Professional Documents
Culture Documents
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
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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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:
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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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 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].
1
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. Law No. 108-173
(December 8, 2003).
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• Reforms to the Hatch-Waxman patent procedure for introducing new generic drugs.
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.
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%).
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:
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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.
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.
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.
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.
Tables 1 and 2 include total patient counts and expenditures data for males versus females for both
dual and non-dual eligibles.
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%
*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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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.
Not Dual
Dual Eligible Medicaid Not Dual Eligible
Gender Dual Eligible Per Capita Eligible Per
Paid Medicaid Paid
Capita
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.
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.
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.
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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 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 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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has a shortage of home health agencies, the services are furnished by nurses employed by the RHC,
and the services are furnished to a homebound recipient under a written plan of treatment.
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Voluntary Sterilizations: FFP is available in expenditures for the sterilization of an individual only if
she is at least age 21, has voluntarily given informed consent in accordance with Medicaid
regulations, and is not a mentally incompetent individual.
Physicians’ Services
Physicians’ services are covered, whether provided in the office, the patient’s home, a hospital, a
nursing facility, or elsewhere. Such services must be within the physicians’ scope of practice of
medicine or osteopathy as defined by State law, and by or under the personal supervision of an
individual licensed under State law to practice medicine or osteopathy.
Prescribed Drugs
Prescribed drugs are simple or compound substances or mixtures of substances prescribed for the
cure, mitigation, or prevention of disease, or for health maintenance, which are prescribed by a
physician or other licensed practitioner of the healing arts within the scope of their professional
practice, as defined and limited by Federal and State law (42 CFR 440.120). The drugs must be
dispensed by licensed authorized practitioners on a written prescription that is recorded and
maintained in the pharmacist’s or the practitioner’s records.
Personal support services consist of a variety of services including personal care, targeted case
management, home and community-based care for functionally disabled elderly, rehabilitative
services, hospice services, and nurse-midwife, nurse practitioner, and private duty nursing. Details of
some of these services are provided below:
1. Personal Care Services: Services provided to an individual who is not an inpatient or
resident of a hospital, nursing facility, intermediate care facility for the mentally
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Nurse-Midwife Services
Nurse-midwife services are those concerned with management of the care of mothers and newborns
throughout the maternity cycle. The Omnibus Budget Reconciliation Act of 1980 required that
payment be made providing for nurse-midwife services to categorically needy recipients (42 CFR
440.165). These provisions require States to provide coverage for nurse-midwife services to the
extent that the nurse-midwife is authorized to practice under State law or regulation. The statute also
requires that States offer direct reimbursement to nurse-midwives as one of the payment options.
Nurse-midwives must be registered nurses who are either certified by an organization recognized by
the Secretary of DHHS or who have completed a program of study and clinical experience that has
been approved by the Secretary.
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• The facility receives a grant under sections 329, 330, or 340 of the Public Health Service
Act;
• The Health Resources and Services Administration (HRSA) recommends, and the DHHS
Secretary determines, that the facility meets the requirements of the grant; or
• The Secretary determines that a facility may qualify through waivers of the requirements.
Such a waiver cannot exceed two years.
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Receiving
Total Cash Medically Poverty 1115 MAS
State Eligibles Assistance Needy Related Other Demonstration Unknown
National Total 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.
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Source: U.S. Department of Commerce, Bureau of the Census, 2003; CMS, MSIS Report, FY 2000 & FY 2001.
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Source: CMS, CMS-64 Report, FY 2001 and CMS-MSIS Report, FY 2000 & FY 2001.
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100%
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
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.
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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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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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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*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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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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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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Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2003. DHHS, CMS, Center for Medicaid & State
Operations.
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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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Section 1915(b) waivers are granted to give States the authority to conduct Medicaid programs
outside of the scope of the Medicaid statute, allowing them to waive freedom of choice, statewide
access to care, and comparability requirements under Section 1902 of the Social Security Act. With a
1915(b) waiver, a State can require mandatory enrollment of Medicaid recipients in managed care
plans. Section 1915(b) waivers can also allow a State to create a “carveout” delivery system for
specialty care, e.g., a Managed Behavioral Health Care Plan. Section 1915(b) waivers cannot
negatively impact beneficiary access or quality of care of services, and must be cost-effective (i.e.,
cost must be less than the Medicaid program would cost without the waiver). Section 1915(b)
waivers are typically limited to a targeted geographical area or population, are approved for an initial
period of two years, and can be renewed on an ongoing basis if the State reapplies.
Four options for 1915(b) waivers exist; each is governed by a different subsection(s) of Section
1915(b);
• Paragraph (b)(1) - Case Management: States are allowed to implement case management
systems which can be as simple as requiring each beneficiary to choose a primary care
provider or as comprehensive as mandating enrollment in a prepaid health plan. The
Balanced Budget Act of 1997 also gave States the option to enroll certain beneficiaries
into managed care via a State Plan Amendment.
• Paragraph (b)(2) - Central Broker: Localities are allowed to act as a central broker in
assisting Medicaid eligibles in selecting among competing health care plans, if such a
restriction does not substantially impair access to medically necessary services of
adequate quality.
• Paragraph (b)(3) - Shared Cost Saving: States are allowed to share (through provision of
additional services) cost savings (resulting from use by the recipient of more cost-
effective medical care) with recipients of medical assistance under the State Plan.
• Paragraph (b)(4) - Restrict Providers: States can limit the number of providers of certain
services. These waivers are sometimes referred to as selective contracting waivers and
are gaining in popularity. For example, some approved 1915(b)(4) waivers include
programs to restrict the number of providers of transportation services, organ transplants,
and inpatient obstetrical care.
Although Section 1915(b) waivers allow States to increase access to managed care plans, States are still
limited under Federal regulations and cannot use them to serve beneficiaries beyond Medicaid State Plan
Eligibility or change their benefits package. In order to expand their Medicaid programs even further
than under Section 1915(b) waivers, States apply for Section 1115 research and demonstration waivers.
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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.
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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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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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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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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Source: U.S. Department of Commerce, Bureau of the Census, 2002 American Community Survey.
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Source: U.S. Department of Commerce, Bureau of the Census, 2002 American Community Survey.
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Source: U.S. Department of Commerce, Bureau of the Census, 2002 American Community Survey.
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% Covered by % Covered by
Total % Covered by % Covered by Military Private
State Population Medicaid Medicare Insurance Insurance % Not Insured
National Total 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.
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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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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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Source: U.S. Department of Labor, Bureau of Labor Statistics, February 27, 2004.
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LEGEND
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Physicians, 2001
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# FTE # FTE
Registered Registered Nurses* Pharmacists** Pharmacists**
State Nurses* per 1,000 population (Licensed by State) per 1,000 population
National Total 962,195 3.4 356,201 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 program defines prescribed drugs as simple or compound substances or mixtures of
substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance,
which are prescribed by a physician or other licensed practitioner of the healing arts within the scope
of their professional practice (42 CFR 440.120). The drugs must be dispensed by licensed authorized
practitioners on a written prescription that is recorded and maintained in the pharmacist’s or the
practitioner’s records.
On July 31, 1987, CMS published a notice of the final rule for limits on payments for drugs in the
Medicaid program. The regulations adopted in the rule became effective October 29, 1987 (52 FR
28648). In this final rule, CMS attempted to (1) respond to public comments on the NPRM (51 FR
2956); (2) provide maximum flexibility to the States in their administration of the Medicaid program;
(3) provide responsible but not burdensome Federal oversight of the Medicaid program; and (4) take
advantage of savings in the marketplace for multiple-source drugs.
To accomplish this, CMS adopted a Federal upper limit standard for certain multiple-source drugs,
based on application of a specific formula. The upper limit for other drugs is similar, in that it retains
the estimated acquisition cost (EAC) as the upper limit standard that State agencies must meet.
However, this standard is applied on an aggregate basis rather than on a prescription-specific basis.
State agencies are therefore encouraged to exercise maximum flexibility in establishing their own
payment methods (see the Federal Register, Vol. 52, No. 147, Friday, July 31, 1987, page 28648).
Multiple-Source Drugs
A multiple-source drug is one that is marketed or sold by two or more manufacturers or labelers, or a
drug marketed or sold by the same manufacturer or labeler under two or more different proprietary
names or under a proprietary name and without such a name.
A specific upper limit for a multiple-source drug may be established if the following requirements are
met:
• All of the formulations of the drug approved by the Food and Drug Administration (FDA) have
been evaluated as therapeutically equivalent in the current edition of the publication, Approved
Drug Products with Therapeutically Equivalent Evaluations; and
• At least three suppliers list the drug (which is classified by the FDA as Category A in its
publication) in the current editions of published compendia of cost information for drugs
available for sale nationally.
The upper limit for a multi-source drug for which a specific limit has been established does not apply
if a physician certifies in his or her own handwriting that a specific brand is “medically necessary” for
a particular recipient.
The handwritten phrase “brand necessary,” “medically necessary,” or “brand medically necessary”
must appear on the face of the prescription. The rule specifically states that a check-off box on a
prescription form is not acceptable, but it does not address the use of two-line prescription forms.
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The formula to be used in calculating the aggregate upper limit of payment for certain multiple-source
drugs will be 150% of the least costly therapeutic equivalent that can be purchased by pharmacists in
quantities of 100 tablets or capsules (or if the drug is not commonly available in quantities of 100, the
package size commonly listed), or in the case of liquids, the commonly listed size, plus a reasonable
dispensing fee.
Other Drugs
A drug described as an “other drug” is (1) a brand name drug certified as medically necessary by the
physician, (2) a multiple-source drug not subject to the 150% formula; or (3) a single-source drug.
Payments for these drugs must not exceed, in the aggregate, payment levels determined by applying
the lower of:
Other Requirements
The rule requires States to submit a State plan that describes their payment methods for prescribed
drugs. The rule does not prescribe a preferred payment method, as long as the State’s aggregate
spending in each category is equal to or below the upper limit requirements. States are also required
to submit assurances to CMS that the requirements are met.
The rule does not prescribe a preferred payment method for the States, but gives States the flexibility
to determine how they will pay for prescription drugs under Medicaid. As long as the State’s
aggregate spending is at or below the amount derived from the formula, the State is free to maintain
its current payment program or adopt other methods. States can alter payment rates for individual
drugs, balancing payment increases for certain products with payment decreases for other drugs so
that, in the aggregate, the program does not exceed the established limit. With the establishment of
upper limit payment maximums, some States may alter their current payment methods to comply with
the established limits.
State programs vary, depending upon whether or not State maximum allowable cost (MAC) programs
cover the same drugs listed by CMS. States with established MAC programs may be unaffected if
their MAC rates are already low, or they may have to make certain adjustments in their MAC levels
to meet the Federal aggregate expenditure limits. States without MAC programs may develop a new
payment method to increase the use of lower cost generic drug products in order to stay within the
upper payment limits, or may simply adopt CMS’ formula for listed drug products.
