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Pharmaceutical Benefits

Under State Medical


Assistance Programs

2004

Published by the
National Pharmaceutical Council, Inc.
1894 Preston White Drive
Reston, VA 20191-5433

©2005 by the National Pharmaceutical


Council
This compilation of data on State Medical Assistance Programs (Title XIX) presents a general
overview of the characteristics of State programs, together with detailed information on the
pharmaceutical benefits provided. The data collection effort covers all States with Medicaid programs
and the District of Columbia.

Information for this compilation was acquired from multiple sources, including a survey of Medicaid
prescription drug programs administered for the National Pharmaceutical Council by Muse &
Associates, Washington, DC with assistance from Total Compensation Solutions and StateScape.
While we have checked all secondary data in the book for consistency relative to the original source,
we have not validated the original data reported by the Centers for Medicare and Medicaid Services
(CMS) and other organizations.

The data were compiled and the book prepared for publication by Donald Muse, Ph.D., David
Goldenberg, Ph.D., Anne Marie Hummel, Stanley Weintraub, C.P.A, Daniel B. Gurley, M.P.A.,
Jaclyn S. Kuwada, M.P.P, Steven Heath, M.P.A., Errica Philpott, Liz Segall, and Tiffany Crawford of
Muse & Associates. Paul Gavejian and Matthew Leach of Total Compensation Solutions prepared
and conducted the 2004 survey. James Elliott at StateScape supervised the compilation of information
on State officials, State professional associations, and expanded drug programs for elderly and
disabled beneficiaries. Gary Persinger and Kimberly Westrich of the National Pharmaceutical Council
provided valuable input and support.
National Pharmaceutical Council Pharmaceutical Benefits 2004

TABLE OF CONTENTS

INTRODUCTION......................................................................................................................................v

SECTION 1: ESTIMATES OF MEDICAID EXPENDITURES AND RECIPIENTS:


FY 2003 TO FY 2005 BY STATE ................................................................................ 1-1

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

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


- Total Medicaid Eligibles by Maintenance Assistance Status, 2002........................ 2-11
- Total Medicaid Eligibles by Age Group, 2002........................................................ 2-12
- Total Medicaid Eligibles by Gender, 2002.............................................................. 2-13
- Total Medicaid Eligibles by Race/Ethnicity 2002................................................... 2-14
- Total Medicaid Eligibles by Basis of Eligibility, 2002 ........................................... 2-15
- Total Medicaid Eligibles by per 1000 Population, 2002 ........................................ 2-16
- Total Net U.S. Medical Assistance Expenditures by Type of Service ................... 2-17
- Federal Medical Assistance Percentages (FMAP), FY 2005 and FY 2006 ........... 2-18
- Medicaid Total Net Expenditures and Eligibles, 2002 ........................................... 2-19
- Total Medicaid Program Expenditures, 2003 ......................................................... 2-20
- Total SCHIP Enrollment, 2003 .............................................................................. 2-21
- Total SCHIP Expenditures, 2003 ........................................................................... 2-22
- Total Medicaid/Medicare Dual Eligibles by Dual Eligibility Type, 2002 .............. 2-23
- Total Medicaid Medical Vendor Payments and Dual Eligibility Status, 2002 ....... 2-25

Medicaid Managed Care Enrollment ................................................................................... 2-27


- Medicaid Managed Care Enrollment, As of June 30, 2004..................................... 2-29
- Pharmaceutical Benefits Under Managed Care Plans ............................................ 2-30
- Medicaid Managed Care Enrollment Trends, 2000-2004 ....................................... 2-31
- Medicaid Managed Care Plan Type, As of June 30, 2004 ...................................... 2-32
- Medicaid Managed Enrollment by Plan Type, As of June 30, 2004....................... 2-33
- Medicaid Managed Care Enrollment by Payment Arrangement,
As of June 30, 2004.. ............................................................................................... 2-34

Medicaid Managed Care Waivers.......................................................................................... 2-35


- Section 1915(b) Waivers, As of June 30, 2003 ....................................................... 2-39
- Section 1115 Research and Demonstration Waivers, As of June 30, 2003............. 2-41
- Pharmacy Plus Demonstrations Program Status, Pharmacy Waivers
Under 1115 Authority.............................................................................................. 2-42

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

Sociodemographics
- Age Demographics, 2003 .......................................................................................... 3-5
- Race Demographics, 2003 ......................................................................................... 3-6
- Hispanic Demographics, 2003 .................................................................................. 3-7
- Insurance Status-Populations, 2003 .......................................................................... 3-8
- Insurance Status-Percentages, 2003 ........................................................................ 3-9
- Poverty Status-Populations, 2003............................................................................ 3-10
- Poverty Status-Percentages, 2003............................................................................ 3-11
- Employment Status, 2004........................................................................................ 3-12

Health Care Delivery System


− Medicaid/Medicare Certified Facilities, 2004 ......................................................... 3-13
− Licensed Pharmacies, As of June 30, 2004.............................................................. 3-14
− Physicians, 2001 ...................................................................................................... 3-16
− Other Providers, 2001/2004 .................................................................................... 3-17

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

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


− Drug Expenditures Trends ......................................................................................... 4-5
− Ranking Based on Drug Expenditures....................................................................... 4-6
− Drugs as a Percentage of Total Net Expenditures, 2003 ........................................... 4-7
− Drugs as a Percentage of Total Net Expenditures, 2001-2003 .................................. 4-8
− Share of Drug Expenditures by Category, 2003 ........................................................ 4-9
− Share of Prescriptions Processed, 2003 ................................................................... 4-11
− Medicaid Average Cost per Prescription, 2003 ....................................................... 4-13

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


− Medicaid Drug Rebates, 2003 ................................................................................. 4-17
− Medicaid Drug Rebate Trends, 1999-2003.............................................................. 4-18
− Medicaid Drug Rebate Trends, Annual Percent Change, 1998-2003...................... 4-19
− Rebates as a Percent of Drug Expenditures, 2003 ................................................... 4-20

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


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

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


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

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

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

APPENDIXES
Appendix A: State and Federal Medicaid Contacts.................................................................... A-1
Appendix B: Medicaid Program Statistics – CMS MSIS Tables ................................................B-1
Appendix C: Medicaid Rebate Law.............................................................................................C-1
Appendix D: Federal Upper Limits for Multiple Source Products............................................. D-1
Appendix E: Glossary ..................................................................................................................E-1

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INTRODUCTION
The 2004 edition of Pharmaceutical Benefits under State Medical Assistance Programs marks the 39th
year that the National Pharmaceutical Council (NPC) has compiled and published one of the largest
sources of information on pharmacy programs within the State Medical Assistance Programs (Title
XIX) and expanded pharmacy programs for the elderly and disabled. Due to the hard work of a skilled
team and countless contributors, the “Medicaid Compilation” has become a standard reference and
invaluable resource in government offices, research libraries, consultancies, the pharmaceutical
industry, numerous businesses, and policy organizations.

The data used to create each edition of the Compilation are assembled from numerous sources. The
Compilation incorporates information on each State pharmacy program from an annual NPC survey of
State Medicaid program administrators and pharmacy consultants, statistics from the Centers for
Medicare and Medicaid Services (CMS), and information from other Federal agencies and
organizations.

In order to give a better understanding of the content of the “Medicaid Compilation,” the information
contained in this version of the book is summarized below by section:
• Section 1: Presents estimates of Medicaid expenditures and recipients for FY 2003 to FY
2005 by State.
• Section 2: Contains an overview of the Medicaid program, details about Medicaid managed
care enrollment, including a breakdown by plan type and enrollment by plan type, and a
synopsis of 1915(b) waivers and 1115 demonstrations.
• Section 3: Consists of sociodemographic statistics, by age, race, insurance, income, and
employment, for the fifty States and the District of Columbia for calendar year 2003.
Additionally, a description of the Medicaid certified facilities in each State, including the
number of hospitals, skilled nursing facilities, and intermediate care facilities for the mentally
retarded (ICFs-MR), home health agencies, and rural health clinics are presented.
• Section 4: Provides Medicaid pharmacy program characteristics, drawn largely from the 2004
NPC annual survey of State pharmacy program administrators. In addition, this section
provides Medicaid eligibility statistics from CMS for fiscal year 2002 and program
expenditure data for fiscal years 2002 and 2003. Medicaid pharmacy programs are
characterized by estimates of total expenditures, drug payments, drug benefit design, and
pharmacy payment and patient cost sharing.
• Section 5: Contains detailed profiles of the States’ Medicaid pharmacy programs. This
section contains a description of medical assistance benefits and eligibles, drug payments and
recipients, benefit design, pharmacy payment and patient cost sharing, use of managed care,
and State contacts.
• Section 6: Profiles the “expanded” drug programs in States that are providing pharmaceutical
coverage or discounts to the elderly and/or disabled persons.
The book also contains a series of appendices. Appendix A features a list of State contacts, CMS
regional offices and Medicaid program personnel. Appendix B provides a national level summary on
total Medicaid program recipients by type of service for FY 2001 and FY 2002 and data on total
number of drug recipients for each State and the nation as a whole for the period 1996-2002.
Appendix C provides the current Medicaid drug rebate law. Appendix D contains the list of CMS
upper limits on multiple source products. Appendix E is a glossary and list of acronyms.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Each year, finding and compiling current, relevant information for inclusion in the Compilation
presents a challenge. This year was no exception. For example, CMS makes available on its website
the Medicaid Statistical Information System (MSIS) Statistical Reports for the most recent enrollment
and expenditure data available. MSIS tables are used in several sections of the Compilation as a
secondary data source. This year, CMS released MSIS reports on Federal Fiscal Year 2002.
However, the 2002 MSIS data have been reformatted to appear more like the older Health Care
Financing Administration (HCFA) 2082 reports. Hence, we requested, and CMS provided, a special
version of the 2002 MSIS Report in original MSIS format. This enabled us to compile 2002 data on
pharmaceutical expenditures and recipients for inclusion in each State profile. Also, CMS has yet to
release an update of The CMS 64-Report, a major data source used throughout the Compilation.
However, we were fortunate to obtain a pre-release version of the 2003 CMS 64-Report and thank
CMS for making it available to us.

For the past several years, the Health Resources and Services Administration’s (HRSA) Area
Resource File (ARF) has served as the primary source for statistics on physicians and registered
nurses. Unfortunately, HRSA was not able to obtain updated physician information for the 2004
version of the ARF. Therefore, we have repeated last year’s data on physicians and registered nurses.

As we continue to update and discover data, we are able to improve the Compilation with new tables
and sources that we believe enhance its overall significance to the user. These new tables and sources
include:

• Data on Medicaid eligibles by gender and race/ethnicity;


• Total SCHIP enrollment by State;
• Information on the number of Medicaid/Medicare dual eligibles and Medicaid medical vendor
payments for dual eligibles by State.

NPC gratefully acknowledges the cooperation and assistance of the many State and Federal program
officials and their staffs. With their cooperation, we were able to achieve a 94 percent response rate to
the 2004 Survey. Unfortunately, not all States were able to submit revised/updated information. In
such instances, we have incorporated the most recently available data from other sources. However,
for these States, much of the information may reflect data that have been presented in previous
versions of the Compilation.

We would also like to thank Muse & Associates and their subcontractors, Total Compensation
Solutions, and StateScape, for administering the survey, compiling the information, and analyzing the
data. We hope you continue to find the information contained in this compilation useful and, as
always, we welcome your suggestions and comments.

Gary Persinger
Vice President, Health Care Systems
National Pharmaceutical Council

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Section 1:
Estimates of Medicaid
Total and Prescription
Drug Expenditures and
Recipients: FY 2003
Through FY 2005 by State

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BACKGROUND AND PURPOSE

The Centers for Medicare and Medicaid Services (CMS) are responsible for publishing data on the
Medicaid program. The most recent State-by-State statistics on recipients and expenditures for the
Medicaid program, as of the date of preparation of this publication, were for 2002.1 Based on the best
available data from states and CMS, the section provides more recent estimates through 2005 of
Medicaid spending and recipients of prescription drugs. Estimates are presented for each State and for
the nation overall.

OBJECTIVES OF THIS SECTION

The objective of this Section is to estimate total Medicaid expenditures and recipients for FY 2003,
FY 2004, and FY 2005 in the aggregate and by State.2 This will provide interested parties with
estimates of trends more current than estimates available through CMS. The Office of the Actuary at
CMS publishes aggregate estimates of Medicaid expenditures in the National Health Accounts.3 The
Congressional Budget Office (CBO) also publishes aggregate estimates of Medicaid expenditures and
recipients.4 Neither of these organizations has published estimates of State-by-State spending through
FY 2005 in recent years.5 However, these previous estimates document the importance and feasibility
of this chapter’s goals. The aggregate estimates presented in this Section are numerically very similar
in all but one instance, projections of 2005 recipients, to those of CMS and CBO.

SUMMARY

The analysis presented in this Section is based on State reports to CMS. Table 1 contains aggregate
data on total expenditures and number of recipients by fiscal year. Estimates by Muse & Associates
are indicated by the bolded text. All other data are State actual, or estimated by the authors.
Table 1
Total Program Expenditures and Recipients by Source
By Fiscal Year: FY 2000 through FY 2005

Fiscal Expenditures Percent Recipients Percent


Year ($ billions) Increase (millions) Increase
2000 $195.2 NA** 42.9 NA**
2001 $215.8 11% 46.2 8%
2002 $245.7 14% 49.8 8%
2003 $259.9 6% 53.4 7%
2004 $289.8* 12% 57.5 8%
2005 $316.2* 9% 62.0 8%
Source: CMS, State data reported to CMS (CMS-37, 64 and MSIS Reports) and Office of the Actuary, National Health Expenditures
Estimates. The 2003-2005 recipient estimates were generated by Muse & Associates.
*CMS, Office of the Actuary, January 2005.
**Not Applicable

1
The most recent estimates can be found at www.cms.hhs.gov/medicaid/msis/mstats.asp.
2
FY stands for Federal Fiscal Year. Federal Fiscal Years are from October 1 to September 30. For example, FY 2003 is
from October 1, 2002 to September 30, 2003.
3
These can be found at www.cms.hhs.gov/statistics/nhe.
4
http://www.cbo.gov/factsheets/2005/Medicaid.pdf
5
Katherine R. Levit, et al, State Health Expenditures Accounts: Building Blocks for State Health Spending Analysis, Health
Care Financing Review, Fall 1995, Vol. 17, No. 1.

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The methodology used for developing the 2003-2005 recipient estimates employed the cube root of
the change over a four year period for each state with outliers trimmed. The trimming procedures are
described later in the paper. The estimation technique we employed is commonly used in statistical
and actuarial estimates and simply means that the fifth point in a curve is estimated by using the rate
of change for the preceding four years. Table 1 shows that expenditures have risen between 6 percent
and 14 percent per year while the number of recipients has increased between 7 percent and 8 percent
per year. We estimate that the accuracy of these estimates is between plus or minus 2.2 percent by
using the methodology to estimate preceding years where the actual data were already available.

DATA

The analysis presented in this Section is based on State data submitted to CMS. We assume that the
States are in the best position to predict the future of their programs. Actual expenditure and recipient
data for FY 2000 through FY 2002 were available from the Medicaid Statistical Information System
(MSIS). Aggregate expenditure data for FY 2003 were available from State reports known as the
CMS-64s. Expenditure estimates for FY 2004 and FY 2005 were compiled from State reports known
as CMS-37s. Aggregate data by type of service and recipient estimates by State were prepared by
Muse & Associates. Each of these sources is discussed below.

MSIS Data

MSIS files are used by CMS to produce data on Medicaid program characteristics and utilization
information by State. The MSIS system collects, manages, analyzes, and disseminates information on
eligibles, beneficiaries, utilization, and payment for services covered by each State Medicaid program.
These data provide CMS with a large-scale database of State eligibles and services for many types of
analyses. States provide CMS with quarterly computer files containing specified data elements for:
(1) eligible persons who received services covered by Medicaid (recipient files); and (2) adjudicated
claims (paid claims files) for medical services reimbursed with Title XIX funds. These data are
furnished on the Federal fiscal year quarterly schedule, which begins October 1 of each year.

Each State recipient file contains one record for each person covered by Medicaid for at least one day
during the reporting quarter. Individual recipient records consist of demographic and monthly
enrollment data. Paid claims files contain information from adjudicated medical service related claims
and capitation payments. Each State submits to CMS four types of claims files representing inpatient,
long-term care, prescription drugs, and non-institutional services. These are claims that have
completed the State's payment processing cycle for which the State has determined it has a liability to
reimburse the provider from Title XIX funds. Claims records contain information on the types of
services provided, providers of services, service dates, costs, types of reimbursement, and
epidemiological variables.

The data files are subjected to quality assurance edits to ensure that the data are within acceptable error
tolerances. A distributional review verifies the reasonableness of the data. Once accepted, valid tape
files are created which serve as the historical source of detailed Medicaid eligibility and paid claims
data maintained by CMS. The individual paid claims and eligible information are used for program
analysis and research and to produce various public use reports that represent national Medicaid
populations and expenditures. After processing, CMS creates the tables and publishes the data. The
MSIS system was our primary source for expenditure and recipient data for FY 2000 through FY
2002.

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CMS-37s and 64s

The primary source of data for our estimates for FY 2003 through FY 2005 is the CMS-37 Report, a
financial reporting form submitted by the States to CMS. This form is submitted on a quarterly basis
and requires the States to project their expenditures for two fiscal years. The single State agency must
attest to the accuracy of the estimates. The data in the CMS-37s are used by CMS to set the amount
the State may withdraw from the Federal Reserve for Federal Medicaid matching.

The data on this form have known strengths and weaknesses. As with all State submitted data, some
States appear to provide more accurate data than others. Not surprisingly, the States are clearly more
accurate at predicting the present year, at this writing FY 2005, than they are at predicting the
following year, FY 2006. States have, as of this writing, yet to adjust their FY 2006 Medicaid
prescription drug expenditures for the implementation of the Medicare Modernization Act (MMA)
which will transfer the fiscal responsibility for those recipients eligible for both Medicare and
Medicaid to the Federal government. The limitations of the data led us not to attempt to estimate FY
2006.

A third source of data was the CMS-64s, another fiscal reporting form submitted by the States which
contains details of their past expenditures. These reports contain expenditures, reversals,
disallowances, third-party collections and a variety of other adjustments. However, they represent the
most current statement of State-by-State expenditures available for FY 2003. Hence, they were used
for FY 2003 expenditure estimates.

It must be noted that while the data from the three sources (the MSIS, CMS-37, and CMS-64) are
highly correlated, they are not identical. The data do not match for a variety of reasons. Some are
prospective and some are retrospective, some contain adjustments and other do not. Table 2 compares
the three sources at the aggregate expenditure level.

Table 2
Total Program Expenditures by Source
By Fiscal Year: FY 2000 through FY 2005
($ billions)

Fiscal Year 37s 64s MSIS


2000 $168.3 $195.2 $168.3
2001 $185.8 $215.8 $185.8
2002 $213.5 $245.7 $213.5
2003 $268.5 $259.9 N/A**
2004* $290.7 N/A** N/A**
2005* $315.7 N/A** N/A**

Source: State data reported to CMS, CMS-37, 64, and MSIS Reports
* CMS 37s as of May 2004.
** N/A is not available

Table 2 clearly shows that the data reported on the CMS-64 reports are higher, until 2003, compared
to the other two data sets. The primary reason for this is that the MSIS reports do not contain
Disproportionate Share (DSH) payments to providers, while the other two reports do contain DSH
data.

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METHODOLOGY

Muse & Associates has accumulated Medicaid data from the CMS-37, CMS-64, MSIS, and the
forerunner to the MSIS, the HCFA 2082, for more than two decades. To create the estimates, we
explored two methodological approaches. The first approach was regression based. Several different
types of regressions were considered, including log-based approaches. The problem we encountered
with regression analysis was that the regression model was over specified.6 This is primarily due to
the fact that the number of States being estimated (fifty-one) is much larger than the small number of
years (three) of data selected for use.7 Five years was selected because of the cyclical nature of the
Medicaid program. CMS published an analysis that clearly shows the trend in drug spending between
the first and second half of the 1990s.8 Their observations and our own analysis show that the
optimum period that State trends appear stable is four years. The regression approach did not yield
results with statistically significant predictability as measured by R2, a measure of the predictive ability
of the regression model. Hence, this approach was abandoned.

The approach that yielded more stable and predictive results was employing the cube root of the
change over a four year period for each state with outliers trimmed.. However, several States had very
significant programmatic changes in recent years that required data trimming. A total of four States
required trimming.9 Outliers were defined as changes of more than 20 percent from year to year for
year to year increase. These were trimmed to 20 percent. Two States, Tennessee and New Mexico
presented special problems. The statistical portions of their data processing systems had considerable
problems over the last five years. The estimates for these States were developed through direct
conversations with State Medicaid officials.

Factors Leading to Year-to-Year Variation in State Estimates

The CMS-37 and CMS-64 reports from States often show significant swings for both total program
and prescription drugs expenditures. State expenditures for Medicaid can have significant swings in
spending for a variety of reasons. For example, all of the Medicaid data systems are on a cash basis
rather than an accrual basis. States often have cash flow concerns that require that they pay claims on
one side or the other at the end of the State fiscal year. Many States have the same Fiscal Year as the
Federal government, which can result in FY data showing decreases followed by substantial increases
in expenditures. In addition, States may incur large settlements with CMS and/or providers in a
particular year. These, and a variety of other factors, lead to real swings in the expenditure data.

DISCUSSION

Presented on the pages that follow are tables showing national and State-level data on Medicaid
expenditures and recipients, including our estimates for the most recent fiscal years. Table 3 shows
national-level data from the CMS-64s for expenditures by type of service for the period FY 2000
through FY 2005. Similarly, Table 4 presents national-level MSIS data on the number of Medicaid
recipients by type of service. Tables 5 through 8 provide national and State-level information on total

6
In non-statistical terms, a regression model becomes over specified when the number of points being estimates
exceeds the number of data points available for the analysis.
7
The District of Columbia was included in the analysis but Puerto Rico and the Trust Territories were excluded.
8
David Baugh, M.A, Penelope I. Pine, Steve Blackwell, Ph.D., J.D. R.Ph. and Gary Ciborowski, M.A..
Medicaid Prescription Drug Spending in the 1990s: A Decade of Change, Health Care Financing Review, Spring
2004, Volume 25, Number 3, page 5 to 23.
9
The States were Connecticut, Delaware, and Nevada. The District of Columbia also required trimming

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Medicaid expenditures, number of recipients, recipients of prescription drugs, and Medicaid program
payments for prescription drugs.

Tables 3 & 4

Table 3 shows the distribution of Medicaid expenditures by service category from the CMS-64s and
the National Health Expenditures Accounts for the period FY 2000 through FY 2005. The data show
that total Medicaid program expenditures have or are expected to increase annually by 6 to 14 percent
per year between FY 2000 and FY 2005, or at an average annual increase of approximately 10 percent
per year. Our estimates indicate that total Medicaid program expenditures will exceed $316 billion in
FY 2005. The data from the CMS-64s indicate that pharmaceuticals are the third highest Medicaid
program expenditure category in each fiscal year, exceeded only by nursing facility expenditures and
payments for inpatient acute care hospital services. For FY 2005, we estimate that Medicaid program
expenditures for pharmaceutical will be $44.3 billion.

Table 4 presents national-level data from the MSIS system on the number of Medicaid recipients by
type of service. Between FY 2000 and FY 2005, the number of Medicaid recipients has or is expected
to increase at annual rates of between 6.4 percent and 7.8 percent, or at an average annual rate of about
seven percent. In FY 2005, it is estimated that 62 million beneficiaries will receive medical services
through the Medicaid program. Aside from capitated payment services (i.e., per capita payments to
managed care organizations), the service category with the highest number of recipients is
pharmaceuticals. It is estimated that 29.9 million Medicaid beneficiaries will receive pharmaceutical
services during FY 2005.

Tables 5 & 6

Presented in Tables 5 and 6 are data on total Medicaid expenditures and number of Medicaid
recipients on a State-by-State basis for the period FY 2000 to FY 2005. The data source for the
expenditures distributions in Table 5 is the CMS-37s. Based on State data submitted to CMS in their
quarterly CMS-37 submissions, Medicaid program expenditures for FY 2005 are expected to total
$315.7 billion, similar to the $316.2 billion FY 2005 estimate derived from the CMS-64s. Also shown
in Table 5 are year-by-year data on total Medicaid expenditures by State for the period. A review of
the State-by-State data indicates that in most States, Medicaid program spending has increased from
one year to the next. There are few instances over the entire period where total Medicaid program
spending has declined from one year to the next.

The MSIS system was the primary source for data on the distribution Medicaid recipients by State
(Table 6). CMS has released MSIS data through FY 2002. FY 2003, FY 2004, and FY 2005 are
estimates, based on the cubed root of change over a 4 year period methodology discussed above. As
shown in Table 6, the total number of Medicaid recipients, like the expenditure data in Table 5, has
increased or is estimated to increase each year between FY 2005 and FY 2006. Likewise, with few
exceptions, the number of Medicaid recipients has increased each year in each State over the period.

Tables 7 & 8

Tables 7 and 8 present MSIS data on State-by-State prescription drug payments and the number of
drug recipients for the period FY 2000-FY 2005. As shown in Table 7, Medicaid program payments
for prescription drugs have more than doubled over the period, from approximately $20 billion in FY
2000 to an estimated $44.3 billion in FY 2005. Few states experienced any declines in prescription
drug payments between one year and the next.

The total number of Medicaid recipients receiving prescription drug services has increased by slightly
more than 50 percent between FY 2000 and FY 2005 (Table 8). For FY 2005, it is estimated that 29.8

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million beneficiaries will receive prescription drug services under the Medicaid program. Most States
are expected to experience increases in the number of Medicaid prescription drug recipients over the
period. However, in a small number of States, including Kansas and Massachusetts, the number of
Medicaid prescription drug recipients are expected to remain relatively constant or even decline
slightly between FY 2000 and FY 2005.

How Good are the Estimates?

One way to ascertain whether an estimation methodology is accurate is to apply it to earlier years
where the estimated year is known. We chose this methodology as way to address the question of the
probable accuracy of our estimates. We applied the final estimation method to the years FY 1999 to
FY 2002. Specifically, we used FY 1999, FY 2000, and FY 2001 data to predict FY 2002, a year in
which we had actual values for aggregate and State-by-State data. The results were that the actual
aggregate totals were within 0.3 percent of the estimated totals. The State-by-State estimates were less
accurate but still within what we judge as acceptable limits. Forty-two States were within plus or
minus five percent. Seven States were within plus or minus twenty percent, and two States exceeded
twenty percent.

Despite these limitations and the variations inherent in the use of different data systems, we believe
that our estimates provide useful information on Medicaid program expenditures and recipients that is
more up to date than that which is currently available from CMS.

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Table 3
Medicaid Expenditures, by Type of Service: In dollars by Fiscal Year

Se rvice FY 2000* FY 2001* FY 2002* FY 2003* FY 2004** FY 2005**


Nursing Facility $39,607,169,035 $43,317,811,704 $47,466,264,432 $44,345,682,144 $46,047,973,158 $46,995,743,244
Inpatient Acute Care Hospital $36,650,532,554 $39,586,413,122 $43,690,502,629 $45,839,127,080 $49,388,028,311 $53,167,576,794
Pharmaceuticals $20,551,215,451 $24,656,812,921 $29,339,050,970 $33,794,520,738 $39,601,058,000 $44,308,084,000
HCBS Waivers $12,628,550,113 $14,864,788,473 $17,169,137,673 $19,302,698,045 $22,235,122,443 $25,429,224,889
ICF-Mentally Retarded $10,184,590,576 $10,686,809,919 $11,205,483,449 $11,614,424,195 $12,134,327,720 $12,659,161,248
Hospital Outpatient $7,055,207,899 $7,709,540,429 $9,245,799,624 $9,394,646,018 $10,335,637,983 $11,396,554,078
Inpatient Mental Health Hospital $7,331,896,067 $6,862,423,184 $7,559,242,098 $7,299,165,193 $7,288,287,404 $7,436,036,077
Clinic $5,863,580,557 $6,689,968,278 $7,499,886,627 $7,582,867,230 $8,261,463,159 $8,863,418,884
Physicians $5,892,807,109 $6,670,379,109 $7,446,842,170 $7,863,653,436 $8,657,484,947 $9,443,626,907
Personal Care Services $4,566,864,434 $5,251,140,806 $6,037,450,986 $7,881,552,380 $9,453,870,484 $11,500,806,850
Home Health Care $2,311,780,853 $2,613,356,673 $2,766,480,497 $2,886,980,643 $3,108,920,442 $3,294,174,359
Dental $1,795,228,321 $2,193,475,415 $2,630,870,620 $3,015,702,590 $3,584,908,827 $4,222,729,183
Other Practitioners $1,030,135,204 $1,141,272,064 $1,413,870,565 $1,438,109,885 $1,607,279,303 $1,801,601,525
EPSDT $829,205,382 $935,836,328 $1,007,637,056 $1,079,836,415 $1,179,206,654 $1,273,659,272
Lab/X-ray $612,378,794 $660,398,684 $781,820,930 $856,521,207 $957,879,281 $1,084,290,467
Other $38,245,755,438 $41,969,472,522 $50,437,280,350 $55,700,409,296 $65,958,551,884 $73,323,312,221

Total Expenditures*** $195,156,897,787 $215,809,899,631 $245,697,620,676 $259,895,896,495 $289,800,000,000 $316,200,000,000


Percent Change from Year to
Year 11% 14% 6% 12% 9%

*Source: CMS-64 Reports


**Source: CMS, Office of the Actuary, National Health Expenditures Estimates, January 2005 and Muse & Associates Estimat
***T otals may not add due to rounding

Table 4
Medicaid Recipients, by Type of Service and Fiscal Year

Se rvice FY 1999* FY 2000* FY 2001* FY 2002* FY 2003** FY 2004** FY 2005**


Capitated Payment Services 20,678,898 21,292,179 23,355,569 25,863,748 27,866,311 30,481,238 33,310,411
Pharmaceuticals 19,428,344 20,324,675 21,910,532 24,424,493 26,027,090 27,929,225 29,946,171
Physicians 18,052,586 18,965,002 20,021,029 22,102,682 23,645,409 25,449,435 27,568,220
Hospital Outpatient 12,323,540 13,169,841 13,731,009 14,861,211 15,818,323 16,814,621 17,989,342
Lab/X-ray 10,103,678 11,438,835 12,339,065 14,067,422 15,708,192 17,459,869 19,601,707
Other Care^ 8,781,097 9,232,630 9,897,625 11,195,848 12,140,216 13,300,258 14,676,970
Clinic 6,660,804 7,677,662 8,463,753 9,498,844 10,691,832 11,939,693 13,390,698
Dental 5,577,468 5,922,244 7,018,692 7,885,538 8,850,397 10,118,626 11,430,801
PCCM Services 3,962,942 5,649,174 6,377,864 7,177,583 8,749,134 10,122,593 11,807,662
Hospital Inpatient 4,479,391 4,912,833 4,879,194 5,051,356 5,257,803 5,378,094 5,555,483
Other Practitioners 3,945,721 4,758,086 5,102,653 5,570,691 6,249,376 6,843,917 7,547,579
Personal Support Services 4,061,799 4,558,732 4,977,823 5,688,386 6,364,231 7,112,898 8,011,532
Nursing Facility 1,624,163 1,705,947 1,702,251 1,765,700 1,815,569 1,853,653 1,907,056
Home Health Care 808,751 1,007,025 1,013,796 1,065,050 1,167,405 1,226,353 1,306,684
ICF-Mentally Retarded 121,318 118,857 116,610 117,497 116,250 115,394 114,992
Mental Health Facility 96,904 99,521 91,209 99,403 100,250 100,495 103,795
Total Unduplicated Recipients*** 40,300,394 42,886,999 46,163,776 49,754,619 53,446,822 57,546,074 61,991,626
Percent Change from Year to Year 6% 8% 8% 7% 8% 8%

*Source: CMS Medicaid Statistical Information System


** Source Muse & Asscoiates Estimates
*** Since any recipient can get any number of different typess of service, the unduplicated total is not a sum.
^ includes sterilizations and unknown care

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Table 5
Total Medicaid Expenditures in thousands of dollars by Fiscal Year by State
S tate FY 2000 FY 2001 FY 2002 FY 2003 FY 2004 FY 2005
National Total $168,307,231 $185,786,851 $213,491,313 $268,496,116 $290,680,584 $315,701,965
Alabama $2,391,195 $2,950,096 $3,204,064 $3,603,097 $3,445,986 $3,850,214
Alaska $470,250 $557,399 $686,795 $774,755 $909,840 $942,281
Arizona $2,111,770 $2,453,184 $2,881,870 $4,253,304 $5,135,647 $5,772,557
Arkansas $1,510,080 $1,684,718 $2,015,437 $2,394,653 $2,762,943 $2,989,172
California $17,060,494 $19,824,989 $23,636,240 $29,897,092 $32,173,749 $36,362,263
Colorado $1,808,569 $1,952,709 $2,166,200 $2,597,187 $2,703,792 $2,902,011
Connecticut $2,839,310 $2,962,088 $3,245,143 $3,691,626 $3,866,361 $4,103,564
Delaware $528,340 $601,182 $651,385 $737,360 $752,775 $855,737
District of Columbia $792,584 $830,258 $1,027,022 $1,072,802 $1,165,242 $1,241,190
Florida $7,350,363 $8,398,160 $9,827,004 $11,041,401 $12,340,063 $13,790,043
Georgia $3,577,903 $3,815,267 $4,796,005 $7,055,152 $7,045,377 $7,154,685
Hawaii $535,163 $535,163 $695,279 $759,731 $846,973 $1,026,277
Idaho $593,751 $713,433 $791,864 $853,256 $905,311 $1,058,487
Illinois $7,807,447 $8,150,021 $9,121,713 $8,954,270 $10,073,437 $11,400,358
Indiana $2,976,177 $3,355,996 $3,725,258 $4,584,428 $4,699,660 $5,563,225
Iowa $1,476,340 $1,660,864 $1,855,817 $2,360,040 $2,196,622 $2,448,931
Kansas $1,226,211 $1,370,248 $1,501,270 $1,789,086 $1,754,285 $2,096,225
Kentucky $2,912,792 $3,235,073 $3,459,366 $3,864,583 $4,075,918 $4,464,305
Louisiana $2,630,563 $2,881,578 $3,234,422 $4,858,435 $4,633,523 $4,990,753
M aine $1,306,809 $1,457,466 $1,716,582 $1,680,703 $1,916,751 $2,072,414
M aryland $3,585,781 $3,855,003 $3,662,090 $4,359,399 $4,494,121 $4,708,992
M assachusetts $5,397,153 $5,765,108 $6,387,100 $8,632,074 $8,987,848 $9,968,515
M ichigan $4,880,769 $5,316,249 $5,918,817 $8,150,661 $8,507,062 $8,850,936
M innesota $3,277,014 $3,766,605 $4,439,494 $5,117,771 $5,225,883 $5,719,244
M ississippi $1,807,392 $2,180,662 $2,499,641 $3,028,552 $3,280,007 $3,658,914
M issouri $3,270,152 $3,626,213 $4,071,544 $5,578,991 $5,966,126 $6,744,680
M ontana $433,208 $482,543 $532,886 $519,065 $601,474 $700,806
Nebraska $958,490 $1,089,788 $1,255,040 $1,351,142 $1,354,239 $1,424,542
Nevada $515,444 $565,300 $723,957 $989,559 $1,053,794 $1,160,591
New Hampshire $650,594 $691,196 $745,754 $1,014,956 $1,180,678 $1,272,117
New Jersey $4,706,929 $5,011,795 $5,497,284 $8,358,844 $7,883,350 $8,416,526
New M exico $1,248,764 $1,476,538 $1,796,901 $2,030,060 $2,230,879 $2,416,959
New York $26,147,613 $27,497,918 $31,488,930 $40,551,353 $49,425,404 $49,312,629
North Carolina $4,830,026 $5,499,094 $6,041,011 $7,139,629 $7,613,812 $8,901,127
North Dakota $356,185 $374,197 $422,745 $463,348 $496,642 $535,293
Ohio $7,090,396 $7,772,738 $9,186,331 $10,601,589 $12,030,919 $12,595,864
Oklahoma $1,603,789 $2,004,799 $2,238,213 $2,402,648 $2,720,199 $2,860,078
Oregon $1,700,409 $1,878,673 $2,136,401 $2,757,488 $2,535,181 $3,057,873
Pennsylvania $6,365,806 $7,634,325 $8,523,928 $13,168,602 $14,422,482 $16,466,731
Rhode Island $1,069,994 $1,095,853 $1,251,440 $1,472,595 $1,533,600 $1,771,549
South Carolina $2,672,146 $3,096,854 $3,382,951 $3,766,709 $3,576,207 $4,097,262
South Dakota $401,175 $426,634 $503,947 $546,789 $579,726 $666,494
Tennessee $3,490,957 $4,059,332 $4,747,550 $6,639,519 $6,735,962 $7,837,560
Texas $9,075,306 $9,644,600 $11,121,020 $15,289,859 $16,621,374 $17,735,949
Utah $959,100 $1,059,730 $1,215,620 $1,123,620 $1,258,360 $1,428,054
Vermont $479,259 $541,283 $607,250 $713,582 $766,279 $862,161
Virginia $2,483,931 $2,715,962 $3,017,870 $3,706,653 $4,156,487 $4,723,322
Washington $2,432,050 $2,432,050 $4,373,171 $5,180,773 $5,304,530 $5,762,663
West Virginia $1,391,731 $1,565,009 $1,577,698 $1,873,502 $1,912,439 $2,157,688
Wisconsin $2,905,599 $3,029,723 $3,605,542 $4,806,489 $4,478,875 $4,403,336
Wyoming $213,958 $241,187 $280,452 $337,334 $342,390 $398,818

* Data from CM S-37 reports filed with CM S by the States.


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National Pharmaceutical Council Pharmaceutical Benefits 2004

Table 6
Total Unduplicated Medicaid Recipients by State by Fiscal Year
State FY 2000* FY 2001* FY 2002* FY 2003** FY 2004** FY 2005**
National Total 42,886,999 46,163,776 49,754,619 53,446,822 57,546,074 61,991,626
Alabama 619,480 882,105 765,328 836,803 925,028 939,796
Alaska 96,432 105,464 109,641 119,836 128,838 137,728
Arizona 681,258 763,422 878,362 976,625 1,101,200 1,244,229
Arkansas 489,325 531,533 579,278 622,674 674,759 730,614
California 7,918,151 8,583,027 9,301,001 10,323,828 11,278,372 12,353,265
Colorado 381,018 393,160 425,878 450,793 476,784 508,439
Connecticut 419,968 685,246 479,051 502,652 533,685 533,685
Delaware 115,267 122,947 167,162 193,885 230,582 276,698
District of Columbia 138,677 140,719 193,494 218,982 255,002 306,002
Florida 2,372,585 2,471,771 2,676,235 2,833,382 3,006,073 3,208,707
Georgia 1,369,006 1,514,398 1,637,329 1,777,775 1,939,549 2,106,303
Hawaii 194,376 191,533 199,966 198,658 200,106 203,048
Idaho 131,077 157,121 176,499 200,665 231,270 263,077
Illinois 1,519,313 1,657,954 1,731,398 1,834,859 1,953,984 2,063,973
Indiana 706,476 777,418 849,427 940,652 1,034,840 1,138,359
Iowa 313,648 319,740 352,635 368,428 388,738 414,900
Kansas 262,557 272,783 289,349 296,359 308,567 321,509
Kentucky 763,587 806,578 808,294 847,565 877,563 902,586
Louisiana 761,252 804,996 898,824 966,003 1,045,831 1,141,171
Maine 193,582 251,511 275,826 316,222 372,421 424,483
Maryland 625,863 656,307 692,539 732,052 771,312 813,962
Massachusetts 1,059,612 1,054,916 1,065,636 1,073,987 1,078,821 1,086,909
Michigan 1,351,852 1,352,610 1,449,915 1,490,027 1,539,155 1,606,888
Minnesota 558,089 600,686 620,652 641,859 672,488 698,281
Mississippi 605,078 707,911 712,457 794,881 870,561 932,694
Missouri 890,338 978,656 1,036,150 1,128,728 1,221,614 1,315,332
Montana 104,354 108,409 103,617 106,048 106,619 106,029
Nebraska 229,379 243,421 255,771 270,822 286,238 302,123
Nevada 138,076 153,777 202,306 231,948 275,728 330,873
New Hampshire 96,935 97,062 104,138 108,072 112,062 117,561
New Jersey 821,579 881,468 954,491 1,002,879 1,071,803 1,143,978
New Mexico 375,585 385,180 798,665 958,398 1,150,078 1,380,093
New York 3,419,983 3,590,999 3,920,718 4,180,420 4,469,771 4,808,120
North Carolina 1,214,174 1,309,810 1,355,269 1,424,834 1,502,884 1,573,372
North Dakota 63,165 63,566 70,132 73,108 76,759 81,739
Ohio 1,304,886 1,498,322 1,656,124 1,805,943 2,012,556 2,220,558
Oklahoma 507,060 589,363 631,498 699,125 778,132 853,644
Oregon 557,809 582,112 621,462 649,472 683,258 720,739
Pennsylvania 1,492,352 1,557,801 1,627,261 1,652,312 1,709,355 1,763,081
Rhode Island 178,859 188,228 199,014 213,572 226,581 241,029
South Carolina 689,159 760,805 809,136 871,535 942,482 1,012,216
South Dakota 102,039 109,516 117,631 130,669 141,898 154,694
T ennessee 1,568,318 1,602,027 1,732,381 1,797,473 1,881,071 1,984,497
T exas 2,633,498 2,659,932 2,952,569 3,113,488 3,292,193 3,534,736
Utah 224,732 232,997 274,707 294,790 322,698 359,703
Vermont 139,351 149,763 153,731 161,978 170,309 177,766
Virginia 626,996 619,727 665,203 680,602 699,471 728,271
Washington 895,567 957,731 1,039,070 1,105,389 1,185,735 1,273,217
West Virginia 342,189 349,229 362,030 367,825 376,790 386,452
Wisconsin 576,636 637,069 716,298 793,773 883,002 984,509
Wyoming 46,451 50,950 59,071 64,164 71,459 79,989

*Source: Data from M edicaid Statistical Information System 2000 to 2002.


** Source: M use and Associates Estimates
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National Pharmaceutical Council Pharmaceutical Benefits 2004

Table 7
Medicaid Prescription Drug Payments, Before Rebates are Deducted
in thousands of dollars by State by Fiscal Year
S tate FY 2000* FY 2001* FY 2002* FY 2003** FY 2004*** FY 2005***

National Total $19,898,312 $23,764,447 $28,408,182 $33,794,521 $39,601,058 $44,308,084


Alabama $331,577 $392,483 $454,370 $536,223 $605,511 $605,879
Alaska $53,404 $66,768 $83,324 $69,512 $116,150 $121,760
Arizona $1,953 $4,668 $4,339 $4,744 $5,548 $6,267
Arkansas $209,933 $248,391 $279,645 $310,709 $387,052 $434,360
California $2,316,407 $2,808,442 $3,402,508 $4,219,505 $4,750,190 $5,317,841
Colorado $153,250 $178,063 $202,286 $225,298 $257,798 $295,078
Connecticut $264,645 $304,481 $356,980 $403,802 $398,722 $472,331
Delaware $66,264 $81,623 $100,113 $109,845 $93,525 $111,529
District of Columbia $55,095 $62,296 $68,051 $81,763 $124,842 $134,209
Florida $1,368,714 $1,490,096 $1,736,992 $2,018,037 $2,429,764 $2,674,708
Georgia $586,864 $702,719 $749,552 $1,073,715 $1,193,822 $1,218,423
Hawaii $58,839 $71,232 $81,454 $97,386 $110,648 $125,751
Idaho $83,568 $105,497 $121,781 $132,143 $149,492 $170,886
Illinois $846,986 $934,231 $1,222,947 $1,469,191 $1,961,260 $2,056,659
Indiana $464,985 $562,127 $636,358 $627,575 $731,105 $824,891
Iowa $194,212 $231,010 $277,754 $331,222 $378,817 $430,892
Kansas $167,632 $189,946 $220,801 $228,921 $270,542 $304,050
Kentucky $465,788 $599,970 $661,410 $685,230 $800,000 $887,357
Louisiana $477,852 $556,393 $682,557 $827,713 $881,272 $978,547
M aine $176,215 $204,015 $250,332 $268,548 $258,764 $253,115
M aryland $222,250 $267,760 $320,314 $429,589 $495,397 $524,293
M assachusetts $682,873 $796,341 $952,791 $946,211 $1,024,485 $1,001,318
M ichigan $374,353 $604,782 $674,898 $758,267 $864,623 $999,294
M innesota $221,522 $265,098 $294,839 $276,731 $413,889 $420,785
M ississippi $370,355 $494,809 $568,084 $568,007 $772,523 $750,000
M issouri $602,457 $682,958 $799,910 $941,522 $1,102,434 $1,292,349
M ontana $59,250 $69,742 $77,981 $79,772 $90,075 $103,011
Nebraska $135,402 $161,820 $196,526 $210,200 $234,619 $253,346
Nevada $51,683 $63,364 $90,135 $106,821 $127,271 $149,591
New Hampshire $80,560 $90,928 $98,837 $112,949 $124,977 $145,276
New Jersey $585,892 $649,650 $686,302 $766,996 $1,074,306 $1,143,626
New M exico $57,504 $70,202 $92,674 $86,408 $99,646 $113,460
New York $2,366,916 $2,782,394 $3,413,405 $4,218,812 $4,942,274 $5,602,883
North Carolina $794,630 $971,104 $1,069,141 $1,291,263 $1,567,559 $1,493,467
North Dakota $38,079 $43,288 $51,750 $56,960 $60,718 $68,164
Ohio $882,955 $1,118,120 $1,330,569 $1,520,147 $1,804,931 $2,087,450
Oklahoma $178,254 $216,827 $267,549 $301,294 $274,858 $486,920
Oregon $163,523 $222,392 $269,937 $262,335 $214,588 $238,388
Pennsylvania $533,534 $690,559 $719,243 $791,054 $904,875 $1,100,066
Rhode Island $89,482 $104,918 $126,331 $140,687 $160,000 $186,000
South Carolina $334,746 $438,502 $456,977 $558,129 $624,704 $571,057
South Dakota $44,651 $52,611 $63,655 $71,223 $83,503 $94,589
Tennessee $0 $0 $573,588 $1,280,130 $1,793,149 $2,536,901
Texas $1,125,248 $1,327,255 $1,591,828 $1,920,866 $2,202,804 $2,554,080
Utah $101,145 $117,478 $140,520 $163,218 $192,000 $233,000
Vermont $92,391 $105,994 $115,624 $127,764 $147,557 $181,165
Virginia $381,391 $419,148 $453,663 $506,414 $595,258 $672,205
Washington $389,977 $464,083 $549,216 $592,437 $659,706 $711,718
West Virginia $216,077 $256,395 $274,613 $345,831 $388,383 $446,874
Wisconsin $349,560 $389,374 $455,721 $592,295 $601,206 $676,921
Wyoming $27,466 $32,100 $38,009 $49,106 $53,916 $55,354

*Source: Data from M edicaid Statistical Information System.


**FY 2003 Data from CM S-64 Report.
***FY 2004 andFY 2005 are M use & Associates estimates.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Table 8
Medicaid Recipients Receiving Prescription Drugs by State by Fiscal Year

S tate FY 1999* FY 2000* FY 2001* FY 2002* FY 2003** FY 2004** FY 2005**


National Total 19,428,344 20,324,675 21,910,532 24,424,493 26,027,090 27,929,225 29,946,171
Alabama 405,330 438,529 464,695 500,789 537,366 575,035 617,357
Alaska 52,070 60,273 65,278 70,550 78,067 85,097 92,960
Arizona 5,545 7,034 9,761 7,805 8,747 9,406 9,291
Arkansas 280,552 290,749 321,920 356,233 385,752 423,875 464,587
California 2,252,441 2,491,537 2,489,050 2,651,229 2,799,273 2,910,077 3,065,689
Colorado 151,537 160,265 143,167 153,520 154,187 152,212 155,353
Connecticut 108,754 113,101 116,785 123,704 129,131 134,964 141,632
Delaware 73,093 78,167 85,350 125,461 150,217 186,761 242,463
District of Columbia 37,862 38,129 35,324 45,216 47,972 51,788 58,833
Florida 991,927 1,078,631 1,165,866 1,245,841 1,344,178 1,446,499 1,554,324
Georgia 843,353 882,309 978,404 1,076,904 1,168,332 1,282,965 1,404,258
Hawaii 35,837 37,316 39,288 39,320 40,555 41,696 42,530
Idaho 81,980 92,776 112,357 125,537 144,697 167,804 191,809
Illinois 966,790 1,013,387 1,068,687 1,199,933 1,289,531 1,397,390 1,528,058
Indiana 361,661 420,071 464,975 490,386 542,771 591,173 640,437
Iowa 213,144 212,178 221,690 245,711 257,637 274,860 295,279
Kansas 153,054 158,334 158,515 157,618 159,169 159,449 159,761
Kentucky 366,051 425,721 476,774 489,416 539,167 583,342 623,917
Louisiana 551,698 581,356 628,574 689,973 743,377 806,860 876,890
M aine 143,548 149,262 194,288 224,664 260,843 314,187 368,782
M aryland 159,779 163,410 171,747 181,101 188,823 198,144 207,815
M assachusetts 671,741 671,716 671,756 659,626 655,636 650,363 643,384
M ichigan 436,848 435,723 551,680 577,785 634,227 718,770 785,038
M innesota 184,075 179,879 187,854 190,577 192,795 197,303 200,557
M ississippi 375,573 415,925 478,409 526,923 589,881 662,747 738,807
M issouri 412,597 447,068 472,645 493,230 523,469 551,734 580,935
M ontana 59,182 58,918 63,352 67,365 70,337 74,615 78,798
Nebraska 155,136 166,031 178,634 194,889 210,287 227,520 246,626
Nevada 48,534 51,170 58,699 71,950 82,040 96,020 113,137
New Hampshire 71,039 73,313 73,489 78,861 81,655 84,642 88,724
New Jersey 301,022 299,356 305,962 296,059 294,423 292,797 288,535
New M exico 55,018 67,239 75,892 122,098 146,518 175,821 210,985
New York 2,024,870 2,173,856 2,458,197 2,567,595 2,779,092 3,016,202 3,229,051
North Carolina 812,234 827,389 907,741 949,795 1,000,644 1,066,112 1,124,820
North Dakota 37,780 38,964 39,758 44,428 46,894 49,882 53,800
Ohio 796,720 777,632 934,632 997,246 1,074,734 1,197,136 1,300,103
Oklahoma 222,456 221,985 252,025 276,111 296,731 326,871 356,469
Oregon 174,931 193,924 223,580 242,865 270,935 302,883 335,137
Pennsylvania 520,221 416,498 461,114 464,848 447,733 458,656 457,840
Rhode Island 49,277 49,809 50,411 53,729 55,301 57,263 59,747
South Carolina 446,893 474,470 542,768 576,136 627,045 688,117 744,752
South Dakota 50,780 53,666 58,212 64,948 70,500 77,212 84,836
Tennessee 0 0 0 916,968 916,968 916,968 916,968
Texas 1,853,348 1,852,828 1,917,398 2,153,316 2,263,730 2,420,033 2,615,316
Utah 130,682 133,224 136,719 152,268 160,228 170,396 183,373
Vermont 89,547 103,635 109,578 112,227 120,998 127,410 133,977
Virginia 377,588 344,877 334,008 319,196 301,812 288,688 274,991
Washington 301,907 339,611 385,408 423,758 474,460 530,402 589,975
West Virginia 274,894 262,675 269,174 276,338 276,821 281,704 286,009
Wisconsin 224,165 267,417 262,238 309,795 345,072 375,679 423,504
Wyoming 33,280 33,342 36,704 42,652 46,330 51,699 57,952

*Source: Data from Medicaid Statistical Information System.


**Source: Muse & Associates Estimates.

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Section 2:
The Medicaid Program

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MEDICAID PROGRAM OVERVIEW


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

MEDICAID ELIGIBILITY

Medicaid Eligibility: Medicaid is a “means tested program for low-income individuals.” To qualify,
a Medicaid recipient must not have “income” or “resources” that exceed the applicable limits
prescribed in the law and regulations.
Every State, in order to receive Federal funding under Title XIX, must provide Medicaid benefits to
certain “categorically needy” persons. These are the “mandatory” categorically needy. In addition,
the State has the option of providing Medicaid benefits to certain additional categories of persons.
These are the “optional” categorically needy. An additional category of Medicaid recipients that a
State may choose to include in its program is the “medically needy.”
Mandatory Categorically Needy: There are numerous and detailed categories under which the
“categorically needy” may qualify for Medicaid benefits. The principal categories of the mandatory
categorically needy are:
• Low-income families with children;
• Recipients of Supplemental Security Income (SSI) for the Aged, Blind, and Disabled
(this includes disabled children);
• Individuals qualified for adoption assistance agreements or foster care maintenance
payments under Title IV-E of the Social Security Act;
• Qualified pregnant women;
• Newborn children of Medicaid-eligible women;
• Various categories of low-income children; and
• Certain low-income Medicare beneficiaries.
Optional Categorically Needy: These are groups of individuals who meet the characteristics of the
mandatory groups, but the eligibility criteria are somewhat more liberally defined. For example, in
determining their incomes and resources, they are allowed to exclude certain kinds of income. The
“optional categorically needy” include individuals who are aged, blind, disabled, caretaker relatives,
and pregnant women who meet the SSI income and resources requirements but are not receiving SSI
cash payments.
Medically Needy: The “medically needy” are those individuals who meet the definitional
requirements described above, except that their income or resources exceed the limitations applicable
to the categorically needy. These individuals can “spend down” to qualify. That is, they can deduct
their medical bills from their income and resources until they meet the applicable income and
resources requirements. Their Medicaid benefits can then begin.
Special Categories: The Medicaid statute also authorizes limited Medicaid benefits to special
categories of individuals. In general, these are individuals whose income and resources would
otherwise be too high to qualify for full Medicaid benefits under the regular provisions.

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For example, a “Qualified Medicare Beneficiary” (QMB) is an individual who qualifies for Medicare
Part A, whose income does not exceed 100 percent of the Federal poverty level, and whose resources
do not exceed twice the SSI resource-eligibility standard. Medicaid coverage of QMBs is limited to
payment of their Medicare cost-sharing charges, such as the Medicare premiums, coinsurance, and
co-payment amounts.
Non-Eligibles: A State can include in its Medicaid program individuals who do not meet the statutory
eligibility criteria. However, the State must pay the full costs for these individuals. There are no
Federal matching payments.

MEDICAID SERVICES

Title XIX lists the many types of medical care that a State may select for inclusion into its Medicaid
State Plan, thus qualifying for Federal matching payments. However, the law requires that certain
basic benefits must be available to all “categorically needy” recipients. These services include:
• Inpatient and outpatient hospital services;
• Physician services;
• Medical and surgical dental services;
• Laboratory and X-ray services;
• Nursing facility services (for persons 21 years of age or older);
• Early and periodic screening, diagnostic, and treatment (EPSDT) services for children
under age 21;
• Family planning services and supplies;
• Home health services for persons eligible for nursing facility services;
• Rural health clinic services and any other ambulatory services offered by a rural health
clinic that are otherwise covered under the State Plan;
• Nurse-midwife services (to the extent authorized under State law);
• Pediatric and family nurse practitioners services; and
• Federally-qualified health center (FQHC) services and any other ambulatory services
offered by an FQHC that are otherwise covered under the State Plan.
If a State chooses to include the “medically needy” population, the State Plan must provide, as a
minimum, the following services:
• Prenatal care and delivery services for pregnant women;
• Ambulatory services to individuals under age 18 and individuals entitled to institutional
services;
• Home health services to individuals entitled to nursing facility services; and
• If the State Plan includes services either in institutions for mental diseases or in
intermediate care facilities for the mentally retarded (ICFs/MR), it must offer medically
needy groups certain specified services provided to the categorically needy.
States may also receive Federal funding if they elect to provide other optional services. The most
commonly covered optional services under the Medicaid program include:
• Clinic services;
• Services of ICFs/MR;
• Nursing facility services (children under 21 years old);
• Prescribed drugs;
• Optometrist services and eyeglasses;

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• TB-related services for TB infected persons;


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

CHARACTERISTICS OF BENEFITS PROVIDED

Inpatient Hospital Services


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

Outpatient Hospital Services


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

Rural Health Clinic Services


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

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and Human Services (DHHS) has determined has a shortage of home health agencies, the services are
furnished by nurses employed by the RHC, and the services are furnished to a homebound recipient
under a written plan of treatment.

Other Laboratory and X-Ray Services


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

Nursing Facility Services


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

Early and Periodic Screening, Diagnostic and Treatment Services


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

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


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

Family Planning Services


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

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Voluntary Sterilizations: FFP is available in expenditures for the sterilization of an individual only if
she is at least age 21, has voluntarily given informed consent in accordance with Medicaid
regulations, and is not a mentally incompetent individual.

Physicians’ Services
Physicians’ services are covered, whether provided in the office, the patient’s home, a hospital, a
nursing facility, or elsewhere. Such services must be within the physicians’ scope of practice of
medicine or osteopathy as defined by State law, and by or under the personal supervision of an
individual licensed under State law to practice medicine or osteopathy.

Prescribed Drugs
Prescribed drugs are simple or compound substances or mixtures of substances prescribed for the
cure, mitigation, or prevention of disease, or for health maintenance, which are prescribed by a
physician or other licensed practitioner of the healing arts within the scope of their professional
practice, as defined and limited by Federal and State law (42 CFR 440.120). The drugs must be
dispensed by licensed authorized practitioners on a written prescription that is recorded and
maintained in the pharmacist’s or the practitioner’s records.

Home Health Services


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

Personal Support Services

Personal support services consist of a variety of services including personal care, targeted case
management, home and community-based care for functionally disabled elderly, rehabilitative
services, hospice services, and nurse-midwife, nurse practitioner, and private duty nursing. Details of
some of these services are provided below:
1. Personal Care Services: Services provided to an individual who is not an inpatient or
resident of a hospital, nursing facility, intermediate care facility for the mentally

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


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

Nurse-Midwife Services
Nurse-midwife services are those concerned with management of the care of mothers and newborns
throughout the maternity cycle. The Omnibus Budget Reconciliation Act of 1980 required that
payment be made providing for nurse-midwife services to categorically needy recipients (42 CFR
440.165). These provisions require States to provide coverage for nurse-midwife services to the
extent that the nurse-midwife is authorized to practice under State law or regulation. The statute also
requires that States offer direct reimbursement to nurse-midwives as one of the payment options.
Nurse-midwives must be registered nurses who are either certified by an organization recognized by
the Secretary of DHHS or who have completed a program of study and clinical experience that has
been approved by the Secretary.

Pediatric Nurse Practitioner and Family Nurse Practitioner Services


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

Federally Qualified Health Center and Other Ambulatory Services


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

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• The facility receives a grant under sections 329, 330, or 340 of the Public Health Service
Act;
• The Health Resources and Services Administration (HRSA) recommends, and the DHHS
Secretary determines, that the facility meets the requirements of the grant; or
• The Secretary determines that a facility may qualify through waivers of the requirements.
Such a waiver cannot exceed two years.

AMOUNT AND DURATION OF SERVICES


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

MEDICAID PAYMENT FOR SERVICES


The Medicaid program operates on the basis of a division of responsibilities between the Federal
government and the States with the Federal government paying States for a portion of State medical
expenditures and administrative costs. Funding for the program is shared between the two bodies,
with the Federal government matching State health care provider reimbursements at an authorized
rate of between 50% and 77%, depending on the State’s per capita income (see the FY 2005 Federal
Medical Assistance Percentage (FMAP) table, page 2-18).
The FMAP is based upon the State’s per capita income; if a State’s per capita income is equal to or
greater than the national average, the Federal share is 50%. If a State’s per capita income is below the
national average, the Federal share is increased, up to a maximum of 77%.
The percentages apply to State expenditures for assistance payments and medical services. Federal
statute provides separate Federal matching amounts for administrative costs. Cost sharing for
administrative expenditures vary with the services, i.e., 75% for training, 90% for designing,
developing or installing mechanized claims processing and information retrieval, etc. (Federal
Medicaid Law (Section 1903(a)(2) et seq.)).
In 2002, the Medicaid program enrolled 51.6 million eligible individuals with vendor payments for
medical care services totaling $213.5 billion. The vendor payments reported in the 2002 MSIS
Report do not include Disproportionate Share Hospital (DSH), Medicare premium payments made by
State Medicaid programs, and other Medicaid program expenditures. The CMS-64 Report, which
does include such expenditures, shows total net expenditures for 2002 of $245.7 billion. When
administrative costs are added to total net expenditures, total Medicaid program expenditures in 2002
were $257.6 billion. For FY 2003, total program expenditures, including those for administration,
were $272.9 billion.

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Total Medicaid Eligibles by Maintenance Assistance Status, 20021

Receiving
Total Cash Medically Poverty 1115 MAS
State Eligibles Assistance Needy Related Other Demonstration Unknown
National Total 51,552,491 18,215,830 4,401,790 15,073,035 8,638,035 5,222,626 1,175
Alabama 845,125 285,853 0 415,276 37,583 106,412 1
Alaska 121,400 51,076 0 59,975 10,349 0 0
Arizona 1,053,602 464,480 0 261,509 191,223 136,390 0
Arkansas 608,017 157,551 10,178 240,028 53,153 147,107 0
California 9,336,447 4,248,290 954,214 515,990 1,439,123 2,178,830 0
Colorado 438,670 219,239 0 163,359 56,072 0 0
Connecticut 487,989 90,988 37,438 77,862 281,701 0 0
Delaware 147,197 69,003 0 13,727 42,564 21,903 0
District of Columbia 204,591 121,320 37,458 35,262 10,551 0 0
Florida 2,691,502 1,113,402 73,312 978,702 387,399 138,672 15
Georgia 1,459,631 525,736 11,140 647,738 275,017 0 0
Hawaii 195,684 97,250 2,434 44,997 15,949 35,054 0
Idaho 196,406 27,994 0 112,074 56,338 0 0
Illinois 2,076,146 293,787 464,565 907,285 247,823 162,686 0
Indiana 881,942 346,171 0 334,326 201,445 0 0
Iowa 358,708 153,913 10,470 111,512 82,813 0 0
Kansas 305,110 106,986 20,423 125,774 51,927 0 0
Kentucky 769,826 343,646 34,626 313,097 78,457 0 0
Louisiana 990,286 347,677 12,207 526,815 103,587 0 0
Maine 346,449 75,324 2,281 89,232 63,619 115,993 0
Maryland 752,065 208,927 91,591 396,639 54,907 0 1
Massachusetts 1,204,312 330,017 21,919 444,390 154,005 253,981 0
Michigan 1,527,627 438,127 128,552 524,624 436,113 0 211
Minnesota 680,627 227,569 55,720 47,787 229,354 120,197 0
Mississippi 707,986 305,857 0 380,081 22,009 0 39
Missouri 1,098,525 679,410 0 128,970 170,202 119,943 0
Montana 106,229 45,831 8,812 25,458 26,119 0 9
Nebraska 266,245 62,809 43,608 130,929 28,238 0 661
Nevada 203,251 78,290 0 65,462 59,499 0 0
New Hampshire 115,517 26,064 11,039 53,280 25,134 0 0
New Jersey 982,676 359,040 5,133 373,027 145,072 100,404 0
New Mexico 462,878 184,972 0 206,152 59,022 12,713 19
New York 4,139,898 1,337,584 1,883,373 420,071 100,457 398,413 0
North Carolina 1,389,455 601,045 42,021 678,924 67,465 0 0
North Dakota 71,619 36,148 14,690 5,330 15,451 0 0
Ohio 1,754,379 430,980 0 363,075 960,324 0 0
Oklahoma 677,788 108,330 7,706 463,661 98,091 0 0
Oregon 637,140 146,559 9,472 171,403 129,447 180,084 175
Pennsylvania 1,710,999 699,940 114,369 574,506 322,184 0 0
Rhode Island 204,789 82,419 4,330 29,368 47,524 41,148 0
South Carolina 895,863 295,611 0 382,483 217,753 0 16
South Dakota 113,925 40,732 0 48,892 24,301 0 0
Tennessee 1,700,384 485,216 121,968 252,406 181,966 658,809 19
Texas 3,202,171 930,165 77,768 1,618,830 574,504 904 0
Utah 233,156 85,897 5,558 87,040 54,661 0 0
Vermont 156,958 30,893 13,253 48,162 14,078 50,572 0
Virginia 727,784 141,198 8,395 422,709 155,481 0 1
Washington 1,104,813 260,809 16,819 394,375 361,851 70,959 0
West Virginia 362,264 133,188 5,087 198,667 25,322 0 0
Wisconsin 776,638 263,555 39,861 124,246 177,525 171,443 8
Wyoming 69,802 18,962 0 37,548 13,283 9 0
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.

Source: CMS, MSIS Report, FY 2002.

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Total Medicaid Eligibles by Age Group, 20021


65 Years and
State Total Eligibles <20 Years 21-64 Years Older Age Unknown
National Total 51,552,491 27,830,240 18,033,921 5,544,601 143,729
Alabama 845,125 455,093 269,582 120,450 0
Alaska 121,400 82,578 31,688 7,134 0
Arizona 1,053,602 574,000 421,245 58,356 1
Arkansas 608,017 365,392 178,945 63,680 0
California 9,336,447 4,230,729 4,277,322 828,384 12
Colorado 438,670 262,328 127,620 48,718 4
Connecticut 487,989 259,235 166,009 62,740 5
Delaware 147,197 75,237 60,665 11,295 0
District of Columbia 204,591 104,485 80,275 19,822 9
Florida 2,691,502 1,520,203 817,314 353,617 368
Georgia 1,459,631 945,513 378,997 135,099 22
Hawaii 195,684 99,110 76,962 19,611 1
Idaho 196,406 136,581 47,020 12,803 2
Illinois 2,076,146 1,171,404 585,568 319,048 126
Indiana 881,942 562,820 240,101 79,021 0
Iowa 358,708 201,581 115,218 41,908 1
Kansas 305,110 190,189 81,486 33,431 4
Kentucky 769,826 424,499 251,029 94,298 0
Louisiana 990,286 653,260 231,482 105,540 4
Maine 346,449 120,724 149,048 76,640 37
Maryland 752,065 459,015 225,256 67,777 17
Massachusetts 1,204,312 532,861 527,402 144,049 0
Michigan 1,527,627 916,024 480,234 131,296 73
Minnesota 680,627 367,223 221,524 91,869 11
Mississippi 707,986 426,575 186,397 95,014 0
Missouri 1,098,525 622,881 374,782 100,861 1
Montana 106,229 59,726 35,435 11,066 2
Nebraska 266,245 169,018 67,742 23,966 5,519
Nevada 203,251 114,834 67,557 20,857 3
New Hampshire 115,517 71,933 30,875 12,709 0
New Jersey 982,676 533,051 308,299 141,326 0
New Mexico 462,878 310,835 121,019 31,011 13
New York 4,139,898 1,781,762 1,729,739 491,484 136,913
North Carolina 1,389,455 778,046 432,309 179,100 0
North Dakota 71,619 36,026 25,492 10,101 0
Ohio 1,754,379 1,014,369 593,119 146,891 0
Oklahoma 677,788 460,532 152,105 64,717 434
Oregon 637,140 291,300 299,144 46,682 14
Pennsylvania 1,710,999 917,552 580,664 212,783 0
Rhode Island 204,789 104,208 76,806 23,773 2
South Carolina 895,863 528,384 288,446 78,998 35
South Dakota 113,925 74,224 27,550 12,151 0
Tennessee 1,700,384 782,478 759,130 158,776 0
Texas 3,202,171 2,069,588 745,796 386,784 3
Utah 233,156 148,783 71,488 12,882 3
Vermont 156,958 72,887 62,894 21,176 1
Virginia 727,784 429,053 196,691 102,023 17
Washington 1,104,813 679,132 346,020 79,661 0
West Virginia 362,264 202,204 126,548 33,512 0
Wisconsin 776,638 395,964 266,229 114,377 68
Wyoming 69,802 44,811 19,653 5,334 4
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.

Source: CMS, MSIS Report, FY 2002.

2-12
National Pharmaceutical Council Pharmaceutical Benefits 2004

Total Medicaid Eligibles by Gender, 20021


State Total Eligibles Female Male Gender Uknown
National Total 51,552,491 30,707,492 20,705,398 139,601
Alabama 845,125 531,748 307,660 5,717
Alaska 121,400 67,277 54,120 3
Arizona 1,053,602 595,081 458,521 0
Arkansas 608,017 381,241 226,535 241
California 9,336,447 5,988,836 3,347,600 11
Colorado 438,670 262,530 176,140 0
Connecticut 487,989 290,201 197,788 0
Delaware 147,197 87,751 59,446 0
District of Columbia 204,591 127,262 77,296 33
Florida 2,691,502 1,596,454 1,093,453 1,595
Georgia 1,459,631 876,947 582,681 3
Hawaii 195,684 106,664 89,020 0
Idaho 196,406 111,449 84,957 0
Illinois 2,076,146 1,239,054 837,092 0
Indiana 881,942 521,432 360,510 0
Iowa 358,708 209,128 149,580 0
Kansas 305,110 176,354 128,712 44
Kentucky 769,826 445,886 323,935 5
Louisiana 990,286 570,955 419,254 77
Maine 346,449 186,109 160,089 251
Maryland 752,065 455,274 296,791 0
Massachusetts 1,204,312 691,423 512,889 0
Michigan 1,527,627 883,138 644,489 0
Minnesota 680,627 393,589 287,038 0
Mississippi 707,986 419,267 288,704 15
Missouri 1,098,525 642,307 456,217 1
Montana 106,229 61,106 45,120 3
Nebraska 266,245 149,431 111,756 5,058
Nevada 203,251 118,988 83,534 729
New Hampshire 115,517 67,520 47,997 0
New Jersey 982,676 589,014 393,662 0
New Mexico 462,878 270,390 192,481 7
New York 4,139,898 2,307,595 1,707,302 125,001
North Carolina 1,389,455 841,783 547,672 0
North Dakota 71,619 42,289 29,329 1
Ohio 1,754,379 1,028,389 725,990 0
Oklahoma 677,788 395,398 282,390 0
Oregon 637,140 349,494 287,642 4
Pennsylvania 1,710,999 1,002,800 708,199 0
Rhode Island 204,789 120,816 83,973 0
South Carolina 895,863 560,528 335,099 236
South Dakota 113,925 64,800 49,125 0
Tennessee 1,700,384 974,861 725,523 0
Texas 3,202,171 1,883,560 1,318,539 72
Utah 233,156 137,218 95,573 365
Vermont 156,958 87,283 69,675 0
Virginia 727,784 432,806 294,978 0
Washington 1,104,813 657,323 447,461 29
West Virginia 362,264 206,131 156,078 55
Wisconsin 776,638 459,856 316,781 1
Wyoming 69,802 40,756 29,002 44
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.

Source: CMS, MSIS Report, FY 2002.

2-13
National Pharmaceutical Council Pharmaceutical Benefits 2004

Total Medicaid Eligibles by Race/Ethnicity, 20021

American
Indian/
Total Black/African Alaska Hispanic or
State Eligibles White American Native Asian Latino Other
National Total 51,552,491 22,476,575 12,282,148 743,956 1,222,704 10,694,241 4,132,867
Alabama 845,125 386,692 413,920 2,204 3,651 13,566 25,092
Alaska 121,400 51,974 6,275 44,388 5,695 4,449 8,619
Arizona 1,053,602 385,624 62,086 137,230 12,181 436,283 20,198
Arkansas 608,017 378,477 194,146 4,844 5,151 21,159 4,240
California 9,336,447 2,136,678 943,186 43,312 460,010 4,871,320 881,941
Colorado 438,670 203,858 31,916 3,275 4,264 163,887 31,470
Connecticut 487,989 227,213 108,673 946 10,545 140,416 196
Delaware 147,197 63,923 63,337 288 2,042 17,181 426
District of Columbia 204,591 3,166 180,962 25 1,568 11,859 7,011
Florida 2,691,502 1,015,714 807,949 1,271 13,788 552,750 300,030
Georgia 1,459,631 595,614 735,738 1,084 13,586 12,675 100,934
Hawaii 195,684 41,169 2,973 469 57,127 5,882 88,064
Idaho 196,406 158,930 1,547 5,082 861 29,782 204
Illinois 2,076,146 837,072 779,474 3,752 50,926 383,503 21,419
Indiana 881,942 609,861 197,903 579 3,173 60,867 9,559
Iowa 358,708 261,289 27,993 1,874 3,504 8,402 55,646
Kansas 305,110 201,217 51,148 4,073 2,696 36,404 9,572
Kentucky 769,826 626,904 97,351 297 1,913 11,867 31,494
Louisiana 990,286 346,283 574,364 1,780 3,425 5,539 58,895
Maine 346,449 334,640 5,131 3,005 2,274 1,399 0
Maryland 752,065 254,437 397,418 1,284 20,551 51,213 27,162
Massachusetts 1,204,312 592,131 127,243 2,646 39,039 188,078 255,175
Michigan 1,527,627 863,660 520,060 7,779 22,142 79,963 34,023
Minnesota 680,627 413,244 105,466 27,520 44,513 2,140 87,744
Mississippi 707,986 241,923 424,485 2,901 2,786 5,042 30,849
Missouri 1,098,525 773,021 283,495 2,204 7,027 351 32,427
Montana 106,229 78,698 730 23,975 435 2,336 55
Nebraska 266,245 180,346 32,801 9,318 2,845 95 40,840
Nevada 203,251 114,714 37,657 3,362 6,727 40,791 0
New Hampshire 115,517 106,887 2,032 95 832 3,342 2,329
New Jersey 982,676 342,642 306,819 3,263 20,462 200,015 109,475
New Mexico 462,878 116,769 10,384 87,040 2,627 236,470 9,588
New York 4,139,898 1,250,339 898,747 52,389 154,509 648,943 1,134,971
North Carolina 1,389,455 607,557 569,579 23,854 12,478 94,973 81,014
North Dakota 71,619 54,016 1,367 15,907 294 0 35
Ohio 1,754,379 1,142,733 529,489 1,788 8,405 51,314 20,650
Oklahoma 677,788 421,204 111,899 87,341 5,973 51,371 0
Oregon 637,140 469,028 27,287 14,161 17,365 102,107 7,192
Pennsylvania 1,710,999 1,020,844 470,098 1,961 32,235 129,568 56,293
Rhode Island 204,789 92,982 17,997 327 5,046 37,098 51,339
South Carolina 895,863 359,348 480,943 1,294 1,757 13,314 39,207
South Dakota 113,925 68,633 2,346 39,991 651 2,120 184
Tennessee 1,700,384 1,121,661 471,076 3,605 11,783 36,923 55,336
Texas 3,202,171 855,101 606,560 11,602 41,413 1,650,717 36,778
Utah 233,156 163,596 4,815 10,234 9,678 41,538 3,295
Vermont 156,958 92,535 1,023 244 425 302 62,429
Virginia 727,784 333,733 335,288 1,125 18,601 37,338 1,699
Washington 1,104,813 709,195 68,751 29,629 52,419 148,121 96,698
West Virginia 362,264 335,086 18,575 180 719 702 7,002
Wisconsin 776,638 378,877 130,331 11,703 20,320 41,865 193,542
Wyoming 69,802 55,337 1,315 5,456 267 6,901 526
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.

Source: CMS, MSIS Report, FY 2002.

2-14
National Pharmaceutical Council Pharmaceutical Benefits 2004

Total Medicaid Eligibles by Basis of Eligibility, 20021

Blind/ Foster Care BCCA BOE


State Total Eligibles Aged Disabled Children Adults Children Women Unknown
National Total 51,552,491 4,759,065 8,055,109 24,583,011 13,245,645 901,951 5,931 1,779
Alabama 845,125 98,709 191,405 411,324 137,462 6,224 0 1
Alaska 121,400 6,569 12,271 73,962 26,602 1,938 58 0
Arizona 1,053,602 43,667 109,978 505,858 386,179 7,920 0 0
Arkansas 608,017 50,510 108,792 304,343 138,152 6,206 0 14
California 9,336,447 664,023 989,758 3,462,819 4,058,935 157,995 2,917 0
Colorado 438,670 47,555 66,257 219,718 87,722 17,297 24 97
Connecticut 487,989 61,797 60,596 255,429 102,704 7,372 91 0
Delaware 147,197 10,769 17,642 64,174 52,705 1,876 31 0
District of Columbia 204,591 13,747 43,794 88,534 51,827 6,689 0 0
Florida 2,691,502 255,655 522,310 1,331,626 538,542 43,369 0 0
Georgia 1,459,631 108,680 232,728 844,963 252,563 19,550 1,147 0
Hawaii 195,684 17,396 23,627 86,034 62,685 5,942 0 0
Idaho 196,406 12,968 26,651 124,773 29,809 2,205 0 0
Illinois 2,076,146 279,046 300,341 1,016,068 395,940 84,506 245 0
Indiana 881,942 78,441 116,543 521,163 152,889 12,730 176 0
Iowa 358,708 41,577 60,717 175,535 70,565 10,314 0 0
Kansas 305,110 30,702 52,879 161,499 47,647 12,383 0 0
Kentucky 769,826 72,121 207,955 370,090 110,257 9,403 0 0
Louisiana 990,286 105,311 177,258 588,077 110,170 9,470 0 0
Maine 346,449 71,964 119,321 97,156 55,101 2,907 0 0
Maryland 752,065 55,354 121,570 415,260 142,405 17,373 0 103
Massachusetts 1,204,312 116,164 243,326 482,300 361,857 665 0 0
Michigan 1,527,627 99,714 297,112 804,779 285,805 40,006 0 211
Minnesota 680,627 69,759 93,872 333,759 174,200 8,983 54 0
Mississippi 707,986 74,033 161,410 384,360 84,985 3,159 0 39
Missouri 1,098,525 98,744 150,368 566,155 258,115 25,143 0 0
Montana 106,229 10,102 17,688 52,662 21,852 3,829 87 9
Nebraska 266,245 23,526 29,885 150,254 51,584 10,267 68 661
Nevada 203,251 19,562 33,202 95,730 46,638 8,119 0 0
New Hampshire 115,517 12,654 14,611 68,911 16,632 2,709 0 0
New Jersey 982,676 111,710 178,819 462,890 207,270 21,926 61 0
New Mexico 462,878 23,371 55,032 290,553 90,085 3,771 47 19
New York 4,139,898 398,070 688,012 1,737,279 1,241,408 75,129 0 0
North Carolina 1,389,455 178,258 236,259 699,139 259,289 16,510 0 0
North Dakota 71,619 10,032 9,841 31,859 18,097 1,790 0 0
Ohio 1,754,379 144,622 279,463 924,487 371,476 33,937 0 394
Oklahoma 677,788 63,837 81,293 432,322 93,949 6,387 0 0
Oregon 637,140 44,325 68,379 247,763 261,511 14,987 0 175
Pennsylvania 1,710,999 212,480 386,422 779,880 283,257 48,635 325 0
Rhode Island 204,789 19,667 38,418 88,794 52,218 5,522 170 0
South Carolina 895,863 78,066 122,846 463,859 222,576 8,423 77 16
South Dakota 113,925 10,139 16,420 67,273 18,157 1,922 14 0
Tennessee 1,700,384 90,398 340,155 723,890 531,554 14,368 0 19
Texas 3,202,171 383,307 379,541 1,870,141 534,638 34,544 0 0
Utah 233,156 12,102 28,075 130,577 55,627 6,676 99 0
Vermont 156,958 19,661 19,109 66,331 49,235 2,610 0 12
Virginia 727,784 98,274 139,382 378,035 97,000 14,946 146 1
Washington 1,104,813 79,445 145,928 579,607 283,313 16,520 0 0
West Virginia 362,264 29,678 89,755 176,277 59,878 6,676 0 0
Wisconsin 776,638 95,507 139,297 335,343 188,479 17,910 94 8
Wyoming 69,802 5,297 8,796 39,397 14,099 2,213 0 0
1
Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year.

Source: CMS, MSIS Report, FY 2002.

2-15
National Pharmaceutical Council Pharmaceutical Benefits 2004
Total Medicaid Eligibles Per 1000 Population, 2002

Total State Total Eligibles per


State Population Eligibles1 1000 Population
National Total 287,973,924 51,552,491 179.0
Alabama 4,478,896 845,125 188.7
Alaska 641,482 121,400 189.2
Arizona 5,441,125 1,053,602 193.6
Arkansas 2,706,268 608,017 224.7
California 35,001,986 9,336,447 266.7
Colorado 4,501,051 438,670 97.5
Connecticut 3,458,587 487,989 141.1
Delaware 805,945 147,197 182.6
District of Columbia 566,157 204,591 361.4
Florida 16,691,701 2,691,502 161.2
Georgia 8,544,005 1,459,631 170.8
Hawaii 1,240,663 195,684 157.7
Idaho 1,343,124 196,406 146.2
Illinois 12,586,447 2,076,146 164.9
Indiana 6,156,913 881,942 143.2
Iowa 2,935,840 358,708 122.2
Kansas 2,711,769 305,110 112.5
Kentucky 4,089,822 769,826 188.2
Louisiana 4,476,192 990,286 221.2
Maine 1,294,894 346,449 267.6
Maryland 5,450,525 752,065 138.0
Massachusetts 6,421,800 1,204,312 187.5
Michigan 10,043,221 1,527,627 152.1
Minnesota 5,024,791 680,627 135.5
Mississippi 2,866,733 707,986 247.0
Missouri 5,669,544 1,098,525 193.8
Montana 910,372 106,229 116.7
Nebraska 1,727,564 266,245 154.1
Nevada 2,167,455 203,251 93.8
New Hampshire 1,274,405 115,517 90.6
New Jersey 8,575,252 982,676 114.6
New Mexico 1,852,044 462,878 249.9
New York 19,134,293 4,139,898 216.4
North Carolina 8,305,820 1,389,455 167.3
North Dakota 636,911 71,619 112.4
Ohio 11,408,699 1,754,379 153.8
Oklahoma 3,489,700 677,788 194.2
Oregon 3,520,355 637,140 181.0
Pennsylvania 12,328,827 1,710,999 138.8
Rhode Island 1,068,326 204,789 191.7
South Carolina 4,103,770 895,863 218.3
South Dakota 760,437 113,925 149.8
Tennessee 5,789,796 1,700,384 293.7
Texas 21,736,925 3,202,171 147.3
Utah 2,318,789 233,156 100.6
Vermont 616,408 156,958 254.6
Virginia 7,287,829 727,784 99.9
Washington 6,067,060 1,104,813 182.1
West Virginia 1,804,884 362,264 200.7
Wisconsin 5,439,692 776,638 142.8
Wyoming 498,830 69,802 139.9
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.

Source: U.S. Department of Commerce, Bureau of the Census, Population Estimates, December 18, 2003; CMS, MSIS Report,
FY 2002.

2-16
National Pharmaceutical Council Pharmaceutical Benefits 2004

Total Net U.S. Medical Assistance Expenditures


by Type of Service, FY 2002 & FY 2003

Percent Percent Percent


Service FY 2003 FY 2002
of Total of Total Change

Inpatient Acute Care Hospital $45,839,127,080 17.6% $43,690,502,629 17.8% 4.9%

Nursing Facility $44,345,682,144 17.1% $47,466,264,432 19.3% -6.6%

Pharmaceuticals $33,794,520,738 13.0% $29,339,050,970 11.9% 15.2%

HCBS Waivers $19,302,698,045 7.4% $17,169,137,673 7.0% 12.4%

ICF-Mentally Retarded $11,614,424,195 4.5% $11,205,483,449 4.6% 3.6%

Hospital Outpatient $9,394,646,018 3.6% $9,245,799,624 3.8% 1.6%

Personal Care Services $7,881,552,380 3.0% $6,037,450,986 2.5% 30.5%

Physicians $7,863,653,436 3.0% $7,559,242,098 3.1% 4.0%

Clinic* $7,582,867,230 2.9% $7,499,886,627 3.1% 1.1%

Inpatient Mental Health Hospital $7,299,165,193 2.8% $7,446,842,170 3.0% -2.0%

Dental $3,015,702,590 1.2% $2,630,870,620 1.1% 14.6%

Home Health Care $2,886,980,643 1.1% $2,766,480,497 1.1% 4.4%

Other Practitioners $1,438,109,885 0.6% $1,413,870,565 0.6% 1.7%

EPSDT $1,079,836,415 0.4% $1,007,637,056 0.4% 7.2%

Lab/X-ray $856,521,207 0.3% $781,820,930 0.3% 9.6%

Other** $55,700,409,296 21.4% $50,437,280,350 20.5% 10.4%

Total Expenditures $259,895,896,495 100% ‡ $245,697,620,676 100% ‡ 5.8%


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

Source: CMS, CMS-64 Report, FY 2002 and FY 2003.

2-17
National Pharmaceutical Council Pharmaceutical Benefits 2004

Federal Medical Assistance Percentage (FMAP),


FY 2005 and FY 2006
2006
2005 Enhanced Enhanced
State 2005 FMAP FMAP* 2006 FMAP FMAP*
Alabama 70.83% 79.58% 69.51% 78.66%
Alaska** 57.58% 70.31% 50.16% 65.11%
Arizona 67.45% 77.22% 66.98% 76.89%
Arkansas 74.75% 82.33% 73.77% 81.64%
California 50.00% 65.00% 50.00% 65.00%
Colorado 50.00% 65.00% 50.00% 65.00%
Connecticut 50.00% 65.00% 50.00% 65.00%
Delaware 50.38% 65.27% 50.09% 65.06%
District of Columbia** 70.00% 79.00% 70.00% 79.00%
Florida 58.90% 71.23% 58.89% 71.22%
Georgia 60.44% 72.31% 60.00% 72.42%
Hawaii 58.47% 70.93% 58.81% 71.17%
Idaho 70.62% 79.43% 69.91% 78.94%
Illinois 50.00% 65.00% 50.00% 65.00%
Indiana 62.78% 73.95% 62.98% 74.09%
Iowa 63.55% 74.49% 63.61% 74.53%
Kansas 61.01% 72.71% 60.41% 72.29%
Kentucky 69.60% 78.72% 69.26% 78.48%
Louisiana 71.04% 79.73% 69.79% 78.85%
Maine 64.89% 75.42% 62.90% 74.03%
Maryland 50.00% 65.00% 50.00% 65.00%
Massachusetts 50.00% 65.00% 50.00% 65.00%
Michigan 56.71% 69.70% 56.59% 69.61%
Minnesota 50.00% 65.00% 50.00% 65.00%
Mississippi 77.08% 83.96% 76.00% 83.20%
Missouri 61.15% 72.81% 61.93% 73.35%
Montana 71.90% 80.33% 70.54% 79.38%
Nebraska 59.64% 71.75% 59.68% 71.78%
Nevada 55.90% 69.13% 54.76% 68.33%
New Hampshire 50.00% 65.00% 50.00% 65.00%
New Jersey 50.00% 65.00% 50.00% 65.00%
New Mexico 74.30% 82.01% 71.15% 79.81%
New York 50.00% 65.00% 50.00% 65.00%
North Carolina 63.63% 74.54% 63.49% 74.44%
North Dakota 67.49% 77.24% 65.85% 76.10%
Ohio 59.68% 71.78% 59.88% 71.92%
Oklahoma 70.18% 79.13% 67.91% 77.54%
Oregon 61.12% 72.78% 61.57% 73.10%
Pennsylvania 53.84% 67.69% 55.05% 68.54%
Rhode Island 55.38% 68.77% 54.45% 68.12%
South Carolina 69.89% 78.92% 69.32% 78.52%
South Dakota 66.03% 76.22% 65.07% 75.55%
Tennessee 64.81% 75.37% 63.99% 74.79%
Texas 60.87% 72.61% 60.66% 72.46%
Utah 72.14% 80.50% 70.76% 79.53%
Vermont 60.11% 72.08% 58.49% 70.94%
Virginia 50.00% 65.00% 50.00% 65.00%
Washington 50.00% 65.00% 50.00% 65.00%
West Virginia 74.65% 82.26% 72.99% 81.09%
Wisconsin 58.32% 70.82% 51.65% 70.36%
Wyoming 57.90% 70.53% 54.23% 67.96%
* The “Enhanced Federal Medical Assistance Percentages” are for use in State Children’s Health Insurance Program under Title XXI, and for some or all
of children’s medical assistance under Medicaid sections 1905(u)(2) and 1905(u)(3).
** The values for Alaska and the District of Columbia were set for the State Plan under Titles XIX and XXI and for capitation payments and DSH
allotments under those titles. For other purposes, including programs remaining in Title IV of the Act, the percentage for Alaska is 53.23% and for the
District of Columbia is 50.00%.
Source: Federal Register, December 3, 2003, Vol. 68, No. 232, pages 67676-67678 and November 24, 2004, Vol. 69, No. 226, pages 68370–68373.

2-18
National Pharmaceutical Council Pharmaceutical Benefits 2004

Medicaid Total Net Expenditures and Eligibles, 2002

Total Net Medical Total Average


1
State Assistance Expenditures Eligibles Per Eligible
National Total $245,697,620,676 51,552,491 $4,766
Alabama $3,093,270,640 845,125 $3,660
Alaska $685,772,985 121,400 $5,649
Arizona $3,541,598,721 1,053,602 $3,361
Arkansas $2,237,817,554 608,017 $3,681
California $26,890,540,967 9,336,447 $2,880
Colorado $2,323,068,699 438,670 $5,296
Connecticut $3,456,338,545 487,989 $7,083
Delaware $634,046,351 147,197 $4,307
District of Columbia $1,021,772,693 204,591 $4,994
Florida $9,871,508,234 2,691,502 $3,668
Georgia $6,241,211,454 1,459,631 $4,276
Hawaii $740,007,314 195,684 $3,782
Idaho $773,534,776 196,406 $3,938
Illinois $8,809,060,004 2,076,146 $4,243
Indiana $4,448,318,143 881,942 $5,044
Iowa $2,575,146,342 358,708 $7,179
Kansas $1,836,717,196 305,110 $6,020
Kentucky $3,763,204,047 769,826 $4,888
Louisiana $4,885,971,853 990,286 $4,934
Maine $1,430,109,134 346,449 $4,128
Maryland $3,613,476,100 752,065 $4,805
Massachusetts $8,063,005,258 1,204,312 $6,695
Michigan $7,562,053,407 1,527,627 $4,950
Minnesota $4,414,511,470 680,627 $6,486
Mississippi $2,877,013,521 707,986 $4,064
Missouri $5,360,607,640 1,098,525 $4,880
Montana $571,456,455 106,229 $5,379
Nebraska $1,339,132,070 266,245 $5,030
Nevada $808,198,344 203,251 $3,976
New Hampshire $1,016,094,814 115,517 $8,796
New Jersey $7,745,877,997 982,676 $7,882
New Mexico $1,776,811,688 462,878 $3,839
New York $36,295,107,368 4,139,898 $8,767
North Carolina $6,723,598,560 1,389,455 $4,839
North Dakota $461,401,546 71,619 $6,442
Ohio $9,658,040,587 1,754,379 $5,505
Oklahoma $2,260,403,490 677,788 $3,335
Oregon $2,571,560,664 637,140 $4,036
Pennsylvania $12,130,925,035 1,710,999 $7,090
Rhode Island $1,358,500,649 204,789 $6,634
South Carolina $3,292,901,444 895,863 $3,676
South Dakota $549,884,391 113,925 $4,827
Tennessee $5,787,079,096 1,700,384 $3,403
Texas $13,523,486,149 3,202,171 $4,223
Utah $984,160,785 233,156 $4,221
Vermont $660,731,979 156,958 $4,210
Virginia $3,812,166,436 727,784 $5,238
Washington $5,168,511,470 1,104,813 $4,678
West Virginia $1,584,166,286 362,264 $4,373
Wisconsin $4,193,175,197 776,638 $5,399
Wyoming $274,565,128 69,802 $3,933
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.

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

2-19
National Pharmaceutical Council Pharmaceutical Benefits 2004

Total Medicaid Program Expenditures, 2003

Total Net Medical Administrative Total Program


State Assistance Expenditures Expenditures Expenditures
National Total $259,895,896,495 $13,046,737,079 $272,942,633,574
Alabama $3,477,832,931 $127,998,912 $3,605,831,843
Alaska $563,428,717 $46,999,870 $610,428,587
Arizona $4,219,253,105 $206,926,196 $4,426,179,301
Arkansas $2,329,593,600 $111,158,811 $2,440,752,411
California $30,051,769,056 $2,056,182,686 $32,107,951,742
Colorado $2,552,159,860 $111,002,758 $2,663,162,618
Connecticut $3,506,583,946 $103,831,118 $3,610,415,064
Delaware $718,470,271 $46,279,569 $764,749,840
District of Columbia $1,076,136,978 $75,714,431 $1,151,851,409
Florida $10,946,214,986 $548,942,130 $11,495,157,116
Georgia $6,300,856,479 $380,246,357 $6,681,102,836
Hawaii $766,109,972 $69,711,658 $835,821,630
Idaho $809,931,820 $68,634,984 $878,566,804
Illinois $9,253,097,164 $695,015,816 $9,948,112,980
Indiana $4,282,435,701 $203,536,402 $4,485,972,103
Iowa $2,136,386,901 $82,657,277 $2,219,044,178
Kansas $1,764,536,608 $90,446,401 $1,854,983,009
Kentucky $3,697,230,708 $106,527,424 $3,803,758,132
Louisiana $4,423,174,011 $161,791,590 $4,584,965,601
Maine $1,747,306,187 $79,401,252 $1,826,707,439
Maryland $4,343,054,613 $294,904,663 $4,637,959,276
Massachusetts $7,680,882,159 $365,645,374 $8,046,527,533
Michigan $7,967,828,590 $498,571,420 $8,466,400,010
Minnesota $3,604,575,049 $211,870,042 $3,816,445,091
Mississippi $2,853,086,305 $94,898,736 $2,947,985,041
Missouri $5,541,604,705 $253,735,879 $5,795,340,584
Montana $511,474,712 $30,195,882 $541,670,594
Nebraska $1,325,133,485 $71,664,220 $1,396,797,705
Nevada $1,015,796,455 $67,798,693 $1,083,595,148
New Hampshire $916,422,038 $62,874,759 $979,296,797
New Jersey $7,858,368,246 $515,324,283 $8,373,692,529
New Mexico $2,006,492,205 $67,963,008 $2,074,455,213
New York $39,585,134,508 $874,715,468 $40,459,849,976
North Carolina $7,050,804,888 $301,214,843 $7,352,019,731
North Dakota $468,522,734 $21,101,570 $489,624,304
Ohio $10,177,517,569 $360,355,327 $10,537,872,896
Oklahoma $2,311,939,159 $168,986,258 $2,480,925,417
Oregon $2,678,357,318 $241,943,386 $2,920,300,704
Pennsylvania $12,772,008,268 $625,292,638 $13,397,300,906
Rhode Island $1,436,618,006 $80,854,110 $1,517,472,116
South Carolina $3,540,107,364 $136,496,403 $3,676,603,767
South Dakota $536,195,894 $17,468,705 $553,664,599
Tennessee $6,348,262,631 $523,172,782 $6,871,435,413
Texas $15,420,026,696 $749,960,111 $16,169,986,807
Utah $1,092,519,199 $79,037,866 $1,171,557,065
Vermont $705,028,688 $63,031,099 $768,059,787
Virginia $3,524,849,814 $226,683,382 $3,751,533,196
Washington $5,006,473,801 $459,002,964 $5,465,476,765
West Virginia $1,857,747,927 $88,915,675 $1,946,663,602
Wisconsin $4,799,267,070 $94,223,622 $4,893,490,692
Wyoming $337,284,398 $25,828,269 $363,112,667
Source: CMS, CMS-64 Report, FY 2003.

2-20
National Pharmaceutical Council Pharmaceutical Benefits 2004

Total SCHIP Enrollment, 2003*


Medicaid SCHIP Non-Medicaid SCHIP Total SCHIP Adults Enrolled in SCHIP
State Enrollment Enrollment Enrollment Demonstrations
National Total 1,503,775 4,370,484 5,874,259 483,728
Alabama - 78,554 78,554 -
Alaska 22,934 - 22,934 -
Arizona - 90,491 90,468 98,431
Arkansas - - - -
California 99,366 855,786 955,152 -
Colorado - 74,144 74,144 1,423
Connecticut - 20,971 20,971 -
Delaware 159 9,744 9,903 -
District of Columbia 5,875 - 5,875 -
Florida 2,188 440,989 443,177 -
Georgia - 251,711 251,711 -
Hawaii 12,022 - 12,022 -
Idaho 16,877 - 16,877 -
Illinois 81,692 53,917 135,609 70,773
Indiana 51,587 22,175 73,762 -
Iowa 14,001 23,059 37,060 -
Kansas - 45,662 45,662 -
Kentucky 57,553 34,275 94,053 -
Louisiana 104,908 - 104,908 -
Maine 19,280 10,194 29,474 -
Maryland 122,229 7,932 130,161 -
Massachusetts 85,104 43,686 128,790 -
Michigan 26,391 51,076 77,467 -
Minnesota 48 NR 48 41,317
Mississippi - 75,010 75,010 -
Missouri 150,954 - 150,954 -
Montana - 13,084 13,084 -
Nebraska 45,490 - 45,490 -
Nevada - 47,183 47,183 -
New Hampshire 517 9,376 9,893 -
New Jersey 40,414 78,858 119,272 123,716
New Mexico 18,841 - 18,841 -
New York NR 795,111 795,111 -
North Carolina - 150,444 150,444 -
North Dakota 1,773 3,180 4,953 -
Ohio 207,854 - 207,854 -
Oklahoma 91,914 - 91,914 -
Oregon - 44,752 44,752 2,129
Pennsylvania - 160,015 160,015 -
Rhode Island 22,893 1,612 24,505 22,044
South Carolina 90,764 - 90,764 -
South Dakota 9,529 2,759 12,288 -
Tennessee - - - -
Texas - 726,428 726,428 -
Utah - 37,766 37,766 -
Vermont - 6,467 6,467 -
Virginia 30,616 53,100 83,716 -
Washington - 9,571 9,571 -
West Virginia - 35,320 35,320 -
Wisconsin 68,641 - 68,641 123,895
Wyoming - 5,241 5,241 -

*The data displayed in this table were compiled from the CMS website at http://www.cms.hhs.gov/schip/enrollment/schip03.pdf.
Column and row values do not always sum to totals.
NR- State has not reported data via the Statistical Enrollment Data System (SEDS).
Source: CMS, SCHIP Enrollment Report, August 5, 2004.

2-21
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Total SCHIP Expenditures, 2003

Medicaid SCHIP Non-Medicaid SCHIP Total SCHIP


State Expenditures Expenditures Expenditures
National Total $1,485,602,154 $4,553,214,312 $6,038,816,466
Alabama $150,501 $89,648,415 $89,798,916
Alaska $31,134,733 $2,712,687 $33,847,420
Arizona $0 $242,147,701 $242,147,701
Arkansas $36,903,302 $3,450,290 $40,353,592
California $53,141,395 $816,155,723 $869,297,118
Colorado $0 $62,458,057 $62,458,057
Connecticut $48,883 $26,708,904 $26,757,787
Delaware $248,572 $6,834,859 $7,083,431
District of Columbia $7,499,314 $117,097 $7,616,411
Florida $81,965,839 $420,667,742 $502,633,581
Georgia $0 $250,756,400 $250,756,400
Hawaii $9,892,694 $280,288 $10,172,982
Idaho $14,386,996 $871,565 $15,258,561
Illinois $43,386,825 $47,932,135 $91,318,960
Indiana $63,114,262 $20,952,924 $84,067,186
Iowa $16,301,477 $27,868,966 $44,170,443
Kansas $0 $51,147,118 $51,147,118
Kentucky $56,334,856 $31,383,334 $87,718,190
Louisiana $92,640,822 $5,431,165 $98,071,987
Maine $16,771,385 $10,828,951 $27,600,336
Maryland $190,811,878 $21,020,162 $211,832,040
Massachusetts $86,316,863 $24,583,525 $110,900,388
Michigan $25,992,200 $62,429,891 $88,422,091
Minnesota $0 $98,837,468 $98,837,468
Mississippi $16,595 $106,051,546 $106,068,141
Missouri $95,388,625 $2,840,651 $98,229,276
Montana $0 $14,854,662 $14,854,662
Nebraska $34,045,772 $871,781 $34,917,553
Nevada $0 $33,446,385 $33,446,385
New Hampshire $400,083 $6,070,794 $6,470,877
New Jersey $44,419,989 $359,565,535 $403,985,524
New Mexico $20,793,527 $1,362,438 $22,155,965
New York $82,448,115 $459,337,745 $541,785,860
North Carolina $0 $177,136,298 $177,136,298
North Dakota $3,016,734 $3,535,216 $6,551,950
Ohio $188,302,322 $6,305,620 $194,607,942
Oklahoma $47,612,740 $660,522 $48,273,262
Oregon $0 $27,505,941 $27,505,941
Pennsylvania $0 $176,193,192 $176,193,192
Rhode Island $24,779,497 $31,490,573 $56,270,070
South Carolina $52,274,653 $4,647,136 $56,921,789
South Dakota $8,289,917 $3,785,231 $12,075,148
Tennessee $0 $0 $0
Texas $452,389 $563,044,186 $563,496,575
Utah $0 $25,145,487 $25,145,487
Vermont $0 $4,042,623 $4,042,623
Virginia $21,674,120 $56,729,935 $78,404,055
Washington $0 $24,851,674 $24,851,674
West Virginia $0 $32,668,647 $32,668,647
Wisconsin $33,377,550 $100,484,536 $133,862,086
Wyoming $0 $5,360,591 $5,360,591
Source: CMS, CMS-64 Report, 2003.

2-22
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Total Medicaid/Medicare Dual Eligibles by Dual Eligibility Type, 20021

Not a QMB/
State All Eligibles Dual Eligible QMB Only Medicaid SLMB Only
National Total 51,552,491 40,008,697 461,055 3,946,067 319,072
Alabama 845,125 627,146 24,763 91,387 22,661
Alaska 121,400 99,842 5 7,852 119
Arizona 1,053,602 891,673 918 52,667 114
Arkansas 608,017 421,744 18,403 96,042 2,907
California 9,336,447 7,523,677 7,008 764,249 3,122
Colorado 438,670 336,155 6,320 41,897 3,476
Connecticut 487,989 376,168 6,209 45,416 3,443
Delaware 147,197 118,672 3,935 5,658 3,242
District of Columbia 204,591 173,783 87 11,381 860
Florida 2,691,502 2,072,192 21,989 280,205 19,242
Georgia 1,459,631 1,163,783 50,127 0 46
Hawaii 195,684 156,830 107 21,515 1,262
Idaho 196,406 171,732 2,809 10,706 0
Illinois 2,076,146 1,581,719 10,717 125,373 2,311
Indiana 881,942 706,225 8,787 61,139 5,842
Iowa 358,708 257,128 4,533 29,288 3,574
Kansas 305,110 227,750 4,191 25,299 2,366
Kentucky 769,826 549,992 24,944 83,171 10,805
Louisiana 990,286 787,181 24,420 101,528 12,220
Maine 346,449 242,436 2,524 31,984 5,013
Maryland 752,065 612,534 13,750 53,339 5,475
Massachusetts 1,204,312 887,127 184 67,784 14,098
Michigan 1,527,627 1,217,506 552 78,539 12,687
Minnesota 680,627 504,862 1,705 58,945 6,072
Mississippi 707,986 523,298 603 140,540 1,512
Missouri 1,098,525 899,710 9,149 58,471 4,953
Montana 106,229 78,459 394 10,236 603
Nebraska 266,245 215,554 0 22,551 2,305
Nevada 203,251 150,778 7,223 18,404 5,670
New Hampshire 115,517 90,356 1,838 17,973 0
New Jersey 982,676 715,363 0 111,678 20,333
New Mexico 462,878 408,518 10,191 4,404 0
New York 4,139,898 2,963,226 2,007 224,938 0
North Carolina 1,389,455 1,004,720 720 194,145 27,374
North Dakota 71,619 51,954 724 1,431 598
Ohio 1,754,379 1,450,281 29,749 0 0
Oklahoma 677,788 495,758 22 82,863 8,308
Oregon 637,140 476,725 4,571 29,713 8,937
Pennsylvania 1,710,999 1,294,399 520 205,913 18,831
Rhode Island 204,789 158,661 221 18,337 1,138
South Carolina 895,863 756,869 0 78,482 17
South Dakota 113,925 88,716 2,370 3,010 1,171
Tennessee 1,700,384 1,322,117 36,052 54,344 21,870
Texas 3,202,171 2,471,405 57,996 280,680 30,912
Utah 233,156 194,965 1,084 8,481 492
Vermont 156,958 120,711 159 9,750 361
Virginia 727,784 524,983 32,289 73,502 13,000
Washington 1,104,813 936,178 8,113 76,956 6,089
West Virginia 362,264 286,111 12,924 0 0
Wisconsin 776,638 565,889 1,686 71,103 2,979
Wyoming 69,802 55,136 1,463 2,798 662
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.
QMB Only = Qualified Medicare Beneficiaries Without Other Medicaid
QMB/ Medicaid = QMBs With Full Medicaid
SLMB Only = Specified Low-Income Beneficiaries Without Other Medicaid
SLMB/Medicaid = SLMBs with full Medicaid
QDWI = Qualified Disabled and Working Individuals
QI 1 = Qualifying Individuals (1)
QI 2 = Qualifying Individuals (2)
Other = Other Dual Eligibles, Dual Category Unknown, and Dual Status Unknown
Source: CMS, MSIS Report, FY 2002.

2-23
National Pharmaceutical Council Pharmaceutical Benefits 2004

Total Medicaid/Medicare Dual Eligibles by Dual Eligibility Type, 2002. (Con’t)1

SLMB/
State Medicaid QDWI QI(1) QI(2) Other
National Total 284,793 3,961 136,263 45,553 6,347,030
Alabama 9,952 0 2,897 62 66,257
Alaska 0 0 0 0 13,582
Arizona 0 0 31 43 108,156
Arkansas 0 3,881 0 0 65,040
California 113,100 4 1,714 1,532 922,041
Colorado 3 1 1,556 767 48,495
Connecticut 6,160 0 4,116 0 46,477
Delaware 0 0 23 0 15,667
District of Columbia 0 0 261 237 17,982
Florida 37,316 0 22,385 0 238,173
Georgia 0 0 0 0 245,675
Hawaii 0 0 0 0 15,970
Idaho 0 0 0 0 11,159
Illinois 17,643 0 10,360 0 328,023
Indiana 14,933 3 3,235 3,278 78,500
Iowa 6,464 0 1,817 1,019 54,885
Kansas 210 0 852 34 44,408
Kentucky 4,315 0 3,979 1,225 91,395
Louisiana 446 0 6,214 4,267 54,010
Maine 1,899 51 1,464 693 60,385
Maryland 0 0 1,833 1,192 63,942
Massachusetts 0 0 2,915 3,267 228,937
Michigan 0 6 5,506 5,628 207,203
Minnesota 10,521 0 2,243 0 96,279
Mississippi 0 0 0 2,840 39,193
Missouri 8,260 0 290 533 117,159
Montana 1,698 0 0 0 14,839
Nebraska 0 0 0 0 25,835
Nevada 0 0 0 0 21,176
New Hampshire 0 0 0 0 5,350
New Jersey 0 0 8,334 0 126,968
New Mexico 0 0 0 0 39,765
New York 0 0 0 0 949,727
North Carolina 5,547 0 12,133 0 144,816
North Dakota 337 0 270 77 16,228
Ohio 0 0 0 0 274,349
Oklahoma 4,688 0 0 0 86,149
Oregon 4 0 4,871 4,647 107,672
Pennsylvania 13,066 0 11,249 4,496 162,525
Rhode Island 0 0 653 564 25,215
South Carolina 0 0 6 2 60,487
South Dakota 934 0 514 152 17,058
Tennessee 0 0 0 0 266,001
Texas 8,073 0 15,658 5,381 332,066
Utah 0 0 223 146 27,765
Vermont 5,266 0 12 0 20,699
Virginia 0 14 4,644 3,218 76,134
Washington 1,923 0 2,700 0 72,854
West Virginia 0 0 0 0 63,229
Wisconsin 8,477 1 969 135 125,399
Wyoming 3,558 0 336 118 5,731
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.
QMB Only = Qualified Medicare Beneficiaries Without Other Medicaid
QMB/ Medicaid = QMBs With Full Medicaid
SLMB Only = Specified Low-Income Beneficiaries Without Other Medicaid
SLMB/Medicaid = SLMBs with full Medicaid
QDWI = Qualified Disabled and Working Individuals
QI 1 = Qualifying Individuals (1)
QI 2 = Qualifying Individuals (2)
Other = Other Dual Eligibles, Dual Category Unknown, and Dual Status Unknown
Source: CMS, MSIS Report, FY 2002.

2-24
National Pharmaceutical Council Pharmaceutical Benefits 2004

Total Medicaid Medical Vendor Payments and Dual Eligibility Status, 20021

Not a QMB/
State All Eligibles Dual Eligible QMB Only Medicaid SLMB Only
National Total $213,491,313,278 $106,490,928,726 $1,030,874,920 $42,127,217,095 $380,179,278
Alabama $3,204,063,602 $1,274,232,277 $15,621,507 $776,780,560 $1,742,014
Alaska $686,795,186 $453,075,715 $2,393 $115,089,861 $42,590
Arizona $2,881,870,077 $1,948,997,686 $1,060,033 $434,460,779 $370,784
Arkansas $2,015,436,554 $883,682,774 $33,136,737 $982,685,560 $876,861
California $23,636,239,505 $13,213,780,910 $17,194,733 $5,372,345,733 $8,953,869
Colorado $2,166,199,614 $1,025,390,092 $2,726,907 $539,103,641 $378,910
Connecticut $3,245,142,644 $1,175,956,667 $4,499,349 $1,158,720,879 $932,196
Delaware $651,384,655 $376,621,212 $5,282,458 $96,699,451 $710,727
District of
Columbia $1,027,022,357 $628,363,371 $31,210 $145,262,877 $391,722
Florida $9,827,003,688 $4,874,067,948 $70,370,898 $1,572,827,572 $1,914,956
Georgia $4,796,005,361 $2,604,578,450 $75,123,488 $0 $481,290
Hawaii $695,279,178 $350,981,489 $98,371 $170,361,874 $438,832
Idaho $791,863,699 $574,360,327 $2,988,527 $155,399,823 $0
Illinois $9,121,713,188 $4,462,411,533 $8,884,937 $1,663,359,310 $150,684
Indiana $3,725,257,965 $1,828,126,131 $4,655,964 $965,283,909 $770,567
Iowa $1,855,817,441 $849,122,634 $4,851,165 $514,241,421 $1,118,401
Kansas $1,501,270,019 $641,032,282 $2,589,548 $442,607,105 $623,360
Kentucky $3,459,365,581 $2,024,455,125 $30,181,481 $837,839,353 $5,423,430
Louisiana $3,234,421,939 $1,818,732,605 $15,725,714 $1,129,348,514 $1,891,563
Maine $1,716,581,955 $1,007,751,695 $2,241,357 $402,060,123 $4,571,138
Maryland $3,662,089,984 $2,174,249,468 $42,413,617 $561,303,632 $7,178,292
Massachusetts $6,387,100,271 $2,842,987,095 $1,119,363 $1,276,162,774 $13,833,824
Michigan $5,918,817,382 $2,383,042,311 $239,353 $324,807,789 $12,825,261
Minnesota $4,439,493,794 $1,971,803,574 $1,834,826 $1,269,281,520 $1,576,820
Mississippi $2,499,640,805 $1,244,615,576 $460,562 $1,115,192,344 $529,391
Missouri $4,071,544,403 $2,116,935,133 $13,187,461 $722,404,739 $1,793,555
Montana $532,886,400 $267,585,800 $95,329 $121,091,801 $1,823
Nebraska $1,255,039,718 $597,240,859 $0 $203,777,475 $830,507
Nevada $723,956,752 $393,365,477 $4,139,667 $205,892,296 $1,351,254
New
Hampshire $745,754,084 $322,552,211 $5,726,610 $393,680,976 $0
New Jersey $5,497,284,438 $2,463,309,859 $0 $2,200,468,218 $21,904,790
New Mexico $1,796,901,383 $270,634,581 $2,669,257 $26,751,670 $0
New York $31,488,930,244 $14,675,424,270 $283,178 $4,530,472,744 $0
North
Carolina $6,041,011,008 $3,069,848,793 $476,113 $1,956,224,103 $11,998,085
North Dakota $422,745,114 $141,026,852 $527,092 $11,637,757 $70,489
Ohio $9,186,330,669 $4,505,534,072 $53,754,743 $0 $0
Oklahoma $2,238,213,087 $1,000,843,567 $1,581 $866,098,451 $1,100,816
Oregon $2,136,400,869 $1,197,343,350 $2,454,895 $331,546,311 $104,945,182
Pennsylvania $8,523,928,057 $4,394,947,388 $180,299 $2,006,722,671 $5,704,980
Rhode Island $1,251,440,036 $618,547,690 $29,133 $197,393,826 $650,916
South
Carolina $3,382,950,504 $1,596,815,267 $0 $633,188,504 $332
South Dakota $503,947,234 $245,685,676 $2,324,910 $86,640,920 $486,079
Tennessee $4,747,549,898 $2,989,461,147 $423,736,615 $193,006,651 $148,528,283
Texas $11,121,020,040 $6,226,003,393 $13,230,318 $2,572,622,555 $2,739,277
Utah $1,215,620,497 $597,811,407 $20,665,614 $148,327,002 $617,489
Vermont $607,249,969 $345,763,875 $326,101 $80,741,638 $810,752
Virginia $3,017,869,649 $1,491,183,939 $97,494,303 $840,368,767 $3,077,319
Washington $4,373,171,467 $1,866,732,897 $11,597,264 $725,557,952 $4,353,706
West Virginia $1,577,697,829 $809,141,082 $32,163,017 $0 $0
Wisconsin $3,605,541,906 $1,518,334,992 $1,330,865 $1,025,297,993 $1,423,172
Wyoming $280,451,579 $136,436,202 $1,146,057 $26,025,571 $62,990
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.
QMB Only = Qualified Medicare Beneficiaries Without Other Medicaid
QMB/ Medicaid = QMBs With Full Medicaid
SLMB Only = Specified Low-Income Beneficiaries Without Other Medicaid
SLMB/Medicaid = SLMBs with full Medicaid
QDWI = Qualified Disabled and Working Individuals
QI 1 = Qualifying Individuals (1)
QI 2 = Qualifying Individuals (2)
Other = Other Dual Eligibles, Dual Category Unknown, and Dual Status Unknown
Source: CMS, MSIS Report, FY 2002
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National Pharmaceutical Council Pharmaceutical Benefits 2004

Total Medicaid Medical Vendor Payments and Dual Eligibility Status, 2002 (Con’t)1

SLMB/
State Medicaid QDWI QI (1) QI (2) Other
National Total $3,559,380,313 $735,149 $178,350,688 $74,882,766 $59,648,764,343
Alabama $112,567,502 $0 $513,112 $92,115 $1,022,514,515
Alaska $0 $0 $0 $0 $118,584,627
Arizona $0 $0 $84,004 $243,720 $496,653,071
Arkansas $0 $672,119 $0 $0 $114,382,503
California $745,947,070 $4,165 $1,162,676 $566,590 $4,276,283,759
Colorado $142 $0 $146,264 $68,737 $598,384,921
Connecticut $197,571,333 $0 $411,137 $0 $707,051,083
Delaware $0 $0 $333,000 $0 $171,737,807
District of Columbia $0 $0 $85,870 $206,988 $252,680,319
Florida $123,645,804 $0 $20,102,739 $0 $3,164,073,771
Georgia $0 $0 $0 $0 $2,115,822,133
Hawaii $0 $0 $0 $0 $173,398,612
Idaho $0 $0 $0 $0 $59,115,022
Illinois $296,069,746 $0 $63,709,153 $0 $2,627,127,825
Indiana $263,277,503 $0 $608,687 $847,483 $661,687,721
Iowa $115,732,538 $0 $615,501 $498,436 $369,637,345
Kansas $1,482,507 $0 $126,091 $0 $412,809,126
Kentucky $105,575,625 $0 $1,404,720 $323,582 $454,162,265
Louisiana $5,298,239 $0 $769,228 $665,812 $261,990,264
Maine $26,664,799 $42,650 $1,479,128 $829,750 $270,941,315
Maryland $0 $0 $676,428 $943,460 $875,325,087
Massachusetts $0 $0 $708,782 $592,059 $2,251,696,374
Michigan $0 $9,474 $5,622,730 $6,009,856 $3,186,260,608
Minnesota $228,125,144 $0 $651,618 $0 $966,220,292
Mississippi $0 $0 $0 $1,279,733 $137,563,199
Missouri $109,503,184 $0 $164,581 $159,402 $1,107,396,348
Montana $23,213,856 $0 $0 $0 $120,897,791
Nebraska $0 $0 $0 $0 $453,190,877
Nevada $0 $0 $0 $0 $119,208,058
New Hampshire $0 $0 $0 $0 $23,794,287
New Jersey $0 $0 $10,312,558 $0 $801,289,013
New Mexico $0 $0 $0 $0 $1,496,845,875
New York $0 $0 $0 $0 $12,282,750,052
North Carolina $145,924,080 $0 $4,503,365 $0 $852,036,469
North Dakota $2,172,957 $0 $28,265 $3,604 $267,278,098
Ohio $0 $0 $0 $0 $4,627,041,854
Oklahoma $80,888,878 $0 $0 $0 $289,279,794
Oregon $20,304 $0 $57,550,344 $58,249,186 $384,291,297
Pennsylvania $418,438,234 $0 $2,601,815 $1,411,225 $1,693,921,445
Rhode Island $0 $0 $121,993 $246,581 $434,449,897
South Carolina $0 $0 $0 $0 $1,152,946,401
South Dakota $22,512,693 $0 $482,607 $95,771 $145,718,578
Tennessee $0 $0 $0 $0 $992,817,202
Texas $150,439,855 $0 $971,338 $0 $2,155,013,304
Utah $0 $0 $158,160 $162,856 $447,877,969
Vermont $129,875,293 $0 $33,049 $0 $49,699,261
Virginia $0 $6,741 $1,129,860 $1,371,915 $583,236,805
Washington $9,357,997 $0 $879,661 $0 $1,754,691,990
West Virginia $0 $0 $0 $0 $736,393,730
Wisconsin $150,448,240 $0 $193,214 $7,787 $908,505,643
Wyoming $94,626,790 $0 $9,010 $6,118 $22,088,741
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.
QMB Only = Qualified Medicare Beneficiaries Without Other Medicaid
QMB/ Medicaid = QMBs With Full Medicaid
SLMB Only = Specified Low-Income Beneficiaries Without Other Medicaid
SLMB/Medicaid = SLMBs with full Medicaid
QDWI = Qualified Disabled and Working Individuals
QI 1 = Qualifying Individuals (1)
QI 2 = Qualifying Individuals (2)
Other = Other Dual Eligibles, Dual Category Unknown, and Dual Status Unknown
Source: CMS, MSIS Report, FY 2002

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MEDICAID MANAGED CARE ENROLLMENT


Since 1981, when Congress authorized States to implement Section 1915(b) and Section 1115
Medicaid waivers to increase access to managed care and test innovative health care financing and
delivery options, enrollment in Medicaid managed care has grown considerably, although the trend
appears to be leveling off. Since 1993, managed care enrollment has increased from 14.4% to 60.7%
of total Medicaid enrollment. In 2004, 60.7% of all Medicaid beneficiaries were enrolled in some
type of managed care program. As of June 30, 2004, all but three States (Alaska, Mississippi, New
Hampshire and Wyoming) were enrolling Medicaid beneficiaries in some type of managed care plan.

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

100%

80% 52.2% 46.4% 44.4% 44.2% 43.2% 42.4% 40.9% 39.3%


59.9%
70.6%
60% 76.8%
85.6%

40%
55.6% 55.8% 56.8% 57.6% 59.1% 60.7%
47.8% 53.6%
20% 29.4%
40.1%
23.2%
14.4%
0%
19 9 3 19 9 4 19 9 5 19 9 6 19 9 7 19 9 8 19 9 9 2000 2001 2002 2003 2004

Managed Care Fee for Service

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2004. DHHS, CMS, Center for Medicaid
& State Operations. *Approximated numbers for 1995. Total Medicaid population was provided by the Office of the Actuary,
which used CMS 2082 data to calculate average Medicaid enrollees over 1995. The managed care population differs from the
11,619,929 reported in the 1995 report as the number represented enrollment of some beneficiaries in more than one plan.

TYPES OF MEDICAID MANAGED CARE PLANS

Medicaid managed care beneficiaries can be enrolled in one of five basic Medicaid managed care
plans:

• Health Insuring Organization (HIO): an entity that provides for or arranges for the
provision of care and contracts on a prepaid capitated risk basis to provide a
comprehensive set of services.
• Commercial Managed Care Organization (Com-MCO): a Com-MCO is a health
maintenance organization with a contract under §1876 or a Medicare+Choice
organization, a provider sponsored organization or any other private or public
organization, which meets the requirements of §1902(w). They provide
comprehensive services to commercial and/or Medicare enrollees, as well as
Medicaid enrollees.
• Medicaid-only Managed Care Organization (Mcaid-MCO): an MCO that
provides comprehensive services to Medicaid beneficiaries, but not commercial or
Medicare enrollees.
• Prepaid Inpatient Health Plan (PIHP): an entity that provides less than
comprehensive services on an at-risk basis or one that provides any benefit package
on a non-risk or other than State reimbursement Plan basis; and provides, arranges

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for or otherwise has responsibility for the provision of any inpatient hospital or
institutional services.
• Prepaid Ambulatory Health Plan (PAHP): a prepaid ambulatory health plan that
provides less than comprehensive services on an at-risk or other than State Plan
reimbursement basis, and does not provide, arranges for, or otherwise has
responsibility for the provision of any inpatient hospital or institutional services.
• Primary Care Case Management (PCCM): a provider (usually a physician,
physician group practice, or an entity employing or having other arrangements with
such physicians, but sometimes also including nurse practitioners, nurse-midwives,
or physician assistants) who contracts to locate, coordinate, and monitor covered
primary care (and sometimes additional services). This category includes those
PIHPs that act as PCCMs.
• Program for All-Inclusive Care for the Elderly (PACE): a program that provides
prepaid, capitated comprehensive health care services to the frail elderly.
• “Other” Managed Care Arrangement: An entity where the plan is not considered
a PCCM, PIHP, PAHP, Comprehensive MCO, Medicaid-only MCO, HIO, or PACE.
The most utilized of these plans are Comprehensive MCOs and Prepaid Health Plans.

Table 2-1: Medicaid Managed Care Plans

Number of Number of Enrollees


Plans
Health Insuring Organization (HIO) 5 513,255
Commercial Managed Care Organization (COM-MCO) 156 9,680,307
Medicaid-Only Managed Care Organization (Mcaid-MCO) 131 7,841,591
Primary Care Case Management (PCCM) 36 5,891,174
Prepaid Inpatient Health Plan (PIHP) 121 7,961,643
Prepaid Ambulatory Health Plan (PAHP) 34 3,799,313
Program of All-Inclusive Care for the Elderly (PACE) 31 9,999
Other 9 213,113
Total 523 35,910,395*
*This table provides duplicated figures by plan type. The total number of enrollees includes 8,996,825 individuals who were
enrolled in more than one managed care plan. It also includes individuals enrolled in State health care reform programs that
expand eligibility beyond traditional Medicaid eligibility standards.

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2004. DHHS, CMS, Center for Medicaid
& State Operations.

The following tables provide an overview of Medicaid managed care enrollment at the State level.

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Medicaid Managed Care Enrollment, As of June 30, 2004

Rank Based on
Medicaid Medicaid Managed Percent in Percent in
State Enrollment Care Enrollment Managed Care Managed Care
National Total 44,355,955 26,913,570 60.68%
Alabama 800,569 439,832 54.94% 39
Alaska 96,630 0 0.00% 50
Arizona 904,658 806,193 89.12% 8
Arkansas 594,264 386,395 65.02% 29
California 6,471,239 3,258,787 50.36% 42
Colorado 378,416 369,270 97.58% 3
Connecticut 402,286 303,404 75.42% 17
Delaware 135,224 99,598 73.65% 18
District of Columbia 138,637 88,452 63.80% 31
Florida 2,207,375 1,450,117 65.69% 27
Georgia 1,323,036 1,273,133 96.23% 5
Hawaii 190,381 145,580 78.04% 15
Idaho 166,088 131,693 79.29% 12
Illinois 1,740,488 158,869 9.13% 48
Indiana 803,786 509,732 63.42% 33
Iowa 284,918 262,487 92.13% 7
Kansas 269,032 153,395 57.02% 38
Kentucky 678,529 625,807 92.23% 6
Louisiana 919,079 723,837 78.76% 14
Maine 258,686 154,785 59.84% 36
Maryland 696,097 469,998 67.52% 24
Massachusetts 947,297 581,520 61.39% 35
Michigan 1,409,832 1,255,067 89.02% 9
Minnesota 568,761 361,381 63.54% 32
Mississippi 637,910 73,445 11.51% 47
Missouri 974,310 432,339 44.37% 44
Montana 86,452 58,030 67.12% 25
Nebraska 206,701 149,405 72.28% 19
Nevada 169,334 89,846 53.06% 40
New Hampshire 96,188 0 0.00% 50
New Jersey 798,132 541,820 67.89% 23
New Mexico 420,935 273,018 64.86% 30
New York 4,022,544 2,341,733 58.22% 37
North Carolina 1,112,341 788,943 70.93% 20
North Dakota 52,458 33,065 63.03% 34
Ohio 1,645,454 507,337 30.83% 46
Oklahoma 518,926 354,110 68.24% 22
Oregon 426,905 345,410 80.91% 11
Pennsylvania 1,599,570 1,265,891 79.14% 13
Puerto Rico 873,211 842,827 96.52% 4
Rhode Island 180,528 124,921 69.20% 21
South Carolina 845,870 69,791 8.25% 49
South Dakota 97,774 95,577 97.75% 2
Tennessee 1,345,131 1,345,131 100.00% 1
Texas 2,692,012 1,150,773 42.75% 45
Utah 188,839 167,338 88.61% 10
Vermont 130,782 86,263 65.96% 26
Virgin Islands 10,900 0 0.00% 50
Virginia 607,493 398,871 65.66% 28
Washington 1,080,738 834,883 77.25% 16
West Virginia 298,093 156,468 52.49% 41
Wisconsin 792,177 374,003 47.21% 43
Wyoming 58,939 0 0.00% 50
State Medicaid enrollment includes individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility
standards. This table provides unduplicated figures for Medicaid Enrollment and Managed Care Enrollment by State for a single point in time. These
values differ significantly (i.e., are lower than) unduplicated annual counts of enrollees over the entire year.

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2004. DHHS, CMS, Center for Medicaid & State Operations.

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Pharmaceutical Benefits Under Managed Care Plans


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

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions.
“-” indicates Not Applicable, “N/A” indicates “No Answer” was received on the Survey.

Sources: As reported by State drug program administrators in the 2004 NPC Survey.

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Medicaid Managed Care Enrollment Trends, 2000-2004


State 2000 2001 2002 2003 2004
National Total 18,786,137 20,773,813 23,117,668 25,262,873 26,913,570
Alabama 325,059 350,485 405,090 404,797 439,832
Alaska 0 0 0 0 0
Arizona 442,254 527,674 697,171 808,506 806,193
Arkansas 222,261 257,662 336,111 374,067 386,395
California 2,525,406 2,870,514 3,191,168 3,258,787 3,258,787
Colorado 254,232 247,181 278,095 262,263 369,270
Connecticut 229,995 239,829 280,106 294,331 303,404
Delaware 75,535 83,422 87,465 86,709 99,598
District of Columbia 78,864 79,673 80,300 85,370 88,452
Florida 1,016,641 1,184,506 1,267,998 1,354,025 1,450,117
Georgia 806,009 878,140 1,043,154 1,212,639 1,273,133
Hawaii 121,581 127,779 132,787 141,399 145,580
Idaho 32,338 37,913 58,284 101,257 131,693
Illinois 137,622 136,497 130,988 137,682 158,869
Indiana 376,066 433,014 484,116 502,401 509,732
Iowa 182,251 206,751 227,495 243,954 262,487
Kansas 108,093 118,209 130,162 141,119 153,395
Kentucky 464,191 489,711 500,987 611,878 625,807
Louisiana 48,802 56,542 206,992 505,434 723,837
Maine 57,151 96,051 110,922 148,151 154,785
Maryland 385,687 421,355 451,307 466,688 469,998
Massachusetts 583,324 616,241 628,832 572,835 581,520
Michigan 1,063,557 1,023,264 1,208,803 1,314,810 1,255,067
Minnesota 291,365 322,640 368,186 362,349 361,381
Mississippi 218,431 297,916 0 0 73,445
Missouri 304,499 378,771 413,361 425,161 432,339
Montana 42,312 46,995 52,209 55,372 58,030
Nebraska 140,199 150,840 163,772 142,377 149,405
Nevada 37,945 47,518 60,823 74,923 89,846
New Hampshire 4,432 6,200 9,206 13,407 0
New Jersey 371,641 459,087 523,904 525,864 541,820
New Mexico 199,297 212,456 243,069 261,015 273,018
New York 691,422 728,709 1,099,900 1,914,794 2,341,733
North Carolina 598,852 674,133 722,089 749,152 788,943
North Dakota 23,962 25,540 30,808 35,515 33,065
Ohio 239,460 277,617 378,476 436,146 507,337
Oklahoma 279,205 299,272 338,819 338,859 354,110
Oregon 312,064 360,926 378,739 330,874 345,410
Pennsylvania 975,211 1,037,374 1,140,211 1,192,031 1,265,891
Puerto Rico 828,021 898,171 865,285 857,310 842,827
Rhode Island 104,041 111,624 117,024 119,257 124,921
South Carolina 32,149 41,716 64,272 71,195 69,791
South Dakota 67,835 79,641 85,868 90,733 95,577
Tennessee 1,323,319 1,426,622 1,430,966 1,304,794 1,345,131
Texas 606,238 753,613 839,798 1,065,945 1,150,773
Utah 119,200 128,898 154,784 162,364 167,338
Vermont 55,605 78,181 82,261 85,751 86,263
Virgin Islands 0 0 0 0 0
Virginia 280,978 291,767 323,863 262,961 398,871
Washington 800,481 766,366 829,625 854,861 834,883
West Virginia 90,631 122,230 144,911 151,515 156,468
Wisconsin 210,423 266,577 317,106 349,246 374,003
Wyoming 0 0 0 0 0

State Medicaid enrollment includes individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid
eligibility standards.

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

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Medicaid Managed Care Plan Type, As of June 30, 2004


Commercial Medicaid-only
State HIO MCO MCO PCCM PIHP PAHP PACE Other
National Total 5 156 131 36 121 34 31 9
Alabama 0 0 0 0 1 0 0 1
Alaska - - - - - - - -
Arizona 0 0 26 0 1 0 0 0
Arkansas 0 0 0 1 0 1 0 0
California 5 23 0 0 0 11 4 1
Colorado 0 0 2 1 9 0 1 0
Connecticut 0 2 2 0 0 0 0 0
Delaware 0 0 1 0 0 0 0 1
District of Columbia 0 0 4 0 1 0 0 0
Florida 0 10 1 1 2 4 1 2
Georgia 0 0 0 1 1 1 0 0
Hawaii 0 2 1 0 2 0 0 1
Idaho 0 0 0 1 0 0 0 0
Illinois 0 3 2 0 0 0 0 0
Indiana 0 0 3 3 0 0 0 0
Iowa 0 3 0 1 1 0 0 0
Kansas 0 0 1 1 0 0 1 0
Kentucky 0 0 1 1 0 1 0 0
Louisiana 0 0 0 1 0 0 0 0
Maine 0 0 0 1 0 0 0 0
Maryland 0 0 7 0 0 0 1 0
Massachusetts 0 2 2 1 1 0 6 0
Michigan 0 7 11 0 18 0 0 0
Minnesota 0 6 3 0 0 0 0 1
Mississippi 0 0 0 0 0 1 0 0
Missouri 0 3 4 0 0 0 1 0
Montana 0 0 0 1 0 0 0 0
Nebraska 0 1 0 1 0 0 0 1
Nevada 0 2 0 0 0 0 0 0
New Hampshire - - - - - - - -
New Jersey 0 2 3 0 0 0 0 0
New Mexico 0 3 0 0 0 0 1 0
New York 0 14 22 6 12 1 4 1
North Carolina 0 1 0 2 0 0 0 0
North Dakota 0 1 0 1 0 0 0 0
Ohio 0 4 2 0 0 0 2 0
Oklahoma 0 0 0 1 0 1 0 0
Oregon 0 2 11 1 10 8 1 0
Pennsylvania 0 2 10 1 28 0 2 0
Puerto Rico 0 5 0 0 2 0 0 0
Rhode Island 0 3 0 0 0 0 0 0
South Carolina 0 0 1 0 0 1 1 0
South Dakota 0 0 0 1 0 1 0 0
Tennessee 0 4 3 0 2 0 1 0
Texas 0 9 2 2 1 0 2 0
Utah 0 0 0 1 12 1 0 0
Vermont 0 0 0 1 0 0 0 0
Virgin Islands - - - - - - - -
Virginia 0 6 1 1 0 0 0 0
Washington 0 5 2 1 14 2 1 0
West Virginia 0 3 0 1 0 0 0 0
Wisconsin 0 28 3 0 3 0 1 1
Wyoming - - - - - - - -

HIO=Health Insuring Organization; Commercial MCO=Commercial Managed Care Organization; Medicaid-only MCO=Medicaid-only
Managed Care Organization; PCCM=Primary Care Case Management; PIHP=Prepaid Inpatient Health Plan; PAHP=Prepaid Ambulatory Health
Plans; PACE=Program for All-Inclusive Care for the Elderly.

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2004. DHHS, CMS, Center for Medicaid & State
Operations.

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Medicaid Managed Care Enrollment by Plan Type,


As of June 30, 2004
Commercial Medicaid-
State HIO MCO only MCO PCCM PIHP PAHP PACE Other
National Total 513,255 9,680,307 7,841,591 5,891,174 7,961,643 3,799,313 9,999 213,113
Alabama - - - - 423,112 - - 16,720
Alaska - - - - - - - -
Arizona - - 806,193 - 75,548 - - -
Arkansas - - - 332,473 - 386,395 - -
California 531,255 2,650,685 - - - 297,180 1,665 2,652
Colorado - - 56,351 57,561 381,312 - 830 -
Connecticut - 223,366 80,038 - - - - 13,565
Delaware - - 85,598 - - - - -
District of Columbia - - 88,452 - 3,198 - - -
Florida - 512,210 195,046 688,109 95,287 88,698 55 17,810
Georgia - - - 840,002 2,235 1,273,133 - -
Hawaii - 100,121 48,459 - 673 - - 1,409
Idaho - - - 131,693 - - - -
Illinois - 80,187 78,682 - - - - -
Indiana - - 294,014 326,484 - - - -
Iowa - 54,253 - 102,434 262,487 - - -
Kansas - - 63,997 89,287 - - 111 -
Kentucky - - 132,813 339,003 - 625,807 - -
Louisiana - - - 723,837 - - - -
Maine - - - 154,785 - - - -
Maryland - - 469,849 - - - 149 -
Massachusetts - 98,639 178,735 304,146 325,344 - 1,310 -
Michigan - 417,394 470,643 - 1,255,067 - - -
Minnesota - 336,417 25,144 - - - - 926
Mississippi - - - - - 73,445 - -
Missouri - 116,997 315,342 - - 0 176 -
Montana - - - 58,030 - - - -
Nebraska - 31,204 - 37,636 - - - 149,405
Nevada - 89,846 - - - - - -
New Hampshire - - - - - - - -
New Jersey - 186,407 355,413 - - - - -
New Mexico - 272,783 - - - - 235 -
New York - 756,800 1,538,431 20,335 9,849 6,725 1,967 10,626
North Carolina - 13,153 - 775,790 - - - -
North Dakota - 794 - 32,271 - - - -
Ohio - 157,281 350,056 - - 458 -
Oklahoma - - - 5,572 - 348,538 - -
Oregon - 24,563 233,567 11,414 291,480 303,495 530 -
Pennsylvania - 233,871 897,047 140,668 1,030,653 - 437 -
Puerto Rico - 842,827 - - 842,827 - - -
Rhode Island - 124,921 - - - - - -
South Carolina - - 52,944 - - 16,480 367 -
South Dakota - - - 74,264 - 95,577 - -
Tennessee - 887,027 458,104 - 1,345,131 - 269 -
Texas - 472,762 320,182 357,097 292,623 - 732 -
Utah - - - 44,898 238,152 154,730 - -
Vermont - - - 86,263 - - - -
Virgin Islands - - - - - - - -
Virginia - 230,959 78,352 89,560 - - - -
Washington - 427,612 48,217 4,087 1,077,312 129,110 215 -
West Virginia - 92,993 - 63,475 - - - -
Wisconsin - 244,235 119,922 - 9,353 - 493 -
Wyoming - - - - - - - -
* This table provides duplicated figures that include enrollees receiving comprehensive and limited benefits. Total number
of enrollees includes those who were enrolled in more than one managed care plan. Figures also include individuals
enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards.

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2004. DHHS, CMS, Center for Medicaid & State
Operations.

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Medicaid Managed Care Enrollment by Payment Arrangement,


As of June 30, 2004
State Fee-for-Service (FFS) Capitated Other
National Total 6,058,012 29,707,004 145,379
Alabama 423,112 16,720
Alaska
Arizona 881,741
Arkansas 332,473 386,395
California 3,465,437
Colorado 57,561 438,493
Connecticut 303,404
Delaware 13,565 85,598
District of Columbia 91,650
Florida 705,895 802,598 88,722
Georgia 840,002 1,275,368
Hawaii 150,662
Idaho 131,693
Illinois 158,869
Indiana 326,484 294,014
Iowa 102,434 316,740
Kansas 89,287 64,108
Kentucky 339,003 758,620
Louisiana 723,837
Maine 154,785
Maryland 469,998
Massachusetts 304,146 604,028
Michigan 2,143,104
Minnesota 926 361,561
Mississippi 73,445
Missouri 432,515
Montana 58,030
Nebraska 187,041 31,204
Nevada 89,846
New Hampshire
New Jersey 541,820
New Mexico 273,018
New York 5,491 2,339,242
North Carolina 775,790 13,153
North Dakota 32,271 794
Ohio 507,795
Oklahoma 5,572 348,538
Oregon 11,414 853,635
Pennsylvania 140,668 2,162,008
Puerto Rico 1,685,654
Rhode Island 124,921
South Carolina 69,791
South Dakota 74,264 95,577
Tennessee 2,690,531
Texas 357,097 1,086,299
Utah 44,898 352,945 39,937
Vermont 86,263
Virgin Islands
Virginia 89,560 309,311
Washington 4,087 1,682,466
West Virginia 63,475 92,993
Wisconsin 374,003
Wyoming

Individual State totals may not sum to total managed care enrollment (page 2-29) because State totals include individuals enrolled in more than
one plan type including dental, mental, and long-term care.

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2004. DHHS, CMS, Center for Medicaid & State
Operation

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MEDICAID MANAGED CARE WAIVERS


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

SECTION 1915(b) “FREEDOM OF CHOICE” WAIVERS

Section 1915(b) waivers are granted to give States the authority to conduct Medicaid programs
outside of the scope of the Medicaid statute, allowing them to waive freedom of choice, statewide
access to care, and comparability requirements under Section 1902 of the Social Security Act. With a
1915(b) waiver, a State can require mandatory enrollment of Medicaid recipients in managed care
plans. Section 1915(b) waivers can also allow a State to create a “carveout” delivery system for
specialty care, e.g., a Managed Behavioral Health Care Plan. Section 1915(b) waivers cannot
negatively impact beneficiary access or quality of care of services, and must be cost-effective (i.e.,
cost must be less than the Medicaid program would cost without the waiver). Section 1915(b)
waivers are typically limited to a targeted geographical area or population, are approved for an initial
period of two years, and can be renewed on an ongoing basis if the State reapplies.
Four options for 1915(b) waivers exist; each is governed by a different subsection(s) of Section
1915(b);
• Paragraph (b)(1) - Case Management: States are allowed to implement case management
systems which can be as simple as requiring each beneficiary to choose a primary care
provider or as comprehensive as mandating enrollment in a prepaid health plan. The
Balanced Budget Act of 1997 also gave States the option to enroll certain beneficiaries
into managed care via a State Plan Amendment.
• Paragraph (b)(2) - Central Broker: Localities are allowed to act as a central broker in
assisting Medicaid eligibles in selecting among competing health care plans, if such a
restriction does not substantially impair access to medically necessary services of
adequate quality.
• Paragraph (b)(3) - Shared Cost Saving: States are allowed to share (through provision of
additional services) cost savings (resulting from use by the recipient of more cost-
effective medical care) with recipients of medical assistance under the State Plan.
• Paragraph (b)(4) - Restrict Providers: States can limit the number of providers of certain
services. These waivers are sometimes referred to as selective contracting waivers and
are gaining in popularity. For example, some approved 1915(b)(4) waivers include
programs to restrict the number of providers of transportation services, organ transplants,
and inpatient obstetrical care.

Refer to the table on page 2-38 for a listing of 1915(b) waivers.

Although Section 1915(b) waivers allow States to increase access to managed care plans, States are still
limited under Federal regulations and cannot use them to serve beneficiaries beyond Medicaid State Plan
Eligibility or change their benefits package. In order to expand their Medicaid programs even further
than under Section 1915(b) waivers, States apply for Section 1115 research and demonstration waivers.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

SECTION 1115 RESEARCH AND DEMONSTRATION WAIVERS

Section 1115 research and demonstration waivers release States from standard Medicaid
requirements, allowing them the flexibility to test substantially new ideas of policy merit. Along with
Section 1915(b) waivers, Section 1115 waivers allow States to waive freedom of choice, statewide
access to care, and comparability requirements. However, a Section 1115 waiver also allows States
to provide new and additional services, test new payment methods, offer benefits to new and
expanded populations, and contract with managed care organizations that do not meet the necessary
criteria of Section 1903 of the Social Security Act.
To receive approval of a Section 1115 waiver, States submit a proposal to CMS for discussion and
review. Once operational, States allow formal evaluations of the research and public policy value of
the programs and to demonstrate that their programs do not exceed costs, which would have
otherwise occurred under traditional Medicaid programs (i.e., States must demonstrate budget
neutrality). Section 1115 waivers are usually granted for a five-year period and each State must
submit a request for continuation. For example, Arizona has operated its program under a Section
1115 waiver for over 20 years. The Benefits Improvement and Protection Act (BIPA) of 2000
streamlined the process for States to submit requests for and receive extensions of Section 1115
demonstration waivers.
Currently, there are 17 Medicaid programs with Section 1115 waiver approvals: Arizona, California,
Delaware, Hawaii, Kentucky, Maryland, Massachusetts, Minnesota, Missouri, New York, Oklahoma,
Oregon, Rhode Island, Tennessee, Utah, Vermont and Wisconsin. Refer to the table on page 2-40 for
a listing of implemented Section 1115 waivers.

PHARMACY PLUS DEMONSTRATIONS UNDER SECTION 1115 AUTHORITY

Section 1115 demonstration authority may be used to extend pharmacy coverage to certain low-
income elderly and disabled individuals who are not otherwise eligible for Medicaid. This type of
Section 1115 waiver program is commonly referred to as “Pharmacy Plus.” Its purpose is to provide
a subsidized pharmacy benefit that is intended to assist individuals in maintaining their healthy status
and avoid spending down to Medicaid income and asset eligibility levels. The waivers will test how
provision of a pharmacy benefit to a non-Medicaid covered population will affect Medicaid costs,
utilization and future eligibility trends.

Pharmacy Plus demonstrations 1) cover an individual’s cost of drugs; 2) cover the individual’s cost
sharing obligation for private prescription programs; and 3) provide wrap-around coverage to bring
private sources of drug coverage up to the level of the Pharmacy Plus benefit. States may construct
their Pharmacy Plus programs to provide eligibility for individuals who are not eligible for full
Medicaid benefits and who have incomes below 200 percent of the Federal Poverty Level. Under a
Pharmacy Plus waiver, States may elect to provide a prescription and over-the-counter drug benefit
that is similar to, or different from, the benefits provided in the Medicaid State Plan. States may
choose to deliver the services via fee-for-service or capitation. Last, States may choose whether to
perform assets tests and income adjustments, and may also choose to enact an enrollment ceiling on
the number of individuals who participate in the demonstration.

Like all 1115 demonstrations, Pharmacy Plus waivers must be budget neutral to the Federal
government. Under the terms and conditions of an approved plan, which is usually granted for a 5-
year period, a ceiling cap is placed on Federal financial payments for services included in the budget
neutrality agreement. States are encouraged to involve the private sector in implementing these
programs and are encouraged to explore the use of pharmacy benefit managers (PBM). Premiums,
cost sharing (deductibles, co-payments and coinsurance), and benefit limitations are all available tools
for providing incentives and cost containment.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

As of September 16, 2004, four States had received Pharmacy Plus demonstration approval: Florida,
Illinois, South Carolina and Wisconsin. Another 8 states had applications pending and one state
withdrew its request.

Refer to the table on page 2-41 for a complete status of the Pharmacy Plus Demonstrations Program.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

SECTION 1915(b) WAIVERS, AS OF JUNE 30, 2003

1915)
Statutes
State Program(s) Approved Utilized Implemented Expiration
st
Alabama Patient 1 1, 3, 4 01/1/97 2/18/04
Alaska None -- -- --
Arizona None -- -- --
Non-Emergency Transportation 1, 4 3/1/98 11/21/05
Arkansas
Primary Care Physician 1 11/1/96 12/17/04
Caloptima 1, 4 10/1/95 7/10/05
Central Coast Alliance for Health 1, 4 1/1/96 7/10/05
Health Plan of San Mateo 1, 4 11/30/87 8/26/04
Hudman 4 4/24/92 10/14/03
Managed Care Network 1, 2, 4 3/1/97 6/30/03
Medi-Cal Mental Health Care Field Test (San Mateo Co.) 4 4/1/95 7/25/05
Medi-Cal Specialty Mental Health Services Consolidation 4 3/15/95 4/27/05
California
Partnership Health Plan of California 1, 4 5/1/94 2/10/05
Primary Care Case Management Program 1, 4 8/1/84 8/13/03
Sacramento Geographic Managed Care 1, 2, 4 4/1/94 10/8/04
San Diego Geographic Managed Care 1, 2, 4 10/17/98 10/10/03
Santa Barbara Health Initiative 1, 4 9/1/83 1/11/05
Selective Provider Contracting Program 4 9/21/82 12/31/04
Two-Plan Model Program 1, 2, 4 1/23/96 11/8/03
Colorado Mental Health Capitation Program 1, 3, 4 7/1/95 5/4/05
Connecticut HUSKY A 1, 4 10/1/95 5/30/04
Delaware None -- -- --
District of
DC Medicaid Managed Care Program
Columbia 1, 2, 4 4/1/94 6/30/04
Managed Health Care 1, 2, 3, 4 10/1/92 9/26/04
Florida Prepaid Mental Health Plan 1, 4 3/1/96 11/12/03
Statewide Inpatient Psychiatric Program 4 4/1/99 12/31/03
Non-Emergency Transportation Broker Program 4 10/1/97 1/10/04
Georgia Preadmission Screening and Annual Resident Review
(PASARR) 1, 4 11/1/94 10/5/05
Hawaii None -- -- --
Idaho Healthy Connections 1, 2 10/1/93 9/21/04
Illinois None -- -- --
Indiana Hoosier Healthwise 1 7/1/94 9/22/05
Indiana Medicaid Select 1 1/1/03 7/22/05
Iowa Iowa Plan for Behavioral Health 1, 3, 4 1/1/99 6/30/05
Kansas None -- -- --
Kentucky Human Service Transportation 1, 4 6/1/98 6/12/05
Louisiana Community Care 1 6/1/92 2/28/04
Maine None -- -- --
Maryland None -- -- --
Massachusetts None -- -- --
Michigan Comprehensive Health Care 1, 2, 4 7/1/97 4/21/05
Minnesota Consolidated Chemical Dependency Treatment Fund 1, 4 1/1/88 3/23/03
Mississippi None -- -- --
Missouri MC+ Managed Care/1915(b) 1, 2, 4 9/1/95 3/14/04

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National Pharmaceutical Council Pharmaceutical Benefits 2004

1915)
Statutes
State Program(s) Approved Utilized Implemented Expiration
Montana Passport to Health 1, 2 1/1/94 4/24/04
Nebraska Nebraska Health Connection Combined Waiver Program 1, 2, 3, 4 7/1/95 6/30/05
Nevada None -- -- --
New
None
Hampshire -- -- --
New Jersey New Jersey Care 2000+ 1915(b) 1, 2 10/1/00 12/29/04
New Mexico SALUD! 1,4 7/1/97 6/30/04
New York Non-Emergency Transportation 1, 4 7/1/96 11/14/04
ACCESS II/III 1915(b) 1 7/1/98 8/5/03
North Carolina Carolina Access 1915(b) 1 4/1/91 8/5/03
Health Care Connection 1915(b) 1 7/1/96 8/5/03
North Dakota None -- -- --
Ohio PremierCare 1, 2, 4 7/1/01 6/30/05
Oklahoma None -- -- --
Oregon Transportation Program 4 9/1/94 7/25/03
Family Care Network 1 2/1/94 10/26/03
Pennsylvania
HealthChoices 1, 2, 3, 4 2/1/97 6/16/04
Puerto Rico None -- -- --
Rhode Island None -- -- --
South Carolina None
-- -- --
South Dakota None -- -- --
Tennessee None -- -- --
Lonestar Select I 4 9/1/94 9/3/04
Lonestar Select II 4 3/10/95 3/4/04
Texas
NorthSTAR 1, 2, 4 11/1/99 11/5/03
STAR 1, 2, 3, 4 8/1/93 8/31/03
Choice of Health Care Delivery 1, 2, 4 7/1/82 7/23/03
Utah Non-Emergency Transportation 1, 4 7/1/01 10/21/05
Prepaid Mental Health Program 4 7/1/91 12/26/05
Vermont None -- -- --
Medallion 1, 2 3/1/92 3/24/04
Virginia
Medallion II 1, 2, 4 1/1/96 12/25/04
Healthy Options 1, 4 10/1/93 7/1/03
Washington
The Integrated Mental Health Services 1, 4 7/1/93 3/4/04
Mountain Health Trust 1, 4 9/1/96 3/22/04
West Virginia
Physician Assured Access System 1,2 6/1/92 4/27/04
Wisconsin None -- -- --
Wyoming None -- -- --

Source: 2003 National Summary of State Medicaid Managed Care Programs. Program Descriptions as of June 30, 2003.
Centers for Medicare and Medicaid Services, Center for Medicaid & State Operations.

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Section 1115 Research and Demonstration Waivers


As of June 30, 2003
State Program Implemented Expiration
Arizona Arizona Health Care Cost Containment System (AHCCCS) 10/1/82 9/30/06
Centers For Elders Independence 4/1/95 11/24/03
On Lok Senior Health Services 11/1/83 11/24/03
California
Senior Care Action Network 1/1/85 12/31/03
Sutter Senior Care 5/1/94 11/24/03
Delaware Diamond State Health Plan 1/1/96 3/15/04
Hawaii Hawaii QUEST 8/1/94 3/31/05
Kentucky Kentucky Health Care Partnership Program 11/1/97 11/1/05
Maryland HealthChoice 6/2/97 5/31/05
Massachusetts Mass Health 7/1/97 6/30/05
MinnesotaCare Program for Families and Children 7/1/95 6/30/05
Minnesota
Prepaid Medical Assistance Program 7/1/85 6/30/05
Missouri MC+ Managed Care/1115 9/1/98 3/1/07
Partnership Plan – Family Health Plus 9/04/01 3/31/06
New York
Partnership Plan Medicaid Managed Care Program 10/1/97 3/31/06
Oklahoma SoonerCare 1/1/96 12/31/03
Oregon Oregon Health Plan 2/1/94 1/31/05
Rhode Island Rite Care 8/1/94 7/31/05
Tennessee TennCare 1/1/94 6/30/07
Utah Primary Care Network (PCN) 7/1/02 7/31/07
Vermont Vermont Health Access 1/1/96 12/31/03
BadgerCare [SCHIP] 7/01/99 3/31/04
Wisconsin
Wisconsin Partnership Program 1/1/96 12/31/03

Source: 2003 National Summary of State Medicaid Managed Care Programs. Program Descriptions as of June 30, 2003. Centers
for Medicare and Medicaid Services, Center for Medicaid & State Operations. Last Modified: 9/16/04.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Pharmacy Plus Demonstrations Program Status

Pharmacy Waivers Under 1115 Authority

STATE PROGRAM NAME STATUS


Arkansas Arkansas RX Senior Care Pending

Connecticut ConnPACE Program Rx Pending

Delaware Delaware Pharmacy Assistance Program Disapproved

Florida Ron Silver Senior Rx Program Approved

Hawaii Prescription Plus Disapproved


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

Massachusetts Pharmacy Waiver Withdrawn

Michigan EPIC Ex Pending


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

Source: CMS Website at www.cms.DHHS.gov/medicaid/1115/pharmplusstatus.asp; last modified on September 16, 2004.

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Section 3:
State Characteristics

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National Pharmaceutical Council Pharmaceutical Benefits 2004

STATE CHARACTERISTICS
Presented in Section 3 of the Compilation is State-by-State information on several topics. The
Section begins with a series of tables showing select State demographic characteristics including
age composition and racial/Hispanic status. Next, insurance coverage, poverty status,
employment, and income data for each State are presented. The final group of tables show select
components of each State’s health care system including Medicare and Medicaid certified
facilities (hospitals, SNFs, ICFs/MR, home health agencies, and rural health clinics), licensed
pharmacies, and health manpower (physicians, Registered Nurses, and pharmacists).

The data in Section 3 have been compiled from a myriad of sources. These include:

• CMS
• The U.S. Bureau of the Census
• The Bureau of Labor Statistics (BLS)
• The Health Resources and Services Administration (HRSA)
• The National Association of Boards of Pharmacy

Because of the unevenness with which the various government agencies and other organizations
have released updated information, we have carefully reviewed all possible information sources
and made judgments on which data to present. In the final analysis, we have included those data
that, in our opinion, best reflect the factors and characteristics on which we have reported.
However, certain limitations in the different sources have resulted in some inconsistencies among
the tables. The following examples illustrate this problem.

The table showing the age distribution of the population is derived from the 2003 American
Community Survey conducted by the U.S. Bureau of the Census. Unfortunately, the
approximately 5 million individuals residing in “group quarters” were not included. Hence, the
total population figure (and the corresponding figures for each State) presented in this table is
lower than the population total in the table showing insurance status.

The data on insurance status was compiled from the Current Population Survey, 2004 Annual
Social and Economic Supplement, a collaborative effort by the Census Bureau and BLS. Hence,
the estimates on the number of Medicare and Medicaid beneficiaries differ slightly from those
published by CMS. In addition, more detailed data on poverty, also compiled from 2004 Annual
Social and Economic Supplement to the Current Population Survey, have been included in this
year’s Compilation.

HRSA’s Bureau of Health Professions, National Center for Health Workforce Analysis is
responsible for compiling the Area Resource File (ARF), an important annual data file for
researchers, planners, policymakers, and others seeking information on the health professions
workforce, health care facilities, health care utilization and expenditures, etc. at a variety of
geographic levels. The ARF has been our primary source of information on physicians and, for
the past several years, registered nurses. Unfortunately, 2002 physician data provided by the
American Medical Association (AMA) that HRSA had hoped to include in the 2004 ARF were
not able to be included. Instead, HRSA carried over 2001 physician data from the 2003 ARF.
Therefore, since no update information was available, we decided not to acquire the 2004 ARF
and have repeated the 2001 physician data that appeared in last year’s Compilation (see page 3-
16).

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National Pharmaceutical Council Pharmaceutical Benefits 2004

The National Sample Survey of Registered Nurses is the most extensive and comprehensive
source of nursing statistics for the U.S health care system. Conducted every four years by
HRSA’s Bureau of Health Professions, Division of Nursing, the most recent data currently
available from this survey are for 2000. Since these data are somewhat out-of-date, we have, for
the past two years, turned to the ARF for nursing statistics. However, as is often the case, data
from different sources are not exactly the same. The ARF, for example, provides information on
the number of “full-time equivalent registered nurses, not a simple body count of the number of
full-time and part-time RNs. Thus, the number of nurses presented in the ARF may be lower than
those compiled from the National Sample Survey of Registered Nurses. Also, since we did not
obtain the 2004 ARF because of the lack of updated physician data, we also repeated the RN data
that were presented in the 2003 Compilation (see page 3-17).

Despite the limitations confronted while compiling these statistics, we believe that the data
presented in Section 3 provide a useful and meaningful picture of State characteristics. Users of
the Compilation are urged to carefully read the source information and notes at the bottom of each
table in order to understand the limitations of the data contained therein.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Age Demographics, 2003*


Total Percent Ages Percent Percent Percent
State Population 19 and under Ages 20-44 Ages 45-64 Ages 65+
National Total 282,909,885 28.1% 35.9% 24.0% 12.0%
Alabama 4,385,446 27.8% 34.6% 24.8% 12.8%
Alaska 629,832 33.3% 35.1% 25.3% 6.3%
Arizona 5,470,843 30.1% 35.4% 21.8% 12.7%
Arkansas 2,650,062 27.9% 34.5% 24.0% 13.6%
California 34,650,690 29.6% 37.6% 22.5% 10.3%
Colorado 4,447,892 28.2% 38.5% 23.9% 9.5%
Connecticut 3,371,241 26.8% 34.4% 26.0% 12.8%
Delaware 792,494 27.0% 35.7% 24.3% 12.9%
District of Columbia 528,759 20.8% 43.5% 23.7% 12.0%
Florida 16,618,145 25.8% 33.2% 24.3% 16.7%
Georgia 8,438,203 29.4% 38.8% 22.6% 9.2%
Hawaii 1,221,885 26.6% 34.3% 25.7% 13.4%
Idaho 1,333,165 30.7% 34.7% 23.6% 11.1%
Illinois 12,328,721 28.5% 36.5% 23.6% 11.4%
Indiana 6,017,445 28.8% 35.5% 23.9% 11.9%
Iowa 2,839,868 26.5% 34.5% 25.0% 14.0%
Kansas 2,641,747 28.5% 35.6% 23.6% 12.3%
Kentucky 4,003,036 27.1% 35.9% 24.9% 12.1%
Louisiana 4,361,271 29.5% 35.4% 23.7% 11.3%
Maine 1,270,602 24.8% 33.4% 27.9% 13.9%
Maryland 5,372,472 27.9% 35.9% 25.2% 11.1%
Massachusetts 6,218,773 25.9% 36.5% 24.8% 12.8%
Michigan 9,825,840 28.2% 35.0% 24.8% 12.0%
Minnesota 4,919,584 27.8% 36.5% 24.2% 11.4%
Mississippi 2,785,493 29.6% 35.3% 23.2% 11.8%
Missouri 5,534,753 27.7% 35.1% 24.5% 12.7%
Montana 892,497 26.8% 32.5% 27.6% 13.1%
Nebraska 1,687,661 28.3% 35.0% 24.0% 12.6%
Nevada 2,207,574 28.6% 36.7% 23.5% 11.1%
New Hampshire 1,251,572 26.5% 35.2% 26.9% 11.4%
New Jersey 8,444,076 27.3% 35.4% 24.8% 12.6%
New Mexico 1,838,277 30.0% 33.9% 24.1% 12.0%
New York 18,600,527 26.4% 36.4% 24.6% 12.6%
North Carolina 8,146,508 27.6% 36.8% 24.0% 11.7%
North Dakota 609,236 26.4% 34.6% 25.0% 14.1%
Ohio 11,134,722 27.6% 34.6% 25.0% 12.8%
Oklahoma 3,396,794 28.3% 34.6% 24.4% 12.6%
Oregon 3,482,337 26.5% 35.6% 25.5% 12.4%
Pennsylvania 11,922,023 25.7% 33.7% 25.8% 14.8%
Rhode Island 1,037,196 25.3% 36.1% 25.0% 13.6%
South Carolina 4,008,553 27.6% 35.2% 25.0% 12.2%
South Dakota 735,349 28.9% 33.8% 23.7% 13.6%
Tennessee 5,689,261 26.7% 35.9% 25.3% 12.0%
Texas 21,547,821 31.5% 37.1% 21.8% 9.6%
Utah 2,309,555 35.1% 38.3% 18.1% 8.5%
Vermont 598,352 25.0% 33.8% 28.5% 12.7%
Virginia 7,151,960 27.4% 36.4% 25.2% 11.0%
Washington 5,990,020 27.4% 36.6% 25.0% 11.0%
West Virginia 1,766,196 24.2% 33.4% 27.5% 14.9%
Wisconsin 5,316,215 27.2% 35.5% 24.8% 12.5%
Wyoming 487,341 27.4% 33.4% 27.6% 11.6%
This information was taken from the 2003 American Community Survey conducted by the U.S. Bureau of The Census. The information
provided is limited to the household population and excludes the population living in institutions, college dormitories, and other group
quarters. This accounts for the difference in the estimates of the U.S. population from this source compared to other estimates presented by
the Bureau of the Census. The data are based on a sample and are subject to sampling variability. Data based on twelve monthly samples
during 2003.
*Sum of percentages may not equal 100 percent due to rounding.

Source: U.S. Department of Commerce, Bureau of the Census, 2003 American Community Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Race Demographics, 2003*


% Native % Indicated
% American Hawaiian and 2
Total Indian and Other Pacific % Some or More
State Population % White % Black % Asian Alaska Native Islander other race Races
National Total 282,909,885 76.2% 12.1% 4.2% 0.8% 0.1% 4.8% 1.9%
Alabama 4,385,446 71.1% 26.2% 0.7% 0.3% 0.0% 0.5% 1.3%
Alaska 629,832 69.6% 3.5% 4.1% 14.7% 0.6% 1.5% 6.1%
Arizona 5,470,843 76.8% 3.0% 2.1% 4.8% 0.2% 11.1% 2.0%
Arkansas 2,650,062 79.3% 15.5% 1.0% 0.6% 0.0% 2.0% 1.6%
California 34,650,690 66.2% 6.2% 11.9% 0.8% 0.3% 11.6% 2.9%
Colorado 4,447,892 83.8% 4.1% 2.7% 0.7% 0.0% 6.7% 2.1%
Connecticut 3,371,241 81.5% 9.1% 3.1% 0.4% 0.0% 4.6% 1.4%
Delaware 792,494 75.5% 19.0% 2.5% 0.3% 0.0% 1.4% 1.4%
District of Columbia 528,759 30.5% 58.9% 3.2% 0.5% 0.1% 5.3% 1.5%
Florida 16,618,145 77.1% 15.2% 2.0% 0.4% 0.1% 3.6% 1.7%
Georgia 8,438,203 66.2% 27.6% 2.5% 0.2% 0.1% 2.5% 1.0%
Hawaii 1,221,885 24.3% 2.1% 42.3% 0.1% 9.0% 1.1% 21.1%
Idaho 1,333,165 92.4% 0.6% 1.5% 1.8% 0.0% 2.8% 1.0%
Illinois 12,328,721 74.5% 14.7% 3.9% 0.2% 0.0% 5.2% 1.4%
Indiana 6,017,445 87.2% 7.9% 1.2% 0.3% 0.0% 1.9% 1.5%
Iowa 2,839,868 93.7% 1.9% 1.5% 0.3% 0.0% 1.1% 1.4%
Kansas 2,641,747 86.5% 5.7% 2.7% 0.8% 0.0% 1.8% 2.5%
Kentucky 4,003,036 89.9% 7.3% 0.8% 0.3% 0.0% 0.6% 1.1%
Louisiana 4,361,271 64.0% 32.1% 1.5% 0.6% 0.1% 0.6% 1.1%
Maine 1,270,602 97.0% 0.4% 0.7% 0.7% 0.0% 0.1% 1.0%
Maryland 5,372,472 64.2% 27.6% 4.7% 0.3% 0.0% 1.7% 1.5%
Massachusetts 6,218,773 84.4% 6.0% 4.4% 0.2% 0.0% 3.5% 1.4%
Michigan 9,825,840 80.3% 13.9% 2.2% 0.5% 0.0% 1.4% 1.7%
Minnesota 4,919,584 88.6% 3.8% 3.5% 0.9% 0.0% 1.5% 1.7%
Mississippi 2,785,493 61.0% 36.6% 0.7% 0.3% 0.0% 0.6% 0.8%
Missouri 5,534,753 85.0% 11.3% 1.4% 0.4% 0.0% 0.6% 1.3%
Montana 892,497 90.1% 0.2% 0.6% 6.4% 0.1% 0.6% 2.1%
Nebraska 1,687,661 89.0% 4.0% 1.7% 0.8% 0.0% 2.9% 1.6%
Nevada 2,207,574 77.2% 6.4% 5.0% 1.3% 0.3% 5.9% 3.8%
New Hampshire 1,251,572 95.5% 0.9% 1.7% 0.2% 0.0% 1.0% 0.7%
New Jersey 8,444,076 72.3% 13.4% 6.7% 0.1% 0.0% 6.0% 1.5%
New Mexico 1,838,277 70.2% 1.8% 1.4% 9.1% 0.3% 14.6% 2.7%
New York 18,600,527 68.8% 15.8% 6.5% 0.3% 0.0% 6.6% 2.0%
North Carolina 8,146,508 71.9% 21.2% 1.6% 1.1% 0.1% 2.6% 1.5%
North Dakota 609,236 92.2% 0.8% 0.9% 4.6% 0.2% 0.6% 0.8%
Ohio 11,134,722 84.9% 11.5% 1.4% 0.2% 0.0% 0.7% 1.3%
Oklahoma 3,396,794 76.1% 7.6% 1.6% 8.0% 0.1% 2.3% 4.3%
Oregon 3,482,337 87.8% 1.7% 3.2% 1.1% 0.3% 2.8% 3.1%
Pennsylvania 11,922,023 85.1% 9.8% 2.0% 0.1% 0.0% 1.9% 1.0%
Rhode Island 1,037,196 85.2% 5.2% 2.7% 0.5% 0.6% 4.6% 1.2%
South Carolina 4,008,553 66.9% 29.8% 1.0% 0.2% 0.0% 0.8% 1.2%
South Dakota 735,349 94.5% 0.7% 0.6% 2.3% 0.0% 0.5% 1.3%
Tennessee 5,689,261 79.9% 16.4% 1.2% 0.3% 0.1% 1.3% 0.9%
Texas 21,547,821 73.0% 11.0% 3.1% 0.4% 0.1% 11.0% 1.5%
Utah 2,309,555 90.3% 1.1% 1.8% 0.7% 0.8% 3.5% 1.8%
Vermont 598,352 96.5% 0.4% 0.9% 0.4% 0.0% 0.4% 1.4%
Virginia 7,151,960 72.7% 19.3% 4.4% 0.3% 0.0% 1.6% 1.7%
Washington 5,990,020 81.3% 3.3% 6.4% 1.2% 0.4% 3.6% 3.8%
West Virginia 1,766,196 95.1% 3.1% 0.5% 0.1% 0.0% 0.2% 1.0%
Wisconsin 5,316,215 88.3% 5.7% 1.8% 0.6% 0.0% 2.0% 1.6%
Wyoming 487,341 92.6% 0.7% 0.5% 2.0% 0.0% 1.9% 2.3%
This information was taken from the 2003 American Community Survey conducted by the U.S. Bureau of The Census. The information provided is limited to the household population and
excludes the population living in institutions, college dormitories, and other group quarters. This accounts for the difference in the estimates of the U.S. population from this source
compared to other estimates presented by U.S. Census. The data are based on a sample and are subject to sampling variability. Data based on twelve monthly samples during 2002.
*Sum of percentages may not equal 100 percent due to rounding.

Source: U.S. Department of Commerce, Bureau of the Census, 2003 American Community Survey.

3-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

Hispanic Demographics, 2003

State Total Population Hispanic Population Percent Hispanic


National Total 282,909,885 39,194,837 13.9%
Alabama 4,385,446 84,021 1.9%
Alaska 629,832 28,011 4.4%
Arizona 5,470,843 1,525,366 27.9%
Arkansas 2,650,062 98,628 3.7%
California 34,650,690 11,980,884 34.6%
Colorado 4,447,892 831,314 18.7%
Connecticut 3,371,241 337,911 10.0%
Delaware 792,494 42,514 5.4%
District of Columbia 528,759 51,900 9.8%
Florida 16,618,145 3,108,578 18.7%
Georgia 8,438,203 530,896 6.3%
Hawaii 1,221,885 92,014 7.5%
Idaho 1,333,165 110,604 8.3%
Illinois 12,328,721 1,694,185 13.7%
Indiana 6,017,445 237,800 4.0%
Iowa 2,839,868 88,869 3.1%
Kansas 2,641,747 178,727 6.8%
Kentucky 4,003,036 60,593 1.5%
Louisiana 4,361,271 108,563 2.5%
Maine 1,270,602 9,946 0.8%
Maryland 5,372,472 259,160 4.8%
Massachusetts 6,218,773 463,452 7.5%
Michigan 9,825,840 341,722 3.5%
Minnesota 4,919,584 155,015 3.2%
Mississippi 2,785,493 38,226 1.4%
Missouri 5,534,753 125,406 2.3%
Montana 892,497 17,646 2.0%
Nebraska 1,687,661 105,122 6.2%
Nevada 2,207,574 487,022 22.1%
New Hampshire 1,251,572 22,649 1.8%
New Jersey 8,444,076 1,234,632 14.6%
New Mexico 1,838,277 797,141 43.4%
New York 18,600,527 3,034,125 16.3%
North Carolina 8,146,508 456,334 5.6%
North Dakota 609,236 8,762 1.4%
Ohio 11,134,722 227,059 2.0%
Oklahoma 3,396,794 191,993 5.7%
Oregon 3,482,337 320,243 9.2%
Pennsylvania 11,922,023 405,083 3.4%
Rhode Island 1,037,196 100,242 9.7%
South Carolina 4,008,553 93,580 2.3%
South Dakota 735,349 9,931 1.4%
Tennessee 5,689,261 135,669 2.4%
Texas 21,547,821 7,614,414 35.3%
Utah 2,309,555 229,386 9.9%
Vermont 598,352 4,339 0.7%
Virginia 7,151,960 379,423 5.3%
Washington 5,990,020 478,824 8.0%
West Virginia 1,766,196 12,322 0.7%
Wisconsin 5,316,215 211,352 4.0%
Wyoming 487,341 33,239 6.8%
This information was taken from the 2003 American Community Survey conducted by the U.S. Bureau of The Census. The information
provided is limited to the household population and excludes the population living in institutions, college dormitories, and other group
quarters. This accounts for the difference in the estimates of the U.S. population from this source compared to other estimates presented by
the U.S. Census. The data are based on a sample and are subject to sampling variability. Data based on twelve monthly samples during
2003.

