Pharmaceutical Benefits Under State Medical Assistance Programs, 2000

Pharmaceutical Benefits
under State Medical Assistance

Programs
2000
Published by the
National Pharmaceutical Council, Inc.
1894 Preston White Drive
Reston, VA 20191-5433
©2000 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 The Lewin Group, Falls Church, Virginia. 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 Health
Care Financing Administration (HCFA) and other organizations.
The data were compiled and the book prepared for publication by Catherine
Harrington, Dawn Bartoszewicz, Corinna Sorenson, Haejin Chung and Sheela
Raju of The Lewin Group; and Kimberly Dietrich of the National
Pharmaceutical Council.
Pharmaceutical Benefits 2000
INTRODUCTION
The year 2000 edition of Pharmaceutical Benefits under State Medical

Assistance Programs marks the 35th year that the National Pharmaceutical
Council (NPC) has published this unique source of information on pharmacy
programs within the State Medical Assistance Programs (Title XIX). Over the
years, this “Medicaid Compilation” of statistics has become a standard reference
in government offices, research libraries, consultancies, and numerous
corporations.
The “Medicaid Compilation” incorporates information on each State pharmacy

program from an annual NPC survey of State Medicaid program administrators
and pharmacy consultants and statistics from the Health Care Financing
Administration (HCFA). A main data source of the compilation, the HCFA-
2082, is an annual report providing State-reported data on Medicaid population
characteristics and utilization during a Federal fiscal year.
Historically, states summarized and reported 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 where states
participating in the MSIS project provided data tapes from their claims
processing systems to HCFA in lieu of the 2082 tables. In accordance with the
Balanced Budget Act of 1997, all claims processed on or after January 1, 1999,
had to be submitted electronically in the MSIS format. This new requirement
has caused some states to have difficulty providing data to HCFA within the
normal timeframe, which has resulted in a delay in the release of the HCFA-
2082 report for fiscal year 1999.
Because of this delay, the NPC is presenting this preliminary draft of the
“Medicaid Compilation, 2000” in Adobe Portable Document Format (PDF).
This preliminary draft contains the latest information provided by State
Medicaid program administrators and pharmacy consultants for Federal fiscal
year 1999, however, it still contains Medicaid population characteristics and
utilization based on the 1998 HCFA-2082 report. Once the HCFA-2082 report
for fiscal year 1999 is released by HCFA, the NPC and The Lewin Group will
update the information and make the full printed edition of the book available.
In order to give a better understanding of the content of the “Medicaid

Compilation,” the information contained in this version of the book is
summarized below by section:
• Section 1: Reports on the trends in of Medicaid expenditures over the last

decade (through 1999, the last year data are available) and highlights
differences between Medicaid and national spending.
• Section 2: Contains details about Medicaid Managed Care enrollment as of

June 30, 1999, including a breakdown by plan type and enrollment by plan
type.
National Pharmaceutical Council iii

• Section 3: Consists of sociodemographic statistics, by age, race, insurance,

income, and employment, for the fifty states and the District of Columbia for
the calendar year 1999. Additionally, a description of the Medicaid certified
facilities in each state, including the number of hospitals, skilled nursing
facilities, and ICF-MR facilities, home health agencies, and rural health
clinics are presented.
• Section 4: Provides Medicaid pharmacy program characteristics, drawn

largely from the 2000 NPC annual survey of State pharmacy program
administrators. In addition, this section provides Medicaid statistics from
the Health Care Financing Administration for fiscal year 1998 (the last year
data are available). Medicaid pharmacy programs are characterized by
estimates of total payments and recipients, drug payments and recipients,
drug benefit design, and pharmacy payment and patient cost sharing.
• Section 5: Profiles the 20 states that are providing pharmaceutical coverage

for the elderly, as of December 31, 2000.
• Section 6: 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.
The book also contains a series of appendixes. Appendix A features a list of

State contacts, HCFA regional offices and Medicaid bureau personnel.
Appendix B provides HCFA statistics on Medicaid eligibles, recipients, and
payments (FY 1998 HCFA-2082 data). Appendix C provides the current
Medicaid drug rebate law. Appendix D contains the list of HCFA upper limits
on multiple source products. Appendix E is a glossary and list of acronyms and
Appendix F lists an index for keywords.
NPC gratefully acknowledges the cooperation and assistance of the many state
and federal program officials and their staffs, and The Lewin Group for
administering the survey 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
iv National Pharmaceutical Council

TABLE OF CONTENTS
INTRODUCTION....................................................................................................................................iii
SECTION 1: EXPENDITURE TRENDS IN MEDICAID.................................................................1-1
SECTION 2: MEDICAID MANAGED CARE ...................................................................................2-1
Medicaid Managed Care Enrollment.......................................................................................2-3
Medicaid Managed Care Waivers ..........................................................................................2-11
SECTION 3: STATE CHARACTERISTICS .....................................................................................3-1
Sociodemographics
− Age Demographics .....................................................................................................3-3
− Race Demographics....................................................................................................3-4
− Insurance Status..........................................................................................................3-5
− Income and Employment............................................................................................3-6
Health Care Delivery System
− Medicaid/Medicare Certified Facilities......................................................................3-7
− Licensed Pharmacies ..................................................................................................3-8
− Physicians.................................................................................................................3-10
− Other Providers ........................................................................................................3-11
SECTION 4: PHARMACY PROGRAM CHARACTERISTICS.....................................................4-1
The Medicaid Program..............................................................................................................4-3

− Total U.S. Medical Assistance Recipients ...............................................................4-10
− Total U.S. Medical Assistance Payments.................................................................4-11
− Federal Medical Assistance Percentages..................................................................4-12
− Medicaid Payments and Recipients..........................................................................4-13
Medicaid Drug Program..........................................................................................................4-15

− Drug Payments and Recipients.................................................................................4-27
− Drug Payment Trends...............................................................................................4-28
− Drug Payment – Percent Change from 1997 to 1998...............................................4-19
− Ranking Based on Drug Payments ...........................................................................4-20
− Drugs as a Percentage of Total Vendor Payments ...................................................4-21
− Drugs as a Percentage of Total Vendor Payments, Trends ......................................4-22
− Share of Drug Payments, Top 5 Therapeutic Categories .........................................4-23
− Total Drug Recipients ..............................................................................................4-24
− Drug Payments Per Recipient...................................................................................4-25
National Pharmaceutical Council i

− Medicaid Drug Reimbursement Report ...................................................................4-26
Medicaid Drug Rebates ...........................................................................................................4-27

− Medicaid Drug Rebates ............................................................................................4-28
− Medicaid Drug Rebate Trends .................................................................................4-29
Medicaid Drug Coverage.........................................................................................................4-31

− Pharmacy Advisory Committees..............................................................................4-33
− Pharmacy Benefit Design – Coverage......................................................................4-34
− Coverage of Injectables ............................................................................................4-37
− Coverage of Vaccines and Unit Dose.......................................................................4-38
− Coverage of Over-the-Counter Medications ............................................................4-39
− Prior Authorization Process and Procedures ............................................................4-41
− Prior Authorization...................................................................................................4-44
− Drug Utilization Review ..........................................................................................4-47
− Prescribing and Dispensing Limits...........................................................................4-48
Pharmacy Payment and Patient Cost Sharing ......................................................................4-49

− Pharmacy Payment and Patient Cost Sharing ..........................................................4-51
− Maximum Allowable Cost Programs.......................................................................4-52
− Mandatory Substitution ............................................................................................4-53
− Counseling Requirements and Payment for Cognitive Services..............................4-54
− Prescription Price Updating .....................................................................................4-55
SECTION 5: EXPANDED DRUG COVERAGE FOR THE ELDERLY ........................................5-1
SECTION 6: STATE PROFILES ........................................................................................................6-1
APPENDIXES
Appendix A: State and Federal Medicaid Contacts .................................................................... A-1
Appendix B: Medicaid Program Statistics – HCFA-2082 Report .............................................. B-1
Appendix C: Medicaid Rebate Law ............................................................................................ C-1
Appendix D: HCFA Upper Limits for Multiple Source Products............................................... D-1
Appendix E: Glossary ................................................................................................................. E-1
ii National Pharmaceutical Council

Section 1:
Expenditure Trends
in Medicaid
National Pharmaceutical Council 1-1

1-2 National Pharmaceutical Council

EXPENDITURE TRENDS IN MEDICAID
Medicaid programs account for a significant portion of all health care expenditures in the United States.
In 1999, Medicaid expenditures totaled $187.0 billion, which is 15.4% of national health care
expenditures.1 Managing a Medicaid budget requires an understanding of the forces that influence
trends in spending including changes in policy at both the state and federal levels. Changes in policy
impact important factors that drive total expense including population size and demographic mix, prices,
managed care penetration, and supply of services (i.e., number of providers). This section focuses on
understanding the trends in of Medicaid expenditures over the last decade (through 1999, the last year
data are available) and highlighting differences between Medicaid and national spending.
SPENDING TRENDS
Overall, Medicaid expenditures have more than doubled in the last decade, from $93.2 million in 1991
to $187.0 million in 1999; however, the spending growth rate has been affected by program changes
over the last decade.1 As seen in Figure 1-1, the rate of growth dropped throughout most of the decade
but then started to rise in 1997. During the early to mid 90’s, welfare reform, moderate growth of the
aged and disabled population, and an improved economy lead to a reduction in spending growth; indeed,
all these led to changes in population size and mix effects.2 Also, increased use of managed care
affected utilization incentives and the supply of providers. More recently, in the late 90’s, eligibility
expansion due to the passage of State Children’s Health Insurance Plans (also known as Title XXI as
part of the Balanced Budget Act of 1997) has lead to an increase in the spending growth rate.1
Figure 1-1: Medicaid Expenditures and Growth Rates1
$250
26.6% 25
$187.0
$200 $171.7
$159.8 20
$152.2
$144.1
$150 16.0% $133.7
$121.6
$108.2 15
$93.2
$100
12.4% 10
10.0%
8.9%
$50 7.7% 7.5% 5
5.6% 5.0%
$0 0
1991 1992 1993 1994 1995 1996 1997 1998 1999

Figure 1-2 shows that the majority of payments in Medicaid is for long-term care services which include
skilled nursing, mental retardation, home health care, and mental health institutions. The spending rate
increase in long-term care is primarily due to rising expenditures for home health services. In 1998,
home health expenses were split into three categories, traditional home health, home and community-
based care, and personal care. Together, spending in the home care categories increased spending 44%
over home health care spending in 1997. Spending for skilled nursing facility services in Medicaid has
been fairly flat with a 4.6% increase from 1997 to 1998). Spending for prescription drugs is also rising
(12.5% increase, 1997-1998), however, the total share of dollars is still relatively small. Spending for
hospital inpatient services and physician services has decreased.3
Figure 1-2: Distribution of Medicaid Spending* by Type of Service3
$70
62^
1995
$60 55
51 52 1996
$50 1997
1998
$40
$30 26 25
23 22 21 21 20
18
$20 14
10 11 12
$10
$0
LTC± Hospital - Physician† Prescription Drugs
Inpatient‡
* Excludes managed care payments

± LTC (long-term care) = nursing facilities, mental health, home health, and mental retardation facilities
‡ Direct payments for services
† Physician, lab, clinic, EPSDT, outpatient hospital
^ Due to a category change, the 1998 LTC figure also includes payments for home and community based services and
personal care support services
POPULATION SIZE, DEMOGRAPHICS, AND GROWTH RATE
Medicaid is the largest financier of health care in the United States in terms of number of beneficiaries.
In 1998, there were 40.6 million Medicaid beneficiaries.4 This number represents an increase of about
12 million Medicaid recipients since 1991, although recent changes to welfare laws and an improved
economy resulted in a decline in the number of eligible people (from 41.6 million in 1997 to 41.4 in
1998).4 In the past, it was automatically assumed that a person who was on welfare would qualify for
the Medicaid program. Recently, welfare reform has resulted in a break in the link between public
assistance and Medicaid. This change was originally intended to allow people who did not receive

public assistance to still qualify for medical coverage. However, due to complex eligibility
requirements, applying for Medicaid is a confusing and difficult process for many people, resulting in
fewer enrollees. Besides the working poor and those on assistance, Medicaid coverage can be extended
to low income people who are elderly, blind, or disabled. In 1998, the majority of Medicaid funds, 71%
of expenditures, were spent on aged, blind, and disabled beneficiaries (who constitute only 26% of
persons served).5 In contrast, in 1998, children made up 53% of the total beneficiaries, yet only 14% of
all Medicaid expenditures went toward children.5 Figure 1-3 below examines the breakdown of
Medicaid expenditures by eligibility type.
Figure 1-3: Medicaid Expenditures & Enrollment by Group, 19985
$101.0
$100
$80
$60
$40
$20.5 18.3 M
$20 $14.8
7.9 M 10.6 M
$0
Adults Children Aged, Blind, & Disabled
Notes: Figures do not include spending for administration ($6.4 B) or disproportionate share hospitals ($15.9 B). Enrollment
figures are in millions.
MANAGED CARE TRENDS
The percentage of beneficiaries enrolled in Medicaid managed care increased from 9.5% in 1991 to
55.6% in 1999.6 The majority of those enrolled in managed care are non-disabled adults and children
where enrollment is mandatory. Over half of all Medicaid managed care enrollees are in a Health
Maintenance Organization (HMO) or Health Insuring Organization (HIO), organizations that contract on
a prepaid capitated risk basis to provide a comprehensive set of services. Room for further growth in
Medicaid managed care exists in the medically needy population of older and disabled persons.
However, the outlook for Medicaid managed care is cloudy right now because of the withdrawal of
many managed care firms from both the Medicare and Medicaid markets.7

PROVIDER PARTICIPATION IN MEDICAID
Physician participation in the fee-for-service Medicaid program is low. In many geographic areas patient
access to primary care services is limited. Physicians hesitate to take on Medicaid patients because
Medicaid reimburses at a much lower rate than does private insurance. By law, Medicaid cannot pay
more than Medicare. Medicare reimburses physicians using a fee schedule, the Resource Based Relative
Value Scale. A comparison of the 1993 Medicare Fee Schedule to average Medicaid payments in 1994
shows that Medicaid paid out an amount equal to an average of 77% of the Medicare Fee Schedule.8 In
contrast, typical physician payments by private insurers run from 115% to 120% of the Medicare Fee
Schedule.9 In addition, states have continued to limit physician payment rates; average fees for
physician services rose just 4.6% overall from 1993 to 1998.2
MEDICARE AND MEDICAID COMPARISON
In some ways it is useful to consider Medicare and Medicaid as a combined entity since changes in one
program often dramatically impact the other. Both programs are federally financed (partially for
Medicaid) and are managed by the Health Care Financing Administration (HCFA). They also both
cover elderly and disabled persons, but differ in the range of services offered. Both programs enroll
about the same number of persons (41.4 million in Medicaid and 38.8 million in Medicare in 1998).10
However, Medicare does not offer much in the way of either prescription drug or nursing home
coverage. Therefore, dually eligible people tend to receive hospital and physician services from
Medicare and prescription drug and nursing home services from Medicaid. Figure 1-4 illustrates the
spending pattern differences between Medicaid and Medicare.
Figure 1-4: Medicare versus Medicaid Spending, 19991
$140
$120
$100
$80
$60 Hospitals
Physicians and Clinical Services
$40
Nursing Homes
$20
$0 Drugs
Medicare
Medicaid

MEDICAID COMPARED TO NATIONAL HEALTH SPENDING
Average annual growth in National Health Expenditures versus Medicaid growth rates are shown below
in Figure 1-5.
Figure 1-5: National versus Medicaid Average Growth Rates1
10%
8.9%
7.7% 7.5%
8%
5.6% 5.4%
6%
Growth
5.4% 5.6%
5.2% 5.0%
4% 4.8%
National
2%
Medicaid
0%
1995 1996 1997 1998 1999
Over the last decade, both national and Medicaid expenditures for nursing home services have risen
steadily. However, the rate of growth for both national and Medicaid nursing home spending has
declined from 1996 to 1999 (except for a significant increase in Medicaid spending from 1998 to 1999).1
See Figures 1-6a and 1-6b below. Most of this decline in the national growth rate was due to
restructuring of the Medicare Prospective Payment System (PPS) for skilled nursing home payments.

Figure 1-6a: National and Medicaid Nursing Home Expenditures1
$100
$88.0 $90.0
$85.1
$79.9
$80 $74.6
National
Medicaid
$60
Billions
$39.8 $40.7 $42.4

$35.4 $37.8
$40
$20
$0
1995 1996 1997 1998 1999
Figure 1-6b: National versus Medicaid Nursing Home Expenditures, Growth Rates1
10%
9.1%
National
8% 7.1%
6.5% Medicaid
6%
6.6%
4.1%
5.3% 3.5%
4%
4.0%
2%
2.3% 2.3%
0%
1995 1996 1997 1998 1999

National hospital spending rose somewhat in the latter half of the 1990’s, while Medicaid hospital
spending grew significantly from 1998 to 1999, approximately 9.4%.1 See Figures 1-7a and 1-7b.
Figure 1-7a: National and Medicaid Hospital Expenditures1
$450
$377.1 $390.9
$400 $367.7
$343.6 $355.9
$350
$300
National
Billions
$250 Medicaid
$200
$150
$100 $56.8 $58.0 $60.8 $66.5
$54.3
$50
$0
1995 1996 1997 1998 1999
Figure 1-7b: National versus Medicaid* Hospital Expenditures, Growth Rates1
10%
9.4%
8%
6% 4.8%
Billions
4.3% 4.5%
3.3%
4%
3.4% 3.6% 3.7%

2% 2.6% National
2.2%
Medicaid
0%
1995 1996 1997 1998 1999

National home health spending rose consistently in the early 1990’s and then dropped after Medicare
changed reimbursement procedures and payment levels in 1997. See Figures 1-8a and 1-8b below.
Spending for home health in the Medicaid program is increasing and is expected to continue to increase
with the implementation of the Olmstead law. The Olmstead ruling requires states to provide
community-based health services to disabled persons, when feasible.
Figure 1-8a: National versus Medicaid Home Health Care Expenditures1
$40
$33.6 $34.5 $33.5 $33.1
$30.5
$30
National
Billions
$20 Medicaid
$10
$4.5 $4.9 $5.4 $5.6
$4.2
$0
1995 1996 1997 1998 1999
Figure 1-8b: National versus Medicaid Home Health Care Expenditures, Growth Rate1
20%
17.1%
National
15%
Medicaid
10.1%
8.9%
10%
11.7%
10.3%
5% 2.8%
6.2%
4.1%
0%
-3.0% -1.4%
-5%
1995 1996 1997 1998 1999

The national rate of spending growth for prescription drugs rose rapidly in the 1990’s. The Medicaid
spending rate for prescription drugs also rose rapidly in the 1990’s, even more rapidly than the national
trend. See Figures 1-9a and 1-9b below. As the mix of enrollees increasingly changes from adults and
children towards the aged and disabled, spending for prescription drugs is likely to continue to rise
(since the latter group has greater need for medication).
Figure 1-9a: National versus Medicaid Prescription Drug Expenditures1
$120
$99.6
$100
$85.2
$80 $75.1
$67.2 National
$60.8
Billions
$60 Medicaid
$40
$14.4 $17.1
$20 $9.7 $10.9 $12.3
$0
1995 1996 1997 1998 1999
Figure 1-9b: National versus Medicaid Prescription Drug Expenditures, Growth Rate1
25%
18.7%
20%
16.7%
13.7%
15% 12.4% 16.9%
12.0%
Rate
13.4%
10% 11.9%
11.2%
10.5%
5% National Rate
Medicaid Rate
0%
1995 1996 1997 1998 1999

SUMMARY
Medicaid expenditure trends for the latter half of the 1990’s were:
• The rate of growth in Medicaid spending was generally higher than the overall national growth
rate. Compared to a national growth rate between 4.8% and 5.6% throughout the latter half of
the 1990’s, the rate of growth in Medicaid was between 5.0% and 8.9%. The Medicaid growth
rate rose significantly from 1997 to 1999 due to program expansions.
• Most Medicaid spending is for long-term care services. Home health and personal care service
expenditures are growing most rapidly in this sector.
• Spending continues to be driven primarily by the aged, blind, and disabled population.
• Spending growth rates for hospital services remained fairly flat in the Medicaid program,
paralleling national rates, until 1999, when Medicaid experienced a major spending increase.
• Pharmacy spending is increasing rapidly in Medicaid and nationally; however, pharmacy costs
still remain a relatively small proportion of total spending.

REFERENCES
1 National Health Expenditures by Type of Service and Source of Funds: Calendar Years 1960-99.
Health Care Financing Administration, Office of the Actuary, National Health Statistics Group.
www.hcfa.gov/stats/nhe-oact/tables/nhe99.csv. Figures for Medicaid do not include Medicaid
SCHIP Expansion or Part B premium payments made by Medicaid.
2 Bruen B and Holahan J. Medicaid and the Uninsured. Slow Growth in Medicaid Spending
Continues in 1997. Issue Paper. The Henry J. Kaiser Foundation, November 1999.
3 Medicaid Statistics, Table 5. Medicaid Vendor Payments by Type of Service.

www.hcfa.gov/medicaid/msis/2082-5.htm. HCFA, CMSO, HCFA-2082 Report.
4 Medicaid Statistics, Table 1. Medicaid Beneficiaries, Vendor, Medical Assistance and

Administrative Payments. www.hcfa.gov/medicaid/msis/2082-1.htm. HCFA, CMSO, HCFA-2082
Report.
5 Medicaid Statistics, Table 3. Medicaid Beneficiaries, and Vendor Payments by Basis of Eligibility,
www.hcfa.gov/medicaid/msis/2082-3.htm. HCFA, CMSO, HCFA-2082 Report.
6 National Summary of Medicaid Managed Care Programs and Enrollment. June 30, 1999. Managed
Care Trends. www.hcfa.gov/medicaid/trends99.htm.
7 Iglehart JK. The American Health Care System. New England Journal of Medicine
1999;340(5):403-8.
8 Norton SA. 1994. The Declining Gap between Medicaid and Medicare Physician Fees. In
Winterbottom C, Liska DW, and Obermaier KM. State-Level Databook on Health Care Access and
Financing, Health Tracking, 2nd ed., Robert Wood Johnson Foundation, 1995, pg. 138.
9 Over 100 private insurers interviewed by The Lewin Group, 2000-2001.
10 1999 HCFA Statistics. Health Care Financing Administration. U.S. Department of Health and
Human Services.


Section 2:
Medicaid Managed Care


MEDICAID MANAGED CARE ENROLLMENT
Since 1981, when Congress authorized states to implement Section 1915b 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. Over the past five years, managed care enrollment as a
percentage of total Medicaid enrollment has increased by 140 percent (i.e., from 23.2% to 55.6%). In 1999, more
than half of all Medicaid beneficiaries were enrolled in some type of managed care program. As of June 30,
1999, all but two states (Alaska and Wyoming) were enrolling Medicaid beneficiaries in some type of managed
care plan.
Figure 2-1: Managed Care Enrollment as a Percentage of Total Medicaid Enrollment
100%
80% 46.4% 44.4%

% of Enrollment
52.2%
59.9%
70.6%
60% 76.8%
85.6%
40% 55.6%
53.6%
47.8%
20% 40.1%
29.4%
23.2%
14.4%
0%
1993 1994 1995* 1996 1997 1998 1999
Managed Care Fee-for-Service
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care.
*Approximated numbers for 1995. Total Medicaid population was provided by the Office of the Actuary, which used HCFA 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.
• Comprehensive Managed Care Organization (Comp-MCO): a health maintenance organization with a

contract under §1876 or a Medicare-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.
• Medicaid-only Managed Care Organization (Mcaid-MCO): a Medicaid-only MCO that provides

comprehensive services to Medicaid beneficiaries, but not commercial or Medicare enrollees.

• Prepaid Health Plan (PHP): an entity that provides less than comprehensive services on an at-risk basis or
one that provides any benefit package on a non-risk basis.
• Primary Care Case Management (PCCM): a provider (usually a physician, physician group practice, or an
entity employing or having other arrangements with such physicians, but sometimes also including nurse
practitioners, nurse midwives, or physician assistants) who contracts to locate, coordinate, and monitor
covered primary care (and sometimes additional services). This category includes any PCCMs and those
PHPs that act as PCCMs.
• “Other” Managed Care Arrangement: arrangements used if the plan is not considered a PCCM, PHP,
Comprehensive MCO, Medicaid-only MCO, or HIO.
The most utilized of these plans are Comprehensive MCO and Prepaid Health Plans.
Table 2-1: Medicaid Managed Care Plans
Number of Number of
Plan Type Plans Enrollees
Health Insuring Organization 6 365,738
Comprehensive Managed Care Organization 237 8,488,107
Comprehensive Medicaid-only Managed Care Organization 136 3,524,049
Primary Care Case Management 60 4,274,456
Prepaid Health Plan 129 8,104,413
Other 13 20,192
Total 581 24,776,955*
* Total number of enrollees includes 7,020,352 individuals enrolled in more than one managed care plan type.
The following tables provide an overview of Medicaid managed care enrollment at the state level.

Medicaid Managed Care Enrollment, As of June 30, 1999

Rank Based on
Medicaid Medicaid Managed Percent in Percent in
State Enrollment Care Enrollment Managed Care Managed Care
National Total 31,940,188 17,756,603 55.59% -
Alabama 513,863 377,952 73.55% 17
Alaska 70,764 0 0.00% 51
Arizona 401,066 363,662 90.67% 6
Arkansas 388,048 232,123 59.82% 30
California 4,972,673 2,540,902 51.10% 36
Colorado 234,753 216,357 92.16% 5
Connecticut 322,181 230,217 71.46% 19
Delaware 88,186 68,869 78.10% 12
District of Columbia 122,918 75,499 61.42% 26
Florida 1,512,216 912,045 60.31% 28
Georgia 848,618 638,082 75.19% 15
Hawaii 152,757 120,246 78.72% 11
Idaho 87,203 31,184 35.76% 42
Illinois 1,312,599 158,888 12.10% 47
Indiana 500,671 331,363 66.18% 22
Iowa 206,822 176,487 85.33% 8
Kansas 180,523 95,868 53.11% 34
Kentucky 539,810 324,447 60.10% 29
Louisiana 771,092 44,741 5.80% 49
Maine 168,092 23,720 14.11% 46
Maryland 501,000 347,937 69.45% 21
Massachusetts 891,428 575,186 64.52% 23
Michigan 1,130,608 1,130,608 100.00% 1
Minnesota 438,133 268,360 61.25% 27
Mississippi 485,716 200,347 41.25% 39
Missouri 714,392 276,628 38.72% 41
Montana 69,738 69,738 100.00% 2
Nebraska 171,723 122,006 71.05% 20
Nevada 92,996 36,945 39.73% 40
New Hampshire 71,407 5,812 8.14% 48
New Jersey 611,589 356,956 58.37% 31
New Mexico 284,705 208,528 73.24% 18
New York 2,255,694 659,569 29.24% 43
North Carolina 831,708 689,104 82.85% 9
North Dakota 43,389 23,886 55.05% 33
Ohio 975,415 244,888 25.11% 44
Oklahoma 372,501 193,902 52.05% 35
Oregon 378,894 308,798 81.50% 10
Pennsylvania 1,304,427 1,004,601 77.01% 13
Puerto Rico 997,474 764,068 76.60% 14
Rhode Island 134,018 85,900 64.10% 24
South Carolina 498,147 23,149 4.65% 50
South Dakota 68,195 50,220 73.64% 16
Tennessee 1,312,969 1,312,969 100.00% 3
Texas 1,788,569 352,062 19.68% 45
Utah 132,566 118,601 89.47% 7
Vermont 113,925 65,692 57.66% 32
Virgin Islands 19,359 0 0.00% 51
Virginia 460,373 292,214 63.47% 25
Washington 707,245 706,202 99.85% 4
West Virginia 256,869 111,532 43.42% 38
Wisconsin 395,336 187,543 47.44% 37
Wyoming 34,825 0 0.00% 51
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.

Pharmaceutical Benefits Under Managed Care Plans

Medicaid Where do managed care recipients Special requirements
Managed Care receive pharmacy benefits? for pharmacy benefits
State Enrollment (State, Managed Care Plan, Both) in managed care?
Alabama 377,952 N/A N/A
Alaska 0 - -
Arizona* 363,662 - -
Arkansas 232,123 State None
California 2,540,902 Both Guidelines, contractual
Colorado 216,357 Managed Care Plan N/A
Connecticut 230,217 Managed Care Plan Contractual
Delaware 68,869 State N/A
District of Columbia 75,499 Both None
Florida 912,045 Managed Care Plan Contractual
Georgia 638,082 N/A N/A
Hawaii 120,246 Both Guidelines, contractual
Idaho 31,184 State N/A
Illinois 158,888 Managed Care Plan Contractual
Indiana 331,363 Managed Care Plan Statutes, contractual
Iowa 176,487 State None
Kansas 95,868 Managed Care Plan Contractual
Kentucky 324,447 Both Contractual
Louisiana 44,741 State N/A
Maine 23,720 State None
Maryland 347,937 Both Regulations
Massachusetts 575,186 Managed Care Plan Contractual
Michigan 1,130,608 Both Contractual
Minnesota 268,360 Managed Care Plan Contractual
Mississippi 200,347 Both Contractual
Missouri 276,628 Managed Care Plan Guidelines, contractual
Montana 69,738 State None
Nebraska 122,006 State Statutes, regulations, guidelines, contractual
Nevada 36,945 Both Contractual
New Hampshire 5,812 State None
New Jersey 356,956 Managed Care Plan Guidelines
New Mexico 208,528 Managed Care Plan N/A
New York 659,569 State Statutes, FFS program
North Carolina 689,104 State None
North Dakota 23,886 State None
Ohio 244,888 Managed Care Plan Statutes
Oklahoma 193,902 Managed Care Plan Contractual
Oregon 308,798 Both Guidelines, contractual
Pennsylvania 1,004,601 Managed Care Plan Contractual
Rhode Island 85,900 Managed Care Plan N/A
South Carolina 23,149 Managed Care Plan Contractual
South Dakota 50,220 N/A N/A
Tennessee* 1,312,969 Managed Care -
Texas 352,062 State N/A
Utah 118,601 State (Carve-out) N/A
Vermont 65,692 State None
Virginia 292,214 Managed Care Plan Contractual
Washington 706,202 Both Contractual
West Virginia 111,532 State N/A
Wisconsin 187,543 Managed Care Plan Statutes, regulations, contractual
Wyoming 0 - -
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Sources: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care. As
reported by state drug program administrators in the 2000 NPC Survey.

Medicaid Managed Care Enrollment Trends, 1997-1999

State 1997 1998 1999
National Total 15,345,502 16,573,996 17,756,603
Alabama 407,643 362,272 377,952
Alaska 0 0 0
Arizona 349,142 368,344 363,662
Arkansas 159,458 186,215 232,123
California 1,854,294 2,246,406 2,540,902
Colorado 184,000 215,936 216,357
Connecticut 231,966 220,803 230,217
Delaware 65,061 62,010 68,869
District of Columbia 80,721 51,022 75,499
Florida 896,559 915,554 912,045
Georgia 560,771 673,528 638,082
Hawaii 135,200 131,761 120,246
Idaho 32,428 30,866 31,184
Illinois 187,048 175,649 158,888
Indiana 220,000 233,065 331,363
Iowa 88,282 190,692 176,487
Kansas 94,430 84,437 95,868
Kentucky 268,205 325,233 324,447
Louisiana 40,469 40,729 44,741
Maine 12,511 16,295 23,720
Maryland 347,640 306,474 347,937
Massachusetts 461,989 532,971 575,186
Michigan 865,434 752,568 1,130,608
Minnesota 169,329 225,498 268,360
Mississippi 81,255 153,562 200,347
Missouri 264,496 252,097 276,628
Montana 62,004 66,331 69,738
Nebraska 93,085 110,606 122,006
Nevada 26,376 35,089 36,945
New Hampshire 9,102 7,368 5,812
New Jersey 384,644 376,839 356,956
New Mexico 139,337 193,818 208,528
New York 660,725 634,233 659,569
North Carolina 351,043 559,035 689,104
North Dakota 24,295 22,045 23,886
Ohio 352,833 292,819 244,888
Oklahoma 222,818 154,270 193,902
Oregon 312,345 299,826 308,798
Pennsylvania 870,365 904,701 1,004,601
Puerto Rico 702,250 813,791 764,068
Rhode Island 70,944 74,446 85,900
South Carolina 14,311 15,823 23,149
South Dakota 41,542 43,834 50,220
Tennessee 1,188,570 1,268,769 1,312,969
Texas 275,951 437,898 352,062
Utah 93,785 112,803 118,601
Vermont 22,946 52,153 65,692
Virgin Islands 0 0 0
Virginia 306,804 299,266 292,214
Washington 730,052 718,023 706,202
West Virginia 125,521 131,349 111,532
Wisconsin 205,523 194,874 187,543
Wyoming 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, 1997; 1998; 1999. DHHS, HCFA, Office of
Managed Care.

Medicaid Managed Care Plan Type, As of June 30, 1999

Comprehensive
Comprehensive Medicaid-only
State HIO MCO MCO PCCM PHP Other
National Total 6 237 136 60 129 13
Alabama 0 1 0 24 9 0
Alaska - - - - - -
Arizona 0 2 30 0 1 0
Arkansas 0 0 0 1 1 0
California 5 18 13 2 9 5
Colorado 1 4 1 1 1 0
Connecticut 0 4 1 0 0 0
Delaware 0 3 0 0 0 0
District of Columbia 0 7 1 0 0 0
Florida 0 16 0 3 1 0
Georgia 0 0 0 1 2 0
Hawaii 0 8 2 0 0 0
Idaho 0 0 0 1 0 0
Illinois 0 7 3 4 0 0
Indiana 0 1 2 1 0 0
Iowa 0 5 0 1 1 0
Kansas 0 0 1 1 0 0
Kentucky 0 0 2 1 1 0
Louisiana 0 0 0 1 0 0
Maine 0 1 0 1 0 0
Maryland 0 3 5 0 0 0
Massachusetts 0 3 2 1 1 0
Michigan 0 15 13 1 49 2
Minnesota 0 8 1 0 0 1
Mississippi 0 3 0 1 0 0
Missouri 0 6 4 0 0 0
Montana 0 2 0 1 1 0
Nebraska 0 2 0 1 1 0
Nevada 0 4 0 0 0 0
New Hampshire 0 2 0 0 0 0
New Jersey 0 4 2 0 0 0
New Mexico 0 3 0 0 0 0
New York 0 16 16 1 8 2
North Carolina 0 5 0 2 1 0
North Dakota 0 1 0 1 0 0
Ohio 0 8 3 0 0 0
Oklahoma 0 4 0 1 0 0
Oregon 0 8 3 0 0 0
Pennsylvania 0 5 8 2 15 0
Puerto Rico 0 4 0 0 0 0
Rhode Island 0 4 0 0 0 0
South Carolina 0 0 1 0 0 2
South Dakota 0 0 0 1 0 0
Tennessee 0 0 9 0 2 0
Texas 0 6 6 1 0 0
Utah 0 5 0 0 8 0
Vermont 0 2 0 0 0 0
Virginia 0 7 0 1 0 0
Washington 0 9 2 1 15 0
West Virginia 0 3 0 1 0 0
Wisconsin 0 18 5 0 2 1
Wyoming - - - - - -
HIO=Health Insuring Organization; Comprehensive MCO=Comprehensive Managed Care Organization; Comprehensive Medicaid-only
MCO=Comprehensive Medicaid-only Managed Care Organization; PCCM=Primary Care Case Management; PHP=Prepaid Health Plan.

Medicaid Managed Care Enrollment by Plan Type,

As of June 30, 1999
Comprehensive Comprehensive
State HIO MCO Medicaid-only MCO PCCM PHP Other
National Total 365,738 8,488,107 3,524,049 4,274,456 8,104,413 20,192
Alabama - 39,597 - 310,584 637,654 -
Alaska - - - - - -
Arizona - 22,889 361,273 - 24,431 -
Arkansas - - - 194,753 232,122 -
California 365,498 938,125 1,208,314 26,617 333,160 2,279
Colorado 240 37,880 43,029 50,214 216,357 -
Connecticut - 193,432 36,785 - - -
Delaware - 68,869 - - - -
District of Columbia - 73,640 1,859 - - -
Florida - 446,538 - 465,507 41,660 -
Georgia - - - 613,560 24,522 -
Hawaii - 191,086 52,356 - - -
Idaho - - - 31,184 - -
Illinois - 98,956 41,505 - 18,427 -
Indiana - 69,194 42,848 219,321 - -
Iowa - 47,048 - 45,570 176,487 -
Kansas - - 22,402 73,466 - -
Kentucky - - 158,628 165,819 - -
Louisiana - - - 44,741 - -
Maine - 5,569 - 18,151 - -
Maryland - 238,240 109,697 - - -
Massachusetts - 117,715 23,808 433,663 627,894 -
Michigan - 521,790 228,830 - 1,130,608 1,124
Minnesota - 264,231 3,885 - - 244
Mississippi - 10,216 - 190,131 - -
Missouri - 186,109 90,519 - - -
Montana - 1,965 - 39,847 69,738 -
Nebraska - 28,052 - 24,345 122,006 -
Nevada - 36,945 - - - -
New Hampshire - 5,812 - - - -
New Jersey - 261,804 95,152 - - -
New Mexico - 2,420,860 - - - -
New York - 359,379 235,065 4,768 59,531 826
North Carolina - 38,881 - 517,511 132,712 -
North Dakota - 718 - 23,168 - -
Ohio - 142,235 102,653 - - -
Oklahoma - 98,140 - 95,762 - -
Oregon - 206,651 23,940 134,279 698,307 -
Pennsylvania - 414,698 428,682 154,468 713,145 -
Puerto Rico - 764,068 - - - -
Rhode Island - 85,900 - - - -
South Carolina - - 7,454 - - 15,695
South Dakota - - - 50,220 - -
Tennessee - 1,312,969 - - 1,312,969
Texas - 107,932 107,929 136,201 - -
Utah - 73,921 - - 118,601 -
Vermont - 65,692 - - - -
Virginia - 150,067 - 142,147 - -
Washington - 323,079 93,221 3,805 1,413,447 -
West Virginia - 46,878 - 64,654 - -
Wisconsin - 182,669 4,215 - 635 24
Wyoming - - - - - -
*The total number of enrollees includes 7,020,352 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.

Medicaid Managed Care Enrollment by Payment Arrangement,

As of June 30, 1999
State Fee-For-Service (FFS) Fully Capitated (FUL) Partially Capitated (PAR)
National Total 4,892,041 17,844,439 2,040,475
Alabama 310,584 677,251 -
Alaska - - -
Arizona - 408,593 -
Arkansas 194,753 232,122 -
California 26,617 2,847,376 -
Colorado 50,214 297,506 -
Connecticut - 230,217 -
Delaware - 68,869 -
District of Columbia - 75,499 -
Florida 465,489 488,216 -
Georgia 613,560 2,408 22,114
Hawaii - 243,442 -
Idaho 31,184 - -
Illinois - 150,554 8,334
Indiana 219,321 112,042 -
Iowa 45,570 223,535 -
Kansas 73,466 22,402 -
Kentucky 165,819 158,628 -
Louisiana 44,741 - -
Maine 18,151 5,569 -
Maryland - 347,937 -
Massachusetts 433,663 141,523 627,894
Michigan - 751,744 1,130,608
Minnesota 244 268,116 -
Mississippi 190,131 10,216 -
Missouri - 276,628 -
Montana 39,847 71,703 -
Nebraska 24,345 28,052 122,006
Nevada - 36,945 -
New Hampshire - 5,812 -
New Jersey - 356,956 -
New Mexico - 208,528 -
New York 4,768 630,887 23,914
North Carolina 517,511 171,593 -
North Dakota 23,168 718 -
Ohio - 244,888 -
Oklahoma - 98,140 95,762
Oregon 134,279 928,898 -
Pennsylvania 154,468 1,556,525 -
Puerto Rico - 764,068 -
Rhode Island - 85,900 -
South Carolina 5,852 7,454 9,843
South Dakota 50,220 - -
Tennessee - 2,625,938 -
Texas 136,201 215,861 -
Utah - 192,522 -
Vermont - 65,692 -
Virginia 142,147 150,067 -
Washington 711,050 1,122,502 -
West Virginia 64,654 46,878 -
Wisconsin 24 187,519 -
Wyoming - - -
Individual state totals will not sum to total managed care enrollment (page 2-5) because state totals include individuals enrolled in more
than one plan type including dental, mental, and long-term care.

MEDICAID MANAGED CARE WAIVERS
In 1981, Congress authorized states to implement Section 1915b 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 granted these waivers to allow states to “waive” requirements in Sections 1902 and
1903 of the Social Security Act and “mandate” enrollment of Medicaid eligibles in managed care programs.
SECTION 1915B “FREEDOM OF CHOICE” WAIVERS
Section 1915b 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 1915b waiver, a state can require mandatory
enrollment of Medicaid recipients in managed care plans. 1915b waivers cannot negatively impact beneficiary
access, quality of care of services, and must be cost-effective (cost must be less than the Medicaid program
would cost without the waiver). Section 1915b waivers are typically limited to a targeted geographical area or
population, are approved for an initial period of two years, and can be renewed in two-year increments if the state
reapplies.
Four options for 1915b waivers exist; each is governed by a different subsection(s) of Section 1915b:
• Subsection 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.
• Subsection 2 - Central Broker: States are allowed to act as a central broker in assisting medical assistance
eligibles in selecting among competing health care plans, if such a restriction does not substantially impair
access to medically necessary services of adequate quality.
• Subsection 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.
• Subsection 4 - Restrict Providers: States can limit the number of providers of certain services. These waivers
are sometimes referred to as selective contracting waivers and were gaining in popularity. Recently approved
1915b(4) waivers included programs to restrict the number of providers of transportation services, organ
transplants, and inpatient obstetrical care.
Refer to the table on page 2-13 for a listing of 1915b waivers.
Although Section 1915b waivers allow states to increase access to managed care plans, states are still limited
under Federal regulation 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 1915b
waivers, states apply for Section 1115 research and demonstration waivers.
SECTION 1115 RESEARCH AND DEMONSTRATION WAIVERS
Section 1115 research and demonstration waivers released states from standard Medicaid requirements, allowing
them the flexibility to test substantially new ideas of policy merit. Along with 1915b waivers, 1115 waivers
allowed states to waive freedom of choice, statewide access to care, and comparability requirements. However,
an 1115 waiver also allowed 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 did 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 HCFA 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 request for continuation. For example, Arizona operated its program
under an 1115 waiver for 17 years.
Currently, there are 20 Medicaid programs with 1115 waiver approvals. Arizona, Arkansas, California, Delaware,
District of Columbia, Hawaii, Kentucky, Maryland, Massachusetts, Minnesota, Missouri, Montana, New York,
Ohio, Oklahoma, Oregon, Rhode Island, Tennessee, Vermont and Wisconsin have actually implemented their
1115 waivers. Refer to the table on page 2-16 for a listing of implemented 1115 waivers.

1915(b) Waivers, As of June 30, 1999
1915b
State Program(s) Approved Statutes Utilized Expiration
Maternity Waiver Program 1 9/30/99
Alabama Partnership Hospital Program 1, 4 3/29/01
st
Patient 1 1, 3, 4 6/29/01
Alaska None -- --
Arizona None -- --
Arkansas Non-Emergency Transportation 1 2/29/00
CALOPTIMA 1, 2, 4 5/06/00
Health Plan of San Mateo 1, 2, 3, 4 7/4/00
Hudman 4 7/21/00
Managed Care Network 1, 3, 4 11/25/99
Medi-Cal Mental Health Care Field Test 4 6/25/00
Medi-Cal Specialty Mental Health Services Consolidation 4 10/4/99
Partnership Health Plan of California 1, 2, 4 2/16/00
California
Primary Care Case Management Program 1, 2, 3, 4 8/09/01
Sacramento Geographic Managed Care – Medical 1, 2, 4 11/16/99
San Diego Geographic Managed Care 1, 2, 4 10/16/00
Santa Barbara Health Initiative 1, 2, 4 1/17/00
Santa Cruz County Health Option (SCCHO) 1, 2, 4 11/19/00
Selective Provider Contracting Program 4 12/12/01
Two-Plan Model Program 1, 2, 3, 4 12/16/00
Mental Health Capitation Program 1, 3, 4 3/8/00
Colorado
Managed Care Program 1, 2 2/28/00
Connecticut HUSKY A 1, 4 12/20/99
Delaware None -- --
District of Columbia DC Managed Care Program 1, 2, 4 3/31/00
MediPass 1 6/30/99
Florida Prepaid Mental Health Plan 1, 4 6/30/01
Sub-Acute Inpatient Psychiatric Program 3, 4 3/22/00
Georgia Better Health Care 1 7/01/00
Georgia
Mental Health/Mental Retardation Services 1, 4 2/19/00
Hawaii None -- --
Idaho Healthy Connections 1, 2 11/15/99
Illinois None -- --
Indiana Hoosier Healthwise 1 1/26/00
Iowa Plan for Behavioral Health 1, 3, 4 12/31/00
Iowa
Iowa Medicaid Managed Health Care 1, 2 5/9/01
KMMC: Prime Care Kansas 1, 2, 4 6/26/00
Kansas
KMMC: Health Connect 1, 2, 4 6/26/00
Human Services Transportation 4 10/30/00
Kentucky Kentucky Patient Access and Care System (KENPAC) 1 4/13/00
Kentucky Access 1, 3, 4 11/24/99

1915b
Louisiana Community Care Program 1 6/28/00
Maine None -- --
Maryland None -- --
Massachusetts None -- --
Comprehensive Health Care Program 1, 2, 4 12/27/99
Michigan
Specialty Community Mental Health Services 1, 4 9/30/00
Minnesota Consolidated Chemical Dependency Treatment Fund 1, 4 3/24/01
Mississippi None -- --
Missouri Managed Care Plus (MC+) 1, 2, 4 3/14/00
Mental Health Access Plan 1 6/30/99
Montana
Passport to Health 1 10/25/99
Medicaid Health Connection – MH/SA 1 6/30/99
Nebraska
Nebraska Health Connection – Med/Surg 1, 2 6/30/99
Nevada None -- --
New Hampshire None -- --
New Jersey None -- --
New Mexico SALUD! 1,4 7/1/99
Non-Emergency Transportation 4 1/13/00
New York Southwest Brooklyn Managed Care Demonstration Project 1, 4 8/16/00
The Westchester County Managed Care Program 1, 4 3/31/00
ACCESS II 1 11/29/99
Carolina Access 1 11/29/99
North Carolina Carolina Alternatives 1, 4 6/30/99
Health Care Connection 1 11/29/99
Health Maintenance Organization (HMO) 1 11/29/99
North Dakota North Dakota Access and Care Program 1 5/5/01
Ohio None -- --
Oklahoma None -- --
Oregon Tri-County Metro. Transportation District 4 1/25/01
Family Care Network 1 7/26/01
HealthChoices SE - Behavioral 1, 2, 3, 4 1/26/00
HealthChoices SE – Physical Health 1, 2, 3, 4 1/26/00
Pennsylvania
HealthChoices SW - Behavioral 1, 2, 3, 4 12/31/99
HealthChoices SW – Physical Health 1, 2, 3, 4 12/31/99
Lancaster Community Health Plan 1 7/21/00
Rhode Island None -- --
South Carolina High Risk Channeling Project (HRCP) 1, 3, 4 2/11/01
South Dakota Prime 1, 3 7/1/00
Tennessee None -- --
Lonestar Select I 4 9/3/00
Lonestar Select II 4 8/19/99
Texas HMO - STAR 1, 2, 3, 4 8/31/010
HMO - STAR Plus (+) 1, 2, 3, 4 1/31/00
PCCM - STAR Plus (+) 1, 2, 3, 4 1/31/00

1915b
Choice of Health Care Delivery 1, 2, 4 2/16/01
Utah
Prepaid Mental Health Program 4 10/28/99
Vermont None -- --
Medallion 1 9/24/99
Virginia
Medallion II 1, 4 9/27/00
Mental Health Services 1, 4 11/7/99
Washington Healthy Options 1, 4 2/24/01
Hospital Selective Contracting 4 12/31/00
Mountain Health Care Trust 1, 4 8/26/99
West Virginia
Physician Assured Access System (PAAS) 1 9/5/99
Wisconsin None -- --
Wyoming Hospital Inpatient Selective Contracting 4 3/15/01
Source: 1999 National Summary of State Medicaid Managed Care Programs. Program Descriptions as of June 30, 1999. U.S. Department
of Health and Human Services, Health Care Financing Administration, Office of Managed Care.

Section 1115 Research and Demonstration Waivers
State Program Implemented Expiration

Alabama Bay Health Plan 5/1/97 10/1/99
Arizona Health Care Cost Containment System
Arizona 10/1/82 9/30/99
(AHCCCS)
On Lock Senior Health Services 11/1/83 9/30/00
Senior Care Action Network 1/1/85 4/30/00
California
Sutter Senior Care 5/1/94 9/30/00
Centers For Elders Independence 4/1/95 9/30/00
Delaware Diamond State Health Plan 1/1/96 12/31/03
District of Columbia Health Services for Children w/Spec. Needs 2/1/96 12/1/99
Hawaii Hawaii QUEST 8/1/94 3/31/02
Kentucky Kentucky Partnerships 11/1/97 10/31/02
Maryland Health Choice 7/1/97 6/1/02
Massachusetts Mass Health 7/1/97 4/30/01
Minnesota Senior Health Options Program (MSHO) 3/1/97 2/28/02
Minnesota MinnesotaCare Program for Families and Children 7/1/95 6/30/02
Prepaid Medical Assistance Program Plus (PMAP+) 7/1/85 6/30/02
Missouri Managed Care Plus (MC+) 9/1/95 3/14/00
Montana HMO 2/1/96 1/31/04
New York New York State Managed Care Program 10/1/97 7/14/02
Ohio Ohio 1115 (TANF & TANF-related) 7/1/96 6/30/01
SoonerCare Choice PCCM Model 1/1/96 12/31/00
Oklahoma
SoonerCare Plus MCO Model 1/1/96 12/31/00
Oregon Oregon Health Plan 2/1/94 1/31/02
Rhode Island Rite Care 8/1/94 7/31/02
Tennessee TennCare 1/1/94 12/31/01
Vermont Vermont Health Access 1/1/96 12/31/01
Wisconsin WI Partnership Program 1/1/96 N/A
Source: 1999 National Summary of State Medicaid Managed Care Programs. Program Descriptions as of June 30, 1999. U.S. Department
of Health and Human Services, Health Care Financing Administration, Office of Managed Care; Comprehensive Health Care Reform
Demonstrations (12/8/00). Available at http://www.hcfa.gov/medicaid/ord-demo.htm. Accessed December 2000.

Section 3:
State Characteristics


Age Demographics, 1999

Total State Percent Ages Percent Percent Percent
State Population 20 and under Ages 21-44 Ages 45-64 Ages 65+
National Total 271,742,826 30.8% 35.9% 21.4% 11.9%
Alabama 4,200,926 27.7% 35.5% 24.0% 12.8%
Alaska 646,842 38.0% 38.7% 18.4% 4.9%
Arizona 4,905,332 33.2% 36.1% 19.7% 11.0%
Arkansas 2,562,587 30.1% 35.0% 19.9% 15.0%
California 33,375,150 32.2% 37.9% 19.6% 10.3%
Colorado 3,970,806 28.8% 42.1% 20.2% 8.9%
Connecticut 3,283,332 29.2% 32.8% 24.8% 13.1%
Delaware 783,012 31.2% 35.5% 19.2% 14.0%
District of Columbia 511,711 23.2% 41.8% 20.1% 14.8%
Florida 14,677,912 26.4% 34.1% 21.2% 18.3%
Georgia 7,666,432 31.1% 36.5% 22.8% 9.7%
Hawaii 1,200,863 30.2% 35.7% 20.4% 13.6%
Idaho 1,274,230 34.7% 33.7% 21.2% 10.4%
Illinois 12,294,861 33.1% 36.4% 19.6% 10.8%
Indiana 5,839,738 30.8% 35.2% 22.6% 11.4%
Iowa 2,837,156 30.7% 33.8% 21.1% 14.4%
Kansas 2,616,318 31.4% 33.6% 19.7% 15.3%
Kentucky 3,864,679 29.0% 33.9% 24.9% 12.1%
Louisiana 4,310,285 31.7% 35.1% 21.5% 11.6%
Maine 1,266,498 27.8% 33.9% 25.5% 12.9%
Maryland 5,046,171 27.2% 37.7% 21.8% 13.2%
Massachusetts 6,116,806 29.3% 36.5% 21.5% 12.7%
Michigan 10,040,679 33.3% 35.2% 19.9% 11.6%
Minnesota 4,833,278 34.1% 35.8% 19.4% 10.7%
Mississippi 2,761,422 32.6% 35.8% 19.0% 12.6%
Missouri 5,405,443 29.5% 36.9% 20.8% 12.7%
Montana 924,582 33.7% 34.3% 21.3% 10.7%
Nebraska 1,716,417 33.5% 35.2% 19.2% 12.0%
Nevada 1,862,276 33.2% 36.4% 19.9% 10.5%
New Hampshire 1,224,200 32.9% 33.7% 23.5% 9.9%
New Jersey 8,092,295 29.7% 36.1% 23.3% 10.9%
New Mexico 1,829,164 35.7% 31.6% 20.2% 12.4%
New York 18,420,007 30.5% 35.5% 21.1% 13.0%
North Carolina 7,426,910 28.2% 36.1% 23.2% 12.5%
North Dakota 646,079 33.7% 32.3% 20.2% 13.9%
Ohio 11,224,522 30.0% 35.3% 22.6% 12.1%
Oklahoma 3,268,838 29.2% 33.4% 23.7% 13.7%
Oregon 3,355,739 30.2% 35.2% 23.8% 10.7%
Pennsylvania 11,912,109 28.6% 34.4% 23.4% 13.6%
Rhode Island 968,057 27.9% 34.9% 21.8% 15.4%
South Carolina 3,851,167 29.6% 35.0% 22.8% 12.6%
South Dakota 711,326 32.9% 33.1% 21.2% 12.9%
Tennessee 5,572,470 31.5% 34.1% 23.9% 10.5%
Texas 19,944,736 33.5% 36.7% 20.2% 9.5%
Utah 2,105,665 37.7% 37.3% 17.4% 7.6%
Vermont 593,161 29.4% 37.1% 23.0% 10.5%
Virginia 6,687,894 29.5% 36.4% 22.2% 12.0%
Washington 5,747,382 30.5% 37.5% 22.4% 9.6%
West Virginia 1,750,073 24.8% 33.0% 24.7% 17.5%
Wisconsin 5,128,974 28.4% 36.7% 23.1% 11.8%
Wyoming 486,314 31.3% 34.4% 23.4% 10.9%
Source: The Lewin Group analysis of the Current Population Survey, March 2000 Supplement.

Race Demographics, 1999

Total State Percent Percent Percent Percent
State Population White Black Hispanic Other
National Total 271,742,826 71.1% 12.5% 11.7% 4.7%
Alabama 4,200,926 71.1% 27.1% 0.8% 0.9%
Alaska 646,842 73.0% 4.1% 1.8% 21.0%
Arizona 4,905,332 65.5% 2.7% 28.7% 3.0%
Arkansas 2,562,587 79.4% 17.5% 1.4% 1.7%
California 33,375,150 50.3% 6.5% 30.3% 12.9%
Colorado 3,970,806 79.8% 3.0% 14.4% 2.8%
Connecticut 3,283,332 76.3% 11.9% 9.9% 1.9%
Delaware 783,012 69.6% 25.4% 3.5% 1.5%
District of Columbia 511,711 25.9% 64.6% 6.3% 3.2%
Florida 14,677,912 65.4% 15.1% 17.6% 1.9%
Georgia 7,666,432 62.0% 32.9% 3.3% 1.8%
Hawaii 1,200,863 21.7% 2.9% 4.3% 71.1%
Idaho 1,274,230 86.6% 0.3% 10.9% 2.3%
Illinois 12,294,861 71.0% 16.0% 10.1% 2.9%
Indiana 5,839,738 90.9% 5.9% 2.5% 0.8%
Iowa 2,837,156 92.5% 1.9% 3.4% 2.2%
Kansas 2,616,318 84.6% 8.8% 4.1% 2.4%
Kentucky 3,864,679 89.0% 8.9% 1.4% 0.7%
Louisiana 4,310,285 61.5% 35.2% 1.6% 1.8%
Maine 1,266,498 97.9% 0.1% 0.6% 1.4%
Maryland 5,046,171 63.7% 27.0% 3.3% 5.9%
Massachusetts 6,116,806 84.1% 5.8% 6.1% 3.9%
Michigan 10,040,679 80.5% 14.2% 2.8% 2.5%
Minnesota 4,833,278 89.4% 2.5% 2.8% 5.3%
Mississippi 2,761,422 61.9% 37.0% 0.8% 0.4%
Missouri 5,405,443 85.8% 11.0% 1.2% 2.0%
Montana 924,582 88.5% 0.2% 1.8% 9.5%
Nebraska 1,716,417 88.7% 4.5% 4.3% 2.5%
Nevada 1,862,276 70.3% 5.0% 18.5% 6.3%
New Hampshire 1,224,200 96.6% 1.0% 1.0% 1.4%
New Jersey 8,092,295 69.5% 14.3% 12.1% 4.2%
New Mexico 1,829,164 47.6% 1.2% 40.4% 10.9%
New York 18,420,007 64.1% 15.2% 15.2% 5.5%
North Carolina 7,426,910 69.5% 24.1% 3.0% 3.4%
North Dakota 646,079 91.6% 0.2% 0.6% 7.6%
Ohio 11,224,522 86.4% 11.3% 1.4% 0.9%
Oklahoma 3,268,838 79.6% 7.5% 2.6% 10.3%
Oregon 3,355,739 85.9% 2.2% 6.3% 5.6%
Pennsylvania 11,912,109 84.3% 10.5% 3.0% 2.2%
Rhode Island 968,057 84.8% 5.3% 5.9% 4.1%
South Carolina 3,851,167 71.2% 26.8% 0.8% 1.2%
South Dakota 711,326 92.0% 1.6% 0.5% 5.8%
Tennessee 5,572,470 82.2% 15.8% 0.8% 1.1%
Texas 19,944,736 51.1% 12.5% 32.9% 3.4%
Utah 2,105,665 88.7% 1.3% 5.8% 4.2%
Vermont 593,161 97.7% 0.3% 0.4% 1.6%
Virginia 6,687,894 73.0% 19.3% 2.5% 5.2%
Washington 5,747,382 88.8% 1.8% 4.0% 5.4%
West Virginia 1,750,073 94.2% 4.3% 0.4% 1.1%
Wisconsin 5,128,974 88.5% 6.7% 1.9% 3.0%
Wyoming 486,314 92.6% 1.6% 4.4% 1.4%

Insurance Status, 1999

Total State Medicaid Percent Covered Medicare Percent Covered
State Population Population by Medicaid Population by Medicare
National Total 271,742,826 28,485,614 10.5% 35,886,603 13.2%
Alabama 4,200,926 399,999 9.5% 634,905 15.1%
Alaska 646,842 117,183 18.1% 33,271 5.1%
Arizona 4,905,332 438,939 8.9% 598,907 12.2%
Arkansas 2,562,587 264,677 10.3% 429,046 16.7%
California 33,375,150 4,277,170 12.8% 3,782,175 11.3%
Colorado 3,970,806 172,031 4.3% 402,074 10.1%
Connecticut 3,283,332 232,809 7.1% 495,807 15.1%
Delaware 783,012 72,312 9.2% 115,330 14.7%
District of Columbia 511,711 107,897 21.1% 80,852 15.8%
Florida 14,677,912 1,243,033 8.5% 2,901,579 19.8%
Georgia 7,666,432 960,075 12.5% 863,436 11.3%
Hawaii 1,200,863 124,588 10.4% 161,514 13.4%
Idaho 1,274,230 117,487 9.2% 147,135 11.5%
Illinois 12,294,861 1,068,655 8.7% 1,451,317 11.8%
Indiana 5,839,738 321,825 5.5% 758,451 13.0%
Iowa 2,837,156 204,886 7.2% 426,795 15.0%
Kansas 2,616,318 205,572 7.9% 426,411 16.3%
Kentucky 3,864,679 408,724 10.6% 549,788 14.2%
Louisiana 4,310,285 584,223 13.6% 592,659 13.7%
Maine 1,266,498 126,610 10.0% 194,020 15.3%
Maryland 5,046,171 222,431 4.4% 695,125 13.8%
Massachusetts 6,116,806 795,817 13.0% 849,412 13.9%
Michigan 10,040,679 1,138,541 11.3% 1,271,138 12.7%
Minnesota 4,833,278 441,987 9.1% 535,510 11.1%
Mississippi 2,761,422 309,529 11.2% 419,869 15.2%
Missouri 5,405,443 506,629 9.4% 768,233 14.2%
Montana 924,582 130,020 14.1% 113,110 12.2%
Nebraska 1,716,417 168,997 9.8% 220,248 12.8%
Nevada 1,862,276 93,607 5.0% 213,939 11.5%
New Hampshire 1,224,200 103,841 8.5% 128,917 10.5%
New Jersey 8,092,295 499,489 6.2% 932,604 11.5%
New Mexico 1,829,164 326,668 17.9% 262,578 14.4%
New York 18,420,007 2,792,226 15.2% 2,596,260 14.1%
North Carolina 7,426,910 730,203 9.8% 1,073,054 14.4%
North Dakota 646,079 67,742 10.5% 95,936 14.8%
Ohio 11,224,522 1,068,729 9.5% 1,564,115 13.9%
Oklahoma 3,268,838 384,492 11.8% 530,082 16.2%
Oregon 3,355,739 480,716 14.3% 411,036 12.2%
Pennsylvania 11,912,109 1,227,356 10.3% 1,761,765 14.8%
Rhode Island 968,057 89,947 9.3% 160,201 16.5%
South Carolina 3,851,167 355,727 9.2% 582,075 15.1%
South Dakota 711,326 75,786 10.7% 99,149 13.9%
Tennessee 5,572,470 1,083,307 19.4% 644,347 11.6%
Texas 19,944,736 1,895,039 9.5% 2,070,144 10.4%
Utah 2,105,665 151,444 7.2% 179,783 8.5%
Vermont 593,161 93,991 15.8% 69,493 11.7%
Virginia 6,687,894 355,615 5.3% 928,879 13.9%
Washington 5,747,382 684,140 11.9% 593,766 10.3%
West Virginia 1,750,073 273,880 15.6% 349,774 20.0%
Wisconsin 5,128,974 457,212 8.9% 657,393 12.8%
Wyoming 486,314 31,811 6.5% 63,196 13.0%

Income and Employment, 1999

Total State Percent Below 100% Poverty Percent
State Population Level Unemployed
National Total 271,742,826 13.1% 2.0%
Alabama 4,200,926 15.1% 1.9%
Alaska 646,842 10.4% 3.7%
Arizona 4,905,332 16.8% 1.8%
Arkansas 2,562,587 15.0% 1.7%
California 33,375,150 15.6% 2.7%
Colorado 3,970,806 9.3% 1.1%
Connecticut 3,283,332 10.1% 1.5%
Delaware 783,012 10.9% 1.4%
District of Columbia 511,711 23.0% 3.9%
Florida 14,677,912 13.6% 1.5%
Georgia 7,666,432 14.7% 2.3%
Hawaii 1,200,863 10.9% 2.6%
Idaho 1,274,230 13.2% 2.4%
Illinois 12,294,861 11.0% 1.5%
Indiana 5,839,738 9.8% 1.0%
Iowa 2,837,156 8.5% 1.4%
Kansas 2,616,318 9.9% 1.2%
Kentucky 3,864,679 14.6% 2.3%
Louisiana 4,310,285 20.1% 2.0%
Maine 1,266,498 10.8% 2.2%
Maryland 5,046,171 7.7% 1.6%
Massachusetts 6,116,806 9.2% 1.7%
Michigan 10,040,679 11.4% 2.0%
Minnesota 4,833,278 10.7% 1.3%
Mississippi 2,761,422 17.4% 2.4%
Missouri 5,405,443 10.1% 1.8%
Montana 924,582 17.3% 2.9%
Nebraska 1,716,417 13.2% 1.0%
Nevada 1,862,276 11.2% 2.4%
New Hampshire 1,224,200 10.0% 1.6%
New Jersey 8,092,295 9.1% 2.6%
New Mexico 1,829,164 20.4% 2.2%
New York 18,420,007 17.0% 2.4%
North Carolina 7,426,910 14.8% 1.4%
North Dakota 646,079 15.2% 2.4%
Ohio 11,224,522 11.4% 1.7%
Oklahoma 3,268,838 14.8% 1.7%
Oregon 3,355,739 15.1% 3.0%
Pennsylvania 11,912,109 11.6% 2.3%
Rhode Island 968,057 11.7% 1.6%
South Carolina 3,851,167 13.0% 1.5%
South Dakota 711,326 10.7% 1.3%
Tennessee 5,572,470 12.8% 2.2%
Texas 19,944,736 15.3% 1.8%
Utah 2,105,665 9.4% 1.7%
Vermont 593,161 10.0% 2.5%
Virginia 6,687,894 8.9% 1.0%
Washington 5,747,382 9.0% 1.8%
West Virginia 1,750,073 18.0% 2.9%
Wisconsin 5,128,974 8.9% 1.9%
Wyoming 486,314 11.7% 2.3%

Medicaid/Medicare Certified Facilities

Skilled Nursing ICF-MR Home Health Rural Health
State Hospitals Facilities Facilities Agencies Clinics
National Total* 6,052 14,831 6,731 7,160 3,352
Alabama 123 221 8 143 60
Alaska 24 15 0 16 11
Arizona 85 149 11 68 8
Arkansas 96 193 40 182 82
California 468 1,269 1,041 579 225
Colorado 83 202 3 131 43
Connecticut 47 250 122 82 0
Delaware 11 38 2 16 0
District of Columbia 16 19 131 16 0
Florida 239 724 108 318 135
Georgia 182 326 13 99 125
Hawaii 27 41 22 19 1
Idaho 48 82 67 54 35
Illinois 219 658 318 288 198
Indiana 151 496 574 180 52
Iowa 120 300 127 180 134
Kansas 149 264 42 149 156
Kentucky 118 307 12 111 72
Louisiana 175 225 473 255 49
Maine 41 126 28 36 50
Maryland 67 244 5 53 0
Massachusetts 119 505 7 133 0
Michigan 174 389 2 193 153
Minnesota 151 412 272 250 60
Mississippi 104 132 13 62 133
Missouri 141 455 18 171 163
Montana 62 101 2 51 32
Nebraska 96 172 4 70 76
Nevada 42 49 20 36 2
New Hampshire 30 67 1 35 21
New Jersey 107 306 9 54 0
New Mexico 51 69 43 67 14
New York 268 665 750 211 10
North Carolina 135 407 333 165 125
North Dakota 51 88 66 35 80
Ohio 205 893 461 348 17
Oklahoma 151 242 54 188 61
Oregon 63 124 1 60 30
Pennsylvania 252 752 206 328 53
Rhode Island 17 99 5 25 1
South Carolina 76 178 158 78 96
South Dakota 63 89 4 46 55
Tennessee 148 276 83 153 34
Texas 479 1,014 915 860 391
Utah 50 81 14 43 15
Vermont 16 42 2 13 23
Virginia 118 229 19 161 58
Washington 97 266 17 62 61
West Virginia 66 114 62 68 69
Wisconsin 142 369 41 131 65
Wyoming 27 34 2 39 18
*National total does not include certified facilities in US territories.

Source: Oscar Report 10. Facility Counts: Active Providers. Health Care Financing Administration, Center for Medicaid and State
Operations. December 2000.

Licensed Pharmacies (As of June 30, 2000)*

Non-Independent
Hospital/ Community Out-of-State or
Total Institutional Independent Pharmacies Non-Resident
State Pharmacies Pharmacies Pharmacies (Four or More) Pharmacies
National Total 73,781 8,502 25,273 15,046 7,714
Alabama 1,779 178 816 548 237
Alaska 111 (g) 12 (h) - - 122
Arizona 845 110 158 577 0
Arkansas 739 173 230 509 117
California 6,271 647 5,456 (a) - 168
Colorado 817 - - - 205
Connecticut 685 58 207 420 175
Delaware 154 13 19 128 216
District of Columbia 150 15 60 75 0
Florida 6,176 1,965 3,581 (a) (a) 272
Georgia 2,358 216 (p) (p) -
Hawaii 407 - - - 167
Idaho 486 57 250 (a, e) - 159
Illinois 2,788 358 2,429 (a) (a) 198
Indiana 1,353 197 - - 145
Iowa 1,188 131 (f) 825 (a, f) (a) 216
Kansas 787 178 609 (a) - 230
Kentucky 1,438 125 466 671 176
Louisiana 1,663 171 585 520 223
Maine 290 42 - - 187
Maryland 1,243 (i) 61 274 600 175
Massachusetts 1,189 (j) 158 345 669 0
Michigan 2,329 - - 31 -
Minnesota 1,338 181 516 461 200
Mississippi 962 130 - - 220
Missouri 1,550 (k) 135 - - 254
Montana 318 24 - - 111
Nebraska 464 95 - - 181 (l)
Nevada 575 43 187 345 172
New Hampshire 263 34 47 169 0
New Jersey 2,308 - - - -
New Mexico 541 56 128 (a) 152 (a) 182
New York 4,456 499 2,042 1,902 N/A
North Carolina 2,032 (f) 154 554 967 189
North Dakota 421 48 162 20 191
Ohio 2,833 (n) 228 574 1,574 234
Oklahoma 1,275 90 (d) 913 (a) (a) 257
Oregon 1,003 118 280 427 172
Pennsylvania 3,198 303 - - -
Rhode Island 206 22 48 138 210
South Carolina 1,079 136 285 566 215
South Dakota 421 41 146 75 159
Tennessee 1,710 370 493 727 120
Texas (a) 5,488 (b) 594 1,664 2,153 188
Utah 689 103 375 (a) (a) 157
Vermont 154 17 137 - 0
Virginia 1,513 - - - 307
Washington 1,440 216 (c) 412 628 184
West Virginia 797 - - - 217
Wisconsin 1,125 - - 0 0
Wyoming 348 - - - 206
*Figures reported reflect number of pharmacies licensed by state boards of pharmacy.
Individual columns will not sum to total. Blanks (-) indicate that information was not available.
Source: 2000-2001 National Association of Boards of Pharmacy, Survey of Pharmacy Law.

LEGEND
a – Chains included in independent community pharmacies figure.

b – Also licenses 889 nuclear, public health, clinic, ambulatory surgical center, and HMO pharmacy.
c – Includes 107 hospital, 17 nursing home, 25 home infusion, six nuclear, 42 HMO, and 19 other pharmacies.
d – Approximately.
e – Plus 19 limited service and 53 parenteral admixture pharmacies.
f – In-state.
g – Includes eight wholesalers drug distributors.
h – Drug rooms.
i – Total includes other areas not listed: clinic, correctional, HMO, nursing home, IV nuclear, research, and other.
j – Total also includes 12 home IV pharmacies, 11LTCF pharmacies, and one mail order pharmacy.
k – Includes 1,296 class A community/ambulatory pharmacies (no breakdown available between independent and chains
[4 or more]). Plus six long-term care, 26 home health, three nuclear, and one renal dialysis.
l – Nebraska “registers” out-of-state pharmacies.
m – Plus 336 who are practicing, but place is unknown.
n – Includes 223 nuclear, clinic, fluid therapy, mail order, specialty, and pharmacies serving nursing homes only.
o – As of January 7, 2000.
p – 2,142 (2,098 independent and chain pharmacies, 10 nuclear pharmacies, 28 prison pharmacies, four pharmacy clinics, and
two pharmacy school).

Physicians, 1998
Physicians Office Based Percent Primary Care Percent
State Physicians Per 1,000 Physicians Office Based Physicians Primary Care
National Total 696,600 2.6% 462,719 66.4% 249,291 35.8%
Alabama 8,816 2.1% 6,316 71.6% 3,335 37.8%
Alaska 1,185 1.8% 850 71.7% 439 37.0%
Arizona 9,821 2.0% 6,991 71.2% 3,393 34.5%
Arkansas 4,966 1.9% 3,615 72.8% 1,957 39.4%
California 82,640 2.5% 58,077 70.3% 29,432 35.6%
Colorado 9,734 2.5% 6,988 71.8% 3,523 36.2%
Connecticut 11,746 3.6% 7,387 62.9% 3,979 33.9%
Delaware 1,787 2.3% 1,216 68.0% 594 33.2%
District of Columbia 4,180 8.2% 1,990 47.6% 1,225 29.3%
Florida 36,573 2.5% 27,359 74.8% 12,327 33.7%
Georgia 16,821 2.2% 11,700 69.6% 6,122 36.4%
Hawaii 3,372 2.8% 2,385 70.7% 1,283 38.0%
Idaho 1,959 1.5% 1,619 82.6% 775 39.6%
Illinois 31,902 2.6% 20,107 63.0% 12,478 39.1%
Indiana 11,630 2.0% 8,429 72.5% 4,442 38.2%
Iowa 5,051 1.8% 3,499 69.3% 1,963 38.9%
Kansas 5,517 2.1% 3,817 69.2% 2,161 39.2%
Kentucky 8,381 2.2% 6,078 72.5% 3,137 37.4%
Louisiana 10,972 2.5% 7,295 66.5% 3,795 34.6%
Maine 2,831 2.2% 2,071 73.2% 1,097 38.7%
Maryland 20,925 4.1% 11,807 56.4% 6,400 30.6%
Massachusetts 25,729 4.2% 14,659 57.0% 7,956 30.9%
Michigan 22,229 2.2% 14,040 63.2% 8,296 37.3%
Minnesota 12,019 2.5% 8,058 67.0% 4,769 39.7%
Mississippi 4,710 1.7% 3,380 71.8% 1,744 37.0%
Missouri 12,801 2.4% 8,229 64.3% 4,303 33.6%
Montana 1,723 1.9% 1,442 83.7% 630 36.6%
Nebraska 3,692 2.2% 2,512 68.0% 1,501 40.7%
Nevada 3,115 1.7% 2,466 79.2% 1,141 36.6%
New Hampshire 2,860 2.3% 2,045 71.5% 1,058 37.0%
New Jersey 24,200 3.0% 15,954 65.9% 8,856 36.6%
New Mexico 3,911 2.1% 2,585 66.1% 1,435 36.7%
New York 71,186 3.9% 39,872 56.0% 24,934 35.0%
North Carolina 17,991 2.4% 12,157 67.6% 6,438 35.8%
North Dakota 1,456 2.3% 1,075 73.8% 603 41.4%
Ohio 26,822 2.4% 17,653 65.8% 10,017 37.3%
Oklahoma 5,841 1.8% 4,165 71.3% 2,158 36.9%
Oregon 7,585 2.3% 5,644 74.4% 2,832 37.3%
Pennsylvania 35,394 3.0% 22,502 63.6% 12,170 34.4%
Rhode Island 3,397 3.5% 2,050 60.3% 1,260 37.1%
South Carolina 8,196 2.1% 5,725 69.9% 3,086 37.7%
South Dakota 1,434 2.0% 1,105 77.1% 591 41.2%
Tennessee 13,728 2.5% 9,589 69.8% 4,946 36.0%
Texas 41,512 2.1% 28,526 68.7% 14,505 34.9%
Utah 4,297 2.0% 3,003 69.9% 1,535 35.7%
Vermont 1,837 3.1% 1,154 62.8% 746 40.6%
Virginia 17,298 2.6% 11,571 66.9% 6,253 36.1%
Washington 13,901 2.4% 9,923 71.4% 5,117 36.8%
West Virginia 4,029 2.3% 2,659 66.0% 1,551 38.5%
Wisconsin 12,037 2.3% 8,723 72.5% 4,622 38.4%
Wyoming 861 1.8% 657 76.3% 381 44.3%
Source: Area Resource File. Office of Research and Planning, Bureau of Health Professions. February 2000.

Other Providers
Registered Nurses* Pharmacists** Pharmacists**
State Registered Nurses* per 1,000 (Licensed by State) per 1,000
National Total 2,161,700 8.1 334,851 1.2
Alabama 32,800 7.6 6,541 1.6
Alaska 6,300 10.3 518 0.8
Arizona 33,200 7.3 5,548 1.1
Arkansas 17,900 7.1 3,374 1.3
California 179,700 5.6 27,152 0.8
Colorado 30,900 7.9 5,254 1.3
Connecticut 33,400 10.2 4,265 1.3
Delaware 7,700 10.5 1,209 1.5
District of Columbia 8,900 16.8 1,350 2.6
Florida 119,300 8.1 19,425 1.3
Georgia 53,600 7.2 9,551 1.2
Hawaii 8,900 7.5 1,372 1.1
Idaho 7,100 5.9 1,447 1.1
Illinois 104,700 8.8 12,278 1.0
Indiana 46,900 8.0 8,038 1.4
Iowa 29,100 10.2 4,878 1.7
Kansas 21,600 8.3 3,540 1.4
Kentucky 30,400 7.8 4,746 1.2
Louisiana 32,400 7.4 5,774 1.3
Maine 13,300 10.7 1,267 1.0
Maryland 43,000 8.4 6,700 1.3
Massachusetts 73,300 12.0 9,283 1.5
Michigan 79,600 8.1 10,693 1.1
Minnesota 46,200 9.9 5,628 1.2
Mississippi 19,900 7.3 3,440 1.2
Missouri 51,200 9.5 6,317 1.2
Montana 7,100 8.1 1,262 1.4
Nebraska 15,200 9.2 2,445 1.4
Nevada 9,900 5.9 7,427 4.0
New Hampshire 11,200 9.6 1,824 1.5
New Jersey 67,100 8.3 15,542 1.9
New Mexico 11,700 6.8 2,258 1.2
New York 167,600 9.2 18,780 1.0
North Carolina 62,000 8.4 8,977 1.2
North Dakota 6,400 10.2 2,039 3.2
Ohio 101,200 9.1 13,797 1.2
Oklahoma 19,600 5.9 4,560 1.4
Oregon 26,500 8.2 3,952 1.2
Pennsylvania 126,300 10.5 16,894 1.4
Rhode Island 11,400 11.6 1,723 1.8
South Carolina 27,400 7.3 5,116 1.3
South Dakota 7,700 10.4 1,391 2.0
Tennessee 46,400 8.0 7,358 1.3
Texas 124,200 6.4 19,825 1.0
Utah 13,000 6.3 2,140 1.0
Vermont 5,300 9.0 793 1.3
Virginia 54,400 8.1 7,471 1.1
Washington 43,500 7.8 6,279 1.1
West Virginia 15,000 8.3 2,948 1.7
Wisconsin 45,600 8.8 5,837 1.1
Wyoming 4,200 8.8 1,001 2.1
*As of December 1996. ** As of June 30, 2000.

Source: U.S. Department of Health and Human Services, Health Resources and Services Administration, Division of Nursing, 1996.
2000-2001 National Association of Boards of Pharmacy, Survey of Pharmacy Law.


Section 4:
Pharmacy Program
Characteristics


THE MEDICAID PROGRAM

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 the U.S. territories of 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 RECIPIENTS
Every state, in order to receive federal funding under Title XIX, must provide Medicaid benefits to certain
“categorically needy” persons. Categorically needy individuals include those who meet the requirements for the
block grant Temporary Assistance for Needy Families (TANF) program (replaced the Aid to Families with
Dependent Children (AFDC) program); and, with a few exceptions, the aged, blind, and disabled who receive
Supplemental Security Income (SSI). Other groups that are categorically needy and thus automatically eligible
for Medicaid include:
• Children under age six whose family income is at or below 133% of the Federal poverty level (FPL),
• All children (under age 19) born after September 30, 1983 in families with incomes at or below the FPL,
• Pregnant women whose family income is below 133% of the FPL,
• Certain Medicare beneficiaries, and
• Recipients of adoption assistance and foster care under Title IV-E of the Social Security Act.
States may also provide Medicaid coverage to optional groups, or other “categorically needy” groups. Optional
coverage may be extended to certain aged, blind, or disabled persons who do not normally qualify for mandatory
coverage due to higher incomes, but who are below the FPL. Coverage may also be extended to pregnant women
and infants up to age one who are not covered under mandatory coverage, but whose income is also below the
federal poverty level.
In addition to the “categorically needy” that must be covered by Medicaid programs, there are other groups who
are “medically needy” who may be included in Medicaid at the option of each state. States may elect to provide
services to persons whose income levels are above the level to qualify for Medicaid but have medical expenses so
excessive as to offset their incomes.
Along with designating groups of people who must be covered by a state’s Medicaid plan and defining other
groups that may be covered at the discretion of the state, the federal government specifies certain general
requirements that must be met for Medicaid eligibility. A state can provide coverage for persons who do not meet
these requirements (i.e., the uninsured), but state and/or local funds must be used to support the medical expenses
of these individuals. A Medicaid agency that chooses to cover other optional groups must provide Medicaid to all
eligible individuals in that group.
MEDICAID SERVICES
The original Title XIX legislation listed several types of medical care as eligible for federal funding. Federal
regulations pertaining to Medicaid mandate that in order to receive federal matching funds, certain basic services
must be offered to all “categorically needy” individuals. These services include:
• Inpatient and outpatient hospital services;

• Physician services;

• Medical and surgical dental services;

• Laboratory and X-ray services;
• Nursing facility services (for persons 21 years of age or older);
• Early and periodic screening, diagnostic, and treatment (EPSDT) services for children under age 21;
• Family planning services and supplies;
• Home health services for persons eligible for nursing facility services;
• Rural health clinic services and any other ambulatory services offered by a rural health clinic that are
otherwise covered under the State plan;
• Nurse-midwife services (to the extent authorized under State law);
• Pediatric and family nurse practitioners services; and
• Federally-qualified health center services and any other ambulatory services offered by a federally-
qualified health center that are otherwise covered under the State plan.
If a State chooses to include the “medically needy” population, the State plan must provide, as a minimum, the
following services:
• Prenatal care and delivery services for pregnant women;

• Ambulatory services to individuals under age 18 and individuals entitled to institutional services;
• Home health services to individuals entitled to nursing facility services; and
• If the State plan includes services either in institutions for mental diseases or in intermediate care facilities
for the mentally retarded (ICF/MRs), it must offer medically needy groups certain 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;
• Intermediate care facilities for the mentally retarded (ICFs/MR);
• Nursing facility services (children under 21 years old);
• Prescribed drugs;
• Optometrist services and eyeglasses;
• 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, rehabilitation, and other services
requested by the State and approved by HCFA.

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;
• 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.
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.
Rural Health Clinic Services
Rural health clinic (RHC) services became mandatory for the categorically needy in July 1978. Each RHC is
required to have a nurse practitioner (NP) or physician’s assistant (PA) on its staff. Therefore, a clinic can be
certified only if the state permits the delivery of primary care by an NP or PA. Services in certified clinics must
be provided and furnished by a physician or by a PA, NP, nurse-midwife, or other specialized nurse practitioner.
Services and supplies are furnished as an incident to professional services. Part-time or intermittent visiting nurse
care and related medical supplies are provided if the clinic is located in a Health Manpower Shortage Area, the
services are furnished by nurses employed by the clinic, 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. As
specified in 42 CFR 440.30 (a-c), federal requirements for Medicaid mandate that these services 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.”
Skilled Nursing Facility Services
Skilled nursing facility (SNF) services are provided to individuals age 21 or older. They do not include services
provided in institutions for mental diseases (42 CFR 440.40(a)). These services must be required on a daily basis
and 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. These requirements include provider agreements, facility certification, and facility
standards; and
• Ordered by and under the direction of a physician.
The services include those provided by any facility located on an Indian reservation and certified by the Secretary
of Health and Human Services. Further, the requirements concerning control of the utilization of Medicaid
services affect skilled nursing facility services in areas such as certification and re-certification of need for
inpatient care, individual written plan of care, etc.
Early and Periodic Screening, Diagnosis and Treatment
Early and periodic screening, diagnosis 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:
• Health and developmental history screening;

• Unclothed physical examination;
• Developmental assessment;
• Immunizations appropriate for age and health history;
• Assessment of nutritional status;
• Vision testing;
• Hearing testing;
• Laboratory procedures appropriate for age and population group;
• Dental services furnished by direct referral to a dentist for diagnosis and treatment for children three years
of age and over;
• Treatment of defects in vision and hearing, including eyeglasses and hearing aids; and
• Dental care needed for relief of pain and infections, restoration of teeth and maintenance of dental health.
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.
Family Planning Services
Family planning services and supplies are allowable for women of childbearing age as a means of enabling
individuals to freely determine the number and spacing of their children. Although there are no federal
regulations defining what family planning services a state can provide, provisional regulations define family
planning services as consultation (including counseling and patient education), examination, and treatment,

furnished by or under the supervision of a physician or prescribed by a physician; laboratory examination;

medically approved methods, procedures, pharmaceutical supplies and devices to prevent conception; natural
family planning methods, diagnosis and treatment for infertility; and voluntary sterilization. In addition, states
may provide any medically approved means other than abortion, for family planning purposes, if furnished by or
under supervision of a physician or if prescribed by a physician. Abortions are specifically excluded from family
planning services and states are prohibited from considering any abortion as a family planning service.
Voluntary sterilization must be included among the range of family planning services offered by a state. Federal
regulations require that the individual to be sterilized voluntarily give informed written consent and that the
individual must be mentally competent and at least 21 years of age at the time consent is obtained.
Physicians’ Services
Physicians’ services are covered, whether provided in the office, the patient’s home, a hospital, a skilled 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 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,
skilled nursing facility, or intermediate care facility (ICF), except for home health services in an ICF that are not
required to be provided by the facility. Services provided must be on physicians’ orders as part of a written plan
of care that is reviewed by the physician every 62 days. Home health services include three mandatory services
(part-time nursing, home health aide, medical supplies and equipment) and four optional service (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 these services are provided below:
• Personal Care Services: Services provided to an individual who is not an inpatient or resident of a
hospital, nursing facility, immediate care facility for the mentally retarded, or institution for mental
disease. Services are authorized by a physician in accordance with treatment or service plan authorized
by the state, provided by a qualified individual who is not a member of the recipients family, and
furnished in a home or other location.
• 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.
• 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 that encompass the management and care of mothers and newborns. Care is
provided throughout the maternity cycle and is furnished within the scope of practice authorized by the
state.
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 HHS 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:
• The facility receives a grant under sections 329, 330, or 340 of the Public Health Service Act;
• The Health Resources and Services Administration recommends, and the HHS 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 person.
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
In 1998, the Medicaid program provided health care services to 40.6 million people, at a cost of $142 billion. 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 83%, depending on the state’s per
capita income (see the Federal Medical Assistance Percentage (FMAP) table, page 4-12).
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 83%.
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.)).

Total U.S. Medical Assistance Recipients*

by Type of Service
Percent Percent Percent

Service FY 1998 Using Service FY 1997 Using Service Change
Pharmaceuticals 19,337,543 47.6% 20,954,163 62.4% -7.7%
Physicians 18,554,746 45.6% 21,170,194 63.0% -12.4%
Hospital Outpatient 12,157,729 29.9% 13,632,035 40.6% -10.8%
Lab/X-ray 9,380,689 23.1% 11,074,000 33.0% -15.3%

EPSDT 6,174,628 15.2% 6,449,748 19.2% -4.3%
Clinic 5,285,415 13.0% 4,713,424 14.0% +12.1%
Dental 4,965,202 12.2% 5,935,344 17.7% -16.3%
Hospital Inpatient 4,408,162 10.8% 4,834,677 14.4% -8.8%
Other Practitioners 4,341,915 10.7% 5,141,685 15.3% -15.6%
Personal Support Services* 3,108,432 7.6% -- -- --
Family Planning 2,011,124 4.9% 2,091,116 6.2% -3.8%
Nursing Facility/Services 1,645,728 4.0% 1,603,018 4.8% +2.7%
Home Health Care 1,224,714 3.0% 1,861,124 5.5% -34.2%
ICF-Mentally Retarded 126,490 0.3% 136,025 0.4% -7.0%
Total Recipients 40,649,482‡ 33,579,168‡ +21.1%
*Many services originally recognized as Home Health Care, Physicians, Other Practitioners and other services are now reported as
Personal Support Services, please refer to page 4-8 for an explanation of these services.
‡Figures will not add to totals due to recipients’ use of multiple services.
Source: HCFA, CMSO, HCFA-2082 Report, FY98.

Total U.S. Medical Assistance Payments*

by Type of Service
Percent Percent Percent

Service FY 1998 of Total FY 1997 of Total Change
Nursing Facility/Services $31,892,064,551 22.4% $30,503,842,614 24.7% +4.6%
Hospital Inpatient $24,299,261,217 17.1% $25,152,622,821 20.4% -3.4%
Pharmaceuticals $13,521,707,689 9.5% $11,972,331,192 9.7% +12.9%
ICF-Mentally Retarded $9,481,723,907 6.7% $9,798,302,785 7.9% -3.2%

Personal Support Services* $8,221,956,899 5.8% -- -- --
Physicians $6,070,022,680 4.3% $7,041,038,648 5.7% -13.8%
Hospital Outpatient $5,758,982,745 4.0% $6,168,996,402 5.0% -6.6%
Clinic $3,921,167,731 2.8% $4,252,480,130 3.4% -7.8%
Home Health Care $2,701,512,000 1.9% $12,236,599,938 9.9% -77.9%
EPSDT $1,334,828,107 0.9% $1,616,718,462 1.3% -17.4%
Lab/X-ray $938,700,266 0.7% $1,032,714,257 0.8% -9.1%
Dental $901,385,043 0.6% $979,220,296 0.8% -7.9%
Other Practitioners $587,137,593 0.4% $1,035,781,863 0.8% -43.3%
Family Planning $449,136,397 0.3% $418,365,295 0.3% +7.4%
Total Payments $142,317,903,795‡ $123,552,098,563‡ +15.2%
*Many services originally recognized as Home Health Care, Physicians, Other Practitioners and other services are now reported as
Personal Support Services, please refer to page 4-8 for an explanation of these services.
‡Figures may not add to totals due to rounding.

Federal Medical Assistance Percentage (FMAP), FY1999 and FY2000

State 1999 FMAP 2000 FMAP 2000 Enhanced FMAP*
Alabama 69.27% 69.57% 78.70%
Alaska** 59.80% 59.80% 71.86%
Arizona 65.50% 65.92% 76.14%
Arkansas 72.96% 72.85% 80.99%
California 51.55% 51.67% 66.17%
Colorado 50.59% 50.00% 65.00%
Connecticut 50.00% 50.00% 65.00%
Delaware 50.00% 50.00% 65.00%
District of Columbia** 70.00% 70.00% 79.00%
Florida 55.82% 56.52% 69.57%
Georgia 60.47% 59.88% 71.91%
Hawaii 50.00% 51.01% 65.71%
Idaho 69.85% 70.15% 79.11%
Illinois 50.00% 50.00% 65.00%
Indiana 61.01% 61.74% 73.22%
Iowa 63.32% 63.06% 74.14%
Kansas 60.05% 60.03% 72.02%
Kentucky 70.53% 70.55% 79.38%
Louisiana 70.37% 70.32% 79.22%
Maine 66.40% 66.22% 76.36%
Maryland 50.00% 50.00% 65.00%
Massachusetts 50.00% 50.00% 65.00%
Michigan 52.72% 55.11% 68.58%
Minnesota 51.50% 51.48% 66.04%
Mississippi 76.78% 76.80% 83.76%
Missouri 60.24% 60.51% 72.36%
Montana 71.73% 72.30% 80.61%
Nebraska 61.46% 60.88% 72.62%
Nevada 50.00% 50.00% 65.00%
New Hampshire 50.00% 50.00% 65.00%
New Jersey 50.00% 50.00% 65.00%
New Mexico 72.98% 73.32% 81.32%
New York 50.00% 50.00% 65.00%
North Carolina 63.07% 62.49% 73.74%
North Dakota 69.94% 70.42% 79.29%
Ohio 58.26% 58.67% 71.07%
Oklahoma 70.84% 71.09% 79.76%
Oregon 60.55% 59.96% 71.97%
Pennsylvania 53.77% 53.82% 67.67%
Rhode Island 54.05% 53.77% 67.64%
South Carolina 69.85% 69.95% 78.96%
South Dakota 68.16% 68.72% 78.11%
Tennessee 63.09% 63.10% 74.17%
Texas 62.45% 61.36% 72.95%
Utah 71.78% 71.55% 80.08%
Vermont 61.97% 62.24% 73.57%
Virginia 51.60% 51.67% 66.17%
Washington 52.50% 51.83% 66.28%
West Virginia 74.47% 74.78% 82.35%
Wisconsin 58.85% 58.78% 71.15%
Wyoming 64.08% 64.04% 74.83%
* The "Enhanced Federal Medical Assistance Percentages" are for use in the new Children's Health Insurance Program under Title
XXI, and for some or all of children's medical assistance under the new Medicaid sections 1905(u)(2) and 1905(u)(3).
** For 1999 and 2000, the values in the table were set for state plans 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
54.13% and for the District of Columbia is 50.00%.
Source: Federal Register, January 12, 1999, Vol. 64, No. 7, pages 1805-1808.

Medicaid Payments and Recipients, 1998

Total Total Payments
State Vendor Payments Recipients Per Recipient
National Total $142,317,903,795 40,649,482 $3,501
Alabama $1,902,300,047 527,078 $3,609
Alaska $330,378,398 74,508 $4,434
Arizona $1,643,966,305 507,668 $3,238
Arkansas $1,375,797,421 424,727 $3,239
California $14,236,592,915 7,082,175 $2,010
Colorado $1,439,366,499 344,916 $4,173
Connecticut $2,420,791,474 381,208 $6,350
Delaware $419,732,143 101,436 $4,138
District of Columbia $731,292,552 166,146 $4,402
Florida $5,686,844,862 1,904,591 $2,986
Georgia $3,012,346,312 1,221,978 $2,465
Hawaii $507,433,146 184,614 $2,749
Idaho $424,512,387 123,176 $3,446
Illinois $6,172,865,261 1,363,856 $4,526
Indiana $2,564,005,047 607,293 $4,222
Iowa $1,288,770,390 314,936 $4,092
Kansas $916,323,608 241,933 $3,788
Kentucky $2,425,288,141 644,482 $3,763
Louisiana $2,383,508,985 720,615 $3,308
Maine $747,027,618 170,456 $4,383
Maryland $2,489,280,148 561,085 $4,437
Massachusetts $4,609,360,933 908,238 $5,075
Michigan $4,345,007,824 1,362,890 $3,188
Minnesota $2,924,447,719 538,413 $5,432
Mississippi $1,442,373,276 485,767 $2,969
Missouri $2,569,646,129 734,015 $3,501
Montana $361,238,668 100,760 $3,585
Nebraska $753,162,904 211,188 $3,566
Nevada $462,087,777 128,144 $3,606
New Hampshire $606,004,232 93,970 $6,449
New Jersey $4,218,822,993 813,251 $5,188
New Mexico $862,144,872 329,418 $2,617
New York $24,298,610,635 3,073,241 $7,907
North Carolina $4,013,996,742 1,167,988 $3,437
North Dakota $341,015,420 62,280 $5,476
Ohio $6,120,967,557 1,290,776 $4,742
Oklahoma $1,177,853,941 342,475 $3,439
Oregon $1,377,514,740 511,171 $2,695
Pennsylvania $6,080,191,710 1,523,120 $3,992
Puerto Rico $250,000,000 964,015 $259
Rhode Island $919,353,410 153,130 $6,004
South Carolina $2,018,620,428 594,962 $3,393
South Dakota $355,833,902 89,537 $3,974
Tennessee $3,167,188,993 1,843,661 $1,718
Texas $7,139,928,843 2,324,810 $3,071
Utah $618,675,433 215,801 $2,867
Vermont $351,341,290 123,992 $2,834
Virgin Islands $10,097,973 19,764 $511
Virginia $2,118,202,866 653,236 $3,243
Washington $2,044,234,831 1,413,208 $1,447
West Virginia $1,243,150,526 342,668 $3,628
Wisconsin $2,206,398,750 518,595 $4,255
Wyoming $192,004,819 46,121 $4,163


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 practitioner’s records.
MEDICAID PRESCRIPTION DRUG REIMBURSEMENT
On July 31, 1987, the Health Care Financing Administration (HCFA) 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, HCFA 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, HCFA 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.
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 HCFA 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 programs cover the same
drugs listed by HCFA. 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 HCFA’s 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.

Drug Payments and Recipients, 1998

Total Total Drug Payments
State Drug Payments Drug Recipients‡ Per Recipient
National Total* $13,521,707,689 19,337,543 $699
Alabama $236,674,147 395,290 $599
Alaska $32,887,828 43,734 $752
Arizona $1,442,917 56,796 $25
Arkansas $150,891,615 262,907 $574
California $1,553,598,462 2,644,430 $587
Colorado $110,159,725 147,033 $749
Connecticut $186,593,992 108,331 $1,722
Delaware $41,350,537 69,027 $599
District of Columbia $41,254,973 57,733 $715
Florida $933,782,041 1,014,372 $921
Georgia $370,562,935 805,923 $460
Hawaii $39,623,380 32,222 $1,230
Idaho $54,971,097 86,775 $633
Illinois $583,239,675 959,472 $608
Indiana $325,712,348 323,811 $1,006
Iowa $147,115,884 215,173 $684
Kansas $118,825,316 155,875 $762
Kentucky $319,983,951 429,102 $746
Louisiana $352,784,785 552,481 $639
Maine $121,771,298 137,816 $884
Maryland $148,532,940 176,403 $842
Massachusetts $497,146,531 613,186 $811
Michigan $374,145,567 589,818 $634
Minnesota $173,602,492 203,220 $854
Mississippi $231,735,360 368,609 $629
Missouri $382,512,566 353,902 $1,081
Montana $42,368,399 58,641 $723
Nebraska $92,558,539 145,408 $637
Nevada $34,518,901 50,903 $678
New Hampshire $55,374,478 70,339 $787
New Jersey $426,075,488 309,849 $1,375
New Mexico $41,507,229 96,637 $430
New York $1,368,451,273 1,803,428 $759
North Carolina $466,528,812 764,886 $610
North Dakota $27,619,684 37,675 $733
Ohio $645,118,962 702,143 $919
Oklahoma - - -
Oregon $87,805,350 148,258 $592
Pennsylvania $525,261,211 580,749 $904
Rhode Island $61,401,958 44,852 $1,369
South Carolina $224,962,203 401,611 $560
South Dakota $31,106,511 46,588 $668
Tennessee $36 1 $36
Texas $817,591,112 1,894,447 $432
Utah $68,827,853 126,953 $542
Vermont $43,445,887 58,037 $749
Virginia $284,578,558 383,880 $741
Washington $244,478,658 274,463 $891
West Virginia $148,962,081 267,398 $557
Wisconsin $232,326,359 221,508 $1,049
Wyoming $17,138,952 32,510 $527
*National figures include Puerto Rico and the Virgin Islands.
**Oklahoma did not submit detailed drug information for 1998.
‡Recipients are defined as individuals who received drugs, not as everyone eligible to receive drugs.

Drug Payment Trends

State 1994 1995 1996 1997 1998
National Total* $8,873,950,031 $9,790,651,449 $10,697,438,066 $11,972,331,192 $13,521,707,689
Alabama $163,021,321 $178,667,753 $203,811,076 $226,105,163 $236,674,147
Alaska $16,744,047 $18,469,364 $21,661,213 $28,376,842 $32,887,828
Arizona $1,165,786 $2,027,734 $2,460,613 $1,855,672 $1,442,917
Arkansas $88,069,017 $102,114,998 $115,070,827 $135,757,334 $150,891,615
California $1,122,754,027 $1,145,514,700 $1,223,444,736 $1,335,065,753 $1,553,598,462
Colorado $70,483,595 $78,833,103 $82,543,502 $96,964,178 $110,159,725
Connecticut $120,470,177 $145,366,245 $146,856,083 $166,667,301 $186,593,992
Delaware $18,351,293 $21,458,681 $27,743,076 $34,713,581 $41,350,537
District of Columbia $25,227,269 $26,231,966 $32,765,197 $37,512,355 $41,254,973
Florida $484,052,934 $556,864,923 $658,291,958 $772,780,639 $933,782,041
Georgia $260,307,087 $288,511,672 $319,230,386 $339,257,021 $370,562,935
Hawaii** $34,461,968 $24,802,573 $26,854,246 - $39,623,380
Idaho $29,378,146 $33,153,237 $41,028,033 $45,042,165 $54,971,097
Illinois $330,697,673 $440,883,001 $446,214,047 $523,561,885 $583,239,675
Indiana $232,645,959 $187,674,037 $269,001,714 $293,318,000 $325,712,348
Iowa $91,202,410 $97,382,501 $111,346,007 $123,861,339 $147,115,884
Kansas $71,285,408 $81,455,408 $90,754,656 $104,628,978 $118,825,316
Kentucky $217,044,606 $251,745,610 $272,539,525 $316,464,180 $319,983,951
Louisiana $269,035,462 $292,293,619 $297,433,210 $315,444,016 $352,784,785
Maine $64,043,624 $63,906,058 $83,822,289 $102,537,196 $121,771,298
Maryland $125,216,705 $139,205,331 $154,908,882 $172,701,280 $148,532,940
Massachusetts $251,184,700 $308,411,398 $302,911,947 $398,076,057 $497,146,531
Michigan $290,264,217 $312,003,749 $352,620,438 $365,282,227 $374,145,567
Minnesota $113,841,194 $148,450,414 $150,350,355 $155,830,086 $173,602,492
Mississippi $140,045,378 $162,743,883 $176,758,960 $208,577,199 $231,735,360
Missouri $228,660,484 $259,657,651 $281,700,005 $320,660,206 $382,512,566
Montana $26,211,646 $28,335,142 $32,742,122 $35,470,912 $42,368,399
Nebraska $55,495,790 $61,738,837 $71,482,836 $79,727,194 $92,558,539
Nevada $17,653,922 $21,320,507 $24,384,747 $26,652,299 $34,518,901
New Hampshire $28,419,726 $34,099,265 $42,310,704 $45,361,780 $55,374,478
New Jersey $308,046,437 $344,176,481 $374,015,636 $369,839,049 $426,075,488
New Mexico $47,770,092 $50,545,800 $61,171,361 $63,345,896 $41,507,229
New York $727,303,151 $819,359,316 $907,083,895 $1,090,917,486 $1,368,451,273
North Carolina $215,197,252 $277,430,790 $344,950,165 $403,811,339 $466,528,812
North Dakota $17,639,044 $19,711,865 $20,904,298 $25,226,544 $27,619,684
Ohio $415,250,727 $480,233,424 $518,641,009 $580,572,988 $645,118,962
Oklahoma** $89,253,227 $100,909,395 $98,292,786 $110,880,182 -
Oregon $85,902,712 $82,647,757 $67,013,699 $73,216,753 $87,805,350
Pennsylvania $489,131,313 $543,774,387 $536,797,657 $552,268,949 $525,261,211
Rhode Island $39,752,373 $47,808,612 $45,679,642 $52,165,739 $61,401,958
South Carolina $110,845,482 $124,500,348 $143,804,519 $159,606,414 $224,962,203
South Dakota $19,017,682 $21,567,935 $24,147,295 $27,591,466 $31,106,511
Tennessee $76,314,794 $190,467 $15,337 $1,118 $36
Texas $511,841,929 $578,661,512 $667,743,192 $750,056,208 $817,591,112
Utah $39,728,466 $44,397,971 $48,149,414 $50,825,675 $68,827,853
Vermont $28,384,265 $33,658,620 $36,539,101 $44,291,004 $43,445,887
Virginia $195,777,613 $213,182,924 $221,421,619 $249,620,903 $284,578,558
Washington $168,193,537 $161,555,588 $172,652,369 $204,980,369 $244,478,658
West Virginia $106,852,366 $130,451,359 $124,984,023 $133,044,683 $148,962,081
Wisconsin $183,836,535 $190,678,825 $205,429,565 $205,503,614 $232,326,359
Wyoming $10,475,463 $11,884,713 $13,635,463 $14,864,016 $17,138,952

**Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively.

Drug Payment - Percent Change from 1997 to 1998

State 1997 1998 Percent Change
National Total* $11,972,331,192 $13,521,707,689 13%
Alabama $226,105,163 $236,674,147 5%
Alaska $28,376,842 $32,887,828 16%
Arizona $1,855,672 $1,442,917 -22%
Arkansas $135,757,334 $150,891,615 11%
California $1,335,065,753 $1,553,598,462 16%
Colorado $96,964,178 $110,159,725 14%
Connecticut $166,667,301 $186,593,992 12%
Delaware $34,713,581 $41,350,537 19%
District of Columbia $37,512,355 $41,254,973 10%
Florida $772,780,639 $933,782,041 21%
Georgia $339,257,021 $370,562,935 9%
Hawaii** - $39,623,380 -
Idaho $45,042,165 $54,971,097 22%
Illinois $523,561,885 $583,239,675 11%
Indiana $293,318,000 $325,712,348 11%
Iowa $123,861,339 $147,115,884 19%
Kansas $104,628,978 $118,825,316 14%
Kentucky $316,464,180 $319,983,951 1%
Louisiana $315,444,016 $352,784,785 12%
Maine $102,537,196 $121,771,298 19%
Maryland $172,701,280 $148,532,940 -14%
Massachusetts $398,076,057 $497,146,531 25%
Michigan $365,282,227 $374,145,567 2%
Minnesota $155,830,086 $173,602,492 11%
Mississippi $208,577,199 $231,735,360 11%
Missouri $320,660,206 $382,512,566 19%
Montana $35,470,912 $42,368,399 19%
Nebraska $79,727,194 $92,558,539 16%
Nevada $26,652,299 $34,518,901 30%
New Hampshire $45,361,780 $55,374,478 22%
New Jersey $369,839,049 $426,075,488 15%
New Mexico $63,345,896 $41,507,229 -34%
New York $1,090,917,486 $1,368,451,273 25%
North Carolina $403,811,339 $466,528,812 16%
North Dakota $25,226,544 $27,619,684 9%
Ohio $580,572,988 $645,118,962 11%
Oklahoma** $110,880,182 - -
Oregon $73,216,753 $87,805,350 20%
Pennsylvania $552,268,949 $525,261,211 -5%
Rhode Island $52,165,739 $61,401,958 18%
South Carolina $159,606,414 $224,962,203 41%
South Dakota $27,591,466 $31,106,511 13%
Tennessee $1,118 $36 -97%
Texas $750,056,208 $817,591,112 9%
Utah $50,825,675 $68,827,853 35%
Vermont $44,291,004 $43,445,887 -2%
Virginia $249,620,903 $284,578,558 14%
Washington $204,980,369 $244,478,658 19%
West Virginia $133,044,683 $148,962,081 12%
Wisconsin $205,503,614 $232,326,359 13%
Wyoming $14,864,016 $17,138,952 15%

Source: HCFA, CMSO, HCFA-2082 Report, FY97, FY98.

