy Program


505/827-3174
None
DUR Board
Human Services Department Officials
Denise Cuellar, Pharm.D.
Greg D’Armour, Pharm.D. Pamela Hyde
Gregory Toney, R.Ph., Ph.C. Secretary
John Piper, Pharm.D. New Mexico Department of Human Services
John Lauriello, M.D. P.O. Box 2348
Gayle Chacon, M.D. Santa Fe, NM 87504-2348
John Seibel, M.D. T: 505/827-7750
Judy Romero, Pharm.D. F: 505/827-6286
Manual Archuleta, M.D. E-mail: pam.hyde@state.nm.us

Prior Authorization Contact Carolyn Ingram


Director
Neal Solomon, M.P.H., R.Ph. New Mexico Department of Human Services
505/827-3174 Medicaid Assistance Division
P.O. Box 2348
Medicaid Drug Rebate Contact Santa Fe, NM 87504-2348
Delfinia Dandoval, Human Services Department T: 505/827-3100
ASD F: 505/827-3185
729 St. Michaels Drive E-mail: carolyn.ingram@state.nm.us
Santa Fe, NM 87504-2348
T: 505/476-8920 Medical Advisory Committee Members
F: 505/827-1147 Linda Sechovec
E-mail: delfinia.sandoval@state.nm.us Executive Director
NM Health Care
New Brand Name Products Contact 6400 Uptown Boulevard, NE, Suite 520-W
Neal Solomon, M.P.H., R.Ph. Albuquerque, NM 87110
505/827-3174

New Mexico-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Yvette Ramirez Ammerman Richard Honsinger, M.S.


Policy Analyst Los Alamos Medical Center
New Mexico Primary Care Association Los Alamos, NM 87544
2309 Renard, S.E., Suite 209
Albuquerque, NM 87106 Maureen Boshier
New Mexico Hospital Association
Chris Isengard 2121 Osuna Road NE
Executive Director Albuquerque, NM 87113
Developmental Disabilities Planning Council
435 St. Michael’s Drive, Bldg. D Joie Glen
Santa Fe, NM 87501 Executive Director
New Mexico Association for Home Care
Michelle Lujan-Grisham 3200 Carlisle N.E., Suite 115
New Mexico State Agency on Aging Albuquerque, NM 87110
228 East Palace Avenue
Santa FE, NM 87501 Bert Umland, M.D.
Division of Family Practice
Sam Cata, Commissioner UNM Medical Center
Office of Indian Affairs Albuquerque, NM 87131
224 E. Palace Avenue 505/277-2165
Santa FE, NM 87501
Executive Officers of State Medical and
Loyola Burgess Pharmaceutical Societies
1801 Dorothy Street, NE
Albuquerque, NM 87112 New Mexico Medical Society
G. R. “Randy” Marshall
Walace Begay, Co-Chairman Executive Director
Pueblo Health Council/All Indian Pueblo Council 7770 Jefferson NE, Suite 400
P.O. Box 56 Albuquerque, NM 87109
New Laguna, NM 87038 T: 505/828-0237
F: 505/828-0336
Rosalyn Curtis E-mail: rmarshal@nmms.org
Director of the Navajo Nation Internet address: nmms.org
Division of Health
P.O. Box 1390 New Mexico Pharmaceutical Association
Window Rock, AZ 86515 R. Dale Tinker
Executive Director
Lila Maples, R.N. 4800 Zuni, S.E.
2769 Villa Venado Albuquerque, NM 87108-2898
Santa Fe, NM 87505 T: 505/265-8729
F: 505/255-8476
Clarice Pick, D.D.S E-mail: daletinker@cs.com
1405 Luisa Street Internet address: www.nm-pharmacy.com
Suite #2
Santa Fe, NM 87505 New Mexico Osteopathic Medical Association
Elizabeth “Betty” Barrett
Richard L. Ragel, D.O. Executive Director
1010 Bridge Boulevard, SW, Suite D P. O. Box 53098
Albuquerque, NM 87105-3734 Albuquerque, NM 87153-3098
T: 505/332-2146
Kathy Minoli, C.F.N.P. F: 505/332-4861
1835 Solano, NE E-mail: admin@nmoma.org
Albuquerque, NM 87110 Internet address: www.nmoma.org

Mary Lou Edward


16 Applewood Lane, N.W.
Albuquerque, NM 87107
505/898-5103

New Mexico-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

State Board of Pharmacy


Jerry Montoya
Chief Inspector/Director
111 Lomas Boulevard, Suite 412
Albuquerque, NM 87102
T: 505/222-9130
F: 505/222-9145
E-mail: joseph.montoya@state.nm.us
Internet address: www.state.nm.us/pharmacy

New Mexico Hospitals and Health Systems


Association
Maureen L. Boshier
President/CEO
2121 Osuna Road, NE
Albuquerque, NM 87113
T: 505/343-0010
F: 505/343-0012
E-mail: mboshier@nmhsa.com
Internet address: www.nmhsa.org

New Mexico-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

New Mexico-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

NEW YORK

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2002** 2003***
Expenditures Recipients Expenditures Recipients

TOTAL $3,660,427,024 $3,949,177,519 2,567,097

RECEIVING CASH ASSISTANCE, TOTAL $2,340,874,399 840,496


Aged $419,244,725 140,438
Blind/Disabled $1,799,235,899 450,143
Child $47,920,289 181,271
Adult $74,473,486 68,544

MEDICALLY NEEDY, TOTAL $1,021,426,022 1,030,106


Aged $265,858,105 113,314
Blind/Disabled $478,087,980 114,547
Child $140,836,085 553,923
Adult $136,643,853 248,322

POVERTY RELATED, TOTAL $552,607,313 635,184


Aged $1,914 28
Blind/Disabled $0 -
Child $68,148,436 289,938
Adult $484,456,964 345,218

TOTAL OTHER EXPENDITURES/ RECIPIENTS* $34,269,785 61,311

* Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
***2003 data provided by the New York State Department of Health, Office of Medicaid Management.
Source: CMS, CMS-64 Report, FY 2002 and New York State Medicaid Statistical Information System, FY 2003.

New York-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Unit Dose: Unit dose packaging not reimbursable.

State Department of Health, Office of Medicaid Formulary/Prior Authorization


Management. Formulary: Open formulary. Utilization managed
through restrictions on use, prior authorization, and
D. PROVISIONS RELATING TO DRUGS quantity limits. General Exclusions: New York
State follows OBRA '90 guidelines in the
Benefit Design reimbursement of prescription drugs.
Drug Benefit Product Coverage: Products covered:
Prior Authorization: State currently has a formal
prescribed insulin; disposable needles and syringe
prior authorization procedure and a Pharmacy and
combinations for insulin; blood glucose test strips;
Therapeutics Committee that meets quarterly.
urine ketone test strips; total parenteral nutrition;
Although there is no formal method for appealing a
and interdialytic parenteral nutrition. Products not
prior authorization decision, the ordering prescriber
covered: cosmetics; fertility drugs; and
may call the voice interactive system until the
experimental drugs.
system issues a prior authorization number. All
requests are approved. Beginning in November
Over-the-Counter Product Coverage: Products
2002, all brand name drugs with A-rated generics
covered with restrictions: allergy, asthma and sinus
require prior authorization.
products; analgesics; cough and cold preparations;
digestive products (non H2 antagonist); feminine
Prescribing or Dispensing Limitations
products; smoking deterrent products (max, 2
courses of treatment/year); and topical products. Prescription Refill Limit: Maximum of 5 refills
Products not covered: digestive products (H2 within 6 months. Also, annual limits on number of
antagonists). prescriptions and prescription and nonprescription
drugs without an override.
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; analgesics, Monthly Dollar Limits: None.
antipyretics, NSAIDs; anticoagulants;
anticonvulsants; antidepressants; antidiabetic Drug Utilization Review
agents; antihistamine drugs; antilipemic agents;
PRODUR system implemented in March 1995.
anti-psychotics; anxiolytics, sedatives, and
State currently has a DUR Board which meets
hypnotics; cardiac drugs; chemotherapy agents;
bimonthly.
contraceptives; ENT anti-inflammatory agents;
estrogens; hypotensive agents; prescribed smoking
deterrents; sympathominetics (adrenergic); and Pharmacy Payment and Patient Cost
thyroid agents. Therapeutic categories partially Sharing
covered: prescribed cold medication and misc. GI Dispensing Fee: $3.50 for brand name drugs, $4.50
drugs. Therapeutic categories requiring prior for generic drugs. Effective 8/1/98.
authorization: antibiotics (zyvox only); second
generation antihistamines; growth hormones; Ingredient Reimbursement Basis: EAC = AWP-
(serostim) medical/surgical supplies; orthopedic 12% (effective 7/1/03)
shoes; compression stockings; and some DME
items. Therapeutic categories not covered: Prescription Charge Formula:
anorectics and agents used for hair growth.
1. Payment for multiple source drugs must not
Coverage of Injectables: Injectable medicines exceed the aggregate of the specified upper
reimbursable through the Prescription Drug limit set by the federal Centers for Medicare
Program when used in home health care facilities and Medicaid Services (CMS), plus a
and through physician payment when used in dispensing fee, for a particular drug; and
physician offices. In extended care facilities 2. Payment for brand name drugs and other
reimbursement for non-self administered injectable multiple source drugs not covered by clause (1)
medicines is included in the facility rate. No special will be the lower of: EAC plus a dispensing
coverage policies exist for self-administered fee; or
injectable medicines.
3. The billing pharmacy's usual and customary
Vaccines: Vaccines are reimbursable under the price charged to the general public.
EPSDT service, CHIP, and the Vaccines for
Children program.

New York-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Maximum Allowable Cost: State imposes Federal − Suffolk Co PHSP


Upper Limits on generic drugs must get prior − Total Care/Syracuse PHSP
authorization for most brand name products. (see − United Healthcare Plan of NY, Inc.
www.health.state.ny.us/nysdoh/medicaid/ − United Healthcare of Upstate
ptcommittee/mandatorggen.htm) − VitaCare, Inc.
− Vytra
Incentive Fee: $1.00 for dispensing a lower cost − Wellcare
multi- source product. − Westchester Prepaid Health Services Plan

Patient Cost Sharing: Copayment is $2.00 for


brand name drugs, $0.50 for generic and OTC F. STATE CONTACTS
drugs. Exceptions include psychotropic drugs as
well as drugs FDA approved for the treatment of State Drug Program Administrator
tuberculosis and family planning drugs. Mark-Richard A. Butt, M.S., R.Ph.
Director, Pharmacy Policy and Operations
Cognitive Services: Does not pay for cognitive Bureau of Program Guidance
services. Office of Medicaid Management
NYS Department of Health
E. USE OF MANAGED CARE 99 Washington Avenue, Suite 606
Albany, NY 12210
Approximately 1.1 million Medicaid recipients T: 518/474-9219
were enrolled in MCOs in FY 2002. Recipients F: 518/473-5508
receive pharmaceutical benefits through the State. E-mail: mrb01@health.state.ny.us
Internet address: www.health.state.ny.us
Health Maintenance Organizations
Pharmacy Advisory Committee
− ABC Health Plan
Kandyce Daley, R.Ph.
− Affinity Health Plan
Patricia Donato, R.Ph.
− AmeriChoice of New York
Steven Giroux, R.Ph.
− Broome MC Thomas Golden, R.Ph.
− Buffalo Community Health John Navarra, R.Ph. (Chairman)
− Care Plus Health Plan Dilip Patel, R.Ph.
− CDPHP Mohammed Saleh, R.Ph.
− Community Choice HP John Westerman, R.Ph.
− Community Premier Plus
− Excellus Formulary Contact
− Fidelis/NYS Catholic Health
Mark-Richard A. Butt, M.S., R.Ph.
− Health Choice
518/474-9219
− HealthFirst PHPS
− Health Plus PHPS Prior Authorization Contact
− HealthNow/BCBS-WNY/Community Blue
− HealthNow/Blue Shield of NENY Mark-Richard A. Butt, M.S., R.Ph.
− HealthSource/Hudson Health Plan 518/474-9219
− HIP
− IHA Pharmacy and Therapeutics Committee
− Manhattan PHSP/CenterCare Roxanne Hall Richardson, R.Ph.
− Metropolitan Plus Health Plan Maria Amodio-Groton, Pharm.D.
− Neighborhood Health Providers Andrew G. Flynn, R.Ph., C.G.P.
− NY Hospital Community PHSP William P. Scheer, R.Ph.
− NYPS Select Health Carl R. Reed, R.Ph., M.B.A.
− NYS Catholic Health Judy K. Shaw, M.S., A.C.R.N., ANP-C
− PCMP Marc A. Johnson, M.D.
− Preferred Care Scott C. Bello, M.D.
− Primary Health Steven E. Barnes, D.O.
Aaron Satloff, M.D.
− Southern Tier
Glenn A. Martin, M.D.
− St. Barnabas/Partners in Health

New York-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

DUR Contact Medicaid Managed Care Contact


Lydia Kosinski, R.Ph. Elizabeth Macfarlane, Director
DUR Manager Bureau of Managed Care Program Planning
Office of Medicaid Management NYS Department of Health
NYS Department of Health Office of Managed Care
99 Washington Avenue, Suite 601 Room 1927, Corning Tower ESP
Albany, NY 12210 Albany, NY 12237-0064
T: 518/474-6866 T: 518/473-0122
F: 518/473-5332 F: 518/474-5886
E-mail: ljk02@health.state.ny.us E-mail: eag01@health.state.ny.us

DUR Committee Disease Management/Patient Education


Programs
Physicians
Richard S. Blum, M.D. Disease/Medical State: AIDS/HIV
Ronald J. Dougherty, M.D. Program Name: Aids Intervention Management
David F. Lehmann, M.D. Program
Jill Braverman-Panza, M.D., R.Ph. Program Sponser: AIDS Institute, NYSDOH

Pharmacists Disease/Medical State: Asthma


Sidney Falow, R.Ph. Program Name: Asthma Quality Improvement
John Gotowko, R.Ph., M.S., M.B.A. Project
Marc L. Speert, R.Ph. Program Sponser: NYSDOH
Frank Barone, R.Ph.
James R. Suhrbier, R.Ph. Disease/Medical State: Diabetes
Program Name: Diabetes Quality Improvement
New Brand Name Products Contact Project
Program Sponser: NYSDOH
Mark-Richard A. Butt, M.S., R.Ph.
518/474-9219
Disease/Medical State: Smoking Cessation
Program Name: Smokers’ Quit Line
Prescription Price Updating Program Sponser: Roswell Park
Carl T. Cioppa, R.Ph.
Manager, Pharmacy Operations Disease Management Program/Initiative
Pharmacy Policy and Operations Contacts
NYS Dept. of Health, Office of Medicaid
Karen A. Fuller, Ph.D.
Management
Director, Bureau of Program Guidance
99 Washington Avenue, Suite 606
NYS Department of Health
Albany, NY 12210
Office of Medicaid Management
T: 518/474-9219
99 Washington Avenue, Suite 606
F: 518/473-5508
Albany, NY 12210
E-mail: ctc02@health.state.ny.us
T: 518/474-9219
F: 518/473-5508
Sally Nelson, R.Ph.
E-mail: kaf01@health.state.ny.us
E-mail: sxn02@health.state.ny.us
Donna Haskin
Medicaid Drug Rebate Contacts E-mail: dlh04@health.state.ny.us
Audit & Policy: Mark-Richard Butt, 518/474-9219
Disputes: Joseph Maiello, 518/474-9219 Denise Spor
PRODUR: Dennis Pidgeon, 518/474-6866 E-mail: des06@health.state.ny.us

Claims Submission Contact Mail Order Pharmacy Program


eMedNY None
Computer Sciences Corporation (CSC)
One CSC Way
Rensselaer, NY 12144
800/343-9000
E-mail: general@emedny.org

New York-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Expanded Drug Program Contact Anita Murray, R.Ph.


Manager, Pharmacy Policy
Julie Naglieri
E-mail: alm04@health.state.ny.us
Acting Director
NYS Department of Health Program
Joseph Maiello, R.Ph.
Elderly Prescription Insurance Coverage (EPIC)
Manager, Pharmacy Rebates
1 Corporate Plaza, Suite 101
518/474-9219
260 Washington Avenue
E-mail: jam22@health.state.ny.us
Albany, NY 12203
T: 518/452-6828
Title XIX Medical Care Advisory Committee
F: 518/452-6882
E-mail: jab15@health.state.ny.us Ruben P. Cowart, D.D.S., (Chairman)
Internet address: John Angerosa, M.D.
www.health.state.ny.us/nysdoh/epic/faq.htm Steven E. Barnes, D.O.
Russel N. Cecil, M.D.
Department of Health Officials David Cerniglia, D.C.
Stoner E. Horey, M.D.
Antonia C. Novello, M.D, M.P.H., Dr. Ph.
Mary K. Lashomb
Commissioner
Norman R. Loomis, M.D.
NYS Department of Health
Hugo M. Morales, M.D., P.C.
Corning Tower
Tanton Mustapha, M.D.
The Governor Nelson A. Rockefeller Empire State
Leon Nadrowski, M.D.
Plaza
Dennis P. Norfleet, M.D.
Albany, NY 12237
Elena Padilla, Ph.D.
T: 518/474-2011
Carl P. Sahler, M.D., Ph.D.
F: 518/474-5450
Robert A. Schwartz, M.D.
E-mail: acn01@health.state.ny.us
Gavin Setzen, M.D.
Kathleen Benson Smith
Kathryn Kuhmerker, Deputy Commissioner
Patricia Stevens, Deputy Commissioner, NYS
Office of Medicaid Management
Office of Temporary and Disability Assistance
NYS Department of Health
(DSS Representative)
Corning Tower
Roger W. Trifthauser, D.D.S., M.S.
The Governor Nelson A. Rockefeller Empire State
Plaza
Executive Officers of State Medical and
Albany, NY 12237
Pharmaceutical Societies
T: 518/474-3018
F: 518/486-6852 Medical Society of the State of New York
E-mail: klk03@health.state.ny.us Charles Aswad, M.D.
Executive Vice President
Karen A. Fuller, Ph.D. 420 Lakeville Road
Assistant Director, Bureau of Program Guidance P.O. Box 5404
Division of Policy and Program Guidance/Office of Lake Success, NY 11042-5404
Medicaid Management T: 516/488-6100
99 Washington Avenue, Suite 606 F: 516-488-6136
Albany, NY 12210 E-mail: mssny@mssny.org
518/474-9219 Internet address: www.mssny.org

Mark-Richard A. Butt, MS, R.Ph. Pharmasists Society of the State of New York
Assistant Director, Pharmacy Policy and Craig Burridge, M.S., CAE
Operations Executive Director
518/474-9219 210 Washington Avenue Extension
E-mail: mrb01@health.state.ny.us Albany, NY 12203
T: 518/869-6595
Carl T. Coppa, R.Ph. F: 518/464-0618
Manager, Pharmacy Operations E-mail: craigb@ppssny.org
518/474-9219 Internet address: www.pssny.org/index_new.htm
E-mail: ctc02@health.state.ny.us

New York-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

New York State Osteopathic Medical Society, Inc.


Martin Diamond, D.O.
Executive Director
1855 Broadway, Suite 1102A
New York, NY 10023
T: 212/261-4137
F: 312/202-1786
E-mail: nysoms@nysoms.org
Internet address: www.nysoms.org

New York State Board of Pharmacy


Lawrence H. Mokhiber
Executive Secretary
89 Washington Avenue, Second Floor W
Albany, NY 12234-1000
T: 518/474-3848
F: 518/473-6995
E-mail: pharmbd@mail.nysed.gov
Internet address: www.nysed.gov/prof/pharm.htm

Healthcare Association of New York State


Daniel Sisto
President
One Empire Drive
Rensselaer, NY 12114
T: 518/431-7800
F: 518/431-7915
E-mail: dsisto@hanys.org
Internet address: www.hanys.org

Greater New York Hospital Association


Subsidiaries and Affiliates
Kenneth E. Raske
President
555 W. 57th Street
15th Floor
New York, NY 10019
T: 212/246-7100
F: 212/262-6350
E-mail: raske@gnyha.org
Internet address: www.gnyha.org

New York-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

NORTH CAROLINA

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $971,066,103 907,413 $1,100,822,176

RECEIVING CASH ASSISTANCE TOTAL $558,673,839 432,859


Aged $154,115,092 65,618
Blind/Disabled $315,225,407 127,822
Child $27,022,573 121,937
Adult $62,310,767 117,482

MEDICALLY NEEDY, TOTAL $64,926,538 28,652


Aged $44,433,190 17,372
Blind/Disabled $16,408,373 6207
Child $614,556 899
Adult $3,470,419 4,174

POVERTY RELATED, TOTAL $327,242,251 402,313


Aged $135,848,480 60,081
Blind/Disabled $128,536,123 50,197
Child $56,963,937
255,320
Adult $5,893,711 36,715

TOTAL OTHER $20,223,475 43,589


EXPENDITURES/RECIPIENTS*

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

North Carolina-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Prior Authorization: Formal prior authorization


process can be found at: ww.ncmedicaidpbm.com.
Division of Medical Assistance, Department of A prescriber’s written justification is required to
Health and Human Services. appeal a prior authorization decision.

Prescribing or Dispensing Limitations


D. PROVISIONS RELATING TO DRUGS
Monthly Quantity Limit: 34-day supply maximum.
Benefit Design Except birth control tablets and hormonal
replacement therapy dial packs: 3 months;
Drug Benefit Product Coverage: Products covered: maintenance non-controlled medications, tied with
select OTC products; total parenteral nutrition; and the FUL and/or SMAC after a prior successful fill
interdialytic parenteral nutrition. Product covered may receive a 3 month supply upon the prescribers
under DME: disposable needles and syringe discretion.
combinations used for insulin; blood glucose test
strip; and urine ketone test strips. Products not Monthly Prescription Limit: Six prescriptions per
covered: cosmetics; fertility drugs; OTC drugs not month per recipient.
listed on the selected coverage list; and those
products mentioned below under “Therapeutic Prescription Dollar Limits: None.
Category Coverage” section.
Drug Utilization Review
Over-the-Counter Product Coverage: North
Carolina covers a select list of OTC products. (see PRODUR system implemented in May 1996. State
www.dhhs.state.nc.us/dma/mp/mpindex.htm) currently has a DUR Board with a quarterly review.

Therapeutic Category Coverage: North Carolina Pharmacy Payment and Patient Cost
provides coverage for all therapeutic categories Sharing
except products used for cosmetic purposes; Dispensing Fee: B: $4.00; G: $5.60, effective 2002.
fertility drugs; diaphragms; IV fluids(Dextrose
500ml or greater) and irrigations fluids used in an Ingredient Reimbursement Basis: EAC = AWP-
inpatient facility; Drugs on DESI list; any drug 10%.
manufactured by a company who has not signed the
federal rebate agreement; and experimental drugs. Prescription Charge Formula: The lowest price of
Prior authorization required for: Drugs used to AWP minus 10%, State MAC or Federal MAC plus
treat ADHD; Procrit/Epogen; Neupogen; Aransep; a dispensing fee or usual and customary, whichever
OxyContin; Growth Hormones;Provigil; Rebetron; is lowest. The pharmacist filling the original
Vioxx; Celebrex; Bextra; Enbrel; Botox; Mybloc; prescription will not be reimbursed for refills for
Zyban, Nicotrol, Nicotine Patch; Synagis; and the same drug within a calendar month.
RespiGam. (see www.ncmedicaidpbm.com for
additional information.)
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific maximum
Coverage of Injectables: Injectable medicines allowable cost (MAC) limits generic drugs. 367
reimbursable through the Prescription Drug drugs are listed on the State-specific MAC list.
Program when used in home health care and Override requires “Brand Medically Necessary”
extended care facility, and through both the written on the face of the prescription by the
Prescription Drug Program and physician payment prescriber.
when used in physician offices.
Incentive Fee: None.
Vaccines: Vaccines reimbursable as part of the
ESPDT service and The Vaccines for Children
Patient Cost Sharing: $1.00 copayment/Rx
Program.
(includes refills) for generic prescriptions; $3.00
copayment/Rx for brand name prescriptions.
Unit Dose: Unit dose packaging not reimbursable.
Cognitive Services: Does not pay for cognitive
Formulary/Prior Authorization services.
Formulary: Open formulary.

North Carolina-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

E. USE OF MANAGED CARE Prescription Price Updating


Sharon Greeson, R.Ph.
Approximately 30,000 Medicaid recipients were Pharmacy Program Manager
enrolled in MCOs in FY 2002. Recipients receive EDS
pharmaceutical benefits through the State. 4905 Waters Edge Drive
Raleigh, NC 27606
Managed Care Organizations T: 919/816-4475
SouthCare/Coventry F: 919/816-4399
2815 Coliseum Center Drive E-mail: sharon.greeson@eds.com
Charlotte, NC 28217
Medicaid Drug Rebate Contact

F. STATE CONTACTS Audits: Sharman C. Leinwand, R.Ph., M.P.H.


919/857-4034
State Drug Program Administrator
Rebate Disputes: Sharon Greeson, R.Ph.
Sharman C. Leinwand, R.Ph., M.P.H. 919/816-4475
Pharmacy Program Manager
Division of Medical Assistance Claims Submission Contact
Department of Health and Human Services
1985 Umstead Drive Sharon Greeson, R.Ph.
2501 Mail Service Center 919/816-4475
Raleigh, NC 27699-2501
T: 919/857-4034 Medicaid Managed Care Contact
F: 919/715-1255 Jeffrey Simms
E-mail: sharman.leinwand@ncmail.net 919/857-4267
Internet address: www.dhhs.state.nc.us/dma
Mail Order Pharmacy Program
Prior Authorization Contact
None
Sharman C. Leinwand, R.Ph., M.P.H.
919/857-4034 Disease Management Program/Initiative
Contact
DUR Contact
Sharman C. Leinwand, R.Ph., M.P.H.
Sharman C. Leinwand, R.Ph., M.P.H. 919/857-4034
919/857-4034
Department of Human Resources Officials
Medicaid Drug Utilization Review Board
Gary Fuquay, Director
Physicians: Department of Health and Human Services
Patricia Burns, M.D. Division of Medical Assistance
Edward Treadwell, M.D. 1985 Umstead Drive
LaVie Ellison, M.D. 2501 Mail Service Center
David Gremillion, M.D. Raleigh, NC 27699-2501
Steve Wegner, M.D. T: 919/857-4011
F: 919/733-6608
Pharmacists: E-mail: gary.fuquay@ncmail.net
Joseph S. Moose, R.Ph., Pharm. D.
Dale Christensen, Ph.D. Carmen Hooker Odom
Wayne Creech, R. Ph. Secretary
Martha Jones, Pharm. D. Department of Health and Human Services
2001 Mail Service Center
New Brand Name Products Contact 101 Blair Drive
Sharman C. Leinwand, R.Ph., M.P.H. Raleigh, NC 27699-2001
919/857-4034 T: 919/733-4534
F: 919/715-4645

North Carolina-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Office of Research Demonstration and


Rural Health Development
Torlen Wade
311 Ashe Avenue
Raleigh, NC 27606
919/857-4267

Executive Officers of State Medical and


Pharmaceutical Societies
North Carolina Medical Society
Bob Seligson, M.B.A., CAE
Executive Vice President & CEO
P.O. Box 27167
Raleigh, NC 27611-7167
T: 919/833-3836
F: 919/833-2023
E-mail: rseligson@ncmedsoc.org
Internet address: www.ncmedsoc.org

North Carolina Association of Pharmacists


Fred Eckel
Executive Director
109 Church Street
Chapel Hill, NC 27516-2505
T: 919/967-2237
F: 919/968-9430
E-mail: fred@ncpharmacists.org
Internet address: www.ncpharmacists.org

North Carolina Osteopathic Medical Association


Jeffrey J. LeBoeuf
Executive Director
8311 Brier Creek Parkway
Raleigh, NC 27617
T: 888/626-6248
F: 910/763-4666
E-mail: jeffrey@ncoma.org
Internet address: www.ncoma.org

State Board of Pharmacy


David R. Work
Executive Director
P.O. Box 4560
Chapel Hill, NC 27515-4560
T: 919/942-4454
F: 919/967-5757
E-mail: drw@ncbop.org
Internet address: www.ncbop.org

North Carolina Hospital Association


William A. Pulley
President
P.O. Box 4449
Cary, NC 27519-4449
T: 919/677-2400
F: 919/677-4200
E-mail: wpully@ncha.org
Internet address: www.ncha.org

North Carolina-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

NORTH DAKOTA

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $43,288,363 39,758 $52,495,878

RECEIVING CASH ASSISTANCE, TOTAL $20,469,921 18,113


Aged $4,465,220 1,978
Blind/Disabled $12,892,102 5,031
Child $1,238,624 7,216
Adult $1,873,975 3,888

MEDICALLY NEEDY, TOTAL $19,371,705 10,427


Aged $12,570,047 5,815
Blind/Disabled $6,083,620 2,136
AFDC-Child $318,364 1,577
AFDC-Adult $399,674 899

POVERTY RELATED, TOTAL $586,363 3,898


Aged $5,838 21
Blind/Disabled $7,750 25
AFDC-Child $481,791 3,324
AFDC-Adult $90,984 528

TOTAL OTHER EXPENDITURES/RECIPIENTS* $2,860,374 7,320

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

North Dakota-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Prior Authorization: State currently has a formal


prior authorization procedure. Beneficiary can
North Dakota Department of Human Services. request a fair hearing to appeal a prior authorization
decision.

D. PROVISIONS RELATING TO DRUGS Prescribing or Dispensing Limitations

Benefit Design Prescription Refill Limit: A prescription drug may


be refilled for 12 months after the date of the
Drug Benefit Product Coverage: Products covered: original prescription, provided that such refills have
prescribed insulin; disposable needles and syringe been authorized by the physician. Limits on the
combinations used for insulin; blood glucose test number of refills by class (e.g., 0 for C-IIs; 5 for C-
strips; and total parenteral nutrition. Products not IIIs, IVs, and Vs).
covered: cosmetics; fertility drugs; urine ketone test
strips; interdialytic parenteral nutrition; drugs used Monthly Quantity Limit: 34-day supply.
for hair growth; prescription vitamins (except
prenatal vitamins); and DESI drugs. Prior Monthly Dollar Limits: None.
authorization required for: nutritional supplements;
and orlistat. Drug Utilization Review
Over-the-Counter Product Coverage: Products PRODUR system implemented in July 1996. State
covered: antacids; analgesics; iron supplements; has a DUR Board that meets quarterly.
artificial tears; digestive products; and anti-ulcer
medications. Products covered with restriction: Pharmacy Payment and Patient Cost
allergy, asthma, and sinus products; smoking Sharing
deterrent products (lifetime limits). Products not Dispensing Fee: $5.60 for generic, $4.60 for brand
covered: cough and cold preparations; feminine effective 8/1/03.
products; and topical products.
Ingredient Reimbursement Basis: EAC = AWP-
Therapeutic Category Coverage: Categories 10%.
covered: anabolic steroids; antibiotics;
anticoagulants; anticouvulsants; anti-depressants; Prescription Charge Formula: Acquisition Cost
antidiabetic agents; antilipemic agents; anti- plus a dispensing fee per prescription or the usual
psychotics; anxiolytics, sedatives, and hypnotics; and customary retail charge, whichever is lower.
cardiac drugs; chemotherapy agents; Acquisition Cost = EAC or MAC.
contraceptives; ENT anti-inflammatory agents;
estrogens; growth hormones; hypotensive agents,
Maximum Allowable Cost: State imposes Federal
sympathominetics (adrenergic); thyroid agents; and
Upper Limits as well as State-specific limits on
prescribed smoking deterrents. Prior authorization
generic drugs. Override requires “Dispense As
required for: brand name NSAIDs, anoretics
Written.”
(orlistat); antihistamines; and PPIs. Categories not
covered: prescribed cold medications.
Incentive Fee: None.
Coverage of Injectables: Injectable medicines
Patient Cost Sharing: $3.00 (brand-name drugs)
reimbursable through both the Prescription Drug
Program and physician payment when used in
Cognitive Services: Does not pay for cognitive
physician offices, home health care, and extended
services
care facilities.

Vaccines: Vaccines reimbursable as part of the E. USE OF MANAGED CARE


EPSDT service.
Approximately 600 Medicaid recipients were
Unit Dose: Unit dose packaging not reimbursable. enrolled in managed care organizations in 2002.
Recipients enrolled in MCO’s receive pharmacy
Formulary/Prior Authorization benefits through the State.
Formulary: Open formulary

North Dakota-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

F. STATE CONTACTS Robert Thompson, MD


Term Expires: 06/30/2005
State Drug Program Administrator
John Windsor, DO
Brendan K. Joyce, Pharm.D., R.Ph. Term Expires: 06/30/2004
Administrator, Pharmacy Services Ex-Officio Members
Department of Human Services Gary Betting, M.D.
600 East Boulevard Avenue, Dept. 325 Medical Consultant, DHS
Bismarck, ND 58505-0250
T: 701/328-1544 Brendan K. Joyce, Pharm.D., R.Ph.
F: 701/328-1544 Medical Services, DHS
E-mail: sojoyb@state.nd.us
Mary Koenecke, RPH
Prior Authorization Contact PHRMA
Brendan K. Joyce, Pharm.D., R.Ph. Term Expires: 06/30/2004
701/328-1544
New Brand Name Products Contact
DUR Contact Brendan K. Joyce, Pharm.D., R.Ph.
Brendan K. Joyce, Pharm.D., R.Ph. 701/328-1544
701/328-1544
Prescription Price Updating

DUR Board Brendan K. Joyce, Pharm.D., R.Ph.


701/328-1544
Mark Biel, RPh
Term Expires: 06/30/2005 Medicaid Drug Rebate Contact
Patricia Churchill, RPh Brendan K. Joyce, Pharm.D., R.Ph.
Term Expires: 06/30/2004 701/328-1544

Leann Ness, PharmD Claims Submission Contact


Term Expires: 06/30/2004 Brendan K. Joyce, Pharm.D., R.Ph.
701/328-1544
Greg Pfister, PharmD
Term Expires: 06/30/2006
Medicaid Managed Care Contact
John Savageau, RPh Tom Solberg, Administrator
Term Expires: 06/30/2006 Managed Care
ND Department of Human Services
Robert Treitline, RPh 600 East Boulevard Avenue, Dept. 325
Term Expires: 06/30/2005 Bismark, ND 58505-0250
T: 701/328-1884
Kamille Sherman, MD F: 701/328-1544
Term Expires: 06/30/2005 E-mail: sosolt@state.nd.us

Ronald Burd, MD Disease Management Program/Initiative


Term Expires: 06/30/2006 Contact
Brendan K. Joyce, Pharm.D., R.Ph.
Norman Byers, MD
701/328-41544
Term Expires: 06/30/2006

Albert Samuelson, MD
Term Expires: 06/30/2004

North Dakota-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Commission on Socio-Economic Affairs


Mail Order Pharmacy Benefit Program
Robert F. Szczys, M.D., Chairman
State currently has a mail order pharmacy program Grand Forks Clinic Ltd.
capability in which all Medicaid recipients are Grand Forks, ND 58206
entitled to participate. However, the mail order
pharmacy must be a North Dakota Medicaid Russel J. Kuzel, M.D., Vice Chairman
provider. Dakota Clinic Ltd.
Fargo, ND 58103
Department of Human Services Officials
Bipin B. Amin, M.D.
Carol K. Olson Mid Dakota Clinic
Executive Director Bismarck, ND 58502
ND Dept. of Human Services
600 E. Boulevard Avenue, Dept. 325 William W. Barnes, M.D.
Bismarck, ND 58505-0250 307 5th Avenue, SE
T: 701/328-2538 Minot, ND 58701
F: 701/328-2359
E-mail: dhseo@state.nd.us Norman E. Bystol, M.D.
Dakota Clinic Ltd.
Dave Zentner Fargo, ND 58108
Medicaid Director
600 E. Boulevard Avenue, Dept. 325 James R. Carpenter, M.D.
Bismarck, ND 58505-0261 Meritcare Medical Group
T: 701/328-2321 Fargo, ND 58123
F: 701/328-1544
E-mail: sozend@state.nd.us Stanley T. Diede, M.D.
Heart and Lung Clinic
Department of Human Services Advisory Bismarck, ND 58502
Committees
Medical Care Advisory Committee Harold W. Evans, M.D.
Terry Dwelle, M.D. Grand Forks Clinic Ltd.
State Health Officer Grand Forks, ND 58206
State Health Department
Gregory A. Gapp, M.D.
Lynn Blakeman Grand Forks Clinic Ltd.
St. Vincent’s Care Center Grand Forks, ND 58206

Alison Fallgater, D.D.S. Stephen H. Goldberger, M.D.


Grand Forks Clinic Ltd.
Amy Fleck, O.D. Grand Forks, ND 58206

Howard Anderson, R.Ph. Genevieve M. Goven, M.D.


Meritcare Clinic Valley City
Terry Johnson, MD Valley City, ND 58072

David Peske Mark B. Hart, M.D.


ND Medical Association The Bone and Joint Center
Bismack, ND 58504
Gary Betting, M.D.
DHS-Medical Consultant George H. Hilts, M.D.
Dakota Eye Institute
2 Medicaid Recipients Bismarck, ND 58504

Mark O. Jensen, M.D.


300 Main Avenue
Fargo, ND 58103

North Dakota-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Donald R. Lamb, M.D. DuWayne Schlittenhard, R.Ph.


100 4th Street, S., Suite 504 3408 Par Street
Fargo, ND 58103 Fargo, ND 58102

Gregory J. Post, M.D. Mary Beth Reinke, R.Ph.


Meritcare Medical Group 3530 SW 28 #301
Fargo, ND 58123 Fargo, ND 58104

David A. Rinn, M.D. Cindy Yeager, R.Ph.


Towner County Medcenter Box 9512
Cando, ND 58324 Fargo, ND 58108

Pierre A. Rioux, M.D. Executive Officers of State Medical and


307 5th Avenue, SE, Suite 300 Pharmaceutical Societies
Minot, ND 58701
Thomas R. Templeton, M.D. North Dakota Medical Association
Great Plains Clinic Bruce Levi
Dickinson, ND Executive Vice President
204 W. Thayer Avenue
Brian C. Willoughby, M.D. P.O. Box 1198
West River Health Clinics Bismarck, ND 58502-1198
Hettinger, ND 58639 T: 701/223-9475
F: 701/223-9476
Councilors Assigned E-mail: blevi@ndmed.com
David H. Lane, M.D. Internet address: www.ndmed.com
Anesthesia Associates Ltd.
Grand Forks, ND 58208 North Dakota State Osteopathic Association
Carmen Christianson Bell
Larry E. Johnson, M.D. President Director
Dakota Clinic Ltd. 1600 2nd Avenue, SW, Suite 20
Minot, ND 58701
P. O. Box 1980
701/852-8798
Jamestown, ND 58402
Internet address: www.ndoma.org
Pharmacy Advisory Committee
North Dakota Pharmaceutical Association
Robert L. Treitline, Chair Wade B. Bilden
941 9th Avenue West Executive Vice President
Dickinson, ND 58601 1906 E. Broadway
Bismarck, ND 58501-4700
Anton P. Welder, R.Ph. T: 701/258-4968
P.O. Box 835 F: 701/258-9312
Bismarck, ND 58502 E-mail: ndpha@nodakpharmacy.com
Internet address: www.nodakpharmacy.com
Doreen M. Beiswanger, R.Ph
1140 SE 6 Street, Unit 10 State Board of Pharmacy
Valley City, ND 58072 Howard C. Anderson
Executive Director
David L. Just, R.Ph. P. O. Box 1354
P.O. Box 99 Bismarck, ND 5807-7340
Beulah, ND 58523 T: 701/328-9535
F: 701/224-9529
David J. Olig, R.Ph. E-mail: ndboph@btinet.net
2400 32nd Avenue South
Fargo, ND 58103

North Dakota-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

North Dakota Hospital Association


Arnold R. Thomas, President
3205 E. Thayer Avenue
Bismarck, ND 58501
701/224-9732
E-mail: athomas@ndha.org

North Dakota-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

OHIO

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 ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients
TOTAL $1,087,552,923 904,380 $1,333,992,298

RECEIVING CASH ASSISTANCE, TOTAL $540,895,726 292,077


Aged $84,684,721 32,916
Blind/Disabled $430,791,473 161,509
Child $11,864,467 66,278
Adult $13,555,065 31,374

MEDICALLY NEEDY, TOTAL $0 -


Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $35,401,852 148,249


Aged $2,188,262 1,883
Blind/Disabled $5,157,289 2,989
Child $24,761,193 122,129
Adult $3,295,108 21,248

TOTAL OTHER EXPENDITURES/RECIPIENTS* $511,255,345 464,054

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Ohio-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Approved Drug List (ADL)/Prior


Authorization
Ohio Department of Job and Family Services, Bureau ADL: Closed ADL with approximately 28,000 NDC-
of Health Plan Policy. specific trade and generic drugs. Products excluded
include obesity, fertility, and experimental drugs.
D. PROVISIONS RELATING TO DRUGS ADL managed by excluding products based on
contracting issues, restrictions on use, and prior
Benefit Design authorization.
Drug Benefit Product Coverage: Products covered: Prior Authorization: State currently has a formal
most drugs including prescribed insulin; total prior authorization procedure. Prior authorization is
parenteral nutrition products; and interdialytic needed for certain individual drugs (see examples
parenteral nutrition products. Products not covered: above) A beneficiary may appeal a prior
cosmetics; fertility drugs; obesity drugs; experimental authorization decision and be granted an
drugs. Prior authorization required for some drugs administrative hearing.
including these examples: Ceredase; Cerebyx;
Cerezyme; Clorazepates; Depo-Provera; Enbrel; Prescribing or Dispensing Limitations
immunoglobulins; Lioresal Intrathecal; Lodosyn;
Nascoral; Orgaran; Oxandrin Panretin; Periostat; State does not impose prescribing or dispensing
Priftin; Prolastin; Proleukin; Provigil; Psoralens; limits on prescriptions.
Remicade; Rituxan; Stimate; Synagis; and Targretin. Drug Utilization Review
Products covered under DME: disposable needles
and syringe combinations used for insulin; blood PRODUR system implemented through POS in Feb
glucose test strips; and urine ketone test strips. 2000. State currently has a DUR Board with quarterly
review.
OTC Coverage: Selected coverage for: allergy,
asthma, and sinus products; analgesics; feminine Pharmacy Payment and Patient Cost Sharing
products; smoking deterrent products; cough and cold Dispensing Fee: $3.70, effective 7/1/98. ($0.50 fee
preparations; digestive products; topical products; for flu vaccine.)
laxatives; antacids; and vitamins and minerals.
Ingredient Reimbursement Basis: EAC = WAC + 9%
Therapeutic Category Coverage: Therapeutic (eff. 5/1/02).
categories covered: analgesics, antipyretics, and
NSAIDS; anticoagulants; anticonvulsants; anti- Prescription Reimbursement Formula:
depressants; anti-psychotics; anxiolytics, sedatives Reimbursement for legend drugs and selected OTC
and hypnotics; chemotherapy agents; contraceptives; products based on the lowest of:
estrogens; and thyroid agents. Prior authorization
required for: antibiotics; antidiabetic agents; 1. Provider’s submitted charge, which should
antihistamines; antilipemic agents; cardiac drugs; reflect usual and customary charge to the general
prescribed cold medications; ENT-anti-inflammatory public;
agents; hypotensive agents; misc. GI drugs; 2. WAC + 9% plus a dispensing fee.
prescribed smoking deterrents; and sympathominetics
(adrenergic). Therapeutic categories not covered: 3. Federal- or state-established Maximum
anbolic steroids; anorectics; growth hormones; Allowable Cost (MAC), for specifically
innovator multi-source drugs; selected high-risk designated generically equivalent drugs plus a
drugs (e.g., Accutane); and drugs used in special dispensing fee.
settings (e.g., outpatient hospital). Non-legend drugs - reimbursement is based on WAC
+ 9% plus a dispensing fee, or MAC if applicable.
Coverage of Injectables: Injectable medicines Special reimbursement for Blood Factors 8 and 9.
reimbursable through the Prescription Drug Program
when used in home health care and extended care Maximum Allowable Cost: State imposes Federal
facilities, and through physician payment when used Upper Limits as well as State-specific limits on
in physicians offices. generic drugs. Override requires prior authorization.

Vaccines: Vaccines reimbursable as part of the Incentive Fee: None.


Vaccines for Children Program.
Patient Cost Sharing: No copayment.
Unit Dose: Unit dose packaging not reimbursable. Cognitive Services: Does not pay for cognitive
services.

Ohio-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

E. USE OF MANAGED CARE Prior Authorization Contacts


Drugs: Robert P. Reid, R.Ph.
Approximately 400,000 Medicaid recipients were 614/466-6420
enrolled in managed care in 2002. All received
pharmacy services through managed care plans. DME/Nutritions: Bonnie Brownlee
614/466-6065
Managed Care Organizations
Buckeye Community health Plan DUR Contact
175 South Third Street Jan Lawson
Suite 520 DUR Administrator
Columbus, OH 43215 255 East Main Street
866/246-4356 Columbus, OH 43215
T: 614/466-9698
Dayton Area Health Plan F: 614/-466-2866
One South Main Street
One Dayton Center DUR Board
Dayton, OH 45402
937/224-3300 Thomas E. Gretter, M.D.
Timothy Garner, M.D.
PrimeTime Medical Insurance Company Jacob F. Palomaki, M.D.
P.O. Box 6907 Beth T. Tranen, D.O.
Canton, OH 44706 Rob Kubasak, R.Ph.
330/451-0934 Sue Eastman, R.Ph.
Jill Orn, R.Ph.
Paramount Care, Inc. Donald Sullivan, Ph.D., R.Ph.
P.O. Box 928
Toledo, OH 43697-0928 Prescription Price Updating
419/887-2550
First DataBank
1111 Bayhill Drive, Suite 350
QualChoice Health Plan
San Bruno, CA 94066
6000 Parkland Boulevard
T: 650/588-5454
Cleveland, OH 44124
F: 650/827-4578
440/460-0093
Medicaid Drug Rebate Contacts
SummaCare
P.O. Box 3620 Robert P. Reid, R.Ph.
Akron, OH 44309 614/466-6420
330/996-8410
Claims Submission Contact
F. STATE CONTACT First Health Services Corp.
4300 Cox Road
State Program Drug Administrator Glen Allen, VA 23060
T: 800/884-2822
Robert P. Reid, R.Ph. F: 800/884-7696
Administrator, Pharmacy Services Unit
Ohio Department of Job and Family Services
Medicaid Managed Care Contact
Bureau of Health Plan Policy
30 East Broad Street, 27th Floor Cynthia Burnell, Chief
Columbus, OH 43215-3414 Bureau of Managed Health Care
T: 614/466-6420 Ohio Department of Job and Family Services
F: 614/466-2908 255 E. Main Street
E-mail: reidr@odjfs.state.oh.us Columbus, OH 43215
614/466-4693
New Brand Name Products Contact
Mail Order Pharmacy Benefit
Robert P. Reid, R.Ph.
614/466-6420 State has mail order providers.

Ohio-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Pharmacy and Therapeutics Committee Robyn Colby, Chief


Bureau of Health Plan Policy
Robert P. Reid, R.Ph., Chairman
614/466-6420
Bureau of Health Plan Policy
30 East Broad Street, 27th Floor
Sheila Fujii, Chief
Columbus, OH 43266-0423
Bureau of Medical Assistance
255 E. Main Street
Suzanne Eastman, R.Ph., M.S.
Columbus, OH 43215
3922 North Cliff Lane
614/466-2365
Cincinnati, OH 43220
Medical Care Advisory Committee
Michael Alexander, D.O.
3219 Sullivant Avenue Jerry Friedman, Chair
Columbus, OH 43204 Cindy Norwood
Ed Lentz
Ruth E. Purdy, D.O. Hubert Wirtz
4830 Slate Run Court Robert Logan
Columbus, OH 43220 Eugene King, J.D.
Pamela Morris
Susan Baker, APN Frank Giganti
2288 Kings Corners East Walter Clark, M.D.
Lexington, OH 44904 Eileen Cooper Reed
Robert Staib
Mary Jo Welker, M.D. Jack Cera
2231 North High Street Art Schlesinger
Columbus, OH 43201 Randall Garland
William Sawyer, M.D.
Jennifer Christner, M.D. Virginia Haller, M.D.
2262 Parkwood Maureen Mitchell, R.N., Ed.D.
Toledo, OH 43620 Richard Tuck, M.D.
Christopher Moore
Sandra Hrometz, R.Ph, Ph.D. Nancy Lee
740 E. College Avenue Kathleen Anderson
Bluffton, OH 43209 Katherine Kuck
Donna Skoda, M.S., R.D., L.D.
Tammie J. Stroup, R.Ph. T. Clifford Deveny, M.D.
30 E. Broad Street, 27th Floor Randy Runyon
Columbus, OH 43215-3414 Brian Tilow

Department of Job and Family Services Executive Officers of State Medical and
Officials Pharmaceutical Societies
Thomas Hayes, Director Ohio State Medical Association
Ohio Department of Job and Family Services Brent Mulgrew
30 East Broad Street, 32nd Floor Executive Director
Columbus, OH 43215-3414 3401 Mill Run Drive
T: 614/466-6282 Hilliard, OH 43026
F: 614/466-2815 T: 800/766-6762
E-mail: hayest@odjfs.state.oh.us F: 614/527-6763
E-mail: brentm@osma.org
Barbara C. Edwards, Deputy Director Internet address: www.osma.org
Ohio Health Plans
Ohio Department of Job and Family Services
30 East Broad Street, 31st Floor
Columbus, OH 43215-3414
T: 614/466-0140
F: 614/752-3986
E-mail: Medicaid@odhs.state.oh.us

Ohio-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Ohio Pharmacists Association


Ernest “Ernie” Boyd
Executive Director
6037 Frantz Road, Suite 106
Dublin, OH 43017
T: 614/798-0037
F: 614/798-0978
E-mail: eboyd@ohiopharmacists.org
Internet address: www.ohiopharmacists.org

Osteopathic Association
Jon F. Wills
Executive Director
53 W. 3rd Avenue
P.O. Box 8130
Columbus, OH 43201
T: 614/299-2107
F: 614/294-0457
E-mail: execdir@ooanet.org
Internet address: www.ooanet.org

State Board of Pharmacy


William T. Winsley
Executive Director
77 S. High Street, Room 1702
Columbus, OH 43215-6126
T: 614/466-4143
F: 614/752-4836
E-mail: exec@bop.state.oh.us
Interent address: www.state.oh.us/pharmacy/

Ohio Hospital Association


James Castle, CEO
155 E. Broad Street, 15th Floor
Columbus, OH 43215-3620
T: 614/221-7614
F: 614/221-4771
E-mail: oha@ohanet.org
Internet address: www.ohanet.org

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Ohio-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

OKLAHOMA 1

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients
TOTAL $215,717,760 249,678 $285,068,869

RECEIVING CASH ASSISTANCE, TOTAL $71,737,280 62,218


Aged $21,886,460 21,329
Blind/Disabled $48,377,145 35,113
Child $903,823 4,161
Adult $569,852 1,615

MEDICALLY NEEDY, TOTAL $296,233 562


Aged $13,911 31
Blind/Disabled $149,640 137
Child $61,257 210
Adult $71,425 184

POVERTY RELATED, TOTAL $26,864,537 129,023


Aged $85,695 170
Blind/Disabled $134,217 149
Child $24,942,717 114,054
Adult $1,701,908 14,650

TOTAL OTHER EXPENDITURES/RECIPIENTS* $116,819,710 57,875

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

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 2003

C. ADMINISTRATION Formulary/Prior Authorization


Oklahoma Health Care Authority. Formulary: Open formulary with the preferred drug
list (PDL). PDL managed through restrictions on
use, prior authorization, therapeutic substitution, use
D. PROVISIONS RELATING TO DRUGS of preferred products, and step therapy.

Benefit Design Prior Authorization: State currently has a formal


Drug Benefit Product Coverage: Products covered: prior authorization procedure and DUR Board.
prescribed insulin. Products covered (DME benefit): Agency grievance process exists for appeal of prior
disposable needles and syringe combinations for authorization decisions or coverage of an excluded
insulin; blood glucose test strips; and urine ketone product.
test strips. Products covered with restrictions: total
parenteral nutrition (reimburse single most costly Prescription or Dispensing Limitations
ingredient, not reimbursed through pharmacy Prescription Refills: None
program). Products not covered: cosmetics; fertility
drugs; and experimental drugs. Monthly Quantity Limits: Three prescriptions per
month/recipient. ICF-MR, Medicaid children, and
Over-the-Counter Product Coverage: Products nursing home recipients are allowed unlimited orders.
covered: birth control products. Products covered Clients on Home and Community Based Waivers
with restrictions: allergy, asthma, and sinus products and DDSD Waivers are also allowed an unlimited
(Claritin OTC only for children < 21 years. PA number of prescriptions each month.
required for adults. Rx required for all ages.);
digestive products (non-H2 antagonists-Prilosec OTC Quantity Limit per Prescription: 34-day supply or
only, Rx required); smoking deterrent products (PA 100 units.
and Rx required). Products not covered: analgesics;
cough and cold preparations; H2 antagonists; Drug Utilization Review
feminine products; topical products.
PRODUR system implemented in 2000. State
Therapeutic Category Coverage: Therapeutic currently has a DUR Board with a monthly review.
categories covered: antibiotics; anticoagulants;
anticonvulsants; antidepressants; antidiabetic agents; Pharmacy Payment and Patient Cost Sharing
antilipemic agents; anti-psychotics; chemotherapy Dispensing Fee: $4.15, effective 10/95.
agents; contraceptives; ENT anti-inflammatory
agents; estrogens; sympathominetics (adrenergic); Ingredient Reimbursement Basis: EAC = AWP –
and thyroid agents. Prior authorization required for: 12.0%.
anoretics (partial coverage); analgesics, antipyretics,
NSAIDs; antihistamine drugs (partial coverage); Prescription Charge Formula: Estimated Acquisition
anxiolytics, sedatives, and hypnotics; cardiac drugs; Cost (EAC) plus dispensing fee, or usual and
growth hormones; hypotensive agents; misc. GI customary charge, whichever is lower. In no event
drugs; prescribed smoking deterrents (partial shall charges to the Welfare Department exceed
coverage) stimulants for ADHD; clopidigrel; and charges made to the general public for the same
montelukast. Therapeutic categories not covered: prescription or item.
anabolic steroids; and prescribed cold medications.
OBRA ’90 drugs identified as "coverage optional." Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
Coverage of Injectables: Injectable medicines generic drugs. Override requires “Brand Medically
reimbursable through both the Prescription Drug Necessary.” Currently, 414 drugs on MAC list.
Program and physician payment when used in home
health care and extended care facilities, and through Incentive Fee: None.
physician payment when used in physician offices.
Patient Cost Sharing: Copayment is $1.00 for
Vaccines: Vaccines reimbursable as part of EPSDT prescriptions up to $29.99, $2.00 for prescriptions
services and the Vaccines for Children Program. over $30.00.
Unit Dose: Unit dose packaging not reimbursable. Cognitive Services: Does not pay for cognitive
services.

Oklahoma-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

E. USE OF MANAGED CARE Medicaid Drug Rebate Contacts


Tom P. Simonson
Approximately 185,000 Medicaid recipients were Drug Rebate Manager
enrolled in MCOs in FY 2002. Recipients receive Oklahoma Healthcare Authority
benefits through both the State and managed care 4545 N. Lincoln, Suite 124
plans. Effective 1/1/2004, there will be no fully Oklahoma City, OK 73105-9901
capitated managed care plans in Oklahoma. The T: 405/522-7327
Primary Care/Care Management System will remain F: 405/530-3236
in place. E-mail: simonsoT@ohca.state.ok.us

F. STATE CONTACTS New Brand Name Products Contact


Rodney Ramsey
State Drug Program Administrator Pharmacy Claims Specialist
Nancy Nesser, D.Ph., J.D. Oklahoma Health Care Authority
Pharmacy Director 4545 N. Lincoln, Suite 124
Oklahoma Health Care Authority Oklahoma City, OK 73105
4545 N. Lincoln, Suite 124 T: 405/522-7492
Oklahoma City, OK 73105-9901 F: 405/530-3238
T: 405/522-7325 E-mail: ramseyr@ohca.state.ok.us
F: 405/522-3240
E-mail: nessern@ohca.state.ok.us Claims Submission Contact
Internet address: www.ohca.state.ok.us EDS
2401 N.W. 23rd Street, Suite 11
Prior Authorization Contact Oklahoma City, OK 73107
Ronald Graham, D.Ph. 405/416-6794
Manager, Operations/DUR
University of Oklahoma, College of Pharmacy Medicare Managed Care Contact
P.O. Box 26901 Melinda Jones
Oklahoma City, OK 73109 Senior Compliance Analyst
T: 405/271-6614 Oklahoma Health Care Authority
F: 405/271-2615 4545 N. Lincoln, Suite 124
E-mail: ronald-graham@ouhsc.edu Oklahoma City, OK 73105-9901
T: 405/522-7125
DUR Contact F: 405/530-3281
Ronald Graham, D.Ph. E-mail: jonesm@ohca.state.ok.us
405/271-6614
Mail Order Pharmacy Program
Medicaid DUR Board Oklahoma does not sponsor a mail order pharmacy
Rick Crensaw, D.O. benefit. However, mail order pharmacies are allowed
Dick Robinson, R.Ph. (Vice-Chair) to contract with the Oklahoma Medicaid program to
Dorothy Gourley, D.Ph. provide prescription products to Oklahoma Medicaid
Cliff Meece, D.Ph. beneficiaries. Pharmacy must be a contracted
Greg Tarasoff, M.D. provider.
Cathy E. Hollen, D.Ph.
Thomas Kuhls, M.D. Disease Management Program/Initiative
Thomas Whitsett, M.D. (Chair) Contact
Dan McNeill, Ph.D., PA-C Kathe Eastham, R.N
James Swaim, D.Ph. Nurse Case Manager III
Oklahoma Health Care Authority
Prescription Price Updating 4545 N. Lincoln, Suite 124
First DataBank Oklahoma City, OK 73105-9901
1111 Bayhill Drive T: 405/522-7155
San Bruno, CA 94066 F: 405/522-7378
800/633-3453 E-mail: easthamk@ohca.state.ok.us
Internet address: www.firstdatabank.com

Oklahoma-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Oklahoma Health Care Authority Officials State Board of Pharmacy


Janis K. McAllister
Michael Fogarty, J.D.
President
Chief Executive Officer
4545 N. Lincoln Boulevard, Suite 112
Oklahoma Health Care Authority
Oklahoma City, OK 73105-3488
4545 N. Lincoln, Suite 124
T: 405/521-3815
Oklahoma City, OK 73105
F: 405/521-3758
T: 405/522-7300
E-mail: pharmacy@oklaosf.state.ok.us
F: 405/522-7187
Internet address: www.state.ok.us/~pharmacy
E-mail: fogartym@ohca.state.ok.us
Oklahoma Hospital Association
Lynn Mitchell, M.D.
Craig W. Jones
State Medicaid Director
President
Oklahoma Health Care Authority
4000 Lincoln Boulevard
4545 N. Lincoln, Suite 124
Oklahoma City, OK 73105
Oklahoma City, OK 73105
T: 405/427-9537
T: 405/530-7365
F: 405/424-4507
F: 405/530-3218
E-mail: jones@okoha.com
E-mail: mitchell@ohca.state.ok.us
Internet address: www.okoha.com
Advisory Committee on Medical Care for
Public Assistance Recipients
Frank Wilson, III, M.D., Chairman
4545 N. Lincoln, Suite 124
Oklahoma City, OK 73105

Executive Officers of State Medical,


Pharmaceutical, and Osteopathic Societies
Oklahoma State Medical Association
Brian O. Foy, Executive Director
601 NW Grand Boulevard
Oklahoma City, OK 73118
T: 405/843-9571 or 800/522-9452
F: 405/842-1834
E-mail: osma@osmaonline.org
Internet address: www.osmaonline.org

Oklahoma Pharmaceutical Association


Phil Woodward, Ph.D., Executive Director
P.O. Box 18731
Oklahoma City, OK 73154
T: 405/528-3338
F: 405/528-1417
E-mail: pwoodward@opha.com
Internet address: www.opha.com

Oklahoma Osteopathic Association


Lynette C. McLain
Executive Director
4848 N. Lincoln Boulevard
Oklahoma City, OK 73105-3321
T: 405/528-4848
F: 405/528-6102
E-mail: ooa@okosteo.org
Internet address: www.okosteo.org

Oklahoma-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

OREGON

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 ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $222,018,784 220,711 $279,029,096

RECEIVING CASH ASSISTANCE TOTAL $81,943,856 59,881


Aged $8,775,572 7,674
Blind/Disabled $66,610,479 31,564
Child $1,293,366 10,333
Adult $5,264,439 10,310

MEDICALLY NEEDY, TOTAL $32,193,369 7,442


Aged $5,225,676 1,960
Blind/Disabled $26,967,693 5,482
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $5,834,456 37,267


Aged $446,133 404
Blind/Disabled $1,288,996 622
Child $3,452,072 31,426
Adult $647,255 4,815

TOTAL OTHER EXPENDITURES/RECIPIENTS* $102,047,103 116,121

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
** 2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Oregon-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Formulary/Prior Authorization


Formulary: Open formulary with a preferred drug list
Office of Medical Assistance Programs (OMAP), (PDL). PDL managed through physician profiling.
Department of Human Services.
Prior Authorization: State currently has a formal
prior authorization procedure. Client may request an
D. PROVISIONS RELATING TO DRUGS administrative hearing to appeal a prior authorization
decision or to appeal the coverage of excluded
Benefit Design products.
Drug Benefit Product Coverage: Products covered:
prescribed insulin. Products covered under DME: Prescribing or Dispensing Limitations
disposable needles and syringe combinations used for 34 days for chronic drugs. (Limits on initial
insulin; blood glucose test strips; and urine ketone prescription for chronic medications to 15 days to
test strips. Prior authorization required for: prevent wasting if drug is changed due to intolerance,
isotretinon; acute anti-ulcer drugs; cosmetics; total side effects, etc.) Therapy duration limits on selected
parenteral nutrition; interdialytic parenteral nutrition; drugs.
retinoic acid; nasal inhalers; coal tar preparations;
and topical testosterone. Products not covered: Drug Utilization Review
cosmetics; fertility drugs; experimental drugs.
PRODUR system implemented in March 1994. State
Over-the-Counter Product Coverage: Products currently has a DUR Board with a quarterly review.
requiring prior authorization and physician
prescription (limited to 3 claims per month in each Pharmacy Payment and Patient Cost Sharing
therapeutic class): allergy, asthma, and sinus Dispensing Fee: $3.50, $3.80, effective 10/01/01.
products; analgesics; cough and cold preparations;
digestive products; feminine products; topical 1) $3.50 (retail);
products; and smoking deterrent products.
2) $3.90 (institutional/SNF: providers operating a
Therapeutic Category Coverage: Therapeutic True or Modified Dose Delivery System).
categories covered: analgesics, antipyretics, and
NSAIDs; antibiotics; anticoagulants; anti- Ingredient Reimbursement Basis: EAC = AWP-15%
depressants; antidiabetic drugs; antilipemic agents; (Retail), AWP-11% (Institutional)
antipsychotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives; Prescription Charge Formula: Estimated acquisition
estrogens; hypotensive agents; prescribed smoking cost (EAC) defined as the lesser of: (1) AWP-15%
deterrents; sympathominetics (andrenergic); and (2) Federal Upper Limits for multiple source drugs or
thyroid agents. Therapeutic categories requiring prior (3) state MAC, or (4) the usual and customary charge
authorization: anabolic steroids; anticonvulsants; plus a dispensing fee.
antihistamine drugs; anxiolytics, sedatives, and
hypnotics; ENT anti-inflammatory agents; growth Maximum Allowable Cost: State imposes Federal
hormones; misc. GI drugs; antifungals; legend Upper Limits as well as State-specific maximum
laxatives; oral nutrionals; topical antibiotics; topical allowable cost (MAC) limits on generic drugs.
antivirals; weight reduction drugs; and any other drug Override requires or “Brand Medically Necessary”
products for which the only indication is for a non- plus documentation of patient intolerance to generic.
funded condition. Therapeutic categories not
covered: anoretics. (The Oregon Health Plan Incentive Fee: None.
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.

Vaccines: Vaccines reimbursable by Medicaid as part


of the Vaccines for Children Program.

Unit Dose: Unit dose packaging not reimbursable.

Oregon-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

E. USE OF MANAGED CARE Marion Polk Community Health Plan


198 Commercial Street, SE, Suite 240
Approximately 265,000 Medicaid Recipients were Salem, OR 97301
enrolled in MCOs in FY 2002. Recipients enrolled in 503/584-2150
MCOs receive pharmaceutical benefits through
managed care plans. Mental health drugs are carved Mid Rogue IPA Health Plan
out of managed care. 820 NE 7th Street
Grants Pass, OR 97526
Care Oregon, Inc 541/471-4106
522 SW Fifth Avenue, Suite 200
Portland, OR 97204 ODS Health Plans
800/224-4840 601 SW 2nd Ave
Portland, OR 97204
Cascade Comprehensive Care, Inc. 800/342-0526
900 Main Street, Suite A
P.O. Box 217 Oregon Health Management Services
Klamath Falls, OR 97601-0368 1051 NE 6th Street, Suite 2C
541/883-2947 Grants Pass, OR 97526
541/ 471-4208
Central Oregon Independent Health Services, Inc.
2650 NE Courtney Drive Providence Health Plan
P.O. Box 5729 1235 NE 47th, Suite 220
Bend, OR 97708-5729 Portland, OR 97213-2196
800/431-4155 800/ 898-8174

Doctors of The Oregon Coast South (DOCS) Tuality Health Alliance


750 Central, Suite 202 335 SE 8th Avenue
P.O. Box 1096 P.O. Box 925
Coos Bay, OR 97420 Hillsboro, OR 97123-0925
541/269-7400 800/681-1901

Douglas County IPA


F. STATE CONTACTS
500 SE Cass, Suite 210
Roseburg, OR 97470
State Drug Program Administrator
541/677-3453
Thomas Drawbaugh
Family Care, Inc Pharmacy Program Manager
2121 SW Broadway, Suite 300 Office of Medical Assistance Programs (OMAP)
Portland, OR 97201 Department of Human Resources
800/335-3205 500 Summer Street, NE, E-35
Salem, OR 97301-1077
Intercommunity Health Network, Inc T: 503/945-6492
3600 NW Samaritan Drive F: 503/373-7689
Corvallis, OR 97330 E-mail: thomas.drawbaugh@state.or.us
800/757-5114 Internet address: www.dhs.state.or.us/healthplan

Kaiser Permanente Prior Authorization Contact


500 NE Multnomah, Suite 100
Portland, OR 97232-2099 Kathy L. Ketchum, R.Ph., M.P.A.: H.A.
800/813-2000 Medicaid Program Coordinator
Oregon State University College of Pharmacy
Lane Individual Practice Association, Inc. (LIPA) 840 SW Gaines Road, MC 212
1500 Valley Rive Drive, Suite 370 Portland, OR 97239-3098
Eugene, OR 97401 T: 503/494-1589
541/485-2155 F: 503/494-8797
E-mail: ketchumk@ohsu.edu

Oregon-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

DUR Contact Disease Management Program/Initiative


Contact
Kathy L. Ketchum, R.Ph., M.P.A.: H.A.
503/494-1589 Chris Barber
Case Management Coordinator
Medicaid DUR Board
Office of Medical Assistance Programs
Rickland G. Asai, D.M.D. 500 Summer Street, NE
Patrick Bowman, R.Ph. Salem, OR 97301
Gerald D. Fairbanks, R.Ph. 503/945-6588
Dean Haxby, Pharm.D. E-mail: chris.barber@state.or.us
Christina Heinrich, Pharm.D. (Vice-Chair)
Robert Ingle, Jr., M.D., M.P.H. Disease Management/Patient Education
Gregory Johnson, M.D. (Chair) Programs
Raymond S. Lee, D.O.
Disease States/Medical Conditions: asthma,
Sharon Leigh, Pharm.D.
cardiovascular disease, diabetes
John Muench, M.D., M.P.H.
Program Name: Care Enhance
Clifford Singer, M.D.
Program Manager: McKesson
New Brand Name Products Contact
Mail Order Pharmacy Program
Kathy L. Ketchum, R.Ph., M.P.A.: H.A.
State has a Mail Order Pharmacy Program. All non-
503/494-1589
institutionalized beneficiaries are entitled to
participate.
Prescription Price Updating
Jim Rowland Office of Medical Assistance Officials
Account Manager
Jean Thorne
First Health Services Corporation
Director
925 Commercial Street
Department of Human Services
Salem, OR 97301-2460
500 Summer Street, NE, E-15
T: 503/391-1980
Salem, OR 97301
F: 503/391-1979
T: 503/945-5944
E-mail: rowlanji@fhsc.com
F: 503/378-2897
E-mail: jean.i.thorne@state.org.us
Medicaid Drug Rebate Contacts
Jim Rowland Lynn Read
503/391-1980 Director
Office of Medical Assistance Programs
Claims Submission Contact Department of Human Services
500 Summer Street, NE
Jim Rowland Salem, OR 97301
503/391-1980 T: 503/945-5772
F: 503/373-7689
Medicaid Managed Care Contact E-mail: lynn.read@state.or.us
Joyce Riggi
Delivery Systems Manager Title XIX Medical Care Advisory Committees
Office of Medical Assistance Programs Elizabeth Byers
500 Summer Street, NE Bruce Bliatout
Salem, OR 97310 Donna Crawford
T: 503/945-6497 Rosemari Davis
F: 503/947-5221 Michael Garland
John Hogan
Kelley Kaiser
Noel Larson, D.M.D.
Amy Malone
Rick Wopat, M.D.