Source: U.S. Department of Commerce, Bureau of the Census, 2003 American Community Survey.

3-7
National Pharmaceutical Council Pharmaceutical Benefits 2004

Insurance Status - Populations, 2003*

Total Medicaid Medicare Military Privately Not


State Population Population Population Insurance Insured Insured
National Total 288,280,000 35,647,000 39,456,000 9,979,000 197,869,000 44,961,000
Alabama 4,427,000 584,000 685,000 182,000 2,997,000 629,000
Alaska 645,000 97,000 55,000 90,000 396,000 122,000
Arizona 5,576,000 739,000 757,000 354,000 3,568,000 951,000
Arkansas 2,671,000 428,000 455,000 188,000 1,621,000 465,000
California 35,394,000 5,340,000 4,132,000 964,000 22,591,000 6,499,000
Colorado 4,480,000 406,000 446,000 250,000 3,125,000 772,000
Connecticut 3,421,000 365,000 525,000 73,000 2,594,000 357,000
Delaware 820,000 92,000 110,000 32,000 620,000 91,000
District of Columbia 554,000 101,000 69,000 12,000 358,000 79,000
Florida 16,921,000 1,900,000 3,116,000 791,000 10,950,000 3,071,000
Georgia 8,571,000 965,000 994,000 280,000 5,954,000 1,409,000
Hawaii 1,253,000 133,000 176,000 104,000 927,000 127,000
Idaho 1,360,000 167,000 167,000 40,000 912,000 253,000
Illinois 12,628,000 1,194,000 1,706,000 216,000 9,238,000 1,818,000
Indiana 6,149,000 566,000 842,000 92,000 4,529,000 853,000
Iowa 2,921,000 233,000 465,000 78,000 2,317,000 329,000
Kansas 2,683,000 237,000 346,000 205,000 2,024,000 294,000
Kentucky 4,110,000 551,000 662,000 248,000 2,813,000 574,000
Louisiana 4,429,000 606,000 605,000 194,000 2,716,000 912,000
Maine 1,283,000 231,000 222,000 54,000 877,000 133,000
Maryland 5,493,000 441,000 673,000 186,000 4,129,000 762,000
Massachusetts 6,367,000 756,000 892,000 112,000 4,740,000 682,000
Michigan 9,918,000 1,258,000 1,394,000 135,000 7,555,000 1,080,000
Minnesota 5,076,000 484,000 572,000 106,000 4,110,000 444,000
Mississippi 2,854,000 537,000 421,000 188,000 1,696,000 511,000
Missouri 5,623,000 680,000 912,000 190,000 4,210,000 620,000
Montana 917,000 114,000 135,000 68,000 589,000 177,000
Nebraska 1,727,000 152,000 216,000 83,000 1,316,000 195,000
Nevada 2,250,000 188,000 278,000 90,000 1,518,000 426,000
New Hampshire 1,264,000 87,000 159,000 30,000 1,003,000 131,000
New Jersey 8,579,000 712,000 1,085,000 124,000 6,368,000 1,201,000
New Mexico 1,871,000 362,000 281,000 91,000 1,033,000 414,000
New York 18,970,000 3,125,000 2,754,000 234,000 12,594,000 2,866,000
North Carolina 8,253,000 1,057,000 1,213,000 438,000 5,277,000 1,424,000
North Dakota 631,000 55,000 88,000 43,000 480,000 69,000
Ohio 11,247,000 1,207,000 1,471,000 230,000 8,413,000 1,362,000
Oklahoma 3,438,000 397,000 555,000 224,000 2,136,000 701,000
Oregon 3,569,000 415,000 475,000 122,000 2,437,000 613,000
Pennsylvania 12,155,000 1,271,000 2,077,000 253,000 9,208,000 1,384,000
Rhode Island 1,053,000 160,000 163,000 27,000 766,000 108,000
South Carolina 4,064,000 553,000 663,000 221,000 2,777,000 584,000
South Dakota 751,000 81,000 119,000 34,000 560,000 91,000
Tennessee 5,909,000 964,000 856,000 258,000 3,935,000 778,000
Texas 21,858,000 2,916,000 2,320,000 686,000 12,663,000 5,374,000
Utah 2,352,000 199,000 208,000 85,000 1,831,000 298,000
Vermont 611,000 113,000 94,000 20,000 435,000 58,000
Virginia 7,386,000 574,000 986,000 750,000 5,301,000 962,000
Washington 6,091,000 842,000 688,000 314,000 4,160,000 944,000
West Virginia 1,787,000 298,000 355,000 65,000 1,089,000 296,000
Wisconsin 5,429,000 654,000 754,000 89,000 4,081,000 593,000
Wyoming 488,000 60,000 64,000 38,000 333,000 78,000
*The sum of rows may be greater than the total State population because individuals may have dual coverage and appear in
more than one category.
Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2004 Annual Social and
Economic Supplement.

3-8
National Pharmaceutical Council Pharmaceutical Benefits 2004

Insurance Status - Percentages, 2003*

% Covered by % Covered by
Total % Covered by % Covered by Military Private
State Population Medicaid Medicare Insurance Insurance % Not Insured
National Total 288,280,000 12.4% 13.7% 3.5% 68.6% 15.6%
Alabama 4,427,000 13.2% 15.5% 4.1% 67.7% 14.2%
Alaska 645,000 15.1% 8.5% 14.0% 61.5% 18.9%
Arizona 5,576,000 13.3% 13.6% 6.3% 64.0% 17.0%
Arkansas 2,671,000 16.0% 17.0% 7.0% 60.7% 17.4%
California 35,394,000 15.1% 11.7% 2.7% 63.8% 18.4%
Colorado 4,480,000 9.1% 9.9% 5.6% 69.8% 17.2%
Connecticut 3,421,000 10.7% 15.4% 2.1% 75.8% 10.4%
Delaware 820,000 11.2% 13.4% 3.9% 75.7% 11.1%
District of Columbia 554,000 18.2% 12.5% 2.1% 64.6% 14.3%
Florida 16,921,000 11.2% 18.4% 4.7% 64.7% 18.2%
Georgia 8,571,000 11.3% 11.6% 3.3% 69.5% 16.4%
Hawaii 1,253,000 10.6% 14.1% 8.3% 74.0% 10.1%
Idaho 1,360,000 12.3% 12.3% 3.0% 67.1% 18.6%
Illinois 12,628,000 9.5% 13.5% 1.7% 73.2% 14.4%
Indiana 6,149,000 9.2% 13.7% 1.5% 73.7% 13.9%
Iowa 2,921,000 8.0% 15.9% 2.7% 79.3% 11.3%
Kansas 2,683,000 8.8% 12.9% 7.6% 75.4% 11.0%
Kentucky 4,110,000 13.4% 16.1% 6.0% 68.4% 14.0%
Louisiana 4,429,000 13.7% 13.7% 4.4% 61.3% 20.6%
Maine 1,283,000 18.0% 17.3% 4.2% 68.4% 10.4%
Maryland 5,493,000 8.0% 12.3% 3.4% 75.2% 13.9%
Massachusetts 6,367,000 11.9% 14.0% 1.8% 74.4% 10.7%
Michigan 9,918,000 12.7% 14.1% 1.4% 76.2% 10.9%
Minnesota 5,076,000 9.5% 11.3% 2.1% 81.0% 8.7%
Mississippi 2,854,000 18.8% 14.8% 6.6% 59.4% 17.9%
Missouri 5,623,000 12.1% 16.2% 3.4% 74.9% 11.0%
Montana 917,000 12.5% 14.7% 7.4% 64.2% 19.4%
Nebraska 1,727,000 8.8% 12.5% 4.8% 76.2% 11.3%
Nevada 2,250,000 8.3% 12.4% 4.0% 67.5% 18.9%
New Hampshire 1,264,000 6.9% 12.6% 2.4% 79.3% 10.3%
New Jersey 8,579,000 8.3% 12.6% 1.4% 74.2% 14.0%
New Mexico 1,871,000 19.3% 15.0% 4.8% 55.2% 22.1%
New York 18,970,000 16.5% 14.5% 1.2% 66.4% 15.1%
North Carolina 8,253,000 12.8% 14.7% 5.3% 63.9% 17.3%
North Dakota 631,000 8.7% 13.9% 6.8% 76.0% 10.9%
Ohio 11,247,000 10.7% 13.1% 2.0% 74.8% 12.1%
Oklahoma 3,438,000 11.5% 16.1% 6.5% 62.1% 20.4%
Oregon 3,569,000 11.6% 13.3% 3.4% 68.3% 17.2%
Pennsylvania 12,155,000 10.5% 17.1% 2.1% 75.8% 11.4%
Rhode Island 1,053,000 15.2% 15.5% 2.5% 72.7% 10.2%
South Carolina 4,064,000 13.6% 16.3% 5.4% 68.3% 14.4%
South Dakota 751,000 10.8% 15.8% 4.6% 74.6% 12.2%
Tennessee 5,909,000 16.3% 14.5% 4.4% 66.6% 13.2%
Texas 21,858,000 13.3% 10.6% 3.1% 57.9% 24.6%
Utah 2,352,000 8.5% 8.8% 3.6% 77.8% 12.7%
Vermont 611,000 18.4% 15.4% 3.3% 71.1% 9.5%
Virginia 7,386,000 7.8% 13.4% 10.2% 71.8% 13.0%
Washington 6,091,000 13.8% 11.3% 5.2% 68.3% 15.5%
West Virginia 1,787,000 16.6% 19.9% 3.6% 60.9% 16.6%
Wisconsin 5,429,000 12.1% 13.9% 1.6% 75.2% 10.9%
Wyoming 488,000 12.3% 13.1% 7.8% 68.2% 15.9%
*The sum of rows may be greater than the total State population because individuals may have dual coverage and appear in
more than one category.
Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2004 Annual Social and
Economic Supplement.

3-9
National Pharmaceutical Council Pharmaceutical Benefits 2004

Poverty Status - Populations, 2003

Population Population Population Population


Total Below 100% Below 135% Below 150% Below 200%
State Population FPL* FPL* FPL* FPL*
National Total 287,699,000 35,861,000 54,460,000 62,553,000 287,699,000
Alabama 4,417,000 663,000 945,000 1,067,000 4,417,000
Alaska 643,000 62,000 99,000 120,000 643,000
Arizona 5,558,000 749,000 1,225,000 1,446,000 5,558,000
Arkansas 2,670,000 474,000 665,000 761,000 2,670,000
California 35,309,000 4,634,000 7,310,000 8,467,000 35,309,000
Colorado 4,478,000 436,000 682,000 789,000 4,478,000
Connecticut 3,417,000 278,000 420,000 496,000 3,417,000
Delaware 818,000 60,000 100,000 120,000 818,000
District of Columbia 550,000 92,000 120,000 135,000 550,000
Florida 16,884,000 2,148,000 3,266,000 3,714,000 16,884,000
Georgia 8,559,000 1,014,000 1,544,000 1,722,000 8,559,000
Hawaii 1,250,000 117,000 184,000 205,000 1,250,000
Idaho 1,356,000 138,000 220,000 263,000 1,356,000
Illinois 12,616,000 1,592,000 2,282,000 2,672,000 12,616,000
Indiana 6,130,000 610,000 1,062,000 1,205,000 6,130,000
Iowa 2,916,000 260,000 418,000 495,000 2,916,000
Kansas 2,676,000 288,000 443,000 508,000 2,676,000
Kentucky 4,100,000 589,000 952,000 1,113,000 4,100,000
Louisiana 4,422,000 750,000 1,129,000 1,239,000 4,422,000
Maine 1,279,000 149,000 246,000 280,000 1,279,000
Maryland 5,485,000 472,000 705,000 863,000 5,485,000
Massachusetts 6,357,000 652,000 1,010,000 1,172,000 6,357,000
Michigan 9,893,000 1,125,000 1,676,000 1,910,000 9,893,000
Minnesota 5,075,000 376,000 570,000 677,000 5,075,000
Mississippi 2,851,000 456,000 681,000 811,000 2,851,000
Missouri 5,606,000 602,000 929,000 1,084,000 5,606,000
Montana 915,000 139,000 231,000 262,000 915,000
Nebraska 1,725,000 168,000 273,000 314,000 1,725,000
Nevada 2,242,000 244,000 408,000 488,000 2,242,000
New Hampshire 1,263,000 73,000 119,000 141,000 1,263,000
New Jersey 8,574,000 741,000 1,138,000 1,304,000 8,574,000
New Mexico 1,867,000 338,000 510,000 589,000 1,867,000
New York 18,922,000 2,707,000 3,879,000 4,354,000 18,922,000
North Carolina 8,223,000 1,289,000 1,912,000 2,202,000 8,223,000
North Dakota 631,000 61,000 103,000 120,000 631,000
Ohio 11,227,000 1,226,000 1,771,000 2,053,000 11,227,000
Oklahoma 3,430,000 440,000 720,000 820,000 3,430,000
Oregon 3,560,000 446,000 646,000 758,000 3,560,000
Pennsylvania 12,135,000 1,279,000 1,894,000 2,237,000 12,135,000
Rhode Island 1,051,000 121,000 176,000 201,000 1,051,000
South Carolina 4,060,000 516,000 843,000 960,000 4,060,000
South Dakota 749,000 95,000 139,000 159,000 749,000
Tennessee 5,901,000 829,000 1,331,000 1,515,000 5,901,000
Texas 21,827,000 3,705,000 5,592,000 6,256,000 21,827,000
Utah 2,346,000 213,000 349,000 390,000 2,346,000
Vermont 610,000 52,000 93,000 107,000 610,000
Virginia 7,367,000 740,000 1,024,000 1,186,000 7,367,000
Washington 6,078,000 766,000 1,041,000 1,230,000 6,078,000
West Virginia 1,785,000 310,000 458,000 517,000 1,785,000
Wisconsin 5,412,000 528,000 851,000 964,000 5,412,000
Wyoming 487,000 48,000 77,000 93,000 487,000
*FPL- Federal Poverty Level

Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2004 Annual Social and
Economic Supplement.

3-10
National Pharmaceutical Council Pharmaceutical Benefits 2004

Poverty Status - Percentages, 2003

Percent Percent Percent Percent


Total Below 100% Below 135% Below 150% Below 200%
State Population FPL* FPL* FPL* FPL*
National Total 287,699,000 12.5% 18.9% 21.7% 31.1%
Alabama 4,417,000 15.0% 21.4% 24.1% 34.4%
Alaska 643,000 9.6% 15.4% 18.6% 27.5%
Arizona 5,558,000 13.5% 22.0% 26.0% 36.7%
Arkansas 2,670,000 17.8% 24.9% 28.5% 40.5%
California 35,309,000 13.1% 20.7% 24.0% 32.9%
Colorado 4,478,000 9.7% 15.2% 17.6% 26.2%
Connecticut 3,417,000 8.1% 12.3% 14.5% 22.0%
Delaware 818,000 7.3% 12.2% 14.7% 24.1%
District of Columbia 550,000 16.8% 21.8% 24.6% 32.5%
Florida 16,884,000 12.7% 19.3% 22.0% 32.6%
Georgia 8,559,000 11.9% 18.0% 20.1% 28.4%
Hawaii 1,250,000 9.3% 14.7% 16.4% 25.1%
Idaho 1,356,000 10.2% 16.2% 19.4% 34.7%
Illinois 12,616,000 12.6% 18.1% 21.2% 29.6%
Indiana 6,130,000 9.9% 17.3% 19.7% 28.2%
Iowa 2,916,000 8.9% 14.3% 17.0% 25.9%
Kansas 2,676,000 10.8% 16.5% 19.0% 28.9%
Kentucky 4,100,000 14.4% 23.2% 27.1% 35.3%
Louisiana 4,422,000 17.0% 25.5% 28.0% 39.9%
Maine 1,279,000 11.6% 19.3% 21.9% 32.5%
Maryland 5,485,000 8.6% 12.9% 15.7% 24.2%
Massachusetts 6,357,000 10.3% 15.9% 18.4% 25.2%
Michigan 9,893,000 11.4% 16.9% 19.3% 28.9%
Minnesota 5,075,000 7.4% 11.2% 13.3% 21.6%
Mississippi 2,851,000 16.0% 23.9% 28.5% 39.7%
Missouri 5,606,000 10.7% 16.6% 19.3% 27.9%
Montana 915,000 15.1% 25.2% 28.6% 38.5%
Nebraska 1,725,000 9.8% 15.9% 18.2% 26.0%
Nevada 2,242,000 10.9% 18.2% 21.8% 30.9%
New Hampshire 1,263,000 5.8% 9.4% 11.1% 18.6%
New Jersey 8,574,000 8.6% 13.3% 15.2% 23.1%
New Mexico 1,867,000 18.1% 27.3% 31.5% 43.6%
New York 18,922,000 14.3% 20.5% 23.0% 31.6%
North Carolina 8,223,000 15.7% 23.2% 26.8% 37.2%
North Dakota 631,000 9.7% 16.3% 19.0% 29.0%
Ohio 11,227,000 10.9% 15.8% 18.3% 27.7%
Oklahoma 3,430,000 12.8% 21.0% 23.9% 35.4%
Oregon 3,560,000 12.5% 18.1% 21.3% 30.2%
Pennsylvania 12,135,000 10.5% 15.6% 18.4% 27.7%
Rhode Island 1,051,000 11.5% 16.7% 19.1% 28.4%
South Carolina 4,060,000 12.7% 20.8% 23.6% 33.7%
South Dakota 749,000 12.7% 18.6% 21.2% 31.2%
Tennessee 5,901,000 14.0% 22.6% 25.7% 35.3%
Texas 21,827,000 17.0% 25.6% 28.7% 39.5%
Utah 2,346,000 9.1% 14.9% 16.6% 28.6%
Vermont 610,000 8.5% 15.2% 17.6% 26.2%
Virginia 7,367,000 10.0% 13.9% 16.1% 23.0%
Washington 6,078,000 12.6% 17.1% 20.2% 28.8%
West Virginia 1,785,000 17.4% 25.7% 29.0% 40.3%
Wisconsin 5,412,000 9.8% 15.7% 17.8% 26.5%
Wyoming 487,000 9.8% 15.8% 19.1% 29.2%
*FPL- Federal Poverty Level

Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2004 Annual Social and
Economic Supplement.

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Employment Status, 2004*

Total Civilian Population Unemployment


State Population Labor Force Unemployed Rate
National Total 223,357,000 147,401,000 8,149,000 5.5%
Alabama 3,484,000 2,149,000 119,000 5.6%
Alaska 465,000 333,000 25,000 7.5%
Arizona 4,266,000 2,774,000 137,000 5.0%
Arkansas 2,102,000 1,306,000 74,000 5.7%
California 26,768,000 17,552,000 1,092,000 6.2%
Colorado 3,468,000 2,522,000 139,000 5.5%
Connecticut 2,700,000 1,797,000 88,000 4.9%
Delaware 643,000 423,000 17,000 4.1%
District of Columbia 443,000 299,000 24,000 8.2%
Florida 13,521,000 8,396,000 399,000 4.8%
Georgia 6,534,000 4,390,000 202,000 4.6%
Hawaii 946,000 616,000 20,000 3.3%
Idaho 1,039,000 703,000 33,000 4.7%
Illinois 9,641,000 6,396,000 396,000 6.2%
Indiana 4,725,000 3,170,000 165,000 5.2%
Iowa 2,307,000 1,624,000 78,000 4.8%
Kansas 2,069,000 1,464,000 80,000 5.5%
Kentucky 3,194,000 1,974,000 104,000 5.3%
Louisiana 3,377,000 2,058,000 117,000 5.7%
Maine 1,055,000 699,000 32,000 4.6%
Maryland 4,223,000 2,883,000 122,000 4.2%
Massachusetts 5,036,000 3,393,000 174,000 5.1%
Michigan 7,748,000 5,079,000 360,000 7.1%
Minnesota 3,943,000 2,952,000 138,000 4.7%
Mississippi 2,169,000 1,330,000 82,000 6.2%
Missouri 4,424,000 3,031,000 172,000 5.7%
Montana 730,000 483,000 21,000 4.4%
Nebraska 1,331,000 985,000 37,000 3.8%
Nevada 1,759,000 1,178,000 51,000 4.3%
New Hampshire 1,018,000 723,000 27,000 3.8%
New Jersey 6,666,000 4,388,000 212,000 4.8%
New Mexico 1,436,000 912,000 52,000 5.7%
New York 14,906,000 9,355,000 543,000 5.8%
North Carolina 6,439,000 4,256,000 236,000 5.5%
North Dakota 497,000 354,000 12,000 3.4%
Ohio 8,828,000 5,885,000 362,000 6.1%
Oklahoma 2,671,000 1,710,000 83,000 4.8%
Oregon 2,800,000 1,856,000 138,000 7.4%
Pennsylvania 9,702,000 6,275,000 348,000 5.5%
Rhode Island 848,000 562,000 29,000 5.2%
South Carolina 3,193,000 2,046,000 140,000 6.8%
South Dakota 586,000 428,000 15,000 3.5%
Tennessee 4,564,000 2,908,000 156,000 5.4%
Texas 16,388,000 11,035,000 672,000 6.1%
Utah 1,697,000 1,203,000 63,000 5.2%
Vermont 499,000 353,000 13,000 3.7%
Virginia 5,605,000 3,815,000 140,000 3.7%
Washington 4,777,000 3,234,000 201,000 6.2%
West Virginia 1,452,000 788,000 42,000 5.3%
Wisconsin 4,280,000 3,071,000 152,000 4.9%
Wyoming 395,000 282,000 11,000 3.9%
*This information was compiled from the U.S. Department of Labor, Bureau of Labor Statistics News Release on State and
Regional Unemployment, 2004 Annual Averages, released on March 10, 2005. The table summarizes the employment status
of the civilian noninstitutional population, 16 years of age and over, by state.

Source: U.S. Department of Labor, Bureau of Labor Statistics, March 10, 2005.

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Medicaid/Medicare Certified Facilities, 2004

Skilled Nursing ICF-MR Home Health Rural Health


State Hospitals Facilities Facilities Agencies Clinics
National Total* 6,0482 14,982 6,521 7,617 3,545
Alabama 126 226 6 141 66
Alaska 24 14 0 16 6
Arizona 91 132 13 67 12
Arkansas 105 203 41 173 71
California 432 1,228 1,117 621 241
Colorado 87 195 3 130 37
Connecticut 45 246 118 84 0
Delaware 10 37 2 15 16
District of Columbia 14 19 128 18 0
Florida 237 686 108 538 154
Georgia 178 332 12 98 93
Hawaii 27 41 20 14 1
Idaho 48 77 66 49 46
Illinois 220 683 308 329 209
Indiana 156 483 520 185 53
Iowa 120 403 133 181 131
Kansas 152 264 31 136 177
Kentucky 119 295 13 105 118
Louisiana 221 297 486 225 62
Maine 42 117 20 30 46
Maryland 65 231 4 48 0
Massachusetts 112 463 6 118 1
Michigan 175 395 1 244 158
Minnesota 147 396 221 213 73
Mississippi 111 168 13 59 141
Missouri 138 482 19 156 284
Montana 66 100 1 40 42
Nebraska 96 185 4 68 99
Nevada 43 41 19 50 6
New Hampshire 32 72 1 35 17
New Jersey 108 357 9 52 0
New Mexico 51 73 43 62 12
New York 245 659 678 192 9
North Carolina 138 420 332 169 103
North Dakota 50 83 68 26 62
Ohio 216 941 421 386 17
Oklahoma 152 273 72 195 40
Oregon 59 120 1 60 53
Pennsylvania 247 710 192 292 41
Rhode Island 15 95 15 22 1
South Carolina 77 177 121 69 95
South Dakota 66 90 1 46 55
Tennessee 153 304 83 139 41
Texas 517 1,030 894 1,220 327
Utah 48 82 15 49 14
Vermont 16 41 2 12 19
Virginia 109 252 27 164 56
Washington 101 240 14 61 111
West Virginia 68 122 61 63 68
Wisconsin 143 369 36 122 58
Wyoming 30 33 2 30 19
*National total does not include certified facilities in Puerto Rico and U.S. territories.
Source: OSCAR Report 10. Facility Counts: Active Providers. CMS, Center for Medicaid and State Operations, January 18,
2005.

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Licensed Pharmacies (As of June 30, 2004)*

Hospital/ Independent Out-of-State or


Total Institutional Community Chain Pharmacies Non-Resident
State Pharmacies Pharmacies Pharmacies (Four or More) Pharmacies
National Total 80,858 7,934 15,443 15,651 13,280
Alabama 1,350 163 724 636 404
Alaska 130 (G) 25 (H) 257
Arizona 1,362 85 98 787 295
Arkansas 739 164 404 335 208
California 6,122 497 198
Colorado 1,232 353
Connecticut 617 (D) 50 (D) 162 (D) 455 (D) 312 (D)
Delaware 245 18 63 182 517
District of Columbia 123 13 27 61 0
Florida 6,841 (F) 1,945 (V) (V) 419
Georgia 3,689 205 (P) (P)
Hawaii 209 184
Idaho 639 275 (A, E) 273
Illinois 2,451 342 2,183 (A) (A) 296
Indiana 1,354 371
Iowa 1,247 130(F) 798 (A, F) (A) 302
Kansas 818 175 348 264 372
Kentucky 1,495 (X) 174 633 493 189
Louisiana 1,760 181 633 555 339
Maine 290 42 187
Maryland 2,168 (I) 65 126 700 331
Massachusetts 1,048 (J) 158 250 740 0
Michigan 2,547 150
Minnesota 1,502 134 478 552 334
Mississippi 962 130 220
Missouri 1,561 (K) 115 224 473 290
Montana 312 93 255
Nebraska 500 N/A 204 (L)
Nevada 794 268
New Hampshire 275 32 43 180 276
New Jersey 1,981
New Mexico 499 52 68 (A) 274
New York 4,644 470 (Q) 1,990 2,072 91
North Carolina 2,123 (F) 166 572 990 286
North Dakota 584 47 156 30 289
Ohio 2,984 (N) 227 573 1,544 374
Oklahoma 1,430 154 (D) 871 (A) (A) 383
Oregon 1,147 123 366 543 469
Pennsylvania 3,172 284 0
Rhode Island 206 21 38 5 363
South Carolina 1,169 403
South Dakota 546 45 123 87 291
Tennessee 1,918 444 525 844 105
Texas 5,981 (B) 583 1,737 2,354 332
Utah 898 106 473 (A) (A) 300
Vermont 158 17 141 89
Virginia 1,549 462
Washington 1,633 230 (C) 341 769 293
West Virginia 549 (J) 331
Wisconsin 3,165 0
Wyoming 140 (F) 29 341
*Figures reported reflect number of pharmacies licensed by state boards of pharmacy. Individual columns will not sum to
total. Total includes other pharmacies not specified in the four practice settings. Blanks indicate that information was not
available.
Source: 2005 National Association of Boards of Pharmacy, Survey of Pharmacy Law.

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LEGEND

A — Chains included in independent community pharmacies figure.


B — Also licenses 975 nuclear, public health, clinic, ambulatory surgical center, and HMO pharmacies.
C — Includes 121 hospital, 26 nursing home, 19 home infusion, 5 nuclear, 41 HMO, and 18 other pharmacies.
D — Approximately.
E — Plus 22 limited service and 61 parenteral admixture pharmacies.
F — In-state.
G — Includes 19 wholesalers drug distributors.
H — Drug rooms.
I — Total includes other areas not listed: clinic, correctional, HMO, nursing home, IV, nuclear, research, and other.
103 pharmacies have waiver (specialty permits) Board issued 682 distributor permits.
J — Total also includes home IV and mail-order pharmacies.
K — Includes the following pharmacy categories: 15 long-term care, 4 home health, 8 radiopharmaceutical, 2 renal
dialysis, 1 sterile pharmaceuticals, 1 consultant pharmacy, 1 medical gas, 1 shared services, and 405 with multiple
classes.
L — Nebraska licenses out-of-state pharmacies.
M — Plus 336 who are practicing, but place is unknown.
N — Includes 266 nuclear, clinic, fluid therapy, mail-order, specialty, and pharmaciesserving nursing homes only.
O — 2,498 technicians, 415 technicians-in training.
P — 2,202 (2,165 independent and chain pharmacies, 14 nuclear pharmacies, 18 prison pharmacies, 5 clinic
pharmacies, and 2 pharmacy schools).
Q — 16 nuclear pharmacies.
R — PTCB Certified – Total number of technicians unknown.
S — 6,525 plus 1,683 (Technicians-in training).
T — 242 of 609 ship controlled substances to ID.
U — Pharmacists may be counted more than once if work more than one job.
V –– For Florida, 4,477 are primarily community pharmacies but cannot be broken down by chain or independent.
W — Another 2,844 pharmacy technicians are applicants and must complete the registration process by paying the
registration fee; 1,443 pharmacy technicians are pending and the applications are waiting to be processed.
X — Includes 6 charitable pharmacies.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Physicians, 2001

Physicians Office Based Percent Primary Care Percent


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

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Other Providers, 2001/2004

# FTE # FTE
Registered Registered Nurses* Pharmacists** Pharmacists**
State Nurses* per 1,000 population (Licensed by State) per 1,000 population
National Total 962,195 3.4 352,869 1.2
Alabama 17,143 3.8 6,026 1.3
Alaska 2,339 3.7 616 0.9
Arizona 13,058 2.5 6,884 1.2
Arkansas 9,898 3.7 3,649 1.3
California 85,878 2.5 29,676 0.8
Colorado 12,034 2.7 5,445 1.2
Connecticut 9,930 2.9 4,486 1.3
Delaware 2,971 3.7 1,385 1.7
District of Columbia 5,011 8.7 1,564 2.8
Florida 56,078 3.4 21,540 1.2
Georgia 28,447 3.4 10,474 1.2
Hawaii 3,470 2.8 1,574 1.2
Idaho 3,599 2.7 1,623 1.2
Illinois 45,501 3.6 13,151 1.0
Indiana 21,436 3.5 8,696 1.4
Iowa 12,404 4.2 5,001 1.7
Kansas 9,102 3.4 3,652 1.3
Kentucky 16,213 4.0 5,383 1.3
Louisiana 17,274 3.9 5,970 1.3
Maine 5,265 4.1 1,267 1.0
Maryland 16,623 3.1 7,391 1.3
Massachusetts 24,133 3.8 9,940 1.5
Michigan 35,094 3.5 11,322 1.1
Minnesota 16,122 3.2 6,052 1.2
Mississippi 12,356 4.3 3,483 1.2
Missouri 23,650 4.2 7,123 1.2
Montana 3,205 3.5 1,556 1.7
Nebraska 7,249 4.2 2,722 1.6
Nevada 5,084 2.4 8,386 3.6
New Hampshire 4,206 3.3 1,963 1.5
New Jersey 28,082 3.3 13,100 1.5
New Mexico 5,258 2.9 2,325 1.2
New York 72,057 3.8 19,136 1.0
North Carolina 32,695 4.0 9,864 1.2
North Dakota 3,175 5.0 2,155 3.4
Ohio 43,869 3.9 14,703 1.3
Oklahoma 10,827 3.1 4,785 1.4
Oregon 11,674 3.4 4,189 1.2
Pennsylvania 48,786 4.0 17,991 1.5
Rhode Island 2,850 2.7 1,810 1.7
South Carolina 14,942 3.7 5,256 1.3
South Dakota 3,829 5.1 1,443 1.9
Tennessee 20,777 3.6 7,498 1.3
Texas 65,056 3.0 21,795 1.0
Utah 5,446 2.4 2,266 0.9
Vermont 1,656 2.7 840 1.4
Virginia 23,152 3.2 8,754 1.2
Washington 15,440 2.6 7,146 1.2
West Virginia 9,307 5.2 2,970 1.6
Wisconsin 16,878 3.1 5,836 1.1
Wyoming 1,666 3.4 1,007 2.0
*FTE- Full-time equivalent employees as of 2001
**As of June 30, 2004
Source: USDHHS, HRSA, Bureau of Health Professions, National Center for Health Workforce Information & Analysis,
Area Resource File, February 2003. 2005 National Association of Boards of Pharmacy, Survey of Pharmacy Law.

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Section 4:
Pharmacy Program
Characteristics

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THE MEDICAID DRUG PROGRAM

The Medicaid program defines prescribed drugs as simple or compound substances or mixtures of
substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance,
which are prescribed by a physician or other licensed practitioner of the healing arts within the scope
of their professional practice (42 CFR 440.120). The drugs must be dispensed by licensed authorized
practitioners on a written prescription that is recorded and maintained in the pharmacist’s or the
practitioner’s records.

MEDICAID PRESCRIPTION DRUG REIMBURSEMENT

On July 31, 1987, CMS published a notice of the final rule for limits on payments for drugs in the
Medicaid program. The regulations adopted in the rule became effective October 29, 1987 (52 FR
28648). In this final rule, CMS attempted to (1) respond to public comments on the NPRM (51 FR
2956); (2) provide maximum flexibility to the States in their administration of the Medicaid program;
(3) provide responsible but not burdensome Federal oversight of the Medicaid program; and (4) take
advantage of savings in the marketplace for multiple-source drugs.

To accomplish this, CMS adopted a Federal upper limit standard for certain multiple-source drugs,
based on application of a specific formula. The upper limit for other drugs is similar, in that it retains
the estimated acquisition cost (EAC) as the upper limit standard that State agencies must meet.
However, this standard is applied on an aggregate basis rather than on a prescription-specific basis.
State agencies are therefore encouraged to exercise maximum flexibility in establishing their own
payment methods (see the Federal Register, Vol. 52, No. 147, Friday, July 31, 1987, page 28648).

Multiple-Source Drugs

A multiple-source drug is one that is marketed or sold by two or more manufacturers or labelers, or a
drug marketed or sold by the same manufacturer or labeler under two or more different proprietary
names or under a proprietary name and without such a name.

A specific upper limit for a multiple-source drug may be established if the following requirements are
met:

• All of the formulations of the drug approved by the Food and Drug Administration (FDA) have
been evaluated as therapeutically equivalent in the current edition of the publication, Approved
Drug Products with Therapeutically Equivalent Evaluations; and
• At least three suppliers list the drug (which is classified by the FDA as Category A in its
publication) in the current editions of published compendia of cost information for drugs
available for sale nationally.
The upper limit for a multi-source drug for which a specific limit has been established does not apply
if a physician certifies in his or her own handwriting that a specific brand is “medically necessary” for
a particular recipient.

The handwritten phrase “brand necessary,” “medically necessary,” or “brand medically necessary”
must appear on the face of the prescription. The rule specifically states that a check-off box on a
prescription form is not acceptable, but it does not address the use of two-line prescription forms.

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The formula to be used in calculating the aggregate upper limit of payment for certain multiple-source
drugs will be 150% of the least costly therapeutic equivalent that can be purchased by pharmacists in
quantities of 100 tablets or capsules (or if the drug is not commonly available in quantities of 100, the
package size commonly listed), or in the case of liquids, the commonly listed size, plus a reasonable
dispensing fee.

Other Drugs

A drug described as an “other drug” is (1) a brand name drug certified as medically necessary by the
physician, (2) a multiple-source drug not subject to the 150% formula; or (3) a single-source drug.
Payments for these drugs must not exceed, in the aggregate, payment levels determined by applying
the lower of:

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


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

Other Requirements

The rule requires States to submit a State plan that describes their payment methods for prescribed
drugs. The rule does not prescribe a preferred payment method, as long as the State’s aggregate
spending in each category is equal to or below the upper limit requirements. States are also required
to submit assurances to CMS that the requirements are met.

The rule does not prescribe a preferred payment method for the States, but gives States the flexibility
to determine how they will pay for prescription drugs under Medicaid. As long as the State’s
aggregate spending is at or below the amount derived from the formula, the State is free to maintain
its current payment program or adopt other methods. States can alter payment rates for individual
drugs, balancing payment increases for certain products with payment decreases for other drugs so
that, in the aggregate, the program does not exceed the established limit. With the establishment of
upper limit payment maximums, some States may alter their current payment methods to comply with
the established limits.

State programs vary, depending upon whether or not State maximum allowable cost (MAC) programs
cover the same drugs listed by CMS. States with established MAC programs may be unaffected if
their MAC rates are already low, or they may have to make certain adjustments in their MAC levels
to meet the Federal aggregate expenditure limits. States without MAC programs may develop a new
payment method to increase the use of lower cost generic drug products in order to stay within the
upper payment limits, or may simply adopt CMS’ formula for listed drug products.

DRUG RECIPIENTS

Drug recipients are defined as individuals who received drugs, not as everyone eligible to receive
drugs. Today, all 50 States and the District of Columbia cover drugs under the Medicaid program.

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Drug Expenditures Trends*

State 2002 2003 % Change 2002-2003


National Total $29,339,050,970 $33,794,520,738 15.2%
Alabama $452,269,953 $536,222,703 18.6%
Alaska $70,708,412 $69,512,220 -1.7%
Arizona $3,725,371 $4,744,244 27.3%
Arkansas $273,257,660 $310,709,182 13.7%
California $3,591,537,830 $4,219,504,969 17.5%
Colorado $189,717,036 $225,297,507 18.8%
Connecticut $357,919,257 $403,802,170 12.8%
Delaware $97,750,161 $109,844,743 12.4%
District of Columbia $66,129,208 $81,762,504 23.6%
Florida $1,717,652,527 $2,018,037,106 17.5%
Georgia $873,703,133 $1,073,715,230 22.9%
Hawaii $88,256,904 $97,386,406 10.3%
Idaho $119,177,013 $132,143,091 10.9%
Illinois $1,293,435,797 $1,469,190,682 13.6%
Indiana $631,637,846 $627,575,345 -0.6%
Iowa $285,467,642 $331,222,324 16.0%
Kansas $213,778,616 $228,920,787 7.1%
Kentucky $652,904,065 $685,229,661 5.0%
Louisiana $714,107,841 $827,713,132 15.9%
Maine $220,420,714 $268,547,563 21.8%
Maryland $297,291,733 $429,589,193 44.5%
Massachusetts $958,972,520 $946,210,618 -1.3%
Michigan $674,222,281 $758,266,989 12.5%
Minnesota $310,174,144 $276,731,202 -10.8%
Mississippi $567,313,801 $568,007,104 0.1%
Missouri $790,853,387 $941,522,305 19.1%
Montana $83,587,410 $79,771,831 -4.6%
Nebraska $207,782,737 $210,199,726 1.2%
Nevada $86,929,536 $106,821,075 22.9%
New Hampshire $99,682,997 $112,948,647 13.3%
New Jersey $694,669,924 $766,995,569 10.4%
New Mexico $73,877,785 $86,408,362 17.0%
New York $3,660,427,024 $4,218,811,815 15.3%
North Carolina $1,100,822,176 $1,291,263,155 17.3%
North Dakota $52,495,878 $56,960,417 8.5%
Ohio $1,333,992,298 $1,520,147,470 14.0%
Oklahoma $285,068,869 $301,294,000 5.7%
Oregon $279,029,096 $262,335,388 -6.0%
Pennsylvania $718,210,352 $791,053,653 10.1%
Rhode Island $125,187,888 $140,686,626 12.4%
South Carolina $451,846,044 $558,129,364 23.5%
South Dakota $62,382,937 $71,223,108 14.2%
Tennessee $905,405,421 $1,280,129,986 41.4%
Texas $1,591,064,713 $1,920,865,985 20.7%
Utah $140,275,267 $163,217,885 16.4%
Vermont $114,157,870 $127,763,857 11.9%
Virginia $458,953,342 $506,414,352 10.3%
Washington $541,963,790 $592,437,155 9.3%
West Virginia $277,039,990 $345,831,214 24.8%
Wisconsin $442,718,195 $592,295,000 33.8%
Wyoming $39,094,579 $49,106,118 25.6%
*Rebates have not been subtracted from these figures.

Source: CMS, CMS-64 Report, FY 2002 and FY 2003.

4-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Ranking Based on Drug Expenditures*

% of 2003 National
2003 2003 Medicaid Drug 2002 2002
State Payments Ranking Expenditures Payments Ranking
National Total $33,794,520,738 $29,339,050,970
California $4,219,504,969 1 12.5% $3,591,537,830 2
New York $4,218,811,815 2 12.5% $3,660,427,024 1
Florida $2,018,037,106 3 6.0% $1,717,652,527 3
Texas $1,920,865,985 4 5.7% $1,591,064,713 4
Ohio $1,520,147,470 5 4.5% $1,333,992,298 5
Illinois $1,469,190,682 6 4.3% $1,293,435,797 6
North Carolina $1,291,263,155 7 3.8% $1,100,822,176 7
Tennessee $1,280,129,986 8 3.8% $905,405,421 9
Georgia $1,073,715,230 9 3.2% $873,703,133 10
Massachusetts $946,210,618 10 2.8% $958,972,520 8
Missouri $941,522,305 11 2.8% $790,853,387 11
Louisiana $827,713,132 12 2.4% $714,107,841 13
Pennsylvania $791,053,653 13 2.3% $718,210,352 12
New Jersey $766,995,569 14 2.3% $694,669,924 14
Michigan $758,266,989 15 2.2% $674,222,281 15
Kentucky $685,229,661 16 2.0% $652,904,065 16
Indiana $627,575,345 17 1.9% $631,637,846 17
Washington $592,437,155 18 1.8% $541,963,790 19
Wisconsin $592,295,000 19 1.8% $442,718,195 23
Mississippi $568,007,104 20 1.7% $567,313,801 18
South Carolina $558,129,364 21 1.7% $451,846,044 22
Alabama $536,222,703 22 1.6% $452,269,953 21
Virginia $506,414,352 23 1.5% $458,953,342 20
Maryland $429,589,193 24 1.3% $297,291,733 26
Connecticut $403,802,170 25 1.2% $357,919,257 24
West Virginia $345,831,214 26 1.0% $277,039,990 30
Iowa $331,222,324 27 1.0% $285,467,642 27
Arkansas $310,709,182 28 0.9% $273,257,660 31
Oklahoma $301,294,000 29 0.9% $285,068,869 28
Minnesota $276,731,202 30 0.8% $310,174,144 25
Maine $268,547,563 31 0.8% $220,420,714 32
Oregon $262,335,388 32 0.8% $279,029,096 29
Kansas $228,920,787 33 0.7% $213,778,616 33
Colorado $225,297,507 34 0.7% $189,717,036 35
Nebraska $210,199,726 35 0.6% $207,782,737 34
Utah $163,217,885 36 0.5% $140,275,267 36
Rhode Island $140,686,626 37 0.4% $125,187,888 37
Idaho $132,143,091 38 0.4% $119,177,013 38
Vermont $127,763,857 39 0.4% $114,157,870 39
New Hampshire $112,948,647 40 0.3% $99,682,997 40
Delaware $109,844,743 41 0.3% $97,750,161 41
Nevada $106,821,075 42 0.3% $86,929,536 43
Hawaii $97,386,406 43 0.3% $88,256,904 42
New Mexico $86,408,362 44 0.3% $73,877,785 45
District of Columbia $81,762,504 45 0.2% $66,129,208 47
Montana $79,771,831 46 0.2% $83,587,410 44
South Dakota $71,223,108 47 0.2% $62,382,937 48
Alaska $69,512,220 48 0.2% $70,708,412 46
North Dakota $56,960,417 49 0.2% $52,495,878 49
Wyoming $49,106,118 50 0.1% $39,094,579 50
Arizona $4,744,244 51 0.0% $3,725,371 51
*Rebates have not been subtracted from these figures.

Source: CMS, HCFA-64 Report, FY 2002 and FY 2003.

4-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

Drugs as a Percentage of Total Net Expenditures, 2003

Total Medicaid
Net Medical Assistance Total Drug % of Total
State Expenditures Expenditures* Net Expenditures
National Total $259,895,896,495 $33,794,520,738 13.0%
Alabama $3,477,832,931 $536,222,703 15.4%
Alaska $563,428,717 $69,512,220 12.3%
Arizona $4,219,253,105 $4,744,244 0.1%
Arkansas $2,329,593,600 $310,709,182 13.3%
California $30,051,769,056 $4,219,504,969 14.0%
Colorado $2,552,159,860 $225,297,507 8.8%
Connecticut $3,506,583,946 $403,802,170 11.5%
Delaware $718,470,271 $109,844,743 15.3%
District of Columbia $1,076,136,978 $81,762,504 7.6%
Florida $10,946,214,986 $2,018,037,106 18.4%
Georgia $6,300,856,479 $1,073,715,230 17.0%
Hawaii $766,109,972 $97,386,406 12.7%
Idaho $809,931,820 $132,143,091 16.3%
Illinois $9,253,097,164 $1,469,190,682 15.9%
Indiana $4,282,435,701 $627,575,345 14.7%
Iowa $2,136,386,901 $331,222,324 15.5%
Kansas $1,764,536,608 $228,920,787 13.0%
Kentucky $3,697,230,708 $685,229,661 18.5%
Louisiana $4,423,174,011 $827,713,132 18.7%
Maine $1,747,306,187 $268,547,563 15.4%
Maryland $4,343,054,613 $429,589,193 9.9%
Massachusetts $7,680,882,159 $946,210,618 12.3%
Michigan $7,967,828,590 $758,266,989 9.5%
Minnesota $3,604,575,049 $276,731,202 7.7%
Mississippi $2,853,086,305 $568,007,104 19.9%
Missouri $5,541,604,705 $941,522,305 17.0%
Montana $511,474,712 $79,771,831 15.6%
Nebraska $1,325,133,485 $210,199,726 15.9%
Nevada $1,015,796,455 $106,821,075 10.5%
New Hampshire $916,422,038 $112,948,647 12.3%
New Jersey $7,858,368,246 $766,995,569 9.8%
New Mexico $2,006,492,205 $86,408,362 4.3%
New York $39,585,134,508 $4,218,811,815 10.7%
North Carolina $7,050,804,888 $1,291,263,155 18.3%
North Dakota $468,522,734 $56,960,417 12.2%
Ohio $10,177,517,569 $1,520,147,470 14.9%
Oklahoma $2,311,939,159 $301,294,000 13.0%
Oregon $2,678,357,318 $262,335,388 9.8%
Pennsylvania $12,772,008,268 $791,053,653 6.2%
Rhode Island $1,436,618,006 $140,686,626 9.8%
South Carolina $3,540,107,364 $558,129,364 15.8%
South Dakota $536,195,894 $71,223,108 13.3%
Tennessee $6,348,265,631 $1,280,129,986 20.2%
Texas $15,420,026,696 $1,920,865,985 12.5%
Utah $1,092,519,199 $163,217,885 14.9%
Vermont $705,028,688 $127,763,857 18.1%
Virginia $3,524,849,814 $506,414,352 14.4%
Washington $5,006,473,801 $592,437,155 11.8%
West Virginia $1,857,747,927 $345,831,214 18.6%
Wisconsin $4,799,267,070 $592,295,000 12.3%
Wyoming $337,284,398 $49,106,118 14.6%
*Rebates have not been subtracted from these figures.

Source: CMS, CMS-64 Report, FY 2003.

4-7
National Pharmaceutical Council Pharmaceutical Benefits 2004

Drugs as a Percentage of Total Net Expenditures, 2001-2003*

State 2001 2002 2003


National Total 11.4% 11.9% 13.0%
Alabama 13.5% 14.6% 15.4%
Alaska 9.7% 10.3% 12.3%
Arizona 0.1% 0.1% 0.1%
Arkansas 13.0% 12.2% 13.3%
California 12.5% 13.4% 14.0%
Colorado 7.7% 8.2% 8.8%
Connecticut 9.5% 10.4% 11.5%
Delaware 13.7% 15.4% 15.3%
District of Columbia 6.5% 6.5% 7.6%
Florida 17.2% 17.4% 18.4%
Georgia 14.6% 14.0% 17.0%
Hawaii 11.8% 11.9% 12.7%
Idaho 14.9% 15.4% 16.3%
Illinois 11.4% 14.7% 15.9%
Indiana 14.0% 14.2% 14.7%
Iowa 14.1% 11.1% 15.5%
Kansas 11.0% 11.6% 13.0%
Kentucky 17.9% 17.3% 18.5%
Louisiana 13.9% 14.6% 18.7%
Maine 14.6% 15.4% 15.4%
Maryland 7.5% 8.2% 9.9%
Massachusetts 12.1% 11.9% 12.3%
Michigan 8.1% 8.9% 9.5%
Minnesota 6.9% 7.0% 7.7%
Mississippi 20.2% 19.7% 19.9%
Missouri 14.2% 14.8% 17.0%
Montana 15.0% 14.6% 15.6%
Nebraska 14.4% 15.5% 15.9%
Nevada 9.1% 10.8% 10.5%
New Hampshire 10.5% 9.8% 12.3%
New Jersey 9.1% 9.0% 9.8%
New Mexico 4.0% 4.2% 4.3%
New York 9.5% 10.1% 10.7%
North Carolina 16.0% 16.4% 18.3%
North Dakota 10.8% 11.4% 12.2%
Ohio 13.0% 13.8% 14.9%
Oklahoma 8.5% 12.6% 13.0%
Oregon 8.6% 10.9% 9.8%
Pennsylvania 6.3% 5.9% 6.2%
Rhode Island 8.6% 9.2% 9.8%
South Carolina 14.5% 13.7% 15.8%
South Dakota 11.1% 11.3% 13.3%
Tennessee 12.4% 15.6% 20.2%
Texas 11.4% 11.8% 12.5%
Utah 14.1% 14.3% 14.9%
Vermont 17.3% 17.3% 18.1%
Virginia 13.8% 12.0% 14.4%
Washington 10.6% 10.5% 11.8%
West Virginia 16.8% 17.5% 18.6%
Wisconsin 9.6% 10.6% 12.3%
Wyoming 12.9% 14.2% 14.6%
*Percentages are based on figures that have not had rebates subtracted from them.

Source: CMS, HCFA-64 Report, FY 2001 - FY 2003.

4-8
National Pharmaceutical Council Pharmaceutical Benefits 2004

Share of Drug Expenditures by Category, 2003

Hormones and
Central Nervous Cardiovascular Anti-Infective Gastrointestinal Synthetic
State System Drugs Drugs Agents Drugs Substitutes
National Total $12,363,631,847 $3,801,947,569 $3,524,213,631 $2,450,238,097 $3,122,393,794
Alabama $190,945,957 $66,659,877 $60,716,138 $27,223,794 $60,041,745
Alaska $40,923,331 $7,768,953 $8,847,721 $9,310,870 $7,442,275
Arizona* - - - - -
Arkansas $124,140,938 $31,785,881 $36,048,688 $15,032,482 $34,833,265
California $1,289,548,645 $559,177,157 $328,595,843 $332,606,715 $446,647,443
Colorado $103,640,073 $22,017,120 $18,531,371 $14,468,064 $20,563,418
Connecticut $175,996,061 $43,649,610 $33,252,384 $33,724,817 $28,069,637
Delaware $35,648,536 $9,932,451 $15,575,193 $6,274,352 $9,960,540
District of Columbia $22,639,645 $11,118,033 $20,050,510 $2,311,674 $5,808,770
Florida $693,597,564 $226,902,557 $327,894,156 $166,461,633 $169,619,538
Georgia $352,660,702 $106,114,919 $146,354,001 $46,097,696 $101,979,157
Hawaii $38,608,056 $16,570,061 $8,256,539 $4,368,883 $10,537,125
Idaho $60,904,208 $9,756,419 $10,628,384 $4,941,868 $12,181,215
Illinois $495,470,501 $216,632,381 $158,093,371 $120,206,662 $147,429,047
Indiana $285,453,451 $56,722,913 $50,052,280 $38,769,474 $61,546,793
Iowa $157,180,331 $29,475,299 $29,648,480 $20,589,271 $31,129,735
Kansas $108,704,011 $20,129,864 $17,339,561 $19,155,941 $20,852,659
Kentucky $259,250,343 $77,499,804 $65,552,414 $38,423,330 $71,239,832
Louisiana $243,290,866 $80,234,506 $109,817,991 $54,704,705 $72,578,920
Maine $117,977,151 $25,767,867 $18,778,785 $25,943,479 $26,564,709
Maryland $204,973,562 $52,518,379 $37,778,689 $30,695,978 $30,165,832
Massachusetts $426,324,589 $92,542,559 $91,559,817 $65,955,409 $76,059,993
Michigan $361,027,746 $76,602,148 $41,181,543 $46,655,710 $59,556,708
Minnesota $181,317,127 $22,612,381 $21,521,170 $26,666,517 $26,618,045
Mississippi $177,433,416 $84,476,651 $66,031,112 $32,146,980 $57,169,431
Missouri $405,814,288 $102,560,092 $85,327,587 $42,501,845 $91,382,260
Montana $40,552,154 $6,856,348 $5,988,940 $7,054,158 $7,814,615
Nebraska $90,518,087 $18,113,336 $17,825,594 $9,825,208 $19,259,675
Nevada $47,839,070 $11,322,593 $12,500,368 $4,793,034 $9,231,504
New Hampshire $55,511,397 $8,670,264 $6,145,697 $7,987,351 $9,272,731
New Jersey $282,889,997 $100,795,953 $86,862,944 $66,022,618 $59,052,329
New Mexico $33,805,242 $10,254,314 $7,189,377 $9,600,179 $11,525,477
New York $1,289,421,527 $466,736,184 $660,900,621 $298,153,780 $377,655,759
North Carolina $448,996,966 $150,623,341 $133,935,843 $137,251,191 $121,245,082
North Dakota $25,861,471 $4,787,469 $3,856,941 $3,635,205 $4,990,743
Ohio $652,799,378 $157,137,204 $135,588,872 $126,543,046 $143,667,021
Oklahoma $119,561,069 $30,104,381 $28,607,550 $17,356,536 $27,406,868
Oregon $141,970,988 $14,073,890 $12,508,942 $9,146,150 $15,944,333
Pennsylvania $307,075,831 $86,090,827 $51,191,071 $76,369,314 $66,108,211
Rhode Island $62,768,301 $18,136,380 $10,787,026 $12,448,121 $11,563,648
South Carolina $207,810,670 $89,756,227 $70,178,436 $28,189,939 $67,604,062
South Dakota $31,103,276 $5,211,572 $7,244,215 $6,629,496 $6,748,303
Tennessee $519,390,119 $161,820,197 $77,633,377 $114,371,425 $102,886,876
Texas $649,950,752 $197,853,618 $227,126,956 $119,278,242 $196,523,211
Utah $76,262,627 $10,588,695 $13,338,853 $12,287,375 $13,644,567
Vermont $12,190,259 $4,029,933 $2,955,483 $1,274,253 $3,432,229
Virginia $191,563,725 $64,498,544 $41,046,594 $55,067,690 $43,083,321
Washington $264,734,853 $57,092,141 $43,927,432 $50,205,897 $54,915,790
West Virginia $132,548,914 $41,425,874 $31,511,034 $22,586,370 $36,930,892
Wisconsin $106,988,776 $34,076,588 $23,531,062 $26,031,579 $27,907,393
Wyoming $18,045,300 $2,663,814 $4,396,675 $2,891,791 $4,001,062
* Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.

Source: CMS, State Drug Utilization Data, FY 2003.

4-9
National Pharmaceutical Council Pharmaceutical Benefits 2004

Share of Drug Expenditures by Category, 2003 (Con't.)

Unclassified
Therapeutic Autonomic Blood Formation
State Agents Drugs and Coagulation Other Total
National Average $1,055,465,025 $1,444,434,327 $1,631,603,922 $4,342,078,576 $33,736,006,788
Alabama $16,933,831 $29,117,413 $24,798,577 $88,291,181 $564,728,513
Alaska $3,017,515 $4,143,870 $6,586,137 $10,045,292 $98,085,964
Arizona* - - - - -
Arkansas $11,391,635 $16,290,279 $20,346,625 $43,386,184 $333,255,977
California $124,486,965 $109,440,799 $277,059,101 $392,418,402 $3,859,981,070
Colorado $8,369,762 $12,209,376 $8,772,382 $28,741,953 $237,313,519
Connecticut $10,845,172 $15,529,027 $15,588,038 $42,629,307 $399,284,053
Delaware $3,080,673 $4,797,072 $4,129,047 $14,564,793 $103,962,657
District of Columbia $1,528,819 $1,881,191 $4,304,599 $11,053,831 $80,697,072
Florida $66,881,733 $92,245,297 $114,802,172 $273,547,974 $2,131,952,624
Georgia $32,931,912 $58,770,316 $47,089,914 $172,266,157 $1,064,264,774
Hawaii $4,528,069 $4,022,621 $6,637,325 $12,070,039 $105,598,718
Idaho $4,314,264 $5,635,849 $2,919,820 $13,229,104 $124,511,131
Illinois $47,769,159 $63,945,423 $85,924,830 $197,901,702 $1,533,373,076
Indiana $23,254,776 $31,028,392 $42,923,482 $102,732,283 $692,483,844
Iowa $9,787,979 $16,730,776 $9,418,099 $39,127,637 $343,087,607
Kansas $7,119,076 $12,062,663 $6,580,327 $28,274,280 $240,218,382
Kentucky $26,072,218 $45,278,547 $30,533,575 $94,528,334 $708,378,397
Louisiana $23,611,873 $38,485,281 $36,873,442 $139,158,070 $798,755,654
Maine $8,040,234 $12,176,814 $10,185,925 $25,153,673 $270,588,637
Maryland $10,075,261 $12,388,585 $21,864,657 $39,448,955 $439,909,898
Massachusetts $25,289,436 $32,901,099 $38,923,231 $105,231,780 $954,787,913
Michigan $24,190,573 $28,593,928 $37,571,523 $85,771,522 $761,151,401
Minnesota $10,553,097 $14,662,898 $13,349,968 $38,123,425 $355,424,628
Mississippi $16,796,656 $27,954,253 $26,440,052 $76,114,896 $564,563,447
Missouri $27,673,946 $51,284,406 $44,879,042 $128,694,744 $980,118,210
Montana $3,539,485 $4,642,139 $2,668,099 $10,979,885 $90,095,823
Nebraska $6,717,962 $9,742,260 $6,302,498 $26,583,522 $204,888,142
Nevada $3,571,056 $5,639,042 $6,116,918 $13,564,994 $114,578,579
New Hampshire $2,992,898 $5,631,726 $2,482,312 $12,988,214 $111,682,590
New Jersey $25,517,275 $33,348,479 $52,697,474 $104,790,316 $811,977,385
New Mexico $3,806,974 $4,222,012 $3,924,480 $13,564,380 $97,892,435
New York $141,742,052 $155,076,486 $197,337,654 $555,046,144 $4,142,070,207
North Carolina $42,606,450 $56,952,033 $60,109,134 $193,389,654 $1,345,109,694
North Dakota $1,697,267 $2,510,695 $1,645,740 $6,675,757 $55,661,288
Ohio $45,200,120 $85,106,203 $57,239,140 $213,194,584 $1,616,475,568
Oklahoma $11,119,046 $14,623,169 $14,922,093 $32,159,087 $295,859,799
Oregon $5,192,257 $8,586,132 $7,653,099 $16,824,128 $231,899,919
Pennsylvania $24,675,241 $44,691,804 $48,107,836 $101,012,127 $805,322,262
Rhode Island $3,880,507 $5,800,930 $4,609,417 $15,825,524 $145,819,854
South Carolina $19,236,343 $28,235,443 $24,643,479 $92,173,886 $627,828,485
South Dakota $2,361,480 $3,460,577 $2,942,659 $10,135,666 $75,837,244
Tennessee $32,266,211 $51,570,846 $37,631,333 $119,158,930 $1,216,729,314
Texas $68,447,771 $95,780,057 $88,073,590 $351,910,677 $1,994,944,874
Utah $4,199,480 $6,240,065 $2,186,777 $19,419,642 $158,168,081
Vermont $1,171,684 $1,460,581 $1,529,437 $4,942,610 $32,986,469
Virginia $15,844,703 $25,131,271 $27,136,311 $71,109,483 $534,481,642
Washington $18,662,019 $24,374,739 $20,421,210 $64,322,622 $598,656,703
West Virginia $11,707,954 $16,987,581 $9,383,374 $43,432,138 $346,514,131
Wisconsin $9,066,980 $10,992,631 $11,481,805 $40,318,584 $290,395,398
Wyoming $1,697,176 $2,051,251 $1,856,163 $6,050,504 $43,653,736
* Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.

Source: CMS, State Drug Utilization Data, FY 2003.

4-10
National Pharmaceutical Council Pharmaceutical Benefits 2004

Share of Prescriptions Processed, 2003

Hormones and
Central Nervous Cardiovascular Anti-Infective Gastrointestinal Synthetic
State System Drugs Drugs Agents Drugs Substitutes
National Average 171,087,805 80,839,088 48,001,985 34,302,085 55,890,837
Alabama 3,171,638 1,567,963 1,138,879 553,609 1,127,896
Alaska 548,257 203,519 122,476 103,357 149,034
Arizona* - - - - -
Arkansas 1,731,110 797,550 759,124 263,680 648,832
California 14,259,438 7,954,722 3,977,118 3,317,303 5,721,487
Colorado 1,583,124 593,377 413,553 244,334 520,571
Connecticut 2,072,006 915,787 259,671 362,472 545,336
Delaware 487,968 184,937 162,745 76,266 169,529
District of Columbia 268,419 225,749 84,515 33,064 98,035
Florida 9,307,006 5,172,090 2,831,244 1,902,380 3,047,416
Georgia 5,424,867 2,495,750 2,494,567 898,164 1,998,544
Hawaii 490,672 324,763 92,049 136,203 177,740
Idaho 763,814 214,445 196,731 82,277 238,825
Illinois 8,266,131 5,540,656 2,496,296 2,101,959 3,234,926
Indiana 4,206,893 1,419,140 992,144 932,118 1,112,689
Iowa 2,232,976 746,404 578,027 304,342 638,478
Kansas 1,429,685 544,022 345,553 244,418 448,490
Kentucky 4,209,055 1,901,993 1,308,853 1,002,805 1,352,565
Louisiana 3,653,912 1,731,401 1,710,847 586,044 1,301,839
Maine 1,909,114 708,202 356,938 323,601 580,394
Maryland 2,485,651 1,120,167 313,685 353,731 609,632
Massachusetts 5,852,176 2,326,321 1,039,851 891,682 1,614,601
Michigan 5,348,834 2,085,945 746,226 801,119 1,280,656
Minnesota 2,088,156 559,625 311,226 451,235 485,462
Mississippi 2,572,856 1,769,873 1,137,394 451,414 1,012,463
Missouri 5,202,372 2,282,561 1,195,140 814,529 1,643,419
Montana 563,101 171,791 129,643 96,744 172,580
Nebraska 1,289,900 447,252 390,739 310,048 385,045
Nevada 599,049 256,638 151,055 81,940 183,761
New Hampshire 783,744 217,582 131,413 158,724 181,359
New Jersey 3,444,576 1,981,577 628,802 714,276 1,021,018
New Mexico 595,916 281,797 134,825 143,222 286,371
New York 16,319,688 9,021,907 5,175,402 4,049,862 5,817,384
North Carolina 6,235,662 3,386,484 2,032,839 1,332,424 2,364,568
North Dakota 357,380 143,776 91,286 50,922 120,832
Ohio 9,926,750 3,864,726 2,349,075 2,407,992 2,899,276
Oklahoma 1,395,693 581,302 512,325 232,606 454,827
Oregon 2,004,987 453,103 222,004 224,644 397,877
Pennsylvania 4,198,755 2,036,284 837,861 948,649 1,335,172
Rhode Island 813,442 308,215 116,847 159,760 192,723
South Carolina 2,928,723 2,021,657 1,047,783 475,084 1,339,858
South Dakota 399,558 147,440 158,080 71,747 138,279
Tennessee 8,340,084 3,670,322 1,286,313 1,496,149 2,213,225
Texas 9,092,238 3,169,705 4,802,083 1,600,010 2,757,927
Utah 1,109,740 241,808 297,363 166,672 294,969
Vermont 166,600 74,664 41,811 22,874 57,384
Virginia 2,838,758 1,428,824 603,632 774,924 853,123
Washington 3,872,043 1,467,594 701,236 823,549 1,224,420
West Virginia 2,215,492 928,170 664,115 359,356 691,640
Wisconsin 1,788,091 1,087,096 333,075 329,368 675,631
Wyoming 241,705 62,412 97,526 38,433 72,729
*Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.

Source: CMS, State Drug Utilization Data, FY 2003.

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Share of Prescriptions Processed, 2003 (Con't)

Unclassified
Therapeutic Autonomic Blood Formation
State Agents Drugs and Coagulation Other Total
National Average 11,853,860 30,838,002 13,382,215 115,859,862 562,055,739
Alabama 212,576 658,280 265,307 2,704,930 11,401,078
Alaska 28,043 87,848 30,535 233,712 1,506,781
Arizona* - - - - -
Arkansas 121,607 322,711 129,844 1,262,522 6,036,980
California 1,119,181 2,220,821 1,370,538 9,121,332 49,061,940
Colorado 96,895 298,800 100,463 850,026 4,701,143
Connecticut 125,679 292,253 156,958 939,638 5,669,800
Delaware 33,085 107,860 26,206 328,206 1,576,802
District of Columbia 21,565 44,891 24,297 218,812 1,019,347
Florida 835,642 1,831,715 861,701 6,044,048 31,833,242
Georgia 392,437 1,305,010 428,075 4,639,338 20,076,752
Hawaii 63,617 82,552 45,988 330,097 1,743,681
Idaho 44,790 120,381 33,901 347,382 2,042,546
Illinois 656,985 1,573,171 928,489 6,946,150 31,744,763
Indiana 230,548 698,234 310,000 2,781,211 12,682,977
Iowa 114,630 354,809 140,862 1,107,657 6,218,185
Kansas 81,549 245,679 90,475 771,341 4,201,212
Kentucky 313,874 870,152 342,808 3,154,670 14,456,775
Louisiana 281,821 863,458 341,589 3,512,998 13,983,909
Maine 97,307 303,890 83,761 675,526 5,038,733
Maryland 130,618 299,880 189,155 1,013,935 6,516,454
Massachusetts 275,688 813,956 301,360 2,415,517 15,531,152
Michigan 275,857 652,859 409,452 2,342,925 13,943,873
Minnesota 90,260 280,272 95,056 941,083 5,302,375
Mississippi 208,689 476,308 285,945 2,158,653 10,073,595
Missouri 287,390 973,232 386,707 3,028,715 15,814,065
Montana 34,681 99,230 25,941 275,126 1,568,837
Nebraska 77,885 230,919 84,325 951,883 4,167,996
Nevada 39,978 123,670 40,868 325,257 1,802,216
New Hampshire 32,045 114,142 35,577 398,917 2,053,503
New Jersey 294,180 575,191 332,324 2,355,693 11,347,637
New Mexico 41,959 101,590 49,449 459,079 2,094,208
New York 1,610,186 3,409,929 1,192,203 13,543,607 60,140,168
North Carolina 524,687 1,193,010 454,082 4,694,793 22,218,549
North Dakota 22,156 52,161 25,011 206,338 1,069,862
Ohio 561,787 1,914,814 739,909 6,915,185 31,579,514
Oklahoma 96,291 266,844 81,798 746,371 4,368,057
Oregon 52,451 196,722 73,708 579,612 4,205,108
Pennsylvania 274,742 754,046 579,899 2,602,161 13,567,569
Rhode Island 49,480 120,909 51,961 387,406 2,200,743
South Carolina 225,238 569,221 268,378 2,314,061 11,190,003
South Dakota 27,068 70,636 29,357 270,255 1,312,420
Tennessee 396,317 1,173,744 503,537 3,793,613 22,873,304
Texas 617,164 2,146,746 626,793 10,040,023 34,852,689
Utah 45,455 158,015 42,323 539,754 2,896,099
Vermont 10,812 29,345 9,374 96,604 509,468
Virginia 205,807 486,953 245,099 2,043,981 9,481,101
Washington 189,025 608,244 213,822 1,954,869 11,054,802
West Virginia 143,269 377,868 125,592 1,222,582 6,728,084
Wisconsin 125,280 238,879 157,435 1,112,614 5,847,469
Wyoming 15,584 46,152 13,978 159,654 748,173
*Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.

Source: CMS, State Drug Utilization Data, FY 2003.

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Medicaid Average Cost Per Prescription, 2003*

Drug Prescriptions Average


State Payments Processed Prescription Cost
National Average $33,736,006,788 562,055,739 $60.02
Alabama $564,728,513 11,401,078 $49.53
Alaska $98,085,964 1,506,781 $65.10
Arizona** - - -
Arkansas $333,255,977 6,036,980 $55.20
California $3,859,981,070 49,061,940 $78.68
Colorado $237,313,519 4,701,143 $50.48
Connecticut $399,284,053 5,669,800 $70.42
Delaware $103,962,657 1,576,802 $65.93
District of Columbia $80,697,072 1,019,347 $79.17
Florida $2,131,952,624 31,833,242 $66.97
Georgia $1,064,264,774 20,076,752 $53.01
Hawaii $105,598,718 1,743,681 $60.56
Idaho $124,511,131 2,042,546 $60.96
Illinois $1,533,373,076 31,744,763 $48.30
Indiana $692,483,844 12,682,977 $54.60
Iowa $343,087,607 6,218,185 $55.17
Kansas $240,218,382 4,201,212 $57.18
Kentucky $708,378,397 14,456,775 $49.00
Louisiana $798,755,654 13,983,909 $57.12
Maine $270,588,637 5,038,733 $53.70
Maryland $439,909,898 6,516,454 $67.51
Massachusetts $954,787,913 15,531,152 $61.48
Michigan $761,151,401 13,943,873 $54.59
Minnesota $355,424,628 5,302,375 $67.03
Mississippi $564,563,447 10,073,595 $56.04
Missouri $980,118,210 15,814,065 $61.98
Montana $90,095,823 1,568,837 $57.43
Nebraska $204,888,142 4,167,996 $49.16
Nevada $114,578,579 1,802,216 $63.58
New Hampshire $111,682,590 2,053,503 $54.39
New Jersey $811,977,385 11,347,637 $71.55
New Mexico $97,892,435 2,094,208 $46.74
New York $4,142,070,207 60,140,168 $68.87
North Carolina $1,345,109,694 22,218,549 $60.54
North Dakota $55,661,288 1,069,862 $52.03
Ohio $1,616,475,568 31,579,514 $51.19
Oklahoma $295,859,799 4,368,057 $67.73
Oregon $231,899,919 4,205,108 $55.15
Pennsylvania $805,322,262 13,567,569 $59.36
Rhode Island $145,819,854 2,200,743 $66.26
South Carolina $627,828,485 11,190,003 $56.11
South Dakota $75,837,244 1,312,420 $57.78
Tennessee $1,216,729,314 22,873,304 $53.19
Texas $1,994,944,874 34,852,689 $57.24
Utah $158,168,081 2,896,099 $54.61
Vermont $32,986,469 509,468 $64.75
Virginia $534,481,642 9,481,101 $56.37
Washington $598,656,703 11,054,802 $54.15
West Virginia $346,514,131 6,728,084 $51.50
Wisconsin $290,395,398 5,847,469 $49.66
Wyoming $43,653,736 748,173 $58.35
*Rebates have not been subtracted from these figures.
**Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
Source: CMS, State Drug Utilization Data, FY 2003.

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MEDICAID DRUG REBATES

In 1990, Congress considered a number of proposals designed to reduce and control Federal and State
expenditures for prescription drug products provided to Medicaid patients (S.2605, the
Pharmaceutical Access and Prudent Purchasing Act; S.3029, the Medicaid Anti-Discriminatory Drug
Act, sponsored by Senator David Pryor; and H.R.5589, the Medicaid Prescription Drug Fair Access
and Pricing Act, sponsored by Representatives Ron Wyden and Jim Cooper). A vigorous
Congressional debate ensued over which of these approaches to pursue. Several pharmaceutical
manufacturers voluntarily offered rebates to the States in exchange for open access for their products,
while the Pharmaceutical Manufacturers Association proposed a set rebate amount in exchange for
open formularies. Numerous public interest groups offered opinions on the proposals and in some
cases proposals of their own.

The Congressional debate ended in both the House and Senate offering somewhat similar proposals.
During the ensuing Conference between the House and Senate, the Office of Management and Budget
(OMB) argued for the inclusion of several proposals into the provisions in budget bill, the Omnibus
Budget Reconciliation Act of 1990 (OBRA ’90). The resulting Public Law 101-508, enacted
November 5, 1990, required a drug manufacturer to enter into and have in effect a national rebate
agreement with the Secretary of DHHS for States to receive Federal funding for outpatient drugs
dispensed to Medicaid patients. (For a detailed account of the debate and genesis of various
provisions see Robert Betz’s analysis of the Medicaid Best Price Law and its effect on pharmaceutical
manufacturers’ pricing policies.∗)

The requirement for rebate agreements does not apply to the dispensing of a single-source or
innovator multiple-source drug if the State has determined that the drug is essential, rated 1-A by the
FDA, and prior authorization is obtained for the exception. Existing rebate agreements qualify under
the law if the State agrees to report all rebates to DHHS and the agreement provides for a minimum
aggregate rebate of 10% of the State’s expenditures for the manufacturer’s products.

OBRA ‘90 was amended by the Veterans Health Care Act of 1992 which also required a drug
manufacturer to enter into discount pricing agreements with the Department of Veterans Affairs and
with covered entities funded by the Public Health Service in order to have its drugs covered by
Medicaid. The Medicaid rebate law, as amended, is included as Appendix C.

The drug rebate program is administered by CMS’ Center for Medicaid and State Operations
(CMSO). Currently, the rebate for covered outpatient drugs is as follows:

• For all innovator products, reimbursement requires: (1) a rebate that is the greater of 15.1
percent of the average manufacturer’s price (AMP) or the difference between the AMP and
the manufacturer’s “best price,” and (2) an additional rebate for any price increase for a
product that exceeds the increase in the Consumer Price Index (CPI-U) for all items since the
fall of 1990. AMP is the average price paid by wholesalers for products distributed to the
retail class of trade. The best price is the lowest price offered to any other customer,
excluding Federal Supply Schedule prices, prices to State pharmaceutical assistance
programs, and prices that are nominal in amount, and includes all discounts and rebates.
• For generic drugs (non-innovator drugs), reimbursement requires: a rebate of 11 percent of
each product’s AMP.


Robert Betz, “The Medicaid Best Price Law and Its Effect on Pharmaceutical Manufacturer’s Pricing Policies and Behavior for
Name Brand, Outpatient Pharmaceutical Products,” unpubl. Ph.D. dissertation, The George Washington University, May 21,
2000.

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Medicaid Drug Rebates, 2003

Allocation of
State Drug Rebate Monies1 Total Rebates2 Federal Share2
National Total $7,008,382,303 $4,145,168,732
Alabama Medicaid Drug Budget $102,784,110 $74,244,635
Alaska General Fund $15,060,446 $8,946,379
Arizona* - - -
Arkansas Medicaid Drug Budget $58,097,761 $44,058,096
California Medicaid Drug Budget $1,207,800,866 $635,884,565
Colorado Medicaid General $32,446,928 $16,743,775
Connecticut General Fund $81,550,711 $42,156,720
Delaware Medicaid General $28,352,506 $14,871,627
District of Columbia Medicaid Drug Budget $15,120,780 $10,813,162
Florida Medicaid Drug Budget $464,880,949 $281,544,767
Georgia General Fund $219,238,104 $133,880,256
Hawaii General Fund $19,212,047 $11,571,434
Idaho General Fund $31,430,642 $22,834,044
Illinois Drug Rebate Fund $292,630,625 $150,740,652
Indiana General Fund $131,850,261 $83,862,599
Iowa Medicaid Drug Budget $62,173,583 $40,568,073
Kansas General Fund $59,849,370 $36,912,589
Kentucky General Fund $124,919,867 $89,772,191
Louisiana Medicaid Drug Budget $165,904,174 $121,064,068
Maine Medicaid Drug Budget $68,331,107 $46,664,469
Maryland Medicaid General $77,934,401 $40,509,917
Massachusetts Medicaid General $208,146,240 $108,049,289
Michigan General Fund $179,774,542 $103,731,878
Minnesota Medicaid General $54,081,115 $27,643,562
Mississippi Medicaid General $114,233,479 $89,163,417
Missouri Medicaid Drug Budget $178,620,625 $112,813,582
Montana General Fund $17,172,113 $12,822,675
Nebraska Medicaid Drug Budget $42,766,762 $26,291,497
Nevada General Fund $21,078,909 $11,402,018
New Hampshire General Fund $27,628,562 $14,223,879
New Jersey Medicaid Drug Budget $149,040,244 $76,924,905
New Mexico General Fund $19,585,223 $14,894,385
New York General Fund $598,407,083 $305,702,916
North Carolina Medicaid General $260,487,290 $168,077,481
North Dakota Medicaid Drug Budget $11,369,358 $8,067,828
Ohio Medicaid General $325,329,459 $196,899,815
Oklahoma Medicaid General $59,205,487 $42,776,373
Oregon General Fund $65,706,778 $40,630,979
Pennsylvania Outpatient Appropriation $149,563,463 $84,158,389
Rhode Island General Fund $30,477,726 $17,361,117
South Carolina Medicaid Drug Budget $119,101,600 $85,684,428
South Dakota Medicaid Drug Budget $14,808,661 $10,010,329
Tennessee Medicaid General $224,072,761 $148,367,141
Texas Medicaid Drug Budget $392,292,711 $242,560,725
Utah General Fund $25,931,043 $19,597,473
Vermont Health Access Trust Fund $28,595,852 $18,448,953
Virginia Medicaid General $112,854,618 $59,506,765
Washington General Fund $123,683,508 $64,563,377
West Virginia Medicaid General $69,568,029 $53,266,225
Wisconsin Medicaid General $118,267,026 $69,458,066
Wyoming Medicaid Drug Budget $6,962,798 $4,425,247
*Does not apply for Arizona. Arizona has a 1115 waiver for which special rules apply.
Sources: 1As reported by State drug program administrators in the 2004 NPC Survey.
2
CMS, CMS-64 Report, FY 2003, includes reported state supplemental rebates for CA, FL, IL, LA, MI, VT, and WV.

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Medicaid Drug Rebate Trends, 1999-2003

State 1999 2000 2001 2002** 2003**


National Total $3,338,497,983 $3,980,646,518 $4,948,222,331 $5,917,504,760 $7,008,382,303
Alabama $49,785,076 $60,984,826 $76,624,463 $84,994,286 $102,784,110
Alaska $7,050,981 $8,594,014 $11,337,883 $14,347,654 $15,060,446
Arizona* - - - - -
Arkansas $37,931,853 $40,814,931 $45,744,406 $56,688,398 $58,097,761
California $539,928,783 $600,895,711 $786,113,991 $946,651,118 $1,207,800,866
Colorado $25,151,080 $28,832,989 $34,264,574 $39,054,140 $32,446,928
Connecticut $38,656,394 $49,164,014 $61,916,192 $62,627,160 $81,550,711
Delaware $9,787,444 $13,780,359 $17,042,045 $16,990,455 $28,352,506
District of Columbia $8,379,982 $9,215,651 $10,446,499 $11,445,790 $15,120,780
Florida $195,512,719 $248,637,014 $297,362,792 $353,649,807 $464,880,949
Georgia $95,237,778 $91,886,605 $110,087,285 $205,469,531 $219,238,104
Hawaii $8,378,292 $10,947,632 $14,363,603 $15,267,796 $19,212,047
Idaho $11,901,778 $13,984,004 $18,841,154 $22,939,130 $31,430,642
Illinois $121,540,781 $143,590,170 $170,733,612 $190,316,986 $292,630,625
Indiana $62,691,135 $84,453,135 $103,148,144 $126,512,101 $131,850,261
Iowa $32,369,409 $36,040,216 $42,602,101 $50,092,788 $62,173,583
Kansas $26,878,486 $31,022,023 $39,731,568 $29,755,595 $59,849,370
Kentucky $72,676,810 $93,688,165 $104,759,238 $133,330,557 $124,919,867
Louisiana $76,147,317 $84,800,897 $115,254,842 $113,729,749 $165,904,174
Maine $30,032,364 $31,598,262 $41,847,632 $47,395,300 $68,331,107
Maryland $32,311,299 $42,081,781 $34,263,429 $54,261,949 $77,934,401
Massachusetts $140,102,747 $146,225,538 $180,517,139 $191,118,385 $208,146,240
Michigan $75,674,128 $75,687,945 $111,716,756 $172,522,597 $179,774,542
Minnesota $37,389,033 $43,228,324 $54,548,714 $62,655,474 $54,081,115
Mississippi $49,332,307 $61,260,326 $88,481,567 $115,221,421 $114,233,479
Missouri $84,620,799 $110,025,619 $133,927,028 $147,281,505 $178,620,625
Montana $9,290,653 $10,985,923 $13,359,968 $15,955,235 $17,172,113
Nebraska $21,609,490 $31,004,940 $30,219,685 $47,855,128 $42,766,762
Nevada $7,727,267 $4,863,879 $16,330,579 $13,547,604 $21,078,909
New Hampshire $12,956,727 $15,073,211 $13,934,765 $20,888,707 $27,628,562
New Jersey $90,472,488 $105,535,091 $124,127,231 $127,373,014 $149,040,244
New Mexico $7,972,600 $8,901,456 $12,110,896 $13,274,387 $19,585,223
New York $356,088,488 $470,317,992 $543,984,948 $663,973,100 $598,407,083
North Carolina $111,326,116 $140,047,825 $207,551,841 $207,064,443 $260,487,290
North Dakota $5,954,387 $6,503,601 $8,780,182 $11,651,682 $11,369,358
Ohio $148,477,399 $171,685,793 $217,702,350 $263,267,258 $325,329,459
Oklahoma $31,992,100 $37,135,809 $40,177,945 $51,471,649 $59,205,487
Oregon $21,360,688 $32,056,386 $34,991,037 $54,474,938 $65,706,778
Pennsylvania $119,340,064 $118,989,849 $129,265,110 $154,338,235 $149,563,463
Rhode Island $14,440,971 $19,223,034 $21,467,002 $26,213,636 $30,477,726
South Carolina $55,971,288 $73,052,676 $95,438,155 $98,272,773 $119,101,600
South Dakota $5,971,015 $7,198,848 $9,405,933 $12,056,925 $14,808,661
Tennessee $22,434,760 $41,302,450 $102,644,077 $180,613,885 $224,072,761
Texas $185,695,267 $222,314,531 $268,557,241 $305,110,523 $392,292,711
Utah $15,145,126 $21,889,639 $21,949,963 $36,756,960 $25,931,043
Vermont $10,579,999 $17,869,053 $22,045,277 $24,488,863 $28,595,852
Virginia $67,715,512 $75,630,717 $79,484,868 $76,776,155 $112,854,618
Washington $54,331,249 $69,782,396 $91,250,830 $100,874,789 $123,683,508
West Virginia $35,941,495 $46,762,149 $52,402,218 $48,976,536 $69,568,029
Wisconsin $51,869,264 $66,358,433 $79,554,207 $89,226,751 $118,267,026
Wyoming $4,364,795 $4,720,686 $5,809,366 $8,681,912 $6,962,798

*Does not apply for Arizona. Arizona has a 1115 waiver for which special rules apply.
**Includes reported State supplemental rebates.
Source: CMS, HCFA-64 Report, FY 1999-FY 2003.

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Medicaid Drug Rebate Trends


Annual Percent Change, 1998-2003

% Change % Change % Change % Change % Change


State 98-99 99-00 00-01 01-02 02-03
National Total 35.2% 19.2% 24.3% 19.6% 18.4%
Alabama 36.3% 22.5% 25.6% 10.9% 20.9%
Alaska 40.3% 21.9% 31.9% 26.5% 5.0%
Arizona* - - - - -
Arkansas 68.4% 7.6% 12.1% 23.9% 2.5%
California 48.8% 11.3% 30.8% 20.4% 27.6%
Colorado 23.1% 14.6% 18.8% 14.0% -16.9%
Connecticut 20.3% 27.2% 25.9% 1.1% 30.2%
Delaware 37.9% 40.8% 23.7% -0.3% 66.9%
District of Columbia 18.0% 10.0% 13.4% 9.6% 32.1%
Florida 29.7% 27.2% 19.6% 18.9% 31.5%
Georgia 48.1% -3.5% 19.8% 86.6% 6.7%
Hawaii 39.8% 30.7% 31.2% 6.3% 25.8%
Idaho 38.2% 17.5% 34.7% 21.8% 37.0%
Illinois 20.6% 18.1% 18.9% 11.5% 53.8%
Indiana 23.6% 34.7% 22.1% 22.7% 4.2%
Iowa 28.1% 11.3% 18.2% 17.6% 24.1%
Kansas 35.4% 15.4% 28.1% -25.1% 101.1%
Kentucky 27.3% 28.9% 11.8% 27.3% -6.3%
Louisiana 15.4% 11.4% 35.9% -1.3% 45.9%
Maine 52.8% 5.2% 32.4% 13.3% 44.2%
Maryland 29.2% 30.2% -18.6% 58.4% 43.6%
Massachusetts 57.4% 4.4% 23.5% 5.9% 8.9%
Michigan 4.3% 0.0% 47.6% 54.4% 4.2%
Minnesota 20.4% 15.6% 26.2% 14.9% -13.7%
Mississippi 23.4% 24.2% 44.4% 30.2% -0.9%
Missouri 27.3% 30.0% 21.7% 10.0% 21.3%
Montana 25.9% 18.2% 21.6% 19.4% 7.6%
Nebraska 30.6% 43.5% -2.5% 58.4% -10.6%
Nevada 50.2% -37.1% 235.8% -17.0% 55.6%
New Hampshire 33.9% 16.3% -7.6% 49.9% 32.3%
New Jersey 27.4% 16.6% 17.6% 2.6% 17.0%
New Mexico -25.3% 11.7% 36.1% 9.6% 47.5%
New York 41.7% 32.1% 15.7% 22.1% -9.9%
North Carolina 37.1% 25.8% 48.2% -0.2% 25.8%
North Dakota 19.3% 9.2% 35.0% 32.7% -2.4%
Ohio 34.4% 15.6% 26.8% 20.9% 23.6%
Oklahoma 37.1% 16.1% 8.2% 28.1% 15.0%
Oregon 48.0% 50.1% 9.2% 55.7% 20.6%
Pennsylvania 24.7% -0.3% 8.6% 19.4% -3.1%
Rhode Island 30.8% 33.1% 11.7% 22.1% 16.3%
South Carolina 42.9% 30.5% 30.6% 3.0% 21.2%
South Dakota 17.8% 20.6% 30.7% 28.2% 22.8%
Tennessee** - 84.1% 148.5% 76.0% 24.1%
Texas 27.5% 19.7% 20.8% 13.6% 28.6%
Utah 51.6% 44.5% 0.3% 67.5% -29.5%
Vermont 19.3% 68.9% 23.4% 11.1% 16.8%
Virginia 32.6% 11.7% 5.1% -3.4% 47.0%
Washington 38.6% 28.4% 30.8% 10.5% 22.6%
West Virginia 34.3% 30.1% 12.1% -6.5% 42.0%
Wisconsin 27.2% 27.9% 19.9% 12.2% 32.5%
Wyoming 44.3% 8.2% 23.1% 49.4% -19.8%
*Does not apply to Arizona. Arizona has a 1115 waiver for which special rules apply.
**Tennessee did not report data for 1998.
Source: CMS, CMS-64 Report, FY 1998 – FY 2003.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Rebates as a Percent of Drug Expenditures, 2003

Rebates as % Drug
State Drug Expenditures Rebates** Expenditure
National Total $33,794,520,738 $7,008,382,303 20.7%
Alabama $536,222,703 $102,784,110 19.2%
Alaska $69,512,220 $15,060,446 21.7%
Arizona* $4,744,244 - -
Arkansas $310,709,182 $58,097,761 18.7%
California $4,219,504,969 $1,207,800,866 28.6%
Colorado $225,297,507 $32,446,928 14.4%
Connecticut $403,802,170 $81,550,711 20.2%
Delaware $109,844,743 $28,352,506 25.8%
District of Columbia $81,762,504 $15,120,780 18.5%
Florida $2,018,037,106 $464,880,949 23.0%
Georgia $1,073,715,230 $219,238,104 20.4%
Hawaii $97,386,406 $19,212,047 19.7%
Idaho $132,143,091 $31,430,642 23.8%
Illinois $1,469,190,682 $292,630,625 19.9%
Indiana $627,575,345 $131,850,261 21.0%
Iowa $331,222,324 $62,173,583 18.8%
Kansas $228,920,787 $59,849,370 26.1%
Kentucky $685,229,661 $124,919,867 18.2%
Louisiana $827,713,132 $165,904,174 20.0%
Maine $268,547,563 $68,331,107 25.4%
Maryland $429,589,193 $77,934,401 18.1%
Massachusetts $946,210,618 $208,146,240 22.0%
Michigan $758,266,989 $179,774,542 23.7%
Minnesota $276,731,202 $54,081,115 19.5%
Mississippi $568,007,104 $114,233,479 20.1%
Missouri $941,522,305 $178,620,625 19.0%
Montana $79,771,831 $17,172,113 21.5%
Nebraska $210,199,726 $42,766,762 20.3%
Nevada $106,821,075 $21,078,909 19.7%
New Hampshire $112,948,647 $27,628,562 24.5%
New Jersey $766,995,569 $149,040,244 19.4%
New Mexico $86,408,362 $19,585,223 22.7%
New York $4,218,811,815 $598,407,083 14.2%
North Carolina $1,291,263,155 $260,487,290 20.2%
North Dakota $56,960,417 $11,369,358 20.0%
Ohio $1,520,147,470 $325,329,459 21.4%
Oklahoma $301,294,000 $59,205,487 19.7%
Oregon $262,335,388 $65,706,778 25.0%
Pennsylvania $791,053,653 $149,563,463 18.9%
Rhode Island $140,686,626 $30,477,726 21.7%
South Carolina $558,129,364 $119,101,600 21.3%
South Dakota $71,223,108 $14,808,661 20.8%
Tennessee $1,280,129,986 $224,072,761 17.5%
Texas $1,920,865,985 $392,292,711 20.4%
Utah $163,217,885 $25,931,043 15.9%
Vermont $127,763,857 $28,595,852 22.4%
Virginia $506,414,352 $112,854,618 22.3%
Washington $592,437,155 $123,683,508 20.9%
West Virginia $345,831,214 $69,568,029 20.1%
Wisconsin $592,295,000 $118,267,026 20.0%
Wyoming $49,106,118 $6,962,798 14.2%
*Does not apply to Arizona. Arizona has a 1115 waiver for which special rules apply.
**Includes reported State supplemental rebates.
Source: CMS, CMS-64 Report, FY 2003.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

MEDICAID DRUG COVERAGE

In general, all prescription products sold by a manufacturer that has signed a drug rebate agreement
are covered outpatient drugs reimbursable by Medicaid. A State Medicaid program may require prior
approval before dispensing of any drug product and may design and implement a formulary intended
to limit coverage for specific drugs. Drug formularies and prior authorization programs must meet
specific requirements established in Medicaid law.

A State Medicaid program can restrict coverage for a drug product through a formulary, if based on
official labeling or information in designated official medical compendia, “the excluded drug does not
have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness or
clinical outcome of such treatment” over other drug products, and there is a written explanation
(available to the public) of the basis for the exclusion. However, drug products excluded from the
formulary under these conditions, nevertheless, must be available through prior authorization.

Drugs in certain specific classes may be restricted or excluded from coverage without regard to the
formulary conditions and need not be available through prior authorization. These classes include:

• Drugs used for anorexia, weight gain, fertility, hair growth, cosmetic effect, symptomatic
relief of cough or colds, or for cessation of smoking.
• Vitamins and minerals (except prenatal prescription vitamins and fluoride preparations) or
non-prescription drugs.
• Drugs that require tests or monitoring services to be purchased exclusively from the
manufacturer or his designee.
• Barbiturates or benzodiazepines.

PRIOR AUTHORIZATION

Whether or not a drug product is on a formulary, States may require physicians to request and receive
official permission before a particular product can be dispensed. This procedure is called Prior
Authorization or Prior Approval.

States may not operate prior authorization plans unless the State provides for a response within 24
hours of a request and provides for a 72-hour emergency supply of the medication.

The Congressional intent for the prior authorization provision was not to encourage the use of such
programs, but rather to make them available to the States for the purpose of controlling utilization of
products that have very narrow indications or high abuse potential.

The majority of States report the establishment of prior authorization programs and have plans to
apply prior authorization to a select number of drugs. Some States will do so only after their Drug
Utilization Review (DUR) program has identified areas of therapeutic concern.

DRUG UTILIZATION REVIEW

DUR Program. Each State must establish a Drug Utilization Review (DUR) Program in order to
assure that prescriptions are appropriate, medically necessary, and not likely to result in adverse
medical results. A DUR Program consists of prospective and retrospective components as well as
components to educate physicians and pharmacists on common drug therapy problems.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Specifically, the program educates physicians and pharmacists how to identify and reduce fraud,
abuse, gross overuse, or inappropriate or medically unnecessary care; potential and actual severe
adverse reactions to drugs, including education on therapeutic appropriateness, overutilization and
underutilization, appropriate use of generic products, therapeutic duplication, drug-disease
contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, drug-
allergy interactions, and clinical abuse or misuse.

The two primary objectives of DUR systems are (1) to improve quality of care; and (2) to assist in
containing health care costs. While there is a general belief that DUR is cost beneficial, it is difficult
to isolate concrete evidence that supports this view. The primary issue facing Medicaid DUR
programs is whether or not the systems currently in place (or envisioned) meet the two objectives
outlined above.

Prospective DUR. Prospective DUR is to be conducted at the point of sale (POS) before delivery of a
medication by the pharmacist to the Medicaid recipient or caregiver. The State is to establish
standards for counseling patients and will require the pharmacist to offer to discuss matters, which, in
the exercise of the pharmacist’s professional judgment are deemed significant, including the
following:

• Name and description of the medication;


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

• Name, address, telephone number, date of birth (or age) and gender;
• Individual history where significant, including a disease state or states, known allergies and
drug reactions, and a comprehensive list of medications and relevant devices; and
• Pharmacist comments relevant to the individual’s pharmaceutical therapy.
Retrospective DUR. This activity continuously assesses data on drug use against established
standards, preferably using automated claims processing and information retrieval techniques to
monitor for therapeutic appropriateness, overutilization and underutilization, appropriate use of
generic products, therapeutic duplication, drug-disease contraindications, drug-drug interactions,
incorrect drug dosage or duration of drug treatment, clinical abuse/misuse and, as necessary,
introduce remedial strategies in order to improve the quality of care and to conserve program funds or
personal expenditures. This activity is also intended to identify patterns of fraud, abuse, gross
overuse, or inappropriate of medically unnecessary care among physicians, pharmacists, and
recipients, or with respect to specific drugs or groups of drugs.

State Drug Use Review Board. Each State must provide for the establishment of a DUR board of
health practitioners (one-third to one-half physicians and at least one-third pharmacists) to help
implement the DUR program. Each State must require its DUR board to make annual reports to
DHHS on its activities and on cost savings resulting from the DUR program.
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National Pharmaceutical Council Pharmaceutical Benefits 2004

Pharmacy Advisory Committees


Preferred Product Introduction
State Pharmacy Advisory Committee Meetings
Process
Alabama Pharmacy & Therapeutic Committee Quarterly Introductory letter
Alaska None - Introductory letter
Arizona* - - Inform health plans directly
Arkansas None - Introductory letter
California Medi-Cal Contract Drug Advisory Committee Ad Hoc Petition with specific content requirements
Colorado Medical Advisory Council - Introductory letter
Connecticut DUR Board and P & T Committee advise Quarterly Introductory letter
Delaware DUR Board Bi-Monthly Introductory letter
District of Columbia DUR Board Monthly Introductory letter
Florida None - Introductory letter
Georgia None - Intro. letter to Express Scripts & Medicaid
Hawaii DUR Board advises Quarterly Formulary kit
Idaho Medical Care Advisory Committee Quarterly Introductory letter
Illinois None - Contact First DataBank
Indiana DUR Board Monthly Electronic form
Iowa DUR Board 8 per year Introductory letter
Kansas DUR Board Bi-Monthly Introductory letter
Kentucky Pharmacy & Therapeutic Advisory Committee Bi-Monthly Introductory letter, Package insert
Louisiana Pharmacy Advisory Committee Semiannually Introductory letter
Maine DUR Committee Monthly Introductory letter
Maryland None - Introductory letter
Massachusetts DUR Board Quarterly Introductory letter
Michigan Pharmacy & Therapeutics Committee Quarterly State form, Introductory letter
Minnesota Drug Formulary Committee Quarterly Introductory letter
Mississippi None - Introductory letter
Missouri Pharmacy Advisory Group Quarterly AMPC format dossier
Montana DUR Board Monthly Electronic submission
Nebraska None - Introductory letter
Nevada DUR Board Quarterly Introductory letter
New Hampshire None - Introductory letter, Information packet
New Jersey None - Introductory letter
New Mexico None - Contact First DataBank
New York Pharmacy Advisory Committee Quarterly Introductory letter
North Carolina NC Physician Advisory Group Quarterly E-mail
North Dakota None - Contact First DataBank
Ohio Pharmacy & Therapeutic Committee Quarterly Introductory letter
Oklahoma DUR Board Monthly E-mail to medicaidrx@ohca.state.ok.us
Oregon DUR Board Quarterly Introductory letter
Pennsylvania Medical Assistance Advisory Committee Monthly Introductory letter to State agency
Rhode Island None - Introductory letter
South Carolina None - Formulary packet
South Dakota Pharmacy & Therapeutics Committee Annually Product profile information
Tennessee* TennCare Pharmacy Advisory Committee Quarterly Introductory letter
Texas None - State form
Utah DUR Board Monthly Introductory letter, FDA information
Vermont DUR Committee Monthly Introductory letter
Virginia Pharmacy Liaison Committee Quarterly Introductory letter
Washington Drug Evaluation Matrix Team Weekly AMCP format dossier
West Virginia Medical Services Fund Advisory Council Quarterly Introductory letter
Wisconsin None - Notification
Wyoming DUR Board Bi-Monthly Introductory letter

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2004 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Pharmacy Benefit Design - Coverage


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

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
PA = Prior Authorization, DME = Durable Medical Equipment
Source: As reported by State drug program administrators in the 2004 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Pharmacy Benefit Design - Coverage (Con’t)


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

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
PA = Prior Authorization, DME = Durable Medical Equipment
Source: As reported by State drug program administrators in the 2004 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Pharmacy Benefit Design - Coverage (Con’t)


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

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
PA= Prior Authorization, DME = Durable Medical Equipment
Source: As reported by State drug program administrators in the 2004 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

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

State Physicians Office Home Health Care Extended Care Facility


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

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2004 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Coverage of Vaccines and Unit Dose


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

^ Early and Periodic Screening, Diagnostic and Treatment (EPSDT), Children Health Insurance Program (CHIP), Vaccines for
Children Program (VCP), or other.
LTC = Long Term Care
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2004 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Coverage of Over-the-Counter Medications


Allergy, Asthma,
State and Sinus Analgesics Cough and Cold Smoking Deterrents
Alabama Covered Covered Covered Not Covered
Alaska Not Covered Not Covered Not Covered Not Covered
Arizona* - - - -
Arkansas Limited Coverage Limited Coverage Limited Coverage Covered with Restrictions
California Limited Coverage Limited Coverage Limited Coverage Covered with Restrictions
Colorado Covered Covered Covered with Restrictions Covered with Restrictions
Connecticut Covered Not Covered Covered Not Covered
Delaware Covered Covered Covered Covered with Restrictions
District of Columbia Not Covered Covered with Restrictions Not Covered Not Covered
Florida Not Covered Covered with Restrictions Covered with Restrictions Covered with Restrictions
Georgia Limited Coverage Covered with Restrictions Covered with Restrictions Not Covered
Hawaii Covered Covered Limited Coverage Covered with Restrictions
Idaho Not Covered Not Covered Not Covered Not Covered
Illinois Covered with Restrictions Covered Not Covered Covered
Indiana Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Iowa Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
Kansas Covered with Restrictions Covered Covered with Restrictions Covered with Restrictions
Kentucky Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
Louisiana Not Covered Not Covered Not Covered Not Covered
Maine Covered Covered Not Covered Covered with Restrictions
Maryland Covered with Restrictions Limited Coverage Not Covered Not Covered
Massachusetts Limited Coverage Limited Coverage Limited Coverage Not Covered
Michigan Limited Coverage Limited Coverage Not Covered Limited Coverage
Minnesota Covered Covered Covered Covered
Mississippi Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Missouri Limited Coverage Limited Coverage Limited Coverage Not Covered
Montana Covered with Restrictions Not Covered Not Covered PA Required
Nebraska Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
Nevada Covered Covered Covered Covered
New Hampshire Covered Covered Covered Covered
New Jersey Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered
New Mexico Covered Covered Covered Covered
New York Covered Covered Covered Limited Coverage
North Carolina Limited Coverage Not Covered Not Covered Not Covered
North Dakota Covered with Restrictions Covered Not Covered Covered with Restrictions
Ohio Selective Coverage Selective Coverage Selective Coverage Selective Coverage
Oklahoma Covered with Restrictions Not Covered Not Covered Covered with Restrictions
Oregon Covered Covered Covered Covered
Pennsylvania Covered with Restrictions Covered Covered with Restrictions Covered
Rhode Island Covered Covered Covered Not Covered
South Carolina Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
South Dakota Limited Coverage Not Covered Not Covered Not Covered
Tennessee* Covered Covered Not Covered Not Covered
Texas Covered Covered Covered Covered
Utah Limited Coverage Not Covered Limited Coverage Not Covered
Vermont Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Virginia Covered Covered Covered Covered
Washington Limited Coverage Limited Coverage Limited Coverage Not Covered
West Virginia Limited Coverage Limited Coverage Limited Coverage PA Required
Wisconsin Covered with Restrictions Covered Covered with Restrictions Not Covered
Wyoming Covered Covered Covered Not Covered
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
PA= Prior Authorization
Source: As reported by State drug program administrators in the 2004 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

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


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

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
PA= Prior Authorization
Source: As reported by State drug program administrators in the 2004 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Prior Authorization Process and Procedures


State PA Procedure Prior Authorization Committee Members Meetings
Alabama Yes Pharmacy and Therapeutics Committee 10 Quarterly
Alaska Yes No - -
Arizona* - - - -
Arkansas Yes DUR Board 9 Quarterly
California Yes No - -
Colorado Yes No - -
Connecticut Yes Pharmaceutical and Therapeutics Committee 14 Quarterly
Delaware Yes No - -
District of Columbia Yes No - -
Florida Yes No - -
Georgia Yes No - -
Hawaii Yes No - -
Idaho Yes Pharmacy and Therapeutics Committee 12 Bi-monthly
At least
Illinois Yes Drugs and Therapeutics Committee 12
quarterly
Indiana Yes No - -
Iowa Yes DUR Board 9 8 per year
Kansas Yes DUR Board 9 Bi-monthly
Kentucky Yes Pharmacy and Therapeutics Advisory Committee 14 Bi-monthly
Louisiana Yes Pharmaceutical and Therapeutics Committee 21 Semi-annually
Maine Yes No - -
Maryland Yes No - -
Massachusetts Yes No - -
Michigan Yes No - -
Minnesota Yes Drug Formulary Committee 9 Quarterly
Mississippi Yes Pharmacy and Therapeutics Committee 12 Bi-monthly
Missouri Yes Prior Authorization Committee 9 Quarterly
Montana Yes DUR Board 10 Monthly
Nebraska Yes No - -
Nevada Yes No - -
New Hampshire Yes Pharmacy and Therapeutics Advisory Committee 13 Quarterly
New Jersey Yes No - -
New Mexico Yes No - -
New York Yes Pharmacy and Therapeutics Committee 11 Quarterly
North Carolina Yes NC Physician Advisory Group 9 Monthly
North Dakota Yes DUR Board 15 Quarterly
Ohio Yes No - -
Oklahoma Yes No - -
Oregon Yes DUR Board 12 Quarterly
Pennsylvania Yes No - -
Rhode Island Yes DUR Board 7 Quarterly
South Carolina Yes No - -
South Dakota No No - -
Tennessee* Yes No - -
Texas Yes Pharmaceutical and Therapeutics Committee 11 Quarterly
Utah Yes No - -
Vermont Yes No - -
Virginia Yes No - -
Washington Yes DUR Team and Drug Eval. Matrix Team 8 Daily, weekly
West Virginia Yes P and T Committee and DUR Board 11 Semi-annually
Wisconsin Yes Pharmacy Prior Authorization Advisory Comm. 9 As needed
Wyoming Yes DUR Board 12 Bi-monthly

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2004 NPC Survey.

4-31
National Pharmaceutical Council Pharmaceutical Benefits 2004

Prior Authorization Process and Procedures (Con’t)


State Initiated By: Annual Requests % Approved
Alabama M.D., R.Ph. N/A N/A
Alaska M.D., R.Ph. 4,600 98%
Arizona* - - -
Arkansas M.D. 195,000 80%
California M.D., R.Ph. 2,900,000 82%
Colorado M.D., M.D.’s Agent 30,000 75%
Connecticut M.D., R.Ph. 99,000 98%
Delaware M.D., R.Ph. 34,000 92%
District of Columbia R.Ph., Pharm. Tech. 9,000 77%
Florida M.D. 440,000 78%
Georgia M.D., R.Ph. 99,000 90%
Hawaii M.D., R.Ph., Pharm. Tech. N/A 99%
M.D., R.Ph., Pharm. Tech., SmartPA 177,000 76%
Idaho
System
Illinois M.D., R.Ph. 400,000 75%
Indiana M.D., Other Providers N/A N/A
Iowa M.D. 60,000 95%
Kansas M.D., R.Ph. N/A N/A
Kentucky M.D., R.Ph. 285,000 58%
Louisiana M.D. 171,000 95%
Maine M.D. 65,000 82%
Maryland M.D., R.Ph. 68,000 >99%
Massachusetts M.D. 137,000 67%
Michigan M.D. 120,000 95%
Minnesota M.D., R.Ph. 36,000 90%
Mississippi M.D. 200,000 90%
Missouri M.D., R.Ph., Other Authorized Prescriber 87,000 58%
Montana M.D., R.Ph., Pharm. Tech. 27,000 80%
Nebraska M.D., R.Ph. 26,000 27%
Nevada M.D. N/A N/A
New Hampshire M.D. 11,700 79%
New Jersey M.D., R.Ph. 715,000 95%
New Mexico M.D. 1,300 N/A
New York M.D./Ordering Provider 630,000 100%
North Carolina M.D. 57,000 86%
North Dakota M.D., R.Ph., Pharm. Tech. 2,000 60%
Ohio M.D. 240,000 Most
Oklahoma R.Ph. 210,500 53%
Oregon M.D. 30,000 73%
Pennsylvania M.D., Other Licensed Prescriber N/A N/A
Rhode Island M.D. N/A N/A
South Carolina M.D. 37,700 60%
South Dakota M.D., R.Ph. 28 100%
Tennessee* M.D. 180,000 74%
Texas M.D. 1,500 95%
Utah M.D. N/A N/A
Vermont M.D., Prescribing Agent 43,000 92%
Virginia M.D. N/A N/A
Washington R.Ph., Pharm. Tech. N/A N/A
West Virginia M.D., R.Ph. 132,000 53%
Wisconsin M.D., R.Ph. 182,000 97%
Wyoming M.D., R.Ph., Pharm. Tech. 4,500 75%

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2004 NPC Survey.

4-32
National Pharmaceutical Council Pharmaceutical Benefits 2004

Prior Authorization Process and Procedures (Con’t)


State Reviewer Review Time Response Vehicle
Alabama R.Ph., Pharm. Tech. 24 hours or less Phone, fax
Alaska R.Ph., Pharm. Tech. 24 hours Phone, fax
Arizona* - - -
Arkansas Voice response system 1-3 minutes Voice response system
California R.Ph. One business day Phone, fax
Colorado Pharm. Tech. 24 hours Phone, fax
Connecticut R.Ph., Pharm. Tech. 2 hours Phone, fax, mail
Delaware M.D., R.Ph., R.N, Pharm. Tech. < 1 working day Phone, mail, e-mail
District of Columbia R.N., R.Ph. 20 minutes Phone, mail
Florida R.Ph., Pharm. Tech., AHCA 24 hours Phone, fax, mail
Analyst
Georgia PBM 10 minutes Phone, fax, mail
Hawaii R.Ph., Pharm. Tech. 24 hours Phone, fax, mail
Idaho M.D., R.Ph., Pharm. Tech., Smart 24 hours Phone, fax, mail
PA System
Illinois M.D., R.Ph. 24 hours or less Phone
Indiana Medicaid Director or designee 10 days Phone, letter
Iowa R.Ph. 4 hours Fax
Kansas R.N., R.Ph. 24 hours or less Phone, mail
Kentucky R.N., R.Ph. 4-24 hours Phone, fax
Louisiana R.Ph. 3-5 minutes Phone, fax
Maine M.D. 4 hours Mail
Maryland M.D., R.Ph., Pharm. Tech. 24 hours or less Phone, fax
Massachusetts R.Ph. 24 hours Phone, mail
Michigan M.D., R.Ph., Pharm. Tech. 24 hours or less Phone, fax
Minnesota R.N. Within minutes Phone, fax, mail, e-mail
Mississippi R.N., R.Ph., Pharm. Tech. 6 hours Phone, fax, mail
Missouri M.D., R.Ph., R.N., Medicaid Tech. < 5 minutes Phone, fax
Montana R.Ph., Pharm. Tech. 1-2 minutes Phone, fax, mail
Nebraska M.D., R.Ph., Pharm, Tech. varies Phone, fax
Nevada R.Ph., Pharm. Tech. 24 hours Phone
New Hampshire R.Ph., Pharm. Tech. 24 hours Phone, fax with written follow-up of denials
New Jersey R.N., R.Ph. 3 minutes Phone, fax, mail
New Mexico R.Ph. 24 hours Phone, fax
New York Voice interactive system Processed during call PA issued to prescriber by phone
North Carolina R.Ph., Pharm. Tech. 24 hours or less Phone, fax, e-mail
North Dakota R.Ph. 4 hours Fax, mail
Ohio R.Ph., Pharm. Tech. Immediate Phone, fax
Oklahoma R.Ph., Pharm. Tech, Pharm. Intern 24 hours Mail
Oregon R.Ph., Pharm. Tech. 24 hours or less Phone, fax
Pennsylvania R.N., M.D. Immediately to 24 hours Phone, mail
Rhode Island Contractor Immediately to 24 hours Phone
South Carolina R.Ph., First Health Per OBRA ‘90 guidelines Phone, fax
South Dakota R.Ph. 24 hours Phone, fax, mail, e-mail
Tennessee* R.Ph. Same day Fax
Texas R.Ph. 15 minutes Phone, e-mail
Utah Nurse 1 working day Phone, fax, mail, e-mail
Vermont R.Ph., Pharm. Tech, Medical 24 hours Phone, fax
Director
Virginia M.D., R.Ph. Less than 3 minutes Mail, e-mail
Washington R.Ph. <24 hours Phone, fax; denial through mail
West Virginia R.Ph. 24 hours Phone, fax
Wisconsin R.Ph., Done electronically Immediate Online, phone, fax, mail
Wyoming R.Ph., Pharm. Tech. 24 hours Phone, fax, mail, e-mail

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2004 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Prior Authorization
Analgesics,
State Anabolic Steroids Antipyretics, NSAIDs Anorectics
Alabama Covered Covered Covered
Alaska Covered Covered, PA Required Not Covered
Arizona* - - -
Arkansas Covered Covered, PA Required Not Covered
California Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
Colorado Covered, PA Required Covered, PA Required Not Covered
Connecticut Covered Covered Not Covered
Delaware Covered Covered, PA Required Covered, PA Required
District of Columbia Not Covered Covered, PA Required Covered, PA Required
Florida Covered Covered, PA Required Covered
Georgia Covered, PA Required Covered, PA Required Not covered
Hawaii Covered, PA Required Covered Covered, PA Required
Idaho Partial Coverage, PA Required Covered, PA Required Not Covered
Illinois Covered, PA Required Covered, PA Required Not Covered
Indiana** N/A N/A N/A
Iowa Covered Covered, PA Required Not Covered
Kansas Covered Covered Partial Coverage, PA Required
Kentucky Covered, PA Required Covered, PA Required Covered, PA Required
Louisiana Covered Covered, PA Required Partial Coverage
Maine Covered, PA Required Covered, PA Required Covered, PA Required
Maryland*** Covered Covered Not Covered
Massachusetts Covered Partial Coverage, PA Required Not Covered
Michigan Partial Coverage, PA Required Covered Not Covered
Minnesota Covered Covered, PA Required Not Covered
Mississippi Covered Covered, PA Required Not Covered
Missouri Partial Coverage Covered Not Covered
Montana Covered Covered, PA Required Not Covered
Nebraska Not Covered Partial Coverage, PA Required Not Covered
Nevada Partial Coverage Covered Not Covered
New Hampshire Covered Covered, PA Required Covered, PA Required
New Jersey Covered Covered Partial Coverage
New Mexico Covered Covered Covered, PA Required
New York Covered Covered Not Covered
North Carolina Covered Covered, PA Required Not Covered
North Dakota Covered Covered Partial Coverage, PA Required
Ohio Covered, PA Required Covered Not Covered
Oklahoma Not Covered Covered, PA Required Partial Coverage, PA Required
Oregon Covered, PA Required Covered Covered, PA Required
Pennsylvania Covered Covered Not Covered
Rhode Island Covered Covered, PA Required Covered, PA Required
South Carolina Covered Covered Not Covered
South Dakota Covered Covered Covered
Tennessee* Covered Covered, PA Required Not Covered
Texas Covered Covered Covered, PA Required
Utah Covered Covered, PA Required Covered
Vermont Covered, PA Required Covered, PA Required Not Covered
Virginia Covered Covered Partial coverage, PA Required
Washington Covered, PA Required Covered, PA Required Not Covered
West Virginia Covered Covered Not Covered
Wisconsin Covered Covered, PA Required Covered, PA Required
Wyoming Not Covered Covered, Some require PA Not Covered

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
** All coverage in accordance with OBRA'90 and OBRA'93.
***PA required for all drugs not on the preferred drug list.
PA = Prior Authorization
Source: As reported by State drug program administrators in the 2004 NPC Survey.
4-34
National Pharmaceutical Council Pharmaceutical Benefits 2004

Prior Authorization (Con’t)


Anxiolytics, Prescribed
State Antihistamines Sedatives, and Hypnotics Cold Medications
Alabama Covered Covered Partial Coverage
Alaska Covered Covered Not Covered
Arizona* - - -
Arkansas Covered, PA Required Covered Partial Coverage
California Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
Colorado Covered, PA Required Covered, PA Required Covered, PA Required
Connecticut Covered Covered Covered
Delaware Covered Covered, PA Required Covered, PA Required
District of Columbia Covered Covered Covered
Florida Covered Covered Partial Coverage
Georgia Covered Covered, PA Required Partial Coverage
Hawaii Partial Coverage, PA Required Covered Covered, PA Required
Idaho Covered, PA Required Covered, PA Required Not Covered
Illinois Covered, PA Required Covered, PA Required Covered, PA Required
Indiana** N/A N/A N/A
Iowa Covered, PA Required Covered, PA Required Covered, PA Required
Kansas Covered Covered Partial Coverage
Kentucky Covered, PA Required Covered, PA Required Covered, PA Required
Louisiana Covered, PA Required Covered, PA Required Partial Coverage
Maine Covered, PA Required Covered, PA Required Not Covered
Maryland*** Covered Covered Partial Coverage
Massachusetts Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage
Michigan Covered Covered Partial Coverage
Minnesota Covered, PA Required Covered, PA Required Covered
Mississippi Covered Covered Partial Coverage, PA Required
Missouri Covered Covered, PA Required Covered, PA Required
Montana Covered, PA Required Covered Not Covered
Nebraska Partial Coverage, PA Required Partial Coverage, PA Required Covered
Nevada Covered Covered Covered
New Hampshire Covered, PA Required Covered, PA Required Covered
New Jersey Covered Covered Covered
New Mexico Covered Covered Covered
New York Covered, PA Required Covered Partial Coverage
North Carolina Covered Covered Covered
North Dakota Covered, PA Required Covered Covered
Ohio Covered, PA Required Covered Covered, PA Required
Oklahoma Partial Coverage, PA Required Covered, PA Required Not Covered
Oregon Covered, PA Required Covered, PA Required Covered
Pennsylvania Covered Covered Covered
Rhode Island Covered, PA Required Covered Covered
South Carolina Covered Covered Covered
South Dakota Covered Covered Covered
Tennessee* Covered, PA Required Covered Not Covered
Texas Covered Covered Covered
Utah Covered Covered Covered
Vermont Covered, PA Required Covered, PA Required Covered, PA Required
Virginia Covered Covered Covered
Washington Covered, PA Required Covered, PA Required Covered, PA Required
West Virginia Covered Covered Covered
Wisconsin Covered Covered Covered
Wyoming Covered Covered Covered
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
**All coverage in accordance with OBRA ’90 and OBRA ’93.
***PA required for all drugs not on the preferred drug list.
PA = Prior Authorization
Source: As reported by State drug program administrators in the 2004 NPC Survey.

4-35
National Pharmaceutical Council Pharmaceutical Benefits 2004

Prior Authorization (Con’t)


Miscellaneous Prescribed
State Growth Hormones GI Products Smoking Deterrents
Alabama Covered Covered Not Covered
Alaska Covered, PA Required Covered Not Covered
Arizona* - - -
Arkansas Covered Covered, PA Required Covered, PA Required
California Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
Colorado Covered, PA Required Covered, PA Required Covered, PA Required
Connecticut Covered Covered Not Covered
Delaware Covered, PA Required Covered Covered, PA Required
District of Columbia Covered, PA Required Covered, PA Required Covered
Florida Covered, PA Required Covered Covered
Georgia Covered, PA Required Covered Not Covered
Hawaii Covered, PA Required Covered Covered, PA Required
Idaho Covered, PA Required Covered, PA Required Not Covered
Illinois Covered, PA Required Covered, PA Required Covered
Indiana** N/A N/A N/A
Iowa Covered, PA Required Covered, PA Required Not Covered
Kansas Covered, PA Required Covered, PA Required Partial Coverage
Kentucky Covered, PA Required Covered, PA Required Not Covered
Louisiana Covered, PA Required Covered, PA Required Covered
Maine Covered, PA Required Covered, PA Required Covered, PA Required
Maryland*** Covered, PA Required Covered Partial Coverage
Massachusetts Covered, PA Required Partial Coverage, PA Required Not Covered
Michigan Covered Covered Partial Coverage, PA Required
Minnesota Covered Covered, PA Required Covered
Mississippi Covered Covered Covered
Missouri Covered, PA Required Covered, PA Required Not Covered
Montana Covered, PA Required Covered Covered, PA Required
Nebraska Partial Coverage, PA Required Partial Coverage, PA Required Not Covered
Nevada Partial Coverage, PA Required Covered Covered
New Hampshire Covered Covered, PA Required Covered
New Jersey Partial Coverage Partial Coverage Covered
New Mexico Covered Covered Covered
New York Covered, PA Required Partial Coverage Covered
North Carolina Covered, PA Required Covered Covered
North Dakota Covered Covered, PA Required Partial Coverage
Ohio Covered, PA Required Covered, PA Required Covered, PA Required
Oklahoma Covered, PA Required Covered, PA Required Partial Coverage, PA Required
Oregon Covered, PA Required Covered, PA Required Covered
Pennsylvania Covered Covered Covered
Rhode Island Covered, PA Required Covered Partial Coverage
South Carolina Covered Covered Not Covered
South Dakota Covered, PA Required Covered Partial Coverage
Tennessee* Covered Covered Not Covered
Texas Covered, PA Required Covered Covered
Utah Covered, PA Required Covered Not Covered
Vermont Covered, PA Required Covered Covered, PA Required
Virginia Covered Covered Covered
Washington Covered, PA Required Covered, PA Required Not Covered
West Virginia Covered, PA Required Covered Covered, PA Required
Wisconsin Covered PA Required Covered, PA Required Covered
Wyoming Partial Coverage Covered, PA Required on PPIs Not Covered
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
***PA required for all drugs not on the preferred drug list.
**All coverage in accordance with OBRA ’90 and OBRA ’93.
PA = Prior Authorization
Source: As reported by State drug program administrators in the 2004 NPC Survey.

4-36
National Pharmaceutical Council Pharmaceutical Benefits 2004

Drug Utilization Review


In-House or PRODUR
State State Contact Telephone Contracted Implemented
Alabama Louise Jones 334-242-5039 Contracted Jul-96
Alaska Dave Campana, R.Ph. 907-334-2425 In-House Jun-95
Arizona* - - - -
Arkansas Pamela Ford, P.D. 501-683-4120 Contracted Mar-97
California Ellis Ellis, Pharm.D. 916-552-9500 Contracted Aug-95
Colorado Catherine Traugott 303-866-2468 Contracted Dec-98
Connecticut James Zakszewski, R.Ph. 860-424-5150 Contracted Sep-96
Delaware Cynthia R. Denemark, R.Ph. 302-453-8453 Contracted Feb-94
District of Columbia Christopher Keeys 301-617-0555 Contracted Sep-96
Florida Linda Barnes 850-487-4441 Contracted Jul-93
Georgia Patricia Z. Jeter, R.Ph., M.P.A. 404-657-9181 In-House Oct-00
Hawaii Kathleen Kang-Kaulupali 808-692-8065 In-House 1997
Idaho Tamara Eide, P.D., B.C.P.S., 208-364-1821 Contracted Jan-98
FASHP
Illinois Pamela Bunch 217-524-7478 In-House Jan-93
Indiana DUR Board Secretary 317-232-4307 Contracted Mar-96
Iowa Julie Kuhle, R.Ph. 515-725-1226 Contracted Jul-97
Kansas Vicki Schmidt 785-274-4287 Contracted Nov-96
Kentucky Debra Bahr, R.Ph. 502-564-7940 In-House 1987
Louisiana Mary J. Terrebonne, Pharm.D. 225-342-9768 Contracted Apr-66
Maine Bruce McClenahan 886-796-2463 Contracted Dec-95
Maryland Jeffrey Gruel 410-767-1455 Contracted Jan-93
Massachusetts Paul L. Jeffrey 617-210-5319 Contracted Oct-95
Michigan Debera Eggleston, M.D. 517-335-5181 Contracted Jul-00
Minnesota Mary Beth Reinke, Pharm.D., 651-215-1239 In-House Feb-96
M.S.A.
Mississippi Judith P. Clark, R.Ph. 601-359-5253 Contracted Oct-93
Missouri Tisha A. Pomering 573-751-6961 In-House Feb-93
Montana Mark Eichler, R.Ph., FASCP 406-457-5818 Contracted Sep-94
Nebraska Beth Wilson, R.Ph. 402-420-1500 Contracted Apr-95
Nevada Dionne Coston, R.N. 702-684-3775 Contracted 2004
New Hampshire Robert Coppola 603-220-2083 Contracted Jul-95
New Jersey Kaye S. Morrow 609-631-2396 In-House Oct-96
New Mexico Neal Solomon, M.P.H., R.Ph. 505-827-3174 In-House Oct-93
New York Lydia Kosinski, R.Ph. 518-474-6866 In-House Mar-95
North Carolina Melissa Weeks, Pharm.D 919-855-4300 Contracted Oct-96
North Dakota Brendan K. Joyce, Pharm.D., R. Ph. 701-328-4023 In-House Jul-96
Ohio Jeff Corzine 614-466-9689 Both Feb-00
Oklahoma Ronald Graham, D.Ph. 405-271-6614 Contracted 2000
Oregon Kathy L. Ketchum, R.Ph., M.P.A 503-494-1589 Contracted Mar-94
Pennsylvania Terri Cathers 717-772-6195 Contracted Jun-93
Rhode Island Paula Avarista, R.Ph., M.B.A. 401-4642-6390 Contracted Dec-94
South Carolina Caroline Sojourner, R.Ph. 803-898-2876 Contracted Nov-00
South Dakota Teddi Martell 605-773-3653 In-House 1996
Tennessee* Jeffrey G. Stockard, D.Ph. 615-532-3107 Contracted Jul-01
Texas Barbara Dean, R.Ph. 512-491-1101 In-House Feb-95
Utah Duane Parke 801-538-6452 In-House 1994
Vermont Felicia Montineri 802-879-5900 Contracted Nov-93
Virginia Rachel E. Cain 804-225-2873 Contracted Jul-94
Washington Nicole Nguyen, Pharm.D. 360-725-1757 In-House Mar-96
West Virginia Vicki M. Cunningham, R.Ph. 304-588-6541 Contracted Mar-95
Wisconsin Michael Mergener, R.Ph., Ph.D. 608-258-3348 Contracted 2001
Wyoming Debra Devereuax, R.Ph. 307-766-6750 Contracted Oct-95
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
PRODUR = Prospective Drug Utilization Review System
Source: As reported by State drug program administrators in the 2004 NPC Survey.
4-37
National Pharmaceutical Council Pharmaceutical Benefits 2004

Prescribing/Dispensing Limits
Limits on
State Rx Limits on Number, Quantity, and Refills of Prescriptions
Alabama Yes 5 refills per Rx, 34 day supply per Rx, 4 brand limit per month
Alaska Yes 30 day supply per Rx, maximum number units for 50 classes and 40 narcotics
Arizona* - -
Arkansas Yes 31 day supply per Rx; 3 Rx per month (extension to 6); 5 refills per Rx within 6 months
California Yes 6 Rx per month, maximum 100 day supply for most medications
Colorado Yes 30 day quantity supply per Rx; reasonable amts. for maint. meds. Other limits may apply
Connecticut Yes 240 units or 30 day supply, 5 refills per RX except 12 month limit on oral contraceptives
Delaware Yes 34 day supply or 100 unit doses per Rx (whichever is greater)
District of Columbia Yes 30 day supply per Rx, 3 refills per Rx within 4 mths. Max/min quantities for certain meds
Florida Yes 4 brand name Rxs per month (with exceptions)
Georgia Yes 34 day supply per Rx; 5 (adult)/6 (child) Rx per month; Per Rx limit: $2999.99 (potential override)
Hawaii Yes 30 day supply or 100 unit doses per Rx, maximum quantities for some drugs
Idaho Yes 34 day supply per Rx (with exceptions); 3 cycles of birth control; limits on refills/early refills
Illinois Yes Medically appropriate monthly quantity
Indiana No -
Iowa Yes Maximum 30 day supply except select maintenance drugs (90 days)
Kansas Yes 31 day supply per Rx, 5 Rx per month, other limitations specific to certain medications
Kentucky Yes 30 day supply, max. 5 refills in 6 months; one dispensing fee per month for maintenance medication
Louisiana Yes 30 day supply or 100 unit doses (whichever is greater); 5 refills per Rx within 6 mos., max. 8 scripts per
recipient per month
Maine Yes 34 day supply (brand), 90 day supply (generic); Maximum 11 refills per prescription, 5 brand scripts
per month
Maryland Yes 34 day supply per Rx; maximum 11 refills per Rx, refills may not exceed 360 day supply
Massachusetts Yes 30 day supply, maximum 11 refills per prescription
Michigan Yes 100 day supply, quantity limits for selected drugs (e.g., sedative hypnotics)
Minnesota Yes 34 day supply
Mississippi Yes 34 day supply or 100 unit doses (whichever is greater); 5 Rx per month; 11 refills maximum
Missouri No -
Montana Yes 34 day supply
Nebraska Yes 90 day/100 unit doses, 5 refills per Rx 6 mos. for controlled substances, 31 days for injectibles
Nevada Yes 34 day supply per Rx; 100 day supply for maintenance medications. 5 refills within 6 months.
New Hampshire Yes 30 day supply, 90 day supply on maintenance medications
New Jersey Yes 34 day supply or 100 unit doses per Rx, 5 refills within 6 months
New Mexico No 34 day supply, except contraceptives (100 days) and maintenance drugs (90 days)
New York Yes 5 refills per Rx; annual limit on number of Rx and OTC drugs avail. (potential override)
North Carolina Yes 34 day supply per Rx, with exceptions; 6 Rx per month
North Dakota Yes 34 day supply per Rx, max 5 refills per script, limits on refills by Class
Ohio Yes 34 day supply; 102 day supply for maintenance medications; 5 refills per Rx
Oklahoma Yes 6 Rx (incl. 5 brands) per month (21+; under 21 unlimited), 34 day supply or 100 unit doses per Rx
Oregon Yes 34 day supply (15 day supply for initial Rx for chronic conditions), duration limits on selected drugs
Pennsylvania Yes 34 day supply or 100 unit doses per Rx (whichever is greater); 5 refills within 6 mos., 6 Rx per month
Rhode Island Yes 30 day supply per Rx (non-maintenance); 5 refills per Rx
South Carolina Yes 34 day supply w/ unlimited Rx (children); 4 Rx per month (adult), (potential override)
South Dakota Yes Varies by drug
Tennessee* Yes 31 day supply, 1 year for non-controlled medications
Texas Yes 3 Rx per month (unlimited Rxs for nursing home recipients or those < 21), max 5 refills or 6 months
Utah Yes 31 day supply per Rx, max 5 refills, cumulative limit on specific drugs
Vermont Yes 60 day supply for maintenance medications, 5 refills per Rx
Virginia Yes 34 day supply per Rx
Washington Yes 34 day supply per Rx; usually 2 refills per month; 4 refills for antibiotics or scheduled drugs
West Virginia Yes 34 day supply; 11 refills per Rx with quantity limits on some drugs
Wisconsin Yes 34 day supply per Rx with exceptions, maximum 11 refills during 12-month period
Wyoming Yes Quantity limits on some medications as deemed clinically appropriate.

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2004 NPC Survey.

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PHARMACY PAYMENT AND PATIENT COST SHARING

Medicaid Payment for Outpatient Prescription Drugs. Federal Medicaid regulations prescribe the
principles that apply to State Medicaid programs when they pay a pharmacy for outpatient drugs.
These regulations don’t just indicate the FFP cannot be based on amounts that exceed drug costs as
determined under the federal formula; they indicate the actual method for paying for prescription
drugs.

Medicaid Managed Care Organizations (MCOs). If the recipient is enrolled in a Medicaid managed
care organization, payment is made to the MCO in accordance with its contract with the State
Medicaid agency to the extent the contract covers outpatient prescribed drugs.

Medicaid Payment to Pharmacies. Each State’s Medicaid State Plan must comprehensively describe
its payment for prescription drugs. Its aggregate Medicaid expenditures for “multiple-source drugs”
must not exceed the Federal Upper Limits published by CMS (see Appendix D) and its payment level
for other drugs must not exceed, in the aggregate, the lower of (1) EAC plus a reasonable dispensing
fee, or (2) providers’ charges to the general public.

PATIENT COST SHARING

States are permitted to require certain recipients to share some of the costs of Medicaid by imposing
on them such payments as enrollment fees, premiums, deductibles, coinsurance, copayments, or
similar cost-sharing charges (42 CFR 447.50). For States that impose cost-sharing payments, the
regulations specify the standards and conditions under which States may impose cost-sharing, set
forth minimum amounts and the methods for determining maximum amounts, and describe
limitations on availability that relate to cost-sharing requirements.

With the passage of the Social Security Amendments of 1972, States were empowered to impose
“nominal” cost-sharing requirements on optional Medicaid services for cash assistance recipients, and
on any services for the medically needy. Section 131 of the Tax Equity and Fiscal Responsibility Act
(TEFRA) of 1982 introduced major changes to Medicaid cost-sharing requirements. Under this act,
States may impose a nominal deductible, coinsurance, copayment, or similar charge on both
categorically needy and medically needy persons for any service offered under the State Plan. Public
Law 97-248, TEFRA, has been in effect since October 1982; it prohibits imposition of cost-sharing
on the following:

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


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

While emergency services are excluded from cost sharing, States may apply for waivers of nominal
amounts for non-emergency services furnished in hospital emergency rooms. Such a waiver allows
States to impose a copayment amount up to twice the current maximum for such services. Approval

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of a waiver request by CMS is based partly on the State’s assurance that recipients will have access to
alternative sources of care.

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Pharmacy Payment and Patient Cost Sharing


State Dispensing Fee Ingredient Reimbursement Basis Copayment
Alabama $5.40 AWP- 10%; WAC+9.2% $0.50 - $3.00
Alaska $3.45 minimum AWP-5% $2.00
Arizona* - - -
Arkansas $5.51 ($7.51 non-MAC generics) B: AWP-14%, G: AWP-20% $0.50 - $5.00
California $7.25 ($8.00 for LTC) AWP-17% $1.00
Colorado $4.00; $1.89 for Institutions AWP-13.5% or WAC+18%, whichever is lowest; B: $3.00, G: $1.00
AWP-35% (for generics)
Connecticut $3.15 AWP-12% None
Delaware $3.65 AWP-14% AWP-16% (LTC) $0.50 - $3.00
DC $4.50 AWP-10% $1.00
Florida $4.23 AWP-15.4%; WAC+5.75% None
Georgia $4.33-$4.63 + $0.50 (for generics) AWP-11% G/P: $0.50, B/NP: $0.50 - $3.00
Hawaii $4.67 AWP-10.5% None
Idaho $4.94 ($5.54 for unit dose) AWP-12% None
Illinois G: $4.60, B: $3.40 B: AWP-12% B: $3.00
Indiana $4.90 B: AWP-13.5%, G: AWP-20% $3.00
Iowa $4.26 AWP-12% $0.50-$3.00
Kansas $3.40 B: AWP-13%, G: AWP-27%, IV AWP-50%, blood $3.00
AWP-30%
Kentucky $4.51 AWP-12% $1.00
Louisiana $4.45 (avg.) to $5.77 AWP-13.5% (AWP-15% for chains) $0.50 - $3.00
Maine $3.35 - $12.50 AWP-15% $2.50, Max $25/rec/pharm/mo
Maryland $2.69-$4.69 Lowest of :WAC+8%, direct+8%, AWP-12% $2.00 Brand not on PDL,
$1.00 Brand on PDL & generics
Massachusetts $3.50 - $5.00 WAC+5% B: $3.00, G: $1.00
Michigan $2.50 ($2.75 – LTC) AWP-13.5% (1-4 stores), AWP-15.1% (5+stores) B: $3.00, G: $1.00, ABW: $1.00
Minnesota $3.65 AWP-11.5% B: $3.00, G: $1.00
Mississippi $3.91 AWP-12% $1.00 - $3.00
Missouri $4.09 - $8.19 AWP-10.43%, WAC+10% $0.50 - $2.00, $5.00 for some
1115 waiver pop.
Montana $2.00 - $4.70 AWP-15% $1.00 - $5.00
Nebraska $3.27 - $5.00 AWP-11% $2.00
Nevada $4.76 AWP-15% None
New Hampshire $1.75 AWP-16% B: $2.00, G: $1.00
New Jersey $3.70 - $4.07 AWP-12.75%, WAC+30%, AAC for injectables None
New Mexico $3.65 AWP-14% None (except $5.00 for CHIP and
working disabled)
New York B: $3.50, G: $4.50 B: AWP-12. 75%;, G: AWP-16.50% G: $0.50, B: $2.00
North Carolina B: $4.00, G: $5.60 AWP-10% G: $1.00, B: $3.00
North Dakota B: $4.60, G: $5.60 AWP-10% $3.00 (Brand)
Ohio $3.70 WAC + 9% $3.00 (PA drugs only)
Oklahoma $4.15 AWP-12.0% $1.00 - $2.00
Oregon Retail: $3.50, Inst./NF: $3.80 AWP-15% (retail), AWP-11% (institutional) B: $3.00, G: $2.00
Pennsylvania $4.00 ($5.00 for compounds) AWP-10% $1.00 ($2.00 for General Assist.)
Rhode Island OP: $3.40, LTC: $2.85 WAC+5% None
South Carolina $4.05 AWP-10% $3.00
South Dakota $4.75 ($5.55 for unit dose) AWP-10.5% $2.00
Tennessee* $2.50 AWP-13% Medicaid: None;
Other: $5/$10 based on income
Texas (EAC+$5.14)/0.98 & delivery fee AWP-15% or WAC+12%, whichever is lowest None
Utah $3.90 (urban), $4.40 (rural) AWP-15% $3.00
Vermont $4.25 AWP-11.9% $1.00 - $3.00 dep. on Rx Cost
Virginia $3.75 AWP-10.25% B: $3.00, G: $1.00
Washington $4.20-$5.20 (based on annual # of Rx) AWP-14% None
West Virginia $3.90 (+ extra $1.00 for compounding) AWP-12% $0.50 - $3.00
Wisconsin $4.88 (to a maximum $40.11) AWP-13% $1.00-$3.00, max
$12/rec/pharm/mo
Wyoming $5.00 (legend), 50% AWP OTC AWP-11% $1.00 - $3.00
WAC = Wholesalers Acquisition Cost; AWP = Average Wholesale Price; EAC = Estimated Acquisition Cost; AAC= Actual Acquisition Cost;
G = Generic; B = Brand Name; OP = Outpatient; LTC = Long Term Care; P = Preferred; NP = Non-Preferred; PDL= Preferred Drug List
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions.
Source: As reported by State drug program administrators in the 2004 NPC Survey.

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Maximum Allowable Cost (MAC) Programs

Federal State-Specific
State Upper Limits Upper Limits MAC Override Provisions
Alabama Yes Yes Brand medically necessary
Alaska Yes No Medically necessary and reason for medical necessity
Arizona* - - -
Arkansas Yes Yes Brand medically necessary MedWatch indicating why generics cannot
be dispensed
California Yes Yes Medically necessary and product unavailable at MAC rate
Colorado Yes Yes Medically necessary with documentation
Connecticut Yes Yes No physician MAC override
Delaware Yes Yes MedWatch form for prior authorization
District of Columbia No No -
Florida Yes Yes MedWatch form and prior authorization request
Georgia Yes Yes Prior authorization (Brand medically necessary and MedWatch form)
Hawaii Yes Yes Prior authorization
Idaho Yes Yes Prior authorization for brand names
Illinois Yes Yes Prior authorization request by M.D. justifying need for brand
Indiana Yes Yes Brand medically necessary, prior authorization
Iowa Yes Yes Brand medically necessary
Kansas Yes Yes Prior authorization and MedWatch form
Kentucky Yes Yes Brand necessary, brand medically necessary, plus PA on some drugs
Louisiana Yes Yes Brand necessary, brand medically necessary
Maine Yes Yes Prior authorization
Maryland Yes Yes Brand medically necessary and MedWatch form
Massachusetts Yes Yes Dispense as written, brand medically necessary, prior authorization
Michigan Yes Yes Brand medically necessary and prior authorization
Minnesota Yes Yes Dispense as written, brand medically necessary, plus prior authorization
Mississippi Yes No Brand medically necessary or prior authorization for brand multi-source
Missouri Yes Yes Brand medically necessary, prior authorization and MedWatch form
Montana Yes No Brand necessary or brand required
Nebraska Yes Yes Brand medically necessary
Nevada No Yes Brand medically necessary
New Hampshire Yes Yes Brand medically necessary
New Jersey Yes No Dispense as written, medically necessary
New Mexico Yes Yes Brand necessary, brand medically necessary
New York Yes No Prior authorization
North Carolina Yes Yes Brand medically necessary in writing on prescription
North Dakota Yes Yes Dispense as written
Ohio Yes Yes Prior authorization
Oklahoma Yes Yes Brand medically necessary plus prior authorization
Oregon Yes Yes Brand medically necessary and documentation of generic intolerance
Pennsylvania Yes Yes Brand necessary, brand medically necessary, plus prior authorization
Rhode Island No No -
South Carolina Yes Yes Brand medically necessary w/cert. by prescriber and prior authorization
South Dakota Yes Yes Brand necessary, brand medically necessary
Tennessee* Yes Yes Dispense as written
Texas Yes Yes Dispense as written, medically necessary, brand necessary, brand
medically necessary
Utah Yes Yes Brand medically necessary plus prior approval
Vermont Yes Yes Dispense as written, medically necessary, brand necessary, brand
medically necessary or DAW 8 (generic not available)
Virginia Yes Yes Medically necessary
Washington Yes Yes Brand medically necessary
West Virginia Yes No Dispense as written, brand medically necessary
Wisconsin No Yes Brand medically necessary plus prior authorization
Wyoming Yes Yes Brand medically necessary

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.

Source: As reported by State drug program administrators in the 2004 NPC Survey.

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Mandatory Substitution

Incentive Fee for Dispensing of Generic Dispensing of Lowest Cost


State Generic Substitution Multi-Source Required Multi-Source Required
Alabama No Yes Yes
Alaska No Yes No
Arizona* - - -
Arkansas $2.00 Yes Yes
California No No Yes
Colorado No Yes No
Connecticut No Yes No
Delaware No Yes No
District of Columbia No Yes No
Florida No Yes No
Georgia $0.50 Yes (brand PA required) Yes
Hawaii No Yes No
Idaho No Yes No
Illinois No No No
Indiana No Yes Yes
Iowa No Yes Yes
Kansas No No No
Kentucky No Yes Yes
Louisiana No No No
Maine No Yes No
Maryland $1.00 Yes Yes
Massachusetts No Yes No
Michigan No No No
Minnesota Yes Yes Yes
Mississippi No Yes No
Missouri No Yes Yes
Montana No Yes No
Nebraska No Yes No
Nevada No Yes No
New Hampshire No Yes No
New Jersey No Yes No
New Mexico No No No
New York $1.00 Yes No
North Carolina $1.60 Yes Yes
North Dakota No Yes No
Ohio No No No
Oklahoma No Yes No
Oregon No Yes No
Pennsylvania No Yes No
Rhode Island No Yes No
South Carolina No Yes No
South Dakota No No No
Tennessee* No Yes Yes
Texas No No No
Utah No Yes Yes
Vermont No Yes Yes
Virginia No Yes No
Washington No Yes Yes
West Virginia No Yes No
Wisconsin No Yes No
Wyoming No Yes No

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.

Source: As reported by State drug program administrators in the 2004 NPC Survey.

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Counseling Requirements and Payment for Cognitive Services

Medicaid Payment
State Patient Counseling Required1 for Cognitive Services2
Alabama All No
Alaska All No
Arizona All -
Arkansas All No
California All No
Colorado Medicaid Only No
Connecticut Medicaid Only No
Delaware All No
District of Columbia Medicaid Only, New Prescriptions No
Florida All No
Georgia All No
Hawaii Medicaid Only No
Idaho All No
Illinois All No
Indiana All No
Iowa All Yes (pharm. Case management)
Kansas All No
Kentucky All No
Louisiana All No
Maine All No
Maryland Medicaid Only, New Prescriptions No
Massachusetts All No
Michigan All No
Minnesota All No
Mississippi All Yes (diabetes, asthma, coagulation, and lipids)
Missouri All Yes (diabetes, asthma, heart failure, and depression
education)
Montana All No
Nebraska All No
Nevada All No
New Hampshire All No
New Jersey All No
New Mexico All No
New York All No
North Carolina All No
North Dakota All No
Ohio All No
Oklahoma All No
Oregon All No
Pennsylvania All No
Rhode Island All No
South Carolina Medicaid Only No
South Dakota All No
Tennessee All No
Texas All No
Utah All No
Vermont All No
Virginia All No
Washington All Yes (emergency contraceptive counseling, clozaril
case management)
West Virginia All No
Wisconsin All Yes
Wyoming All No

Source: 12003-2004 National Association of Boards of Pharmacy Law, Survey of Pharmacy Law; 2 As reported by State drug
program administrators in the 2004 NPC Survey.

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Prescription Price Updating

State Contact Telephone Updated


Alabama Allyn Williford 334-242-5034 Biweekly
Alaska Dave Campana 907-334-2425 Weekly
Arizona* - - -
Arkansas First DataBank 650-588-5454 Weekly
California EDS Federal Corp. 916-636-1000 Monthly
Colorado Martha Warner 303-866-3176 Weekly
Connecticut Ellen Arce, R.Ph. 860-832-5885 Weekly
Delaware Cynthia R. Denemark, R.Ph. 302-453-8453 Weekly
District of Columbia Christine Quinn 202-906-8304 Monthly
Florida First DataBank 650-588-5454 Weekly
Georgia Express Scripts 770-552-3793 Daily
Hawaii ACS State Healthcare 800-358-2381 Weekly
Idaho Katie Ayad 208-364-1970 Bimonthly
Illinois First DataBank 650-588-5454 Weekly
Indiana First DataBank 650-588-5454 Weekly
Iowa Patrick Danlan 515-725-1226 Weekly
Kansas Mary H. Obley 785-296-3981 Weekly
Kentucky Unisys Provider Services 502-226-1140 Weekly
Louisiana Maggie Vick, Unisys Corp. 225-237-3251 Weekly
Maine Bruce McClanahan 886-796-2463 Weekly
Maryland First DataBank 650-588-5454 Weekly
Massachusetts First DataBank 650-588-5454 Weekly
Michigan First Health Service Corp. 877-864-9014 Weekly
Minnesota First DataBank 650-588-5454 Weekly
Mississippi Terri R. Kirby, R.Ph. 601-359-5253 Weekly
Missouri First DataBank 650-588-5454 Weekly
Montana First DataBank 650-588-5454 Weekly
Nebraska Dyke Anderson, R.Ph. 402-471-9379 Weekly
Nevada First DataBank 650-588-5454 Monthly
New Hampshire First Health Services Corp. 800-884-2822 Weekly
New Jersey First DataBank 650-588-5454 Weekly
New Mexico First DataBank 800-633-3453 Weekly
New York Carl Cioppa, Pharm.D. 518-474-9219 Monthly
North Carolina Tom D’Andrea, R.Ph., M.B.A. 919-855-4300 Weekly
North Dakota Brendan K. Joyce, Pharm.D., R.Ph. 701-328-4023 Biweekly
Ohio First DataBank 650-588-5454 Monthly
Oklahoma First DataBank 800-633-3453 Weekly
Oregon First Health Service Corp. 503-391-1980 Biweekly
Pennsylvania First DataBank 800-633-3453 Monthly
Rhode Island Paula Avarista, R.Ph., M.B.A. 401-462-6390 Biweekly
South Carolina First DataBank 650-588-5454 Weekly
South Dakota Mark Petersen, R.Ph. 605-773-3498 Biweekly
Tennessee* First DataBank 650-588-5454 Weekly
Texas Martha McNeill, R.Ph. 512-491-1157 Continuously
Utah RaeDell Ashley, R.Ph. 801-538-6495 Bimonthly
Vermont Cathy England 804-965-7717 Monthly
Virginia Keith T. Hayashi 804-225-2773 Weekly
Washington Tom Zuchlewski 360-725-1837 Weekly
West Virginia Heather Bodiford 866-322-5960 Weekly
Wisconsin First DataBank 800-633-3453 Biweekly
Wyoming First DataBank 800-633-3453 Weekly
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.

Source: As reported by State drug program administrators in the 2004 NPC Survey.

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Section 5:
State Pharmacy Program
Profiles

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Profiles of State Medicaid Drug Programs


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

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ALABAMA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $454,370,478 500,789 $536,222,703

RECEIVING CASH ASSISTANCE TOTAL $315,943,060 220,205


Aged $37,738,144 24,294
Blind/Disabled $257,913,536 131,463
Child $11,592,612 46,873
Adult $8,698,768 17,575

MEDICALLY NEEDY, TOTAL $0 0


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

POVERTY RELATED, TOTAL $59,283,383 228,391


Aged $825,181 717
Blind/Disabled $881,876 798
Child $56,041,627 216,945
Adult $1,534,699 9,931
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $79,144,035 52,193


*Total other expenditures/recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
** 2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

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C. ADMINISTRATION Formulary/Prior Authorization

Alabama Medicaid Agency. Formulary: Open formulary with preferred drug list.
Formulary managed through restrictions on use, prior
D. PROVISIONS RELATING TO DRUGS authorization, therapeutic substitution, preferred
products, physician profiling, and voluntary
Benefit Design supplemental rebates. Prior authorization required for
non-preferred drugs. Anti-psychotics and HIV/AIDs
Drug Benefit Product Coverage: Products covered: drugs are exempted from the prior authorization
disposable needles and syringe combinations used for requirements. (For additional information see:
insulin. Products covered with restriction: prescribed www.medicaid.state.al.us.)
insulin. Products covered as DME: blood glucose test
strips; urine ketone test strips. Prior authorization Prior Authorization: State currently has a formal
required for: total parenteral nutrition; interdialytic prior authorization procedure. Prior authorization
parenteral nutrition; Retin A; Accutane; decisions may be appealed by physician submitting
Dipyridamole; and Synagis. Products not covered: written notice along with medical documentation to
cosmetics; fertility drugs; experimental drugs; drugs the administrative services contractor for physician
for anorexia or weight gain; hair growth products; review. The request is forwarded to the Medicaid
and DESI drugs. agency’s Medical Director for review.

Over-the-Counter Product Coverage: Products Prescribing or Dispensing Limitations


covered if prescribed by a physician: allergy, asthma
and sinus products; analgesics; cough and cold Prescription Refill Limit: maximum of five refills.
preparations; digestive products; prenatal vitamins;
hemorrhoidal products. Partial coverage for: topical Monthly Quantity Limit: 34-day supply.
products. Products not covered: smoking deterrent
products and feminine products. Monthly Prescription Limit: four brand limit.
Therapeutic Category Coverage: Therapeutic Drug Utilization Review
categories covered: anabolic steroids; analgesics,
antipyretics, and NSAIDs; anoretics; antibiotics; PRODUR system implemented in July 1996. State
anticoagulants; anticonvulsants; antidepressants; currently has a DUR Board with a quarterly review.
antidiabetic agents; antihistamines; antilipemic
agents; anti-psychotics; anxiolytics, sedatives, and
Pharmacy Payment and Patient Cost Sharing
hypnotics; cardiac drugs; chemotherapy agents; ENT
anti-inflammatory agents; estrogens; growth
Dispensing Fee: $5.40.
hormones; hypotensive agents; misc. GI drugs;
sympathominetics (adrenergic); and thyroid agents.
Ingredient Reimbursement Basis: AWP-10%, WAC
Partial coverage for: prescribed cold medications;
+ 9.2%.
and contraceptives. Prior authorization required for:
nutritional supplements; and Synagis. Therapeutic
Prescription Charge Formula: Medicaid pays for
categories not covered: prescribed smoking
prescribed legend and non-legend drugs authorized
deterrents.
under the program based upon and shall not exceed
the lowest of:
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program 1. The Maximum Allowable Cost (MAC) of the
when used in home healthcare and extended care drug plus a dispensing fee,
facilities, and through physician payment when used
in physicians’ offices. 2. The Estimated Acquisition Cost (EAC) of the
drug plus a dispensing fee, or
Vaccines: Vaccines reimbursable as part of the 3. The provider’s usual and customary charge to
Vaccines for Children Program. Adult vaccines are the public for the drug.
available through the Health Department.

Unit Dose: Unit dose packaging reimbursable.

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Maximum Allowable Cost: State imposes Federal Medicaid DUR Board


Upper Limits as well as State-specific limits on
John Searcy, M.D.
generic drugs. Override requires “Brand Medically
Jimmy Jackson, R.Ph.
Necessary” in the physician’s own handwriting.
Darin Elliot, Pharm.D.
Greer L. Geiger, M.D.
Incentive Fee: None.
W. Kevin Green, M.D.
Richard Freeman, M.D.
Patient Cost Sharing: Tiered copayment.
Gary Magouirk, M.D.
Drug Ingredient Cost Copayment Paula Thompson, Pharm.D.
$0.00 to $10.00 $0.50 W. Thomas Geary, Jr., M.D.
$10.01 to $25.00 $1.00 Steven Rostand, M.D.
$25.01 to $50.00 $2.00 Rhonda Harden, Pharm.D.
$50.01 or more $3.00 Rob Colburn, R.Ph.
Exemptions: No copayment amount is to be collected New Brand Name Products Contact
by the pharmacy or paid by the recipient for
Louise F. Jones
recipients under age 18, pregnant, or living in nursing
334/242-5039
facilities.
Prescription Price Updating
Cognitive Services: Does not pay for cognitive
services. Allyn Williford
Alabama Medicaid Agency
E. USE OF MANAGED CARE 501 Dexter Avenue
P.O. Box 5624
Does not use MCOs to deliver services to Medicaid Montgomery, AL 36103-5424
recipients. T: 334/242-5034
F: 334/353-7014
F. STATE CONTACTS Medicaid Drug Rebate Contact

State Drug Program Administrator Lynn M. Abrell


Alabama Medicaid Agency
Louise F. Jones, Director 501 Dexter Avenue
Pharmacy Services P.O. Box 5624
Alabama Medicaid Agency Montgomery AL 36103-5624
501 Dexter Avenue T: 334/242-2326
P.O. Box 5624 F: 334/353-7014
Montgomery, AL 36103-5624 E-mail: ggray@medicaid.state.al.us
T: 334/242-5039
F: 334/353-7014 Claims Submission Contact
E-mail: lljones@medicaid.state.al.us
Internet address: www.medicaid.state.al.us Cyndi Crocket, Supervisor
EDS
Prior Authorization Contact 301 Technacenter Dr.
Montgomery, AL 36117
Louise F. Jones 334/215-0111
334/242-5039
Medicaid Managed Care Contact
DUR Contact
Kim Davis-Allen, Director
Louise Jones Managed Care
334/242-5039 Alabama Medicaid Agency
501 Dexter Avenue
Montgomery, AL 36103-5624
334/242-5011

Alabama-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

J.A. Powell, M.D.


Mail Order Pharmacy Program
Marsha D. Raulerson, M.D.
None John Searcy, M.D.
Doug Sewell
Disease Management Program/Initiative
Karin Scott
Contact
Steve Shivers
Mary H. Finch Wilburn Smith, Jr., M.D.
Associate Medical Director David Stone
Alabama Medicaid Agency Page Walley
501 Dexter Avenue Donald Williamson, M.D.
Montgomery, AL 36103-5624 Helen Wilson
334/242-5610
Pharmacy and Therapeutics Committee
Alabama Medicaid Agency Officials
A. Z. Holloway, M.D.
Carol Herrmann Richard Freeman, M.D.
Commissioner Ben Main, R.Ph.
Alabama Medicaid Agency Gary Magouirk, M.D.
501 Dexter Avenue David Herrick, M.D.
P.O. Box 5624 Jackie Feldman, M.D.
Montgomery, AL 36103-5624 Sheri Lynn Boston, R.Ph.
T: 334/242-5600 Mary McIntyre, M.D.
F: 334/242-5097 Jimmie P. Clark, M.D.
E-mail: Almedicaid@medicaid.state.al.us Dane Yarbrough, R.Ph.
Internet address: www.medicaid.state.al.us
Executive Officers of State Medical and
John Searcy, M.D. Pharmaceutical Societies
Medical Director
Medical Association of the State of Alabama (MASA)
Alabama Medicaid Agency
Cary Kuhlmann
501 Dexter Avenue
Executive Director
P.O. Box 5624
19 S. Jackson Street
Montgomery, AL 36103
P.O. Box 1900
334/242-5619
Montgomery, AL 36102-1900
T: 334/954-2500
Title XIX Medical Care Advisory Committee
F: 334/269-5200
Carol Herrmann E-mail: cary@masalink.org
Amanda Buttenshaw Internet address: www.masalink.org
Bill Chandler
Irene Collins Alabama Osteopathic Medical Association
Louis E. Cottrell, Jr. E. Jason Hatfield, D.O.
Page Dunlap Secretary -Treasurer
William S. Eley, II P.O. Box 1857
Teresa Easterling U.S. Highway 43
Al Fox Winfield, AL 35594
Jean Fulton T: 205/487-3625
Lawrence F. Gardella F: 205/487-7559
Melane Golson Internet address: www.aloma.org
Frank Harris
Frank Holden Alabama Pharmacy Association (APA)
John Houston William S. Eley, II
Jolene Jones Executive Director
Leigh Moorer Jones 1211 Carmichael Way
Olivia Kendrick Montgomery, AL 36106-3672
Carl J. Kuhlman T: 334/271-4222
Roosevelt McCorvey, M.D. F: 334/271-5423
Linda McWilliams E-mail: aparx@aparx.org
Holley Midgley Internet address: www.aparx.org
Louise Pittman

Alabama-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Alabama State Board of Pharmacy


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

Alabama Independent Drugstore Association (AIDA)


Sharon Taylor, Executive Director
400 Interstate Park Drive
Suite 401
Montgomery, AL 36109
T: 334/213-2432
F: 334/213-2406
E-mail: Sharon@aidarx.org
Internet address: www.aidarx.org

Alabama Hospital Association


Tom Cooper, CEO
500 North East Blvd.
Montgomery, AL 36117
T: 334/272-8781
F: 334/270-9527
E-mail: tcooper@alaha.org
Internet address: www.alaha.org

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Alabama-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

ALASKA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/ Child Adult Aged Blind/ Child Adult
Disabled Disabled

Prescribed Drugs ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Inpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Outpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Laboratory & X-ray Service ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Nursing Facility Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Physician Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Dental Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. DRUG PAYMENTS AND RECIPIENTS


2002 2003
Expenditure Recipients Expenditure Recipients

TOTAL $83,324,085 70,550 $96,939,771 74,245

RECEIVING CASH ASSISTANCE TOTAL $64,580,513 33,632 $74,705,928 35,317


Aged $11,177,801 4,845 $13,303,796 5,015
Blind/Disabled $42,891,082 9,620 $48,808,026 9,877
Child $1,864,091 8,904 $2,673,066 10,400
Adult $8,647,539 10,263 $9,921,040 10,025

MEDICALLY NEEDY, TOTAL $0 0 $11,440,828 32,957


Aged $0 0 $7,200 6
Blind/Disabled $0 0 $4,799 4
Child $0 0 $10,337,354 29,226
Adult $0 0 $1,091,475 3,721

POVERTY RELATED, TOTAL $7,856,059 29,364 $9,535,143 4,828


Aged $8,177 8 $3,204,802 696
Blind/Disabled $17,643 7 $4,075,976 846
Child $6,492,328 23,878 $1,260,868 2,208
Adult $1,181,976 5,434 $993,497 1,078
BCCA Women $155,935 37 N/A N/A

TOTAL OTHER EXPENDITURES/RECIPTENTS* $10,887,513 7,554 1,257,872 1,143

*Total Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
Source: CMS, MSIS Report, FY 2002 and Alaska Medicaid Management Information System, FY 2003.
Note: Alaska estimates 2004 drug expenditures of approximately $113.5 million and the number of Medicaid drug recipients to be
75,000.

Alaska-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Formulary/Prior Authorization


Department of Health and Social Services, Division of Formulary: No formulary. Preferred drug list (PDL)
Health Care Services. managed by exclusion of products based on
contracting issues, restrictions on use, therapeutic
D. PROVISIONS RELATING TO DRUGS substitution, preferred products, and physician
profiling.
Benefit Design
Prior Authorization: State currently has a formal prior
Drug Benefit Product Coverage: Products covered: authorization procedure. Request for fair hearing
cosmetics (covered with restrictions- non hair growth required for appealing coverage of an excluded
products); prescribed insulin; and total parental product and PA decision. Medical necessity form
nutrition. Covered under DME: disposable needles and required.
syringe combinations used for insulin; blood glucose
test strips; and urine ketone test strips. Prior Prescribing or Dispensing Limitations
authorization required for: Clorazil; Lupron Depot;
ADC infant vitamins; some DME; Synagis; Panretin; Monthly Quantity Limit: Prescriptions are limited to
and Actig Naltrexone. Products not covered: fertility 30-day supplies (except family planning drugs).
drugs; experimental drugs; and intedialytic parenteral Dispensing of generic multi-source product is required.
nutrition. Maximum number of units for about 50 therapeutic
classes and 40 narcotic analgesics.
Over-the Counter Product Coverage: Products
covered with restrictions: feminine products (yeast Drug Utilization Review
antifungal drugs when ordered by prescription); topical
products (Bacitracin ointment only). Products not PRODUR system implemented in June 1995. State
covered: allergy, asthma, and sinus products; currently has a 5-member DUR Board that meets nine
analgesics; cough and cold preparations, digestive times per year.
products; and smoking deterrent products.
Pharmacy Payment and Patient Cost Sharing
Therapeutic Category Coverage: Categories covered:
anabolic steroids; antibiotics; anticoagulants; Dispensing Fee: No less than $3.45 and no more than
anticonvulsants; anti-depressants; antidiabetic agents; the 90th percentile of all dispensing fees determined
antihistamine drugs; antilipemic agents; anti- under the formula:
psychotics; anxiolytics, sedatives, and hypnotics;
cardiac drugs; chemotherapy agents; contraceptives; 1) $23,192 added to the number resulting from
ENT anti-inflammatory agents; estrogens; hypotensive multiplying total prescriptions filled by that
agents; miscellaneous GI drugs; sympathominetics pharmacy in the previous calendar year by 5.070;
(adrenergic); and thyroid agents. Prior authorization
required for: analgesics, antipyretics, and NSAIDs; 2) to 1), add the result of multiplying total Medicaid
growth hormones. Categories not covered: anoretics; prescriptions filled in the previous calendar year
prescribed cold medications; amphetamines (except for by 12.44;
narcolepsy and hyperactivity); prescribed smoking
deterrents; cough suppressants; DESI drugs; vitamins
3) from 2), subtract the result of multiplying the total
(except prenatal); and vitamins with fluoride.
floor space volume of the pharmacy in sq. ft. by
2.103;
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program
4) divide 3) by total prescriptions filled by that
when used in home health care and extended care
pharmacy
facilities, and through physician payment when used in
physicians’ offices.
5) add $0.73 to 4)
Vaccines: Vaccines reimbursable at cost as part of
Extra fee for compounding:
EPSDT services, the Children’s Health Insurance
Program, and the Vaccines for Children Program.
Long-term care pharmacies receive highest dispensing
fee once per month per NDC.
Unit Dose: Unit dose packaging reimbursable.

Alaska-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Ingredient Reimbursement Basis: EAC = AWP-5%. DUR Contact


Dave Campana, R.Ph.
Maximum Allowable Cost: State imposes Federal
907/334-2425
Upper Limits on generic drugs. Override requires
“Medically Necessary” and the reason of necessity. New Brand Name Products Contact
Dave Campana, R.Ph.
Incentive Fee: None.
907/334-2425
Cognitive Services: Does not pay for cognitive
Prescription Price Updating
services.
Dave Campana, R.Ph.
Patient Cost Sharing: $2.00 copayment for branded 907/334-2425
and generic products.
Medicaid Drug Rebate Contact
E. USE OF MANAGED CARE Amanda Burger
Division of Medical Assistance
Does not use MCOs to deliver services to Medicaid 4501 Business Park Blvd., Suite 24
recipients. Anchorage, AK 99503
T: 907/334-2409
F: 907/561-1684
F. STATE CONTACTS E-mail: amanda.burger@health.state.ak.us

Medicaid Drug Program Administrator Claims Submission Contact


Dave Campana, R.Ph. Dave Campana, R.Ph.
Pharmacy Program Manager 907/334-2425
Division of Health Care Services
Disease Management Program/Initiative
4501 Business Park Blvd., Suite 24
Contact
Anchorage, AK 99503
T: 907/334-2425 Doug Jones
F: 907/561-1684 Acting Deputy Director
E-mail: david_campana@health.state.ak.us Division of Medical Assistance
Internet Address: www.hss.state.ak.us/dhcs 4501 Business Park Blvd, Suite 24
Anchorage, AK 99503
Health and Social Services Department
907/334-2400
Officials
E-mail: doug_jones@health.state.ak.us
Joel Gilbertson, Commissioner
Department of Health and Social Services Mail Order Pharmacy Benefit
P.O. Box 110601
Yes, for all Medicaid recipients.
Juneau, AK 99811-0601
T: 907/465-3030
Alaska DUR Committee
F: 907/465-3068
E-mail: joel_gilbertson@health.state.ak.us Dave Campana, R.Ph.
Anchorage, AK
Jerry Fuller, Director
Division of Medical Assistance, DHSS Heide Brainerd, R.Ph.
P.O. Box 110660 Anchorage, AK
Juneau, AK 99811-0660
T: 907/465-3030 Greg Polston, M.D.
F: 907/465-3068 Fairbanks, AK.
E-mail: jerry_fuller@health.state.ak.us
Charlene Hampton, R.Ph.
Prior Authorization Contact Anchorage, AK
Dave Campana, R.Ph.
Alexander von Hafften, M.D.
907/334-2425
Anchorage, AK

Alaska-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Medical Care Advisory Committee Alaska Pharmacists Association


Nancy Davis, Executive Director
David Alexander, M.D. (Chair)
4107 Laurel Street, Suite 101
Anchorage, AK
Anchorage, AK 99508-5334
T: 907/563-8880
Gary Givens, R.Ph.
F: 907/563-7880
Anchorage, AK
E-mail: akphrmcy@alaska.net
Internet address: www.alaskapharmacy.org
Angela Gonzalez
Anchorage, AK
Alaska State Board of Pharmacy
Sher Zinn
Deborah Kiley, FNP
Licensing Examiner
Anchorage, AK
P.O. Box 110806
Juneau, AK 99811-0806
Karen Sidell
T: 907/465-2589
Bethel, AK
F: 907/465-2974
E-mail: sher_zinn@commerce.state.ak.us
Lavada “Sam” Bush
Internet address: www.dced.state.ak.us/occ/ppha.htm
Fairbanks, AK
Alaska State Hospital and Nursing Home Association
Marie Darlin
Rod L. Betit
Juneau, AK
President/CEO
426 Main Street
Brenda Knapp
Juneau, AK 99801
Juneau, AK
T: 907/586-1790
F: 907/463-3573
Kathy Dillard
E-mail: rodbetit@msn.com
Kodiak, AK
Internet address: www.ashnha.com
Marilyn Mories
Palmer, AK

David Gilbreath
Soldotna,AK

Jerry Fuller (Commissioner’s designee non-voting)


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

Alaska Osteopathic Medical Association


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

Alaska-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

ARIZONA
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
(AHCCCS - PRONOUNCED "ACCESS")
• Capitation of the State by the Federal
AHCCCS FEATURES Government.
The Arizona Health Care Cost-Containment System Primary Care Physicians as Gatekeepers
(AHCCCS), Arizona’s Medicaid program, is a Title
XIX (Medicaid) 1115 Research and Demonstration AHCCCS legislation provided that all members must
Waiver project, jointly funded by the federal be under the care and supervision of a primary care
government and the State of Arizona. Begun in physician who assumed the role of gatekeeper. A
October 1982, it serves as a model for providing statewide network of primary care physicians was
medical services to the indigent in a managed care established to perform the gatekeeping function for
system rather than through fee-for-service the system.
arrangements. Typically, Medicaid programs have
incorporated the traditional hallmarks of the U.S. Prepaid Capitated Financing
health care system: namely, independent providers
and fee-for-service reimbursement. In contrast, It was the intent of the AHCCCS legislation that
organized health plans and capitation mark the health plans and their providers offer all covered
AHCCCS model. services to groups of members within a geographical
area for a fixed price, for a definite period. The law
In traditional Medicaid programs, the States assume allowed for the establishment of a statewide bidding
responsibility for contracting with individual process to accomplish this. Services are provided on
pharmacies and reimbursing them. In the AHCCCS a county-by-county basis, by prepaid health plans.
model however, the State contracts, instead, with pre- Providers may bid on a prepaid capitated basis for
paid health plans, HMOs and HMO-like entities. covered services to be provided within a particular
These plans are paid on a capitation basis and are county. The law allows for expansion and
responsible for providing all of the services covered contraction of bids to achieve the best possible
by the program. Thus, with the exception of system. In the event there are insufficient bids for a
behavioral health drugs which are carved out of given area, the legislation permits capped fee-for-
managed care, the delivery of pharmacy services is service arrangements. It is intended, however, that
the responsibility of each prepaid plan. capped fee-for-service will be authorized as a last
resort only.
GENERAL INFORMATION
In essence, AHCCCS prepaid health plans (PHPs),
The Arizona Health Care Cost Containment System health maintenance organizations (HMOs), and other
(AHCCCS), developed in Senate Bill 1001, was types of organized health delivery systems charge a
passed by the Legislature and signed by the Governor fixed fee per individual enrolled (i.e., a capitation
in November 1981. It contained six major rate) and assume responsibility for providing a broad
mechanisms for restraining health care costs at the array of health care services to members. The plan or
same time ensuring that appropriate levels of quality contractor is then “at risk” to deliver the necessary
health care services are provided to eligible persons services within the capitated amount. AHCCCS
in a dignified fashion. The goal of these 6 items was receives Federal, State, and county funds to operate,
to contribute to the establishment of health care plus some monies from Arizona’s tobacco tax.
financing that is less expensive than conventional
fee-for-service systems. The six mechanisms were: Competitive Bidding Process
• Primary Care Physicians Acting as
The statewide competitive aspect of the bid process
Gatekeepers
for selecting providers and offering prepaid capitated
• Prepaid Capitated Financing services is the most unique feature of the AHCCCS
• Competitive Bidding Process model. A competition of this magnitude had never
• Cost Sharing been attempted in any other State. The AHCCCS
• Limitations on Freedom-of-Choice administration believes competitive bidding for
health care service contracts, as opposed to

Arizona-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

conventional negotiation processes, provides for the State to monitor health care costs on a careful
accessible cost-effective delivery of health care and continuous basis.
without sacrificing quality performance.
IMPLEMENTATION OF AHCCCS
The AHCCCS administration issues an invitation to
qualified health plans once every five years. AHCCCS is based on plans that have been tested, in
Qualified health plans may bid to offer the full range part, on smaller scales in different areas of the
of AHCCCS services in one or more counties. country. By combining a number of key mechanisms
on a statewide basis, AHCCCS represents a novel
Cost Sharing health care model. The purpose of this section is to
present a discussion of how the key concepts
The fourth major device for containing costs in the embodied in the AHCCCS legislation will be
AHCCCS model is a provision for cost sharing by implemented and rendered operational.
users. A statewide copayment schedule was
developed for this purpose, and the medically needy Provider Participation
participate in coinsurance cost sharing. It is expected
that the imposition of nominal copayments will Providers may participate in AHCCCS in 2 different
ensure optimal effectiveness in the area of service ways. First, they may contract with prepaid capitated
utilization. The copayment schedule accomplishes plans as either full or partial benefit providers.
three objectives: curtailment of over-utilization;
enhancement of patient dignity; and service The second mode of participation is on a capped fee-
utilization by members for truly needed health care. for-service basis. Here, providers agree to accept
There is no copayment for drugs and medication, capped fee payments as payments in full for services
prenatal care including all obstetrical visits, members provided on a FFS basis.
in long care facilities and for visits scheduled by the
primary care physician or practitioner, and not at the Functions of the AHCCCS Administration
request of the member.
The Arizona Health Care Containment System
Limitations On Freedom-of-Choice Administration (AHCCCSA) contracts with full
benefit capitated health plans to serve AHCCCS
The fifth major item for containing costs is a members through a network of providers.
restriction on provider/physician selection by
AHCCCS members. Unlike conventional delivery Contracting Health Plans
models, Arizona does not rely on fee-for-service
arrangements. The goal is to have the State Under the Contracting Health Plan arrangement,
completely blanketed with prepaid capitated plans are defined in terms of explicit groups of
arrangements. Members are linked to selected or providers organized as entities that are more formal.
assigned plans for definite durations of time. These consortia, or formal entities, are capable of
Freedom-of-choice is permitted to the extent providing the full range of AHCCCS benefits within
practicable for members to select the particular group a defined service area for all AHCCCS members who
with which to enroll, as well as the primary care elect to join the plans, up to a predetermined
physician within the selected group. Capped fee-for- capacity. This is the dominant mode of operation
service health service arrangements are used as a last within AHCCCS -- with two or more competing
resort, and only in areas not covered by prepaid plans wherever possible.
capitated plans.
The Contracting Health Plans are delivery systems,
CAPITATION BY THE FEDERAL not simply insurance plans, but they need not be
GOVERNMENT Health Maintenance Organizations by any legal or
conventional definition of the term. The AHCCCS
The State of Arizona will itself be capitated by the legislation provides for the creation of provider
Federal government and therefore will be at financial consortia for the purpose of participation in the
risk for containing health care costs. Capitation rates program. The Contracting Health Plan may be a
will be established according to sound actuarial loosely organized system, but it must be capable of
principles, and will represent no more than 95 providing the full range of AHCCCS benefits to a
percent of the estimated cost of services delivered in defined population at a capitation rate.
Arizona under conventional fee-for-service
arrangements. Capitation provides a key incentive

Arizona-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

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


Administration found on the agency’s website at
www.ahcccs.state.az.us)
The AHCCCS Administration has been charged with
the general implementation and monitoring of the MEDICAL PLANS AND
AHCCCS program. ADMINISTRATORS
The AHCCCS Administration develops the Rules AHCCCS Contracted Health Plans
and Regulations; manages the health plan bidding
processes; awards the contracts; provides technical Arizona Physicians IPA, Inc.
assistance to providers for the purpose of forming 3141 North 3rd Avenue
consortia to contract with AHCCCS; and monitors Phoenix, AZ 85013
the overall operation of the program. 800/445-1683

The Operational Role of the AHCCCS Care1st Health Plan of Arizona, Inc.
Administration 2355 E. Camelback Rd.
Suite 300
Organizationally, the AHCCCS Administration Phoenix, AZ 85016
assumes responsibility for the oversight of every day 866/560-4042
operations.
Health Choice Arizona
The AHCCCS Administration has overall Suite 260
responsibility for the following activity areas: 1600 West Broadway
Tempe, AZ 85282-1136
• Eligibility Oversight T: 480/968-6866
• Procurement of Health Plans F: 800/322-8670
• Quality Management
• Health Plan Oversight Maricopa Health Plan
• Provider, Member Call Center 2502 East University Drive
• Grievances and Complaints Phoenix, AZ 85034
• Fee-for-Service for IHS 800/582-8686

AHCCCS became effective December 1, 1981, and Mercy Care Plan


services commenced October 1, 1982. Services Suite 400
include: inpatient, outpatient, laboratory, x-ray, 2800 North Central
prescription drugs, medical supplies, prosthetic Phoenix, AZ 85004
devices, emergency dental care including extractions T: 602/263-3000
and dentures, treatment of eye conditions and F: 800/624-3879
EPSDT.
Phoenix Health Plan/Community Connection
Though AHCCCS was a three-year experiment that 7878 North 16th Street, Suite 105
was to end in October 1985, the Federal government Phoenix, AZ 85020
continues to extend funding for the program. In 800/747-7997
1988, AHCCCS received a five-year extension from
the Federal government and in 1993, it received an Pima Health System
additional one-year extension. In 1994, AHCCCS Suite A-200
received a three-year extension and in 1998, it 5055 East Broadway
received a one-year extension. Since then, AHCCCS Tucson, AZ 85711
has received additional extensions. Currently, 800/423-3801
AHCCCS is operating under a five year waiver
extension that will expire on September 30, 2006. University Family Care
Some 20 years after it first began, AHCCCS has 575 East River Road
grown in numbers from the first wave of 180,000 Tucson, AZ 85704
enrollees to approximately 1 million beneficiaries, 888/708-2930
(Oct. 1, 2004) representing 18 percent of Arizona’s
population. AHCCCS has also become a model as
managed care is increasingly by being implemented
in other States’ Medicaid programs.