DRUG RECIPIENTS
Drug recipients are defined as individuals who received drugs, not as everyone eligible to receive
drugs. Today, all 50 States and the District of Columbia cover drugs under the Medicaid program.
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% of 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.
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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.
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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.
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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.
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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.
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National Pharmaceutical Council Pharmaceutical Benefits 2003
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.
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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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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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*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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*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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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
In general, all prescription products sold by a manufacturer that has signed a drug rebate agreement
are covered outpatient drugs reimbursable by Medicaid. A State Medicaid program may require prior
approval before dispensing of any drug product and may design and implement a formulary intended
to limit coverage for specific drugs. Drug formularies and prior authorization programs must meet
specific requirements established in Medicaid law.
A State Medicaid program can restrict coverage for a drug product through a formulary, if based on
official labeling or information in designated official medical compendia, “the excluded drug does not
have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness or
clinical outcome of such treatment” over other drug products, and there is a written explanation
(available to the public) of the basis for the exclusion. However, drug products excluded from the
formulary under these conditions, nevertheless, must be available through prior authorization.
Drugs in certain specific classes may be restricted or excluded from coverage without regard to the
formulary conditions and need not be available through prior authorization. These classes include:
• Drugs used for anorexia, weight gain, fertility, hair growth, cosmetic effect, symptomatic
relief of cough or colds, or for cessation of smoking.
• Vitamins and minerals (except prenatal prescription vitamins and fluoride preparations) or
non-prescription drugs.
• Drugs that require tests or monitoring services to be purchased exclusively from the
manufacturer or his designee.
• Barbiturates or benzodiazepines.
PRIOR AUTHORIZATION
Whether or not a drug product is on a formulary, States may require physicians to request and receive
official permission before a particular product can be dispensed. This procedure is called Prior
Authorization or Prior Approval.
States may not operate prior authorization plans unless the State provides for a response within 24
hours of a request and provides for a 72-hour emergency supply of the medication.
The Congressional intent for the prior authorization provision was not to encourage the use of such
programs, but rather to make them available to the States for the purpose of controlling utilization of
products that have very narrow indications or high abuse potential.
The majority of States report the establishment of prior authorization programs and have plans to
apply prior authorization to a select number of drugs. Some States will do so only after their Drug
Utilization Review (DUR) program has identified areas of therapeutic concern.
DUR Program. Each State must establish a Drug Utilization Review (DUR) Program in order to
assure that prescriptions are appropriate, medically necessary, and not likely to result in adverse
medical results. A DUR Program consists of prospective and retrospective components as well as
components to educate physicians and pharmacists on common drug therapy problems.
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Specifically, the program educates physicians and pharmacists how to identify and reduce fraud,
abuse, gross overuse, or inappropriate or medically unnecessary care; potential and actual severe
adverse reactions to drugs, including education on therapeutic appropriateness, overutilization and
underutilization, appropriate use of generic products, therapeutic duplication, drug-disease
contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, drug-
allergy interactions, and clinical abuse or misuse.
The two primary objectives of DUR systems are (1) to improve quality of care; and (2) to assist in
containing health care costs. While there is a general belief that DUR is cost beneficial, it is difficult
to isolate concrete evidence that supports this view. The primary issue facing Medicaid DUR
programs is whether or not the systems currently in place (or envisioned) meet the two objectives
outlined above.
Prospective DUR. Prospective DUR is to be conducted at the point of sale (POS) before delivery of a
medication by the pharmacist to the Medicaid recipient or caregiver. The State is to establish
standards for counseling patients and will require the pharmacist to offer to discuss matters, which, in
the exercise of the pharmacist’s professional judgment are deemed significant, including the
following:
• Name, address, telephone number, date of birth (or age) and gender;
• Individual history where significant, including a disease state or states, known allergies and
drug reactions, and a comprehensive list of medications and relevant devices; and
• Pharmacist comments relevant to the individual’s pharmaceutical therapy.
Retrospective DUR. This activity continuously assesses data on drug use against established
standards, preferably using automated claims processing and information retrieval techniques to
monitor for therapeutic appropriateness, overutilization and underutilization, appropriate use of
generic products, therapeutic duplication, drug-disease contraindications, drug-drug interactions,
incorrect drug dosage or duration of drug treatment, clinical abuse/misuse and, as necessary,
introduce remedial strategies in order to improve the quality of care and to conserve program funds or
personal expenditures. This activity is also intended to identify patterns of fraud, abuse, gross
overuse, or inappropriate of medically unnecessary care among physicians, pharmacists, and
recipients, or with respect to specific drugs or groups of drugs.
State Drug Use Review Board. Each State must provide for the establishment of a DUR board of
health practitioners (one-third to one-half physicians and at least one-third pharmacists) to help
implement the DUR program. Each State must require its DUR board to make annual reports to
DHHS on its activities and on cost savings resulting from the DUR program.
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*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2003 NPC Survey.
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*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
PA = Prior Authorization, DME = Durable Medical Equipment
Source: As reported by State drug program administrators in the 2003 NPC Survey.
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*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
PA = Prior Authorization, DME = Durable Medical Equipment
Source: As reported by State drug program administrators in the 2003 NPC Survey.
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*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
PA= Prior Authorization, DME = Durable Medical Equipment
Source: As reported by State drug program administrators in the 2003 NPC Survey.
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Coverage of Injectables
Reimbursement for Non Self-Administered Medicines via
the Prescription Drug Program (PDP) or Physician Payment (PP)
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2003 NPC Survey.
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^ Early and Periodic Screening, Diagnostic and Treatment (EPSDT), Children Health Insurance Program (CHIP), Vaccines for
Children Program (VCP), or other.
LTC = Long Term Care
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2003 NPC Survey.
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*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
PA= Prior Authorization
Source: As reported by State drug program administrators in the 2003 NPC Survey.
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*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2003 NPC Survey.
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*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2003 NPC Survey.
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*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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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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*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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*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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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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Medicaid Payment for Outpatient Prescription Drugs. Federal Medicaid regulations prescribe the
principles that apply to State Medicaid programs when they pay a pharmacy for outpatient drugs.
These regulations don’t just indicate the FFP cannot be based on amounts that exceed drug costs as
determined under the federal formula; they indicate the actual method for paying for prescription
drugs.
Medicaid Managed Care Organizations (MCOs). If the recipient is enrolled in a Medicaid managed
care organization, payment is made to the MCO in accordance with its contract with the State
Medicaid agency to the extent the contract covers outpatient prescribed drugs.
Medicaid Payment to Pharmacies. Each State’s Medicaid State Plan must comprehensively describe
its payment for prescription drugs. Its aggregate Medicaid expenditures for “multiple source drugs”
must not exceed the Federal Upper Limits published by CMS (see Appendix D) and its payment level
for other drugs must not exceed, in the aggregate, the lower of (1) EAC plus a reasonable dispensing
fee, or (2) providers’ charges to the general public.
States are permitted to require certain recipients to share some of the costs of Medicaid by imposing
on them such payments as enrollment fees, premiums, deductibles, coinsurance, copayments, or
similar cost-sharing charges (42 CFR 447.50). For States that impose cost-sharing payments, the
regulations specify the standards and conditions under which States may impose cost-sharing, set
forth minimum amounts and the methods for determining maximum amounts, and describe
limitations on availability that relate to cost-sharing requirements.
With the passage of the Social Security Amendments of 1972, States were empowered to impose
“nominal” cost-sharing requirements on optional Medicaid services for cash assistance recipients, and
on any services for the medically needy. Section 131 of the Tax Equity and Fiscal Responsibility Act
(TEFRA) of 1982 introduced major changes to Medicaid cost-sharing requirements. Under this act,
States may impose a nominal deductible, coinsurance, copayment, or similar charge on both
categorically needy and medically needy persons for any service offered under the State Plan. Public
Law 97-248, TEFRA, has been in effect since October 1982; it prohibits imposition of cost-sharing
on the following:
While emergency services are excluded from cost sharing, States may apply for waivers of nominal
amounts for non-emergency services furnished in hospital emergency rooms. Such a waiver allows
States to impose a copayment amount up to twice the current maximum for such services. Approval
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of a waiver request by CMS is based partly on the State’s assurance that recipients will have access to
alternative sources of care.
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Federal State-Specific
State Upper Limits Upper Limits MAC Override Provisions
Alabama Yes Yes Brand medically necessary
Alaska Yes No 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
*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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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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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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ALABAMA 1
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.
Alabama-1
National Pharmaceutical Council Pharmaceutical Benefits 2003
Unit Dose: Unit dose packaging reimbursable. Drug Ingredient Cost Copayment
$0.00 to $10.00 $0.50
$10.01 to $25.00 $1.00
Alabama-2
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Alabama-3
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334/242-5610
Alabama-4
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Alabama-5
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Alabama-6
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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
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ALASKA
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
*Total Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**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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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.
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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
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ARIZONA
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
(AHCCCS - PRONOUNCED "ACCESS")
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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.
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The Operational Role of the AHCCCS Care1st Health Plan of Arizona, Inc.
Administration 2355 E. Camelback Rd.
Suite 300
Organizationally, the AHCCCS Administration Phoenix, AZ 85016
assumes responsibility for the oversight of every day 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.
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ARKANSAS
*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.
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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
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CALIFORNIA
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
Note: Certain classifications of aliens in the above categories are eligible only for emergency and pregnancy-related benefits.
*Total Other Expenditures/ Recipients include foster care children, demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
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Under the Health and Human Services Agency with Formulary: The Medi-Cal List of Contract Drugs is a
direct administration by the Department of Health preferred drug list. It contains over 600 drugs, in
Services. differing strengths and dosage forms, listed
generically. Patients can get prior authorization for
The Department of Health Services Pharmaceutical unlisted drugs or for listed drugs that are restricted to
Unit of the Medi-Cal Policy Division monitors the specific use(s), if medically justified. Manufacturers
full scope and quality of pharmaceutical benefits frequently petition Medi-Cal to add drugs to the List
covered under the provisions of the California of Contract Drugs. Based on Medi-Cal’s five criteria
Medical Assistance Program. (safety, efficacy, misuse potential, essential need, and
cost), a drug may be added to the list by contractual
D. PROVISIONS RELATING TO DRUGS agreement with the manufacturer to provide the State
a negotiated rebate. The Medi-Cal website at:
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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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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COLORADO
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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.
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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.
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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
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National Pharmaceutical Council Pharmaceutical Benefits 2003
Robert Slay
Jefferson Co. CCB
7456 W. 5th Avenue
Lakewood, CO 80226
303/233-3363 x366
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CONNECTICUT
*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
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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%.
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F. STATE CONTACTS
DUR Contact
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DELAWARE
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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.
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DISTRICT OF COLUMBIA
*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.
District of Columbia-1
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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
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FLORIDA
*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.