Oregon-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Consultants to Health and Social Services Osteopathic Physicians and Surgeons of Oregon
Section Jeff Heatherington
Executive Director
Thomas Turek, M.D.
2121 SW Broadway, Suite 300
Medical Director
Portland, OR 97201
Office of Medical Assistance Programs
T: 503/222-2779
Department of Human Resources
F: 503/222-2392
500 Summer Street, NE
E-mail: jeffh@opso.org
Salem, OR 97301
Internet address: www.opso.com
Pharmacy Advisory Task Force
State Board of Pharmacy
Tom Holt, Chairman Gary Schnabel
Mike Dardis, R.Ph. Executive Director
Jim Waletich, R.Ph. State Office Bldg., Room 425
Ed Hughes, R.Ph. 800 NE Oregon Street, #9
Ron Dulwick, R.Ph. Portland, OR 97232
Jenny Kudna, R.Ph. T: 503/731-4032
Dennis Perry, R.Ph. F: 503/731-4067
Larry Cartier, R.Ph. E-mail: gary.a.schnabel@state.or.us
Richard Hartmann, R.Ph. Internet address: www.pharmacy.state.or.us
Chris Vorrath, R.Ph.
Susie Morris, R.Ph. Oregon Association of Hospitals and Health Systems
Tom Hornsby, R.Ph. Ken Ballantyne
Kathy Ketchum, R.Ph. Senior Vice President
John Mansfield, R.Ph. 4000 Kruse Way Place
Dave Lewis, R.Ph. Building 2, Suite 100
Dave Walden, R.Ph. Lake Oswego, OR 97035-2543
Cynthia Wong, R.Ph. T: 503/636-2204
F: 503/636-8310
Executive Officers of State Medical and E-mail: kenb@oahhs.org
Pharmaceutical Associations Internet address: www.oahhs.org
Oregon Medical Association
Stephanie Munoz
Director of Operations
5210 SW Corbett Street
Portland, OR 97239-3897
T: 503/226-1555
F: 503/241-7148
E-mail: stephanie@theoma.org
Internet address: www.ormedassoc.org

Oregon State Pharmacists Association


Tom Holt
Executive Director
29702-B Town Center Loop West
Wilsonville, OR 97070-6481
T: 503/582-9055
F: 503/582-9046
E-mail: tomh@oregonpharmacists.com
Internet address: www.oregonpharmacists.com

Oregon-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Oregon-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

PENNSYLVANIA

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**

Expenditures Recipients Expenditures Recipients


TOTAL $690,558,773 461,114 $718,210,352

RECEIVING CASH ASSISTANCE, TOTAL $295,061,741 162,880


Aged $63,115,582 25,318
Blind / Disabled $210,975,578 76,006
Child $8,864,185 39,509
Adult $12,106,396 22,047

MEDICALLY NEEDY, TOTAL $68,796,845 36,604


Aged $60,348,380 23,250
Blind / Disabled $4,759,422 1,278
Child $2,469,233 7,645
Adult $1,219,810 4,431

POVERTY RELATED, TOTAL $146,089,558 155,466


Aged $47,997,255 19,730
Blind / Disabled $79,066,222 33,769
Child $17,670,812 92,287
Adult $1,355,269 9,680

TOTAL OTHER EXPENDITURES/RECIPIENTS* $180,610,629 106,164

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Pennsylvania-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Formulary/Prior Authorization


Formulary: Open formulary.
Office of Medical Assistance Programs, Department
of Public Welfare. Prior Authorization: State currently has a prior
authorization procedure screening for drug classes
and individual drugs. Products that require PA
D. PROVISIONS RELATING TO DRUGS include BMN brand name drugs that have A-rated
generics, H2 antagonists used >90 days, and drugs
Benefit Design for erectile dysfunction. Also, Oxycontin
Drug Benefit Product Coverage: Products covered: prescriptions with doses in excess of 3 tablets per
prescribed insulin; disposable needles and syringe day, or being on more than 2 different strengths
combinations used for insulin; blood glucose test concurrently and COX-2 drugs if the patient is taking
strips; urine ketone test strips; interdialytic parenteral another NSAID, the prescribed dose is higher than
nutrition; and total parenteral nutrition. Products not the FDA recommended dose, or the patient is under
covered: cosmetics; fertility drugs; and experimental 70 years of age and is not taking an anticoagulant.
drugs.
Prescribing or Dispensing Limitations
Over-the-Counter Product Coverage: Products Quantity Limit: 34-day supply or 100 units,
covered: analgesics; feminine products; topical whichever is greater.
products; laxatives; scabicides containing permethrin;
oral electrolytes; and smoking deterrent products. Refill Limit: Up to 5 within 6 months.
Products covered with restrictions: allergy, asthma,
and sinus (indication or prescribed); cough and cold Monthly Prescription Limit: 6
preparations (indication other than C+C on Rx);
digestive products (not including H2 antagonists) Drug Utilization Review
(legend products only); and digestive products (H2
antagonists) (PA > 90 days at acute dose). Products PRODUR system implemented in June 1993. DUR
not covered: emollients and digestive products (non Board has 10 members and meets quarterly.
H2 antagonists).
Pharmacy Payment and Patient Cost Sharing
Therapeutic Category Coverage: Therapeutic Dispensing Fee: $4.00 ($5.00 for compounds),
categories covered: anabolic steroids; analgesics, effective 10/1/95.
antipyretics, NSAIDs; antibiotics; anticoagulants;
anticonvulsants; anti-depressants; antidiabetic agents; Ingredient Reimbursement Basis: EAC = AWP-10%.
antihistamine drugs; antilipemic agents; anti-
psychotics; anxiolytics, sedatives, and hypnotics; Prescription Charge Formula:
cardiac drugs; chemotherapy agents; contraceptives;
ENT anti-inflammatory agents; estrogens; growth 1. Payment for single source drugs and those
hormones; hypotensive agents; misc. GI drugs; multisource brand name drugs certified as
sympathominetics (adrenergic); thyroid agents; and medically necessary will be the lower of the
prescribed smoking deterrent products; and EAC plus dispensing fee or the pharmacy's usual
prescribed cold medications. Therapeutic categories and customary charge.
not covered: anorectics (unless for treatment of 2. State MAC for the drug plus dispensing fee or
hyperkinesis or narcolepsy); hair restoration drugs, the pharmacy's usual and customary charge.
vitamins (with some exceptions); and products from
companies not participating in the rebate program. 3. For compound prescriptions, an additional fee of
$1.00 is allowed to a pharmacy, bringing the
Coverage of Injectables: Injectable medicines total dispensing fee to $5.00.
reimbursable through the Prescription Drug Program
when used in physician offices, home health care, Maximum Allowable Cost: State imposes Federal
and extended care facilities. Upper Limits as well as State-specific limits on
generic drugs. 465 drugs are listed on the State-
Vaccines: Vaccines reimbursable at AWP – 10% as specific MAC list. Override requires “Brand
part of the Medical Assistance, Children Health Medically Necessary” or “Brand Necessary,” plus
Insurance Program, the Vaccines for Children prior authorization.
Program, and EPSDT Program.
Incentive Fee: None.
Unit Dose: Unit dose packaging not reimbursable.

Pennsylvania-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Patient Cost Sharing: Copayment is $1.00; $2.00 for F. STATE CONTACTS


General Assistance. The copayment will not apply to
those recipients who are federally exempt, under 21 State Drug Program Administrator
years of age, pregnancy cases and long-term care
patients, plus patients receiving drugs in the Joseph E. Concino, R.Ph., Chief
following categories: Office of Medical Assistance Programs
Pharmacy Services Section
− Anticonvulsants P.O. Box 8046
− Antidiabetic agents Harrisburg, PA 17105
− Antiglaucoma agents T: 717/772-6341
− Antihypertensive agents F: 717/772-6366
− Antineoplastic agents E-mail: jconcino@state.pa.us
− Antiparkinson agents Internet address: www.dpw.state.pa.us/omap
− Cardiovascular preparations
− HIV/AIDS specific drugs Welfare Department Officials
− Psychotherapeutic agents
Estelle B. Richman
Cognitive Services: Does not pay for cognitive Secretary
services. Department of Public Welfare
Health and Welfare Building
P.O. Box 2675
E. USE OF MANAGED CARE Harrisburg, PA 17105-2675
T: 717/787-2600
Approximately 936,000 unduplicated Medicaid F: 717/772-2062
recipients were enrolled in managed care in 2002. E-mail: ra-dpwsecretarynet@state.pa.us
All receive pharmacy services, depending on their
category of assistance, through managed care. David S. Feinberg
Deputy Secretary for Medical Assistance Programs
Managed Care Organizations Department of Public Welfare
Health and Welfare Building
AmeriHealth HMO/Mercy Health Plan 65,312
P.O. Box 2675
1901 Market Street, 45th Floor
Harrisburg, PA 17105-2675
Philadelphia, PA 19103
T: 717/787-1870
F: 717/787-4639
Keystone Mercy Healthplan 246,609
E-mail: pamedicaid@state.pa.us
200 Stevens Drive, Suite 900
Philadelphia, PA 19113-1570
Gwendolyn A. Poles, D.O.
Clinical Management Consultant
Americhoice of PA 103,240
The Wanamaker Building
Teresa Shuchart
100 Penn Square East, Suite 900
Director
Philadelphia, PA 19107
Division of Data and Claims Management
Health Partners of Philadelphia 126,060
Richard M. Wallace
841 Chestnut Street, Suite 900
Acting Director
Philadelphia, PA 19107
Bureau of Program Integrity
Three Rivers Health Plans/MedPlus+ 135,525
Donald R. Yearsley
300 Oxford Drive
Acting Director
Monroeville, PA 15146
Bureau of Policy, Budget, and Planning
UPMC Health Plan, Inc./Best 63,823
Patricia S. Jacobs
Healthcare of Western PA
Acting Director
One Chatam Center
Bureau of Fee-for-Service Programs
112 Washington Place
Pittsburgh, PA 15219
Michael Jacobs
Acting Director
Gateway Health Plan 195,723
Bureau of Managed Care Operations
Two Chatam Center, Suite 500
Pittsburgh, PA 15219

Pennsylvania-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Andrew Major New Brand Name Products Contact


Director
Joseph E. Concino, R.Ph.
Bureau of Long Term Care Programs
717/772-6341
Louis J. Cappello, R.Ph.
Pharmacy Consultant Prescription Price Updating
Pharmacy Services Section First DataBank
1111 Bayhill Drive
John Ferrara, R.Ph. San Bruno, CA 94066
Director 800/633-3453
Division of Program Integrity
Medicaid Drug Rebate Contacts
DUR Board
Technical: David Ehrhart, 717/772-6305
Richard D. Baltz, M.D. Policy: Donald Yearsley, 717/772-6341
3028 Market Street Disputes: Louis Cappello, 610/447-5385
Camp Hill, PA 17011
Claims Submission Contact
Richard T. Bell, M.D.
Chairman EDS
2016 Redwood Avenue 275 Grandview Avenue
Wyomissing, PA 19610 Camp Hill, PA 17011
(Calls with contractor must be made through state
Richard W. Sloan, M.D. agency.)
Thomas Hart Family Practice Center
York Hospital Medicaid Managed Care Contact
1001 South George Street Michael Jacobs
York, PA 17405 Acting Director, Division of MCO Monitoring and
Compliance
Otto F. Wolke, R.Ph. Office of Medical Assistance Programs
Geisinger Health Plan Cherrywood Bldg, DPW Complex #2
Geisinger Office Building Harrisburg, PA 17105
Danville, PA 17822 T: 717/772-6300
F: 717/772-2730
Patricia A. Keys, Pharm.D., R.Ph. E-mail: mjacobs@state.pa.us
1514 Scenery Ridge Drive
Pittsburgh, PA 15241 Mail Order Pharmacy Program
Marshall P. Burnside, R.Ph. None
6000 Bell Road
Harrisburg, PA 17111 Expanded Drug Coverage Program Contact
Thomas M. Snedden, Director
Michael A. Zemaitis, Ph.D., R.Ph. PACE Program
133 Shadowlawn Drive PA Department of Aging
Pittsburgh, PA 15261 555 Walnut Street, 5th Floor.
Harrisburg, PA 17101
Robert L. Mayer, Jr., Pharm.D., R.Ph. 717/787-7313
5814 Elmer Street
Pittsburgh, PA 15232 Medical Assistance Advisory Committee
Keith Burkhart, M.D. Christine Allen
206 Mine Road PACE/LTCCAP c/o LIFE
Hershey, PA 17033 University of Pennsylvania School of Nursing
4101 Woodland Avenue
Philadelphia, PA 19104-4510
Jeffrey P. Staab, M.D., M.S.
5 Heritage Lane
Phoenixville, PA 19460-4607

Pennsylvania-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Shirley Beer Dolores Hodgkiss


Armstrong County Low Income Rights Organization Managed Care Association of Pennsylvania
RD #8, Box 134 240 North Third Street, Suite 501
Kittanning, PA 16201 Harrisburg, PA 17101

Shelley Bishop Kathy Hubert


Pennsylvania Mental Health Consumers Association Pennsylvania County Drug and Alcohol
4105 Derry Street Program Administrators
Harrisburg, PA 17111 17 North Front Street
Harrisburg, PA 17101
Kent D. W. Bream, M.D.
Department of Family Practice Michelle Jones
University of Pennsylvania Healthy Start, Inc.
2 Gates, HUP, 3400 Spruce Street 400 North Lexington Street
Philadelphia, PA 19104 Pittsburgh, PA 15208

Louise Brookins George Kimes


Philadelphia State Welfare Rights Organization Pennsylvania Community Providers Association
1231 N. Franklin Street 2400 Park Drive
Philadelphia, PA 19122 Harrisburg, PA 17110

Kevin Casey Christine Klejbuk


Pennsylvania Protection and Advocacy PA Assn. Non-Profit Homes for the Aging
1414 Cameron Street, Suite C Dir. of Public Policy
Harrisburg, PA 17103 1100 Bent Creek Boulevard
Mechanicsburg, PA 17050
Michael D. Chambers
County Commissioners Association of Pennsylvania Ms. Carol Lavoritano
17 North Front Street AmeriChoice
Harrisburg, PA 17101 The Wanamaker Building
100 Penn Square East, Suite 900
Barbara Coffin Philadelphia, PA 19107
Pennsylvania Association of Area Agencies on Aging
Berks County Office of Aging Yvette Long
County Services Center Philadelphia Welfare Rights Organization
633 Court Street 1231 North Franklin Street
Reading, PA 19601-4303 Philadelphia, PA 19122

Dona Dmitrovic Donald McCoy (Chair)


Executive Director Pennsylvania Medical Society
Pennsylvania Recovery Organization Alliance, Inc. 777 East Park Drive
900 South Arlington Avenue, Suite 119 P.O. Box 8820
Harrisburg, PA 17109 Harrisburg, PA 17105-8820

Henry R. Fiumelli Anne R. McHugh


Executive Director Hospital and Healthsystem Association of
Pennsylvania Forum for Primary Health Care Pennsylvania
1035 Mumma Road, Suite 1 4750 Lindle Road
Wormleysburg, PA 17043 P.O. Box 8600
Harrisburg, PA 17105-8600

Vickie Hoak (Vice-Chair) Donna McNonagle


Pennsylvania Homecare Association Philadelphia Coordinated Health Care
20 Erford Road, Suite 115 123 South Broad Street, 22nd Floor
Lemoyne, PA 17043 Philadelphia, PA 19109
717/546-7643, Ext. 3652

Pennsylvania-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Jonna Miller Pennsylvania Podiatry Association


Delaware County Office of Behavior Health Michael Q. Davis
20 South 69th Street, 3rd Floor Executive Director
Upper Darby, PA 19082 757 Poplar Church Road
Camp Hill, PA 17011
Richard R. Orlandi 717/763-7665
Pennsylvania Medical Society
777 East Park Drive State Board of Pharmacy
P.O. Box 8820 Melanie Zimmerman
Harrisburg, PA 17105-8820 Executive Secretary
124 Pine Street
Mary Ellen Rehrman P.O. Box 2649
10 Bertolet School Road Harrisburg, PA 17105-2649
Spring City, PA 19475 T: 717/783-7156
F: 717/787-7769
Dale Laninga - Ex-Officio Member E-mail: pharmacy@pados.dos.state.pa.us
Department of Aging Internet address:
Intra Governmental Council on Long Term Care www.dos.state.pa.us/bpoa/phabd/mainpage.htm
555 Walnut Street, 5th Floor
Harrisburg, PA 17101-1919 The Hospital and Healthsystem Association of
Pennsylvania
Michael A. Yantis, Jr. - Ex-Officio Member Carolyn F. Scanlan
Pennsylvania Department of Health Office of Policy President/CEO
Room 808, Health and Welfare Building 4750 Lindle Road
Harrisburg, PA 17120 P.O. Box 8600
Harrisburg, PA 17105-8600
Executive Officers of State Medical and T: 717/561-5314
Pharmaceutical Associations F: 717/561-5334
E-mail: cscanlan@haponline.org
Pennsylvania Medical Society
Internet address: www.haponline.org
Roger F. Mecum
Executive Vice President
777 E. Park Drive
P.O. Box 8820
Harrisburg, PA 17105-8820
T: 717/558-7750
F: 717/558-7840
E-mail: rmecum@pamedsoc.org
Internet address: www.pamedsoc.org

Pennsylvania Pharmacists Association


Patricia A. Epple, CAE
Executive Director
508 North Third Street
Harrisburg, PA 17101-1199
T: 717/234-6151
F: 717/236-1618
E-mail: pepple@papharmacists.com
Internet address: www.papharmacists.com

Pennsylvania Osteopathic Medical Association


Mario E.J. Lanni
Executive Director
1330 Eisenhower Boulevard
Harrisburg, PA 17111-2395
T: 717/939-9318
F: 717/939-7255
E-mail: poma@poma.org
Internet address: www.poma.org

Pennsylvania-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

RHODE ISLAND

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expended Recipients Expended Recipients

TOTAL $104,912,603 50,379 $120,952,122 50,155

RECEIVING CASH ASSISTANCE TOTAL $63,036,440 28,257


Aged $7,362,321 4,417
Blind/Disabled $55,530,351 22,501
Child $49,522 595
Adult $94,246 744

MEDICALLY NEEDY, TOTAL $8,948,203 3,671


Aged $6,099,170 2,960
Blind/Disabled $2,848,698 709
Child $0 -
Adult $335 2

POVERTY RELATED, TOTAL $333,172 911


Aged $94,162 97
Blind/Disabled $152,155 111
Child $61,352 523
Adult $25,503 180

TOTAL OTHER EXPENDITURES/RECIPIENTS* $32,594,788 17,540

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
2002 data provided by the Rhode Island Department of Human Services.

Source: CMS, MSIS Report, FY 2001 and Rhode Island Medicaid Statistical Information System, FY 2002.

Note: Rhode Island estimates 2003 drug expenditures to be $139 million and the number of Medicaid drug recipients to be 52,000.

Rhode Island-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Formulary/Prior Authorization


Formulary: State has a formulary. Prior
Rhode Island Department Human Services. authorization is used to manage the formulary. Fair
hearing process to appeal prior authorization
D. PROVISIONS RELATING TO DRUGS decision.

Benefit Design Prescribing or Dispensing Limitations

Drug Benefit Product Coverage: Products covered: Prescription Refill Limit: Refills to a maximum of 5
prescribed insulin; disposable needles and syringe are allowed.
combinations used for insulin; urine ketone test
strips. Products covered under DME: blood glucose Monthly Quantity Limit: One month’s supply for
test strips; total parenteral nutrition (prior non-maintenance drugs. One inhaler per fill. 8 tablets
authorization required); and interdialytic parenteral per month for erectile dysfunctions medication.
nutrition (prior authorization required). Products not
covered: cosmetics; fertility drugs; experimental Maintenance Medication: The attending physician
drugs; DESI drugs. may prescribe certain maintenance drugs of 100
tablets, capsules or pint of liquid or a 30-day supply
Over-the-Counter Product Coverage: Products of these drugs - whichever is greater.
covered: allergy, asthma, and sinus products;
analgesics (acetaminophen); cough and cold Monthly Dollar Limits: None
preparations (guifenisin, diphenhydramine,
chlorpheniramine); digestive products (non-H2 Drug Utilization Review
antagonists); topical products; (antibiotics only); PRODUR system implemented in December 1994.
antacids; and laxatives. Products not covered: State has a DUR Board that meets quarterly.
allergy, asthma, and sinus products; digestive
products (H2 antagonists); feminine products; and Pharmacy Payment and Patient Cost Sharing
smoking deterrent products.
Dispensing Fee: $3.40 (ambulatory) and $2.85
Therapeutic Category Coverage: Products covered: (nursing homes), effective 1987.
anabolic steroids; analgesics, antipyretics, and
NSAIDs; antibiotics; anticoagulants; anticonvulsants; Ingredient Reimbursement Basis: EAC = WAC +
anti-depressants; antidiabetic agents, antilipemic 5%.
agents; anti-psychotics; anxiolytics, sedatives, and
hypnotics; cardiac drugs; chemotherapy agents, Prescription Charge Formula:
prescribed cold medications; contraceptives; ENT 1. In accordance with Federal regulation the upper
anti-inflammatory agents; estrogens; hypotensive limit for payment for prescribed drugs will be
agents; sympathominetics (adrenergic); and thyroid based upon the amount allowed by the Medical
agents. Prior authorization required for: anoretics; Assistance Program or the usual and customary
antihistamines; growth hormones; misc. GI drugs; charge to the general public, whichever is lower.
PPIs; Provigil; CNS stimulants; Tracleer; Remodulin;
Flolan; Xolair; erectile dysfunction products; and 2. Payment for over-the-counter drugs (non-legend
Cox 2 inhibitors; Therapeutic categories not covered: drugs) will be based upon the lower of either the
prescribed smoking deterrents; products for hair allowable cost of the drug plus 5 percent, the
growth. usual and customary charge to the general
public, or the allowable cost plus the
Coverage of Injectables: Injectable medicines professional fee for service.
reimbursable under the Prescription Drug Program
when used in home health care and extended care Maximum Allowable Cost: State imposes Federal
facilities, and through physician payment when used Upper Limits on generic drugs. Override requires
in physician offices. “Brand Medically Necessary” with a documented
medical reason why a generic cannot be used.
Vaccines: Limited coverage under the Vaccines for
Children Program and through the physician payment Incentive Fee: None.
program for adults.
Patient Cost Sharing: No copayment.
Unit Dose: Unit dose packaging not reimbursable.
Cognitive Services: Does not pay for cognitive
services.

Rhode Island-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

E. USE OF MANAGED CARE Medicaid Managed Care Contact


Tricia Leddy, Administrator
Approximated 135,000 Medicaid recipients were Department of Human Services
enrolled in managed care in 2003. Managed care 600 New London Avenue
recipients receive pharmaceutical benefits through Cranston, RI 02919
managed care plans. 401/462-2127
E-mail: tleddy@dhs.ri.gov
Managed Care Organizations
− United Healthcare of New England Mail Order Pharmacy Program
− Coordinated Health Partners, Inc. None
− Neighborhood Health Plan of Rhode Island
Department of Human Services Officials
F. STATE CONTACTS Jane Hayward
Director
State Drug Program Administrator Department of Human Services
Paula J. Avarista, R.Ph. 600 New London Avenue
Chief of Pharmacy Cranston, RI 02920
Department of Human Services T: 401/462-2121
600 New London Avenue F: 401/462-3677
Cranston, RI 02919 E-mail: jhayward@gw.dhs.state.ri.us
T: 401/462-6390
F: 401/462-6336 John Young
E-mail: pavarista@dhs.state.ri.us Associate Director
Internet address: www.dhs.state.ri.us Medical Services
Department of Human Services
DUR Contact 600 New London Avenue
Cranston, RI 02920
Paula J. Avarista, R.Ph. T: 401/462-3575
401/462-6390 F: 401/462-6338
E-mail: jyoung@gw.dhs.state.ri.us
Rhode Island DUR Board
Raymond Maxim, M.D. Executive Officers of State Medical and
Edward Westlake, M.D. Pharmaceutical Societies
Richard Wagner, M.D. Rhode Island Medical Society
Steve Kogurt, Ph.D. Newell E. Warde, Executive Director
Craig Bowen, Pharm.D. 235 Promenade Street, Suite 500
John Zevzavadjian R.Ph. Providence, RI 02908
Ellen Mauro, R.N, M.P.H. T: 401/331-3207
F: 401/751-8050
New Brand Name Products Contact E-mail: nwarde@rimed.org
Paula J. Avarista, R.Ph. Internet address: www.rimed.org
401/462-6390
Rhode Island Society of Osteopathic Physicians and
Prescription Price Updating Surgeons/Northeast Osteopathic Consortion
Donald J. Halpin, Executive Director
Paula J. Avarista, R.Ph. P.O. Box 487
401/462-6390 Winchester, MA 01800
781/721-9900
Medicaid Drug Rebate Contacts E-mail: nocdos@shore.net
Internet address: www.northeastosteo.org
Technical: Helen Vaughn (EDS), 401/784-3879
Policy: Paula J. Avarista, 401/462-6390

Claims Submission Contact


EDS
401/784-3879

Rhode Island-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Rhode Island Pharmacists Association


James Hutson
Executive Director
1643 Warwick Avenue
PMB 113
Warwick, RI 02889
T: 401/737-2600
F: 401/737-0959
E-mail: jhutson@ripharmacists.org
Internet address: www.ripharmacists.org

State Board of Pharmacy


Catherine A. Cordy
Chief of The Board
3 Capitol Hill, Room 205
Providence, RI 02908-5097
T: 401/277-2837
F: 401/222-2158
E-mail: cathyc@doh.state.ri.us
Internet address:
www.healthri.org//hsr/professions/pharmacy.htm

Hospital Association of Rhode Island


Edward J. Quinlan, President
880 Butler Drive, Suite One
Providence, RI 02906
T: 401/274-1647
F: 401/274-1838
E-mail: edwardq@hari.org
Internet address: www.hari.org

Rhode Island-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

SOUTH CAROLINA

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 ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $438,498,935 542,764 $456,972,236 576,065

RECEIVING CASH ASSISTANCE, TOTAL $217,671,240 201,137 $219,601,046 214,691


Aged $54,051,659 30,510 $49,524,373 29,073
Blind/Disabled $133,255,085 73,126 $131,756,715 72,534
Child $11,428,870 53,959 $14,462,664 62,082
Adult $18,935,626 43,542 $23,857,294 51,002

MEDICALLY NEEDY, TOTAL $0 - $0 -


Aged $0 - $0 -
Blind/Disabled $0 - $0 -
Child $0 - $0 -
Adult $0 - $0 -

POVERTY RELATED, TOTAL $135,326,028 239,631 $145,484,844 255,443


Aged $41,923,282 24,199 $42,051,488 24,724
Blind/Disabled $51,608,068 21,735 $53,686,398 23,236
Child $39,949,877 179,897 $47,894,525 194,168
Adult $1,844,801 13,800 $1,852,433 13,315

TOTAL OTHER EXPENDITURES/RECIPIENTS* $85,501,667 101,996 $91,886,346 105,931

*Total Other Expenditures/ Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data provided by the South Carolina Department of Health and Human Services.

Source: CMS, MSIS Report, FY 2001, and South Carolina Medicaid Statistical Information System, FY 2002.

South Carolina-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION 4. Pharmaceuticals determined by the FDA to be


less than effective and identical, related, or
South Carolina Department of Health & Human similar drugs.
Services. 5. Injectable pharmaceuticals administered by the
practitioner in the office in a clinic, or in a
D. PROVISIONS RELATING TO DRUGS mental health center (Synagis is reimbursable
through the Physician Services Program and is
Benefit Design non-covered through Pharmacy Services).
6. Products used as flushes to maintain patency of
Drug Benefit Product Coverage: Products covered: devices.
prescribed insulin, and disposable needles and 7. Devices and supplies (e.g., diabetic supplies,
syringe combinations used for insulin. Products infusion supplies, etc.)
covered as DME: blood glucose test strips; urine 8. Fertility products.
ketone test strips; total parenteral nutrition; and 9. Smoking cessation products, whether legend or
interdialytic nutrition. Products not covered: OTC.
cosmetics; fertility drugs; DESI drugs; and 10. Pharmaceuticals which are not rebated.
experimental drugs. 11. Nutritional supplements
12. Oral hydration therapies for adults.
Over-the-Counter Product Coverage: Within 13. Pharmaceuticals used for cosmetic purposes or
program guidelines and limitations, the Medicaid hair growth.
program covers all rebated OTC medications and
their generic equivalents. Products not covered: Prior Authorization: State currently has a prior
smoking deterrent products. authorization program. Beneficiaries can request a
fair hearing and exception to policy to appeal a prior
Therapeutic Category Coverage: Therapeutic authorization decision. The prescriber must obtain
categories covered: anabolic steroids; analgesics, prior authorization for Medicaid coverage of the
antipyretics, NSAIDs; antibiotics; anticoagulants; following products:
anticonvulsants; antidepressants; antidiabetic agents;
antihistamine drugs; antilipemic agents; anti- 1. Brand name products (excluding certain
psychotics; anxiolytics, sedatives, and hypnotics; narrow, therapeutic index drugs) for which
cardiac drugs; chemotherapy agents; prescribed cold there are A-rated, therapeutically equivalent,
medications; contraceptives; ENT anti-inflammatory less costly generics available.
agents; estrogens; growth hormones; hypotensive 2. COX-2 inhibitors for patients < age 60.
agents; misc. GI drugs; sympathominetics 3. Erectile dysfunction products.
(adrenergic); and thyroid agents. Therapeutic 4. OxyContin® (when maximum quantity
categories not covered: anoretics and prescribed limitation is exceeded).
smoking deterrents. 5. Panretin®.
6. Proton pump inhibitors for patients > age
Coverage of Injectables: Injectable medicines 21.
reimbursable through the Physician Services Program 7. Serostim®.
when used in physicians’ offices. Injectables 8. Targretin®.
reimbursable through the Prescription Drug Program 9. Xenical®.
when used at home, through home health care, or in
long-term care facilities. Prescribing or Dispensing Limitations
Prescription Refill Limit: The prescriber authorizes
Vaccines: Vaccines reimbursable based on CDC the number of refills.
price as part of the Vaccines for Children Program
(age under 21). Monthly Quantity Limit: Children (birth to age 21)
are allowed unlimited prescriptions per month.
Unit Dose: Unit dose packaging reimbursable. Beneficiaries over the age of 21 are limited to a
maximum of four prescriptions per month; however,
Formulary/Prior Authorization pharmacists may override the monthly prescription
Formulary: Open formulary; certain drug limit for adult Medicaid beneficiaries if the
classifications excluded. prescription meets certain specified override criteria.

General Exclusions: Quantity Limit per Prescription: 34 days’ supply per


1. Weight control products. prescription.
2. Investigational pharmaceuticals or products.
3. Immunizing agents. Monthly Dollar Limit: None.

South Carolina-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Drug Utilization Review F. STATE CONTACTS


PRODUR system implemented November 2000.
State currently has a DUR Board with a monthly State Drug Program Administrator
review. James M. Assey, R.Ph., Division Director
Division of Pharmaceutical Services and DME
Pharmacy Payment and Patient Cost Sharing S.C. Department of Health & Human Services
Dispensing Fee: $4.05, effective 7/1/89. P.O. Box 8206
Columbia, SC 29202-8206
Ingredient Reimbursement Basis: EAC = AWP-10%. T: 803/898-2876
F: 803/255-8353
Prescription Charge Formula: Medicaid E-mail: asseyj@dhhs.state.sc.us
reimbursement for pharmacy services will be based Internet address: www.dhhs.state.sc.us
on the lowest of: the Estimated Acquisition Cost
(EAC); Federal or State maximum allowable cost Prior Authorization Contact
(MAC); or the provider's submitted usual and Caroline Y. Sojourner, R.Ph., Dept. Head
customary charge. Department of Pharmacy Services
S.C. Department of Health and Human Services
Maximum Allowable Cost: State imposes Federal P.O. Box 8206
Upper Limits as well as State-specific maximum Columbia, SC 29202-8206
allowable costs (MAC) on additional drugs. T: 803/898-2876
Override requires “Brand Medically Necessary” with F: 803/255-8353
handwritten certification by the prescriber and prior E-mail: sojourne@dhhs.state.sc.us
authorization.
DUR Contact
Incentive Fee: None.
Caroline Y. Sojourner, R.Ph.
Patient Cost Sharing: $3.00 copayment per 803/898-2876
prescription.
DUR Committee
Cognitive Services: Does not pay for cognitive Gwendolyn C. Galphin, M.D.
services. F. Joseph Hodge, R.Ph.
Henry Rose, R.Ph.
E. USE OF MANAGED CARE Leslie M. Stuck, M.D.
Caroline Sojourner, R.Ph.
Approximately 74,000 Medicaid recipients were Michele Burnett, R.Ph.
enrolled in MCOs in FY 2003. Recipients receive
pharmaceutical benefits through managed care plans. New Brand Name Products Contact

Managed Care Organizations James M. Assey, R.Ph.


803/898-2876
Select Health of South Carolina, Inc.
Patricia Marquis, Chief Operating Officer Prescription Price Updating
P.O. Box 40024
Charleston, SC 29403 First DataBank,
843/569-1759 1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
T: 650/588-5454
F: 650/588-4003

Medicaid Drug Rebate Contacts


Technical: Rod Davis, 803/898-2610
Policy: James Assey, 803/898-2876
DUR & PA: Caroline Sojourner, 803/898-2876
Disputes: Laurel Kennerly, 803/898-2954

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Claims Submission Contact Medical Care Advisory Council


Rod Davis Ms. Valerie Aiken
Deputy Director of Information Technology Mr. John P. Barber
S.C. Department of Health and Human Services Ms. Susan B. Berkowitz
P.O. Box 8206 Ms. Lesly A. Bowers
Columbia, SC 29202-8206 Dr. Gloria Bonali
803/898-2610 Mr. Bruce Carlson
E-mail: davisr@dhhs.state.sc.us Mr. Tommy Cockrell
Charles P. Darby, M.D.
Medicare Managed Care Contact C. Warren Derrick, M.D.
Ana DeFede, Ph.D
Bruce Harbaugh
James M. DuRant, Jr., M.D.
Department of Primary Care & Alternative
C. Morrison Farish, M.D.
Reimbursement Programs
Mr. Ron Fitzwater
S.C. Department of Health and Human Services
Ms. Laura Fowler
P.O. Box 8206
Ms. Connie Ginsberg
Columbia, SC 29202-8206
Dr. Barbara Haight
803/898-2818
Jerome E. Kurent, M.D.
Mr. Rudy Long
Mail Order Drug Program Ms. Amy McDonald
None, however, mail order pharmacies may enroll. Mr. J.J. McLawhorn
Albert D. Mims, M.D.
Disease Management Program/Initiative Dr. Linda S. Moore
Contact Mr. John A. Morris
J. Michael Ross, R.Ph.
Kathie Reed Sabra Slaughter, Ph.D.
Division of Client Education and Outreach Services Mr. Lewis Stephens
S.C. Department of Health and Human Services Ms. Cindy White
P.O. Box 8206 Ms. Deborah Williamson
Columbia, SC 29202-8206 Dr. Constance Yearling
803/898-2638 Dr. Foster H. Young, Jr.
E-mail: reed@dhhs.state.sc.us Mr. Hal Zorn
South Carolina Department of Health and Executive Officers of State Medical and
Human Services Officials Pharmaceutical Societies
Robert Kerr, Director South Carolina Medical Association
S. C. Department of Health & Human Services Todd K. Atwater, Chief Executive Officer
1801 Main Street 132 West Park Boulevard
P.O. Box 8206 P.O. Box 11188
Columbia, SC 29202-8206 Columbia, SC 29210
T: 803/898-2504 T: 803/798-6207
F: 803/898-4515 F: 803/772-6783
E-mail: kerr@gov.sc.gov E-mail: todd@scmanet.org
Internet address: www.scmanet.org
Melanie Giese, Chief
Bureau of Health Services South Carolina Osteopathic Medical Society
803/898-2870 Tom Underwood, Executive Director
655 St. Andrews Road, Suite 1
Caroline Y. Sojourner, R.Ph., Department Head Columbia, SC 29210-5136
Department of Pharmacy Services T: 877/886-3672
803/898-2876 F: 502/223-4937
E-mail: info@scoms.org
Internet address: www.scoms.org

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National Pharmaceutical Council Pharmaceutical Benefits 2003

South Carolina Pharmacy Association


James R. Bracewell, Executive Vice President
1350 Browning Road
Columbia, SC 29210-6903
T: 803/354-9977
F: 803/354-9207
E-mail: jbracewell@scrx.org
Internet address: www.scrx.org/scrx

State Board of Pharmacy


Lee Ann F. Bundrick, Administrator
South Carolina Board of Pharmacy
Kingstree Building
110 Centerview Drive, Suite 306
Columbia, SC 29210
T: 803/898-4700
F: 803/896-4596
E-mail: bundricl@mail.llr.state.sc.us
Internet address: www.llr.state.sc.us/pol/pharmacy

South Carolina Hospital Association


Kenneth A. Shull, President
101 Medical Circle
P.O. Box 6009
West Columbia, SC 29171-6009
T: 803/796-3080
F: 803/796-2938
E-mail: kshull@scha.org
Internet address: www.scha.org

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National Pharmaceutical Council Pharmaceutical Benefits 2003

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National Pharmaceutical Council Pharmaceutical Benefits 2003

SOUTH DAKOTA

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 ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $52,608,524 58,203 $62,382,937

RECEIVING CASH ASSISTANCE, TOTAL $27,648,344 20,993


Aged $3,255,890 1,849
Blind/Disabled $21,559,128 8,701
Child $1,147,090 6,450
Adult $1,686,236 3,993

MEDICALLY NEEDY, TOTAL $0 -


Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $4,526,417 21,497


Aged $39,540 49
Blind/Disabled $66,140 61
Child $4,065,705 19,072
Adult $355,032 2,315

TOTAL OTHER EXPENDITURES/RECIPIENTS* $20,433,763 15,713

*Total Other Expenditures/recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Prescribing or Dispensing Limitations


Department of Social Services, Office of Medical Prescription Dollar Limit: None.
Services. Monthly Quantity Limit: None.

Drug Utilization Review


D. PROVISIONS RELATING TO DRUGS
PRODUR system implemented in 1996. State has a
DUR Board with annual review.
Benefit Design
Drug Benefit Product Coverage: Products covered: Pharmacy Payment and Patient Cost Sharing
prescribed insulin; disposable needles and syringe
Dispensing Fee: $4.75 to $5.55 (with unit dose fee
combinations used for insulin; blood glucose test
applied), effective 7/1/1991
strips; and urine ketone test strips. Products not
covered: cosmetics; DESI drugs; fertility drugs;
Ingredient Reimbursement Basis: EAC = AWP-
experimental drugs; total parental nutrition; drugs for
10.5%.
impotence; and interdialytic parenteral nutrition.
Prescription Charge Formula: Payment is the lower
Over-the-Counter Product Coverage: Products not
of:
covered: allergy, asthma and sinus products;
analgesics; cough and cold preparations; digestive 1. FUL, State MAC plus a dispensing fee, or
products; feminine products; topical products; and 2. EAC plus a dispensing fee, or usual and
smoking deterrents. customary charge to the general public.

Therapeutic Category Coverage: Therapeutic Maximum Allowable Cost: State imposes Federal
categories covered: anabolic steroids; analgesics, Upper Limits as well as State-specific limits on
antipyretics, NSAIDs; anoretics; antibiotics; generic drugs. Approximately 1,000 drugs are listed
anticoagulants; anticonvulsants; antidepressants; on the State-specific MAC list. Override requires
antidiabetic agents; antihistamine drugs; antilipemic “Brand Medically Necessary.”
agents; anti-psychotics; anxiolytics, sedatives, and
hypnotics; cardiac drugs; chemotherapy agents; Incentive Fee: $10.00
contraceptives; ENT anti-inflammatory agents;
estrogens; hypotensive agents; misc. GI drugs; Patient Cost Sharing: Copayment is $2.00.
sympathominetics (adrenergic); prescribed cold
medications and thyroid agents. Prior authorization Cognitive Services: Does not pay for cognitive
required for: growth hormones. Partial coverage for: services.
prescribed smoking deterrents. Therapeutic
categories not covered: nutritional supplements;
clozapine. E. USE OF MANAGED CARE

Coverage of Injectables: Injectable medicines Does not use MCOs to deliver pharmacy services to
reimbursable through physician payment when used Medicaid recipients.
in physicians offices, home health care, and extended
care facilities. F. STATE CONTACTS
Vaccines: Vaccines reimbursable with HCPC code as
State Drug Program Administrator
part of the Vaccines for Children Program.
Mark Petersen, R.Ph.
Unit Dose: Unit dose packaging reimbursable. Pharmacy Consultant
Department of Social Services
Formulary/Prior Authorization Office of Medical Services
700 Governors Drive
Formulary: Open formulary. Pierre, SD 57501
T: 605/773-3495
Prior Authorization: State currently has a formal F: 605/773-5246
prior authorization procedure. Request for fair E-mail: markp@state.sd.us
hearing required for appealing coverage of an
excluded product or a prior authorization decision.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Prior Authorization Contact South Dakota Medicaid Agency Officials


Mark Petersen, R.Ph. James Ellenbecker
605/773-3495 Secretary
Department of Social Services
DUR Contact 700 Governors Drive
Pierre, SD 57501-2291
Michael Jockheck, R.Ph. T: 605/773-3165
Pharmacy Consultant
F: 605/773-4855
SD Dept of Social Services E-mail: info@dss.state.sd.us
700 Governors Drive
Pierre, SD 57501
Damian Prunty
605/773-6439 Program Administrator
E-mail: mike.jockheck@state.sd.us Medical Services
Department of Social Services
Steering Committee (Medicaid DUR Board) 700 Governors Drive
Damian Prunty (Program Administrator) Pierre, SD 57501-2291
Tom Carlson, R.Ph. T: 605/773-3495
Richard Holm, M.D. F: 605/773-5246
Pam Jones, R.Ph. E-mail: Medicaid@dss.state.sd.us
Bruce Lushbough, M.D.
Medical Advisory Committee
New Brand Name Products Contact Paul Engbrecht, Chairman
Mark Petersen, R.Ph. Tieszen Memorial Home
605/773-3495 437 State Street
Marion, SD 57043
Prescription Price Updating 605/648-3384
Mark Petersen, R.Ph. John Jones, Vice Chairman
605/773-3495 Division of Health, Medical & Laboratory Services
Health Laboratory Building
Medicaid Drug Rebate Contacts 615 E. 4th Street
Helen Rokusek c/o 500 E. Capitol Avenue
Rebate Coordinator Pierre, SD 57501
Dept. of Social Services 605/773-3737
700 Governors Drive
Pierre, SD 57501 Jud Bergan, O.D.
605/773-3653 103 South Eagan
Madison, SD 57042
Claims Submission Contact
Sheryl Petersen
Meredith Heerman 218 W. Third Street
Dept. of Social Services Pierre, SD 57501
700 Governors Drive
Pierre, SD 57501 James D. M. Russell
T: 605/773-3495 Hospital Admin.
F: 605/773-5246 St. Mary's Hospital
E-mail: meredith_heerman@state.sd.us 803 E. Dakota
Pierre, SD 57501
Disease Management Program/Initiative 605/224-3100
Contact
Mark Petersen, R.Ph., 605/773-3495 Herb McClellan, Jr., D.D.S.
Box 189
Mobridge, SD 57601-0189

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Lynn Greff State Board of Pharmacy


Apothecary Shop at Medical Arts Dennis M. Jones
719 St. Francis Street Executive Secretary
Rapid City, SD 57701 4305 S. Louise Avenue, Suite 104
Sioux Falls, SD 57106
Stephen Schroeder, M.D. T: 605/362-2737
Hand Co. Clinic F: 605/361-2738
P.O. Box 287 E-mail: dennis.jones@state.sd.us
Miller, SD 57362 Internet address: www.state.sd.us/dcr/pharmacy

Michelle Miller South Dakota Association of Healthcare


McKennan Home Health Organizations
800 E. 21st Street David R. Hewett
Sioux Falls, SD 57105-1016 President/CEO
3708 Brooks Place, Suite 1
A.A. Lampert, M.D. Sioux Falls, SD 57106
13075 Bogus Jim Road T: 605/361-2281
Rapid City, SD 57702-9720 F: 605/361-5175
E-mail: hewett@sdaho.org
Evaluation Committee Internet address: www.sdaho.org
V. R. Brandenburg, M.D.
Dennis Hodge, Pharm.D.
Helen Fiechtner, Pharm.D.
Jane Mort, Pharm.D.
James Clem, Pharm.D.
Marc Aldrich (Physician)

Executive Officers of State Medical and


Pharmaceutical Societies
South Dakota State Medical Association
L. Paul Jenson
Chief Executive Officer
1323 South Minnesota Avenue
Sioux Falls, SD 57105
T: 605/336-1965
F: 605/336-0270
E-mail: pjensen@sdsma.org
Internet address: www.sdsma.org

South Dakota Osteopathic Association


David A. Lauer, D.O.
Secretary-Treasurer
P.O. Box 247
Sturgis, SD 57785
T: 605/347-3616
F: 605/347-4713

South Dakota Pharmacists Association


Robert Overturf
Executive Director
215 W. Sioux Avenue
P.O. Box 518
Pierre, SD 57501-0518
T: 605/224-2338
F: 605/224-1280
E-mail: sdpha@midconetwork.com
Internet address: www.sdpha.org

South Dakota-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

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 for a five- cervical cancer.
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

Tennessee-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

TennCare Standard is similar to a commercial Formulary: Preferred Drug List (PDL) was phased
HMO package. People eligible for TennCare in from October 15th through December 15th in 3
standard are adults below the 100 percent of the phases (see http://tennessee.fhsc.com).
federal poverty level, children below 200 percent of
the poverty level, and people who are “medically Prior Authorization: Prior authorization procedures
eligible” a new term to describe what the state are administered by Consultec (through 12/31/03)
previously referred to as “uninsurables.” The and First Health starting on 1/1/04.
difference is that “Medical eligibility” will be
determined by a State-appointed health insurance Copayment: Deductibles and copayments apply to
underwriter. Under the previous TennCare system, services other than preventive services (e.g.,
a denial letter from an insurance company defined immunizations) based on a sliding scale according
“uninsurability.” to income. Medicaid recipients and persons or
families with income under 100% of the Federal
The five-year waiver that TennCare began on July poverty level are not required to pay premiums,
1, 2002 also includes an annual “open enrollment” deductibles, or copayments in order to participate in
period, which would allow people who are the TennCare program.
uninsured or medically eligible above poverty to
enroll in TennCare. The current fiscal year’s budget
does not allow for an open enrollment period, at C. USE OF MANAGED CARE
least through the end of the current fiscal year, June
30, 2003. However, if an applicant is both below Medicaid recipients and the uninsured/uninsurable
are enrolled in MCOs through the TennCare
100 percent of the poverty level and medically
eligible, enrollment will be allowed at any time program. All receive pharmacy benefits through
during the year. managed care.

Persons wanting to apply for TennCare must visit Managed Care Organizations
the local Tennessee Department of Human Services Better Health Plans
(DHS) office. There is a local DHS office in every 890 Willow Tree Circle
Tennessee County. For the applicants' convenience, Cordova, TN 38018
DHS will make a copy of the application, date
stamp it, and process the application. BlueCare
801 Pine Street
Chattanooga, TN 37402-2555
A. ADMINISTRATION
John Deere Health Plan
Tennessee Department of Finance and
Executive Tower I, Suite 400
Administration, Bureau of TennCare
408 N. Cedar Bluff Road
Knoxville, TN 37923
B. PROVISIONS RELATING TO DRUGS
TLC Family Care Healthplan
Benefit Design P.O. Box 49
Memphis, TN 38101
Pharmacy services are provided by the managed
care organizations. Within Federal and State OmniCare Health Plan, Inc.
guidelines, each individual managed care and 1991 Corporate Avenue, 5th Floor
pharmacy benefit management organization makes Memphis, TN 38132
formulary/drug decisions. Pharmacy services are
to be covered as medically necessary, excluding PHP TennCare
DESI, less than effective and IRS drugs and some 1420 Centerpoint Boulevard
drugs for which TennCare does not mandate Knoxville, TN 37932
coverage (e.g., drugs for infertility, weight
reduction, cosmetic purposes, hair growth products, TennCare Select
products for symptomatic relief of cough and colds, 801 Pine Street
experimental drugs; smoking cessation products, Chattanooga, TN 37402-2555
and OTCs). Starting in July 1, 2003 all eligible
products dispensed through ambulatory VHP Community Care
pharmacies are invoiced through the CMS rebate 215 Centerview Drive, Suite 300
program. Brentwood, TN 37027

Tennessee-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

MCO/Behavioral Health Organization Diane Crutchfield, D.Ph.


1223 Eaglenest Lane
Better Health Plans
Knoxville, TN 37922
Blue Care
John Deere Health Plan
Martha Drannon, Pharm.D.
OmniCare Health Plan
Frayser Family Counseling Center Pharmacy
Preferred Health Partnership (PHP)
2150 Whitney Avenue
Premier Behavioral Systems
Memphis, TN 38127
Tennessee Behavioral Health, Inc.
TLC Family Health Care Health Plan
Don Hazelwood, D.Ph.
VHP Community Care
E.W. James Pharmacy
3100 S. First Street
D. STATE CONTACTS Milan, TN 38358

State Drug Program Administrator Connie J. Holladay, M.D.


6432 River Tide Drive
Jeffrey G. Stockard, D.Ph. Memphis, TN 38120
Associate Pharmacy Director
Bureau of TennCare Mack A. Land, M.D.
729 Church Street 5210 Poplar Avenue, Suite 200
Nashville, TN 37247-6501 Memphis, TN 38119
T: 615/532-3107
F: 615/253-5481 David Shepard, Pharm.D., B.C.P.P.
E-mail: jeff.stockard@state.tn.us Dickson Apothecary East
104 Highway 70 East
TennCare Officials Dickson, TN 37055
Manny Martins, Deputy Commissioner
Bureau of TennCare Daniel D. Sumrok, M.D.
Department of Finance and Administration Family Practice
729 Church Street 22700 Highway 22
Nashville, TN 37247-6501 McKenzie, TN 38201
T: 615/741-0213
F: 615/741-0882 TennCare Pharmacy Advisory Board
E-mail: manny.martins@state.tn.us James Powers, M.D. (Chairman)
7155 Vanderbilt
TennCare Information Line Medical Center East
800/669-1851 Nashville, TN 37232
Prior Authorization Contact Alan Corley, D.Ph. (Vice Chairman)
Jeffrey G. Stockard, D.Ph. P.O. Box 874
615/532-3107 Greenville, TN 37744

DUR Contact Dianne Todd Pace, Ph.D., R.N., FNP


886 Wood Cairn Cove
Jeffrey G. Stockard, D.Ph. Cordova , TN 38018
615/532-3107
Edward Capparelli, M.D.
TennCare DUR Advisory Board 121 Moore Street
Butch Benson, D.Ph. Newport, TN 37821
1310 Mulberry Court
Murfreesboro, TN 37130 James King, M.D.
1 Prime Care Drive
Christi Capers, Pharm.D. Selmer, TN 38375
Clin. Edu. Consultant, Pfizer Inc.
4043 Farmingham Woods Drive Lisa D’Souza, J.D.
Hermitage, TN 37076-4405 301 Charlotte Avenue
Nashville, TN 37201

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Peter Frizzell, M.D. Don Hazelwood, D.Ph.


1 Roundtree Court 3100 S. First Street
Johnson City, TN 37604 Milan, TN 38358

Lynn Knott, Pharm.D., CGP, FASCP Cato Johnson


1744 Stillwater Circle Methodist Healthcare
Brentwood, TN 37027 1211 Union Street, Suite 700
Memphis, TN 38104
Stanley Dowell, M.D.
Eastmoreland Internal Medicine Joe Brown
1325 Eastmoreland Avenue, Suite 245 Hardin County Nursing Home
Memphis, TN 38104 2006 Wayne Road
Savannah, TN 38372
Sheila Spates, Pharm.D.
809 Tree Trunk Road Sheryl McCormick
Knoxville, TN 37922 Region 2 Mental Health Council
7208 Merriwood Drive
Terry Shea, Pharm.D. Knoxville, TN 37919
3 Chamblee Court
Signal Mountain, TN 37377 Don Redden
Developmental Services of Dickson County
William Terrell, M.D. P.O. Box 628
1444 E. Shelby Drive, Suite 317 Dickson, TN 37056
Memphis, TN 38116
Tony Halton
Tracy Purcell (ex-officio) National Health Care for the Homeless Council
Bureau of TennCare P.O. Box 60427
729 Church Street Nashville, TN 37206
Nashville, TN 37247-6501
Osbie Howard
David Hollis, M.D. (ex-officio) OmniCare Health Plan, Inc.
Bureau of TennCare 1991 Corporate Avenue, 5th Floor
729 Church Street Memphis, TN 38132
Nashville, TN 37247-6501
Nancy Reykdal
TennCare Bureau Blue Cross/Blue Shield of Tennessee
801 Pine Street
Jeffrey G. Stockard, D.Ph. Chattanooga, TN 37402
615/532-3107
Yolanda McClain
TennCare Medical Care Advisory The Salvation Army
Committee 611 Stockell Street
Iris Snider, M.D. Nashville, TN 37207
TN Chapter of American Academy of Pediatrics
111 Epperson Avenue Effie Candis Pelfrey
Athens, TN 37303 Tennessee Health Care Campaign
1103 Foothill Court
Lloyd A. Walwyn, M.D., J.D. Nashville, TN 37217
601 Due West Avenue
Madison, TN 37115 Virginia T. Lodge, Commissioner
Department of Human Services
Deb Murph, R.N. 400 Deaderick Street, 15th Floor
Cherokee Health Systems Nashville, TN 37248
6350 West Andrew Johnson Highway
Talbott, TN 37877

Jeannie Beauchamp, D.D.S.


1833 Memorial Drive
Clarksville, TN 37043

Tennessee-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Prescription Price Updating Executive Officers of State Medical and


Pharmaceutical Societies
First DataBank
1111 Bayhill Drive, Suite 350 Tennessee Medical Association
San Bruno, CA 94066 Donald H. Alexander, CEO
T: 650/588-5454 P.O. Box 120909
F: 650/588-6867 2301 21st Avenue South
Nashville, TN 37212-0909
Medicaid Drug Rebate Contacts T: 615/385-2100
F: 615/385-3319
Audits: Sybil Creekmore, 615/741-0213 E-mail: dona@tma.medwire.org
Disputes: Jeff Stockard, D.Ph., 615/532-3107
Internet address: www.medwire.org
Claims Submission Contact Tennessee Osteopathic Medical Association
Carmen Gilbert Menser Dee Ann Walker, CAE
First Health Executive Director
4300 Cox Road 200 4TH Avenue North, Suite 900
Glen Allen, VA 23060 Nashville, TN 37219
T: 804/965-7513 T: 615/301-3048
F: 804/290-4831 F: 615/254-7047
E-mail: cngilbert@fhsc.com E-mail: dawalker@walkermgt.com
Internet address: www.tomanet.org
Medicaid Managed Care Contact
Tennessee Pharmacists Association
Michael Drescher, Public Information Officer Baeteena M. Black, Ph.D.
Bureau of TennCare Executive Director
729 Church Street 226 Capitol Boulevard, Suite 840
Nashville, TN 37247-6501 Nashville, TN 37219-1893
T: 615/741-0213 T: 615/256-3023
F: 615/741-0882 F: 615/255-3528
E-mail: michael.drescher@state.tn.us E-mail: tpa@tnpharm.org
Internet address: www.tnpharm.org
Mail Order Pharmacy Program
Tennessee has a mail order pharmacy option in its State Board of Pharmacy
Medical Assistance Program. All beneficiaries are Kendall M. Lynch, Director
entitled to participate. Davy Crocket Tower
500 James Robertson Parkway, 2nd Floor
Disease Management Patient Education Nashville, TN 37243-1149
Programs T: 615/741-2718
F: 615/741-2722
Program Name: TennCare Centers for Excellence E-mail: kendall.lynch@state.tn.us
Disease/Medical States: Asthma, Cardiovascular Internet address:
Disease, and Diabetes http://www.state.tn.us/commerce/boards/
Program Manager: Applied Health Outcomes pharmacy/index.htm

Disease Management Patient Education Tennessee Hospital Association


Contact Craig A. Becker
Judy Black President
Director of Disease Management 500 Interstate Boulevard South
Bureau of TennCare Nashville, TN 37210-4634
729 Church Street T: 615/256-8240
Nashville, TN 37247-6501 F: 615/242-4803
T: 615/532-6705 Internet address: www.tha.com
F: 615/741-0882

Tennessee-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Hospital Alliance of Tennessee


Adrienna Knestrick
President
211 Seventh Avenue North, Suite 400
Nashville, TN 37219
T: 615/254-1941
F: 615/254-1942
E-mail: adrienna@hospitalalliancetn.com
Internet address: www.hospitalalliance.com

Tennessee-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

TEXAS

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 ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients
TOTAL $1,327,222,456 1,917,351 $1,591,064,713

RECEIVING CASH ASSISTANCE, TOTAL $757,087,849 713,254


Aged $225,287,571 155,312
Blind / Disabled $439,674,579 240,642
Child $50,653,592 221,789
Adult $41,472,107 95,511

MEDICALLY NEEDY, TOTAL $13,645,641 30,183


Aged $0 -
Blind / Disabled $0 -
Child $56,065 264
Adult $13,589,576 29,919

POVERTY RELATED, TOTAL $171,959,460 810,157


Aged $812,066 930
Blind / Disabled $821,022 815
Child $149,515,656 665,651
Adult $20,810,716 142,761

TOTAL OTHER EXPENDITURES/RECIPIENTS* $384,529,506 363,757

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Texas-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Formulary/Prior Authorization


Formulary: Open formulary; however, products
Texas Health and Human Services Commission. must be listed in the Texas Drug Code Index.
Vendor drug program was implemented September Formulary managed through exclusions based on
1, 1971. contracting issues, restrictions on use, and prior
authorization. General exclusions (diseases, drug
D. PROVISIONS RELATING TO DRUGS categories, etc.) include: amphetamines, appliances,
durable medical equipment (bedpans, etc. - either
Benefit Design rental or purchase), elastic stockings, first aid
supplies, medical supplies, oxygen, supports and
Drug Benefit Product Coverage: Products covered: suspensories, and trusses.
prescribed insulin; disposable needles (pen needles
only) and syringe combinations used for insulin. Prior Authorization: State currently has a prior
Products not covered: cosmetics; fertility drugs; authorization procedure screening for drug classes
experimental drugs; total parenteral nutrition; and and individual drugs. Prior Authorization
interdialytic parenteral nutrition; blood glucose test pharmacist may be contacted to appeal a prior
strips; urine ketone test strips. authorization decision.

Over-the-Counter Product Coverage: Products Prescribing or Dispensing Limitations


covered: feminine products; topical products;
allergy, asthma, and sinus products; analgesics; Prescription Refill Limit: Five refills, but total
cough and cold preparations; digestive products; amount may not exceed 6-month supply.
smoking deterrent products. Products not covered:
Certain OTC drugs are covered on a prescription Monthly Quantity Limit: Prescribed quantity cannot
basis except as otherwise provided in the exceed 6-month supply.
reimbursement formula and vendor payment to
hospitals, nursing homes and institutions. Monthly Prescription Limit: Limited to 3 per month
except for recipients under age 21 and nursing
Therapeutic Category Coverage: Therapeutic home recipients.
categories covered: anabolic steroids; antibiotics;
analgesics; antipyretics, NSAIDs; anticoagulants; Other Limit: Recipients in managed care pilots
anticonvulsants; anti-depressants; antidiabetic receive unlimited prescription coverage.
drugs; antihistamine drugs; antilipemic agents;
antipsychotics; anxiolytics, sedatives, and Drug Utilization Review
hypnotics; cardiac drugs; chemotherapy agents; PRODUR system implemented in February 1995.
contraceptives; prescribed cold medications; ENT State currently has a DUR board with a quarterly
anti-inflammatory agents; estrogens; hypotensive review.
agents; misc. GI drugs; thyroid agents; prescribed
smoking deterrents; and sympathominetics Pharmacy Payment and Patient Cost
(adrenergic). Prior authorization required for: Sharing
growth hormones; dextroamphetamines (>21 years
of age); xenical (hyperlipidemia only). Therapeutic Dispensing Fee: . $5.14. ($5.27 was reduced for
categories not covered: anti-obesity agents; cost containment purposes in October 2003). The
vitamins (except prenatal); children’s vitamins with dispensing fee, including all costs of filling a
fluoride; and DESI drugs. prescription, was established by cost accounting
and service evaluation of the expenses involved in
Coverage of Injectables: Injectable medicines dispensing a prescription.
reimbursable through the Prescription Drug
Program when used in home health care, through Ingredient Reimbursement Basis: EAC = AWP-
physician payment when used in physicians offices, 15% or WAC + 12%, whichever is lower, AAC for
and through both the Prescription Drug Program hospitals and public health providers.
and Physician payment in extended care facilities.
Prescription Charge Formula: Average dispensing
Vaccines: Vaccines reimbursable as part of EPSDT expense (ADE) formula for payment:
service, the Children’s Health Insurance Program,
and the Vaccines for Children Program. 1. (EAC + 5.14) divided by 0.9805 = amount paid
+ $0.15 delivery service.
Unit Dose: Unit dose packaging reimbursable if 2. DEAC only for Wyeth-Ayerst and Abbott.
there is not an added expense for the packaging.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Insulin and approved non-legend drugs on First Care Health Plan


prescription: pharmacists and dispensing physicians 12940 N. Highway 183
will be reimbursed on the basis of usual charges to Austin, TX 78750
the general public or cost plus 50% of cost,
whichever is lower; 50% of cost not to exceed JPS/MetroWest Health Plan
assigned variable dispensing fee. 1617 Hemphill
Fortworth, TX 76104
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on Parkland Health First
generic drugs. 1,317 therapeutic classes and 8,169 2777 N. Stemmons Breeway, Suite 1750
NDC numbers are listed on the State-specific MAC Dallas, TX 75207
list. Override requires “Dispense as Written”,
“Medically Necessary”, “Brand Necessary”, or
“Brand Medically Necessary.” F. STATE CONTACTS

Incentive Fee: None. State Drug Program Administrator


Barbara Dean, R.Ph.
Cognitive Services: Does not pay for cognitive Acting Director, Vendor Drug Program
services. Texas Health and Human Services Commission
1100 W. 49th Street
Patient Cost Sharing: No copayment. Austin, TX 78756-3174
T: 512/491-1101
E. USE OF MANAGED CARE F: 512/491-1959
E-mail: barbara.dean@hhsc.state.tx.us
Internet address: www.hhsc.state.tx.us
Approximately 530,000 Medicaid recipients were
enrolled in MCOs in 2002 (all of whom are
AFDC/AFDC- related). Recipients in managed Health and Human Services Commission
care receive pharmaceutical benefits through the Officials
State. (Pharmacy program is “carved out.”) Albert Hawkins
Executive Commissioner
Managed Care Organizations Texas Health and Human Service Commission
4900 N. Lamar Boulevard
AMERIGROUP, Inc.
Austin, TX 78751
1200 East Copeland Road, Suite 200
T: 512/424-6502
Arlington, TX 76011
F: 512/424-6587
E-mail: albert.hawkins@hhsc.state.tx.us
Community First Health Plan
4801 NW Loop 410, Suite 1000
Jason Cooke
San Antonio, TX 78229
Associate Commissioner for Medicaid
Texas Health and Human Services Commission
El Paso First Health Plans
4900 N. Lamar Boulevard
2501 North Mesa
Austin, TX 78751
El Paso, TX 79902
T: 512/424-6517
F: 512/424-6587
HMO Blue-Medicaid
E-mail: Medicaid@hhsc.state.tx.us
901 S. Central Expressway
Richardson, TX 75080
Prior Authorization Contact
Texas Children’s Health Plan Don Valdes, R.Ph.
1919 Braeswood Pharmacist II
Houston, TX 77230 Vendor Drug Program
Texas Health and Human Services Commission
Superior Health Plan 1100 W. 49th Street
2100 S. IH35, Suite 202 Austin, TX 78756
Auston, TX 78704 T: 512/491-1172
F: 512/491-1962
Community Health Choice E-mail: Don.Valdes@hhsc.state.tx.us
2636 South Loop, Suite 700
Houston, TX 77054

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National Pharmaceutical Council Pharmaceutical Benefits 2003

DUR Contact New Brand Name Products Contact


Barbara Dean, R.Ph. Martha McNeill, R.Ph.
Manager, DUR Program Product and Prescriber Manager
Texas Health and Human Services Commission Texas Health and Human Services Commission
1100 W. 49th Street 11209 Metric Boulevard, Building H
Austin, TX 78756-3174 Austin, TX 78758
T: 512/491-1101 T: 512/491-1157
F: 512/491-1959 F: 512/491-1961
E-mail: barbara.dean@hhsc.state.tx.us E-mail: Martha.mcneill@hhsc.state.tx.us

DUR Board Prescription Price Updating


Leroy Knodel, Pharm.D., Vice Chairman Martha McNeill, R.Ph.
Drug Information Service 512/491-1157
Department of Pharmacology
The University of Texas Health Science Center Medicaid Drug Rebates Contact
7703 Floyd Curl Drive
San Antonio, TX 78284-7766 Heather Murphy
Manager, Pharmacy Rebates
Thomas Lee Kurt, M.D., M.P.H. Vendor Drug Program
8600 Thackery, Suite 162 Texas Health and Human Services Commission
Dallas, TX 75225 1100 W. 49th Street
Austin, TX 78745
T: 512/491-1163
Mark S. Gittings, D.O., R.Ph.
F: 512/491-1960
12340 Almeda Trace Circle, Suite 2302
E-mail: heather.murphy@hhsc.state.tx.us
Austin, TX 78727

Robert L. Hogue, M.D. Claims Submission Contact


101 A South Park Drive Laura Bagheri
Brownwood, TX 76801 Manager, Pharmacy Resolutions
Vendor Drug Program
Daniel Saylak, D.O., Chairman Texas Health and Human Services Commission
841 N. Rosemary Drive 1100 West 49th Street
Bryan, TX 77802 Austin, TX 78745
T: 512/491-1741
Mary Spies Maxwell, M.D. F: 512/491-1958
4526 Burnet Road E-mail: laura.bagheri@hhsc.state.tx
Austin, TX 78731
Medicaid Managed Care Contact
Adelina Barbosa, R.Ph.
#10 Casa De Palmas Pamela Coleman
Brownsville, TX 78521 Director, Health Plan Operations
Texas Health and Human Services Commission
Anita Martinez, R.Ph., CDE 1100 W. 49th Street
2819 Burning Hill Austin, TX 78756
San Antonio, TX 78247 512/491-1302
E-mail: pam.coleman@hhsc.state.tx.us
James B. Hills, R.Ph.
9100 South West Freeway Mail Order Pharmacy Program
Houston, TX 77054 None

Robert T. Reilly, Pharm.D.