Arizona-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Phoenix Area Indian Health Services (IHS) Yavapai County LTC


Two Renaissance Square Yavapai County Department of Medical Assistance
40 N. Central Avenue 6717 East Second Street
Phoenix, AZ 85004-5036 Prescott, AZ 86314
602/364-5039 520/771-3560

Tucson Area Indian Health Services (IHS)


7900 South J. Stock Road STATE CONTACTS
Tucson, AZ 85746
520/295-2405 AHCCCS Officials

Navajo Area Indian Health Services (IHS) Anthony D. Rodgers, Director


P.O. Box 9020 AHCCCS
Window Rock, AZ 86515-9020 801 E. Jefferson Street
928/871-5811 Phoenix, AZ 85034
T: 602/417-4111
Long-Term Care Contractor List F: 602/252-6536
E-mail: anthony.rodgers@ahcccs.state.az.us
Cochise Health Systems Internet address: www.ahcccs.state.az.us
Cochise County Health & Social Services
1415 West Melody Lane, Building A Dell Swan
P.O. Box 4249 Pharmacy Program Administrator
Bisbee, AZ 85603-4249 AHCCCS
800/285-7485 701 East Jefferson Street
MD 8000
DES/DDD Phoenix, AZ 85034
1789 West Jefferson, 4th Floor 602/417-4726
Phoenix, AZ 85007 E-mail: dwswan@ahcccs.state.az.us
866/229-5553
Executive Officers of State Medical and
Evercare Select Pharmaceutical Societies
314 N. 3rd Avenue, Suite 100 Arizona Medical Association
Phoenix, AZ 85013 Chic Older
800/293-0039 Executive Vice President
810 West Bethany Home Road
Maricopa Long Term Care Plan Phoenix, AZ 85013
2502 East University Drive T: 602/246-8901
Phoenix, AZ 85034 F: 602/242-6283
800/852-8686 E-mail: chicolder@azmedassn.org
Internet address: www.azmedassn.org
Mercy Care Plan
Suite 400 Arizona Pharmacy Association
2800 North Central Kathy Boyle
Phoenix, AZ 85004 Executive Director
800/624-3879 1845 E. Southern Ave.
Tempe, AZ 85282-5831
Pima Long Term Care T: 480/838-3385
Pima Health System F: 480/838-3557
5055East Broadway E-mail: azpa@azpharmacy.org
Suite A-200 Internet address: www.azpharmacy.org
Tucson, AZ 85711
800/423-3801

Pinal/Gila LTC
P.O. Box 2140
971 Jason Lopez Circle
Florence, AZ 85232-2140
800/624-3879

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Arizona Osteopathic Medical Association


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

Arizona State Board of Pharmacy


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

Arizona Hospital and Healthcare Association


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

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ARKANSAS

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003
Expended Recipients Expended Recipients

TOTAL $279,644,642 356,233 $325,295,608 398,819

RECEIVING CASH ASSISTANCE, TOTAL $157,798,100 118,809 $178,457,300 120,706


Aged $17,336,361 12,289 $16,740,556 11,538
Blind/Disabled $128,477,401 70,462 $148,620,681 73,243
Child $5,658,548 22,298 $6,158,213 22,945
Adult $6,325,790 13,760 $6,937,850 12,980

MEDICALLY NEEDY, TOTAL $4,608,841 6,164 $5,491,687 7,673


Aged $106,947 201 $128,939 260
Blind/Disabled $2,808,184 2,067 $3,010,610 2,508
Child $326,251 1,231 $534,266 1,562
Adult $1,367,459 2,665 $1,817,872 3,343

POVERTY RELATED, TOTAL $33,825,156 138,273 $46,906,430 167,697


Aged $295,773 306 $1,918,203 2,513
Blind/Disabled $1,266,719 808 $1,215,050 895
Child $29,880,903 122,032 $42,456,630 155,252
Adult $2,381,761 15,127 $1,316,547 9,037
BCCA Women $0 0 $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $83,412,545 92,987 $94,440,191 102,743

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.

Source: CMS, MSIS Report, FY 2002 and Arkansas Medical Management Information System, FY 2003.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Formulary/Prior Authorization


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

Coverage of Injectables: Injectable medicines are Drug Utilization Review


reimbursable through the Prescription Drug Program
when used in home health care and extended care PRODUR system implemented in March 1997. State
facilities, and through physician payment when used currently has a DUR Board with a quarterly review.
in physicians offices. Some products may require
prior authorization. Pharmacy Payment and Patient Cost Sharing

Vaccines: Vaccines reimbursable as part of EPSDT Dispensing Fee: $5.51 effective 7/1/99. Effective
services, the Children’s Health Insurance Program, 3/1/02, non-MAC generics receive an additional
and the Vaccines for Children Program. $2.00 dispensing fee. LTC pharmacies generally
receive one dispensing fee per NDC per month.
Unit Dose: Unit dose packaging reimbursable.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Ingredient Reimbursement Basis: EAC = AWP-14% F. STATE CONTACTS


(Brand), AWP-20% (Generic).
Medicaid Drug Program Administrator
Prescription Charge Formula: Legend drugs: lower
of the EAC plus a dispensing fee or CFA/state upper Suzette Bridges, P.D., Administrator
limit plus a dispensing fee. Total charge may not Pharmacy Program
exceed provider’s charge to the self-paying public. Division of Medical Services
Dept. of Human Services
Maximum Allowable Costs: State imposes Federal P.O. Box 1437, Slot S 415
Upper Limits as well as State-specific limits on Little Rock, AR 72203-1437
generic drugs. State-specific MAC list contains 800 T: 501/683-4120
drugs (see www.medicaid.ar.us). Override requires F: 501/683-4124
physician documentation on MedWatch form as to E-mail: suzette.bridges@medicaid.state.ar.us
why the generic cannot be dispensed. Prior Authorization Contact

Incentive Fee: $2.00 additional dispensing fee on Suzette Bridges, P.D.


non-MAC generics. 501/683-4120

Patient Cost Sharing: Effective 9/1/92, for each DUR Contact


prescription reimbursed, the Medicaid recipient is Pamela Ford, P.D.
responsible for paying a copayment based on the Pharmacist II
following: Division of Medical Services
Dept. of Human Services
State Payment Copay P.O. Box 1437, Slot S 415
Little Rock, AR 72203-1437
$10.00 or less $0.50 T: 501/683-4120
F: 501/683-4124
$10.01 to $25.00 $1.00 E-mail: pamela.ford@medicaid.state.ar.us

$25.01 to $50.00 $2.00 DUR Board


Steve Bryant, P.D.
$50.01 or more $3.00
Gary Bass, P.D.
Ken Lancaster, P.D.
ArKids $5.00
Debbie Hayes
Ann Blaylock, A.P.N.
Services to individuals under 18, pregnant women,
Thomas Lewellen, D.O.
nursing home residents, emergency services, family
Michael N. Moody, M.D.
planning services, and services provided by an HMO
Laurence Miller, M.D.
to its enrollees are excluded from the Medicaid copay
P. Justin Boyd, P.D.
policy.
New Brand Name Products Contact
Cognitive Services: Does not pay for cognitive
services. Suzette Bridges, P.D.
501/683-4120
E. USE OF MANAGED CARE Prescription Price Updating
An estimated 300,000 Medicaid recipients were First DataBank
enrolled with Primary Care Physicians and 1111 Bay Hill Drive
approximately 70,000 children are enrolled in ArKids San Bruno, CA 94066
at the end of 2004. Pharmaceutical benefits are T: 650/588-5454
provided through the State. F: 650/588-4003

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Medicaid Drug Rebate Contacts Department of Human Services Officials


Audits: Suzette Bridges, P.D., 501/683-4120 Kurt Knickrehm, Director
Department of Human Services
Dispute Resolution: Dana Boyer P.O. Box 1437, Slot 201
Rebate Analyst Little Rock, AR 72203-1437
EDS T: 501/682-8650
500 President Clinton Ave, Suite 400 F: 501/682-6836
Little Rock, AR 72201 E-mail: kurt.knickrehm@state.ar.us
T: 501/374-6608 Internet address: www.state.ar.us/dhs
F: 501/372-2971
E-mail: dana.boyer@mediciad.state.ar.us Roy Jeffus, Director
Division of Medical Services
P.O. Box 1437, Slot 1100
Claims Submission Contact
Little Rock, AR 72203-1437
John Herzog, Account Manager T: 501/682-1671
EDS F: 501/682-1197
500 President Clinton Ave, Suite 400 E-mail: roy.jeffus@medicaid.state.ar.us
Little Rock, AR 72201
Executive Officers of State Medical and
T: 501/374-6608
Pharmaceutical Societies
F: 501/372-2971
E-mail: john.herzog@medicaid.state.ar.us Arkansas Hospital Association
James R. Teeter
Medicaid Managed Care Contact President/CEO
419 Natural Resources Drive
Kellie Phillips
Little Rock, AR 72205
Program Administrator
T: 501/224-7878
Medical Assistance
F: 501/224-0519
Division of Medicaid Services
E-mail: aha@arkhospital.org
Dept. of Human Services
Internet address: www.arkhospitals.org
P.O. Box 1437, Slot 410
Little Rock, AR 72203
Arkansas Pharmacists Association
T: 501/682-8306
Mark Riley
F: 501/682-1197
Executive Director
E-mail: kellie.phillips@medicaid.state.ar.us
417 S. Victory Street
Little Rock, AR 72201-2932
Disease Management/Patient Education T: 501/372-5250
Programs F: 501/372-0546
Disease/Medical State: Diabetes E-mail: mriley@arpharmacists.org
Program Name: Arkansas Medicaid Diabetes Project Internet address: www.arpharmacists.org
Program Manager: Coalition of Dept. of Health and
Medicaid Arkansas State Board of Pharmacy
Sponsor: Eli Lilly and Company Charles S. Campbell
Executive Director
Disease/Medical State: Behavioral Health 101 E. Capitol, Suite 218
Program Name: Arkansas Behavioral Health Project Little Rock, AR 72201
Program Manager: Medicaid T: 501/682-0190
Sponsor: Comprehensive NeuroScience /Eli Lilly and F: 501/682-0195
Company E-mail: charlie.campbell@mail.state.ar.us
Internet address: www.state.ar.us/asbp
Disease Management/ Patient Education
Contact
Suzette Bridges, P.D.
501/683-4120
Mail Order Pharmacy Benefit
None

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Arkansas Osteopathic Medical Association


Ed Bullington
Executive Director
412 Union Station
1400 West Markham
Little Rock, AR 72201
T: 501/374-8900
F: 501/374-8959
E-mail: osteomed@ipa.net
Internet address: www.arkosteomed.org

Arkansas Medical Society


Ken LaMastus
Executive Vice President
P.O. Box 55088
Little Rock, AR 72215
T: 501/224-8967
F: 501/224-6489
E-mail: klamastus@arkmed.org
Internet address: www.arkmed.org

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CALIFORNIA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/ Child Adult Aged Blind/ Child Adult
Disabled Disabled

Prescribed Drugs ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Inpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Outpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Laboratory & X-ray Service ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Nursing Facility Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Physician Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Dental Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Note: Certain classifications of aliens in the above categories are eligible only for emergency and pregnancy-related benefits.

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $3,402,508,001 2,651,229 $4,219,504,969

RECEIVING ASSISTANCE, TOTAL $2,552,720,446 1,379,776


Aged $582,176,474 278,543
Blind/Disabled $1,826,731,055 593,945
Children $49,316,799 304,963
Adult $94,496,118 202,325

MEDICALLY NEEDY, TOTAL $499,284,360 281,471


Aged $248,136,400 130,533
Blind/Disabled $223,302,948 58,736
Children $10,574,655 55,277
Adults $17,270,357 36,925

POVERTY RELATED, TOTAL $126,084,007 135,070


Aged $40,135,036 27,679
Disabled $75,923,867 22,313
Children $5,580,840 51,160
Adults $2,671,613 32,398
BCCA Women $1,772,651 1,520

TOTAL OTHER EXPENDITURES/RECIPIENTS* $224,419,188 854,912

*Total Other Expenditures/ Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Formulary/Prior Authorization

Under the Health and Human Services Agency with Formulary: The Medi-Cal List of Contract Drugs is a
direct administration by the Department of Health preferred drug list. It contains over 600 drugs, in
Services. differing strengths and dosage forms, listed
generically. Patients can get prior authorization for
The Department of Health Services Pharmaceutical unlisted drugs or for listed drugs that are restricted to
Unit of the Medi-Cal Policy Division monitors the specific use(s), if medically justified. Manufacturers
full scope and quality of pharmaceutical benefits frequently petition Medi-Cal to add drugs to the List
covered under the provisions of the California of Contract Drugs. Based on Medi-Cal’s five criteria
Medical Assistance Program. (safety, efficacy, misuse potential, essential need, and
cost), a drug may be added to the list by contractual
D. PROVISIONS RELATING TO DRUGS agreement with the manufacturer to provide the State
a negotiated rebate. The Medi-Cal website at:
Benefit Design http://www.dhs.ca.gov/mcs/mcpd/MBB/contracting/h
tml/faqpage.htm has details of how the drug
Drug Benefit Product Coverage: The Medi-Cal contracting process works.
pharmacy benefit covers practically all FDA-
approved drugs, including both legend and over-the- Examples of general limitations and exclusions
counter products. There are very few drugs or (other uses require prior authorization):
classes of drugs that are non-benefits. Non-benefits
1. CNS stimulants, e.g., amphetamines and
include common household remedies; non-legend
methylphenidate, are restricted to attention
analgesics and cough/cold medications, except when
deficit disorder in individuals between 4 and 16
specifically listed; multivitamin preparations, except
years of age.
certain pre-natal and pediatric products; cosmetics;
fertility drugs; and experimental drugs. Most other 2. Diazepam is restricted to use in cerebral palsy,
products are potential benefits. athetoid states, and spinal cord degeneration.
3. Most non-steroidal anti-inflammatory agents are
In general, products that are listed on the Medi-Cal
restricted to use for arthritis.
List of Contract Drugs do not require prior
authorization. Those not on the List of Contract 4. Some antibiotics have diagnostic and/or age
Drugs do require prior authorization. restrictions.
5. Acyclovir capsules are restricted to herpes
Physician-administered drugs: The Medi-Cal List of
genitalis, immunocompromised, and herpes
Contract Drugs applies to drugs dispensed from
zoster (shingles) patients.
pharmacies to patients. Drugs administered directly
in a physician's, dentist's, or podiatrist's office are not 6. Codeine Combinations: payment to a pharmacy
bound by the List of Contract Drugs. for ASA or APAP with codeine 30 mg is limited
to a maximum dispensing quantity of 45 tablets
Coverage of Injectables: Injectable medicines are or capsules and a maximum of 3 claims for the
reimbursable through the Prescription Drug Program same beneficiary in any 75-day period.
when used in home health care and extended care
7. Enteral nutritional supplements or replacements
facilities and through physician payment when used
are covered, subject to prior authorization, if
in physician offices.
used as a therapeutic regimen to prevent serious
disability or death in patients with medically
Vaccines: Vaccines are reimbursable by schedule as
diagnosed conditions that preclude the full use of
part of the Vaccines for Children Program. Vaccines
regular foodstuffs.
for adults are covered through the prescription drug
program or as administered in a physician's office. 8. Cancer, AIDS, and DESI Drugs: Any
antineoplastic drug approved by FDA for the
Unit Dose: Unit dose packaging reimbursable. treatment of cancer and any drug approved by
FDA for the treatment of AIDS or AIDS-related
condition is covered through the Medi-Cal List
of Contract Drugs; most DESI drugs rated less-
than-effective by FDA are not covered.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Prior Authorization: Nearly all drugs not included on Monthly Prescription Limit: Limited to 6 per month
the Medi-Cal list of Contract Drugs require prior without prior authorization. The limit does not apply
authorization. State currently has a formal prior to family planning drugs, patients in nursing
authorization procedure to appeal prior authorization facilities, or to AIDS or cancer drugs.
decisions.
Hospital Discharge Medications: Quantities
The patient’s physician or pharmacist may request furnished as discharge medications are limited to no
prior authorization from the field office Medi-Cal more than a 10-day supply. Charges are incorporated
consultant for approval of unlisted drugs or for listed in the hospital’s claims for inpatient services.
drugs that are restricted to specific use(s). This is
done by completing a Treatment Authorization Drug Utilization Review
Request (TAR) form. Providers may appeal prior
authorization decisions within 60 days of notification Prospective DUR system implemented in August
to the local field office and then to field services 1995. State currently has a DUR Board with a
headquarters if necessary. Beneficiaries also have the quarterly review.
ability to request a hearing to review the denial and
must do so within 90 days of notification. Pharmacy Payment and Patient Cost Sharing
TARs may be approved for: covered items or Dispensing Fee: $7.25 ($8.00 LTC), effective 9/1/04.
services not included on the Medi-Cal List of
Contract Drugs (including special circumstance such Ingredient Reimbursement Basis: EAC = AWP-17%
as the need to override multiple source drug price
ceilings or minimum quantity/ frequency of billing Prescription Charge Formula: Reimbursement is
limitations); and for patients exceeding the 6 Rx per based on the lowest of:
month limit. Statewide mail and fax requests are
accepted in the Stockton and Los Angeles Medi-Cal 1. Estimated Acquisition Cost (EAC) + dispensing
Field Offices. Requests must include adequate fee, less $0.50 for most patients, or less $0.10 for
information and justification. Authorization may nursing home patients.
only be given for the lowest cost item or service that 2. Federal Upper Limit (FUL) + dispensing fee,
meets the patient’s medical needs. less $0.50 for most patients, or less $0.10 for
nursing home patients.
Beneficiary or Prescriber Prior Authorization: On a 3. State Maximum Allowable Ingredient Cost
case by case basis, the Dept. of Health Services (MAIC) + dispensing fee, less $0.50 for most
restricts, through the requirements of prior patients, or less $0.10 for nursing home patients.
authorization, the availability of designated 4. Pharmacy’s usual price to general public, less
prescription drugs to certain beneficiaries or $0.50 for most patients, or less $0.10 for nursing
prescribers found by the Department to abuse those home patients.
benefits. State law requires that reimbursement for blood
factors be by NDC and not exceed 120 percent of the
Prescribing or Dispensing Limitations average selling price during the preceding quarter.
Maximum Allowable Cost: State imposes a
Prescription Refill Limit: A prescription refill can be
combination of Federal and State-specific limits on
dispensed as authorized by prescriber. An exception
generic drugs. Maximum Allowable Ingredient Costs
is allowed for refill of a reasonable quantity when
(MAICs) are established for about 50 multi-source
prescriber is unavailable (pursuant to California law).
items. Override requires “Medically Necessary” or
Fee is to be pro-rated so that total fee (for partial
unavailability of drug products at or below MAC.
quantity and balance of the prescription after
List is periodically revised and price limits changed
prescriber is contacted) does not exceed the fee for
to reflect current market conditions.
the same prescription when refilled as a routine
service.
Incentive Fee: None.
Monthly Quantity Limit: This is flexible, but should
be consistent with the medical needs of the patient. Patient Cost Sharing: $1.00 copayment for branded
Limited to 100 days’ supply on most drugs. Many and generic products.
maintenance drugs are subject to minimum quantity
or maximum frequency of billing controls. Cognitive Services: Does not pay for cognitive
services, but this is under consideration.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

E. USE OF MANAGED CARE Inland Empire Health Plan


303 East Vauderbilt Way, Suite 400
Approximately 2.7 million Medicaid recipients were San Bernardino, CA 92408
enrolled in MCOs in FY 2003. Recipients receive 909/890-2000
pharmaceutical benefits through the State and
managed care plans. Certain psychiatric drugs Kaiser Foundation Health Plan, Inc.
(antipsychotics, lithium, MAO inhibitors) and some 393 E. Walnut Street
anti-Parkinson drugs are carved out of managed care. Pasadena, CA 91188
Most AIDS drugs are no longer carved out of 800/390-3510
managed care.
Kern Health Systems
Kern Family Health Care
AIDS Healthcare Foundation 1600 Norris Road
Positive HealthCare Bakersfield, CA 93308
6255 W. Sunset Blvd., 21st Floor 661/391-4036
Los Angeles, CA 90028
323/860-5231 LA Care Health Plan
555 W. Fifth Street, 20th Floor
Alameda Alliance for Health Los Angeles, CA 90013
1240 South Loop Road 213/694-1250
Alameda, CA 94502
510/747-4500 Molina Healthcare of California
One Golden Shore Drive
Altamed Senior BuenaCare Long Beach, CA 90802
5425 East Pomona Boulevard 562/432-3666
Los Angeles, CA 90022
323/728-0411 On Lok Senior Health Services-Alameda
159 Washington Boulevard
Blue Cross of California Fremont, CA 94539
P.O. Box 9054 415/292-8888
Oxnard, CA 93031
800/407-4627 On Lok Senior Health Services-SF
1333 Bush Street
Center for Elders Independence San Francisco, CA 94109
1955 San Pablo Avenue 415/292-8888
Oakland, CA 94612
510/433-1150 Orange County Organized Health System
CalOPTIMA
Community Health Group 1120 West La Veta Ave.
740 Bay Blvd. Orange, CA 92868
Chula Vista, CA 91910 714/246-8400
619/498-6457
Placer County Managed Care Network
County of Contra Costa 379 Nevada Street
Contra Costa Health Plan Auburn, CA 95603
595 Center Avenue, Suite 100 888/215-5453
Martinez, CA 94553
925/313-6008 San Francisco Health Authority
San Francisco Health Plan
Health Net of California 568 Howard Street, Fifth Floor
3400 Data Drive, 1st Floor West San Francisco, CA 94105
Rancho Cordova, CA 95670 415/547-7800
800/675-6110
San Francisco City & County Public Health
Health Plan of San Joaquin Family Mosaic Project
1550 W. Fremont Street, Suite 200 1309 Evans Avenue
Stockton, CA 95203-2643 San Francisco, CA 94124
209/939-3500 415/206-7600

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National Pharmaceutical Council Pharmaceutical Benefits 2004

San Mateo Health Commission Western Health Advantage


Health Plan of San Mateo 1331 Garden Highway Suite 100
701 Gateway Blvd., Suite 400 Sacramento, CA 95833
South San Francisco, CA 94080 916/563-3189
650/616-0050
F. STATE CONTACTS
Santa Barbara Regional Health Authority
Santa Barbara Health Initiative State Drug Program Administrator
110 Castilian Drive
Goleta, CA 93117 J. Kevin Gorospe, Pharm.D.
805/685-9525 (Northern CA) Chief, Pharmacy Policy Unit
800/421-2560 (Southern CA) California Department of Health Services
Medi-Cal Policy Division
Santa Clara Family Health Plan Pharmacy Contracting and Policy Section
210 E Hacienda Ave 1501 Capitol Ave.
Campbell, CA 95008 P.O. Box 997413, MS 4604
408/376-2000 Sacramento, CA 95814
T: 916/552-9500
Santa Cruz -Monterey F: 916/552-9563
Managed Care Commission E-mail: jgorospe@dhs.ca.gov
Central Coast Alliance for Health Internet Address: www.medi-cal.ca.gov
375 Encinal Street, Suite A New Brand Name Products Contact
Santa Cruz, CA 95060
800/700-3874 J. Kevin Gorospe, Pharm.D.
916/552-9500
Scan Health Plan Prior Authorization Contact
Senior Care Action Network
3780 Kilroy Airport Way, Suite 600 J. Kevin Gorospe, Pharm.D.
Long Beach, CA 90801 916/552-9500
562/989-5100 DUR Contact

Sharp Health Plan Ellis Ellis, Pharm.D.


4305 University Avenue, Suite 200 Pharmaceutical Counsultant II
San Diego, CA 92105 California Department of Health Services
619/228-2377 Medi-Cal Policy Division
Pharmacy Contracting and Policy Section
Solano-Napa County Commission on Medical Care 1501 Capitol Ave.
Partnership Health Plan of California P.O. Box 997413, MS 4604
360 Campus Lane, Suite 100 Sacramento, CA 95814
Fairfield, CA 94534 T: 916/552-9500
707/863-4100 F: 916/552-9563
E-mail: eellis2@dhs.ca.gov
Sonoma County Partners for Health Managed Care Medi-Cal Drug Utilization Review Board (DUR
Network Board)
415 Humboldt Street
Santa Rosa, CA 95404 Timothy E. Albertson, M.D., Ph.D.
707/565-4600 University of California-Davis
Pulmonary/Critical Care Medicine
Sutter Senior Care Sacramento, CA
1234 U Street
Sacramento, CA 95818 Craig Jones, M.D.
916/446-3100 Director, Division of Allergy/Immunology
Department of Pediatrics
Universal Care LA County/USC Medical Center
1600 E. Signal Hill Street Calabasas, CA
Signal Hill, CA 90806
800/635-6668

California-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Janeen G. McBride, Pharm.D. Medicaid Managed Care Contact


Associate Vice President
Ronald Sanui, Pharm D.
Medimpact Healthcare Systems, Inc.
Pharmaceutical Consultant II
San Diego, CA
California Department of Health Services
Medi-Cal Managed Care Division
Gary M. McCart, Pharm.D.
1501 Capitol Ave.
Professor of Clinical Pharmacy
P.O. Box 997413, MS 4404
University of California Medical Center
Sacramento, CA 95814
San Francisco, CA
916-449-5138
E-mail: rsanui@dhs.ca.gov
Kenneth Schell, Pharm.D.
Clinical Operations Manager
Disease Management Program/Initiatives
Pharmacy Services
Contact
Kaiser Permanente
San Diego, CA Marcia Ehinger, M.D.
Senior Medical Consultant
Stephen M. Stahl, M.D., Ph.D. California Department of Health Services
Director Medi-Cal Policy Division
Clinical Neuroscience Research Center 1501 Capitol Ave., MS 4600
UCSD School of Medicine P.O. Box 997413
San Diego, CA Sacramento, CA 95814
T: 916/552-9400
Andrew L. Wong, M.D. F: 916/555-9960
Chief of Rheumatology E-mail: mehinger@dhs.ca.gov
UCLA Medical Center
Sylmar, CA Mail Order Drug Benefit
State currently has a mail order pharmacy capability
Prescription Price Updating
in the Medi-Cal program. All fee-for-service
EDS Federal Corp. beneficiaries are entitled to participate.
P.O. Box 13029
Sacramento, CA 95813-4029 Department of Health Services
916/636-1000
Sandra Shewry, Director
Department of Health Services
Medicaid Drug Rebate Contact
P.O. Box 997413, MS 000
Craig Miller Sacramento, CA 95899
Chief, Drug Rebate and Vision Section T: 916/440-7400
California Department of Health Services F: 916/440-7404
Medi-Cal Policy Division E-mail address: sshewry@dhs.ca.gov
Pharmacy Contracting and Policy Section
1501 Capitol Ave. Stan Rosenstein
P.O. Box 997413, MS 4604 Deputy Director
Sacramento, CA 95814 Medical Care Services
T: 916/552-9500 California Department of Health Services
F: 916/552-9563 1501 Capitol Ave.
E-mail: cmiller2@dhs.ca.gov P.O. Box 942732
Sacramento, CA 95814
T: 916/ 440-7800
Claims Submission Contact
F: 916/ 440-7805
EDS Federal Corp. E-mail: srosenst.dhs.ca.gov
P.O. Box 13029
Sacramento, CA 95813-4029 Medi-Cal Contract Drug Advisory Committee
916/636-1000
William B. Ness, M.D.
Lincoln, CA

Bruce K. Uyeda, Pharm.D.


Mountain View, CA

California-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

Adrian M. Wong, Pharm.D. California Healthcare Association


San Francisco, CA C. Duane Dauner
President
Richard H. White, M.D. 1215 K Street, Suite 800
U.C. Davis Medical Center Sacramento, CA 95814
Division of General Medicine T: 916/443-7401
Sacramento, CA F: 916/552-7596
E-mail: info@calhealth.org
Shirley Ann Floyd Internet address: www.calhealth.org
Blue Cross of California
Bakersfield, CA 93301

Executive Officers of State Medical and


Pharmaceutical Associations/Boards
California Medical Association
Jack C. Lewin, M.D.
Executive Vice-President and CEO
1201 J Street, Suite 200
Sacramento, CA 95814
T: 916/444-5532
F: 415/882-3349
Internet address: www.cmanet.org

Osteopathic Physicians & Surgeons of California


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

California Pharmacists’ Association


Carlo Michelotti, R.Ph., M.P.H.
Chief Executive Officer
4030 Lennane Drive
Sacramento, CA 95834
T: 916/779-1400
F: 916/779-1401
E-mail: cpha@cpha.com
Internet address: www.cpha.com

California State Board of Pharmacy


Stanley Goldenberg, R.Ph.
President
400 R Street, Suite 4070
Sacramento, CA 95814
T: 916/445-5014
F: 916/327-6308
Internet address: www.pharmacy.ca.gov

California-7
National Pharmaceutical Council Pharmaceutical Benefits 2004

California-8
National Pharmaceutical Council Pharmaceutical Benefits 2004

COLORADO

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $202,286,461 153,520 $225,297,507

RECEIVING CASH ASSISTANCE, TOTAL $131,455,323 81,187


Aged $42,740,055 18,549
Blind/Disabled $78,779,997 26,398
Child $3,365,340 18,079
Adult $6,568,168 18,160
Unknown $1,763 1

MEDICALLY NEEDY, TOTAL $0 0


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

POVERTY RELATED, TOTAL $6,751,922 40,538


Aged $127,100 128
Blind/Disabled $226,817 129
Child $4,875,966 29,415
Adult $1,515,915 10,854
BCCA Women 6,124 12

TOTAL OTHER EXPENDITURES/RECIPIENTS* $64,079,216 31,795


*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Colorado-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Vaccines: Vaccines reimbursable as part of the


EPSDT Program.
Colorado Department of Health Care Policy and
Financing administers the drug program. Eligibility Unit Dose: Unit dose packaging reimbursable.
is determined by 63 County Departments of Social
Services and the Department.
Formulary/Prior Authorization

D. PROVISIONS RELATING TO DRUGS Formulary: Open formulary. Managed through


restrictions on use and prior authorization.
Benefit Design
Prior Authorization: State currently has a formal
Drug Benefit Product Coverage: Products covered: prior authorization procedure. There is an appeal
Products covered: prescribed insulin; total parenteral process and re-review when appealing coverage of an
nutrition; and interdialytic parenteral nutrition. excluded product and prior authorization decisions.
Products not covered: cosmetics; DESI drugs;
fertility drugs; prescribed vitamins (except prenatal); Prescribing or Dispensing Limitations
and experimental drugs. Disposable needles and
syringe combinations used for insulin; blood glucose Monthly Quantity Limit: New prescriptions for
test strips; and urine ketone test strips are considered chronic or acute conditions are prescribed at the
DME and do not fall under the State’s drug benefit. discretion of the physician. Normal quantity limit is
a 30-day supply. However, reasonable amounts for
Over-the-Counter Product Coverage: Products more than a 30-day supply for chronic conditions are
covered: allergy, asthma, and NSAIDs; analgesics; recommended. Maximum supply is determined by
and digestive products. Products covered with the medication. Standard limit of 4 bottles per month
restrictions: cough and cold preparations (< 21);
feminine products (must be medically necessary); Other Limits: Additional quantity limits may be
topical products (must be medically necessary); and applied to certain drugs. Oxycontin: 2 tablet (any
smoking deterrent products (prior authorization, once strength) per day limit without prior authorization.
in a lifetime benefit, 90-day supply in conjunction
with smoking cessation program). Drug Utilization Review
Therapeutic Category Coverage: Therapeutic PRODUR system implemented in December 1998.
categories covered: antibiotics; anticonvulsants; DUR Board meets quarterly.
antidepressants; antidiabetic agents; antilipemic
agents; cardiac drugs; contraceptives; ENT anti- Lock-In Review Procedures: The Department
inflammatory agents; hypotensive agents; and thyroid receives computer processed printouts designed to
agents. Prior authorization required for: anabolic discover over-utilization of drugs prescribed by
steroids; analgesics, antipyretics, and NSAIDs; physicians, dispensed by vendors, and received by
anticoagulants; antihistamines; anti-psychotics; eligible recipients.
anxiolytics, sedatives, and hypnotics, chemotherapy
agents; prescribed cough and cold medications;
Pharmacy Payment and Patient Cost Sharing
estrogens; growth hormones; misc. GI drugs;
sympathominetics (adrenergic); vitamins; acne
Dispensing fee: $4.00 as of July 1, 2001.
products; leukocyte stimulants; LHRH/GnRH;
Institutional pharmacies receive a dispensing fee
injectables; plasma products; Epoetin; fluoride
equal to $1.89. Dispensing physicians shall not
preparations; antisera; Oxycontin; erectile
receive a dispensing fee unless their offices or sites
dysfunction products; Ambien; Sonata; Toradol;
of practice are located more than 25 miles from the
Amerge; Axert; Frova; Imitres; Maxalt; Relpax;
nearest participating pharmacy. In the latter case,
Zomig; Anzemet; Emend; Dytril, Zofran; and
physicians receive a fee equal to $1.89.
prescribed smoking deterrents. Products not
covered: anoretics.
Ingredient Reimbursement Basis: EAC = AWP-
13.5% or WAC (wholesaler acquisition cost) + 18%.
Coverage of Injectables: Injectable medicines
AWP-35% for generics. Other: FUL, State Mac,
reimbursable through the Prescription Drug Program
usual and customary.
when used in home health care and extended care
facilities, and through physician payment when used
in physician offices. Prior authorization is required
for self-administration at home.

Colorado-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Prescription Charge Formula: Benefit drugs shall be If a recipient requests a brand name for a prescription
reimbursed at the lesser of the Medicaid allowable that is subject to MAC, then he/she may pay the
reimbursement charge, or the provider’s usual and ingredient cost difference between the MAC and
customary charge or whatever is accepted from any brand name drug. The recipient must sign the
third party, discounts, rebates, etc. prescription stating that he/she is willing to pay the
difference in ingredient cost to the pharmacy. The
The Medicaid allowable reimbursement charge is the pharmacy will be paid MAC plus a dispensing fee or
sum of the ingredient cost of the drug dispensed and reimbursement charges, whichever is lower.
the provider’s dispensing fee.
High volume Estimated Acquisition Cost (EAC):
Ingredient cost for retail pharmacies (estimated Reimbursement for single source drugs or certain
acquisition cost) is the price of the drug actually multiple source drugs which are most frequently
dispensed as defined below or the MAC or the high prescribed will be based upon average wholesale
volume EAC, whichever is less. prices (AWP) minus 13.5%, or direct manufacturers’
prices for package sizes containing quantities greater
The ingredient cost for institutional and government than 100 dosage units or less if not available in
pharmacies is defined as the actual cost of acquisition 100’s.
for the drug dispensed or the MAC, or the high
volume EAC, whichever is less. Basis for inclusion in the high volume estimated
acquisition cost list includes but is not limited to:
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on (1) Single source manufacturers;
generic drugs. Override requires Medically (2) High volume Medicaid recipient utilization;
Necessary with explanation of medical necessity
(MedWatch form). (3) Interchangeability problems with multiple source
drugs;
The State MAC is the maximum ingredient cost
allowed by the Department for certain multiple- (4) Package sizes in excess of 100.
source drugs. The establishment of a MAC is
Drug Pricing: The Department will maintain a drug-
subject, but not limited to, the following
pricing file that will be updated at least monthly. The
considerations:
average wholesale price of a drug as determined by
(1) Multiple manufacturers; the Department, MAC, and high volume EAC, will
be the basis for setting the prices in the drug pricing
(2) Broad wholesale price span; file.
(3) Availability of drugs to retailers at the selected
cost; The Department will determine the average
wholesale price that will be placed in the drug-
(4) High volume of Medicaid recipient utilization; pricing file as follows:
(5) Bioequivalence or interchangeability.
(1) The average wholesale price as it appears in the
When Federal MAC limits for multiple source drugs Red Book, its supplements, and Medi-Span will be
are announced, they will be adopted if they are less the first source. However, if there is a difference
than State MACs or if no State MACs exist. between the two published average wholesale prices,
the Department will set the price as the published
The ingredient cost of any drug subject to MAC shall amount which is the closest to the lowest average
be limited to MAC or wholesale price as determined price charged by two drug wholesalers doing
by the Department, whichever is less. Exceptions business in Colorado.
that will allow reimbursement greater than MAC for
a drug entity are obtained through a prior (2) If there is a price change which does not appear
authorization mechanism. An exception will be immediately in the Red Book, its supplements, or in
granted if the patient’s response to the generic drug is Medi-Span, then the Department will set the average
not therapeutic, an allergic reaction is involved, or wholesale price by averaging the wholesale prices of
any similar situation exists. three drug wholesalers doing business in Colorado,
until the price is published in the Red Book, its
supplements, or in Medi-Span.

Colorado-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

(3) If the prices or changes do not appear in the 10350 East Dakota Avenue
publications or the wholesalers’ records, then the Denver, CO 80905
distributors’ or manufacturers’ prices will be adjusted 303/344-7250
to the wholesale pricing level and used in the drug
Rocky Mountain HMO
pricing file as the price of the drug.
2775 Crossroads Boulevard
Grand Junction, CO 81506
If the difference between the pharmacist’s invoice
800/843-0719
purchase price and the average wholesale price which
Colorado Access
appears in the Red Book, its supplements, or Medi-
600 South Cherry Street, Suite 800
Span exceeds 18%, then the Department may adopt a
Denver, CO 80222
lower price after a survey is conducted to determine
303/355-6707
the validity of the published prices. The price from
the distributor or manufacturer will be adjusted the
Community Health Plan of the Rockies
same as in 3 above.
400 South Colorado Boulevard, Suite 300
Special Note: The Maximum Allowable Cost shall be Denver, CO 80222
determined by the Division of Medical Assistance, 303/355-3220
based upon professional determination of a quality
product available at the least expense possible. United Healthcare
6251 Greenwood Plaza Boulevard, Suite 200
Exceptions to the above are:
Englewood, CO 80111-4910
- Shelf package size oral liquid medications, in pint 303/267/3594
size only, or smaller package size when not packaged
in pint size.
F. STATE CONTACTS
- Shelf package size oral tablet and capsule
medications in quantities of 100 only or smaller Medicaid Drug Program Administrator
when not available in package size of 100.
Martha Warner
- Prescriptions for less than minimum amounts will Pharmacy Supervisor
be denied reimbursement of the professional fee Department of Health Care Policy and Financing
unless the physician notified the Department in 1570 Grant Street
writing of the medical need for amounts less than a Denver, CO 80203
30-day supply. Medical consultation determines the T: 303/866-3176
decision. F: 303/866-2573
Incentive Fee: None. E-mail: martha.warner@state.co.us

Patient Cost Sharing: Brand: $3.00; Generic: $1.00 DUR Contact


Catherine Traugott
Cognitive Services: Does not pay for cognitive Pharmacist
services. Department of Health Care Policy and Financing
1570 Grant Street
Denver, CO 80203
E. USE OF MANAGED CARE T: 303/866-2468
F: 303/866-2573
Over 208,000 Medicaid recipients were enrolled in E-mail: catherine.traugott@state.co.us
managed care in FY 2003. Recipients receive
pharmaceutical benefits through the Managed Care
DUR Board
Organization.
Gail Bosch, R.Ph., C.G.P.
Managed Care Organizations David A. Downs, Jr., M.D.
Total Long-Term Care Lucy Williams Loomis, M.D., M.S.P.H.
303 East 17th Avenue, Suite 650 Robert D. McCartney, M.D., F.A.C.P.
Denver, CO 80203 Mary Newell, R.Ph.
303/896-4664 Candace A. Reith, Pharm.D.
Terrie A. Sajbel, Pharm.D.
Edra B. Weiss, M.D., F.A.A.P.
Timothy D. Hynek, R.Ph.
Kaiser Permanente

Colorado-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

New Brand Names Products Contact Mail Order Pharmacy Program


Martha Warner None
303/866-3176
Health Care Policy & Financing Department
Prescription Price Updating
Officials
Martha Warner
Karen K. Reinertson
303/866-3176
Executive Director
Medicaid Drug Rebate Contacts Department of Health Care Policy and Financing
1570 Grant Street
Vince Sherry
Denver, CO 80203-1818
Drug Rebate Manager
T: 303/866-2993
Department of Health Care Policy and Financing
F: 303/866-4411
1570 Grant Street
E-mail: karen.reinertson@state.co.us
Denver, CO 80203
Internet address: www.chcpf.state.co.us
T: 303/866-5408
F: 303/866-2573
Vivianne M. Chaumont, Director
E-mail: vince.sherry@state.co.us
Medical Assistance Office
Department of Healthcare Policy and Financing
Claims Submission Contact
1570 Grant Street
ACS, State Healthcare Denver, CO 80203
600 17th Street 303/866-3058
Suite 600 North
Denver, CO 80202 Medical Services Board
T: 800/237-0757
Michael Oliva
F: 303/534-0439
Julie Reiskin (President)
Mary Ellen Faules
Medicaid Managed Care Contact
Joan M. Johnson
Katie Brookler Wendell Phillips
Managed Care Manager Joe Rall
Department of Health Care Policy and Financing Maguerite Salazar
1570 Grant Street Steve Tool (Vice President)
Denver, CO 80203 Mathew Dunn, M.D.
T: 303/866-2416 Sally Schaefer
F: 303/866-2573 David Bolin
E-mail: katie.brookler@state.co.us
Medical Advisory Council
Disease Management/Patient Education Donald W. Schiff, M.D.
Programs Littleton, CO
Disease/Medical State: Asthma Molly A. Markert
Program Name: Asthma Management Program Aurora, CO
Program Manager: Sue Tripathi, Ph.D.
Program Sponsor: National Jewish Medical and Mary Jo Jacobs, M.D.
Research Center Denver, CO

Disease/Medical State: Diabetes Walter Daniels, D.D.S.


Program Name: Diabetes Disease Management Denver, CO
Program
Program Manager: Sue Tripathi, Ph.D. Rodney Fair, O.D.
Program Sponsor: McKesson Health Solutions, Inc. Brighton, CO

Disease Management/Patient Education Douglas Clinkscales


Contact Denver, CO

Katie Brookler, 303/866-2416 Cathy Corcoran


Golden, CO

Colorado-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Ernestine Kotthoff-Burrell Colorado Health and Hospital Association


Englewood, CO Larry H. Wall
President
Carol Bartley 7335 East Orchard Road, Suite 100
Denver, CO Greenwood Village, CO 80111-2512
T: 720/489-1630
Mary Ellen Kuhlman, M.S.W. F: 720/489-9400
Grand Junction Internet address: www.cha.com

Dan Stenerson
Aurora, CO

Mark Kunart, D.O.


Aurora, CO

Robert Slay
Lakewood, CO
Executive Officers of State Medical and
Pharmaceutical Societies
Colorado Medical Society
Alfred Gilchrist
Executive Director
7351 Lowry Boulevard
Denver, CO 80230
T: 720/859-1001
F: 303/771-8659
E-mail: alfred_gilchrist@cms.org
Internet address: www.cms.org

Colorado Pharmacists Society


Val Kalnins, R.Ph., Executive Director
6825 E. Tennessee Avenue, Suite 510
Denver, CO 80224-1662
T: 303/756-3069
F: 303/756-3649
E-mail: val@copharm.org
Internet address: www.copharm.org

Colorado Society of Osteopathic Medicine


Marie Kowalsky
Executive Director
650 South Cherry Street, Suite 510
Denver, CO 80246
T: 303/322-1752
F: 303/332-1956
E-mail: coloradodo@aol.com
Internet address: www.coloradodo.org

Colorado State Board of Pharmacy


Susan L. Warren
Program Director
1560 Broadway, Suite 1310
Denver, CO 80202
T: 303/894-7750
F: 303/894-7764
E-mail: pharmacy@dora.state.co.us
Internet address: www.dora.state.co.us/pharmacy

Colorado-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

CONNECTICUT

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $356,980,484 123,704 $403,802,170

RECEIVING CASH ASSISTANCE, TOTAL $86,045,876 26,172


Aged $16,590,546 5,940
Blind/Disabled $68,770,620 15,311
Child $183,663 2,686
Adult $501,047 2,235

MEDICALLY NEEDY, TOTAL $107,981,037 31,035


Aged $25,232,717 10,618
Blind/Disabled $82,442,392 19,884
Child $171,259 332
Adult $134,669 201

POVERTY RELATED, TOTAL $3,928,268 5,859


Aged $665,123 577
Blind/Disabled $2,090,017 1,002
Child $1,002,861 3,228
Adult $69,818 981
BCCA Women $100,449 71

TOTAL OTHER EXPENDITURES/RECIPIENTS* $159,025,303 60,638

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable
Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Connecticut-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Vaccines: Vaccines reimbursable as part of the


Children Health Insurance Program.
State of Connecticut Department of Social Services
through three regional offices and twelve sub-offices. Unit Dose: Unit dose packaging not reimbursable.
D. PROVISIONS RELATING TO DRUGS Formulary/Prior Authorization

Benefit Design Formulary: Open formulary, managed through prior


authorization. However, the following products are
Drug Benefit Product Coverage: Products covered: excluded from Medicaid prescription coverage:
prescribed insulin, disposable needles and syringe experimental drugs, cosmetics, fertility drugs; smoking
combinations for insulin; blood glucose test strips; cessation products; DESI drugs, and drugs available
urine ketone test strips. Products not covered: free from the Department of Health Services.
cosmetics; fertility drugs; experimental drugs; total
parenteral nutrition; interdialytic parenteral nutrition; Prior Authorization: State currently has a prior
and weight loss products. authorization procedure. Clients can request an
administrative hearing to appeal prior authorization
Over-the-Counter Product Coverage: allergy, decisions.
asthma, and sinus products; cough and cold
preparations (children < 19 years) and topical Prescribing or Dispensing Limitations
products. Products covered with restrictions:
digestive products (non H2 antagonists) – liquid Prescription Refill Limit: 5 refills per prescription
generics only (legend drugs not covered); digestive except for oral contraceptives, which have a 12-
products (H2 antagonists) – after first 60 days, month limit.
diagnosis required on the prescription for continued
use; birth control products; antihistamines; and Monthly Quantity Limit: Maximum 240 tablets or
decongestants. Products not covered: smoking capsules/30-day supply. Oral contraceptives: 3
deterrent products; analgesics; feminine products; months supply may be dispensed at one time.
iron; calcium; and some trace elements. For nursing Physicians are encouraged to prescribe drugs
home patients, the department will not pay for OTC generically, when possible.
drugs used in nursing facilities (such drugs are covered
in the per diem rate). Some drugs require diagnosis Drug Utilization Review
for reimbursement such as CNS stimulants for ADD
and narcolepsy. Pro-DUR system implemented September 1996.
Retro-DUR since September 1991; the State
Therapeutic Category Coverage: Therapeutic currently has a 9 member DUR Board with a
categories covered: anabolic steroids; analgesics, quarterly review.
antipyretics, NSAIDs; antibiotics; anticoagulants;
anticonvulsants; antidepressants; antidiabetic agents; Pharmacy Payment and Patient Cost Sharing
antihistamine drugs; antilipemic agents; anti-
psychotics; anxiolytics, sedatives, and hypnotics; Dispensing Fee: $3.15, effective 7/1/04.
cardiac drugs; chemotherapy agents; prescribed cold
medications; contraceptives; ENT anti-inflammatory Ingredient Reimbursement Basis: EAC = AWP-12%.
agents; estrogens; hypotensive agents; misc. GI Special rules for Factor VIII (AAC + 8%), OTCs
drugs; sympathominetics (adrenergic); thyroid (AWP x # units x 1.15), and enteral and parenteral
agents; and growth hormones. Therapeutic nutritionals (AWP x # units x 1.15).
categories not covered: anorectics and prescribed
Prescription Charge Formula: Federal MAC or EAC
smoking deterrents. Prior authorization required for;
plus dispensing fee; or usual and customary if lower.
Brand Medically Necessary prescriptions; early
Special rules for blood factor VIII and
refills; and prescriptions costing more than $500.
enteral/parenteral nutrition products.
Coverage of Injectables: Injectable medicines
Maximum Allowable Cost: State imposes a
reimbursable through physician payment when used in
combination of Federal and State specificUpper
home health care, extended care facilities, and in
Limits on generic drugs. Effective 1/1/2003, the
physicians offices.
Department implemented a state MAC to include
additional multi-source generic products that are not

Connecticut-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

on the FUL list. The State MAC reimbursement is F: 860/424-5206


AWP-40%. E-mail: evelyn.dudley@po.state.ct.us
Internet address: www.dss.state.ct.us
Patient Cost Sharing: None.
Department of Social Services Officials
Cognitive Services: Does not pay for cognitive
Patricia A. Wilson-Coker
services.
Commissioner
E. USE OF MANAGED CARE Department of Social Services
25 Sigourney Street
Connecticut had more than 371,000 Medicaid Hartford, CT 06016-5033
recipients enrolled in managed care in 2003. Over 80 T: 860/424-5008
percent (305,000) recovered pharmaceutical services F: 860/566-2022
through managed care plans. E-mail: pat.wilson-coker@po.state.ct.us

Managed Care Organizations David Parrella, Director


Medical Care Administration
Anthem Blue Cross/Blue Shield of CT Department of Social Services
Blue Care Family Plan 25 Sigourney Street
Paula Smyth, Director Hartford, CT 06106
Medicaid Managed Care T: 860/424-5116
370 Bassett Road F: 860/424-5114
North Haven, CT 06473-4201
T: 203/654-3506 DUR Contact
F: 203/234-5310 James R. Zakszewski, R.Ph.
Pharmacy Consultant
Community Health Network of CT Department of Social Services
Sylvia Kelly, CEO 25 Sigourney Street
290 Pratt - 2nd Floor Hartford, CT 06106-5033
Meriden, CT 06450 T: 860/424-5150
T: 203/237-4000 F: 860/424-5206
F: 203/634-8411 E-mail: james.zakszewski@po.state.ct.us
Health Net Connecticut DUR Board
Janice Perkins, Vice President Kenneth Fisher, R.Ph.
One Far Mill Crossing, Box 904 Brooks Pharmacy
Shelton, CT 06484-0944
T: 203/225-8630 Arturo Morales, M.D.
F: 203/225-4175 St. Francis Hospital
First Choice of CT, Preferred One Lori Jane Duntz Lord, R.Ph.
Douglas Hayward, Chief Operating Officer Greenville Drug
23 Maiden Lane
North Haven, CT 06473 Dennis J. Chapron, R.Ph.
T: 203/239-7444 Pharmokinetics Lab
F: 203/239-3381
Keith Lyke, R.Ph.
Pelton’s Pharmacy
F. STATE CONTACTS
Frederick N. Rowland, M.D.
Medicaid Drug Program Administrator St. Francis Hospital and Medical Center
Evelyn A. Dudley
Manager, Pharmacy Unit Richard Gannon, Pharm.D.
Department of Social Services Hartford Hospital
Medical Operations Unit #4
25 Sigourney Street Kathryn Mashey, DPM
Hartford, CT 06106-5033 Community Health Services
T: 860/424-5654

Connecticut-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Michael Moore, R.Ph. Farmington, CT


Hebrew Home Hospital

Prescription Price Updating Stella Cretella


West Haven, CT
Ellen Arce, R.Ph.
Pharmacy Manager
Richard Carbray, Jr., R.Ph.
EDS
Newington, CT
1000 Stanley Street
New Britain, CT 06053
Kenneth Marcus, M.D.
T: 860/832-5885
New Haven, CT
F: 860-832-5921
E-mail: ellen.arce@eds.com
Peggy Memoli, R.Ph. (Vice Chair)
Medicaid Drug Rebate Contacts Stratford, CT
Afrika Hinds-Ayala
Joseph Misiak, M.D.
Health Program Associate
Windsor, CT
Department of Social Services
Medical Operations Unit #4
Lucille Russell, M.D.
25 Sigourney Street
Rawayton, CT
Hartford, CT 06106-5033
T: 860/424-5150
Carl Sherter, M.D. (Chair)
F: 860/424-5206
Southbury, CT
E-mail: afrika.hinds-ayala@po.state.ct.us
Lawrence Sobel, R.Ph.
Ellen Arce, R.Ph. (Rebates & Disputes)
West Hartford, CT
860/832-5885
Dorothy Stubbe, M.D.
Claims Submission Contact New Haven, CT
Ellen Arce, R.Ph. Robert Zavoski, M.D.
860/832-5858 West Simsbury, CT
Medicaid Managed Care Contact Executive Officers of State Medical and
Pharmaceutical Societies
Rose Ciarcia
Director, Managed Care Connecticut State Medical Society
Department of Social Services Timothy B. Norbeck, Executive Director
25 Sigourney Street 160 St. Ronan Street
Hartford, CT 06106-5033 New Haven, CT 06511-2390
T: 860/424-5139 T: 203/865-0587
F: 860/424-4958 F: 203/865-4997
E-mail: rose.ciarcia@po.state.ct.us E-mail: tnorbeck@csms.org
Internet address: www.csms.org
Mail Order Pharmacy Program
None Connecticut Pharmacists Association
Margherita R. Guiliano, R.Ph. Executive V.P.
Disease Management Contact 35 Cold Spring Road, Suite 121
Rocky Hill, CT 06067-3161
David Parrella T: 860/563-4619
Director, Medical Care Administration F: 860/257-8241
T: 860/424-5116 E-mail: mguiliano@ctpharmacists.org
Elderly Drug Coverage Program Contact Internet address: www.ctpharmacists.org
Evelyn Dudley Connecticut Osteopathic Medical Society
860/424-5654 Donald Halpin, Executive Director
P.O. Box 487
Pharmaceutical and Therapeutics Committee Winchester, MA 01800-0487
Holly Bessoni-Lutz, R.N. T: 781/721-9900

Connecticut-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

F: 781/721-4400
E-mail: nocdos@shore.net

Connecticut Commission Pharmacy


Michelle Sylvestre, R.Ph.
Board Administrator
Department of Consumer Protection
165 Capitol Avenue
Hartford, CT 06106
T: 860/713-6065
F: 860/713-7242
E-mail: michelle.sylvestre@po.state.ct.us
Internet address:
www.ctdrugcontrol.com/rxcommission.htm

Connecticut Hospital Association, Inc.


Jennifer Jackson
President and CEO
110 Barnes Road
Wallingford, CT 06492-0090
T: 203/265-7611
F: 203/284-9318
E-mail: jackson@chime.org
Internet address: www.chime.org

Connecticut-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Connecticut-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

DELAWARE

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $100,112,623 125,461 $109,844,743

RECEIVING CASH ASSISTANCE, TOTAL $48,342,702 47,053


Aged $6,124,532 2,456
Blind/Disabled $28,909,766 10,035
Child $5,126,585 22,562
Adult $18,181,819 12,000

MEDICALLY NEEDY, TOTAL $0 0


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

POVERTY RELATED, TOTAL $1,583,883 4,248


Aged $176,789 141
Blind/Disabled $636,901 337
Child $688,345 3,473
Adults $53,731 278
BCCA Women $28,117 19

TOTAL OTHER EXPENDITURES/RECIPIENTS* $50,186,038 74,160

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Delaware-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Prior Authorization: State currently has a formal


prior authorization procedure. Standard procedures
Division of Social Services, Department of Health for clients to request a fair hearing to appeal prior
and Social Services, through three county offices of authorization decisions.
the State agency.
Prescribing or Dispensing Limitations

D. PROVISIONS RELATING TO DRUGS Monthly Limit on Scripts: 15 medications per 30


days.
Benefit Design Prescription Refills: Prescription blank has space for
physician to authorize renewals.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Monthly Quantity Limit: Greater of 34-day supply or
combinations used for insulin; blood glucose test 100 dosing units.
strips; urine ketone test strips; total parenteral
nutrition; and interdialytic parenteral nutrition. Monthly Dollar Limits: None.
Products not covered: cosmetics; fertility drugs;
experimental drugs; and quality of life medications. Drug Utilization Review
Over-the-Counter Product Coverage: Products PRODUR system implemented in August 1994. State
covered: allergy, asthma and sinus products; has a DUR Board that meets bimonthly.
analgesics; cough and cold preparations; digestive
products; and topical products. Products covered Pharmacy Payment and Patient Cost Sharing
with restrictions: smoking deterrent products (prior Dispensing Fee: $3.65.
authorization and quantity limits). Products not
covered: feminine products. Ingredient Reimbursement Basis: EAC = AWP-
14.0%. (AWP-16% for LTC)
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; anticoagulants; Prescription Charge Formula: Payment is based on
anticonvulsants; antidepressants; antidiabetic agents; AWP-14.0% or maximum allowable cost (MAC)
antihistamine drugs; chemotherapy agents; plus a dispensing fee, or the usual and customary cost
contraceptives; ENT anti-inflammatory agents; to the general public, whichever is lower.
estrogens; hypotensive agents; misc. GI drugs;
sympathominetics (adrenergic); and thyroid agents. Maximum Allowable Cost: State imposes Federal
Prior authorization required for: analgesics, Upper Limits as well as State-specific limits on
antipyretics, and NSAIDs; anoretics; antibiotics; generic drugs. Override requires completion of an
antilpemic agents; anti-psychotics; anxiolytics, FDA MedWatch form.
sedatives, and hypnotics; cardiac drugs; prescribed
col medications; growth hormones; prescribed Incentive Fee: None.
smoking deterrents; Regranex; Zyvox; Soma
Accutane Cipro; Cholinesterase inhibitors;
Patient Cost Sharing: $0.50-$3.00
Modafanil; and Epoetin.
Cognitive Services: Does not pay for cognitive
Coverage of Injectables: Injectable medicines
services.
reimbursable through the Prescription Drug Program
when used in extended care facilities, and through E. USE OF MANAGED CARE
both the prescription drug program and physician
payment when used in physicians’ offices. Approximately 90,000 Medicaid recipients were
enrolled in MCOs in FY 2003. Recipients receive
Vaccines: Vaccines reimbursable under the CHIP pharmaceutical benefits through the State.
Program and Vaccines for Children program.
Managed Care Organizations
Unit Dose: Unit dose packaging not reimbursable.
DelawareCare
Formulary/Prior Authorization 2751 Centerville Road, Suite 400
Wilmington, DE 19808
Formulary: Open formulary with preferred drug list.
215/937-8285
PDL managed through preferred products and prior
authorization.

Delaware-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

First State Health Plan Medicaid Drug Rebate Contacts


1801 Rockland Road, Suite 300
Cynthia R. Denemark, R.Ph.
Wilmington, DE 19803
302/453-8453
302/576-7603
Claims Submission Contact
F. STATE CONTACTS Cynthia R. Denemark, R.Ph.
302/453-8453
State Drug Program Administrator Medicaid Managed Care Contact
Cynthia R. Denemark, R.Ph. Mary Marinari
Director of Pharmacy Services Health Policy Analyst
DSS/EDS Managed Care/QA
248 Chapman Road, Suite 100 DSS
Newark, DE 19702 Herman Holloway Campus
T: 302/453-8453 Lewis Building
F: 302/454-0224 1901 North DuPont Highway
E-mail: Cynthia.denemark@eds.com New Castle, DE 19720
Internet address: www.dmap.state.de.us T: 302/255-9548
F: 302/255-4481
Prior Authorization Contact E-mail: mary.marinari@state.de.us
Cynthia R. Denemark, R.Ph. Mail Order Pharmacy Benefit
302/453-8453
None
DUR Contact
Health and Social Services Department
Cynthia R. Denemark, R.Ph. Officials
302/453-8453
Vincent P. Meconi
DUR Board Secretary
Dept. of Health & Social Services
Calvin Freedman, R.Ph. (Chair) 1901 North DuPont Highway-Main Bldg.
Scott Harrison, D.O. New Castle, DE 19720
Richard Steele, R.Ph. T: 302/255-9040
Susan Fullerton, A.P.N. F: 302/255-4429
Mark Borer, M.D. E-mail: vmeconi@state.de.us
Nadia Helenga, Pharm.D. Internet address : www.state.de.us/dhhs
Christopher Sauls, R.Ph.
Frank Falco, M.D. (Vice Chair) Harry Hill
Sebastion Hamilton, R.Ph. Deputy Director
Albert Rizzo, M.D. Planning and Development
Michael Marcus, M.D. Dept. of Health & Social Services
1901 North DuPont Highway-Lewis Bldg.
New Brand Name Products Contact New Castle, DE 19720
T: 302/577-4901
Joli Martini F: 302/255-4425
Pharmacist Consultant-Clinical Reviews E-mail: harry.hill@state.de.us
EDS
248 Chapman Road, Suite 100 Pharmaceutical and Therapeautics
Newark, DE 19702 Committee
T: 302/453-8453
F: 302/454-0224 Cedric T. Barnes, D.O.
E-mail: joli.martini@eds.com Louis Bartoshesky, M.D.
Renee Beaman, R.N.
Prescription Price Updating Kimberly A. Couch, Pharm.D.
Cynthia R. Denemark, R.Ph. Calvin Freedman, R.P.h.
302/453-8453 Valerie Green, M.D.
Pat Klishevich, R.Ph.
James Lafferty

Delaware-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Brian Levine, M.D.


Michael N. Marcus, M.D.
M. Diana Metzger, M.D.
Tamara J. Newell, A.P.N.
Obi Onyewu, M.D.
James A. Owen, R.Ph.
Michael J. Pasquale, M.D.
Jose Quinones
Albert A. Rizzo, M.D.

Executive Officers of State Medical and


Pharmaceutical Societies
Medical Society of Delaware
Mark Meister
Executive Director
131 Continental Drive, Suite 405
Newark, DE 19713
T: 302/658-7596
F: 302/658-9669
E-mail: mama@medsocdel.org
Internet address: www.msdhub.com

Delaware Pharmacists Society Delaware Healthcare Association


Patricia Carroll-Grant, R.Ph., CDE Joseph M. Letnaunchyn
Executive Director President and CEO
P.O. Box 454 1280 South Governors Avenue
Smyrna, DE 19977-0454 Dover, DE 19904-4802
T: 800/782-3716 T: 302/674-2853
F: 302/659-3089 F: 302/734-2731
E-mail: questions@depharmacy.net E-mail: joelet@deha.org
Internet address: www.depharmacy.net Internet address: www.deha.org

Delaware Osteopathic Medical Society


Edward Sobel, D.O.
Executive Director
P.O. Box 8177
Talleyville, DE 19803-8177
T: 302/764-1198
F: 302/764-1322
E-mail: info@deosteopathic.org
Internet address: www.deosteopathic.org

Delaware State Board of Pharmacy


David W. Dryden, R.Ph., J.D.
Executive Secretary
Jesse Cooper Building, Room 205
P.O. Box 637
Dover, DE 19903
T: 302/744-4547
F: 302/739-3071
E-mail: david.dryden@state.de.us
Internet address:
www.professionallicensing.state.de.us/boards

Delaware-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

DISTRICT OF COLUMBIA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $68,050,981 45,216 $81,762,504

RECEIVING CASH ASSISTANCE TOTAL $45,487,560 28,198


Aged $4,038,389 3,279
Blind/Disabled $39,946,424 21,040
Child $282,114 1,256
Adult $1,220,633 2,623

MEDICALLY NEEDY, TOTAL $9,287,462 5,984


Aged $1,685,420 1,132
Blind/Disabled $6,992,364 3,355
Child $115,789 666
Adult $493,889 831

POVERTY RELATED, TOTAL $9,410,167 6,432


Aged $3,096,675 2,294
Blind/Disabled $6,096,888 2,657
Child $164,442 1,330
Adult $52,162 151
BCCA Women $0 0

TOTAL OTHER EXPENDITURE/RECIPIENTS* $3,865,792 4,602

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

District of Columbia-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

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


the EPSDT service and The Vaccines for Children
The District of Columbia Department of Health Program.
(DOH), Medical Assistance Administration.
Unit Dose: Unit dose packaging not reimbursable
D. PROVISIONS RELATING TO DRUGS
Formulary/Prior Authorization
Benefit Design
Formulary: Open formulary with restrictions on use,
Drug Benefit Product Coverage: Products covered: prior authorization, and therapeutic substitution.
prescribed insulin; disposable needles and syringe Appeals for coverage of an excluded product can be
combinations used for insulin; blood glucose test made to The Office of Appeals. Providers may also
strips; urine ketone test strips; and ferrous sulfate. appeal prior authorization decisions to First Health
Prior authorization required for: cosmetics; injectable Services Corporation’s Risk Manager.
drugs administered on an outpatient basis; anorexic
drugs for treatment of narcolepsy and minimal brain Prescribing or Dispensing Limitations
dysfunction in children; acute anti-ulcer drugs, and
Monthly Quantity Limit: In general, amounts
brand NSAIDs. Products not covered: fertility drugs;
dispensed are to be limited to quantities sufficient to
experimental drugs; total parenteral nutrition;
treat an episode of illness. Maintenance drugs such
interdialytic parenteral nutrition; anesthetics; infant
as thyroid, digitalis, etc. may be dispensed in
formulas; cold tar preparations; reusable
amounts up to a 30-day supply with 3 refills that
needles/syringes (non-insulin); and all other non-
must be dispensed within 4 months. Antibiotic
legend items.
medications used in treatment of acute infections are
not to be dispensed in excess of a 10-day supply.
Over-the-Counter Product Coverage: Products
Birth control tablets may be dispensed in 3-cycle
covered with restrictions: oral analgesics;
units with a maximum of 3 refills within one year.
contraceptive foams and jellies; prenatal, pediatric
Other limits on specific products.
and geriatric vitamins; and bowel preparation kits.
Products not covered: allergy, asthma, and sinus Monthly Dollar Limits: $1,500 limit. Physicians are
products; cough and cold preparations; digestive to request prior authorization for prescriptions that
products; feminine products; topical products; and exceed this amount.
smoking deterrent products.
Drug Utilization Review
Therapeutic Category Coverage: Therapeutic
PRODUR system implemented in September 1996.
categories covered: antibiotics; anticoagulants;
The District currently has a DUR Board that meets
anticonvulsants; anti-depressants; antidiabetic agents;
monthly.
antihistamines; antilipemic agents; anti-psychotics;
anxiolytics; sedatives; and hypnotics; cardiac drugs; Pharmacy Payment and Patient Cost Sharing
chemotherapy agents; prescribed cold medications;
contraceptives; ENT anti-inflammatory agents; Dispensing Fee: $4.50.
estrogens; hypotensive agents; prescribed smoking
deterrents; sympathominetics (adrenergic); and Ingredient Reimbursement Basis: AWP-10%.
thyroid agents. Prior authorization required for:
analgesics, antipyretics, and NSAIDs; anoretics; Prescription Charge Formula: The lesser of: FUL or
growth hormones; misc. GI drugs; erectile the AWP-10% plus the dispensing fee or usual and
dysfunction products; Brand Medically Necessary customary to the public.
drugs; immunosuppressants; amphetamines; Stadol;
Levocamitine; Hepatitis C medications; and Synagis. Maximum Allowable Cost: The District does not
Therapeutic categories not covered: anabolic impose MAC limits on generic drugs.
steroids.
Incentive Fee: None.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program Patient Cost Sharing: $1.00 copay by recipient.
when used in home health care and extended care Does not apply to recipients under 18, prescriptions
facilities, and through physician payment when used for family planning, nursing home patients, or
in physicians’ offices. pregnancy related.

District of Columbia-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Cognitive Services: Does not pay for cognitive District of Columbia DUR Board
services.
Christopher Keeyes, Pharm.D. (Chair)
Chairman, Clinical Pharmacy Associates
E. USE OF MANAGED CARE 316 Talbott Avenue
Laurel, MD 20707
Approximately 90,000 Medicaid recipients were 301/617-0555
enrolled in managed care in 2003. Recipients
enrolled in managed care receive pharmaceutical Martin Dillard, M.D. (Vice Chair)
benefits through managed care plans. Assistant Dean for Clinical Affairs
Chief, Division of Nephrology
Managed Care Organizations Howard University Hospital
2041 Georgia Avenue, NW, Suite 5C02
D.C. Chartered Health Plan Washington, DC 20060
1025 15th Street, N.W. 202/865-1191
Washington, DC 20005
202/408-4720 Howard Robinson, R.Ph.
Manager, Central Pharmacy
Amerigroup Greater Community Hospital
750 First Street, NE, Suite 1120 1310 Southern Avenue, SE
Washington, DC 20002 Washington, DC 20032
800/600-4441
Dr. Kim Bullock
Health Right, Inc. Providence Hospital
1101 14th Street, NW, Suite 900 Emergency Room
Washington, DC 20005 1150 Varnum St., NE
202/418-0380 Washington, DC 20017
202/269-7863

F. STATE CONTACTS Prior Authorization Contacts

State Drug Program Administrator Cheryl S. Wilson


202/442-9078
Cheryl S. Wilson
Risk Manager-Pharmacy/ DME Medicaid Drug Rebate Contact
Department of Health
Medical Assistance Administration Jeffrey Dzieweczynski, R.Ph., M.S.
825 North Capitol Street, NE ACS State Healthcare
Suite 5135 750 First Strweet, NE
Washington, DC 20002 Washington, DC 20002
T: 202/442-9078 T: 202/906-8353
F: 202/442-4790 F: 202/906-8399
E-mail: cheryl.wilson@dcgov.org E-mail: jeffrey.dzieweczynski@acs-inc.com
Internet address: www.dchealth.dc.gov New Brand Name Products Contact
DUR Contact Cheryl S. Wilson
Christopher A. Keeys, Pharm.D., BCPS, R.Ph. 202/442-9078
Chairman
Clinical Pharmacy Associates, Inc. Prescription Price Updating Contact
316 Talbott Avenue
Laurel, MD 20707 Christine Quinn
T: 301/617-0555 Account Manager
F: 301/617-0225 ACS State Heathcare
E-mail: ckeeys@clinphar.com 750 First Street, NE
Washington, DC 20002
T: 202/906-8304
F: 202/906-8378
E-mail: christine.quinn@acs-inc.com

District of Columbia-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Claims Submission Contact Executive Officers of District Medical and


Pharmaceutical Societies
Jacqueline Bonner
Clinical Manager Medical Society of the District of Columbia
First Health Service Corporation K. Edward Shanbacker
4300 Cox Road 2175 K Street, NW, Suite 200
Glen Allen, VA 23060 Washington, DC 20037
T: 800/884-2822 T: 202/466-1800
F: 804/273-6961 F: 202/452-1542
E-mail: bonner.ja@fhsc.com E-mail: shanbacker@msdc.org
Internet address: www.msdc.org
Medicaid Managed Care Contact
Washington D.C. Pharmacy Association
Maude R. Holt
Herbert Kwash, R.Ph., President
Chief Administrator-Manor Care
6406 Georgia Avenue, N.W.
Department of Health
Washington, DC 20012-2960
Medical Assistance Administration
T: 202/829-1515
825 North Capitol Street, NE
F: 202/829-1515
Washington, DC 20002
T: 202/442-9014
Osteopathic Association of the District of Columbia
F: 202/442-4790
K. Joseph Heaton, D.O., President
E-mail: maude.holt@dc.gov
2517 North Glebe Road
Mail Order Pharmacy Program Arlington, VA 22207
T: 703/522-8404
None
F: 703/522-2692
Department of Human Services Officials DC Board of Pharmacy
Gregory Pane, M.D. Beverly Mims, Chairperson
Director 825 North Capitol Street, NE, Room 224
Department of Health Washington, DC 20002
825 North Capitol Street, NE T: 202/442-4775
Fourth Floor T: 202/442-9200
Washington, DC 20002 F: 202/442-9431
T: 202/671-5000 E-mail: gramseur@dchealth .com
F: 202/442-4795 Internet address: www.dchealth.dc.gov/prof_license
E-mail: gregory.pane@dc.gov
Internet Address: www.dchealth.dc.gov District of Columbia Hospital Association
Robert Malson, President
Robert Maruca 1250 Eye Street, NW, Suite 700
Senior Deputy Director Washington, DC 20005
Department of Health T: 202/682-1581
Medical Assistance Administration F: 202/371-8151
825 North Capitol Street, NE E-mail: rmalson@dcha.org
Fifth Floor Internet address: www.dcha.org
Washington, DC 20002
T: 202/442-5988
F: 202/442-4790
E-mail: robert.maruca@dc.gov
Internet address: www.dchealth.dc.gov

District of Columbia-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

**2003 data provided by the Florida Agency for Health Care


Administration.
FLORIDA

A. BENEFITS PROVIDED AND GROUPS


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $1,736,991,594 1,245,841 $2,422,440,384 1,292,241

RECEIVING CASH ASSISTANCE TOTAL $1,003,983,709 559,948 $1,371,908,887 593,679


Aged $170,559,577 80,626 $238,260,026 82,337
Blind/Disabled $745,290,114 236,377 $994,536,618 243,728
Child $38,098,660 152,574 $61,235,847 170,765
Adult $50,035,358 90,371 $77,786,396 96,849

MEDICALLY NEEDY, TOTAL $79,151,203 26,944 $234,190,202 45,851


Aged $6,303 7 $31,015,312 6,050
Blind/Disabled $62,557,905 9,963 $169,380,236 19,159
Child $2,228,296 3,206 $4,379,348 2,856
Adult $14,358,699 13,768 $29,414,779 17,785
Other $527 1

POVERTY RELATED, TOTAL $392,630,319 400,492 $486,460,426 454,297


Aged $140,952,724 74,911 $173,981,996 65,907
Blind/Disabled $182,755,926 46,604 $203,471,205 45,142
Child $63,888,019 249,619 $94,203,449 258,882
Adult $5,033,650 29,358 $14,803,776 84,366
BCCA Women $0 0

TOTAL OTHER EXPENDITURE/RECIPIENTS $261,226,363 258,457 $329,880,869 198,414

*Total other Expenditures/Recipients include foster care


children, 1115 demonstration participants, other recipients,
and unknown.

District of Columbia-5
National Pharmaceutical Council Pharmaceutical Benefits 2003

Source: CMS, MSIS Report, FY 2002 and Florida Medicaid Statistical Information System, FY 200
C. ADMINISTRATION Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program
Agency for Health Care Administration. Claims when used in home health care and extended care
processing and payment by contract with fiscal agent. facilities, and through physician payment when used
in physicians’ offices.
D. PROVISIONS RELATING TO DRUGS
Vaccines: Vaccines reimbursable as part of the
Benefit Design Vaccines for Children Program.

Drug Benefit Product Coverage: Products covered: Unit Dose: Unit dose packaging reimbursable.
prescribed insulin; total parenteral nutrition;
interdialytic parenteral nutrition; and urine ketone Formulary/Prior Authorization
test strips (children under age 21only). Products
covered with restrictions (non-PDL products require Formulary: Preferred Drug List (PDL) with
prior authorization): disposable needles and syringe mandatory limits and exclusions. All covered drugs
combinations used for insulin; blood glucose test are available through the preferred drug process.
strips. Prior authorization required for: Actiq; General exclusions include excluding products based
Albumin; Aranesp; Procrit; Botox; Cytogam; on contracting issues, restrictions on use, prior
Fuzeon; growth hormone for adults; Intravenous authorization, therapeutic substitution, preferred
Immune Globulin (IVIG); Neupogen; Leukine; products, physician profiling and supplemental
Neulasta; Neurontin; Neutrexin; Panretin; Orfadin; rebates. Specific limits and exclusions include:
Oxycontin; Proleukin; Provigil; Targretin; Valcyte;
Venofer; Vfend; Xenical; Regranex (long-term care); 1. Vitamins and phosphate binders only for dialysis
and nutritional supplements and non-preferred patients.
products. Products not covered: cosmetics; fertility 2. Prostheses; appliances; devices; and personal
drugs; and experimental drugs. care items.
3. Non-legend drugs (except for prescribed insulin,
Over-the-Counter Product Coverage: Products pancreatic enzymes, buffered and enteric coated
covered with restrictions: analgesics (selected aspirin aspirin when prescribed as an anti-inflammatory
and Tylenol products); cough and cold preparations agent only, and single entity hematinics).
(select products); digestive products (non-H2 4. Anorexants unless the drug is prescribed for an
antagonists); feminine products; and smoking indication other than obesity (i.e., narcolepsy,
deterrent products. Products not covered: allergy, hyperkinesis).
asthma, and sinus products; digestive products (H2 5. Drugs with questionable efficacy as rated by
antagonists); and topical products. FDA (DESI).
6. Investigational and experimental items.
Therapeutic Category Coverage: Therapeutic 7. Oral vitamins with exception of fluorinated
categories covered: anaboilic steroids; antibiotics; pediatric vitamins prescribed for pediatric
anticoagulants; anticonvulsants; anti-depressants; patients, vitamins for dialysis patients, prenatal
antidiabetic agents; antihistamines; antilipemic vitamins.
agents; antipsychotics; anxiolytics, sedatives, and 8. Nursing home floor stock drugs.
hypnotics; cardiac drugs; chemotherapy agents;
contraceptives; ENT anti-inflammatory agents; Prior Authorization: State currently has a formal
estrogens; hypotensive agents; misc. GI drugs; prior authorization procedure. Direct appeal to
prescribed smoking deterrents; sympathominetics AHCA and/or formal request for administrative
(adrenergic); and thyroid agents. Partial coverage for: hearing required to appeal prior authorization
prescribed cold medications. Prior authorization decisions.
required for: analgesics, antipyretics, and NSAIDs;
growth hormones; mental health drugs; anti- Prescribing or Dispensing Limitation
retrovirals for HIV; drugs not included on the
Medicaid preferred drug list; and brand name Prescription Refill Limit:
prescriptions beyond the four brand cap unless 1. Limited to four brand name RXs per month with
exempted. Therapeutic categories not covered: exceptions for specific therapeutic groups.
anoretics. Exemptions are: Anti-Retrovirals for HIV, Anti-
Psychotics, Depressants and Convulsants,

Florida-6
National Pharmaceutical Council Pharmaceutical Benefits 2003

Family Planning, and Diabetic supplies and E. USE OF MANAGED CARE


insulin, unlimited generic prescriptions.
2. Drugs not included in the Preferred Drug list Approximately 644,000 Medicaid recipients (30% of
(PDL) require PA. Anti-retrovirals and mental all recipients) received pharmaceutical benefits
health are exempted. through managed care plans (inclusion of such
3. Maintenance medication should be dispensed benefits is mandated under State law) in FY 2002-
and billed for at least a one-month supply. 2003.
4. Refills must be authorized by the prescriber
andcan be made for up to one year, except that Managed Care Organizations
controlled substances can be refilled only in
accordance with Federal and State regulations. Amerigroup Florida, Inc.
5. Nutritional supplements are covered with prior (FKA Physicians Health Care Plans, Inc.)
authorization when the patient is otherwise at 4200 W. Cypress Street, Suite 900
risk of hospitalization. Tampa, Fl 33607-4173
6. Other third parties, including Medicare, must be T: 813/830-6900
billed first. F: 813/314-2045

Drug Utilization Review Buena Vista Medicaid


Vista Health Plan, Inc.
PRODUR system implemented in July 1993. State (FKA Beacon and Discovery)
currently has a DUR board with a quarterly review. 300 South Park Road
Retrospective Drug Utilization Review has been in Hollywood, FL 33021
place since 1982. The State Medicaid agency and the 866/847-8235
Florida Pharmacy Association, which performs the
reviews, share the administration of the program. Citrus Health Care, Inc.
5420 Bay Center Drive, Suite 250
Heritage Information Systems contracts to provide Tampa, FL 33609
DUR and prescriber pattern profiling and clinical T: 877/624-8787
review assistance. F: 813/490-8907

Healthease of Florida, Inc.


Pharmacy Payment and Patient Cost Sharing
8735 Henderson Road, Ren 2
Tampa, FL 33634
Dispensing Fee: $4.23, effective 3/11/86.
T: 800/278-0656
F: 813/290-6332
Ingredient Reimbursement Basis: AWP-15.40 % or
WAC+5.75%. (effective 7/1/04)
Humana Family
c/o Humana Medical Plan, Inc.
Prescription Charge Formula: Lower of:
3501 SW 160th Street
1. FUL (Federal Upper Limits or State MAC) plus Miramar, FL 33027
dispensing fee. T: 800/533-5001
2. EAC plus dispensing fee. F: 305/626-5086
3. Usual and customary charge.
4. In-house unit dose diff. + 0.015/dose. Jackson Memorial Health Plan
1801 NW 9th Ave., Suite 700
Maximum Allowable Cost: State imposes Federal
Miami, FL 33136
Upper Limits as well as State-specific limits on
T: 800/721-2993
generic drugs. MAC override by physicians requires
F: 305/545-5212
completed MedWatch form and prior authorization.
Personal Health Plan
Incentive Fee: No incentive fee.
324 Datura Street, Suite 401
West Palm Beach, FL 33401
Patient Cost Sharing: No copayment T: 561/659-1270
F: 561/833-9786
Cognitive Services: Does not pay for cognitive
services.

Florida-7
National Pharmaceutical Council Pharmaceutical Benefits 2003

Preferred Medical Plan, Inc. Prior Authorization Contact


4950 SW 8th Street
Bruce McCall, Pharm.D.
Coral Gables, FL 33134
Pharmacy Program Manager
T: 305/447-8373
Agency for Health Care Administration
F: 305/447-4959
2727 Mahan Drive, MS 38
Tallahassee, FL 32308
StayWell Health Plan of Florida, Inc.
T: 850/487-4441
8735 Henderson Road, Ren C
F: 850/922-0685
Tampa, FL 33634
E-mail: ahca.myflorida.com
T: 813/935-5227
F: 813/290-6332
DUR Contact
United Healthcare of Florida, Inc. Linda G. Barnes
13621 N.W. 12th Street Pharmacy Program Manager
Sunrise, FL 33323 Agency for Health Care Administration
800/910-3145 2727 Mahan Drive, MS 38
Tallahassee, FL 32308
Vista South Florida T: 850/487-4441
(FKA Foundation Health Plan) F: 850/922-0685
300 South Park Road E-mail: barnesl@ahca.myflorida.com
Hollywood, FL 33021
T: 800/441-5501 Medicaid DUR Board
F: 954/986-6082
Arijit Aichbhaumik, R.Ph.
Plant City, FL
F. State Contacts
Lois Adams, R.Ph.
State Drug Program Administrator Orlando, FL
Jerry F. Wells, Bureau Chief
Bryan Bognar, M.D.
Medicaid Pharmacy Services
Lutz, FL
Agency for Health Care Administration
2727 Mahan Drive, MS 38
Leanne Lai, Ph.D.
Tallahassee, FL 32308
Ft. Lauderdale, FL
T: 850/487-4441
F: 850/922-0685
David Levine, DPM, D.O.
E-mail: wellsj@ahca.myflorida.com
Ft. Lauderdale, FL
Internet address: ahca.myflorida.com
Earlene Lipowski, Ph.D., R.Ph.
Agency for Health Care Administration
Gainesville, FL
Officials
Alan Levine Larry Mattingly, D.O.
Secretary Orange Park, FL
Agency for Health Care Administration
2727 Mahan Drive, MS 1 Jeane McCarthy, M.D., Ph.D.
Tallahassee, FL 32308 St. Petersburg, FL
T: 850/922-3809
F: 850/488-0043 Richard Roberts, Pharm.D.
E-mail: alan.levine@myflorida.com Jacksonville, FL

Thomas W. Arnold Peggann Zaenger, Pharm.D.


Deputy Secretary for Medicaid Jacksonville, FL
Agency for Health Care Administration
2727 Mahan Drive, MS 8
Tallahassee, FL 32308
T: 850/488-3560
F: 850/488-2520
E-mail: thomas.arnold@myflorida.com

Florida-8
National Pharmaceutical Council Pharmaceutical Benefits 2003

Prescribing Pattern Review Panel Medicaid Drug Rebate Contacts


Stephen Clark, M.D. Regina Wiggins
Walter Flesner, D.O. Rebate Coordinator
Cynthia Griffin, Pharm.D. Agency for Health Care Administration
Dennis Penzell, D.O. 2727 Mahan Drive, MS 38
John Steele, M.D. Tallahassee, FL 32308
George Thomas, M.D. T: 850/487-4441
F: 850/922-0685
Pharmaceutical and Therapeutics Committee
E-mail: wigginsr@ahca.myflorida.com
Robert Blackburn, D.O. (Chair)
Spring Hill, FL Claims Submission Contact
Kevin Whittington
James Brookins, M.D.
Clinical Program Coordinator
Tampa, FL
ACS State Healthcare
9040 Roswell Road
Leanne Lai, Ph.D.
Roswell, GA
Ft. Lauderdale, FL
850/201-1111
Martin Lazoritz, M.D.
Medicaid Managed Care Contact
Gainesville, FL
Melanie Brown-Woofter
John Lelekis, R.Ph., M.B.A. AHCA Administrator
Belleair, FL Agency for Health Care Administration
2727 Mahan Drive, MS 8
Jeane McCarthy, M.D., Ph.D. Tallahassee, FL 32308
St. Petersburg, FL T: 850/487-2355
F: 850/410-1676
Lorianne McElheney, R.Ph. E-mail: brownme@ahca.myflorida.com
Palmetto, FL
Mail Order Pharmacy Program
Dorinda Segovia, Pharm.D.
Hialeah, FL State has a mail order pharmacy benefit under its
diabetes demonstration waiver.
Jerry Jean Stambaugh, Pharm.D.
Lantana, FL Disease Management/Patient Eduction
Programs
Craig A. Trigueiro, M.D.
Bradenton, FL Disease/ Medical State: AIDS/HIV
Program Manager: Donna Sabatino
New Brand Name Products Contact Program Sponsor: AIDS Healthcare Foundation

Jerry F. Wells Disease/ Medical State: Asthma


850/487-4441 Program Manager: Lisa Casanta
Program Sponsor: Pfizer Health Solutions
Prescription Price Updating
First DataBank
Disease/ Medical State: Cardiovascular Disease
1111 Bayhill Drive, Suite 350
Program Manager: Lisa Casanta/ Joyce Stickles
San Bruno, CA 94066
Program Sponsor: Pfizer Health Solutions/ Life
T: 650/588-5454
Masters Supported Selfcare, Inc.
F: 650/827-4578
Disease/ Medical State: Diabetes
Program Manager: Nicole Cook/ Diana Schmidt
Program Sponsor: DiabetikSmart/ Bristol-Myers
Squibb

Florida-9
National Pharmaceutical Council Pharmaceutical Benefits 2003

Disease Management Program/Initiative Florida Hospital Association


Contact Wayne N. Nesmith
President
Maresa Thomas
306 East College Avenue
Medicaid Health Systems Development
Tallahassee, FL 32301-1522
Agency for Health Care Administration
T: 850/222-9800
2727 Mahan Drive, MS 20
F: 850/561-6230
Tallahassee,FL 32308
E-mail: wayne@fha.org
T: 850/487-0737
Internet address: www.fha.org
F: 850/410-1676
E-mail: thomasm@ahca.myflorida.com

Executive Officers of State Medical and


Pharmaceutical Societies
Florida Medical Association, Inc.
Sandra B. Mortham
Executive Vice President and CEO
123 Adams Street
Tallahassee, FL 32301
T: 850/224-6496
F: 850/222-8030
E-mail: smortham@medone.org
Internet address: www.fmaonline.org

Florida Pharmacy Association


Michael Jackson, R.Ph.
Executive Director
610 North Adams Street
Tallahassee, FL 32301-1114
T: 850/222-2400
F: 850/561-6758
E-mail: fpa@pharmview.com
Internet address: www.pharmview.com

Florida Osteopathic Medical Association


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

Florida State Board of Pharmacy


Dana Droz, R.Ph., J.D.
Executive Director
4052 Bald Cypress Way, Bin C04
Tallahassee, FL 32399-3254
T: 850/245-4292 ext. 3600
F: 850/413-6982
E-mail: mqa_pharmacy@doh.state.fl.us
Internet address: www.doh.state.fl.us/mqa/pharmacy

Florida-10
National Pharmaceutical Council Pharmaceutical Benefits 2004

GEORGIA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $749,552,199 1,076,904 $1,073,715,230

RECEIVING CASH ASSISTANCE, TOTAL $448,422,546 383,966


Aged $49,087,789 30,164
Blind/Disabled $337,070,842 155,825
Child $28,579,385 123,343
Adults $33,684,530 74,634

MEDICALLY NEEDY, TOTAL $16,602,873 9,145


Aged $5,773,374 3,893
Blind/Disabled $10,829,303 5,248
Child $196 4
Adults $0 0

POVERTY RELATED, TOTAL $79,977,136 351,470


Aged $3,873,063 2,310
Blind/Disabled $3,943,280 2,328
Child $60,781,933 277,697
Adults $10,358,627 68,181
BCCA Women $1,020,233 954

TOTAL OTHER EXPENDITURES/RECIPIENTS* $204,549,644 332,323

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Georgia-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION estrogens; hypotensive agents; misc. GI drugs;


sympathominetics (andrenergic); and thyroid agents.
Department of Community Health, Division of Prior authorization required for: anabolic steroids;
Medical Assistance. analgesics, antipyretics, NSAIDS for single source;
anxiolytics, sedatives, and hypnotics; growth
D. PROVISIONS RELATING TO DRUGS hormones; immunoglobulins; COX-II’s; Quinolones;
Cephalosporins; Atypical Antipsychotics;
Benefit Design ADHD/Ophthalmic Prostaglandin Agents/ Beta
Drug Benefit Product Coverage: Products covered: Adrenergic Neb/Inhaled Corticosteroids; Bone
Most Federal Legend products with CMS rebates Ossification; COX-IIs/ CCB’s/ Nasal Steroids; RB’s/
except as otherwise noted. Selected OTC prducts are Serotonin Receptor Agonists; Topical
also covered with prescriptions. Products covered Immunodulators; Urinary Tract Antispas modics; and
with restrictions: human insulins (Novo Nordisk Immunodulators. Therapeutic categories not covered:
human insulins and disposable needles and syringe anoretics; prescribed smoking deterrents; and fertility
combinations used for insulin administration are drugs.
preferred); blood glucose test strips (Roche products
only); urine ketone test strips; (total parenteral Coverage of Injectables: Injectable medicines
nutrition (21 and younger); and interdialytic reimbursable through the Prescription Drug Program
parenteral nutrition (21 and younger). Products when used in home health care and extended care
requiring prior authorization: Marinol; Betaseron, facilities, and through physician payment when used
Avonex, Rebif, Leukine, Crinone 8%, Forteo, growth in physicians offices.
hormone, immune globulin, Fuzeon, Penlac, Epoetin;
interferons; lactulose; Neupogen; top.vit.A Vaccines: Vaccines reimbursable as part of the
derivatives; Toradol; Regranex; Viagra; Cialis; EPSDT service, the CHIP program, and as part of the
Levitra; Oral Diflucan 50mg, 100mg & 200mg; Vaccines for Children Program.
Panretin Gel; Vfend; Zetia; topical testosterone;
Insulin Pen Delivery Systems and Cartridges for Unit Dose: Unit dose packaging reimbursable.
adults; PPIs; Oral Lamisil; ESRD drugs; Oral Formulary/Prior Authorization
Sporanox; Botox; Oxycontin; brand names and
multi-source. See PDL for a comprehensive list of Formulary: Closed formulary with restrictions on use
covered products (www.dch.state.ga.us-providers- (quantity level limits), PA, preferred products, and
pharmacy-PDL). Products not covered: cosmetics; physician profiling.
fertility drugs; experimental drugs; prescription
vitamins and minerals (except for prenatal and Prior Authorization: State currently has a formal
fluorides not in combination with other vitamins); prior authorization procedure with right of appeal.
barbituates (except Seconal & Mebaral ); DESI Clients may write to the Medicaid Medical Director
drugs; and smoking cessation products. to appeal coverage and prior authorization decisions.

Over-the-Counter Product Coverage: Products Prescribing or Dispensing Limitations:


covered: with a prescription; analgesics (Ibuprofen Prescription Refill Limit: Maximum of five refills for
suspension) covered with restriction for ages less adults, six for children. May be overridden at POS by
than 21; loratadine; diphenhydramine; enteric coated the pharmacist for certain maintenance drugs.
asprin; topical products; PIN-X; NIX; Lice-B- Gone;
OTC iron and multivitamins; Klout; and meclizine. Monthly Quantity Limit: 34-day supply maximum.
Products not covered: allergy, asthma, and sinus
products other than those listed as covered; digestive Monthly Dollar Limit: $2,999.99 requires an
products; feminine products; and smoking deterrent override; >$9,999.99 requires paper claim and a copy
products. of the prescription.
Drug Utilization Review
Therapeutic Category Coverage: Therapeutic
categories covered: Most therapeutic categories are On-line PRODUR system implemented in October
covered, including but not limited to the following 2000. State has a 20 member DUR Board (4-6
and their exceptions: antibiotics; anticoagulants; meetings per year).
anticonvulsants; antidepressants; antidiabetic agents;
antihistamines; hyperlipidemic agents;
antipsychotics; cardiac drugs; chemotherapy agents;
prescribed cold medications (partial coverage);
contraceptives; ENT anti-inflammatory agents;

Georgia-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Pharmacy Payment and Patient Cost Sharing Department of Community Health


Dispensing Fee: $4.33-$5.13, effective 6/15/02 Tim Burgess, Commissioner
Non-profit pharmacy: $4.33 (non-generics); Department of Community Health
$4.83 (generics) 2 Peachtree Street, NW, Suite 4043
For profit pharmacy: $4.63 (non-generics); $5.13 Atlanta, GA 30303-3159
(generics) T: 404/656-4507
F: 404/651-6880
Ingredient Reimbursement Basis: EAC = AWP -
E-mail: dbevelle@dch.state.ga.us
11% or MFN price.
Mark Trail, Chief
Prescription Charge Formula: Lower of average
Medical Assistance Plans
wholesale price (AWP) minus 11% plus dispensing
Department of Community Health
fee, MAC plus fee, or usual and customary.
2 Peachtree Street, NW, Suite 3733
Atlanta, GA 30303-3159
Maximum Allowable Cost: State imposes a
T: 404/657-1502
combination of Federal Upper Limits as well as
F: 866/283-0128
State- Specific Limits on generic drugs. Override
E-mail: mtrail@dma.state.ga.us
requires Prior Approval (Brand Medically Necessary
and MedWatch form). Approximately 1,300 drugs on Prior Authorization Contact
the State-specific MAC list.
Manny Conduah, Pharm.D.
Clinical Program Manager
Incentive Fee: $0.50 for generic drug.
Express Scripts, Inc.
300 Colonial Center Parkway
Patient Cost Sharing: $0.50 per prescription for Roswell, GA 30076
generics or preferred drugs. $0.50 - $3.00 for non- T: 770/552-3793
preferred and brand drugs, dependent on the cost of F: 770/992-8949
the drug. E-mail: mconduah@express-scripts.com
Cognitive Services: Does not pay for cognitive DUR Contact
services. Pat Zeigler Jeter, M.P.A., R.Ph.
DUR Coordinator-Rebate Pharmacist
E. USE OF MANAGED CARE Department of Community Health
Division of Medical Assistance
Does not use MCOs to deliver services to Medicaid 2 Peachtree Street, 37th Floor
recipients. Atlanta, GA 30303-3159
T: 404/657-9181
F: 404/657-5461
F. STATE CONTACTS E-mail: pjeter@dch.state.ga.us
State Drug Program Administrator
Jerry L. Dubberly, R.Ph., M.B.A. Medicaid DUR Board
Director, Pharmacy Services William W. Bina, III, M.D.
Department of Community Health Bruce Welsh Bode, M.D.
Division of Medical Assistance Joseph R. Bona, M.D.
2 Peachtree Street, NW, 37th Floor Kimberly S. Carroll, M.D.
Atlanta, GA 30303-3659 Jennifer Kent Davis, Pharm.D, M.B.A.
T: 404/657-4044 Stacy Michael Dickens, R.Ph., CDM
F: 404/657-5461 Gregory Allen Foster, M.D.
E-mail: jdubberly@dch.state.ga.us Davis Markowitz Greenberg, M.D.
Internet address: www.dch.state.ga.us Julie Ann Hixson-Wallace, Pharm.D., BCPS
Andrew M. Howe, Pharm.D.
Marilavinia Jones, M.D.
James Russell Lee, Jr., R.Ph., CGP
Robyn Loris, Pharm.D.
J. Russell May, Pharm.D.
Vanessa D. Mickles, Pharm.D.
Mathew Perri, III, R.Ph., Ph.D. (Chair)

Georgia-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Raymond Rossenberg, M.D. Disease Management Program/Initiative


Richard S. Singer, D.D.S. Contact
Cynthia Allen Wainscott
Charmaine Heard, M.D.
Gary M. Williams, M.D. (Vice-Chair)
Medical Director
Department of Community Health
New Brand Name Products Contact 2 Peachtree Street, NW, 37th Floor
Atlanta, GA 30303-3159
Etta L. Hawkins, R. Ph.
T: 404/463-7638
Medicaid Program Pharmacy Manager
F: 404/657-5461
Department of Community Health
E-mail: cheard@dch.state.ga.us
Division of Medical Assistance
2 Peachtree Street, 37th Floor Mail Order Pharmacy Benefits
Atlanta, GA 30303-3159
None
T: 404/657-4044
F: 404/657-5461
Medical Assistance Advisory Committee
E-mail: ehawkins@dch.state.ga.us
Representatives from each of the following groups:
Medical Association of Georgia
Prescription Price Updating
Georgia Pharmaceutical Association
Manny Conduah, Pharm.D. Atlanta Medical Association
770/552-3793 Georgia Health Care Association
Georgia Hospital Association
Medicaid Drug Rebate Contact
Georgia Dental Association
Pat Zeigler-Jeter, M.P.A., R.Ph. Georgia Osteopathic Medical Association
404-657-9181 National Pharmaceutical Association
Claims Submission Contact Executive Officers of State Medical and
Pharmaceutical Societies
Mary Kay Kruchten
Senior Account Manager Medical Association of Georgia
Express Scripts, Inc. David Cook, Executive Director
6625 W. 78th St., BL-0440 1330 W. Peachtree Street, NW, Suite 500
Bloomington, MN 55439 Atlant, GA 30309
T: 952/837-7401 T: 404/876-7535
F: 952/837-7184 F: 404/881-5021
E-mail: kruchtem@express-scripts.com E-mail: dcook@mag.org
Internet address: www.mag.org
Medicaid Managed Care Contact
Kathy Driggers Georgia Pharmacy Association
Chief of Medicaid Managed Care Buddy Harden
Department of Community Health Executive Vice President
2 Peachtree Street, NW, 36th Floor 50 Lenox Pointe, NE
Atlanta, GA 30303 Atlanta, GA 30324-3170
T: 404/657-7793 T: 404/231-5074
F: 404/656-5537 F: 404/237-8435
E-mail: kdriggers@dch.state.ga.us E-mail: bharden@gpha.org
Internet address: www.gpha.org
Disease Management/Patient Education Georgia Osteopathic Medical Association
Programs Holly Barnwell
Disease/Medical State: Asthma Executive Director
Program Name: Asthma Disease State Management 2037 Grayson Highway, Suite 200
Program Grayson, GA 30017
Program Mamager: Charmaine Heard, M.D. T: 770/493-9278
Sponsor: Georgia Department of Community Health F: 770/908-3210
E-mail: exdir@goma.org
Internet address: www.goma.org

Georgia-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Georgia State Board of Pharmacy


Sylvia L. Bond
Executive Director
237 Coliseum Drive
Macon, GA 31217-3858
T: 478/207-1686
F: 404/656-0513
E-mail: slbond@sos.state.ga.us
Internet address: www.sos.state.ga.us/plb/pharmacy/

Georgia State Medical Association


Price R. Walker, M.D.
President
P.O. Box 9516
Columbus, GA
T: 706/322-6890
F: 706/322-8361

Georgia Hospital Association


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

Georgia-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Georgia-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

HAWAII

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002* 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $81,453,811 39,320 $97,386,406

RECEIVING CASH ASSISTANCE TOTAL $46,778,608 20,066


Aged $12,383,241 7,063
Blind/Disabled $34,312,136 12,263
Child $27,304 361
Adult $55,927 379

MEDICALLY NEEDY, TOTAL $3,666,738 1,958


Aged $2,392,598 1,527
Blind/Disabled $1,274,140 431
Child $0 0
Adult $0 0

POVERTY RELATED, TOTAL $25,699,618 12,272


Aged $10,230,442 6,724
Blind/Disabled $15,354,226 5,215
Child $114,950 333
Adult $0 0
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $5,308,847 5,024

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report FY 2003.

Hawaii-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Formulary/Prior Authorization


Formulary: Open formulary managed through
Hawaii Department of Human Services through its preferred products and prior authorization. Preferred
Med-Quest Division and four county branch offices. drug list implemented in 2004.

D. PROVISIONS RELATING TO DRUGS Prior Authorization: State currently has a formal


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

Coverage of Injectables: Injectable medicines E. USE OF MANAGED CARE


reimbursable through the Prescription Drug Program
when used in home health care, extended care Approximately 125,000 Medicaid recipients were
facilities and physicians’ offices. enrolled in MCOs in FY 2003. Recipients receive
most of their pharmaceutical benefits through
Vaccines: Vaccines reimbursable as part of EPSDT managed care plans. State has specific guidelines for
service, CHIP, and the Vaccines for Children the pharmacy benefit for Medicaid recipients enrolled
Program. in managed care plans. Drugs prescribed by dentists
are “carved out” of managed care and provided
Unit Dose: Unit dose packaging reimbursable through the State.

Hawaii-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Managed Care Organizations Linda Tom, M.D. (Geriatric Medicine), Vice-Chair


347 N. Kuakini Street, HPM-9
AlohaCare, Inc.
Honolulu, HI 96817
Mr. John McComas
808/523-8461
1357 Kapiolani Blvd., Suite 1250
Honolulu, HI 96814 James Lumeng, M.D. (Medicine/Pathology)
808/973-1650 850 West Hind Drive, #114
Honolulu, HI 96821
Hawaii Medical Service Association (HMSA) 808/377-5485
QUEST Administration
Brian Matsuura (Medical Services Rep.)
818 Keeaumoku Street
DHS/MQD/MSB
Honolulu, HI 96814
P.O. Box 700190
808/948-0111
Kapolei, HI 96709-0190
808/692-8065
Kaiser Foundation Health Plan, Inc.
Ms. Virginia Vierra Joy Higa, Pharm.D. (Long Term Care), Chair
1441 Kapiolani Blvd, Suite 1600 DHS/MQD/MSB
Honolulu, HI 96814 P.O. Box 700190
808/944-0261 Kapolei, HI 96709-0190
808/692-8065
Jerry Smead, R.Ph. (Ambulatory Care)
F. STATE CONTACTS Kaiser Parmanente Hawaii Region
Medicaid Drug Program Administrator P.O. Box 700190
Kapolei, HI 96709-0190
Lynn S. Donovan, R.Ph. 808/692-8065
Pharmacy Consultant
Department of Human Services Kerry Kitsu, R.Ph. (Community, chain)
Med-Quest Division DHS/MQD/MSB
601 Kamokila Boulevard, Suite 506B P.O. Box 700190
Kapolei, HI 96707 Kapolei, HI 96709-0190
T: 808/692-8116 808/692-8065
F: 808/692-8131
Internet address: www.med-quest.us New Brand Name Products Contact
Prior Authorization Contact Lynn S. Donovan, R.Ph.
808/692-8116
Lynn S. Donovan, R.Ph.
808/692-8116
Prescription Price Updating
DUR Contact ACS State Healthcare
365 Northridge Road, Suite 400
Kathleen Kang-Kaulupali
Atlanta, GA 30350
Pharmacy Consultant
Attn: Hawaii Medicaid
Department of Human Services
T: 800/358-2381
Med-Quest Division
F: 770/730-5198
601 Kamokila Blvd., Room 506-B
Kapolei, HI 96707 Medicaid Drug Rebate Contacts
T: 808/692-8065
Martha Kessinich
F: 808/692-8131
Drug Rebate Manager
Medicaid DUR Board ACS State Healthcare
365 Northridge Road, Suite 400
Myron Shirasu, M.D. (Internal Medicine)
Atlanta, GA 30350
321 North Kuakini Street, Suite 200
T: 800/358-2381
Honolulu, HI 96817
F: 770/730-5198
808/523-8611
Gregory E.M. Yuen, M.D. (Psychiatry)
1188 Bishop Street, Suite 806
Honolulu, HI 96813
808/599-5050

Hawaii-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Claims Submission Contact Shaun F. Young


President
Becky Garrigan
P.O. Box 1198
Account Manager
Honolulu, HI 96807-1198
ACS State Healthcare
T: 808/282-3722
365 Northridge Road, Suite 400
F: 808/432-5535
Attn: Hawaii Medicaid
E-mail: shaun.f.young@aol.com
T: 800/358-2381
F: 770/730-5198
Hawwaii Assoc .of Osteopathic Physicians and
E-mail: becky.garrigan@acs-inc.com
Surgeons
Disease Management/Patient Education Ronald H. Kienitz, President
Contact 545 Ohohia Street
Honolulu, HI 96819
Lynn S. Donovan, R.Ph.
T: 808/831-3000
808/692-8116
F: 808/834-5763
Mail Order Pharmacy Benefit
Hawaii State Board of Pharmacy
None
Lee Ann Teshima
Department of Human Services Officials Executive Officer
P.O. Box 3469
Lillian Koller Honolulu, HI 96801
Director T: 808/586-2694
Department of Human Services F: 808/586-2689
1390 Miller Street, Room 209 E-mail: pharmacy@dcca.state.hi.us
Honolulu, HI 96813 Internet address: www.state.hi.us/dcca/pvl
T: 808/586-4997
F: 808/586-4890 Healthcare Association of Hawaii
E-mail: lillian.b.koller@hawaii.gov Richard E. Meiers
President and CEO
Angie Payne 932 Ward Avenue, Suite 430
Acting Administrator, Med-Quest Division Honolulu, HI 96814-2126
Department of Human Services T: 808/521-8961
P.O. Box 399 F: 808/599-2879
Honolulu, HI 96809-0339 E-mail: rmeiers@hah.org
T: 808/692-8050 Internet address: www.hah.org
F: 808/692-8173
E-mail: apayne@medicaid.dhs.state.hi.us

Executive Officers of State Medical and


Pharmaceutical Societies
Hawaii Medical Association
Paula Arcena
Executive Director
1360 S. Beretania Street, Suite 200
Honolulu, HI 96814-1520
T: 808/536-7702
F: 808/528-2376
E-mail: paula_arcena@hma-assn.org
Internet address: www.hmaonline.net

Hawaii Pharmacist Association

Hawaii-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

IDAHO

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $121,780,793 125,537 $132,143,091

RECEIVING CASH ASSISTANCE, TOTAL $72,269,410 23,218


Aged $5,418,059 2,078
Blind/Disabled $66,398,243 20,077
Child $270,352 842
Adult $182,756 221

MEDICALLY NEEDY, TOTAL $0 0


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

POVERTY RELATED, TOTAL $12,870,890 63,429


Aged $326,033 147
Blind/Disabled $384,836 178
Child $11,104,429 56,523
Adult $1,055,592 6,581
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $36,640,493 38,890

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Idaho-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Program, the Vaccines for Children Program, and the


State Vaccine Program.
Division of Medicaid
Idaho Department of Health & Welfare Unit Dose: Unit dose packaging reimbursable when
By the State Department of Health and Welfare used in unit dose systems.
through seven regional offices, each serves five or Formulary Authorization
more of the State’s 44 counties.
Formulary:None.
D. PROVISIONS RELATING TO DRUGS Pharmacy program is managed through an enhanced
prior authorization program (Smart PA), restrictions
Benefit Design on use, therapeutic substitution, preferred products,
Drug Benefit Product Coverage: Products covered: physician profiling, and generic substitution for
prescribed insulin; disposable needles and syringe multi-source products.
combinations used for insulin. Products covered
through DME: blood glucose test strips; urine keton Prior Authorization: State currently has a formal
test strips; total parenteral nutrition; and interdialytic prior authorization procedure and a prior
parenteral nutrition. Products not covered: cosmetics; authorization committee. Informal reconsideration of
fertility drugs; experimental drugs. denied prior authorization requests followed by a
formal appeal process Written “notice of appeal”
OTC Coverage: Products covered: permethrin; required for fair hearing.
Prilosec OTC; oral iron salts; insulin and insulin Prescribing or Dispensing Limitations
syringes. Products not covered: allergy, asthma, and
sinus products; analgesics, cough and cold Monthly Quantity Limit: Prescription drugs are
preparations; digestive products; feminine products; limited to a 34-day supply. Limits on the number of
topical products; and smoking deterrent products. refills per script and early refills. The following drugs
are limited to a 100-day supply: cardiac glycosides,
Therapeutic Category Coverage: Therapeutic thyroids, prenatal vitamins, nitroglycerin, fluoride,
categories covered: anticonvulsants; anti-psychotics; fluoride and vitamin combinations, non-legend oral
chemotherapy agents; sympathominetics iron salts and 3 cycles of birth control.
(adrenergic); and thyroid agents. Prior authorization
required for: anabolic steroids; analgesics; Drug Utilization Review
antipyretics, and NSAIDs; antibiotics; Contracted DUR through Idaho State University.
anticoagulants; anti- depressants; antidiabetic agents; PRODUR system implemented January 1998. State
antihistamines; antilipemic agents; anxiolytics, currently has a DUR board with a quarterly review.
sedatives, and hypnotics; cardiac drugs;
contraceptives; ENT-anti- inflammatory agents; Pharmacy Payment and Patient Cost Sharing
estrogens; growth hormones; hypotensive agents; Dispensing Fee: $4.94 ($5.54 for unit dose),
misc. GI drugs; PPIs; Cox IIs; Triptans; long acting effective March 1999.
opiods; urinary incontinence products; select prenatal
vitamins; stimulants; antiemetics; retinoids; topical Ingredient Reimbursement Basis: Discounted AWP =
antiacne products; Provigil; Aldara; Synagis; AWP-12% as determined by First DataBank Data
Regranex; Androgel; Prolastin; Klonopin Wafers; File Service or manufacturer direct price for selected
Marinol; Nascobal; Xenical; Penlac; Prozac Weekly; manufacturers.
Remeron Sol. Tabs; Restasis; Strattera; Taladine;
Thalomid; Triostat; Triptans; Zetia; Xanax XR; Prescription Charge Formula: Lower of FUL,
Xolair; Vytorin; and brand names of FUL and SMAC or Discounted AWP plus a dispensing fee or
SMAC drugs. Therapeutic categories not covered: provider’s usual and customary price to the general
anorectics; prescribed cold medications; and smoking public.
deterrents.
Maximum Allowable Cost: State imposes Federal
Coverage of Injectables: Injectable medicines Upper Limits as well as State-specific limits on
reimbursable through the Physician Payment when generic drugs. Override requires failure of two
used in home health care extended care facilities, and generic formulations and submission of a Med Watch
physicians offices. form.

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


EPSDT service, The Children’s Health Insurance Patient Cost Sharing: No copayment.

Idaho-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Board Members:
Cognitive Services: Does not pay for cognitive Gary Wilburn, R.Ph.
services. Don Smith, R.Ph.
Kent Jensen, R.Ph.
E. USE OF MANAGED CARE Joseph Steiner, Pharm. D.
Nancy Mann, M.D.
Does not use MCOs to deliver services to Medicaid Kevin Clifford, M.D.
recipients. Robert Ting, M.D.

F. STATE CONTACTS Staff:


Tamara Eide, Pharm. D., Dept. Contact
Medicaid Drug Program Administrator Vaughn Culbertson, Pharm.D. Project Dir.
Ike Gayfield New Brand Name Products Contact
Bureau Chief-Acting Pharmacy Manager
Department of Health and Welfare Mary Wheatley, R.Ph.
Division of Medicaid Pharmacy Services Specialist
3232 Elder Department of Health and Welfare
Boise, ID 83705 Division of Medicaid
T: 208/364-1829 3232 Elder
F: 208/364-1864 Boise, ID 83705
E-mail: gayfieldi@idhw.state.id.us T: 208/364-1832
Internet address: www.healthandwelfare.idaho.gov F: 208/364-1864
E-mail: wheatlem@idw.state.id.us
Prior Authorization Contact
Prescription Price Updating
Ike Gayfield
Bureau Chief-Acting Pharmacy Manager Katie Ayad, CPhT
208/364-1829 Technical Records Specialist II
Department of Health and Welfare
Pharmacy and Therapeutics Committee Division of Medicaid
Bob Comstock, R.Ph. 3232 Elder
Catherine Gundlach, Pharm.D. Boise, ID 83705
Cindy Bunde, P.A. T: 208/364-1970
George Pfoertner, M.D. F: 208/364-1864
Phil Peterson, M.D. E-mail: ayadk@idhw.state.id.us
Richard J. Pines, D.O. (vice-chair) Medicaid Drug Rebate Contact
Rick Sutton, R.Ph.
Thomas Rau, M.D. Mary Wheatley, R.Ph.
Richard Markuson, R.Ph. 208/364-1832
Selma Gearhardt, Pharm. D. Claims Submission Contact
Stephen Montamat, M.D.
W. Terry Gipson, M.D. (chair) Electronic Data Systems (EDS)
P.O. Box 23
DUR Contact Boise, ID 83707
Tamara Eide, Pharm.D., BCPS, FASHP T: 208/395-2000
Pharmacy Service Specialist F: 208/395-2030
Department of Health and Welfare
Division of Medicaid Medicaid Managed Care Contact
3232 Elder State currently has no managed care program.
Boise, ID 83705
T: 208/364-1821 Mail Order Pharmacy Program
F: 208/364-1864 State currently has no mail order pharmacy program.
E-mail: eidet@idhw.state.id.us

Medicaid DUR Board

Idaho-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Health and Welfare Department Officials Mark Leeper


Disabled Community
Karl Kurtz, Director
Dept. of Health & Welfare
Marla Lewis
450 West State Street
Kootenai County Welfare Department
Boise, ID 83720-0036
T: 208/334-5500
Mary Lou Long
F: 208/334-6558
St. Luke’s Hospice
E-mail: kurtzk@idhw.state.id.us
Randy Robinson
David Rogers, Administrator
Legal Aid- Lewiston
Department of Health and Welfare
Division of Medicaid
Representative Bill Sali
Americana Building
Idaho House of Representatives
3232 Elder Street
Boise, ID 83705
Dick Schultz
T: 208/334-5747
Division of Health
F: 208/364-1811
E-mail: rogersd@mmis.state.id.us
Mark Turner, M.D.
Board Certified Physician
Title XIX Medical Care Advisory Committee
Judith Baily Robert VandeMerwe
Idaho Medical Association Idah Heatlh Care Association

Bill Bankula Gene Wiggers


Idaho Association of Develomental Disabilities AARP

Senator Skip Brandt Marcie Young


Idaho Senate Idaho Medicaid Program

Leslie Clement Executive Officers of State Medical and


Idaho Medical Program Pharmaceutical Societies
Idaho Medical Association
JoAn Condie
Robert Seehusen, CEO
Idaho State Pharmacy Association
P.O. Box 2668
305 West Jefferson
April Crandall
Boise, ID 83701
Mental Health Provider’s Association
T: 208/344-7888
F: 208/344-7903
Greg Dickerson
E-mail: mail@idmed.org
Mental Health Provider’s Association
Internet address: www.idmed.org
Bill Foxcroft
Idaho State Pharmacy Association
Idaho Primary Care Association
JoAn Condie
Executive Director
Bonnie Haines
P.O. Box 140117
Idaho Hospital Association
Boise, ID 83714-0117
T: 208/424-1107
Elizabeth Henry
F: 208/376-3131
American Indian Tribes
E-mail: condie@velocitus.net
Internet address: www.idahopharmacy.org
Deedra Hunt
Aged Community

Linda Johann
Individual

Idaho-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Idaho State Board of Pharmacy


Richard K. Markuson, R.Ph.
Executive Director
P.O. Box 83720
Boise, ID 83720-0067
T: 208/334-2356
F: 208/334-3536
E-mail: rmarkuson@bop.state.id.us
Internet address: www.state.id.us.bop

Idaho Hospital Association


Steven A. Millard
President
615 North Seventh Street
P.O. Box 1278
Boise, ID 83701
T: 208/338-5100
F: 208/338-7800
E-mail: info@teamiha.org
Internet address: www.teamiha.org

Idaho-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Idaho-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

ILLINOIS

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/ Child Adult Aged Blind/ Child Adult
Disabled Disabled

Prescribed Drugs ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Inpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Outpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Laboratory & X-ray Service ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Nursing Facility Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Physician Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Dental Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $1,222,947,241 1,199,933 $1,469,190,682

RECEIVING CASH ASSISTANCE TOTAL $428,095,975 211,001


Aged $50,859,185 20,248
Blind/Disabled $361,528,367 126,826
Child $8,870,084 48,180
Adult $6,838,339 15,747

MEDICALLY NEEDY, TOTAL $489,678,297 314,648


Aged $138,597,747 55,634
Blind/Disabled $270,370,434 85,271
Child $542,742 839
Adult $80,167,374 172,904

POVERTY RELATED, TOTAL $123,171,941 495,926


Aged $4,663,774 2,288
Blind/Disabled $15,624,787 5,122
Child $98,238,455 455,846
Adult $4,305,676 32,478
BCCA Women $339,249 192

OTHER EXPENDITURES/RECIPIENTS* $182,001,028 178,358

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration partictipants, other
recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are
unavailable.
Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Illinois-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Formulary/Prior Authorization


Illinois Department of Public Aid, Division of Formulary: Open formulary. State PDL is managed
Medical Assistance. through restrictions on use, prior authorization, and
preferred products.
D. PROVISIONS RELATING TO DRUGS Prior Authorization: State currently has a formal
prior authorization procedure and a Drugs and
Benefit Design Therapeutics Committee. Manufacturers can appeal a
decision to place products on non-preferred status to
the Drug and Therapeutics Committee. Recipients
Drug Benefit Product Coverage: Products covered: can appeal prior authorization decisions through the
total parenteral nutrition; interdialytic; parenteral Department’s Bureau of Administrative Hearings.
nutrition; and urine ketone test strips. Products
covered with restrictions: (PDL applies): prescribed Prescribing or Dispensing Limitations
insulin; disposable needles and syringe combinations
used for insulin; and blood glucose test strips.
Products not covered: cosmetics; DESI-ineffectives; Prescription Refill Limit: Maximum of eleven refills.
fertility drugs; and experimental drugs.
Monthly Quantity Limit: As medically appropriate.
OTC Coverage: Products covered: analgesics and Also edit for maximum daily quantities.
smoking deterrent products. Products covered with Drug Utilization Review
restrictions (PDL applies): allergy, asthma, and sinus
products; digestive products (non-H2 antagonist);
and topical products. Products not covered: cough PRODUR system implemented in January 1993.
and cold preparations; digestive products (H2
antagonists) and feminine products. Pharmacy Payment and Patient Cost Sharing

Therapeutic Category Coverage: Categories


covered: anticogulants; anticonvulsants; Dispensing Fee: $3.40 for branded drugs; $4.60 for
chemotherapy agents; contraceptives; prescribed generics.
smoking deterrents; and thyroid agents. Prior
authorization required for: anabolic steroids; Ingredient Reimbursement Basis: EAC = B: AWP-
analgesics, antipyretics, and NSAIDs, antibiotics; 12%.
anti-depressants; antidiabetic agents; antihistamines;
antilipemic agents; anti-psychotics; anxiolytics, Prescription Charge Formula: Lowest of 1) usual
sedatives and hypnotics; cardiac drugs; ENT anti- and customary, 2) Department's MAC plus fee.
inflammatory agents; prescribed cold medications; Professional fee: $3.58 up to EAC of $35.80; above
estrogens; growth hormones; hypotensive agents; EAC of $35.80, fee is 10% of EAC.
misc. GI drugs; sympathominetics (adrenergic); and
Cox IIs. Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
Coverage of Injectables: Injectable medicines generic drugs. Override requires prior authorization.
reimbursable through the Prescription Drug Program (i.e., letter from physician justifying medical need for
when used in home health care and extended care the brand drugs)
facilities and through both the Prescription Drug
Program and physician payment when used in Incentive Fee: None.
physician offices. PDL rules apply.
Patient Cost Sharing: $3.00 for branded drugs. No
Vaccines: Vaccines are reimbursable as part of the copay for generics.
EPSDT service and the Vaccines for Children
Program. Cognitive Services: Does not pay for cognitive
services.
Unit Dose: Unit dose packaging not reimbursable.
E. USE OF MANAGED CARE
Approximately 140,000 Medicaid recipients were
voluntarily enrolled in MCOs in 2003. Recipients
receive pharmaceutical benefits through managed
care plans.

Illinois-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Managed Care Organizations DUR Contact


Amerigroup Illinois Pamela Bunch
211 Wacker Drive 217/524-7478
Suite 1350
New Brand Name Products Contact
Chicago, IL 60606-3101
T: 312/214-0400 Lisa Voils
F: 312/214-0424 Special Assistant to Medicaid Deputy Administrator
Illinois Department of Public Aid
United Health Care of IL 201 S. Grand Avenue East
233 N. Michigan Ave. 8th Fl-12th Fl. Springfield, IL 62763
Chicago, IL 60607 T: 217/782-2570
T: 312/424-4460 F: 217/7825672
F: 312/424-5584 E-mail: lisa.voils@idpa.state.il.us
Internet address: www.dpaillinois.com
Harmony Health Plan of Illinois
125 South Wacker Drive
Suite 2600 Prescription Price Updating
Chicago, IL 60606 First DataBank
T: 312/630-2025 111 Bayhill Dr.
F: 312/368-1784 San Bruno, CA 94066
650/588-5454
Humana Health Plan
30 South Wacker Drive Medicaid Drug Rebate Contact
Suite 3100 Brandley Wallner, Chief
Chicago, IL 60606 Bureau of Budget and Cash Management
T: 800/599-1754 Illinois Department of Public Aid
F: 312/601-0314 2200 Churchill Road
Springfield, IL 62702
Family Health Network T: 217/524-7161
910 West Van Buren F: 217/785-4174
6th Floor E-mail: Bradley.wallner@idpa.state.il.us
Chicago, IL 60607
T: 312/491-1956 Claims Submission Contact
F: 312-491-1175 Illinois Department of Public Aid
201 S. Grand Avenue East
F. STATE CONTACTS Springfield, IL 62763
T: 217/782-2570
F: 217/782-5672
State Drug Program Administrator

Medicaid Managed Care Contact


Pamela Bunch
Medicaid Pharmacy Manager Kelly Carter, Chief
Illinois Department of Public Aid Bureau of Contract Management
201 S. Grand Avenue East Illinois Department of Public Aid
Springfield, IL 62763 201 S. Grand Avenue East
T: 217/524-7478 Springfield, IL 62763
F: 217/524-7535 T: 217/524-7478
E-mail: pam.bunch@idpa.state.il.us F: 217/524-7535
Internet address: www.dpaillinois.com E-mail: Kelly.carter@idpa.state.il.us
Prior Authorization Contact
Pharmacy Unit Staff
217/524-2570

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Mail Order Pharmacy Benefit Kim Mitroka


Christopher, IL
State has a mail order pharmacy benefit. Any
Medicaid beneficiary can choose to receive pharmacy
Leticia Overholt
services from a Medicaid enrolled mail order
Wilmette, IL
pharmacy.
Elderly Expanded Drug Coverage Program Richard Perry, D.D.S.
OakPark, IL
Circuit Breaker Pharmacutical Assistance Program
Eli Pick
Jane LeBegue, Manager
Des Plaines, IL
Illinois Department of Aging
101 W. Jefferson
Pedro A. Poma, M.D.
Springfield, IL 62704
Chicago, IL
T: 217/524-4009
F: 217/524-9213
Stephen Saunders, M.D., M.P.H.
E-mail: llebegue@revenue.state.il.us
Springfield, IL
Physician-Administered Drug Program
Contact John S. Shlofrock
Northfield, IL
Cheryl Bechner
217/782-5565
Deborah Kinsey
Illinois Medicaid Agency Officials Springfield, IL
Barry Maram, Director Neil Winston, M.D.
Illinois Department of Public Aid Chicago, IL
201 South Grand Avenue, East, Third Floor
Springfield, IL 62794 Executive Officers of State Medical and
T: 217/782-1200 Pharmaceutical Societies
F: 217/524-7120
Illinois State Medical Society
E-mail: directordpa@mail.idpa.state.il.us
Craig A. Backs, M.D.
President
Dr. Anne Marie Murphy, Director
20 N. Michigan Avenue, Suite 700
Medicaid and SCHIP Programs
Chicago, IL 60602
Illinois Department of Public Aid
T: 312/782-1654
201 South Grand Avenue, East, Third Floor
F: 312/782-2023
Springfield, IL 62763-0001
E-mail: info@isms.org
T: 217/782-7570
Internet address: www.isms.org
F: 217/524-5672
Title XIX Medical Care Advisory Committees Illinois Pharmacists Association
J. Michael Patton
Robert Anselmo, R.Ph. Executive Director
Wauconda, IL 204 West Cook Street
Springfield, IL 62704-2526
Diane Coleman T: 217/522-7300
Forest Park, IL F: 217/522-7349
E-mail: mpatton@ipha.org
Robyn Gabel Internet address: www.ipha.org
Chicago, IL
Illinois Osteopathic Medical Society
Susan Hayes Gardon Elizabeth Forkins Harano
Chicago, IL Executive Director
142 East Ontario Avenue, Suite 1023
Alvin Holley Chicago, IL 60611-2854
Chicago, IL T: 312/202-8174
F: 312/202-8224
Michael Jones E-mail: ioms@ioms.org
Springfield, IL Internet address: www.ioms.org

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Illinois State Board of Pharmacy


Alisha Purchase
Board Liaison
Illinois Department of Professional Regulation
Pharmacy Section
320 West Washington Street
Springfield, IL 62786
217/782-0458
Internet address: www.dpr.state.il.us/who/phar.asp

Illinois Hospital Association


Kenneth C. Robbins
President
Center for Health Affairs
1151 East Warrenville Road
P.O. Box 3015
Naperville, IL 60566
T: 630/276-5400
F: 630/505-9457
E-mail: krobbins@ihha.org
Internet address: www.ihatoday.org

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National Pharmaceutical Council Pharmaceutical Benefits 2004

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National Pharmaceutical Council Pharmaceutical Benefits 2004

INDIANA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/ Child Adult Aged Blind/ Child Adult
Disabled Disabled

Prescribed Drugs ‹ ‹ ‹ ‹
Inpatient Hospital Care ‹ ‹ ‹ ‹
Outpatient Hospital Care ‹ ‹ ‹ ‹
Laboratory & X-ray Service ‹ ‹ ‹ ‹
Nursing Facility Services ‹ ‹ ‹ ‹
Physician Services ‹ ‹ ‹ ‹
Dental Services ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients
TOTAL $636,357,519 490,386 $627,575,345

RECEIVING CASH ASSISTANCE, TOTAL $315,484,522 200,489


Aged $52,184,587 16,691
Blind/Disabled $217,167,920 59,727
Child $17,736,334 70,416
Adult $28,395,681 53,655

MEDICALLY NEEDY, TOTAL $0 0


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

POVERTY RELATED, TOTAL $56,010,936 156,012


Aged $400,906 482
Blind/Disabled $1,018,867 777
Child $53,085,594 145,439
Adult $1,391,683 9,198
BCCA Women $113,886 116

TOTAL OTHER EXPENDITURES/RECIPENTS* $264,862,061 133,885

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable..

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Ingredient Reimbursement Basis:


Office of Medicaid Policy and Planning
EAC = Brand: AWP-13.5%
Generic: AWP-20%
*NOTE WELL—All requests for information by,
or on behalf of, drug manufacturers must
Legend Drug Reimbursement Methodology:
be made ONLY to: PDL@FSSA.state.in.us
Lower/Lowest of:
Phone requests will not be accepted.
1. Federal MAC, if applicable, plus a dispensing
fee.
D. PROVISIONS RELATING TO DRUGS
2. State MAC, if applicable, plus a dispensing fee.
3. EAC plus a dispensing fee.
Benefit Design
4. Pharmacy’s usual and customary charge to the
Drug Benefit Product Coverage: Products covered: general public.
All FDA-approved legend drugs from rebating
Maximum Allowable Cost: State imposes Federal
labelers, excluding those products specifically non-
Upper Limits as well as State-specific limits on
covered by State law (e.g., cosmetics; enhancement
generic drugs. Overide requires “Brand Medically
drugs; and experimental drugs). For more detailed
Necessary” plus prior authorization (as of September
coverage information see www.indianamedicaid.com
2001).
or www.indiana.pbm.com.
Incentive Fee: None.
Over-the-Counter Product Coverage: Indiana has a
Medicaid OTC drug formulary. Listed drugs are
Patient Cost Sharing: $3.00
reimbursed based on State MAC.
Cognitive Services: None.
Therapeutic Category Coverage: All coverage in
accordance with OBRA ’90 & ’93.
E. USE OF MANAGED CARE
Coverage of Injectables: Covered.
Approximately 246,000 Medicaid recipients were
Vaccines: Covered. enrolled in MCOs in FY 2003. Recipients receive
pharmaceutical benefits through managed care plans.
Unit Dose: In accordance with OBRA 1990 Managed Care Organizations
Requirements. MCFA policy only.
Harmony Health Management, Inc.
Formulary/Prior Authorization
504 Broadway, Suite 200
Formulary: Preferred Drug List (see Gary, IN 46404-4300
www.indianapbm.com-pharmacyservices) 219/880-4400

Prior Authorization: State has a prior authorization Managed Health Services


program with formal appeal process. 1099 N. Meridian Street, Suite 400
Indianapolis, IN 46204
Prescribing or Dispensing Limitations 800/944-9661
Monthly Quantity Limit: None.
MDwise
Drug Utilization Review 1099 N. Meridian Street, Suite 320
Indianapolis, IN 46204
317/630-2828
PRODUR system implemented in March 1996. State
currently has a DUR Board with a monthly review. AmeriChoice
333 N. Alabama
Pharmacy Payment and Patient Cost Sharing
Suite 350
Indianapolis, IN 46204
Dispensing Fee: $4.90, effective 05/30/02. 317/263-0355

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National Pharmaceutical Council Pharmaceutical Benefits 2004

CareSource Health Care Economist


151 N. Delaware Street, Suite 1840 Marko Mychaskiw, R.Ph., Ph.D.
Indianapolis, IN 46204
937/531-3000 Pharmacologist
Terry Lindstrom, Ph.D.
Molina
8001 Broadway, Suite 400 Representative from HMO
Merrillville, IN 46410 Vicki Perry
219/736-9101
Prescription Pricing Updating
Health Care Excel First DataBank
P.O. Box 53380 1111 Bay Hill Drive
Indianaplois, IN 53380 San Bruno, CA 94066
317/347-4500 650/588-5454
F. STATE CONTACTS Medicaid Drug Rebate Contact
State Drug Program* Martha Kessenich
Marc Shirley, R.Ph. Rebate Accounting Manager
Pharmacist ACS State Healthcare
Office of Medicaid Policy and Planning 365 Northridge Road, Suite 400
Room West 382 Atlanta, GA 30350
Indiana State Government Center South T: 770/730-3292
402 W. Washington Street F: 866/759-4100
Indianapolis, IN 46204-2739 E-mail: martha.kessenich@acs-inc.com
T: 317/232-4307 Claims Submission Contact
F: 317/232-7382
Internet address: www.indianamedicaid.com ACS State Healthcare
365 Northridge Road, Suite 400
*NOTE WELL—All requests for information by, Atlanta, GA 30350
or on behalf of, drug manufacturers must T: 866-322-5960 x4032
be made ONLY to: PDL@FSSA.state.in.us F: 866/759-4100
Phone requests will not be accepted. Medicaid Managed Care Contact
DUR Contact Managed Care Director
Office of Medicaid Policy and Planning
DUR Board Secretary 402 W. Washington Street
Office of Medicaid Policy & Planning Room W382, MS07
Room W382, Indiana Sate Government Center South Indianapolis, IN 46204-2739
402 West Washington Street T: 317/233-4697
Indianapolis, IN 46204 F: 317/232-7382
T: 317/232-4307
F: 317/232-7382 Disease Management Program/Initiatives
Contact
Medicaid DUR Board Kathryn A. Moses
Physicians Director of Chronic Diseases
Neil Irick, M.D. Office of Medicaid Policy and Planning,
Patricia Treadwell, M.D. Indiana State Government Center South, Room
John J. Wernert, M.D. W382
Philip N. Eskew, Jr., M.D. (Vice-Chair) 402 W. Washington Street
Room W382, MS07
Pharmacists Indianapolis, IN 46204
Paula J. Ceh, Pharm.D. 317/233-7346
Brian W. Musial, R.Ph. (Chair)
Thomas A. Smith, P.D., M.S., F.A.S.C.P. Mail Order Pharmacy Program
G. Thomas Wilson, R.Ph., J.D. None

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Administration Officials Indiana Optometric Association


Marjorie Knotts, O.D.
Mitch Roob, Secretary
Family & Social Services Administration
Indiana Pharmaceutical Association
Room 461, MS 25
Monica Foye
P.O. Box 7083
402 W. Washington Street
Indiana Psychological Association
Indianapolis, IN 46207
Paul Schneider, Ph.D.
T: 317/233-4690
F: 317/233-4693
Indiana State Chiropractic Association
E-mail: mitch.roob@fssa.in.gov
Michael Gallagher
Jean M. Labrecque, Director
Indiana Ambulance Association
Office of Medicaid Policy and Planning
Vacant
402 West Washington Street, Room W382
Indianapolis, IN 46204-2739
Indiana Association for Home Care
T: 317/234-2407
Todd Stallings
F: 317/232-7382
E-mail: jeane.labrecque@fssa.state.in.gov
Indiana Academy of Ophthalmology
Kim Williams
Medicaid Advisory Committee
Indiana Speech and Hearing Association
Indiana Council of Community Mental Health
Susan Holbert
Centers
James F. Jones
Agricultural Interests
Vacant
Indian State Medical Association
Vacant
Business and Industrial Interests
Lula E. Baxter
Indiana State Chapter of American Academy of
Pediatrics
Labor Interests
Vacant
Donald Mulligan, Sr.
Indiana Hospital Association
Insurance Interests
L. Richard Gohman
Vacant
Indiana Dental Association
Taxpayer Interests
Ed Popcheff
Vacant
Indiana State Psychiatric Association
Parent Advocates (2)
Vacant
Vacant
Indiana State Osteopathic Association
Citizens’ Representatives (3)
Edward A. White, D.O.
Vacant
Indiana State Nurses Association
Indiana State Senate Represenative
Ernest C. Klein
Senator Jim Merritt
Indiana State Licensed Practical Nurses Association
Indiana State House of Representatives (2)
Vacant
Representative William Crawford
Representative Jeffrey Espich
Indiana State Podiatry Association
Kirk S. Holston, D.P.M.
Indiana State Health Commissioner’s Representative
Joe Hunt (ex-officio)
Indiana Health Care Association
John Kukla
Administrator’s Representative
Melanie Bella (ex-officio)

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Indiana Division of Mental Health and Addiction Indiana Hospital and Health Association
Representatitve Kenneth G. Stella
Katy Howard (ex-officio) President
One American Square
Indiana Therapeutics Committee Suite 1900
Indianapolis, IN 46282
Judith Ann Monroe, M.D.
T: 317/633-4870
Nancy F. Stater, M.D.
F: 317/633-4875
Michael C. Sha, M.D. (Chair)
E-mail: kstella@inhha.org
Stephen Dunlop, M.D. (Vice Chair)
Internet address: www.inha.org
James T. Poulos, M.D.
Bill Malloy, M.S., Pharm.D., B.C.P.S.
Bruce G. Hancock, M.S., R.Ph.

Executive Officers of State Medical and


Pharmaceutical Societies
Indiana State Medical Association
Richard R. King, J.D.
Executive Director
322 Canal Walk
Indianapolis, IN 46202-3268
T: 317/261-2060
F: 317/261-2076
E-mail: rking@ismanet.org
Internet address: www.ismanet.org

Indiana Pharmacists Alliance


Lawrence J. Sage
Executive Vice President
729 N. Pennsylvania, Suite 1171
Indianapolis, IN 46204-1171
T: 317/634-4968
F: 317/632-1219
Email: inpharm@indianapharmacists.org
Internet address: www.indianapharmacists.org

Indiana Osteopathic Association


Michael H. Claphan
Executive Director
3520 Guion Road, Suite 202
Indianapolis, IN 46222-1672
T: 317/926-3009
F: 317/926-3984
Email: info@inosteo.org
Internet address: www.inosteo.org

Indiana State Board of Pharmacy


Joshua Bolin
Director
402 W. Washington Street, Room W066
Indianapolis, IN 46204-2739
T: 317/234-2067
F: 317/233-4236
Email: jbolin@hpb.state.in.gov
Internet address: www.in.gov/hpb/boards/isbp

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National Pharmaceutical Council Pharmaceutical Benefits 2004

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National Pharmaceutical Council Pharmaceutical Benefits 2004

IOWA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $277,753,942 245,711 $331,222,324

RECEIVING CASH ASSISTANCE TOTAL $134,268,348 112,725


Aged $16,496,475 6,468
Blind/Disabled $93,745,177 32,850
Child $9,755,348 42,757
Adult $14,271,348 30,650

MEDICALLY NEEDY, TOTAL $12,771,499 5,887


Aged $3,985,026 2,020
Blind/Disabled $7,050,585 1,716
Child $112,460 300
Adult $1,623,428 1,851

POVERTY RELATED, TOTAL $12,521,471 58,277


Aged $420,755 677
Blind/Disabled $738,034 672
Child $9,796,078 48,440
Adult $1,566,604 8,488
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $118,192,624 68,822

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Coverage of Injectables: Injectable medicines


reimbursable through both the Prescription Drug
State Department of Human Services, Bureau of Program and through physician payment when used
Long Term Care. in home health care, extended care facilities, and
physicians’ offices.
D. PROVISIONS RELATING TO DRUGS
Vaccines: Vaccines reimbursable as part of the
Benefit Design Vaccines for Children Program.

Drug Benefit Product Coverage: Products covered: Unit Dose: Unit dose packaging reimbursable.
prescribed insulin; total parenteral nutrition; and
interdialytic parenteral nutrition. Products covered
Formulary/Prior Authorization
requiring prior authorization: PPIs; dipyridamole;
epoetin; filgrastim; vitamins and minerals;
ergotamine derivatives; narcotic agonist-antagonist Formulary: No formulary. Preferred drug list
nasal sprays; isotretinoin; oral antifungals; non- managed through prior authorization.
parenteral vasopressin derivatives; and Serotonin 5-
HT1 receptor agonists. Products not covered: fertility Prior Authorization: State currently has a formal
drugs; experimental drugs; cosmetics; disposable prior authorization procedure. State appeals and a
needles and syringe combinations for insulin; blood fair hearing procedure required for appeal of prior
glucose test strips; urine ketone test strips; and DESI authorization decisions and coverage of an excluded
drugs. For additional information on drug product product.
coverage, see www.iowamedicaidpdl.com.
Prescribing and Dispensing Limitations:
Over-the-Counter Product Coverage: Products
covered with restriction (selected products): allergy,
asthma, and sinus products; analgesics; cough and Prescribing or Dispensing Limitations: Maximum 30
cold preparations; and topical products. Products not day supply except select maintenance drugs (90 days)
covered: digestive products (non-H2 antagonists and including oral contraceptives, cardiac drugs,
H2 antagonists); feminine products; and smoking hypotensive agents, antidiabetic agents, diuretics,
deterrent products. anticonvulsants and thyroid/antithyroid agents.

The Iowa Department of Human Services adopted an Drug Utilization Review


administrative rule that permits coverage for certain
non-prescription drugs. A list of covered OTC
products, may be found at PRODUR system implemented in July 1997. State
www.iowamedicaidpdl.com. currently has a DUR Board that meets 8 times per
year.
Therapeutic Category Coverage: Therapeutic Pharmacy Payment and Patient Cost Sharing
categories covered: anabolic steroids; antibiotics;
anticoagulants; anticonvulsants; antidepressants; Dispensing Fee: $4.26, effective 7/1/03.
antidiabetic agents; antilipemic agents; anti-
psychotics; cardiac drugs; chemotherapy agents; Ingredient Reimbursement Basis: EAC = AWP-12%.
contraceptives; ENT anti-inflammatory agents;
estrogens; hypotensive agents; sympathominetics Prescription Charge Formula: Payment will be
(adrenergic); and thyroid agents. Prior authorization based on the pharmacist's usual, customary and
required for: analgesics, antipyretics, NSAIDs; reasonable charge, but payment may not exceed EAC
amphetamines; antihistamines; anxiolytics, sedatives, plus a dispensing fee.
and hypnotics; prescribed cold medications; growth
hormones; and misc. GI drugs. Partial coverage for:
Maximum Allowable Cost: State imposes Federal
prescribed smoking deterrents. Therapeutic
Upper Limits as well as State-specific limits on
categories not covered: anorectics; drugs for strictly
generic drugs. Override requires “Brand Medically
cosmetic purposes and hair growth; fertility drugs;
Necessary.”
and drugs without signed Medicaid rebate
agreements.
Incentive Fee: None.

Patient Cost Sharing: Copayment of $0.50-$3.00 for


brand products, depending on the cost of the drug.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Cognitive Services: State pays for pharmaceutical DUR Contact


case management.
Julie Kuhle, R.Ph.
Project Coordinator
E. USE OF MANAGED CARE Iowa Medicaid Enterprise
100 Army Post Road
Approximately 280,000 Medicaid beneficiaries were Des Moines, IA 50315
enrolled in managed care organizations in 2004. This T: 515/725-1226
includes both medical managed care organizations F: 515/725-1010
and the behavioral care carve-out program. Iowa
Medicaid recipients enrolled in managed care receive Medicaid DUR Commission
pharmaceutical benefits through the State fee-for-
service payment program. Richard Rinehart, M.D.
Connie Connolly, R.Ph.
Managed Care Organizations Ronald Miller, M.D., M.B.A.
Bruce Alexander, R.Ph., Pharm. D.
Sandi Birchem, D.O.
Coventry Health Care of Iowa Dan Murphy, R.Ph.
Cheryl Barkau Julie Kuhle, R.Ph., Project Coordinator
Account Manager Cheryl Clark, R.Ph.
4600 Westown Parkway, Suite 301 Janalyn Phillips, R.Ph.
West Des Moines, IA 50266 Susan Parker, Pharm.D.
515/225-1234 Craig Logemann, R.Ph., Pharm.D.
Magellan Heath Services Sara Schutte-Schenck, D.O.
Joan Discher, COO
2600 Westown Parkway, Suite 200 New Brand Name Products Contact
West Des Moines, IA 50266 Susan L. Parker, Pharm.D.
515/273-0306 515/725-1226
Prescription Price Updating
F. STATE CONTACTS
Patrick Danlen
State Drug Program Administrator POS Account Manager
Susan L. Parker, Pharm.D. Iowa Medicaid Enterprise
Pharmacy Consultant 100 Army Post Road
Iowa Medicaid Enterprise Des Moines, IA 50315
100 Army Post Road T: 515/725-1226
Des Moines, IA 50315 F: 515/725-1010
T: 515/725-1226 Medicaid Drug Rebate Contacts
F: 515/725-1010
E-mail: sparker2@dhs.state.ia.us Patrick Danlen
Internet address: www.iowamedicaidpdl.com 515/725-1226

Prior Authorization Contact Claims Submission Contact

Sandy Pranger, R.Ph. Patrick Danlen


Clinical Pharmacy Manager 515/725-1226
Iowa Medicaid Enterprise
100 Army Post Road Medicaid Managed Care Contact
Des Moines, IA 50315
T: 515/725-1272 Dennis Janssen, Chief
F: 515/725-1010 Iowa Medicaid Enterprise
100 Army Post Road
Des Moines, IA 50315
T: 515/725-1136
F: 515/725-1010
E-mail: djansse@dhs.state.ia.us

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Mail Order Pharmacy Program Iowa Nurses Association


Linda Goeldner
State currently has a mail order pharmacy program.
1501 42nd Street, Suite 471
Participating pharmacies must be enrolled as an Iowa
West Des Moines, IA 50266
Medicaid provider.
Iowa Medical Society
Pharmaceutical and Therapeutics Committee Karla Fultz McHenry
Vice President Public Policy and Advocacy
Bradley J. Archer, M.D.
1001 Grand Avenue
Cheryl L. Clarke, R.Ph., C.D.M.
West Des Moines, IA 50265
William R. Doucette, Ph.D.
Michael A. Flaum, M.D.
Opticians Assn. of Iowa
Carole A. Frier, D.O.
Ben Bolar, President
Hayley, L. Harvey, D.D.S., M.S.
McFarland Eye Wear
Susan Purcell, R.Ph., C.G.P.
3600 W. Lincoln Way
Priscilla Ruhe, M.D.
Ames, IA 50014
Mary F. Winegardner, PA-C, M.P.A.S.
Iowa Senate
Iowa Human Services Department Officials
Sen. Maggie Tinsman
Kevin W. Concannon, Director 3541 E. Kimberly Road
Dept. of Human Services Davenport, IA 52807
Hoover State Office Bldg., 5th Floor
Des Moines, IA 50319-0014 Senator Jack Hatch
T: 515/281-5452 696 18th Street
F: 515/281-7791 Des Moines, IA 50314
E-mail: kconcan@dhs.state.ia.us
Iowa Dept. of Public Health
Eugene Gessow Dr. Robert Russell
Medicaid Director Public Health Dental Director
Department of Human Services Lucas State Office Bldg., 5th Floor
Hoover State Office Building, 5th Floor Des Moines, IA 50319-0075
Des Moines, IA 50319-6242
T: 515/281-6249 Public Representatives
F: 515/281-8512 Brian Sheesley
E-mail: egessow@dhs.state.ia.us Director of Research
Iowa Health Systems
Title XIX Medical Assistance Advisory 1415 Woodland, Suite 218
Council Des Moines, IA 50309-3203
College of Medicine
Stacey T. Cyphert, Ph.D. John Grush
Special Advisor to the President for Science Health 226 Benton
Government Relations Boone, IA 50036
Senior Assistant Director of University Hospitals and
Clinics Jodi Tomlonovic
The University of Iowa Executive Director
Iowa City, IA 52242-1009 Family Planning Council of Iowa
108 Third Street, Suite 220
House of Representatives Des Moines, IA 50309
Joe Hunter
# 5 Hunter Lane Iowa Speech & Hearing Association
Bertendorf, IA 52722 Barbara Nebel
Children’s Therapy Service
Deborah Berry 950 Office Park Road, Suite 100
241 Madison Street West Des Moines, IA 50265
Waterloo, IA 50703

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Iowa Hospital Association Iowa Optometric Association


Tracy Warner Gary Ellis
100 E. Grand Avenue, Suite 100 1454 30th Street, Suite 204
Des Moines, IA 50309-1835 West Des Moines, IA 50266-1312

Iowa Health Care Association Iowa Podiatric Medical Association


Steve Ackerson Dr. Richard Spencer
Executive Director Spencer Foot & Ankle Clinics
6750 Westown Parkway, Suite 100 110 East McLane
West Des Moines, IA 50266-7726 Osceola, IA 50213

Iowa Assn. for Home Care Iowa Psychological Society


Larry L. Breeding Mark Peltan, Ph.D.
Executive Director Mercy Medical Center-North Iowa
1520 High Street, Suite 203-B 1000 4th Street, SW
Des Moines, IA 50309 Mason City, IA 50401-2921

Iowa Chiropractic Society Iowa Association of Hearing Health Professionals


Gene Handley Bev Thomas, Executive Director
1605 N. Ankeny Boulevard 1001 Office Park Road, Suite 105
Ankeny, IA 50021-4159 West Des Moines, IA 50265

Iowa Pharmacy Association Alliance for the Mentally Ill of Iowa


Thomas Temple, R.Ph., M.S. Margaret Stout
Executive Vice President and CEO 5911 Meredith Drive, Suite E
8515 Douglass, Suite 16 Urbandale, IA 50322
Des Moines, IA 50322
Iowa Psychiatric Society
Iowa Assn. of Homes and Services for the Aging James J. Pullen, M.D.
Dana Petrowsky 1500 Crown Colony Court, Suite 640
President and CEO Des Moines, IA 50310
1701 48th Street, Suite 203
West Des Moines, IA 50266-6723 Iowa Governor’s Developmental Disabilities Council
Rick Shannon
Iowa Association of Community Providers 617 E. 2nd Street
Michelle Wray Des Moines, IA 50309
Abbe Inc.
800 First Street, NW Iowa Academy of Family Physicians
Cedar Rapids, IA 52405 Dr. Dave Carlyle
1215 Duff Avenue
Iowa Dental Association Ames, IA 50010
Larry Carl
Executive Director Iowa Physical Therapy Association
505 5th Avenue, Suite 333 Lorelie Heisinger
Des Moines, IA 50309 Attorney at Law
411 Seasons Drive
Iowa Council of Health Care Centers Waterlou, IA 50701
George W. Appleby
Carney, Appleby, Neilson and Skinner PLC Iowa Physician Assistant Society
303 Locust Street, 400 Homestead Building Don St. John
Des Moines, IA 50309 University of Iowa Behavioral Health
200 Hawkins Drive
Iowa Osteopathic Medical Association Iowa City, IA 52242
Leah McWilliams
Executive Director Iowa Association of Nurse Practitioners
950 12th Street Kathleen Gradoville, C.P.N.P.
Des Moines, IA 50309-1001 Blank School Based Health Center

Iowa-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Iowa Association of Rural Health Clinics Iowa Osteopathic Medical Association


Ed Friedmann Leah McWilliams
1013 1st Street, Box C Executive Director
Redfield, IA 50233 950 12th Street
Des Moines, IA 50309-1001
Iowa Occupational Therapy Association T: 515/283-0002
Angela Hansen-Abbas F: 515/283-0355
161 315th Street E-mail: leah@ioma.org
Perry, IA 50220 Internet address: www.ioma.org

The ARC of Iowa Iowa State Board of Pharmacy Examiners


Vacant Lloyd K. Jessen
Executive Secretary/Director
Des Moines University-Osteopathic Medical Center 400 SW 8th Street, Suite E
Vacant Des Moines, IA 50309-4688
T: 515/281-5944
Iowa Chapter-Nat’l. Association of Social Workers F: 515/281-4609
Jay J. Cayner, A.C.S.W., L.I.S.W. E-mail: debbie.jorgenson@ibpe.state.ia.us
Assistant Hospital Director and Director, Social, Internet address: www.state.ia.us/ibpe
Patient, and Family Services
University of Iowa Hospitals and Clinics Iowa Hospital Association
200 Hawkins Drive J. Kirk Norris
Iowa City, IA 52242 President
100 East Grand Avenue, Suite 100
Iowa Chapter-Am. Academy of Pediatrics Des Moines, IA 50309-1835
Rizwan Z. Shah, M.D. T: 515/288-1955
Children’s Health Center F: 515/283-9366
1212 Pleasant Street E-mail: norrisk@ihaonline.org
Des Moines, IA 50309 Internet address: www.ihaonline.org
Iowa State Association of Counties
Jill Davisson
Supervisor
P.O. Box 2957
Clinton, IA 52733

Executive Officers of State Medical and


Pharmaceutical Societies
Iowa Medical Society
Michael Abrams
Executive Vice President
1001 Grand Avenue West
Des Moines, IA 50265
T: 515/223-1401
F: 515/223-0590
E-mail: mambrams@iowamedical.org
Internet address: www.iowamedical.org

Iowa Pharmacy Association


Thomas R. Temple, R.Ph., M.S.
Executive Vice President and CEO
8515 Douglas
Des Moines, IA 50322-2927
T: 515/270-0713
F: 515/270-2979
E-mail: ipa@iarx.org
Internet address: www.iarx.org

Iowa-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

KANSAS

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/ Child Adult Aged Blind/ Child Adult
Disabled Disabled

Prescribed Drugs ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Inpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Outpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Laboratory & X-ray Service ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Nursing Facility Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Physician Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Dental Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $220,800,602 157,618 $228,920,787

RECEIVING CASH ASSISTANCE TOTAL $99,282,654 61,641


Aged $9,283,080 4,097
Blind/Disabled $82,468,988 30,470
Child $2,944,174 15,227
Adult $4,586,412 11,847

MEDICALLY NEEDY, TOTAL $14,150,472 10,958


Aged $2,617,843 1,251
Blind/Disabled $9,464,393 2,729
Child $802,606 3,799
Adult $1,265,630 3,179

POVERTY RELATED, TOTAL $9,866,701 45,961


Aged $232,385 170
Blind/Disabled $506,336 266
Child $8,430,609 39,595
Adult $697,371 5,930
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $97,500,775 39,058

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Kansas-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Formulary/Prior Authorization

State Department of Social and Rehabilitation Formulary: State currently maintains a formulary
Services, Health Care Policy Division. along with a Preferred Drug List (PDL). (See
www.srskansas.org/hcp/medicalpolicy/pharma for a
D. PROVISIONS RELATING TO DRUGS listing of PDL categories.) The formulary/ PDL is
managed through restrictions on use, preferred
Benefit Design products, and physician profiling. Prior authorization
required for non-PDL products.
Drug Benefit Product Coverage: Products covered:
prescribed insulin and syringe combinatios used for Prior Authorization: State currently has a formal
insulin. Products covered under DME: disposable prior authorization procedure. The individual
needles used for insuline (prior authorization appealing may request an administrative hearing to
required); blood glucose test strips; urine ketone test appeal a prior authorization decision by sending a
strips; total parenteral nutrition; and interdialytic request in writing to:
parenteral nutrition. Products not covered: cosmetics;
fertility drugs; experimental drugs; DESI drugs; and Administrative Hearing Office
drugs not rebated by the manufacturer. 610 S.W. 10th Ave, 2nd Floor
Topeka, KS 66612-1616
Over-the-Counter Product Coverage: Products
covered: analgesics; digestive products; feminine Prescribing or Dispensing Limitations
products; and topical products. Products covered with
restrictions: allergy, asthma, and sinus products Monthly Prescription Limit: 5 single source
(some-for children); cough and cold preparations; and scripts/month.
smoking deterrent products (patches covered for
limited time period). Products not covered: OTC Prescription Refill Limit: As authorized by the
nutritional supplements. prescriber and allowed by statute up to a one-year
period from the date of issuance of the prescription
Therapeutic Category Coverage: Therapeutic for non-controlled drugs. No early refills (<75% Rx
categories covered: anabolic steroids; analgesics (for utilized).
children), antipyretics (for children), NSAIDs;
antibiotics; anticoagulants; anticonvulsants; Monthly Quantity Limit: 31-day supply.
antidepressants; antidiabetic agents; antihistamine
drugs; anti-psychotics; antilipemic agents; Other: Narcotics, Viagra, Cialis, Levitra, Ketorolac,
anxiolytics, sedatives, and hypnotics; cardiac drugs; Toradol Relenza and triptans have other specific
chemotherapy agents; contraceptives; ENT anti- limits.
inflammatory agents; estrogens; hypotensive agents; Drug Utilization Review
misc. GI drugs; sympathominetics (adrenergic); and
thyroid agents. Partial coverage for: prescribed cold PRODUR system implemented in November 1996.
medications; prescribed smoking deterrents. Prior State currently has a DUR Board that meets every
authorization required for: anorectics; growth two months.
hormones; triptans; nasal steroids; PPIs, statins; cox-
II inhibitors; wound products; brand name drugs with Pharmacy Payment and Patient Cost
bioequivalent generics; and all non-preferred drugs. Sharing
Dispensing Fee: $3.40, effective 7/1/02.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program Ingredient Reimbursement Basis: EAC Brand, =
when used in home health care and extended care AWP-13%. Generics, AWP-27%. IV fluids, AWP-
facilities, and through physician payment program 50%. Blood fraction products, AWP-30%.
when used in physician offices.
Prescription Charge Formula: Pharmacies are
Vaccines: Vaccines reimbursed as part of the reimbursed the lesser of usual and customary, MAC,
Vaccines for Children Program. FUL, or acquisition cost (EAC) plus a dispensing
fee.
Unit Dose: Unit dose packaging not reimbursable.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific maximum
allowable cost (MAC) limits on generic drugs.

Kansas-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Override requires prior authorization and MedWatch DUR Contact


form.
Vicki L. Schmidt, Pharmacist
Health Care Policy Division
Incentive Fee: None.
Department of Social and Rehabilitation Services
915 SW Harrison, Rm. 651-South
Patient Cost Sharing: A recipient copay charge of
Topeka, KS 66612-1570
$3.00 (effective 7/02) applies to each new and refill
T: 785/274-4287
prescription not specifically exempted under Federal
F: 785/267-7670
regulations.
E-mail: vixs@srskansas.org
Cognitive Services: Does not pay for cognitive DUR Board
services.
Michael Burke, M.D., Ph.D. (Chair)
Barry Sarvis, R.Ph.
E. USE OF MANAGED CARE Dennis W. Grauer, Ph.D.
John Lowdermilk, R.Ph.
Approximately 105,000 Medicaid Recipients were R. Kevin Bryant, M.D., C.M.D
enrolled in MCOs in FY 2003. Recipients receive Brenda Schewe, M.D.
most pharmaceutical benefits through managed care Roger D. Unruh, D.O.
plans. However, Hemophilia drugs and certain other Linda Kroeger, ARNP, FNP
specific compounds are carved out of managed care. Prescription Price Updating
Managed Care Organizations Mary H.Obley, Pharmacist
First Guard Health Plans 785/296-3981
4001 Blue Pkwy, Suite 300 Medicaid Preferred Drug List Advisory
Kansas City, MO 64130 Committee
888/827-5698
Michael Burke, M.D., Ph.D.
F. STATE CONTACTS Kristen H. Fink, Pharm.D.
Robert Haneke, Pharm.D.
State Drug Program Administrator Glenn Harte, Pharm.D.
Mary H. Obley, Pharmacist Vernon Mills, M.D.
Pharmacy Program Manager Brenda Schewe, M.D.
Health Care Policy Division Donna Sweet, M.D.
Department of Social and Rehabilitation Services Dennis Tietze, M.D.
915 SW Harrison, Rm. 651-South Kenneth Mishler, Pharm.D.
Topeka, KS 66612-1570 Medicaid Drug Rebate Contacts
T: 785/296-3981
F: 785/296-4813 Policy: Mary H. Obley, Pharmacist
E-mail: mho@srskansas.org Pharmacy Program Manager
Internet address: 785/296-3981
www.srskansas.org/hcp/medicalpolicy/pharmacy Technical: Cindy LaClair
New Brand Name Products Contact Rebate Analyst
EDS
Mary H. Obley, Pharmacist 3600 SW Topeka Boulevard, Suite 204
785/296-3981 Topeka, KS 66611
Prior Authorization Contact T: 785/274-5987
F: 785/267-7687
Mary H. Obley, Pharmacist E-mail: cindy.laclair@ksxix.hcg.eds.com
785/296-3981
Claims Submission Contact
EDS
3600 SW Topeka Boulevard, Suite 204
Topeka, KS 66611
T: 785/274-4200
F: 785/267-7687

Kansas-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Medicaid Managed Care Contact Kansas Pharmacists Association


John L. Kiefhaber, Executive Director
Debra Bachmann, R.N. IV
1020 SW Fairlawn Road
Manager, HealthWave Title XIX
Topeka, KS 66604-2275
Department of Social and Rehabilitation Services
T: 785/228-2327
Health Care Policy Division
F: 785/228-9147
915 SW Harrison, Rm. 651-South
E-mail: info@kansaspharmacy.org
Topeka, KS 66612-1570
Internet address: www.kansaspharmacy.org
T: 785/296-3981
F: 785/296-4813
Kansas Association of Osteopathic Medicine
E-mail: djzb@srskansas.org
Charles Wheelen, Executive Director
Mail Order Pharmacy Program 1260 SW Topeka Boulevard
Topeka, KS 66612
None
T: 785/234-5563
Social and Rehabilitation Services F: 785/234-5564
Department Officials E-mail: kansasdo@aol.com
Internet address: www.ostheopathic-kansas.org
Gary J. Daniels, Acting Secretary
Department of Social and Rehabilitation Services
Kansas State Board of Pharmacy
Docking State Office Bldg.
Debra Billingsley, Executive Secretary
915 SW Harrison, 6th Floor
Landon State Office Building
Topeka, KS 66612
900 Jackson, Room 560
T: 785/296-3271
Topeka, KS 66612-1231
F: 785/296-2173
T: 785/296-4056
E-mail: GJD@srskansas.org
F: 785/296-8420
E-mail: pharmacy@ pharmacy.state.ks.us
Scott C. Brunner, Director
Internet address: www.accesskansas.org/pharmacy
Medical Policy/Medicaid
Department of Social and Rehabilitation Services
Kansas Hospital Association
915 SW Harrison, 5th Floor
Tom Bell
Topeka, KS 66612
President
T: 785/296-3773
215 Southeast Eighth Avenue
F: 785/296-0509
P.O. Box 2308
E-mail: scb@srskansas.org
Topeka, KS 66603-2308
T: 785/233-7436
Medical Care Advisory Committee Contact F: 785/233-6955
Nialson Lee, B.S.N., M.H.A E-mail: rfuller@kha-net.org
Administrator, Health Care Systems and Policy/ Internet address: www.kha-net.org
Medical
Department of Social and Rehabilitation Services
915 SW Harrison, Rm. 651-S
Topeka, KS 66612-1570
T: 785/296-4753
F: 785/2964813
E-mail: nxl@srskansas.org

Executive Officers of State Medical and


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

Kansas-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

KENTUCKY 1

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $661,409,737 489,416 $685,229,661

RECEIVING CASH ASSISTANCE, TOTAL $466,733,445 245,159


Aged $37,620,114 15,676
Blind / Disabled $388,598,724 140,619
Child $16,398,100 55,943
Adult $24,116,507 32,921

MEDICALLY NEEDY, TOTAL $21,156,198 20,816


Aged $5,714,524 2,250
Blind / Disabled $4,820,219 1,765
Child $2,774,925 8,607
Adult $7,846,530 8,194

POVERTY RELATED, TOTAL $47,434,056 155,883


Aged $595,876 627
Blind / Disabled $1,664,425 981
Child $41,796,311 136,285
Adult $3,377,444 17,990
BCCA Woman $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $126,086,038 67,558

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

1 The State of Kentucky did not respond to the 2004 NPC Survey. Using CMS data and other source materials, we have, to the extent possible,
updated the Profile and the tables in the other sections of the Compilation. Users should contact the Kentucky Medicaid program to assess the
accuracy and currency of the information included.

Kentucky-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

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


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

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

Benefit Design Formulary/Prior Authorization

Drug Benefit Product Coverage: Products covered: Formulary: Closed Formulary. The Kentucky
prescribed insulin; syringe combinations used for Medicaid Program maintains a closed formulary and
insulin. Products covered with restrictions (i.e., covers all rebated products. The State manages the
require prior authorization): total parenteral nutrition; formulary through a variety of techniques including
and interdialytic parenteral nutrition. Products not the exclusion of products based on contracting issues,
covered: cosmetics; fertility drugs; experimental restrictions on use, prior authorization, algorithms,
drugs; disposable needles used for insulin; blood and preferred products. Prior authorization required
glucose test strips; and urine ketone test strips. for many brand name products with generic
equivalents.
Over-the-Counter Product Coverage: Products
covered with restrictions (i.e., require prior Prior Authorization: State currently has a prior
authorization): allergy, asthma and sinus products; authorization procedure. A formal appeals process is
analgesics; cough and cold preparations; digestive available if a request is denied.
products (H2 and non-H2 antagonists); feminine
products and topical products. Products not covered: Prescribing or Dispensing Limitations
smoking deterrent products.
Prescription Refill Limit: (1) No prescriptions may be
refilled more than 5 times or more than 6 months
Therapeutic Category Coverage: Therapeutic
after the prescription is written. (2) After initial
categories covered: antibiotics; anticoagulants;
filling, one dispensing fee per 30-day period for
anticonvulsants; antidepressants; antidiabetic agents;
designated maintenance drugs.
chemotherapy agents; contraceptives; ENT anti-
inflammatory agents; estrogens; and thyroid agents. Monthly Quantity Limit: For designated classes of
Prior authorization required for: anabolic steroids; maintenance drugs, refills of the original prescription
analgesics, antipyretics, NSAIDs; anoretics; and subsequent prescriptions for these drugs must be
antihistamine drugs; antilipemic agents; anti- prescribed and dispensed in quantities of not less
psychotics; anxiolytics, sedatives, and hypnotics; than a 30 day supply unless the prescriber requests an
cardiac drugs; prescribed cold medications; growth exception to his policy.
hormones; hypotensive agents; misc. GI drugs;
topical steroids; erectile dysfunction products; Drug Utilization Review
Leukotriene inhibitors; Synagis; Respigam; Zetia;
CNS stimulants for ADHD and other disorders;
Avodart; Proscar; anti-fungals for nails; Serotonin PRODUR system implemented in 1987. State
5HT1 Receptor Agonosts; GCSF products; currently has a DUR Board with a quarterly review.
Recombinant Human Erythropoietin agents; and Pharmacy Payment and Patient Cost Sharing
Xolair. Therapeutic categories not covered:
prescribed smoking deterrents; agents for cosmetic
purposes or hair growth and agents to promote Dispensing Fee: $4.51, effective 1/16/01.
fertility.
Ingredient Reimbursement Basis: EAC = AWP-12%.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program Prescription Charge Formula: Reimbursement
when used in home health care and extended care consists of the lowest of: (1) the usual and customary
facilities, and through both the Prescription Drug charge; (2) the FMAC, if any, plus a dispensing fee;
Program and physician payment when used in or (3) the EAC plus a dispensing fee, or (4), SMAC
physician offices. Reimbursement is limited to if any, plus a dispensing fee.
antineoplastic drugs with “J” codes in physician
offices, several antibiotics, Depo-Provera for birth
control.

Kentucky-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Maximum Allowable Cost: State imposes Federal R. Michael Cayce, R.Ph.


Upper Limits as well as State-specific limits on Garry A. Hamm. R.Ph.
generic drugs. Override requires “Brand Necessary,” Dan Yeager, R.Ph. (non-voting)
“Brand Medically Necessary,” or Prior
DUR Contact
Authorization.
Debra Bahr, R.Ph.
Incentive Fee: None. Pharmacy Services Program Manager
Department for Medicaid Services
Patient Cost Sharing: $1.00 CHR Building, 6 W-A
275 East Main Street
Cognitive Services: Does not pay for cognitive Frankfort, KY 40621
services. T: 502/564-7940
F: 502/564-0509
E-mail: Debra.Bahr@ky.gov
E. USE OF MANAGED CARE
Drug Management Review Advisory Board
Approximately 153,000 Medicaid recipients were Richard Arnold, M.D. (Chair)
enrolled in MCOs in FY 2003. Recipients receive Phillip Bressoud, M.D.
pharmaceutical benefits through both the State and Phillip Baier, O.D.
managed care plans. Medications prescribed by a Patricia Freeman, R.Ph., Ph.D.
board certified psychiatrist are carved out of James S. Davis, M.D.
managed care. Karen Barnes, M.D.
Managed Care Organization Janice Sullivan, M.D.
Madonna H. Ringswald, D.O.
Passport Health Plan John Spencer, Pharm.D.
Joyce Schifano, Executive Director Sandra Thornbury
Jacob Hutti, Pharm.D.
F. STATE CONTACTS Misha Glendening, A.R.N.P.
Pam Koob, Ph.D. A.R.N.P.
Medicaid Drug Program Administrator Scott Moody, Pharm.D. (non-voting)
Dan Yeager, R.Ph.
Interim Pharmacy Director New Brand Name Products Contact
Department for Medicaid Services
CHR Building, 6 W-A Debra Bahr, R.Ph.
275 East Main Street 502/564-7940
Frankfort, KY 40621 Prescription Price Updating
T: 502/564-7940
F: 502/564-0509 UNYSIS Provider Services
E-mail: dan.yeager@ky.gov P.O. Box 2106
Internet address: www.chs.ky.us/dms Frankfort, KY 40602
T: 502/226-1140
Prior Authorization Contact F: 502/226-1860
Dan Yeager, R.Ph. Medicaid Drug Rebate Contact
502/564-7940
Betsy Scott
Pharmacy and Therapeutics Advisory Department for Medicaid Services
Committee CHR Building, 6 E-B
Robert C. Hughes, M.D. (Chair) 275 East Main Street
Truman Perry, M.D. Frankfort, KY 40621
Dale E. Toney, M.D. T: 502/564-5472
Christopher A. Cunha, M.D. F: 502/564-3232
Carol Lee Steltenkamp, M.D., M.B.A. E-mail: Betsy.Scott@ky.gov
Connie Gayle White, M.D. (Vice-Chair)
Naren N. James, M.D.
Carmel Wallace, M.D.
Andrew T. Cooley, M.D.
Janet Poe Wright, Pharm.D.