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Florida-2
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Florida-3
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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
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GEORGIA
*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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Georgia-2
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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
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HAWAII
*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.
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IDAHO
*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.
Idaho-1
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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.
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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
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Mitzi Smith
St. Luke’s Hospital
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1
ILLINOIS
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**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.
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INDIANA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/ Child Adult Aged Blind/ Child Adult
Disabled Disabled
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**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.
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Indiana-2
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Indiana-3
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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
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IOWA
*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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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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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
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Iowa-6
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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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KANSAS
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients and unknown.
**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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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.
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KENTUCKY
*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.
Kentucky-1
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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,”
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LOUISIANA
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Louisiana-1
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Louisiana-2
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MAINE
*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.
Maine-1
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MARYLAND
*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.
Maryland-1
National Pharmaceutical Council Pharmaceutical Benefits 2003
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%.
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National Pharmaceutical Council Pharmaceutical Benefits 2003
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
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
Maryland-5
National Pharmaceutical Council Pharmaceutical Benefits 2003
Maryland-6
National Pharmaceutical Council Pharmaceutical Benefits 2003
MASSACHUSETTS
*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.
Massachusetts-1
National Pharmaceutical Council Pharmaceutical Benefits 2003
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
Massachusetts-3
National Pharmaceutical Council Pharmaceutical Benefits 2003
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
*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.
Michigan-1
National Pharmaceutical Council Pharmaceutical Benefits 2003
Michigan-2
National Pharmaceutical Council Pharmaceutical Benefits 2003
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
Michigan-4
National Pharmaceutical Council Pharmaceutical Benefits 2003
Michigan-5
National Pharmaceutical Council Pharmaceutical Benefits 2003
Michigan-6
National Pharmaceutical Council Pharmaceutical Benefits 2003
MINNESOTA
*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.
Minnesota-1
National Pharmaceutical Council Pharmaceutical Benefits 2003
Minnesota-2
National Pharmaceutical Council Pharmaceutical Benefits 2003
Minnesota-3
National Pharmaceutical Council Pharmaceutical Benefits 2003
Minnesota-4
National Pharmaceutical Council Pharmaceutical Benefits 2003
Minnesota-5
National Pharmaceutical Council Pharmaceutical Benefits 2003
Minnesota-6
National Pharmaceutical Council Pharmaceutical Benefits 2003
MISSISSIPPI
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Nursing Facility Services
Skilled Nursing Home Services
Physician Services
Dental Services
**Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Mississippi-1
National Pharmaceutical Council Pharmaceutical Benefits 2003
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
Mississippi-3
National Pharmaceutical Council Pharmaceutical Benefits 2003
Mississippi-4
National Pharmaceutical Council Pharmaceutical Benefits 2003
Mississippi-5
National Pharmaceutical Council Pharmaceutical Benefits 2003
Mississippi-6
National Pharmaceutical Council Pharmaceutical Benefits 2003
MISSOURI
**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.
Missouri-1
National Pharmaceutical Council Pharmaceutical Benefits 2003
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
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
Missouri-3
National Pharmaceutical Council Pharmaceutical Benefits 2003
Missouri-4
National Pharmaceutical Council Pharmaceutical Benefits 2003
Missouri-5
National Pharmaceutical Council Pharmaceutical Benefits 2003
Missouri-6
National Pharmaceutical Council Pharmaceutical Benefits 2003
MONTANA
*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
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
Montana-3
National Pharmaceutical Council Pharmaceutical Benefits 2003
Montana-4
National Pharmaceutical Council Pharmaceutical Benefits 2003
NEBRASKA
*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
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
Nebraska-3
National Pharmaceutical Council Pharmaceutical Benefits 2003
Nebraska-4
National Pharmaceutical Council Pharmaceutical Benefits 2003
Nebraska-5
National Pharmaceutical Council Pharmaceutical Benefits 2003
Nebraska-6
National Pharmaceutical Council Pharmaceutical Benefits 2003
NEVADA
*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.
Nevada-1
National Pharmaceutical Council Pharmaceutical Benefits 2003
Nevada-2
National Pharmaceutical Council Pharmaceutical Benefits 2003
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
Nevada-4
National Pharmaceutical Council Pharmaceutical Benefits 2003
NEW HAMPSHIRE
*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
New Hampshire-2
National Pharmaceutical Council Pharmaceutical Benefits 2003
New Hampshire-3
National Pharmaceutical Council Pharmaceutical Benefits 2003
New Hampshire-4
National Pharmaceutical Council Pharmaceutical Benefits 2003
NEW JERSEY 1
*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
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
New Jersey-3
National Pharmaceutical Council Pharmaceutical Benefits 2003
New Jersey-4
National Pharmaceutical Council Pharmaceutical Benefits 2003
NEW MEXICO
*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.
New Mexico-1
National Pharmaceutical Council Pharmaceutical Benefits 2003
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
New Mexico-3
National Pharmaceutical Council Pharmaceutical Benefits 2003
New Mexico-4
National Pharmaceutical Council Pharmaceutical Benefits 2003
New Mexico-5
National Pharmaceutical Council Pharmaceutical Benefits 2003
New Mexico-6
National Pharmaceutical Council Pharmaceutical Benefits 2003
NEW YORK
* 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
New York-2
National Pharmaceutical Council Pharmaceutical Benefits 2003
New York-3
National Pharmaceutical Council Pharmaceutical Benefits 2003
New York-4
National Pharmaceutical Council Pharmaceutical Benefits 2003
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-6
National Pharmaceutical Council Pharmaceutical Benefits 2003
NORTH CAROLINA
*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.
North Carolina-1
National Pharmaceutical Council Pharmaceutical Benefits 2003
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
North Carolina-3
National Pharmaceutical Council Pharmaceutical Benefits 2003
North Carolina-4
National Pharmaceutical Council Pharmaceutical Benefits 2003
NORTH DAKOTA
*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.
North Dakota-1
National Pharmaceutical Council Pharmaceutical Benefits 2003
North Dakota-2
National Pharmaceutical Council Pharmaceutical Benefits 2003
Albert Samuelson, MD
Term Expires: 06/30/2004
North Dakota-3
National Pharmaceutical Council Pharmaceutical Benefits 2003
North Dakota-4
National Pharmaceutical Council Pharmaceutical Benefits 2003
North Dakota-5
National Pharmaceutical Council Pharmaceutical Benefits 2003
North Dakota-6
National Pharmaceutical Council Pharmaceutical Benefits 2003
OHIO
*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.
Ohio-1
National Pharmaceutical Council Pharmaceutical Benefits 2003
Ohio-2
National Pharmaceutical Council Pharmaceutical Benefits 2003
Ohio-3
National Pharmaceutical Council Pharmaceutical Benefits 2003
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
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
Ohio-5
National Pharmaceutical Council Pharmaceutical Benefits 2003
Ohio-6
National Pharmaceutical Council Pharmaceutical Benefits 2003
OKLAHOMA 1
*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
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
Oklahoma-2
National Pharmaceutical Council Pharmaceutical Benefits 2003
Oklahoma-3
National Pharmaceutical Council Pharmaceutical Benefits 2003
Oklahoma-4
National Pharmaceutical Council Pharmaceutical Benefits 2003
OREGON
*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.
Oregon-1
National Pharmaceutical Council Pharmaceutical Benefits 2003
Oregon-2
National Pharmaceutical Council Pharmaceutical Benefits 2003
Oregon-3
National Pharmaceutical Council Pharmaceutical Benefits 2003
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
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PENNSYLVANIA
*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.
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Pennsylvania-4
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Pennsylvania-6
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RHODE ISLAND
*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.
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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.
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SOUTH CAROLINA
*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.
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South Carolina-2
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SOUTH DAKOTA
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
*Total Other Expenditures/recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
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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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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
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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
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TEXAS
*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.
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UTAH
*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.
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VERMONT1
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
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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
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VIRGINIA
*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
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Richard Grossman
Vectre Corporation
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WASHINGTON
*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.
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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.
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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)
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Raleigh Watts
Department of Health
P.O. Box 47481
Olympia, WA 98504-7841
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WEST VIRGINIA 1
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
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WISCONSIN
*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.
Wisconsin-1
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WYOMING
*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.
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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.
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Section 6:
State Pharmacy Assistance
Programs
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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.
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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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• 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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• 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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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
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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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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Arizona
Prescription Discount Program (CoppeRx Card)
Program Type: Discount
Law Enacted: 2001
Estimated Number of Recipients (December 2003): 15,000*
ELIGIBILITY CRITERIA
DRUG COVERAGE
Formulary: None
Drugs Covered: All FDA-approved drugs.
Drug Coverage Restrictions: None
PROGRAM CONTACT
*
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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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
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
PROGRAM CONTACT
∗
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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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.
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
∗
Price inquires do not always result in sales, because customers may elect not to purchase a pharmaceutical once
its price has been quoted.
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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.
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.
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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
DRUG COVERAGE
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PROGRAM CONTACT
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Delaware
Nemours Pharmacy Assistance
Program Type: Private Discount
Year Operational: 1981
Number of Enrollees (December 2003): 7,822
ELIGIBILITY CRITERIA
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
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Delaware
Prescription Assistance Program (DPAP)
Program Type: Direct Assistance
Year Operational: 2000
Number of Recipients (December 2003): 6,100
ELIGIBILITY CRITERIA
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
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Florida
Silver SaveRx Program
Program Type: Direct Assistance (1115 waiver)
Year Operational: 2002
Number of Enrollees (January 2004): 52,074
ELIGIBILITY CRITERIA
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
PROGRAM CONTACT
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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.
DRUG COVERAGE
Formulary: None
Drugs Covered: All prescription drugs
Drug Coverage Restrictions: None
PROGRAM CONTACT
∗
By law Florida pharmacies are required to provide this discount in order to participate in Medicaid.
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Georgia
Georgia Cares Program*
Program Type: Coordinate Assistance Between Elderly and Charitable
Pharmaceutical Programs
Year Operational: 2002
Number of Recipients: 24,739
ELIGIBILITY CRITERIA
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.
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PROGRAM CONTACT
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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.
DRUG COVERAGE
PROGRAM CONTACT
*
The legislature will conduct further study and propose additional amendments during 2004 before
implementing the program.
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Illinois
Pharmaceutical Assistance Program (PAP)
“Circuit Breaker”
Program Type: Direct Assistance
Year Operational: 1985
Number of Recipients (December 2003): 57,034
ELIGIBILITY CRITERIA
DRUG COVERAGE
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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
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Illinois
Illinois Rx SeniorCare
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 2002
Number of Recipients (December 2003): 170,969
ELIGIBILITY CRITERIA
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DRUG COVERAGE
PROGRAM CONTACT
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Illinois
Illinois Rx Buying Club
Program Type: Direct Discount
Year Operational: 2004
Number of Eligible Recipients: 1.5 million
ELIGIBILITY CRITERIA
DRUG COVERAGE
PROGRAM CONTACT
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Indiana
Indiana Prescription Drug Program
“HoosierRx”
Program Type: Point of Sale
Year Operational: 2000
Number of Recipients (December 2003): 17,179
ELIGIBILITY CRITERIA
DRUG COVERAGE
Formulary: None
Drugs Covered: All prescription drugs, as well as insulin
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PROGRAM CONTACT
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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.