Ranking Based on Drug Payments

% of 1998 Total
1998 1998 Medicaid Drug 1997 1997
State Payments Ranking Payments Payments Ranking
California $1,553,598,462 1 11.49% $1,335,065,753 1
New York $1,368,451,273 2 10.12% $1,090,917,486 2
Florida $933,782,041 3 6.91% $772,780,639 3
Texas $817,591,112 4 6.05% $750,056,208 4
Ohio $645,118,962 5 4.77% $580,572,988 5
Illinois $583,239,675 6 4.31% $523,561,885 7
Pennsylvania $525,261,211 7 3.88% $552,268,949 6
Massachusetts $497,146,531 8 3.68% $398,076,057 9
North Carolina $466,528,812 9 3.45% $403,811,339 8
New Jersey $426,075,488 10 3.15% $369,839,049 10
Missouri $382,512,566 11 2.83% $320,660,206 13
Michigan $374,145,567 12 2.77% $365,282,227 11
Georgia $370,562,935 13 2.74% $339,257,021 12
Louisiana $352,784,785 14 2.61% $315,444,016 15
Indiana $325,712,348 15 2.41% $293,318,000 16
Kentucky $319,983,951 16 2.37% $316,464,180 14
Virginia $284,578,558 17 2.10% $249,620,903 17
Washington $244,478,658 18 1.81% $204,980,369 21
Alabama $236,674,147 19 1.75% $226,105,163 18
Wisconsin $232,326,359 20 1.72% $205,503,614 20
Mississippi $231,735,360 21 1.71% $208,577,199 19
South Carolina $224,962,203 22 1.66% $159,606,414 24
Connecticut $186,593,992 23 1.38% $166,667,301 23
Minnesota $173,602,492 24 1.28% $155,830,086 25
Arkansas $150,891,615 25 1.12% $135,757,334 26
West Virginia $148,962,081 26 1.10% $133,044,683 27
Maryland $148,532,940 27 1.10% $172,701,280 22
Iowa $147,115,884 28 1.09% $123,861,339 28
Maine $121,771,298 29 0.90% $102,537,196 31
Kansas $118,825,316 30 0.88% $104,628,978 30
Colorado $110,159,725 31 0.81% $96,964,178 32
Nebraska $92,558,539 32 0.68% $79,727,194 33
Oregon $87,805,350 33 0.65% $73,216,753 34
Utah $68,827,853 34 0.51% $50,825,675 37
Rhode Island $61,401,958 35 0.45% $52,165,739 36
New Hampshire $55,374,478 36 0.41% $45,361,780 38
Idaho $54,971,097 37 0.41% $45,042,165 39
Vermont $43,445,887 38 0.32% $44,291,004 40
Montana $42,368,399 39 0.31% $35,470,912 42
New Mexico $41,507,229 40 0.31% $63,345,896 35
Delaware $41,350,537 41 0.31% $34,713,581 43
District of Columbia $41,254,973 42 0.31% $37,512,355 41
Hawaii* $39,623,380 43 0.29% - -
Nevada $34,518,901 44 0.26% $26,652,299 46
Alaska $32,887,828 45 0.24% $28,376,842 44
South Dakota $31,106,511 46 0.23% $27,591,466 45
North Dakota $27,619,684 47 0.20% $25,226,544 47
Wyoming $17,138,952 48 0.13% $14,864,016 48
Arizona $1,442,917 49 0.01% $1,855,672 49
Tennessee $36 50 0.00% $1,118 50
Oklahoma* - - - $110,880,182 29
*Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively.
Source: HCFA, CMSO, HCFA-2082 Report, FY97, FY98.

Drugs as a Percentage of Total Vendor Payments, 1998

Total Total % of Total
State Drug Payments Vendor Payments Vendor Payments
National Total* $13,521,707,689 $142,317,903,795 9.5%
Alabama $236,674,147 $1,902,300,047 12.4%
Alaska $32,887,828 $330,378,398 10.0%
Arizona $1,442,917 $1,643,966,305 0.1%
Arkansas $150,891,615 $1,375,797,421 11.0%
California $1,553,598,462 $14,236,592,915 10.9%
Colorado $110,159,725 $1,439,366,499 7.7%
Connecticut $186,593,992 $2,420,791,474 7.7%
Delaware $41,350,537 $419,732,143 9.9%
District of Columbia $41,254,973 $731,292,552 5.6%
Florida $933,782,041 $5,686,844,862 16.4%
Georgia $370,562,935 $3,012,346,312 12.3%
Hawaii $39,623,380 $507,433,146 7.8%
Idaho $54,971,097 $424,512,387 12.9%
Illinois $583,239,675 $6,172,865,261 9.4%
Indiana $325,712,348 $2,564,005,047 12.7%
Iowa $147,115,884 $1,288,770,390 11.4%
Kansas $118,825,316 $916,323,608 13.0%
Kentucky $319,983,951 $2,425,288,141 13.2%
Louisiana $352,784,785 $2,383,508,985 14.8%
Maine $121,771,298 $747,027,618 16.3%
Maryland $148,532,940 $2,489,280,148 6.0%
Massachusetts $497,146,531 $4,609,360,933 10.8%
Michigan $374,145,567 $4,345,007,824 8.6%
Minnesota $173,602,492 $2,924,447,719 5.9%
Mississippi $231,735,360 $1,442,373,276 16.1%
Missouri $382,512,566 $2,569,646,129 14.9%
Montana $42,368,399 $361,238,668 11.7%
Nebraska $92,558,539 $753,162,904 12.3%
Nevada $34,518,901 $462,087,777 7.5%
New Hampshire $55,374,478 $606,004,232 9.1%
New Jersey $426,075,488 $4,218,822,993 10.1%
New Mexico $41,507,229 $862,144,872 4.8%
New York $1,368,451,273 $24,298,610,635 5.6%
North Carolina $466,528,812 $4,013,996,742 11.6%
North Dakota $27,619,684 $341,015,420 8.1%
Ohio $645,118,962 $6,120,967,557 10.5%
Oklahoma** - $1,177,853,941 -
Oregon $87,805,350 $1,377,514,740 6.4%
Pennsylvania $525,261,211 $6,080,191,710 8.6%
Rhode Island $61,401,958 $919,353,410 6.7%
South Carolina $224,962,203 $2,018,620,428 11.1%
South Dakota $31,106,511 $355,833,902 8.7%
Tennessee $36 $3,167,188,993 0.0%
Texas $817,591,112 $7,139,928,843 11.5%
Utah $68,827,853 $618,675,433 11.1%
Vermont $43,445,887 $351,341,290 12.4%
Virginia $284,578,558 $2,118,202,866 13.4%
Washington $244,478,658 $2,044,234,831 12.0%
West Virginia $148,962,081 $1,243,150,526 12.0%
Wisconsin $232,326,359 $2,206,398,750 10.5%
Wyoming $17,138,952 $192,004,819 8.9%

**Oklahoma did not submit detail drug information for 1998.
Source: The Lewin Group analysis of HCFA, CMSO, HCFA-2082 Report, FY98

Drugs as a Percentage of Total Vendor Payments, Trend

State 1994 1995 1996 1997 1998
National* 8.2% 8.1% 8.8% 9.7% 9.5%
Alabama 12.4% 12.3% 13.9% 14.4% 12.4%
Alaska 6.9% 7.3% 7.8% 8.8% 10.0%
Arizona 0.6% 0.9% 1.2% 0.8% 0.1%
Arkansas 7.0% 7.4% 9.4% 10.4% 11.0%
California 11.2% 10.9% 11.0% 11.7% 10.9%
Colorado 7.4% 7.4% 8.0% 8.6% 7.7%
Connecticut 6.2% 6.8% 7.2% 8.3% 7.7%
Delaware 6.6% 6.6% 9.0% 12.6% 9.9%
District of Columbia 4.6% 4.9% 4.6% 5.4% 5.6%
Florida 11.4% 11.6% 14.1% 15.8% 16.4%
Georgia 9.2% 9.4% 10.3% 11.0% 12.3%
Hawaii** 10.2% 9.6% 10.1% - 7.8%
Idaho 8.9% 9.2% 10.1% 10.4% 12.9%
Illinois 6.9% 7.9% 8.3% 9.1% 9.4%
Indiana 10.3% 10.0% 11.0% 12.3% 12.7%
Iowa 9.3% 9.4% 10.2% 11.4% 11.4%
Kansas 9.1% 9.8% 10.5% 11.4% 13.0%
Kentucky 12.2% 12.9% 14.1% 13.9% 13.2%
Louisiana 10.0% 10.8% 12.1% 13.5% 14.8%
Maine 7.9% 8.4% 11.6% 13.2% 16.3%
Maryland 6.7% 6.9% 7.6% 7.8% 6.0%
Massachusetts 8.2% 7.8% 8.0% 10.3% 10.8%
Michigan 8.9% 9.2% 10.5% 10.2% 8.6%
Minnesota 5.7% 5.8% 6.2% 6.6% 5.9%
Mississippi 12.9% 12.9% 13.2% 14.6% 16.1%
Missouri 12.6% 12.7% 14.0% 15.3% 14.9%
Montana 8.7% 8.7% 9.3% 11.2% 11.7%
Nebraska 9.4% 10.2% 10.5% 11.5% 12.3%
Nevada 5.8% 6.1% 6.7% 7.1% 7.5%
New Hampshire 7.3% 7.2% 7.7% 8.2% 9.1%
New Jersey 8.5% 9.0% 10.0% 10.4% 10.1%
New Mexico 7.5% 7.1% 7.0% 7.7% 4.8%
New York 3.9% 3.7% 4.1% 5.1% 5.6%
North Carolina 8.0% 8.7% 9.4% 10.7% 11.6%
North Dakota 6.2% 6.6% 7.0% 7.7% 8.1%
Ohio 8.3% 8.6% 9.4% 9.9% 10.5%
Oklahoma** 9.2% 9.6% 9.6% 10.7% -
Oregon 8.3% 6.2% 5.1% 5.0% 6.4%
Pennsylvania 11.6% 11.7% 11.5% 11.8% 8.6%
Rhode Island 5.8% 7.1% 6.7% 7.1% 6.7%
South Carolina 7.9% 8.7% 9.4% 9.9% 11.1%
South Dakota 6.7% 7.1% 7.6% 8.7% 8.7%
Tennessee 3.9% 0.0% 0.0% 0.0% 0.0%
Texas 8.3% 8.8% 9.7% 10.2% 11.5%
Utah 8.8% 9.6% 11.4% 12.0% 11.1%
Vermont 10.9% 10.5% 12.1% 14.4% 12.4%
Virginia 11.4% 11.6% 12.5% 13.4% 13.4%
Washington 10.7% 11.1% 12.4% 14.7% 12.0%
West Virginia 9.7% 11.2% 11.1% 10.6% 12.0%
Wisconsin 10.1% 10.1% 10.8% 10.9% 10.5%
Wyoming 6.7% 7.0% 7.5% 8.1% 8.9%

Source: The Lewin Group analysis of HCFA, CMSO, HCFA-2082 Report, FY94-FY98.

Share of Drug Payments, Top 5 Therapeutic Categories, 1999

Analgesics and Cardiovascular Miscellaneous Psycho-
State Antipyretics Antibiotics Drugs GI Drugs Therapeutics
National Average 6.5% 5.4% 6.1% 8.8% 20.1%
Alabama 5.1% 9.2% 8.1% 9.3% 14.9%
Alaska 10.5% 5.8% 4.3% 8.3% 19.5%
Arizona* - - - - -
Arkansas 6.0% 6.4% 8.0% 9.0% 17.3%
California 5.2% 3.6% 7.7% 8.6% 17.2%
Colorado* - - - - -
Connecticut 5.5% 3.5% 6.5% 7.4% 24.5%
Delaware 7.0% 6.3% 5.1% 7.8% 15.0%
District of Columbia 3.3% 4.1% 8.8% 3.6% 13.1%
Florida 6.1% 5.8% 5.4% 8.4% 13.2%
Georgia 6.8% 8.6% 7.4% 8.1% 15.4%
Hawaii 6.1% 3.7% 7.6% 3.2% 19.5%
Idaho 7.7% 5.4% 3.7% 11.2% 22.0%
Illinois 5.3% 6.3% 6.4% 8.7% 18.6%
Indiana 7.2% 5.2% 5.1% 9.9% 19.1%
Iowa 5.6% 5.7% 5.3% 6.7% 22.6%
Kansas 7.2% 5.5% 5.3% 10.1% 22.9%
Kentucky 5.7% 6.7% 6.6% 13.1% 18.0%
Louisiana 7.7% 7.9% 7.1% 8.4% 13.0%
Maine 8.0% 4.0% 5.2% 11.4% 20.5%
Maryland 4.0% 2.7% 6.2% 7.0% 28.0%
Massachusetts 5.3% 3.9% 5.5% 7.9% 25.6%
Michigan 7.3% 4.3% 7.2% 8.4% 19.4%
Minnesota 5.1% 3.9% 4.2% 7.5% 28.7%
Mississippi* - - - - -
Missouri 7.1% 5.0% 6.1% 10.4% 19.8%
Montana 7.1% 5.4% 4.5% 9.8% 21.0%
Nebraska 7.2% 7.3% 5.0% 9.7% 19.4%
Nevada 8.1% 7.0% 5.8% 8.7% 18.5%
New Hampshire 6.9% 3.6% 4.4% 8.9% 25.9%
New Jersey 6.1% 3.3% 6.1% 8.9% 15.6%
New Mexico 7.5% 3.8% 7.2% 12.3% 16.9%
New York 5.0% 5.0% 6.6% 7.1% 16.7%
North Carolina 6.4% 6.6% 7.1% 10.6% 14.6%
North Dakota 6.2% 5.4% 5.8% 8.9% 22.9%
Ohio 7.1% 4.9% 6.2% 10.3% 20.1%
Oklahoma 7.6% 6.7% 6.8% 8.8% 17.5%
Oregon 5.2% 2.7% 3.6% 3.7% 47.2%
Pennsylvania 5.9% 5.1% 6.7% 9.2% 19.3%
Rhode Island 4.8% 3.8% 7.5% 10.1% 23.6%
South Carolina 7.1% 6.5% 8.3% 9.8% 14.5%
South Dakota 6.0% 7.7% 5.3% 9.1% 18.5%
Tennessee* - - - - -
Texas* - - - - -
Utah 7.0% 7.4% 3.4% 8.7% 24.3%
Vermont 7.4% 3.7% 6.3% 12.0% 18.8%
Virginia 6.5% 5.4% 6.5% 10.6% 15.8%
Washington 8.0% 3.6% 5.3% 9.6% 22.0%
West Virginia 5.8% 8.0% 6.5% 5.8% 18.3%
Wisconsin 6.9% 3.5% 6.2% 7.4% 24.7%
Wyoming 6.9% 7.1% 4.2% 9.1% 20.7%
*Data not reported for Arizona, Colorado, Mississippi, Tennessee, or Texas.
Source: The Lewin Group analysis of HCFA Drug Utilization data, FY99.

Total Drug Recipients‡

State 1994 1995 1996 1997 1998
National Total* 24,473,189 23,723,349 22,585,295 20,954,163 19,337,543
Alabama 409,406 404,581 412,511 412,739 395,290
Alaska 40,812 40,076 40,839 42,174 43,734
Arizona 63,944 66,860 63,103 80,450 56,796
Arkansas 257,861 253,181 255,211 254,079 262,907
California 3,796,517 3,656,783 3,565,667 3,158,386 2,644,430
Colorado 209,290 196,737 173,707 156,631 147,033
Connecticut 255,218 273,511 209,557 120,522 108,331
Delaware 54,384 56,710 61,380 68,672 69,027
District of Columbia 68,211 53,992 66,349 64,494 57,733
Florida 1,197,915 1,111,466 1,079,467 1,024,555 1,014,372
Georgia 825,875 875,647 891,335 846,963 805,923
Hawaii** 95,805 28,971 29,657 - 32,222
Idaho 81,394 81,755 84,553 79,961 86,775
Illinois 1,054,436 1,134,214 1,028,753 1,008,740 959,472
Indiana 480,648 428,116 401,042 352,814 323,811
Iowa 237,667 231,256 230,749 221,061 215,173
Kansas 184,400 186,362 179,653 170,167 155,875
Kentucky 493,689 491,370 497,251 494,293 429,102
Louisiana 604,163 598,579 593,415 563,864 552,481
Maine 136,623 120,029 138,360 139,524 137,816
Maryland 299,875 291,626 268,440 256,423 176,403
Massachusetts 531,851 558,233 527,114 559,215 613,186
Michigan 863,391 823,485 763,232 688,882 589,818
Minnesota 294,307 305,363 294,589 227,027 203,220
Mississippi 411,813 416,065 404,263 391,328 368,609
Missouri 543,833 561,167 469,821 395,478 353,902
Montana 68,661 67,244 66,465 62,092 58,641
Nebraska 128,501 131,974 138,322 151,973 145,408
Nevada 55,336 59,170 60,274 55,876 50,903
New Hampshire 67,200 73,938 75,701 71,692 70,339
New Jersey 611,638 612,074 518,833 347,105 309,849
New Mexico 172,752 178,087 197,565 184,502 96,637
New York 1,920,814 1,880,506 1,737,372 1,667,927 1,803,428
North Carolina 653,792 737,558 764,482 779,229 764,886
North Dakota 42,442 41,128 40,062 39,654 37,675
Ohio 1,023,733 1,007,970 902,211 786,322 702,143
Oklahoma** 283,428 285,654 245,075 207,441 -
Oregon 227,825 181,553 154,801 149,461 148,258
Pennsylvania 996,129 941,013 857,818 763,255 580,749
Rhode Island 57,942 93,639 52,239 46,817 44,852
South Carolina 355,545 365,571 365,409 359,910 401,611
South Dakota 47,614 47,969 49,056 47,845 46,588
Tennessee 454,323 1,395 18 3 1
Texas 1,989,651 2,020,864 2,058,903 1,986,178 1,894,447
Utah 120,093 119,776 114,321 105,676 126,953
Vermont 74,224 78,694 78,376 83,057 58,037
Virginia 470,048 480,405 417,580 396,719 383,880
Washington 495,379 405,558 305,791 292,733 274,463
West Virginia 273,714 295,210 299,967 280,550 267,398
Wisconsin 342,705 329,711 309,582 265,987 221,508
Wyoming 35,964 35,505 35,415 33,426 32,510
Source: HCFA, CMSO, HCFA-2082 Report, FY94-FY98.

Drug Payments Per Recipient‡

State 1994 1995 1996 1997 1998
National* $363 $413 $474 $571 $699
Alabama $398 $442 $494 $548 $599
Alaska $410 $461 $530 $673 $752
Arizona $18 $30 $39 $23 $25
Arkansas $342 $403 $451 $534 $574
California $296 $313 $343 $423 $587
Colorado $337 $401 $475 $619 $749
Connecticut $472 $531 $701 $1,383 $1,722
Delaware $337 $378 $452 $505 $599
District of Columbia $370 $486 $494 $582 $715
Florida $404 $501 $610 $754 $921
Georgia $315 $329 $358 $401 $460
Hawaii** $360 $856 $905 - $1,230
Idaho $361 $406 $485 $563 $633
Illinois $314 $389 $434 $519 $608
Indiana $484 $438 $671 $831 $1,006
Iowa $384 $421 $483 $560 $684
Kansas $387 $437 $505 $615 $762
Kentucky $440 $512 $548 $640 $746
Louisiana $445 $488 $501 $559 $639
Maine $469 $532 $606 $735 $884
Maryland $418 $477 $577 $674 $842
Massachusetts $472 $552 $575 $712 $811
Michigan $336 $379 $462 $530 $634
Minnesota $387 $486 $510 $686 $854
Mississippi $340 $391 $437 $533 $629
Missouri $420 $463 $600 $811 $1,081
Montana $382 $421 $493 $571 $723
Nebraska $432 $468 $517 $525 $637
Nevada $319 $360 $405 $477 $678
New Hampshire $423 $461 $559 $633 $787
New Jersey $504 $562 $721 $1,065 $1,375
New Mexico $277 $284 $310 $343 $430
New York $379 $436 $522 $654 $759
North Carolina $329 $376 $451 $518 $610
North Dakota $416 $479 $522 $636 $733
Ohio $406 $476 $575 $738 $919
Oklahoma** $315 $353 $401 $535 -
Oregon $377 $455 $433 $490 $592
Pennsylvania $491 $578 $626 $724 $904
Rhode Island $686 $511 $874 $1,114 $1,369
South Carolina $312 $341 $394 $443 $560
South Dakota $399 $450 $492 $577 $668
Tennessee $168 $137 $852 $373 $36
Texas $257 $286 $324 $378 $432
Utah $331 $371 $421 $481 $542
Vermont $382 $428 $466 $533 $749
Virginia $417 $444 $530 $629 $741
Washington $340 $398 $565 $700 $891
West Virginia $390 $442 $417 $474 $557
Wisconsin $536 $578 $664 $773 $1,049
Wyoming $291 $335 $385 $445 $527
Source: The Lewin Group analysis of HCFA, CMSO, HCFA-2082 Report, FY94-FY98.

Medicaid Drug Reimbursement Report, 1998

Drug Drug Prescriptions Average
State Payments1 Recipients1 Processed2 Prescription Cost2
Alabama $236,674,147 395,290 7,852,261 $30.34
Alaska $32,887,828 43,734 662,575 $51.73
Arizona* $1,442,917 56,796 - -
Arkansas $150,891,615 262,907 3,142,993 $37.44
California $1,553,598,462 2,644,430 40,646,534 $40.56
Colorado $110,159,725 147,033 1,431,595 $37.14
Connecticut* $186,593,992 108,331 - -
Delaware $41,350,537 69,027 830,829 $38.68
District of Columbia $41,254,973 57,733 1,858,364 $43.83
Florida $933,782,041 1,014,372 18,681,483 $47.86
Georgia $370,562,935 805,923 9,284,700 $31.24
Hawaii $39,623,380 32,222 1,119,545 $34.40
Idaho $54,971,097 86,775 630,770 $42.21
Illinois $583,239,675 959,472 17,981,685 $34.01
Indiana $325,712,348 323,811 4,379,620 $40.46
Iowa $147,115,884 215,173 4,457,957 $19.70
Kansas* $118,825,316 155,875 - -
Kentucky $319,983,951 429,102 9,630,473 $33.41
Louisiana $352,784,785 552,481 20,664,690 $34.35
Maine $121,771,298 137,816 2,868,068 $41.85
Maryland $148,532,940 176,403 2,336,929 $42.54
Massachusetts $497,146,531 613,186 12,598,550 $40.18
Michigan $374,145,567 589,818 10,357,765 $34.23
Minnesota $173,602,492 203,220 4,612,393 $35.23
Mississippi $231,735,360 368,609 5,368,429 $40.27
Missouri $382,512,566 353,902 9,860,308 $38.58
Montana $42,368,399 58,641 1,179,484 $34.74
Nebraska $92,558,539 145,408 2,991,257 $33.36
Nevada $34,518,901 50,903 814,185 $43.14
New Hampshire $55,374,478 70,339 1,572,638 $34.11
New Jersey $426,075,488 309,849 8,400,194 $47.83
New Mexico $41,507,229 96,637 1,176,851 $33.36
New York $1,368,451,273 1,803,428 35,512,292 $44.45
North Carolina $466,528,812 764,886 11,633,909 $41.24
North Dakota $27,619,684 37,675 585,260 $35.44
Ohio $645,118,962 702,143 19,983,451 $33.15
Oklahoma** - - 3,449,399 $41.07
Oregon $87,805,350 148,258 2,374,283 $40.56
Pennsylvania $525,261,211 580,749 14,219,369 $38.75
Rhode Island $61,401,958 44,852 1,570,662 $41.26
South Carolina $224,962,203 401,611 3,555,427 $49.21
South Dakota $31,106,511 46,588 762,406 $37.17
Tennessee* $36 1 - -
Texas* $817,591,112 1,894,447 - -
Utah $68,827,853 126,953 2,063,349 $34.25
Vermont $43,445,887 58,037 799,552 $39.94
Virginia $284,578,558 383,880 8,098,755 $35.70
Washington $244,478,658 274,463 6,552,127 $37.60
West Virginia $148,962,081 267,398 5,370,453 $30.13
Wisconsin $232,326,359 221,508 6,358,445 $36.87
Wyoming $17,138,952 32,510 453,071 $39.98
*Data not reported for Arizona, Connecticut, Kansas, Tennessee, or Texas.

**Oklahoma did not submit detailed information for 1998.
Source: 1HCFA, CMSO, HCFA-2082 Report, FY98. 2The Lewin Group analysis of HCFA Drug Utilization data, Fiscal Year 1998.

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). Following the introduction of this legislation, 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.
In the course of the budget debate, the Office of Management and Budget (OMB) incorporated various
components of these proposals into the budget bill, the Omnibus Budget Reconciliation Act of 1990 (OBRA `90).
The resulting Public Law 101-508, enacted November 5, 1990, required a drug manufacturer to enter into and
have in effect a national rebate agreement with the Secretary of the Department of Health and Human Services
(HHS) for States to receive federal funding for outpatient drugs dispensed to Medicaid patients.
The requirement for rebate agreements does not apply to the dispensing of a single-source or innovator multiple-
source drug if the state has determined that the drug is essential, rated 1-A by the FDA, and prior authorization is
obtained for the exception. Existing rebate agreements qualify under the law if the state agrees to report all
rebates to HHS and the agreement provides for a minimum aggregate rebate of 10% of the state’s expenditures for
the manufacturer’s products.
OBRA ‘90 was amended by the Veterans Health Care Act of 1992 which also required a drug manufacturer to
enter into discount pricing agreements with the Department of Veterans Affairs and with covered entities funded
by the Public Health Service in order to have its drugs covered by Medicaid. The Medicaid rebate law, as
amended, is included as Appendix C.
The drug rebate program is administered by HCFA's 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.

Medicaid Drug Rebates

Allocation of 1999 1999
State Drug Rebate Moneys1 Total Rebates2 Federal Share2
National Total $3,316,594,880 $1,899,896,508
Alabama Medicaid Drug Budget $49,785,076 $34,533,102
Alaska General Fund $7,050,981 $4,216,486
Arizona* - - -
Arkansas Medicaid General $37,931,853 $27,703,515
California Medicaid Drug Budget $533,191,914 $278,960,679
Colorado Medicaid General $25,150,259 $12,868,802
Connecticut General Fund $38,656,394 $19,328,198
Delaware Medicaid General $9,787,444 $4,945,369
District of Columbia Medicaid General $8,379,982 $5,866,114
Florida Medicaid Drug Budget $195,512,719 $109,644,101
Georgia General Fund $94,903,175 $57,612,243
Hawaii General Fund $8,378,292 $4,189,146
Idaho Medicaid General $11,901,778 $8,313,393
Illinois General Fund $121,540,781 $61,133,375
Indiana General Fund $62,691,135 $38,247,862
Iowa General Fund $32,369,409 $20,570,660
Kansas General Fund $26,878,486 $16,184,126
Kentucky Medicaid General $72,676,810 $51,258,954
Louisiana Medicaid Drug Budget $76,147,317 $53,686,416
Maine General Fund $30,032,364 $19,941,489
Maryland Medicaid General $32,403,851 $16,274,193
Massachusetts General Fund $140,102,747 $70,660,841
Michigan Medicaid Drug Budget $75,674,128 $39,969,595
Minnesota Medicaid General $37,389,033 $19,255,352
Mississippi Medicaid Special Refund $49,332,307 $37,964,206
Missouri Medicaid Drug Budget $84,620,799 $51,306,706
Montana General Fund $9,290,653 $6,688,938
Nebraska General Fund and Medicaid General $21,609,490 $13,454,079
Nevada Medicaid Drug Budget $7,727,267 $3,882,559
New Hampshire General Fund $12,956,727 $6,478,364
New Jersey Medicaid Drug Budget $89,197,702 $44,750,228
New Mexico General Fund $7,972,600 $5,818,404
New York General Fund $356,088,488 $178,044,244
North Carolina Medicaid General $111,326,116 $70,372,764
North Dakota Medicaid General $5,954,387 $4,171,965
Ohio Medicaid General $148,477,399 $86,502,933
Oklahoma Medicaid General $31,992,100 $22,786,690
Oregon General Fund $21,360,688 $13,062,439
Pennsylvania Medicaid Drug Budget- $119,340,064 $64,407,705
Rhode Island Medicaid General $14,440,971 $7,805,345
South Carolina Medicaid Drug Budget $55,971,288 $39,382,765
South Dakota Medicaid General $5,971,015 $4,094,537
Tennessee - $22,434,760 $14,154,090
Texas Medicaid Drug Budget $185,695,267 $116,237,687
Utah General Fund $14,721,050 $10,566,770
Vermont Medicaid General $10,579,999 $6,556,425
Virginia Medicaid Medical Budget $67,715,512 $35,066,017
Washington General Fund $54,331,249 $28,566,897
West Virginia Medicaid General $35,941,495 $26,765,632
Wisconsin Medicaid Drug Budget $38,644,764 $22,837,194
Wyoming Medicaid Drug Budget $4,364,795 $2,806,914
*Does not apply for Arizona.

Sources: 1As reported by state drug program administrators in the 2000 NPC Survey.
2
HCFA 64, Medicaid Financial Management Report, FY99.

Medicaid Drug Rebate Trends, 1995-1999

1995 1996 1997 1998 1999
State Drug Rebate Drug Rebate Drug Rebate Drug Rebate Drug Rebate
National Total $1,795,369,481 $1,961,842,019 $2,212,579,458 $2,469,136,949 $3,316,594,880
Alabama $26,713,236 $35,746,548 $47,135,670 $36,537,095 $49,785,076
Alaska $3,392,270 $3,631,600 $4,900,641 $5,026,624 $7,050,981
Arizona* - - - - -
Arkansas $15,838,282 $19,942,216 $24,514,373 $22,518,230 $37,931,853
California $214,571,699 $259,522,046 $307,645,326 $362,808,597 $533,191,914
Colorado $16,164,945 $17,354,887 $16,950,071 $20,424,896 $25,150,259
Connecticut $29,670,883 $30,787,226 $27,318,565 $32,128,587 $38,656,394
Delaware $39,108,649 $4,424,652 $5,851,285 $7,096,836 $9,787,444
District of Columbia $6,212,050 $5,669,258 $6,668,493 $7,100,983 $8,379,982
Florida $99,995,743 $110,282,689 $128,466,755 $150,733,077 $195,512,719
Georgia $51,400,489 $56,905,277 $59,756,017 $64,320,077 $94,903,175
Hawaii $5,451,328 $3,720,038 $4,654,126 $5,992,722 $8,378,292
Idaho $5,364,698 $6,534,816 $8,369,523 $8,614,444 $11,901,778
Illinois $68,635,826 $85,146,120 $85,128,380 $100,811,862 $121,540,781
Indiana $39,660,999 $45,845,822 $43,645,256 $50,710,861 $62,691,135
Iowa $17,082,336 $18,770,263 $21,755,142 $25,265,390 $32,369,409
Kansas $13,274,426 $16,682,962 $11,797,675 $19,852,439 $26,878,486
Kentucky $42,282,025 $43,116,489 $59,890,925 $57,082,387 $72,676,810
Louisiana $49,319,520 $55,702,577 $54,650,344 $65,994,910 $76,147,317
Maine $13,111,934 $16,131,900 $18,246,061 $19,650,719 $30,032,364
Maryland $25,339,673 $28,493,983 $34,567,082 $25,017,660 $32,403,851
Massachusetts $53,656,921 $65,037,309 $73,047,452 $89,011,664 $140,102,747
Michigan $64,564,101 $67,989,816 $74,116,928 $72,526,027 $75,674,128
Minnesota N/A $6,992,875 $31,873,349 $31,058,740 $37,389,033
Mississippi $30,380,557 $32,191,139 $37,108,638 $39,983,265 $49,332,307
Missouri $45,080,603 $51,527,496 $54,614,194 $66,460,159 $84,620,799
Montana $5,565,740 $6,031,657 $6,775,176 $7,378,206 $9,290,653
Nebraska $10,418,227 $12,330,363 $14,931,313 $16,545,572 $21,609,490
Nevada $4,038,721 $4,400,121 $5,391,025 $5,143,136 $7,727,267
New Hampshire $5,046,055 $7,912,982 $8,788,296 $9,676,461 $12,956,727
New Jersey $62,240,335 $65,377,388 $66,748,605 $70,992,525 $89,197,702
New Mexico $9,071,911 $11,509,943 $13,367,028 $10,670,766 $7,972,600
New York $151,313,836 $150,547,790 $200,157,978 $251,273,382 $356,088,488
North Carolina $43,275,244 $57,099,702 $68,332,867 $81,211,796 $111,326,116
North Dakota $3,548,429 $3,734,060 $4,651,348 $4,990,065 $5,954,387
Ohio $97,259,136 $103,428,427 $84,238,194 $110,484,575 $148,477,399
Oklahoma $18,519,577 $19,696,492 $20,776,998 $23,329,251 $31,992,100
Oregon $18,887,522 $19,668,133 $13,852,833 $14,433,179 $21,360,688
Pennsylvania $89,645,272 $99,204,380 $115,510,606 $95,692,149 $119,340,064
Rhode Island $8,904,676 $9,336,162 $10,121,820 $11,041,552 $14,440,971
South Carolina $27,588,863 $30,483,825 $34,643,502 $39,156,574 $55,971,288
South Dakota $3,248,482 $3,248,037 $4,940,121 $5,070,643 $5,971,015
Tennessee $1,110,475 $247,255 - $840 $22,434,760
Texas $106,027,639 $114,442,343 $130,576,891 $145,635,499 $185,695,267
Utah $7,608,692 $9,145,247 $8,374,299 $9,988,037 $14,721,050
Vermont $7,363,796 $6,794,891 $8,255,707 $8,868,263 $10,579,999
Virginia $49,153,407 $41,059,487 $45,240,474 $51,079,391 $67,715,512
Washington $33,803,617 $33,586,091 $38,326,646 $39,191,376 $54,331,249
West Virginia $20,248,539 $27,287,834 $26,079,819 $26,753,285 $35,941,495
Wisconsin $32,786,506 $34,494,898 $37,146,544 $40,776,543 $38,644,764
Wyoming $2,421,591 $2,624,507 $2,679,097 $3,025,632 $4,364,795
*Does not apply for Arizona.

Source: HCFA 64, Medicaid Financial Management Report, FY95-FY99.


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. Under the Omnibus Budget Reconciliation Act of 1993, 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 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
Drug Utilization Review (DUR) is defined as a structured and continuing program that reviews, analyzes, and
interprets patterns of drug usage in a given health care environment against predetermined standards.
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.
OBRA `90 required that, by January 1, 1993, states had to establish a Drug Utilization Review (DUR) program,
consisting of prospective and retrospective components as well as components to educate physicians and
pharmacists on common drug therapy problems and assessments of whether usage complies with predetermined
standards.
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 judgement 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.
OBRA `90 required that retrospective review is to be ongoing, based on compendia standards and medical
literature, and to include remedial strategies for educational outreach through a wide range of interventions. Each
state is to establish a Drug Utilization Review board, consisting of no more than 51% physicians and at least one-
third pharmacists.

Pharmacy Advisory Committees

State Pharmacy Advisory Committee Meetings Preferred Product Introduction Process
Alabama Pharmacy & Therapeutic Committee Bi-Monthly Contact First Data Bank
Alaska None - Introductory letter
Arizona* - - Inform health plans directly
Arkansas N/A - Introductory letter
California Contract Drug Advisory Committee Ad Hoc Introductory letter
Colorado DUR Board advises Quarterly Introductory letter
Connecticut None - Introductory letter
Delaware DUR Board advises Bi-Monthly Introductory letter
District of Columbia N/A - Introductory letter
Florida DUR Board advises Quarterly Introductory letter
Georgia Yes Quarterly Introductory letter
Hawaii DUR Board advises Quarterly Introductory letter
Idaho DUR Board advises Bi-Monthly Introductory letter
Illinois No - Contact First Data Bank
Indiana DUR Board advises Quarterly Introductory letter
Iowa Medicaid Pharmacy Advisory Committee Semiannually Introductory letter
Kansas DUR Board advises Bi-Monthly Introductory letter, Formulary packet
Kentucky Drug Management Review Advisory Board Quarterly State form, Package insert
Louisiana Benefits Management Advisory Committee Ad Hoc Introductory letter
Maine DUR Committee Bi-Monthly Introductory letter
Maryland No - Introductory letter
Massachusetts DUR Committee Quarterly Introductory letter
Michigan No - State form
Minnesota Drug Formulary Committee Quarterly Introductory letter
Mississippi No - Introductory letter
Missouri Pharmacy Subcommittee Quarterly Introductory letter
Montana DUR Board advises Monthly Introductory letter
Nebraska Medicaid Pharmacy Advisory Committee Ad Hoc Introductory letter
Nevada None - Introductory letter
New Hampshire None - Introductory letter, FDA updates
New Jersey None - Introductory letter
New Mexico N/A - Introductory letter
New York Pharmacy Advisory Committee Quarterly Introductory letter
North Carolina None - Introductory letter, Package insert
North Dakota None - Introductory letter
Ohio Pharmacy & Therapeutic Committee Quarterly Introductory letter
Oklahoma Yes Monthly Introductory letter
Oregon None Contact First Data Bank
Pennsylvania Medical Assistance Advisory Committee Monthly Introductory letter
Rhode Island N/A - Introductory letter
South Carolina None - Formulary packet
South Dakota None - Introductory letter
Tennessee* - - -
Texas None - Introductory letter, State form
Utah DUR Committee Monthly Introductory letter
Vermont DUR Committee Bi-Monthly Introductory letter
Virginia Pharmacy Liaison Committee Bi-Monthly Introductory letter
Washington Drug Utilization and Education Council Bi-Monthly State form
West Virginia Medical Services Fund Advisory Council Quarterly Introductory letter
Wisconsin None - Introductory letter
Wyoming None Bi-Monthly Introductory letter, Contact First Data Bank
decisions.
Source: As reported by state drug program administrators in the 2000 NPC Survey.

Pharmacy Benefit Design - Coverage

State Cosmetics Fertility Drugs Experiment Drugs
Alabama PA Required Not Covered Not Covered
Alaska Not Covered 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 N/A N/A N/A
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 Covered Covered 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 Covered Covered Covered
Mississippi Not Covered Not Covered Not Covered
Missouri Not Covered Not Covered Not Covered
Montana Not Covered Not Covered Not Covered
Nebraska Not Covered Not Covered Not Covered
Nevada Not Covered Not Covered Not Covered
New Hampshire Not Covered Not Covered Not Covered
New Jersey Not Covered Not Covered Not Covered
New Mexico Not Covered Not Covered Not Covered
New York Covered Covered 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 PA Required Not Covered Not Covered
Pennsylvania Not Covered Not Covered Not Covered
Rhode Island N/A N/A N/A
South Carolina Covered Covered Covered
South Dakota Not Covered Not Covered Not Covered
Tennessee* - - -
Texas Not Covered Not Covered Not Covered
Utah Not Covered Not Covered Not Covered
Vermont Not Covered Not Covered Not Covered
Virginia Not Covered Covered with Restrictions 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 Covered with Restrictions Not Covered Not Covered
decisions.
PA = Prior Authorization, DME = Durable Medical Equipment

Pharmacy Benefit Design – Coverage (Con’t)

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

Pharmacy Benefit Design – Coverage (Con’t)

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

Coverage of Injectables
Reimbursement for Non Self-Administered Medicines via
the Prescription Drug Program (PDP) or Physician Payment (PP)
State Physicians Office Home Health Care Extended Care Facility

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

Coverage of Vaccines and Unit Dose

State Method for Vaccine Reimbursement ^ Reimbursement for Unit Dose
Alabama EPSDT, VCP Yes
Alaska EPSDT, CHIP, VCP Yes
Arizona* - -
Arkansas VCP Yes
California VCP No
Colorado VCP No
Connecticut CHIP No
Delaware VCP No
District of Columbia EPSDT No
Florida VCP Yes
Georgia EPSDT, CHIP, VCP Yes
Hawaii EPSDT, VCP Yes
Idaho EPSDT, CHIP, VCP Yes
Illinois Special Program No
Indiana EPSDT, CHIP, VCP No
Iowa EPSDT, VCP Yes
Kansas CHIP, VCP No
Kentucky EPSDT, CHIP, VCP, Pharmacy Services Yes
Louisiana EPSDT, VCP No
Maine EPSDT Yes
Maryland EPSDT Yes, LTC
Massachusetts EPSDT No
Michigan EPSDT, CHIP Yes
Minnesota EPSDT, CHIP, VCP Yes
Mississippi EPSDT No
Missouri EPSDT, CHIP, VCP Yes
Montana EPSDT, CHIP, VCP Yes
Nebraska EPSDT, CHIP, VCP No
Nevada EPSDT Yes
New Hampshire EPSDT, CHIP, VCP Yes, LTC
New Jersey EPSDT, VCP Yes, LTC
New Mexico VCP No
New York EPSDT, VCP No
North Carolina Health Check Yes
North Dakota EPSDT No
Ohio VCP No
Oklahoma ESPDT, VCP Yes
Oregon VCP Yes
Pennsylvania EPSDT, CHIP, VCP, Pharmacy Services No
Rhode Island N/A No
South Carolina VCP Yes
South Dakota VCP Yes
Tennessee* - -
Texas EPSDT Yes
Utah EPSDT, CHIP, VCP, Medical Services Yes
Vermont EPSDT Yes
Virginia VCP, Health Dept. Yes
Washington EPSDT Yes
West Virginia EPSDT, VCP Yes
Wisconsin VCP Yes
Wyoming EPSDT, CHIP, VCP No
^ Early and Periodic Screening, Diagnostic and Treatment (EPSDT), Children Health Insurance Program (CHIP), Vaccines for Children
Program (VCP), or other.
LTC = Long Term Care
decisions.

Coverage of Over-the-Counter Medications

Allergy, Asthma,
State and Sinus Analgesics Cough and Cold Smoking Deterrents
Alabama Covered with Rx Covered with Rx Covered with Rx Not Covered
Alaska Not Covered Not Covered Not Covered Not Covered
Arizona* - - - -
Arkansas Limited Coverage Limited Coverage Limited Coverage Not Covered
California PA Required PA Required PA Required PA Required
Colorado Not Covered Limited Coverage Not Covered Limited Coverage
Connecticut Not Covered Limited Coverage Limited Coverage Not Covered
Delaware Covered Covered Covered Covered
Florida Limited Coverage Limited Coverage Limited Coverage Covered
Georgia Not Covered Limited Coverage Limited Coverage Not Covered
Hawaii Limited Coverage Limited Coverage Limited Coverage Not Covered
Idaho Not Covered Not Covered Not Covered Not Covered
Illinois Not Covered PA Required PA Required Covered
Indiana N/A N/A N/A N/A
Iowa Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
Kansas Not Covered Covered Limited Coverage Limited Coverage
Kentucky Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered
Louisiana Not Covered Not Covered Not Covered Not Covered
Maine Covered with Restrictions Covered with Restrictions Not Covered Covered
Maryland Not Covered Not Covered Not Covered Not Covered
Massachusetts Covered Covered Covered with Restrictions Not Covered
Michigan Limited Coverage Limited Coverage Not Covered Limited Coverage
Minnesota Limited Coverage Limited Coverage Limited Coverage Covered with Restrictions
Mississippi Not Covered Limited Coverage Limited Coverage Not Covered
Missouri Covered Covered Covered Not Covered
Montana Not Covered Limited Coverage Not Covered Not Covered
Nebraska Covered Covered Covered Not Covered
Nevada Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
New Jersey Limited Coverage Limited Coverage Limited Coverage Not Covered
New Mexico Covered Covered Covered Covered
New York Limited Coverage Limited Coverage Limited Coverage Covered
North Carolina Not Covered Not Covered Not Covered Not Covered
North Dakota Not Covered Covered Not Covered PA Required
Ohio Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Oklahoma Not Covered Not Covered Not Covered Not Covered
Oregon Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Pennsylvania Covered with Restrictions Covered Covered with Restrictions Not Covered
South Carolina Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered
South Dakota Not Covered Not Covered Not Covered Not Covered
Tennessee* - - - -
Texas Covered Covered Covered Covered
Utah Limited Coverage Covered Covered Not Covered
Vermont PA Required PA Required PA Required PA Required
Virginia Covered with Restrictions Covered Covered with Restrictions Not Covered
Washington Limited Coverage Limited Coverage Limited Coverage Covered
West Virginia Limited Coverage Limited Coverage Limited Coverage PA Required
Wisconsin Not Covered Covered Covered with Restrictions Not Covered
Wyoming Limited Coverage Covered Covered Not Covered
decisions.
PA= Prior Authorization

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

Digestive Products
State (no H2 antagonists) H2 Antagonists Feminine Products Topical Products
Alabama Covered with Rx Covered with Rx Not Covered Covered with Rx
Alaska Not Covered Not Covered Limited Coverage Limited Coverage
Arizona* - - - -
Arkansas Limited Coverage Covered Limited Coverage Limited Coverage
California PA Required PA Required PA Required PA Required
Colorado Not Covered Not Covered Not Covered Not Covered
Connecticut Covered Not Covered Covered Not Covered
Delaware Covered Covered Limited Coverage Limited Coverage
Florida Not Covered Not Covered Covered with Rx Not Covered
Georgia Not Covered Not Covered Not Covered Not Covered
Hawaii Covered with Restrictions Covered with Restrictions Limited Coverage Limited Coverage
Idaho Not Covered Not Covered Not Covered Not Covered
Illinois PA Required Covered Not Covered PA Required
Indiana N/A N/A N/A N/A
Iowa Not Covered Not Covered Not Covered Covered with Restrictions
Kansas Not Covered Covered Not Covered Not Covered
Kentucky Covered with Restrictions Not Covered Covered with Restrictions Covered with Restrictions
Louisiana Not Covered Not Covered Not Covered Covered
Maine Covered with Restrictions Covered with Restrictions Not Covered Covered with Restrictions
Maryland Not Covered Not Covered Not Covered Not Covered
Massachusetts Covered Covered with Restrictions Covered Covered with Restrictions
Michigan Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Minnesota Limited Coverage Covered Limited Coverage Limited Coverage
Mississippi Not Covered Not Covered Not Covered Not Covered
Missouri Covered Covered Not Covered Limited Coverage
Montana Covered Covered Not Covered Not Covered
Nebraska Covered Covered Covered Covered
Nevada Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
New Jersey Not Covered Not Covered Not Covered Covered with Restrictions
New Mexico Covered Covered Covered with Restrictions Covered
New York Limited Coverage Covered Limited Coverage Limited Coverage
North Carolina Not Covered Not Covered Not Covered Not Covered
North Dakota Not Covered Covered Not Covered Not Covered
Ohio Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Oklahoma Not Covered Not Covered Not Covered Not Covered
Oregon Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Pennsylvania Covered with Restrictions Covered with Restrictions Covered Covered
South Carolina Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
South Dakota Not Covered Not Covered Not Covered Not Covered
Tennessee* - - - -
Texas Covered Covered Covered Covered
Utah Covered Covered N/A Limited Coverage
Vermont PA Required PA Required PA Required PA Required
Virginia Covered Covered Covered Limited Coverage
Washington Covered Not Covered Limited Coverage Limited Coverage
West Virginia Limited Coverage Not Covered Covered Covered
Wisconsin Covered with Restrictions Not Covered Not Covered Covered with Restrictions
Wyoming Not Covered Covered Covered Limited Coverage
decisions.

Prior Authorization Process and Procedures

State PA Procedure Prior Authorization Committee Members Meetings
Alabama Yes N/A N/A N/A
Alaska Yes No - -
Arizona* - - - -
Arkansas Yes DUR Board N/A N/A
California Yes No - -
Colorado Yes Yes N/A N/A
Connecticut No - - -
Delaware Yes No N/A N/A
District of Columbia Yes N/A N/A N/A
Florida Yes No - -
Georgia Yes Yes 14 Quarterly
Hawaii Yes DUR Board 9 Quarterly
Idaho Yes Yes (Used only for Growth Hormones) 3 Ad hoc
Illinois Yes Committee on Drugs and Therapeutics Varies Quarterly
Indiana No - - -
Iowa Yes No - -
Kansas Yes No - -
Kentucky Yes Prior Authorization Subcommittee 6 Quarterly
Louisiana No - - -
Maine Yes No - -
Maryland No - - -
Massachusetts Yes No - -
Michigan Yes No - -
Minnesota Yes Drug Formulary Committee 9 Quarterly
Mississippi No No - -
Missouri Yes Prior Authorization Committee 7 Quarterly
Montana Yes No
Nebraska Yes Utilization Review Committee 7 Ad hoc
Nevada Yes No - -
New Hampshire No - - -
New Jersey Yes No - -
New Mexico Yes No - -
New York No - - -
North Carolina No - - -
North Dakota Yes No - -
Ohio Yes No - -
Oklahoma Yes DUR Board 10 Monthly
Oregon Yes No 12 Quarterly
Pennsylvania Yes No - -
Rhode Island Yes No - -
South Carolina Yes No - -
South Dakota Yes No - -
Tennessee* - - - -
Texas Yes No - -
Utah Yes No - -
Vermont Yes No - -
Virginia Yes Yes N/A Not Active
Washington Yes Drug Utilization and Education Council 8 Bimonthly
West Virginia Yes DUR Board - -
Wisconsin Yes No - -
Wyoming No - - -
decisions.

Prior Authorization Process and Procedures (Con’t)

State Initiated By: Annual Requests % Approved
Alabama M.D., R.Ph. N/A N/A
Alaska R.Ph. 3,634 74%
Arizona* - - -
Arkansas M.D., R.Ph. 126,248 83%
California M.D., R.Ph. 1,200,000 87%
Colorado M.D. 12,000 90%
Connecticut N/A N/A N/A
Delaware M.D., R.Ph. 50 N/A
Florida M.D., R.Ph. N/A N/A
Georgia M.D., R.Ph. 50,000 85%
Hawaii M.D., R.Ph. N/A N/A
Idaho M.D. 1,200 97%
Illinois M.D., R.Ph. 670,000 N/A
Indiana N/A N/A N/A
Iowa M.D., R.Ph. 30,000 80%
Kansas M.D., R.Ph. 10,085 85%
Kentucky M.D., R.Ph., Social Worker 298,244 70%
Louisiana N/A N/A N/A
Maine M.D. 1,500 90%
Maryland M.D., R.Ph 8,640 95%
Massachusetts M.D 14,000 95%
Michigan M.D. 18,000 82%
Minnesota R.Ph. 6,000 96%
Mississippi M.D. 40000 99%
Missouri M.D. 10,000 N/A
Montana M.D., R.Ph., Nurse 12,078 84%
Nebraska M.D., R.Ph. 2,500 80%
Nevada M.D., R.Ph. 40,000 90%
New Hampshire N/A N/A N/A
New Jersey R.Ph., DME Supplier 386,000 90%
New Mexico M.D., R.Ph. 60 80%
New York Order Provider N/A N/A
North Carolina N/A 395 85
North Dakota R.Ph. 625 96%
Ohio M.D. 40,000 99%
Oklahoma M.D., R.Ph. 6,000 75%
Oregon M.D. 24974 70%
Pennsylvania M.D. N/A N/A
Rhode Island R.Ph. 200 N/A
South Carolina M.D., R.Ph. 4,200 90%
South Dakota M.D., R.Ph. 50 95%
Tennessee* - - -
Texas M.D., R.Ph. N/A N/A
Utah R.Ph. N/A N/A
Vermont M.D. N/A 99%
Virginia M.D. N/A N/A
Washington M.D., R.Ph. 82,480 80%
West Virginia M.D., R.Ph. 153,235 73%
Wisconsin R.Ph. 58,321 99%
Wyoming N/A N/A N/A
decisions.

Prior Authorization Process and Procedures (Con’t)

State Reviewer Review Time Response Vehicle
Alabama R.N., M.D., R.Ph. 24 hours Phone, fax, mail
Alaska M.D., R.Ph., other Verbal-instant; paper-2 weeks Verbal, fax, mail
Arizona* - - -
Arkansas Voice Response 1-3 minutes Voice Response System
California R.Ph. 24 hours Fax or telephone inquiry system
Colorado R.Ph., Fiscal Agent PA line Less than 1 working day Phone
Connecticut N/A N/A N/A
Delaware R.Ph. 1 working day Phone, fax
Florida R.N., R.Ph., Other 10 minutes to 72 hours Verbal, fax, mail
Georgia R.Ph. 24 hours Phone, fax, mail
Hawaii R.N., M.D. 24 hours Phone
Idaho M.D., R.Ph. 24 hours or less Mail, fax
Illinois M.D., R.Ph. 24 hours Automated phone
Indiana N/A N/A N/A
Iowa R.Ph. 24 hours or less Phone, fax
Kansas R.N., M.D., R.Ph. 24 hours or less Phone
Kentucky R.N., M.D., R.Ph. Minutes to hours+ Phone, mail
Louisiana N/A N/A N/A
Maine M.D., R.Ph. 24 hours or less Phone, mail
Maryland M.D., R.Ph. 24 hours or less Phone
Massachusetts R.Ph. 24 hours Phone, on-line
Michigan Health Care Analysts 24 hours or less Phone
Minnesota R.N. Within 10 days Phone, mail
Mississippi R.N., R.Ph., other 5-10 minutes Phone
Missouri R.N., Medicaid Tech. Within 24 hours Phone, fax
Montana R.Ph. 10-15 minutes Phone, fax
Nebraska R.N., M.D., R.Ph. 1 hour Fax, mail
Nevada R.N., M.D., R.Ph. 24 hours Phone, fax, mail
New Hampshire N/A N/A N/A
New Jersey R.N., R.Ph. Minutes Phone
New Mexico R.Ph. 3 minutes Requestor notified if PA is denied
New York R.N., R.Ph., other Under 21 days PA sent to ordering provider
North Carolina R.Ph. 24 hours Fax
North Dakota R.Ph., M.D., R.N. 2-3 days Mail
Ohio R.Ph. 24 hours Phone, fax
Oklahoma R.Ph. 5-20 minutes Phone, fax
Oregon R.Ph. 3-4 minutes Phone, fax
Pennsylvania R.N., M.D. Immediately to 24 hours Phone
Rhode Island R.Ph. Within 72 hours N/A
South Carolina R.Ph. Per OBRA '90 guidelines Phone, fax, mail
South Dakota M.D. or R.Ph. 24 hours Phone, fax, mail
Tennessee* - - -
Texas R.Ph. N/A Phone, fax, mail, e-mail
Utah Nurse 24 hours Phone, fax, mail
Vermont R.N. 24 hours Phone, mail
Virginia M.D., R.Ph. 24 hours Phone, fax, mail
Washington R.N., M.D., R.Ph.# 24 hours Phone, fax; denial through mail
West Virginia R.Ph. 3 minutes to 2 hours Phone, fax
Wisconsin R.Ph. Immediate to a few days+ Phone, fax, mail
Wyoming N/A N/A N/A
decisions.
+
Depends on urgency.
#
Reviewer also includes Medical Claims Examiner.

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

Prior Authorization (Con’t)

Anxiolytics, Prescribed
State Antihistamines Sedatives, and Hypnotics Cold Medications
Alabama Covered, PA Required Covered Covered
Alaska Covered Covered Not Covered
Arizona* - - -
Arkansas Covered, PA Required Partial Coverage Partial Coverage
California Covered, Some PA Required Covered, Some PA Required Covered, Some PA Required
Colorado Covered Covered Partial Coverage, Under 21
Connecticut Covered Covered Covered
Delaware Covered Covered Covered
Florida Covered Covered Not Covered
Georgia Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage
Hawaii Covered, PA Required Covered, PA Required Covered
Idaho Covered Covered Covered
Indiana N/A N/A N/A
Iowa Covered, PA Required Covered Covered
Kansas Covered Partial Coverage, PA Required Covered
Kentucky Covered, PA Required Covered, Some PA Required Covered, Some PA Required
Louisiana Covered Covered Not Covered
Maine Covered Covered Not Covered
Maryland Covered Covered Covered
Massachusetts Covered Covered, PA for prolonged use Covered, PA Required
Michigan Covered Covered Not Covered
Minnesota Covered Covered Covered
Mississippi Covered Covered Not Covered
Missouri Covered Partial Coverage, PA Required Covered
Montana Covered Covered, PA Required Covered
Nebraska Covered Covered Covered
Nevada Covered Covered Covered, PA Required
New Jersey Covered Covered Covered
New York Covered Covered Partial Coverage, PA Required
North Dakota Covered Covered Partial Coverage
Ohio Covered Covered Covered
Oklahoma Covered, PA Required Covered, PA Required Not Covered
Oregon Covered, PA Required Covered Covered, PA Required
Pennsylvania Covered Covered Partial Coverage
South Dakota Covered Covered Covered
Tennessee* N/A N/A N/A
Texas Covered Covered Covered
Utah Covered Covered Covered
Virginia Partial Coverage Covered Partial Coverage
Washington Covered, PA Required Covered, PA Required Covered, PA Required
West Virginia Covered Partial Coverage Partial Coverage
Wisconsin Partial Coverage Covered Partial Coverage
Wyoming Covered Covered Covered
decisions.

Prior Authorization (Con’t)

Miscellaneous Prescribed
State Growth Hormones GI Products Smoking Deterrents
Alabama Covered, PA Required Covered Not Covered
Alaska Covered, PA Required Covered Not Covered
Arizona* N/A N/A N/A
Arkansas Covered Covered, PA Required Covered, PA Required
California Covered, PA Required Covered, Some PA Required Covered, Some PA Required
Colorado Covered, PA Required Covered Covered, PA Required
Connecticut Covered Covered Not Covered
Delaware Covered, PA Required Covered Covered
Florida Covered, PA Required Covered Covered
Georgia Covered, PA Required Covered Not Covered
Hawaii Covered, PA Required Covered, PA Required Covered, PA Required
Idaho Covered, PA Required Covered Not Covered
Indiana N/A N/A N/A
Iowa Covered, PA Required Covered, PA Required Not Covered
Kansas Covered, PA Required Covered Covered
Kentucky Covered Covered Not Covered
Louisiana Covered Covered Covered
Maine Covered, PA Required Covered Covered
Maryland Covered, PA Required Covered Covered
Massachusetts Covered Covered, PA for prolonged use Not Covered
Michigan Covered, PA Required Covered Covered, PA Required
Minnesota Covered Covered, PA Required Covered
Mississippi Covered, PA Required Covered Not Covered
Missouri Not Covered Covered Not Covered
Montana Covered, PA Required Partial Coverage, PA Required Covered, PA Required
Nebraska Covered, PA Required Covered Not Covered
Nevada Covered, PA Required Covered Covered
New Jersey Partial Coverage Covered Partial Coverage
New York Covered Partial Coverage, PA Required Covered
North Dakota N/A Covered Covered, PA Required
Ohio Covered, PA Required Covered Covered
Oklahoma Covered, PA Required Covered, PA Required Partial Coverage, PA Required
Oregon Covered, PA Required Covered, PA Required Covered
Pennsylvania Covered Covered Not Covered
South Carolina Covered Covered Partial Coverage
South Dakota Covered PA Required Covered Not Covered
Tennessee* N/A N/A N/A
Texas Covered Covered Covered
Utah Partial Coverage, PA Required Covered Not Covered
Vermont Covered Covered Covered, PA Required
Virginia Covered Covered Covered
Washington Partial Coverage, PA Required Covered, PA Required Not Covered
West Virginia Covered, PA Required Covered, PA Required Covered, PA Required
Wisconsin Covered PA Required Covered, PA Required Covered, PA Required
Wyoming Covered Covered Not Covered
decisions.

Drug Utilization Review

PRODUR
State State Contact Telephone In-House or Contracted Implemented
Alabama Louise Jones 334-242-5039 Contracted Jul-96
Alaska Dave Campana, R.Ph. 907-273-3224 In-House and Contracted Jun-95
Arizona* - - - -
Arkansas Suzette Bridges, P.D. 501-324-9141 Contracted Mar-97
California Vic Walker, R.Ph., B.C.P.P. 916-657-0785 In-House Aug-95
Colorado Allen Chapman 303-866-3176 Contracted Dec-98
Connecticut Elizabeth Geary, R.Ph. 860-424-5150 Contracted Sep-96
Delaware Cynthia Denemark 302-453-8453 Contracted Feb-94
District of Columbia Christopher Keeyes, Pharm.D. 301-572-1616 In-House No
Florida Marie Donnelly-Stephens 850-487-4441 Contracted Jul-95
Georgia Jean B. Cox, R.Ph. 404-657-7241 In-House Planned for 2000
Hawaii Kathleen Kang-Kaulupali 808-692-8115 In-House N/A
Idaho Gary Duerr, R.Ph. 208-364-1829 Contracted Jan-98
Illinois N/A N/A In-House Jan-93
Indiana Karen Baer 317-232-4391 Contracted Mar-96
Iowa Cheryl Clarke, R.Ph. 515-270-0713 Contracted Jul-97
Kansas Glenn McNees, R.Ph., M.S. 785-864-3164 Contracted Nov-96
Kentucky Debra Bahr 502-564-6511 Contracted Sep-94
Louisiana Melwyn Wendt 504-219-4154 Contracted Apr-96
Maine Timothy Clifford, M.D. 207-287-2674 Contracted Dec-95
Maryland Judy Geisler 410-767-1728 Contracted Jan-93
Massachusetts Anna Morin 508-721-7104 Contracted Oct-95
Michigan Mary Sandusky 517-335-5280 Contracted Jul-00
Minnesota MaryBeth Reinke, Pharm.D. 651-215-1239 In-House Feb-96
Mississippi James G. "Jack" Lee, R.Ph. 601-359-6296 Contracted Oct-95
Missouri Jayne Zemmer 573-751-6963 Contracted Feb-93
Montana Mark Eichler, R.Ph. 406-443-4020 Contracted Sep-94
Nebraska Allison Jorgensen, Pharm.D., R.Ph. 402-420-1500 Contracted Apr-95
Nevada Laurie Squartsoff, R.Ph. 702-687-4869 Contracted Planned for 2001
New Hampshire Lisè Farrand 603-271-4419 Contracted Aug-95
New Jersey Edward Vaccaro, R.Ph. 609-588-2721 In-House Oct-96
New Mexico Chuck Reynolds 505-827-3174 Contracted Oct-93
New York Michael Zegarelli 518-474-0691 In-House Mar-95
North Carolina Sharman Leinwand 919-733-3590 In-House Oct-96
North Dakota Pat Kramer 701-328-4893 In-House Jul-96
Ohio Jan Lawson 614-466-7936 Contracted Feb-00
Oklahoma John Crumly, M.H.A., R.Ph. 405-522-7300 Contracted Mar-93
Oregon Mariellen Rich 503-391-1980 Contracted Mar-94
Pennsylvania N/A - In-House Jun-93
Rhode Island Paula Avarista 401-464-2183 Contracted Dec-94
South Carolina Caroline Sojourner 803-898-2876 In-House and Contracted No
South Dakota Michael Jockheck 605-773-6439 In-House Planned for 2000
Tennessee* - - - -
Texas Curtis Burch 512-338-6922 In-House Feb-95
Utah Duane Parke 801-538-6452 In-House Jun-95
Vermont Gloria Jacobs 802-241-2763 Contracted Nov-93
Virginia Marianne Rollins, R.Ph. 804-225-4268 Contracted Jul-94
Washington Siri Childs 360-725-1564 In-House Mar-96
West Virginia Peggy A. King, R.Ph. 304-588-1753 Contracted Mar-95
Wisconsin Dr. Michael Mergener 608-258-3348 Contracted Planned for 2001
Wyoming Debra Devereuax, R.Ph. 307-766-6120 Contracted Oct-95
decisions.
PRODUR = Prospective Drug Utilization Review System

Prescribing/Dispensing Limits
Limits on
State Prescriptions Limits on Number, Quantity, and Refills of Prescriptions
Alabama Yes 5 refills per Rx
Alaska Yes 30 day supply per Rx
Arizona* - -
Arkansas Yes 30 day supply per Rx; 3 Rx per month (extension to 6); 5 refills per Rx within 6 months
California Yes 6 Rx per month without PA, other limitations specific to certain medications
Colorado No 100 day supply for maintenance medication
Connecticut No -
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 Variable 6/8/10/12 Rxs per month (with exceptions); Max/min quantities for certain meds
Georgia Yes 30 day supply per Rx; 5 (adult)/6 (child) Rx per month; Per Rx limit: $1000/Rx
Hawaii Yes 30 day supply or 100 unit doses per Rx
Idaho Yes 34 day supply per Rx (with exceptions); 3 cycles of birth control
Illinois Yes Medically appropriate monthly quantity; 11 refills per Rx
Indiana No -
Iowa No -
Kansas Yes 34 day supply per Rx, other limitations specific to certain medications
Kentucky Yes Maximum 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 months
Maine No -
Maryland Yes 34 day supply per Rx; 2 refills per Rx
Massachusetts Yes 5 refills within 6 months per Rx
Michigan Yes No refills for Schedule II drugs; Schedule III & V, 5 refills per 180 days
Minnesota Yes 30 day supply for maintenance drugs; max 3 month supply
Mississippi Yes 34 day supply or 100 unit doses (whichever is greater); 5 Rx per month; 5 refills maximum
Missouri Yes 34 day supply or 100 unit doses; up to 90 day per Rx maximum
Montana Yes 34 day supply or 100 unit doses per Rx (whichever is greater)
Nebraska Yes 3 month supply maximum, 5 refills per Rx within 6 months for controlled substances
Nevada Yes 34 day supply per Rx; 3 Rx per month
New Hampshire Yes 34 day supply or 100 unit doses per Rx (whichever is greater)
New Jersey Yes 34 day supply or 100 unit doses per Rx
New Mexico No 6 months supply maximum
New York Yes 5 refills per Rx; annual limit on number of Rx and OTC drugs avail. (potential override)
North Carolina Yes 100 day supply per Rx; 6 Rx per month
North Dakota Yes 34 day supply per Rx
Ohio Yes Consistent with State/Federal requirements
Oklahoma Yes 3 Rx per month (21+; under 21 unlimited)
Oregon Yes 34 day supply per Rx
Pennsylvania Yes 34 day supply or 100 unit doses per Rx (whichever is greater); 5 refills within 6 months
Rhode Island Yes 30 day supply per Rx (non-maintenance); 5 refills per Rx
South Carolina Yes 100 day supply w/ unlimited Rx (children); 4 Rx per month
South Dakota No -
Tennessee* - -
Texas Yes 3 Rx per month with exceptions; unlimited Rxs for nursing home recipients or those < 21
Utah Yes Monthly quantity limit, maximum varies per person
Vermont No -
Virginia No -
Washington Yes 34 day supply per Rx; usually 2 refills per month; 4 refills for antibiotics or scheduled drugs
West Virginia Yes 10 Rx per month; 5 refills per Rx
Wisconsin No 34 day supply per Rx
Wyoming Yes 90 day supply for maintenance drugs and birth control, 34 day supply for all others
decisions.

PHARMACY PAYMENT AND PATIENT COST SHARING

Federal Medicaid regulations dictate the method for reimbursing prescription drugs. Reimbursement is made on a
retrospective, fee-for-service basis, with payments limited to the lower of:
• The estimated acquisition cost (EAC) of the drug (the price generally and currently paid by providers for
a particular drug in the package size most frequently purchased by providers), as determined by the
program agency, plus a reasonable dispensing fee; or
• The providers’ usual and customary charge to the public for the drug.
Regulations require states to submit a state plan that describes their payment methods for prescribed drugs. The
regulations do not prescribe a preferred payment method, but states are required to submit assurances to HCFA
that the requirements are met.
The Health Care Financing Administration’s (HCFA) publishes a list of multiple-source drugs (generic drugs) to
which the upper limit payment formula applies (commonly referred to as the Federal Upper Limit List).
Revisions to the list are provided periodically through Medicaid program issuances under the title “State Medicaid
Manual - Part 6, Payment for Services.” Any price revisions are included in these issuances. The current version
of this list is included as Appendix D: Specific Upper Limits for Multiple Source and “Other” Drugs. The
formula does not apply to any prescription for which the prescriber certified in his or her own handwriting that a
certain brand of drug is “medically necessary” for the patient.
According to the regulations, 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. State programs
implemented to comply with these requirements are frequently referred to as Maximum Allowable Cost (MAC)
programs.
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 of a waiver request by HCFA is
based partly on the state’s assurance that recipients will have access to alternative sources of care.

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 AWP-5% $2.00
Arizona* - - -
Arkansas $5.51 AWP-10.5% $0.50 - $3.00
California $4.05 AWP-5% G: $1.00, B: $1.00
Colorado $4.08 AWP-10% or WAC+18%, whichever is lowest G: $0.50, B: $2.00
Connecticut $4.10 AWP-12% None
Delaware $3.65 AWP-12.9% None
District of Columbia $3.75 AWP-10% $1.00
Florida $4.23 AWP-13.25% None
Georgia $4.63 AWP-10% $0.50
Hawaii $4.67 AWP-10.5% None
Idaho $4.94 ($5.54 for unit dose) AWP-11% None
Illinois G: $3.75, B: $3.45 AWP-10%, AWP-12% for multi-source drugs None
Indiana $4.00 AWP-10% $0.50 - $3.00
Iowa $4.13 - $6.42 AWP-10% $1.00
Kansas $4.50 AWP-10% $2.00
Kentucky OP: $4.75, LTC: $5.75 AWP-10% None
Louisiana $5.77 AWP-10.5% $0.50 - $3.00
Maine $3.35 (+ extra fees for compounding) AWP-10% $0.50 - $3.00
Maryland $4.21 Lowest of :WAC + 10%, direct + 10%, AWP -10% $1.00
Massachusetts $3.00 WAC+10% $0.50
Michigan $3.72 AWP-13.5% (1 to 4 stores), AWP-15.1% (5+ stores) $1.00
Minnesota $3.65 AWP-9% None
Mississippi $4.91 AWP-10% $1.00
Missouri $4.09 AWP-10.43% $0.50 - $2.00
Montana $2.00 - $4.20 AWP-10% G: $1.00, B: $2.00
Nebraska $3.20 - $5.05 AWP-8.71% $1.00
Nevada $4.76 AWP-10% None
New Hampshire $2.50 AWP-12% G: $0.50, B: $1.00
New Jersey $3.73 - $4.07 AWP-10% None
New Mexico $4.00 AWP-12.5% None
New York B: $3.50 G: $4.50 AWP-10% G: $0.50, B: $2.00
North Carolina $5.60 AWP-10% $1.00
North Dakota $4.60 AWP-10% None
Ohio $3.70 AWP-11% None
Oklahoma $4.15 AWP-10.5% $1.00 - $2.00
Oregon $3.91-$4.28 (based on annual # of Rx) AWP-11% None
Pennsylvania $4.00 AWP-10% $1.00 - $2.00
Rhode Island OP: $3.40, LTC: $2.85 WAC+5% None
South Carolina $4.05 AWP-10% $2.00
South Dakota $4.75 ($5.55 for unit dose) AWP-10.5% $2.00
Tennessee* - - -
Texas $5.27 + 2% of ingredient & dispensing fee AWP-15% or WAC+12%, whichever is lowest None
Utah $3.90 - $4.40 (based on geographic area) AWP-12% $1.00 - $5.00
Vermont $4.25 AWP-11.9% $1.00 - $2.00
Virginia $4.25 AWP-9% $1.00
Washington $4.06 - $5.02 (based on annual # of Rx) AWP-11% None
West Virginia $3.90 (+ extra fees for compounding) AWP-12% $0.50 - $2.00
Wisconsin $4.88 AWP-10% $0.50 - $1.00
Wyoming $4.70 AWP-4% $2.00
WAC = Wholesalers Acquisition Cost; AWP = Average Wholesale Price; EAC = Estimated Acquisition Cost;
G = Generic; B = Brand Name; OP = Outpatient; LTC = Long Term Care.
decisions.

Maximum Allowable Cost (MAC) Programs

Federal Upper State-Specific
State Limits Upper Limits MAC Override Provisions
Alabama Yes Yes Brand medically necessary
Alaska Yes No Brand medically necessary and reason for medical necessity
Arizona* Yes No Brand necessary
Arkansas Yes Yes Brand medically necessary
California Yes Yes Medically necessary and other products unavailable at MAC rate
Colorado Yes Yes Prior authorization
Connecticut Yes No Brand medically necessary
Delaware Yes Yes Brand medically necessary
District of Columbia Yes No Brand medically necessary
Florida Yes Yes If drug is on Florida Negative Formulary
Georgia Yes Yes Brand medically necessary
Hawaii Yes No Brand necessary, prior authorization
Idaho Yes Yes Brand medically necessary, handwritten by M.D., prior authorization
Illinois Yes Yes Prior authorization request by M.D. or R.Ph
Indiana Yes No Brand medically necessary
Iowa Yes No Brand medically necessary
Kansas Yes Yes Brand medically necessary, prior authorization
Kentucky Yes No Brand necessary, brand medically necessary
Louisiana Yes No Brand necessary or brand medically necessary
Maine Yes No Dispense as written
Maryland Yes Yes Brand medically necessary and reason for medical necessity
Massachusetts Yes No Dispense as written, brand medically necessary
Michigan Yes Yes Prior authorization
Minnesota Yes Yes Brand medically necessary
Mississippi Yes No Brand medically necessary
Missouri Yes Yes Prior authorization
Montana Yes No Dispense as written, brand necessary
Nebraska Yes Yes Brand medically necessary and MC-6 form signed by M.D.
Nevada Yes No Brand medically necessary
New Hampshire Yes No Brand medically necessary
New Jersey Yes No Brand medically necessary
New Mexico Yes No Brand medically necessary
New York Yes No Dispense as written and brand necessary, or brand medically necessary
North Carolina Yes No Brand medically necessary
North Dakota Yes No Dispense as written
Ohio Yes Yes Prior authorization
Oklahoma Yes Yes Brand medically necessary
Oregon Yes No Brand necessary, medically necessary, or brand medically necessary
Pennsylvania Yes Yes Brand necessary or brand medically necessary, plus prior authorization
Rhode Island Yes No Dispense as written, brand medically necessary
South Carolina Yes Yes Brand necessary or brand medically necessary
South Dakota Yes No Brand medically necessary
Tennessee* - - -
Texas Yes Yes Brand necessary or brand medically necessary
Utah Yes No Dispense as written, brand medically necessary, or medical necessary
Vermont Yes No Dispense as written
Virginia Yes Yes Brand necessary
Washington No Yes Brand medically necessary
West Virginia Yes No Brand medically necessary
Wisconsin No Yes Brand medically necessary
Wyoming No No -
decisions.

Mandatory Substitution
Incentive Fee for Dispensing of Generic Dispensing of Lowest Cost
State Generic Substitution Multisource Required Multisource Required
Alabama No No No
Alaska No Yes No
Arizona* - - -
Arkansas No Yes No
California No No Yes
Colorado No Yes (if FUL or State MAC) No
Connecticut $0.50 No No
Delaware No Yes No
District of Columbia No No Yes
Florida No Yes No
Georgia No Yes (brand PA required) Yes
Hawaii No Yes (if FUL) No
Idaho No Yes No
Illinois No No No
Indiana No Yes No
Iowa No Yes No
Kansas No No No
Kentucky No Yes Yes
Louisiana No No No
Maine No Yes No
Maryland No No (payment based on generic) No
Massachusetts No Yes No
Michigan No No No
Minnesota No Yes Yes
Mississippi No No No
Missouri No No No
Montana No No No
Nebraska No No No
Nevada No Yes Yes
New Hampshire No Yes Yes
New Jersey No Yes No
New Mexico No Yes Yes
New York Yes Yes (if M.D. allows substitution) No
North Carolina No Yes No
North Dakota No No No
Ohio No No No
Oklahoma No Yes No
Oregon No Yes No
Pennsylvania No Yes No
Rhode Island No Yes No
South Carolina No Yes (if M.D. authorizes) Yes
South Dakota No No No
Tennessee* - - -
Texas No Yes No
Utah No Yes No
Vermont No Yes No
Virginia No No No
Washington No No (except MAC drug, 3+ labelers) No
West Virginia No Yes No
Wisconsin No No No
Wyoming No No No
decisions.

Counseling Requirements and Payment for Cognitive Services

Medicaid Payment
State Patient CounselingRequired1 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 Pending No
Florida All No
Georgia All No
Hawaii Medicaid Only No
Idaho All No
Illinois All No
Indiana All No
Iowa All No
Kansas All No
Kentucky All No
Louisiana All No
Maine All Yes
Maryland Medicaid Only No
Massachusetts All No
Michigan All No
Minnesota Medicaid Only No
Mississippi All No
Missouri All No
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 -
Texas All No
Utah All No
Vermont All No
Virginia All No
Washington All No
West Virginia All No
Wisconsin All Yes
Wyoming All No
Source: 12000-2001 National Association of Boards of Pharmacy Law, Survey of Pharmacy Law; 2As reported by state drug program
administrators in the 2000 NPC Survey.

Prescription Price Updating

State Contact Telephone Updated
Alabama First DataBank 650-588-5454 Biweekly
Alaska Dave Campana 907-273-3224 Weekly
Arizona* - - -
Arkansas First DataBank 650-588-5454 Weekly
California Electronic Data Systems 916-636-1000 Monthly
Colorado Allen Chapman 303-866-3176 Weekly
Connecticut First DataBank 650-588-5454 Weekly
Delaware Cynthia Denemark 302-453-8453 Bimonthly
District of Columbia First DataBank 650-588-5454 Monthly
Florida First DataBank 650-588-5454 Weekly
Georgia Etta Hawkins 404-657-7239 Monthly
Hawaii First DataBank 800-633-3453 Monthly
Idaho Gary Duerr 208-334-5795 Bimonthly
Illinois First DataBank 650-588-5454 Weekly
Indiana First DataBank 317-469-5200 Monthly
Iowa Sherry Swanson 515-327-0950 Weekly
Kansas Karen Bramen 785-296-6968 Weekly
Kentucky Unisys 502-226-1140 Bimonthly
Louisiana Maggie Vick, Unisys Corp. 504-237-3251 Weekly
Maine Susan Curtis 207-287-1818 Bimonthly
Maryland First DataBank 650-588-5454 Weekly
Massachusetts Christopher Burke 617-210-5592 Weekly
Michigan First DataBank 650-588-5454 Weekly
Minnesota First DataBank 650-588-5454 Bimonthly
Mississippi James G. Lee 601-359-6296 Weekly
Missouri First DataBank 650-588-5454 Weekly
Montana First DataBank 650-588-5454 Weekly
Nebraska First DataBank 650-588-5454 Weekly
Nevada First DataBank 650-588-5454 Monthly
New Hampshire First DataBank 650-588-5454 Biweekly
New Jersey First DataBank 650-588-5454 Weekly
New Mexico Chuck Reynolds 505-827-3174 Weekly
New York Carl Cioppa, Pharm.D.. 518-486-3209 Monthly
North Carolina Benny Ridout 919-857-4034 Weekly
North Dakota First DataBank 800-633-3453 Biweekly
Ohio First DataBank 650-588-5454 Monthly
Oklahoma Angela Thomasson 405-522-7307 Weekly
Oregon Kathy Franklin, First DataBank 650-588-5454 Bimonthly
Pennsylvania First DataBank 800-633-3453 Monthly
Rhode Island Paula Avarista 401-464-2183 Biweekly
South Carolina First DataBank 650-588-5454 Monthly
South Dakota Mark Petersen 605-773-3498 Bimonthly
Tennessee* - - -
Texas Martha McNeill 512-338-6965 Continuously
Utah RaeDell Ashley 801-538-6495 Bimonthly
Vermont Christine Dapkiewicz 802-879-4450 Biweekly
Virginia David Shepherd 804-786-8057 Monthly
Washington Marilyn Mueller 360-725-1569 Weekly
West Virginia Leslie Bratton 800-358-2381 Weekly
Wisconsin First DataBank 800-633-3453 Bimonthly
Wyoming First DataBank 800-633-3453 Weekly
decisions.


Section 5:
State
Pharmacy Assistance
Programs


State Pharmacy Assistance Programs

As of the end of December 2000, 26 states had authorized some type of program to provide pharmaceutical
coverage or assistance to low-income elderly and/or persons with disabilities who do not qualify for Medicaid.
These programs range from providing access to state-negotiated discounts to state subsidies and tax credits for
prescription drug expenditures. These programs currently provide assistance to over 850,000 individuals, and an
estimated 1.5 million more individuals are eligible for assistance.
Authorized State Pharmacy Assistance Programs
State Program Name Law Enacted

California Discount Prescription Medication Program 1999
Connecticut Pharmaceutical Assistance Contract to the Elderly and
Connecticut 1985
the Disabled Program (ConnPACE)
Nemours Pharmacy Assistance 1981
Delaware
Delaware Prescription Drug Assistance Program (DPAP) 1999
Florida Pharmaceutical Expense Assistance Program 2000
Illinois Pharmaceutical Assistance Program (PAP) 1985
Indiana Indiana Prescription Drug Fund -- HoosierRx 2000
Iowa Pharmaceutical Discount Program †‡
Kansas Senior Pharmacy Assistance Program 2000†
Low Cost Drugs for the Elderly Program 1975
Maine
Maine Rx Program 2000†
Maryland Pharmacy Assistance Program 1979
Maryland
Short-Term Prescription Drug Subsidy Plan 2000
The Pharmacy Program 1996
Massachusetts Pharmacy Program Plus 1999
Subsidized Catastrophic Prescription Drug Insurance Program 2000†
Michigan Emergency Pharmaceutical Program for Seniors (MEPPS) 1988
Michigan
State Medical Plan 1988
Minnesota Senior Citizen Drug Program 1997
Missouri State Income Tax Credit for Legend Drugs 1999
New Hampshire New Hampshire Senior Prescription Drug Discount Program ‡
New Jersey Pharmaceutical Assistance to the Aged and Disabled (PAAD) 1975
New York Elderly Pharmaceutical Insurance Coverage (EPIC) 1987
Nevada Subsidy Program 1999
North Carolina Prescription Drug Assistance Program 1999
Pharmaceutical Assistance Contract for the Elderly (PACE) 1984
Pennsylvania
PACE Needs Enhancement Tier (PACENET) 1996
Rhode Island Rhode Island Pharmaceutical Assistance to the Elderly (RIPAE) 1985
South Carolina SilverCard Program 2000
VSCRIPT 1989
Vermont Vermont Health Access Program (VHAP) 1996
Pharmacy Discount Program (PDP) 2000
A Washington Alliance to Reduce Prescription-Drug Spending
Washington ‡
(AWARDS)
West Virginia Senior Prescription Assistance Network II (SPAN II) ‡
Wyoming Minimum Medical Program 1988
†Program not yet operational.
‡Not written into law. Program is either in pilot phase or under executive orders.

Nine states (Florida, Iowa, Kansas, Maine, Massachusetts, Nevada, South Carolina, Vermont, and Washington)
have plans for new programs that are expected to commence in the year 2001 or later.
• Florida’s Pharmaceutical Expense Assistance Program: Florida’s program is designed to provide a

subsidy, limited to $80 per month, to individuals over 65 who are dually-eligible for Medicaid and Medicare
but do not have pharmaceutical coverage. Participants will be required to pay a 10% coinsurance payment
for each prescription. An estimated 30,000 individuals are eligible for this program. This program went into
effect on January 1, 2001.
• Iowa’s Pharmaceutical Discount Program: Iowa legislators have acquired federal funds to establish a
demonstration project to lower pharmaceutical costs for individuals and other purchasers through the
establishment of a prescription drug purchasing co-op. Individuals as well as local pharmacies would be
eligible to join the co-op with additional participants eligible including employers, the self-employed,
insurers and others. Participants would be required to a minimal fee to join the co-op. The State of Iowa
would either directly or through a private sector contractor negotiate volume-purchasing discounts with drug
manufacturers. Members of the co-op would then pay the discounted rate when they purchase their
medications. This project is scheduled to go into effect on July 1, 2001.
• Kansas’ Senior Pharmacy Assistance Program: This new law (HB 2814), signed into law in May 2000, is
designed to provide direct subsidies to low-income seniors for the purchase of prescription drugs. The
minimum age for eligibility will be 67 years of age, and the income eligibility level will be 150% of the
federal poverty level. This program is scheduled to go into effect on July 1, 2001.
• Maine Rx Program: The Rx Program was created to provide a discounted price on prescription drugs for any
eligible resident who enrolls in the program. The law, which created the new program, also provides
authorization for the Commissioner of Human Services to establish maximum retail prices effective July
2003 “if prices paid under the Maine Rx program for the most common drugs are not reasonably comparable
to the lowest prices paid in the state.” The program is scheduled to commence on April 1, 2001.
• Massachusetts’s Subsidized Catastrophic Prescription Drug Insurance Program. Planned to replace the
two programs currently in effect in Massachusetts, this new program will offer benefits to individuals 65
years of age or older, or individuals under age 65 who work less than 40 hours per month and meet the
disability guidelines for CommonHealth. There will be no income eligibility requirement; however, monthly
premiums, deductibles, and copay will be based on income. This new program is scheduled to go into effect
on April 1, 2001.
• Nevada’s Subsidy Program: Nevada’s SenioRx is a prescription insurance subsidy program that began on
January 1, 2001. The program is comprised of two plans: the Basic Plan and the Enhanced Plan, with
monthly premiums of $74.76 and $98.31 respectively, the latter covering some brand name drugs. Both
include a $100 yearly deductible, a $10 copayment for generic drugs, and a $5,000 maximum yearly benefit.
Seniors with annual income of $12,700 or less would be eligible for a $40 monthly subsidy; seniors with
income up to $21,500 would be eligible for less. The state will pay a maximum of $480 per year toward the
cost of the policy. The minimum age is 62. The program will be funded by the tobacco settlement.
• South Carolina’s SilverxCard Program: South Carolina’s new program went into effect on January 1, 2001.
This program offers assistance to those who are 65 years or older, have income below 175% of the federal
poverty level ($14,612 for single; $19,678 for married), and have been South Carolina residents for 6 months.
Total program funding for 2001 is estimated to be $20 million from the state’s tobacco settlement. Senior
citizens enrolled in the SilverxCard program are not eligible for Medicaid and may not have other
prescription insurance coverage.

• Vermont’s Pharmacy Discount Program: The Pharmacy Discount Program is an expansion of the current
Vermont Health Access Program. Under the new program, eligibility is expanded to include any Medicare-
covered individual with income above 150% of federal poverty level without drug coverage and all
individuals with incomes up to 300% federal poverty level who do not have a benefit program that includes
drug coverage. Beneficiaries have the ability to purchase drugs at a price that is equivalent to the price that is
available to the Medicaid program. Approximately 69,000 individuals are eligible for this program which
began on January 1, 2001.
• A Washington Alliance to Reduce Prescription-Drug Spending: The AWARDS program, in operation since
January 15, 2001, will offer Washington residents aged 55 and older significantly lower prescription drug
costs. Eligible beneficiaries will pay an annual fee of $15 per individual or $25 per family to join what will
be considered a “buyer's club.” Through combined agency purchasing power, beneficiaries can expect to
save anywhere from 12 percent to 30 percent of retail price for prescriptions.
The following pages provide profiles of 20 states that provided pharmacy assistance in 2000. Details were
provided by state contacts on program characteristics, including eligibility criteria, funding and reimbursement
information, and drug coverage.

California
Discount Prescription Medication Program
Program Type: State-Negotiated Discounts
Year Operational: 2000
Estimated Eligibles (FY 00): 1,300,000
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+

Eligible Income Level (Single): None Eligible Income Level (Married): None
Other Eligibility Notes: Anyone who has a Medicare card is eligible
FUNDING AND REIMBURSEMENT
Funding Source: No funding, program offers state-negotiated discounts

Budget (FY 00): N/A
Cost per Participant (FY 00): N/A
# of Rx’s Per Participant (FY 00): N/A
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 5%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $0.15 per prescription
Notes: All enrollees are eligible for discounts on prescriptions
DRUGS COVERAGE
Formulary: Open Formulary

Drugs Covered: All prescription drugs
Drug Coverage Restrictions: No formulary restrictions and no prior authorization
Notes: Pharmacies that participate in the Medi-Cal (Medicaid) program must
also allow Medicare recipients to purchase drugs for the same price
paid by Medi-Cal. Pharmacies must participate in this program in
order to participate in the Medi-Cal program.
PROGRAM CONTACT
Department of Health Services Phone: 916/657-4213

714 P Street, Room 1253
Sacramento, CA 95814

Connecticut
ConnPACE
Program Type: Direct Assistance
Number of Recipients (FY 00): 31,666
(Elderly: 27,434; Disabled: 4,232)

Eligible Income Level (Single): $14,700 Eligible Income Level (Married): $17,700
Other Eligibility Notes: None
Funding Source: General Revenue Fund

Budget (FY 00): $39.6 million
Cost per Participant (FY 00): $1,357.62
# of Rx’s Per Participant (FY 00): 22.44
Enrollment Fee: $25.00/annual
Copayment Amount: $12.00/Rx
Dispensing Fee: $4.10
DRUGS COVERAGE

Drugs Covered: All prescription drugs and insulin, 120 unit or 30 day supply limit,
whichever is greater
Drug Coverage Restrictions: Restrictions on antihistamines, cough preparations, cosmetic, diet and
fertility/contraceptive drugs. Also restricted are multivitamins,
smoking cessation gum and DESI drugs.
Prescription Drug Utilization: $39,417,855 program spending, 651,585 scripts
Notes: ConnPACE pays the difference between the copayment paid by the
enrollee and the cost of the drug.
PROGRAM CONTACT
Elizabeth A. Geary, R.Ph. Phone: 860/424-5150

Department of Social Services Fax: 860/951-9544
25 Siqourney Street E-mail: elizabeth.geary@po.state.ct.us
Hartford, CT 06106

Delaware
Nemours Pharmacy Assistance
Program Type: Private Discount Program

Other Eligibility Notes: U.S. Citizen, Resident of Delaware
Funding Source: Nemours Foundation (Program receives no state or federal funds)

Budget: N/A
Cost per Participant (FY 99): $622.63
Manufacturer Rebate Type: None
Ingredient Cost Calculation: None
Copayment Amount: 20% of drug cost
Dispensing Fee: None
Notes: Maximum yearly benefit: $2,000 based on average retail cost
DRUGS COVERAGE

Drugs Covered: Prescription drugs, insulin syringes, and prescribed OTCs
Drug Coverage Restrictions: Injectables, except for insulin
Prescription Drug Utilization: Program spending, volume of scripts unknown
Notes: One central pharmacy distributes all drugs by courier to branch
locations where citizens can pick up a 2-3 month supply. Formulary
limited due to budgetary restraints.
PROGRAM CONTACT
W. Frank Morris, Jr. Phone: 302/651-4405

Nemours Clinic Pharmacy Assistance Fax: 302/651-4445
1801 Rockland Road E-mail: fmorris@nemours.org
Wilmington, DE 19803

Delaware
Prescription Assistance Program (DPAP)
(Elderly: 986; Disabled: 1,217)

Other Eligibility Notes: Senior citizens eligible for the Nemours program are not eligible for
this program. Elderly and SSDI individuals who have income over
these amounts may also be eligible if they have drug costs that are
over 40% of their yearly income.
Funding Source: Tobacco settlement (not subject to budget appropriation)

Budget: $7.5 million
Ingredient Cost Calculation: AWP – 12.9%
Copayment Amount: Greater of $5 or 25% AAC
DRUGS COVERAGE

Drugs Covered: Similar to Medicaid but limited by state rebate participation
Drug Coverage Restrictions: Annual limit of $2,500 per person
Prescription Drug Utilization: N/A
Notes: None
PROGRAM CONTACT
Cynthia Denemark Phone: 302/453-8453 ext. 211

Division of Social Services Fax: 302/454-7603
248 Chapman Road Suite 200 E-mail: cynthia.denemark@eds.com
Newark, DE 19702

Illinois
Pharmaceutical Assistance Program (PAP)

Other Eligibility Notes: Widow(er) who turned 63 or 64 before deceased claimant’s death is
eligible
Funding Source: General Revenue Fund (subject to budget appropriations)

Budget: $35 million
Cost per Participant (FY 99): $207.84 annually
Ingredient Cost Calculation: AWP – 10% or MAC if generic is available
Enrollment Fee: $5 if below FPL, $25 if above FPL
Copayment Amount: No copayment if below FPL, then 20% of drug cost after program
pays $2,000 in a fiscal year.
$3.00 copayment if above FPL, then 20% of drug cost after program
pays $2,000 in a fiscal year.
DRUGS COVERAGE

Drugs Covered: Prescription medication used for cancer, Alzheimer’s disease,
Parkinson’s disease, glaucoma, lung disease and smoking-related
diseases.
Drug Coverage Restrictions:
Notes:
PROGRAM CONTACT
Sue Coombe Phone: 217/785-5905

Illinois Department of Revenue Fax: 217/524-9213
P.O. Box 19021 E-mail: scoombe@revenue.state.il.us
Springfield, IL 62794-9021

Indiana
Prescription Drug Fund “HoosierRx”
Program Type: Refunds
Estimated Eligibles (FY 00): 66,000
Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): N/A

Other Eligibility Notes: None
Funding Source: National Tobacco Fund

Budget: $20 million
Manufacturer Rebate Type: N/A
Ingredient Cost Calculation: N/A
Notes: Refunds based on monthly income.
DRUGS COVERAGE

Drugs Covered: FDA-approved prescription drugs and insulin
Drug Coverage Restrictions: Maximum benefit of $1,000 per year
Notes: Refund amount is limited to 50% of actual out-of-pocket expenses, up to
the maximum benefit, based on monthly income:
Single Married Refund
$940 or less $1,266 or less 50% refund up to $500 per year
$835 or less $1,125 or less 50% refund up to $750 per year
$696 or less $938 or less 50% refund up to $1,000 per year
PROGRAM CONTACT
Grace Chandler Phone: 866/267-4679

HoosierRx
P.O. Box 6224
Indianapolis, IN 46206-6224

Maine
Low Cost Drugs for the Elderly and Disabled Program

Other Eligibility Notes: If 40% of income goes to drugs the eligible incomes increase to
$19,185 for Single and $25,575 for Married.
Funding Source: General Revenue Fund

Copayment Amount: Greater of $2 or 20% of drug cost
DRUGS COVERAGE

Drugs Covered: All drugs from participating manufacturers used for the chronic
treatment of diabetes, asthma, COPD, cardiac conditions, arthritis
Drug Coverage Restrictions: N/A
Notes:
PROGRAM CONTACT
Christine Gee Phone: 207/287-4018

Department of Human Services Fax: 207/287-8601
11 State House Station
August, ME 04333-0011

Maryland
Pharmacy Assistance Program
Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages
Other Eligibility Notes: No age restriction on eligibility
Funding Source: General Revenue Fund (subject to budget appropriations)

Cost per Participant (FY 99): $1,124
Ingredient Cost Calculation: WAC + 10%
Copayment Amount: $5.00
Dispensing Fee: $3.73 - $4.07
DRUGS COVERAGE

Drugs Covered: Specified categories of maintenance drugs used to treat chronic
conditions, anti-infective drugs, and insulin syringes and needles
Drug Coverage Restrictions: 75% utilization required before prescription refill
Notes: The following groups are ineligible for participation: people detained
in a correctional (federal, state, local) system, Medicaid recipients,
and non-residents
PROGRAM CONTACT
Paul A. Roeger, Division Chief Phone: 410/767-5397

Office of Operations & Eligibility- Fax: 410/333-7290
DHMH E-mail: roeger@dhmh.state.md.us
201 West Preston Street
Baltimore, MD 21201

Maryland
Short-Term Prescription Drug Subsidy Plan
Enacted: 2000
Eligibility Age (Elderly): 65+* Eligibility Age (Disabled): N/A

Eligible Income Level (Single): N/A Eligible Income Level (Married): N/A
Other Eligibility Notes: *And eligible for Medicare+Choice. Limited to residents of 17
underserved counties
Funding Source: N/A

Budget: N/A
Enrollment Fee: $460/annually
Deductible Amount: $50
Copayment Amount: $10 for generics, $20 for branded products
Dispensing Fee: N/A
DRUGS COVERAGE
Formulary: N/A
Drugs Covered: N/A
Drug Coverage Restrictions: Maximum benefit of $1,000 per year
Notes:
PROGRAM CONTACT
Secretary of Health and Mental Hygiene

Baltimore, MD 21201

Massachusetts
The Pharmacy Program
(formerly Senior Pharmacy Assistance Program)


Other Eligibility Notes: Six month Massachusetts residency required; no enrollees receiving
drug coverage from MassHealth or CommonHealth; disabled
participants must work 40 hours per month and meet guidelines for
CommonHealth
Funding Source: Cigarette tax revenues and general revenue fund

Budget: $30 million
Cost per Participant (FY 99): $735
Ingredient Cost Calculation: WAC+10% or lowest and customary fee
Enrollment Fee: $15.00/annually
Copayment Amount: $3.00 (generic), $10.00 (brand)
DRUGS COVERAGE

Drugs Covered: All therapeutic classes except those excluded from MassHealth. Some
prior authorizations are required
Drug Coverage Restrictions: Annual limit of $1,250 per person
Medicaid (MassHealth) recipients are ineligible for the program
Notes:
PROGRAM CONTACT
Sheila Martin Phone: 617/727-7750

Senior Pharmacy Program Fax: 617/727-9368
One Ashburton Place, Room 517
Boston, MA 02108

Massachusetts
Pharmacy Program Plus

Other Eligibility Notes: Eligibles must have spent at least 10% of gross monthly income on
prescription drugs in 3 of 6 months prior to enrollment and must
project to have drug expenses greater than 5% of gross monthly
income as long as eligible under program.
Funding Source: Cigarette tax revenues and general revenue fund

Budget: N/A
Ingredient Cost Calculation: WAC+10% or lowest and customary fee
Copayment Amount: $3 for generics, $10 for branded products
Dispensing Fee: N/A
DRUGS COVERAGE

Drugs Covered: All therapeutic classes except those excluded from MassHealth. Some
prior authorizations are required
Notes: Once enrolled in The PHARMACY Program Plus and exhausted all
other prescription benefits, including Medicare HMO or The
PHARMACY Program prescription benefits, enrollees will receive
unlimited prescription coverage to pay for their prescription
medicines.
PROGRAM CONTACT
Sheila Martin Phone: 617/727-7750

Senior Pharmacy Program Fax: 617/727-9368
One Ashburton Place, Room 517
Boston, MA 02108

Michigan
Emergency Pharmaceutical Program for Seniors (MEPPS)
Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible

Other Eligibility Notes: Rx drug costs must be 10% (Single)/8% (Married) or more of the
monthly income
Funding Source: Construction tax

Budget: $6 million
# of Rx’s Per Participant (FY 99): 6
Copayment Amount: Voluntary copay: $0.25/Rx
DRUGS COVERAGE

Drugs Covered: All prescriptions
Drug Coverage Restrictions: • Coverage limited to 3 months per year
• Generics must be dispensed unless specified by the physician
• No experimental or over-the-counter drugs
Notes: Funding cap on total spending set by legislature. Michigan also has a
tax credit program with a pro rata adjustment to tax credits based
upon funding cap set by legislature. Program will be phased out in
2001 by the new Elder Prescription Insurance Coverage (EPIC)
Program.
PROGRAM CONTACT
Alisa Hamilton Phone: 517/373-7881

Office of Services to the Aging Fax: 517/373-4092
611 West Ottawa, P.O. Box 30676
Lansing, Michigan 48909-8176

Michigan
State Medical Plan
Program Type: Tax Credit
Eligibility Age (Elderly): None Eligibility Age (Disabled): Not eligible

Eligible Income Level (Single): 150% of FPL Eligible Income Level (Married): 150% of FPL
Other Eligibility Notes:
Funding Source: Construction tax

Budget: N/A
Cost per Participant (FY 99): None
Enrollment Fee: N/A
Deductible Amount: N/A
Copayment Amount: N/A
Dispensing Fee: N/A
DRUGS COVERAGE

Drugs Covered: All prescriptions
Drug Coverage Restrictions:
Notes: Seniors are eligible to a refundable tax up to $600 for prescription
drug expenditures that exceed 5% of income. Program will be phased
out in 2001 by the new Elder Prescription Insurance Coverage (EPIC)
Program.
PROGRAM CONTACT
Alisa Hamilton Phone: 517/373-7881

Office of Services to the Aging Fax: 517/373-4092
611 West Ottawa, P.O. Box 30676
Lansing, Michigan 48909-8176

Minnesota
Senior Citizen Drug Program
Number of Recipients (00): 5,000

Other Eligibility Notes: Cannot have other prescription drug coverage in past four months or
Medigap. Legislative action will make certain qualifying disabled
persons under the age of 65 eligible for the program starting in 7/1/02
Funding Source: General Revenue Fund plus rebates (subject to budget appropriations)
Budget: $19 million for FY 00 and FY 01
Cost per Participant (FY 99): $725.30 (for the 2,167 elderly recipients in FY 99)
# of Rx’s Per Participant (FY 99): 24.07 (for the 2,167 elderly recipients in FY 99)
Manufacturer Rebate Type: Same as Medicaid minus any CPI add-on
Deductible Amount: $35/month
DRUGS COVERAGE
Formulary: Closed Formulary

Drugs Covered: Same drugs as paid under Medicaid if manufacturer signs rebate
agreement with Dept. of Human Services. Covers over-the-counter
drugs for antacid, insulin products, and vitamins
Drug Coverage Restrictions: Most other over-the-counter drugs are not covered
Notes:
PROGRAM CONTACT
Steven Hamilton Phone: 651/296-6627

Department of Human Services Fax: 651/282-6744
444 Lafayette Road E-mail: steven.hamilton@state.mn.us
St. Paul, MN 55155-3853

Missouri
State Income Tax Credit for Legend Drugs
Program Type: Tax Credit
Number of Recipients (FY 00): N/A

Eligible Income Level (Single): <$15,000 Eligible Income Level (Married): N/A
Funding Source: N/A

Budget: N/A
Dispensing Fee: N/A
Notes: Income tax credit for legend drugs. Income up to $15,000 = $200
credit. Credit reduced by $2 for each addition $100 of income.
DRUGS COVERAGE
Formulary: N/A
Drugs Covered: Legend drugs only
Notes:
PROGRAM CONTACT
Department of Revenue Phone: 573/751-4081

301 West High Street
Jefferson City, MO 65101

New Hampshire
Senior Prescription Drug Discount Program
Program Type: State-Negotiated Discounts
Estimated Number of Eligibles: 75,000

Eligible Income Level (Single): None Eligible Income Level (Married): None
Other Eligibility Notes: Must be a New Hampshire resident
Funding Source: Rebates and incentives from pharmaceutical manufacturers

Budget: N/A
Dispensing Fee: N/A
DRUGS COVERAGE
Formulary: No Formulary
Drugs Covered: Most frequently prescribed medication for this population for multiple
health problems
Notes: Discounts will vary depending on pharmacy and medication.
Discounts could be up to 40% for generics and up to 15% for branded
products
PROGRAM CONTACT
Health And Human Services Phone: 800/351-1888

Division Of Elderly And Adult
Services
129 Pleasant Street
Concord, NH 03301

New Jersey
Pharmaceutical Assistance to the Aged and Disabled (PAAD)
(Elderly: 163,958; Disabled: 23,400)

Other Eligible Groups: Groups receiving Social Security Disability Benefits are eligible
Funding Source: State General Fund and Casino Revenue Fund

Budget: $273 million
Cost per Participant (FY 99): Elderly: $1,313 (gross), $1,116 (net);
Disabled: $2,654 (gross), $1,974 (net)
# of Rx’s Per Participant (FY 99): 30 Elderly; 43 Disabled
Manufacturer Rebate Type: Medicaid without CPI component
Ingredient Cost Calculation: AWP – 10%, Federal MAC, or Usual & Customary
Dispensing Fee: $3.73 - $4.07
DRUGS COVERAGE
Drugs Covered: All legend drugs, syringes, needles, and diabetic testing materials
Drug Coverage Restrictions: DESI drugs, non-rebatable drugs, and over-the-counter drugs
Prescription Drug Utilization: Branded: $273,946,609 (3,817,842 scripts)
Generic: $37,180,099 (2,455,755 scripts)
PROGRAM CONTACT
Kathleen Mason Phone: 609/588-7032

PAAD Program Fax: 609/588-7037
P.O. Box 715 E-mail: kmason@doh.state.nj.us
Trenton, NJ 08625

New York
Elderly Pharmaceutical Insurance Coverage (EPIC) Program

Other Eligible Groups: None
Funding Source: State General Fund and tobacco tax and settlement funds
Cost per Participant (FY 99): $890 (net state cost)
Manufacturer Rebate Type: Same as Medicaid, with modified additional (CPI) rebates
Ingredient Cost Calculation: AWP (less 5% for high volume pharmacies)
Enrollment Fee: Lower income seniors only (<$20,000 if single, <$26,000 if married )
$8-$300 depending on total income and marital status
Deductible Amount: Upper income seniors only (over $20,000 single; over $26,000
married); $530-$1,715 depending on total income and marital status
Copayment Amount: $3 to $20 based on cost of prescription
Dispensing Fee: $2.75 ($3.00 for full-service pharmacies)
Notes: Based on level of income, seniors may enroll in the Fee Plan or the
Deductible Plan.
DRUGS COVERAGE
Drugs Covered: All legend drugs, insulin, and insulin syringes and needles
Drug Coverage Restrictions: DESI drugs and non-participating manufacturers. Viagra limited to six
tables per month
Prescription Drug Utilization: 86% of prescription drug spending on branded; 16% spending on
generic
61% of scripts were branded; 39% of scripts were generic.
PROGRAM CONTACT
Julie A. Naglieri, Acting Director Phone: 518/452-6828

NYS Department of Health, EPIC Program Fax: 518/452-6882
260 Washington Avenue Ext. E-mail: jab15@health.state.ny.us
One Corporate Plaza, Suite 101
Albany, NY 12203

North Carolina
Prescription Drug Assistance Plan

Eligible Income Level (Single): 150% FPL Eligible Income Level (Married): 150% FPL
Other Eligibility Notes: Individuals must have cardiovascular disease and/or diabetes
Funding Source: N/A

Budget: $500,000
Deductible Amount: N/A
Dispensing Fee: N/A
DRUGS COVERAGE
Formulary: N/A
Drugs Covered: Only certain drugs used to treat cardiovascular disease and/or diabetes
Drug Coverage Restrictions: Program will not pay for other drugs
Notes: Prescriptions may be issued for up to a 100-day supply
PROGRAM CONTACT
Charles Reed Phone: 919-715-3338

Department of Health and Human
Services
2001 Mail Service Center
Raleigh, NC 27699

Pennsylvania
Pharmaceutical Assistance Contract for the Elderly (PACE)
Type of Program: Direct Assistance

Funding Source: State Lottery

Budget: $290 million (subject to annual legislative appropriations)
Ingredient Cost Calculation: AWP - 10%
DRUGS COVERAGE

Drugs Covered: All federal legend drugs and insulin, insulin syringes and needles
manufactured by companies who participate in the PACE rebate
program
Drug Coverage Restrictions: No experimental drugs or drugs for baldness and wrinkles, OTCs,
most off-label uses; mandatory generic substitution for A-rated
products; DESI drugs require documentation of medical necessity.
Prescription Drug Utilization $243,112,901 program spending for brand drugs; 5,498,976 scripts.
$63,066,626 program spending for generic drugs; 3,760,786 scripts.
Notes:
PROGRAM CONTACT
Thomas Snedden Phone: 717/787-7313

PA Department of Aging Fax: 717/772-2730
555 Walnut Street, 5th Floor E-mail: tsnedden@aging.state.pa.us
Harrisburg, PA 17101-1919

Pennsylvania
PACE Needs Enhancement Tier (PACENET)

Funding Source: State Lottery

Budget: $290 million (subject to annual legislative appropriations)
Cost per Participant (FY 99): $330
Manufacturer Rebate Type: Mandatory 17% of AMP on all units reimbursed
Deductible Amount: $500 per year
Copayment Amount: $15.00 brand name, $8.00 generic
DRUGS COVERAGE

Drugs Covered: All federal legend drugs and insulin, insulin syringes and needles
manufactured by companies who participate in the PACE rebate
program
Drug Coverage Restrictions: No experimental drugs or drugs for baldness and wrinkles, OTCs, most
off-label uses; mandatory generic substitution for A-rated products;
DESI drugs require documentation of medical necessity
Notes:
PROGRAM CONTACT
Thomas Snedden Phone: 717/787-7313

PA Department of Aging Fax: 717/772-2730
555 Walnut Street, 5th Floor E-mail: tsnedden@aging.state.pa.us

Rhode Island
Pharmaceutical Assistance for the Elderly (RIPAE)
Eligible Income Level (Single): <$35,000 Eligible Income Level (Married): <$40,000
Funding Source: State General Revenue Fund
Budget: $8.5 million for FY 01 (subject to legislature and governor
appropriation yearly)
Copayment Amount: Copayment amount is based on yearly income:
Single Married Copayment
$15,932 or less $19,916 or less 40%
$15,933 to $20,000 $19,917 to $25,000 70%
$20,001 to $35,000 $25,001 to $40,000 85%
Dispensing Fee: $2.75 per Rx

DRUGS COVERAGE
Drugs Covered: Drugs for Alzheimer’s disease, anti-infectives, arthritis, asthma and
chronic respiratory conditions, cancer, circulatory insufficiency,
depression, diabetes (including insulin syringes), heart problems, high
cholesterol, hypertension, Parkinson’s disease, glaucoma, prescription
mineral and vitamin supplements for renal patients, urinary
incontinence.
Drug Coverage Restrictions: Limited by therapeutic class
Notes:
PROGRAM CONTACT
Denis Costa Phone: 401/222-2858 x105
Rhode Island Dept. of Elderly Affairs Fax: 401/222-3389
160 Pine St. E-mail: dennis@dea.state.ri.us
Providence, RI 02903

Vermont
VSCRIPT
Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Any age

Funding Source: Cigarette tax revenue and federal funding

Copayment Amount: $1.00 to $2.00 based on prescription cost
DRUGS COVERAGE
Drugs Covered: Maintenance drugs only.
Drug Coverage Restrictions: No experimental or over-the-counter drugs.
Notes: Health Trust Fund is paid for by an increase in the tobacco tax.
Program only covers maintenance drugs, not acute drugs.
PROGRAM CONTACT
Paul Wallace-Brodeur Phone: 802/241-3985

Office of Vermont Health Access Fax: 802/241-2897
103 South Main Street E-mail: paulw@wpgate1.ahs.state.vt.us
Waterbury, VT 05671-1201

Vermont
Health Access Plan (VHAP)
Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Any age

Funding Source: Cigarette tax revenue and federal funding

Copayment Amount: $1.00 to $2.00 based on prescription cost
DRUGS COVERAGE
Drugs Covered: Approved prescription medications
Drug Coverage Restrictions: No experimental or over-the-counter drugs
Notes: None
PROGRAM CONTACT
Paul Wallace-Brodeur Phone: 802/241-3985

Office of Vermont Health Access Fax: 802/241-2897
103 South Main Street E-mail: paulw@wpgate1.ahs.state.vt.us
Waterbury, VT 05671-1201

West Virginia
Senior Prescription Assistance Network II (SPAN II)
Program Type: State-Negotiated Discount

Eligible Income Level (Single): <$25,050 Eligible Income Level (Married): <$33,750
Funding Source: N/A

Budget: N/A
Dispensing Fee: N/A
Notes: Enrollees will receive discounts on prescription drugs
DRUGS COVERAGE
Drugs Covered: All FDA approved Federal legend pharmaceuticals
Drug Coverage Restrictions: Cannot be used in conjunction with other discount programs or
prescription drug coverage plans
Notes:
PROGRAM CONTACT
WV Bureau of Senior Services Phone: 877/987-4463

1900 Kanawha Boulevard, East
Holly Grove, Building #10
Charleston, WV 25305-0160

Wyoming
Minimum Medical Program
Number of Recipients (FY 00): 550
Eligibility Age (Elderly): Any age Eligibility Age (Disabled): Any age
Eligible Income Level (Single): $8,350 Eligible Income Level (Married): 100% of FPL
Funding Source: State General Fund

Budget: Approximately $600,000
Copayment Amount: $25.00/Rx (3 Rx/month cap)
DRUGS COVERAGE

Drugs Covered: Approved prescription medications
Drug Coverage Restrictions: No smoking cessation agents, hair growth products, anorexiant
products, or fertility promotion agents.
Notes: Health Trust Fund is paid for by an increase in the tobacco tax.
Program only covers maintenance drugs, not acute drugs.
PROGRAM CONTACT
Roxanne Homar, R.Ph. Phone: 307/777-6032

Community and Family Health Fax: 307/777-6964
Division E-mail: rhomar@state.wy.us
Hathaway Bldg, Rm 157
2300 Capitol Ave.
Cheyenne, WY 82002


Section 6:
State Pharmacy Program
Profiles


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. Provision 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

ALABAMA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1

Type of Benefit Categorically Needy Medically Needy (MN) Other
OAA AB APTD MLIF OAA AB APTD AFDC Children <21 SFO
Prescribed Drugs    
Inpatient Hospital Care    
Outpatient Hospital Care    
Laboratory & X-ray Service    
Skilled Nursing Home Services    
Physician Services    
Dental Services *
*Dental Services EPSDT - under 21 years old.
1
See Appendix E, page E-29, for a list of acronyms.
B. EXPENDITURES FOR DRUGS
1998* 1999*
Expended Recipients Expended Recipients
TOTAL $236,674,147 395,290
CATEGORICALLY NEEDY RECEIVING

MAINTENANCE ASSISTANCE, TOTAL
Aged
Blind
Disabled
Children-Families w/Dep. Children
Adults-Families w/Dep. Children
Other Title XIX Recipients
CATEGORICALLY NEEDY NOT RECEIVING

MAINTENANCE ASSISTANCE, TOTAL
Aged
Blind
Disabled
MEDICALLY NEEDY TOTAL

Aged
Blind
Disabled
Source: HHS State HCFA-2082 Reports.
*1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.
1-Alabama National Pharmaceutical Council

C. ADMINISTRATION Prescribing or Dispensing Limitations
Alabama Medicaid Agency. Prescription Refill Limit: Maximum of five refills.
D. PROVISIONS RELATING TO DRUGS Drug Utilization Review
Benefit Design PRODUR system implemented in July 1996. State

currently has a DUR Board with a quarterly review.
Drug Benefit Product Coverage: Products covered:
cosmetics; prescribed insulin, disposable needles and Pharmacy Payment and Patient Cost Sharing
syringe combinations for insulin; blood glucose test strips;
urine ketone test strips; total parenteral nutrition; and Dispensing Fee: $5.40.
interdialytic parenteral nutrition. Prior authorization
required for: cosmetics, Retin A, Accutane, Dipyridamole. Ingredient Reimbursement Basis: AWP-10%, WAC +
Products not covered: fertility drugs and experimental 9.2%.
drugs.
Prescription Charge Formula: Medicaid pays for
Over-the-Counter Product Coverage: Products covered if prescribed legend and non-legend drugs authorized under
prescribed by a physician: allergy, asthma and sinus the program based upon and shall not exceed the lowest
products; analgesics; cough and cold preparations; of:
digestive products, topical products; antidiabetic products; 1. The Maximum Allowable Cost (MAC) of the drug
prenatal vitamins; hemorrhoidal products. Products not plus a dispensing fee,
covered: smoking deterrent products and feminine 2. The Estimated Acquisition Cost (EAC) of the drug
products. plus a dispensing fee, or
Therapeutic Category Coverage: Therapeutic categories 3. The provider’s usual and customary charge to the
covered: antibiotics; anticoagulants; anticonvulsants; public for the drug.
antidepressants; antidiabetic agents; antilipemic agents; Maximum Allowable Cost: State imposes Federal Upper
anxiolytics, sedatives, and hypnotics; cardiac drugs; Limits as well as state-specific limits on generic drugs.
chemotherapy agents; contraceptives; estrogens; Override requires “Brand Medically Necessary.”
hypotensive agents; misc. GI drugs; sympathominetics
(adrenergic); thyroid agents. Prior authorization required Incentive Fee: None.
for: anabolic steroids; analgesics, antipyretics, NSAIDs;
antihistamine drugs; anti-psychotics; ENT anti- Patient Cost Sharing: Variable copayment.
inflammatory agents; growth hormones; nutritional
supplements. Therapeutic categories not covered: Drug Ingredient Cost Copayment
anorectics; prescribed smoking deterrents. $0.00 to $10.00 $0.50
$10.01 to $25.00 $1.00
Coverage of Injectables: Injectable medicines $25.01 to $50.00 $2.00
reimbursable through the Prescription Drug Program $50.01 or more $3.00
when used in physician offices, home health care, and Exemptions: No copayment amount is to be collected by
extended care facilities. the pharmacy or paid by the recipient for recipients under
age 18, pregnant or living in nursing facilities.
Vaccines: Vaccines reimbursable as part of the EPSDT
service and the Vaccines for Children Program. Cognitive Services: Does not pay for cognitive services.
Unit Dose: Unit dose packaging reimbursable.
E. USE OF MANAGED CARE
Formulary/Prior Authorization
Does not use MCOs to deliver services to Medicaid
recipients.
Formulary: Open formulary.
Prior Authorization: State currently has a formal prior

authorization procedure. Review by Medicaid’s Assoc.
Medical Director required for appeal of prior
authorization decisions.
National Pharmaceutical Council Alabama-2

Kelly S. Derbin, M.D.