Thomason Hospital
Department of Pharmacy
4815 Alameda Avenue, P. O. Box 2009
El Paso, TX 79905

Texas-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Executive Officers of State Medical and


Pharmaceutical Societies
Texas Medical Association
Louis J. Goodman, Ph.D., CAE
Executive Vice President/CEO
401 W. 15th Street
Austin, TX 78701-1680
T: 800/880-1300
F: 512/370-1632
E-mail: lou.goodman@texmed.org
Internet address: www.texmed.org

Texas Pharmacy Association


Jim Martin, R.Ph.
Executive Director/CEO
P. O. Box 14709
1624 E. Anderson Lane
Austin, TX 78761-4709
T: 512/836-8350
F: 512/836-8308
E-mail: jmartin@txpharmacy.com
Internet address: www.txpharmacy.com

Texas Osteopathic Medical Association


Terry Boucher, M.P.H.
Executive Director, Secretary/Treasurer
1415 Lavaca Street
Austin, TX 78701-1634
T: 512/708-8662
F: 512/708-1415
E-mail: terryb@txosteo.org
Internet address: www.txosteo.org

State Board of Pharmacy


Gay Dodson, R.Ph.
Executive Director/Secretary
William P. Hobby Building, Box 21
333 Guadalupe Street, Suite 3-600
Austin, TX 78701-3942
T: 512/305-8000
F: 512/305-8082
E-mail: gay.dodson@tsbp.state.tx.us
Internet address: www.tsbp.tx.us

Texas Hospital Association


Richard Bettis, CAE
President & CEO
P.O. Box 15587
Austin, TX 78761-5587
T: 512/465-1000
F: 512/465-1090
E-mail: rbettis@tha.org
Internet address: www.thaonline.org

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Texas-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

UTAH

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $117,101,302 136,682 $140,275,267

RECEIVING CASH ASSISTANCE TOTAL $48,529,173 33,260


Aged $5,275,146 2,848
Blind/Disabled $37,273,244 12,442
Child $1,949,135 11,105
Adult $4,031,648 6,865

MEDICALLY NEEDY, TOTAL $5,661,159 2,569


Aged $1,083,310 528
Blind/Disabled $3,965,954 965
Child $82,975 441
Adult $528,920 635

POVERTY RELATED, TOTAL $57,527,963 77,811


Aged $15,915,526 6,468
Blind/Disabled $25,732,028 7,940
Child $5,852,559 39,384
Adult $10,027,850 24,019

TOTAL OTHER EXPENDITURES/RECIPIENTS* $5,383,007 23,042

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Utah-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Products covered with restrictions: feminine


products; topical products: Products not covered:
Division of Health Care Financing, State vitamins (except for expectant mothers and children
Department of Health. to age 5); smoking deterrent products (special
program for expectant mothers); and digestive
products.
D. PROVISIONS RELATING TO DRUGS
For additional information or to obtain a list of
Benefit Design covered over-the-counter products, contact the Utah
Drug Benefit Product Coverage: Prior Medicaid program at
authorization required for: amphetamines; http://hlunix.hl.state.ut.us/Medicaid/.
Ritalin/methylphenidate; darvocet; darvon; enbrel;
relenza; human growth hormones; lactulose syrup, Therapeutic Category Coverage: Products covered:
lufyllin, oxandrin; panretin topiacal gel; prolastin; antibiotics; anticoagulants; anticonvulsants;
regranex retin-a-gel; tamiflu; zofran; aggrenox; antidiabetic agents; antihistamines; antilipemic
cerezyme; adagen; xenical; lovenox; prilosec; agents; anxiolytics, sedatives, and hypnotics;
prevacid; aciphex; protonix, normiflo; fragmin; cardiac drugs; chemotherapy agents; prescribed
kytril; and anzemet. Products covered under DME: cold medications; contraceptives; ENT anti-
total parenteral nutrition. Products covered with flammatory agents; estrogens; hypotensive agents;
restrictions: disposable needles and syringe misc. GI drugs; and thyroid agents. Products
combinations used for insulin (prefilled restricted to covered with restrictions: anti-depressants;
blind clients only) and interdialytic parenteral sympathominetics (adrenergic). Prior authorization
nutrition. Products not covered: cosmetics; fertility required for: analgesics, antipyretics, and NSAIDs;
drugs; experimental drugs; and hair growth anti-psychotics; and growth hormones (partial
products. coverage). Products not covered: anabolic steroids;
anoretics; prescribed smoking deterrents; diet
Over-the-Counter Product Coverage: OTC medications.
products that are covered require a written
prescription just like legend drugs in order for the Coverage of Injectables: Injectable medicines
pharmacy to fill them. Clients must present a reimbursable through the Prescription Drug
Medicaid card and a prescription. Products Program when used in home health care and
covered: extended care facilities, and through both the
− Acetone tests (e.g., Acetest, Chemstrip-K, Prescription Drug Program and physician payment
Ketostix) when used in physician offices.
− Allergy, asthma and sinus products (generics
only) Vaccines: Vaccines reimbursable at AWP minus
− Analgesics (generics only) 15% plus a fee as part of the EPSDT service, the
− Contraceptives Children’s Health Insurance Program, and the
− Cough and cold preparations (generics only) Vaccines for Children Program.
− DSS, caps liquid and syrup
− DSS concentrate drops 5% Unit Dose: Unit dose packaging reimbursable.
− Ferrous fumerate, All dosage forms
− Ferrous gluconate, All dosage forms Formulary/Prior Authorization
− Ferrous sulfate, All dosage forms Formulary: Open formulary.
− Glucose blood tests (e.g., Chemstrip, BG,
Dextrostix, Visidex) Prior Authorization:State has a prior authorization
− Glucose urine tests (e.g., Clinitest, Clinistix, procedure screening for individual drugs with fair
Diatrix, Tes Tape, Chemstrip G) hearing appeal process to DUR board.
− Insulin
− Insulin syringes/needles/disposable Prescribing or Dispensing Limitations
(100/month)
− Kaolin w/pectin suspension (e.g., Kaopectate) Prescription Refill Limit: Limited to five.
− Lactobacillus acidophilus (e.g., Bacid,
Lactinex) Monthly Quantity Limit: In general, the quantity of
− Nutrients (all nutrients require prior approval) medication shall be limited to a supply not to
− Pedialyte liquid exceed 31 days. Cumulative limits on specific
− Prophylactics male drugs Maximum scripts per month (except children
− Psyllium muciloid powder and pregnant women).
− Quinine, 5 gr.

Utah-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Drug Utilization Review F. STATE CONTACTS


PRODUR system implemented in 1994.
State Drug Program Administrator
Pharmacy Payment and Patient Cost RaeDell Ashley, R.Ph.
Sharing Pharmacy Director
Dispensing Fee: $3.90 for urban, $4.40 for rural, Division of Health Care Financing
effective 1998. $1.00 for OTCs. Department of Health
288 North 1460 West
Ingredient Reimbursement Basis: EAC = Lesser of P.O. Box 143102
AWP-15% or AAC. Salt Lake City, UT 84114-3102
T: 801/538-6495
Prescription Charge Formula: Lowest of: F: 801/538-6099
E-mail: rashley@utah.gov
1. EAC/MAC plus a dispensing fee, or Internet address: www.utah.gov
2. Usual and customary charges to the private
sector for legend and generic legend drugs. New Brand Name Products Contact
Formula for OTCs is AWP minus 15% plus $1.00
dispensing fee. RaeDell Ashley, R.Ph.
801/538-6495
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on DUR Contact
generic drugs. Override requires “Dispense as Duane Parke
Written”, “Medically Necessary”, or “Brand DUR Director
Medically Necessary.” Division of Health Care Financing
Department of Health
Incentive Fee: None. P.O. Box 143102
Salt Lake City, UT 84114-3102
Patient Cost Sharing: Copayment = $3.00 T: 801/538-6452
F: 801/538-6099
Cognitive Services: Does not pay for cognitive E-mail: dpark@utah.gov
services.
DUR Board
E. USE OF MANAGED CARE Lowry Bushnell, M.D.
Western Institute of Neuropsychiatry
Approximately 14,000 Medicaid recipients are 501 Chipeta Way
enrolled in managed care. Pharmacy benefits are Salt Lake City, UT 84108
through the State.
Bradford D. Hare, M.D., Ph.D.
Managed Care Organizations Department of Anesthesiology
50 North Medical Drive
American Family Care
Salt Lake City, UT 84132
2120 South 13th East #303
Salt Lake City, UT 84106
Jeff Jones, R.Ph.
Healthy U Riverton Drug
35 W. Broadway 1741 West 12600 South
Salt Lake City, VT 84101 Riverton, UT 84065
IHC Access
Richard Martinez, D.D.S.
P.O. Box 116670
2936 Highland Drive
Salt Lake City, UT 84147
Salt Lake City, UT 84106
Med Utah Healthwise
Karen M. Gunning, Pharm.D.
P.O. Box 30804
Univ. of Utah College of Pharmacy
Salt Lake City, UT 84130-0804
30 South 2000 East, Room 265
Salt Lake City, UT 84112-5820
United Medchoice
7910 South 3500 East
Salt Lake City, UT 84121

Utah-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Colin B. Van Orman, M.D. Mail Order Pharmacy Program


PCMC
State has a mail order pharmacy program. Utah
100 North Medical Drive, Suite 2700
Medicaid beneficiaries may choose to obtain
Salt Lake City, UT 84113
prescription drugs through mail order.
Derek Christensen, R.Ph.
9842 Grouse Bend Circle Department of Health Officials
South Jordan, UT 84095 Scott D.Williams
Executive Director
Joseph Miner, M.D. Department of Health
Utah County Health Department P.O. Box 141000
589 South State Street Salt Lake City, UT 84114-1000
Provo, UT 84601 T: 801/538-6111
F: 801/538-6306
Dominic DeRose, R.Ph. E-mail: scottwilliams@utah.gov
Value Drug
1080 West 300 North Michael Deily, Director
Clearfield, UT 84015 Department of Health
Division of HealthCare Financing
Laurie Ott, PA-C Department of Health
2107 West 3500 South P.O. Box 143101
West Valley City, UT 84119 Salt Lake City, UT 84114-1000
T: 801/538-6406
Prescription Price Updating F: 801/538-6099
E-mail: mdeily@utah.gov
RaeDell Ashley, R.Ph.
801/538-6495
Executive Officers of State Medical and
Medicaid Drug Rebate Contacts Pharmaceutical Societies
Technical: RaeDell Ashley, R.Ph., 801/538-6495 Utah Medical Association
Policy: RaeDell Ashley, R.Ph., 801/538-6495 J. Leon Sorenson
PA: RaeDell Ashley, R.Ph., 801/538-6495 Executive Vice President
DUR: Duane Parke, 801/538-6452 540 East 500 South
Salt Lake City, UT 84102
Claims Submission Contact T: 801/355-7477
F: 801/532-1550
Connie Higley
E-mail: uma@utahmed.org
Information Technology Director
Internet address: www.utahmed.org
Division of Health Care Financing
Department of Health
Utah Osteopathic Medical Association
P.O. Box 143102
Shelly Hanks
Salt Lake City, UT 84114-3102
Secretary
801/538-6691
462 South 1240 East
E-mail: chigley@utah.gov
Payson, UT 84651-8533
T: 801/465-9545
Medicaid Managed Care Contact
F: 801/794-9545
Julie Olsen, Director E-mail: info@uoma.net
Managed Health Care Internet address: www.uoma.net
Division of Health Care Financing
Department of Health Utah Pharmaceutical Association
P.O. Box 143102 Reid L. Barker
Salt Lake City, UT 84114-3102 Executive Director
T: 801/538-6303 1850 South Columbia Lane
F: 801/538-6009 Orem, UT 84097
E-mail: jolsen@utah.gov T: 801/762-0452
F: 801/762-0454
E-mail: upha@upha.com
Internet address: www.upha.com

Utah-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Utah Board of Pharmacy


Diana L. Baker
Bureau Director
160 East 300 South
P.O. Box 146741
Salt Lake City, UT 84116-6741
T: 801/530-6179
F: 801/530-6511
E-mail: dbaker@utah.gov
Internet address: www.dopl.utah.gov

Utah Hospitals and Health Systems Association


Joseph M. Krella, FACHE
President
2180 South 1300 East, Suite 440
Salt Lake City, UT 84016
T: 801/486-9915
F: 801/486-0882
E-mail: joe@uha-utah.org
Internet address: www.uha-utah.org

Utah-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Utah-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

VERMONT1

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $105,673,417 109,328 $114,157,870


RECEIVING CASH ASSISTANCE TOTAL $39,685,114 25,169
Aged $3,799,046 1,741
Blind/Disabled $30,223,439 10,679
Child $2,061,532 8,225
Adult $3,601,097 4,524

MEDICALLY NEEDY, TOTAL $17,804,948 9,407


Aged $6,488,482 2,836
Blind/Disabled $9,113,456 2,639
Child $537,853 1,641
Adult $1,665,157 2,291

POVERTY RELATED, TOTAL $4,956,436 26,895


Aged $0 -
Blind/Disabled $0 -
Child $4,726,155 25,385
Adult $230,281 1,510

TOTAL OTHER $43,226,919 47,857


EXPENDITURES/RECIPIENTS*
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

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.

Vermont-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Monthly Quantity Limit: Initial prescription should


be sufficient to allow for the determination of the
Department of Prevention, Assistance, Transition, patient’s tolerance of the medication without
and Health Access (PATH) creating unnecessary waste (expense) to the
program. This quantity could be up to a 60-day
supply on all maintenance medication prescriptions.
D. PROVISIONS RELATING TO DRUGS
Drug Utilization Review
Benefit Design
PRODUR system implemented in November 1993.
Drug Benefit Product Coverage: Products covered: State currently has a DUR board with a bimonthly
prescribed insulin; disposable needles and syringe review.
combinations used for insulin; blood glucose test
strips; urine ketone test strips; total parenteral Pharmacy Payment and Patient Cost
nutrition; and interdialytic parenteral nutrition. Sharing
Products not covered: cosmetics and experimental
drugs. Dispensing Fee: $4.25, effective 7/1/96.

Over-the-Counter Product Coverage: Products Ingredient Reimbursement Basis: EAC = AWP–


covered with prior authorization: allergy, asthma 11.9%.
and sinus products; analgesics; cough and cold
preparations; digestive products; feminine products; Prescription Charge Formula: Pharmacies bill their
topical products; and smoking deterrent products. usual and customary charge. Medicaid pays the
lower of:
Therapeutic Category Coverage: Therapeutic 1. Usual and customary charge;
categories covered: anabolic steroids; analgesics, 2. EAC plus a dispensing fee; or
antipyretics, NSAIDs; anorectics; antibiotics; 3. Maximum allowable cost plus a dispensing fee.
anticoagulants; anticonvulsants; anti-depressants;
antidiabetic agents; antihistamine drugs; Maximum Allowable Cost: State imposes Federal
antilipemic agents; anti-psychotics; anxiolytics, Upper Limits as well as State-specific limits on
sedatives, and hypnotics; cardiac drugs; generic drugs. Override requires “Dispense as
chemotherapy agents; prescribed cold medications; Written.”
contraceptives; ENT anti-inflammatory agents;
estrogens; hypotensive agents; misc. GI drugs; Incentive Fee: None.
sympathominetics (adrenergic); and thyroid agents.
Prior authorization required for: prescribed Patient Cost Sharing: Generics: $3.00, Brand:
smoking deterrents. $6.00 to a maximum of $50.00 per beneficiary per
quarter.
Coverage of Injectables: Injectable medicines
reimbursable when used in physician offices, home Cognitive Services: Does not pay for cognitive
health care, and extended care facilities. services.

Vaccines: Reimbursable at AWP minus 10% as part


of EPSDT service. E. USE OF MANAGED CARE

Unit Dose: Unit dose packaging reimbursable. Approximately 82,000 total Medicaid recipients are
enrolled in a PCCM in 2002.
Formulary/Prior Authorization
Formulary: Open formulary with preferred drug list F. STATE CONTACTS
(PDL). General exclusions include cosmetics and
experimental drugs. State Drug Program Administrator
Samantha Haley
Prior Authorization: Prior authorization required Operations Manager
screening for drugs not listed on PDL Office of Vermont Health Access
103 South Main Street
Prescribing or Dispensing Limitations Waterbury, VT 05671-1201
Prescription Refill Limit: Up to 5 may be T: 802/241-2765
authorized by a physician. F: 802/241-2974
E-mail: samantha@path.state.vt.us

Vermont-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Agency of Human Services Officials Medicaid Drug Rebate Contacts


Charles Smith Christine Dapkiewicz
Secretary 802/979-4450
Agency of Human Services
103 South Main Street Claims Submission Contact
Waterbury, VT 05671-0201
T: 802/241-2220 Leanne Miles
F: 802/241-2979 312 Hurricane Lane, Suite 101
E-mail: charles@wpgatei@aah.state.vt.us Williston, VT 05495
T: 802/879-4450
Joshua Slen F: 802/878-3440
Medicaid Director
Dept. of Prevention, Assistance, Transition, and Medicaid Managed Care Contact
Health Access Liz Reardon
103 South Main Street lizr@path.state.vt.us
Waterbury, VT 05676-1201
T: 802/879-5900 Disease Management Initiative/Program
F: 802/879-5962 Contact
E-mail: joshuas@path.state.vt.us
Shona Mossey-Lothrop
Prior Authorization Contact Pharmacy Consultant
312 Hurricane Lane, Suite 101
Roger Tremblay Williston, VT 05495
rogert@path.state.vt.us T: 802/879-4450
F: 802/878-3440
DUR Contact E-mail: mossesm@vtxix.slg.acs.com
Scott Strenio, M.D.
Clinical Consultant Expanded Drug Coverage Program Contact
Office of VT Health Access Esther Pearlman
103 S. Main St. estherp@path.state.vt.us
Waterbury, VT 05671
802/741-7975 Executive Officers of State Medical and
E-mail: scottstrenio@msn.com Pharmaceutical Societies

DUR Board Vermont Medical Society


Paul Harrington
James A. Gray, M.D. (Chair) Executive Vice President
Jeffrey P. Firlik, R.Ph. 134 Main Street
Cheryl A. Gibson, M.D. P.O. Box 1457
Virginia L. Hood, M.D. Montpelier, VT 05601
Donna M. Kiley, M.D. T: 802/223-7898
Frank J. Landry, M.D. F: 802/223-1201
John R. Low, R.Ph. E-mail: info@vtmd.org
Andrew C. Miller, R.Ph. Internet address: www.vtmd.org
Michael Scovner, M.D.
Lloyd (Tim) L. Thompson, M.D. Vermont Pharmacists Association
Norman S. Ward, M.D. James Marmar
Executive Director
Prescription Price Updating Box 90
Christine Dapkiewicz Woodstock, VT 05091
Drug Rebate Coordinator T: 877/483-2646
312 Hurricane Lane, Suite 101 F: 802/433-4803
Williston, VT 05495 E-mail: vtpa@sovern.net
T: 802/879-4450 Internet address: www.vtpharmacists.org
F: 802/878-3440

Vermont-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Vermont State Association of Osteopathic


Physicians & Surgeons, Inc.
John M. Peterson, D.O.
Executive Director
72 Barre Street
Montpelier, VT 05602-3508
T: 802/229-9418
F: 802/229-5619

State Board of Pharmacy


Peggy Atkins
Board Administrator
26 Terrace Street, Drawer 09
109 State Street, Pavilion Office Building
Montpelier, VT 05609-1101
T: 802/828-2875
F: 802/828-2465
E-mail: patkins@sec.state.vt.us
Internet address:
www.vtprofessionals.org/oprl/pharmacists

Vermont Association of Hospitals and Healthcare


Systems
Marie Beatrice Grause
President & CEO
148 Main Street
Montpelier, VT 05602
T: 802/223-3461
F: 802/223-0364
E-mail: bea@vahhs.org
Internet address: www.vahhs.org

Vermont-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

VIRGINIA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/ Child Adult Aged Blind/ Child Adult
Disable Disabled
d
Prescribed Drugs ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Inpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Outpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Laboratory & X-ray Service ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Nursing Facility Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Physician Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Dental Services All eligible recipients under age 21

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $419,133,293 333,880 $453,634,681 319,184


RECEIVING CASH ASSISTANCE TOTAL $252,905,212 102,360 $260,847,901 98,158
Aged $73,894,551 34,599 $81,793,718 33,845
Blind/Disabled $178,608,437 66,480 $178,993,058 64,248
Child $140,364 733 $17,496 90
Adult $261,860 548 $43,629 75
MEDICALLY NEEDY, TOTAL $14,259,566 6,474 $13,520,329 5,705
Aged $5,995,613 3,354 $5,782,480 2,811
Blind/Disabled $8,230,689 2,951 $7,565,189 2,617
Child $27,529 136 $19,393 141
Adult $5,735 33 $153,267 136

POVERTY RELATED, TOTAL $35,351,169 140,124 $54,335,573 137,101


Aged $2,442,573 2,295 $12,378,957 7,008
Blind/Disabled $3,725,012 2,539 $15,064,557 6,389
Child $26,581,071 116,636 $24,559,080 106,380
Adult $2,602,513 18,654 $2,332,979 17,324

TOTAL OTHER EXPENDITURES/RECIPIENTS $116,617,346 84,922 $124,930,878 78,220

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data provided by the Virginia Department of Medical Assistance Services.

Source: CMS, MSIS Report, FY 2001 and Virginia Medicaid Statistical Information System, FY 2002.

Virginia-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION prior authorization, therapeutic substitution,


preferred products; and physician profiling.
Department of Medical Assistance Services.
Eligibility determination by the Department of Prior Authorization: State currently has a formal
Social Services. prior authorization process to appeal prior
authorization decisions (see
www.dmas.virginia.gov under pharmacy initiatives
D. PROVISIONS RELATING TO DRUGS for appropriate process). Prior authorization
procedure screening for individual drugs for weight
Benefit Design loss.
Drug Benefit Product Coverage: Products Covered:
prescribed insulin; disosable needles and syringe Prescribing or Dispensing Limitations
combinations used for insulin; blood glucose test Prescription Refill Limit: Physicians may authorize
strips; total parenteral nutrition; and interdialytic refills according to legal requirements.
parenteral nutrition. Products not covered:
cosmetics; fertility drugs; hair growth products; Monthly Quantity Limit: 34-day supply.
designated DESI drugs; experimental drugs; non-
legend drugs; and expired drugs. Drug Utilization Review

Over-the-Counter Drug Coverage: A majority of PRODUR (online) system implemented in July


OTC drugs reimbursable when used in nursing 1994. RetroDUR Program also implemented in
homes and certain classes in outpatient populations. 1994. State currently has a DUR Board with
These include: allergy, asthma, and sinus products; quarterly meetings.
analgesics; cough and cold preparations; digestive
products; feminine products; topical products; and Pharmacy Payment and Patient Cost
smoking deterrent products. Sharing
Dispensing Fee: $3.75, effective 7/1/04.
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; analgesics, Ingredient Reimbursement Basis: EAC = AWP –
antipyretics, and NSAIDs; anoretics; antibiotics; 10.25%.
anticoagulants; anticonvulsants; anti-depressants;
antidiabetic agents; antihistamines; antilipemic Prescription Charge Formula: Based upon the
agents; anti-psychotics; anxiolytics, sedatives, and lower of VMAC or EAC plus a fee, or the usual
hypnotics; cardiac drugs; chemotherapy agents; and customary charge minus a copayment of $1.00
prescribed cold medications; estrogens; growth for generics and $3.00 for brand-name products,
hormones; hypotensive agents; misc. GI drugs; where appropriate.
prescribed smoking deterrents, sympathominetics
(adrenergic); and thyroid agents. Prior authorization Maximum Allowable Cost: State imposes State-
required for: weight loss drugs and non-preferred specific limits on generic drugs. Override requires
drugs. “Dispense as Written.”
Coverage of Injectables: Injectable medicines Incentive Fee: None.
reimbursable through both the Prescription Drug
Program and physician payment when used in Patient Cost Sharing: Copayment is $1.00/Rx for
home health care, extended care facilities, and generics and $3.00/Rx on brand-name products.
physician offices. qualifying prescriptions. Exclusions include less
than 21 years old, pregnancy related, family
Vaccines: Vaccines reimbursable as part of the planning, and nursing home patients.
Vaccines for Children Program.
Cognitive Services: Does not pay for cognitive
Unit Dose: Unit dose packaging reimbursable in services at present.
nursing homes.

Formulary/Prior Authorization E. USE OF MANAGED CARE


Formulary: Open Formulary with preferred drug Approximately 344,000 beneficiaries enrolled in
list (PDL). Managed through excluding products HMOs in 2002. Recipients enrolled in managed
based on contracting issues, restrictions on use, care organizations receive pharmaceutical benefits
through managed care plans.

Virginia-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Managed Care Organizations Medicaid Drug Rebate Contacts


Virginia Premier Health Plan Policy: Javier Menendez, R.Ph.
Anthem HealthKeepers Plus 804/783-2196
Sentara Family Care
Disputes: Charles Townsend
Southern Health/CareNet
Pharmacy Manager
UNICARE Health Plan of Virginia
First Health Services Corporation
Community Pharmacy Coalition
F. STATE CONTACTS 4300 Cox Road
Glen Allen, VA 23060
State Drug Program Administrator 804/965-7400
E-mail: townseCH@fhsc.com
Javier Menendez, R.Ph.
Pharmacy Manager Claims Submission Contact
Department of Medical Assistance Services
600 East Broad Street, Suite 1300 Frank Fury
Richmond, VA 23219 Operations Manager
T: 804/783-2196 First Health Services Corporation
F: 804/786-0973 4300 Cox Road
E-mail: javier.menendez@virginia.gov Glen Allen, VA 23060
Internet address: www.dmas.virginia.gov Community Pharmacy Coalition
804/965-7400
DUR Contact
Mail Order Pharmacy Program
Javier Menendez, R.Ph.
804/783-2196 None

DUR Board Medical Managed Care Contact


Robert O. Friedel, M.D. Mary Mitchell
Catherine Kelso, M.D. Supervisor for Managed Care
Jason Lynam, M.D. Department of Medical Assistance Services
Jennifer Edwards, Pharm.D. 600 East Broad Street, Suite 1300
Elaine Ferrary, M.S. Richmond, VA 23219
Jane Settle, N.P. T: 804/786-3594
Geneva Briggs, Pharm.D. (Chair) F: 804/786-5799
Sandra Dawson, R.Ph. E-mail: mary.mitchell@dmas.virginia.gov
Kelly Goode, Pharm.D.
Mark Johnson, Pharm.D. Department of Medical Assistance Services
Bill Rock, Pharm.D. Officials
Patrick W. Finnerty
New Brand Name Products Contact Director
Javier Menendez, R.Ph. Department of Medical Assistance Services
804/783-2196 600 East Broad Street, Suite 1300
Richmond, VA 23219
Prescription Price Updating T: 804/786-4231
F: 804/225-4512
Javier Menendez, R.Ph. E-mail: pfinnert@dmas.state.va.us
804/783-2196

Virginia Medicaid Pharmacy Liaison


Committee
Bill Hancock, R.Ph.
Long Term Care Pharmacy Coalition

Alexander Maculey, R.Ph.


Community Pharmacy

Michael Ayotte, R.Ph.


Virginia Association of Chain Drug Stores

Virginia-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Rebecca Snead, R.Ph. Virginia Hospital and Healthcare Association


Virginia Pharmacist Association Laurens Sartoris
President
Jan Burrus 4200 Innslake Drive
Pharmaceutical Research and Manufacturers of Glen Allen, VA 23060
America T: 804/965-1216
F: 804/965-0475
Ann Leigh Kerr E-mail: lsartoris@vhha.com
Troutman Sanders LLP Internet address: www.vhha.com

Richard Grossman
Vectre Corporation

Executive Officers of State Medical and


Pharmaceutical Societies
Medical Society of Virginia
Paul Kitchen
Executive Vice President
4205 Dover Road
Richmond, VA 23221-3267
T: 804/353-2721
F: 804/355-6189
E-mail: pkitchen@msv.org
Internet address: www.msv.org

Virginia Pharmacists Association


Rebecca P. Snead
Executive Director
5501 Patterson Avenue, Suite 200
Richmond, VA 23226
T: 804/285-4145
F: 804/285-4227
E-mail: becky@vapharmacy.org
Internet address: www.vapharmacy.org

State Board of Pharmacy


Elizabeth Scott Russell
Executive Director
6603 W. Broad Street, 5th Floor
Richmond, VA 23230-1712
T: 804/662-9911
F: 804/662-9313
E-mail: pharmbd@dhp.state.va.us
Internet address: www.dhp.state.va.us/pharmacy

Virginia Osteopathic Medical Association


Maria Harris
Executive Director
48 East Square Lane
Richmond, VA 23233
T: 804/784-2204
F: 804/784-2231
E-mail: voma@erols.com
Internet address: www.voma-net.org

Virginia-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

WASHINGTON

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001** 2002**
Expenditures Recipients Expenditures Recipients
TOTAL $458,332,414 $541,963,790

RECEIVING CASH ASSISTANCE, TOTAL


Aged
Blind / Disabled
Child
Adult

MEDICALLY NEEDY, TOTAL


Aged
Blind / Disabled
Child
Adult

POVERTY RELATED, TOTAL


Aged
Blind / Disabled
Child
Adult

TOTAL OTHER EXPENDITURES/RECIPIENTS*

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001and 2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are
unavailable.

Source: CMS, CMS-64 Report, FY 2001 and 2002.

Washington-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Vaccines: Vaccines reimbursable at EAC as part of


EPSDT services.
Medical Assistance Administration, Department of
Social and Health Services. Unit Dose: Unit dose packaging is reimbursable.

Formulary/Prior Authorization
D. PROVISIONS RELATING TO DRUGS
Formulary: Open formulary with preferred drug list
Benefit Design (PDL). Managed through prior authorization,
preferred products, and physician profiling.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Prior Authorization: State currently has a prior
combinations for insulin; blood glucose test strips; authorization program and a Drug Utilization and
urine ketone test strips; total parenteral nutrition; and Education Review Council. Recipients can request
interdialytic parenteral nutrition. Products not a fair hearing and exception to policy to appeal an
covered: cosmetics; fertility drugs; DESI drugs; and excluded product or prior authorization decision.
experimental drugs.
Prescribing or Dispensing Limitations
Over-the-Counter Product Coverage: Products
covered with restrictions: allergy, asthma and sinus Prescription Refill Limit: Two (2) refills in 30-day
products (selected items); analgesics (ASA and period except for antibiotics, anti-asthmatics,
acetaminophen); cough and cold preparations Schedule II and III drugs, anti-neoplastic, topicals,
(selected items); digestive products (selected items); and any propoxyphene, which may have 4 refills.
feminine products (selected items); and topical
products (selected items). Products not covered: Monthly Prescription Limit: Review of client drug
smoking deterrent products. (Note: Zyban only profile by a clinical pharmacist when request for 5th
covered for pregnant women in smoking cessation brand name prescription in any one-month period.
program).
Monthly Quantity Limit: Maximum 34-day supply
Therapeutic Category Coverage: Therapeutic (90 days on select items).
categories covered: antibiotics; anticoagulants;
anticonvulsants; antidiabetic agents; anti- Drug Utilization Review
depressants; antilipemic agents; cardiac drugs; PRODUR system implemented in March 1996.
chemotherapy agents; contraceptives; ENT anti- State currently has a DUR Board with a quarterly
inflammatory agents; estrogens; hypotensive agents; review.
sympathominetics (adrenergic); and thyroid agents.
Therapeutic categories requiring prior Pharmacy Payment and Patient Cost
authorization:* Sharing
anabolic steroids; analgesics, antipyretics, and
NSAIDs; antihistamine drugs; anti-psychotics; Dispensing Fee: $4.20 to $5.20, effective 7/1/02.
anxiolytics, sedatives, and hypnotics; prescribed cold − $4.20 - Retail pharmacies, filling over 35,000
medications; growth hormones; misc. GI drugs; and Rxs annually.
non-preferred drugs. Therapeutic categories not − $4.51 - Retail pharmacies, filling 15,001-
covered: anoretics; prescribed smoking deterrents 35,000 Rxs annually.
and weight loss drugs; products for hair growth; and − $5.20 - Retail pharmacies, filling 15,000 or less
figidity, impotency, or sexual dysfunction drugs. Rxs annually.
− $5.20 - Unit dose systems (nursing home Rxs).
*Drugs considered for prior authorization are drugs
with high risk/benefit ratio, high potential for Ingredient Reimbursement Basis: EAC = AWP –
abuse/misuse, narrow therapeutic indication, and 14%, except drugs on the MAC list with 5 or more
high cost. A complete list of drugs requiring prior labelers/manufacturers are reimbursed at AWP-
authorization may be found on the Medical 50%.
Assistance Administration’s web site:
wwws2.wa.gov/dshs/maa. Prescription Charge Formula: The amount shall
not exceed the usual and customary charge to the
Coverage of Injectables: Injectable medicines public or EAC plus a dispensing fee. Any drug
reimbursable through the Prescription Drug Program with more than 3 labelers will be reimbursed
when used in home health care and extended care according to the Maximum Allowable Cost.
facilities, and through physician payment when used
in physician offices.

Washington-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Maximum Allowable Cost: State imposes Federal Regence Blue Shield


Upper Limits as well as State-specific limits on P.O. Box 21267
generic drugs. Override requires “Medically Mail Stop BR 390
Necessary” or “Brand Medically Necessary.” Seattle, WA 98111-3267
253/573-3248
Incentive Fee: None.

Patient Cost Sharing: No copayment. F. STATE CONTACTS

Cognitive Services: State pays for cognitive services State Drug Program Administrator
under the Emergency Contraceptive Program. Siri A. Childs, Pharm D.
Pharmacy Research Specialist/Manager
E. USE OF MANAGED CARE Medical Assistance Administration, DSHS
805 Plum Street, SE
P.O. Box 45506
Approximately 450,000 Medicaid recipients were
Olympia, WA 98504-5506
enrolled in MCOs in FY 2002. Recipients receive
T: 360/725-1564
pharmaceutical benefits through both the State and
F: 360/586-8827
managed care plans. Anti-retrovirals, mental health
E-mail: childsa@dshs.wa.gov
drugs, and family planning products are carved out
Internet address: http://maa.dshs.wa.gov/pharmacy
of managed care.
Prior Authorization Contact
Managed Care Organizations
Siri A. Childs, Pharm.D.
Asuris Northwest Health Plan
360/725-1564
P.O. Box 91130
Mail Stop BR 325
Seattle, WA 98111 DUR Contact
253/573-3248 Nicole N. Nguyen, Pharm.D.
Clinical Pharmacist
Columbia United Providers Medical Assistance Administration, DSHS
19120 SE. 34th Street, Suite 201 805 Plum Street, SE
Vancouver, WA 98683 P.O. Box 45506
360/449-8867 Olympia, WA 98504-5506
T: 360/725-1757
Community Health Plan of Washington F: 360/586-8827
720 Olive Way, Suite 300 E-mail: nguyen@dshs.wa.gov
Seattle, WA 98101
206/613-8940 Department of Social and Health Services
Drug Utilization and Education Council
Group Health Cooperative
521 Wall Street Council Members
Seattle, WA 98121 Carol Cordy, M.D.
206/448-6110 Gerald Yorioka, M.D.
Alvin Goo, Pharm.D.
Kaiser Foundation Health Steve Williams, Pharm.D.
Plan of the Northwest Patti Varley, ARNP, MN, CS
500 NE Multnomah, Suite 100 Kenneth Wiscomb, PA-C
Portland, OR 97232-2099 Dana Hadfield, R.Ph.
503/813-3985
Medical Advisor
Premera Blue Cross Melicent Whinston, M.D.
P.O. Box 12890
Seattle, WA 98111-4890 Resource Staff
800/869-7175 Nancy Donigan (Client Advocate)

Molina Healthcare of Washington, Inc. (MHC) WSU Staff


P.O. Box 1469 Daniel Baker, Pharm.D., FASCP, FASHP
Bothell, WA 98041 Drug Information Center
800/869-7175

Washington-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

New Brand Name Products Contact Disease/Medical State: Renal Disease


Program Manager: Renaissance
Siri A. Childs, Pharm.D.
360/725-1564
Disease Management Program/Initiative
Contact
Prescription Price Updating
Alice R. Lind
Tom Zuchlewski
Managed Care Coordination Section
Pharmacy Rates Manager
Medical Assistance Administration, DSHS
Medical Assistance Administrator, DSHS
P.O. Box 45530
P.O. Box 45510
Olympia, WA 98504-45530
Olympia, WA 98504-5510
360/725-1629
T: 360/725-1837
E-mail: lindar@dshs.wa.gov
F: 360/753-9152
E-mail: zuchltm@dshs.wa.gov
Social and Health Services Department
Medicaid Drug Rebate Contact Officials
Connie L. Riddle Dennis Braddock
Medical Assistance Administration Secretary
P.O. Box 45503 Department of Social and Health Services
Lacy, WA 98504-5503 P.O. Box 45010
360/725-1243 Olympia, WA 98504-5010
E-mail: riddle1@dshs.wa.gov T: 360/902-7800
F: 360/902-7848
Claims Submission Contact E-mail: braddd@dshs.wa.gov
Chris Johnson
Doug Porter
Claims Processing Manager
Assistant Secretary
Medical Assistance Administrator, DSHS
Medical Assistance Administration
P.O. Box 45509
P.O. Box 45100
Olympia, WA 98504-5509
Olympia, WA 98504-5100
360/725-1239
T: 360/725-1863
E-mail: johnsc2@dshs.wa.gov
F: 360/902-7855
E-mail: portejd@dshs.wa.gov
Medicaid Managed Care Contact
MaryAnne Lineblad, Director Department of Social and Health Services
Division of Program Support Title XIX Advisory Committee
Medical Assistance Administration, DSHS
Janet Varon, Co-chair
P.O. Box 45530
Executive Director, NoHLA
Lacey, WA 98504-5530
1820 East Pine Street, Suite 322
360/725-1786
Seattle, WA 98122
E-mail: lindem@dshs.wa.gov
Robert Wardell, Co-chair
Mail Order Pharmacy Program 3815 N. Pearl, Apartment K-1
State has mail order pharmacy program for fee-for- Tacoma, WA 98407
service clients.
Elise Chayet
Disease Management/Patient Education WSHA
Programs Harborview Medical Center
325 Ninth Avenue
Disease/Medical State: Asthma Seattle, WA 98104-2499
Program Manager: McKesson
Ted Rudd, M.D.
Disease/Medical State: Congestive Heart Failure WSMA
Program Manager: McKesson 209 S. 12th Avenue, #A
Yakima, WA 98902
Disease/Medical State: Diabetes
Program Manager: McKesson

Washington-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Janene Jones-Heino Bruce Yoder, D.D.S.


WSPA WSDA
12856 NE Central Valley Road 1890 Pottery Avenue
Poulsbo, WA 98370 Port Orchard, WA 98366
360/377-3753
DSHS Staff Members
Doug Porter Debbie Meyer
Assistant Secretary Secretary
Medical Assistance Administration Medical Assistance Administration
P.O. Box 45080 P.O. Box 45080
Olympia, WA 98504-5080 Olympia, WA 98504-5080

Allena Barnes Pharmacy Drug Use Review Team Members


7827 South 113th Street
Seattle, WA 98178 Siri A. Childs, Pharm.D.
Nicole Nguyen, Pharm.D.
Kathy Carson Joan Baumgartner, M.D.
Sea-King Co. Dept. of Health Olin Cantrell, PA-C
Linda Ayers, A.R.N.P.
999 Third Avenue, Suite 900
Seattle, WA 98104-4039 Valerie Vertz
Charles Agte
Debbie Bellerud
Shawna Connolly
Premera Blue Cross Aimee Bennett
P.O. Box 327 David Conaway
Kevin Davenport
Seattle, WA 98111-0327
Do Huynh
Steven Gobin Celeste Moore
Robin Pfeiffer
6700 Totem Beach Road
Marysville, WA 98271 Sam Trimble
Patty Orth
Blanche Jones
Gentiva Health Services Executive Officers of State Medical and
4020 South 56th Street, Suite 101 Pharmaceutical Societies
Tacoma, WA 98409 Washington State Medical Association
Thomas Curry
Barbara Malich Executive Director
Peninsula Community Health Services 2033 Sixth Avenue, Suite 1100
P.O. Box 960 Seattle, WA 98121
Bremerton, WA 98337 T: 206/441-9762
F: 206/441-5863
Eleanor Owen E-mail: wsma@wsma.org
802 Northwest 70th Internet address: www.wsma.org
Seattle, WA 98117
Washington State Pharmacists Association
Mark Secord Rod Shafer
Neighborhood Health Centers CEO
905 Spruce Street, Suite 201 1501 Taylor Avenue, SW
Seattle, WA 98104 Renton, WA 98055-3139
T: 425/228-7171
Laura Toepfer F: 425/277-3897
AOA E-mail: rshafer@wsparx.org
31708 2nd Avenue South Internet address: www.wsparx.org
Federal Way, WA 98003-5260

Raleigh Watts
Department of Health
P.O. Box 47481
Olympia, WA 98504-7841

Washington-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Washington Osteopathic Medical Association, Inc.


Kathleen S. Itter
Executive Director
P.O. Box 16486
Seattle, WA 98116-0486
T: 206/937-5358
F: 206/933-6529
E-mail: kathie@woma.org
Internet address: www.woma.org

State Board of Pharmacy


Donald H. Williams
Executive Director
Department of Health
310 Israel Road
P.O. Box 47863
Olympia, WA 98504-7863
T: 360/236-4825
F: 360/586-4359
E-mail: don.williams@doh.wa.gov
Internet address:
wws2.wa.gov/doh/hpql/HPS4/Pharmacy/default.htm

Washington State Hospital Association


Leo F. Greenawalt
President/CEO
300 Elliott Avenue W., Suite 300
Seattle, WA 98119-4118
T: 206/281-7211
F: 206/283-6122
E-mail: leog@wsha.org
Internet address: www.wsha.org

Washington-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

WEST VIRGINIA 1

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 Service ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Physician Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Dental Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001* 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $256,395,319 269,174 $272,457,097 273,908

RECEIVING CASH ASSISTANCE, TOTAL $195,637,527 118,929 $205,598,570 113,800


Aged $50,185,943 22,104 $50,676,511 21,404
Blind/Disabled $130,303,218 61,244 $140,221,050 63,111
Child $857,251 5,485 $13,569 538
Adult $14,291,115 30,096 $14,687,440 28,747

MEDICALLY NEEDY, TOTAL $6,131,673 4,239 $6,544,451 4,605


Aged $503,211 436 $504,387 458
Blind/Disabled $4,672,424 2,545 $4,797,111 2,712
Child $13,214 14 $2,652 12
Adult $942,824 1,244 $1,240,301 1,423

POVERTY RELATED, TOTAL $30,971,475 122,564 $36,538,255 135,209


Aged $643,374 382 $519,840 282
Blind/Disabled $3,506,525 1,578 $3,889,793 1,572
Child $25,536,971 113,637 $30,296,278 125,627
Adult $1,284,605 6,967 $1,832,344 7,728

TOTAL OTHER EXPENDITURES/RECIPIENTS* $23,654,644 23,442 $23,775,822 20,294


*Total other expenditures/recipients includes foster care children, 1115 demonstration participants, other recipients and
unknown.
**2002 data provided by the West Virginia Department of Health and Human Resources, Bureau for Medical Services.

Source: CMS, MSIS Report, FY 2001 and West Virginia Medicaid Statistical Information System, FY 2002.

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.

West Virginia-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

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).
Restrictions include preferred products and prior
D. PROVISIONS RELATING TO DRUGS authorization through the Rational Drug Therapy
Program. General exclusions include: legend agents
Benefit Design used for cosmetics purposes or hair growth; DESI
drugs; fertility drugs; and products used for anorexia
Drug Benefit Product Coverage: Products covered or weight gain.
with restrictions (i.e., quanity limits): disposable
needles and syringe combinations used for insulin; Prior Authorization: State currently has a prior
blood glucose test strips; and urine ketone test strips. authorization screening procedure for drug classes
Products covered as DME: total parenteral nutrition. and home health care.
Prior authorization required for: prescribed insulin
(pens); branded NSAIDs, Retin-A for adults; ED Prescribing or Dispensing Limitations
drugs; proton pump inhibitors; drugs to treat
impotency; most injectable medications; and non- All covered outpatient drugs are reimbursed up to a
preferred drugs. Products not covered: cosmetics; 34-day supply and five refills.
fertility drugs; experimental drugs; and interdialytic Exceptions include:
parenternal nutrition. 1. Antibiotics are covered for a 14-day supply and
one refill.
Over-the-Counter Product Coverage: Products 2. Opiate agonists (excluding Schedule II drugs),
covered with restrictions (i.e., limited analgesics and miscellaneous antipyretics are
formulary/prescription required): feminine products; covered for 30 days and one refill.
topical products; allergy, asthma, and sinus products; 3. Sedatives and hypnotics are covered for a 30-
analgesics; cough and cold preparations; and day supply and one refill.
digestive products (non-H2 antagonist). Prior
authorization for: smoking deterrent products. Drug Utilization Review
Products not covered: digestive products (H2
antagonists). PRODUR system implemented in March 1995.
State currently has a DUR Board with a quarterly
Therapeutic Category Coverage: Therapeutic review.
categories covered: anabolic steroids;
anticonvulsants; anti-depressants; antidiabetic drugs; Pharmacy Payment and Patient Cost
antilipemic agents; antihistamine drugs; Sharing
antipsychotics; anxiolytics, sedatives, and hypnotics Dispensing Fee: $3.90, effective 1/1/96. For a
(partial coverage); cardiac drugs; contraceptives; compounded prescription, an additional $1.00 will
prescribed cold mediation (partial coverage); ENT be added to the dispensing fee. A compound
anti-inflammatory agents; estrogens; hypotensive prescription is defined as any legend medication
agents; and thyroid agents. Therapeutic categories requiring a combination of any two or more
requiring prior authorization: analgesics, substances to exclude normal reconstitution
antipyretics, NSAIDs; antibiotics; anticoagulants; operations.
chemotherapy agents; growth hormones; prescribed
smoking deterrents; misc. GI drugs; and Ingredient Reimbursement Basis: EAC = AWP -
sympathominetics (adrenergic). Therapeutic 12%.
categories not covered: anorectics; and hair growth
products. Prescription Charge Formula: Reimbursement
based on the lowest of:
Coverage of Injectables: Injectable medicines
reimbursable under the Prescription Drug Program 1. The estimated acquisition cost (EAC) plus a
when used in home health care and extended care dispensing fee.
facilities, and through both the Prescription Drug 2. The maximum allowable cost (MAC) plus a
Program and physician payment in physician offices; dispensing fee.
most require prior approval. 3. The usual and customary price charged by the
pharmacy to the general public including any
Vaccines: Vaccines reimbursable as part of CHIP sale price that may be in effect on the date of
and the Vaccines for Children Program. service.

West Virginia-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Maximum Allowable Cost: State imposes Federal F. STATE CONTACTS


Upper Limits on generic drugs. Override will
require physician certification of “Brand Medically State Drug Program Administrator
Necessary.”
Peggy A. King, R.Ph.
Incentive Fee: None. Director, Office of Pharmacy Services
Department of Health and Human Resources
Patient Cost Sharing: Copayment varies - $0.50 to 350 Capitol Street, Room 251
$2.00. Exclusions include: Charleston, WV 25301-3709
T: 304/558-5967
1. Family planning services and supplies. F: 304/558-1542
2. Prescriptions originating with the Early and E-mail: pking@wvdhhr.org
Periodic Screening, Diagnosis and Treatment Internet address: www.wvdhhr.org/bma
Program.
3. Nursing home residents. Department of Health & Human Resources
4. Children under the age of 18 years. Officials
Paul Nusbaum, Secretary
Cognitive Services: Does not pay for cognitive Department of Health and Human Resources
services. Building 3, State Capitol Complex, Room 206
Charleston, WV 25305
E. USE OF MANAGED CARE T: 304-558-0684
F: 304/558-1130
E-mail: wvdhhrsecretary@wvdhhr.org
Approximately 50,000 unduplicated Medicaid
recipients were enrolled in MCOs in 2002.
Nancy Atkins, Commissioner
Beneficiares in managed care receive pharmacy
Department of Health and Human Resources
services through the State.
Bureau for Medical Services
7012 MacCorkle Avenue, SE
Managed Care Organizations
Charleston, WV 25301
Carelink Health Plans T: 304/558-1700
Michelle Coon F: 304/558-1509
Manager of Government Programs E-mail: nancyatkins@wvdhhr.org
500 Virginia Street East, Suite 400
Charleston, WV 25326-1711 Sandra Joseph, M.D.
T: 304/348-2041 Medical Director
F: 304/348-3948 Division of Medical Care
Department of Health and Human Resources
The Health Plan of the Upper Ohio Valley 350 Capitol Street, Room 251
Tom Samol, Director/Government Programs Charleston, WV 25301-3709
52160 National Road, East T: 304/558-5967
St. Clairsville, OH 43950 F: 304/558-1509
T: 740/695-3585
F: 740/695-5297 Prior Authorization Contact
Stephen Small, R.Ph., M.S.
Physician Assured Access System (PAAS)
Director, Rational Drug Therapy Program
Shelley Baston, Director
West Virginia University School of Pharmacy
Office of Medicaid Managed Care
Robert C. Byrd Health Sciences Center
Bureau for Medical Services
P.O. Box 9511
350 Capitol Street, Room 251
Morgantown, WV 26506-9511
Charleston, WV 25301
T: 800/847-3859
T: 304/558-1700
F: 800/531-7787
F: 304/558-4398
E-mail: ssmall@hsc.wvu.edu

West Virginia-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Pharmaceutical and Therapeutics Prescription Price Updating


Committee
Becky Garrigan
Kevin W. Yingling, M.D., R.Ph. PBM Account Manager
Steve R. Matulis, M.D. ACS, Inc.
Thomas L. Gilligan, D.O. 365 Northridge Rd.
David Avery, M.D. Northridge Center One, Suite 400
John D. Justice, M.D. Atlanta, GA 30350
Teresa Dunsworth, Pharm.D. T: 770/352-8592
James D. Bartsch, R.Ph. F: 770/730-5198
Harriett Nottingham, R.Ph. E-mail: Becky.Garrigan@acs-inc.com
Kristy H. Lucas, Pharm.D.
Tom Harwood, PA-C Medicaid Drug Rebate Contacts
Barbara Koster, M.S.N., R.N.C. – A.N.P.
Technical: Gail Goodnight, R.Ph., 304/558-1700
Policy: Peggy A. King, R.Ph., 304/558-1700
DUR Contact
Rebate: Gail Goodnight, R.Ph., 304/558-1700
Vicki M. Cunningham, R.Ph.
DUR Coordinator Claims Submission Contact
Bureau for Medical Services
Office of Pharmacy Services Becky Garrigan
770/352-8592
350 Capitol Street, Room 251
Charleston, WV 25301-3709
T: 304/558-1700 Medicaid Managed Care Contact
F: 304/558-1542 Shelley Baston, Director
E-mail: vickicunningham@wvdhhr.org Bureau of Medical Services
Department of Health and Human Resources
Medicaid DUR Board 350 Capitol Street, Room 251
Charleston, WV 25301-3709
Steven C. Judy, R.Ph.
Kevin W. Yingling, M.D., R.Ph. T: 304/558-5978
David P. Elliott, Pharm.D. F: 304/558-4398
Bernard Lee Smith, R.Ph., M.B.A, M.H.A (Vice
Chair) Mail Order Pharmacy Program
Patrick M. Regan, R.Ph. None
Karen Reed, R.Ph. (Chair)
Mary Nemeth-Pyles, M.S.N., R.N., C.S. Disease Management/Patient Educated
Mitch Shaver, M.D. Programs
Myra Chiang, M.D.
Matthew Watkins, D.O. Disease/Medical State: Diabetes
John R. Vanin, M.D. Program Name: WV Health Initiative Project
Lester Labus, M.D. Program Manager: Bureau of Medical Services
Ernest Miller, D.O.
Christopher Terpening, Pharm.D., R.Ph Disease Management Initiative/Program
James M. Bennett, M.D. Contact
Kerry Sitzinger, R.Ph. Vicki M. Cunningham, R.Ph.
George Bryant, PA-C 304/558-1700
Daniel Dickman, M.D.

New Brand Name Products Contact


Peggy A. King, R.Ph.
304/558-5967

West Virginia-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Medical Services Fund Advisory Council West Virginia Hospital Association


Steven J. Summer
Violet Burdette
President
William McFarland, R.Ph
100 Association Drive
Doug Coffman
Charleston, WV 25311
John Elliott
T: 304/344-9744
Sheryl Kiser
F: 304/344-9745
Charles Smith, D.D.S.
E-mail: ssummer@wvha.com
John Russell
Internet address: www.wvha.com
Scott McClanahan
Mark B. Ayoubi, M.D.
Larry Robertson
G. Anne Cather, M.D.
Chris Cutis
Fred Booth

Executive Officers of State Medical and


Pharmaceutical Societies
West Virginia State Medical Association
Evan Jenkins, Executive Director
4307 MacCorkle Avenue SE
P.O. Box 4106
Charleston, WV 25364
T: 304/925-0342
F: 304/925-0345
E-mail: evan@wvsma.com
Internet address: www.wvsma.com

West Virginia Pharmacists Association


Richard D. Stevens, Executive Director
2003 Quarrier Street
Charleston, WV 25311-2212
T: 304/344-5302
F: 304/344-5316
E-mail: wvrds@aol.com

West Virginia Society of Osteopathic Medicine


Charlotte Ann Cales Pulliam
Executive Director
400 Allen Drive, Suite 201
P.O. Box 5266
Charleston, WV 25361-0266
T: 304/345-9836
F: 304/345-9865
E-mail: wvdo@wvsominc.org
Internet address: www.wvsominc.org

State Board of Pharmacy


William T. Douglas, Jr.
Executive Director & General Counsel
232 Capitol Street
Charleston, WV 25301
T: 304/558-0558
F: 304/558-0572
E-mail: wdouglass@wvbop.com
Internet address: www.wvbop.com

West Virginia-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

West Virginia-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

WISCONSIN

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 ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients

TOTAL $389,373,521 262,238 $442,718,195

RECEIVING CASH ASSISTANCE TOTAL $195,261,895 107,145


Aged $20,208,955 11,879
Blind/Disabled $171,261,361 73,646
Child $1,321,948 11,038
Adult $2,469,631 10,582

MEDICALLY NEEDY, TOTAL $29,447,709 16,508


Aged $12,300,642 6,621
Blind/Disabled $16,741,054 5,048
Child $327,772 3,962
Adult $78,241 877

POVERTY RELATED, TOTAL $7,821,202 24,252


Aged $392,139 593
Blind/Disabled $4,837,078 1,794
Child $2,164,005 17,197
Adult $427,980 4,668

TOTAL OTHER EXPENDITURES/RECIPIENTS* $156,842,715 114,333

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Wisconsin-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Coverage of Injectables: Injectable medicines


reimbursable through the prescription drug program
State Department of Health and Family Services, when used in home health care and in extended care
Division of Health Care Financing. facilities, and through both the prescription drug
program and physician payment when in
physicians’ offices.
D. PROVISIONS RELATING TO DRUGS
Vaccines: Vaccines provided plus reimbursement
Benefit Design for administrative fee as part of the Vaccines for
Drug Benefit Product Coverage: Products covered: Children Program.
prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test Unit Dose: Unit dose packaging reimbursable.
strips; urine ketone test strips; total parenteral
nutrition; and interdialytic parenteral nutrition. Formulary/Prior Authorization
Products not covered: cosmetics; fertility drugs; Formulary: Open formulary managed through
experimental drugs; progesterone for PMS; topical restrictions on use and prior authorization.
minaxidil, legend prenatal vitamins; and impotence
treatment drugs. Prior Authorization: State currently has formal
prior authorization procedure and a Medicaid
Over-The-Counter Product Coverage: Products Pharmacy Prior Authorization Committee.
covered: analgesics; ophthalmic lubricants. Beneficiaries can request an administrative hearing
Products covered with restrictions: allergy, asthma, to appeal prior authorization decisions or coverage
and sinus products (loratadine, diphenhydramine, for an excluded product.
pseudoephedrine); cough and cold preparations
(cough syrups containing expectorant with or Prescribing or Dispensing Limitations:
without dextromethorphan only); non-H2
antagonists (Prilosec OTC only); feminine products Quantity of Medication: Pharmacists may not
(vaginal antifungals); and topical products dispense more than 34-day supply of a legend drug.
(antibiotics, antifungal agents; capsacin, Certain exceptions for some maintenance drugs
hydrocortisone). Products not covered: digestive (100 day supply limit).
products (H2 antagonists); smoking deterrent Refills: Maximum of 11 refills during a 12-month
products. period for non-scheduled medications.
Therapeutic Category Coverage: Products covered: Dollar Limits: None.
anabolic steroids; antibiotics; anticoagulants;
anticonvulsants; anti-depressants; anti-diabetic Pharmacy Payment and Patient Cost
agents; anti-psychotics; anxiolytics, sedatives, and Sharing
hypnotics; cardiac drugs; chemotherapy agents; Dispensing Fee: $4.88 to a maximum of $40.11,
prescribed cold medications; contraceptives, ENT- effective 7/1/98. Incremental increases based on
anti-inflammatory agents; prescribed smoking pharmaceutical care services being provided.
deterrents; sympathominetics (adrenergic); and Maximum of two dispensing fees per month, per
thyroid products. Prior authorization required for: prescription.
analgesics; antipyretics, and (brand name) NSAIDs;
anoretics; brand name non-sedating antihistamines Ingredient Reimbursement Basis: EAC = AWP–
(except loratudine); antilipemic agents; human 12.0%. (AWP-13% effective 7/1/04.)
growth hormone; hypotensive agents; scheduale III
and IV stimulants; enteral nutrition products; Prescription Charge Formula: Reimbursement at
Cerezyme; Mupirocin; fertility enhaning drugs; the lowest of:
anti-obesity drugs; alitretinoin gel; brand name
ACE inhibitors; brand name statins; brand name AWP-12.0% plus dispensing fee; Maximum
PPIs, stimulants and anti-obesity drugs; and Allowable Cost (MAC) plus dispensing fee; or
medically necessary drugs with no rebate providers usual and customary.
agreement.
Maximum Allowable Cost: State imposes State-
specific limits on generic drugs. Override requires
hand written “Brand Medically Necessary” by the
prescriber.

Incentive Fee: None.

Wisconsin-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

Cognitive Services: Provides an expanded Security Health Plan of Wisconsin, Inc.


dispensing fee for cognitive services. P.O. Box 8000
Marshfield, WI 54449
Patient Cost Sharing: All generic legend drugs are United Healthcare
subject to a $1.00 copay, brand legend drugs are 10701 W. Research Drive
subject to a $3.00 copay, limited to $12.00 per Milwaukee, WI 53226
month maximum per pharmacy. OTCs are subject
to a $0.50 copay. Disposable medical supplies are Unity Health Plans Insurance Corporation
subject to a sliding scale copayment system. 840 Carolina Street
Residents of Skilled Nursing Facilities (SNF) or Sauk City, WI 53583-1374
Intermediate Care Facilities (ICF), subsidized
adoption recipients, children under age 18 and Valley Health Plan
HMO enrollees are exempt from the copayment. 2270 EastRidge Center
P.O. Box 3128
Eau Claire, WI 54702-3128
E. USE OF MANAGED CARE
Touchpoint Health Plane
Approximately 321,000 Medicaid recipients were 5 Innovation Court
enrolled in MCOs in FY 2002. Recipients receive P.O. Box 507
pharmaceutical benefits through managed care Appleton, WI 54912
plans. (Some mental health plans carve out
pharmaceutical benefits.)
F. STATE CONTACTS
Managed Care Organizations
Pharmacy Practices Consultant
Atrium Health Plan, Inc.
c/o Group Health Cooperative of Eau Claire Michael C. Boushon, R.Ph.
P.O. Box 3217 Pharmacy Practices Consultant
Eau Claire, WI 54702-3217 Division of Health Care Financing
Department of Health and Family Services
Dean Health Plan, Inc. One West Wilson Street
P.O. Box 56099 P.O. Box 309
Madison, WI 53705 Madison, WI 53701-0309
T: 608/261/7791
Group Health Cooperative of Eau Claire F: 608/267-3380
P.O. Box 3217 E-mail: boushmc@dhfs.state.wi.us
Eau Claire, WI 54702-3217 Internet address: www.dhfs.wisconsin.gov

Group Health Cooperative of Prior Authorization Contact


South Central Wisconsin
Michael C. Boushon, R.Ph.
P.O. Box 44971
608/261-7791
Madison, WI 53744-4971

Health Tradition HealthPlan Prior Authorization Advisory Committee


8202 Excelsior Drive Standing
LaCrosse, WI 53717 Steve Maike, R.Ph.
Larry Fleming, M.D.
Managed Health Services Insurance Corp. Peg Smelser
1205 S. 70th Street, Suite 500 Tom Frazier, Exec. Dir., CWAG
West Allis, WI 53214 Breadley Fedderly, M.D.
James Heersma, M.D.
MercyCare Insurance Company Christine Sorkness, Pharm. D.
P.O. Box 2770 John Gates, R.Ph.
Janesville, WI 53547-2770 Tom Hirsch, M.D.

Network Health Plan


c/o Managed Health Services
1205 S. 70th Street, Suite 500
West Allis, WI 53214

Wisconsin-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Expanded for SSRIs Medicaid Drug Rebate Contacts


Barry Blackwell, M.D.
Ellen Orsburne
Diane Greenley
Medicaid Systems Analyst
Ken Robbins, M.D.
Division of Health Care Financing
John Frey III, M.D.
Department of Health and Family Services
Virginia Bryan
One West Wilson Street
Allen Liegal, R.Ph.
P.O. Box 309
Molly Cisco
Madison, WI 53701-0309
Randy Lewis
608/267-7939
Michelle Thoma, R.Ph.
E-mail: orsburne@dhfs.state.wi.us
DUR Contact
Claims Submission Contact
Michael A. Mergener, R.Ph., Ph.D.
Mark Gajewski
Chief Pharmacist
Account Director
APS Healthcare
EDS
10 East Doty Street, Suite 210
6406 Bridge Road
Madison, WI 53703
Madison, WI 53784-0014
T: 608/258-3348
T: 608/221-4746
F: 608/258-3359
F: 608/221-4567
Wisconsin Drug Utilization Review
Medicaid Managed Care Contact
Committee
Angela Dombrowicki, Director
Robert M. Breslow, R.Ph.
Division of Healthcare Financing
Ward Brown, M.D.
Bureau of Managed Health Care Programs
Mark E. Buhler, R.Ph.
Department of Health and Family Services
Daniel R. Erickson, M.D.
One West Wilson
Barry Hess, R.Ph.
P.O. Box 309
Nancy E. Ness, M.D.
Madison, WI 53701-0309
Pamela Ploetz, R.Ph.
T: 608/266-1935
Lee C. Vermeulen, Jr., R.Ph., M.S.
F: 608/261-7792
Mary Jo Willis, M.S., N.P.
E-mail: dombra@dhfs.state.wi.us
New Brand Name Prescription Contact
Mail Order Pharmacy Program
Carol Neeno
None
Pharmacy Assistant
Division of Health Care Financing
Department of Health and Family Services Health and Family Services Department
One West Wilson Street Officials
P.O. Box 309 Helene Nelson, Secretary
Madison, WI 53701-0309 Department of Health and Family Services
T: 608/266-1203 One West Wilson Street
F: 608/267-3380 Madison, WI 53701
E-mail: neenocj@dhfs.state.wi.us T: 608/266-9622
F: 608/266-7882
Prescription Price Updating E-mail: wemaster@dhfs.state.wi.us
First Databank
Mark P. Moody, Administrator
1111 Bayhill Drive, Suite 350
Division of Health Care Financing
San Bruno, CA 94066
Department of Health and Family Services
T: 800/633-3453
One West Wilson Street
F: 415/588-6867
P.O. Box 309
Madison, WI 53701-0309
T: 608/266-2522
F: 608/266-1096
E-mail: webmaster@dhfs.state.wi.us

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Executive Officers of State Medical and


Pharmaceutical Societies
State Medical Society of Wisconsin
John Patchett, J.D.
Executive Vice President
330 East Lakeside, Box 1109
Madison, WI 53701-1109
T: 608/257-6781
F: 608/442-3802
E-mail: johnp@wismed.org
Internet address: wisconsinmedicalsociety.org

Wisconsin Association of Osteopathic Physicians &


Surgeons
Heather Jesina
Executive Director
5645 Randall Lane
Racine, WI 53402
262/752-2280
E-mail: waops@wi.rr.com

Pharmacy Society of Wisconsin


Christopher J. Decker
Executive Vice President
701 Heartland Trail
Madison, WI 53717
T: 608/827-9200
F: 608/827-9292
E-mail: cdecker@pswi.org
Internet address: www.pswi.org

Wisconsin Pharmacy Examing Board


Tom Ryan, Director
1400 E. Washington Avenue
Madison, WI 53703
T: 608/266-2812
F: 608/261-7083
E-mail: web@drl.state.wi.us
Internet address: www.drl.state.wi.us

Wisconsin Health and Hospital Association


Steve Brenton, CEO
5721 Odana Road
Madison, WI 53719-4992
T: 608/274-1820
F: 608/274-8554
E-mail: sbrenton@wha.org
Internet address: www.wha.org

Wisconsin Health Care Association


Thomas P. Moore
Executive Director
121 South Pinckney Street, Suite 500
Madison, WI 53703
T: 608/257-0125
F : 608/257-0025
E-mail: tomm@whca.com
Internet address: www.whca.com

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National Pharmaceutical Council Pharmaceutical Benefits 2003

WYOMING

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 ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2001 2002**
Expenditures Recipients Expenditures Recipients
TOTAL $31,881,860 36,704 $39,094,579

RECEIVING CASH ASSISTANCE, TOTAL $12,791,205 12,347


Aged $1,358,763 746
Blind / Disabled $8,964,573 3,913
Child $948,764 4,687
Adult $1,519,105 3,001

MEDICALLY NEEDY, TOTAL $0 -


Aged $0 -
Blind / Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $2,817,574 14,975


Aged $13,038 15
Blind / Disabled $20,761 28
Child $2,437,127 12,689
Adult $346,648 2,243

TOTAL OTHER EXPENDITURES/RECIPIENTS* $16,273,081 9,382

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

Wyoming-1
National Pharmaceutical Council Pharmaceutical Benefits 2003

C. ADMINISTRATION Formulary/Prior Authorization


Formulary: Open formulary with preferred drug list
Department of Health, Director’s Office. (PDL). General exclusions include anorexants,
except amphetamines and derivatives which are
D. PROVISIONS RELATING TO DRUGS used for narcolepsy and hyperkinetic states;
products to stimulate hair growth. Prior
Benefit Design authorization implemented 10/1/02.

Drug Benefit Product Coverage: Products covered: Prior Authorization: State currently has a formal
prescribed insulin, syringe combinations and prior authorization procedure with review/appeal
disposable needles used for insulin; blood glucose process.
test strips; and urine ketone test strips. Products
covered under DME: total parenteral nutrition; and Prescribing or Dispensing Limitations
interdialytic parenteral nutrition. Products not
covered: cosmetics; fertility drugs; tobacco Monthly Quantity Limits: Quantity limits on some
cessation products; weight loss products; hair medications as deemed clinically appropriate.
growth products; IQ enhancers and experimental
drugs. Drug Utilization Review
PRODUR system implemented in October 1995.
Over-the-Counter Product Coverage: Products State currently has a DUR Board with 12 members
covered (must be listed in State’s system and filed that meet bimonthly.
with First DataBank): allergy, asthma, and sinus
products; analgesics; cough and cold products; Pharmacy Payment and Patient Cost
digestive products (H2 antagonists); feminine Sharing
products; topical agents; antidiarrheal products;
food thickeners; nutrition products; laxatives; Dispensing Fee: $5.00, effective 7/01.
pediatric and prenatal vitamins; and artificial tears.
Products not covered: non-H2 antagonists; smoking Ingredient Reimbursement Basis: EAC = AWP –
deterrent products. 11%.

Therapeutic Category Coverage: Products covered: Prescription Charge Formula: Payments shall be
analgesics, antipyretics, and NSAIDs (prior the lowest of:
authorization for COX 2s and oxycontin); 1. The Estimated Acquisition Cost (AWP - 11%)
antibiotics; anticoagulants; anticonvulsants; anti- of the ingredient, plus a dispensing fee.
depressants; antidiabetic agents; antihistamines; 2. Usual and customary charge.
antilipemic agents; anti-psychotics; anxiolytics, 3. The upper limit established by CMS for
sedatives, and hypnotics; cardiac drugs; multiple source drugs or State MAC.
chemotherapy agents; prescribed cold medications;
contraceptives; ENT anti-inflammatory agents; Maximum Allowable Cost: State imposes Federal
estrogens; growth hormones; hypotensive agents; Upper Limits as well as State-specific limits on
misc. GI drugs (prior authorization for PPIs); generic drugs. Override requires “Brand Medically
sympathominetics (adrenergic); thyroid agents; Necessary.” Currently, 6 drugs are included on the
antifungals; antiparasitic products; and State’s MAC list.
bronchodiolators. Products not covered; anabolic
steroids; prescribed smoking deterrents. Incentive Fee: None.