DRUG COVERAGE
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PROGRAM CONTACT
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Kansas
Kansas Senior Pharmacy Assistance Program
Program Type: Reimbursement
Year Operational: 2001
Number of Enrollees (June 2003): 1,500
ELIGIBILITY CRITERIA
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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PROGRAM CONTACT
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Louisiana
Louisiana Seniors Pharmacy Assistance Program
Program Type: Reimbursement
Year Operational: Not Yet Operational
Number of Recipients: N/A
ELIGIBILITY CRITERIA
DRUG COVERAGE
Formulary: None
Drugs Covered: Not available
Drug Coverage Restrictions: Not available
PROGRAM CONTACT
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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
DRUG COVERAGE
Formulary: None
Drugs Covered: Based on a manufacturer’s charitable program criteria.
Drug Coverage Restrictions: Not available
PROGRAM CONTACT
*
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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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.
DRUG COVERAGE
PROGRAM CONTACT
*
This program replaces the Maine Rx Program, which faced significant legal challenges and was never
implemented. Additionally, beneficiaries from the former Healthy Maine Prescription Program were
immediately eligible for the Maine Rx Plus program.
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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
DRUG COVERAGE
*
The Low Cost Drugs for the Elderly and Disabled (DEL) Program is also run under the Maine Rx Plus
umbrella, distinguished by the eligibility criteria differences.
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PROGRAM CONTACT
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Maryland
Maryland Pharmacy Assistance Program
Program Type: Direct Assistance
Year Operational: 1979
Number of Recipients (December 2003): 47,133
ELIGIBILITY CRITERIA
DRUG COVERAGE
PROGRAM CONTACT
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Maryland
Senior Prescription Drug Program
Program Type: Direct Assistance
Year Operational: 2001∗
Number of Recipients (December 2003): 33,400
ELIGIBILITY CRITERIA
DRUG COVERAGE
∗
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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PROGRAM CONTACT
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Maryland
Maryland Pharmacy Discount Program
Program Type: Discount (1115 Waiver)
Operational Date: July 1, 2003
Number of Recipients (December 2003): 24,000
ELIGIBILITY CRITERIA
Funding Source: State General Revenue funds and Federal matching funds
Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid guidelines
Ingredient Cost Calculation: For brand name drugs, lower of AWP-11%, WAC+9%, Direct
Manufacturer’s Cost (DMC)+10%, or Direct Cost (DC)+10%.
For generic drugs, lower of EAC, State MAC, or Federal MAC.
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: 65% of the Medicaid price
Dispensing Fee: $1.00 per prescription
DRUG COVERAGE
PROGRAM CONTACT
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Massachusetts
Prescription Advantage*
Program Type: Direct Assistance
Year Operational: 2001
Number of Recipients (December 2003): 80,000
ELIGIBILITY CRITERIA
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DRUG COVERAGE
PROGRAM CONTACT
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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
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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Michigan
Elder Prescription Insurance Coverage (EPIC)
Program
Program Type: Direct Assistance
Year Operational: 2001
Number of Enrollees (December 2003): 14,000
ELIGIBILITY CRITERIA
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DRUG COVERAGE
PROGRAM CONTACT
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Minnesota
Prescription Drug Program∗
Program Type: Direct Assistance
Year Operational: 1999
Number of Enrollees (December 2003): 7,100
ELIGIBILITY CRITERIA
∗
Formerly the Senior Citizen Drug Program.
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DRUG COVERAGE
PROGRAM CONTACT
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Missouri
Senior Rx Program
Program Type: Direct Assistance
Year Operational: 2002
Number of Enrollees (December 2003): 19,000
ELIGIBILITY CRITERIA
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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PROGRAM CONTACT
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Montana
Prescription Drug Expansion Program
Program Type: Discount (CMS Pharmacy Plus Program waiver)
Year Operational: Not available*
Number of Recipients: Not available
ELIGIBILITY CRITERIA
DRUG COVERAGE
Formulary: None
Drugs Covered: Based on participating manufacturers’ pharmaceutical products
Drug Coverage Restrictions: None
PROGRAM CONTACT
*
The program will not be implemented given the passage of the Federal Medicare prescription drug program.
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Nevada
Senior Rx
Program Type: Subsidy
Year Operational: 2001
Number of Recipients (December 2003): 8,600
ELIGIBILITY CRITERIA
DRUG COVERAGE
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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
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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
DRUG COVERAGE
Formulary: No formulary
Drugs Covered: All prescription drugs
Drug Coverage Restrictions: Over-the-counter drugs are not covered
PROGRAM CONTACT
*
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
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
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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
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 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
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National Pharmaceutical Council Pharmaceutical Benefits 2003
New Mexico
Senior Prescription Drug Program
Program Type: Discount
Operational Date: 2003
Number of Recipients (December 2003): 3,200
ELIGIBILITY CRITERIA
DRUG COVERAGE
Formulary: None
Drugs Covered: Manufacturers’ participating prescription drug products
Drug Coverage Restrictions: None
PROGRAM CONTACT
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National Pharmaceutical Council Pharmaceutical Benefits 2003
New York
Elderly Pharmaceutical Insurance Coverage (EPIC)
Program
Program Type: Direct Assistance
Year Operational: 1987
Number of Recipients (December 2003): 329,000
ELIGIBILITY CRITERIA
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
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National Pharmaceutical Council Pharmaceutical Benefits 2003
North Carolina
Senior Care∗
Program Type: Direct Assistance
Year Operational: 2002
Number of Recipients (December 2003): 24,000
ELIGIBILITY CRITERIA
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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National Pharmaceutical Council Pharmaceutical Benefits 2003
Ohio
Golden Buckeye Prescription Drug Program
Program Type: Negotiated Discounts
Operational Date: 2003
Estimated eligibles (December 2003): 2 million
ELIGIBILITY CRITERIA
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National Pharmaceutical Council Pharmaceutical Benefits 2003
DRUG COVERAGE
PROGRAM CONTACT
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National Pharmaceutical Council Pharmaceutical Benefits 2003
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
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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National Pharmaceutical Council Pharmaceutical Benefits 2003
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
DRUG COVERAGE
Formulary: None
Drugs Covered: Based on a manufacturer’s charitable program criteria.
Drug Coverage Restrictions: Not available
PROGRAM CONTACT
*
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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National Pharmaceutical Council Pharmaceutical Benefits 2003
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.
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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National Pharmaceutical Council Pharmaceutical Benefits 2003
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
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
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National Pharmaceutical Council Pharmaceutical Benefits 2003
Pennsylvania
PACE Needs Enhancement Tier (PACENET)
Program Type: Direct Assistance
Year Operational: 1996
Number of Recipients (December 2003): 38,730
ELIGIBILITY CRITERIA
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
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National Pharmaceutical Council Pharmaceutical Benefits 2003
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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National Pharmaceutical Council Pharmaceutical Benefits 2003
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
DRUG COVERAGE
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Notes: Brand name drugs are dispensed when generic drugs are not
available. Over-the-counter drugs are paid for when authorized
with a prescription. Insulin syringes, insulin, or other injectable
products that are either administered at home or self-
administered are also covered.
Diabetic supplies such as alcohol wipes and test strips; smoking
cessation products; certain lifestyle drugs; and, injectable
products administered in a physician’s office or clinic are not
covered.
PROGRAM CONTACT
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National Pharmaceutical Council Pharmaceutical Benefits 2003
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.
DRUG COVERAGE
Formulary: None
Drugs Covered: All prescription drugs
Drug Coverage Restrictions: None
PROGRAM CONTACT
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National Pharmaceutical Council Pharmaceutical Benefits 2003
Texas
State Prescription Drug Program
Program Type: State-Subsidy
Law Enacted: 2001∗
Estimated Eligibles: None
ELIGIBILITY CRITERIA
Funding Source: State General Revenue Fund, unless funds are available under
Federal law to fund all or part of the program
Budget: None
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Not available
Ingredient Cost Calculation: Not available
Enrollment Fee: Not available
Deductible Amount: Not available
Copayment Amount: Not available
Dispensing Fee: Not available
Notes: According to statute, the Health and Human Services
Commission may require a cost-sharing payment.
DRUG COVERAGE
∗
This program has not been implemented due to the fact that no funding has been budgeted for it.
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PROGRAM CONTACT
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Vermont
VSCRIPT
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 1989∗
Number of Recipients (FY03): 3,081
ELIGIBILITY CRITERIA
DRUG COVERAGE
PROGRAM CONTACT
∗
This program was integrated into the VHAP (1115 waiver) program in 1999.
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National Pharmaceutical Council Pharmaceutical Benefits 2003
Vermont
VSCRIPT Expanded
Program Type: Direct Assistance
Year Operational: 2000
Number of Recipients (FY 03): 3,364
ELIGIBILITY CRITERIA
DRUG COVERAGE
PROGRAM CONTACT
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National Pharmaceutical Council Pharmaceutical Benefits 2003
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
DRUG COVERAGE
PROGRAM CONTACT
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National Pharmaceutical Council Pharmaceutical Benefits 2003
Vermont
Healthy Vermonters Program
Program Type: Direct Assistance (1115 Waiver)
Year Operational: July 1, 2002
Eligible Recipients (FY 04): 11,373
ELIGIBILITY CRITERIA
DRUG COVERAGE
PROGRAM CONTACT
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National Pharmaceutical Council Pharmaceutical Benefits 2003
Washington
Rx Card Program
Program Type: Negotiated Rebates
Year Operational: 2004*
Number of Recipients: not available
ELIGIBILITY CRITERIA
*
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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National Pharmaceutical Council Pharmaceutical Benefits 2003
West Virginia
Gold Mountaineer Card Program
Program Type: Direct Assistance
Year Operational: 2001
Number of Recipients (December 2003): 17,000/month*
ELIGIBILITY CRITERIA
DRUG COVERAGE
Formulary: None
Drugs Covered: All FDA federal legend pharmaceuticals and diabetic supplies
Drug Coverage Restrictions: None
PROGRAM CONTACT
*
There are a total of 360,000 eligible seniors for the Gold Mountaineer Card Program. Monthly card usage
varies.
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National Pharmaceutical Council Pharmaceutical Benefits 2003
Wisconsin
SeniorCare
Program Type: Direct Assistance
Year Operational: 2002
Estimated Enrollment (May 2003): 86,700
ELIGIBILITY CRITERIA
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National Pharmaceutical Council Pharmaceutical Benefits 2003
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
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National Pharmaceutical Council Pharmaceutical Benefits 2003
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.