F. STATE CONTACTS University of South Alabama
Department of Family Practice
State Drug Program Administrator 1504 Springhill Avenue
Louise F. Jones Mobile, AL 36604
Alabama Medicaid Agency 335/434-3489
501 Dexter Avenue
P.O. Box 5624 Keith Fuller, D.O.
Montgomery, AL 36103-5624 2125 Executive Park Drive
T: 334/242-5039 Opelika, AL 36801
F: 334/353-7014 334/741-0075
E-mail: lljones@Medicaid.state.al.us
Agency Internet Address: www.medicaid.state.al.us William P. McCann, M.D.
University of Alabama Birmingham
Prior Authorization Contact School of Medicine
3875 South Cove Drive
Larry Tatum, 334/242-5489 Birmingham, AL 35213
205/934-7047
DUR Contact
Louise Jones, 334/353-7014 John Searcy, M.D.
Alabama Medicaid Agency
Medicaid DUR Board Medical Director
501 Dexter Avenue
Keith Campagna, Pharm.D. Montgomery, AL 36130
Auburn University 334/242-5619
Montgomery Family Medicine Residence Program
4371 Narrow Lane Rd. Suite 100 Sara Redden, R.Ph.
Montgomery, AL 36116 3654 Wiley Road
334/613-3687 Montgomery, AL 36106
334/286-3201
Betty McCamy, R.Ph.
Wal-Mart Pharmacy John E. Brandon, M.D.
102 Lanceleaf Court Intersection Highway 82 and 86
Dothan, AL 36303 P.O. Box 390
334/792-5131 Gordo, AL 35466
205/364-7135
Terry Wingo
Madison Drugs Larry Tatum, R.Ph.
7131 University Drive Alabama Medicaid Agency
Huntsville, AL 35806 Senior Pharmacist
256/837-1747 334/242-5489
Tim Covington, Pharm.D., Chair Mike Mikell, R.Ph.

Samford University Mike’s Pharmacy
2024 Glen Eagle Road P.O. Box 1006
Birmingham, AL 35242 Millbrook, AL 36054
205/870-2988 334/285-5154
Richard L. Bendinger, M.D. Richard Freeman, M.D.

217 Dothan Road 411 B Opelika Road
Abbeville, AL 36310 Auburn, AL 36830
334/585-6421 334/821-4766

Larry A. Tatum, R.Ph., Associate Director

Pharmaceutical Programs
First DataBank Alabama Medicaid Agency
1111 Bayhill Drive, Suite 350 501 Dexter Avenue; P.O. Box 5624
San Bruno, CA 94066 Montgomery, AL 36103
650/588-5454 334/242-5489
Medicaid Drug Rebate Contacts Title XIX Medical Care Advisory Committee
Technical: Jim Morrison, 334/242-2323 Medical Association of State of Alabama
Policy: Larry Tatum, 334/242-5489 Marsha D. Raulerson, M.D.
Audits: Jim Morrison 334/242-2323 1205 Belleville Avenue
Brewton, AL 36426-1304
Claims Submission Contact 334/867-3609
Ricky Pope
Roy T. Hager, M.D.
Account Manager, EDS
Institute for Total Eye Care
301 Technacenter Dr.
4255 Carmichael Ct. North
Montgomery, AL 36117
334/215-0111
334/277-9111
Medicaid Managed Care Contact Alabama Nursing Home Association
Vicki Huff Frank R. Brown, Jr.
Director, Managed Care P.O. Box 190
Alabama Medicaid Agency Cullman, AL 35056
501 Dexter Avenue 334/784-5573
Montgomery, AL 36103-5624
334/242-5011 Montgomery Area Council on Aging
Rose Posey
Disease Management Program/Initiative Contact 115 East Jefferson Street
Mary G. McIntyre, M.D. 334/263-0532
Associate Medical Director
Alabama Medicaid Agency Alabama State Medical Association
501 Dexter Avenue Jefferson Underwood, III, M.D.
Montgomery, AL 36103-5624 1031 Oak Street
334/242-5574 Montgomery, AL 36108
Physician-Administered Drug Program Contact Recipient Representative
Larry Tatum Charles G. Spradling, Jr.
334/242-5472 P.O. Box 11765
Birmingham, AL 35202
Alabama Medicaid Agency Officials 334/328-3540
W. Dale Walley American Academy of Family Physicians

Acting Commissioner Dr. John E. Brandon
Alabama Medicaid Agency P.O. Box 390
501 Dexter Avenue Gordo, AL 35466
P.O. Box 5624 334/364-7135
334/242-5600 S. T. Christian, Ph.D., Professor
University of Alabama at Birmingham
John Searcy, M.D., Director School of Medicine/Behavioral Neurobiology
Professional Services Birmingham, AL 35294
Alabama Medicaid Agency
501 Dexter Avenue; P.O. Box 5624
334/242-5619

Alabama Pharmaceutical Association Pharmacy and Therapeutics Committee

Danny Cottrell
A.Z. Holloway, M.D., Chair
1335 McMillen, Box 259
2611 Woodley Park Drive
Brewton, AL 36426
334/867-5454
334/288-0009
Alabama State Nurses Association
Richard L. Bendinger, M.D.
Elizabeth Morris
217 Dothan Road
360 N. Hull Street
Abbeville, AL 36310
334/585-6421
334/262-8321
Richard Freeman, M.D.
Alabama Institute for the Deaf and Blind
411 B Opelika Road
Terry Graham, Ed.D.
Auburn, AL 36830
P. O. Drawer 698
334/821-4766
Talladega, AL 35160
334/761-3274
Michael Hogue, Pharm. D.
800 Lakeshore Drive
Consumer Representative
Ruth Smith
205/726-2669
4001 Meadowood Drive
Jimmy Crane
334/290-5187
413 19th Street West
Ensley, AL 35218
Mike Woodall
205/787-4671
Director, Recreation Department
450 Gilmer
Edward Goldblatt
Tallassee, AL 36078
3517 S. Lake Parkway
334/283-4726
205/802-6650
Dr. A. Z. Holloway
2611 Woodley Park Drive
Phil Jenkins, R.Ph.
12740 Country Lane
334/288-0009
Northport, AL 35476
205/391-3636
Alabama Chap. American Academy of Pediatrics
Dr. John Searcy
Roosevelt McCorvey, M.D.
1105 West Main
3088 Rosa L. Parks Avenue
Dothan, AL 36301
334/262-0259
Medicaid Recipient Representative
Gladys Stautner
Ray Thweatt, M.D.
Rt. 4, Box 315
801 Princeton Avenue, SW
Greenville, AL 36037
Suite 506
334/382-6255
205/783-7060
Sabrina Cooper
218 Lands End Avenue
Selma, AL 36701 Executive Officers of State Medical and
334/874-9001 Pharmaceutical Societies
Medical Association of the State of Alabama (MASA)
West Alabama Health Services, Inc.
Cary Kuhlmann
Sandra Hullett, M.D., MPH
19 S. Jackson Street
Health Services Director
P.O. Box 1900
P.O. Box 711
Eutaw, AL 35462
334/263-6441
334/372-3281

Alabama State Medical Association Nursing Home Association

Joel Powell, M.D. Margie Sellers
1408 5th Avenue, SE Executive Director
Suite 1 4156 Carmichael Road
Decatur, AL 35601 Montgomery, AL 36106
205/350-3405 334/271-6214
Alabama Pharmacy Association (APA) Alabama Hospital Association

William s. Eley, II Michael Horsley
1211 Carmichael Way President, CEO
Montgomery, AL 36106 500 North East Blvd.
334/271-4222 Montgomery, AL 36117
334/272-8781
Alabama Optometric Association
Amanda Jones Alabama Pharmacy Coop, Inc. (APCI)
Executive Director Danny Johnson
400 South Union Street, Suite 435 P.O. Box 170747
Montgomery, AL 36104 Birmingham, AL 35217-0747
205/870-3301
State Board of Pharmacy
Charles Thomas Electronic Data Systems (EDS)
1 Perimeter Park South, Suite 425 John Craft
Birmingham, AL 35243 P.O. Box 7600
205/967-0130 Montgomery, AL 36107
334/834-8330
Alabama Independent Drugstore Association (AIDA)
Sharon Taylor Alabama Retail Association
400 Interstate Park Drive Charles McDonald
Suite 401 President
Montgomery, AL 36109 #2 North Jackson
334/213-2432 P.O. Box 1909
Alabama Primary Health Care Association 334/263-5757
Al Fox
6008 East Shirley Lane Suite A Provider Notice Correspondence:
Montgomery, AL 36117 Eckerd Corporation
334/271-7068 813/395-6145
CVS/Revco
Alabama Quality Assurance Foundation (AQAF) 205/424-3421 x447
Dr. James DeLong
Medicaid Pharmacy Admin. Service
1 Perimeter Park South, Suite 300
1-888-Medicaid
Department of Health
Jim McVay, Director
343 Monroe Street
334/206-5226
Alabama State Nursing Association

Ruth Harrell
360 North Hull Street

ALASKA

OAA AB APTD AFDC OAA AB APTD AFDC Children <21 SFO
Inpatient Hospital Care     
Outpatient Hospital Care     
Laboratory & X-ray Service     
Skilled Nursing Home Services     
Physician Services     
Dental Services     
1
B. DRUG PAYMENTS AND RECIPIENTS

1998* 1999
TOTAL $32,887,828 43,734 $41,149,318 51,631
CATEGORICALLY NEEDY CASH TOTAL $35,948,104 34,829

Aged $5,527,030 3,993
Blind $23,025,340 7,586
Disabled $0 0
Children-Families w/Dep. Children $2,038,831 13,499
Adults-Families w/Dep. Children $5,356,902 9,751
Other Title XIX Recipients $0 0
CATEGORICALLY NEEDY NON-CASH TOTAL $0 0

Aged $0 0
Blind $0 0
Disabled $0 0
Children-Families w/Dep. Children $0 0
Adults-Families w/Dep. Children $0 0
MEDICALLY NEEDY TOTAL $1,431,244 11,128

Aged $6,860 6
Blind $0 0
Disabled $0 0
Adults-Families w/Dep. Children $272,355 2,046
Source: HHS State HCFA-2082 Reports.

*1998 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.
1-Alaska National Pharmaceutical Council

C. ADMINISTRATION Prior Authorization: State currently has a formal prior

authorization procedure. Request for fair hearing required
Department of Health and Social Services, Division of for appealing coverage of an excluded product and PA
Medical Assistance. decision.
D. PROVISIONS RELATING TO DRUGS Prescribing or Dispensing Limitations
Benefit Design Monthly Quantity Limit: Prescriptions are limited to 30-day

supplies. Dispensing of generic multi-source product is
Drug Benefit Product Coverage: Products covered: required.
prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test strips; Drug Utilization Review
urine ketone test strips; total parental nutrition; and
interdialytic parenteral nutrition. Prior authorization PRODUR system implemented in June 1995. State
required for: Clorazil; Lupron Depot; ADC infant vitamins; currently has a DUR Board that meets nine times per year.
some DME; Synagis; Pauretin; and Actig Naltrexone.
Products not covered: cosmetics; fertility drugs; and Pharmacy Payment and Patient Cost Sharing
experimental drugs.
Dispensing Fee: No less than $3.45 and no more than the
Over-the Counter Product Coverage: Products covered: 90th percentile of all dispensing fees determined under the
feminine products (vaginal yeast drugs, miconazole, formula:
ctotrimazole); topical products (bacitracin ointment); and
calcium. Products not covered: allergy, asthma and sinus 1) $23,192 added to the number resulting from
products; analgesics; cough and cold preparations; digestive multiplying total prescriptions filled by that pharmacy
products; and smoking deterrent products. in the previous calendar year by 5.070;
Therapeutic Category Coverage: Categories covered: 2) to 1), add the result of multiplying total Medicaid
anabolic steroids; analgesics, antipyretics, NSAIDs; prescriptions filled in the previous calendar year by
antibiotics; anticoagulants; anticonvulsants; anti- 12.44;
depressants; antidiabetic agents; antihistamine drugs;
antilipemic agents; anti-psychotics; anxiolytics, sedatives, 3) from 2), subtract the result of multiplying the total floor
and hypnotics; cardiac drugs; chemotherapy agents; space volume of the pharmacy in sq. ft. by 2.103;
contraceptives; ENT anti-inflammatory agents; estrogens;
hypotensive agents; miscellaneous GI drugs; and thyroid 4) divide 3) by total prescriptions filled by that pharmacy
agents. Prior authorization required for: growth hormones.
Categories not covered: anorectics; prescribed cold 5) add $0.73 to 4)
medications; amphetamines (except for narcolepsy and
hyperactivity); prescribed smoking deterrents; Ingredient Reimbursement Basis: EAC = AWP - 5%.
sympathominetics (adrenergic); cough suppressants; DESI
drugs; vitamins (except prenatal); and vitamins with
Maximum Allowable Cost: State imposes Federal Upper
fluoride.
Limits on generic drugs. Override requires “Brand
Medically Necessary” with the reason supplied.
Coverage of Injectables: Injectable medicines reimbursable
through the Prescription Drug Program when used in home
Incentive Fee: None.
health care, extended care facilities and through physician
payment when used in physician offices. No injectable drug
Cognitive Services: Does not pay for cognitive services.
list.
Patient Cost Sharing: $2.00 copayment for branded and
Vaccines: Vaccines reimbursable at cost as part of EPSDT
generic products.
service, Children Health Insurance Program and the
Vaccines for Children Program.
Unit Dose: Unit dose packaging reimbursable when used in
long-term care. Does not use MCOs to deliver services to Medicaid
recipients.
Formulary: No formulary.
National Pharmaceutical Council Alaska-2

F. STATE CONTACTS Claims Submission Contact

State Drug Program Administrator Rose-Ellen Hope
Pharmacist
Dave Campana, R.Ph. First Health
Division of Medical Assistance 565 Union St. NE #205
4501 Business Park Blvd., Suite 24 Salem, OR 97301
Anchorage, AK 99503 T: 503/391-0184
T: 907/273-3224 F: 503/391-1979
F: 907/561-1684
E-mail: david_campana@health.state.ak.us
Disease Management Program/Initiative Contact
Health and Social Services Department Officials
Bob Labbe
Karen Perdue Director, Division of Medical Assistance
Department of Health and Social Services P.O. Box 110660
Pouch H-01, Juneau, AK 99811-6040 Juneau, AK 99811-0660
907/465-3030 T: 907/465-3355
F: 907/465-2204
Bob Labbe, Director
Division of Medical Assistance, DHSS Physician-Administered Drug Program Contact
Pouch H-07, Juneau, AK 99811
907/465-3355 Tom Porter, M.D.
907/561-2171
Jack Nielson, Deputy Director
Medical Assistance Alaska Medical Care Advisory Committee
4501 Business Park Blvd., Suite 24
Dr. Patricia Connors Allen
Anchorage, AK 99503
2231 N. Jordan Avenue
907/561-2171
Juneau, AK 99801
Prior Authorization Contact Alaska DUR Committee
Dave Campana 907/273-3224 Dave Campana, R.Ph.
DUR Contact Anchorage, AK 99503
Dave Campana 907/273-3224 Thomas Porter, M.D.
Prescription Price Updating Anchorage, AK 99503
Dave Campana 907/273-3224
Richard Reem, M.D.
Medicaid Drug Rebate Contacts 231 Iditarod
Fairbanks, AK 99701-3639
Technical: Velma Drake, 907/561-2171
Policy: Dave Campana, 907/273-3224 Linda Shull, R.Ph.
Audit: Dave Campana, 907/273-3224 1132 Wolkoff
Kodiak, AK 99615
Arthur Hansen, D.D.S.

1329 McGrath Rd.
Fairbanks, AK 99712
Ted Summers
P.O. Box 3126
Palmer, AK 99645
3-Alaska National Pharmaceutical Council

Executive Officers of State Medical and

Pharmaceutical Societies
Alaska State Medical Association
Jim Jordan
4107 Laurel Street
Anchorage, AK 99508
T: 907/562-2662
F: 907/561-2063
Alaska Pharmaceutical Association

Erin Carey-Byrne, Executive Secretary
Box 10-1185
Anchorage, AK 99510
907/563-8880
Alaska State Board of Pharmacy

Josephine Dawson
Lic. Examiner
P.O. Box 110806
Juneau, AK 99811-0806
907/465-2589
Alaska State Hospital and Nursing Home Association

Harlan R. Knudson
Pres., CEO
319 Seward Street, Suite 11
Juneau, AK 99801
907/586-1790
Alaska Osteopathic Medical Association

Byron Perkins, D.O.
Secretary/Treasurer
P.O. Box 870470
Wasilla, AK 99687
907/745-0170
National Pharmaceutical Council Alaska-4

ARIZONA
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
(AHCCCS - PRONOUNCED "ACCESS")
of primary care physicians was established to perform the
AHCCCS FEATURES gatekeeping function for the system. Because the primary
care physicians must approve all care, the primary care
The Arizona Health Care Cost-Containment System network eliminated self-referrals to specialists and
(AHCCCS) is a Title XIX (Medicaid) demonstration diminished excessive use of emergency rooms -- both of
project, jointly funded by the federal government and the which have contributed substantially to high medical
State of Arizona. Begun in October 1982, it serves as a costs.
model for providing medical services to the indigent in a
managed care system rather than through fee-for-service Prepaid Capitated Financing
arrangements. Typically, Medicaid programs have
incorporated the traditional hallmarks of the U.S. health It was the intent of the AHCCCS legislation that health
care system: namely, independent providers and fee-for- plans and their providers offer all covered services to
service reimbursement. In contrast, organized health groups of members within a geographical area for a fixed
plans and capitation mark the AHCCCS model. price, for a definite period. The law allowed for the
In traditional Medicaid programs, the states assume establishment of a statewide bidding process to
responsibility for contracting with individual pharmacies accomplish this. Services are provided on a county-by-
and reimbursing them. In the AHCCCS model however, county basis, by prepaid health plans. Providers may bid
the state contracts instead with pre-paid health plans, on a prepaid capitated basis for covered services to be
HMOs and HMO-like entities. These plans are paid on a provided within a particular county. The law allows for
capitation basis and are responsible for providing all of expansion and contraction of bids to achieve the best
the services covered by the program. Thus, the delivery possible system. In the event there are insufficient bids
of pharmacy services is the responsibility of each prepaid for a given area, the legislation permits capped fee-for-
plan. service arrangements. It is intended, however, that capped
fee-for-service will be authorized as a last resort only.
GENERAL INFORMATION
In essence, AHCCCS prepaid health plans (PHPs), health
The Arizona Health Care Cost Containment System maintenance organizations (HMOs), and other types of
(AHCCCS), developed in Senate Bill 1001, was passed by organized health delivery systems charge a fixed fee per
the Legislature and signed by the Governor in November individual enrolled (i.e., a capitation rate) and assume
1981. It contained six major mechanisms for restraining responsibility for providing a broad array of health care
health care costs at the same time ensuring that services to members.
appropriate levels of quality health care services are
provided to eligible persons in a dignified fashion. The Competitive Bidding Process
goal of these 6 items was to contribute to the
establishment of health care financing that is less The statewide competitive aspect of the bid process for
expensive than conventional fee-for-service systems. The selecting providers and offering prepaid capitated services
six mechanisms were: is the most unique feature of the AHCCCS model. A
competition of this magnitude had never been attempted
• Primary Care Physicians Acting as Gatekeepers in any other state. The AHCCCS administration believes
• Prepaid Capitated Financing competitive bidding for health care service contracts, as
• Competitive Bidding Process opposed to conventional negotiation processes, provides
• Cost Sharing accessible cost-effective delivery of health care without
• Limitations on Freedom-of-Choice sacrificing quality performance.
• Capitation of the State by the Federal
Government The AHCCCS administration issues an invitation to
qualified health plans once every five years. Qualified
Primary Care Physicians as Gatekeepers
health plans may bid to offer the full range of AHCCCS
services in one or more counties.
AHCCCS legislation provided that all members must be
under the care and supervision of a primary care physician
who assumed the role of gatekeeper. A statewide network
1-Arizona National Pharmaceutical Council

Cost Sharing Provider Participation
The fourth major device for containing costs in the Providers may participate in AHCCCS in 2 different
AHCCCS model is a provision for cost sharing by users. ways. First, they may contract with prepaid capitated plans
A statewide co-payment schedule was developed for this as either full or partial benefit providers.
purpose, and the medically needy participate in
coinsurance cost sharing. It is expected that the The second mode of participation is on a capped fee-for-
imposition of nominal co-payments will ensure optimal service basis. Here, providers agree to accept capped fee
effectiveness in the area of service utilization. The copayments as payments in full for services provided on a
payment schedule accomplishes three objectives: FFS basis.
curtailment of over-utilization; enhancement of patient
dignity; and service utilization by members for truly Functions of the AHCCCS Administration
needed health care. There is no co-payment for drugs and
medication, prenatal care including all obstetrical visits, The Arizona Health Care Containment System
members in long care facilities and for visits scheduled by Administration (AHCCCSA) contracts with full benefit
the primary care physician or practitioner, and not at the capitated health plans to serve AHCCCS members
request of the member. through a network of providers.
Limitations On Freedom-of-Choice Contracting Health Plans
The fifth major item for containing costs is a restriction on Under the Contracting Health Plan arrangement, plans are
provider/physician selection by AHCCCS members. defined in terms of explicit groups of providers organized
Unlike conventional delivery models, Arizona does not as entities that are more formal. These consortia, or
rely on fee-for-service arrangements. The goal is to have formal entities, are capable of providing the full range of
the state completely blanketed with prepaid capitated AHCCCS benefits within a defined service area for all
arrangements. Members are linked to selected or assigned AHCCCS members who elect to join the plans, up to a
plans for definite durations of time. Freedom-of-choice is predetermined capacity. This is the dominant mode of
permitted to the extent practicable for members to select operation within AHCCCS -- with two or more competing
the particular group with which to enroll, as well as the plans wherever possible.
primary care physician within the selected group. Capped
fee-for-service health service arrangements are used as a The Contracting Health Plans are delivery systems, not
last resort, and only in areas not covered by prepaid simply insurance plans, but they need not be Health
capitated plans. Maintenance Organizations by any legal or conventional
definition of the term. The AHCCCS legislation provides
CAPITATION BY THE FEDERAL for the creation of provider consortia for the purpose of
GOVERNMENT participation in the program. The Contracting Health Plan
may be a loosely organized system, but it must be capable
The State of Arizona will itself be capitated by the Federal of providing the full range of AHCCCS benefits to a
Government and therefore will be at financial risk for defined population at a capitation rate.
containing health care costs. Capitation rates will be
established according to sound actuarial principles, and The Organizational Role of AHCCCS
will represent no more than 95 percent of the estimated Administration
cost of services delivered in Arizona under conventional
fee-for-service arrangements. Capitation provides a key The AHCCCS Administration has been charged with the
incentive for the state to monitor health care costs on a general implementation and monitoring of the AHCCCS
careful and continuous basis. program.
The AHCCCS Administration develops the Rules and

IMPLEMENTATION OF AHCCCS
Regulations; manages the health plan bidding processes;
awards the contracts; provides technical assistance to
AHCCCS is based on plans that have been tested, in part,
providers for the purpose of forming consortia to contract
on smaller scales in different areas of the country. By
with AHCCCS; and monitors the overall operation of the
combining a number of key mechanisms on a statewide
program.
basis, AHCCCS represents a novel health care model.
The purpose of this section is to present a discussion of
how the key concepts embodied in the AHCCCS
legislation will be implemented and rendered operational.
National Pharmaceutical Council Arizona-2

The Operational Role of the AHCCCS Doctor’s Health Plan, P.C. 520/428-7801
Administration 517 Main Street
Stafford, AZ 85546
Organizationally, the AHCCCS Administration assumes
responsibility for the oversight of every day operations. Family Health Plan of NE Arizona 520/921-8944
P.O. Box 2069
The AHCCCS Administration has overall responsibility Cottonwood, AZ 86326
for the following activity areas:
Health Choice Arizona 602/968-6866
• Promotion of AHCCCS Suite 260
• Procurement of Health Plans 1600 West Broadway
• Quality Management Tempe, AZ 85282-1136
• Provider Management
• Provider, Member, and Public Relations Maricopa Managed Care Systems 602/681-8700
• Program Operations 2516 East University Drive
AHCCCS became effective December 1, 1981, and Phoenix, AZ 85034
services commenced October 1, 1982. Services include:
inpatient, outpatient, laboratory, x-ray, prescription drugs, Mercy Care Plan 602/230-9921
medical supplies, prosthetic devices, emergency dental 2800 North Central, Suite 400
care including extractions and dentures, treatment of eye Phoenix, AZ 85004
conditions and EPSDT.
Phoenix Health Plan 602/824-3700
Though AHCCCS was a three-year experiment that was to 2700 North 3rd Street
end in October 1985, the federal government continues to Phoenix, AZ 85004
extend funding for the program. In 1988, AHCCCS
received a five-year extension from the federal Pima Health System 602/512-5500
government and in 1993, it received an additional one- Suite A-200
year extension. In 1994, AHCCCS received a three-year 5055 East Broadway
extension and in 1998, it is expected to receive a one-year Tucson, AZ 85711
extension.
Regional AHCCCS Health Plan 520/426-6648
1955 North Casa Grande Avenue, #116
MEDICAL PLANS AND ADMINISTRATORS Casa Grande, AZ 85222
Contract terminated, effective 5/1/97
AHCCCS Contracted Health Plans
Access Blue Connection 602/864-4445 University Family Care 520/321-7248
2444 W. Las Palmaritas Drive 575 East River Road
Phoenix, AZ 85021 Tucson, AZ 85704
Contract terminated, effective 10/1/97
Phoenix Arizona Indian Health Services (IHS)
Arizona Health Concepts 602/331-5100 Two Renaissance Square 602/640-2120
7600 N. 16th Street, Suite 150 40 N. Central Avenue
Phoenix, AZ 85020 Phoenix, AZ 85004-5036
Arizona Physicians IPA, Inc. 602/274-6102 Phoenix Indian Medical Center 602/263-1200
3141 North 3rd Avenue 4212 North 16th Street
Phoenix, AZ 85013 Phoenix, AZ 85016
CIGNA Community Choice 602/942-4462 Indian Health Services (IHS) 520/295-2550

11001 North Black Canyon Highway Southern Region
Phoenix, AZ 85029 7900 J.J. Stock Road
Tucson, AZ 85746
DES/CMDP 602/351-2245
CMDP-942-C Navajo Area Indian Health Services (IHS)
Century Plaza Building, 10th Floor P.O. Box 9020 520/871-5880
3225 North Central Avenue Window Rock, AZ 86515-9020
Phoenix, AZ 85012
3-Arizona National Pharmaceutical Council

ALTCS Contractor List STATE CONTACTS

Arizona Physicians IPA (ALTCS)
242 West 28th Street, Suite A AHCCCS Officials
Yuma, AZ 85364 John H. Kelly, Acting Director
520/783-5691 AHCCCS
801 E. Jefferson
Cochise Health Systems Phoenix, AZ 85034
Cochise County Health & Social Services 602/417-4680
Cochise Health Systems
1415 West Melody Lane, Building A Leonard Jasinski, M.D.
Bisbee, AZ 85603 Medical Director
520/432-9481
DES/DDD Executive Officers of State Medical and

1789 West Jefferson, 4th Floor Pharmaceutical Societies
Phoenix, AZ 85034 Arizona Medical Association, Inc.
602/542-6866 Chic Older
Executive Vice President
Maricopa Managed Care Systems 810 West Bethany Home Road
2516 East University Drive Phoenix, AZ 85013
Phoenix, AZ 85034 602/246-8901
602/681-8700
Arizona Pharmacy Association
Pima County LTC Kathy Boyle
Pima Health System Executive Director
Suite A-200, 5055 East Broadway 1845 E. Southern Ave.
Tucson, AZ 85711 Tempe, AZ 852-82-5831
520/512-5500 602/838-3385
Pinal County Health Plan - LTC Arizona Osteopathic Medical Association

P.O. Box 2140 Amanda Weaver
574 South Central Avenue Executive Director
Florence, AZ 85232-2140 5150 N. 16th St., #A122
520/868-6775 Phoenix, AZ 85016
602/266-6699
Ventana Health Systems
Apache, Gila, Graham, Greenlee, Mohave, Arizona Board of Pharmacy
Navajo, LaPaz & Santa Cruz Counties L. A. Lloyd
7600 N. 16th St., Ste. 150 Executive Director
Phoenix, AZ 85020 5060 North 19th Avenue, Ste. 101
602/331-5100 Phoenix, AZ 85015
602/255-5125
Yavapai County LTC
Yavapai County Department of Medical Assistance Arizona Hospital and Healthcare Association
255 East Gurley Street, First Floor John R. Rivers
Prescott, AZ 86301 Pres., CEO
520/771-3560 1501 West Fountainhead Parkway
Suite 650
AHCCCS FFS (ALTCS) Tempe, AZ 85282
Ventilator Dependent 602/968-1083
Central Office (Office of the Medical Director)
602/417-4283
National Pharmaceutical Council Arizona-4

ARKANSAS

Prescribed Drugs         
Inpatient Hospital Care         
Outpatient Hospital Care         
Laboratory & X-ray Service         
Skilled Nursing Home Services         
Physician Services         
Dental Services         
1

1998* 1999
TOTAL $150,891,615 262,907 $174,122,352 272,863
RECEIVING CASH ASSISTANCE, TOTAL $21,923,101 43,898

Aged $15,746,553 15,658
Blind/Disabled $979,341 919
Child $3,073,535 20,352
Adult $2,123,161 6,967
Unemployed Parent-Child $64 1
Unemployed Parent-Adult $445 1
MEDICALLY NEEDY, TOTAL $90,570,658 20,598

Aged $82,938 4
Blind/Disabled $86,427,655 12,882
Child $1,886,271 7,512
Adult $2,173,792 200
POVERTY RELATED, TOTAL $15,416,172 63,625

Aged $124,995 4
Child $13,586,659 63,573
Adult $813,529 44
OTHER, TOTAL $59,618,981 42,100 $46,212,420 9,548
Source: HHS Report HCFA-2082, Sections A-4 and B-4.

C. ADMINISTRATION
Department of Human Services, Division of Medical

Services, Pharmacy.
1-Arkansas National Pharmaceutical Council

D. PROVISIONS RELATING TO DRUGS Formulary/Prior Authorization

Benefit Design Formulary: Closed formulary. General exclusions
include:
prescribed insulin; disposable needles and syringe 1. Agents used for hair growth.
combinations used for insulin. Products not covered: 2. Vitamin products except prescription prenatal
blood glucose test strips; urine ketone test strips; total vitamins.
parenteral nutrition, interdialytic parenteral nutrition; 3. Drugs determined by the FDA to be ineffective
cosmetics; fertility drugs; and experimental drugs. Prior (DESI drugs).
authorization required for: nitroglycerin patches; agents 4. Sedatives and hypnotics in the benzodiazepine
for impotence; Synagis; and Respigam. category (partial coverage).
5. Compounded prescriptions (mixtures of two or more
Over-the-Counter Product Coverage: Products covered: ingredients). States are not allowed to have state
digestive products (H2 antagonist). Limited coverage for: codes such as 99999-9999-99. All drugs reimbursed
allergy, asthma and sinus products; analgesics; cough and by the State must be traced by NDC code and appear
cold preparations; digestive products (non-H2 antagonist ) on the utilization report.
(under 21 years and long-term care limited needs);
feminine products; and topical products. Product not Prior Authorization: State currently has a prior
covered: smoking deterrent products. authorization procedure.
Therapeutic Category Coverage: Therapeutic categories Prescribing or Dispensing Limitations

covered: anabolic steroids; antibiotics; anticoagulants; Prescription Refill Limit: 5 refills within 6 months are
anticonvulsants; anti-depressants; antidiabetic agents; allowed. New Rx required every 6 months.
antilipemic agents; anti-psychotics; cardiac drugs;
chemotherapy agents; contraceptives; ENT anti- Monthly Quantity Limit: 30-day supply.
inflammatory agents; estrogens; growth hormones;
hypotensive agents; sympathominetics (adrenergic); and Monthly Prescription Limit: Three prescriptions per
thyroid agents. Prior authorization required for: month per recipient, except unlimited in certified LTC
analgesics, antipyretics, NSAIDs; antihistamine drugs; recipients and recipients under 21 years old. Others can
misc. GI drugs; prescribed smoking deterrents. receive extension of three more per month.
Therapeutic categories not covered: anorectics.
Coverage of Injectables: Injectable medicines are
reimbursable through the Prescription Drug Program PRODUR system implemented in March 1997. State
when used in home health care, extended care facilities currently has a DUR Board with a quarterly review.
and through physician payment when used in physicians
offices. No injectable drug list. Pharmacy Payment and Patient Cost Sharing
Vaccines: Vaccines reimbursable as part of the Vaccines Dispensing Fee: $5.51 effective 7/1/99.
for Children Program.
Ingredient Reimbursement Basis: EAC = AWP – 10.5%.
Prescription Charge Formula: Legend drugs: lower of the
EAC plus a dispensing fee or CFA/state upper limit plus a
dispensing fee. Total charge may not exceed provider’s
charge to the self-paying public.
Maximum Allowable Costs: State imposes Federal Upper

Limits as well as state-specific limits on generic drugs.
State-specific MAC list contains 200 drugs. Override
requires “Brand Medically Necessary.” PA must be
obtained once the pharmacy obtains the BNM Rx.
National Pharmaceutical Council Arkansas-2

Patient Cost Sharing: Effective 9/1/92, for each Scott Harris, P.D.
prescription reimbursed, the Medicaid recipient is 9601 I-630, Ext. 7
responsible for paying a copayment based on the Little Rock, AR 72205-1749
following: 501/202-1749
State Payment Copay
Benji Post, P.D.
$10.00 or less $0.50
$10.01 to $25.00 $1.00
Physicians
$25.01 to $50.00 $2.00
Thomas Lewellen, D.O.
$50.01 or more $3.00
105 West Waterman
ArKids $5.00
Dumas, AR 71639
870/382-1188
Services to individuals under 18, pregnant women,
nursing home residents, emergency services, family Michael N. Moody, M.D.
planning services, and services provided by an HMO to its P.O. Box 829
enrollees are excluded from the Medicaid copay policy. Salem, AR 72576
501/895-2541
Charles Rodgers, M.D.
4202 South University
Little Rock, AR 72204
501/562-4838
An estimated 230,000 Medicaid recipients were enrolled
with managed care organizations PCP and ArKids.
Medicaid Pharmacist
Pharmaceutical benefits are provided through the state.
Suzette Bridges
F. STATE CONTACTS Prescription Price Updating
Medicaid Drug Program Administrator First DataBank
1111 Bay Hill Drive
Suzette Bridges, P.D. San Bruno, CA 74066
Division of Medical Services 415/588-5454
Dept. of Human Services
P.O. Box 1437, Slot 4105
Medicaid Drug Rebate Contacts
T: 501/324-9141 Audits: Suzette Bridges, P.D., 501/324-9141
F: 501/324-9140 PA: Mary Alice Easterling, EDS, 501/374-6608
E-mail: suzette.bridges@medicaid.state.ar.us
Claims Submission Contact
Prior Authorization Contact John Herzog
EDS Federal Corp.
Suzette Bridges
500 East Markham, Ste 400
501/324-9141
501/374-6608
Dr. Judith McGhee
501/682-6442DUR Contact
Medicaid Managed Care Contact
Suzette Bridges
Bob Paladino
501/324-9141
P.O. Box 1437, Slot 1102
DUR Board
Pharmacists:
Steve Bryant, P.D.
Bryant’s Pharmacy
2000 Harrison Street
Batesville, AR 72501
501/793-3999
3-Arkansas National Pharmaceutical Council

CALIFORNIA
A. BENEFITS PROVIDED AND GOUPS ELIGIBLE1

Type of Benefit Categorically Needy Medically Needy (MN)
>21 Children <21
Prescribed Drugs   
Inpatient Hospital Care   
Outpatient Hospital Care   
Laboratory & X-ray Service   
Physician Services   
Dental Services   
Note: Certain classifications of aliens in the above categories are eligible only for emergency and pregnancy-related
benefits.
1

1998 1999*
TOTAL $1,553,598,462 2,644,430
CATEGORICALLY NEEDY, RECEIVING

ASSISTANCE, TOTAL $1,181,162,264 1,564,857
Aged $254,611,395 248,440
Blind/Disabled $812,296,210 536,457
AFDC-Children $35,413,433 383,891
AFDC-Adult $47,289,063 188,195
AFDC-Unemployed-Children $10,991,408 120,991
AFDC-Unemployed-Adults $20,560,755 75,883

Aged $105,624,178 111,101
Blind/Disabled $125,615,464 60,154
AFDC-Children $23,988,641 283,220
AFDC-Adult $24,884,939 111,605

Aged $732,955 659
Blind/Disabled $578,605 1,319
AFDC-Children $12,486,033 139,977
AFDC-Adult $1,168,000 21,843
OTHER, TOTAL $1,695,126 301,095
Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.

*1999 total and expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.
National Pharmaceutical Council California-1

C. ADMINISTRATION Unit Dose: Reimbursable at buck prices.
Under the Health and Human Services Agency with direct Formulary/Prior Authorization
administration by the Department of Health Services.
Formulary: Closed formulary. Medi-Cal List of Contract
The Department of Health Services Pharmaceutical Unit Drugs: Over 600 drugs in differing strengths and dosage
of the Medi-Cal Policy Division monitors the full scope forms listed generically. A drug may be added to the list
and quality of pharmaceutical benefits covered under the on contractual agreement by the manufacturer to provide
provisions of the California Medical Assistance Program. the state a rebate based on the quantity reimbursed to
pharmacies for Medi-Cal recipients. The patient’s
D. PROVISIONS RELATING TO DRUGS physician or pharmacist may request prior authorization
from the field office Medi-Cal consultant for approval of
Benefit Design unlisted drugs or for listed drugs that are restricted to
specific use(s).
prescribed insulin; disposable needles and syringe Examples of general limitations and exclusions (other
combinations used for insulin; blood glucose test strips; uses require prior authorization):
and urine ketone test strips. Products covered with prior
1. CNS stimulants, i.e., amphetamines and
authorization: total parenteral nutrition and interdialytic
methylphenidate, are restricted to attention deficit
parenteral nutrition. Products not covered: cosmetics;
disorder in individuals between 4 and 16 years of age.
fertility drugs; and experimental drugs.
2. Diazepam is restricted to use in cerebral palsy,
Over-the-Counter Product Coverage: Products covered athetoid states, and spinal cord degeneration.
with prior authorization: allergy, asthma and sinus
3. Cimetidine, Famotidine are restricted to therapy
products; analgesics; cough and cold preparations; non-
lasting up to 90 days from the dispensing date of the
H2 antagonist digestive products; digestive products, H2
first prescription.
antagonists; feminine products; topical products; and
smoking deterrent products. 4. Most non-steroidal anti-inflammatory agents are
restricted to use for arthritis.
Therapeutic Category Coverage: Therapeutic categories
5. Many antibiotics have diagnostic and/or age
covered: chemotherapy agents and contraceptives. Prior
restrictions.
authorization required for: anabolic steroids; analgesics,
antipyretics, NSAIDs; antibiotics; anticoagulants; 6. Acyclovir capsules are restricted to herpes genitalis,
anticonvulsants; antidepressants; antidiabetic agents; immunocompromised patients and herpes zoster
antihistamine drugs; antilipemic agents; anti-psychotics; (shingles).
anxiolytics, sedatives, and hypnotics; cardiac drugs;
7. Codeine Combinations: payment to a pharmacy for
prescribed cold medications; ENT anti-inflammatory
ASA or APAP with codeine 30 mg is limited to a
agents; estrogens; growth hormones; hypotensive agents;
maximum dispensing quantity of 45 tablets or
misc. GI drugs; prescribed smoking deterrents;
capsules and a maximum of 3 claims for the same
sympathominetics (adrenergic); and thyroid agents. Medi-
beneficiary in any 75-day period.
Cal fee-for-service does not blanket exclude drug classes.
Drugs for the treatment of cancer or AIDS are exempt 8. Excluded from coverage: multivitamins for persons
from prior authorization. over five years of age (except pre-natal vitamin-
mineral products for pregnant women); cosmetic
Coverage of Injectables: Injectable medicines drugs and fertility drugs; and most OTC household
reimbursable through the Prescription Drug Program remedies.
when used in home health care, extended care facilities
9. Enteral nutritional supplements or replacements are
and through physician payment when used in physician
covered, subject to prior authorization, if used as a
offices.
therapeutic regimen to prevent serious disability or
death in patients with medically diagnosed conditions
Vaccines: Vaccines reimbursable by schedule as part of
that preclude the full use of regular foodstuffs.
the Vaccines for Children Program. Vaccines for adults
covered through the prescription drug program. 10. Cancer, AIDS, and DESI Drugs: Any antineoplastic
drug approved by FDA for the 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
2-California National Pharmaceutical Council

drugs rated less-than-effective by FDA are not Hospital Discharge Medications: Quantities furnished as
covered. discharge medications are limited to no more than a 10-
day supply. Charges are incorporated in the hospital’s
claims for inpatient services.
authorization procedure. Medi-Cal frequently petitions to
add drugs to the list of contract drugs. Denials of these Drug Utilization Review
petitions can be appealed to the director of the
Department of Health and Human Services by the PRODUR system implemented in August 1995. State
petitioner within 30 days after notice of the denial. currently has a DUR Board with a quarterly review.
Providers may appeal prior authorization decisions within
60 days of notification to the local field office and then to Pharmacy Payment and Patient Cost Sharing
field services headquarters if necessary. Beneficiaries also
have the ability to request a hearing to review the denial Dispensing Fee: $4.05, effective 8/85.
and must do so within 90 days of notification.
Ingredient Reimbursement Basis: EAC = AWP-5%, or
Approval may be obtained from a Medi-Cal consultant direct price for 11 specified manufacturers.
for: covered items or services not included on the Medi-
Cal List of Contract Drugs (including special Prescription Charge Formula: Reimbursement is based
circumstance override of multiple source drug price on the lowest of:
ceilings or minimum quantity/ frequency of billing
limitations); and for patients exceeding the 6 Rx per For Legend Drugs:
month limit. Statewide mail and fax requests are accepted 1. Estimated Acquisition Cost (EAC) + dispensing fee,
in the Stockton and Los Angeles Medi-Cal Field Offices. less $0.25.
Requests must include adequate information and 2. Federal Upper Limit (FUL) + dispensing fee, less
justification. Authorization may only be given for the $0.25.
lowest cost item or service that meets the patient’s 3. State Maximum Allowable Ingredient Cost (MAIC) +
medical needs. dispensing fee, less $0.25.
4. Pharmacy’s usual price to general public, less $0.25.
Beneficiary or Prescriber Prior Authorization: On a case
by case basis, the Dept. of Health Services restricts,
through the requirements of prior authorization, the For Over-the-Counter Drugs:
availability of designated prescription drugs to certain 1. Estimated acquisition cost (EAC) x 1.5, less $0.50.
beneficiaries or prescribers found by the Department to 2. Federal Upper Limit (FUL) x 1.5, less $0.50.
abuse those benefits. 3. State Maximum Allowable Ingredient Cost
(MAIC) x 1.5, less $0.50.
Prescribing or Dispensing Limitations 4. Pharmacy’s usual price to the general public, less
$0.50.
Prescription Refill Limit: A prescription refill can be
dispensed as authorized by prescriber. Exception is (Reimbursement is reduced by $0.25 per claim line as of
allowed for refill of a reasonable quantity when prescriber January 1, 2000.
is unavailable (pursuant to California law). Fee is pro-
rated so that total fee (for partial quantity and balance of Maximum Allowable Cost: State MACs are established
the prescription after prescriber is contacted) does not for 51 multi-source items. Override requires “Medically
exceed fee for same prescription when refilled as routine Necessary” or unavailability of drug products at or below
service. MAC. List is periodically revised and price limits
changed to reflect current market conditions.
Monthly Quantity Limit: This is flexible, but should be
consistent with the medical needs of the patient. Limited Incentive Fee: None.
to 100 tabs on some drugs, 100 days’ supply on others.
Many maintenance drugs are subject to minimum quantity Patient Cost Sharing: Copayment: $1.00 (optional).
or maximum frequency of billing controls.
Monthly Prescription Limit: Limited to 6 per month Cognitive Services: Does not pay for cognitive services,
without prior authorization. The limit does not apply to but this is under consideration.
family planning drugs, patients in nursing facilities or to
AIDS or cancer drugs.

Orange County Organized Health System

E. USE OF MANAGED CARE CalOptima
1120 West La Veta Ave, 5th Floor
Approximately 2,500,000 total unduplicated number of Orange, CA 92668
Medicaid recipients were enrolled in MCOs in FY 1999.
Recipients receive pharmaceutical benefits through the Santa Cruz County -Monterey
state and managed care plans. Managed Care Commission
Kaiser Foundation Santa Cruz County Health Options
Health Plan, Inc. 375 Encinal Street, Suite A
Northern California Region Santa Cruz, CA 95060
1800 Harrison Street, 9th Floor
P.O. Box 12916 Sutter Senior Care
Oakland, CA 94612-2998 1234 U Street
Omni Health Care
2450 Ventura Oaks, Suite 300 Altamed Health Services Corp.
Sacramento, CA 95833-3292 500 Citadel Drive, Suite 490
Los Angeles, CA 90040
Denticare
125 Technology Street CompCare Health Plan, Inc.
Irvine, CA 92618 3200 Fourth Ave, Suite 200
San Diego, CA 92103
Universal Care
1600 E. Signal Hill Street Blue Cross of California
Signal Hill, CA 90806-3682 5151-A Camino Ruiz
Camarillo, CA 93012
County of Contra Costa
Contra Costa Health Plan Kern Health Systems
595 Center Avenue, Suite 100 Kern Family Health care
Martinez, CA 94553 1600 Norris Road
Bakersfield, CA 93308
Western Health Advantage
1331 Garden Highway Suite 100 LA Care Health Plan
Sacramento, CA 95833-9754 3530 Wilshire Boulevard, Suite 704
CaliforniaCare Health Plans
2000 Corporate Center Dr., Bldg. 7 Inland Empire Health Plan
Newbury Park, CA 91320 303 E. Vanderbilt Way, Suite 400
San Bernardino, CA 92408
Placer County Managed Care Network
11730 Enterprise Drive San Francisco Health Authority
Auburn, CA 95603 San Francisco Health Plan
568 Howard Street, Fifth Floor
Sonoma County Medi-Cal San Francisco, CA 94105
Managed care Network
1221 Farmers Lane, Suite 200 Health Plan of San Joaquin
Santa Rosa, CA 95404-1705 1550 W. Fremont Street
Stockton, CA 95203-2643
Watts Health Foundation, Inc.
United Health Plan Omni Healthcare Inc.
3405 West Imperial Highway, Suite 600 2450 Venture Oaks, Suite 300
Inglewood, CA 90303 Sacramento, CA 95833
Maxicare
1149 South Broadway, Suite 819

UCSD Healthcare Center for Elders Independence

200 West Arbor Dr. 1955 San Pablo Ave
San Diego, CA 92103 Oakland, CA 94612
Delta Dental Plan of CA HealthReach Family Care Center

7687 Folsom Blvd 7237 Lennane Drive, Suite 200
Sacramento, CA 95826 Sacramento, CA 95834
Western Dental Srvs., Inc. #424 AIDS Healthcare Foundation

300 Plaza Alicante, Ste. 810 6255 W. Sunset Blvd., 16th Floor
Garden Grove, CA 92640 Los Angeles, CA 90028-8073
Health Net
3400 Data Drive, 1st Fl. W Cohan Medical Corp
Rancho Cordova, CA 95670 Tower Health Services
200 Oceangate, Sixth Pl.
Molina Medical Centers Long Beach, CA 90802
One Golden Shore Drive
Long Beach, CA 90802 Alameda Alliance for Health
1850 Fairway Drive
Orange County Organized Health System San Leandro, CA 94557
CalOptima
1120 West la Veta Ave., 5th Floor San Francisco City & County Public Health
Orange, CA 92668 Family Mosaic Project
1309 Evans Avenue
San Mateo Health Commission San Francisco, CA 94124
Health Plan of San Mateo
1500 Fashion Island Blvd., Suite 300 Scan Health Plan
San Mateo, CA 94404 Senior Care
Action Network
Santa Barbara County Special Healthcare Authority 3780 Kilroy Airport Way, Suite 600
Santa Barbara Health Initiative Long Beach, CA 90806-2460
110 Castilian Dr.
Goleta, CA 93117-3028 Santa Clara Family Health Plan
4050 Moopark Avenue
Solano County Medical Care Commission San Jose, CA 95117
Solano Partnership Health Plan
421 Executive Court North, Suite A Access Dental Plan, Inc.
Suisun City, CA 94585 555 University Ave, Suite 182
Solano-Napa County
Commission on Medical Care
Partnership HealthPlan of California F. STATE CONTACTS
421 Executive Court North, Suite A
Suisun City, CA 94585 State Drug Program Administrator
J. Kevin Gorospe, Pharm.D.
Santa Cruz-Monterey Chief, Pharmaceutical Unit
Managed Medical Care Commission Medi-Cal Policy Division
Central Coast Alliance for Health 714 P Street, Room 1540
375 Encinal Street, Suite A Sacramento, CA 95814
Santa Cruz, CA 95060 T: 916/657-4213
F: 916/654-0513
OnLok Senior Health Services E-mail: kgorospe@dhs.ca.gov
1441 Powell Street Agency Internet Address: http://www.dhs.ca.gov
San Francisco, CA 94133-3879

Prior Authorization Contact Medicaid Drug Rebate Contacts

DUR: Vic Walker, R.Ph., B.C.P.P. 916/657-0785
J. Kevin Gorospe, 916/657-4213
PA: J. Kevin Gorospe, Pharm.D., 916/657-4213
DUR Contact
Vic Walker, R.Ph. B.C.P.P
Dennis Dworman
Sr. Pharmaceutical Consultant
Executive Program Director
Medi-Cal Policy Division
EDS-Medi-Cal
714 P Street, Room 1540
Electronic Data Systems
3215 Prospect Park Drive
T: 916/654-0785
Rancho Cordova, CA 95670
F: 916/654-0513
916/636-1000
E-mail: vwalker@dhs.ca.gov
Medi-Cal Drug Utilization Review Board (DUR
Board)
Susanne Hughes
Timothy E. Albertson, M.D., Ph.D. Acting Division Chief
University of California-Davis Medi-Cal Managed Care Division
Pulmonary/Critical Care Medicine 714 P Street, Room 650
4301 X Street, Professional Bldg., Room 2120 Sacramento, CA 95814
Sacramento, CA 95817 T: 916/654-8076
F: 916/657-2069
Robert J. Matutat, Pharm.D. E-mail: shughes2@dhs.ca.gov
First Databank
Attn: inpatient Pharmacy Disease Management Program/Initiative Contact
1425 S. Main
J. Kevin Gorospe, 916/657-4213
Walnut Creek, CA 94596
Physician-Administered Drug Program Contact
Janeen G. McBride, R.Ph.
Rx America Fulton Lipscomb, M.D.
1500 South Anaheim Blvd. 916/657-1460
Anaheim, CA 92815-0017
Health and Welfare Agency Officials
Gary M. McCart, Pharm.D.
Grantland Johnson
University of California, San Francisco
Secretary
400 Parnassus Ave., Box 312
California Health and Human Services Agency
San Francisco, CA 94143
1600 9th Street, Suite 460
Anoush Miridjanian, M.D.
Southern California Permanente Medical Group
Diana Bonta, R.N., Director
Department of Internal Medicine
Department of Health Services
4647 Zion Ave.
714 P Street, P. O. Box 942732
San Diego, CA 92120
Stephen M. Stahl, M.D., Ph.D.
Gail L. Margolis, Acting Deputy Director
Clinical Neuroscience Research Center
Medical Care Services
8899 University Center Lane, Ste. 130
San Diego, CA 92122
Medi-Cal Contract Drug Advisory Committee
Prescription Price Updating Michael B. Huff, M.D.
314 West Fourth St.
EDS
Oxnard, CA 93030
P. O. Box 13029
Sacramento, CA 95813-4029
916/636-1000

William B. Ness, M.D.

65 North 14th Street
San Jose, CA 95112
Gary M. McCart, Pharm.D.

University of California
School of Pharmacy
Division of Clinical Pharmacy
Box 0622
Adrian M. Wong, Pharm.D.

17 Warren Drive
San Francisco, CA 94131
415/731-6239
Richard H. White, M.D.

U.C. California, Davis
Division of General Medicine
Primary Care Center, Room 3107
2221 Stockton Blvd.
Shirley Ann Floyd

131 Chester Ave., Suite A
Bakersfield, CA 93301

Pharmaceutical Associations/Boards
California Medical Association
Jack C. Lewin, M.D.
P.O. Box 7690
415/541-0900
Osteopathic Physicians & Surgeons of California

Gary A. Gramm. D.O.
Executive Director
1900 Point West Way, Suite 188
916/561-0724
California Pharmacists’ Association

Carlo Michelotti, R.Ph., M.P.H.
Chief Executive Officer
1112 I Street, Suite 300
T: 916/444-7811
F: 916/443-1915

Patricia F. Harris
Executive Officer
400 R Street, #4070
916/445-5014

COLORADO

Dental Services    
1

1998* 1999*
TOTAL $110,159,725 147,033

ASSISTANCE, TOTAL
Aged
Blind/Disabled
AFDC-Children
AFDC-Adult
AFDC-Unemployed-Children
AFDC-Unemployed-Adults
MEDICALLY NEEDY, TOTAL

Aged
Blind/Disabled
AFDC-Children
AFDC-Adult
POVERTY RELATED, TOTAL

Aged
Blind/Disabled
AFDC-Children
AFDC-Adults
OTHER, TOTAL

1-Colorado National Pharmaceutical Council


C. ADMINISTRATION authorization procedure. There is an appeal process and
re-review when appealing coverage of an excluded
Eligibility is determined by 63 County Departments of product and prior authorization decisions.
Social Services, and the Colorado Department of Health
Care Policy and Financing administers the drug program. Prescribing or Dispensing Limitations
D. PROVISIONS RELATING TO DRUGS Monthly Quantity Limit: New prescriptions for chronic or
acute conditions are prescribed at the discretion of the
Benefit Design physician. However, reasonable amounts for more than a
30-day supply for chronic conditions are recommended.
Drug Benefit Product Coverage: Products covered: Maximum supply is 100 days for maintenance medication
prescribed insulin. Products covered with restriction:
disposable needles and syringe combinations used for Drug Utilization Review
insulin; blood glucose test strips; urine ketone test strips,
total parenteral nutrition; and interdialytic parenteral PRODUR system implemented in December 1998.
nutrition. Products not covered: cosmetics; DESI drugs;
fertility drugs; prescribed vitamins (except prenatal); and Lock-In Review Procedures: The Department receives
experimental drugs. computer processed printouts designed to discover over-
utilization of drugs prescribed by physicians, dispensed by
Over-the-Counter Product Coverage: Products covered vendors, and received by eligible recipients.
with restriction: analgesics (ASA only); cough and cold
preparations (except >21) and smoking deterrent products. Pharmacy Payment and Patient Cost Sharing
Products not covered: allergy, asthma and sinus products;
digestive products (non-H2 antagonist); digestive products Dispensing fee: $4.08 as of July 1, 1990. Institutional
(H2 antagonist); feminine products; and topical products. pharmacies will receive a dispensing fee equal to $1.89.
Dispensing physicians shall not receive a dispensing fee
Therapeutic Category Coverage: Therapeutic categories unless their offices or sites of practice are located more
covered: analgesics, antipyretics, NSAIDs; antibiotics; than 25 miles from the nearest participating pharmacy. In
anticoagulants; anticonvulsants; antidepressants; the latter case, physicians receive a fee equal to $1.89.
antidiabetic agents; antihistamine drugs; antilipemic
agents; anti-psychotics; anxiolytics, sedatives, and Ingredient Reimbursement Basis: EAC = AWP-10% or
hypnotics; cardiac drugs; chemotherapy agents (given in WAC (wholesaler acquisition cost) + 18%. Other: FUL,
home); contraceptives; ENT anti-inflammatory agents; state Mac, usual and customary.
estrogens; hypotensive agents; misc. GI drugs;
sympathominetics (adrenergic); and thyroid agents. Prescription Charge Formula: Benefit drugs shall be
Therapeutic categories partially covered: anorectics. Prior reimbursed at the lesser of the Medicaid allowable
authorization required for: anabolic steroids; prescribed reimbursement charge, or the provider’s usual and
cough and cold medication; growth hormones; vitamins; customary charge or whatever is accepted from any third
sexual dysfunction; Epogen; brand name and FUL drugs; party, discounts, rebates, etc.
and prescribed smoking deterrents.
The Medicaid allowable reimbursement charge is the sum
Coverage of Injectables: Injectable medicines of the ingredient cost of the drug dispensed and the
reimbursable through the Prescription Drug Program provider’s dispensing fee.
and through physician payment when used in physician Ingredient cost for retail pharmacies (estimated
offices. acquisition cost) is the price of the drug actually dispensed
as defined below or the MAC or the high volume EAC,
Vaccines: Vaccines reimbursable as part of the Vaccines whichever is less.
The ingredient cost for institutional and government
Unit Dose: Unit dose packaging not reimbursable. pharmacies is defined as the actual cost of acquisition for
the drug dispensed or the MAC, or the high volume EAC,
Formulary/Prior Authorization whichever is less.
Formulary: Closed formulary Maximum Allowable Cost: The state MAC is the
maximum ingredient cost allowed by the Department for
National Pharmaceutical Council Colorado-2

certain multiple-source drugs. The establishment of a (1) The average wholesale price as it appears in the Red
MAC is subject, but not limited to, the following Book, its supplements, and Medi-Span will be the first
considerations: source. However, if there is a difference between the two
published average wholesale prices, the Department will
(1) Multiple manufacturers;
set the price as the published amount which is the closest
(2) Broad wholesale price span;
to the lowest average price charged by two drug
(3) Availability of drugs to retailers at the selected cost;
wholesalers doing business in Colorado.
(4) High volume of Medicaid recipient utilization;
(5) Bioequivalence or interchangeability.
(2) If there is a price change which does not appear
When federal MAC limits for multiple source drugs are immediately in the Red Book, its supplements, or in Medi-
announced, they will be adopted if they are less than state Span, then the Department will set the average wholesale
MACs or if no state MACs exist. price by averaging the wholesale prices of three drug
wholesalers doing business in Colorado, until the price is
The ingredient cost of any drug subject to MAC shall be published in the Red Book, its supplements, or in Medi-
limited to MAC or wholesale price as determined by the Span.
Department, whichever is less. Exceptions that will allow
reimbursement greater than MAC for a drug entity are (3) If the prices or changes do not appear in the
obtained through a prior authorization mechanism. An publications or the wholesalers’ records, then the
exception will be granted if the patient’s response to the distributors’ or manufacturers’ prices will be adjusted to
generic drug is not therapeutic, an allergic reaction is the wholesale pricing level and used in the drug pricing
involved, or any similar situation exists. file as the price of the drug.
If a recipient requests a brand name for a prescription that If the difference between the pharmacist’s invoice
is subject to MAC, then he/she may pay the ingredient purchase price and the average wholesale price which
cost difference between the MAC and brand name drug. appears in the Red Book, its supplements, or Medi-Span
The recipient must sign the prescription stating that he/she exceeds 18%, then the Department may adopt a lower
is willing to pay the difference in ingredient cost to the price after a survey is conducted to determine the validity
pharmacy. The pharmacy will be paid MAC plus a of the published prices. The price from the distributor or
dispensing fee or reimbursement charges, whichever is manufacturer will be adjusted the same as in 3 above.
lower.
Special Note: The Maximum Allowable Cost shall be
High volume Estimated Acquisition Cost (EAC): determined by the Division of Medical Assistance, based
Reimbursement for single source drugs or certain multiple upon professional determination of a quality product
source drugs which are most frequently prescribed will be available at the least expense possible.
based upon average wholesale prices (AWP) minus 10%,
or direct manufacturers’ prices for package sizes Exceptions to the above are:
containing quantities greater than 100 dosage units or less
if not available in 100’s. - Shelf package size oral liquid medications, in pint size
only, or smaller package size when not packaged in pint
Basis for inclusion in the high volume estimated size.
acquisition cost list includes but is not limited to: - Shelf package size oral tablet and capsule medications
(1) Single source manufacturers; in quantities of 100 only or smaller when not available in
(2) High volume Medicaid recipient utilization; package size of 100.
(3) Interchangeability problems with multiple source - Prescriptions for less than minimum amounts will be
drugs; denied reimbursement of the professional fee unless the
(4) Package sizes in excess of 100. physician notified the Department in writing of the
Drug Pricing: The Department will maintain a drug- medical need for amounts less than a 30-day supply.
pricing file that will be updated at least monthly. The Medical consultation determines the decision.
average wholesale price of a drug as determined by the
Department, MAC, and high volume EAC, will be the
basis for setting the prices in the drug pricing file.
Patient Cost Sharing: Copay is $2.00 for brand name
products and $0.50 for generic.
The Department will determine the average wholesale
price that will be placed in the drug-pricing file as
follows:

DUR Contact
Allen Chapman, 303/886-3176
Approximately 210,000 total unduplicated number of
Medicaid recipients were enrolled in MCOs in FY 1999. Prescription Price Updating
Recipients receive pharmaceutical benefits through
managed care plans. Allen Chapman, 303/886-3176
Managed Care Organizations Medicaid Drug Rebate Contacts

Total Long-term Care Technical: Vince Sherry, 303/866-5408
303 East 17th Avenue Suite 650 DUR & PA: Allen Chapman, 303/866-3176
Denver, Colorado 80203
303/896-4664 Claims Submission Contact
Consultec, Inc.
HMO Colorado
600 17th Street
700 Broadway
Suite 600 North
Denver CO 80203
303/831-2374
800/237-0757
Kaiser Permanente
10350 East Dakota Avenue Medicaid Managed Care Contact
Gary Snider
303/344-7250
Director Managed Care Contractor
Department of Health Care Policy and Financing
Rocky Mountain HMO
1575 Sherman Street, 5th Floor
2775 Crossroads boulevard
Denver, CO 80203
Grand Junction, Colorado 81506
T: 303/886-3163
800/843-0719
F: 303/866-2573
Colorado Access
600 South Cherry STREET Suite 800 Physician-Administered Drug Program Contact
Patti Campbell
303/-355-6707
303/866-5459
Community Health Plan of the Rockies
400 South Colorado Boulevard Suite 300 Health Care Policy & Financing Department
Denver, Colorado 80222 Officials
303/355-3220
James T. Rizzato, Executive Director
Richard Allen, Director Health Plan and Medical Services
United Healthcare
6251 Greenwood Plaza Blvd, Suite 200
Office of Medical Assistance
Englewood, Colorado 80111-4910
Colorado Department of Health Care Policy & Financing
303/267/3594
1575 Sherman Street
F. STATE CONTACTS
Medical Advisory Council
Medicaid Drug Program Administrator
Donald W. Schiff, M.D.
Allen Chapman, R.Ph., M.S. 600 Front Range Road
Department of Health Care Policy and Financing Littleton, CO 80120
1575 Sherman Street, 5th Floor 303/837-2745
Denver, CO 80203
T: 303/886-3176 Molly A. Markert
F: 303/866-2573 11060 E. Wesley Pl.
Aurora, CO 80014
303/756-7234
National Pharmaceutical Council Colorado-4

Mary Jo Jacobs, M.D. Robert Slay

7425 E. Kenyon Ave. Jefferson Co. CCB
Denver, CO 80237 7456 W. 5th Avenue
303/694-2878 Lakewood, CO 80226
303/233-3363 x366
Walter Daniels, D.D.S.
1633 Filmore Street Department Contact
Denver, CO 80206 Richard Allen, Director
303/388-0989 Health Plans and Medical Services
303/866-6092
Rodney Fair, O.D.
105 Bridge Street Legislative Liaison
Brighton, CO 80601 Dean Woodward
303/659-3036 Department of Health Care Policy and Financing
303/866-2708
Douglas Clinkscales
Denver Health and Hospitals
777 Bannock Street
Denver, CO 80204
303/426-7253 Colorado Medical Society
Sandra Mahoney
Cathy Corcoran Executive Vice President
15920 W. 66th Place 7800 E. Dorado Pl.
Golden, CO 80403 Englewood, CO 80111-2306
303/861-6256 303/779-5455
Ernestine Kotthoff-Burrell Colorado Pharmaceutical Association

6098 S. Iola Ct. Val Kalnins
Englewood, CO 80111 5150 East Yale Circle, Suite 304
303/270-8974 Englewood, CO 80112-1360
303/756-3069
Carol Bartley
Denver VNA Colorado Society of Osteopathic Medicine
3801 E. Florida Ave., Suite 800 Kathleen Brennan
Denver, CO 80201 Executive Director
303/753-7312 50 S. Steele Street, Suite 770
Denver, CO 80209
Mary Ellen Kuhlman, MSW 303/322-1752
St. Mary’s Hospital & Medical Center
P.O. Box 1628 State Board of Pharmacy
Grand Junction, CO 81502 Kent Mount
970/244-2273 Program Administration
1560 Broadway, Suite 1310
Dan Stenerson Denver, CO 80202-5146
Shalom Park 303/894-7750
14800 E. Belleview
Aurora, CO 80015 Colorado Hospital Association
303/680-5000 Larry Wall
President
Mark Kunart, D.O. 2140 South Holly St.
17200 E. Iliff Avenue Denver, CO 80222-5607
Aurora, CO 80013 303/758-1630
303/755-4111

CONNECTICUT

Prescribed Drugs          
Inpatient Hospital Care          
Outpatient Hospital Care          
Laboratory & X-ray Service          
Skilled Nursing Home Services          
Physician Services          
Dental Services          
1

1998* 1999*
TOTAL $186,593,992 108,331

ASSISTANCE, TOTAL
Aged
Blind/Disabled
Child
Adult
Unemployed Parent-Child
Unemployed Parent-Adult

Aged
Blind/Disabled
Child
Adult

Aged
Blind/Disabled
Child
Adult
OTHER, TOTAL

National Pharmaceutical Council Connecticut-1

C. ADMINISTRATION Formulary/Prior Authorization
State of Connecticut Department of Social Services through Formulary: Open formulary, however, the following
five regional offices and nine sub-offices. products are excluded from Medicaid prescription
coverage: experimental drugs, cosmetics, fertility drugs;
D. PROVISIONS RELATING TO DRUGS smoking cessation products; DESI drugs, and drugs
available free from the Department of Health Services.
Benefit Design
Prior Authorization: State currently has no prior
Drug Benefit Product Coverage: Products covered: authorization procedure.
prescribed insulin, disposable needles and syringe
combinations for insulin; blood glucose test strips; urine Prescribing or Dispensing Limitations
ketone test strips; total parenteral nutrition (except in
NH); and interdialytic parenteral nutrition (except in NH). Prescription Refill Limit: 6-month refill limit except for
Products not covered: cosmetics; fertility drugs; and oral contraceptives, which have a 12-month limit.
experimental drugs. Controlled substances have a 5 refill or 6-month limit.
Over-the-Counter Product Coverage: Products covered: Monthly Quantity Limit: Maximum 240 tablets or
digestive products (non-H2 antagonists); feminine capsules. Oral contraceptives: 3 months supply may be
products; analgesics; and cough and cold preparations dispensed at one time.
(children < 19 years). Products not covered: smoking Physicians are encouraged to prescribe drugs generically,
deterrent products; allergy, asthma and sinus products; when possible.
digestive products (H2 antagonists); topical products;
iron; calcium; oral contraceptives; and some trace Drug Utilization Review
elements. For nursing home patients, the department will
not pay for OTC drugs used in nursing facilities (such drugs PRODUR system implemented September 1996. Retro
are covered in the per diem rate). Some drugs require DUR since September 1991; the state currently has a
diagnosis for reimbursement such as CNS stimulants for DUR Board with a quarterly review.
ADD and narcolepsy. Pharmacy Payment and Patient Cost Sharing
covered: anabolic steroids; analgesics, antipyretics, Dispensing Fee: $4.10, effective 1/1/91.
NSAIDs; antibiotics; anticoagulants; anticonvulsants;
antidepressants; antidiabetic agents; antihistamine drugs; Ingredient Reimbursement Basis: EAC = AWP-12%.
antilipemic agents; anxiolytics, sedatives, and hypnotics;
cardiac drugs; chemotherapy agents; prescribed cold Prescription Charge Formula: Federal MAC or EAC plus
medications; contraceptives; ENT anti-inflammatory dispensing fee; or usual and customary if lower.
agents; estrogens; hypotensive agents; misc. GI drugs;
sympathominetics (adrenergic); thyroid agents; and Maximum Allowable Cost: State imposes Federal Upper
growth hormones. Therapeutic categories not covered: Limits on generic drugs. Override requires “Brand
anorectics and prescribed smoking deterrents. Medically Necessary.”
Coverage of Injectables: Injectable medicines reimbursable Incentive Fee: The Department will pay an incentive
through the Prescription Drug Program when used in home professional dispensing fee of $0.50 per prescription, in
health care, extended care facilities, and through physician addition to any other dispensing fee, for substituting a
payment when used in physicians offices. No injectable generically equivalent drug product.
drug list.
Patient Cost Sharing: None.
Vaccines: Vaccines reimbursable as part of the Children
Health Insurance Program. Cognitive Services: Does not pay for cognitive services.
Unit Dose: Unit dose packaging not reimbursable. E. USE OF MANAGED CARE
Connecticut has approximately 230,000 Medicaid recipients

enrolled in managed care and receive pharmaceutical
benefits.
2-Connecticut National Pharmaceutical Council

Michael Starkowski, Deputy Commissioner

Managed Care Organizations
860/424-5053
Blue Cross / Blue Shield of CT
Blue Care Family Plan David Parrella, Director
John Brangi, Director Medical Administration Policy
Medicaid Managed Care 203/424-5116
370 Bassett Road
North Haven, CT 06473-4201 Michelle Parsons, Manager
203/985-6464 Alternate Care Unit
860/951-9544 203/424-5177
Community Health Network of CT James Linnane, Manager

290 Pratt - 2nd Floor Benefit Design Unit
Meriden, CT 06450 203/424-5111
203/237-4000
Marcia Mains, Manager
PHS Healthy Options Medical Operations
Janice Perkins, Assistant VP 203/424-5219
Government Relations and Programs
One Far Mill Crossing, Box 904
DUR Contact
Shelton, CT 06484-0944
203/239-7444 x664 Elizabeth A. Geary, R.Ph.
860/424-5150
HealthChoice of CT
Preferred One
Connecticut DUR Board
Sylvia Kelley, VP, Executive Director
23 Maiden Lane Kenneth Fisher R.Ph.
North Haven, CT 06473 Brooks Pharmacy
203/239-7444 x664
(withdrawing from program as of 4th quarter of 2000) Arturo Morales M.D.
St. Francis Hospital
860/714-2976
F. STATE CONTACTS
Lori Jane Duntz Lord R.Ph.
Medicaid Drug Program Administrator Greenville Drug
Elizabeth A. Geary, R.Ph. 860/889-9857
Health Program Supervisor
Dept. of Social Services Jeffrey J. Messina R.Ph.
25 Sigourney Street Fort Hill Pharmacy
Hartford, CT 06106 860/445-6431
T: 860/424-5150
F: 860/951-9544 Rick Carbray, R.Ph.
E-mail: elizabeth.geary@po.state.ct.us 16 Beacon Street
Newington, CT 06111
860/529-6305
Department of Social Services Administrative
Officials Frederick N. Rowland, M.D.
Patricia A. Wilson-Coker St. Francis Hospital and Medical Center
Commissioner 860/679-2281
Dept. of Social Services
25 Sigourney St. Dennis Chapron, R.Ph., M.S.
Hartford, CT 06016-5033 UConn Health Center
860/679-2281
Rita Pacheco, Deputy Commissioner
203/424-5055
National Pharmaceutical Council Connecticut-3

Cynthia Huge, R.Ph. Connecticut Pharmacists Association

Lexicon Pharmacy Services Margherita R. Guiliano, R.Ph. Executive V.P.
800/233-7873 35 Cold Spring Road, Ste. 124
800/342-4980 Rocky Hill, CT 06067-3100
203/563-4619
Osteopathic Medical Society
Lynne Freiburger-Epstein, D.O.
First Data Bank
Secretary/Treasurer
225 Main Street
Medicaid Drug Rebate Contacts Manchester, CT 06040
Elizabeth Geary 860/645-7014
Medical Operations
860/424-5150 State Board of Pharmacy
Ellen Arce, R.Ph., 860/832-5885 (Audits) Michelle Sylvestre, R.Ph.
Board Administrator
State Office Building, Room G-1A
Claims Submission Contact Hartford, CT 06106
Twila Smith 203/566-3290
EDS Federal Corp.
100 Stanley Drive Connecticut Hospital Association, Inc.
New Britain, CT 06053 Dennis P. May
860/832-5800 President
110 Barnes Road
P.O. Box 90
Medicaid Managed Care Contact Wallingford, CT 06492-0090
James Gaito 203/294-7202
Department of Social Services
25 Signourney St. Prescription Price Adjustments and Updates
Hartford, CT 06106
860/424-5137 First Data Bank-Blue Book
E-mail: james.gaito@po.state.ct.us
Elderly Drug Coverage Program Contact

Elizabeth Geary
860/424-5150

Zanita McKinney, Medical Policy
25 Sigourney Street
Hartford, CT 06106
860/424-535
State Pharmacy Commission

William Summa, P.D., Chairman

State Medical Society
Timothy B. Norbeck, Executive Director
160 St. Ronan Street
New Haven, CT 06511
203/865-0587
4-Connecticut National Pharmaceutical Council

DELAWARE

1

1998* 1999*
TOTAL $41,350,537 69,027
RECEIVING CASH ASSISTANCE, TOTAL

Aged
Blind/Disabled
AFDC-Children
AFDC-Adult
AFDC-Unemployed-Children
AFDC-Unemployed-Adults

Aged
Blind/Disabled
AFDC-Children
AFDC-Adult

Aged
Blind/Disabled
AFDC-Children
AFDC-Adults
OTHER, TOTAL

National Pharmaceutical Council Delaware-1


Prescription Refills: Prescription blank has space for
Division of Social Services, Department of Health and physician to authorize renewals.
Social Services, through three county offices of the state
agency. Monthly Quantity Limit: Greater of 34-day supply or 100
dosing units.
D. PROVISIONS RELATING TO DRUGS
Monthly Dollar Limits: None.
Benefit Design
prescribed insulin; disposable needles and syringe PRODUR system implemented in August 1994.
combinations used for insulin; blood glucose test strips;
urine ketone test strips; and total parenteral nutrition. Pharmacy Payment and Patient Cost Sharing
Products not covered: cosmetics; fertility drugs;
experimental drugs; and interdialytic parenteral nutrition. Dispensing Fee: $3.65.
Over-the-Counter Product Coverage: Products covered: Ingredient Reimbursement Basis: EAC = AWP-12.9%.
allergy, asthma and sinus products; analgesics; cough and
cold preparations; digestive products (non-H2 antagonist); Prescription Charge Formula: Payment is based on
digestive products (H2 antagonists); and smoking AWP-12.9% or maximum allowable cost (MAC) plus a
deterrent products. Products covered with restriction: dispensing fee, or the usual and customary cost to the
feminine products (antifungals) and topical products (anti- general public, whichever is lower.
infectants).
Therapeutic Category Coverage: Therapeutic categories Limits as well as state-specific limits on generic drugs.
covered: anabolic steroids; analgesics, antipyretics, State-specific MAC list contains 90 drugs. Override
NSAIDs; antibiotics; anticoagulants; anticonvulsants; requires “Brand Medically Necessary.”
antidepressants; antidiabetic agents; antihistamine drugs;
antilipemic agents; anti-psychotics; anxiolytics, sedatives, Incentive Fee: None.
and hypnotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives; ENT anti- Patient Cost Sharing: None.
inflammatory agents; estrogens; hypotensive agents; misc.
GI drugs; prescribed smoking deterrents; Cognitive Services: Does not pay for cognitive services.
sympathominetics (adrenergic); and thyroid agents. Prior
authorization required for: anorectics and growth E. USE OF MANAGED CARE
hormones.
Coverage of Injectables: Injectable medicines Medicaid recipients were enrolled in MCOs in FY 1999.
reimbursable through the Prescription Drug Program and Recipients receive pharmaceutical benefits through the
physician payment when used in physician offices. state.
Reimbursable only through the Prescription Drug Program
when used in extended care facilities. Managed Care Organizations
DelawareCare
Vaccines: Vaccines reimbursable under the Vaccines for
2751 Centerville Road, Suite 400
Children program.
215/937-8285
Unit Dose: Unit dose packaging not reimbursable. No
price based on AWP.
First State Health Plan
1801 Rockland Road, Suite 300
302/576-7603

authorization procedure.
2-Delaware National Pharmaceutical Council

Carl Mulveny
F. STATE CONTACTS 1941 Limestone Rd.
State Drug Program Administrator
Phile Soulé Michael Glacken
Delaware Health and Social Services 500 West 10th St.
1901 N. Dupont Highway Wilmington, DE 19801
New Castle, DE 19720
T: 302/577-4900 Prescription Price Updating
F: 302/577-4405 Cynthia Denemark , 302/453-8453
Agency Internet Address:
http://www.state.de.us/govern/agencies/dhss Medicaid Drug Rebate Contacts
Prior Authorization Contact Technical: Ralph Dominica, 302/454-7622
Policy: E. Beth Laucius, 302/577-4902
Cynthia Denemark Dispute Resolution: Jessica Bullion, 302/454-7622
Pharmacist Consultant
EDS Claims Submission Contact
248 Chapman Road, Suite 200
Newark, DE 197029720 Thomas Ignudo
T: 302/453-8453 Account Manager
F: 302/454-7603 EDS
E-mail: cynthia.denemark@eds.com 248 Chapman Rd
Newark, DE 19702
DUR Contact
Cynthia Denemark , 302/453-8453
Cynthia Denemark , 302/453-8453
DUR Board
Health and Social Services Department Officials
Calvin Freedman, R.Ph.
302 Lark Drive Secretary
Newark, DE 19713-1216 Dept. of Health & Social Services
Delaware State Hospital
Marvin H. Dorph, M.D. New Castle, DE 19720
614 Loveville Road 302/577-4500
Unit E4H Coffee Run Condo
Hockessin, DE 19707 Philip P. Soulé, Sr.
Deputy Director, Medicaid
Daniel M. Hauser, Pharm.D. 302/577-4901
325 W. Broadstair
Dover, DE 19904 Dr. James B. Salva
Medical Consultant
Victoria Paoletti 302/577-4900
153 Owenwood Dr.
Lincoln University, PA 19352 Medical Advisory Committee Members
Edward R. Sobel, D.O.
Richard Steele
1100 S. Broom Street
2617 Epping Rd.
Anne Aldridge, M.D.
Marcus Wilson, Pharm.D.
671 Clifton Dr.
29 Peninsula Court
Bear, DE 19701
Bear, DE 19701
Sister Jeanne Cashman, O.S.U.
Sharon Wisneski, R.N., M.S.
Ursuline Academy Convent
336 Pine Valley Road
1104 Pennsylvania Avenue
Dover, DE 19901

Neil McLaughlin George English
Fernhook Community Mental Health Blue Cross Blue Shield of DE
14 Central Avenue One Brandywine Plaza
New Castle, DE 19720 Wilmington, DE 19899
Richard Cherrin Micheal Glacken, M.D.

Visiting Nurses Association Medical Director
New Castle Corporate Commons Connections, CSP
One Reads Way 500 West 10th St.
New Castle, DE 19720 Wilmington, DE 19801
Steven A. Dowshen, M.D. Daniese McMullin-Powell

A.I. duPont Institute A.D.A.P.T
P.O. Box 269 24 S. Old Baltimore Pike
Wilmington, DE 19899 Newark, DE 19702
Bob Welch Leonard Nitowski, M.D.

Bureau Health Planning & Resource Management Doctors for Emergency Services
Jesse Cooper Building, Suite 160 PO Box 3048
Dover, DE 19901 Wilmington, DE 19804
John A. Forrest, Jr., M.D. Julia M. Pillsbury, D.O.

195 Lynnhaven Drive Center for Pediatric and Adolescent Medicine
Dover, DE 19904 125-1 Greentree Drive
Dover, DE 19904
Mark Meister
Medical Society of Delaware Ulder Jane Tillman, M.D.
1925 Lovering Avenue Jesse Cooper Building
Wilmington, DE 19806 417 Federal and Water Streets
Dover, DE 19901
Olga Ramirez
Community Legal Aid Society, Inc. Yrene E. Waldron
913 Washington Street Executive Director
Wilmington, DE 19801 DE Health Care Facilities Association
Two Mill Rd., Suite 200
Penny D. Chelucci Wilmington, DE 19806
De Counsel on Gambling Problems
100 W. 10th Street Executive Officers of State Medical and
Community Service Bldg., Suite 303 Pharmaceutical Societies
Medical Society of Delaware
Mark Meister, Sr.
Joseph Letnaunchyn
Executive Director
Delaware Health Care Association
1925 Lovering Avenue
1280 S. Governor’s Avenue
Dover, DE 19901
302/658-7596
David Allen Delaware Pharmaceutical Society
Vice President Martin Golden
Ambulatory & Continuing Care Services Executive Director
Milford Memorial Hospital Tindell Square Professional Plaza
21 W. Clark Ave. 1601 Milltown Road, Suite 8
Milford, DE 19963 Wilmington, DE 19808
302/892-2880
4-Delaware National Pharmaceutical Council

Osteopathic Medical Society

Edward Sobel, D.O.
Executive Secretary
P. O. Box 845
302/475-6881

David Dryden, R.Ph., J.D.
Executive Secretary
Cooper Building
Federal and Water Streets
Dover, DE 19901
302/739-4708
Association of Delaware Hospitals

Joseph M. Letnaunchyn
President
1280 South Governors Avenue
Dover, DE 19904-4802
302/674-2853

DISTRICT OF COLUMBIA

1

1998* 1999*
TOTAL $41,254,973 57,733
CATEGORICALLY NEEDY CASH TOTAL

Aged
Blind
Disabled
Children - Families w/Dep. Children
Adults - Families w/Dep. Children
CATEGORICALLY NEEDY NON-CASH TOTAL

Aged
Blind
Disabled

Aged
Blind
Disabled

1-District of Columbia National Pharmaceutical Council

C. ADMINISTRATION Pharmacy Payment and Patient Cost Sharing
The District of Columbia Department of Health (DOH), Dispensing Fee: $3.75.

Medical Assistance Administration.
Ingredient Reimbursement Basis: AWP - 10%.
Prescription Charge Formula: The lesser of: Upper limit
Benefit Design established by HCFA or the AWP - 10% plus the
dispensing fee or usual and customary to the public.
prescribed insulin; disposable needles and syringe Maximum Allowable Cost: State imposes Federal Upper
combinations used for insulin; and ferrous sulfate. Prior Limits on generic drugs. Override requires “Brand
authorization required for: injectable drugs administered Medically Necessary” with explanation.
on an outpatient basis; anorexic drugs for treatment of
narcolepsy and minimal brain dysfunction in children; Incentive Fee: None.
acute anti-ulcer drugs, and brand NSAIDS. Products not
covered: all other non-legend items. Patient Cost Sharing: $1.00 copay by recipient. Does not
apply to recipients under 18, prescriptions for family
Over-the-counter Product Coverage: Products covered: planning, nursing home patients, or pregnancy related.
oral analgesics; oral antacids; contraceptive foams and
jellies; prenatal vitamin formulations; geriatric vitamin Cognitive Services: Does not pay for cognitive services.
formulations for recipients 65 and over; and multivitamin
formulations for children 7 years of age and over. E. USE OF MANAGED CARE
Coverage of Injectables: Injectable medicines Recipients enrolled in managed care receive

reimbursable when used in physicians offices, home pharmaceutical benefits through managed care plans.
health care, and extended care facilities.
Vaccines: Vaccines reimbursable at cost as part of the
Advantage Health Plan, Inc.
EPSDT service.
P.O. Box 9596
Washington, DC 20016
Unit Dose: Unit dose packaging not reimbursable
202/686-8555
Formulary/Prior Authorization American Preferred Provider Plan Mid-Atlantic, Inc.
1501 M Street, NW, Suite 500
Formulary: Open formulary Washington, DC 20002
202/408-0460
Prescribing or Dispensing Limitations
Monthly Quantity Limit: In general, amounts dispensed D.C. Chartered Health Plan
are to be limited to quantities sufficient to treat an episode 820 First Street, NE, Ste. LL100
of illness. Maintenance drugs such as thyroid, digitalis, Washington, DC 20002
etc. may be dispensed in amounts up to a 30-day supply 202/408-4710
with 3 refills that must be dispensed within 4 months.
Antibiotic medications used in treatment of acute Capitol Community Health Plan
infections are not to be dispensed in excess of a 10-day 750 First Street, NE, Ste. 1120
supply. Birth control tablets may be dispensed in 3-cycle Washington, DC 20002
units with a maximum of 3 refills within one year. 202/408-0460
Monthly Dollar Limits: $1,500 limit. Physicians are to George Washington University Health Plan
request prior authorization for prescriptions that exceed 4550 Montgomery Avenue
this amount. Beheads, MD 20814
301/941-2044
PRODUR system implemented in September 1996.
National Pharmaceutical Council District of Columbia-2

Health Right, Inc. Physician-Administered Drug Program Contact

3020 14th Street, NW
Donna Bovell
202/727-0753
202/518-2370
Prudential Health Care Plan
Department of Human Services Officials
2800 N. Charles Street
Baltimore, MD 21218 Geraldine Williams
410/554-7224 Director
Department of Human Services
2700 MLK Avenue, SE
F. STATE CONTACTS (801 East Bldg.)
Donna Bowel Marlene Kelly, M.D.
Pharmacist Consultant Acting Director
Commission on Health Care Finance Department of Health
2100 M.L. King Jr. Ave. SE 1660 L Street, NW
Suite 302 12th Floor
Washington, DC 20020 Washington, DC 20002
202/727-0753
Paul Offner
Deputy Director, DOH
District of Columbia DUR Board Medical Assistance Administration
Christopher Keeyes, Pharm.D. (Chair) 2100 M.L. King Jr. Ave. SE
President, Clinical Pharmacy Associates Suite 302
11710 Beltsville Drive, Suite 510 Washington, DC 20020
Calberton, MD 20705
301/572-1616 Executive Officers of District Medical and
Martin Dillard, M.D. (Vice Chair)
Assistant Dean for Clinical Affairs Medical Society of the District of Columbia
Chief, Division of Nephrology K. Edward Shanbacker
Howard University Hospital 2215 M St., NW
2041 Georgia Avenue, NW, Suite 5C02 Washington, DC 20037-2059
Washington, DC 20060 202/466-1800
202/865-1191
Pharmaceutical Association
Howard Robinson, R.Ph. Herbert Kwash, R.Ph., President
Manager, Central Pharmacy 6406 Georgia Ave, NW
Greater Community Hospital Washington, DC 20012
1310 Southern Avenue, SE 202/829-1515
Osteopathic Association
Dr. Kim Bullock Roy Heaton, D.O., Secretary
Providence Hospital 4001 N. 9th Street, Suite 216
Emergency Room Arlington, VA 22203
1150 Varuum St., NE 703/522-8404
202/269-7863 DC Board of Pharmacy
Cheryl A. Robinson, Chair
614 H Street N.W., Rm. 904
Medicaid Drug Rebate Contacts Washington, DC 20001
Technical: Ken Boni, 202/965-7400 202/727-7468
Policy: Donna Bovell, 202/727-0753
DUR: Donna Bovell, 202/727-0753
3-District of Columbia National Pharmaceutical Council

District of Columbia Hospital Association

Robert Malson, President
1250 Eye Street, NW, Suite 700
Washington, DC 20005-3980
202/682-1581
Fiscal Intermediary
Jack Zaelo
First Health Services, Inc.
122 C Street, N. W.
202/783-5610
National Pharmaceutical Council District of Columbia-4

FLORIDA

Skilled Nursing Home Services   
Dental Services  
1

1998* 1999
TOTAL $933,782,041 1,014,372 $1,089,866,582 982,886

Aged $126,584,312 76,097
Blind / Disabled $509,397,909 212,404
AFDC-Child $26,292,425 151,467
AFDC-Adult $36,189,923 69,409
AFDC-Unemployed-Child $4,312,209 25,383
AFDC-Unemployed-Adult $7,646,737 21,063

Aged $62,129 20
Blind / Disabled $38,021,526 8,395
AFDC-Child $2,782,675 3,521
AFDC-Adult $5,497,271 7,088

Aged $71,343,167 45,811
Blind / Disabled $93,785,943 36,579
AFDC-Child $22,471,261 145,201
AFDC-Adult $6,059,226 54,575
OTHER $139,419,869 125,873

C. ADMINISTRATION
Agency for Health Care Administration. Claims

processing and payment by contract with fiscal agent.
1-Florida National Pharmaceutical Council

D. PROVISIONS RELATING TO DRUGS 3. Non-legend drugs (except for prescribed insulin,

pancreatic enzymes, buffered and enteric coated
Benefit Design aspirin when prescribed as an anti-inflammatory
agent only, and single entity hematinics).
Drug Benefit Product Coverage: Products covered: 4. Anorexants unless the drug is prescribed for an
prescribed insulin; disposable needles and syringe indication other than obesity (i.e. narcolepsy,
combinations used for insulin; blood glucose test strips; hyperkinesis).
total parenteral nutrition; and urine ketone test strips for 5. Drugs with questionable efficacy as rated by FDA
children under age 21. Prior authorization required for: (DESI).
Cytogam; Proleukin; Serostim; Albumin; Neutrexin; 6. Investigational and experimental items.
Provigil; Zoloft 50mg; Paxil 10mg; Panretin gel; 7. Oral vitamins with exception of fluorinated pediatric
Regranex (long term care); Botox; and nutritional vitamins prescribed for pediatric patients, vitamins
supplements. Products not covered: cosmetics; fertility for dialysis patients, prenatal vitamins.
drugs; experimental drugs; and interdialytic parenteral 8. Smoking cessation products only to EPSDT clients
nutrition. under age 21.
9. Nursing home floor stock drugs.
Over-the-Counter Product Coverage: Products covered:
smoking deterrents; allergy, asthma and sinus medication Prior Authorization: State currently has a formal prior
(limited); analgesics (aspirin); cough and cold authorization procedure. An appeal hearing request is
preparations (only children under 21 years); feminine required to appeal prior authorization decisions.
products (prior Rx only); iron supplements; Guaifenesin;
and vaginal antifungals. Products not covered: digestive Prescribing or Dispensing Limitations
products (H2 antagonists) and topical products.
Prescription Refill Limit:
Therapeutic Category Coverage: Therapeutic categories 1. Six (6) prescriptions monthly for community patients;
covered: anabolic steroids; analgesics, antipyretics, 8 prescriptions per month for institutionalized
NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti- patients. Increased grants are available based on need
depressants; antidiabetic agents; antipsychotics; and diagnosis.
anxiolytics, sedatives, and hypnotics; cardiac drugs; 2. Maintenance medication should be dispensed and
chemotherapy agents; contraceptives; ENT anti- billed for at least a one-month supply.
inflammatory agents; estrogens; hypotensive agents; misc. 3. Refills must be authorized by the prescriber and can
GI drugs; prescribed smoking deterrents (only children be made for up to one year, except that controlled
under 21 years); sympathominetics (adrenergic); and substances can be refilled only in accordance with
thyroid agents. Prior authorization required for: growth federal and state regulations.
hormones. Therapeutic categories not covered: 4. Anti-ulcer, anti-anxiety, and sedative hypnotic drugs
anorectics. limited to 1 per therapeutic class per month, 1 refill
per prescription.
Coverage of Injectables: Injectable medicines 5. Nutritional supplements are covered with prior
reimbursable through the Prescription Drug Program authorization when the patient is otherwise at risk of
when used in home health care and extended care hospitalization.
facilities, and through physician payment when used in 6. Other third parties, including Medicare, must be
physician offices. billed first
Vaccines: Vaccines reimbursable as part of the Vaccines
Formulary: Open formulary with the following limits and

exclusions.
1. Vitamins and phosphate binders only for dialysis
patients.
2. Prostheses; appliances; devices; and personal care
items.
National Pharmaceutical Council Florida-2

Florida 1st Health Plans, Inc.

Contact: Frank Willis
3425 Lake Alfred Road
PRODUR system implemented in July 1994. State
Winter Haven, FL 33881
currently has a DUR board with a quarterly review.
941/293-0785
Retrospective Drug Utilization Review has been in place
since 1982. The state Medicaid agency and the Florida
Foundation Health,
Pharmacy Association, which performs the reviews, share
A Florida Health Plan, Inc.
the administration of the program.
Contact: Michael Comerford
1340 Concord Terrace
Pharmacy Payment and Patient Cost Sharing Sunrise, FL 33323
800/422-7335
Dispensing Fee: $4.23, effective 3/11/86.
Healthease
Ingredient Reimbursement Basis: AWP-13.25 %. Contact: Christopher O’Connor
6800 N. Dale Mabry Hwy., Suite 168
Prescription Charge Formula: Lower of: Tampa, FL 33614-3988
1. FUL (Federal Upper Limits or State MAC) plus 813/290-6358
dispensing fee.
2. EAC plus dispensing fee. Healthy Palm Beaches, Inc.
3. Usual and customary charge.
4. In-house unit dose diff. + 0.015/dose. Humana Family
Contact: Patricia L. Hubrig
Maximum Allowable Cost: State imposes Federal Upper c/o Humana Medical Plan, Inc.
Limits and State Specific Limits on generic drugs. 3400 Lakeside Drive, 5th Floor
Provisions for MAC override by physicians only if listed Miramar, FL 33027
on negative formulary. 305/626-5616
Incentive Fee: No incentive fee. Jackson Memorial Health Plan
Contact: Taryn Davis
Patient Cost Sharing: No copayment 1801 NW 9th Ave., Suite 700
Miami, FL 33136
Cognitive Services: Does not pay for cognitive services. 305/575-3700
E. USE OF MANAGED CARE MedChoice Health Plan

Contact: Jeffery G. Keiser
All Medicaid recipients receive pharmaceutical benefits 5300 West Atlantic Avenue
through managed care plans (inclusion of such benefits is Delray Beach, FL 33484-8190
mandated under state law). 561/496-0505
Managed Care Organizations Neighborhood Health Partnership, Inc.

Alpha Health Plan, Inc. Contact: Heidi Etzold
7600 Corporate Center Dr., Suite 300
Beacon Health Plans, Inc. Miami, Fl 33126-1216
Contact: Ana M. Berenguer 305/715-4318
2511 Ponce de Leon Blvd., 5th Floor
Coral Gables, FL 33134 Personal Health Plan
305/774-2599 Contact: Debi L. Gavras
Dr. Jeff Davis, D.O. (Interim)
Discovery Plan 324 Datura Street, Suite 401
Contact: Robert Wychulis West Palm Beach, FL 33401
3520 Thomasville Road, Suite 200 561/659-1270 ext. 5885
Tallahassee, FL 32308
850/894-0100 ext. 801

Physicians Healthcare Plans, Inc.