Kentucky-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Claims Submission Contact Bettie Speicher Weyler


Donnie Wilhite
Unisys Provider Services
John Withrow
P.O. Box 2106
Frankfort, KY 40602
T: 502/226-1140 Executive Officers of State Medical and
F: 502/226-1860 Pharmaceutical Societies
Kentucky Medical Association
Medicaid Managed Care Contact William T. Applegate
Executive Vice President
Lorraine Dumas
4965 U.S. Highway 42, Suite 2000
Department of Medicaid Services
Louisville, KY 40222-6301
CHR Building, 6 E-C
T: 502/426-6200
275 E. Main St
F: 502/426-6877
Frankfort, KY 40621
E-mail: member@kyma.org
T: 502/564-4923
Internet address: www.kyma.org
F: 502/564-0223
E-mail: Lorraine.Dumas@ky.gov
Kentucky Pharmacists Association
Mail Order Pharmacy Program Mike Mayes, FACHE
Executive Director
Sate currently has a mail order pharmacy program.
1228 U.S. Highway 127 South
Mail order pharmacy program is open to all Medicaid
Frankfort, KY 40601
recipients. Must use a pharmacy that participates in
T: 502/227-2303
the Kentucky Medicaid Program.
F: 502/227-2854
Department for Medicaid Services Officials E-mail: info@kphanet.org
Internet address: www.kphanet.org
James W. Holsinger, Jr., M.D., Secretary
Cabinet for Health and Family Services
Kentucky State Board of Pharmacy
CHR Building, 5 C-A
Jeffrey L. Osman
275 East Main Street
Interim Executive Director
Frankfort, KY 40621
23 Millcreek Park
T: 502/564-6786
Frankfort, KY 40601-9230
F: 502/564-0274
T: 502/573-1580
F: 502/573-1582
Shannon Turner, Acting Commissioner
E-mail: pharmacy.board@mail.state.ky.us
Department for Medicaid Services
Internet address: www.pharmacy.ky.gov
Sixth Floor
275 East Main Street
Kentucky Society of Health-System Pharmacists
Frankfort, KY 40621
Dwaine K. Green
T: 502/564-4321
Executive Vice President
F: 502/564-0509
One Quality Street
State Advisory Council on Medical Lexington, KY 40507-1428
Assistance T: 859/433-3641
F: 859/257-7297
Frank Butler E-mail: dgree1@uky.edu
Elvin E. Dodson Internet address: www.kshp.org
Bob Gray
William P. Mattingly Kentucky Osteopathic Medical Association
Marsha Mercer J. Tom Underwood, Executive Director
Marcia Morgan 1501 Twilight Trail
Chester A. Nava Jr., D.P.M. (chair) Frankfort, KY 40601
Kristin V. Paul, R.N. T: 502/223-5322
Vickie L. Prichard F: 502/223-4937
William K. Rich, D.M.D Internet address: www.koma.org
Leslie Rogers
Nancy Steele
Suzanne Watkins, O.D.
William T. Watkins, M.D.

Kentucky-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Kentucky Hospital Association


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

Kentucky Association of Health Care Facilities


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

Kentucky-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Kentucky-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

LOUISIANA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/ Child Adult Aged Blind/ Child Adult
Disabled Disabled

Prescribed Drugs ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Inpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Outpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Laboratory & X-ray Service ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Nursing Facility Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Physician Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Dental Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $682,557,080 689,973 $827,713,132

RECEIVING CASH ASSISTANCE, TOTAL $417,471,680 265,688


Aged $102,349,922 40,066
Blind/Disabled $273,812,613 117,247
Child $18,906,266 65,315
Adult $22,402,879 43,060

MEDICALLY NEEDY, TOTAL $9,814,798 6,976


Aged $3,765,950 1,276
Blind/Disabled $3,341,251 1,654
Child $80,023 313
Adult $2,627,574 3,733

POVERTY RELATED, TOTAL $103,843,466 327,000


Aged $2,384,492 1,455
Blind/Disabled $2,321,558 1,603
Child $93,885,845 295,607
Adult $5,251,571 28,335
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $151,427,136 90,309

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Prescribing or Dispensing Limitations

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


physician within 6 months and not to exceed 5 refills.

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


Benefit Design issued for drugs given on a continuing basis, after 5
refills or after 6 months. Maximum quantity for
Drug Benefit Product Coverage: Products covered: prescriptions shall be either 30-day supply or 100
prescribed insulin; disposable needles and syringe unit doses, whichever is greater. Monthly limit of 8
combinations used for insulin; blood glucose test prescriptions per recipient.
strips; and urine ketone test strips. Products covered
as DME: total parenteral nutrition and interdialytic Other: Viagra and other drugs to treat impotence are
parenteral nutrition. Products not covered: limited to a quantity of 6 pills per month.
cosmetics; DESI drugs; fertility drugs; experimental Drug Utilization Review
drugs; and cough and cold preparation.
PRODUR system implemented in April 1996. State
Over-the-Counter Product Coverage: Products not has a DUR Board that meets quarterly.
covered (with limited exceptions): allergy, asthma,
and sinus products; analgesics; cough and cold Pharmacy Payment and Patient Cost Sharing
preparations; digestive products; feminine products;
topical products; and smoking deterrent products. Dispensing Fee: $4.45 on average to $5.77
maximum, effective 7/1/94.
Therapeutic Category Coverage: Therapeutic
categories/products covered: all except cosmetics; Ingredient Reimbursement Basis: EAC = AWP-
cough and cold preparations; DESI drugs; and 13.5% for Independent Pharmacies. AWP-15% for
experimental drugs. Prior authorization required for: chain pharmacies. (Chain pharmacies are defined as
analgesics, antipyretics, and NSAIDs; antibiotics; ownership of more than fifteen (15) Medicaid
anticoagulants; anti-depressants; antidiabetic agents; enrolled pharmacies under common ownership.)
antihistamines; antilipemic agents; anxiolytics,
sedatives, and hypnotics; cardiac drugs; Prescription Charge Formula: Medicaid
contraceptives; ENT anti-inflammatory agents; reimbursement for pharmacy services will be based
estrogens; growth hormones; hypotensive agents; on the lower of:
misc. GI drugs; and sympathominetics (adrenergic). 1. AWP minus 13.5% for independent pharmacies
Partial coverage for: anoretics; prescribed cold and AWP minus 15% for chain pharmacies plus
medications. a dispensing fee for single source products or
multiple source products with no maximum
Coverage of Injectables: Injectable medicines allowable cost limitations or when physician
reimbursable under the Prescription Drug Program authorizes “Brand Medically Necessary” for a
and through physician payment when used in brand name product which has a State MAC or
physician offices. FUL.
2. Louisiana Maximum Allowable Costs (LMAC)
Vaccines: Vaccines reimbursable at cost as part of
or the Federal Upper Limit plus the dispensing
EPSDT service and Vaccines for Children Program.
fee.
Unit Dose: Unit dose packaging reimbursable. 3. AWP for multi-source drugs when lower than
FUL or LMAC.
Formulary/Prior Authorization
4. The provider’s usual and customary charge to
other payors.
Formulary: Open formulary with preferred drug list
(PDL). General management techniques include Maximum Allowable Cost: State imposes Federal
restrictions on use, prior authorization, and preferred Upper Limits as well as State-specific limits on
products. generic drugs. Approximately 800 drugs are listed on
the State-specific MAC list. Override requires
Prior Authorization: State currently has a formal “Brand Necessary” or “Brand Medically Necessary.”
prior authorization procedure but no method of
appealing a prior authorization decision. Incentive Fee: None.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Patient Cost Sharing: $ 0.50 - $3.00 copayment Baton Rouge, LA


depending of the cost of the prescription, effective Susan Hinton, Pharm.D.
7/13/95. New Orleans, LA

Cognitive Services: Does not pay for cognitive Richard A. Soileu, Pharm.D.
services New Iberia, LA

Paul Staab, M.D.


E. USE OF MANAGED CARE Marrero, LA
Does not use MCOs to deliver services to Medicaid Charmaine Venters, M.D.
recipients. Baton Rouge, LA

F. STATE CONTACTS New Brand Name Products Contact

State Drug Program Administrator Mary J. Terrebonne, P.D.


225/342-9768
Mary J. Terrebonne, Pharm.D.
Pharmacy Director Prescription Price Updating
Department of Health & Hospitals Maggie Vick
1201 Capital Access Road, 6th Floor Unisys
P.O. Box 91030 8591 United Plaza Boulevard, Suite 300
Baton Rouge, LA 70821 Baton Rouge, LA 70809
T: 225/342-9768 T:225/237-3251
F: 225/342-1980 F: 225/237-3334
E-mail: mterrebo@dhh.la.gov E-mail: margaret.vick@unisys.com
Internet address: www.lamedicaid.com
Medicaid Drug Rebate Contacts
Department of Health and Hospital
Administration Officials Technical: Timothy Williams, 225/342-5194
Policy: Mary J. Terrebonne, 225/342-9768
Frederick P. Cerise, Secretary Disputes: Katie Landry, 225/342-0427
Department of Health and Hospitals
P.O. Box 629, Bin #2 Claims Submission Contact
Baton Rouge, LA 70821-0629 Doug Hasty
T: 225/342-9500 Project Manager
F: 225/342-9508 Unisys
E-mail: fcerise@dhh.state.la.us 8591 United Plaza Blvd., Suite 300
Ben A. Bearden, Director Baton Rouge, LA 70809
Bureau of Health Services Financing T: 225/237-3391
Department of Health and Hospitals F: 225/237-3334
P.O. Box 91030 E-mail: doug.hasty@unisys.com
Baton Rouge, LA 70821-9030 Mail Order Pharmacy Program
T: 225/342-3891
F: 225/342-9508 State has a voluntary mail order pharmacy program
E-mail: bbearden@dhhmail.dhh-state.la.us open to all Medicaid recipients.

DUR Contact Medicaid Managed Care Contact

Mary J. Terrebonne, Pharm.D. Mary J. Terrebonne, P.D.


225/342-9768 225/342-9768
Medical Care Advisory Committee
DUR Board
Sandra C. Adams (Chairperson)
Edwin Adams, Pharm.D. Brenda Armstrong
Monroe, LA Ralph D. Balentine
Dr. Donnie Batie
Ken Ardoin, Senior Manager Francine Boyles
Westlake, TX Dr. Floyd A. Buras
Jennifer Canaday
Sylvia Heidingsfelder, M.D.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Marcia Daigle Lake Charles, LA


Sen. John L. “Jay” Dardenne, Jr.
Partricia DeMichele James R. Lang
Daily Dupre, Jr. Many, LA
Wanda Ellis W. Chapman Lee, M.D.
Warren Hebert Baton Rouge, LA
Paul Hildreth
Robert D. Horneman Catherine A. McDonald, M.D.
Amelia Lafont Lafayette, LA
Rep. Jerry L. “Luke” LeBlane
Dr. Charles Clinton Lewis Marty R. McKay, R.Ph.
Kay Marcel Alexandria, LA
Dr. Robert L. Marier
June Peach John B. Pope, M.D.
Dr. Keith M. Perrin Shreveport, LA
Ms. Bea Piker
Tawana Pounders Carolyn Tackett
Sean Prados Hammond, LA
Willa Rawls
Sen. J. “Tom” Schedler Ann Henderson Tilton, M.D.
Greg Scott New Orleans, LA
Mary Scott
Richard “Andy” Soileau Roxane Townsend, M.D.
Mary Tonore Baton Rouge, LA
Dr. Leonard Weather, Jr.
Linda Welch Leonard J. Weather, Jr., M.D.
Ms. Ann Williamson New Orleans, LA
Medicaid Pharmaceutical and Therapeutics
Lolie C. Yu, M.D.
Committee
New Orleans, LA
Mr. Joseph Adams, R.Ph.
Pharmacy Advisory Committee
Mandeville, LA
Ken Ardoin
Donnie Batie, M.D. Michelle Wolf-Selfo
Baton Rouge, LA Scott Napoli
Lamar Pritchard
Frederick P. Cerise, M.D. Allan Brinkhaus
Baton Rouge, LA Clovis Burch
Horace Bynum
Richard Doskey, M.D. Wayne T. Harris
Metairie, LA Tim Jacks
Ruth “Cookie” Jean
Blackwell B. Evans, Jr., M.D. Ricky Guidry
New Orleans, LA Carl Aron
Andy Soileau
Conchetta W. Fulton, M.D. Marty McKay
New Orleans, LA Jerry Wallace
Kirt Soileau
Kyle Ardoin
Larry Hebert, M.D. Sandy Blake
Baton Rouge, LA Peggy Van
Jessica Monroe
Charles W. Jastram, Jr., R.Ph. David Osborn
New Orleans, LA Leann Causey
Executive Officers of State Medical and
Ernest W. Kinchen, M.D. Pharmaceutical Societies
Lafayette, LA
Michael L. Kudla, M.D.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Louisiana State Medical Society Baton Rouge, LA 70898-0720


Dave L. Tarver T: 225/928-0026
Executive Vice President F: 225/923-1004
6767 Perkins Road, Suite 100 E-mail: jmatessino@lhaonline.org
Baton Rouge, LA 70808 Internet address: www.laha.org
T: 225/763-8500
F: 225/763-6122
E-mail: executive@lsms.org
Internet address: www.lsms.org

Louisiana Osteopathic Medical Association


Nancy Bellemare, D.O.
President
215 Friedrichs Avenue
Metairie, LA 70005-4516
800/621-1773, ext. 8188
E-mail: info@loma-net.org
Internet address: www.loma-net.org

Louisiana State Board of Pharmacy


Malcolm J. Broussard
Executive Director
5615 Corporate Boulevard, Suite 8E
Baton Rouge, LA 70808-2537
T: 225/925-6496
F: 225/925-6499
E-mail: labp@labp.com
Internet address: www.labp.com

Louisiana Pharmacists Association


Donna Mayeux
Executive Director
234 Joseph Street
P.O. Box 14446
Baton Rouge, LA 70802
T: 225/408-2730
F: 225/381-7424
E-mail: webmaster@louisianapharmacists.com
Internet address: www.louisianapharmacists.com

Louisiana Society of Health-System Pharmacists


Tommy Mannino
President
8550 United Plaza Boulevard, Suite 1001
Baton Rouge, LA 70809
T: 225/922-4520
F: 225/922-4611
E-mail: lshp@pncpa.com
Internet address: www.lshp.org

Louisiana Hospital Association


John A. Matessino
President and CEO
9521 Brookline Avenue

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National Pharmaceutical Council Pharmaceutical Benefits 2004

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National Pharmaceutical Council Pharmaceutical Benefits 2004

MAINE 1

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients
TOTAL $250,331,526 224,664 $268,547,563

RECEIVING CASH ASSISTANCE, TOTAL $108,471,190 60,793


Aged $11,438,641 4,719
Blind/Disabled $82,399,461 28,595
Child $2,552,699 10,124
Adults $12,080,389 17,355

MEDICALLY NEEDY, TOTAL $6,010,987 2,105


Aged $4,459,097 1,633
Blind/Disabled $1,488,866 372
Child $19,514 40
Adults $43,510 60

POVERTY RELATED, TOTAL $54,374,249 60,765


Aged $14,428,282 8,407
Blind/Disabled $27,044,560 9,424
Child $12,399,263 41,078
Adult $502,144 1,856
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $81,475,100 101,001

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report FY 2002 and CMS-64 Report, FY 2003.

1
The State of Maine did not respond to the 2004 NPC Survey. Using CMS data and other source materials, we have, to the
extent possible, updated the profile and the tables in the other sections of the Compilation. Users should contact the Maine
Medicaid Program to assess the accuracy and currency of the information included.

Maine-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Formulary/Prior Authorization


State Department of Human Services, Bureau of Formulary: Closed formulary with restrictions on
Medical Services. use, prior authorization, and preferred products.
(The Maine Care Preferred Drug List can be seen at
www.ghsinc.com.)
D. PROVISIONS RELATING TO DRUGS
Prior Authorization: State currently has a formal
Benefit Design prior authorization procedure. Prior authorization
Drug Benefit Product Coverage: Products covered: may be obtained in the case of necessary
prescribed insulin; disposable needles and syringe exceptions. Fair hearing appeal of denials through
combinations used for insulin (not covered for the Office of Administrative Hearings. State has no
nursing home patients); blood glucose test strips formal prior authorization committee.
(with HbA1e values); urine ketone test strips.
Products not covered: cosmetics; fertility drugs; Prescribing or Dispensing Limitations
experimental drugs; total parenteral nutrition; Monthly Prescription Limit: 5 brand name scripts
interdialytic parenteral nutrition (part of procedure); per month
vitamins and vitamin preparations (except
pregnancy); and injectables when oral medication is Monthly Quantity Limit: 34-day for brand name
available for equally effective treatment. drugs and 90 days for generic drugs per month.

Over-the-Counter Product Coverage: Products Prescription Refill Limit: maximum of 11 refills


covered: allergy, asthma, and sinus products; per prescription.
analgesics; digestive products (non H2 antagonists);
topical products; and feminine products. Products Drug Utilization Review
covered with restrictions: H2 antagonists (limited
coverage after 1/1/01); smoking deterrent products PRODUR system implemented in 1995. State
(by Rx only). Products not covered: cough and cold currently has a DUR Board that meets 12 times per
preparations. year.

Therapeutic Category Coverage: Therapeutic Pharmacy Payment and Patient Cost


categories covered: (prior authorization required): Sharing
anabolic steroids; analgesics, antipyretics, and Dispensing Fee: $3.35 - $12.50 (Effective
NSAIDs; anoretics; antibiotics anticoagulants; 1/20/2004)
anticonvulsants; anti-depressants; antidiabetic
agents; antihistamine drugs; antilipemic agents; Ingredient Reimbursement Basis: EAC = AWP-
anti-psychotics; anxiolytics, sedatives, and 15%.
hypnotics; cardiac drugs; chemotherapy agents; Prescription Charge Formula: Lowest of usual and
contraceptives; ENT anti-inflammatory agents; customary, FUL, AWP-15%, or Maine MAC.
estrogens; growth hormones; hypotensive agents; Maine MAC includes 1,232 drug products in
misc. GI drugs; prescribed smoking deterrents; addition to FUL products.
sympathominetics (adrenergic); thyroid agents;
injectable arthritis medications; acute migraine Maximum Allowable Cost: State imposes Federal
medications; Synvisc; antifungals; EPO; Synagis, Upper Limits as well as State-specific limits on
and erectile dysfunction products. generic drugs. Override requires prior
authorization.
Coverage of Injectables: Injectable medicines Incentive Fee: None.
reimbursable through the Prescription Drug
Program when used in home health care and Patient Cost Sharing: $2.50 per script up to a
extended care facilities and in physician offices. maximum of $25.00 per month.
Cognitive Services: State does not pay for cognitive
Vaccines: Vaccines reimbursable based on cost as services.
part of the EPSDT service (admin. fees), as part of
the Children’s Health Insurance Program, and as
part of the Vaccines for Children Program.

Unit Dose: Unit dose packaging not reimbursable.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

E. USE OF MANAGED CARE Andy Cook, M.D.


Laurie Roscoe, R.Ph.
State does not use managed care organizations to Reggie Gracie, R.Ph.
provide service services to Maine Medicaid Jessica R. Osterheld, M.D.
beneficiaries. Approximately 150,000 Medicaid
recipients were enrolled in primary care case New Brand Name Products Contact
management in 2003. Medicaid recipients enrolled
in primary care case management receive Bruce McClenahan
pharmaceutical benefits through the State. 866/796-2463

Prescription Price Updating


F. STATE CONTACTS
Bruce McClenahan
State Drug Program Administrator 866/796-2463
Bruce McClenahan Medicaid Drug Rebate Contact
Pharmacy Unit Manager
Department of Human Services Rossi Rowe
Bureau of Medical Services Insurance Recovery/ Drug Rebate Manager
11 SHS, 442 Civic Center Drive Department of Human Services
Augusta, ME 04333 Bureau of Medical Services
T: 866/796-2463 11 SHS, 442 Civic Center Drive
F: 207/287-8601 Augusta, ME 04333
E-mail: bruce.mcclenahan@maine.gov T: 207/287-1838
Internet address: www.maine.gov/bms F: 207/287-1788
E-mail: rossi.rowe@maine.gov
Prior Authorization Contact
Bruce McClenahan Claims Submission Contact
866/796-2463 Marcia Pykare
Manager of Data Processing
Pharmacy Advisory Group Goold Health Systems
Alroy Chow, M.D. P.O. Box 1090
Tim Clifford, M.D. Augusta, ME 04332-1090
Edward Ervin, M.D. T: 207/622-7153
Jabbar Fazeli, M.D. F: 207/623-5125
Thomas Hayward, M.D. E-mail: movkare@ghsinc.com
Lawrence Losey, M.D.
James Raczek. M.D. Medicaid Managed Care Contact
John Grotton, R.Ph. Bruce McClenahan
Paula Knight, R.Ph. 866/796-2463
Dennis Lyons, R.Ph.
Steve McPike, R.Ph. Mail Order Pharmacy Program
Gary Roy, R.Ph.
State has a mail order Medical Assistance
DUR Contact pharmacy program.
Bruce McClenahan Disease Management Program/Initiative
866/796-2463 Contact
Maine DUR Board Bruce McClenahan
866/796-2463
Timothy Clifford, M.D.
William Alto, M.D.
Michael Ouellette, R.Ph.
James Demosthenes, R.Ph.
Julie Pease, M.D.
Syd Sewall, M.D.
Gary Roy, R.Ph.
Robert Weiss, M.D.
Jabbar Fazeli, M.D.

Maine-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Human Services Department Officials Maine Board of Pharmacy


Kelly L. Mclaughlin
John R. Nichols, Commissioner
Office of Licensing and Registration
Department of Human Services
35 State House Station
State House Station 11
Augusta, ME 04333
221 State Street
T: 207/624-8620
Augusta, ME 04333-0011
F: 207/624-8637
T: 207/287-1921
E-mail: kelly.l.mclaughlin@maine.gov
F: 207/287-3005
Internet address: www.maine.us/prf/olr/
E-mail: jack.r.nichols@maine.gov
Internet address: www.maine.gov/dhs
Maine Hospital Association
Steve Michaud
Christine Gianopoulos, Acting Director
President
Bureau of Medical Services
33 Fuller Road
Department of Human Services
Augusta, ME 04330
State House Station 11
T: 207/622-4794
442 Civic Center Drive
F: 207/622-3073
Augusta, ME 04333-0011
E-mail: smichaud@themha.org
T: 207/287-2674
Internet address: www.themha.org
F: 207/287-2675
E-mail: christine.gianopoulos@maine.gov
Maine Health Care Association
Internet address: www.maine.gov/bms
Richard A. Erb
President and CEO
Executive Officers of State Medical and 317 State Street
Pharmaceutical Societies Augusta, ME 04330
Maine Medical Association T: 207/623-1146
Gordon Smith, Esq. F: 207/623-4080
Executive Vice President E-mail: rerb@mehca.org
Frank O. Stred Building Internet address: www.mehca.org
P. O. Box 190
Manchester, ME 04351
T: 207/622-3374
F: 207/622-3332
E-mail: info@mainemed.com
Internet address: www.mainemed.com

Maine Pharmacy Association


Polly LeVasseur, President
127 Pleasant Hill Road
Scarborough, ME 040704
T: 207/396-5340
F: 207/396-5341
E-mail: levasp@mmc.org
Internet address: www.mparx.com

Maine Osteopathic Association


Kellie Miller, M.S.
Executive Director
693 Western Avenue, #1
Manchester, ME 04351
T: 207/623-1101
F: 207/623-4228
E-mail: kmiller@mainedo.org
Internet address: www.mainedo.org

Maine-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

MARYLAND

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $320,313,995 181,101 $429,589,193

RECEIVING CASH ASSISTANCE, TOTAL $177,261,021 84,026


Aged $36,606,581 16,294
Blind / Disabled $134,096,117 51,811
Child $3,025,652 7,317
Adult $3,484,807 8,561
Unknown $47,864 43

MEDICALLY NEEDY, TOTAL $79,642,289 36,286


Aged $51,496,176 18,001
Blind / Disabled $22,625,834 11,248
Child $3,390,163 2,816
Adult $2,130,116 4,221

POVERTY RELATED, TOTAL $43,538,946 47,229


Aged $14,076,445 8,115
Blind / Disabled $17,110,997 5,620
Child $11,615,154 26,700
Adult $736,350 6,794
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $19,871,739 13,560

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Maryland-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Coverage of Injectables: Injectable medicines


State Department of Health and Mental Hygiene, reimbursable through the Prescription Drug
Division of Health Care Financing. Program when used in home health care and
extended care facilities, and through both the
D. PROVISIONS RELATING TO DRUGS Prescription Drug Program and physician payment
when used in physician offices.
Benefit Design
Vaccines: Vaccines reimbursable as part of the
Drug Benefit Product Coverage: Products covered: Vaccines for Children Program.
legend drugs; prescribed insulin; disposable needles
and syringe combinations used for insulin; total Unit Dose: Unit dose packaging not reimbursable.
parenteral nutrition; and interdialytic parenteral
nutrition (must be medically necessary). Products Formulary/Prior Authorization
covered under DME: blood glucose test strips;
urine ketone test strips. Products not covered: Formulary: Open formulary with a preferred drug
cosmetics; fertility drugs; experimental drugs; list (PDL) managed through preferred products and
DESI drugs; prescriptions and injections for central prior authorization. Prior authorization required for
nervous system stimulants; food supplements or all non-PDL products.
infant formulas; products for which Federal
financial participation is not allowed, i.e., "less than Prior Authorization: State currently has a prior
effective" drugs and products whose manufacturers authorization procedure. A general appeals
have not signed rebate agreements; and certain procedure is available when a physician can
other items as specified in the State's Medicaid provide additional information to justify the
Plan. medical necessity of a particular product.
Over-the-Counter Product Coverage: Products Preauthorization is needed for any prescription with
covered: contraceptives; oral ferrous sulfate; a usual and customary charge exceeding $400.
allergy, asthma, and sinus products (specific Prior authorization is also needed for early refills,
preferred products); analgesics (enteric coated nutritional supplements, brand medically necessary
aspirin only); H2 antagonists (specific preferred and excessive quantities.
products). Products not covered: cough and cold
preparations; non H2 antagonists; feminine
products (except contraceptives); topical products; Prescribing or Dispensing Limitations
and smoking deterrent products.
Prescription Refill Limit: Maximum of eleven
Therapeutic Category Coverage: Therapeutic refills. The original prescription and its refills may
categories covered*: anabolic steroids; analgesics, not exceed a 360-day supply.
antipyretics, NSAIDs; antibiotics; anticoagulants;
anticonvulsants; antidepressants; antidiabetic Monthly Quantity Limit: The amount of medication
agents; antihistamine drugs; antilipemic agents; to be dispensed on a prescription at one time is
anti-psychotics; anxiolytics, sedatives, and limited to a less than 34-day supply except for
hypnotics; cardiac drugs; chemotherapy agents; specific maintenance drugs for chronic conditions,
contraceptives; ENT anti-inflammatory agents; where up to a 100-day supply may be dispensed at
estrogens; hypotensive agents; misc. GI drugs; one time.
sympathominetics (adrenergic); and thyroid agents.
Partial coverage for: prescribed legend cold Drug Utilization Review
medications; prescribed legend smoking deterrents.
Prior authorization required for: growth hormones; PRODUR system implemented January 1993. State
synagis; and nutritional supplements for tube-fed currently has a DUR Board with a quarterly review.
recipients. Therapeutic categories not covered:
anorectics.

*Prior authorization required for all drugs not on


the preferred drug list.

Maryland-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Pharmacy Payment and Patient Cost Helix Family Choice, Inc.


Sharing 8094 Sandpiper Circle
Baltimore, MD 21236
Dispensing Fee: $2.69 - $4.69 as of July 2004.
410/933-3021
$2.69 - non-PDL Brand.
$3.69 - PDL Generic
Jai Medical Systems, Inc.
$3.69-Nursing Home non-PDL
5010 York Road
Brand
Baltimore, MD 21212
$4.69 - Nursing Home PDL or
410/433-2200
Generic
Maryland Physicians Care MCO
7104 Ambassador Road
Ingredient Reimbursement Basis: Estimated
Suite 100
Acquisition Cost (EAC) equals/lowest of:
Baltimore, MD 21244
1. Wholesale Acquisition Cost (WAC) plus 8%. 410/277-9710
2. Direct cost plus 8%.
Diamond Plan
3. Distributor's price plus 8%. Coventry Health Care of Delaware, Inc.
4. Average Wholesale Price (AWP) minus 12%. Ambassador Center D
7125 Ambassador Road
Prescription Charge Formula: Reimbursement will Suite 100
be the lower of: (1) the calculated ingredient cost Woodlawn, MD 21244
plus a dispensing fee; (2) the usual and customary 866/212-5305
fee.
Priority Partners MCO
Maximum Allowable Cost: State imposes Federal Baymeadow Industrial Park
Upper Limits as well as State-specific limits on 6704 Curtis Court
generic drugs. Approximately 1,000 drugs are Glen Burnie, MD 21060
listed on the State-specific MAC list. Override 410/424-4400
requires “Brand Medically Necessary” and a
MedWatch form documenting the reason for the Ameri Group
request. 857 Elkridge Landing Road, #300
Incentive Fee: $1.00 higher for dispensing a lower Linthicum, MD 21090
cost multisource product. 410/859-5800

Patient Cost Sharing: Copayment = $2.00 for


F. STATE CONTACTS
Brands not on the PDL; $1.00 for generics and
drugs on the PDL. Does not apply to managed
care, family planning, nursing home residents, State Drug Program Administrator
recipients under 21 years old, or generic drugs.
Joseph L. Fine
Director
Cognitive Services: Does not pay for cognitive
Maryland Pharmacy Program
services.
DHMH, Office of Operation, Eligibility, and
Pharmacy
E. USE OF MANAGED CARE 201 West Preston Street, Room 407
Baltimore, MD 21201
Approximately 471,000 Medicaid recipients were T: 410/767-1455
enrolled in MCOs in FY 2003. Recipients receive F: 410/333-5398
pharmaceutical benefits through the State and E-mail: jfine@dhmh.state.md.us
managed care plans. (Mental health drugs are Internet address:
“carved out” of managed care.) www.dhmh.state.md.us/mma/mpap

Managed Care Organizations


United Healthcare Family First
Lyndwood Executive Center
6095 Marshalee Drive
Elkridge, MD 21075
800/368-3400

Maryland-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

New Brand Name Products Contact Medicaid Drug Rebate Contacts


Frank T. Tetkoski, P.D. Policy: Jeffrey Gruel
Pharmacy Consultant 410/767-1455
Maryland Pharmacy Program
DHMH Disputes:
201 West Preston Street, Room 409 Barry Pope
Baltimore, MD 21201 Rebate Pharmacist
T: 410/767-1460 First Health Services Corporation
F: 410/333-5398 Montgomery Park Business Center
E-mail: tetkoskif@dhmh.state.md.us 1800 Washington Boulevard, Suite 420
Baltimore, MD 21230
T: 410/263-7048
Prior Authorization Contact F: 410/263-7062
Tuong A. Nguyen, P.D.
Consultant Pharmacist Claims Submission Contact
Maryland Pharmacy Program
First Health Services Corporation
DHMH
Division of Claims Processing
201 W. Preston St.
James Demery
Baltimore, MD 21201
Manager, Pharmacy Services
T: 410/767-5701
201 W. Preston St.
F: 410/333-5398
Baltimore, MD 21201
E-mail: nguyent@dhmh.md.us
T: 410/767-6028
DUR Contact F: 410/333-5398
E-mail: demeryj@dhmh.state.md.us
Jeffrey Gruel
Deputy Director
DHMH Medicare Managed Care Contact
Maryland Pharmacy Program
Jim Gardner
201 W. Preston Street, Room 408
Chief
Baltimore, MD 21201
Division of Health Choice Management
T: 410/767-1455
201 W. Preston St., Room 208
F: 410/333-5398
Baltimore, MD 21201
E-mail: gruelj@dhmh.state.md.us
410/767-1482

DUR Board Mail Order Pharmacy Benefit


Deneen Bowlin, M.D. None
John Boronow, M.D., (Vice Chair)
Stephen Wienner, R.Ph.
Steven J. Kravet, M.D. Expanded Drug Coverage Program
Lori Fantry, M.D., M.P.H. Joseph L. Fine
Vincent Ferrari, R.Ph. (Chair) 410/767-1455
Steve A. Anifowshe, R.Ph.
Elliot S. Gottlieb, R.Ph. Maryland Medical Advisory Committee
Bernard J. Lechman, R.Ph.
Kevin Lindamood
Cynthia Demarest
Prescription Price Updating Lori Doyle
Mark Levi
First DataBank
1111 Bayhill Dr. Miguel McInnis
San Bruno, CA 94066 Jacquelyn Rose, M.D.
Lynda E. Meade
T: 415/588-5454
F: 415/827-4578 Irona Pope
Virginia Keane, M.D.
Frances Knoll
Thomas Myers
David Ward
Grisele Booker
Michael Douglas

Maryland-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Harry S.Goodman, D.M.D. Executive Officers of State Medical and


Peter Perini Pharmaceutical Societies
Charles I. Shubin, M.D.
Maryland State Medical Society
Josie Thomas
T. Michael Preston
Kate Tumulty, R.N.
Executive Director
John J. Hafer
1211 Cathedral Street
Delores G. Kelley
Baltimore, MD 21201
Eric M. Bromwell
T: 410/539-0872
Robert A. Costa
F: 410/547-0915
Shirley Nathan-Pulliam
E-mail: mpreston@medchi.org
Kevin M. McGuire (ex-officio))
Internet address: www.medchi.org
Pamela W. Barclay (ex-officio)
Frances B. Phillips, R.N. (ex-officio)
Maryland Association of Osteopathic Physicians
Randi Braman
Health and Mental Hygiene Department President
Officials 3603 Southside Drive
Phoenix, MD 21131
S. Anthony McCann, Secretary
T: 410/683-8100
Department of Health and Mental Hygiene
F: 410/683-8200
201 W. Preston Street
E-mail: thebramans@aol.com
Baltimore, MD 21201
Internet address: www.maops.com
T: 410/225-6505
F: 410/161-6489
Maryland Pharmacists Association
E-mail: samccann@dhmh.state.md.us
Howard Schiff
Executive Director
John Folkemer
650 West Lombard Street
Deputy Secretary for Health Care Financing
Baltimore, MD 21201
Department of Health and Mental Hygiene
T: 410/727-0746
201 W. Preston Street
F: 410/727-2253
Baltimore, MD 21201
E-mail: hschiff@marylandpharmacist.org
T: 410/767-5806
Internet address: www.marylandpharmacist.org
F: 410/333-7505
E-mail: jfolkemer@dhmh.md.state.us
Maryland Society of Health-System Pharmacists
Bruce Gordon, President
Medical Assistance Staff Committee 8480-M Baltimore National Pike, Ste. 252
Members Ellicott City, MD 21042
Joseph Fine, Director T: 410/465-9975
Maryland Pharmacy Program F: 410/465-7073
201 W. Preston Street E-mail:bgscuba@aol.com
Baltimore, MD 21201 Internet address: www.mshp.org

Frank Tetkoski, P.D. Maryland State Board of Pharmacy


Services and Preauthorization LaVerne G. Naesea
Maryland Pharmacy Program Executive Director
201 W. Preston Street, Room 409 4201 Patterson Avenue
Baltimore, MD 21201 Baltimore, MD 21215-2299
T: 410/764-4755
Phil Cogan F: 410/358-6207
Preferred Drug List E-mail: mdbop@dhmh.state.md.us
Maryland Pharmacy Program Internet address:
201 W. Preston Street www.dhmh.state.md.us/pharmacyboard
Baltimore, MD 21201

Tuong Nguyen, P.D.


Maryland Pharmacy Program
201 W. Preston St.
Baltimore, MD 21201

Maryland-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Association of Maryland Hospitals and Health


Systems
Calvin M. Pierson, President
6820 Deerpath Road
Elkridge, MD 21075-6234
T: 410/379-6200
F: 410/379-8239
E-mail: cpierson@mhaonline.org
Internet address: www.mdhospitals.org

Health Facilities Association of Maryland


Adele Wilzack, President
7060 Oakland Mills Road, Suite M
Columbia, MD 21046
T: 410/792-4390
T: 301/490-8413
F: 410/792-4617
E-mail: awilzack@hfam.org
Internet address: www.hfam.org

Maryland-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

MASSACHUSETTS

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $952,790,939 659,626 $946,210,618

RECEIVING CASH ASSISTANCE TOTAL $464,206,888 225,282


Aged $50,116,594 26,400
Blind/Disabled $381,221,991 126,509
Child $9,530,411 43,726
Adult $23,337,892 28,647

MEDICALLY NEEDY, TOTAL $38,451,280 16,745


Aged $16,299,026 8,974
Blind/Disabled $22,152,254 7,771
Child $0 0
Adult $0 0

POVERTY RELATED, TOTAL $272,625,841 220,501


Aged $67,368,453 29,267
Blind/Disabled $165,887,679 49,900
Child $36,950,055 136,765
Adult $2,419,654 4,569
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $177,506,930 197,098

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Massachusetts-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Coverage of Injectables: Injectable medicines


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

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


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

Drug Benefit Product Coverage: Products covered: Unit Dose: Unit dose packaging not reimbursable.
prescribed insulin. Products covered (except in
LTC facilities): disposable needles and syringe Formulary/Prior Authorization
combinations used for insulin; blood glucose test
strips; urine ketone test strips. Products covered Formulary: Open formulary managed through
with restrictions: total parenteral nutrition (prior restrictions on use, prior authorization, and
authorization required). Products not covered: physician profiling.
cosmetics; fertility drugs; experimental drugs; Prior Authorization: State currently has a prior
interdialytic parenteral nutrition; DESI drugs; authorization procedure. A recipient may file a
legend vitamins not on Drug List, non-legend drugs request for a fair hearing to appeal a prior
not on Drug List; propoxyphene-containing authorization decision.
products and products rated by the FDA as less-
than-effective. Prescribing or Dispensing Limitations
Over-the-Counter Product Coverage: Products Prescription Refill Limit: Prescription may be
covered with restrictions (limited OTC list-generics refilled, as authorized, with a limit of up to 11
only- not covered in LTC facilities): allergy, refills from the filling of the original prescription
asthma and sinus products; analgesics; cough and Monthly Quantity Limit: Schedule II and III drugs
cold preparations; digestive products; feminine are limited to a 30-day supply, except Ritalin and
products and topical products. Products not Dexedrine, which may be dispensed up to a 60-day
covered: smoking deterrent products. supply.
Therapeutic Category Coverage: Therapeutic Monthly Dollar Limits: None.
categories covered: anabolic steroids; antibiotics;
anticoagulants; chemotherapy agents; Drug Utilization Review
contraceptives; estrogens, and thyroid agents. Prior PRODUR system implemented in October 1995.
authorization required for: growth hormones; State currently has a DUR Board with a quarterly
Erythropoeitin; and selected biotech drugs. Partial review.
coverage for: prescribed cold medications. Partial
coverage with prior authorization required for: Pharmacy Payment and Patient Cost
analgesic, antipyretics, and NSAIDs; Sharing
anticonvulsants; anti-depressants; antidiabetic
agents; antihistamines; antilipemic agents; anti- Dispensing Fee: $3.00 (basic) plus $1.00-$2.00
psychotics; anxiolytics, sedatives, and hypnotics; additional for compounded Rx’s, effective
cardiac drugs; ENT anti-inflammatory agents; 1/1/2004.
hypotensive agents; misc. GI drugs; and
sympathominetics (adrenergic). Therapeutic Ingredient Reimbursement Basis: EAC = WAC +
categories not covered: anoretics; prescribed 5%.
smoking deterrents; weight loss or gain
medications; medications to treat sexual
dysfunction; experimental or investigational drugs;
and less than effective drugs.

Massachusetts-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Prescription Charge Formula: Payment shall be for F. STATE CONTACTS


the lowest of:
State Drug Program Administrator
1. EAC plus dispensing fee;
Paul L. Jeffrey
2. The usual and customary charge defined as Director of Pharmacy
the lowest price charged or accepted by a Office of Medicaid
provider for any payor; 600 Washington Street, 5th Floor
3. FULP plus a dispensing fee; or Boston, MA 02111
T: 617/210-5319
F: 617/210-5865
4. MULP plus a dispensing fee.
E-mail: pjeffrey@masmail.state.ma.us
Internet Address: www.state.ma.us/dma
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
Prior Authorization Contact
generic drugs. Override requires “Dispense as
Written,” and/or “Brand Medically Necessary” plus Paul L. Jeffrey
prior authorization. 617/210-5319

Patient Cost Sharing: Copayment = $3.00 (Brands) DUR Contact


and $1.00 (Generics), effective 2/1/2004.
Exceptions include: Paul L. Jeffrey
617/210-5319
− Institutionalized patients
New Brand Name Products Contact
− Children under age 19
Christopher T. Burke
− Pregnant and postpartum women Policy Analyst
− Hospice care Office of Medicaid
600 Washington Street, 5th Floor
− Family planning items Boston, MA 02111
T: 617/210-5592
Incentive Fee: None.
F: 617/210-5597
Cognitive Services: Does not pay for cognitive E-mail: christoper.burke@massmail.state.ma.us
services.
Prescription Price Updating
E. USE OF MANAGED CARE First Data Bank
111 Bayhill Drive, Suite 350
Approximately 270,000 Medicaid recipients were San Bruno, CA 94066
enrolled in MCOs in FY 2003 with another 324,000 T: 650/588-5454
enrolled in pre-paid health plans (PHPs) and F: 650/827-4578
304,000 in PCCM.. Recipients receive
pharmaceutical benefits through managed care Medicaid Drug Rebate Contacts
plans. Enrollees in the PCCM program receive
pharmaceutical benefits from the State. Martha Kessenich
Rebate Analyst
ACS State Healthcare
Managed Care Organization 365 North Ridge Road, Suite 400
Primary Care Clinician Plan Atlanta, GA 30350
Boston Medical Center HealthNet Plan T: 800/358-2381
Fallon Community Health Plan F: 770/730-5198
Neighborhood Health Plan Claims Submission Contact
Network Health
ACS State Healthcare
365 North Ridge Road, Suite 400
Atlanta, GA 30350
T: 800/358-2381
F: 770/730-5198

Massachusetts-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Medicaid Managed Care Contact Massachusetts Osteopathic Society, Inc.


William Seeglitz
President
Kate Willrich-Nordahl, Director
P.O. Box 487
Massachusetts Health MCO Program
Winchester, MA 01890
Department of Public Health
781/721-9900
250 Washinton Street, 6th Floor
E-mail: nocdos@shore.net
Boston, MA 02108
T: 617/624-5693
Massachusetts Board of Registration in Pharmacy
F: 617/624-5698
Charles R. Young
E-mail: kate.willrich-nordahl@state.ma.us
Executive Director
239 Causeway Street, Suite 500
Mail Order Pharmacy Benefit Boston, MA 02114
None T: 617/727-9953
F: 617/727-2197
Executive Offices of Health and Human E-mail: james.d.coffey@state.ma.us
Services Internet address: www.state.ma.us/reg/boards/ph
Ronald Preston, Secretary Massachusetts Society of Health-Systems
Executive Office of Health and Human Services Pharmacists
One Ashburton Place, Room 1109 Trisha LaPointe
Boston, MA 02108 President
T: 617/727-0077 500 West Commings Park, Suite 3475
F: 617/727-5134 Woburn, MA 01801
E-mail: ronald.preston@state.ma.us T: 781/937-0175
Internet address: www.masscares.org F: 781/937-0176
E-mail: admin@mashp.org
Beth Waldman, Director Internet address: www.mashp.org
Division of Medicaid Assistance
600 Washington Street Massachusetts Hospital Association
Boston, MA 02111 Ronald M. Hollander
T: 617/210-5690 President
F: 617/210-5697 Five New England Executive Park
E-mail: bwaldman@nt.dma.state.ma.us Burlington, MA 01803
Internet address: www.state.ma.us/dma T: 781/272-8000
F: 781/272-0466
Executive Officers of State Medical and E-mail: info@mhalink.org
Pharmaceutical Societies Internet address: www.mhalink.org
Massachusetts Medical Society
Corrine Broderick Massachusetts Extended Care Federation
Executive Vice President Abraham E. Morse
860 Winter Street President
Waltham Woods Corporate Center 2310 Washington Street
Waltham, MA 02451-1411 Newton Lower Falls, MA 02462
T: 781/893-4610 T: 617/558-0202
F: 781/893-9136 F : 617/558-3546
E-mail: broderick@massmed.org E-mail: amorse@mecf.org
Internet address: www.massmed.org Internet address: www.mecf.org

Massachusetts Pharmacists Association


Carmelo Cinqueonce
Executive President
500 West Cummings Park, Suite 3475
Woburn, MA 01801
T: 781/933-1107
F: 781/933-1109
E-mail: staff@masspharmacists.org

Massachusetts-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

MICHIGAN
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/ Child Adult Aged Blind/ Child Adult
Disabled Disabled

Prescribed Drugs ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Inpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Outpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Laboratory & X-ray Service ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Nursing Facility Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Physician Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Dental Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $674,898,273 577,785 $758,266,989

RECEIVING CASH ASSISTANCE TOTAL $307,384,075 196,929


Aged $37,319,381 18,461
Blind/Disabled $258,120,665 128,992
Child $3,777,147 21,894
Adult $8,166,882 27,582

MEDICALLY NEEDY, TOTAL $38,770,065 50,815


Aged $9,855,071 5,560
Blind/Disabled $15,916,105 5,625
Child $2,502,941 10,303
Adult $10,495,948 29,327

POVERTY RELATED, TOTAL $39,642,975 125,509


Aged $2,192,596 1,436
Blind/Disabled $16,721,292 5,860
Child $16,792,151 91,350
Adult $3,936,936 26,863
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $289,101,158 204,532

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Michigan-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Coverage of Injectables: Injectable medicines


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

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


fee/or vaccine replacement as part of the EPSDT
Benefit Design service, the Children Health Insurance Program,
and the Vaccines for Children Program.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Unit Dose: Unit dose packaging reimbursable.
combinations used for insulin; blood glucose test
strips; and urine ketone test strips. Products covered Formulary/Prior Authorization
with restrictions: total parenteral nutrition (prior
authorization for equipment and supplies) and Formulary: Closed formulary and a preferred drug
interdialytic parenteral nutrition (prior authorization list (PDL). (See www.michigan.fhsc.com for
required for self administration). Prior authorization listing of drugs on the PDL.) Formulary managed
required for: brand name products equivalent to through restrictions on use, prior authorization
MACs; Accutane & Retin-A; Dexedrine and requirements, age/gender editing, and clinical
Adderall; Persantine; Lactulose (Cephulac); editing for “first line” therapy.
Methylphenidate (selected ages); selected
benzodiazepines; Epogen administered in the home Prior Authorization: State currently has a formal
setting; dietary formulas; and drugs not listed on the prior authorization procedure. Beneficiaries have a
formulary. Products not covered: cosmetics; right to appeal prior authorization decisions on the
fertility drugs; and experimental drugs. basis of medical necessity. Informal review of
additional information can be conducted at any
Over-the-Counter Product Coverage: Products time. Beneficiaries also have fair hearing rights to
covered with restrictions (only selected products in appeal denial of coverage for an excluded product.
each category): allergy, asthma and sinus products
(antihistamines); analgesics (payment limits, Prescribing or Dispensing Limitations
considered part of nursing home per diem Prescription Refill Limit: None
reimbursement); non-H2 antagonists (payment
limits, considered part of nursing home per diem Monthly Quantity Limit: Prescribed quantities
reimbursement); H2 antagonist (payment limits); should be limited to an amount necessary to keep
feminine products (payment limits); topical the recipient supplied during the therapy regimen.
products; and smoking deterrent products (tablets, Quantity limits for selected pharmaceuticals (e.g.,
patches and gum-quanity limits per beneficiary per sedative hypnotics). In certain cases and
year). Products not covered: cough and cold conditions, more than a month’s supply will be
preparations. appropriate. However, in no instance may more
than 100-days supply be dispensed per
Therapeutic Category Coverage: Therapeutic prescription.
categories covered: analgesics, antipyretics,
NSAIDs; antibiotics; anticoagulants; Drug Utilization Review
anticonvulsants; antidepressants; antidiabetic
agents; antihistamine drugs; antilipemic agents; PRODUR system implemented in July 2000. State
anti-psychotics; anxiolytics, sedatives, and currently has a DUR Board with a quarterly
hypnotics; cardiac drugs; chemotherapy agents; review.
contraceptives; ENT anti-inflammatory agents;
estrogens; growth hormones; hypotensive agents; Pharmacy Payment and Patient Cost
misc. GI drugs; sympathominetics (adrenergic); and Sharing
thyroid agents. Partial coverage for: anabolic
Dispensing Fee: $2.50, ($2.75 for long-term care)
steroids (prior authorization required); prescribed
effective Nov. 1, 2004
cold medications; and prescribed smoking deterrents
(prior authorization required). Therapeutic
Ingredient Reimbursement Basis: 1-4 stores =
categories not covered: anoretics.
AWP-13.5%, 5 or more stores = AWP-15.1%.

Michigan-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Prescription Charge Formula: Reimbursement for Managed Care Organizations


legend drugs is limited to the lower of:
Cape Health Plan
1. AWP-13.5% for 1 to 4 stores & AWP-15.1% 26711 Northwestern Highway, Suite 300
for 5 or more stores or LTC, plus dispensing Southfield, MI 48034
fee minus patient copay, or T: 248/386-3000
F: 888/354-2273
2. The MAC rate, plus dispensing fee, or Internet address: www.capehealth.com
3. The provider’s usual and customary charge to
the general public. Community Choice Michigan
2369 Woodlake Drive
Maximum Allowable Cost: State imposes Federal Okemos, MI 48864
Upper Limits as well as State-specific limits on T: 517/349-9922
generic drugs. Override requires “Brand Medically F: 800/390-7102
Necessary” and prior authorization. Internet address: www.ccmhmo.org

Incentive Fee: None. Great Lakes Health Plan, Inc.


17117 W. Nine Mile, Suite 1600
Patient Cost Sharing: Effective Jan. 1, 2005, Southfield, MI 48075
ambulatory recipients age 21 and older are required T: 248/559-5656
to pay a $3.00 copayment for brand name drugs and F: 800/903-5253
a $1.00 copayment for generic drugs. Effective Internet address: www.glhp.com
March 1, 2005, Adult Benefit Waiver (ABW)
beneficiaries are required to pay a $1.00 copayment Health Plan of Michigan, Inc.
for each prescription drug dispensed. If the 17515 W. Nine Mile, Suite 650
recipient is unable to pay a required copayment on Southfield, MI 48075
the date of service, the pharmacy cannot refuse to T: 248/557-3700
render the service. However, the pharmacy may bill F: 888/437-0606
the recipient for the copayment amount, and he/she Internet address: www.hpmich.com
is responsible for paying it. If the recipient fails to
pay a copayment, the pharmacy could, in the future, HealthPlus Partners, Inc.
refuse to serve the recipient as a Medicaid recipient. 2050 S. Linden Road
P.O. Box 1700
Drugs not requiring a co-payment include Flint, MI 48501-1700
pregnancy-related and family planning products. T: 810/230-2132
F: 800/322-9161
Recipients are not required to make a copayment if: Internet address: www.healthplus.com
− They are under age 21, or
M-Caid
− They reside in a long-term care facility (nursing 2301 Commonwealth Blvd.
home, hospital long-term care facility, or Ann Arbor, MI 48105-1573
medical care facility), or 800/527-5549
Internet address: www.mcare.org
− Health Maintenance Organization (HMO), or a
capitated Clinic Plan. McLaren Health Plan
Cognitive Services: Does not pay for cognitive G 3245 Beacher Road, Suite 200
services. Flint, MI 48532
888/327-0671
Internet address: www.mclarenhealthplan.org
E. USE OF MANAGED CARE
Midwest Health Plan
Approximately 900,000 Medicaid recipients were 5050 Schaefer Road
enrolled in MCOs in FY 2003. Recipients receive Dearborn, MI 48126
pharmaceutical benefits through managed care T: 313/581-3700
plans. Psychotropics, antidepressants, anti-mania, F: 888/654-2200
central nervous system stimulants, and other select Internet address: www.midwesthealthplan.com
classes of drugs are administered by managed care
organizations but paid for by the State.

Michigan-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Molina Healthcare of Michigan F. STATE CONTACTS


100 W. Big Beaver Road, Suite 600
Troy, MI 48084 State Drug Program Administrator
T: 248/925-1700
F: 888/898-7969 Giovannino A. Perri, M.D.
Internet address: www.molinahealthcare.com Chief Medical Consultant
MDCH/Medical Services Administration
OmniCare Health Plan, Inc. 400 South Pine Street
1333 Gratiot P.O. Box 30479
Suite 400 Lansing, MI 48909-7979
Detroit, MI 48207 T: 517/335-5181
T: 313/465-1518 F: 517/241-8135
F: 866/711-6664 E-mail: perrig@michigan.gov
Internet address: www.omnicarehealthplan.com Internet address: www.michigan.gov/mdch

PHP- MM Family Care New Brand Names Products Contact


P.O. Box 30377
Lansing, MI 48909-7877 Donna Hammel
T: 517/364-8400 Office of Medical Affairs
F: 800/661-8299 MDCH/ Medical Services Administration
Internet address: www.phpmm.org 400 South Pine Street
P.O. Box 30479
PHP of Southwest Michigan, Inc. Lansing, MI 48909-7979
106 Farmers Alley, Suite 300 T: 517/335-5181
Kalamazoo, MI 49007 F: 517/241-8135
T: 269/341-7200 E-mail: hammeld@michigan.gov
F: 800/261-0084
Internet address: www.ibahealthplans.com Prior Authorization Contact
Priority Health, Government Programs, Inc. First Health Service Corporation
1231 E. Beltline, NE 4300 Cox Road
Grand Rapids, MI 49525-4501 Glen Allen, VA 23060
T: 616/942-0954 T: 877/864-9014
F: 888/975-8102 F: 888/603-7696
Internet address: www.priority-health.com
DUR Contact
ProCare
3956 Mt. Elliot Debera Eggleston, M.D.
Detroit, MI 48207 MDCH- Medical Services Administration
T: 313/925-4607 400 S. Pine St.
F: 866/776-0891 P.O. Box 30479
Lansing, MI 48909-7979
Total Health Care T: 517/335-5181
3011 W. Grand Blvd., Suite 1600 F: 517/241-8135
Detroit, MI 48202 E-mail: egglestond@michigan.gov
T: 313/871-2000
Medicaid DUR Board
F: 800/826-2862
Internet address: totalhealthcareonline.com Richard Henderson, M.D.
34650 Versailles Court
Upper Peninsula Health Plan Farmington Hills, MI 48331
228 W. Washington Street 810/474-1397
Marquette, MI 49855
T: 906/225-7500 Frank Check, M.D.
F: 800/835-2556 St. Joseph Mercy Hospital
Internet address: www.uphp.com 900 Woodward Avenue
Pontiac, MI 48341
313/858-3233

Michigan-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Duane Kirking, Ph.D. Medicaid Managed Care Contact


College of Pharmacy
Sue Moran, Chief
University of Michigan
Bureau of Medicaid Operations and Quality
Ann Arbor, MI 48109-1065
MDCH- Medical Services Administration
313/764-4483
400 S. Pine Street
313/764-7312
P.O. Box 30479
Lansing, MI 48909-7979
William Overkamp
T: 517/335-5181
2929 Walker, N.W.
F: 517/241-8135
Grand Rapids, MI 49544
E-mail: morans@michigan.gov
Karen Jonas, R.Ph.
13121 Willow Grove Road Disease Management Program/Initiative
Dewitt, MI 48820 Contact
517/315-1243 Giovannino A. Perri, M.D.
517/335-5181
James Kenyon, R.Ph.
Michigan Department of Community Health Mail Order Pharmacy Program
Medical Services Administration
P.O. Box 30479 None
Lansing, MI 48909
Elderly Expanded Drug Coverage Contact
Otto Graesser, D.O.
1421 W. Mt. Hope Thomas Chisnell
Lansing, MI 48910 MDCH/ Medical Services Administration
400 South Pine Street
Prescription Price Updating P.O. Box 30479
Lansing, MI 48909-7979
First Health Services Corporation T: 517/335-5181
T: 877/864-9014 F: 517/241-8135
F: 888/603-7696 E-mail: chisnellt@michigan.gov

Medicaid Drug Rebate Contacts Michigan Dept. of Community Health


Technical: Dawn Parsons (MDCH)
Pharmacy Consultant Janet Olszewski, Director
MDCH/ Medical Services MCDH/ Lewis Cass Building
Administration 320 South Walnut Street
400 South Pine Street Lansing, MI 48913
P.O. Box 30479 T: 517/335-0267
Lansing, MI 48909-7979 F: 517-373-4288
T: 517/335-5181 E-mail: norris@michigan.gov
F: 517/241-8135
E-mail: parsonsd@michigan.gov Paul Reinhart, Deputy Director
Michigan Department of Community Health
Audits: First Health Services Corporation 320 South Walnut Street
877/864-9014 Lansing, MI 48913
T: 517/241-7882
Claims Submission Contact F: 517/335-5007
First Health Services Corp E-mail: reinhartpl@michigan.gov
T: 877/864-9014
F: 888/603-7696

Michigan-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Formulary Review Committee Michigan Osteopathic Association


Dennis Paradis, Executive Director
James Kenyon, R.Ph.
2445 Woodlake Circle
Giovannino Perri, M.D.
Okemos, MI 48864
Debera Eggleston, M.D.
T: 800/657-1556
Max Robins, D.O.
F: 517/347-1566
Lawerence Nagel, D.D.S.
E-mail: dennis@moa-do.com
Chris Farrell
Internet address: www.moa-do.com
Robert Pheteplace, R.Ph. (Alternate)
Michigan State Board of Pharmacy
Addresses for all members:
Roberta Armstrong, Chairperson
Medical Services Administration
Bureau of Health Services
Michigan Department of Community Health
611 W. Ottawa, First Floor
400 S. Pine Street
P.O. Box 30670
Lansing, MI 48933
Lansing, MI 48909-8170
517/335-0918
Michigan Pharmacy and Therapeutics Internet address: www.michigan.gov/cis/
Committee
Michigan Health and Hospital Association
Robert P. Coffey, Pharm.D. Spencer C. Johnson, President
Debera Hayes Eggleston, M.D. 6215 West St. Joseph Highway
Robert Ernst, M.D. Lansing, MI 48917
Jonathan G.A. Henry, M.D. T: 517/323-3443
Annette Paul, R.Ph. F: 517/323-0946
Giovannino A. Perri, M.D. E-mail: sjohnson@lans.mha.org
Max Robins, D.O. Internet address: www.mha.org
Luenetta Jackson, Pharm.D.
Justus Jackson, M.D. Health Care Association of Michigan
Dean Van Loo, Pharm.D. Reginald Carter, Ph.D.
Richard Slaughter, M.Sc., FCCP President and CEO
P.O. Box 80050
Executive Officers of State Medical and Lansing, MI 48908
Pharmaceutical Societies T: 517/627-1561
F: 517/627-3016
Michigan State Medical Society E-mail: recarter@hcam.org
William E. Madigan, Executive Director Internet address: www.hcam.org
120 West Saginaw Street
East Lansing, MI 48823
T: 517/337-1351
F: 517/337-2490
E-mail: wmadigan@msms.org
Internet address: www.msms.org

Michigan Pharmacists Association


Larry D. Wagenknecht, CEO
815 N. Washington Avenue
Lansing, MI 48906-5198
T: 517/484-1466
F: 517/484-4893
E-mail: larry@michiganpharmacists.org
Internet address: www.michigan pharmacists.org

Michigan-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

MINNESOTA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $294,838,630 190,577 $276,731,202

RECEIVING CASH ASSISTANCE, TOTAL $161,712,804 84,306


Aged $6,759,656 4,182
Blind / Disabled $147,337,336 50,623
Child $2,746,917 15,191
Adult $4,868,895 14,310

MEDICALLY NEEDY, TOTAL $56,712,355 27,809


Aged $19,826,418 13,434
Blind / Disabled $35,344,455 9,576
Child $328,726 1,389
Adult $1,212,756 3,410

POVERTY RELATED, TOTAL $1,833,878 9,033


Aged $170,597 285
Blind / Disabled $451,718 302
Child $996,671 6,704
Adult $211,724 1,732
BCCA Women $3,168 10

TOTAL OTHER EXPENDITURES/RECIPIENTS* $74,579,593 69,429

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Minnesota-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION anxiolytics, sedatives; and hypnotics; cardiac drugs;


hypotensive agents; misc. GI drugs; and
Minnesota Department of Human Services, Health sympathominetics (adrenergic). Therapeutic
Care Management Division, Medical Assistance categories not covered: anoretics; DESI drugs.
Program.
Coverage of Injectables: Injectable medicines
D. PROVISIONS RELATING TO DRUGS reimbursable through the pharmacy benefit when
dispensed by a pharmacy and through physician
Benefit Design payment when used in physician offices.

Drug Benefit Product Coverage: Products covered: Vaccines: Vaccines reimbursable when billed as
prescribed insulin; disposable needles and syringe part of the Vaccines for Children Program.
combinations used for insulin; blood glucose test
strips; urine ketone test strips; total parenteral Unit Dose: Unit dose packaging reimbursable.
nutrition; and interdialytic parenteral nutrition.
Products not covered: drugs used for cosmetic Formulary/ Prior Authorization
purposes; drugs used for hair growth; fertility Formulary: Open formulary with general
drugs; appetite supressants; and experimental exclusions, restrictions, prior authorization, and
drugs. Products covered with limitations: sildenafil; preferred products.
methylphenidate (including d-methylphenidate);
Adderall; pemoline; dextroamphetamine; vitamins; Prior Authorization: State currently has a prior
and cough and cold preparations. Prior authorization procedure and a Drug Formulary
authorization required for: alglucerase; Interferon Committee. Recipient has the right to appeal prior
Alfa N-3; Interferon Gamma-1B; Ondansetron; authorization decisions and coverage of an
Granisetron; omeprazole (including s-omeprazole); excluded product by appeals referee followed by an
sertraline 25mg and 50mg tablets; Butulinum Toxin appeal in court.
Types A & B; valdecoxib; Esomeprazole;
dolasetron; celecoxib; rofecoxib; escitalopram Prescribing or Dispensing Limitations
10mg; citalopram 10mg and 20mg; paroxetine
10mg; modafinil 100mg; trandolapril; Monthly Quantity Limit: 3 month supply. Minimum
trandolapril/verapamil combination; quinapril; 34-days for maintenance drugs. Contraceptives may
quinapril/HCTZ; amlodipine/benazepril; be filled to provide a 3-month supply.
benazepril/HCTZ; benazepril; fosinopril; and
fosinopril/HCTZ. (For a complete list of products Drug Utilization Review
requiring prior authorization, contact the Pharmacy
PRODUR system implemented in February 1996.
Program at The Minnesota Department of Human
State currently has a DUR Board with a quarterly
Services, Health Care Management Division,
review.
Medical Assistance Program at
http://www.dhs.state.mn.us/provider/pharm/.)
Pharmacy Payment and Patient Cost
Sharing
Over-the-Counter Product Coverage: Products
covered: allergy, asthma and sinus products; Dispensing Fee: $3.65, effective 7/1/99.
analgesics; cough and cold preparations; digestive Pharmacies that dispense drugs that they package
products; feminine products (antifungals covered); into unit packaging receive an additional $0.30 per
topical products; and smoking deterrent products. prescription.
Products covered with limitations: vitamins; ocular
lubricants; pediculocides; and activated charcoal Ingredient Reimbursement Basis: EAC = AWP-
and ipecac. 11.5%.

Therapeutic Category Coverage: Therapeutic Prescription Charge Formula: Reimbursement is


categories covered: anabolic steroids; based on the lesser of submitted AWP minus 11.5%
anticoagulants; anticonvulsants; antidepressants; plus a dispensing fee, MAC plus a dispensing fee,
anti-psychotics; chemotherapy agents; prescribed or usual and customary. Special rules for IV
cold medications; contraceptives; ENT anti- admixtures.
inflammatory agents; estrogens; growth hormones;
prescribed smoking deterrents; and thyroid agents..
Prior authorization required for: analgesics,
antipyretics, and NSAIDS; antibiotics; antidiabetic
agents; antihistamines; antilipemic agents;

Minnesota-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Maximum Allowable Cost: State imposes a PrimeWest Health System


combination of Federal Upper Limits and State- 305 8th Avenue West
specific MAC on generic drugs. Override requires Alexandria, MN
“dispense as written or “brand medically T: 888/588-4420
necessary.” Prescriber must also obtain prior F: 320/762-8750
authorization.
UCare Minnesota
Incentive Fee: None. P.O. Box 52
Minneapolis, MN 55440-0052
Patient Cost Sharing: Brand: $3.00 T: 612/676-6500
Generic: $1.00
F: 612/676-6555
Cognitive Services: State does not pay for
Cognitive Services.
F. STATE CONTACTS
E. USE OF MANAGED CARE State Drug Program Administrator
Approximately 275,000 Medicaid recipients were Cody C. Wiberg, Pharm.D., R.Ph.
enrolled in MCOs in FY 2003. Recipients receive Pharmacy Program Manager
pharmaceutical benefits through managed care Minnesota Department of Human Services
plans. 444 Lafayette Road North
St. Paul, MN 55155-3853
T: 651/296-8515
Managed Care Organizations F: 651/282-6744
Itasca Medical Care E-mail: cody.c.wiberg@state.mn.us
Itasca Resource Center Internet address:
1209 SE 2nd Ave. www.dhs.state.mn.us/provider/pharm
Grand Rapids, MN 55744-3983
T: 800/843-9536 Prior Authorization Contact
F: 218/327-5545
Mary Claire Wohletz
Blue Plus Clinical Pharmacy Consultant
P.O. Box 64179 Minnesota Department of Human Services
St. Paul, MN 55164-0179 444 Lafayette Road North
651/662-5200 St. Paul, MN 55155-3853
T: 651/215-1632
First Plan Blue F: 651/282-6744
525 South Lake Avenue E-mail: mary.c.wohletz@state.mn.us
Duluth, MN 55802 Internet address:
T: 800/635-4159 www.dhs.state.mn.us/provider/pharm
F: 218/724-9176
DUR Contact
HealthPartners
8100 34th Avenue South Mary Beth Reinke, Pharm.D., M.S.A.
P.O. Box 1309 DUR Coordinator
Minneapolis, MN 55414-1309 Minnesota Department of Human Services
T: 952/967-6633 444 Lafayette Road North
St. Paul, MN 55155-3853
Medica T: 651/215-1239
P.O. Box 9310 F: 651/282-6744
Minneapolis, MN 55440-9310 E-mail: mary.beth.reinke@state.mn.us
T: 952/992-3200
F: 952/992-3198

Metropolitan Health Plan


822 South 3rd Street, Suite 140
Minneapolis, MN 55415
T: 612/347-6308
F: 612/904-4493

Minnesota-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Medicaid DUR Board Prescription Drug Updating


Physicians First DataBank
Pierre Rioux, M.D. 1111 Bayhill Drive, Suite 350
Mayo Health Systems-Austin San Bruno, CA 94066
Behavioral Health Center T: 650/588-5454
101 14th Street, N.W. F: 650/588/4003
Austin, MN 55912
Claims Submission Contact
Tim Ronnenberg, M.D.
Phalen Village Clinic Dwaine Voas
MMIS Unit Supervisor
1414 Maryland Avenue
St. Paul, MN 55105 Minnesota Department of Human Services
800 Minnehaha Avenue
Christine Ziebold, M.D., Ph.D., M.P.H. St. Paul, MN 55155
Pediatrics Infection Control
Pharmacy Manager Medicaid Drug Rebate Contacts
Parker Hughes Clinics
2665 Long Lake Road Jarvis Jackson, R.Ph.
Roseville, MN 55113 Drug Rebate Coordinator
Minnesota Department of Human Services
Health Care Professional 444 Lafayette Road North
Marilyn M. Ulseth, M.S., R.N., C.N.P. St. Paul, MN 55155-3853
2909 33rd Ave South T: 651/282-5881
Minneapolis, MN 55406 F: 651/282-6744
E-mail: jarvis.p.jackson@state.mn.us
Pharmacists
Ruth Buchmayer, R.Ph. Disease Management Program/Initiative
Prime Therapeutics Contact
P.O. Box 64812 Mary Claire Wohtetz
St. Paul, MN 55164 Clinical Pharmacist
Minnesota Department of Human Services
Margaret T. Schmidt, Pharm.D., M.B.A. 444 Lafayette Road North
NorthPoint Health Center St. Paul, MN 55155-3853
1313 Penn. Avenue North T: 651/215-1632
Minneapolis, MN 55411 F: 651/282-6744
E-mail: mary.c.whohetz@state.mn.us
Wendy L. St. Peter, Pharm.D.
Hennepin County Medical Center Mail Order Pharmacy Benefit
Nephrology Analytical Services
USRDS Coordinating Center None
914 Eighth Avenue South
Minneapolis, MN 55404 Elderly Expanded Drug Coverage Program
Contact
Consumers Representative Cody C. Wiberg, Pharm.D., R.Ph.
Vacant 651/296-8515
DHS Staff Department of Human Services Officials
Cody C. Wiberg, Pharm.D., R.Ph.
Pharmacy Program Manager Kevin Goodno
Commissioner
Mary Beth Reinke, Pharm.D., M.S.A. Department of Human Services
DUR Coordinator 444 Lafayette Road North
St. Paul, MN 55155-3815
New Brand Names Product Contact T: 651/297-7515
F: 651/297-3230
Cody C. Wiberg, Pharm.D., R.Ph. E-mail: commissioner.dhs@state.mn.us
651/296-8515

Minnesota-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Christine Bronson DHS Staff


Acting Medicaid Director Mary K. Woheltz, Pharm D.
Department of Human Services Clinical Pharmacist
444 Lafayette Road
St. Paul, MN 55155-3852 Executive Officers of State Medical and
T: 651/297-7515 Pharmaceutical Societies
F: 651/297-3230
Minnesota Medical Association
E-mail: christine.bronson@state.mn.us
Robert K. Meiches
Chief Executive Officer
Drug Formulary Committee 1300 Godward Street, NE, Suite 2500
Minneapolis, MN 55413-1878
Gary J. Gustafson, R.Ph. T: 612/378-1875
Fairview Pharmacy Services F: 612/378-3875
711 Kasota Avenue E-mail: rmeiches@mnmed.org
Minneapolis, MN Internet address: www.mnmed.org
Al Heaton, Pharm.D., R.Ph. Minnesota Pharmacists Association
Senior Director Julie K. Johnson, R.Ph.
Prime Therapeutics
Executive Vice-President
1020 Discovery Road, No. 100 1935 W. County Road, B2 #450
Eagan, MN 55121 Roseville, MN 55113
T: 651/697-1771
Paul Johnson, M.D. F: 651/697-1776
HCMCS E-mail: julie@mpha.org
Division of General Medicine
Internet address: www.mpha.org
701 Park Avenue
Minneapolis, MN 55415 Minnesota Osteopathic Medical Society
Colleen Jensen
William P. Korchik, M.D. Executive Director
Veterans Affairs Medical Center P.O. Box 314
One Veteran Drive (11L)
Lakeland , MN 55043-0314
Minneapolis, MN 55417 T: 612/623-3268
F: 612/677-3200
Ronna Linroth Internet address: www.mndo.org
Manager
Adult/North Clinic Services
State Board of Pharmacy
Gillette Lifetime Specialty Healthcare David E. Holmstrom
555 County Road D, Suite 12 Executive Director
New Brighton, MN 55112
2829 University Avenue SE, #530
Kim Allan Macnab, M.D., Pharm.D., CCFP (EM) Minneapolis, MN 55414-3251
714 Barton Ave, N.W. T: 612/617-2201
Buffalo, MN 55313 F: 612/617-2212
E-mail: David.Holstrom@state.mn.us
Lynne M. Schneider, R.Ph. Internet address: www.phcybrd.state.mn.us
12910-37th Avenue North
Plymouth, MN 55441 Minnesota Hospital and Healthcare Partnership
Bruce Rueben
John Simon, M.D. President
Clinical Psychopharmacology Consultants, P.A. 2550 University Avenue West, Suite 350S
Riverside Park Plaza, Suite 303 St. Paul, MN 55114-1900
701 25th Avenue South T: 651/641-1121
Minneapolis, MN 55454 F: 651/659-1477
E-mail: info@mnhospitals.org
Robert Straka, Pharm.D. Internet address: www.mnhospitals.org
University of Minnesota College of Pharmacy
7-148 Weaver-Densford Hall
308 Harvard Street, S.E.
Minneapolis, MN 55455

Minnesota-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Minnesota Society of Health System-Pharmacists


Scott Marin
Executive Director
13911 Ridgedale Drive, Suite 260
Minnetonka, MN 55305
T: 952/541-9499
F: 952/541-9684
E-mail: dstanton@mnshp.org
Internet address: www.mnshp.org

Care Providers of Minnesota


Rick E. Carter
President & CEO
7851 Metro Parkway
Suite 200
Bloomington, MN 55425
T: 612/854-2844
F: 612/854-6214
E-mail: rcarter@careproviders.org
Internet address: www.careproviders.org

Minnesota-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

MISSISSIPPI

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/ Child Adult Aged Blind/ Child Adult
Disabled Disabled

Prescribed Drugs ‹ ‹ ‹ ‹
Inpatient Hospital Care ‹ ‹ ‹ ‹
Outpatient Hospital Care ‹ ‹ ‹ ‹
Nursing Facility Services ‹ ‹ ‹ ‹
Skilled Nursing Home Services ‹ ‹ ‹ ‹
Physician Services ‹ ‹ ‹ ‹
Dental Services ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $568,084,274 526,923 $568,007,104

RECEIVING CASH ASSISTANCE TOTAL $297,248,432 240,302


Aged $39,630,817 20,265
Blind/Disabled $219,218,827 105,764
Child $17,536,770 72,324
Adult $20,862,018 41,949

MEDICALLY NEEDY, TOTAL $0 0


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

POVERTY RELATED, TOTAL $206,384,484 265,482


Aged $66,656,881 31,322
Blind/Disabled $88,036,351 30,492
Child $47,118,247 179,454
Adult $4,573,005 24,214
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $64,451,358 21,139

**Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Mississippi-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

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


minerals (except prenatal); and DESI drugs.
Division of Medicaid, Office of the Governor.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug
D. PROVISIONS RELATING TO DRUGS Program when used in home health care and
extended care facilities, and through physician
Benefit Design payment when used in physicians’ offices.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; and total parenteral nutrition. Unit Dose: Unit dose packaging is reimbursable.
Prior authorization required for: brand name
multisource products; Sandimmune; oral erectile Vaccines: Vaccines reimbursable as part of the
dysfunction agents; enteral feeding products; Vaccine for Children Program. LTC reimbursed in
nutritional products; immunosuppressant agents; cost reports. POS only for adult non-LTC
Clozaril (must be prescribed by Board Certified or beneficiaries. Counts against monthly Rx limits.
Board Eligible Psychiatrist); * Xenical,
Benzodiazepines, NSAD, Protropin and Formulary/Prior Authorization
Humatrope; * all Antihemophilic Factors including Formulary: Open formulary with preferred drug list
VIII and IX; * Synagis; Enbrel; Brand SR opioid (PDL). General exclusions include:
agonists; Neurontin; and all Home IV drug
therapies. Products not covered: cosmetics; fertility 1. Drugs used for anorexia or weight gain.
drugs; experimental drugs; disposable needles and
syringe combinations used for insulin; blood 2. Drugs when used for the symptomatic relief of
glucose test strips; urine ketone test strips; and cough and colds (except quaifenesin syrup 100
interdialytic parenteral nutrition. mg/5 ml, iodinated glycerol tablets 30 mg,
which are covered).
* These products are covered only for children ages 3. Prescription vitamins and mineral products
0-21 years through the Early and Periodic (except prenatal vitamins and fluoride
Screening, Diagnosis and Treatment Program preparations, which are covered).
(EPSDT).
4. Covered outpatient drugs for which the
Over-the-Counter Product Coverage: Products manufacturer requires (as a condition of sale)
covered with restrictions (i.e., must be on limited that associated tests or monitoring services be
formulary, requires a prescription, and counts purchased exclusively from the manufacturer
against monthly service limits): allergy, asthma, or its designee.
and sinus products (Benadryl); analgesics (ASA, 5. Barbiturates (except amobarbital, butabarbital,
generic Tylenol); cough and cold preparations mephobarbital, pentobarbital, phenobarbital,
(generic Robitussin); digestive products (non-H2 secobarbital, which are covered).
antagonist); feminine products; topical products;
smoking deterrent products; certain vitamins 6. Benzodiazepines (except Klonopin,
(prenatal and dialysis). Products not covered: H2 Lorazapam, Diazepam and Temazepam which
antagonists. are covered).
7. DESI drugs (those drugs that are designated
Therapeutic Category Coverage: Therapeutic less than effective by the FDA).
categories covered: anabolic steroids; antibiotics;
anticoagulants; anticonvulsants; antidepressants; Additional techniques to manage the PDL include
antidiabetic agents; antihistamines; anti-psychotics; restrictions on use, prior authorization, and
anxiolytics, sedatives, and hypnotics; cardiac drugs; preferred products.
chemotherapy agents; contraceptives; ENT anti- Prior Authorization: State currently has a prior
inflammatory agents; estrogens; growth hormones; authorization procedure. A written request
hypotensive agents; misc.; GI drugs; prescribed (including medical justification for beneficiaries
smoking deterrents, antilipemic agents (PA under age 21) must be made within 30 days of
required for xenical); sympathominetics denial to appeal a prior authorization decision.
(adrenergic); and thyroid agents. Prior Review and determination made by clinical
authorization required for: analgesics, antipyretics, specialists within 3 days of receipt. All parties
NSAIDs. Partial coverage for: prescribed cold notified in writing within 24 hours of decision.
medications. Products not covered: anoretics;

Mississippi-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Prescribing or Dispensing Limitations E. USE OF MANAGED CARE


Prescription Refill Limit: Limited to 11 scripts per
year. No Medicaid recipients receive health benefits
through MCOs.
Monthly Quantities Limit: 34-day supply or 100
units or doses, whichever is greater. Birth control
F. STATE CONTACTS
pills may be supplied in 3-month quantities.
Monthly Prescription Limit: Total prescriptions State Drug Program Administrator
dispensed per month per recipient are limited to 5.
Judith P. Clark, R.Ph.
Two additional prescriptions per month may be
Pharmacy Director
allowed with prior authorization. Beneficiaries
Division of Medicaid
under age 21 years old or in long term care
Robert E. Lee Building
facilities are exempt from monthly prescription
239 North Lamar Street, Suite 801
limits.
Jackson, MS 39201
Drug Utilization Review T: 601/359-5253
F: 601/359-9555
PRODUR system implemented in 1993. State has a E-mail: phipc@medicaid.state.ms.us
12 member DUR Board that meets quarterly. Internet address: www.dom.state.ms.us

Pharmacy Payment and Patient Cost Division of Medicaid Official


Sharing
Warren A. Jones, M.D., Executive Director
Dispensing Fee: $3.91 (effective 5/1/02). IV Division of Medicaid
mixtures can receive up to a $30 per liter Suite 801, Robert E. Lee Building
dispensing fee. 239 North Lamar Street
Jackson, MS 39201
Ingredient Reimbursement Basis: EAC = AWP- T: 601/359-6050
12%, effective July 1, 1990. F: 601/359-6048
E-mail: wajones@medicaid.state.ms.us
Prescription Charge Formula: Reimbursement for
legend drugs will be at the lessor of AWP-12% plus Prior Authorization Contact
a dispensing fee or usual and customary charge.
OTC drugs will be paid at lessor of AWP plus a Judith P. Clark, R.Ph.
dispensing fee, usual and customary price, or 601/359-5253
estimated shelf price plus a dispense fee.
DUR Contact

Maximum Allowable Cost: State imposes Federal Judith P. Clark, R.Ph.


Upper Limits on generic drugs. Override requires 601/359-5253
“Brand Medically Necessary” or prior authorization
(e.g., brand name multi-source prior authorization Mississippi DUR Board
form showing allergic Rx, ADR, or failure to Lee Montgomery, M.D.
respond) for brand multi-source drugs. Premier Family Practice
602 South Adams
Incentive Fee: None. Fulton, MS 38843
Patient Cost Sharing: Tiered copayment of $1.00-
$3.00. Tim Alford, M.D. (Chair)
$1.00 - preferred generic Kosciusko Medicaid Clinic
$2.00 - preferred brand Highway 12
$3.00 - non-preferred brand Kosciusko, MS 39090

Cognitive Services: Pays for disease management John R. Mitchell, M.D.


services for diabetes, hyperlipidemia, asthma, and Tupelo Family Medicine Residency Center
coagulatory disorders (effective 8/1/98). Pays $20 1665 South Green Street
for average 30-minute encounter. Tupelo, MS 38804

Cynthia Undesser, M.D.


P.O. Box 5102
Brandon, MS 39047

Mississippi-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Andrea Phillips, M.D. Medicaid Drug Rebate Contact


Phillips Medical Services
Robert Reedy, C.Ph.T.
P.O. Box 21214
DRAMS Business Analyst
Jackson, MS 39289
ACS State Healthcare
385-B Highland Colony Parkway
Rudy Runnels, M.D.
Ridgeland, MS 39157
Medical and Surgical Clinic
T: 601/206-2936
376 A Simpson Highway 149
F: 601/206-3119
Magee, MS 39114
E-mail: robert.reedy@acs-inc.com
Joe McGuffee, R.Ph.
McGuffee Drugs Claims Submission Contact
102 North Main Street Robert Reedy, C.Ph.T.
Mendenhall, MS 39114 ACS State Healthcare
T: 601/206-2936
D. Montez Carter, Pharm.D.
P.O. Box 1414 Disease Management/Patient Education
Greenwood, MS 38935 Programs
Disease/Medical State: Asthma
Leigh Ann Ramsey, Pharm.D. Program Name: Asthma Disease Management (eff.
231 Winged Foot Circle 2/03)
Jackson, MS 39211 Program Manager: Mckesson

Billy R. Brown, Pharm.D. Disease/Medical State: Diabetes


2825 Glen Derry Street Program Name: Diabetes Disease Management
Jackson, MS 39212 (eff. 2/03)
Program Manager: Mckesson
Clarence DuBose, R.Ph. (Vice-Chair)
Medi-Mart Pharmacy Disease/Medical State: Hypertension
3737 Main Street Program Name: Hypertension Disease
Moss Point, MS 39563 Management (eff. 2/03)
Program Manager: Mckesson
Randy Calvert, R.Ph.
655 Duling Avenue Disease Management/Patient Education
Jackson, MS 39216 Contact

New Brand Names Product Contact Alicia K. Crowder, R.N., M.P.H.


Director of Medical Services
Judith P. Clark, R.Ph. Division of Medicaid
601/359-5253 Robert E. Lee Building
239 North Lamar Street, Suite 801
Prescription Price Updating Jackson, MS 39201
Terri R. Kirby, R.Ph. T: 601/359-5243
Pharmacist F: 601/359-5252
E-mail: maskc@medicaid.state.ms.us
Divison of Medicaid
239 North Lamar Street, Suite 801
Jackson, MS 39201 Mail Order Pharmacy Program
T: 601/359-5253 None
F: 601/359-9555
E-mail: phtrk@medicaid.state.ms.us Pharmacy and Therapeutics Committee
Craig Dawkins, M.D.
1213 Broad Avenue, Suite 210
Gulfport, MS 39501

Jennifer Gholson, M.D.


110 Franklinton Street
Tylertown, MS 39667

Mississippi-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Michael L. O’Dell, M.D. (Vice-Chair) Mississippi Pharmacists Association


Director, Family Medicine Bo Dalton, R.Ph.
Residency Program Executive Director
North Mississippi Medical Center 341 Edgewood Terrace Drive
1665 South Green Street Jackson, MS 39206-6217
Tupelo, MS 38804 601/981-0416
E-mail: mpha@bellsouth.net
Gary Davis, M.D. Internet address: www.mspharm.org
571 East Beasley Road, Suite D
Jackson, MS 39206 Mississippi State Board of Pharmacy
Leland “Mac” McDivitt
Raymond Wynn, M.D. Executive Director
Singing River Hospital System 204 Key Drive, Suite D
Director, The Regional Cancer Center Madison, MS 39110
2809 Denny Avenue T: 601/605-5388
Pascagoula, MS 39581 F: 601/605-9546
E-mail: lmcdivitt@mbp.state.ms.us
Betsy Commings, C.F.N.P Internet address: www.mbp.state.ms.us
1740 McClain Street
Greenville, MS 38701 Mississippi Osteopathic Medical Association
Jeffrey J. LeBoeuf
Pearl Wales, Pharm.D. Executive Director
164 Tithelo Road P.O. Box 16890
Canton, MS 39046 Jackson, MS 39236
T: 601/366-3105
David Hudson, R.Ph. F: 601/366-2868
389 NW Depot Street E-mail: info@moma-net.org
Durant, MS 39063 Internet address: www.moma-net.org

Todd Barrett, R.Ph. Mississippi Hospital Association


Covenant Pharmacy Sam W. Cameron
2506 Lakeland Drive, Suite 101 President/CEO
Flowood, MS 39232 P.O. Box 16444
6425 Lakeover Road
Jeff Jones, R.Ph. Jackson, MS 39236-6444
Carthage Discount Drugs T: 800/289-8884
602 Highway 16E F: 601/368-3200
Carthage, MS 39051-4212 E-mail: scameron@mhanet.org
Internet address: www.mhanet.org
Larry Calvert, R.Ph. (Chair)
720 Sarazen Drive Mississippi Society of Health-System Pharmacists
Gulfport, MS 39507 Dianna McGowan, R.Ph.
Association Manager
Executive Officers of State Medical and 328 Dover Lane
Pharmaceutical Societies Madison, MS 39110
T: 601/856-9273
Mississippi State Medical Association F: 601/856-8539
William F. Roberts
E-mail: johnnymcg@msn.com
Executive Director Internet address: www.pharmd.org/mshp
P.O. Box 2548
Ridgeland, MS 39158-2548
Mississippi Health Care Association
601/853-6733 Vanessa P. Henderson
E-mail: wroberts@msmaonline.com Executive Director
Internet address: www.msmaonline.com 114 Marketridge Drive
Ridgeland, MS 39157
T: 601/956-3472
F: 601/977-0273
E-mail: vanessa@mshca.com
Internet address: www.mshca.com

Mississippi-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Mississippi-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

MISSOURI

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $799,910,014 493,230 $941,522,305

RECEIVING CASH ASSISTANCE TOTAL $356,695,975 275,059


Aged $51,673,954 18,903
Blind/Disabled $225,953,649 66,602
Child $35,102,211 110,002
Adult $43,966,161 79,552

MEDICALLY NEEDY, TOTAL $0 0


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

POVERTY RELATED, TOTAL $35,427,693 47,905


Aged $7,218,295 4,168
Blind/Disabled $16,527,657 4,142
Child $9,869,502 27,036
Adult $1,812,239 12,559
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $407,786,346 170,266

**Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Missouri-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Formulary/Prior Authorization


Formulary: Open formulary with preferred drug
Division of Medical Services, Missouri Department list. PDL managed through exclusions and
of Social Services. restrictions, including preferred products, physician
profiling, prior authorization, therapeutic
D. PROVISIONS RELATING TO DRUGS substitution, clinical edits, and step therapy.

Benefit Design Prior Authorization: State currently has a prior


authorization procedure and a Drug Prior
Drug Benefit Product Coverage: Categories or Authorization Committee composed of 9 members
drugs that are covered: prescribed insulin; urine who meet quarterly. Fair hearing process to appeal
ketone test strips; total parenteral nutrition; and prior authorization decisions.
interdialytic parenteral nutrition. Products covered
with restrictions (single source supplies): Prescribing or Dispensing Limitations
disposable needles and syringe combinations used
for insulin; blood glucose test strips. Limited Prescription Refill Limit: None
coverage (limited to OTC formulary) for: allergy,
asthma, and sinus products; analgesics; cough and Monthly Quantity Limit: Physician encouraged to
cold preparations; digestive products (non-H2 prescribe 34-day or 100 dose supply but may, at
antagonists); and topical products. Prior own discretion, prescribe up to a maximum 90-day
authorization required for: amphetamines; supply.
barbiturates; Isotretinoin; Orlistat; and Retinoic
Acid. Products not covered: cosmetics; fertility Dose Limit: Prescriptions for the following must be
drugs; experimental drugs; H2 antagonists; dispensed for at least 200 units per prescriptions:
smoking deterrent products; feminine products; hair Acetaminophen 5 gr. Prenatal vitamins must be
growth products; Halazepam; Prazepam; dispensed in a quantity of at least 30.
Estazolam; Quazepam; and non-legend products.
Drug Utilization Review
Therapeutic Catogory Coverage: Therapeutic PRODUR system implemented in 1993. State
categories covered: analgesics, antipyretics, and currently has a 13 member DUR Board with a
NSAIDs; antibiotics; anticoagulants; quarterly review.
anticonvulsants; anti-depressants; antidiabetic
agents; antihistamines; antilipemic agents; anti- Pharmacy Payment and Patient Cost
psychotics; cardiac drugs; chemotherapy agents; Sharing
contraceptives; ENT anti-inflammatory agents;
estrogens; hypotensive agents; sympathominetics Dispensing Fee: $4.09 (out-of-state), $8.04 (in-
(adrenergic); and thyroid agents. Prior authorization state), $8.19 (long-term care pharmacies).
required for: anxiolytics, sedatives, and hypnotics;
prescribed cold medications; growth hormones; and Ingredient Reimbursement Rate: EAC = AWP-
GI drugs. Partial coverage for: anabolic steroids. 10.43% or WAC+10%.
Categories not covered: anoretics; prescribed
smoking deterrents. Prescription Charge Formula:
1. Method of reimbursement payment is based on
(For additional information on products and/or
acquisition cost plus a dispensing fee per
category coverage, see the pharmacy provider
prescription filled. Acquisition may vary
bulletin at www.medicaid.state.mo.us.)
depending whether it is based on AWP and
Federal or Missouri MAC.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug 2. Any drug that is not a Federal or Missouri
Program when used in physician offices, home MAC drug will be based on the AWP-10.43%
health care settings, and extended care facilities. or the WAC+10%. The majority of drugs listed
are based on AWP. The method of pricing will
Vaccines: Vaccines reimbursable as part of the be taken from the NDC number.
Vaccines for Children Program.

Unit Dose: Unit dose packaging reimbursable.

Missouri-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Maximum Allowable Cost: State imposes Federal FirstGuard Health Plan


Upper Limits as well as State-specific limits on 4001 Blue Parkway, Suite 300
generic drugs. 1,067 drugs are listed on the State- Kansas City, MO 64130
specific MAC list. Override requires prior 816/922-7250
authorization and a MedWatch form.
Family Health Partners Health Plan
Incentive Fee: None. 215 W. Pershing Road, 6th Floor
P.O. Box 411806
Patient Cost Sharing: Variable tiered copayment: Kansas City, MO 64108
816/855-1888
Drug Ingredient Cost Copayment
Missouri Care Health Plan
$0.00 to $10.00 $0.50 2404 Forum Boulevard
Columbia, MO 65203
$10.01 to $25.00 $1.00 573/441-2100

$25.01 or more $2.00


F. STATE CONTACTS
($5.00 copayment for certain 1115 waiver
populations (see Pharmacy Bulletin).) State Drug Program Administrator
George L. Oestreich, Pharm.D., M.P.A.
Copayment retained by pharmacist. Pharmacy Program Director
Department of Social Services
Cognitive Services: Payment for cognitive services Division of Medical Services
is provided to qualified pharmacies who enroll to 2023 St. Mary’s Boulevard
provide asthma, diabetes, heart failure, and P.O. Box 6500
depression education. Jefferson City, MO 65102-6500
T: 573/751-6961
E. USE OF MANAGED CARE F: 573/522-8514
E-mail: George.L.Oestreich@dds.mo.gov
Approximately 417,000 Medicaid recipients are Internet address: www.dss.mo.gov/dms
enrolled in managed care organizations in 2003.
All receive pharmacy services through managed Social Services Department Officials
care. Protease inhibitors are carved out of managed Steve Renne, Acting Director
care. Department of Social Services
Broadway State Office Building
Managed Care Organizations 221 West High Street
Healthcare USA P.O. Box 1527
10 South Broadway, Suite 1200 Jefferson City, MO 65102
St. Louis, MO 63102 T: 573/751-4815
800/213-7792 F: 573/751-3203
E-mail: dorisia.lorts@dss.mo.gov
Blue Cross and Blue Shield of Kansas City
P.O. Box 419169 Michael Ditmore, M.D., Interim Director
2301 Main St., 3rd Floor Department of Social Services
Kansas City, MO 64108 Division of Medical Services
816/395-2119 615 Howerton Court, P.O. Box 6500
Jefferson City, MO 65102-6500
Mercy Health Plan T: 573/751-6922
14528 S. Outer 40 Road, Suite 300 F: 573/751-6564
Chesterfield, MO 63017 E-mail: karen.a.lewis@dss.state.mo.us
314/214-8010

Community Care Plus Health Plan


10123 Corporate Square Drive
St. Louis, MO 63112
800/875-0679

Missouri-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

New Brand Name Products Contact DUR Contact


Rhonda A. Driver Tisha A. Pomering
Clinical Pharmacist DUR Coordinator
Department of Social Services Division of Medical Services
Division of Medical Services 2023 St. Mary’s Boulevard
2023 St. Mary’s Boulevard P.O. Box 6500
P.O. Box 6500 Jefferson City, MO 65102-6500
Jefferson City, MO 65102- 6500 T: 573/751-6961
T: 573/751-6961 F: 573/522-8514
F: 573/522-8514 E-mail: Tisha.A.Pomering@dss.mo.gov
E-mail: Rhonda.Driver@dss.mo.gov
DUR Board
Prior Authorization Contact
John W. Newcomer, M.D. (Chair)
Rhonda A. Driver Stacy Mangum, Pharm.D.
573/751-6961 Jacquelyn Garrett, M.D.
Joy S. Gronstedt, D.O.
Pharmacy Advisory Group Joseph M. Yasso, D.O.
Harold Lurie, M.D.
Matt Carlise, R.Ph. Karla Dwyer, R.Ph.
St. Peters, MO
Susan Abdel-Rahman, Pharm.D.
Peggy Wanner-Barjenbrunch, M.D.
Gene Forrester, R.Ph. Sandra Bollinger, Pharm.D.
Columbia, MO
Stephen Calloway, R.Ph.
Robert Dale Potter, R.N.
Curtis Hartin, R.Ph.
St. Louis, MO Drug Prior Authorization Committee
Patrick J. Bryant, Pharm.D.
Ed Powers, R.Ph.
Kansas City, MO
Macon, MO
Joseph Parks, M.D.
Steve Hartwig, R.Ph.
Jefferson City, MO
Marshall, MO
Gene Forrester, R.Ph.
Jim Harlan, R.Ph.
Columbia, MO
Poplar Bluff, MO
Henry Petry, D.O.
Barb Hauck, R.Ph.
Edina, MO
Deerfield, IL
Jay R. Bryant-Wimp, R.Ph.
Christie Beisner, R.Ph.
Columbia, MO
Nevada, MO
Lorraine C. Brown, D.O.
John Fester, R.Ph.
Lebanon , MO
Steelville, MO
Conrad S. Balcer, D.O.
Janice Steiger, R.Ph.
Jefferson City, MO
Florissant, MO
Karen Norris, Pharm.D. (alternate)
Kevin James, R.Ph. Kansas City, MO
Bentonville, AR
Prescription Price Updating
First DataBank
1111 Bayhill Drive
San Bruno, CA 94066
T: 650/588-5454
F: 650/872-4510

Missouri-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Medicaid Drug Rebate Contact Craig Leonard, R.Ph.


Lee’s Summit, MO
Vickie L. Harper
Medicaid Unit Supervisor
Division of Medicaid Services Executive Officers of State Medical and
Drug Rebate Unit Pharmaceutical Societies
2023 St. Mary’s Boulevard
P.O. Box 6500 Missouri State Medical Association
C. C. Swarens
Jefferson City, MO 65102-6500
T: 573/526-5664 Executive Secretary
F: 573/522-4650 113 Madison Street, P.O. Box 1028
Jefferson City, MO 65102
E-mail: Vicki.L.Harper@dss.mo.gov
T: 573/636-5151
F: 573/636-8552
Claims Submission Contact E-mail: cswarens@msma.org
Internet address:
Diane Twehous
www.momed.net/momed/index.htm
Account Manager
Infocrossing Health Care Services, Inc.
Missouri Pharmacy Association
905 Weathered Rock Road
Ron Fitzwater
Jefferson City, MO 65109
Chief Executive Officer
573/635-2434
211 East Capitol Avenue
Jefferson City, MO 65101-3001
Medicaid Managed Care Contact T: 573/636-7522
F: 573-636-7485
Michael Ditmore, M.D. E-mail: ron@morx.com
Interim Director Internet address: www.morx.com
573/751-6922
Mail Order Pharmacy Program Missouri Assoc. of Osteopathic
Physicians/Surgeons, Inc.
None Bonnie M. Bowles
Executive Director
Disease Management/ Patient Education 1423 Randy Lane
Programs Jefferson City, MO 65102
Disease Medical States: Asthma T: 573/634-3415
Cardiovascular Disease F: 573/634-5635
Depression E-mail: contact@maops.org
Diabetes Internet address: www.maops.com
Program Manager: Jennifer Cornelious
Program Sponsor: State of Missouri Missouri State Board of Pharmacy
Kevin E. Kinkade
Disease Management Initiatives Contact Executive Director
3605 Missouri Boulevard
George Oestreich, Pharm.D., M.P.A. P.O. Box 62
573/781-6961 Jefferson City, MO 65102
T: 573/751-0091
Pharmacy Subcommittee Roster F: 573/526-3464
Bill Fitzpatrick, R.Ph. E-mail: pharmacy@pr.mo.gov
St. Louis, MO Internet address: www. pr.mo.gov/pharmacists.asp

Philip A. Bangert, R.Ph. Missouri Hospital Association


Florissant, MO Marc Smith
President
Tom Beetem, R.Ph., Chairman 4712 Country Club Drive
Holts Summit, MO P.O. Box 60
Jefferson City, MO 65102-0060
Robert D. Hurley, R.Ph. T: 573/893-3700
Florissant, MO F: 573/893-2809
E-mail: msmith@mail.mhanet.com
Internet address: www.mhanet.com

Missouri-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Missouri-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

MONTANA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $77,980,883 67,365 $79,771,831

RECEIVING CASH ASSISTANCE, TOTAL $37,487,485 28,190


Aged $3,002,578 1,524
Blind / Disabled $28,824,343 10,729
Child $2,079,303 9,751
Adult $3,581,261 6,186

MEDICALLY NEEDY, TOTAL $22,256,552 7,821


Aged $12,864,890 5,336
Blind / Disabled $9,380,602 2,449
Child $10,732 34
Adult $328 2

POVERTY RELATED, TOTAL $2,541,402 13,561


Aged $14 1
Blind / Disabled $0 0
Child $2,084,695 11,322
Adult $399,668 2,183
BCCA Women $57,025 55

TOTAL OTHER EXPENDITURES/RECIPIENTS* $15,695,444 17,793

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are
unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Montana-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION smoking deterrents and growth hormones.


Therapeutic categories not covered: anoretics;
Department of Public Health and Human Services, prescribed cold medications.
Health Resources Division, Medicaid Services
Bureau Coverage of Injectables: Injectable medicines
reimbursable through the physician payment when
used in home health care and extended care
D. PROVISIONS RELATING TO DRUGS facilities, and physician offices.

Benefit Design Vaccines: Vaccines reimbursable as part of the


Drug Benefit Product Coverage: Products covered: EPSDT service, the Children Health Insurance
legend drugs, prescribed insulin; fertility drugs; Program, and the Vaccines for Children Program.
syringe combinations used for insulin; certain
prescribed over-the-counter products, vaccines Unit Dose: Unit dose packaging reimbursable.
except children 18 and under and clients with
Medicare Part B coverage; compounded Formulary/Prior Authorization
prescriptions; contraceptive supplies and devices. Formulary: Open formulary with a preferred drug
Products not covered: cosmetics; experimental list. Formulary managed through exclusion of
drugs; disposable needles used for insulin, blood products based on contracting issues, restrictions on
glucose test strips; and urine ketone test strips. Prior use, prior authorization preferred products, and
authorization required for: total parenteral nutrition; physician profiling. Drugs classified as less-than-
interdialytic parenteral nutrition; non-steroidal anti- effective (LTE) by the FDA are not covered. Drugs
inflammatory drugs; all single source NSAIDs; with no manufacturer rebate are not covered.
Celebrex, Vioxx; disease-modifying anti-rheumatic
drugs (Arava, Enbrel, Remicade); growth Prior Authorization: State has a formal prior
hormones; single-source benzodiazepines; gastro- authorization procedure. Prescriber letter
intestinal drugs (including H2 antagonists, proton documenting evidence for use of prescribed
pump inhibitors, Carafate and Cytotec); migraine medication in treatment of disease is reviewed by
headache drugs for certain monthly quantities on DUR Board for appeal of excluded product. An
Imitrex, Maxalt, Zomig, Migranal, Amerge; weight appeal procedure through the Department possible
reduction drugs (Fastin, Ionamin, Meridia, for PA decisions.
Xenical); smoking-cessation drugs; Toradoloral;
Dipyridamole; Aggrenox; Trental, Pletal; Ambien
Prescribing or Dispensing Limitations
and Sonata; Viagra; Thalomid; Zyvox; Tretinoin;
Zoloft; Hismanal; Bextra; Kineret; Stadol; Prescription Refill Limit: None
Isoetherine; and Isoproterenol.
Monthly Quantity Limit: 34-day supply. May have
quantity limits on certain medications selected by
Over-the-Counter Product Coverage: Products the DUR Board.
covered (i.e., when prescribed): allergy, asthma,
and sinus products (Claritin OTC only); insulin;
Drug Utilization Review
laxatives; head lice treatments; H2 antagonists; GI
products; bronchosaline; and smoking deterrent PRODUR system implemented in September 1994.
products (prior authorization required). Products State DUR Board meets monthly.
not covered: analgesics; cold and cough
preparations; non-H2 antagonists; feminine Pharmacy Payment and Patient Cost
products; and topical products. Sharing
Dispensing Fee: $2.00-$4.70; effective 7/1/02.
Therapeutic Category Coverage: Therapeutic
Pharmacies submit documentation showing their
categories covered: anabolic steroids; antibiotics;
costs. Dispensing fee is based on their cost up to a
anticoagulants; anticonvulsants; antidepressants;
maximum of $4.70. Pharmacies that do not submit
antidiabetic agents; antilipemic agents; anti-
documentation receive a dispensing fee of $2.00.
psychotics; anxiolytics, sedatves, and hypnotics;
cardiac drugs; chemotherapy agents; Ingredient Reimbursement Basis: EAC = AWP-
contraceptives; ENT anti-inflammatory agents; 15%.
estrogens; hypotensive agents; misc. GI drugs;
Prescription Charge Formula: The lower of EAC,
sympathominetics (adrenergic); and thyroid agents.
the Federal MAC (plus a dispensing fee), or the
Prior authorization required for: antihistamines;
provider usual and customary charge.
analgesics, antipyretics, and NSAIDs; prescribed

Montana-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Maximum Allowable Cost: State imposes Federal Prior Authorization Contact


Upper Limits on generic drugs. Override requires
Mark Eichler, R.Ph., FASCP
“Brand Necessary” or “Brand Required” on the
Pharmacy Programs Director
prescription.
Mountain-Pacific Quality Health Foundation
Incentive Fee: None. 3404 Cooney Drive
Helena, MT 59602
Patient Cost Sharing: Copayment of $1.00 - $5.00.
T: 406/457-5818
Recipient pays 5% of Medicaid allowable cost
F: 406/443-7014
between $1.00 and $5.00. $5.00 copayment cap per
E-mail: meichler@mpqhf.org
prescription. $25.00 copayment cap per month.
Cognitive Services: Does not pay for cognitive DUR Contact
services.
Mark Eichler, R.Ph., FASCP
T: 406/457-5818
E. USE OF MANAGED CARE
Montana DUR Board
Does not use MCO’s to provide services to Mark Eichler, R.Ph., FASCP
Medicaid recipients. DUR Coordinator

F. STATE CONTACTS Lee Ann Bradley, Pharm.D.


Sherrill Brown, Pharm.D.
State Drug Program Administrator Bill Burton, R.Ph.
Carla Cobb, Pharm.D.
Dan Peterson Pharmacy Program Officer Jim Crichton, M.D.
Department of Public Health and Human Services Lori Fitzgerald, Pharm.D.
Medicaid Services Bureau V. Lee Harrison, M.D.
1400 Broadway Stephen S. Nagy, M.D.
P.O. Box 202951 Richard Sargent, M.D.
Helena, MT 59620-2951
T: 406/444-2738 New Brand Name Products Contact
F: 406/444-1861 Dan Peterson
E-mail: danpeterson@mt.gov 406/444-2738
Internet address: www.mtmedicaid.org
Prescription Price Updating

Public Health and Human Services Officials First DataBank


1111 Bayhill Dr.
Dr. Robert E. Wynia, Director San Bruno, CA 94066
Department of Public Health and Human Services T: 650/588-5454
111 N. Sanders, Room 301 F: 650/827-4578
P.O. Box 4210
Helena, MT 59604-4210 Medicaid Drug Rebate Contacts
T:406/444-5622
F: 406/444-1970 Betty DeVaney, Drug Rebate Coordinator
E-mail: rewynia@state.mt.us Department of Public Health & Human Services
Medicaid Services Bureau
John Chappuis P.O. Box 202951
Medicaid Director 1400 Broadway
Division of Health Policy and Services Helena, MT 59620-2591
Department of Public Health and Human Services T: 406/444-3457
1400 Broadway F: 406/444-1861
Helena, MT 59601 E-mail: bdevaney@state.mt.us
T: 406/444-4084
F: 406/444-1861
E-mail: j.chappuis@state.mt.us

Montana-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Claims Submission Contact Montana State Board of Pharmacy


Rebecca Deschamps, R.Ph.
Brett Jakovac, Executive Account Manager
Executive Director
ACS, State Healthcare
P.O. Box 200513
34 N. Last Chance Gulch, Suite 200
301 South Park, 4th Floor
Helena, MT 59601
Helena, MT 59620-0513
T: 406/457-9555
T: 406/841-2371
F: 406/442-2819
F: 406/841-2305
E-mail: brett.jakovac@acs-inc.com
E-mail: dlibspdha@state.mt.gov
Internet address:
Medicaid Managed Care Contact discoveringmontana.com/dli/bsd/license/bsd_board
Niki Scoffield, Program Officer s/pha_board/board_page.asp
Dept. of Public Health and Human Services
Medicaid Services Bureau Montana Osteopathic Medical Association
1400 Broadway Carmen Bell
P.O. Box 202951 Executive Director
Helena, MT 59620-2951 1600 2nd Avenue, SW, Suite 120
T: 406/444-4148 Minot, ND 58701
F: 406/444-1861 701/852-8789
E-mail: niscoffield@mt.gov E-mail: ndoma@ndoma.org
Internet Address: www.mtoma.org
Mail Order Pharmacy Benefit
Association of Montana Health Care Providers
None Dick Brown
Sr. Vice President/Executive Director
Executive Officers of State Medical and P.O. Box 5119
Pharmaceutical Societies 1720 Ninth Avenue
Helena, MT 59601
Montana Medical Association 406/442-1911
G. Brian Zins E-mail: dick@mtha.org
Executive Vice President and CEO Internet address: www.mtha.org
2021 11th Avenue, Suite 1
Helena, MT 59601-4890
T: 406/443-4000
F: 406/443-4042
E-mail: brian@mmaoffice.com
Internet address: www.mmaoffice.com

Montana Pharmacy Association


Jim E. Smith
Executive Director
P.O. Box 1569
34 West 6th Avenue, Suite 2E
Helena, MT 59601-5074
T: 406/449-3843
F: 406/443-1592
E-mail: jimesmith@qwe.net
Internet address: www.rxmt.org/services.htm

Montana-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

NEBRASKA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $196,526,107 194,889 $197,518,471 197,704

RECEIVING CASH ASSISTANCE TOTAL $69,279,614 48,501


Aged $9,843,626 3,983
Blind/Disabled $49,388,569 15,517
Child $4,534,213 19,350
Adult $5,513,206 9,651

MEDICALLY NEEDY, TOTAL $48,643,279 33,380


Aged $29,632,049 9,808
Blind/Disabled $6,684,567 1,527
Child $2,260,713 6,761
Adult $10,065,950 15,284

POVERTY RELATED, TOTAL $65,092,537 90,997


Aged $15,871,572 6,505
Blind/Disabled $29,727,730 8,077
Child $18,756,687 71,241
Adult $694,614 5,144
BCCA Women $41,934 30

TOTAL OTHER EXPENDITURES/RECIPIENTS* $13,510,677 22,011

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data provided by the Nebraska Department of Health and Human Services, Finance and Support, Medicaid Division.

Source: CMS, MSIS Report, FY 2002 and Nebraska Medicaid Statistical Information System, FY 2003
Note: Nebraska estimates 2004 drug expenditures to be approximately $216.5 million and the number of Medicaid drug
recipients to be 192,000.

Nebraska-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Vaccines: Vaccines reimbursable by Medicaid for


individuals under 21 years of age as part of EPSDT
State Department of Health and Human Services, services, through the Children’s Health Insurance
Finance and Support, Medicaid Division. Program, and through the Vaccines for Children
Program.
D. PROVISIONS RELATING TO DRUGS
Unit Dose: Unit dose packaging not reimbursable.
Benefit Design
Formulary/Prior Authorization
Drug Benefit Product Coverage: Products covered:
legend drugs, compound prescriptions, prescribed Formulary: Open formulary managed through
insulin with prior approval (i.e., must be medically restrictions on use and prior authorization. General
necessary on pre-filled syringes). Products covered exclusions include:
under the supplier program: disposable needles
1. More than a three-month supply of birth
used for insulin; blood glucose test strips; urine
control tablets;
ketone test strips; total parenteral nutrition; and
interdialytic parenteral nutrition. Products not 2. Experimental drugs or non-FDA approved
covered: DESI drugs, drugs for weight control; drugs;
cosmetics; fertility drugs; and experimental drugs.
Prior authorization required for: methadone; IV 3. Drugs or items when the prescribed use is not
infusions; and protein replacement supplements. for a medically accepted indication;
4. Liquors (any alcoholic beverages);
Over-the-Counter Product Coverage: Products
covered: (must be prescribed and subject to rebate) 5. DESI drugs and all identical, related, or similar
allergy, asthma, and sinus products; analgesics; drugs;
topical products; vitamin/mineral supplements; 6. Personal care items (e.g. non-medical
eye/ear 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: anticoagulants; anticonvulsants; facility and intermediate care facility for the
antilipemic agents; anti-psychotics; cardiac drugs; mentally retarded (ICF/MR) patients;
prescribed cold medications; contraceptives; ENT 8. Over-the-counter (OTC) drugs not listed on the
anti-inflammatory agents; estrogens; hypotensive Department’s Drug Name/License Number
agents; sympathominetics (adrenergic); antibiotics; Listing microfiche;
anti-depressants; antidiabetic agents; and thyroid
agents. Prior authorization required for: 9. Baby foods or metabolic agents (Lofenalac,
sunscreens; Erythropoetin (e.g., Epogen, Procrit); etc.,) normally supplied by the Nebraska
modified versions of FUL or SMAC drugs; Department of Health;
convenience packaged drugs (e.g., Refresh 10. Drugs distributed or manufactured by certain
Ophthalmic 0.3 ml and Novalin penfil insulin); drug manufacturers or labelers that have not
drugs to prevent or treat Respiratory Syncytial agreed to participate in the drug rebate
Virus Immune Globulin (e.g., Palivizumab, RSV- program.
IG); and drugs for sexual dysfunction (e.g.,
Sildenafil, Alprostadil). Partial coverage (PA Drugs, items, or manufacturers that are identifiable
required) for: analgesics, antipyretics, NSAIDs; as non-covered are so designated on the NE-POP
antihistamines; anxiolytics, sedatives, and system, and on the Department’s Drug
hypnotics; chemotherapy agents; growth hormones; Name/License Number Listing microfiche or
and misc. GI drugs. Therapeutic categories not website.
covered: anabolic steroids; anorectics; and
prescribed smoking deterrents.

Coverage of Injectables: Injectables reimbursable


through the Pharmacy program when used in home
health care and extended care facilities, and through
physician payment when used in physician offices.

Nebraska-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Prior Authorization: State currently has a formal Maximum Allowable Cost: State imposes Federal
prior authorization procedure. Prescriber must Upper Limits as well as State-specific limits on
submit a letter of medical necessity with generic drugs. More than 1,500 drugs are listed on
documentation. The Department requires that the State-specific MAC list. Override requires a
authorization be granted prior to payment for “Brand Medically Necessary” form signed by the
certain products. Prior authorization can be physician.
verified through the NE-POP System, or by
contacting the Department. (or its designated Incentive Fee: None.
contractor) if authorization is not verified through
the NE-POP System. Patient Cost Sharing: Copayment = $2.00.

Additional Pharmacy Payments: Additional


Prescribing or Dispensing Limitations
payments for tablet splitting (effective 2000)
Prescription Refill Limit: As authorized by the
prescribing physician. For controlled substances,
maximum 5 refills every 6 months. E. USE OF MANAGED CARE
Monthly Quantity Limit: 90-day supply or 100 Approximately 65,000 unduplicated Medicaid
dosage units, whichever is greater. 31-days for recipients were enrolled in managed care in 2003.
injectables. Recipient enrolled in MCOs receive pharmaceutical
services through the State.
Drug Utilization Review
PRODUR system implemented in April 1995. Managed Care Organizations
State currently has a DUR Board that meets 10 Share Advantage
times each year. United Healthcare of the Midland
2717 North 118th Circle
Pharmacy Payment and Patient Cost Omaha, NE 68164
Sharing
Dispensing Fee: $3.27 - $5.00. The Nebraska Primary Care +
Department of Health and Human Services assigns Blue Cross/Blue Shield of Nebraska
a dispensing fee to each individual pharmacy based P.O. Box 241739
on location, services, volume, and other third-party Omaha, NE 68124
participation. The fee is calculated from
information obtained through the Department’s Magellan Behavioral Health
Prescription Survey. P.O. Box 82047
Lincoln, NE 68501
Ingredient Reimbursement Basis: EAC = AWP -
11%. F. STATE OFFICIALS
Prescription Charge Formula: Lower of: State Drug Program Administrator
1. Product cost (EAC, SMAC, or FUL) plus a Dyke Anderson, R.Ph
dispensing fee, or Pharmacy Consultant
Department of Health and Human Services
2. The usual and customary price to the general
Finance and Support /Medicaid Division
public.
301 Centennial Mall South, 5th Floor-NSOB
Listed OTCs are reimbursed at the lower of: P.O. Box 95026
Lincoln, NE 68509-5026
1. Product cost (EAC, SMAC, or FUL) plus a
T: 402/471-9379
dispensing fee,
F: 402/471-9092
2. The usual and customary shelf price to the E-mail: dyke.anderson@hhss.ne.gov
general public, or
3. Product cost (EAC, SMAC, or FUL) plus a
50% mark-up.

Nebraska-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Health and Human Services Department Physician Members:


Officials Kay Anderson, M.D.
Fred Ayers, M.D.
Richard P. Nelson, Director Kirk Muffly, M.D.
Department of Health and Human Services Thomas B. Murray, M.D.
Finance and Support Sam Perry, M.D.
P.O. Box 95026
Lincoln, NE 68509-5026 New Brand Name Products Contact
T: 402/471-8566
F: 402/471-9449 Dyke Anderson, R.Ph.
E-mail: kelly.ostrander@hhss.ne.gov 402/471-9379

Mary Steiner, Interim Administrator Prescription Price Updating


Medicaid Division Dyke Anderson, R.Ph.
Department of Health and Human Services 402/471-9379
Finance and Support
P.O. Box 95007 Medicaid Drug Rebate Contacts
301 Centennial Mall South, 5th Floor Technical
Lincoln, NE 68509-5007 Karen Jaques
T: 402/471-9567 Accountant II
F: 402/471-9092 Health and Human Services – Finance and Support
E-mail: mary.steiner@hhss.ne.gov 301 Centennial Mall South
5th Floor – NSOB
Prior Authorization Contacts P.O. Box 95026
Lincoln, NE 68509-5026
Dyke Anderson, R.Ph. T: 402/471-9397
402/471-9379 F: 402/471-7783
Barbara Mart E-mail: karen.jaques@hhss.ne.gov
Pharmacy Consultant
Health and Human Services Policy
301 Centennial Mall South Dyke Anderson, R.Ph.
5th Floor-NSOB 402/471-9379
P.O. Box 95026
Lincoln, NE 68509-5026 Claims Submission Contact
T: 402/471-9301 Barbara Pavolony
F: 402/471-9092 Account Manager
E-mail: barb.mart@hhss.ne.gov ACS State Healthcare
365 Northridge Road
DUR Contact Northridge Center One, Suite 400
Beth Wilson, R.Ph. Atlanta, GA 30350
DUR Director T: 770/352-8536
Nebraska Pharmacists Association F: 770/730-5198
6221 South 58th Street, Suite A E-mail: barbara.pavolony@acs-inc.com
Lincoln, NE 68516
T: 402/420-1500 Medicaid Managed Care Contact
F: 402/420-1406 David Cygan
E-mail: beth@npharm.org Managed Care Program Administrator
HHSS-Finance & Support-Medicaid
Nebraska DUR Board 301 Centennial Mall South
Pharmacist Members: P.O. Box 95026
Kevin Borcher, R.Ph. Lincoln, NE 68509
Elissa Carney, R.Ph. T: 402/471-9050
Patty Gollner, R.Ph. F: 402/471-9092
David Hutsell, R.Ph. E-mail: david.cygan@hhss.ne.gov
John Franklin, R.Ph.
Kim Hamik, R.Ph.
Shannon Nelson, R.Ph.
Phillip Vuchetich, R.Ph.

Nebraska-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Mail Order Pharmacy Program Pat Snyder


Executive Director
None
Nebraska Health Care Association
421 South 9th Street, Suite 137
Medical Advisory Committee Lincoln, NE 68508
Marlene Brondel
League of Human Dignity James Walker, D.D.S.
1701 P Street 1640 South 70th, Suite 200
Lincoln, NE 68508 Lincoln, NE 68506

Tim Bruner Executive Officers of State Medical and


Director of Fiscal Services Pharmaceutical Societies
Lincoln General Hospital
Nebraska Medical Association
2300 South 16th Street
Sandra Johnson
Lincoln, NE 68502
Executive Vice President
233 S. 13th Street, Suite 1512
Joni Cover, J.D.
Lincoln, NE 68508-2091
Executive Vice President
402/474-4472
Nebraska Pharmacists Association
E-mail: nebmed@nebmed.org
6221 South 58th Street, Suite A
Internet address: www.nebmed.org
Lincoln, NE 68502
Nebraska Pharmacists Association
Karen Miller, Health Insurance Specialist
Joni Cover, J.D.
Room 227, Federal Building
Executive Vice President
601 East 12th Street
6221 South 58th, Suite A
Kansas City, MO 64106
Lincoln, NE 68516-3679
T: 402/420-1500
Edmund A. Schneider, O.D.
F: 402/420-1406
Lincoln Vision Clinic
E-mail: joni@npharm.org
810 North 48th Street
Internet address: www.npharm.org
Lincoln, NE 68504
Nebraska Assn. of Osteopathic Physicians &
Steven Lorenzen
Surgeons
Director, Federal Programs
Blue Cross/Blue Shield of NE
(Inactive)
Main P.O. Station Box 3248
Omaha, NE 68180
Nebraska State Board of Pharmacy
Becky Wisell
John Milligan
Section Administrator, Pharmacist Licensure
Legal Services of Southeast Nebraska
P.O. Box 94986
825 Terminal Building
Lincoln, NE 68509
Lincoln, NE 68508
T: 402/471-2118
F: 402/471-3577
Joan Penrod, Ph.D.
E-mail: becky.wisell@hhss.state.ne.us
Department of Preventive and Social Medicine
Internet address:
UNMC
www.hhs.state.ne.us/medical/pharm/
Box 984350, 600 S. 42nd Street
Omaha, NE 68198
Nebraska Hospital Association
Laura J. Redoutey, FACHE
Larry Rennecker
President
NAHHS
1640 L Street, Suite D
1640 L Street, Suite D
Lincoln, NE 68508-2509
Lincoln, NE 68508
T: 402/458-4900
F: 402/475-4091
Sandy Johnson
E-mail: lredoutey@nhanet.org
Executive Secretary
Internet address: www.nhanet.org
Nebraska Medical Association
First Bank Bldg., Suite 1512
Lincoln, NE 68508

Nebraska-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Nebraska-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

Nevada-0
National Pharmaceutical Council Pharmaceutical Benefits 2004

*Total Other Expenditures/Recipients includes foster care


NEVADA2 children, 1115 demonstration participants, other recipients and
unknown.
A. BENEFITS PROVIDED AND **2003 data on expenditures and number of recipients by
maintenance assistance status and basis of eligibility are
GROUPS ELIGIBLE unavailable.

Type of Benefit Categorically Needy Source: CMS, MSIS Report


Medically
FY 2002Needy (MN)Report, FY
and CMS-64
Blind/ 2003 Blind/
Aged Child Adult Aged Child Adult
Disabled Disabled
Prescribed Drugs ‹ ‹ ‹ ‹
Inpatient Hospital Care ‹ ‹ ‹ ‹
Outpatient Hospital Care ‹ ‹ ‹ ‹
Laboratory & X-ray Service ‹ ‹ ‹ ‹
Nursing Facility Services ‹ ‹ ‹ ‹
Physician Services ‹ ‹ ‹ ‹
Dental Services ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS

2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $90,134,969 71,950 $106,821,075

RECEIVING CASH ASSISTANCE TOTAL $64,869,022 34,682


Aged $13,073,373 6,228
Blind/Disabled $49,568,652 17,472
Child $953,980 6,473
Adult $1,273,017 4,509

MEDICALLY NEEDY, TOTAL $0 0


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

POVERTY RELATED, TOTAL $2,687,912 11,667


Aged $163,078 204
Blind/Disabled $423,871 329
Child $834,644 5,694
Adult $1,266,319 5,440
BCC Women $0 $0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $22,578,035 25,601

2 The State of Nevada did not respond to the 2004 NPC


Survey. Using CMS data and other source materials, we
have, to the extent possible, updated the profile and the
tables in other sections of the Compilation. Users should
contact the Nevada Medicaid Program to assess the
accuracy and currency of the information included.

Nevada-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Vaccines: Vaccines reimbursable at cost plus an


administration fee ($3.83) as part of the EPSDT
Division of Health Care Financing and Policy of service.
the Department of Human Resources. Unit Dose: Unit dose packaging reimbursable.

D. PROVISIONS RELATING TO DRUGS Formulary/Prior Authorization


Formulary: Open formulary. General exclusions
Benefit Design include:
Drug Benefit Product Coverage: Products covered: 1. Agents used for cosmetic purposes or hair
prescribed insulin; disposable needles and syringe growth.
combinations used for insulin; blood glucose test
2. Yohimbine (e.g., Yocon).
strips; and urine ketone test strips. Products covered
under DME: total parental nutrition; interdialytic 3. Radiopaque agents (e.g., Telepaque, Hypaque,
parenteral nutrition. Products not covered: Barium Sulfate).
cosmetics; fertility drugs; and experimental drugs. 4. Radiographic adjuncts (e.g., Perchloracap).
5. Pharmaceuticals designed “ineffective,” or
Over-the-Counter Product Coverage: Products “less than effective” (including identical,
covered: allergy, asthma, and sinus products; related, or similar drugs) by the FDA.
analgesics; cough and cold preparations; digestive
6. Non-rebated medications.
products; and smoking deterrent products. Products
covered with restrictions: topical products. OTC Prior Authorization: State currently has a prior
drugs are reimbursed at EAC+$4.76 or the usual authorization procedure with appeals process. Prior
and customary amount, whichever is less, and authorization procedure screening for individual
require prior authorization. Products not covered: drugs. Drugs requiring PA include:
feminine products. 1. Amphetamine (e.g., Dexedrine)
2. Chorionic Gonadotropin (HCG)
Therapeutic Category Coverage: Therapeutic
categories covered: analgesics, antipyretics, and 3. Dipyridamole (e.g., Persantine)
NSAIDs; antibiotics; anticoagulants; 4. Erythropoietin (e.g., Epogen, Procrit)
anticonvulsants; anti-depressants; antidiabetic 5. Gonadotropin releasing hormone analog (e.g.,
agents; antihistamine drugs; antilipemic agents; Lupron, Zoladex)
anti-psychotics; anxiolytics, sedatives, and
6. Growth hormone (e.g., Protropin, Nutropin)
hypnotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives; ENT 7. Interferon (all combinations manufactured by
anti-inflammatory agents; hypotensive agents; recombinant DNA technology)
misc. GI products; prescribed smoking deterrents; 8. Intravenous antibiotic therapy
sympathominetics (adrenergic); and thyroid agents. 9. Methylphenidate (e.g., Ritalin)
Prior authorization required for: CNS stimulants;
Hemapopoiletic; PPIs; Cox2 inhibitors; erectile 10. Non-legend pharmaceuticals
dysfunction medications; duragisic patches; HCG; 11. Nutritional supplements or replacements
Gonadotropin, Gonadotropin releasing hormone 12. Pemoline (e.g., Cylert)
analog; Erythropoetin; Interferon; IV antibiotic; 13. Pulmozyme
Methylpenidate, Peomoline; vitamins; and
Remicade. Partial coverage for: growth hormones 14. Vitamins, vitamin/mineral combinations or
(prior authorization required); estrogens; and hematinics
anabolic steroids. Therapeutic categories not Prescribing or Dispensing Limitations
covered: anorectics; amphetamine combinations;
radiopague and radiographic products; DESI drugs; Monthly Quantity Limit: The maximum dispensable
yohimbine; and drugs not participating in the drug quantity is limited to a 34-day supply. Maintenance
rebate program. medications limited to a 100-day supply.

Coverage of Injectables: Injectable medicines Monthly Quantity Limit: 5 refills within 6 months
reimbursable through the Prescription Drug for controlled drugs. Up to 11 refills for non-
Program when used in home health care and controlled drugs.
extended care facilities, and through physician
payment when used in physicians’ office

Nevada-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Drug Utilization Review F. STATE CONTACTS


State currently has a DUR Board with a quarterly
review by a PRODUR contractor. PRODUR system State Drug Program Administrator
implemented in 2003. Dionne Coston, R.N., Medical Services Specialist
Division of Health Care Financing and Policy
Pharmacy Payment and Patient Cost Pharmacy Program
Sharing 1100 E. Williams Street
Dispensing Fee: $4.76, effective 10/1/98. IV Carson City, NV 89701
dispensing fee is $16.80 for first ingredient; $5.60 T: 775/684-3775
for other ingredients. F: 775/684-3762
Email: dcpstpm@dhcfp.state.nv.us
Internet address: www.dhcfp.state.nv.us
Ingredient Reimbursement Basis: EAC = AWP-
15%.
Human Resources Department Officials
Prescription Charge Formula: The lowest of (1)
specific upper limit (SUL) plus a dispensing fee, (2) Michael J. Willden, Director
estimated acquisition cost (EAC) plus a dispensing Department of Human Resources
fee, or (3) the pharmacy's usual charge to the State Capital Complex
general public. 505 East King Street, Room 600
Carson City, NV 89710
Maximum Allowable Cost: State imposes State- T: 775/684-4000
specific limits on generic drugs. Override requires F: 775/684-4010
“Brand Medically Necessary.” E-mail: slindsey@dhr.state.nv.us

Incentive Fee: None. Charles Duarte, Administrator


Division of Health Care Financing and Policy
Patient Cost Sharing: None. 1100 E. Williams Street, Suite 116
Carson City, NV 89710
Cognitive Services: Does not pay for cognitive T: 775/684-3676
services. F: 775/684-8792
E-mail: cduarte@govmail.state.nv.us
E. USE OF MANAGED CARE Prior Authorization Contact
Approximately 75,000 Medicaid recipients are Dionne Coston, R.N.
enrolled in MCOs in 2003; all receive pharmacy 775/684-3775
benefits through their managed care plan. Steve Espy, R.Ph., Director of Drug Utilization
Health Information Design, Inc.
Managed Care Organizations 1550 Pumphrey Avenue
Health Plan of Nevada Auburn, AL 36832
P.O. Box 15645 T: 205/402-9530
Las Vegas, NV 89114 F: 205/402-9531
702/242-7317
DUR Contact
NevadaCare, Inc.
Dionne Coston, R.N.
10600 W. Charleston Blvd.
775/684-3775
Las Vegas, NV 89135
T: 702/304-5500
DUR Board
F: 702/474-7592
Joseph W. Johnson, M.D.
Steven W. Parker, M.D.
David England, R.Ph., Pharm.D. (Chair)
Lori Winchell, R.N.P.
Keith W. MacDonald, Pharm.D.
Amy H. Schwartz
Marjorie Uhalde, M.D., Ph.D.

Nevada-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

New Brand Name Products Contact Pharmacy and Therapeutics Committee


Dionne Coston, R.N. Steven L. Phillips, M.D. (Chair)
775/684-3775 Diana L. Bond, R.Ph.
Judy Britt, Pharm.D.
Prescription Price Updating
Linda Flynn, R.Ph.
First DataBank Alan Greenberg, M.D.
1111 Bayhill Drive, Suite 350 Carl Heard, M.D.
San Bruno, CA 94066 Robert L. Horne, M.D.
T: 650/588-5454 Larry L. Pinson, Pharm.D.
F: 650/827-4578 Susan L. Pintar, M.D.
Thomas H. Wiser, Pharm.D.
Medicaid Drug Rebate Contacts Executive Officers of State Medical and
Technical: Anita Sheard, 775/684-3749 Pharmaceutical Societies
Policy: Dionne Coston, R.N., 775/684-3755 Nevada State Medical Association
Rebate: Anita Sheard, 775/684-3749 Lawrence P. Matheis
Executive Director
Claims Submission Contact 3660 Baker Lane, Suite 101
First Health Services Corp. Reno, NV 89509
4300 Cox Road T: 775/825-6788
Glen Allen, VA 23060 F: 775/825-3202
800/884-3238 E-mail: nsma@nsmadocs.org
Internet address: www.nsmadocs.org
Medicaid Managed Care Contact
Nevada Pharmacy Alliance
Hilary Jones, R.N. Mary Grear, R.Ph.
Medicaid Services Specialist III Executive Vice President
1100 E. Williams Street, Suite 204 c/o Nevada College of Pharmacy
Carson City, NV 89701 5740 S. Eastern Avenue, Suite 24C
775/684-3697 Las Vegas, NV 89119
E-mail: hjones@dhcfp.state.nv.us T: 702/259-3449
F: 702/259-3521
Mail Order Pharmacy Program E-mail: nvphall@ludi.net
None Internet address: www.nvphall.org

Physician-Administered Drug Program Nevada Osteopathic Medical Association


Contact Denise Selleck Davis
Executive Director
Coleen Lawrence, 775-684-3744 405 Max Court, Suite K
Henderson, NV 89015
Medical Care Advisory Committee T: 702/434-7112
Trudy Larson, M.D. (Chair) F: 702/434-7110
Mr. Paul Boyar (LTC Administrator) E-mail: nvoma@earthlink.com
Patricia Craddock, D.D.S. Internet address: www.nevadaosteopathic.com
Ms. Jessie Harris
Mr. Keith MacDonald, Pharm.D. Nevada State Board of Pharmacy
Mr. Ken Richardson (Admnistrator, Health Care Keith W. MacDonald, R.Ph.
Clinic) Executive Secretary
Ms. Linda Sheldon (Advocate for Children) 555 Double Eagle Court, Suite 1100
Bradford Lee, M.D. (Nevada State Health Officer) Reno, NV 89511-8991
T: 775/850-1440
F: 775/850-1444
E-mail: pharmacy@govmail.state.nv.us
Internet address: www.state.nv.gov/pharmacy

Nevada-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Nevada Hospital Association


Bill M. Welch
President and CEO
5250 Neil Road
Suite 302
Reno, NV 89502
T: 775/827-0184
F: 775/827-0190
E-mail: bill@nvha.net
Internet address: www.nvha.net

Nevada-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Nevada-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

**2003 data on expenditures and number of recipients by


maintenance assistance status and basis of eligibility are
NEW HAMPSHIRE unavailable.
Source: CMS, MSIS Report, FY 2002 and CMS-64
Report, FY 2003.
A. BENEFITS PROVIDED AND
GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/ Child Adult Aged Blind/ Child Adult
Disabled Disabled
Prescribed Drugs ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Inpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Outpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Laboratory & X-ray Service ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Nursing Facility Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Physician Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Dental Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $98,836,636 78,861 $112,948,647

RECEIVING CASH ASSISTANCE, TOTAL $27,161,385 19,253


Aged $3,424,175 1,431
Blind/Disabled $19,092,652 5,671
Child $1,763,556 7,911
Adult $2,881,002 4,240

MEDICALLY NEEDY, TOTAL $24,082,471 9,223


Aged $10,981,139 4,380
Blind/Disabled $10,425,563 2,472
Child $463,065 935
Adult $2,212,704 1,436

POVERTY RELATED, TOTAL $8,422,399 30,040


Aged $441,811 287
Blind/Disabled $600,362 327
Child $7,006,717 27,509
Adult $373,509 1,917
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/ RECIPIENTS* $39,170,381 20,345

*Total Other Expenditures/Recipients includes foster care


children, 1115 demonstration participants, other recipients,
and unknown.

Nevada-7
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION providers for routine vaccines, although an


administration fee is allowed.
Office of Medicaid, Business and Policy;
Department of Health and Human Services. Unit Dose: Unit dose packaging reimbursable.

D. PROVISIONS RELATING TO DRUGS Formulary/Prior Authorization


Formulary: States maintain a formulary with a
Benefit Design preferred drug list. General exclusions include
Drug Benefit Product Coverage: Products covered: cosmetic agents for hair growth, experimental and
prescribed insulin; disposable needles and syringe fertility drugs. Management of formulary includes
combinations for insulin; blood glucose test strips; prior authorization and quantity limits on certain
urine ketone test strips; total parenteral nutrition; products (e.g., anti-emetics, anti-migraine agents,
and interdialytic parenteral nutrition. Products not etc.).
covered: cosmetics; fertility drugs; and
experimental drugs. Prior Authorization: State currently has a formal
prior authorization procedure with an associated
Over-the-Counter Product Coverage: Products grievance and appeal procedure.
covered: allergy, asthma, and sinus products;
analgesics; cough and cold preparations; digestive Prescribing or Dispensing Limitations
products (including H2 antagonists); feminine Monthly Quantity Limit: Limited to 30-day supply
products smoking deterrents; and topical products. Maintenance Medications: Limited to 90-day
Supply
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; Monthly Dollar Limits: None.
anticoagulants; anticonvulsants; chemotherapy
agents; prescribed cold medications; Drug Utilization Review
contraceptives; estrogens; growth hormones;
thyroid agents; and prescribed smoking deterrents. PRODUR system implemented in July 1995. State
Therapeutic categories/products requiring prior currently has a DUR Board with a quarterly review.
authorization: analgesics, antipyretcs; and
NSAIDs*; anorectics; antibiotics; antidepressants; Pharmacy Payment and Patient Cost
antidiabetic agents; antihistamines; antilipemic Sharing
agents; anti-psychotics; anxiolytics, sedatives, and
Dispensing Fee: $1.75, effective 1/24/2004.
hypnotics; cardiac drugs; ENT anti-inflammatory
agents; hypotensive agents; misc. GI drugs*;
Ingredient Reimbursement Basis: EAC = AWP-
sympathominetics (adrenergic); erectile dyfunction
16%.
products; PPIs; Cox IIs; CNS stimulants; anti-
fungals for nail fungus; leukotrine modifiers;
Prescription Charge Formula: Lesser of usual and
glaucoma agents; triptans; anti-emetics;
customary charge or AWP-16%, Federal Upper
Alzheimer’s agents; and rheumatoid arthritis
Limit; State MAC; or DOJ pricing, plus a
agents.
dispensing fee. Special rules for Blood Factor
*Brand approval override required for NSAIDs, products on the DOJ price list.
controlled substances, and GI drugs for which there
are therapeutically equivalent (A-rated) generics Maximum Allowable Cost: State imposes Federal
available. Upper Limits as well as State-specific limits on
generic drugs. Override requires “Brand Medically
Coverage of Injectables: Injectable medicines
Necessary.”
reimbursable through the Prescription Drug
Program when used in home healthcare and
extended care facilities, and through physician Incentive Fee: None.
payment when used in physicians’ offices.
Patient Cost Sharing: Copayment – Generics:
Vaccines: Vaccines reimbursable as part of the $1.00; Brand: $2.00, effective 3/1/04. Copayments
EPSDT, CHIP, and VCP service. Childhood apply to all recipients except nursing home patients
immunization vaccine is provided to all children in SNF or ICF facilities; home and community
through the Division of Public Health Services. based care waived recipients holding form 949;
The Medicaid program does not reimburse pregnant women; children under 18 years; and
prescriptions for family planning drugs.

New Hampshire-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Cognitive Services: Does not pay for cognitive Medicaid DUR Board
services.
Paul S. Collins, M.D.
Mark Henschke, D.O.
E. USE OF MANAGED CARE Emory Kaplan, M.D.
Steve Lawrence, M.D.
None as of June 2003. Thomas Mellman, M.D.
Elizabeth Gower, R.Ph.
Helen Pervanas, R.Ph.
F. STATE CONTACTS Michael Smith, R.Ph.
John Zinka, R.Ph.
State Drug Program Administrator
Margaret A. Clifford New Brand Name Products Contact
Pharmacy Administrator Lise C. Farrand, R.Ph.
Office of Medicaid Business and Policy Pharmaceautical Services Specialist
129 Pleasant Street, Annex 1 Office of Medicaid Business and Policy
Concord, NH 03301 129 Pleasant Street, Annex 1
T: 603/271-4210 Concord, NH 03301
F: 603/271-8701 T: 603/271-4419
E-mail: mclifford@dhhs.state.nh.us F: 603/271-8701
Internet address: E-mail: lfarrand@dhhs.state.nh.us
www.dhhs.state.nh.gov/dhhs/medicaidprogram

Department of Health and Human Services Prescription Price Updating


Officials Sherrill Bryant
John A. Stephen Plan Administrator
Commissioner First Health Services Corporation
Department of Health and Human Services 4300 Cox Road
129 Pleasant Street Glen Allen, VA 23060
Concord, NH 03301-3857 T: 800/884-2822
T: 603/271-4331 F: 804/965-7647
F: 603/271-4912 E-mail: bryantsh@fhsc.com
E-mail: jstephen@dhhs.state.nh.us
Medicaid Drug Rebate Contacts
Stephen Norton
Director John Cox
Office of Health Planning & Medicaid Rebate Pharmacist
Office of the Commissioner First Health Services Corporation
129 Pleasant Street 4300 Cox Road
Concord, NH 03301-6521 Glen Allen, VA 23060
T: 603/271-3676 T: 800/884-2822
F: 603/271-8431 F: 804/965/7647
E-mail: snorton@dhhs.state.nh.us E-mail: coxjo@fhsc.com

DUR Contact Claims Submission Contact

Robert Coppola Sherrill Bryant


Clinical Manager 800/884-2822
First Health Services Corporation
17 Chenell Drive Medicaid Managed Care Contact
Concord, NH 03301 Margaret A. Clifford
T: 603/224-2083 603/271-4210
F: 603/224-6690
E-mail: coppolro@fhsc.com Mail Order Pharmacy Benefit
None

New Hampshire-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Disease Management/Patient Education New Hampshire State Board of Pharmacy


Contact Paul G. Boisseau, R.Ph.
Executive Secretary
Doris Lotz, M.D.
57 Regional Drive
Medicaid Medical Director
Concord, NH 03301-8518
Office of Health Planning & Medicaid
T: 603/271-2350
129 Pleasant Street, Annex 1
F: 603/271-2856
Concord, NH 03301
E-mail: nhpharmacy@nhsa.state.nh.us
T: 603/271-8166
Internet address: www.state.nh.us/pharmacy
F: 603/271-8701
E-mail: dlotz@dhhs.state.nh.us
New Hampshire Hospital Association
Michael J. Hill, C.H.E.
Pharmacy & Therapeutics Advisory President
Committee 125 Airport Road
William Kassler, M.D., M.P.H. Concord, NH 03301-7300
Stephen Bartels, M.D. T: 603/225-0900
Doris Lotz, M.D. F: 603/225/4346
Bryan King, M.D. E-mail: mhill@nhha.org
Steven Paris, M.D. Internet address: www.nhha.org
Richard Lafleur, M.D.
Eric Pollak, M.D., M.P.H.Lenny Parker, R.Ph.
Margaret Clifford, R.Ph.
Roger Hebert, R.Ph.
Paul Santos, Pharm.D.
Robert Lenza, R.Ph.

Executive Officers of State Medical and


Pharmaceutical Services
New Hampshire Medical Society
Palmer P. Jones
Executive Vice President
7 N. State Street
Concord, NH 03301-4018
T: 603/224-1909
F: 603/226-2432
E-mail: palmer.jones@nhms.org
Internet address: www.nhms.org
New Hampshire Pharmacists Association
David Minnis
Executive Director
2 Eagle Square, Suite 400
Concord, NH 03301
T: 603/229-0292
F: 603/224-7769
E-mail: mms@worldpath.net
Internet address: www.nhpharmacists.org
New Hampshire Osteopathic Association, Inc.
Robert Soucy, D.O.
President
7 North State Street
Concord, NH 03301
603/224-1909
E-mail: nhspecsoc@juno.com
Internet address: www.nhosteopath.org

New Hampshire-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

NEW JERSEY

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $686,301,522 296,059 $766,995,569

RECEIVING CASH ASSISTANCE, TOTAL $363,069,902 139,560


Aged $72,311,029 28,986
Blind / Disabled $285,795,677 85,000
Child $2,049,951 14,902
Adult $2,913,245 10,672

MEDICALLY NEEDY, TOTAL $10,351,402 3,657


Aged $9,122,951 3,389
Blind / Disabled $1,223,455 254
Child $4,996 14
Adult $0 0

POVERTY RELATED, TOTAL $111,545,421 57,258


Aged $34,813,603 13,901
Blind / Disabled $73,422,788 16,669
Child $2,790,853 21,063
Adult $469,454 5,587
BCCA Women $48,723 38

TOTAL OTHER EXPENDITURES/RECIPIENTS* $201,334,797 95,584

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.

1 The State of New Jersey did not respond to the 2002 or 2003 NPC Surveys. Using CMS data and other source materials, we have, to the
extent possible, updated the Profile and the tables in other sections of the Compilation. Users should contact the New Jersey Medicaid
program to assess the accuracy and currency of the information included.

New Jersey-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

New Jersey-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Formulary/Prior Authorization


Formulary: Open formulary. General exclusions
Division of Medical Assistance and Health include experimental drugs, cosmetics, fertility
Services, Department of Human Services. drugs, DESI drugs, and drugs for which FFP is not
available (OBRA '90).
D. PROVISIONS RELATING TO DRUGS
Prior Authorization: State currently has a formal
Benefit Design prior authorization procedure. Prior authorization is
implemented by DUR edit criteria, not by
Drug Benefit Product Coverage: Products covered: therapeutic category. Periodic review for
prescribed insulin; disposable needles and syringe reconsideration possible for excluded product from
combinations for insulin use; blood glucose test formulary. Fair hearings possible for appealing
strips; urine ketone test strips; total parenteral prior authorization decisions.
nutrition; and interdialytic parenteral nutrition.
Products not covered: cosmetics; fertility drugs; Prescribing or Dispensing Limitations
and experimental drugs, and DESI drugs. Prior
authorization required for: methadone; IV Prescription Refill Limit: 5 times within a 6-month
infusions; and protein replacement supplements. period.

Over-the-Counter Product Coverage: Products Monthly Quantity Limit: Original, 34-day supply.
covered: digestive products (non-H2 antagonists); Refills, 34 days or 100 units, whichever is more.
smoking deterrent products (inhalers or nasal
spray); contraceptive devices and supplies; and Drug Utilization Review
family planning supplies (e.g., pregnancy test kits). PRODUR system implemented in October 1996.
Products covered with restrictions (for children State currently has a DUR Board with a quarterly
under age 21 only): allergy, asthma, and sinus review.
products; analgesics; topical products; and cough
and cold preparations. Products not covered: Pharmacy Payment and Patient Cost
digestive products; (H2 antagonists); feminine Sharing
products; contraceptives; inhalation drugs; and
antacids. Dispensing Fee: $3.73 for legend drugs.
Additional add-ons per/Rx shall be given to
Therapeutic Category Coverage: Therapeutic pharmacy providers who provide the following:
categories covered: anabolic steroids; analgesics,
antipyretics, NSAIDs; antibiotics; anticoagulants; 1. 24-hr. Emergency Service: add $0.11
anticonvulsants; anti-depressants; antidiabetic 2. Patient Consultation: add $0.08
agents; antihistamines; antilipemic agents; anti-
psychotics; anxiolytics, sedatives, and hypnotics; 3. Impact Area Location: add $0.15 (provider
cardiac drugs; chemotherapy agents; prescribed shall have a combined Medicaid, NJ KidCare
cold medications; ENT anti-inflammatory agents; and PAAD prescription volume equal to or
estrogens; hypotensive agents; prescribed smoking greater than 50% of total prescription volume.
deterrents; sympathominetics (adrenergic); and
Ingredient Reimbursement Basis: EAC = AWP-
thyroid agents. Partial coverage for: anorectics (for
12.5%. AAC for injectables, effective 5/1/00.
ADD); contraceptives; growth hormones; and misc.
GI drugs.
Prescription Charge Formula: “Maximum
Allowable Cost,” or Average Wholesale Price-
Coverage of Injectables: Injectable medicines
12.5% (reduction from AWP is pharmacy specific)
reimbursable through both the Prescription Drug
plus a dispensing fee or the provider’s usual and
Program and through physician payment when used
customary charge, whichever is lower.
in home health care, extended care facilities, and
physician offices.
Maximum Allowable Cost: State imposes Federal
Upper Limits on generic drugs. Override requires
Vaccines: Vaccines reimbursable at AWP as part of
“Dispense as Written” or “Medically Necessary.”
the Vaccines for Children Program.
Incentive Fee: None.
Unit Dose: Unit dose packaging reimbursable in
Patient Cost Sharing: None.
long-term care facilities only, not in retail settings
(unless u/d is only way item is packaged).

New Jersey-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Cognitive Services: Does not pay for cognative Department of Human Services Officials
services.
James M. Davy, Commissioner
Department of Human Services
E. USE OF MANAGED CARE Capitol Place One CN-700, 5th Floor
P.O. Box 700
Approximately 640,000 Medicaid recipients Trenton, NJ 08625
received pharmacy benefits through managed care T: 609/292-3717
in 2003. Beneficiaries receive pharmaceutical F: 609/292-3824
benefits through the State and through MCOs. E-mail: james.davy@dhs.state.nj.us
Mental health drugs and prescriptions for the aged,
blind, and disabled (ABD) population are carved Ann Clemency Kohler, Director
out of managed care. Division of Medical Assistance and Health Services
Department of Human Services
Managed Care Organizations P.O. Box 712
Trenton, NJ 08625-0712
AMERIGROUP New Jersey, Inc T: 609/588-2600
399 Thornall Street, 9th Floor F: 609/588-3583
Edison, NJ 08837 E-mail: ann.kohler@dhs.state.nj.us
800/600-4441
DUR Contact
Health Net of New Jersey, Inc.
CNA Building Kaye Morrow
3501 State Highway 66 Assistant Director
Neptune, NJ 07754 Department of Human Services
800/555-2604 Division of Medical Assistance and Health Services
Office of Provider Relations
AmeriChoice of New Jersey, Inc. P.O. Box 712
Two Gateway Center, 13th Floor Trenton, NJ 08619
Newark, NJ 07102 T: 609/631-2396
800/941-4647 F: 609/588-3889
E-mail: kaye.s.morrow@dhs.state.nj.us
Horizon NJ Health Medicaid DUR Board
210 Silvia Street
Trenton, NJ 08628 Christopher A. Cella, R.Ph.
800/765-4325 Judith Martinez Rodriguez, R.Ph.
Joseph Nicholas Micale, M.D.
University Health Plans, Inc. Rochelle Dallago, R. Ph.
550 Broad Street, 17th Floor Linda Gooen, Pharm D., R.Ph.
Newark, NJ 07102 Eileen Moynihan, M.D.
800/564-6847 David Ethan Swee, M.D.

Prior Authorization Contact


F. STATE CONTACTS
Marion Pardes
State Drug Program Administrator Director
First Health Services Corporation
Joseph B. Martinez, Chief College Road
Pharmaceutical Services Plainsboro, NJ 08536
Department of Human Services T: 609/919-1897
Division of Medical Assistance and Health Services F: 609/919-9465
Office of Utilization Management E-mail: mepardes@fhsc.com
P.O. Box 712
Trenton, NJ 08619 New Brand Name Products Contact
T: 609/588-2774 Joseph B. Martinez
F: 609/588-3889 T: 609/588-2774
E-mail: joseph.b.martinez@dhs.state.nj.us
Internet address: www.state.nj.us

New Jersey-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Prescription Price Updating Executive Officers of State Medical and


Pharmaceutical Societies
First DataBank
1111 Bayhill Dr. Medical Society of New Jersey
San Bruno, CA 94066 Michael T. Kornett
415/588-5454 Executive Director
2 Princess Road
Medicaid Drug Rebate Contacts Lawrenceville, NJ 08648-2302
T: 609/896-1766
Technical: Daniel Upright, 609/588-4611 F: 609/896-1368
Policy: Joseph B. Martinez, 609/588-2774 E-mail: mkornett@msnj.org
Internet address: www.msnj.org
Claims Submission Contact
New Jersey Pharmacists Association
Edward J. Vaccaro, R. Ph. Joseph V. Roney, R.Ph.
Assistant Director Chief Executive Officer
Office of Utilization Management 760 Alexander Road, P.O. Box 1
Department of Human Services Princeton, NJ 08543-0001
Division of Medical Assistance and Health Services T: 609/275-4246
P.O. Box 712 F: 609/275-4066
Trenton, NJ 08619 E-mail: joeroney@njaj.com
T: 609/588-3475 Internet address: www.njpharma.org
F: 609/588-3889
E-mail: edward.vaccaro@dhs.state.nj.us New Jersey Association of Osteopathic Physicians
Medicaid Managed Care Contact & Surgeons
Robert W. Bowen
Jill Simone, M.D. Executive Director
Director 1 Distribution Way, Suite 201
Managed Health Care Monmouth Junction, NJ 08852
Department of Human Services T: 732/940-9000
Division of Medical Assistance and Health Services F: 732/940-8899
P.O. Box 712 E-mail: rbowen@njosteo.com
Trenton, NJ 08619 Internet address: www.njosteo.com
T: 609/588-2705
F: 609/588-2774 New Jersey State Board of Pharmacy
E-mail: jill.simone@dhs.state.nj.us Remi Erdos
Executive Director
Mail Order Benefit Program P.O. Box 45013
Newark, NJ 07101
None 973/504-6450
E-mail: askconsumeraffairs@dca.lps.state.nj.us
Elderly Expanded Drug Coverage Contact Internet address:
www.state.nj.us/lps/ca/brief/pharm.htm
Wade Epps, Director
Department of Health and Senior Services New Jersey Hospital Association
12 Quakerbridge Plaza Gary S. Carter, FACHE
Mercerville, NJ 08619 President & CEO
T: 609/588-7640 760 Alexander Road, P.O. Box 1
F: 609/631-4667 Princeton, NJ 08543-0001
E-mail: wad.epps@doh.state.nj.us 609/275-4000
E-mail: gcarter@njha.com
Internet address: www.njha.com

New Jersey-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

NEW MEXICO

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003*
Expenditures Recipients Expenditures Recipients

TOTAL $92,674,018 122,098 $86,408,362

RECEIVING CASH ASSISTANCE TOTAL $11,574,166 24,286


Aged $2,231,875 5,200
Blind/Disabled $8,861,075 12,384
Child $167,821 3,257
Adult $313,385 3,445

MEDICALLY NEEDY, TOTAL $0 0


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

MEDICALLY NEEDY, TOTAL $667,225 8,009


Aged $41,483 132
Blind/Disabled $165,963 254
Child $430,430 7,110
Adult $29,349 513
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $80,432,627 89,803

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

New Mexico-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Coverage of Injectables: Injectable medicines


reimbursable through both the Prescription Drug
Human Services Department (HSD), Medical Program and physician payment when used in
Assistance Division. physician offices, home health care, and extended
care facilities.
D. PROVISIONS RELATING TO DRUGS Vaccines: Vaccines reimbursable as part of the
EPSDT service, the Children’s Health Insurance
Benefit Design Program, the Vaccine for Children Program,and
various Department of Health Programs.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe
Unit Dose: Does not reimburse for unit dose
combinations used for insulin; blood glucose test
packaging.
strips; urine ketone test strips; total parenteral
nutrition; and interdialytic parenteral nutrition. Prior
Formulary/Prior Authorization
authorization required for: amphetamines and
stimulants for ADD (adults only); nutritional Formulary: Open formulary with preferred drug list
supplements; and drugs used to treat impotence. (PDL). PDL managed through restrictions on use,
Products not covered: drugs for treatment of prior authorization, and therapeutic “step”
tuberculosis; cosmetics; experimental drugs; requirements.
fertility drugs; drugs and immunizations available
from any other source; medications supplied by the Prior Authorization: State currently has a formal
New Mexico State Hospital to clients on prior authorization procedure screening for drug
convalescent leave from hospital; hormones; classes with right of fair hearing to appeal a prior
stimulants; drugs classified by FDA as authorization decision.
“ineffective;” hypnotic drugs (barbiturates); and
drugs without Medicaid rebate participation Prescribing or Dispensing Limitations
agreement.
Monthly Quantity Limit: 34-day supply maximum,
Over-the-Counter Product Coverage: OTC excluding birth control pills (1 year) and maintain
products covered when a) they may be the drug of drugs (90 days). Number of refills must conform to
choice for common medical conditions or b) when applicable State and Federal laws.
they are an appropriate and therapeutic alternative
to prescription drugs. Products covered: insulin; Drug Utilization Review
antacids for active gastric and duodenal ulcers;
infant vitamin drops for up to 1 year; Salicylates PRODUR system implemented in October 1993.
and acetaminophen; vitamins; iron; minerals; and State currently has a DUR Board that meets at
pediculocides; laxatives, stool softeners, calcium, between 1-4 times per year.
nicotine replacement, ibuprofen, antihistamines,
decongestants, expectorants, cough suppressants, Pharmacy Payment and Patient Cost Sharing
anti-candida, and antifungals. Products covered
with restriction: topical products (specific Dispensing Fee: $3.65, effective 6/12/02.
therapeutic categories). Products not covered: Ingredient Reimbursement Basis: EAC = AWP-
personal care items (i.e., over-the-counter shampoo 14%.
and soap); feminine products.
Prescription Charge Formula: Prescriptions
Therapeutic Category Coverage: Products Covered: reimbursed at the lesser of the following:
anabolic steroids; analgesics, antipyretics, and
NSAIDs, antibiotics; anticoagulants; 1. Cost (EAC or MAC) dispensed plus a
anticonvulsants; antidepressants; antidiabetic dispensing fee or,
agents, antihistamines; antilipemic agents; anti- 2. The usual and customary charge by the
psychotics; anxyolitics, sedatives, and hypnotics; pharmacy to the general public.
cardiac drugs; chemotherapy agents; prescribed
cold medications; contraceptives; ENT anti- Maximum Allowable Cost: State imposes Federal
inflammatory agents; estrogens; growth hormones; Upper Limits as well as State-specific limits on
hypotensive agents; misc. GI drugs; prescribed generic drugs. Override “Brand Necessary” or
smoking deterrents; and thyroid agents. Prior “Brand Medically Necessary.” Also prescriber is
authorization required: anoretics; sympathominetics not prohibited from generic substitution and, if due
(adrenergic); and drugs used to treat impotence. to drug shortage, requesting reimbursement at the
brand level.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Incentive Fee: None. Medicaid Drug Rebate Contact


Sherry Montoya, Pharmacist
Patient Cost Sharing: No copayment, except $5.00
Human Services Department
for CHIP clients and working disabled clients.
Medical Assistance Division
Cognitive Services: Does not pay for cognitive P.O. Box 2348
services. Santa Fe, NM 87504-2348
T: 505/827-7777
F: 505/827-3196
E. USE OF MANAGED CARE E-mail: sherry.montoya@state.nm.us

Approximately 250,000 Medicaid recipients New Brand Name Products Contact


enrolled in are MCOs in FY 2003. Recipients Neal Solomon, M.P.H., R.Ph.
receive pharmaceutical benefits through managed 505/827-3174
care plans.
Prescription Price Updating Contact

F. STATE CONTACTS First DataBank


111 Bayhill Drive, Suite 350
State Drug Program Administrator San Bruno, CA 94066
800/633-3453
Neal Solomon, M.P.H., R.Ph.
Pharmacist, Human Services Department Claims Submission
Medical Assistance Division
P.O. Box 2348 ACS State Healthcare
Santa Fe, NM 87504-2348 365 Northridge Road
T: 505/827-3174 Northridge Center One, Suite 400
F: 505/827-3196 Atlanta, GA 30350
E-mail: neal.solomon@state.nm.us T: 770/352-8592
F: 770/730-5198
DUR Contact Medicaid Managed Care Contact
Neal Solomon, M.P.H., R.Ph. Alana Reeves, Chief
505/827-3174 Contract Administration Bureau
Human Services Department
DUR Board Medical Assistance Division
P.O. Box 2348
Denise Cuellar, Pharm.D. Santa Fe, NM 87504-2348
Greg D’Armour, Pharm.D. T: 505/827-3131
Gregory Toney, R.Ph., Ph.C. F: 505/827-3185
John Piper, Pharm.D. E-mail: alana.reeves@state.nm.us
John Lauriello, M.D.
Gayle Chacon, M.D. Mail Order Pharmacy Program
John Seibel, M.D.
Judy Romero, Pharm.D. None
Manual Archuleta, M.D.
Human Services Department Officials
Prior Authorization Contact Pamela Hyde, J.D.
Cynthia Wilson Secretary
Pharmacy Program Manager New Mexico Department of Human Services
Human Services Department P.O. Box 2348
Medical Assistance Division Santa Fe, NM 87504-2348
P.O. Box 2345 T: 505/827-7750
Santa Fe, NM 87504-2345 F: 505/827-6286
T: 505/827-3174 E-mail: pam.hyde@state.nm.us
F: 505/827-3196 Internet address: www.state.nm.us/hsd
E-mail: cynthiao.wilson@state.nm.us

New Mexico-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Carolyn Ingram Lila Maples, R.N.


Director 2769 Villa Venado
Medicaid Assistance Division Santa Fe, NM 87505
New Mexico Department of Human Services
P.O. Box 2348 Clarice Pick, D.D.S
Santa Fe, NM 87504-2348 1405 Luisa Street
T: 505/827-3106 Suite #2
F: 505/827-3185 Santa Fe, NM 87505
E-mail: carolyn.ingram@state.nm.us
Richard L. Ragel, D.O.
Medical Advisory Committee Members 1010 Bridge Boulevard, SW, Suite D
Albuquerque, NM 87105-3734
Linda Sechovec
Executive Director Kathy Minoli, C.F.N.P.
NM Health Care 1835 Solano, NE
6400 Uptown Boulevard, NE, Suite 520-W
Albuquerque, NM 87110
Albuquerque, NM 87110
Mary Lou Edward
Yvette Ramirez Ammerman
16 Applewood Lane, N.W.
Policy Analyst Albuquerque, NM 87107
New Mexico Primary Care Association 505/898-5103
2309 Renard, S.E., Suite 209
Albuquerque, NM 87106 Richard Honsinger, M.S.
Los Alamos Medical Center
Chris Isengard
Los Alamos, NM 87544
Executive Director
Developmental Disabilities Planning Council Maureen Boshier
435 St. Michael’s Drive, Bldg. D
New Mexico Hospital Association
Santa Fe, NM 87501 2121 Osuna Road NE
Albuquerque, NM 87113
Michelle Lujan-Grisham
New Mexico State Agency on Aging Joie Glen
228 East Palace Avenue Executive Director
Santa FE, NM 87501 New Mexico Association for Home Care
Sam Cata, Commissioner 3200 Carlisle N.E., Suite 115
Office of Indian Affairs
Albuquerque, NM 87110
224 E. Palace Avenue
Santa FE, NM 87501 Bert Umland, M.D.
Division of Family Practice
Loyola Burgess UNM Medical Center
1801 Dorothy Street, NE Albuquerque, NM 87131
Albuquerque, NM 87112
505/277-2165
Walace Begay, Co-Chairman
Executive Officers of State Medical and
Pueblo Health Council/All Indian Pueblo Council
Pharmaceutical Societies
P.O. Box 56
New Laguna, NM 87038
New Mexico Medical Society
Rosalyn Curtis G. R. “Randy” Marshall
Director of the Navajo Nation Executive Director
Division of Health 7770 Jefferson NE, Suite 400
P.O. Box 1390 Albuquerque, NM 87109
Window Rock, AZ 86515 T: 505/828-0237
F: 505/828-0336
E-mail: rmarshal@nmms.org
Internet address: www.nmms.org

New Mexico-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

New Mexico Pharmaceutical Association


R. Dale Tinker
Executive Director
4800 Zuni, SE
Albuquerque, NM 87108-2898
T: 505/265-8729
F: 505/255-8476
E-mail: daletinker@cs.com
Internet address: www.nm-pharmacy.com

New Mexico Osteopathic Medical Association


Elizabeth “Betty” Barrett
Executive Director
P.O. Box 53098
Albuquerque, NM 87153-3098
T: 505/332-2146
F: 505/332-4861
E-mail: admin@nmoma.org
Internet address: www.nmoma.org

New Mexico State Board of Pharmacy


Bill Harvey, R.Ph.
Executive Director/Chief Drug Inspector
5200 Oakland, NE, Suite A
Albuquerque, NM 87113
T: 505/222-9830
F: 505/222-9845
E-mail: william.harvey@state.nm.us
Internet address: www.state.nm.us/pharmacy

New Mexico Hospitals and Health Systems


Association
Jeff Dye
President and CEO
2121 Osuna Road, NE
Albuquerque, NM 87113
T: 505/343-0010
F: 505/343-0012
E-mail: jdye@nmhsc.com
Internet address: www.nmhhsa.org

New Mexico-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

New Mexico-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

NEW YORK

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $3,413,404,507 2,567,595 $4,218,811,815

RECEIVING CASH ASSISTANCE, TOTAL $2,125,736,518 989,129


Aged $372,043,201 143,685
Blind/Disabled $1,586,923,061 452,780
Child $62,747,562 277,409
Adult $104,022,694 115,255

MEDICALLY NEEDY, TOTAL $881,847,140 1,030,821


Aged $227,546,353 111,929
Blind/Disabled $415,602,060 109,328
Child $99,410,347 453,643
Adult $139,288,380 355,921

POVERTY RELATED, TOTAL $44,803,433 221,363


Aged $0 0
Blind/Disabled $0 0
Child $44,035,613 215,136
Adult $767,820 6,227
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/ RECIPIENTS* $361,017,416 326,282

* Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

New York-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Formulary/Prior Authorization


Formulary: Open formulary. Utilization managed
State Department of Health, Office of Medicaid through restrictions on use, prior authorization, and
Management. quantity limits. General exclusions: New York
State follows OBRA '90 guidelines in the
D. PROVISIONS RELATING TO DRUGS reimbursement of prescription drugs.

Benefit Design Prior Authorization: State currently has a formal


prior authorization procedure and a Pharmacy and
Drug Benefit Product Coverage: Products covered:
Therapeutics Committee that meets quarterly.
prescribed insulin; disposable needles and syringe
Although there is no formal method for appealing a
combinations for insulin; blood glucose test strips;
prior authorization decision, the ordering prescriber
urine ketone test strips; total parenteral nutrition;
may call the voice interactive system until the
and interdialytic parenteral nutrition. Products not
system issues a prior authorization number. All
covered: cosmetics; fertility drugs; and
requests are approved. Beginning in November
experimental drugs.
2002, all brand name drugs with A-rated generics
require prior authorization.
Over-the-Counter Product Coverage: Products
covered: allergy, asthma and sinus products;
Prescribing or Dispensing Limitations
analgesics; cough and cold preparations; digestive
products; feminine products; smoking deterrent Prescription Refill Limit: Maximum of 5 refills
products (max. 2 courses of treatment/year); and within 6 months. Also, annual limits on number of
topical products. prescriptions and prescription and nonprescription
drugs without an override.
Therapeutic Category Coverage: Therapeutic Monthly Dollar Limits: None.
categories covered: anabolic steroids; analgesics,
antipyretics, NSAIDs; anticoagulants;
Drug Utilization Review
anticonvulsants; antidepressants; antidiabetic
agents; antihistamine drugs; antilipemic agents; PRODUR system implemented in March 1995.
anti-psychotics; anxiolytics, sedatives, and State currently has a DUR Board which meets
hypnotics; cardiac drugs; chemotherapy agents; bimonthly.
contraceptives; ENT anti-inflammatory agents;
estrogens; hypotensive agents; prescribed smoking Pharmacy Payment and Patient Cost
deterrents; sympathominetics (adrenergic); and Sharing
thyroid agents. Therapeutic categories partially
Dispensing Fee: $3.50 for brand name drugs, $4.50
covered: prescribed cold medication and misc. GI
for generic drugs. Effective 8/1/98.
drugs. Therapeutic categories requiring prior
authorization: antibiotics (zyvox only); second
generation antihistamines; growth hormones; Ingredient Reimbursement Basis: EAC = AWP-
(serostim) medical/surgical supplies; orthopedic 12.75% for brand name drugs and AWP-16.5% for
shoes; compression stockings; and some DME generics (effective 10/1/04).
items. Therapeutic categories not covered:
anorectics and agents used for hair growth. Prescription Charge Formula:
1. Payment for multiple source drugs must not
Coverage of Injectables: Injectable medicines exceed the aggregate of the specified upper
reimbursable through the Prescription Drug limit set by the Federal Centers for Medicare
Program when used in home health care facilities and Medicaid Services (CMS), plus a
and through physician payment when used in dispensing fee, for a particular drug; and
physician offices. In extended care facilities
reimbursement for non-self administered injectable 2. Payment for brand name drugs and other
medicines is included in the facility rate. No special multiple source drugs not covered by clause (1)
coverage policies exist for self-administered will be the lower of: EAC plus a dispensing
injectable medicines. fee; or
3. The billing pharmacy's usual and customary
Vaccines: Vaccines are reimbursable under the price charged to the general public.
EPSDT service, CHIP, and the Vaccines for
Children program.
Unit Dose: Unit dose packaging not reimbursable.