DRUG COVERAGE
PROGRAM CONTACT
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6-86
National Pharmaceutical Council Pharmaceutical Benefits 2003
Appendix A:
State and Federal
Medicaid Contacts
A-1
National Pharmaceutical Council Pharmaceutical Benefits 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
A-2
National Pharmaceutical Council Pharmaceutical Benefits 2003
A-3
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
A-5
National Pharmaceutical Council Pharmaceutical Benefits 2003
A-6
National Pharmaceutical Council Pharmaceutical Benefits 2003
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
A-7
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
A-8
National Pharmaceutical Council Pharmaceutical Benefits 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
A-9
National Pharmaceutical Council Pharmaceutical Benefits 2003
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
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National Pharmaceutical Council Pharmaceutical Benefits 2003
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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National Pharmaceutical Council Pharmaceutical Benefits 2003
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
A-18
National Pharmaceutical Council Pharmaceutical Benefits 2003
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
A-20
National Pharmaceutical Council Pharmaceutical Benefits 2003
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
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
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National Pharmaceutical Council Pharmaceutical Benefits 2003
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
A-22
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
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
A-23
National Pharmaceutical Council Pharmaceutical Benefits 2003
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
A-24
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
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National Pharmaceutical Council Pharmaceutical Benefits 2003
State Contact
Nicole N. Nguyen, Pharm.D.
Clinical Pharmacist
Medical Assistance Administration, DSHS
WASHINGTON 805 Plum Street, SE
In-House DUR P.O. Box 45506
Olympia, WA 98504-5506
T: 360/725-1757
F: 360/586-8827
E-mail: nguyen@dshs.wa.gov
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National Pharmaceutical Council Pharmaceutical Benefits 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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National Pharmaceutical Council Pharmaceutical Benefits 2003
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
A-28
National Pharmaceutical Council Pharmaceutical Benefits 2003
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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National Pharmaceutical Council Pharmaceutical Benefits 2003
NORTH DAKOTA
Brendan K. Joyce, Pharm. D., R.Ph.
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National Pharmaceutical Council Pharmaceutical Benefits 2003
WISCONSIN
A-31
National Pharmaceutical Council Pharmaceutical Benefits 2003
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
A-32
National Pharmaceutical Council Pharmaceutical Benefits 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
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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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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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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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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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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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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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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
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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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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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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WYOMING
Governor
Honorable Dave Freudenthal
State Capitol, Room 124
Cheyenne, WY 82002-0010
T: 307/777-7434
F: 307/632-3909
E-mail:
governor@missc.state.wy.us
Internet address: www.state.wy.us
Medicaid Director
Ms. Iris Oleske,
State Medicaid Agent
Department of Health
147 Hathaway Building
Cheyenne, WY 82002
T: 307/777-7531
F: 307/777-6964
E-mail: iolesk@state.wy.us
Internet address: wdhfs.state.wy.us
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Source: CMS, Central Office, Centers for Medicaid and State Operations, as of February 11, 2004.
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Appendix B:
Medicaid Program Statistics -
CMS MSIS Tables
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The CMS MSIS Report is an annual report designed to collect State-reported statistical summary data
on eligibles, recipients, services, and expenditures during a Federal fiscal year (i.e., October l through
September 30). The data reported for a given year represent recipients of service and the amount of
payments for claims adjudicated during the year. The data reflect bills adjudicated during the year
rather than the services used during the year.
Historically, States summarized and reported the data processed through their Medicaid claims
processing and payment operations unless they opted to participate in the Medicaid Statistical
Information System (MSIS) project. Prior to Federal fiscal year 1999, MSIS was a voluntary
program and those States participating in the MSIS project provide data tapes from their claims
processing systems to HCFA in lieu of HCFA-2082 tables. However, in accordance with the
Balanced Budget Act of 1997, all claims processed on or after January 1, 1999, must be submitted
electronically in the MSIS format.
The MSIS Report is the primary CMS source on recipients’ use of services and the associated
payments for these services. However, the new reporting requirements have resulted in a lag in the
timely release of MSIS summary tables. The most recent MSIS service utilization information
available from CMS is for FY 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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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.
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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%
*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.
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*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.
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*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.
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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.
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*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.
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*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.
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*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.
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*Hawaii did not report on time for FY 1997 and FY 1999 and was excluded from the national totals for those years. Hawaii also did not report for
FY 2000 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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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
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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.
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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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*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.
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Appendix C:
Medicaid Rebate Law
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(1) In general
In order for payment to be available under section 1396b(a) of this title or under part B of title XVIII
for covered outpatient drugs of a manufacturer, the manufacturer must have entered into and have in
effect a rebate agreement described in subsection (b) of this section with the Secretary, on behalf of
States (except that, the Secretary may authorize a State to enter directly into agreements with a
manufacturer), and must meet the requirements of paragraph (5)(with respect to drugs purchased by a
covered entity on or after the first day of the first month that begins after November 4, 1992) and
paragraph (6). Any agreement between a State and a manufacturer prior to April 1, 1991, shall be
deemed to have been entered into on January 1, 1991, and payment to such manufacturer shall be
retroactively calculated as if the agreement between the manufacturer and the State had been entered
into on January 1, 1991. If a manufacturer has not entered into such an agreement before March 1,
1991, such an agreement, subsequently entered into, shall become effective as of the date on which the
agreement is entered into or, at State option, on any date thereafter on or before the first day of the
calendar quarter that begins more than 60 days after the date of the agreement is entered into.
(3) Authorizing payment for drugs not covered under rebate agreements
Paragraph (1), and section 1396b(i)(10)(A) of this title, shall not apply to the dispensing of a single
source drug or innovator multiple source drug if (A)(i) the State has made a determination that the
availability of the drug is essential to the health of beneficiaries under the State Plan for medical
assistance; (ii) such drug has been given a rating of 1-A by the Food and Drug Administration; and
(iii)(I) the physician has obtained approval for use of the drug in advance of its dispensing in
accordance with a prior authorization program described in subsection (d) of this section, or (II) the
Secretary has reviewed and approved the State’s determination under subparagraph (A); or (B) the
Secretary determines that in the first calendar quarter of 1991, there were extenuating circumstances.
1
This is section 1927 of the Social Security Act. It is codified as Section 1396r-8 of Title 42 of the United States Code.
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A manufacturer meets the requirements of this paragraph if the manufacturer has entered into
an agreement with the Secretary that meets the requirements of section 256b of this title with
respect to covered outpatient drugs purchased by a covered entity on or after the first day of
the first month that begins after November 4, 1992.
(6) Requirements relating to master agreements for drugs procured by Department of Veterans Affairs
and certain other Federal agencies
(A) In general
A manufacturer meets the requirements of this paragraph if the manufacturer complies with
the provisions of section 8126 of title 38, including the requirement of entering into a master
agreement with the Secretary of Veterans Affairs under such section.
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after November 4, 1992) and would have entered into an agreement under such section (as
such section was in effect at such time), but for a legislative change in such section after
November 4, 1992.
(A) In general
A rebate agreement under this subsection shall require the manufacturer to provide, to each
State Plan approved under this subchapter, a rebate for a rebate period in an amount specified
in subsection (c) of this section for covered outpatient drugs of the manufacturer dispensed
after December 31, 1990, for which payment was made under the State Plan for such period.
Such rebate shall be paid by the manufacturer not later than 30 days after the date of receipt of
the information described in paragraph (2) for the period involved.
(B) Audits
A manufacturer may audit the information provided (or required to be provided) under
subparagraph (A). Adjustments to rebates shall be made to the extent that information
indicates that utilization was greater or less than the amount previously specified.
(A) In general. -- Each manufacturer with an agreement in effect under this section shall report
to the Secretary –
(i) not later than 30 days after the last day of each rebate period under the agreement
(beginning on or after January 1, 1991), on the average manufacturer price (as defined in
subsection (k)(1) of this section) and, (for single source drugs and innovator multiple source
drugs), the manufacturer’s best price (as defined in subsection (c)(2)(B) of this section) for
covered outpatient drugs for the rebate period under the agreement;
(ii) not later than 30 days after the date of entering into an agreement under this section on
the average manufacturer price (as defined in subsection (k)(1) of this section) as of October
1, 1990 for each of the manufacturer’s covered outpatient drugs; and
(iii) for calendar quarters beginning on or after January 1, 2004, in conjunction with
reporting required under clause (i) and by National Drug Code (including package size)—
(I) the manufacturer’s average sales price (as defined in section 1847A(c)) and the
total number of units specified under section 1847A(b)(2)(A);
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(II) if required to make payment under section 1847A, the manufacturer’s wholesale
acquisition cost, as defined in subsection (c)(6) of such section; and
(III) information on those sales that were made at a nominal price or otherwise
described in section 1847A(c)(2)(B);
for a drug or biological described in subparagraph (C), (D), (E), or (G) of section 1842 (o)(1)
or section 1881(b)(13)(A)(ii).
Information reported under this subparagraph is subject to audit by the Inspector General of
the Department of Health and Human Services.
(C) Penalties
(i) Failure to provide timely information
In the case of a manufacturer with an agreement under this section that fails to provide
information required under subparagraph (A) on a timely basis, the amount of the penalty
shall be increased by $10,000 for each day in which such information has not been
provided and such amount shall be paid to the Treasury, and, if such information is not
reported within 90 days of the deadline imposed, the agreement shall be suspended for
services furnished after the end of such 90-day period and until the date such information
is reported (but in no case shall such suspension be for a period of less than 30 days).
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(ii) to permit the Comptroller General to review the information provided, and
(iii) to permit the Director of the Congressional Budget Office to review the information
provided.
The previous sentence shall also apply to information disclosed under section 1860D-2(d)(2)
or 1860D-4(c)(2)(E) and drug pricing data reported under the first sentence of section 1860D-
31(i)(1).
(A) In general
A rebate agreement shall be effective for an initial period of not less than 1 year and shall be
automatically renewed for a period of not less than one year unless terminated under
subparagraph (B).
(B) Termination
(i) By the Secretary
The Secretary may provide for termination of a rebate agreement for violation of the
requirements of the agreement or other good cause shown. Such termination shall not be
effective earlier than 60 days after the date of notice of such termination. The Secretary
shall provide, upon request, a manufacturer with a hearing concerning such a termination,
but such hearing shall not delay the effective date of the termination.
(ii) By a manufacturer
A manufacturer may terminate a rebate agreement under this section for any reason. Any
such termination shall not be effective until the calendar quarter beginning at least 60 days
after the date the manufacturer provides notice to the Secretary.
(iii) Effectiveness of termination
Any termination under this subparagraph shall not affect rebates due under the agreement
before the effective date of its termination.
(iv) Notice to States
In the case of a termination under this subparagraph, the Secretary shall provide notice of
such termination to the States within not less than 30 days before the effective date of such
termination.