Prior Authorization Contact
Contact: Peter Jimenez
2333 Ponce de Leon Blvd. Ste 303 Linda Anthony, R.Ph.
Coral Gables, FL 33134 Senior Pharmacist
305/441-9400 ext. 125 Agency for Health Care Administration
2727 Mahan Drive
Preferred Medical Plan, Inc. Tallahassee, FL 32308
Contact: Tamara Meyerson T: 850/922-0679
4950 SW 8th Street F: 850/922-0685
Coral Gables, FL 33134
305/445-8373 DUR Contact
Coordinator: Marie Donnelly-Stephens
St. Augustine Health Care, Inc.
Senior Health Care Program Analyst
Contact: Mary Lynn Leach
Agency for Health Care Administration
Mail: P.O. Box 23160
2727 Mahan Drive
Location: 4300 NW 89th Blvd.
Gainesville, FL 32606
T: 850/487-4441
352/337-8650
F: 850/922-0685
Stay Well Health Plan
Contact: Nancy Gareau Medicaid DUR Board
6800 N. Dale Mabry Hwy., Ste. 209-211
Tampa, FL 33614 Matthew Cohen, M.D.
813/290-6283 Bryan A. Bognar, M.D.
David B. Levine, D.P.M., D.O.
United Healthcare of Florida, Inc. Richard Roberts, Pharm.D.
Contact: Linna Van Nette Michael Thompson, Pharm.D.
800 North Magnolia Ave., Suite 600 Earlene E. Lipowski, Ph.D.
Orlando, FL 32803 Mechelle LaWarre, Pharm.D.
407/872-1000 Larry L. Mattingly, D.O.
L. Leanne Lai, Ph.D.
United ElderCare Plan Lynn G. Massey, Pharm.D.
800 N. Magnolia Ave., #600
Orlando, FL 32803 Program Retro-DUR
800/643-5337
Gaylon Fruit, R.Ph.
Director Retro DUR Program
F. STATE CONTACTS
Prescribing Pattern Review Panel
J. David Moore, M.D.
Jerry F. Wells
Walter Flesner, D.O.
Pharmacy Program Manager
Daryl D. Wier, M.D.
Mary Stelnicki, R.Ph.
2727 Mahan Drive, MS 38
Stephen Clark, M.D.
Dennis Penzell, D.O.
T: 850/487-4441
B.L. Stalnaker, M.D.
F: 850/922-0685
Cynthia Griffin, Pharm.D.
E-mail: wellsj@fdhc.state.fl.us

Agency for Health Care Administration Officials
Ruben J. King-Shaw, Jr., Director First Data Bank
Gary Crayton, Director for Medicaid
850/488-3560

S. Shai Gold,
Director, Business and Proposal Development Center
Technical: Ralph Quinn, 850/488-9190 The South Florida Community Care Network
Policy: Jerry Wells, 850/487-4441 1801 NW 9th Avenue, Ste 700
Audits: Jerry Wells, 850/487-4441 Miami, FL 33136
Disputes: Greg Bracko, 850/488-9193 T: 305/585-5187
F: 305/585-3815
E-mail: umimbdc@compusource.net
Mark Steck Diabetes:
PBM Director Virginia M. Dollar
Consultec, Inc. Coordinated Care Solutions
9040 Roswell Road, Suite 700 210 N. University Drive, Ste 700
Atlanta, GA 30350 Coral Springs, FL 33071
770/594-7799 T: 954/344-2444
F: 954/796-3688
Medicaid Managed Care Contact Asthma:
Ralph Anderson, R.N. ITG (program sponsor)
2727 Mahan Drive, BLD 1, Rm 323 Plans exist for disease management programs for End-
Tallahassee, FL 32308 Stage Renal Disease (ESRD) and congestive heart failure.
T: 850/487-0640 Contact: Bob Sharpe
F: 850/414-5418 Assistant Deputy Director for Medicaid
2727 Mahan Drive
Disease Management Program/Initiative Contact Tallahassee, FL 32308
850/488-3560
Hemophilia:
Michael L. Ansel
Accordant Health Services Physician-Administered Drug Program
5509-A West Friendly Avenue, Ste 101 Laura Rutledge
Greensboro, NC 27410 850/488-4481
T: 336/855-5870 ext.134
F: 336/852-7413
E-mail: mansel@accordant.com Executive Officers of State Medical and
George E. Hurrell, Jr.
Florida Medical Association, Inc.
Director, Disease Management
Charles S. Amorosino, Jr.
Caremark Inc.
P.O. Box 10269
1127 Bryn Mawr Avenue
123 S. Adams St.
Redlands, CA 92374
T: 909/799-4160
904/224-6496
F: 909/7998-4335
E-mail: george.hurrell@mdmnetwork.com
Florida Pharmacy Association
Michael Jackson, R.Ph.
AIDS:
Peter D. Reis
610 North Adams Street
Director of Business Development
AIDS Healthcare Foundation
850/222-2400
6255 West Sunset Blvd, 16th Fl.
Florida Osteopathic Medical Association
T: 213/860-5200
Larry Mattingly, D.O.
F: 213/860-5235
2007 Apalachee Parkway
E-mail: pdreisjr@aol.com
The Hull Building
850/878-7364


John Taylor
Executive Director
NorthWood Center
1940 North Monroe Street, Suite 60
Tallahassee, FL 32399-0775
850/488-7546
Florida Hospital Association

Charles F. Pierce, Jr.
President
307 Park Lake Circle
P.O. Box 531107
Orlando, FL 32853-1107
407/841-6230

GEORGIA

Type of Benefit Categorically Needy Medically Needy (MN)* Other
OAA AB APTD AFDC OAA AB APTD AFDC** Children <21 SFO
Prescribed Drugs      
Inpatient Hospital Care      
Outpatient Hospital Care      
Laboratory & X-ray Service      
Skilled Nursing Home Services      
Physician Services      
Dental Services      
1
*Aged, Blind & Disabled (all services) effective April, 1990
**Pregnant Women Only

1998 1999*
TOTAL $370,562,935 805,923

Aged $36,834,592 38,041
Blind/Disabled $177,559,013 151,138
CATEGORICALLY NEEDY NON-CASH TOTAL $41,423,040 330,361

Aged $804,074 1,409
MEDICALLY NEEDY TOTAL $740,135 458

Aged $75,378 57
Children-Families w/Dep. Children $6,968 29

*1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable
.
1-Georgia National Pharmaceutical Council


C. ADMINISTRATION
Department of Community Health, Division of Medicaid
Formulary: Closed formulary.
Benefit Design authorization procedure
Drug Benefit Product Coverage: Products covered: Prescribing or Dispensing Limitations:

prescribed insulin; prescribed disposable needles; and
syringe combinations for insulin. Products covered with Prescription Refill Limit: Maximum of five refills for
restrictions: blood glucose test strips (100 per month); adults, six for children
urine ketone test strips (100 per month); total parenteral
nutrition (21 and younger); and interdialytic parenteral Monthly Quantity Limit: Physicians are encouraged to
nutrition (21 and younger). Products requiring prior prescribe a 31-day supply.
authorization: Marinol; Epoetin; interferons; lactulose;
neupogen; acutretin; top.vit.A derivatives; blood factors; Monthly Dollar Limit: $1000, followed by manual review.
toradol; H2RA full dose > 2months; Regranex; Viagra;
PPIs; Sucralfate full dose after 2 months; brand names and Drug Utilization Review
multi-source; and hemophilia clotting factors. Products
not covered: cosmetics; fertility drugs; experimental On-line PRODUR system implementation planned with a
drugs; prescription vitamins and minerals (except for Sept.1, 2000 start date. State currently has a DUR Board
prenatal and fluorides not in combination with other under development.
vitamins); barbituates (except Seconal); DESI drugs; and
Miralax. Pharmacy Payment and Patient Cost Sharing
Over-the-Counter Product Coverage: Products covered: Dispensing Fee: $4.63, effective 7/1/98.
analgesics (Ibuprofen suspension) covered with restriction
for ages less than 21; cough and cold preparations; PIN- Ingredient Reimbursement Basis: EAC = AWP - 10%.
X; NIX; iron; and meclizine. Products not covered:
digestive products; feminine products; topical products; Prescription Charge Formula: Lower of average
and smoking deterrent products. wholesale price (AWP) minus 10% plus dispensing fee,
MAC plus fee, or usual and customary.
Therapeutic Category Coverage: Therapeutic Categories
Covered: antibiotics; anticoagulants; anticonvulsants; Maximum Allowable Cost: State imposes Federal Upper
antidepressants; antidiabetic agents; antilipemic agents; Limits and State Specific Limits on generic drugs.
antipsychotics; cardiac drugs; chemotherapy agents; Override requires “Brand Medically Necessary.”
contraceptives; ENT anti-inflammatory agents; estrogens; Approximately 55 drugs on the state-specific MAC list.
(andrenergic); and thyroid agents. Prior authorization
required for: anabolic steroids; analgesics, antipyretics,
NSAIDS for single source; anorectics; antihistamine drugs
Patient Cost Sharing: $0.50 per prescription copayment
for non-sedating >21yo; anxiolytics, sedatives, and
(branded or generic).
hypnotics; growth hormones; and immunoglobulins.
Therapeutic categories not covered: prescribed smoking
deterrents.
Coverage of Injectables: Injectable medicines E. USE OF MANAGED CARE

reimbursable through the Prescription Drug Program
when used in home health care, extended care facilities, Does not use MCOs to deliver services to Medicaid
and through physician payment when used in physicians recipients. Program discontinued October 1999.
offices.

service, Children Health Insurance Program, and as part
of the Vaccines for Children Programs.
National Pharmaceutical Council Georgia-2

Catherine E. Burley, M.D., Chairperson

F. STATE CONTACTS 7365 Old National Hwy, Ste A
Riverdale, GA 30296
Etta L. Hawkins, R.Ph. Hal J. Henderson, R.Ph.
Department of Community Health-Medical Division Medical Arts Health Care
2 Peachtree Street, 37th Floor 1483-B Milstead Ave.
Atlanta, GA 30303-3159 Conyers, GA 30012
T: 404/657-7239
F: 404/656-8366 Randall T. Maret, R.Ph.
E-mail: ehawkins@dch.state.ga.us Vice Chairperson
Agency Internet Address: http://www.state.ga.us/dch Maret’s Prescription Shop
222 N. Pentz Street
Department of Community Health Dalton, GA 30720
Russ Toal, Commissioner J. Russell May, Pharm.D.

Department of Community Health Department of Pharmacy
2 Peachtree Street Medical College of Georgia
Atlanta, GA 30303-3159 Hospital and Clinics
404/656-4479 1120 15th Street
Augusta, GA 30912-5600
Herb Weldon, Deputy Commissioner
Bill Connell, Interim Director A. Thomas Taylor, Pharm.D.
Div. of Professional Services Medical College of Georgia
Dona Cole, Director College of Pharmacy
Division of Acute Car Department of Family Medicine
2 Peachtree Street 4799 Hereford Farm Road
Atlanta, GA 30303-3159 Evans, GA 30809
Earl S. Ward, Pharm.D.

Prior Authorization Contact Mercer University School of Pharmacy
Jean Cox, R.Ph. 3001 Mercer University Drive
DUR/PA Coordinator Atlanta, GA 30341
DCH Medicaid
2 Peachtree Street, 37th floor Gary C. Richter, M.D,
Atlanta, GA 30303-3159 Consultative Gastroenterology
T: 404/657-7241 121 Linden Avenue, Suite 103
F: 404/656-8366 Atlanta, GA 30308
E-mail: jcox@dch.state.ga.us
Norman C. Moore, M.D.
Brain Research Center
DUR Contact 655 First Street
Jean Cox, 404/657-7241 Macon, GA 31201
Medicaid DUR Board John Dorland Rowlett, M.D.

John Stephen Antalis, M.D. Children’s Hospital at Memorial Medical Center
Dalton Family Practice, P.C. PO Box 23089
1114 Professional Blvd. Savannah, GA 31403
Dalton, GA 30720
Term: 7/1/97-6/30/99 J.Grady Strom, Jr. Ph.D.
Mercer University School of Pharmacy
Edwin D. Bransome, Jr., M.D. 3001 Mercer University Drive
Department of Medicine Atlanta, GA 30341-4155
Room BIW-542
Medical College of Georgia Harry Strothers, M.D.
Augusta, GA 30912-3185 505 Fairburn Rd. S.W.
Atlanta, GA 30331
3-Georgia National Pharmaceutical Council

Reuben S. Roberts, Jr., M.D.

Medical Assistance Advisory Committees
Pulaski Professional Building
P.O. Drawer 1237 Representatives from each of the following groups:
Hawkinsville, GA 31036 Medical Association of Georgia
Georgia Pharmaceutical Association
Prescription Price Updating Atlanta Medical Association
Georgia Health Care Association
Etta L. Hawkins, 404/657-7239 Georgia Hospital Association
Georgia Dental Association
Georgia Osteopathic Medical Association
National Pharmaceutical Association
Policy: Susan Oh, 404/657-9181
PA: First Health Services, 770/916-9269 Executive Officers of State Medical and
Audits: Susan Oh, 404/657-9181 Pharmaceutical Societies
Medical Association of Georgia
Cheryl Collier Paul Shanor
Account Manager, EDS Executive Director
736 Park North Blvd 938 Peachtree Street, N. E.
P.O. Box 736 Atlanta, GA 30309
Clarkston, GA 30021 404/876-7535
T: 404/297-3700
F: 404/298-1031 Georgia Pharmaceutical Association
Oren “Buddy” Harden
Medicaid Managed Care Contact Executive Vice President
20 Lenox Pointe, P.O. Box 95527
Kathy Driggers Atlanta, GA 30347
Director, Managed Care 404/231-5074
Department of Community Health
2 Peachtree Street, N.W. Osteopathic Medical Association
Atlanta, Georgia 30303 Jerome E. Mersberger, D.O.
T: 404/657-7793 Secretary/Treasurer
F: 404/656-8366 2160 Idlewood Road
E-mail: kdriggers@dch.state.ga.us Tucker, GA 30084
770/493-9278
Disease Management Program/Initiative Contact State Board of Pharmacy
Mark Trail Gregg W. Schuder
Director of Program Policy Executive Director
Department of Community Health- Medicaid 166 Pryor Street, SW
2 Peachtree Street, N.W. Atlanta, GA 30303
Atlanta, Georgia 30303 404/656-3912
T: 404/657-1502
F: 404/656-8366 Medical Georgia Association
E-mail: mtrail@dch.state.ga.us Katherine Daniels
Executive Director
Morehouse School of Medicine
Physician-Administered Drug Program Contact 720 Westview Drive, S.W.
Shirley Benson Atlanta, GA 30310-1495
2 Peachtree Street, N.E. 404/752-1564
Atlanta, Georgia 30303
404/656-3961 Georgia Hospital Association
Joseph A. Parker
President
1675 Terrell Mill Road
Marietta, GA 30067
770/955-5801
National Pharmaceutical Council Georgia-4

HAWAII

1

1998* 1999*
TOTAL $39,623,380 32,222

Aged
Blind
Disabled

Aged
Blind
Disabled

Aged
Blind
Disabled
Source: HHS Report HCFA-2082.

‡This group accounts for the Aged, Blind and Disabled population only. 130,000 recipients are in managed care. Expenditures
for prescribed drugs total $250,000,000 and are included in the capitation rate.
1-Hawaii National Pharmaceutical Council

By the State Department of Human Services through its Quantity of Medication: Physicians are encouraged to
Med-Quest Division and four county branch offices. prescribe a 30-day supply or 100 units.
D. PROVISIONS RELATING TO DRUGS Drug Utilization Review
Benefit Design PRODUR system implemented in September 1997. State

currently has a DUR board with a quarterly review.
prescribed insulin; disposable needles and syringe Pharmacy Payment and Patient Cost Sharing
combinations for insulin; blood glucose test strips; urine
ketone test strips; total parenteral nutrition; and Dispensing Fee: $4.67, effective May 9, 1990.
interdialytic parenteral nutrition. Products requiring prior
authorization: Clorazil; Procardia XL; Norvasc; brand Ingredient Reimbursement Basis: EAC = AWP - 10.5%.
products on FUL price list; and Betaseron. Products not
covered: cosmetics; fertility drugs; and experimental Prescription Charge Formula: Payment for prescription
drugs. and OTC drugs listed in the formulary is limited to the
federally established MAC price, or Estimated
Over-the-Counter Product Coverage: Products covered: Acquisition Cost (EAC) plus dispensing fee, or billed
some allergy, asthma and sinus products; some analgesics; amount, whichever is lowest.
some cough and cold preparations; digestive products;
some feminine products; and some topical products. Maximum Allowable Cost: State imposes Federal Upper
Products covered with restrictions: some non-H2 Limits on generic drugs. Override requires “Brand
antagonist digestive products and H2 antagonist digestive Medically Necessary” and “Dispense As Written” as well
products (requires diagnosis of H. Pylori, GERD, etc.). as prior authorization approval. Exclusions: anti-seizure
Products not covered: smoking deterrent products. medication and oral contraceptives.
Therapeutic Category Coverage: Prior authorization Incentive Fee: None.

required for: anabolic steroids; anorectics; antihistamine
drugs; anti-psychotics; anxiolytics, sedatives, and Patient Cost Sharing: No copayment.
hypnotics; estrogens; misc. GI drugs; prescribed smoking
deterrents; proton pump inhibitors; single source NSAIDs; Cognitive Services: Does not pay for cognitive services.
chemotherapy agents; and growth hormones.
Coverage of Injectables: Injectable medicines
reimbursable through the prescription drug program when Approximately 140,000 total unduplicated number of
used in home health care, extended care facilities, and Medicaid recipients were enrolled in MCOs in FY 1999.
through physician payment when used in physicians Recipients receive pharmaceutical benefits through
offices. state/managed care plans or both.
Vaccines: Vaccines reimbursable as part of EPSDT Managed Care Organizations

service if not covered by the Vaccines for Children
DentiCare
Program.
Wesley K.S. Mun
900 Fort Street Mall, Suite 930
Unit Dose: Unit dose packaging reimbursable
Honolulu, HI 96813
808/528-4904
Hawaii Medical Service Association (HMSA)
Ms. Carolyn J. Gire, Director
QUEST Administration
818 Keeaumoku Street
authorization procedure. A fair hearing may be requested
Honolulu, HI 96808
for appeal of prior authorization decisions.
808/948-6588
National Pharmaceutical Council Hawaii-2

Queen’s Hawaii Care DUR Contact

Mr. Richard M. Jackson, General Manager
Kathleen Kang-Kaulupali, 808/692-8115
Two Waterfront Plaza
500 Ala Moana Boulevard
Honolulu, HI 96813 Medicaid DUR Board
808/522-7522
Myron Shirasu, M.D. (Internal Medicine)
321 North Kuakini Street #200
Straub Clinic and Hospital, Inc.
Honolulu, HI 96817
Deborah Stampfle, Executive Director
808/523-8611
641 Kailua Road
Kailua, HI 96734 Tube 63
Gregory E.M. Yuen, M.D. (Psychiatry)
808/266-6554
Chair
1154 Fort Street Mall, Suite 200
AlohaCare, Inc.
Honolulu, HI 96813
Mr. John McComas
808/599-5050
1357 Kapiolani Blvd., Suite 1250
Honolulu, HI 96814
Linda Tom MD (Geriatric Medicine)
808/973-1650
347 N. Kuakini Street, HPM-9
Honolulu, HI 96817
Kaiser Foundation Health Plan, Inc.
808/523-8461
Ms. Virginia Vierra
1441 Kapliolani Blvd, Suite 1600
James Lumeng, M.D. (Medicine/Pathology)
Honolulu, HI 96814
850 West Hind Drive, #114
808/944-0261
Honolulu, HI 96821
808/377-5485
Kapliolani Health Hawaii
Plan Administrator: Greg Oishi
Brian Matsuura (Medical Services Rep.)
55 Merchant Street, 27th Floor
864 Kealahou St.
Honolulu, HI 96813-4306
Honolulu, HI 96825
808/535-7425
808/396-3974
Behavioral Health Services
Joy Higa, R.Ph. (Long Term Care)
Community Care Services (CCS)
47-135 Heno Place
Sharon Yoshiura or Carolyn Gire
Kaneohe, HI 96744
810 N. Vineyard Blvd.
808/239-6353
Honolulu, HI 96817
T: 808/ 948-5379
Karen Huang, R.Ph. (Ambulatory Care)
F: 808/948-6588
1010 Pensacola Street
Honolulu, HI 96814
F. STATE CONTACTS F: 808/597-2549
Pager: 808/363-0838
Medicaid Drug Program Administrator
Kerry Kitsu, R.Ph. (Community, chain)
Lynn Donovan, R.Ph. 98-629 Nohoalii Street
Medicaid Pharmacy Consultant Aiea, HI 96701
Med-Quest Division T: 808/536-5542
P.O. Box 339 F: 808/536-0659
T: 808/692-8116 Carl Mudrick, R.Ph. (Community, independent)
F: 808/692-8131 2011 Coyne Street
Honolulu. HI 96826
Prior Authorization Contact T: 808/739-1188
F: 808/735-6545
Lynn S. Donovan
808/692-8116
3-Hawaii National Pharmaceutical Council


Ruth Gushiken
First Data Bank Executive Secretary
111 Bayhill Dr. P. O. Box 3469
San Bruno, CA 94066 Honolulu, HI 96801
800/633-3453 808/586-2698
Healthcare Association of Hawaii

Richard E. Meiers
Technical: Lynn Donovan, 808/692-8116 Pres., CEO
Policy: Lynn Donovan, 808/692-8116 932 Ward Avenue
Audits: Lynn Donovan, 808/692-8116 Suite 430
DUR: Kathleen Kang-Kaulupali, 808/692-8115 Honolulu, HI 96814-2126
808/521-8961
HMSA - Medicaid Claims Service
Attn: Luukia Abbley
P.O. Box 860
Honolulu, HI 96808
808/948-5361

Susan M. Chandler, Director
808/586-4997
Chuck Duarte
Administrator, Med-Quest Division

Hawaii Medical Association
Stephanie Averio, Executive Director
1360 S. Beretania Street, Suite 100
Honolulu, HI 96814
808/536-7702
Hawaii Pharmaceutical Association

Todd Inafuku, R.Ph.
Executive Director
P. O. Box 1198
Honolulu, HI 96807
808/941-8321
Association of Osteopathic Physicians and Surgeons

Alan R. Becker, D.O.
Secretary/Treasurer
122 Oneawa Street
Kailua, HI 96734
808/261-6105
National Pharmaceutical Council Hawaii-4

IDAHO

Dental Services 
1

1998 1999*
TOTAL $54,971,097 86,775

Aged $2,228,943 1,434
Blind / Disabled $12,543,258 6,397
AFDC-Child $254,663 2,098
AFDC-Adult $669,332 1,231
AFDC-Unemployed-Child $501 10
AFDC-Unemployed-Adult $2,529 24
MEDICALLY NEEDY, TOTAL $0 0

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

Aged $14,394,179 8,038
Blind / Disabled $12,703,668 8,035
AFDC-Child $857,649 6,575
AFDC-Adult $1,714,000 3,571
OTHER $5,318,605 37,215

1-Idaho National Pharmaceutical Council


authorization procedure and a Growth hormone prior
Idaho Medicaid Agency authorization committee. Written “notice of appeal”
required for fair hearing.
By the State Department of Health and Welfare through
seven regional offices, each serves five or more of the Prescribing or Dispensing Limitations
State’s 44 counties.
Monthly Quantity Limit: Prescription drugs are limited to
D. PROVISIONS RELATING TO DRUGS a 34-day supply. The following drugs are limited to a 100-
day supply: Digoxin, thyroids, prenatal vitamins,
Benefit Design nitroglycerin, fluoride, fluoride and vitamin combinations,
non-legend oral iron salts and 3 cycles of birth control.
prescribed insulin; disposable needles and syringe Drug Utilization Review
ketone test strips; total parenteral nutrition; and Contracted DUR through Idaho State University.
interdialytic parenteral nutrition. Products not covered: PRODUR system implemented January 1998. State
cosmetics; fertility drugs; and experimental drugs. currently has a DUR board with a quarterly review.
OTC Coverage: Products covered: prescribed insulin; Pharmacy Payment and Patient Cost Sharing
disposable needles and syringe combinations used for
insulin; permethrin; and oral iron salts. Products not Dispensing Fee: $4.94 ($5.54 for unit dose), effective
covered: allergy, asthma, and sinus; analgesics, cough and March 1999.
cold preparations; digestive products; feminine products;
topical products; and smoking deterrent products. Ingredient Reimbursement Basis: EAC = AWP-11% as
determined by First DataBank Data File Service or
Therapeutic Category Coverage: Therapeutic Categories manufacturer direct price for selected manufacturers.
covered: anabolic steroids; analgesics, antipyretics,
NSAIDs; antibiotics; anticoagulants; anticonvulsants; Prescription Charge Formula: Lower of FUL, SMAC or
antidepressants; antidiabetic agents; antihistamine drugs; EAC plus a dispensing fee or provider’s usual and
antilipemic agents; anti-psychotics; anxiolytics, sedatives, customary price to the general public.
prescribed cold medications; contraceptives; ENT anti- Maximum Allowable Cost: State imposes Federal Upper
inflammatory agents; estrogens; hypotensive agents; misc. Limits and state-specific limits on generic drugs. Override
GI drugs; sympathominetics (adrenergic); and thyroid requires prior authorization.
agents. Prior authorization required for: growth
hormones. Therapeutic categories not covered: anorectics Incentive Fee: None.
and prescribed smoking deterrents.
Patient Cost Sharing: No copayment.
reimbursable through the Prescription Drug Program Cognitive Services: Does not pay for cognitive services.
when used in home health care, extended care facilities,
offices.
Vaccines: Vaccines reimbursable as part of the Children
Health Insurance Program, and the Vaccines for Children Does not use MCOs to deliver services to Medicaid
Program. recipients. Some Medicaid recipients are enrolled in
primary care case management and receive their benefits
Unit Dose: Unit dose packaging reimbursable when used from the state.
in unit dose systems.
Formulary Authorization
National Pharmaceutical Council Idaho-2

F. STATE CONTACTS Medicaid Managed Care Contact

Pam Mason
Medicaid Drug Program Administrator Primary Physician Managed Care Program
Gary Duerr, R.Ph. Healthy Connections Manager
Medicaid Policy P.O. Box 83720
Americana Terrace, Suite 140 Boise, ID 83720
P.O. Box 83720 T: 208/364-1890
Boise, ID 83720-0036 F: 208/364-1846
T: 208/364-1829 E-mail: masonpa@mmig.state.id.us
F: 208/364-1846
E-mail: duerrgp@mmis.state.id.us Physician-Administered Drug Program Contact
Robbie Charlton
Prior Authorization Contact Medicaid Policy
PO Box 83720
Gary Duerr, 208/364-1829 Boise, ID 83720-0036
DUR Contact
Health and Welfare Department Officials
Gary Duerr, 208/364-1829 Karl Kurtz, Director
Dept of Health & Welfare, Medicaid Division
Medicaid DUR Board Towers Building, 10th Floor
Board Members: PO Box 83720
Bill Johns, R.Ph. Boise, Idaho 83720-0036
Don Smith, R.Ph. 208/334-5500
Kent Jensen, R.Ph.
Barbara Wells, R.Ph. Bureau of Medicaid Policy and Reimbursement
John Lassere, M.D. Dee Anne Moore, Bureau Chief
E. Gregory Thompson, M.D. Joe Brunson, Medicaid Administration
Robert Ting, M.D. Gary Duerr, R.Ph., Pharmacy Services Specialist
Clayton Morgan, M.D., retired Tom Young, M.D., Medical Consultant
Staff: Title XIX Medical Care Advisory Committee

Gary Duerr, R.Ph., Dept. Contact
Vaughn Culbertson, Pharm.D. Project Dir. Bob Beutler
1217 Kirk Drive
Moscow, ID 83943
Prescription Price Updating 208/882-5536
First Data Bank
Rep. Max C. Black
3731 Buckingham Drive
Medicaid Drug Rebate Contacts Boise, ID 83704
Technical: Gary Duerr, R.Ph. 208/364-1829 208/327-3400
Policy: Gary Duerr, 208/364-1829
DUR: Gary Duerr, 208/ 364-1829 Marj Boren
PA: Gary Duerr, 208/ 364-1829 1002 E. Bannock
Audits: David Mendoza, 208/ 364-1838 Boise, ID 83712
208/342-4368
Claims Submission Contact Sen. Hal Bunderson

EDS 582 River Heights Drive
P.O. Box 1168 Meridian, ID 83642
Boise, ID 83701 208/888-7156
208/395-2000
3-Idaho National Pharmaceutical Council

Loni Debbon, President JoAn Silva, Director

Idaho Head Start Association Region III Health & Welfare
200 N. 4th 111 Poplar, PO Box 1219
Boise, ID 83702 Caldwell, ID 83606
208/345-1182 208/459-7456
Bonnie Haines, Senior Vice President Acting Executive Director

Idaho Hospital Association Idaho State Council on Developmental Disabilities
PO Box 1278 280 N. 8th, Suite 208 Statehouse
Boise, ID 83701-1278 Boise, ID 83720
208/338-5100 208/334-2178
Steven Hanson Scott Spears

Human Service Connection Idaho Health Care Association
1380 Benton PO Box 2623
Idaho Falls, ID 83401 Boise, ID 83701
208/523-2490 208/343-9735
Cathy Hart
Idaho Office on Aging
Statehouse, Room 108
Boise, ID 83720-0007 Idaho Medical Association
208/334-3833 Robert Seehusen
Executive Director
Sally Higginson 305 West Jefferson, P.O. Box 2668
Boise Alliance for the Mentally Ill Boise, ID 83702
331 N. Allumbaugh 208/344-7888
Boise, ID 83704
208/376-4304 Idaho State Pharmaceutical Association
Jo An Condie
Shirley Osborn Executive Director
5553 W. Lockport 305 W. Jefferson, P.O. Box 140117
Boise, ID 83703 Boise, ID 83714
208/334-3110 208/424-1107
Jim Peart Idaho Osteopathic Medical Association

Idaho Legal Aid, Caldwell Area Office Ron Higgenbotham, D.O.
708 Main Street, PO Box 1116 Secretary-Treasurer
Caldwell, ID 83606-1116 522 West Main Street
208/345-2193 Grangeville, ID 83530
208/983-1133
Cathleen Pierson
3368 N. 34th Street State Board of Pharmacy
Boise, ID 83703 Richard K. Markuson
208/385-7305 Executive Director
3380 Americana Terrace #320
Rex Redden, President Boise, ID 83706
IACOR 208/334-2356
PO Box 50457
Idaho Falls, ID 83405 Idaho Hospital Association
208/523-0053 Steven A. Millard
President
Bob Seehusen, Executive Director 802 West Bannock St.
Idaho Medical Association Suite 500
305 W. Jefferson Boise, ID 83702-5842
Boise, ID 83702 208/338-5100
208/344-7888
National Pharmaceutical Council Idaho-4

ILLINOIS

1

1998* 1999*
TOTAL $583,239,675 959,472

Aged
Blind
Disabled

Aged
Blind
Disabled

Aged
Blind
Disabled

1-Illinois National Pharmaceutical Council

C. ADMINISTRATION Drug Utilization Review
Illinois Department of Public Aid, Division of Medical PRODUR system implemented in January 1993. State
Assistance. currently has a DUR board with a review on an as needed
basis.
Benefit Design
Dispensing Fee: $3.75/$3.45 for generic/branded drugs
Drug Benefit Product Coverage: Products covered: costing up to $37.50; 10.46% of the drug cost for drugs
prescribed insulin; disposable needles and syringe costing $37.51 and more; maximum of $15.70/$15.40 for
combinations used for insulin; blood glucose test strips; generic/branded drugs. Effective 7/1/99.
and urine ketone test strips. Products not covered:
cosmetics; DESI-ineffectives; fertility drugs; experimental Ingredient Reimbursement Basis: EAC = AWP - 10%,
drugs; total parenteral nutrition; and interdialytic AWP - 12% for multisource drugs.
parenteral nutrition.
Prescription Charge Formula: Lowest of 1) usual and
OTC Coverage: Products covered: digestive products (H2 customary, 2) Department's MAC plus fee. Professional
antagonists) and smoking deterrent products. Products fee: $3.58 up to EAC of $35.80; above EAC of $35.80,
requiring prior authorization: analgesics; digestive fee is 10% of EAC.
products (non-H2 antagonist); and topical products.
Products not covered: allergy, asthma, and sinus; cough Maximum Allowable Cost: State imposes Federal Upper
and cold preparations; and feminine products. Limits as well as state-specific limits on generic drugs.
All drugs are interchangeable in Illinois but not for those
Coverage of Injectables: Injectable medicines with a Federal MAC. Other drugs appear on the Illinois
reimbursable through the Prescription Drug Program MAC list where the Federal MAC was inappropriate.
when used in physician offices, home health care, and Override requires prior authorization.
extended care facilities.
Vaccines: Vaccines are reimbursable as part of a special
program. Patient Cost Sharing: No copayment.
Unit Dose: Unit dose packaging not reimbursable. Cognitive Services: Does not pay for cognitive services.
Formulary/Prior Authorization E. USE OF MANAGED CARE
Formulary: Closed formulary. Approximately 158,000 Medicaid recipients were

voluntarily enrolled in MCOs in 1999. Recipients receive
Prior Authorization: State currently has a formal prior pharmaceutical benefits through managed care plans.
authorization procedure and a Committee on Drugs and
Therapeutics. Recipient must file an appeal with their Managed Care Organizations
local office in order to appeal prior authorization Americaid Community Care
decisions. To appeal the coverage of an excluded product, 211 Wacker Drive
the recipient can request the opportunity to appear before Suite 1350
the Committee on Drugs and Therapeutics. Chicago, IL 60606-3101
Prescribing or Dispensing Limitations United Health Care of IL
233 N. Michigan Ave. 8th Fl-12th Fl.
Prescription Refill Limit: Maximum of eleven refills. Chicago, IL 60601
Monthly Quantity Limit: As medically appropriate. Harmony Health Plan of Illinois
125 South Wacker Drive
Suite 2900
Chicago, IL 60606-4402
National Pharmaceutical Council Illinois-2

Humana Health Plan

30 South Wacker Drive
Suite 3100 Technical: Marvin Hazelwood, 217/524-7112
Chicago, IL 60606 Policy: Marvin Hazelwood, 217/524-7112
Audits: Alberta Levan, 217/782-5565
Illinois Masonic Community Health Plan Dispute Resolutions: Alberta Levan, 217/524-7161
836 West Wellington
Chicago, IL 60657-5147 Medicaid Managed Care Contact
Family Health Network Nelly Ryan

910 West Van Buren Bureau Chief
6th Floor Illinois Department of Public Aid
Chicago, IL 60607-3523 201 S. Grand Avenue East
Springfield, Illinois 62763
Neighborly Care Plan T: 217/524-7478
129 N. Eighth Street F: 217/524-7535
East St. Louis, IL 62201-2999
Elderly Expanded Drug Coverage Program
F. STATE CONTACTS Cheryl Payne
Supervisor, Circuit Breaker Program
State Drug Program Administrator Illinois Department of Revenue
Marvin L. Hazelwood 101 W. Jefferson - Level 3- 250
Illinois Department of Public Aid Springfield, Illinois 62794
Division of Medical Assistance 217/785-2097
1001 N. Walnut St.
Springfield, IL 62702
T: 217/524-7112
F: 217/524-7194 Cheryl Bechner
E-mail: aidd2958@mail.idpa.state.il.us 217/782-5565
Agency E-mail Address: http://www.state.il.us/dpa/
Illinois Medicaid Agency Officials
Prior Authorization Contact Ann Patla, DR.HL
Rick Mazzotti, R.Ph. Illinois Department of Public Aid
217/787-6252 Division of Medical Assistance
201 South Grand Avenue, East
Springfield, IL 62763-0001
DUR Contact 217/782-1200
Starlin Hayden Greatting, R.Ph.
Pharmacy Consultant, DUR coordinator Mary Ann Langston, Administrator
Illinois Department of Public Aid Division of Policy
1001 N. Walnut St.
Springfield, Illinois 62702 Norman L. Ryan, Administrator
T: 217/524-7112 Division of General Services
F: 217/524-7194
Kenneth J. Durst, Chief
Bureau of Research & Analysis
First Data Bank Matt Powers, Administrator
111 Bayhill Dr. Division of Medical Programs
San Bruno, CA 94066
Steve Bradley, Chief
Bureau of Comprehensive Health Services

Patty Steward, R.Ph., Pharmacist Consultant Joan E. Cummings, M.D.

Department of Public Aid Extended Care
P.O. Box 19117 181 Hines VA Hospital
Springfield, IL 62794-9117 Building 1, Room C-124D
217/782-5565 Hines, IL 60141
708/343-7200 ext. 5057
Title XIX Medical Care Advisory Committees
David B. Littman, M.D.
State Medical Advisory Committee 1030 Old Elm Road
Arthur Traugott, M.D. Highland Park, IL 60035
32207 Weisiger Way 708/433-3900
Urbana, IL 61801
Richard P. Snodgrass, M.D.
Committee on Drugs and Therapeutics 550 30th Avenue
Marshall Blankenship, M.D., Chairman Moline, IL 61265
1555 Astor Avenue 309/764-1910
Chicago, IL 60610
708/636-3757 IDPA Representative
Marvin Hazelwood
Nicholas C. Bellios, M.D. Illinois Department of Public Aid
2504 Washington 1001 N. Walnut St.
Waukegan, IL 60085 Springfield, IL 62702
708/249-3660 217/524-7112
Armand Littman, M.D. Illinois State Medical Society

Medical Services Kenneth E. Ryan
Hines VA Hospital Director, Department of Economics
Hines, IL 60141 20 N. Michigan Avenue, Suite 700
708/216-2006 Chicago, IL 60602
312/782-1654
Vincent A. Costanzo, Jr., M.D.
7501 South Stony Island Avenue IDPH Representative:
Chicago, IL 60649 Ron Gottrich, R.Ph
312/995-1075 Illinois Department of Public Health
525 W. Jefferson
Theodore M. Kanellakes, M.D. Springfield, IL 62761
229 N. Hammes Avenue 217/782-7532
Joliet, IL 60435
815/744-2300
Patrick R. Staunton, M.D.
156 N. Oak Park Avenue Illinois State Medical Society
Oak Park, IL 60301 Alexander R. Lerner
708/696-5887 Executive Vice President
20 N. Michigan Avenue, Suite 700
Board of Trustees Chicago, IL 60602
Phillip D. Boren, M.D. 312/782-1654
Doctor's Clinic
S. Plum Street Illinois Pharmacists Association
Carmi, IL 62821 Mark Pilkington, R.Ph.
223 W. Jackson, Suite 1000
T: 312/939-7300
F: 312/939-7220
National Pharmaceutical Council Illinois-4

Illinois Assoc. of Osteopathic Physicians &

Surgeons, Inc.
Terrill K. Haws, D.O.
Second Vice President
P.O. Box 2273
1015 La Salle
Ottawa, IL 61350
815/434-5576

John Rosa
Pharmacy Coordinator
Illinois Department of Professional Regulation
Pharmacy Section
320 West Washington Street, 3rd Floor
217/782-8556
Illinois Hospital and Health Systems Association

Kenneth C. Robbins
President
Center for Health Affairs
1151 East Warrenville Road
P.O. Box 3015
Naperville, IL 60566-7015
630/505-7777

INDIANA

1

1998* 1999*
TOTAL $325,712,348 323,811

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult
AFDC-Unemployed-Child
AFDC-Unemployed-Adult

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult
OTHER

National Pharmaceutical Council Indiana-1

C. ADMINISTRATION Legend Drug Reimbursement Methodology:
Office of Medicaid Policy and Planning Lower/Lowest of:

1. Federal MAC, if applicable, plus a dispensing fee.
D. PROVISIONS RELATING TO DRUGS 2. EAC plus a dispensing fee.
3. Pharmacy’s usual and customary charge to the
Benefit Design general public.
Drug Benefit Product Coverage: Products covered: Maximum Allowable Cost: State imposes Federal Upper
prescribed insulin; disposable needles and syringe Limits. Override requires “Brand Medically Necessary.”
urine ketone test strips; total parenteral nutrition; and Incentive Fee: None.
interdialytic parenteral nutrition. Products not covered:
cosmetics; fertility drugs; and experimental drugs. Patient Cost Sharing: Copayment varies from $0.50 to
$3.00 for branded drugs and is $0.50 for generic drugs.
Over-the-Counter Product Coverage: Products covered if
prescribed by a physician: Indiana has a Medicaid OTC Cognitive Services: None.
drug formulary. Listed drugs are reimbursed based on
State MAC. E. USE OF MANAGED CARE
Therapeutic Category Coverage: All coverage in Approximately 330,000 total unduplicated number of
accordance with OBRA ’90 & ’93. Medicaid recipients were enrolled in MCOs in FY 2000.
Recipients receive pharmaceutical benefits through
Coverage of Injectables: Covered. managed care plans.
Vaccines: Vaccines reimbursable as part of the EPSDT F. STATE CONTACTS

service, the Children Health Insurance Program, and the
Vaccines for Children Program. State Drug Program Administrator
Marc Shirley, R.Ph.
Unit Dose: In accordance with OBRA 1990
Pharmacy Program Director
Requirements. MCFA policy only.
Office of Medicaid Policy and Planning
Room W382
Indiana State Government Center South
402 W. Washington Street
Formulary: No formulary for legend drugs. All coverage
in accordance with OBRA ’90 & ’93. No PA for drugs.
T: 317/232-4343
F: 317/232-7382
Prior Authorization: State currently does not have a
E-mail: mshirley@fssa.state.in.us
formal prior authorization procedure.
*DO NOT CONTACT STATE DRUG PROGRAM
Prescribing or Dispensing Limitations ADMINISTRATOR WITH SURVEYS. DIRECT ALL
INDUSTRY/INDUCTRY CONTRACTOR
Prescribing Refill Limit: None. INQUIRIES IN WRITING TO:
Drug Utilization Review EDS
950 N. Meridian St, 10th Floor
PRODUR system implemented in March 1996. State Indianapolis, IN 46704
NO PHONE SURVEYS WILL BE ACCEPTED
Dispensing Fee: $4.00, effective November 1989.
Ingredient Reimbursement Basis: EAC = AWP - 10%.
2-Indiana National Pharmaceutical Council

DUR Contact Medicaid Managed Care Contact

Karen Baer Sharon Steadman
DUR Board Secretary Managed Care Director
Office of Medicaid Policy & Planning Office of Medicaid Policy and Planning
Room W-382, Indiana Sate Government Center South, 402 W. Washington St
402 West Washington St. Room W382, MS07
Indianapolis, IN 46204 Indianapolis, IN 46204
T: 317/232-4391 T: 317/233-4697
F: 317/232-7382 F: 317/232-7382
E-mail: kbaer@fssa.state.in.us
Medicaid DUR Board
EDS
Physicians
950 N. Meridian Street, 10th Floor
Thomas Bright, M.D.
Indianapolis, IN 46204
Neil Irick, M.D.
Patricia Treadwell, M.D.
Administration Officials
John J. Wienert, M.D.
Kathleen D. Gifford
Pharmacists Assistant Secretary
Paula Ceh, R.Ph. Medicaid Policy & Planning
Hamid Abbaspour, R.Ph. Indiana Family & Social Services Administration
Thomas A. Smith, R.Ph. 402 W. Washington Street, Room W382
G. Thomas Wilson, R.Ph. Indianapolis, IN 46204
317/233-4455
Health Care Economist
(Vacant) Sharon Steadman
Managed Care Director
Pharmacologist 317/233-4697
Terry Lindstrom, Ph.D.
Pat Nolting, Director
Representative from Med Care Medicaid Program Operations
Kirby Davis, R.Ph. 317/232-4318
Prescription Pricing Updating Medicaid Advisory Committee

John B. DeLap
First Data Bank
2365 Chestnut Street
Columbus, IN 47201
Marcia Finn Deborah A. Freund
Myers and Stauffer/EDS 1327 East First Street
317/488-5000 Bloomington, IN 47402
Eleanor DeArman Kinney

5140 Reed Road
EDS Indianapolis, IN 46254
950 N. Meridian Street, 10th Floor
Indianapolis, IN 46204 Kayla Templin West
1014 N. Arsenal Avenue
Edward A. White, D.O.

410 North Main Street
Princeton, IN 47670-1516

Beverly Richards, D.N.S., R.N. Vickie Trout

Indiana St. Nurses Association Division of Mental Health
2915 North High School Road 402 W. Washington - W 353
Indianapolis, IN 46224-2969 Indianapolis, IN 46204
David Giles, M.D. David Harris

6934 Hillsdale Court 125 East 48th Street
L. Richard Gohman Donald Mulligan, Sr.

One American Sq. - Ste 1100 6185 Broughton
Indianapolis, IN 46204 Portage, IN 46368
Polly E. Hendricks, O.D. Barry Delks

3222 Oceanline E. Drive 21 Peregrine Court
Indianapolis, IN 46214 West Lafayette, IN 47906
James F. Jones, M.S. Lula E. Baxter

101 W. Ohio Street - Ste 610 9710 East 38th Street
Mike Weber R. Stanley Wilson, M.D.

Indiana Health Care Association 3 Hazelwood Drive
One N. Capital, Ste 1115 Vinciennes, IN 47591
Paul Schneider, Ph.D.
Anna Schenk, Pres., ILPNA 6320 Latona Court
1501 W. 500 North Indianapolis, IN 46278
Marion, IN 47952
Robert S. Mandresh, D.P.M.
Paul C. Johnson, D.D.S. 3351 N. Meridian #101
8240 Naab Road Indianapolis, IN 46208
Chip Garver
Robin Taylor, R.Ph., President 101 West Ohio, Suite 560
Healthcare Prescription Svs, Inc. Indianapolis, IN 46204
3830 E. Southport Road, Ste C
Indianapolis, IN 46237 Michael Sullivan
Ind. Assn. For Home Care, Inc.
Greg Wilson, M.D. 8888 Keystone Crossing
Developmental Pediatrics Suite 1000
702 Barnhill Dr., Room 1601 Indianapolis, IN 46202
Louis Cantor, M.D.
Sen. Marvin Riegsecker 702 Rotary Circle
801 S. 6th Street Indianapolis, IN 46202
Goshen, IN 46526
Joe D. Hunt, Director
Rep. William Crawford Bureau of Policy Development
PO Box 18446 State Department of Health
Indianapolis, IN 46218-0446 1330 W. Michigan Street
Rep. Jeffrey K. Espich
1250 W. Hancock Street, Box 158
Uniondale, IN 46791
4-Indiana National Pharmaceutical Council


Indiana State Medical Association
Richard R. King
Executive Director
322 Canal Walk, Canal Level
317/261-2060
Indiana Pharmacists Association

Larry Sage
156 E. Market Street, #900
317/634-4968
Indiana Association of Osteopathic Physicians and

Surgeons, Inc.
Michael Claphan
Executive Director
3520 Guion Road, #202
317/926-3009

Kristen Burch
Director
Indiana Health Professions Bureau

402 West Washington Street, Room 041
317/232-1140
Indiana Hospital and Health Association

Kenneth G. Stella
President
One American Square
P.O. Box 82063

IOWA

OAA AB APTD AFDC OAA AB APTD AFDC* Children <21 SFO
1
*Pregnant women

1998 1999*
TOTAL $147,115,884 215,173
RECEIVING CASH ASSISTANCE TOTAL $82,025,517 99,753

Aged $11,582,919 8,054
Blind / Disabled $57,606,338 33,570
AFDC-Child $5,286,110 32,489
AFDC-Adult $6,159,274 18,297
AFDC-Unemployed-Child $492,801 3,817
AFDC-Unemployed-Adult $898,075 3,526

Aged $4,661,291 3,388
Blind / Disabled $5,986,116 2,540
AFDC-Child $197,038 742
AFDC-Adult $755,741 1,784

Aged $1,201,194 1,478
Blind / Disabled $1,355,437 1,060
AFDC-Child $2,707,203 24,765
AFDC-Adult $790,935 7,389
OTHER $46,573,607 67,074

1-Iowa National Pharmaceutical Council

− Permethrin Liquid 1%
C. ADMINISTRATION
− Pseudoephedrine Hydrochloride: 30/60 mg Tablets;
30mg/5mg Liquid
State Department of Human Services, Division of Medical
− Salicylic Acid Liquid 17%
Services.
− Senokot: 326 mg/tsp Granules for children aged 20
and under; 187 mg Tablets for children aged 20 and
D. PROVISIONS RELATING TO DRUGS under
− Sodium Chloride Solution 0.9% for inhalation, with
Benefit Design metered dispensing valve 90 ml, 240 ml
− Tolnaftate 1% Cream, Solution, Powder
− Nonprescription multiple vitamin and mineral
prescribed insulin. Products covered requiring prior
products specifically formulated and recommended for
authorization: PPIs; dipyridamole; epoetin; filgrastim;
use as a dietary supplement during pregnancy and
vitamins; ergotamine derivatives; narcotic agonist-
lactation
antagonist nasal sprays; isotretinoin; oral antifungals; non-
− With prior authorization, nonprescription multiple
parenteral vasopressin derivatives; and Serotonin 5-HT1
vitamins and minerals under the conditions specified
receptor agonists. Products not covered: fertility drugs;
in subparagraph 78.1(2) “a” (3)
experimental drugs; cosmetics; disposable needles and
syringe combinations for insulin; blood glucose test strips; − Insulin
urine ketone test strips; total parenteral nutrition; and − Oral solid forms of the above-covered items shall be
interdialytic parenteral nutrition. prescribed and dispensed in a minimum quantity of
100 units per prescription or the currently available
Over-the-Counter Product Coverage: Products covered consumer package size except when dispensed via a
with restriction (selected products): allergy, asthma and unit dose system. When used for maintenance therapy,
sinus products; analgesics; cough and cold preparations; all of the above-listed items may be prescribed and
H2 antagonists; and topical products. Products not dispensed in 90-day quantities
covered: digestive products; feminine products; and
smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories
covered: anabolic steroids; antibiotics; anticoagulants;
The Iowa Department of Human Services adopted an anticonvulsants; antidepressants; antidiabetic agents;
administrative rule that permits coverage for these non- antilipemic agents; anti-psychotics; anxiolytics, sedatives,
prescription drugs: and hypnotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives; ENT anti-
− Aspirin: 325/650 mg Tabs; 81mg Chewable; Aspirin
inflammatory agents; estrogens; hypotensive agents;
Enteric Coated: 325/650mg Tabs; 81mg Chewable;
Aspirin Tablets Buffered, 325 mg
authorization required for: analgesics, antipyretics,
− Acetaminophen: 325/500mg Tablets; 120mg/5ml and
NSAIDs; amphetamines; antihistamine drugs; growth
160mg/5mL Elixir; 100 mg/ml Solution; 120mg
hormones; and misc. GI drugs. Therapeutic categories not
Suppositories
covered: anorectics and prescribed smoking deterrents.
− Bacitracin Ointment 500 units/gm
− Benzoyl Peroxide 5% and 10%, Cleanser, Lotion,
Cream, Gel
− Chlorpheniramine Maleate Tablets 4 mg when used in home health care, extended care facilities,
− Diphenhydramine Hydrochloride: 25 mg Capsules; and through physician payment when used in physicians
6.25mg/5mL and 12.5mg/5ml Liquid offices.
− Ferrous Sulfate: 300/325mg Tablets; 220mg/5ml
Elixir; 75 mg/0.6 ml Drops Vaccines: Vaccines reimbursable as part of the EPSDT
− Ferrous Gluconate: 300/325mg Tablets; 300mg/5ml service and the Vaccines for Children Program.
Elixir
− Ferrous Fumarate Tablets 300 mg, 325 mg Unit Dose: Unit dose packaging reimbursable.
− Guafenesin 100 mg/5 ml with Dextromethorphan 10
mg/5 ml liquid
− Meclizine Hydrochloride Tablets 15.5 mg, 25 mg
− Miconazole Nitrate: Topical and Vaginal Cream 2%,
Vaginal Suppositories, 100mg
− Nicotinic Acid (Niacin) Tablets: 25/50/100/250/500
mg
− Pediatric Oral Electrolyte Solutions
National Pharmaceutical Council Iowa-2

John Deere Healthplan

Cynthia Greene
Administrator / Government Programs
Formulary: No formulary.
Attn: Government Programs
1300 River Drive, Suite 200
Moline, IA 61265
authorization procedure. State appeals and a fair hearing
309/765-7637
procedure required for appeal of prior authorization
decisions and coverage of an excluded product.
Coventry Health Care of Iowa
Lou Garcia, Executive Director
Prescribing and Dispensing Limitations: 4600 Westown Parkway, Ste. 301
Des Moines, IA 50392-0445
Prescribing or Dispensing Limitations: None. 515/225-1234
Drug Utilization Review Iowa Health Solutions
Paul Carter, President
PRODUR system implemented in July 1997. State 2550 Middle Road, Ste. 405
currently has a DUR Board with a monthly review. Bettendorf, IA 52722
319/359-8999
Dispensing Fee: $4.13 to $6.42, effective 7/1/00. F. STATE CONTACTS
Ingredient Reimbursement Basis: EAC = AWP - 10%. State Drug Program Administrator
Ronald Mahrenholz, R.Ph., M.S.
Prescription Charge Formula: Payment will be based on Pharmacist Consultant
the pharmacist's usual, customary and reasonable charge, Division of Medical Services
but payment may not exceed EAC plus a dispensing fee. Dept. of Human Services
Hoover State Office Bldg.
Maximum Allowable Cost: State imposes Federal Upper Des Moines, IA 50319
Limits on generic drugs. Override requires “Brand T: 515/281-6199
Medically Necessary.” F: 515/281-6230
E-mail: rmahren@dhs.state.ia.us
Patient Cost Sharing: Copayment of $1.00 branded and
generic (federal exclusions). Randy Brentnall, R.Ph.
Consultec, Inc.
Cognitive Services: Does not pay for cognitive services. P.O. Box 14422
E. USE OF MANAGED CARE T: 515/327-1322
F: 515/327-0945
Iowa Medicaid recipients receive pharmaceutical benefits
through the state. DUR Contact
Managed Care Organizations Cheryl Clarke, R.Ph.

United Health Care of the Midlands, Inc. /Share DUR Coordinator
Kathy Ellithorpe Iowa Pharmacists Association
2717 North 118th Circle 8515 Douglas Ave, Suite 16
Omaha, NE 68164 Des Moines, IA 50322
402/445-5566 T: 515/270-0713
F: 515/270-2979
E-mail: cclarke@iowapharmacists.org

IPA Medicaid Advisory Committee

Medicaid DUR Board
Joe Cunningham
Ronnie Martin, R.Ph., D.O. 608 5th St. SW
Rick Wilkens, M.D. Waukon, IA 52172
Ilyenn Wiesley, R.Ph. 319/568-4267
Sharon Meyer, Pharm.D., M.S.
Ronald Miller, M.D. Robert Dean
Stephen Elliott, D.O., Ph.D. 2725 S. Paxton
R. Joe Mahrenholz, R.Ph., M.S. Sioux City, IA 51106
James F. Scott, R.Ph. 712/276-1307
Paul Perry, Ph.D.
Derek Duncan
Prescription Price Updating 4836 71st Street
Urbandale, IA 50322
Sherry Swanson 515/266-3174
Deputy Account Manager
Consultec, Inc. Helen Eddy
P. O. Box 14422 209 S. 27th St.
Des Moines, IA 50306-3422 West Des Moines, IA 50265
T: 515/327-0950 ext. 1107 515/267-2800
F: 515/327-0945
Hal Jackson
Medicaid Drug Rebate Contacts 218 S. 4th Ave.
Technical: Rocco Russo, 515/327-0950 ext. 1114 Winterset, IA 50273
Policy: Ron Mahrenholz, 515/281-6199 515/462-2479
Audits: Rocco Russo, 515/327-0950 ext. 1114
DUR: Cheryl Clarke, 515/270-0713 Patty Kumbera
PA: Randy Brentnall, 515/327-0950 ext. 1322 4704 80th Place
Urbandale, IA 50322
Kristi Sheakley Beverly McMahon

Account Manager 625 Davis Ave.
Consultec, Inc. Corning, IA 50841
P. O. Box 14422 515/322-3324
T: 515/327-0950 ext. 1108 Mark Richards
F: 515/327-0945 8119 Oakwood Dr.
Urbandale, IA 50322
515/278/0778
Dann Stevens Kenneth Hampson
MHC Program Manager PO Box 271
Medical Services- DHS Ames, IA 50010
Hoover Building, 5th Floor 515/232-7315
T: 515/281-7269
F: 515/281-6230 Alan Shepley
113 1st St. East
Mount Vernon, IA 52314
Physician-Administered Drug Program Contact 319/895-6248
Sherry Swanson
Consultec, Inc. Wally Tschopp
P. O. Box 14422 861 1st St. SE
Des Moines, IA 50306-3422 Hartley, IA 51346
T: 515/327-0950 ext. 1107 712/728-2563
F: 515/327-0945

John Swegle Iowa Senate

833 1st St. NW Sen. Elaine Szymoniak
Mason City, IA 50401 2116-44th Street
515/422-0587 Des Moines, IA 50310
Iowa Human Services Department Officials
Iowa State Dept. of Public Health
Jessie K. Rasmussen, Director Dr. Edward Schor
Dept. of Human Services Lucas State Office Bldg.
Hoover State Office Bldg. Des Moines, IA 50319
Des Moines, IA 50319
515/281-8621 Public Representatives
Vacant
Denis Headlee, Administrator Diana Walvoord
Division of Medical Services 503 3rd Ave S.E.
Spencer, IA 51301
Title XIX Medical Assistance Council
Orvil Nelson
College of Medicine 1534 Second Street
Stacey T. Cyphert Boone, IA 50036
University Hospitals
Iowa City, IA 52242 Dr. Silvano Wueschner
1722 Lake Road
House of Representatives Ottumwa, IA 52501
Polly Bukta
604 S. 32nd St. Iowa Speech, Language & Hearing Association
Clinton, IA 52732 Barbara Vogen
1401 50th Street, Suite 115
Brad Hansen West Des Moines, IA 50266
1015 Shoal Pointe Dr.
Carter Lake, IA 51510 Association of Iowa Hospitals and Health Systems
Tracy Warner
Iowa Nurses Association 100 E. Grand Avenue
Linda Goeldner Des Moines, IA 50309
1501 42nd Street, Suite 471
West Des Moines, IA 50266 Iowa Health Care Association
Steve Ackerson
Iowa Medical Society 950 12th Street
Sheryl Nuzum Des Moines, IA 50309
1001 Grand Avenue
West Des Moines, IA 50265 Iowa Assn. for Home Care
Larry Breeding
Opticians Assn. of Iowa 1540 High Street, Suite 203-B
Vacant Des Moines, IA 50309
Iowa Assn. of Retarded Citizens Board of Chiropractic Examiners

Becky Godfrey Dr. Terry Burk
715 E. Locust P.O. Box 370
Des Moines, IA 50309 Huxley, IA 50124
Iowa Senate Iowa Pharmacy Association

Sen. Maggie Tinsman Cheryl Clarke, R.Ph.
3541 E. Kimberly Road 8515 Douglas, Suite 16
Davenport, IA 52857 Des Moines, IA 50322

Iowa Assn. of Homes for the Aging Iowa State Association of Counties
William Thayer Virginia Bordwell
613 West North Street P.O. Box 889
Madrid, IA 50156 Washington, IA 52353
Community Mental Health Centers of IA Iowa Governor’s Planning Council for Developmental
Michelle Wray Disabilities
520 11th Street, N.W. Rick Shannon, DD Council
Cedar Rapids, IA 52405 617 E. 2nd Street
Iowa Dental Association
Robert Harpster Iowa Academy of Family Physicians
333 Insurance Exchange Building Dr. Dave Carlyle
Des Moines, IA 50309 1215 Duff Avenue
Ames, IA 50010
Iowa Council of Health Care Centers
George Appleby Iowa Physical Therapy Association
400 Homestead Building, Ste. 300 Steven Clark
Des Moines, IA 50309 2386 Scenic View Dr.
Adel, IA 50003
Iowa Osteopathic Medical Association
Norman Pawlewski Iowa Physician Assistant Society
950 12th St. Michael Farley
Des Moines, IA 50309 4524 Boulevard Pl.
Iowa Optometric Association
Gary Ellis Iowa Association of Nurse Practitioners
1454 30th Street, Suite 204 Wanda Marshall
West Des Moines, IA 50266-1312 2301 Beaver Avenue
Iowa Pediatric Medical Society
Rick DelPrado, D.P.M. Iowa Association of Rural Health Clinics
110 NW 9th, Suite 5 Ed Friedmann
Ankeny, IA 50021 1013 1st Street, Box C
Redfield, IA 50233
Iowa Psychological Association
Mark Peltan Iowa Occupational Therapy Association
North Iowa Mercy Health Center Angela Hanson-Abbas
84 Beaumont Drive 161 315th St.
Mason City, IA 50401-2921 Perry, IA 50220
Iowa Hearing Aid Society

Bev Thomas
532 42nd St.
DesMoines, IA 50312 Iowa Medical Society
Michael Abrams
Alliance for the Mentally Ill of Iowa Executive Vice-President
Margaret Stout 1001 Grand Avenue
5911 Meredith Drive West Des Moines, IA 50265
Urbandale, IA 50322 515/223-1401
Iowa Psych. Nurse Managers Network Iowa Pharmacy Association

Vacant Thomas R. Temple, R.Ph., M.S.
8515 Douglas, Suite 16

Iowa Osteopathic Medical Association

Norman Pawlewski
Executive Director
950 12th St.
515/283-0002
State Board of Pharmacy Examiners

Lloyd Jessen
Executive Secretary/Director
400 SW 8th St., Suite E
515/281-5944
The Association of Iowa Hospitals and Health Systems

Stephen F. Brenton
President
100 East Grand Avenue
Suite 100
515/288-1955

KANSAS

Dental Services .................................................KAN Be Healthy (EPSDT) .................................................
1

1998* 1999*
TOTAL $118,825,316 155,875

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult
OTHER

National Pharmaceutical Council Kansas-1


authorization procedure. The individual appealing may
State Department of Social and Rehabilitation Services. request an administrative hearing to appeal a prior
authorization hearing by sending a request in writing to:
Administrative Hearing Office
Benefit Design 610 S. W. 10th Ave, 2nd Floor
Topeka, KS 66612-1616
prescribed insulin; disposable needles and syringe Prescribing or Dispensing Limitations
urine ketone test strips; and total parenteral nutrition. Prescription Refill Limit: As authorized by the prescriber
Products covered with restriction: interdialytic parenteral and allowed by statute up to a one-year period from the
nutrition. Products not covered: cosmetics; fertility drugs; date of issuance of the prescription for non-controlled
experimental drugs; DESI drugs; and drugs not rebated by drugs. No early refills (<75% Rx utilized).
the manufacturer.
Monthly Quantity Limit: 34-day supply.
analgesics (for adults); digestive products (H2 antagonist); Other: Narcotics, Viagra, and Relenza have other specific
and antifungals. Products covered with restrictions: cough limits.
and cold preparations and smoking deterrent products.
Products not covered: allergy, asthma and sinus products; Drug Utilization Review
digestive products (non-H2 antagonists); feminine
products; and topical products. PRODUR system implemented in November 1996. State
currently has a DUR Board with review every two
Therapeutic Category Coverage: Therapeutic categories months.
covered: anabolic steroids; analgesics (for children),
antipyretics (for children), NSAIDs; antibiotics; Pharmacy Payment and Patient Cost Sharing
anticoagulants; anticonvulsants; antidepressants;
antidiabetic agents; antihistamine drugs; anti-psychotics Dispensing Fee: $2.78-$6.71, average of $4.94, effective
antilipemic agents; cardiac drugs; chemotherapy agents; 1/95.
inflammatory agents; estrogens; hypotensive agents; misc. Ingredient Reimbursement Basis: EAC = AWP - 10%.
GI drugs; prescribed smoking deterrents; IV fluids, AWP - 50%. Blood fraction products,
sympathominetics (adrenergic); and thyroid agents. Prior AWP - 30%.
authorization required for: anxiolytics, sedatives, and
hypnotics; anorectics; and growth hormones. Prescription Charge Formula: Pharmacies are reimbursed
the lesser of usual and customary, MAC, FUL, or
Coverage of Injectables: Injectable medicines acquisition cost (EAC) plus a dispensing fee.
when used in home health care, extended care facilities, Maximum Allowable Cost: State imposes a combination
and through physician payment program when used in of Federal Upper Limits and State Maximum Allowable
physician offices. Cost (MAC).
Vaccines: Vaccines reimbursed as part of the Children Incentive Fee: None.

Health Insurance Program and the Vaccines for Children
Program. Patient Cost Sharing: A recipient copay charge of $2.00
(effective 7/1/94) applies to each new and refill
Unit Dose: Unit dose packaging not reimbursable. prescription not specifically exempted under federal
regulations.
2-Kansas National Pharmaceutical Council

E. USE OF MANAGED CARE Medicaid Drug Rebate Contacts

Technical: Karen Braman, 785/296-6968
Approximately 95,000 total unduplicated number of Policy: Karen Braman
Medicaid Recipients were enrolled in MCOs in FY 1999. DUR: Glenn McNees, 785/864-3264
Recipients receive pharmaceutical benefits through PA: Karen Braman
managed care plans.
Managed Care Organizations Claims Submission Contact

First Guard Blue Cross Blue Shield of Kansas
3801 Blue Pky P.O. Box 3571
Kansas City, MO 64130 Topeka, KS 66611
800/933-6593
F. STATE CONTACTS
State Drug Program Administrator Bobbie Graff-Hendrixson
Karen Braman, R.Ph., M.S. Managed Care Team Leader
Department of Social and Rehabilitation Services Health Care Policy Division, Kansas Dept. of SRS
915 SW Harrison, Rm. 651-S DSOB Topeka, KS 66612-1570
Topeka, KS 66612-1570 T: 785/296-3981
T: 785/296-6968 F: 785/296-4813
F: 785/296-4813
E-mail: ksb@srskansas.org Social and Rehabilitation Services Department
Agency Internet Address: www.ink.org/public/srs/ Officials
Janet Schalansky
Prior Authorization Contact Secretary
Karen Braman, 785/296-6968 Department of Social and Rehabilitation Services
Docking State Office Bldg.
915 SW Harrison
DUR Contact Topeka, KS 66612-1570
Glenn McNees, R.Ph., M.S., BCPS 785/296-3981
DUR Program Director
KU School of Pharmacy Medical Care Advisory Committee Contact
6052 Malott Hall Robert Day, Ph.D.
Lawrence, KS 66045-2500 Medicaid Policy/Medicaid Director
T: 785/864-3264 Health Care Policy Division
F: 785/864-5849 Kansas Dept of SRS
915 SW Harrison
Topeka, KS 66612-1570
DUR Board 785/296-3981
Michael Burke, M.D., Ph.D. Executive Officers of State Medical and

Lawrence Davidow, Ph.D., R.Ph. Pharmaceutical Societies
Stanley Edlavitch, Ph.D., M.A.
John Lowdermilk, R.Ph. Kansas Medical Society
Linda McAnarney, R.N. Jerry Slaughter
Janette McMillan, R.Ph. Executive Director
Kathy Miller-Lemke, R.Ph. 623 SW 10th Avenue
Brenda Shewe, M.D. Topeka, KS 66612
John Whitehead, D.O. 785/235-2383

Karen Braman, 785/296-6968
National Pharmaceutical Council Kansas-3

Kansas Pharmaceutical Association

Robert R. Williams, M.S., CAE
Executive Director
1308 West 10th Street
Topeka, KS 66604-1299
785/232-0439
Kansas Association of Osteopathic Medicine

Harold Riehm, CAE
Executive Director
1260 SW Topeka Boulevard
Topeka, KS 66612
785/234-5563

Larry Froelich, R.Ph.
Executive Secretary
Landon State Office Building
900 Jackson, Room 513
Topeka, KS 66612
785/296-4056
Kansas Hospital Association

Donald A. Wilson
President
215 Southeast Eighth Street
P.O. Box 2308
Topeka, KS 66601-2308
785/233-7436
Fiscal Manager
Rick Schultz
Health Care Policy Division
Kansas Dept. SRS
Room 651 S, Docking State Office Building
Topeka, KS 66612-1570
785/296-3981
4-Kansas National Pharmaceutical Council

KENTUCKY

1

1998* 1999*
TOTAL $319,983,951 429,102

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult
OTHER

National Pharmaceutical Council Kentucky-1

Department for Medicaid Services, within the Cabinet for Formulary: Closed Formulary. The Kentucky Medicaid
Health Services. Program maintains a drug file of approximately 96,800
drugs and covers all rebated products, some of which
D. PROVISIONS RELATING TO DRUGS require prior authorization.
Benefit Design Prior Authorization: State currently has a prior

authorization procedure and a Drug List and Prior
Drug Benefit Product Coverage: Products covered: Authorization Sub-Committee. Review of written
cosmetics; fertility drugs; experimental drugs; disposable documentation by a peer review contractor is required for
needles used for insulin; blood glucose test strips; and appeal of prior authorization decisions. A formal appeals
urine ketone test strips. Products not covered: prescribed process is available if a request is denied.
insulin; syringe combinations used for insulin; total
parenteral nutrition; and interdialytic parenteral nutrition. Prescribing or Dispensing Limitations
Prescription Refill Limit: (1) No prescriptions may be

refilled more than 5 times or more than 6 months after the
smoking deterrent products. Products covered with
prescription is written. (2) After initial filling, one
restrictions: allergy, asthma and sinus products;
dispensing fee per 30-day period for designated
analgesics; cough and cold preparations; digestive
maintenance drugs.
products (non-H2 antagonist); feminine products; and
topical products. Products not covered: digestive Monthly Quantity Limit: For designated classes of
products (H2 antagonists). maintenance drugs, refills of the original prescription and
subsequent prescriptions for these drugs must be
Therapeutic Category Coverage: Therapeutic categories prescribed and dispensed in quantities of not less than a
covered: antibiotics; anticoagulants; anticonvulsants; thirty-day supply unless the prescriber requests an
antidepressants; antidiabetic agents; antilipemic agents; exception to his policy.
anti-psychotics; cardiac drugs; contraceptives; ENT anti-
inflammatory agents; estrogens; hypotensive agents; misc. Drug Utilization Review
GI drugs; sympathominetics (adrenergic); and thyroid
agents. Prior authorization required for: anabolic steroids; PRODUR system implemented in September 1994. State
analgesics, antipyretics, NSAIDs; antihistamine drugs; currently has a DUR Board with a quarterly review.
anxiolytics, sedatives, and hypnotics; chemotherapy
agents; prescribed cold medications; and growth Pharmacy Payment and Patient Cost Sharing
hormones. Therapeutic categories not covered: anorectics
and prescribed smoking deterrents. Dispensing Fee: $4.75 for outpatients and $5.75 for LTC
facility patients, effective July 1, 1991.
reimbursable through the Prescription Drug Program Ingredient Reimbursement Basis: EAC = AWP-10%.
when used in physicians offices, home health care and
extended care facilities and through physician payment Prescription Charge Formula: Reimbursement consists of
when used in physician offices. Reimbursement is limited the lowest of: (1) the usual and customary charge; (2) the
to antineoplastic drugs with “J” codes in physician offices. MAC, if any, plus a dispensing fee; or (3) the EAC plus a
dispensing fee.
Vaccines: Vaccines reimbursable in the cost of the
physician visit as part of EPSDT service, Children’s Maximum Allowable Cost: State imposes Federal Upper
Health Insurance Program, Vaccines for Children Limits on generic drugs. Override requires “Brand
Program and through the pharmacy. Medically Necessary.”
Unit Dose: Unit dose packaging reimbursable. Incentive Fee: None.
2-Kentucky National Pharmaceutical Council

Industry Representatives:
E. USE OF MANAGED CARE J. Scott Moody, Glaxo Wellcome
Kevin WeMett, Pharmacia & Upjohn
Recipients receive pharmaceutical benefits through the Drugs Technical Advisory Committee
state and managed care plans. Steve Adams, R.Ph.
Region 3 217 Lexington Street
Passport Health Plan, Fincastle Bldg. Lancaster, KY 40444
305 W. Broadway, 4th Floor
Louisville, KY 40202 R. N. Smith, R.Ph.
502/585-7900 P. O. Box 247
Burkesville, KY 42717
F. STATE CONTACTS Clarence F. Sullivan III, R.Ph.

1095 Tatesbrook Drive
Medicaid Drug Program Administrator Lexington, KY 40517
Debra Bahr, R.Ph.
Pharmacy Services Program Manager Paul Easley, R.Ph.
Department for Medicaid Services 9804 Springbark Drive
CHR Building, 6th Floor Louisville, KY 40241
275 East Main Street
Frankfort, KY 40621 Gary Wientjes, R.Ph.
T: 502/564-6511 496 Skaggs Road
F: 502/564-3852 Morehead, KY 40351
E-mail: debra.bahr@mail.state.ky.us
Drug Management Review Advisory Board
Prior Authorization Contact Robert C. Hughes, M.D., Chair
300 S. 8th Street, Suite 480W
Debra Bahr, R.Ph., 502/564-6511 Murray, KY 42071
Prior Authorization Subcommittee Tim Jenkins, R.Ph., Vice Chair

11502 Saratoga Ridge Drive
Robert Hughes, M.D. (Chair) Louisville, KY 40299-8316
Marsha Adams, PAC
James S. Davis, M.D. Marsha Adams, P.A.-C
Nancy Stiles, M.D. 792 Mt. Carmel Road
Kirksey, KY 42054
DUR Contact
Debra Bahr, R.Ph., 502/564-6511 Richard W. Arnold, M.D.
300 East Pleasant Street
DUR Committee Cynthiana, KY 41031
George Rodgers Jr., M.D. Phillip Baier, O.D.

Richard Arnold, M.D. 121 Franklin Square Shopping Center
Phillip Baier, O.D. Frankfort, KY 40601
Patricia Freeman, R.Ph., Ph.D.
Tim Jenkins, R.Ph. James S. Davis, M.D.
Marilyn Osborne, M.S.N., A.R.N.P. Department of Public Health
Vaughn Payne, M.D. 275 East Main Street-2GWB
Janet Poe Wright, Pharm.D. Frankfort, KY 40621
Ms. Kathy Wheeler, MSN, ARNP**
Patricia Freeman, R.Ph., Ph.D.
American Pharmacy Services Corp.
975 Riverbend Road, Suite 1
Frankfort, KY 40601

Bill Howe
Medicaid Drug Rebate Contact
Government Relations Manager
Pfizer Inc. Marie Couch
209 North Walnut, Suite C Program Coordinator
Lansing, MI 48933 CHR Building, 6th Floor
Ms. Marilyn Osborne, MSN, ARNP Frankfort, KY 40621
Perry County Health Center 502/564-3476
239 Lovern Street
Hazard, KY 41701
Vaughn Payne, M.D. Unisys Provider Services
6420 Dutchman’s Pkwy. P.O. Box 2100
Louisville, KY 40205 Frankfort, KY 40602
T: 502/226-1140
George C. Rodgers, Jr., M.D.* F: 502/226-1860
4250 Georgetown-Greenville Rd.
Georgetown, KY 47122-8816 Medicaid Managed Care Contact
Nancy Stiles, M.D. Philip M. Kremer

K512 Kentucky Clinic Director for Division of Physical Health
Lexington, KY 40536-0284 Department of Medicaid Services
275 E. Main St
Ms. Kathy Wheeler, MSN, ARNP** Frankfort, KY 40621
201 Ashby Circle T: 502/564-5969
Versailles, KY 40383-1549 F: 502/564-3852
Janet Poe Wright, Pharm.D. Physician-Administered Drug Program Contact

RR #2, Box 6 Barbara Utter
Owenton, KY 40359-9601 275 East Main Street
Frankfort, KY 40621
Janet Poe Wright, Pharm.D. 502/564-2687
430 Roland Avenue
Owenton, KY 40359-9601
Department for Medicaid Services Officials
*Proxy: Janice Sullivan, M.D. Jimmy D. Helton, Secretary
2908 Murray Hill Pike Cabinet for Human Resources
Louisville, KY 40242 CHR Building, 4th Floor
**Proxy: Patricia Birchfield, ARNP, DSN Frankfort, KY 40621
171 Louisiana Avenue 502/564-7130
Lexington, KY 40502
Association Contact: State Advisory Council on Medical Assistance

Robert L. Barnett, Jr., R.Ph. Chester L. Parker, Pharm.D., R.Ph.
Executive Director 2086 Old Nassau
Kentucky Pharmacists Association, Inc. Lexington, KY 40504
1228 Highway 127 South 606/277-5723
Frankfort, KY 40601
502/227-2303 Chester A. Nava, Jr., D.P.M.
110 North Hubbards Lane
Louisville, KY 40207-3903
502/897-2047
4-Kentucky National Pharmaceutical Council

Carol J. Braun, D.D.S. Patricia Conner-Young

2816 Veach Road 10409 Christina Court
Owensboro, KY 42303 Louisville, KY 40223
502/683-7114 502/5835034
James A. Burcham Nancy Durham

P.O. Box 20 8900 Hawley-Gibson
Burlington, KY 41005 Crestwood, KY 40014
606/431-2244 502/241-9072
Leslie H. Rogers Vicki Prichard

109 Daniel Drive 222 Ft. Mitchell Avenue
Hazard, KY 41701 Fr. Mitchell, KY 41011
606/344-0277
William T. Watkins, M.D.
125 Volunteer Drive
Somerset, KY 42501
606/679-2169 Kentucky Medical Association
William T. Applegate
Frank A. Butler, Hospital Director 4965 U.S. Highway 42, Suite 2000
University of Kentucky Hospital Louisville, KY 40222-6301
800 Rose Street 502/426-6200
Lexington, KY 40536-0084
606/323-5767 Kentucky Pharmacists Association
Robert Barnett, Jr., R.Ph.
Faye Hensley, R.N. Executive Director
P.O. Box 85 1228 U.S. Highway 127 South
Manchester, KY 40962 Frankfort, KY 40601
Bettie Speicher Weyler State Board of Pharmacy

3420 Grandview Avenue Michael Mone
Louisville, KY 40207 Executive Director
502/893-4964 1024 Capital Center Drive, Suite 210
Frankfort, KY 40601-8204
Bob Gray 502/573-1580
2504 Duke Drive, Apt. 24
Owensboro, KY 42301 Kentucky Osteopathic Medical Association
502/685-2976 Tom Underwood
Executive Director
Donnie Wilhite 1501 Twilight Trail
106 Creekstone Court Frankfort, KY 40601
Frankfort, KY 40601 502/223-5322
502/223-1052
Kentucky Hospital Association
Betty Rose Boyd Michael T. Rust
Apt. #19, Highland Heights President
Prestonsburg, KY 41653 1302 Clear Spring Trace
606/886-0343 P.O. Box 24163
Louisville, KY 40224
Marianne Keller 502/426-6220
The Good Samaritan Center
106177 Watterson Terrace
Jeffersontown, KY 40299
502/267-7403

LOUISIANA

1

1998 1999*
TOTAL $352,784,785 552,481

Aged $73,418,794 48,320
Blind / Disabled $147,147,115 121,962
AFDC-Child $14,280,841 95,024
AFDC-Adult $13,311,365 39,945
AFDC-Unemployed-Child $40,778 235

Aged $1,348,745 1,031
Blind / Disabled $1,275,027 1,246
AFDC-Child $141,936 705
AFDC-Adult $961,464 2,624

Aged $630,135 1,161
Blind / Disabled $248,094 438
AFDC-Child $19,625,711 106,479
AFDC-Adult $2,600,747 22,940
OTHER $77,698,124 110,222

1-Louisiana National Pharmaceutical Council

Prescription Charge Formula: Medicaid reimbursement

C. ADMINISTRATION for pharmacy services will be based on the lower of:
Department of Health and Hospitals. 1. AWP minus 10.5% plus a dispensing fee for single
source products or multiple source products with no
D. PROVISIONS RELATING TO DRUGS maximum allowable cost limitations or when
physician authorizes “Brand Medically Necessary”
Benefit Design for a brand name product which has a state MAC or
FUL.
Drug Benefit Product Coverage: Products not covered:
2. Louisiana Maximum Allowable Costs (LMAC) or the
cosmetics; DESI drugs; and experimental drugs.
Federal Upper Limit plus the dispensing fee.
Over-the-Counter Product Coverage: Products not 3. AWP for multi-source drugs when lower than FUL or
covered: cough and cold preparations. LMAC.
4. The provider’s usual and customary charge to other
Therapeutic Category Coverage: Therapeutic categories payors.
not covered: anorectics.
Coverage of Injectables: Injectable medicines Limits as well as state-specific limits on generic drugs.
reimbursable when used in physician offices, home health 414 drugs are listed on the state-specific MAC list.
care, and extended care facilities. Override requires “Brand Necessary” or “Brand
Medically Necessary.”
Vaccines: Vaccines reimbursable at cost as part of
EPSDT service and Vaccines for Children Program. Incentive Fee: None.
Unit Dose: Unit dose packaging reimbursable. Patient Cost Sharing: $ 0.50 - $3.00 copayment
dependent of the cost of the drug, effective 7/13/95.
Cognitive Services: Does not pay for cognitive services
Formulary: Open formulary
Prior Authorization: State currently does not have a
formal prior authorization procedure. Does not use MCOs to deliver services to Medicaid
recipients.
Prescription Refill Limit: Permitted as indicated by F. STATE CONTACTS

physician within 6 months and not to exceed 5 refills.
Monthly Quantity Limit: New prescription must be issued
for drugs given on a continuing basis, after 5 refills or M.J. Terrebonne, P.D.
after 6 months. Maximum quantity for prescriptions shall Pharmacy Program Director
be either 30-day supply or 100 unit doses, whichever is P.O. Box 91030
greater. Baton Rouge, LA 70821
T: 504/342-9479
Other: Viagra and other drugs to treat impotence are F: 504/342-3893
limited to 6 prescriptions per month. E-mail: mterrebo@dhhmail.dhh.state.la.us
Department of Health and Hospital
PRODUR system implemented in April 1996. Administration Officials
Thomas Collins, Director
Pharmacy Payment and Patient Cost Sharing Bureau of Health Services Financing
Department of Health and Hospitals
Dispensing Fee: $5.77 maximum, effective 7/1/94. 1201 Capitol Access Road
Baton Rouge, LA 70821
Ingredient Reimbursement Basis: EAC = AWP - 10.5%. 504/342-3891
National Pharmaceutical Council Louisiana-2

David Hood, Secretary Susan Hinton, Pharm.D.

Department of Health and Hospitals 7680 Dune Drive
504/342-9500 New Orleans, LA 70128
504/483-7570
Melwyn Wendt
Pharmaceutical Consultant Paul Staab, M.D.
504/219-4154 5216 Lapalco Boulevard
Marrero, LA 70072
504/348-4357
DUR Committee
Region I: Nancy Toedter, Pharm.D.
Lisa Chetta, P.D. 1701 McKean Place, Apartment 58
Donald Fellows, P.D. Monroe, LA 71201
Edward J. Lang, P.D. 318/329-4554
Paul Staab, M.D.
Charmaine Venters, M.D.
Region II: Earl K. Long Hospital
Leslie Day, P.D. 5825 Airline Highway
Blake Pitre, P.D. Baton Rouge, LA 70805
Don Ramirez, P.D. 225/358-1063
Charles Raborn, M.D.
Region III:
John Baker, P.D. Technical: Susan Taskin, 504/342-3855
Shawn McGee, P.D. Policy: M.J. Terrebonne, 504/342-9479
Matthew Peterson, P.D. Disputes: M.J. Terrebonne, 504/342-9479
Lori Vidrine-Parks, M.D. DUR: Dan Scholl, 504/237-3208
Region IV:
Paul Chachere, P.D.
W. Merwin McMahen, P.D. Kandis McDaniel
Donna White, P.D. 504/342-0127
Johnny Johnston, M.D.
Medicaid Drug Program Committee
Louisiana DUR Board Committee Members
Cathi Fontenot, M.D.
Ken Ardoin, Senior Manager LSU Medical Center
State Government Relations 1542 Tulane Avenue
Pfizer, Inc. New Orleans, LA 70112
7 Village Circle, Suite 400 504/568-4791
Westlake, TX 76262
817/491-8410 Naurang Agrawal, M.D.
Gastroenterologist
Brad Belding, P.D. Tulane University School of Medicine
Director of Pharmacy 1430 Tulane Avenue
Thibodaux Hospital New Orleans, LA 70112
402 Easy Street 504/588-5838
Thibodaux, LA 70301
504/493-4786 Keith C. Ferdinand, M.D.
1201 Poland Avenue
Sylvia Heidingsfelder, M.D. New Orleans, LA 70117
5805 Highland Road 504/943-1177
225/358-1069

Elvin G. Tubre, M.D. Kathleen Kennedy, Pharm.D.

Internal Medicine Charity Hospital Pharmacy
3418 Medical Park Drive 1532 Tulane Avenue
Suite 22 Dept. of Medicine
Monroe, LA 71201 New Orleans, LA 70112
318/361-0016
Milton C. Chapman, M.D.
Pediatrician
921 Shreveport-Barksdale Hwy. Louisiana State Medical Society
Shreveport, LA 71105 Dave L. Tarver
3501 North Causeway Boulevard, Suite 800
Merlin H. Allen, M.D. Metairie, LA 70002-3673
Family Practice 504/832-9815
Box A
Ponchatoula, LA 70454 Louisiana State Pharmacists Association
4744 Jamestown, Suite 101
Philip J. Medon, Ph.D. Building 7-B
Northeast Louisiana University Baton Rouge, LA 70808
School of Pharmacy 504/926-2666
Monroe, LA 71201
318/342-4174 Louisiana Association of Osteopathic Physicians
George Cowan, D.O.
Charles Trahan, P.D. Secretary-Treasurer
721 East Academy 6018 Colbert Street
Jennings, LA 70127 New Orleans, LA 70124
381/824-1648 504/488-6743
Attn: Linda Foreman
Leon Richard, P.D. Malcolm Broussard
Pharmacy Center LTD. Executive Director
5310 Norgate Drive 5615 Corporate Boulevard, Suite 8E
New Orleans, LA 70127 Baton Rouge, LA 70808-2537
504/246-3620 504/925-6496
Ken Ardoin Louisiana Hospital Association

Pfizer Pharmaceuticals Robert D. Merkel
502 Fountain Parkway President
Grand Prairie, TX 75050-1499 9521 Brookline Avenue
214/647-0222 Baton Rouge, LA 70898-0720
504/928-0026
M. J. Terrebonne, P.D.
Designee for the Secretary MANAGEMENT WORK GROUP
Dept. of Health & Hospitals Ken Ardoin, Director
P. O. Box 91030; BIN #24 State Government Relations
Baton Rouge, LA 70821-9030 Pfizer Inc.
504/342-3956 7 Village Circle, Suite 400
Westlake, TX 76262
Thomas Collins, Director 817/491-8410
P. O. Box 91030; BIN #24
Baton Rouge, LA 70821-9030 Barney Barnhill
504/342-3956 212 Forrest Lake Lane
Natchitoches, LA 71457
318/352-7037
National Pharmaceutical Council Louisiana-4

Belaire Bourg Marty McKay

Eckerd Drugs Pearson’s Pharmacy
4530 S. Sherwood Forrest 74 Foxfire
Baton Rouge, LA 70816 Alexandria, LA 71302
504/291-0596 318/443-8807
William Bourn, Dean Angelo M. Rini, R.Ph.

or Designee Louisiana Pharmacists Association
Northeast Louisiana University 504 Fairfield Avenue
School of Pharmacy Gretna, LA 70056
Monroe, LA 71209-0470 504/362-9812
318/342-1600
Andy Soileau
Allan Brinkhaus Medicine Shoppe
P.O. Drawer F 401 ½ E. St. Peters Street
Sunset, LA 70584 New Iberia, LA 70560
318/662-5411 318/365-6721
Bob Broadus, Manager Kirt Soileau

State Government Relations Soileau’s Vital Care Pharmacy
Pharmacia and Upjohn 2647 Riverview Blvd.
7147 Creekwood Drive Suite 115
Mandeville, LA 70471 Gonzales, LA 70737
504/674-0058 800/522-5706
Clovis Burch George Taylor

Medic Pharmacy Cecilia Pharmacy
271 E. 70th Street Hwy 355, Box 309
Shreveport, LA 71106 Cecilia, LA 70521
318/865-0234 318/667-6271
Horace Bynum Carl Aron, President

Bynum and Sons LA Board of Pharmacy
3840 S. Bernard Ave. 1209 North 18th Street
New Orleans, LA 70122 Monroe, LA 71201-5495
504/288-4829
Fiscal Intermediary
Marcellus Grace, Dean
Or Designee UNISYS
Xavier University P.O. Box 91030
College of Pharmacy Baton Rouge, LA 70821
7325 Palmetto Street 504/924-7051
New Orleans, LA 70125 Claims Processing: Dan Scholl
504/483-7420 Price Updates: Maggie Vick
Tim Jacks
Professional Pharmacy Services
4106 Desiard Street
Monroe, LA 71203
318/345-2891
Ruth “Cookie” Jean

Medical Center of LA
Dept. of Pharmacy
2021 Perdido Street
New Orleans, LA 70112
504/588-3019

MAINE

Dental Services        * * 
1
*Routine dental services; other categories eligible for non-routine dental service only.

1998* 1999*
TOTAL $121,771,298 137,816

Aged
Blind
Disabled

Aged
Blind
Disabled

Aged
Blind
Disabled

National Pharmaceutical Council Maine-1

C. ADMINISTRATION Prior Authorization: May be obtained in the case of

necessary exceptions. State has no formal prior
State Department of Human Services. authorization committee.
Benefit Design Monthly Quantity Limit: 34 day for brand-name drugs and
90 days for generic drugs per month.
prescribed insulin; disposable needles and syringe Drug Utilization Review
combinations used for insulin (not covered for nursing
home patients); blood glucose test strips; urine ketone test PRODUR system implemented in 1996. State currently
strips; total parenteral nutrition; interdialytic parenteral has a DUR Board.
nutrition; products not covered: vitamin and vitamin
preparations (except pregnancy); and injectables when
oral medication is available for equally effective Pharmacy Payment and Patient Cost Sharing
treatment.
Dispensing Fee: $3.35 for stock supply, or for solutions
Over-the-Counter Product Coverage: Products covered: or lotions involving no weighing. $4.35 for compounding
allergy, asthma, and sinus products (limited coverage after ointments and for solutions/lotions involving weighing
1/1/01); analgesics (limited coverage after 1/1/01); cough one or more ingredients and making home IV solutions.
and cold preparations (limited coverage after 1/1/01); $5.35 for compounding handmade supplies, pwd. papers,
digestive products, H2 antagonists (limited coverage after capsules and tablet priturates and for mixing home TPN
1/1/01); topical products; smoking deterrent products (by hyperalimentation.
Rx only); products not covered: digestive products (not
including H2 antagonists); feminine products. Ingredient Reimbursement Basis: EAC = AWP - 10%.
Therapeutic Category Coverage: Therapeutic categories Prescription Charge Formula: Lowest of usual and
covered: anabolic steroids; antibiotics; anticoagulants; customary, FUL, AWP-10%, or Maine MAC. Maine
anticonvulsants; antidepressants; antidiabetic agents; MAC includes approximately 50 drug products in addition
antilipemic agents; anti-psychotics; anxiolytics, sedatives, to FUL products.
contraceptives; ENT anti-inflammatory agents; estrogens; Maximum Allowable Cost: State imposes Federal Upper
hypotensive agents; misc. GI drugs; prescribed smoking Limits as well as state-specific limits on generic drugs.
deterrents; sympathominetics (adrenergic); and thyroid Override requires “brand medically necessary” by the
agents. Prior authorization required for: analgesics, physician and prior authorization for some drugs.
antipyretics, NSAIDs; anorectics; antihistamine drugs;
prescribed cold medications; growth hormones. Incentive Fee: None.
Coverage of Injectables: Injectable medicines Patient Cost Sharing: Sliding copay scale based on cost:
reimbursable when used in physician offices, home health $0.50 to $3.00 for branded, $0.50-$2.00 for generic drugs.
care, and extended care facilities.
Cognitive Services: State does not pay for cognitive
Vaccines: Vaccines reimbursable based on cost as part of services.
the EPSDT service (admin. fees) and as part of the Bureau
of Health Immunization Program (vaccine fees). E. USE OF MANAGED CARE
Unit Dose: Unit dose packaging reimbursable. About 23,000 Medicaid recipients are enrolled in MCOs.
2-Maine National Pharmaceutical Council

Paula Knight, R.Ph.

F. STATE CONTACTS 31 Birch Circle
Sidney, ME 04330
State Drug Program Administrator 207/547-3881
Christine Gee
Director of Pharmacy Programs Stephen McPike, R.Ph.
Department of Human Services 15 Wildwood Lane
Bureau of Medical Services Gray, ME 04039
Pharmacy Programs 207822-7627
Building 205, 3rd Fl.
11 State House Station Michael Ouellette, R.Ph.
Augusta, ME 04333-0011 RFD 3
T: 207/287-4018 Box 4235
F: 207/287-8601 Winslow, ME 04901
E-mail: christine.gee@state.me.us 207/281-2727
http://www.state.me.us/bms/bmshome.htm Christine Gee
207/287-4018
Non-voting:
Christine Gee
Bureau of Medical Services Robert E. Carroll, Jr., R.Ph.
Pharmacy Programs Department of Professional and Financial Regulation
Building 205, 3rd Fl. Office of Licensing and Registration
11 State House Station 35 State House Station
Augusta, ME 04333-0011 Augusta, ME 04333-0035
207/287-4018 207/624-8689
DUR Contact Joe Bruno (President)

Christine Gee Goold Health Systems
207/287-4018 24 Stone Street
P.O. Box 708
Augusta, ME 04332
Maine DUR Board 207/622-7153
Timothy Clifford, M.D.
Bureau of Medical Services Dennis G. Lyons, R.Ph.
11 State House Station 255 Bear Hill Rd., 2nd Fl.
August, ME 04333 Waltham, MA 02451
207/287-2674
William Alto, M.D. Kathy Chadwick
Maine Dartmouth Family Practice First DataBank
4 Sheridan Drive 800/633-3453
Fairfield, ME 04937
207/861-5000 Medicaid Drug Rebate Contacts
John Grotton, R.Ph. Technical: Rossi Rowe, 207/287-1838

Goold Health Systems Policy: Chris Zukas-Lessard, 207/624-5221
24 Stone Street Rebates: Rossi Rowe, 207/287-1838
P.O. Box 708 Audits: Vacant
Augusta, ME 04332
207/622-7153
National Pharmaceutical Council Maine-3

Maine Pharmacy Association

Gregory Jamison
Marcia Pykare Executive Director
Manager of Data Processing P. O. Box 346
Gold Health Systems Brewer, ME 04412-0346
P.O. Box 1090 207/989-6190
Augusta, ME 04332
207/622-7153 Maine Osteopathic Association
Kellie P. Miller
Elderly Expanded Drug Coverage Program Executive Director
RR2, P.O. Box 1920
Christine Gee
Manchester, ME 04351
Maine Drugs for the Elderly and Disabled Program
207/623-1101
207/287-2674
http://www.state.me.us/sos/cec/rc/apa/10/chaps10.htm
Maine Commission of Pharmacy
Susan Greenlaw
Disease Management Program/Initiative Contact Board Clerk
Department of Professional and Financial Regulation
Timothy Clifford, M.D. Division of Licensing and Enforcement
207/287-2674 State House Station No. 35
Augusta, ME 04333
Human Services Department Officials 207/624-8603
Francis Finnegan, Director
Bureau of Medical Services Maine Hospital Association
207/287-2674 Bruce J. Rueben
President
Susan Curtis 150 Capitol Street
Drug Program Coordinator Augusta, ME 04330
Medical Claims Review 207/622-4794
207/287-1818
Margaret Ross, Director

Medicaid Surveillance/Utilization Review
207/624-5220
Medical Assistance Advisory Committee

Robert Philbrook
MAC c/o BMS
Augusta, ME 04333-0011

Maine Medical Association
Gordon Smith, Esq.
P. O. Box 190
Manchester, ME 04351-0190
207/622-3374
4-Maine National Pharmaceutical Council

MARYLAND

OAA AB APTD AFDC OAA AB APTD AFDC Children <21 SFO*
Prescribed Drugs        
1
*Effective December 1, 1992, all State-Only services except subsidized adoptions were discontinued. Prescription services
for these recipients were transferred to Pharmacy Assistance Program.

1998* 1999*
TOTAL $148,532,940 176,403

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult
OTHER

National Pharmaceutical Council Maryland-1

State Department of Health and Mental Hygiene. Formulary: Open formulary.
D. PROVISIONS RELATING TO DRUGS Prior Authorization: State currently as a Prior

Authorization procedure. A general appeals procedure is
Benefit Design required for appeal of prior authorization decisions.
Drug Benefit Product Coverage: Products covered: Prior authorization required from the HealthChoice and
prescribed insulin; disposable needles and syringe Acute Care Administration when the usual and customary
combinations used for insulin; and total parenteral charge exceeds $100 and the prescribed amount is a 34-
nutrition. Products not covered: cosmetics; fertility drugs; day supply or more. Preauthorization is needed for any
experimental drugs; blood glucose test strips; urine ketone prescription with a usual and customary charge exceeding
test strips; interdialytic parenteral nutrition; DESI drugs; $400. Prior authorization is also needed for early refills,
prescriptions and injections for central nervous system; nutritional supplements, and excessive quantities.
food supplements or infant formulas; products for which
Federal Financial Participation is not allowed, i.e., "less Prescribing or Dispensing Limitations
than effective" drugs and products whose manufacturers
have not signed rebate agreements; and (e) certain other Prescription Refill Limit: Maximum of two refills. The
items as specified in the state's Medicaid plan. original prescription and its refills may not exceed a 100-
day supply except for birth control pills and oral sodium
Over-the-Counter Product Coverage: Products covered: fluoride preparations. Refills may not be dispensed after
contraceptives; oral ferrous sulfide; and aspirin for 100 days of date of original prescription except for birth
arthritis. Products not covered: allergy, asthma and sinus control pills and oral sodium fluoride preparations
products; analgesics; cough and cold preparations;
Monthly Quantity Limit: The amount of medication to be
digestive products (H2 and non-H2 antagonists); feminine
dispensed on a prescription at one time is limited to a less
products; topical products; and smoking deterrent
than 34-day supply except for specific maintenance drugs
products.
for chronic conditions, where up to a 100-day supply may
be dispensed at one time.
covered: anabolic steroids; analgesics, antipyretics, Drug Utilization Review
antidepressants; antidiabetic agents; antihistamine drugs; PRODUR system implemented January 1993. State
antilipemic agents; anti-psychotics; anxiolytics, sedatives, currently has a DUR Board with a quarterly review.
prescribed cold medications; contraceptives; ENT anti- Pharmacy Payment and Patient Cost Sharing
GI drugs; prescribed smoking deterrents; Dispensing Fee: $4.21 as of July 1, 1996.
authorization required for: growth hormones. Therapeutic Ingredient Reimbursement Basis: Estimated Acquisition
categories not covered: anorectics. Cost (EAC) equals/lowest of:
Coverage of Injectables: Injectable medicines 1. Wholesale Acquisition Cost (WAC) plus 10%.
reimbursable through the Prescription Drug Program 2. Direct cost plus 10%.
when used in home health care, extended care facilities, 3. Distributor's price plus 10%.
and through physician payment when used in physician 4. Average Wholesale Price (AWP) minus 10%.
offices.
Prescription Charge Formula: Reimbursement will be the
Vaccines: Vaccines reimbursable as part of the EPSDT lower of: (1) the calculated ingredient cost plus a
service. dispensing fee; (2) the usual and customary fee.
Unit Dose: Unit dose packaging reimbursable for nursing Maximum Allowable Cost: State imposes Federal Upper
home patients only for commercially available products. Limits as well as state-specific limits on generic drugs.
Approximately 1,000 drugs are listed on the state-specific
MAC list. Override requires “Brand Medically
Necessary” and a reason.
2-Maryland National Pharmaceutical Council


F. STATE CONTACTS
Patient Cost Sharing: Copayment = $1.00. Does not
apply to managed care, family planning, nursing home State Drug Program Administrator
residents or recipients under 21 years old. Mr. Frank Tetkoski
Pharmacy Services Manager
Cognitive Services: Does not pay for cognitive services. Division of Pharmacy and Clinic Services
E. USE OF MANAGED CARE Baltimore, MD 21201
T: 410/767-1455
Approximately 375,000 total unduplicated number of F: 410/333-7049
Medicaid recipients were enrolled in MCOs in FY 1999. E-mail: tetkoskif@dhmh.state.md.us
Recipients receive pharmaceutical benefits through the
state and managed care plans. Prior Authorization Contact
Tuong Nguyen, P.D.
Chesapeake FamilyFirst 68,785 DHMH-Office of Health Services
6300 Security Boulevard Division of Pharmacy and Clinical Services
Baltimore, MD 21207 201 W. Preston St., Rm. 132
Baltimore, MD 21201
FreeState Health Plan 97,363 T: 410/787-1455
Blue Cross Blue Shield F: 410/333-7049
10455 Mill Run Circle E-mail: nguyent@dhmh.md.us
Owings Mills, MD 21117-5559
DUR Contact
Helix Family Choice, Inc. 18,039
2330 W. Joppa Road Judy Geisler, P.D.
Suite 301 Pharmacist Consultant
Lutherville, MD 21093 DHMH-Office of Health Services
Division of Pharmacy and Clinical Services
Jai Medical Systems, Inc. 4,817 201 W. Preston Street
5010 York Road Baltimore, MD 212010
Baltimore, MD 21212 T: 410/767-1728
Maryland Physicians Care MCO 28,958 DUR Board

7106 Ambassador Road
Scott A. Spier, M.D., Chair
Suite 100
Medical Director
Baltimore, MD 21244
Outpatient Chemical Dependency Unit
Mercy Medical Center Professional Building
Prime Health Corporation 15,405
301 St. Paul Place, Room 812
9602-C M.L.K., Jr. Hwy
Baltimore, MD 21202
Lanham, MD 20706
410/332-9230
Priority Partners MCO 55,349
Bonnie Rosiak, Pharm.D., Chair
The Candler Building
8809 Heron’s Flight
111 Market Place
Laurel, MD 20723
Baltimore, MD 21202
Barbara A. Bartman, M.D., M.P.H.
Ameri Group 85,393
3972 Ducks Foot Lane
857 Elkridge Landing Road, #300
Ellicott City, MD 21042
Linthicum, MD 21040
410/955-1314

Krishna Chary, R.Ph.

804 Bear Cabin Drive
Forest Hill, MD 21050 First Health DataBank
800/380-9342 Division of Claims Processing
Charlotte Krueger, Chief
Babette S. Duncan, Pharm.D., BCPS 201 W. Preston St.
Senior Director, Clinical Services Baltimore, MD 21201
Advance Paradigm, Inc. T: 410/767-5347
11350 McCormick Road F: 410/333-7186
Suite 1000, Executive Plaza II
Hunt Valley, MD 21031 Medicare Managed Care Contact
410/785-2182
Rosalie Kosloff
Chief, Division of Health Choice Management
Michelle A. Forrest-Smith, Pharm.D.
Office of Health Services
1822 Chatfield Terrace
201 W. Preston St.
Severn, MD 21144
Baltimore, MD 21201
410/748-6291
410/767-5690
Myron Miller, M.D.
8201 Spring Bottom Way Elderly Expanded Drug Coverage Program
Baltimore, MD 21208 Paul Roeger
410/653-7952 Manager, Pharmacy Assistance Program
Medical Care Operations and Eligibility
Richard D. Moore, M.D. 201 W. Preston St
Johns Hopkins Hospital Baltimore, MD 21201
1830 E. Monument Street, 8th floor T: 410/767-5394
Baltimore, MD 21205 F: 410/333-7290
410/955-2144
Jill RachBeisel, MD
University of Maryland Medical System Edward Watters, M.D.
22 South Greene Street 201 W. Preston Street
S12A03 Baltimore, MD 21201
Baltimore, MD 21201 410/767-1482
Prescription Price Updating Health and Mental Hygiene Department Officials
First DataBank Georges C. Benjamin, M.D.