New York-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Maximum Allowable Cost: State imposes Federal − Southern Tier


Upper Limits on generic drugs. Must get prior − St. Barnabas/Partners in Health
authorization for most brand name products. (see − Suffolk Health Plan
www.health.state.ny.us/nysdoh/medicaid/ − United Healthcare Plan of NY, Inc.
ptcommittee/mandatorggen.htm) − Univera Community Health
− VidaCare, Inc.
Incentive Fee: $1.00 for dispensing a lower cost − Wellcare of New York
multi- source product.
F. STATE CONTACTS
Patient Cost Sharing: Copayment is $2.00 for
brand name drugs, $0.50 for generic and OTC State Drug Program Administrator
drugs. Exceptions include psychotropic drugs as
well as drugs FDA approved for the treatment of Mark-Richard A. Butt, M.S., R.Ph.
tuberculosis and family planning drugs. Director, Pharmacy Policy and Operations
Office of Medicaid Management
Cognitive Services: Does not pay for cognitive NYS Department of Health
services. 99 Washington Avenue
Albany, NY 12210
T: 518/474-9219
E. USE OF MANAGED CARE F: 518/473-5508
E-mail: mrb01@health.state.ny.us
Approximately 2.1 million Medicaid recipients Internet address: www.health.state.ny.us
were enrolled in MCOs in FY 2003. Recipients
receive pharmaceutical benefits through the State. Pharmacy Advisory Committee
Kandyce Daley, R.Ph.
Health Maintenance Organizations
Patricia Donato, R.Ph.
− ABC Health Plan Steven Giroux, R.Ph.
− Affinity Health Plan Thomas Golden, R.Ph.
− AmeriChoice of New York John Navarra, R.Ph. (Chairman)
− Broome MAX Dilip Patel, R.Ph.
− Capitol District Physicians’ Health Plan Mohammed Saleh, R.Ph.
− Care Plus John Westerman, R.Ph.
− Center Care/Manhattan PHSP
− Community Choice HP of Westchester Formulary Contact
− Community Premier Plus Mark-Richard A. Butt, M.S., R.Ph.
− Excellus Health Plan 518/474-9219
− Fidelis/NYS Catholic Health Plan
− GHI HMO Prior Authorization Contact
− HealthFirst PHPS Linda J. Jones
− Health Insurance Plan of Greater New York Assistant Director
− Health Plus PHPS Bureau of Program Guidance
− HealthNow/BCBS-WNY/Community Blue NYS Department of Health
− HealthNow/Blue Shield of NENY 99 Washington Avenue
− HealthSource/Hudson Health Plan Albany, NY 12210
− Independent Health Association T: 518/474-9219
− Managed Health F: 518/473-5508
− Manhattan PHSP/CenterCare E-mail: ljm07@health.state.ny.us
− MetroPlus Health Plan
− MVP Health Plan
− Neighborhood Health Providers
− NYPS Select Health
− NYP Community Health Plan
− NYS Catholic Health Plan
− PCMP
− Preferred Care
− SCHC Total Care/Syracuse PHSP

New York-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Pharmacy and Therapeutics Committee Medicaid Drug Rebate Contacts


Roxanne Hall Richardson, R.Ph. Audits:
Maria Amodio-Groton, Pharm.D. Thomas E. Howe
Andrew G. Flynn, R.Ph., C.G.P. Director, Audit Unit
William P. Scheer, R.Ph. NYS Department of Health
Carl R. Reed, R.Ph., M.B.A. Corning Tower, Room 1336
Judy K. Shaw, M.S., A.C.R.N., ANP-C Empire State Plaza
Marc A. Johnson, M.D. Albany, NY 12237
Scott C. Bello, M.D. T: 518/473-3920
Steven E. Barnes, D.O. F: 518/486-1405
Aaron Satloff, M.D.
Glenn A. Martin, M.D. Disputes:
Joseph A. Maiello
Pharmacy Rebate Manager
DUR Contact Office of Medicaid Management
Lydia J. Kosinski, R.Ph., Manager NYS Department of Health
Recipient Activitiest and Utilization Review 99 Washington Avenue
Office of Medicaid Management Albany, NY 12210
NYS Department of Health T: 518/474-9219
800 North Pearl Street F: 518/473-5508
Albany, NY 12204 E-mail: jam@health.state.ny.us
T: 518/474-6866
F: 518/473-5332 Policy:
E-mail: ljk02@health.state.ny.us Mark-Richard A. Butt, M.S., R.Ph.
518/474-9219
DUR Committee Claims Submission Contact
Physicians eMedNY
Richard S. Blum, M.D. Computer Sciences Corporation (CSC)
Ronald J. Dougherty, M.D. Attn: eMedNY Webmaster
David F. Lehmann, M.D. One CSC Way
Jill Braverman-Panza, M.D., R.Ph. Rensselaer, NY 12144
800/343-9000
Pharmacists E-mail: general@emedny.org
Sidney Falow, R.Ph.
John Gotowko, R.Ph., M.S., M.B.A.
Marc L. Speert, R.Ph. Medicaid Managed Care Contact
Frank Barone, R.Ph.
Elizabeth Macfarlane, Director
James R. Suhrbier, R.Ph.
Bureau of Managed Care Planning
Office of Managed Care
New Brand Name Products Contact NYS Department of Health
Mark-Richard A. Butt, M.S., R.Ph. Room 1927, Corning Tower
518/474-9219 Empire State Plaza
Albany, NY 12237-0064
Prescription Price Updating T: 518/473-0122
F: 518/474-5886
Carl T. Cioppa, Pharm,D. E-mail: eag01@health.state.ny.us
Pharmacy Operations Manager
NYS Dept. of Health Disease Management/Patient Education
Office of Medicaid Management Programs
99 Washington Avenue
Albany, NY 12210 Disease/Medical State: AIDS/HIV
T: 518/474-9219 Program Name: Aids Intervention Management
F: 518/473-5508 Program
E-mail: ctc02@health.state.ny.us Program Manager: Guthrie Birkhead
Program Sponser: AIDS Institute, NYSDOH

New York-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Disease/Medical State: Asthma Department of Health Officials


Program Name: NYS Asthma Grant
Antonia C. Novello, M.D, M.P.H., Dr. Ph.
Program Manager: Patricia Waniewski
Commissioner
Program Sponser: Division of Family Health,
NYS Department of Health
NYSDOH
Corning Tower
The Governor Nelson A. Rockefeller Empire State
Disease/Medical State: Diabetes
Plaza
Program Name: Diabetes Prevention and Control
Albany, NY 12237
Program
T: 518/474-2011
Program Manager: Maureen Spence
F: 518/474-5450
Program Sponser: Bureau of Chronic Disease
E-mail: acn01@health.state.ny.us
Services, NYSDOH
Kathryn Kuhmerker, Deputy Commissioner
Disease/Medical State: Smoking Cessation
Office of Medicaid Management
Program Name: Smokers’ Quit Line
NYS Department of Health
Program Manager: QuitSite@Roswellpark.org
Corning Tower
Program Sponsor: Roswell Park and NYSDOH
The Governor Nelson A. Rockefeller Empire State
Disease/Medical State: Cardiovascular Disease Plaza
Program Name: Healthy Heart Program Albany, NY 12237
Program Manager: hhp@health.state.ny.us T: 518/474-3018
Program Sponser: NYDOH F: 518/486-6852
E-mail: klk03@health.state.ny.us
Disease Management Program/Initiative
Contacts
Title XIX Medical Care Advisory Committee
Karen A. Fuller, Ph.D.
Director, Bureau of Program Guidance Ruben P. Cowart, D.D.S., (Chairman)
Office of Medicaid Management John Angerosa, M.D.
NYS Department of Health Steven E. Barnes, D.O.
99 Washington Avenue Russel N. Cecil, M.D.
Albany, NY 12210 David Cerniglia, D.C.
T: 518/474-9219 Stoner E. Horey, M.D.
F: 518/473-5508 Mary K. Lashomb
E-mail: kaf01@health.state.ny.us Norman R. Loomis, M.D.
Hugo M. Morales, M.D., P.C.
Tanton Mustapha, M.D.
Mail Order Pharmacy Program
Leon Nadrowski, M.D.
None Dennis P. Norfleet, M.D.
Elena Padilla, Ph.D.
Expanded Drug Program Contact Carl P. Sahler, M.D., Ph.D.
Julie Naglieri Robert A. Schwartz, M.D.
Director Gavin Setzen, M.D.
NYS Department of Health Program Kathleen Benson Smith
Elderly Prescription Insurance Coverage (EPIC) Patricia Stevens, Deputy Commissioner, NYS
1 Corporate Plaza, Suite 101 Office of Temporary and Disability Assistance
260 Washington Avenue (DSS Representative)
Albany, NY 12203 Roger W. Trifthauser, D.D.S., M.S.
T: 518/452-6828
F: 518/452-6882
E-mail: jab15@health.state.ny.us
Internet address:
www.health.state.ny.us/nysdoh/epic

New York-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Executive Officers of State Medical and Greater New York Hospital Association
Pharmaceutical Societies Kenneth E. Raske
President
Medical Society of the State of New York
555 W. 57th Street
William R. Abrams
15th Floor
Executive Vice President
New York, NY 10019
420 Lakeville Road
T: 212/246-7100
P.O. Box 5404
F: 212/262-6350
Lake Success, NY 11042-5404
E-mail: raske@gnyha.org
T: 516/488-6100
Internet address: www.gnyha.org
F: 516-488-6136
E-mail: mssny@mssny.org
Internet address: www.mssny.org

Pharmasists Society for the State of New York


Craig M. Burridge, M.S., CAE
Executive Director
210 Washington Avenue Extension
Albany, NY 12203-5335
T: 518/869-6595
F: 518/464-0618
E-mail: craigb@ppssny.org
Internet address: www.pssny.org/index_new.htm
New York State Osteopathic Medical Society, Inc.
Martin Diamond, D.O.
Interim Executive Director
1855 Broadway, Suite 1102A
New York, NY 10023
T: 800/841-4131
F: 312/202-8224
E-mail: nysoms@nysoms.org
Internet address: www.nysoms.org

New York State Board of Pharmacy


Lawrence H. Mokhiber
Executive Secretary
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue, Second Floor W
Albany, NY 12234-1000
T: 518/474-3817
F: 518/473-6995
E-mail: pharmbd@mail.nysed.gov
Internet address: www.nysed.gov/prof/pharm.htm

Healthcare Association of New York State


Daniel Sisto
President
One Empire Drive
Rensselaer, NY 12114
T: 518/431-7600
F: 518/431-7915
E-mail: dsisto@hanys.org
Internet address: www.hanys.org

New York-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

NORTH CAROLINA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $1,069,140,895 949,795 $1,291,263,155

RECEIVING CASH ASSISTANCE TOTAL $603,557,480 450,000


Aged $158,697,938 63,887
Blind/Disabled $340,911,000 130,730
Child $32,488,999 132,601
Adult $71,459,543 122,782

MEDICALLY NEEDY, TOTAL $69,821,479 28,176


Aged $47,950,356 16,850
Blind/Disabled $18,071,505 6,202
Child $276,567 789
Adult $3,523,051 4,335

POVERTY RELATED, TOTAL $370,773,038 421,345


Aged $148,954,057 61,023
Blind/Disabled $147,615,329 53,941
Child $68,217,052 272,181
Adult $5,986,600 34,200
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS $24,988,898 50,274

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

North Carolina-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Prior Authorization: Formal prior authorization


process can be found at: ww.ncmedicaidpbm.com.
Division of Medical Assistance, Department of A prescriber’s written justification is required to
Health and Human Services. appeal a prior authorization decision.

Prescribing or Dispensing Limitations


D. PROVISIONS RELATING TO DRUGS
Monthly Quantity Limit: 34-day supply maximum.
Benefit Design Except birth control tablets and hormonal
replacement therapy dial packs: 3 months;
Drug Benefit Product Coverage: Products covered: maintenance non-controlled medications, tied with
prescribed insulin. Products not covered: cosmetics; the FUL and/or SMAC after a prior successful fill
fertility drugs; experimental drugs; disposable may receive a 3 month supply upon the prescribers
needles and syringe combinations used for insulin; discretion.
blood glucose test strips; total parenteral nutrition;
interdialytic parenteral nutrition; OTC drugs not Monthly Prescription Limit: Six prescriptions per
listed on the selected coverage list; and those month per recipient.
products/categories mentioned below under
“Therapeutic Category Coverage” section. Prescription Dollar Limits: None.

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


Carolina covers a select list of OTC products. (See
www.dhhs.state.nc.us/dma/mp/mpindex.htm for a PRODUR system implemented in May 1996. State
complete list of covered OTC products.) currently has a DUR Board with a quarterly review.

Therapeutic Category Coverage: North Carolina Pharmacy Payment and Patient Cost
provides coverage for all therapeutic categories Sharing
except anoretics; products used for cosmetic Dispensing Fee: B: $4.00; G: $5.60, effective 2002.
purposes; fertility drugs; diaphragms; IV fluids
(Dextrose 500ml or greater) and irrigations fluids Ingredient Reimbursement Basis: EAC = AWP-
used in an inpatient facility; drugs on the DESI list; 10%.
any drug manufactured by a company who has not
signed the Federal rebate agreement; and Prescription Charge Formula: The lowest price of
experimental drugs. Prior authorization required AWP minus 10%, State MAC or Federal MAC plus
for: analgesics, antipyretics, and NSAIDs; drugs a dispensing fee or usual and customary, whichever
used to treat ADHD; Procrit/Epogen; Neupogen; is lowest. The pharmacist filling the original
Aransep; OxyContin; Growth Hormones;Provigil; prescription will not be reimbursed for refills for
Rebetron; Vioxx; Celebrex; Bextra; Botox; the same drug within a calendar month.
Mybloc; Zyban, Nicotrol, Nicotine Patch; Synagis;
and RespiGam. (See www.ncmedicaidpbm.com for
Maximum Allowable Cost: State imposes Federal
additional information.)
Upper Limits as well as State-specific maximum
allowable cost (MAC) limits generic drugs. 433
Coverage of Injectables: Injectable medicines drugs are listed on the State-specific MAC list.
reimbursable through the Prescription Drug Override requires “Brand Medically Necessary”
Program when used in home health care and written on the face of the prescription by the
extended care facility, and through physician prescriber.
payment when used in physician offices.
Incentive Fee: $1.60 to dispense a lower cost
Vaccines: Vaccines reimbursable as part of the multisource product.
ESPDT service and The Vaccines for Children
Program.
Patient Cost Sharing: $1.00 copayment/Rx
(includes refills) for generic prescriptions; $3.00
Unit Dose: Unit dose packaging not reimbursable. copayment/Rx for brand name prescriptions.
Formulary/Prior Authorization Cognitive Services: Does not pay for cognitive
Formulary: Open formulary. services.

North Carolina-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

E. USE OF MANAGED CARE Members at Large


Sandy Newton
Approximately 11,500 Medicaid recipients were Gina Upchurch
enrolled in MCOs in FY 2003. Recipients receive New Brand Name Products Contact
pharmaceutical benefits through the State.
Tom D’Andrea, R.Ph., M.B.A.
Managed Care Organizations 919/855-4300
SouthCare/Coventry Prescription Price Updating
2815 Coliseum Center Drive
Suite 550 Tom D’Andrea, R.Ph., M.B.A.
Charlotte, NC 28217 919/855-4300
800/350-6294
Medicaid Drug Rebate Contact
F. STATE CONTACTS Audits: Tom D’Andrea, R.Ph., M.B.A.
919/855-4300
State Drug Program Administrator
Tom D’Andrea, R.Ph., M.B.A. Rebate Disputes: Sharon Greeson, R.Ph.
Chief of Pharmacy and Ancillary Services Pharmacy Program Manager
Department of Health and Human Services EDS
Division of Medical Assistance 4905 Waters Edge Drive
1985 Umstead Drive Raleigh, NC 27606
2501 Mail Service Center T: 919/816-4475
Raleigh, NC 27699 F: 919/816-4399
T: 919/855-4300 E-mail: Sharon.greeson@ncxix.hcg.eds.com
F: 919/715-1255 Claims Submission Contact
E-mail: Tom.Dandrea@ncmail.net
Internet address: www.dhhs.state.nc.us/dma Sharon Greeson, R.Ph.
919/816-4475
Prior Authorization Contact
Medicaid Managed Care Contact
Tom D’Andrea, R.Ph., M.B.A.
919/855-4300 Jeffrey Simms
Assistant Director- Managed Care
DUR Contact Department of Health and Human Services
Division of Medical Assistance
Melissa Weeks, R.Ph., Pharm.D. 1985 Umstead Drive
Department of Health and Human Services 2501 Mail Service Center
Division of Medical Assistance Raleigh, NC 27613
1985 Umstead Drive 919/647-8170
2501 Mail Service Center
Raleigh, NC 27699 Mail Order Pharmacy Program
T: 919/855-4300
F: 919/715-1255 None
E-mail: Melissa.Weeks@ncmail.net
Department of Human Resources Officials
Medicaid Drug Utilization Review Board
Carmen Hooker Odom
Physicians: Secretary
Edward Treadwell, M.D. Department of Health and Human Services
Steve Wegner, M.D. 2001 Mail Service Center
101 Blair Drive
Pharmacists: Raleigh, NC 27699-2001
Joseph S. Moose, R.Ph., Pharm. D. T: 919/733-4534
Al Lockramy F: 919/715-4645
Wayne Creech, R. Ph. E-mail: Carmen.Hooker@ncmail.net
Martha Jones, Pharm. D.
Thomas Thutt

North Carolina-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Mark Benton, Interim Director North Carolina Hospital Association


Department of Health and Human Services William A. Pulley
Division of Medical Assistance President
1985 Umstead Drive P.O. Box 4449
2501 Mail Service Center Cary, NC 27519-4449
Raleigh, NC 27699-2501 T: 919/677-2400
T: 919/855-4100 F: 919/677-4200
F: 919/733-6608 E-mail: wpully@ncha.org
E-mail: mark.benton@ncmail.net Internet address:

Executive Officers of State Medical and


Pharmaceutical Societies
North Carolina Medical Society
Robert W. Seligson, M.B.A., CAE
Executive Vice President and CEO
P.O. Box 27167
Raleigh, NC 27611-7167
T: 919/833-3836
F: 919/833-2023
E-mail: rseligson@ncmedsoc.org
Internet address: www.ncmedsoc.org

North Carolina Association of Pharmacists


Fred Eckel
Executive Director
109 Church Street
Chapel Hill, NC 27516-2502
T: 919/967-2237
F: 919/968-9430
E-mail: fred@ncpharmacists.org
Internet address: www.ncpharmacists.org

North Carolina Osteopathic Medical Association


Jeffrey J. LeBoeuf
Executive Director
8311 Brier Creek Parkway
Raleigh, NC 27617
T: 888/626-6248
F: 910/763-4666
E-mail: jeffrey@ncoma.org
Internet address: www.ncoma.org

North Carolina State Board of Pharmacy


David R. Work
Executive Director
P.O. Box 4560
Chapel Hill, NC 27515-4560
T: 919/942-4454
F: 919/967-5757
E-mail: drw@ncbop.org
Internet address: www.ncbop.org

North Carolina-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

NORTH DAKOTA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $51,749,961 44,428 $56,960,417

RECEIVING CASH ASSISTANCE, TOTAL $24,615,037 22,125


Aged $4,732,778 1,868
Blind/Disabled $14,828,540 5,185
Child $1,914,375 9,228
Adult $3,139,344 5,844

MEDICALLY NEEDY, TOTAL $22,863,537 9,804


Aged $14,650,825 5,748
Blind/Disabled $7,382,657 2,254
AFDC-Child $377,862 1,083
AFDC-Adult $452,193 719

POVERTY RELATED, TOTAL $367,360 1,758


Aged $7,319 32
Blind/Disabled $6,279 22
AFDC-Child $335,504 1,549
AFDC-Adult $18,258 155
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $3,904,027 10,741

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

North Dakota-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Formulary/Prior Authorization


Formulary: Open formulary
North Dakota Department of Human Services.
Prior Authorization: State currently has a formal
D. PROVISIONS RELATING TO DRUGS prior authorization procedure. Beneficiary can
request a fair hearing to appeal a prior authorization
Benefit Design decision.

Drug Benefit Product Coverage: Products covered: Prescribing or Dispensing Limitations


prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test Prescription Refill Limit: 5 refills per script.
strips; and total parenteral nutrition. Products not
covered: cosmetics; fertility drugs; urine ketone test Monthly Quantity Limit: 34-day supply.
strips; interdialytic parenteral nutrition; drugs used
for hair growth; prescription vitamins (except Monthly Dollar Limits: None.
prenatal vitamins); and DESI drugs. Prior
authorization required for: nutritional supplements; Drug Utilization Review
and orlistat. PRODUR system implemented in July 1996. State
has a DUR Board that meets quarterly.
Over-the-Counter Product Coverage: Products
covered: antacids; analgesics; iron supplements; Pharmacy Payment and Patient Cost
digestive products; and anti-ulcer medications. Sharing
Products covered with restriction: allergy, asthma,
and sinus products (loratadine only); and topical Dispensing Fee: $5.60 for generic, $4.60 for brand
products (artificial tears only); smoking deterrent effective 8/1/03.
products (lifetime limits). Products not covered:
cough and cold preparations; feminine products. Ingredient Reimbursement Basis: EAC = AWP-
10%.
Therapeutic Category Coverage: Categories
covered: anabolic steroids; analgesics, antipyretics, Prescription Charge Formula: Acquisition Cost
and NSAIDs; antibiotics; anticoagulants; plus a dispensing fee per prescription or the usual
anticouvulsants; anti-depressants; antidiabetic and customary retail charge, whichever is lower.
agents; antilipemic agents; anti-psychotics; Acquisition Cost = EAC or MAC.
anxiolytics, sedatives, and hypnotics; cardiac drugs;
chemotherapy agents; prescribed cold medications; Maximum Allowable Cost: State imposes Federal
contraceptives; ENT anti-inflammatory agents; Upper Limits as well as State-specific limits on
estrogens; growth hormones; hypotensive agents, generic drugs. Override requires “Dispense As
sympathominetics (adrenergic); thyroid agents; and Written.”
prescribed smoking deterents (partial coverage).
Prior authorization required for: brand name Incentive Fee: None.
NSAIDs, anoretics (orlistat); antihistamines; and
PPIs. Patient Cost Sharing: $3.00 (brand-name drugs)

Coverage of Injectables: Injectable medicines Cognitive Services: Does not pay for cognitive
reimbursable through the Prescription Drug services
Program when used in home health care, and
extended care facilities, and through both the E. USE OF MANAGED CARE
Prescription drug program and physician payment
when used in physician offices. Approximately 3,500 Medicaid recipients were
enrolled in managed care organizations in 2003.
Vaccines: Vaccines reimbursable as part of the Recipients enrolled in MCO’s receive pharmacy
EPSDT service. benefits through the State.

Unit Dose: Unit dose packaging not reimbursable.

North Dakota-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

F. STATE CONTACTS Claims Submission Contact


Brendan K. Joyce, Pharm.D., R.Ph.
State Drug Program Administrator 701/328-4023
Brendan K. Joyce, Pharm.D., R.Ph.
Administrator, Pharmacy Services Medicaid Managed Care Contact
Department of Human Services Tom Solberg, Administrator
600 East Boulevard Avenue, Dept. 325 Managed Care
Bismarck, ND 58505-0250 ND Department of Human Services
T: 701/328-4023 600 East Boulevard Avenue, Dept. 325
F: 701/328-1544 Bismark, ND 58505-0261
E-mail: sojoyb@state.nd.us T: 701/328-1884
Internet address: www.state.nd.us/humanservices F: 701/328-1544
E-mail: sosolt@state.nd.us
Prior Authorization Contact
Brendan K. Joyce, Pharm.D., R.Ph. Disease Management Program/Initiative
701/328-4023 Contact
Brendan K. Joyce, Pharm.D., R.Ph.
DUR Contact 701/328-4023
Brendan K. Joyce, Pharm.D., R.Ph. Mail Order Pharmacy Benefit Program
701/328-4023 None

DUR Board Department of Human Services Officials


Carrie Sorenson, Pharm.D. Carol K. Olson
Patricia Churchill, R.Ph. Executive Director
Leann Ness, Pharm.D. ND Dept. of Human Services
Greg Pfister, Pharm.D. 600 E. Boulevard Avenue, Dept. 325
John Savageau, R.Ph. Bismarck, ND 58505-0250
Robert Treitline, RPh T: 701/328-2538
Kamille Sherman, MD F: 701/328-1545
Cheryl Huber, M.D. E-mail: dhseo@state.nd.us
Norman Byers, M.D.
Albert Samuelson, M.D. Dave Zentner, Director
Jay Huber, M.D. Division of Medical Services
Gary Betting, M.D. 600 E. Boulevard Avenue, Dept. 325
Brendan K. Joyce, Pharm.D., R.Ph. Bismarck, ND 58505-0261
Scott Setzepfandt, R.Ph. T: 701/328-2321
F: 701/328-1544
New Brand Name Products Contact E-mail: dhsmed@state.nd.us
Brendan K. Joyce, Pharm.D., R.Ph.
701/328-4023 Medical Care Advisory Committee
Terry Dwelle, M.D.
Prescription Price Updating Lynn Blakeman
Brendan K. Joyce, Pharm.D., R.Ph. Alison Fallgater, D.D.S.
701/328-4023 Amy Fleck, O.D.
Howard Anderson, R.Ph.
Medicaid Drug Rebate Contact Terry Johnson, M.D.
David Peske
Brendan K. Joyce, Pharm.D., R.Ph. Gary Betting, M.D.
701/328-4023

North Dakota-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Pharmacy Advisory Committee North Dakota State Board of Pharmacy


Howard C. Anderson
Robert L. Treitline (Chair)
Executive Director
Dickinson, ND
P. O. Box 1354
Bismarck, ND 5802-1354
Anton P. Welder, R.Ph.
T: 701/328-9535
Bismarck, ND
F: 701/328-9536
E-mail: ndboph@btinet.net
Doreen M. Beiswanger, R.Ph.
Internet address: www.nodakpharmacy.com
Valley City, ND
North Dakota Healthcare Association
David L. Just, R.Ph.
Arnold R. Thomas, President
Beulah, ND
P.O. Box 7340
1622 E. Interstate Avenue
David J. Olig, R.Ph.
Bismarck, ND 58503
Fargo, ND
T: 701/224-9732
F: 701/224-9529
DuWayne Schlittenhard, R.Ph.
E-mail: athomas@ndha.org
Fargo, ND
Internet address: www.ndha.org
Mary Beth Reinke, R.Ph.
Fargo, ND

Cindy Yeager, R.Ph.


Fargo, ND

Executive Officers of State Medical and


Pharmaceutical Societies
North Dakota Medical Association
Bruce Levi
Executive Vice President
P.O. Box 1198
Bismarck, ND 58502-1198
T: 701/223-9475
F: 701/223-9476
E-mail: blevi@ndmed.com
Internet address: www.ndmed.com

North Dakota State Osteopathic Association


Carmen Christianson Bell
President Director
1600 2nd Avenue, SW, Suite 20
Minot, ND 58701
701/852-8798
E-mail: ndoma@ndoma.org
Internet address: www.ndoma.org

North Dakota Pharmacists Association


Patricia A. Hill
Executive Vice President
1661 Capitol Way, Suite 102
Bismarck, ND 58501-2195
T: 701/258-4968
F: 701/258-9312
E-mail: phill@nodakpharmacy.net
Internet address: www.nodakpharmacy.net

North Dakota-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

OHIO

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $1,330,569,382 997,246 $1,520,147,470

RECEIVING CASH ASSISTANCE, TOTAL $636,705,938 287,972


Aged $98,218,659 33,902
Blind/Disabled $510,976,291 171,277
Child $13,850,390 59,837
Adult $13,660,598 22,956

MEDICALLY NEEDY, TOTAL $0 0


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

POVERTY RELATED, TOTAL $47,855,411 164,830


Aged $2,277,564 1,878
Blind/Disabled $5,780,069 3,194
Child $36,005,788 138,564
Adult $3,791,990 21,194
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $646,008,033 544,444

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Ohio-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Approved Drug List (ADL)/Prior


Authorization
Ohio Department of Job and Family Services, Bureau ADL: Closed ADL of preferred products with
of Health Plan Policy. approximately 28,000 NDC-specific trade and
generic drugs. Products excluded include obesity,
D. PROVISIONS RELATING TO DRUGS fertility, and experimental drugs. ADL managed by
Benefit Design excluding products based on contracting issues,
restrictions on use, and prior authorization.
Drug Benefit Product Coverage: Products covered:
most drugs including prescribed insulin. Products not Prior Authorization: State currently has a formal
covered: cosmetics; fertility drugs; obesity drugs; prior authorization procedure. Prior authorization is
experimental drugs. Prior authorization required for needed for certain individual drugs (see examples
some drugs including these examples: Ceredase; above) A beneficiary may appeal a prior
Cerebyx; Cerezyme; Clorazepates; Depo-Provera; authorization decision and be granted an
Enbrel; immunoglobulins; Lioresal Intrathecal; administrative hearing. Manufactures may also
Lodosyn; Nascobal; Orgaran; Oxandrin Panretin; request reconsideration for an excluded product.
Periostat; Priftin; Prolastin; Proleukin; Provigil; Prescribing or Dispensing Limitations
Psoralens; Remicade; Rituxan; Stimate; Synagis; and
Targretin. Products covered under DME: disposable Monthly Dollar Limits: None
needles and syringe combinations used for insulin;
blood glucose test strips; urine ketone test strips; total Monthly Quanity Limits: None
parentaral nutrition (PA required); and interdialytic
parenteral nutrition (PA required). Quanity Limit per Prescription: 34-day supply. 102-
day supply for chronic maintenance medications.
OTC Coverage: Selective coverage for: allergy,
asthma, and sinus products; analgesics; feminine Prescription Refill Limit: 5 refills per script.
products; smoking deterrent products; cough and cold
preparations; digestive products; topical products; Drug Utilization Review
laxatives; antacids; and vitamins and minerals. PRODUR system implemented through POS in Feb
2000. State currently has a DUR Board with quarterly
Therapeutic Category Coverage: Therapeutic review.
categories covered: analgesics, antipyretics, and
NSAIDS; antibiotics; anticoagulants; Pharmacy Payment and Patient Cost Sharing
anticonvulsants; anti-depressants; antidiabetic agents; Dispensing Fee: $3.70, effective 7/1/98. ($0.50 fee
antilipemic agents; anti-psychotics; anxiolytics, for flu vaccine.)
sedatives, and hypnotics; chemotherapy agents;
contraceptives; ENT anti-inflammatory agents; Ingredient Reimbursement Basis: EAC = WAC+9%
estrogens; sympathominetics (adrenergic); and (eff. 5/1/02).
thyroid agents. Prior authorization required for:
anbabolic steroids; antihistamines; cardiac drugs; Prescription Reimbursement Formula:
prescribed cold medications; growth hormones; Reimbursement for legend drugs and selected OTC
hypotensive agents; misc. GI drugs; and prescribed products based on the lowest of:
smoking deterrents. Therapeutic categories not
covered: anorectics; innovator multi-source drugs; 1. Provider’s submitted charge, which should
selected high-risk drugs (e.g., Accutane); and drugs reflect usual and customary charge to the general
used in special settings (e.g., outpatient hospital). public;
2. WAC+9% plus a dispensing fee.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program 3. Federal- or state-established Maximum
when used in home health care and extended care Allowable Cost (MAC), for specifically
facilities, and through physician payment when used designated generically equivalent drugs plus a
in physicians offices. dispensing fee.
Non-legend drugs - reimbursement is based on WAC
Vaccines: Vaccines reimbursable as part of the + 9% plus a dispensing fee, or MAC if applicable.
Vaccines for Children Program. Special reimbursement for Blood Factors 8 and 9.
Unit Dose: Unit dose packaging not reimbursable.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. Override requires prior authorization.

Ohio-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Incentive Fee: None. F. STATE CONTACTS


State Program Drug Administrator
Patient Cost Sharing: $3.00 (for prior authorized
drugs) Robert P. Reid, R.Ph.
Administrator, Pharmacy Services Unit
Ohio Department of Job and Family Services
Cognitive Services: Does not pay for cognitive Bureau of Health Plan Policy
services. 30 East Broad Street, 27th Floor
Columbus, OH 43215-3414
E. USE OF MANAGED CARE T: 614/466-6420
F: 614/466-2908
Approximately 435,000 Medicaid recipients were E-mail: reidr@odjfs.state.oh.us
enrolled in managed care in 2003. All received Internet address: www.jfs.ohio.gov
pharmacy services through managed care plans.
New Brand Name Products Contact
Managed Care Organizations
Robert P. Reid, R.Ph.
Buckeye Community Health Plan 614/466-6420
175 South Third Street
Suite 1200
Prior Authorization Contacts
Columbus, OH 43215
866/246-4356 Drugs: Robert P. Reid, R.Ph.
614/466-6420
Dayton Area Health Plan (CareSource)
One South Main Street DME/Nutritions: Bonnie Brownlee
Suite 900 614/466-6065
Dayton, OH 45402
DUR Contact
937/224-3300
Jeff Corzine
PrimeTime Medical Insurance Company DUR Administrator
(MediPlan) 255 East State Street
P.O. Box 6907 Columbus, OH 43215
Canton, OH 44706 T: 614/466-9689
330/451-0934 F: 614/-466-2866
DUR Board
Paramount Care, Inc.
P.O. Box 928 Thomas E. Gretter, M.D.
Toledo, OH 43697-0928 Timothy Garner, M.D.
419/887-2550 Jacob F. Palomaki, M.D.
Beth T. Tranen, D.O.
QualChoice Health Plan Rob Kubasak, R.Ph.
6000 Parkland Boulevard Sue Eastman, R.Ph.
Cleveland, OH 44124 Jill Orn, R.Ph.
440/460-0093 Donald Sullivan, Ph.D., R.Ph.

SummaCare Prescription Price Updating


P.O. Box 3620 First DataBank
Akron, OH 44309 1111 Bayhill Drive, Suite 350
330/996-8410 San Bruno, CA 94066
T: 650/588-5454
F: 650/827-4578
Medicaid Drug Rebate Contacts
Robert P. Reid, R.Ph.
614/466-6420

Ohio-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Claims Submission Contact Department of Job and Family Services


Officials
First Health Services Corp.
4300 Cox Road Barbara Riley, Director
Glen Allen, VA 23060 Ohio Department of Job and Family Services
T: 800/884-2822 30 East Broad Street, 32nd Floor
F: 800/884-7696 Columbus, OH 43215-3414
T: 614/466-6282
Medicaid Managed Care Contact
F: 614/466-2815
John Barley E-mail: rileyb@odjfs.state.oh.us
Bureau of Managed Health Care
Ohio Department of Job and Family Services Barbara C. Edwards, Deputy Director
255 E. Main Street Ohio Health Plans
Columbus, OH 43215 Ohio Department of Job and Family Services
614/466-4693 30 East Broad Street, 31st Floor
Columbus, OH 43215-3414
Mail Order Pharmacy Benefit T: 614/466-0140
F: 614/752-3986
State has mail order providers. Recipients free to E-mail: edwarb@odhs.state.oh.us
select mail order pharmacy of their choosing.
Pharmacy and Therapeutics Committee Medical Care Advisory Committee
Robert P. Reid, R.Ph., Chairman Jerry Friedman, (Chair)
Bureau of Health Plan Policy Cindy Norwood
30 East Broad Street, 27th Floor Ed Lentz
Columbus, OH 43266-0423 Hubert Wirtz
Robert Logan
Suzanne Eastman, R.Ph., M.S. Eugene King, J.D.
3922 North Cliff Lane Pamela Morris
Cincinnati, OH 43220 Frank Giganti
Walter Clark, M.D.
Michael Alexander, D.O. Sam Chapman
3219 Sullivant Avenue Robert Staib
Columbus, OH 43204 Jack Cera
Art Schlesinger
Ruth E. Purdy, D.O. Randall Garland
4830 Slate Run Court William Sawyer, M.D.
Columbus, OH 43220 Lolita M. McDavid, M.D., M.P.A.
Maureen Mitchell, R.N., Ed.D.
Susan Baker, APN Sherri Morgan, M.D., M.P.H.
2288 Kings Corners East Christopher Moore
Lexington, OH 44904 Nancy Lee
Kathleen Anderson
Mary Jo Welker, M.D. Katherine Kuck
2231 North High Street Donna Skoda, M.S., R.D., L.D.
Columbus, OH 43201 Clifford Deveny, M.D.
Randy Runyon
Jennifer Christner, M.D. Brian Tilow
2262 Parkwood
Toledo, OH 43620

Sandra Hrometz, R.Ph, Ph.D.


740 E. College Avenue
Bluffton, OH 43209

Tammie J. Stroup, R.Ph.


30 E. Broad Street, 27th Floor
Columbus, OH 43215-3414

Ohio-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Executive Officers of State Medical and


Pharmaceutical Societies
Ohio State Medical Association
Brent Mulgrew
Executive Director
3401 Mill Run Drive
Hilliard, OH 43026
T: 800/766-6762
F: 614/527-6763
E-mail: brentm@osma.org
Internet address: www.osma.org

Ohio Pharmacists Association


Ernest E. Boyd
Executive Director
6037 Frantz Road, Suite 106
Dublin, OH 43017
T: 614/798-0037
F: 614/798-0978
E-mail: eboyd@ohiopharmacists.org
Internet address: www.ohiopharmacists.org

Ohio 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 State Board of Pharmacy


William T. Winsley
Executive Director
77 S. High Street, Room 1702
Columbus, OH 43215-6126
T: 614/466-4143
F: 614/752-4836
E-mail: exec@bop.state.oh.us
Interent address: www.state.oh.us/pharmacy/

Ohio Hospital Association


James Castle
President and CEO
155 E. Broad Street, 15th Floor
Columbus, OH 43215-3620
T: 614/221-7614
F: 614/221-4771
E-mail: oha@ohanet.org
Internet address: www.ohanet.org

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Ohio-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

OKLAHOMA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN)


Aged Blind/ Child Adult Aged Blind/ Child Adult
Disabled Disabled
Prescribed Drugs ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Inpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Outpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Laboratory & X-ray Service ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Nursing Facility Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Physician Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Dental Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $267,549,002 276,111 $301,294,000

RECEIVING CASH ASSISTANCE, TOTAL $93,374,439 64,654


Aged $26,963,385 22,887
Blind/Disabled $64,994,426 37,378
Child $791,061 3,079
Adult $625,567 1,310

MEDICALLY NEEDY, TOTAL $386,198 607


Aged $16,944 40
Blind/Disabled $195,575 148
Child $104,496 220
Adult $69,183 199

POVERTY RELATED, TOTAL $35,945,183 148,226


Aged $124,949 217
Blind/Disabled $195,087 211
Child $33,687,481 132,437
Adult $1,937,666 15,361
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $137,843,182 62,624

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

1
Note: As of January 1, 2004, (after the survey was conducted) the Oklahoma Medicaid program, according to its website,
underwent changes regarding managed care. These changes will be reflected in the 2004 compilation. Please contact the State for
information on the changes in managed care.

Oklahoma-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Oklahoma-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Formulary/Prior Authorization


Oklahoma Health Care Authority. Formulary: Open formulary with the preferred drug
list (PDL). PDL managed through restrictions on
use, prior authorization, therapeutic substitution, use
D. PROVISIONS RELATING TO DRUGS of preferred products, and step therapy.
Benefit Design
Prior Authorization: State currently has a formal
Drug Benefit Product Coverage: Products covered: prior authorization procedure. Grievance process
prescribed insulin. Products covered (DME benefit): exists for appeal of prior authorization decisions or
disposable needles and syringe combinations for coverage of an excluded product to the agency’s
insulin; blood glucose test strips; and urine ketone Administrative Law Judge. Recipient must present
test strips. Products covered with restrictions: total compelling reason to obtain coverage.
parenteral nutrition (reimburse single most costly
ingredient, not reimbursed through pharmacy Prescription or Dispensing Limitations
program). Products not covered: cosmetics; fertility Prescription Refills: None
drugs; and experimental drugs.
Monthly Quantity Limits: Six prescriptions per
Over-the-Counter Product Coverage: Products month/recipient, including a maximum of three brand
covered: birth control products. Products covered name scripts. ICF-MR, Medicaid children, and
with restrictions: allergy, asthma, and sinus products nursing home recipients are allowed unlimited orders.
(Claritin OTC only for children < 21 years. PA Clients on Home and Community Based Waivers and
required for adults. Rx required for all ages.); DDSD Waivers are also allowed an unlimited
digestive products (non-H2 antagonists-Prilosec OTC number of prescriptions each month.
only, Rx required); smoking deterrent products (PA
and Rx required). Products not covered: analgesics; Quantity Limit per Prescription: Greater of 34-day
cough and cold preparations; H2 antagonists; supply or 100 units.
feminine products; topical products.
Drug Utilization Review
Therapeutic Category Coverage: Therapeutic PRODUR system implemented in 2000. State
categories covered: antibiotics; anticoagulants; currently has a DUR Board with a monthly review.
anticonvulsants; antidepressants; antidiabetic agents;
antilipemic agents; anti-psychotics; chemotherapy Pharmacy Payment and Patient Cost Sharing
agents; contraceptives; ENT anti-inflammatory Dispensing Fee: $4.15, effective 10/95.
agents; estrogens; sympathominetics (adrenergic);
and thyroid agents. Prior authorization required for: Ingredient Reimbursement Basis: EAC = AWP-
anoretics (partial coverage); analgesics, antipyretics, 12.0%.
NSAIDs; antihistamine drugs (partial coverage);
anxiolytics, sedatives, and hypnotics; cardiac drugs; Prescription Charge Formula: Estimated Acquisition
growth hormones; hypotensive agents; misc. GI Cost (EAC) plus dispensing fee, or usual and
drugs; prescribed smoking deterrents (partial customary charge, whichever is lower. In no event
coverage) stimulants for ADHD; clopidigrel; and shall charges to the Welfare Department exceed
montelukast. Therapeutic categories not covered: charges made to the general public for the same
anabolic steroids; and prescribed cold medications. prescription or item.
OBRA ’90 drugs identified as "coverage optional."
Maximum Allowable Cost: State imposes Federal
Coverage of Injectables: Injectable medicines Upper Limits as well as State-specific limits on
reimbursable through both the Prescription Drug generic drugs. Override requires “Brand Medically
Program and physician payment when used in home Necessary” and prior authorization (effective 12/04).
health care and extended care facilities, and through Currently, 917 drugs on MAC list.
physician payment when used in physician offices.
Incentive Fee: None.
Vaccines: Vaccines reimbursable as part of EPSDT
services and the Vaccines for Children Program. Patient Cost Sharing: Copayment is $1.00 for
prescriptions up to $29.99, $2.00 for prescriptions
Unit Dose: Unit dose packaging not reimbursable. over $30.00.

Cognitive Services: Does not pay for cognitive


services.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

E. USE OF MANAGED CARE Medicaid Drug Rebate Contact


Tom P. Simonson
Approximately 185,000 Medicaid recipients were Drug Rebate Manager
enrolled in MCOs in FY 2003. Recipients receive Oklahoma Healthcare Authority
benefits through both the State and managed care 4545 N. Lincoln, Suite 124
plans. Effective 1/1/2004, there will be no fully Oklahoma City, OK 73105
capitated managed care plans in Oklahoma. The T: 405/522-7327
Primary Care/Care Management System will remain F: 405/530-3236
in place. E-mail: simonsot@ohca.state.ok.us
New Brand Name Products Contact
F. STATE CONTACTS
Rodney Ramsey
State Drug Program Administrator Drug Reference Coordinator
Nancy Nesser, D.Ph., J.D. Oklahoma Health Care Authority
Pharmacy Director 4545 N. Lincoln, Suite 124
Oklahoma Health Care Authority Oklahoma City, OK 73105
4545 N. Lincoln, Suite 124 T: 405/522-7492
Oklahoma City, OK 73105 F: 405/530-7119
T: 405/522-7325 E-mail: ramseyr@ohca.state.ok.us
F: 405/530-3235 Claims Submission Contact
E-mail: nessern@ohca.state.ok.us
Internet address: www.ohca.state.ok.us EDS
2401 N.W. 23rd Street, Suite 11
Prior Authorization Contact Oklahoma City, OK 73107
Ronald Graham, D.Ph. 405/416-6794
Manager, Operations/DUR Medicare Managed Care Contact
University of Oklahoma, College of Pharmacy
P.O. Box 26901 Melinda Jones
Oklahoma City, OK 73109 Senior Compliance Analyst
T: 405/271-6614 Oklahoma Health Care Authority
F: 405/271-2615 4545 N. Lincoln, Suite 124
E-mail: ronald-graham@ouhsc.edu Oklahoma City, OK 73105-9901
T: 405/522-7125
DUR Contact F: 405/530-3281
Ronald Graham, D.Ph. E-mail: jonesm@ohca.state.ok.us
405/271-6614
Mail Order Pharmacy Program
Medicaid DUR Board
Oklahoma has a mail order pharmacy option.
Dick Robinson, D.Ph. (Vice-Chair) Pharmacy must be a contracted provider.
Dorothy Gourley, D.Ph.
Cliff Meece, D.Ph. Disease Management Program/Initiative
Greg Tarasoff, M.D. Contact
Cathy E. Hollen, D.Ph. Alex Easton
Brent Bell, D.O., D.Ph. Pharmacy Operations Manager
Thomas Whitsett, M.D. (Chair) Oklahoma Health Care Authority
Dan McNeill, Ph.D., PA-C 4545 N. Lincoln, Suite 124
James Swaim, D.Ph. Oklahoma City, OK 73105
Prescription Price Updating T: 405/522-7453
F: 405/522-3238
First DataBank E-mail: eastona@ohca.state.ok.us
1111 Bayhill Drive
San Bruno, CA 94066
800/633-3453
Internet address: www.firstdatabank.com

Oklahoma-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Oklahoma Health Care Authority Officials Executive Officers of State Medical,


Pharmaceutical, and Osteopathic Societies
Michael Fogarty, J.D.
Chief Executive Officer Oklahoma State Medical Association
Oklahoma Health Care Authority Brian O. Foy, Executive Director
4545 N. Lincoln, Suite 124 601 NW Grand Boulevard
Oklahoma City, OK 73105 Oklahoma City, OK 73118
T: 405/522-7300 T: 405/843-9571
F: 405/522-7187 F: 405/842-1834
E-mail: fogartym@ohca.state.ok.us E-mail: osma@osmaonline.org
Internet address: www.osmaonline.org
Lynn Mitchell, M.D., M.P.H.
Medicaid Director Oklahoma Pharmacists Association
Oklahoma Health Care Authority Phil Woodward, Ph.D., Executive Director
4545 N. Lincoln, Suite 124 P.O. Box 18731
Oklahoma City, OK 73105 Oklahoma City, OK 73154
T: 405/530-7365 T: 405/528-3338
F: 405/530-3218 F: 405/528-1417
E-mail: mitchell@ohca.state.ok.us E-mail: pwoodward@opha.com
Internet address: www.opha.com
Oklahoma Health Care Authority Board
Charles Ed McFall (Chair) Oklahoma Osteopathic Association
Wayne Hoffman (Vice Chair) Lynette C. McLain
George Miller Executive Director
Anne M. Roberts 4848 N. Lincoln Boulevard
Lyle Roggow Oklahoma City, OK 73105
T: 405/528-4848
Medical Advisory Committee F: 405/528-6102
Steven A. Crawford, M.D. (Chair) E-mail: ooa@okosteo.org
Dan McNeil, Ph.D. (Vice Chair) Internet address: www.okosteo.org
E. Edward Beckham, Ph.D.
Bruce Bennett Oklahoma State Board of Pharmacy
Steve Buck Bryan Potter
Tanya Case Executive Director
Terry Cline, Ph.D. 4545 N. Lincoln Boulevard, Suite 112
Mike Crutcher, M.D. Oklahoma City, OK 73105-3488
Sherry Davis, A.R.N.P. T: 405/521-3815
Steve Goforth F: 405/521-3758
Michael Grim, Ph.D. E-mail: pharmacy@oklaosf.state.ok.us
Stanley E. Grogg, D.O. Internet address: www.pharmacy.state.ok.us
Howard Hendrick
Jo Hill Oklahoma Hospital Association
Ragina Holiman, M.S., C.N.S. Craig W. Jones
Craig Jones President
Richard Langerman, D.O. 4000 Lincoln Boulevard
Greg Machtolff, D.D.S. Oklahoma City, OK 73105
Kelli McNeal T: 405/427-9537
James Murtaugh, D.D.S. F: 405/424-4507
Ann S. Owen, Ph.D. E-mail: jones@okoha.com
J. Daniel Post, D.C. Internet address: www.okoha.com
Jerry Unruh
Steven Walker, D.P.M.
Gara Wilsie, D.Ph.
Travis Yadon, O.D.

Oklahoma-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

OREGON

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $269,936,847 242,865 $262,335,388

RECEIVING CASH ASSISTANCE TOTAL $101,222,484 67,680


Aged $12,149,831 8,646
Blind/Disabled $80,475,039 33,840
Child $1,687,922 12,138
Adult $6,909,692 13,056

MEDICALLY NEEDY, TOTAL $39,179,280 8,559


Aged $6,131,229 2,149
Blind/Disabled $33,048,051 6,410
Child $0 0
Adult $0 0

POVERTY RELATED, TOTAL $6,445,727 38,728


Aged $491,212 402
Blind/Disabled $1,097,160 576
Child $4,123,226 32,729
Adult $734,129 5,021
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $123,089,356 127,898

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
** 2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Oregon-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Formulary/Prior Authorization


Formulary: Open formulary with a preferred drug list
Office of Medical Assistance Programs (OMAP), (PDL). PDL managed through physician profiling.
Department of Human Services.
Prior Authorization: State currently has a formal
prior authorization procedure. Client may request an
D. PROVISIONS RELATING TO DRUGS administrative hearing to appeal a prior authorization
Benefit Design decision or to appeal the coverage of excluded
products.
Drug Benefit Product Coverage: Products covered:
prescribed insulin. Products covered under DME: Prescribing or Dispensing Limitations
disposable needles and syringe combinations used for 34-day supply. (Limits on initial prescription for
insulin; blood glucose test strips; and urine ketone chronic medications to 15 days to prevent wasting if
test strips. Prior authorization required for: drug is changed due to intolerance, side effects, etc.)
isotretinon; acute anti-ulcer drugs; cosmetics; total Therapy duration limits on selected drugs.
parenteral nutrition; interdialytic parenteral nutrition;
retinoic acid; nasal inhalers; coal tar preparations; Drug Utilization Review
and topical testosterone. Products not covered: PRODUR system implemented in March 1994. State
cosmetics; fertility drugs; experimental drugs. currently has a DUR Board with a quarterly review.

Over-the-Counter Product Coverage: Products Pharmacy Payment and Patient Cost Sharing
covered: allergy, asthma, and sinus products; Dispensing Fee: effective 2/1/03.
analgesics; cough and cold preparations; digestive
products; feminine products; and topical products. 1) $3.50 (retail);
Products not covered: topical products (cosmetics,
acne medications, and psoriasis products). 2) $3.91 (institutional/SNF: providers operating a
True or Modified Dose Delivery System).
Therapeutic Category Coverage: Therapeutic
categories covered: analgesics, antipyretics, and Ingredient Reimbursement Basis: EAC = AWP-15%
NSAIDs; antibiotics; anticoagulants; anti- (Retail), AWP-11% (Institutional)
depressants; antidiabetic drugs; antilipemic agents;
antipsychotics; cardiac drugs; chemotherapy agents; Prescription Charge Formula: Estimated acquisition
prescribed cold medications; contraceptives; cost (EAC) defined as the lesser of: (1) AWP-15%
estrogens; hypotensive agents; prescribed smoking (2) Federal Upper Limits for multiple source drugs or
deterrents; sympathominetics (andrenergic); and (3) State MAC, or (4) the usual and customary charge
thyroid agents. Therapeutic categories requiring prior plus a dispensing fee.
authorization: anabolic steroids; anoretics;
anticonvulsants; antihistamine drugs; anxiolytics, Maximum Allowable Cost: State imposes Federal
sedatives, and hypnotics; ENT anti-inflammatory Upper Limits as well as State-specific maximum
agents; growth hormones; misc. GI drugs; allowable cost (MAC) limits on generic drugs.
antifungals; legend laxatives; oral nutrionals; topical Override requires or “Brand Medically Necessary”
antibiotics; topical antivirals; weight reduction drugs; plus documentation of patient intolerance to generic.
and any other drug products for which the only
indication is for a non-funded condition. (The Oregon Incentive Fee: None.
Health Plan coverages are limited to conditions
which appear on the HSC prioritized list.) Patient Cost Sharing: $2.00 (generic); $3.00 (brand)
Coverage of Injectables: Injectable medicines Cognitive Services: Does not pay for cognitive
reimbursable through physician payment when used services.
in physician offices, home health care, and extended
care facilities.

Vaccines: Vaccines reimbursable by Medicaid as part


of the Vaccines for Children Program.

Unit Dose: Unit dose packaging not reimbursable.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

E. USE OF MANAGED CARE Mid Rogue IPA Health Plan


820 NE 7th Street
Approximately 241,000 Medicaid Recipients were Grants Pass, OR 97526
enrolled in MCOs in FY 2003. Recipients enrolled in 541/471-4106
MCOs receive pharmaceutical benefits through
managed care plans. Mental health drugs are carved Oregon Health Management Services
out of managed care. 1051 NE 6th Street, Suite 2C
Grants Pass, OR 97526
Care Oregon, Inc 541/ 471-4208
522 SW Fifth Avenue, Suite 200
Portland, OR 97204 Providence Health Assurance
800/224-4840 1235 NE 47th, Suite 220
Portland, OR 97213-2196
Cascade Comprehensive Care, Inc. 800/ 898-8174
900 Main Street, Suite A
P.O. Box 217 Tuality Health Alliance
Klamath Falls, OR 97601-0368 335 SE 8th Avenue
541/883-2947 P.O. Box 925
Hillsboro, OR 97123-0925
Central Oregon Independent Health Services, Inc. 800/681-1901
2650 NE Courtney Drive
P.O. Box 5729
F. STATE CONTACTS
Bend, OR 97708-5729
800/431-4155 State Drug Program Administrator
Thomas Drawbaugh
Doctors of The Oregon Coast South (DOCS)
750 Central, Suite 202 Pharmacy Program Manager
P.O. Box 1096 Office of Medical Assistance Programs (OMAP)
Department of Human Resources
Coos Bay, OR 97420
541/269-7400 500 Summer Street, NE, E-35
Salem, OR 97301-1077
T: 503/945-6492
Douglas County IPA
500 SE Cass, Suite 210 F: 503/373-7689
Roseburg, OR 97470 E-mail: thomas.drawbaugh@state.or.us
Internet address: www.dhs.state.or.us/healthplan
541/672-1685
Prior Authorization Contact
Family Care, Inc
2121 SW Broadway, Suite 300 Kathy L. Ketchum, R.Ph., M.P.A.: H.A.
Portland, OR 97201 Medicaid Program Coordinator
800/458-9518 Oregon State University College of Pharmacy
840 SW Gaines Road, MC 212
Intercommunity Health Network, Inc Portland, OR 97239-3098
3600 NW Samaritan Drive T: 503/494-1589
Corvallis, OR 97330 F: 503/494-8797
800/757-5114 E-mail: ketchumk@ohsu.edu
DUR Contact
Lane Individual Practice Association, Inc. (LIPA)
1500 Valley Rive Drive, Suite 370 Kathy L. Ketchum, R.Ph., M.P.A.: H.A.
Eugene, OR 97401 503/494-1589
541/485-2155 Medicaid DUR Board

Marion Polk Community Health Plan Rickland G. Asai, D.M.D.


198 Commercial Street, SE, Suite 240 Maggie Bennington-Davis, M.D.
Salem, OR 97301 Sherry Barrett, R.Ph.
503/584-2150 Patrick Bowman, R.Ph.
George R. Gerding, R.Ph.
Dean Haxby, Pharm.D.
Robert Ingle, Jr., M.D., M.P.H.
Gregory Johnson, M.D. (Chair)

Oregon-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

J. Allen Johnson, M.D. Mail Order Pharmacy Program


Raymond S. Lee, D.O.
State has a mail order pharmacy program. All non-
John Muench, M.D., M.P.H.
institutionalized beneficiaries are entitled to
Kevin Russell, R.Ph.
participate.
New Brand Name Products Contact
Office of Medical Assistance Officials
Kathy L. Ketchum, R.Ph., M.P.A.: H.A.
Gary Weeks
503/494-1589
Director
Prescription Price Updating Department of Human Services
500 Summer Street, NE, E-15
Jim Rowland
Salem, OR 97301
Account Manager
T: 503/945-5944
First Health Services Corporation
F: 503/378-2897
925 Commercial Street
E-mail: gary.weeks@state.org.us
Salem, OR 97302
T: 503/391-1980
Barney H. Speight
F: 503/391-1979
Administrator
E-mail: rowlanji@fhsc.com
Office of Medical Assistance Programs
Department of Human Services
Medicaid Drug Rebate Contacts 500 Summer Street, NE, E-49
Jim Rowland Salem, OR 97301
503/391-1980 T: 503/373-7689
F: 503/373-7823
Claims Submission Contact E-mail: barney.h.speight@state.or.us
Jim Rowland Title XIX Medical Care Advisory Committees
503/391-1980
Elizabeth Byers
Medicaid Managed Care Contact Bruce Bliatout
Joyce Riggi Donna Crawford
Delivery Systems Unit Manager Rosemari Davis
Office of Medical Assistance Programs Michael Garland
500 Summer Street, NE, E-35 John Hogan
Salem, OR 97310 Kelley Kaiser
T: 503/945-6497 Noel Larson, D.M.D.
F: 503/947-5221 Amy Malone
E-mail: joyce.m.riggi@state.or.us Rick Wopat, M.D.
Disease Management Program/Initiative
Contact Pharmacy Advisory Task Force
Chris Barber Tom Holt, Chairman
Case Management Coordinator Mike Dardis, R.Ph.
Office of Medical Assistance Programs Jim Waletich, R.Ph.
500 Summer Street, NE, E-35 Ed Hughes, R.Ph.
Salem, OR 97301 Ron Dulwick, R.Ph.
T: 503/945-6588 Jenny Kudna, R.Ph.
F: 503/373-7689 Dennis Perry, R.Ph.
E-mail: chris.barber@state.or.us Larry Cartier, R.Ph.
Richard Hartmann, R.Ph.
Disease Management/Patient Education Chris Vorrath, R.Ph.
Programs Susie Morris, R.Ph.
Disease States/Medical Conditions: asthma, Tom Hornsby, R.Ph.
cardiovascular disease, diabetes Kathy Ketchum, R.Ph.
Program Name: Care Enhance John Mansfield, R.Ph.
Program Manager: McKesson Dave Lewis, R.Ph.
Dave Walden, R.Ph.
Cynthia Wong, R.Ph.

Oregon-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Executive Officers of State Medical and


Pharmaceutical Associations
Oregon Medical Association
John C. Moorhead
President
5210 SW Corbett Street
Portland, OR 97239-3897
T: 503/226-1555
F: 503/241-7148
E-mail: andreab@theoma.org
Internet address: www.theoma.org

Oregon State Pharmacy Association


Tom Holt, CEO
29702-B Town Center Loop West
Wilsonville, OR 97070-6481
T: 503/582-9055
F: 503/582-9046
E-mail: tomh@oregonpharmacy.org
Internet address: www.oregonpharmacists.com

Osteopathic Physicians and Surgeons of Oregon


Jeff Heatherington
Executive Director
2121 SW Broadway, Suite 300
Portland, OR 97201
T: 503/222-2779
F: 503/222-2392
E-mail: jeffh@opso.org
Internet address: www.opso.com

Oregon State Board of Pharmacy


Gary A. Schnabel
Executive Director
State Office Bldg., Room 425
800 NE Oregon Street
Portland, OR 97232
T: 503/731-4032
F: 503/731-4067
E-mail: gary.a.schnabel@state.or.us
Internet address: www.pharmacy.state.or.us

Oregon Association of Hospitals and Health Systems


Ken Rutledge
President
4000 Kruse Way Place
Building 2, Suite 100
Lake Oswego, OR 97035-2543
T: 503/636-2204
F: 503/636-8310
E-mail: kenr@oahhs.org
Internet address: www.oahhs.org

Oregon-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Oregon-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

PENNSYLVANIA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**

Expenditures Recipients Expenditures Recipients

TOTAL $719,243,402 464,848 $791,053,653

RECEIVING CASH ASSISTANCE, TOTAL $289,159,044 163,053


Aged $63,502,096 25,125
Blind / Disabled $204,581,556 76,620
Child $8,207,666 37,962
Adult $12,867,726 23,346

MEDICALLY NEEDY, TOTAL $78,820,915 36,294


Aged $69,435,876 23,554
Blind / Disabled $5,799,806 1,375
Child $2,269,641 6,755
Adult $1,315,592 4,610

POVERTY RELATED, TOTAL $150,197,883 158,264


Aged $47,969,716 19,213
Blind / Disabled $80,402,609 36,860
Child $19,935,060 92,408
Adult $1,410,384 9,614
BCCA Women $480,114 169

TOTAL OTHER EXPENDITURES/RECIPIENTS* $201,065,560 107,237

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Pennsylvania-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Vaccines for Children Program, the EPSDT Program,


and the Pharmacy Services Program.
Office of Medical Assistance Programs, Department Unit Dose: Unit dose packaging not reimbursable.
of Public Welfare. Formulary/Prior Authorization
Formulary: Open formulary.
D. PROVISIONS RELATING TO DRUGS
Benefit Design Prior Authorization: State currently has a prior
authorization procedure screening for drug classes
Drug Benefit Product Coverage: Products covered: and individual drugs. Products that require PA
prescribed insulin; disposable needles and syringe include BMN brand name drugs that have A-rated
combinations used for insulin; blood glucose test generics, H2 antagonists used >90 days, and drugs
strips; urine ketone test strips; interdialytic parenteral for erectile dysfunction. Also, Oxycontin
nutrition; and total parenteral nutrition. Products not prescriptions with doses in excess of 3 tablets per
covered: cosmetics; fertility drugs; and experimental day, or being on more than 2 different strengths
drugs. concurrently and COX-2 drugs if the patient is taking
another NSAID, the prescribed dose is higher than
Over-the-Counter Product Coverage: Products the FDA recommended dose, or the patient is under
covered: analgesics; feminine products; topical 70 years of age and is not taking an anticoagulant.
products; laxatives; scabicides containing permethrin; State hearing and appeals process available to appeal
oral electrolytes; and smoking deterrent products. a prior authorization decision.
Products covered with restrictions: allergy, asthma,
and sinus (indication or prescribed); cough and cold Prescribing or Dispensing Limitations
preparations (indication other than C+C on Rx); Quantity Limit: 34-day supply or 100 units,
digestive products (not including H2 antagonists) whichever is greater.
(legend products only); and digestive products (H2
antagonists) (PA > 90 days at acute dose). Products Refill Limit: Up to 5 within 6 months.
not covered: emollients and digestive products (non-
H2 antagonists). Monthly Prescription Limit: 6

Therapeutic Category Coverage: Therapeutic Drug Utilization Review


categories covered: anabolic steroids; analgesics, PRODUR system implemented in June 1993. DUR
antipyretics, NSAIDs; antibiotics; anticoagulants; Board has 10 members and meets quarterly.
anticonvulsants; anti-depressants; antidiabetic agents;
antihistamine drugs; antilipemic agents; anti- Pharmacy Payment and Patient Cost Sharing
psychotics; anxiolytics, sedatives, and hypnotics; Dispensing Fee: $4.00 ($5.00 for compounds),
cardiac drugs; chemotherapy agents; contraceptives; effective 10/1/95.
ENT anti-inflammatory agents; estrogens; growth
hormones; hypotensive agents; misc. GI drugs; Ingredient Reimbursement Basis: EAC = AWP-10%.
sympathominetics (adrenergic); thyroid agents; and
prescribed smoking deterrent products; prescribed Prescription Charge Formula:
cold medications. Prior authorization required for:
1. Payment for single source drugs and those
Cox-2s; erectile dysfunction products; Oxycodone/
multisource brand name drugs certified as
Oxycontin; and Brand Medically Necessary drugs.
medically necessary will be the lower of the
Therapeutic categories not covered: anorectics
EAC plus dispensing fee or the pharmacy's usual
(unless for treatment of hyperkinesis or narcolepsy);
and customary charge.
hair restoration products; drugs prescribed for
obesity; appetite control products; vitamins (with 2. State MAC for the drug plus dispensing fee or
some exceptions); and products from companies not the pharmacy's usual and customary charge.
participating in the rebate program.
3. For compound prescriptions, an additional fee of
Coverage of Injectables: Injectable medicines $1.00 is allowed to a pharmacy, bringing the
reimbursable through the Prescription Drug Program total dispensing fee to $5.00.
when used in physician offices, home health care,
and extended care facilities. Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
Vaccines: Vaccines reimbursable at AWP-10% as generic drugs. 225 drugs (not including different
part of the Children Health Insurance Program, the strengths on package sizes) are listed on the State-
specific MAC list. Override requires “Brand

Pennsylvania-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Medically Necessary” or “Brand Necessary,” plus UPMC Health Plan, Inc.


prior authorization. One Chatham Center
112 Washington Place, Suite 800
Incentive Fee: None. Pittsburgh, PA 15219
412/454-7640
Patient Cost Sharing: Copayment is $1.00; $2.00 for
General Assistance. The copayment will not apply to Gateway Health Plan
those recipients who are federally exempt, under 21 U.S. Steel Tower, Floor 41
years of age, pregnancy cases and long-term care 600 Grant Street
patients, plus patients receiving drugs in the Pittsburgh, PA 15219
following categories: 412/255-4640
− Anticonvulsants Ion Health, Inc.
− Antidiabetic agents 1527 East Lake Road
− Antiglaucoma agents Erie, PA 16511
− Antihypertensive agents
814/874-3098
− Antineoplastic agents
− Antiparkinson agents
− Cardiovascular preparations
F. STATE CONTACTS
− HIV/AIDS specific drugs State Drug Program Administrator
− Psychotherapeutic agents
Terri Cathers
Cognitive Services: Does not pay for cognitive Director of Pharmacy
services. Department of Public Welfare
P.O. Box 2675
Harrisburg, PA 17105
E. USE OF MANAGED CARE T: 717/772-6195
F: 717/705-8391
Approximately 1.3 million unduplicated Medicaid E-mail:c-tcathers@state.pa.us
recipients were enrolled in managed care in 2003. Internet address: www.dpw.state.pa.us/omap
All receive pharmacy services, depending on their Welfare Department Officials
category of assistance, through managed care.
Estelle B. Richman
Managed Care Organizations Secretary
AmeriHealth HMO/Mercy Health Plan Department of Public Welfare
200 Stevens Drive Health and Welfare Building
Philadelphia, PA 19113 P.O. Box 2675
215/937-8200 Harrisburg, PA 17105-2675
T: 717/787-2600
Keystone Mercy Healthplan F: 717/772-2062
200 Stevens Drive, Suite 900 E-mail: ra-dpwsecretarynet@state.pa.us
Philadelphia, PA 19113-1570
215/937-8200 David S. Feinberg
Deputy Secretary for Medical Assistance Programs
Americhoice of PA Department of Public Welfare
The Wanamaker Building Health and Welfare Building
100 Penn Square East, Suite 900 P.O. Box 2675
Philadelphia, PA 19107 Harrisburg, PA 17105-2675
215/835-4602 T: 717/787-1870
F: 717/787-4639
Health Partners of Philadelphia E-mail: dfeinberg@state.pa.us
833 Chestnut Street, Suite 900
Philadelphia, PA 19107 Prior Authorization Contact
215/849-9606 Terri Cathers
717/772-6195
Three Rivers Health Plans/MedPlus+
300 Oxford Drive
Monroeville, PA 15146
412/858-4000

Pennsylvania-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

DUR Board Claims Submission Contact


Richard D. Baltz, M.D. EDS
3028 Market Street 275 Grandview Avenue
Camp Hill, PA 17011 Camp Hill, PA 17011
(All contacts with contractor must be made through
Richard T. Bell, M.D. State agency.)
Chairman
Medicaid Managed Care Contact
2016 Redwood Avenue
Wyomissing, PA 19610 Patricia S. Jacobs
Director
Richard W. Sloan, M.D. Bureau of Managed Care Operations
Thomas Hart Family Practice Center Department of Public Welfare
York Hospital P.O. Box 2675
1001 South George Street Harrisburg, PA 17105
York, PA 17405 T: 717/772-6300
F: 717/772-6328
Otto F. Wolke, R.Ph.
Geisinger Health Plan Disease Management Program/ Initative
Geisinger Office Building Contact
Danville, PA 17822
Joanie Morgan
Project Manager
Patricia A. Keys, Pharm.D., R.Ph.
1514 Scenery Ridge Drive Access Plus
Pittsburgh, PA 15241 Department of Public Welfare
P.O. Box 2675
Marshall P. Burnside, R.Ph. Harrisburg, PA 17105
6000 Bell Road
Harrisburg, PA 17111 Mail Order Pharmacy Program
None
Michael A. Zemaitis, Ph.D., R.Ph.
133 Shadowlawn Drive Expanded Drug Coverage Program Contact
Pittsburgh, PA 15261 Thomas M. Snedden, Director
PACE Program
Robert L. Mayer, Jr., Pharm.D., R.Ph. PA Department of Aging
5814 Elmer Street 555 Walnut Street, 5th Floor.
Pittsburgh, PA 15232 Harrisburg, PA 17101
T: 717/787-7313
Keith Burkhart, M.D. F: 717/772-2730
206 Mine Road
Hershey, PA 17033 Medical Assistance Advisory Committee

Jeffrey P. Staab, M.D., M.S. Christine Allen


5 Heritage Lane American PACE Exchange
Phoenixville, PA 19460-4607 215 Stoneway Lane
Merion Station, PA 19066-1819
New Brand Name Products Contact
Terri Cathers Shirley Beer
717/772-6195 Armstrong County Low Income Rights Organization
251 Briar Hill Road
Prescription Price Updating Kittanning, PA 16201
First DataBank
1111 Bayhill Drive Kent D. W. Bream, M.D.
San Bruno, CA 94066 Department of Family Practice
University of Pennsylvania
800/633-3453
2 Gates, HUP, 3400 Spruce Street
Medicaid Drug Rebate Contacts Philadelphia, PA 19104
Terri Cathers
717/772-6195

Pennsylvania-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Louise Brookins Yvette Long


Philadelphia State Welfare Rights Organization Philadelphia Welfare Rights Organization
1231 N. Franklin Street 1231 North Franklin Street
Philadelphia, PA 19122 Philadelphia, PA 19122

Michael D. Chambers Donald McCoy (Chair)


County Commissioners Association of Pennsylvania Pennsylvania Medical Society
17 North Front Street 777 East Park Drive
Harrisburg, PA 17101 P.O. Box 8820
Harrisburg, PA 17105-8820
Barbara Coffin
Pennsylvania Association of Area Agencies on Aging Russ McDaid
Berks County Office of Aging PA Association of Non-Profit Homes for the Aging
County Services Center 1100 Bent Creek Boulevard
633 Court Street Mechanicsburg, PA 17050
Reading, PA 19601-4303
Eugene McGuire, D.D.S.
Jonna L. Stefano PA Dental Association
Delaware County Office of Behavioral Health 1575 Pond Road, Suite 105
20 South 69th Street, 3rd Floor Allentown, PA 18104
Upper Darby, PA 19802
Anne R. McHugh
Henry R. Fiumelli Hospital and Healthsystem Association of
Executive Director Pennsylvania
Pennsylvania Forum for Primary Health Care 4750 Lindle Road
1035 Mumma Road, Suite 1 P.O. Box 8600
Wormleysburg, PA 17043 Harrisburg, PA 17105-8600

Vickie Hoak (Vice-Chair) Donna McNonagle


Pennsylvania Homecare Association Philadelphia Coordinated Health Care
20 Erford Road, Suite 115 123 South Broad Street, 22nd Floor
Lemoyne, PA 17043 Philadelphia, PA 19109

Dolores Hodgkiss Thomas Peifer


Managed Care Association of Pennsylvania Hospital and Health System
240 North Third Street, Suite 501 Association of Pennsylvania
Harrisburg, PA 17101 4750 Lindle Road
Harrisburg, PA 17105
Michelle Jones
Healthy Start, Inc. Mary Ellen Rehrman
400 North Lexington Street 10 Bertolet School Road
Pittsburgh, PA 15208 Spring City, PA 19475

Coleen Kayden Margery Lynn Wasko, M.D.


PA Pharmacists Association Hamilton Health Center, Inc.
508 North Third Street 1821 Fulton Street
Harrisburg, PA 17101 Harrisburg, PA 17110

George Kimes Ivonne Bucher - Ex-Officio Member


Pennsylvania Community Providers Association Department of Aging
2400 Park Drive Office of Community Services and Advocacy
Harrisburg, PA 17110 555 Walnut Street, 5th Floor
Harrisburg, PA 17101-1919
Carol Lavoritano
AmeriChoice Brian Ebersole - Ex-Officio Member
The Wanamaker Building Pennsylvania Department of Health
100 Penn Square East, Suite 900 Room 808, Health and Welfare Building
Philadelphia, PA 19107 Harrisburg, PA 17120

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Executive Officers of State Medical and The Hospital and Healthsystem Association of
Pharmaceutical Associations Pennsylvania
Carolyn F. Scanlan
Pennsylvania Medical Society
President and CEO
Roger F. Mecum
4750 Lindle Road
Executive Vice President
P.O. Box 8600
777 E. Park Drive
Harrisburg, PA 17105-8600
P.O. Box 8820
T: 717/564-9200
Harrisburg, PA 17105-8820
F: 717/561-5334
T: 717/558-7750
E-mail: cscanlan@haponline.org
F: 717/558-7840
Internet address: www.haponline.org
E-mail: rmecum@pamedsoc.org
Internet address: www.pamedsoc.org

Pennsylvania Pharmacists Association


Patricia A. Epple, CAE
Executive Director
508 North Third Street
Harrisburg, PA 17101-1199
T: 717/234-6151
F: 717/236-1618
E-mail: pepple@papharmacists.com
Internet address: www.papharmacists.com

Pennsylvania Osteopathic Medical Association


Mario E.J. Lanni
Executive Director
1330 Eisenhower Boulevard
Harrisburg, PA 17111-2395
T: 717/939-9318
F: 717/939-7255
E-mail: poma@poma.org
Internet address: www.poma.org
Pennsylvania Podiatry Association
Michael Q. Davis
Executive Director
757 Poplar Church Road
Camp Hill, PA 17011
717/763-7665

Pennsylvania State Board of Pharmacy


Melanie Zimmerman
Executive Secretary
P.O. Box 2649
Harrisburg, PA 17105-2649
T: 717/783-7156
F: 717/787-7769
E-mail: st-pharmacy@state.pa.us
Internet address:
www.dos.state.pa.us/bpoa/cwp/view.asp

Pennsylvania-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

RHODE ISLAND

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expended Recipients Expended Recipients

TOTAL $126,331,040 53,729 $140,686,626

RECEIVING CASH ASSISTANCE TOTAL $75,903,018 29,656


Aged $8,594,928 4,365
Blind/Disabled $67,160,656 24,010
Child $34,974 516
Adult $112,460 765

MEDICALLY NEEDY, TOTAL $10,071,564 3,728


Aged $6,921,415 3,002
Blind/Disabled $3,149,477 723
Child $0 0
Adult $672 3

POVERTY RELATED, TOTAL $614,107 1,266


Aged $134,738 107
Blind/Disabled $291,154 138
Child $40,337 662
Adult $34,272 228
BCCA Women $113,606 131

TOTAL OTHER EXPENDITURES/RECIPIENTS* $39,742,351 19,079

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 CMS-64 Report, FY 2003.

Rhode Island-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Formulary/Prior Authorization


Formulary: No formulary. Prior prescription drug use
Rhode Island Department Human Services. authorization is used to manage appeal process to
appeal prior authorization decisions and exclusion of
D. PROVISIONS RELATING TO DRUGS specific products.

Benefit Design Prescribing or Dispensing Limitations


Drug Benefit Product Coverage: Products covered: Prescription Refill Limit: Refills to a maximum of 5
prescribed insulin; disposable needles and syringe are allowed.
combinations used for insulin; urine ketone test
strips. Products covered under DME: blood glucose Monthly Quantity Limit: One month’s supply for
test strips; total parenteral nutrition (prior non-maintenance drugs. One inhaler per fill. 8 tablets
authorization required); and interdialytic parenteral per month for erectile dysfunctions medication.
nutrition (prior authorization required). Products not
covered: cosmetics; fertility drugs; experimental Maintenance Medication: The attending physician
drugs; DESI drugs. may prescribe certain maintenance drugs of 100
tablets, capsules or pint of liquid or a 30-day supply
Over-the-Counter Product Coverage: Products of these drugs - whichever is greater.
covered: allergy, asthma, and sinus products;
analgesics (acetaminophen); cough and cold Monthly Dollar Limits: None
preparations (guifenisin, diphenhydramine,
chlorpheniramine); feminine products; topical Drug Utilization Review
products; (antibiotics only); antacids; and laxatives. PRODUR system implemented in December 1994.
Products not covered: digestive products; smoking State has a DUR Board that meets quarterly.
deterrent products.
Pharmacy Payment and Patient Cost Sharing
Therapeutic Category Coverage: Products covered: Dispensing Fee: $3.40 (ambulatory) and $2.85 (long-
anabolic steroids; antibiotics; anticoagulants; term care), effective 1987.
anticonvulsants; anti-depressants; antidiabetic agents,
antilipemic agents; anti-psychotics; anxiolytics, Ingredient Reimbursement Basis: EAC = WAC+5%.
sedatives, and hypnotics; cardiac drugs;
chemotherapy agents, prescribed cold medications; Prescription Charge Formula:
contraceptives; ENT anti-inflammatory agents;
estrogens; hypotensive agents; misc. GI drugs 1. In accordance with Federal regulation the upper
sympathominetics (adrenergic); and thyroid agents. limit for payment for prescribed drugs will be
Prior authorization required for: analgesics, based upon the amount allowed by the Medical
antipyretics, and NSAIDs; anoretics; antihistamines; Assistance Program or the usual and customary
growth hormones; PPIs; Provigil; CNS stimulants; charge to the general public, whichever is lower.
Tracleer; Remodulin; Flolan; Xolair; erectile 2. Payment for over-the-counter drugs (non-legend
dysfunction products; and Cox 2 inhibitors. Partial drugs) will be based upon the lower of either the
coverage for: prescribed smoking deterrents. allowable cost of the drug plus 5 percent, the
Therapeutic categories not covered: products for hair usual and customary charge to the general
growth. public, or the allowable cost plus the
professional fee for service.
Coverage of Injectables: Injectable medicines
reimbursable under the Prescription Drug Program Maximum Allowable Cost: State does not impose
when used in home health care, extended care Upper Limits on generic drugs.
facilities, and physician offices.
Incentive Fee: None.
Vaccines: Limited coverage under the Vaccines for
Children Program. Patient Cost Sharing: No copayment.
Unit Dose: Unit dose packaging not reimbursable. Cognitive Services: Does not pay for cognitive
services.

Rhode Island-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

E. USE OF MANAGED CARE Medicaid Managed Care Contact


Tricia Leddy, Administrator
Approximated 135,000 Medicaid recipients were Department of Human Services
enrolled in managed care in 2003. Managed care 600 New London Avenue
recipients receive pharmaceutical benefits through Cranston, RI 02919
managed care plans. 401/462-2127
Managed Care Organizations E-mail: tleddy@dhs.ri.gov
− United Healthcare of New England Mail Order Pharmacy Program
− Coordinated Health Partners, Inc. None
− Neighborhood Health Plan of Rhode Island
Department of Human Services Officials
F. STATE CONTACTS Jane A. Hayward
State Drug Program Administrator Director
Department of Human Services
Paula J. Avarista, R.Ph., M.B.A. 600 New London Avenue
Chief of Pharmacy Cranston, RI 02920
Department of Human Services T: 401/462-2121
600 New London Avenue F: 401/462-3677
Cranston, RI 02920 E-mail: jhayward@gw.dhs.state.ri.us
T: 401/462-6390
F: 401/462-6836 John C. Young
E-mail: pavarista@dhs.ri.gov Associate Director
Internet address: www.dhs.state.ri.us Health Care Quality, Financing, and Purchasing
DUR Contact Department of Human Services
600 New London Avenue
Paula J. Avarista, R.Ph., M.B.A. Cranston, RI 02920
401/462-6390 T: 401/462-3575
Rhode Island DUR Board F: 401/462-6338
E-mail: jyoung@gw.dhs.state.ri.us
Raymond Maxim, M.D.
Edward Westrick, M.D., Ph.D. Executive Officers of State Medical and
Richard Wagner, M.D. Pharmaceutical Societies
Steve Kogut, Ph.D., M.B.A. Rhode Island Medical Society
Tara Higgins, R.Ph. Newell E. Warde, Executive Director
John Zevzavadjian R.Ph. 235 Promenade Street, Suite 500
Ellen Mauro, R.N, M.P.H. Providence, RI 02908
New Brand Name Products Contact T: 401/331-3207
F: 401/751-8050
Paula J. Avarista, R.Ph., M.B.A. E-mail: nwarde@rimed.org
401/462-6390 Internet address: www.rimed.org
Prescription Price Updating
Rhode Island Society of Osteopathic Physicians and
Paula J. Avarista, R.Ph., M.B.A. Surgeons/Northeast Osteopathic Consortion
401/462-6390 Donald J. Halpin, Executive Director
Medicaid Drug Rebate Contacts P.O. Box 487
Winchester, MA 01800
Helen Vaughn T: 781/721-9900
Analyst T: 800/454-9663
EDS E-mail: nocdos@comcast.net
1471 Elmwood Avenue
Cranston, RI 02910
401/784-3879
Claims Submission Contact
EDS, 401/784-3879

Rhode Island-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Rhode Island Pharmacists Association


Jack Hutson
Executive Director
1643 Warwick Avenue
PMB 113
Warwick, RI 02889
T: 401/737-2600
F: 401/737-0959
E-mail: jhutson@associationsystems.com
Internet address: www.ripharmacists.org

Rhode Island State Board of Pharmacy


Catherine A. Cordy
Board Administrator
3 Capitol Hill, Room 205
Providence, RI 02908-5097
T: 401/222-2837
F: 401/222-2158
E-mail: cathyc@doh.state.ri.us
Internet address:
www.healthri.org//hsr/professions/pharmacy.php

Hospital Association of Rhode Island


Edward J. Quinlan, President
880 Butler Drive, Suite One
Providence, RI 02906
T: 401/274-1647
F: 401/274-1838
E-mail: edwardq@hari.org
Internet address: www.hari.org

Rhode Island-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

SOUTH CAROLINA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $456,976,916 576,136 $559,618,608

RECEIVING CASH ASSISTANCE, TOTAL $221,186,878 214,690 $257,211,722


Aged $51,109,927 29,073 $53,002,997
Blind/Disabled $131,758,033 72,534 $157,058,050
Child $14,462,767 62,082 $16,940,364
Adult $23,856,151 51,001 $30,210,311

MEDICALLY NEEDY, TOTAL $0 0 $0 0


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

POVERTY RELATED, TOTAL $145,547,570 255,510 $177,510,401


Aged $42,051,973 24,724 $47,343,069
Blind/Disabled $53,686,499 23,236 $66,311,073
Child $47,895,973 194,169 $59,918,715
Adult $1,852,433 13,315 $3,937,544
BCCA Women $60,692 66 N/A N/A

TOTAL OTHER EXPENDITURES/RECIPIENTS* $90,242,468 105,936 $124,896,485

*Total Other Expenditures/ Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data provided by the South Carolina Department of Health and Human Services. 2003 data on number of recipients by
maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002, and South Carolina Medicaid Statistical Information System, FY 2003.

South Carolina-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION 3. Immunizing agents. (except for influenza,


pneumococall, and hepatitis-B vaccines where
South Carolina Department of Health & Human certain criteria are met)
Services. 4. Pharmaceuticals determined by the FDA to be
less than effective and identical, related, or
D. PROVISIONS RELATING TO DRUGS similar drugs (Referred to as “DESI” drugs).
5. Injectable pharmaceuticals administered by the
Benefit Design practitioner in the office, in a clinic, or in a
Drug Benefit Product Coverage: Products covered: mental health center .
most rebated legend generic drugs; prescribed 6. Products used as flushes to maintain potency of
insulin, and disposable needles and syringe indwelling peripheral or central venipuncture
combinations used for insulin. Products covered as devices.
DME: blood glucose test strips; urine ketone test 7. Devices and supplies (e.g., diabetic supplies,
strips; total parenteral nutrition; and interdialytic infusion supplies, etc.)
nutrition. Products not covered: pharmaceutical for 8. Fertility products.
cosmetics purposes or hair growth; fertility drugs; 9. Pharmaceuticals which are not rebated.
DESI drugs; and experimental drugs. 10. Nutritional supplements
11. Oral hydration therapies for adults.
Over-the-Counter Product Coverage: Within 12. Pharmaceuticals used for cosmetic purposes or
program guidelines and limitations, the Medicaid hair growth.
program covers all rebated OTC medications and 13. Anti- hemophilia factor.
their generic equivalents. Products not covered:
brand name products for which equivalent generics Prior Authorization: State currently has a prior
are available. authorization program. A preferred drug list (PDL)
was implemented in calendar year 2004.
Therapeutic Category Coverage: Therapeutic Consideration of additional therapeutic classes is on-
categories covered: anabolic steroids; analgesics, going. Beneficiaries can request a fair hearing and
antipyretics, NSAIDs; antibiotics; anticoagulants; exception to policy in order to appeal a prior
anticonvulsants; antidepressants; antidiabetic agents; authorization decision. The prescriber must obtain
antihistamine drugs; antilipemic agents; anti- prior authorization for Medicaid coverage of the
psychotics; anxiolytics, sedatives, and hypnotics; following products:
cardiac drugs; chemotherapy agents; prescribed cold 1. Non- preferred drugs.
medications; contraceptives; ENT anti-inflammatory 2. Brand name products (excluding certain
agents; estrogens; growth hormones; hypotensive narrow, therapeutic index drugs) for which
agents; misc. GI drugs; sympathominetics there are A-rated, therapeutically equivalent,
(adrenergic); thyroid agents; and prescribed smoking less costly generics available.
deterrents. 3. COX-2 inhibitors for patients < age 60.
4. Erectile dysfunction products.
Coverage of Injectables: Injectable medicines are 5. OxyContin® (when maximum quantity
reimbursable through the Medicaid Physician limitation is exceeded).
Services Program when used in physicians’ offices. 6. Panretin®.
Injectables are reimbursable through the Pharmacy 7. Proton pump inhibitors (patients age 12 and
Services Program when used at home, through home younger may receive Prevacid without PA).
health care, or in long-term care facilities. 8. Growth hormone products
9. Targretin®.
Vaccines: Vaccines are reimbursable based on CDC 10. Xenical®.
price as part of the Vaccines for Children Program
(age under 21). Prescribing or Dispensing Limitations
Prescription Refill Limit: The prescriber authorizes
Unit Dose: Unit dose packaging is reimbursable. the number of refills.
Formulary/Prior Authorization
Formulary: Open formulary; certain drug
classifications excluded.
General Exclusions:
1. Weight control products. (except for lipase
inhibitors)
2. Investigational pharmaceuticals or products.

South Carolina-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Monthly Quantity Limit: Children (birth to age 21) Patricia Marquis, Chief Operating Officer
are allowed unlimited prescriptions per month. P.O. Box 40024
Beneficiaries over the age of 21 are limited to a Charleston, SC 29403
maximum of four prescriptions per month; however, 843/569-1759
pharmacists may override the monthly prescription
limit for adult Medicaid beneficiaries if the Better Health Care Plans
prescription meets certain specified override criteria. Dan Gallagher
Vice President and Executive Director
Quantity Limit per Prescription: 34-day supply per 250 Berryhill Road, Suite 514
prescription. Maximum quantity limitations have Columbia, SC 29210
been established for certain pharmaceuticals. 803/798-8210

Monthly Dollar Limit: None. F. STATE CONTACTS


Drug Utilization Review State Drug Program Administrator
PRODUR system implemented November 2000. James M. Assey, R.Ph., Division Director
State currently has a DUR Panel with a monthly Division of Pharmaceutical Services and DME
review. S.C. Department of Health & Human Services
Pharmacy Payment and Patient Cost Sharing P.O. Box 8206
Columbia, SC 29202-8206
Dispensing Fee: $4.05, effective 7/1/89. T: 803/898-2876
F: 803/255-8353
Ingredient Reimbursement Basis: EAC = AWP-10%. E-mail: asseyj@dhhs.state.sc.us
Internet address: www.dhhs.state.sc.us
Prescription Charge Formula: Medicaid
reimbursement for pharmacy services will be based Prior Authorization Contact
on the lowest of: the Estimated Acquisition Cost Caroline Y. Sojourner, R.Ph., Dept. Head
(EAC); Federal or State maximum allowable cost Department of Pharmacy Services
(MAC); or the provider's submitted usual and S.C. Department of Health and Human Services
customary charge. P.O. Box 8206
Columbia, SC 29202-8206
Maximum Allowable Cost: State imposes Federal T: 803/898-2876
Upper Limits as well as State-specific maximum F: 803/255-8353
allowable costs (MAC) on additional drugs. E-mail: sojourne@dhhs.state.sc.us
Override requires “Brand Medically Necessary,”
handwritten certification by the prescriber, and prior DUR Contact
authorization. Caroline Y. Sojourner, R.Ph.
803/898-2876
Incentive Fee: None.
DUR Panel
Patient Cost Sharing: $3.00 co-payment per Gwendolyn C. Galphin, M.D.
prescription for most adult beneficiaries, unless F. Joseph Hodge, R.Ph.
otherwise accepted. SilverxCard beneficiaries are Henry Rose, R.Ph.
subject to a three- tiered co-payment schedule: $10 Leslie M. Stuck, M.D.
for generic drugs, $15 for brand name drugs, and $21 Caroline Sojourner, R.Ph.
for drugs requiring prior authorization.
New Brand Name Products Contact
Cognitive Services: Does not pay for cognitive
services. James M. Assey, R.Ph.
803/898-2876

E. USE OF MANAGED CARE Prescription Price Updating

Approximately 74,000 Medicaid recipients were First DataBank,


enrolled in MCOs in FY 2003. Recipients receive 1111 Bayhill Drive, Suite 350
pharmaceutical benefits through managed care plans. San Bruno, CA 94066
T: 650/588-5454
F: 650/588-4003
Managed Care Organizations
Select Health of South Carolina, Inc.

South Carolina-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Medicaid Drug Rebate Contacts Pharmacy and Therapeutics Committee


Technical: Rod Davis, 803/898-2610 J. Kevin Baugh, M.D.
Policy: James Assey, 803/898-2876 Edward M. Behling, M.D.
DUR & PA: Caroline Sojourner, 803/898-2876 Gregory V. Browning, M.D.
Disputes: Laurel Kennerly, 803/898-2954 Matthew K. Cline, M.D.
Joseph A. Horvath, M.D.
Claims Submission Contact
Albert Humphrey, M.D.
Rod Davis Kelly W. Jones, Pharm.D.
Deputy Director of Information Technology Jerome E. Kurent, M.D.
S.C. Department of Health and Human Services Robin Kelley LaCroix, M.D.
P.O. Box 8206 James M. Lindsey, M.D.
Columbia, SC 29202-8206 Thomas R. Phillips, R.Ph.
803/898-2610 Deborah J. Tapley, R.Ph., M.B.A.
E-mail: davisr@dhhs.state.sc.us George E. “Ed” Vess. Pharm.D.
Harry H. Wright, M.D.
Managed Care Contact
Bruce Harbaugh Medical Care Advisory Council
Department of Managed Care Ms. Valerie Aiken
Reimbursement Programs
Mr. John P. Barber
S.C. Department of Health and Human Services Ms. Susan B. Berkowitz
P.O. Box 8206 Ms. Lesly A. Bowers
Columbia, SC 29202-8206
Dr. Gloria Bonali
803/898-2618 Mr. Bruce Carlson
E-mail: harbaugh@dhhs.state.sc.us Mr. Tommy Cockrell
Charles P. Darby, M.D.
Mail Order Drug Program C. Warren Derrick, M.D.
None, however, mail order pharmacies may enroll. Ana DeFede, Ph.D.
James M. DuRant, Jr., M.D.
Disease Management Program/Initiative C. Morrison Farish, M.D.
Contact Mr. Ron Fitzwater
Beverly Hamilton Ms. Laura Fowler
Division of Care Management Ms. Connie Ginsberg
S.C. Department of Health and Human Services Dr. Barbara Haight
P.O. Box 8206 Jerome E. Kurent, M.D.
Columbia, SC 29202-8206 Mr. Rudy Long
803/898-4502 Ms. Amy McDonald
E-mail: hamiltbv@dhhs.state.sc.us Mr. J.J. McLawhorn
Albert D. Mims, M.D.
South Carolina Department of Health and Dr. Linda S. Moore
Human Services Officials Mr. John A. Morris
Robert Kerr, Director J. Michael Ross, R.Ph.
S. C. Department of Health & Human Services Sabra Slaughter, Ph.D.
1801 Main Street Mr. Lewis Stephens
P.O. Box 8206 Ms. Cindy White
Columbia, SC 29202-8206 Ms. Deborah Williamson
T: 803/898-2504 Dr. Constance Yearling
F: 803/898-4515 Dr. Foster H. Young, Jr.
E-mail: kerr@dhhs.state.sc.us Mr. Hal Zorn

Melanie Giese, Chief


Bureau of Health Services
803/898-2870

Caroline Y. Sojourner, R.Ph., Department Head


Department of Pharmacy Services
803/898-2876

South Carolina-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Executive Officers of State Medical and


Pharmaceutical Societies
South Carolina Medical Association
Todd K. Atwater, Chief Executive Officer
132 West Park Boulevard
P.O. Box 11188
Columbia, SC 29210
T: 803/798-6207, Ext. 490
F: 803/772-6783
E-mail: todd@scmanet.org
Internet address: www.scmanet.org

South Carolina Osteopathic Medical Society


Valerie Smith
Southeast Regional Manager
P.O. Box 433
Red Bay, AL 35585
866/356-4481
E-mail: info@scoms.org
Internet address: www.scoms.org

South Carolina Pharmacy Association


James R. Bracewell, Executive Vice President
1350 Browning Road
Columbia, SC 29210-6903
T: 803/354-9977
F: 803/354-9207
E-mail: jbracewell@scrx.org
Internet address: www.scrx.org/scrx

South Carolina State Board of Pharmacy


Lee Ann F. Bundrick, Administrator
Kingstree Building
110 Centerview Drive, Suite 306
Columbia, SC 29210
T: 803/896-4700
F: 803/896-4596
E-mail: bundricl@mail.llr.state.sc.us
Internet address: www.llr.state.sc.us/pol/pharmacy

South Carolina Hospital Association


J. Thornton Kirby, President
1000 Center Point Road
Columbia, SC 29210-5802
T: 803/796-3080
F: 803/796-2938
E-mail: info@scha.org
Internet address: www.scha.org

South Carolina-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

South Carolina-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

SOUTH DAKOTA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/ Child Adult Aged Blind/ Child Adult
Disabled Disabled

Prescribed Drugs ‹ ‹ ‹ ‹
Inpatient Hospital Care ‹ ‹ ‹ ‹
Outpatient Hospital Care ‹ ‹ ‹ ‹
Laboratory & X-ray Service ‹ ‹ ‹ ‹
Nursing Facility Services ‹ ‹ ‹ ‹
Physician Services ‹ ‹ ‹ ‹
Dental Services ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $63,654,623 64,948 $71,223,108

RECEIVING CASH ASSISTANCE, TOTAL $32,400,063 22,529


Aged $3,687,941 1,793
Blind/Disabled $24,972,780 8,898
Child $1,514,094 7,211
Adult $2,225,248 4,627

MEDICALLY NEEDY, TOTAL $0 0


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

POVERTY RELATED, TOTAL $6,304,155 25,351


Aged $38,283 62
Blind/Disabled $110,,665 99
Child $5,678,563 22,699
Adult $464,812 2,481
BCCA Women $11,832 10

TOTAL OTHER EXPENDITURES/RECIPIENTS* $24,950,405 17,068

*Total Other Expenditures/recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

South Dakota-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Prior Authorization: State currently has no formal


prior authorization procedure.
Department of Social Services, Office of Medical
Services.
Prescribing or Dispensing Limitations
Prescription Dollar Limit: None.
D. PROVISIONS RELATING TO DRUGS
Benefit Design Refill Limit: None

Drug Benefit Product Coverage: Products covered: Monthly Quantity Limit: Varies by drug.
prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test Monthly Prescription Limit: None
strips; and urine ketone test strips. Prior authorization
required for: total parenteral nutrition and
interdialytic parenteral nutrition. Products not Drug Utilization Review
covered: cosmetics; DESI drugs; fertility drugs;
experimental drugs; and drugs for impotence. PRODUR system implemented in 1996.
Pharmacy Payment and Patient Cost Sharing
Over-the-Counter Product Coverage: Product Dispensing Fee: $4.75 to $5.55 (with unit dose fee
covered with restrictions: allergy, asthma, and sinus applied), effective 7/1/1991
products (OTC loratadine only) and digestive
products (non-H2 antagonists-OTC omeprazole Ingredient Reimbursement Basis: EAC = AWP-
only). Products not covered: analgesics; cough and 10.5%.
cold preparations; digestive products; (H2
antagonists); feminine products; topical products; and Prescription Charge Formula: Payment is the lower
smoking deterrents. of:

Therapeutic Category Coverage: Therapeutic 1. FUL, State MAC plus a dispensing fee, or
categories covered: anabolic steroids; analgesics, 2. EAC plus a dispensing fee, or usual and
antipyretics, NSAIDs; anoretics; antibiotics; customary charge to the general public.
anticoagulants; anticonvulsants; antidepressants;
antidiabetic agents; antihistamine drugs; antilipemic Maximum Allowable Cost: State imposes Federal
agents; anti-psychotics; anxiolytics, sedatives, and Upper Limits as well as State-specific limits on
hypnotics; cardiac drugs; chemotherapy agents; generic drugs. Approximately 1,000 drugs are listed
contraceptives; ENT anti-inflammatory agents; on the State-specific MAC list. Override requires
estrogens; hypotensive agents; misc. GI drugs; “Brand Necessary” or “Brand Medically Necessary.”
sympathominetics (adrenergic); prescribed cold
medications and thyroid agents. Prior authorization Incentive Fee: None
required for: growth hormones. Partial coverage for:
prescribed smoking deterrents. Therapeutic Patient Cost Sharing: Copayment is $2.00.
categories not covered: nutritional supplements;
clozapine. Cognitive Services: Does not pay for cognitive
services.
Coverage of Injectables: Injectable medicines
reimbursable through both the Prescription Drug E. USE OF MANAGED CARE
Program and physician payment when used in
physician offices, home health care, and extended
Does not use MCOs to deliver pharmacy services to
care facilities.
Medicaid recipients.
Vaccines: Vaccines reimbursable with HCPC code as
part of EPSDT services, The Children’s Health
Insurance Program, and the Vaccines for Children
Program.

Unit Dose: Unit dose packaging reimbursable.


Formulary/Prior Authorization
Formulary: Open formulary.

South Dakota-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

F. STATE CONTACTS Disease Management Program/Initiative


Contact
State Drug Program Administrator
Mark Petersen, R.Ph.
Mark E. Petersen, R.Ph. 605/773-3495
Pharmacy Consultant
Department of Social Services South Dakota Medicaid Agency Officials
Office of Medical Services
700 Governors Drive James Ellenbecker
Pierre, SD 57501 Secretary
T: 605/773-3498 Department of Social Services
F: 605/773-5246 700 Governors Drive
E-mail: mark.peterson@state.sd.us Pierre, SD 57501-2291
Internet Address : T: 605/773-3165
www.state.sd.us/social/medical/index.htm F: 605/773-4855
E-mail: dssinfo@state.sd.us
Prior Authorization Contact
Mark E. Petersen, R.Ph. Larry Iverson
605/773-3498 Division Director
Medical Services
DUR Contact Department of Social Services
700 Governors Drive
Teddi Martell Pierre, SD 57501-2291
Rebate Coordinator T: 605/773-3495
Department of Social Services F: 605/773-5246
700 Governors Drive E-mail: Medical@dss.state.sd.us
Pierre, SD 57501
605/773-3653 Medical Advisory Committee
E-mail: teddi.martell@state.sd.us Paul Engbrecht, Chairman
New Brand Name Products Contact Marion, SD
Mark E. Petersen, R.Ph. John Jones, Vice Chairman
605/773-3498 Pierre, SD
Prescription Price Updating
Jud Bergan, O.D.
Mark E. Petersen, R.Ph. Madison, SD 57042
605/773-3498
Medicaid Drug Rebate Contact Sheryl Petersen
Pierre, SD
Teddi Martell
605/773-3653 James D. M. Russell
Claims Submission Contact Pierre, SD

Meredith Heerman Herb McClellan, Jr., D.D.S.


Claims Processing Administrator Mobridge, SD
Department of Social Services
700 Governors Drive Lynn Greff
Pierre, SD 57501 Rapid City, SD
T: 605/773-3495
F: 605/773-5246 Stephen Schroeder, M.D.
E-mail: Meredith.Heerman@state.sd.us Miller, SD

Michelle Miller
Sioux Falls, SD

A.A. Lampert, M.D.


Rapid City, SD

South Dakota-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Executive Officers of State Medical and


Pharmaceutical Societies
South Dakota State Medical Association
L. Paul Jensen
Chief Executive Officer
1323 South Minnesota Avenue
Sioux Falls, SD 57105
T: 605/336-1965
F: 605/336-0270
E-mail: pjensen@sdsma.org
Internet address: www.sdsma.org

South Dakota Osteopathic Association


David A. Lauer, D.O.
Secretary-Treasurer
P.O. Box 247
Sturgis, SD 57785
T: 605/347-3616
F: 605/347-4713

South Dakota Pharmacists Association


Sue Schaefer
Executive Director
320 East Capitol
P.O. Box 518
Pierre, SD 57501-0518
T: 605/224-2338
F: 605/224-1280
E-mail: sue@sdpha.org
Internet address: www.sdpha.org

South Dakota State Board of Pharmacy


Dennis M. Jones
Executive Secretary
4305 S. Louise Avenue, Suite 104
Sioux Falls, SD 57106
T: 605/362-2737
F: 605/362-2738
E-mail: dennis.jones@state.sd.us
Internet address: www.state.sd.us/dcr/pharmacy

South Dakota Association of Healthcare


Organizations
David R. Hewett
President and CEO
3708 Brooks Place, Suite 1
Sioux Falls, SD 57106
T: 605/361-2281
F: 605/361-5175
E-mail: hewett@sdaho.org
Internet address: www.sdaho.org

South Dakota-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

TENNESSEE -- TennCare

On January 1, 1994, Tennessee made history by demonstration project ended December 31, 1998.
withdrawing from the Medicaid Program and HCFA approved a waiver extension for three years
implementing an innovative new health care reform beginning January 1, 1999 through December 31,
plan called TennCare. In order to implement 2001. On July 1, 2002, Tennessee reached a new
TennCare, Tennessee was granted a Section 1115 five-year agreement with the federal government to
demonstration waiver by the Federal government. continue TennCare.
TennCare replaced the existing Medicaid Program
with a program of managed health care. TennCare TennCare services are offered through managed
receives about 66 percent of its annual budget from care organizations (MCOs) and behavioral health
the Federal government. Approximately one-third organizations (BHOs) under contract with the State.
of the TennCare budget consists of State funds. These MCOs, spread out over the twelve regions of
TennCare required no new taxes and extended Tennessee, are paid a fixed amount. The MCOs and
health coverage not only to the nearly 800,000 BHOs negotiate payment rates with individual
Tennesseans in the Medicaid population, but also to providers. Enrollees have a choice of MCOs (and
an approximately 400,000 uninsured or uninsurable their corresponding BHO partner plan) from those
persons using a system of managed care. available in their geographic area. Effective January
Enrollment was open in 1994 to eligible persons in 1, 1997, all services are delivered within a strict
the uninsured, uninsurable, and Medicaid-eligible "gatekeeper" model system requiring primary care
categories. providers to manage enrollees' health care.

On January 1, 1995, TennCare reached 90% of its TennCare services, as determined medically
target enrollment and closed enrollment in the necessary by the MCO, cover inpatient and
uninsured category. However, on April 1, 1997, outpatient hospital care, physician services,
enrollment in the uninsured category re-opened to prescription drugs, lab and x-ray services, medical
children under the age of 18 who do not have supplies, home health care, hospice care, and
access to health insurance through a parent or ambulance transportation. Excluded from TennCare
guardian. On May 21, 1997, TennCare enrollment managed care services are long-term care services
became available for eligible dislocated workers. In and Medicare cross-over payments which are
an effort to expand coverage to more of Tennessee's continuing as they were under the former Medicaid
uninsured children, the Bureau of TennCare opened system.
enrollment on January 1, 1998 to uninsured
Tennesseans under the age of nineteen (19) with TennCare is financed by pooling current Federal,
access to health insurance whose individual family State, and local expenditures for indigent health
incomes are below 200% of the poverty level. care. Pooled resources totaled $5.5 billion in FY
Effective January 1, 1998, uninsured children under 2001. In the future, competition among managed
age nineteen (19) who meet the TennCare criteria care networks, combined with the enrollment cap,
for uninsured are being allowed to enroll in should enable TennCare to grow at a predictable
TennCare indefinitely. The Bureau of TennCare rate not exceeding the annual rate of growth in
eliminated deductibles and limited co-payments to State spending.
$5 and $10 for these new eligibility populations and
all uninsured children under eighteen (18) years of
ELIGIBILITY FOR TENNCARE COVERAGE
age who enrolled in TennCare during previous open
enrollment periods. Enrollment remains open to The current federal waiver separates TennCare into
persons who are Medicaid-eligible or who are Two products: TennCare Medicaid and TennCare
uninsurable. Current enrollment (1/23/04) is Standard. Tenncare Medicaid is a continuation of
approximately 1.3 million of which 1 million are the basic TennCare Medicaid program with a few
Medicaid eligibles and 300,000 are in the minor changes in benefits. TennCare Medicaid adds
uninsured/uninsurable categories. a new eligibility category: woman under 65 who
have been screened by The Centers for Disease
The State of Tennessee was granted approval by the Control and are in need of treatment for breast or
Health Care Financing Administration (now CMS) cervical cancer.
for a five-year demonstration project under Section
1115 of the Social Security Act. State rules were
promulgated to assist in administering the statewide
program (TSOP). The initial five-year

Tennessee-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

TennCare Standard is similar to a commercial Accordingly, the State has proposed terminating
HMO package. People eligible for TennCare coverage for the adult demonstration population as
standard are adults below the 100 percent of the well as for the adult non-pregnant Medically Needy
federal poverty level, children below 200 percent of population. As a result, approximately 396,000
the poverty level, and people who are “medically Medicaid eligible adults will retain a “reasonable”
eligible” a new term to describe what the state level of coverage while another 323,000 adults who
previously referred to as “uninsurables.” The are not elegible for Medicaid but who are covered
difference is that “Medical eligibility” will be under TennCare via a Federal waiver will lose
determined by a State-appointed health insurance coverage.
underwriter. Under the previous TennCare system,
In addition, some types of coverage would be
a denial letter from an insurance company defined
eliminated and certain limits or restrictions will be
“uninsurability.”
imposed on other programs, including pharmacy.
Managed care organizations participating in
The five-year waiver that TennCare began on July
TennCare would be asked to assume greater
1, 2002 also includes an annual “open enrollment”
financial risk.
period, which would allow people who are
uninsured or medically eligible above poverty to The TennCare Plan amendments are being
enroll in TennCare. The current fiscal year’s budget reviewed by CMS.
does not allow for an open enrollment period, at
least through the end of the current fiscal year, June
30, 2003. However, if an applicant is both below A. ADMINISTRATION
100 percent of the poverty level and medically
eligible, enrollment will be allowed at any time Tennessee Department of Finance and
during the year. Administration, Bureau of TennCare

Persons wanting to apply for TennCare must visit B. PROVISIONS RELATING TO DRUGS
the local Tennessee Department of Human Services
(DHS) office. There is a local DHS office in every Benefit Design
Tennessee County. For the applicants' convenience,
Pharmacy services are provided by the managed
DHS will make a copy of the application, date
care organizations. Within Federal and State
stamp it, and process the application.
guidelines, each individual managed care and
Recent Proposed Changes to TennCare pharmacy benefit management organization makes
formulary/drug decisions. Pharmacy services are
The TennCare program is currently undergoing a to be covered as medically necessary, excluding
major restructuring as a result of rapidly escalating DESI, less than effective and IRS drugs and some
program costs, Tennessee, during 2004, developed drugs for which TennCare does not mandate
a plan to restructure TennCare in a manner that coverage (e.g., drugs for infertility, weight
would allow the State to maintain coverage while reduction, cosmetic purposes, hair growth products,
reining in the unstainable increase in program costs. products for symptomatic relief of cough and colds,
In September 2004, Tennessee submitted a proposal experimental drugs; smoking cessation products,
to CMS to amend the TennCare program. experimental drugs; and OTCs). Starting in July 1,
While continuing to engage in decisions with 2003 all eligible products dispensed through
various stakeholders regarding the proposed ambulatory pharmacies are invoiced through the
changes, numerous legal objections and possible CMS rebate program.
law suits have made it more difficult to implement
many of the proposed changes. While still hoping Formulary/Prior Authorization
to implement many of the reforms that were Formulary: Preferred Drug List (PDL) was phased
previously announced, because of the rapidly in from October 15th through December 15th in 3
deteriorating budget outlook, the State has had to phases (see http://tennessee.fhsc.com). The PDL is
contemplate more drastic reform measures in order managed through preferred products and prior
to stabilize the program. The proposed revisions, authorization.
which the State has submitted to CMS for approval,
are designed to reduce TennCare enrollment trim Prior Authorization: State currently has a formal
benefits without returning to a traditional Medicaid prior authorization procedure. Recipient may
program. appeal coverage and prior authorization decisions
The State’s objective is to maintain current levels to the TennCare Solutions Unit.
of coverage for the more than 600,000 children who
rely on the TennCare program for their care.

Tennessee-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Pharmacy Payment and Patient Cost 1420 Centerpoint Boulevard


Sharing Knoxville, TN 37932
T: 800/705-5248
Prescription Dollar Limit: None
F: 865-470-7404
Monthly Quantity Limit: 31-day supply
TennCare Select
801 Pine Street
Refill Limit: up to one year for non-controlled
Chattanooga, TN 37402-2555
prescriptions
T: 800/276-1978
F: 423/752-6790
Copayment: Deductibles and copayments apply to
services other than preventive services (e.g.,
Windsor Health Plan of Tennessee
immunizations) based on a sliding scale according
215 Centerview Drive, Suite 300
to income. Medicaid recipients and persons or
Brentwood, TN 37027
families with income under 100% of the Federal
T: 615/782-7878
poverty level are not required to pay premiums,
F: 615/782-7812
deductibles, or copayments in order to participate in
the TennCare program.
D. STATE CONTACTS
C. USE OF MANAGED CARE State Drug Program Administrator
1.4 million Medicaid recipients and the Jeffrey G. Stockard, D.Ph.
uninsured/uninsurable are enrolled in MCOs Associate Pharmacy Director
through the TennCare program. All receive Bureau of TennCare
pharmacy benefits through managed care. 729 Church Street
Nashville, TN 37247-6501
Managed Care Organizations
T: 615/532-3107
Better Health Plans F: 615/253-5481
890 Willow Tree Circle E-mail: jeff.stockard@state.tn.us
Cordova, TN 38018 Internet address: www.tennessee.gov/tenncare
T: 800/600-9007
F: 901/737-1420 TennCare Pharmacy Information Line
800/816-1680
BlueCare
TennCare Officials
801 Pine Street
Chattanooga, TN 37402-2555 Gina Lodge, Commissioner
T: 800/468-9736 Department of Human Services
F: 423-752-6790 400 Deaderick Street, 15th Floor
Nashville, TN 37248-0001
John Deere Health Plan T: 615/313-4700
Executive Tower I, Suite 400 F 615/741-4165
408 N. Cedar Bluff Road E-mail: gina.lodge@state.tn.us
Knoxville, TN 37923
T: 800/832-1539 Manny Martins, Deputy Commissioner
F: 865/690-1941 Bureau of TennCare
Department of Finance and Administration
TLC Family Care Healthplan 729 Church Street
1407 Union Avenue, Suite 200 Nashville, TN 37247-6501
Memphis, TN 38104 T: 615/741-5346
T: 800/473-6523 F: 615/741-0882
F: 901/725-2846 E-mail: manny.martins@state.tn.us

OmniCare Health Plan, Inc.


1991 Corporate Avenue, 5th Floor
Memphis, TN 38132
T: 800/346-0034
F: 901/348-2212

PHP TennCare

Tennessee-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Marry-Anne Rudolph, Director TennCare Pharmacy Advisory Board


Medicaid Policy Unit
James Powers, M.D. (Chairman)
400 Deaderick Street, 12th Floor
Nashville, TN
Nashville, TN 37248
T: 615/313-4873
Alan Corley, Pharm.D. (Vice Chairman)
F: 615/313-6639
Greenville, TN
E-mail: mary-ann.rudolph@state.tn.us
Prior Authorization Contact Diane Todd Pace, Ph.D., R.N., F.N.P.
Cordova , TN
Jeffrey G. Stockard, D.Ph.
615/532-3107
Edward Capparelli, M.D.
DUR Contact Newport, TN
James King, M.D.
Jeffrey G. Stockard, D.Ph. Selmer, TN
615/532-3107
TennCare DUR Advisory Board Lisa D’Souza, J.D.
Nashville, TN
Physician Member:
Peter Frizzell, M.D.
Tracy Doering, M.D. Johnson City, TN
Nashville, TN
Lynn Knott, Pharm.D., C.G.P., F.A.S.C.P.
Pharmacist Members: Brentwood, TN
Philip E. Johnston, Pharm.D. Stanley Dowell, M.D.
Nashville, TN Memphis, TN
Stephanie Johnson Nichols, Pharm.D. Sheila Spates, Pharm.D.
Harriman, TN Knoxville, TN
Richard Randolph, Pharm.D. Terry Shea, Pharm.D.
Manchester, TN Chattanooga, TN
David Shepard, Pharm.D., B.C.P.P. William Terrell, M.D.
Dickson, TN Memphis, TN
Bill Staggs, D.Ph. Tracy Purcell (ex-officio)
Nashville, TN Nashville, TN
Bureau of TennCare Members: David Hollis, M.D. (ex-officio)
Nashville, TN
Wendy Long, M.D., M.P.H. (ex-officio)
Chief Medical Officer TennCare Medical Care Advisory
Committee
Jeffrey G. Stockard, D.Ph. (ex-officio) Iris Snider, M.D.
Assocciate Pharmacy Director
TN Chapter of American Academy of Pediatrics
111 Epperson Avenue
First Health Member: Athens, TN 37303
Shana Bush, Pharm.D. Lloyd A. Walwyn, M.D., J.D.
Clinical Manager 601 Due West Avenue
Madison, TN 37115

Deb Murph, R.N.


Cherokee Health Systems
6350 West Andrew Johnson Highway
Talbott, TN 37877

Tennessee-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Jeannie Beauchamp, D.D.S. Prescription Price Updating


1833 Memorial Drive
First DataBank
Clarksville, TN 37043
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
Don Hazelwood, D.Ph.
T: 650/588-5454
3100 S. First Street
F: 650/588-6867
Milan, TN 38358
Medicaid Drug Rebate Contact
Cato Johnson
Methodist Healthcare Sybil Creekmore
Accounting Manager
1211 Union Street, Suite 700
Memphis, TN 38104 Bureau of TennCare
729 Church Street
Joe Brown Nashville, TN 37247-6501
Hardin County Nursing Home T: 615/741-0018
F: 615/532-3479
2006 Wayne Road
Savannah, TN 38372 E-mail: sybil.creekmore@state.tn.us
Claims Submission Contact
Sheryl McCormick
Region 2 Mental Health Council Maria P. Hogan
7208 Merriwood Drive Plan Administrator
Knoxville, TN 37919 First Health Service Corporator
4300 Cox Road
Don Redden Glen Allen, VA 23060
Developmental Services of Dickson County T: 804/965-7451
P.O. Box 628 F: 804/290-4831
Dickson, TN 37056 E-mail: mphogan@fhsc.com
Medicaid Managed Care Contact
Tony Halton
National Health Care for the Homeless Council Michael Drescher, Public Information Officer
P.O. Box 60427 Bureau of TennCare
Nashville, TN 37206 729 Church Street
Nashville, TN 37247-6501
Osbie Howard T: 615/741-0213
OmniCare Health Plan, Inc. F: 615/741-0882
1991 Corporate Avenue, 5th Floor E-mail: michael.drescher@state.tn.us
Memphis, TN 38132 Mail Order Pharmacy Program

Nancy Reykdal Tennessee has a mail order pharmacy option in its


Blue Cross/Blue Shield of Tennessee Medical Assistance Program. All beneficiaries are
801 Pine Street entitled to participate.
Chattanooga, TN 37402 Disease Management Patient Education
Contact
Yolanda McClain
The Salvation Army Judith Black
611 Stockell Street Director of Disease Management
Nashville, TN 37207 Bureau of TennCare
706 Church Street
Effie Candis Pelfrey Nashville, TN 37247-6501
Tennessee Health Care Campaign T: 615/532-6705
1103 Foothill Court F: 615/741-0882
Nashville, TN 37217 E-mail: judith.j.black@state.tn.us

Virginia T. Lodge, Commissioner


Department of Human Services
400 Deaderick Street, 15th Floor
Nashville, TN 37248

Tennessee-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Executive Officers of State Medical and Hospital Alliance of Tennessee


Pharmaceutical Societies Paige Kisber
President
Tennessee Medical Association
211 Seventh Avenue North, Suite 400
Donald H. Alexander, CEO
Nashville, TN 37219
P.O. Box 120909
T: 615/254-1941
2301 21st Avenue South
F: 615/254-1942
Nashville, TN 37212-0909
E-mail: paige@hospitalalliancetn.com
T: 615/385-2100
Internet address: www.hospitalalliance.com
F: 615/385-3319
E-mail: dona@tma.medwire.org
Internet address: www.medwire.org

Tennessee Osteopathic Medical Association


Michael Darling
Executive Director
618 Church Street, Suite 220
Nashville, TN 37219
T: 615/254-3687
F: 615/254-7047
E-mail: mdarling@walkermgt.com
Internet address: www.tomanet.org

Tennessee Pharmacists Association


Baeteena M. Black, D.Ph.
Executive Director
500 Church Street, Suite 650
Nashville, TN 37219
T: 615/256-3023
F: 615/255-3528
E-mail: bblack@tnpharm.org
Internet address: www.tnpharm.org

Tennessee State Board of Pharmacy


Kendall M. Lynch, Director
Davy Crocket Tower
500 James Robertson Parkway, 2nd Floor
Nashville, TN 37243-1149
T: 615/741-2718
F: 615/741-2722
E-mail: kendall.lynch@state.tn.us
Internet address:
www.state.tn.us/commerce/boards/ pharmacy

Tennessee Hospital Association


Craig A. Becker
President
500 Interstate Boulevard South
Nashville, TN 37210-4634
T: 615/256-8240
F: 615/242-4803
Internet address: www.tha.com

Tennessee-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

TEXAS

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $1,591,828,224 2,153,316 $1,920,865,985

RECEIVING CASH ASSISTANCE, TOTAL $886,280,924 731,289


Aged $257,064,144 156,415
Blind / Disabled $527,377,291 256,884
Child $57,465,862 222,276
Adult $44,373,627 95,714

MEDICALLY NEEDY, TOTAL $19,389,921 40,399


Aged $0 0
Blind / Disabled $0 0
Child $51,557 206
Adult $19,338,364 40,193

POVERTY RELATED, TOTAL $236,871,319 1,015,231


Aged $726,956 863
Blind / Disabled $992,885 974
Child $209,138,086 854,824
Adult $26,013,392 158,570
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $449,286,060 366,397

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003

Texas-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

Texas-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Formulary/Prior Authorization


Texas Health and Human Services Commission. Formulary: Open formulary; however, products
Vendor drug program was implemented September must be listed in the Texas Drug Code Index.
1, 1971. Formulary managed through restrictions on use,
prior authorization and preferred products. General
exclusions (diseases, drug categories, etc.) include:
D. PROVISIONS RELATING TO DRUGS amphetamines, appliances, durable medical
Benefit Design equipment (bedpans, etc. - either rental or
purchase), elastic stockings, first aid supplies,
Drug Benefit Product Coverage: Products covered: medical supplies, oxygen, supports and
prescribed insulin; disposable needles (pen needles suspensories, and trusses.
only) and syringe combinations used for insulin.
Products not covered: cosmetics; fertility drugs; Prior Authorization: State currently has a prior
experimental drugs; total parenteral nutrition; and authorization procedure screening for drug classes
interdialytic parenteral nutrition; blood glucose test and individual drugs. The prescriber can request
strips; urine ketone test strips. reconsideration and the beneficiary can request a
hearing through the fair hearings process to appeal
Over-the-Counter Product Coverage: Products a prior authorization decision.
covered: feminine products; topical products;
allergy, asthma, and sinus products; analgesics; Prescribing or Dispensing Limitations
cough and cold preparations; digestive products; Prescription Refill Limit: Five refills, but total
smoking deterrent products. Products not covered: amount may not exceed 6-month supply.
Certain OTC drugs are covered on a prescription
basis except as otherwise provided in the Monthly Quantity Limit: Prescribed quantity cannot
reimbursement formula and vendor payment to exceed 6-month supply.
hospitals, nursing homes and institutions.
Monthly Prescription Limit: Limited to 3 per month
Therapeutic Category Coverage: Therapeutic except for recipients under age 21 and nursing
categories covered: anabolic steroids; antibiotics; home recipients.
analgesics; antipyretics, NSAIDs; anticoagulants;
anticonvulsants; anti-depressants; antidiabetic Other Limit: Recipients in managed care pilots (i.e.,
drugs; antihistamine drugs; antilipemic agents; community based waiver programs) receive
antipsychotics; anxiolytics, sedatives, and unlimited prescription coverage.
hypnotics; cardiac drugs; chemotherapy agents;
contraceptives; prescribed cold medications; ENT Drug Utilization Review
anti-inflammatory agents; estrogens; hypotensive PRODUR system implemented in February 1995.
agents; misc. GI drugs; thyroid agents; prescribed State currently has a DUR board with a quarterly
smoking deterrents; and sympathominetics review.
(adrenergic). Prior authorization required for:
anoretics; growth hormones; dextroamphetamines Pharmacy Payment and Patient Cost
(>21 years of age); xenical (hyperlipidemia only) Sharing
and drugs not included on the preferred drug list. Dispensing Fee: . $5.14. The dispensing fee,
Therapeutic categories not covered: anti-obesity including all costs of filling a prescription, was
agents; vitamins (except prenatal); children’s established by cost accounting and service
vitamins with fluoride; and DESI drugs. evaluation of the expenses involved in dispensing a
prescription.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Ingredient Reimbursement Basis: EAC = AWP-
Program when used in home health care, and 15% or WAC+12%, whichever is lower, AAC for
extended care facilities and through physician hospitals and public health providers.
payment when used in physicians’ offices.
Prescription Charge Formula: Average dispensing
Vaccines: Vaccines reimbursable as part of EPSDT expense (ADE) formula for payment:
service, the Children’s Health Insurance Program,
and the Vaccines for Children Program. 1. (EAC+5.14) divided by 0.9805 = amount paid
+ $0.15 delivery service.
Unit Dose: Unit dose packaging reimbursable if 2. DEAC only for Wyeth-Ayerst and Abbott.
there is not an added expense for the packaging.

Texas-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Insulin and approved non-legend drugs on Community Health Choice


prescription: pharmacists and dispensing physicians 2636 South Loop, Suite 700
will be reimbursed on the basis of usual charges to Houston, TX 77054
the general public or cost plus 50% of cost, 800/760-2600
whichever is lower; 50% of cost not to exceed
assigned variable dispensing fee. Texas Health Network
12375-B Riata Trace Parkway
Maximum Allowable Cost: State imposes Federal Austin, TX 78727
Upper Limits as well as State-specific limits on 800/925-9126
generic drugs. Over 3,000 drugs are listed on the
State-specific MAC list. Override requires First Care Health Plan
“Dispense as Written”, “Medically Necessary”, 12940 N. Highway 183
“Brand Necessary”, or “Brand Medically Austin, TX 78750
Necessary.” 800/431-7798

Incentive Fee: None. Parkland Health First


2777 N. Stemmons Freeway, Suite 300
Cognitive Services: Does not pay for cognitive Dallas, TX 75207
services. 888/672-2277

Patient Cost Sharing: No copayment. F. STATE CONTACTS


State Drug Program Administrator
E. USE OF MANAGED CARE
Barbara Dean, R.Ph.
Acting Director, Vendor Drug Program
Approximately 900,000 Medicaid recipients were
Texas Health and Human Services Commission
enrolled in MCOs in 2003 (all of whom are
Medicaid/CHIP Division
AFDC/AFDC-related). Recipients in managed care
1100 W. 49th Street
receive pharmaceutical benefits through the State.
Austin, TX 78756
(Pharmacy program is “carved out.”)
T: 512/491-1101
Managed Care Organizations F: 512/491-1962
E-mail: Barbara.Dean@hhsc.state.tx.us
AMERIGROUP, Inc.
Internet address: www.hhsc.state.tx.us/HCF/VDP
1200 East Copeland Road, Suite 200
Arlington, TX 76011 Health and Human Services Commission
800/600-4441 Officials
Albert Hawkins
Community First Health Plan
Executive Commissioner
4801 NW Loop 410, Suite 1000
Texas Health and Human Service Commission
San Antonio, TX 78229
4900 N. Lamar Boulevard
800/434-2347
Austin, TX 78751
T: 512/424-6502
El Paso First Health Plans
F: 512/424-6587
2501 North Mesa
E-mail: laura.ozuna@hhsc.state.tx.us
El Paso, TX 79902
877/532-3778
David Ballard, Interim Director
Texas Health and Human Services Commission
Texas Children’s Health Plan
4900 N. Lamar Boulevard, 4th Floor
1919 Braeswood
Austin, TX 78711
Houston, TX 77230
T: 512/491-1463
800/990-8247
F: 512/424-6587
E-mail: david.ballard@hhsc.state.tx.us
Superior Health Plan
2100 S. IH35, Suite 202
Auston, TX 78704
800/302-6688

Texas-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Prior Authorization Contact New Brand Name Products Contact


Don Valdes, R.Ph. Martha McNeill, R.Ph.
DUR Pharmacist Product and Prescriber Manager
Texas Health and Human Services Commission Texas Health and Human Services Commission
Vendor Drug Program 11209 Metric Boulevard, Building H
11209 Metric Boulevard Austin, TX 78758
Austin, TX 78756 T: 512/491-1157
T: 512/491-1172 F: 512/491-1961
F: 512/491-1962 E-mail: Martha.Mcneill@hhsc.state.tx.us
E-mail: Don.Valdes@hhsc.state.tx.us
Prescription Price Updating
DUR Contact
Martha McNeill, R.Ph.
Barbara Dean, R.Ph. 512/491-1157
Manager, DUR Program
Medicaid Drug Rebates Contact
Texas Health and Human Services Commission
11209 Metric Boulevard, Building H Heather Murphy, Manager
Austin, TX 78758 Pharmacy Contracts and Rebates
T: 512/491-1101 Vendor Drug Program
F: 512/491-1962 Texas Health and Human Services Commission
E-mail: Barbara.Dean@hhsc.state.tx.us 11209 Metric Boulevard, Bulding H
Austin, TX 78759
DUR Board
T: 512/491-1163
Leroy Knodel, Pharm.D., Vice Chairman F: 512/491-1967
San Antonio, TX E-mail: heather.murphy@hhsc.state.tx.us
Claims Submission Contact
Thomas Lee Kurt, M.D., M.P.H.
Dallas, TX Barbara Dean, R.Ph.
512/491-1101
Mark S. Gittings, D.O., R.Ph.
Austin, TX Medicaid Managed Care Contact
Pamela Coleman
Robert L. Hogue, M.D. Director, Health Plan Operations
Brownwood, TX Texas Health and Human Services Commission
11209 Metric Boulevard, Building H
Daniel Saylak, D.O., Chairman Austin, TX 78758
Bryan, TX 512/491-1302
E-mail: Pam.Coleman@hhsc.state.tx.us
Mary Spies Maxwell, M.D.
Austin, TX Mail Order Pharmacy Program
None
Adelina Barbosa, R.Ph.
Brownsville, TX Pharmaceutical and Therapeutics
Committee
Anita Martinez, R.Ph., CDE Richard C. Adams, M.D.
San Antonio, TX Plano, TX

James B. Hills, R.Ph. Anthony J. Busti, Pharm.D., R.Ph.


Houston, TX Midlothian, TX

Robert T. Reilly, Pharm.D. Harris M. Hauser, M.D. (chair)


El Paso, TX Houston, TX

Melbert C. Hillert, Jr., M.D.


Dallas, TX

David E. King, R.Ph.


Kingwood, TX

Texas-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Julie Elaine Lewis, M.S., R.Ph. Texas State Board of Pharmacy


Frisco, TX Gay Dodson, R.Ph.
Executive Director
Valerie Robinson, M.D. William P. Hobby Building
Lubbock, TX Tower 3, Suite 600
333 Guadalupe Street, Suite 3-600
Donna Burkett Rogers, M.S., R.Ph. (Vice Chair) Austin, TX 78701-3942
San Antonio, TX T: 512/305-8000
F: 512/305-8082
J.C. Jackson, R.Ph. E-mail: gay.dodson@tsbp.state.tx.us
Seabrook, TX Internet address: www.tsbp.tx.us

Guadalupe Zamora, M.D. Texas Hospital Association


Austin, TX Richard Bettis, CAE
President and CEO
John McCall Zerwas, M.D. P.O. Box 15587
Richmond, TX Austin, TX 78761-5587
T: 512/465-1000
F: 512/465-1090
Executive Officers of State Medical and
E-mail: rbettis@tha.org
Pharmaceutical Societies
Internet address: www.thaonline.org
Texas Medical Association
Louis J. Goodman, Ph.D., CAE
Executive Vice President and CEO
401 W. 15th Street
Austin, TX 78701-1680
T: 800/880-1300
F: 512/370-1632
E-mail: lou.goodman@texmed.org
Internet address: www.texmed.org

Texas Pharmacy Association


Jim Martin, R.Ph.
Executive Director and CEO
P.O. Box 14709
Austin, TX 78761-4709
T: 800/505-5463
F: 512/836-0308
E-mail: jmartin@txpharmacy.com
Internet address: www.txpharmacy.com

Texas Osteopathic Medical Association


Sam Tessen
Executive Director
1415 Lavaca Street
Austin, TX 78701-1634
T: 512/708-8662
F: 512/708-1415
E-mail: sam@txosteo.org
Internet address: www.txosteo.org

Texas-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

Texas-7
National Pharmaceutical Council Pharmaceutical Benefits 2004

UTAH

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $140,520,420 152,268 $160,833,586 199,234

RECEIVING CASH ASSISTANCE TOTAL $65,104,788 58,926 $71,038,782 73,150


Aged $5,882,916 2,943 $6,277,365 3,125
Blind/Disabled $42,629,889 12,766 $45,681,680 13,942
Child $5,115,660 26,318 $6,337,127 33,275
Adult $11,476,323 16,899 $12,742,610 22,808

MEDICALLY NEEDY, TOTAL $6,058,454 2,530 $6,720,897 5,475


Aged $1,270,722 493 $1,577,810 1,561
Blind/Disabled $4,063,939 939 $4,535,970 2,650
Child $110,743 403 $77,482 494
Adult $613,050 695 $529,635 770

POVERTY RELATED, TOTAL $29,475,262 52,714 $34,233,657 69,852


Aged $4,823,173 2,263 $5,161,498 2,656
Blind/Disabled $16,876,649 4,770 $19,228,073 6,399
Child $5,162,177 33,086 $6,506,524 44,553
Adult $2,526,754 12,511 $3,337,562 16,244
BCCA Women $86,509 84 N/A N/A

TOTAL OTHER EXPENDITURES/RECIPIENTS* $39,881,916 38,098 $48,840,250 50,757

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data provided by the Utah Department of Health Division of Health Care Financing.

Source: CMS, MSIS Report, FY 2002 and Utah Medicaid Statistical Information System, FY 2003.

Note: Utah estimates 2004 drug expenditures to be approximately $177.5 million and the number of Medicaid drug recipients to
be 212,000.

Utah-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION − Psyllium muciloid powder


− Quinine, 5 gr.
Division of Health Care Financing, State Products not covered: analgesics; feminine
Department of Health. products; vitamins (except for expectant mothers
and children to age 5); smoking deterrent products
(special program for expectant mothers); and
D. PROVISIONS RELATING TO DRUGS digestive products.
Benefit Design
For additional information or to obtain a list of
Drug Benefit Product Coverage: Products covered: covered over-the-counter products, contact the Utah
prescribed insulin; blood glucose test strips; urine Medicaid program at
ketone test strips. Prior authorization required for: http://health.utah.gov/medicaid/pdfs/otclist.pdf
amphetamines; Ritalin/methylphenidate; darvocet;
darvon; enbrel; relenza; human growth hormones; Therapeutic Category Coverage: Products covered:
lactulose syrup, lufyllin, oxandrin; panretin topiacal antibiotics; anticoagulants; anticonvulsants;
gel; prolastin; regranex retin-a-gel; tamiflu; zofran; antidiabetic agents; antihistamines; antilipemic
aggrenox; cerezyme; adagen; xenical; lovenox; agents; anxiolytics, sedatives, and hypnotics;
prilosec; prevacid; aciphex; protonix, normiflo; cardiac drugs; chemotherapy agents; prescribed
fragmin; kytril; anzemet; and self-administered cold medications; contraceptives; ENT anti-
injectables. Products covered under DME: flammatory agents; estrogens; hypotensive agents;
disposable needles used for insulin; total parenteral misc. GI drugs; and thyroid agents. Products
nutrition; and interdialytic parenteral nutrition. covered with restrictions: anti-depressants;
Products covered with restrictions: syringe sympathominetics (adrenergic). Prior authorization
combinations used for insulin (disposable syringes, required for: analgesics, antipyretics, and NSAIDs;
prefilled covered only with prior authorization). anti-psychotics; and growth hormones (partial
Products not covered: cosmetics; fertility drugs; coverage). Products not covered: anabolic steroids;
experimental drugs; and hair growth products. anoretics; prescribed smoking deterrents; diet
medications.
Over-the-Counter Product Coverage: OTC
products that are covered require a written Coverage of Injectables: Injectable medicines
prescription just like legend drugs in order for the reimbursable through the Prescription Drug
pharmacy to fill them. Clients must present a Program when used in home health care and
Medicaid card and a prescription. Products extended care facilities, and through physician
covered: payment when used in physician offices.
− Acetone tests (e.g., Acetest, Chemstrip-K,
Ketostix) Vaccines: Vaccines reimbursable at AWP minus
− Allergy, asthma and sinus products (specific 15% plus a fee as part of the Vaccines for Children
products covered by special programs only) Program.
− Analgesics (generics only)
− Contraceptives Unit Dose: Unit dose packaging reimbursable.
− Cough and cold preparations (generics only)
− DSS, caps liquid and syrup Formulary/Prior Authorization
− DSS concentrate drops 5% Formulary: Open formulary. No preferred drug list.
− Ferrous fumerate, All dosage forms Prior authorization required for some products.
− Ferrous gluconate, All dosage forms
− Ferrous sulfate, All dosage forms Prior Authorization: State has a prior authorization
− Glucose blood tests (e.g., Chemstrip, BG, procedure screening for individual drugs with fair
Dextrostix, Visidex) hearing appeal process to DUR board.
− Glucose urine tests (e.g., Clinitest, Clinistix,
Diatrix, Tes Tape, Chemstrip G) Prescribing or Dispensing Limitations
− Insulin Prescription Refill Limit: Limited to five.
− Insulin syringes/needles/disposable
(100/month) Monthly Quantity Limit: In general, the quantity of
− Kaolin w/pectin suspension (e.g., Kaopectate) medication shall be limited to a supply not to
− Lactobacillus acidophilus (e.g., Bacid, exceed 31 days. Cumulative limits on specific
Lactinex) drugs Maximum scripts per month (except children
− Nutrients (all nutrients require prior approval) and pregnant women).
− Pedialyte liquid
− Prophylactics male

Utah-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Drug Utilization Review Med Utah Healthwise


P.O. Box 30804
PRODUR system implemented in 1994. State has a
Salt Lake City, UT 84130-0804
DUR Board that meets monthly.
800/624-6519
Pharmacy Payment and Patient Cost
Sharing United Medchoice
7910 South 3500 East
Dispensing Fee: $3.90 for urban, $4.40 for rural,
Salt Lake City, UT 84121
effective 1995. 800/401-0660
Ingredient Reimbursement Basis: EAC = Lesser of
AWP-15% or Federal/State MAC. F. STATE CONTACTS
State Drug Program Administrator
Prescription Charge Formula: Lowest of:
RaeDell Ashley, R.Ph.
1. EAC/MAC plus a dispensing fee, or Pharmacy Director, Medicaid Program
2. Usual and customary charges to the private Division of Health Care Financing
sector for legend and generic legend drugs. Department of Health
Formula for OTCs is AWP minus 15% plus 288 North 1460 West
dispensing fee. P.O. Box 143102
Salt Lake City, UT 84114-3102
Maximum Allowable Cost: State imposes Federal T: 801/538-6495
Upper Limits as well as State-specific limits on F: 801/538-6099
generic drugs. Override requires “Brand Medically E-mail: rashley@utah.gov
Necessary” plus prior approval to obtain brand Internet address: www.health.utah.gov/medicaid
name product.
New Brand Name Products Contact
Incentive Fee: None. RaeDell Ashley, R.Ph.
801/538-6495
Patient Cost Sharing: Copayment = $3.00
DUR Contact
Cognitive Services: Does not pay for cognitive Duane Parke
services. DUR Director, Medicaid Program
Division of Health Care Financing
Department of Health
E. USE OF MANAGED CARE
P.O. Box 143102
Salt Lake City, UT 84114-3102
Approximately 110,000 Medicaid recipients are
T: 801/538-6452
enrolled in managed care in 2003. Pharmacy
F: 801/538-6099
benefits are through the State.
E-mail: dpark@utah.gov
Managed Care Organizations
DUR Board
American Family Care
Lowry Bushnell, M.D.
2120 South 13th East #303
Western Institute of Neuropsychiatry
Salt Lake City, UT 84106
501 Chipeta Way
888/483-0760
Salt Lake City, UT 84108
Healthy U
Bradford D. Hare, M.D., Ph.D.
35 W. Broadway
Department of Anesthesiology
Salt Lake City, VT 84101
50 North Medical Drive
888/271-5870
Salt Lake City, UT 84132
IHC Access
Jeff Jones, R.Ph.
P.O. Box 116670
Riverton Drug
Salt Lake City, UT 84147
1741 West 12600 South
800/442-9023
Riverton, UT 84065

Wilhelm Tilehmann, M.D.


1520 Emerson Averson
Salt Lake, UT 84105

Utah-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Karen M. Gunning, Pharm.D. Mail Order Pharmacy Program


Univ. of Utah College of Pharmacy
State has a mail order pharmacy program. Utah
30 South 2000 East, Room 265
Medicaid beneficiaries may choose to obtain
Salt Lake City, UT 84112-5820
prescription drugs through mail order.
Charles M. Arena, M.D. Department of Health Officials
5337 Cottonwood Club Drive
David Sundwall, M.D.
Salt Lake City, UT 84117
Executive Director
Colin B. Van Orman, M.D. Department of Health
P.O. Box 141000
PCMC
100 North Medical Drive, Suite 2700 Salt Lake City, UT 84114-1000
Salt Lake City, UT 84113 T: 801/538-6111
F: 801/538-6306
Derek Christensen, R.Ph. E-mail: davidsundwall@utah.gov
9842 Grouse Bend Circle
South Jordan, UT 84095 Michael Deily, Director
Department of Health
Division of Health Care Financing
Joseph Miner, M.D.
Utah County Health Department P.O. Box 143101
589 South State Street Salt Lake City, UT 84114-3101
T: 801/538-6406
Provo, UT 84601
F: 801/465-9546
Dominic DeRose, R.Ph. E-mail: mdeily@utah.gov
Value Drug
1080 West 300 North Executive Officers of State Medical and
Clearfield, UT 84015 Pharmaceutical Societies
Utah Medical Association
Prescription Price Updating J. Leon Sorenson
RaeDell Ashley, R.Ph. Executive Vice President
801/538-6495 540 East 500 South
Salt Lake City, UT 84102
Medicaid Drug Rebate Contacts T: 801/355-7477
Technical: RaeDell Ashley, R.Ph., 801/538-6495 F: 801/532-1550
Policy: RaeDell Ashley, R.Ph., 801/538-6495 E-mail: uma@utahmed.org
PA: RaeDell Ashley, R.Ph., 801/538-6495 Internet address: www.utahmed.org
DUR: Duane Parke, 801/538-6452
Utah Osteopathic Medical Association
Shelly Hanks
Claims Submission Contact
Secretary
Connie Higley 462 South 1240 East
Information Technology Director Payson, UT 84651-8533
Division of Health Care Financing T: 801/465-9545
Department of Health F: 801/465-9546
P.O. Box 143102 E-mail: info@uoma.net
Salt Lake City, UT 84114-3102 Internet address: www.uoma.net
801/538-6691
E-mail: chigley@utah.gov

Medicaid Managed Care Contact


Julie Olsen, Director, Managed Health Care
Division of Health Care Financing
Department of Health
P.O. Box 143102
Salt Lake City, UT 84114-3102
T: 801/538-6303
F: 801/538-6009
E-mail: jolsen@utah.gov

Utah-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Utah Pharmaceutical Association


Reid L. Barker
Executive Director
1850 South Columbia Lane
Orem, UT 84097
T: 801/762-0452
F: 801/762-0454
E-mail: upha@upha.com
Internet address: www.upha.com

Utah State Board of Pharmacy


Diana L. Baker
Bureau Director
160 East 300 South
P.O. Box 146741
Salt Lake City, UT 84114-6741
T: 801/530-6628
F: 801/530-6511
E-mail: dbaker@utah.gov
Internet address:
www.dopl.utah.gov/licensing/pharmacy

Utah Hospitals and Health Systems Association


Joseph M. Krella, FACHE
President
2180 South 1300 East, Suite 440
Salt Lake City, UT 84016
T: 801/486-9915
F: 801/486-0882
E-mail: joe@uha-utah.org
Internet address: www.uha-utah.org

Utah-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Utah-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

VERMONT
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN)


Aged Blind/ Child Adult Aged Blind/ Child Adult
Disabled Disabled
Prescribed Drugs ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Inpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Outpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Laboratory & X-ray Service ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Nursing Facility Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Physician Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Dental Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $115,623,970 112,227 $127,763,857


RECEIVING CASH ASSISTANCE TOTAL $40,886,714 24,609
Aged $3,730,992 1,680
Blind/Disabled $31,655,468 10,964
Child $2,387,467 7,760
Adult $3,112,787 4,205

MEDICALLY NEEDY, TOTAL $19,598,384 10,415


Aged $6,923,615 2,889
Blind/Disabled $9,935,004 2,730
Child $521,190 1,542
Adult $2,218,575 3,254

POVERTY RELATED, TOTAL $6,798,032 29,107


Aged $0 0
Blind/Disabled $0 0
Child $6,475,960 27,574
Adult $312,886 1,523
BCCA Women $0 0
Unknown $9,186 10

TOTAL OTHER EXPENDITURES/RECIPIENTS* $48,340,840 48,096


*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

1 The State of Vermont did not respond to the 2001, 2002, or 2003 NPC Surveys. Using CMS data and other source materials, we have, to
the extent possible, updated the Profile and the tables in other sections of the Compilation. Users should contact The Vermont Medicaid
program to assess the accuracy and currency of the information included.

Vermont-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Formulary/Prior Authorization


Formulary: Open formulary with preferred drug list
Agency of Human Services, Office of Vermont (PDL). PDL managed through exclusion of
Health Access. products based on contracting issues, restrictions on
use, prior authorization, and preferred products.
D. PROVISIONS RELATING TO DRUGS General exclusions include cosmetics and
experimental drugs.
Benefit Design
Drug Benefit Product Coverage: Products covered: Prior Authorization: State has formal prior
prescribed insulin; disposable needles and syringe authorization procedure and a method for appealing
combinations used for insulin; blood glucose test coverage of an excluded product and prior
strips. Products covered as DME: total parenteral authorization decisions. To appeal coverage of an
nutrition. Products not covered: cosmetics; fertility excluded product, a provider can request a review
drugs; experimental drugs; urine ketone test strips; by the Medicaid program’s Medical director or
and interdialytic parenteral nutrition (covered by request a fair hearing. For prior authorization
Medicare). Prior authorization may be required for decisions, the prescriber can initiate a first appeal
certain self-administered injectables. and, if the request remains unresolved, contact the
Medicaid Director. Prior authorization required for
Over-the-Counter Product Coverage: Products drugs not listed on the PDL.
covered with a prescription and manufacturer’s Prescribing or Dispensing Limitations
signed rebate agreement: allergy, asthma and sinus
products; analgesics; cough and cold preparations; Prescription Refill Limit: Up to 5 may be
digestive products; single source/multisource authorized by a physician.
vitamins pending condition; lice shampoos; and
topical products. Products covered with restrictions: Monthly Quantity Limit: Initial prescription should
feminine products (for bladder control only) and be sufficient to allow for the determination of the
smoking deterrent products (maximum of 2 scripts patient’s tolerance of the medication without
for up to 90-day supply each year). creating unnecessary waste (expense) to the
program. This quantity could be up to a 60-day
Therapeutic Category Coverage: Therapeutic supply on all maintenance medication prescriptions.
categories covered: contraceptives; ENT anti- Drug Utilization Review
inflammatory agents; estrogens; hypotensive
agents; misc. GI drugs; sympathominetics PRODUR system implemented in November 1993.
(adrenergic); and thyroid agents. Prior State currently has a DUR board with a bimonthly
authorization required for: anabolic steroids; review.
analgesics, antipyretics, and NSAIDs; antibiotics; Pharmacy Payment and Patient Cost
anticoagulants; anticonvulsants; anti-depressants; Sharing
antidiabetic agents; antihistamines; antipilipemic
agents; anti-psychotics; anxiolytics, sedatives, and Dispensing Fee: $4.25, effective 7/1/96.
hypnotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; growth hormones Ingredient Reimbursement Basis: EAC = AWP-
(must meet clinical criteria); prescribed smoking 11.9%.
deterrents; erectile dysfunction products; and
antiobesity drugs. Therapeutic categories not Prescription Charge Formula: Pharmacies bill their
covered: anoretic. usual and customary charge. Medicaid pays the
lower of:
Coverage of Injectables: Injectable medicines 1. Usual and customary charge;
reimbursable through physician payment when used 2. EAC plus a dispensing fee; or
in physician offices, home health care, and 3. Maximum allowable cost plus a dispensing fee.
extended care facilities.
Maximum Allowable Cost: State imposes Federal
Vaccines: The Vermont Department of Health Upper Limits as well as State-specific limits on
provides vaccines to physician offices. generic drugs. Override requires “Dispense as
Written”, “Medically Necessary,” “Brand
Unit Dose: Unit dose packaging reimbursable. Necessary,”or DAW8 (generic not available).

Incentive Fee: None.

Vermont-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Patient Cost Sharing: State uses a system of tired DUR Contact


copayments ($1.00 - $3.00):
Felicia Montineri
Pharmacist
$1.00 – for scripts < $30.00
First Health Services Corporation
$2.00 – for Scripts $30.00 - $49.99
312 Hurricane Lane, Suite 200
$3.00 – for Scripts $50.00 and above.
Williston, VT O5495
T: 802/879-5900
Cognitive Services: Does not pay for cognitive
F: 802/879-5919
services.
E-mail: montinfe@fhsc.com
DUR Board
E. USE OF MANAGED CARE
James A. Gray, M.D. (Chair)
Does not use use MCOs to deliver services to Jeffrey P. Firlik, R.Ph.
Medicaid beneficiaries. Cheryl A. Gibson, M.D.
Stuart Graves, M.D.
Rich Harvie, R.Ph.
F. STATE CONTACTS Virginia L. Hood, M.D.
State Drug Program Administrator Frank J. Landry, M.D.
John R. Low, R.Ph.
Ann E. Rugg Andrew C. Miller, R.Ph.
Deputy Director Michael Scovner, M.D.
Office of Vermont Health Access Lloyd (Tim) L. Thompson, M.D.
312 Hurricane Lane, Suite 200 Norman S. Ward, M.D.
Williston, VT 05495
T: 802/879-5900 New Brand Name Products Contact
F: 802/879-5919 Felicia Montineri
E-mail: arugg@ahs.state.vt.us 802/879-5900
Internet address: www.ohva.state.vt.us
Prescription Price Updating
Agency of Human Services Officials
Cathy England, Manager
Michael K. Smith Rebate Administration
Secretary First Health Services Corporation
Agency of Human Services 4300 Cox Road
103 South Main Street Glen Allen, VA 23060
Waterbury, VT 05671-0201 804/965-7717
T: 802/241-2220
F: 802/241-2979 Medicaid Drug Rebate Contacts
E-mail: mike.smith@state.vt.us
Internet address: www.ahs.state.vt.us Christine Dapkiewicz
EDS
Joshua Slen 312 Hurricane Lane, Suite 100
Medicaid Director Williston, VT 05495
Agency for Human Services T: 802/879-4450
Office of Vermont Health Access F: 802/878-3440
103 South Main Street Claims Submission Contact
Waterbury, VT 05676-1201
T: 802/879-5900 First Health Services Corporation
F: 802/879-5962 4300 Cox Road
E-mail: joshuas@path.state.vt.us Glen Allen, VA 23060
804/965-7717
Prior Authorization Contact
Mail Order Pharmacy Benefit
OVHA staff do not meet with pharmaceutical
industry representatives None

Vermont-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Medical Advisory Board Executive Officers of State Medical and


Pharmaceutical Societies
Kim Cheney
AARP Vermont Medical Society
Paul Harrington
Dave Reynolds Executive Vice President
Bi-State Primary Care Association 134 Main Street
P.O. Box 1457
Michael Sirotkin Montpelier, VT 05601
Community of Vermont Elders T: 802/223-7898
F: 802/223-1201
Donna Sutton Fay E-mail: pharrington@vtmd.org
Health Care Ombudsman Internet address: www.vtmd.org

Jacqueline Majoros Vermont Pharmacists Association


LTC Ombudsman James Marmar
Executive Director
Peter Cobb Box 90
VT Assembly of Home Health Agencies Woodstock, VT 05091
T: 877/483-2646
Bea Grause F: 802/433-4803
VT Association of Hospitals and Health Systems E-mail: vtpa@sover.net
Internet address: www.vtpharmacists.org
Lila Richardson
VT Coalition for Disability Rights Vermont State Association of Osteopathic
Physicians & Surgeons, Inc.
Peter Taylor John M. Peterson, D.O.
VT Dental Society Executive Director
72 Barre Street
Mary Shriver Montpelier, VT 05602-3508
VT Health Care Association T: 802/229-9418
T: 802/454-9663
Paul Harrington E-mail: nocdos@comcast.net
VT Medical Society Internet address: www.osteopathic.org/index

Margaret Joyal Vermont State Board of Pharmacy


VT Council of Community Mental Health Services Peggy Atkins
Board Administrator
Kristi Kistler 26 Terrace Street, Drawer 09
Dartmouth Hitchcock Medical Center Montpelier, VT 05609-1101
T: 802/828-2373
Julie Arel F: 802/828-2465
Parent to Parent E-mail: patkins@sec.state.vt.us
Internet address:
Garry Schaedel www.vtprofessionals.org/oprl/pharmacists
Department of Health
Vermont Association of Hospitals and Healthcare
Edna Fairbanks-Williams Systems
Marie Beatrice Grause
Sarah Littlefeather President and CEO
148 Main Street
Nancy Osborne Montpelier, VT 05602
T: 802/223-3461
Michelle Parent F: 802/223-0364
E-mail: bea@vahhs.org
Linda Bassick Internet address: www.vahhs.org

Dale Hacket

Vermont-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

VIRGINIA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/ Child Adult Aged Blind/ Child Adult
Disable Disabled
d
Prescribed Drugs ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Inpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Outpatient Hospital Care ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Laboratory & X-ray Service ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Nursing Facility Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Physician Services ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹
Dental Services All eligible recipients under age 21

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $453,663,058 319,196 $506,414,352

RECEIVING CASH ASSISTANCE TOTAL $260,853,039 98,159


Aged $81,793,724 33,845
Blind/Disabled $178,998,190 64,149
Child $17,496 90
Adult $43,629 75

MEDICALLY NEEDY, TOTAL $13,371,925 5,595


Aged $5,782,597 2,811
Blind/Disabled $7,565,189 2,617
Child $19,393 141
Adult $4,746 26

POVERTY RELATED, TOTAL $54,484,185 137,210


Aged $12,378,967 7,008
Blind/Disabled $15,064,557 6,389
Child $24,558,740 106,379
Adult $2,33,400 17,324
BCCA Women $148,521 110

TOTAL OTHER EXPENDITURES/RECIPIENTS $124,953,909 78,232

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Virginia-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Formulary/Prior Authorization


Formulary: Open Formulary with preferred drug
Department of Medical Assistance Services. list (PDL). Managed through prior authorization,
Eligibility determination by the Department of therapeutic substitution, and preferred products.
Social Services.
Prior Authorization: State currently has a formal
D. PROVISIONS RELATING TO DRUGS prior authorization process with right to appeal
prior authorization decisions (see
Benefit Design www.dmas.virginia.gov under pharmacy initiatives
Drug Benefit Product Coverage: Products Covered: for appropriate process). Prior authorization
prescribed insulin; disposable needles and syringe procedure screening for individual drugs for weight
combinations used for insulin; blood glucose test loss.
strips; urine ketone test strips total parenteral Prescribing or Dispensing Limitations
nutrition; and interdialytic parenteral nutrition.
Products not covered: cosmetics; fertility drugs; Prescription Refill Limit: Physicians may authorize
hair growth products; designated DESI drugs; refills according to legal requirements.
experimental drugs; non-legend drugs; and expired
drugs. Monthly Quantity Limit: 34-day supply.
Drug Utilization Review
Over-the-Counter Drug Coverage: A majority of
OTC drugs reimbursable when used in nursing PRODUR (online) system implemented in July
homes and certain classes in outpatient populations. 1994. RetroDUR Program also implemented in
These include: allergy, asthma, and sinus products; 1994. State currently has a DUR Board with
analgesics; cough and cold preparations; digestive quarterly meetings.
products; feminine products; topical products; and Pharmacy Payment and Patient Cost
smoking deterrent products. Sharing
Therapeutic Category Coverage: Therapeutic Dispensing Fee: $3.75, effective 7/1/03.
categories covered: anabolic steroids; analgesics,
antipyretics, and NSAIDs; antibiotics; Ingredient Reimbursement Basis: EAC = AWP-
anticoagulants; anticonvulsants; anti-depressants; 10.25%.
antidiabetic agents; antihistamines; antilipemic
agents; anti-psychotics; anxiolytics, sedatives, and Prescription Charge Formula: Based upon the
hypnotics; cardiac drugs; chemotherapy agents; lower of VMAC or EAC plus a fee, or the usual
prescribed cold medications; contraceptives; ENT and customary charge minus a copayment of $1.00
anti-inflammatory agents; estrogens; growth for generics and $3.00 for brand-name products,
hormones; hypotensive agents; misc. GI drugs; where appropriate.
prescribed smoking deterrents, sympathominetics
(adrenergic); and thyroid agents. Partial coverage Maximum Allowable Cost: State imposes Federal
for: anoretics (PA required). Prior authorization Upper Limits as well as State-specific limits on
required for: weight loss drugs and non-preferred generic drugs. Override requires “Medically
drugs. Necessary.”

Coverage of Injectables: Injectable medicines Incentive Fee: None.


reimbursable through the Prescription Drug
Program when used in home health care, and Patient Cost Sharing: Copayment is $1.00/Rx for
extended care facilities, and through physican generics and $3.00/Rx on brand-name products.
payment when used in physician offices. qualifying prescriptions. Exclusions include less
than 21 years old, pregnancy related, family
Vaccines: Vaccines reimbursable as part of the planning, and nursing home patients.
Vaccines for Children Program.
Cognitive Services: Does not pay for cognitive
Unit Dose: Unit dose packaging reimbursable in services at present.
nursing homes.

Virginia-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

E. USE OF MANAGED CARE DUR Board


Approximately 260,000 beneficiaries enrolled in Robert O. Friedel, M.D.
HMOs in 2003. Recipients enrolled in managed Catherine Kelso, M.D.
care organizations receive pharmaceutical benefits Jason Lynam, M.D.
through managed care plans. Jennifer Edwards, Pharm.D.
Elaine Ferrary, M.S.
Managed Care Organizations Jane Settle, N.P., M.C.V.
Virginia Premier Health Plan Geneva Briggs, Pharm.D. (Chair)
Anthem HealthKeepers Plus Sandra Dawson, R.Ph.
Sentara Family Care Kelly Goode, Pharm.D.
Southern Health/CareNet Mark Johnson, Pharm.D.
UNICARE Health Plan of Virginia Bill Rock, Pharm.D.
Thomas Moffatt, M.D.
Mathew J. Goodman, M.D.
F. STATE CONTACTS
New Brand Name Products Contact
State Drug Program Administrator
Keith T. Hayashi
Javier Menendez, R.Ph. Pharmacist I
Pharmacy Manager Department of Medical Assistance Services
Department of Medical Assistance Services 600 East Broad Street, Suite 1300
600 East Broad Street, Suite 1300 Richmond, VA 23219
Richmond, VA 23219 T: 804/225-2773
T: 804/783-2196 F: 804/786-0973
F: 804/786-0973 E-mail: Keith.Hayashi@dmas.virginia.gov
E-mail: Javier.Menendez@dmas.virginia.gov
Internet address: www.dmas.virginia.gov Prescription Price Updating

Prior Authorization Contact Keith T. Hayashi


804/225-2773
Debra Moody
Clinical Manager Medicaid Drug Rebate Contacts
First Health Services Corporation Policy: Javier Menendez, R.Ph.
4300 Cox Road 804/783-2196
Glen Allen, VA 23060
T: 804/956-7431 Audits: Keith T. Hayashi
F: 804/273-6961 804/225-2773
E-mail: moodyde@fhsc.com Disputes: Lezli Jeter
DUR Contact Rebate Pharmacist
First Health Services Corporation
Rachel E. Cain 4300 Cox Road
Pharmacist I Glen Allen, VA 23060
Department of Medical Assistance Services T: 804/527-3009
600 East Broad Street, Suite 1300 F: 804/217-7911
Richmond, VA 23219
T: 804/225-2873 Disease Management/Patient Education
F: 804/786-0973 Programs
E-mail: Rachel.Cain@dmas.virginia.gov Disease/ Medical State: Cardiovascular Disease
Program Name: Pilot Congestive Heart Failure
and/or Cornary Artery Disease Program
Program Manager: Policy Division and Director of
Research
Program Sponsor: Anthem

Virginia-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Disease Management/Patient Education Jan Burrus


Initiatives Contact PhRMA
Howard B. Tomlinson II
Ann Leigh Kerr
Director, Health Care Services Division
Troutman Sanders LLP
Department of Medical Assistance Services
600 East Broad Street, Suite 1300
Richard Grossman
Richmond, VA 23219
Vectre Corporation
T: 804/371-7398
F: 804/786-5799 Executive Officers of State Medical and
E-mail: Bryan.Tomlinson@dmas.virginia.gov Pharmaceutical Societies
The Medical Society of Virginia
Claims Submission Contact
Paul Kitchen
Frank Fury Executive Vice President
Processing Admnistrator 4205 Dover Road
First Health Services Corporation Richmond, VA 23221
4300 Cox Road T: 804/377-1034
Glen Allen, VA 23060 F: 804/355-6189
804/965-7400 E-mail: pkitchen@msv.org
Internet address: www.msv.org
Medicaid Managed Care Contact
Mary Mitchell Virginia Pharmacists Association
Managed Care Unit Manager Rebecca P. Snead
Department of Medical Assistance Services Executive Director
600 East Broad Street, Suite 1300 5501 Patterson Avenue, Suite 200
Richmond, VA 23219 Richmond, VA 23226
T: 804/786-3594 T: 800/527-8742
F: 804/786-5799 F: 804/285-4227
E-mail: Mary.Mitchell@dmas.virginia.gov E-mail: becky@vapharmacy.org
Internet address: www.vapharmacy.org
Mail Order Pharmacy Program
None Virginia State Board of Pharmacy
Elizabeth Scott Russell
Department of Medical Assistance Services Executive Director
Officials 6603 W. Broad Street, 5th Floor
Patrick W. Finnerty Richmond, VA 23230-1712
Director T: 804/662-9911
Department of Medical Assistance Services F: 804/662-9313
600 East Broad Street, Suite 1300 E-mail: pharmbd@dhp.state.va.us
Richmond, VA 23219 Internet address: www.dhp.state.va.us/pharmacy
T: 804/786-4231
F: 804/225-4512 Virginia Osteopathic Medical Association
E-mail: pfinnert@dmas.state.va.us Maria Harris, Executive Director
48 East Square Lane
Virginia Medicaid Pharmacy Liaison Richmond, VA 23238
Committee T: 804/784-2204
F: 804/784-2231
Bill Hancock, R.Ph. E-mail: voma@erols.com
Long Term Care Pharmacy Coalition Internet address: www.voma-net.org
Alexander Maculey, R.Ph. Virginia Hospital and Healthcare Association
Community Pharmacy Laurens Sartoris, President
4200 Innslake Drive
Michael Ayotte, R.Ph. Glen Allen, VA 23060
Virginia Association of Chain Drug Stores T: 804/965-1216
F: 804/965-0475
Rebecca Snead, R.Ph. E-mail: lsartoris@vhha.com
Virginia Pharmacist Association Internet address: www.vhha.com

Virginia-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

WASHINGTON

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $549,216,380 423,758 $592,437,155

RECEIVING CASH ASSISTANCE, TOTAL $303,547,520 153,308


Aged $50,050,991 25,016
Blind / Disabled $245,256,705 91,560
Child $2,228,696 19,049
Adult 6,011,128 17,683

MEDICALLY NEEDY, TOTAL $50,911,333 14,782


Aged $13,280,920 6,056
Blind / Disabled $37,601,159 8,674
Child $8,139 18
Adult $21,115 34

POVERTY RELATED, TOTAL $22,401,575 102,651


Aged $2,533,118 1,852
Blind / Disabled $7,413,952 2,754
Child $7,841,982 61,232
Adult $4,612,523 36,813
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $172,355,952 153,017


*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Washington-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION Coverage of Injectables: Injectable medicines


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

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


Benefit Design EPSDT services.

Drug Benefit Product Coverage: Products covered: Unit Dose: Unit dose packaging is reimbursable.
prescribed insulin; disposable needles and syringe
combinations for insulin; blood glucose test strips; Formulary/Prior Authorization
urine ketone test strips; total parenteral nutrition; and Formulary: Open formulary with preferred drug list
interdialytic parenteral nutrition. Products not (PDL). Managed through excluding products based
covered: cosmetics; fertility drugs; DESI drugs; and on contracting issues; prior authorization,
experimental drugs. therapeutic substitution; preferred products, and
physician profiling.
Over-the-Counter Product Coverage: Products
covered with restrictions: allergy, asthma and sinus Prior Authorization: State currently has a prior
products (selected items); analgesics (ASA and authorization program and a Drug Utilization
acetaminophen); cough and cold preparations Review Team and a Drug Evaluation Matrix Team.
(selected items); digestive products (selected items); Recipients can request a fair hearing and exception
feminine products (selected items); and topical to policy to appeal an excluded product or prior
products (selected items). Products not covered: authorization decision.
smoking deterrent products. (Note: Zyban only
covered for pregnant women in smoking cessation Prescribing or Dispensing Limitations
program). Prescription Refill Limit: Two (2) refills in 30-day
period except for antibiotics, anti-asthmatics,
Therapeutic Category Coverage: Therapeutic Schedule II and III drugs, anti-neoplastic, topicals,
categories covered: antibiotics; anticoagulants; and any propoxyphene, which may have 4 refills.
anticonvulsants; anti-depressants; cardiac drugs;
chemotherapy agents; contraceptives; ENT anti- Monthly Prescription Limit: Review of client drug
inflammatory agents; hypotensive agents; profile by a clinical pharmacist when request for 5th
sympathominetics (adrenergic); and thyroid agents. brand name prescription in any one-month period.
Therapeutic categories requiring prior authorization:
anabolic steroids; analgesics, antipyretics, and Monthly Quantity Limit: Maximum 34-day supply
NSAIDs; antidiabetic agents; antihistamines; (90 days on select items).
antilipemic agents; anti-psychotics; anxiolytics,
sedatives, and hypnotics; prescribed cold Drug Utilization Review
medications; estrogens; growth hormones; misc. GI PRODUR system implemented in March 1996.
drugs; and non-preferred drugs*. Therapeutic State currently has a P&T Committee/DUR Board
categories not covered: anoretics; prescribed with a quarterly review.
smoking deterrents (except Zyban for pregnant
women enrolled in a smoking cessation program); Pharmacy Payment and Patient Cost
weight loss drugs; products for hair growth; drugs Sharing
for infertility, and frigidity, impotency, or sexual Dispensing Fee: $4.20 to $5.20, effective 7/1/02.
dysfunction. − $4.20 - Retail pharmacies, filling over 35,000
Rxs annually.
*Drugs considered for prior authorization are drugs − $4.51 - Retail pharmacies, filling 15,001-
with high risk/benefit ratio, high potential for 35,000 Rxs annually.
abuse/misuse, narrow therapeutic indication, and − $5.20 - Retail pharmacies, filling 15,000 or less
high cost. A complete list of drugs requiring prior Rxs annually.
authorization may be found on the Medical − $5.20 - Unit dose systems (nursing home Rxs).
Assistance Administration’s web site:
http://maa.dshs.wa.gov/pharmacy Ingredient Reimbursement Basis: EAC = AWP-
14%, except drugs on the MAC list with 5 or more
labelers/manufacturers are reimbursed at AWP-
50%.

Washington-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Prescription Charge Formula: The amount shall not Molina Healthcare of Washington, Inc. (MHC)
exceed the usual and customary charge to the public P.O. Box 1469
or EAC plus a dispensing fee. Any drug with more Bothell, WA 98041
than 3 labelers will be reimbursed according to the 800/869-7165
Maximum Allowable Cost.
Regence Blue Shield
Maximum Allowable Cost: State imposes Federal P.O. Box 21267
Upper Limits as well as State-specific limits on Mail Stop BR 390
generic drugs. Override requires “Brand Medically Seattle, WA 98111-3267
Necessary.” 800/689-8791

Incentive Fee: None.


F. STATE CONTACTS
Patient Cost Sharing: No copayment. State Drug Program Administrator

Cognitive Services: State pays for emergency Siri A. Childs, Pharm D.


contraceptive counseling and clozaril case Pharmacy Policy Manager
management. Medical Assistance Administration, DSHS
805 Plum Street, SE
P.O. Box 45506
E. USE OF MANAGED CARE Olympia, WA 98504-5506
T: 360/725-1564
Approximately 450,000 Medicaid recipients were F: 360/586-8827
enrolled in MCOs in FY 2003. Recipients receive E-mail: childsa@dshs.wa.gov
pharmaceutical benefits through both the State and Internet address: http://maa.dshs.wa.gov/pharmacy
managed care plans. Anti-retrovirals, mental health
Prior Authorization Contact
drugs, and family planning products are carved out
of managed care. Siri A. Childs, Pharm.D.
360/725-1564
Managed Care Organizations
DUR Contact
Asuris Northwest Health Plan
P.O. Box 91130 Nicole N. Nguyen, Pharm.D.
Mail Stop BR 325 Clinical Pharmacist
Seattle, WA 98111 Medical Assistance Administration, DSHS
888/240-9580 805 Plum Street, SE
P.O. Box 45506
Columbia United Providers Olympia, WA 98504-5506
19120 SE. 34th Street, Suite 201 T: 360/725-1757
Vancouver, WA 98683 F: 360/586-8827
800/315-7862 E-mail: nguyen@dshs.wa.gov

Community Health Plan of Washington Pharmacy and Therapeutics


720 Olive Way, Suite 300 Committee/DUR Board
Seattle, WA 98101 Robert Bray, M.D.
800/440-1561 Carol Cordy, M.D. ( Vice Chair)
Daniel Lessler, M.D. (Chair)
Group Health Cooperative T. Vyn Reese, M.D.
521 Wall Street Angelo Ballasiotes, Pharm.D.
Seattle, WA 98121 Alvin Goo, Pharm.D.
888/901-4636 Jason Iltz, Pharm.D.
Janet Kelly, Pharm.D.
Kaiser Foundation Health John White, P.A., Pharm.D.
Plan of the Northwest Patty Varley, A.R.N.P.
500 NE Multnomah, Suite 100
Portland, OR 97232-2099 New Brand Name Products Contact
800/813-2000
Siri A. Childs, Pharm.D.
360/725-1564

Washington-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Prescription Price Updating Disease Management Program/Initiative


Contact
Tom Zuchlewski
Pharmacy Rates Manager Alice R. Lind
Medical Assistance Administrator, DSHS Managed Care Coordination Section
P.O. Box 45510 Medical Assistance Administration, DSHS
Olympia, WA 98504-5510 P.O. Box 45530
T: 360/725-1837 Olympia, WA 98504-45530
F: 360/753-9152 360/725-1629
E-mail: zuchltm@dshs.wa.gov E-mail: lindar@dshs.wa.gov
Medicaid Drug Rebate Contact
Social and Health Services Department
Connie L. Riddle Officials
Medical Assistance Administration
Robin Arnold-Williams
P.O. Box 45503
Secretary
Lacy, WA 98504-5503
Department of Social and Health Services
360/725-1243
P.O. Box 45010
E-mail: riddle1@dshs.wa.gov
Olympia, WA 98504-5010
Claims Submission Contact T: 360/902-7800
F: 360/902-7848
Chris Johnson
E-mail: arnolr@dshs.wa.gov
Claims Processing Manager
Medical Assistance Administrator, DSHS
Doug Porter
P.O. Box 45509
Assistant Secretary
Olympia, WA 98504-5509
Medical Assistance Administration
360/725-1239
P.O. Box 45100
E-mail: johnsc2@dshs.wa.gov
Olympia, WA 98504-5100
Medicaid Managed Care Contact T: 360/725-1863
F: 360/902-7855
MaryAnne Lineblad, Director
E-mail: portejd@dshs.wa.gov
Division of Program Support
Medical Assistance Administration, DSHS Department of Social and Health Services
P.O. Box 45530 Title XIX Advisory Committee
Lacey, WA 98504-5530
Janet Varon, Co-chair
360/725-1786
Executive Director, NoHLA
E-mail: lindem@dshs.wa.gov
1820 East Pine Street, Suite 322
Mail Order Pharmacy Program Seattle, WA 98122
State has mail order pharmacy program for fee-for-
Robert Wardell, Co-chair
service clients. 3815 N. Pearl, Apartment K-1
Disease Management/Patient Education Tacoma, WA 98407
Programs
Elise Chayet
Disease/Medical State: Asthma WSHA
Program Manager: McKesson Harborview Medical Center
325 Ninth Avenue
Disease/Medical State: Congestive Heart Failure Seattle, WA 98104-2499
Program Manager: McKesson
Ted Rudd, M.D.
Disease/Medical State: Diabetes WSMA
Program Manager: McKesson 209 S. 12th Avenue, #A
Yakima, WA 98902
Disease/Medical State: Renal Disease
Program Manager: Renaissance Janene Jones-Heino
WSPA
12856 NE Central Valley Road
Poulsbo, WA 98370
360/377-3753

Washington-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Doug Porter DSHS Staff Members


Assistant Secretary Debbie Meyer, Secretary
Medical Assistance Administration Medical Assistance Administration
P.O. Box 45080 P.O. Box 45080
Olympia, WA 98504-5080 Olympia, WA 98504-5080
Pharmacy Drug Use Review Team Members
Allena Barnes
7827 South 113th Street Siri A. Childs, Pharm.D.
Seattle, WA 98178 Nicole Nguyen, Pharm.D.
Joan Baumgartner, M.D.
Kathy Carson Olin Cantrell, PA-C
Sea-King Co. Dept. of Health Linda Ayers, A.R.N.P.
999 Third Avenue, Suite 900 Valerie Vertz
Seattle, WA 98104-4039 Charles Agte
Debbie Bellerud
Shawna Connolly Aimee Bennett
Premera Blue Cross David Conaway
P.O. Box 327 Kevin Davenport
Seattle, WA 98111-0327 Do Huynh
Celeste Moore
Steven Gobin Robin Pfeiffer
6700 Totem Beach Road Sam Trimble
Marysville, WA 98271 Patty Orth

Blanche Jones Executive Officers of State Medical and


Gentiva Health Services Pharmaceutical Societies
4020 South 56th Street, Suite 101 Washington State Medical Association
Tacoma, WA 98409 Thomas Curry
Executive Director
Barbara Malich 2033 Sixth Avenue, Suite 1100
Peninsula Community Health Services Seattle, WA 98121
P.O. Box 960 T: 206/441-9762
Bremerton, WA 98337 F: 206/441-5863
E-mail: wsma@wsma.org
Eleanor Owen Internet address: www.wsma.org
802 Northwest 70th
Seattle, WA 98117 Washington State Pharmacy Association
Rod Shafer
Mark Secord CEO
Neighborhood Health Centers 1501 Taylor Avenue, SW
905 Spruce Street, Suite 201 Renton, WA 98055-3139
Seattle, WA 98104 T: 425/228-7171
Laura Toepfer F: 425/277-3897
AOA E-mail: rshafer@wsparx.org
31708 2nd Avenue South Internet address: www.wsparx.org
Federal Way, WA 98003-5260
Washington Osteopathic Medical Association, Inc.
Raleigh Watts Kathleen S. Itter
Department of Health Executive Director
P.O. Box 47481 P.O. Box 16486
Olympia, WA 98504-7841 Seattle, WA 98116-0486
T: 206/937-5358
Bruce Yoder, D.D.S. F: 206/933-6529
WSDA E-mail: kitter@woma.org
1890 Pottery Avenue Internet address: www.woma.org
Port Orchard, WA 98366

Washington-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Washington State Board of Pharmacy


Steve Sax
Executive Director
Department of Health
310 Israel Road
P.O. Box 47863
Olympia, WA 98504-7863
T: 360/236-4825
F: 360/586-4359
E-mail: steven.sax@doh.wa.gov
Internet address:
wws2.wa.gov/doh/hpql/HPS4/Pharmacy/default.htm

Washington State Hospital Association


Leo F. Greenawalt
President and CEO
300 Elliott Avenue W., Suite 300
Seattle, WA 98119-4118
T: 206/281-7211
F: 206/283-6122
E-mail: leog@wsha.org
Internet address: www.wsha.org

Washington-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

WEST VIRGINIA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2001 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $274,613,136 276,338 $339,816,022 366,987

RECEIVING CASH ASSISTANCE, TOTAL $205,990,651 114,996 $253,457,293 129,958


Aged $49,146,107 20,959 $59,294,089 23,842
Blind/Disabled $141,883,170 63,432 $177,696,813 70,138
Child $83,757 445 -$1,108,621*** 491
Adult $14,877,617 30,160 $17,575,011 35,487

MEDICALLY NEEDY, TOTAL $6,336,007 4,365 $9,030,712 6,862


Aged $497,245 423 $722,820 745
Blind/Disabled $4,630,102 2,566 $6,657,321 3,816
Child $2,694 13 $3,253 20
Adult $1,205,966 1,363 $1,647,318 2,281

POVERTY RELATED, TOTAL $36,870,384 133,411 $47,758,201 203,737


Aged $581,879 342 $569,126 5,909
Blind/Disabled $4,337,649 1,794 $5,010,476 6,095
Child $29,971,587 123,471 $39,356,061 179,714
Adult $1,979,269 7,804 $2,822,538 12,019
BCCA Women $0 0 N/A N/A

TOTAL OTHER EXPENDITURES/RECIPIENTS* $25,416,094 23,566 $29,569,816 26,430


*Total other expenditures/recipients includes foster care children, 1115 demonstration participants, other recipients and
unknown.
**2003 data provided by the West Virginia Department of Health and Human Resources, Bureau for Medical Services.
***Represents a prior year adjustment.
Source: CMS, MSIS Report, FY 2002 and West Virginia Medicaid Statistical Information System, FY 2003.