(v) Application to terminations of other agreements
The provisions of this subparagraph shall apply to the terminations of agreements described
in section 256b(a)(1) of this title and master agreements described in section 8126(a) of title
38.
(c) In the case of any rebate agreement with a manufacturer under this section which is terminated,
another such agreement with the manufacturer (or a successor manufacturer) may not be entered
into until a period of 1 calendar quarter has elapsed since the date of the termination, unless the
Secretary finds good cause for an earlier reinstatement of such an agreement.
(1) Basic rebate for single source drugs and innovator multiple source drugs
(A) In general
Except as provided in paragraph (2), the amount of the rebate specified in this subsection for a
rebate period (as defined in subsection (k)(8) of this section) with respect to each dosage form
and strength of a single source drug or an innovator multiple source drug shall be equal to the
product of -
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(i) the total number of units of each dosage form and strength paid for under the State Plan
in the rebate period (as reported by the State); and
(ii) subject to subparagraph (B)(ii), the greater of -
(I) the difference between the average manufacturer price and the best price (as defined
in subparagraph (C)) for the dosage form and strength of the drug, or
(II) the minimum rebate percentage (specified in subparagraph (B)(i)) of such average
manufacturer price, for the rebate period.
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(III) shall not take into account prices that are merely nominal in amount.
(iii) Application of auditing and recordkeeping requirements
With respect to a covered entity described in section 340B(a)(4)(L) of the Public Health
Service Act, any drug purchased for inpatient use shall be subject to the auditing and
recordkeeping requirements described in section 340B(a)(5)(C) of the Public Health
Service Act.
(2) Additional rebate for single source and innovator multiple source drugs
(A) In general
The amount of the rebate specified in this subsection for a rebate period, with respect to each
dosage form and strength of a single source drug or an innovator multiple source drug, shall be
increased by an amount equal to the product of -
(i) the total number of units of such dosage form and strength dispensed after December 31,
1990, for which payment was made under the State Plan for the rebate period; and
(ii) the amount (if any) by which -
(I) the average manufacturer price for the dosage form and strength of the drug for the
period, exceeds
(II) the average manufacturer price for such dosage form and strength for the calendar
quarter beginning July 1, 1990 (without regard to whether or not the drug has been sold
or transferred to an entity, including a division or subsidiary of the manufacturer, after
the first day of such quarter), increased by the percentage by which the consumer price
index for all urban consumers (United States city average) for the month before the
month in which the rebate period begins exceeds such index for September 1990.
.
(B) Treatment of subsequently approved drugs
In the case of a covered outpatient drug approved by the Food and Drug Administration after
October 1, 1990, clause (ii)(II) of subparagraph (A) shall be applied by substituting “the first
full calendar quarter after the day on which the drug was first marketed” for “the calendar
quarter beginning July 1, 1990” and “the month prior to the first month of the first full
calendar quarter after the day on which the drug was first marketed” for “September 1990.”
(A) In general
The amount of the rebate paid to a State for a rebate period with respect to each dosage form
and strength of covered outpatient drugs (other than single source drugs and innovator
multiple source drugs) shall be equal to the product of -
(i) the applicable percentage (as described in subparagraph (B)) of the average
manufacturer price for the dosage form and strength for the rebate period, and
(ii) the total number of units of such dosage form and strength dispensed after December
31, 1990, for which payment was made under the State Plan for the rebate period.
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(A) A State may subject to prior authorization any covered outpatient drug. Any such prior
authorization program shall comply with the requirements of paragraph (5).
(B) A State may exclude or otherwise restrict coverage of a covered outpatient drug if -
(i) the prescribed use is not for a medically accepted indication (as defined in subsection
(k)(6) of this section);
(ii) the drug is contained in the list referred to in paragraph (2);
(iii) the drug is subject to such restrictions pursuant to an agreement between a
manufacturer and a State authorized by the Secretary under subsection (a)(1) of this section
or in effect pursuant to subsection (a)(4) of this section; or
(iv) the State has excluded coverage of the drug from its formulary established in
accordance with paragraph (4).
(A) Agents when used for anorexia, weight loss, or weight gain.
(B) Agents when used to promote fertility.
(C) Agents when used for cosmetic purposes or hair growth.
(D) Agents when used for the symptomatic relief of cough and colds.
(E) Agents when used to promote smoking cessation.
(F) Prescription vitamins and mineral products, except prenatal vitamins and fluoride
preparations.
(G) Nonprescription drugs.
(H) Covered outpatient drugs which the manufacturer seeks to require as a condition of sale
that associated tests or monitoring services be purchased exclusively from the manufacturer or
its designee.
(I) Barbiturates.
(J) Benzodiazepines.
(B) Except as provided in subparagraph (C), the formulary includes the covered outpatient
drugs of any manufacturer which has entered into and complies with an agreement under
subsection (a) of this section (other than any drug excluded from coverage or otherwise
restricted under paragraph (2)).
(C) A covered outpatient drug may be excluded with respect to the treatment of a specific
disease or condition for an identified population (if any) only if, based on the drug’s labeling
(or, in the case of a drug the prescribed use of which is not approved under the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 301 et seq.) but is a medically accepted indication, based
on information from the appropriate compendia described in subsection (k)(6) of this section),
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the excluded drug does not have a significant, clinically meaningful therapeutic advantage in
terms of safety, effectiveness, or clinical outcome of such treatment for such population over
other drugs included in the formulary and there is a written explanation (available to the
public) of the basis for the exclusion.
(D) The State Plan permits coverage of a drug excluded from the formulary (other than any
drug excluded from coverage or otherwise restricted under paragraph (2)) pursuant to a prior
authorization program that is consistent with paragraph (5).
(E) The formulary meets such other requirements as the Secretary may impose in order to
achieve program savings consistent with protecting the health of program beneficiaries. A
prior authorization program established by a State under paragraph (5) is not a formulary
subject to the requirements of this paragraph.
(B) except with respect to the drugs on the list referred to in paragraph (2), provides for the
dispensing of at least 72-hour supply of a covered outpatient prescription drug in an
emergency situation (as defined by the Secretary).
(1) In general
During the period beginning on January 1, 1991, and ending on
December 31, 1994 –
(A) a State may not reduce the payment limits established by regulation under this subchapter
or any limitation described in paragraph (3) with respect to the ingredient cost of a covered
outpatient drug or the dispensing fee for such a drug below the limits in effect as of January 1,
1991, and
(B) except as provided in paragraph (2), the Secretary may not modify by regulation the
formula established under sections 447.331 through 447.334 of title 42, Code of Federal
Regulations, in effect on November 5, 1990, to reduce the limits described in subparagraph
(A).
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(1) In general
(A) In order to meet the requirement of section 1396b(i)(10)(B) of this title, a State shall
provide, by not later than January 1, 1993, for a drug use review program described in
paragraph (2) for covered outpatient drugs in order to assure that prescriptions (i) are
appropriate, (ii) are medically necessary, and (iii) are not likely to result in adverse medical
results. The program shall be designed to educate physicians and pharmacists to identify and
reduce the frequency of patterns of fraud, abuse, gross overuse, or inappropriate or medically
unnecessary care, among physicians, pharmacists, and patients, or associated with specific
drugs or groups of drugs, as well as potential and actual severe adverse reactions to drugs
including education on therapeutic appropriateness, overutilization and underutilization,
appropriate use of generic products, therapeutic duplication, drug-disease contraindications,
drug-drug interactions, incorrect drug dosage or duration of drug treatment, drug-allergy
interactions, and clinical abuse/misuse.
(B) The program shall assess data on drug use against predetermined standards, consistent
with the following:
(i) compendia which shall consist of the following:
(I) American Hospital Formulary Service Drug Information;
(II) United States Pharmacopeia-Drug Information; and
(III) the DRUGDex information System.
(ii) the peer-reviewed medical literature.
(C) The Secretary, under the procedures established in section 1396b of this title, shall pay to
each State an amount equal to 75 per centum of so much of the sums expended by the State
Plan during calendar years 1991 through 1993 as the Secretary determines is attributable to the
statewide adoption of a drug use review program which conforms to the requirements of this
subsection.
(D) States shall not be required to perform additional drug use reviews with respect to drugs
dispensed to residents of nursing facilities which are in compliance with the drug regimen
review procedures prescribed by the Secretary for such facilities in regulations implementing
section 1396r of this title, currently at section 483.60 of title 42, Code of Federal Regulations.
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(A) Establishment
Each State shall provide for the establishment of a drug use review board (hereinafter referred
to as the “DUR Board”) either directly or through a contract with a private organization.
(B) Membership
The membership of the DUR Board shall include health care professionals who have
recognized knowledge and expertise in one or more of the following:
(i) The clinically appropriate prescribing of covered outpatient drugs.
(ii) The clinically appropriate dispensing and monitoring of covered outpatient drugs.
(iii) Drug use review, evaluation, and intervention.
(iv) Medical quality assurance.
The membership of the DUR Board shall be made up at least 1/3 but no more than 51
percent licensed and actively practicing physicians and at least 1/3 licensed and actively
practicing pharmacists.
(C) Activities
The activities of the DUR Board shall include but not be limited to the following:
(i) Retrospective DUR as defined in section.
(ii) Application of standards as defined in paragraph (2)(C).
(iii) Ongoing interventions for physicians and pharmacists, targeted toward therapy
problems or individuals identified in the course of retrospective drug use reviews
performed under this subsection. Intervention programs shall include, in appropriate
instances, at least:
(I) information dissemination sufficient to ensure the ready availability to physicians and
pharmacists in the State of information concerning its duties, powers, and basis for its
standards;
(II) written, oral, or electronic reminders containing patient-specific or drug-specific (or
both) information and suggested changes in prescribing or dispensing practices,
communicated in a manner designed to ensure the privacy of patient-related information;
(III) use of face-to-face discussions between health care professionals who are experts in
rational drug therapy and selected prescribers and pharmacists who have been targeted
for educational intervention, including discussion of optimal prescribing, dispensing, or
pharmacy care practices, and follow-up face-to-face discussions; and
(IV) intensified review or monitoring of selected prescribers or dispensers. The Board
shall re-evaluate interventions after an appropriate period of time to determine if the
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intervention improved the quality of drug therapy, to evaluate the success of the
interventions and make modifications as necessary.
(1) In general
In accordance with chapter 35 of title 44 (relating to coordination of Federal information policy), the
Secretary shall encourage each State agency to establish, as its principal means of processing claims
for covered outpatient drugs under this subchapter, a point-of-sale electronic claims management
system, for the purpose of performing on-line, real time eligibility verifications, claims data capture,
adjudication of claims, and assisting pharmacists (and other authorized persons) in applying for and
receiving payment.