1111 Bayhill Dr. Secretary
San Bruno, CA 94066 Department of Health and Mental Hygiene
T: 415/588-5454 201 W. Preston Street
F: 415/827-4578 Baltimore, MD 21201
Medicaid Drug Rebate Contacts Debbie I. Chang

Deputy Secretary
Technical: Jeffrey Gruel, 410/767-1455 Health Care Financing
Policy: Jeffrey Gruel, 410/767-1455 201 W. Preston Street
P/A: Lynette Lane, 410/767-1728 Baltimore, MD 21201
Audits: Kenneth Smoot, 410/767-5186
Disputes: Katherine Novak, 410/582-9305 Joseph M. Millstone
Executive Director
Office of Health Services
201 W. Preston Street
Baltimore, MD 21201
4-Maryland National Pharmaceutical Council

Shelby Boggs Howard Schiff

Director of Healthcare and Acute Care Executive Director
Office of Health Services 650 West Lombard Street
201 W. Preston Street Baltimore, MD 21201-1572
Baltimore, MD 21201
Jeffrey Gruel LaVerne G. Naesea
Chief Executive Director
Division of Pharmacy and Clinic Services 4201 Patterson Avenue
Office of Health Services Baltimore, MD 21215-2299
201 W. Preston Street 410/764-4755
Baltimore, MD 21201
410/767-1455 Maryland Osteopathic Association, Inc.
Francisco E. Ward, D.O.
Joseph Fine, P.D. Secretary/Treasurer
Chief P.O. Box 6314
Division of Recoveries Annapolis, MD 21401
Medical Care Operations and Eligibility 800/664-4274
Baltimore, MD 21201 The Maryland Hospital Association, Inc.
410/767-5795 Calvin M. Pierson, President
1301 York Road, Suite 800
Paul Roeger Lutherville, MD 21093-6087
Program Manager 410/321-6200
Pharmacy Assistance Program
PO Box 386
Baltimore, MD 21203
410/767-5392
Medical Assistance Staff Committee Members

Judy Geisler, P.D.
Division of Pharmacy and Clinic Services
Baltimore, MD 21201
Mr. Frank Tetkoski, P.D., Manager, Pharmacy Services

201 W. Preston Street, Room 129
Baltimore, MD 21201
Tuong Nguyen, P.D.

201 W. Preston St., Rm. 132
Baltimore, MD 21201

Medical/Chirurgical Faculty of Maryland
T. Michael Preston
Executive Director
1211 Cathedral Street
Baltimore, MD 21201
410/539-0872
Maryland Pharmacists Association

MASSACHUSETTS

1

1998* 1999*
TOTAL $497,146,531 613,186

Aged
Blind
Disabled

Aged
Blind
Disabled

Aged
Blind
Disabled

1-Massachusetts National Pharmaceutical Council

Unit Dose: Unit dose packaging reimbursable; however,

C. ADMINISTRATION will not pay extra for the packaging.
Executive Offices of Health and Human Services, Formulary/Prior Authorization
Division of Medical Assistance.
Prior Authorization: State currently has a prior
Benefit Design authorization procedure. A fair hearing process by the
recipient on an individual basis is required for appealing a
Drug Benefit Product Coverage: Products covered: prior authorization decision.
combinations used for insulin; blood glucose test strips; Prescribing or Dispensing Limitations
urine ketone test strips; total parenteral nutrition; and
interdialytic parenteral nutrition. Products covered with Prescription Refill Limit: Prescription may be refilled, as
restrictions: Ritalin and amphetamines are limited to authorized, with a limit of up to 5 refills within 6 months
treatment of hyperkinesis for children under age 17, from the filling of the original prescription.
except by prior authorization; and ADD by prior
authorization (not covered for appetite control). Products Monthly Quantity Limit: Schedule II and III drugs are
not covered: cosmetics; fertility drugs; experimental limited to a 30-day supply, except Ritalin and Dexedrine,
drugs; DESI drugs; legend vitamins not on Drug List, which may be dispensed up to a 60-day supply.
non-legend drugs not on Drug List; propoxyphene-
containing products and products rated by the FDA as Monthly Dollar Limits: None.
less-than-effective.
allergy, asthma and sinus products; analgesics; digestive PRODUR system implemented in October 1995. State
products (non-H2 antagonist); and feminine products. currently has a DUR Board with a quarterly review.
Products covered with restrictions: cough and cold
preparations (except in LTC facilities or PA); digestive Pharmacy Payment and Patient Cost Sharing
products (H2 antagonists) (90 days then PA required); and
topical products (acne preps require PA). Products not Dispensing Fee: $3.00.
covered: smoking deterrent products.
Ingredient Reimbursement Basis: EAC = WAC + 10%.
covered: anabolic steroids; analgesics, antipyretics, Prescription Charge Formula: Payment shall be for the
NSAIDs; antibiotics; anticoagulants; anticonvulsants; lowest of:
antidepressants; antidiabetic agents; antihistamine drugs;
antilipemic agents; anti-psychotics; cardiac drugs; 1. EAC plus dispensing fee;
chemotherapy agents; contraceptives; ENT anti- 2. The usual and customary charge defined as the lowest
inflammatory agents; estrogens; growth hormones; price charged or accepted by a provider for any
hypotensive agents; sympathominetics (adrenergic); and payor; or
thyroid agents. Prior authorization required for: 3. FULP plus a dispensing fee.
anorectics; anxiolytics, sedatives, and hypnotics;
prescribed cold medications and misc. GI drugs. Maximum Allowable Cost: State imposes Federal Upper
Therapeutic categories not covered: prescribed smoking Limits as well as state-specific limits on generic drugs.
deterrents. Override requires “Dispense as Written” and/or “Brand
reimbursable through the Prescription Drug Program Patient Cost Sharing: Copayment = $0.50 with the
when used in home health care, extended care facilities following exceptions:
− Institutionalized patients
offices.
− Children under age 19
− Pregnant and postpartum women
− Hospice care
service if not provided by the Department of Public
− Family planning items
Health.
National Pharmaceutical Council Massachusetts-2


Cognitive Services: Does not pay for cognitive services. Christopher Burke
Pharmacy Program Analyst
E. USE OF MANAGED CARE Dept of Medical Assistance
600 Washington Street
Approximately 500,000 total unduplicated number of Boston, MA 02111
Medicaid recipients were enrolled in MCOs in FY 1999. T: 617/210-5592
Recipients receive pharmaceutical benefits through F: 617/210-5597
managed care plans. E-mail: Cburke@nt.dma.state.ma.us
F. STATE CONTACTS Medicaid Drug Rebate Contacts
State Drug Program Administrator Technical: Paula McAree, R.Ph., 617/210-5594

Policy: Paula McAree, R.Ph., 617/210-5594
Gary Gilmore, R.Ph. Audits: Policy: Paula McAree, R.Ph., 617/210-5594
Division of Medical Assistance
600 Washington Street Claims Submission Contact
Boston, MA 02111
T: 617/210-5593 Unisys Corp
F: 617/210-5597 P.O. Box 9101
E-mail: ggilmore@nt.dma.state.ma.us Somerville, MA 02145
Agency Internet Address: dma@nt.dma.state 617/576-4451
Pricilla Portis
Anna Morin, Pharm.D. Director, Primary and Specialty Services
DVR Program Director Division of Medical Assistance
UMASS Medical School 600 Washington Street
11 Midstate Hwy Boston, MA 02111
Auburn, MA 01501-1863 T: 617/210-5700
T: 508/721-7104 F: 617/210-5597
F: 508/721-7138 E-mail: pportis@nt.dma.state.ma.us
E-mail: anna.morin@umassmed.edu
DUR Contact
Annette Hanson, MD
Anna Morin, 508/721-7104 Medical Director
Medicaid DUR Board 600 Washington Street
Boston, MA 02111
Spencer Wilking, MD (Chairman) T: 617/210-5683
C. Michael Bliss, MD F: 617/210-5597
Sarah Cheeseman, MD E-mail: ahanson@nt.dma.state.ma.us
Thomas Hewitt, MD
Anne Marie McCloskey, R.Ph.
Leo McKenna, R.Ph. Elderly Expanded Drug Coverage Program
Dave Morgan, R.Ph. Contact
Robert Portney, MD
James Scanlon, R.Ph. Pricilla Portis, 617/210-5700
David Kosegarten, Ph.D.
Gerry Longnecker, Pharm.D. Executive Offices of Health and Human Services
William O’Leary
Secretary
Executive Offices of Health and Human Services
1 Ashburton Place
Boston, MA 02108
3-Massachusetts National Pharmaceutical Council


Massachusetts Medical Society
Harry L. Greene II, M.D.
1440 Main Street
Waltham, MA 02154
617/893-4610
Massachusetts Pharmacists
Linda Barry
617/736-0101
Massachusetts Osteopathic Society, Inc.

Charles Radbill, D.O.
Secretary
100 Concord Street
Framingham, MA 01701
508/872-8900

Lori Bassinger
Executive Director
100 Cambridge Street
Room 1514
Boston, MA 02202
617/727-9953
Massachusetts Hospital Association

Ronald M. Hollander
President
Five New England Executive Park
Burlington, MA 01803
617/272-8000
National Pharmaceutical Council Massachusetts-4

MICHIGAN

Dental Services -----Limited for all eligibles-----
1

1998* 1999*
TOTAL $374,145,567 589,818

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult
OTHER

1-Michigan National Pharmaceutical Council


C. ADMINISTRATION
Michigan Department of Community Health, Medical
Services Administration. Formulary: Closed formulary.
D. PROVISIONS RELATING TO DRUGS Prior Authorization: State currently has a formal prior
authorization procedure. In order to appeal prior
Benefit Design authorization decisions, a department appeals section in
the Medicaid program sets up hearings for beneficiaries.
Drug Benefit Product Coverage: Products covered: The beneficiary is sent a letter with instructions on their
prescribed insulin; disposable needles and syringe appeal rights when appealing the coverage of an excluded
combinations used for insulin; blood glucose test strips; product.
and urine ketone test strips. Products covered with
restrictions: total parenteral nutrition (paid to medical Prescribing or Dispensing Limitations
suppliers) and interdialytic parenteral nutrition. Prior
authorization required for: brand name products Prescription Refill Limit: Based on state law.
equivalent to MACs; Accutane & Retin-A; Dexedrine and
Adderall; Persantine; Lactulose (Cephulac); Monthly Quantity Limit: Prescribed quantities should be
Methylphenidate (selected ages); selected limited to an amount necessary to keep the recipient
benzodiazepines; Epogen administered in the home supplied during the therapy regimen. In certain cases and
setting; dietary formulas; and drugs not listed on the conditions, more than a month’s supply will be
formulary. Products not covered: cosmetics; fertility appropriate. However, in no instance may more than 100
drugs; and experimental drugs. days supply be dispensed per prescription.
Over-the-Counter Product Coverage: Products covered Drug Utilization Review

with restrictions (only selected products in each category):
allergy, asthma and sinus products; analgesics; digestive PRODUR system implemented in July 2000. State
products (non-H2 and H2 antagonists); feminine products; currently has a DUR Board with a quarterly review.
topical products; and smoking deterrent products (patches
and gum). Products not covered: cough and cold Pharmacy Payment and Patient Cost Sharing
preparations.
covered: analgesics, antipyretics, NSAIDs; antibiotics; Ingredient Reimbursement Basis: 1-4 stores = AWP-
anticoagulants; anticonvulsants; antidepressants; 13.5%, 5 or more stores = AWP - 15.1%.
antidiabetic agents; antihistamine drugs; antilipemic
agents; anti-psychotics; anxiolytics, sedatives, and Prescription Charge Formula: Reimbursement for legend
hypnotics; cardiac drugs; contraceptives; ENT anti- drugs is limited to the lower of:
GI drugs; sympathominetics (adrenergic); and thyroid 1. AWP - 13.5% for 1 to 4 stores & AWP - 15.1% for 5
agents. Prior authorization required for: chemotherapy or more stores or LTC, plus dispensing fee minus
agents; growth hormones; and prescribed smoking selected $1.00 patient copay, or
deterrents. Therapeutic categories not covered: anabolic 2. The MAC rate, plus dispensing fee, or
steroids; anorectics; and prescribed cold medications. 3. The provider’s usual and customary charge to the
general public.
reimbursable through the Prescription Drug Program Maximum Allowable Cost: State imposes Federal Upper
when used in home health care, extended care facilities, Limits as well as state-specific limits on generic drugs.
and through physician payment when used in physicians 800 drugs are listed on the state-specific MAC list.
offices. Override requires “Dispense as Written” and prior
authorization.
Vaccines: Vaccines reimbursable at cost plus a fee/or
vaccine replacement as part of the EPSDT service and the Incentive Fee: None.
Children Health Insurance Program.
National Pharmaceutical Council Michigan-2

Care Choices HMO

Patient Cost Sharing: Ambulatory recipients age 21 and
34605 Twelve Mile Road
older are required to pay a $1.00 copayment for most
Farmington Hills, MI 48331
legend drugs. If the recipient is unable to pay a required
248/489-6000
copayment on the date of service, the pharmacy cannot
800/893-1113
refuse to render the service. However, the pharmacy may
bill the recipient for the copayment amount, and he/she is
Community Care Plan
responsible for paying it. If the recipient fails to pay a
1925 Breton Road, SE, #204
copayment, the pharmacy could, in the future, refuse to
Grand Rapids, MI 49516
serve the recipient as a Medicaid recipient.
616/252-4792
800/807-5244
Drugs not requiring a co-payment include pregnancy-
related and family planning products.
Community Choice Michigan
2369 Woodlake Drive
Recipients are not required to make a copayment if:
Okemos, MI 48864
− They are under age 21, or 800/390-7102
− They reside in a long-term care facility (nursing
home, hospital long-term care facility, or medical DMC Clinic Plan
care facility), or Centrum Bldg., 7th Floor
− Health Maintenance Organization (HMO), or a 20901 Northwestern Hwy.
capitated Clinic Plan. Southfield, MI 48075
Cognitive Services: Does not pay for cognitive services. Family Health Plan of Michigan
2200 Jefferson Avenue
E. USE OF MANAGED CARE Toledo, OH 43624
800/231-8274
Approximately 1,000,000 total unduplicated number of 734/457-5370 (Monroe Office)
Recipients receive pharmaceutical benefits through the Good Health Michigan
state and managed care plans. 2000 S. Woodward, Ste. 200
Bloomfield Hills, MI 48302
Managed Care Organizations 248/454-1070
888/898-7969
American Family Care
2000 S. Woodward, Ste. 200 Great Lakes Health Plan, Inc.
Bloomfield Hills, MI 48302 17117 W. Nine Mile, Ste. 1600
248/454-1070 Southfield, MI 48075
888/898-7969 248/559-5656
800/903-5253
Blue Care Network
25925 Telegraph Road Health Alliance Plan
Southfield, MI 48086 2850 W. Grand Blvd.
248/799-6674 Detroit, MI 48202
800/414-3457 313/664-8360
800-801-1769
Botsford Health Plan
28050 Grand River Health Plan of Michigan
Farmington Hills, MI 48336 17515 W. Nine Mile, Ste. 650
248/473-6190 Southfield, MI 48075
800/479-5122 248/569-8640
888/437-0606
Cape Health Plan
17421 Telegraph, Suite 209
Detroit, MI 48219
888/354-2273

Health Plus of Michigan PHP of West Michigan, Inc.

2050 S. Linden Road 250 Morris Ave., Ste 5500
P.O. Box 1700 Muskegon, MI 49440-1143
Flint, MI 48501-1700
810/230-2222 Priority Health
800/322-9161 1231 E. Beltline, NE
Grand Rapids, MI 49525-4501
M-Care 616/942-0954
2301 Commonwealth Blvd. 888/975-8102
Ann Arbor, MI 48105-1573
800/527-5549 Pro-Care Health Plan
3956 Mount Elliot
McLaren Health Plan Detroit, MI 48207
401 W. Greenlawn 313/925-4607
Lansing, MI 48910 888/861-0061
517/346-4834
888/327-0671 SelectCare HMO
2401 W. Big Beaver Road
Midwest Health Plan Suite 700
5050 Schaefer Road Troy, MI 48084
Dearborn, MI 48126 248/637-6777
313/581-3700 800/332-2365
888/654-2200
Total Health Care
North Med 3011 W. Grand Blvd., Ste. 1600
109 E. Front, Ste. 204 Detroit, MI 48202
Traverse City, MI 49684 313/871-2000
616/935-0550 800/826-2862
877/935-0599
Ultimed HMO of Michigan
Oakwood St. John Health Plan 2401 20th Street
19853 W. Outer Drive, Ste. 301 Detroit, MI 48216
Dearborn, MI 48124 313/961-1717
313/791-5229 800/242-7955
888/493-4300
Upper Peninsula
OmniCare Health Plan 104 Coles Drive, Suite E
1155 Brewery Park Blvd. Marquette, MI 49855
Suite 250 906/225-7500
Detroit, MI 48207 888/904-7526
313/259-4000
800/955-4578 The Wellness Plan
2875 W. Grand Blvd.
PHP of Mid-Michigan, Inc. Detroit, MI 48202
P.O. Box 30377-7877 313/875-4200
Lansing, MI 48909-7877 800/875-9355
517/347-9425
800/661-8299
PHP of South Michigan, Inc.

209 E. Washington Ave., Ste. 315E
P.O. Box 4055
Jackson, MI 49204
PHP of Southwest Michigan, Inc.

106 Farmers Alley, Ste. 400
Kalamazoo, MI 49007

Karen Jonas, R.Ph.

F. STATE CONTACTS 13121 Willow Grove Road
Dewitt, MI 48820
James Kenyon, R.Ph.
Pharmacist Consultant James Kenyon, R.Ph.
MDCH/Medical Services Administration Michigan Department of Community Health
400 South Pine Street Medical Services Administration
Lansing, MI 48933 P.O. Box 30479
T: 517/335-5265 Lansing, MI 48909
F: 517/335-5294
E-mail: kenyonj@state.mi.us Otto Graesser, DO
Agency Internet Address: www.michigan.fhsc.com 1421 W. Mt. Hope
www.mdch.state.mi.us Lansing, MI 48910

First DataBank
James Kenyon, 517/335-5265 1111 Bayhill Drive
San Bruno, CA 94066
Mary Sandusky, R.Ph. Medicaid Drug Rebate Contacts

MDCH- Medical Services Administration Technical: Randy Rothfuss, 517/335-5040
400 S. Pine St. Audits: James Kenyon, 517/335-5265
Lansing, MI 48933 PA: Barbara Jones, 517/335-5061
T: 517/335-5280
F: 517/241-7813 Claims Submission Contact
E-mail: sanduskyM@state.mi.us
First Health Services Corp
4300 Cox Rd.
Medicaid DUR Board Glen Allen, VA 23060
Richard Henderson, M.D.
34650 Versailles Court Medicaid Managed Care Contact
Farmington Hills, MI 48331 Rick Murdock, Director
810/474-1397 Comprehensive Health Plan Division
MDCH- Medical Services Administration
Frank Check, M.D. 400 S. Pine Street
St. Joseph Mercy Hospital Lansing, MI 48933
900 Woodward Avenue T: 517/241-7933
Pontiac, MI 48341 F: 517/241-8231
313/858-3233
Duane Kirking, Ph.D.
College of Pharmacy Mary Sandusky, 517/335-5280
University of Michigan
Ann Arbor, MI 48109-1065
Elderly Expanded Drug Coverage Contact
313/764-4483
313/764-7312 Jean Friend
MDCH- Aging, Community Services Division
William Overkamp 517/373-4064
2929 Walker, N.W. E-mail: JeanFriend@state.mi.us
Grand Rapids, MI 49544


Carol Johnson
Linda McCardel Licensing Administrator
Medical Services Administration 611 W. Ottawa, P.O. Box 30018
P.O. Box 30479 Lansing, MI 48909
Lansing, MI 48909 517/373-0620
517/335-5115
Michigan Health and Hospital Association
Michigan Dept. of Community Health (MDCH)
Spencer C. Johnson
James Haveman President
Director 6215 West St. Joseph Highway
Michigan Department of Community Health Lansing, MI 48917
517/373-7720 517/323-3443
Robert Smedes
Deputy Director
Medical Services Administration
P. O. Box 30479
Lansing, MI 48909
Formulary Review Committee

James Kenyon, R.Ph.
Giovannino Perri, M.D.
Debera Eggleston, M.D.
Max Robins, D.O.
Lawerence Nagel, D.D.S.
Chris Farrell
Robert Pheteplace, P.Ph. (Alternate)
Addresses for all members:

Medical Services Administration
Michigan Department of Community Health
400 S. Pine Street
Lansing, MI 48933

Michigan State Medical Society
William E. Madigan, Executive Director
120 West Saginaw
East Lansing, MI 48826-0950
517/337-1351
Michigan Pharmacists Association

Larry D. Wagenknecht, Executive Director
815 N. Washington Avenue
Lansing, MI 48906
517/484-1466
Michigan Association of Osteopathic Physicians &

Surgeons, Inc.
William Stevenson, Executive Director
2445 Woodlake Circle
Oklemos, MI 48364
517/347-1555 or 800/657-1556 (within Michigan)

MINNESOTA

1

1998 1999*
TOTAL $173,602,492 203,220

Aged $7,783,421 7,013
Blind / Disabled $83,068,585 45,306
AFDC-Child $2,941,090 23,913
AFDC-Adult $4,128,630 15,857
Other $40,928 96

Aged $6,333,476 5,072
Blind / Disabled $11,739,504 5,030
AFDC-Child $98,025 477
AFDC-Adult $32,350 286
Other $25,918 41
POVERTY RELATED, TOTAL $787,642 2,390

Aged $184,259 414
AFDC-Child $175,561 1,509
Other $42,228 53
OTHER $56,062,790 94,246

1-Minnesota National Pharmaceutical Council

C. ADMINISTRATION Formulary/ Prior Authorization
Minnesota Department of Human Services, Health Care Formulary: Open formulary with general exclusions.
Management Division, Medical Assistance Program.
D. PROVISIONS RELATING TO DRUGS authorization procedure and a Drug Formulary
Committee. Recipient has the right to appeal Prior
Benefit Design authorization decisions and coverage of an excluded
product by appeals referee followed by an appeal in court.
cosmetics; fertility drugs; and experimental drugs. Prescribing or Dispensing Limitations
Products covered with restriction: interdialytic parenteral
nutrition. Prior Authorization required for: Desmopressin; Monthly Quantity Limit: 3 month supply. Minimum 30-
Epoetin Alpha; Filgrastim; Interferon Alfa; Interferon days for maintenance drugs. Contraceptives may be filled
Gamma-IB; Ondansetron; Granisetron; and Sargramostim to provide a 3-month supply.
Products not covered: prescribed insulin; disposable
needles and syringe combinations used for insulin; blood Drug Utilization Review
glucose test strips; urine ketone test strips; and total
parenteral nutrition. PRODUR system implemented in February 1996. State
Over-the-Counter Product Coverage: Products covered if
prescribed by a physician: digestive products (H2 Pharmacy Payment and Patient Cost Sharing
antagonists). Products covered with restrictions: allergy,
asthma and sinus products; analgesics; cough and cold Dispensing Fee: $3.65, effective 7/1/97.
preparations; digestive products (non-H2 antagonist);
feminine products (antifungals covered); topical products; Ingredient Reimbursement Basis: EAC = AWP - 9%.
and smoking deterrent products (within deterrent
program). Prescription Charge Formula: Reimbursement is based
on the lesser of submitted AWP minus 9% plus a
Therapeutic Category Coverage: Therapeutic categories dispensing fee, MAC plus a dispensing fee, or usual and
covered: anabolic steroids; analgesics, antipyretics, customary.
antidepressants; antidiabetic agents; antihistamine drugs; Maximum Allowable Cost: State imposes Federal Upper
antilipemic agents; anti-psychotics; anxiolytics, sedatives, Limits on generic drugs. Override requires “brand
and hypnotics; cardiac drugs; chemotherapy agents; medically necessary.”
growth hormones; hypotensive agents; prescribed Incentive Fee: None.
smoking deterrents; sympathominetics (adrenergic); and
thyroid agents. Prior authorization required for: misc. GI Patient Cost Sharing: No copayment.
drugs (proton pump inhibitor). Therapeutic categories not
covered: anorectics and tretinoin products (covered only Cognitive Services: Does not pay for cognitive services.
for acne).
reimbursable through the Prescription Drug Program Approximately 280,000 total unduplicated number of
when used in home health care, extended care facilities, Medicaid recipients were enrolled in MCOs in FY 1999.
and through physician payment when used in physician Recipients receive pharmaceutical benefits through
offices. managed care plans.
Vaccines: Vaccines reimbursable when billed as part of Managed Care Organizations

the EPSDT service, the Children’s Health Insurance
Program, and the Vaccines for Children Program. Itasca Medical Care
Karen Campbell
Unit Dose: Unit dose packaging reimbursable. 123 1st Avenue SE
Grand Rapids, MN 55744
National Pharmaceutical Council Minnesota-2

Blue Plus/Blue Shield of MN Public Programs

DUR Contact
Cynthia MacDonald, Director
1200 Yankee Doodle Road, W4-43 Mary Beth Reinke, Pharm.D., R.Ph.
Eagan, MN 55121-2202 DUR Coordinator
444 Lafayette Road
First Plan of Minnesota St. Paul, MN 55155-3853
1601 London Road T: 651/215-1239
Duluth, MN 55812 F: 651/282-6744
E-mail: mary.beth.reinke@state.mn.us
HealthPartners Government Programs
8100 34th Avenue South Medicaid DUR Board
P.O. Box 1309
Physicians
Minneapolis, MN 55414-1309
C. Dwight Townes, M.D.
16 Meadow Lane, South
Medica
Minneapolis, MN 55416
P.O. Box 9310
612/377-8469
Mail Route 80280
William P. Korchik, M.D.
Veterans Affairs Medical Center
Metropolitan Health Plan
One Veteran Drive (11L)
Mail Code 611
822 South 3rd Street, Suite 140
612/725-2035
Michael F. Koch, M.D.
UCare Minnesota
Director, Child Psychiatry
2550 University Avenue, West
Hennepin County Medical Center
Suite 330N
701 Park Avenue South
St. Paul, MN 55114
612/347-2617
Altru Health Plan Minnesota
3065 Demers Avenue
Health Care Professional
Grand Forks, ND 58201-4018
Marilyn M. Ulseth, MS, RN, CNP
2909-33rd Ave South
F. STATE CONTACTS Minneapolis, MN 55406
State Drug Program Administrator Pharmacists

Lynne M. Schneider, R.Ph.
Cody Wiberg, Pharm.D., R.Ph. 12910 37th Avenue North
Acting Pharmacy Program Manager Plymouth, MN 55441
Minnesota Department of Human Services 612/571-2220
444 Lafayette Road
St. Paul, MN 55155-3853 Ron Johnson, R.Ph.
T: 651/296-8515 Lloyd’s Pharmacy
F: 651/282-6744 720 North Snelling
E-mail: code.c.winberg@state.mn.us St. Paul, MN 55104
Agency E-mail Address: www.dhs.state.mn.us 651/645-8636
Prior Authorization Contact Micheal J. Barrett, PD-FASCP

Director of Pharmacy
Cody Wiberg, 651/296-8515 Long Praire Memorial Hospital & Home
20 Southeast Ninth Street
Long Prarie, MN 56347-1404

Wendy L. St. Peter, Pharm.D. Chris Reisdorf

Hennepin County Medical Center Supervisor
Nephrology Analytical Services Primary Care Benefits Policy
USRDS Coordinating Center 651/296-8822
914 Eighth Avenue South
Minneapolis, MN 55404 Drug Formulary Committee
Al Heaton, Pharm.D., R.Ph.
Consumers Representative
Senior Director
Vacant
Prime Therapeutics
1020 Discovery Road No. 100
DHS Staff
Eagan, MN 55164
Cody Wiberg, Pharm.D., R.Ph.
Acting Pharmacy Program Manager
Charlene Nusman
Minnesota Department of Human Services
Consumer Representative
444 Lafayette Road, North
2534 Lynn Avenue So.
St. Paul, MN 55155-3853
St. Louis Park, MN 55416
651/296-8515
William P. Korchik, M.D.
Prescription Drug Updating
Veterans Affairs Medical Center
First DataBank One Veteran Drive (11L)
Medicaid Drug Rebate Contacts 612/725-2035
Audits: Jarvis Jackson, 651/282-5881
Jack Alexander, M.D.
Policy: Cody Wiberg, 651/296-8515
Fairview Red Wing Clinic
2835 South Service Clinic
Disease Management Program/Initiative Contact Red Wing, MN 55066
Cody Wiberg, 651/296-8515
Elderly Expanded Drug Coverage Program
Contact Minnesota Medical Association
John Van Etta, M.D., President
Cody Wiberg, 651/296-8515 3433 Broadway Street NE, Suite 300
Chris Reisdorf Minnesota Pharmacists Association
Department of Human Services Keith Pearson
444 Lafayette Road Interim Executive Director
St. Paul, MN 55155 2550 University Avenue, West
612/296-8822 Minneapolis, MN 55114
612/644-3566
Michael O’Keefe Minnesota Osteopathic Medical Society
Commissioner Drenda G. Wendell, D.O.
Department of Human Services Executive Director
444 Lafayette Road 2912 80th Circle North
St. Paul, MN 55155-3815 Brooklyn Park, MN 55444-1644
651/296-2701 612/560-3346
Mary Kennedy State Board of Pharmacy

Medicaid Director David Holmstrom
2829 University Avenue SE #530
612/617-2201
National Pharmaceutical Council Minnesota-4

Minnesota Hospital and Healthcare Partnership

Bruce Rueben
President
2550 University Avenue, West
Suite 350S
St. Paul, MN 55114
651/641-1121

MISSISSIPPI

1

1998* 1999
TOTAL $231,735,360 368,609 $260,515,719 374,942

Aged $774,913 26,072
Blind $32,397 1,239
Disabled $2,505,079 102,843
CATEGORICALLY NEEDY NON-CASH TOTAL $862,937 143,942

Aged $0 0
Blind $0 0
Disabled $0 0
Children-Families w/Dep. Children $562,150 96,592
MEDICALLY NEEDY TOTAL $0 0

Aged $0 0
Blind $0 0
Disabled $0 0

National Pharmaceutical Council Mississippi-1

Division of Medicaid, Office of the Governor. Formulary: Open formulary, however, general exclusions
include:
D. PROVISIONS RELATING TO DRUGS 1. Drugs used for anorexia or weight gain.
2. Drugs when used for the symptomatic relief of cough
Benefit Design and colds (except quaifenesin syrup 100 mg/5 ml,
iodinated glycerol tablets 30 mg, which are covered).
Drug Benefit Product Coverage: Products covered: 3. Prescription vitamins and mineral products (except
prescribed insulin, syringe combinations used for insulin; prenatal vitamins and fluoride preparations, which are
total parenteral nutrition; and interdialytic parenteral covered).
insulin. Products not covered: cosmetics; fertility drugs; 4. Covered outpatient drugs for which the manufacturer
experimental drugs; disposable needles used for insulin; requires (as a condition of sale) that associated tests
blood glucose test strips; and urine ketone test strips. or monitoring services be purchased exclusively from
Prior authorization required for: Sandimmune; Viagra; the manufacturer or its designee.
enteral feeding products; Clozaril (must be prescribed by 5. Barbiturates (except amobarbital, butabarbital,
Board Certified or Board Eligible Psychiatrist);* mephobarbital, pentobarbital, phenobarbital,
Protropin and Humatrope;* all Antihemophilic Factors secobarbital, which are covered).
including VIII and IX;* and all Home IV Drug Therapies. 6. Benzodiazepines (except Klonopin, Lorazapam,
Diazepam and Temazepam which are covered).
* These products are covered only for children ages 0-21 7. DESI drugs (those drugs that are designated less than
years through the Early and Periodic Screening, Diagnosis effective by the FDA).
and Treatment Program (EPSDT).
Prior Authorization: Administrative hearing require to
Over-the-Counter Product Coverage: Products covered: appeal prior authorization decisions.
ASA, generic Tylenol; generic Robitussin, Benadryl; iron
supplements; and calcium supplements. Products not Prescribing or Dispensing Limitations
covered: allergy, asthma, and sinus products; digestive
products; feminine products; topical products; and Prescription Refill Limit: Limited to five (5).
smoking deterrent products.
Monthly Quantities Limit: 34-day supply or 100 units or
doses, whichever is greater. Birth control pills may be
supplied in 3-month quantities.
covered: anabolic steroids; anorectics; antibiotics;
anticoagulants; anticonvulsants; antidepressants; Monthly Prescription Limit: Total prescriptions dispensed
antidiabetic agents; antihistamine drugs; antilipemic per month per recipient are limited to 5. With prior
agents; anti-psychotics; anxiolytics, sedatives, and authorization recipients may get up to 10.
hypnotics; cardiac drugs; chemotherapy agents;
contraceptives; ENT anti-inflammatory agents; estrogens; Drug Utilization Review
(adrenergic); and thyroid agents. Prior authorization PRODUR system implemented in 1993. No state DUR
required for: analgesics, antipyretics, NSAIDS; and Board exists.
growth hormones. Therapeutic categories not covered:
prescribed cold medications and prescribed smoking Pharmacy Payment and Patient Cost Sharing
deterrents.
Dispensing Fee: $4.91.
reimbursable through the Prescription Drug Program Ingredient Reimbursement Basis: EAC = AWP - 10%,
when used in home health care, extended care facilities, effective July 1, 1990.
offices. Prescription Charge Formula: Reimbursement for legend
drugs will be at the lessor of AWP-10% plus a dispensing
fee or usual and customary charge. OTC drugs will be
paid at lessor of AWP plus a dispensing fee, AWP + 50%,
program.
or shelf price. OTC drugs are to be billed on pharmacy
invoice at shelf price.
Unit Dose: Unit dose packaging not reimbursable.
2-Mississippi National Pharmaceutical Council

Maximum Allowable Cost: State imposes Federal Upper Robert McMurry, M.D.
Limits on generic drugs. Override requires “Brand University of MS Medical Center
Medically Necessary.” L525 Clinical Sciences Bldg.
2500 North State St.
Incentive Fee: None. Jackson, MS 39216
601/362-4471 ext.1865
Patient Cost Sharing: Copayment $1.00.
Cindy Nobel, Pharm.D.
Cognitive Services: Pays for Disease Management University of MS
Services for arthritis, diabetes, hyperlipidemia, asthma, Department of Family Medicine
and coagulatory disorders (effective 8/1/98). Pays $20 for 2500 North State St.
average 30-minute encounter. Jackson, MS 39216
601/984-5425
Richard Ogletree, Pharm.D.
No Medicaid recipients receive health benefits through University of MS
MCOs. Department of Pharmacy
F. STATE CONTACTS Jackson, MS 39216
601/984-2055
State Drug Program Administrator Jerry Perry, R.Ph.

James G. (Jack) Lee, R.Ph. 1700 Terry Road
Division of Medicaid, Office of the Governor Jackson, MS 39204
239 North Lamar St., Ste.. 801 601/355-2438
Jackson, MS 39201-1399
T: 601/359-6296 Dennis Read, R.Ph.
F: 601/359-4185 28 Wansley Rd.
E-mail: msjgl@Medicaid.state.ms.us Laurel, MS 39440
http://www.dom.state.ms.us 601/428-8839
Mike Vinson, Pharm.D.

Division of Medicaid Official
University of MS
Rica Lewis-Payton P.O. Box 1274
Director, Division of Medicaid University, MS 38677
Suite 801, Robert E. Lee Building 601/232-1052
239 North Lamar Street
DUR Contact
Jack Lee, R.Ph.
Jack Lee, R.Ph. T: 601/359-6296
T: 601/359-6296
Medicaid DUR Board
Technical: Terry Childress, 601/359-6050
R. Terry Jackson, M.D. Rebate: Glenda Grant, 601/359-6050
University of MS PA: Jack Lee, 601/359-6296
Jackson, MS 39216 Claims Submission Contact
Robert Forbes, M.D. Terry Childress

University of MS Director of Systems
2500 North State St. 239 North Lamar Street
Jackson, MS 39216 Jackson, MS 39201
T: 601/359-6050
F: 601/359-6048
E-mail: pptcc@Medicaid.state.ms.us
National Pharmaceutical Council Mississippi-3

Medicaid Managed Care Contact Fiscal Intermediary

Melzana Fuller EDS
Director of Provider and Beneficiary Relations 111 Capitol St. Ste 390
Division of Medicaid, Office of the Governor Jackson, MS 39201
239 North Lamar Street, Ste. 801 601/960-2800
Jackson, MS 39201
T: 601/359-6063
F: 601/359-4185
E-mail: mcmmf@Medicaid.state.ms.us

Patsy Crews, R.N.
Director of Bureau of Policy
Division of Medicaid
239 N. Lamar Street
Jackson, MS 39201
601/359-5142

Mississippi State Medical Association
Charles L. Mathews
Executive Director
735 Riverside Drive
601/354-5433
Mississippi Pharmacists Association

Bo Dalton, R.Ph.
Executive Director
341 Edgewood Terrace Drive
601/981-0416
William L. Stevens, R.Ph.

Executive Director
P.O. Box 24507
601/354-6750
Mississippi Osteopathic Medical Association

Henry B. Pace, Ph.D.
Executive Director
89 Jeff St.
Oxford, MS 38655
601/234-6551
Mississippi Hospital Association

Sam W. Cameron
President, CEO
6425 Lakeover Rd.
Jackson, MS 39213
601/982-3251
4-Mississippi National Pharmaceutical Council

MISSOURI

1
See Appendix D, page D-29, for a list of acronyms.

1998 1999*
TOTAL $382,512,566 353,902

Aged $9,278,584 4,400
Blind / Disabled $26,315,038 8,683
AFDC-Child $5,053,612 32,774
AFDC-Adult $8,135,303 18,671
AFDC-Unemployed-Adult $0 0

Aged $0 0
AFDC-Child $0 0
AFDC-Adult $0 0

Aged $1,654,387 1,770
Blind / Disabled $5,035,842 2,080
AFDC-Child $12,580,584 77,140
AFDC-Adult $1,762,945 19,468
OTHER $312,696,271 188,916

National Pharmaceutical Council Missouri-1

C. ADMINISTRATION Dose Limit: Prescriptions for the following must be

dispensed for at least 200 units per prescriptions: Aspirin
Division of Medical Services of the State Department of 5 gr.; Aspirin buffered 5 gr.; Aspirin enteric-coated 5 gr.;
Social Services. Acetaminophen 5 gr. Prenatal vitamins must be dispensed
in a quantity of at least 100.
Benefit Design
PRODUR system implemented in 1993. State currently
has a DUR Board with a quarterly review.
Drug Benefit Product Coverage: Categories or drugs that
are covered: prescribed insulin; disposable needles and
syringe combinations used for insulin; nonlegend
ophthalmic preparations; nonlegend acne preparations;
nonlegend weight control preparations; hemorrhoid
products; estazolam; halazepam; prazepam; and
Ingredient Reimbursement Rate: EAC = AWP - 10.43%.
quazepam. Products covered through the Durable
Medical Equipment Program: blood glucose test strips;
Prescription Charge Formula:
interdialytic parenteral nutrition. Prior authorization 1. Method of reimbursement payment is based on
required for: amphetamines; Isotretinoin; and Retinoic acquisition cost plus a dispensing fee of $4.09 per
Acid. prescription filled. Acquisition may vary depending
whether it is based on AWP and Federal or Missouri
Coverage of Injectables: Injectable medicines MAC.
when used in physician offices, home health care settings, 2. Any drug that is not a federal or Missouri MAC drug
and extended care facilities. will be based on the AWP less 10.43%. The majority
of drugs listed are based on AWP. The method of
Vaccines: Vaccines reimbursable as part of EPSDT pricing will be taken from the NDC number.
program, Children Health Insurance Program, and
Vaccines for Children Program.
Limits as well as state-specific limits on generic drugs. 32
drugs are listed on the state-specific MAC list. Override
requires prior authorization.
Formulary: Open formulary with exclusions.
Patient Cost Sharing: Variable copayment:
authorization procedure, and 7 committee members who Drug Ingredient Cost Copayment
meet quarterly. $0.00 to $10.00 $0.50
$10.01 to $25.00 $1.00
Prescribing or Dispensing Limitations $25.01 or more $2.00
Prescription Refill Limit: Federal regulations must be Copayment retained by pharmacist.

observed for all drugs on the formulary that are listed in
BNDD Schedules 2, 3, 4, and 5. All other prescriptions Cognitive Services: Payment for cognitive services is
refilled should be in accordance with the directions given under consideration.
by the prescribing physician.
Monthly Quantity Limit: Physician encouraged to
prescribe 34-day or 100 dose supply but may, at own
discretion, prescribe up to a maximum 90-day supply.
2-Missouri National Pharmaceutical Council

E. USE OF MANAGED CARE F. STATE CONTACTS
Approximately 270,000 Medicaid recipients are enrolled State Drug Program Administrator
in managed care organizations. All receive pharmacy
Susan McCann, R.Ph.
services through managed care.
Pharmaceutical Consultant
Division of Medical Services
P.O. Box 6500
Healthcare USA Jefferson City, MO 65102-6500
100 South 4th Street, Suite 1100 T: 573/751-6963
St. Louis, MO 63102 F: 573/526-4650
314/444-7239 E-mail: susanmccann@mail.medicaid.state.mo.us
Blue Advantage Plus Health Plan
Social Services Department Officials
P.O. Box 419130
2301 Main St. Gary J. Stangler, Director
Kansas City, MO 64141 Department of Social Services
816/395-3891 Broadway State Office Building
P.O. Box 1527
Mercy Health Plan Jefferson City, MO 65102
1508 S. Grand
St. Louis, MO 63104 Gregory Vadner, Director
314/214-8000 Division of Medical Services
615 Howerton Court, P.O. Box 6500
Care Partners Health Plan Jefferson City, MO 65102
The Clayton Center
120 S. Central, 8th Floor Prior Authorization Contact
St. Louis, MO 63105
Allison Lauf, R.N.
314/505-5400
Nurse Consultant
Community Care Plus Health Plan
P.O. Box 6500
5615 Pershing Avenue, Suite 29
St. Louis, MO 63112
573/751-3762
314/454-0055 ext. 234
HealthNet Health Plan DUR Contact

2300 Main Street, Suite 700 Jayne Zimmer
Kansas City, MO 64108 DUR Coordinator
816/221-8400 Division of Medical Services
P.O. Box 6500
FirstGuard Health Plan Jefferson City, MO 65102
3801 Blue Parkway 573/751-6963
Kansas City, MO 64130
816/922-7250 DUR Board
Family Health Partners Health Plan John W. Newcomer, M.D. (Chair)

215 W. Pershing Road, Suite 310 Assistant Professor of Psychiatry
P.O. Box 411806 Washington University, School of Medicine
Kansas City, MO 64141 Campus Box 8134
816/855-1871 660 S. Euclid
St. Louis, MO 63110
Missouri Care Health Plan
2404 Forum Blvd. Ronald Graham, Pharm.D.
Columbia, MO 65203 Government Relations Manager
573/441-2100 Novartis Corporation
1311 Granite Creek Drive
Blue Springs, MO 64015

Randall Huss, M.D. Gene Forrester, R.Ph.

Rolla Family Practice 2400 S. Blackthorne
910 W. 10th Street Columbia, MO 65201
Rolla, MO 65401
Henry Petry, D.O.
Pamela C. Waggoner, MSN, R.N. Laurie Clinic
539 Wyatt Drive P.O. Box 1277
St. Peters, MO 63376 Laurie, MO 65038
Joy S. Gronstedt, D.O. James E. Edwards, M.D.

30580 Summers Drive 1000 Executive Pkwy, Suite 103
Sedalia, MO 65301 St. Louis, MO 63141
Joseph M. Yasso, D.O. Lorraine C. Brown, D.O.

3513 NW Primrose Lane Rt. 2, Box 247C
Lee’s Summit, MO 64064 Camdenton, MO 65020
Jacquelyn B. Dilworth, M.D. Conrad S. Balcer, D.O.

1101 Courtwood Circle 1241 W. Stadium Blvd.
Ballwin, MO 63011 Jefferson City, MO 65109
Karla Dwyer, R.Ph. Prescription Price Updating

901 Cherry Lane
First DataBank
Kirksville, MO 63501
1111 Bayhill Dr.
San Bruno, CA 94066
Susan Abdel-Rahman, Pharm.D.
T: 650/588-5454
Division of Clinical Pharmacology
Children’s Mercy Hospital
2401 Gillham Road, Ste 0411 Medicaid Drug Rebate Contacts
Kansas City, MO 64108 Technical: Julie Schulte, 573/751-7996
Policy: Susan McCann, 573/751-6963
Peggy Wanner-Barjenbrunch, M.D. Dispute Resolution: Lynn Hebenheimer, 573/751-2005
Rt. 5, Box 82A Audits: Lynn Hebenheimer, 573/751-2005
Mexico, MO 65265
Sandra Bollinger, R.Ph.
112 E. Tywappity Jim Judge
Benton, MO 63736 GTE Data Services
905 Weathered Rock Road
Drug Prior Authorization Committee Jefferson City, MO 65101
573/635-2434
Patrick J. Bryant, Pharm.D.
Drug Information Center Medicaid Managed Care Contact
School of Pharmacy
University of Missouri - Kansas City Janice Gentile
MG-200 Medical School Building Regional Administrator
2411 Holmes Street Division of Medical Services
Kansas City, MO 64108-2792 P.O. Box 6500
M. Dale Terrell, M.D. 573/526-4274
Washington University School of Medicine
Division of Geriatric Medicine Physician-Administered Drug Program Contact
Room M238 Pam Jarrett
1402 South Grand Blvd. Division of Medical Services
St. Louis, MO 63104 P.O. Box 6500
Jefferson City, MO 65102-6500
573/751-3277
4-Missouri National Pharmaceutical Council

Missouri Hospital Association

Pharmacy Subcommittee Roster
Charles L. Bowman
Bill Fitzpatrick, R.Ph. President
Interlock Pharmacy Systems 4712 Country Club Drive
2292 Weldon Parkway Jefferson City, MO 65109-4544
St. Louis, MO 63146 573/893-3700
Philip A. Bangert, R.Ph.

Bangert Pharmacy, Ltd.
13300 New Halls Ferry
Florissant, MO 63033
Tom Beetem, R.Ph., Chairman

1425 Eastview Drive
Holts Summit, MO 65043
Robert D. Hurley, R.Ph.

Walgreens
440 N. Highway 67
Florissant, MO 63031
Craig Leonard, R.Ph.

Lee’s Summit Pharmacy
615 W. 3rd Street
Lee’s Summit, MO 64063

Missouri State Medical Association
C. C. Swarens
Executive Secretary
113 Madison Street, P.O. Box 1028
573/636-5151
Missouri Pharmaceutical Association

George Oestrich
Executive Director
410 Madison Street
Jefferson City, MO 65101-3189
573/636-7522
Missouri Assoc. of Osteopathic Physicians/Surgeons, Inc.

Bonnie Bowles
Executive Director
1423 Randy Lane - P.O. Box 748
573/634-3415

Kevin E. Kinkade
Executive Director
P. O. Box 625
573/751-0091

MONTANA

1

1998* 1999*
TOTAL $42,368,399 58,641 $46,269,102 59,201

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult
OTHER, TOTAL

1-Montana National Pharmaceutical Council

C. ADMINISTRATION Unit Dose: Unit dose packaging reimbursable.
Department of Public Health and Human Services. Formulary/Prior Authorization
D. PROVISIONS RELATING TO DRUGS Formulary: Open formulary. Drugs classified as less-

than-effective (LTE) by the FDA are not covered. Drugs
Benefit Design with no manufacturer rebate are not covered.
Drug Benefit Product Coverage: Products covered: Prior Authorization: State has a formal prior authorization
prescribed insulin. Products not covered: cosmetics; procedure. Prescriber letter documenting evidence for use
fertility drugs; experimental drugs; disposable needles of prescribed medication in treatment of disease is
used for insulin, syringe combinations for insulin use; reviewed by DUR Board for appeal of excluded product.
blood glucose test strips; urine ketone test strips; total An appeal procedure through the Department possible for
parenteral nutrition; and interdialytic parenteral nutrition. PA decisions.
Prior authorization required for Dipyridamole; Carafate;
Ambien; Sonata; Cilostazol; Pentoxifylline; Isoproterenol; Prescribing or Dispensing Limitations
Isoetherine; Viagra; Thalidomide; DMARDs; Mobic, Prescription Refill Limit: 25% grace period over a 3-
Celebrex, and Vioxx; anti-obesity drugs; Duract; Stadol; month period is allowed.
Tretinoin; and Zoloft (50mg); migraine headache drugs;
single-source non-steroidal anti-inflammatory drugs; Monthly Quantity Limit: 100 doses or 34-day supply,
growth hormones; smoking cessation; oral Ketorolac; H2- whichever is greater.
antagonists, proton pump inhibitors, single source
benzodiazepines; hair growth products; and fertility
agents. Drug Utilization Review
PRODUR system implemented in September 1994. State
Over-the-Counter Product Coverage: Products covered: DUR Board has 6 members and meets monthly.
analgesics (Aspirin only); digestive products; head lice
treatment products (permethrin and pyrethrin combination Pharmacy Payment and Patient Cost Sharing
products); H-2 antagonists. Products not covered: allergy,
asthma, and sinus products; cold and cough preparations; Dispensing Fee: $2.00-4.20; effective 7/1/98. Additional
feminine products; topical products; and smoking $0.75 is added to prescriptions unit dosed by the
deterrent products. pharmacy.
Therapeutic Category Coverage: Therapeutic categories Ingredient Reimbursement Basis: EAC = AWP - 10%, or
covered: anabolic steroids; antibiotics; anticoagulants; manufacturer’s direct price, if available.
anticonvulsants; antidepressants; antidiabetic agents;
antihistamine drugs; antilipemic agents; anti-psychotics; Prescription Charge Formula: The lower of EAC, the
cardiac drugs; chemotherapy agents; contraceptives; ENT Federal MAC (plus a dispensing fee), or the provider
anti-inflammatory agents; estrogens; hypotensive agents; usual and customary charge.
authorization required for: anorectics; anxiolytics, Maximum Allowable Cost: State imposes Federal Upper
sedatives, and hypnotics; analgesics, antipyretics, Limits on generic drugs. Override requires “Brand
NSAIDs; misc. GI drugs; growth hormones; and Necessary.”
prescribed smoking deterrents.
reimbursable through the Prescription Drug Program Patient Cost Sharing: Copayment - $1.00 for all generic;
when used in home health care, extended care facilities, $2.00 for all others; effective 5/1/94.
offices. Cognitive Services: Does not pay for cognitive services.

service, the Children Health Insurance Program, and as
part of the Vaccines for Children Program.
National Pharmaceutical Council Montana-2

E. USE OF MANAGED CARE DUR Contact

Mark Eichler, R.Ph.
HMO availability began November 1995, to FAIM 406/443-4020
recipients. SSI and SSI-related clients were eligible to
enroll October 1, 1997. HMO coverage ended June 30, Montana DUR Board
2000.
Mark Eichler, R.Ph., FASCP
F. STATE CONTACTS DUR Coordinator
Mountain Pacific Quality Health Foundation
State Drug Program Administrator 3404 Cooney Drive
Helena, MT 59602
Dorothy D. Poulsen 406/443-4020
Pharmacy Program Officer
Department of Public Health and Human Services V. Lee Harrison, M.D.
Medicaid Services Bureau Richard Sargent, M.D.
P.O. Box 202951 Nathan A. Munn, M.D.
1400 Broadway DeeDee Cress, Pharm.D.
Helena, MT 59624 Marcella Barnhill, R.Ph.
406/444-2738 Ann Geidel, R.Ph.
Fax 406/444-1861
Public Health and Human Services Officials
First DataBank
Laurie Ekanger 1111 Bayhill Dr.
Director San Bruno, CA 94066
Department of Public Health and Human Services T: 415/588-5454
P.O. Box 202951
1400 Broadway Medicaid Drug Rebate Contacts
Helena, MT 59624
406/444-5622 Technical: Dan Forbes, 406/444-1794
P & A: Betty DeVaney, 406/444-3457
Nancy Ellery, Administrator
Health Policy and Services Claims Submission Contact
406/444-4141 Brett Jakovac
Consultec, Inc.
Mary Dalton, Bureau Chief 34 N. Last Chance Gulch, Suite 200
Medicaid Services Bureau Helena, MT 59601
406/444-4144 T: 406/442-1837
F: 406/442-4402
Jeff Buska, Supervisor E-mail: brett.jakovac@consultec-inc.com
Acute Services Section
406/444-4145 Medicaid Managed Care Contact
Mary Angela Collins, Supervisor Mary Angela Collins
Managed Care Section Supervisor, Managed Care Section
406/444-4146 Dept. of Public Health and Human Services
Medicaid Services Bureau
Prior Authorization Contact P.O. Box 202951
Helena, MT 59620-2951
Mark Eichler, R.Ph. T: 406/444-4146
DUR Coordinator F: 406/444-1861
Mountain Pacific Quality Health Foundation E-mail: mcollins@state.mt.us
3404 Cooney Drive
Helena, MT 59602
T: 406/443-4020
F: 406/443-4585
E-mail: meichler@initco.net
3-Montana National Pharmaceutical Council


Dorothy Poulsen
Dept. of Public Health and Human Services
P.O. Box 202951
Helena, MT 59620-2951
T: 406/444-2738
F: 406/444-1861
E-mail: dpoulsen@state.mt.us

Randy Bowsher
P.O. Box 202951
1400 Broadway
Helena, MT 59624
406/444-3995

Montana Medical Association
G. Brian Zins
Executive Director
2021 11th Avenue, Suite 1
Helena, MT 59601-4890
406/443-4000
Montana State Pharmaceutical Association

Jim Smith
Executive Director
P. O. Box 4718
Helena, MT 59604
406/449-3843

Executive Director
P.O. Box 200513
Helena, MT 59620
406/444-1698
Montana Osteopathic Association

Cathy Holmes, Secretary
Montana Building, Suite 401
Lewistown, MT 59457
406/538-7721
Montana Hospital Association

James F. Ahrens
President
1720 Ninth Avenue
Helena, MT 59601
406/442-1911
National Pharmaceutical Council Montana-4

NEBRASKA

1

1998* 1999*
TOTAL $92,558,539 145,408 $114,094,719 154,493

Aged
Blind
Disabled

Aged
Blind
Disabled

Aged
Blind
Disabled

1-Nebraska National Pharmaceutical Council

State Department of Health and Human Services, Finance Formulary: Open formulary. General exclusions include:
and Support, Medicaid Division. 1. More than a three-month supply of birth control
tablets;
D. PROVISIONS RELATING TO DRUGS 2. Experimental drugs or non-FDA approved drugs;
3. Drugs or items when the prescribed use is not for a
Benefit Design medically accepted indication;
4. Liquors (any alcoholic beverages);
Drug Benefit Product Coverage: Products covered: 5. DESI drugs and all identical, related, or similar
prescribed insulin with prior approval on pre-filled drugs;
syringes. Products not covered: disposable needles and 6. Personal care items (e.g. non-medical mouthwashes,
syringe combinations for insulin; blood glucose test strips; deodorants, talcum powders, bath powders, soaps,
urine ketone test strips; total parenteral nutrition; dentrifices, eye washes, and contact solutions);
interdialytic parenteral nutrition; cosmetics; fertility drugs; 7. Medical supplies and certain drugs for nursing facility
and experimental drugs. Prior authorization required for: and intermediate care facility for the mentally
methadone; IV infusions; and protein replacement retarded (IDF/MR) patients;
supplements. 8. Over-the-counter (OTC) drugs not listed on the
Department’s Drug Name/License number Listing
Over-the-Counter Product Coverage: Products covered: microfiche;
allergy, asthma, and sinus products; analgesics; topical 9. Baby foods or metabolic agents (Lofenalac, etc.,)
products; cough and cold preparations; digestive products normally supplied by the Nebraska Department of
(H2 antagonists); and feminine products. Products not Health;
covered: smoking deterrent products. 10. Drugs distributed or manufactured by certain drug
manufacturers or labelers that have not agreed to
Therapeutic Category Coverage: Therapeutic categories participate in the drug rebate program.
NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti- Drugs, items, or manufacturers that are identifiable as
depressants; antidiabetic agents; antihistamine drugs; non-covered are so designated on the NE-POP system,
antilipemic agents; anti-psychotics; anxiolytics, sedatives, and on the Department’s Drug Name/License Number
and hypnotics; cardiac drugs; chemotherapy agents; Listing microfiche.
inflammatory agents; estrogens; hypotensive agents; misc. Prior Authorization: The Department requires that
GI drugs; sympathominetics (adrenergic); and thyroid authorization be granted prior to payment for certain
agents. Prior authorization required for: growth products. Prior authorization can be verified through the
hormones; sunscreens; Erythropoetin (e.g., Epogen, NE-POP System, or by contacting the Department. (or its
Procrit); modified versions of FUL or SMAC drugs; designated contractor) if authorization is not verified
convenience packaged drugs (e.g., Refresh Ophthalmic through the NE-POP System.
0.3 ml and Novalin penfil insulin); drugs to prevent or
treat Respiratory Syncytial Virus Immune Globulin (e.g., Prescribing or Dispensing Limitations
Palivizumab, RSV-IG); and drugs for sexual dysfunction Prescription Refill Limit: As authorized by the prescribing
(e.g., Sildenafil, Alprostadil). Therapeutic categories not physician. For controlled substances, maximum 5 refills
covered: anorectics and prescribed smoking deterrents. every 6 months.
Coverage of Injectables: Injectables reimbursable through Monthly Quantity Limit: 90-day supply or 100 dosage
the Pharmacy program when used medicine used in home units, whichever is greater.
health care, extended care facilities and through physician
payment when used in physician offices. Drug Utilization Review
Vaccines: Vaccines reimbursable by Medicaid for PRODUR system implemented in April 1995. State
individuals under 21 years of age through the Vaccines for currently has a DUR Board with a monthly review.
Children Program, the Children Health Insurance Program
and as part of the EPSDT service.
National Pharmaceutical Council Nebraska-2

Blue Cross/Blue Shield of Nebraska

P.O. Box 241739
Omaha, NE 68124
Dispensing Fee: $4.66. The Nebraska Department of
Health and Human Services assigns a dispensing fee to
Value Options Mental Health
each individual pharmacy. The fee is calculated from
10330 Regency Parkway
information obtained through the Department’s
Omaha, NE 68114
Prescription Survey.
Ingredient Reimbursement Basis: EAC = AWP - 8.71%. F. STATE OFFICIALS

Direct for some pharmaceutical companies.
Prescription Charge Formula: Lower of:
1. Product cost (EAC, SMAC, or FUL) plus a Gary J. Cheloha R.Ph.
dispensing fee, or Pharmaceutical Consultant
2. The usual and customary price to the general public. Health and Human Services, Finance and Support
Medicaid Division, 5th Floor-NSOB
Listed OTCs are reimbursed at the lower of: P.O. Box 95026
Lincoln, NE 68509
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 general
E-mail: gary.cheloha@hhss.state.ne.us
public, or
3. Product cost (EAC, SMAC, or FUL) plus a 50%
mark-up. Health and Human Services Department Officials
Maximum Allowable Cost: State imposes Federal Upper Richard Raymond, M.D., Acting Director
Limits as well as state-specific limits on generic drugs. Department of Health and Human Services
Approximately 450 drugs are listed on the state-specific 301 Centennial Mall
MAC list. Override requires an MC-6 form signed by the Lincoln, NE 68509
physician. 402/471-9105
Incentive Fee: None. Robert J. Seiffert, Administrator

Medicaid Division
Patient Cost Sharing: Copayment = $1.00. 402/471-3121
Cognitive Services: State provides additional payment for Ms. Kris Azimi
cognitive services, effective January 2000. Utilization Review Consultant
402/471-9365
Christine Wright, M.D., Medical Director
Approximately 122,006 unduplicated Medicaid recipients Medicaid Division
were enrolled in managed care in 1999. None received 402/471-9136
pharmacy services through managed care.
John Franklin, Pharm.D., R.Ph.
Share Advantage Clinical Pharmacist
United HealthPlans of the Midlands HHSS-Medicaid Division
2717 North 118th Circle P.O. Box 95026; NSOB 5th Fl.
Omaha, NE 68164 Lincoln, NE 68509-5026
402/471-9301
Wellness Option
Exclusive Health Care, Inc.
10250 Regency Circle
Suite 250
Omaha, NE 68114
Primary Care +

DUR Contact Disease Management Initiative/Program Contact
Allison Jorgensen, Pharm.D., R.Ph. Gay Jeffries, R.N., B.A.

DUR Director QI Manager
Nebraska Pharmacists Association HHSS-Nebraska Medicaid
6221 South 58th; Ste A 301 Centennial Mall South
Lincoln, NE 68516 Lincoln, ME 68509
402/420-1500 402/471-9415
Nebraska DUR Board Physician-Administered Drug Program Contact
Pharmacist Members: Lorelee Novak, R.N.

Kevin Borcher, R.Ph. Department of Health and Human Services
Janet Darnell, R.Ph. 301 Centennial Mall, 5th floor
Patty Gollner, R.Ph. 402/471-9368
Duane Mines, R.Ph.
John Guzallis, R.Ph. Health and Human Services Department
Kim Hamik, R.Ph.
Shannon Nelson, R.Ph. Medical Care Advisory Committee
Monty Scheele, R.Ph. Marlene Brondel
Phillip Vuchetich, R.Ph. League of Human Dignity
1701 P Street
Physician Members: Lincoln, NE 68508
Warren Bosley, MD
Kirk Muffly, MD Tim Bruner
Thomas B. Murray, MD Director of Fiscal Services
Fred Ayers, MD Lincoln General Hospital
2300 South 16th Street
Prescription Price Updating Lincoln, NE 68502
First DataBank Tom Dolan, R.Ph.

1111 Bayhill Dr. Executive Director
San Bruno, CA 94066 Nebraska Pharmacists Association
T: 415/588-5454 6221 South 58th Street, Suite A
Lincoln, NE 68502
Karen Miller
Technical: Arlene Ropers, 402/471-9159 Health Insurance Specialist
Policy: Gary Cheloha, R.Ph., 402/471-9379 Room 227, Federal Building
601 East 12th Street
Claims Submission Contact Kansas City, MO 64106
Janice Jones, R.Ph. Edmund A. Schneider, O.D.
Clinical Pharmacy Manager Lincoln Vision Clinic
4300 Cox Road 810 North 48th Street
Glen Allen, VA 23060 Lincoln, NE 68504
804/965-7517
Steven Lorenzen
Medicaid Managed Care Contact Director, Federal Programs
Blue Cross/Blue Shield of NE
David Cygan Main P. O. Station Box 3248
Managed Care Program Administrator Omaha, NE 68180
HHSS-Finance & Support-Medicaid
301 Centennial Mall South
Lincoln, ME 68509
402/471-9050

John Milligan John Franklin, R.Ph.

Legal Services of Southeast Nebraska 4501 Elkridge Road
825 Terminal Building Lincoln, NE 68516
Lincoln, NE 68508
Eric Hamik, R.Ph.
Joan Penrod, Ph.D. 19 Kings Court
Department of Preventive and Social Medicine Kearney, NE 68845
UNMC
Box 984350, 600 S. 42nd Street Roger Kaczmarek, R.Ph.
Omaha, NE 68198 15763 Fountain Hills Drive
Omaha, NE 68118
Larry Rennecker
NAHHS Duane Mines, R.Ph.
1640 L Street, Suite D 202 North Main Street
Lincoln, NE 68508 Hooper, NE 68031
William Schellpepper Gordon Ockinga, R.Ph.

Executive Secretary 1810 Stolley Park Circle
Nebraska Medical Association Grand Island, NE 68803
First Bank Bldg., Suite 1512
Lincoln, NE 68508 Ran Varney, R.Ph.
P.O. Box 70
Pat Snyder Broken Now, NE 68822
Executive Director
Nebraska Health Care Assoc. Michael Wendt, R.Ph.
421 South 9th Street, Suite 137 608 N 3rd Street
Lincoln, NE 68508 Tecumseh, NE 68450
James Walker, D.D.S. Beth Wilson, R.Ph.

1640 South 70th, Suite 200 5601 South 72nd Street
Lincoln, NE 68506 Lincoln, NE 68516
Medicaid Pharmacy Advisory Committee Executive Officers of State Medical and

Ken Kunce, R.Ph., Chairman
1000 Reavis Street Nebraska Medical Association
Falls City, NE 68355 William Schellpeper
Executive Secretary
Will Davis, R.Ph. 233 S. 13th Street, Suite 1512
729 Walnut Drive Lincoln, NE 68508-2091
Wayne, NE 68787 402/474-4472
David Brehm, R.Ph. Nebraska Pharmacists Association

1609 Custer Street Thomas R. Dolan, R.Ph.
St. Paul, NE 68873 Executive Director
6221 South 58th, Suite A
Jacob Dering, R.Ph. Lincoln, NE 68516
P.O. Box 333 402/420-1500
Crete, NE 68333
Nebraska Assn. of Osteopathic Physicians & Surgeons
Leroy Dinslage, R.Ph. Arthur Weaver, D.O.
Pac N’ Save Secretary
1519 West Hwy 34 P.O. Box 24744
Seward, NE 68434 W. Omaha Station
Omaha, NE 68124
402/333-2744

C. Curt Barr, R.Ph.

Chairman
P. O. Box 95007
Lincoln, NE 68509
402/471-2115
Nebraska Association of Hospitals and Health Systems

Harlan M. Heald, Ph.D.
President
1640 L St., Suite D
Lincoln, NE 68508-2509

NEVADA

1

1998 1999*
TOTAL $34,518,901 50,903

Aged $5,265,564 5,071
Blind $18,443,130 13,572
Disabled $698,439 6,722
Other Title XIX Recipients $60,389 370

Aged $156,978 710
Blind $70,489 168
Disabled $70,820 147
Adults-Families w/Dep. Children $4,284 123
MEDICALLY NEEDY TOTAL $0 0

Aged $0 0
Blind $0 0
Disabled $0 0
Other Title XIX Recipients $8,721,337 19,345

1-Nevada National Pharmaceutical Council

4. Radiographic adjuncts (e.g., Perchloracap).

C. ADMINISTRATION 5. Pharmaceuticals designed “ineffective,” or “less than
effective” (including identical, related, or similar
State Welfare Division of the Department of Human drugs) by the FDA.
Resources. 6. Non-rebated medications.
D. PROVISIONS RELATING TO DRUGS Prior Authorization: Prior authorization procedure

screening for individual drugs. Drugs requiring PA
Benefit Design include:
1. Amphetamine (e.g., Dexedrine)
Drug Benefit Product Coverage: Products covered: 2. Chorionic Gonadotropin (HCG)
prescribed insulin and total parenteral nutrition (prior 3. Dipyridamole (e.g., Persantine)
payment authorization). Products not covered: cosmetics; 4. Erythropoietin (e.g., Epogen, Procrit)
fertility drugs; experimental drugs; disposable needles and 5. Gonadotropin releasing hormone analog (e.g.,
syringe combinations for insulin; blood glucose test strips; Lupron, Zoladex)
and urine ketone test strips. 6. Growth hormone (e.g., Protropin, Nutropin)
7. Interferon (all combinations manufactured by
Over-the-Counter Product Coverage: Products covered recombinant DNA technology)
with restrictions: digestive products (H2 antagonists); 8. Intravenous antibiotic therapy
smoking deterrent products; allergy, asthma and sinus 9. Methylphenidate (e.g., Ritalin)
products; analgesics; cough and cold preparations; and 10. Non-legend pharmaceuticals
topical products. OTC Coverage: OTC drugs are 11. Nutritional supplements or replacements
reimbursed at EAC+$4.76 or the usual and customary 12. Pemoline (e.g., Cylert)
amount, whichever is less, and require prior payment 13. Pulmozyme
authorization. 14. Vitamins, vitamin/mineral combinations or
hematinics
covered: anabolic steroids; antibiotics; anticoagulants; Prescribing or Dispensing Limitations
anticonvulsants; anti-depressants; antidiabetic agents;
antihistamine drugs; antilipemic agents; anti-psychotics; Monthly Prescription Limit: Eligible Medicaid recipients
anxiolytics, sedatives, and hypnotics; cardiac drugs; may receive three outpatient prescriptions per month plus
chemotherapy agents; contraceptives; ENT anti- those issued for EITHER prenatal OR family planning
inflammatory agents; estrogens; hypotensive agents; purposes.
prescribed smoking deterrents; sympathominetics
(adrenergic); and thyroid agents. Prior authorization Monthly Quantity Limit: The maximum dispensable
required for: analgesics, antipyretics, NSAIDs; growth quantity is limited to a 34-day supply.
hormones; and prescribed cold medication. Therapeutic
categories not covered: anorectics. Drug Utilization Review
Coverage of Injectables: Injectable medicines Plans to implement PRODUR system in February 2001.
reimbursable through the Prescription Drug Program State currently has a DUR Board with a quarterly review.
when used in home health care, extended care facilities, or
through physician payment when used in physicians Pharmacy Payment and Patient Cost Sharing
offices.
Vaccines: Vaccines reimbursable at cost plus an
administration fee ($3.83) as part of the EPSDT service. Ingredient Reimbursement Basis: EAC = AWP - 10%.
Unit Dose: Unit dose packaging reimbursable. Prescription Charge Formula: The lowest of (1) specific
upper limit (SUL) plus a dispensing fee, (2) estimated
Formulary/Prior Authorization acquisition cost (EAC) plus a dispensing fee, or (3) the
pharmacy's usual charge to the general public.
Formulary: Open formulary. General exclusions include:
1. Agents used for cosmetic purposes or hair growth.
2. Yohimbine (e.g., Yocon).
3. Radiopaque agents (e.g., Telepaque, Hypaque,
Barium Sulfate).
National Pharmaceutical Council Nevada-2

Mary Loherry
Deputy Administrator
Nevada Medicaid Welfare Division
2527 N. Carson Street
Carson City, NV 89710
702/687-4378
Laurie Squartsoff, R.Ph.
E. USE OF MANAGED CARE T: 702/687-4869
Approximately 38,614 Medicaid recipients are enrolled in DUR Contact

MCOs; all receive pharmacy benefits through managed
care. Laurie Squartsoff, R.Ph.
T: 702/687-4869
DUR Board
Health Plan of Nevada 9,894
P.O. Box 15645 Joseph W. Johnson, M.D.
Las Vegas, NV 89114 110 E. Lake Mead Boulevard, #201
Henderson, NV 89015
NevadaCare, Inc. 25,164 702/565-8911
1701 W. Charleston Blvd.
Suite 420 Steven W. Parker, M.D.
Las Vegas, NV 89102 75 Pringle Way, #603
Reno, NV 89503
United Healthcare 3,556 702/329-0333
1160 Town Center Drive, Suite 390
Las Vegas, NV 89134 David England, R.Ph.
University Medical Center Pharmacy
F. STATE CONTACTS 1800 W. Charleston Boulevard
Las Vegas, NV 89102
Laurie Squartsoff, R.Ph. Lori Winchell, R.N.

Pharmaceutical Consultant 341 Pinnacle Court
Nevada Medicaid Office Henderson, NV 89014
2527 N. Carson Street 702/895-3377
Capitol Complex
Carson City, NV 89710 Prescription Price Updating
T: 702/687-4869
F: 702/687-8724 First DataBank
E-mail: lsquarts@govmail.state.nv.us 1111 Bayhill Dr.
San Bruno, CA 94066
Human Resources Department Officials T: 650/588-5454
Charlotte Crawford, Director Medicaid Drug Rebate Contacts

Department of Human Resources
State Capital Complex Technical: Phil Boord, 702/687-7029
505 East King St. Room 600 Policy: Laurie Squartsoff, 702/687-4869
Carson City, NV 89710 Rebate: Laurie Squartsoff, 702/687-4869
3-Nevada National Pharmaceutical Council

Linda Gellinger
1500 West Warm Springs
Henderson, NV 89014
Anthem Blue Cross/Blue Shield
P.O. Box 12127
James Boscacci
Reno, NV 89510-2127
3061 Conte Drive
775/448-4020
Hilary Jones, R.N.
Medicaid Services Specialist III
Nevada State Medical Association
1100 E. Williams St., Ste 204
Larry Matheis
Executive Director
775/687-4176
3660 Baker Lane, Suite 101
Reno, NV 89509
702/825-6788
Laurie Squartsoff, R.Ph. Nevada Pharmaceutical Association
Nevada Medicaid Office Mary Grear, R.Ph.
2527 North Carson Street Executive Director
Carson City, NV 89710 3006 S. Amryland Parkway, #400
702/687-4869 Las Vegas, NV 89109
Medical Care Advisory Group Nevada Osteopathic Medical Association
Patrick J. Boland, D.O.
Robert J. Burn Secretary-Treasurer
77 Pringle Way 2950 E. Flamingo Road, Suite E-4
Reno, NV 89502 Las Vegas, NV 89121
702/731-0304
David England, Pharm.D.
4430 N. Cheiftain State Board of Pharmacy
Las Vegas, NV 89129 Keith W. MacDonald, R.Ph.
Executive Secretary
Mary Guinan, M.D. 1201 Terminal Way
Nevada State Health Officer Suite 212
505 East King Street, Room 201 Reno, NV 89502
Carson City, NV 89701-4797 702/322-0691
J. Gordon Kinard, D.D.S. Nevada Association of Hospitals and Health Systems
4121 West Sahara Avenue Jeanette Belz
Las Vegas, NV 89102 President, CEO
4600 Kietzke Lane
Jon Sasser Suite A-108
650 Tahoe Reno, NV 89502
Reno, NV 89509 702/827-0184
Mitchell Miller, M.D.
762 14th Street
Elko, NV 89801
Mike Rodolicco, Ed.D.

1175 Harvard Way
Reno, NV 89520
National Pharmaceutical Council Nevada-4

NEW HAMPSHIRE

1

1998* 1999*
TOTAL $55,374,478 70,339
CATEGORICALLY NEEDY, RECEIVING ASST

Aged
Blind/Disabled
AFDC-Child
AFDC-Adult

Aged
Blind/Disabled
AFDC-Child
AFDC-Adult

Aged
Blind
AFDC-Child
AFDC-Adult
OTHER, TOTAL

1-New Hampshire National Pharmaceutical Council

Prior Authorization: No prior authorization procedure.

C. ADMINISTRATION
Office of Medical Services, Department of Health and
Human Services. Monthly Quantity Limit: Limited to 30-day supply or 100-
unit dosage, whichever is greater.
D. PROVISIONS RELATING TO DRUGS Monthly Dollar Limits: None.
Benefit Design Drug Utilization Review
Drug Benefit Product Coverage: Products covered: PRODUR system implemented in July 1995. State
prescribed insulin; disposable needles and syringe currently has a DUR Board with a quarterly review.
ketone test strips; total parenteral nutrition; and Pharmacy Payment and Patient Cost Sharing
cosmetics; fertility drugs; and experimental drugs. Dispensing Fee: AWP-12%+$2.50, effective 2/1/96.
Over-the-Counter Product Coverage: Products covered: Ingredient Reimbursement Basis: EAC = AWP - 12%.
allergy, asthma, and sinus products; analgesics; cough and
cold preparations; digestive products (H2 antagonists), Prescription Charge Formula:
feminine products; smoking deterrents; and topical
products. 1. Lower of usual and customary charge or AWP - 12%
or HCFA Upper Limit plus a dispensing fee.
Therapeutic Category Coverage: Therapeutic categories 2. Maintenance medications are reimbursed by the
covered: anabolic steroids; analgesics, antipyretics, above formula once every 34 days per recipient per
NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti- provider: any refills of maintenance medications
depressants; antidiabetic agents; antihistamine drugs; within the 34-day period are reimbursed at cost only.
antilipemic agents; anti-psychotics; anxiolytics, sedatives, Maximum Allowable Cost: State imposes Federal Upper
and hypnotics; cardiac drugs; chemotherapy agents; Limits on generic drugs. Override requires “Brand
prescribed cold medications; contraceptives; ENT anti- Medically Necessary.”
hypotensive agents; misc. GI drugs; sympathominetics Incentive Fee: None.
(adrenergic); thyroid agents; and prescribed smoking
deterrents. Therapeutic categories not covered: Patient Cost Sharing: Copayment - $0.50 to $1.00.
anorectics. Copayments apply to all recipients except nursing home
patients in SNF or ICF facilities; home and community
Coverage of Injectables: Injectable medicines based care waived recipients holding form 949; pregnant
reimbursable through the Prescription Drug Program women; children under 18 years; and prescriptions for
when used in home health care, extended care facilities family planning drugs.
and though physician payment when used in physician
offices. Cognitive Services: Does not pay for cognitive services.
Vaccines: Vaccines reimbursable as part of the EPSDT,
CHIP, and VCP service. Childhood immunization
vaccine is provided to all children through the Division of
Approximately 5,000 Medicaid recipients are enrolled in
Public Health Services. The Medicaid program does not
MCOs. None receive pharmaceutical benefits through
reimburse providers for routine vaccines, although an
managed care.
administration fee is allowed.
Unit Dose: Unit dose packaging reimbursable for
residents in long-term care facilities only. Anthem Blue Cross/Blue Shield of New Hampshire
Matthew Thornton Health Plan
Formulary/Prior Authorization 3000 Goffs Falls Road
Manchester, NH 03103-6020
Formulary: Open formulary. General exclusions include
anorectics, anorexiants (stimulants) except for treatment Tufts Associated Healthplans of New England
of narcolepsy and hyperkinetic children, cosmetic agents 333 Wyman Street
for hair growth, experimental and fertility drugs. Waltham, MA 02254-9112
National Pharmaceutical Council New Hampshire-2


F. STATE CONTACTS Technical: Julie Simpson, 603/224-1747 ext. 3016
Audits: Julie Simpson, 603/224-1747 ext. 3016
Lisè Farrand, R.Ph.
Pharmaceutical Services Specialist Gary Patanaude
Medicaid Administration Bureau EDS Federal Corp.
6 Hazen Drive 7 Eagle Sq.
Concord, NH 03301-6521 Concord, NH 03301
T: 603/271-4419 T: 603/224-1747
F: 603/271-4376
E-mail: lfarrand@dhhs.state.nh.us Medicaid Managed Care Contact
Brenda Lovely
Department of Health and Human Services Program Specialist
Officials NH DHHS, Medicaid Administration Bureau
Carol Early 6 Hazen Drive
Director Concord, NH 03301
Medicaid Administration Bureau T: 603/271-4350
Office of Health Management F: 603/271-4376
6 Hazen Drive E-mail: blovely@dhhs.state.nh.us
Concord, NH 03301-6521
T: 603/271-8887 Disease Management Initiative/Program Contact
Colin McHugh
Donald Shumway Administrator II
Commissioner Special Medical Services
Department of Health and Human Services 6 Hazen Drive
Concord, NH 03301
DUR Contact T: 603/271-0546
Lisè Farrand, R.Ph.
T: 603/271-4419 Physician-Administered Drug Program Contact
Vacant
Medicaid DUR Board
James P. Pilliod, M.D. Executive Officers of State Medical and
Elaine M. Silverman, M.D. Pharmaceutical Services
Steve Lawrence, M.D.
New Hampshire Medical Society
Paul S. Collins, M.D.
Palmer P. Jones
Mark Henschke, D.O.
John Zinka, R.Ph.
7 N. State Street
Elizabeth Gower, R.Ph.
Helen Pervanas, R.Ph.
603/224-1909
Jody Goodrich, A.R.N.P.
Michael Smith, R.Ph.
New Hampshire Pharmaceutical Association
2 Eagle Square
Prescription Price Updating Concord, NH 03301-4956
First DataBank 603/753-8758
New Hampshire Osteopathic Association, Inc.

Barry Gendron, D.O.
Vice President
P.O. Box 1624
Derry, NH 03038
603/625-1254
3-New Hampshire National Pharmaceutical Council


Paul G. Boisseau
Executive Secretary
57 Regional Drive
603/271-2350
New Hampshire Hospital Association

Michael J. Hill
President
125 Airport Road
603/225-0900
National Pharmaceutical Council New Hampshire-4

NEW JERSEY

Prescribed Drugs     
Laboratory & X-ray Service       
1

1998 1999*
TOTAL $426,075,488 309,849
CATEGORICALLY NEEDY, RECEIVING ASST $270,025,213 167,661

Aged $42,974,940 30,587
Blind / Disabled $219,896,088 100,921
AFDC-Child $2,115,119 20,294
AFDC-Adult $5,039,066 15,859
MEDICALLY NEEDY $4,504,987 3,906

Aged $3,708,823 2,543
AFDC-Child $268,969 1,192
AFDC-Adult $0 0
POVERTY RELATED $60,253,456 60,784

Aged $21,199,966 15,320
Blind / Disabled $36,779,674 13,728
AFDC-Child $1,591,982 22,027
AFDC-Adult $681,834 9,709
OTHER $91,291,832 77,498

1-New Jersey National Pharmaceutical Council


authorization procedure. Periodic review for
Division of Medical Assistance and Health Services, reconsideration possible for excluded product from
Department of Health and Human Services. formulary. Fair hearings possible for appealing prior
authorization decisions.
Benefit Design
Prescription Refill Limit: 5 times within a 6-month period.
prescribed insulin; disposable needles and syringe Monthly Quantity Limit: Originally, 34-day supply. Now,
combinations for insulin use; blood glucose test strips; 34 days or 100 units, whichever is more.
interdialytic parenteral nutrition. Products not covered: Drug Utilization Review
cosmetics; fertility drugs; and experimental drugs. Prior
authorization required for: methadone; IV infusions; and PRODUR system implemented in October 1996. State
protein replacement supplements. currently has a DUR Board with a quarterly review.
Over-the-Counter Product Coverage: Products covered: Pharmacy Payment and Patient Cost Sharing
allergy, asthma, and sinus products; analgesics; topical
products; and cough and cold preparations for children Dispensing Fee: $3.73 for legend drugs. Additional add-
under age 21. Products not covered: digestive products; ons per/Rx shall be given to pharmacy providers who
feminine products; and smoking deterrent products. provide the following:
Therapeutic Category Coverage: Therapeutic categories 1. 24-hr Emergency Service: add $0.11
covered: analgesics, antipyretics, NSAIDs; antibiotics; 2. Patient Consultation: add $0.08
anticoagulants; anticonvulsants; anti-depressants;
antidiabetic agents; antihistamine drugs; anti-psychotics; 3. Impact Area Location: add $0.15 (provider shall have
anxiolytics, sedatives, and hypnotics; cardiac drugs; a combined Medicaid, NJ KidCare and PAAD
chemotherapy agents; prescribed cold medications; prescription volume equal to or greater than 50% of
contraceptives; ENT anti-inflammatory agents; estrogens; total prescription volume.
(adrenergic); and thyroid agents. Prior authorization Ingredient Reimbursement Basis: EAC = AWP - 10%,
required for: antilipemic agents. Partial coverage for: WAC + 30%. AAC for injectables, effective 5/1/00.
anabolic steroids; anorectics (for ADD); growth
hormones; and prescribed smoking deterrents. Prescription Charge Formula: “Maximum Allowable
Cost,” or Average Wholesale Price – 10% (reduction from
Coverage of Injectables: Injectable medicines AWP is pharmacy specific) plus a dispensing fee or the
reimbursable when used in physician offices, home health provider’s usual and customary charge, whichever is
care, and extended care facilities. lower.
Vaccines: Vaccines reimbursable at AWP as part of the Maximum Allowable Cost: State imposes Federal Upper
EPSDT program and the Vaccines for Children Program. Limits on generic drugs. Override requires “Brand
Medically Necessary”.
Unit Dose: Unit dose packaging reimbursable in long-
term care facilities only, not in retail settings (unless u/d is Incentive Fee: None.
only way item is packaged).
Cognitive Services: State pays for cognitive services.
Formulary: Open formulary. General exclusions include
experimental drugs, cosmetics, fertility drugs, DESI
drugs, and drugs for which FFP is not available (OBRA
'90).
National Pharmaceutical Council New Jersey-2


Approximately 400,000 Medicaid recipients received Edward J. Vaccaro, R.Ph.
pharmacy benefits through managed care. All receive Assistant Director, Office of Utilization Management
pharmaceutical benefits from MCOs. Dept. of Human Services, Div. of Medical Assistance and
Health Services
Managed Care Organizations P.O. Box 712, Bldg. 11-A
Trenton, NJ 08625
Amerigroup of NJ T: 609/588-2721
732/452-6002 F: 609/588-3839
Aetna/US HealthCare E-mail: ejvaccaro@dhs.state.nj.us
610/251-6272
Physicians Health Services Medicaid DUR Board

1-800-963-6286 Christopher A. Cella, R.Ph.
Alfred F. Sorbelo, D.O.
Americhoice of NJ Edith Kessler-Feinstein, R.Ph.
212/509-5999 Joseph Nicholas Micale, M.D.
Charles DeFeri, Jr., Pharm. D.
Mercy Health Plan Thomas A. Cavalieri, D.O.
1-800-682-9091 Linda Gooen, R.Ph.
Mary E Petit, Pharm.D.
University Health Plan David Ethan Swee, M.D.
1-800-564-6847
F. STATE CONTACTS Prescription Price Updating

First DataBank
State Drug Program Administrator 1111 Bayhill Dr.
Carl Tepper, R.Ph. San Bruno, CA 94066
Chief, Pharmaceutical Services T: 415/588-5454
Division of Medical Assistance and Health Services Medicaid Drug Rebate Contacts
P.O. Box 712, Bldg. 11-A
Trenton, NJ 08625-0712 Technical: Daniel Upright, 609/588-2792
T: 609/588-2724 Policy: Carl Tepper, 609/588-2724
F: 609/588-3889 PA: Carl Tepper, 609/588-2724
E-mail: cdtepper@dhs.state.nj.us
P. Ringel
Michele Guhl Unisys
Commissioner Deputy Project Director
Department of Human Services 3705 Quakerbridge Rd. Suite 101
Capitol Place 1 Trenton, NJ 08619
Trenton, NJ 08625 T:609/588-6000
F: 609/584-8270
Margaret Murray E-mail: ringelp@nipo1.him.unisys.com
Director
Division of Medical Assistance and Health Services
Edward Vaccaro
T: 609/588-2721
3-New Jersey National Pharmaceutical Council

Elderly Expanded Drug Coverage Contact

Kathleen Mason
Director of PAAD
Dept. of Health and Senior Services
P.O. Box 715
Trenton, NJ 08625
T:609/588-7032
F: 609/584-7037

Edward Vaccaro
609/588-2721

Medical Society of New Jersey
Walter Kahn, M.D.
Executive Director
2 Princess Road
Lawrenceville, NJ 08648-2302
609/896-1766
New Jersey Pharmacists Association

Joseph Morris
3B Marlen Drive
Robbinsville, NJ 08691
609/584-9063
New Jersey Association of Osteopathic Physicians &

Surgeons
Jeff Kramer, FACHE
Executive Director
1 Distribution Way
Monmouth Junction, NJ 08852-3001
732-940-8899

H. Lee Gladstein, R.Ph.
Executive Director
P.O. Box 45013
Newark, NJ 07101
201/504-6450
New Jersey Hospital Association

Gary S. Carter
President, CEO
760 Alexander Road CN-1
Princeton, NJ 08543-0001
609/275-4000
National Pharmaceutical Council New Jersey-4

NEW MEXICO

Inpatient Hospital Care     
Outpatient Hospital Care     
Laboratory & X-ray Service     
Skilled Nursing Home Services     
Physician Services     
1

1998* 1999*
TOTAL $41,507,229 96,637

Aged
Blind
Disabled

Aged
Blind
Disabled

Aged
Blind
Disabled

1-New Mexico National Pharmaceutical Council

C. ADMINISTRATION Drug Utilization Review
Human Services Department (HSD). PRODUR system implemented in October 1993.
D. PROVISIONS RELATING TO DRUGS Pharmacy Payment and Patient Cost Sharing
Benefit Design Dispensing Fee: $4.00, effective 7/1/94.
Drug Benefit Product Coverage: Prior Authorization Ingredient Reimbursement Basis: EAC = AWP - 12.5%,
required for: amphetamines and stimulants for ADD. effective 7/1/97.
Products not covered: drugs for treatment of tuberculosis;
cosmetics; experimental drugs; fertility drugs; drugs and Prescription Charge Formula: Prescriptions reimbursed
immunizations available from any other source; at the lesser of the following:
medications supplied by the New Mexico State Hospital
to clients on convalescent leave from hospital; legend 1. Cost (EAC or MAC) dispensed plus a dispensing fee
multiple vitamins; tonic preparations and combinations or,
with minerals, hormones, stimulants; hematinics (except 2. The usual and customary charge by the pharmacy to
non-sustained release forms of Ferrous Sulfate, Ferrous the general public.
Gluconate, Ferrous Fumarate); drugs classified by FDA as
“ineffective”; and hypnotic drugs (barbiturates). Maximum Allowable Cost: State imposes Federal Upper
Over-the-Counter Product Coverage: insulin; antacids for Over 72 drugs are listed on the state-specific MAC list.
active gastric and duodenal ulcers; infant vitamin drops Override requires “Brand Medically Necessary.”
for up to 1 year; Salicylates and acetaminophen; non-
sustained release forms of Ferrous Sulfate, Ferrous Incentive Fee: None.
Gluconate, Ferrous Fumarate; Scabicides and
Pediculocides; Laxatives, stool softeners, calcium, Patient Cost Sharing: No copayment.
nicotine replacement, ibuprofen, antihistamines,
decongestants, expectorants, cough suppressants, anti- Cognitive Services: Does not pay for cognitive services.
candida, and antifungals.
reimbursable when used in physician offices, home health Full-risk capitation managed care program implemented
care, and extended care facilities. on July 1, 1997. Recipients receive pharmaceutical
benefits through managed care plans.
Vaccines: Vaccines reimbursable at acquisition cost plus
35% as part of the EPSDT program. F. STATE CONTACTS
Unit Dose: Does not reimburse for unit dose packaging. State Drug Program Administrator
Neil Solomon
Formulary: Open formulary Drug Program Administrator
Medical Services Bureau
Prior Authorization: State currently has a formal prior P. O. Box 2348
authorization procedure screening for drug classes. Santa Fe, NM 87504-2398
T: 505/827-3174
Prescribing or Dispensing Limitations F: 505/827-3185
Prescription Refill Limit: Payment will be made to a

particular pharmacy only three times for the same drug for Drug Education & Utilization Review Board
the same client in a 90-day period. John A. Heaton, R.Ph.
Corner Drug Store, Inc.
Monthly Quantity Limit: 6-month supply maximum, 201 W. Fox
excluding birth control pills. Carlsbad, NM 88220
National Pharmaceutical Council New Mexico-2

Fredrica Smith, M.D. Chris Isengard

Los Alamos Medical Center Executive Director
3917 West Road Developmental Disabilities Planning Council
Los Alamos, NM 87544 435 St. Michael’s Dr., Bldg. D
Santa Fe, NM 87501
Charles T. Spalding, M.D., Ph.D.
Lovelace Medical Center Michelle Lujan-Grisham
5400 Gibson, S.E. New Mexico State Agency on Aging
Albuquerque, NM 87108 228 East Palace Avenue
Santa FE, NM 87501
William Troutman, Pharm. D.
University of New Mexico Drug Information and Sam Cata, Commissioner
Poison Control Center Office of Indian Affairs
University of New Mexico 224 E. Palace Avenue
Albuquerque, NM 87131-0176 Santa FE, NM 87501
Lionel Anaya R.Ph. Loyola Burgess

111 Coors Road N.W. 1801 Dorothy Street, NE
Albuquerque, NM 87110 Albuquerque, NM 87112
Walace Begay, Co-Chairman

Pueblo Health Council/All Indian Pueblo Council
Technical: Sal Montano, 505/827-3143 P.O. Box 56
Policy: Sonya Miera, 505/827-7777 New Laguna, NM 87038
DUR & PA: Chuck Reynolds, 505/827-3174
Heather Wilson, Secretary
CYFD, PERA Building
Human Services Department Officials
1120 Paseo de Peralta
Robin O Dozier Santa Fe, NM 87501
Secretary Designate
P. O. Box 2348 Rosalyn Curtis
Santa Fe, NM 87504-2398 Director of the Navajo Nation
T: 505/827-4072 Division of Health
P.O. Box 1390
Chuck Milligan Window Rock, AZ 86515
Director
Medical Assistance Division Lila Maples, R.N.
2769 Villa Venado
Ross Becker Santa Fe, NM 87505
Deputy Director
Clarice Pick, D.D.S
1405 Luisa Street
Medical Advisory Committee Members Suite #2
Linda Sechovec Santa Fe, NM 87505
Executive Director
NM Health Care Richard L. Ragel, D.O.
6400 Uptown Blvd., NE, Suite 520-W 1010 Bridge Blvd., SW
Albuquerque, NM 87110 Suite D
Albuquerque, NM 87105-3734
Yvette Ramirez Ammerman
Policy Analyst Kathy Minoli, C.F.N.P.
New Mexico Primary Care Association 1835 Solano, NE
2309 Renard, S.E., Suite 209 Albuquerque, NM 87110
Albuquerque, NM 87106
3-New Mexico National Pharmaceutical Council

Mary Lou Edward State Board of Pharmacy

16 Applewood Lane, N.W. David Denoyer, Executive Director
Albuquerque, NM 87107 University Towers
505/898-5103 1650 University Blvd., NE, Suite 400B
Richard Honsinger, M.S. 505/841-9102
Los Alamos Medical Center
Los Alamos, NM 87544 New Mexico Hospitals and Health Systems Association
Maureen L. Boshier
Maureen Boshier President, CEO
New Mexico Hospital Association 2121 Osuna Road, NE
2121 Osuna Road NE Albuquerque, NM 87113
Albuquerque, NM 87113 505/343-0010
Joie Glen
Fiscal Intermediary
Executive Director
New Mexico Association for Home Care Diane Gately
3200 Carlisle N.E., Suite 115 Consultec
Albuquerque, NM 87110 510 N. Guadelupe, Suite C
Santa Fe, NM 87501
Dr. Norton Kalishman 505/983-5555
Chief Medical Officer
P.O. Box 26110
Santa Fe, NM 87502-6110
Bert Umland, M.D.

Division of Family Practice
UNM Medical Center
505/277-2165

New Mexico Medical Society
G. R. “Randy” Marshall
Executive Director
7770 Jefferson NE, Suite 400
505/828-0237
New Mexico Pharmaceutical Association

Dale Tinker
Executive Director
4800 Zuni, S.E.
505/265-8720
New Mexico Osteopathic Medical Association

Floyd F. Smith
Executive Director
P. O. Box 90396
505/828-1905
National Pharmaceutical Council New Mexico-4

NEW YORK

1

1998 1999
TOTAL $1,368,451,273 1,803,428 1,906,521,831 2,122,000
RECEIVING CASH ASSISTANCE, TOTAL $973,744,961 1,073,631 1,292,083,557 1,202,687

Aged $185,897,780 145,227 220,345,467 147,162
Blind / Disabled $688,950,800 390,585 893,845,203 421,594
AFDC-Child $37,327,228 358,928 58,757,046 430,163
AFDC-Adult $61,569,154 178,891 119,135,841 203,768
AFDC-Unemployed-Child $0 0 0 0
AFDC-Unemployed-Adult $0 0 0 0
MEDICALLY NEEDY, TOTAL $326,652,214 515,780 425,045,080 657,663

Aged $98,546,169 80,929 117,455,198 85,432
Blind / Disabled $174,038,100 81,238 219,616,402 88,679
AFDC-Child $30,387,933 254,244 46,307,214 346,029
AFDC-Adult $23,680,012 99,369 41,666,266 137,523
POVERTY RELATED, TOTAL $59,670,691 183,844 170,522,367 227,669

Aged $0 0 0 0
Blind / Disabled $0 0 0 0
AFDC-Child $6,050,198 65,735 1,509,819 13,993
AFDC-Adult $53,620,494 118,109 177,012,546 213,676
OTHER $8,383,406 32,173 10,870,828 33,981
1-New York National Pharmaceutical Council

C. ADMINISTRATION Prior Authorization: State currently does not have a

formal prior authorization procedure.
State Department of Health.
D. PROVISIONS RELATING TO DRUGS Prescription Refill Limit: Cannot exceed 5, and the life of
a prescription cannot exceed 6 months.
Benefit Design
Monthly Dollar Limits: None.
cosmetics; fertility drugs; and experimental drugs. Drug Utilization Review
Products not covered: prescribed insulin; disposable
needles and syringe combinations for insulin; blood PRODUR system implemented in March 1995. State
glucose test strips; urine ketone test strips; total parenteral currently has a DUR Board with a review every other
nutrition; and interdialytic parenteral nutrition. month.
Over-the-Counter Product Coverage: Products covered: Pharmacy Payment and Patient Cost Sharing
digestive products (H2 antagonists) and smoking deterrent
products. Products covered with restrictions: allergy, Dispensing Fee: $3.50 for brand name drugs, $4.50 for
asthma and sinus products; analgesics; cough and cold generic drugs. Effective 8/1/98.
preparations; digestive products (non H2 antagonist);
feminine products; and topical products. Ingredient Reimbursement Basis: EAC = AWP - 10%.
Therapeutic Category Coverage: Therapeutic categories Prescription Charge Formula:

NSAIDs; antibiotics; anticoagulants; anticonvulsants; 1. Payment for multiple source drugs must not exceed
antidepressants; antidiabetic agents; antihistamine drugs; the aggregate of the specified upper limit set by the
antilipemic agents; anti-psychotics; anxiolytics, sedatives, federal Health Care Financing Administration
and hypnotics; cardiac drugs; chemotherapy agents; (HCFA), plus a dispensing fee, for a particular drug;
contraceptives; ENT anti-inflammatory agents; estrogens; and
growth hormones; hypotensive agents; prescribed 2. Payment for brand name drugs and other multiple
smoking deterrents; sympathominetics (adrenergic); and source drugs not covered by clause (1) will be the
thyroid agents. Therapeutic categories partially covered: lower of: EAC plus a dispensing fee; or
prescribed cold medication and misc. GI drugs. 3. The billing pharmacy's usual and customary price
Therapeutic categories requiring prior authorization; charged to the general public.
medical/surgical supplies; orthopedic shoes; compression Maximum Allowable Cost: State imposes Federal Upper
stockings; and some DME items. Therapeutic categories Limits on generic drugs. Override requires “Dispense as
not covered: anorectics and agents used for hair growth. Written” and “Brand Necessary, ” or “Brand Medically
Necessary.”
reimbursable through the Prescription Drug Program Incentive Fee: None.
and through physician payment when used in physician Patient Cost Sharing: Copayment is $2.00 for brand name
offices. No special coverage policies exist for self- drugs, $0.50 for generic and OTC drugs. Exceptions
administered injectable medicines. include psychotropic drugs as well as drugs FDA
approved for the treatment of tuberculosis and family
Vaccines: Vaccines are reimbursable under the EPSDT planning drugs.
service and the Vaccines for Children program.
Formulary: Open formulary. General Exclusions: New
York State follows OBRA '90 guidelines in the
reimbursement of prescription drugs.
state.
National Pharmaceutical Council New York-2

Health Maintenance Organizations Formulary Contact

− ABC Mark-Richard A. Butt, 518/486-3209
− Bluechoice HMO Options
− Broome MC
− Bronx HP Mark-Richard A. Butt, 518/486-3209
− Buffalo Com. Health DUR Contact
− Careplus, LLC
− CDPHP Michael Zegarelli
− Center Care, Inc. DUR Manager, Office of Medical Management
− Community Blue NYS Department of Health
99 Washington Ave. Suite 601
− Community Choice HP
Albany, NY 12237
− Community Premier Plus
T: 518/474-6866
− Compre-Care, Inc.
F: 518/473-5332
− Capital Area CHP E-mail: maz03@health.state.ny.us
− Empire BCBS Healthnet
− Fidelis DUR Committee
− Genesis HP, Inc.
− Health Choice Physicians
− HealthFirst Richard S. Blum, M.D.
− Health Plus 25 Spruce Drive
− HIP/Nassau East Hills, NY 11576
− HIP/Westchester
Ronald J. Dougherty, M.D.
− HMO of Greater NY
9429 Woodlawn Drive
− HUM Healthcare Systems
Brewerton, NY 13029-9724
− IHA/WNY
− Managed Healthcare Systems Bernard Berkowitz, M.D.
− Metropolitan Plus Health Plan 63 Franklin Street
− Neighborhood Health Saratoga Springs, NY 12866
− NY Hosp CHP
− Partners David F. Lehmann, M.D.
− Preferred Care Dept. of Medicine
− Suffolk Co PHSP 750 East Adams Street
− Total Care Syracuse, NY 13210
− United Healthcare Plan of NY, Inc.
− United Healthcare of Upstate Pharmacists
− Vytra Jill Braverman-Panza, M.D.
− Wellcare 2 Executive Park Drive
− Westchester Prepaid Health Services Plan Albany, NY 12203
Sidney Falow, R.Ph.

F. STATE CONTACTS 12 Shore Park Road
Great Neck, NY 11023-2033
Marilyn C. Fortin, R.Ph.
Mark-Richard A. Butt, M.S., R.Ph.
NYS Department of Health
Director, Pharmacy Policy and Operations
Office of Continuing Care
Division of Provider Relations
EPIC
Office of Medicaid Management
260 Washington Avenue
Albany, NY 12212
99 Washington Ave., Suite 606
Albany, NY 12210
Marc L. Speert, R.Ph.
T: 518/486-3209
110 Russell Street
F: 518/473-5508
Cornwall, NY 12518
E-mail: mrb01@health.state.ny.us
http://www.health.state.ny.us

James R. Suhrbier, R.Ph. Disease Management Program/Initiative Contact

482 Mount Airy Road
Karen A. Fuller, Ph.D.
New Windsor, NY 12553
Director, Bureau of Program Guidance
DUR Experts
Mary Andritz, Pharm.D., R.Ph.
99 Washington Ave, Suite 606
Albany College of Pharmacy
Albany, NY 12210-2806
106 New Scotland Ave.
T: 518/474-9219
Albany, NY 12210
F: 518/473-5508
E-mail: KAF01@health.state.ny.us
Robert A. Hamilton, Pharm.D., R.Ph.
Albany College of Pharmacy
106 New Scotland Ave. Expanded Drug Program Contact
Albany, NY 12210
Julie Naglieri
Acting Director
Department Designee
Elderly Prescription Insurance Coverage (EPIC)
Lydia Kosinski, R.Ph.
1 Corporate Plaza, Suite 101
260 Washington Ave., Ext.
Albany, NY 12203
T: 518/452-6828
99 Washington Ave., Suite 601
F: 518-452-6882
Albany, NY 12210
E-mail: jab15@health.state.ny.us
518/474-6866
Karen A. Fuller, Ph.D., 518/474-9219
Carl T. Cioppa
Pharmacy Operations Manager
Pharmacy Policy and Operations Department of Health Officials
NYS Dept. of Health, Office of Medicaid Management Antonia C. Novello, M.D, M.P.H., Dr. Ph.
99 Washington Ave., Suite 606 Commissioner
Albany, NY 12210 NYS Department of Health
T: 518/486-3209 Corning Tower
F: 518/473-5508 The Governor Nelson A Rockefeller Empire State Plaza
E-mail: ctc02@health.state.ny.us Albany, NY 12237
Medicaid Drug Rebate Contacts Kathryn Kuhmerker

Deputy Commissioner
Audit & Policy: Mark-Richard Butt, 518/486-3209
Disputes: Mark-Richard Butt, 518/486-3209
PRODUR: Dennis Pidgeon, 518/474-6866
Corning Tower
The Governor Nelson A. Rockefeller Empire State Plaza
Albany, NY 12237
Computer Sciences Corporation (CSC)
800 North Pearl St. Karen A. Fuller, Ph.D.
Albany, NY 12204 Director, Bureau of Program Guidance
518/447-9200 Division of Provider Relations/Office of Medicaid
Management
Medicaid Managed Care Contact 99 Washington Ave., Suite 606
Albany, NY 12210
Elizabeth Macfarlane
618/474-9219
Director, Bureau of Program Planning
NYS DOH Office of Managed Care
Room 1927, Corning Tower ESP
Albany, NY 12237-0064
T: 518/473-0122
F: 518/474-5886
E-mail: EAG01@health.state.ny.us

Carl Cioppa, R.Ph. William O'Dwyer, M.D.

Pharmacy Operations Manager 14 Loudon Parkway
Division of Provider Relations Loudonville, NY 12211
NYS Department of Health Elena Padilla, Ph.D.
99 Washington Ave., Suite 606 3 Washington Square Village
Albany, NY 12210 Apt. 15-0
New York, NY 10012
Marlene Dickson, R.Ph.
Pharmacy Program Specialist Hugo Morales, M.D. P.C.
Division of Provider Relations Medical Director
Bronx Mental Health Center
Anita Murray, R.Ph. Psychiatry & Neurology
Pharmacy Program Specialist 1211 Gerard Avenue
Division of Provider Relations Bronx, NY 10452
Joseph Maiello, R.Ph. Ruben Cowart, D.D.S., Chairman

Pharmacy Program Specialist Executive Director
Division of Provider Relations Syracuse Community Health Center
819 South Salina Street
Anne Budin, R.N. Syracuse, NY 13202
Pharmacy Program Specialist
Division of Provider Relations Randall Bloomfield, M.D.
NYS Medical Society
Sally Nelsen, R.Ph. 188 Lincoln Road
Pharmacy Program Specialist Brooklyn, NY 11225
Ellen Chiang
Title XIX Medical Care Advisory Committee Prestige Care
150 W. 28th Street, Room 503
John Hollomon, M.D.
New York, NY 10001
27-40 Ericsson Street
E. Elmhurst, NY 11369 Tanton Mustapha, M.D.
848 Columbia Street
Roger W. Trifshauser, D.D.S., M.S. Hudson, NY 12534
63 Ellicott Avenue
Batavia, NY 14020 Dennis P. Norfleet, M.D.
40 West Mohawk Street
Ellen M. Vossler, D.D.S. Oswego, NMY 13126
57 High Park Blvd.
Amherst, NY 14226 Louis Goldberg, DDS.
University at Buffalo School of Dental Medicine
Charles Wisor, M.D. 3435 Main St.
70 Mason Street Buffalo, NY 14214
Geneva, NY 14456
Ann Wilkinson
Stoner E. Horey, M.D. CHAP Office
20 Elm Street, Suite 6 Jamaica Hospital
Hornell, NY 14823 89th Avenue and Van Wyck Expressway
Jamaica, NY 11418
Norman R. Loomis, M.D.
7736 Tamarak Lane John Angerosa, M.D.
Ontario, NY 14519 11 Boyle Road
Scotia, NY 12302

DSS Designee: Charles Aswad, M.D.

Patricia Stevens, Deputy Commissioner Executive Vice President
NYS Office of Temporary and Disability Assistance 420 Lakeville Road
Division of Temporary Assistance P.O. Box 5404
40 N. Pearl St., 7th floor Lake Success, NY 11042-5404
Albany, NY 12243 516/488-6100
Pharmacy Advisory Committee Pharmaceutical Society of the State of New York

John P. Navarra, Chairman Craig Burridge, Executive Director
Town Total Nutrition Pine West Plaza IV
45 East 30th Street Washington Avenue Extension
New York, NY 10016 Albany, NY 12205
212-213-5570 518/869-6595
Patricia Donato New York State Osteopathic Medical Society, Inc.

Capital Consultants Christian M. Hynes
251 New Karner Road Executive Director
Albany, NY 12205 181 Weber Hill Road
518/456-3216 Carmel, NY 10512
800/841-4131
John Westerman, Jr.
14 Osprey Hill Drive New York State Board of Pharmacy
Newburgh, New York 12550 Lawrence H. Mokhiber
914/561-4890 Executive Secretary
Cultural Education Center Rm. 3035
Kandyce J. Daley Albany, NY 12230
Eckerd Drug Co. Inc. 518/474-3848
7245 Henry Clay Boulevard
Liverpool, NY 13088 Healthcare Association of New York State
315/451-8000 x2292 Daniel Sisto
President
Thomas F. Golden, Jr. 74 North Pearl St.
Eckerd Drug Co. Inc. Albany, NY 12207
1483 Route 9 518/431-7600
Halfmoon, NY 12065
518/371-1513 Greater New York Hospital Association
Subsidiaries and Affiliates
Dilip Patel Kenneth E. Raske
7 Rubinstein Court President
New Hempstead, NY 10977 555 W. 57th Street.
212-567-3384 15th Floor
New York, NY 10019
Mohammed Saleh 212/246-7100
M & I Pharmacy
853 East New York Avenue
Brooklyn, NY 11203
718/493-8118
Stephen L. Giroux
Middleport Family Health Center
81 Rochester Road, Box 188
Middleport, NY 14105
716/735-7550

Medical Society of the State of New York

NORTH CAROLINA

1

1998 1999*
TOTAL $466,528,812 764,886

Aged $102,046,805 75,511
Blind / Disabled $137,208,166 103,517
AFDC-Child $19,309,935 147,596
AFDC-Adult $30,503,271 86,761

Aged $58,286,777 38,339
Blind / Disabled $74,389,528 45,957
AFDC-Child $663,154 2,975
AFDC-Adult $4,324,387 7,732

Aged $0 0
AFDC-Child $27,787,899 209,686
AFCC-Adult $3,123,777 26,820
OTHER $7,345,941 14,222
Source: HHS State HCFA-2082 Reports, Section A-4 and B-4.