Coverage of Injectables: Injectable medicines Patient Cost Sharing: Copayment is $2.00. The
reimbursable through physician payment when used following recipients or products are exempt from
in home health care, extended care facilities and the copayment:
physician offices. − Pregnant women
− Foster care children
Vaccines: Vaccines reimbursable at AWP plus a − Home and community based waiver recipients
$7.00 injection fee as part of the EPSDT services, − Eligible recipients under age 21
the Children’s Health Insurance Program and the − Patients residing in nursing homes
Vaccines for Children Program. − Family planning products
Unit Dose: Unit dose packaging not reimbursable. Cognitive Services: Does not pay for cognitive
services.

Wyoming-2
National Pharmaceutical Council Pharmaceutical Benefits 2003

E. USE OF MANAGED CARE Roxanne Homar, R.Ph. (ex-officio)


307/777-6032
Does not use MCOs to deliver services to Medicaid
recipients. Kathryn Kohler, M.D.
Women’s Clinic
204 McCollum Drive, Suite 104
F. STATE CONTACTS Laramie, WY 82070
307/745-8991
State Drug Program Administrator
Antoinette Brown, R.Ph. Leonard Kosirog, R.Ph.
Medicaid Pharmacist 3095 Galloway
Department of Health-Pharmacy Unit Riverton, WY 82501
2424 Pioneer Avenue, Suite 100 307/856-6993
Cheyenne, WY 82002
T: 307/777-6016 Scott Johnston, M.D.
F: 307/777-8623 P.O. Box 100
Email: abrown@state.wy.us Wright, WY 82732
Internet address: www.pharmacy.state.wy.us 307/464-0422

Department of Health Officials George Zaharas, R.Ph.


Town and Country Pharmacy
Deb Fleming, Ph.D. 514 S. Greeley
Director Cheyenne, WY 82009
Department of Health 307/634-6662
117 Hathaway Building
2300 Capitol Avenue Stephen Brown, M.D.
Cheyenne, WY 82002-0710 2521 E. 15th Street
T: 307/777-7656 Casper, WY 82609
F: 307/777-7439 307/234-3638
E-mail: wdh@state.wy.us
Michael Carpenter, PA-C
DUR Contact 1121 Washington Boulevard
Newcastle, WY 82701
Debra Devereaux, R.Ph.
307/746-3582
DUR Coordinator
University of Wyoming School of Pharmacy
William Harrison, M.D.
P.O. Box 3375
Cheyenne Medical Specialists
Laramie, WY 82071-3375
5050 Powderhouse Road
T: 307/766-6750
Cheyenne, WY 82009
F: 307/766-2953
307/638-6820
E-mail: debdev@concentric.com
Kendra Grande, R.Ph. (ex-officio)
DUR Board
University of Wyoming School of Pharmacy
Antoinette Brown, R.Ph. (re-officio) Drug Information
307/777-6016 P.O. Box 3375
Laramie, WY 82071
Debra Devereaux, R.Ph. (DUR Coordinator) 307/766-6988
307/766-6750
Richard L. Johnson, R.Ph.
Becky Drnas, R.Ph. Emissary Pharmacy
K-Mart Pharmacy 401 East Collins Drive
2450 Foothill Boulevard Casper, WY 82601
Rock Springs, WY 82901 800/281-2026
307/362-7990
Cory L. Moss, Pharm.D.
Dawn Ford, R.Ph. University of Wyoming School of Pharmacy
2022 Reagan Avenue P.O. Box 3375
Rock Springs, WY 82901 Laramie, WY 82071
307/382-5437 307/766-6128

Wyoming-3
National Pharmaceutical Council Pharmaceutical Benefits 2003

Linda G. Martin, R.Ph. (ex-officio) Wyoming Pharmacy Association


University of Wyoming Mindy Rasmussen
School of Pharmacy Executive Director
P.O. Box 3375 P.O. Box 366
Laramie, WY 82071-3375 Cheyenne, WY 82003
307/766-6128 T: 307/772-8044
F: 307/772-8004
New Brand Name Products Contact E-mail: director@wpha.net
Internet address: www.wpha.net
Antoinette Brown, R.Ph.
307/777-6016
State Board of Pharmacy
Jim T. Carder
Prescription Price Updating Executive Director
First DataBank 1720 S. Poplar Street, Suite 4
1111 Bayhill Drive Casper, WY 82601
San Bruno, CA 94066 T: 307/234-0294
T: 800/633-3453 F: 307/234-7226
F: 650/872-4510 E-mail: wypharmbd@wercs.com
Internet address: www.pharmacyboard.state.wy.us
Medicaid Drug Rebate Contacts
Wyoming Hospital Association
Sheila McInerney Robert C. Kidd II
TPL Manager President
ACS 2005 Warren Avenue
P.O. Box 667 P.O. Box 249
Cheyenne, WY 82003 Cheyenne, WY 82003
T: 307/772-8400 T: 307/632-9344
F: 307/772-8405 F: 307/632-9347
E-mail: bob@wyohospitals.com
Claims Submission Contact Internet address: www.wyohospitals.com
ACS
Northridge Center 1, Suite 400
365 Northridge Road
Atlanta, GA 30350
T: 866/322-5960
F: 888/335-8459

Mail Order Pharmacy Program


None

Executive Officers of State Medical and


Pharmaceutical Societies
Wyoming State Medical Society
Stephen Brown, M.D.
President
1920 Evans
P.O. Box 4009
Cheyenne, WY 82003-4009
T: 307/635-2424
F: 307/632-1973
E-mail: prez@wyomed.org
Internet address: www.wyomed.org

Wyoming-4
National Pharmaceutical Council Pharmaceutical Benefits 2003

Section 6:
State Pharmacy Assistance
Programs

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National Pharmaceutical Council Pharmaceutical Benefits 2003

State Pharmacy Assistance Programs


As of February 2004, 40 States had various pharmaceutical assistance programs providing
coverage or assistance to the low-income elderly and/or persons with disabilities who do not
qualify for Medicaid. These programs provide access to State-negotiated discounts or State
subsidies, and tax credits for prescription drug expenditures. In addition, we are now including
programs that provide coordination of seniors’ services to access manufacturers’ charitable
prescription assistance programs.

The new Medicare law signed December 8, 2003, will cover or impact many of the same people
now served by the State programs listed below. However, State subsidy programs will not be
directly affected until 2006. State discount programs already in operation remain effective for
now. In 2004, the Federal plan anticipates a series of Department of Health and Human Services
(HHS)-endorsed Medicare discount cards that will impact existing state-only discount plans. A
limited discount card subsidy (up to $600) also may impact existing benefits. Several State
programs have established sunset dates to coincide with the implementation of the Medicare
prescription drug benefit program.

Authorized State Pharmacy Assistance Programs

State Program Name Law Enacted


Alabama SenioRx 2002
Arizona Prescription Discount Program (CoppeRx Card) 2004‡
Arkansas ARx Senior Program 2001
Discount Prescription Medication Program 1999
California
Golden Bear State Pharmacy Assistance Program 2001†
Connecticut Pharmaceutical Assistance Contract to the
Connecticut 1986
Elderly and Disabled (ConnPACE)
Nemours Pharmacy Assistance 1981
Delaware Delaware Prescription Drug Assistance Program
1999
(DPAP)
Silver SaveRx (formerly Formally, Ron Silver Senior
2002
Florida Drug Program/Prescription Affordability Act)
Prescription Discount Program 2000
Georgia Georgia Cares 2002
Hawaii Hawaii Rx Discount Program 2002†
Pharmaceutical Assistance Program (“Circuitbreaker”) 1985
Illinois Rx SeniorCare 2001
Illinois
Senior Citizen Prescription Drug Discount Program
2003†
(Senior Rx Buying Club)
Indiana Indiana Prescription Drug Program, “HoosierRx” 2000
None. Created by
Iowa Iowa Priority Prescription Savings Program
federal grant.
Kansas Senior Pharmacy Assistance Program 2000
Louisiana Seniors Pharmacy Assistance Program 2003
Louisiana
Louisiana SenioRx Program 2003
Maine Rx+ 2003
Maine
Low Cost Drugs for the Elderly Program (DEL) 1975
Maryland Pharmacy Assistance Program 1979
Maryland Senior Prescription Drug Program 2000
Maryland Pharmacy Discount Program 2001

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Prescription Advantage 2000


Massachusetts
MassMedLine 2001
Michigan Elder Prescription Insurance Coverage Program 2001
Minnesota Prescription Drug Program 1999
Missouri Senior Rx Program 2001
Montana Prescription Drug Expansion Program 2003†
Nevada Senior Rx Program 2000
New
Senior Prescription Drug Discount Program 2000
Hampshire
Pharmaceutical Assistance to the Aged and Disabled
1975
New Jersey (PAAD)
Senior Gold Prescription Discount Program 2001
New Mexico Senior Prescription Drug Program 2002
Elderly Pharmaceutical Insurance Coverage (EPIC)
New York 1987
Program
North Carolina Senior Care 2002
Golden Buckeye Prescription Drug Program 2002
Ohio
Ohio’s Best Rx Program 2003†
Oklahoma Pharmacy Connection Council Program 2003
Oregon Senior Prescription Drug Assistance Program 2001
Pharmaceutical Assistance Contract for the Elderly
1984
Pennsylvania (PACE)
PACE Needs Enhancement Tier (PACENET) 1996
Rhode Island Pharmaceutical Assistance to the Elderly
Rhode Island 1985
(RIPAE)
South Carolina SilveRxCard Senior Prescription Drug Program 2000
South Dakota Senior citizen prescription drug benefit program. 2003
Texas State Prescription Drug Program 2001†
VSCRIPT 1989
VSCRIPT Expanded 1999
Vermont
Vermont Health Access Plan (VHAP) 1996
Healthy Vermonters Program 2002
Washington Washington Rx Card 2003†
West Virginia Golden Mountaineer Card Program 2000
Wisconsin SeniorCare Prescription Drug Assistance Program 2001
Wyoming Prescription Drug Assistance Program 2002
† Program not yet operational; see below for more details.
‡ Established by executive order.

The Maine Rx Plus Program was finalized during 2003 and 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. Beneficiaries with incomes up to 350 percent of the Federal poverty level will be
able to buy any drug on the Medicaid preferred drug list (PDL) for the Medicaid price. The State
will also begin negotiations with manufacturers for additional program rebates. If successful, the
State will not use prior authorization as a management tool.

South Dakota also began a new Prescription Drug Discount Card Program in 2003, while three
States (Illinois, Ohio and Washington) have plans for new programs that will begin during 2004.
Efforts in Tennessee to expand a prescription drug program through TennCare are pending and a
new prescription drug program in Montana was cancelled due to enactment of the Federal
Medicare prescription drug benefit.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

• South Dakota Senior Citizen Prescription Drug Benefit Program: SB 216 was signed into law
March 20, 2003. It establishes a senior citizen prescription drug discount card program and is
open to any resident age 65 and older and any person meeting the eligibility criteria for a
disability. It is run by the Bureau of Personnel and administered by AdvancePCS. Legislation
has been introduced to sunset the program 120 days after the federal Medicare drug discount
card program begins in 2004.

• Illinois Senior Rx Buying Club: SB 3 was signed into law June 16, 2003. The new Senior Rx
Buying Club, which went into effect on January 1, 2004, is open to all Illinois residents who are
65 or older and the disabled for an annual administrative fee of $25. By leveraging the buying
power of the State’s seniors and disabled with that of nine state entities that purchase $1.8
billion in drugs a year, the State expects pharmaceutical companies will be enticed to participate
and offer lower prices and higher rebates. Unlike the Circuit Breaker and SeniorCare programs,
the new discount card program is not income-based.

• Ohio’s Best Rx Program: HB 311 was signed into law December 18, 2003. It establishes
Ohio’s Best Rx Program, a prescription drug discount card program for low-income residents
under 60 years of age, or residents 60 and older who have no prescription drug insurance
coverage. A Pharmacy Benefit Manager (PBM) will negotiate manufacturer discounts that will
be fully passed on to all enrollees. The program will use an open formulary and optional mail-
order delivery. The implementation date is April 1, 2004.

• Washington Rx Card: SB 6088 was signed into law June 26, 2003. It establishes a discount and
a subsidy program. Eligible residents, defined as the disabled age 19-49 and people age 50 or
older with incomes up to 300 percent of the Federal poverty level, will be able to purchase
pharmaceuticals at a discounted price, based on voluntary negotiated discounts initiated by the
Health Care Authority for State agencies. Participants are charged an enrollment fee. The
program is subject to sunset review and termination on June 30, 2010. The law also requires the
State to seek a "Pharmacy Plus" waiver under Medicaid to provide subsidies to Medicare-
eligible residents up to 200 percent of Federal poverty guidelines.

• The TennCare Rx Program Prescription Benefit (pending): HB 1650 was signed into law June
13, 2003. It creates the TennCare prescription drug program that will expand drug coverage to
individuals lacking prescription drug insurance based on criteria established by the TennCare
Bureau and the legislature. The program will serve a non-Medicaid population and may utilize
tiered copayments, prior authorization and step therapy requirements based on the State PDL.
Given TennCare funding difficulties, it is unclear when this program will be implemented.

• Montana Prescription Drug Expansion Program (canceled): SB 473 was signed into law May
1, 2003. It provided for a prescription drug expansion program through Medicaid and a Centers
for Medicare and Medicaid Services (CMS) Pharmacy Plus waiver. It offered discounted
pharmaceutical prices to qualified individuals with income levels up to 200 percent of the
federal poverty level. The program was halted due to the enactment of a Federal Medicare
prescription drug benefit on December 8, 2003.

Four States (Alabama, Georgia, Louisiana and Oklahoma) have programs which assist eligible
State residents in coordinating services from various manufacturers’ charitable prescription
assistance programs. These State programs do not, however, contribute any money for the direct
purchase of prescription drugs.

Several programs, slated to begin in 2003, were postponed due to lack of funding or support from
manufacturers.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

• Golden Bear State Pharmacy Assistance Program: Authorized by passage of SB 696 in


October 2001, the Golden Bear State Pharmacy Assistance Program would provide discounts to
California seniors over and above those provided by the Discount Prescription Medication
Program. The program has been postponed due to lack of manufacturer participation and the
pending Federal Medicare prescription drug benefit program scheduled to be implemented
between 2004 and 2006.

• Hawaii Rx Program: Authorized by passage of HB 2834 in June 2002, the Hawaii Rx Program
is pending implementation. The legislature will conduct further study and propose additional
amendments during 2004 before launching the program.

• Texas Prescription Drug Program: State funding for the program has not been established for
2004-2005.

The following pages provide profiles of the States that provided pharmacy assistance in 2003, as
well as profiles of the new State programs. Details were provided by 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 site (www.ncsl.org), which is a good
source for the most up-to-date information.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Alabama
Alabama SenioRx Program*
Program Type: Coordinate Assistance Between Elderly and Charitable
Pharmaceutical Programs
Year Operational: 2002
Number of Recipients (December 2003): 8,495

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 60+ Eligibility Age (Disabled): 60+


Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of
FPL
Other Eligibility Notes: Individuals may not have any other insurance coverage for
medicines. Individuals must re-enroll in the program on a
quarterly basis to verify eligibility.

FUNDING AND REIMBURSEMENT

Funding Source: State general revenue


Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: None
Ingredient Cost Calculation: None
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: Not available
Notes: The purpose of the program is to utilize available State resources
to help eligible seniors find appropriate charitable
pharmaceutical programs from various manufacturers. The
State will also coordinate and complete all necessary paperwork
for each participant.

DRUG 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, i.e., 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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National Pharmaceutical Council Pharmaceutical Benefits 2003

PROGRAM CONTACT
Tina Hartley Phone: 334/242-5743
Interim Director Fax: 334/242-5594
Alabama Dept. of Senior Services E-mail: ageline@adss.state.al.us
770 Washington Avenue
RSA Plaza, Suite 470
Montgomery, AL 36130

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Arizona
Prescription Discount Program (CoppeRx Card)
Program Type: Discount
Law Enacted: 2001
Estimated Number of Recipients (December 2003): 15,000*

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): none


Eligible Income Level (Single): None Eligible Income Level (Married): None
Other Eligibility Notes: Open to all seniors and Medicare-eligible disabled who are
residents of Arizona.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco Settlement Fund


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: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $3.00 for retail and $2.00 for mail order
Notes: Average percent savings off the regular prescription price: brand
name drugs (17.7%) and generic drugs (40.1%). Average
savings per prescription: $13.39. Total savings to all participants
(through 12/31/03) over $1.1 million. RxAmerica (PBM)
negotiates discounts with participating manufacturers.

DRUG COVERAGE

Formulary: None
Drugs Covered: All FDA-approved drugs.
Drug Coverage Restrictions: None

PROGRAM CONTACT

Del Swan Phone: 602/417-4726


Pharmacy Program Administrator
Arizona Health Care Cost
Containment System
801 E. Jefferson St.
Phoenix, AZ 85034

*
Replaces RxAmerica (Arizona Drug Discount Program); 15,000 enrollees automatically rolled into the new
program. Membership cards sent to more than 1 million eligible residents.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Arkansas
ARx Senior Program
(Prescription Drug Access Improvement Act)
Program Type: Direct Assistance (1115 Waiver)
Law Enacted: 2001∗
Projected Number of Recipients: Not available

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+


Eligible Income Level (Single): 100% of FPL Eligible Income Level (Married): 100% of
FPL
Other Eligibility Notes: Program provides prescription drug coverage to Qualified
Medicare Beneficiary (QMB) seniors lacking prescription drug
coverage.

FUNDING AND REIMBURSEMENT

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 name-brand drugs
Dispensing Fee: Not Available

DRUG COVERAGE

Formulary: Same as Medicaid program


Drugs Covered: Legend drugs and controlled substances
Drug Coverage Restrictions: Enrollees are limited to 2 prescriptions per month.

PROGRAM CONTACT

Carolyn Patrick Phone: 501/682-8359


Arkansas Department of Human Fax: 501/683-4124
Services E-mail: carolyn.patrick@medicaid.state.ar.us
Division of Medical Services
Slot 415
P.O. Box 1437
Little Rock, AR 72203-1437


Program implementation is contingent upon CMS approval of 1115 waiver application. As of January 2004, no
communications from CMS had been received. As a result, implementation date is still pending.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

California
Discount Prescription Medication Program
Program Type: Discount
Year Operational: 2000
Number of Recipients (December 2003): 850,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): All Medicare Eligibility Age (Disabled): All Medicare
eligible eligible
Eligible Income Level (Single): All income Eligible Income Level All income
levels (Married): levels
Other Eligibility Notes: Program covers pharmaceuticals not covered by a private
insurer.

FUNDING AND REIMBURSEMENT

Funding Source: Medi-Cal pharmacies


Budget (FY 02-03): $380,000
Cost per Participant: Not available
# of Rx’s Per Participant: 850,000 price inquiries per month∗
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: Average wholesale price (AWP) – 10%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $4.05 per prescription (-50 cents to help balance the State
budget, + 15 cents for switching costs)
Notes: Pharmacies that participate in the Medi-Cal (Medicaid) program
must allow Medicare recipients to purchase drugs for the same
price paid by Medi-Cal. Recipients must pay Medi-Cal price for
drug and a 15 cents processing fee.

DRUG COVERAGE

Formulary: No formulary
Drugs Covered: Almost all prescription drugs
Drug Coverage Restrictions: Over-the-counter drugs and compound drugs not covered

PROGRAM CONTACT

Janice Hall Phone: 916/552-9714


Department of Health Services 1-800-434-0222
714 P Street, Room 1253
Sacramento, CA 95814


Price inquires do not always result in sales, because customers may elect not to purchase a pharmaceutical once
its price has been quoted.

6-11
National Pharmaceutical Council Pharmaceutical Benefits 2003

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 All income
levels (Married): 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.

FUNDING AND REIMBURSEMENT

Funding Source: Manufacturer negotiated discounts


Budget: None
Cost per Participant: Not Available
# of Rx’s Per Participant: Not Available
Manufacturer Rebate Type: Medicaid rebate plus manufacturer-negotiated discounts
Ingredient Cost Calculation: AWP – 10%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $4.05 per prescription (-50 cents to help balance the FY 02-03 state
budget, + 15 cents for switching costs)
Notes: Implementation of the Golden Bear State Pharmacy Assistance
Program is pending as no pharmaceutical manufacturers are
participating in the program. The program has been postponed due to
the Federal Medicare prescription drug benefit enacted by Congress
in 2003.

DRUG 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
Janice Spitzer Phone: 916/552-9557
Department of Health Services
714 P Street, Room 1253
Sacramento, CA 95814

*
Golden Bear State Pharmacy Assistance Program is not operational. No manufacturers are participating.

6-12
National Pharmaceutical Council Pharmaceutical Benefits 2003

Connecticut
Pharmaceutical Assistance Contract to the Elderly and
Disabled (ConnPACE)
Program Type: Direct Assistance
Year Operational: 1986
Number of Recipients (December 2003): 52,086

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+


Eligible Income Level (Single): $20,800 Eligible Income Level (Married): $28,100
Other Eligibility Notes: Disabled persons 18-64 must be Social Security Disability
Insurance (SSDI) or Supplemental Security Insurance (SSI)
eligible. Effective February 2004, new means test will be used
to determine “liquid assets”; $100,000 - individuals; $125,000 –
married

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund


Budget (FY 04): $77.9 million
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 12%
Enrollment Fee: $30.00 per year
Deductible Amount: None
Copayment Amount: $16.25
Dispensing Fee: $3.30

DRUG COVERAGE

Formulary: Open formulary


Drugs Covered: All prescription drugs and insulin.
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.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

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 may
implement PDL in the future.

PROGRAM CONTACT

Evelyn A. Dudley Phone: 860/424-5654


Manager Fax: 860/424-5206
Department of Social Services E-mail: evelyndudley@po.state.ct.us
25 Sigourney Street
Hartford, CT 06106

6-14
National Pharmaceutical Council Pharmaceutical Benefits 2003

Delaware
Nemours Pharmacy Assistance
Program Type: Private Discount
Year Operational: 1981
Number of Enrollees (December 2003): 7,822

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+


Eligible Income Level (Single): $12,500 Eligible Income Level (Married): $17,125
Other Eligibility Notes: Must be a U.S. citizen and resident of Delaware.

FUNDING AND REIMBURSEMENT

Funding Source: Nemours Foundation


Budget: Not available
Cost per Enrollee: Not available
# of Rx’s Per Enrollee (2003): Not available
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.

DRUG 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

W. Frank Morris, Jr. Phone: 302/651-4405


Nemours Clinic Pharmacy Assistance Fax: 302/651-4445
1801 Rockland Road E-mail: fmorris@nemours.org
Wilmington, DE 19803

6-15
National Pharmaceutical Council Pharmaceutical Benefits 2003

Delaware
Prescription Assistance Program (DPAP)
Program Type: Direct Assistance
Year Operational: 2000
Number of Recipients (December 2003): 6,100

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+


Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of
FPL
Other Eligibility Notes: Must be a U.S. citizen and resident of Delaware. Couples are
counted as two individuals. Individuals with income over 200%
of FPL can qualify if they have prescription costs exceeding
40% of their income. Those age 65 and over who are eligible
for the Nemours Foundation prescription benefit are not eligible
for DPAP. DPAP does not replicate coverage for Nemours
clients. Disabled persons 18-64 must be Social Security
Disability Insurance (SSDI) eligible.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco Settlement funds


Budget: Not available; not subject to budget appropriation
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Negotiated between the State and individual manufacturers
Ingredient Cost Calculation: Lower of AWP – 12.9% or Federal Upper Limit or State
maximum allowable cost (MAC)
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: Greater of $5.00 or 25% of the cost of the prescription
Dispensing Fee: $3.48
Notes: Annual maximum benefit of $2,500.00 per recipient.
EDS administers program on behalf of the State.

DRUG COVERAGE

Formulary: Open
Drugs Covered: Same as Medicaid (medically necessary prescription drugs)
Drug Coverage Restrictions: Only drugs from manufacturers that agree to participate in State
rebate program.

PROGRAM CONTACT

Judy Ackerman – EDS Phone: 302/453-8453


Division of Social Services Fax: 302/454-7603
248 Chapman Road Suite 100 E-mail: judy.ackerman@eds.com
Newark, DE 19702

6-16
National Pharmaceutical Council Pharmaceutical Benefits 2003

Florida
Silver SaveRx Program
Program Type: Direct Assistance (1115 waiver)
Year Operational: 2002
Number of Enrollees (January 2004): 52,074

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+


Eligible Income Level (Single): 88% - 120% Eligible Income Level 88% - 120%
of FPL (Married): of FPL
Other Eligibility Notes: Program covers dual eligibles only. Eligibility is determined on
a monthly basis.

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund, Federal matching funds, and
manufacturer rebates
Budget (FY 03): $100 million
Cost per Enrollee (FY 03): $160 per month – maximum benefit
# of Rx’s Per Enrollee (FY 03): 108 (estimated)
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 up to $160 deposited monthly in a Silver
Saver account that is maintained by the Medicaid program.

DRUG COVERAGE

Formulary: Preferred drug list


Drugs Covered: Same as Medicaid
Drug Coverage Restrictions: Same as Medicaid

PROGRAM CONTACT

Michele Hudson Phone: 850/487-4441


Agency for Health Care Admin. E-mail: hudsons@fdhc.state.fl.us
2727 Mahan Drive
Tallahassee, FL 32308-7703

6-17
National Pharmaceutical Council Pharmaceutical Benefits 2003

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 All income
levels (Married): levels
Other Eligibility Notes: Anyone who has a Medicare card is eligible.

FUNDING AND REIMBURSEMENT

Funding Source: None


Budget: None
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Not available
Ingredient Cost Calculation: AWP – 9%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $4.50
Notes: Pharmacies that participate in Medicaid must offer participants a
discount based on AWP – 9% + $4.50 dispensing fee.

DRUG COVERAGE

Formulary: None
Drugs Covered: All prescription drugs
Drug Coverage Restrictions: None

PROGRAM CONTACT

Michele Hudson Phone: 850/487-4441


Agency for Health Care E-mail: hudsons@fdhc.state.fl.us
Administration
2727 Mahan Drive
Tallahassee, FL 32308-7703


By law Florida pharmacies are required to provide this discount in order to participate in Medicaid.

6-18
National Pharmaceutical Council Pharmaceutical Benefits 2003

Georgia
Georgia Cares Program*
Program Type: Coordinate Assistance Between Elderly and Charitable
Pharmaceutical Programs
Year Operational: 2002
Number of Recipients: 24,739

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+


Eligible Income Level (Single): None Eligible Income Level (Married): None
Other Eligibility Notes: Individuals may not have any other insurance coverage for
medicines.

FUNDING AND REIMBURSEMENT

Funding Source: State and Federal grant money


Budget (FY 04): $580,000
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: None
Ingredient Cost Calculation: None
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: Not available
Notes: The purpose of the program is to utilize available State resources
to help eligible seniors find appropriate charitable pharmaceutical
programs from various manufacturers. The program also
receives some in-kind grant money from the “Thanks Mom &
Dad Fund,” a 501(c)(3) charitable organization that collects
private donations for senior assistance programs.

DRUG COVERAGE

Formulary: None
Drugs Covered: Based on a manufacturer’s charitable program criteria.
Drug Coverage Restrictions: Not available

*
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.

6-19
National Pharmaceutical Council Pharmaceutical Benefits 2003

PROGRAM CONTACT

Jennie Deese Phone: 404/463-8578


Coordinator Fax: 404/657-5285
Georgia Cares
Division of Aging Services Alternate Contact:
2 Peachtree Street, NW J. Eric Ryan
Atlanta, GA 30303 Program Consultant
Georgia Cares
Phone: 404/657-5333
E-mail: joryan@dhr.state.ga.us

6-20
National Pharmaceutical Council Pharmaceutical Benefits 2003

Hawaii
Hawaii Rx*
Program Type: Direct Discount
Projected Operational Date: Pending
Projected Number of Recipients: Not Available

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages
Eligible Income Level (Single): All income Eligible Income Level All income
levels (Married): levels
Other Eligibility Notes: Open to all Hawaii residents, regardless of income.

FUNDING AND REIMBURSEMENT

Funding Source: State General Fund


Budget (FY 02-03): $200,000 for plan development and implementation
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Efforts will be made to obtain an initial rebate amount equal to
or greater than the rebate calculated for Medicaid.
Ingredient Cost Calculation: Not available
Enrollment Fee: Not available
Deductible Amount: Not available
Copayment Amount: Not available
Dispensing Fee: Not less than fee provided under the State Medicaid program.

DRUG COVERAGE

Formulary: Not available


Drugs Covered: Not available
Drug Coverage Restrictions: Not available
Notes: Each pharmacy participating in the program will discount the
price of drugs covered by the program and sold to program
participants. Participating pharmacies will submit claims to the
Department of Human Services and will be reimbursed for the
discounted drugs.

PROGRAM CONTACT

Eileen Hiramatsu Phone: 808/692-8050


Department of Human Services
1390 Miller Street, Room 209
Honolulu, HI 96813

*
The legislature will conduct further study and propose additional amendments during 2004 before
implementing the program.

6-21
National Pharmaceutical Council Pharmaceutical Benefits 2003

Illinois
Pharmaceutical Assistance Program (PAP)
“Circuit Breaker”
Program Type: Direct Assistance
Year Operational: 1985
Number of Recipients (December 2003): 57,034

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 16+


Eligible Income Level (Single): 250% of FPL Eligible Income Level 250% of FPL
(Married):
Other Eligibility Notes: A widow or widower who turns 63 or 64 before a deceased
enrollee’s death is eligible for PAP. Also, a married couple with
a $35,740 annual household income would be eligible if they
were filing with one other resident. An individual would be
eligible with a $35,740 annual household income if they were
filing with two other residents.

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund and Tobacco Settlement


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 a Express Scripts (PBM) on behalf of 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

DRUG COVERAGE

Formulary: State preferred product formulary


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.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Drug Coverage Restrictions Participants are able to receive brand-name drugs even if generic
are available provided the doctor marks “dispense as written” on
the prescription and the drug is classified as a “Narrow
Therapeutic Index Drug.”

PROGRAM CONTACT

Susan Rohrer Phone: 217/785-5905


Pharmaceutical Assistance Programs Fax: 217/524-9213
Illinois Department of Revenue E-mail: srohrer@revenue.state.il.us
P.O. Box 19021
Springfield, IL 62794-9021

6-23
National Pharmaceutical Council Pharmaceutical Benefits 2003

Illinois
Illinois Rx SeniorCare
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 2002
Number of Recipients (December 2003): 170,969

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 16+


Eligible Income Level (Single): 200% of FPL Eligible Income Level 200% of
(Married): FPL
Other Eligibility Notes: Seniors who are already enrolled in the State’s Circuit Breaker/
Pharmaceutical Assistance Program and fall at or below 200% of
FPL are automatically enrolled in this program. Eligible
individuals who already have pharmaceutical health insurance
benefits may choose to receive a $25 rebate check monthly. By
choosing the SeniorCare Rebate, individuals must use their own
health insurance to pay for prescription drugs.

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund and Tobacco Settlement


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- 10% 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 $8,979 a
year, or if participant lives with his/her spouse and together the
income is no more than $12,119, 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 $8,980
to $17,960 a year, or if the participants are a married and living
together with a total household income of $12,120 to $24,240 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 $1 for each prescription plus
the difference in price between the generic and the brand-name
drug.
Dispensing Fee: Not available

6-24
National Pharmaceutical Council Pharmaceutical Benefits 2003

DRUG COVERAGE

Formulary: Preferred product formulary plus over-the-counter medications


like analgesics, stool softeners, laxatives and antacids.
Drugs Covered: Prescription medication used for cancer, Alzheimer’s disease,
Parkinson’s disease, glaucoma, lung disease and smoking-
related diseases, cardiovascular, arthritis, diabetes, osteoporosis
and the over-the-counter medications listed above.
Drug Coverage Restrictions Only covered medications

PROGRAM CONTACT

Susan Rohrer Phone: 217/785-5905


Pharmaceutical Assistance Programs Fax: 217/524-9213
Illinois Department of Revenue E-mail: srohrer@revenue.state.il.us
P.O. Box 19021
Springfield, IL 62794-9021

6-25
National Pharmaceutical Council Pharmaceutical Benefits 2003

Illinois
Illinois Rx Buying Club
Program Type: Direct Discount
Year Operational: 2004
Number of Eligible Recipients: 1.5 million

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Medicare


eligible
Eligible Income Level (Single): None Eligible Income Level (Married): See notes
Other Eligibility Notes: Membership is available to individuals only. Circuit Breaker/
Pharmaceutical Assistance participants are automatically
enrolled in the buying club.

FUNDING AND REIMBURSEMENT

Funding Source: Enrollment fees


Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Sav-Rx (PBM) negotiates discounts with participating
manufacturers.
Ingredient Cost Calculation: Not available
Enrollment Fee: $25.00
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: Not available
Notes: The Illinois Rx Buying Club provides discounts on all categories
of prescription drugs. The program also has a mail-order option
for enrollees. The $25.00 enrollment fee entitles beneficiary to
savings of 20% or more on each prescription for 12 months.

DRUG COVERAGE

Formulary: Preferred Drug List


Drugs Covered: All prescriptions ordered by physician that are on the PDL
Drug Coverage Restrictions: All FDA-approved drugs are eligible for the program

PROGRAM CONTACT

Deb Corso Phone: 217/524-7478


Illinois Department on Aging Fax: 217/785-4477
421 East Capitol Avenue, #100
Springfield, IL 62701-1789

6-26
National Pharmaceutical Council Pharmaceutical Benefits 2003

Indiana
Indiana Prescription Drug Program
“HoosierRx”
Program Type: Point of Sale
Year Operational: 2000
Number of Recipients (December 2003): 17,179

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): 135% of FPL Eligible Income Level 135% of FPL
(Married):
Other Eligibility Notes: Must be an Indiana resident for at least 90 days in the past 12
months, without prescription drug coverage through an
insurance plan, Medicaid or Medicaid with a spend-down.
Benefit is available for one year. Recipients must submit a new
application each year.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco Settlement Fund


Budget (FY 04): $8 million
Cost per Participant (FY 03): $540
# of Rx’s Per Participant (FY 03): 51.6
Manufacturer Rebate Type: None
Ingredient Cost Calculation: Medicaid reimbursement rate
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: 50% of HoosierRx negotiated price, up to the maximum benefit
limit ($500.00, $750.00 or $1,000.00 per year, depending on
income)
Dispensing Fee: $4.90
Notes: Once maximum benefit limit is reached, recipients may continue
to receive the HoosierRx discounted rate during the rest of the
enrollment year.

DRUG COVERAGE

Formulary: None
Drugs Covered: All prescription drugs, as well as insulin

6-27
National Pharmaceutical Council Pharmaceutical Benefits 2003

PROGRAM CONTACT

Lola Sawyerr Phone: 317/233-0587


HoosierRx Fax: 317/232-7382
Family & Social Services Email: lsawyerr@fssa.state.in.us
Administration
402 W. Washington Street
W-386, MS-07
Indianapolis, IN 46204-2739

6-28
National Pharmaceutical Council Pharmaceutical Benefits 2003

Iowa
Iowa Priority Prescription Savings Program
Program Type: Negotiated Discount
Year Operational: 2002
Number of Enrollees (December 2003): 68,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): All Medicare Eligibility Age (Disabled): All Medicare
eligibles eligibles
Eligible Income Level (Single): All income Eligible Income Level All income
levels (Married): levels
Other Eligibility Notes: Medicaid recipients are not eligible.

FUNDING AND REIMBURSEMENT

Funding Source: Federal grant and enrollment fees


Budget (FY 03): $1.2 million
Cost per Enrollee: Not available
# of Rx’s Per Enrollee (FY 03): 36
Manufacturer Rebate Type: A pharmacy benefit manager (PBM) negotiates discounts with
participating manufacturers.
Ingredient Cost Calculation: Reimbursement rate based on negotiated contract with each
participating manufacturer.
Enrollment Fee: $20.00 per year
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: Not available
Notes: The Iowa Priority prescription savings program is a nonprofit
organization run by the non-profit Iowa Prescription Drug
Corporation. Discounts are available on participating
manufacturers’ drugs (Bristol-Myers Squibb, Merck, Novartis,
and Schering-Plough). 100% of the discount is passed through
directly to the consumer at the point of sale.

DRUG COVERAGE

Formulary: Preferred drug list


Drugs Covered: The following therapeutic classes of drugs are covered: Allergy,
Alzheimer’s Disease, Anti-Convulsant Agents, Anti-Fungal
Agent, Anti-Psychotic Agent, Antiviral, Arthritis and Analgesia,
Asthma, Breast Cancer, Central Nervous System Stimulants,
Cholesterol Lowering Agents, Dermatological Products,
Diabetes, Enlarged Prostate Treatment, Glaucoma Agents,
Hormone Replacement, Hypertension/High Blood Pressure and
Cardiovascular, Irritable Bowel Syndrome, Osteoporosis
Treatment, Parkinson’s Disease, and Voltaren Ophthalmic®
(diclofenac ophthalmic).
Drug Coverage Restrictions: None

6-29
National Pharmaceutical Council Pharmaceutical Benefits 2003

PROGRAM CONTACT

David Fries Phone: 515/327-5405, ext. 203


Iowa Prescription Drug Corporation Fax: 515/327-5422
1231 8th Street, Suite 232 Email: info@iowapriority.org
West Des Moines, IA 50265

6-30
National Pharmaceutical Council Pharmaceutical Benefits 2003

Kansas
Kansas Senior Pharmacy Assistance Program
Program Type: Reimbursement
Year Operational: 2001
Number of Enrollees (June 2003): 1,500

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+


Eligible Income Level (Single): 135% of FPL Eligible Income Level 135% of FPL
(Married):
Other Eligibility Notes: Must be a Kansas resident; not covered under a private
prescription reimbursement plan; not eligible for or enrolled in
any other local, State, or Federal prescription program; not have
voluntarily canceled a local, State, Federal, or private
prescription drug program within six months of application to
the program. Must be current recipient of benefits through the
Qualified Medicare Beneficiary Program or Low Income
Medicare Beneficiary Program.
If funded, law permits income eligibility up to 200% of poverty
level.

FUNDING AND REIMBURSEMENT

Funding Source: State funds


Budget (FY 04): $1.2 million
Cost per Enrollee (FY 03): $306 (estimated)
# of Rx’s Per Enrollee: Not available
Manufacturer Rebate Type: None
Ingredient Cost Calculation: None
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: 30% of pharmaceutical cost
Dispensing Fee: None
Notes: Maximum annual benefit is $1,200.00 per enrollee annually,
with reimbursement checks to be sent by December 31 of each
year.

DRUG 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.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

PROGRAM CONTACT

Janet Boscom Phone: 785/296-4986


Department on Aging General E-mail: wwwmail@aging.state.ks.us
503 S. Kansas Avenue
Topeka, KS 66603-3404

6-32
National Pharmaceutical Council Pharmaceutical Benefits 2003

Louisiana
Louisiana Seniors Pharmacy Assistance Program
Program Type: Reimbursement
Year Operational: Not Yet Operational
Number of Recipients: N/A

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+


Eligible Income Level (Single): 100% of FPL Eligible Income Level 100% of FPL
(Married):
Other Eligibility Notes:

FUNDING AND REIMBURSEMENT

Funding Source: Not Available


Budget (FY 04): Not Available
Cost per Participant: Not available
# of Rx’s Per Participant (FY 04): Not Available
Manufacturer Rebate Type: None
Ingredient Cost Calculation: None
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: Not available
Notes:

DRUG COVERAGE

Formulary: None
Drugs Covered: Not available
Drug Coverage Restrictions: Not available

PROGRAM CONTACT

Melissa Jenkins Phone: 225/342-7100 or 342-3570


Coordinator Fax: 225/342-7133
Governor's Office of Elderly Affairs
P.O. Box 80374
Baton Rouge, LA 70898

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Louisiana
Louisiana SenioRx Program*
Program Type: Coordinate Assistance Between Elderly and Charitable
Pharmaceutical Programs
Year Operational: 2003
Number of Recipients: Under 1,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 60+ Eligibility Age (Disabled): 60+


Eligible Income Level (Single): 300% of FPL Eligible Income Level 300% of FPL
(Married):
Other Eligibility Notes: Individuals may not have any other insurance coverage for
medicines.

FUNDING AND REIMBURSEMENT

Funding Source: State general revenue


Budget (FY 04): $500,000
Cost per Participant: Not available
# of Rx’s Per Participant (FY 04): 84
Manufacturer Rebate Type: None
Ingredient Cost Calculation: None
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: Not available
Notes: The purpose of the program is to utilize available State resources
to help eligible seniors find appropriate charitable programs
from various manufacturers. The State will also coordinate and
complete all necessary paperwork for each participant.

DRUG COVERAGE

Formulary: None
Drugs Covered: Based on a manufacturer’s charitable program criteria.
Drug Coverage Restrictions: Not available

PROGRAM CONTACT

Melissa Jenkins Phone: 225/342-7100 or 342-3570


Coordinator Fax: 225/342-7133
Governor's Office of Elderly Affairs
P.O. Box 80374
Baton Rouge, LA 70898

*
The Louisiana Senior Rx 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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National Pharmaceutical Council Pharmaceutical Benefits 2003

Maine
Maine Rx Plus*
Program Type: Discount
Year Operational: 2004
Estimated Eligibles (FY 04): 275,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages
Eligible Income Level (Single): 350% FPL Eligible Income Level 350% FPL
(Married):
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.

FUNDING AND REIMBURSEMENT

Funding Source: State appropriations and subsidies


Budget (FY 04): $800,000
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: State-only rebates
Ingredient Cost Calculation: AWP – 13%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: Program combines discounts from participating pharmacies with
negotiated rebates from manufacturers
Dispensing Fee: $3.35

DRUG COVERAGE

Formulary: Closed formulary


Drugs Covered: Only “preferred” drugs included on the MaineCare (Maine
Medicaid) PDL.
Drug Coverage Restrictions: Non-preferred drugs (as indicated non-covered on the
MaineCare PDL).

PROGRAM CONTACT

Jude Walsh Phone: 207/287-1815


Department of Human Services Fax: 207/287-8601
11 State House Station E-mail: jude.e.walsh@maine.gov
Augusta, ME 04333-0011

*
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.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Maine
Low Cost Drugs for the Elderly and Disabled Program
(DEL)*
Program Type: Subsidy and Discount
Year Operational: 1975
Number of Recipients (December 2003): 37,802

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 62+ Eligibility Age (Disabled): 19+


Eligible Income Level (Single): 185% of FPL Eligible Income Level 185% of FPL
(Married):
Other Eligibility Notes: This program is made available to Maine residents fitting the age
and income eligibility criteria. Individuals with full MaineCare
(Maine Medicaid) benefits are not eligible. Medicare recipients
are not necessarily excluded.

FUNDING AND REIMBURSEMENT

Funding Source: State appropriations and subsidies


Budget (FY 04): $18 million
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: State-only rebates
Ingredient Cost Calculation: AWP –15%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: Basic: 20% +$2.00 of the cost of generic drugs; 20% + $2.00 of
the cost of prescriptions for select medical conditions; 84% of
the cost of other covered prescriptions. Supplemental: State
pays $2.00 toward the cost of all other drugs from participating
manufacturers.
Dispensing Fee: $2.35
Notes: A participant is eligible for a Catastrophic benefit once he or she
has paid total copayments in the DEL benefit of at least $1,000
between August 1 and July 31 of any year(s) in which the
participant is eligible.

DRUG COVERAGE

Formulary: Open formulary


Drugs Covered: Only those drugs covered with manufacturer participation.
Drug Coverage Restrictions: 34-day supply limit for brand name drugs, 90-day limit for
generic drugs. Some prescriptions require prior approval to
assure quality, dose strength, and cost effectiveness.

*
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.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

PROGRAM CONTACT

Jude Walsh Phone: 207/287-1815


Department of Human Services Fax: 207/287-8601
11 State House Station E-mail: jude.e.walsh@maine.gov
Augusta, ME 04333-0011

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Maryland
Maryland Pharmacy Assistance Program
Program Type: Direct Assistance
Year Operational: 1979
Number of Recipients (December 2003): 47,133

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): See notes


Eligible Income Level (Single): 116% of FPL Eligible Income Level 100% of FPL
(Married):
Other Eligibility Notes: No age restrictions on eligibility if they are Medicare-eligible
and MD residents. The following groups are ineligible for
participation: people detained in a correctional (Federal, State,
local) system, Medicaid recipients. Disabled are covered if they
are Medicare-eligible.

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund


Budget (FY 03): $73.2 million
Cost per Participant (FY 03): $1,697.96
# of Rx’s Per Participant (FY 03): 27.55
Manufacturer Rebate Type: Medicaid
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 Estimated Acquisition Cost (EAC),
State MAC, or Federal MAC.
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $7.50 for brand-name; $2.50 for generics (per prescription)
Dispensing Fee: $3.69 for brand-name; $4.69 for generics

DRUG COVERAGE

Formulary: PDL for certain therapeutic classes.


Drugs Covered: Follows Medicaid guidelines
Drug Coverage Restrictions: Prior authorization for certain medications, including steroids
and some controlled substances. 75% utilization required for
prescription refill.

PROGRAM CONTACT

Paul A. Roeger, Division Chief Phone: 443/263-7031


Office of Operations & Eligibility E-mail: roegerp@dhmh.state.md.us
Department of Health and Mental
Hygiene Alternate contact:
201 West Preston Street Frank Tetkosky, 410/767-1460
Baltimore, MD 21201

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Maryland
Senior Prescription Drug Program
Program Type: Direct Assistance
Year Operational: 2001∗
Number of Recipients (December 2003): 33,400

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): See notes


Eligible Income Level (Single): 300% of FPL Eligible Income Level 300% of FPL
(Married):
Other Eligibility Notes: Program open to all MD residents who have no other
prescription drug insurance plan. Disabled are covered if they
are Medicare-eligible.

FUNDING AND REIMBURSEMENT

Funding Source: CareFirst subsidizes program through a 2% premium tax


exemption from the State of Maryland.
Budget (FY 04): $23 million available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: PBM-negotiated with individual drug companies
Ingredient Cost Calculation: PBM-negotiated with contracted pharmacies
Enrollment Fee: $10 monthly premium
Deductible Amount: None
Copayment Amount: $10 for generics, $20 for preferred brand-name products, $35
non-preferred brand-name products
Dispensing Fee: Varies among contracted pharmacies.
Notes: Maximum benefit is $1,000 per enrollee per 12-month period.
AdvancePCS administers the pharmacy benefit and negotiates
contracts with individual pharmaceutical manufacturers and
pharmacies. Enrollees are expected to save between 13% and
16% on each prescription.

DRUG COVERAGE

Formulary: CareFirst formulary


Drugs Covered: Most generic and brand drugs approved by the Food and Drug
Administration (FDA) are included under this program.
Drug Coverage Restrictions: Anorexants are excluded. Over the counter drugs are excluded.
Quantity limits on certain drugs such as Viagra, migraine
medicines and Oxycontin. Prior authorizations on certain drugs
such as growth hormones.


The program sunsets June 30, 2005, but may be extended through 12/31/05 to coincide with Federal Medicare
drug benefit program changes.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

PROGRAM CONTACT

Richard Popper, Commissioner Phone: 410/576-2053


Maryland Health Insurance Plan
1 Calvert Place Alternate contact:
Baltimore, MD 21202 Robin Vahle
CareFirst Plan Coordinator,
Phone: 410/998-5444,
E-mail: robin.vahle@carefirst.com

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Maryland
Maryland Pharmacy Discount Program
Program Type: Discount (1115 Waiver)
Operational Date: July 1, 2003
Number of Recipients (December 2003): 24,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): See notes


Eligible Income Level (Single): 175% of FPL Eligible Income Level 175% of FPL
(Married):
Other Eligibility Notes: Must be a Medicare recipient and a Maryland resident. Disabled
are covered if they are Medicare-eligible.

FUNDING AND REIMBURSEMENT

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 Medicaid price
Dispensing Fee: $1.00 per prescription

DRUG COVERAGE

Formulary: PDL for certain therapeutic classes.


Drugs Covered: Medicaid guidelines
Drug Coverage Restrictions: Medicaid guidelines

PROGRAM CONTACT

Paul A. Roeger Phone: 443/767-5394


Division Chief E-mail: roegerp@dhmh.state.md.us
Office of Operations & Eligibility
Department of Health Alternate contact:
and Mental Hygiene Frank Tetkosky, 410/767-1460
201 West Preston Street
Baltimore, MD 21201

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Massachusetts
Prescription Advantage*
Program Type: Direct Assistance
Year Operational: 2001
Number of Recipients (December 2003): 80,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): See notes


Eligible Income Level (Single): Sliding scale Eligible Income Level Sliding scale
(Married):
Other Eligibility Notes: Disabled participants may participate if they are under age 65,
work 40 or fewer hours per month, meet CommonHealth
disability guidelines and have gross annual household incomes
at or below 188% of the Federal Poverty Level. Individuals
receiving Medicaid are not eligible to join Prescription
Advantage.

FUNDING AND REIMBURSEMENT

Funding Source: State general funding


Budget (FY 04): $96.3 million
Cost per Participant (FY 03): $90.44 per member per month
$ Rx’s Per Participant (FY 03): $1,085.28
Manufacturer Rebate Type: AdvancePCS negotiates price and rebates with drug
manufacturers.
Ingredient Cost Calculation: AWP-14%
Enrollment Fee: Single: $0-$99 per month per enrollee, depending on income;
Married: $0-$74 per month per enrollee, depending on income
Deductible Amount: $0-$500 annually, depending on income. Payments are accepted
quarterly.
Copayment Amount: 30-day Rx fill (retail): $9 to $50 based on drug plan level
(tiered)
90-day Rx fill (mail-order): $18 to $100 based on drug plan level
(tiered)
Dispensing Fee: $2.40 for retail pharmacy
Notes: Premiums, deductibles and copayments are determined through
a sliding scale based on income levels. The annual out-of-pocket
limit per enrollee is $2,000 or 10% of income, whichever is less.
For married members, the out-of-pocket spending limit is $3,000
combined, or 10% of gross annual household income, whichever
is less. The lower premium for married members only applies to
those members who are both enrolled in the plan; when not
joining as a couple, a married member must pay the individual
rate.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

DRUG COVERAGE

Formulary: Prescription Advantage formulary


Drugs Covered: All therapeutic classes, except those excluded from MassHealth.
Includes all FDA approved oral drugs as well as many injectable
drugs, including insulin and disposable insulin syringes with
needles.
Drug Coverage Restrictions: No OTC
Notes: The plan utilizes a formulary that categorizes prescription drugs
into three categories: generic drugs, brand-name drugs, and
additional brand-name drugs. Generic drugs have the lowest
copayment, while additional brand-name drugs have the highest
copayment.

*Program operational. Enrollment temporarily closed due to budgetary restrictions.

PROGRAM CONTACT

Molly McGinnis Phone: 617/727-7750


Massachusetts Executive Office of Fax: 617/727-9368
Elder Affairs
One Ashburton Place Prescription Advantage information line: 800/243-4636
Boston, MA 02108

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Massachusetts
MassMedLine*
Program Type: Coordinate Assistance Between State Residents and
Charitable Pharmaceutical Programs
Year Operational: 2001
Estimated Number of Recipients (2004): 13,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): none Eligibility Age (Disabled): none


Eligible Income Level (Single): none Eligible Income Level (Married): none
Other Eligibility Notes: Anyone may call MassMedLine. Charitable programs have their
own eligibility guidelines.

FUNDING AND REIMBURSEMENT

Funding Source: The program is funded partly by the state with the balance of the
operational costs subsidized by the Massachusetts College of
Pharmacy and Health Sciences with support from Federal,
foundation and corporate grants.
Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: None
Ingredient Cost Calculation: None
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: Not available
Notes: The purpose of the program is to utilize available State resources
to help residents find appropriate charitable pharmaceutical
programs from various manufacturers.

DRUG COVERAGE

Formulary: None
Drugs Covered: Based on a manufacturer’s charitable program criteria.
Drug Coverage Restrictions: Not available

PROGRAM CONTACT
MassMedLine™ 19 Foster Street
Massachusetts College of Pharmacy Worcester, MA, 01608-1705
and Health Sciences Phone: 866/633-1617

*
MassMedLine assists 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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National Pharmaceutical Council Pharmaceutical Benefits 2003

Michigan
Elder Prescription Insurance Coverage (EPIC)
Program
Program Type: Direct Assistance
Year Operational: 2001
Number of Enrollees (December 2003): 14,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+


Eligible Income Level (Single): 200% of FPL Eligible Income Level 200% of FPL
(Married):
Other Eligibility Notes: EPIC enrollment is currently closed due to budget constraints,
except for 45-day emergency coverage, which is available up to
two times a year. In addition to normal coverage eligibility
requirements, to be eligible for emergency coverage:
• A single applicant must make less than 150% of FPL
• A married applicant must make equal to or less than 150%
of FPL
• A true medical emergency must exist
To be eligible for normal coverage, an applicant:
• Must be a resident of Michigan for three months prior to
application
• Cannot be residing in an institution
• Cannot have other insurance or program coverage for
prescription drugs
• Cannot currently receive Medicaid benefits

FUNDING AND REIMBURSEMENT

Funding Source: State general fund plus rebate revenue


Budget: Not available
Cost per Enrollee (FY 03): $2,400 (estimated)
# of Rx’s Per Enrollee (FY 03): 60
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: Lesser of usual and customary charge, AWP – 15.1% or 13.5%
(depending on the pharmacy), or the State MAC price
Enrollment Fee: $25.00
Deductible Amount: Based on the participant’s total annual household income.
Maximum annual cost-share amount is divided into twelfths so
that a monthly amount must be met. If the out-of-pocket amount
is not met in that month, the amount is cumulative, and any
remainder is added to the following month. Deductibles are re-
established yearly.
Copayment Amount: If a brand name drug is prescribed and dispensed when a
generically equivalent drug is available, a $15.00 copayment in

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National Pharmaceutical Council Pharmaceutical Benefits 2003

addition to the monthly out-of-pocket share is charged. No


copayment may exceed 20% of the cost of the drug
Dispensing Fee: $3.77

DRUG 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

Tom Chisnell Phone: 517/373-3364


Department of Community Health
611 West Ottawa, P.O. Box 30676
Lansing, MI 48909-8176

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Minnesota
Prescription Drug Program∗
Program Type: Direct Assistance
Year Operational: 1999
Number of Enrollees (December 2003): 7,100

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18-64


Eligible Income Level (Single): 120% of FPL Eligible Income Level 120% of FPL
(Married):
Other Eligibility Notes: On July 1, 2002, the program expanded to include coverage for
persons on Medicare due to a disability. To be eligible, enrollees
must:
• Be a Medicare enrollee, age 65 or older, or disabled
• Be a Minnesota resident for six months
• Have liquid assets (other than home, car, burial funds, etc.)
of $10,000 or less for one person or $18,000 or less for a
married couple
• Not be eligible for Medicaid
• Not have prescription drug coverage within four months of
applying
• Not be enrolled in MinnesotaCare
• Be enrolled in, or applying for, one of the following
Medicare supplement programs, which help enrollees pay
their Medicare premiums: Qualified Medicare Beneficiary
(QMB), or Service Limited Medicare Beneficiary (SLMB)

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund plus manufacturer rebates


Budget (FY 04): $9 million
Cost per Enrollee: Not available
# of Rx’s Per Enrollee: Not available
Manufacturer Rebate Type: Same as Medicaid
Ingredient Cost Calculation: AWP – 11.5%
Enrollment Fee: None
Deductible Amount: $35.00 per month
Copayment Amount: None
Dispensing Fee: $3.65


Formerly the Senior Citizen Drug Program.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

DRUG COVERAGE

Formulary: Minnesota Medicaid program formulary


Drugs Covered: Same drugs as covered under Medicaid if manufacturer signs
rebate agreement with Department of Human Services. Covers
over-the-counter drugs for antacid, insulin products, smoking
cessation products, lice medication and vitamins.
Drug Coverage Restrictions: Most other over-the-counter drugs are not covered.

PROGRAM CONTACT

Steve Hamilton Phone: 651/297-7699


Rebate Analyst E-mail: steve.hamilton@state.mn.us
Prescription Drug Program
Department of Human Services
444 Lafayette Road
St. Paul, MN 55155-3853

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Missouri
Senior Rx Program
Program Type: Direct Assistance
Year Operational: 2002
Number of Enrollees (December 2003): 19,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): Tier I: $12,000 Eligible Income Level Tier I: $17,000
Tier II: $17,000 (Married): Tier II: $23,000
Other Eligibility Notes: Applicant must be a Missouri resident and have lived in the State
for 12 months by July 1, 2003. Applicants may not receive
Medicaid or veterans pharmacy benefits or have prescription
insurance that is equivalent to or greater than the Missouri SenioRx
Program. Married couples may have household income up to
$25,000 before a $2,000 marital deduction.

FUNDING AND REIMBURSEMENT

Funding Source: Funding comes from the Missouri Senior Rx Fund, which
consists of enrollment fees and manufacturer rebates, and funds
that are appropriated to it by the general assembly.
Budget (FY 04): $20 million
Cost Per Enrollee (FY 03): $850 per year
# of Rx’s Per Enrollee (FY 03): 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

DRUG COVERAGE

Formulary: None
Drugs Covered: Follows Medicaid program guidelines.
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.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

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.
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.
Discount cards cannot be used in conjunction with the program.

PROGRAM CONTACT

Bill Rootes Phone: 573/522-3066


Missouri Senior Rx Program
Health and Senior Services
Department
P.O. Box 570
Jefferson City, MO 65102

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Montana
Prescription Drug Expansion Program
Program Type: Discount (CMS Pharmacy Plus Program waiver)
Year Operational: Not available*
Number of Recipients: Not available

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 62+ Eligibility Age (Disabled): Medicare eligible


Eligible Income Level (Single): 200% of FPL Eligible Income Level 200% of FPL
(Married):
Other Eligibility Notes: Montana resident

FUNDING AND REIMBURSEMENT

Funding Source: $1 million State loan and Federal funding


Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP
Enrollment Fee: $25.00
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: See notes
Notes: Client is responsible for paying the dispensing fee. Dispensing
fee set at the discretion of each participating pharmacist. (This
was done to alleviate concerns that the pharmacists’ $4.70
dispensing fee for Medicaid is inadequate.) State pays the
discount rate of the prescription drug and the “client” pays the
remaining drug cost(s). Discounts average between 6% and
25%.

DRUG COVERAGE

Formulary: None
Drugs Covered: Based on participating manufacturers’ pharmaceutical products
Drug Coverage Restrictions: None

PROGRAM CONTACT

Duane Preshinger Phone: 406/444-4144


Section Supervisor Fax: 406/444-1861
Medicaid Services Bureau E-mail: dpreshinger@state.mt.us
Cogswell Building
1400 Broadway
Helena, MT 59620

*
The program will not be implemented given the passage of the Federal Medicare prescription drug program.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Nevada
Senior Rx
Program Type: Subsidy
Year Operational: 2001
Number of Recipients (December 2003): 8,600

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 62+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): $22,016 Eligible Income Level $28,660
$22,434 (7/04) (Married): $29,205 (7/04)
Other Eligibility Notes: Must be a Nevada resident for at least one year and not eligible
for full Medicaid benefits.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco Settlement Fund


Budget (FY 04): $18 million
Cost per Participant (FY 03): $550.00
# of Rx’s Per Participant (FY 03): 42
Manufacturer Rebate Type: Not available
Ingredient Cost Calculation: Brand: AWP-14%; Generics: Lower of AWP-14% or CMS’
MAC
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: Retail Pharmacy Co-Pays (30-day fill): $10.00 for generics;
$25.00 for preferred brand-name drugs or medically necessary
brand name drugs; and provider’s discounted rate for all other
drugs.
Mail Order Co-Pays (90-day fill): $20.00 for generics, $50.00
for preferred brand-name drugs or medically necessary brand
name drugs.
Dispensing Fee: $2.25
Notes: Maximum benefit of $5,000.00 per year. An annual per enrollee
deductible of $100.00 is paid by the State to Pharmaceutical
Care Network (PCN), the pharmacy benefit manager that
manages the program.

DRUG COVERAGE

Formulary: Managed formulary (by PCN)


Drugs Covered: Most prescription drugs

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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 co-pay 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

Jane Smedes Phone: 775/687-8711


Department of Human Resources E-mail: jasmedes@dhr.state.nv.us
505 E. King Street, Room 201
Carson City, NV 89701-4797

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New Hampshire
Senior Prescription Drug Discount Program*
Program Type: Discount
Year Operational: 2000
Number of Enrollees (December 2003): 70,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): All income Eligible Income Level All income
levels (Married): levels
Other Eligibility Notes: Must be a New Hampshire resident.

FUNDING AND REIMBURSEMENT

Funding Source: Rebates and incentives from pharmaceutical manufacturers


negotiated through Express Scripts, which operates the program.
Budget: The State has not had to fund the program, since it is based on
rebates and incentives
Cost Per Enrollee: There is no associated cost per enrollee.
# of Rx’s Per Enrollee: Not available
Manufacturer Rebate Type: Rebates negotiated by Express Scripts with manufacturer.
Ingredient Cost Calculation: Not available
Deductible Amount: None
Enrollment Fee: None
Copayment Amount: Participant receives discount and must pay remainder of cost of
prescription.
Dispensing Fee: None
Notes: Discounts vary depending on pharmacy and medication.
Discounts can be up to 16% for brand-name products and up to
40% for generics.

DRUG COVERAGE

Formulary: No formulary
Drugs Covered: All prescription drugs
Drug Coverage Restrictions: Over-the-counter drugs are not covered

PROGRAM CONTACT

Kim Hadank Swenson Phone: 603/271-7857


Health And Human Services
Division Of Elderly And Adult
Services
129 Pleasant Street
Concord, NH 03301

*
The program is offered by Express Scripts and has no State funding.

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New Jersey
Pharmaceutical Assistance to the Aged and Disabled
(PAAD)
Program Type: Direct Assistance
Year Operational: 1975
Projected Number of Recipients (FY 03): 217,484

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18-64


Eligible Income Level (Single): $20,437 Eligible Income Level $25,058
(Married):
Other Eligibility Notes: Disabled individuals are only eligible if they receive Title II
Social Security Disability benefits. Married couples must file
individual PAAD applications. If an individual has health
insurance or a retiree prescription benefit equal to or better than
PAAD, or if s/he receives Medicaid, s/he is not eligible for the
PAAD program.

FUNDING AND REIMBURSEMENT

Funding Source: State General Fund and Casino Revenue Fund


Budget (FY 04): $291.4 million
Cost per Participant (FY 03): Senior: $2,200.00 (projected)
Disabled: $4,200.00 (projected)
# of Rx’s Per Participant (FY 03): Senior: 34 (projected)
Disabled: 45 (projected)
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 12.5%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $5.00 per prescription
Dispensing Fee: $3.73 to $4.07

DRUG 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 2003

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).

PROGRAM CONTACT

Jennifer Barron Phone: 609/588-3460


PAAD/Senior Gold Operations Fax: 609/588-7139
P.O. Box 715 E-mail: jennifer.barron@doh.state.nj.us
Trenton, NJ 08625-0715

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National Pharmaceutical Council Pharmaceutical Benefits 2003

New Jersey
Senior Gold Prescription Discount Program
Program Type: Direct Assistance
Year Operational: 2001
Projected Number of Recipients (FY 03): 61,972

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18-64


Eligible Income Level (Single): $20,437 - Eligible Income Level $25,058 -
$30,437 (Married): $35,058
Other Eligibility Notes: Senior citizens and disabled individuals eligible for the
Pharmaceutical Assistance for the Aged and Disabled program
are not eligible for the Senior Gold Prescription Discount
Program. Disabled individuals are only eligible if they receive
Title II Social Security Disability benefits.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco Settlement Fund


Budget (FY 04): $28.4 million
Cost Per Participant (FY 03): Senior: $574.00 (projected)
Disabled: $764.00 (projected)
# of Rx’s Per Participant (FY 03): Senior: 25.4 (projected)
Disabled: 31.2 (projected)
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 12.5%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $15.00 plus 50% of the remaining cost of the prescription or the
actual cost if less than $15.00. After unreimbursed out of pocket
costs reach $2,000.00 for an individual, or $3,000.00 for a
couple, copayments for additional prescriptions that year are
$15.00.
Dispensing Fee: $3.73 to $4.07
Notes: Once an enrollee incurs in one year unreimbursed out-of-pocket
costs of $2,000.00, if single, or $3,000.00, if married,
prescriptions may be obtained for the balance of that eligibility
period for a flat $15.00 copayment or the actual price, if less
than $15.00.

DRUG 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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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.)
All first-time prescriptions are limited to a 34-day supply. Senior
Gold allows for refills up to a 34-day supply or 100 unit doses,
whichever is greater.
Program mandates an enhanced Drug Utilization Review
(DUR).

PROGRAM CONTACT

Jennifer Barron Phone: 609/588-3460


PAAD/Senior Gold Operations Fax: 609/588-7139
P.O. Box 724 E-mail: jennifer.barron@doh.state.nj.us
Trenton, NJ 08625-0724

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New Mexico
Senior Prescription Drug Program
Program Type: Discount
Operational Date: 2003
Number of Recipients (December 2003): 3,200

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): All income Eligible Income Level All income levels
levels (Married):
Other Eligibility Notes: Must be a New Mexico resident and have no other prescription
drug benefit through private insurance or other government
programs.

FUNDING AND REIMBURSEMENT


Funding Source: $10,000 left from State general funds
Budget: State Agency on Aging provided $30,000 for initial administration
costs during 2002. No additional State funding is available.
Cost per Recipient: Not available
# of Rx’s Per Recipient: Not available
Manufacturer Rebate Type: Negotiated by PBM with individual manufacturers
Ingredient Cost Calculation: Retail: AWP-12% for brand name drugs; AWP-50% for generics
Mail order: AWP-19.5% for brand name drugs; AWP-55% for
generics
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: See notes
Dispensing Fee: $3.50 – retail pharmacy; $1.50 – mail order
Notes: Cost of prescription is contracted discounted price plus dispensing fee.
For brand name prescriptions average discount is 13%; for generics
average discount is 50%. Express Scripts administers the pharmacy
benefit. The State receives an additional $2 for each prescription
when enrollees use mail order pharmacy.

DRUG COVERAGE
Formulary: None
Drugs Covered: Manufacturers’ participating prescription drug products
Drug Coverage Restrictions: None

PROGRAM CONTACT

Lauri Hogan Phone: 505/883-0250


New Mexico Retiree Health Care Fax: 505/983-8667
Authority E-mail: lauri@nmrhca.state.nm.us
810 West San Mateo, Suite D
Santa Fe, NM 87505

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New York
Elderly Pharmaceutical Insurance Coverage (EPIC)
Program
Program Type: Direct Assistance
Year Operational: 1987
Number of Recipients (December 2003): 329,000
ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level, Fee Plan $20,000 Eligible Income Level, Fee $26,000
(Single): Plan (Married):
Eligible Income Level, Deductible $20,001- Eligible Income Level, $26,001-
Plan (Single): $35,000 Deductible Plan (Married): $50,000
Other Eligibility Notes: Medicaid enrollees are not eligible.

FUNDING AND REIMBURSEMENT

Funding Source: State General Fund


Budget (FY 03-04): $610 million
Cost per Participant (FY 03): $2,083
# of Rx’s Per Participant (FY 03): 36
Manufacturer Rebate Type: Full Medicaid rate (base rate plus Consumer Price Index
penalty)
Ingredient Cost Calculation: Federal upper limit, when available, on generics and AWP –
12% on brands
Enrollment Fee: $2.00 - $75.00 per quarter, based on income level
Deductible Amount: $530.00 - $1,715.00 annually, based on income level
Copayment Amount: $3.00 (prescription cost up to $15.00); $7.00 (prescription cost
from $15.01 to $35.00); $15.00 (prescription cost from $35.01 to
$55.00); and $20.00 (prescription cost over $55.00)
Dispensing Fee: $4.50 for generics and $3.50 for brand-name drugs

DRUG 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

PROGRAM CONTACT

Julie A. Naglieri Phone: 518/452-6828


Acting Director Fax: 518/452-6882
NYS EPIC Program E-mail: jab15@health.state.ny.us
1 Corporate Plaza
260 Washington Avenue Ext.
Albany, NY 12203

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North Carolina
Senior Care∗
Program Type: Direct Assistance
Year Operational: 2002
Number of Recipients (December 2003): 24,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+


Eligible Income Level (Single): 200% of FPL Eligible Income Level 200% of FPL
(Married):
Other Eligibility Notes: Individuals must be diagnosed with cardiovascular disease,
chronic obstructive pulmonary disease and/or diabetes, and must
not be eligible for Medicaid benefits or have other coverage for
drugs covered by Senior Care.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco settlement funds


Budget (FY 04): $30 million
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 10%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $6.00
Dispensing Fee: $5.60 (40 cents retained by claims processor)
Notes: Maximum annual prescription benefit of $600.00. Senior Care pays
for 60% of the first $1,000.00 of prescription costs, and members pay
the remaining 40%. Maximum benefit per year of $1,000

DRUG COVERAGE
Formulary: None
Drugs Covered: All prescription drugs
Drug Coverage Restrictions: This program will not pay for over-the-counter drugs or
potassium supplements.