1 The State of West Virginia did not respond to the 2003 NPC Survey. Using CMS data and other source materials, we have, to the extent
possible, updated the profile and the tables in other sections of the Compilation. Users should contact the West Virginia Medicaid program to
assess the accuracy and currency of the information included.

West Virginia-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

Note: West Virginia estimates 2004 drug expenditures to be approximately $360 million and the number of Medicaid drug
recipients to be 364,000.

C. ADMINISTRATION
Unit Dose: Unit dose packaging reimbursable.
Bureau for Medical Services, Department of Health Formulary/Prior Authorization
& Human Resources.
Formulary: Closed formulary (as of 1/17/03) with
preferred drug list. Restrictions include preferred
D. PROVISIONS RELATING TO DRUGS products and prior authorization through the Rational
Benefit Design Drug Therapy Program. General exclusions include:
legend agents used for cosmetics purposes or hair
Drug Benefit Product Coverage: Products covered: growth; DESI drugs; fertility drugs; and products
prescribed insulin; disposable needles and syringe used for anorexia or weight gain.
combinations used for insulin; blood glucose test
strips; and urine ketone test strips. Products not Prior Authorization: State currently has a prior
covered: cosmetics; fertility drugs; experimental authorization screening procedure for drug classes
drugs; total parenteral nutrition; and interdialytic and home health care. Written appeal to the Medical
parenternal nutrition. Director by the prescriber required to appeal a prior
authorization decision. P&T Committee and DUR
Over-the-Counter Product Coverage: Products Board make prior authorization recommendations.
covered with restrictions (i.e., limited
formulary/prescription required): feminine products; Prescribing or Dispensing Limitations
topical products; allergy, asthma, and sinus products; All covered outpatient drugs are reimbursed up to a
analgesics; cough and cold preparations; and 34-day supply and eleven refills.
digestive products (non-H2 antagonist). Prior
Exceptions include:
authorization for: smoking deterrent products.
Products not covered: digestive products (H2 1. Antibiotics are covered for a 14-day supply and
antagonists). one refill.
2. Opiate agonists (excluding Schedule II drugs),
Therapeutic Category Coverage: Therapeutic analgesics and miscellaneous antipyretics are
categories covered: anabolic steroids; analgesics, covered for 30 days and five refills, in
antipyretics, and NSAIDs; antibiotics; accordance with Federal law.
anticoagulants; anti-depressants; antidiabetic drugs; 3. Sedatives and hypnotics are covered for a 30-
antilipemic agents; antihistamine drugs; day supply and five refills, in accordance with
antipsychotics; anxiolytics, sedatives, and hypnotics Federal law.
(partial coverage); cardiac drugs; chemotherapy Drug Utilization Review
agents; contraceptives; prescribed cold mediation
(partial coverage); ENT anti-inflammatory agents; PRODUR system implemented in March 1995.
estrogens; hypotensive agents; misc. GI drugs; State currently has a DUR Board with a quarterly
sympathominetics (adrenergic); and thyroid agents. review.
Therapeutic categories requiring prior authorization: Pharmacy Payment and Patient Cost
growth hormones; prescribed smoking deterrents; Sharing
and all stimulants except strattera (for beneficiaries >
18 yrs. of age). Therapeutic categories not covered: Dispensing Fee: $3.90, effective 1/1/96. For a
anorectics; agents for cosmetic use; and weight loss compounded prescription, an additional $1.00 will
products. be added to the dispensing fee. A compound
prescription is defined as any legend medication
Coverage of Injectables: Injectable medicines requiring a combination of any two or more
reimbursable under the Prescription Drug Program substances to exclude normal reconstitution
when used in home health care and extended care operations.
facilities, and through physician payment in
physician offices. All injectable medications Ingredient Reimbursement Basis: EAC = AWP-
dispensed through outpatient pharmacies require 12%.
prior authorization.

Vaccines: Vaccines reimbursable as part of CHIP


and the Vaccines for Children Program.

West Virginia-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

Prescription Charge Formula: Reimbursement F. STATE CONTACTS


based on the lowest of: State Drug Program Administrator
1. The estimated acquisition cost (EAC) plus a Peggy A. King, R.Ph.
dispensing fee. Director, Office of Pharmacy Services
2. The maximum allowable cost (MAC) plus a Department of Health and Human Resources
dispensing fee. Bureau for Medical Services
3. The usual and customary price charged by the 350 Capitol Street, Room 251
pharmacy to the general public including any Charleston, WV 25301-3707
sale price that may be in effect on the date of T: 304/558-1700
service. F: 304/558-1542
E-mail: pking@wvdhhr.org
Maximum Allowable Cost: State imposes Federal Internet address: www.wvdhhr.org/bms/pharmacy
Upper Limits on generic drugs. Override will
require physician certification of “Dispense as Department of Health & Human Resources
Written” or “Brand Medically Necessary.” Officials
Incentive Fee: None. Martha Yeager Walker, Secretary
Department of Health and Human Resources
Patient Cost Sharing: Copayment varies - $0.50 to Building 3, State Capitol Complex, Room 206
$3.00 based on ingredient costs. Exclusions include: Charleston, WV 25305
T: 304-558-0684
1. Family planning services and supplies. F: 304/558-1130
2. Prescriptions originating with the Early and E-mail: marthaywalker@wvdhhr.org
Periodic Screening, Diagnosis and Treatment Internet address: www.wvdhhr.org
Program.
3. Nursing home residents. Nancy Atkins, Commissioner
4. Children under the age of 18 years. Department of Health and Human Resources
Bureau for Medical Services
Cognitive Services: Does not pay for cognitive 7012 MacCorkle Avenue, SE
services. Charleston, WV 25301
T: 304/558-1700
F: 304/558-1509
E. USE OF MANAGED CARE E-mail: nancyatkins@wvdhhr.org

Approximately 98,000 unduplicated Medicaid Sandra Joseph, M.D.


recipients were enrolled in MCOs in 2003. Medical Director
Beneficiares in managed care receive pharmacy Department of Health and Human Resources
services through the State. Division of Medical Care
Managed Care Organizations 350 Capitol Street, Room 251
Charleston, WV 25301-3709
Carelink Health Plans T: 304/558-5967
500 Virginia Street East, Suite 400 F: 304/558-1509
Charleston, WV 25326-1711
T: 304/348-2041 Prior Authorization Contact
F: 304/348-3948 Stephen Small, R.Ph., M.S.
Director, Rational Drug Therapy Program
The Health Plan of the Upper Ohio Valley West Virginia University School of Pharmacy
52160 National Road, East Robert C. Byrd Health Sciences Center
St. Clairsville, OH 43950 P.O. Box 9511
T: 740/695-3585 Morgantown, WV 26506-9511
F: 740/695-5297 T: 800/847-3859
F: 800/531-7787
Wellpoint – Unicare E-mail: ssmall@hsc.wvu.edu
5151-A Camino Ruiz
Camarillo, CO

West Virginia-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Pharmaceutical and Therapeutics DUR Contact


Committee
Vicki M. Cunningham, R.Ph.
Kevin W. Yingling, M.D., R.Ph. DUR Coordinator
Steve R. Matulis, M.D. (Chair) Department of Health and Human Services
Thomas L. Gilligan, D.O. Bureau for Medical Services
David Avery, M.D. Office of Pharmacy Services
John D. Justice, M.D. 350 Capitol Street, Room 251
Teresa Dunsworth, Pharm.D. Charleston, WV 25301
James D. Bartsch, R.Ph. T: 304/558-6541
Harriett Nottingham, R.Ph. F: 304/558-1542
Kristy H. Lucas, Pharm.D. E-mail: vickicunningham@wvdhhr.org
David Grome, PA-C
Medicaid DUR Board
Barbara Koster, M.S.N., R.N.C. – A.N.P.
Steven C. Judy, R.Ph.
Pharmaceutical Cost Management Council
Kevin W. Yingling, M.D., R.Ph.
Robert W. Ferguson, Jr. David P. Elliott, Pharm.D.
Cabinet Secretary Bernard Lee Smith, R.Ph., M.B.A, M.H.A
Department of Administration Patrick M. Regan, R.Ph.
Karen Reed, R.Ph. (Chair)
Martha Yeager Walker Mary Nemeth-Pyles, M.S.N., R.N., C.S.
Secretary Mitch Shaver, M.D.
Department of Health and Human Resources Myra Chiang, M.D.
Matthew Watkins, D.O.
Felice Joseph John R. Vanin, M.D.
Pharmacy Director Lester Labus, M.D.
Public Employees Insurance Agency Ernest Miller, D.O.
Christopher Terpening, Pharm.D., R.Ph
Nancy Atkins James M. Bennett, M.D.
Commissioner Kerry Sitzinger, R.Ph.
Bureau for Medical Services George Bryant, PA-C
Daniel Dickman, M.D. (Vice Chair)
George A. Burton
Executive Director New Brand Name Products Contact
Workers’ Compensation Commission
Peggy A. King, R.Ph.
Charles “Laddie” Burdette”, R.Ph. 304/558-1700
Fruth Pharmacy Prescription Price Updating

Wayne C. Spiggle, M.D. Heather Bodiford


Primary Care Physician PBM Account Manager
ACS State Healthcare
Stephen Neal, R.Ph. 365 Northridge Rd.
The Health Plan Northridge Center One, Suite 400
Atlanta, GA 30350
William Lytton T: 866/322-5960
Program Director F: 770/730-5198
Bureau for Senior Services E-mail: heather.bodiford@acs-inc.com
Medicaid Drug Rebate Contact
Heather Bresch
Vice President Gail A. Goodnight, R.Ph.
Mylan Laboratories, Inc. Rebate Coordinator
Department of Health and Human Services
Kevin Outterson Bureau for Medical Services
Associate Professor of Law 350 Capitol Street, Room 251
West Virginia University College of Law Charleston, WV 25301
T: 304/558-5977

West Virginia-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

F: 304/558-1542 Executive Officers of State Medical and


E-mail: gailgoodnight@wvdhhr.org Pharmaceutical Societies
Claims Submission Contact
West Virginia State Medical Association
Heather Bodiford Evan Jenkins, Executive Director
866/322-5960 4307 MacCorkle Avenue SE
P.O. Box 4106
Medicaid Managed Care Contact
Charleston, WV 25364
Shelley Baston, Director T: 304/925-0342
Office of Managed Care F: 304/925-0345
Bureau of Medical Services E-mail: evan@wvsma.com
Department of Health and Human Resources Internet address: www.wvsma.com
350 Capitol Street, Room 251
Charleston, WV 25301-3709 West Virginia Pharmacists Association
T: 304/558-5978 Patty Johnson, President
F: 304/558-4398 2003 Quarrier Street
E-mail: shelleybaston@wvdhhr.org Charleston, WV 25311-2212
Mail Order Pharmacy Program T: 304/252-5305
F: 304/344-5316
None
E-mail: wvrds@aol.com
Disease Management/Patient Education
Programs West Virginia Society of Osteopathic Medicine
Charlotte Ann Cales Pulliam
Disease/Medical State: Cardiovascular Disease Executive Director
Program Name: West Virginia on the Move 400 Allen Drive, Suite 201
Program Manager: Bonnie Mehan The Westmoreland Place
Program Sponsor: Pfizer Charleston, WV 23502
Disease/Medical State: Diabetes T: 304/345-9836
Program Name: Medicaid Diabetes Management F: 304/345-9865
Program E-mail: charlotteann@wvsominc.org
Program Manager: Bonnie Mehan Internet address: www.wvsominc.org
Program Sponsor: West Virginia Diabetes Control
Program West Virginia State Board of Pharmacy
William T. Douglas, Jr.
Disease Management Initiative/Program Executive Director and General Counsel
Contact 232 Capitol Street
Bonnie Meehan Charleston, WV 25301
Disease Management Coordinator T: 304/558-0558
Department of Health and Human Services F: 304/558-0572
Bureau for Medical Services E-mail: wdouglass@wvbop.com
3500 Capitol Street, Room 251 Internet address: www.wvbop.com
Charleston, WV 25301
T: 304/558-1727 West Virginia Hospital Association
F: 304/558-4398 Steven J. Summer
E-mail: bonniemeehan@wvdhhr.org President and CEO
100 Association Drive
Medical Services Fund Advisory Council Charleston, WV 25311
Violet Burdette T: 304/344-9744
William McFarland, R.Ph F: 304/344-9745
Doug Coffman E-mail: ssummer@wvha.com
John Elliott Internet address: www.wvha.com
Sheryl Kiser
Charles Smith, D.D.S.
John Russell
Scott McClanahan
Mark B. Ayoubi, M.D.
G. Anne Cather, M.D.
Chris Cutis
Fred Booth

West Virginia-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

West Virginia-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

WISCONSIN

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $455,720,622 309,795 $592,295,000

RECEIVING CASH ASSISTANCE TOTAL $220,578,511 116,396


Aged $22,398,037 11,614
Blind/Disabled $191,378,131 74,550
Child $2,277,339 15,043
Adult $4,525,004 15,189

MEDICALLY NEEDY, TOTAL $31,711,402 16,672


Aged $13,143,083 6,424
Blind/Disabled $18,053,101 5,070
Child $399,451 4,243
Adult $115,767 935

POVERTY RELATED, TOTAL $14,239,112 26,101


Aged $315,971 521
Blind/Disabled $10,747,774 3,584
Child $2,632,959 17,837
Adult $476,387 4,096
BCCA Women $66,021 63

TOTAL OTHER EXPENDITURES/RECIPIENTS* $189,191,597 150,626

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

Wisconsin-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C. ADMINISTRATION
Vaccines: Vaccines provided plus reimbursement
State Department of Health and Family Services, for administrative fee as part of the Vaccines for
Division of Health Care Financing. Children Program.

Unit Dose: Unit dose packaging not reimbursable.


D. PROVISIONS RELATING TO DRUGS
Formulary/Prior Authorization
Benefit Design
Formulary: Open formulary with preferred drug
Drug Benefit Product Coverage: Products covered: list. PDL managed through restrictions on use, prior
prescribed insulin; disposable needles and syringe authorization, therapeutic substitution, preferred
combinations used for insulin; blood glucose test products, and physical profiling.
strips; urine ketone test strips; total parenteral
nutrition; and interdialytic parenteral nutrition. Prior Authorization: State currently has formal
Products not covered: cosmetics; fertility drugs; prior authorization procedure and a Medicaid
experimental drugs; progesterone for PMS; topical Pharmacy Prior Authorization Committee.
minoxidil, legend prenatal vitamins; and impotence Beneficiaries can request an administrative hearing
treatment drugs. to appeal prior authorization decisions or coverage
for an excluded product.
Over-The-Counter Product Coverage: Products
covered: analgesics; digestive products (H2 Prescribing or Dispensing Limitations:
antagonists) feminine products; and ophthalmic Quantity of Medication: Pharmacists may not
lubricants. Products covered with restrictions: dispense more than 34-day supply of a legend drug.
allergy, asthma, and sinus products (loratadine, Certain exceptions for some maintenance drugs
diphenhydramine, pseudoephedrine); cough and (100 day supply limit).
cold preparations (cough syrups containing
expectorant with or without dextromethorphan Refills: Maximum of 11 refills during a 12-month
only); non-H2 antagonists (Prilosec OTC only); period for non-scheduled medications.
topical products (antibiotics, antifungal agents; Dollar Limits: None.
capsaicin, hydrocortisone). Products not covered:
digestive smoking deterrent products. Pharmacy Payment and Patient Cost
Sharing
Therapeutic Category Coverage: Therapeutic Dispensing Fee: $4.88 to a maximum of $40.11,
categories covered: anabolic steroids; antibiotics; effective 7/1/98. Incremental increases based on
anticoagulauts; anticonvulsants; antihistamines; pharmaceutical care services being provided.
antilipemic agents; anti-psychotics; chemotherapy Maximum of two dispensing fees per month, per
agents; prescribed cold medications; contraceptives, prescription.
ENT-anti-inflammatory agents; estrogens;
prescribed smoking deterrents; sympathominetics Ingredient Reimbursement Basis: EAC = AWP-
(adrenergic); and thyroid products. Prior 3.0% (effective 7/1/04.)
authorization required for: analgesics; antipyretics,
and (brand name) NSAIDs; anoretics; Prescription Charge Formula: Reimbursement at
antidepressants; antidiabetic; agents; cardiac drugs; the lowest of:
antilipemic agents; human growth hormone;
hypotensive agents; misc. GI drugs; schedule III AWP-13.0% plus dispensing fee; Maximum
and IV stimulants; enteral nutrition products; Allowable Cost (MAC) plus dispensing fee; or
Cerezyme; Mupirocin; fertility enhaning drugs; providers usual and customary.
anti-obesity drugs; alitretinoin gel; brand name
ACE inhibitors; brand name statins; brand name Maximum Allowable Cost: State imposes State-
PPIs, stimulants and anti-obesity drugs; and specific limits on generic drugs. Override requires
medically necessary drugs with no rebate hand written “Brand Medically Necessary” by the
agreement. prescriber plus prior authorization.

Coverage of Injectables: Injectable medicines Incentive Fee: None.


reimbursable through the prescription drug program
when used in home health care and in extended care Cognitive Services: Provides an expanded
facilities, and through both the prescription drug dispensing fee for cognitive services.
program and physician payment when in
physicians’ offices. Patient Cost Sharing: State uses tiered system of
copayments. All generic legend drugs are subject to

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National Pharmaceutical Council Pharmaceutical Benefits 2004

a $1.00 copay, brand legend drugs are subject to a


$3.00 copay, limited to $12.00 per month Touchpoint Health Plan
maximum per pharmacy. OTCs are subject to a 5 Innovation Court
$0.50 copay. Disposable medical supplies are Appleton, WI 54912
subject to a sliding scale copayment system.
Residents of Skilled Nursing Facilities (SNF) or United Healthcare of Wisconsin
Intermediate Care Facilities (ICF), subsidized 10701 W. Research Drive
adoption recipients, children under age 18 and Milwaukee, WI 53226
HMO enrollees are exempt from the copayment.
Unity Health Plans Insurance Corporation
840 Carolina Street
E. USE OF MANAGED CARE Sauk City, WI 53583-1374
Approximately 495,000 Medicaid recipients were
enrolled in MCOs in FY 2003. Recipients receive Valley Health Plan
pharmaceutical benefits through managed care 401 West Michigan Street
plans. (Some mental health plans carve out Milwaukee, WI 53203
pharmaceutical benefits.)
F. STATE CONTACTS
Managed Care Organizations
Pharmacy Practices Consultant
Abri Health Plan, Inc.
216 Green Bay Road, Suite 109 Mark Moody
Thiensville, WI 53092 Administrator
Division of Health Care Financing
Atrium Health Plan, Inc. Department of Health and Family Services
4222 Bagley Parkway One West Wilson Street
Madison, WI 53705 P.O. Box 309
Madison, WI 53701-0309
Dean Health Plan, Inc. T: 608/266-8922
1277 Denning Way F: 608/266-1096
Madison, WI 53717 E-mail: webmaster@dhfs.state.wi.us
Internet address: www.dhfs.state.wi.us
Group Health Cooperative of Eau Claire
Prior Authorization Contact
2503 N. Hillcrest Parkway
Eau Claire, WI 54702 Rita Hallett
Nurse Consultant
Group Health of Division of Health Care Financing
South Central Wisconsin Department of Health and Family Services
1265 John Q. Hammons Drive One West Wilson Street
Madison, WI 53717 P.O. Box 309
Madison, WI 53701-0309
Health Tradition Health Plan T: 608/267-0938
800 East Main Street F: 608/266-1096
Onalaska, WI 54650 E-mail: haller@dhfs.state.wi.us
Internet address: www.dhfs.state.wi.us
Managed Health Services Insurance Corp.
1205 S. 70th Street, Suite 500 Prior Authorization Advisory Committee
West Allis, WI 53214
Standing
MercyCare Insurance Company Steve Maike, R.Ph.
3430 Palmer Drive Larry Fleming, M.D.
Peg Smelser
Janesville, WI 53546
Tom Frazier, Exec. Dir., CWAG
Network Health Plan Bradley Fedderly, M.D.
James Heersma, M.D.
1570 Midway Place
Menasha, WI 54952 Christine Sorkness, Pharm. D.
John Gates, R.Ph.
Tom Hirsch, M.D.
Security Health Plan of Wisconsin, Inc.
1515 St. Joseph Avenue
Marshfield, WI 54449

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DUR Contact Claims Submission Contact


Michael A. Mergener, R.Ph., Ph.D. Mark Gajewski
Chief Pharmacist Account Director
APS Healthcare EDS
10 East Doty Street, Suite 210 6406 Bridge Road
Madison, WI 53703 Madison, WI 53784-0014
T: 608/258-3348 T: 608/221-4746
F: 608/258-3359 F: 608/221-4567
E-mail: mergema@state.wi.us
Medicaid Managed Care Contact
Wisconsin Drug Utilization Review
Committee Angela Dombrowicki, Director
Bureau of Managed Health Care Programs
Robert M. Breslow, R.Ph.
Division of Healthcare Financing
Ward Brown, M.D.
Department of Health and Family Services
Mark E. Buhler, R.Ph.
One West Wilson
Daniel R. Erickson, M.D.
P.O. Box 309
Barry Hess, R.Ph.
Madison, WI 53701-0309
Nancy E. Ness, M.D.
T: 608/266-1935
Pamela Ploetz, R.Ph.
F: 608/261-7792
Lee C. Vermeulen, Jr., R.Ph., M.S.
E-mail: dombra@dhfs.state.wi.us
Mary Jo Willis, M.S., R.N., N.P.
Mail Order Pharmacy Program
New Brand Name Prescription Contact
None
Carol Neeno
Health and Family Services Department
Pharmacy Assistant
Officials
Division of Health Care Financing
Department of Health and Family Services Helene Nelson, Secretary
One West Wilson Street Department of Health and Family Services
P.O. Box 309 One West Wilson Street, Room 650
Madison, WI 53701-0309 Madison, WI 53702
T: 608/266-1203 T: 608/266-9622
F: 608/267-3380 F: 608/266-7882
E-mail: neenocj@dhfs.state.wi.us E-mail: wemaster@dhfs.state.wi.us

Prescription Price Updating Mark P. Moody, Administrator


Division of Health Care Financing
First Databank
Department of Health and Family Services
1111 Bayhill Drive, Suite 350
One West Wilson Street
San Bruno, CA 94066
P.O. Box 309
T: 800/633-3453
Madison, WI 53701-0309
F: 415/588-6867
T: 608/266-8922
Medicaid Drug Rebate Contacts F: 608/266-1096
E-mail: webmaster@dhfs.state.wi.us
Ellen Orsburne
Medicaid Systems Analyst Executive Officers of State Medical and
Division of Health Care Financing Pharmaceutical Societies
Department of Health and Family Services
State Medical Society of Wisconsin
One West Wilson Street
Susan L. Turney
P.O. Box 309
Executive Vice President/ CEO
Madison, WI 53701-0309
330 East Lakeside
608/267-7939
P.O. Box 1109
E-mail: orsbuer@dhfs.state.wi.us
Madison, WI 53701-1109
T: 866/442-3800
F: 608/442-3802
E-mail: susant@wismed.org
Internet address:
www.wisconsinmedicalsociety.org

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Wisconsin Association of Osteopathic Physicians &


Surgeons
Patricia A. Hurley
Executive Director
P.O. Box 044657
Racine, WI 53402
T: 262/752-2280
F: 262/752-2280
E-mail: waops@yahoo.com
Internet address: www.waops.org

Pharmacy Society of Wisconsin


Christopher J. Decker
Executive Vice President
701 Heartland Trail
Madison, WI 53717
T: 608/827-9200
F: 608/827-9292
E-mail: cdecker@pswi.org
Internet address: www.pswi.org

Wisconsin Pharmacy Examing Board


Tom Ryan, Director
Bureau of Health Professions
1400 E. Washington Avenue
Madison, WI 53703
T: 608/266-8098
F: 608/261-7083
E-mail: web@drl.state.wi.us
Internet address: www.drl.wi.gov/boards/phm

Wisconsin Hospital Association


Steve Brenton, President
5510 Research Park Drive
Madison, WI 53725-9038
T: 608/274-1820
F: 608/274-8554
E-mail: sbrenton@wha.org
Internet address: www.wha.org

Wisconsin Health Care Association


Thomas P. Moore
Executive Director
121 South Pinckney Street, Suite 500
Madison, WI 53703
T: 608/257-0125
F : 608/257-0025
E-mail: tomm@whca.com
Internet address: www.whca.com

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WYOMING

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2002 2003**
Expenditures Recipients Expenditures Recipients

TOTAL $38,008,542 42,652 $49,106,118

RECEIVING CASH ASSISTANCE, TOTAL $14,500,432 12,414


Aged $1,506,985 721
Blind / Disabled $9,963,809 3,834
Child $1,031,505 4,484
Adult $1,998,133 3,375

MEDICALLY NEEDY, TOTAL $0 0


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

POVERTY RELATED, TOTAL $4,496,942 20,111


Aged $23,845 20
Blind / Disabled $87,312 53
Child $3,852,812 17,310
Adult $532,973 2,728
BCCA Women $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $19,011,168 10,127

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

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C. ADMINISTRATION Vaccines: Vaccines reimbursable at AWP plus a


$7.00 injection fee as part of the EPSDT services,
Department of Health, Director’s Office. the Children’s Health Insurance Program, and the
Vaccines for Children Program.

D. PROVISIONS RELATING TO DRUGS Unit Dose: Unit dose packaging not reimbursable.
Benefit Design
Drug Benefit Product Coverage: Products covered: Formulary/Prior Authorization
prescribed insulin, syringe combinations and Formulary: Open formulary with preferred drug list
disposable needles used for insulin; blood glucose (PDL). PDL managed through preferred products
test strips; and urine ketone test strips. Products and prior authorization. General exclusions include
covered under DME: total parenteral nutrition; and anorexants, except amphetamines and derivatives
interdialytic parenteral nutrition. Products not which are used for narcolepsy and hyperkinetic
covered: cosmetics; fertility drugs; tobacco states; products to stimulate hair growth. Prior
cessation products; weight loss products; hair authorization implemented 10/1/02.
growth products; IQ enhancers; DESI drugs; and
experimental drugs. Prior Authorization: State currently has a formal
prior authorization procedure with review/appeal
Over-the-Counter Product Coverage: Products process to the Department of Health Pharmacy
covered (must be ordered by a licensed prescribing Unit.
practitioner, furnished to a client who is not
residing in a nursing facility, is listed in State’s Prescribing or Dispensing Limitations
system, and filed with First DataBank): allergy, Monthly Quantity Limits: Quantity limits on some
asthma, and sinus products; analgesics; cough and medications as deemed clinically appropriate.
cold products; digestive products (H2 antagonists);
topical agents; food thickeners; nutrition products; Drug Utilization Review
pediatric and prenatal vitamins; and artificial tears. PRODUR system implemented in October 1995.
Products covered with reatrictions: non-H2 State currently has a DUR Board with 12 members
antagonists (antacids, antidiarrheals and laxatives) that meet bimonthly.
and feminine products (vaginal anti-infective agents
and contraceptives). Products not covered: smoking Pharmacy Payment and Patient Cost
deterrent products. Sharing
Dispensing Fee: $5.00 and 50% of AWP for OTCs,
Therapeutic Category Coverage: Products covered: effective 7/01.
analgesics, antipyretics, and NSAIDs (prior
authorization for COX 2s and oxycontin); Ingredient Reimbursement Basis: EAC = AWP-
antibiotics; anticoagulants; anticonvulsants; anti- 11%.
depressants; antidiabetic agents; antihistamines;
antilipemic agents (prior authorization for statins); Prescription Charge Formula: Payments shall be
anti-psychotics; anxiolytics, sedatives, and the lowest of:
hypnotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives; ENT 1. The Estimated Acquisition Cost (AWP-11%)
anti-inflammatory agents; estrogens; hypotensive of the ingredient, plus a dispensing fee.
agents; (prior authorization for ACE Inhibitors); 2. Usual and customary charge.
misc. GI drugs (prior authorization for PPIs); 3. The upper limit established by CMS for
sympathominetics (adrenergic); thyroid agents; multiple source drugs or State MAC.
antifungals; antiparasitic products; and
bronchodilators. Partial coverage for: growth Maximum Allowable Cost: State imposes Federal
hormones. Products not covered; anabolic steroids; Upper Limits as well as State-specific limits on
anoretics; and prescribed smoking deterrents. generic drugs. Override requires “Brand Medically
Necessary.” Currently, 1,226 drugs are included on
Coverage of Injectables: Injectable medicines the State’s MAC list.
reimbursable through physician payment when used
in home health care, extended care facilities, and Incentive Fee: None.
physician offices.

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Patient Cost Sharing: State uses a system of tiered DUR Contact


copayments:
Debra Devereaux, R.Ph.
$3.00 – Non-preferred brand DUR Coordinator
$2.00 – Preferred brand University of Wyoming School of Pharmacy
$1.00 – Generics P.O. Box 3375
Laramie, WY 82071
The following recipients or products are exempt
T: 307/766-6750
from the copayment:
F: 307/766-2953
− Pregnant women E-mail: debdev@concentric.net
− Foster care children
− Home and community based waiver recipients DUR Board
− Eligible recipients under age 21
− Patients residing in nursing homes Antoinette Brown, R.Ph. (ex-officio)
− Family planning products Debra Devereaux, R.Ph. (DUR Coordinator)
Becky Drnas, R.Ph.
Cognitive Services: Does not pay for cognitive Dean Winsch, Pharm.D.
services. Roxanne Homar, R.Ph. (ex-officio)
Kathryn Kohler, M.D.
Leonard Kosirog, R.Ph.
E. USE OF MANAGED CARE Scott Johnston, M.D.
George Zaharas, R.Ph.
Does not use MCOs to deliver services to Medicaid Stephen Brown, M.D.
recipients. Michael Carpenter, PA-C
William Harrison, M.D.
Kendra Grande, R.Ph. (ex-officio)
F. STATE CONTACTS Richard L. Johnson, R.Ph.
State Drug Program Administrator Aimee Lewis (ex-officio)
Linda G. Martin, Pharm.D. (ex-officio)
Antoinette K. Brown, R.Ph.
Medicaid Pharmacist New Brand Name Products Contact
Department of Health-Pharmacy Unit Antoinette Brown, R.Ph.
2300 Capitol Avenue, Suite 147 307/777-6016
Cheyenne, WY 82002
T: 307/777-6016 Prescription Price Updating
F: 307/777-8623
First DataBank
Email: abrown@state.wy.us
1111 Bayhill Drive
Internet address: www.pharmacy.state.wy.us
San Bruno, CA 94066
Department of Health Officials T: 800/633-3453
F: 650/588-4003
Deb Fleming, Ph.D.
Director Medicaid Drug Rebate Contacts
Department of Health
Sheila McInerney
117 Hathaway Building
TPL Manager
2300 Capitol Avenue
ACS State Healthcare
Cheyenne, WY 82002
P.O. Box 667
T: 307/777-7656
Cheyenne, WY 82003
F: 307/777-7439
T: 307/772-8400
E-mail: wdh@state.wy.us
F: 307/772-8405
Iris Oleske E-mail: sheila.mcinerney@acs-inc.com
State Medicaid Agent
Claims Submission Contact
147 Hathaway Building
Cheyenne, WY 82002 ACS State Healthcare
T: 307/777-7531 Northridge Center 1, Suite 400
F: 307/777-6964 365 Northridge Road
E-mail: iolesk@state.wy.us Atlanta, GA 30350
T: 866/322-5960
F: 888/335-8459

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Mail Order Pharmacy Program


None
Executive Officers of State Medical and
Pharmaceutical Societies
Wyoming State Medical Society
Wendy P. Curran
Executive Director
1920 Evans
P.O. Box 4009
Cheyenne, WY 82003
T: 307/635-2424
F: 307/632-1973
E-mail: wcurran@wyomed.org
Internet address: www.wyomed.org

Wyoming Pharmacy Association


Mindy Rassmussen
Executive Director
P.O. Box 366
Cheyenne, WY 82003
T: 307/772-8044
F: 307/772-8004
E-mail: director@wpha.net
Internet address: www.wpha.net

Wyoming State Board of Pharmacy


Jim T. Carder
Executive Director
4632 South David Street
Casper, WY 82601
T: 307/234-0294
F: 307/234-7226
E-mail: wybop@state.wy.us
Internet address: www.pharmacyboard.state.wy.us

Wyoming Hospital Association


Robert C. Kidd II
President
2005 Warren Avenue
P.O. Box 249
Cheyenne, WY 82003
T: 307/632-9344
F: 307/632-9347
E-mail: bob@wyohospitals.com
Internet address: www.wyohospitals.com

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Section 6:
State Pharmacy Assistance
Programs

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National Pharmaceutical Council Pharmaceutical Benefits 2004

State Pharmacy Assistance Programs


As of July 2005, 44 States and the District of Columbia had established various pharmaceutical
assistance programs providing coverage or improved access to the low-income elderly and/or
persons with disabilities who do not qualify for Medicaid. These programs range from State-
negotiated discounts or State subsidies, to tax credits for prescription drug costs, and
coordinating seniors’ access to manufacturers’ charitable prescription assistance programs.

The Federal Medicare Prescription Drug, Improvement, and Modernization Act of 2004 (P.L
108-173, commonly known as the Medicare Modernization Act) will impact every State,
whether or not they have a pharmacy assistance program. State pharmacy assistance programs
(SPAPs) are not required to coordinate or provide any financial assistance with respect to a
Medicare Part D plan, but many are either planning to sunset current pharmacy assistance
programs, use the SPAP as a “wrap-around” program, or develop some other coordination, yet
to be determined. Currently, four States have indicated that their respective pharmacy assistance
plans will end, barring State legislative action to modify and/or coordinate these programs with
the Medicare Part D program.

Authorized State Pharmacy Assistance Programs

State Program Name Law Enacted


Alabama SenioRx 2002*
Alaska SeniorCare Rx 2004
Arizona Prescription Discount Program (CoppeRx Card) 2004‡
ARx Senior Program 2001†
Arkansas
Arkansas Rx Program 2005†
Discount Prescription Medication Program 1999
California
Golden Bear State Pharmacy Assistance Program 2001†
Connecticut Pharmaceutical Assistance Contract to the
Connecticut 1986
Elderly and Disabled (ConnPACE)
Nemours Pharmacy Assistance 1981
Delaware Delaware Prescription Drug Assistance Program
1999
(DPAP)
District of
AccessRx Program 2004
Columbia
Silver SaveRx (formerly, Ron Silver Senior Drug
2002
Florida Program/Prescription Affordability Act)
Prescription Discount Program 2000
Georgia Georgia Cares Program 2002*
Hawaii Hawaii Rx Plus Program 2004
Pharmaceutical Assistance Program (“Circuitbreaker”) 1985
Illinois Illinois SeniorCare 2001
Illinois Rx Buying Club 2004†
Indiana Indiana Prescription Drug Program, “HoosierRx” 2000
Iowa Iowa Priority Prescription Savings Program Federal grant
Kansas Kansas Senior Pharmacy Assistance Program 2000
Kentucky Kentucky Pharmaceutical Assistance Program 2005†
Louisiana Louisiana SenioRx Program 2003
Maine RX Plus 2003
Maine Low Cost Drugs for the Elderly and Disabled Program
1975
(DEL)

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Maryland Pharmacy Assistance Program 1979


Maryland Senior Prescription Drug Program 2000
Maryland Pharmacy Discount Program 2001
Massachusetts Prescription Advantage 2000
Elder Prescription Insurance Coverage Program (EPIC) 2001
Michigan
MI Rx Prescription Savings Program 2004
Minnesota Prescription Drug Program 1999
Mississippi Mississippi Seniors and Indigents Rx Program 2004*
Missouri SenioRx Program 2001
Prescription Drug Expansion Program 2003†
Montana Pharmacy Access Prescription Drug Benefit Program 2005†
Prescription Drug Plus Program 2005†
Nevada Senior Rx Insurance Subsidy for Prescription Drugs 2000
New
Senior Prescription Drug Discount Program 2000
Hampshire
Pharmaceutical Assistance to the Aged and Disabled
1975
New Jersey (PAAD)
Senior Gold Prescription Discount Program 2001
New Mexico Senior Prescription Drug Program 2002
Elderly Pharmaceutical Insurance Coverage (EPIC)
New York 1987
Program
North Carolina Senior Care 2002
Golden Buckeye Prescription Drug Program 2002
Ohio
Ohio’s Best Rx Program 2003
Pharmacy Connection Council Program 2003*
Oklahoma
Oklahoma Prescription Drug Discount Program 2005†
Oregon Senior Prescription Drug Assistance Program 2001
Pharmaceutical Assistance Contract for the Elderly
1984
Pennsylvania (PACE)
PACE Needs Enhancement Tier (PACENET) 1996
Rhode Island Pharmaceutical Assistance to the Elderly
1985
(RIPAE)
Rhode Island
Rhode Island Pharmacy Prescription Drug Discount
2005†
Program for the Uninsured
South Carolina SilveRxCard Senior Prescription Drug Program 2000
South Dakota Senior Citizen Prescription Drug Benefit Program 2003
Tennessee TennCare Rx 2003†
Kidney Health Care Program (KHC) 1999
Texas
State Prescription Drug Program 2001†
VSCRIPT 1989
VSCRIPT Expanded 1999
Vermont
Vermont Health Access Plan (VHAP) Pharmacy 1996
Healthy Vermonters Program 2002
Washington Pharmacy Connections 2003*
Washington Rx Washington Card 2003
Medicaid Prescription Drug Assistance Program 2003†
Golden Mountaineer Card Program 2000
West Virginia West Virginia Prescription Drug Assistance
2004*
Clearinghouse Program
Wisconsin SeniorCare Prescription Drug Assistance Program 2001
Wyoming Prescription Drug Assistance Program 2002
* Coordination assistance for manufacturer pharmaceutical programs.
† Program not operational; see below for more details.
‡ Established by executive order.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

The following programs were legislatively approved, but have yet to be implemented:

• Arkansas’ ARx Senior Program, a Federal §1115 waiver program, has not received
approval from CMS. Program officials indicate that it is unlikely that the program
will be implemented given the Medicare Part D prescription drug program beginning
in 2006.

• Arkansas Rx Program: HB1241 was signed into law March 3, 2005. It establishes a
discount program for residents without prescription coverage. There are no income
limits for those 65 and over, while those under 65 and below 350% of the FPL are
eligible. Medicaid and Medicare Part D enrollees will not be eligible.

• Golden Bear State Pharmacy Assistance Program: Authorized by passage of SB


696 in October 2001, the Golden Bear State Pharmacy Assistance Program would
provide discounts to California seniors over and above those provided by the
Discount Prescription Medication Program. The program has been tabled due to lack
of manufacturer participation and the pending Federal Medicare prescription drug
benefit program.

• Kentucky Pharmaceutical Assistance Program: SB23 was signed into law March
18, 2005. It is designed to wrap around Medicare Part D for seniors over 65 and
under 150% of the FPL. Enrollment is scheduled to begin October 1, 2005 with the
program beginning January 1, 2006.

• Montana Prescription Drug Expansion Program, a CMS pharmacy plus waiver,


will not be implemented given the passage of the Medicare Modernization Act
(MMA) of 2003 and the 2006 start date for the Part D program.

• Montana’s Pharmacy Access Prescription Drug Benefit Program and


Prescription Drug Plus Program: Both programs were authorized by the passage of
SB324. The first program will cover Part D premiums for Medicare enrollees below
200 percent of the FPL, and deductibles if funds are available. The second program
is a discount program open to any uninsured resident with income up to 250 percent
of the FPL, regardless of age.

• Oklahoma Prescription Drug Discount Program: SB547 was signed into law June
6, 2005. The law establishes a discount program for uninsured residents, with an
enrollment fee only for those above 150 percent of the FPL.

• 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.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

• Texas Prescription Drug Program: State funding for the program was not
established for 2004-2005.

• South Dakota Senior Prescription Drug Benefit Program: Under South Dakota HB
1312, the Senior Prescription Drug Benefit Program was repealed by legislation,
effective September 1, 2004.

• Washington Medicaid Prescription Drug Assistance Program: Enacting legislation


of 2003 required an 1115 waiver from the Centers for Medicare and Medicaid
Services (CMS). The State decided not to pursue the waiver, given passage of the
Medicare Modernization Act of 2003.

The following pharmacy assistance programs are scheduled to sunset during 2005, barring
legislative action to operate the programs in conjunction with, or in addition to, the Medicare
Part D program: Maryland Senior Prescription Drug Program, Minnesota Prescription Drug
Program, Missouri SenioRx Program, and North Carolina Senior Care. There are 14 States
that are reviewing current pharmacy assistance programs in an effort to coordinate benefits
with the Medicare Part D program. (These States are noted throughout this section.)

The following States authorized new programs, based on 2004 legislation:

• Alaska SeniorCare Program: HB 374, effective April 1, 2004, established the


SeniorCare program within the Alaska Department of Health and Social Services.
The program provides cash assistance or drug benefits to eligible senior citizens until
2006, when the Medicare Part D program begins. Legislation has been offered in the
2005 session (HB 106, SB 78) that would continue the program to complement the
Medicare Part D.

• District of Columbia AccessRx Program: B 569, effective May 18, 2004, established
the AccessRx program, requiring drug manufacturers and labelers that sell
prescription drugs in the District through a publicly funded pharmaceutical assistance
program to enter into rebate agreements with the District. The rebates are used to
fund the AccessRx program for low-income elderly District of Columbia residents.

• Hawaii Rx Program: Authorized by passage of HB 2834 in June 2002, the Hawaii


Rx Program was implemented in 2004, after further study and revisions to program
guidelines. (Enacted by HB 2796 and SB 3237 during 2004.)

• Mississippi Seniors and Indigents Rx Program: The Seniors and Indigents Rx


Program was enacted July 1, 2004, to help seniors and qualified indigent persons
access pharmaceutical manufacturers’ discount cards and programs. The program
provides these clearinghouse services and an application for the appropriate
program(s).

• Rhode Island Prescription Drug Discount Program for the Uninsured: HB7374
(SB 2886), effective July 2, 2004, established the Rhode Island Prescription Drug
Discount Program for the Uninsured. The program requires the Departments of
Human Services and Elderly Affairs to develop a prescription drug discount program
for uninsured State residents between 18 years and 65 years of age, with family

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National Pharmaceutical Council Pharmaceutical Benefits 2004

incomes at or below 200 percent of the Federal poverty level (FPL). The State is
currently developing the program and reviewing RFP bids from interested pharmacy
benefit managers (PBMs). The program implementation date is slated for May 2005.

• West Virginia Pharmaceutical Availability and Affordability Act: HB 4084,


effective March 13, 2004, established the West Virginia Pharmaceutical Availability
and Affordability Act. The program creates a pharmaceutical information
clearinghouse to assist low-income, uninsured State residents find access to
prescription medications available through existing private and public section
programs, and such programs offered by pharmaceutical manufacturers. The bill also
established the West Virginia Pharmaceutical Cost Management Council to develop
strategies and improve access to prescription drugs for all State residents.

The following pages provide profiles of the States that provided pharmacy assistance in 2004,
as well as profiles of the new State programs. Details were provided by State contacts on
program characteristics, including eligibility criteria, funding and reimbursement information,
and drug coverage. Supplemental information was obtained from special surveys of State
programs, including the National Conference of State Legislatures’ internet site
(www.ncsl.org/programs/health/drugaid.htm), which is a good source for the most up-to-date
information.

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Alabama
Alabama SenioRx Program*
Program Type: Coordinate Assistance Between Elderly and Manufacturers’
Pharmaceutical Programs
Year Operational: 2002
Number of Recipients (January 2005): 16,769

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 60+ Eligibility Age (Disabled): 60+


Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of
FPL
Other Eligibility Notes: Individuals may not have any other insurance coverage for
medicines. Individuals must re-enroll in the program on a
quarterly basis to verify eligibility.

FUNDING AND REIMBURSEMENT

Funding Source: State general revenue


Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: None
Ingredient Cost Calculation: None
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: Not available
Notes: The purpose of the program is to utilize available State resources
to help eligible seniors find appropriate charitable pharmaceutical
programs from various manufacturers. The State will also
coordinate and complete all necessary paperwork for each participant.

DRUGS COVERAGE

Formulary: None
Drugs Covered: Based on a manufacturer’s charitable program criteria.
Drug Coverage Restrictions: Not available
Notes: Enrollees must have chronic health care conditions to participate
in the program, e.g., maintenance medications for long-term
problems like hypertension. Participants with short-term illnesses
are not eligible for the program.

*
The Alabama SenioRx Program assists eligible State residents in coordinating services from various manufacturers’
charitable prescription assistance programs. The State does not contribute any money for the direct purchase of
prescription drugs.

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PROGRAM CONTACT

Tina Hartley Phone: 334/242-5743


Alabama Dept. of Senior Services Fax: 334/242-5594
770 Washington Avenue Email: ageline@adss.state.al.us
RSA Plaza, Suite 470
Montgomery, AL 36130

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Alaska
SeniorCare Rx
Program Type: Direct Assistance
Year Operational: 2004
Number of Recipients (January 2005): 7,000∗

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): 135% to Eligible Income Level (Married): 135% to
150% FPL 150% FPL
Other Eligibility Notes: SeniorCare bridges the gap for low-income seniors until the full
Medicare prescription drug coverage begins in 2006, and provides
a statewide senior information, resource, and referral service for all
Alaska seniors. A beneficiary can receive direct prescription drug
benefits or cash assistance. Recipient’s FPL dictates eligibility for
one of two benefit levels.

FUNDING AND REIMBURSEMENT

Funding Source: State general funds


Budget (FY 05): $15 million
Cost per Participant (FY 05): Not available
# of Rx’s Per Participant (FY 05): Not available
Manufacturer Rebate Type: None
Ingredient Cost Calculation: AWP-5% (CMS rate for Medicaid)
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $3.45 - $11. 46 (based on pharmacy/Medicaid volume, i.e., CMS rate)
Notes: For a recipient at 135% FPL, without comprehensive Medicaid Rx
coverage, the maximum cash benefit is $1,600 per year. For recipient
between 135% and 150% FPL maximum cash benefit is $1,000 per
year.

DRUGS COVERAGE

Formulary: State Preferred Drug List (PDL)


Drugs Covered: State PDL
Drug Coverage Restrictions: None
Notes: The legislature is considering two bills which would extend a
modified SeniorCare pharmacy assistance program. The revised plan
would complement the Medicare Part D program by helping eligible
seniors with Part D copays and/or premiums.


Currently, only 50 beneficiaries are using a direct pharmaceutical benefit provided by the program.

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PROGRAM CONTACT

Jon Sherwood Phone: 907/465-5820


SeniorCare E-mail: jon_sherwood@health.state.ak.us
Department of Health and Social
Services
Post Office Box 110601
Juneau, AK 99811-0601

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Arizona
Prescription Discount Program (CoppeRx Card)
Program Type: Discount
Law Enacted: 2001
Estimated Number of Recipients (January 2005): 17,000*

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+


Eligible Income Level (Single): None Eligible Income Level (Married): None
Other Eligibility Notes: Open to all seniors and Medicare-eligible disabled who are residents
of Arizona.

FUNDING AND REIMBURSEMENT

Funding Source: Discounts/rebates from manufacturers; negotiated through contracted


PBM.
Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Negotiated through PBM contract
Ingredient Cost Calculation: Not available
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $3.00 for retail and $2.00 for mail order
Notes: Average percent savings off the regular prescription price: brand name
drugs- retail (15%) and generic drugs -retail (35%). Average discounts
for mail order- brand name (20%); generic (55%). RxAmerica (PBM)
negotiates discounts with participating manufacturers. 500
participating pharmacies throughout the State.

DRUGS COVERAGE

Formulary: None
Drugs Covered: All FDA-approved drugs
Drug Coverage Restrictions: None
Notes: The State is discussing the impact of the Medicare Part D program on
the CoppeRx program and future reforms. Preliminary discussions
only at this time.

*
967,061 eligible residents sent program information, as of January 2005.

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PROGRAM CONTACT

Del Swan Phone: 602/417-4726


Pharmacy Program Administrator
Arizona Health Care Cost
Containment System
801 E. Jefferson St.
Phoenix, AZ 85034

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Arkansas
ARx Senior Program
Program Type: Direct Assistance (1115 Waiver)
Law Enacted: 2001∗
Projected Number of Recipients: Not Available

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+


Eligible Income Level (Single): 90% of FPL Eligible Income Level (Married): 90% of FPL
Other Eligibility Notes: Program provides prescription drug coverage to Qualified Medicare
Beneficiary (QMB) seniors lacking prescription drug coverage.

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund and Federal matching funds
Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: Medicaid reimbursement rate
Enrollment Fee: $25.00 per year
Deductible Amount: $5.00
Copayment Amount: $10.00 for generic drugs and $20.00 for brand name drugs
Dispensing Fee: Not available
Notes: The program has not received approval from CMS, as the State has
been unable to design a program with budget neutrality. Arkansas
will likely withdraw its 1115 waiver request depending on the
success of the Medicare Part D program.

DRUGS COVERAGE

Formulary: Same as Medicaid program


Drugs Covered: Legend drugs and controlled substances
Drug Coverage Restrictions: Enrollees are limited to 2 prescriptions per month.

PROGRAM CONTACT

Carolyn Patrick Phone: 501/682-8359


Arkansas Department of Human Fax: 501/683-4124
Services E-mail: carolyn.patrick@medicaid.state.ar.us
Division of Medical Services
Slot 415
P.O. Box 1437
Little Rock, AR 72203-1437

Program implementation is contingent upon CMS approval of 1115 waiver application. The State is unlikely to
pursue the ARx program after implementation of the Medicare Part D program contained in the Medicare Prescription
Drug, Improvements and Modernization Act of 2003.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Arkansas
Arkansas Rx Program
Program Type: Discount
Law Enacted: 2005∗
Projected Number of Recipients: Not Available

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): See notes Eligibility Age (Disabled): See notes
Eligible Income Level (Single): See notes Eligible Income Level (Married): See notes
Other Eligibility Notes: No income limit for 65+, under 65 < 350% FPL. Medicaid and
Medicare Part D enrollees not eligible.

FUNDING AND REIMBURSEMENT

Funding Source: Manufacturer negotiated rebates


Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Not available
Ingredient Cost Calculation: Not available
Enrollment Fee: $25.00 per year
Deductible Amount: Not available
Copayment Amount: Not available
Dispensing Fee: Not available
Notes:

DRUGS COVERAGE

Formulary: Not available


Drugs Covered: Not available
Drug Coverage Restrictions: Not available

PROGRAM CONTACT

Not available


Program is not yet operational.

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California
Prescription Drug Discount for Medicare Recipients Program
Program Type: Discount
Year Operational: 2000
Number of Recipients (January 2005): 1,595,434

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): All Medicare Eligibility Age (Disabled): All Medicare
eligible eligible
Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: Must be a Medicare beneficiary not on Medicaid.

FUNDING AND REIMBURSEMENT

Funding Source: See notes


Budget (FY 05): Not available
Cost per Participant: Not available
# of Rx’s Per Participant: 850,000 price inquiries per month∗
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: Average wholesale price (AWP)-17%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $7.25
Notes: Pharmacies that participate in the Medi-Cal (Medicaid) program
must allow Medicare recipients to purchase drugs for the same
price paid by Medi-Cal. Recipients must pay Medi-Cal price for
drug and a 15 cents processing fee.

DRUGS COVERAGE

Formulary: No formulary
Drugs Covered: Almost all prescription drugs
Drug Coverage Restrictions: Over-the-counter drugs and compound drugs not covered.

PROGRAM CONTACT

Janice Hall Phone: 916/552-9714


Department of Health Services 1-800-434-0222
714 P Street, Room 1253
Sacramento, CA 95814


Price inquires do not always result in sales, because customers may elect not to purchase a pharmaceutical once its
price has been quoted.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

California
Golden Bear State Pharmacy Assistance Program
Program Type: State-Negotiated Discounts
Projected Operational Date: Not Available
Estimated Eligibles (November 2002): 1 to 3 million

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): See notes Eligibility Age (Disabled): See notes
Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: Program covers pharmaceuticals not covered by a private insurer or
other State program. Anyone who has a Medicare card is eligible;
however, unlike the California Discount Prescription Medication
Program, enrollment is required to receive services.

FUNDING AND REIMBURSEMENT

Funding Source: Manufacturer negotiated discounts


Budget: None
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid rebate plus manufacturer-negotiated discounts
Ingredient Cost Calculation: AWP-10%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $4.05 per prescription
Notes: The Golden Bear State Pharmacy Assistance Program has no
pharmaceutical manufacturers participating and the program has been
postponed due to the Federal Medicare prescription drug benefit
enacted by Congress in 2003.

DRUGS COVERAGE

Formulary: No formulary
Drugs Covered: Prescription drugs for which the State has negotiated manufacturer
discounts that supplement the Medi-Cal discount already mandated
under the California Discount Prescription Medication Program.
Drug Coverage Restrictions: Only prescription drugs with manufacturer-negotiated discounts.

PROGRAM CONTACT

Janice Spitzer Phone: 916/552-9557


Department of Health Services
714 P Street, Room 1253
Sacramento, CA 95814

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Connecticut
Pharmaceutical Assistance Contract to the Elderly and
Disabled (ConnPACE)
Program Type: Direct Assistance
Year Operational: 1986
Number of Recipients (January 2005): 49,138

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+


Eligible Income Level (Single): $20,800 Eligible Income Level (Married): $28,100
Other Eligibility Notes: Disabled persons aged 18-64 must be Social Security Disability
Insurance (SSDI) eligible. Effective February 2004, new means test
will be used to determine “liquid assets”; $100,000 for individuals;
$120,000 for married.

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund


Budget (FY 05): $77.9 million (estimated)
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP-12%
Enrollment Fee: $30.00 per year
Deductible Amount: None
Copayment Amount: $16.25
Dispensing Fee: $3.15
Notes: The governor wants cuts to program budget and dispensing fees and
is urging the legislature to enact them. The State faces a $1 billion
deficit.

DRUGS COVERAGE

Formulary: Open formulary


Drugs Covered: All prescription drugs and insulin.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Drug Coverage Restrictions: ConnPACE does not cover drugs prescribed for cosmetic purposes,
experimental drugs, drugs FDA has determined are ineffective,
antihistamines, contraceptives, cough preparations, anti-obesity drugs,
multi-vitamin combinations, smoking cessation gum, vaccines
obtained free of charge from the Department of Health Services,
prescription drugs in excess of manufacturer’s recommendations with
documented legal justification, drugs for lock-in clients from other
than lock-in pharmacy, and over-the-counter drugs (with certain
exceptions). Other drugs may not be covered if pharmaceutical
manufacturers opt not to participate in the Drug Rebate Program.
ConnPACE restricts beneficiaries to 120 units or a 30-day supply,
whichever is greater.
Notes: Generic drugs must be substituted for brand name drugs, unless
otherwise indicated by the prescribing physician (prior authorization
required). Prior authorization is required for early refills, drug product
costs over $500, physician request for a brand name product. Under
statutory authority, State is completing implementation of a preferred
drug list (PDL). PDL will start after appropriate training and outreach
with providers.

ConnPACE enrollees were automatically enrolled in Medicare-


approved prescription drug programs (PDPs), which will facilitate
further State “wrap-around” efforts once the Part D benefit begins in
2006.

PROGRAM CONTACT

Evelyn A. Dudley Phone: 860/424-5654


Manager Fax: 860/424-5206
Department of Social Services E-mail: evelyndudley@po.state.ct.us
25 Sigourney Street
Hartford, CT 06106 Alternate contact:
James Zakszewski
Phone: 860/424-4961

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Delaware
Nemours Pharmacy Assistance
Program Type: Private Discount
Year Operational: 1981
Number of Enrollees (January 2005): 9,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+


Eligible Income Level (Single): $12,500 Eligible Income Level (Married): $17,125
Other Eligibility Notes: Must be a U.S. citizen and resident of Delaware.

FUNDING AND REIMBURSEMENT

Funding Source: This program is a privately funded program; no State funds are used.
Budget: Not available
Cost per Enrollee: Not available
# of Rx’s Per Enrollee (2003): 18
Manufacturer Rebate Type: None
Ingredient Cost Calculation: Not available
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: 20% of drug cost
Dispensing Fee: $5.00
Notes: Maximum annual benefit is $2,000.00 per enrollee.

DRUGS COVERAGE

Formulary: None
Drugs Covered: Due to severe budgetary constraints, covered drugs are chosen
individually, based on physician recommendations.
Drug Coverage Restrictions: As many recommended drugs as allowed by the budget are purchased
and made available to enrollees.
Notes: One central pharmacy distributes all drugs by courier to branch
locations where citizens can pick up a 2-3 month supply.

PROGRAM CONTACT

Jack Lagowski Phone: 302/651-4403


Nemours Clinic Pharmacy Assistance Fax: 302/651-4445
1801 Rockland Road
Wilmington, DE 19803

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Delaware
Prescription Assistance Program (DPAP)
Program Type: Direct Assistance
Year Operational: 2000
Number of Recipients (January 2005): 7,206

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+


Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of FPL
Other Eligibility Notes: Must be a U.S. citizen and resident of Delaware. Couples are counted
as two individuals. Individuals with income over 200% of FPL can
qualify if they have prescription costs exceeding 40% of their income.
Those age 65 and over who are eligible for the Nemours Foundation
prescription benefit are not eligible for DPAP. DPAP does not
replicate coverage for Nemours clients. Disabled persons 18-64 must
be Social Security Disability Insurance (SSDI) eligible.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco Settlement funds


Budget: Not available; not subject to budget appropriation
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Negotiated between the State and individual manufacturers
Ingredient Cost Calculation: Lower of AWP-14% or Federal Upper Limit or State maximum
allowable cost (MAC). Reimbursement rate for certain specialty
pharmaceuticals is AWP-16%.
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: Greater of $5.00 or 25% of the cost of the prescription
Dispensing Fee: $3.65
Notes: Annual maximum benefit of $2,500.00 per recipient.
EDS administers program on behalf of the State.

DRUGS COVERAGE

Formulary: Preferred Drug List (PDL)


Drugs Covered: Medically necessary prescription drugs
Drug Coverage Restrictions: Only drugs from manufacturers that agree to participate in State rebate
program.
Notes: The prescription assistance program implemented a PDL program,
effective April 1, 2005.

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PROGRAM CONTACT

Cindy Denemark – EDS Phone: 302/453-8453


Division of Social Services Fax: 302/454-7603
248 Chapman Road Suite 100 E-mail: cindy.denemark@eds.com
Newark, DE 19702

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National Pharmaceutical Council Pharmaceutical Benefits 2004

District of Columbia
Access Rx
Program Type: Manufacturer Rebates
Law Enacted: March 2004

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): 88% - 120% Eligible Income Level (Married): 88% - 120%
of FPL of FPL
Other Eligibility Notes: The program also has a component for uninsured individuals up to
350% of FPL.

FUNDING AND REIMBURSEMENT

Funding Source: Manufacturer rebates


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: The AccessRx Act of 2004 authorizes the Director of the Department to
negotiate rebate agreements with drug manufacturers and labelers that sell
prescription drugs through publicly funded pharmaceutical assistance
programs in the District. Rebate monies will be placed in an AccessRx Fund
and used to reimburse pharmacies for drug discounts. Manufacturers and
labelers who do not participate in this program will have their names
publicized, as a partial incentive to participate.

DRUGS COVERAGE

Formulary: Not available


Drugs Covered: Not available
Drug Coverage Restrictions: Not available

PROGRAM CONTACT

Department of Health Phone: 202/671-5000


825 North Capitol Street, NE
Washington DC 20002

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Florida
Silver SaveRx Program
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 2002
Number of Enrollees (January 2005): 55,036

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): 88% - 120% of FPL Eligible Income Level 88% - 120%
(Married): of FPL
Other Eligibility Notes: Program covers dual eligibles.

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund, Federal matching funds, and manufacturer
rebates
Budget (FY 05): $100 million
Cost per Enrollee (FY 05): $160 per month maximum benefit per user, per month
# of Rx’s Per Enrollee (FY 05): Between 2.77 and 3.67 per user/per month
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: The lesser of AWP-13.25%, Wholesalers Acquisition Cost (WAC)+7%, or
the usual and customary
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $2.00 for generic drugs, $5.00 for brand name drugs on the preferred drug
list, and $15.00 for brand name drugs not on the preferred drug list
Dispensing Fee: $4.23
Notes: Enrollees will have $160 deposited in a Silver Saver account that is
maintained by the Medicaid program. Eligibility is determined on a
monthly basis. During Calendar Year 2004, an average of 23% of
beneficiaries used the maximum allowed benefit of $160 per month.

DRUGS COVERAGE

Formulary: Preferred drug list


Drugs Covered: Same as Medicaid
Drug Coverage Restrictions: Same as Medicaid
Notes: The program will likely be restructured to better integrate options with the
Medicare Part D program. Preliminary discussions are underway but
specific details have yet to be announced.

PROGRAM CONTACT

Jeffrey Parrott Phone: 850/487-4441


Agency for Health Care Admin. E-mail: parrottj@fdhc.state.fl.us
2727 Mahan Drive
Tallahassee, FL 32308-7703

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Florida
Medicare Prescription Discount Program∗
Program Type: Discount
Year Operational: 2000
Estimated Participants: Not Available

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): See notes Eligibility Age (Disabled): See notes
Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: Anyone who has a Medicare card is eligible.

FUNDING AND REIMBURSEMENT

Funding Source: None


Budget: None
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Not available
Ingredient Cost Calculation: AWP-9%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $4.50
Notes: Pharmacies that participate in Medicaid must offer participants a
discount based on AWP-9% + $4.50 dispensing fee.

DRUGS COVERAGE

Formulary: None
Drugs Covered: All prescription drugs
Drug Coverage Restrictions: None

PROGRAM CONTACT

Jeff Parrott Phone: 850/487-4441


Agency for Health Care E-mail: parrottj@fdhc.state.fl.us
Administration
2727 Mahan Drive
Tallahassee, FL 32308-7703


By law Florida pharmacies are required to provide this discount in order to participate in Medicaid.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Georgia
Georgia Cares Program*
Program Type: Coordinate Assistance Between Elderly and Charitable
Pharmaceutical Programs
Year Operational: 2002
Number of Recipients (January 2005): 24,739

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+


Eligible Income Level (Single): None Eligible Income Level (Married): None
Other Eligibility Notes: Individuals may not have any other insurance coverage for medicines.

FUNDING AND REIMBURSEMENT

Funding Source: State and Federal grant money


Budget (FY 05): $580,000
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: None
Ingredient Cost Calculation: None
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: Not available
Notes: The purpose of the program is to utilize available State resources to help
eligible seniors find appropriate charitable pharmaceutical programs from
various manufacturers. The program also receives some in-kind grant money
from the “Thanks Mom & Dad Fund,” a 501(c)(3) charitable organization that
collects private donations for senior assistance programs.

DRUGS COVERAGE

Formulary: None
Drugs Covered: Based on a manufacturer’s charitable program criteria
Drug Coverage Restrictions: Not available

PROGRAM CONTACT

Jennie Deese Phone: 404/463-8578


Coordinator Fax: 404/657-5285
Georgia Cares
Division of Aging Services
2 Peachtree Street, NW
Atlanta, GA 30303

*
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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National Pharmaceutical Council Pharmaceutical Benefits 2004

Hawaii
Hawaii Rx Plus
Program Type: Direct Discount
Operational Date: 2004
Number of Recipients (January 2005): 147,685

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages
Eligible Income Level (Single): $38,000 Eligible Income Level (Married): $51,000
Other Eligibility Notes: Open to all Hawaii residents, providing that they have no other
prescription drug coverage.

FUNDING AND REIMBURSEMENT

Funding Source: Manufacturer rebates


Budget (FY 05): Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Rebate amounts equal to or greater than the rebate calculated for
Medicaid.
Ingredient Cost Calculation: AWP-10.5%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: Not less than fee provided under the State Medicaid program.

DRUGS COVERAGE

Formulary: None
Drugs Covered: All FDA approved drugs
Drug Coverage Restrictions: None
Notes: Each pharmacy participating in the program discounts the price of
drugs covered by the program and sold to program participants.
Participating pharmacies submit claims to the Department of Human
Services and are reimbursed for the discounted drugs. Legislation is
being considered to restructure this program in order to “wrap-around”
the Medicare Part D program. The legislation would provide benefits
for dual eligibles to pay co-payments.

PROGRAM CONTACT

Tracey Okubo Phone: 808/586-5036


Department of Human Services
1390 Miller Street, Room 209
Honolulu, HI 96813

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Illinois
Pharmaceutical Assistance Program (PAP)
“Circuit Breaker”
Program Type: Direct Assistance
Year Operational: 1985
Number of Recipients (January 2005): 45,394

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 16+


Eligible Income Level (Single): 250% of FPL Eligible Income Level (Married): 250% of FPL
Other Eligibility Notes: A widow or widower who turns 63 or 64 before a deceased enrollee’s
death is eligible for PAP. Also, a married couple with a $35,740
annual household income would be eligible if they were filing with
one other resident. An individual would be eligible with a $35,740
annual household income if they were filing with two other residents.

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund and Tobacco Settlement Fund
Budget (FY 04): $83 million
Cost per Participant (FY 03): $1,255.66
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type Negotiated by State
Ingredient Cost Calculation: AWP-14%
Enrollment Fee: $5.00 if income is below 100% of FPL and $25.00 if income is at or
above 100% of FPL
Deductible Amount: None
Copayment Amount: For income less than 100% of FPL, there is no copayment until annual
drug cost exceeds $2,000; then copayment is 20% of drug cost. For
income at 100% of FPL or greater, there is a $3.00 copayment until
annual drug cost exceeds $2,000.00; then copayment is 20% of drug
cost.
Dispensing Fee: $2.55

DRUGS COVERAGE

Formulary: Some drugs covered by preferred drug list (PDL); prior authorization.
Drugs Covered: Prescription medication used for cancer, Alzheimer’s disease,
Parkinson’s disease, glaucoma, lung disease and smoking-related
diseases, cardiovascular, arthritis, diabetes, and osteoporosis, heart and
blood pressure problems, multiple sclerosis, and osteoporosis.
Drug Coverage Restrictions Some classes of drugs covered by preferred drug list (PDL); prior
authorization.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

PROGRAM CONTACT

Susan Rohrer Phone: 217/785-5905


Pharmaceutical Assistance Programs Fax: 217/524-9213
Illinois Department of Revenue E-mail: srohrer@revenue.state.il.us
P.O. Box 19021
Springfield, IL 62794-9021

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Illinois
Illinois SeniorCare
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 2002
Number of Recipients (January 2005): 195,746

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not applicable


Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of FPL
Other Eligibility Notes: Eligible individuals who already have pharmaceutical health insurance
benefits may choose to receive a $25 rebate check monthly. By choosing the
SeniorCare Rebate, individuals must use their own health insurance to pay for
prescription drugs.

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund and Tobacco Settlement Fund
Budget (FY 03): $102 million
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type Negotiated by State
Ingredient Cost Calculation: AWP-14% or MAC if generic is available
Enrollment Fee: None, but participants must reapply every year.
Deductible Amount: None
Copayment Amount: If the participant is single with income of no more than $9,569 a year, or if
participant lives with his/her spouse and together the income is no more
than $12,829, SeniorCare pays up to $1,750 per person in a year at no cost.
After $1,750, participant pays 20% of each prescription.
If the participant is a single individual with an income of $9,750 to $19,140
a year, or if the participants are a married and living together with a total
household income of $12,830 to $25,600 a year, SeniorCare pays for the
first $1,750 per person. The participants are also required to pay $1 for a
generic drug and $4 for each brand name drug. After the $1,750 limit is
met, the participants continue to pay $1 for a generic drug and $4 for each
brand name drug plus 20% of the cost of each prescription.
If a generic drug is available but the participant requests a brand name drug,
participants must pay $4 for each prescription plus the difference in price
between the generic and the brand name drug.
Dispensing Fee: $2.25

DRUGS COVERAGE

Formulary: All prescription medications manufactured by companies participating in


the Federal rebate program.
Drugs Covered: Most prescription drugs

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Drug Coverage Restrictions Some classes of drugs covered by the preferred drug list (PDL) or prior
authorization.

PROGRAM CONTACT

Pamela J. Bunch Phone: 217/524-7478


SeniorCare Fax: 217/524-7535
Illinois Department of Public Aid E-mail: pam.bunch@idpa.state.il.us
201 S. Grand Avenue East
Springfield, IL 627636-0001

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Illinois
Illinois Rx Buying Club
Program Type: Direct Discount
Year Operational: 2004
Number of Eligible Recipients: 1.5 million

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Medicare


eligible
Eligible Income Level (Single): None Eligible Income Level (Married): See notes
Other Eligibility Notes: Membership is available to individuals only. Circuit Breaker/
Pharmaceutical Assistance participants are automatically enrolled in
the buying club.

FUNDING AND REIMBURSEMENT

Funding Source: Enrollment fees


Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Sav-Rx (PBM) negotiates discounts with participating manufacturers.
Ingredient Cost Calculation: Not available
Enrollment Fee: $25.00
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: Not available
Notes: The Illinois Rx Buying Club provides discounts on all categories of
prescription drugs. The program also has a mail-order option for
enrollees. The $25.00 enrollment fee entitles beneficiary to savings of
20% or more on each prescription for 12 months.

DRUGS COVERAGE

Formulary: Preferred Drug List


Drugs Covered: All prescriptions ordered by physician that are on the PDL
Drug Coverage Restrictions: All FDA-approved drugs are eligible for the program.

PROGRAM CONTACT

Deb Corso Phone: 217/524-7478


Illinois Department on Aging Fax: 217/785-4477
421 East Capitol Avenue, #100
Springfield, IL 62701-1789

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Indiana
Indiana Prescription Drug Program
“HoosierRx”
Program Type: Discount
Year Operational: 2000
Number of Recipients (January 2005): 26,800

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): 135% of FPL Eligible Income Level (Married): 135% of FPL
Other Eligibility Notes: Must be an Indiana resident for at least 90 days in the past 12 months,
without prescription drug coverage through an insurance plan,
Medicaid or Medicaid with a spend-down. Benefit is available for one
year.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco Settlement Fund


Budget (FY 05): $22 million
Cost per Participant (FY 03): $450.54
# of Rx’s Per Participant (FY 03): 51.6
Manufacturer Rebate Type: None
Ingredient Cost Calculation: Medicaid reimbursement rate
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: 25% of HoosierRx negotiated price, up to the maximum benefit limit
(MBL) is based on when the participant applied. If the applicant
applied in June 2004, the MBL was $1,200; in October it was $1,000.
For 2005, the figures, based on enrollment month, are: January: $800,
April: $600, July: $400, October: $200.
Dispensing Fee: $4.90
Notes: Once maximum benefit limit is reached, recipients may continue to
receive the HoosierRx discounted rate during the rest of the enrollment
year.

DRUGS COVERAGE

Formulary: None
Drugs Covered: All prescription drugs, as well as insulin

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National Pharmaceutical Council Pharmaceutical Benefits 2004

PROGRAM CONTACT

Neil Steffens Phone: 317/233-0587


HoosierRx Fax: 317/232-7382
Family & Social Services Email: neil.steffens@fssa.in.gov
Administration
402 W. Washington Street
W-386, MS-07
Indianapolis, IN 46204-2739

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Iowa
Iowa Priority Prescription Savings Program
Program Type: Negotiated Discount
Year Operational: 2002
Number of Enrollees (January 2005): 50,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): All Medicare eligibles Eligibility Age (Disabled): All Medicare
eligibles
Eligible Income Level (Single): All income levels Eligible Income Level All income levels
(Married):
Other Eligibility Notes: Medicaid recipients are not eligible. Novartis has an income requirement:
only a couple with an income of more than $16,862 and less than $24,000,
or individuals with an income of more than $12,569 and less than $18,000,
qualifies for medications at a flat-fee of $12.

FUNDING AND REIMBURSEMENT

Funding Source: Federal grant and enrollment fees


Budget (FY 05): Not available
Cost per Enrollee: Not available
# of Rx’s Per Enrollee (FY 05): Not available
Manufacturer Rebate Type: A pharmacy benefit manager (PBM) negotiates discounts with participating
manufacturers.
Ingredient Cost Calculation: Reimbursement rate based on negotiated contract with each participating
manufacturer.
Enrollment Fee: $20.00 per year
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: Not available
Notes: The Iowa Priority prescription savings program is a nonprofit plan run by
the non-profit Iowa Prescription Drug Corporation. Discounts are
available on participating manufacturers’ drugs (Bristol-Myers Squibb,
Merck, Novartis, and Schering-Plough). 100% of the discount is passed
through directly to the consumer at the point of sale. Budget, cost and
prescription usage is not provided for proprietary reasons.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

DRUGS COVERAGE

Formulary: Preferred drug list


Drugs Covered: The following therapeutic classes of drugs are covered: Allergy,
Alzheimer’s Disease, Anti-Convulsant Agents, Anti-Fungal Agent,
Anti-Psychotic Agent, Antiviral, Arthritis and Analgesia, Asthma,
Breast Cancer, Central Nervous System Stimulants, Cholesterol
Lowering Agents, Dermatological Products, Diabetes, Enlarged
Prostate Treatment, Glaucoma Agents, Hormone Replacement,
Hypertension/High Blood Pressure and Cardiovascular, Irritable
Bowel Syndrome, Osteoporosis Treatment, Parkinson’s Disease, and
Voltaren Ophthalmic® (diclofenac ophthalmic).
Drug Coverage Restrictions: None

PROGRAM CONTACT

David Fries Phone: 515/327-5405, ext. 203


Iowa Prescription Drug Corporation Fax: 515/327-5422
1231 8th Street, Suite 232 Email: info@iowapriority.org
West Des Moines, IA 50265

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Kansas
Kansas Senior Pharmacy Assistance Program
Program Type: Reimbursement
Year Operational: 2001
Number of Enrollees (January 2005): 2,416

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+


Eligible Income Level (Single): 135% of FPL Eligible Income Level (Married): 135% of FPL
Other Eligibility Notes: Must be a Kansas resident; not covered under a private prescription
reimbursement plan; not eligible for or enrolled in any other local, State,
or Federal prescription program; not have voluntarily canceled a local,
State, Federal, or private prescription drug program within six months of
application to the program. Must be current recipient of benefits
through the Qualified Medicare Beneficiary Program (QMB) or Low
Income Medicare Beneficiary (SLMB) Program.

FUNDING AND REIMBURSEMENT

Funding Source: State funds


Budget (FY 05): $1.2 million
Cost per Enrollee (FY 05): $471 (estimated)
# of Rx’s Per Enrollee: Not available
Manufacturer Rebate Type: None
Ingredient Cost Calculation: None
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: 30% of pharmaceutical cost
Dispensing Fee: None
Notes: Maximum annual benefit is $1,200.00 per enrollee annually, with
reimbursement checks to be sent by December 31 of each year. Benefit
is direct reimbursement from State to enrollee.

DRUGS COVERAGE

Formulary: None
Drugs Covered: Legend drugs, diabetic supplies not covered by Medicare
Drug Coverage Restrictions: Program does not cover over-the-counter or lifestyle drugs.
Notes: Kansas Senior Pharmacy Assistance Program will be terminated once
the Medicare Part D program begins.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

PROGRAM CONTACT

Janet Boscom Phone: 785/296-4986


Department on Aging General E-mail: wwwmail@aging.state.ks.us
503 S. Kansas Avenue
Topeka, KS 66603-3404

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Kentucky
Kentucky Pharmaceutical Assistance Program
Program Type: Direct Assistance
Year Operational: Begins 1/1/2006
Projected Number of Enrollees: not available

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): Medicare Eligibility Age (Disabled): Medicare


eligible eligible
Eligible Income Level (Single): 150% FPL Eligible Income Level (Married): 150% FPL
Other Eligibility Notes:

FUNDING AND REIMBURSEMENT

Funding Source: Not available


Budget (FY 05): Not available
Cost per Participant: Not available
# of Rx’s Per Participant (FY 05): 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: Program is designed to wrap around Medicare Part D. “May pay all of
some of the deductibles, coinsurance payments, premiums, and
copayments” for Part D.

DRUGS COVERAGE

Formulary: Not available


Drugs Covered: Not available
Drug Coverage Restrictions: Not available

PROGRAM CONTACT

Not available

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Louisiana
Louisiana SenioRx Program*
Program Type: Coordinate Assistance between Elderly and Charitable
Pharmaceutical Programs
Year Operational: 2003
Number of Enrollees (January 2005): 7,182

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 60+ Eligibility Age (Disabled): 60+


Eligible Income Level (Single): $28,710 Eligible Income Level (Married): $38,490
Other Eligibility Notes: Individuals may not have any other insurance coverage for medicines.

FUNDING AND REIMBURSEMENT

Funding Source: State general revenue


Budget (FY 05): $500,000
Cost per Participant: Not available
# of Rx’s Per Participant (FY 05): 84
Manufacturer Rebate Type: None
Ingredient Cost Calculation: None
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: Not available
Notes: The purpose of the program is to utilize available State resources to
help eligible seniors find appropriate charitable pharmaceutical
programs from various manufacturers. The State will also coordinate
and complete all necessary paperwork for each participant.

DRUGS COVERAGE

Formulary: None
Drugs Covered: Based on a manufacturer’s charitable program criteria.
Drug Coverage Restrictions: Not available

PROGRAM CONTACT

Sharon Booker Phone: 225/342-3570


Coordinator Fax: 225/342-7133
Governor's Office of Elderly Affairs
P.O. Box 80374 Alternate Contact :
Baton Rouge, LA 70898 Charlene Hayes
225/342-7129

*
The Louisiana SeniorRx Program assists eligible State residents in coordinating services from various manufacturers’
charitable prescription assistance programs. State does not contribute money for direct purchase of prescription drugs.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Maine
Maine Rx Plus*
Program Type: Subsidy and Discount
Law Enacted: 2003
Number of Enrollees (Fiscal Year 2005): 275,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages
Eligible Income Level (Single): 350% of FPL Eligible Income Level (Married): 350% of FPL
Other Eligibility Notes: Any person who incurs unreimbursed expenses for prescription drugs
equaling 5% or more of family income, or who incurs unreimbursed
expenses for all medical care equaling 15% or more of family income, is
eligible for the remainder of the eligibility period.

FUNDING AND REIMBURSEMENT

Funding Source: State appropriations and subsidies


Budget (FY 05): $800,000 (estimated)
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: State-only rebates
Ingredient Cost Calculation: AWP-13%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: Program combines discounts from participating pharmacies with
negotiated rebates from manufacturers.
Dispensing Fee: $3.35

DRUGS COVERAGE

Formulary: Closed formulary


Drugs Covered: Only “preferred” drugs included on the MaineCare (Maine Medicaid) PDL.
Drug Coverage Restrictions: Non-preferred drugs (as indicated non-covered on the MaineCare PDL).
Notes: Legislation is being considered to enable the Maine Rx Plus program to
“wrap-around” the Medicare Part D program.

PROGRAM CONTACT

Jude Walsh Phone: 207/624-9844


Department of Human Services Fax: 207/287-8601
11 State House Station E-mail: jude.e.walsh@maine.gov
Augusta, ME 04333-0011

*
This program replaces the Maine Rx Program, which faced significant legal challenges and was never implemented.
Additionally, beneficiaries from the former Healthy Maine Prescription Program were immediately eligible for the
Maine Rx Plus program. Program includes a pharmacy incentive program, in which Maine Rx Plus sends out over
$50,000 per year to pharmacies that qualify.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Maine
Low Cost Drugs for the Elderly and Disabled Program
(DEL)*
Program Type: Subsidy and Discount
Year Operational: 1975
Number of Recipients (January 2005): 41,200

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 62+ Eligibility Age (Disabled): 19+


Eligible Income Level (Single): 185% of FPL Eligible Income Level (Married): 185% of FPL
Other Eligibility Notes: This program is made available to Maine residents fitting the age and
income eligibility criteria. Individuals with full MaineCare (Maine
Medicaid) benefits are not eligible. Medicare recipients are not
necessarily excluded.

FUNDING AND REIMBURSEMENT

Funding Source: State appropriations and subsidies


Budget (FY 05): Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: State-only rebates
Ingredient Cost Calculation: AWP-15%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: Basic: 20% +$2.00 of the cost of generic drugs; 20% + $2.00 of the cost of
prescriptions for select medical conditions; 84% of the cost of other covered
prescriptions. Supplemental: State pays $2.00 toward the cost of all other
drugs from participating manufacturers.
Dispensing Fee: $2.35
Notes: A participant is eligible for a Catastrophic benefit once he or she has paid
total copayments in the DEL benefit of at least $1,000 between August 1 and
July 31 of any year(s) in which the participant is eligible.

DRUGS COVERAGE

Formulary: Open formulary


Drugs Covered: Only those drugs covered with manufacturer participation
Drug Coverage Restrictions: 34-day supply limit for brand name drugs, 90-day limit for generic drugs.
Some prescriptions require prior approval to assure quality, dose strength,
and cost effectiveness.
Notes: Legislation is being considered to enable the DEL program to wrap around
the Medicare Part D program.

*
The Low Cost Drugs for the Elderly and Disabled (DEL) Program is also run under the Maine Rx Plus umbrella,
distinguished by the eligibility criteria differences. Program includes a pharmacy incentive program, in which the DEL
program sends out over $200,000 per year to pharmacies that qualify.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

PROGRAM CONTACT

Jude Walsh Phone: 207/624-9844


Department of Human Services Fax: 207/287-8601
11 State House Station E-mail: jude.e.walsh@maine.gov
Augusta, ME 04333-0011

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Maryland
Maryland Pharmacy Assistance Program
Program Type: Direct Assistance
Year Operational: 1979
Number of Recipients (January 2005): 62,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): See notes


Eligible Income Level (Single): $926/mo Eligible Income Level (Married): $1,070/mo
Other Eligibility Notes: This program also takes into account resources and assets. A single
person must have resources below $4,000, and married couples must
have resources below $6,000. No age restrictions on eligibility if
enrollees are Medicare-eligible and Maryland residents. The
following groups are ineligible for participation: people detained in a
correctional (Federal, State, local) system, Medicaid recipients.
Disabled are covered if they are Medicare-eligible.

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund


Budget (FY 05): Not available
Cost per Participant (FY 05): Not available
# of Rx’s Per Participant (FY 05): Not available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: For brand name drugs, lower of AWP-11%, WAC+9%, Direct
Manufacturer’s Cost (DMC)+10%, or Direct Cost (DC)+10%. For
generic drugs, lower of Estimated Acquisition Cost (EAC), State
MAC, or Federal MAC.
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $7.50 for brand-name; $2.50 for generics (per prescription)
Dispensing Fee: $3.69 for brand-name; $4.69 for generics

DRUGS COVERAGE

Formulary: PDL for certain therapeutic classes


Drugs Covered: Follows Medicaid guidelines
Drug Coverage Restrictions: Prior authorization for certain medications, including steroids and
some controlled substances. 75% utilization required for prescription
refill.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

PROGRAM CONTACT

Paul A. Roeger Phone: 443/263-7031


Division Chief E-mail: roegerp@dhmh.state.md.us
Office of Operations & Eligibility
Department of Health and Mental
Hygiene
201 West Preston Street
Baltimore, MD 21201

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Maryland
Senior Prescription Drug Program
Program Type: Direct Assistance
Year Operational: 2001
Number of Recipients (January 2005): 35,500

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): See notes


Eligible Income Level (Single): 300% of FPL Eligible Income Level (Married): 300% of FPL
Other Eligibility Notes: Program is open to all Maryland residents who have no other
prescription drug insurance plan. Disabled are covered if they are
Medicare-eligible.

FUNDING AND REIMBURSEMENT

Funding Source: CareFirst subsidizes program through a 2% premium tax exemption


from the State of Maryland.
Budget (FY 05): $26 million
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: PBM-negotiated with individual drug companies
Ingredient Cost Calculation: PBM-negotiated with contracted pharmacies
Enrollment Fee: $10 monthly premium
Deductible Amount: None
Copayment Amount: $10 for generics, $20 for preferred brand name products, $35 non-
preferred brand-name products
Dispensing Fee: Varies among contracted pharmacies.
Notes: Maximum benefit is $1,100 per enrollee per 12-month period.
Caremark administers the pharmacy benefit and negotiates contracts
with individual pharmaceutical manufacturers and pharmacies.
Enrollees are expected to save between 13% and 16% on each
prescription once they have met maximum benefits.

DRUGS COVERAGE

Formulary: CareFirst formulary


Drugs Covered: Most generic and brand drugs approved by the Food and Drug
Administration (FDA) are included under this program.
Drug Coverage Restrictions: Anorexants are excluded. Over-the-counter drugs, with the exception
of insulin, are excluded. Quantity limits on certain drugs such as
Viagra, migraine medicines and Oxycontin. Prior authorization on
certain drugs such as growth hormones.
Notes: The program sunsets June 30, 2005, but may be extended through
12/31/05 to coincide with Federal Medicare drug benefit program
changes. There are, however, several measures in the General
Assembly to enable the Senior Rx program to continue as a “wrap-
around” program in conjunction with the Medicare Part D program.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

PROGRAM CONTACT

Robin Vahle Phone: 410/998-5444


Project Manager E-mail: robin.vahle@carefirst.com
Senior Rx Program
1 Calvert Place
Baltimore, MD 21202

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Maryland
Maryland Pharmacy Discount Program
Program Type: Discount (1115 Waiver)
Operational Date: July 1, 2003
Number of Recipients (January 2005): 3,965

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): See notes


Eligible Income Level (Single): $1,396/mo Eligible Income Level (Married): $1,872/mo
Other Eligibility Notes: Must be a Medicare recipient and a Maryland resident. Disabled are
covered if they are Medicare-eligible.

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue funds and Federal matching funds
Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid guidelines
Ingredient Cost Calculation: For brand name drugs, lower of AWP-11%, WAC+9%, Direct
Manufacturer’s Cost (DMC)+10%, or Direct Cost (DC)+10%. For
generic drugs, lower of EAC, State MAC, or Federal MAC.
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: 65% of the State’s reduced cost
Dispensing Fee: $1.00 per prescription

DRUGS COVERAGE

Formulary: PDL for certain therapeutic classes


Drugs Covered: Medicaid guidelines
Drug Coverage Restrictions: Medicaid guidelines

PROGRAM CONTACT

Paul A. Roeger Phone: 443/767-5394


Division Chief E-mail: roegerp@dhmh.state.md.us
Office of Operations & Eligibility
Department of Health
and Mental Hygiene
201 West Preston Street
Baltimore, MD 21201

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Massachusetts
Prescription Advantage
Program Type: Direct Assistance
Year Operational: 2001
Number of Recipients (January 2005): 84,880

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): See notes


Eligible Income Level (Single): Sliding scale Eligible Income Level (Married): Sliding scale
Other Eligibility Notes: Disabled participants may participate if they are under age 65, work
40 or fewer hours per month, meet CommonHealth disability
guidelines and have gross annual household incomes at or below
188% of the Federal Poverty Level. Individuals receiving Medicaid
are not eligible to join Prescription Advantage.

FUNDING AND REIMBURSEMENT

Funding Source: State general funding


Budget (FY 05): $104 million
Cost per Participant (FY 05): $90 per member per month (est.)
# of Rx’s Per Participant (FY 05): $1,085 (est.)
Manufacturer Rebate Type: Caremark negotiates price and rebates with drug manufacturers.
Ingredient Cost Calculation: AWP-14%
Enrollment Fee: Single: $0-$99 per month per enrollee, depending on income; Married:
$0-$74 per month per enrollee, depending on income
Deductible Amount: $0-$500 annually, depending on income. Payments are accepted
quarterly.
Copayment Amount: 30-day Rx fill (retail): $9 to $50 based on drug plan level (tiered)
90-day Rx fill (mail-order): $18 to $100 based on drug plan level
(tiered)
Dispensing Fee: $2.40 for retail pharmacy
Notes: Premiums, deductibles and copayments are determined through a
sliding scale based on income levels. The annual out-of-pocket limit
per enrollee is $2,000 or 10% of income, whichever is less. For
married members, the out-of-pocket spending limit is $3,000
combined, or 10% of gross annual household income, whichever is
less. The lower premium for married members only applies to those
members who are both enrolled in the plan; when not joining as a
couple, a married member must pay the individual rate.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

DRUGS COVERAGE

Formulary: Prescription Advantage formulary


Drugs Covered: All therapeutic classes, except those excluded from MassHealth.
Includes all FDA approved oral drugs as well as many injectable
drugs, including insulin and disposable insulin syringes with needles.
Drug Coverage Restrictions: No OTC
Notes: The plan utilizes a formulary that categorizes prescription drugs into
three categories: generic drugs, brand name drugs, and additional
brand name drugs. Generic drugs have the lowest copayment, while
additional brand name drugs have the highest copayment.

Plan officials have begun early discussions regarding changes to the


program in light of Medicare prescription drug coverage. Preliminary
efforts are focused on enabling Prescription Advantage to continue as a
“wrap-around” program in conjunction with the Medicare Part D
program.

PROGRAM CONTACT

Molly McGinnis Phone: 617/727-7750


Massachusetts Executive Office of Fax: 617/727-9368
Elder Affairs
One Ashburton Place Prescription Advantage information line: 800/243-4636
Boston, MA 02108

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Michigan
Elder Prescription Insurance Coverage (EPIC) Program
Program Type: Direct Assistance
Year Operational: 2001
Number of Enrollees (February 2005): 10,900

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+


Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of FPL
Other Eligibility Notes: EPIC enrollment is currently closed due to budget constraints, except
for 45-day emergency coverage, which is available up to two times a
year. In addition to normal coverage eligibility requirements, to be
eligible for emergency coverage:
• A single applicant must make less than 150% of FPL
• A married applicant must make equal to or less than 150% of FPL
• A true medical emergency must exist.
To be eligible for normal coverage, an applicant:
• Must be a resident of Michigan for three months prior to
application
• Cannot be residing in an institution
• Cannot have other insurance or program coverage for prescription
drugs
• Cannot currently receive Medicaid benefits.

FUNDING AND REIMBURSEMENT

Funding Source: State General Fund plus rebate revenue


Budget: Not available
Cost per Enrollee (FY 05): $2,400 (estimated)
# of Rx’s Per Enrollee (FY 05): 60
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: Lesser of usual and customary charge, AWP-15.1% or 13.5%
(depending on the pharmacy), or the State MAC price
Enrollment Fee: $25.00
Deductible Amount: Based on the participant’s total annual household income. Maximum
annual cost-share amount is divided into twelfths so that a monthly
amount must be met. If the out-of-pocket amount is not met in that
month, the amount is cumulative, and any remainder is added to the
following month. Deductibles are re-established yearly.
Copayment Amount: If a brand name drug is prescribed and dispensed when a generically
equivalent drug is available, a $15.00 copayment in addition to the
monthly out-of-pocket share is charged. No copayment may exceed
20% of the cost of the drug
Dispensing Fee: $3.77

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National Pharmaceutical Council Pharmaceutical Benefits 2004

DRUGS COVERAGE

Formulary: Drugs not on the Michigan Pharmaceutical Products List (MPPL) may
require prior authorization before they are paid for by EPIC. The use
of generic drugs is encouraged.
Drugs Covered: Most prescription drugs plus insulin and syringes for diabetics, with
some exceptions.
Drug Coverage Restrictions: The EPIC program does not cover the following types of drugs:
products used for weight loss or weight gain; fertility or infertility
drugs; drugs used to treat erectile dysfunction; drugs or products used
for contraception; products used to promote hair growth or for other
cosmetic purposes; drugs used to treat the skin aging process; smoking
cessation products; cold and cough preparations; fluoride preparations;
experimental and investigational drugs; Drug Efficacy Study
Implementation program (DESI) drugs; vitamins/minerals, alone or in
combination; dietary formulas or nutritional supplements; central
nervous system (CNS) stimulants; Acquired Immunodeficiency
Syndrome (AIDS) drugs/injectables and orals; injectable drugs; allergy
serums; compounds; over-the-counter (OTC) drugs except for
prescription insulin and OTC drugs with prescriptions used for
approved step therapy programs; miscellaneous products associated
with a specific drug administration, except for diabetes needles and
syringes; drugs produced by manufacturers not participating in the
rebate program; non-Food and Drug Administration (FDA) approved
drugs; and drugs for which the manufacturer seeks to require as a
condition of sale that associated tests or monitoring services be
purchased exclusively from the manufacturer or its designee.
Notes: Most prescription drugs have a 30-day supply; however, covered
maintenance drugs may be filled for 100-day supply.

PROGRAM CONTACT

Tom Chisnell Phone: 517/373-3364


Department of Community Health
611 West Ottawa, P.O. Box 30676
Lansing, MI 48909-8176

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Michigan
MI Rx Prescription Savings Program
Program Type: Discount
Operational Date: September 2004
Number of Recipients: Est: 50,000 – 200,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): none Eligibility Age (Disabled):


Eligible Income Level (Single): Sliding scale Eligible Income Level (Married): Sliding scale
Other Eligibility Notes:

FUNDING AND REIMBURSEMENT

Funding Source: Not available


Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid guidelines
Ingredient Cost Calculation: Discount of 20%-- negotiated by State
Enrollment Fee: None
Deductible Amount: Not available
Copayment Amount: Not available
Dispensing Fee: Not available

DRUGS COVERAGE

Formulary: Not available


Drugs Covered: Not available
Drug Coverage Restrictions: Not available

PROGRAM CONTACT

Michigan Department of Community Phone: 1-866-755-6479


Health

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Minnesota
Prescription Drug Program∗
Program Type: Direct Assistance
Year Operational: 1999
Number of Enrollees (January 2005): 7,500

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18-64


Eligible Income Level (Single): 120% of FPL Eligible Income Level (Married): 120% of FPL
Other Eligibility Notes: On July 1, 2002, the program expanded to include coverage for
persons on Medicare due to a disability. To be eligible, enrollees
must:
• Be a Medicare enrollee, age 65 or older, or disabled
• Be a Minnesota resident for six months
• Have liquid assets (other than home, car, burial funds, etc.) of
$10,000 or less for one person or $18,000 or less for a married
couple
• Not be eligible for Medicaid
• Not have prescription drug coverage within four months of
applying
• Not be enrolled in MinnesotaCare
• Be enrolled in, or applying for, one of the following Medicare
supplement programs, which help enrollees pay their Medicare
premiums: Qualified Medicare Beneficiary (QMB), or Service
Limited Medicare Beneficiary (SLMB).

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund plus manufacturer rebates


Budget (FY 05): $9 million (estimated)
Cost per Enrollee: Not available
# of Rx’s Per Enrollee: Not available
Manufacturer Rebate Type: Same as Medicaid
Ingredient Cost Calculation: AWP-11.5%
Enrollment Fee: None
Deductible Amount: $35.00 per month
Copayment Amount: None
Dispensing Fee: $3.65


Formerly the Senior Citizen Drug Program.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

DRUGS COVERAGE

Formulary: Minnesota Medicaid program formulary


Drugs Covered: Same drugs as covered under Medicaid if manufacturer signs rebate
agreement with Department of Human Services. Covers over-the-
counter drugs for antacid, insulin products, smoking cessation
products, lice medication and vitamins.
Drug Coverage Restrictions: Most other over-the-counter drugs are not covered.
Notes: The sunset date for this program is December 31, 2005. State officials
and lawmakers are in preliminary discussions on whether or not to
terminate the program and implement a revised plan that would
complement the Medicare Part D program.

PROGRAM CONTACT

Steve Hamilton Phone: 651/297-7699


Rebate Analyst E-mail: steve.hamilton@state.mn.us
Prescription Drug Program
Department of Human Services
444 Lafayette Road
St. Paul, MN 55155-3853

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Mississippi
Mississippi Seniors and Indigents Rx Program
Program Type: Coordinate Assistance Between Eligibles and Manufacturers’
Charitable Pharmaceutical Programs
Law enacted: July 2004

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): Not available Eligibility Age (Disabled): Not available
Eligible Income Level (Single): Not available Eligible Income Level (Married): Not available
Other Eligibility Notes: The program awaits implementation.

FUNDING AND REIMBURSEMENT

Funding Source: Federal funds and gifts, voluntary funding in the form of grants
available to build community, public sector and private sector
partnerships.
Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Not available
Ingredient Cost Calculation: Not available
Enrollment Fee: Not available
Deductible Amount: Not available
Copayment Amount: Not available
Dispensing Fee: Not available
Notes: The purpose of the program is to help seniors and qualified indigents
in accessing pharmaceutical manufacturers’ discount cards and
pharmaceutical assistance programs and to provide seniors and
qualified indigents with applications for those programs.

DRUGS COVERAGE

Formulary: Not available


Drugs Covered: Not available
Drug Coverage Restrictions: Not available

PROGRAM CONTACT

Larry Calvert, R. Ph. Phone: 601/576-7400


Chairman Fax: 228/896-4549
State Board of Health
Gulfport, MS 39505

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Missouri
SenioRx Program
Program Type: Direct Assistance
Year Operational: 2002
Number of Enrollees (January 2005): 17,500

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): Tier I: $12,000 Eligible Income Level (Married): Tier I: $17,000
Tier II: $17,000 Tier II: $23,000
Other Eligibility Notes: Applicant must be a Missouri resident and have lived in the state for 12
months by July 1, 2003. Applicants may not receive Medicaid or
veterans pharmacy benefits or have prescription insurance that is
equivalent to or greater than the Missouri SenioRx Program. Married
couples may have household income up to $25,000 before a $2,000
marital deduction.

FUNDING AND REIMBURSEMENT

Funding Source: Funding comes from the Missouri Senior Rx Fund, consisting of
enrollment fees and manufacturer rebates, and funds appropriated by
the General Assembly.
Budget (FY 05): $26.7 million
Cost Per Enrollee (FY 05): $800 per year
# of Rx’s Per Enrollee (FY 05): 32.4
Manufacturer Rebate Type: 15% for brand drugs; 11% for generic drugs
Ingredient Cost Calculation: AWP-10.43%
Enrollment Fee: $25.00 or $35.00, depending on income level
Deductible Amount: $250.00 or $500.00, depending on income level
Copayment Amount: 40% of prescription cost
Dispensing Fee: $4.09
Notes: Maximum annual benefit of $5,000.00
If an enrollee has already met the deductible and a brand name drug is
needed, the enrollee must pay: 1) the cost difference between the brand
name and generic drug and 2) 40% of the generic drug price.
If the enrollee has not met the deductible, the enrollee pays the full
cost of the brand name drug and the cost of the generic drug will be
applied to the deductible.

DRUGS COVERAGE

Formulary: None
Drugs Covered: Medicaid guidelines.

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Drug Coverage Restrictions: The following drugs are not covered: drugs manufactured by
companies that do not participate in the Missouri SenioRx rebate
program; over-the-counter (OTC) products; drugs used for weight gain
or anorexia; drugs used to promote fertility; cosmetic and hair growth
agents; cough and cold preparations; prescription strength vitamins;
barbiturates; benzodiazepines; insulin syringes and diabetic supplies;
food supplements; and medical equipment, devices and supplies. Use
of generics is encouraged.
Notes: The program requires the use of generic drugs whenever available. If
a drug is available in generic form, the program covers the brand name
drug only if the doctor determines it is necessary.
Discount cards cannot be used in conjunction with the program.
The program is to sunset, effective 12/13/05. There are, however,
several measures in the General Assembly to enable the Senior Rx
program to continue as a “wrap-around” program in conjunction with
the Medicare Part D program.

PROGRAM CONTACT

Jerry Simon Phone: 573/522-3064


Interim Director Fax: 573/522-3073
Missouri Senior Rx Program Email: simonj@dhss.mo.gov
Health and Senior Services
Department
P.O. Box 570
Jefferson City, MO 65102

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Montana
Prescription Drug Expansion Program
Program Type: Discount (CMS Pharmacy Plus Program Waiver)
Law Enacted: 2003*

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 62+ Eligibility Age (Disabled): Medicare


eligible
Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of FPL
Other Eligibility Notes: Montana resident

FUNDING AND REIMBURSEMENT

Funding Source: $1 million State loan and Federal funding


Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid equivalent
Ingredient Cost Calculation: Medicaid rate
Enrollment Fee: $25.00
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: See notes
Notes: Client is responsible for paying the dispensing fee. Dispensing fee set
at the discretion of each participating pharmacist. (This was done to
alleviate concerns that the pharmacists’ $4.70 dispensing fee for
Medicaid is inadequate.) State pays the discount rate of the
prescription drug and the “client” pays the remaining drug costs.
Discounts average between 6% and 25%.

DRUGS COVERAGE

Formulary: None
Drugs Covered: Based on participating manufacturers’ pharmaceutical products
Drug Coverage Restrictions: None

PROGRAM CONTACT

Duane Preshinger Phone: 406/444-4144


Section Supervisor Fax : 406/444-1861
Medicaid Services Bureau E-mail: dpreshinger@state.mt.us
Cogswell Building
1400 Broadway
Helena, MT 59620

*
The program will not be implemented given the passage of the Federal Medicare prescription drug program.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Montana
Pharmacy Access Prescription Drug Benefit Program
Program Type: Direct Assistance
Law Enacted: 2005*

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): Medicare Eligibility Age (Disabled): Medicare


enrollee enrollee
Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of FPL
Other Eligibility Notes:

FUNDING AND REIMBURSEMENT

Funding Source: Not available


Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Not available
Ingredient Cost Calculation: Not available
Enrollment Fee: Not available
Deductible Amount: Not available
Copayment Amount: Not available
Dispensing Fee: Not available
Notes: Program will pay premiums for Part D, and may pay deductibles if
funds are available.

DRUGS COVERAGE

Formulary: Not available


Drugs Covered: Not available
Drug Coverage Restrictions: Not available

PROGRAM CONTACT

Not available

*
The program is not yet operational.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Montana
Prescription Drug Plus Program
Program Type: Discount
Law Enacted: 2005*

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): See notes Eligibility Age (Disabled): See notes
Eligible Income Level (Single): 250% of FPL Eligible Income Level (Married): 250% of FPL
Other Eligibility Notes: No age limit. Must lack Rx coverage or have exhausted benefit.

FUNDING AND REIMBURSEMENT

Funding Source: Manufacturer negotiated rebates


Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Not available
Ingredient Cost Calculation: Medicaid rate
Enrollment Fee: Not available
Deductible Amount: Not available
Copayment Amount: Not available
Dispensing Fee: Not available
Notes:

DRUGS COVERAGE

Formulary: Not available


Drugs Covered: Not available
Drug Coverage Restrictions: Not available

PROGRAM CONTACT

Not available

*
The program is not yet operational.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Nevada
Senior Rx Insurance Subsidy for Prescription Drugs∗
Program Type: Subsidy
Year Operational: 2001
Number of Recipients (January 2005): 9,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 62+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): $22,434 Eligible Income Level (Married): $29,205
Other Eligibility Notes: Must be a Nevada resident for at least one year and not eligible for full
Medicaid benefits. Eligibility income levels will change every July
along with changes in consumer pricing.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco Settlement Fund


Budget (FY 05): $9.8 million
Cost per Participant (FY 05): $65 per member, per month
# of Rx’s Per Participant (FY 05): Not available
Manufacturer Rebate Type: Not available
Ingredient Cost Calculation: Brand: AWP-14%; Generics: lower of AWP-14% or CMS’ MAC rate
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: Retail Pharmacy Co-Pays (30-day fill): $10.00 for generics; $25.00
for preferred brand name drugs or medically necessary brand name
drugs; and provider’s discounted rate for all other drugs.
Mail Order Co-Pays (90-day fill): $20.00 for generics, $50.00 for
preferred brand name drugs or medically necessary brand name drugs.
Dispensing Fee: $2.25
Notes: Maximum benefit of $5,000.00 per year. An annual per enrollee
deductible of $100.00 is paid by the State to Pharmaceutical Care
Network (PCN), the pharmacy benefit manager that manages the
program.

DRUGS COVERAGE

Formulary: Managed formulary (by PCN)


Drugs Covered: Most prescription drugs


Formerly the Nevada Senior Rx.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Drug Coverage Restrictions: Coverage for generic and preferred brand name drugs is provided under
the Senior Rx Prescription Drug Program for the co-pay options
outlined above. If the prescription is for a non-preferred brand name
drug, coverage is available if the drug is determined to be medically
necessary. The copay for medically necessary non-preferred drugs is
$25.00. If the non-preferred drug is not medically necessary, or is
specifically excluded by the policy, it will cost 100% of the pharmacy
discount rate.
General exclusions for over-the-counter drugs; blood glucose meters;
insulin injecting devices; biologicals; durable medical equipment;
nutritional supplements; and cosmetic drugs.

PROGRAM CONTACT

Jane Smedes Phone: 775/687-8711


Department of Human Resources E-mail: jasmedes@dhr.state.nv.us
505 E. King Street, Room 201
Carson City, NV 89701-4797

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National Pharmaceutical Council Pharmaceutical Benefits 2004

New Hampshire
Senior Prescription Drug Discount Program*
Program Type: Discount
Year Operational: 2000
Number of Enrollees (January 2005): 70,000†

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: Must be a New Hampshire resident.

FUNDING AND REIMBURSEMENT

Funding Source: Rebates and incentives from pharmaceutical manufacturers negotiated


through Express Scripts, which operates the program.
Budget: The State has not had to fund the program, since it is based on rebates
and incentives.
Cost Per Enrollee: There is no associated cost per enrollee.
# of Rx’s Per Enrollee: Not available
Manufacturer Rebate Type: Rebates negotiated by Express Scripts with manufacturer.
Ingredient Cost Calculation: Not available
Deductible Amount: None
Enrollment Fee: None
Copayment Amount: Participant receives discount and must pay remainder of cost of
prescription.
Dispensing Fee: None
Notes: This program is offered solely at the discretion of Express Scripts.
Discounts vary depending on pharmacy and medication. Discounts
can be up to 16% for brand name products and up to 40% for generics.

DRUGS COVERAGE

Formulary: No formulary
Drugs Covered: All prescription drugs
Drug Coverage Restrictions: Over-the-counter drugs are not covered.
Notes: The State will likely offer some type of additional “wrap-around”
program to better integrate options with the Medicare Part D program.
Legislation is pending in the Legislature and very early discussions
have begun on a program framework and implementation.

*
The program is offered by Express Scripts and has no State funding.

Active number of participants about 12,000.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

PROGRAM CONTACT

Kim Hadank Swenson Phone: 603/271-7857


Health And Human Services
Division Of Elderly And Adult
Services
129 Pleasant Street
Concord, NH 03301

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National Pharmaceutical Council Pharmaceutical Benefits 2004

New Jersey
Pharmaceutical Assistance to the Aged and Disabled
(PAAD)
Program Type: Direct Assistance
Year Operational: 1975
Estimated Number of Recipients (January 2005): 191,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18-64


Eligible Income Level (Single): $20,437 Eligible Income Level (Married): $25,058
Other Eligibility Notes: Disabled individuals are only eligible if they receive Title II Social
Security Disability benefits. Married couples must file individual
PAAD applications. If an individual has health insurance or a retiree
prescription benefit equal to or better than PAAD, or if s/he receives
Medicaid, s/he is not eligible for the PAAD program.

FUNDING AND REIMBURSEMENT

Funding Source: State General Fund and Casino Revenue Fund


Budget (FY 05): $414 million
Cost per Participant (FY 05): Senior: $2,680.00 (estimated)
Disabled: $4,780.00 (estimated)
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP-12.5%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $5.00 per prescription
Dispensing Fee: $3.73 to $4.07

DRUGS COVERAGE

Formulary: No formulary
Drugs Covered: Legend drugs, insulin, syringes, insulin needles, certain diabetic testing
materials and syringes, and injectables used in treatment of multiple
sclerosis
Drug Coverage Restrictions: Drugs must be purchased in New Jersey, and must be covered by a
Manufacturer’s Rebate Agreement. Drug Efficacy Study
Implementation program (DESI) drugs are not covered. Generic drugs
must be dispensed unless physician requires brand name drug.
(Medical justification required in obtaining authorization for brand
version of multi-source drugs.)
All first-time prescriptions are limited to a 34-day supply. PAAD
allows for refills up to a 34-day supply or 100 unit doses, whichever is
greater. Program mandates an enhanced Drug Utilization Review
(DUR).

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Notes: The program will likely be restructured to better integrate options with
the Medicare Part D program. Preliminary changes are under
consideration but formal discussions have not started.

PROGRAM CONTACT

Wade Daniel Epps Phone: 609/588-3460


Director Fax: 609/588-7139
PAAD/Senior Gold Operations Email: wade.epps@doh.state.nj.us
P.O. Box 715
Trenton, NJ 08625-0715 Alternate contact:
Jennifer Barron
PAAD/Senior Gold Operations
E-mail: jennifer.barron@doh.state.nj.us

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National Pharmaceutical Council Pharmaceutical Benefits 2004

New Jersey
Senior Gold Prescription Discount Program
Program Type: Direct Assistance
Year Operational: 2001
Estimated Number of Recipients (January 2005): 29,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18-64


Eligible Income Level (Single): $20,437 - Eligible Income Level (Married): $25,058 -
$30,437 $35,058
Other Eligibility Notes: Senior citizens and disabled individuals eligible for the Pharmaceutical
Assistance for the Aged and Disabled program are not eligible for the
Senior Gold Prescription Discount Program. Disabled individuals are
only eligible if they receive Title II Social Security Disability benefits.
Program eligibility is required annually.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco Settlement Fund


Budget (FY 05): $24.9 million
Cost Per Participant (FY 05): Senior: $574.00 (projected)
Disabled: $764.00 (projected)
# of Rx’s Per Participant (FY 05): Senior: 25.4 (projected)
Disabled: 31.2 (projected)
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP-12.5%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $15.00 plus 50% of the remaining cost of the prescription or the actual
cost if less than $15.00. After unreimbursed out-of-pocket costs reach
$2,000.00 for an individual, or $3,000.00 for a couple, copayments for
additional prescriptions are $15.00 for the remainder of the year.
Dispensing Fee: $3.73 to $4.07
Notes: Once an enrollee incurs in one year unreimbursed out-of-pocket costs
of $2,000.00, if single, or $3,000.00, if married, prescriptions may be
obtained for the balance of that eligibility period for a flat $15.00
copayment or the actual price, if less than $15.00.

DRUGS COVERAGE

Formulary: No formulary
Drugs Covered: Legend drugs, insulin, syringes, insulin needles, certain diabetic testing
materials and syringes, and injectables used in treatment of multiple
sclerosis

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Drug Coverage Restrictions: Drugs must be purchased in New Jersey, and must be covered by a
Manufacturer’s Rebate Agreement. Drug Efficacy Study
Implementation program (DESI) drugs are not covered. Generic drugs
must be dispensed unless physician requires dispensing of brand name
drug. (Medical justification required in obtaining authorization for
brand version of multi-source drugs.)

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.

Notes: Program mandates an enhanced Drug Utilization Review (DUR).


The program will likely be restructured to better integrate options with
the Medicare Part D program. Preliminary changes are under
consideration but formal discussions have not started.

PROGRAM CONTACT

Wade Daniel Epps Phone: 609/588-3460


Director Fax: 609/588-7139
PAAD/Senior Gold Operations Email: wade.epps@doh.state.nj.us
P.O. Box 715
Trenton, NJ 08625-0715 Alternate contact:
Jennifer Barron
PAAD/Senior Gold Operations
E-mail: jennifer.barron@doh.state.nj.us

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National Pharmaceutical Council Pharmaceutical Benefits 2004

New Mexico
Senior Prescription Drug Program
Program Type: Discount
Operational Date: 2003
Number of Recipients (January 2005): 4,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: Must be a New Mexico resident and have no other prescription drug
benefit through private insurance or other government programs.

FUNDING AND REIMBURSEMENT

Funding Source: $10,000 left from State general funds


Budget: Not available
Cost per Recipient: Not available
# of Rx’s Per Recipient: Not available
Manufacturer Rebate Type: Negotiated by PBM with individual manufacturers
Ingredient Cost Calculation: Retail: AWP-12% for brand name drugs; AWP-50% for generics
Mail order: AWP-19.5% for brand name drugs; AWP-55% for
generics
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: See notes
Dispensing Fee: $3.50 – retail pharmacy; $1.50 – mail order
Notes: Cost of prescription is contracted discounted price plus dispensing fee.
For brand name prescriptions average discount is 13%; for generics
average discount is 50%. Express Scripts administers the pharmacy
benefit. The State receives an additional $2 for each prescription when
enrollees use mail order pharmacy.

DRUGS COVERAGE

Formulary: None
Drugs Covered: Manufacturers’ participating prescription drug products
Drug Coverage Restrictions: None
Notes:

PROGRAM CONTACT

Lauri Michael Phone: 505/848-9545


New Mexico Retiree Health Care Authority Fax: 505/983-8667
810 West San Mateo, Suite D E-mail: lauri@nmrhca.state.nm.us
Santa Fe, NM 87505

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New York
Elderly Pharmaceutical Insurance Coverage (EPIC)
Program
Program Type: Direct Assistance
Year Operational: 1987
Number of Recipients (January 2005): 348,269
ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level, Fee Plan $20,000 Eligible Income Level, Fee Plan $26,000
(Single): (Married):
Eligible Income Level, Deductible $20,001- Eligible Income Level, Deductible $26,001-
Plan (Single): $35,000 Plan (Married): $50,000
Other Eligibility Notes: Medicaid enrollees are not eligible.

FUNDING AND REIMBURSEMENT

Funding Source: State General Fund


Budget (FY 05): $851 million
Cost per Participant (FY 05): $2,083
# of Rx’s Per Participant (FY 05): Not available
Manufacturer Rebate Type: Full Medicaid rate (base rate plus Consumer Price Index penalty)
Ingredient Cost Calculation: AWP-16.5% or Federal Upper Limit (FUL) where available, on
generics and AWP-12.75% on brands
Enrollment Fee: $2.00 - $75.00 per quarter, based on income level
Deductible Amount: $530.00 - $1,715.00 annually, based on income level
Copayment Amount: $3.00 (prescription cost up to $15.00); $7.00 (prescription cost from
$15.01 to $35.00); $15.00 (prescription cost from $35.01 to $55.00);
and $20.00 (prescription cost over $55.00)
Dispensing Fee: $4.50 for generics and $3.50 for brand name drugs

DRUGS COVERAGE

Formulary: None
Drugs Covered: All legend drugs, insulin and insulin syringes and needles
Drug Coverage Restrictions: Drug Efficacy Study and Implementation program (DESI) drugs and non-
participating manufacturers excluded
Notes: There are several measures in the legislation to enable the EPIC program to
fully wraparound Part D if a senior joins Part D, and would waive EPIC
enrollment fees for participants that join Part D as a full subsidy individual.

PROGRAM CONTACT

Julie A. Naglieri, Acting Director Phone: 518/452-6828


NYS EPIC Program Fax: 518/452-6882
1 Corporate Plaza E-mail: jab15@health.state.ny.us
260 Washington Avenue Ext.
Albany, NY 12203

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North Carolina
Senior Care∗
Program Type: Direct Assistance
Year Operational: 2002
Number of Recipients (January 2005): 113,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+


Eligible Income Level (Single): 250% of FPL Eligible Income Level (Married): 250% of FPL
Other Eligibility Notes: Individuals must not be eligible for Medicaid benefits or have other
coverage for drugs covered by Senior Care.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco settlement funds


Budget (FY 05): Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP-10%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: 5%-10% of the prescription cost
Dispensing Fee: $4.90 (40 cents retained by claims processor)
Notes: Maximum annual prescription benefit of $600.00. Senior Care pays
for 60% of the first $1,000.00 of prescription costs, and members pay
the remaining 40%. Maximum benefit per year of $1,000

DRUGS COVERAGE

Formulary: None
Drugs Covered: All prescription drugs
Drug Coverage Restrictions: This program will not pay for over-the-counter drugs or potassium
supplements. Identical restrictions as those for the Medicare Discount Card.
Notes: Sunset date for this program is on December 31, 2005. There are no plans
addressing the Medicare Part D program as of yet, however legislation is
being considered.

PROGRAM CONTACT

Michael Keough Phone: 919/733-2040


Department of Health and Human E-mail: Michael.Keough@ncmail.net
Services
2001 Mail Service Center
Raleigh, NC 27699


Previously referred to as Carolina CaRxes in State legislation.

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Ohio
Golden Buckeye Prescription Drug Program
Program Type: Negotiated Discounts
Operational Date: 2003
Estimated Eligibles: 2 million

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 60+ Eligibility Age (Disabled): 18-59


Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: Must be an Ohio resident. The “Special Assistance Program” within
the Golden Buckeye Prescription Drug Program establishes further
savings for Medicare eligible beneficiaries who have no other
prescription drug assistance. Eligibility income levels for the “Special
Assistance Program” are: $30,000-individual; $40,000-married.

FUNDING AND REIMBURSEMENT

Funding Source: Manufacturer negotiated rebates, 50% of which go to a PBM for


running the program.
Budget: Based on manufacturers’ negotiated rebates
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Negotiated by PBM with individual manufacturers. Estimated savings
range from 5% to 40%.
Ingredient Cost Calculation: Reimbursement rate based on negotiated contract with each
participating manufacturer.
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: Not available
Notes: MemberHealth is the PBM administrator for the Golden Buckeye
Prescription Drug Program and the Ohio’s Best Rx Program.
Nineteen manufacturers are participating in the Golden Buckeye
Prescription Drug Program, including Solvay, Procter & Gamble
Pharmaceuticals, KOS, Boerhinger, Bausch & Lomb, Andrx Labs,
Bayer, Barr, Schering, Merck, Celltech, Abbott Labs, Daiichi, Novo
Nordisk, and Novartis.
Four manufacturers are participating in the Special Assistance
Prescription Drug Program within the Golden Buckeye Program:
GlaxoSmithKline, Novartis, Bristol Myers Squibb, and Merck.

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DRUGS COVERAGE

Formulary: Preferred Drug List


Drugs Covered: Drugs for which the PBM has negotiated rebates with manufacturers.
Drug Coverage Restrictions: None
Notes: MemberHealth conducts drug utilization reviews for these programs.

PROGRAM CONTACT

Gary Panek Phone: 614/466-3583


Manager of Golden Buckeye Program Fax: 614/466-8893
Department of Aging E-mail: gpanek@age.state.oh.us
50 W. Broad Street, 9th Floor
Columbus, OH 43215

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Ohio
Ohio’s Best Rx Program
Program Type: Negotiated Discounts
Year Operational: 2005
Number of Recipients (January 2005): 14,934

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 60 + Eligibility Age (Disabled): 18+


Eligible Income Level (Single): 250% of FPL Eligible Income Level (Married): 250% of FPL
Other Eligibility Notes: Enrollee must not have other outpatient prescription drug coverage.
No income requirements for those over 60.

FUNDING AND REIMBURSEMENT

Funding Source: Initially State funded; however, by January 2006 this program is expected
to be self-funded by obtaining rebates from drug manufacturers and
collecting a small administrative fee from participants.
Budget (FY 05): $10 million for start-up costs from the State
Cost per Participant (FY 05): $34.78
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Negotiated with each individual manufacturer. Estimated discounts range
between 20% and 40%.
Ingredient Cost Calculation: Based on contractual arrangements with participating manufacturers
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $1 transaction cost
Dispensing Fee: $3.00
Notes: Discounts are calculated from the average rebate paid by drug
manufacturers to State retirement and employees benefit plans. Up to 5%
of the money collected through manufacturers’ rebates may be used for the
contract with the PBM program administrator, MemberHealth.

DRUGS COVERAGE

Formulary: Open
Drugs Covered: Based on pharmaceutical manufacturers participating in the program.
Drug Coverage Restrictions: None
Notes:

PROGRAM CONTACT

Cynthia Burnell, Program Director Phone: 614/446-9783


Ohio's Best Rx Fax: 614/466-9181
Ohio Department of E-mail: burnec@odjff.state.oh.us
Job & Family Services
Office of Family Stability
145 S. Front St, 2nd Floor
Columbus, OH 43215

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Oklahoma
Pharmacy Connection Council Program*
Program Type: Coordinate Assistance Between Elderly and Manufacturers’
Pharmaceutical Programs
Year Operational: 2003
Number of Recipients: Not Available

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Medicare


eligible
Eligible Income Level (Single): Not available Eligible Income Level (Married): Not available
Other Eligibility Notes: Eligibility criteria may vary according to manufacturers’ programs.

FUNDING AND REIMBURSEMENT

Funding Source: None


Budget: None
Cost per Participant: None
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: None
Ingredient Cost Calculation: None
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: Not available
Notes: To obtain these free or discounted prescriptions, the individual must
complete an application on a form provided by the manufacturer of the
drug. One section is for the patient to complete and the other for the
prescriber. The doctor submits the application and the prescription to
the manufacturer. When approved, the manufacturer sends the free
drug to the doctor, who then gives it to the patient.

DRUGS COVERAGE

Formulary: None
Drugs Covered: Based on a manufacturer’s charitable program criteria.
Drug Coverage Restrictions: Not available

*
The Pharmacy Connection Council program assists eligible State residents in coordinating services from various
manufacturers’ charitable prescription assistance programs. The State does not contribute any money for the direct
purchase of prescription drugs.

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PROGRAM CONTACT

Nancy Davis Phone: 405/271-6576


Pharmacy Bureau Fax: 405/271-1308
State Dept. of Health General E-mail: Medicalfacilities@health.state.ok.us
1000 Northeast Tenth St
Oklahoma City, OK 73117

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Oklahoma
Oklahoma Prescription Drug Assistance Program*
Program Type: Discount
Law Enacted: 2005
Projected Number of Recipients: Not Available

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): See notes Eligibility Age (Disabled): See notes
Eligible Income Level (Single): See notes Eligible Income Level (Married): See notes
Other Eligibility Notes: No age limit, all uninsured residents are eligible. No income limit, but
enrollment fee for those above 150% FPL.

FUNDING AND REIMBURSEMENT

Funding Source: Manufacturer negotiated rebates


Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Not available
Ingredient Cost Calculation: Medicaid reimbursement
Enrollment Fee: Only for those above 150% FPL
Deductible Amount: Not available
Copayment Amount: Not available
Dispensing Fee: Not available
Notes:

DRUGS COVERAGE

Formulary: Not available


Drugs Covered: Not available
Drug Coverage Restrictions: Not available

PROGRAM CONTACT

Not available

*
The program is not yet operational.

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Oregon
Senior Prescription Drug Assistance Program*
Program Type: Discount
Operational Date: 2003
Number of Recipients (January 2005): 100

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+


Eligible Income Level (Single): 185% of FPL Eligible Income Level (Married): 185% of FPL
Other Eligibility Notes: Individuals must not be covered under any public or private prescription
drug benefit program for the previous six months and must have less than
$2,000.00 in liquid resources. Enrollees are issued enrollment cards that
entitle them to Medicaid prices.

FUNDING AND REIMBURSEMENT

Funding Source: Enrollment fees


Budget: None
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Not available
Ingredient Cost Calculation: Matches Medicaid rate or AWP-14%
Enrollment Fee: $50.00 annually
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $3.50 for retail pharmacy; $3.80 for institutional pharmacies
Notes : The law authorizing the program allows for coverage up to 50% of
pharmaceutical cost, with a maximum annual benefit of $2,000.00. The
program operates as a discount program based on voluntary participation
from pharmacies.

DRUGS COVERAGE

Formulary: None
Drugs Covered: All legend drugs
Drug Coverage Restrictions OTC drugs and medical supplies and medical equipment are not
covered.

*
Legislation was enacted in 2003 seeking a CMS waiver for the creation of the Medication Expansion for Disabled
Persons and Seniors (MEDS) program. MEDS would have expanded drug coverage for additional seniors’ 65 years of
age and older using a sliding scale, cost-share and co-insurance matrix based on income levels. The waiver has not
been approved to date. Oregon officials may not seek implementation of the program given the Medicare prescription
drug benefit enacted by Congress in 2003.

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PROGRAM CONTACT

Sandy Wood Phone: 503/945-6530


Program Manager Email: sandy.a.wood@state.or.us
Office of Medical Assistance
Programs
Human Services Building
500 Summer St. NE, E25
Salem, OR 97301-1098

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Pennsylvania
Pharmaceutical Assistance Contract for the Elderly
(PACE)
Type of Program: Direct Assistance
Year Operational: 1984
Number of Recipients (January 2005): 194,717

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): $14,500 Eligible Income Level (Married): $17,700
Other Eligibility Notes: Must be a resident of Pennsylvania for at least 90 days prior to the
date of application. Must establish intent to maintain a permanent
home in Pennsylvania for the indefinite future.

FUNDING AND REIMBURSEMENT

Funding Source: State Lottery, Tobacco Settlement funds


Budget (FY 05): $507 million
Cost per Participant (FY 05): $2,367
# of Rx’s Per Participant: 50.88
Manufacturer Rebate Type: 22% of Average Manufacturer Price
Ingredient Cost Calculation: Lesser of AWP-10% or usual and customary
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $9.00 for brand name drugs; $6.00 for generics
Dispensing Fee: $4.00
Notes: Quarterly reporting for Average Manufacturer Price (AMP) rebate
information.

DRUGS COVERAGE

Formulary: None
Drugs Covered: All Federal legend drugs and insulin, insulin syringes and needles
Drug Coverage Restrictions: 30-day supply or 100 units, whichever is less. No experimental
drugs, drugs for baldness and wrinkles, over-the-counter drugs, or
most off-label uses. Mandatory generic substitution for A-rated
(therapeutically equivalent) products. Drug Efficacy Study and
Implementation program (DESI) drugs require documentation of
medical necessity.

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PROGRAM CONTACT

Thomas Snedden Phone: 717/787-7313


Director, PACE Program Fax: 717/772-2730
Department of Aging E-mail: tsnedden@state.pa.us
555 Walnut Street, 5th Floor
Harrisburg, PA 17101-1919

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Pennsylvania
PACE Needs Enhancement Tier (PACENET)
Program Type: Direct Assistance
Year Operational: 1996
Number of Recipients (January 2005): 104,178

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): $14,500 to Eligible Income Level (Married): $17,700 to
$23,500 $31,500
Other Eligibility Notes: Must be a resident of Pennsylvania for at least 90 days prior to the date
of application.

FUNDING AND REIMBURSEMENT

Funding Source: State Lottery, Tobacco Settlement funds


Budget (FY 05-06): $507 million
Cost per Participant (FY 05-06): $1,503
# of Rx’s Per Participant: 43.40
Manufacturer Rebate Type: 22% of Average Manufacturer Price (AMP)
Ingredient Cost Calculation: Lesser of AWP-10% or usual and customary
Enrollment Fee: None
Deductible Amount: $480.00 per year ($40/month)
Copayment Amount: $15.00 for brand name drugs and $8.00 for generics
Dispensing Fee: $4.00
Notes: Quarterly reporting for Average Manufacturer Price (AMP) rebate
information.

DRUGS COVERAGE

Formulary: None
Drugs Covered: All Federal legend drugs and insulin, insulin syringes and needles
Drug Coverage Restrictions: 30-day supply or 100 units, whichever is less. No experimental drugs,
drugs for baldness and wrinkles, over-the-counter drugs, or most off-
label uses. Mandatory generic substitution for A-rated (therapeutically
equivalent) products. Drug Efficacy Study and Implementation
program (DESI) drugs require documentation of medical necessity.

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PROGRAM CONTACT

Thomas Snedden Phone: 717/787-7313


Director, PACE Program Fax: 717/772-2730
Department of Aging E-mail: tsnedden@state.pa.us
555 Walnut Street, 5th Floor
Harrisburg, PA 17101-1919

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Rhode Island
Rhode Island Pharmaceutical Assistance to the Elderly
(RIPAE)
Program Type: Direct Assistance, Discount
Year Operational: 1985
Number of Enrollees (January 2005): 38,500

ELIGIBILITY CRITERIA
Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 55-65
Eligible Income Level (Single): See notes Eligible Income Level (Married): See notes
Other Eligibility Notes: Income levels exclude income spent on medical expenses if greater
than 3% of total income.
FUNDING AND REIMBURSEMENT
Funding Source: State General Revenue Fund
Budget (FY 05): Not available
Cost per Enrollee (FY 05): Not available
# of Rx’s Per Enrollee (FY 05): Not available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP-13% for brand name drugs; MAC for generics
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: Participant pays co-pay of 40%, 70%, or 85% of prescription cost
depending on income levels. For members in the lowest income class,
the program will pay 100% of the cost of covered medications after the
member has paid $1,500.00 in copayments.
Dispensing Fee: $2.75
Notes: Participating pharmaceutical manufacturers must sign a rebate
agreement with the State for covered products.
DRUGS COVERAGE
Formulary: Open formulary
Drugs Covered: Drugs for Alzheimer’s disease, anti-infectives, arthritis, asthma and
other chronic respiratory conditions, cancer, circulatory insufficiency,
depression, diabetes (including insulin syringes), glaucoma, heart
problems, high cholesterol, hypertension, osteoporosis, Parkinson’s
disease, prescription mineral and vitamin supplements for renal
patients, and urinary incontinence.
Drug Coverage Restrictions: Non-cosmetic Food and Drug Administration approved drugs that
were not previously listed are covered at the program’s discount price
or at the Federal MAC price, whichever is lower.
Notes: Program officials have begun preliminary discussions on using the
RIPAE program as a “wrap-around” program once the Medicare
Prescription Drug Program (Part D) is operational. Specific criteria
have yet to be determined.

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PROGRAM CONTACT
Kristin Pono Phone: 401/462-0510
Rhode Island Dept. of Elderly Affairs Fax: 401/462-0586
Benjamin Rush Building #55
35 Howard Avenue
Cranston, RI 02920

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Rhode Island
Rhode Island Pharmacy Prescription Drug Discount
Program for the Uninsured
Program Type: Cash Discount
Year Operational: 2005∗
Number of Enrollees: Not Available

ELIGIBILITY CRITERIA
Eligibility Age (Elderly): 19-65 Eligibility Age (Disabled): 19-65
Eligible Income Level (Single): 200% (FPL) Eligible Income Level (Married): 200% (FPL)
Other Eligibility Notes: Must be uninsured with no prescription drug coverage. Family income
may not exceed 200 percent of the Federal poverty level (FPL).
FUNDING AND REIMBURSEMENT
Funding Source: PBM negotiated contracts with manufacturers
Budget (FY 05): Not available
Cost per Enrollee (FY 05): Not available
# of Rx’s Per Enrollee (FY 05): Not available
Manufacturer Rebate Type: PBM negotiated contracts with pharmaceutical manufacturers
Ingredient Cost Calculation: Criteria based on the lower of the usual and customary or:
AWP-15% (retail –brand); AWP-17% (retail – mail); Retail generic:
CMS MAC rate or AWP-40%; Mail-order generic: CMS MAC rate or
AWP-50%.
Enrollment Fee: Annual, non-refundable enrollment fee, up to $30, may be charged.
Deductible Amount: Not available
Copayment Amount: Not available
Dispensing Fee: Not available
Notes: Request for Proposal (RFP) is under evaluation. Specific funding and
reimbursement criteria will be determined based on the winning
vendor bid from pharmacy benefits manager (PBM).
DRUGS COVERAGE
Formulary: To be determined based on winning RFP bid.
Drugs Covered: To be determined based on winning RFP bid.


Program is scheduled to begin May 2005; however, the Request For Proposal (RFP) is still under evaluation, as of
April 1, 2005.

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PROGRAM CONTACT
Kristin Pono Phone: 401/462-0510
Rhode Island Dept. of Elderly Affairs Fax: 401/462-0586
Benjamin Rush Building #55
35 Howard Avenue
Cranston, RI 02920

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National Pharmaceutical Council Pharmaceutical Benefits 2004

South Carolina
SilveRxCard Senior Prescription Drug Program
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 2003
Number of Enrollees (January 2005): 53,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of FPL
Other Eligibility Notes: Must be a South Carolina resident. Must be ineligible for Medicaid
with no prescription benefits from any other source.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco Settlement Fund and Federal matching funds


Budget (FY 05): $14 million
Cost per Enrollee: Not available
# of Rx’s Per Enrollee : 4 per month
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP-10%
Enrollment Fee: None
Deductible Amount: $500.00 per calendar year
Copayment Amount: Members receive discounts up to 10% on prescriptions until the
deductible is met. After the $500.00 deductible, the copayment is
$10.00 for generic drugs, $15.00 for brand name drugs, and $21.00 for
drugs requiring prior authorization.
Dispensing Fee: $4.05

DRUGS COVERAGE

Formulary: Same as Medicaid


Drugs Covered: Same as Medicaid
Drug Coverage Restrictions: Some drugs require prior authorization. SilveRxCard covers up to a 34
days’ supply of medication and generally 4 covered prescriptions or
refills during a calendar month. Overrides of the monthly limit are
allowed for some conditions, including acute sickle cell disease,
behavioral health disorder, cancer, cardiac disease, diabetes,
HIV/AIDS, hypertension, and terminal illnesses.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Notes: Brand name drugs are dispensed when generic drugs are not available.
Over-the-counter drugs are paid for when authorized with a
prescription. Insulin syringes, insulin, or other injectable products that
are either administered at home or self-administered are also covered.
Diabetic supplies such as alcohol wipes and test strips; smoking
cessation products; certain lifestyle drugs; and, injectable products
administered in a physician’s office or clinic are not covered.
The program will likely be restructured to better integrate options with
the Medicare Part D program. Legislation is being discussed but
specific details have yet to be announced. An effort to expand drug
coverage through the South Carolina Retirees and Individuals Pooling
Together for Savings (SCRIPTS) Program has been postponed due to
the Federal Medicare prescription drug coverage program.

PROGRAM CONTACT

Frank Williams Phone: 803/898-2511


SilveRxCard General E-mail: info@dhhs.state.sc.us
Office of Insurance Services
1201 Main Street, Suite 350
Columbia, SC 29201

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South Dakota
Senior Citizen Prescription Drug Benefit Program
Program Type: Negotiated Discount
Year Operational: 2003*
Number of Enrollees (December 2003): 36,361

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): All Medicare Eligibility Age (Disabled): All Medicare
eligibles eligibles
Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: Must be a resident of South Dakota. Medicaid recipients are not
eligible.

FUNDING AND REIMBURSEMENT

Funding Source: Not available


Budget: Not available
Cost per Enrollee: Not available
# of Rx’s Per Enrollee: Not available
Manufacturer Rebate Type: PBM negotiated discounted prescription costs rather than trying to set
mandatory price reductions. Prescription discounts averaged between
15% and 20%.
Ingredient Cost Calculation: AWP-10.5%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $3.50

DRUGS COVERAGE

Formulary: None
Drugs Covered: All prescription drugs
Drug Coverage Restrictions: None

PROGRAM CONTACT

Larry Kucker Phone: 605/773-3148


Bureau of Personnel Fax: 605/773-4344
500 East Capitol Avenue
Pierre, SD 57501

*
This program was repealed by legislation, effective September 1, 2004.

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Tennessee
TennCare Rx
Program Type: Direct Assistance (1115 Waiver)
Law Enacted: 2003*
Number of Recipients: None

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): To be Eligibility Age (Disabled): To be


determined determined
Eligible Income Level (Single): To be Eligible Income Level (Married): To be
determined determined
Other Eligibility Notes: Chapter Number 350 of the Public Acts of 2003 says only that this
program is “intended to provide a prescription drug benefit to
individuals lacking prescription drug insurance coverage who meet
criteria established by the Bureau of TennCare and the General
Assembly in its annual appropriations bill.” These criteria have yet to
be established.

FUNDING AND REIMBURSEMENT

Funding Source: State and Federal funds


Budget: None
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Rebates negotiated by State or by State PBM with manufacturers.
Ingredient Cost Calculation: Not available
Enrollment Fee: Authorized by enacting legislation but not yet specified.
Deductible Amount: None
Copayment Amount: Authorized by enacting legislation but not yet specified.
Dispensing Fee: Not available
Notes: Enacting legislation provides that program participants may purchase
drugs through pharmacies participating in the State network.

DRUGS COVERAGE

Formulary: State PDL


Drugs Covered: Not available
Drug Coverage Restrictions: Enacting legislation authorizes, but does not specify, prior
authorization and step therapy requirements.

PROGRAM CONTACT

Jeff Stockard, Associate Director Phone: 615/ 741-0213


TennCare Pharmacy Bureau E-mail: Jeff.Stockard@state.tn.us
729 Church Street
Nashville, Tennessee 37247

*
This program has not yet been implemented.

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Texas
Kidney Health Care Program (KHC)
Program Type: Direct Assistance
Year Operational: 1999
Number of Recipients (January 2005): 17,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): None Eligibility Age (Disabled): None


Eligible Income Level (Single): $60,000 Eligible Income Level (Married): $60,000
Other Eligibility Notes: To be eligible for KHC benefits the following criteria must be met:
1) Texas residency must be documented; 2) end-state renal disease
(ESRD) must be certified; 3) applicant must be receiving a regular
course of chronic renal dialysis treatments or have received a kidney
transplant; 4) an application for benefits must be submitted through a
Medicare approved hospital, VA facility, or KHC approved facility;
5) an application for ESRD benefits must be filed with Medicare; and
6) KHC-established financial criteria must be met. Medicaid
recipients are not eligible for this program.

FUNDING AND REIMBURSEMENT

Funding Source: State funds


Budget (FY 04-05): $38.7 million
Cost per Participant (FY 04): Approximately $1,473
# of Rx’s Per Participant (FY 04): Approximately 2 per month
Manufacturer Rebate Type: Voluntary
Ingredient Cost Calculation: AWP-15% or WAC+12%, whichever is lowest
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $6.00
Dispensing Fee: $5.14

DRUGS COVERAGE

Formulary: Closed formulary


Drugs Covered: Drugs for end-state renal disease and transplants
Drug Coverage Restrictions: Restricted to drugs for end-state renal disease and transplants

PROGRAM CONTACT

Lisa Rodriguez, M. Ed. Phone: 512/458-7150


Manager, Customer Services Fax: 512/456-7162
Kidney Health Care Program
Department of State Health Services
1100 West 49th Street (1938)
Austin, TX 78756

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Texas
State Prescription Drug Program
Program Type: Subsidy
Law Enacted: 2001∗
Estimated Eligibles: None

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): 100% of FPL Eligible Income Level (Married): 100% of FPL
Other Eligibility Notes: Upper income limits may increase if funding becomes available. However,
the categories most likely to qualify for the program at proposed FY 04-05
funding levels are Qualified Medicare Beneficiaries (QMBs) and Specified
Low-Income Medicare Beneficiaries (SLMBs).

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund, unless funds are available under Federal law
to fund all or part of the program
Budget: None
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Not available
Ingredient Cost Calculation: Not available
Enrollment Fee: Not available
Deductible Amount: Not available
Copayment Amount: Not available
Dispensing Fee: Not available
Notes: According to statute, the Health and Human Services Commission may
require a cost-sharing payment.

DRUGS COVERAGE

Formulary: Not available


Drugs Covered: Not available
Drug Coverage Restrictions: Not available
Notes: The Health and Human Services Commission may require that, unless the practitioner’s signature on
a prescription clearly indicates that the prescription must be dispensed as written, the pharmacist
may select a generic equivalent of the prescribed drugs. The Health and Human Resources
Commission is also authorized to establish a formulary, prior authorization requirements, and a drug
utilization program.

PROGRAM CONTACT

Sharon Carter Phone: 512/424-6514


Health and Human Services Commission
P.O. Box 13247
Austin, TX 787111-3247


This program has not been implemented due to the fact that no funding has been budgeted.

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Vermont
VSCRIPT
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 1989∗
Number of Eligibles (February 2005): 2,752

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): All ages


Eligible Income Level (Single): 150% - 175% Eligible Income Level (Married): 150% - 175%
of FPL of FPL

FUNDING AND REIMBURSEMENT

Funding Source: Federal and State funds


Budget (FY 05): $5.5 million
Cost per Participant (FY 05): $155.90 per month
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP-11.9%
Enrollment Fee: $17.00 per month
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $4.25

DRUGS COVERAGE

Formulary: Preferred Drug List


Drugs Covered: Maintenance drugs covered by Medicaid
Drug Coverage Restrictions: No experimental or over-the-counter drugs, except Prilosec OTC and
Loratadine.

PROGRAM CONTACT

Esther Perlman Phone: 802/879-5900


Office of Vermont Health Access Fax: 802/879-5962
103 South Main Street
Waterbury, VT 05676


This program was integrated into the VHAP (1115 waiver) program in 1999.

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Vermont
VSCRIPT Expanded
Program Type: Direct Assistance
Year Operational: 2000
Number of Recipients (February 2005): 2,665

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): All ages


Eligible Income Level (Single): 175% - 225% Eligible Income Level (Married): 175% - 225%
of FPL of FPL

FUNDING AND REIMBURSEMENT

Funding Source: State General Fund


Budget (FY 05): $5.7 million
Cost per Participant (FY 05): Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid equivalent
Ingredient Cost Calculation: AWP-11.9%
Enrollment Fee: $35.00 per month
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $4.25

DRUGS COVERAGE

Formulary: Preferred Drug List


Drugs Covered: Medicaid covered maintenance drugs under separate manufacturer’s
rebate agreement
Drug Coverage Restrictions: No experimental or over-the-counter drugs, except Prilosec OTC and
Loratadine.

PROGRAM CONTACT

Esther Perlman Phone: 802/879-5900


Office of Vermont Health Access Fax: 802/879-5962
103 South Main Street
Waterbury, VT 05676

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Vermont
Vermont Health Access Plan (VHAP) Pharmacy
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 1996
Number of Recipients (February 2005): 8,465

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Medicare


eligible
Eligible Income Level (Single): 150% of FPL Eligible Income Level (Married): 150% of FPL
Other Eligibility Notes: Medicaid recipients are not eligible. Individuals may not have any
other prescription drug insurance.

FUNDING AND REIMBURSEMENT

Funding Source: Federal and State funds


Budget (FY 05): $15.4 million
Cost per Participant (FY05): Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP-11.9%
Enrollment Fee: $13.00 per month
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $4.25

DRUGS COVERAGE

Formulary: Preferred Drug List


Drugs Covered: All drugs covered by Vermont Medicaid, including insulin and insulin
syringes.
Drug Coverage Restrictions: No experimental or over-the-counter drugs, except Prilosec OTC and
Loratadine.

PROGRAM CONTACT

Esther Perlman Phone: 802/879-5900


Office of Vermont Health Access Fax: 802/879-5962
103 South Main Street
Waterbury, VT 05676

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Vermont
Healthy Vermonters Program
Program Type: Direct Assistance (1115 Waiver)
Year Operational: July 1, 2002
Eligible Recipients (February 2005): 13,469

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Medicare


eligible
Eligible Income Level (Single): 400% of FPL Eligible Income Level (Married): 400% of FPL
Other Eligibility Notes: Vermont residentsof any age with incomes at or below 300% FPL are
also eligible. This program is for those who have no insurance for
prescriptions or those who have a commercial insurance plan with a
yearly limit. This program also covers drugs for acute conditions for
VScript or VScript Expanded beneficiaries (up to 225% of FPL) who
previously received a benefit only for maintenance drugs. VScript and
VScript Expanded beneficiaries will be automatically enrolled in
Healthy Vermonters and have the advantage of Healthy Vermonters
benefits for prescriptions not covered under the VScripts programs.

FUNDING AND REIMBURSEMENT

Funding Source: None


Budget (FY 05): None
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Not available
Ingredient Cost Calculation: AWP-11.9%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing fee: $4.25
Note: Beneficiary purchases drugs at the Medicaid payment rate.

DRUGS COVERAGE

Formulary: Medicaid Formulary


Drugs Covered: Drugs covered by Medicaid
Drug Coverage Restrictions: No experimental or over-the-counter drugs

PROGRAM CONTACT

Esther Perlman Phone: 802/879-5900


Office of Vermont Health Access Fax: 802/879-5962
103 South Main Street
Waterbury, VT 05676

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Washington
Pharmacy Connections
Program Type: Coordinate Assistance Between Elderly and Manufacturers’
Pharmaceutical Programs
Year Operational: 2003
Number of Individuals Assisted (2004): 26,000∗

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): None Eligibility Age (Disabled): None


Eligible Income Level (Single): None Eligible Income Level (Married): None
Other Eligibility Notes: Pharmacy Connections provides toll-free telephone assistance for
Washington residents to get information about manufacturer-
sponsored prescription drug assistance programs and to assist them
with applying for these programs. The program also serves as a one-
stop “clearinghouse” to provide information on other prescription drug
resources such as the Medicare discount cards and the Rx Washington
Card program. Although the program specifically targets senior
citizens, it is open to all Washington residents.

FUNDING AND REIMBURSEMENT

Funding Source: State funds


Budget (FY 04-05): $750,000
Cost per Participant: Not available
# of Rx’s Per Participant: Not applicable
Manufacturer Rebate Type: Not applicable
Ingredient Cost Calculation: Not applicable
Enrollment Fee: None
Deductible Amount: Not applicable
Copayment Amount: Not applicable
Dispensing Fee: Not applicable

DRUGS COVERAGE

Formulary: Not applicable


Drugs Covered: Not applicable


The program provided 15,000 individuals with referral information for drug manufacturer-sponsored patient assistance
programs and drug discount cards. The program also helped 11,000 individuals complete applications. These numbers
are expected to increase dramatically based on confusion surrounding implementation of the Medicare prescription drug
benefit in 2006.

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PROGRAM CONTACT

Erika Clayton Phone: 206/521-2027


Project Coordinator
Prescription Drug Program
Health Care Authority
P.O. Box 91132
Seattle, WA 98111-9232

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Washington
Rx Washington Card
Program Type: Direct Discounts
Year Operational: 2004
Number of Recipients (February 2005): 50∗

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 50+ Eligibility Age (Disabled): 19-49


Eligible Income Level (Single): 300% of FPL Eligible Income Level (Married): 300% of FPL
Other Eligibility Notes: Individuals may not have any other prescription drug insurance
coverage or prescription drug benefits.

FUNDING AND REIMBURSEMENT

Funding Source: None


Budget: None
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Discounts of 15%-20% negotiated by Express Scripts, Inc.
Ingredient Cost Calculation: Pass-through negotiated by Express Scripts. In 2004, the average for
brand name drugs was AWP-16.4%; for generics AWP-63.5%.
Enrollment Fee: $10.00
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: Ranges from $2.00 to $2.50, depending on pharmacy.

DRUGS COVERAGE

Formulary: PBM formulary


Drugs Covered: Not available
Drug Coverage Restrictions: None
Notes: State officials wanted to use a State-sponsored PDL; however, the
PBM would not agree to these terms, as the program’s overall market
share is not large enough.


Enrollment in Rx Washington has remained low due to a variety of factors, including: (1) availability of the Medicare
drug discount card; (2) provisions in law preventing negotiated discounts from hurt retail pharmacies; (3) the existence
of programs offered by drug manufacturers; and (4) the fact that the program is mail order only.

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PROGRAM CONTACT

Erika Clayton Phone: 206/521-2027


Project Coordinator
Prescription Drug Program
Health Care Authority
P.O. Box 91132
Seattle, WA 98111-9232

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Washington
Medicaid Prescription Drug Assistance Program
Program Type: Direct Assistance (1115 Waiver)
Law Enacted: 2003∗
Number of Recipients: None

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18-64


Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of FPL
Other Eligibility Notes: Must not be Medicaid eligible and must lack prescription drug
insurance coverage. Enacting legislation provides that enrollment may
be limited to prevent over expenditure or to comply with Federal
waiver budget neutrality requirements.

FUNDING AND REIMBURSEMENT

Funding Source: State and Federal funds


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: Authorized by enacting legislation but not specified.
Deductible Amount: Authorized by enacting legislation but not specified.
Copayment Amount: Authorized by enacting legislation but not specified.
Dispensing Fee: Not available
Notes: Enacting legislation provides that the benefit design may differ from
the Medical Assistance Program benefit design, that more than one
benefit design may be offered, and that it may include a deductible
benefit to provide coverage when enrollees incur higher prescription
drug costs.

DRUGS COVERAGE

Formulary: Not available


Drugs Covered: Not available
Drug Coverage Restrictions: Not available


The program has not been implemented. The State decided not to pursue the requisite 1115 demonstration waiver
after passage of the Medicare Prescription Drug Improvements and Modernization Act of 2003.

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PROGRAM CONTACT

Erika Clayton Phone: 206/521-2027


Project Coordinator
Prescription Drug Program
Health Care Authority
P.O. Box 91132
Seattle, WA 98111-9232

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West Virginia
Golden Mountaineer Card Program
Program Type: Direct Assistance
Year Operational: 2001
Number of Recipients (2004): 14,000-16,000/month*

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 60+ Eligibility Age (Disabled): 60+


Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: Must be a resident of West Virginia.

FUNDING AND REIMBURSEMENT

Funding Source: Lottery funds and State General Fund


Budget (FY 05): $25,000
Cost per Participant: Not available
# of Rx’s Per Participant (2004): 33
Manufacturer Rebate Type: Rebates negotiated by PBM (Caremark) with individual manufacturers
Ingredient Cost Calculation: AWP-13% for brand name drugs and generics and AWP-60% for
MAC drugs.
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $3.50
Notes: Enrollees will receive discounts set by PBM.

DRUGS COVERAGE

Formulary: None
Drugs Covered: All FDA Federal legend pharmaceuticals and diabetic supplies
Drug Coverage Restrictions: None

PROGRAM CONTACT

Jan Bowen Phone: 304/558-3317


Bureau of Senior Services Fax: 304/558-0004
Holly Grove, Building No. 10
Charleston, WV 25305-0160

*
There are a total of 360,000 eligible seniors for the Gold Mountaineer Card Program. Monthly card usage varies.

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West Virginia
West Virginia Prescription Drug Assistance Clearinghouse
Program
Program Type: Coordinate Assistance Between Elderly and Manufacturers’
Pharmaceutical Programs
Law Enacted: April 2004

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): Not available Eligibility Age (Disabled): Not available
Eligible Income Level (Single): 200% FPL Eligible Income Level (Married): 200% FPL
Other Eligibility Notes: Uninsured West Virginia residents who have had no coverage for at
least 6 months.

FUNDING AND REIMBURSEMENT

Funding Source: Brand name drug manufacturers


Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: Not available
Ingredient Cost Calculation: Not available
Enrollment Fee: Not available
Deductible Amount: Not available
Copayment Amount: Not available
Dispensing Fee: $3.50
Notes: Pharmacies participating in the voluntary program(s) will be
responsible for no more than fifty percent of the discount offered by
the manufacturer to the participant.

DRUGS COVERAGE

Formulary: None
Drugs Covered: None
Drug Coverage Restrictions: None
Notes: The clearinghouse portion of the program assists low-income State residents or uninsured to gain
access to existing manufacturers’ private and public sector prescription drug assistance programs
offered by manufacturers. The discount drug program provides low-income, uninsured individuals
prescription drugs from participating brand pharmaceutical companies and pharmacists through
either a State-sponsored discount card program or a program extending current brand
pharmaceutical manufacturer prescription drug assistance programs.

PROGRAM CONTACT

Robert W. Ferguson, Jr., Phone: 304/558-4331


Cabinet Secretary Fax: 304/558-2999
State Capitol Complex, Room E-119 E-mail: rferguson@wvadmin.gov
Charleston, West Virginia 25305

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Wisconsin
SeniorCare Prescription Drug Assistance Program
Program Type: Direct Assistance
Year Operational: 2002
Estimated Enrollment (March 2005): 88,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): N/A


Eligible Income Level (Single): See note Eligible Income Level (Married): See note
Other Eligibility Notes: Person must not be a recipient of medical assistance and must be a
resident of the State. The State implemented four participation levels
for the program and each has a corresponding out-of-pocket expense
and/or co-pay amount.
SeniorCare level FPL
Level 1 up to 160%
Level 2a between 160% and 200%
Level 2b between 200% and 240%
Level 3 greater than 240%

FUNDING AND REIMBURSEMENT

Funding Source: State general revenue and Federal funding.


Budget (FY 03-05): $79.6 million in State general revenue
Cost per Participant: $1,914
# of Rx’s Per Participant: 46
Manufacturer Rebate Type: Manufacturers must sign separate SeniorCare rebate agreement with
the State.
Ingredient Cost Calculation: AWP-13% or MAC. The National Drug Code (NDC) innovator price
will be paid when “Brand Medically Necessary” is handwritten on the
prescription by the physician and prior authorization is granted.
Enrollment Fee: $30.00
Deductible Amount: Level 1: No deductible.
Level 2a: $500 deductible per person and pay SeniorCare rate
for drugs.
Level 2b: $850 deductible per person and pay SeniorCare rate
for drugs.
Level 3: Pay retail price for drugs equal to the difference
between your income and $22,968 per individual or
$30,792 per couple. This is called "spenddown."
During “spenddown”, no discount for drugs. After
“spenddown”, meet an $850 deductible per person but
pay SeniorCare rate for covered drugs.

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Copayment Amount: Level 1: $15 co-pay for covered brand name drugs, $5 co-pay
for covered generics
Level 2a: After $500 deductible, $15 co-pay for covered brand
name drugs, $5 co-pay for covered generics
Level 2b: After $850 deductible, $15 co-pay for covered brand
name drugs, $5 co-pay for covered generics
Level 3: After spenddown and an $850 deductible are met, $15
co-pay for covered brand name drugs, $5 co-pay for
covered generics
Dispensing Fee: $4.88

DRUGS COVERAGE

Formulary: PDL
Drugs Covered: Manufacturers’ products that have a signed SeniorCare rebate
agreement
Drug Coverage Restrictions: Reimbursement for most drugs is limited to a 34-day supply. Some
maintenance drugs may be provided in a 100-day supply.
A preferred drug list (PDL) has been implemented.

PROGRAM CONTACT

Pamela S. Appleby Phone: 608/266-7685


Budget & Policy Analyst Fax: 608/266-1096
Division of Health Care Financing
1 West Wilson Street
P.O. Box 309
Madison, WI 53701-0309

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Wyoming
Prescription Drug Assistance Program
Program Type: Direct Assistance
Year Operational: 2003
Number of Recipients (FY 2004): 1,066 (monthly average)*

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages
Eligible Income Level (Single): 100% of FPL Eligible Income Level (Married): 100% of FPL
Other Eligibility Notes: Medicaid enrollees are not eligible for this program. Also, an asset
test was implemented effective July 1, 2004. The asset test takes into
account motor vehicles worth more than $15,000 and resources in
excess of $2,500. Homes are exempt.

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund


Budget (FY 04-05): $4 million
Cost per Participant (FY 04-05): $135.56 per month
# of Rx’s Per Participant (FY 04- 2.17 per month
05):
Manufacturer Rebate Type: Voluntary manufacturer rebate. (Program may shift to mandatory
rebates in future.)
Ingredient Cost Calculation: AWP-11%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $10.00 for generics and $25.00 for brand-name drugs
Dispensing Fee: $5.00
Notes: Maximum 3 prescriptions per month

DRUGS COVERAGE

Formulary: Medicaid PDL


Drugs Covered: Any FDA approved prescription medications
Drug Coverage Restrictions: No smoking cessation agents, hair growth products, anorexiant
products, cosmetic agents (e.g., retin-A), weight gain agents (e.g.,
anabolic steroids), or fertility promotion agents. One month supply
restriction.

*
Program closed to new enrollment effective July 1, 2003.

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PROGRAM CONTACT

Susan Malm Phone: 307/777-5548


Community and Family Health Fax: 307/777-6964
Division
Hathaway Bldg, Rm 157
2300 Capitol Ave.
Cheyenne, WY 82002

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Appendix A:
State and Federal
Medicaid Contacts

A-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

STATE MEDICAID DRUG PROGRAM ADMINISTRATORS, 2004

ALABAMA CALIFORNIA
Louise F. Jones J. Kevin Gorospe, Pharm.D.
Director Chief, Pharmacy Policy Unit
Pharmacy Services California Department of Health Services
Alabama Medicaid Agency Medi-Cal Policy Division
501 Dexter Avenue Pharmacy Contracting and Policy Section
P.O. Box 5624 1501 Capitol Avenue
Montgomery, AL 36103-5624 P.O. Box 997413, MS 4604
T: 334/242-5039 Sacramento, CA 95814
F: 334/353-7014 T: 916/552-9500
E-mail: lljones@Medicaid.state.al.us F: 916/552-9563
Internet address: www.medicaid.state.al.us E-mail: jgorospe@dhs.ca.gov
Internet address: http://www.medi-cal.ca.gov
ALASKA
COLORADO
Dave Campana, R.Ph.
Pharmacy Program Manager Martha Warner
Division of Health Care Services Pharmacy Supervisor
4501 Business Park Blvd., Suite 24 Department of Health Care Policy and Financing
Anchorage, AK 99503 1570 Grant Street
T: 907/334-2425 Denver, CO 80203
F: 907/561-1684 T: 303/866-3176
E-mail: david_campana@health.state.ak.us F: 303/866-2573
Internet address: www.hss.state.ak.us/dhcs E-mail: martha.warner@state.co.us

CONNECTICUT
ARIZONA
Evelyn A. Dudley
Dell Swan
Manager, Pharmacy Unit
Pharmacy Program Administrator
Department of Social Services, Medical Operations
AHCCCS
25 Sigourney Street
701 East Jefferson Street
Hartford, CT 06106-5033
MD 8000
T: 860/424-5654
Phoenix, AZ 85034
F: 860/424-5206
T: 612/417-4726
E-mail: evelyn.dudley@po.state.ct.us
E-mail: dwswan@ahcccs.state.az.us
Internet address: www.dss.state.ct.us
Internet address: www.ahcccs.state.az.us

DELAWARE
ARKANSAS
Cynthia R. Denemark, R.Ph.
Suzette Bridges, P.D., Administrator
Director of Pharmacy Services
Pharmacy Program
DSS/EDS
Department of Human Services
248 Chapman Road, Suite 100
Division of Medical Services
Newark, DE 19702
P.O. Box 1437, Slot 415
T: 302/453-8453
Little Rock, AR 72203-1437
F: 302/454-0224
T: 501/683-4120
E-mail: Cynthia.denemark@eds.com
F: 501/683-4124
Internet address: www.dmap.state.de.us
E-mail: suzette.bridges@medicaid.state.ar.us

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National Pharmaceutical Council Pharmaceutical Benefits 2004

DISTRICT OF COLUMBIA IDAHO


Cheryl S. Wilson Ike Gayfield
Risk Manager – Pharmacy/DME Bureau Chief – Acting Pharmacy Manager
Department of Health Department of Health and Welfare
Medical Assistance Administration Division of Medicaid
825 North Capitol Street, NE, Suite 5135 3232 Elder
Washington, DC 20002 Boise, ID 83705
T: 202/442-9078 T: 208/364-1829
F: 202/442-4790 F: 208/364-1864
E-mail: cheryl.wilson@dcgov.org E-mail: gayfieldi@idhw.state.id.us
Internet address: www.healthandwelfare.idaho.gov
FLORIDA
ILLINOIS
Jerry F. Wells
Bureau Chief Pamela Bunch
Medicaid Pharmacy Services Medicaid Pharmacy Manager
Agency for Healthcare Administration Services Department of Public Aid
2727 Mahan Drive, MS 38 201 S. Grand Avenue East
Tallahassee, FL 32308 Springfield, IL 62763
T: 850/487-4441 T: 217/524-7478
F: 850/922-0685 F: 217/524-7535
E-mail: wellsj@ahca.myflorida.com E-mail: pam.bunch@idpa.state.il.us
Internet address: www.ahca.myflorida.com Internet address: www.dpaillinois.com

GEORGIA INDIANA
Jerry L. Dubberly, R.Ph., M.B.A. Marc Shirley, R.Ph.
Director, Pharmacy Services Pharmacist
Department of Community Health Office of Medicaid Policy and Planning
Division of Medical Assistance Indiana State Government Center South-Rm. W382
2 Peachtree Street, N.W., 37th Floor 402 West Washington Street
Atlanta, GA 30303-3159 Indianapolis, IN 46204-2739
T: 404/657-4044 T: 317/232-4343
F: 404/657-5461 F: 317/232-7382
E-mail: jdubberly@dch.state.ga.us E-mail: mshirley@fssa.state.in.us
Internet address: www.dch.state.ga.us
Note: All requests for information by, or on behalf of drug
manufacturers must be made ONLY to: PDL@FSSA.state.in.us.
HAWAII Phone requests will not be accepted.

Lynn S. Donovan, R.Ph.


Pharmacy Consultant IOWA
Department of Human Services Susan L. Parker, Pharm.D.
Med-Quest Division Pharmacy Consultant
601 Kamokila Boulevard, Room 506B Iowa Medicaid Enterprise
P.O. Box 700190 100 Army Post Road
Honolulu, HI 96707 Des Moines, IA 50315
T: 808/692-8116 T: 515/725-1226
F: 808/692-8131 F: 515/725-1010
Internet address: www.med-quest.us E-mail: sparker2@dhs.state.ia.us
Internet address: www.iowamedicaidpdl.com

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National Pharmaceutical Council Pharmaceutical Benefits 2004

KANSAS MARYLAND
Mary H. Obley, Pharmacist Joseph L. Fine
Pharmacy Program Manager Director
Health Care Policy Division Maryland Pharmacy Program
Department of Social and Rehabilitation Services DHMH, Office of Operations and Eligibility, and
Docking State Office Building Pharmacy
915 SW Harrison, Room 651-South 201 West Preston Street, Room 407
Topeka, KS 66612-1570 Baltimore, MD 21201
T: 785/296-3981 T: 410/767-1455
F: 785/296-4813 F: 410/333-5398
E-mail: mho@srskansas.org E-mail: jfine@dhmh.state.md.us
Internet address: www.srskansas.org/hcp Internet address: www.dhmh.state.md.us/mma/mpap

KENTUCKY MASSACHUSETTS
Dan Yeager, R.Ph. Paul L. Jeffrey
Interim Pharmacy Director Director of Pharmacy
Department for Medicaid Services Office of Medicaid
CHR Building, 6 W-A 600 Washington Street, 5th Floor
275 East Main Street Boston, MA 02111
Frankfort, KY 40621 T: 617/210-5319
T: 502/564-7940 F: 617/210/5865
F: 502/564-0509 E-mail: pjeffrey@MassMail.state.ma.us
E-mail: dan.yeager@ky.gov Internet address: www.state.ma.us/dma

LOUISIANA MICHIGAN
Mary J. Terrebonne, Pharm.D. Giovannino A. Perri, M.D.
Pharmacy Director Chief Medical Consultant
Department of Health and Hospitals MDCH/Medical Services Administration
1201 Capitol Access Road, 6th Floor 400 South Pine Street
P.O. Box 91030 P.O. Box 30479
Baton Rouge, LA 70821 Lansing, MI 48909-7979
T: 225/342-9768 T: 517/335-5181
F: 225/342-1980 F: 517/241-8135
E-mail: mterrebo@dhh.la.gov E-mail: perrig@michigan.gov
Internet address: www.lamedicaid.com Internet address: www.michigan.gov/mdch

MAINE MINNESOTA
Bruce McClanahan Cody C. Wiberg, Pharm.D., R.Ph.
Pharmacy Unit Manager Pharmacy Program Manager
Department of Human Services Department of Human Services
Bureau of Medical Services 444 Lafayette Road North
11 SHS, 442 Civic Center Drive St. Paul, MN 55155-3853
Augusta, ME 04333 T: 651/296-8515
T: 886/796-2463 F: 651/282-6744
F: 207/287-8601 E-mail: cody.c.wiberg@state.mn.us
E-mail: bruce.mcclanahan@maine.gov Internet address: www.dhs.mn.us/provider/pharm
Internet address: www.maine.gov/bms

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National Pharmaceutical Council Pharmaceutical Benefits 2004

MISSISSIPPI NEVADA
Judith P. Clark, R.Ph. Dionne Coston, R.N.
Pharmacy Director Medicaid Services Specialist
Division of Medicaid Division of Health Care Financing and Policy
Robert E. Lee Building Pharmacy Program
239 North Lamar Street, Suite 801 1100 E. Williams Street
Jackson, MS 39201 Carson City, NV 89701
T: 601/359-5253 T: 775/684-3775
F: 601/359-9555 F: 775/684-3762
E-mail: phipc@medicaid.state.ms.us E-mail: dcpstpm@dhcfp.state.nv.us
Internet address: www.dom.state.ms.us Internet address: www.dhcfp.state.nv.us

MISSOURI NEW HAMPSHIRE


George L. Oestreich, Pharm.D., M.P.A. Margaret A. Clifford
Pharmacy Program Director Pharmacy Administrator
Department of Social Services Office of Medicaid Business and Policy
Division of Medical Services 129 Pleasant Street, Annex 1
2023 St. Mary’s Boulevard Concord, NH 03301
P.O. Box 6500 T: 603/271-4210
Jefferson City, MO 65102-6500 F: 603/271-8701
T: 573/751-6961 E-mail: mclifford@dhhs.state.nh.us
F: 573/522-8514 Internet address:
E-mail: George.L.Oestreich@dss.mo.gov www.dhhs.state.nh.us/DHHS/MEDICAIDPROGRAM/
Internet address: www.dss.mo.gov/dms

MONTANA NEW JERSEY

Dan Peterson Joseph B. Martinez


Pharmacy Program Officer Chief, Pharmaceutical Services
Department of Public Health and Human Services Department of Medical Assistance and Human
Medicaid Services Bureau Services
1400 Broadway, P.O. Box 202951 Office of Utilization Management
Helena, MT 59620-2951 P.O. Box 712
T: 406/444-2738 Trenton, NJ 08619
F: 406/444-1861 T: 609/588-2774
E-mail: danpeterson@mt.gov F: 609/588-3889
Internet address: www.mtmedicaid.org E-mail: joseph.b.martinez@dhs.state.nj.us

NEBRASKA NEW MEXICO

Dyke Anderson, R.Ph. Neal Solomon, M.P.H., R.Ph.