1-North Carolina National Pharmaceutical Council


Monthly Quantity Limit: 100-day supply maximum.
Division of Medical Assistance, Department of Human
Resources. Monthly Prescription Limit: Six prescriptions per month
per recipient.
Prescription Dollar Limits: None.
Benefit Design
prescribed insulin. Prior authorization required for: Viagra PRODUR system implemented in May 1996. State
and Serostim. Products not covered: cosmetics; fertility currently has a DUR Board with a quarterly review.
drugs; experimental drugs; disposable needles and syringe
combinations used for insulin; blood glucose test strips; Pharmacy Payment and Patient Cost Sharing
urine ketone test strips, total parenteral nutrition; and
interdialytic parenteral nutrition. Dispensing Fee: $5.60, effective January 1992.
Over-the-Counter Product Coverage: Products not Ingredient Reimbursement Basis: EAC = AWP-10%.
covered: allergy, asthma and sinus products; analgesics;
cough and cold preparations; non-H2 antagonist digestive Prescription Charge Formula: The lowest price of AWP
products; digestive products, H2 antagonists; feminine minus 10% or MAC, plus a dispensing fee for each
products; topical products; and smoking deterrent different drug dispensed during a month, or AWP plus the
products. lowest dispensing fee accepted from other third party
payers. The pharmacist filling the original prescription
Therapeutic Category Coverage: Therapeutic categories will not be reimbursed for refills for the same drug within
covered: anabolic steroids; analgesics, antipyretics, a calendar month.
NSAIDs; anorectics; antibiotics; anticoagulants;
anticonvulsants; antidepressants; antidiabetic agents; Maximum Allowable Cost: State imposes Federal Upper
antihistamine drugs; antilipemic agents; anti-psychotics; Limits on generic drugs. 223 drugs are listed on the state-
anxiolytics, sedatives, and hypnotics; cardiac drugs; specific MAC list. Override requires “Brand Medically
chemotherapy agents; prescribed cold medications; Necessary.”
growth hormones; hypotensive agents; misc. GI drugs; Incentive Fee: None.
prescribed smoking deterrents; sympathominetics
(adrenergic); and thyroid agents. Patient Cost Sharing: $1.00 copayment/Rx (includes
refills).
reimbursable through the Prescription Drug Program Cognitive Services: Does not pay for cognitive services.
when used in home health care, extended care facility, and
through physician payment when used in physician
offices.
Vaccines: Vaccines reimbursable as part of the Health
Check service.
state.
Unit Dose: Unit dose packaging reimbursable if packaged
in unit dose only.
The Wellness Plan of NC, Inc.
Formulary: Closed formulary. Tim O’Brien
1409 East Blvd, Ste. 204
Prior Authorization: State currently does not have a Charlotte, NC 28203-5476
formal prior authorization procedure. A hearing officer is 704/370-0090
required to appeal prior authorization decisions.
National Pharmaceutical Council North Carolina-2

United HealthCare of NC Pharmacists:

Charren Nelson Joseph S. Moose, R.Ph., Pharm. D.
2307 W. Cone Blvd. Moose Professional Pharmacy
Greensboro, NC 28217 390 Copperfield Boulevard
Concord, NC 28025
SouthCare/Coventry 704/784-9613
2815 Coliseum Center Dr. Bruce R. Canaday, Pharm. D.
Charlotte, NC 28217
Jennifer Burch, Pharm. D.
F. STATE CONTACTS Jeff Peterson, R.Ph.
Glaxo
State Drug Program Administrator 207 Glen Abbey Drive
C. Benny Ridout, R.Ph. Cary, NC 27513
Pharmacist Consultant 919/460-9375
NC Division of Medical Assistance
1985 Umstead Drive Penny S. Shelton, Pharm.D.
2511 Mail Service Center 113 Honeysuckle Lane
Raleigh, NC 27699-2511 Durham, NC 27703
T: 919/733-4034 919/733-5266
F: 919/733-2796
E-mail: benny.ridout@ncmail.net Prescription Price Updating
Prior Authorization Contact C. Benny Ridout, 919/733-4034
C. Benny Ridout, 919/733-4034 Medicaid Drug Rebate Contacts
DUR Contact Tech.: Dewey Cassell, 919/851-8888 x 158

P & A: Benny Ridout, 919/857-4034
Sharman Leinwand Rebate Disputes: Sharon Greeson, 919/233-6829
DUR Coordinator DUR: Sharman Leinwand, 919/733-3590
N.C. Division of Medical Assistance
2515 Mail Service Center Claims Submission Contact
Raleigh, NC 27699-2515
T: 919/733-3590 Sharon Greeson, R.Ph.
F: 919/715-7706 Pharmacist Consultant, EDS
4905 Waters Edge Drive
Medicaid Drug Utilization Review Board Raleigh, NC 27606
Physicians: T: 919/233-6829
Patricia Burns, M.D. F: 919/859-9703
E-mail: sharon.greeson@eds.com
Douglas Pritchard, M.D.
Carolina Anesthesia Associates Medicaid Managed Care Contact
P.O. Box 801
Statesville, NC 28677 C. Benny Ridout, 919/733-4034
Edward Treadwell, M.D. Disease Management Program/Initiative Contact

ECU School of Medicine
C. Benny Ridout, 919/733-4034
Department of Medicine/Rheumatology
Greenville, NC 27858
Geneva Fearrington
Department of Health and Human Services
1985 Umstead Drive

Department of Human Resources Officials

Benny Ridout
Paul R. Peruzzi, Director Box 88
Department of Health and Human Services Morrisville, NC 27560
1985 Umstead Drive William Holshouser
2517 Mail Service Center 13 Dogwood Road
Raleigh, NC 27699-2517 Salisbury, NC 28144
Daphne O. Lyon
Deputy Director George McLarty
PO Box 1028
H. David Bruton, M.D. High Point, NC 27261-1028
Secretary
Department of Health and Human Services Walton P. O’Neal III
101 Blair Drive 302 Sunnyside Drive
2001 Mail Service Center Washington, NC 27889
Health Care Access Committee II-3
Department of Human Resources Advisory Jack R. Page, M.D., Chairman
Committees 3 Hartley Place
Durham, NC 27707
Pharmaceutical Association, Third Party
William Taylor Donald T. Lucey, M.D. Vice-Chair
8208 Brownleigh Drive 2800 Blue Ridge Blvd., Suite 403
Raleigh, NC 27612 Raleigh, NC 27607
Paul Bisette H. David Burton, M.D.
PO Box 785 NC Department of Human Resources
Wilson, NC 27893-0785 101 Blair Drive
PO Box 29526
David T. Hix Raleigh, NC 27626-0526
235 Burke Street
Gibsonville, NC 27249-2402 Lindsey E. deGuehery, M.D.
1812 Glendale Drive
Jim LeCroy Wilson, NC 27893
5454 Eastwind Road
Wilmington, NC 28403 Raphael J. DiNapoli, Jr., M.D.
1985 Umstead Drive, P. O. Box 29529
Jim Hall Raleigh, NC 27626-0529
138 N. Churton Street
Hillsboro, NC 27278 E. Stephen Edwards, M.D.
2800 Blue Ridge Blvd.
David S. Moody Jr. Ste. 501
4100 Grove Ridge Drive Raleigh, NC 27607-6496
Durham, NC 27703
Brian R. Forrest
Mickey Watts, Liaison 6016 Farmgate Road
PO Box 39 Raleigh, NC 27606
Concord, NC 28026
Shelton P. Hager
Vince Stevens 2651 MacGregor Down Road
8408 Inverness Way Apt. K
Chapel Hill, NC 27516 Greenville, NC 27858
John Zatti Ann Faris
5 Porchlight Court 2720 Bitting Road
Durham, NC 27707 Winston-Salem, NC 27104

Johnson H. Kelly, M.D. Lee B. Hoffman

1001 N. Washington Street Chief
Shelby, NC 28150 Certificate of Need Section
Facility Services Division
Donald T. Lucy, M.D. North Carolina Department of Human Resources
2800 Blue Ridge Blvd., Ste. 403 P.O. Box 29530
Raleigh, NC 27607 Raleigh, NC 27626-0530
William O. McMillan, Jr., M.D. Jeffrey A. Katz

P.O. Box 9025 18 Cherry Grove Road
Wilmington, NC 28402-9025 Hickory, NC 28602
Edwin W. Monroe, M.D. Barbara D. Matula

104 W. Longmeadow Rd. Director
Greenville, NC 27858-3714 Medical Assistance Division
NC Department of Human Resources
William J. Murray, M.D. P.O. Box 29579
Duke University Medical Center Raleigh, NC 27626-0529
Box 3094
Durham, NC 27710 David E. Rice
Sara Lee Corporation
Paul R. Peruzzi P.O. Box 2760
Deputy Director Winston-Salem, NC 27102-2760
Medical Assistance Division
NC Dept. of Human Resources Pam Silberman, JD
PO Box 29529 2108 Umstead Drive
Raleigh, NC 27626-0529 Raleigh, NC 27603
Kenneth G. Reeb, M.D. Executive Officers of State Medical and

UNC School of Medicine, Family Practice Department Pharmaceutical Societies
Chapel Hill, NC 27599
North Carolina Medical Society
Bob Seligson, M.B.A., CAE
C. Stewart Rogers, M.D.
1200 N. Elm Street
222 North Person St., P.O. Box 27167
Greensboro, NC 27401-1020
919/833-3836
William J. Spencer, M.D.
851 Brookleigh Court
North Carolina Pharmaceutical Association
Winston-Salem, NC 27104
Dan Garrette
Executive Director
Delford L. Stickel, M.D.
Box 151
Duke University, Box 3917
Chapel Hill, NC 27514-0151
Durham, NC 27710
919/967-2237
James D. Bernstein
North Carolina Osteopathic Association, Inc.
Rural Health and Resources Development Office
Barbara Walker, D.O.
President
311 Ashe Avenue
207 Viking Drive
Raleigh, NC 27606
Fayetteville, NC 28303
910/864-7515
James A. Clarke, Ed.D.
Associate State Director
PO Box 37067
Raleigh, NC 27627


David R. Work
Executive Director
P. O. Box 459
Carrboro, NC 27510-0459
919/942-4454
North Carolina Hospital Association

William A. Pulley
President
P.O. Box 80428
919/677-2400

NORTH DAKOTA

1

1998* 1999
TOTAL $27,619,684 37,675 $27,619,684 37,675

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult

Aged
Blind / Disabled
AFDC-Child
AFDC-Adult
OTHER

1-North Dakota National Pharmaceutical Council

C. ADMINISTRATION Prescription Charge Formula: Acquisition Cost plus a

dispensing fee per prescription or the usual and customary
North Dakota Department of Human Services. retail charge, whichever is lower. Acquisition Cost =
EAC or MAC.
Benefit Design Limits on generic drugs. Override requires “Dispense As
Written.”
cosmetics; drugs used for hair growth; prescription Incentive Fee: None..
vitamins (except prenatal vitamins); and DESI drugs.
Prior authorization required for: smoking cessation and Patient Cost Sharing: No copayment.
nutritional supplements.
Cognitive Services: Does not pay for cognitive services
antacids; analgesics; iron supplements; artificial tears; and E. USE OF MANAGED CARE
anti-ulcer medications.
!"#$%&&'(((%)#*+,-+*%$#,+.+#/01%2#$#%#/$344#*%+/
Coverage of Injectables: Injectable medicines 5-/-6#*%,-$#%+/%7889:%%;3/#%$#,#+"#*%.<-$5-,=%1#$"+,#1
reimbursable when used in physician offices, home health 0<$3>6<%5-/-6#*%,-$#.
F. STATE CONTACTS
service. State Drug Program Administrator
Unit Dose: Unit dose packaging not reimbursable. Rick Detwiller, R.Ph.
Administrator, Pharmacy Services
600 East Boulevard Avenue, Dept. 325
Bismarck, ND 58505-0261
701/328-4023
Fax 701/328-1544
Prior Authorization:
Pat Kramer, R.Ph.
Director, Utilization Management
Prescription Refill Limit: A prescription drug may be Pharmacy Services, Medical Services
refilled for 12 months after the date of the original Department of Human Services
prescription, provided that such refills have been State Capital
authorized by the physician. 600 East Boulevard Avenue
Monthly Quantity Limit: 34-day supply. 701/328-4893
Monthly Dollar Limits: None. DUR Board

Mark Biel, R.Ph.
517 W. Reno Ave.
Bismarck, ND 58504
PRODUR system implemented in July 1996.
701/223-0936
Patricia M. Churchill, R.Ph.
103 West Ave. B
Dispensing Fee: $4.60, effective 8/1/97. Bismark, ND 58501
701/663-5188
Ingredient Reimbursement Basis: EAC = AWP-10%.
National Pharmaceutical Council North Dakota-2

Gregory L. Culver, M.D. Joseph Cleary, M.D.

Towner County MedCenter Medical Consultant
P.O. Box 579 ND Department of Human Services
Cando, ND 58324 State Capitol - Judicial Wing
701/968-3337 Bismarck, ND 58505-0250
701/328-2321
Community Practice Medical Resident
(rotational contact: Susan Thompson) Rick Detwiller R.Ph.
UND Family Practice Center Administrator, Pharmacy Services
515 Broadway Avenue Medical Services, DHS
Bismarck, ND 58501 600 East Boulevard Ave, Dept 325
701/328-9950 Bismarck, ND 58505-0261
701/328-4023
Delbert J. Hlavinka, M.D.
MeritCare Mayville Clinic
730 E Main Street Technical: Rick Detwiller, 701/328-4023
Mayville, ND 58257 Policy: Rick Detwiller, 701/328-4023
701/786-4503 DUR: Pat Kramer, 701/328-4893
PA: Pat Kramer, 701/328-4893
James H. Irsfeld, R.Ph.
1042 West 4th Ave Department of Human Services Officials
Dickinson, ND 58601
Carol Olson
701/225-4858
Executive Director
ND Dept. of Human Services
Karen K. Iverson, R.Ph.
Capitol Building
Student Health Service Pharmacy
Bismarck, ND 58505
North Dakota State University
PO Box 5313
LeRoy Bollinger
Fargo, ND 58105-5313
Administrator
701/231-7332
Research and Statistics
Anthony T. Johnson, M.D.
Dave Zentner
102 Mandan Ave.
Medicaid Director
Mandan, ND 58554
701/667-5005
Department of Human Services Advisory
Marty Meese, Pharm.D., R.Ph. Committees
St. Alexis Pharmacy
900 East Broadway Medical Care Advisory Committee
Bismarck, ND 58501 Jon Rice, M.D.
701/224-7378 State Health Officer
State Health Department
Pierre Rioux, MD 600 East Boulevard
307 5th Ave Southeast Bismarck, ND 58505
Minot, ND 58701 701/328-2372
701/852-0735
Joseph W. Cleary, M.D.
Ex-Officio Members 104 Seminole Avenue
Patricia A. Kramer, R.Ph. Bismarck, ND 58501
Medical Services, DHS Robert A. Schindler, D.D.S.
600 East Boulevard Ave, Dept 325 Northbrook Mall
Bismarck, ND 58505-0261 1929 N. Washington
701/328-4893 Bismarck, ND 58501
701/223-3694

Howard Anderson, R.Ph. Gregory A. Gapp, M.D.

PO Box 70 Grand Forks Clinic Ltd.
Turtle Lake, ND 58575 Grand Forks, ND 58206
701/448-2542
Stephen H. Goldberger, M.D.
Delores Farrell Grand Forks Clinic Ltd.
401 North 14th Street Grand Forks, ND 58206
Bismark, ND 58501
Genevieve M. Goven, M.D.
Patricia Carlson Meritcare Clinic Valley City
172 Boise Avenue Valley City, ND 58072
Bismarck, ND 58504
701/222-1822 Mark B. Hart, M.D.
The Bone and Joint Center
Arne Springan, O.D. Bismack, ND 58504
1203 Oahe Bend
Bismarck, ND 58504 George H. Hilts, M.D.
Dakota Eye Institute
Christine Becker Bismarck, ND 58504
HCO4 Box 12
Mandan, ND 58554 Mark O. Jensen, M.D.
701/663-2659 300 Main Avenue
Fargo, ND 58103
Commission on Socio-Economic Affairs
Robert F. Szczys, M.D., Chairman Donald R. Lamb, M.D.
Grand Forks Clinic Ltd. 100 4th Street, S., Ste. 504
Grand Forks, ND 58206 Fargo, ND 58103
Russel J. Kuzel, M.D., Vice Chairman Gregory J. Post, M.D.

Dakota Clinic Ltd. Meritcare Medical Group
Fargo, ND 58103 Fargo, ND 58123
Bipin B. Amin, M.D. David A. Rinn, M.D.

Mid Dakota Clinic Towner County Medcenter
Bismarck, ND 58502 Cando, ND 58324
William W. Barnes, M.D. Pierre A. Rioux, M.D.

307 5th Avenue, SE 307 5th Avenue, SE Ste. 300
Minot, ND 58701 Minot, ND 58701
Norman E. Bystol, M.D. Thomas R. Templeton, M.D.

Dakota Clinic Ltd. Great Plains Clinic
Fargo, ND 58108 Dickinson, ND
James R. Carpenter, M.D. Brian C. Willoughby, M.D.

Meritcare Medical Group West River Health Clinics
Fargo, ND 58123 Hettinger, ND 58639
Stanley T. Diede, M.D. Councilors Assigned

Heart and Lung Clinic David H. Lane, M.D.
Bismarck, ND 58502 Anesthesia Associates Ltd.
Grand Forks, ND 58208
Harold W. Evans, M.D.
Grand Forks Clinic Ltd. Larry E. Johnson, M.D.
Grand Forks, ND 58206 Dakota Clinic Ltd.
P. O. Box 1980
Jamestown, ND 58402
National Pharmaceutical Council North Dakota-4

Pharmacy Advisory Committee State Board of Pharmacy

Howard Anderson
Robert L. Treitline, Chair
Executive Director
941 9th Avenue West
P. O. Box 1354
Dickinson, ND 58601
701/328-9535
Anton P. Welder, R.Ph.
P.O. Box 835
North Dakota Association of Osteopathic Physicians and
Bismarck, ND 58502
Surgeons
James Wolff
Doreen M. Beiswanger, R.Ph
Executive Director
1140 SE 6 Street, Unit 10
736 Broadway
Valley City, ND 58072
Fargo, ND 58123
701/234-2400
David L. Just, R.Ph.
P.O. Box 99
North Dakota Hospital Association
Beulah, ND 58523
Arnold R. Thomas
President
David J. Olig, R.Ph.
1120 College Drive
2400 32nd Avenue South
P.O. Box 7340
Fargo, ND 58103
701/224-9732
DuWayne Schlittenhard, R.Ph.
3408 Par Street
Fargo, ND 58102
Mary Beth Reinke, R.Ph.

3530 SW 28 #301
Fargo, ND 58104
Cindy Yeager, R.Ph.

Box 9512
Fargo, ND 58108

North Dakota Medical Association
Cathy Rydell
204 W. Thayer Avenue
P.O. Box 1198
701/223-9475
North Dakota Pharmaceutical Association

Galen Jordre
P.O. Box 5008, 405 E. Broadway
701/258-9312

OHIO

1

1998* 1999
TOTAL $645,118,962 702,143 $758,909,302 794,436
CATEGORICALLY NEEDY CASH TOTAL 40,749,264 149,166

Aged 1,225,142 915
Blind 16,198 12
Disabled 13,101,026 6,316
Children-Families w/Dep. Children 13,637,456 100,354
Adults-Families w/Dep. Children 12,769,439 41,569
CATEGORICALLY NEEDY NON-CASH TOTAL 718,160,037 645,270

Aged 261,686,553 134,410
Blind 1,363,558 815
Disabled 403,254,744 194,524
Children-Families w/Dep. Children 32,170,912 233,067
Adults-Families w/Dep. Children 17,540,711 72,849
Other Title XIX Recipients 2,143,557 9,605
MEDICALLY NEEDY TOTAL 0 0

Aged 0 0
Blind 0 0
Disabled 0 0
Children-Families w/Dep. Children 0 0
Adults-Families w/Dep. Children 0 0
Other Title XIX Recipients 0 0

National Pharmaceutical Council Ohio-1

Ohio Department of Job and Family Services. Formulary: Closed formulary with approximately 38,000
NDC-specific trade and generic drugs. Products excluded
D. PROVISIONS RELATING TO DRUGS include obesity, fertility, and experimental drugs.
Benefit Design Prior Authorization: Prior authorization is needed for

certain individual drugs (listed above).
Drug Benefit Product Coverage: Products covered under
DME/med supply program: prescribed insulin; total Prescribing or Dispensing Limitations
parenteral nutrition; interdialytic parenteral nutrition. Prescription Refill Limit: 11 for non-controlled drugs up
Products not covered: cosmetics; fertility drugs; to one year. Thirteen for birth control drugs up to one
experimental drugs; disposable needles and syringe year. Five for Scheduled III, IV, V drugs up to six
combinations used for insulin; urine ketone test strips; and months. None for Scheduled II drugs.
blood glucose test strips. Prior authorization required for:
Ceredase; Cerebyx; Cerezyme; Clorazepates; Depo- Monthly Quantity Limit: Maximum of 34-day supply for
Provera; Enbrel; immunoglobulins; Lioresal Intrathecal; acute and 102-dosage units for chronic maintenance
Lodosyn; Methadone; Nascoral; Orgaran; Oxandrin medications. Amount designated in Ohio Medicaid drug
Panretin; Periostat; Priftin; Prolastin; Proleukin; Provigil; formulary.
Psoralens; Rebetin; Remicade; Piluter; Rituxan; Stimate;
Synagis; and Targretin.
OTC Coverage: Selected coverage for: allergy, asthma,
and sinus products; analgesics; feminine products; PRODUR system implemented in Feb 2000. State
smoking deterrent products; cough and cold preparations; currently has a DUR Board with a quarterly review.
non-H2 antagonist digestive products; digestive products,
H2 antagonists; and topical products.
covered: analgesics, antipyretics, NSAIDs; antibiotics; Dispensing Fee: $3.70, effective 7/1/98.
antidiabetic drugs; antihistamine drugs; antilipemic Ingredient Reimbursement Basis: EAC = WAC+11%.
agents; anti-psychotics; anxiolytics, sedatives, and
hypnotics; cardiac drugs; chemotherapy agents; prescribed Prescription Reimbursement Formula: Reimbursement
cold medications; contraceptives; ENT anti-inflammatory for legend drugs and selected OTC products based on the
agents; estrogens; hypotensive agents; prescribed smoking lowest of:
deterrents; sympathominetics (andrenergic); and thyroid
agents. PA required for: anabolic steroids and growth 1. Provider’s submitted charge, which should reflect
hormones. Therapeutic categories not covered: anorectics; usual and customary charge to the general public;
innovator multi-source drugs; certain antibiotics (last-line 2. WAC+11% plus a dispensing fee.
therapies); selected high-risk drugs like (e.g., Accutane); 3. Federal- or state-established Maximum Allowable
and drugs used in special settings (e.g., outpatient Cost (MAC), for specifically designated generically
hospital). equivalent drugs plus a dispensing fee.
Coverage of Injectables: Injectable medicines Non-legend drugs - reimbursement is based on
reimbursable through the Prescription Drug Program WAC+11% plus a dispensing fee, or MAC if applicable.
and through physician payment when used in physicians Maximum Allowable Cost: State imposes Federal Upper
offices. Limits as well as state-specific limits on generic drugs.
Override requires prior authorization.
Vaccines: Vaccines reimbursable as part of the Vaccines
for Children Program. Incentive Fee: None.
Unit Dose: Unit dose packaging not reimbursable. Patient Cost Sharing: No copayment.
2-Ohio National Pharmaceutical Council

Sheila Fujii, Chief

E. USE OF MANAGED CARE Bureau of Medical Assistance
65 E. State St., 4th Floor
!""#$%&'()*+,-.//0111-$2-3*4&5(&4-#*5&"&*6)7-8*#* Columbus, OH 43215
*6#$++*4-&6-'(6(9*4-5(#*-&6-:;;;<--!++-#*5*&=*4-">(#'(5,
614/466-2365
7*#=&5*7-)>#$?9>-'(6(9*4-5(#*-"+(67.
Robert P. Reid, R.Ph.
• Butler Health Plan 614/466-6420
• ChoiceCare
• Community Health Plan DUR Contact
• DayMed
• Dayton Area Health Plan Jan Lawson
• Emerald HMO, Inc. DUR Administrator
• Family Health Plan SUR
• Genesis Health Plan of Ohio 65 E. State St. 4th Fl.
Columbus, OH 43215
• Health Care USA
• Health Power
DUR Board
• HealthFirst
• HMO Health Ohio Thomas E. Gretter, M.D.
• Paramount Care, Inc. Stephen Baez, M.D.
• Personal Physician Care Jacob F. Palomaki, M.D.
• QualChoice Health Plan, Inc. Beth T. Tranen, D.O.
• SummaCare, Inc. Rob Kubasak, R.Ph.
• SuperBlue HMO Suzanne Eastman, R.Ph.
• SuperMed HMO Jill Orn, R.Ph.
Donald Sullivan, Ph.D.
• Total Health Care Plan
• United Health Care
Robert P. Reid, R.Ph.
F. STATE CONTACT 614/466-6420
State Drug Program Administrator Medicaid Drug Rebate Contacts
Robert P. Reid, R.Ph. Technical: JD Salvatore, 614/728-3955
Administrator, Pharmacy Services Unit Policy: Robyn Colby, 614/486-6420
Ohio Department of Job and Family Services Audits: Robert Reid, 614/486-6420
Bureau of Health Plan Policy
30 East Broad St., 27th Floor
Columbus, OH 43266-0423
T: 614/466-6420 First Health Services
F: 614/466-2908 4300 Cox Road
E-mail: rreid@odjfs.state.oh.us Glen Allen, VA 23060
Richmond, VA
Medicaid Department Officials 800/884-2822
Jacqueline Romer-Sensky, Director
Ohio Department of Job and Family Services
30 East Broad Street, 32nd Flr. Cynthia Burnell
Columbus, OH 43266-0423 Bureau Chief
Managed Health Care
Barbara C. Edwards, Deputy Director Ohio Department of Job and Family Services
Office of Medicaid 65 E. State St., 3rd Fl.
Columbus, OH 43266
Robyn Colby, Chief 614/466-4693
National Pharmaceutical Council Ohio-3

Physician Administered Drug Program Contact Executive Officers of State Medical and
Robert Reid, R.Ph.
Bureau of Health Plan Policy Ohio State Medical Association
30 East Broad St., 27th Floor D. Brent Mulgrew
Columbus, OH 43266-0423 1500 Lakeshore Drive
T: 614/466-6420 Columbus, OH 43204
F: 614/466-2908 614/486-2401
Pharmacy and Therapeutics Committee Ohio Pharmacists Association

Ernest “Ernie” Boyd
(2 vacancies pending) Executive Director
6037 Frantz Road, Ste. 106
Robert P. Reid, R.Ph., Chairman
Columbus, OH 43017
614/798-0037
30 East Broad Street, 27th Floor
Osteopathic Association
Jon F. Wills
Suzanne Eastman, R.Ph., M.S.
Executive Director
3922 North Cliff Lane
53 W. 3rd Avenue
Cincinnati, OH 43220
P.O. Box 8130
Columbus, OH 43201
Charles B. May, D.O.
614/299-2107
2467 Plymouth Avenue
Columbus, OH 43209
William Winsley
Ruth E. Purdy, D.O.
Executive Director
100 West Third Avenue
77 S. High Street, 17th Floor
Columbus, OH 43201
614/466-4143
Susan Baker, APN
137 Otterbein
Ohio Hospital Association
Lexington, OH 44904
James Castle
President
Mary Jo Walker, M.D.
155 E. Broad St.
2231 North High Street
Columbus, OH 43215
Columbus, OH 43210
614/221-7614
Walter J. Wielkiewicz, M.D.
Formulary Contact Person
5190 Heritage Drive
Nashport, OH 43830 Robert P. Reid, R.Ph.
James Visconti, Ph.D. 30 E. Broad Street, 27th Floor
410 W. Tenth Avenue Columbus, OH 43266-0423
Columbus, OH 43210 T: 614/466-6420
F: 614/466-2908
Tammie J. Stroup, R.Ph. E-mail: reidr@odjfs.state.oh.us
30 E. Broad Street, 27th Fl.
4-Ohio National Pharmaceutical Council

OKLAHOMA

1

1998 1999*
TOTAL $135,622,036 217,322

Aged $21,639,323 22,550
Blind $385,479 481
Disabled $46,695,570 41,968
CATEGORICALLY NEEDY NON-CASH TOTAL $56,590,131 78,701

Aged $34,623,534 21,563
Blind $53,640 34
Disabled $14,102,481 7,749
MEDICALLY NEEDY TOTAL $846,239 2,128

Aged $169,914 166
Blind $6,048 1
Disabled $383,769 344
Adults-Families w/Dep. Children $102,784 380

*1999 expenditures broken down by maintenance assistance and basis of eligibility are unavailable.
National Pharmaceutical Council Oklahoma-1

C. ADMINISTRATION Prescription or Dispensing Limitations

Prescription Refills: Shall be provided only if authorized
Oklahoma Health Care Authority. by the prescriber, no more than 1 year.
D. PROVISIONS RELATING TO DRUGS Monthly Quantity Limits: Three prescriptions per

month/recipient. ICF-MR, Medicaid children, and
Benefit Design nursing home recipients are allowed unlimited orders.
Quantity Limit per Prescription: 34-day supply or 100
Drug Benefit Product Coverage: Products covered (DME units.
benefit): prescribed insulin, disposable needles and
syringe combinations for insulin; blood glucose test strips;
and urine ketone test strips. Products covered with Drug Utilization Review
restrictions: total parenteral nutrition (reimburse single
most costly ingredient). Products not covered: cosmetics; PRODUR system implemented in 1993 with a new system
fertility drugs; and experimental drugs. in 2000. State currently has a DUR Board with a quarterly
review.
birth control. Products not covered: allergy, asthma and Pharmacy Payment and Patient Cost Sharing
sinus products; analgesics; cough and cold preparations;
digestive products, feminine products; topical products; Dispensing Fee: $4.15, effective 10/95.
and smoking deterrent products.
Ingredient Reimbursement Basis: EAC = AWP - 10.5%.
covered: antibiotics; anticoagulants; anticonvulsants; Prescription Charge Formula: Estimated Acquisition
antidepressants; antidiabetic agents; antilipemic agents; Cost (EAC) plus dispensing fee, or usual and customary
anti-psychotics; cardiac drugs; chemotherapy agents; charge, whichever is lower. In no event shall charges to
contraceptives; ENT anti-inflammatory agents; estrogens; the Welfare Department exceed charges made to the
hypotensive agents; sympathominetics (adrenergic); and general public for the same prescription or item.
thyroid agents. Prior authorization required for:
analgesics, antipyretics, NSAIDs; antihistamine drugs Maximum Allowable Cost: State imposes Federal Upper
(partially covered); anxiolytics, sedatives, and hypnotics; Limits. Override requires “Medically Necessary” or
growth hormones; misc. GI drugs; and prescribed “Brand Medically Necessary.”
smoking deterrents (partially covered). Therapeutic
categories not covered: anabolic steroids; anorectics; Incentive Fee: None.
prescribed cold medications; and OBRA ’90 Drugs
identified as coverage optional. Patient Cost Sharing: Copayment is $1.00 for
prescriptions up to $29.99, $2.00 for prescriptions over
Coverage of Injectables: Injectable medicines $30.00.
reimbursable through the prescription drug program when
used in home health care, extended care facilities and Cognitive Services: Does not pay for cognitive services.
through physician payment when used in physician
offices.
Vaccines: Vaccines reimbursable as part of EPSDT
!""#$%&'()*+,-:;@0@@@-)$)(+-?64?"+&5()*4-6?'A*#-$2
service and the Vaccines for Children Program.
3*4&5(&4-#*5&"&*6)7-8*#*-*6#$++*4-&6-3BC7-&6-DE-:;;;<
F*5&"&*6)7-#*5*&=*-A*6*2&)7-)>#$?9>-'(6(9*4-5(#*-"+(67<
Community Care
Formulary: Closed formulary. P.O. Box 3249
Tulsa, OK 74033
authorization procedure and DUR Board. Agency Heartland
Grievance process exists for appeal of prior authorization 100 North Broadway, Ste. 1400
decisions or coverage of an excluded product. Oklahoma City, OK 73102-8601
2-Oklahoma National Pharmaceutical Council

Prime Advantage
1602 SW 82nd St.
Lawton, OK 73505 Technical: Judi Worsham, 405/530-3222
Policy: Jim Hancock 405/530-3268
Unicare Director: Tom Simonson 405-522-7327
P.O Box 268985
Oklahoma City, OK 73126 Claims Submission Contact
Laura Dickey-Hottel
F. STATE CONTACTS DP Analyst/Planning Specialist III
Oklahoma Health Care Authority
State Drug Program Administrator 4545 N. Lincoln, Ste. 124
Oklahoma City, OK 73105-7378
John M. Crumley, R.Ph., MHA T: 405/522-7228
Pharmacy Programs Director F: 405/522-7378
Oklahoma Health Care Authority E-mail: Hottell@ohca.state.ok.us
4545 N. Lincoln, Ste. 124
Oklahoma City, OK 73105
Medicare Managed Care Contact
T: 405/522-7325
F: 405/522-7378 John M. Crumley, 405/522-7325
E-mail: crumlyj@ohca.state.ok.us
Agency Internet Address: www.ohca.state.ok.us Disease Management Program/Initiative Contact
Kathe Eastham, R.N
Nurse Manager III
John M. Crumley, 405/522-7325
DUR Contact T: 405/522-7115
John M. Crumley, 405/522-7325 F: 405/522-7378
E-mail: Easthamk@ohca.state.ok.us
Medicaid DUR Board
Rick Crensaw, D.O.
Dick Robinson, R.Ph. Lynn Mitchell, M.D.
Dorothy Gourley, R.Ph. Medical Director
Cliff Meece, R.Ph. 4545 N. Lincoln, Ste. 124
Gary Kirk, R.Ph. Oklahoma City, OK 73105
Cathy E. Hollen, R.Ph. 405/530-3365
Francois DuToit, M.D.
Thomas Whitsett, M.D. (Chair)
Oklahoma Health Care Authority Officials
Dan McNeill, Ph.D., PA-C
(Vacant position pending OSMA recommendation) Michael Fogarty, J.D.
Angela Thomasson Oklahoma City, OK 73105
Pharmacy Claims Specialist
Oklahoma Health Care Authority Michael Fogarty, J.D.
4545N Lincoln Blvd, Ste. 124 State Medicaid Director
Oklahoma City, OK 73105-9901 4545 N. Lincoln, Ste. 124
T: 405/522-7307 Oklahoma City, OK 73105
F: 405/522-7378
E-mail: thomassa@ohca.state.ok.us Darcedia McCauley, Ph.D.
Director of Quality Assurance
405/530-3355
National Pharmaceutical Council Oklahoma-3

Advisory Committee on Medical Care for Public

Assistance Recipients
Frank Wilson, III, M.D., Chairman
Executive Officers of State Medical,

Pharmaceutical, and Osteopathic Societies
Oklahoma State Medical Association
Kathy Musson
601 W. I-44 Service Road
405/843-9571
Oklahoma Pharmaceutical Association

John D. Donner, Executive Director
Box 18731
405/528-3338
Oklahoma Osteopathic Association

Bob E. Jones, CAE
Executive Director
4848 N. Lincoln Boulevard
405/528-4848

Bryan H. Potter
Executive Director
4545 N. Lincoln Boulevard, Ste. 112
405/521-3815
Oklahoma Hospital Association

John C. Coffey
President
4000 Lincoln Boulevard
405/427-9537
Fiscal Agent
UNISYS
405/841-3400
4-Oklahoma National Pharmaceutical Council

OREGON

Skilled Nursing Home Services        
1

1998* 1999*
TOTAL $87,805,350 148,258

Aged
Blind
Disabled

Aged
Blind
Disabled

Aged
Blind
Disabled

National Pharmaceutical Council Oregon-1


authorization procedure. Client may request an
Office of Medical Assistance Programs (OMAP), administrative hearing to appeal a prior authorization
Department of Human Services. decision or to appeal the coverage of excluded products.
Benefit Design Monthly Quantity Limit: 34-day supply per Rx.
Drug Benefit Product Coverage: Products covered: Drug Utilization Review

prescribed insulin and syringe combinations used for
insulin (when insulin filled). Prior authorization required PRODUR system implemented in March 1994. State
for: isotretionoin; acute anti-ulcer drugs; cosmetics; total currently has a DUR Board with a quarterly review.
parenteral nutrition; and interdialytic parenteral nutrition.
Products not covered: fertility drugs; experimental drugs; Pharmacy Payment and Patient Cost Sharing
disposable needles used for insulin; urine ketone test
strips; and blood glucose test strips. Dispensing Fee: $3.91 - $4.28, effective 10/01/00.
Over-the-Counter Product Coverage: Products covered: 1) $4.05 for providers filling between 15,000 and
analgesics; feminine products; and smoking deterrent 30,000 total prescriptions annually;
products. Products requiring prior authorization and
physician prescription: allergy, asthma, and sinus; cough 2) $4.05 for providers filling 1-15,000 or providers
and cold preparations; digestive products (non-H2 filling between 15,000 and 30,000 with greater than
antagonist); digestive products (H2 antagonists); and 20% Medicaid prescription volume annually;
topical products.
3) $4.28 for providers filling 1-15,000 total
Therapeutic Category Coverage: Therapeutic categories prescriptions annually with greater than 20%
covered: Anabolic steroids; analgesics, antipyretics, Medicaid prescription volume annually or providers
NSAIDs; anorectics; antibiotics; anticoagulants; operating with a True or Modified Unit Dose
anticonvulsants; anti-depressants; antidiabetic drugs; Delivery System.
antilipemic agents; antipsychotics; anxiolytics, sedatives,
and hypnotics; cardiac drugs; chemotherapy agents; Ingredient Reimbursement Basis: EAC = AWP - 11%.
hypotensive agents; prescribed smoking deterrents; Prescription Charge Formula: Estimated acquisition cost
sympathominetics (andrenergic); and thyroid agents. (EAC) defined as the lesser of: (1) AWP - 11% (2) HCFA
Therapeutic categories requiring prior authorization: upper limits for multiple source drugs or (3) the usual and
selected antihistamine drugs; prescribed cold medications customary charge plus a dispensing fee.
(selected products); growth hormones; selected
antifungals; legend laxatives; coal tar preparations; and Maximum Allowable Cost: State imposes Federal Upper
misc. GI drugs (selected products). Limits on generic drugs. Override requires “Brand
reimbursable through physician payment when used in Incentive Fee: None.
physician offices, home health care, and extended care
facilities. Patient Cost Sharing: No copayment.
Vaccines: Vaccines reimbursable by Medicaid as part of Cognitive Services: Does not pay for cognitive services.
the Vaccines for Children Program.
2-Oregon National Pharmaceutical Council

Lane Individual Practice Association, Inc. (LIPA)

E. USE OF MANAGED CARE 1500 Valley Rive Drive, Ste. 370
Eugene, OR 97401
Approximately 400,000 total unduplicated number of (541) 485-2155
Medicaid Recipients were enrolled in MCOs in FY 1999.
Recipients received pharmaceutical benefits through both Mid Rogue IPA Health Plan
state and managed care plans. 820 NE 7th Street
Care Oregon, Inc Grants Pass, OR 97526
522 SW Fifth Ave, Ste. 200 (541) 471-4106
Portland, OR 97204
(800) 224-4840 ODS Health Plans
601 SW 2nd Ave
Cascade Comprehensive Care, Inc. Portland, OR 97204
900 Main Street, Suit A (800) 342-0526
PO Box 217
Klamath Falls, OR 97601-0368 Oregon Health Management Services
(541) 883-2947 1051 NE 6th Street, Ste. 2C
Grants Pass, OR 97526
Central Oregon Independent Health Services, Inc. (541) 471-4208
2650 NE Courtney Drive
P0 Box 5729 Providence Health Plan
Bend, OR 97708-5729 1235 NE 47th, Ste. 220
(800) 431-4155 Portland, OR 97213-2196
(800) 898-8174
Deschutes County CDO
Deschutes County Human Services Dept. Regence HMO Oregon
Alcohol and Drug Treatment Program 201 High Street SE
409 NE Greenwood Ave PO Box 12625
Bend, OR 97701 Salem, OR 97309
(800) 541-8981
Doctors of The Oregon Coast South (DOCS)
750 Central, Ste. 202 Tuality Health Alliance
PO Box 1096 335 SE 8th Avenue
Coos Bay, OR 97420 PO Box 925
(541) 269-7400 Hillsboro, OR 97123-0925
(800) 681-1901
Douglas County IPA
500 SE Cass, Ste. 210
F. STATE CONTACTS
Roseburg, OR 97470
(541) 677-3453
Family Care, Inc Jesse Anderson
2121 SW Broadway, Ste. 300 Office of Medical Assistance Programs (OMAP)
Portland, OR 97201 Department of Human Resources
(800) 335-3205 500 Summer Street, NE
Salem, OR 97310-1014
Intercommunity Health Network, Inc T: 503/945-6492
3600 NW Samaritan Drive F: 503/373-7689
Corvallis, OR 97330 E-mail: jesse.anderson@state.or.us
(800)757-5114 Agency Internet Address: www.omap.hr.state.or.us
Kaiser Permanente
500 NE Multnomah, Ste. 100
Portland, OR 97232-2099
(800) 813-2000

Prior Authorization Contact James W. Winde, M.D.

1212 Aspen Drive
Jesse Anderson, 503/945-6492 La Grande, OR 97850
DUR Contact Dean Haxby, R.Ph., Ph.D.

Oregon Health Sciences University
Mariellen Rich, R.Ph.
3181 SW Sam Jackson Park Rd., GH212
Pharmacist Account Manager
Portland, OR 97201-3098
First Health Service Corporation
565 Union St., NE, Ste. 205
Nancy Elder, MD
Salem, OR 97310
Dept of Family Medicine
T: 503/391-1980
3181 SW Sam Jackson Park Rd.
F: 503/391-1979
Portland, OR 97201
E-mail: merich@fhsc.com
Medicaid DUR Board Prescription Price Updating
Todd L. Anderson R.Ph., FASCP Kathy Frankiln
Budget Pharmacy Customer Support Department
2829 Barclay Road First Databank, Inc.
Medford, OR 97504 1111 Bayhill Drive NE
San Bruno, CA 94066
Rickland G. Asai DMD T: 650/588-5454
2375 SW Cedar Hills Blvd. F: 650/588-4003
Portland, OR 97225 E-mail: kathy.franklin@firstdatabank.com
Beverly Castor Medicaid Drug Rebate Contacts

Office of Medical Assistance Programs
500 Summer Street NE Audits: Jesse Anderson, 5033/945-6492
Salem OR 97310-1014 Disputes: Becky Smith, 503/391-1981
Marshall D. Bedder M.D., F.R.C.P. (C) Claims Submission Contact

Advanced Pain Management Group
Mariellen Rich, R.Ph., 503/391-1980
2625 Lovejoy
Portland, OR 97210
Charlene Charroll Clark M.D. (Vacant Position)
Oregon State University Delivery Systems Manager
MC: Student Health Center OSU Campus Shuttle Office of Medical Assistance Programs
Corvallis, OR 97330 500 Summer Street, NE
Salem, OR 97310-1014
Mariellen Rich R.Ph. T: 503/945-6497
First Health F: 503/947-5221
565 Union Street NE, Ste. 205
Salem OR 97301 2460
Jesse Anderson, 503/945-6492
William H. Wilson M.D.
Oregon Health Sciences University
3181 SW Sam Jackson Park Road
MC: UHN –79 (Vacant Position)
Portland, OR 97201-3098 Office of Medical Assistance Programs
John E. Launer R.Ph. 500 Summer Street, NE
South Salem Pharmacy Salem, OR 97310
925 Commercial Street Se Ste. 100 503/945-6490
Salem, OR 97302
4-Oregon National Pharmaceutical Council


Office of Medical Assistance Officials
Pharmaceutical Associations
Gary Weeks
Oregon Medical Association
Director
Robert L. Dernedde, CAE
Executive Director
500 Summer Street, NE
5210 SW Corbett Street
Salem, OR 97310-1012
Portland, OR 97201
503/378-2263
503/226-1555
Hersh Crawford
Oregon State Pharmaceutical Association
Director
Tom Holt
Executive Director
1460 State Street
Title XIX Medical Care Advisory Committees Salem, OR 97301-4296
503/585-4887
Micheal Bierman, DMD
Bruce Bliatout
Osteopathic Physicians and Surgeons of Oregon
Rita Catapano
Jeff Heatherington
Donna Crawford
Executive Director
Maryann Curry
2121 SW Broadway, Ste. 300
James Davis
Portland, OR 97201
Rosemari Fitts
800/533-6776
Michael Garland
John Hogan
David Strough
Gary Schnabel
Rick Wopat, MD
Executive Director
State Office Bldg., Room 425
Consultants to Health and Social Services 800 NE Oregon St., #9
Section Portland, OR 97232
503/731-4032
Joseph Intile, M.D.
Medical Director
Oregon Association of Hospitals and Health Systems
Kenneth M. Rutledge
President
500 Summer Street, NE
4000 Kruse Way Place
Salem, OR 97310
Building 2, Ste. 100
Lake Oswego, OR 97035-2543
Pharmacy Advisory Task Force 503/636-2204
Tom Holt, Chairman
Mike Dardis, R.Ph.
Jim Waletich, R.Ph.
Ed Hughes, R.Ph.
Ron Dulwick, R.Ph.
Jenny Kudna, R.Ph.
Dennis Perry, R.Ph.
Larry Cartier, R.Ph.
Richard Hartmann, R.Ph.
Chris Vorrath, R.Ph.
Susie Morris, R.Ph.
Tom Hornsby, R.Ph.
Kathy Ketchum, R.Ph.
John Mansfield, R.Ph.
Dave Lewis, R.Ph.
Dave Walden, R.Ph.
Cynthia Wong, R.Ph.

PENNSYLVANIA

Dental Services      
1

1998 1999*
TOTAL $525,261,211 580,749

Aged $59,380,437 41,206
Blind / Disabled $176,079,255 105,477
AFDC-Child $8,326,245 52,459
AFDC-Adult $12,352,307 24,557

Aged $31,035,505 19,173
Blind / Disabled $2,050,862 970
AFDC-Child $3,404,034 18,857
AFDC-Adult $584,012 2,741

Aged $88,149,940 53,584
AFDC-Child $11,368,722 105,835
AFDC-Adult $1,225,209 12,263
OTHER $130,272,301 138,810

1-Pennsylvania National Pharmaceutical Council

Office of Medical Assistance, Department of Public Quantity Limit: Not to exceed a 34-day supply or 100
Welfare. units, whichever is greater.
D. PROVISIONS RELATING TO DRUGS Refill Limit: Up to 5 within 6 months.

Benefit Design
PRODUR system implemented in June 1993. DUR Board
Drug Benefit Product Coverage: Products covered: has 9 members (plus 1 vacancy) and meets quarterly.
combinations used for insulin; blood glucose test strips; Pharmacy Payment and Patient Cost Sharing
urine ketone test strips; interdialytic parenteral nutrition;
and total parenteral nutrition. Products not covered: Dispensing Fee: $4.00, effective 10/1/95.
cosmetics; fertility drugs; and experimental drugs.
Ingredient Reimbursement Basis: EAC = AWP-10%.
analgesics; feminine products; topical products; laxatives; Prescription Charge Formula:
oral electrolytes; allergy, asthma, and sinus (indication or
prescribed); cough and cold preparations (indication other 1. Payment for single source drugs and those
than C+C on Rx); digestive products (not including H2 multisource brand name drugs certified as medically
antagonists) (legend products only); and digestive necessary will be the lower of the EAC dispensing fee
products (H2 antagonists) (PA > 90 days at acute dose). or the pharmacy's usual and customary charge.
Products not covered: smoking deterrent products. 2. State MAC for the drug plus dispensing fee or the
pharmacy's usual and customary charge.
covered: anabolic steroids; analgesics, antipyretics, 3. For compound prescriptions, an additional fee of
NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti- $1.00 is allowed to a pharmacy, bringing the total
depressants; antidiabetic agents; antihistamine drugs; dispensing fee to $5.00.
antilipemic agents; anti-psychotics; anxiolytics, sedatives, Maximum Allowable Cost: State imposes Federal Upper
and hypnotics; cardiac drugs; chemotherapy agents; Limits as well as state-specific limits on generic drugs.
contraceptives; ENT anti-inflammatory agents; estrogens; 667 drugs are listed on the state-specific MAC list.
growth hormones; hypotensive agents; misc. GI drugs; Override requires “Brand Medically Necessary” or
sympathominetics (adrenergic); and thyroid agents. “Brand Necessary,” plus prior authorization.
Partially covered: prescribed cold medications.
Therapeutic categories not covered: anorectics (unless for Incentive Fee: None.
treatment of hyperkinesis or narcolepsy); and prescribed
smoking deterrents. Patient Cost Sharing: Copayment is $1.00. The
copayment will not apply to those recipients who are
Coverage of Injectables: Injectable medicines federally exempt, under 21 years of age, pregnancy cases
reimbursable when used in physician offices, home health and long-term care patients, plus patients receiving drugs
care, and extended care facilities. in the following categories:
Vaccines: Vaccines reimbursable at AWP – 10% as part − Anticonvulsants
of the Medical Assistance, Children Health Insurance − Antidiabetic agents
Program, and the Vaccines for Children Program. − Antiglaucoma agents
− Antihypertensive agents
Unit Dose: Unit dose packaging not reimbursable. − Antineoplastic agents
− Antiparkinson agents
Formulary/Prior Authorization − Cardiovascular preparations
− HIV/AIDS specific drugs
Formulary: Open formulary. − Psychotherapeutic agents

authorization procedure screening for drug classes and
individual drugs. Products that require PA include BMN
brand name drugs that have A-rate generics, anti-ulcer
drugs, and drugs for erectile dysfunction.
National Pharmaceutical Council Pennsylvania-2

Cognitive Services: Does not pay for cognitive services. F. STATE CONTACTS

Joseph E. Concino, R.Ph..
!""#$%&'()*+,-G.H0@.I-?64?"+&5()*4-3*4&5(&4-#*5&"&*6)7
8*#*-*6#$++*4-&6-'(6(9*4-5(#*-&6-:;;;<--!++-#*5*&=*4 P.O. Box 8046
">(#'(5,-7*#=&5*70-4*"*64&69-$6-)>*&#-5()*9$#,-$2 Harrisburg, PA 17105
(77&7)(65*0-)>#$?9>-'(6(9*4-5(#*! T: 717/772-6341
F: 717/772-6366
AmeriHealth HMO/Mercy Health Plan 18,334 Welfare Department Officials
1901 Market Street, 45th Floor Feather O. Houstoun
Philadelphia, PA 19103 Secretary
Department of Public Welfare
Keystone Mercy Healthplan 217,733 Health and Welfare Building
200 Stevens Drive, Ste. 900 Harrisburg, PA 17120
Philadelphia, PA 19113-1570
Peg J. Dierkers, Ph.D.
Oaktree/Oxford Health Plan 57,501 Deputy Secretary for Medical Assistance Programs
The Curtis Center, Ste. 900
Independence Square West Christopher P. Gorton, M.D.
Philadelphia, PA 19106 Medical Director
Healthcare Management Alternatives 71,970 Robert Kelly

The Wanamaker Building Director
100 Penn Square East, Ste. 900 Division of Data and Claims Management
Philadelphia, PA 19107
Jeffrey Bechtel
Health Partners of Philadelphia/Partnership 119,024 Director
841 Chestnut St. Ste. 900 Bureau of Program Integrity
Suzanne Love
Three Rivers Health Plans/MedPlus 115,318 Director
300 Oxford Drive Bureau of Policy, Budget, and Planning
Monroeville, PA 15146
Guy L. Ridge, III
UPMC Health Plan, Inc./Best 73,776 Acting Director
Healthcare of Western PA Bureau of Fee-for-Service Programs
One Chatam Center
112 Washington Place Christine M. Bowser
Pittsburgh, PA 15219 Director
Bureau of Managed Care Operations
Gateway Health Plan 147,454
Two Chatum Ctr, Ste. 500 Andrew Major
Pittsburgh, PA 15219 Director
Bureau of Long Term Care Programs
PhilCare Health Systems, Inc./Pennsylvania 19,103
HealthMATE William M Peifer, R.Ph.
2005 Market Street, Ste. 500 Pharmacy Consultant
Philadelphia, PA 19103 Pharmacy Services Section
John Ferrara, R.Ph.

Director
Division of Program Integrity

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
(Calls with contractor must be made through state
Richard T. Bell, M.D. agency.)
Chairman
2016 Redwood Avenue
Wyomissing, PA 19610
Michael Jacobs
Richard W. Sloan, M.D. Director, Division of MCO Monitoring and Compliance
Thomas Hart Family Practice Center Office of Medical Assistance Programs
York Hospital Cherrywood Bldg, DPW Complex #2
1001 South George Street Harrisburg, PA 17105
York, PA 17405 717/772-6977
Otto F. Wolke, R.Ph.

Expanded Drug Coverage Program Contact
Geisinger Health Plan
Geisinger Office Building Thomas Snedden
Danville, PA 17822 PACE Program
PA Dept. of Aging
Patricia A. Keys, Pharm.D. 555 Walnut St., 5th Fl.
1514 Scenery Ridge Drive Harrisburg, PA 17101
Pittsburgh, PA 15241 717/787-7313
Marshall P. Burnside, R.Ph.

6000 Bell Road Medical Assistance Advisory Committee
Harrisburg, PA 17111 Peter D. Archey
PA Association of Area Agencies on Aging
Michael A. Zemaitis, Ph.D., R.Ph. 4701 Devonshire Rd Ste. 102
133 Shadowlawn Drive Harrisburg, PA 17109
Pittsburgh, PA 15261
Shirley Beer
Bruce Pollock, M.D. Armstrong County Low Income Rights Organization
7032 Meade Place RD, #8, Box 134
Pittsburgh, PA 15208 Kittanning, PA 16201
724/543-5031
Robert J. Kordella, R.Ph.
145 Stilwell Court Kent D.W. Breams, M.D.
Mt. Lebanon, PA 15228 Department of Family Practice
University of Pennsylvania
2 Gates, HUP, 3400 Spruce Street
First Data Bank 215/614-0523
1111 Bayhill Drive
San Bruno, CA 94066 Louise Brookins
800/633-3453 Philadelphia Welfare Rights
4358 N. Franklin Street
214/455-3497
Technical: David Ehrhart, 717/772-6305
Policy: Suzanne Love, 717/772-6142 Kevin Casey
Disputes: Vacant, 717/772-6341 Pennsylvania Protection and Advocacy
1414 Cameron Street, 2nd Floor
Harrisburg, PA 17103
717/236-8110

Michael D. Chambers Kathy Hubert

County commissioners Association of Pennsylvania Pennsylvania County Drug and Alcohol
17 North Front Street Program Administrators
Harrisburg, PA 17101 17 North Front Street
717/232-7554 Harrisburg, PA 17107
717/232-7554
Cindy W. Christian, M.D.
The Children’s Hospital of Philadelphia Christine Klejbuk
34th Street and Civic Center Boulevard, Room 2416 PA Assn. Non-Profit Homes for the Aging
Philadelphia, PA 19104 Dir. of Public Policy
215/590-2058 4720 Old Gettysburg Road, Ste. 409
Mechanicsburg, PA 17055
Barbara Coffin 717/763-5724
Pennsylvania Association of Area Agencies on Again
Berks County Office of Aging Sefi Knoble, M.D.
County Services Center Pennsylvania Medical Directors Association
633 Court Street Philadelphia, PA 19131
Reading, PA 19601-4303 215/581-0705
610/478-6500
Kimberly Kockler
C. Lu Conser Vice-Chair
Pennsylvania Community Providers Association Managed Care Association of Pennsylvania
2400 Park Drive 240 North Third Street, Ste. 203
Harrisburg, PA 17110 P.O. Box 12108
717/657-7078 Harrisburg, PA 17108-2108
717/238-2600
Barbara J. Custer
Clarion County Welfare Rights Organization Beverly Mackereth
4096 Master Road Healthy York County Coalition
Emlenton, PA 16373 1001 S. George Street
814/797-0060 York, PA 17405-7198
717/851-2333
Peg Dierkers (Ex-Officio Co-Chair)
Pennsylvania Department of Health Donald McCoy
Office of Policy, Health and Welfare Building, Pennsylvania Medical Society
Room 515 777 East Park Drive
Harrisburg, PA 17120 P.O. Box 8820
Shelley Eppley 717/558-7823
Pennsylvania Mental Health Consumers Association
4105 Derry Street Kearline McKellar-Jones
Harrisburg, PA 17111 Health Partners
717/564-4930 841 Chestnut Street, Ste. 900
Henry R. Fiumelli 215/991-4063
Executive Director
Pennsylvania Forum for Primary Health Care Richard R. Orlandi
1017 Mumma Road, Ste. 209 Pennsylvania Medical Society
Wormleysburg, PA 17043 777 East Park Drive
717/761-6443 ext. 203 PO Box 8820
William L. Greene, R.Ph. 717/558-7750
Pennsylvania Pharmaceutical Association
2020 Union Boulevard
Allentown, PA 18103
610/433-7577

Kenneth J. Pierce
Pennsylvania State Welfare Rights Organization
Pharmaceutical Associations
119 Camp Avenue
Braddock, PA 15104 Pennsylvania Medical Society
412/271-1426 Roger F. Mecum
Charles Pruitt, Jr. 777 E. Park Drive
Seniorcare Solutions LLC Harrisburg, PA 17105-8820
1215 Hulton Road 717/558-7750
Oakmont, PA 15139
412/826-6100 Pennsylvania Pharmaceutical Association
Carmen A. DiCello, R.Ph.
Mary Ellen Rehrman Executive Director
National Alliance for the Mentally Ill 508 North Third Street
2149 N. Second Street Harrisburg, PA 17101-1199
Harrisburg, PA 17110 717/234-6151
717/268-1514
Pennsylvania Osteopathic Medical Association
Virginia Schierscher Mario E.J. Lanni
HAP Executive Director
4750 Lindle Road 1330 Eisenhower Boulevard
P.O. Box 8600 Harrisburg, PA 17111
Harrisburg, PA 17105-8600 717/939-9318
717/657-1222
Pennsylvania Podiatry Association
David E. Shapter, D.D.S. Nancy Sullivan
Pennsylvania Dental Association Assistant Executive Director
4934 Peach Street 757 Poplar Church Road
Erie, PA 16509 Camp Hill, PA 17011
814/868-8673 717/763-7665
Michael A. Yantis, Jr. State Board of Pharmacy

Pennsylvania Department of Health Office of Policy W. Richard Marshman
Room 808, Health and Welfare Building Executive Secretary
Harrisburg, PA 17120 124 Pine St.
717/787-4525 P.O. Box 2549
Dawn Guzik Stocker 717/783-7157
Gateway Health Plan
Two Chatham Center, Ste 500 Hospital Association of Pennsylvania
Pittsburgh, PA 15219 Carolyn F. Scanlan
412/255-4569 President, CEO
4750 Lindle Road
Jessie Rohner P.O. Box 8600
PA State Nurses Association Harrisburg, PA 17105-8600
2578 Interstate Drive 717/564-9200
717/657-1222

RHODE ISLAND

1

1998* 1999*
TOTAL $61,401,958 44,852

Aged
Blind
Disabled

Aged
Blind
Disabled

Aged
Blind
Disabled

1-Rhode Island National Pharmaceutical Council

C. ADMINISTRATION Pharmacy Payment and Patient Cost Sharing
State Department Human Services. Dispensing Fee: $3.40, effective in 1987.

Dispensing fee for nursing homes = $2.85.
Ingredient Reimbursement Basis: EAC = WAC + 5%.
Benefit Design
Prescription Charge Formula:
1. In accordance with federal regulation the upper limit
DESI drugs; smoking cessation drugs; drugs for hair
for payment for prescribed drugs will be based upon
growth; and fertility drugs. Prior authorization required
the amount allowed by the Medical Assistance
for: anorexants; central nervous system stimulants for
Program or the usual and customary charge to the
recipients over 21 years of age; brand name vitamins; and
general public, whichever is lower.
hematinics and lipotropic preparations (selling for over
$10 per 100 tablets/capsules or pint). 2. Payment for over-the-counter drugs (non-legend
drugs) will be based upon the lower of either the
Over-the-Counter Product Coverage: analgesics; cough allowable cost of the drug plus 50 percent, the usual
and cold preparations; and digestive products. and customary charge to the general public, or the
allowable cost plus the professional fee for service.
reimbursable when used in physician offices, home health Maximum Allowable Cost: State imposes Federal Upper
care, and extended care facilities. Limits on generic drugs. Override requires “Dispense as
Written” or “Brand Medically Necessary.”
Vaccines: Limited coverage. Documentation must be submitted with a medical reason
why a generic cannot be used.
Prescription Refill Limit: Refills to a maximum of five are
allowed for specified drugs: anti-hypertensives, diuretics, 3(6(9*4-5(#*-#*5&"&*6)7-#*5*&=*-">(#'(5*?)&5(+-A*6*2&)7
anti-convulsants, coronary vasodilators, tranquilizers, )>#$?9>-'(6(9*4-5(#*-"+(67<
antidepressants, hormones, antibiotics, etc. Refills are not
allowed for specified drugs, e.g., central nervous system Managed Care Organizations
stimulants, narcotics (Schedule II, III), and pentazocine.
− United Healthcare of New England
Monthly Quantity Limit: One month’s supply of drugs. − Coordinated Health Partners, Inc.
− Neighborhood Health Plan of Rhode Island
Maintenance Medication: The attending physician may − Harvard/Pilgrim Healthcare of New England
prescribe certain maintenance drugs of 100 tablets,
capsules or pint of liquid or a 30-day supply of these F. STATE CONTACTS
drugs - whichever is greater.
Monthly Dollar Limits: None
Paula Avarista, R.Ph.
Chief of Pharmacy
Drug Utilization Review Department of Human Services
600 New London Avenue
PRODUR system implemented in December 1994. Cranston, RI 02920
401/462-2183
National Pharmaceutical Council Rhode Island-2

Dr. Craig Winderman

Rhode Island DUR Board
Harvard Pilgrim Health Plan
Kimberly McDonough, Pharm.D. 1 Hoppin Street
Chairperson Providence, RI 02903
Advanced Pharmacy Concepts, Inc. 401/331-4034 x.42276
52 Grinnell Street
Jamestown, RI 02835 David Yoburn, M.D.
401/423-2542 1076 North Main Street
Dr. James Burrill 401/861-7711
Co-Chairperson
135 Cass Avenue
Woonsocket, RI 02895
401/765-3135 Technical: EDS
Policy: Paula Avarista, 401/462-2183
Paul Avarista, R.Ph. DUR: Paula Avarista, 401/462-2813
Chief of Pharmacy PA: Paula Avarista, 401/462-2813
Rhode Island Department of Human Services
Cranston, RI 02920
401/464-2183 Don Sullivan
Craig Bowen, Pharm.D. Cranston, RI 02910
405 Lapham Farm Road 401/464-2176
Pascoag, RI 02859
401/568-2536
Anne Hume, Pharm.D. Christine Ferguson
233 Lepes Road Director
Portsmouth, RI 02871 Department of Human Services
401/729-2760 600 New London Avenue
Cranston, RI 02920
Peter Jussila, RPH
10 Henry Brown Road John Young
West Greenwich, RI 02817-2469 Associate Director
401/397-6371 Medical Services
Peter Kogut, R.Ph. 600 New London Avenue
Harvard Pilgrim Health Plan Cranston, RI 02920
1 Hoppin Street
401/331-3000 x.42150 Executive Officers of State Medical and
John Pagliarini, R.Ph. Rhode Island Medical Society
Regional Director/Government Programs Newell E. Warde, Ph.D.
Medco Containment Services, Inc. Executive Director
One Gateway Center, Ste. 804 106 Francis Street
Newton, MA 02158 Providence, RI 02903
617/969-5371 401/331-3207
John Stoukides, M.D. Rhode Island Pharmaceutical Association

Roger Williams Medical Center Donald Fowler
825 Chalkstone Avenue Interim Executive Director
Providence, RI 02903 500 Prospect Street
401/456-2000 Independence Square
Pawtucket, RI 02860
401/725-4141
3-Rhode Island National Pharmaceutical Council

Society of Osteopathic Physicians and Surgeons

Robert Salk, D.O.
President
P.O. Box 2344
Woonsocket, RI 02895
401/647-9150

Norman Phelps
Administrator
3 Capitol Hill
Room 304
Providence, RI 02908-5097
401/277-2837
Hospital Association of Rhode Island

Gerald G. McClure
President
Weld Building
Second Floor
880 Butler Drive
Ste. One
401/453-8400
National Pharmaceutical Council Rhode Island-4

SOUTH CAROLINA

1
Medically Needy Program was discontinued effective October 1, 1992.

1998 1999*
TOTAL $224,962,203 404,611

Aged $35,789,672 33,696
Blind / Disabled $74,950,233 68,329
AFDC-Child $4,327,091 36,715
AFDC-Adult $5,833,129 18,170

Aged $0 0
AFDC-Child $0 0
AFDC-Adult $0 0

Aged $22,045,692 20,281
Blind / Disabled $25,565,926 17,087
AFDC-Child $12,703,177 108,314
AFDC-Adult $2,222,058 24,647
OTHER $20,177,225 67,193

1-South Carolina National Pharmaceutical Council

− Routinely covered for females of childbearing age

C. ADMINISTRATION − Mylanta Tablets/Liquid
− Mylanta Double Strength Tablets/Liquid
South Carolina Department of Health & Human Services. − Niacin 50 mg Tablets
− Niacin 100 mg Tablets
D. PROVISIONS RELATING TO DRUGS − Parepectolin Suspension
− Pepcid AC Tablets
Benefit Design − Riopan Plus Tablets/Suspension
− Robitussin AC
Drug Benefit Product Coverage: Products covered: − Robitussin DAC
cosmetics; fertility drugs; experimental drugs; blood − Robitussin DM
glucose test strips; urine ketone test strips; total parenteral − Tagamet HB Tablets
nutrition; and interdialytic parenteral nutrition. Products − Titralac Tablets
not covered: prescribed insulin; disposable needles and − Zantac 75 Tablets
syringe combinations used for insulin.
Over-the-Counter Product Coverage: Products covered: covered: anabolic steroids; analgesics, antipyretics,
smoking deterrent products. Products covered with NSAIDs; antibiotics; anticoagulants; anticonvulsants;
restrictions: allergy, asthma and sinus products; antidepressants; antidiabetic agents; antihistamine drugs;
analgesics; cough and cold preparations; digestive antilipemic agents; anti-psychotics; anxiolytics, sedatives,
products (non-H2 antagonist); digestive products (H2 and hypnotics; cardiac drugs; chemotherapy agents;
antagonists); feminine products; and topical products. prescribed cold medications; contraceptives; ENT anti-
OTC Coverage: The following OTC medications and their hypotensive agents; misc. GI drugs; prescribed smoking
generic equivalents are covered by the Medicaid program deterrents; sympathominetics (adrenergic); and thyroid
provided the manufacturer rebates the pharmaceutical agents. Therapeutic categories partially covered:
dispensed. Federal or state upper limits of payment anorectics.
restrictions apply to several of these medications.
− Acetaminophen, all strengths and forms Coverage of Injectables: Injectables reimbursable through
− Actifed Tablets the Prescription Drug Program when used in home health
− Alternagel Liquid care, extended care facilities and though physician
− Ascriptin, All Strengths and Forms payment when used in physician offices.
− Aspirin, All Strengths and Forms
− Axid AR Tablets Vaccines: Vaccines reimbursable based on CDC price as
− Basaljel, All Strengths and Forms part of the Vaccines for Children Program (age under 21).
− Cerose DM Syrup Unit Dose: Unit dose packaging reimbursable.
− Contraceptive Condoms
− Contraceptive Products (i.e., foams, creams, films)
− Debrisan Beads Formulary/Prior Authorization
− Dimenhydrinate Tablets/Liquid
− Dimetane Extentabs Formulary: Open formulary.
− Gaviscon Tablets/Suspension
− Gaviscon-2 Tablets With certain drug classifications excluded.
− Hydrocortisone 0.5% Cream/Ointment General Exclusions:
− Insulin, all forms
− Insulin Syringes 1. Anorexants.
− Iron Preparations 2. Investigational pharmaceuticals or products.
− Routinely covered for females of childbearing age 3. Immunizing agents.
and children 4. Pharmaceuticals determined by the FDA to be less
− Maalox Tablets/Suspension than effective and identical, related, or similar drugs.
− Maalox Extra Strength Suspension 5. Injectable pharmaceuticals administered by the
− Maalox Plus Suspension practitioner in the office in a clinic, or in a mental
− Micatin 2% Cream health center (Synagis is reimbursable through the
− Multivitamins Physician Services Program and is non-covered
through Pharmacy Services).
6. Fertility Products.
7. Smoking cessation products whether legend or OTC.
National Pharmaceutical Council South Carolina-2

8. Pharmaceuticals which are not rebated. authorization requests must be accompanied by a

9. Nutritional supplements which are administered current, written statement from the prescriber
orally. detailing: 1) patient’s diagnosis and prognosis, 2)
10. Pharmaceuticals used for cosmetic purposes or hair documentation regarding the defined organic cause,
growth. medical condition, or specific disease state resulting
in the patient’s condition, including, but not limited
Prior Authorization: State currently has a formal prior to: age of the patient, date of onset of disease causing
authorization procedure. To appeal a prior authorization ED, date of ED diagnosis, statement verifying that the
decision, further documentation may be furnished to the patient is not on nitrates, if requesting Medicaid
pharmacy services program by the pharmacy provider. reimbursement for sildenafil citrate.
The pharmacist or physician may request coverage for the
following medications, which require special Prescribing or Dispensing Limitations
authorization (SA) by completing the Special
Authorization Request form and submitting it to the Prescription Refill Limit: The prescriber authorizes the
Department of Pharmacy Services: number of refills.
1. Vitamins and vitamin combinations for the treatment Monthly Quantity Limit: Children (birth to age 21) are
of vitamin deficiencies for male patients as well as allowed unlimited prescriptions per month. Recipients
female patients of non-childbearing age. Oral dosage over the age of 21 are limited to a maximum of four
forms of iron preparations, multivitamins (whether prescriptions per month.
legend or OTC) and folic acid are routinely covered
for females of childbearing age. Oral iron Quantity Limit per Prescription: 100-day supply
preparations prescribed for children in the prevention maximum. In chronic conditions and for maintenance
and treatment of iron deficiency are routinely drugs, a minimum of a 30-day supply where appropriate.
covered. The category of oral iron preparations
includes: ferrous fumarate, ferrous gluconate, ferrous Monthly Dollar Limit: None.
sulfate, and polysaccharide-iron complex. Special
authorization is necessary in order for Medicaid to Drug Utilization Review
reimburse for vitamins and vitamin/mineral
combination products dispensed to children. Fluoride Plans are under development for PRODUR system. State
vitamins for children are routinely covered. currently has a DUR Board with a monthly review.
2. Compounded prescriptions when the primary or most
expensive ingredient is NOT a routinely covered Pharmacy Payment and Patient Cost Sharing
product. Special authorization requests should not be
submitted for compounds that are commercially Dispensing Fee: $4.05, effective 7/1/89.
available in similar formulations.
Ingredient Reimbursement Basis: EAC = AWP - 10%.
3. Non-routinely covered OTC medications.
4. The following home-administered injectable Prescription Charge Formula: Medicaid reimbursement
products: Intravenous hydration therapies, injectable for pharmacy services will be based on the lowest of: the
immune serums, injectable vitamins, and Estimated Acquisition Cost (EAC); federal or state
Serostim.Immunosuppressants such as CellCept, maximum allowable cost (MAC); or the provider's
Imuran, Neoral, Prograf, Sandimmune, submitted usual and customary charge.
Zenapax, and Simulect.
5. Prior Authorization: Medicare for a period of 36 Limits as well as state-specific limits on generic drugs.
months from the date of discharge following a Override requires “Brand Necessary” or “Brand
hospital stay during which the Medicare covered Medically Necessary” handwritten certification by the
organ or tissue transplant surgery was performed. prescriber.
6. Pharmaceutical products used to treat erectile
dysfunction (ED) regardless of route of
administration. This category of products currently
Patient Cost Sharing: $2.00 copayment per prescription.
includes pharmaceuticals such as alprostadil and
sildenafil citrate. Special authorization will only be
considered for males, age 21 and older, diagnosed Cognitive Services: Does not pay for cognitive services.
with ED resulting from a defined organic cause,
medical condition, and/or a specific disease. Special


First Data Bank, Inc.
!""#$%&'()*+,-.H0@@@-)$)(+-?64?"+&5()*4-6?'A*#-$2 The Hearst Corporation
3*4&5(&4-#*5&"&*6)7-8*#*-*6#$++*4-&6-3BC7-&6-DE-:;;;<
1111 Bayhill Dr.
F*5&"&*6)7-#*5*&=*-">(#'(5*?)&5(+-A*6*2&)7-)>#$?9>
San Bruno, CA 94066
'(6(9*4-5(#*-"+(67<
T: 650/588-5454
F: 650/588-4003
Select Health of South Carolina, Inc.
Patricia Marquis, Chief Operating Officer
P.O. Box 40024 Technical: Rod Davis, 803/898-2610
Charleston, SC 29403 Policy: James Assey, 803/898-2876
843/569-1759 DUR & PA: Caroline Sojourner, 803/898-2876
Disputes: Kathy Bass, 803/898-2974
F. STATE CONTACTS
James M. Assey, R.Ph. Rod Davis
Pharmacy Services, DME & Legislative Liaison Bureau Chief, Bureau of Information Systems
S.C. Department of Health & Human Services S.C. Department of Health and Human Services
P.O. Box 8206, P.O. Box 8206
Columbia, SC 29202-8206 Columbia, SC 29202-8206
T: 803/898-2876 803/898-2610
F: 803/898-4517 E-mail: davisr@dhhs.state.sc.us
E-mail: asseyj@dhhs.state.sc.us
Agency Internet Address: www.dhhc.state.sc.us Medicare Managed Care Contact
Prior Authorization Contact Rosina Brown

Department of Managed Care
Caroline Y. Sojourner, R.Ph. S.C. Department of Health and Human Services
Department Head P.O. Box 8206
Department of Pharmacy Services Columbia, SC 29202-8206
S.C. Department of Health and Human Services 803/898-2650
P.O. Box 8206 E-mail: brownr@dhhs.state.sc.us
Columbia, SC 29202-8206
T: 803/898-2876
F: 803/898-4517
E-mail: sojourne@dhhs.state.sc.us Sharon Parker
S.C. Department of Health and Human Services
DUR Contact P.O. Box 8206
Caroline Y. Sojourner, 803/898-2876 803/898-3021
E-mail: parkers@dhhs.state.sc.us
DUR Committee
Gwendolyn Cambron, M.D.
F. Joseph Hodge, R.Ph. Mary Barnett
Henry Rose, R.Ph. S.C. Department of Health & Human Services
Leslie M. Stuck, M.D. P.O. Box 8206
Caroline Sojourner, R.Ph. Columbia, SC 29202-8206
Michele Burnett, R.Ph. 803/898-2645
Ira Horton, M.D.
National Pharmaceutical Council South Carolina-4

South Carolina Department of Health and Human

Services Officials
J. Samuel Griswold, Ph.D.
Director
South Carolina Department of Health & Human Services
P.O. Box 8206
803/898-2500
Darlynn Thomas
Chief
Bureau of Health Services
803/898-2870
Caroline Y. Sojourner, R.Ph.

Department Head
Department of Pharmacy Services
South Carolina Department of Health and Human Services
P.O. Box 8206
803/898-2876

South Carolina Medical Association
William F. Mahon
3210 Fernandina Rd.
P. O. Box 11188
Columbia, SC 29211
803/798-6207
South Carolina Pharmacy Association

James R. Bracewell
1405 Calhoun Street, Ste. 200
803/254-1065

Cheryl A. Ruff
Administrator, South Carolina Board of Pharmacy
P. O. Box 11927
803/898-4700
South Carolina Hospital Alliance

Kenneth A. Shull
101 Medical Circle
P.O. Box 6009
West Columbia, SC 29171-6009
803/796-3080

SOUTH DAKOTA

Prescribed Drugs     +
Inpatient Hospital Care     +
Outpatient Hospital Care     +
Laboratory & X-ray Service     +
Skilled Nursing Home Services     +
Physician Services     +
Dental Services     +
1
+Renal Disease

1998 1999
TOTAL $31,106,511 46,588 $36,412,365 49,069
RECEIVING CASH ASSISTANCE, TOTAL $17,382,625 18,645 $20,094,115 19,620

Aged $2,111,867 1,976 $2,473,792 1,930
Blind / Disabled $14,081,986 8,867 $15,974,007 8,857
AFDC-Child $614,756 5,279 $769,033 5,747
AFDC-Adult $572,236 2,504 $874,164 3,043
AFDC-Unemployed-Child $489 8 $1,873 22
AFDC-Unemployed-Adult $1,291 11 $1,246 21
MEDICALLY NEEDY, TOTAL $0 0 $0 0

Aged $0 0 $0 0
Blind / Disabled $0 0 $0 0
AFDC-Child $0 0 $0 0
AFDC-Adult $0 0 $0 0
POVERTY RELATED, TOTAL $1,677,158 14,610 $2,158,960 15,499

Aged $0 0 $0 0
Blind / Disabled $0 0 $0 0
AFDC-Child $1,505,739 12,477 $1,964,103 13,506
AFDC-Adult $171,419 2,133 $194,857 1,993
OTHER $12,046,728 13,333 $14,159,290 13,950
National Pharmaceutical Council South Dakota-1


C. ADMINISTRATION
PRODUR system implemented in 1998. State has a DUR
Department of Social Services, Office of Medical Board with annual review.
Services.
Dispensing Fee: $4.75 to $5.55, effective 7/1/1991
Benefit Design
Ingredient Reimbursement Basis: EAC = AWP-10.5%.
prescribed insulin; disposable needles and syringe Prescription Charge Formula: Payment is the lower of:
combinations used for insulin; blood glucose test strips; 1. FUL, state MAC plus a dispensing fee, or
and urine ketone test strips. Products not covered: 2. EAC plus a dispensing fee, or usual and customary
cosmetics; DESI drugs; fertility drugs; experimental charge to the general public.
drugs; total parental nutrition; drugs for impotence; and
interdialytic parenteral nutrition. Maximum Allowable Cost: State imposes Federal Upper
Over-the-Counter Product Coverage: Products not Medically Necessary.”
covered: allergy, asthma and sinus products; analgesics;
cough and cold preparations; digestive products; feminine Incentive Fee: None.
products; topical products; and smoking deterrents.
Patient Cost Sharing: Copayment is $2.00.
covered: anabolic steroids; analgesics, antipyretics, Cognitive Services: Does not pay for cognitive services.
antidepressants; antidiabetic agents; antihistamine drugs; E. USE OF MANAGED CARE
antilipemic agents; anti-psychotics; anxiolytics, sedatives,
and hypnotics; cardiac drugs; chemotherapy agents; Does not use MCOs to deliver pharmacy services to
contraceptives; ENT anti-inflammatory agents; estrogens; Medicaid recipients.
(adrenergic); and thyroid agents. Prior authorization F. STATE CONTACTS
required for: growth hormones. Therapeutic categories not
covered: anorectics; nutritional supplements; and State Drug Program Administrator
prescribed smoking deterrents.
Office of Medical Services
Mark Petersen, R.Ph.
Department of Social Services
reimbursable through physician payment when used in
700 Governors Drive
physicians offices, home health care, and extended care
Pierre, SD 57501
facilities.
T: 605/773-3495
F: 605/773-5246
Vaccines: Vaccines reimbursable with HCPC code as part
of the Vaccines for Children Program.
Mark Petersen, R.Ph., 605/773-3495
DUR Contact
Formulary: Closed formulary.
Mike Jockheck, R.Ph.
Pharmacy Consultant
SD Dept of Social Services
authorization procedure.
700 Governors Dr.
Pierre, SD 57501
Prescribing or Dispensing Limitations 605/773-6439
E-mail: mike.jockheck@state.sd.us
Prescription Dollar Limit: None.
Monthly Quantity Limit: None.
2-South Dakota National Pharmaceutical Council

John Jones, Vice Chairman

Steering Committee (Medicaid DUR Board)
Division of Health, Medical & Laboratory Services
Damian Prunty (Program Administrator) Health Laboratory Building
Tom Carlson, R.Ph. 615 E. 4th Street
Richard Holm, M.D. c/o 500 E. Capitol Avenue
Pam Jones, R.Ph. Pierre, SD 57501
Bruce Lushbough, M.D. 605/773-3737
Jud Bergan, O.D.
Mark Petersen, R.Ph., 605/773-3495 103 South Eagan
Madison, SD 57042
Technical/Policy: Vacant Sheryl Petersen
Disputes/Audits: 218 W. Third Street
Helen Rokusek Pierre, SD 57501
Rebate Coordinator
Dept. of Social Services James D. M. Russell
700 Governors Dr Hospital Admin.
Pierre, SD 57501 St. Mary's Hospital
605/773-3653 803 E. Dakota
Pierre, SD 57501
Meredith Heerman Herb McClellan, Jr., D.D.S.

Dept. of Social Services Box 189
700 Governors Dr Mobridge, SD 57601-0189
Pierre, SD 57501
T: 605/773-3495 Lynn Greff
F: (605) 773-5246 Apothecary Shop at Medical Arts
E-mail: meredith_heerman@state.sd.us 719 St. Francis Street
Rapid City, SD 57701
Stephen Schroeder, M.D.
Mark Petersen, R.Ph., 605/773-3495 Hand Co. clinic
P.O. Box 287
Miller, SD 57362
South Dakota Medicaid Agency Officials
James Ellenbecker Michelle Miller
Secretary McKennan Home Health
Office of Medical Services 800 E. 21st Street
Department of Social Services Sioux Falls, SD 57105-1016
700 Governors Drive
Pierre, SD 57501 A.A. Lampert, M.D.
13075 Bogus Jim Road
Damian Prunty Rapid City, SD 57702-9720
Program Administrator
Medical Services Evaluation Committee
V. R. Brandenburg, M.D.
Medical Advisory Committee Dennis Hodge, Pharm.D.
Paul Engbrecht, Chairman Helen Fiechtner, Pharm.D.
Tieszen Memorial Home Jane Mort, Pharm.D.
437 State Street James Clem, Pharm.D.
Marion, SD 57043 Marc Aldrich (Physician)
605/648-3384
National Pharmaceutical Council South Dakota-3


South Dakota State Medical Association
Robert D. Johnson
1323 Minnesota Avenue
Sioux Falls, SD 57105
605/336-1965
South Dakota Pharmaceutical Association

Robert Coolidge, R.Ph.
Secretary
222 East Capitol, Box 518
Pierre, SD 57501-0518
605/224-2338
South Dakota Osteopathic Association

David A. Lauer, D.O.
Secretary-Treasurer
c/o MASSA-Berry Clinic
Sturgis, SD 57785
605/347-3616

Dennis Jones
Secretary
4305 S. Louise Ave., Ste. 104
605/362-2737
South Dakota Association of Healthcare Organizations

Frank M. Drew
President
3708 Brooks Place
Ste. 1
605/361-2281
4-South Dakota National Pharmaceutical Council

TENNESSEE -- TennCare
In 1994, Tennessee made history by withdrawing from the TennCare services are offered through managed care
Medicaid Program and implementing an innovative new organizations (MCOs) and behavioral health organizations
health care reform plan called TennCare. TennCare (BHOs) under contract with the State. These MCOs,
replaced the existing Medicaid Program with a program of spread out over the twelve regions of Tennessee, are paid
managed health care. TennCare required no new taxes a fixed amount which averages $116 per enrollee per
and extended health coverage not only to the nearly month for the MCO services. BHOs are paid $319.41 for
800,000 Tennesseans in the Medicaid population, but also priority participants and a variable rate for all other
to an approximately 400,000 uninsured or uninsurable TennCare enrollees and state onlys. The MCOs and BHOs
persons using a system of managed care. Enrollment was negotiate payment rates with individual providers.
open in 1994 to eligible persons in the uninsured, Enrollees have a choice of MCOs (and their
uninsurable, and Medicaid-eligible categories. corresponding BHO partner plan) from those available in
their geographic area. Effective January 1, 1997, all
On January 1, 1995, TennCare reached 90% of its target services are delivered within a strict "gatekeeper" model
enrollment and closed enrollment in the uninsured system requiring primary care providers to manage
category. However, on April 1, 1997, enrollment in the enrollees' health care.
uninsured category re-opened to children under the age of
18 who do not have access to health insurance through a TennCare services, as determined medically necessary by
parent or guardian. On May 21, 1997, TennCare the MCO, cover inpatient and outpatient hospital care,
enrollment became available for eligible dislocated physician services, prescription drugs, lab and x-ray
workers. Enrollment remains open to persons and their services, medical supplies, home health care, hospice care,
dependents who have lost access to a COBRA insurance and ambulance transportation. Excluded from TennCare
plan and do not have access to other health insurance. In managed care services are long-term care services and
an effort to expand coverage to more of Tennessee's Medicare cross-over payments which are continuing as
uninsured children, the Bureau of TennCare opened they were under the former Medicaid system.
enrollment on January 1, 1998 to uninsured Tennesseans
under the age of nineteen (19) with access to health TennCare is financed by pooling current federal, state and
insurance whose individual family incomes are below local expenditures for indigent health care, which include
200% of the poverty level. Effective January 1, 1998, $2.4 billion for the TennCare/Medicaid Program in the
uninsured children under age nineteen (19) who meet the 1998-99 fiscal year's budget. Pooled resources total
TennCare criteria for uninsured are being allowed to $3.779 billion, including $226 million in local Certified
enroll in TennCare indefinitely. The Bureau of TennCare Public Expenditures. Within this budget, $1.418 billion is
eliminated deductibles and limited co-payments to 2% for identified as funding for long-term care programs, Home
these new eligibility populations and all uninsured and Community Based Services Waiver programs,
children under eighteen (18) years of age who enrolled in Medicare cross-overs through the Medicaid system,
TennCare during previous open enrollment periods. Medicare premiums, and administration for the total
Enrollment remains open to persons who are Medicaid- program. The remaining $2.361 billion has been identified
eligible or who are uninsurable as determined by an to fund the current year of the TennCare Program. In the
insurance company's denial (for medical reasons) of health future, competition among managed care networks,
insurance to the individual. Current enrollment (5/30/00) combined with the enrollment cap, should enable
is approximately 1,316,216, of which 795,968 are TennCare to grow at a predictable rate not exceeding the
Medicaid eligibles and 520,248 are in the annual rate of growth in state spending.
uninsured/uninsurable categories.
Source: TennCare Home Page on the World Wide Web,
last updated 08/09/00. http://www.state.tn.us/tenncare/
The State of Tennessee was granted approval by the
Health Care Financing Administration for a five-year
demonstration project under Section 1115 of the Social ELIGIBILITY FOR TENNCARE COVERAGE
Security Act. State rules were promulgated to assist in
administering the statewide program (TSOP). The initial Currently, Medicaid eligible persons, children under age
five-year demonstration project ended December 31, 19 with no access to health insurance, dislocated workers
1998. HCFA approved a waiver extension for three years who previously had health insurance through employers
beginning January 1, 1999 through December 31, 2001. and become uninsured due to a bona fide closure of a
business or plant, and persons with proof of
uninsurability, are eligible for TennCare coverage. To
National Pharmaceutical Council Tennessee-1

provide proof of uninsurability, one must have a letter of Formulary: Varying formularies used by the individual
denial from an insurance company, on company letterhead MCOs. Most are closed formularies. MCO formularies
stationary, that is licensed in the State of Tennessee. The must conform to TennCare guidelines. TennCare must
TennCare applicant may then send in their application approve formulary additions/deletions.
along with a copy of this letter to the address provided on
the TennCare application. Prior Authorization: Prior authorization procedures are
administered by the individual MCOs.
Someone is not uninsurable if they cannot afford health
insurance. Someone is not a dislocated worker if they are Copayment: Deductibles and copayments apply to
laid-off or terminated at a plant that continues to operate. services other than preventive services (e.g.,
The Tennessee Department of Human Services makes immunizations) based on a sliding scale according to
decisions for most Medicaid eligibility categories. The income. Medicaid recipients and persons or families with
Social Security Administration makes decisions regarding income under 100% of the federal poverty level are not
eligibility for Medicaid for disabled individuals. The required to pay premiums, deductibles, or copayments in
Tennessee Department of Labor determines bona fide order to participate in the TennCare program.
closures of businesses or plants. In some TennCare
eligibility categories, persons may be eligible in cases C. USE OF MANAGED CARE
where COBRA coverage is offered. In some TennCare
eligibility categories, persons may not be eligible until Medicaid recipients and the uninsured/uninsurable are
their opportunity to purchase COBRA coverage has enrolled in MCOs through the TennCare program. All
expired. Contact the TennCare Hotline with questions. receive pharmacy benefits through managed care.
A TennCare application can be received by calling the Managed Care Organizations

TennCare Hotline at 1-800-669-1851 or by visiting the
local Tennessee Department of Health office. There is a Heritage National Health Plan of Tennessee, Inc.
local Health Department office in every Tennessee (John Deere Health Care/
county. For the applicants' convenience, the Health Heritage National Health Plan)
Department will make a copy of the application, date Executive Tower I, Ste. 400
stamp it, and keep it on file. If the applicant mails the 408 N. Cedar Bluff Road
application from their home, they should keep a copy for Knoxville, TN 37923
their personal files.
Memphis Managed Care Corporation
Source: TennCare Home Page on the World Wide Web, (TLC Family Care Healthplan)
last updated 08/07/00. http://www.state.tn.us/tenncare/ P.O. Box 49
Memphis, TN 38101
A. ADMINISTRATION
OmniCare Health Plan, Inc.
1991 Corporate Ave. 5th Floor
Tennessee Department of Health, Bureau of TennCare
Memphis, TN 38132
B. PROVISIONS RELATING TO DRUGS Preferred Health Partnership of Tennessee, Inc.
1420 Centerpoint Blvd.
Benefit Design Knoxville, TN 37932
Pharmacy services are provided by the managed care Tennessee Managed Care Network
organizations. Pharmacy services are to be covered as (Access...MedPlus)
medically necessary, excluding DESI, less than effective 210 Athens Way
and IRS drugs and some drugs for which TennCare does Nashville, TN 37228
not mandate coverage (e.g., drugs for infertility, weight
reduction, cosmetic purposes, hair growth products, Xantus Health Plan of Tennessee, Inc.
products for symptomatic relief of cough and colds, 3401 West End Ave., Ste. 470
smoking cessation products, and most OTCs). Growth Nashville, TN 37203
hormone products and oral contraceptives require
approval by the TennCare Prior Approval Unit. While the
MCOs may participate in the drug rebate program, the VUMC Care, Inc.
State does not. (VHP Community Care)
210 Westwood Place, Ste 200
Brentwood, TN 37027
2-Tennessee National Pharmaceutical Council

MCO/BHO "Partners" Pharmacy and Therapeutics Committee

Premier Behavioral Systems of Tennessee (800-325- – Director of the Bureau of TennCare
7864) – TennCare Medical Director
• Blue Care (except in East Tennessee and Knox – TennCare Pharmacy Director
County) – TennCare Associate Medical Director
• John Deere Health Plan – Associated Medical Director of the
• OmniCare Health Plan TennCare Grievance Unit
• Xantus Gold – Medical Director of the TennCare Grievance
• VHP Community Care Intervention Unit
Tennessee Behavioral Health, Inc. (800-447-7242) – One Public Health Physician
• Access...Med Plus – One Physician who is a TennCare
• Blue Care (in East Tennessee and Knox County) participating provider
• Preferred Health Partnership (PHP) – One Pharmacist who is a TennCare
participating provider
• Prudential Community Care
• TLC Family Care Healthplan
Each MCO is required to have its own Pharmacy and
Therapeutics Committee.
D. STATE CONTACTS
Pharmaceutical Care Advisory Board
A statewide TennCare Pharmaceutical Care Advisory
Leo Sullivan, D.Ph. Board is being created. Board members are to be
Director of Pharmacy Services appointed by the Commissioner of Health.
Bureau of TennCare
729 Church Street
Nashville, TN 37243 Executive Officers of State Medical and
T: 615/741-8155 Pharmaceutical Societies
F: 615/532-3479 Tennessee Medical Association
TennCare Officials Donald H. Alexander
2301 21st Avenue, S.
Karen Oldham, M.D., C.M.C.M. P.O. Box 120909
Chief Medical Officer, Bureau of TennCare Nashville, TN 37212-0909
729 Church Street 615/385-2100
Nashville, TN 37243
T: 615/253-3262 State Board of Pharmacy
F: 615/741-0064 Kendall M. Lynch, Director
Volunteer Plaza, Second Floor
Susie Baird 500 James Robertson Parkway
Director of Programs Nashville, TN 37243-1149
615/741-2718
Ken Okolo, FACHE
Directory of Quality Oversight
Keith Gaither
Fiscal Director
Office of Business, Finance & Research
Joanna Damons
Division of Long Term Care
TennCare Information Line

800-669-1851
Consultec, Inc.
T: 877/296-1935
National Pharmaceutical Council Tennessee-3

Tennessee Osteopathic Medical Association

Cathy M. Garris
Executive Director
1900 The Exchange
Ste. 380
Atlanta, GA 30339
404/955-5538
THS-An Association of Hospitals and Health Systems

Craig A. Becker
President
500 Interstate Boulevard, S.
Nashville, TN 37210-4634
615/256-8240
4-Tennessee National Pharmaceutical Council

TEXAS

Prescribed Drugs      
Inpatient Hospital Care      
Outpatient Hospital Care      
Laboratory & X-ray Service      
Skilled Nursing Home Services      
Physician Services      
1

1998 1999*
TOTAL $817,591,112 1,894,447

Aged $148,567,470 156,181
Blind / Disabled $254,181,888 229,124
AFDC-Child $41,448,918 265,634
AFDC-Adult $34,025,698 116,765
AFDC-Unemployed-Child $3,946,327 22,624

Aged $0 0
AFDC-Child $3,806,777 6,185
AFDC-Adult $5,934,165 19,379

Aged $497,968 865
AFDC-Child $92,122,948 597,641
AFDC-Adult $10,682,258 109,445
OTHER $219,562,843 356,080

*1999 recipient data broken down by maintenance assistance status and basis of eligibility are unavailable.
National Pharmaceutical Council Texas-1

Texas Department of Health. Vendor drug program was Formulary: Open formulary; however, products must be
implemented September 1, 1971. listed in the Texas Drug Code Index. General exclusions
(diseases, drug categories, etc.) include: amphetamines,
D. PROVISIONS RELATING TO DRUGS appliances, durable medical equipment (bedpans, etc. -
either rental or purchase), elastic stockings, first aid
Benefit Design supplies, medical supplies, oxygen, supports and
suspensories, and trusses.
prescribed insulin; disposable needles (pen needles only) Prior Authorization: Prior authorization procedure
and syringe combinations used for insulin. Products not screening for drug classes and individual drugs.
covered: cosmetics; fertility drugs; experimental drugs;
total parenteral nutrition; and interdialytic parenteral Prescribing or Dispensing Limitations
nutrition; blood glucose test strips; urine ketone test strips. Prescription Refill Limit: Five refills, but total amount
Prior authorization required for: human growth hormones may not exceed 6-month supply.
and dextramphetamines.
Monthly Quantity Limit: Prescribed quantity cannot
Over-the-Counter Product Coverage: Products covered: exceed 6-month supply.
feminine products; topical products; allergy, asthma, and
sinus products; analgesics; cough and cold preparations; Monthly Prescription Limit: Limited to 3 per month
digestive products (non-H2 antagonist); smoking deterrent except for recipients under age 21 and nursing home
products; digestive products (H2 antagonists). Certain recipients.
OTC drugs are covered on a prescription basis except as
otherwise provided in the reimbursement formula and Other Limit: Recipients in managed care pilots receive
vendor payment to hospitals, nursing homes and unlimited prescription coverage.
institutions.
covered: anabolic steroids; antibiotics; authorization: PRODUR system implemented in February 1995. State
analgesics, antipyretics, NSAIDs; anticoagulants; currently has a DUR board with a quarterly review.
anticonvulsants; anti-depressants; antidiabetic drugs;
antihistamine drugs; antilipemic agents; antipsychotics; Pharmacy Payment and Patient Cost Sharing
chemotherapy agents; contraceptives; prescribed cold Dispensing Fee: $5.27 +2%. The dispensing fee,
mediation; ENT anti-inflammatory agents; estrogens; including all costs of filling a prescription, was
hypotensive agents; misc. GI drugs; thyroid agents; established by cost accounting and service evaluation of
prescribed smoking deterrents; and sympathominetics the expenses involved in dispensing a prescription.
(adrenergic). Prior authorization required for: growth Therefore, fees paid to providers who experience different
hormones. Therapeutic categories not covered: anorectics. cost and service factors considered in arriving at the fee
may receive more or less than actual costs incurred in
Coverage of Injectables: Injectable medicines dispensing.
when used in home health care, extended care facilities Ingredient Reimbursement Basis: EAC = AWP-15% or
and through physician payment when used in physicians WAC + 12%, whichever is lower, AAC for hospitals and
offices. public health providers.
Vaccines: Vaccines reimbursable as part of EPSDT Prescription Charge Formula: Average dispensing
service, not under the Vendor Drug program. expense (ADE) formula for payment:
1. (EAC + 5.27) divided by 0.980 = amount paid +
Unit Dose: Unit dose packaging reimbursable only when $0.15 delivery service.
there is not an added expense for the packaging. 2. DEAC only for Wyeth-Ayerst.
Insulin and approved non-legend drugs on prescription:
pharmacists and dispensing physicians will be reimbursed
on the basis of usual charges to the general public or cost
2-Texas National Pharmaceutical Council

plus 50% of cost, whichever is lower; 50% of cost not to Debbie Blount
exceed assigned variable dispensing fee. Deputy Commissioner for Health Care Financing
Maximum Allowable Cost: State imposes Federal Upper Prior Authorization Contact
Barbara Dean, R.Ph.
465 drugs are listed on the state-specific MAC list.
Pharmacist III
Override requires “Brand Necessary” or “Brand
Texas Department of Health
1100 W. 49th Street
Austin, TX 78756-3174
512/338-6920
E-mail: barbara.dean@tdh.state.tx.us
Vendor Drug Program
Martha McNeill, R.Ph.
E. USE OF MANAGED CARE Director, Product Enrollment Division
An undisclosed number of Medicaid recipients are 1100 W. 49th Street
enrolled in MCOs (all of whom are AFDC/AFDC Austin, TX 78756-3174
related). 512/338-6965
E-mail: martha.mcneill@tdh.state.tx.us
Patsy Napier, R.Ph.
Physician Corporation of America Pharmacy Field Coordinator
8303 Mopac, Ste. 450 512/338-6992
Austin, TX 78759-8370
DUR Contact
Vista, Inc.
9310 North Lomar Curtis Burch, R.Ph.
Austin, TX 78753 Director, Drug Utilization Review Division
Primary Care Case Management 1100 W. 49th Street
Austin, TX 78756-3174
F. STATE CONTACTS T: 512/338-6922
F: 512/338-6910
State Drug Program Administrator E-mail: curtis.burch@tdh.state.tx.us
Robert Harriss, Director DUR Board

1100 W. 49th Street Robert Barr, M.D., R.Ph.
Austin, TX 78756 Chairman
T: 512/338-6961 2414 Florence Avenue
F: 512/338-6910 Pasadena, TX 77502
Department of Health Officials Leroy Knodel, Pharm.D., Vice Chairman

Drug Information Service
Reyn Archer, M.D. Department of Pharmacology
Commissioner The University of Texas Health Science Center
Texas Department of Health 7703 Floyd Curl Drive
1100 W. 49th Street San Antonio, TX 78284-7766
Austin, TX 78756
Thomas Lee Kurt, M.D., M.P.H.
Linda Wertz 3645 Stratford Avenue
Medicaid Director Dallas, TX 75205
Texas Health & Human Services Commission
P. O. Box 13247
Austin, TX 78711
512/502-3200
National Pharmaceutical Council Texas-3

Mark S. Gittings, D.O., R.Ph.

4327 Grants Glen
Wichita Falls, TX 76309 Susan P. Milam, Ph.D.
Chief, Bureau of Managed Care
Robert L. Hogue, M.D. Texas Department of Health
101 A South Park Drive 1100 W. 49th Street
Brownwood, TX 75801 Austin, TX 78756
T: 512/794-6836
Daniel Saylak, D.O. www.tdh.state.tx.us/hcf/mcstart.htm
4607 Locksford
Bryan, TX 77802 Physician-Administered Drug Program Contact
Rodger Love, Director
Mary Spies Maxwell, M.D.
1100 W. 49th Street
4526 Burnet Road
Austin, TX 78756-3168
Austin, TX 78731
512/338-6505
Adelina Barbosa, R.Ph.
#10 Casa De Palmas Executive Officers of State Medical and
Brownsville, TX 78521 Pharmaceutical Societies
Texas Medical Association
Anita Martinez, R.Ph. J. James Rohack, M.D.
2819 Burning Hill President
San Antonia, TX 78247 401 W. 15th Street
Austin, TX 78701-1680
James B. Hills, R.Ph. 512/370-1300
Lava Rock Apothecary
1907 E. Southmore Street Texas Pharmaceutical Association
Pasadena, TX 77502 Lonnie Hollingsworth, R.Ph.
Interim Executive Director
Robert T. Reilly, Pharm.D. P. O. Box 14709- 1624 E. Anderson Lane
Thomason Hospital Austin, TX 78761-4709
Department of Pharmacy 512/836-8350
4815 Alameda Avenue, P. O. Box 2009
El Paso, TX 79998 Texas Osteopathic Medical Association
Terry Boucher
W. Perry Flowers Executive Director, Secretary/Treasurer
6607 Sandie Dr. 1415 Lavaca
Amarillo, RX 79109 Austin, TX 78701-1634
(512) 708-8662
Martha McNeill, R.Ph. State Board of Pharmacy
512/338-6965 Gay Dodson
Executive Director/Secretary
William P. Hobby Building
Medicaid Program Contacts
Ste. 3-600
Technical: Matt Sneed, 512/231-5604 (claims) 333 Guadalupe St.
Policy: Patricia Gladden, 512/338-6967 Box 21
Rebate: Heather Murphy, 512/338-6963 Austin, TX 78701-3942
Claims: Patsy McElroy, 512/338-6909 512/305-8000
Texas Hospital Association

Terry Townsend
FACHE, CAE, President, CEO
6225 US Highway 290 E.
P.O. Box 15587
Austin, TX 78761-5587
512/465-1000
4-Texas National Pharmaceutical Council

UTAH

1

1998* 1999*
TOTAL $68,827,853 126,953

Aged
Blind/Disabled

Aged
Blind/Disabled

Aged
Blind/Disabled

National Pharmaceutical Council Utah-1

C. ADMINISTRATION Unit Dose: Manufacturer unit dose packaging

reimbursable.
Division of Health Care Financing, State Department of
Health. Formulary/Prior Authorization
D. PROVISIONS RELATING TO DRUGS Formulary: Open formulary.
Benefit Design Prior Authorization: Prior authorization procedure

screening for individual drugs.
Drug Benefit Product Coverage: Prior authorization
required for: Relenza; human growth hormones; and anti- Prescribing or Dispensing Limitations
ulcer drugs. Products not covered: hair growth products. Prescription Refill Limit: Limited to five.

Monthly Quantity Limit: In general, the quantity of
− Acetaminophen, All dosage forms medication shall be limited to a supply not to exceed 30
− Acetone tests (e.g., Acetest, Chemstrip-K, Ketostix) days.
− Antacid liquid and tablets
− Aspirin, All dosage forms Drug Utilization Review
− Contraceptive creams, foams, tablets and sponges
− DSS caps liquid and syrup PRODUR system implemented in June 1995.
− DSS concentrate drops 5%
− Ferrous fumerate, All dosage forms Pharmacy Payment and Patient Cost Sharing
− Ferrous gluconate, All dosage forms
− Ferrous sulfate, All dosage forms Dispensing Fee: $3.90 for urban, $4.40 for rural, effective
− Glucose blood tests (e.g., Chemstrip, BG, Dextrostix, 1993.
Visidex)
− Glucose urine tests (e.g., Clinitest, Clinistix, Diatrix, Ingredient Reimbursement Basis: EAC = AWP - 12%.
Tes Tape, Chemstrip G)
− Insulin Prescription Charge Formula: Lowest of:
− Insulin syringes/needles/disposable
− Kaolin w/pectin suspension (e.g., Kaopectate) 1. EAC/MAC plus a dispensing fee, or
− Lactobacillus acidophilus (e.g., Bacid, Lactinex) 2. Usual and customary charges to the private sector for
− Nutrients (all nutrients require prior approval) legend and generic legend drugs.
− Pedialyte liquid Formula for OTCs is AWP minus 12% plus $1.00
− Prophylactics male dispensing fee.
− Psyllium muciloid powder
− Quinine, 5 gr. Maximum Allowable Cost: State imposes Federal Upper
Products not covered: vitamins (except for expectant Limits as well as state-specific limits on generic drugs.
mothers and children to age 5); smoking deterrent Override requires “Brand Medically Necessary.”
products; and
Therapeutic Category Coverage: Products not covered:
anorectics (except for amphetamines and derivatives only Patient Cost Sharing: Copayment = $1.00, maximum is
for specific indications of narcolepsy and hyperkinesis). $5.00 per month.
Coverage of Injectables: Injectable medicines Cognitive Services: Does not pay for cognitive services.
reimbursable when used in home health care, and
extended care facilities, and through physician payment. E. USE OF MANAGED CARE
Vaccines: Vaccines reimbursable at AWP minus 12% plus An unavailable number of Medicaid recipients are
a fee as part of the EPSDT service, Children Health enrolled in managed care; however the number of
Insurance Program, and the Vaccines for Children enrollees is listed for some of the following MCOs. The
Program. pharmacy benefits are through the state.
2-Utah National Pharmaceutical Council

Carter Burke
Hoechst Marion Roussel
Altius 1912 Lawrence Circle
10421 S. Jordan Gateway South Jordan, UT 84065
South Jordan, UT 84095 801/254-9026
American Family Care Jeff Coursey

2120 South 13th East #303 774 5th Avenue
Salt Lake City, UT 84106 Salt Lake City, UT 84103
801/537-7219
IHC Access
P.O. Box 116670 Larry Dent, Pharm.D.
Salt Lake City, UT 84147 11756 S. Briarglen Drive
Sandy, UT 84092
Med Utah Healthwise 801/571-4155
P.O. Box 30804
Salt Lake City, UT 84130-0804 Terry Frank, R.Ph.
Apothecary Shoppe
PHS 1002 East South Temple
35 West Broadway Salt Lake City, UT 84102
Salt Lake City, UT 84101
Bradford D. Hare, M.D.
United Medchoice Department of Anesthesiology
7910 South 3500 East 50 North Medical Drive
801/585-7246
U of U Health Network
35 W. Broadway Jeff Jones, R.Ph.
Salt Lake City, VT 84101 Riverton Drug
1741 West 12600 South
Riverton, UT 84065
F. STATE CONTACTS 801/254-3911
State Drug Program Administrator Richard Martinez, D.D.S.