PROGRAM CONTACT
Michael Keough Phone: 919/733-2040
Department of Health and Human E-mail: Michael.Keough@ncmail.net
Services
2001 Mail Service Center
Raleigh, NC 27699


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 (December 2003): 2 million

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 60+ Eligibility Age (Disabled): 18-59


Eligible Income Level (Single): All income Eligible Income Level All income
levels (Married): levels
Other Eligibility Notes: Must be an Ohio resident. The “Special Assistance Program”
within the Golden Buckeye Prescription Drug Program
establishes further savings for Medicare eligible beneficiaries
who have no other prescription drug assistance. Eligibility
income levels for the “Special Assistance Program” are:
$30,000 - individual; $40,000 – married.

FUNDING AND REIMBURSEMENT

Funding Source: Manufacturer negotiated rebates, 50% of which go to a PBM for


running the program.
Budget: Based on manufacturers’ negotiated rebates
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Negotiated by PBM with individual manufacturers. Estimated
savings range from 5% to 40%.
Ingredient Cost Calculation: Reimbursement rate based on negotiated contract with each
participating manufacturer.
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: Not available
Notes: MemberHealth is the PBM administrator for the Golden
Buckeye Prescription Drug Program and the newly announced
Ohio’s Best Rx Program.
Nineteen manufacturers are participating in the Golden Buckeye
Prescription Drug Program, including Solvay, Procter & Gamble
Pharmaceuticals, KOS, Boerhinger, Bausch & Lomb, Andrx
Labs, Bayer, Barr, Schering, Merck, Celltech, Abbott Labs,
Daiichi, Novo Nordisk, Novartis
Four manufacturers are participating in the Special Assistance
Prescription Drug Program within the Golden Buckeye
Program: GlaxoSmithKline, Novartis, Bristol Meyers Squibb,
and Merck.

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DRUG COVERAGE

Formulary: Preferred Drug List


Drugs Covered: Drugs for which the PBM has negotiated rebates with
manufacturers.
Drug Coverage Restrictions: None
Notes: MemberHealth conducts drug utilization reviews for these
programs.

PROGRAM CONTACT

Gary Panek Phone: 800/301-6446


Manager of Golden Buckeye Program E-mail: gpanek@age.state.oh.us
Department of Aging
50 W. Broad Street, 9th Floor Alternate contact:
Columbus, OH 43215 Steve Proctor,
MemberHealth, 800/422-1976

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Ohio
Ohio’s Best Rx Program*
Program Type: Negotiated Discounts
Year Operational: 2004 (Not yet operational)
Estimated Number of Recipients: 1.3 Million

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 60 + Eligibility Age (Disabled): 18+


Eligible Income Level (Single): 250% of FPL Eligible Income Level 250% of FPL
(Married):
Other Eligibility Notes: Enrollee must not have other outpatient prescription drug
coverage

FUNDING AND REIMBURSEMENT

Funding Source: Rebates from participating manufacturers


Budget (FY 04): $10 million allocated for start up costs
Cost per Participant: Not available
# 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: $3.00 dispensing fee and $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. Program may offer both retail
and mail order pharmacy services.

DRUG COVERAGE

Formulary: Open
Drugs Covered: Based on pharmaceutical manufacturers participating in the
program.
Drug Coverage Restrictions: None
Notes: The Ohio’s Best Rx Program Council will advise the
Department of Job and Family Services on the program.

*
Program details are still under development. Implementation expected by late summer 2004.

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PROGRAM CONTACT
Ohio Department of Job Phone: 614/446-6282
and Family Services Fax: 614/466-2815
30 E. Broad St., 32nd Floor
Columbus, OH 43215-3414

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Oklahoma
Pharmacy Connection Council Program*
Program Type: Coordinate Assistance Between Elderly and Charitable
Pharmaceutical Programs
Year Operational: 2003
Number of Recipients: Not Available

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Medicare eligible


Eligible Income Level (Single): Not available Eligible Income Level Not available
(Married):
Other Eligibility Notes: Eligibility criteria may vary according to manufacturers’ programs.

FUNDING AND REIMBURSEMENT

Funding Source: Not available


Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: None
Ingredient Cost Calculation: None
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: Not available
Notes: To obtain these free or discounted prescriptions, the individual
must complete an application on a form provided by the
manufacturer of the drug. One section is for the patient to
complete and the other for the prescriber. The doctor submits the
application and the prescription to the manufacturer. When
approved, the manufacturer sends the free drug to the doctor,
who then gives it to the patient.

DRUG COVERAGE

Formulary: None
Drugs Covered: Based on a manufacturer’s charitable program criteria.
Drug Coverage Restrictions: Not available

PROGRAM CONTACT

Nancy Davis Phone: 405/271-6576


Pharmacy Bureau, Dept. of Health Fax: 405/271-1308
1000 Northeast Tenth St General E-mail: Medicalfacilities@health.state.ok.us
Oklahoma City, OK 73117

*
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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Oregon
Senior Prescription Drug Assistance Program*
Program Type: Discount
Operational Date: 2003
Number of Recipients (December 2003): 206
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+
Eligible Income Level (Single): 185% of FPL Eligible Income Level 185% of FPL
(Married):
Other Eligibility Notes: Individuals must not be covered under any public or private
prescription drug benefit program for the previous six months
and must have less than $2,000.00 in liquid resources. Enrollees
are issued enrollment cards that entitle them to Medicaid prices.

FUNDING AND REIMBURSEMENT


Funding Source: Enrollment fees
Budget: None
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Not available
Ingredient Cost Calculation: AWP – 14%
Enrollment Fee: $50.00 annually
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $3.50 for retail pharmacy; $3.80 for institutional pharmacies
Notes : Currently, the program operates as a discount program based on
voluntary participation from pharmacies.

DRUG COVERAGE
Formulary: None
Drugs Covered: All legend drugs.
Drug Coverage Restrictions OTC drugs and medical supplies and medical equipment are not
covered.

PROGRAM CONTACT
Sandy Wood, Program Manager Phone: 503/945-6530
Office of Medical Assistance Programs Email: sandy.a.wood@state.or.us
Human Services Building
500 Summer St. NE, E25
Salem, OR 97301-1098

*
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 implement the program given the Medicare prescription drug
benefit enacted by Congress in 2003.

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Pennsylvania
Pharmaceutical Assistance Contract for the Elderly
(PACE)
Type of Program: Direct Assistance
Year Operational: 1984
Number of Recipients (December 2003): 190,482

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): $14,500 Eligible Income Level $17,700
(Married):
Other Eligibility Notes: Must be a resident of Pennsylvania for at least 90 days prior to
the date of application.

FUNDING AND REIMBURSEMENT

Funding Source: State Lottery, Tobacco Settlement funds


Budget (FY 03-04): $507 million
Cost per Participant (FY 02-03): $2,136.00
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: 22% of Average Manufacturer Price
Ingredient Cost Calculation: Lesser of AWP – 10% or usual and customary
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $9.00 for brand name drugs; $6.00 for generics
Dispensing Fee: $4.00
Notes: Quarterly reporting for Average Manufacturer Price (AMP)
rebate information.

DRUG 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

Thomas Snedden Phone: 717/787-7313


Director, PACE Program Fax: 717/772-2730
Department of Aging E-mail: tsnedden@aging.state.pa.us
555 Walnut Street, 5th Floor
Harrisburg, PA 17101-1919 Alternate contact:
Terry Brown, PACE/PACENET program,
Phone: 717/787-7313

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Pennsylvania
PACE Needs Enhancement Tier (PACENET)
Program Type: Direct Assistance
Year Operational: 1996
Number of Recipients (December 2003): 38,730

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): $14,500 to Eligible Income Level $17,700 to
$23,500 (Married): $31,500
Other Eligibility Notes: Must be a resident of Pennsylvania for at least 90 days prior to
the date of application

FUNDING AND REIMBURSEMENT

Funding Source: State Lottery, Tobacco Settlement funds


Budget (FY 03-04): $507 million
Cost per Participant (FY 02-03): $1,344.00
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: 22% of Average Manufacturer Price (AMP)
Ingredient Cost Calculation: Lesser of AWP – 10% or usual and customary
Enrollment Fee: None
Deductible Amount: $480.00 per year ($40 per month, but cumulative if not met each
month)
Copayment Amount: $15.00 for brand name drugs and $8.00 for generics
Dispensing Fee: $4.00
Notes: Quarterly reporting for Average Manufacturer Price (AMP)
rebate information.

DRUG 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.

PROGRAM CONTACT

Thomas Snedden Phone: 717/787-7313


Director, PACE Program Fax: 717/772-2730
Department of Aging E-mail: tsnedden@aging.state.pa.us
555 Walnut Street, 5th Floor
Harrisburg, PA 17101-1919 Terry Brown, PACE/PACENET program,
Phone: 717/787-7313

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Rhode Island
Rhode Island Pharmacy Assistance to the Elderly
(RIPAE)
Program Type: Direct Assistance, Discount
Year Operational: 1985
Number of Enrollees (December 2003): 38,600

ELIGIBILITY CRITERIA
Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 55-65
Eligible Income Level (Single): 420% of Eligible Income Level 420% of poverty
poverty level. (Married): level. See notes
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 04): $14.8 million
Cost per Enrollee (FY 04): $730.00 (estimated)
# of Rx’s Per Enrollee (FY 04): 16.8
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.
DRUG 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.
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.
PROGRAM CONTACT
Dennis Costa Phone: 401/462-3000
Rhode Island Dept. of Elderly Affairs E-mail: Dennis@dea.state.ri.us
Benjamin Rush Building #55
35 Howard Avenue
Cranston, RI 02920

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South Carolina
SILVERxCard Senior Prescription Drug Program
Program Type: Direct Assistance (1115 waiver)
Year Operational: 2001
Number of Enrollees (December 2003): 52,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): 200% of FPL Eligible Income Level 200% of FPL
(Married):
Other Eligibility Notes: Must be a South Carolina resident. Must be ineligible for
Medicaid with no prescription benefits from any other source.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco Settlement Fund and Federal matching funds


Budget: Not available
Cost per Enrollee: Not available
# of Rx’s Per Enrollee : Not available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 10%
Enrollment Fee: None
Deductible Amount: $500.00 per calendar year
Copayment Amount: Members receive discounts up to 10% on prescriptions until the
deductible is met. After the $500.00 deductible, the copayment
is $10.00 for generic drugs, $15.00 for brand name drugs, and
$21.00 for drugs requiring prior authorization.
Dispensing Fee: Not available
Notes: SILVERxCard covers up to a 34 days’ supply of medication and
generally 4 covered prescriptions or refills during a calendar
month. Overrides of the monthly limit are allowed for some
conditions, including acute sickle cell disease, behavioral health
disorder, cancer, cardiac disease, diabetes, HIV/AIDS,
hypertension, and terminal illnesses.
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 proposal enacted by
Congress in 2003.

DRUG COVERAGE

Formulary: Same as Medicaid


Drugs Covered: Same as Medicaid
Drug Coverage Restrictions: Some drugs require prior authorization

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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.

PROGRAM CONTACT

Frank Williams Phone: 803/898-2511


SILVERxCard General E-mail: info@dhhs.state.sc.us
Office of Insurance Services
1201 Main Street, Suite 350
Columbia, SC 29201

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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 All income levels
levels (Married):
Other Eligibility Notes: Must be a resident of South Dakota. Medicaid recipients are not
eligible.

FUNDING AND REIMBURSEMENT

Funding Source: Not available


Budget: Not available
Cost per Enrollee: Not available
# of Rx’s Per Enrollee: Not available
Manufacturer Rebate Type: AdvancePCS (PBM) negotiates discounted prescription costs
rather than trying to set mandatory price reductions.
Prescription discounts average between 15% and 20%.
Ingredient Cost Calculation: AWP-10.5%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $3.50
Notes: Since July 1, 2003, AdvancePCS has processed 117,000
prescriptions with direct savings to the enrollee of $913,000.
The average discount per prescription is 17.7%.

DRUG COVERAGE

Formulary: None
Drugs Covered: All prescription drugs
Drug Coverage Restrictions: None

PROGRAM CONTACT

Larry Kucker Phone: 605/773-3148


Bureau of Personnel Fax: 605/773-4344
500 East Capitol Avenue
Pierre, SD 57501

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Texas
State Prescription Drug Program
Program Type: State-Subsidy
Law Enacted: 2001∗
Estimated Eligibles: None

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): 100% of FPL Eligible Income Level 100% of FPL
(Married):
Other Eligibility Notes: Upper income limits may increase if funding becomes available.
However, the categories most likely to qualify for the program at
proposed FY 04-05 funding levels are Qualified Medicare
Beneficiaries (QMBs) and Specified Low-Income Medicare
Beneficiaries (SLMBs).

FUNDING AND REIMBURSEMENT

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.

DRUG COVERAGE

Formulary: Not available


Drugs Covered: Not available
Drug Coverage Restrictions: Not available
Notes: The Health and Human Services Commission may require that,
unless the practitioner’s signature on a prescription clearly
indicates that the prescription must be dispensed as written, the
pharmacist may select a generic equivalent of the prescribed
drugs. The Health and Human Resources Commission is also
authorized to establish a formulary, prior authorization
requirements, and a drug utilization program.


This program has not been implemented due to the fact that no funding has been budgeted for it.

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PROGRAM CONTACT

Sharon Carter Phone: 512/424-6514


Health and Human Services
Commission
P.O. Box 13247
Austin, TX 787111-3247

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Vermont
VSCRIPT
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 1989∗
Number of Recipients (FY03): 3,081

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): All ages


Eligible Income Level (Single): 150% - 175% Eligible Income Level 150% - 175% of
of FPL (Married): FPL

FUNDING AND REIMBURSEMENT

Funding Source: Federal and State funds


Budget (FY 04): $4.3 million
Cost per Participant (FY 03): $1,408.00
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 11.9%
Enrollment Fee: $17.00 per month
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $4.25

DRUG COVERAGE

Formulary: Preferred Drug List


Drugs Covered: Maintenance drugs covered by Medicaid.
Drug Coverage Restrictions: No experimental or over-the-counter drugs.

PROGRAM CONTACT

Joshua Slen Phone: 802/879-5901


Director Fax: 802/879-5962
Office of Vermont Health Access E-mail: joshuas@path.state.vt.us
103 South Main Street
Waterbury, VT 05676


This program was integrated into the VHAP (1115 waiver) program in 1999.

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Vermont
VSCRIPT Expanded
Program Type: Direct Assistance
Year Operational: 2000
Number of Recipients (FY 03): 3,364

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): All ages


Eligible Income Level (Single): 175% - 225% Eligible Income Level 175% - 225% of
of FPL (Married): FPL

FUNDING AND REIMBURSEMENT

Funding Source: State General Fund


Budget (FY 04): $1.2 million
Cost per Participant (FY 03): $338.00
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 11.9%
Enrollment Fee: $35.00 per month
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $4.25

DRUG COVERAGE

Formulary: Preferred Drug List


Drugs Covered: Medicaid covered maintenance drugs under separate
manufacturer’s rebate agreement
Drug Coverage Restrictions: No experimental or over-the-counter drugs

PROGRAM CONTACT

Joshua Slen Phone: 802/879-5901


Director Fax: 802/879-5962
Office of Vermont Health Access E-mail: joshuas@path.state.vt.us
103 South Main Street
Waterbury, VT 05676

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Vermont
Vermont Health Access Plan (VHAP) Pharmacy
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 1996
Number of Recipients (FY 03): 8,570

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Medicare eligible


Eligible Income Level (Single): 150% of FPL Eligible Income Level 150% of FPL
(Married):
Other Eligibility Notes: Medicaid recipients are not eligible. Individuals may not have
any other prescription drug insurance.

FUNDING AND REIMBURSEMENT

Funding Source: Federal and State funds


Budget (FY 03): $13.3 million
Cost per Participant (FY03): $1,554.00
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 11.9%
Enrollment Fee: $13.00 per month
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $4.25

DRUG COVERAGE

Formulary: Preferred Drug List


Drugs Covered: All drugs covered by Vermont Medicaid, including insulin and
insulin syringes.
Drug Coverage Restrictions: No experimental or over-the-counter drugs

PROGRAM CONTACT

Joshua Slen Phone: 802/879-5901


Director Fax: 802/879-5962
Office of Vermont Health Access E-mail: joshuas@path.state.vt.us
103 South Main Street
Waterbury, VT 05676

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Vermont
Healthy Vermonters Program
Program Type: Direct Assistance (1115 Waiver)
Year Operational: July 1, 2002
Eligible Recipients (FY 04): 11,373

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Medicare eligible


Eligible Income Level (Single): 400% of FPL Eligible Income Level 400% of FPL
(Married):
Other Eligibility Notes: Vermont residentsof any age who have an income at or below
300% FPL are also eligible. This program is for those who have
no insurance for prescriptions or those who have a commercial
insurance plan with a yearly limit. This program also covers
drugs for acute conditions for VScript or VScript Expanded
beneficiaries (up to 225% of FPL) who previously received a
benefit only for maintenance drugs. VScript and VScript
Expanded beneficiaries will be automatically enrolled in Healthy
Vermonters and have the advantage of Healthy Vermonters
benefits for prescriptions not covered under the VScripts
programs.

FUNDING AND REIMBURSEMENT

Funding Source: State revenue fund


Budget (FY 04): $200,000
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Not available
Ingredient Cost Calculation: AWP – 11.9%
Enrollment Fee: Not available
Deductible Amount: None
Copayment Amount: Not available
Dispensing fee: $4.25
Note: Beneficiary purchases drugs at the Medicaid payment rate.

DRUG COVERAGE

Formulary: Medicaid Formulary


Drugs Covered: Drugs covered by Medicaid
Drug Coverage Restrictions: No experimental or over-the-counter drugs

PROGRAM CONTACT

Joshua Slen, Director Phone: 802/879-5901


Office of Vermont Health Access Fax: 802/879-5962
103 South Main Street E-mail: joshuas@path.state.vt.us
Waterbury, VT 05676

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Washington
Rx Card Program
Program Type: Negotiated Rebates
Year Operational: 2004*
Number of Recipients: not available

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 50+ Eligibility Age (Disabled): 19-49


Eligible Income Level (Single): 300% of FPL Eligible Income Level 300% of FPL
(Married):
Other Eligibility Notes: Individuals may not have any other prescription drug insurance
coverage or prescription drug benefits.
FUNDING AND REIMBURSEMENT
Funding Source: Enrollment fees
Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Not available
Ingredient Cost Calculation: AWP-13%
Enrollment Fee: $10.00
Deductible Amount: Not available
Copayment Amount: Not available
Dispensing Fee: $3.00
Notes: Express Scripts (PBM) will administer the program for the State. The Washington Health
Care Authority is working with Express Scripts to determine discount levels, program costs
and processing applications. The program is scheduled to be operational by April 1, 2004.
DRUG COVERAGE
Formulary: PBM formulary
Drugs Covered: Not Available
Drug Coverage Restrictions: Not Available
Notes: State officials wanted to use a State-sponsored PDL; however,
the PBM would not agree to these terms, as the program’s
overall market share is not large enough.
PROGRAM CONTACT
Erika Barker, Project Coordinator Phone: 206/521-2027
Prescription Drug Program Alternate Contact:
Health Care Authority Duane Thurman,
Post Office Box 91132 Health Care Authority,
Seattle, WA 98111-9232 206/521-2036

*
The Washington Rx Card has not yet been implemented. It is being revised to coordinate with recent changes in
federal law that will provide transitional prescription drug discount cards to Medicare-eligible individuals beginning in
June 2004. . This is one component of broader efforts by the State to combine use of a Preferred Drug List (PDL), an
evidence-based prescription drug program, the Washington State Pharmacy and Therapeutics Committee, and,
participating practitioners. The ultimate goal of these various programs is to maximum purchasing through a pooled
pharmaceutical-buying program.

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West Virginia
Gold Mountaineer Card Program
Program Type: Direct Assistance
Year Operational: 2001
Number of Recipients (December 2003): 17,000/month*

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 60+ Eligibility Age (Disabled): 60+


Eligible Income Level (Single): All income Eligible Income Level All income
levels (Married): levels
Other Eligibility Notes: Must be a resident of West Virginia.

FUNDING AND REIMBURSEMENT

Funding Source: Lottery funds and State General Fund


Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant (2002): 33
Manufacturer Rebate Type: Rebates negotiated by PBM (AdvancePCS) with individual
manufacturers
Ingredient Cost Calculation: AWP – 13% for brand name drugs and generics and AWP –
60% for MAC drugs.
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $3.50
Notes: Enrollees will receive discounts set by PBM.

DRUG COVERAGE

Formulary: None
Drugs Covered: All FDA federal legend pharmaceuticals and diabetic supplies
Drug Coverage Restrictions: None

PROGRAM CONTACT

Jan Bowen Phone: 304/558-3317


Bureau of Senior Services Fax: 304/558-0004
Holly Grove, Building No. 10
Charleston, WV 25305-0160

*
There are a total of 360,000 eligible seniors for the Gold Mountaineer Card Program. Monthly card usage
varies.

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Wisconsin
SeniorCare
Program Type: Direct Assistance
Year Operational: 2002
Estimated Enrollment (May 2003): 86,700

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+


Eligible Income Level (Single): See note Eligible Income Level See note
(Married):
Other Eligibility Notes: Person must not be a recipient of medical assistance and must be
a resident of the State. The State implemented four participation
levels for the program and each has a corresponding out-of-
pocket expense and/or co-pay amount.
SeniorCare level FPL
Level 1 up to 160%
Level 2a between 160% and
200%
Level 2b between 200% and
240%
Level 3 greater than 240%

FUNDING AND REIMBURSEMENT

Funding Source: State general revenue and some Federal funding.


Budget (FY 03-05): $23 million
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Manufacturers must sign separate SeniorCare rebate agreement
with the State.
Ingredient Cost Calculation: AWP-12% or MAC. The National Drug Code (NDC) innovator
price will be paid only when “Brand Medically Necessary” is
handwritten on the prescription.
Enrollment Fee: $30.00
Deductible Amount: Level 1: No deductible
Level 2a: $500 deductible per person and pay SeniorCare
rate for drugs
Level 2b: $850 deductible per person and pay SeniorCare
rate for drugs
Level 3: Pay retail price for drugs equal to the difference
between your income and $21,553 per
individual or $29,089 per couple. This is called
"spenddown." During “spenddown”, no
discount for drugs. After “spenddown”, meet an
$850 deductible per person but pay SeniorCare
rate for covered drugs.

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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 $850 deductible is met, $15 co-pay for
covered brand name drugs, $5 co-pay for
covered generics
Dispensing Fee: $4.88

DRUG COVERAGE

Formulary: None
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.

PROGRAM CONTACT

Michael Boushon Phone: 608/261-7791


Pharmacy Program Fax: 608/267-3380
Division of Health Care Financing
1 West Wilson Street Alternate contact:
P.O. Box 309 Pamela Appleby
Madison, WI 53701-3380 Budget and Policy Analyst,
Division of Health Care Financing,
Phone: 608/266-7685;
Fax: 608/266-1096;
Email: appleps@dhfs.state.wi.us

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Wyoming
Prescription Drug Assistance Program
Program Type: Direct Assistance
Year Operational: 2003
Number of Recipients (November 2003): 1,081 (monthly average)

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages
Eligible Income Level (Single): 100% of FPL Eligible Income Level 100% of FPL
(Married):
Other Eligible Groups: Medicaid enrollees are not eligible.

FUNDING AND REIMBURSEMENT

Funding Source: General Revenue Fund


Budget (FY 03-04): $2.1 million
Cost per Participant (FY 03): $1,591.20
# of Rx’s Per Participant (FY 03): 25.2
Manufacturer Rebate Type: Varies by participating manufacturer
Ingredient Cost Calculation: AWP – 11%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $10.00 for generics and $25.00 for brand-name drugs
Dispensing Fee: $5.00
Notes: Maximum 3 prescriptions per month and oxygen services if
needed

DRUG COVERAGE

Formulary: Open formulary


Drugs Covered: Any FDA approved prescription medications
Drug Coverage Restrictions: No smoking cessation agents, hair growth products, anorexiant
products, or fertility promotion agents. One month supply
restriction.

PROGRAM CONTACT

Susan Malm Phone: 307/777-5548


Community and Family Health Fax: 307/777-6964
Division
Hathaway Bldg, Rm 157
2300 Capitol Ave.
Cheyenne, WY 82002

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Appendix A:
State and Federal
Medicaid Contacts

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National Pharmaceutical Council Pharmaceutical Benefits 2003

STATE MEDICAID DRUG PROGRAM ADMINISTRATORS, 2003

ALABAMA CALIFORNIA
Louise F. Jones J. Kevin Gorospe, Pharm.D.
Pharmacy Program Manager California Department of Health Services
Alabama Medicaid Agency Chief, Medi-Cal Pharmacy Policy Unit
501 Dexter Avenue Medi-Cal Policy Division
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: kgorospe@dhs.ca.gov
Internet address: http://www.dhs.ca.gov
ALASKA
COLORADO
Dave Campana, R.Ph.
Pharmacy Program Manager Martha Warner
Division of Medical Assistance 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
E-mail: martha.warner@state.co.us
ARIZONA
CONNECTICUT
Dell Swan
Pharmacy Program Administrator Evelyn A. Dudley
AHCCCS Pharmacy Unit Manager
801 East Jefferson Street Department of Social Services, Medical Operations
MD 400 25 Sigourney Street
Phoenix, AZ 85034 Hartford, CT 06106-5033
612/417-4000 T: 860/424-5654
E-mail: dwswan@ahcccs.state.az.us F: 860/424-5206
E-mail: evelyn.dudley@po.state.ct.us
Internet address: www.dss.state.ct.us
ARKANSAS
Suzette Bridges, P.D., Administrator
DELAWARE
Pharmacy Program
Department of Human Services Cynthia R. Denemark, R.Ph.
Division of Medical Services Director of Pharmacy Services
P.O. Box 1437, Slot 415 DSS/EDS
Little Rock, AR 72203-1437 248 Chapman Road, Suite 100
T: 501/683-4120 Newark, DE 19702
F: 501/683-4124 T: 302/453-8453
E-mail: suzette.bridges@medicaid.state.ar.us F: 302/454-0224
E-mail: cynthia.denemark@eds.com
Internet address: www.dmap.state.de.us

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National Pharmaceutical Council Pharmaceutical Benefits 2003

DISTRICT OF COLUMBIA IDAHO


Donna Bovell, R.Ph. Shawna L. Kittridge, R.Ph., M.H.S.
Pharmacist Consultant Pharmacy Services Supervisor
Department of Health Department of Health and Welfare
Medical Assistance Administration Division of Medicaid
825 North Capitol Street, NE, Fifth Floor 3232 Elder
Washington, DC 20002 Boise, ID 83705
T: 202/442-5988 T: 208/364-1956
F: 202/442-4790 F: 208/364-1864
E-mail: donna.bovell@dcgov.org E-mail: kittrids@idhw.state.id.us
Internet address: www.idahohealth.org
FLORIDA
Jerry F. Wells ILLINOIS
Pharmacy Program Manager
Marvin L. Hazelwood
Agency for Healthcare Administration Services
Pharmacy and Ancillary Services Programs
2727 Mahan Drive, MS 38
Illinois Department of Public Aid
Tallahassee, FL 32308
Division of Medical Assistance
T: 850/487-4441
1001 N. Walnut St.
F: 850/922-0685
Springfield, IL 62702
E-mail: wellsj@fdhc.state.fl.us
T: 217/782-5565
Internet address: www.fdhc.state.fl.us
F: 217/524-7194
E-mail: dpa_webmaster@state.il.us
GEORGIA Internet address: www.state.il.us/dpa
Lori S. Garner, R.Ph., M.B.A., M.H.S.
Director, Pharmacy Services INDIANA
Department of Community Health-Medicaid Division
Marc Shirley, R.Ph.
2 Peachtree Street, N.W., 37th Floor
Pharmacy Program Director
Atlanta, GA 30303-3159
Office of Medicaid Policy and Planning
T: 404/656-4044
Indiana State Government Center South-Rm. W382
F: 404/656-8366
402 W. Washington Street
E-mail: lgarner@dch.state.ga.us
Indianapolis, IN 46204-2739
Internet address: www.dch.state.ga.us
T: 317/232-4343
F: 317/232-7382
HAWAII E-mail: mshirley@fssa.state.in.us
Lynn S. Donovan, R.Ph. Internet address: www.indianamedicaid.com
Pharmacy Consultant
Department of Human Services IOWA
Med-Quest Division
Susan L. Parker, Pharm.D.
601 Kanokila Boulevard, Room 506B
Pharmacy Consultant
P.O. Box 700190
Division of Medical Services
Honolulu, HI 96707
Bureau of Long Term Care
T: 808/692-8116
Hoover State Office Bldg.
F: 808/692-8131
Des Moines, IA 50319
Internet address: www.med-quest.us
T: 515/281-3002
F: 515/281-6230
E-mail: sparker2@dhs.state.ia.us

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National Pharmaceutical Council Pharmaceutical Benefits 2003

KANSAS MARYLAND
Mary H. Obley, Pharmacist Mr. Joseph L. Fine
Pharmacy Program Manager Director
Health Care Policy Division Maryland Pharmacy Program
Kansas Department of Social and Rehabilitation DHMH, Office of Operations and Eligibility
Services 201 West Preston Street
Docking State Office Building Baltimore, MD 21201
915 SW Harrison, Room 651-South T: 410/767-1455
Topeka, KS 66612-1570 F: 410/333-5398
T: 785/296-8406 E-mail: jfine@dhmh.state.md.us
F: 785/296-4813 Internet address: www.dhmh.state.md.us
E-mail: mho@srskansas.org
Internet address: www.srskansas.eds.org
MASSACHUSETTS
KENTUCKY Paul L. Jeffrey, Director of Pharmacy
Office of Medicaid
Dan Yeager, R.Ph.
600 Washington Street, 5th Floor
Interim Pharmacy Director
Boston, MA 02111
Department for Medicaid Services
T: 617/210-5319
CHR Building, 6 W-A
F: 617/210/5865
275 East Main Street
E-mail: pjeffrey@nt.dma.state.ma.us
Frankfort, KY 40621
Internet address: www.state.ma.us/dma
T: 502/564-7940
F: 502/564-0509
E-mail: dan.yeager.ky.gov MICHIGAN
Giovannino A. Perri, M.D.
LOUISIANA Chief Medical Consultant
MDCH/Medical Services Administration
Mary J. Terrebonne, Pharm. D. 400 South Pine Street
Pharmacy Director P.O. Box 30479
Department of Health and Hospitals Lansing, MI 48909-7979
1201 Capitol Access Road, 6th Floor T: 517/335-5181
P.O. Box 91030 F: 517/241-8135
Baton Rouge, LA 70821 E-mail: perrig@michigan.gov
T: 225/342-9768 Internet address: www.michigan.gov/mdhc
F: 225/342-1980
E-mail: mterrebo@dhh.la.gov
Internet address: www.lamedicaid.com MINNESOTA
Cody C. Wiberg, Pharm.D., R.Ph.
MAINE Pharmacy Program Manager
Jude Walsh, Director Minnesota Department of Human Services
Health Care Management Division 444 Lafayette Road North
Department of Human Services St. Paul, MN 55155-3853
Bureau of Medical Services T: 651/296-8515
11 SHS, 442 Civic Center Drive F: 651/282-6744
Augusta, ME 04333 E-mail: cody.c.winberg@state.mn.us
T: 207/287-1815 Internet address: www.dhs.mn.us
F: 207/287-6533
E-mail: jude.c.walsh@maine.gov
Internet address: www.maine.gov/bms

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National Pharmaceutical Council Pharmaceutical Benefits 2003

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

MISSOURI NEW HAMPSHIRE


George L. Oestreich Margaret A. Clifford
Pharmacy Program Director Pharmacy Administrator
Department of Social Services Office of Health Planning & Medicaid
Division of Medical Services 129 Pleasant Street, Annex 1
P.O. Box 6500 Concord, NH 03301
Jefferson City, MO 65102-6500 T: 603/271-4210
T: 573/751-6961 F: 603/271-8701
F: 573/522-8514 E-mail: mclifford@dhhs.state.nh.us
E-mail: George.L.Oestreich@dss.mo.gov Internet address: www.dhhs.state.nh.us
Internet address: www.dss.mo.gov/dms

MONTANA NEW JERSEY

Dan Peterson Edward J. Vaccaro, R.Ph.


Pharmacy Program Officer Assistant Director
Department of Public Health and Human Services Office of Utilization Management
Medicaid Services Bureau Division of Medical Assistance and Health Services
P.O. Box 202951 P.O. Box 712, Bldg. 11-A
1400 Broadway Trenton, NJ 08625-0712
Helena, MT 59620-2951 T: 609/588-2726
T: 406/444-2738 F: 609/588-3889
F: 406/444-1861 E-mail: ejvaccano@dhs.state.nj.us
E-mail: danpeterson@state.mt.gov
Internet address: www.dphhs.state.mt.us NEW MEXICO
Neal Solomon, M.P.H., R.Ph.
NEBRASKA Drug Program Administrator
Dyke Anderson, R.Ph. Human Services Department
Pharmaceutical Consultant Medical Assistance Division
Department of Health and Human Services P.O. Box 2348
Finance and Support, Medicaid Division Santa Fe, NM 87504-2348
301 Centennial Mall South, 5th Floor - NSOB T: 505/827-3174
P.O. Box 95026 F: 505/827-3185
Lincoln, NE 68509-5026 E-mail: neal.solomon@state.nm.us
T: 402/471-9379
F: 402/471-9092
E-mail: dyke.anderson@hhss.state.ne.us
Internet address: www.hhs.state.ne.us

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National Pharmaceutical Council Pharmaceutical Benefits 2003

NEW YORK OKLAHOMA


Mark-Richard Butt, M.S., R.Ph. Nancy Nesser, D.Ph., J.D.
Director, Pharmacy Policy and Operations Pharmacy Director
Bureau of Program Guidance Oklahoma Health Care Authority
Office of Medicaid Management 4545 N. Lincoln Boulevard, Suite 124
NYS Department of Health Oklahoma City, OK 73105-9901
99 Washington Ave., Room 606 T: 405/522-7325
Albany, NY 12210 F: 405/522-3240
T: 518/474-9219 E-mail: nessern@ohca.state.ok.us
F: 518/473-5508 Internet address: www.ohca.state.ok.us
E-mail: mrb01@health.state.ny.us
Internet address: www.health.state.ny.us
OREGON
Thomas Drawbaugh
NORTH CAROLINA
Pharmacy Program Manager
Sharman C. Leinwand, R.Ph., M.P.H. Department of Human Resources
Pharmacy Program Manager Office of Medical Assistance Programs
Division of Medical Assistance 500 Summer Street, NE, E-35
Department of Health and Human Services Salem, OR 97301-1077
1985 Umstead Drive T: 503/945-6492
2501 Mail Service Center F: 503/373-7689
Raleigh, NC 27699-2501 E-mail: thomas.drawbaugh@state.or.us
T: 919/857-4034 Internet address: www.dhs.state.or.us/healthplan
F: 919/715-1255
E-mail: sharman.leinwand@ncmail.net
PENNSYLVANIA
Internet address: www.dhhs.state.nc.us/dma
Joseph E. Concino, R.Ph., Chief
Pharmacy Services Section
NORTH DAKOTA
Office of Medical Assistance Programs
Brendan K. Joyce, Pharm.D., R.Ph. P.O. Box 8046
Administrator, Pharmacy Services Harrisburg, PA 17105
Department of Human Services T: 717/772-6341
600 East Boulevard Avenue F: 717/772-6366
Department 325 E-mail: jconcino@state.pa.us
Bismarck, ND 58505-0250 Internet address: www.dpw.state.pa.us/omap
T: 701/328-1544
F: 701/328-1544
RHODE ISLAND
E-mail: sojoyb@state.nd.us
Paula J. Avarista, R.Ph.
Chief of Pharmacy
OHIO
Department of Human Services
Robert P. Reid, R.Ph. 600 New London Avenue
Administrator, Pharmacy Services Unit Cranston, RI 02919
Ohio Department of Job and Family Services T: 401/462-6390
Bureau of Health Plan Policy F: 401/462-6336
30 East Broad St., 27th Floor E-mail: pavarista@dhs.ri.gov
Columbus, OH 43215-3414 Internet address: www.dhs.state.ri.us
T: 614/466-6420
F: 614/466-2908
E-mail: reidr@odjfs.state.oh.us

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National Pharmaceutical Council Pharmaceutical Benefits 2003

SOUTH CAROLINA UTAH


James M. Assey, R.Ph., Division Director RaeDell Ashley, R.Ph.
Division of Pharmaceutical Services and DME Pharmacy Director
S.C. Department of Health & Human Services Division of Health Care Financing
P.O. Box 8206 Utah Department of Health
Columbia, SC 29202-8206 288 North 1460 West
T: 803/898-2876 P.O. Box 143102
F: 803/898-4517 Salt Lake City, UT 84114-3102
E-mail: asseyj@dhhs.state.sc.us T: 801/538-6495
Internet address: www.dhhs.state.sc.us F: 801/538-6099
E-mail: rashley@.utah.gov
SOUTH DAKOTA Internet address: www.utah.gov

Mark Petersen, R.Ph.


VERMONT
Pharmacy Consultant
Department of Social Services Samantha Haley, Operations Manager
Office of Medical Services Office of Vermont Health Access
700 Governors Drive 103 South Main Street
Pierre, SD 57501 Waterbury, VT 05671-1201
T: 605/773-3495 T: 802/241-8765
F: 605/773-5246 F: 802/241-2974
E-mail: markp@state.sd.us E-mail: samantha@path.state.vt.us

TENNESSEE VIRGINIA
Jeffrey G. Stockard, D.Ph. Javier Menendez, R.Ph.
Associate Pharmacy Director Pharmacy Consultant
Bureau of TennCare Department of Medical Assistance Services
729 Church Street 600 East Broad Street, Ste 1300
Nashville, TN 37247-6501 Richmond, VA 23219
T: 615/532-3107 T: 804/786-2196
F: 615/253-5481 F: 804/786-0973
E-mail: jeff.stockard@state.tn.us E-mail: javier.menendez@dmas.virginia.gov
Internet address: www.state.tn.us/health/tenncare Internet address: www.dmas.virginia.gov

TEXAS WASHINGTON
Barbara Dean Siri A. Childs, Pharm D.
Acting Director, Vendor Drug Program Pharmacy Research Specialist/Manager
Texas Health and Human Services Commission Medical Assistance Administration, DSHS
1100 W. 49th Street 805 Plum Street, SE
Austin, TX 78756-3174 P.O. Box 45506
T: 512/491-1101 Olympia, WA 98504-5506
F: 512/491-1959 T: 360/725-1564
E-mail: barbara.dean@hhsc.state.tx.us F: 360/586-8827
Internet address: www.hhsc.state.tx.us E-mail: childsa@dshs.wa.gov/pharmacy
Internet address: http://maa.dshs.wa.gov/pharmacy

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National Pharmaceutical Council Pharmaceutical Benefits 2003

WEST VIRGINIA
Peggy A. King, R.Ph.
Director, Office of Pharmacy Services
WV Department of Health and Human Resources
350 Capitol St., Room 251
Charleston, WV 25301-3709
T: 304/558-5967
F: 304/558-1542
E-mail: pking@wvdhhr.org
Internet address: www.wvhhhr.org/bms

WISCONSIN
Michael C. Boushon, R.Ph.
Pharmacy Practices Consultant
Division of Health Care Financing
Department of Health and Family Services
One West Wilson Street
P.O. Box 309
Madison, WI 53701-0309
T: 608/261-7791
F: 608/267-3380
E-mail: boushmc@dhfs.state.wi.us
Internet address: www.dhfs.wisconsin.gov

WYOMING
Antoinette Brown, R.Ph.
Medicaid Pharmacist
Department of Health-Pharmacy Unit
2424 Pioneer Ave, Suite 100
Cheyenne, WY 82002
T: 307/777-6016
F: 307/777-8623
Email: abrown@state.wy.us
Internet address: www.pharmacy.state.wy.us

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National Pharmaceutical Council Pharmaceutical Benefits 2003

NEW BRAND NAME PRODUCT CONTACT INFORMATION, 2003

ALABAMA CALIFORNIA
Louise F. Jones J. Kevin Gorospe, Pharm.D.
Pharmacy Program Manager Chief, Medi-Cal Pharmacy Policy Unit
Alabama Medicaid Agency California Department of Health Services
501 Dexter Avenue Medi-Cal Policy Division
P.O. Box 5624 1501 Capitol Avenue
Montgomery, AL 36103-5624 P.O. Box 997413, MS 4604
T: 334/242-5039 Sacramento, CA 95899-7413
F: 334/353-7014 T: 916/552-9500
E-mail: lljones@medicaid.state.al.us F: 916/552-9563
E-mail: kgorospe@dhs.ca.gov

ALASKA
COLORADO
Dave Campana, R.Ph.
Pharmacy Program Manager Catherine Traugott
Division of Medical Assistance Pharmacist
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: 303/866-2463
E-mail: david_campana@health.state.ak.us F: 303/866-2578
E-mail: catherine.traugott@state.co.us

ARIZONA
Contact health plans directly. CONNECTICUT
Evelyn A. Dudley
Pharmacy Unit Manager
ARKANSAS Department of Social Services, Medical Operations
Suzette Bridges, P.D., Administrator 25 Sigourney Street
Pharmacy Program Hartford, CT 06106-5033
Dept. of Human Services T: 860/424-5654
Division of Medical Services F: 860/424-5206
P.O. Box 1437, Slot S 415 E-mail: evelyn.dudley@po.state.ct.us
Little Rock, AR 72203-1437
T: 501/683-4120
F: 501/683-4124 DELAWARE
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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National Pharmaceutical Council Pharmaceutical Benefits 2003

DISTRICT OF COLUMBIA IDAHO


Donna Bovell, R.Ph. Shawna L. Kittridge, R.Ph., M.H.S.
Pharmacist Consultant Pharmacy Services Supervisor
Department of Health Department of Health and Welfare
Medical Assistance Administration Division of Medicaid
825 North Capitol Street, NE 3232 Elder
Fifth Floor Boise, ID 83705
Washington, DC 20002 T: 208/364-1956
T: 202/442-5988 F: 208/364-1864
F: 202/442-4790 E-mail: kittrids@idhw.state.id.us
E-mail: donna.bovell@dcgov.org

ILLINOIS
FLORIDA Marvin L. Hazelwood, Manager
Jerry F. Wells Pharmacy and Ancillary Services Programs
Pharmacy Program Manager Illinois Department of Public Aid
Agency for Health Care Administration Division of Medical Assistance
2727 Mahan Drive, MS 38 1001 N. Walnut Street
Tallahassee, FL 32308 Springfield, IL 62702
T: 850/487-4441 T: 217/524-5565
F: 850/922-0685 F: 217/524-7194
E-mail: wellsj@fdhc.state.fl.us E-mail: dpa_webmaster@state.il.us

GEORGIA INDIANA
Lori S. Garner, R.Ph., M.B.A., M.H.S. Marc Shirley, R.Ph.
Director, Pharmacy Services Pharmacy Program Director
Department of Community Health Office of Medicaid Policy and Planning
Medicaid Division Room W382
2 Peachtree Street, NW, 37th Floor Indiana State Government Center South
Atlanta, GA 30303-3159 402 W. Washington Street
T: 404/656-4044 Indianapolis, IN 46204-2739
F: 404/656-8366 T: 317/232-4343
E-mail: lgarner@dch.state.ga.us F: 317/232-7382
E-mail: mshirley@fssa.state.in.us
Note: All manufacturer inquiries and/or submissions must be in
HAWAII electronic format and sent to PDL@fssa.state.in.us. Paper copies will
not be accepted and should not be mailed to any of the involved parties,
Lynn S. Donovan, R.Ph. including OMPP, ACS, or the Therapeutic Committee. Visit:
Pharmacy Consultant http://indianapbm.com/downloads/T-
Department of Human Services committe%20PDL%20submission%20Form1-5-04.pdf for necessary
forms.
Med-Quest Division
601 Kanokila Boulevard, Suite 506B
Kapolei, HI 96707
T: 808/692-8116
F: 808/692-8131

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National Pharmaceutical Council Pharmaceutical Benefits 2003

IOWA MAINE
Susan L. Parker, Pharm.D. Jude Walsh, Director
Pharmacy Consultant Health Care Management Division
Division of Medical Services Department of Human Services
Bureau of Long Term Care Bureau of Medical Services
Hoover State Office Building 11 SHS, 442 Civic Center Drive
Des Moines, IA 50319 Augusta, ME 04333
T: 515/281-3002 T: 207/287-1815
F: 515/281-8512 F: 207/287-6533
E-mail: sparker2@dhs.state.ia. E-mail: jude.c.walsh@maine.gov

KANSAS MARYLAND
Mary H. Obley, Pharmacist Frank Tetkoski
Pharmacy Program Manager Manager
Health Care Policy Division Services and Preauthorization
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: 785-296-8406 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: cburke@nt.dma.state.ma.us
E-mail: Debra.Bahr@ky.go

MICHIGAN
LOUISIANA Donna Hammel
Mary J. Terrebonne, P.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 2003

NEBRASKA
MINNESOTA
Dyke Anderson, R.Ph
Cody C. Wiberg, Pharm.D., R.Ph. Pharmacy Consultant
Pharmacy Program Manager Department of Health and Human Services
Minnesota Department of Human Services Finance and Support-Medicaid Division
444 Lafayette Road North 301 Centennial Mall South
St. Paul, MN 55155-3853 5th Floor-NSOB
T: 651/296-8515 P.O. Box 95026
F: 651/282-6744 Lincoln, NE 68509-5026
E-mail: cody.c.wiberg@state.mn.us T: 402/471-9379
F: 402/471-9092
E-mail: dyke.anderson@hhss.state.ne.us
MISSISSIPPI
Judith P. Clark, R.Ph.
Pharmacy Director NEVADA
Division of Medicaid Dionne Coston, R.N.
Robert E. Lee Building Medical Services Specialist
239 North Lamar Street, Suite 801 Division of Health Care Financing and Policy
Jackson, MS 39201 Pharmacy Program
T: 601/359-5253 1100 E. Williams Street
F: 601/359-9555 Carson City, NV 89701
E-mail: phipc@medicaid.state.ms.us T: 775/684-3775
F: 775/684-3762
E-mail: dcpstpm@dhcfp.state.nv.us
MISSOURI
Rhonda A. Driver
Clinical Pharmacist NEW HAMPSHIRE
Department of Social Services Lisè Farrand, R.Ph.
Division of Medical Services Pharmaceutical Services Specialist
P.O. Box 6500 Office of Health Planning & Medicaid
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 Edward J. Vaccaro, R.Ph.
Department of Public Health and Human Services Assistant Director
Medicaid Services Bureau Office of Utilization Management
P.O. Box 202951 Department of Human Services
1400 Broadway Division of Medical Assistance and Health Services
Helena, MT 59620-2951 P.O. Box 712, Bldg. 11-A
T: 406/444-2738 Trenton, NJ 08625-0712
F: 406/444-1861 T: 609/588-2726
E-mail: danpeterson@state.mt.us F: 609/588-3889
Email: ejvaccaro@dhs.state.nj.us

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National Pharmaceutical Council Pharmaceutical Benefits 2003

OHIO
NEW MEXICO
Robert P. Reid, R.Ph.
Neal Solomon, M.P.H., R.Ph. Administrator, Pharmacy Services Unit
Pharmacist Ohio Department of Job and Family Services
Human Services Department Bureau of Health Plan Policy
Medical Assistance Division 30 East Broad Street, 27th Floor
P.O. Box 2348 Columbus, OH 43215-3414
Santa Fe, NM 87504-2348 T: 614/466-6420
T: 505/827-3174 F: 614/466-2908
F: 505/827-3185 E-mail: reidr@odjfs.state.oh.us
E-mail: neal.solomon@state.nm.us

OKLAHOMA
NEW YORK
Rodney Ramsey
Mark-Richard A. Butt, M.S., R.Ph. Pharmacy Claims Specialist
Director, Pharmacy Policy and Operations Oklahoma Health Care Authority
Bureau of Program Guidance 4545 North Lincoln, Suite 124
Office of Medicaid Management Oklahoma City, OK 73105
NYS Department of Health T: 405/522-7492
99 Washington Avenue, Suite 606 F: 405/530-3238
Albany, NY 12210 E-mail: ramseyr@ohca.state.ok.us
T: 518/474-9219
F: 518/473-5508
E-mail: mrb01@health.state.ny.us OREGON
Kathy L. Ketchum, R.Ph., M.P.A.-H.A.
Medicaid Program Coordinator
NORTH CAROLINA
Oregon State University College of Pharmacy
Sharman C. Leinwand, R.Ph., M.P.H. 840 SW Gaines Road, MC 212
Pharmacy Program Manager Portland, OR 97239-3098
Division of Medical Assistance T: 503/494-1589
Department of Health and Human Services F: 503/494-8797
1985 Umstead Drive, 2501 Mail Service Center E-mail: ketchumk@ohsu.edu
Raleigh, NC 27699-2501
T: 919/857-4034
F: 919/715-1255 PENNSYLVANIA
E-mail: sharman.leinwand@ncmail.net
Joseph E. Concino, R.Ph., Chief
Office of Medical Assistance Programs
Pharmacy Services Section
NORTH DAKOTA
P.O. Box 8046
Brendan K. Joyce, Pharm.D., R.Ph. Harrisburg, PA 17105
Administrator, Pharmacy Services T: 717/772-6341
Department of Human Services F: 717/772-6366
600 East Boulevard Avenue E-mail: jconcino@state.pa.us
Department 325
Bismarck, ND 58505-0250
T: 701/328-1544
F: 701/328-1544
E-mail: sojoyb@state.nd.us

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National Pharmaceutical Council Pharmaceutical Benefits 2003

TEXAS
RHODE ISLAND
Martha McNeil, R.Ph.
Paula J. Avarista, R.Ph. Product and Prescriber Manager
Chief of Pharmacy Texas Health and Human Services Commission
Department of Human Services 11209 Metric Boulevard, Building H
600 New London Avenue Austin, TX 78758
Cranston, RI 02919 T: 512/491-1157
T: 401/462-6390 F: 512/491-1961
F: 401/462-6336 E-mail: martha.mcneil@hhsc.state.tx.us
E-mail: pavarista@dhs.state.ri.us

UTAH
SOUTH CAROLINA
RaeDell Ashley, R.Ph.
James M. Assey, R.Ph., Division Director Pharmacy Director
Division of Pharmaceutical Services and DME Division of Health Care Financing
S.C. Department of Health & Human Services Department of Health
P.O. Box 8206 288 North 1460 West
Columbia, SC 29202-8206 P.O. Box 143102
T: 803/898-2876 Salt Lake City, UT 84114-3102
F: 803/255-8353 T: 801/538-6495
E-mail: asseyj@dhhs.state.sc.us F: 801/538-6099
E-mail: rashley@utah.gov

SOUTH DAKOTA
VERMONT
Mark Petersen, R.Ph.
Pharmacy Consultant Samantha Haley
Department of Social Services Operations Manager
Office of Medical Services Office of Vermont Health Access
700 Governors Drive 103 South Main Street
Pierre, SD 57501 Waterbury, VT 05671-1201
T: 605/773-3495 T: 802/241-2765
F: 605/773-5246 F: 802/241-2974
E-mail: markp@state.sd.us E-mail: samantha@path.state.vt.us

TENNESSEE VIRGINIA
Jeffrey G. Stockard, D.Ph. Javier Menendez, R.Ph.
Associate Pharmacy Director Pharmacy Manager
Bureau of TennCare Department of Medical Assistance Services
729 Church Street 600 East Broad Street, Suite 1300
Nashville, TN 37247-6501 Richmond, VA 23219
T: 615/532-3107 T: 804/786-2196
F: 615/253-5481 F: 804/786-0973
E-mail: jeff.stockard@state.tn.us E-mail: javier.menendez@dmas.virginia.gov

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National Pharmaceutical Council Pharmaceutical Benefits 2003

WASHINGTON
Siri A. Childs, Pharm D.
Pharmacy Research Specialist/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
350 Capitol Street, Room 251
Charleston, WV 25301-3709
T: 304/558-5967
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 Brown, R.Ph.
Medicaid Pharmacist
Department of Health
Pharmacy Unit
2424 Pioneer Avenue, Suite 100
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 2003

DUR CONTACT INFORMATION, 2003


State Contact Contractor
Louise F. Jones Not Available
Pharmacy Program Manager
Alabama Medicaid Agency
501 Dexter Avenue
ALABAMA
P.O. Box 5624
Contracted DUR
Montgomery, AL 36103-5624
T: 334/242-5039
F: 334/353-7014
E-mail: lljones@medicaid.state.al.us

State Contact Contractor


Dave Campana, R.Ph. Not Available
Pharmacy Program Manager
Division of Medical Assistance
ALASKA 4501 Business Park Blvd., Ste. 24
Contracted DUR Anchorage, AK 99503
T: 907/334-2425
F: 907/561-1684
E-mail: david_campana@health.state.ak.us

Within Federal and State guidelines,


ARIZONA individual managed care and pharmacy
DUR is conducted at benefit management organizations make
the plan level. formulary/drug decisions.

State Contact Contractor


Pamela Ford Cherly Avants
Pharmacist II Director, Retrospective DUR
Arkansas Department of Human Services Health Information Design
Division of Medical Services 1550 Pumphrey Avenue
ARKANSAS
Pharmacy Program Auburn, AL 36832
Contracted DUR
P.O. Box 1437, Slot 415 T: 205/402-9530
Little Rock, AR 72203-1437 F: 205/402-9531
T: 501/683-4120 E-mail: clavants@aol.com
F: 501/683-4124
E-mail: pamela.ford@medicaid.state.ar.us

State Contact Contractor


Vic Walker, R.Ph. B.C.P.P. Jude Simon-Leack
Senior Consulting Pharmacist DUR Pharmacist
California Department of Health Services EDS Medi-Cal
Medi-Cal Policy Division 3215 Prospect Park Dr.
CALIFORNIA
1501 Capitol Avenue Rancho Cordova, CA 95670
Contracted DUR
P.O. Box 997413, MS 4604 T: 916/636-1000
Sacramento, CA 95899-7413 F: 916/636-1002
T: 916/552-9500 E-mail: jude.simon-leack@eds.com
F: 916/552-9563
E-mail: vwalker@dhs.ca.gov

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National Pharmaceutical Council Pharmaceutical Benefits 2003

State Contact Contractor


Catherine Traugott Steve Espy, R.Ph.
Pharmacist Director of Drug Utilization
Deptartment of Health Care Policy and Health Information Designs, Inc.
COLORADO Financing 1550 Pumphrey Avenue
Contracted DUR 1570 Grant Street Auburn, AL 36832
Denver, CO 80203 T: 205/402-9530
T: 303/866-2468 F: 205/402-9531
F: 303/866-2573
E-mail: catherine. traugott@state.co.us

State Contact Contractor


James Zakszewski, R.Ph. Vita Judkins
Pharmacy Consultant Account Manager
Department of Social Services ACS State Healthcare
CONNECTICUT Medical Operations Unit 365 Northridge Road, Suite 400
Contracted DUR 25 Sigourney Street Atlanta, GA 30350
Hartford, CT 06106-5033 T: 866/759-4113
T: 860/424-4961 F: 866/759-4110
F: 860/424-5206 E-mail:
E-mail: james.zakszewski@po.state.ct.us vita.judkins@acs-inc.com

State Contact Contractor


Cynthia R. Denemark Joli Martini
Director of Pharmacy Services Pharmacist Consultant
DSS/EDS DSS/EDS
DELAWARE
248 Chapman Road, Suite 100 248 Chapman Road, Suit 100
Contracted DUR
Newark, DE 19702 Newark, DE 19702
T: 302/453-8453 T: 302/453-8453
F: 302/454-0224 F: 302/454-0224
E-mail: cynthia.denemark@eds.com

State Contact
Donna Bovell, R.Ph.
Pharmacy Consultant
Department of Health
DISTRICT OF Medical Assistance Administration
COLUMBIA 825 North Capitol Street, NE
In-House DUR Fifth Floor
Washington, DC 20002
T: 202/442-5988
F: 202/442-4790
E-mail: donna.bovell@dcgov.org

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State Contact Contractor


Linda G. Barnes Rita Brown
Senior Pharmacist DUR Coordinator
Agency for Health Care Administration Florida Pharmacy Association
FLORIDA
2727 Mahan Drive, MS 38 610 N. Adams Street
Contracted DUR
Tallahassee, FL 32308 Tallahassee, FL 32301
T: 850/487-4441 T: 850/222-2400
F: 850/922-0685 F: 850/561-6758
E-mail: barnesl@fdhc.state.fl.us

State Contact
Jean Cox, R.Ph.
Drug Utilization/Prior Approval Coordinator
GA Dept. of Community Health
GEORGIA Division of Medical Assistance
In-House DUR 2 Peachtree St. NW, 37th Floor
Atlanta, GA 30303-3159
T: 404/657-7241
F: 404/656-8366
E-mail: jcox@dch.state.ga.us

State Contact
Kathleen Kang-Kaulupali
Pharmacy Consultant
Department of Human Services
HAWAII
Med-Quest Division
In-House DUR
601 Kanokila Boulevard, Room 506-B
Kapolei, HI 90707
T: 808/692-8065
F: 808/692-8131

State Contact Contractor


Tamara Eide, Pharm.D., BCPS, FASHP Vaughn Culbertson, Pharm.D.
Pharmacy Services Specialist DUR Project Coordinator
Department of Health and Welfare Idaho State U. - College of Pharmacy
IDAHO
Division of Medicaid Campus Box 8356
Contracted DUR
3232 Elder Pocatello, ID 83209-8356
Boise, ID 83705 T: 208/282-2586
T: 208/364-1821 F: 208/282-4482
F: 208/364-1864 E-mail: vculb@otc.isu.edu
E-mail: eidet@idhw.state.id.us
State Contact
Marvin L. Hazelwood, Manager
Pharmacy and Ancillary Services Program
Illinois Department of Public Aid
Division of Medical Assistance
ILLINOIS
1001 N. Walnut Street
In-House DUR
Springfield, IL 62702
T: 217/524-5565
F: 217/524-7194
E-mail: dpa_webmaster@state.il.us

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National Pharmaceutical Council Pharmaceutical Benefits 2003

State Contact Contractor


Karen Clifton ACS
DUR Board Secretary 365 Northridge Road, Suite 400
Office of Medicaid Policy and Planning Atlanta, GA 30350
Indiana State Government Center T: 866/322-5960
INDIANA
South-Room W382 F: 866/759-4100
Contracted DUR
402 West Washington Street
Indianapolis, IN 46204
T: 317/232-4307
F: 317/232-7382
E-mail: kclifton@fssa.state.in.us

State Contact Contractor


Julie Kuhle, R.Ph. Julie Kuhle, R.Ph.
DUR Coordinator DUR Coordinator
IOWA Iowa Pharmacy Association Iowa Pharmacy Association
Contracted DUR 8515 Douglas, Ste. 16
Des Moines, IA 50322
T: 515/270-0713
F: 515/270-2979

State Contact Contractor


Vicki L. Schmidt Not Available
Pharmacist
Health Care Policy Division
Kansas Department of Social and
KANSAS Rehabilitation Services
Contracted DUR Docking State Office Building
915 SW Harris, Room 651-South
Topeka, KS 66612-1570
T: 785/274-4287
F: 785/296-4813
E-mail: vixs@srskansas.org

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 2003

State Contact Contractor


Mary J. Terrebonne, Pharm.D. Shelly Delaville
Pharmacy Director Pharmacist
Department of Health and Hospitals Unisys
LOUISIANA 1201 Capitol Access Road, 6th Floor 8591 United Plaza Blvd., Ste.300
Contracted DUR P.O. Box 91030 Baton Rouge, LA 70809
Baton Rouge, LA 70821 T: 225/237-3227
T: 225/342-9768 F: 225/237-3334
F: 225/342-1980 E-mail: shelly.delaville@unisys.com
E-mail: mterrebo@dhh.state.la.us

State Contact Contractor


Jude Walsh, Director Not Available
Health Care Management Division
442 Civic Center Drive
MAINE 11SHS, DHS – Bureau of Medical Services
Contracted DUR Augusta, ME 04333
T: 207/287-1815
F: 207/287-6533
E-mail: jude.c.walsh@maine.gov

State Contact Contractor


Judy Geisler Contact Judy Geisler
Pharmacist Consultant Pharmacist Consultant
DHMH-Office of Operations and Eligibility
MARYLAND Division of Pharmacy Services
Contracted DUR 201 W. Preston St.
Baltimore, MD 21201
T: 410/787-1455
F: 410/333-5398
E-mail: geislerj@dhmh.state.md.us

State Contact Contractor


Paul Jeffrey Paul L. Jeffrey
Director of Pharmacy Director of Pharmacy
Office of Medicaid
MASSACHUSETTS
600 Washington Street, 5th Floor
Contracted DUR
Boston, MA 02111
T: 617/210-5319
F: 617/210-5865
E-mail: pjeffrey@nt.dma.state.ma.us

State Contact Contractor


Debera Eggleston, M.D. First Health Services Corp.
MDCH/Medical Services Administration 4300 Cox Rd.
400 S. Pine Street Glen Allen, VA 23060
MICHIGAN
P.O. Box 30479 T: 877/864-9014
Contracted DUR
Lansing, MI 48909-7979 F: 888/603-7696
T: 517/335-5181
F: 517/241-8135
E-mail: egglestond@michigan.gov

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State Contact
Mary Beth Reinke, Pharm.D., R.Ph.
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 Contractor


Judith P. Clark, R.Ph. Sam Warman, R.Ph.
Pharmacy Director Project Manager
Division of Medicaid Heritage Information Design
MISSISSIPPI Robert E. Lee Building P.O. Box 320506
Contracted DUR 239 North Lamar St., Ste. 801 Flowood, MS 39232
Jackson, MS 39201 T: 601/709-0000
T: 601/359-6296 F: 800/459-2135
F: 601/359-9555 E-mail: pa-ms@hidinc.com
E-mail: phipc@medicaid.state.ms.us

State Contact
Jayne Zemmer
DUR Coordinator
Div. of Medical Services
MISSOURI
P.O. Box 6500
In-House DUR
Jefferson City, MO 65102-6500
T: 573/751-1612
F: 573/526-4650
E-mail: jayne.a.zemmer@dss.mo.gov

State Contact Contractor


Mark Eichler, R.Ph., FASCP Mark Eichler, R.Ph.
DUR Coordinator Mountain-Pacific Quality Health
Mountain-Pacific Quality Health Foundation Foundation
MONTANA
3404 Cooney Drive
Contracted DUR
Helena, MT 59602
T: 406/443-4020
F: 406/443-4585
E-mail: meichler@mpqhf.org

State Contact Contractor


Beth Wilson Same as State Contact
DUR Director
Nebraska Pharmacists Association
NEBRASKA
6221 South 58th, Suite A
Contracted DUR
Lincoln, NE 68516
T: 402/420-1500
F: 402/420-1406
E-mail: beth@npharm.org

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State Contact Contractor


Dionne Coston, R.N. Steve Espy, R.Ph.
Medical Services Specialist Director of Drug Utilization
Division of Health Care Financing and Policy Health Info. Design, Inc.
NEVADA Pharmacy Program 1550 Pumphrey Avenue
Contracted DUR 1100 E. Williams Street Auburn, AL 36832
Carson City, NV 89701 T: 205/402-9530
T: 775/684-3775 F: 205/402-9531
F: 775/684-3762
E-mail: dcpstpm@dhcfp.state.nv.us

State Contact Contractor


Lisè Ferrand, R.Ph. Robert Coppola
Pharmaceutical Services Specialist Clinical Manager
Office of Health Planning & Medicaid First Health Services Corp.
NEW HAMPSHIRE
129 Pleasant Street, Annex 1 17 Chenell Drive
Contracted DUR
Concord, NH 03301 Concord, NH 03301
T: 603/271-4419 T: 603/224/2083
F: 603/271-8701 F: 603/224/6690
E-mail: lfarrand@dhhs.state.nh.us E-mail: coppola@fhsc.com

State Contact
Edward Vaccaro, R.Ph.
Assistant Director
Office of Utilization Management
Division of Medical Assistance and Health
NEW JERSEY Services
In-House DUR Office of Health Service Administration
P.O Box 712, Bldg. 11-A
Trenton, NJ 08625-0712
T: 609/588-2726
F: 609/588-3889
E-mail: ejvaccaro@dhs.state.nj.us

State Contact Contractor


Neal Solomon, M.P.H., R. Ph. UNM College of Pharmacy
Pharmacist
Human Services Department
NEW MEXICO
Medical Assistance Division
In-House and
P.O. Box 2348
Contracted DUR
Sante Fe, NM 87504-2348
T: 505/827-3174
F: 505/827-3185
E-mail: neal.solomon@state.nm.us

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National Pharmaceutical Council Pharmaceutical Benefits 2003

State Contact
Lydia Kosinski, R.Ph.
DUR Manager
Office of Medicaid Management
NEW YORK NYS Dept. of Health
In-House DUR 99 Washington Ave, Suite 601
Albany, NY 12210
T: 518/474-6866
F: 518/473-5332
E-mail: ljk02@health.state.ny.us

State Contact Contractor


Sharman C. Leinwand, R.Ph., M.P.H. Sharon Greeson, R.Ph.
Pharmacy Program Manager Pharmacy Program Manager
Division of Medical Assistance EDS
Department of Human Resources 4905 Waters Edge Drive
NORTH CAROLINA
1985 Umstead Drive Raleigh, NC 27606
Contacted DUR
2501 Mail Services Center T: 919-816-4475
Raleigh, NC 27699-2501 F: 919/816-4399
T: 919/857-4034 E-mail: sharon.greeson@eds.com
F: 919/715-1255
E-mail: sharman.leinwand@ncmail.net

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

State Contact Contractor


Jan Lawson First Health Services Corporation
OHIO DUR Administrator 4300 Cox Road
In-House and 255 East Main Street Glen Allen, VA 23060
Contracted DUR Columbus, OH 43215 T: 800/884-2822
T: 614/466-9698 F: 800/884-7696
F: 614/466-2866

State Contact Contractor


Nancy Nesser, D.Ph., J.D. Ronald Graham, D.Ph.
Medicaid Pharmacy Director Manager, Operations/DUR
Oklahoma Health Care Authority University of Oklahoma
OKLAHOMA 4545 N. Lincoln Blvd. Ste 124 College of Pharmacy
Contracted DUR Oklahoma City, OK 73105-9901 P.O. Box 26801
T: 405/522-7325 Oklahoma City, OK 73109
F: 405/522-3240 T: 405/271-6614
E-mail: nessern@ohca.state.ok.us F: 405/271-2615
E-mail: ronald-graham@ouhsc.edu

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National Pharmaceutical Council Pharmaceutical Benefits 2003

State Contact Contractor


Kathy L. Ketchum, R.Ph., M.P.A.: H.A. Jim Rowland
Medicaid Program Coordinator Account Manager
Oregon State University College of Pharmacy First Health Services Corporation
OREGON
840 SW Gaines Road, MC 212 925 Commercial Street SE, Suite 350
Contracted DUR
Portland, OR 97239-3098 Salem, OR 97301-2460
T: 503/494-1589 T: 503/391-1980
F: 503/494-8797 F: 503/391-1979
E-mail: ketchumk@ohsu.edu E-mail: rowlandj@fhsc.com

State Contact Contractor


Office of Medical Assistance Programs PRODUR: EDS
PENNSYLVANIA P.O. Box 8046 RETRODUR: University of Maryland
Contracted DUR Harrisburg, PA 17105
T: 717/772-6341
F: 717/772-6366

State Contact Contractor


Paula J. Avarista, R.Ph. Joseph Paradis
Chief of Pharmacy Clinical Pharmacist
Departrment of Human Services Health Information Designs, Inc.
RHODE ISLAND
600 New London Avenue 228 West Church Street
Contracted DUR
Cranston, RI 02919 Salisbury, MD 21801
T: 401/462-6390 866/260-2555
F: 401/462-6336 E-mail: joe@hidinc.com
E-mail: pavarista@dhs.ri.gov

State Contact Contractor


Caroline Y. Sojourner, R.Ph. First Health Services Corporation
Deptartment Head, Pharmacy Services 4300 Cox Road
S.C. Department of Health & Human Glen Allen, VA 23060
SOUTH CAROLINA
Services T: 800/884-2822
In-House and
P.O. Box 8206 F: 804/273-6961
Contracted DUR
Columbia, SC 29202-8206
T: 803/898-2876
F: 803/255-8353
E-mail: sojourne@dhhs.state.sc.us

State Contact
Michael Jockheck, R.Ph.
Pharmacy Consultant
SOUTH DAKOTA SD Department of Social Services
In-House DUR 700 Governors Drive
Pierre, SD 57501
605/773-6439
E-mail: mike.jockheck@state.sd.us

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Contractor
State Contact Walter Fitzgerald
Jeffery G. Stockard, D.Ph. Professor of Pharmacy
Associate Pharmacy Director University of Tennessee College of
Bureau of TennCare Pharmacy
TENNESSEE 729 Church Street 26 South Dunlap, Suite 202
Nashville, TN 37247-6501 Memphis, TN 38163
Contracted DUR
T: 615/532-3107 T: 901/448-2351
F: 615/253-5481 F: 901/448-3701
E-mail: jeff.stockard@state.tn.us E-mail: wfitzgerald@utmem.edu

Within Federal and State guidelines, individual managed care and pharmacy benefit
management organizations make formulary/drug decisions.