Pharmacy Consultant Pharmacist
Department of Health and Human Services Human Services Department
Finance and Support/Medicaid Division Medical Assistance Division
301 Centennial Mall South, 5th Floor - NSOB P.O. Box 2348
P.O. Box 95026 Santa Fe, NM 87504-2348
Lincoln, NE 68509-5026 T: 505/827-3174
T: 402/471-9379 F: 505/827-3196
F: 402/471-9092 E-mail: neal.solomon@state.nm.us
E-mail: dyke.anderson@hhss.ne.gov
Internet address: www.hhs.state.ne.us/med

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National Pharmaceutical Council Pharmaceutical Benefits 2004

NEW YORK OKLAHOMA


Mark-Richard Butt, M.S., R.Ph. Nancy Nesser, D.Ph., J.D.
Director, Pharmacy Policy and Operations Pharmacy Director
Office of Medicaid Management Oklahoma Health Care Authority
Department of Health 4545 N. Lincoln Boulevard, Suite 124
99 Washington Avenue Oklahoma City, OK 73105
Albany, NY 12210 T: 405/522-7325
T: 518/474-9219 F: 405/530-3235
F: 518/473-5508 E-mail: nessern@ohca.state.ok.us
E-mail: mrb01@health.state.ny.us Internet address: www.ohca.state.ok.us
Internet address: www.health.state.ny.us
OREGON
NORTH CAROLINA
Thomas Drawbaugh
Tom D’Andrea, R.Ph., M.B.A. Pharmacy Program Manager
Chief of Pharmacy and Ancillary Services Department of Human Resources
Department of Health and Human Services Office of Medical Assistance Programs
Division of Medical Assistance 500 Summer Street, NE, E-35
1985 Umstead Drive Salem, OR 97301-1077
2501 Mail Service Center T: 503/945-6492
Raleigh, NC 27699 F: 503/373-7689
T: 919/855-4300 E-mail: thomas.drawbaugh@state.or.us
F: 919/715-1255 Internet address: www.dhs.state.or.us/healthplan
E-mail: Tom.Dandrea@ncmail.net
Internet address: www.dhhs.state.nc.us/dma PENNSYLVANIA
Terri Cathers
NORTH DAKOTA
Director of Pharmacy
Brendan K. Joyce, Pharm.D., R.Ph. Department of Public Welfare
Administrator, Pharmacy Services P.O. Box 2675
Department of Human Services Harrisburg, PA 17105
600 East Boulevard Avenue T: 717/772-6195
Department 325 F: 717/705-8391
Bismarck, ND 58505-0250 E-mail: c-tcathers@state.pa.us
T: 701/328-4023 Internet address: www.dpw.state.pa.us/omap
F: 701/328-1544
E-mail: sojoyb@state.nd.us RHODE ISLAND
Internet address: www.state.nd.us/humanservices
Paula J. Avarista, R.Ph., M.B.A.
Chief of Pharmacy
OHIO
Department of Human Services
Robert P. Reid, R.Ph. 600 New London Avenue
Administrator, Pharmacy Services Unit Cranston, RI 02920
Department of Job and Family Services T: 401/462-6390
Bureau of Health Plan Policy F: 401/462-6836
30 East Broad St., 27th Floor E-mail: pavarista@dhs.ri.gov
Columbus, OH 43215-3414 Internet address: www.dhs.state.ri.us
T: 614/466-6420
F: 614/466-2908
E-mail: reidr@odjfs.state.oh.us
Internet address: www.jfs.ohio.gov

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National Pharmaceutical Council Pharmaceutical Benefits 2004

SOUTH CAROLINA UTAH


James M. Assey, R.Ph., Division Director RaeDell Ashley, R.Ph.
Division of Pharmaceutical Services and DME Pharmacy Director
Department of Health & Human Services Medicaid Program
P.O. Box 8206 Division of Health Care Financing
Columbia, SC 29202-8206 Department of Health
T: 803/898-2876 288 North 1460 West
F: 803/898-4517 P.O. Box 143102
E-mail: asseyj@dhhs.state.sc.us Salt Lake City, UT 84114-3102
Internet address: www.dhhs.state.sc.us T: 801/538-6495
F: 801/538-6099
SOUTH DAKOTA E-mail: rashley@.utah.gov
Internet address: www.health.utah.gov/medicaid
Mark E. Petersen, R.Ph.
Pharmacy Consultant
VERMONT
Department of Social Services
Office of Medical Services Ann E. Rugg
700 Governors Drive Deputy Director
Pierre, SD 57501 Office of Vermont Health Access
T: 605/773-3498 312 Hurricane Lane, Suite 200
F: 605/773-5246 Williston, VT 05495
E-mail: Mark.Petersen@state.sd.us T: 802/879-5900
Internet address: F: 802/879-5919
www.state.sd.us/social/medical/index.htm E-mail: arugg@ahs.state.vt.us
Internet address: www.OVHA.state.vt.us
TENNESSEE
VIRGINIA
Jeffrey G. Stockard, D.Ph.
Associate Pharmacy Director Javier Menendez, R.Ph.
Bureau of TennCare Pharmacy Manager
729 Church Street Department of Medical Assistance Services
Nashville, TN 37247-6501 600 East Broad Street, Suite 1300
T: 615/532-3107 Richmond, VA 23219
F: 615/253-5481 T: 804/786-2196
E-mail: jeff.stockard@state.tn.us F: 804/786-0973
Internet address: www.tennessee.gov/tenncare E-mail: Javier.Menendez@dmas.virginia.gov
Internet address: www.dmas.virginia.gov
TEXAS
WASHINGTON
Barbara Dean, R.Ph.
Acting Director, Vendor Drug Program Siri A. Childs, Pharm.D.
Health and Human Services Commission Pharmacy Policy Manager
Medicaid/CHIP Division Medical Assistance Administration, DSHS
1100 W. 49th Street 805 Plum Street, SE
Austin, TX 78756 P.O. Box 45506
T: 512/491-1101 Olympia, WA 98504-5506
F: 512/491-1962 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
Internet address: http://maa.dshs.wa.gov/pharmacy

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National Pharmaceutical Council Pharmaceutical Benefits 2004

WEST VIRGINIA
Peggy A. King, R.Ph.
Director, Office of Pharmacy Services
Department of Health and Human Resources
Bureau for Medical Services
350 Capitol St., Room 251
Charleston, WV 25301-3707
T: 304/558-1700
F: 304/558-1542
E-mail: pking@wvdhhr.org
Internet address: www.wvhhhr.org/bms/pharmacy

WISCONSIN
Mark Moody
Administrator
Division of Health Care Financing
Department of Health and Family Services
One West Wilson Street
P.O. Box 309
Madison, WI 53701-0309
T: 608/266-8922
F: 608/266-1096
E-mail: webmaster@dhfs.state.wi.us
Internet address: www.dhfs.state.wi.us

WYOMING
Antoinette K. Brown, R.Ph.
Medicaid Pharmacist
Department of Health-Pharmacy Unit
2300 Capitol Avenue, Suite 147
Cheyenne, WY 82002
T: 307/777-6016
F: 307/777-8623
E-mail: abrown@state.wy.us
Internet address: www.pharmacy.state.wy.us

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National Pharmaceutical Council Pharmaceutical Benefits 2004

NEW BRAND NAME PRODUCT CONTACT INFORMATION, 2004

ALABAMA CALIFORNIA
Louise F. Jones J. Kevin Gorospe, Pharm.D.
Director Chief, Pharmacy Policy Unit
Pharmacy Services California Department of Health Services
Alabama Medicaid Agency Medi-Cal Policy Division
501 Dexter Avenue Pharmacy Contracting and Policy Section
P.O. Box 5624 1501 Capitol Avenue
Montgomery, AL 36103-5624 P.O. Box 997413, MS 4604
T: 334/242-5039 Sacramento, CA 95814
F: 334/353-7014 T: 916/552-9500
E-mail: lljones@Medicaid.state.al.us F: 916/552-9563
E-mail: jgorospe@dhs.ca.gov
ALASKA
Dave Campana, R.Ph.
COLORADO
Pharmacy Program Manager
Division of Health Care Services Martha Warner
4501 Business Park Blvd., Suite 24 Pharmacy Supervisor
Anchorage, AK 99503 Department of Health Care Policy and Financing
T: 907/334-2425 1570 Grant Street
F: 907/561-1684 Denver, CO 80203
E-mail: david_campana@health.state.ak.us T: 303/866-3176
F: 303/866-2573
E-mail: martha.warner@state.co.us
ARIZONA
Contact health plans directly.
CONNECTICUT
Evelyn A. Dudley
ARKANSAS Manager, Pharmacy Unit
Suzette Bridges, P.D., Administrator Department of Social Services, Medical Operations
Pharmacy Program 25 Sigourney Street
Department of Human Services Hartford, CT 06106-5033
Division of Medical Services T: 860/424-5654
P.O. Box 1437, Slot S 415 F: 860/424-5206
Little Rock, AR 72203-1437 E-mail: evelyn.dudley@po.state.ct.us
T: 501/683-4120
F: 501/683-4124
E-mail: suzette.bridges@medicaid.state.ar.us DELAWARE
Joli Martini
Pharmacist Consultant – Clinical Reviews
DSS/EDS
248 Chapman Road, Suite 100
Newark, DE 19702
T: 302/453-8453
F: 302/454-0224
E-mail: Joli.martini@eds.com

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National Pharmaceutical Council Pharmaceutical Benefits 2004

DISTRICT OF COLUMBIA
IDAHO
Cheryl S. Wilson
Risk Manager – Pharmacy/DME Mary Wheatley, R.Ph.
Department of Health Pharmacy Services Specialist
Medical Assistance Administration Department of Health and Welfare
825 North Capitol Street, NE Division of Medicaid
Suite 5135 3232 Elder
Washington, DC 20002 Boise, ID 83705
T: 202/442-9078 T: 208/364-1832
F: 202/442-4790 F: 208/364-1864
E-mail: cheryl.wilson@dcgov.org E-mail: wheatlem@idhw.state.id.us

FLORIDA ILLINOIS
Jerry F. Wells Lisa Voils
Bureau Chief Special Assistant to the Medicaid Deputy
Medicaid Pharmacy Services Adminstrator
Agency for Health Care Administration Illinois Department of Public Aid
2727 Mahan Drive, MS 38 201 S. Grand Avenue East
Tallahassee, FL 32308 Springfield, IL 62763
T: 850/487-4441 T: 217/782-2570
F: 850/922-0685 F: 217/782-5672
E-mail: wellsj@ahca.myflorida.com E-mail: lisa.voils@idpa.state.il.us

GEORGIA INDIANA
Etta L. Hawkins, R.Ph. Marc Shirley, R.Ph.
Medicaid Program Pharmacy Manager Pharmacist
Department of Community Health Office of Medicaid Policy and Planning
Division of Medical Assistance Room W382
2 Peachtree Street, NW, 37th Floor Indiana State Government Center South
Atlanta, GA 30303-3159 402 West Washington Street
T: 404/657-4044 Indianapolis, IN 46204-2739
F: 404/657-5461 T: 317/232-4343
E-mail: ehawkins@dch.state.ga.us F: 317/232-7382
Note: All manufacturer inquiries and/or submissions must be in
electronic format and sent to PDL@fssa.state.in.us. Paper copies
HAWAII will not be accepted and should not be mailed to any of the involved
parties, including OMPP, ACS, or the Therapeutic Committee.
Lynn S. Donovan, R.Ph. Visit: http://indianapbm.com/downloads/T-
committe%20PDL%20submission%20Form1-5-04.pdf for
Pharmacy Consultant necessary forms.
Department of Human Services
Med-Quest Division
601 Kamokila Boulevard, Suite 506B
Kapolei, HI 96707
T: 808/692-8116
F: 808/692-8131

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National Pharmaceutical Council Pharmaceutical Benefits 2004

IOWA MAINE
Susan L. Parker, Pharm.D. Bruce McClanahan
Pharmacy Consultant Pharmacy Unit Manager
Iowa Medicaid Enterprise Department of Human Services
100 Army Post Road Bureau of Medical Services
Des Moines, IA 50315 11 SHS, 442 Civic Center Drive
T: 515/725-1226 Augusta, ME 04333
F: 515/725-1010 T: 886/796-2463
E-mail: sparker2@dhs.state.ia. F: 207/287-8601
E-mail: bruce.mcclanahan@maine.gov

KANSAS
MARYLAND
Mary H. Obley
Pharmacist Frank Tetkoski, P.D
Pharmacy Program Manager Pharmacist Consultant
Health Care Policy Division Maryland Pharmacy Program
Department of Social and Rehabilitation Services DHMH
Docking State Office Building Division of Pharmacy Services
915 SW Harrison, Room 651-South 201 W. Preston Street, Room 409
Topeka, KS 66612-1570 Baltimore, MD 21201
T: 785-296-3981 T: 410/767-1460
F: 785/296-4813 F: 410/333-5398
E-mail: mho@srskansas.org E-mail: tetkoskif@dhmh.state.md.us

KENTUCKY MASSASCHUSETTS
Debra Bahr, R.Ph. Christopher T. Burke
Pharmacy Services Program Manager Policy Analyst
Department for Medicaid Services Office of Medicaid
CHR Building, 6 W-A 600 Washington Street, 5th Floor
275 East Main Street Boston, MA 02111
Frankfort, KY 40621 T: 617/210-5592
T: 502/564-7940 F: 617/210-5597
F: 502/564-0509 E-mail: christopher.burke@MassMail.state.ma.us
E-mail: Debra.Bahr@ky.go

MICHIGAN
LOUISIANA Donna Hammel
Mary J. Terrebonne, Pharm.D. Office of Medical Affairs
Pharmacy Director MDCH/Medical Services Administration
Department of Health & Hospitals 400 South Pine Street
1201 Capitol Access Road, 6th Floor P.O. Box 30479
P.O. Box 91030 Lansing, MI 48909-7979
Baton Rouge, LA 70821 T: 517/335-5181
T: 225/342-9768 F: 517/241-8135
F: 225/342-1980 E-mail: hammeld@michigan.gov
E-mail: mterrebo@dhh.la.gov

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National Pharmaceutical Council Pharmaceutical Benefits 2004

MINNESOTA
NEBRASKA
Cody C. Wiberg, Pharm.D., R.Ph.
Dyke Anderson, R.Ph
Pharmacy Program Manager
Pharmacy Consultant
Department of Human Services
Department of Health and Human Services
444 Lafayette Road North
Finance and Support/Medicaid Division
St. Paul, MN 55155-3853
301 Centennial Mall South
T: 651/296-8515
5th Floor-NSOB
F: 651/282-6744
P.O. Box 95026
E-mail: cody.c.wiberg@state.mn.us
Lincoln, NE 68509-5026
T: 402/471-9379
F: 402/471-9092
MISSISSIPPI
E-mail: dyke.anderson@hhss.ne.gov
Judith P. Clark, R.Ph.
Pharmacy Director
Division of Medicaid NEVADA
Robert E. Lee Building
Dionne Coston, R.N.
239 North Lamar Street, Suite 801
Medical Services Specialist
Jackson, MS 39201
T: 601/359-5253 Division of Health Care Financing and Policy
Pharmacy Program
F: 601/359-9555
1100 E. Williams Street
E-mail: phipc@medicaid.state.ms.us
Carson City, NV 89701
T: 775/684-3775
F: 775/684-3762
MISSOURI
E-mail: dcpstpm@dhcfp.state.nv.us
Rhonda A. Driver
Clinical Pharmacist
Department of Social Services NEW HAMPSHIRE
Division of Medical Services
2023 St. Mary’s Boulevard Lisè C. Farrand, R.Ph.
P.O. Box 6500 Pharmaceutical Services Specialist
Office of Medicaid Business and Policy
Jefferson City, MO 65102- 6500
129 Pleasant Street, Annex 1
T: 573/751-6961
Concord, NH 03301
F: 573/522-8514
T: 603/271-4419
E-mail: Rhonda.Driver@dss.mo.gov
F: 603/271-8701
E-mail: lfarrand@dhhs.state.nh.us
MONTANA
Dan Peterson NEW JERSEY
Pharmacy Program Officer
Department of Public Health and Human Services Joseph B. Martinez
Medicaid Services Bureau Chief, Pharmaceutical Services
1400 Broadway Department of Medical Assistance and Human
P.O. Box 202951 Services
Helena, MT 59620-2951 Office of Utilization Management
T: 406/444-2738 P.O. Box 712
F: 406/444-1861 Trenton, NJ 08619
E-mail: danpeterson@mt.gov T: 609/588-2774
F: 609/588-3889
E-mail: joseph.b.martinez@dhs.state.nj.us

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National Pharmaceutical Council Pharmaceutical Benefits 2004

NEW MEXICO OHIO


Neal Solomon, M.P.H., R.Ph. Robert P. Reid, R.Ph.
Pharmacist Administrator, Pharmacy Services Unit
Human Services Department Department of Job and Family Services
Medical Assistance Division Bureau of Health Plan Policy
P.O. Box 2348 30 East Broad Street, 27th Floor
Santa Fe, NM 87504-2348 Columbus, OH 43215-3414
T: 505/827-3174 T: 614/466-6420
F: 505/827-3196 F: 614/466-2908
E-mail: neal.solomon@state.nm.us E-mail: reidr@odjfs.state.oh.us

NEW YORK OKLAHOMA


Mark-Richard A. Butt, M.S., R.Ph. Rodney Ramsey
Director, Pharmacy Policy and Operations Drug Reference Coordinator
Office of Medicaid Management Oklahoma Health Care Authority
Department of Health 4545 North Lincoln, Suite 124
99 Washington Avenue Oklahoma City, OK 73105
Albany, NY 12210 T: 405/522-7492
T: 518/474-9219 F: 405/530-7119
F: 518/473-5508 E-mail: ramseyr@ohca.state.ok.us
E-mail: mrb01@health.state.ny.us

OREGON
NORTH CAROLINA
Kathy L. Ketchum, R.Ph., M.P.A.-H.A.
Tom D’Andrea, R.Ph., M.B.A. Medicaid Program Coordinator
Chief of Pharmacy and Ancillary Services Oregon State University College of Pharmacy
Department of Health and Human Services 840 SW Gaines Road, MC 212
Division of Medical Assistance Portland, OR 97239-3098
1985 Umstead Drive, 2501 Mail Service Center T: 503/494-1589
Raleigh, NC 27699 F: 503/494-8797
T: 919/855-4300 E-mail: ketchumk@ohsu.edu
F: 919/715-1255
E-mail: Tom.Dandrea@ncmail.net
PENNSYLVANIA
Terri Cathers
NORTH DAKOTA
Director of Pharmacy
Brendan K. Joyce, Pharm.D., R.Ph. Department of Public Welfare
Administrator, Pharmacy Services P.O. Box 2675
Department of Human Services Harrisburg, PA 17105
600 East Boulevard Avenue T: 717/772-6195
Department 325 F: 717/705-8391
Bismarck, ND 58505-0250 E-mail: c-tcathers@state.pa.us
T: 701/328-4023
F: 701/328-1544
E-mail: sojoyb@state.nd.us

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National Pharmaceutical Council Pharmaceutical Benefits 2004

RHODE ISLAND
TEXAS
Paula J. Avarista, R.Ph., M.B.A.
Martha McNeil, R.Ph.
Chief of Pharmacy
Product and Prescriber Manager
Department of Human Services
Texas Health and Human Services Commission
600 New London Avenue
11209 Metric Boulevard, Building H
Cranston, RI 02920
Austin, TX 78758
T: 401/462-6390
T: 512/491-1157
F: 401/462-6836
F: 512/491-1961
E-mail: pavarista@dhs.state.ri.us
E-mail: Martha.Mcneil@hhsc.state.tx.us

SOUTH CAROLINA
UTAH
James M. Assey, R.Ph., Division Director
Division of Pharmaceutical Services and DME RaeDell Ashley, R.Ph.
Pharmacy Director
Department of Health & Human Services
Medicaid Program
P.O. Box 8206
Division of Health Care Financing
Columbia, SC 29202-8206
Department of Health
T: 803/898-2876
F: 803/255-8353 288 North 1460 West
P.O. Box 143102
E-mail: asseyj@dhhs.state.sc.us
Salt Lake City, UT 84114-3102
T: 801/538-6495
F: 801/538-6099
SOUTH DAKOTA
E-mail: rashley@utah.gov
Mark E. Petersen, R.Ph.
Pharmacy Consultant
Department of Social Services VERMONT
Office of Medical Services
Felicia Montineri
700 Governors Drive
Clinical Pharmacist
Pierre, SD 57501
First Health Services Corporation
T: 605/773-3498
312 Hurricane Lane, Suite 200
F: 605/773-5246
Williston, VT 05495
E-mail: Mark.Petersen@state.sd.us
T: 802/879-5900
F: 802/879-5919
E-mail: MontinFe@fhsc.com
TENNESSEE
Jeffrey G. Stockard, D.Ph.
Associate Pharmacy Director VIRGINIA
Bureau of TennCare
Keith T. Hayashi
729 Church Street
Pharmacist I
Nashville, TN 37247-6501
Department of Medical Assistance Services
T: 615/532-3107
600 East Broad Street, Suite 1300
F: 615/253-5481
Richmond, VA 23219
E-mail: jeff.stockard@state.tn.us
T: 804/225-2773
F: 804/786-0973
E-mail: Keith.Hayashi@dmas.virginia.gov

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National Pharmaceutical Council Pharmaceutical Benefits 2004

WASHINGTON
Siri A. Childs, Pharm D.
Pharmacy Policy Manager
Medical Assistance Administration, DSHS
805 Plum Street, SE
P.O. Box 45506
Olympia, WA 98504-5506
T: 360/725-1564
F: 360/586-8827
E-mail: childsa@dshs.wa.gov

WEST VIRGINIA
Peggy A. King, R.Ph.
Director, Office of Pharmacy Services
Department of Health and Human Resources
Bureau for Medical Services
350 Capitol Street, Room 251
Charleston, WV 25301-3707
T: 304/558-1700
F: 304/558-1542
E-mail: pking@wvdhhr.org

WISCONSIN
Carol Neeno
Pharmacy Assistant
Division of Health Care Financing
Department of Health and Family Services
One West Wilson Street
P.O. Box 309
Madison, WI 53701-0309
T: 608/266-1203
F: 608/267-3380
E-mail: neenocj@dhfs.state.wi.us

WYOMING
Antoinette K. Brown, R.Ph.
Medicaid Pharmacist
Department of Health
Pharmacy Unit
2300 Capitol Avenue, Suite 147
Cheyenne, WY 82002
T: 307/777-6016
F: 307/777-8623
E-mail: abrown@state.wy.us

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DUR CONTACT INFORMATION, 2004


State Contact Contractor
Louise F. Jones, Director Health Information Designs
Pharmacy Services
Alabama Medicaid Agency
501 Dexter Avenue
ALABAMA
P.O. Box 5624
Contracted DUR
Montgomery, AL 36103-5624
T: 334/242-5039
F: 334/353-7014
E-mail: lljones@medicaid.state.al.us

State Contact
Dave Campana, R.Ph.
Pharmacy Program Manager
Division of Health Care Services
ALASKA 4501 Business Park Blvd., Ste. 24
In-House DUR Anchorage, AK 99503
T: 907/334-2425
F: 907/561-1684
E-mail: david_campana@health.state.ak.us

Within Federal and State guidelines,


ARIZONA individual managed care and pharmacy
DUR is conducted at benefit management organizations make
the plan level. formulary/drug decisions.

State Contact Contractor


Pamela Ford, P.D. Cherly Avants
Pharmacist II Director, Retrospective DUR
Arkansas Department of Human Services Health Information Design
Division of Medical Services 1550 Pumphrey Avenue
ARKANSAS
Pharmacy Program Auburn, AL 36832
Contracted DUR
P.O. Box 1437, Slot 415 T: 205/402-9530
Little Rock, AR 72203-1437 F: 205/402-9531
T: 501/683-4120 E-mail: clavants@aol.com
F: 501/683-4124
E-mail: pamela.ford@medicaid.state.ar.us

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State Contact Contractor


Ellis Ellis, Pharm.D. Not Available
Pharmaceutical Consultant II
California Department of Health Services
Medi-Cal Policy Division
CALIFORNIA Pharmacy Contracting and Policy Section
Contracted DUR 1501 Capitol Avenue
P.O. Box 997413, MS 4604
Sacramento, CA 95814
T: 916/552-9500
F: 916/552-9563
E-mail: eellis2@dhs.ca.gov

State Contact Contractor


Catherine Traugott Catherine Traugott
Pharmacist Pharmacist
Deptartment of Health Care Policy and
COLORADO Financing
Contracted DUR 1570 Grant Street
Denver, CO 80203
T: 303/866-2468
F: 303/866-2573
E-mail: catherine.traugott@state.co.us

State Contact Contractor


James R. Zakszewski, R.Ph. Michelle Laster-Bradley
Pharmacy Consultant Account Manager
Department of Social Services ACS State Healthcare
CONNECTICUT Medical Operations Unit 365 Northridge Road, Suite 400
Contracted DUR 25 Sigourney Street Atlanta, GA 30350
Hartford, CT 06106-5033 T: 866/322-5960
T: 860/424-5150 F: 866/246-8510
F: 860/424-5206 E-mail: michelle.laster-bradley@acs-
E-mail: james.zakszewski@po.state.ct.us inc.com

State Contact Contractor


Cynthia R. Denemark, R.Ph. Cynthia R. Denemark, R.Ph.
Director of Pharmacy Services Director of Pharmacy Services
DSS/EDS DSS/EDS
DELAWARE
248 Chapman Road, Suite 100
Contracted DUR
Newark, DE 19702
T: 302/453-8453
F: 302/454-0224
E-mail: Cynthia.denemark@eds.com

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State Contact Contractor


Christopher A. Keeys, Pharm.D., R.Ph. Jeffrey Dzieweczynski, R.Ph., M.S.
Chairman ACS State Healthcare
DISTRICT OF Clinical Pharmacy Associates, Inc. 750 First Street, NE
COLUMBIA 316 Talbott Avenue Washington, DC 20002
Contracted DUR Laurel, MD 20707 T: 202/906-8353
T: 301/617-0555 F: 202/906-8399
F: 301/617-0225 E-mail: jeffrey.dzieweczynski@acs-
E-mail: ckeeys@clinphar.com inc.com

State Contact Contractor


Linda G. Barnes Heritage Information Systems
Pharmacy Program Manager
Agency for Health Care Administration
FLORIDA
2727 Mahan Drive, MS 38
Contracted DUR
Tallahassee, FL 32308
T: 850/487-4441
F: 850/922-0685
E-mail: barnesl@ahca.myflorida.com

State Contact
Patricia Zeigler Jeter, R.Ph., M.P.A.
DUR Coordinator-Rebate Pharmacist
Department of Community Health
GEORGIA Division of Medical Assistance
In-House DUR 2 Peachtree St. NW, 37th Floor
Atlanta, GA 30303-3159
T: 404/657-9181
F: 404/657-5461
E-mail: pjeter@dch.state.ga.us

State Contact
Kathleen Kang-Kaulupali
Pharmacy Consultant
Department of Human Services
HAWAII
Med-Quest Division
In-House DUR
601 Kamokila Boulevard, Room 506-B
Kapolei, HI 90707
T: 808/692-8065
F: 808/692-8131

State Contact Contractor


Tamara Eide, Pharm.D., BCPS, FASHP Idaho Drug Utilization Review
Pharmacy Services Specialist Idaho State U. - College of Pharmacy
Department of Health and Welfare 970 South 5th Street
IDAHO Division of Medicaid Campus Box 8288
Contracted DUR 3232 Elder Pocatello, ID 83209-8288
Boise, ID 83705 T: 208/282-4597
T: 208/364-1821
F: 208/364-1864
E-mail: eidet@idhw.state.id.us

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State Contact
Pamela Bunch
Medicaid Pharmacy Manager
Illinois Department of Public Aid
ILLINOIS
201 S. Grand Avenue East
In-House DUR
Springfield, IL 62763
T: 217/524-7478
F: 217/524-7535
E-mail: pam.bunch@idpa.state.il.us

State Contact Contractor


DUR Board Secretary ACS State Healthcare
Office of Medicaid Policy and Planning 365 Northridge Road, Suite 400
Indiana State Government Center Atlanta, GA 30350
INDIANA
South-Room W382 T: 866/322-5960
Contracted DUR
402 West Washington Street F: 866/759-4100
Indianapolis, IN 46204
T: 317/232-4307
F: 317/232-7382

State Contact Contractor


Julie Kuhle, R.Ph. Julie Kuhle, R.Ph.
Project Coordinator Project Coordinator
IOWA Iowa Medicaid Enterprise Iowa Medicaid Enterprise
Contracted DUR 100 Army Post Road
Des Moines, IA 50315
T: 515/725-1226
F: 515/725-1010

State Contact Contractor


Vicki L. Schmidt Heritage Information Systems, Inc.
Pharmacist 2810 N. Parham Road
Health Care Policy Division Suite 210
Kansas Department of Social and Richmond, VA 23294
KANSAS Rehabilitation Services T: 804/644-8707
Contracted DUR Docking State Office Building
915 SW Harris, Room 651-South
Topeka, KS 66612-1570
T: 785/274-4287
F: 785/296-4813
E-mail: vixs@srskansas.org

State Contact
Debra Bahr, R.Ph.
Pharmacy Services Program Manager
Department for Medicaid Services
KENTUCKY CHR Building, 6 W-A
In-House DUR 275 East Main Street
Frankfort, KY 40621
T: 502/564-7940
F: 502/564-0509
E-mail: Debra.Bahr@ky.gov.us

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National Pharmaceutical Council Pharmaceutical Benefits 2004

State Contact Contractor


Mary J. Terrebonne, Pharm.D. Shelly Delaville
Pharmacy Director Pharmacist
Department of Health and Hospitals Unisys
LOUISIANA 1201 Capitol Access Road, 6th Floor 8591 United Plaza Blvd., Ste.300
Contracted DUR P.O. Box 91030 Baton Rouge, LA 70809
Baton Rouge, LA 70821 T: 225/237-3227
T: 225/342-9768 F: 225/237-3334
F: 225/342-1980 E-mail: shelly.delaville@unisys.com
E-mail: mterrebo@dhh.state.la.us

State Contact Contractor


Bruce McClanahan Not Available
Pharmacy Unit Manager
442 Civic Center Drive
MAINE
11SHS, DHS – Bureau of Medical Services
Contracted DUR
Augusta, ME 04333
T: 886/796-2463
F: 207/287-8601
E-mail: bruce.mclanahan@maine.gov

State Contact Contractor


Jeffrey Gruel Health Information Design
Deputy Director
Maryland Pharmacy Program
DHMH
MARYLAND
Division of Pharmacy Services
Contracted DUR
201 W. Preston St., Room 408
Baltimore, MD 21201
T: 410/787-1455
F: 410/333-5398
E-mail: GruelJ.@dhmh.state.md.us

State Contact Contractor


Paul L. Jeffrey Paul L. Jeffrey
Director of Pharmacy Director of Pharmacy
Office of Medicaid
MASSACHUSETTS
600 Washington Street, 5th Floor
Contracted DUR
Boston, MA 02111
T: 617/210-5319
F: 617/210-5865
E-mail: paul.jeffrey@MassMail.state.ma.us

State Contact Contractor


Debera Eggleston, M.D. First Health Services Corp.
MDCH/Medical Services Administration 4300 Cox Rd.
400 S. Pine Street Glen Allen, VA 23060
MICHIGAN
P.O. Box 30479 T: 877/864-9014
Contracted DUR
Lansing, MI 48909-7979 F: 888/603-7696
T: 517/335-5181
F: 517/241-8135
E-mail: egglestond@michigan.gov

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State Contact
Mary Beth Reinke, Pharm.D., M.S.A.
DUR Coordinator
Minnesota Dept. of Human Services
MINNESOTA
444 Lafayette Rd. North
In-House DUR
St. Paul, MN 55155-3853
T: 651/215-1239
F: 651/282-6744
E-mail: mary.beth.reinke@state.mn.us

State Contact Contractor


Judith P. Clark, R.Ph. Sam Warman, R.Ph.
Pharmacy Director Project Manager
Division of Medicaid Heritage Information Design
MISSISSIPPI Robert E. Lee Building P.O. Box 320506
Contracted DUR 239 North Lamar St., Ste. 801 Flowood, MS 39232
Jackson, MS 39201 T: 601/709-0000
T: 601/359-5253 F: 800/459-2135
F: 601/359-9555 E-mail: pa-ms@hidinc.com
E-mail: phipc@medicaid.state.ms.us

State Contact
Tisha A. Pomering
DUR Coordinator
Div. of Medical Services
MISSOURI 2023 St. Mary’s Boulevard
In-House DUR P.O. Box 6500
Jefferson City, MO 65102-6500
T: 573/751-6961
F: 573/522-8514
E-mail: Tisha.A.Pomering@dss.mo.gov

State Contact Contractor


Mark Eichler, R.Ph., FASCP Mark Eichler, R.Ph.
Pharmacy Programs Director Mountain-Pacific Quality Health
Mountain-Pacific Quality Health Foundation Foundation
MONTANA
3404 Cooney Drive
Contracted DUR
Helena, MT 59602
T: 406/457-5818
F: 406/443-7014
E-mail: meichler@mpqhf.org

State Contact Contractor


Beth Wilson Beth Wilson
DUR Director DUR Director
Nebraska Pharmacists Association Nebraska Pharmacists Association
NEBRASKA
6221 South 58th Street, Suite A
Contracted DUR
Lincoln, NE 68516
T: 402/420-1500
F: 402/420-1406
E-mail: beth@npharm.org

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State Contact Contractor


Dionne Coston, R.N. Steve Espy, R.Ph.
Medical Services Specialist Director of Drug Utilization
Division of Health Care Financing and Policy Health Info. Design, Inc.
NEVADA Pharmacy Program 1550 Pumphrey Avenue
Contracted DUR 1100 E. Williams Street Auburn, AL 36832
Carson City, NV 89701 T: 205/402-9530
T: 775/684-3775 F: 205/402-9531
F: 775/684-3762
E-mail: dcpstpm@dhcfp.state.nv.us

State Contact Contractor


Robert Coppola Robert Coppola
Clinical Manager Clinical Manager
First Health Services Corp. First Health Services Corp.
NEW HAMPSHIRE
17 Chennell Drive
Contracted DUR
Concord, NH 03301
T: 603/224-2083
F: 603/224-6690
E-mail: coppola@fhsc.com

State Contact
Kaye S. Morrow
Assistant Director
Department of Medical Assistance and
Human Services
NEW JERSEY
Office of Provider Relations
In-House DUR
P.O Box 712
Trenton, NJ 08619
T: 609/631-2396
F: 609/588-3889
E-mail: kaye.s.morrow@dhs.state.nj.us

State Contact
Neal Solomon, M.P.H., R. Ph.
Pharmacist
Human Services Department
NEW MEXICO Medical Assistance Division
In-House DUR P.O. Box 2348
Sante Fe, NM 87504-2348
T: 505/827-3174
F: 505/827-3196
E-mail: neal.solomon@state.nm.us

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National Pharmaceutical Council Pharmaceutical Benefits 2004

State Contact
Lydia J. Kosinski, R.Ph., Manager
Recipient Activities and Utilization Review
Office of Medicaid Management
NEW YORK NYS Dept. of Health
In-House DUR 800 North Pearl Street
Albany, NY 12204
T: 518/474-6866
F: 518/473-5332
E-mail: ljk02@health.state.ny.us

State Contact Contractor


Melissa Weeks, R.Ph., Pharm.D. UNC-Chapel Hill
Department of Human Resources Office of Sponsored Research
Division of Medical Assistance Administrative Office Building
NORTH CAROLINA 1985 Umstead Drive 104 Airport Drive
Contacted DUR 2501 Mail Services Center Chapel Hill, NC 27599
Raleigh, NC 27699
T: 919/855-4300
F: 919/715-1255
E-mail: melissa.weeks@ncmail.net

State Contact
Brendan K. Joyce, Pharm.D., R.Ph.
Administrator, Pharmacy Services
North Dakota Department of Human Services
NORTH DAKOTA
600 E. Boulevard Avenue, Dept. 325
In-House DUR
Bismarck, ND 58505-0250
T: 701/328-4023
F: 701/328-1544
E-mail: sojoyb@state.nd.us

State Contact Contractor


Jeff Corzine First Health Services Corporation
OHIO DUR Administrator 4300 Cox Road
In-House and 255 East Main Street Glen Allen, VA 23060
Contracted DUR Columbus, OH 43215 T: 800/884-2822
T: 614/466-9689 F: 800/884-7696
F: 614/466-2866

State Contact Contractor


Ronald Graham, D.Ph. Ronald Graham, D.Ph.
Manager, Operations/DUR Manager, Operations/DUR
University of Oklahoma University of Oklahoma
OKLAHOMA College of Pharmacy College of Pharmacy
Contracted DUR P.O. Box 26801
Oklahoma City, OK 73109
T: 405/271-6614
F: 405/271-2615
E-mail: ronald-graham@ouhsc.edu

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National Pharmaceutical Council Pharmaceutical Benefits 2004

State Contact Contractor


Kathy L. Ketchum, R.Ph., M.P.A.: H.A. Jim Rowland
Medicaid Program Coordinator Account Manager
Oregon State University College of Pharmacy First Health Services Corporation
OREGON
840 SW Gaines Road, MC 212 925 Commercial Street SE
Contracted DUR
Portland, OR 97239-3098 Salem, OR 97302
T: 503/494-1589 T: 503/391-1980
F: 503/494-8797 F: 503/391-1979
E-mail: ketchumk@ohsu.edu E-mail: rowlandj@fhsc.com

State Contact Contractor


Terri Cathers EDS
Director of Pharmacy
Department of Public Welfare (All contacts with contractor must
PENNSYLVANIA
P.O. Box 2675 be made through State agency)
Contracted DUR
Harrisburg, PA 17105
T: 717/772-6195
F: 717/705-8391
E-mail: c-tcathers@state.pa.us

State Contact Contractor


Paula J. Avarista, R.Ph., M.B.A. Not Available
Chief of Pharmacy
Departrment of Human Services
RHODE ISLAND
600 New London Avenue
Contracted DUR
Cranston, RI 02920
T: 401/462-6390
F: 401/462-6836
E-mail: pavarista@dhs.ri.gov

State Contact Contractor


Caroline Y. Sojourner, R.Ph. First Health Services Corporation
Deptartment Head, Pharmacy Services 4300 Cox Road
SOUTH CAROLINA Department of Health & Human Services Glen Allen, VA 23060
In-House and P.O. Box 8206 T: 800/884-2822
Contracted DUR Columbia, SC 29202-8206 F: 804/273-6961
T: 803/898-2876
F: 803/255-8353
E-mail: sojourne@dhhs.state.sc.us

State Contact
Teddi Martell
Rebate Coordinator
SOUTH DAKOTA Department of Social Services
In-House DUR 700 Governors Drive
Pierre, SD 57501
T: 605/773-3653
E-mail: Teddi.Martell@state.sd.us

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National Pharmaceutical Council Pharmaceutical Benefits 2004

State Contact Contractor


Jeffery G. Stockard, D.Ph. First Health Services Corporation
Associate Pharmacy Director 4300 Cox Road
Bureau of TennCare Glen Allen, VA 23060
TENNESSEE 729 Church Street T: 800/884-2822
Nashville, TN 37247-6501 F: 804/273-6961
Contracted DUR
T: 615/532-3107
F: 615/253-5481
E-mail: jeff.stockard@state.tn.us

Within Federal and State guidelines, individual managed care and pharmacy benefit
management organizations make formulary/drug decisions.

State Contact
Barbara Dean, R.Ph.
Acting Director, Vendor Drug Program
Texas Health and Human Services
TEXAS Commision
In-House DUR 11209 Metric Boulevard, Building H
Austin, TX 78758
T: 512/491-1101
F: 512/491-1962
E-mail: Barbara.Dean@hhsc.state.tx.us

State Contact
Duane Parke
DUR Director
Medicaid Program
Division of Health Care Financing
UTAH
Department of Health
In-House DUR
P.O. Box 143102
Salt Lake City, UT 84114-3102
T: 801/538-6452
F: 801/538-6099
E-mail: dpark@utah.gov

State Contact Contractor


Felicia Montineri Felicia Montineri
Clinical Pharmacist Clinical Pharmacist
First Health Services Corporation First Health Services Corporation
VERMONT
312 Hurricane Lane, Suite 200
Contracted DUR
Williston, VT 05495
T: 802/879-5900
F: 802/879-5919
E-mail: MontinFe@fhsc.com

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National Pharmaceutical Council Pharmaceutical Benefits 2004

State Contact Contractor


Rachel E. Cain Donna Johnson
Pharmacist I Clinical Manager
Deparment of Medical Asistance Services First Health Services Corporation
VIRGINIA
600 East Broad Street, Suite 1300 4300 Cox Road
Contracted DUR
Richmond, VA 23219 Glen Allen, VA 23060
T: 804/783-2873 T: 804/290-4833
F: 804/786-0973 E-mail: dpjohnson@fhsc.com
E-mail: Rachel.Cain@dmas.virginia.gov

State Contact
Nicole N. Nguyen, Pharm.D.
Clinical Pharmacist
Medical Assistance Administration, DSHS
WASHINGTON 805 Plum Street, SE
In-House DUR P.O. Box 45506
Olympia, WA 98504-5506
T: 360/725-1757
F: 360/586-8827
E-mail: nguyen@dshs.wa.gov

State Contact Contractor


Vicki M. Cunningham, R.Ph. Craig Boon, Director
DUR Coordinator Account Management
Department of Health and Human Services ACS-Heritage Information Systems
Bureau for Medical Services 2810 N. Parham Road, Suite 210
WEST VIRGINIA
Office of Pharmacy Services Richmond, VA 23294
Contracted DUR
350 Capitol Street, Room 251 T: 804/644-8707
Charleston, WV 25301 F: 804/644-0644
T: 304/558-6541 E-mail: craigb@heritage-info.com
F: 304/558-1542
E-mail: vickicunningham@wvdhhr.org

State Contact Contractor


Michael Mergener, R.Ph., Ph.D. Michael Mergener, R.Ph. Ph.D.
Chief Pharmacist Chief Pharmacist
APS Healthcare APS Healthcare
WISCONSIN 10 East Doty St., Suite 210
Contracted DUR Madison, WI 53703
T: 608/258-3348
F: 608/258-3359
E-mail: mergema.state.wi.us

State Contact Contractor


Debra Devereaux, R.Ph. Debra Devereaux, R.Ph.
DUR Coordinator DUR Coordinator
University of Wyoming School of Pharmacy University of Wyoming School of
WYOMING
P.O. Box 3375 Pharmacy
Contracted DUR
Laramie, WY 82071
T: 307/766-6750
F: 307/766-2953
E-mail: debdev@concentric.net

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CLAIMS SUBMISSION CONTACTS, 2004

COLORADO
ALABAMA
ACS State Healthcare
Cyndi Crockett
600 17th Street
Supervisor
Suite 600 North
EDS
Denver, CO 80202
301 Technacenter Dr.
T: 800/237-0757
Montgomery, AL 36117
F: 303/534-0439
T: 334/215-0111

CONNECTICUT
ALASKA
Ellen Arce, R.Ph.
Dave Campana, R.Ph.
Pharmacy Manager
Pharmacy Program Manager
EDS
Division of Health Care Services
1000 Stanley Drive
4501 Business Park Blvd., Suite 24
New Britain, CT 06053
Anchorage, AK 99503
T: 860/832-5885
T: 907/334-2425
F: 860/832-5921
F: 901/561-1684
E-mail: ellen.arce@eds.com
E-mail: david_campana@health.state.ak.us

DELAWARE
ARIZONA
Cynthia R. Denemark, R.Ph.
Dell Swan
Director of Pharmacy Services
Pharmacy Program Administrator
DSS/EDS
AHCCCS
248 Chapman Rd, Suite 100
701 East Jefferson Street
Newark, DE 19702
MD 8000
T: 302/453-8453
Phoenix, AZ 85034
F: 302/454-0224
T: 612/417-4726
E-mail: Cynthia.denemark@eds.com
E-mail: dwswan@ahcccs.state.az.us

DISTRICT OF COLUMBIA
ARKANSAS
Jacqueline Bonner
John Herzog
Clinical Manager
Account Manager
First Health Services Corporation
EDS
4300 Cox Road
500 President Clinton Ave., Suite 400
Glen Allen, VA 23060
Little Rock, AR 72201
T: 800/884-2822
T: 501/374-6608
F: 804/273-6961
F: 501/372-2971
E-mail: bonner.ja@fhsc.com
E-mail: john.herzog@medicaid.state.ar.us

CALIFORNIA
EDS
P.O. Box 13029
Sacramento, CA 95813-4029
T: 916/636-1000

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FLORIDA INDIANA
Kevin Whittington ACS State Healthcare
Clinical Program Coordinator 365 Northridge Rd., Suite 400
ACS State Healthcare Atlanta, GA 30350
9040 Roswell Road T: 866-322-5960
Roswell, GA F: 866/759-4100
T: 850/201-1418
IOWA
GEORGIA
Patrick Danlen
Mary K. Kruchten POS Account Manager
Senior Account Manager Iowa Medicaid Enterprise
Express Scripts, Inc. 100 Army Post Road
6625 W. 78th St., BL-0440 Des Moines, IA 50315
Bloomington, MN 55439 T: 515/725-1226
T: 952/837-7401 F: 515/725-1010
F: 952/837-7184
E-mail: kruchtem@express-scripts.com
KANSAS
EDS
HAWAII
3600 SW Topeka Boulevard
Becky Garrigan Suite 204
Account Manager Topeka, KS 66611
ACS State Healthcare T: 785/274-4200
365 Northridge Road, Suite 400 F: 785/267-7687
Atlanta, GA 30350
Attn: Hawaii Medicaid
KENTUCKY
T: 866/322-5960
F: 866/759-4100 Unisys Provider Services
P.O. Box 2106
Frankfort, KY 40602
IDAHO
T: 502/226-1140
EDS F: 502/226-1860
P.O. Box 23
Boise, ID 83707
LOUISIANA
T: 208/395-2000
F: 208/395-2030 Doug Hasty
Project Manager
Unisys
ILLINOIS
8591 United Plaza Blvd., Ste. 300
Illinois Dept. of Public Aid Baton Rouge, LA 70809
201 S. Grand Avenue East T: 225/237-3391
Springfield, IL 62763 F: 225/237-3334
T: 217/782-2570 E-mail: doug.hasty@unisys.com
F: 217/782-5672
E-mail: dpa_webmaster@state.il.us

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MAINE MISSISSIPPI
Marcia Pykare Robert Reedy, C.Ph.T.
Manager of Data Processing PBM Account Manager
Goold Health Systems ACS State Healthcare
P.O. Box 1090 385-B Highland Colony Parkway
Augusta, ME 04332-1090 Ridgeland, MS 39157
T: 207/622-7153 T: 601/296-2936
F: 207/623-5125 F: 601/296-3119
E-mail: movkare@ghsinc.com E-mail: robert.reedy@acs-inc.com

MARYLAND MISSOURI
James Demery Diane Twehous
Manager, Pharmacy Services Account Manager
First Health Services Corporation Infocrossing Health Care Services, Inc.
Division of Claims Processing 905 Weathered Rock Rd.
201 W. Preston St. Jefferson City, MO 65109
Baltimore, MD 21201 T: 573/635-2434
T: 401/767-6028
F: 410/333-5398 MONTANA
E-mail: demeryj@dhmh.state.md.us
Brett Jakovac
Executive Account Manager
MASSACHUSETTS
ACS State Healthcare
ACS State Healthcare 34 N. Last Chance Gulch, Suite 200
365 Northridge Road Helena, MT 59601
Northridge Center One, Suite 400 T: 406/457-9555
Atlanta, GA 30350 F: 406/442-2819
T: 800/358-2381 E-mail: brett.jakovac@acs-inc.com
F: 770/730-5198
NEBRASKA
MICHIGAN
Barbara Pavolony
First Health Services Corp. Account Manager
4300 Cox Rd. ACS State Healthcare
Glen Allen, VA 23060 365 Northridge Road
T: 877/864-9014 Northridge Center One, Suite 400
F: 888/603-7696 Atlanta, GA 30350
T: 770/352-8536
MINNESOTA F: 770/730-5198
E-mail: barbara.pavolony@acs-inc.com
Dwaine Voas
MMIS Unit Supervisor
NEVADA
Minnesota Dept. of Human Services
800 Minnehaha Avenue First Health Services Corp.
St. Paul, MN 51555 4300 Cox Road
Glen Allen, VA 23060
T: 800/884-3238

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NEW HAMPSHIRE NORTH DAKOTA


Sherrill Bryant Brendan K. Joyce, Pharm. D., R.Ph.
Plan Administrator Administrator, Pharmacy Services
First Health Services Corp. North Dakota Department of Human Services
4300 Cox Road 600 East Boulevard Avenue
Glen Allen, VA 23060 Department 325
T: 800/884-2822 Bismarck, ND 58505-0250
F: 804/965-7647 T: 701/328-4023
E-mail: bryantsh@fhsc.com F: 701/328-1544
E-mail: sojoyb.@state.nd.us
NEW JERSEY
OHIO
Edward J. Vaccaro, R.Ph.
Assistant Director First Health Services Corp.
Office of Utilization Management 4300 Cox Rd.
Department of Medical Assistance and Human Glen Allen, VA 23060
Services T: 800/884-2822
P.O. Box 712 F: 800/884-7696
Trenton, NJ 08619
T: 609/588-3475 OKLAHOMA
F: 609/588-3889
E-mail: edward.j.vacarro@dhs.state.nj.us EDS
2401 N.W. 23rd Street, Suite 11
Oklahoma City, OK 73107
NEW MEXICO
T: 405/416-6794
ACS State Healthcare
365 Northridge Road OREGON
Northridge Center One, Suite 400
Atlanta, GA 30350 Jim Rowland
T: 770/352-8592 Account Manager
F: 770/730-5198 First Health Services Corporation
925 Commercial Street SE
Salem, OR 97302
NEW YORK
T: 503/391-1980
eMedNY F: 503/391-1979
Computer Sciences Corporation E-mail: rowlanji@fhsc.com
Attn: eMedNY Webmaster
One CSC Way PENNSYLVANIA
Rensselaer, NY 12144
T: 800/343-9000 EDS
E-mail: general@emedny.org 275 Grandview Avenue
Camp Hill, PA 17011
NORTH CAROLINA
(All contacts with contractor must be
Sharon Greeson, R.Ph. made through State agency.)
Pharmacy Program Manager
EDS
4905 Waters Edge Dr.
Raleigh, NC 27606
T: 919/816-4475
F: 919/816-4399
E-mail: sharon.greeson@ncxix.hcg.eds.com

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RHODE ISLAND UTAH


EDS Connie Higley
1471 Elmwood Avenue Information Technology Director
Cranston, RI 02910 Division of Health Care Financing
T: 401/784-3879 Department of Health
P.O. Box 143102
SOUTH CAROLINA Salt Lake City, UT 84114-3102
T: 801/538-6136
Rod Davis F: 801-538-6099
Deputy Director of Information Technology E-mail: chigley@utah.gov
S.C. Department of Health & Human Services
P.O. Box 8206
VERMONT
Columbia, SC 29202-8206
T: 803/898-2610 First Health Services Corporation
E-mail: davisr@dhhs.state.sc.us 4300 Cox Road
Glen Allen, VA 23060
T: 804/965-7717
SOUTH DAKOTA
Meredith Heerman
VIRGINIA
Claims Processing Administrator
Department of Social Services Frank Fury
700 Governors Drive Processing Administrator
Pierre, SD 57501 First Health Services Corporation
T: 605/773-3495 4300 Cox Road
F: 605/773-5246 Glen Allen, VA 23060
E-mail: Meredith.Heerman@state.sd.us T: 804/965-7400

TENNESSEE WASHINGTON
Maria P. Hogan Chris Johnson
Plan Administrator Claims Processing Manager
First Health Services Corporation Medical Assistance Administrator, DSHS
4300 Cox Road P.O. Box 45509
Glen Allen, VA 23060 Olympia, WA 98504-5509
T: 804/965-7400 T: 360/725-1239
E-mail: mphogan@fhsc.com E-mail: johnsc2@dshs.wa.gov

TEXAS WEST VIRGINIA


Barbara Dean, R.Ph. Heather Bodiford
Acting Director PBM Account Manager
Vendor Drug Program ACS State Healthcare
Texas Health and Human Services Commission 365 Northridge Road
1100 West 49th Street Northridge Center One, Suite 400
Austin, TX 78756 Atlanta, GA 30350
T: 512/491-1101 T: 866/322-5960
F: 512/491-1962 F: 770/730-5198
E-mail: Barbara.Dean@hhsc.state.tx.us E-mail: Heather.Bodiford@acs-inc.com

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National Pharmaceutical Council Pharmaceutical Benefits 2004

WISCONSIN
Mark Gajewski
Account Director
EDS
6406 Bridge Road
Madison, WI 53784-0014
T: 608/221-4746
F: 608/221-4567

WYOMING
ACS State Healthcare
Northridge Center One, Suite 400
365 Northridge Road
Atlanta, GA 30350
T: 866/322-5960
F: 888/335-8459

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National Pharmaceutical Council Pharmaceutical Benefits 2004

PRESCRIPTION PRICE UPDATING CONTACTS, 2004


ALABAMA
COLORADO
Allyn Williford
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: martha.warner@state.co.us
ALASKA
Dave Campana, R.Ph. CONNECTICUT
Pharmacy Program Manager
Ellen Arce, R.Ph.
Division of Health Care Services
Pharmacy Manager
4501 Business Park Blvd., Suite 24
EDS
Anchorage, AK 99503
1000 Stanley Drive
T: 907/273-3224
New Britain, CT 06053
F: 907/561-1684
T: 860/832-5885
E-mail: david_campana@health.state.ak.us
F: 860/832-5921
E-mail: ellen.arce@eds.com
ARIZONA
Dell Swan DELAWARE
Pharmacy Program Administrator
Cynthia R. Denemark, R.Ph.
AHCCCS
Director of Pharmacy Services
701 East Jefferson Street
248 Chapman Road, Suite 100
MD 8000
Newark, DE 19702
Phoenix, AZ 85034
T: 302/453-8453
T: 612/417-4726
F: 302/454-0224
E-mail: dwswan@ahcccs.state.az.us
E-mail: Cynthia.denemark@eds.com

ARKANSAS
DISTRICT OF COLUMBIA
First DataBank
Christine Quinn
1111 Bayhill Drive, Suite 350
Account Manager
San Bruno, CA 94066
ACS State Healthcare
T: 650/588-5454
750 First Street, NE
F: 650/588-4003
Washingotn, DC 20002
T: 202/906-8304
CALIFORNIA F: 202/906-8378
EDS Federal Corporation E-mail: christine.quinn@acs-inc.com
P.O. Box 13029
Sacramento, CA 95813-4029
T: 916/636-1000

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National Pharmaceutical Council Pharmaceutical Benefits 2004

FLORIDA INDIANA
First DataBank First DataBank
1111 Bayhill Drive, Suite 350 1111 Bayhill Drive, Suite 350
San Bruno, CA 94066 San Bruno, CA 94066
T: 650/588-5454 T: 650/588-5454
F: 650/827-4578 F: 650/588-4003

GEORGIA IOWA
Manny Conduah, Pharm.D. Patrick Danlen
Clinical Program Manager POS Account Manager
Express Scripts, Inc. Iowa Medicaid Enterprise
300 Colonial Center Parkway 100 Army Post Road
Roswell, GA 30076 Des Moines, IA 50315
T: 770/552-3793 T: 515/725-1226
F: 770/992-8949 F: 515/725-1010
E-mail: mconduah@express-scripts.com
KANSAS
HAWAII
Mary H. Obley
ACS State Healthcare Pharmacist
365 Northridge Road, Suite 400 Pharmacy Program Manager
Atlanta, GA 30350 Health Care Policy Division
Attn: Hawaii Medicaid Department of Social and Rehabilitation Services
T: 800/358-2381 Docking State Office Building
F: 770/730-5198 915 SW Harrison, Room 651-South
Topeka, KS 66612-1570
IDAHO T: 785/296-3981
F: 785/296-4813
Katie Ayad, C.Ph.T. E-mail: mho@srskansas.org
Technical Records II
Department of Health and Welfare
KENTUCKY
Division of Medicaid
3232 Elder Unisys Provider Services
Boise, ID 83705 P.O. Box 2106
T: 208/364-1970 Frankfort, KY 40602
F: 208/364-1864 T: 502/226-1140
E-mail: ayadk@idhw.state.id.us F: 502/226-1860

ILLINOIS LOUISIANA
First DataBank Maggie Vick
1111 Bayhill Drive, Suite 350 Unisys
San Bruno, CA 94066 8591 United Plaza Blvd., Ste. 300
T: 650/588-5454 Baton Rouge, LA 70809
F: 650/588-4003 T: 225/237-3251
F: 225/237-3334
E-mail: margaret.vick@unisys.com

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National Pharmaceutical Council Pharmaceutical Benefits 2004

MAINE MISSISSIPPI
Bruce McClanahan Terri R. Kirby, R.Ph.
Pharmacy Unit Manager Pharmacist
Department of Human Services Division of Medicaid
Bureau of Medical Services Robert E. Lee Building
11 SHS, 442 Civic Center Drive 239 North Lamar St., Suite 801
Augusta, ME 04333 Jackson, MS 39201
T: 886/796-2463 T: 601/359-5253
F: 207/287-8601 F: 601/359-9555
E-mail: bruce.mcclanahan@maine.gov E-mail: phtrk@medicaid.state.ms.us
Internet address: www.maine.gov/bms
MISSOURI
MARYLAND
First DataBank
First DataBank 1111 Bayhill Drive, Suite 350
1111 Bayhill Drive, Suite 350 San Bruno, CA 94066
San Bruno, CA 94066 T: 650/588-5454
T: 415/588-5454 F: 650/827-4510
F: 415/827-4578
MONTANA
MASSACHUSETTS
First DataBank
First DataBank 1111 Bayhill Drive, Suite 350
1111 Bayhill Drive, Suite 350 San Bruno, CA 94066
San Bruno, CA 94066 T: 650/588-5454
T: 650/588-5454 F: 650/827-4578
F: 650/827-4578
NEBRASKA
MICHIGAN
Dyke Anderson, R.Ph.
First Health Services Corporation Pharmacy Consultant
4300 Cox Road Department of Health and Human Services
Glen Allen, VA 23060 Finance and Support/Medicaid Division
T: 877/864-9014 301 Centennial Mall South, 5th Floor-NSOB
F: 888/603-7696 P.O. Box 95026
Lincoln, NE 68509-5026
T: 402/471-9379
MINNESOTA
F: 402/471-9092
First DataBank E-mail: dyke.anderson@hhss.ne.gov
1111 Bay Hill Drive, Suite 350
San Bruno, CA 94066
NEVADA
T: 650/588-5454
F: 650/588-4003 First DataBank
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
T: 650/588-5454
F: 650/827-4578

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National Pharmaceutical Council Pharmaceutical Benefits 2004

NEW HAMPSHIRE
Sherrill Bryant NORTH DAKOTA
Plan Administrator
Brendan K. Joyce, Pharm.D., R.Ph.
First Health Services Corp.
Administrator, Pharmacy Services
4300 Cox Road
North Dakota Department of Human Services
Glen Allen, VA 23060
600 East Boulevard Avenue
T: 800/884-2822
Dept. 325
F: 804/965-7647
Bismark, ND 58505-0250
E-mail: bryantsh@fhsc.com
T: 701/328-4023
F: 701/328-1544
NEW JERSEY E-mail: sojoyb.@state.nd.us
First DataBank
1111 Bayhill Drive, Suite 350 OHIO
San Bruno, CA 94066
First DataBank
T: 650/588-5454
1111 Bayhill Drive, Suite 350
F: 650/827-4578
San Bruno, CA 94066
T: 650/588-5454
NEW MEXICO F: 650/827-4578
First DataBank
1111 Bayhill Drive, Suite 350 OKLAHOMA
San Bruno, CA 94066
First DataBank
T: 800/633-3453
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
NEW YORK T: 800/633-3453
Carl T. Cioppa, Pharm.D.
Pharmacy Operations Manager OREGON
Department of Health
Jim Rowland
Office of Medicaid Management
Account Manager
99 Washington Avenue
First Health Sevices Corporation
Albany, NY 12210
925 Commercial Street SE
T: 518/474-9219
Salem, OR 97302
F: 518/473-5508
T: 503/391-1980
E-mail: ctc02@health.state.ny.us
F: 503/391-1979
E-mail: rowlanji@fhsc.com
NORTH CAROLINA
Tom D’Andrea, R.Ph., M.B.A. PENNSYLVANIA
Chief of Pharmacy and Ancillary Services
First DataBank, Inc.
Department of Health and Human Services
1111 Bayhill Drive, Suite 350
Division of Medical Assistance
San Bruno, CA 94066
1985 Umstead Drive
T: 800/633-3453
2501 Mail Service Center
Raleigh, NC 27699
T: 919/855-4300
F: 919/715-1255
E-mail: Tom.Dandrea@ncmail.net

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National Pharmaceutical Council Pharmaceutical Benefits 2004

RHODE ISLAND UTAH


Paula J. Avarista, R.Ph., M.B.A. RaeDell Ashley, R.Ph.
Chief of Pharmacy Pharmacy Director
Department of Human Services Medicaid Program
600 New London Avenue Division of Health Care Financing
Cranston, RI 02919 Department of Health
T: 401/462-6390 P.O. Box 143102
F: 401/462-6836 Salt Lake City, UT 84114-3102
E-mail: pavarista@dhs.ri.gov T: 801/538-6495
F: 801/538-6099
SOUTH CAROLINA E-mail: rashley@utah.gov

First DataBank
VERMONT
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066 Cathy England, Manager
T: 650/588-5454 Rebate Administration
F: 650/588-4003 First Health Services Corporation
4300 Cox Road
SOUTH DAKOTA Glen Allen, VA 23060
T: 804/965-7717
Mark E. Petersen, R.Ph.
Pharmacy Consultant
VIRGINIA
Department of Social Services
Office of Medical Services Keith T. Hayashi
700 Governors Drive Pharmacist I
Pierre, SD 57501 Department of Medical Assistance Services
T: 605/773-3498 600 East Broad Street, Suite 1300
F: 605/773-5246 Richmond, VA 23219
E-mail: Mark.Petersen@state.sd.us T: 804/225-2773
F: 804/786-0973
TENNESSEE E-mail: Keith.Hayashi@virginia.gov

First DataBank
WASHINGTON
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066 Tom Zuchlewski
T: 650/588-5454 Pharmacy Rates Manager
F: 650/588/6867 Medical Assistance Administration, DSHS
P.O. Box 45510
TEXAS Olympia, WA 98504-5510
T: 360/725-1837
Martha McNeill, R.Ph. F: 360/753-9152
Product and Prescriber Manager E-mail: zuchltm@dshs.wa.gov
Texas Health and Human Services Commission
11209 Metric Boulevard, Building H
Austin, TX 78758
T: 512/491-1157
F: 512/491-1961
E-mail: Martha.Mcneill@hhsc.state.tx.us

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National Pharmaceutical Council Pharmaceutical Benefits 2004

WEST VIRGINIA
Heather Bodiford
PBM Account Manager
ACS State Healthcare
365 Northridge Road
Northridge Center, Suite 400
Atlanta, GA 30350
T: 866/322-5960
F: 770/730-5198
E-mail: Heather.Bodiford@acs-inc.com

WISCONSIN
First DataBank
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
T: 800/633-3453
F: 650/588-6867

WYOMING
First DataBank
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
T: 800/633-3453
F: 650/588-4003

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National Pharmaceutical Council Pharmaceutical Benefits 2004

MEDICAID DRUG REBATE CONTACTS, 2004

ALABAMA
CALIFORNIA
Cyndi Crocket, Supervisor
EDS Craig Miller
301 Technacenter Drive Chief, Drug Rebate and Vision Section
Montgomery, AL 36117 Department of Health Services
T: 334/215-0111 Medi-Cal Policy Division
Pharmacy Contracting and Policy Section
1501 Capitol Avenue
ALASKA
P.O. Box 997413, MS 4604
Amanda Burger Sacramento, CA 95814
Division of Medical Assistance T: 916/552-9500
4501 Business Park Blvd., Suite 24 F: 916/552-9563
Anchorage, AK 99503 E-mail: cmiller2@dhs.ca.gov
T: 907/334-2409
F: 907/561-1684
COLORADO
E-mail: amanda.burger@health.state.ak.us
Vince Sherry
Drug Rebate Manager
ARIZONA
Department of Health Care Policy and Financing
Dell Swan 1570 Grant Street
Pharmacy Program Administrator Denver, CO 80203
AHCCCS T: 303/866-5408
701 East Jefferson Street F: 303/866-2573
MD 8000 E-mail: vince.sherry@state.co.us
Phoenix, AZ 85034
T: 612/417-4726
CONNECTICUT
E-mail: dwswan@ahcccs.state.az.us
Afrika Hinds-Ayala
Health Program Associate
ARKANSAS
Department of Social Services
Suzette Bridges, P.D., Administrator Medical Operations Unit #4
Pharmacy Program 25 Sigourney Street
Department of Human Services Hartford, CT 06106-5033
Division of Medical Services T: 860/424-5150
Pharmacy Program F: 860/424-5206
P.O. Box 1437, Slot 415 E-mail: afrika.hinds-ayala@po.state.ct.us
Little Rock, AR 72203-1437
T: 501/683-4120
DELAWARE
F: 501/683-4124
E-mail: suzette.bridges@medicaid.state.ar.us Cynthia R. Denemark, R.Ph.
Director of Pharmacy Services
DSS/EDS
248 Chapman Road, Suite 100
Newark, DE 19702
T: 302/453-8453
F: 302/454-0224
E-mail: Cynthia.denemark@eds.com

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DISTRICT OF COLUMBIA IDAHO


Jeffrey Dzieweczynski, R.Ph., M.S. Mary Wheatley, R.Ph.
ACS State Healthcare Pharmacy Services Specialist
750 First Street, NE Department of Health and Welfare
Washington, DC 20002 Division of Medicaid
T: 202/906-8353 3232 Elder
F: 202/906-8399 Boise, ID 83705
E-mail: jeffrey.dzieweczynski@acs-inc.com T: 208/364-1832
F: 208/364-1864
E-mail: wheatlem@idhw.state.id.us
FLORIDA
Regina Wiggins
ILLINOIS
Rebate Coordinator
Agency for Health Care Administration Bradley Wallner, Chief
2727 Mahan Dr., MS 38 Bureau of Budget and Cash Management
Tallahassee, FL 32308 Illinois Department of Public Aid
T: 850/487-4441 2200 Churchill Road
F: 850/922-0685 Springfield, IL 62702
E-mail: wigginsr@ahca.myflorida.com T: 217/524-7161
F: 217/785-4174
GEORGIA E-mail: bradley.wallner@idpa.state.il.us

Patricia Zeigler Jeter, M.P.A., R.Ph.


INDIANA
DUR Coordinator-Rebate Pharmacist
Department of Community Health Martha Kessenich
Division of Medical Assistance Rebate Accounting Manager
2 Peachtree St., NW, 37th Floor ACS State Healthcare
Atlanta, GA 30303-3159 365 Northridge Rd., Suite 400
T: 404/657-9181 Atlanta, GA 30350
F: 404/657-5461 T: 770/730-3292
E-mail: pjeter@dch.state.ga.us F: 866/759-4100
E-mail: martha.kessenich@acs-inc.com
HAWAII
IOWA
Martha Kessenich
Drug Rebate Manager Patrick Danlen
ACS State Healthcare POS Account Manager
365 Northridge Road, Suite 400 Iowa Medicaid Enterprise
Atlanta, GA 30350 100 Army Post Road
Attn: Hawaii Medicaid Des Moines, IA 50315
T: 800/358-2381 T: 515/725-1226
F: 770/730-5198 F: 515/725-1010
E-mail: martha.kessenich@acs-inc.com

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National Pharmaceutical Council Pharmaceutical Benefits 2004

KANSAS MARYLAND
Mary H. Obley Barry Pope
Pharmacist Rebate Pharmacist
Pharmacy Program Manager First Health Services Corporation
Health Care Policy Division Montgomery Park Business Center
Dept. of Social and Rehabilitation Services 1800 Washington Boulevard, Suite 420
Docking State Office Building Baltimore, MD 21230
915 SW Harrison, Room 651-South T: 410/263-7048
Topeka, KS 66612-1570 F: 410/263-7062
T: 785/296-3981
F: 785/296-4813 MASSACHUSETTS
E-mail: mho@srskansas.org
Martha Kessenich
Rebate Analyst
KENTUCKY
ACS State Healthcare
Betsy Scott 365 Northridge Road, Suite 400
Department for Medicaid Services Atlanta, GA 30350
CHR Building, 6 E-B T: 800/358-2381
275 E. Main Street F: 770/730-5198
Frankfort, KY 40621 E-mail: martha.kessenich@acs-inc.com
T: 502/564-5472
F: 502/564-0223
MICHIGAN
E-mail: Betsy.Scott@ky.gov
Dawn Parsons
Pharmacy Consultant
LOUISIANA
MDCH/ Medical Services Administration
Timothy T. Williams 400 South Pine Street
Health Services Financing P.O. Box 30479
Program Director Lansing, MI 48909-7979
Department of Health and Hospitals T: 517/335-5181
1201 Capitol Access Road, 6th Floor F: 517/241-8135
P.O. Box 91030 E-mail: parsonsd@michigan.gov
Baton Rouge, LA 70821
T: 225/342-5194
F: 225/342-1980 MINNESOTA
E-mail: ttwilliams@dhh.la.gov Jarvis P. Jackson, R.Ph.
Drug Rebate Coordinator
Department of Human Services
MAINE 444 Lafayette Rd. North
Rossi Rowe St. Paul, MN 55155-3853
Insurance Recovery/ Drug Rebate Manager T: 651/282-5881
Department of Human Services F: 651/282-6744
Bureau of Medical Services E-mail: jarvisp.jackson@state.mn.us
11 SHS, 442 Civic Center Drive
Augusta, ME 04333
T: 207/287-1838
F: 207/287-1788
E-mail: rossi.rowe@maine.gov

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National Pharmaceutical Council Pharmaceutical Benefits 2004

NEVADA
MISSISSIPPI
Dionne Coston, R.N.
Robert Reedy, C.Ph.T.
Medicaid Services Specialist
DRAMS Business Analyst
Nevada Medicaid Office
ACS State Healthcare
Pharmacy Program
385-B Highland Colony Parkway
1100 E. Williams Street
Ridgeland, MS 39157
Carson City, NV 89701
T: 601/206-2936
T: 775/684-3775
F: 601/206-3119
F: 775/684-3762
E-mail: robert.reedy@acs-inc.com
E-mail: dcpstpm@dhcfp.state.nv.us

MISSOURI
NEW HAMPHSHIRE
Vickie L. Harper
John Cox
Medicaid Unit Supervisor
Rebate Pharmacist
Division of Medical Services
First Health Services Corp.
Drug Rebate Unit
4300 Cox Road
2023 St. Mary’s Boulevard
Glen Allen, VA 23060
P.O. Box 6500
T: 800/884-2822
Jefferson City, MO 65102
F: 804/965-7647
T: 573/526-5664
E-mail: coxjo@fhsc.com
F: 573/522-4650
E-mail: Vicki.L.Harper@dss.mo.gov
NEW JERSEY
MONTANA Joseph B. Martinez, R.Ph.
Chief, Pharmaceutical Services
Betty DeVaney
Department of Medical Assistance and Human
Drug Rebate Coordinator
Services
Dept. of Public Health and Human Services
Office of Utilization Management
Medicaid Services Bureau
P.O. Box 712
1400 Broadway
Trenton, NJ 08619
P.O. Box 202951
T: 609/588-2774
Helena, MT 59620-2951
F: 609/588-3889
T: 406/444-3457
E-mail: joseph.b.martinez@dhs.state.nj.us
F: 406/444-1861
E-mail: bdevaney@state.mt.us
NEW MEXICO
NEBRASKA Sherry Montoya, Pharmacist
Human Services Department
Karen Jaques
Medical Assistance Division
Accountant II
P.O. Box 2348
HHSS-Finance and Support
Santa Fe, NM 87504-2348
301 Centennial Mall South
T: 505/827-7777
NSOB, 5th Floor
F: 505/827-3196
P.O. Box 95026
E-mail: sherry.montoya@state.nm.us
Lincoln, NE 68509-5026
F: 402/471-9397
E-mail: karen.jaques@hhss.ne.gov

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National Pharmaceutical Council Pharmaceutical Benefits 2004

NEW YORK OKLAHOMA


Mark-Richard A. Butt, M.S., R.Ph. Tom Simonson
Director, Pharmacy Policy and Operations Drug Rebate Manager
Office of Medicaid Management Oklahoma Health Care Authority
Department of Health 4545 N. Lincoln Blvd, Suite 124
99 Washington Ave. Oklahoma City, OK 73105
Albany, NY 12210 T: 405/522-7327
T: 518/474-9219 F: 405/522-3236
F: 518/473-5508 E-mail: simonsot@ohca.state.ok.us
E-mail: mrb01@health.state.ny.us
OREGON
NORTH CAROLINA
Jim Rowland
Tom D’Andrea, R.Ph., M.B.A. Account Manager
Chief of Pharmacy and Ancillary Services First Health Sevices Corporation
Department of Health and Human Services 925 Commercial Street SE
Division of Medical Assistance Salem, OR 97302
1985 Umstead Drive T: 503/391-1980
2501 Mail Service Center F: 503/391-1979
Raleigh, NC 27699 E-mail: rowlanji@fhsc.com
T: 919/855-4300
F: 919/715-1255
PENNSYLVANIA
E-mail: Tom.Dandrea@ncmail.net
Terri Cathers
Director of Pharmacy
NORTH DAKOTA
Department of Public Welfare
Brendan K. Joyce, Pharm.D., R.Ph. P.O. Box 2675
Administrator, Pharmacy Services Harrisburg, PA 17105
Department of Human Services T: 717/772-6195
600 East Boulevard Ave. F: 717/705-8391
Department 325 E-mail: c-tcathers@state.pa.us
Bismarck, ND 58505-0250
T: 701/328-4023
RHODE ISLAND
F: 701/328-1544
E-mail: sojoyb@state.nd.us Helen Vaughn
Analyst
EDS
OHIO
1471 Elmwood Avenue
Robert P. Reid, R.Ph. Cranston, RI 02910
Administrator, Pharmacy Services Unit T: 401/784-3879
Department of Job and Family Services
Bureau of Health Plan Policy
SOUTH CAROLINA
30 East Broad Street, 27th Floor
Columbus, OH 43215-3414 Caroline Y. Sojurner, R.Ph.
T: 614/466-6420 Department Head
F: 614/466-2908 Department of Pharmacy Services
E-mail: reidr@odjfs.state.oh.us Department of Health & Human Services
P.O. Box 8206
Columbia, SC 29202-8206
T: 803/898-2876
F: 803/255-8353
E-mail: sojurne@dhhs.state.sc.us

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SOUTH DAKOTA VIRGINIA


Helen Rokusek Keith T. Hayashi, Pharmacist I
Rebate Coordinator Department of Medical Assistance Services
Department of Social Services 600 East Broad Street, Suite 1300
700 Governors Drive Richmond, VA 23219
Pierre, SD 57501 T: 804/225-2773
T: 605/773-3653 F: 804/786-0973
E-mail: Keith.Hayashi@dmas.virginia.gov
TENNESSEE
WASHINGTON
Sybil Creekmore
Accounting Manager Connie Riddle
Bureau of TennCare Medical Assistance Administration, DSHS
729 Church Street P.O. Box 45503
Nashville, TN 37247-6501 Lacey, WA 98504-5503
T: 615/741-0018 T: 360/725-1243
F: 615/532-3479 E-mail: riddle1@dshs.wa.gov
E-mail: sybil.creekmore@state.tn.us
WEST VIRGINIA
TEXAS
Gail Goodnight, R.Ph.
Heather Murphy Rebate Coordinator
Manager, Pharmacy Contracts and Rebates Department of Health and Human Services
Vendor Drug Program Bureau for Medical Services
Health and Human Services Commission Office of Pharmacy Services
11209 Metric Boulevard, Building H 350 Capitol Street, Room 251
Austin, TX 78759 Charleston, WV 25301-3709
T: 512/491-1163 T: 304/558-5977
F: 512/491-1967 F: 304/558-1542
E-mail: heather.murphy@hhsc.state.tx.us E-mail: gailgoodnight@wvdhhr.org

UTAH WISCONSIN
Raedell Ashley, R.Ph. Ellen Orsburne
Pharmacy Director Medicaid Systems Analyst
Medicaid Program Division of Health Care Financing
Division of Health Care Financing Department of Health and Family Services
P.O. Box 143102 One West Wilson Street
Salt Lake City, UT 84114-3102 P.O. Box 309
T: 801/538-6495 Madison, WI 53701-0309
F: 801/538-6099 T: 608/267-7939
E-mail: rashley@utah.gov E-mail: orsbuer@dhfs.state.wi.us

VERMONT WYOMING
Christine Dapkiewicz Sheila McInerney
Drug Rebate Coordinator TPL Manager
EDS ACS State Healthcare
312 Hurricane Lane, Suite 100 P.O. Box 667
Williston, VT 05495 Cheyenne, WY 82003
T: 802/879-4450 T: 307/772-8400
F: 802/878-3440 F: 307/772-8405
E-mail: sheila.mcinerney@acs-inc.com

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STATE OFFICIALS -- 2005

ALABAMA ALASKA ARIZONA


Governor Governor Governor
Honorable Bob Riley Honorable Frank Murkowski Honorable Janet Napolitano
State Capitol P.O. Box 110001 State Capitol
600 Dexter Avenue Juneau, AK 99811-0001 1700 W. Washington
Montgomery, AL 36103 T: 907/465-3500 Phoenix, AZ 85007
T: 334/242-7100 F: 907/465-3532 T: 602/542-4331
F: 334/353-0004 E-mail: governor@gov.state.ak.us F: 602/542-1381
E-mail: Internet address: E-mail: azgov@azgov.state.az.us
governor@governor.state.al.us www.gov.state.ak.us Internet address:
Internet address: www.governor.state.az.us
www.governor.state.al.us Single State Agency Director
Mr. Joel Gilbertson, Commissioner Single State Agency Director
Single State Agency Director Department of Health and Social Mr. Anthony D. Rodgers, Director
Ms. Carol Herrmann Services Arizona Health Care Cost
Commissioner P.O. Box 110601 Containment System (AHCCCS)
Alabama Medicaid Agency 350 Main Street, Room 229 80l East Jefferson Street
501 Dexter Avenue Juneau, AK 99811-0601 Phoenix, AZ 85034
P.O. Box 5624 T: 907/465-3030 T: 602/417-4111
Montgomery, AL 36103-5624 F: 907/465-3068 F: 602/252-6536
T: 334/242-5600 E-mail: E-mail:
F: 334/242-0597 joel_gilbertson@health.state.ak.us anthony.rodgers@ahccs.state.az.us
E-mail: Internet address: Internet address:
ALmedicaid@medicaid.state.al.us www.hss.state.ak.us www.ahcccs.state.az.us
Internet address :
www.medicaid.state.al.us Medicaid Director Medicaid Director
Mr. Jerry Fuller, Director Mr. Anthony D. Rodgers, Director
Medicaid Director Division of Medical Assistance Arizona Health Care Cost
Ms. Carol Herrmann Department of Health and Social Containment System (AHCCCS)
Commissioner Services 801 East Jefferson Street
Alabama Medicaid Agency P.O. Box 110660 Phoenix, AZ 85034
501 Dexter Avenue Juneau, AK 99811-0660 T: 602/417-4111
P.O. Box 5624 T: 907/465-3030 F: 602/252-6536
Montgomery, AL 36103-5624 F: 907/465-3068 E-mail:
T: 334/242-5600 E-mail: anthony.rodgers@ahcccs.state.az.u
F: 334/242-0597 jerry_fuller@health.state.ak.us s
E-mail: Internet address: Internet address:
Almedicaid@medicaid.state.al.us www.hss.state.ak.us/dhcs www.ahcccs.state.az.us
Internet address :
www.medicaid.state.al.us

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ARKANSAS CALIFORNIA COLORADO


Governor Governor Governor
Honorable Mike Huckabee Honorable Arnold Schwarzenegger Honorable Bill Owens
State Capitol Building State Capitol, First Floor State Capitol
Room 250 Sacramento, CA 958l4 Room 136
Little Rock, AR 72201 T: 916/445-2841 Denver, CO 80203-1792
T: 501/682-2345 F: 916/445-4633 T: 303/866-2471
F: 501/682-3597 E-mail: governor@governor.ca.gov F: 303/866-2003
E-mail: mike.huckabee@state.ar.us Internet address: E-mail:
Internet address: www.governor.ca.gov/state/govsite/ governorowens@state.co.us
www.arkansas.gov/governor gov_hompage.jsp Internet address:
www.colorado.gov/governor
Single State Agency Director Single State Agency Director
Mr. Kurt Knickrehm, Director Ms. Sandra Shewry, Director Single State Agency Director
Department of Human Services Department of Health Services Ms. Marva Livingston Hammons
P.O. Box 1437, Slot 201 1501 Capitol Avenue Executive Director
Little Rock, AR 72203-1437 Sacramento, CA 95899 Department of Human Services
T: 501/682-8650 T: 916/440-7400 l575 Sherman Street
F: 501/682-6836 F: 916/440-7404 Denver, CO 80203-1714
E-mail: kurt.knickrehm@state.ar.us E-mail: sshewry@dhs.ca.gov T: 303/866-5700
Internet address: Internet address: www.dhs.ca.gov F: 303/866-4047
www.state.ar.us/dhs E-mail:
Medicaid Director Marva.hammons@state.co.us
Medicaid Director Mr. Stan Rosenstein Internet address:
Mr. Roy Jeffus, Director Deputy Director www.cdhs.state.co.us
Division of Medical Services Medical Care Services
Dept. of Human Services Department of Health Services Medicaid Director
P.O. Box 1437, Slot 1100 1501 Capitol Avenue, 6th Floor Ms. Vivianne M. Chaumont
103 East 7th Street P.O. Box 942732 Director
Little Rock, AR 72203-1437 Sacramento, CA 95814 Office of Medical Assistance
T: 50l/682-1671 T: 916/440-7800 Department of Health Care Policy
F: 501/682-1197 F: 916/440-7805 and Financing
E-mail: E-mail: Upareja@dhs.ca.gov 1570 Grant Street
roy.jeffus@medicaid.state.ar.us Internet address: www.medi- Denver, CO 80203-1818
Internet address: cal.ca.gov T: 303/866-5929
www.medicaid.state.ar.us F: 303/866-2573
E-mail:
vivianne.chaumont@state.co.us
Internet address:
www.chcpf.state.co.us

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CONNECTICUT DELAWARE DISTRICT OF COLUMBIA


Governor Governor Mayor
Honorable M. Jodi Rell Honorable Ruth Ann Minner Honorable Anthony A. Williams
Executive Office of the Governor Tatnall Building John A. Wilson Building
State Capitol, Room 210 William Penn Street 1350 Pennsylvania Avenue, NW
Hartford, CT 06l06 Dover, DE 19901 Washington, DC 20004
T: 860/566-4840 T: 302/744-4101 T: 202/727-2980
F: 820/524-7396 F: 302/739-2775 F: 202/727-6561
E-mail: E-mail: gminner@state.de.us E-mail: mayor@dc.gov
governor.rell@po.state.ct.us Internet address: Internet address: www.dc.gov
Internet address: www.state.de.us/governor
www.state.ct.gov/governorrel Single State Agency Director
Single State Agency Director Dr. Gregory A. Pane
Single State Agency Director Mr. Vincent P. Meconi, Secretary Department of Health
Ms. Patricia Wilson-Coker Department of Health and Social 825 North Capitol Street, NE
Commissioner Services Fourth Floor
Department of Social Services 1901 North DuPont Highway Washington, DC 20002
25 Sigourney Street New Castle, DE l9720 T: 202/442-5000
Hartford, CT 06106-5033 T: 302/255-9040 F: 202/442-4795
T: 860/424-5008 F: 302/255-4429 E-mail: gregory.pane@dc.gov
F: 860/566-2022 E-mail: vmeconi@state.de.us Internet address:
E-mail: pat.wilson- Internet address: www.dchealth.dc.gov
coker@po.state.ct.us www.state.de.us/dhss
Internet address: Medicaid Director
www.dss.state.ct.us Medicaid Director Mr. Robert Maruca
Mr. Harry Hill Senior Deputy Director
Medicaid Director Deputy Director Medical Assistance Administration
Mr. David Parella, Director Planning and Development Department of Health
Medical Care Administration Department of Health and Social 825 North Capitol Street, NE
Department of Social Services Services Fifth Floor
25 Sigourney Street Lewis Building Washington, DC 20002
Hartford, CT 06106 1901 North DuPont Highway T: 202/442-5988
T: 860/424-5116 New Castle, DE 19720 F: 202/442-4790
F: 860/424-5114 T: 302/577-4901 E-mail: robert.maruca@dc.gov
E-mail: F: 302/255-4425 Internet address:
david.parrella@po.state.ct.us E-mail: harry.hill@state.de.us www.dchealth.dc.gov
Internet address: Internet address:
www.dss.state.ct.us www.state.de.us/dhss

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FLORIDA GEORGIA GUAM


Governor Governor Governor
Honorable Jeb Bush Honorable Sonny Purdue Honorable Felix Comacho
The State Capitol 203 State Capitol Adelup Complex
Tallahassee, FL 32399-0001 Atlanta, GA 30334 P.O. Box 2950
T: 850/488-4441 T: 404/656-l776 Agana, GU 96932
F: 850/487-0801 F: 404/657-7332 T: 671/479-2002
E-mail: governor@myflorida.com E-mail: governor@gov.state.ga.us F: 671/479-2009
Internet address: Internet address: E-mail: governor@mail.gov.gu
www.myflorida.com/b_eog/owa/b_ www.gagovernor.org Internet address:
eog_www.html.main_page www.gov.gu/webtax/govoff.html
Single State Agency Director
Single State Agency Director Mr. Tim Burgess, Commissioner Single State Agency Director
Mr. Alan Levine, Secretary Department of Community of Health Mr. PeterJohn B. Comacho,
Agency for Health Care 2 Peachtree Street, NW Administrator
Administration Suite 4043 Dept. of Public Health and Social
2727 Mahan Drive, Mail Stop 1 Atlanta, GA 30303-3159 Services
Tallahassee, FL 32308 T: 404/656-4507 P.O. Box 2816
T: 850/922-3809 F: 404/651-6880 Agana, GU 96932
F: 850/488-0043 E-mail: dbevelle@hch.state.ga.us T: 671/735-7102
E-mail: Internet address: F: 671/734-5910
alan.levine@myflorida.com www.dch.state.ga.us E: mail:
Internet address: director@dphss.govguam.net
www.ahca.myflorida.com Medicaid Director
Mr. Mark Trail, Director Medicaid Director
Medicaid Director Department of Community Health Ms. Ma Theresa Arcangel, Acting
Mr. Thomas W. Arnold Medical Assistance Division Administrator
Deputy Secretary 2 Peachtree Street, NW Bureau of Health Care Financing
Agency for Health Care Suite 3733 Department of Public Health and
Administration Atlanta, GA 30303 Social Services
2727 Mahan Drive T: 404/656-1502 P.O. Box 28l6
Tallahassee, FL 32308 F: 866/283-0128 Agana, GU 96910
T: 850/488-3560 E-mail: mtrail@dma.state.ga.us T: 671/735-7282
F: 850/488-2520 Internet address: F: 671/734-5910
E-mail: www.dch.state.ga.us
thomas.arnold@myflorida.com
Internet address:
www.ahca.myflorida.com/Medicai
d

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HAWAII IDAHO ILLINOIS


Governor Governor Governor
Honorable Linda Lingle Honorable Dirk Kempthorne Honorable Rod Blagojevich
State Capitol P.O. Box 83720 207 State Capitol Building
415 S. Beretania Street Boise, ID 83720-0034 Springfield, IL 62706
Honolulu, HI 968l3 T: 208/334-2100 T: 2l7/782-6830
T: 808/586-0034 F: 208/334-3454 F: 217/782-1853
F: 808/586-0006 E-mail: governer@gov.state.id.us E-mail: governor@state.il.us
E-mail: gov@gov.state.hi.us Internet address: Internet address:
Internet address: www2.state.id.us/gov/index.htm www.state.il.us/gov
www.gov.state.hi.us
Single State Agency Director Single State Agency Director
Single State Agency Director Mr. Karl Kurtz, Director Mr. Barry Maram, Director
Ms. Lillian B. Koller, Director Department of Health and Welfare Department of Public Aid
Department of Human Services 450 West State Street 201 South Grand Avenue, East
1390 Miller Street, Room 209 Boise, ID 83720-0036 Third Floor
Honolulu, HI 96813 T: 208/334-5500 Springfield, IL 62794
T: 808/586-4997 F: 208/334-6558 T: 2l7/782-1200
F: 808/586/4890 E-mail: kurtzk@idhw.state.id.us F: 217/524-7120
E-Mail: lillian.b.koller@hawaii.gov Internet address: E-mail:
Internet address: www.healthandwelfare.idaho.gov directordpa@mail.idpa.state.il.us
www.state.hi.us/dhs Internet address:
Medicaid Director www.dpaillinois.com
Medicaid Director Mr. David Rogers, Administrator
Ms. Angie Payne Division of Medicaid Medicaid Director (Medical
Acting Administrator Department of Health and Welfare Operations)
Med-Quest Division Americana Building Dr. Anne Marie Murphy, Director
Department of Human Services 3232 Elder Street Medicaid and SCHIP Progams
P.O. Box 399 Boise, ID 83705 Department of Public Aid
Honolulu, HI 96809-0339 T: 208/334-5747 20l South Grand Avenue, East
T: 808/692-8050 F: 208/364-1811 Springfield, IL 62763-0001
F: 808/692-8173 E-mail: rogersd@idwh.state.id.us T: 2l7/782-7570
E-mail: Internet address: F: 217/524-5672
apayne@medicaid.dhs.state.hi.us www.healthandwelfare.idaho.gov E-mail:
Internet address: www.med- directordpa@mail.idpa.state.il.us
quest.us Internet address:
www.dpaillinois.com/medical

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INDIANA IOWA KANSAS


Governor Governor Governor
Honorable Mitch Daniels Honorable Thomas J. Vilsack Honorable Kathleen Sebelius
State House, Room 206 State Capitol Building 2nd Floor
200 W. Washington Street Des Moines, IA 503l9 State Capitol Building
Indianapolis, IN 46204 T: 5l5/28l-0561 Topeka, KS 66612-1590
T: 3l7/232-4567 F: 515/281-6611 T: 785/296-3232
F: 317/232-3443 E-mail: gen.office@igov.state.ia.us F: 785/296-7973
E-mail: mdaniels@gov.state.in.us Internet address: E-mail: governor@ink.org
Internet address: www.in.gov/gov www.state.ia.us/governor Internet address:
www.ksgovernor.org
Single State Agency Director Single State Agency Director
Mr. Mitch Roob, Secretary Mr. Kevin Concannon, Director Single State Agency Director
Family and Social Services Department of Human Services Mr. Gary Daniels, Acting Secretary
Administration Hoover State Office Building Kansas Department of Social and
Room 461, Mail Stop 25 Fifth Floor Rehabilitation Services
P.O. Box 7083 Des Moines, IA 503l9-0114 Docking State Office Building
402 W. Washington Street T: 5l5/28l-5452 915 SW Harrison Street, 6th Floor
Indianapolis, IN 46207-7083 F: 515/281-4980 Topeka, KS 66612
T: 317/233-4690 E-mail: kconcan@dhs.state.ia.us T: 785/296-3271
F: 317/233-4693 Internet address: F: 785/296-2173
E-Mail: www.dhs.state.ia.us E-mail: jxxm@srskansas.org
mitch.roob@fssa.state.in.us Internet address:
Internet address: Medicaid Director www.srskansas.org
www.state.in.us/fssa Mr. Eugene Gessow
Medicaid Director Medicaid Director
Medicaid Director Division of Medical Services Mr. Scott Brunner, Director
Ms. Jeanne Labrecque, Director Department of Human Services Medical Policy/Medicaid
Office of Medicaid Policy and Hoover State Office Building Department of Social and
Planning Fifth Floor Rehabilitation Services
Family and Social Services Des Moines, IA 503l9-0114 Docking State Office Building, 5th
Administration T: 5l5/725-1121 Floor
402 W. Washington Street F: 515/725-1010 915 SW Harrison Street,
Room W382 E-mail: egessow@dhs.state.ia.us Topeka, KS 66612
Indianapolis, IN 46204-2739 Internet address: T: 785/296-3773
T: 317/234-2407 www.dhs.state.ia.us F: 785/296-0509
F: 317/232-7382 E-mail: scxb@srskansas.org
E-mail: Internet address:
jeanne.labrecque@fssa.state.in.us www.srskansas.org/hcp/MPmain.
Internet address: html
www.in.gov/fssa/servicedisabl/med
icaid

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KENTUCKY LOUISIANA MAINE


Governor Governor Governor
Honorable Ernie Fletcher Honorable Kathleen Blanco Honorable John Baldacci
State Capitol Building State Capitol 1 State House Station
700 Capitol Avenue P.O. Box 94004 Augusta, Maine 04333-0001
Frankfort, KY 4060l Baton Rouge, LA 70804 T: 207/287-3531
T: 502/564-2611 T: 225/342-7015 F: 207/287-1034
F: 502/564-2517 F: 225/342-7099 E-mail: governor@state.me.us
E-mail: governor@mail.state.ky.us E-mail: Internet address:
Internet address: www.gov.state.la.us/gov_email.html www.main.gov/governor/baldacci/
www.governor.ky.gov Internet address: index.shtml
www.gov.state.la.us
Single State Agency Director Single State Agency Director
Mr. James W. Holsinger, Jr., M.D. Single State Agency Director Mr. John R. Nichols
Secretary Mr. Frederick P. Cerise, Secretary Commissioner
Cabinet for Health and Family Department of Health and Hospitals Department of Human Services
Services P.O. Box 629, Bin #2 State House Station 11
275 East Main Street, 5C-A Baton Rouge, LA 70821-0629 211 State Street
Frankfort, KY 40621 T: 225/342-9500 Augusta, ME 04333-0011
T: 502/564-6786 F: 225/342-9508 T: 207/287-1921
F: 502/564-0274 E-mail: fcerise@dhh.state.la.us F: 207/287-3005
E-mail: Internet address: E-mail: jack.r.nichols@maine.gov
brandyp.cantor@mail.state.ky.us www.dhh.state.la.us Internet address:
Internet address: www.main.gov/dhs/index.htm
www.chs.state.ky.us Medicaid Director
Mr. Ben Bearden, Director Medicaid Director
Medicaid Director Bureau of Health Services Financing Ms. Christine Gianopoulos
Ms. Shannon Turner Department of Health and Hospitals Acting Director
Acting Commissioner P.O. Box 91030 Bureau of Medical Services
Department for Medicaid Services Baton Rouge, LA 70821-9030 Department of Human Services
Sixth Floor T: 225/342-3891 State House Station 11
275 East Main Street F: 225/342-9508 442 Civic Center Drive
Frankfort, KY 40621 E-mail: BBearden@dhhmail.dhh- Augusta, ME 04333-0011
T: 502/564-4321 state.la.us T: 207/287-2674
F: 502/564-0509 Internet address: F: 207/287-2675
Internet address: www.dhh.state.la.us/MEDICAID/ E-mail:
www.chs.ky.gov./dms index.htm christine.gianapoulos@maine.gov
Internet address :
www.state.me.us/bms/bmshome.
htm

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MARYLAND MASSACHUSETTS MICHIGAN


Governor Governor Governor
Honorable Robert Ehrlich Honorable Mitt Romney Honorable Jennifer Granholm
State House Executive Office, State House P.O. Box 30013
Annapolis, MD 21401 Room 360 Lansing, MI 48909
T: 410/974-3901 Boston, MA 02133 T: 5l7/335-7858
F: 410/974-3275 T: 617/727-6250 F: 517/335-6863
E-mail: governor@gov.state.md.us F: 617/727-9725 E-mail: www.michigan.gov/gov
Internet address: E-mail: goffice@state.ma.us Internet address:
www.gov.state.md.us Internet address: www.michigan.gov/gov
www.mass.gov
Single State Agency Director Single State Agency Director
Mr. S. Anthony McCann Single State Agency Director Ms. Janet Olszewski
Secretary Mr. Ronald Preston, Secretary Director
Department of Health & Mental Health and Human Services Michigan Department of
Hygiene Executive Office Community Health
Herbert R. O'Connor Building One Ashburton Place, Room 1109 Lewis Cass Building
201 West Preston Street Boston, MA 02108 320 South Walnut Street
Fifth Floor T: 617/727-0077 Lansing, MI 48913
Baltimore, MD 21201 F: 617/727-5134 T: 517/335-0267
T: 410/767-6505 E-mail: ronald.preston@state.ma.us F: 517/373-4288
F: 410/161-6489 Internet address: www.masscare.org E-mail: norris@michigan.gov
E-mail: Internet address:
samccann@dhmh.state.md.us Medicaid Director www.michigan.gov/mdch
Internet address: Ms. Beth Waldman, Director
www.dhmh.state.md.us Divison of Medical Assistance Medicaid Director
600 Washington Street Mr. Paul Reinhart
Medicaid Director Boston, MA 02111 Deputy Director
Mr. John Folkemer T: 617/210-5690 Michigan Department of
Deputy Secretary for Health Care F: 617/210-5697 Community Health
Financing E-mail: 320 South Walnut Street
Office of Planning and Finance bwaldman@nt.dma.state.ma.us Lansing, MI 48913
Medical Care Programs Internet address : T: 517/241-7882
Department of Health & Mental www.state.ma.us/dma F: 517/335-5007
Hygiene E-mail: reinhartp1@michigan.gov
201 West Preston Street, 2nd Floor Internet address:
Baltimore, MD 21201 www.michigan.gov/mdch
T: 410/767-5806
F: 410/333-7505
E-mail:
jfolkemer@dhmh.md.state.us
Internet address:
www.dhmh.state.md.us

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MINNESOTA MISSISSIPPI MISSOURI


Governor Governor Governor
Honorable Tim Pawlenty Honorable Haley Barbour Honorable Matt Blunt
130 State Capitol State Capitol State Capitol Building, Room 216
St. Paul, MN 55155-1099 P.O. Box 139 P.O. Box 720
T: 651/296-3391 Jackson, MS 39205 Jefferson City, MO 65102-0720
F: 651/296-2089 60l/359-3150 T: 573/751-3222
E-mail: tim.pawlenty@state.mn.us E-mail: F: 573/751-1495
Internet address: www.governor.state.ms.us/aboutthe E-mail: mogov@mail.state.mo.us
www.governor.state.mn.us gov/writetoindex.html Internet address:
Internet address: www.gov.state.mo.us
Single State Agency Director www.governor.state.ms.us
Mr. Kevin Goodno Single State Agency Director
Commissioner Single State Agency Director Mr. Steve Renne, Acting Director
Minnesota Department of Human Mr. Donald Taylor Department of Social Services
Services Executive Director 221 West High Street
444 Lafayette Road North Department of Human Services P.O. Box 1527
St. Paul, MN 55155-3815 750 North State Street Jefferson City, MO 65102
T: 651/296-2701 Jackson, MS 39202 T: 573/751-4815
F: 651/297-3230 T: 601/359-4500 F: 573/751-3203
E-mail: F: 601/359-4477 E-mail:
commissioner.dhs@state.mn.us E-mail: dtaylor@mdhs.state.ms.us doris.a.lorts@dss.state.mo.us
Internet address: Internet address: Internet address:
www.dhs.state.mn.us www.mdhs.state.ms.us www.dss.state.mo.us

Medicaid Director Medicaid Director Medicaid Director


Ms. Christine Bronson Mr. Warren A. Jones, M.D. Dr. Michael Ditmore
Acting Medicaid Director Executive Director Acting Director
Minnesota Department of Human Division of Medicaid Division of Medical Services
Services Suite 801, Robert E. Lee Building Department of Social Services
444 Lafayette Road 239 North Lamar Street 615 Howerton Court
St. Paul, MN 55l55-3853 Jackson, MS 39201-1399 P.O. Box 6500
T: 651/296-4332 T: 601/359-6050 Jefferson City, MO 65102-6500
F: 651/296-5868 F: 601/359-6048 T: 573/751-6922
E-mail: E-mail: F: 573/751-6564
christine.bronson@state.mn.us wajones@medicaid.state.ms.us E-mail: karen.a.lewis@dss.mo.us
Internet address: Internet address: Internet address:
www.dhs.state.mn.us www.mdhs.state.ms.us www.dss.state.mo.us/dms

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MONTANA NEBRASKA NEVADA


Governor Governor Governor
Honorable Brian Schweitzer Honorable Dave Heineman Honorable Kenny C. Guinn
Office of the Governor P.O. Box 94848 State Capitol
State Capitol Lincoln, NE 68509-4848 Carson City, NV 89710
P.O. Box 200801 T: 402/471-2244 T: 702/684-5670
Helena, MT 59620-0801 F: 402/471-6031 F: 775/684-5683
T: 406/444-3111 E-mail: jodee@mail.state.ne.us E-mail:
F: 406/444-4151 Internet address: www.gov.nol.org www.gov.state.nv.us/mail.gov.htm
E-mail: governor@mt.gov Internet address:
Internet address: Single State Agency Director www.gov.state.nv.us
www.governor.mt.gov Mr. Richard P. Nelson, Director
Nebraska Department of Health and Single State Agency Director
Single State Agency Director Human Services Mr. Mike Wilden, Director
Dr. Robert E. Wynia Finance and Support Department of Human Resources
Department of Public Health and P.O. Box 95026 505 East King Street, Room 600
Human Services Lincoln, NE 68509-5026 Carson City, NV 89710
P.O. Box 4210 T: 402/471-8566 T: 775/684-4000
111 N. Sanders F: 402/471-9449 F: 775/684-4010
Helena, MT 59604-4210 E-mail: E-mail: nvdhr@dhr.state.nv.us
T: 406/444-5622 kelly.ostrander@hhss.ne.gov Internet address:
F: 406/444-1970 Internet address: www.hr.state.nv.us
E-mail: rewynia@state.mt.us www.hhs.state.ne.us/svc/svcindex.
Internet address: htm Medicaid Director
www.dphhs.state.mt.us Mr. Charles Duarte, Administrator
Medicaid Director Division of Health Care Financing
Medicaid Director Ms. Mary Steiner and Policy
Mr. John Chappuis Interim Administrator 1100 East William Street, Suite 116
Medicaid Director Medicaid Division Carson City, NV 89710
Division of Health Policy and Nebraska Department of HHS T: 775/684-3676
Services Finance and Support F: 775/687-3893
Department of Public Health and P.O. Box 95007 E-mail:
Human Services 301 Centennial Mall South, 5th Floor cduarte@govmail.state.nv.us
1400 Broadway Lincoln, NE 68509-5007 Internet address:
Helena, MT 59601 T: 402/471-9567 www.dhcfp.state.nv.us
T: 406/444-4084 F: 402/471-9092
F: 406/444-1861 E-mail: mary.steiner@hhss.ne.gov
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 HAMPSHIRE NEW JERSEY NEW MEXICO


Governor Governor Governor
Honorable John Lynch Honorable Richard Codey Honorable Bill Richardson
Office of the Governor Acting Governor Office of the Governor
State House 125 West State Street State Capitol
Room 208 State House CN-001 Suite 400
107 North Main Street Trenton, NJ 08625 Santa Fe, NM 87501
Concord, NH 03301-4990 T: 609/292-6000 T: 505/476-2200
T: 603/271-2121 F: 609/292-3454 F: 505/476-2226
F: 603/271-5686 E-mail: E-mail: gov@gov.state.nm.us
E-mail: governorlynch@nh.gov www.state.nj.us/governor/govmail. Internet address:
Internet address: html www.governor.state.nm.us
www.state.nh.us/governor Internet address:
www.state.nj.us/governor Single State Agency Director
Single State Agency Director Ms. Pamela Hyde, J.D.
Mr. John Stephen, Commissioner Single State Agency Director Secretary
Department of Health and Human Mr. James M. Davy, Commissioner New Mexico Human Services
Services Department of Human Services Department
129 Pleasant Street P.O. Box 700 P.O. Box 2348
Concord, NH 03301-3857 Trenton, NJ 08625 Santa Fe, NM 87504-2348
T: 603/271-4331 T: 609/292-3717 T: 505/827-7750
F: 603/271-4912 F: 609/292-3824 F: 505/827-6286
E-mail: jstephen@dhhs.state.us E-mail: james.davy@dhs.state.nj.us E-mail: pam.hyde@state.nm.us
Internet address: Internet address: Internet address:
www.dhhs.state.nh.us/DHHS/ www.state.nj.us/humanservices www.state.nm.us/hsd
DHHS_SITE/default.htm
Medicaid Director Medicaid Director
Medicaid Director Ms. Ann Clemency Kohler, Director Ms. Carolyn Ingram, Director
Mr. Stephen Norton Division of Medical Assistance and Medical Assistance Division
Medicaid Director Health Services New Mexico Human Services
Office of Health Policy & 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: 505/827-3106
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: 603/271-3676 Internet address: carolyn.ingram@state.nm.us
F: 603/271-8431 www.state.nj.us/humanservices/ Internet address:
E-mail: snorton@dhhs.state.nh.us dmahs/index.html www.state.nm.us/hsd/mad/index.
Internet address: html
www.dhhs.state.nh.us/DHHS/
MEDICAIDPROGRAM/
default.htm

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NEW YORK NORTH CAROLINA NORTH DAKOTA


Governor Governor Governor
Honorable George E. Pataki Honorable Mike Easley Honorable John Hoeven
Executive Chamber Office of the Governor Department 101
State Capitol 116 West Jones Street 600 East Boulevard Avenue
Albany, NY 12224 20301 Mail Service Center Bismarck, ND 58505-0001
T: 5l8/474-8390 Raleigh, NC 27699-0301 T: 701/328-2200
F: 518/474-3767 T: 919/733-4240 F: 701/328-2205
E-mail: T: 919/733-5811 E-mail: governor@state.nd.us
gov.pataki@chamber.state.ny.us F: 919/733-2120 Internet address:
Internet address: F: 919/715-3175 www.governor.state.nd.us
www.state.ny.us/governor E-mail:
www.governor.state.nc.us/email.asp Single State Agency Director
Single State Agency Director ?to=1 Ms. Carol K. Olson, Executive
Ms. Antonia C. Novello, M.D., Internet address: Director
M.P.H., Commissioner www.governor.state.nc.us Department of Human Services
NYS Department of Health 600 East Boulevard Avenue,
ESP, Corning Tower Building Single State Agency Director Dept. 325
Albany, NY 12237 Ms. Carmen Hooker Odom, Bismarck, ND 58505-0250
T: 518/474-2011 Secretary T: 701/328-2538
F: 518/474-5450 Department of Health and Human F: 701/328-1545
E-mail: acn01@health.state.ny.us Services E-mail: dhseo@state.nd.us
Internet address: 2001 Mail Service Center Internet address:
www.health.state.ny.us/homens6. Raleigh, NC 27699-2001 www.state.nd.us/humanservices.nsf
html T: 919/733-4534
F: 919/715-4645 Medicaid Director
Medicaid Director E-mail: Mr. David J. Zentner
Ms. Kathryn Kuhmerker, Deputy carmen.hookerodom@ncmail.net Director
Director Internet address: Division of Medical Services
NYS Department of Health www.dhhs.state.nc.us Department of Human Services
Office of Medicaid Management 600 East Boulevard Avenue
Empire State Plaza Medicaid Director Dept. 325
Room 1466, Corning Tower Mr. Mark Benton, Interim Director Bismarck, ND 58505-0261
Building Division of Medical Assistance T: 701/328-2321
Albany, NY 12237 Department of Health and Human F: 701/328-1544
T: 518/474-3018 Services E-mail: dhsmed@state.nd.us
F: 518/486-6852 2501 Mail Service Center Internet address:
E-mail: klk03@health.state.ny.us Raleigh, NC 27699-2501 www.state.nd.us/humanservices/
Internet address : T: 919/855-4100 services/medicalserv
www.health.state.ny.us/health_care F: 919/733-6608
/medicaid E-mail: mark.benton@ncmail.net
Internet address:
www.dhhs.state.nc.us/dma

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NORTHERN MARIANA OHIO OKLAHOMA


ISLANDS Governor Governor
Governor Honorable Bob Taft Honorable Brad Henry
Honorable Juan N. Babauta 77 South High Street, 30th Floor 212 State Capitol
Office of the Governor Columbus, OH 43215-6117 2300 N. Lincoln Boulevard
Commonwealth of the Northern T: 614/466-3555 Oklahoma City, OK 73105
Mariana Islands F: 614/466-9354 T: 405/521-2342
Juan S. Atalig Memorial Building E-mail: F: 405/521-3353
Isa Drive, Capitol Hill governor.taft@das.state.oh.us E-mail: governor@gov.state.ok.us
Caller Box 10007 Internet address: Internet address:
Saipan, MP 96950 www.state.oh.us/gov www.governor.state.ok.us
670/322-5091
Single State Agency Director Single State Agency Director
Single State Agency Director Ms. Barbara Riley, Director Mr. Mike Fogarty, J.D.
Dr. James Hofschneider Ohio Department of Job and Family Chief Executive Officer
Secretary for Health Services Services Oklahoma Health Care Authority
Department of Public Health and 30 East Broad Street, 32nd Floor 4545 North Lincoln Boulevard
Environmental Services Columbus, OH 43215-3414 Suite 124
Commonwealth of the Northern T: 614/466-6282 Oklahoma City, OK 73105
Mariana Islands F: 614/466-2815 T: 405/522-7300
P.O. Box 409 CK E-mail: rileyb@odjfs.state.oh.us F: 405/522-7187
Saipan, MP 96950 Internet address: www.jfs.ohio.gov E-mail: fogartym@ohca.state.ok.us
670/234-8950 Internet address:
Medicaid Director www.ohca.state.ok.us
Medicaid Director Ms. Barbara Coulter Edwards
Ms. Maria Sablan Deputy Director Medicaid Director
Medical Administrator Ohio Health Plans Ms. Lynn Mitchell, M.D., M.P.H.
Department of Public Health and Ohio Department of Job and Family Medical Director
Environmental Services Services Oklahoma Health Care Authority
Commonwealth of the Northern 30 East Broad Street, 31st Floor 4545 North Lincoln Boulevard
Mariana Islands Columbus, OH 43215-3414 Suite 124
P.O. Box 409 CK T: 614/466-0140 Oklahoma City, OK 73105
Saipan, MP 96950 F: 614/752-3986 T: 405/522-7365
T: 670/664-4880 E-mail: edwarb@odhs.state.oh.us F: 405/530-3218
F: 670/664-4885 Internet address : E-mail: mitchelll@ohca.state.ok.us
www.jfs.ohio.gov.ohp Internet address:
www.ohca.state.ok.us

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OREGON PENNSYLVANIA PUERTO RICO


Governor Governor Governor
Honorable Ted Kulongoski Honorable Ed Rendell Honorable Anibal Acevedo-Vila
State Capitol 25 Main Capitol Building Office of the Governor
900 Court Street NE Harrisburg, PA 17120 La Fortaleza
Salem, OR 97310-4047 T: 717/787-2500 P.O. Box 82
T: 503/378-3111 F: 717/772-8284 San Juan, PR 00901
F: 503/378-4863 E-mail: 809/721-7000
E-mail: www.governor.state.or.us/ www.state.pa.us/pa_exec/governor/
Contact.htm govmail.html Single State Agency Director
Internet address: Internet address: Mr. John Rullan, M.D.
www.governor.state.or.us www.state.pa.us/governor Secretary
Department of Health
Single State Agency Director Single State Agency Director G.P.O. Box 70184
Mr. Gary Weeks, Director Ms. Estelle B. Richman, Secretary San Juan, PR 00936
Department of Human Resources Department of Public Welfare 787/7274-7676
500 Summer Street, NE Health and Welfare Building
Human Resources Building, E15 P.O. Box 2675 Medicaid Director
Salem, OR 97301 Harrisburg, PA 17105-2675 Mr. William Gonzalez, Director
T: 503/945-5944 T: 717/787-2600 Office of Economic Assistance to
F: 503/378-2897 F: 717/772-2062 The Medically Indigent
E-mail: gary.weeks@state.or.us E-mail: ra-dpwsecretarynet Department of Health
Internet address: @state.pa.us G.P.O. Box 70184
www.dhs.state.or.us Internet address: San Juan, PR 00936
www.dpw.state.pa/us T: 787/765-1230, ext. 200
Medicaid Director F: 787/250-0990
Mr. Barney H. Speight Medicaid Director E-mail: wgonzalez@salvd.gov.pr
Administrator Mr. David S. Feinberg
Office of Medical Assistance Deputy Secretary
Programs Office of Medical Assistance
Department of Human Services Programs
500 Summer Street, NE, E49 Department of Public Welfare
Salem, OR 97301 Health and Welfare Building,
T: 503/373-7689 Room 515
F: 503/373-7823 P.O. Box 2675
E-mail: Harrisburg, PA 17105-2675
barney.h.speight@state.or.us T: 717/787-1870
Internet address: F: 717/787-4639
www.dhs.state.or.us/healthplan E-mail: dfeinberg@state.pa.us
Internet address:
www.dpw.state.pa.us/omap

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RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA


Governor Governor Governor
Honorable Don Carcieri Honorable Mark Sanford Honorable Mike Rounds
222 State House P.O. Box 12267 500 East Capitol
Providence, RI 02903-1196 Columbia, SC 29211 Pierre, SD 57501
T: 401/222-2080 T: 803/734-2100 T: 605/773-3212
F: 401/222-8096 F: 803/734-5167 F: 605/773-4711
E-mail: rigov@gov.state.ri.us E-mail: E-mail: governor@state.sd.us
Internet address: governor@govoepp.state.sc.us Internet address:
www.governor.state.ri.us Internet address: www.state.sd.us/governor
www.state.sc.us/governor
Single State Agency Director Single State Agency Director
Ms. Jane Hayward, Director Single State Agency Director Mr. James W. Ellenbecker,
Department of Human Services Mr. Robert Kerr, Director Secretary
600 New London Avenue Department of Health and Human Department of Social Services
Cranston, RI 02920 Services Richard F. Kneip Building
T: 401/462-2121 1801 Main Street 700 Governors Drive
F: 401/462-3677 P.O. Box 8206 Pierre, SD 57501-2291
E-mail: Columbia, SC 29202-8206 T: 605/773-3165
jhayward@gw.dhs.state.ri.us T: 803/898-2504 F: 605/773-4855
Internet address: F: 803/898-4515 E-mail: dssinfo@.state.sd.us
www.dhs.state.ri.us E-mail: malonel@dhhs.state.sc.us Internet address:
Internet address: www.state.sd.us/social
Medicaid Director www.dhhs.state.sc.us
Mr. John C. Young, C.P.M. Medicaid Director
Associate Director Medicaid Director Mr. Larry Iverson
Division of Medical Services Mr. Robert Kerr, Director Division Director
Department of Human Services Department of Health and Human Medical Services
600 New London Avenue Services Department of Social Services
Cranston, RI 02920 1801 Main Street Richard F. Kneip Building
T: 401/462-3575 P.O. Box 8206 700 Governors Drive
F: 401/462-6338 Columbia, SC 29202-8206 Pierre, SD 57501-2291
E-mail: Jyoung@gw.dhs.state.ri.us T: 803/898-2504 T: 605/773-3495
Internet address: F: 803/898-4515 F: 605/773-5246
www.dhs.state.ri.us E-mail: malonel@dhhs.state.sc.us E-mail: medical@state.sd.us
Internet address: Internet address:
www.dhhs.state.sc.us www.state.sd.us/social/medical

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TENNESSEE TEXAS UTAH


Governor Governor Governor
Honorable Phil Bredesen Honorable Rick Perry Honorable John Huntsman
State Capitol, First Floor State Capitol Office of the Governor
Nashville, TN 37243-0001 P.O. Box 12428 Utah East Office Building
T: 615/741-2001 Austin, TX 78711 Suite E220
F: 615/532-9711 T: 5l2/463-2000 Salt Lake City, UT 84114
E-mail: phil.brendsen@state.tn.us F: 512/463-1849 T: 801/538-1000
Internet address: E-mail: F: 801/538-1528
www.state.tn.us/governor www.governor.state.tx.us/contact E-mail: governor@utah.gov
Internet address: Internet address:
Single State Agency Director www.governor.state.tx.us www.utah.gov/governor
Ms. Gina Lodge, Commissioner
Department of Human Services Single State Agency Director Single State Agency Director
400 Deaderick Street, 15th Floor Mr. Albert Hawkins, Commissioner Mr. David Sundwall, M.D.
Nashville, TN 37248-0001 Health and Human Services Executive Director
T: 615/313-4700 Commission Department of Health
F: 615/741-4165 4900 N. Lamar Boulevard P.O. Box 141000
E-mail: P.O. Box 13247 Salt Lake City, UT 84114-1000
gina.lodge@state.tn.us Austin, TX 78751 T: 801/538-6111
Internet address: T: 5l2/424-6502 F: 801/538-6306
www.state.tn.us/humanserv F: 512/424-6587 E-mail: davidsundwall@utah.gov
E-mail: Internet address:
Medicaid Director laura.ozuna@hhsc.state.tx.us www.health.utah.gov
Ms. Mary-Anne Rudolph, Director Internet address:
Medicaid Policy Unit www.hhsc.state.tx.us Medicaid Director
Citizen’s Plaza Building, 12th Floor Mr. Michael Deily, Director
400 Deaderick Street Medicaid Director Department of Health
Nashville, TN 37248 Mr. David Balland Division of Health Care Financing
T: 615/313-4873 Interim Director P.O. Box 14301
F: 615/313-6639 Health and Human Services Salt Lake City, UT 84114-3101
E-mail: mary- Commission T: 801/538-6406
anne.rudolph@state.tn.us 4900 N. Lamar Boulevard, 4th Floor F: 801/538-6099
Internet address: P.O. Box 13247 E-mail: mdeily@utah.gov
www.state.tn.us/humanserv/medi. Austin, TX 78751 Internet address:
htm T: 512/491-1463 www.health.utah.gov/medicaid
F: 512/424-6587
E-mail:
david.balland@hhsc.state.tx.us
Internet address:
www.hhsc.tx.us/medicaid

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VERMONT VIRGINIA VIRGIN ISLANDS


Governor Governor Governor
Honorable James Douglas Honorable Mark Warner Honorable Charles Turnbull
109 State Street State Capitol Building, Third Floor Government House
Montpelier, VT 05609 Richmond, VA 232l9 21-22 Kongens Gada Street
T: 802/828-3333 T: 804/786-2211 Charlotte Amalie
F: 802/828-3339 F: 804/692-0121 St. Thomas, VI 00802
Internet address: E-mail: T: 340/774-0001
www.gov.state.vt.us www.governor.state.va.us/contact/ F: 340/776-4912
email_form.html E-mail: rcanton@govhouse.gov.vi
Single State Agency Director Internet address: Internet address: www.gov.vi
Mr. Michael K. Smith, Secretary www.governor.state.va.us
Agency of Human Services Single State Agency Director
103 South Main Street Single State Agency Director Ms. Darlene A Carty
Waterbury, VT 05671-0201 Ms. Jane H. Woods, Secretary Commissioner of Health
T: 802/241-2220 Office of The Secretary of Health Virgin Islands Department of
F: 802/241-2979 and Human Resources Health
E-mail: mike.smith@state.vt.us 202 N. Ninth Street, Suite 622 48 Sugar Estate
Internet address: P.O. Box 1475 St. Thomas, VI 00802
www.ahs.state.vt.us Richmond, VA 23219 T: 340/774-0117
T: 804/786-7765 F: 340/777-4001
Medicaid Director F: 804/371-6984 E-mail: darlene.carty@usvi-
Mr. Joshua Slen, Medicaid Director E-mail: shhr@gov.state.va.us doh.org
Agency of Human Services Internet address :
Office of Vermont Health Access www.hhr.state.va.us Medicaid Director
103 South Main Street Ms. Jane Laws, Executive Director
Waterbury, VT 05676-1201 Medicaid Director Bureau of Health Insurance and
T: 802/879-5900 Mr. Patrick Finnerty, Director Medical Assistance
F: 802/879-5962 Department of Medical Assistance Department of Health
E-mail: joshuas@path.state.vt.us Services 3730 Altona, Suite 302 Frostco
Internet address: 600 East Broad Street Center
www.dsw.state.vt.us Suite 1300 Charlotte Amalie
Richmond, VA 23219 St. Thomas, VI 00802
T: 804/786-4231 T: 340/774-4624
F: 804/371-4981 F: 340/774-4918
E-mail: pfinnert@dmas.state.va.us E-mail: jane.law@usvi-doh.org
Internet address:
www.dmas.state.va.us

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WASHINGTON WEST VIRGINIA WISCONSIN


Governor Governor Governor
Honorable Christine Gregoire Honorable Joe Manchin III Honorable Jim Doyle
Office of the Governor State Capitol Office of The Governor
P.O. Box 40002 Charleston, WV 25305-0370 115 East State Capitol
Olympia, WA 98504-0002 T: 304/558-2000 Madison, WI 53702
T: 360/902-4111 F: 304/342-7025 T: 608/266-1212
F: 360-753-4110 E-mail: governor@state.wv.us F: 608/267-8983
E-mail: Internet address: E-mail: wisgov@gov.state.wi.us
www.governor.wa.gov/contact.gov www.state.wv.us/governor Internet address:
email.htm www.wisgov.state.wi.us
Internet address: Single State Agency Director
www.governor.wa.gov Ms. Martha Yeager Walker Single State Agency Director
Secretary Ms. Helene Nelson, Secretary
Single State Agency Director Department of Health and Human Department of Health and Family
Ms. Robin Arnold-Williams Resources Services
Secretary Building 3, State Capitol Complex One West Wilson Street, Room 650
Department of Social and Health Room 206 Madison, WI 53702
Services Charleston, WV 25305 T: 608/266-9622
P.O. Box 45010 T: 304/558-0684 F: 608/266-7882
Olympia, WA 98504-5010 F: 304/558-1130 E-mail:
T: 360/902-7800 E-mail: marthaywalker@wvdhhr.org webmaster@dhfs.state.wi.us
F: 360/902-7848 Internet address: www.wvd.hhr.org Internett address:
E-mail: arnolr@dshs.wa.gov www.dhfs.state.wi.us
Internet address: www.wa.gov/dshs Medicaid Director
Ms. Nancy Atkins, Commissioner Medicaid Director
Medicaid Director Bureau for Medical Services Mr. Mark B. Moody, Administrator
Mr. Doug Porter Department of Health and Human Division of Health Care Financing
Assistant Secretary Resources One West Wilson Street
Medical Assistance Administration 7012 MacCorkle Avenue, SE P.O. Box 309
P.O. Box 45100 Charleston, WV 25301 Madison, WI 53701-0309
Olympia, WA 98504-5100 T: 304/558-1700 T: 608/266-2522
T: 360/902-1863 F: 304/558-1509 F: 608/266-1096
F: 360/902-7855 E-mail: nancyatkins@wvdhhr.org E-mail:
E-mail: portejd@dshs.wa.gov Internet address: webmaster@dhfs.state.wi.us
Internet address: www.wvdhhr.org/bms Internet address:
www.fortress.wa.gov/dshs/maa www.dhfs.state.wi.us

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WYOMING
Governor
Honorable Dave Freudenthal
State Capitol, Room 124
Cheyenne, WY 82002-0010
T: 307/777-7434
F: 307/632-3909
E-mail:
governor@missc.state.wy.us
Internet address: www.state.wy.us

Single State Agency Director


Ms. Deb Fleming, Ph.D., Director
Department of Health
117 Hathaway Building
Cheyenne, WY 82002
T: 307/777-7656
F: 307/777-7439
E-mail: wdh@state.wy.us
Internet address:
www.wdhfs.state.wy.us

Medicaid Director
Ms. Iris Oleske,
State Medicaid Agent
Department of Health
147 Hathaway Building
Cheyenne, WY 82002
T: 307/777-7531
F: 307/777-6964
E-mail: iolesk@state.wy.us
Internet address: wdhfs.state.wy.us

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CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)


REGIONAL OFFICES
ASSOCIATE REGIONAL ADMINISTRATORS - MEDICAID

Region I Peggy Leoni Connecticut, Maine, Massachusetts,


Boston Regional Office John F. Kennedy Federal Bldg. New Hampshire, Rhode Island,
Government Center, Room 2325 Vermont
Boston, MA 02203-0003
617/565-1299
Region II Sue Kelly New Jersey, New York, Puerto Rico,
New York Regional Office 26 Federal Plaza Virgin Islands
Room 3811
New York, NY 10278-0063
212/264-2058
Region III Sue Cuerdon Delaware, District of Columbia,
Philadelphia Regional Office The Public Ledger Building, Suite 216 Maryland, Pennsylvania, Virginia,
150 S. Independence Mall West West Virginia
Philadelphia, PA 19106
215/861-4261
Region IV Hugh Webster (Acting) Alabama, Florida, Georgia, Kentucky,
Atlanta Regional Office Atlanta Federal Center Mississippi, North Carolina, South
61 Forsyth Street, SW, Suite 4T20 Carolina, Tennessee
Atlanta, GA 30303-8909
404/562-7432
Region V Cheryl Harris Illinois, Indiana, Michigan,
Chicago Regional Office 233 North Michigan Avenue Minnesota, Ohio, Wisconsin
Suite 600
Chicago, IL 60601-5519
312/353-2702
Region VI Andrew Fredrickson Arkansas, Louisiana, New Mexico,
Dallas Regional Office 1301 Young Street, Room 714 Oklahoma, Texas
Dallas, TX 75202
214/767-6385
Region VII James Scott Iowa, Kansas, Missouri, Nebraska
Kansas City Regional Office Richard Bolling Federal Building
601 East 12th Street, Room 235
Kansas City, MO 64106-2808
816/426-6417
Region VIII Diane Livesay Colorado, Montana, North Dakota,
Denver Regional Office Colorado State Bank Building South Dakota, Utah, Wyoming
1600 Broadway, Suite 700
Denver, CO 80202-4367
303/844-7057
Region IX Linda Minamoto Arizona, California, Hawaii, Guam
San Francisco Regional Office 75 Hawthorne Street, 4th & 5th Floors Nevada, and Pacific Islands
San Francisco, CA 94105-3901
415/744-3568
Region X Karen O’Connor Alaska, Idaho, Oregon, Washington
Seattle Regional Office 2201 6th Avenue
Mail Stop RX-43
Seattle, WA 98121-2500
206/615-2330

Source: CMS, Central Office, Centers for Medicaid and State Operations, as of April 2005.

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CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)


NATIONAL ACCOUNT REPRESENTATIVES

STATE CENTRAL OFFICE REGIONAL OFFICE

Alabama Virginia Wanamaker Jay Gavens


Deputy Director Financial Analyst
Division of Laboratory Services Atlanta Federal Center
Survey and Certification Group 61 Forsyth Street, SW, Suite 4T20
Center for Medicaid and State Operations Atlanta, GA 30303-8909
Mail Stop S2-26-12 T: 404/562-7430
7500 Security Boulevard E-mail: jgavens@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-7304
E-mail: vwanamaker@cms.hhs.gov

Alaska Richard Strauss Elizabeth Trias


Director Health Insurance Specialist
Division of Financial Management Medicaid Branch, Region X
Finance, Systems and Budget Group 2201 6th Avenue
Center for Medicaid and State Operations MS/RX-43
Mail Stop S2-26-12 Seattle, WA 98121
7500 Security Boulevard T: 206/615-2400
Baltimore, MD 21244-1850 E-mail: etrias@cms.hhs.gov
T: 410/786-2019
E-mail: rstrauss@cms.hhs.gov

American Samoa Linda Murphy Mary Rydell


Health Insurance Specialist Pacific Area Representative
Family and Children’s Health Programs Group P.O. Box 50081
Center for Medicaid and State Operations 300 Ala Moana Blvd., 6-225
Mail Stop S2-26-12 Honolulu, HI 96850
7500 Security Boulevard T: 808/541-2732
Baltimore, MD 21244-1850 E-mail: mrydell@cms.hhs.gov
T: 410/786-0435
E-mail: lmurphy@cms.hhs.gov

Arizona Angela Brice-Smith Ronald Reepen


Deputy Director Health Insurance Specialist
Survey and Certification Group 75 Hawthorne Street, Room 408
Center for Medicaid and State Operations San Francisco, CA 94105-3901
Mail Stop S2-26-12 T: 415/744-3601
7500 Security Boulevard E-mail: rreepen@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-4340
E-mail: abricesmith@cms.hhs.gov

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Arkansas Marty Svolos J. P. Peters


Director Health Insurance Specialist
Division of Eligibility, Enrollment and Outreach 1301 Young Street, Room 833
Family and Children's Health Program Group Dallas, TX 75202
Center for Medicaid and State Operations T: 214/767-2628
Mail Stop S2-26-12 E-mail: jpeters@cms.hhs.gov
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-4582
E-mail: msvolos@cms.hhs.gov

California Bill Lasowski Pat Daley


Financial Advisor Health Insurance Specialist
Office of the Center Director 75 Hawthorne Street, Room 408
Center for Medicaid and State Operations San Francisco, CA 94105-3901
Mail Stop S2-26-12 T: 415/744-3592
7500 Security Boulevard E-mail: pdaley@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-2003
E-mail: wlasowski@cms.hhs.gov

Colorado Edward Gendron Cynthia Gillaspie


Director Colorado State Bank Building
Finance, Systems and Budget Group 1600 Broadway, Suite 700
Center for Medicaid and State Operations Denver, CO 80202-4367
Mail Stop S2-26-12 T: 303/844-4725
7500 Security Boulevard E-mail: cgillaspie@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-1064
E-mail: egendron@cms.hhs.gov

Connecticut Edward Hutton Irvin Rich


Technical Director JFK Federal Building
Disabled and Elderly Health Programs Group Government Center, Room 2325
Center for Medicaid and State Operations Boston, MA 02203-0003
Mail Stop S2-26-12 T: 617/565-1247
7500 Security Boulevard E-mail: irich@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6616
E-mail: ehutton@cms.hhs.gov

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Delaware Denise Bazemore Paul Hughes


Technical Director Health Insurance Specialist
Division of State Systems The Public Ledger Building, Suite 216
Finance, Systems and Budget Group 150 S. Independence Mall West
Center for Medicaid and State Operations Philadelphia, PA 19106
Mail Stop S2-26-12 T: 215/861-4171
7500 Security Boulevard E-mail: phughes1@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-4449
E-mail: dbazemore@cms.hhs.gov

District of Rick Fenton Marguerite Clark


Columbia Deputy Director Health Insurance Specialist
Family and Children's Health Programs Group The Public Ledger Building, Suite 216
Center for Medicaid and State Operations 150 S. Independence Mall West
Mail Stop S2-26-12 Philadelphia, PA 19106
7500 Security Boulevard T: 215/861-4199
Baltimore, MD 21244-1850 E-mail: mclark@cms.hhs.gov
T: 410/786-5920
E-mail: rfenton@cms.hhs.gov

Florida Jim Frizzera Roberta Kelley


Co-Lead, National Institutional Reimbursement Team Atlanta Federal Center
Center for Medicaid and State Operations 61 Forsyth Street, SW, Suite 4T20
Mail Stop S2-26-12 Atlanta, GA 30303-8909
7500 Security Boulevard T: 404/562-7338
Baltimore, MD 21244-1850 E-mail: rkelley@cms.hhs.gov
T: 410/786-9535
E-mail: jfrizzera@cms.hhs.gov

Georgia Jerry Zelinger Hugh Webster


Medical Advisor Chief
Division of Benefits, Coverage and Payment Medicaid Financial Management Branch
Family and Children’s Health Programs Group Atlanta Federal Center
Center for Medicaid and State Operations 61 Forsyth Street, SW, Suite 4T20
Mail Stop S2-26-12 Atlanta, GA 30303-8909
7500 Security Boulevard T: 404/562-7432
Baltimore, MD 21244-1850 E-mail: hwebster@cms.hhs.gov
T: 410/786-5929
E-mail: gzelinger@cms.hhs.gov

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Guam Paul Miner Eddie Martin


Technical Director Accountant
Finance, Systems and Budget Group 75 Hawthorne Street, Room 408
Center for Medicaid and State Operations San Francisco, CA 94105-3901
Mail Stop S2-26-12 T: 415/744-3588
7500 Security Boulevard E-mail: emartin@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-5937
E-mail: pminer@cms.hhs.gov

Hawaii Larry Reed Susan Castleberry


Co-Lead, Pharmacy Team Health Insurance Specialist
Family and Children's Health Program Group 75 Hawthorne Street, Room 408
Center for Medicaid and State Operations San Francisco, CA 94105-3901
Mail Stop S2-26-12 T: 415/744-3599
7500 Security Boulevard E-mail: scastleberry@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-3325
E-mail: lreed2@cms.hhs.gov

Idaho Georgia Johnson David Meacham


Technical Director Health Insurance Specialist
Division of Continuing Care Providers 2201 6th Avenue
Survey and Certification Group MS/RX-43
Center for Medicaid and State Operations Seattle, WA 98121
Mail Stop S2-26-12 T: 206/615-2356
7500 Security Boulevard E-mail: dmeacham@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6859
E-mail: gjohnson4@cms.hhs.gov

Illinois Mary Beth Hance Alice Holden


Director 233 N. Michigan Avenue
Policy Coordination and Planning Group Suite 600
Center for Medicaid and State Operations Chicago, IL 60601
Mail Stop S2-26-12 T: 312/353-1582
7500 Security Boulevard E-mail: aholden@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-4299
E-mail: mhance@cms.hhs.gov

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Indiana Kristin Fan Leslie Campbell


Supervisory Health Insurance Specialist Indiana State Representative
Division of Reimbursement and State Finance 233 N. Michigan Avenue
Finance, Systems and Budget Group Suite 600
Center for Medicaid and State Operations Chicago, IL 6061
Mail Stop S2-26-12 T: 312/353-1557
7500 Security Boulevard E-mail: lcampbell@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-4581
E-mail: kristin.fan@cms.hhs.gov

Iowa Mary Jean Duckett James G. Scott


Director Branch Manager
Division of Benefits, Coverage and Payment DMCH, PSB
Disabled and Elderly Health Programs Group Richard Bolling Federal Building
Center for Medicaid and State Operations 601 East 12th Street, Room 235
Mail Stop S2-26-12 Kansas City, MO 64106-2808
7500 Security Boulevard T: 816/426-6417
Baltimore, MD 21244-1850 E-mail: jscott1@cms.hhs.gov
T: 410/786-3294
E-mail: mduckett@cms.hhs.gov

Kansas Frank Sokolik Tim Watson


Director Health Insurance Specialist
Division of Acute Care Richard Bolling Federal Building
Center for Medicaid and State Operations 601 East 12th Street, Room 227
Mail Stop S2-26-12 Kansas City, MO 64106-2808
7500 Security Boulevard T: 816/426-6462
Baltimore, MD 21244-1850 E-mail: twatson@cms.hhs.gov
T: 410/786-7089
E-mail: fsokolik@cms.hhs.gov

Kentucky Jack Williams Renard Murray


Director Associate Regional Administrator
Division of National Systems Atlanta Federal Center
Finance, Systems and Budget Group 61 Forsyth Street, SW, Suite 4T20
Center for Medicaid and State Operations Atlanta, GA 30303-8909
Mail Stop S2-26-12 T: 404/562-7417
7500 Security Boulevard E-mail: rmurray@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6743
E-mail: jwilliams2@cms.hhs.gov

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Louisiana Jean Sheil Robert Cowan


Director Financial Operations Specialist
Family and Children’s Health Programs Group 1301 Young Street, Room 714
Center for Medicaid and State Operations Dallas, TX 75202
Mail Stop S2-26-12 T: 214/767-6485
7500 Security Boulevard E-mail: rcowan@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-1285
E-mail: jsheil@cms.hhs.gov

Maine Roger Buchanan Richard Pecorella


Director JFK Federal Building
Division of Informational Analysis and Technical Government Center, Room 2325
Assistance Boston, MA 02203-0003
Finance, Systems and Budget Group T: 617/565-1244
Center for Medicaid and State Operations E-mail: rpecorella@cms.hhs.gov
Mail Stop S2-26-12
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-0780
E-mail: rbuchanan@cms.hhs.gov

Maryland Kathy Rama James Hake


Technical Director Health Insurance Specialist
Division of Advocacy and Special Issues The Public Ledger Building, Suite 216
Disabled and Elderly Health Programs Group 150 S. Independence Mall West
Center for Medicaid and State Operations Philadelphia, PA 19106
Mail Stop S2-26-12 T: 215/861-4196
7500 Security Boulevard E-mail: jhake@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6659
E-mail: krama@cms.hhs.gov

Massachusetts Tom Hamilton Alan P. Bryan


Director Health Insurance Specialist
Disabled and Elderly Health Programs Group JFK Federal Building
Center for Medicaid and State Operations Government Center, Room 2275
Mail Stop S2-26-12 Boston, MA 02203-0003
7500 Security Boulevard T: 617/565-1246
Baltimore, MD 21244-1850 E-mail: abryan@cms.hhs.gov
T: 410/786-6763
E-mail: thamilton@cms.hhs.gov

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Michigan Lillian Gibbons Ruth Hughes


Senior Advisor 233 N. Michigan Avenue
Family and Children’s Health Programs Group Suite 600
Center for Medicaid and State Operations Chicago, IL 60601
Mail Stop S2-26-12 T: 312/353-1670
7500 Security Boulevard E-mail: rhughes@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-8705
E-mail: lgibbons@cms.hhs.gov

Minnesota Terry Pratt Doris Ross


Director 233 N. Michigan Avenue
Division of Integrated Health Systems Suite 600
Disabled and Elderly Health Programs Group Chicago, IL 60601
Center for Medicaid and State Operations T: 312/353-9843
Mail Stop S2-26-12 E-mail: dross2@cms.hhs.gov
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-9499
E-mail: tpratt@cms.hhs.gov

Mississippi Diona Kristian Selwyn White


Technical Director Atlanta Federal Center
Family and Children’s Health Programs Group 61 Forsyth Street, SW, Suite 4T20
Center for Medicaid and State Operations Atlanta, GA 30303-8909
Mail Stop S2-26-12 T: 404/562-7427
7500 Security Boulevard E-mail: swhite3@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-3283
E-mail: dkristian@cms.hhs.gov

Missouri Peggy Clark Jackie Glaze


Technical Director Health Insurance Specialist
Division of Integrated Health Systems Richard Bolling Federal Building
Disabled and Elderly Health Programs Group 601 East 12th Street, Room 227
Center for Medicaid and State Operations Kansas City, MO 64106-2808
Mail Stop S2-26-12 T: 816/426-6458
7500 Security Boulevard E-mail: jglaze@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-5321
E-mail: pclark@cms.hhs.gov

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Montana Kathleen Farrell Betty Strecker


Special Assistant Colorado State Bank Building
Office of the Center Director 1600 Broadway
Center for Medicaid and State Operations Suite 700
Mail Stop S2-26-12 Denver, CO 80202-4367
7500 Security Boulevard T: 303/844-7028
Baltimore, MD 21244-1850 E-mail: bstrecker@cms.hhs.gov
T: 410/786-1236
E-mail: kfarrell@cms.hhs.gov

Nebraska Tracey Mummert Diana Townsend


Special Assistant Health Insurance Specialist
Survey and Certification Group Richard Bolling Federal Building
Center for Medicaid and State Operations 601 East 12th Street, Room 227
Mail Stop S2-26-12 Kansas City, MO 64106-2808
7500 Security Boulevard T: 816/426-6456
Baltimore, MD 21244-1850 E-mail: dtownsend@cms.hhs.gov
T: 410/786-3398
E-mail: tmummert@cms.hhs.gov

Nevada Judy Yost Barbie Robinson


Director Health Insurance Specialist
Division of Laboratory Services 75 Hawthorne Street, Room 408
Survey and Certification Group San Francisco, CA 94105-3901
Center for Medicaid and State Operations T: 415/744-3591
Mail Stop S2-26-12 E-mail: brobinson4@cms.hhs.gov
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-3407
E-mail: jyost@cms.hhs.gov

New Hampshire Jan Tarantino Harold Finn


Deputy Director JFK Federal Building
Division of Continuing Care Providers Government Center, Room 2325
Center for Medicaid and State Operations Boston, MA 02203-0003
Mail Stop S2-26-12 T: 617/565-1225
7500 Security Boulevard E-mail: hfinn@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-0905
E-mail: jtarantino@cms.hhs.gov

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New Jersey Fred Gladden Julie Alberino


Technical Director 26 Federal Plaza
Division of Nursing Homes Room 3800
Survey and Certification Group New York, NY 10278-0063
Center for Medicaid and State Operations T: 212/264-3904
Mail Stop S2-26-12 E-mail: jalberino@cms.hhs.gov
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-3033
E-mail: fgladden@cms.hhs.gov

New Mexico David Escobedo Jack Allen


Supervisory Health Insurance Specialist Health Insurance Specialist
Survey and Administrative Budget Staff 1301 Young Street, Room 827
Finance, Systems and Budget Group Dallas, TX 75202
Center for Medicaid and State Operations T: 214/767-4425
Mail Stop S2-26-12 E-mail: jallen@cms.hhs.gov
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-5401
E-mail: david.escobedo@cms.hhs.gov

New York Carmen Keller Sue Kelly


Acting Deputy Director 26 Federal Plaza
Center for Medicaid and State Operations Room 3800
Mail Stop S2-26-12 New York, NY 10278-0063
7500 Security Boulevard T: 212/264-2058
Baltimore, MD 21244-1850 E-mail: skelly@cms.hhs.gov
T: 410/786-3230
E-mail: carmen.keller@cms.hhs.gov

North Carolina Joe Razes Donna Cross


Technical Director State Representative for North Carolina
Division of Advocacy and Special Issues Atlanta Federal Center
Disabled and Elderly Health Programs Group 61 Forsyth Street, SW, Suite 4T20
Center for Medicaid and State Operations Atlanta, GA 30303-8909
Mail Stop S2-26-12 T: 404/562-7406
7500 Security Boulevard E-mail: dcross@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6126
E-mail: jrazes@cms.hhs.gov

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North Dakota James Merrill Bernadette Quevedo-Mendoza


Life Safety Code Specialist State Program Coordinator
Division of Nursing Homes Office of the Regional Administrator,
Survey and Certification Group CMS
Center for Medicaid and State Operations Colorado State Bank Building
Mail Stop S2-26-12 1600 Broadway, Suite 700
7500 Security Boulevard Denver, CO 80202-4367
Baltimore, MD 21244-1850 T: 303/844-7121
T: 410/786-6998 E-mail: bquevedo-mendoza@cms.hhs.gov
E-mail: jmerrill@cms.hhs.gov

Northern Edward Mortimore H. Stephen Deering


Mariana Islands Technical Director Deputy Regional Administrator, CMS
Division of Nursing Homes 75 Hawthorne Street, Room 408
Survey and Certification Group San Francisco, CA 94105-3901
Center for Medicaid and State Operations T: 415/744-3501
Mail Stop S2-26-12 E-mail: sdeering@cms.hhs.gov
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-3509
E-mail: emortimore@cms.hhs.gov

Ohio Deirdre Duzor Gwendolyn Sampson


Co-Lead, Pharmacy Team 233 N. Michigan Avenue
Finance, Systems and Budget Group Suite 600
Center for Medicaid and State Operations Chicago, IL 60601
Mail Stop S2-26-12 T: 312/353-9861
7500 Security Boulevard E-mail: gsampson@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-4626
E-mail: dduzor@cms.hhs.gov

Oklahoma Melissa Hulbert Ford Blunt


Director Health Insurance Specialist
Division of Continuing Care Providers 1301 Young Street, Room 827
Center for Medicaid and State Operations Dallas, TX 75202
Mail Stop S2-26-12 T: 214/767-6381
7500 Security Boulevard E-mail: fblunt@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6568
E-mail: mhulbert@cms.hhs.gov

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Oregon Alissa DeBoy Barbara Subert


Special Assistant Health Insurance Specialist
Disabled and Elderly Health Programs Group Medicaid Branch, Region X
Center for Medicaid and State Operations 2201 6th Avenue
Mail Stop S2-26-12 MS/RX-43
7500 Security Boulevard Seattle, WA 98121
Baltimore, MD 21244-1850 T: 206/615-2390
T: 410/786-6041 E-mail: bsubert@cms.hhs.gov
E-mail: adeboy@cms.hhs.gov

Pennsylvania Cheryl Austein-Casnoff Michael Cruse


Director Health Insurance Specialist
Division of State Children’s Health Insurance The Public Ledger Building, Suite 216
Family and Children's Health Program Group 150 S. Independence Mall West
Center for Medicaid and State Operations Philadelphia, PA 19106
Mail Stop S2-26-12 T: 215/861-4216
7500 Security Boulevard E-mail: mcruse@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-4196
E-mail: causteincasnoff@cms.hhs.gov

Puerto Rico Cindy Melanson Frank Fournier


Health Program Evaluator La Torre de Plaza Las Americas
Division of Acute Care Services Suite 1116
Survey and Certification Group 525 F.SD. Roosevelt Ave.
Center for Medicaid and State Operations San Juan, PR 000919-8024
Mail Stop S2-26-12 T: 787/771-3687
7500 Security Boulevard E-mail: ffournier@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-0310
E-mail: cmelanson@cms.hhs.gov

Rhode Island Rick Friedman Elena Nicolella


Director Health Insurance Specialist
Division of State Systems JFK Federal Building
Finance, Systems and Budget Group Government Center, Room 2325
Center for Medicaid and State Operations Boston, MA 02203-0003
Mail Stop S2-26-12 T: 617/565-1243
7500 Security Boulevard E-mail: enicolella@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-4451
E-mail: rfriedman2@cms.hhs.gov

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South Carolina Helaine Jeffers Jessie Spillers


Deputy Director 61 Forsyth Street, SW, Suite 4T20
Division of Acute Care Services Atlanta, GA 30303-8909
Survey and Certification Group T: 404/562-7418
Center for Medicaid and State Operations E-mail: jspillers@cms.hhs.gov
Mail Stop S2-26-12
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-5648
E-mail: hjeffers@cms.hhs.gov

South Dakota David Eddinger Cynthia Riddle


Technical Director State Program Coordinator
Division of Laboratory Systems Office of the Regional Administrator
Survey and Certification Group Colorado State Bank Building
Center for Medicaid and State Operations 1600 Broadway, Suite 700
Mail Stop S2-26-12 Denver, CO 80202-4367
7500 Security Boulevard T: 303/844-7116
Baltimore, MD 21244-1850 E-mail: criddle@cms.hhs.gov
T: 410/786-3429
E-mail: deddinger@cms.hhs.gov

Tennessee Mike Fiore Dorothy Smith


Acting Director Health Insurance Specialist
Division of Benefits, Coverage and Payment Atlanta Federal Center
Disabled and Elderly Health Programs 61 Forsyth Street, SW, Suite 4T20
Center for Medicaid and State Operations Atlanta, GA 30303-8909
Mail Stop S2-26-12 T: 404/562-7159
7500 Security Boulevard E-mail: dsmith5@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-0623
E-mail: mfiore@cms.hh.gov

Texas Marlene Jones Joe Reeder


Lead Health Insurance Specialist Health Insurance Specialist
Policy Coordination and Planning Group 1301 Young Street, Room 714
Center for Medicaid and State Operations Dallas, TX 75202
Mail Stop S2-26-12 T: 214/767-4419
7500 Security Boulevard E-mail: jreeder@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-3290
E-mail: maymarlene.jones@cms.hhs.gov

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Utah Aaron Blight Tilly Rollin


Acting Director Utah State Program Coordinator
Division of Benefits, Coverage and Payment Office of the Regional Administrator
Family and Children’s Health Program Group Colorado State Bank Building
Center for Medicaid and State Operations 1600 Broadway, Suite 700
Mail Stop S2-26-12 Denver, CO 80202-4367
7500 Security Boulevard T: 303/844-7111
Baltimore, MD 21244-1850 E-mail: trollin@cms.hhs.gov
T: 410/786-9560
E-mail: ablight@cms.hhs.gov

Vermont Clarke Cagey Chong B. Tieng


Special Assistant Health Insurance Specialist
Office of the Director JFK Federal Building
Center for Medicaid and State Operations Government Center, Room 2275
Mail Stop S2-26-12 Boston, MA 02203-0003
7500 Security Boulevard T: 617/565-9157
Baltimore, MD 21244-1850 E-mail: ctieng@cms.hhs.gov
T: 410/786-3135
E-mail: ccagey@cms.hhs.gov

Virginia Ginni Hain Jake Hubik


Director Health Insurance Specialist
Division of Eligibility, Enrollment and Outreach The Public Ledger Building, Suite 216
Disabled and Elderly Health Programs Group 150 S. Independence Mall West
Center for Medicaid and State Operations Philadelphia, PA 19106
Mail Stop S2-26-12 T: 215/861-4181
7500 Security Boulevard E-mail: jhubik@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6036
E-mail: ghain@cms.hhs.gov

Virgin Islands Cindy Graunke Ricardo Holligan


Director 26 Federal Plaza
Division of Nursing Homes Room 3811
Center for Medicaid and State Operations New York, NY 10278-0063
Mail Stop S2-26-12 T: 212/264-3978
7500 Security Boulevard E-mail: rholligan@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6782
E-mail: cgraunke@cms.hhs.gov

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Washington Gale Arden Carol Crimi


Director Health Insurance Specialist
Private Health Insurance Group Medicaid Branch
Center for Medicaid and State Operations Division of Medicaid and State
Mail Stop S2-26-12 Operations
7500 Security Boulevard 2201 6th Avenue
Baltimore, MD 21244-1850 MS/RX-43
T: 410/786-6810 Seattle, WA 98121
E-mail: garden@cms.hhs.gov T: 206/615-2515
E-mail: ccrimi@cms.hhs.gov

West Virginia Joan Simmons Donna Fischer


Deputy Director Health Insurance Specialist
Division of Nursing Homes The Public Ledger Building, Suite 230
Survey and Certification Group 150 S. Independence Mall West
Center for Medicaid and State Operations Philadelphia, PA 19106
Mail Stop S2-26-12 T: 215/861-4221
7500 Security Boulevard E-mail: dfischer@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-3409
E-mail: jsimmons1@cms.hhs.gov

Wisconsin Glenn Stanton Pam Carson


Deputy Director 233 N. Michigan Avenue
Disabled and Elderly Health Programs Group Suite 600
Center for Medicaid and State Operations Chicago, IL 60601
Mail Stop S2-26-12 T: 312/353-0108
7500 Security Boulevard E-mail: pcarson@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6768
E-mail: gstanton@cms.hhs.gov

Wyoming George Karahalis Robert Tonsberg


Director, Training Staff Epidemiologist, Sr. Health Services
Survey and Certification Group Office Manager
Center for Medicaid and State Operations Office of the Regional Administrator
Mail Stop S2-26-12 Colorado State Bank Bldg.
7500 Security Boulevard 1600 Broadway, Suite 700
Baltimore, MD 21244-1850 Denver, CO 80202-4367
T: 410/786-3486 T: 303/844-1981
E-mail: gkarahalis@cms.hhs.gov E-mail: rtonsberg@cms.hhs.gov

Source: CMS Website at www.cms.hhs.gov/states/natreps.pdf Central Office CMSO staff: Information as of April 2005.

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CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)


CENTER FOR MEDICAID AND STATE OPERATIONS (CMSO)
CENTRAL OFFICE STAFF
7500 Security Boulevard
Baltimore, MD 21244-1850
410/786-3000
Director Acting Deputy Director Financial Advisor
Dennis Smith Carmen Keller Bill Lasowski
410/786-3870 410/786-3230 410/786-3870

Appeals and Grievances Eligibility


Bob Tomlinson (Fee-for-Service) Marty Svolos (Families & Children)
410/786-4463 410/786-4582
Roy Trudel (Disabled/Elderly)
Assignment of Rights to Benefits 410/786-3417
Cheryl Camillo
410/786-1068 Family/Children 1915(b) Waivers; 1115 Demonstrations;
and the Health Insurance Flexibility & Accountability
Budget Information for State Agencies Initiative (HIFA)
John Hoover Bruce Greenstein
410/786-2020 410/786-3283

Children’s Health Insurance HCFA 2082 Statistical Report


Kathleen Farrell Cindy Foltz
410/786-1236 410/786-0253

Coordination of Benefits Home and Community Based Waiver Program Reviews;


Sarah deLone (Disabled & Elderly) Independence Plus Initiative
410/786-7010 Susie Bosstick
Marty Svolos (Families & Children) 410/786/1301
410/786-4582 Deidra Abbott
410/786/0690
Data Inquiries
Dennis Franz Managed Care Enrollment Report
410/786-6117 Carolyn Lawson
410/786/0704
Department Appeals Board Decisions
Ed Davis Medicaid Statistical Information System (MSIS)
410/786-3280 Ron North410/786-5651

Disabled/Elderly 1915(b) Waivers; 1115 Demonstrations; Pharmacy Issues


And PACE Program (Coverage, Payment & Rebate Program)
Terri Pratt Larry Reed
410/786-5831 410/786-3325
Deirdre Duzor
Drug Rebate Agreement/Data 410/786-4626
Vince Powell
410/786-3314 National Institutional Reimbursement Team
Bob Reed
Drug Utilization Review 206/615-2596
Christina Lyon
410/786-3332 Non-Institutional Payment Team
Linda Tavener
410/786-3838

Source: CMS Central Office, CMSO: April 2005.

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Appendix B:
Medicaid Program Statistics -
CMS MSIS Tables

B-1
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B-2
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Medicaid Program Statistics -- MSIS Report

The CMS MSIS Report is an annual report designed to collect State-reported statistical summary data
on eligibles, recipients, services, and expenditures during a Federal fiscal year (i.e., October l through
September 30). The data reported for a given year represent recipients of service and the amount of
payments for claims adjudicated during the year. The data reflect bills adjudicated during the year
rather than the services used during the year.

Historically, States summarized and reported the data processed through their Medicaid claims
processing and payment operations unless they opted to participate in the Medicaid Statistical
Information System (MSIS) project. Prior to Federal fiscal year 1999, MSIS was a voluntary
program and those States participating in the MSIS project provide data tapes from their claims
processing systems to HCFA in lieu of HCFA-2082 tables. However, in accordance with the
Balanced Budget Act of 1997, all claims processed on or after January 1, 1999, must be submitted
electronically in the MSIS format.

The MSIS Report is the primary CMS source on recipients’ use of services and the associated
payments for these services. However, the new reporting requirements have resulted in a lag in the
timely release of MSIS summary tables. The most recent MSIS service utilization information
available from CMS is for FY 2002. In addition, Puerto Rico and the U.S. territories have been
excluded from the tables and the National totals.

In an effort to provide more recent recipient information as well as to maintain continuity with
previous version of the Compilation, we have compiled ten tables from the MSIS data system for
inclusion in this Appendix. The first two tables provide national level summary information on total
expenditures and total number of recipients by type of service for FY 2001 and FY 2002. The
remaining tables present State-by-State and national level data, including some trend information, on
total Medicaid recipients, total Medicaid payments, number of prescription drug recipients, and
Medicaid prescription drug payments. Additionally, there are three tables at the end of the Appendix
that correspond to FY 2002 tables presented in Section 2.

B-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

B-4
National Pharmaceutical Council Pharmaceutical Benefits 2004

Total U.S. Medical Assistance Recipients By Type of Service

Percent Percent Percent


Service FY 2001 of Total* FY 2002 of Total* Change 2001-2002
Capitated Payment Services 23,355,569 50.6% 25,863,748 52.0% 15.8%
Pharmaceuticals 21,910,532 47.5% 24,424,493 49.1% 12.4%
Physicians 20,021,029 43.4% 22,102,682 44.4% 10.9%
Hospital Outpatient 13,731,009 29.7% 14,861,211 29.9% 9.5%
Lab/X-ray 12,339,065 26.7% 14,067,422 28.3% 14.6%
Other Care 9,897,625 21.4% 11,195,848 22.5% 16.2%
Clinic 8,463,753 18.3% 9,498,844 19.1% 13.5%
Dental 7,018,692 15.2% 7,885,538 15.8% 14.1%
PCCM Services 6,337,864 13.7% 7,177,583 14.4% 16.4%
Personal Support Services 4,977,823 10.8% 5,688,386 11.4% 15.6%
Other Practitioners 5,102,653 11.1% 5,570,691 11.2% 10.5%
Hospital Inpatient 4,879,194 10.6% 5,051,356 10.2% 4.8%
Nursing Facility 1,702,251 3.7% 1,765,700 3.5% 7.8%
Home Health Care 1,013,796 2.2% 1,065,050 2.1% 7.7%
ICF-Mentally Retarded 116,610 0.3% 117,497 0.2% 1.7%
Mental Health Facility 91,029 0.2% 99,403 0.2% 11.5%
Total Unduplicated
Recipients* 46,163,776 49,754,619 11.1%

*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.

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

B-5
National Pharmaceutical Council Pharmaceutical Benefits 2004

Total U.S. Medical Assistance Payments By Type of Service

Percent of Percent of Percent


Service FY 2001 Total* FY 2002 Total* Change 2001-2002
Nursing Facility $37,322,711,413 20.0% $39,282,167,886 18.4% 6.0%
Capitated Payment Services $29,368,456,447 15.7% $33,634,458,789 15.8% 21.2%
Hospital Inpatient $25,943,089,983 13.9% $29,127,066,408 13.6% 14.0%
Pharmaceuticals $23,764,446,937 12.7% $28,408,181,719 13.3% 19.8%
Other Care $16,756,580,093 9.0% $20,042,516,439 9.4% 21.6%
Personal Support Services $13,134,684,443 7.0% $15,363,088,322 7.2% 18.1%
ICF-Mentally Retarded $9,700,947,510 5.2% $10,681,301,264 5.0% 10.7%
Hospital Outpatient $7,496,052,121 4.0% $8,470,604,661 4.0% 12.8%
Physicians $7,438,667,704 4.0% $8,354,616,947 3.9% 12.6%
Clinic $5,602,689,477 3.0% $6,693,856,507 3.1% 20.0%
Home Health Care $3,520,674,702 1.9% $3,924,725,800 1.8% 12.0%
Dental $1,896,588,616 1.0% $2,308,811,686 1.1% 24.0%
Lab/X-Ray $1,622,597,746 0.9% $2,157,359,177 1.0% 34.2%
Mental Health Facility $1,959,318,414 1.0% $2,122,406,677 1.0% 9.0%
Unknown $437,818,978 0.2% $1,878,534,734 0.9% 31.6%
Other Practitioners $761,679,926 0.4% $841,952,557 0.4% 11.9%
PCCM Services $186,779,869 0.1% $199,663,705 0.1% 9.7%

Total Payments $186,913,784,379 $213,491,313,278 14.9%

*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.

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

B-6
National Pharmaceutical Council Pharmaceutical Benefits 2004

2002 Baseline Data


Drug $ as a
State Total Payments Drug Payments Total Recipients Drug Recipients % of Total $
National Total $213,491,313,278 $28,408,181,719 49,754,619 24,424,493 13.3%
Alabama $3,204,063,602 $454,370,478 765,328 500,789 14.2%
Alaska $686,795,186 $83,324,085 109,641 70,550 12.1%
Arizona $2,881,870,077 $4,338,712 878,362 7,805 0.2%
Arkansas $2,015,436,554 $279,644,642 579,278 356,233 13.9%
California $23,636,239,505 $3,402,508,001 9,301,001 2,651,229 14.4%
Colorado $2,166,199,614 $202,286,461 425,878 153,520 9.3%
Connecticut $3,245,142,644 $356,980,484 479,051 123,704 11.0%
Delaware $651,384,655 $100,112,623 167,162 125,461 15.4%
District of Columbia $1,027,022,357 $68,050,981 193,494 45,216 6.6%
Florida $9,827,003,688 $1,736,991,594 2,676,235 1,245,841 17.7%
Georgia $4,796,005,361 $749,552,199 1,637,329 1,076,904 15.6%
Hawaii $695,279,178 $81,453,811 199,966 39,320 11.7%
Idaho $791,863,699 $121,780,793 176,499 125,537 15.4%
Illinois $9,121,713,188 $1,222,947,241 1,731,398 1,199,933 13.4%
Indiana $3,725,257,965 $636,357,519 849,427 490,386 17.1%
Iowa $1,855,817,441 $277,753,942 352,635 245,711 15.0%
Kansas $1,501,270,019 $220,800,602 289,349 157,618 14.7%
Kentucky $3,459,365,581 $661,409,737 808,294 489,416 19.1%
Louisiana $3,234,421,939 $682,557,080 898,824 689,973 21.1%
Maine $1,716,581,955 $250,331,526 275,826 224,664 14.6%
Maryland $3,662,089,984 $320,313,995 692,539 181,101 8.7%
Massachusetts $6,387,100,271 $952,790,939 1,065,636 659,626 14.9%
Michigan $5,918,817,382 $674,898,273 1,449,915 577,785 11.4%
Minnesota $4,439,493,794 $294,838,630 620,652 190,577 6.6%
Mississippi $2,499,640,805 $568,084,274 712,457 526,923 22.7%
Missouri $4,071,544,403 $799,910,014 1,036,150 493,230 19.6%
Montana $532,886,400 $77,980,883 103,617 67,365 14.6%
Nebraska $1,255,039,718 $196,526,107 255,771 194,889 15.7%
Nevada $723,956,752 $90,134,969 202,306 71,950 12.5%
New Hampshire $745,754,084 $98,836,636 104,138 78,861 13.3%
New Jersey $5,497,284,438 $686,301,522 954,491 296,059 12.5%
New Mexico $1,796,901,383 $92,674,018 798,665 122,098 5.2%
New York $31,488,930,244 $3,413,404,507 3,920,718 2,567,595 10.8%
North Carolina $6,041,011,008 $1,069,140,895 1,355,269 949,795 17.7%
North Dakota $422,745,114 $51,749,961 70,132 44,428 12.2%
Ohio $9,186,330,669 $1,330,569,382 1,656,124 997,246 14.5%
Oklahoma $2,238,213,087 $267,549,002 631,498 276,111 12.0%
Oregon $2,136,400,869 $269,936,847 621,462 242,865 12.6%
Pennsylvania $8,523,928,057 $719,243,402 1,627,261 464,848 8.4%
Rhode Island $1,251,440,036 $126,331,040 199,014 53,729 10.1%
South Carolina $3,382,950,504 $456,976,916 809,136 576,136 13.5%
South Dakota $503,947,234 $63,654,623 117,631 64,948 12.6%
Tennessee $4,747,549,898 $573,588,021 1,732,381 916,968 12.1%
Texas $11,121,020,040 $1,591,828,224 2,952,569 2,153,316 14.3%
Utah $1,215,620,497 $140,520,420 274,707 152,268 11.6%
Vermont $607,249,969 $115,623,970 153,731 112,227 19.0%
Virginia $3,017,869,649 $453,663,058 665,203 319,196 15.0%
Washington $4,373,171,467 $549,216,380 1,039,070 423,758 12.6%
West Virginia $1,577,697,829 $274,613,136 362,030 276,338 17.4%
Wisconsin $3,605,541,906 $455,720,622 716,298 309,795 12.6%
Wyoming $280,451,579 $38,008,542 59,071 42,652 13.6%

Source: CMS, MSIS Report, FY 2002.

B-7
National Pharmaceutical Council Pharmaceutical Benefits 2004

Medicaid Payments and Recipients, 2002

State Total Payments Total Recipients Payments Per Recipient


National Total $213,491,313,278 49,754,619 $4,291
Alabama $3,204,063,602 765,328 $4,187
Alaska $686,795,186 109,641 $6,264
Arizona $2,881,870,077 878,362 $3,281
Arkansas $2,015,436,554 579,278 $3,479
California $23,636,239,505 9,301,001 $2,541
Colorado $2,166,199,614 425,878 $5,086
Connecticut $3,245,142,644 479,051 $6,774
Delaware $651,384,655 167,162 $3,897
District of Columbia $1,027,022,357 193,494 $5,308
Florida $9,827,003,688 2,676,235 $3,672
Georgia $4,796,005,361 1,637,329 $2,929
Hawaii $695,279,178 199,966 $3,477
Idaho $791,863,699 176,499 $4,487
Illinois $9,121,713,188 1,731,398 $5,268
Indiana $3,725,257,965 849,427 $4,386
Iowa $1,855,817,441 352,635 $5,263
Kansas $1,501,270,019 289,349 $5,188
Kentucky $3,459,365,581 808,294 $4,280
Louisiana $3,234,421,939 898,824 $3,599
Maine $1,716,581,955 275,826 $6,223
Maryland $3,662,089,984 692,539 $5,288
Massachusetts $6,387,100,271 1,065,636 $5,994
Michigan $5,918,817,382 1,449,915 $4,082
Minnesota $4,439,493,794 620,652 $7,153
Mississippi $2,499,640,805 712,457 $3,508
Missouri $4,071,544,403 1,036,150 $3,929
Montana $532,886,400 103,617 $5,143
Nebraska $1,255,039,718 255,771 $4,907
Nevada $723,956,752 202,306 $3,579
New Hampshire $745,754,084 104,138 $7,161
New Jersey $5,497,284,438 954,491 $5,759
New Mexico $1,796,901,383 798,665 $2,250
New York $31,488,930,244 3,920,718 $8,031
North Carolina $6,041,011,008 1,355,269 $4,457
North Dakota $422,745,114 70,132 $6,028
Ohio $9,186,330,669 1,656,124 $5,547
Oklahoma $2,238,213,087 631,498 $3,544
Oregon $2,136,400,869 621,462 $3,438
Pennsylvania $8,523,928,057 1,627,261 $5,238
Rhode Island $1,251,440,036 199,014 $6,288
South Carolina $3,382,950,504 809,136 $4,181
South Dakota $503,947,234 117,631 $4,284
Tennessee $4,747,549,898 1,732,381 $2,740
Texas $11,121,020,040 2,952,569 $3,767
Utah $1,215,620,497 274,707 $4,425
Vermont $607,249,969 153,731 $3,950
Virginia $3,017,869,649 665,203 $4,537
Washington $4,373,171,467 1,039,070 $4,209
West Virginia $1,577,697,829 362,030 $4,358
Wisconsin $3,605,541,906 716,298 $5,034
Wyoming $280,451,579 59,071 $4,748

Source: CMS, MSIS Report, FY 2002.

B-8
National Pharmaceutical Council Pharmaceutical Benefits 2004

Drug Payments and Recipients, 2002

State Total Drug Payments Total Drug Recipients Drug Payments Per Recipient
National Total $28,408,181,719 24,424,493 $1,163
Alabama $454,370,478 500,789 $907
Alaska $83,324,085 70,550 $1,181
Arizona $4,338,712 7,805 $556
Arkansas $279,644,642 356,233 $785
California $3,402,508,001 2,651,229 $1,283
Colorado $202,286,461 153,520 $1,318
Connecticut $356,980,484 123,704 $2,886
Delaware $100,112,623 125,461 $798
District of Columbia $68,050,981 45,216 $1,505
Florida $1,736,991,594 1,245,841 $1,394
Georgia $749,552,199 1,076,904 $696
Hawaii $81,453,811 39,320 $2,072
Idaho $121,780,793 125,537 $970
Illinois $1,222,947,241 1,199,933 $1,019
Indiana $636,357,519 490,386 $1,298
Iowa $277,753,942 245,711 $1,130
Kansas $220,800,602 157,618 $1,401
Kentucky $661,409,737 489,416 $1,351
Louisiana $682,557,080 689,973 $989
Maine $250,331,526 224,664 $1,114
Maryland $320,313,995 181,101 $1,769
Massachusetts $952,790,939 659,626 $1,444
Michigan $674,898,273 577,785 $1,168
Minnesota $294,838,630 190,577 $1,547
Mississippi $568,084,274 526,923 $1,078
Missouri $799,910,014 493,230 $1,622
Montana $77,980,883 67,365 $1,158
Nebraska $196,526,107 194,889 $1,008
Nevada $90,134,969 71,950 $1,253
New Hampshire $98,836,636 78,861 $1,253
New Jersey $686,301,522 296,059 $2,318
New Mexico $92,674,018 122,098 $759
New York $3,413,404,507 2,567,595 $1,329
North Carolina $1,069,140,895 949,795 $1,126
North Dakota $51,749,961 44,428 $1,165
Ohio $1,330,569,382 997,246 $1,334
Oklahoma $267,549,002 276,111 $969
Oregon $269,936,847 242,865 $1,111
Pennsylvania $719,243,402 464,848 $1,547
Rhode Island $126,331,040 53,729 $2,351
South Carolina $456,976,916 576,136 $793
South Dakota $63,654,623 64,948 $980
Tennessee $573,588,021 916,968 $626
Texas $1,591,828,224 2,153,316 $739
Utah $140,520,420 152,268 $923
Vermont $115,623,970 112,227 $1,030
Virginia $453,663,058 319,196 $1,421
Washington $549,216,380 423,758 $1,296
West Virginia $274,613,136 276,338 $994
Wisconsin $455,720,622 309,795 $1,471
Wyoming $38,008,542 42,652 $891

Source: CMS, MSIS Report, FY 2002.

B-9
National Pharmaceutical Council Pharmaceutical Benefits 2004

Drug Payment Trends, Percent Change 2001-2002

State 2001 2002 Percent Change


National Total $23,764,446,937 $28,408,181,719 19.54%
Alabama $392,482,787 $454,370,478 15.77%
Alaska $66,767,949 $83,324,085 24.80%
Arizona $4,667,946 $4,338,712 -7.05%
Arkansas $248,390,866 $279,644,642 12.58%
California $2,808,441,711 $3,402,508,001 21.15%
Colorado $178,062,912 $202,286,461 13.60%
Connecticut $304,481,051 $356,980,484 17.24%
Delaware $81,623,058 $100,112,623 22.65%
District of Columbia $62,296,126 $68,050,981 9.24%
Florida $1,490,095,934 $1,736,991,594 16.57%
Georgia $702,719,257 $749,552,199 6.66%
Hawaii $71,231,541 $81,453,811 14.35%
Idaho $105,497,059 $121,780,793 15.44%
Illinois $934,231,380 $1,222,947,241 30.90%
Indiana $562,126,868 $636,357,519 13.21%
Iowa $231,010,303 $277,753,942 20.23%
Kansas $189,946,034 $220,800,602 16.24%
Kentucky $599,970,167 $661,409,737 10.24%
Louisiana $556,393,280 $682,557,080 22.68%
Maine $204,014,566 $250,331,526 22.70%
Maryland $267,759,816 $320,313,995 19.63%
Massachusetts $796,340,945 $952,790,939 19.65%
Michigan $604,782,305 $674,898,273 11.59%
Minnesota $265,097,886 $294,838,630 11.22%
Mississippi $494,809,464 $568,084,274 14.81%
Missouri $682,958,006 $799,910,014 17.12%
Montana $69,741,505 $77,980,883 11.81%
Nebraska $161,820,256 $196,526,107 21.45%
Nevada $63,364,124 $90,134,969 42.25%
New Hampshire $90,927,594 $98,836,636 8.70%
New Jersey $649,649,655 $686,301,522 5.64%
New Mexico $70,202,173 $92,674,018 32.01%
New York $2,782,394,132 $3,413,404,507 22.68%
North Carolina $971,104,266 $1,069,140,895 10.10%
North Dakota $43,288,363 $51,749,961 19.55%
Ohio $1,118,119,811 $1,330,569,382 19.00%
Oklahoma $216,827,265 $267,549,002 23.39%
Oregon $222,391,952 $269,936,847 21.38%
Pennsylvania $690,558,773 $719,243,402 4.15%
Rhode Island $104,918,227 $126,331,040 20.41%
South Carolina $438,502,264 $456,976,916 4.21%
South Dakota $52,610,673 $63,654,623 20.99%
Tennessee $0 $573,588,021 -
Texas $1,327,254,967 $1,591,828,224 19.93%
Utah $117,477,586 $140,520,420 19.61%
Vermont $105,993,594 $115,623,970 9.09%
Virginia $419,148,437 $453,663,058 8.23%
Washington $464,082,836 $549,216,380 18.34%
West Virginia $256,395,319 $274,613,136 7.11%
Wisconsin $389,373,742 $455,720,622 17.04%
Wyoming $32,100,206 $38,008,542 18.41%

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

B-10
National Pharmaceutical Council Pharmaceutical Benefits 2004

Rankings Based on Drug Payments

2002 % of 2002 Total Medicaid 2001


State Payments Ranking Drug Payments Payments Ranking
New York $3,413,404,507 1 12.02% $2,782,394,132 2
California $3,402,508,001 2 11.98% $2,808,441,711 1
Florida $1,736,991,594 3 6.11% $1,490,095,934 3
Texas $1,591,828,224 4 5.60% $1,327,254,967 4
Ohio $1,330,569,382 5 4.68% $1,118,119,811 5
Illinois $1,222,947,241 6 4.30% $934,231,380 7
North Carolina $1,069,140,895 7 3.76% $971,104,266 6
Massachusetts $952,790,939 8 3.35% $796,340,945 8
Missouri $799,910,014 9 2.82% $682,958,006 11
Georgia $749,552,199 10 2.64% $702,719,257 9
Pennsylvania $719,243,402 11 2.53% $690,558,773 10
New Jersey $686,301,522 12 2.42% $649,649,655 12
Louisiana $682,557,080 13 2.40% $556,393,280 16
Michigan $674,898,273 14 2.38% $604,782,305 13
Kentucky $661,409,737 15 2.33% $599,970,167 14
Indiana $636,357,519 16 2.24% $562,126,868 15
Tennessee $573,588,021 17 2.02% $0 51
Mississippi $568,084,274 18 2.00% $494,809,464 17
Washington $549,216,380 19 1.93% $464,082,836 18
South Carolina $456,976,916 20 1.61% $438,502,264 19
Wisconsin $455,720,622 21 1.60% $389,373,742 22
Alabama $454,370,478 22 1.60% $392,482,787 21
Virginia $453,663,058 23 1.60% $419,148,437 20
Connecticut $356,980,484 24 1.26% $304,481,051 23
Maryland $320,313,995 25 1.13% $267,759,816 24
Minnesota $294,838,630 26 1.04% $265,097,886 25
Arkansas $279,644,642 27 0.98% $248,390,866 27
Iowa $277,753,942 28 0.98% $231,010,303 28
West Virginia $274,613,136 29 0.97% $256,395,319 26
Oregon $269,936,847 30 0.95% $222,391,952 29
Oklahoma $267,549,002 31 0.94% $216,827,265 30
Maine $250,331,526 32 0.88% $204,014,566 31
Kansas $220,800,602 33 0.78% $189,946,034 32
Colorado $202,286,461 34 0.71% $178,062,912 33
Nebraska $196,526,107 35 0.69% $161,820,256 34
Utah $140,520,420 36 0.49% $117,477,586 35
Rhode Island $126,331,040 37 0.44% $104,918,227 38
Idaho $121,780,793 38 0.43% $105,497,059 37
Vermont $115,623,970 39 0.41% $105,993,594 36
Delaware $100,112,623 40 0.35% $81,623,058 40
New Hampshire $98,836,636 41 0.35% $90,927,594 39
New Mexico $92,674,018 42 0.33% $70,202,173 42
Nevada $90,134,969 43 0.32% $63,364,124 45
Alaska $83,324,085 44 0.29% $66,767,949 44
Hawaii $81,453,811 45 0.29% $71,231,541 41
Montana $77,980,883 46 0.27% $69,741,505 43
District of Columbia $68,050,981 47 0.24% $62,296,126 46
South Dakota $63,654,623 48 0.22% $52,610,673 47
North Dakota $51,749,961 49 0.18% $43,288,363 48
Wyoming $38,008,542 50 0.13% $32,100,206 49
Arizona $4,338,712 51 0.02% $4,667,946 50

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

B-11
National Pharmaceutical Council Pharmaceutical Benefits 2004

Drugs as a Percentage of Total Payments, 2002

State Drug Payments Total Payments Percent of Total Payments


National Total $28,408,181,719 $213,491,313,278 13.3%
Alabama $454,370,478 $3,204,063,602 14.2%
Alaska $83,324,085 $686,795,186 12.1%
Arizona $4,338,712 $2,881,870,077 0.2%
Arkansas $279,644,642 $2,015,436,554 13.9%
California $3,402,508,001 $23,636,239,505 14.4%
Colorado $202,286,461 $2,166,199,614 9.3%
Connecticut $356,980,484 $3,245,142,644 11.0%
Delaware $100,112,623 $651,384,655 15.4%
District of Columbia $68,050,981 $1,027,022,357 6.6%
Florida $1,736,991,594 $9,827,003,688 17.7%
Georgia $749,552,199 $4,796,005,361 15.6%
Hawaii $81,453,811 $695,279,178 11.7%
Idaho $121,780,793 $791,863,699 15.4%
Illinois $1,222,947,241 $9,121,713,188 13.4%
Indiana $636,357,519 $3,725,257,965 17.1%
Iowa $277,753,942 $1,855,817,441 15.0%
Kansas $220,800,602 $1,501,270,019 14.7%
Kentucky $661,409,737 $3,459,365,581 19.1%
Louisiana $682,557,080 $3,234,421,939 21.1%
Maine $250,331,526 $1,716,581,955 14.6%
Maryland $320,313,995 $3,662,089,984 8.7%
Massachusetts $952,790,939 $6,387,100,271 14.9%
Michigan $674,898,273 $5,918,817,382 11.4%
Minnesota $294,838,630 $4,439,493,794 6.6%
Mississippi $568,084,274 $2,499,640,805 22.7%
Missouri $799,910,014 $4,071,544,403 19.6%
Montana $77,980,883 $532,886,400 14.6%
Nebraska $196,526,107 $1,255,039,718 15.7%
Nevada $90,134,969 $723,956,752 12.5%
New Hampshire $98,836,636 $745,754,084 13.3%
New Jersey $686,301,522 $5,497,284,438 12.5%
New Mexico $92,674,018 $1,796,901,383 5.2%
New York $3,413,404,507 $31,488,930,244 10.8%
North Carolina $1,069,140,895 $6,041,011,008 17.7%
North Dakota $51,749,961 $422,745,114 12.2%
Ohio $1,330,569,382 $9,186,330,669 14.5%
Oklahoma $267,549,002 $2,238,213,087 12.0%
Oregon $269,936,847 $2,136,400,869 12.6%
Pennsylvania $719,243,402 $8,523,928,057 8.4%
Rhode Island $126,331,040 $1,251,440,036 10.1%
South Carolina $456,976,916 $3,382,950,504 13.5%
South Dakota $63,654,623 $503,947,234 12.6%
Tennessee $573,588,021 $4,747,549,898 12.1%
Texas $1,591,828,224 $11,121,020,040 14.3%
Utah $140,520,420 $1,215,620,497 11.6%
Vermont $115,623,970 $607,249,969 19.0%
Virginia $453,663,058 $3,017,869,649 15.0%
Washington $549,216,380 $4,373,171,467 12.6%
West Virginia $274,613,136 $1,577,697,829 17.4%
Wisconsin $455,720,622 $3,605,541,906 12.6%
Wyoming $38,008,542 $280,451,579 13.6%

Source: CMS, MSIS Report, FY 2002.