(2) Encouragement
In order to carry out paragraph (1) -
(A) for calendar quarters during fiscal years 1991 and 1992, expenditures under the State Plan
attributable to development of a system described in paragraph (1) shall receive Federal
financial participation under section 1396b(a)(3)(A)(i) of this title (at a matching rate of 90
percent) if the State acquires, through applicable competitive procurement process in the State,
the most cost-effective telecommunications network and automatic data processing services
and equipment; and
(B) the Secretary may permit, in the procurement described in subparagraph (A) in the
application of part 433 of title 42, Code of Federal Regulations, and parts 95, 205, and 307 of
title 45, Code of Federal Regulations, the substitution of the State’s request for proposal in
competitive procurement for advance planning and implementation documents otherwise
required.
(1) In general
Not later than May 1 of each year the Secretary shall transmit to the Committee on Finance of the
Senate, the Committee on Energy and Commerce of the House of Representatives, and the
Committees on Aging of the Senate and the House of Representatives a report on the operation of this
section in the preceding fiscal year.
(2) Details
Each report shall include information on –
(A) ingredient costs paid under this subchapter for single source drugs, multiple source drugs,
and nonprescription covered outpatient drugs;
(B) the total value of rebates received and number of manufacturers providing such rebates;
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(C) how the size of such rebates compare with the size of rebates offered to other purchasers
of covered outpatient drugs;
(D) the effect of inflation on the value of rebates required under this section;
(E) trends in prices paid under this subchapter for covered outpatient drugs; and
(F) Federal and State administrative costs associated with compliance with the provisions of
this subchapter.
(1) Covered outpatient drugs dispensed by health maintenance organizations, including Medicaid
managed care organizations that contract under section 1396b(m) of this title, are not subject to the
requirements of this section.
(2) The State Plan shall provide that a hospital (providing medical assistance under such Plan) that
dispenses covered outpatient drugs using drug formulary systems, and bills the Plan no more than the
hospital’s purchasing costs for covered outpatient drugs (as determined under the State Plan) shall not
be subject to the requirements of this section.
(3) Nothing in this subsection shall be construed as providing that amounts for covered outpatient
drugs paid by the institutions described in this subsection should not be taken into account for
purposes of determining the best price as described in subsection (c) of this section.
(k) Definitions
In this section -
(A) of those drugs which are treated as prescribed drugs for purposes of section 1396d(a)(12)
of this title, a drug which may be dispensed only upon prescription (except as provided in
paragraph (5)), and -
(i) which is approved for safety and effectiveness as a prescription drug under section 505
or 507 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355, 357) or which is
approved under section 505(j) of such Act (21 U.S.C. 355(j));
(ii)(I) which was commercially used or sold in the United States before October 10, 1962,
or which is identical, similar, or related (within the meaning of section 310.6(b)(1) of title
21 of the Code of Federal Regulations) to such a drug, and (II) which has not been the
subject of a final determination by the Secretary that it is a “new drug” (within the meaning
of section 201(p) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 321(p))) or an
action brought by the Secretary under section 301, 302(a), or 304(a) of such Act (21 U.S.C.
331, 332(a), 334(a)) to enforce section 502(f) or 505(a) of such Act (21 U.S.C. 352(f),
355(a)); or
(iii)(I) which is described in section 107(c)(3) of the Drug Amendments of 1962 and for
which the Secretary has determined there is a compelling justification for its medical need,
or is identical, similar, or related (within the meaning of section 310.6(b)(1) of title 21 of
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the Code of Federal Regulations) to such a drug, and (II) for which the Secretary has not
issued a notice of an opportunity for a hearing under section 505(e) of the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 355(e)) on a proposed order of the Secretary to
withdraw approval of an application for such drug under such section because the Secretary
has determined that the drug is less than effective for some or all conditions of use
prescribed, recommended, or suggested in its labeling; and
(C) insulin certified under section 506 of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 356).
(C) Dental services, except that drugs for which the State Plan authorizes direct
reimbursement to the dispensing dentist are covered outpatient drugs.
(F) Nursing facility services and services provided by an intermediate care facility for the
mentally retarded.
(5) Manufacturer
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(7) Multiple source drug; innovator multiple source drug; noninnovator multiple source drug; single
source drug
(A) Defined
(i) Multiple source drug
The term “multiple source drug” means, with respect to a rebate period, a covered
outpatient drug (not including any drug described in paragraph (5)) for which there are 2 or
more drug products which -
(I) are rated as therapeutically equivalent (under the Food and Drug Administration’s
most recent publication of “Approved Drug Products with Therapeutic Equivalence
Evaluations”),
(II) except as provided in subparagraph (B), are pharmaceutically equivalent and
bioequivalent, as defined in subparagraph (C) and as determined by the Food and Drug
Administration, and
(III) are sold or marketed in the State during the period.
(ii) Innovator multiple source drug The term “innovator multiple source drug” means a
multiple source drug that was originally marketed under an original new drug application
approved by the Food and Drug Administration.
(iii) Noninnovator multiple source drug
The term “noninnovator multiple source drug” means a multiple source drug that is not an
innovator multiple source drug.
(iv) Single source drug
The term “single source drug” means a covered outpatient drug which is produced or
distributed under an original new drug application approved by the Food and Drug
Administration, including a drug product marketed by any cross-licensed producers or
distributors operating under the new drug application.
(B) Exception
Subparagraph (A)(i)(II) shall not apply if the Food and Drug Administration changes by
regulation the requirement that, for purposes of the publication described in subparagraph
(A)(i)(I), in order for drug products to be rated as therapeutically equivalent, they must be
pharmaceutically equivalent and bioequivalent, as defined in subparagraph (C).
(C) Definitions
For purposes of this paragraph -
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(i) drug products are pharmaceutically equivalent if the products contain identical amounts
of the same active drug ingredient in the same dosage form and meet compendial or other
applicable standards of strength, quality, purity, and identity;
So in original. Probably should be “pharmaceutically”.
(ii) drugs are bioequivalent if they do not present a known or potential bioequivalence
problem, or, if they do present such a problem, they are shown to meet an appropriate
standard of bioequivalence; and
(iii) a drug product is considered to be sold or marketed in a State if it appears in a
published national listing of average wholesale prices selected by the Secretary, provided
that the listed product is generally available to the public through retail pharmacies in that
State.
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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.
Acebutolol Hydrochloride
Eq 200 mg base, Capsule, Oral 100 $0.4612 B
Eq 400 mg base, Capsule, Oral 100 0.6713 B
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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
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
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Amitriptyline Hydrochloride
10 mg, Tablet, Oral 100 0.0608 B
25 mg, Tablet, Oral 100 0.0653 B
50 mg, Tablet, Oral 100 0.0666 B
75 mg, Tablet, Oral 100 0.1425 B
100 mg, Tablet, Oral 100 0.1500 R
150 mg, Tablet, Oral 100 0.2430 B
Amoxapine
50 mg, Tablet, Oral 100 0.5425 R
Amoxicillin
250 mg, Capsule, Oral 100 0.0636 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; 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
Benzonatate
100 mg, Capsule, Oral 100 0.4387 B
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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
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
Carteolol Hydrochloride
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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
Cimetidine Hydrochloride
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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
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
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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
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
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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
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
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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
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
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Hydralazine Hydrochloride
10 mg, Tablet, Oral 100 0.0354 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
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
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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
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
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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
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
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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
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
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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
Oxaprozin
600 mg, Tablet, Oral 100 0.6758 B
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
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National Pharmaceutical Council Pharmaceutical Benefits 2003
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
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
Propranolol Hydrochloride
10 mg, Tablet, Oral 100 0.0585 B
20 mg, Tablet, Oral 100 0.0705 B
40 mg, Tablet, Oral 100 0.0848 B
80 mg, Tablet, Oral 100 0.1140 B
Ranitidine Hydrochloride
Eq 150 mg base, Tablet, Oral, 100 0.3411 R
Eq 300 mg base, Tablet, Oral 100 0.3180 B
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National Pharmaceutical Council Pharmaceutical Benefits 2003
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
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
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National Pharmaceutical Council Pharmaceutical Benefits 2003
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
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
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Appendix E:
Glossary
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National Pharmaceutical Council Pharmaceutical Benefits 2003
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National Pharmaceutical Council Pharmaceutical Benefits 2003
Term Definition
Access A patient’s ability to obtain medical care. The ease of access is determined
by components such as the availability of medical services and their
acceptability to the patient, the location of health care facilities,
transportation, hours of operation and affordability of care.
Actual Acquisition Cost (AAC) The pharmacist’s net payment made to purchase a drug product, after
taking into account such items as purchasing allowances, discounts, and
rebates.
Actual Charge The amount a physician or other provider actually bills a patient for a
particular medical service, procedure or supply in a specific instance. The
actual charge may differ from the usual, customary, prevailing, and/or
reasonable charge.
Additional Drug Benefit List A list of pharmaceutical products approved by a health plan and employer
for dispensing in larger quantities than the standards covered under a
benefit package in order to facilitate long-term patient use. The list is
subject to periodic review and modification by the health plan. Also called
“drug maintenance list.”
Administrative Costs The costs incurred by a carrier, such as an insurance company or HMO,
for services such as claims processing, billing and enrollment, and
overhead costs. Administrative costs can be expressed as a percentage of
premiums or on a per member per month basis. Additional costs that are
often expressed as administrative include those related to utilization
review, insurance marketing, medical underwriting, agents’ commissions,
premium collection, claims processing, insurer profit, quality assurance
activities, medical libraries and risk management.
Administrative Services Only An insurance arrangement requiring the employer to be at risk for the cost
(ASO) of health care services provided, while a separate company delivers
administrative services. This is a common arrangement when an employer
sponsors a self-funded health care program.
Adverse Selection A term used to describe a situation in which a health plan disproportionally
enrolls a population that is prone to higher than average utilization of
benefits, thereby driving up costs and increasing financial risk.
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National Pharmaceutical Council Pharmaceutical Benefits 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.
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.
Average Cost Per Claim The average dollar amount of administrative and/or medical services
rendered for the unit of measure within each expenditure category. The
calculation is $amount / #of units.
Average Manufacturer Price The average price paid by wholesalers for products distributed to the retail
(AMP) class of trade.
Average Wholesale Price The published suggested wholesale price of a drug. It is often used by
(AWP) pharmacies as a cost basis for pricing prescriptions.
Behavioral Health Care Assessment and treatment of mental and/or psychoactive substance abuse
disorders.
Benefit Maximum Specifies a dollar limit for the total reimbursement of health care costs
during a benefit period.
Benefit Package Services an insurer, government agency, or health plan offers to a group or
individual under the terms of a contract.
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National Pharmaceutical Council Pharmaceutical Benefits 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.
Cafeteria Plan An employee benefit plan under which all participants are permitted to
choose among two or more benefit options according to their needs and/or
ability to pay. Also called a flexible benefit plan of “flex plan.”
Capitation Fund A fund based on the number of members multiplied by the budgeted or
capitated amount each member pays. Some HMOs, in lieu of reimbursing
physicians on a direct capitation basis, may establish such a fund.