State Contact
Barbara Dean
Acting Director, Vendor Drug Program
Texas Health and Human Services
TEXAS Commision
In-House DUR 1100 West 49th Street
Austin, TX 78756-3174
T: 512/491-1101
F: 512/491-1959
E-mail: barbara.dean@hhsc.state.tx.us

State Contact
Duane Parke
DUR Director
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

State Contact Contractor


Scott Strenio, M.D. EDS
Clinical Consultant Fiscal Agent
Office of VT Health Access 312 Hurrican Lane, Suite 101
VERMONT
103 S. Main St. Williston, VT 05495
Contracted DUR
Waterbury, VT 05671 T: 802/879-4450
T: 802/741-7975 F: 802/878-3440
F: 802/241-2974
E-mail: scottstrenio@msn.com

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State Contact Contractor


Javier Menendez, R.Ph. Donna Johnson
Pharmacy Manager Pharmacy Manager
Deparment of Medical Asistance Services First Health Services Corporation
VIRGINIA
600 East Broad Street, Suite 1300 4300 Cox Road
In-House DUR
Richmond, VA 23219 Glen Allen, VA 23060
T: 804/783-2196 804/965-7400
F: 804/786-0973 E-mail: dpjohnson@fhsc.com
E-mail: javier.menendez@dmas.virginia.gov

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

State Contact Contractor


Vicki M. Cunningham, R.Ph. Robert Berringer, Pharm.D.
DUR Coordinator Account Manager
Bureau for Medical Services Heritage Information Systems
WEST VIRGINIA Office of Pharmacy Services 410 West Franklin St.
Contracted DUR 350 Capitol Street, Room 251 Richmond, VA 23220
Charleston, WV 25301-3709 T: 804/644-8707
T: 304/558-1700 F: 804/644-8709
F: 304/558-1542 E-mail: robertb@heritage-info.com
E-mail: vickicunningham@wvdhhr.org

State Contact Contractor


Michael Mergener, R.Ph., Ph.D. Same as State contact
Chief Pharmacist
APS Healthcare
WISCONSIN
10 East Doty St., Suite 210
Contracted DUR
Madison, WI 53703
T: 608/258-3348
F: 608/258-3359

State Contact Contractor


Debra Devereaux, R.Ph. Same as State contact
DUR Coordinator,
University of Wyoming School of Pharmacy
WYOMING
P.O. Box 3375
Contracted DUR
Laramie, WY 82071-3375
T: 307/766-6750
F: 307/766-2953
E-mail: debdev@concentric.net

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CLAIMS SUBMISSION CONTACTS, 2003

ALABAMA COLORADO
Cyndi Crockett ACS, Inc.
Supervisor 600 17th Street
EDS Suite 600 North
301 Technacenter Dr. Denver CO 80202
Montgomery, AL 36117 T: 800/237-0757
334/215-0111 F: 303/534-0439

CONNECTICUT
ALASKA
Sheila Dorval
Linda Walsh
Health Program Supervisor
Systems Administrator
Department of Social Services
Division of Medical Assistance
Medical Operations Unit
4501 Business Park Blvd., Suite 24
25 Sigourney Street
Anchorage, AK 99503
Hartford, CT 06106-5033
T: 907/334-2441
T: 860/424-5149
F: 901/561-1684
F: 860/424-5206
E-mail: linda_walsh@health.state.ak.us
E-mail: sheila.dorval@po.state.ct.us

ARIZONA
DELAWARE
Dell Swan
Jose Tieso
Pharmacy Program Administrator
System Manager
AHCCCS
EDS
801 East Jefferson Street
248 Chapman Rd, Suite 100
MD 400
Newark, DE 19702
Phoenix, AZ 85034
T: 302/453-8453
612/417-4000
F: 302/454-0224
E-mail: dwswan@ahcccs.state.az.us

DISTRICT OF COLUMBIA
ARKANSAS
Anita Martin
John Herzog
Manager-Plan Administration
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: 804/965-7425
T: 501/374-6608
F: 804/273-6961
F: 501/372-2971
E-mail: camartin@fhsc.com
E-mail: john.herzog@medicaid.state.ar.us

CALIFORNIA
EDS
P.O. Box 13029
Sacramento, CA 95813-4029
916/636-1000
Internet address: www.medi-cal.ca.gov

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FLORIDA INDIANA
Kevin Whittington Ulka Pandya
Clinical Program Coordinator ACS State Healthcare
ACS 365 Northridge Rd., Suite 400
9040 Roswell Road Atlanta, GA 30350
Roswell, GA T: 866-322-5960 x4032
850/201-1418 F: 866/759-4100

GEORGIA IOWA
Dustin Gruhlke Mindy Ruby
Account Manager Claims Manager
Express Scripts, Inc. ACS
6625 W. 78th St., BL-0420 P.O. Box 14422
Bloomington, MN 55439 Des Moines, IA 50306-3422
T: 952/837-7741 T: 515/327-0950 x1108
F: 952/837-7741 F: 515/327-0945
E-mail: dustin.gruhlke@express-scripts.com
KANSAS
HAWAII
EDS
Heather Bodiford 3600 SW Topeka Boulevard
Account Manager Suite 204
ACS State Healthcare Topeka, KS 66611
365 Northridge Road, Suite 400 785/274-4200
Atlanta, GA 30350
T: 866/322-5960
KENTUCKY
F: 866/759-4100
Attn: Hawaii Medicaid 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
1001 North Walnut Street T: 225/237-3391
Springfield, IL 62702 F: 225/237-3334
T: 217/782-5565 E-mail: doug.hasty@unisys.com
F: 217524-7194
E-mail: dpa_webmaster@state.il.us

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MAINE MISSISSIPPI
Marcia Pykare Bob Parenteu
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: 601/296-2934
F: 207/623-5125 F: 601/296-3119
E-mail: movkare@ghsinc.com E-mail: bob-parenteau@acs-inc.com

MARYLAND MISSOURI
James Demery Diane Twehous
Manager, Pharmacy Services Claims Process Administrator
First Health Services Corporation Verzion Data Services
Division of Claims Processing 905 Weathered Rock Rd.
201 W. Preston St. Jefferson City, MO 65109
Baltimore, MD 21201 573/635-2434
T: 401/767-1460
F: 410/333-5398
MONTANA
E-mail: demeryj@dhmh.state.md.us
Kevin Quinn
Executive Account Manager
MASSACHUSETTS
ACS, Inc.
ACS State Health Care 34 N. Last Chance Gulch, Suite 200
365 Northridge Road Helena, MT 59601
Northridge Center One, Suite 400 T: 406/449-7693
Atlanta, GA 30350 F: 406/442-2819
800/358-2381 E-mail: kevin.quinn@acs-inc.com

MICHIGAN NEBRASKA
First Health Services Corp. Steve Smith
4300 Cox Rd. Account Representative
Glen Allen, VA 23060 ACS State Healthcare
T: 877/864-9014 365 Northridge Road
F: 888/603-7696 Northridge Center One, Suite 400
Atlanta, GA 30350
MINNESOTA T: 770/901-5002
F: 770/730-5198
Dwaine Voas E-mail: stephen.m.smith@acs-inc.com
MMIS Unit Supervisor
Minnesota Dept. of Human Services
800 Minnehaha Avenue NEVADA
St. Paul, MN 51555
First Health Services Corp.
4300 Cox Road
Glen Allen, VA 23060
800/884-3238

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NEW HAMPSHIRE Administrator, Pharmacy Services


North Dakota Department of Human Services
Sherrill Bryant
600 East Boulevard Avenue
Plan Administrator
Department 325
First Health Services Corp.
Bismarck, ND 58505-0250
4300 Cox Road
T: 701/328-1544
Glen Allen, VA 23060
F: 701/328-1544
T: 800/884-2822
E-mail: sojoyb.@state.nd.us
F: 804/965-7647
E-mail: bryantsh@fhsc.com
OHIO

NEW JERSEY First Health Services Corp.


4300 Cox Rd.
Peter Ringel, Deputy Project Director Glen Allen, VA 23060
Unisys T: 800/884-2822
3705 Quakerbridge Rd., Suite 101 F: 800/884-7682
Trenton, NJ 08619
T: 609/588-6000
F: 609/584-8270 OKLAHOMA
E-mail: ringel@njpo1.him.unisys.com EDS
2401 N.W. 23rd Street, Suite 11
NEW MEXICO Oklahoma City, OK 73107
405/416-6794
ACS, Inc.
365 Northridge Road
Northridge Center One, Suite 400 OREGON
Atlanta, GA 30350 Jim Rowland
T: 770/352-8592 Pharmacist Account Manager
F: 770/730-5198 First Health Services Corporation
925 Commercial Street SE, Suite 350
NEW YORK Salem, OR 97301-2460
T: 503/391-1980
eMedNY F: 503/391-1979
Computer Sciences Corporation E-mail: rowlanji@fhsc.com
One CSC Way
Rensselaer, NY 12144
800/343-9000 PENNSYLVANIA
E-mail: webmaster@emedny.org EDS
275 Grandview Avenue
NORTH CAROLINA Camp Hill, PA 17011
(Calls to contractor must be
Sharon Greeson, R.Ph. made through State agency.)
Pharmacy Program Manager
EDS
4905 Waters Edge Dr.
Raleigh, NC 27606
T: 919/816-4475
F: 919/816-4399
E-mail: sharon.greeson@eds.com

NORTH DAKOTA
Brendan K. Joyce, Pharm. D., R.Ph.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

RHODE ISLAND UTAH


EDS Connie Higley
1471 Elmwood Avenue Information Technology Director
Cranston, RI 02910 Division of Health Care Financing
401/784-3879 Department of Health
P.O. Box 143102
Salt Lake City, UT 84114-3102
SOUTH CAROLINA
T: 801/538-6136
Rod Davis F: 801-538-6099
Deputy Director of Information Technology E-mail: chigley@utah.gov
S.C. Department of Health & Human Services
P.O. Box 8206
VERMONT
Columbia, SC 29202-8206
803/898-2610 EDS
E-mail: davisr@dhhs.state.sc.us 312 Hurricane Lane, Ste 101
Williston, VT 05495
T: 802/879-4450
SOUTH DAKOTA
F: 802/878-3440
Meredith Heerman
SD Dept. of Social Services
VIRGINIA
Claims Processing Supervisor
700 Governors Dr. Frank Fury
Pierre, SD 57501 Operations Manager
T: 605/773-3495 First Health Services Corporation
F: 605/773-5246 4300 Cox Road
E-mail: meredith_heerman@state.sd.us Glen Allen, VA 23060
Community Pharmacy Coalition
804/965-7400
TENNESSEE
Rita Marcoux
WASHINGTON
Account Manager
First Health Services Corporation Chris Johnson
4300 Cox Road Claims Processing Manager
Glen Allen, VA 23060 Medical Assistance Administrator, DSHS
804/965-7400 P.O. Box 45509
Olympia, WA 98504-5509
360/725-1239
TEXAS
E-mail: johnsc2@dshs.wa.gov
Laura Bagheri
Manager, Pharmacy Resolutions
WEST VIRGINIA
Vendor Drug Program
Texas Health and Human Services Commission Becky Garrigan
1100 West 49th Street PBM Account Manager
Austin, TX 78745 ACS, Inc.
T: 512/491-1741 365 Northridge Road
F: 512/491-1958 Northridge Center One, Suite 400
E-mail: laura.bagheri@hhsc.state.tx.us Atlanta, GA 30350
T: 770/352/8592
F: 770/730-5198
E-mail: becky.garrigan@acs-inc.com

WISCONSIN

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Mark Gajewski
Account Director
EDS
6406 Bridge Road
Madison, WI 53784-0014
T: 608/221-4746
F: 608/221-4567

WYOMING
ACS
Northridge Center One, Suite 400
365 Northridge Road
Atlanta, GA 30350
T: 866/322-5960
F: 888/335-8459

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PRESCRIPTION PRICE UPDATING CONTACTS, 2003

ALABAMA COLORADO
Beverly R. Churchwell, Administrator Martha Warner
Alabama Medicaid Agency Pharmacy Supervisor
501 Dexter Avenue Department of Health Care Policy and Financing
P.O. Box 5624 1570 Grant Street
Montgomery, AL 36103-5624 Denver, CO 80203
T: 334/242-5034 T: 303/866-3176
F: 334/353-7014 F: 303/866-2573
E-mail: bchurchwell@medicaid.state.al.us E-mail: martha.warner@state.co.us

ALASKA CONNECTICUT
Dave Campana, R.Ph James Zakszewski, R.Ph.
Pharmacy Program Manager Pharmacy Consultant
Division of Medical Assistance Department of Social Services
4501 Business Park Blvd., Suite 24 Medical Operations Unit
Anchorage, AK 99503 25 Sigourney Street
T: 907/273-3224 Hartford, CT 06106-5033
F: 907/561-1684 T: 860/424-4961
E-mail: david_campana@health.state.ak.us F: 860/424-5206
E-mail: james.zakszewski@po.state.ct.us
ARIZONA
DELAWARE
Dell Swan
Pharmacy Program Administrator Don Cohn
AHCCCS DSS/EDS
801 East Jefferson Street 248 Chapman Road, Suite 100
MD 400 Newark, DE 19702
Phoenix, AZ 85034 T: 302/453-8453
612/417-4000 F: 302/454-0224
E-mail: dwswan@ahcccs.state.az.us
DISTRICT OF COLUMBIA
ARKANSAS
Glenn Sharp
First DataBank Clinical Account Manager
1111 Bayhill Drive, Suite 350 First Help Service Corporation
San Bruno, CA 94066 4300 Cox Road
T: 650/588-5454 Glen Allen, VA 23060
F: 650/588-4003 T: 804/965-7447
F: 804/273-6961
CALIFORNIA E-mail: sharpgl@fhsc.com

EDS Federal Corporation FLORIDA


P.O. Box 13029 First DataBank
Sacramento, CA 95813-4029 1111 Bayhill Drive, Suite 350
916/636-1000 San Bruno, CA 94066
T: 650/588-5454
F: 650/827-4578

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National Pharmaceutical Council Pharmaceutical Benefits 2003

GEORGIA IOWA
Andrew Shim, Pharm.D. Sherey Swanson
Clinical Program Manager Deputy Account Manager
Express Scripts, Inc. ACS, Inc.
6625 W 78th Street, BL0420 P.O. Box 14422
Bloomington, MN 55439 Des Moines, IA 50306-3422
T: 952-837-5326 T: 515/327-0950 x1107
F: 952-837-7184 F: 515/327-0945
E-mail: andrew.shim@express-scripts.com
KANSAS
HAWAII
Mary H. Obley
First DataBank Pharmacist
1111 Bayhill Drive, Suite 350 Pharmacy Program Manager
San Bruno, CA 94066 Health Care Policy Division
800/633-3453 Kansas Department of Social and Rehabilitation
Services
IDAHO Docking State Office Building
915 SW Harrison, Room 651-South
Katie Ayad Topeka, KS 66612-1570
Technical Records II T: 785/296-8406
Department of Health and Welfare F: 785/296-4813
Division of Medicaid E-mail: mho@srskansas.org
3232 Elder
Boise, ID 83705
KENTUCKY
T: 208/364-1970
F: 208/364-1864 Unisys Provider Services
E-mail: ayadk@idhw.state.id.us P.O. Box 2106
Frankfort, KY 40602
ILLINOIS T: 502/226-1140
F: 502/226-1860
First DataBank
1111 Bayhill Drive, Suite 350
LOUISIANA
San Bruno, CA 94066
650/588-5454 Maggie Vick
Unisys
INDIANA 8591 United Plaza Blvd., Ste. 300
Baton Rouge, LA 70809
First DataBank T: 225/237-3251
1111 Bayhill Drive, Suite 350 F: 225/237-3334
San Bruno, CA 94066 E-mail: margaret.vick@unisys.com
T: 650/588-5454
F: 650/588-4003

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National Pharmaceutical Council Pharmaceutical Benefits 2003

MAINE MISSISSIPPI
Jude Walsh, Director Judith P. Clark, R.Ph.
Health Care Management Division Pharmacy Director
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: 207/287-1815 T: 601/359-5253
F: 207/287-6533 F: 601/359-9555
E-mail: jude.c.walsh@maine.gov E-mail: phipc@medicaid.state.ms.us
Internet address: www.maine.gov/bms Internet address: www.dom.state.ms.us

MARYLAND
MISSOURI
First DataBank
First DataBank
1111 Bayhill Drive, Suite 350
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
San Bruno, CA 94066
T: 415/588-5454
T: 650/588-5454
F: 415/827-4578 F: 650/827-4510

MASSACHUSETTS MONTANA
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

MICHIGAN NEBRASKA
First Health Services Corporation First DataBank
4300 Cox Road 1111 Bayhill Drive, Suite 350
Glen Allen, VA 23060 San Bruno, CA 94066
T: 877/864-9014 T: 650/588-5454
F: 888/603-7696 F: 650/827-4578

MINNESOTA NEVADA
First DataBank First DataBank
1111 Bay Hill 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: 650/588-4003 F: 650/827-4578

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National Pharmaceutical Council Pharmaceutical Benefits 2003

NEW HAMPSHIRE NORTH CAROLINA


Sherrill Bryant Sharon Greeson, R.Ph.
Plan Administrator Pharmacy Programs Manager
First Health Services Corp. EDS
4300 Cox Road 4905 Waters Edge Drive
Glen Allen, VA 23060 Raleigh, NC 27606
T: 800/884-2822 T: 919/816-4475
F: 804/965-7647 F: 919/816-4399
E-mail: bryantsh@fhsc.com E-mail: sharon.greeson@eds.com

NEW JERSEY NORTH DAKOTA


First DataBank, Inc. Brendan K. Joyce, Pharm.D., R. Ph.
1111 Bayhill Drive, Suite 350 Administrator, Pharmacy Services
San Bruno, CA 94066 North Dakota Department of Human Services
T: 650/588-5454 600 East Boulevard Ave.
F: 650/827-4578 Dept. 325
Bismark, ND 58505-0250
NEW MEXICO T: 701/328-1544
F: 701/328-1544
Neal Solomon, M.P.H., R.Ph. E-mail: sojoyb.@state.nd.us
Pharmacist
Human Services Department
OHIO
Medical Assistance Division
P.O. Box 2348 First DataBank
Santa Fe, NM 87504-2348 1111 Bayhill Drive, Suite 350
T: 505/827-3174 San Bruno, CA 94066
F: 505/827-3185 T: 650/588-5454
E-mail: neal.solomon@state.nm.us F: 650/827-4578

NEW YORK OKLAHOMA


Carl Cioppa, Pharm. D. First DataBank
Manager, Pharmacy Operations 1111 Bayhill Drive, Suite 350
Pharmacy Policy and Operations San Bruno, CA 94066
Office of Medicaid Management 800/633-3453
NYS Dept. of Health E-mail: www.firstdatabank.com
99 Washington Ave., Suite 606
Albany, NY 12210
OREGON
T: 518/474-9219
F: 518/473-5508 Jim Rowland
E-mail: ctc02@health.state.ny.us Account Manager
First Health Sevices Corporation
925 Commercial Street SE, Suite 350
Salem, OR 97301-2460
T: 503/391-1980
F: 503/391-1979
E-mail: rowlanji@fhsc.com

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National Pharmaceutical Council Pharmaceutical Benefits 2003

PENNSYLVANIA TEXAS
First DataBank, Inc. Martha McNeill, R.Ph.
1111 Bayhill Drive, Suite 350 Product and Prescriber Manager
San Bruno, CA 94066 Texas Health and Human Services Commission
800/633-3453 11209 Metric Boulevard, Building H
Austin, TX 78758
T: 512/491-1157
RHODE ISLAND
F: 512/491-1961
Paula J. Avarista, R.Ph. E-mail: martha.mcneill@hhsc.state.tx.us
Chief of Pharmacy
Department of Human Services
UTAH
600 New London Avenue
Cranston, RI 02919 RaeDell Ashley, R.Ph.
T: 401/462-6390 Pharmacy Director
F: 401/462-6336 Division of Health Care Financing
E-mail: pavarista@dhs.ri.gov Department of Health
P.O. Box 143102
Salt Lake City, UT 84114-3102
SOUTH CAROLINA
T: 801/538-6495
First DataBank F: 801/538-6099
1111 Bayhill Drive, Suite 350 E-mail: rashley@utah.gov
San Bruno, CA 94066
T: 650/588-5454
VERMONT
F: 650/588-4003
Christine Dapkiewicz
Drug Rebate Coordinator
SOUTH DAKOTA
312 Hurricane Lane, Suite 101
Mark Petersen, R.Ph. Williston, VT 05495
Pharmacy Consultant T: 802/879-4450
Department of Social Services F: 802/878-3440
Office of Medical Services
700 Governors Drive
VIRGINIA
Pierre, SD 57501
T: 605/773-3495 Javier Menendez, R.Ph.
F: 605/773-5246 Pharmacy Manager
E-mail: markp@state.sd.us Department of Medical Assistance Services
600 East Broad Street, Ste. 1300
TENNESSEE Richmond, VA 23219
T: 804/783-2196
First DataBank F: 804/786-0973
1111 Bayhill Drive, Suite 350 E-mail: javier.menendez@virginia.gov
San Bruno, CA 94066 Internet address: www.dmas.virginia.gov
T: 650/588-5454
F: 650/588/6867

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National Pharmaceutical Council Pharmaceutical Benefits 2003

WASHINGTON
Tom Zuchlewski
Pharmacy Rates Manager
Medical Assistance Administration, DSHS
P.O. Box 45510
Olympia, WA 98504-5510
T: 360/725-1837
F: 360/753-9152
E-mail: zuchltm@dshs.wa.gov

WEST VIRGINIA
Becky Garrigan
PBM Account Manager
ACS, Inc.
365 Northridge Road
Northridge Center, Suite 400
Atlanta, GA 30350
T: 770/352-8592
F: 770/730-5198
E-mail: Becky.Garrigan@acs-inc.com

WISCONSIN
First DataBank
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
T: 800/633-3453
F: 650/827-4578

WYOMING
First DataBank
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
T: 800/633-3453
F: 650/872-4510

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National Pharmaceutical Council Pharmaceutical Benefits 2003

MEDICAID DRUG REBATE CONTACTS, 2003

ALABAMA CALIFORNIA
Gladys Gray, Associate Director Craig Miller
Alabama Medicaid Agency Chief, Medi-Cal Rebate and Vision Section
501 Dexter Avenue Medi-Cal Policy Division
P.O. 5624 1501 Capitol Avenue
Montgomery, AL 36103-5624 P.O. Box 997413, MS 4604
334/242-2323 Sacramento, CA 95899-7413
E-mail: ggray@medicaid.state.al.us T: 916/552-9500
F: 916/552-9563
E-mail: cmiller2@dhs.ca.gov
ALASKA
Amanda Burger
Division of Medical Assistance COLORADO
4501 Business Park Blvd., Suite 24
Vince Sherry
Anchorage, AK 99503
Drug Rebate Manager
T: 907/334-2409
Department of Health Care Policy and Financing
F: 907/561-1684
1570 Grant Street
E-mail: amanda.burger@health.state.ak.us
Denver, CO 80203
T: 303/866-5408
ARIZONA F: 303/866-2573
E-mail: vince.sherry@state.co.us
Dell Swan
Pharmacy Program Administrator
AHCCCS CONNECTICUT
801 East Jefferson Street Mark Heuschkel
MD 400 Lead Planning Analyst - Pharmacy
Phoenix, AZ 85034 Department of Social Services
612/417-4000 Medical Operations Unit
E-mail: dwswan@ahcccs.state.az.us 25 Sigourney Street
Hartford, CT 06106
ARKANSAS T: 860/424-5347
F: 860/424-5206
Suzette Bridges, P.D., Administrator E-mail: mark.heuschkel@po.state.ct.us
Pharmacy Program
Department of Human Services
Division of Medical Services DELAWARE
Pharmacy Program Frank Long
P.O. Box 1437, Slot 415 Contracts Manager
Little Rock, AR 72203-1437 DSS
T: 501/683-4120 Herman Holloway Campus
F: 501/683-4124 Lewis Building
E-mail: suzette.bridges@medicaid.state.ar.us 1901 North DuPont Highway
New Castle, DE 19720
T: 302/255-9624
F: 302/255-4425

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National Pharmaceutical Council Pharmaceutical Benefits 2003

DISTRICT OF COLUMBIA IDAHO


Donna Bovell, R.Ph. Mary Wheatly
Pharmacist Consultant Pharmacy Services Specialist
Department of Health Department of Health and Welfare
Medical Assistance Administration Division of Medicaid
825 North Capitol Street, NE 3232 Elder
5th Floor Boise, ID 83705
Washington, DC 20002 T: 208/364-1832
T: 202/442-5988 F: 208/364-1864
F: 202/442-4790 E-mail: wheatlem@idhw.state.id.us
E-mail: donna.bovell@dcgov.org

ILLINOIS
FLORIDA
Bradley Wallner
Jason Ottinger
Manager
Rebate Coordinator
Illinois Department of Public Aid
Agency for Health Care Administration
2200 Churchill Road
2727 Mahan Dr., MS 38
Springfield, IL 62704
Tallahassee, FL 32308
217/785-6114
T: 850/922-7794
E-mail: dpa_webmaster@state.il.us
F: 850/922-0685
E-mail: ottingej@fdhc.state.fl.us
INDIANA
GEORGIA Martha Kessenich
Rebate Accounting Manager
Patricia Zeigler Jeter, M.P.A., R.Ph.
Indiana State Healthcare
Pharmacist
365 Northridge Rd., Suite 400
Pharmacy Services Unit, Program Policy Section
Atlanta, GA 30350
Division of Medical Assistance
T: 770/730-3292
2 Peachtree St., NW, 37th Floor
F: 866/759-4100
Atlanta, GA 30303
E-mail: martha.kessenich@acs-inc.com
T: 404/657-9181
F: 404/656-8366
E-mail: pjeter@dch.state.ga.us IOWA
Rocco Russo
HAWAII Third Party Liability Manager
Lynn S. Donovan, R.Ph. ACS
Pharmacy Consultant P.O. Box 14422
Department of Human Services Des Moines, IA 50306-3422
Med-Quest Division T: 515/327-0950 Ext. 1114
601 Kanokila Boulevard, Suite 506B F: 515/327-0945
Kapolei, HI 96707
T: 808/692-8116
F: 808/692-8131
Internet address: www.med-quest.us

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National Pharmaceutical Council Pharmaceutical Benefits 2003

KANSAS MARYLAND
Mary H. Obley Alex Taylor
Pharmacist First Health Services Corporation
Pharmacy Program Manager Montgomery Park Business Center
Health Care Policy Division 1800 Washington Boulevard, Suite 420
KS Dept of Social and Rehabilitation Services Baltimore, MD 21230
Docking State Office Building T: 443/263-7048
915 SW Harrison, Room 651-South F: 443/263-7062
Topeka, KS 66612-1570
T: 785/296-8406
MASSACHUSETTS
F: 785/296-4813
E-mail: mho@srskansas.org Martha Kessenich
Rebate Accounting Manager
ACS State Healthcare
KENTUCKY
365 Northridge Road, Suite 400
Betsy Scott Atlanta, GA 30350
Department for Medicaid Services 800/358-2381
CHR Building, 6 E-B
275 E. Main St.
MICHIGAN
Frankfort, KY 40621
T: 502/564-5472 Dawn Parsons
F: 502/564-0223 Pharmacy Consultant
E-mail: Betsy.Scott@ky.gov MDCH/ Medical Services Administration
400 South Pine Street
P.O. Box 30479
LOUISIANA
Lansing, MI 48909-7979
Timothy T. Williams T: 517/335-5181
Health Services Financing F: 517/241-8135
Program Director E-mail: parsonsd@michigan.gov
Department of Health and Hospitals
1201 Capitol Access Road, 6th Floor
P.O. Box 91030 MINNESOTA
Baton Rouge, LA 70821 Jarvis P. Jackson, R.Ph.
T: 225/342-5194 Drug Rebate Coordinator
F: 225/342-1980 Dept. of Human Services
E-mail: ttwilliams@dhh.la.gov 444 Lafayette Rd. North
St. Paul, MN 55155-3853
T: 651/282-5881
MAINE
F: 651/282-6744
Rossi Rowe E-mail: jarvisp.jackson@state.mn.us
Insurance Recovery/ Drug Rebate Manager
Department of Human Services MISSISSIPPI
Bureau of Medical Services
11 SHS, 442 Civic Center Drive Glenda Grant
Augusta, ME 04333 Division of Medicaid
T: 207/287-1838 Robert E. Lee Building
F: 207/287-1788 239 North Lamar St., Suite 801
E-mail: rossi.rowe@maine.gov Jackson, MS 39201
601/359-6050
E-mail: acgag@medicaid.state.ms.us

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National Pharmaceutical Council Pharmaceutical Benefits 2003

MISSOURI NEW HAMPHSHIRE


Lynn Hebenheimer John Cox
Medicaid Unit Supervisor Rebate Pharmacist
Division of Medical Services First Health Services Corp.
Drug Rebate Unit 4300 Cox Road
P.O. Box 6500 Glen Allen, VA 23060
Jefferson City, MO 65102 T: 800/884-2822
T: 573/526-5664 F: 804/965-7647
F: 573/522-2594 E-mail: coxjo@fhsc.com
E-mail: lynn.hebenheimer@dss.mo.gov
NEW JERSEY
MONTANA
Edward J. Vaccaro, R.Ph.
Betty DeVaney Assistant Director
Drug Rebate Coordinator Office of Utilization Management
Dept. of Public Health and Human Services Division of Medical Assistance and Health Services
Medicaid Services Bureau P.O. Box 712, Bldg 11-A
1400 Broadway Trenton, NJ 08625
P.O. Box 202951 T: 609/588-2726
Helena, MT 59620-2951 F: 609/588-3889
T: 406/444-3457 E-mail: ejvaccaro@dhs.state.nj.us
F: 406/444-1861
E-mail: bdevaney@state.mt.us
NEW MEXICO
Delfinia Sandoval
NEBRASKA
Human Services Department
Karen Jaques ASD
Accountant II 729 St. Michaels Drive
HHSS-Finance and Support Santa Fe, NM 87504-2348
301 Centennial Mall South T: 505/476-8920
NSOB, 5th Floor F: 505/827-1147
P.O. Box 95026 E-mail: delfinia.sandoval@state.nm.us
Lincoln, NE 68509-5026
F: 402/471-9397
E-mail: karen.jaques@hhss.state.ne.us NEW YORK
Mark-Richard A. Butt, M.S., R.Ph.
NEVADA Director, Pharmacy Policy and Operations
Bureau of Program Guidance
Dionne Coston, R.N.
Office of Medicaid Management
Medicaid Services Specialist
NYS Department of Health
Nevada Medicaid Office
99 Washington Ave., Suite 606
Pharmacy Program
Albany, NY 12210
1100 E. Williams Street
T: 518/474-9219
Carson City, NV 89701
F: 518/473-5508
T: 775/684-3775
E-mail: mrb01@health.state.ny.us
F: 775/684-3762
E-mail: dcpstpm@dhcfp.state.nv.us

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National Pharmaceutical Council Pharmaceutical Benefits 2003

NORTH CAROLINA OREGON


Sharon Greeson, R.Ph. Jim Rowland
Pharmacy Program Manager Account Manager
EDS First Health Sevices Corporation
4905 Waters Edge Dr. 925 Commercial Street SE, Suite 350
Raleigh, NC 27606 Salem, OR 97301-2460
T: 919/816-4475 T: 503/391-1980
F: 919/816-4399 F: 503/391-1979
E-mail: sharon.greeson@eds.com E-mail: rowlanji@fhsc.com

NORTH DAKOTA PENNSYLVANIA


Brendan K. Joyce, Pharm.D., R.Ph. Louis J. Cappello
Administrator, Pharmacy Services Pharmacy Consultant
Department of Human Services Office of Medical Assistance Programs
600 East Boulevard Ave. 701 Crosby Street, Suite A
Department 325 Chester, PA 19013
Bismarck, ND 58505-0250 T: 610/447-5385
T: 701/328-1544 F: 610/447-5385
F: 701/328-1544 E-mail: lcappello@state.pa.us
E-mail: sojoyb@state.nd.us
RHODE ISLAND
OHIO
Paula J. Avarista, R.Ph.
Robert P. Reid, R.Ph. Chief of Pharmacy
Administrator, Pharmacy Services Unit Department of Human Services
Ohio Department of Job and Family Services 600 New London Avenue
Bureau of Health Plan Policy Cranston, RI 02919
30 East Broad Street, 27th Floor T: 401/462-6390
Columbus, OH 43215-3414 F: 401/462-6336
T: 614/466-6420 E-mail: pavarista@dhs.ri.gov
F: 614/466-2908
E-mail: reidr@odjfs.state.oh.us
SOUTH CAROLINA
Caroline Y. Sojurner, R.Ph.
OKLAHOMA
Department Head
Tom Simonson Department of Pharmacy Services
Drug Rebate Manager S.C. Department of Health & Human Services
Oklahoma Health Care Authority P.O. Box 8206
4545 N. Lincoln Blvd, Suite 124 Columbia, SC 29202-8206
Oklahoma City, OK 73105-9901 T: 803/898-2876
T: 405/522-7327 F: 803/255-8353
F: 405/522-3236 E-mail: sojurne@dhhs.state.sc.us
E-mail: simonsoT@ohca.state.ok.us

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National Pharmaceutical Council Pharmaceutical Benefits 2003

SOUTH DAKOTA VIRGINIA


Helen Rokusek Javier Menendez, R.Ph.
Rebate Coordinator Pharmacy Manager
SD Dept. of Social Services Department of Medical Assistance Services
700 Governors Drive 600 East Broad Street, Suite 1300
Pierre, SD 57501 Richmond, VA 23219
605/773-3653 T: 804/786-2196
F: 804/786-0973
TENNESSEE E-mail: javier.menendez@dmas.virginia.gov

Sybil Creekmore
Accounting Manager WASHINGTON
Bureau of TennCare Connie Riddle
729 Church Street Medical Assistance Administration, DSHS
Nashville, TN 37247-6501 P.O. Box 45503
T: 615/741-0213 Lacey, WA 98504-5503
F: 615/253-5481 360/725-1243
E-mail: sybil.creekmore@state.tn.us E-mail: riddle1@dshs.wa.gov

TEXAS WEST VIRGINIA


Heather Murphy Gail Goodnight, R.Ph.
Manager, Pharmacy Rebates Rebate Coordinator
Vendor Drug Program Bureau for Medical Services
Texas Health and Human Services Commission Office of Pharmacy Services
1100 West 49th Street 350 Capitol Street, Room 251
Austin, TX 78745 Charleston, WV 25301-3709
T: 512/491-1163 T: 304/558-1700
F: 512/491-1960 F: 304/558-1542
E-mail: heather.murphy@hhsc.state.tx.us E-mail: gailgoodnight@wvdhhr.org

UTAH WISCONSIN
Raedell Ashley, R.Ph. Ellen Orsburne
Pharmacy Director Medicaid Systems Analyst
Division of Health Care Financing Division of Health Care Financing
P.O. Box 143102 Department of Health and Family Services
Salt Lake City, UT 84114-3102 One West Wilson Street
T: 801/538-6495 P.O. Box 309
F: 801/538-6099 Madison, WI 53701-0309
E-mail: rashley@utah.gov 608/267-7939
E-mail: orsbuer@dhfs.state.wi.us
VERMONT
Christine Dapkiewicz WYOMING
Drug Rebate Coordinator Sheila McInerney
312 Hurricane Lane, Suite 101 TPL Manager
Williston, VT 05495 ACS
T: 802/879-4450 P.O. Box 667
F: 802/878-3440 Cheyenne, WY 82003
T: 307/772-8400
F: 307/772-8405

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STATE OFFICIALS -- 2004

ALABAMA ALASKA ARIZONA


Governor Governor Governor
Honorable Bob Riley Honorable Frank Murkowski Honorable Janet Napolitano
State Capitol P.O. Box 110001 State Capitol
600 Dexter Avenue Juneau, AK 99811-0001 1700 W. Washington
Montgomery, AL 36103 T: 907/465-3500 Phoenix, AZ 85007
T: 334/242-7100 F: 907/465-3532 T: 602/542-4331
F: 334/353-0004 E-mail: governor@gov.state.ak.us F: 602/542-1381
E-mail: Internet address: E-mail: azgov@azgov.state.az.us
governor@governor.state.al.us www.gov.state.ak.us Internet address:
Internet address: www.governor.state.az.us
www.governor.state.al.us Single State Agency Director
Mr. Joel Gilbertson, Commissioner Single State Agency Director
Single State Agency Director Department of Health and Social Ms. Phyllis Beidess, Director
Mr. Mike Lewis, Commissioner Services Arizona Health Care Cost
Alabama Medicaid Agency P.O. Box 110601 Containment System
501 Dexter Avenue 350 Main Street, Room 229 80l East Jefferson Street
P.O. Box 5624 Juneau, AK 99811-0601 Phoenix, AZ 85034
Montgomery, AL 36103-5624 T: 907/465-3030 T: 602/417-4680
T: 334/242-5600 F: 907/465-3068 F: 602/252-6536
F: 334/242-0556 E-mail: E-mail:
E-mail: joel_gilbertson@health.state.ak.us PXBiedess@ahccs.state.az.us
ALmedicaid@medicaid.state.al.us Internet address: Internet address:
Internet address : www.hss.state.ak.us www.ahcccs.state.az.us
www.medicaid.state.al.us
Medicaid Director Medicaid Director
Medicaid Director Mr. Dwayne Peeples, Director Ms. Phyllis Beidess, Director
Mr. Mike Lewis, Commissioner Division of Medical Assistance Arizona Health Care Cost
Alabama Medicaid Agency Department of Health and Social Containment System
501 Dexter Avenue Services 801 East Jefferson Street
P.O. Box 5624 P.O. Box 110660 Phoenix, AZ 85034
Montgomery, AL 36103-5624 Juneau, AK 99811-0660 T: 602/417-4680
T: 334/242-5600 T: 907/465-3355 F: 602/252-6536
F: 334/242-0556 F: 907/465-2204 E-mail:
E-mail: E-mail: PXBiedess@ahcccs.state.az.us
Almedicaid@medicaid.state.al.us dwayne_peeples@health.state.ak.us Internet address:
Internet address: www.ahcccs.state.az.us
www.hss.state.ak.us/dma

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ARKANSAS CALIFORNIA COLORADO


Governor Governor Governor
Honorable Mike Huckabee Honorable Arnold Schwarzenegger Honorable Bill Owens
State Capitol Building State Capitol, First Floor State Capitol
Room 250 Sacramento, CA 958l4 Room 136
Little Rock, AR 72201 T: 916/445-2841 Denver, CO 80203-1792
T: 501/682-2345 F: 916/445-4633 T: 303/866-2471
F: 501/682-3597 E-mail: governor@governor.ca.gov F: 303/866-2003
E-mail: mike.huckabee@state.ar.us Internet address: E-mail:
Internet address: www.governor.ca.gov/state/govsite/ governorowens@state.co.us
www.state.ar.us/governor/staff.htm gov_hompage.jsp Internet address:
l www.state.co.us/gov_dir/governor
Single State Agency Director _office.html
Single State Agency Director Mr. Richard Bayquen, Chief Deputy
Mr. Kurt Knickrehm, Director Mr. Tom McCaffrey, Chief Deputy Single State Agency Director
Department of Human Services Department of Health Services Ms. Marva Livingston Hammons
P.O. Box 1437, Slot 201 1501 Capitol Avenue Executive Director
Little Rock, AR 72203-1437 Sacramento, CA 95899 Department of Human Services
T: 501/682-8650 T: 916/440-7400 l575 Sherman Street
F: 501/682-6836 F: 916/657-5183 Denver, CO 80203-1714
E-mail: kurt.knickrehm@state.ar.us E-mail: dbayquen@dhs.ca.gov T: 303/866-5700
Internet address: Internet address: F: 303/866-4047
www.accessarkansas.org/dhs www.dhs.cahwnet.gov E-mail:
Marva.hammons@state.co.us
Medicaid Director Medicaid Director Internet address:
Mr. Roy Jeffus, Director Mr. Stan Rosenstein, Deputy www.cdhs.state.co.us
Division of Medical Services, Director
Dept. of Human Services Medical Care Services Medicaid Director
P.O. Box 1437, Slot 1100 Department of Health Services Ms. Karen K. Reinertson
Little Rock, AR 72203-1437 1501 Capitol Avenue Executive Director
T: 50l/682-1671 P.O. Box 997413, MS 4000 Department of Health Care Policy
F: 501/682-1197 Sacramento, CA 95899-7413 and Financing
E-mail: T: 916/440-7800 1570 Grant Street
roy.jeffus@medicaid.state.ar.us F: 916/440-7805 Denver, CO 80203-1818
Internet address: E-mail: srosenst@dhs.ca.gov T: 303/866-2993
www.medicaid.state.ar.us Internet address: www.medi- F: 303/866-4411
cal.ca.gov E-mail:
karen.reinertson@state.co.us
Internet address:
www.chcpf.state.co.us

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CONNECTICUT DELAWARE DISTRICT OF COLUMBIA


Governor Governor Mayor
Honorable John G. Rowland Honorable Ruth Ann Minner Honorable Anthony A. Williams
State Capitol, Room 210 Tatnall Building John A. Wilson Building
Hartford, CT 06l06 William Penn Street 1350 Pennsylvania Avenue, NW
T: 860/566-4840 Dover, DE 19901 Washington, DC 20004
F: 820/524-7395 T: 302/744-4101 T: 202/727-2980
E-mail: F: 302/739-2775 F: 202/727-6561
governor.rowland@po.state.ct.us E-mail: gminner@state.de.us E-mail: mayor@dc.gov
Internet address: Internet address: Internet address: www.dc.gov
www.state.ct.us/governor www.state.de.us/governor
Single State Agency Director
Single State Agency Director Single State Agency Director Mr. James A. Buford, Director
Ms. Patricia Wilson-Coker, Mr. Vincent P. Meconi, Secretary Department of Health
Commissioner Department of Health and Social 825 North Capitol Street, NE
Department of Social Services Services Fourth Floor
25 Sigourney Street 1901 North DuPont Highway Washington, DC 20002
Hartford, CT 06106-5033 New Castle, DE l9720 T: 202/442-5999
T: 860/424-5008 T: 302/255-9040 F: 202/442-4788
F: 860/566-2022 F: 302/255-4429 E-mail: james.buford@dc.gov
E-mail: pat.wilson- E-mail: vmeconi@state.de.us Internet address:
coker@po.state.ct.us Internet address: www.dchealth.dc.gov
Internet address: www.state.de.us/dhss
www.dss.state.us.ct Medicaid Director
Medicaid Director Mr. Robert Maruca
Medicaid Director Mr. Philip Soulé Senior Deputy Director
Mr. David Parella, Deputy Medicaid Division/Deputy Director Medical Assistance Administration
Commissioner Department of Health and Social Department of Health
Department of Social Services Services 825 North Capitol Street, NE
25 Sigourney Street Lewis Building Fifth Floor
Hartford, CT 06106-5116 1901 North DuPont Highway Washington, DC 20002
T: 860/424-5116 New Castle, DE 19720 T: 202/442-5988
F: 860/424-5114 T: 302/255-9501 F: 202/442-4790
E-mail: F: 302/255-4425 E-mail: robert.maruca@dc.gov
david.parrella@po.state.ct.us E-mail: psoule@state.de.us Internet address:
Internet address: Internet address: www.dchealth.dc.gov
www.dss.state.ct.us www.state.de.us/dhss

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FLORIDA GEORGIA GUAM


Governor Governor Governor
Honorable Jeb Bush Honorable Sonny Purdue Honorable Felix Comacho
The State Capitol 203 State Capitol Adelup Complex
Tallahassee, FL 32399-0001 Atlanta, GA 30334 P.O. Box 2950
T: 850/488-4441 T: 404/656-l776 Agana, GU 96932
F: 850/487-0801 F: 404/657-7332 T: 671/479-2002
E-mail: governor@myflorida.com E-mail: governor@gov.state.ga.us F: 671/479-2009
Internet address: Internet address: E-mail: governor@mail.gov.gu
www.myflorida.com/b_eog/owa/b_ www.gagovernor.org Internet address:
eog_www.html.main_page www.gov.gu/webtax/govoff.html
Single State Agency Director
Single State Agency Director Mr. Gary Redding, Commissioner Single State Agency Director
Vacant Department of Community of Health Mr. Peter John B. Comacho,
Agency for Health Care 2 Peachtree Street, NW Administrator
Administration Suite 4043 Dept. of Public Health and Social
2727 Mahan Drive, Mail Stop 1 Atlanta, GA 30303-3159 Services
Tallahassee, FL 32308 T: 404/656-4507 P.O. Box 2816
T: 850/922-3809 F: 404/651-6880 Agana, GU 96932
F: 850/488-0043 E-mail: gredding@dma.state.ga.us T: 671/735-7102
E-mail: Internet address: F: 671/734-5910
AHCAcontact@fdhc.state.fl.us www.dch.state.ga.us E: mail:
Internet address: director@dphss.govguam.net
www.fdhc.state.fl.us Medicaid Director
Mr. Mark Trail, Director Medicaid Director
Medicaid Director Department of Community Health Ms. Ma Theresa Arcangel, Acting
Mr. Bob Sharpe, Deputy Secretary Medical Assistance Division Administrator
Agency for Health Care 2 Peachtree Street, NW Bureau of Health Care Financing
Administration Suite 4043 Department of Public Health and
2727 Mahan Drive, Mail Stop 8 Atlanta, GA 30303-3159 Social Services
Tallahassee, FL 32308 T: 404/656-4496 P.O. Box 28l6
T: 850/488-3560 F: 404/651-6880 Agana, GU 96910
F: 850/488-2520 E-mail: mtrail@dma.state.ga.us T: 671/735-7282
E-mail: Internet address: F: 671/734-5910
AHCAcontact@fdhc.state.fl.us www.dch.state.ga.us
Internet address:
www.fdhc.state.fl.us

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HAWAII IDAHO ILLINOIS


Governor Governor Governor
Honorable Linda Lingle Honorable Dirk Kempthorne Honorable Rod Blagojevich
State Capitol P.O. Box 83720 207 Capitol Building
415 S. Beretania Street Boise, ID 83720-0034 State Capitol
Honolulu, HI 968l3 T: 208/334-2100 Springfield, IL 62706
T: 808/586-0034 F: 208/334-3454 T: 2l7/782-6830
F: 808/586-0006 E-mail: governer@gov.state.id.us F: 217/782-1853
E-mail: gov@gov.state.hi.us Internet address: E-mail: governor@state.il.us
Internet address: www2.state.id.us/gov/index.htm Internet address:
www.gov.state.hi.us www.state.il.us/gov
Single State Agency Director
Single State Agency Director Mr. Karl Kurtz, Director Single State Agency Director
Ms. Lillian B. Koller Department of Health and Welfare Mr. Barry Maram, Director
Department of Human Services 450 West State Street Department of Public Aid
1390 Miller Street, Room 209 Boise, ID 83720-0036 201 South Grand Avenue, East
Honolulu, HI 96813 T: 208/334-5500 Third Floor
T: 808/586-4997 F: 208/334-6558 Springfield, IL 62794
F: 808/586/4890 E-mail: dhwinfo@idhw.state.id.us T: 2l7/782-1200
E-Mail: lillian.b.koller@hawaii.gov Internet address: F: 217/524-7120
Internet address: www2.state.id.us/dhw E-mail:
www.state.hi.us/dhs directordpa@mail.idpa.state.il.us
Medicaid Director Internet address:
Medicaid Director Mr. Joe Brunson, Administrator www.state.il.us/dpa
Ms. Aileen Hiramastu, Division of Medicaid
Administrator Department of Health and Welfare Medicaid Director (Medical
Med-Quest Division Americana Building Operations)
Department of Human Services P.O. Box 83720 Mr. A. George Hovanec,
P.O. Box 399 Boise, ID 83720-0036 Administrator
Honolulu, HI 96809-0339 T: 208/364-5747 Division of Medical Programs
T: 808/692-8050 F: 208/334-1811 Department of Public Aid
F: 808/586-4890 E-mail: Allynkp@mmis.state.id.us 20l South Grand Avenue, East
E-mail: Internet address: Third Floor
AHiramatsu@medicaid.dhs.state.hi www2.state.id.us/dhw Springfield, IL 62763-0001
.us T: 2l7/782-1200
Internet address: F: 217/524-7979
www.state.hi.us/dhs E-mail:
directordpa@mail.idpa.state.il.us
Internet address:
www.state.il.us/dpa

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INDIANA IOWA KANSAS


Governor Governor Governor
Honorable Frank O’Bannon Honorable Thomas J. Vilsack Honorable Kathleen Sebelius
State House, Room 206 State Capitol Building 2nd Floor
200 W. Washington Street Des Moines, IA 503l9 State Capitol Building
Indianapolis, IN 46204 T: 5l5/28l-0561 Topeka, KS 66612-1590
T: 3l7/232-4567 F: 515/281-6611 T: 785/296-3232
F: 317/232-3443 E-mail: gen.office@igov.state.ia.us F: 785/296-7973
E-mail: fobannon@gov.state.in.us Internet address: E-mail: governor@ink.org
Internet address: www.in.gov/gov www.state.ia.us/governor Internet address:
www.ksgovernor.org
Single State Agency Director Single State Agency Director
Mr. John Hamilton, Secretary Mr. Kevin Concannon, Director Single State Agency Director
Family and Social Services Department of Human Services Ms. Janet Schalansky, Secretary
Administration Hoover State Office Building Kansas Department of Social and
Room 461, Mail Stop 25 Fifth Floor Rehabilitation Services
P.O. Box 7083 Des Moines, IA 503l9-0114 Docking State Office Building
402 W. Washington Street T: 5l5/28l-5452 915 SW Harrison Street
Indianapolis, IN 46207-7083 F: 515/281-4980 Topeka, KS 66612
T: 317/233-4690 E-mail: kconcan@dhs.state.ia.us T: 785/296-3271
F: 317/233-4693 Internet address: F: 785/296-2173
E-Mail: Jhamilton@fssa.state.in.us www.dhs.state.ia.us E-mail: JKS@srskansas.org
Internet address: Internet address:
www.state.in.us/fssa Medicaid Director www.srskansas.org
Mr. Eugene Gessow
Medicaid Director Medicaid Director Medicaid Director
Ms. Melanie Bella, Assistant Division of Medical Services Mr. Robert Day, Commissioner
Secretary Department of Human Services Adult and Medical Services
Medicaid Policy and Planning Hoover State Office Building Department of Social and
Family and Social Services Fifth Floor Rehabilitation Services
Administration Des Moines, IA 503l9-0114 Docking State Office Building
402 W. Washington Street, Room T: 5l5/281-6249 915 SW Harrison Street,
W382 F: 515/281-8512 Room 651 South
Indianapolis, IN 46204-2739 E-mail: egessow@dhs.state.ia.us Topeka, KS 66612
T: 317/233-4455 Internet address: T: 785/296-3981
F: 317/232-7382 www.dhs.state.ia.us F: 785/296-4813
E-mail: mbella@fssa.state.in.us E-mail: rmd@srskansas.org
Internet address: Internet address:
www.state.in.us/fssa www.srskansas.org

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KENTUCKY LOUISIANA MAINE


Governor Governor Governor
Honorable Ernie Fletcher Honorable Kathleen Blanco Honorable John Baldacci
State Capitol Building State Capitol 1 State House Station
700 Capitol Avenue P.O. Box 94004 Augusta, Maine 04333-0001
Frankfort, KY 4060l Baton Rouge, LA 70804 T: 207/287-3531
T: 502/564-2611 T: 225/342-7015 F: 207/287-1034
F: 502/564-2517 F: 225/342-7099 E-mail: governor@state.me.us
E-mail: governor@mail.state.ky.us E-mail: Internet address:
Internet address: www.gov.state.la.us/gov_email.html www.main.gov/governor/baldacci/
www.governor.ky.gov Internet address: index.shtml
www.gov.state.la.us
Single State Agency Director Single State Agency Director
Mr. James W. Holsinger, Jr., M.D. Single State Agency Director Mr. Peter Walsh
Secretary Mr. Frederick P. Cerise, Secretary Acting Commissioner
Cabinet for Health and Family Department of Health and Hospitals Department of Human Services
Services P.O. Box 629, Bin #2 State House Station 11
275 East Main Street, 5W-A Baton Rouge, LA 70821-0629 Augusta, ME 04333-0011
Frankfort, KY 40621 T: 225/342-9500 T: 207/287-2736
T: 502/564-6786 F: 225/342-9508 F: 207/287-3005
F: 502/564-0274 E-mail: fcerise@dhh.state.la.us E-mail: peter.e.walsh@maine.gov
E-mail: Internet address: Internet address:
brandyp.cantor@mail.state.ky.us www.dhh.state.la.us www.main.gov/dhs/index.htm
Internet address:
www.chs.state.ky.us Medicaid Director Medicaid Director
Mr. Ben Bearden, Director Ms. Chris Zukas Lessard, Director
Medicaid Director Bureau of Health Services Financing Bureau of Medical Services
Mr. Mike Robinson, Commissioner Department of Health and Hospitals Department of Human Services
Department for Medicaid Services P.O. Box 91030 State House Station 11
Sixth Floor Baton Rouge, LA 70821-9030 Augusta, ME 04333-0011
275 East Main Street T: 225/342-3891 T: 207/287-2674
Frankfort, KY 40621 F: 225/342-9508 F: 207/287-2675
T: 502/564-4321 E-mail: BBearden@dhhmail.dhh- E-mail:
F: 502/564-0509 state.la.us chris.zukas-lessard@maine.gov
E-mail: Internet address:
mike.robinson@mail.state.ky.us www.dhh.state.la.us/MEDICAID/
Internet address: index.htm
www.chs.ky.gov./dms

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MARYLAND MASSACHUSETTS MICHIGAN


Governor Governor Governor
Honorable Robert Ehrlich Honorable Mitt Romney Honorable Jennifer Granholm
State House Executive Office, State House P.O. Box 30013
Annapolis, MD 21401 Room 360 Lansing, MI 48909
T: 410/974-3901 Boston, MA 02133 T: 5l7/335-7858
F: 410/974-3275 T: 617/727-6250 F: 517/335-6863
E-mail: governor@gov.state.md.us F: 617/727-9725 E-mail: wwwimichigan.gov/gov
Internet address: E-mail: goffice@state.ma.us Internet address:
www.gov.state.md.us www.michigan.gov/gov
Single State Agency Director
Single State Agency Director Mr. Ronald Preston, Secretary Single State Agency Director
Mr. Nelson J. Sabatini Health and Human Services Ms. Janet Olszewski
Secretary Executive Office Director
Department of Health & Mental One Ashburton Place, Room 1109 Michigan Department of
Hygiene Boston, MA 02108 Community Health
Herbert R. O'Connor Building T: 617/727-0077 Lewis Cass Building
201 West Preston Street F: 617/727-5134 320 South Walnut Street
Fifth Floor E-mail: ronald.preston@state.ma.us Lansing, MI 48913
Baltimore, MD 21201 Internet address: www.masscare.org T: 517/335-0267
T: 410/225-6500 F: 517/373-4288
F: 410/161-6489 Medicaid Director E-mail: norris@michigan.gov
E-mail: Ms. Beth Waldman, Director Internet address:
nsabatini@dhmh.state.md.us Office of Medicaid www.michigan.gov/mdch
Internet address: One Ashburton Place, Room 1109
www.dhmh.state.md.us Boston, MA 02108 Medicaid Director
T: 617/573-1770 Mr. Patrick Barrie
Medicaid Director F: 617/573-1894 Deputy Director
Ms. Debbie Chang E-mail: Health Programs Administration
Deputy Secretary for Health Care bwaldman@nt.dma.state.ma.us Michigan Department of
Financing Community Health
Department of Health & Mental 400 S. Pine Street
Hygiene Lansing, MI 48909
201 West Preston Street T: 517/335-5001
Baltimore, MD 21201 F: 517/335-5007
T: 410/767-4664 E-mail: barriep@michigan.gov
F: 410/333-7687 Internet address:
E-mail: Dchang@dhmh.md.state.us www.michigan.gov/mdch
Internet address:
www.dhmh.state.md.us

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MINNESOTA MISSISSIPPI MISSOURI


Governor Governor Governor
Honorable Tim Pawlenty Honorable Haley Barbour Honorable Bob Holden
130 State Capitol State Capitol State Capitol Building, Room 218
St. Paul, MN 55155-1099 P.O. Box 139 P.O. Box 720
T: 651/296-3391 Jackson, MS 39205 Jefferson City, MO 65102-0720
F: 651/296-2089 60l/359-3150 T: 573/751-3222
E-mail: tim.pawlenty@state.mn.us E-mail: F: 573/751-1495
Internet address: www.governor.state.ms.us/aboutthe E-mail:
www.governor.state.mn.us gov/writetoindex.html www.gov.state.mo.us/mail1.htm
Internet address: Internet address:
Single State Agency Director www.governor.state.ms.us www.gov.state.mo.us
Mr. Kevin Goodno,
Commissioner Single State Agency Director Single State Agency Director
Minnesota Department of Human Mr. Donald Taylor Mr. Steve Roling, Director
Services Executive Director Department of Social Services
444 Lafayette Road North Department of Human Services 221 West High Street
St. Paul, MN 55155-3815 750 North State Street P.O. Box 1527
T: 651/296-2701 Jackson, MS 39201-1399 Jefferson City, MO 65102
F: 651/297-3230 T: 601/359-4500 T: 573/751-4815
E-mail: F: 601/359-4910 F: 573/751-3203
commissioner.dhs@state.mn.us E-mail: dtaylor@mdhs.state.ms.us E-mail:
Internet address: Internet address: dlorts@mail.dss.state.mo.us
www.dhs.state.mn.us www.mdhs.state.ms.us Internet address:
www.dss.state.mo.us
Medicaid Director Medicaid Director
Ms. Mary B. Kennedy, Medicaid Mr. Warren A. Jones, M.D. Medicaid Director
Director Executive Director Ms. Christine Rackers, Director
Minnesota Department of Human Division of Medicaid Division of Medical Services
Services Suite 801, Robert E. Lee Building Department of Social Services
444 Lafayette Road 239 North Lamar Street 615 Howerton Court
St. Paul, MN 55l55-3852 Jackson, MS 39201-1399 P.O. Box 6500
T: 651/297-7515 T: 601/359-6050 Jefferson City, MO 65102-6500
F: 651/297-3230 F: 601/359-6048 T: 573/751-3425
E-mail: mary.kennedy@state.mn.us E-mail: F: 573/751-6564
Internet address: exfmp@medicaid.state.ms.us E-mail: crackers@mail.state.mo.us
www.dhs.state.mn.us Internet address: Internet address:
www.mdhs.state.ms.us www.dss.state.mo.us/dms

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MONTANA NEBRASKA
Governor Governor
NEVADA
Honorable Judy Martz Honorable Mike Johanns
State Capitol P.O. Box 94848 Governor
Helena, MT 59620-0801 Lincoln, NE 68509-4848 Honorable Kenny C. Guinn
T: 406/444-3111 T: 402/471-2244 State Capitol
F: 406/444-4151 F: 402/471-6031 Carson City, NV 89710
E-mail: E-mail: jodee@mail.state.ne.us T: 702/684-5670
www.state.mt.us/gov2/css/staff/ Internet address: www.gov.nol.org F: 775/684-5683
contact.asp E-mail:
Internet address: Single State Agency Director www.gov.state.nv.us/mail.gov.htm
www.state.mt.us/governor/css/defa Mr. Stephen Curtiss, Director Internet address:
ult.asp Nebraska Department of Health and www.gov.state.nv.us
Human Services
Single State Agency Director Finance and Support Single State Agency Director
Dr. Gail Gray, Director P.O. Box 95026 Mr. Mike Wilden, Director
Department of Public Health and Lincoln, NE 68509-5026 Department of Human Resources
Human Services T: 402/471-8533 505 East King Street, Room 600
P.O. Box 4210 F: 402/471-9449 Carson City, NV 89710
111 N. Sanders E-mail: T: 775/684-4000
Helena, MT 59604-4210 kelly.ostrander@hhss.state.ne.us F: 775/684-4010
T: 406/444-5622 Internet address: E-mail: slindsey@dhr.state.nv.us
F: 406/444-1970 www.hhs.state.ne.us/fin/finindex.ht Internet address:
E-mail: ggray@state.mt.us m www.hr.state.nv.us
Internet address:
www.dphhs.state.mt.us Medicaid Director Medicaid Director
Mr. Robert J. Seiffert Mr. Chuck Duarte, Administrator
Medicaid Director Administrator Division of Health Care Financing
Mr. John Chappuis Medicaid Division and Policy
Medicaid Director Nebraska Department of HHS 1100 East William Street, Suite
Division of Health Policy and Finance and Support 116
Services P.O. Box 95026 Carson City, NV 89710
Department of Public Health and 301 Centennial Mall South, 5th Floor T: 775/684-3676
Human Services Lincoln, NE 68509-5026 F: 775/687-3893
1400 Broadway T: 402/471-9223 E-mail:
Helena, MT 59601 F: 402/471-9092 cduarte@govmail.state.nv.us
T: 406/444-4141 E-mail: Internet address:
F: 406/444-1861 bob.seiffert@hhss.state.ne.us www.dhcfp.state.nv.us
E-mail: jchappuis@state.mt.us Internet address:
Internet address: www.hhs.state.ne.us/med/medindex.
www.dphhs.state.mt.us/hpsd/index. htm
htm

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NEW JERSEY
NEW HAMPSHIRE NEW MEXICO
Governor
Governor Honorable Jim McGreevey Governor
Honorable Craig Benson 125 West State Street Honorable Bill Richardson
State House State House CN-001 Office of the Governor
Room 208 Trenton, NJ 08625 State Capitol
107 North Main Street T: 609/292-6000 Suite 400
Concord, NH 03301-4990 F: 609/292-3454 Santa Fe, NM 87501
T: 603/271-2121 E-mail: T: 505/476-2200
F: 603/271-5686 www.state.nj.us/governor/govmail. F: 505/476-2226
E-mail: www.state.nh.us/governor/ html E-mail: gov@gov.state.nm.us
comment.html Internet address: Internet address:
Internet address: www.state.nj.us/governor www.governor.state.nm.us
www.state.nh.us/governor
Single State Agency Director Single State Agency Director
Single State Agency Director Ms. Gwendolyn L. Harris, Ms. Pamela Hyde, Secretary
Mr. John Stephen, Commissioner Commissioner New Mexico Human Services
Department of Health and Human Department of Human Services Department
Services P.O. Box 700 P.O. Box 2348
129 Pleasant Street Trenton, NJ 08625 Santa Fe, NM 87504-2348
Concord, NH 03301-3857 T: 609/292-3717 T: 505/827-7750
T: 603/271-4331 F: 609/292-3824 F: 505/827-6286
F: 603/271-4912 E-mail: webmaster@dhs.state.nj.us E-mail: pam.hyde@state.nm.us
E-mail: jstephen@dhhs.state.us Internet address: Internet address:
Internet address: www.state.nj.us/humanservices www.state.nm.us/hsd
www.dhhs.state.nh.us/DHHS/
DHHS_SITE/default.htm Medicaid Director Medicaid Director
Ms. Ann Clemency Kohler, Director Ms. Carolyn Ingram, Director
Medicaid Director Division of Medical Assistance and Medical Assistance Division
Ms. Lori Rea, Director Health Services New Mexico Human Services
Office of Health Planning & Department of Human Services Department
Medicaid P.O. Box 712 P.O. Box 2348
Department of Health and Human Trenton, NJ 08625-0712 Santa Fe, NM 87504-2348
Services T: 609/588-2600 T: 505/827-3100
129 Pleasant Street F: 609/588-3583 F: 505/827-3185
Concord, NH 03301-3857 E-mail: ann.kohler@dhs.state.nj.us E-mail:
T: 603/271-5254 Internet address: carolyn.ingram@state.nm.us
F: 603/271-8431 www.state.nj.us/humanservices/ Internet address:
E-mail: dmahs/index.html www.state.nm.us/hsd/mad/index
www.dhhs.state.nh.us/DHHS/
DHHS_SITE/special/feedback.htm
Internet address:
www.dhhs.state.nh.us/DHHS/
MEDICAIDPROGRAM/
default.htm

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NEW YORK NORTH CAROLINA NORTH DAKOTA


Governor Governor Governor
Honorable George E. Pataki Honorable Mike Easley Honorable John Hoeven
Executive Chamber Office of the Governor Department 101
State Capitol 116 West Jones Street 600 East Boulevard Avenue
Albany, NY 12224 20301 Mail Service Center Bismarck, ND 58505-0001
T: 5l8/474-8390 Raleigh, NC 27699-0301 T: 701/328-2200
F: 518/474-3767 T: 919/733-4240 F: 701/328-2205
E-mail: T: 919/733-5811 E-mail: governor@state.nd.us
gov.pataki@chamber.state.ny.us F: 919/733-2120 Internet address:
Internet address: F: 919/715-3175 www.governor.state.nd.us
www.state.ny.us/governor E-mail:
www.governor.state.nc.us/email.asp Single State Agency Director
Single State Agency Director ?to=1 Ms. Carol Olson, Executive
Antonio C. Novello, M.D., M.P.H., Internet address: Director
Commissioner www.governor.state.nc.us Department of Human Services
NYS Department of Health 600 East Boulevard Avenue,
ESP, Corning Tower Building Single State Agency Director Dept. 325
Albany, NY 12237 Ms. Carmen Hooker Odom, Bismarck, ND 58505-0250
T: 518/474-2011 Secretary T: 701/328-2538
F: 518/474-5450 Department of Health and Human F: 701/328-2359
E-mail: acn01@health.state.ny.us Services E-mail: dhseo@state.nd.us
Internet address: 2001 Mail Service Center Internet address:
www.health.state.ny.us/homens6. Raleigh, NC 27699-2001 www.lnotes.state.nd.us/dhs/dhsweb
html T: 919/733-4534 .nsf
F: 919/715-4645
Medicaid Director E-mail: Medicaid Director
Ms. Kathryn Kuhmerker, Deputy carmen.hookerodom@ncmail.net Mr. David J. Zentner, Director
Director Internet address: Division of Medical Assistance
NYS Department of Health www.dhhs.state.nc.us Department of Human Services
Office of Medicaid Management 600 East Boulevard Avenue,
Empire State Plaza Medicaid Director Dept. 325
Room 1466, Corning Tower Mr. Gary Fuquay, Interim Director Bismarck, ND 58505-0261
Building Division of Medical Assistance T: 701/328-2321
Albany, NY 12237 Department of Health and Human F: 701/328-1544
T: 518/474-3018 Services E-mail: dhsmed@state.nd.us
F: 518/486-6852 2501 Mail Service Center Internet address:
E-mail: kk03@health.state.ny.us Raleigh, NC 27699-2501 www.lnotes.state.nd.us/dhs/dhsweb
Internet address : T: 919/857-4011 .nsf
www.health.state.ny.us/nysdoh/ F: 919/733-6608
medicaid/medicaid.htm E-mail: gary.fuquay@ncmail.net
Internet address:
www.dhhs.state.nc.us/dma

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NORTHERN MARIANA OHIO OKLAHOMA