B-12
National Pharmaceutical Council Pharmaceutical Benefits 2004

Drugs as a Percentage of Total Payments, 1996 – 2002*

State 1996 1997 1998 1999 2000 2001 2002


National Total 8.8% 9.7% 9.5% 10.8% 11.8% 12.7% 13.3%
Alabama 13.9% 14.4% 12.4% 16.6% 13.9% 13.3% 14.2%
Alaska 7.8% 8.8% 10.0% 9.9% 11.3% 11.9% 12.1%
Arizona 1.2% 0.8% 0.1% 0.1% 0.1% 0.2% 0.2%
Arkansas 9.4% 10.4% 11.0% 13.4% 13.6% 14.4% 13.9%
California 11.0% 11.7% 10.9% 11.9% 13.5% 14.1% 14.4%
Colorado 8.0% 8.6% 7.7% 8.0% 8.5% 9.1% 9.3%
Connecticut 7.2% 8.3% 7.7% 8.3% 9.3% 10.3% 11.0%
Delaware 9.0% 12.6% 9.9% 11.6% 12.5% 13.6% 15.4%
District of Columbia 4.6% 5.4% 5.6% 5.9% 7.0% 7.5% 6.6%
Florida 14.1% 15.8% 16.4% 16.3% 18.4% 17.4% 17.7%
Georgia 10.3% 11.0% 12.3% 14.3% 16.2% 17.3% 15.6%
Hawaii 10.1% - 7.8% 8.4% 9.8% 12.0% 11.7%
Idaho 10.1% 10.4% 12.9% 13.2% 14.1% 14.8% 15.4%
Illinois 8.3% 9.1% 9.4% 10.6% 10.8% 11.5% 13.4%
Indiana 11.0% 12.3% 12.7% 13.7% 15.6% 16.7% 17.1%
Iowa 10.2% 11.4% 11.4% 12.4% 13.2% 13.9% 15.0%
Kansas 10.5% 11.4% 13.0% 12.7% 13.7% 13.9% 14.7%
Kentucky 14.1% 13.9% 13.2% 13.8% 15.9% 18.5% 19.1%
Louisiana 12.1% 13.5% 14.8% 16.0% 18.2% 19.3% 21.1%
Maine 11.6% 13.2% 16.3% 12.1% 13.4% 14.0% 14.6%
Maryland 7.6% 7.8% 6.0% 6.7% 7.4% 8.1% 8.7%
Massachusetts 8.0% 10.3% 10.8% 12.0% 12.6% 13.8% 14.9%
Michigan 10.5% 10.2% 8.6% 6.8% 7.7% 11.4% 11.4%
Minnesota 6.2% 6.6% 5.9% 6.1% 6.8% 7.0% 6.6%
Mississippi 13.2% 14.6% 16.1% 17.2% 20.5% 22.7% 22.7%
Missouri 14.0% 15.3% 14.9% 17.2% 18.4% 18.8% 19.6%
Montana 9.3% 11.2% 11.7% 13.4% 14.0% 14.7% 14.6%
Nebraska 10.5% 11.5% 12.3% 13.2% 14.1% 14.8% 15.7%
Nevada 6.7% 7.1% 7.5% 8.8% 10.0% 10.6% 12.5%
New Hampshire 7.7% 8.2% 9.1% 12.3% 12.4% 13.2% 13.3%
New Jersey 10.0% 10.4% 10.1% 11.2% 12.4% 12.9% 12.5%
New Mexico 7.0% 7.7% 4.8% 4.2% 4.6% 4.7% 5.2%
New York 4.1% 5.1% 5.6% 7.6% 9.1% 10.0% 10.8%
North Carolina 9.4% 10.7% 11.6% 14.3% 16.4% 17.6% 17.7%
North Dakota 7.0% 7.7% 8.1% 9.1% 10.6% 11.5% 12.2%
Ohio 9.4% 9.9% 10.5% 12.0% 12.4% 13.9% 14.5%
Oklahoma 9.6% 10.7% - 11.7% 11.1% 10.8% 12.0%
Oregon 5.1% 5.0% 6.4% 7.7% 9.5% 11.8% 12.6%
Pennsylvania 11.5% 11.8% 8.6% 9.9% 8.4% 9.0% 8.4%
Rhode Island 6.7% 7.1% 6.7% 8.5% 8.4% 9.6% 10.1%
South Carolina 9.4% 9.9% 11.1% 10.5% 12.1% 14.2% 13.5%
South Dakota 7.6% 8.7% 8.7% 10.0% 11.1% 12.3% 12.6%
Tennessee 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 12.1%
Texas 9.7% 10.2% 11.5% 11.7% 12.1% 13.8% 14.3%
Utah 11.4% 12.0% 11.1% 10.5% 10.5% 11.0% 11.6%
Vermont 12.1% 14.4% 12.4% 16.0% 19.2% 19.6% 19.0%
Virginia 12.5% 13.4% 13.4% 14.9% 15.4% 15.4% 15.0%
Washington 12.4% 14.7% 12.0% 11.8% 16.0% 17.1% 12.6%
West Virginia 11.1% 10.6% 12.0% 14.6% 15.5% 16.4% 17.4%
Wisconsin 10.8% 10.9% 10.5% 12.4% 11.8% 12.2% 12.6%
Wyoming 7.5% 8.1% 8.9% 11.2% 12.8% 13.3% 13.6%

*Hawaii did not report on time for FY 1997 and FY 1999 and was excluded from the national totals for those years. Hawaii also did not report
for FY 2000. CMS included their FY 1999 data in the FY 2000 MSIS Report. Oklahoma did not report for FY 1998 and was excluded from the
national total for that year.

Source: CMS, HCFA-2082 Reports, FY 1996 - FY 1998 and MSIS Reports, FY 1999 – FY 2002.

B-13
National Pharmaceutical Council Pharmaceutical Benefits 2004

Total Drug Recipients *

State 1996 1997 1998 1999 2000 2001 2002


National Total 22,575,656 20,943,872 19,324,605 19,428,344 20,324,675 21,910,532 24,424,493
Alabama 412,511 412,739 395,290 405,330 438,529 464,695 500,789
Alaska 40,839 42,174 43,734 52,070 60,273 65,278 70,550
Arizona 63,103 80,450 56,796 5,545 7,034 9,761 7,805
Arkansas 255,211 254,079 262,907 280,552 290,749 321,920 356,233
California 3,565,667 3,158,386 2,644,430 2,252,441 2,491,537 2,489,050 2,651,229
Colorado 173,707 156,631 147,033 151,537 160,265 143,167 153,520
Connecticut 209,557 120,522 108,331 108,754 113,101 116,785 123,704
Delaware 61,380 68,672 69,027 73,093 78,167 85,350 125,461
District of Columbia 66,349 64,494 57,733 37,862 38,129 35,324 45,216
Florida 1,079,467 1,024,555 1,014,372 991,927 1,078,631 1,165,866 1,245,841
Georgia 891,335 846,963 805,923 843,353 882,309 978,404 1,076,904
Hawaii 29,657 - 32,222 35,837 37,316 39,288 39,320
Idaho 84,553 79,961 86,775 81,980 92,776 112,357 125,537
Illinois 1,028,753 1,008,740 959,472 966,790 1,013,387 1,068,687 1,199,933
Indiana 401,042 352,814 323,811 361,661 420,071 464,975 490,386
Iowa 230,749 221,061 215,173 213,144 212,178 221,690 245,711
Kansas 179,653 170,167 155,875 153,054 158,334 158,515 157,618
Kentucky 497,251 494,293 429,102 366,051 425,721 476,774 489,416
Louisiana 593,415 563,864 552,481 551,698 581,356 628,574 689,973
Maine 138,360 139,524 137,816 143,548 149,262 194,288 224,664
Maryland 268,440 256,423 176,403 159,779 163,410 171,747 181,101
Massachusetts 527,114 559,215 613,186 671,741 671,716 671,756 659,626
Michigan 763,232 688,882 589,818 436,848 435,723 551,680 577,785
Minnesota 294,589 227,027 203,220 184,075 179,879 187,854 190,577
Mississippi 404,263 391,328 368,609 375,573 415,925 478,409 526,923
Missouri 469,821 395,478 353,902 412,597 447,068 472,645 493,230
Montana 66,465 62,092 58,641 59,182 58,918 63,352 67,365
Nebraska 138,322 151,973 145,408 155,136 166,031 178,634 194,889
Nevada 60,274 55,876 50,903 48,534 51,170 58,699 71,950
New Hampshire 75,701 71,692 70,339 71,039 73,313 73,489 78,861
New Jersey 518,833 347,105 309,849 301,022 299,356 305,962 296,059
New Mexico 197,565 184,502 96,637 55,018 67,239 75,892 122,098
New York 1,737,372 1,667,927 1,803,428 2,024,870 2,173,856 2,458,197 2,567,595
North Carolina 764,482 779,229 764,886 812,234 827,389 907,741 949,795
North Dakota 40,062 39,654 37,675 37,780 38,964 39,758 44,428
Ohio 902,211 786,322 702,143 796,720 777,632 934,632 997,246
Oklahoma 245,075 207,441 - 222,456 221,985 252,025 276,111
Oregon 154,801 149,461 148,258 174,931 193,924 223,580 242,865
Pennsylvania 857,818 763,255 580,749 520,221 416,498 461,114 464,848
Rhode Island 52,239 46,817 44,852 49,277 49,809 50,411 53,729
South Carolina 365,409 359,910 401,611 446,893 474,470 542,768 576,136
South Dakota 49,056 47,845 46,588 50,780 53,666 58,212 64,948
Tennessee^ 18 3 1 0 0 0 916,968
Texas 2,058,903 1,986,178 1,894,447 1,853,348 1,852,828 1,917,398 2,153,316
Utah 114,321 105,676 126,953 130,682 133,224 136,719 152,268
Vermont 78,376 83,057 58,037 89,547 103,635 109,578 112,227
Virginia 417,580 396,719 383,880 377,588 344,877 334,008 319,196
Washington 305,791 292,733 274,463 301,907 339,611 385,408 423,758
West Virginia 299,967 280,550 267,398 274,894 262,675 269,174 276,338
Wisconsin 309,582 265,987 221,508 224,165 267,417 262,238 309,795
Wyoming 35,415 33,426 32,510 33,280 33,342 36,704 42,652

Note: Recipients are defined as individuals who received drugs, not as everyone eligible to receive drugs.
*Hawaii did not report on time for FY 1997. They are excluded from the national total for that year. Oklahoma did not report for FY 1998. They are
excluded from the national total for that year.
^Until 2002, Tennessee did not report drug recipients because beneficiaries are enrolled in managed care & receive pharmaceutical benefits through these
plans.

Source: CMS, HCFA-2082 Report, FY 1996 - FY1998 and MSIS Report, FY 1999 – FY 2002.

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Total Medicaid Eligibles by Basis of Eligibility, 2002

Total Blind/ Foster Care BOE BCCA


State Eligibles Aged Disabled Children Adults Children Unknown Woman
National Total 51,552,491 4,759,065 8,055,109 24,583,011 13,245,645 901,951 1,779 5,931
Alabama 845,125 98,709 191,405 411,324 137,462 6,224 1 0
Alaska 121,400 6,569 12,271 73,962 26,602 1,938 0 58
Arizona 1,053,602 43,667 109,978 505,858 386,179 7,920 0 0
Arkansas 608,017 50,510 108,792 304,343 138,152 6,206 14 0
California 9,336,447 664,023 989,758 3,462,819 4,058,935 157,995 0 2917
Colorado 438,670 47,555 66,257 219,718 87,722 17,297 97 24
Connecticut 487,989 61,797 60,596 255,429 102,704 7,372 0 91
Delaware 147,197 10,769 17,642 64,174 52,705 1,876 0 31
District of Columbia 204,591 13,747 43,794 88,534 51,827 6,689 0 0
Florida 2,691,502 255,655 522,310 1,331,626 538,542 43,369 0 0
Georgia 1,459,631 108,680 232,728 844,963 252,563 19,550 0 1147
Hawaii 195,684 17,396 23,627 86,034 62,685 5,942 0 0
Idaho 196,406 12,968 26,651 124,773 29,809 2,205 0 0
Illinois 2,076,146 279,046 300,341 1,016,068 395,940 84,506 0 245
Indiana 881,942 78,441 116,543 521,163 152,889 12,730 0 176
Iowa 358,708 41,577 60,717 175,535 70,565 10,314 0 0
Kansas 305,110 30,702 52,879 161,499 47,647 12,383 0 0
Kentucky 769,826 72,121 207,955 370,090 110,257 9,403 0 0
Louisiana 990,286 105,311 177,258 588,077 110,170 9,470 0 0
Maine 346,449 71,964 119,321 97,156 55,101 2,907 0 0
Maryland 752,065 55,354 121,570 415,260 142,405 17,373 103 0
Massachusetts 1,204,312 116,164 243,326 482,300 361,857 665 0 0
Michigan 1,527,627 99,714 297,112 804,779 285,805 40,006 211 0
Minnesota 680,627 69,759 93,872 333,759 174,200 8,983 0 54
Mississippi 707,986 74,033 161,410 384,360 84,985 3,159 39 0
Missouri 1,098,525 98,744 150,368 566,155 258,115 25,143 0 0
Montana 106,229 10,102 17,688 52,662 21,852 3,829 9 87
Nebraska 266,245 23,526 29,885 150,254 51,584 10,267 661 68
Nevada 203,251 19,562 33,202 95,730 46,638 8,119 0 0
New Hampshire 115,517 12,654 14,611 68,911 16,632 2,709 0 0
New Jersey 982,676 111,710 178,819 462,890 207,270 21,926 0 61
New Mexico 462,878 23,371 55,032 290,553 90,085 3,771 19 47
New York 4,139,898 398,070 688,012 1,737,279 1,241,408 75,129 0 0
North Carolina 1,389,455 178,258 236,259 699,139 259,289 16,510 0 0
North Dakota 71,619 10,032 9,841 31,859 18,097 1,790 0 0
Ohio 1,754,379 144,622 279,463 924,487 371,476 33,937 394 0
Oklahoma 677,788 63,837 81,293 432,322 93,949 6,387 0 0
Oregon 637,140 44,325 68,379 247,763 261,511 14,987 175 0
Pennsylvania 1,710,999 212,480 386,422 779,880 283,257 48,635 0 325
Rhode Island 204,789 19,667 38,418 88,794 52,218 5,522 0 170
South Carolina 895,863 78,066 122,846 463,859 222,576 8,423 16 77
South Dakota 113,925 10,139 16,420 67,273 18,157 1,922 0 14
Tennessee 1,700,384 90,398 340,155 723,890 531,554 14,368 19 0
Texas 3,202,171 383,307 379,541 1,870,141 534,638 34,544 0 0
Utah 233,156 12,102 28,075 130,577 55,627 6,676 0 99
Vermont 156,958 19,661 19,109 66,331 49,235 2,610 12 0
Virginia 727,784 98,274 139,382 378,035 97,000 14,946 1 146
Washington 1,104,813 79,445 145,928 579,607 283,313 16,520 0 0
West Virginia 362,264 29,678 89,755 176,277 59,878 6,676 0 0
Wisconsin 776,638 95,507 139,297 335,343 188,479 17,910 8 94
Wyoming 69,802 5,297 8,796 39,397 14,099 2,213 0 0

Note: Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year.

Source: CMS, MSIS Report, FY 2002.

B-15
National Pharmaceutical Council Pharmaceutical Benefits 2004

Total Medicaid Eligibles Per 1000 Population, 2002

Total State Total Eligibles per


State Population Eligibles 1000 Population
National Total 287,973,924 51,552,491 179.0
Alabama 4,478,896 845,125 188.7
Alaska 641,482 121,400 189.2
Arizona 5,441,125 1,053,602 193.6
Arkansas 2,706,268 608,017 224.7
California 35,001,986 9,336,447 266.7
Colorado 4,501,051 438,670 97.5
Connecticut 3,458,587 487,989 141.1
Delaware 805,945 147,197 182.6
District of Columbia 566,157 204,591 361.4
Florida 16,691,701 2,691,502 161.2
Georgia 8,544,005 1,459,631 170.8
Hawaii 1,240,663 195,684 157.7
Idaho 1,343,124 196,406 146.2
Illinois 12,586,447 2,076,146 164.9
Indiana 6,156,913 881,942 143.2
Iowa 2,935,840 358,708 122.2
Kansas 2,711,769 305,110 112.5
Kentucky 4,089,822 769,826 188.2
Louisiana 4,476,192 990,286 221.2
Maine 1,294,894 346,449 267.6
Maryland 5,450,525 752,065 138.0
Massachusetts 6,421,800 1,204,312 187.5
Michigan 10,043,221 1,527,627 152.1
Minnesota 5,024,791 680,627 135.5
Mississippi 2,866,733 707,986 247.0
Missouri 5,669,544 1,098,525 193.8
Montana 910,372 106,229 116.7
Nebraska 1,727,564 266,245 154.1
Nevada 2,167,455 203,251 93.8
New Hampshire 1,274,405 115,517 90.6
New Jersey 8,575,252 982,676 114.6
New Mexico 1,852,044 462,878 249.9
New York 19,134,293 4,139,898 216.4
North Carolina 8,305,820 1,389,455 167.3
North Dakota 636,911 71,619 112.4
Ohio 11,408,699 1,754,379 153.8
Oklahoma 3,489,700 677,788 194.2
Oregon 3,520,355 637,140 181.0
Pennsylvania 12,328,827 1,710,999 138.8
Rhode Island 1,068,326 204,789 191.7
South Carolina 4,103,770 895,863 218.3
South Dakota 760,437 113,925 149.8
Tennessee 5,789,796 1,700,384 293.7
Texas 21,736,925 3,202,171 147.3
Utah 2,318,789 233,156 100.6
Vermont 616,408 156,958 254.6
Virginia 7,287,829 727,784 99.9
Washington 6,067,060 1,104,813 182.1
West Virginia 1,804,884 362,264 200.7
Wisconsin 5,439,692 776,638 142.8
Wyoming 498,830 69,802 139.9

Note: Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year.

Source: U.S. Department of Commerce, Bureau of the Census, 2003; CMS, MSIS Report, FY 2002.

B-16
National Pharmaceutical Council Pharmaceutical Benefits 2004

Medicaid Total Net Expenditures and Eligibles, 2002

Total Net Medical Total Average


State Assistance Expenditures Eligibles Per Eligible
National Total $245,697,620,676 51,552,491 $4,766
Alabama $3,093,270,640 845,125 $3,660
Alaska $685,772,985 121,400 $5,649
Arizona $3,541,598,721 1,053,602 $3,361
Arkansas $2,237,817,554 608,017 $3,681
California $26,890,540,967 9,336,447 $2,880
Colorado $2,323,068,699 438,670 $5,296
Connecticut $3,456,338,545 487,989 $7,083
Delaware $634,046,351 147,197 $4,307
District of Columbia $1,021,772,693 204,591 $4,994
Florida $9,871,508,234 2,691,502 $3,668
Georgia $6,241,211,454 1,459,631 $4,276
Hawaii $740,007,314 195,684 $3,782
Idaho $773,534,776 196,406 $3,938
Illinois $8,809,060,004 2,076,146 $4,243
Indiana $4,448,318,143 881,942 $5,044
Iowa $2,575,146,342 358,708 $7,179
Kansas $1,836,717,196 305,110 $6,020
Kentucky $3,763,204,047 769,826 $4,888
Louisiana $4,885,971,853 990,286 $4,934
Maine $1,430,109,134 346,449 $4,128
Maryland $3,613,476,100 752,065 $4,805
Massachusetts $8,063,005,258 1,204,312 $6,695
Michigan $7,562,053,407 1,527,627 $4,950
Minnesota $4,414,511,470 680,627 $6,486
Mississippi $2,877,013,521 707,986 $4,064
Missouri $5,360,607,640 1,098,525 $4,880
Montana $571,456,455 106,229 $5,379
Nebraska $1,339,132,070 266,245 $5,030
Nevada $808,198,344 203,251 $3,976
New Hampshire $1,016,094,814 115,517 $8,796
New Jersey $7,745,877,997 982,676 $7,882
New Mexico $1,776,811,688 462,878 $3,839
New York $36,295,107,368 4,139,898 $8,767
North Carolina $6,723,598,560 1,389,455 $4,839
North Dakota $461,401,546 71,619 $6,442
Ohio $9,658,040,587 1,754,379 $5,505
Oklahoma $2,260,403,490 677,788 $3,335
Oregon $2,571,560,664 637,140 $4,036
Pennsylvania $12,130,925,035 1,710,999 $7,090
Rhode Island $1,358,500,649 204,789 $6,634
South Carolina $3,292,901,444 895,863 $3,676
South Dakota $549,884,391 113,925 $4,827
Tennessee $5,787,079,096 1,700,384 $3,403
Texas $13,523,486,149 3,202,171 $4,223
Utah $984,160,785 233,156 $4,221
Vermont $660,731,979 156,958 $4,210
Virginia $3,812,166,436 727,784 $5,238
Washington $5,168,511,470 1,104,813 $4,678
West Virginia $1,584,166,286 362,264 $4,373
Wisconsin $4,193,175,197 776,638 $5,399
Wyoming $274,565,128 69,802 $3,933

Note: Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year.
Source: CMS, CMS-64 Report, FY 2002 and CMS-MSIS Report, 2002.

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B-18
National Pharmaceutical Council Pharmaceutical Benefits 2004

Appendix C:
Medicaid Rebate Law

C-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

C-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

TITLE 42 - THE PUBLIC HEALTH AND WELFARE


CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

Sec. 1396r-8. Payment for covered outpatient drugs1

(a) Requirement for rebate agreement

(1) In general
In order for payment to be available under section 1396b(a) of this title or under part B of title XVIII
for covered outpatient drugs of a manufacturer, the manufacturer must have entered into and have in
effect a rebate agreement described in subsection (b) of this section with the Secretary, on behalf of
States (except that, the Secretary may authorize a State to enter directly into agreements with a
manufacturer), and must meet the requirements of paragraph (5)(with respect to drugs purchased by a
covered entity on or after the first day of the first month that begins after November 4, 1992) and
paragraph (6). Any agreement between a State and a manufacturer prior to April 1, 1991, shall be
deemed to have been entered into on January 1, 1991, and payment to such manufacturer shall be
retroactively calculated as if the agreement between the manufacturer and the State had been entered
into on January 1, 1991. If a manufacturer has not entered into such an agreement before March 1,
1991, such an agreement, subsequently entered into, shall become effective as of the date on which the
agreement is entered into or, at State option, on any date thereafter on or before the first day of the
calendar quarter that begins more than 60 days after the date of the agreement is entered into.

(2) Effective date


Paragraph (1) shall first apply to drugs dispensed under this subchapter on or after January 1, 1991.

(3) Authorizing payment for drugs not covered under rebate agreements
Paragraph (1), and section 1396b(i)(10)(A) of this title, shall not apply to the dispensing of a single
source drug or innovator multiple source drug if (A)(i) the State has made a determination that the
availability of the drug is essential to the health of beneficiaries under the State Plan for medical
assistance; (ii) such drug has been given a rating of 1-A by the Food and Drug Administration; and
(iii)(I) the physician has obtained approval for use of the drug in advance of its dispensing in
accordance with a prior authorization program described in subsection (d) of this section, or (II) the
Secretary has reviewed and approved the State’s determination under subparagraph (A); or (B) the
Secretary determines that in the first calendar quarter of 1991, there were extenuating circumstances.

(4) Effect on existing agreements


In the case of a rebate agreement in effect between a State and a manufacturer on November 5, 1990,
such agreement, for the initial agreement period specified therein, shall be considered to be a rebate
agreement in compliance with this section with respect to that State, if the State agrees to report to the
Secretary any rebates paid pursuant to the agreement and such agreement provides for a minimum
aggregate rebate of 10 percent of the State’s total expenditures under the State Plan for coverage of the
manufacturer’s drugs under this subchapter. If, after the initial agreement period, the State establishes
to the satisfaction of the Secretary that an agreement in effect on November 5, 1990, provides for
rebates that are at least as large as the rebates otherwise required under this section, and the State
agrees to report any rebates under the agreement to the Secretary, the agreement shall be considered to
be a rebate agreement in compliance with the section for the renewal periods of such agreement.

(5) Limitation on prices of drugs purchased by covered entities

(A) Agreement with Secretary

1
This is section 1927 of the Social Security Act. It is codified as Section 1396r-8 of Title 42 of the United States Code.

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A manufacturer meets the requirements of this paragraph if the manufacturer has entered into
an agreement with the Secretary that meets the requirements of section 256b of this title with
respect to covered outpatient drugs purchased by a covered entity on or after the first day of
the first month that begins after November 4, 1992.

(B) “Covered entity” defined


In this subsection, the term “covered entity” means an entity described in section 256b(a)(4) of
this title.

(C) Establishment of alternative mechanism to ensure against duplicate discounts or rebates


If the Secretary does not establish a mechanism under section 256b(a)(5)(A) of this title within
12 months of November 4, 1992, the following requirements shall apply:
(i) Entities
Each covered entity shall inform the single State agency under section 1396a(a)(5) of this title
when it is seeking reimbursement from the State Plan for medical assistance described in
section 1396d(a)(12) of this title with respect to a unit of any covered outpatient drug which is
subject to an agreement under section 256b(a) of this title.
(ii) State agency
Each such single State agency shall provide a means by which a covered entity shall indicate
on any drug reimbursement claims form (or format, where electronic claims management is
used) that a unit of the drug that is the subject of the form is subject to an agreement under
section 256b of this title, and not submit to any manufacturer a claim for a rebate payment
under subsection (b) of this section with respect to such a drug.

(D) Effect of subsequent amendments


In determining whether an agreement under subparagraph (A) meets the requirements of
section 256b of this title, the Secretary shall not take into account any amendments to such
section that are enacted after November 4, 1992.

(E) Determination of compliance


A manufacturer is deemed to meet the requirements of this paragraph if the manufacturer
establishes to the satisfaction of the Secretary that the manufacturer would comply (and has
offered to comply) with the provisions of section 256b of this title (as in effect immediately
after November 4, 1992) and would have entered into an agreement under such section (as
such section was in effect at such time), but for a legislative change in such section after
November 4, 1992.

(6) Requirements relating to master agreements for drugs procured by Department of Veterans Affairs
and certain other Federal agencies

(A) In general
A manufacturer meets the requirements of this paragraph if the manufacturer complies with
the provisions of section 8126 of title 38, including the requirement of entering into a master
agreement with the Secretary of Veterans Affairs under such section.

(B) Effect of subsequent amendments


In determining whether a master agreement described in subparagraph (A) meets the
requirements of section 8126 of title 38, the Secretary shall not take into account any
amendments to such section that are enacted after November 4, 1992.

(C) Determination of compliance


A manufacturer is deemed to meet the requirements of this paragraph if the manufacturer
establishes to the satisfaction of the Secretary that the manufacturer would comply (and has
offered to comply) with the provisions of section 8126 of title 38, (as in effect immediately

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after November 4, 1992) and would have entered into an agreement under such section (as
such section was in effect at such time), but for a legislative change in such section after
November 4, 1992.

(b) Terms of rebate agreement

(1) Periodic rebates

(A) In general
A rebate agreement under this subsection shall require the manufacturer to provide, to each
State Plan approved under this subchapter, a rebate for a rebate period in an amount specified
in subsection (c) of this section for covered outpatient drugs of the manufacturer dispensed
after December 31, 1990, for which payment was made under the State Plan for such period.
Such rebate shall be paid by the manufacturer not later than 30 days after the date of receipt of
the information described in paragraph (2) for the period involved.

(B) Offset against medical assistance


Amounts received by a State under this section (or under an agreement authorized by the
Secretary under subsection (a)(1) of this section or an agreement described in subsection (a)(4)
of this section) in any quarter shall be considered to be a reduction in the amount expended
under the State Plan in the quarter for medical assistance for purposes of section 1396b(a)(1)
of this title.

(2) State provision of information

(A) State responsibility


Each State agency under this subchapter shall report to each manufacturer not later than 60
days after the end of each rebate period and in a form consistent with a standard reporting
format established by the Secretary, information on the total number of units of each dosage
form and strength and package size of each covered outpatient drug dispensed after December
31, 1990, for which payment was made under the plan during the period, and shall promptly
transmit a copy of such report to the Secretary.

(B) Audits
A manufacturer may audit the information provided (or required to be provided) under
subparagraph (A). Adjustments to rebates shall be made to the extent that information
indicates that utilization was greater or less than the amount previously specified.

(3) Manufacturer provision of price information

(A) In general. -- Each manufacturer with an agreement in effect under this section shall report
to the Secretary –
(i) not later than 30 days after the last day of each rebate period under the agreement
(beginning on or after January 1, 1991), on the average manufacturer price (as defined in
subsection (k)(1) of this section) and, (for single source drugs and innovator multiple source
drugs), the manufacturer’s best price (as defined in subsection (c)(2)(B) of this section) for
covered outpatient drugs for the rebate period under the agreement;
(ii) not later than 30 days after the date of entering into an agreement under this section on
the average manufacturer price (as defined in subsection (k)(1) of this section) as of October
1, 1990 for each of the manufacturer’s covered outpatient drugs; and
(iii) for calendar quarters beginning on or after January 1, 2004, in conjunction with
reporting required under clause (i) and by National Drug Code (including package size)—
(I) the manufacturer’s average sales price (as defined in section 1847A(c)) and the
total number of units specified under section 1847A(b)(2)(A);

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(II) if required to make payment under section 1847A, the manufacturer’s wholesale
acquisition cost, as defined in subsection (c)(6) of such section; and
(III) information on those sales that were made at a nominal price or otherwise
described in section 1847A(c)(2)(B);

for a drug or biological described in subparagraph (C), (D), (E), or (G) of section 1842 (o)(1)
or section 1881(b)(13)(A)(ii).

Information reported under this subparagraph is subject to audit by the Inspector General of
the Department of Health and Human Services.

(B) Verification surveys of average manufacturer price and manufacturer’s average sales price
The Secretary may survey wholesalers and manufacturers that directly distribute their covered
outpatient drugs, when necessary, to verify manufacturer prices and manufacturer’s average
sales prices (including wholesale acquisition cost) if required to make payment reported under
subparagraph (A). The Secretary may impose a civil monetary penalty in an amount not to
exceed $100,000 on a wholesaler, manufacturer, or direct seller, if the wholesaler,
manufacturer, or direct seller of a covered outpatient drug refuses a request for information
about charges or prices by the Secretary in connection with a survey under this subparagraph
or knowingly provides false information. The provisions of section 1320a-7a of this title
(other than subsections (a) (with respect to amounts of penalties or additional assessments)
and (b)) shall apply to a civil money penalty under this subparagraph in the same manner as
such provisions apply to a penalty or proceeding under section 1320a-7a(a) of this title.

(C) Penalties
(i) Failure to provide timely information
In the case of a manufacturer with an agreement under this section that fails to provide
information required under subparagraph (A) on a timely basis, the amount of the penalty
shall be increased by $10,000 for each day in which such information has not been
provided and such amount shall be paid to the Treasury, and, if such information is not
reported within 90 days of the deadline imposed, the agreement shall be suspended for
services furnished after the end of such 90-day period and until the date such information
is reported (but in no case shall such suspension be for a period of less than 30 days).

(ii) False information


Any manufacturer with an agreement under this section that knowingly provides false
information is subject to a civil money penalty in an amount not to exceed $100,000 for
each item of false information. Such civil money penalties are in addition to other
penalties as may be prescribed by law. The provisions of section 1320a-7a of this title
(other than subsections (a) and (b)) shall apply to a civil money penalty under this
subparagraph in the same manner as such provisions apply to a penalty or proceeding
under section 1320a-7a(a) of this title.

(D) Confidentiality of information


Notwithstanding any other provision of law, information disclosed by manufacturers or
wholesalers under this paragraph or under an agreement with the Secretary of Veterans Affairs
described in subsection (a)(6)(A)(ii) of this section (other than the wholesale acquisition cost
for purposes of carrying out section 1847A) is confidential and shall not be disclosed by the
Secretary or the Secretary of Veterans Affairs or a State agency (or contractor therewith) in a
form which discloses the identity of a specific manufacturer or wholesaler, prices charged for
drugs by such manufacturer or wholesaler, except-
(i) as the Secretary determines to be necessary to carry out this section, to carry out section
1847A (including the determination and implementation of the payment amount), or to
carry out section 1847B,

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(ii) to permit the Comptroller General to review the information provided, and
(iii) to permit the Director of the Congressional Budget Office to review the information
provided.

The previous sentence shall also apply to information disclosed under section 1860D-2(d)(2)
or 1860D-4(c)(2)(E) and drug pricing data reported under the first sentence of section 1860D-
31(i)(1).

(4) Length of agreement

(A) In general
A rebate agreement shall be effective for an initial period of not less than 1 year and shall be
automatically renewed for a period of not less than one year unless terminated under
subparagraph (B).

(B) Termination
(i) By the Secretary
The Secretary may provide for termination of a rebate agreement for violation of the
requirements of the agreement or other good cause shown. Such termination shall not be
effective earlier than 60 days after the date of notice of such termination. The Secretary
shall provide, upon request, a manufacturer with a hearing concerning such a termination,
but such hearing shall not delay the effective date of the termination.
(ii) By a manufacturer
A manufacturer may terminate a rebate agreement under this section for any reason. Any
such termination shall not be effective until the calendar quarter beginning at least 60 days
after the date the manufacturer provides notice to the Secretary.
(iii) Effectiveness of termination
Any termination under this subparagraph shall not affect rebates due under the agreement
before the effective date of its termination.
(iv) Notice to States
In the case of a termination under this subparagraph, the Secretary shall provide notice of
such termination to the States within not less than 30 days before the effective date of such
termination.
(v) Application to terminations of other agreements
The provisions of this subparagraph shall apply to the terminations of agreements described
in section 256b(a)(1) of this title and master agreements described in section 8126(a) of title
38.

(C) Delay before reentry

(c) In the case of any rebate agreement with a manufacturer under this section which is terminated,
another such agreement with the manufacturer (or a successor manufacturer) may not be entered
into until a period of 1 calendar quarter has elapsed since the date of the termination, unless the
Secretary finds good cause for an earlier reinstatement of such an agreement.

Determination of amount of rebate

(1) Basic rebate for single source drugs and innovator multiple source drugs

(A) In general
Except as provided in paragraph (2), the amount of the rebate specified in this subsection for a
rebate period (as defined in subsection (k)(8) of this section) with respect to each dosage form
and strength of a single source drug or an innovator multiple source drug shall be equal to the
product of -

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(i) the total number of units of each dosage form and strength paid for under the State Plan
in the rebate period (as reported by the State); and
(ii) subject to subparagraph (B)(ii), the greater of -
(I) the difference between the average manufacturer price and the best price (as defined
in subparagraph (C)) for the dosage form and strength of the drug, or
(II) the minimum rebate percentage (specified in subparagraph (B)(i)) of such average
manufacturer price, for the rebate period.

(B) Range of rebates required


(i) Minimum rebate percentage
For purposes of subparagraph (A)(ii)(II), the “minimum rebate percentage” for rebate
periods beginning -
(I) after December 31, 1990, and before October 1, 1992, is 12.5 percent;
(II) after September 30, 1992, and before January 1, 1994, is 15.7 percent;
(III) after December 31, 1993, and before January 1, 1995, is 15.4 percent;
(IV) after December 31, 1994, and before January 1, 1996, is 15.2 percent; and
(V) after December 31, 1995, is 15.1 percent.
(ii) Temporary limitation on maximum rebate amount
In no case shall the amount applied under subparagraph (A)(ii) for a rebate period
beginning -
(I) before January 1, 1992, exceed 25 percent of the average manufacturer price; or
(II) after December 31, 1991, and before January 1, 1993, exceed 50 percent of the
average manufacturer price.

(C) “Best price” defined


For purposes of this section -
(i) In general
The term “best price” means, with respect to a single source drug or innovator multiple
source drug of a manufacturer, the lowest price available from the manufacturer during the
rebate period to any wholesaler, retailer, provider, health maintenance organization,
nonprofit entity, or governmental entity within the United States, excluding -
(I) any prices charged on or after October 1, 1992, to the Indian Health Service, the
Department of Veterans Affairs, a State home receiving funds under section 1741 of title
38, the Department of Defense, the Public Health Service, or a covered entity described
in subsection (a)(5)(B) of this section (including inpatient prices charged to hospitals
described in section 340B(a)(4)(L) of the Public Health Service Act);
(II) any prices charged under the Federal Supply Schedule of the General Services
Administration;
(III) any prices used under a State pharmaceutical assistance program; and
(IV) any depot prices and single award contract prices, as defined by the Secretary, of
any agency of the Federal Government;
(V) the prices negotiated from drug manufacturers for covered discount card drugs under
an endorsed discount card program under section 1860D-31; and
(VI) any prices charged which are negotiated by a prescription drug plan under part D of
title XVIII, by an MA-PD plan under part C of such title with respect to covered part D
drugs or by a qualified retiree prescription drug plan (as defined in section 1860D-
22(a)(2)) with respect to such drugs on behalf of individuals entitled to benefits under
part A or enrolled under part B of such title.
(ii) Special rules
The term “best price” -
(I) shall be inclusive of cash discounts, free goods that are contingent on any purchase
requirement, volume discounts, and rebates (other than rebates under this section);
(II) shall be determined without regard to special packaging, labeling, or identifiers on
the dosage form or product or package; and

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(III) shall not take into account prices that are merely nominal in amount.
(iii) Application of auditing and recordkeeping requirements
With respect to a covered entity described in section 340B(a)(4)(L) of the Public Health
Service Act, any drug purchased for inpatient use shall be subject to the auditing and
recordkeeping requirements described in section 340B(a)(5)(C) of the Public Health
Service Act.

(2) Additional rebate for single source and innovator multiple source drugs

(A) In general
The amount of the rebate specified in this subsection for a rebate period, with respect to each
dosage form and strength of a single source drug or an innovator multiple source drug, shall be
increased by an amount equal to the product of -
(i) the total number of units of such dosage form and strength dispensed after December 31,
1990, for which payment was made under the State Plan for the rebate period; and
(ii) the amount (if any) by which -
(I) the average manufacturer price for the dosage form and strength of the drug for the
period, exceeds
(II) the average manufacturer price for such dosage form and strength for the calendar
quarter beginning July 1, 1990 (without regard to whether or not the drug has been sold
or transferred to an entity, including a division or subsidiary of the manufacturer, after
the first day of such quarter), increased by the percentage by which the consumer price
index for all urban consumers (United States city average) for the month before the
month in which the rebate period begins exceeds such index for September 1990.
.
(B) Treatment of subsequently approved drugs
In the case of a covered outpatient drug approved by the Food and Drug Administration after
October 1, 1990, clause (ii)(II) of subparagraph (A) shall be applied by substituting “the first
full calendar quarter after the day on which the drug was first marketed” for “the calendar
quarter beginning July 1, 1990” and “the month prior to the first month of the first full
calendar quarter after the day on which the drug was first marketed” for “September 1990.”

(3) Rebate for other drugs

(A) In general
The amount of the rebate paid to a State for a rebate period with respect to each dosage form
and strength of covered outpatient drugs (other than single source drugs and innovator
multiple source drugs) shall be equal to the product of -
(i) the applicable percentage (as described in subparagraph (B)) of the average
manufacturer price for the dosage form and strength for the rebate period, and
(ii) the total number of units of such dosage form and strength dispensed after December
31, 1990, for which payment was made under the State Plan for the rebate period.

(B) “Applicable percentage” defined


For purposes of subparagraph (A)(i), the “applicable percentage” for rebate periods beginning
-
(i) before January 1, 1994, is 10 percent, and
(ii) after December 31, 1993, is 11 percent.

(d) Limitations on coverage of drugs

(1) Permissible restrictions

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(A) A State may subject to prior authorization any covered outpatient drug. Any such prior
authorization program shall comply with the requirements of paragraph (5).

(B) A State may exclude or otherwise restrict coverage of a covered outpatient drug if -
(i) the prescribed use is not for a medically accepted indication (as defined in subsection
(k)(6) of this section);
(ii) the drug is contained in the list referred to in paragraph (2);
(iii) the drug is subject to such restrictions pursuant to an agreement between a
manufacturer and a State authorized by the Secretary under subsection (a)(1) of this section
or in effect pursuant to subsection (a)(4) of this section; or
(iv) the State has excluded coverage of the drug from its formulary established in
accordance with paragraph (4).

(2) List of drugs subject to restriction


The following drugs or classes of drugs, or their medical uses, may be excluded from coverage or
otherwise restricted:

(A) Agents when used for anorexia, weight loss, or weight gain.
(B) Agents when used to promote fertility.
(C) Agents when used for cosmetic purposes or hair growth.
(D) Agents when used for the symptomatic relief of cough and colds.
(E) Agents when used to promote smoking cessation.
(F) Prescription vitamins and mineral products, except prenatal vitamins and fluoride
preparations.
(G) Nonprescription drugs.
(H) Covered outpatient drugs which the manufacturer seeks to require as a condition of sale
that associated tests or monitoring services be purchased exclusively from the manufacturer or
its designee.
(I) Barbiturates.
(J) Benzodiazepines.

(3) Update of drug listings


The Secretary shall, by regulation, periodically update the list of drugs or classes of drugs described in
paragraph (2) or their medical uses, which the Secretary has determined, based on data collected by
surveillance and utilization review programs of State medical assistance programs, to be subject to
clinical abuse or inappropriate use.

(4) Requirements for formularies


A State may establish a formulary if the formulary meets the following requirements:

(A) The formulary is developed by a committee consisting of physicians, pharmacists, and


other appropriate individuals appointed by the Governor of the State (or, at the option of the
State, the State’s drug use review board established under subsection (g)(3) of this section).

(B) Except as provided in subparagraph (C), the formulary includes the covered outpatient
drugs of any manufacturer which has entered into and complies with an agreement under
subsection (a) of this section (other than any drug excluded from coverage or otherwise
restricted under paragraph (2)).

(C) A covered outpatient drug may be excluded with respect to the treatment of a specific
disease or condition for an identified population (if any) only if, based on the drug’s labeling
(or, in the case of a drug the prescribed use of which is not approved under the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 301 et seq.) but is a medically accepted indication, based
on information from the appropriate compendia described in subsection (k)(6) of this section),

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the excluded drug does not have a significant, clinically meaningful therapeutic advantage in
terms of safety, effectiveness, or clinical outcome of such treatment for such population over
other drugs included in the formulary and there is a written explanation (available to the
public) of the basis for the exclusion.

(D) The State Plan permits coverage of a drug excluded from the formulary (other than any
drug excluded from coverage or otherwise restricted under paragraph (2)) pursuant to a prior
authorization program that is consistent with paragraph (5).

(E) The formulary meets such other requirements as the Secretary may impose in order to
achieve program savings consistent with protecting the health of program beneficiaries. A
prior authorization program established by a State under paragraph (5) is not a formulary
subject to the requirements of this paragraph.

(5) Requirements of prior authorization programs


A State Plan under this subchapter may require, as a condition of coverage or payment for a covered
outpatient drug for which Federal financial participation is available in accordance with this section,
with respect to drugs dispensed on or after July 1, 1991, the approval of the drug before its dispensing
for any medically accepted indication (as defined in subsection (k)(6) of this section) only if the
system providing for such approval –

(A) provides response by telephone or other telecommunication device within 24 hours of a


request for prior authorization; and

(B) except with respect to the drugs on the list referred to in paragraph (2), provides for the
dispensing of at least 72-hour supply of a covered outpatient prescription drug in an
emergency situation (as defined by the Secretary).

(6) Other permissible restrictions


A State may impose limitations, with respect to all such drugs in a therapeutic class, on the minimum
or maximum quantities per prescription or on the number of refills, if such limitations are necessary to
discourage waste, and may address instances of fraud or abuse by individuals in any manner
authorized under this chapter.

(e) Treatment of pharmacy reimbursement limits

(1) In general
During the period beginning on January 1, 1991, and ending on
December 31, 1994 –

(A) a State may not reduce the payment limits established by regulation under this subchapter
or any limitation described in paragraph (3) with respect to the ingredient cost of a covered
outpatient drug or the dispensing fee for such a drug below the limits in effect as of January 1,
1991, and

(B) except as provided in paragraph (2), the Secretary may not modify by regulation the
formula established under sections 447.331 through 447.334 of title 42, Code of Federal
Regulations, in effect on November 5, 1990, to reduce the limits described in subparagraph
(A).

(2) Special rule


If a State is not in compliance with the regulations described in paragraph (1)(B), paragraph (1)(A)
shall not apply to such State until such State is in compliance with such regulations.

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(3) Effect on State maximum allowable cost limitations


This section shall not supersede or affect provisions in effect prior to January 1, 1991, or after
December 31, 1994, relating to any maximum allowable cost limitation established by a State for
payment by the State for covered outpatient drugs, and rebates shall be made under this section
without regard to whether or not payment by the State for such drugs is subject to such a limitation or
the amount of such a limitation.

(4) Establishment of upper payment limits


The Secretary shall establish a Federal upper reimbursement limit for each multiple source drug for
which the FDA has rated three or more products therapeutically and pharmaceutically equivalent,
regardless of whether all such additional formulations are rated as such and shall use only such
formulations when determining any such upper limit.

(f) Repealed and redesignated

(g) Drug use review

(1) In general

(A) In order to meet the requirement of section 1396b(i)(10)(B) of this title, a State shall
provide, by not later than January 1, 1993, for a drug use review program described in
paragraph (2) for covered outpatient drugs in order to assure that prescriptions (i) are
appropriate, (ii) are medically necessary, and (iii) are not likely to result in adverse medical
results. The program shall be designed to educate physicians and pharmacists to identify and
reduce the frequency of patterns of fraud, abuse, gross overuse, or inappropriate or medically
unnecessary care, among physicians, pharmacists, and patients, or associated with specific
drugs or groups of drugs, as well as potential and actual severe adverse reactions to drugs
including education on therapeutic appropriateness, overutilization and underutilization,
appropriate use of generic products, therapeutic duplication, drug-disease contraindications,
drug-drug interactions, incorrect drug dosage or duration of drug treatment, drug-allergy
interactions, and clinical abuse/misuse.

(B) The program shall assess data on drug use against predetermined standards, consistent
with the following:
(i) compendia which shall consist of the following:
(I) American Hospital Formulary Service Drug Information;
(II) United States Pharmacopeia-Drug Information; and
(III) the DRUGDex information System.
(ii) the peer-reviewed medical literature.

(C) The Secretary, under the procedures established in section 1396b of this title, shall pay to
each State an amount equal to 75 per centum of so much of the sums expended by the State
Plan during calendar years 1991 through 1993 as the Secretary determines is attributable to the
statewide adoption of a drug use review program which conforms to the requirements of this
subsection.

(D) States shall not be required to perform additional drug use reviews with respect to drugs
dispensed to residents of nursing facilities which are in compliance with the drug regimen
review procedures prescribed by the Secretary for such facilities in regulations implementing
section 1396r of this title, currently at section 483.60 of title 42, Code of Federal Regulations.

(2) Description of program


Each drug use review program shall meet the following requirements for covered outpatient drugs:

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(A) Prospective drug review


(i) The State plan shall provide for a review of drug therapy before each prescription is
filled or delivered to an individual receiving benefits under this subchapter, typically at the
point-of-sale or point of distribution. The review shall include screening for potential drug
therapy problems due to therapeutic duplication, drug-disease contraindications, drug-drug
interactions (including serious interactions with nonprescription or over-the-counter drugs),
incorrect drug dosage or duration of drug treatment, drug-allergy interactions, and clinical
abuse/misuse. Each State shall use the compendia and literature referred to in paragraph
(1)(B) as its source of standards for such review.
(ii) As part of the State’s prospective drug use review program under this subparagraph
applicable State law shall establish standards for counseling of individuals receiving
benefits under this subchapter by pharmacists which includes at least the following:
(I) The pharmacist must offer to discuss with each individual receiving benefits under
this subchapter or caregiver of such individual (in person, whenever practicable, or
through access to a telephone service which is toll-free for long-distance calls) who
presents a prescription, matters which in the exercise of the pharmacist’s professional
judgment (consistent with State law respecting the provision of such information), the
pharmacist deems significant including the following:
(aa) The name and description of the medication.
(bb) The route, dosage form, dosage, route of administration, and duration of drug
therapy.
(cc) Special directions and precautions for preparation, administration and use by
the patient.
(dd) Common severe side or adverse effects or interactions and therapeutic
contraindications that may be encountered, including their avoidance, and the
action required if they occur.
(ee) Techniques for self-monitoring drug therapy.
(ff) Proper storage.
(gg) Prescription refill information.
(hh) Action to be taken in the event of a missed dose.
(II) A reasonable effort must be made by the pharmacist to obtain, record, and maintain
at least the following information regarding individuals receiving benefits under this
subchapter:
(aa) Name, address, telephone number, date of birth (or age) and gender.
(bb) Individual history where significant, including disease state or states, known
allergies and drug reactions, and a comprehensive list of medications and relevant
devices.
(cc) Pharmacist comments relevant to the individual’s drug therapy.
Nothing in this clause shall be construed as requiring a pharmacist to provide
consultation when an individual receiving benefits under this subchapter or
caregiver of such individual refuses such consultation.

(B) Retrospective drug use review


The program shall provide, through its mechanized drug claims processing and information
retrieval systems (approved by the Secretary under section 1396b(r) of this title) or otherwise,
for the ongoing periodic examination of claims data and other records in order to identify
patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care, among
physicians, pharmacists and individuals receiving benefits under this subchapter, or associated
with specific drugs or groups of drugs.

(C) Application of standards


The program shall, on an ongoing basis, assess data on drug use against explicit predetermined
standards (using the compendia and literature referred to in paragraph (1)(B) as the source of
standards for such assessment) including but not limited to monitoring for therapeutic

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appropriateness, overutilization and underutilization, appropriate use of generic products,


therapeutic duplication, drug-disease contraindications, drug-drug interactions, incorrect drug
dosage or duration of drug treatment, and clinical abuse/misuse and, as necessary, introduce
remedial strategies, in order to improve the quality of care and to conserve program funds or
personal expenditures.

(D) Educational program


The program shall, through its State drug use review board established under paragraph (3),
either directly or through contracts with accredited health care educational institutions, State
medical societies or State pharmacists associations/societies or other organizations as
specified by the State, and using data provided by the State drug use review board on common
drug therapy problems, provide for active and ongoing educational outreach programs
(including the activities described in paragraph (3)(C)(iii) of this subsection) to educate
practitioners on common drug therapy problems with the aim of improving prescribing or
dispensing practices.

(3) State drug use review board

(A) Establishment
Each State shall provide for the establishment of a drug use review board (hereinafter referred
to as the “DUR Board”) either directly or through a contract with a private organization.

(B) Membership
The membership of the DUR Board shall include health care professionals who have
recognized knowledge and expertise in one or more of the following:
(i) The clinically appropriate prescribing of covered outpatient drugs.
(ii) The clinically appropriate dispensing and monitoring of covered outpatient drugs.
(iii) Drug use review, evaluation, and intervention.
(iv) Medical quality assurance.
The membership of the DUR Board shall be made up at least 1/3 but no more than 51
percent licensed and actively practicing physicians and at least 1/3 licensed and actively
practicing pharmacists.

(C) Activities
The activities of the DUR Board shall include but not be limited to the following:
(i) Retrospective DUR as defined in section.
(ii) Application of standards as defined in paragraph (2)(C).
(iii) Ongoing interventions for physicians and pharmacists, targeted toward therapy
problems or individuals identified in the course of retrospective drug use reviews
performed under this subsection. Intervention programs shall include, in appropriate
instances, at least:
(I) information dissemination sufficient to ensure the ready availability to physicians and
pharmacists in the State of information concerning its duties, powers, and basis for its
standards;
(II) written, oral, or electronic reminders containing patient-specific or drug-specific (or
both) information and suggested changes in prescribing or dispensing practices,
communicated in a manner designed to ensure the privacy of patient-related information;
(III) use of face-to-face discussions between health care professionals who are experts in
rational drug therapy and selected prescribers and pharmacists who have been targeted
for educational intervention, including discussion of optimal prescribing, dispensing, or
pharmacy care practices, and follow-up face-to-face discussions; and
(IV) intensified review or monitoring of selected prescribers or dispensers. The Board
shall re-evaluate interventions after an appropriate period of time to determine if the

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intervention improved the quality of drug therapy, to evaluate the success of the
interventions and make modifications as necessary.

(D) Annual report


Each State shall require the DUR Board to prepare a report on an annual basis. The State shall
submit a report on an annual basis to the Secretary which shall include a description of the
activities of the Board, including the nature and scope of the prospective and retrospective
drug use review programs, a summary of the interventions used, an assessment of the impact
of these educational interventions on quality of care, and an estimate of the cost savings
generated as a result of such program. The Secretary shall utilize such report in evaluating the
effectiveness of each State’s drug use review program.

(h) Electronic claims management

(1) In general
In accordance with chapter 35 of title 44 (relating to coordination of Federal information policy), the
Secretary shall encourage each State agency to establish, as its principal means of processing claims
for covered outpatient drugs under this subchapter, a point-of-sale electronic claims management
system, for the purpose of performing on-line, real time eligibility verifications, claims data capture,
adjudication of claims, and assisting pharmacists (and other authorized persons) in applying for and
receiving payment.

(2) Encouragement
In order to carry out paragraph (1) -

(A) for calendar quarters during fiscal years 1991 and 1992, expenditures under the State Plan
attributable to development of a system described in paragraph (1) shall receive Federal
financial participation under section 1396b(a)(3)(A)(i) of this title (at a matching rate of 90
percent) if the State acquires, through applicable competitive procurement process in the State,
the most cost-effective telecommunications network and automatic data processing services
and equipment; and

(B) the Secretary may permit, in the procurement described in subparagraph (A) in the
application of part 433 of title 42, Code of Federal Regulations, and parts 95, 205, and 307 of
title 45, Code of Federal Regulations, the substitution of the State’s request for proposal in
competitive procurement for advance planning and implementation documents otherwise
required.

(i) Annual report

(1) In general
Not later than May 1 of each year the Secretary shall transmit to the Committee on Finance of the
Senate, the Committee on Energy and Commerce of the House of Representatives, and the
Committees on Aging of the Senate and the House of Representatives a report on the operation of this
section in the preceding fiscal year.

(2) Details
Each report shall include information on –

(A) ingredient costs paid under this subchapter for single source drugs, multiple source drugs,
and nonprescription covered outpatient drugs;

(B) the total value of rebates received and number of manufacturers providing such rebates;

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(C) how the size of such rebates compare with the size of rebates offered to other purchasers
of covered outpatient drugs;

(D) the effect of inflation on the value of rebates required under this section;

(E) trends in prices paid under this subchapter for covered outpatient drugs; and

(F) Federal and State administrative costs associated with compliance with the provisions of
this subchapter.

(j) Exemption of organized health care settings

(1) Covered outpatient drugs dispensed by health maintenance organizations, including Medicaid
managed care organizations that contract under section 1396b(m) of this title, are not subject to the
requirements of this section.

(2) The State Plan shall provide that a hospital (providing medical assistance under such Plan) that
dispenses covered outpatient drugs using drug formulary systems, and bills the Plan no more than the
hospital’s purchasing costs for covered outpatient drugs (as determined under the State Plan) shall not
be subject to the requirements of this section.

(3) Nothing in this subsection shall be construed as providing that amounts for covered outpatient
drugs paid by the institutions described in this subsection should not be taken into account for
purposes of determining the best price as described in subsection (c) of this section.

(k) Definitions
In this section -

(1) Average manufacturer price


The term “average manufacturer price” means, with respect to a covered outpatient drug of a
manufacturer for a rebate period, the average price paid to the manufacturer for the drug in the United
States by wholesalers for drugs distributed to the retail pharmacy class of trade, after deducting
customary prompt pay discounts.

(2) Covered outpatient drug


Subject to the exceptions in paragraph (3), the term “covered outpatient drug” means -

(A) of those drugs which are treated as prescribed drugs for purposes of section 1396d(a)(12)
of this title, a drug which may be dispensed only upon prescription (except as provided in
paragraph (5)), and -
(i) which is approved for safety and effectiveness as a prescription drug under section 505
or 507 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355, 357) or which is
approved under section 505(j) of such Act (21 U.S.C. 355(j));
(ii)(I) which was commercially used or sold in the United States before October 10, 1962,
or which is identical, similar, or related (within the meaning of section 310.6(b)(1) of title
21 of the Code of Federal Regulations) to such a drug, and (II) which has not been the
subject of a final determination by the Secretary that it is a “new drug” (within the meaning
of section 201(p) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 321(p))) or an
action brought by the Secretary under section 301, 302(a), or 304(a) of such Act (21 U.S.C.
331, 332(a), 334(a)) to enforce section 502(f) or 505(a) of such Act (21 U.S.C. 352(f),
355(a)); or
(iii)(I) which is described in section 107(c)(3) of the Drug Amendments of 1962 and for
which the Secretary has determined there is a compelling justification for its medical need,
or is identical, similar, or related (within the meaning of section 310.6(b)(1) of title 21 of

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the Code of Federal Regulations) to such a drug, and (II) for which the Secretary has not
issued a notice of an opportunity for a hearing under section 505(e) of the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 355(e)) on a proposed order of the Secretary to
withdraw approval of an application for such drug under such section because the Secretary
has determined that the drug is less than effective for some or all conditions of use
prescribed, recommended, or suggested in its labeling; and

(B) a biological product, other than a vaccine which -


(i) may only be dispensed upon prescription,
(ii) is licensed under section 262 of this title, and
(iii) is produced at an establishment licensed under such section to produce such product;
and

(C) insulin certified under section 506 of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 356).

(3) Limiting definition


The term “covered outpatient drug” does not include any drug, biological product, or insulin provided
as part of, or as incident to and in the same setting as, any of the following (and for which payment
may be made under this subchapter as part of payment for the following and not as direct
reimbursement for the drug):

(A) Inpatient hospital services.

(B) Hospice services.

(C) Dental services, except that drugs for which the State Plan authorizes direct
reimbursement to the dispensing dentist are covered outpatient drugs.

(D) Physicians’ services.

(E) Outpatient hospital services.

(F) Nursing facility services and services provided by an intermediate care facility for the
mentally retarded.

(G) Other laboratory and x-ray services.

(H) Renal dialysis.


Such term also does not include any such drug or product for which a National Drug Code
number is not required by the Food and Drug Administration or a drug or biological used for a
medical indication which is not a medically accepted indication. Any drug, biological
product, or insulin excluded from the definition of such term as a result of this paragraph shall
be treated as a covered outpatient drug for purposes of determining the best price (as defined
in subsection (C)(1)(C) of this section) for such drug, biological product, or insulin.

(4) Nonprescription drugs


If a State Plan for medical assistance under this subchapter includes coverage of prescribed drugs as
described in section 1396d(a)(12) of this title and permits coverage of drugs which may be sold
without a prescription (commonly referred to as “over-the-counter” drugs), if they are prescribed by a
physician (or other person authorized to prescribe under State law), such a drug shall be regarded as a
covered outpatient drug.

(5) Manufacturer

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The term “manufacturer” means any entity which is engaged in -

(A) the production, preparation, propagation, compounding, conversion, or processing of


prescription drug products, either directly or indirectly by extraction from substances of
natural origin, or independently by means of chemical synthesis, or by a combination of
extraction and chemical synthesis, or

(B) in the packaging, repackaging, labeling, relabeling, or distribution of prescription drug


products. Such term does not include a wholesale distributor of drugs or a retail pharmacy
licensed under State law.

(6) Medically accepted indication


The term “medically accepted indication” means any use for a covered outpatient drug which is
approved under the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 301 et seq.) or the use of which
is supported by one or more citations included or approved for inclusion in any of the compendia
described in subsection (g)(1)(B)(i) of this section.

(7) Multiple source drug; innovator multiple source drug; noninnovator multiple source drug; single
source drug

(A) Defined
(i) Multiple source drug
The term “multiple source drug” means, with respect to a rebate period, a covered
outpatient drug (not including any drug described in paragraph (5)) for which there are 2 or
more drug products which -
(I) are rated as therapeutically equivalent (under the Food and Drug Administration’s
most recent publication of “Approved Drug Products with Therapeutic Equivalence
Evaluations”),
(II) except as provided in subparagraph (B), are pharmaceutically equivalent and
bioequivalent, as defined in subparagraph (C) and as determined by the Food and Drug
Administration, and
(III) are sold or marketed in the State during the period.
(ii) Innovator multiple source drug The term “innovator multiple source drug” means a
multiple source drug that was originally marketed under an original new drug application
approved by the Food and Drug Administration.
(iii) Noninnovator multiple source drug
The term “noninnovator multiple source drug” means a multiple source drug that is not an
innovator multiple source drug.
(iv) Single source drug
The term “single source drug” means a covered outpatient drug which is produced or
distributed under an original new drug application approved by the Food and Drug
Administration, including a drug product marketed by any cross-licensed producers or
distributors operating under the new drug application.

(B) Exception
Subparagraph (A)(i)(II) shall not apply if the Food and Drug Administration changes by
regulation the requirement that, for purposes of the publication described in subparagraph
(A)(i)(I), in order for drug products to be rated as therapeutically equivalent, they must be
pharmaceutically equivalent and bioequivalent, as defined in subparagraph (C).

(C) Definitions
For purposes of this paragraph -

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(i) drug products are pharmaceutically equivalent if the products contain identical amounts
of the same active drug ingredient in the same dosage form and meet compendial or other
applicable standards of strength, quality, purity, and identity;
So in original. Probably should be “pharmaceutically”.
(ii) drugs are bioequivalent if they do not present a known or potential bioequivalence
problem, or, if they do present such a problem, they are shown to meet an appropriate
standard of bioequivalence; and
(iii) a drug product is considered to be sold or marketed in a State if it appears in a
published national listing of average wholesale prices selected by the Secretary, provided
that the listed product is generally available to the public through retail pharmacies in that
State.

(8) Rebate period


The term “rebate period” means, with respect to an agreement under subsection (a) of this section, a
calendar quarter or other period specified by the Secretary with respect to the payment of rebates
under such agreement.

(9) State agency


The term “State agency” means the agency designated under section 1396a(a)(5) of this title to
administer or supervise the administration of the State Plan for medical assistance.

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Appendix D:
Federal Upper Limits for
Multiple Source Products

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The following list of multiple source drugs meets the criteria set forth in 42 CFR 447.332 and
§1927(e) of the Social Security Act, as amended by OBRA 1993. The development of the current
Federal Upper Limit (FUL) listing has been accomplished by computer. Payments for multiple source
drugs identified and listed in the accompanying addendum must not exceed, in the aggregate, payment
levels determined by applying to each drug entity a reasonable dispensing fee (established by the State
and specified in the State Plan), plus an amount based on the limit per unit which CMS has determined
to be equal to a 150 percent applied to the lowest price listed (in package sizes of 100 units, unless
otherwise noted) in any of the published compendia of cost information of drugs. Issued by CMS on
November 20, 2001 the initial listing was based on data current as of April 2001 from the First Data
Bank (Blue Book), Medi-Span, and the Red Book. The listing was revised to reflect additional
changes (i.e., additions, deletions, pricing changes) through January 14, 2005. The list does not
reference the commonly known brand names. However, the brand names are included in the FUL
listing provided to the State agencies in electronic media format. The FUL price list is in Microsoft
Word format at http://www.cms.hhs.gov/Medicaid/drugs/drug10.asp.

In accordance with current policy, Federal financial participation will not be provided for any drug on
the FUL listing for which the Food and Drug Administration (FDA) has issued a notice of an
opportunity for a hearing as a result of the Drug Efficacy Study and Implementation (DESI) program
and which has been found to be less than effective or is identical, related, or similar (IRS) to the DESI
drug. The DESI drug is identified by the FDA or reported by the drug manufacturer for purposes of
the Medicaid drug rebate program.

The November 20, 2001 list has been amended with all changes to be implemented no later than
February 14, 2005.

Generic Name Upper Limit per Unit (Source)

Acebutolol Hydrochloride
Eq 200 mg base, Capsule, Oral 100 $0.4612 B
Eq 400 mg base, Capsule, Oral 100 0.6713 B

Acetaminophen; Butalbital; Caffeine


500 mg; 50mg; 40 mg, Tablet, Oral 100 0.6870 B

Acetaminophen; Codeine Phosphate


300 mg; 15 mg, Tablet, Oral 100 0.1500 R
300 mg; 30 mg, Tablet, Oral 100 0.2137 B
300 mg; 60 mg, Tablet, Oral 100 0.3833 B

Acetaminophen; Hydrocodone Bitartrate


500 mg; 5 mg, Capsule, Oral 100 0.1943 B
500 mg /15 ml; 7.5 mg/15 ml Elixir, Oral 473 ml 0.1014 R
500 mg, 2.5 mg, Tablet, Oral 100 0.2190 B
500 mg; 5 mg, Tablet, Oral 100 0.0833 B
500 mg; 7.5 mg, Tablet, Oral 100 0.1913 B
500 mg; 10 mg, Tablet, Oral 100 0.4603 B
650 mg; 7.5 mg, Tablet, Oral 100 0.1550 B
650 mg; 10 mg, Tablet, Oral 100 0.1852 R
660 mg; 10 mg, Tablet, Oral 100 0.5284 B
750 mg; 7.5 mg, Tablet, Oral 100 0.1750 R

Generic Name Upper Limit per Unit (Source)


SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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Acetaminophen; Oxycodone Hydrochloride


500 mg; 5 mg, Capsule, Oral 100 0.2248 B
325 mg; 5 mg, Tablet, Oral 100 0.1192 B

Acetaminophen; Propoxyphene Hydrochloride


650 mg; 65 mg, Tablet, Oral 100 0.1688 B

Acetaminophen; Propoxyphene Napsylate


650 mg; 100 mg, Tablet, Oral 100 0.1800 R

Acetazolamide
250 mg, Tablet, Oral 100 0.2454 R

Acyclovir
200 mg, Capsule, Oral 100 0.1478 B
400 mg, Tablet, Oral 100 0.4425 B
800 mg, Tablet, Oral 100 0.8700 B

Albuterol
0.09 mg/inh, Aerosol, Metered, Inhalation, 17 gm 0.8823 B

Albuterol Sulfate
Eq 0.083% base, Solution, Inhalation 3ml 0.1450 B
Eq 0.5% base, Solution, Inhalation 20 ml 0.3360 B
4 mg, Tablet, Oral 100 0.1425 B

Allopurinol
100 mg, Tablet, Oral 100 0.0784 B
300 mg, Tablet, Oral 100 0.1671 B

Alprazolam
0.25 mg, Tablet, Oral 100 0.0614 R
0.5 mg, Tablet, Oral 100 0.0698 B
1 mg, Tablet, Oral 100 0.0885 B
2 mg, Tablet, Oral 100 0.1745 R

Amantadine Hydrochloride
50 mg/5 ml, Syrup, Oral 480 ml 0.0656 M

Amiloride Hydrochloride; Hydrochlorothiazide


Eq 5 mg Anhydrous; 50 mg, Tablet, Oral 100 0.0675 B

Amiodarone Hydrochloride
200 mg, Tablet, Oral 60 1.6875 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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Generic Name Upper Limit per Unit (Source)

Amitriptyline Hydrochloride
10 mg, Tablet, Oral 100 0.0608 B
25 mg, Tablet, Oral 100 0.0653 B
50 mg, Tablet, Oral 100 0.0666 B
75 mg, Tablet, Oral 100 0.1425 B
100 mg, Tablet, Oral 100 0.1500 R
150 mg, Tablet, Oral 100 0.2430 B

Amitriptyline Hydrochloride; Perphenazine


10 mg; 2 mg, Tablet, Oral 100 0.0704 B
25 mg; 2 mg, Tablet, Oral 100 0.0869 B

Amoxapine
50 mg, Tablet, Oral 100 0.5425 R

Amoxicillin
250 mg, Capsule, Oral 100 0.0675 B
500 mg, Capsule, Oral 100 0.1302 R
125 mg/5 ml, Powder for Reconstitution, Oral 150 0.0201 B
250 mg/5 ml, Powder for Reconstitution, Oral 100 0.0281 B

Ampicillin/Ampicillin Trihydrate
250 mg, Capsule, Oral 100 0.1736 B
500 mg, Capsule, Oral 100 0.2991 B

Aspirin; Butalbital; Caffeine


325 mg; 50 mg; 40 mg, Tablet, Oral 100 0.2400 R

Aspirin; Carisoprodol
325 mg; 200 mg, Tablet, Oral 100 0.3522 B

Atenolol
25 mg, Tablet, Oral 100 0.0975 B
50 mg, Tablet, Oral 100 0.1058 B
100 mg, Tablet, Oral 100 0.1943 B

Atenolol; Chlorthalidone
50 mg; 25 mg, Tablet, Oral 100 0.1762 B
100 mg; 25 mg, Tablet, Oral 100 0.2549 B

Atropine Sulfate; Diphenoxylate Hydrochloride


0.025 mg; 2.5 mg, Tablet, Oral 100 0.1088 B

Baclofen
10 mg, Tablet, Oral, 100 0.4492 B
20 mg, Tablet, Oral, 100 0.8438 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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Generic Name Upper Limit per Unit (Source)

Benazepril Hydrochloride
5 mg, Tablet, Oral, 100 0.4905 R
10 mg, Tablet, Oral, 100 0.4905 R
20 mg, Tablet, Oral, 100 0.4905 R
40 mg, Tablet, Oral, 100 0.4905 R

Benazepril Hydrochloride; Hydrochlorothiazide


5 mg; 6.25 mg, Tablet, Oral, 100 0.4958 B
10 mg; 12.5 mg, Tablet, Oral, 100 0.4958 B
20 mg; 12.5 mg, Tablet, Oral, 100 0.4958 B
20 mg; 25 mg, Tablet, Oral, 100 0.4958 B

Benzonatate
100 mg, Capsule, Oral 100 0.4387 B

Benztropine Mesylate
0.5 mg, Tablet, Oral 100 0.1227 B
1 mg, Tablet, Oral 100 0.1502 B
2 mg, Tablet, Oral 100 0.1930 B

Betamethasone Dipropionate
Eq 0.05% base, Cream, Topical 15 gm 0.2330 B
Eq 0.05% base, Lotion, Topical 60 ml 0.1500 B

Betamethasone Valerate
Eq 0.1% base, Cream, Topical 45 gm 0.1197 B

Bisoprolol Fumarate; Hydrochlorothiazide


2.5 mg; 6.25 mg, Tablet, Oral 100 1.0260 B
5 mg; 6.25 mg, Tablet, Oral 100 1.0260 B
10 mg; 6.25 mg, Tablet, Oral 100 0.8250 B

Brompheniramine Maleate/Dextromethorphan Hydrobromide/


Pseudoephedrine Hydrochloride
2 mg/10 mg/30 mg per 5 ml, Syrup, Oral, 480 ml 0.0387 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

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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Generic Name Upper Limit per Unit (Source)

Captopril
12.5 mg, Tablet, Oral 100 0.0232 B
50 mg, Tablet, Oral, 100 0.0390 B
100 mg, Tablet, Oral 100 0.1080 B

Captopril; Hydrochlorothiazide
25 mg; 15 mg, Tablet, Oral 100 0.2360 B
50 mg; 25 mg, Tablet, Oral 100 0.3702 B

Carbamazepine
200 mg, Tablet, Oral 100 0.1388 R

Carbidopa; Levodopa
10 mg; 100 mg, Tablet, Oral 100 0.3644 B
25 mg; 100 mg, Tablet, Oral 100 0.4455 B
25 mg; 250 mg, Tablet, Oral 100 0.5145 B

Carisoprodol
350 mg, Tablet, Oral 100 0.3743 B

Carteolol Hydrochloride
1%, Solution/Drops, Ophthalmic 10 ml 3.6775 R

Cefaclor
Eq 250 mg base, Capsule, Oral 100 0.6600 B
Eq 500 mg base, Capsule, Oral 100 1.2900 B
Eq 125 mg base/5 ml,
Powder for reconstitution, Oral 150 0.0980 B
Eq 187 mg base/5 ml,
Powder for reconstitution, Oral 100 0.1470 B
Eq 250 mg base/5 ml,
Powder for reconstitution, Oral 150 0.2995 B
Eq 375 mg base/5 ml,
Powder for reconstitution, Oral 100 0.4492 B

Cefadroxil/Cefadroxil Hemihydrate
Eq 500 mg base, Capsule, Oral 50 2.4837 B

Cephalexin
Eq 250 mg base, Capsule, Oral 100 0.1835 R
Eq 500 mg base, Capsule, Oral 100 0.3641 R

Chlordiazepoxide Hydrochloride
5 mg, Capsule, Oral 100 0.1140 B
10 mg, Capsule, Oral 100 0.0877 B

Chlorhexidine Gluconate
0.12%, Solution, Dental 480 ml 0.0109 B

Generic Name Upper Limit per Unit (Source)

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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Chlorpropamide
100 mg, Tablet, Oral 100 0.1837 B
250 mg, Tablet, Oral 100 0.3885 B

Chlorzoxazone
500 mg, Tablet, Oral 100 0.0757 B

Cholestyramine
Eq 4 gm Resin/Packet, Powder, Oral 60 1.2767 B

Cimetidine
200 mg, Tablet, Oral 100 0.1313 B
300 mg, Tablet, Oral 100 0.1313 B
400 mg, Tablet, Oral 100 0.1071 R
800 mg, Tablet, Oral 100 0.2775 B

Cimetidine Hydrochloride
Eq 300 mg base/ 5 ml Solution, Oral , 240 ml 0.1139 B

Ciprofloxacin Hydrochloride
0.3%, Solution/Drops, Ophthalmic, 5ml 7.5690 B
250 mg, Tablet, Oral, 100 0.3750 B
500 mg, Tablet, Oral, 100 0.4500 B
750 mg, Tablet, Oral, 100 0.4800 B

Clindamycin Hydrochloride
Eq 150 mg base, Capsule, Oral 100 0.9180 R

Clindamycin Phosphate
Eq 1% base, Solution, Topical 60 ml 0.2060 R

Clobetasol Propionate
0.05%, Cream, Topical 30 gm 0.8315 B

Clomipramine Hydrochloride
25 mg, Capsule, Oral 100 0.3322 R
50 mg, Capsule, Oral 100 0.5138 B
75 mg, Capsule, Oral 100 0.6623 B

Clonazepam
0.5 mg, Tablet, Oral 100 0.2455 B
1 mg, Tablet, Oral 100 0.2852 B
2 mg, Tablet, Oral 100 0.3903 B

Clonidine Hydrochloride
0.1 mg, Tablet, Oral 100 0.0968 B
0.2 mg, Tablet, Oral 100 0.1350 B
0.3 mg, Tablet, Oral 100 0.1830 B

Generic Name Upper Limit per Unit (Source)

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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Clorazepate Dipotassium
3.75 mg, Tablet, Oral 100 0.8350 B
7.5 mg, Tablet, Oral 100 1.0388 B
15 mg, Tablet, Oral 100 1.4094 B

Cromolyn Sodium
4%, Solution/ Drops, Ophthalmic 10 ml 3.3750 B

Cyclobenzaprine Hydrochloride
10 mg, Tablet, Oral 100 0.2728 B

Desonide
0.05%, Ointment, Topical 60 gm 0.4077 B
0.05%, Cream, Topical 100 0.2337 B

Dexamethasone; Neomycin Sulfate; Polymyxin B Sulfate


0.1%; Eq 3.5 mg base/gm; 10,000 units/gm, Ointment, Ophthalmic 3.5 gm 1.0713 B

Dextroamphetamine Sulfate
10 mg, Tablet, Oral, 100 0.3435 B

Diazepam
2 mg, Tablet, Oral 100 0.0423 B
5 mg, Tablet, Oral 100 0.0718 B
10 mg, Tablet, Oral 100 0.0573 B

Diclofenac Potassiuim
50 mg, Tablet, Oral 100 0.8625 B

Diclofenac Sodium
50 mg, Tablet, Delayed Release, Oral 100 0.4748 R
75 mg, Tablet, Delayed Release, Oral 100 0.5850 R

Dicyclomine Hydrochloride
10 mg, Capsule, Oral 100 0.1222 B
20 mg, Tablet, Oral 100 0.1185 B

Diltiazem Hydrochloride
30 mg, Tablet, Oral 100 0.1019 B
60 mg, Tablet, Oral 100 0.1114 B
90 mg, Tablet, Oral 100 0.2312 B
120 mg, Tablet, Oral 100 0.2331 B

Diphenhydramine Hydrochloride
12.5 mg/5 ml, Elixir, Oral 120 ml 0.0137 B

Dipivefrin Hydrochloride
0.1%, Solution/Drops, Ophthalmic 5 ml 0.8700 B

Generic Name Upper Limit per Unit (Source)

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Doxazosin Mesylate
1 mg, Tablet, Oral 100 0.5918 B
2 mg, Tablet, Oral 100 0.5918 B
4 mg, Tablet, Oral 100 0.6210 B
8 mg, Tablet, Oral 100 0.6518 B

Doxepin Hydrochloride
Eq 10 mg base, Capsule, Oral 100 0.0891 R
Eq 25 mg base, Capsule, Oral 100 0.1822 B
Eq 50 mg base, Capsule, Oral 100 0.1447 R
Eq 75 mg base, Capsule, Oral 100 0.2052 R
Eq 100 mg base, Capsule, Oral 100 0.4174 B
Eq 10 mg base/ml, Concentrate, Oral 120 ml 0.1145 R

Doxycycline Hyclate
Eq 50 mg base, Capsule, Oral 50 0.1317 B
Eq 100 mg base, Capsule, Oral 50 0.1491 B
Eq 100 mg base, Tablet, Oral 50 0.1287 B

Doxycycline Hydrochloride
Eq 50 mg base, Capsule, Oral 50 0.0945 R
Eq 100 mg base, Capsule, Oral 50 0.1215 R

Enalapril Maleate
2.5 mg, Tablet, Oral, 100 0.4334 B
5 mg, Tablet, Oral, 100 0.5490 B
10 mg, Tablet, Oral, 100 0.6863 B
20 mg, Tablet, Oral, 100 0.9150 B

Erythromycin
2%, Solution, Topical 60 ml 0.0687 B
2%, Gel, Topical, 30 gm 0.6250 B
0.5%, Ointment, Ophthalmic, 3 gm 1.0714 B

Estazolam
1 mg, Tablet, Oral 100 0.5925 R
2 mg, Tablet, Oral 100 0.6449 R

Estradiol
0.5 mg, Tablet, Oral 100 0.1791 B
1 mg, Tablet, Oral 100 0.2175 B
2 mg, Tablet, Oral 100 0.3060 B

Estropipate
0.75 mg, Tablet, Oral 100 0.2754 B
1.5 mg, Tablet, Oral 100 0.3450 B
3 mg, Tablet, Oral 100 0.8622 B

Generic Name Upper Limit per Unit (Source)

Etodolac

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

D-10
National Pharmaceutical Council Pharmaceutical Benefits 2004

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 0.1500 B
40 mg, Tablet, Oral 100 0.3000 B

Fenoprofen Calcium
Eq 600 mg base, Tablet, Oral 100 0.2400 R

Flecainide Acetate
50 mg, Tablet, Oral, 100 0.8610 B
100 mg, Tablet, Oral, 100 1.4070 B
150 mg, Tablet, Oral, 100 1.9328 B

Fluocinonide
0.05%, Cream, Topical 60 gm 0.0790 R
0.05%, Gel, Topical 60 gm 0.4965 R
0.05%, Solution, Topical 60 ml 0.2483 R

Fluocinonide Emulsified Base (Fluocinonide-E)


0.05%, Cream, Topical, 60 gm 0.2453 R

Fluorometholone
0.1%, Suspension/Drops, Ophthalmic 5 ml 1.6590 B

Fluoxetine Hydrochloride
10 mg, Capsule, Oral 100 0.5850 B
20 mg, Capsule, Oral 100 0.2520 B
40 mg Capsule, Oral 30 4.0125 B
20 mg/5ml, Solution, Oral 120 ml 0.7500 R
10 mg, Tablets, Oral 30 0.6000 B

Fluphenazine Hydrochloride
1 mg, Tablet, Oral 100 0.2273 B
2.5 mg, Tablet, Oral 100 0.2775 B
5 mg, Tablet, Oral 100 0.3546 B
10 mg, Tablet, Oral 100 0.5099 R

Flurazepam Hydrochloride
15 mg, Capsule, Oral 100 0.0975 B
30 mg, Capsule, Oral 100 0.1148 B

Flurbiprofen
100 mg, Tablet, Oral 100 0.2438 B

Generic Name Upper Limit per Unit (Source)

Flurbiprofen Sodium
0.03%, Solution/Drops, Ophthalmic 2ml 4.0679 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Furosemide
10 mg/ml, Solution, Oral 60 ml 0.1300 B
20 mg, Tablet, Oral 100 0.0563 B
40 mg, Tablet, Oral 100 0.0599 B
80 mg, Tablet, Oral 100 0.1043 B

Gemfibrozil
600 mg, Tablet, Oral 500 0.3800 B

Gentamicin Sulfate
Eq 0.3% Base, Solution/Drops, Ophthalmic 5 ml 0.5700 B

Glipizide
5 mg, Tablet, Oral 100 0.0699 B
10 mg, Tablet, Oral 100 0.1192 B

Glyburide
1.5 mg, Tablet, Oral 100 0.2549 R
3 mg, Tablet, Oral 100 0.3202 R

Gramicidin; Neomycin Sulfate; Polymyxin B Sulfate


0.025 mg/ml; Eq 1.75 mg base/ml; 10,000 units/ml
Solution/Drops, Ophthalmic 10 ml 2.0250 B

Guanfacine Hydrochloride
Eq 1 mg base, Tablet, Oral 100 0.5250 B
Eq 2 mg base, Tablet, Oral 100 0.7200 B

Haloperidol Lactate
Eq 2 mg base/ml, Concentrate, Oral 120 ml 0.1369 B

Hydrochlorothiazide
25 mg, Tablet, Oral, 1000 0.0577 R
50 mg, Tablet, Oral, 1000 0.1019 R

Hydrochlorothiazide; Propranolol Hydrochloride


25 mg; 40 mg, Tablet, Oral 100 0.0877 B
25 mg; 80 mg, Tablet, Oral 100 0.1320 B

Hydrochlorothiazide; Spironolactone
25 mg; 25 mg, Tablet, Oral 100 0.3463 B

Hydrochlorothiazide; Triamterene
25 mg; 37.5 mg, Capsule, Oral 100 0.3177 B
25 mg; 37.5 mg, Tablet, Oral 100 0.1683 R
50 mg; 75 mg, Tablet, Oral 100 0.0488 B
Generic Name Upper Limit per Unit (Source)

Hydrocortisone
0.5%, Cream, Topical, 30 gm 0.0510 M
1%, Cream, Topical 30 gm 0.0572 B
2.5%, Cream, Topical 30 gm 0.1820 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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National Pharmaceutical Council Pharmaceutical Benefits 2004

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
2.5 mg, Tablet, Oral 100 0.1125 B

Ipratropium Bromide
0.02%, Solution for Inhalation, 2.500 ml, 25s 0.1080 R

Isoniazid
300 mg, Tablet, Oral 100 0.0890 B

Isosorbide Dinitrate
5 mg, Tablet, Oral 100 0.0217 R
10 mg, Tablet, Oral 100 0.0228R
20 mg, Tablet, Oral 100 0.0558B

Isosorbide Mononitrate
10 mg, Tablet, Oral 100 0.6110 R
20 mg, Tablet, Oral 100 0.4950 B
60 mg, Tablet, Extended Release, Oral 100 0.7492 B

Generic Name Upper Limit per Unit (Source)

Ketoconazole
200 mg, Tablet, Oral 100 2.2500 R

Ketorolac Tromethamine
10 mg, Tablet, Oral 100 0.6773 M

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

D-13
National Pharmaceutical Council Pharmaceutical Benefits 2004

Labetalol Hydrochloride
100 mg, Tablet, Oral 100 0.2157 B
200 mg, Tablet, Oral 100 0.3582 B
300 mg, Tablet, Oral 100 0.5363 B

Lactulose
10 gm/15 ml, Solution, Oral 480 ml 0.0219 B

Levobunolol Hydrochloride
0.25%, Solution/Drops, Ophthalmic 10 ml 1.2749 B
0.5%, Solution/Drops, Ophthalmic 10 ml 1.4925 B

Lidocaine Hydrochloride
2%, Solution, Oral 100 ml 0.0315 R

Lisinopril
2.5 mg, Tablet, Oral, 100 0.3855 B
5 mg, Tablet, Oral, 100 0.5783 B
10 mg, Tablet, Oral, 100 0.5970 B
20 mg, Tablet, Oral, 100 0.6390 B
30 mg, Tablet, Oral, 100 0.9038 B
40 mg, Tablet, Oral, 100 0.9345 B

Lisinopril ; Hydrochlorothiazide
10 mg ; 12.5 mg, Tablet, Oral, 100 0.6450 B
20 mg ; 12.5 mg, Tablet, Oral, 100 0.6983 B
20 mg ; 25 mg, Tablet, Oral, 100 0.7065 B

Lithium Carbonate
300 mg, Capsule, Oral, 1000 0.1350 B

Lorazepam
0.5 mg, Tablet, Oral 100 0.4350 B
1 mg, Tablet, Oral 100 0.5718 B
2 mg, Tablet, Oral 100 0.5698 B

Lovastatin
10 mg, Tablet, Oral 60 0.7487 B
20 mg, Tablet, Oral 60 1.2488 B
40 mg, Tablet, Oral 60 3.2012 B

Generic Name Upper Limit per Unit (Source)

Meclizine Hydrochloride
12.5 mg, Tablet, Oral 100 0.0599 B
25 mg, Tablet, Oral 100 0.0420 B

Medroxyprogesterone Acetate
2.5 mg, Tablet, Oral 100 0.2025 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

D-14
National Pharmaceutical Council Pharmaceutical Benefits 2004

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
1000 mg, Tablet, Oral, 100 0.4597 B

Methazolamide
25 mg, Tablet, Oral 100 0.3150 R
50 mg, Tablet, Oral 100 0.4650 R

Methenamine Mandelate
1 gm, Tablet, Oral 100 0.2923 B

Methocarbamol
500 mg, Tablet, Oral 100 0.1463 B
750 mg. Tablet, Oral 100 0.1792 B

Methotrexate Sodium
Eq 2.5 mg base, Tablet, Oral 100 1.2637 B

Methylphenidate Hydrochloride
5 mg, Tablet, Oral 100 0.3020 B
10 mg, Tablet, Oral 100 0.4224 B
20 mg, Tablet, Oral 100 0.6180 B

Methylprednisolone
4 mg, Tablet, Oral 100 0.2849 B

Metoclopramide
10 mg, Tablet, Oral 100 0.1095 B

Generic Name Upper Limit per Unit (Source)

Metoclopramide Hydrochloride
Eq 5 mg base/5 ml, Solution, Oral 480 ml 0.0155 B
Eq 5 mg base, Tablet, Oral 100 0.1842 B
Eq 10 mg base, Tablet, Oral 100 0.1089 B

Metoprolol Tartrate
50 mg, Tablet, Oral 100 0.0500 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

D-15
National Pharmaceutical Council Pharmaceutical Benefits 2004

100 mg, Tablet, Oral 100 0.0690 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

Mirtazapine
15 mg, Tablet, Oral, 30 1.6300 B
30 mg, Tablet, Oral, 30 1.6775 B
45 mg, Tablet, Oral, 30 1.7100 B

Nadolol
20 mg, Tablet, Oral 100 0.4650 B
40 mg, Tablet, Oral 100 0.4289 B
80 mg, Tablet, Oral 100 0.8025 B

Naltrexone Sodium
50 mg, Tablet, Oral 100 4.0400 B

Naphazoline Hydrochloride
0.1%, Solution/Drops, Ophthalmic 15 ml 0.3140 R

Naproxen
250 mg, Tablet, Oral 100 0.1044 R
375 mg, Tablet, Oral 100 0.1383 R
500 mg, Tablet, Oral 100 0.1805 B

Niacin
500 mg, Tablet, Oral 100 0.0390 B

Generic Name Upper Limit per Unit (Source)

Nicardipine Hydrochloride
20 mg, Capsule, Oral 100 0.3375 B
30 mg, Capsule, Oral 100 0.4050 B

Nizatidine
150 mg, Capsule, Oral, 60 1.8307 B
300 mg, Capsule, Oral, 30 3.6615 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

D-16
National Pharmaceutical Council Pharmaceutical Benefits 2004

Nortriptyline Hydrochloride
Eq 10 mg base, Capsule, Oral 100 0.1019 B
Eq 25 mg base, Capsule, Oral 100 0.1406 B
Eq 50 mg base, Capsule, Oral 100 0.1722 B
Eq 75 mg base, Capsule, Oral 100 0.2203 B

Nystatin
100,000 units/gm, Cream, Topical 30 gm 0.0755 B
100,000 units/gm, Ointment, Topical 15 gm 0.1019 B

Nystatin; Triamcinolone Acetonide


100,000 units/gm; 0.1%, Cream, Topical 30 gm 0.0975 B

Oxaprozin
600 mg, Tablet, Oral 100 0.6758 B

Oxazepam
10 mg, Capsule, Oral 100 0.5363 B
15 mg, Capsule, Oral 100 0.5709 B
30 mg, Capsule, Oral 100 1.2337 R

Oxybutynin Chloride
5 mg, Tablet, Oral 100 0.1260 R

Oxycodone Hydrochloride
5 mg, Capsule, Oral, 100 0.2138 B
20 mg/ml, Concentrate, Oral, 30 ml 0.9500 B
5 mg, Tablet, Oral, 100 0.2399 B
15 mg, Tablet, Oral, 100 0.6695 M
30 mg, Tablet, Oral, 100 1.3094 M

Paroxetine Hydrochloride
10 mg, Tablet, Oral, 30 2.4300 R
20 mg, Tablet, Oral, 30 2.5200 R
30 mg, Tablet, Oral, 30 2.6100 R
40 mg, Tablet, Oral, 30 2.7000 R

Pentoxifylline
400 mg, Tablet, Extended Release, Oral 100 0.3147 B

Generic Name Upper Limit per Unit (Source)

Perphenazine
2 mg, Tablet, Oral 100 0.3473 R
16 mg, Tablet, Oral 100 1.3833 B

Piroxicam
10 mg, Capsule, Oral 100 0.0891 B
20 mg, Capsule, Oral 100 0.1131 B

Polymyxin B Sulfate; Trimethoprim Sulfate

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

D-17
National Pharmaceutical Council Pharmaceutical Benefits 2004

10,000 units/ml; Eq 1 mg base/ml, Solution/Drops, Ophthalmic 10 ml 1.2360 B

Potassium Chloride
8 MEQ, Tablet, Extended Release, Oral 100 0.0893 B

Prednisolone
15 mg/5 ml, Syrup, Oral 480 ml 0.2081 B

Prednisolone Acetate
1%, Suspension/Drops, Ophthalmic 10 ml 1.6950 B

Primidone
250 mg, Tablet, Oral 100 0.6956 R

Probenecid
500 mg, Tablet, Oral 100 0.7059 B

Prochlorperazine Maleate
Eq 5 mg base, Tablet, Oral 100 0.3986 B
Eq 10 mg base, Tablet, Oral 100 0.5766 B

Propafenone Hydrochloride
150 mg, Tablet, Oral 100 1.1049 B
225 mg, Tablet, Oral 100 1.5624 B

Propranolol Hydrochloride
10 mg, Tablet, Oral 100 0.0585 B
20 mg, Tablet, Oral 100 0.0705 B
40 mg, Tablet, Oral 100 0.0848 B
80 mg, Tablet, Oral 100 0.1140 B

Pseudoephedrine Hydrochloride; Tripolidine Hydrochloride


60 mg; 2.5 mg, Tablet, Oral 100 0.0336 B

Ranitidine Hydrochloride
Eq 150 mg base, Tablet, Oral, 100 0.3411 R
Eq 300 mg base, Tablet, Oral 100 0.3180 B

Rimantadine Hydrochloride
100 mg, Tablet, Oral, 100 1.5120 B
Generic Name Upper Limit per Unit (Source)

Selegiline Hydrochloride
5 mg, Tablet, Oral 60 0.7658 R

Selenium Sulfide
2.5%, Lotion/Shampoo, Topical 120 ml 0.0750 B

Sotalol Hydrochloride (Does Not Apply to the “AF” Versions)


80 mg, Tablet, Oral, 100 1.7850 B
120 mg, Tablet, Oral, 100 2.3550 B
160 mg, Tablet, Oral, 100 2.9250 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

D-18
National Pharmaceutical Council Pharmaceutical Benefits 2004

240 mg, Tablet, Oral, 100 3.9750 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 0.1454 R

Sulfasalazine
500 mg, Tablet, Oral 100 0.1565 B

Sulindac
150 mg, Tablet, Oral 100 0.3317 B
200 mg, Tablet, Oral 100 0.4289 B

Tamoxifen Citrate
10 mg, Tablet, Oral, 60 0.9713 B
20 mg, Tablet, Oral, 30 1.9425 B

Temazepam
15 mg, Capsule, Oral 100 0.1365 B
30 mg, Capsule, Oral 100 0.1748 B

Terazosin Hydrochloride
Eq 1 mg base, Capsule, Oral 100 1.5413 B
Eq 2 mg base, Capsule, Oral 100 1.5413 B
Eq 5 mg base, Capsule, Oral 100 1.5413 B
Eq 10 mg base, Capsule, Oral 100 1.5413 B

Tetracycline Hydrochloride
500 mg, Capsule, Oral 100 0.0975 B

Generic Name Upper Limit per Unit (Source)

Thioridazine Hydrochloride
10 mg, Tablet, Oral 100 0.2190 B
25 mg, Tablet, Oral 100 0.3030 B
50 mg, Tablet, Oral 100 0.3885 R
100 mg, Tablet, Oral 100 0.4941 B

Thiothixene
1 mg, Capsule, Oral 100 0.1388 B
2 mg, Capsule, Oral 100 0.1860 B
5 mg, Capsule, Oral 100 0.2963 B
10 mg, Capsule, Oral 100 0.4065 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

D-19
National Pharmaceutical Council Pharmaceutical Benefits 2004

Ticlopidine Hydrochloride
250 mg, Tablet, Oral 60 0.2732 B

Timolol Maleate
Eq 0.25% base, Solution/Drops, Ophthalmic 10 ml 0.6975 B
Eq 0.5% base, Solution/Drops, Ophthalmic 15 ml 0.9000 B

Tizanidine Hydrochloride
2 mg, Tablet, Oral, 150 0.6499 B
4 mg, Tablet, Oral, 150 0.7899 B

Tobramycin
0.3%, Solution/Drops, Ophthalmic 5 ml 0.6720 B

Tolazamide
250 mg, Tablet, Oral 100 0.4005 B

Tramadol Hydrochloride
50 mg, Tablet, Oral, 100 0.3068 B

Trazodone Hydrochloride
50 mg, Tablet, Oral 100 0.0742 R
100 mg, Tablet, Oral 100 0.1140 B
150 mg, Tablet, Oral 100 0.3113 B

Triamcinolone Acetonide
0.1%, Cream, Topical 80 gm 0.0469 B
0.5%, Cream, Topical 15 gm 0.2370 B
0.1%, Ointment, Topical 80 gm 0.0502 B

Triazolam
0.125 mg, Tablet, Oral 100 0.4041 B

Trihexyphenidyl Hydrochloride
2 mg, Tablet, Oral 100 0.1275 B
5 mg, Tablet, Oral 100 0.2295 B

Generic Name Upper Limit per Unit (Source)

Tropicamide
0.5%, Solution/Drops, Ophthalmic 15 ml 0.6550 B
1%, Solution/Drops, Ophthalmic 15 ml 0.7000 B

Valproic Acid
250 mg, Capsule, Oral 100 0.5250 B
250 mg/5 ml, Syrup, Oral 480 ml 0.0594 M

Verapamil Hydrochloride
120 mg, Capsule, Extended Release, Oral 100 0.8250 B
180 mg, Capsule, Extended Release, Oral 100 0.8700 B
240 mg, Capsule, Extended Release, Oral 100 0.4350 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

D-20
National Pharmaceutical Council Pharmaceutical Benefits 2004

40 mg, Tablet, Oral 100 0.1509 B


80 mg, Tablet, Oral 100 0.0735 B
120 mg, Tablet, Oral 100 0.1110 B
180 mg, Tablet, Extended Release, Oral 100 0.4838 B
240 mg, Tablet, Extended Release, Oral 100 0.4350 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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D-22
National Pharmaceutical Council Pharmaceutical Benefits 2004

Appendix E:
Glossary

E-1
National Pharmaceutical Council Pharmaceutical Benefits 2004

E-2
National Pharmaceutical Council Pharmaceutical Benefits 2004

GLOSSARY OF MEDICAL, MEDICAID,


AND MANAGED CARE TERMS

Term Definition

Access A patient’s ability to obtain medical care. The ease of access is determined
by components such as the availability of medical services and their
acceptability to the patient, the location of health care facilities,
transportation, hours of operation and affordability of care.

Actual Acquisition Cost (AAC) The pharmacist’s net payment made to purchase a drug product, after
taking into account such items as purchasing allowances, discounts, and
rebates.

Actual Charge The amount a physician or other provider actually bills a patient for a
particular medical service, procedure or supply in a specific instance. The
actual charge may differ from the usual, customary, prevailing, and/or
reasonable charge.

Acute Care Medical treatment rendered to individuals whose illnesses or health


problems are of a short-term or episodic nature. Acute care facilities are
those hospitals that mainly serve persons with short-term health problems.

Additional Drug Benefit List A list of pharmaceutical products approved by a health plan and employer
for dispensing in larger quantities than the standards covered under a
benefit package in order to facilitate long-term patient use. The list is
subject to periodic review and modification by the health plan. Also called
“drug maintenance list.”

Adjudication Processing a claim through a series of edits in order to determine proper


payment.

Administrative Costs The costs incurred by a carrier, such as an insurance company or HMO,
for services such as claims processing, billing and enrollment, and
overhead costs. Administrative costs can be expressed as a percentage of
premiums or on a per member per month basis. Additional costs that are
often expressed as administrative include those related to utilization
review, insurance marketing, medical underwriting, agents’ commissions,
premium collection, claims processing, insurer profit, quality assurance
activities, medical libraries and risk management.

Administrative Services Only An insurance arrangement requiring the employer to be at risk for the cost
(ASO) of health care services provided, while a separate company delivers
administrative services. This is a common arrangement when an employer
sponsors a self-funded health care program.

Adverse Selection A term used to describe a situation in which a health plan disproportionally
enrolls a population that is prone to higher than average utilization of
benefits, thereby driving up costs and increasing financial risk.

E-3
National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Aged For purposes of Medicare enrollment, persons 65 years of age or over are
considered to be aged. Medicaid eligibility is determined on the basis of
financial need for people who meet Supplemental Security Income (SSI)
eligibility criteria (aged, blind, or disabled individuals) and Temporary
Assistance for Needy Families (TANF) criteria (adults and children).
Eligibility determinations are made for an entire economic unit or “case”
(sometimes a family) based on whether or not one member of a case meets
the criteria. For example, an “aged” case could consist of a 66 year old
male and his 63 year old wife. In contrast, a disabled enrollee could be
over 65 years of age. May also be defined as “Elderly.”

Agency for Healthcare A Federal agency under Health and Human Services (HHS) whose
Research and Quality (AHRQ) purpose is to enhance the quality and effectiveness of health care by
funding healthcare services research, conducting health technology
assessments and outcomes studies, and developing and disseminating
clinical practice guidelines.

Aid to Families with Dependent A State-based Federal cash assistance program for low-income families. In
Children (AFDC) all States, AFDC recipiency may be used to establish Medicaid eligibility.
Now known as Temporary Assistance for Needy Families (TANF).

Allied Health Personnel Specially trained and licensed (when necessary) health workers other than
physicians, dentists, optometrists, chiropractors, podiatrists and nurses.
The term is sometimes used synonymously with paramedical personnel, all
health workers who perform tasks that must otherwise be performed by a
physician, or health workers who do not usually engage in independent
practice.

Allowable Charge The maximum fee that a third party will reimburse a provider for a given
service. An allowable charge may not be the same amount as either a
reasonable or customary charge.

Allowable Costs Charges for services rendered or supplies furnished by a health provider,
which qualify for an insurance reimbursement.

Ambulatory Care All types of health services that are provided on an outpatient basis, in
contrast to services provided in the home or to persons who are inpatients.
While many inpatients may be ambulatory, the term ambulatory care
usually implies that the patient must travel to a location to receive services
which do not require an overnight stay.

Ambulatory Surgery Any minor surgical procedures that can be performed at any type of
medical facility on an outpatient basis, i.e., not requiring an overnight stay.

American National Standards A nonprofit organization that coordinates the development of voluntary
Institute (ANSI) national standards in both the public and private sectors.

Ancillary Charge (1) The fee associated with additional service performed prior to and/or
secondary to a significant procedure. (2) Also referred to as hospital
“extras” or miscellaneous hospital charges. They are supplementary to a
hospital’s daily room and board charge. They include such items as
charges for drugs, medicines and dressings, lab services, X-ray
examinations, and use of the operating room.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Ancillary Services Hospital services other than room, board, and professional services. They
may include X-rays, lab tests, or anesthesia.

Antitrust A legal term encompassing a variety of efforts on the part of government


to assure that sellers do not conspire to restrain trade or fix prices for their
goods or services in the market.

Any Willing Provider A requirement that a health insurance plan or a health maintenance
organization (HMO) must sign a contract for the delivery of health care
services with any provider in the area that would like to provide such
services to the plan’s or HMO’s enrollees, and can meet the terms of a
contract.

Assignee The person to whom the rights to a health insurance policy are assigned,
either in part or in whole, by the original policyholder.

Assignment of Benefits A method under which a claimant requests that his/her benefits under a
claim be paid to some designated person or institution, usually a physician
or hospital.

At-Risk Accepting prepayment as full coverage for a predetermined health care


benefit and assuming financial liability for any loss that occurs when
premiums paid are less than the cost of services provided.

Authorization As it applies to managed care, authorization is the approval of care, such as


hospitalization.

Average Cost Per Claim The average dollar amount of administrative and/or medical services
rendered for the unit of measure within each expenditure category. The
calculation is $amount / #of units.

Average Manufacturer Price The average price paid by wholesalers for products distributed to the retail
(AMP) class of trade.

Average Wholesale Price The published suggested wholesale price of a drug. It is often used by
(AWP) pharmacies as a cost basis for pricing prescriptions.

Barriers To Access Barriers to access can be financial (insufficient monetary resources),


geographic (distance to providers), organizational (lack of available
providers) and sociological (e.g., discrimination, language barriers). Efforts
to improve access often focus on providing/improving health coverage.

Behavioral Health Care Assessment and treatment of mental and/or psychoactive substance abuse
disorders.

Beneficiary An individual who receives benefits from or is covered by an insurance


policy or other health care financing program. Also known as a "member,"
"enrollee," "subscriber," or "insured."

Benefit A service provided under an insurance policy or prepayment plan.

Benefit Maximum Specifies a dollar limit for the total reimbursement of health care costs
during a benefit period.

Benefit Package Services an insurer, government agency, or health plan offers to a group or
individual under the terms of a contract.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Best Price For purposes of Medicaid rebate calculations, lowest price paid for a
product by any purchaser other than Federal agencies and State
pharmaceutical assistance programs.

Biological Equivalents Those chemical equivalents which, when administered in the same amounts,
will provide the same biological or physiological availability, as measured
by blood levels, urine levels, etc.

Blue Book (MDBT) The generic name for a widely used pricing guide entitled the American
Druggist First Databank Annual Directory of Pharmaceuticals. Brand
name and generic drugs are listed by product, manufacturer, National Drug
or Universal Price Codes, direct price and average wholesale price (AWP).
Other pricing guides are the Red Book and Medispan’s Pricing Guide.

Brand Name Name identifying a drug as the product of a specific pharmaceutical


company. Also known as proprietary trademark name.

Cafeteria Plan An employee benefit plan under which all participants are permitted to
choose among two or more benefit options according to their needs and/or
ability to pay. Also called a flexible benefit plan of “flex plan.”

Capitation A method of payment in which a health plan, such as an HMO or a


specific health care provider, receives a fixed amount for each person
eligible to receive services ($ per member per month), which is made
whether or not the covered person becomes an active patient and without
regard to the number and mix of services used by that patient.

Capitation Fund A fund based on the number of members multiplied by the budgeted or
capitated amount each member pays. Some HMOs, in lieu of reimbursing
physicians on a direct capitation basis, may establish such a fund.
Physicians are then reimbursed on a fee-for-service basis from the
capitation fund. The HMO monitors patient visits for over-utilization;
patients exceeding the norm are notified.

Card Programs The use of a drug benefit identification card which, when presented to a
participating pharmacy by employees or their dependents, usually entitles
them to receive the medication for a copay.

Care Coordinator A primary health care practitioner: (1) who provides primary care services
to an enrollee, (2) who is generally responsible for coordinating the
enrollee’s health care, and (3) with whom, other than in an emergency, a
patient must consult to obtain a referral to a specialist provider in order to
obtain the highest level of benefits available under a health plan. Care
coordinators are sometimes called “gatekeepers.”

Carve Out A decision to purchase separately a service that is typically a part of an


indemnity or HMO plan. Example: an HMO may “carve out” the
behavioral health benefits and select a specialized vendor to supply these
services on a stand-alone basis.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Case Management (1) A process whereby covered persons with specific health care needs are
identified and a plan designed to efficiently utilize health care resources is
formulated and implemented to achieve the optimum patient outcome in the
most cost-effective manner. (2) A utilization management program that
assists the patient in determining the most appropriate and cost-effective
treatment plan. It is used for patients who have prolonged expensive or
chronic conditions, helps determine the treatment location (hospital, or
other institution, or home), and authorizes payment for such care if it is not
covered under the patient’s benefit agreement.

Case Manager An experienced professional (e.g., nurse, doctor or social worker) who
works with patients, providers and insurers to coordinate all services
deemed necessary to provide the patient with a plan of medically necessary
and appropriate health care.

Categorically Needy Under Medicaid, categorically needy are aged, blind, or disabled
individuals or families and children who meet financial eligibility
requirements for TANF, Supplemental Security Income, or an optional
State supplement.

Center for Medicaid and State The agency within the Centers for Medicare and Medicaid Services (CMS)
Operations (CMSO) with responsibility for administering the Medicaid and The Children’s
Health Insurance Program (SCHIP).

Centers for Medicare and The government agency within the Department of Health and Human
Medicaid Services (CMS) Services which directs the Medicare and Medicaid programs (Titles XVIII
and XIX of the Social Security Act) and conducts research to support those
programs. Formerly known as the Health Care Financing Administration
(HCFA).

Certificate of Need (CON) A certificate issued by a government body, where required, to an


individual or organization proposing to construct or modify a health
facility, acquire major new medical equipment, or offer a new or different
health service. Such issuance recognizes that a facility or services, when
available, will meet the needs of those for whom it is intended.

Chain Pharmacy One of a group of pharmacies, usually three or more, under the same
management or ownership.

Charity Care Pools The assets of several funds combined to cover health care costs to the poor
and uninsured. The pools are established by organizations such as
hospitals and insurance companies to offset a portion of the cost for
providing health care to the indigent.

Chemical Equivalents Those multiple-source drug products containing identical amounts of the
same active ingredients, in equivalent dosage forms, and meeting existing
physical/chemical standards.

Chronic Care Care and treatment rendered to individuals whose health problems are of a
long-term and continuing nature. Rehabilitation facilities, nursing homes,
and mental hospitals may be considered chronic care facilities.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Claim Information on medical services provided that is submitted by a provider or


a covered person from which processing for payment to the provider or
covered person is made. The term generally refers to the liability for health
care services received by covered persons.

Claims Administration A carrier function involving the review of health insurance claims
submitted for payment, by individual claim or in the aggregate. Claims
administration, as it relates to professional review programs, is an
identification procedure, screening treatment or charge pattern, for
subsequent peer review and adjudication.

Claims Clearinghouse System A system which allows electronic claims submission through a single
source.

Claims Review The method by which an enrollee’s health care service claims are reviewed
before reimbursement is made. The purpose of this monitoring system is to
validate the medical appropriateness of the provided services and to be
sure the cost of the service is not excessive.

Clearinghouse Capability A company capable of submitting electronic and/or paper claims to several
third-party payers.

Clinical Indicator A tool or marker used to monitor and evaluate care to assure desirable
outcomes and to explain or prevent undesirable outcomes.

Clinical Outcome The status of the patient’s health, especially after receipt of medical care
services. Assessment of outcomes may be dependent upon targeted goals,
clinical markers, and the ability to provide objective measurements.

Clinical Practice Guidelines Guidelines that specify the appropriate course(s) of treatment for specified
health conditions.

Closed-Panel HMO Generally offers the services of a relatively limited number of health care
providers, e.g., physicians employed by the HMO. Staff- and group-model
HMOs are usually referred to as being in this category.

CMS MSIS Report The CMS MSIS Report, formerly the HCFA-2082 Report, is the basic
source of State-reported eligibility and claims data on the Medicaid
population, their characteristics, utilization, and payments. Through FY
1998, the HCFA-2082 was an annual State submitted report designed to
collect aggregate statistical data on Medicaid eligibles, recipients, services,
and expenditures during each federal fiscal year. States summarized and
reported the data processed through their own Medicaid claims processing
and payment systems unless they opted to participate in the Medicaid
Statistical Information System (MSIS) where the 2082 Report was
produced by CMS. State-by-State national summary tables were developed
based on the 2082 Reports. As a result of legislation enacted by The
Balanced Budget Act of 1997, States, beginning in FY 1999, are required
to submit all of their eligibility and claims data on a quarterly basis
through MSIS. The State requirement for completing the HCFA-2082
Report has been eliminated.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

CMS-64 Report The CMS-64 Report is a product of the financial budget and grant system.
It is a statement of expenditures for the Medicaid program that States
submit to CMS 30 days after each quarter. The Report is an accounting
statement of actual expenditures made by the States for which they are
entitled to receive Federal reimbursement under Title XIX for that quarter.
Along with The CMS MSIS Report, it is one of the primary sources for
Medicaid statistical data.

Coinsurance The portion of covered health care costs for which the covered person has
a financial responsibility, usually according to a fixed percentage. Often
coinsurance applies after first meeting a deductible requirement.

Commercial Managed Care A health maintenance organization with a contract §1876 or a Medicare +
Organization (Comp-MCO) Choice organization, a provider sponsored organization, or any private or
public organization which meets the requirements of §1902(w). They
provide comprehensive services to commercial and/or Medicare, as well as
Medicaid enrollees.

Community Rating A method of determining a premium structure that is influenced not by the
expected level of benefit utilization by specific groups, but by expected
utilization by the population as a whole. Most often based on the entire
population of a metropolitan statistical area (MSA). The intent is to spread
risk over a large number of covered lives.

Competitive Medical Plan A status granted by the Federal government to an organization meeting
(CMP) specified criteria, enabling that organization to obtain a Medicare risk
contract.

Compliance The degree to which patients follow treatment recommendations.

Comprehensive Benefits Plan A variation of the major medical plan which carries copayment
requirements, usually 10-20 percent of all health expenses and deductibles
ranging from $100 to $1,000.

Concurrent Drug Evaluation An electronic assessment of claims at the point of service to detect potential
problems that should be addressed prior to dispensing drugs to patients.

Consolidated Omnibus A Federal law that, among other things, requires employers to offer
Reconciliation Act (COBRA) continued health insurance coverage to certain employees and their
beneficiaries whose group health insurance coverage has been terminated.

Consumer Price Index (CPI) A price index constructed monthly by the U.S. Department of Labor using
retail prices of goods and services sold in large cities across the country.

Continuous Quality A formal process of constantly seeking better ways to achieve stated goals.
Improvement (CQI)

Continuum of Care A range of clinical services provided to an individual or group, which may
reflect treatment rendered during a single inpatient hospitalization, or care
for multiple conditions over a lifetime. The continuum provides a basis
for analyzing quality, cost and utilization over the long term.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Contract Pharmacy System Pharmaceutical benefit delivery arrangement in which an HMO contracts
with community pharmacies (chain or selected independents) to provide
medications to members. Reimbursement may be by fee-for-service,
capitation, or some other arrangement.

Contributory Program A method of payment for group coverage in which part of the premium is
paid by the employee and part is paid by the employer or union.

Copay/Copayment A cost-sharing arrangement in which a covered person pays a specified


charge for a specified service, such as $10 for an office visit. The covered
person is usually responsible for payment at the time the care is rendered.
Typical copayments are fixed or variable flat amounts for physician office
visits, prescriptions or hospital services. Some copayments are referred to
as coinsurance, with the distinguishing characteristics that copayments are
flat or variable dollar amounts and coinsurance is a defined percentage of
the charges for services rendered.

Cosmetic Procedures Those procedures which involve physical appearance, but which do not
correct or materially improve a physiological function and are not deemed
medically necessary.

Cost Sharing Any provision of a health insurance policy that requires the insured to pay
some portion of medical expenses. The general term includes deductibles,
copayments, and coinsurance.

Cost Shifting The redistribution of payment sources. Typically, cost shifting occurs
when one payer obtains a discount on provider services, and the providers
increase costs to another payer to make up the difference.

Cost-Based Reimbursement Payment by third-party insurers in which the amount is based on the cost to
the provider of delivering services.

Cost-Effectiveness Usually considered as a ratio, the cost-effectiveness of a drug or procedure,


for example, relates the cost of that drug or procedure to the health benefits
resulting from it. In health terms, it is often expressed as the cost per year
per life saved.

Counter Detailing A process of re-educating or influencing prescribers in a closed or


controlled HMO plan. Usually done in order to gain more compliance with
a formulary. In a counter-detailing program, techniques used by
pharmaceutical sales representatives are adapted to a “counter” objective,
i.e., to provide doctors with basic pharmacological information designed to
influence their prescribing habits.

Coverage Entire range of protection provided under an insurance contract.

Covered Expenses Medical and related costs, experienced by those covered under the policy,
that qualify for reimbursement under terms of the insurance contract.

Covered Services The specific services and supplies for which Medicaid will provide
reimbursement. Covered services under Medicaid consist of a
combination of mandatory and optional services within each State.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Credentialing A process of review to approve a provider who applies to participate in a


health plan. Specific criteria and prerequisites are applied in determining
initial and ongoing participation in the health plan.

Customary Charge The charge a physician or supplier usually bills his patients for furnishing
a particular service or supply is called the customary charge.

Customary, Prevailing, and Method of reimbursement which limits payment to the lowest of the
Reasonable Charges following: physician’s actual charge, physician’s median charge in a recent
prior period (customary), or the 75th percentile of charges in the same time
period (prevailing).

Day Supply Maximum The maximum amount of medication a person may receive at one time,
usually the amount needed for 30 (acute) or 90 (maintenance) days of
therapy, as defined by the drug benefit.

Deductible An amount the insured person must pay before payments for covered
services begin. For example, an insurance plan might require the insured to
pay the first $250 of covered expenses during a calendar year before the
insurance company will begin payment.

Demand The amount of care a population seeks to obtain through the health delivery
system.

Dependent An individual who relies on an employee for support or obtains health


coverage through a spouse, parent, or grandparent who is the covered
person.

Depot Price The price(s) available to any depot of the Federal government, for
purchase of drugs from the manufacturer through the depot system of
procurement.

Diagnosis Center Freestanding or hospital-based facility that specializes in diagnosing


illnesses and injuries.

Diagnosis Related Group A system of classification for inpatient hospital services based on principal
(DRG) diagnosis, secondary diagnosis, surgical procedures, age, sex and presence
of complications. This system of classification is used as a financing
mechanism to reimburse hospital and selected other providers for services
rendered.

Disability (1) Any condition that results in functional limitations that interfere with
an individual’s ability to perform his/her customary work and which
results in substantial limitation in one of more major life activities. (2)
Condition(s) that prevent or limit an individual’s ability to engage in
normal activities. These may be temporary.

Disability Income Insurance Type of health insurance that periodically pays a disabled subscriber to
replace income lost during the period of disability.

Disease Management An effort to improve patient outcomes and lower costs by organizing
managed care initiatives around patients with a particular disease or
condition.

Dismemberment Loss of body parts stemming from accidental physical injury.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Dispense As Written (DAW) A prescribing directive issued by physicians to indicate that the pharmacy
should not in any way alter a prescription. Such alterations are usually done
in order to substitute a generic drug for the brand name drug ordered.

Dispensing, Fill or Professional The amount paid to a pharmacy for each prescription, in addition to the
Fee negotiated formula for reimbursing ingredient cost.

Dispensing or Prescribing Limitations on the number of prescriptions per month, or the amount of
Limits medication that may be prescribed in a given time frame.

Disproportionate Share A disproportionate share hospital (DSH) is a hospital that serves a


Hospital (DSH) disproportionate number of low-income patients with special needs and
receives a payment adjustment for providing such services. In addition to
certain requirements for the provision of obstetrical services to individuals
entitled to medical assistance, a hospital is deemed to be a disproportionate
share hospital if 1) the hospital’s Medicaid inpatient utilization rate is at
least one standard deviation above the mean Medicaid inpatient utilization
rate for hospitals receiving Medicaid payments in the State, or 2) the
hospital’s low-income utilization rate exceeds 25 percent.

Drug Detailing Presenting information about a brand name drug product to prescribers to
educate them about its activity, uses, side effects, proper dosage and
administration, etc.

Drug Formulary A listing of prescription medications which are preferred for use by a health
plan and which may be dispensed through participating pharmacies to
covered persons. This list is subject to periodic review and modification by
the health plan. A plan that has adopted an “open or voluntary” formulary
allows coverage for both formulary and non-formulary medications. A plan
that has adopted a “closed, select or mandatory” formulary limits coverage
to those drugs in the formulary.

Drug Use Evaluation (DUE) Evaluations of prescribing patterns of prescribers to specifically determine
the appropriateness of drug therapy. There are three forms of DUE:
prospective (before or at the time of prescription dispensing), concurrent
(during the course of drug therapy), and retrospective (after the therapy has
been completed). Same as “Drug Utilization Review.”

Drug Utilization The prescribing, dispensing, administering and ingestion or use of


pharmaceutical products.

Drug Utilization Review (DUR) A quantitative evaluation of prescription drug use, physician prescribing
patterns or patient drug utilization to determine the appropriateness of drug
therapy. Most often focuses on over-utilization.

Dual Eligibles The term describes a population of low-income elderly and individuals
with disabilities who qualify for both Medicare and Medicaid coverage.
While Medicare covers basic health services, including physician and
hospital care, dual eligibles rely on Medicaid to pay Medicare premiums
and cost-sharing and to cover critical benefits Medicare does not cover,
such as long-term care and prescription drugs. However starting in 2006,
coverage of prescription drugs for dual eligibles will shift from Medicaid
to Medicare.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Early and Periodic Screening, The EPSDT program covers screening and diagnostic services to
Diagnostic, and Treatment determine physical or mental defects in recipients under age 21, as well as
(EPSDT) health care and other measures to correct or ameliorate any defects and
chronic conditions discovered.

Electronic Data Interchange The computer-to-computer exchange of business or other information. The
(EDI) data may be in either a standardized or priority format.

Employee Benefits Program Health insurance and other benefits, beyond salaries, offered to employees
at their place of work. The employer typically picks up all or part of the
cost of these benefits.

Employee Retirement Income A Federal Act passed in 1974, that established new standards and
Security Act of 1974, Public reporting/disclosure requirements for employer-funded pension and health
Law 93-406 (ERISA) benefit programs. To date, self-funded health benefit plans operating under
ERISA have been held to be exempt from State insurance laws.

Enrollment The total number of covered persons in a health plan. Also refers to the
process by which a health plan signs up groups and individuals for
membership, or the number of enrollees who sign up in any one group.

Estimated Acquisition Cost An estimate of the price generally, and currently, paid by providers for a
(EAC) drug marketed or sold by a particular manufacturer or labeler in the
package size most frequently purchased by providers.

Exclusions Specific conditions or circumstances listed in the contract or employee


benefit plan for which the policy or plan will not provide benefit
payments.

Exclusivity Clause A part of a contract which prohibits physicians from contracting with more
than one health maintenance organization or preferred provider
organization.

Expenditures Under Medicaid, “expenditures” refers to an amount paid out by a State


agency for the covered medical expenses of eligible participants.

Experience Rating The process of setting rates based partially or in whole on previous claims
experience and projected required revenues for a future policy year for a
specific group or pool of groups.

Experimental, Investigational Medical, surgical, psychiatric, substance abuse or other health care services,
or Unproven Procedures supplies, treatments, procedures, drug therapies or devices that are
determined by the health plan (at the time it makes a determination
regarding coverage in a particular case) to be either: not generally accepted
by informed health care professionals in the U.S. as effective in treating the
condition, illness or diagnosis for which their use is proposed; or not proven
by scientific evidence to be effective in treating the condition, illness or
diagnosis for which their use is proposed.

Extended Care Long-term care, ranging from routine assistance for daily activities to
sophisticated medical and nursing care for those needing it. The care,
covered under certain insurance policies, can be provided in homes, day-
care centers or other facilities.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Family Planning Services Any medically approved means, including diagnosis, treatment, drugs,
supplies and devices, and related counseling which are furnished or
prescribed by or under the supervision of a physician for individuals of
childbearing age for purposes of enabling such individuals freely to
determine the number or spacing of their children.

Favorable Selection A tendency for utilization of health services in a population group to be


lower than expected or estimated.

Federal Financial Participation The technical term for Federal Medicaid matching funds paid to States for
allowable expenditures for Medicaid services or administrative costs.

Federal Medical Assistance The Federal Medical Assistance Percentage (FMAP) determines that
Percentage (FMAP) Federal government’s share of medical assistance expenditures under each
State’s Medicaid program. Each year, the FMAP is established by a
formula that compares the State's average per capita income level with the
national income average. States with a higher per capita income level are
reimbursed a smaller share of their costs. By law, the FMAP cannot be
lower than 50 percent or higher than 83 percent. The FMAP is defined in
Section 1933(d) of the Social Security Act.

Federal Poverty Level (FPL) The Federal government’s working definition of poverty is used as the
reference point for the income standard for Medicaid eligibility for certain
categories of beneficiaries. The Federal Poverty Level is the
administrative version of the poverty measure and is issued by the
Department of Health and Human Services (HHS). It is a simplification of
the poverty thresholds and is used in determining financial eligibility for
certain Federal programs. The FPL is also referred to as the Federal
poverty guidelines.

Federal Upper Limits (FUL) The upper limit amount that Medicaid can reimburse for a drug product if
there are three or more generic versions of the product rated
therapeutically equivalent and at least three suppliers listed in the current
editions of published national compendia. These limits are intended to
assure that the Federal government acts as a prudent buyer of drugs. The
upper limits program seeks to achieve savings by taking advantage of
current market prices.

Federally Qualified Health Federally Qualified Health Centers are facilities or programs more
Center (FQHC) commonly known as Community Health Centers, Migrant Health Centers,
and Health Care for The Homeless. These centers may qualify as Medicaid
providers of services if: 1) The facility receives a grant under sections 329,
330, or 340 of The Public Health Services Act; 2) HRSA recommends,
and the HHS Secretary determines, that the facility meets the requirements
of the grant; or 3) The Secretary determines that a facility may qualify
through waivers of the requirements (such a waiver cannot exceed two
years).

Federally Qualified HMOs HMOs that meet certain Federally stipulated provisions aimed at
protecting consumers: e.g., providing a broad range of basic health
services, assuring financial solvency, and monitoring the quality of care.
HMOs must apply to the Federal government for qualification. The Office
of Prepaid Health Care of CMS administers the process.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Fee Maximum The maximum amount a participating provider may be paid for a specific
health care service provided to a covered person under a specific contract.
Sometimes called “fee max.”

Fee Schedule A listing of codes and related services with pre-established payment
amounts that could be percentages of billed charges, flat rates or maximum
allowable amounts.

Fee-for-Service The traditional health care payment system, under which physicians and
Reimbursement other providers receive a payment that does not exceed their billed charge
for each unit of service provided. Fees are paid as care is rendered.

First-Dollar Coverage Health policies that pay all or a portion of medical expenses upon
enrollment, without a deductible charge.

Fiscal Agent A contractor that processes or pays vendor claims on behalf of a Medicaid
agency.

Fiscal Intermediary The agent that has contracted with providers of service to process claims
for reimbursement under health care coverage. In addition to handling
financial matters, it may perform other functions such as providing
consultative services or serving as a center for communication with
providers and making audits of providers’ records.

Fiscal Year Any predetermined set of 12 months for which annual accounts are kept.
The Federal government’s fiscal year extends from Oct. 1 to the following
Sept. 30.

Fixed Fee An established “fee” schedule for pharmacy services allowed by certain
government and private third-party programs in lieu of cost-of-doing
business markups.

Formulary See “Drug Formulary.”

Free-Standing Hospital Any hospital that is not affiliated with a multihospital system.

Freedom-of-Choice (FOC) Legislation requiring managed care organizations to allow members to


choose providers whether or not they connect with the plans (often
coupled with any willing provider (AWP) legislation).

Gatekeeper See “Care Coordinator.”

Generic Drug A chemically equivalent copy of a brand name drug whose patent has
expired. Drug formulations must be of identical composition with respect
to the active ingredient (i.e., meet official standards of identity, purity, and
quality of active ingredient). Also called generic equivalent or non-
innovator multiple source drug.

Generic Equivalent See “Generic Drug.”

Generic Substitution Dispensing a generic drug in place of a brand name medication.

Global Target A financing method identical to a global budget except that no


enforcement mechanism is used to keep providers and hospitals within
budget (i.e., providers and hospitals will receive additional funding if their
costs exceed their budgeted payments).

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

HCFA 1500 A universal form developed by the government agency previously known
as the Health Care Financing Administration (HCFA, now CMS), for
providers of services to bill professional fees to health carriers.

HCFA Common Procedural A listing of services, procedures and supplies offered by physicians and
Coding System (HCPCS) other providers. HCPCS includes current procedural terminology (CPT)
codes, national alphanumeric codes and local alphanumeric codes. The
national codes are developed by CMS in order to supplement CPT codes.
They include physician services not included in CPT as well as non-
physician services such as ambulance, physical therapy and durable medical
equipment. The local codes are developed by local Medicare carriers in
order to supplement the national codes. HCPCS codes are 5-digit codes, the
first digit a letter followed by four numbers. HCPCS codes beginning with
A through V are national; those beginning with W through Z are local.

Health Care Financing See “Centers for Medicare and Medicaid Services.”
Administration (HCFA)

Health Care Prepayment Plan A cost contract with the CMS that prepays a health plan a flat amount per
(HCPP) month to provide Medicare-eligible Part B medical services to enrolled
members. Members pay premiums to cover the Medicare coinsurance,
deductibles and copayments, plus any additional non-Medicare covered
services that the plan provides. The HCPP does not arrange for Part A
services.

Health Insurance Financial protection against the medical care costs arising from disease or
accidental bodily injury. Such insurance usually covers all or part of the
medical costs of treating the disease or injury. Insurance may be obtained
on either an individual or a group basis.

Health Insurance Flexibility A Medicaid and State Children’s Health Insurance Program (SCHIP)
and Accountability (HIFA) demonstration waiver, using Section 1115 waiver authority, that offers
Waiver States greater flexibility in setting benefits and cost-sharing for some
groups of Medicaid beneficiaries. States can use the waiver to cut benefits
and /or increase cost-sharing for certain Medicaid beneficiaries and invest
resulting savings into expanding coverage of uninsured individuals
through Medicaid and SCHIP.

Health Insurance Portability Public Law 104-191, a law which requires each State’s Medicaid
and Accountability Act of 1996 Management Information System (MMIS) to have the capacity to exchange
(HIPAA) data with the Medicare program and contains “administrative
simplification” provisions that require State Medicaid Programs to use
standard codes for electronic transactions relating to the processing of
health claims.

Health Insuring Organization An entity that provides for or arranges for the provision of care and
(HIO) contracts on a prepaid capitated risk basis to provide a comprehensive set of
services.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Health Maintenance (1) An entity that provides, offers or arranges for coverage of designated
Organizations (HMO’s) health services needed by plan members for a fixed, prepaid premium.
There are four basic models of HMOs: staff model, group model, network
model and individual practice association; (2) Under the Federal HMO Act,
an entity must have three characteristics to call itself an HMO: (a) An
organized system for providing health care or otherwise assuring health care
delivery in a geographic area, (b) An agreed upon set of basic and
supplemental health maintenance and treatment services, and (c) A
voluntary enrolled group of people.

Health Plan An organization that provides a defined set of benefits; this term usually
refers to an HMO-like entity, as opposed to an indemnity insurer.

Health Plan Employer Data and A core set of performance measures to assist employers and other health
Information Set (HEDIS) purchasers in understanding the value of health care purchases and
evaluating health plan performance. HEDIS 2005 is currently used and
distributed by NCQA (National Committee for Quality Assurance).

HMO - Group Model A health care model involving contracts with physicians organized as a
partnership, professional corporation, or other association. The health plan
compensates the medical group for contracted services at a negotiated rate,
and that group is responsible for compensating its physicians and
contracting with hospitals for care of their patients.

HMO - Individual Practice A health care model that contracts with physicians and other community
Association (IPA) health care providers, to provide services in return for a negotiated fee.
Physicians continue in their existing individual or group practices and are
compensated on a per capita, fee schedule, or fee-for-service basis.

HMO - Network Model An HMO type in which the HMO contracts with more than one physician
group, and may contract with single- and multi-specialty groups. The
physician works out of his/her own office. The physician may share in
utilization savings, but does not necessarily provide care exclusively for
HMO members.

HMO - Staff Model A health care model that employs physicians to provide health care to its
members. All premiums and other revenues accrue to the HMO, which
compensates physicians by salary and incentive programs.

Home and Community-Based See “Section 1915(c) Waivers.”


Waivers

Home Health Agency (HHA) A facility or program licensed, certified or otherwise authorized pursuant
to State and Federal laws to provide health care services in the home.

Home Health Services Services and items furnished to an individual who is under the care of a
physician by a home health agency or by others under arrangements made
by such agency. Services are furnished under a plan established and
periodically reviewed by a physician. They are provided on a visiting basis
in an individual’s home and include: nursing, physical therapy, dietary,
counseling, and social services; part-time or intermittent skilled nursing
care; physical, occupational, or speech therapy; medical social services,
medical supplies and appliances (other than drugs and biologicals); home
health aide services; and services of interns and residents.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Hospice A program that provides palliative and supportive care for terminally ill
patients and their families, either directly or on a consulting basis with the
patient's physician or another community agency. Originally a medieval
name for a way station for crusaders where they could be replenished,
refreshed, and cared for, hospice is used here for an organized program of
care for people going through life's "last station." The whole family is
considered the unit of care, and care extends through their period of
mourning.

Indemnity Insurance An insurance program in which the insured person is reimbursed or the
provider is paid for covered expenses after services are rendered.

Innovator Multiple-Source An innovator multiple-source drug is a multiple source drug that was
Drug originally marketed under an original new drug application approved by
the FDA.

Inpatient Hospital Services Items and services furnished to a resident patient of a hospital by the
hospital. May include such items as: bed and board; nursing and related
services; diagnostic and therapeutic services; and medical or surgical
services.

Integrated Behavioral Health A carve-out benefit plan that combines independent managed care services
into what is designed as a seamless delivery system for behavioral health
concerns. Components could include employee assistance services, a
telephone counseling triage, utilization management, behavioral health
treatment networks, claims payment, and data management.

Integrated Delivery System A generic term referring to a joint effort of physician/hospital integration
for a variety of purposes. Some models of integration include physician-
hospital organization, group practice without walls, integrated provider
organization and medical foundation.

Intensive Care Skilled nursing services, usually in a hospital, prescribed by a physician


for individuals with serious medical conditions and delivered with the
guidance of a registered nurse.

Intergovernmental Transfer The transfer of non-Federal public funds from a local government (or
(IGT) locally owned hospital or nursing facility) to the State Medicaid agency, or
from another State agency (or State-owned hospital) to the State Medicaid
agency, usually for the purpose of providing the State share of a Medicaid
expenditure in order to draw down Federal matching funds.

Intermediate Care Facility for The ICF/MR benefit is an optional Medicaid benefit for States. Section
the Mentally Retarded 1905(d) of the Social Security Act created this benefit to fund
(ICF/MR) "institutions" (4 or more beds) for people with mental retardation, and
specifies that these institutions must provide health and/or rehabilitative
services.

International Classification of A listing of diagnoses and identifying codes used by physicians for
Diseases, 9th Edition (Clinical reporting diagnoses of health plan enrollees. The coding and terminology
Modification) (ICD-9-CM) provide a uniform language that can accurately designate primary and
secondary diagnoses and provide for reliable, consistent communications on
claim forms.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Investigational Treatments Medical treatments, including drugs waiting for FDA approval, that are
considered experimental and, therefore, may not be covered by insurance
plans. The definition of experimental currently varies from plan to plan.

Laboratory and Radiological Professional and technical laboratory and radiological services ordered by
Services a licensed practitioner, provided in an office or similar facility (other than
a hospital outpatient department or clinic) or by a qualified lab.

Legend Drug A drug that, by law, can be obtained only by prescription and bears the
label, “Caution: Federal law prohibits dispensing without a prescription.”
See “Prescription Medication.”

Lifetime Maximum Benefit A limitation on financial coverage for health care for an individual stated by
an insurer. This amount serves as a cap on contractual liability and can be
exceeded only in rare and unusual circumstances.

Long-Term Care A set of health care, personal care and social services required by persons
who have lost, or never acquired, some degree of functional capacity (e.g.,
the chronically ill, aged, disabled, or retarded) in an institution or at home,
on a long-term basis. The term is often used more narrowly to refer only to
long-term institutional care such as that provided in nursing homes, homes
for the retarded and mental hospitals. Ambulatory services such home
health care, which can also be provided on a long-term basis, are seen as
alternatives to long-term institutional care.

Magnetic Resonance Imaging State-of-the-art machine used as a diagnostic tool, using magnetic fields to
produce comprehensive pictures of the anatomy.

Managed Care (1) A system of health care delivery that influences utilization and cost of
services and measures performance. The goal is a system that delivers
value by giving people access to high quality, cost-effective health care;
(2) A systemized approach which seeks to ensure the provision of the right
health care at the right time, place and cost.

Managed Care Organization Broad term that encompasses various types of health plans, including
(MCO) Health Maintenance Organizations (HMOs), Preferred Provider
Organizations (PPOs), Point-of-Service plans (POSs) and Provider-
Sponsored Organizations (PSOs). Often used to refer to a health plan that
is similar to an HMO but which does not have an HMO license and serves
only Medicaid beneficiaries.

Mandated Benefits Those benefits which health plans are required by State or Federal law to
provide to policyholders and eligible dependents.

Maximum Allowable Cost, or A fixed maximum cost for which the pharmacist can be reimbursed for
“Reasonable Cost Range” selected products, as identified in a “formulary.”

Maximum Out-of-Pocket Costs The limit on total member copayments, deductibles and coinsurance under a
benefit contract.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Means Testing The policy of basing eligibility for benefits upon an individual’s lack of
means, as measured by his or her income or resources. Means testing, by
definition, requires the disclosure of personal financial information by an
applicant as a condition of eligibility. Medicaid and SCHIP are means
tested programs.
Medicaid A Federally aided State-operated and administered program that provides
medical benefits for certain indigent or low-income persons in need of
health and medical care. The program, authorized by Title XIX of the
Social Security Act, is basically for the poor. It does not cover all of the
poor, however, but only persons who meet specified eligibility criteria.
Subject to broad Federal guidelines, States determine the benefits covered,
program eligibility, rates of payment for providers, and methods of
administering the program. Also referred to as State Medical Assistance
Programs.

Medicaid Buy-In A provision in certain health reform proposals whereby the uninsured
would be allowed to purchase Medicaid coverage by paying premiums on
a sliding scale based on income.

Medicaid Management Federally developed guidelines for a computer system designed to achieve
Information System (MMIS) national standardization of Medicaid claims processing, payment, review
and reporting for all health care claims.

Medicaid-only Managed Care An MCO that provides comprehensive services to Medicaid beneficiaries
Organization (Mcaid-MCO) but not commercial or Medicare enrollees.

Medicaid Statistical The information system developed by CMS to collect detailed data on
Information System (MSIS) eligibility, utilization, and payments for services covered by State Medicaid
programs.

Medical Assistance The term used in the Federal Medicaid statute (Title XIX of the Social
Security Act) to refer to payment for items and services covered under a
State’s Medicaid program.
Medical Care Advisory Committee A committee, consisting of physicians, other health professionals,
(MCAC)
Medicaid beneficiaries, and the director of the public health or welfare
agency, appointed by the Medicaid agency director to participate in policy
development and administration of a State’s Medicaid program.
Medical Necessity
The evaluation of health care services to determine if they are: medically
appropriate and required to meet basic health needs; consistent with the
diagnosis or condition and rendered in a cost-effective manner; and
consistent with national medical practice guidelines regarding type,
frequency and duration of treatment.
Medical Savings Account A non-taxable savings account used to cover medical expenses. Based
(MSA) loosely on the idea of individual retirement accounts.

Medically Needy Under Medicaid, medically needy cases are aged, blind, or disabled
individuals or families and children who are not otherwise eligible for
Medicaid, and whose income resources are above the limits for eligibility
as categorically needy (TANF or SSI) but are within limits set under the
Medicaid State Plan.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Medicare A U.S. health insurance program for people aged 65 and over, for persons
eligible for social security disability payments for two years or longer, and
for certain workers and their dependents who need kidney transplantation
or dialysis. Monies from payroll taxes and premiums from beneficiaries
are deposited in special trust funds for use in meeting the expenses
incurred by the insured. It consists of two separate but coordinated
programs: hospital insurance (Part A) and supplementary medical
insurance (Part B). Recent legislation has expanded the Medicare program
to include an HMO option (Part C) and a prescription drug benefit (Part
D). See “Medicare Prescription Drug, Improvement and Modernization
Act of 2003.”

Medicare Beneficiary A person designated by the Social Security Administration as entitled to


receive Medicare benefits.

Medicare Payment Advisory A Federal commission established under the Balanced Budget Act of 1997
Commission (MedPAC) to advise and assist Congress and the Department of Health and Human
Services in maintaining and updating the Medicare prospective payment
system. MedPAC replaces and assumes the responsibilities of the
Physician Payment Review Commission (PPRC) and the Prospective
Payment Assessment Commission (ProPAC).
Medicare Prescription Drug, The Medicare Prescription Drug, Improvement, and Modernization Act
Improvement, and (Public Law 108-173), also known as the Medicare Modernization Act
Modernization Act of 2003 (MMA) was enacted December 8, 2003. It enacted the Prescription Drug
(MMA) Program (Medicare Part D) effective January 2006, under which Medicare
will assume responsibility for the prescription drug needs of beneficiaries
eligible for both Medicare and Medicaid. It also enacted the temporary
Medicare Prescription Drug Discount Card Program, effective June 2004-
December 2005. Many other amendments to the Medicare and Medicaid
programs were also enacted, including coverage of an initial preventive
physical examination, cardiovascular screening blood tests, and diabetes
screening tests. Health Savings Accounts were also authorized. Medicare
payment limits were established for certain hospital outpatient
departments.
Medicare Supplemental
Insurance A policy guaranteeing that a health plan will pay a policyholder’s
coinsurance, deductible and copayments and will provide additional health
plan or non-Medicare coverage for services up to a predefined benefit
limit. In essence, the product pays for the portion of the cost of services
not covered by Medicare. Also called “Medigap” or “Medicare wrap.”
Medigap (Medicare See “Medicare Supplemental Insurance.”
Supplemental Insurance)
Members A participant in a health plan (member or eligible dependent). Also used to
describe an individual specified within a subscriber contract that may
receive health care services according to the terms of the subscriber
policy. Also known as "beneficiary," "enrollee," "subscriber," or
"insured."

Modified Fee-for-Service A system in which providers are paid on a fee-for-service basis, with certain
fee maximums for each procedure.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Most Favored Nations Discount A contractual agreement that stipulates that a vendor must provide to a
or Clause particular payor the lowest prices that would be available to any purchaser.
The Federal government often invokes most favored nation clauses for
health care contracts.

Multiple-Source Drug A multiple-source drug is one that is marketed or sold by two or more
manufacturers or labelers, or a drug marketed or sold by the same
manufacturer or labeler under two or more different proprietary names or
under a proprietary name and without such a name.

National Committee for Quality A national organization founded in 1979 composed of 14 directors
Assurance (NCQA) representing consumers, purchasers, and providers of managed health care.
It accredits quality assurance programs in prepaid managed health care
organizations, and develops and coordinates programs for assessing the
quality of care and service in the managed care industry, including the
HEDIS quality measures.

National Drug Code (NDC) A national classification system for identification of drugs. Similar to the
Universal Product Code (UPC).

Network Plan A phrase that generally refers to arrangements where providers contract
with payers or a managed care plan to provide services for patients
enrolled in the managed care plan. See “Managed Care.”

Nurse-Midwife Services Nurse-midwife services are those concerned with the management of care
of mothers and newborns throughout the maternity cycle. OBRA 1980
required that payment be made for providing nurse-midwife services to
categorically needy recipients to the extent that the nurse-midwife is
authorized to practice under State law or regulation. States are also
required to offer direct reimbursement to nurse-midwives as one of the
payment options. Nurse-midwives must be registered nurses who are either
certified by an organization recognized by the Secretary of HHS or who
have completed a program of study and clinical experience that has been
approved by the Secretary.

Nursing Facility (NF) A facility in either freestanding or part of a hospital, that accepts patients
in need of rehabilitation and medical care that is of a lesser intensity than
that received in a hospital.

Nursing Facility Services All services furnished to inpatients of, and billed for by, a formally
certified nursing facility that meets standards set by Secretary of DHHS.

Other Practitioners’ Services Health care services of licensed practitioners other than physicians and
dentists.

Out-of-Pocket Costs/Expenses The portion of payments for health services required to be paid by the
(OOPs) enrollee, including copayments, coinsurance and deductibles.

Out-of-Pocket Limit The total payments toward eligible expenses that a covered person funds for
him/herself and/or dependents: i.e., deductibles, copays and coinsurance -
as defined per the contract. Once this limit is reached, benefits will increase
to 100% for health services received during the rest of that calendar year.
Some out-of-pocket costs (e.g., mental health, penalties for non-
precertification, etc.) are not eligible for out-of-pocket limits.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Outcome Measures Assessments which gauge the effect or results of treatment for a particular
disease or condition. Outcome measures include such parameters as: the
patient’s perception of restoration of function, quality of life and functional
status, as well as objective measures of mortality, morbidity and health
status.

Outcomes Management Systematically improving health care results, typically by modifying


practices in response to data gleaned through outcomes measurement, then
remeasuring and remodifying - often in a formal program of continuous
quality improvement.

Outcomes Research Studies aimed at measuring the effect of a given product, procedure, or
medical technology on health or costs.

Outlier An observation in a distribution that is outside a certain range, often defined


as two or three standard deviations from the mean or exceeding a specific
percentile. Frequently refers to a case or hospital stay that is unusually long
or expensive for its type, or to a physician practice that uses an abnormally
high or low volume of resources.

Outpatient Services Outpatient services are medical and other services provided on a non-
resident basis (patients are not admitted to the facility) by a hospital or
other qualified facility, such as a mental health clinic, rural health clinic,
mobile X-ray unit, or freestanding dialysis unit. Such services include
outpatient physical therapy services, diagnostic X-ray and laboratory tests,
and X-ray and other radiation therapy.

Over-the-Counter (OTC) A drug product that does not require a prescription under Federal or State
law.

Participating Provider A provider who has contracted with the health plan to provide medical
services to covered persons. The provider may be a hospital, pharmacy,
other facility or a physician who has contractually accepted the terms and
conditions as set forth by the health plan.

Patient Health Status Survey Questionnaire used to solicit patient perceptions regarding the state of their
health. Questions may be general and address overall health status with
regard to a specific condition (e.g., an arthritic patient’s ability to make a
fist or an asthmatic patient’s ability to climb a flight of stairs).

Patient Satisfaction Survey Questionnaire used to solicit the perceptions the plan enrollees or patients
have regarding how a health plan meets their medical needs and how the
delivery of care is handled, (e.g., waiting time, access to treatments).

Payer A general term indicating the responsible party for the payment of medical
care service expenses. Payers may be patients, insurance companies,
government agencies, or a combination of these.
Pediatric Nurse Practitioner Services furnished as authorized under State law by a registered
and Family Nurse Practitioner professional nurse who meets a State’s advanced educational and clinical
Services practice requirements, whether or not the practitioner is under the
supervision of or associated with a physician or other health care provider.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Peer Review The evaluation of quality of total health care provided, by medical staff
with equivalent training.

Peer Review Organization An entity established by the Tax Equity and Fiscal Responsibility Act of
(PRO) 1982 (TERFA) to review quality of care and appropriateness of
admissions, readmissions and discharges for Medicare and Medicaid.
These organizations are held responsible for maintaining and lowering
admission rates, and reducing lengths of stay while insuring against
inadequate treatment. Also known as “Professional Standards Review
Organization.”

Personal Support Services Personal support services consist of a variety of services including personal
care, targeted case management, home and community-based care for
functionally disabled elderly, rehabilitative services, hospice services, and
nurse-midwife, nurse practitioner, and private duty nursing services.

Pharmacy And Therapeutics An organized panel of physicians and pharmacists from varying practice
(P&T) Committee specialties, who function as an advisory panel to the plan regarding the safe
and effective use of prescription medications. Often comprises the official
organizational line of communication between the medical and pharmacy
components of the health plan. A major function of such a committee is to
develop, manage and administer a drug formulary.

Pharmaceutical Benefits An entity that is responsible for managing prescription benefits.


Manager (PBM)

Physician Any doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who is duly
licensed and qualified under the law of jurisdiction in which treatment is
received.

Physician-Hospital A legal entity formed by a hospital and a group of physicians to further


Organization (PHO) mutual interests and to achieve market objectives. A PHO generally
combines physicians and a hospital into a single organization for the
purpose of obtaining payer contracts. Doctors maintain ownership of their
practices and agree to accept managed care patients according to the terms
of a professional service agreement with the PHO. The PHO serves as a
collective negotiating and contracting unit. It is typically owned and
governed jointly by a hospital and shareholder physicians.

Point-Of-Service (POS) Plan A health plan allowing the covered person to choose to receive a service
from a participating or non-participating provider, with different benefit
levels associated with the use of participating providers. POS can be
provided in several ways: an HMO may allow members to obtain limited
services from non-participating providers; an HMO may provide non-
participating benefits through a supplemental major medical policy; a PPO
may be used to provide both participating and non-participating levels of
coverage and access; or various combinations of the above may be used.

Portability Requirement that health plans guarantee continuous coverage without


waiting periods for persons moving between plans.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Practice Guideline Systematically developed statements on medical practice that assist a


practitioner and a patient in making decisions about appropriate health care
for specific medical conditions. Managed care organizations frequently
use these guidelines to evaluate appropriateness and medical necessity of
care. Terms used synonymously include practice parameters, standard
treatment protocols and clinical practice guidelines.

Practice Parameters See “Practice Guidelines.”

Practice Variation An assessment of the patterns of a practitioner’s practice to determine if


the provider’s care is significantly different from others with similar
practices. If there is a significant difference, the practitioner’s practice is
analyzed to determine the reasons for the variation and whether that
practitioner’s practice patterns should be modified.

Pre-Certification Review See “Utilization Review.”

Pre-Existing Condition (PEC) Any medical condition that has been diagnosed or treated within a
specified period immediately preceding the covered person’s effective date
of coverage under the master group contract.

Preferred Provider A program in which contracts are established with providers of medical
Organization (PPO) care. Providers under such contracts are referred to as preferred providers.
Usually, the benefit contract provides significantly better benefits (fewer
copayments) for services received from preferred providers, thus
encouraging covered persons to use these providers. Covered persons are
generally allowed benefits for non-participating providers’ services,
usually on an indemnity basis with significantly higher copayments. A
PPO arrangement can be insured or self-funded. Providers may be, but are
not necessarily, paid on a discounted fee-for-service basis.

Prepaid Group Practice Plans Organized medical groups of essentially full-time physicians in
appropriate specialties, as well as other professional and subprofessional
personnel, who, for regular compensation, undertake to provide
comprehensive care to an enrolled population for premium payments that
are made in advance by the consumer and/or their employers.

Prepaid Health Plan (PHP) An entity that provides a non-comprehensive set of services on either
capitated risk or non-risk basis or the entity provides comprehensive
services on a non-risk basis.

Prescribed Drugs Prescribed drugs are drugs dispensed by a licensed pharmacist on the
prescription of a practitioner licensed by law to administer such drugs, and
drugs dispensed by a licensed practitioner to his own patients. This item
does not include a practitioner’s drug charges that are not separable from
his other charges, or drugs covered by a hospital bill.

Prescription Medication A drug which has been approved by the Food and Drug Administration and
which can, under Federal and State law, be dispensed only pursuant to a
prescription order from a duly licensed prescriber, usually a physician.

Preventive Care Comprehensive care emphasizing priorities for prevention, early detection
and early treatment of conditions, generally including routine physical
examinations, immunization and well person care.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Primary Care Basic or general health care traditionally provided by family practice,
pediatrics and internal medicine. See also “Secondary Care.”

Primary Care Case Managed care arrangements where primary care providers receive a per
Management (PCCM) capita management fee to coordinate a patient's care in addition to
reimbursement (fee-for-service or capitation) for the medical services they
provide.

Primary Care Physician (PCP) The primary care practitioner (e.g., internist, family/general practitioner,
pediatrician, and in some cases, OB/Gyn) in managed care organizations
who determines whether the presenting patient needs to see a specialist or
requires other non-routine services. See Care Coordinator.

Prior Authorization The process of obtaining prior approval as to the appropriateness of a


service or medication. Prior authorization does not guarantee coverage.

Prospective Financing Financing for health care services based on prices or budgets determined
prior to the delivery of service. Payments can be per unit of service, per
member, or per time period. In all its forms prospective financing differs
from cost-based reimbursement, under which a provider is paid for costs
incurred.

Protocol See “Practice Guidelines.”

Provider Network See “Network Plan.”

Providers A physician, hospital, group practice, nurse, nursing home, pharmacy or


any individual or group of individuals that provides a health care service.

Qualified Medicare Beneficiary An individual who qualifies for Medicare Part A, whose income does not
(QMB) exceed 100 percent of the Federal poverty level, and whose resources do
not exceed twice the SSI resource-eligibility standard. Medicaid coverage
of QMBs is limited to payments of their Medicare cost-sharing charges,
such as Medicare premiums, coinsurance, and copayment amounts.

Quality Assurance (QA) or A formal set of activities to review and affect the quality of services
Quality Improvement (QI) provided. Quality assurance includes assessment and corrective actions to
remedy any deficiencies identified in the quality of direct patient,
administrative and support services.

Rate Setting A form of financing under which hospitals or nursing homes are paid
prices that are prospectively determined, generally by a State agency.
Prospectively determined prices may be paid by all payers for all covered
services, as in all payer systems, or by only some payers. The unit of
payment can be service, patient, or time period. See “Prospective
Financing.”

Rational Drug Therapy Prescribing the right drug for the right patient, at the right time, in the right
amount, and with due consideration of relative cost.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Reasonable Charge In processing claims for Supplementary Medical Insurance benefits,


carriers use CMS guidelines to establish the reasonable charge for services
rendered. The reasonable charge is the lowest of: the actual charge billed
by the physician or supplier; the charge the physician or supplier
customarily bills his patients for the same services, and the prevailing
charge which most physicians or suppliers in that locality bill for the same
service. Increases in the physicians’ prevailing charge levels are
recognized only to the extent justified by an index reflecting changes in
the costs of practice and in general earnings.

Reasonable Cost In processing claims for health insurance benefits, intermediaries use CMS
guidelines to determine the reasonable cost incurred by the individual
providers in furnishing covered services to enrollees. The reasonable cost
is based on the actual cost of providing such services, including direct and
indirect costs of providers, excluding any costs that are unnecessary in the
efficient delivery of services covered by the insurance program.

Rebate A monetary amount that is returned to a payer from a prescription drug


manufacturer based upon utilization by a covered person or purchases by a
provider.

Recipient A recipient of Medicaid is an individual who has been determined to be


eligible for Medicaid and who has used medical services covered under
Medicaid.

Referral The process of sending a patient from one practitioner to another for health
care services. Health plans may require that designated primary care
providers authorize a referral for coverage of specialty services.

Restrictive Formulary A term often used synonymously with closed formulary. See “Drug
Formulary.”

Retrospective Review Determination of medical necessity and/or appropriate billing practice for
services already rendered.

Risk Responsibility for paying for or otherwise providing a level of health care
services based on an unpredictable need for these services.

Risk Contract (1) An agreement between a State Medicaid program and an HMO or
competitive medical plan requiring the HMO to furnish at a minimum all
Medicaid covered services to Medicaid eligible enrollees for an annually
determined, fixed monthly payment rate from the State government. The
HMO is then liable for services regardless of their extent, expense or
degree. (2) An agreement between a provider and payer, or intermediary,
on behalf of a payer, that requires the provider to furnish all specified
services for a specified enrollee for a set fee, usually prepaid, and for a set
period of time (usually one year). The provider is then liable for services
regardless of their extent, expense or degree. Such stated limitations for
such liability are stated in advance and may be subject to reinsurance.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Rural Health Clinic A rural health clinic is an outpatient facility which is primarily engaged in
furnishing physician and other medical and health services, which meets
certain other requirements designed to ensure the health and safety of the
individuals served by the clinic. The clinic must be located in an area that
is not urbanized as defined by the Census Bureau and that is designated by
the Secretary of DHHS either as an area with a shortage of personal health
services, or as a health manpower shortage area, and has filed an
agreement with the Secretary not to charge any individual or other person
for items or services for which such individual is entitled to have payment
made by Medicare, except for the amount of any deductible or coinsurance
amount applicable.

Secondary Care Services provided by medical specialists, such as cardiologists, urologists


and dermatologists, who generally do not have first contact with patients.
See also “Primary Care.”

Section 1115 Waivers Section 1115 of the Social Security Act grants the Secretary of Health and
Human Services broad authority to waive certain laws relating to Medicaid
for the purpose of conducting pilot, experimental or demonstration
projects. Section 1115 demonstration waivers allow States to change
provisions of their Medicaid programs, including: eligibility requirements,
the scope of services available, the freedom to choose a provider, a
provider’s choice to participate in a plan, the method of reimbursing
providers, and the statewide application of the program. Projects typically
run three to five years.
Section 1915(b) of the Social Security Act authorizes the Secretary of
Section 1915(b) Waivers
Health and Human Services to waive compliance with certain portions of
the Medicaid statute that prevent a State from mandating Medicaid
beneficiaries obtain their care from a single provider or health plan.
Section 1915(b) waivers allow States to operate mandatory managed care
programs in all or portions of the State while continuing to receive Federal
Medicaid matching funds. Waivers must be approved by the Centers for
Medicare & Medicaid Services (CMS).
Section 1915(c) Waivers Section 1915(c) of the Social Security Act authorizes the Secretary of
Health and Human Services to allow State Medicaid programs to offer
special services to beneficiaries at risk of institutionalization in a nursing
facility or facility for the mentally retarded. These services, which would
otherwise not qualify for Federal matching funds, include case
management, homemaker/home health aide services, rehabilitation
services, and respite care. They also include, in the case of individuals,
with chronic mental illness, day treatment and partial hospitalization,
psychosocial rehabilitation, and clinic services. Also know as home and
community-based (HCBS) waivers.

Self-Referral Restrictions Restrictions on or prohibitions against providers referring patients to a


designated health service (e.g., pharmacies, clinical laboratories, and
outpatient surgery) in which the provider or the provider’s immediate
family member has a financial interest.

Sin Taxes Taxes imposed on items considered harmful to public health interests, such
as tobacco and alcohol.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Single-Source Drug A single-source drug is a covered outpatient drug which is produced or


distributed under an original new drug application approved by the FDA,
including a drug product marketed by any cross-licensed producers or
distributors operating under the new drug application.
Single State Agency The agency within State government designated as responsible for
administration of the State Medicaid Plan. The Single State Agency is not
required to administer the entire Medicaid program. It may delegate
certain functions or supervise other State agencies, private contractors, or
both.

Skilled Nursing Facility (SNF) See “Nursing Facility.”

Specified Low-Income These individuals are entitled to Medicare Part A, have income of greater
Medicare Beneficiary (SLMB) than 100% FPL, but less than 120% FPL and resources that do not exceed
Program twice the limit for SSI eligibility, and are not otherwise eligible for
Medicaid as a dual eligible. Medicaid pays their Medicare Part B
premiums only, but they are not eligible for Medicaid payment for their
Medicare cost-sharing obligations.

Spend-Down Under Medicaid, “spend-down” refers to a method by which an individual


establishes Medicaid eligibility by reducing gross income through
incurring medical expenses until net income (after medical expenses)
meets Medicaid financial requirements.

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.

State Medical Assistance See “ Medicaid.”


Programs

State Pharmacy Assistant State authorized programs to provide pharmaceutical coverage or


Programs assistance to low-income and/or persons with disabilities who do not
qualify for Medicaid. Also known as Expanded Drug Benefit Programs.

State Plan The Medicaid State Plan is a comprehensive written commitment by a


Medicaid agency to administer or supervise the administration of a
Medicaid program in accordance with Federal requirements.

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

State Plan Amendment A State that wishes to change its Medicaid eligibility criteria or its covered
benefits or its provider reimbursement rates must amend its State Medicaid
Plan to reflect the proposed change. The State must submit the State Plan
Amendment to CMS for approval.
Stop Loss
That point at which a third party has reinsurance to protect against the
overly large single claim or the excessively high aggregate claim during a
given period of time. Large employers, who are self-insured, may also
purchase “reinsurance” for stop-loss purposes.

Supplemental Security Income A Federal cash assistance program for low-income aged, blind and
(SSI) disabled individuals established by Title XVI of the Social Security Act.
States may use SSI income limits to establish Medicaid eligibility.

Tax Equity and Fiscal The Federal law which created the current risk and cost contract provisions
Responsibility Act of 1982 under which health plans contract with CMS and which defined the primary
(TEFRA) and secondary coverage responsibilities of the Medicare program.

Temporary Assistance to Needy Federal-State welfare program which replaces Aid to Families with
Families (TANF) Dependent Children. Authorized by the 1996 Welfare Reform Act. States
may use TANF to establish Medicaid eligibility.

Therapeutic Alternatives Drug products containing different chemical entities but which should
provide similar treatment effects, the same pharmacological action or
chemical effect when administered to patients in therapeutically equivalent
doses.

Therapeutic Substitution Dispensing by a pharmacist of a product different from that which was
prescribed, but which is deemed to be therapeutically equivalent. In most
States such a practice requires the prescribing physician’s authorization
before the substitution may occur. A pharmacy and therapeutics committee
(P&T) most often approves the rationale for therapeutic equivalency prior
to such practice.

Third-Party Administrator An independent person or corporate entity (third party) that administers
(TPA) group benefits, claims and administration for a self-insured company/group.
A TPA does not underwrite the risk.

Third-Party Liability Under Medicaid, third-party liability exists if there is any entity (i.e., other
government programs or insurance) which is or may be liable to pay all or
part of the medical cost or injury, disease, or disability of an applicant or
recipient of Medicaid.

Total Quality Management See “Continuous Quality Improvement.”


(TQM)

Title XIX See “ Medicaid.”

Universal Access The availability of affordable public or private insurance coverage for
every United States citizen or legal resident. There is no guarantee,
however, that all individuals will actually choose to purchase or have the
funds to purchase coverage. See “Universal Coverage.”

Universal Coverage The guaranteed provision of at least basic health care services to every
United States citizen or legal resident. See “Universal Access.”

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National Pharmaceutical Council Pharmaceutical Benefits 2004

Term Definition

Usual, Customary and A term used to refer to the commonly charged or prevailing fees for health
Reasonable Charges services within a geographic area. A fee is considered to be reasonable if
it falls within the parameters of the average or commonly charged fee for
the particular service within that specific community.

Utilization The extent to which the members of a covered group use a program or
obtain a particular service, or category of procedures, over a given period of
time. Usually expressed as the number of services used per year or per 100
or 1,000 persons eligible for the service.

Utilization Management (UM) A process of integrating review and case management of services in a
cooperative effort with other parties, including patients, providers, and
payers.

Utilization Review A formal assessment of the medical necessity, efficiency, and/or


appropriateness of health care services and treatment plans on a
prospective, concurrent or retrospective basis.

Vaccines for Children Program A program under which the Federal government, through the Centers for
(VCF) Disease Control and Prevention, purchases and distributes pediatric
vaccines to States at no charge and the State, in turn, arranges for the
immunization of Medicaid-eligible and uninsured children through public
and private physicians or other authorized providers.

Vendor A medical vendor is an institution, agency, organization, or individual


practitioner that provides health or medical products and/or services either
to a medical provider, who in turn interfaces with patients, or directly to
the public.

Vendor Payments In welfare programs, direct payments are made by the State to providers
such as physicians, pharmacists and health care institutions rather than to
the welfare recipient himself.

Waiver A rider or clause in a health insurance contract excluding an insurer’s


liability for some sort of pre-existing illness or injury. Also refers to a plan
amendment, such as a CMS waiver or State Plan modification.

Withhold “At-risk” portion of a claim deducted and withheld by the health plan
before payment is made to a participating physician as an incentive for
appropriate utilization and quality of care. This amount – for example,
20% of the claim – remains within the plan and is credited to the doctor’s
account. Can be used where the plan needs additional funds to pay for
claims. The withhold may be returned to the physician in varying levels
which are determined based on analysis of his/her performance or
productivity compared against his/her peers. Also called “physician
contingency reserve (PCR).”

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National Pharmaceutical Council Pharmaceutical Benefits 2004

ACRONYMS

AABD Aid to Aged, Blind, and Disabled


AAC Actual Acquisition Cost
AHRQ Agency for Health Research and Quality
AIDS Acquired Immune Deficiency Syndrome
AMP Average Manufacturer Price
ANSI American National Standards Institute
ARF Area Resource File
ASO Administrative Services Only
AWP Any Willing Provider or Average Wholesale Price
BBA Balanced Budget Act of 1997
BIPA Benefits Improvement and Protection Act
BLS Bureau of Labor Statistics
CHIP See SCHIP
CFR Code of Federal Regulations
CMP Competitive Medical Plan
CMS Centers for Medicare and Medicaid Services (formerly HCFA)
CMSO CMS’ Center for Medicaid and State Operations
CNAB Categorically Needy Aid to the Blind
CNAFDC Categorically Needy Aid to Families with Dependent Children
CNAPTD Categorically Needy Aid to the Permanently and Totally Disabled
CNOAA Categorically Needy Old Age Assistance
COBRA Consolidated Omnibus Reconciliation Act of 1985
COM-MCO Commercial Managed Care Organization
CON Certificate of Need
CPI Consumer Price Index
CPR Customary Prevailing, and Reasonable (charges)
CPT Current Procedural Terminology
CQI Continuous Quality Improvement
DAW Dispense As Written
DBA Doing Business As
DEFRA Deficit Reduction Act of 1984
DESI Drug Efficacy Study and Implementation
DHHS Department of Health and Human Services
DRGs Diagnostic Related Groupings
DSH Disproportionate Share Hospital
DUE Drug Use Evaluation
DUR Drug Utilization Review
EAC Estimated Acquisition Cost
EDI Electronic Data Interchange

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National Pharmaceutical Council Pharmaceutical Benefits 2004

EPSDT Early and Periodic Screening, Diagnostic and Treatment


ERISA Employee Retirement Income Security Act
ESRD End Stage Renal Disease
FDA Food and Drug Administration
FFP Federal Financial Participation
FFS Fee-for-Service
FMAP Federal Medical Assistance Percentage
FOC Freedom of Choice
FPL Federal Poverty Level
FQHC Federally Qualified Health Center
FUL Federal Upper Limits
FY Fiscal Year
HCFA Health Care Financing Administration (see CMS)
HCPCS HCFA Common Procedural Coding System
HCPP Health Care Prepayment Plan
HEDIS Health Plan Employer Data and Information Set
HH Home Health
HIFA Health Insurance Flexibility and Accountability
HIO Health Insuring Organizations
HIPAA Health Insurance Portability and Accountability Act
HMO Health Maintenance Organization
HRSA Health Resources and Services Administration
ICF-MR Intermediate Care Facility for the Mentally Retarded
IGT Intergovernmental Transfer
IPA Individual Practice Association
MAC Maximum Allowable Cost
MAIC Maximum Allowable Ingredient Cost
MCAC Medical Care Advisory Committee
MCAID-MCO Medicaid-only Managed Care Organization
MCO Managed Care Organization
Medicare Prescription Drug, Improvement and Modernization Act of
MMA
2003
MMIS Medicaid Management Information System
MNAB Medically Needy Aid to the Blind
MNAFDC Medically Needy Aid to Families with Dependent Children
MNAPTD Medically Needy Aid to the Permanently and Totally Disabled
MNOAA Medically Needy Old Age Assistance
MQC Medicaid Quality Control
MSA Medical Savings Account
MSIS Medicaid Statistical Information System
NDC National Drug Code
NF Nursing Facility

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National Pharmaceutical Council Pharmaceutical Benefits 2004

NP Nurse Practitioner
OACT Office of the Actuary
OASDI Old Age, Survivors, and Disability Insurance
OBRA Omnibus Budget Reconciliation Act
OHS Outpatient Hospital Services
OMB Office of Management and Budget
ORD Office of Research and Demonstrations
OT Occupational Therapy
OTC Over-the-Counter (drugs)
P&T Pharmacy and Therapeutics Committee
PA Physician’s Assistant or Prior Authorization
PBM Pharmaceutical Benefits Manager
PCCM Primary Care Case Management
PCF Program Characteristics File
PCP Primary Care Physician
PHP Prepaid Health Plan
PMPM Per Member Per Month
PHO Physician-Hospital Organization
POS Point-of-Service
PPO Preferred Provider Organization
PRO Peer Review Organization
ProPAC Prospective Payment Assessment Commission
PT Physical Therapy
QA/QI Quality Assurance/Quality Improvement
QMB Qualified Medicare Beneficiary
RHC Rural Health Clinic
RPH Registered Pharmacist
Rx Pharmaceutical
SCHIP State Children’s Health Insurance Program
SFO State Funds Only
SLMB Specified Low-Income Medicare Beneficiary
SSA Social Security Administration
SSI Supplemental Security Income
SSP State Supplemental Payments
TANF Temporary Assistance for Needy Families
TDOC Total Days of Care
TEFRA Tax Equity & Fiscal Responsibility Act
Title XIX Title XIX of The Social Security Act (See Medicaid)
TPA Third-Party Administrator
TQM Total Quality Management
UCR Usual, Customary and Reasonable
UM Utilization Management

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UR Utilization Review
VCF Vaccines for Children Program
WAC Weighted Average Cost or Wholesale Acquisition Cost

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