RaeDell Ashley 2936 Highland Drive
Pharmacy Director Salt Lake City, UT 84106
Division of Health Care Financing 801/467-6555
288 N. 1460 West J. Brent Muhlestein, M.D.
Salt Lake City, UT 84114-2906 Department of Cardiology
T: 801/538-6495 Eighth Avenue and C Street
F: 801/538-6099 Salt Lake City, UT 84143
801/321-5013
DUR Board
Lynda Oderda, Pharm.D.
Dennis Beasley, R.Ph. Assistant Professor (Clinical)
76 North 1100 East Department of Pharmacy Practice
American Fork, UT 84003 University of Utah College of Pharmacy
801/756-5866 Salt Lake City, UT 84112
801/581-6304
Lowry Bushnell, M.D.
University of Utah Neuropsychiatric Institute Rodney A. Pollary, M.D.
501 Chipeta Way Nighttime Pediatrics
Salt Lake City, UT 84108 Attention: Lynda Stuart
801/584-2034 7001 S. 900 E. Ste. 400
Midvale, UT 84047-1761
801/256-6483
National Pharmaceutical Council Utah-3

John M. Tudor, Jr., M.D. State Board of Pharmacy

Cigna Healthcare of Utah Theresa Whitney
5295 South 320 West 160 E. 300 South
Ste. 280 P.O. Box 45802
801/261-7502 801/530-6740
Utah Association of Healthcare Providers
Technical: RaeDell Ashley, 801/538-6495 Richard B. Kinnersley
Policy: RaeDell Ashley, 801/538-6495 President
PA: RaeDell Ashley, 801/538-6495 127 South 500 East
DUR: Duane Parke, 801/538-6495 Ste. 625
RaeDell Ashley
Division of Health Care Financing
288 N. 1460 West
Salt Lake City, UT 84114-2906
801/538-6495
Department of Health Officials

Rod Betit, MD
Executive Director
288 N. 1460 West
801/538-6151

Utah State Medical Association
J. Leon Sorenson
Executive Director
540 East 500 South
801/355-7477
Utah Pharmaceutical Association

C. Neil Jensen
Executive Director
1062 East 21st St. S., Ste. 212
801/484-9141
Utah Osteopathic Medical Association

T. Scott Smith, D.O.
Secretary/Treasurer
70 E. 1100 N
Richfield, UT 84701
801/896-8254
4-Utah National Pharmaceutical Council

VERMONT

1

1998 1999*
TOTAL $43,445,887 58,307

Aged $2,902,730 2,146
Blind / Disabled $15,354,411 9,295
AFDC-Child $450,223 5,058
AFDC-Adult $723,299 2,754

Aged $1,155,290 504
Blind / Disabled $2,504,106 1,174
AFDC-Child $207,975 1,378
AFDC-Adult $371,029 1,274

Aged $7,569,978 7,308
Blind / Disabled $4,295,028 2,357
AFDC-Child $875,242 9,514
AFDC-Adult $351,851 5,018
OTHER $5,053,540 8,019

National Pharmaceutical Council Vermont-1

Monthly Quantity Limit: Initial prescription should be

C. ADMINISTRATION sufficient to allow for the determination of the patient’s
tolerance of the medication without creating unnecessary
Agency of Human Services. waste (expense) to the program. This quantity could be
up to a 60-day supply on all maintenance medication
D. PROVISIONS RELATING TO DRUGS prescriptions.
Benefit Design Drug Utilization Review
Drug Benefit Product Coverage: Products covered: PRODUR system implemented in November 1993. State
prescribed insulin; disposable needles and syringe currently has a DUR board with a bimonthly review.
urine ketone test strips; total parenteral nutrition; and Pharmacy Payment and Patient Cost Sharing
cosmetics and experimental drugs. Dispensing Fee: $4.25, effective 7/1/96.
Over-the-Counter Product Coverage: Products covered Ingredient Reimbursement Basis: EAC = AWP – 11.9%.
with prior authorization: allergy, asthma and sinus
products; analgesics; cough and cold preparations; Prescription Charge Formula: Pharmacies bill their usual
digestive products (H2 antagonists); feminine products; and customary charge. Medicaid pays the lower of:
topical products; and smoking deterrent products.
1. Usual and customary charge;
2. EAC plus a dispensing fee; or
3. Maximum allowable cost plus a dispensing fee.
NSAIDs; anorectics; antibiotics; anticoagulants;
anticonvulsants; anti-depressants; antidiabetic agents;
Limits and State-specific limits on generic drugs.
antihistamine drugs; antilipemic agents; anti-psychotics;
Override requires “Dispense as Written.”
chemotherapy agents; prescribed cold medications;
Patient Cost Sharing: Copayment of $1.00 per
(adrenergic); and thyroid agents. Prior authorization
dispensation required (excluding standard federal
required for: prescribed smoking deterrents.
exemptions). Copayment of $2.00 when ingredient cost
exceeds $29.99.
reimbursable when used in physician offices, home health
Vaccines: Reimbursable at AWP minus 10% as part of E. USE OF MANAGED CARE

EPSDT service. !""#$%&'()*+,-JI0J;.-)$)(+-3*4&5(&4-#*5&"&*6)7-(#*
*6#$++*4-&6-3BC7<--K$6*-#*5*&=*4-">(#'(5,-7*#=&5*7
Unit Dose: Unit dose packaging reimbursable. )>#$?9>-'(6(9*4-5(#*<-
Formulary/Prior Authorization F. STATE CONTACTS
Formulary: Open formulary. General exclusions include State Drug Program Administrator
cosmetics and experimental drugs.
Pat House
Prior Authorization: Prior authorization procedure Operations Manager
screening for drug classes. PA is required for non- Office of Vermont Health Access
pregnancy multi-vitamins, smoking deterrents, 103 South Main Street
amphetamines, food supplements, and OTC drugs. Waterbury, VT 05671
T: 802/241-2765
Prescribing or Dispensing Limitations F: 802/241-2974
E-mail: pathouse@wpgate1.ahs.state.vt.us
Prescription Refill Limit: Up to 5 may be authorized by a
physician.
2-Vermont National Pharmaceutical Council

Dr. Virginia Hood

Agency of Human Services Officials
UVM, Nephrology Unit
Jane M. Kitchel FAHC, Burgess 318
Secretary 111 Colchester Ave
Agency of Human Services Burlington, VT 05156
103 South Main Street
Waterbury, VT 05650-1201 Prescription Price Updating
802/241-2880
Christine Dapkiewicz
Drug Rebate Coordinator
Eileen Elliott
312 Hurricane Lane
Commissioner
Williston, VT 05495
Department of Social Welfare
T: 802/879-4450
F: 802/878-3440
John Dick
Policy & Procedures
802/241-2880
Technical: Christine Dapkiewicz, 802/979-4450
Prior Authorization Contact Policy: Vacant
Disputes: Shona M. Lothrop, 802/879-4450
Pat House
802/241-2765
DUR Contact EDS
Fiscal Agent
Gloria Jacobs
312 Hurricane Lane, Ste 101
Operations Administrator
Williston, VT 05495
Office of VT Health Access
T: 802/879-4450
103 S. Main St.
F: 802/878-3440
Waterbury, VT 05671
T: 802/241-2763
F: 802/241-2974
E-mail: gloriaj@wpgate1.ahs.state.vt.us Pat House
802/241-2765
DUR Board
Disease Management Initiative/Program Contact
John Low, R.Ph.
Chairman Shona Mossey-Lothrop
10 Greenbriar Dr. Pharmacy Consultant
Essex Junction, VT 05452 EDS
Richard Harvie, R.Ph. Williston, VT 05495
Brooks Pharmacy T: 802/879-4450
60 Main Street F: 802/878-3440
Montpelier, VT 05602 E-mail: mossesm@vtxix.slg.eds.com
Norman Ward, M.D. Expanded Drug Coverage Program Contact

P.O. Box 1150
Burlington, VT 05402 Pat House
802/241-2765
Dr. James Gray
253 Stratton Road Physician-Administered Drug Program Contact
Rutland, VT 05701 Dr. Joseph Jacobs
Medical Director
Dennis Fortier, R.Ph. Office of Vermont Health Access
Pharmacy Department Department of Social Welfare
Springfield Hospital 103 South Main Street
25 Ridgewood Road Waterbury, VT 05650-1201
Springfield, VT 05156 802/241-2745
National Pharmaceutical Council Vermont-3


Vermont Medical Society
Karen Meyer
Executive Director
136 Main Street
P.O. Box 1457
Montpelier, VT 05602
802/223-7898
Vermont Pharmacists Association

Fred Dobson
Executive Director
P. O. Box 790
Richmond, VT 05477
802/434-3001
Vermont State Association of Osteopathic Physicians &

Surgeons, Inc.
John M. Peterson, D.O.
Secretary-Treasurer
72 Barre Street
802/229-9418

Carla Preston
Secretary of State’s Office
Office of Professional Regulation
109 State Street, Pavilion Office Building
Montpelier, VT 05609-1106
802/828-2875
Vermont Hospital Association

Norman E. Wright
President
148 Main Street
802/223-3461
4-Vermont National Pharmaceutical Council

VIRGINIA

Dental Services All eligible recipients under age 21
1

1998* 1999*
TOTAL $284,578,558 383,880

Aged
Blind
Disabled

Aged
Blind
Disabled

Aged
Blind
Disabled

National Pharmaceutical Council Virginia-1

C. ADMINISTRATION Ingredient Reimbursement Basis: EAC = AWP - 9%.
Department of Medical Assistance Services. Eligibility Prescription Charge Formula: Based upon the lower of
determination by the Department of Social Services. MAC or EAC plus a fee if legend, or the usual and
customary charge minus an applicable copayment.
Benefit Design Limits as well as state-specific limits on generic drugs.
Override requires “Brand Necessary.”
fertility drugs; hair growth products; designated DESI Incentive Fee: None.
drugs; experimental drugs; non-legend drugs; and expired
drugs. Patient Cost Sharing: Copayment is $1.00/Rx for all
qualifying prescriptions. Exclusions include less than 21
Over-the-Counter Drug Coverage: A majority of OTC years old, pregnancy related, family planning, and nursing
drugs reimbursable when used in nursing homes and home patients.
certain classes in outpatient populations.
Cognitive Services: Does not pay for cognitive services at
Therapeutic Category Coverage: Prior authorization present.
required for: amphetamines and growth hormones.
reimbursable through physician payment when used in F*5&"&*6)7-#*5*&=*-">(#'(5*?)&5(+-A*6*2&)7-)>#$?9>
physician offices (through physician payment), home '(6(9*4-5(#*-"+(67<
health care, and extended care facilities. 1) Medallion - primary care physicians,
2) Options - optional enrollment for recipients into
Vaccines: Vaccines reimbursable based on HCPCS code HMOs, and
as part of the Health Department and Vaccines for 3) Medallion II - mandatory HMOs in the Tidewater
Children Program. region and the Richmond area.
Unit Dose: Unit dose packaging reimbursable in nursing F. STATE CONTACTS

homes.
David B. Shepherd, R.Ph.
Formulary: Open formulary. Pharmacy Supervisor
Division of Program Operations
Prior Authorization: Prior authorization procedure Department of Medical Assistance Services
screening for individual drugs. 600 East Broad Street, Ste. 1300
Richmond, VA 23219
Prescribing or Dispensing Limitations T: 804/225-2773
F: 804/786-0414
Prescription Refill Limit: Physicians may authorize refills
according to legal requirements.
Monthly Quantity Limit: Physicians requested to prescribe
maintenance drugs in quantities reflecting a 30-day Policy: David Shepherd, 804/225-2773
supply, or 100 units or doses. DUR: Marianne Rollings, 804/225-4268
Disputes: Mike Beahm, 804/225-3359

PRODUR system implemented in July 1994. Sally Rice
804/786-9490
2-Virginia National Pharmaceutical Council

Department of Medical Assistance Services Fiscal Intermediary

Officials
First Health Services
Dennis Smith P.O. Box 6987
Director Richmond, VA 23230
Department of Medical Assistance Services
600 East Broad Street, Ste. 1300
Virginia Medicaid Pharmacy Liaison Committee
Richmond, VA 23219
(PLC)
804/786-8099
Bill Hancock, R.Ph.
Sally Rice Pharmacist
Manager Long Term Care Pharmacy Coalition
Provider Relations
Division of Program Operations Cindy Warriner, R.Ph.
804/786-9490 Pharmacist
Community Pharmacy Coalition
David Kozera, R.Ph.
Medical Society of Virginia Pharmacist
Paul Kitchen Virginia Association of Chain Drug Stores
Executive Vice-President
4205 Dover Road Rebecca Snead, R.Ph.
Richmond, VA 23221-3267 Pharmacist
804/353-2721 Virginia Pharmacists Association
Virginia Pharmaceutical Association Ellen Frank

Rebecca Smead Government Relations Mtg.
Executive Director Pharmaceutical Research and Manufacturers of America
5501 Patterson Ave., Ste. 200
Richmond, VA 23226

Elizabeth Scott Russell
Executive Director
6606 W. Broad Street, Ste. 400
Richmond, VA 23230-1717
804/662-9911
Virginia Osteopathic Medical Association

Peter C. Gent, D.O.
Secretary/Treasurer
11900 Hull St. Road
Midlothian, VA 23112-2904
804/744-3551
Virginia Hospital and Healthcare Association

Laurens Sartoris
President
4200 Innslake Drive
Glen Allen, VA 23060
P.O. Box 1394
Richmond, VA 23294
804/747-8600
National Pharmaceutical Council Virginia-3

WASHINGTON

OAA AB APTD AFDC OAA AB APTD AFDC Children <21* SFO
1
*Limited to children in foster care, subsidized adoption, SNH, IFC, ICMR or inpatient psychiatric facility.

1998 1999*
TOTAL $244,478,658 274,463
RECEIVING CASH ASSISTANCE, TOTAL $150,637,488 149.823

Aged $24,421,684 20,484
Blind / Disabled $120,847,808 77,084
AFDC-Child $1,203,115 21,981
AFDC-Adult $3,447,197 21,817

Aged $7,032,474 5,164
Blind / Disabled $14,817,475 5,167
AFDC-Child $4,148 25

Aged $435,200 631
AFDC-Child $1,052,246 17,157
AFDC-Adult $494,640 9,210
OTHER $69,224,013 86,103

1-Washington National Pharmaceutical Council

Medical Assistance Administration, Department of Social Formulary: Open formulary

and Health Services.
D. PROVISIONS RELATING TO DRUGS authorization procedure and a Drug Utilization and
Education Review Council. Recipients can request a fair
Benefit Design hearing and exception to policy to appeal an excluded
product or prior authorization decision.
prescribed insulin; disposable needles and syringe Prescribing or Dispensing Limitations
combinations for insulin; blood glucose test strips; urine Prescription Refill Limit: Two (2) refills in 30-day period
ketone test strips; total parenteral nutrition; and except for antibiotics, anti-asthmatics, Schedule II and III
interdialytic parenteral nutrition. Products requiring prior drugs, anti-neoplastic, topicals, and any propoxyphene,
authorization: Alzheimer drugs; MS drugs (betaseron); which may have 4 refills.
AIDS wasting drugs; non sedating histamines; and
laxatives. Products not covered: cosmetics; fertility drugs; Monthly Quantity Limit: No maximums, minimum of 34-
DESI drugs; and experimental drugs. day supply for maintenance medications.
Over-the-Counter Product Coverage: Products covered: Drug Utilization Review

digestive products (non-H2 antagonists) and smoking
deterrent products. Products covered with restrictions: PRODUR system implemented in March 1996. State
allergy, asthma and sinus products (selected items); currently has a DUR Board with a bi-monthly review.
analgesics (ASA and Acetaminophen); cough and cold
preparations (selected items); feminine products (selected Pharmacy Payment and Patient Cost Sharing
items); and topical products. Products not covered:
digestive products (H2 antagonists). Dispensing Fee: $3.98 to $4.92, effective 7/1/99.
Therapeutic Category Coverage: Therapeutic categories − $3.98 - Retail pharmacies, filling over 35,000 Rxs
covered: antibiotics; anticoagulants; anticonvulsants; annually.
antidiabetic agents; antilipemic agents; cardiac drugs; − $4.26 - Retail pharmacies, filling 15,000-35,000 Rxs
chemotherapy agents; contraceptives; ENT anti- annually.
inflammatory agents; estrogens; hypotensive agents; − $4.92 - Retail pharmacies, filling 15,000 or less Rxs
sympathominetics (adrenergic); and thyroid agents. annually.
Therapeutic categories covered requiring prior − $4.92 - Unit dose systems (nursing home Rxs).
authorization: anti-depressants; antihistamine drugs; anti-
psychotics; anxiolytics, sedatives, and hypnotics; Ingredient Reimbursement Basis: EAC = AWP - 11%.
prescribed cold medications; and misc. GI drugs.
Therapeutic categories partially covered: anorectics. Prescription Charge Formula: The amount shall not
Therapeutic categories partially covered requiring prior exceed the usual and customary charge to the public or
authorization: anabolic steroids; analgesics, antipyretics, EAC plus a dispensing fee. Any drug with more than 3
NSAIDs; and growth hormones. Therapeutic categories labelers will be reimbursed according to the Maximum
not covered: prescribed smoking deterrents and weight Allowable Cost.
loss drugs.
Maximum Allowable Cost: State imposes State-specific
Coverage of Injectables: Injectable medicines limits on generic drugs. Override requires “Brand
reimbursable through the Physician Drug Program when Medically Necessary.”
used in home health care, extended care facilities and
through physician payment when used in physician Incentive Fee: None.
offices.
Vaccines: Vaccines reimbursable at EAC as part of
EPSDT service. Cognitive Services: Does not pay for cognitive services.
Unit Dose: Unit dose packaging is reimbursable.
National Pharmaceutical Council Washington-2

Regence Blue Shield

E. USE OF MANAGED CARE 1800 Ninth Avenue
PO Box 21267
Approximately 700,000 total unduplicated number of Seattle, WA 98111-3267
Medicaid recipients were enrolled in MCOs in FY 1999. 206/464-3600
state and managed care plans.
F. STATE CONTACTS
Aetna US Healthcare of Washington
1400 One Union Square Siri Childs, Pharm D.
Seattle, WA 98101 Pharmacy Research Specialist
Medical Assistance Administration, DSHS
Clark United Providers/SWMD 805 Plum Street, SE
505 NE 87th Avenue, LL-46 P.O. Box 45506
Vancouver, WA 98664 Olympia, WA 98504-5506
800/325-7862 T: 360/725-1564
F: 360/664-3884
Community Health Plan of Washington E-mail: childsa@dshs.wa.gov
401 Second Avenue, Ste. 400 Internet Agency Address: http://maa.dshs.wa.gov
Seattle, WA 98104-2891
800/444-1561
Group Health Cooperative
Siri Childs, 360/725-1564
12400 East Marginal Way South
DUR Contact
206/901-4424
Kaiser Foundation Health
Plan of the Northwest
500 NE Multnomah, Ste. 100 Department of Social and Health Services Drug
Portland, OR 97232-2099 Utilization and Education Council
800/813-2000 Council Members
Marc Avery, M.D.
Kitsap Physician Service 2704 “I” Street, NE
P.O. Box 339 Auburn, WA 98002
Bremerton, WA 98337 253/833-7444
800/552-7114
Louis Saeger, M.D.
Northwest Washington Medical Bureau 2500 Cherry Street, Ste. 103
110 South 2nd Bremerton, WA 98310
PO Box 699 360/373-9026
Mount Vernon, WA 98273-0699
Gerald N. Yorioka, M.D.
Premera Blue Cross Co-Chair
PO Box 327 805 164th SE, Ste. 100
Seattle, WA 98111-0327 Mill Creek, WA 98012
425/742-4242
Qual-Med Health Plan
P.O. Box 3387 Cara Marks, ARNP
Bellevue, WA 98009-3387 2025 1st Avenue, Ste. 790
(2331 130th Ave. NE, Ste. 200 Seattle, WA 98121
Bellevue, Washington 98005) 206/663-1808
T: 800/423-9899
F: 800/869-7175

Chris Wilkinson, PA-C Teri L. Ferreira, R.Ph.

833 NW 54th Street 13514 Lost Lake Road
Seattle, WA 98107 Snohomish, WA 98296
206/783-2061 425/820-7600
E-mail: llcustom@gte.net
Teri L. Ferreira, R.Ph.
13514 Lost Lake Road Louis Saeger, M.D.
Snohomish, WA 98296 2500 Cherry, Ste. 103
425/820-7600 Bremerton, WA 98310
360/373-9026
Dana Hadfield, R.Ph. E-mail: nwpain@silverlink.net
507 6th Avenue South
Edmonds, WA 98020 Chris Wilkinson, PA-C
425/744-1793 833 NW 54th Street
Seattle, WA 98107
Coordinating Staff 206/783-2061
Tom K. Hazlet, Pharm.D., Ph.D. E-mail: kayakrr2@aol.com
School of Pharmacy
University of Washington Gerald N. Yorioka, M.D.
P.O. Box 357630 805 – 164th SE, Ste. 100
Seattle, WA 98195 Mill Creek, WA 98012
206/616-2732 425/742-4242
E-mail: dryorioka@aol.com
Siri Childs, Pharm D
DUR Program Coordinator Dana Hadfield, R.Ph.
805 Plum Street SE 507 – 6th Avenue South
Olympia, WA 98504-5506 Edmonds, WA 98020
360/725-1564 425/744-1793
Joan Baumgartner
Medical Consultant
MAA, P.O. Box 45540 Marilyn Mueller
Olympia, WA 98504-5540 Pharmacy Program Manager
360/586-5274 Medical Assistance Administrator-DSHS
P.O. Box 45506
Tim Fuller, R.Ph. Olympia, WA 98504-5506
Board of Pharmacy 360/725-1569
1948 Boyer Ave. East E-mail: meullerf@dshs.wa.gov
Seattle, WA 98112
360/753-6834
Support Staff Manager: Sue Hilton, 360/586-7179
Johnna Dodge Technical: Rich Boyesen, 360/586-2593
206/586-5269 Policy: Geo Sego, 360/753-4259
Audits/Disputes: George Sego, 360/753-4259
Drug Utilization and Education Council PA: Gini Egan 360/664-8140
Marc Avery, M.D.

2704 “I” Street NE
Auburn, WA 98002 Chris Johnson
253/833-7444 Claims Processing Manager
Medical Assistance Administrator-DSHS
Cara Marks, ARNP P.O. Box 45506
2025 First Ave., Ste. 790 Olympia, WA 98504-5506
Seattle, WA 98121 T: 360/725-1067
206/663-1808 F: 360/586-4994
E-mail: cmarks@u.washington.edu E-mail: johnsc2@dshs.wa.gov

Robert Wardell, Co-chair

3815 N. Pearl Apt. K-1
Diane Weeden Tacoma, WA 98407
Director
Division of Program Support- MAA/DSHS Elise Chayet
805 Plum St. S.E. Harborview Medical Center
Olympia, WA 98504-5506 325 Ninth Avenue
T: 360/725-1786 Seattle, WA 98104-2499
F: 360/753-7315
E-mail: weededm@dshs.wa.gov Ted Rudd, M.D.
307 S. 12th Avenue #12
Disease Management Program/Initiative Contact Yakima, WA 98902
Andy Anderson
Family Health Center
Social and Health Services Department Officials P.O. Box 1340
Lyle Quasim Okanogan, WA 98840
Secretary 509/422-1925
Department of Social and Health Services
PO Box 44 Errol Fife, DDS
Olympia, WA 98504 3999 Englewood
Yakima, WA 98902
Tom Bedell 509/577-8277
Assistant Secretary
Medical Assistance Administration Tom Price
P.O. Box 5500 P.O. Box 339
Olympia, WA 98504-5500 Bremerton, WA 98337
360/478-2608
(Vacant)
DRI Medical Director Janene Jones-Heino
Office of the Medical Director 12856 NE Central Valley Road
P.O. Box 5506 Poulsbo, WA 98370
Olympia, WA 98504-5506 360/377-3753
Maxine Hayes, M.D.

Social and Health Services Department Medical Department of Health
Consultants MS: 7880
Full-time: Olympia, WA 98504
Joan Baumgartner, MD 206/753-7021
Sam Salama, M.D.
Nancy Anderson, M.D. Jane Beyer
Eric Houghton, M.D. Assistant Secretary
Medical Assistance Administration
Part-time: P.O. box 45080
James B. Hutchinson, DDS (Dental) Olympia, WA 98504-5080
Kevin Moss (Orthodontia)
Jerrol R. Neupert, MD (Ophthalmology) Linda Casten
PO Box 5200
Tacoma, WA 98415-0200
Department of Social and Health Services
Title XIX Advisory Committee Bonnie Kostelecky
Janet Varon, Co-chair 2000 Fort Vancouver Way
3303 E. Howell Vancouver, WA 98663
Seattle, WA 98122

DSHS Staff Members

Debbie Meyer
Secretary
P.O. Box 45080
Olympia, WA 98504-5080
Pharmacy Drug Use Review Team Members

Siri Childs, Pharm.D.
Gini Egan, R.N.
Joan Baumgartner, M.D.
Marilyn Mueller
Debbie Bellerud
Celeste Moore
Johanna Dodge
Patty Orth

Washington State Medical Association
Bob Perna
Executive Director
2033 Sixth Avenue, Ste. 1100
Seattle, WA 98121
206/441-9762
Washington State Pharmacists Association

Rod Shafer
Executive Director
1420 Maple Avenue, Ste. 101
Renton, WA 98055-3196
206/228-7171
Washington Osteopathic Medical Association, Inc.

Kathleen Itter
Executive Director
P. O. Box 16486
206/937-5358

Donald H. Williams
Executive Director
1300 Quince Street, SE
P. O. Box 47863
360/753-6834
Washington State Hospital Association

Leo F. Greenawalt
President, CEO
300 Elliott Avenue W., Ste. 300
206/281-7211

WEST VIRGINIA

Prescribed Drugs       
Inpatient Hospital Care       
Outpatient Hospital Care       
Laboratory & X-ray Service       
Skilled Nursing Home Services        
Physician Services        
Dental Services        
1
1998 1999
TOTAL $148,962,081 267,398 $195,202,609 274,214
CATEGORICALLY NEEDY CASH TOTAL $115,591,878 152,428 $158,223,906 161,897

Aged $30,914,085 21,877 $39,137,625 22,736
Blind/Disabled $67,956,619 53,764 $98,120,814 59,192
Children-Families w/Dep. Children $5,737,746 41,057 $7,672,107 42,241
Adults-Families w/Dep. Children $8,792,794 24,769 $11,610,190 29,937
AFDC Unemployed – Children (98) 690,594 5,584 $502,409 3,574
AFDC Unemployed – Adult (98) $1,500,040 5,377 $1,180,758 4,217
Other Title XIX Recipients $0 0 0 0
CATEGORICALLY NEEDY NON-CASH TOTAL - - $14,674,077 22,719

Aged $399,304 321
Blind/Disabled $12,610,179 8,880
Other Title XIX Recipients 0 0
MEDICALLY NEEDY TOTAL $3,652,798 3,544 $4,859,746 4,610

Aged $306,383 312 $385,039 420
Blind/Disabled $2,640,270 2,230 $3,781,126 3,027
Children-Families w/Dep. Children $21,311 77 $18,428 81
Adults-Families w/Dep. Children $684,834 925 $675,152 1,082
Other Title XIX Recipients $0 0 0 0
1-West Virginia National Pharmaceutical Council

C. ADMINISTRATION Prior Authorization: Prior authorization procedure

screening for drug classes and home health care.
Bureau for Medical Services, Department of Health &
Human Resources. Prescribing or Dispensing Limitations
D. PROVISIONS RELATING TO DRUGS Prescriptions are limited to 10 per recipient per month.
All covered outpatient drugs are reimbursed up to a 34-
Benefit Design day supply and five refills.
Drug Benefit Product Coverage: Products covered: Exceptions include:

prescribed insulin. Covered under DME program: 1. Antibiotics are covered for a 14-day supply and one
disposable needles and syringe combinations used for refill.
insulin; total parenteral nutrition; interdialytic parenteral 2. Opiate agonists (excluding Schedule II drugs),
nutrition; blood glucose test strips; and urine ketone test analgesics and miscellaneous antipyretics are covered
strips. Products not covered: cosmetics; fertility drugs; for 30 days and one refill.
and experimental drugs. Prior authorization required for: 3. Sedatives and hypnotics are covered for a 30-day
acute dosing of anti-ulcer medications, branded NSAIDS, supply and one refill.
Retin-A for adults, Ultram; ED drugs; and most injectable
medications. Drug Utilization Review
Over-the-Counter Product Coverage: Products covered: PRODUR system implemented in March 1995. State
feminine products and topical products. Selected currently has a DUR Board with a quarterly review.
coverage: allergy, asthma, and sinus products; analgesics;
cough and cold preparations; digestive products (non-H2 Pharmacy Payment and Patient Cost Sharing
antagonist). Prior authorization for: smoking deterrent
products. Products not covered: digestive products (H2 Dispensing Fee: $3.90, effective 1/1/96. For a
antagonists). compounded prescription, an additional $1.00 will be
added to the dispensing fee. A compound prescription is
Therapeutic Category Coverage: Therapeutic categories defined as any legend medication requiring a combination
covered: anabolic steroids; antibiotics; anticoagulants; of any two or more substances to exclude normal
anticonvulsants; anti-depressants; antidiabetic drugs; reconstitution operations.
antilipemic agents; antihistamine drugs; antipsychotics;
anxiolytics, sedatives, and hypnotics (partial coverage); Ingredient Reimbursement Basis: EAC = AWP - 12%.
cardiac drugs; chemotherapy agents; contraceptives;
prescribed cold mediation (partial coverage); ENT anti- Prescription Charge Formula: Reimbursement based on
inflammatory agents; estrogens; hypotensive agents; and the lowest of:
thyroid agents. Therapeutic categories requiring prior
authorization: analgesics, antipyretics, NSAIDs; growth 1. The estimated acquisition cost (EAC) plus a
hormones; prescribed smoking deterrents; and dispensing fee.
sympathominetics (adrenergic). Therapeutic categories 2. The maximum allowable cost (MAC) plus a
not covered: anorectics; and hair growth products. dispensing fee.
3. The usual and customary price charged by the
Coverage of Injectables: Injectable medicines pharmacy to the general public including any sale
reimbursable when used in physician offices, home health price that may be in effect on the date of service.
care, and extended care facilities; most require prior 4. Children under age of 18 years.
approval.
Vaccines: Vaccines reimbursable as part of the EPSDT Limits on generic drugs. Override will require physician
service and the Vaccines for Children Program. certification of “Brand Medically Necessary.”
Unit Dose: Unit dose packaging reimbursable. Incentive Fee: None.
Formulary: Open formulary. General exclusions include:

legend agents used for cosmetic purposes; DESI drugs.
National Pharmaceutical Council West Virginia-2

Patient Cost Sharing: Copayment varies - $0.50 to $2.00. Prior Authorization Contact
Exclusions include:
Steve Small, R.Ph., M.S.
1. Family planning services and supplies. Director, Rational Drug Therapy Program
2. Prescriptions originating with the Early and Periodic Robert C. Byrd Health Sciences Center
Screening, Diagnosis and Treatment Program. P.O. Box 9511
Morgantown, WV 26506-9511
3. Nursing home residents.
800/847-3859
E-mail: ssmall@hsc.wvu.edu

Peggy A. King, R.Ph.
!""#$%&'()*+,-::@0@@@-?64?"+&5()*4-3*4&5(&4-#*5&"&*6)7 T: 304/926-1753
8*#*-*6#$++*4-&6-3BC7-&6-:;;;<--K$6*-#*5*&=*4
">(#'(5,-7*#=&5*7-)>#$?9>-'(6(9*4-5(#*<
Medicaid DUR Board
Managed Care Organizations Steven C. Judy, R.Ph. (Chairman)
Tom Robinette, R.Ph., M.S., Director, Pharm. Ser.
Carelink Health Plans
Kevin W. Yingling, M.D.
141 Summers Square
David P. Elliott, Pharm.D.
Charleston, WV 25301
Wallace Johnson, M.D.
304/348-2041
Bernard Lee Smith, R.Ph., MBA, MHA
Patrick M. Regan, R.Ph.
The Health Plan of the Upper Ohio Valley
Karen Reed, R.Ph.
52160 National Road, East
Mary Nemeth-Pyles, M.S.N., R.N., C.S.
St. Clairsville, OH 43950
Mitch Shaver, M.D.
740/695-3585
Myra Chiang, M.D.
Matthew Watkins, D.O.
Optimum Choice
John R. Vanin, M.D.
Lester Labus, M.D.
Physician Assured Access System (PAAS)
Ernest Miller, D.O.
Carl Malanga, Ph.D.
F. STATE CONTACTS James M. Bennett, M.D.
Kent Van Devender, PA-C
State Drug Program Administrator Lisa Hedrick, R.Ph.
Daniel Dickman, M.D.
Pharmaceutical Coordinator Prescription Price Updating
WV Department of Human Services
350 Capitol Street, Rm 251 Leslie Bratton
Charleston, WV 25301-3707 Account Manager
T: 304/926-1753 Consultec, Inc.
F: 304/926-1993 9040 Roswell Road, Ste 700
E-mail: pking@wvdhhr.org Atlanta, GA 30350
800/358-2381
Department of Health & Human Resources E-mail: lbratton@consultec-inc.com
Officials
Greg Clarke, M.D.
Medical Director Technical: Pharmacy Management Consultants, Inc.,
Division of Medical Care 304/558-1700
West Virginia Department of Human Services Policy: Peggy A. King, 304/558-1753
350 Capitol St., Rm 251 Rebate: Gail Goodnight, R.Ph., 304/558-1700
3-West Virginia National Pharmaceutical Council

Hospice Representative
Charlene Farrell
Leslie Bratton Executive Director
800/358-2381 Hospice of Huntington, Inc.
Medicaid Managed Care Contact Pharmacist Representative

William McFarland, R.Ph.
Randy Myers
Loop Plaza Pharmacy
Director, Office of Medicaid Managed Care
Bureau for Medical Services
Consumer/Dental Representative
350 Capitol Street, Rm 251
Charles Smith, D.D.S.
304/558-5974
Hospital Representative
E-mail: randymyers@wvdhhr.org
Dan Hogan
Assistant Executive Director/CFO
Disease Management Initiative/Program Contact St. Mary’s Hospital
T: 304/926-1753 Ex-Officio Bureau for Children and Families
Representative
Physician-Administered Drug Program Contact Jack Frazier
Commissioner
Barbara White Bureau for Children and Families
West Virginia Department of Human Services
350 Capitol St., Rm 251 Executive Officers of State Medical and
Charleston, WV 25301-3707 Pharmaceutical Societies
304/558-1700
West Virginia State Medical Association
Medical Services Fund Advisory Council George Rider, Executive Director
4307 MacCorkle Avenue SE
Box 4106
William A. Neal, M.D., Chairperson Charleston, WV 25364
Mark B. Ayoubi, M.D.
West Virginia Pharmacists Association
Nursing Home Representative Richard D. Stevens, Executive Director
John Elliot 2003 Quarrier St.
Ex Officio Public Health Member
Henry Taylor, M.D. West Virginia Society of Osteopathic Medicine
Commissioner, Bureau of Public Health Charlotte Ann Cales Pulliam
Executive Director
Consumer Representative P.O. Box 5266
Sheryl Kiser Charleston, WV 25361-0266
MH/BH Health Representative State Board of Pharmacy
John Russell William T. Douglass, Jr.
West Virginia Behavioral Health Care Providers Executive Director
Association 236 Capitol Street
Aging Program Representative
Earl Jarvis West Virginia Hospital Association
Chair Steven J. Summer
Kanawha Valley Senior Services President
100 Association Drive
Home Health Representative Charleston, WV 25311
Violet Burdette
Executive Director
Extended Care, Inc.
National Pharmaceutical Council West Virginia-4

WISCONSIN

Type of Benefit Categorically Needy Medically Needy (MN) Other*
OAA AB APTD AFDC OAA AB APTD AFDC Children <21 (SFO)
1

1998 1999*
TOTAL $232,328,359 221,508

Aged $15,629,581 14,671
Blind / Disabled $113,162,140 78,454
AFDC-Child $688,895 9,304
AFDC-Adult $1,411,683 7,364

Aged $6,454,692 5,408
Blind / Disabled $9,336,436 4,489
AFDC-Child $144,518 3,210
AFDC-Adult $59,277 1,123

Aged $466,539 727
AFDC-Child $392,495 8,455
AFDC-Adult $371,784 7,079
OTHER $83,881,774 78,454

*1999 expenditures are broken down by maintenance assistance status and basis if eligibility are unavailable.
1-Wisconsin National Pharmaceutical Council

C. ADMINISTRATION Vaccines: Vaccines provided plus reimbursement for

administrative fee as part of the Vaccines for Children
State Department of Health and Family Services. Program.
D. PROVISIONS RELATING TO DRUGS Unit Dose: Unit dose packaging reimbursable.
Benefit Design Formulary/Prior Authorization
Drug Benefit Product Coverage: Products covered: Formulary: Open formulary.

prescribed insulin and syringe combinations for insulin.
Products covered with restrictions: disposable needles Prior Authorization: State currently has a formal prior
used for insulin (over 100/mo requires PA); blood glucose authorization procedure. When appealing coverage of an
test strips (over 100/mo requires PA); enteral nutrition excluded product or prior authorization procedure, the
(requires PA); alpha one proteinase inhibitors (requires recipient is notified of the denial and given instructions on
PA); urine ketone test strips (over 200/mo requires PA); how to request a hearing.
total parenteral nutrition (must be billed as a compound
drug); and interdialytic parenteral nutrition (must be billed Prescribing or Dispensing Limitations
as a compound drug). Products not covered: cosmetics; Prescription Refill Limit: Maximum of 11 refills during a
fertility drugs; impotence treatment drugs; and 12-month period for non-scheduled medications.
experimental drugs.
Monthly Quantity Limit: Pharmacists may not dispense
Over-the-Counter Product Coverage: Products covered more than 34-day supply of a legend drug. Certain
with restriction: analgesics (not buffered); digestive exceptions for maintenance drugs (100-day supply).
products (non-H2 antagonists) (general antacids); topical
products (generic antifungals, antibiotics, trocortisone Monthly Dollar Limits: None.
ointment); insulin; ophthlubran; anti-lice; contraceptives;
diphenhydramine; cough preps with/out DM; codeine; Drug Utilization Review
meclizine; psedoephed; and oral electrolyte replacement
therapy. Products not covered: allergy, asthma and sinus Implementation of PRODUR system planned for 2001.
products; cough and cold preparations (psedoephedrine State currently has a DUR Board with a quarterly review.
covered); digestive products (H2 antagonists); feminine
products; and smoking deterrent products. Pharmacy Payment and Patient Cost Sharing
covered: anabolic steroids; antibiotics; anticoagulants; Dispensing Fee: $4.88 to a maximum of $40.11, effective
anticonvulsants; anti-depressants; antidiabetic agents; 7/1/98. Maximum of two dispensing fees per month, per
antihistamine drugs (legend only); antilipemic agents; drug.
anti-psychotics; anxiolytics, sedatives, and hypnotics;
cardiac drugs; chemotherapy agents; prescribed cold Ingredient Reimbursement Basis: EAC = AWP - 10%.
medications (legend only); contraceptives; ENT anti-
inflammatory agents; estrogens; prescribed smoking Prescription Charge Formula: Reimbursement at the
deterrents; sympathominetics (adrenergic); and thyroid lowest of:
agents. Therapeutic categories covered requiring prior
authorization: analgesics, antipyretics, NSAIDs (cox2 1. AWP-10% plus dispensing fee; Maximum Allowable
inhibitor and brands for which no generic exists); Cost (MAC) plus dispensing fee; or providers usual
anorectics; growth hormones; hypotensive agents (some and customary.
ACE inhibitors for which no generic exists); and misc. GI
2. State MAC or direct price for selected manufacturers:
drugs (Axid, Pepcid).
Wyeth-Ayerst, Merck & Co., and Pharmacia &
Upjohn.
Override requires “Brand Medically Necessary.”
offices.
National Pharmaceutical Council Wisconsin-2

Eldercare of Dane County

Patient Cost Sharing: All legend drugs are subject to a
2802 International Lane
$1.00 copay, limited to $5.00 per month maximum.
Madison, WI 53704
OTCs and disposable medical supplies are subject to a
$0.50 copay. Residents of Skilled Nursing Facilities
Family Health Plan Cooperative
(SNF) or Intermediate Care Facilities (ICF), subsidized
11524 W. Theodore Trecker Way
adoption recipients, children under age 18 and HMO
Milwaukee, WI 53214
enrollees are exempt from the copayment.
Greater La Crosse Health Plans, Inc.
Cognitive Services: Provides payment for cognitive
P.O. Box 188
services.
La Crosse, WI 54602-0118
E. USE OF MANAGED CARE Group Health Cooperative of Eau Claire
P.O. Box 3217
!""#$%&'()*+,-:;@0@@@-)$)(+-?64?"+&5()*4-6?'A*#-$2 Eau Claire, WI 54702
3*4&5(&4-#*5&"&*6)7-8*#*-*6#$++*4-&6-3BC7-&6-DE-:;;;<-
F*5&"&*6)7-#*5*&=*-">(#'(5*?)&5(+-A*6*2&)7-)>#$?9>-
Group Health Cooperative of
'(6(9*4-5(#*-"+(67<
South Central Wisconsin
P.O. Box 44971
Madison, WI 53744-4971
Atrium Health Plan, Inc.
c/o Group Health Cooperative of Eau Claire Humana Wisconsin Health Organizations
P.O. Box 3217 Ins. Corp.
Eau Claire, WI 54702-3217 111 W. Pleasant Street
P.O. Box 12359
Children Comefirst Milwaukee, WI 53212-0359
Dane County Department of Human Services
Human services Independent Care
1202 Northpost Drive 1555 N. Rivercenter Dr.
Madison, WI 53704 Ste. 202 A
Milwaukee, WI 53212-3958
Compcare Health Services Insurance
Corporation Managed Health Services Insurance Corp.
401 W. Michigan Street 2040 W. Wisconsin Ave., Ste. 452
Milwaukee, WI 53202 Milwaukee, WI 53233
Community Care for the Elderly MercyCare Insurance Company

1555 South Layton Blvd. P.O. Box 2770
Milwaukee, WI 53215 Janesville, WI 53547-2770
Community Health Partnership Network Health Services

2240 Fastridge Center c/o Managed Health Services
Eau Claire, WI 54701 2040 W. Wisconsin Ave., Ste. 452
Milwaukee, WI 53233
Community Living Alliance
22 N 2nd St. Physicians Plus Insurance Corporation
Madison, WI 53704 P.O. Box 2078
Coordinated Care Health Plan of Wisconsin
c/o Managed Health Services PrimeCare Health Plan, Inc.
2040 W. Wisconsin Ave., Ste. 452 10701 W. Research Drive
Milwaukee, WI 53233 Milwaukee, WI 53226
Dean Health Plan, Inc. Security Health Plan of Wisconsin, Inc.

P.O. Box 56099 P.O. Box 8000
Madison, WI 53705 Marshfield, WI 54449

Touchpoint Health Plan Mark E. Buhler, R.Ph.

5 Innovation Court 3905 Vista Drive,
P.O. Box 507 Racine, WI 53405
Appleton, WI 54912-0507
Daniel R. Erickson, M.D.
Unity Health Plans Insurance Corporation 146 Larabee Street
840 Carolina Street P.O. Box 127
Sauk City, WI 53583-1374 Horicon, WI 53032
Valley Health Plan Barry Hess, R.Ph.

2270 EastRidge Center 3209 Latham Drive
P.O. Box 3128 Madison, WI 53713
Eau Claire, WI 54702-3128 608/277-1110
Wraparound of Milwaukee Nancy E. Ness MD

9501 Watertown Plank Rd. 100 W. Monroe St,
Milwaukee, WI 53226 Mauston, WI 53948
Pamela Ploetz, R.Ph.

F. STATE CONTACTS
Lee C. Vermeulen, Jr., R.Ph., M.S.
State Drug Program Administrator 21 Lancaster Court
Roma Rowlands, R.Ph. Madison, WI 53719
Pharmacy Practices Consultant
Division of Health Care Financing Mary Jo Willis, MS, NP
Department of Health and Family Services 2653 Stardust Trail,
One West Wilson Street Verona, WI 53948
P.O. Box 309
Madison, WI 53701-0309 Prescription Price Updating
T: 608/266-3753 First Databank
F: 608/266-1096 1111 Bayhill Dr.
E-mail: rowlarm@dhfs.state.wi.us San Bruno, CA 94066
Agency Internet Address: www.dhfs.state.wi.us/medicaid T: 800/633-3453
F: 415/588-6867
Roma Rowlands, 608/266-3753 Medicaid Drug Rebate Contacts
Audits: Roma Rowlands, 608/266-3753
DUR Contact Disputes: Ellen Orsburne, 608/267-7939
Michael A. Mergener, R.Ph., Ph.D. Technical: Randy Zirk, 608/266-8532
Chief Pharmacist Policy: Rita Hallett, 608/267-0938
Meridian Resource Corporation
10 East Duty St., Ste. 210 Claims Submission Contact
Madison, WI 53703 Mark Gajewski
T: 608/258-3348 Account Director
F: 608/258-3359 EDS
6406 Bridge Rd.
Wisconsin Drug Utilization Review Committee Madison, WI 53713
Robert M. Breslow, R.Ph. 608/221-9326
1926 N. Kollath Road
Verona, WI 53593
Ward Brown, M.D.

1836 South Avenue
LaCrosse, WI 54601
608/782-7300, X2076
National Pharmaceutical Council Wisconsin-4

Medicaid Managed Care Contact State Board of Pharmacy

Patrick Braatz
Jodie Mender, Chief
Director
Department of Health and Family Services
Bureau of Health Professions
Division of Health and Family Services
P.O. Box 8935
Bureau of Managed Health Care Programs
1400 E. Washington Ave.
1 W. Wilson
Madison, WI 53708
Madison, WI 53701
608/266-2812
T: 608/261-6763
F: 608/261-7792
Wisconsin Hospital Association
E-mail: mendejj@dhfs.state.wi.us
Robert C. Taylor
President, CEO
5721 Odana Road
Richard Carr, M.D. Madison, WI 53719-1289
608/266-0957 608/274-1820
Health and Family Services Department Officials

Joe Leann
Secretary
State Office Building
One West Wilson Street
Madison, WI 53701
John Chapin
Administrator
Division of Health
Peggy L. Bartels
Director
Division of Health Care Financing, Medicaid

State Medical Society of Wisconsin
John Patchett, J.D.
330 East Lakeside, Box 1109
608/257-6781
Wisconsin Pharmacists Association

Christopher Decker
Executive Director
202 Price Place
Madison, WI 53705
608/238-5515
Wisconsin Association of Osteopathic Physicians &

Surgeons
Robert J. Finnegan, CAE
Executive Director
34615 Road E.
Oconomowoc, WI 53066
414/567-0520

WYOMING

1

1998 1999*
TOTAL $17,138,952 32,510

Aged $857,467 762
Blind / Disabled $4,943,472 3,760
AFDC-Child $290,311 1,836
AFDC-Adult $227,486 587
AFDC-Unemployed-Children $0 0

Aged $0 0
AFDC-Child $0 0
AFDC-Adult $0 0

Aged $29,388 43
AFDC-Child $803,303 6,569
AFDC-Adult $280,024 2,810
OTHER, TOTAL $9,496,162 15,946

C. ADMINISTRATION
Department of Health, Division of Health Care Financing.
National Pharmaceutical Council Wyoming-1

D. PROVISIONS RELATING TO DRUGS Formulary/Prior Authorization

Benefit Design Formulary: Open formulary. General exclusions include
anorexants, except amphetamines and derivatives which
Drug Benefit Product Coverage: Products covered: are used for narcolepsy and hyperkinetic states; products
prescribed insulin, syringe combinations, disposable to stimulate hair growth.
needles for insulin; cosmetics (Retin A not covered over
age 21); blood glucose test strips; urine ketone test strips; Prior Authorization: No prior authorization procedure.
total parenteral nutrition; and interdialytic parenteral
nutrition (covered under DME programs). Products not
covered: fertility drugs; and experimental drugs.
Quantity Limit: No more than a maximum quantity of a
Over-the-Counter Product Coverage: Products covered: 90-day supply may be dispensed for a maintenance drug
allergy, asthma, and sinus products (some); analgesics; or any drug used in a chronic manner as defined. Oral
cough and cold preparations; digestive products (H2 contraceptives -- a 3-month supply may be dispensed at
antagonists); feminine products; some topical products; one time. A maximum quantity to be dispensed for a
antidiarrheals; antitussives; hyperglycemics; laxatives; prescription drug for all other conditions shall be a one-
pediatric and prenatal vitamins; sodium chloride for month supply.
nebulizer; topical antifungals; vaginal antifungals.
Covered OTC drugs are reimbursed at 150% of AWP.
Products not covered: digestive products (non-H2 Drug Utilization Review
antagonists); and smoking deterrent products. Upon
PRODUR system implemented in October 1995. State
approval, additional OTC drugs may be covered if they
currently has a DUR Board with 13 members.
are alternatives to more expensive therapy or they are
unavailable by prescription order.
covered: analgesics, antipyretics, NSAIDs; antibiotics; Dispensing Fee: $4.70, effective 3/91.
antidiabetic agents; antihistamine drugs; antilipemic Ingredient Reimbursement Basis: EAC = AWP - 4%.
agents; anti-psychotics; anxiolytics, sedatives, and
hypnotics; cardiac drugs; chemotherapy agents; prescribed Prescription Charge Formula: Payments shall be the
cold medications; contraceptives; ENT anti-inflammatory lowest of:
agents; estrogens; growth hormones (covered under CHS
1. The Estimated Acquisition Cost (AWP - 4%) of the
program); hypotensive agents; misc. GI drugs;
ingredient, plus a dispensing fee.
sympathominetics (adrenergic); and thyroid agents.
2. Usual and customary charge.
Therapeutic categories not covered: anabolic steroids;
3. The upper limit established by the Health Care
anorectics; and prescribed smoking deterrents.
Financing Administration (HCFA) for multiple source
drugs.
reimbursable when used in physician offices, home health Maximum Allowable Cost: State imposes Federal Upper
care, and extended care facilities. Limits on generic drugs. Override requires “Brand
Medically Necessary” or “Brand Necessary.”
Vaccines: Vaccines reimbursable at AWP plus a $7.00
injection fee as part of the EPSDT service. Incentive Fee: None.
Unit Dose: Unit dose packaging not reimbursable. Patient Cost Sharing: Copayment is $2.00. The following
recipients or products are exempt from the copayment:
− Pregnant women
− Foster care children
− Home and community based waiver recipients
− Eligible recipients under age 21
− Patients residing in nursing homes
− Family planning products
2-Wyoming National Pharmaceutical Council

E. USE OF MANAGED CARE DUR Board

Debra Devereaux, R.Ph.
Does not use MCOs to deliver services to Medicaid DUR Coordinator
recipients. University of Wyoming School of Pharmacy
P.O. Box 3375
F. STATE CONTACTS Laramie, WY 82071-3375
307/766-6750
State Drug Program Administrator E-mail: debdev@concentric.com
Roxanne Homar, R.Ph.
Deputy Administrator Ed Baker, R.Ph.
Community and Family Health Division Smith’s Pharmacy
Primary Case Services 2531 Foothill Blvd.
2300 Capital Ave. Rock Springs, WY 82901
Hathaway Building, 1st Fl. 307/362-1841
Cheyenne, WY 82002
T: 307/777-6032 Dawn Ford, R.Ph.
F: 307/777-6964 2022 Reagan Avenue
Internet Agency Address: http://www.state.wy.us Rock Springs, WY 82901
307/382-5437
Shannon Whalen, R.Ph.
Pharmacy Program Manager Roxanne Homar, R.Ph.
2300 Capital Ave. Deputy Administrator
Hathaway Building, 1st Fl. Community and Family Health Director
Cheyenne, WY 82002 Primary Care Services
T: 307/777-6016 2300 Capital Ave.
F: 307/777-6964 Hathaway Building, 1st Fl.
E-mail: swhale@state.wy.us Cheyenne, WY 82002
307/777-6032
Department of Health Officials Kathryn Kohler, M.D.

Garry McKee, Ph.D., M.P.H. 204 McCollum Drive
Director Laramie, WY 82070
Department of Health 307/745-8991
117 Hathaway Building
Cheyenne, WY 82002-0710 Leonard Kosirog, R.Ph.
T: 307/777-7656 3095 Galloway
Riverton, WY 82501
Roxanne Homar, R.Ph. 307/856-6993
Community and Family Health Division Jay Swedberg, M.D.
Primary Case Services 1020 S. Conwell
2300 Capital Ave. Casper, WY 82609
Hathaway Building, 1st Fl. 307/577-5100
Cheyenne, WY 82002
T: 307/777-6032 George Zaharas, R.Ph.
F: 307/777-6964 Town and Country Pharmacy
514 S. Greeley
Cheyenne, WY 82009
Debra Devereaux, R.Ph.
DUR Coordinator Stephen Brown, M.D.
University of Wyoming School of Pharmacy 2521 E. 15th St.
P.O. Box 3375 Casper, WY 82609
Laramie, WY 82071-3375 307/234-3638
T: 307/766-6750

Michael Carpenter, PA-C

1121 Washington Blvd.
Newcastle, WY 82701 Shannon Whalen, R.Ph.
307/746-3582 307/777-6016
William Harrison, M.D.

MedPed Primary Care Clinic
903-A South Greeley Highway, Ste A
Cheyenne, WY 82007 Wyoming State Medical Society
307/634-8800 Wendy Curran
Executive Director
Linda G. Martin, R.Ph. 1920 Evans
University of Wyoming P.O. Box 4009
School of Pharmacy Cheyenne, WY 82003-4009
P.O. Box 3375 307/635-2424
Laramie, WY 82071-3375
307/766-6128 Wyoming Pharmacists Association
Robert E. Smith, R.Ph.
Shannon Whalen, R.Ph. Executive Director
Community & Family Health Div. Glenrock, WY 82432
2300 Capital Avenue 307/436-8001
154 Hathaway Building
Cheyenne, WY 82002 Wyoming Association of Osteopathic Physicians &
307/777-6016 Surgeons
Shirley Carpenter
Executive Director
625 Albany Avenue
First Data Bank Torrington, WY 82240
T: 800/633-3453 307/532-2107
F: 650/872-4510
Jim Carder
Executive Director
Technical: Renee Greenmeyer, 307/777-5500 1720 S. Poplar Street, Ste. 5
Policy: Shannon Whalen, R.Ph., 307/777-6016 Casper, WY 82601
Audits: Shannon Whalen, R.Ph., 307/777-6016 307/234-0294
Wyoming Hospital Association

Dan Perdue
Jennifer Dillinger President
Account Manager 2005 Warren Avenue
Consultec, Inc. Cheyenne, WY 82001
P.O. Box 667 307/632-9344
Cheyenne, WY 82003
307/777-5500
E-mail: jdilli1@state.wy.us

307/777-6016
Expanded Drug Coverage Program Contact

307/777-6016
4-Wyoming National Pharmaceutical Council


Appendix A:
State and Federal
Medicaid Contacts
National Pharmaceutical Council A-1

A-2 National Pharmaceutical Council

STATE MEDICAID DRUG PROGRAM ADMINISTRATORS, 2000
ALABAMA CALIFORNIA
Louise F. Jones J. Kevin Gorospe, Pharm.D.
Pharmacy Program Manager Chief, Pharmaceutical Unit
Alabama Medicaid Agency Medi-Cal Policy Division
501 Dexter Avenue 714 P Street, Room 1540
P.O. Box 5624 Sacramento, CA 95814
Montgomery, AL 36103-5624 P: 916/657-4213
P: 334/242-5039 F: 916/654-0513
F: 334/353-7014 E-mail: kgorospe@dhs.ca.gov
E-mail: lljones@Medicaid.state.al.us Agency Internet Address: http://www.dhs.ca.gov
Agency Internet Address: www.medicaid.state.al.us
COLORADO
ALASKA
Allen Chapman
Dave Campana, R.Ph. Department of Health Care Policy & Financing
Pharmacy Program Manager 1575 Sherman Street, 5th Floor
Division of Medical Assistance Denver, CO 80203
4501 Business Park Blvd., Suite 24 P: 303/866-3176
Anchorage, AK 99503 F: 303/866-2573
P: 907/273-3224
F: 907/561-1684 CONNECTICUT
E-mail: david_campana@health.state.ak.us Elizabeth A. Geary
Health Program Supervisor
ARIZONA Department of Social Services
25 Sigourney Street
Juman Abujbara, M.D.
Hartford, CT 06106
Director
P: 860/424-5150
Arizona Health Care Containment System
F: 860/951-9544
801 E. Jefferson Street
E-mail: elizabeth.geary@po.state.ct.us
Phoenix, AZ 85034
Agency Internet Address: http://www.dss.state.ct.us
P: 602/417-4241
F: 602/254-1769
DELAWARE
ARKANSAS Phile Soulé
Medicaid Pharmacy Director
Suzette Bridges, P.D.
Delaware Health and Social Services
1901 N. Dupont Highway
New Castle, DE 19720
Pharmacy Program
P: 302/577-4900
P.O. Box 1437, Slot 4105
F: 302/577-4405
P: 501/324-9141
F: 501/324-9140
E-mail: suzette.bridges@Medicaid.state.ar.us

DISTRICT OF COLUMBIA IDAHO

Donna Bovell, R.Ph. Gary Duerr, R.Ph.
Pharmacist Consultant Medicaid Policy
Commission on Health Care Finance Americana Terrace, Suite 140
2100 M.L. King Jr. Ave. SE, Suite 302 P.O. Box 83720
Washington, DC 20023 Boise, ID 83720-0036
P: 202/698-2043 P: 208/364-1829
F: 202/610-3209 F: 208/364-1846
E-mail: donna.bovell@dcgov.org E-mail: duerrgp@mmis.state.id.us
FLORIDA ILLINOIS
Jerry Wells Marvin L. Hazelwood
Agency for Healthcare Administration Services Illinois Department of Public Aid
2727 Mahan Drive, Building 1, Room 170 Division of Medical Assistance
Tallahassee, FL 32308 1001 N. Walnut St.
P: 850/922-0681 Springfield, IL 62702
F: 850/922-0685 P: 217/524-7112
E-mail: wellsj@fdhc.state.fl.us F: 217/524-7194
Agency Internet Address: www.fdhc.state.fl.us E-mail: Aidd2958@mail.idpa.state.il.us
Agency Internet Address: www.state.il.us/dpa/
GEORGIA
INDIANA
Etta L. Hawkins, R.Ph.
Department of Community Health-Medical Division Marc Shirley, R.Ph.
2 Peachtree Street, 37th Floor Pharmacy Program Director-Indiana Medicaid
Atlanta, GA 30303-3159 Office of Medicaid Policy and Planning
P: 404/657-7239 Indiana State Government Center South-Rm. W382
F: 404/656-8366 402 W. Washington Street
E-mail: ehawkins@dch.state.ga.us Indianapolis, IN 46204-2739
Agency Internet Address: www.state.ga.us/dch P: 317/232-4343
F: 317/232-7382
HAWAII E-mail: mshirley@fssa.state.in.us
Lynn Donovan, R.Ph.

IOWA
Medicaid Pharmacy Consultant
Med-Quest Division Ronald J. Mahrenholz, R.Ph.
P.O. Box 339 Pharmacist Consultant
Honolulu, HI 96809-0339 Division of Medical Services
P: 808/692-8116 Department of Human Services
F: 808/692-8131 Hoover State Office Bldg.
P: 515/281-6199
F: 515/281-6230
E-mail: rmahren@dhs.state.ia.us

KANSAS MARYLAND
Karen Braman, R.Ph., M.S. Frank Tetkoski
Health Care Policy Division Pharmacy Services Manager
Kansas Department of Social and Rehabilitation Division of Pharmacy and Clinic Services
Services 201 West Preston Street
915 SW Harrison, Room 651-South DSOB Baltimore, MD 21201
Topeka, KS 66612-1570 P: 410/767-1455
P: 785/296-6968 F: 410/333-7049
F: 785/296-4813 E-mail: tetkoskif@dhmh.state.md.us
E-mail: ksb@srskansas.org Agency Internet Address: www.dhmh.state.md.us
Agency Internet Address: www.ink.org/public/srs
MASSACHUSETTS
KENTUCKY
Gary P. Gilmore, R.Ph.
Debra Bahr, R.Ph. Division of Medical Assistance
Pharmacy Services Program Manger 600 Washington Street
Department for Medicaid Services Boston, MA 02111
CHR Building, 6th Floor P: 617/210-5593
275 East Main Street F: 617/210/5597
Frankfort, KY 40621 E-mail: ggilmore@nt.dma.state.ma.us
P: 502/564-6511
F: 502/564-3852 MICHIGAN
James Kenyon, R.Ph.
LOUISIANA
MDCH/ Medical Services Administration
M.J. Terrebonne, P.D. 400 South Pine Street
Pharmacy Program Director Lansing, MI 48933
Department of Health and Hospitals P: 517/335-5265
P.O. Box 91030 F: 517/335-5294
Baton Rouge, LA 70821 E-mail: kenyonj@state.mi.us
P: 225/342-9479 Agency Internet Address: www.mdch.state.mi.us
F: 225/342-3893
E-mail: mterrebo@dhh.state.la.us MINNESOTA
Cody Wiberg, Pharm.D., R.Ph.
MAINE
Acting Pharmacy Program Manager
Christine Gee Minnesota Department of Human Services
Director of Pharmacy Programs 444 Lafayette Road
Department of Health Services St. Paul, MN 55155-3853
Bureau of Medical Services P: 651/296-8515
Pharmacy Programs F: 651/282-6744
Building 205, 3rd Fl. E-mail: cody.c.winberg@state.mn.us
Augusta, ME 04333
P: 207/287-4018
F: 207/287-8601
E-mail: christine.gee@state.me.us

MISSISSIPPI NEVADA
James G. (Jack) Lee, R.Ph. Laurie Squartsoff, R.Ph.
Division of Medicaid, Office of the Governor Pharmaceutical Consultant
Robert E. Lee Building Nevada Medicaid Office
239 North Lamar Street, Suite 801 2527 N. Carson Street, Capitol Complex
Jackson, MS 39201-1399 Carson City, NV 89710
P: 601/359-6296 P: 702/687-4869
F: 601/359-4185 F: 702/687-8724
E-mail: msjgl@medicaid.state.ms.us E-mail: lsquarts@govmail.state.nv.us
MISSOURI NEW HAMPSHIRE

Susan McCann, R.Ph. Lisè Farrand, R.Ph.
Pharmaceutical Consultant Pharmaceutical Services Specialist
Division of Medical Services Medicaid Administration Bureau
615 Howerton Court 6 Hazen Drive
P.O. Box 6500 Concord, NH 03301-6521
Jefferson City, MO 65102-6500 T: 603/271-4419
P: 573/751-6963 F: 603/271-4376
F: 573/526-4650 E-mail: lfarrand@dhhs.state.nh.us
E-mail: susanmccann@mail.medicaid.state.mo.us
NEW JERSEY
MONTANA
Carl D. Tepper, R.Ph.
Dorothy D. Poulsen
Department of Public Health and Human Services
P.O. Box 712, Room 202
Trenton, NJ 08625-0712
P.O. Box 202951
P: 609/588-2724
1400 Broadway
F: 609/588-3889
Helena, MT 59620-2951
E-mail: cdtepper@dhs.state.nj.us
P: 406/444-2738
F: 406/444-1861
E-mail: dpoulsen@state.mt.gov NEW MEXICO
Neil Solomon
NEBRASKA Medicaid Assistance Division
P. O. Box 2348
Gary J. Cheloha M.B.A., R.Ph.
Santa Fe, NM 87504
Department of Health and Human Services
P: 505/827-3174
Finance and Support, Medicaid Division
F: 505/827-3185
P.O. Box 95026
301 Centennial Mall S., 5th Fl.
Lincoln, NE 68509
P: 402/471-9379
F: 402/471-9092
E-mail: gary.cheloha@hhss.state.ne.us
Agency Internet Address: www.hhs.state.ne.us

NEW YORK OKLAHOMA

Mark-Richard Butt, M.S., R.Ph. John Crumly, MHA., R.Ph.
NYS Department of Health Oklahoma Health Care Authority
Pharmacy Policy and Operations 4545 N. Lincoln Boulevard, Suite 124
Office of Medicaid Management Oklahoma City, OK 73105-9901
99 Washington Ave., Room 606 P: 405/522-7300
Albany, NY 12210 F: 405/522-7378
P: 518/486-3209 E-mail: crumlyj@ohca.state.ok.us
F: 518/473-5508
E-mail: mrb01@health.state.ny.us OREGON
Agency Internet Address: www.health.state.ny.us
Jesse Anderson
NORTH CAROLINA
C. Benny Ridout, R.Ph. 500 Summer Street, NE
NC Division of Medical Assistance Salem, OR 97310-1014
1985 Umstead Drive P: 503/945-6492
2511 Mail Service Center F: 503/373-7689
Raleigh, NC 27699-2511 E-mail: jesse.anderson@state.or.us
P: 919/733-4034
F: 919/733-2796 PENNSYLVANIA
E-mail: benny.ridout@ncmail.net
Joseph E. Concino, R.Ph.
Chief, Pharmacy Services
NORTH DAKOTA
Cindy Frolick P.O. Box 8046
Department of Human Services Harrisburg, PA 17105
State Capital, 600 East Boulevard P: 717/772-6341
Department 325 F: 717/772-6366
P: 701/328-4023 RHODE ISLAND
F: 701/328-1544
E-mail: sodetre@state.nd.us Paula J. Avarista, R.Ph.
Chief of Pharmacy
OHIO
Robert P. Reid, R.Ph. Cranston, RI 02920
Administrator, Pharmacy Services Unit P: 401/462-2183
Department of Human Services F: 401/462-2185
30 East Broad St., 31st Floor
Columbus, OH 43266-0423 SOUTH CAROLINA
P: 614/466-6420
F: 614/466-2908 James M. Assey, R.Ph.
E-mail: reidr@odhs.state.oh.us Division Director
S.C. Department of Health & Human Services
P.O. Box 8206
P: 803/898-2876
F: 803/898-4517
E-mail: asseyj@dhhs.state.sc.us

SOUTH DAKOTA VERMONT

Mark Petersen, R.Ph. Paul Wallace-Brodeur
Department of Social Services Office of Vermont Health Access
700 Governors Drive 103 South Main Street
Pierre, SD 57501 Waterbury, VT 05671-1201
P: 605/773-3498 P: 802/241-2156
F: 605/773-5246 F: 802/241-2974
E-mail: markp@state.sd.us E-mail: paulw@wpgate1.ahs.state.vt.us
TENNESSEE VIRGINIA
Jeff Stockard, D.Ph. David B. Shepherd, R.Ph.
Director of Pharmacy Department of Medical Assistance Services
Bureau of TennCare 600 East Broad Street, Ste 1300
729 Church Street, 1st Floor Richmond, VA 23219
Nashville, TN 37247-6501 P: 804/225-2773
P: 615/532-3107 F: 804/786-0414
F: 615/741-0882 E-mail: dshepher@dmas.state.va.us
www.state.tn.us/health/tenncare/ WASHINGTON
Siri A. Childs, Pharm D.
TEXAS
Pharmacy Research Specialist
Robert P. Harriss Medical Assistance Administration, DSHS
Director, TX Department of Health 805 Plum Street, SE
Vendor Drug Program P.O. Box 45506
1100 W. 49th Street Olympia, WA 98504-5506
Austin, TX 78756-3174 P: 360/725-1564
P: 512/338-6961 F: 360/664-3884
F: 512/338-6910 E-mail: childsa@dshs.wa.gov
E-mail: bob.harriss@tdh.state.tx.us
WEST VIRGINIA
UTAH
RaeDell Ashley, R.Ph.
Pharmaceutical Coordinator
Pharmacy Director
WV Department of Human Services
350 Capitol St., Room 251
Utah Department of Health
288 N. 1460 West, P.O. Box 143102
P: 304/558-1753
F: 304/558-1542
P: 801/538-6495
E-mail: pking@wvdhhr.org
F: 801/538-6099
E-mail: rashley@doh.state.ut.us

WISCONSIN
Roma Rowlands, R.Ph.
P.O. Box 309
P: 608/266-3753
F: 608/266-1096
E-mail: rowlarm@dhfs.state.wi.us
www.dhfs.state.wi.us/medicaid
WYOMING
Roxanne Homar, R.Ph.
Shannon Whalen, Medicaid Pharmacist
Community and Family Health Division
Primary Care Services
2300 Capital Avenue
Hathaway Building, 1st Floor
Cheyenne, WY 82002
P: 307/777-6016
F: 307/777-6964
E-mail: rhomar@.state.wy.us


DUR CONTACT INFORMATION, 2000

State Contact Contractor
Louise F. Jones Alabama Quality Assurance
Alabama Medicaid Agency Foundation
501 Dexter Avenue 1 Perimeter Park South, Suite 200N
ALABAMA P.O. Box 5624 Birmingham, AL 35243
Contracted DUR Montgomery, AL 36103-5624 P: 205/970-1600
P: 334/242-5039
F: 334/353-7014
E-mail: lljones@medicaid.state.al.us

Dave Campana, R.Ph Not Available
ALASKA
4501 Business Park Blvd., Ste. 24
In-House and
Anchorage, AK 99503
contracted DUR
P: 907/273-3224
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.

Suzette Bridges, P.D. Craig Atkins, Pharm D.
Administrator Director, Retro Spective DUR
Arkansas Department of Human Services Health Information Design
ARKANSAS Division of Medical Services 1550 Pumphrey Avenue
Contracted DUR P.O. Box 1437, Slot 4105 Auburn, AL 36832
Little Rock, AR 72203 P: 205/402-9530
P: 501/324-9141 F: 205/402-9531
F: 501/324-9140
E-mail: suzette.bridges@medicaid.state.ar.us
State Contact
Vic Walker, R.Ph. B.C.P.P.
Sr. Pharmaceutical Consultant
Medi-Cal Policy Division
CALIFORNIA
714 P Street, Rm. 1540
In-House DUR
P: 916/657-0785
F: 916/654-0513
E-mail: vwalker@dhs.ca.gov


Allen Chapman Not Available
Pharmacist
Deptartment of Health Care Policy and
COLORADO
Financing
Contracted DUR
1575 Sherman St., 5th Floor
Denver, CO 80203
P: 303/866-3176
F: 303/866-2573

Elizabeth Geary, R.Ph. Michelle Lester-Bradley
Health Program Supervisor Account Manager
Department of Social Services Health Information Designs
CONNECTICUT
25 Sigourney Street 1550 Pumphrey Ave.
Contracted DUR
Hartford, CT 06106 Auburn, AL 35832
P: 860/424-5150 P: 334/502-3262 x21
F: 860/951-9544 F: 334/821-6589
E-mail: elizabeth.geary@po.state.ct.us E-mail: Michelle@hdinfo.com

Cynthia Denemark Cynthia Denemark
Pharmacist Consultant Pharmacist Consultant
EDS EDS
DELAWARE
248 Chapman Road, Suite 200
Contracted DUR
Newark, DE 197029720
P: 302/453-8453
F: 302/454-7603
E-mail: cynthia.denemark@eds.com
State Contact
Chrisopher Keeyes, Pharm.D.
DISTRICT OF President
COLUMBIA Clinical Pharmacy Administration
In-House DUR 11710 Beltsville Drive, Ste. 510
Calberton, MD 20705
P: 301/572-1616

Marie Donnelly-Stephens Gaylen Fruit, R.Ph.
Senior Healthcare Program Analyst DUR Coordinator
FLORIDA
AHCA Florida Pharmacy Association
In-house and
2727 Mahan Drive, mail stop 38 610 N. Adams St.
Contracted DUR
Tallahassee, FL 32308 Tallahassee, FL 32301
P: 850/487-4441 P: 850/222-2400
F: 850/922-0685

State Contact
Jean B. Cox, R.Ph.
DUR Coordinator
GA Dept. of Community Health
GEORGIA
2 Peachtree St. NW
In-house DUR
Atlanta, GA 30303
P: 404/657-7241
F: 404/656-8366
E-mail: Jcox@dch.state.ga.us
State Contact
Kathleen Kang-Kaulupali
Pharmacy Consultant
HAWAII Med-Quest Division
In-House DUR PO Bopx 339
P: 808/692-8115
F: 808/692-8131

Gary Duerr, R.Ph. Vaughn Culbertson, Pharm.D.
Medicaid Policy DUR Coordinator
Americana Terrace, Suite 140 Idaho State U. - College of Pharmacy
IDAHO
PO Box 83720 Campus Box 8356
Contracted DUR
Boise, ID 83720-0036 Pocatello, ID 83209-8356
P: 208/364-1829 P: 208/236-4385
F: 203/364-1846 F: 208/236-4482
E-mail: duerrgp@mmis.state.id.us E-mail: Vculb@otc.isu.edu
State Contact
Starlin Haydon Greatting, R.Ph.
DUR Coordinator
ILLINOIS
Illinois Department of Public Aid
In-House DUR
1001 N. Walnut St.
P: 217/524-7112
F: 217/524-7194

Ms. Karen Baer Pharmacy Services
DUR Board Secretary EDS
INDIANA
Office of Medicaid Policy and Planning 950 N. Meridian St., 11th Floor
Contracted DUR
P: 317/232-4391 Indianapolis, IN 46204
F: 317/232-7382 P: 317/488-5000
E-mail: kbaer@fssa.state.in.us


Cheryl Clarke, R.Ph. Cheryl Clarke, R.Ph.
DUR Coordinator DUR Coordinator
Iowa Pharmacy Association Iowa Pharmacy Association
IOWA
8515 Douglas, Ste. 16
Contracted DUR
P: 515/270-0713
F: 515/270-2979
E-mail: cclarke@iowapharmacists.org

Glenn McNeese, R.Ph., M.S., BCPS Glenn McNeese, R.Ph., M.S., BCPS
DUR Program Director DUR Program Director
Kansas University School of Pharmacy Kansas University School of Pharmacy
KANSAS
6052 Malott Hall
Contracted DUR
Lawrence, KS 66045-2500
P: 785/864-3264
F: 785/864-5849
E-mail: Gmcnees@rx.pharm.ukans.edu

Debra Bahr, R.Ph. Kim Moore, R.Ph.
Pharmacy Services Program Manger Unisys
Department for Medicaid Services PO Box 2100
KENTUCKY CHR Building, 6th Floor Frankfort, KY 40602
Contracted DUR 275 East Main Street P: 502/226-1867
Frankfort, KY 40621 F: 502/266-1860
P: 502/564-6511
F: 502/564-3852

Melwyn Wendt Dan Scholl
Pharmaceutical Consultan Pharmacy Director
Department of Health and Hospitals Unisys
LOUISIANA
PO Box 91030 PO Box 3396
Contracted DUR
Baton Rouge, LA 70821 Baton Rouge, LA 70809
P: 225/219-4154 P: 225/237-3208
F: 225/342-3893 F: 225/924-6179
E-mail: mwendt@dhhmail.dhh.state.la.us E-mail: dan.scholl@unisys.com

Christine Gee Dennis G. Lyons, R.Ph.
Director of Pharmacy Programs Retrospective DUR Director
DHS – Bureau of Medical Servies Pharmaceutical Strategies Inc.
MAINE
Bldg 205, 3rd Fl. 255 Bennhill Rd.
Contracted DUR
11 State House Station Waltham, MA 02451
Augusta, ME 04333-0011 P: 781/830-3435
P: 207/287-2674
F: 207/287-8601


Judy Geisler Contact Judy Geisler
Pharmacist Consultant Pharmacist Consultant
DHMH-Office of Health Services
MARYLAND Division of Pharmacy and Clinical Services
Contracted DUR 201 W. Preston St., Rm. 208A
Baltimore, MD 21201
P: 410/787-1728
F: 410/333-7049
E-mail: Geislerj@dhmh.state.md.us

Anna Morin, Pharm.D. Anna Morin, Pharm.D.
DUR Program Director DUR Program Director
UMASS Medical school UMASS Medical school
MASSACHUSETTS
11 Midstate Hwy mailto:Anna.morin@umassmed.edu
Contracted DUR
Auburn, MA 01501-1863
P: 508/721-7104
F: 508/721-7138
E-mail: Anna.morin@umassmed.edu

Mary Sandusky, R.Ph. First Health Services Corp.
Pharmacist Consultant 4300 Cox Rd.
MDCH/Medical Services Administration Glen Allen, VA 23060
MICHIGAN
400 S. Pine Street
Contracted DUR
Lansing, MI 48933
P: 517/335-5280
F: 517/335-7813
E-mail: sanduskym@state.mi.us
State Contact
Mary Beth Reinke, Pharm.D.
DUR Coordinator
Minnesota Dept. of Human Services
MINNESOTA
444 Lafayette Rd.
In-House DUR
St. Paul, MN 55155-3853
P: 651/215-1239
F: 651/282-6744
E-mail: Mary.beth.reinke@state.mn.us

Jack Lee, R.Ph. Cliff Oshon
Pharmacy Program Administrator Heritage Information System, Inc.
Div. Of Medicaid, Office of the Governor 2618 A. Southerland Dr.
MISSISSIPPI
239 North Lamar St., Ste. 801 Jackson, MS 39216
Contracted DUR
Jackson, MS 39201-1399 P: 601/362-3388
P: 601/359-6296 F: 601/982-0143
F: 601/369-4185
E-mail: msjgl@medicaid.state.ms.us


Jayne Zemmer ProVantage retro DUR)
DUR Coordinator 1300 N. 17th St., Ste. 1350
Div. Of Medical Services Arlington, VA 22209
MISSOURI PO Box 6500 P: 703/243-9571
Contracted DUR Jefferson City, MO 65102-6500 F: 703/528-5869
P: 573/751-6963
F: 573526-4650
E-mail:
jaynezemmer@mail.medicaid.state.mo.us

Mark Eichler, R.Ph. Mark Eichler, R.Ph.
DUR Coordinator Mountain-Pacific Quality Health
Mountain-Pacific Quality Health Foundation Foundation
MONTANA
3404 Cooney Drive
Contracted DUR
Helena, MT 59602
P: 406/443-4020
F: 406/443-4585
E-mail: meichler@initco.com

Allison Jorgensen, Pharm.D., R.Ph. Allison Jorgensen, Pharm.D., R.Ph.
DUR Director DUR Director
Nebraska Pharmacists Association Nebraska Pharmacists Association
NEBRASKA
6221 South 58th, Ste. A 6221 South 58th, Ste. A
Contracted DUR
Lincoln, NE 68516 Lincoln, NE 68516
P: 402/420-1500 P: 402/420-1500
F: 402/420-1406 F: 402/420-1406
E-mail: dur@npharm.org E-mail: dur@npharm.org
State Contact
Pharmacy Services Consultant
NEVADA Nevada Medicaid
In-House DUR 2527 N. Carson St., Capitol Complex
P: 702/687-4869
F: 702/687-8724

Lisè Ferrand, R.Ph. Julie Simpson, R.Ph.
Pharmaceutical Services Specialist Pharmacy Consultant
Medicaid Administration Bureau EDS Federal Corp.
NEW HAMPSHIRE
6 Hazen Drive 7 Eagle Square
Contracted DUR
Concord, NH 03301 Concord, NH 03301
P: 603/271-4359 P: 603/225-4899
F: 603/271-4376
E-mail: Pcliffor@dhhs.state.nh.us

State Contact
Edward Vaccaro, R.Ph.
Assistant Director, OHSA
Division of Medical Assistance and Health
Services
NEW JERSEY
Office of Health Service Administration, P.O.
In-House DUR
Box 712
Trenton, NJ 08625-0712
P: 609/588-2721
F: 609/588-3889
E-mail: ejvaccaro@dhs.state.nj.us

NEW MEXICO
Neil Solomon UNM College of Pharmacy
Contracted DUR
P: 505/827-3174
State Contact
Michael Zegarelli
DUR Manager, Office of Medicaid
Management
NEW YORK NYS Dept. of Health
In-House DUR 99 Washington Ave, Suite 601
Albany, NY 12210
P: 518/474-6866
F: 518/473-5332
E-mail: maz03@health.state.ny.us
State Contact
Sharman Leinwand
DUR Coordinator
NORTH CAROLINA N.C. Division of Medical Assistance
In-House DUR 2515 Mail Service Center
P: 919/733-3590
F: 919/715-7706
State Contact
Pat Kramer
Human Services
NORTH DAKOTA
600 E. Blvd., Dept. 325
In-House DUR
P: 701/328-4893
F: 701/328-1544
E-mail: sokrap@state.nd.us


Jan Lawson Theresa Shireman
DUR Coordinator University of Cincinnati Medical
OHIO
DUR Center
Contracted DUR
6S E. State, 4th Floor 3223 Eden Avenue
Columbus, OH 43215 Cincinnati, Ohio 45267-0004
P: 614/466-7936 P: 614/466-7936

John Crumly, MHA, R.Ph. Ron Graham
Medicaid Pharmacy Director Pharmacy Consultant Manager
Oklahoma Health Care Authority College of Pharmacy
OKLAHOMA
4545 N. Lincoln Blvd. Ste 124 P.O.Box 26901
Contracted DUR
Oklahoma City, OK 73105-9901 Oklahoma City, OK 73190
P: 405/522-7300 P: 405/271-9039
F: 405/522-7378 F: 405/271-2615
E-mail: Crumlyj@ohca.state.ok.us E-mail: Ronald-graham@ouhsc.edu

Mariellen Rich, R.Ph. Same as state contact.
Pharmacist Account Manager
First Health Service Corporation
OREGON
565 Union St., NE, Suite 205
Contracted DUR
Salem, OR 97310
P:503/391-1980
F: 503/391-1979
E-mail: merich@fhsc.com
State Contact
PRODUR – EDS/ RETRODUR – University
PENNSYLVANIA
of Maryland
In-House DUR
P.O. Box 8046

RHODE ISLAND
Paula Avarista EDS -- Merck/Medco
Contracted DUR
P: 401/462-2183

Caroline Y. Sojourner, R.Ph. First Health Services Corporation
Deptartment Head, Pharmacy Services 4300 Cox Road
S.C. Department of Health & Human Glen Allen, VA 23060
SOUTH CAROLINA
Services P: 800/884-2822
In-House and
P.O. Box 8206 F: 804/273-6961
Contracted DUR
P: 803/898-2876
F: 803/898-4517
E-mail: sojourne@dhhs.state.sc.us


Michael Jockheck, R.Ph. Michael Jockheck, R.Ph.
Pharmacy Consultant Pharmacy Consultant
SOUTH DAKOTA SD Department of Social Services SD Department of Social Services
In-House DUR 700 Governors Drive
Pierre, SD 57501
P: 605/773-6439
E-mail: mike.jockheck@state.sd.us
TENNESSEE
Within Federal and State guidelines, individual managed care and pharmacy benefit
DUR is conducted at management organizations make formulary/drug decisions.
the plan level.
State Contact
Curtis Burch
Director
Drug Utilization Review Division
TEXAS Texas Department of Health
In-House DUR 1100 West 49th Street
Austin, TX 78756-3174
P: 512/338-6922
F: 512/338-6910
E-mail: curtis.burch@tdh.state.tx.us
State Contact
Duane Parke
DUR Coordinator
UTAH Health Care Financing
In-House DUR 288 N. 1460 West, P.O. Box 143102
P: 801/538-6452
F: 801/538-6099

Gloria Jacobs EDS
Operations Administrator Fiscal Agent
Office of VT Health Access 312 Hurrican Lane, Ste 101
VERMONT
103 S. Main St. Williston, VT 05495
Contracted DUR
Waterbury, VT 05671 P: 802/879-4450
P: 802/241-2763 F: 802/878-3440
F: 802/241-2974
E-mail: gloriaj@wpgate1.ahs.state.vt.us

Marianne Rollins, R.Ph. First Health Services
DUR Coordinator Glen Allen, VA
VIRGINIA
Deparment of Medical Asisstance Services
Contracted DUR
600 East Broad Street, Suite 1300
Richmond, VA 23112
P: 804/225-4268

State Contact
Siri A. Childs, Pharm D.
Pharmacy Research Specialist
Medical Assistance Administration, DSHS
WASHINGTON 805 Plum Street, SE
In-House DUR P.O. Box 45506
P: 360/725-1564
F: 360/664-3884
E-mail: childsa@dshs.wa.gov

Peggy A. King Martha Kophazi
Pharmacy CoordinatoBureau for Medical Health Information Design
Services 11200 Waples Mill Road, Suite 360
WEST VIRGINIA
7012 MacCorkle Ave., SE Fairfax, VA 22032
Contracted DUR
Charleston, WV 25304 P: 703/218-5800
P: 304/926-1753 F: 703/218-5810
F: 304/926-1993 E-mail: KophaziME@hidinc.com
E-mail: Pking@wvdhhr.Org

Michael Mergener, R.Ph., Ph.D. Same as state contact
Chief Pharmacist
Meridian Resource Corporation
WISCONSIN
10 East Duty St., Suite 210
Contracted DUR
Madison, WI 53703
P: 608/258-3348
F: 608/258-3359

Debra Devereaux, M.B.A., R.Ph. Shannon Whalen
DUR Coordinator, WY-DUR Pharmacy Program Manager
University of Wyoming-School of Pharmacy Office of Primary Care-CAFHD
WYOMING
P.O. Box 3375 2300 Capital Ave,
Contracted DUR
Laramie, WY 82071-3375 154 Hathaway Bldg.
P: 307/766-6120 Chyenne, WY 82002
P: 307/777-3016
F: 307/777-6964
E-mail: swhale@state.wy.us

CLAIMS SUBMISSION, 2000
ALABAMA COLORADO
Ricky Pope Consultec, Inc.
Account Manager, EDS 600 17th Street
301 Technacenter Dr. Suite 600 North
Montgomery, AL 36117 Denver CO 80203
P: 334/215-0111 P: 800/237-0757
F: 303/534-0435
ALASKA
CONNECTICUT
Rose-Ellen Hope
Pharmacist Twila Smith
First Health Account Manager
565 Union St. NE #205 EDS
Salem, OR 97301 100 Stanley Drive
P: 503/391-0184 New Britain, CT 06053
P: 860/832-5800
ARIZONA
DELAWARE
AHCCCS/DBF/CLMS
Lori Petre, Claims Administrator Thomas Ignudo
701 E. Jefferson Account Manager
Phoenix, AZ 85034 EDS
P: 602/417-4547 248 Chapman Rd
Newark, DE 19702
ARKANSAS
John Herzog
Account Manager Contact not provided
EDS Federal Corp
500 East Markham, Suite 400 FLORIDA
P: 501/374-6608 Mark Steck
F: 501/372-2971 PBM Director
E-mail: John.herzog@Medicaid.state.ar.us Consultec, Inc.
9040 Roswell Rd. Suite 700
Atlanta, GA 30350
CALIFORNIA
P: 770/594-7799
Dennis Dworman
Executive Program Director GEORGIA
EDS-Medi-Cal
Electronic Data Systems Cheryl Collier
3215 Prospect Park Drive Account Manager, EDS
Rancho Cordova, CA 95670 736 Park North Blvd
P: 916/636-1000 P.O. Box 736
F: 916/636-1000 Clarkston, GA 30021
P: 404/297-3700
F: 404/298-1031

HAWAII LOUISIANA
Luukia Abbley Department of Health and Hospitals
Supervisor, Medicaid Susan Taskin, Chief, MMIS
HMSA - Medicaid Claims Service P.O. Box 91030
P.O. Box 860 Baton Rouge, LA 70821
Honolulu, HI 96808 P: 225/342-9494
P: 808/948-5361
MAINE
IDAHO
Marcia Pykare
EDS Goold Health Systems
P.O. Box 1168 12 Stone Street
Boise, ID 83701 Augusta, ME 04332
P: 208/395-2000 P: 207/622-7153
ILLINOIS MARYLAND
Self-administered Charlotte Krueger, Chief
First Health Services Corporation
INDIANA Division of Claims Processing
201 W. Preston St.
EDS Baltimore, MD 21201
950 North Meridan Street, 11th Floor P: 401/767-5347
Indianapolis, IN 46204 F: 410/333-7186
P: 317/488-5000
MASSACHUSETTS
IOWA
Unisys
Kristi Sheakley P.O. Box 9101
Account Manager Somerville, MA 02145
Consultec, Inc. P: 617/576-4451
P.O. Box 14422
MICHIGAN
P: 515/327-0950 x1108
F: 515/327-0945 First Health Services Corp.
4300 Cox Rd.
KANSAS Glen Allen, VA 23060
Blue Cross Blue Shield of Kansas

MINNESOTA
P.O. Box 3571
Topeka, KS 66611 Minnesota Dept. of Human Services
P: 800/933-6593 P: 415/588-5454
KENTUCKY MISSISSIPPI
Unisys-Provider Services Terry Childress
P.O. Box 2100 Director of Systems
Frankfort, KY 40602 239 North Lamar St.
P: 502/226-1140 Jackson, MS 39201-1399
F: 502/226-1860 P: 601/359-6050
E-mail: PPTCC@medicaid.state.ms.us

MISSOURI NEW MEXICO

GTE Data Services Neil Solomon
Jim Judge P: 505/827-3174
905 Weathered Rock Rd.
Jefferson City, MO 65101 NEW YORK
P: 573/635-2434
Computer Sciences Corporation
800 North Pearl Street
MONTANA
Albany, NY 12204
Consultec, Inc. P: 518/447-9200
Brett Jakovac, Account Manager
34 N. Last Chance Gulch, Ste. 200 NORTH CAROLINA
Helena, MT 59601
P: 406/442-1837 EDS
Sharon Greeson, R.Ph., Pharmacist Consultant
4905 Waters Edge Dr.
NEBRASKA
Raleigh, NC 27606
First Health Services Corp. P: 919/233-6829
Janice Jones, R.Ph., Clinical Pharmacy Manager F: 919/859-9703
4300 Cox Rd. E-mail: sharon.greeson@eds.com
Glen Allen, VA 23060
P: 804/965-7517 NORTH DAKOTA
F: 804/273-6961
E-mail: lacoe@fhsc.com Cindy Froler
State Capital, 600 East Boulevard
NEVADA
Department 325
Anthem/ Blue Cross Blue Shield Bismarck, ND 58505-0250
P.O. Box 12127 P: 701/328-4023
Reno, NV 89510-2127 F: 701/328-1544
P: 775/448-4020 E-mail: sodetre@state.nd.us
NEW HAMPHSHIRE OHIO

EDS First Health Services Corp.
Gary Patenaude, Account Manager 4300 Cox Rd.
7 Eagle Square Glen Allen, VA 23060
Concord, NJ 03301 P: 800/884-2822
P: 603/225-4899 F: 800/884-7682
E-mail: gary.patenaude.@nhxix.sod.eds.com
OKLAHOMA
NEW JERSEY
Laura Dickey-Hottel
Unisys DP Analyst/Planning Specialist III
P.Ringel, Chief Architect Oklahoma Health Care Authority
3705 Quakerbridge Rd., Suite 101 4545 N. Lincoln Blvd, Suite 124
Trenton, NJ 08619 Oklahoma City, OK 73105-9901
P: 609/588-6000 P: 405/522-7228
F: 609/584-8270 F: 405/522-7378
E-mail: RingelP@njpo1.him.unisys.com E-mail: Hottell@ohca.state.ok.us

OREGON UTAH
Mariellen Rich, R.Ph. Brenda Bryant (In-House)
Director, Pharmacist Account Manager Health Care Financing
First Health Service, Corporation 288 North 1460 West
565 Union St., NE, Suite 205 Salt Lake City, UT 84114
Salem, OR 97310
P: 503/391-1980 VERMONT
F: 503/391-1979
E-mail: merich@fhsc.com EDS
Williston, VT 05495
PENNSYLVANIA
P: 802/879-4450
EDS F: 802/878-3440
E-mail: mossesm@vtxix.slg.eds.com
RHODE ISLAND
VIRGINIA
Contact not provided.
First Health Services
SOUTH CAROLINA Glen Allen, VA
Rod Davis
WASHINGTON
Bureau Chief, Bureau of Information Systems
S.C. Department of Health & Human Services Chris Johnson
P.O. Box 8206 Claims Processing Manager
Columbia, SC 29202-8206 Medical Assistance Administrator
P: 803/898-2610 P.O. Box 45560
E-mail: davisr@dhhs.state.sc.us Olympia, WA 98504-5506
P: 360/725-1067
SOUTH DAKOTA F: 360/586-4994
E-mail: Johnsc2@dshs.wa.gov
Meredith Heerman
SD Dept. of Social Services
WEST VIRGINIA
Claims Processing Supervisor
700 Governors Dr. Consultec, Inc.
Pierre, SD 57501 Leslie Bratton, Account Manager
P: 605/773-3495 9040 Roswell Road, Suite 700
E-mail: meredith_heerman@state.sd.us Atlanta, GA 30350
P: 800/358-2381
TENNESSEE F: 800/793-2305
E-mail: Lbratton@consultec-inc.com
Contact not provided
WISCONSIN
TEXAS
Mark Gajewski
Texas Dept. of Health Account Director
Patsy McElroy, Director, Electronic Claims EDS
Management 6406 Bridge Road
1100 West 49th Street Madison, WI 53713
Austin, TX 78756 P: 608/221-9326
P: 512/338-6909
E-mail: patsy.mcelroy@tdh.state.tx.us

WYOMING
Consultec, Inc.
Jennifer Dillinger, Account Manager
P.O. Box 667
Cheyenne, WY 82003
P: 307/777-5500


PRESCRIPTION PRICE UPDATING CONTACTS, 2000
ALABAMA CONNECTICUT
First DataBank First DataBank
1111 Bayhill Drive, Suite 350 1111 Bayhill Drive
San Bruno, CA 94066 San Bruno, CA 94066
P: 650/588-5454 P: 650/588-5454
ALASKA DELAWARE
Dave Campana, R.Ph Cynthia Denemark
Pharmacy Program Manager Pharmacist Consultant
Division of Medical Assistance EDS
4501 Business Park Blvd., Ste. 24 248 Chapman Road, Suite 200
Anchorage, AK 99503 Newark, DE 197029720
P: 907/273-3224 P: 302/453-8453
F: 907/561-1684 F: 302/454-7603
E-mail: david_campana@health.state.ak.us E-mail: cynthia.denemark@eds.com
ARIZONA DISTRICT OF COLUMBIA

Joan Terry First DataBank
DBF/CLMS/AHCCCS 1111 Bayhill Drive
701 E. Jefferson San Bruno, CA 94066
Phoenix, AZ 85034 P: 650/588-5454
P: 602/417-7927
FLORIDA
ARKANSAS
First DataBank
First DataBank 1111 Bayhill Drive, Suite 350
1111 Bayhill Drive San Bruno, CA 94066
San Bruno, CA 94066 P: 650/588-5454
P: 650/588-5454
GEORGIA
CALIFORNIA
Etta L. Hawkins, R.Ph.
EDS Department of Community Health-Medical Division
PO Box 13029 2 Peachtree Street, 37th Floor
Sacramento, CA 95813-4029 Atlanta, GA 30303-3159
P: 916/636-1000 P: 404/657-7239
F: 404/656-8366
COLORADO E-mail: ehawkins@dch.state.ga.us
Allen Chapman
HAWAII
Department of Health Care Policy and Financing
1575 Sherman St., 5th Floor First DataBank
Denver, CO 00008-0203 111 Bayhill Dr.
P: 303/866-3176 San Bruno, CA 94066
F: 303/866-2573 P: 800/633-3453

IDAHO LOUISIANA
Gary Duerr, R.Ph. Maggie Vick
Pharmacy Services Specialist Unisys
Idaho Medicaid Policy PO Box 3396
Americana Terrace, Suite 140 Baton Rouge, LA 70809
PO Box 83720 P: 225/219-3251
Boise, ID 83720-0036 F: 225/219-4164
P: 208/364-1829 E-mail: margaret.vick@unisys.com
F: 203/364-1846
MAINE
ILLINOIS
Kathy Chadwick
First Data Bank First DataBank
1111 Bay Hill Drive 1111 Bay Hill Drive
P: 650/588-5454 P: 800/633-3453
E-mail: kathy_chadwick@firstdatabank.com
INDIANA
MARYLAND
First DataBank
1111 Bay Hill Drive First DataBank
San Bruno, CA 94066 1111 Bayhill Drive, Suite 350
P: 650/588-5454 San Bruno, CA 94066
P: 650/588-5454
IOWA
MASSACHUSETTS
Sherey Swanson
Deputy Account Manager Christopher Burke
Consultec, Inc. Pharmacy Program Analyst
P.O. Box 14422 Division of Medical Assistance
Des Moines, IA 50306-3422 600 Washington Street
P: 515/327-0950 x1107 Boston, MA 02111
F: 515/327-0945 P: 617/210-5592
F: 617-210-5597
KANSAS
MICHIGAN
Karen Braman, R.Ph., M.S.
Health Care Policy Division First DataBank
Kansas Department of Social and Rehabilitation 1111 Bayhill Drive, Suite 350
Services San Bruno, CA 94066
915 SW Harrison, Room 651-South DSOB P: 650/588-5454
Topeka, KS 66612-1570 F: 650/827-4578
P: 785/296-3981
KENTUCKY
Unisys-Provider Services
P.O. Box 2100
Frankfort, KY 40602
P: 502/226-1140

MINNESOTA NEW HAMPSHIRE

First DataBank First DataBank
1111 Bay Hill Drive 1111 Bay Hill Drive
P: 650/588-5454 P: 650/588-5454
F: 650/827-4578 F: 650/827-4578
MISSISSIPPI NEW JERSEY

Jack Lee, R.Ph. First DataBank, Inc.
Pharmacy Program Administrator 1111 Bayhill Drive
Div. Of Medicaid, Office of the Governor San Bruno, CA 94066
239 North Lamar St., Ste. 801 P: 650/588-5454
Jackson, MS 39201-1399 F: 650/827-4578
P: 601/359-6296
F: 601/369-4185 NEW MEXICO
Neil Solomon
MISSOURI
Medicaid Assistance Division
First DataBank P. O. Box 2348
1111 Bayhill Drive, Suite 350 Santa Fe, NM 87504
San Bruno, CA 94066 P: 505/827-3174
P: 650/588-5454
F: 650/827-4578 NEW YORK
Carl Cioppa
MONTANA
Pharmacy Program Specialist
First DataBank Pharmacy Policy and Operations
1111 Bayhill Drive, Suite 350 Office of Medicaid Management
San Bruno, CA 94066 NYS Dept. of Health
P: 650/588-5454 99 Washington Ave., Suite 606
F: 650/827-4578 Albany, NY 12210
P: 518/486-3209
NEBRASKA F: 518/473-55008
E-mail: ctc02@health.state.ny.us
First DataBank
1111 Bayhill Drive, Suite 350
NORTH CAROLINA
San Bruno, CA 94066
P: 650/588-5454 C. Benny Ridout, R.Ph.
F: 650/827-4578 Pharmacist Director
NC Division of Medical Assistance
NEVADA 1985 Umstead Drive
First DataBank Raleigh, NC 27699-2511
1111 Bayhill Drive, Suite 350 P: 919/857-4034
San Bruno, CA 94066 F: 919/733-2796
P: 650/588-5454 E-mail: benny.ridout@ncmail.net
F: 650/827-4578

NORTH DAKOTA SOUTH CAROLINA

First DataBank, Inc. First DataBank, Inc.
1111 Bayhill Drive 1111 Bayhill Drive
P: 800/633-3453 P: 650/588-5454
F: 650/588-4003
OHIO
SOUTH DAKOTA
First DataBank
1111 Bayhill Drive, Suite 350 Mark Petersen, R.Ph.
San Bruno, CA 94066 Department of Social Services
P: 650/588-5454 700 Governors Drive
F: 650/827-4578 Pierre, SD 57501
P: 605/773-3498
OKLAHOMA F: 605/773-5246
E-mail: markp@state.sd.us
Angela Thomasson
Pharmacy Claims Specialist
TENNESSEE
4545 N. Lincoln Blvd., Suite 124 Contact Not Provided
P: 405/522-7307 TEXAS
F: 405/522-7378
E-mail: thomassa@ohca.state.ok.us Martha McNeill
Director, Product Enrollment Division
OREGON
Kathy Frankiln Austin, TX 78756-3174
Customer Support Department P: 512/338-6965
First DataBank, Inc. F: 512/338-6462
1111 Bayhill Drive
San Bruno, CA 94066 UTAH
P: 650/588-5454
F: 650/588-4003 RaeDell Ashley
Pharmacy Director
Health Care Financing
PENNSYLVANIA
288 N. 1460 West, P.O. Box 143102
First DataBank, Inc. Salt Lake City, UT 84114-2905
1111 Bayhill Drive P: 801/538-6495
San Bruno, CA 94066 F: 801/538-6099
P: 800/633-3453
VERMONT
RHODE ISLAND
Christine Dapkiewicz
Paula J. Avarista, R.Ph. Drug Rebate Coordinator
Department of Human Services EDS
600 New London Avenue 312 Hurricane Lane
Cranston, RI 02920 Williston, VT 05495
P: 401/462-2183 P: 802/879-4450
F: 401/462-2185 F: 802/878-3440

VIRGINIA
David B. Shepherd, R.Ph.
Pharmacy Consultant
Department of Medical Asisstance Services
600 East Broad Street, Suite 1300
Richmond, VA 23112
P: 804/786-8057
F: 804/786-0414
WASHINGTON
Marilyn Mueller
Medical Assistance Administration--DSHS
P.O. Box 45506
P: 360/725-1569
E-mail: muellmf@dshs.wa.gov
WEST VIRGINIA
Leslie Bratton
Account Manager
Consultec, Inc.
9040 Roswell Road, Suite 700
Atlanta, GA 30350
P: 800/358-2381
F: 800/793-2305
E-mail: LBratton@consultec-inc.com
WISCONSIN
First DataBank
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
P: 650/588-5454
F: 650/827-4578
WYOMING
First DataBank
1111 Bayhill Drive
San Bruno, CA 94066
P: 800/633-3453


MEDICAID DRUG REBATE, 2000
ALABAMA COLORADO
Jim Morrison Vince Sherry
Alabama Medicaid Agency Department of Health Care Policy and Financing
501 Dexter Avenue 1575 Sherman St., 5th Floor
Montgomery, AL 36103-5624 Denver, CO 00008-0203
334/242-2323 P: 303/866-5408
E-mail: jmorrison@medicaid.state.al.us F: 303/866-2573
ALASKA CONNECTICUT
Dave Campana, R.Ph Ellen Arce, R.Ph.
Pharmacy Program Manager Pharmacy Team Lead
Division of Medical Assistance EDS
4501 Business Park Blvd., Ste. 24 100 Stanley Drive
Anchorage, AK 99503 New Britain, CT 06053
P: 907/273-3224 P: 860/832-5885
F: 907/561-1684 F: 860/832-5832
ARIZONA DELAWARE
AHCCCS/DBF/CLMS Christine Whitlock
Lori Petre, Claims Administrator Rebate Analyst
701 E. Jefferson EDS
Phoenix, AZ 85034 248 Chapman Road
P: 602/417-4547 Newark, DE 19702
P: 302/454-7622
ARKANSAS F: 302/454-7603
E-mail: christine.whitlock@eds.com
Suzette Bridges, P.D.
Pharmacy Program Contact not provided
P.O. Box 1437, Slot 4105
Little Rock, AR 72203 FLORIDA
P: 501/324-9141
Greg Bracko
Rebate Coordinator
CALIFORNIA
AHCA
Craig Miller 2727 Mahan Dr.
Chief, Contracting Unit Tallahassee, FL 32308
Medi-Cal Policy Division P: 850/488-9193
714 P Street, Room 1540 E-mail: Brackog@fdhc.state.fl.us
P: 916/654-0532
F: 916/654-0513
E-mail: cmiller2@dhs.ca.gov

GEORGIA IOWA
Susan Oh Rocco Russo
Drug Rebate Coordinator Third Party Liability Manager
Department of Community Health Consultec, Inc.
2 Peachtree St. 37th Floor P.O. Box 14422
Atlanta, GA 30303 Des Moines, IA 50306-3422
P: 404/657-9181 P: 515/327-0950 x1114
F: 404/656-8366
E-mail: so@dch.state.ga.us KANSAS
Karen Braman, R.Ph., M.S.
HAWAII
Health Care Policy Division
Brian Pang KS Dept of Social and Rehabilitation Services
Finance Officer 915 SW Harrison, Room 651-South DSOB
Department of Human Services Topeka, KS 66612-1570
Med QUEST Division P: 785/296-3981
P.O. Box 339
Honolulu, HI 96809-0339 KENTUCKY
P: 808/692-7956
F: 808/692-7989 Marie Couch
Department for Medicaid Services
275 E. Main St.
IDAHO
Frankfort, KY 40621
David Mendoza P: 502/564-3476
Medicaid Programs F: 502/564-3852
P.O.Box 83720
Boise, ID 83720-0036 LOUISIANA
P: 208/364-1838
F: 208/364-1846 Susan Taskin, Chief, MMIS
E-mail: mendodr@mmis.state.id.us Department of Health and Hospitals
P.O. Box 91030
ILLINOIS
P: 225/342-9494
Alberta Levan
Supervisor MAINE
Illinois Department of Public Aid
110 West Lawrence Rossi Rowe
Springfield, IL 62763 TPL Manager
P: 217/524-7161 DHS/BMS
F: 217/524-5176 Building 205, 2nd Fl.
Augusta, ME 04333-0011
P: 207/287-1838
INDIANA
F: 207/287-1788
EDS E-mail: rossi.rowe@state.me.us
950 North Meridan Street, 11th Floor
P: 317/488-5000

MARYLAND MISSOURI
Kenneth Smoot Lynn Hebenheimer
Deputy Director Pharmacy Rebate Manager
Office of Management and Finance Division of Medical Services
201 W. Preston St. P.O. Box 6500
Baltimore, MD 21201 Jefferson City, MO 65102
P: 401/767-5186 P: 573/751-2005
F: 410/333-5409 F: 573/526-2045
E:mail:
MASSACHUSETTS lynnhebenheimer@mail.medicaid.state.mo.us
Paula McAree
MONTANA
Drug Rebate Specialist
Division of Medical Assistance Betty DeVaney
600 Washington St. Drug Rebate Coordinator
Boston, MA 02111 Dept. of Public Health and Human Services
P: 617/210-5594 P.O. Box 202951
F: 617/210-5597 Helena, MT 59620-2951
E-mail: pmcaree@nt.dma.state.ma.us P: 406/444-3457
F: 406/444-1861
MICHIGAN Bdevaney@state.mt.us
Dawn Parsons, R.Ph.