ISLANDS Governor
Governor
Governor Honorable Bob Taft Honorable Brad Henry
Honorable Juan N. Babauta 77 South High Street, 30th Floor 212 State Capitol
Commonwealth of the Northern Columbus, OH 43215-6117 2300 N. Lincold Boulevard
Mariana Islands T: 614/466-3555 Oklahoma City, OK 73105
Caller Box 10007 F: 614/466-9354 T: 405/521-2342
Capitol Hill E-mail: F: 405/521-3353
Saipan, MP 96950 governor.taft@das.state.oh.us E-mail: governor@gov.state.ok.us
670/322-5091 Internet address: Internet address:
www.state.oh.us/gov www.governor.state.ok.us
Single State Agency Director
Dr. James Hofschneider Single State Agency Director Single State Agency Director
Secretary for Health Services Mr. Tom Hayes, Director Mike Fogarty, J.D.
Department of Public Health and Ohio Department of Job and Family Director
Environmental Services Services Oklahoma Health Care Authority
Commonwealth of the Northern 30 East Broad Street, 32nd Floor 4545 North Lincoln Boulevard
Mariana Islands Columbus, OH 43215-3414 Suite 124
P.O. Box 409 CK T: 614/466-6282 Oklahoma City, OK 73105
Saipan, MP 96950 F: 614/466-2815 T: 405/522-7300
670/234-8950 E-mail: hayest01@odjfs.state.oh.us F: 405/522-7187
Internet address: www.jfs.ohio.gov E-mail: fogartym@ohca.state.ok.us
Medicaid Director Internet address:
Ms. Maria Sablan, Medical Medicaid Director www.ohca.state.ok.us
Administrator Ms. Barbara Coulter Edwards,
Department of Public Health and Deputy Director Medicaid Director
Environmental Services Ohio Health Plans Lynn Mitchell, M.D.
Commonwealth of the Northern Ohio Department of Job and Family Oklahoma Health Care Authority
Mariana Islands Services 4545 North Lincoln Boulevard
P.O. Box 409 CK 30 East Broad Street, 31st Floor Suite 124
Saipan, MP 96950 Columbus, OH 43215-3414 Oklahoma City, OK 73105
T: 670/664-4880 T: 614/466-0140 T: 405/522-7365
F: 670/664-4885 F: 614/752-3986 F: 405/530-3218
E-mail: Medicaid@odhs.state.oh.us E-mail: mitchelll@ohca.state.ok.us
Internet address : Internet address:
www.state.oh.us/odjfs/ohp www.ohca.state.ok.us

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OREGON PENNSYLVANIA PUERTO RICO


Governor Governor Governor
Honorable Ted Kulongoski Honorable Ed Rendell Honorable Sila Maria Calderon
State Capitol 25 Main Capitol Building La Fortaleza
900 Court Street NE Harrisburg, PA 17120 P.O. Box 82
Salem, OR 97310-4047 T: 717/787-2500 San Juan, PR 00901
T: 503/378-3111 F: 717/772-8284 809/721-7000
F: 503/378-4863 E-mail:
E-mail: www.governor.state.or.us/ www.state.pa.us/pa_exec/governor/ Single State Agency Director
Contact.htm govmail.html John Rullan, M.D.
Internet address: Internet address: Secretary
www.governor.state.or.us www.state.pa.us/governor Department of Health
G.P.O. Box 70184
Single State Agency Director Single State Agency Director San Juan, PR 00936
Ms. Jean Thorne, Director Ms. Estelle B. Richman, Acting 787/7274-7676
Department of Human Resources Secretary
500 Summer Street, NE Department of Public Welfare Medicaid Director
Human Resources Building, E15 Health and Welfare Building Mr. William Gonzalez, Director
Salem, OR 97301 P.O. Box 2675 Office of Economic Assistance to
T: 503/945-5944 Harrisburg, PA 17105-2675 The Medically Indigent
F: 503/378-2897 T: 717/787-2600 Department of Health
E-mail: jean.i.thorne@state.or.us F: 717/772-2062 G.P.O. Box 70184
Internet address: E-mail: ra-dpwsecretarynet San Juan, PR 00936
www.dhs.state.or.us @state.pa.us T: 787/765-1230, ext. 200
Internet address: F: 787/250-0990
Medicaid Director www.dpw.state.pa/us E-mail: wgonzalez@salvd.gov.pr
Ms. Lynn Read, Director
Office of Medical Assistance Medicaid Director
Programs Mr. David S. Feinberg
Department of Human Services Deputy Secretary
500 Summer Street, NE, E37 Office of Medical Assistance
Salem, OR 97301 Programs
T: 503/945-5772 Department of Public Welfare
F: 503/373-7689 Health and Welfare Building,
E-mail: lynn.read@state.or.us Room 515
Internet address: P.O. Box 2675
www.dhs.state.or.us/healthplan Harrisburg, PA 17105-2675
T: 717/787-1870
F: 717/787-4639
E-mail: pamedicaid2@state.pa.us
Internet address:
www.dpw.state.pa.us/omap

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RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA


Governor Governor Governor
Honorable Don Carcieri Honorable Mark Sanford Honorable Mike Rounds
222 State House P.O. Box 12267 500 East Capitol
Providence, RI 02903-1196 Columbia, SC 29211 Pierre, SD 57501
T: 401/222-2080 T: 803/734-2100 T: 605/773-3212
F: 401/222-8096 F: 803/734-5167 F: 605/773-4711
E-mail: rigov@gov.state.ri.us E-mail: E-mail: sdgov@gov.state.sd.us
Internet address: governor@govoepp.state.sc.us Internet address:
www.governor.state.ri.us Internet address: www.state.sd.us/governor
www.state.sc.us/governor
Single State Agency Director Single State Agency Director
Ms. Jane Hayward, Director Single State Agency Director Mr. James W. Ellenbecker,
Department of Human Services Mr. Robert Kerr, Director Secretary
600 New London Avenue Department of Health and Human Department of Social Services
Cranston, RI 02920 Services Richard F. Kneip Building
T: 401/462-2121 1801 Main Street 700 Governors Drive
F: 401/462-3677 P.O. Box 8206 Pierre, SD 57501-2291
E-mail: Columbia, SC 29202-8206 T: 605/773-3165
jhayward@gw.dhs.state.ri.us T: 803/898-2504 F: 605/773-4855
Internet address: F: 803/898-4515 E-mail: dssinfo@.state.sd.us
www.dhs.state.ri.us E-mail: malonel@dhhs.state.sc.us Internet address:
Internet address: www.state.sd.us/social
Medicaid Director www.dhhs.state.sc.us
Mr. John C. Young, C.P.M. Medicaid Director
Associate Director Medicaid Director Mr. Damian Prunty, Adninistrator
Division of Medical Services Mr. Robert Kerr, Director Medical Services
Department of Human Services Department of Health and Human Department of Social Services
600 New London Avenue Services Richard F. Kneip Building
Cranston, RI 02920 1801 Main Street 700 Governors Drive
T: 401/462-3575 P.O. Box 8206 Pierre, SD 57501-2291
F: 401/462-6338 Columbia, SC 29202-8206 T: 605/773-3495
E-mail: Jyoung@gw.dhs.state.ri.us T: 803/898-2504 F: 605/773-5246
Internet address: F: 803/898-4515 E-mail: medical@state.sd.us
www.dhs.state.ri.us E-mail: malonel@dhhs.state.sc.us Internet address:
Internet address: www.state.sd.us/social/medical
www.dhhs.state.sc.us

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TENNESSEE TEXAS UTAH


Governor Governor Governor
Honorable Phil Brendsen Honorable Rick Perry Honorable Olene S. Walker
State Capitol, First Floor State Capitol 210 State Capitol
Nashville, TN 37243-0001 P.O. Box 12428 Salt Lake City, UT 84114
T: 615/741-2001 Austin, TX 78711 T: 801/538-1000
F: 615/532-9711 T: 5l2/463-2000 F: 801/538-1528
E-mail: phil.brendsen@state.tn.us F: 512/463-1849 E-mail: governor@utah.gov
Internet address: E-mail: Internet address:
www.state.tn.us/governor www.governor.state.tx.us/contact www.utah.gov/governor
Internet address:
Single State Agency Director www.governor.state.tx.us Single State Agency Director
Ms. Gina Lodge, Commissioner Mr. Scott D. Williams, Executive
Department of Human Services Single State Agency Director Director
400 Deaderick Street, 15th Floor Mr. Albert Hawkins, Commissioner Department of Health
Nashville, TN 37248-0001 Health and Human Services P.O. Box 141000
T: 615/313-4700 Commission Salt Lake City, UT 84114-1000
F: 615/741-4165 4900 N. Lamar Boulevard T: 801/538-6111
E-mail: P.O. Box 13247 F: 801/538-6306
humanservices.webmaster@ Austin, TX 78751 E-mail: scottwilliams@utah.gov
state.tn.us T: 5l2/424-6502 Internet address:
Internet address: F: 512/424-6587 www.hlunix.hl.state.ut.us
www.state.tn.us/humanserv E-mail: contact@hhsc.state.tx.us
Internet address: Medicaid Director
Medicaid Director www.hhsc.state.tx.us Mr. Michael Deily, Director
Mr. Manny Martins Department of Health
Deputy Commissioner Medicaid Director Division of Health Care Financing
Department of Finance and Mr. Jason Cooke P.O. Box 14301
Administration Associate Commissioner for Salt Lake City, UT 84114-3101
Bureau of TennCare Medicaid T: 801/538-6406
729 Church Street Health and Human Services F: 801/538-6099
Nashville, TN 37247 Commission E-mail: mdeily@utah.gov
T: 615/741-0213 4900 N. Lamar Boulevard, 4th Floor Internet address: www.hlunix.
F: 615/741-0882 P.O. Box 13247 Ex.state.ut.us/medicaid
E-mail: many.martins@state.tn.us Austin, TX 78751
Internet address: T: 512/424-6517
www.state.tn.us/tenncare F: 512/424-6587
E-mail: medicaid@hhsc.state.tx.us
Internet address:
www.hhsc.tx.us/medicaid

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VIRGINIA
VERMONT Governor VIRGIN ISLANDS
Honorable Mark Warner
Governor State Capitol Building, Third Floor Governor
Honorable James Douglas Richmond, VA 232l9 Honorable Charles Turnbull
109 State Street T: 804/786-2211 Government House
Montpelier, VT 05609 F: 804/692-0121 21-22 Kongens Gada Street
T: 802/828-3333 E-mail: Charlotte Amalie
F: 802/828-3339 www.governor.state.va.us/contact/ St. Thomas, VI 00802
Internet address: email_form.html T: 340/774-0001
www.gov.state.vt.us Internet address: F: 340/776-4912
www.governor.state.va.us E-mail: rcanton@govhouse.gov.vi
Single State Agency Director Internet address: www.gov.vi
Mr. Charlie Smith, Secretary Single State Agency Director
Agency of Human Services Ms. Jane H. Woods, Secretary Single State Agency Director
103 South Main Street Office of The Secretary of Health Ms. Darlene A Carty
Waterbury, VT 05671-0201 and Human Resources Commissioner of Health
T: 802/241-2220 202 N. Ninth Street, Suite 622 Virgin Islands Department of
F: 802/241-2979 P.O. Box 1475 Health
E-mail: Richmond, VA 23219 48 Sugar Estate
charlies@wpgate1.aah.state.vt.us T: 804/786-7765 St. Thomas, VI 00802
Internet address: F: 804/371-6984 T: 340/774-0117
www.ahs.state.vt.us E-mail: shhr@gov.state.va.us F: 340/777-4001
Internet address : E-mail: darlene.carty@usvi-
Medicaid Director www.hhr.state.va.us doh.org
Mr. Joshua Slen, Medicaid Director
Department of Prevention, Medicaid Director Medicaid Director
Transition, and Health Access Mr. Patrick Finnerty, Director Ms. Priscilla Berry-Quetel,
103 South Main Street Department of Medical Assistance Executive Director
Waterbury, VT 05676-1201 Services Bureau of Health Insurance and
T: 802/879-5900 600 East Broad Street Medical Assistance
F: 802/879-5962 Suite 1300 Department of Health
E-mail: joshuas@path.state.vt.us Richmond, VA 23219 3730 Altona, Suite 302 Frostco
Internet address: T: 804/786-4231 Center
www.dsw.state.vt.us F: 804/371-4981 Charlotte Amalie
E-mail: pfinnert@dmas.state.va.us St. Thomas, VI 00802
Internet address: T: 340/774-4624
www.dmas.state.va.us F: 340/774-4918
E-mail: prisene@viaccess.net

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WASHINGTON WEST VIRGINIA WISCONSIN


Governor Governor Governor
Honorable Gary Locke Honorable Bob Wise Honorable Jim Doyle
Office of the Governor State Capitol Office of The Governor
P.O. Box 40002 Charleston, WV 25305-0370 115 East State Capitol
Olympia, WA 98504-0002 T: 304/558-2000 Madison, WI 53702
T: 360/902-4111 F: 304/342-7025 T: 608/266-1212
F: 360-753-4110 E-mail: governor@state.wv.us F: 608/267-8983
E-mail: Internet address: E-mail: wisgov@gov.state.wi.us
www.governor.wa.gov/contact.gov www.state.wv.us/governor Internet address:
email.htm www.wisgov.state.wi.us
Internet address: Single State Agency Director
www.governor.wa.gov Mr. Paul Nusbaum, Secretary Single State Agency Director
Department of Health and Human Ms. Helene Nelson, Secretary
Single State Agency Director Resources Department of Health and Family
Mr. Dennis Braddock, Secretary Building 3, State Capitol Complex Services
Department of Social and Health Room 206 One West Wilson Street, Room
Services Charleston, WV 25305 650
P.O. Box 45010 T: 304/558-0684 Madison, WI 53702
Olympia, WA 98504-5010 F: 304/558-1130 T: 608/266-9622
T: 360/902-7800 E-mail: F: 608/266-7882
F: 360/902-7848 wvdhhrsecretary@wvdhhr.org E-mail:
E-mail: braddd@dshs.wa.gov Internet address: www.wvd.hhr.org webmaster@dhfs.state.wi.us
Internet address: www.wa.gov/dshs Internett address:
Medicaid Director www.dhfs.state.wi.us
Medicaid Director Ms. Nancy Atkins, Commissioner
Mr. Doug Porter, Assistant Bureau for Medical Services Medicaid Director
Secretary Department of Health and Human Mr. Mark B. Moody, Administrator
Medical Assistance Administration Resources Division of Health Care Financing
P.O. Box 45100 350 Capitol Street, Room 251 One West Wilson Street
Olympia, WA 98504-5100 Charleston, WV 25301 P.O. Box 309
T: 360/902-1863 T: 304/558-1700 Madison, WI 53701-0309
F: 360/902-7855 F: 304/558-1451 T: 608/266-2522
E-mail: portejd@dshs.wa.gov E-mail: nancyatkins@wvdhhr.org F: 608/266-1096
Internet address: Internet address: E-mail:
www.fortress.wa.gov/dshs/maa www.wvdhhr.org/bms webmaster@dhfs.state.wi.us
Internet address:
www.dhfs.state.wi.us

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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

Single State Agency Director


Ms. Deb Fleming, Ph.D., Director
Department of Health
117 Hathaway Building
Cheyenne, WY 82002
T: 307/777-7656
F: 307/777-7439
E-mail: wdh@state.wy.us
Internet address:
www.wdhfs.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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CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)


REGIONAL OFFICES
ASSOCIATE REGIONAL ADMINISTRATORS - MEDICAID

Region I Bruce Greenstein Connecticut, Maine, Massachusetts,


Boston Regional Office John F. Kennedy Federal Bldg. New Hampshire, Rhode Island,
Government Center, Room 2325 Vermont
Boston, MA 02203-0003
617/565-1223
Region II Sue Kelly New Jersey, New York, Puerto Rico,
New York Regional Office 26 Federal Plaza Virgin Islands
Room 3811
New York, NY 10278-0063
212/264-2058
Region III Mary McSorley Delaware, District of Columbia,
Philadelphia Regional Office The Public Ledger Building, Suite 216 Maryland, Pennsylvania, Virginia,
150 S. Independence Mall West West Virginia
Philadelphia, PA 19106
215/861-4261
Region IV Hugh Webster (Acting) Alabama, Florida, Georgia, Kentucky,
Atlanta Regional Office Atlanta Federal Center Mississippi, North Carolina, South
61 Forsyth Street, SW, Suite 4T20 Carolina, Tennessee
Atlanta, GA 30303-8909
404/562-7432
Region V Cheryl Harris Illinois, Indiana, Michigan,
Chicago Regional Office 233 North Michigan Avenue Minnesota, Ohio, Wisconsin
Suite 600
Chicago, IL 60601-5519
312/353-2702
Region VI Andrew Fredrickson Arkansas, Louisiana, New Mexico,
Dallas Regional Office 1301 Young Street, Room 714 Oklahoma, Texas
Dallas, TX 75202
214/767-6385
Region VII Tom Lenz Iowa, Kansas, Missouri, Nebraska
Kansas City Regional Office Richard Bolling Federal Building
601 East 12th Street, Room 235
Kansas City, MO 64106-2808
816/426-5925
Region VIII Diane Livesay Colorado, Montana, North Dakota,
Denver Regional Office Colorado State Bank Building South Dakota, Utah, Wyoming
1600 Broadway, Suite 700
Denver, CO 80202-4367
303/844-7057
Region IX Linda Minamoto Arizona, California, Hawaii, Guam
San Francisco Regional Office 75 Hawthorne Street, 4th & 5th Floors Nevada, and Pacific Islands
San Francisco, CA 94105-3901
415/744-3568
Region X Karen O’Connor Alaska, Idaho, Oregon, Washington
Seattle Regional Office 2201 6th Avenue
Mail Stop RX-43
Seattle, WA 98121-2500
206/615-2330

Source: CMS, Central Office, Centers for Medicaid and State Operations, as of February 11, 2004.

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CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)


NATIONAL ACCOUNT REPRESENTATIVES

STATE CENTRAL OFFICE REGIONAL OFFICE

Alabama Virginia Wanamaker Jay Gavens


Deputy Director Financial Analyst
Division of Laboratory Services Atlanta Federal Center
Survey and Certification Group 61 Forsyth Street, SW, Suite 4T20
Center for Medicaid and State Operations Atlanta, GA 30303-8909
Mail Stop S2-26-12 T: 404/562-7430
7500 Security Boulevard E-mail: jgavens@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-7304
E-mail: vwanamaker@cms.hhs.gov

Alaska Richard Strauss Elizabeth Trias


Director Health Insurance Specialist
Division of Financial Management Medicaid Branch, Region X
Finance, Systems and Budget Group 2201 6th Avenue
Center for Medicaid and State Operations MS/RX-43
Mail Stop S2-26-12 Seattle, WA 98121
7500 Security Boulevard T: 206/615-2400
Baltimore, MD 21244-1850 E-mail: etrias@cms.hhs.gov
T: 410/786-2019
E-mail: rstrauss@cms.hhs.gov

American Samoa Linda Murphy Mary Rydell


Health Insurance Specialist Pacific Area Representative
Family and Children’s Health Programs Group P.O. Box 50081
Center for Medicaid and State Operations 300 Ala Moana Blvd., 6-225
Mail Stop S2-26-12 Honolulu, HI 96850
7500 Security Boulevard T: 808/541-2732
Baltimore, MD 21244-1850 E-mail: mrydell@cms.hhs.gov
T: 410/786-0435
E-mail: lmurphy@cms.hhs.gov

Arizona Rhonda Rhodes Ronald Reepen


Director Health Insurance Specialist
Division of Benefits, Coverage and Payment 75 Hawthorne Street, Room 408
Family and Children's Health Programs Group San Francisco, CA 94105-3901
Center for Medicaid and State Operations T: 415/744-3601
Mail Stop S2-26-12 E-mail: rreepen@cms.hhs.gov
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-1848
E-mail: rrhodes@cms.hhs.gov

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Arkansas Marty Svolos J. P. Peters


Director Health Insurance Specialist
Division of Eligibility, Enrollment and Outreach 1301 Young Street, Room 833
Family and Children's Health Program Group Dallas, TX 75202
Center for Medicaid and State Operations T: 214/767-2628
Mail Stop S2-26-12 E-mail: jpeters@cms.hhs.gov
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-4582
E-mail: msvolos@cms.hhs.gov

California Bill Lasowski Pat Daley


Financial Advisor Health Insurance Specialist
Office of the Center Director 75 Hawthorne Street, Room 408
Center for Medicaid and State Operations San Francisco, CA 94105-3901
Mail Stop S2-26-12 T: 415/744-3592
7500 Security Boulevard E-mail: pdaley@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-2003
E-mail: wlasowski@cms.hhs.gov

Colorado Todd Lawson Penny Finnegan


Budget Staff Director State Program Coordinator
Survey and Certification Group Office of the Regional Administrator
Center for Medicaid and State Operations Colorado State Bank Building
Mail Stop S2-26-12 1600 Broadway, Suite 700
7500 Security Boulevard Denver, CO 80202-4367
Baltimore, MD 21244-1850 T: 303/844-7117
T: 410/786-5366 E-mail: pfinnegan@cms.hhs.gov
E-mail: tlawson1@cms.hhs.gov

Connecticut Edward Hutton Elena Nicolella


Technical Director Health Insurance Specialist
Disabled and Elderly Health Programs Group JFK Federal Building
Center for Medicaid and State Operations Government Center, Room 2325
Mail Stop S2-26-12 Boston, MA 02203-0003
7500 Security Boulevard T: 617/565-1243
Baltimore, MD 21244-1850 E-mail: enicolella@cms.hhs.gov
T: 410/786-6616
E-mail: ehutton@cms.hhs.gov

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Delaware Mike Goldman Paul Hughes


Technical Director Health Insurance Specialist
Division of Continuing Care Providers The Public Ledger Building, Suite 216
Survey and Certification Group 150 S. Independence Mall West
Center for Medicaid and State Operations Philadelphia, PA 19106
Mail Stop S2-26-12 T: 215/861-4171
7500 Security Boulevard E-mail: phughes1@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6813
E-mail: mgoldman@cms.hhs.gov

District of Rick Fenton Marguerite Clark


Columbia Deputy Director Health Insurance Specialist
Family and Children's Health Programs Group The Public Ledger Building, Suite 216
Center for Medicaid and State Operations 150 S. Independence Mall West
Mail Stop S2-26-12 Philadelphia, PA 19106
7500 Security Boulevard T: 215/861-4199
Baltimore, MD 21244-1850 E-mail: mclark@cms.hhs.gov
T: 410/786-5920
E-mail: rfenton@cms.hhs.gov

Florida Jim Frizzera Roberta Kelley


Co-Lead, National Institutional Reimbursement Team Atlanta Federal Center
Center for Medicaid and State Operations 61 Forsyth Street, SW, Suite 4T20
Mail Stop S2-26-12 Atlanta, GA 30303-8909
7500 Security Boulevard T: 404/562-7338
Baltimore, MD 21244-1850 E-mail: rkelley@cms.hhs.gov
T: 410/786-9535
E-mail: jfrizzera@cms.hhs.gov

Georgia Jerry Zelinger Hugh Webster


Medical Advisor Chief
Division of Benefits, Coverage and Payment Medicaid Financial Management Branch
Family and Children’s Health Programs Group Atlanta Federal Center
Center for Medicaid and State Operations 61 Forsyth Street, SW, Suite 4T20
Mail Stop S2-26-12 Atlanta, GA 30303-8909
7500 Security Boulevard T: 404/562-7432
Baltimore, MD 21244-1850 E-mail: hwebster@cms.hhs.gov
T: 410/786-5929
E-mail: gzelinger@cms.hhs.gov

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Guam Paul Miner Eddie Martin


Technical Director Accountant
Finance, Systems and Budget Group 75 Hawthorne Street, Room 408
Center for Medicaid and State Operations San Francisco, CA 94105-3901
Mail Stop S2-26-12 T: 415/744-3567
7500 Security Boulevard E-mail: emartin@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-5937
E-mail: pminer@cms.hhs.gov

Hawaii Larry Reed Susan Castleberry


Co-Lead, Pharmacy Team Health Insurance Specialist
Family and Children's Health Program Group 75 Hawthorne Street, Room 408
Center for Medicaid and State Operations San Francisco, CA 94105-3901
Mail Stop S2-26-12 T: 415/744-3599
7500 Security Boulevard E-mail: scastleberry@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-3325
E-mail: lreed2@cms.hhs.gov

Idaho Georgia Johnson David Meacham


Technical Director Health Insurance Specialist
Division of Continuing Care Providers 2201 6th Avenue
Survey and Certification Group MS/RX-43
Center for Medicaid and State Operations Seattle, WA 98121
Mail Stop S2-26-12 T: 206/615-2356
7500 Security Boulevard E-mail: dmeacham@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6859
E-mail: gjohnson4@cms.hhs.gov

Illinois Mary Beth Hance Vera Drivalas


Director 233 N. Michigan Avenue
Policy Coordination and Planning Group Suite 600
Center for Medicaid and State Operations Chicago, IL 60601
Mail Stop S2-26-12 T: 312/886-0792
7500 Security Boulevard E-mail: vdrivalas@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-4299
E-mail: mhance@cms.hhs.gov

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Indiana Regina Fletcher Leslie Campbell


Special Assistant Indiana State Representative
Family and Children's Health Programs Group 233 N. Michigan Avenue
Center for Medicaid and State Operations Suite 600
Mail Stop S2-26-12 Chicago, IL 6061
7500 Security Boulevard T: 312/353-1557
Baltimore, MD 21244-1850 E-mail: lcampbell@cms.hhs.gov
T: 410/786-3293
E-mail: rfletcher@cms.hhs.gov

Iowa Mary Jean Duckett Sharon Taggart


Director Health Insurance Specialist
Division of Benefits, Coverage and Payment Richard Bolling Federal Building
Disabled and Elderly Health Programs Group 601 East 12th Street, Room 227
Center for Medicaid and State Operations Kansas City, MO 64106-2808
Mail Stop S2-26-12 T: 816/426-3406 Ext. 3320
7500 Security Boulevard E-mail: staggart@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-3294
E-mail: mduckett@cms.hhs.gov

Kansas Frank Sokolik Tim Watson


Director Health Insurance Specialist
Division of Acute Care Richard Bolling Federal Building
Center for Medicaid and State Operations 601 East 12th Street, Room 227
Mail Stop S2-26-12 Kansas City, MO 64106-2808
7500 Security Boulevard T: 816/426-3406 Ext. 3309
Baltimore, MD 21244-1850 E-mail: twatson@cms.hhs.gov
T: 410/786-7089
E-mail: fsokolik@cms.hhs.gov

Kentucky Jack Williams Renard Murray


Director Atlanta Federal Center
Division of National Systems 61 Forsyth Street, SW, Suite 4T20
Finance, Systems and Budget Group Atlanta, GA 30303-8909
Center for Medicaid and State Operations T: 404/562-7417
Mail Stop S2-26-12 E-mail: rmurray@cms.hhs.gov
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-6743
E-mail: jwilliams2@cms.hhs.gov

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Louisiana Jean Sheil Robert Cowan


Director Financial Operations Specialist
Family and Children’s Health Programs Group 1301 Young Street, Room 714
Center for Medicaid and State Operations Dallas, TX 75202
Mail Stop S2-26-12 T: 214/767-6485
7500 Security Boulevard E-mail: rcowan@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-1285
E-mail: jsheil@cms.hhs.gov

Maine Roger Buchanan Irvin Rich


Director JFK Federal Building
Division of Informational Analysis and Technical Government Center, Room 2325
Assistance Boston, MA 02203-0003
Finance, Systems and Budget Group T: 617/565-1247
Center for Medicaid and State Operations E-mail: irich@cms.hhs.gov
Mail Stop S2-26-12
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-0780
E-mail: rbuchanan@cms.hhs.gov

Maryland Kathy Rama James Hake


Technical Director Health Insurance Specialist
Division of Advocacy and Special Issues The Public Ledger Building, Suite 216
Disabled and Elderly Health Programs Group 150 S. Independence Mall West
Center for Medicaid and State Operations Philadelphia, PA 19106
Mail Stop S2-26-12 T: 215/861-4196
7500 Security Boulevard E-mail: jhake@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6659
E-mail: krama@cms.hhs.gov

Massachusetts Tom Hamilton Alan P. Bryan


Director Health Insurance Specialist
Disabled and Elderly Health Programs Group JFK Federal Building
Center for Medicaid and State Operations Government Center, Room 2275
Mail Stop S2-26-12 Boston, MA 02203-0003
7500 Security Boulevard T: 617/565-1246
Baltimore, MD 21244-1850 E-mail: abryan@cms.hhs.gov
T: 410/786-6763
E-mail: thamilton@cms.hhs.gov

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Michigan Lillian Gibbons Ruth Hughes


Senior Advisor 233 N. Michigan Avenue
Family and Children’s Health Programs Group Suite 600
Center for Medicaid and State Operations Chicago, IL 60601
Mail Stop S2-26-12 T: 312/353-1670
7500 Security Boulevard E-mail: rhughes@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-8705
E-mail: lgibbons@cms.hhs.gov

Minnesota Terry Pratt Doris Ross


Director 233 N. Michigan Avenue
Division of Integrated Health Systems Suite 600
Disabled and Elderly Health Programs Group Chicago, IL 60601
Center for Medicaid and State Operations T: 312/353-9843
Mail Stop S2-26-12 E-mail: dross2@cms.hhs.gov
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-9499
E-mail: tpratt@cms.hhs.gov

Mississippi Diona Kristian Selwyn White


Technical Director Atlanta Federal Center
Family and Children’s Health Programs Group 61 Forsyth Street, SW, Suite 4T20
Center for Medicaid and State Operations Atlanta, GA 30303-8909
Mail Stop S2-26-12 T: 404/562-7427
7500 Security Boulevard E-mail: swhite3@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-3283
E-mail: dkristian@cms.hhs.gov

Missouri Peggy Clark Jackie Glaze


Technical Director Health Insurance Specialist
Division of Integrated Health Systems Richard Bolling Federal Building
Disabled and Elderly Health Programs Group 601 East 12th Street, Room 227
Center for Medicaid and State Operations Kansas City, MO 64106-2808
Mail Stop S2-26-12 T: 816/426-3406 Ext. 3318
7500 Security Boulevard E-mail: jglaze@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-5321
E-mail: pclark@cms.hhs.gov

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Montana Steven Lutzky, Ph.D. Robert Lyon


Director Colorado State Bank Building
Division of Advocacy for Systems Improvement 1600 Broadway
Disabled and Elderly Health Programs Group Suite 700
Center for Medicaid and State Operations Denver, CO 80202-4367
Mail Stop S2-26-12 T: 303/844-7114
7500 Security Boulevard E-mail: rlyon@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-3257
E-mail: slutzky@cms.hhs.gov

Nebraska Tracey Mummert Diana Townsend


Special Assistant Health Insurance Specialist
Survey and Certification Group Richard Bolling Federal Building
Center for Medicaid and State Operations 601 East 12th Street, Room 227
Mail Stop S2-26-12 Kansas City, MO 64106-2808
7500 Security Boulevard T: 816/426-3406 Ext. 3316
Baltimore, MD 21244-1850 E-mail: dtownsend@cms.hhs.gov
T: 410/786-3398
E-mail: tmummert@cms.hhs.gov

Nevada Judy Yost Lee Netzer


Director Health Insurance Specialist
Division of Laboratory Services 75th Hawthorne Street, Room 408
Survey and Certification Group San Francisco, CA 94105-3901
Center for Medicaid and State Operations T: 415/744-3595
Mail Stop S2-26-12 E-mail: lnetzer@cms.hhs.gov
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-3407
E-mail: jyost@cms.hhs.gov

New Hampshire Jan Tarantino Harold Finn


Deputy Director JFK Federal Building
Division of Continuing Care Providers Government Center, Room 2325
Center for Medicaid and State Operations Boston, MA 02203-0003
Mail Stop S2-26-12 T: 617/565-1225
7500 Security Boulevard E-mail: hfinn@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-0905
E-mail: jtarantino@cms.hhs.gov

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New Jersey Fred Gladden Julie Alberino


Technical Director 26 Federal Plaza
Division of Nursing Homes Room 3800
Survey and Certification Group New York, NY 10278-0063
Center for Medicaid and State Operations T: 212/264-3904
Mail Stop S2-26-12 E-mail: jalberino@cms.hhs.gov
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-3033
E-mail: fgladden@cms.hhs.gov

New Mexico Susan Cuerdon Jack Allen


Policy Advisor Health Insurance Specialist
Office of the Director 1301 Young Street, Room 827
Center for Medicaid and State Operations Dallas, TX 75202
Mail Stop S2-26-12 T: 214/767-4425
7500 Security Boulevard E-mail: jallen@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-1146
E-mail: scuerdon@cms.hhs.gov

New York Charlene Brown Sue Kelly


Deputy Director 26 Federal Plaza
Center for Medicaid and State Operations Room 3800
Mail Stop S2-26-12 New York, NY 10278-0063
7500 Security Boulevard T: 212/264-2058
Baltimore, MD 21244-1850 E-mail: skelly@cms.hhs.gov
T: 410/786-3230
E-mail: cbrown2@cms.hhs.gov

North Carolina Joe Razes Donna Cross


Technical Director State Representative for North Carolina
Division of Advocacy and Special Issues Atlanta Federal Center
Disabled and Elderly Health Programs Group 61 Forsyth Street, SW, Suite 4T20
Center for Medicaid and State Operations Atlanta, GA 30303-8909
Mail Stop S2-26-12 T: 404/562-7406
7500 Security Boulevard E-mail: dcross@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6126
E-mail: jrazes@cms.hhs.gov

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North Dakota James Merrill Bernadette Quevedo-Mendoza


Life Safety Code Specialist State Program Coordinator
Division of Nursing Homes Office of the Regional Administrator,
Survey and Certification Group CMS
Center for Medicaid and State Operations Colorado State Bank Building
Mail Stop S2-26-12 1600 Broadway, Suite 700
7500 Security Boulevard Denver, CO 80202-4367
Baltimore, MD 21244-1850 T: 303/844-7121
T: 410/786-6998 E-mail: bquevedo-mendoza@cms.hhs.gov
E-mail: jmerrill@cms.hhs.gov

Northern Edward Mortimore H. Stephen Deering


Mariana Islands Technical Director Deputy Regional Administrator, CMS
Division of Nursing Homes 75 Hawthorne Street, Room 408
Survey and Certification Group San Francisco, CA 94105-3901
Center for Medicaid and State Operations T: 415/744-3501
Mail Stop S2-26-12 E-mail: sdeering@cms.hhs.gov
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-3509
E-mail: emortimore@cms.hhs.gov

Ohio Deirdre Duzor Gwendolyn Sampson


Co-Lead, Pharmacy Team 233 N. Michigan Avenue
Finance, Systems and Budget Group Suite 600
Center for Medicaid and State Operations Chicago, IL 60601
Mail Stop S2-26-12 T: 312/353-9861
7500 Security Boulevard E-mail: gsampson@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-4626
E-mail: dduzor@cms.hhs.gov

Oklahoma Melissa Hulbert Ford Blunt


Director Health Insurance Specialist
Division of Continuing Care Providers 1301 Young Street, Room 827
Center for Medicaid and State Operations Dallas, TX 75202
Mail Stop S2-26-12 T: 214/767-6381
7500 Security Boulevard E-mail: fblunt@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6568
E-mail: mhulbert@cms.hhs.gov

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Oregon Alissa DeBoy Barbara Subert


Special Assistant Health Insurance Specialist
Disabled and Elderly Health Programs Group Medicaid Branch, Region X
Center for Medicaid and State Operations 2201 6th Avenue
Mail Stop S2-26-12 MS/RX-43
7500 Security Boulevard Seattle, WA 98121
Baltimore, MD 21244-1850 T: 206/615-2390
T: 410/786-6041 E-mail: bsubert@cms.hhs.gov
E-mail: adeboy@cms.hhs.gov

Pennsylvania Cheryl Austein-Casnoff Michael Cruse


Director Health Insurance Specialist
Division of State Children’s Health Insurance The Public Ledger Building, Suite 216
Family and Children's Health Program Group 150 S. Independence Mall West
Center for Medicaid and State Operations Philadelphia, PA 19106
Mail Stop S2-26-12 T: 215/861-4216
7500 Security Boulevard E-mail: mcruse@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-4196
E-mail: causteincasnoff@cms.hhs.gov

Puerto Rico Cindy Melanson Frank Fournier


Health Program Evaluator La Torre de Plaza Las Americas
Division of Acute Care Services Suite 1116
Survey and Certification Group 525 F. SD. Roosevelt Ave.
Center for Medicaid and State Operations San Juan, PR 000919-8024
Mail Stop S2-26-12 T: 787/771-3687
7500 Security Boulevard E-mail: ffournier@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-0310
E-mail: cmelanson@cms.hhs.gov

Rhode Island Rick Friedman Richard Pecorella


Director JFK Federal Building
Division of State Systems Government Center, Room 2325
Finance, Systems and Budget Group Boston, MA 02203-0003
Center for Medicaid and State Operations T: 617/565-1244
Mail Stop S2-26-12 E-mail: rpecorella@cms.hhs.gov
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-4451
E-mail: rfriedman2@cms.hhs.gov

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South Carolina Helaine Jeffers Jessie Spillers


Deputy Director 61 Forsyth Street, SW, Suite 4T20
Division of Acute Care Services Atlanta, GA 30303-8909
Survey and Certification Group T: 404/562-7418
Center for Medicaid and State Operations E-mail: jspillers@cms.hhs.gov
Mail Stop S2-26-12
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-5648
E-mail: hjeffers@cms.hhs.gov

South Dakota David Eddinger Cynthia Myers


Technical Director State Program Coordinator
Division of Laboratory Systems Office of the Regional Administrator
Survey and Certification Group Colorado State Bank Building
Center for Medicaid and State Operations 1600 Broadway, Suite 700
Mail Stop S2-26-12 Denver, CO 80202-4367
7500 Security Boulevard T: 303/844-7116
Baltimore, MD 21244-1850 E-mail: cmyers2@cms.hhs.gov
T: 410/786-3429
E-mail: deddinger@cms.hhs.gov

Tennessee Mike Fiore Dorothy Smith


Director Health Insurance Specialist
Division of Integrated Health Systems Atlanta Federal Center
Family and Children's Health Programs Group 61 Forsyth Street, SW, Suite 4T20
Center for Medicaid and State Operations Atlanta, GA 30303-8909
Mail Stop S2-26-12 T: 404/562-7159
7500 Security Boulevard E-mail: dsmith5@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-0623
E-mail: mfiore@cms.hhs.gov

Texas Dave McNally Joe Reeder


Financial Management Specialist Health Insurance Specialist
Finance, Systems and Budget Group 1301 Young Street, Room 714
Center for Medicaid and State Operations Dallas, TX 75202
Mail Stop S2-26-12 T: 214/767-4419
7500 Security Boulevard E-mail: jreeder@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-3292
E-mail: dmcnally@cms.hhs.gov

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Utah Aaron Blight Tilly Rollin


Special Assistant State Program Coordinator
Office of the Director Office of the Regional Administrator
Center for Medicaid and State Operations Colorado State Bank Building
Mail Stop S2-26-12 1600 Broadway, Suite 700
7500 Security Boulevard Denver, CO 80202-4367
Baltimore, MD 21244-1850 T: 303/844-7111
T: 410/786-5239 E-mail: trollin@cms.hhs.gov
E-mail: ablight@cms.hhs.gov

Vermont Clarke Cagey Chong B. Tieng


Special Assistant Health Insurance Specialist
Office of the Director JFK Federal Building
Center for Medicaid and State Operations Government Center, Room 2275
Mail Stop S2-26-12 Boston, MA 02203-0003
7500 Security Boulevard T: 617/565-9157
Baltimore, MD 21244-1850 E-mail: ctieng@cms.hhs.gov
T: 410/786-3135
E-mail: ccagey@cms.hhs.gov

Virginia Ginni Hain Jake Hubik


Director Health Insurance specialist
Division of Eligibility, Enrollment and Outreach The Public Ledger Building, Suite 216
Disabled and Elderly Health Programs Group 150 S. Independence Mall West
Center for Medicaid and State Operations Philadelphia, PA 19106
Mail Stop S2-26-12 T: 215/861-4181
7500 Security Boulevard E-mail: jhubik@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6036
E-mail: ghain@cms.hhs.gov

Virgin Islands Cindy Graunke Ricardo Holligan


Director 26 Federal Plaza
Division of Nursing Homes Room 3811
Center for Medicaid and State Operations New York, NY 10278-0063
Mail Stop S2-26-12 T: 212/264-3978
7500 Security Boulevard E-mail: rholligan@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6782
E-mail: cgraunke@cms.hhs.gov

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Washington Gale Arden Carol Crimi


Director Health Insurance Specialist
Private Health Insurance Group Medicaid Branch, Region X
Center for Medicaid and State Operations 2201 6th Avenue
Mail Stop S2-26-12 MS/RX-43
7500 Security Boulevard Seattle, WA 98121
Baltimore, MD 21244-1850 T: 206/615-2515
T: 410/786-6810 E-mail: ccrimi@cms.hhs.gov
E-mail: garden@cms.hhs.gov

West Virginia Joan Simmons Donna Fischer


Deputy Director Health Insurance Specialist
Division of Nursing Homes The Public Ledger Building, Suite 230
Survey and Certification Group 150 S. Independence Mall West
Center for Medicaid and State Operations Philadelphia, PA 19106
Mail Stop S2-26-12 T: 215/861-4221
7500 Security Boulevard E-mail: dfischer@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-3409
E-mail: jsimmons1@cms.hhs.gov

Wisconsin Glenn Stanton Pam Carson


Deputy Director 233 N. Michigan Avenue
Disabled and Elderly Health Programs Group Suite 600
Center for Medicaid and State Operations Chicago, IL 60601
Mail Stop S2-26-12 T: 312/353-0108
7500 Security Boulevard E-mail: pcarson@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6768
E-mail: gstanton@cms.hhs.gov

Wyoming Sidney Trieger Robert Tonsberg


Technical Director Epidemiologist, Sr. Health Services
Division of Integrated Health Systems Office Manager
Family and Children’s Health Program Group Office of the Regional Administrator
Center for Medicaid and State Operations Colorado State Bank Bldg.
Mail Stop S2-26-12 1600 Broadway, Suite 700
7500 Security Boulevard Denver, CO 80202-4367
Baltimore, MD 21244-1850 T: 303/844-1981
T: 410/786-6613 E-mail: rtonsberg@cms.hhs.gov
E-mail: strieger@cms.hhs.gov

Source: CMS Website at www.cms.hhs.gov/states/natreps.pdf. Information as of January 21, 2004.

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CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)


CENTER FOR MEDICAID AND STATE OPERATIONS (CMSO)
CENTRAL OFFICE STAFF
7500 Security Boulevard
Baltimore, MD 21244-1850
410/786-3000
Director Deputy Director Financial Advisor
Dennis Smith Charlene Brown Bill Lasowski
410/786-3870 410/786-3870 410/786-3870

Appeals and Grievances Eligibility


Tim Roe (Managed Care) Marty Svolos (Families & Children)
410/786-2006 410/786-4582
Bob Tomlinson (Fee for Service) Roy Trudel (Disabled/Elderly)
410/786-4463 410/786-3417

Assignment of Rights to Benefits Family/Children 1915(b) Waivers; 1115 Demonstrations;


Cheryl Camillo And the Health Insurance Flexibility & Accountability
410/786-1068 Initiative (HIFA)
Mike Fiore
Budget Information for State Agencies 410/786-0623
John Hoover
410/786-2020 HCFA 2082 Statistical Report
Cindy Foltz
Children’s Health Insurance 410/786-0253
Cheryl Austein Casnoff
410/786-6614 Home and Community Based Waiver Program Reviews;
Independence Plus Initiative
Coordination of Benefits Mary Jean Duckett
Gina Clemens (Disabled & Elderly) 410/786-3294
410/786-9644
Marty Svolos (Families & Children) Investigational/Experimental Drugs
410/786-4582 Larry Reed
410/786-3325
Data Inquiries Deirdre Duzor
Marilyn McMillan 410/786-4626
410/786-4623
Managed Care Enrollment Report
Department Appeals Board Decisions Carolyn Lawson
Ed Davis 410/786-0704
410/786-3280
Medicaid Statistical Information System (MSIS)
Disabled/Elderly 1915(b) Waivers; 1115 Demonstrations; Ron North
And PACE Program 410/786-5651
Terri Pratt
410/786-5831 Pharmacy Issues
(Coverage, Payment & Rebate Program)
Drug Rebate Agreement/Data Larry Reed
Vince Powell 410/786-3325
410/786-3314 Deirdre Duzor
410/786-4626
Drug Utilization Review
Christina Lyon
410/786-3332
Carl Tepper Source: CMS Central Office, CMSO, February 11, 2004.
410/786-2137

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Appendix B:
Medicaid Program Statistics -
CMS MSIS Tables

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Medicaid Program Statistics -- MSIS Report

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 2001. However, MSIS data for FY 2001 are missing for Washington
and Hawaii. The latest available MSIS data has been substituted in its place. 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 2000 and FY 2001. 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 partial tables at the end of the
Appendix that correspond to FY 2001 tables presented in Section 2.

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Total U.S. Medical Assistance Recipients By Type of Service

Service FY 2000** Percent of Total* FY 2001** Percent of Total* Percent Change 2000-2001
Capitated Payment Services 21,261,218 49.7% 22,342,525 49.9% 4.8%
Pharmaceuticals 20,516,882 48.0% 21,729,110 48.5% 5.6%
Physicians 19,103,558 44.7% 19,930,824 44.5% 4.2%
Hospital Outpatient 13,226,305 30.9% 13,565,921 30.3% 2.5%
Lab/X-ray 11,395,712 26.6% 12,278,048 27.4% 7.2%
Other Care 9,036,596 21.1% 9,633,385 21.5% 6.2%
Clinic 7,666,977 17.9% 8,369,692 18.7% 8.4%
Dental 5,891,733 13.8% 6,910,064 15.4% 14.7%
PCCM Services 5,560,441 13.0% 6,166,012 13.8% 9.8%
Hospital Inpatient 4,933,277 11.5% 4,820,360 10.8% -2.3%
Other Practitioners 4,735,427 11.1% 5,040,417 11.3% 6.1%
Personal Support Services 4,549,488 10.6% 4,919,252 11.0% 7.5%
Nursing Facility 1,702,885 4.0% 1,638,484 3.7% -3.9%
Home Health Care 994,801 2.3% 989,339 2.2% -0.6%
ICF-Mentally Retarded 118,171 0.3% 115,531 0.3% -2.3%
Mental Health Facility 99,342 0.2% 89,142 0.2% -11.4%
Total Unduplicated
Recipients* 42,763,233 44,793,217 4.5%

*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.
**Hawaii did not report for FY 2000 and FY 2001**. Their FY 1999 data are included in the FY 2000 and FY 2001 totals. Washington State did
not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals.

Source: CMS, MSIS Report, FY 1999, FY 2000, and FY 2001.

B-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Total U.S. Medical Assistance Payments By Type of Service

Percent of Percent of
Service FY 2000** Total* FY 2001** Total* Percent Change 2000-2001
Nursing Facility $34,432,018,376 20.5% $37,065,353,039 20.0% 7.1%
Capitated Payment Services $24,412,582,129 14.5% $27,756,782,607 14.9% 12.0%
Hospital Inpatient $24,265,794,997 14.4% $25,557,564,614 13.8% 5.1%
Pharmaceuticals $20,013,770,558 11.9% $23,712,173,253 12.8% 15.6%
Other Care $14,808,103,169 8.8% $16,483,018,278 8.9% 10.2%
Personal Support Services $11,567,367,970 6.9% $13,009,737,222 7.0% 11.1%
ICF-Mentally Retarded $9,374,506,773 5.6% $9,645,307,943 5.2% 2.8%
Hospital Outpatient $7,053,041,842 4.2% $7,506,157,691 4.0% 6.0%
Physicians $6,805,694,595 4.0% $7,421,942,400 4.0% 8.3%
Clinic $6,174,164,021 3.7% $5,580,484,682 3.0% -10.6%
Home Health Care $3,118,966,203 1.9% $3,505,452,939 1.9% 11.0%
Mental Health Facility $1,768,270,710 1.1% $1,946,334,080 1.0% 9.1%
Dental $1,404,498,611 0.8% $1,862,434,571 1.0% 24.6%
Lab/X-Ray $1,288,213,313 0.8% $1,607,744,292 0.9% 19.9%
Unknown $997,460,227 0.6% $1,427,842,139 0.8% 30.1%
Other Practitioners $658,455,027 0.4% $752,657,038 0.4% 12.5%
PCCM Services $164,562,061 0.1% $182,020,535 0.1% 9.6%

Total Payments $168,307,398,582 $185,786,851,245 9.4%

*Percentages may not add to 100% due to rounding. Puerto Rico and the U.S. Territories are not included in these national totals.
**Hawaii did not report for FY 2000 and FY 2001. Their FY 1999 data are included in the FY 2000 and FY 2001 totals. Washington State did
not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals.

Source: CMS, MSIS Report, FY 1999, FY 2000 and FY 2001.

B-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

2001 Baseline Data*


State Total Payments Drug Payments Total Recipients Drug Recipients Drugs as a % of Total
National Total $185,786,851,245 $23,712,173,253 44,793,217 21,750,110 12.8%
Alabama $2,950,095,956 $392,482,787 703,486 464,695 13.3%
Alaska $557,398,672 $64,923,574 105,464 65,278 11.6%
Arizona $2,453,184,175 $4,254,191 763,422 9,761 0.2%
Arkansas $1,684,717,766 $248,392,084 531,533 321,920 14.7%
California $19,824,989,448 $2,808,298,437 8,596,862 2,486,910 14.2%
Colorado $1,952,708,545 $177,115,553 393,195 143,169 9.1%
Connecticut $2,962,088,094 $304,470,534 684,717 116,755 10.3%
Delaware $601,182,212 $81,623,058 122,948 85,351 13.6%
District of Columbia $830,258,078 $62,292,004 140,720 35,324 7.5%
Florida $8,398,159,525 $1,487,935,645 2,458,609 1,159,155 17.7%
Georgia $3,815,267,274 $655,515,772 1,256,990 856,797 17.2%
Hawaii $535,162,729 $44,849,664 203,763 35,687 8.4%
Idaho $713,433,025 $105,473,425 157,121 112,357 14.8%
Illinois $8,150,021,068 $934,241,252 1,655,958 1,068,535 11.5%
Indiana $3,355,995,714 $562,120,344 771,785 464,879 16.7%
Iowa $1,660,864,098 $230,430,967 319,741 221,691 13.9%
Kansas $1,370,248,183 $189,290,260 272,783 158,515 13.8%
Kentucky $3,235,072,953 $598,093,343 807,435 475,365 18.5%
Louisiana $2,881,578,117 $554,670,701 804,987 628,571 19.2%
Maine $1,457,465,782 $203,693,259 249,050 192,833 14.0%
Maryland $3,855,002,531 $417,080,496 634,273 413,755 10.8%
Massachusetts $5,765,107,723 $795,309,302 1,039,979 664,891 13.8%
Michigan $5,316,248,739 $604,759,491 1,352,418 551,593 11.4%
Minnesota $3,766,604,923 $265,240,353 609,314 188,566 7.0%
Mississippi $2,180,662,071 $494,805,247 707,899 478,404 22.7%
Missouri $3,626,212,602 $680,574,899 978,546 472,624 18.8%
Montana $482,543,436 $69,552,397 107,708 63,338 14.4%
Nebraska $1,089,787,848 $161,577,499 242,901 178,365 14.8%
Nevada $565,299,853 $62,849,319 133,103 55,580 11.1%
New Hampshire $691,195,787 $90,927,579 97,062 73,489 13.2%
New Jersey $5,011,794,888 $649,274,352 898,685 307,798 13.0%
New Mexico $1,476,537,827 $70,147,344 379,207 75,669 4.8%
New York $27,497,918,486 $2,779,026,904 3,039,436 2,283,293 10.1%
North Carolina $5,499,093,501 $971,066,103 1,304,684 907,413 17.7%
North Dakota $374,197,254 $43,288,363 60,217 39,758 11.6%
Ohio $7,772,738,205 $1,087,552,923 1,413,925 904,380 14.0%
Oklahoma $2,004,799,211 $215,717,760 570,671 249,678 10.8%
Oregon $1,878,673,356 $222,018,784 564,820 220,711 11.8%
Pennsylvania $7,634,325,250 $690,558,773 1,557,802 461,114 9.0%
Rhode Island $1,095,852,989 $104,912,603 188,188 50,379 9.6%
South Carolina $3,096,853,528 $438,498,935 760,797 542,764 14.2%
South Dakota $426,633,598 $52,608,524 109,461 58,203 12.3%
Tennessee $4,059,332,053 $0 1,602,027 0 0.0%
Texas $9,644,600,358 $1,327,222,456 2,659,682 1,917,351 13.8%
Utah $1,059,729,740 $117,101,302 232,520 136,682 11.1%
Vermont $541,283,084 $105,673,417 149,262 109,328 19.5%
Virginia $2,715,962,318 $419,133,293 618,395 333,880 15.4%
Washington $2,432,050,117 $387,877,281 895,279 339,440 15.9%
West Virginia $1,565,008,585 $256,395,319 349,229 269,174 16.4%
Wisconsin $3,029,722,940 $389,373,521 633,463 262,238 12.9%
Wyoming $241,187,030 $31,881,860 51,068 36,704 13.2%

*Hawaii did not report for FY 2000 and FY 2001. Their FY 1999 data are included in the FY 2001 totals. Washington State did
not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals.

Source: CMS, MSIS Report, FY1999, FY2000, and FY 2001.

B-7
National Pharmaceutical Council Pharmaceutical Benefits 2003

Medicaid Payments and Recipients, 2001*

State Total Payments Total Recipients Payments Per Recipient


National Total $185,786,851,245 45,329,755 $4,099
Alabama $2,950,095,956 703,486 $4,194
Alaska $557,398,672 105,464 $5,285
Arizona $2,453,184,175 763,422 $3,213
Arkansas $1,684,717,766 531,533 $3,170
California $19,824,989,448 8,596,862 $2,306
Colorado $1,952,708,545 393,195 $4,966
Connecticut $2,962,088,094 684,717 $4,326
Delaware $601,182,212 122,948 $4,890
District of Columbia $830,258,078 140,720 $5,900
Florida $8,398,159,525 2,458,609 $3,416
Georgia $3,815,267,274 1,256,990 $3,035
Hawaii $535,162,729 203,763 $2,626
Idaho $713,433,025 157,121 $4,541
Illinois $8,150,021,068 1,655,958 $4,922
Indiana $3,355,995,714 771,785 $4,348
Iowa $1,660,864,098 319,741 $5,194
Kansas $1,370,248,183 272,783 $5,023
Kentucky $3,235,072,953 807,435 $4,007
Louisiana $2,881,578,117 804,987 $3,580
Maine $1,457,465,782 249,050 $5,852
Maryland $3,855,002,531 634,273 $6,078
Massachusetts $5,765,107,723 1,039,979 $5,543
Michigan $5,316,248,739 1,352,418 $3,931
Minnesota $3,766,604,923 609,314 $6,182
Mississippi $2,180,662,071 707,899 $3,080
Missouri $3,626,212,602 978,546 $3,706
Montana $482,543,436 107,708 $4,480
Nebraska $1,089,787,848 242,901 $4,487
Nevada $565,299,853 133,103 $4,247
New Hampshire $691,195,787 97,062 $7,121
New Jersey $5,011,794,888 898,685 $5,577
New Mexico $1,476,537,827 379,207 $3,894
New York $27,497,918,486 3,039,436 $9,047
North Carolina $5,499,093,501 1,304,684 $4,215
North Dakota $374,197,254 60,217 $6,214
Ohio $7,772,738,205 1,413,925 $5,497
Oklahoma $2,004,799,211 570,671 $3,513
Oregon $1,878,673,356 564,820 $3,326
Pennsylvania $7,634,325,250 1,557,802 $4,901
Rhode Island $1,095,852,989 188,188 $5,823
South Carolina $3,096,853,528 760,797 $4,071
South Dakota $426,633,598 109,461 $3,898
Tennessee $4,059,332,053 1,602,027 $2,534
Texas $9,644,600,358 2,659,682 $3,626
Utah $1,059,729,740 232,520 $4,099
Vermont $541,283,084 149,262 $4,194
Virginia $2,715,962,318 618,395 $5,285
Washington $2,432,050,117 895,279 $3,213
West Virginia $1,565,008,585 349,229 $3,170
Wisconsin $3,029,722,940 633,463 $2,306
Wyoming $241,187,030 51,068 $4,966

*Hawaii did not report for FY 2000 and FY 2001. Their FY 1999 data are included in the FY 2001 totals. Washington State did
not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals.

Source: CMS, MSIS Report, FY 1999, FY 2000,and FY 2001.

B-8
National Pharmaceutical Council Pharmaceutical Benefits 2003

Drug Payments and Recipients, 2001*

State Total Drug Payments Total Drug Recipients Drug Payments per Recipient
National Total $23,712,173,253 21,750,110 $1,090
Alabama $392,482,787 464,695 $845
Alaska $64,923,574 65,278 $995
Arizona $4,254,191 9,761 $436
Arkansas $248,392,084 321,920 $772
California $2,808,298,437 2,486,910 $1,129
Colorado $177,115,553 143,169 $1,237
Connecticut $304,470,534 116,755 $2,608
Delaware $81,623,058 85,351 $956
District of Columbia $62,292,004 35,324 $1,763
Florida $1,487,935,645 1,159,155 $1,284
Georgia $655,515,772 856,797 $765
Hawaii $44,849,664 35,687 $1,257
Idaho $105,473,425 112,357 $939
Illinois $934,241,252 1,068,535 $874
Indiana $562,120,344 464,879 $1,209
Iowa $230,430,967 221,691 $1,039
Kansas $189,290,260 158,515 $1,194
Kentucky $598,093,343 475,365 $1,258
Louisiana $554,670,701 628,571 $882
Maine $203,693,259 192,833 $1,056
Maryland $417,080,496 413,755 $1,008
Massachusetts $795,309,302 664,891 $1,196
Michigan $604,759,491 551,593 $1,096
Minnesota $265,240,353 188,566 $1,407
Mississippi $494,805,247 478,404 $1,034
Missouri $680,574,899 472,624 $1,440
Montana $69,552,397 63,338 $1,098
Nebraska $161,577,499 178,365 $906
Nevada $62,849,319 55,580 $1,131
New Hampshire $90,927,579 73,489 $1,237
New Jersey $649,274,352 307,798 $2,109
New Mexico $70,147,344 75,669 $927
New York $2,779,026,904 2,283,293 $1,217
North Carolina $971,066,103 907,413 $1,070
North Dakota $43,288,363 39,758 $1,089
Ohio $1,087,552,923 904,380 $1,203
Oklahoma $215,717,760 249,678 $864
Oregon $222,018,784 220,711 $1,006
Pennsylvania $690,558,773 461,114 $1,498
Rhode Island $104,912,603 50,379 $2,082
South Carolina $438,498,935 542,764 $808
South Dakota $52,608,524 58,203 $904
Tennessee $0 0 $0
Texas $1,327,222,456 1,917,351 $692
Utah $117,101,302 136,682 $857
Vermont $105,673,417 109,328 $967
Virginia $419,133,293 333,880 $1,255
Washington $387,877,281 339,440 $1,143
West Virginia $256,395,319 269,174 $953
Wisconsin $389,373,521 262,238 $1,485
Wyoming $31,881,860 36,704 $869

*Hawaii did not report for FY 2000 and FY 2001. Their FY 1999 data are included in the FY 2001 totals. Washington State did
not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals.

Source: CMS, MSIS Report, FY 1999, FY 2000, and FY 2001.

B-9
National Pharmaceutical Council Pharmaceutical Benefits 2003

Drug Payment Trends, Percent Change 2000-2001*

State 2000 2001 Percent Change


National Total $20,013,770,558 $23,712,173,253 15.6%
Alabama $331,574,388 $392,482,787 15.5%
Alaska $51,196,685 $64,923,574 21.1%
Arizona $1,952,231 $4,254,191 54.1%
Arkansas $209,933,612 $248,392,084 15.5%
California $2,316,135,493 $2,808,298,437 17.5%
Colorado $152,478,786 $177,115,553 13.9%
Connecticut $264,641,409 $304,470,534 13.1%
Delaware $66,263,771 $81,623,058 18.8%
District of Columbia $55,092,178 $62,292,004 11.6%
Florida $1,366,193,807 $1,487,935,645 8.2%
Georgia $580,612,920 $655,515,772 11.4%
Hawaii $44,849,664 $44,849,664 0.0%
Idaho $83,525,730 $105,473,425 20.8%
Illinois $847,001,431 $934,241,252 9.3%
Indiana $464,982,829 $562,120,344 17.3%
Iowa $193,832,443 $230,430,967 15.9%
Kansas $167,216,488 $189,290,260 11.7%
Kentucky $465,178,958 $598,093,343 22.2%
Louisiana $476,400,908 $554,670,701 14.1%
Maine $175,938,952 $203,693,259 13.6%
Maryland $374,121,433 $417,080,496 10.3%
Massachusetts $682,519,910 $795,309,302 14.2%
Michigan $374,334,359 $604,759,491 38.1%
Minnesota $221,682,000 $265,240,353 16.4%
Mississippi $370,355,016 $494,805,247 25.2%
Missouri $600,484,118 $680,574,899 11.8%
Montana $58,634,278 $69,552,397 15.7%
Nebraska $135,355,734 $161,577,499 16.2%
Nevada $51,682,326 $62,849,319 17.8%
New Hampshire $80,562,181 $90,927,579 11.4%
New Jersey $584,533,211 $649,274,352 10.0%
New Mexico $57,502,713 $70,147,344 18.0%
New York $2,366,900,006 $2,779,026,904 14.8%
North Carolina $794,550,074 $971,066,103 18.2%
North Dakota $38,076,519 $43,288,363 12.0%
Ohio $882,579,749 $1,087,552,923 18.8%
Oklahoma $178,254,361 $215,717,760 17.4%
Oregon $163,263,562 $222,018,784 26.5%
Pennsylvania $533,527,373 $690,558,773 22.7%
Rhode Island $89,482,143 $104,912,603 14.7%
South Carolina $334,740,332 $438,498,935 23.7%
South Dakota $44,650,518 $52,608,524 15.1%
Tennessee $0 $0 0%
Texas $1,125,238,856 $1,327,222,456 15.2%
Utah $100,794,076 $117,101,302 13.9%
Vermont $91,724,918 $105,673,417 13.2%
Virginia $382,471,744 $419,133,293 8.7%
Washington $387,877,281 $387,877,281 0.0%
West Virginia $216,077,217 $256,395,319 15.7%
Wisconsin $349,558,072 $389,373,521 10.2%
Wyoming $27,233,795 $31,881,860 14.6%

*Hawaii did not report for FY 2000 and FY 2001. Their FY 1999 data are included in the FY 2000 and FY 2001 totals.
Washington State did not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals.

Source: CMS, MSIS Report, FY 1999, FY 2000, and 2001.

B-10
National Pharmaceutical Council Pharmaceutical Benefits 2003

Rankings Based on Drug Payments*

% of 2000 Total Medicaid 2000


State 2001 Payments 2001 Ranking Drug Payments 2000 Payments Ranking
California $2,808,298,437 1 11.84% $2,316,135,493 2
New York $2,779,026,904 2 11.72% $2,366,900,006 1
Florida $1,487,935,645 3 6.27% $1,366,193,807 3
Texas $1,327,222,456 4 5.60% $1,125,238,856 4
Ohio $1,087,552,923 5 4.59% $882,579,749 5
North Carolina $971,066,103 6 4.10% $794,550,074 7
Illinois $934,241,252 7 3.94% $847,001,431 6
Massachusetts $795,309,302 8 3.35% $682,519,910 8
Pennsylvania $690,558,773 9 2.91% $533,527,373 12
Missouri $680,574,899 10 2.87% $600,484,118 9
Georgia $655,515,772 11 2.76% $580,612,920 11
New Jersey $649,274,352 12 2.74% $584,533,211 10
Michigan $604,759,491 13 2.55% $374,334,359 18
Kentucky $598,093,343 14 2.52% $465,178,958 14
Indiana $562,120,344 15 2.37% $464,982,829 15
Louisiana $554,670,701 16 2.34% $476,400,908 13
Mississippi $494,805,247 17 2.09% $370,355,016 20
South Carolina $438,498,935 18 1.85% $334,740,332 22
Virginia $419,133,293 19 1.77% $382,471,744 17
Maryland $417,080,496 20 1.76% $374,121,433 19
Alabama $392,482,787 21 1.66% $331,574,388 23
Wisconsin $389,373,521 22 1.64% $349,558,072 21
Washington $387,877,281 23 1.64% $387,877,281 16
Connecticut $304,470,534 24 1.28% $264,641,409 24
Minnesota $265,240,353 25 1.12% $221,682,000 25
West Virginia $256,395,319 26 1.08% $216,077,217 26
Arkansas $248,392,084 27 1.05% $209,933,612 27
Iowa $230,430,967 28 0.97% $193,832,443 28
Oregon $222,018,784 29 0.94% $163,263,562 32
Oklahoma $215,717,760 30 0.91% $178,254,361 29
Maine $203,693,259 31 0.86% $175,938,952 30
Kansas $189,290,260 32 0.80% $167,216,488 31
Colorado $177,115,553 33 0.75% $152,478,786 33
Nebraska $161,577,499 34 0.68% $135,355,734 34
Utah $117,101,302 35 0.49% $100,794,076 35
Vermont $105,673,417 36 0.45% $91,724,918 36
Idaho $105,473,425 37 0.44% $83,525,730 38
Rhode Island $104,912,603 38 0.44% $89,482,143 37
New Hampshire $90,927,579 39 0.38% $80,562,181 39
Delaware $81,623,058 40 0.34% $66,263,771 40
New Mexico $70,147,344 41 0.30% $57,502,713 42
Montana $69,552,397 42 0.29% $58,634,278 41
Alaska $64,923,574 43 0.27% $51,196,685 45
Nevada $62,849,319 44 0.27% $51,682,326 44
District of Columbia $62,292,004 45 0.26% $55,092,178 43
South Dakota $52,608,524 46 0.22% $44,650,518 47
Hawaii $44,849,664 47 0.19% $44,849,664 46
North Dakota $43,288,363 48 0.18% $38,076,519 48
Wyoming $31,881,860 49 0.13% $27,233,795 49
Arizona $4,254,191 50 0.02% $1,952,231 50
Tennessee $0 51 0.00% $0 51

*Hawaii did not report for FY 2000 and FY 2001. Their FY 1999 data are included in the FY 2000 and FY 2001 totals.
Washington State did not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals.

Source: CMS, MSIS Report, FY 1999, FY 2000, and FY 2001.

B-11
National Pharmaceutical Council Pharmaceutical Benefits 2003

Drugs as a Percentage of Total Payments, 2001*

State Drug Payments Total Payments Percent of Total Payments


National Total $23,712,173,253 $2,950,095,956 12.8%
Alabama $392,482,787 $557,398,672 13.3%
Alaska $64,923,574 $2,453,184,175 11.6%
Arizona $4,254,191 $1,684,717,766 0.2%
Arkansas $248,392,084 $19,824,989,448 14.7%
California $2,808,298,437 $1,952,708,545 14.2%
Colorado $177,115,553 $2,962,088,094 9.1%
Connecticut $304,470,534 $601,182,212 10.3%
Delaware $81,623,058 $830,258,078 13.6%
District of Columbia $62,292,004 $8,398,159,525 7.5%
Florida $1,487,935,645 $3,815,267,274 17.7%
Georgia $655,515,772 $535,162,729 17.2%
Hawaii $44,849,664 $713,433,025 8.4%
Idaho $105,473,425 $8,150,021,068 14.8%
Illinois $934,241,252 $3,355,995,714 11.5%
Indiana $562,120,344 $1,660,864,098 16.7%
Iowa $230,430,967 $1,370,248,183 13.9%
Kansas $189,290,260 $3,235,072,953 13.8%
Kentucky $598,093,343 $2,881,578,117 18.5%
Louisiana $554,670,701 $1,457,465,782 19.2%
Maine $203,693,259 $3,855,002,531 14.0%
Maryland $417,080,496 $5,765,107,723 10.8%
Massachusetts $795,309,302 $5,316,248,739 13.8%
Michigan $604,759,491 $3,766,604,923 11.4%
Minnesota $265,240,353 $2,180,662,071 7.0%
Mississippi $494,805,247 $3,626,212,602 22.7%
Missouri $680,574,899 $482,543,436 18.8%
Montana $69,552,397 $1,089,787,848 14.4%
Nebraska $161,577,499 $565,299,853 14.8%
Nevada $62,849,319 $691,195,787 11.1%
New Hampshire $90,927,579 $5,011,794,888 13.2%
New Jersey $649,274,352 $1,476,537,827 13.0%
New Mexico $70,147,344 $27,497,918,486 4.8%
New York $2,779,026,904 $5,499,093,501 10.1%
North Carolina $971,066,103 $374,197,254 17.7%
North Dakota $43,288,363 $7,772,738,205 11.6%
Ohio $1,087,552,923 $2,004,799,211 14.0%
Oklahoma $215,717,760 $1,878,673,356 10.8%
Oregon $222,018,784 $7,634,325,250 11.8%
Pennsylvania $690,558,773 $1,095,852,989 9.0%
Rhode Island $104,912,603 $3,096,853,528 9.6%
South Carolina $438,498,935 $426,633,598 14.2%
South Dakota $52,608,524 $4,059,332,053 12.3%
Tennessee $0 $9,644,600,358 0.0%
Texas $1,327,222,456 $1,059,729,740 13.8%
Utah $117,101,302 $541,283,084 11.1%
Vermont $105,673,417 $2,715,962,318 19.5%
Virginia $419,133,293 $2,432,050,117 15.4%
Washington $387,877,281 $1,565,008,585 15.9%
West Virginia $256,395,319 $3,029,722,940 16.4%
Wisconsin $389,373,521 $241,187,030 12.9%
Wyoming $31,881,860 $2,950,095,956 13.2%

*Hawaii did not report for FY 2000 and FY 2001. Their FY 1999 data are included in the FY 2001 totals. Washington State did
not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals.