Physicians are then reimbursed on a fee-for-service basis from the
capitation fund. The HMO monitors patient visits for over-utilization;
patients exceeding the norm are notified.
Card Programs The use of a drug benefit identification card which, when presented to a
participating pharmacy by employees or their dependents, usually entitles
them to receive the medication for a copay.
Care Coordinator A primary health care practitioner: (1) who provides primary care services
to an enrollee, (2) who is generally responsible for coordinating the
enrollee’s 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.”
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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).
Chain Pharmacy One of a group of pharmacies, usually three or more, under the same
management or ownership.
Charity Care Pools The assets of several funds combined to cover health care costs to the poor
and uninsured. The pools are established by organizations such as
hospitals and insurance companies to offset a portion of the cost for
providing health care to the indigent.
Chemical Equivalents Those multiple-source drug products containing identical amounts of the
same active ingredients, in equivalent dosage forms, and meeting existing
physical/chemical standards.
Chronic Care Care and treatment rendered to individuals whose health problems are of a
long-term and continuing nature. Rehabilitation facilities, nursing homes,
and mental hospitals may be considered chronic care facilities.
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National Pharmaceutical Council Pharmaceutical Benefits 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.
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
Cosmetic Procedures Those procedures which involve physical appearance, but which do not
correct or materially improve a physiological function and are not deemed
medically necessary.
Cost Sharing Any provision of a health insurance policy that requires the insured to pay
some portion of medical expenses. The general term includes deductibles,
copayments, and coinsurance.
Cost Shifting The redistribution of payment sources. Typically, cost shifting occurs
when one payer obtains a discount on provider services, and the providers
increase costs to another payer to make up the difference.
Cost-Based Reimbursement Payment by third party insurers in which the amount is based on the cost to
the provider of delivering services.
Covered Expenses Medical and related costs, experienced by those covered under the policy,
that qualify for reimbursement under terms of the insurance contract.
Covered Services The specific services and supplies for which Medicaid will provide
reimbursement. Covered services under Medicaid consist of a
combination of mandatory and optional services within each State.
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.
Depot Price The price(s) available to any depot of the Federal government, for
purchase of drugs from the Manufacturer through the depot system of
procurement.
Diagnosis Related Group A system of classification for inpatient hospital services based on principal
(DRG) diagnosis, secondary diagnosis, surgical procedures, age, sex and presence
of complications. This system of classification is used as a financing
mechanism to reimburse hospital and selected other providers for services
rendered.
Disability (1) Any condition that results in functional limitations that interfere with
an individual’s ability to perform his/her customary work and which
results in substantial limitation in one of more major life activities. (2)
Condition(s) that prevent or limit an individual’s ability to engage in
normal activities. These may be temporary.
Disability Income Insurance Type of health insurance that periodically pays a disabled subscriber to
replace income lost during the period of disability.
Disease Management An effort to improve patient outcomes and lower costs by organizing
managed care initiatives around patients with a particular disease or
condition.
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.
Drug Detailing Presenting information about a brand name drug product to prescribers to
educate them about its activity, uses, side effects, proper dosage and
administration, etc.
Drug Formulary A listing of prescription medications which are preferred for use by a health
plan and which may be dispensed through participating pharmacies to
covered persons. This list is subject to periodic review and modification by
the health plan. A plan that has adopted an “open or voluntary” formulary
allows coverage for both formulary and non-formulary medications. A plan
that has adopted a “closed, select or mandatory” formulary limits coverage
to those drugs in the formulary.
Drug Use Evaluation (DUE) Evaluations of prescribing patterns of prescribers to specifically determine
the appropriateness of drug therapy. There are three forms of DUE:
prospective (before or at the time of prescription dispensing), concurrent
(during the course of drug therapy), and retrospective (after the therapy has
been completed). Same as “Drug Utilization Review.”
Drug Utilization Review (DUR) A quantitative evaluation of prescription drug use, physician prescribing
patterns or patient drug utilization to determine the appropriateness of drug
therapy. Most often focuses on over-utilization.
Dual Eligibles The term describes a population of low-income elderly and individuals
with disabilities who qualify for both Medicare and Medicaid coverage.
While Medicare covers basic health services, including physician and
hospital care, dual eligibles rely on Medicaid to pay Medicare premiums
and cost-sharing and to cover critical benefits Medicare does not cover,
such as long-term care and prescription drugs. However starting in 2006,
coverage of prescription drugs for dual eligibles will shift from Medicaid
to Medicare.
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.
Exclusivity Clause A part of a contract which prohibits physicians from contracting with more
than one health maintenance organization or preferred provider
organization.
Experience Rating The process of setting rates based partially or in whole on previous claims
experience and projected required revenues for a future policy year for a
specific group or pool of groups.
Experimental, Investigational Medical, surgical, psychiatric, substance abuse or other 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.
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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.
Free-Standing Hospital Any hospital that is not affiliated with a multihospital system.
Generic Drug A chemically equivalent copy of a brand name drug whose patent has
expired. Drug formulations must be of identical composition with respect
to the active ingredient (i.e., meet official standards of identity, purity, and
quality of active ingredient). Also called generic equivalent or non-
innovator multiple source drug.
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 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.
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 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 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.”
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 Research Studies aimed at measuring the effect of a given product, procedure, or
medical technology on health or costs.
Outpatient Services Outpatient services are medical and other services provided on a non-
resident basis (patients are not admitted to the facility) by a hospital or
other qualified facility, such as a mental health clinic, rural health clinic,
mobile X-ray unit, or freestanding dialysis unit. Such services include
outpatient physical therapy services, diagnostic X-ray and laboratory tests,
and X-ray and other radiation therapy.
Over-the-Counter (OTC) A drug product that does not require a prescription under Federal or State
law.
Participating Provider A provider who has contracted with the health plan to provide medical
services to covered persons. The provider may be a hospital, pharmacy,
other facility or a physician who has contractually accepted the terms and
conditions as set forth by the health plan.
Patient Health Status Survey Questionnaire used to solicit patient perceptions regarding the state of their
health. Questions may be general and address overall health status with
regard to a specific condition (e.g., an arthritic patient’s ability to make a
fist or an asthmatic patient’s ability to climb a flight of stairs).
Patient Satisfaction Survey Questionnaire used to solicit the perceptions the plan enrollees or patients
have regarding how a health plan meets their medical needs and how the
delivery of care is handled, (e.g., waiting time, access to treatments).
Payer A general term indicating the responsible party for the payment of medical
care service expenses. Payers may be patients, insurance companies,
government agencies, or a combination of these.
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.
Physician Any doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who is duly
licensed and qualified under the law of jurisdiction in which treatment is
received.
Point-Of-Service (POS) Plan A health plan allowing the covered person to choose to receive a service
from a participating or non-participating provider, with different benefit
levels associated with the use of participating providers. POS can be
provided in several ways: an HMO may allow members to obtain limited
services from non-participating providers; an HMO may provide non-
participating benefits through a supplemental major medical policy; a PPO
may be used to provide both participating and non-participating levels of
coverage and access; or various combinations of the above may be used.
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National Pharmaceutical Council Pharmaceutical Benefits 2003
Term Definition
Pre-Existing Condition (PEC) Any medical condition that has been diagnosed or treated within a
specified period immediately preceding the covered person’s effective date
of coverage under the master group contract.
Preferred Provider A program in which contracts are established with providers of medical
Organization (PPO) care. Providers under such contracts are referred to as preferred providers.
Usually, the benefit contract provides significantly better benefits (fewer
copayments) for services received from preferred providers, thus
encouraging covered persons to use these providers. Covered persons are
generally allowed benefits for non-participating providers’ services,
usually on an indemnity basis with significantly higher copayments. A
PPO arrangement can be insured or self-funded. Providers may be, but are
not necessarily, paid on a discounted fee-for-service basis.
Prepaid Group Practice Plans Organized medical groups of essentially full-time physicians in
appropriate specialties, as well as other professional and subprofessional
personnel, who, for regular compensation, undertake to provide
comprehensive care to an enrolled population for premium payments that
are made in advance by the consumer and/or their employers.
Prepaid Health Plan (PHP) An entity that provides a non-comprehensive set of services on either
capitated risk or non-risk basis or the entity provides comprehensive
services on a non-risk basis.
Prescribed Drugs Prescribed drugs are drugs dispensed by a licensed pharmacist on the
prescription of a practitioner licensed by law to administer such drugs, and
drugs dispensed by a licensed practitioner to his own patients. This item
does not include a practitioner’s drug charges that are not separable from
his other charges, or drugs covered by a hospital bill.
Prescription Medication A drug which has been approved by the Food and Drug Administration and
which can, under Federal and State law, be dispensed only pursuant to a
prescription order from a duly licensed prescriber, usually a physician.
Preventive Care Comprehensive care emphasizing priorities for prevention, early detection
and early treatment of conditions, generally including routine physical
examinations, immunization and well person care.
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.
Prospective Financing Financing for health care services based on prices or budgets determined
prior to the delivery of service. Payments can be per unit of service, per
member, or per time period. In all its forms prospective financing differs
from cost-based reimbursement, under which a provider is paid for costs
incurred.
Qualified Medicare Beneficiary An individual who qualifies for Medicare Part A, whose income does not
(QMB) exceed 100 percent of the Federal poverty level, and whose resources do
not exceed twice the SSI resource-eligibility standard. Medicaid coverage
of QMBs is limited to payments of their Medicare cost-sharing charges,
such as Medicare premiums, coinsurance, and copayment amounts.
Quality Assurance (QA) or A formal set of activities to review and affect the quality of services
Quality Improvement (QI) provided. Quality assurance includes assessment and corrective actions to
remedy any deficiencies identified in the quality of direct patient,
administrative and support services.
Rate Setting A form of financing under which hospitals or nursing homes are paid
prices that are prospectively determined, generally by a State agency.
Prospectively determined prices may be paid by all payers for all covered
services, as in all payer systems, or by only some payers. The unit of
payment can be service, patient, or time period. See “Prospective
Financing.”
Rational Drug Therapy Prescribing the right drug for the right patient, at the right time, in the right
amount, and with due consideration of relative cost.
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National Pharmaceutical Council Pharmaceutical Benefits 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.
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.
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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.
Sin Taxes Taxes imposed on items considered harmful to public health interests, such
as tobacco and alcohol.
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.
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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.
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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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.
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.
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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Term Definition
Withhold “At-risk” portion of a claim deducted and withheld by the health plan
before payment is made to a participating physician as an incentive for
appropriate utilization and quality of care. This amount – for example,
20% of the claim – remains within the plan and is credited to the doctor’s
account. Can be used where the plan needs additional funds to pay for
claims. The withhold may be returned to the physician in varying levels
which are determined based on analysis of his/her performance or
productivity compared against his/her peers. Also called “physician
contingency reserve (PCR).”
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ACRONYMS
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