Source: CMS, MSIS Report, FY 1999, FY 2000, and FY 2001

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Drugs as a Percentage of Total Payments, 1996 – 2001*

State 1996 1997 1998 1999 2000 2001


National Total 8.8% 9.7% 9.5% 10.9% 11.9% 12.8%
Alabama 13.9% 14.4% 12.4% 16.6% 13.9% 13.3%
Alaska 7.8% 8.8% 10.0% 9.9% 10.9% 11.6%
Arizona 1.2% 0.8% 0.1% 0.1% 0.1% 0.2%
Arkansas 9.4% 10.4% 11.0% 13.4% 13.9% 14.7%
California 11.0% 11.7% 10.9% 12.2% 13.6% 14.2%
Colorado 8.0% 8.6% 7.7% 8.0% 8.4% 9.1%
Connecticut 7.2% 8.3% 7.7% 8.3% 9.3% 10.3%
Delaware 9.0% 12.6% 9.9% 11.6% 12.5% 13.6%
District of Columbia 4.6% 5.4% 5.6% 5.9% 7.0% 7.5%
Florida 14.1% 15.8% 16.4% 17.0% 18.6% 17.7%
Georgia 10.3% 11.0% 12.3% 14.3% 16.2% 17.2%
Hawaii 10.1% - 7.8% - 8.4% -
Idaho 10.1% 10.4% 12.9% 13.2% 14.1% 14.8%
Illinois 8.3% 9.1% 9.4% 10.6% 10.8% 11.5%
Indiana 11.0% 12.3% 12.7% 13.7% 15.6% 16.7%
Iowa 10.2% 11.4% 11.4% 12.4% 13.1% 13.9%
Kansas 10.5% 11.4% 13.0% 12.7% 13.6% 13.8%
Kentucky 14.1% 13.9% 13.2% 13.8% 16.0% 18.5%
Louisiana 12.1% 13.5% 14.8% 16.0% 18.1% 19.2%
Maine 11.6% 13.2% 16.3% 12.1% 13.5% 14.0%
Maryland 7.6% 7.8% 6.0% 9.6% 10.4% 10.8%
Massachusetts 8.0% 10.3% 10.8% 12.0% 12.6% 13.8%
Michigan 10.5% 10.2% 8.6% 6.8% 7.7% 11.4%
Minnesota 6.2% 6.6% 5.9% 6.1% 6.8% 7.0%
Mississippi 13.2% 14.6% 16.1% 17.2% 20.5% 22.7%
Missouri 14.0% 15.3% 14.9% 17.2% 18.4% 18.8%
Montana 9.3% 11.2% 11.7% 13.1% 13.5% 14.4%
Nebraska 10.5% 11.5% 12.3% 13.2% 14.1% 14.8%
Nevada 6.7% 7.1% 7.5% 8.8% 10.0% 11.1%
New Hampshire 7.7% 8.2% 9.1% 12.3% 12.4% 13.2%
New Jersey 10.0% 10.4% 10.1% 11.2% 12.4% 13.0%
New Mexico 7.0% 7.7% 4.8% 4.2% 4.6% 4.8%
New York 4.1% 5.1% 5.6% 7.8% 9.1% 10.1%
North Carolina 9.4% 10.7% 11.6% 14.3% 16.5% 17.7%
North Dakota 7.0% 7.7% 8.1% 9.1% 10.7% 11.6%
Ohio 9.4% 9.9% 10.5% 12.0% 12.4% 14.0%
Oklahoma 9.6% 10.7% - 11.7% 11.1% 10.8%
Oregon 5.1% 5.0% 6.4% 7.8% 9.6% 11.8%
Pennsylvania 11.5% 11.8% 8.6% 9.9% 8.4% 9.0%
Rhode Island 6.7% 7.1% 6.7% 8.5% 8.4% 9.6%
South Carolina 9.4% 9.9% 11.1% 10.9% 12.5% 14.2%
South Dakota 7.6% 8.7% 8.7% 10.0% 11.1% 12.3%
Tennessee 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Texas 9.7% 10.2% 11.5% 11.7% 12.4% 13.8%
Utah 11.4% 12.0% 11.1% 10.5% 10.5% 11.1%
Vermont 12.1% 14.4% 12.4% 15.9% 19.1% 19.5%
Virginia 12.5% 13.4% 13.4% 14.8% 15.4% 15.4%
Washington 12.4% 14.7% 12.0% 11.8% 15.9% -
West Virginia 11.1% 10.6% 12.0% 14.6% 15.5% 16.4%
Wisconsin 10.8% 10.9% 10.5% 12.4% 12.0% 12.9%
Wyoming 7.5% 8.1% 8.9% 11.2% 12.7% 13.2%

*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 and FY 2001. CMS included their FY 1999 data in the FY 2000 MSIS Report. New York did not provide Quarter 1 MSIS data for FY
1999 and was included based on totals estimated from State hard-copy reporting. Oklahoma did not report for FY 1998 and was excluded from
the national total for that year. Washington State did not report data for FY 2001.

Source: CMS, HCFA-2082 Reports, FY 1996-FY 1998 and MSIS Reports, FY 1999-2001.

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Total Drug Recipients *

State 1996 1997 1998 1999 2000 2001


National Total 22,575,656 20,943,872 19,324,605 19,854,953 20,516,082 21,750,110
Alabama 412,511 412,739 395,290 405,338 438,529 464,695
Alaska 40,839 42,174 43,734 52,086 60,273 65,278
Arizona 63,103 80,450 56,796 5,545 7,034 9,761
Arkansas 255,211 254,079 262,907 280,573 290,749 321,920
California 3,565,667 3,158,386 2,644,430 2,264,942 2,487,875 2,486,910
Colorado 173,707 156,631 147,033 151,581 160,264 143,169
Connecticut 209,557 120,522 108,331 108,753 113,089 116,755
Delaware 61,380 68,672 69,027 73,093 78,167 85,351
District of Columbia 66,349 64,494 57,733 37,862 38,129 35,324
Florida 1,079,467 1,024,555 1,014,372 1,079,997 1,072,082 1,159,155
Georgia 891,335 846,963 805,923 841,024 847,730 856,797
Hawaii 29,657 - 32,222 35,687 - -
Idaho 84,553 79,961 86,775 81,943 92,776 112,357
Illinois 1,028,753 1,008,740 959,472 965,747 1,013,254 1,068,535
Indiana 401,042 352,814 323,811 361,784 420,041 464,879
Iowa 230,749 221,061 215,173 213,161 212,178 221,691
Kansas 179,653 170,167 155,875 153,117 158,334 158,515
Kentucky 497,251 494,293 429,102 372,254 427,514 475,365
Louisiana 593,415 563,864 552,481 549,296 581,356 628,571
Maine 138,360 139,524 137,816 142,043 148,049 192,833
Maryland 268,440 256,423 176,403 345,740 409,511 413,755
Massachusetts 527,114 559,215 613,186 664,528 666,627 664,891
Michigan 763,232 688,882 589,818 436,652 435,654 551,593
Minnesota 294,589 227,027 203,220 184,947 180,104 188,566
Mississippi 404,263 391,328 368,609 375,585 415,925 478,404
Missouri 469,821 395,478 353,902 411,959 447,062 472,624
Montana 66,465 62,092 58,641 59,204 58,899 63,338
Nebraska 138,322 151,973 145,408 155,169 165,891 178,365
Nevada 60,274 55,876 50,903 48,535 51,169 55,580
New Hampshire 75,701 71,692 70,339 71,037 73,313 73,489
New Jersey 518,833 347,105 309,849 302,687 298,450 307,798
New Mexico 197,565 184,502 96,637 55,020 67,238 75,669
New York 1,737,372 1,667,927 1,803,428 2,193,515 2,173,791 2,283,293
North Carolina 764,482 779,229 764,886 797,903 827,039 907,413
North Dakota 40,062 39,654 37,675 38,191 38,957 39,758
Ohio 902,211 786,322 702,143 796,720 777,632 904,380
Oklahoma 245,075 207,441 - 224,742 221,984 249,678
Oregon 154,801 149,461 148,258 171,997 191,101 220,711
Pennsylvania 857,818 763,255 580,749 520,251 416,498 461,114
Rhode Island 52,239 46,817 44,852 49,285 49,809 50,379
South Carolina 365,409 359,910 401,611 446,938 474,465 542,764
South Dakota 49,056 47,845 46,588 50,783 53,666 58,203
Tennessee^ 18 3 1 0 0 0
Texas 2,058,903 1,986,178 1,894,447 1,853,536 1,852,801 1,917,351
Utah 114,321 105,676 126,953 128,297 133,164 136,682
Vermont 78,376 83,057 58,037 88,322 103,228 109,328
Virginia 417,580 396,719 383,880 373,491 347,251 333,880
Washington 305,791 292,733 274,463 301,753 339,440 -
West Virginia 299,967 280,550 267,398 274,842 261,544 269,174
Wisconsin 309,582 265,987 221,508 224,213 267,417 262,238
Wyoming 35,415 33,426 32,510 33,285 33,342 36,704

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. Hawaii also did not report for FY 2000 and FY 2001. They are excluded from the national total for that
year. Washington State did not report data for FY 2001. Oklahoma did not report for FY 1998. They are excluded from the national total for that
year.
^Tennessee does 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 1999-2001.

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Total Medicaid Eligibles by Basis of Eligibility, 2001*

Blind/ Foster Care BOE


State Total Eligibles Aged Disabled Children Adults Children Unknown
National Total 46,910,257 4,400,601 7,657,411 22,438,138 11,546,609 866,692 806
Alabama 780,434 89,484 182,696 377,130 125,448 5,676 0
Alaska 115,996 6,403 11,443 70,446 25,920 1,772 12
Arizona 808,386 37,102 102,909 430,749 229,944 7,682 0
Arkansas 550,668 52,240 104,421 267,241 120,840 5,913 13
California 8,495,030 626,550 959,584 3,169,960 3,598,569 140,366 1
Colorado 410,611 46,708 65,407 202,166 79,337 16,878 115
Connecticut 446,326 59,510 58,579 234,953 84,401 8,862 21
Delaware 133,079 9,613 16,500 59,452 45,580 1,934 0
District of Columbia 152,597 9,957 31,334 71,667 35,007 4,632 0
Florida 2,462,171 248,466 478,847 1,190,510 503,789 40,545 14
Georgia 1,328,379 109,245 229,725 717,007 253,525 18,877 0
Hawaii 202,912 18,824 21,616 85,074 73,338 4,060 -
Idaho 172,348 11,839 24,701 108,036 25,799 1,973 0
Illinois 1,798,723 112,455 282,956 952,915 368,149 82,248 0
Indiana 825,556 78,267 113,799 484,090 137,344 12,056 0
Iowa 331,025 41,128 57,426 157,333 65,498 9,640 0
Kansas 291,837 31,659 52,513 150,022 44,424 13,219 0
Kentucky 762,871 70,730 207,524 374,318 101,494 8,805 0
Louisiana 886,518 101,002 173,725 499,771 102,480 9,540 0
Maine 277,843 56,942 74,955 91,418 51,163 3,365 0
Maryland 704,628 54,654 114,951 386,346 132,309 16,367 1
Massachusetts 1,125,607 112,994 235,157 453,373 323,473 610 0
Michigan 1,430,246 100,156 288,790 744,902 255,755 40,564 79
Minnesota 609,856 64,108 83,579 309,972 142,313 9,884 0
Mississippi 681,161 74,018 159,306 369,654 74,943 3,224 16
Missouri 1,032,047 95,603 140,938 538,423 233,282 23,801 0
Montana 101,966 9,952 17,757 50,954 19,335 3,947 21
Nebraska 249,079 23,026 28,877 138,980 47,826 10,121 249
Nevada 167,247 17,920 29,993 79,283 35,217 4,834 0
New Hampshire 108,562 12,833 13,507 63,942 15,675 2,605 0
New Jersey 923,697 106,976 164,564 436,335 195,988 19,834 0
New Mexico 423,543 22,605 50,326 268,391 78,634 3,587 0
New York 3,548,630 385,586 684,658 1,573,767 825,201 79,418 0
North Carolina 1,397,486 180,515 234,304 685,285 281,193 16,189 0
North Dakota 65,425 10,242 9,672 29,750 14,026 1,735 0
Ohio 1,660,463 145,324 263,878 861,621 348,936 40,533 171
Oklahoma 631,996 62,350 76,638 397,586 88,507 6,915 0
Oregon 594,679 43,195 64,579 234,692 237,679 14,525 9
Pennsylvania 1,647,440 206,976 364,161 754,343 275,074 46,886 0
Rhode Island 194,113 19,137 36,402 84,191 48,834 5,548 1
South Carolina 871,675 78,673 120,088 444,607 220,606 7,692 9
South Dakota 106,154 9,894 16,042 61,743 16,704 1,771 0
Tennessee 1,601,406 88,350 324,191 682,755 493,266 12,822 22
Texas 2,729,660 362,522 351,509 1,526,365 458,079 31,185 0
Utah 214,597 11,855 26,386 119,196 50,579 6,581 0
Vermont 154,991 19,534 18,529 67,666 46,876 2,382 4
Virginia 700,715 97,093 137,282 359,463 92,498 14,334 45
Washington 916,838 69,054 121,662 520,323 191,871 13,927 1
West Virginia 351,489 31,183 86,566 168,367 58,889 6,484 0
Wisconsin 673,538 61,165 133,983 299,529 160,354 18,505 2
Wyoming 58,013 4,984 8,476 32,076 10,638 1,839 0

Note: Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year.
*Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 data are used in this table. Washington State did not
report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals.

Source: CMS, MSIS Report, FY 1999, FY 2000, and FY 2001.

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Total Medicaid Eligibles Per 1000 Population, 2001*

State Total State Population Total Eligibles* Eligibles per 1000 Populations
National Total 285,093,813 46,910,257 164.5
Alabama 4,466,440 780,434 174.7
Alaska 632,674 115,996 183.3
Arizona 5,297,684 808,386 152.6
Arkansas 2,692,041 550,668 204.6
California 34,533,054 8,495,030 246.0
Colorado 4,428,786 410,611 92.7
Connecticut 3,432,550 446,326 130.0
Delaware 795,576 133,079 167.3
District of Columbia 572,716 152,597 266.4
Florida 16,355,193 2,462,171 150.5
Georgia 8,394,795 1,328,379 158.2
Hawaii 1,225,038 202,912 165.6
Idaho 1,321,309 172,348 130.4
Illinois 12,517,168 1,798,723 143.7
Indiana 6,126,470 825,556 134.8
Iowa 2,932,225 331,025 112.9
Kansas 2,700,453 291,837 108.1
Kentucky 4,067,336 762,871 187.6
Louisiana 4,466,001 886,518 198.5
Maine 1,284,691 277,843 216.3
Maryland 5,383,377 704,628 130.9
Massachusetts 6,399,869 1,125,607 175.9
Michigan 10,005,218 1,430,246 143.0
Minnesota 4,985,202 609,856 122.3
Mississippi 2,857,716 681,161 238.4
Missouri 5,636,220 1,032,047 183.1
Montana 905,954 101,966 112.6
Nebraska 1,719,000 249,079 144.9
Nevada 2,094,633 167,247 79.8
New Hampshire 1,258,974 108,562 86.2
New Jersey 8,504,114 923,697 108.6
New Mexico 1,829,110 423,543 231.6
New York 19,074,843 3,548,630 186.0
North Carolina 8,195,249 1,397,486 170.5
North Dakota 636,285 65,425 102.8
Ohio 11,385,833 1,660,463 145.8
Oklahoma 3,467,181 631,996 182.3
Oregon 3,472,629 594,679 171.2
Pennsylvania 12,298,363 1,647,440 134.0
Rhode Island 1,058,992 194,113 183.3
South Carolina 4,059,818 871,675 214.7
South Dakota 758,156 106,154 140.0
Tennessee 5,745,808 1,601,406 278.7
Texas 21,340,598 2,729,660 127.9
Utah 2,279,590 214,597 94.1
Vermont 612,923 154,991 252.9
Virginia 7,192,697 700,715 97.4
Washington 5,992,760 916,838 153.0
West Virginia 1,801,641 351,489 195.1
Wisconsin 5,405,140 673,538 124.6
Wyoming 493,720 58,013 117.5

*Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 MSIS data are used in this table. Washington State
did not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals.

Source: U.S. Department of Commerce, Bureau of the Census, 2003; CMS, MSIS Report, FY 2000 and FY 2001.

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Medicaid Total Net Expenditures and Eligibles, 2001*

Total Net Medical Total Average


State Assistance Expenditures Eligibles Per Eligible
National Total $215,809,899,631 46,910,257 $4,000
Alabama $2,875,372,953 780,434 $3,684
Alaska $576,586,201 115,996 $4,971
Arizona $2,665,261,328 808,386 $3,297
Arkansas $1,852,176,546 550,668 $3,364
California $23,870,521,004 8,495,030 $2,810
Colorado $2,142,029,851 410,611 $5,217
Connecticut $3,213,848,086 446,326 $7,201
Delaware $591,974,246 133,079 $4,448
District of Columbia $979,941,105 152,597 $6,422
Florida $8,557,796,303 2,462,171 $3,476
Georgia $5,037,084,881 1,328,379 $3,792
Hawaii $634,781,970 202,912 $3,128
Idaho $693,205,598 172,348 $4,022
Illinois $7,764,611,352 1,798,723 $4,317
Indiana $4,008,812,857 825,556 $4,856
Iowa $1,666,923,701 331,025 $5,036
Kansas $1,686,410,544 291,837 $5,779
Kentucky $3,304,053,663 762,871 $4,331
Louisiana $4,201,982,590 886,518 $4,740
Maine $1,315,523,163 277,843 $4,735
Maryland $3,256,576,882 704,628 $4,622
Massachusetts $6,619,524,971 1,125,607 $5,881
Michigan $7,218,697,113 1,430,246 $5,047
Minnesota $3,835,870,579 609,856 $6,290
Mississippi $2,438,979,981 681,161 $3,581
Missouri $4,744,963,426 1,032,047 $4,598
Montana $482,357,404 101,966 $4,731
Nebraska $1,187,237,577 249,079 $4,767
Nevada $674,337,888 167,247 $4,032
New Hampshire $873,248,831 108,562 $8,044
New Jersey $7,123,653,988 923,697 $7,712
New Mexico $1,467,417,736 423,543 $3,465
New York $31,367,464,639 3,548,630 $8,839
North Carolina $6,150,681,587 1,397,486 $4,401
North Dakota $406,418,593 65,425 $6,212
Ohio $8,433,412,161 1,660,463 $5,079
Oklahoma $2,021,033,069 631,996 $3,198
Oregon $2,658,358,391 594,679 $4,470
Pennsylvania $10,908,343,146 1,647,440 $6,621
Rhode Island $1,187,880,819 194,113 $6,120
South Carolina $3,019,387,228 871,675 $3,464
South Dakota $464,455,469 106,154 $4,375
Tennessee $5,501,312,153 1,601,406 $3,435
Texas $11,583,679,558 2,729,660 $4,244
Utah $833,720,115 214,597 $3,885
Vermont $601,467,093 154,991 $3,881
Virginia $3,036,846,387 700,715 $4,334
Washington $4,305,724,247 916,838 $4,696
West Virginia $1,548,398,817 351,489 $4,405
Wisconsin $3,976,142,914 673,538 $5,903
Wyoming $243,408,927 58,013 $4,196

*Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 MSIS data are used in this table. Washington State
did not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals.

Source: CMS, CMS-64 Report, FY 2001 and CMS-MSIS Report, 2001.

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Appendix C:
Medicaid Rebate Law

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TITLE 42 - THE PUBLIC HEALTH AND WELFARE


CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

Sec. 1396r-8. Payment for covered outpatient drugs1

(a) Requirement for rebate agreement

(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.

(2) Effective date


Paragraph (1) shall first apply to drugs dispensed under this subchapter on or after January 1, 1991.

(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.

(4) Effect on existing agreements


In the case of a rebate agreement in effect between a State and a manufacturer on November 5, 1990,
such agreement, for the initial agreement period specified therein, shall be considered to be a rebate
agreement in compliance with this section with respect to that State, if the State agrees to report to the
Secretary any rebates paid pursuant to the agreement and such agreement provides for a minimum
aggregate rebate of 10 percent of the State’s total expenditures under the State Plan for coverage of the
manufacturer’s drugs under this subchapter. If, after the initial agreement period, the State establishes
to the satisfaction of the Secretary that an agreement in effect on November 5, 1990, provides for
rebates that are at least as large as the rebates otherwise required under this section, and the State
agrees to report any rebates under the agreement to the Secretary, the agreement shall be considered to
be a rebate agreement in compliance with the section for the renewal periods of such agreement.

(5) Limitation on prices of drugs purchased by covered entities

(A) Agreement with Secretary

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.

(B) “Covered entity” defined


In this subsection, the term “covered entity” means an entity described in section 256b(a)(4) of
this title.

(C) Establishment of alternative mechanism to ensure against duplicate discounts or rebates


If the Secretary does not establish a mechanism under section 256b(a)(5)(A) of this title within
12 months of November 4, 1992, the following requirements shall apply:
(i) Entities
Each covered entity shall inform the single State agency under section 1396a(a)(5) of this title
when it is seeking reimbursement from the State Plan for medical assistance described in
section 1396d(a)(12) of this title with respect to a unit of any covered outpatient drug which is
subject to an agreement under section 256b(a) of this title.
(ii) State agency
Each such single State agency shall provide a means by which a covered entity shall indicate
on any drug reimbursement claims form (or format, where electronic claims management is
used) that a unit of the drug that is the subject of the form is subject to an agreement under
section 256b of this title, and not submit to any manufacturer a claim for a rebate payment
under subsection (b) of this section with respect to such a drug.

(D) Effect of subsequent amendments


In determining whether an agreement under subparagraph (A) meets the requirements of
section 256b of this title, the Secretary shall not take into account any amendments to such
section that are enacted after November 4, 1992.

(E) Determination of compliance


A manufacturer is deemed to meet the requirements of this paragraph if the manufacturer
establishes to the satisfaction of the Secretary that the manufacturer would comply (and has
offered to comply) with the provisions of section 256b of this title (as in effect immediately
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.

(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.

(B) Effect of subsequent amendments


In determining whether a master agreement described in subparagraph (A) meets the
requirements of section 8126 of title 38, the Secretary shall not take into account any
amendments to such section that are enacted after November 4, 1992.

(C) Determination of compliance


A manufacturer is deemed to meet the requirements of this paragraph if the manufacturer
establishes to the satisfaction of the Secretary that the manufacturer would comply (and has
offered to comply) with the provisions of section 8126 of title 38, (as in effect immediately

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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.

(b) Terms of rebate agreement

(1) Periodic rebates

(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) Offset against medical assistance


Amounts received by a State under this section (or under an agreement authorized by the
Secretary under subsection (a)(1) of this section or an agreement described in subsection (a)(4)
of this section) in any quarter shall be considered to be a reduction in the amount expended
under the State Plan in the quarter for medical assistance for purposes of section 1396b(a)(1)
of this title.

(2) State provision of information

(A) State responsibility


Each State agency under this subchapter shall report to each manufacturer not later than 60
days after the end of each rebate period and in a form consistent with a standard reporting
format established by the Secretary, information on the total number of units of each dosage
form and strength and package size of each covered outpatient drug dispensed after December
31, 1990, for which payment was made under the plan during the period, and shall promptly
transmit a copy of such report to the Secretary.

(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.

(3) Manufacturer provision of price information

(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


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).

(ii) False information


Any manufacturer with an agreement under this section that knowingly provides false
information is subject to a civil money penalty in an amount not to exceed $100,000 for
each item of false information. Such civil money penalties are in addition to other
penalties as may be prescribed by law. The provisions of section 1320a-7a of this title
(other than subsections (a) 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.

(D) Confidentiality of information


Notwithstanding any other provision of law, information disclosed by manufacturers or
wholesalers under this paragraph or under an agreement with the Secretary of Veterans Affairs
described in subsection (a)(6)(A)(ii) of this section (other than the wholesale acquisition cost
for purposes of carrying out section 1847A) is confidential and shall not be disclosed by the
Secretary or the Secretary of Veterans Affairs or a State agency (or contractor therewith) in a
form which discloses the identity of a specific manufacturer or wholesaler, prices charged for
drugs by such manufacturer or wholesaler, except-
(i) as the Secretary determines to be necessary to carry out this section, to carry out section
1847A (including the determination and implementation of the payment amount), or to
carry out section 1847B,

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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).

(4) Length of agreement

(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) Delay before reentry

(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.

Determination of amount of rebate

(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.

(B) Range of rebates required


(i) Minimum rebate percentage
For purposes of subparagraph (A)(ii)(II), the “minimum rebate percentage” for rebate
periods beginning -
(I) after December 31, 1990, and before October 1, 1992, is 12.5 percent;
(II) after September 30, 1992, and before January 1, 1994, is 15.7 percent;
(III) after December 31, 1993, and before January 1, 1995, is 15.4 percent;
(IV) after December 31, 1994, and before January 1, 1996, is 15.2 percent; and
(V) after December 31, 1995, is 15.1 percent.
(ii) Temporary limitation on maximum rebate amount
In no case shall the amount applied under subparagraph (A)(ii) for a rebate period
beginning -
(I) before January 1, 1992, exceed 25 percent of the average manufacturer price; or
(II) after December 31, 1991, and before January 1, 1993, exceed 50 percent of the
average manufacturer price.

(C) “Best price” defined


For purposes of this section -
(i) In general
The term “best price” means, with respect to a single source drug or innovator multiple
source drug of a manufacturer, the lowest price available from the manufacturer during the
rebate period to any wholesaler, retailer, provider, health maintenance organization,
nonprofit entity, or governmental entity within the United States, excluding -
(I) any prices charged on or after October 1, 1992, to the Indian Health Service, the
Department of Veterans Affairs, a State home receiving funds under section 1741 of title
38, the Department of Defense, the Public Health Service, or a covered entity described
in subsection (a)(5)(B) of this section (including inpatient prices charged to hospitals
described in section 340B(a)(4)(L) of the Public Health Service Act);
(II) any prices charged under the Federal Supply Schedule of the General Services
Administration;
(III) any prices used under a State pharmaceutical assistance program; and
(IV) any depot prices and single award contract prices, as defined by the Secretary, of
any agency of the Federal Government;
(V) the prices negotiated from drug manufacturers for covered discount card drugs under
an endorsed discount card program under section 1860D-31; and
(VI) any prices charged which are negotiated by a prescription drug plan under part D of
title XVIII, by an MA-PD plan under part C of such title with respect to covered part D
drugs or by a qualified retiree prescription drug plan (as defined in section 1860D-
22(a)(2)) with respect to such drugs on behalf of individuals entitled to benefits under
part A or enrolled under part B of such title.
(ii) Special rules
The term “best price” -
(I) shall be inclusive of cash discounts, free goods that are contingent on any purchase
requirement, volume discounts, and rebates (other than rebates under this section);
(II) shall be determined without regard to special packaging, labeling, or identifiers on
the dosage form or product or package; and

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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.”

(3) Rebate for other drugs

(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.

(B) “Applicable percentage” defined


For purposes of subparagraph (A)(i), the “applicable percentage” for rebate periods beginning
-
(i) before January 1, 1994, is 10 percent, and
(ii) after December 31, 1993, is 11 percent.

(d) Limitations on coverage of drugs

(1) Permissible restrictions

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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).

(2) List of drugs subject to restriction


The following drugs or classes of drugs, or their medical uses, may be excluded from coverage or
otherwise restricted:

(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.

(3) Update of drug listings


The Secretary shall, by regulation, periodically update the list of drugs or classes of drugs described in
paragraph (2) or their medical uses, which the Secretary has determined, based on data collected by
surveillance and utilization review programs of State medical assistance programs, to be subject to
clinical abuse or inappropriate use.

(4) Requirements for formularies


A State may establish a formulary if the formulary meets the following requirements:

(A) The formulary is developed by a committee consisting of physicians, pharmacists, and


other appropriate individuals appointed by the Governor of the State (or, at the option of the
State, the State’s drug use review board established under subsection (g)(3) of this section).

(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.

(5) Requirements of prior authorization programs


A State Plan under this subchapter may require, as a condition of coverage or payment for a covered
outpatient drug for which Federal financial participation is available in accordance with this section,
with respect to drugs dispensed on or after July 1, 1991, the approval of the drug before its dispensing
for any medically accepted indication (as defined in subsection (k)(6) of this section) only if the
system providing for such approval –

(A) provides response by telephone or other telecommunication device within 24 hours of a


request for prior authorization; and

(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).

(6) Other permissible restrictions


A State may impose limitations, with respect to all such drugs in a therapeutic class, on the minimum
or maximum quantities per prescription or on the number of refills, if such limitations are necessary to
discourage waste, and may address instances of fraud or abuse by individuals in any manner
authorized under this chapter.

(e) Treatment of pharmacy reimbursement limits

(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).

(2) Special rule


If a State is not in compliance with the regulations described in paragraph (1)(B), paragraph (1)(A)
shall not apply to such State until such State is in compliance with such regulations.

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(3) Effect on State maximum allowable cost limitations


This section shall not supersede or affect provisions in effect prior to January 1, 1991, or after
December 31, 1994, relating to any maximum allowable cost limitation established by a State for
payment by the State for covered outpatient drugs, and rebates shall be made under this section
without regard to whether or not payment by the State for such drugs is subject to such a limitation or
the amount of such a limitation.

(4) Establishment of upper payment limits


The Secretary shall establish a Federal upper reimbursement limit for each multiple source drug for
which the FDA has rated three or more products therapeutically and pharmaceutically equivalent,
regardless of whether all such additional formulations are rated as such and shall use only such
formulations when determining any such upper limit.

(f) Repealed and redesignated

(g) Drug use review

(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.

(2) Description of program


Each drug use review program shall meet the following requirements for covered outpatient drugs:

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(A) Prospective drug review


(i) The State plan shall provide for a review of drug therapy before each prescription is
filled or delivered to an individual receiving benefits under this subchapter, typically at the
point-of-sale or point of distribution. The review shall include screening for potential drug
therapy problems due to therapeutic duplication, drug-disease contraindications, drug-drug
interactions (including serious interactions with nonprescription or over-the-counter drugs),
incorrect drug dosage or duration of drug treatment, drug-allergy interactions, and clinical
abuse/misuse. Each State shall use the compendia and literature referred to in paragraph
(1)(B) as its source of standards for such review.
(ii) As part of the State’s prospective drug use review program under this subparagraph
applicable State law shall establish standards for counseling of individuals receiving
benefits under this subchapter by pharmacists which includes at least the following:
(I) The pharmacist must offer to discuss with each individual receiving benefits under
this subchapter or caregiver of such individual (in person, whenever practicable, or
through access to a telephone service which is toll-free for long-distance calls) who
presents a prescription, matters which in the exercise of the pharmacist’s professional
judgment (consistent with State law respecting the provision of such information), the
pharmacist deems significant including the following:
(aa) The name and description of the medication.
(bb) The route, dosage form, dosage, route of administration, and duration of drug
therapy.
(cc) Special directions and precautions for preparation, administration and use by
the patient.
(dd) Common severe side or adverse effects or interactions and therapeutic
contraindications that may be encountered, including their avoidance, and the
action required if they occur.
(ee) Techniques for self-monitoring drug therapy.
(ff) Proper storage.
(gg) Prescription refill information.
(hh) Action to be taken in the event of a missed dose.
(II) A reasonable effort must be made by the pharmacist to obtain, record, and maintain
at least the following information regarding individuals receiving benefits under this
subchapter:
(aa) Name, address, telephone number, date of birth (or age) and gender.
(bb) Individual history where significant, including disease state or states, known
allergies and drug reactions, and a comprehensive list of medications and relevant
devices.
(cc) Pharmacist comments relevant to the individual’s drug therapy.
Nothing in this clause shall be construed as requiring a pharmacist to provide
consultation when an individual receiving benefits under this subchapter or
caregiver of such individual refuses such consultation.

(B) Retrospective drug use review


The program shall provide, through its mechanized drug claims processing and information
retrieval systems (approved by the Secretary under section 1396b(r) of this title) or otherwise,
for the ongoing periodic examination of claims data and other records in order to identify
patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care, among
physicians, pharmacists and individuals receiving benefits under this subchapter, or associated
with specific drugs or groups of drugs.

(C) Application of standards


The program shall, on an ongoing basis, assess data on drug use against explicit predetermined
standards (using the compendia and literature referred to in paragraph (1)(B) as the source of
standards for such assessment) including but not limited to monitoring for therapeutic

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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, and 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.

(D) Educational program


The program shall, through its State drug use review board established under paragraph (3),
either directly or through contracts with accredited health care educational institutions, State
medical societies or State pharmacists associations/societies or other organizations as
specified by the State, and using data provided by the State drug use review board on common
drug therapy problems, provide for active and ongoing educational outreach programs
(including the activities described in paragraph (3)(C)(iii) of this subsection) to educate
practitioners on common drug therapy problems with the aim of improving prescribing or
dispensing practices.

(3) State drug use review board

(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.

(D) Annual report


Each State shall require the DUR Board to prepare a report on an annual basis. The State shall
submit a report on an annual basis to the Secretary which shall include a description of the
activities of the Board, including the nature and scope of the prospective and retrospective
drug use review programs, a summary of the interventions used, an assessment of the impact
of these educational interventions on quality of care, and an estimate of the cost savings
generated as a result of such program. The Secretary shall utilize such report in evaluating the
effectiveness of each State’s drug use review program.

(h) Electronic claims management

(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.

(i) Annual report

(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.

(j) Exemption of organized health care settings

(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 -

(1) Average manufacturer price


The term “average manufacturer price” means, with respect to a covered outpatient drug of a
manufacturer for a rebate period, the average price paid to the manufacturer for the drug in the United
States by wholesalers for drugs distributed to the retail pharmacy class of trade, after deducting
customary prompt pay discounts.

(2) Covered outpatient drug


Subject to the exceptions in paragraph (3), the term “covered outpatient drug” means -

(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

(B) a biological product, other than a vaccine which -


(i) may only be dispensed upon prescription,
(ii) is licensed under section 262 of this title, and
(iii) is produced at an establishment licensed under such section to produce such product;
and

(C) insulin certified under section 506 of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 356).

(3) Limiting definition


The term “covered outpatient drug” does not include any drug, biological product, or insulin provided
as part of, or as incident to and in the same setting as, any of the following (and for which payment
may be made under this subchapter as part of payment for the following and not as direct
reimbursement for the drug):

(A) Inpatient hospital services.

(B) Hospice services.

(C) Dental services, except that drugs for which the State Plan authorizes direct
reimbursement to the dispensing dentist are covered outpatient drugs.

(D) Physicians’ services.

(E) Outpatient hospital services.

(F) Nursing facility services and services provided by an intermediate care facility for the
mentally retarded.

(G) Other laboratory and x-ray services.

(H) Renal dialysis.


Such term also does not include any such drug or product for which a National Drug Code
number is not required by the Food and Drug Administration or a drug or biological used for a
medical indication which is not a medically accepted indication. Any drug, biological
product, or insulin excluded from the definition of such term as a result of this paragraph shall
be treated as a covered outpatient drug for purposes of determining the best price (as defined
in subsection (C)(1)(C) of this section) for such drug, biological product, or insulin.

(4) Nonprescription drugs


If a State Plan for medical assistance under this subchapter includes coverage of prescribed drugs as
described in section 1396d(a)(12) of this title and permits coverage of drugs which may be sold
without a prescription (commonly referred to as “over-the-counter” drugs), if they are prescribed by a
physician (or other person authorized to prescribe under State law), such a drug shall be regarded as a
covered outpatient drug.

(5) Manufacturer

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The term “manufacturer” means any entity which is engaged in -

(A) the production, preparation, propagation, compounding, conversion, or processing of


prescription drug products, either directly or indirectly by extraction from substances of
natural origin, or independently by means of chemical synthesis, or by a combination of
extraction and chemical synthesis, or

(B) in the packaging, repackaging, labeling, relabeling, or distribution of prescription drug


products. Such term does not include a wholesale distributor of drugs or a retail pharmacy
licensed under State law.

(6) Medically accepted indication


The term “medically accepted indication” means any use for a covered outpatient drug which is
approved under the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 301 et seq.) or the use of which
is supported by one or more citations included or approved for inclusion in any of the compendia
described in subsection (g)(1)(B)(i) of this section.

(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.

(8) Rebate period


The term “rebate period” means, with respect to an agreement under subsection (a) of this section, a
calendar quarter or other period specified by the Secretary with respect to the payment of rebates
under such agreement.

(9) State agency


The term “State agency” means the agency designated under section 1396a(a)(5) of this title to
administer or supervise the administration of the State Plan for medical assistance.

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Appendix D:
Federal Upper Limits for
Multiple Source Products

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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 March 20, 2004. 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
March 20, 2004.

Generic Name Upper Limit per Unit (Source)

Acebutolol Hydrochloride
Eq 200 mg base, Capsule, Oral 100 $0.4612 B
Eq 400 mg base, Capsule, Oral 100 0.6713 B

Acetaminophen; Butalbital; Caffeine


500 mg; 50mg; 40 mg, Tablet, Oral 100 0.5399 B

Acetaminophen; Codeine Phosphate


300 mg; 15 mg, Tablet, Oral 100 0.1500 R
300 mg; 30 mg, Tablet, Oral 100 0.2137 B
300 mg; 60 mg, Tablet, Oral 100 0.2812 B

Acetaminophen; Hydrocodone Bitartrate


500 mg; 5 mg, Capsule, Oral 100 0.1943 B
500 mg /15 ml; 7.5 mg/15 ml Elixir, Oral 473 ml 0.1014 R
500 mg, 2.5 mg, Tablet, Oral 100 0.2190 B
500 mg; 5 mg, Tablet, Oral 100 0.1153 B
500 mg; 7.5 mg, Tablet, Oral 100 0.1913 B
500 mg; 10 mg, Tablet, Oral 100 0.4603 B
650 mg; 7.5 mg, Tablet, Oral 100 0.1550 B
650 mg; 10 mg, Tablet, Oral 100 0.1852 R
660 mg; 10 mg, Tablet, Oral 100 0.5284 B
750 mg; 7.5 mg, Tablet, Oral 100 0.1750 R

Generic Name Upper Limit per Unit (Source)


SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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Acetaminophen; Oxycodone Hydrochloride


500 mg; 5 mg, Capsule, Oral 100 0.2137 B
325 mg; 5 mg, Tablet, Oral 100 0.1192 B

Acetaminophen; Propoxyphene Hydrochloride


650 mg; 65 mg, Tablet, Oral 100
0.1688 B
Acetaminophen; Propoxyphene Napsylate
650 mg; 100 mg, Tablet, Oral 100 0.1800 R

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

Amiloride Hydrochloride; Hydrochlorothiazide


Eq 5 mg Anhydrous; 50 mg, Tablet, Oral 100 0.0675 B

Aminophylline
100 mg, Tablet, Oral 100 0.0278 B
200 mg, Tablet, Oral 100 0.0390 R

Amiodarone Hydrochloride
200 mg, Tablet, Oral 60 1.6875 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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Generic Name Upper Limit per Unit (Source)

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

Amitriptyline Hydrochloride; Perphenazine


10 mg; 2 mg, Tablet, Oral 100 0.0704 B
25 mg; 2 mg, Tablet, Oral 100 0.0869 B

Amoxapine
50 mg, Tablet, Oral 100 0.5425 R

Amoxicillin
250 mg, Capsule, Oral 100 0.0636 B
500 mg, Capsule, Oral 100 0.1272 B
125 mg/5 ml, Powder for Reconstitution, Oral 150 0.0201 B
250 mg/5 ml, Powder for Reconstitution, Oral 100 0.0281 B
250 mg, Tablet, Chewable, Oral 100 0.1595 B

Ampicillin/Ampicillin Trihydrate
250 mg, Capsule, Oral 100 0.1736 B
500 mg, Capsule, Oral 100 0.2991 B

Aspirin; Butalbital; Caffeine


325 mg; 50 mg; 40 mg, Tablet, Oral 100 0.2400 R

Aspirin; Carisoprodol
325 mg; 200 mg, Tablet, Oral 100 0.3522 B

Atenolol
25 mg, Tablet, Oral 100 0.1595 B
50 mg, Tablet, Oral 100 0.0885 B
100 mg, Tablet, Oral 100 0.1650 B

Atenolol; Chlorthalidone
50 mg; 25 mg, Tablet, Oral 100 0.1762 B
100 mg; 25 mg, Tablet, Oral 100 0.2549 B

Atropine Sulfate; Diphenoxylate Hydrochloride


0.025 mg; 2.5 mg, Tablet, Oral 100 0.3743 R

Benzonatate
100 mg, Capsule, Oral 100 0.4387 B

Generic Name Upper Limit per Unit (Source)

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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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 0.1437 B

Betamethasone Valerate
Eq 0.1% base, Cream, Topical 45 gm 0.1197 B
Eq 0.1% base, Lotion, Topical 60 ml 0.1087 B

Bisoprolol Fumarate; Hydrochlorothiazide


2.5 mg; 6.25 mg, Tablet, Oral 100 0.8250 B
5 mg; 6.25 mg, Tablet, Oral 100 0.8250 B
10 mg; 6.25 mg, Tablet, Oral 100 0.8250 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

Captopril
12.5 mg, Tablet, Oral 100 0.0398 B
100 mg, Tablet, Oral 100 0.1867 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

Generic Name Upper Limit per Unit (Source)

Carteolol Hydrochloride

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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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 0.1107 B
Eq 187 mg base/5 ml,
Powder for reconstitution, Oral 100 0.1661 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 0.2513 B
Eq 500 mg base, Capsule, Oral 100 0.4446 B

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 0.0146 B

Chlorpheniramine Maleate
4 mg, Tablet, Oral 100 0.0171 M

Chlorpropamide
100 mg, Tablet, Oral 100 0.1837 B
250 mg, Tablet, Oral 100 0.3885 B

Chlorzoxazone
500 mg, Tablet, Oral 100 0.1085 B

Cholestyramine
Eq 4 gm Resin/Packet, Powder, Oral 60 1.2767 B

Cimetidine
200 mg, Tablet, Oral 100 0.1238 B
300 mg, Tablet, Oral 100 0.1313 B
400 mg, Tablet, Oral 100 0.1537 B
800 mg, Tablet, Oral 100 0.2775 B

Generic Name Upper Limit per Unit (Source)

Cimetidine Hydrochloride

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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Eq 300 mg base/ 5 ml Solution, Oral , 240 ml 0.1139 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 0.5772 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

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

Dexamethasone; Neomycin Sulfate; Polymyxin B Sulfate


0.1%; Eq 3.5 mg base/gm; 10,000 units/gm, Ointment, Ophthalmic 3.5 gm 1.0713 B

Diazepam
2 mg, Tablet, Oral 100 0.0423 B
5 mg, Tablet, Oral 100 0.0718 B
10 mg, Tablet, Oral 100 0.1417 B
Generic Name Upper Limit per Unit (Source)

Diclofenac Potassiuim
50 mg, Tablet, Oral 100 0.8625 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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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

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 0.0915 B
Eq 100 mg base, Capsule, Oral 50 0.1050 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

Generic Name Upper Limit per Unit (Source)

Enalapril Maleate
2.5 mg, Tablet, Oral, 100 0.3075 B
5 mg, Tablet, Oral, 100 0.5490 B
10 mg, Tablet, Oral, 100 0.6863 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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20 mg, Tablet, Oral, 100 0.9150 B

Erythromycin
250 mg, Capsule, Delayed Released Pellets, Oral 100 0.1538 B
2%, Solution, Topical 60 ml 0.0687 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 0.1932 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
200 mg, Capsule, Oral 100 0.4800 B
400 mg, Tablet, Oral 100 0.3600 R
500 mg, Tablet, Oral 100 1.0032 R

Famotidine
20 mg, Tablet, Oral 100 0.6210 B
40 mg, Tablet, Oral 100 1.2000 B

Fenoprofen Calcium
Eq 600 mg base, Tablet, Oral 100 0.2400 R

Fluocinonide
0.05%, Cream, Topical 60 gm 0.1789 B
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

Generic Name Upper Limit per Unit (Source)

Fluoxetine Hydrochloride
10 mg, Capsule, Oral 100 0.5850 B
20 mg, Capsule, Oral 100 0.6000 R
40 mg Capsule, Oral 30 4.0125 B
20 mg/5ml, Solution, Oral 120 ml 0.7500 R

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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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 0.3600 B

Flurbiprofen Sodium
0.03%, Solution/Drops, Ophthalmic 2ml 4.0679 B

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 0.6540 B

Glipizide
5 mg, Tablet, Oral 100 0.0699 B
10 mg, Tablet, Oral 100 0.0944 B

Glyburide
1.5 mg, Tablet, Oral 100 0.2549 R
3 mg, Tablet, Oral 100 0.3202 R

Gramicidin; Neomycin Sulfate; Polymyxin B Sulfate


0.025 mg/ml; Eq 1.75 mg base/ml; 10,000 units/ml
Solution/Drops, Ophthalmic 10 ml 2.2185 B

Generic Name Upper Limit per Unit (Source)

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 0.1500 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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Homatropine Methylbromide; Hydrocodone Bitartrate


1.5 mg/5 ml; 5mg/5 ml, Syrup, Oral 480 ml 0.0280 R

Hydralazine Hydrochloride
10 mg, Tablet, Oral 100 0.0354 B

Hydrochlorothiazide; Propranolol Hydrochloride


25 mg; 40 mg, Tablet, Oral 100 0.0877 B
25 mg; 80 mg, Tablet, Oral 100 0.1320 B

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 0.1932 B
50 mg; 75 mg, Tablet, Oral 100 0.0488 B

Hydrocortisone
0.5%, Cream, Topical, 30 gm 0.0375 B
1%, Cream, Topical 30 gm 0.0572 B
2.5%, Cream, Topical 30 gm 0.1820 B
1%, Lotion, Topical 120 ml 0.0572 B
2.5%, Lotion, Topical 59 ml 0.6814 B

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

Generic Name Upper Limit per Unit (Source)

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

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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2.5 mg, Tablet, Oral 100 0.1125 B

Ipratropium Bromide
0.02%, Solution for Inhalation, 2.500 ml, 25s 0.2340 R

Isoniazid
300 mg, Tablet, Oral 100 0.0890 B

Isosorbide Dinitrate
5 mg, Tablet, Oral 100 0.0198 R
10 mg, Tablet, Oral 100 0.0205 R
20 mg, Tablet, Oral 100 0.0375 R
2.5 mg, Tablet, Sublingual 100 0.0488 B

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 2.7750 B

Ketoprofen
50 mg, Capsule, Oral 100 0.4749 B
75 mg, Capsule, Oral 100 0.4058 B

Ketorolac Tromethamine
10 mg, Tablet, Oral 100 0.6773 M

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

Generic Name Upper Limit per Unit (Source)

Lidocaine Hydrochloride
2%, Solution, Oral 100 ml 0.0278 M

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

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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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

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 0.0717 B

Medroxyprogesterone Acetate
2.5 mg, Tablet, Oral 100 0.2025 B
5 mg, Tablet, Oral 100 0.3061 B
10 mg, Tablet, Oral 100 0.3787 B

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

Generic Name Upper Limit per Unit (Source)

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 0.1425 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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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 0.0703 B
100 mg, Tablet, Oral 100 0.0914 B

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

Generic Name Upper Limit per Unit (Source)

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

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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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

Nifedipine
10 mg, Capsule, Oral 100 0.1875 B

Nizatidine
150 mg, Capsule, Oral, 60 1.8307 B
300 mg, Capsule, Oral, 30 3.6615 B

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
100,000 units/ml, Suspension, Oral 60 ml 0.1757 B

Nystatin; Triamcinolone Acetonide


100,000 units/gm; 0.1%, Cream, Topical 30 gm 0.0975 B

Oxaprozin
600 mg, Tablet, Oral 100 0.6758 B

Generic Name Upper Limit per Unit (Source

Oxazepam
10 mg, Capsule, Oral 100 0.5363 B
15 mg, Capsule, Oral 100 0.7624 B
30 mg, Capsule, Oral 100 1.2337 R

Oxybutynin Chloride
5 mg, Tablet, Oral 100 0.1260 R

Pentoxifylline
400 mg, Tablet, Extended Release, Oral 100 0.3147 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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Perphenazine
2 mg, Tablet, Oral 100 0.3473 R
4 mg, Tablet, Oral 100 0.3713 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

Polymyxin B Sulfate; Trimethoprim Sulfate


10,000 units/ml; Eq 1 mg base/ml, Solution/Drops, Ophthalmic 10 ml 1.2360 B

Potassium Chloride
8 mEq, Tablet, Extended Release, Oral 100 0.0772 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

Generic Name Upper Limit per Unit (Source)

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

Pseudoephedrine Hydrochloride; Tripolidine Hydrochloride


60 mg; 2.5 mg, Tablet, Oral 100 0.0336 B

Ranitidine Hydrochloride
Eq 150 mg base, Tablet, Oral, 100 0.3411 R
Eq 300 mg base, Tablet, Oral 100 0.3180 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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Selegiline Hydrochloride
5 mg, Tablet, Oral 60 0.7658 R

Selenium Sulfide
2.5%, Lotion/Shampoo, Topical 120 ml 0.0750 B

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 0.1590 B

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

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

Generic Name Upper Limit per Unit (Source)

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

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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National Pharmaceutical Council Pharmaceutical Benefits 2003

10 mg, Capsule, Oral 100 0.4065 B

Ticlopidine Hydrochloride
250 mg, Tablet, Oral 60 1.5119 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 0.8071 B
4 mg, Tablet, Oral, 150 0.9560 B

Tobramycin
0.3%, Solution/Drops, Ophthalmic 5 ml 1.1850 M

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
0.025%, Cream, Topical 80 gm 0.0364 B
0.1%, Cream, Topical 80 gm 0.0448 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

Generic Name Upper Limit per Unit (Source)

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

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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National Pharmaceutical Council Pharmaceutical Benefits 2003

180 mg, Capsule, Extended Release, Oral 100 0.8700 B


240 mg, Capsule, Extended Release, Oral 100 0.4350 B
40 mg, Tablet, Oral 100 0.1963 R
80 mg, Tablet, Oral 100 0.0735 B
120 mg, Tablet, Oral 100 0.1110 B
180 mg, Tablet, Extended Release, Oral 100 0.4838 B
240 mg, Tablet, Extended Release, Oral 100 0.4350 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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Appendix E:
Glossary

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National Pharmaceutical Council Pharmaceutical Benefits 2003

GLOSSARY OF MEDICAL, MEDICAID,


AND MANAGED CARE TERMS

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.

Acute Care Medical treatment rendered to individuals whose illnesses or health


problems are of a short-term or episodic nature. Acute care facilities are
those hospitals that mainly serve persons with short-term health problems.

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.”

Adjudication Processing a claim through a series of edits in order to determine proper


payment.

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 2003

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 healthcare 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 2003

Term Definition

Ancillary Services Hospital services other than room, board, and professional services. They
may include X-rays, lab tests, or anesthesia.

Antitrust A legal term encompassing a variety of efforts on the part of government


to assure that sellers do not conspire to restrain trade or fix prices for their
goods or services in the market.

Any Willing Provider A requirement that a health insurance plan or a health maintenance
organization (HMO) must sign a contract for the delivery of healthcare
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.

At-Risk Accepting prepayment as full coverage for a predetermined healthcare


benefit and assuming financial liability for any loss that occurs when
premiums paid are less than the cost of services provided.

Authorization As it applies to managed care, authorization is the approval of care, such as


hospitalization.

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.

Barriers To Access Barriers to access can be financial (insufficient monetary resources),


geographic (distance to providers), organizational (lack of available
providers) and sociological (e.g., discrimination, language barriers). Efforts
to improve access often focus on providing/improving health coverage.

Behavioral Health Care Assessment and treatment of mental and/or psychoactive substance abuse
disorders.

Beneficiary An individual who receives benefits from or is covered by an insurance


policy or other health care financing program. Also known as a "member,"
"enrollee," "subscriber," or "insured."

Benefit A service provided under an insurance policy or prepayment plan.

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 2003

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.

Brand Name Name identifying a drug as the product of a specific pharmaceutical


company. Also known as proprietary trademark name.

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 A method of payment in which a health plan, such as an HMO or a


specific health care provider, receives a fixed amount for each person
eligible to receive services ($ per member per month), which is made
whether or not the covered person becomes an active patient and without
regard to the number and mix of services used by that patient.

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 healthcare, 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.”

Carve Out A decision to purchase separately a service that is typically a part of an


indemnity or HMO plan. Example: an HMO may “carve out” the
behavioral health benefits and select a specialized vendor to supply these
services on a stand-alone basis.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

Case Management (1) A process whereby covered persons with specific health care needs are
identified and a plan designed to efficiently utilize healthcare 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.

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).

Certificate of Need (CON) A certificate issued by a government body, where required, to an


individual or organization proposing to construct or modify a health
facility, acquire major new medical equipment, or offer a new or different
health service. Such issuance recognizes that a facility or services, when
available, will meet the needs of those for whom it is intended.

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.

Claim Information on medical services provided that is submitted by a provider or


a covered person from which processing for payment to the provider or
covered person is made. The term generally refers to the liability for health
care services received by covered persons.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

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 healthcare
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.

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.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

Coinsurance The portion of covered healthcare 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.

Compliance The degree to which patients follow treatment recommendations.

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.

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.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

Copay/Copayment A cost-sharing arrangement in which a covered person pays a specified


charge for a specified service, such as $10 for an office visit. The covered
person is usually responsible for payment at the time the healthcare is
rendered. Typical copayments are fixed or variable flat amounts for
physician office visits, prescriptions or hospital services. Some copayments
are referred to as coinsurance, with the distinguishing characteristics that
copayments are flat or variable dollar amounts and coinsurance is a defined
percentage of the charges for services rendered.

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.

Cost-Effectiveness Usually considered as a ratio, the cost-effectiveness of a drug or procedure,


for example, relates the cost of that drug or procedure to the health benefits
resulting from it. In health terms, it is often expressed as the cost per year
per life saved.

Counter Detailing A process of re-educating or influencing prescribers in a closed or


controlled HMO plan. Usually done in order to gain more compliance with
a formulary. In a counter-detailing program, techniques used by
pharmaceutical sales representatives are adapted to a “counter” objective,
i.e., to provide doctors with basic pharmacological information designed to
influence their prescribing habits.

Coverage Entire range of protection provided under an insurance contract.

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.

Credentialing A process of review to approve a provider who applies to participate in a


health plan. Specific criteria and prerequisites are applied in determining
initial and ongoing participation in the health plan.

Customary Charge The charge a physician or supplier usually bills his patients for furnishing
a particular service or supply is called the customary charge.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

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.

Dependent An individual who relies on an employee for support or obtains health


coverage through a spouse, parent, or grandparent who is the covered
person.

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 Center Freestanding or hospital-based facility that specializes in diagnosing


illnesses and injuries.

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.

Dismemberment Loss of body parts stemming from accidental physical injury.

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.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

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.

Disproportionate Share A disproportionate share hospital (DSH) is a hospital that serves a


Hospital (DSH) disproportionate number of low-income patients with special needs and
receives a payment adjustment for providing such services. In addition to
certain requirements for the provision of obstetrical services to individuals
entitled to medical assistance, a hospital is deemed to be a disproportionate
share hospital if 1) the hospital’s Medicaid inpatient utilization rate is at
least one standard deviation above the mean Medicaid inpatient utilization
rate for hospitals receiving Medicaid payments in the State, or 2) the
hospital’s low-income utilization rate exceeds 25 percent.

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 The prescribing, dispensing, administering and ingestion or use of


pharmaceutical products.

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.

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.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

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.

Exclusions Specific conditions or circumstances listed in the contract or employee


benefit plan for which the policy or plan will not provide benefit
payments.

Exclusivity Clause A part of a contract which prohibits physicians from contracting with more
than one health maintenance organization or preferred provider
organization.

Expenditures Under Medicaid, “expenditures” refers to an amount paid out by a State


agency for the covered medical expenses of eligible participants.

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 healthcare 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 healthcare 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.

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.

Favorable Selection A tendency for utilization of health services in a population group to be


lower than expected or estimated.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

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 1933d 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 are 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.

Fee Maximum The maximum amount a participating provider may be paid for a specific
healthcare 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 healthcare 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.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

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.

Formulary See “Drug Formulary.”

Free-Standing Hospital Any hospital that is not affiliated with a multihospital system.

Freedom-of-Choice (FOC) Legislation requiring managed care organizations to allow members to


choose providers whether or not they connect with the plans (often
coupled with any willing provider (AWP) legislation).

Gatekeeper See “Care Coordinator.”

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.

Generic Equivalent See “Generic Drug.”

Generic Substitution Dispensing a generic drug in place of a brand-name medication.

Global Target A financing method identical to a global budget except that no


enforcement mechanism is used to keep providers and hospitals within
budget (i.e., providers and hospitals will receive additional funding if their
costs exceed their budgeted payments).

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.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

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 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.

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 healthcare or otherwise assuring healthcare
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.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

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 healthcare purchases and
evaluating health plan performance. HEDIS 2003 is currently used and
distributed by NCQA (National Committee for Quality Assurance).

HMO - Group Model A healthcare 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 healthcare model that contracts with physicians and other community
Association (IPA) healthcare 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 healthcare model that employs physicians to provide healthcare to its
members. All premiums and other revenues accrue to the HMO, which
compensates physicians by salary and incentive programs.

Home and Community-Based See “Section 1915(c) Waivers.”


Waivers

Home Health Agency (HHA) A facility or program licensed, certified or otherwise authorized pursuant
to State and Federal laws to provide healthcare 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.

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.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

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.

Intensive Care Skilled nursing services, usually in a hospital, prescribed by a physician


for individuals with serious medical conditions and delivered with the
guidance of a registered nurse.

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.

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 healthcare 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.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

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 healthcare 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 healthcare; (2)
A systemized approach which seeks to ensure the provision of the right
healthcare 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 maximum cost is fixed 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.

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.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

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 Necessity The evaluation of healthcare 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.

Medicare (Part A/Part B) 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).

Medicare Beneficiary A person designated by the Social Security Administration as entitled to


receive Medicare benefits.

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 Supplemental A policy guaranteeing that a health plan will pay a policyholder’s
Insurance 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 2003

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
healthcare 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 2003

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 Management Systematically improving healthcare results, typically by modifying


practices in response to data gleaned through outcomes measurement, then
remeasuring and remodifying - often in a formal program of continuous
quality improvement.

Outcomes Research Studies aimed at measuring the effect of a given product, procedure, or
medical technology on health or costs.

Outlier An observation in a distribution that is outside a certain range, often defined


as two or three standard deviations from the mean or exceeding a specific
percentile. Frequently refers to a case or hospital stay that is unusually long
or expensive for its type, or to a physician practice that uses an abnormally
high or low volume of resources.

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.

Peer Review The evaluation of quality of total healthcare provided, by medical staff
with equivalent training.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

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 compromises 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.

Pharmaceutical Benefits An entity that is responsible for managing prescription benefits.


Manager (PBM)

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.

Physician-Hospital A legal entity formed by a hospital and a group of physicians to further


Organization (PHO) mutual interests and to achieve market objectives. A PHO generally
combines physicians and a hospital into a single organization for the
purpose of obtaining payer contracts. Doctors maintain ownership of their
practices and agree to accept managed care patients according to the terms
of a professional service agreement with the PHO. The PHO serves as a
collective negotiating and contracting unit. It is typically owned and
governed jointly by a hospital and shareholder physicians.

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.

Portability Requirement that health plans guarantee continuous coverage without


waiting periods for persons moving between plans.

Practice Guideline Systematically developed statements on medical practice that assist a


practitioner and a patient in making decisions about appropriate healthcare
for specific medical conditions. Managed care organizations frequently
use these guidelines to evaluate appropriateness and medical necessity of
care. Terms used synonymously include practice parameters, standard
treatment protocols and clinical practice guidelines.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

Practice Parameters See “Practice Guidelines.”

Practice Variation An assessment of the patterns of a practitioner’s practice to determine if


the provider’s care is significantly different from others with similar
practices. If there is a significant difference, the practitioner’s practice is
analyzed to determine the reasons for the variation and whether that
practitioner’s practice patterns should be modified.

Pre-Certification Review See “Utilization Review.”

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.

Primary Care Basic or general healthcare 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.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

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.

Prior Authorization The process of obtaining prior approval as to the appropriateness of a


service or medication. Prior authorization does not guarantee coverage.

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.

Protocol See “Practice Guidelines.”

Provider Network See “Network Plan.”

Providers A physician, hospital, group practice, nurse, nursing home, pharmacy or


any individual or group of individuals that provides a healthcare service.

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.

Reasonable Charge In processing claims for Supplementary Medical Insurance benefits,


carriers use CMS guidelines to establish the reasonable charge for services
rendered. The reasonable charge is the lowest of: the actual charge billed
by the physician or supplier; the charge the physician or supplier
customarily bills his patients for the same services, and the prevailing
charge which most physicians or suppliers in that locality bill for the same
service. Increases in the physicians’ prevailing charge levels are
recognized only to the extent justified by an index reflecting changes in
the costs of practice and in general earnings.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

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.

Rebate A monetary amount that is returned to a payer from a prescription drug


manufacturer based upon utilization by a covered person or purchases by a
provider.

Recipient A recipient of Medicaid is an individual who has been determined to be


eligible for Medicaid and who has used medical services covered under
Medicaid.

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.

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.

Secondary Care Services provided by medical specialists, such as cardiologists, urologists


and dermatologists, who generally do not have first contact with patients.
See also “Primary Care.”

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

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.

Self-Referral Restrictions Restrictions on or prohibitions against providers referring patients to a


designated health service (e.g., pharmacies, clinical laboratories, and
outpatient surgery) in which the provider or the provider’s immediate
family member has a financial interest.

Sin Taxes Taxes imposed on items considered harmful to public health interests, such
as tobacco and alcohol.

Single-Source Drug A single-source drug is a covered outpatient drug which is produced or


distributed under an original new drug application approved by the FDA,
including a drug product marketed by any cross-licensed producers or
distributors operating under the new drug application.

Skilled Nursing Facility (SNF) See “Nursing Facility.”

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.

Spend-Down Under Medicaid, “spend-down” refers to a method by which an individual


establishes Medicaid eligibility by reducing gross income through
incurring medical expenses until net income (after medical expenses)
meets Medicaid financial requirements.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

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. There are over 800 mandates nationwide.

State Medical Assistance See “ Medicaid.”


Programs

State Pharmacy Assistant State authorized programs to provide pharmaceutical coverage or


Programs assistance to low-income and/or persons with disabilities who do not
qualify for Medicaid. Also known as Expanded Drug Benefit Programs.

State Plan The Medicaid State Plan is a comprehensive written commitment by a


Medicaid agency to administer or supervise the administration of a
Medicaid program in accordance with Federal requirements.

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.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

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.

Total Quality Management See “Continuous Quality Improvement.”


(TQM)

Title XIX See “ 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.”

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.

Utilization Review A formal assessment of the medical necessity, efficiency, and/or


appropriateness of healthcare services and treatment plans on a prospective,
concurrent or retrospective basis.

Vendor A medical vendor is an institution, agency, organization, or individual


practitioner that provides health or medical products and/or services either
to a medical provider, who in turn interfaces with patients, or directly to
the public.

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.

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National Pharmaceutical Council Pharmaceutical Benefits 2003

Term Definition

Waiver A rider or clause in a health insurance contract excluding an insurer’s


liability for some sort of pre-existing illness or injury. Also refers to a plan
amendment, such as a CMS waiver or plan modification.

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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National Pharmaceutical Council Pharmaceutical Benefits 2003

ACRONYMS

AABD Aid to Aged, Blind, and Disabled


AAC Actual Acquisition Cost
AHRQ Agency for Health Research and Quality
AIDS Acquired Immune Deficiency Syndrome
AMP Average Manufacturer Price
ANSI American National Standards Institute
ARF Area Resource File
ASO Administrative Services Only
AWP Any Willing Provider OR Average Wholesale Price
BBA Balanced Budget Act of 1997
BIPA Benefits Improvement and Protection Act
BLS Bureau of Labor Statistics
CHIP See SCHIP
CFR Code of Federal Regulations
CMP Competitive Medical Plan
CMS Centers for Medicare and Medicaid Services (formerly HCFA)
CMSO CMS’ Center for Medicaid and State Operations
CNAB Categorically Needy Aid to the Blind
CNAFDC Categorically Needy Aid to Families with Dependent Children
CNAPTD Categorically Needy Aid to the Permanently and Totally Disabled
CNOAA Categorically Needy Old Age Assistance
COBRA Consolidated Omnibus Reconciliation Act of 1985
COM-MCO Commercial Managed Care Organization
CON Certificate of Need
CPI Consumer Price Index
CPR Customary Prevailing, and Reasonable (charges)
CPT Current Procedural Terminology
CQI Continuous Quality Improvement
DAW Dispense As Written
dba Doing Business As
DEFRA Deficit Reduction Act of 1984
DESI Drug Efficacy Study and Implementation
DHHS Department of Health and Human Services
DRGs Diagnostic Related Groupings
DSH Disproportionate Share Hospital
DUE Drug Use Evaluation
DUR Drug Utilization Review
EAC Estimated Acquisition Cost
EDI Electronic Data Interchange

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National Pharmaceutical Council Pharmaceutical Benefits 2003

EPSDT Early and Periodic Screening, Diagnostic and Treatment


ERISA Employee Retirement Income Security Act
ESRD End Stage Renal Disease
FDA Food and Drug Administration
FFP Federal Financial Participation
FFS Fee-for-Service
FMAP Federal Medical Assistance Percentage
FOC Freedom of Choice
FPL Federal Poverty Level
FQHC Federally Qualified Health Center
FUL Federal Upper Limits
FY Fiscal Year
HCFA Health Care Financing Administration (see CMS)
HCPCS HCFA Common Procedural Coding System
HCPP Health Care Prepayment Plan
HEDIS Health Plan Employer Data and Information Set
HH Home Health
HIFA Health Insurance Flexibility and Accountability
HIO Health Insuring Organizations
HIPAA Health Insurance Portability and Accountability Act
HMO Health Maintenance Organization
HRSA Health Resources and Services Administration
ICF Intermediate Care Facility
ICF-MR Intermediate Care Facility for the Mentally Retarded
IPA Individual Practice Association
MAC Maximum Allowable Cost
MAIC Maximum Allowable Ingredient Cost
MCAID-MCO Medicaid-only Managed Care Organization
MCO Managed Care Organization
MMIS Medicaid Management Information System
MNAB Medically Needy Aid to the Blind
MNAFDC Medically Needy Aid to Families with Dependent Children
MNAPTD Medically Needy Aid to the Permanently and Totally Disabled
MNOAA Medically Needy Old Age Assistance
MQC Medicaid Quality Control
MSA Medical Savings Account
MSIS Medicaid Statistical Information System
NDC National Drug Code
NF Nursing Facility
NP Nurse Practitioner
OACT Office of the Actuary
OASDI Old Age, Survivors, and Disability Insurance

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National Pharmaceutical Council Pharmaceutical Benefits 2003

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
UR Utilization Review
WAC Weighted Average Cost OR Wholesale Acquisition Cost

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