NEBRASKA
MDCH/Medical Services Administration
400 S. Pine St. Arlene Rogers
Lansing, MI 48933 Fiscal Project Analyst
P: 517/335-5078 HHSS-Finance and Support
E-mail: parsonsdaw@state.mi.us NSOB, 5th Floor
Lincoln, NE 68509
MINNESOTA P: 402/471-9159
Jarvis Jackson, R.Ph. F: 7402/471-7783
Drug Rebate Coordinator E-mail: arlene.rogers@hhss.state.ne.us
Dept. of Human Services
444 Lafayette Rd. NEVADA
St. Paul, MN 55155-3849
P: 651/282-5881
Pharmacy Services Consultant
F: 651/282-6744
Nevada Medicaid
E-mail: jarvis.jackson@state.mn.us
2527 N. Carson St. Capitol Complex
MISSISSIPPI
P: 775/687-4869
Glenda Grant F: 775/687-8724
Rebate Coordinator Lsqarts@govmail.state.nv.usn
Division of Medicaid, Office of the Governor
239 North Lamar St., Ste 801
Jackson, MS 39201
P: 601/359-6050
F: 601/359-6712
E-mail: acgag@medicaid.state.ms.us

NEW HAMPHSHIRE NORTH DAKOTA

Julie Simpson, R.Ph. Cindy Frolick
EDS Federal Corp. Department of Human Services
7 Eagle Square State Capital, 600 East Boulevard
Concord, NH 03301 Department 325
P: 603/224-1747 ext. 3016 Bismarck, ND 58505-0250
E-mail: julie.simpson@nhxix.sod.eds P: 701/328-4023
F: 701/328-1544
NEW JERSEY E-mail: sodetre@state.nd.us
Carl Tepper, R.Ph.

OHIO
Chief, Pharmaceutical Services
Department of Human Services Program Administrator
P.O. Box 712, Bldg 11-A OKLAHOMA
Trenton, NJ 08625
P: 609/588-2724 Tom Simonson
F: 609/588-3889 Drug Rebate Manager
E-mail: cdtepper@dhs.state.nj.us Oklahoma Health Care Authority
4545 N. Lincoln Blvd, Suite 124
NEW MEXICO
P: 405/522-7327
Neil Solomon F: 405/522-7472
P: 505/827-3174 E-mail: Simonsot@ohca.state.ok.us
NEW YORK OREGON

Mark-Richard Butt, M.S., R.Ph. Becky Smith
Director, Pharmacy Policy and Operations Rebate Analyst
NYS Department of Health First Health Services Corporation
Office of Medicaid Management 565 Union St. NE, Suite 205
99 Washington Ave., Room 606 Salem, OR 97301
Albany, NY 12210 P: 503/391-1981
P: 518/486-3209 F: 503/391-1979
F: 518/473-5508 E-mail: Rssmith@fhsc.com
NORTH CAROLINA PENNSYLVANIA

Sharon Greeson, R.Ph. EDS
EDS RHODE ISLAND
4905 Waters Edge Dr.
Raleigh, NC 27606 Contact not provided.
P: 919/233-6829
F: 919/859-9703
E-mail: sharon.greeson@eds.com

SOUTH CAROLINA VIRGINIA

Kathy Bass First Health Services
Department Head Glen Allen, VA
S.C. Department of Health & Human Services
P.O. Box 8206 WASHINGTON
P: 803/898-2974 Sue Hilton
E-mail: bass@dhhs.state.sc.us Drug Rebate Manager
P.O. Box 45503
SOUTH DAKOTA
Helen Rokusek P: 360/725-1251
Rebate Coordinator F: 360/586-2373
SD Dept. of Social Services E-mail: Hiltosd@dshs.wa.gov
700 Governors Dr.
Pierre, SD 57501 WEST VIRGINIA
P: 605/773-3653
Gail Goodnight, R.Ph.
Rebate Coordinator
TENNESSEE
DHHR, Bureau for Medical Services
Contact not provided 350 Capitol Street, Room 251
TEXAS P: 304/558-1700
F: 304/558-1542
Texas Dept. of Health Gailgoodnight@wvdhhr.org
Patsy McElroy, Director, Electronic Claims
Management
WISCONSIN
Austin, TX 78756 Ellen Orsborne
P: 512/338-6909 Division of Health Care Financing
E-mail: patsy.mcelroy@tdh.state.tx.us Department of Health and Family Services
One West Wilson Street, Rm 472
UTAH P.O. Box 309
Brenda Bryant (In-House) P: 608/267-7939
Health Care Financing F: 608/266-1096
288 North 1460 West
WYOMING
VERMONT Shannon Whalen

Christine Dapkiewicz Office of Primary Care-CAFHD
Drug Rebate Coordinator 2300 Capital Ave, 154 Hathaway Bldg.
EDS Cheyenne, WY 82002
312 Hurricane Lane P: 307/777-6016
Williston, VT 05495 F: 307/777-6964
P: 802/879-4450 Swhale@state.wy.us
F: 802/878-3440


STATE OFFICIALS, 2000

ALABAMA ARIZONA
Governor Governor
Honorable Don Siegelman Honorable Jane Dee Hull
State Capitol State Capitol
600 Dexter Avenue 1700 W. Washington
Montgomery, AL 36103 Phoenix, AZ 85007
334/242-7100 602/542-4331
Single State Agency Director Single State Agency Director
Mr. W. Dale Walley Ms. Phyllis Beidess, Director
Acting Commissioner, Alabama Medicaid Agency Arizona Health Care Cost Containment System
501 Dexter Avenue 80l East Jefferson Street
P.O. Box 5624 Phoenix, AZ 85034
Montgomery, AL 36103-5624 602/417-4680
334/242-5010 F: 602/252-6536
Medicaid Director E-mail – PXBiedess@ahccs.state.az.us
Mr. W. Dale Walley Medicaid Director
Acting Commissioner, Alabama Medicaid Agency Ms. Phyllis Beidess, Director
501 Dexter Avenue Arizona Health Care Cost Containment System
P.O. Box 5624 801 East Jefferson Street
Montgomery, AL 36103-5624 Phoenix, AZ 85034
334/242-5600 602/417-4680
F: 334/242-5097 F: 602/252-6536
E-mail – Almedicaid@medicaid.state.al.us E-mail – PXBiedess@ahcccs.state.az.us
ALASKA ARKANSAS
Governor Governor
Honorable Tony Knowles Honorable Mike Huckabee
P.O. Box 110001 State Capitol Building
Juneau, AK 99811-0001 Little Rock, AR 72201
907/465-3500 501/682-2345
Ms. Karen Perdue Mr. Kurt Knickrehm, Director
Commissioner Department of Human Services
Department of Health and Social Services P.O. Box 1437, Slot 329
P.O. Box 110601 Little Rock, AR 72203-1437
Juneau, AK 99811-0601 501/682-8650
907/465-3030 Fax 501/682-6836
Medicaid Director E-mail – kurt.knickrehm@state.ar.us
Mr. Bob Labbe Medicaid Director
Director Mr. Ray Hanley, Director
Division of Medical Assistance Division of Medical Services Dept. of Human Services
Department of Health and Social Services P.O. Box 1437, Slot 1100
P.O. Box 110660 Little Rock, AR 72203-1437
Juneau, AK 99811-0660 50l/682-8292
907/465-3355 F: 501/682-1197
F: 907/465-2204 E-mail – Ray.Hanley@medicaid.state.ar.us
E-mail – Blabbe@health.state.ak.us

CALIFORNIA CONNECTICUT
Governor Governor
Honorable Gray Davis Honorable John G. Rowland
State Capitol, First Floor State Capitol, Room 202
Sacramento, CA 958l4 Hartford, CT 06l06
916/445-2841 860/566-4840
F: 916/445-4633 Single State Agency Director
Single State Agency Director Ms. Patricia Wilson-Coker, Commissioner
Ms. Diana M. Bonta, Director Department of Social Services
714 P Street, Room 1253 25 Sigourney Street
Sacramento, CA 95814 Hartford, CT 06106-5033
916/657-1425 860/424-5008
Medicaid Director Medicaid Director
Ms. Gail M. Margolis, Deputy Director Mr. David Parella, Deputy Commissioner
Medical Care Services Department of Social Services
Department of Health Services 25 Sigourney Street
714 P Street, Room 1253 Hartford, CT 06106-5116
Sacramento, CA 95814 860/424-5116
916/654-0391 F: 860/424-5114
F: 916/657-1156 E-mail – David.Parrella@PO.state.ct.us
E-mail – gmargolis@dhs.ca.gov
DELAWARE
COLORADO
Governor
Governor Honorable Thomas R. Carper
Honorable Bill Owens Tatnall Building
State Capitol William Penn Street
Room 136 Dover, DE 19901
Denver, CO 80203 302/739-4101
303/866-2471 Single State Agency Director
F: 303/866-2003 Mr. Greg Sylvester
Single State Agency Director Secretary
Mr. James T. Rizzuto Department of Health and Social Services
Executive Director 1901 North DuPont Highway
Department of Human Services New Castle, DE l9720
l575 Sherman Street 302/421-6705
Denver, CO 80203-1714 Medicaid Director
303/866-5096 Mr. Philip Soulé, Sr.
F: 303/866-4740 Director
E-mail – jimt.rizzuto@state.co.us Medical Assistance Program
Medicaid Director Department of Health and Social Services
Mr. Richard Allen P.O. Box 906, Lewis Building
Executive Director 1901 North DuPont Highway
Department of Health Care Policy and Financing New Castle, DE 19720
l575 Sherman Street 302/577-4901
Denver, CO 80203-1714 F: 302/577-4577
303/866-5401 E-mail – Psoule@state.de.us
F: 303/866-2803
TDD 303/866-3883
E-mail – Richard.allen@state.co.us

DISTRICT OF COLUMBIA GEORGIA

Mayor Governor
Honorable Anthony A. Williams Honorable Roy Barnes
District of Columbia 203 State Capitol
441 4th Street, NW Atlanta, GA 30334
Suite 1100 404/656-l776
Washington, DC 20001 Single State Agency Director
202/727-2980 Russ Toal, Commissioner
Single State Agency Director Department of Community of Health
Ivan C. A. Walks, MD, Director 2 Peachtree Street, NW
Department of Health Suite 4043
825 North Capitol S., NE Atlanta, GA 30303-3159
Fourth Floor 404/656-4479
Washington, DC 20002 Medicaid Director
202/442-5999 Gary B. Redding, Director
F: 202/442-4788 Department of Community Health
Medicaid Director 2 Peachtree Street, NW
Mr. Herbert H. Weldon, Jr., Deputy Director Suite 4043
Medical Assistance Administration Atlanta, GA 30303-3159
825 North Capitol S., NE F: 404/651-6880
Fifth Floor E-mail – wtaylor@dma.state.ga.us
202/442-9090
GUAM
Governor
FLORIDA
Honorable Carl T. C. Gutierrez
Governor Adelup Complex
Honorable Jeb Bush P.O. Box 2950
State Capitol Agana, GU 96932
Plaza 05 671/472-8931
Tallahassee, FL 32399-0001 F: 671/472-4926
Single State Agency Director Dennis Rodriguez, Director
Mr. Ruben King-Shaw, Director Dept. of Public Health and Social Services
Agency for Health Care Administration P.O. Box 2816
325 John Knox Road Agana, GU 96910
Suite 301 Atrium 671/734-7123
Tallahassee, FL 32303 F: 671/734-5910
904/922-5527 Medicaid Director
Medicaid Director Ms. Ma Theresa Arcangel, Acting Administrator
Mr. Gary Crayton, Director of Medicaid Bureau of Health Care Financing
Agency for Health Care Administration Department of Public Health and Social Services
2727 Mahan Drive, Bldg. 3 P.O. Box 28l6
Tallahassee, FL 32308 Agana, GU 96910
850/922-6463 671/735-7269
F: 850/488-3560 F: 671/734-5910
E-mail – Lutzr@sdhc.state.fl.us

HAWAII ILLINOIS
Governor Governor
Honorable Carl Benjamin J. Cayetano Honorable George H. Ryan
State Capitol 207 Capitol Building
Honolulu, HI 968l3 State Capitol
808/586-0034 Springfield, IL 62706
Single State Agency Director 2l7/782-6830
Ms. Susan M. Chandler, Director Single State Agency Director
Department of Human Services Ms. Ann Patla, Dr.HL, Director
P.O. Box 339 Department of Public Aid
Honolulu, HI 96809-0339 201 South Grand Avenue, East, Third Floor
808/586-4997 Springfield, IL 62763-0001
Medicaid Director 2l7/782-6717
Mr. Chuck C. Duarte, Administrator F: 217/524-7979
Med-Quest Division Medicaid Director
Department of Human Services Mr. Matt Powers, Administrator
P.O. Box 399 Department of Public Aid
Honolulu, HI 96809-0339 20l South Grand Avenue, East, Third Floor
808/692-8056 Springfield, IL 62763-0001
F: 808/692-8173 2l7/782-2570
E-mail – Chuck@I-one.com F: 217/524-7979
E-mail – aidd0007@mail.idpa.state.il.us
IDAHO
INDIANA
Governor
Honorable Dirk Kempthorne Governor
P.O. Box 83720 Honorable Frank O’Bannon
Boise, ID 83720-0034 State House, Room 206
208/334-2100 Indianapolis, IN 46204
Mr. Karl Kurtz, Director Single State Agency Director
Department of Health and Welfare Mr. Peter Sybinsky, Secretary
450 West State Street Family and Social Services Administration
Boise, ID 83720-0036 Room 461, Mail Stop 25
208/334-5500 P.O. Box 7083
F: 208/334-6558 402 W. Washington Street
Medicaid Director Indianapolis, IN 46207-7083
Mr. Joe Brunson, Administrator 317/233-4452
Division of Medicaid E-Mail: Vmoore@fssa.state.in.us
Department of Health and Welfare Medicaid Director
Americana Building Ms. Kathleen D. Gifford, Assistant Secretary
P.O. Box 83720 Medicaid Policy and Planning
Boise, ID 83720-0036 Family and Social Services Administration
208/364-1802 402 W. Washington Street, Room W382
F: 208/334-1811 Indianapolis, IN 46204-2739
E-mail: Allynkp@mmis.state.id.us 317/233-4455
F: 317/232-7382
E-Mail: Kgifford@fssa.state.in.us

IOWA KENTUCKY
Governor Governor
Honorable Thomas J. Vilsack Honorable Paul E. Patton
State Capitol Building State Capitol Building
Des Moines, IA 503l9 700 Capitol Avenue
5l5/28l-5211 Frankfort, KY 4060l
F: 515/281-6611 502/564-2611
Jessie K. Rasmussen, Director Mr. Jimmy D. Helton, Commissioner
Department of Human Services Department for Medicaid Services
Hoover State Office Building Third Floor
Fifth Floor 275 East Main Street
Des Moines, IA 503l9-0114 Frankfort, KY 40621
5l5/28l-5452 502/564-4321
F: 515/281-4597 Medicaid Director
Medicaid Director Mr. Dennis Boyd, Commissioner
Dennis Headlee, Administrator Department for Medicaid Services
Division of Medical Services Third Floor
Department of Human Services 275 East Main Street
Hoover State Office Building Frankfort, KY 40621
Fifth Floor 502/564-4321
Des Moines, IA 503l9-0114 F: 502/564-0509
5l5/281-8621 E-mail- Lmccarthy@mail.state.ky.us
F: 515/281-7791
LOUISIANA
KANSAS
Governor
Governor Honorable M. J. “Mike” Foster
Honorable Bill Graves State Capitol
2nd Floor P.O. Box 94004
State Capitol Building Baton Rouge, LA 70804
Topeka, KS 66612-1590 504/342-7015
785/296-3232 F: 504/342-7099
Single State Agency Director Mr. David W. Hood, Secretary
Ms. Janet Schalansky, Secretary Department of Health and Hospitals
Kansas Department of Social and Rehabilitation Services P.O. Box 629, Bin #2
State Office Building Baton Rouge, LA 70821-0629
Topeka, KS 66612 504/342-9500
785/296-3271 F: 504/342-5568
F: 785/296-4685 Medicaid Director
E-mail – JKS@srsexec.wpo.state.ks.st Mr. Thomas D. Collins, Director
Medicaid Director Bureau of Health Services Financing
Mr. Robert Day, Commissioner Department of Health and Hospitals
Adult and Medical Services P.O. Box 91030
Department of Social and Rehabilitation Services Baton Rouge, LA 70821-9030
Docking State Office Building 504/342-3891
915 Harrison Street F: 504/342-9508
Topeka, KS 66612 E-mail – TCOLLINS@dhhmail.dhh-state.la.us
785/296-8904
F: 785/296-4813
E-mail – ODG@srmspo.wpo.state.ks.us

MAINE MASSACHUSETTS
Governor Governor
Honorable Angus S. King, Jr. Honorable Argeo Paul Cellucci
1 State House Station Executive Office, State House
Augusta, Maine 04333-0001 Room 360
207/287-3531 Boston, MA 02133
Single State Agency Director 617/727-9173
Mr. Kevin Concannon, Commissioner Single State Agency Director
Department of Human Services Mr. Bruce Bullen, Commissioner
State House Station 11 Division of Medical Assistance
Augusta, ME 04333-0011 Medicaid Division
207/287-2736 600 Washington Street
Medicaid Director Boston, MA 02111
Mr. Francis T. Finnegan, Jr., Director 617/210-5690
Bureau of Medical Services Medicaid Director
Department of Human Services Mr. Bruce Bullen, Commissioner
State House Station 11 Division of Medical Assistance
Augusta, ME 04333-0011 600 Washington Street
207/287-2093 Boston, MA 02111
F: 207/287-2675 617/210-5690
E-mail: fran.finnegan@state.me.us F: 617/210-5697
E-mail: Bbullen@nt.dma.state.ma.us
MARYLAND
MICHIGAN
Governor
Honorable Parris N. Glendening Governor
State House Honorable John Engler
Annapolis, MD 21401 P.O. Box 30013
410/974-3901 Lansing, MI 48909
Georges Benjamin, M.D. Single State Agency Director
Secretary Mr. James K. Haveman, Jr., Director
Department of Health & Mental Hygiene Michigan Department of Community Health
Herbert R. O'Connor Building Lewis Cass Building
201 West Preston Street 320 South Walnut Street
Fifth Floor Lansing, MI 48913
Baltimore, MD 21201 517/335-0267
Medicaid Director Mr. Robert M. Smedes, Chief Executive Officer
Debbie Chang Medical Services Administration
Deputy Secretary for Health Care Financing Michigan Department of Community Health
Department of Health & Mental Hygiene 400 S. Pine Street
201 West Preston Street Lansing, MI 48909
Baltimore, MD 21201 517/335-5001
410/767-4664 F: 517/335-5007
F: 410/333-7687 E-mail – smedes@state.mi.us
E-mail – Dchang@dhmh.md.state.us

MINNESOTA MISSOURI
Governor Governor
Honorable Jesse Ventura Honorable Mel Carnahan
130 State Capitol State Capitol Building
St. Paul, MN 55155-1099 P.O. Box 720
651/296-3391 Jefferson City, MO 65101
Mr. Michael O’Keefe, Commissioner F: 573/751-1495
Minnesota Department of Human Services Single State Agency Director
444 Lafayette Road North Mr. Gary J. Stangler, Director
St. Paul, MN 55155-3815 Department of Social Services
651/296-2701 P.O. Box 1527
F: 651/297-3230 Jefferson City, MO 65102
E-mail – Michael.Okeefe@state.mn.us 573/751-4815
Medicaid Director F: 573/751-3203
Ms. Mary B. Kennedy, Medicaid Director Medicaid Director
Assistant Commissioner Health Care Mr. Gregory A. Vadner
Minnesota Department of Human Services Division of Medical Services
444 Lafayette Road Department of Social Services
St. Paul, MN 55l55-3852 615 Howerton Court
651/282-9921 P.O. Box 6500
F: 651/297-3230 Jefferson City, MO 65102-6500
E-mail – mary.kennedy@state.mn.us 573/751-6922
F: 573/751-6564
E-mail – Victornine@aol.com
MISSISSIPPI
Governor
MONTANA
Honorable Kirk Fordice
State Capitol Governor
P.O. Box 139 Honorable Marc Racicot
Jackson, MS 39205 Capitol Station
60l/359-3150 Helena, MT 59620-0801
Ms. Helen Wetherbee, Executive Director Single State Agency Director
Division of Medicaid Ms. Laurie Ekanger, Director
Office of the Governor Department of Public Health and Human Services
Suite 801, Robert E. Lee Building P.O. Box 4210
239 North Lamar Street 111 N. Sanders
Jackson, MS 39201-1399 Helena, MT 59604-4210
601/359-6050 406/444-5622
Ms. Helen Wetherbee, Executive Director Ms. Nancy Ellery, Administrator
Division of Medicaid Division of Health Policy and Services
Office of the Governor Department of Public Health and Human Services
Suite 801, Robert E. Lee Building 1400 Broadway
239 North Lamar Street Helena, MT 59601
Jackson, MS 39201-1399 406/444-4141
601/359-6050 F: 406/444-1861
F: 601/359-6048 E-mail – Nellery@state.mt.us
E-mail – Exgaw@medicaid.state.ms.us

NEBRASKA NEW HAMPSHIRE

Governor Governor
Honorable Mike Johanns Honorable Jeanne Shaheen
P.O. Box 94848 Room 208
Lincoln, NE 68509-4848 Concord, NH 03301-4990
402/471-2244 603/271-2121
Single State Agency Director Mr. Donald L. Shumway, Commissioner
Jeff Elliot, Director Department of Health and Human Services
Nebraska Department of Health and Human Services 129 Pleasant Street
Finance and Support Concord, NH 03301-3857
P.O. Box 95026 603/271-4331
Lincoln, NE 68509-5026 F: 603/271-4912
F: 402/471-9449 Carol Early
Bob Seiffert, Administrator Medicaid Administration Bureau
Medicaid Division Department of Health and Human Services
Nebraska Department of HHS Finance and Support 6 Hazen Drive
P.O. Box 95026 Concord, NH 03301-6521
Lincoln, NE 68509-5026 603/271-8887
402/471-9506 F: 603/271-4376
F: 402/471-9092
NEW JERSEY
NEVADA
Governor
Governor Honorable Christine Todd Whitman
Honorable Kenny C. Guinn 125 West State Street
State Capitol State House CN-001
Carson City, NV 89710 Trenton, NJ 08625
702/687-5670 609/292-6000
Ms. Charlotte Crawford, Director Ms. Michele Guhl, Commissioner
Department of Human Resources Department of Human Services
505 East King Street, Room 600 Capitol Place One CN-700, Fifth Floor
Carson City, NV 89710 222 South Warren Street
775/684-4000 Trenton, NJ 08625
F: 775/684-4010 609/292-3717
Mr. Mike Willden, Administrator Ms. Margaret A. Murray, Director
Nevada State Welfare Division Division of Medical Assistance and Health Services
2527 North Carson Street Department of Human Services
Carson City, NV 89706 P.O. Box 712
775/687-4128 Trenton, NJ 08625-0712
F: 775/687-5080 609/588-2600
Mr. Chuck Duarte, Administrator F: 609/588-3583
Division of Health Care Financing and Policy
1100 East William Street, Suite 116
775/687-4176 ext. 251
F: 775/684-8792
E-mail – cduarte@govmail.state.nv.us

NEW MEXICO NORTH CAROLINA

Governor Governor
Honorable Gary E. Johnson Honorable James B. Hunt, Jr.
State Capitol 116 West Jones Street
Suite 400 Raleigh, NC 27603-8001
Santa Fe, NM 87503 919/733-4240
Single State Agency Director David Bruton, M.D., Secretary
Mr. William H. Johnson Jr., Secretary Department of Human and Human Services
New Mexico Human Services Department P.O. Box 29526
P.O. Box 2348 101 Blair Drive, Adams Building
Santa Fe, NM 87504-2348 Raleigh, NC 27626-0526
505/827-7750 919/733-4534
F: 505/827-6286 Mr. Paul R. Perruzzi, Director
Medicaid Director Division of Medical Assistance
Mr. Charles J. Milligan, Director Department of Health and Human Services
Medical Assistance Division 1985 Umstead Drive
New Mexico Human Services Department P.O. Box 29529
P.O. Box 2348 Raleigh, NC 27626-0529
Santa Fe, NM 87504-2348 919/857-4011
505/827-3106 F: 919/733-6608
888/997-2583 Toll free client info E-mail – Dick.Perruzzi@ncmail.net
F: 505/827-3185
E-mail: charles.milligan@state.nm.us
NORTH DAKOTA
Governor
NEW YORK
Honorable Edward T. Schafer
Governor 600 East Boulevard Avenue
Honorable George E. Pataki Bismarck, ND 58505-0001
Executive Chamber 701/328-2200
State Capitol Single State Agency Director
Albany, NY 12224 Ms. Carol Olson, Executive Director
5l8/474-1041 Department of Human Services
Single State Agency Director 600 East Boulevard Avenue
Antonio C. Novello, M.D., M.P.H., Commissioner Bismarck, ND 58505-0250
NYS Department of Health 701/328-2310
ESP, Corning Tower Building Medicaid Director
Albany, NY 12237 Mr. David J. Zentner, Director
518/474-2011 Division of Medical Assistance
Medicaid Director Department of Human Services
Kathryn Kuhmerker, Deputy Commissioner 600 East Boulevard Avenue
NYS Department of Health Bismarck, ND 58505-0261
Office of Medicaid Management 701/328-3194
Empire State Plaza F: 701/328-1544
Room 1466, Corning Tower Building E-mail – sozend@state.nd.us
Albany, NY 12237
518/474-3018
F: 518/486-6652
E-mail – Dbf02@health.state.ny.us

NORTHERN MARIANA ISLANDS OKLAHOMA

Governor Governor
Honorable Froilan C. Tenorio Honorable Frank Keating
Commonwealth of the Northern Mariana Islands 212 State Capitol
Capitol Hill Oklahoma City, OK 73105
Saipan, MP 96950 405/521-2342
Single State Agency Director Garth L. Splinter, M.D.
Mr. Joseph K.P. Villagomez Chief Executive Officer
Secretary for Health Services Oklahoma Health Care Authority
Department of Public Health and Environmental Services 4545 North Lincoln Boulevard
Commonwealth of the Northern Mariana Islands Suite 124
P.O. Box 409 CK Oklahoma City, OK 73105
Saipan, MP 96950 405/522-7439
670/234-6225 F: 405/530-3471
Ms. Maria A.V. Leon Guerrero, Medical Administrator Mr. Michael Fogarty, State Medicaid Director
Department of Public Health and Environmental Services Oklahoma Health Care Authority
Commonwealth of the Northern Mariana Islands 4545 North Lincoln Boulevard
P.O. Box 409 CK Suite 124
Saipan, MP 96950 Oklahoma City, OK 73105
670/234-8931 405/522-7373
F: 405/530-3478
E-mail – Fogartym@ohca.state.ok.us
OHIO
Governor
OREGON
Honorable Bob Taft
77 South High Street, 30th Floor Governor
Columbus, OH 43266-0601 Honorable John A. Kitzhaber
614/466-3555 State Capitol
Single State Agency Director Salem, OR 97310
Ms. Jacqueline Romer-Sensky, Director 503/378-3111
Department of Human Services Single State Agency Director
30 East Broad Street, 32nd Floor Ms. Gary Weeks, Director
Columbus, OH 43266-0423 Department of Human Resources
614/466-6282 500 Summer Street, NE
Medicaid Director Human Resources Building
Ms. Barbara Edwards, Deputy Director Salem, OR 97310-1012
Office of Medicaid 503/945-5944
Department of Human Services Medicaid Director
30 East Broad Street, 31st Floor Mr. Hersh Crawford, Director
Columbus, OH 43266-0423 Senior and Disabled Services Division
614/644-0140 Department of Human Resources
F: 614/752-3986 500 Summer Street, NE 2nd Floor
E-mail – Medicaid@odhs.state.oh.us Human Resources Building, Third Floor
Salem, OR 97310-1015
503/945-5767
F: 503/373-7689
E-mail – herschel.crawford@state.or.us

PENNSYLVANIA RHODE ISLAND

Governor Governor
Honorable Thomas J. Ridge Honorable Lincoln C. Almond
25 Main Capitol Building State House
Harrisburg, PA 17120 Room 143
717/787-2500 Providence, RI 02903
Ms. Feather O. Houstoun, Secretary Single State Agency Director
Department of Public Welfare Ms. Christine C. Ferguson, Director
Health and Welfare Building Department of Human Services
P.O. Box 2675 600 New London Avenue
Harrisburg, PA 17120 Cranston, RI 02920
717/787-2600 401/462-2121
Margaret J. Dierkers, Ph.D. Mr. John Young, C.P.M.
Deputy Secretary Associate Director
Medical Assistance Programs Division of Medical Services
Department of Public Welfare Department of Human Services
Health and Welfare Building, Room 515 600 New London Avenue
Harrisburg, PA 17120 Cranston, RI 02920
717/787-1870 401/462-3113
F: 717/787-4639 F: 401/462-6338
E-mail – pamedicaid2@dpw.state.pa.us E-mail – Jyoung@gw.dhs.state.ri.us
PUERTO RICO SOUTH CAROLINA

Governor Governor
Honorable Pedro Rossello Honorable Jim Hodges
La Fortaleza P.O. Box 11369
P.O. Box 82 Columbia, SC 29211
San Juan, PR 00901 803/734-9818
Single State Agency Director Dr. J. Samuel Griswold, Director
Carmen Feliciano-DeMelecio, M.D. Department of Health and Human Services
Secretary P.O. Box 8206
Department of Health Columbia, SC 29202-8206
G.P.O. Box 70184 803/253-6100
San Juan, PR 00936 Medicaid Director
809/765-1230 Dr. J. Samuel Griswold, Director
Medicaid Director Department of Health and Human Services
Ms. Margarita Latorre, Medicaid Director P.O. Box 8206
Office of Economic Assistance to the Medically Indigent Columbia, SC 29202-8206
G.P.O. Box 70184 F: 803/898-4515
San Juan, PR 00936 E-mail – Griswold@dhhs.state.sc.us
809/765-1230
F: 809/250-0990

SOUTH DAKOTA TEXAS

Governor Governor
Honorable William J. Janklow Honorable George W. Bush
500 East Capitol State Capitol
Pierre, SD 57501 P.O. Box 12428
605/773-3212 Austin, TX 78711
Mr. James W. Ellenbecker, Secretary Single State Agency Director
Department of Social Services Don Gilbert, Commissioner
Richard F. Kneip Building Health and Human Services Commission
700 Governors Drive P.O. Box 13247
Pierre, SD 57501-2291 Austin, TX 78711
605/773-3165 5l2/424-6502
Medicaid Director F: 512/424-6586
Mr. David M. Christensen E-mail don_g@hhsc.state.tx.us
Program Administrator Medical Services Medicaid Director
Department of Social Services Ms. Linda K. Wertz
Richard F. Kneip Building State Medicaid Director
700 Governors Drive Health and Human Services Commission
Pierre, SD 57501-2291 P.O. Box 13247
605/773-3495 Austin, TX 78711
F: 605/773-5246 512/424-6549
E-mail – Dave.Christensen@state.sd.us F: 512/424-6547
E-mail – Linda.wertz@hhsc.state.tx.us
TENNESSEE
UTAH
Governor
Honorable Don Sundquist Governor
State Capitol Honorable Michael O. Leavitt
First Floor 210 State Capitol
Nashville, TN 37243-0001 Salt Lake City, UT 84114
615/741-2001 801/538-1000
Mr. John Ferguson, Commissioner Mr. Rod Betit, Executive Director
Department of Finance and Administration Department of Health
1st Floor, State Capitol P.O. Box 141000
Nashville, TN 37219 Salt Lake City, UT 84114-1000
615/741-2401 801/538-6111
Mr. John Tighe Mr. Rod Betit, Executive Director
Deputy Commissioner Department of Health
Department of Finance and Administration Division of Health Care Financing
729 Church Street P.O. Box 14100
Nashville, TN 37247-6501 Salt Lake City, UT 84114-1000
615/741-0213 801/538-6111
F: 615/741-0882 F: 801/538-6306
E-mail – Blapps@mail.state.tn.us

VERMONT VIRGIN ISLANDS

Governor Governor
Honorable Howard Dean, M.D. Honorable Roy L. Schneider
109 State Street Government House
Montpelier, VT 05609 21-22 Kongens Gada
802/828-3333 Charlotte Amalie
Single State Agency Director St. Thomas, VI 00802
Mr. Cornelius D. Hogan, Secretary 809/774-0001
Agency of Human Services Single State Agency Director
103 South Main Street Jose F. Poblete, M.D.
Waterbury, VT 05671-0201 Commissioner of Health
802/241-2220 Virgin Island Department of Health
Medicaid Director Charles Harwood Hospital
Mr. Paul Wallace-Brodeur, Director 3500 Richmond
Office of Health Access Christenstead, St. Croix, VI 00820-4370
Department of Social Welfare 809/774-0117
103 South Main Street Medicaid Director
Waterbury, VT 05676 Ms. Priscilla Berry-Quetel, Director
802/241-3985 Bureau of Health Insurance and Medical Assistance
F: 802/241-2974 Department of Health
E-mail – Paulw@wpgatel.ahs.state.vt.us 210-3A Altona, Suite 302 Frostco Center
Charlotte Amalie, VI 00802
809/774-4624
VIRGINIA F: 809/774-4918
Governor
Honorable James S. Gilmore III
WASHINGTON
State Capitol Building, Third Floor
Richmond, VA 232l9 Governor
804/786-2211 Honorable Gary Locke
Single State Agency Director Legislative Building
Mr. Dennis G. Smith, Director Olympia, WA 98504-0002
Department of Medical Assistance Services 360/753-6780
600 East Broad Street Single State Agency Director
Suite 1300 Mr. Lyle Quasim, Secretary
Richmond, VA 23219 Department of Social and Health Services
804/786-7933 P.O. Box 45010
Medicaid Director Olympia, WA 98504-5010
Mr. Dennis G. Smith, Director 360/902-7800
Department of Medical Assistance Services F: 360/902-7848
600 East Broad Street Medicaid Director
Suite 1300 Mr. Tom Bedell, Acting Assistant Secretary
Richmond, VA 23219 Medical Assistance Administration
804/786-8099 P.O. Box 45080
F: 804/371-4981 Olympia, WA 98504-5080
E-mail – Dsmith@dmas.state.va.us 360/902-7807
F: 360/902-7855
E-mail – Bedeltw@dshs.wa.gov

WEST VIRGINIA WYOMING

Governor Governor
Honorable Cecil Underwood Honorable Jim Geringer
State Capitol State Capitol, Room 124
Charleston, WV 25305-0370 Cheyenne, WY 82002
304/558-2000 307/777-7434
Ms. Joan Ohl, Secretary Mr. Garry KcKee, Director
Department of Health and Human Resources Department of Health
Building 3, State Capitol Complex 2300 Capital Avenue
Room 206 Hathaway Building, Room 117
Charleston, WV 25305 Cheyenne, WY 82002
304/348-0627 307/777-7656
Ms. Elizabeth Lawton, Commissioner Mr. Daniel G. Stackis, Administrator
Bureau for Medical Services Health Care Access and Resource Division
Department of Health and Human Resources Department of Health
7012 MacCorkle Avenue, SE Hathaway Building, Suite 154
Charleston, WV 25304 2300 Capitol Avenue
304/926-1703 ask for Ms. Lawton’s Secty) Cheyenne, WY 82002
F: 304/926-1833 307/777-7531
E-mail: Elawton@wvdhhr.org F: 307/777-6964
E-mail – rdavis@state.wy.us
WISCONSIN
Governor
Honorable Tommy G. Thompson
State Capitol
P.O. Box 7863
Madison, WI 53707
608/266-1212
Single State Agency Director
Mr. Joe Leean, Secretary
Department of Health and Social Services
Room 650
Madison, WI 53701
608/266-9622
Medicaid Director
Ms. Peggy Bartels, Administrator
Department of Health and Social Services
One West Wilson Street, Room 350
Madison, WI 53701
608/266-8922
F: 608/266-1096
E-mail – BARTEPL@dhfs.state.wi.us

REGIONAL ADMINISTRATIVE OFFICES

HEALTH AND HUMAN SERVICES
HEALTH CARE FINANCING ADMINISTRATION
Region I John F. Kennedy Federal Bldg. Connecticut, Maine, Massachusetts,

Boston Regional Office Government Center, Room 2325 New Hampshire, Rhode Island,
Boston, MA 02203-0003 Vermont
617/565-1223
Region II 26 Federal Plaza New Jersey, New York, Puerto Rico,

New York Regional Office Room 3811 Virgin Islands
New York, NY 10278-0063
212/264-2058
Region III Suite 216, The Public Ledger Building Delaware, District of Columbia,
Philadelphia Regional Office 150 South Independence Mall West Maryland, Pennsylvania, Virginia,
Philadelphia, PA 19106 West Virginia
215/861-4263
Region IV Atlanta Federal Center Alabama, Florida, Georgia, Kentucky,

Atlanta Regional Office 61 Forsyth Street, S.W., Suite 4T20 Mississippi, North Carolina, South
Atlanta, GA 30303-8909 Carolina, Tennessee
404/562-7400
Region V 233 North Michigan Avenue Illinois, Indiana, Michigan,

Chicago Regional Office Suite 600 Minnesota, Ohio, Wisconsin
312/353-9805
Region VI 1301 Young Street, Room 714 Arkansas, Louisiana, New Mexico,
Dallas Regional Office Dallas, TX 75202 Oklahoma, Texas
214/767-6301
Region VII Richard Bolling Federal Building Iowa, Kansas, Missouri, Nebraska
Kansas City Regional Office 601 East 12th Street, Room 235
Kansas City, MO 64106-2808
816/426-5925
Region VIII Colorado State Bank Building Colorado, Montana, North Dakota,
Denver Regional Office 1600 Broadway, Suite 700 South Dakota, Utah, Wyoming
Denver, CO 80202-4367
303/844-1977
Region IX 75 Hawthorne Street, 4th & 5th Floors Arizona, California, Hawaii, Guam
San Francisco Regional Office San Francisco, CA 94105-3901 Nevada, and Pacific Islands
415/744-3568
Region X 2201 6th Avenue Alaska, Idaho, Oregon, Washington

Seattle Regional Office Mail Stop RX-40
206/615-2313

HEALTH CARE FINANCING ADMINISTRATION (HCFA)

CENTER FOR MEDICAID AND STATE OPERATIONS
7500 Security Boulevard

Baltimore, MD 21244-1850
410/786-3000
Director
Tim Westmoreland
410/786-3870
Deputy Director
Rachel Block
410/786-3230
Appeals and Grievances Drug Rebate Agreement/Data

Nicole Martin Judy Allison
410/786-1068 410/786-3330
Assignment of Rights to Benefits Drug Utilization Review

Bob Nakielny Christina Lyon
410/786-4466 410/786-3332
Beneficiary Services Eligibility

Lindsey Cometa Marty Svolos
410/786-8201 410/786-4582
Budget Information for State Agencies Investigational/Experimental Drugs

Miles McDermott Tami Bruce
410/786-3722 410/786-1519
Child Health Insurance HCFA 2082 Statistical Report

Cindy Shirk Roger Buchanan
410/786-6614 410/786-0780
Coordination of Benefits Managed Care Enrollment Report

Dave Witt Carolyn Lawson
410/786-5600 410/786-0704
Data Inquiries Program Reviews

Marilyn McMillan Mary Jean Duckett
410/786-4623 410/786-3294
Department Appeals Board Decisions Pharmacy Issues/Pharmacy Reimbursement

Ed Davis Sue Gaston
410/786-3280 410/786-6918
Drugs Statistical Information System

(Coverage, Payment & Rebate Program Issues) Roger Buchanan
Larry Reed 410/786-0780
410/786-3325

Appendix B:
Medicaid Program Statistics --
HCFA-2082 Report
National Pharmaceutical Council B-1

B-2 National Pharmaceutical Council

Medicaid Program Statistics -- HCFA-2082 Report
The HCFA-2082 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 the 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.
FY 1998 HCFA-2082 The Federal Fiscal Year 1998 (October 1997-September 1998) HCFA-2082 data
CAVEATS AND DATA tables are based on information reported to HCFA on an annual basis by the 50
LIMITATIONS* States, the District of Columbia, Puerto Rico, and the Virgin Islands. These
tables reflect fiscal year 1998 data submitted by the States through September
1999. When using the data, note the following caveats and data limitations.
GENERAL
• The 1998 reports include managed care capitation payments on the Medicaid
Medical Vendor Payments tables and managed care recipients are now
included on the Medicaid Recipient tables. Managed care utilization and
payments are also broken out in the Type of Service tables. Tables 33
through 48 are specifically managed care tables.
STATE-SPECIFIC
• Alabama submitted totals only for their Prepaid Health Care and PCCM
recipients and payments. This data is reported as Unknown. The total Child
eligible population went up 25%. This was the result of the new program
called ARKIDSFIRST.
• Arizona submitted reported capitation payments (Prepaid Health Care data)

but no recipients were reported to correspond with these payments. The PHC
count for recipients was taken from the Medicaid Managed Care Enrollment
Report -1998
• Hawaii's recipient, eligible and vendor payment data are a result of

combining their fee-for-service and Quest data. The Quest data consists of
mainly Prepaid Health Care/Poverty Related data. This combined data was
reported in Sections A, B, C, D (1), D (2), D (3), G, H and Sections K (1)
and M.

• The total Child eligible population went up 37% and adults went down 29%.
This data agrees with Louisiana's 1996 data. Louisiana's FFY 1997 data
appears to include a misallocation of eligibles between the adult and child
categories.
• The total Child eligible population went up 67%. Maryland's FFY 1997
data counted some children as adults; the FFY 1998 data is correct. They
also implemented the Maryland Children Health Program in July of 1998.
• The total Child eligible population went up 32%. Massachusetts made a lot
of corrections to their data in FFY 1998 causing the counts to go up. Health
Care Reform also increased the eligible population for Children.
• Nebraska submitted data for Sections A, B, C and D only.
• New York's PCCM payments and eligibles in Section K (2) (Table 33) are
not correct. These counts include Targeted Case Management data. The total
adult eligible population went up 56%. The increase was due to New York's
new Medicaid Managed Care Waiver - Home and Community Based
program. The increase in this area was about 400K adults.
• Oklahoma submitted total recipients, eligibles and vendor payments only.

Their data is reported as Unknown. The total Child eligible population
decreased 34% from 97 due to a misallocation of Children in the 97 data
counts.
• Puerto Rico submitted a total recipient count only. The vendor payment
amount was taken from the HCFA-64. Their data is reported as Unknown.
• The total adult eligible population went up 25%. South Carolina always
used the midpoint of the FFY (03/31) to determine age, under MSIS they use
09/30 as the date.
• The total adult eligible population went up 17%. This was due to Vermont's
expansion of Medicaid population. More adults are now eligible for
Medicaid and more services are provided to these adults.
• Total adult eligible population decreased by 17%. When the Wisconsin

Work Not Welfare (W2) initiative was implemented a lot of recipients lost
Medicaid eligibility. Wisconsin then conducted an outreach campaign that
brought a number of these individuals back to Medicaid.
*Readers of the book should be cautioned that discrepancies in the 2082 data
can extend beyond these caveats and data limitations presented by HCFA.

Table 1. Medicaid Recipients by Maintenance Assistance Status and by State: FY 1998
Total Receiving Medically Poverty MAS

State Name Recipients Cash Payments Needy Related Other Unknown
National Total 40,649,482 17,556,201 4,368,961 9,202,219 6,347,817 3,174,284
Alabama 527,078 231,997 - 219,029 74,385 1,667
Alaska 74,508 48,821 - 14,556 9,315 1,816
Arizona 507,668 171,977 - 175,730 159,961 -
Arkansas 424,727 157,450 33,542 162,638 63,045 8,052
California 7,082,175 3,595,292 1,647,992 287,622 1,113,380 437,889
Colorado 344,916 120,745 - 84,801 135,255 4,115
Connecticut 381,208 151,939 41,568 52,394 135,307 -
Delaware 101,436 36,876 - 46,928 15,291 2,341
District of Columbia 166,146 87,261 17,242 7,753 4,108 49,782
Florida 1,904,591 1,100,787 41,070 498,267 249,348 15,119
Georgia 1,221,978 473,537 841 536,420 179,778 31,402
Hawaii 184,614 109,151 4,751 58,953 4,006 7,753
Idaho 123,176 13,767 - 34,793 56,599 18,017
Illinois 1,363,856 608,119 286,438 248,864 220,435 -
Indiana 607,293 231,768 - 181,086 172,542 21,897
Iowa 314,936 129,836 12,299 63,159 107,262 2,380
Kansas 241,933 90,083 32,802 79,787 33,327 5,934
Kentucky 644,482 346,507 50,532 184,829 53,190 9,424
Louisiana 720,615 372,578 8,629 190,227 149,181 -
Maine 170,456 73,907 2,396 47,447 42,843 3,863
Maryland 561,085 274,117 49,892 142,031 69,419 25,626
Massachusetts 908,238 445,998 224,414 191,690 46,136 -
Michigan 1,362,890 660,669 323,778 252,770 46,477 79,196
Minnesota 538,413 239,835 15,263 69,756 204,665 8,894
Mississippi 485,767 235,016 231 200,645 38,716 11,159
Missouri 734,015 206,175 - 259,920 251,738 16,182
Montana 100,760 47,965 7,586 15,922 23,572 5,715
Nebraska 211,188 104,483 436 71,025 35,244 -
Nevada 128,144 61,123 - 5,534 54,947 6,540
New Hampshire 93,970 28,219 9,734 33,005 21,900 1,112
New Jersey 813,251 418,784 6,296 167,133 213,615 7,423
New Mexico 329,418 144,046 - 167,569 15,579 2,224
New York 3,073,241 1,679,561 1,009,659 302,265 81,756 -
North Carolina 1,167,988 594,269 122,027 389,458 62,234 -
North Dakota 62,280 22,462 15,711 12,196 9,618 2,293
Ohio 1,290,776 515,191 - 730,667 44,918 -
Oklahoma 342,475 - - - - 342,475
Oregon 511,171 139,766 6,843 222,907 121,234 20,421
Pennsylvania 1,523,120 718,234 119,253 361,594 322,065 1,974
Puerto Rico 964,015 - - - - 964,015
Rhode Island 153,130 92,176 9,437 21,172 22,610 7,735
South Carolina 594,962 190,767 - 225,889 155,498 22,808
South Dakota 89,537 36,920 - 31,169 21,448 -
Tennessee 1,843,661 449,326 139,188 628,086 221,416 405,645
Texas 2,324,810 917,603 38,247 903,813 465,147 -
Utah 215,801 54,561 5,080 27,564 97,612 30,984
Vermont 123,992 38,507 9,057 56,418 18,082 1,928
Virgin Islands 19,764 6,316 11,991 - 1,457 -
Virginia 653,236 285,976 17,884 245,429 103,947 -
Washington 1,413,208 397,055 12,333 183,766 265,814 554,240
West Virginia 342,668 172,278 3,895 29,197 111,592 25,706
Wisconsin 518,595 216,998 30,624 63,944 199,063 7,966
Wyoming 46,121 9,407 - 14,402 21,740 572
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

Table 2. Medicaid Recipients by Basis of Eligibility and by State: FY 1998
Total Age 65 Blind/

State Name Recipients And Older Disabled Children
National Total 40,649,482 3,964,223 6,637,980 18,309,145
Alabama 527,078 64,651 145,892 262,547
Alaska 74,508 5,306 8,912 37,429
Arizona 507,668 27,473 78,121 282,256
Arkansas 424,727 50,746 96,507 179,405
California 7,082,175 587,326 926,252 3,345,491
Colorado 344,916 43,264 62,492 154,206
Connecticut 381,208 51,741 51,586 189,083
Delaware 101,436 6,652 13,726 49,425
District of Columbia 166,146 7,979 22,551 58,488
Florida 1,904,591 186,566 383,978 944,280
Georgia 1,221,978 89,197 226,263 666,385
Hawaii 184,614 17,022 16,913 75,329
Idaho 123,176 12,210 17,395 57,056
Illinois 1,363,856 108,132 262,773 620,251
Indiana 607,293 72,880 91,514 313,972
Iowa 314,936 39,847 51,219 138,633
Kansas 241,933 27,388 43,388 120,383
Kentucky 644,482 65,739 178,672 273,114
Louisiana 720,615 93,838 160,544 345,723
Maine 170,456 22,669 37,064 74,213
Maryland 561,085 44,502 104,461 264,965
Massachusetts 908,238 113,876 197,426 409,962
Michigan 1,362,890 91,663 259,243 616,825
Minnesota 538,413 58,701 73,913 293,632
Mississippi 485,767 60,567 131,439 218,491
Missouri 734,015 88,776 113,652 384,773
Montana 100,760 9,130 16,378 45,686
Nebraska 211,188 25,162 27,724 106,023
Nevada 128,144 12,320 19,320 65,349
New Hampshire 93,970 12,291 12,124 51,166
New Jersey 813,251 94,244 151,050 372,807
New Mexico 329,418 19,601 44,824 209,014
New York 3,073,241 393,567 592,598 1,315,777
North Carolina 1,167,988 158,676 198,254 609,190
North Dakota 62,280 10,376 8,953 27,779
Ohio 1,290,776 168,246 232,986 586,546
Oklahoma 342,475 - - -
Oregon 511,171 39,401 97,889 129,409
Pennsylvania 1,523,120 222,458 272,083 745,977
Puerto Rico 964,015 - - -
Rhode Island 153,130 17,540 28,524 64,882
South Carolina 594,962 72,074 102,904 269,751
South Dakota 89,537 9,496 15,767 48,794
Tennessee 1,843,661 88,948 302,470 554,235
Texas 2,324,810 301,368 288,293 1,327,276
Utah 215,801 9,716 20,093 106,259
Vermont 123,992 14,101 15,258 53,842
Virgin Islands 19,764 1,516 1,208 11,424
Virginia 653,236 86,550 121,112 333,370
Washington 1,413,208 61,996 112,306 489,005
West Virginia 342,668 29,157 73,037 153,021
Wisconsin 518,595 63,432 120,136 231,607
Wyoming 46,121 4,146 6,793 24,639

Table 2. Medicaid Recipients by Basis of Eligibility and by State: FY 1998 (Con’t)
Foster Care Other/

State Name Adults Children Unknown
National Total 7,907,935 654,684 3,175,515
Alabama 48,049 4,038 1,901
Alaska 19,990 1,055 1,816
Arizona 114,360 5,458 -
Arkansas 85,023 4,994 8,052
California 1,646,576 138,609 437,921
Colorado 66,485 14,354 4,115
Connecticut 81,613 7,185 -
Delaware 28,831 461 2,341
Florida 354,337 20,311 15,119
Georgia 202,223 6,508 31,402
Hawaii 64,575 3,022 7,753
Idaho 17,147 1,351 18,017
Illinois 293,879 78,821 -
Indiana 101,228 5,802 21,897
Iowa 78,021 4,836 2,380
Kansas 40,811 4,029 5,934
Kentucky 111,161 6,369 9,427
Louisiana 120,369 141 -
Maine 30,487 2,160 3,863
Maryland 106,312 15,219 25,626
Massachusetts 186,362 612 -
Michigan 287,617 28,346 79,196
Minnesota 96,443 6,476 9,248
Mississippi 61,217 2,894 11,159
Missouri 115,773 14,859 16,182
Montana 20,665 3,186 5,715
Nebraska 42,199 10,080 -
Nevada 21,460 3,155 6,540
New Hampshire 14,838 2,434 1,117
New Jersey 172,122 15,605 7,423
New Mexico 52,197 1,558 2,224
New York 689,543 81,756 -
North Dakota 11,398 1,481 2,293
Ohio 278,603 24,395 -
Oklahoma - - 342,475
Oregon 210,350 13,701 20,421
Pennsylvania 257,602 23,026 1,974
Puerto Rico - - 964,015
Rhode Island 30,866 3,583 7,735
South Carolina 121,013 6,412 22,808
South Dakota 14,154 1,326 -
Tennessee 479,727 12,130 406,151
Texas 391,786 16,087 -
Utah 44,966 3,783 30,984
Vermont 36,814 1,952 2,025
Virgin Islands 5,616 - -
Virginia 107,944 4,260 -
Washington 181,319 14,342 554,240
West Virginia 56,682 5,065 25,706
Wisconsin 82,360 13,094 7,966
Wyoming 9,448 523 572

Table 3. Medicaid Recipients by Type of Service and by State: FY 1998
Inpatient Inpatient Nursing

Total General Mental Facility ICF Mentally
State Name Recipients Hospital Hospital Services Retarded
National Total 40,649,482 4,272,878 135,284 1,645,728 126,490
Alabama 527,078 28,911 1,329 23,844 750
Alaska 74,508 11,084 627 887 8
Arizona 507,668 94,153 710 14,670 209
Arkansas 424,727 72,883 3,146 21,486 1,867
California 7,082,175 495,143 463 123,270 9,885
Colorado 344,916 24,250 361 18,928 500
Connecticut 381,208 26,198 398 28,791 1,556
Delaware 101,436 3,781 531 3,256 342
District of Columbia 166,146 17,487 162 4,217 821
Florida 1,904,591 241,668 253 73,030 3,567
Georgia 1,221,978 161,694 - 40,390 1,728
Hawaii 184,614 3,221 - 37,583 146
Idaho 123,176 17,056 39 5,297 1,012
Illinois 1,363,856 176,928 3,768 79,751 12,081
Indiana 607,293 91,414 2,134 44,524 6,035
Iowa 314,936 32,182 958 25,115 2,338
Kansas 241,933 27,435 333 16,802 1,441
Kentucky 644,482 93,875 4,338 27,439 1,240
Louisiana 720,615 153,081 2,847 34,403 6,014
Maine 170,456 18,009 705 9,278 361
Maryland 561,085 43,196 1,827 27,834 627
Massachusetts 908,238 91,546 952 72,342 1,949
Michigan 1,362,890 128,694 2,334 44,678 1,322
Minnesota 538,413 42,969 249 37,580 4,273
Mississippi 485,767 111,615 2,334 19,552 2,490
Missouri 734,015 72,848 9 37,226 1,442
Montana 100,760 12,315 14 5,316 149
Nebraska 211,188 24,577 418 16,528 685
Nevada 128,144 19,926 686 3,747 293
New Hampshire 93,970 10,832 200 7,700 33
New Jersey 813,251 70,725 1,899 48,552 4,514
New Mexico 329,418 54,968 468 8,170 362
New York 3,073,241 462,705 45,770 135,450 11,928
North Carolina 1,167,988 171,477 2,387 41,683 4,853
North Dakota 62,280 8,480 145 5,506 637
Ohio 1,290,776 165,016 783 86,236 8,162
Oklahoma 342,475 - - - -
Oregon 511,171 3,014 761 11,960 373
Pennsylvania 1,523,120 116,765 8,512 76,592 5,757
Puerto Rico 964,015 - - - -
Rhode Island 153,130 11,993 341 11,128 100
South Carolina 594,962 137,289 1,531 17,352 2,856
South Dakota 89,537 15,126 51 6,095 337
Tennessee 1,843,661 58 - 86,763 -
Texas 2,324,810 444,750 - 88,522 13,935
Utah 215,801 16,934 2 5,433 867
Vermont 123,992 6,235 133 3,804 17
Virgin Islands 19,764 1,056 - 67 -
Virginia 653,236 98,015 36,689 28,053 2,126
Washington 1,413,208 42,082 28 23,949 156
West Virginia 342,668 43,213 1,564 11,677 609
Wisconsin 518,595 45,591 2,087 40,715 3,600
Wyoming 46,121 8,415 8 2,557 137

Table 3. Medicaid Recipients by Type of Service and by State: FY 1998 (Con’t)
Physician Outpatient EPSDT Prescribed Dental

State Name Services Hospital Screening Services Drugs Services
National Total 18,554,746 12,157,729 6,174,628 19,337,543 4,965,202
Alabama 393,194 221,538 121,122 395,290 68,485
Alaska 50,070 37,166 1,074 43,734 20,498
Arizona 237,544 192,365 360,994 56,796 91,734
Arkansas 271,538 160,321 100,589 262,907 37,433
California 2,621,178 1,466,203 680,220 2,644,430 76,020
Colorado 150,497 84,807 37,337 147,033 52,131
Connecticut 103,264 79,692 5,176 108,331 42,588
Delaware 16,453 9,203 1,495 69,027 8,065
District of Columbia 42,789 50,346 848 57,733 12,682
Florida 754,818 644,876 256,591 1,014,372 374,202
Georgia 872,557 540,218 287,928 805,923 229,794
Hawaii 34,412 16,154 341 32,222 3,475
Idaho 88,192 45,261 22,688 86,775 31,969
Illinois 902,308 647,402 482,495 959,472 2,086
Indiana 345,017 218,100 125,592 323,811 105,402
Iowa 197,337 120,492 60,276 215,173 95,466
Kansas 142,424 79,508 75,475 155,875 34,083
Kentucky 438,403 292,864 38,422 429,102 131,560
Louisiana 598,546 355,568 279,309 552,481 128,341
Maine 92,879 38,361 50,661 137,816 28,593
Maryland 203,528 105,346 45,814 176,403 8,725
Massachusetts 497,694 411,868 33,551 613,186 288,682
Michigan 544,576 372,791 155,631 589,818 331,316
Minnesota 215,960 133,447 16,844 203,220 86,274
Mississippi 365,280 177,966 143,184 368,609 24,282
Missouri 259,688 246,492 71,161 353,902 85,188
Montana 61,621 32,775 10,866 58,641 20,635
Nebraska 133,342 77,751 32,513 145,408 63,484
Nevada 60,344 46,068 27,822 50,903 22,372
New Hampshire 61,209 42,768 16,155 70,339 25,024
New Jersey 275,224 220,552 12,317 309,849 93,991
New Mexico 125,982 77,898 17,983 96,637 19,263
New York 1,486,182 1,302,949 503,968 1,803,428 847,717
North Carolina 805,816 459,214 387,904 764,886 212,697
North Dakota 37,865 25,740 42 37,675 16,598
Ohio 729,550 548,785 124,921 702,143 238,685
Oklahoma - - - - -
Oregon 71,294 48,058 - 148,258 3,018
Pennsylvania 522,594 386,011 163,797 580,749 174,702
Puerto Rico - - - - -
Rhode Island 34,577 36,740 3,953 44,852 51,266
South Carolina 418,331 233,585 108,591 401,611 130,360
South Dakota 51,049 39,419 13,837 46,588 45
Tennessee 220,657 - - 1 -
Texas 1,783,470 1,011,359 1,046,345 1,894,447 7,026
Utah 67,664 40,234 5,142 126,953 48,521
Vermont 46,583 30,432 19,735 58,037 44,187
Virgin Islands 79 2,070 347 12,938 1,788
Virginia 438,974 267,436 85,641 383,880 76,341
Washington 286,442 147,633 36,564 274,463 275,281
West Virginia 242,889 166,885 61,956 267,398 81,557
Wisconsin 115,612 146,281 31,200 221,508 102,194
Wyoming 37,250 18,731 8,211 32,510 9,376

Other Clinic Lab & Family Home

State Name Practitioner Services X-Ray Planning Health
National Total 4,341,915 5,285,415 9,380,689 2,011,124 1,224,714
Alabama 72,649 111,804 157,551 35,953 43,277
Alaska 10,699 15,352 31,121 1,710 583
Arizona 25,836 59,496 156,286 30,092 15,650
Arkansas 77,588 80,534 120,126 50,089 9,966
California 693,399 801,776 1,692,841 248,680 60,918
Colorado 19,792 70,266 64,421 9,321 19,626
Connecticut 63,038 24,389 29,134 4,183 18,372
Delaware 22,641 3,050 5,549 4,821 2,113
Florida 121,191 169,145 463,748 137 33,507
Georgia 132,412 60,632 167,860 107,417 84,820
Hawaii 6,974 2,592 21,327 233 698
Idaho 22,693 16,147 38,057 6,188 1,869
Illinois 73,268 200,455 581,922 92,355 17,259
Indiana 141,790 94,541 211,802 20,754 10,243
Iowa 71,169 41,158 29,810 22,447 14,628
Kansas 30,572 72,021 71,632 15,530 6,395
Kentucky 95,907 144,896 238,713 34,698 67,405
Louisiana 71,230 69,912 432,781 60,975 41,705
Maine 33,625 29,225 62,810 8,570 6,825
Maryland 19,151 39,897 50,211 19,141 8,114
Massachusetts 115,654 120,551 114,014 80,262 39,534
Michigan 110,247 298,371 328,030 65,390 10,823
Minnesota 83,294 45,304 138,016 18,684 71,770
Mississippi 9,598 134,967 74,063 - 10,879
Missouri 84,827 293,062 118,223 23,557 24,954
Montana 10,391 7,420 26,931 3,695 -
Nebraska 51,858 6,698 52,194 13,268 3,512
Nevada 11,224 7,463 17,716 2,632 1,445
New Hampshire 20,508 29,049 12,930 7,861 2,359
New Jersey 93,388 88,631 192,194 40,837 17,611
New Mexico 25,720 60,811 16,603 5,401 2,026
New York 433,693 616,595 933,858 262,810 230,195
North Carolina 159,902 182,633 594,307 73,849 62,187
North Dakota 11,748 17,361 25,018 3,757 678
Ohio 237,356 108,729 110,324 16,802 29,654
Oklahoma - - - - -
Oregon 24,468 25,546 38,933 8,442 7,298
Pennsylvania 137,692 122,534 282,362 45,743 14,398
Rhode Island 10,880 11,113 23,188 1,926 11,794
South Carolina 87,212 224,554 150,252 112,341 10,331
South Dakota 10,826 17,975 23,615 4,579 530
Tennessee 1 31 - - 13
Texas 478,837 267,969 815,014 181,434 116,552
Utah 14,449 16,087 37,823 7,554 922
Vermont 16,716 18,629 22,021 9,919 2,600
Virgin Islands - 10,912 91 1,496 -
Virginia 70,449 95,786 180,726 23,655 7,470
Washington 91,089 56,459 152,580 166,048 3,997
West Virginia 62,112 98,672 78,244 25,549 21,797
Wisconsin 57,506 182,191 151,585 22,174 48,247
Wyoming 5,809 4,685 22,547 3,849 4,251

Personal Care Home/Community Other Prepaid PCCM

State Name Support Services Based Services Care Healthcare Services
National Total 3,108,432 467,451 6,975,027 20,202,887 4,066,440
Alabama 52,098 4,112 75,170 344,907 151,910
Alaska 9,482 1,741 24,510 - -
Arizona 18,635 3,567 152,121 368,344 -
Arkansas 30,524 9,369 100,502 244,768 243,266
California 497,531 36,286 1,722,936 6,022,536 54,471
Colorado 3,335 9,267 51,060 316,060 48,907
Connecticut 20,376 12,262 52,881 271,411 -
Delaware 4,353 1,442 14,266 85,239 -
District of Columbia 6,641 - 23,241 100,867 8,623
Florida 199,651 - 275,172 791,752 841,304
Georgia 194,528 15,251 137,889 78,463 879,554
Hawaii - - 11,940 144,744 -
Idaho 17,888 787 29,513 - 50,665
Illinois 39,760 88,727 312,616 142,429 16,414
Indiana 70,735 4,523 129,439 271,005 242,844
Iowa 13,974 7,751 70,781 246,582 80,428
Kansas 8,579 15,406 47,549 44,003 123,902
Kentucky 27,589 13,125 208,539 194,164 -
Louisiana 67,602 2,751 142,350 - -
Maine 24,933 3,245 57,423 9,324 -
Maryland 63,467 3,820 44,395 449,825 -
Massachusetts 4,661 13,452 309,835 768,831 264,035
Michigan 141,167 12,147 175,146 758,185 53,733
Minnesota 61,532 18,048 93,767 318,854 -
Mississippi 4,430 - 63,361 17,628 -
Missouri 75,373 104 92,017 336,057 -
Montana 18,270 - 19,901 96,701 59,578
Nebraska 1,056 1,781 31,651 159,614 27,577
Nevada 16,328 1,647 15,756 55,923 28,638
New Hampshire 5,973 3,828 16,940 11,176 -
New Jersey 41,062 12,995 109,463 545,380 -
New Mexico 8,636 - 41,592 263,256 103,867
New York 349,647 31,868 681,519 884,443 804
North Carolina 356,450 14,421 165,210 220,700 591,740
North Dakota 5,096 4,265 17,115 1,549 32,566
Ohio 29,241 28,640 335,039 453,265 -
Oklahoma - - - - -
Oregon 78,965 26,753 39,196 481,498 11,163
Pennsylvania 51,201 1,888 177,888 902,896 -
Rhode Island 13,129 1,627 27,042 96,178 -
South Carolina 61,734 14,675 113,086 17,195 -
South Dakota 13,841 2,024 15,852 83,998 39,858
Tennessee 4,337 - 2 1,764,279 -
Texas 209,980 25,762 186,423 - -
Utah 15,280 3,247 16,230 170,319 -
Vermont 6,333 2,734 34,118 69,682 -
Virgin Islands - - 2,268 - -
Virginia 31,984 4,589 100,122 159,392 110,559
Washington 16,623 - 234,814 1,146,180 -
West Virginia 60,409 5,437 36,243 52 -
Wisconsin 45,441 - 135,974 293,233 34
Wyoming 8,572 2,087 3,164 - -

Table 4. Medicaid Recipients Who Receive Cash Payments by Basis of Eligibility and by State: FY 1998
Total Age 65 Blind/ Other/

State Name Recipients And Older Disabled Children Adults Unknown
National Total 17,556,201 1,663,402 4,938,095 7,518,095 3,436,434 175
Alabama 231,997 33,782 133,568 47,498 17,149 -
Alaska 48,821 4,707 8,439 22,130 13,545 -
Arizona 171,977 11,050 62,484 62,968 35,475 -
Arkansas 157,450 19,810 79,422 40,822 17,396 -
California 3,595,292 366,023 791,034 1,690,580 747,655 -
Colorado 120,745 19,733 10,839 61,544 28,629 -
Connecticut 151,939 7,743 20,673 82,351 41,172 -
Delaware 36,876 2,208 10,415 17,496 6,757 -
District of Columbia 87,261 2,889 17,408 46,490 20,474 -
Florida 1,100,787 94,402 305,121 486,777 214,487 -
Georgia 473,537 42,268 181,366 182,592 67,311 -
Hawaii 109,151 15,367 16,471 49,699 27,614 -
Idaho 13,767 1,597 7,174 3,225 1,771 -
Illinois 608,119 24,430 173,098 283,637 126,954 -
Indiana 231,768 21,814 59,055 97,242 53,657 -
Iowa 129,836 9,088 40,438 50,912 29,398 -
Kansas 90,083 5,115 32,803 34,049 18,116 -
Kentucky 346,507 26,791 162,095 105,190 52,431 -
Louisiana 372,578 51,275 143,060 128,630 49,613 -
Maine 73,907 3,862 24,631 29,368 16,046 -
Maryland 274,117 17,585 83,990 124,733 47,809 -
Massachusetts 445,998 44,593 148,246 173,428 79,731 -
Michigan 660,669 22,413 191,253 290,969 156,034 -
Minnesota 239,835 16,395 51,453 117,548 54,288 151
Mississippi 235,016 29,516 116,291 62,653 26,556 -
Missouri 206,175 4,697 9,476 132,426 59,576 -
Montana 47,965 1,995 13,072 21,795 11,103 -
Nebraska 104,483 9,475 25,281 38,101 31,626 -
Nevada 61,123 6,409 16,060 26,717 11,937 -
New Hampshire 28,219 1,619 6,119 13,912 6,569 -
New Jersey 418,784 33,922 120,029 175,742 89,091 -
New Mexico 144,046 9,522 40,594 61,327 32,603 -
New York 1,679,561 179,121 469,035 726,236 305,169 -
North Carolina 594,269 83,182 126,773 254,658 129,656 -
North Dakota 22,462 3,820 6,365 8,470 3,807 -
Ohio 515,191 1,218 10,443 352,125 151,405 -
Oklahoma - - - - - -
Oregon 139,766 8,805 42,068 51,743 37,150 -
Pennsylvania 718,234 69,084 208,952 316,699 123,499 -
Puerto Rico - - - - - -
Rhode Island 92,176 4,867 22,199 42,872 22,238 -
South Carolina 190,767 35,808 78,065 55,126 21,768 -
South Dakota 36,920 2,658 13,886 13,865 6,511 -
Tennessee 449,326 40,467 241,337 117,476 50,022 24
Texas 917,603 164,663 251,266 350,262 151,412 -
Utah 54,561 3,039 12,257 24,936 14,329 -
Vermont 38,507 2,339 10,635 17,305 8,228 -
Virgin Islands 6,316 429 583 3,627 1,677 -
Virginia 285,976 38,986 97,404 103,548 46,038 -
Washington 397,055 22,597 88,491 183,623 102,344 -
West Virginia 172,278 22,828 57,955 57,225 34,270 -
Wisconsin 216,998 16,484 94,396 72,808 33,310 -
Wyoming 9,407 912 4,527 2,940 1,028 -

Table 5. Medically Needy Medicaid Recipients by Basis of Eligibility and by State: FY 1998

National Total 4,368,961 791,880 553,524 1,980,201 1,042,805 551
Alabama - - - - - -
Alaska - - - - - -
Arizona - - - - - -
Arkansas 33,542 356 6,210 16,132 10,844 -
California 1,647,992 193,514 116,129 977,396 360,953 -
Colorado - - - - - -
Connecticut 41,568 14,001 18,741 4,822 4,004 -
Delaware - - - - - -
Florida 41,070 23 11,243 12,031 17,773 -
Georgia 841 99 682 58 2 -
Hawaii 4,751 1,597 442 1,447 1,265 -
Idaho - - - - - -
Illinois 286,438 63,711 51,144 88,849 82,734 -
Indiana - - - - - -
Iowa 12,299 3,898 3,304 1,468 3,629 -
Kansas 32,802 21,739 9,265 1,631 167 -
Kentucky 50,532 5,363 3,754 25,574 15,841 -
Louisiana 8,629 1,315 1,989 1,199 4,126 -
Maine 2,396 816 538 652 390 -
Maryland 49,892 20,476 15,532 8,832 5,052 -
Massachusetts 224,414 31,375 6,593 109,840 76,606 -
Michigan 323,778 66,766 65,436 104,792 86,784 -
Minnesota 15,263 6,644 6,728 1,243 577 71
Mississippi 231 211 20 - - -
Missouri - - - - - -
Montana 7,586 5,461 2,112 3 10 -
Nebraska 436 135 211 23 67 -
Nevada - - - - - -
New Hampshire 9,734 4,565 2,604 1,297 1,267 1
New Jersey 6,296 3,340 1,117 1,837 2 -
New Mexico - - - - - -
New York 1,009,659 214,446 123,563 474,192 197,458 -
North Carolina 122,027 46,527 55,200 6,974 13,326 -
North Dakota 15,711 6,520 2,559 3,632 3,000 -
Ohio - - - - - -
Oregon 6,843 2,317 4,526 - - -
Pennsylvania 119,253 23,357 4,068 50,761 41,067 -
Rhode Island 9,437 5,811 2,085 68 1,473 -
South Carolina - - - - - -
South Dakota - - - - - -
Tennessee 139,188 18,667 10,989 39,504 69,549 479
Texas 38,247 - - 9,164 29,083 -
Utah 5,080 550 806 1,890 1,834 -
Vermont 9,057 881 1,363 3,583 3,230 -
Virgin Islands 11,991 1,087 625 7,345 2,934 -
Virginia 17,884 9,792 6,504 1,308 280 -
Washington 12,333 6,092 6,127 76 38 -
West Virginia 3,895 355 2,401 106 1,033 -
Wisconsin 30,624 6,519 5,240 15,969 2,896 -
Wyoming - - - - - -

Table 6. Poverty Related Medicaid Recipients by Basis of Eligibility and by State: FY 1998

National Total 9,202,219 600,117 571,132 6,116,866 1,914,007 97
Alabama 219,029 11,413 5,906 184,459 17,251 -
Alaska 14,556 4 4 10,231 4,317 -
Arizona 175,730 142 653 147,738 27,197 -
Arkansas 162,638 7,398 4,881 103,574 46,785 -
California 287,622 2,544 5,076 234,783 45,219 -
Colorado 84,801 1,477 2,275 56,902 24,147 -
Connecticut 52,394 1,025 508 45,200 5,661 -
Delaware 46,928 1,267 692 26,499 18,470 -
District of Columbia 7,753 1,535 1,469 4,127 622 -
Florida 498,267 54,232 51,193 303,233 89,609 -
Georgia 536,420 20,439 12,492 407,203 96,286 -
Hawaii 58,953 58 - 23,532 35,363 -
Idaho 34,793 10,613 9,610 9,864 4,706 -
Illinois 248,864 17,300 25,510 167,005 39,049 -
Indiana 181,086 4,666 6,153 151,004 19,263 -
Iowa 63,159 3,920 2,677 43,854 12,708 -
Kansas 79,787 407 354 66,183 12,843 -
Kentucky 184,829 11,124 7,692 131,909 34,103 1
Louisiana 190,227 12,317 5,102 134,775 38,033 -
Maine 47,447 8,539 6,213 28,633 4,062 -
Maryland 142,031 6,423 3,644 96,672 35,292 -
Massachusetts 191,690 37,908 40,053 105,030 8,699 -
Michigan 252,770 2,225 2,478 206,938 41,129 -
Minnesota 69,756 2,190 1,538 64,120 1,816 92
Mississippi 200,645 16,531 12,352 147,744 24,018 -
Missouri 259,920 6,146 4,950 211,830 36,994 -
Montana 15,922 186 60 11,492 4,184 -
Nebraska 71,025 3,646 996 66,383 - -
Nevada 5,534 2,060 2,121 903 450 -
New Hampshire 33,005 286 151 29,507 3,057 4
New Jersey 167,133 17,386 15,700 107,203 26,844 -
New Mexico 167,569 115 546 147,314 19,594 -
New York 302,265 - - 115,349 186,916 -
North Carolina 389,458 - - 346,302 43,156 -
North Dakota 12,196 29 29 10,405 1,733 -
Ohio 730,667 167,028 222,543 224,508 116,588 -
Oregon 222,907 614 7,768 60,676 153,849 -
Pennsylvania 361,594 84,483 1,379 248,475 27,257 -
Rhode Island 21,172 20 17 15,856 5,279 -
South Carolina 225,889 21,738 18,248 155,544 30,359 -
South Dakota 31,169 682 316 25,094 5,077 -
Tennessee 628,086 4 44,431 290,466 293,185 -
Texas 903,813 26,121 11,642 729,443 136,607 -
Utah 27,564 2,281 3,713 5,965 15,605 -
Vermont 56,418 7,502 2,530 23,797 22,589 -
Virgin Islands - - - - - -
Virginia 245,429 14,215 10,117 176,514 44,583 -
Washington 183,766 1,947 2,206 157,526 22,087 -
West Virginia 29,197 5,883 12,681 774 9,859 -
Wisconsin 63,944 1,579 - 45,021 17,344 -
Wyoming 14,402 469 463 9,307 4,163 -

Table 7. Medicaid Recipients of Other Coverage Groups by Basis of Eligibility and by State: FY 1998
Total Age 65 Blind/ Foster Other/

State Name Recipients And Older Disabled Children Adults Children Unknown
National Total 6,347,817 908,824 575,229 2,693,983 1,514,689 654,684 408
Alabama 74,385 19,456 6,418 30,590 13,649 4,038 234
Alaska 9,315 595 469 5,068 2,128 1,055 -
Arizona 159,961 16,281 14,984 71,550 51,688 5,458 -
Arkansas 63,045 23,182 5,994 18,877 9,998 4,994 -
California 1,113,380 25,245 14,013 442,732 492,749 138,609 32
Colorado 135,255 22,054 49,378 35,760 13,709 14,354 -
Connecticut 135,307 28,972 11,664 56,710 30,776 7,185 -
Delaware 15,291 3,177 2,619 5,430 3,604 461 -
District of Columbia 4,108 1 - 1,368 1,075 1,664 -
Florida 249,348 37,909 16,421 142,239 32,468 20,311 -
Georgia 179,778 26,391 31,723 76,532 38,624 6,508 -
Hawaii 4,006 - - 651 333 3,022 -
Idaho 56,599 - 611 43,967 10,670 1,351 -
Illinois 220,435 2,691 13,021 80,760 45,142 78,821 -
Indiana 172,542 46,400 26,306 65,726 28,308 5,802 -
Iowa 107,262 22,941 4,800 42,399 32,286 4,836 -
Kansas 33,327 127 966 18,520 9,685 4,029 -
Kentucky 53,190 22,461 5,131 10,441 8,786 6,369 2
Louisiana 149,181 28,931 10,393 81,119 28,597 141 -
Maine 42,843 9,452 5,682 15,560 9,989 2,160 -
Maryland 69,419 18 1,295 34,728 18,159 15,219 -
Massachusetts 46,136 - 2,534 21,664 21,326 612 -
Michigan 46,477 259 76 14,126 3,670 28,346 -
Minnesota 204,665 33,472 14,194 110,721 39,762 6,476 40
Mississippi 38,716 14,309 2,776 8,094 10,643 2,894 -
Missouri 251,738 77,933 99,226 40,517 19,203 14,859 -
Montana 23,572 1,488 1,134 12,396 5,368 3,186 -
Nebraska 35,244 11,906 1,236 1,516 10,506 10,080 -
Nevada 54,947 3,851 1,139 37,729 9,073 3,155 -
New Hampshire 21,900 5,821 3,250 6,450 3,945 2,434 -
New Jersey 213,615 39,596 14,204 88,025 56,185 15,605 -
New Mexico 15,579 9,964 3,684 373 - 1,558 -
New York 81,756 - - - - 81,756 -
North Carolina 62,234 28,967 16,281 1,256 3,554 12,176 -
North Dakota 9,618 7 - 5,272 2,858 1,481 -
Ohio 44,918 - - 9,913 10,610 24,395 -
Oklahoma - - - - - - -
Oregon 121,234 27,665 43,527 16,990 19,351 13,701 -
Pennsylvania 322,065 45,534 57,684 130,042 65,779 23,026 -
Puerto Rico - - - - - - -
Rhode Island 22,610 6,842 4,223 6,086 1,876 3,583 -
South Carolina 155,498 14,528 6,591 59,081 68,886 6,412 -
South Dakota 21,448 6,156 1,565 9,835 2,566 1,326 -
Tennessee 221,416 29,810 5,713 106,789 66,971 12,130 3
Texas 465,147 110,584 25,385 238,407 74,684 16,087 -
Utah 97,612 3,846 3,317 73,468 13,198 3,783 -
Vermont 18,082 3,379 730 9,157 2,767 1,952 97
Virgin Islands 1,457 - - 452 1,005 - -
Virginia 103,947 23,557 7,087 52,000 17,043 4,260 -
Washington 265,814 31,360 15,482 147,780 56,850 14,342 -
West Virginia 111,592 91 - 94,916 11,520 5,065 -
Wisconsin 199,063 38,850 20,500 97,809 28,810 13,094 -
Wyoming 21,740 2,765 1,803 12,392 4,257 523 -

Table 8. Medicaid Medical Vendor Payments by Maintenance Assistance Status of Recipient

and by State: FY 1998

State Name Payments Cash Payments Needy Related Other Unknown
National Total $142,317,903,795 $63,034,798,342 $25,138,863,775 $19,758,455,422 $30,686,156,426 $3,699,629,829
Alabama 1,902,300,047 602,742,522 - 176,216,348 607,749,253 515,591,924
Alaska 330,378,398 213,828,341 - 43,610,989 71,856,764 1,082,304
Arizona 1,643,966,305 712,364,833 - 238,491,706 693,109,765 -
Arkansas 1,375,797,421 713,252,376 79,146,711 223,104,306 596,207,736 (235,913,708)
California 14,236,592,915 8,647,488,244 3,879,870,004 295,066,192 1,262,422,388 151,746,087
Colorado 1,439,366,499 304,817,936 - 129,898,201 960,589,934 44,060,428
Connecticut 2,420,791,474 563,107,925 331,270,561 90,114,928 1,436,298,060 -
Delaware 419,732,143 183,870,881 - 79,747,325 152,583,054 3,530,883
District of Columbia 731,292,552 361,750,299 233,651,729 27,498,854 21,665,816 86,725,854
Florida 5,686,844,862 2,950,414,878 126,182,907 1,348,334,446 1,236,568,867 25,343,764
Georgia 3,012,346,312 1,377,872,299 3,794,773 689,569,489 889,614,162 51,495,589
Hawaii 507,433,146 349,140,826 58,350,850 81,498,940 7,972,123 10,470,407
Idaho 424,512,387 77,400,112 - 236,140,479 70,620,282 40,351,514
Illinois 6,172,865,261 2,639,261,770 2,449,228,109 415,474,024 668,901,358 -
Indiana 2,564,005,047 954,525,663 - 220,277,390 1,370,926,082 18,275,912
Iowa 1,288,770,390 522,779,438 43,959,500 80,855,385 637,601,466 3,574,601
Kansas 916,323,608 374,101,538 385,066,257 90,102,609 52,944,805 14,108,399
Kentucky 2,425,288,141 1,376,672,479 174,912,771 275,954,959 588,092,271 9,655,661
Louisiana 2,383,508,985 1,227,251,177 35,159,084 227,270,626 893,828,098 -
Maine 747,027,618 289,878,332 11,059,685 101,617,050 332,465,141 12,007,410
Maryland 2,489,280,148 1,233,921,421 798,379,206 231,634,487 189,104,492 36,240,542
Massachusetts 4,609,360,933 2,143,677,179 856,606,399 1,482,929,991 126,147,364 -
Michigan 4,345,007,824 2,009,893,152 1,613,885,806 272,152,987 70,708,537 378,367,342
Minnesota 2,924,447,719 1,209,395,516 138,072,538 64,387,956 1,494,649,325 17,942,384
Mississippi 1,442,373,276 714,491,940 29,257 306,914,267 417,485,900 3,451,912
Missouri 2,569,646,129 340,186,310 - 274,104,538 1,942,734,440 12,620,841
Montana 361,238,668 141,690,577 104,383,328 20,793,093 88,089,349 6,282,321
Nebraska 753,162,904 430,209,028 2,974,236 82,582,317 237,397,323 -
Nevada 462,087,777 222,245,177 - 4,622,406 211,394,224 23,825,970
New Hampshire 606,004,232 170,615,173 121,049,747 52,614,350 260,382,807 1,342,155
New Jersey 4,218,822,993 1,963,153,334 57,860,478 458,183,790 1,725,703,499 13,921,892
New Mexico 862,144,872 437,218,245 - 241,810,168 177,322,949 5,793,510
New York 24,298,610,635 12,312,300,018 10,634,644,651 984,445,331 367,220,635 -
North Carolina 4,013,996,742 2,080,692,247 1,266,350,628 558,638,298 108,315,569 -
North Dakota 341,015,420 121,167,482 179,804,840 14,402,609 22,843,885 2,796,604
Ohio 6,120,967,557 824,053,633 - 5,180,692,237 116,221,687 -
Oklahoma 1,177,853,941 - - - - 1,177,853,941
Oregon 1,377,514,740 392,064,018 19,562,289 613,603,111 335,137,219 17,148,103
Pennsylvania 6,080,191,710 2,471,881,538 696,874,020 821,478,988 2,087,655,250 2,301,914
Puerto Rico 250,000,000 - - - - 250,000,000
Rhode Island 919,353,410 430,262,938 140,267,792 27,623,971 308,397,218 12,801,491
South Carolina 2,018,620,428 751,927,407 - 448,329,281 558,650,582 259,713,158
South Dakota 355,833,902 156,736,607 - 31,265,704 167,831,591 -
Tennessee 3,167,188,993 988,402,868 162,210,873 693,524,367 923,383,603 399,667,282
Texas 7,139,928,843 3,164,249,057 125,836,860 1,024,387,837 2,825,455,089 -
Utah 618,675,433 150,439,909 17,227,134 67,272,642 311,792,358 71,943,390
Vermont 351,341,290 143,568,188 21,108,255 70,329,475 115,229,024 1,106,348
Virgin Islands 10,097,973 3,007,722 6,056,113 - 1,034,138 -
Virginia 2,118,202,866 1,013,741,200 163,396,812 276,531,633 664,533,221 -
Washington 2,044,234,831 845,368,582 80,835,552 155,230,925 830,670,996 132,128,776
West Virginia 1,243,150,526 830,135,721 24,132,569 121,766,318 144,277,023 122,838,895
Wisconsin 2,206,398,750 859,392,921 95,661,451 84,267,682 1,170,245,392 (3,168,696)
Wyoming 192,004,819 36,187,365 - 21,090,417 134,124,312 602,725

Table 9. Medicaid Medical Vendor Payments by Basis of Eligibility of Recipient and by State: FY 1998
Total Age 65 Blind/

State Name Payments And Older Disabled Children
National Total $142,317,903,795 $40,602,116,833 $60,375,123,225 $20,459,140,959
Alabama 1,902,300,047 550,365,257 597,810,766 186,782,542
Alaska 330,378,398 57,121,304 115,136,373 85,965,470
Arizona 1,643,966,305 324,219,550 609,672,915 405,457,935
Arkansas 1,375,797,421 430,018,281 791,182,772 262,322,716
California 14,236,592,915 2,877,789,089 6,143,133,891 2,665,260,487
Colorado 1,439,366,499 437,704,252 581,915,898 149,568,323
Connecticut 2,420,791,474 1,048,144,688 890,332,880 289,118,311
Delaware 419,732,143 95,287,226 196,514,572 67,829,755
District of Columbia 731,292,552 150,809,511 346,252,423 78,395,395
Florida 5,686,844,862 1,555,193,567 2,659,251,017 846,258,629
Georgia 3,012,346,312 493,367,044 1,402,741,189 582,740,389
Hawaii 507,433,146 157,256,534 128,342,971 117,090,747
Idaho 424,512,387 124,484,856 167,695,747 51,677,781
Illinois 6,172,865,261 1,104,777,674 3,262,390,656 786,450,294
Indiana 2,564,005,047 863,879,770 1,083,989,118 399,777,342
Iowa 1,288,770,390 463,839,101 489,399,669 179,317,603
Kansas 916,323,608 253,024,983 450,243,800 131,960,635
Kentucky 2,425,288,141 583,123,078 1,162,378,389 386,980,809
Louisiana 2,383,508,985 672,322,724 1,101,257,511 371,500,804
Maine 747,027,618 239,292,715 329,088,855 96,498,432
Maryland 2,489,280,148 603,934,490 1,183,637,666 386,698,407
Massachusetts 4,609,360,933 1,475,161,716 2,174,271,507 561,432,617
Michigan 4,345,007,824 940,257,050 1,944,525,068 515,623,409
Minnesota 2,924,447,719 993,413,008 1,223,393,074 455,098,154
Mississippi 1,442,373,276 415,324,517 665,398,149 225,920,481
Missouri 2,569,646,129 927,285,221 1,016,081,357 410,373,527
Montana 361,238,668 114,977,600 138,852,060 56,626,017
Nebraska 753,162,904 264,480,513 278,110,955 107,639,405
Nevada 462,087,777 91,651,233 174,129,939 79,001,535
New Hampshire 606,004,232 226,786,873 221,210,838 98,665,958
New Jersey 4,218,822,993 1,325,345,586 1,977,873,602 433,771,126
New Mexico 862,144,872 145,828,469 310,111,561 269,533,249
New York 24,298,610,635 7,871,285,862 11,645,320,828 2,324,009,772
North Carolina 4,013,996,742 1,193,291,589 1,663,065,550 716,185,408
North Dakota 341,015,420 131,361,999 140,167,178 33,676,323
Ohio 6,120,967,557 2,245,207,690 2,544,856,524 705,040,424
Oklahoma 1,177,853,941 - - -
Oregon 1,377,514,740 112,980,883 267,864,281 366,507,811
Pennsylvania 6,080,191,710 2,510,003,519 1,988,012,614 1,024,778,811
Puerto Rico 250,000,000 - - -
Rhode Island 919,353,410 298,102,394 454,553,955 81,377,077
South Carolina 2,018,620,428 477,950,896 762,312,898 305,302,576
South Dakota 355,833,902 107,444,635 160,719,294 57,057,240
Tennessee 3,167,188,993 674,937,423 990,880,890 410,584,137
Texas 7,139,928,843 2,341,889,852 2,484,970,969 1,397,377,640
Utah 618,675,433 90,122,694 226,841,136 120,451,826
Vermont 351,341,290 97,201,440 135,753,840 54,910,386
Virgin Islands 10,097,973 2,490,221 1,767,095 3,125,020
Virginia 2,118,202,866 638,501,136 933,333,485 336,321,911
Washington 2,044,234,831 572,572,467 622,897,992 340,856,081
West Virginia 1,243,150,526 359,268,463 473,514,655 153,582,113
Wisconsin 2,206,398,750 816,986,679 978,356,783 256,202,612
Wyoming 192,004,819 54,049,511 83,606,070 30,455,507

Table 9. Medicaid Medical Vendor Payments by Basis of Eligibility of Recipient

and by State: FY 1998 (Con’t)
Foster Other/
National Total $14,833,097,385 $2,346,800,698 $3,701,624,687
Alabama 33,684,838 17,825,019 515,831,625
Alaska 61,419,264 9,653,683 1,082,304
Arizona 296,765,130 7,850,767 -
Arkansas 99,324,540 28,862,820 (235,913,708)
California 2,149,128,619 249,516,816 151,764,013
Colorado 124,900,958 101,216,640 44,060,428
Connecticut 175,979,323 17,216,272 -
Delaware 54,956,394 1,613,313 3,530,883
District of Columbia 53,304,930 15,804,439 86,725,854
Florida 549,341,749 51,456,136 25,343,764
Georgia 458,044,573 23,957,528 51,495,589
Hawaii 88,877,805 5,394,682 10,470,407
Idaho 37,809,908 2,492,581 40,351,514
Illinois 686,289,405 332,957,232 -
Indiana 175,348,016 22,734,889 18,275,912
Iowa 134,057,212 18,582,204 3,574,601
Kansas 59,588,457 7,397,334 14,108,399
Kentucky 239,916,610 43,231,020 9,658,235
Louisiana 238,273,512 154,433 -
Maine 43,739,741 26,400,465 12,007,410
Maryland 238,767,249 40,001,794 36,240,542
Massachusetts 397,513,145 981,948 -
Michigan 514,607,970 51,626,985 378,367,342
Minnesota 196,885,958 36,699,762 18,957,763
Mississippi 119,880,832 12,397,385 3,451,912
Missouri 156,676,911 46,608,272 12,620,841
Montana 38,484,670 6,016,000 6,282,321
Nebraska 66,708,154 36,223,877 -
Nevada 52,414,904 41,064,196 23,825,970
New Hampshire 33,867,455 24,126,996 1,346,112
New Jersey 370,456,043 97,454,744 13,921,892
New Mexico 104,703,118 26,174,965 5,793,510
New York 2,090,773,539 367,220,635 -
North Carolina 396,970,898 44,483,297 -
North Dakota 22,899,991 10,113,325 2,796,604
Ohio 554,468,305 71,394,614 -
Oklahoma - - 1,177,853,941
Oregon 576,396,640 36,617,022 17,148,103
Pennsylvania 457,250,934 97,843,918 2,301,914
Puerto Rico - - 250,000,000
Rhode Island 59,149,256 13,369,237 12,801,491
South Carolina 162,109,475 51,231,425 259,713,158
South Dakota 26,827,646 3,785,087 -
Tennessee 632,709,631 57,825,355 400,251,557
Texas 871,515,674 44,174,708 -
Utah 79,480,227 29,836,160 71,943,390
Vermont 46,777,227 15,461,003 1,237,394
Virgin Islands 2,715,637 - -
Virginia 200,657,760 9,388,574 -
Washington 353,872,825 21,906,690 132,128,776
West Virginia 101,663,671 32,282,729 122,838,895
Wisconsin 123,315,198 34,706,174 (3,168,696)
Wyoming 21,825,458 1,465,548 602,725

Table 10. Medicaid Medical Vendor Payments by Type of Service and by State: FY 1998
Inpatient Nursing
Total Inpatient General Mental Facility ICF Mentally
State Name Payments Hospital Hospital Services Retarded
National Total $142,317,903,795 $21,498,719,619 $2,800,541,598 $31,892,064,551 $9,481,723,907
Alabama 1,902,300,047 42,908,107 26,475,030 522,825,844 55,663,840
Alaska 330,378,398 55,725,816 13,764,917 45,782,809 293,827
Arizona 1,643,966,305 75,903,069 20,966 16,458,558 -
Arkansas 1,375,797,421 178,532,888 54,470,602 300,012,732 108,852,817
California 14,236,592,915 2,539,212,053 7,648,556 2,158,053,360 559,948,974
Colorado 1,439,366,499 186,830,191 5,955,144 333,591,591 26,124,204
Connecticut 2,420,791,474 166,380,038 23,576,663 858,713,862 203,094,688
Delaware 419,732,143 15,358,566 10,648,377 83,062,656 32,687,748
District of Columbia 731,292,552 198,380,143 2,498,290 155,399,067 71,613,329
Florida 5,686,844,862 1,038,563,277 14,638,423 1,340,608,163 255,636,949
Georgia 3,012,346,312 668,075,530 - 603,835,584 107,450,025
Hawaii 507,433,146 36,301,298 - 144,973,700 10,066,595
Idaho 424,512,387 68,827,832 770,647 90,878,627 44,777,200
Illinois 6,172,865,261 1,690,971,723 355,291,866 1,268,060,053 661,728,014
Indiana 2,564,005,047 411,039,286 19,825,621 699,667,232 314,681,105
Iowa 1,288,770,390 144,960,334 18,447,053 318,547,045 179,085,736
Kansas 916,323,608 115,383,465 5,935,917 189,319,221 73,011,007
Kentucky 2,425,288,141 277,720,828 42,689,470 491,196,404 79,305,645
Louisiana 2,383,508,985 527,916,078 15,963,066 490,677,315 322,468,549
Maine 747,027,618 47,116,426 19,950,621 169,130,251 27,011,643
Maryland 2,489,280,148 324,719,290 56,546,963 546,941,004 55,095,149
Massachusetts 4,609,360,933 546,768,099 30,800,067 1,276,236,770 250,951,685
Michigan 4,345,007,824 792,887,794 39,700,896 898,994,947 92,056,064
Minnesota 2,924,447,719 252,541,378 16,286,663 843,536,749 234,768,692
Mississippi 1,442,373,276 324,944,298 15,483,002 313,037,056 125,503,877
Missouri 2,569,646,129 313,541,971 248,998 677,899,462 101,104,939
Montana 361,238,668 48,271,464 308,414 95,255,260 16,269,810
Nebraska 753,162,904 97,977,946 5,651,820 234,516,077 42,963,860
Nevada 462,087,777 106,004,413 11,508,517 72,595,501 28,894,383
New Hampshire 606,004,232 34,844,009 1,904,281 195,434,499 1,519,278
New Jersey 4,218,822,993 402,674,879 72,438,654 1,154,707,872 347,217,754
New Mexico 862,144,872 90,148,335 2,077,546 138,825,024 16,317,149
New York 24,298,610,635 3,972,442,080 1,525,566,813 5,032,111,363 2,196,796,587
North Carolina 4,013,996,742 692,184,068 26,557,229 760,826,548 361,838,061
North Dakota 341,015,420 30,884,006 3,918,724 111,162,630 44,567,046
Ohio 6,120,967,557 870,502,764 4,452,888 1,911,111,609 537,681,556
Oklahoma 1,177,853,941 - - - -
Oregon 1,377,514,740 12,124,512 35,339,858 188,522,343 77,395,292
Pennsylvania 6,080,191,710 539,676,985 85,078,979 1,961,739,776 442,232,151
Puerto Rico 250,000,000 - - - -
Rhode Island 919,353,410 178,178,042 12,260,928 234,578,181 4,930,618
South Carolina 2,018,620,428 522,891,024 47,960,982 302,667,749 167,959,347
South Dakota 355,833,902 67,004,925 2,818,786 101,120,652 19,582,925
Tennessee 3,167,188,993 76,296 - 1,066,992,955 -
Texas 7,139,928,843 1,643,167,234 - 1,384,415,773 728,574,336
Utah 618,675,433 90,973,076 218 90,411,547 43,954,818
Vermont 351,341,290 19,306,558 1,219,044 74,038,926 1,031,673
Virgin Islands 10,097,973 3,739,587 - 1,194,261 -
Virginia 2,118,202,866 334,376,705 101,470,932 394,719,042 143,102,604
Washington 2,044,234,831 265,579,863 101,471 496,372,294 8,999,877
West Virginia 1,243,150,526 194,479,017 24,905,723 256,580,323 47,738,110
Wisconsin 2,206,398,750 210,485,418 37,293,417 748,856,930 198,693,920
Wyoming 192,004,819 29,216,635 68,556 45,867,354 10,480,451

Table 10. Medicaid Medical Vendor Payments by Type of Service and by State: FY 1998 (Con’t)
Physician Outpatient EPSDT Prescribed Dental

State Name Services Hospital Screening Drugs Services
National Total $6,070,022,680 $5,758,982,745 $1,334,828,107 $13,521,707,689 $901,385,043
Alabama 115,683,384 55,232,113 14,722,820 236,674,147 9,698,164
Alaska 36,742,125 22,710,772 125,107 32,887,828 8,420,013
Arizona 24,742,477 8,377,604 4,361,822 1,442,917 2,518,958
Arkansas 120,802,774 37,099,507 55,748,372 150,891,615 7,789,946
California 744,150,459 332,585,224 46,051,880 1,553,598,462 17,764,417
Colorado 55,434,596 48,863,284 3,011,047 110,159,725 9,477,271
Connecticut 43,027,135 63,273,506 400,479 186,593,992 7,461,733
Delaware 5,689,663 3,309,098 99,029 41,350,537 1,752,407
District of Columbia 15,832,207 40,597,949 238,707 41,254,973 1,367,185
Florida 201,410,207 322,884,138 28,486,368 933,782,041 79,571,073
Georgia 367,096,683 266,142,731 25,513,441 370,562,935 32,076,080
Hawaii 32,883,850 12,656,332 38,941 39,623,380 342,042
Idaho 30,240,179 16,952,114 4,114,029 54,971,097 9,262,516
Illinois 242,774,121 202,113,879 64,468,090 583,239,675 215,457
Indiana 116,841,929 83,721,391 7,082,193 325,712,348 25,616,874
Iowa 67,672,741 59,171,793 5,485,072 147,115,884 17,727,507
Kansas 37,813,417 12,667,886 8,874,886 118,825,316 8,611,769
Kentucky 164,972,078 211,965,422 61,282,505 319,983,951 23,876,778
Louisiana 196,895,190 146,755,783 43,497,715 352,784,785 18,204,824
Maine 21,137,156 17,436,520 3,421,839 121,771,298 4,500,980
Maryland 46,541,325 53,105,201 73,840,753 148,532,940 354,031
Massachusetts 197,750,106 231,764,549 2,388,137 497,146,531 53,661,108
Michigan 130,599,586 149,872,689 13,622,196 374,145,567 33,412,598
Minnesota 84,806,776 50,953,215 2,935,735 173,602,492 13,553,739
Mississippi 177,155,371 68,541,350 21,663,630 231,735,360 2,746,014
Missouri 51,276,977 154,379,218 40,121,136 382,512,566 9,726,354
Montana 27,356,355 16,184,168 1,610,004 42,368,399 5,062,200
Nebraska 49,001,395 31,187,108 3,281,729 92,558,539 9,742,058
Nevada 39,449,916 25,062,559 3,914,920 34,518,901 12,458,638
New Hampshire 18,962,156 26,598,507 983,291 55,374,478 4,589,120
New Jersey 72,855,718 282,697,673 735,125 426,075,488 13,016,134
New Mexico 35,207,392 34,276,483 1,921,546 41,507,229 3,947,881
New York 327,039,971 1,145,218,581 109,536,163 1,368,451,273 182,756,864
North Carolina 335,106,875 209,392,736 30,846,296 466,528,812 42,821,503
North Dakota 14,780,039 20,795,249 211,991 27,619,684 4,451,231
Ohio 271,665,208 244,422,218 13,012,653 645,118,962 33,705,390
Oklahoma - - - - -
Oregon 15,646,781 17,909,248 - 87,805,350 424,893
Pennsylvania 115,538,851 112,286,027 182,678,258 525,261,211 20,591,630
Rhode Island 7,051,133 19,380,312 211,727 61,401,958 9,372,139
South Carolina 150,905,913 52,518,262 7,942,631 224,962,203 18,640,048
South Dakota 20,495,792 27,514,589 5,817,668 31,106,511 17,126
Tennessee 112,908,373 - - 36 -
Texas 661,475,584 446,493,015 416,748,794 817,591,112 2,165,089
Utah 20,149,326 19,162,944 307,155 68,827,853 10,531,291
Vermont 9,490,861 11,029,031 1,819,403 43,445,887 7,965,583
Virgin Islands 195,307 303,353 28,550 2,796,833 88,095
Virginia 187,632,422 120,861,960 8,139,341 284,578,558 10,991,454
Washington 91,489,892 89,625,083 2,388,569 244,478,658 75,222,685
West Virginia 111,149,189 61,622,445 7,642,253 148,962,081 18,553,850
Wisconsin 26,755,558 65,575,950 2,482,161 232,326,359 12,373,895
Wyoming 17,740,161 5,731,976 971,950 17,138,952 2,186,408

Other Clinic Lab & Family Home

State Name Practitioner Services X-Ray Planning Health
National Total $587,137,593 $3,921,167,731 $938,700,266 $449,136,397 $2,701,512,000
Alabama 4,502,485 62,372,094 9,563,557 6,639,031 22,844,852
Alaska 1,122,830 41,247,912 5,947,523 1,022,171 1,098,932
Arizona 154,063 17,310,281 1,379,779 884,686 1,015,977
Arkansas 7,022,549 128,802,658 11,348,972 8,389,414 13,985,570
California 84,350,296 427,958,908 259,080,646 32,791,127 82,965,929
Colorado 4,054,732 34,940,819 6,240,321 2,893,789 168,003,075
Connecticut 27,819,279 19,702,620 4,409,946 976,553 101,980,227
Delaware 8,839,087 20,037,258 294,317 656,579 7,437,812
District of Columbia 8,567,475 12,113,259 2,128,643 821,195 15,216,416
Florida 37,239,783 103,185,250 36,231,750 81,663 75,237,726
Georgia 18,735,368 114,306,637 12,445,037 27,091,933 42,656,324
Hawaii 1,164,072 766,029 2,826,800 25,718 1,767,751
Idaho 2,193,545 4,467,987 3,391,858 836,858 3,013,366
Illinois 24,532,236 68,143,140 46,360,141 17,568,951 27,167,763
Indiana 44,540,516 21,354,616 19,574,422 2,486,445 47,073,916
Iowa 6,178,733 9,897,420 1,441,968 5,191,063 39,364,761
Kansas 2,871,248 35,264,649 3,843,169 3,733,061 13,271,790
Kentucky 8,865,468 98,656,658 26,978,851 8,543,697 96,406,052
Louisiana 4,492,336 33,718,060 42,386,889 11,599,544 41,600,791
Maine 3,660,348 7,483,979 4,583,536 1,509,167 13,702,291
Maryland 1,016,724 6,643,345 3,137,857 4,613,117 48,456,286
Massachusetts 7,732,818 110,221,454 9,377,844 20,222,721 178,727,342
Michigan 5,349,653 331,384,716 24,631,759 9,163,934 30,029,536
Minnesota 22,306,688 12,456,913 15,517,890 3,713,564 51,998,745
Mississippi 522,487 72,866,687 5,643,549 - 11,727,240
Missouri 4,862,991 68,809,727 6,568,226 5,124,562 46,793,370
Montana 2,795,476 1,469,660 5,460,753 1,162,644 -
Nebraska 8,861,275 3,127,968 5,773,091 3,250,360 15,357,587
Nevada 2,506,707 2,307,097 1,231,397 1,096,613 4,806,532
New Hampshire 3,277,888 88,397,728 873,180 2,043,842 4,044,940
New Jersey 7,891,739 117,799,809 18,202,916 5,446,420 84,239,565
New Mexico 3,792,233 20,484,797 1,204,963 999,819 3,621,004
New York 28,371,373 1,220,723,903 49,239,115 68,785,044 805,659,216
North Carolina 10,405,963 47,713,966 69,535,830 22,561,251 98,708,726
North Dakota 1,033,246 15,462,744 2,552,182 954,964 1,671,089
Ohio 22,152,879 44,383,797 9,581,841 13,237,826 97,338,109
Oklahoma - - - - -
Oregon 13,049,696 7,404,707 2,644,788 1,154,298 5,451,650
Pennsylvania 16,378,048 68,910,361 20,529,415 14,783,309 36,365,790
Rhode Island 1,188,997 3,386,680 1,800,816 479,444 147,013,312
South Carolina 6,023,393 138,424,592 12,185,658 34,421,428 15,473,934
South Dakota 1,749,501 6,329,164 2,100,717 783,923 813,135
Tennessee 18 1,196 - - 4,524
Texas 70,751,154 52,613,251 94,105,855 40,544,183 98,543,994
Utah 1,571,558 31,508,963 2,011,687 700,045 2,586,721
Vermont 4,557,773 5,429,887 1,523,301 1,729,559 3,726,368
Virgin Islands - 1,191,919 47,288 120,767 -
Virginia 7,747,728 44,638,403 12,882,270 2,750,996 8,156,865
Washington 5,664,924 34,712,064 34,356,590 49,005,157 6,274,767
West Virginia 10,060,720 46,008,114 5,844,856 2,458,392 17,894,521
Wisconsin 13,966,929 51,528,358 17,001,830 3,357,816 56,048,763
Wyoming 640,565 3,095,527 2,674,677 727,754 4,167,048

Personal Care Home/Community Other Prepaid PCCM

State Name Support Services Based Services Care Healthcare Services
National Total $8,221,956,899 $6,708,703,006 $4,386,176,341 $19,296,223,487 $134,367,179
Alabama 71,655,382 83,614,761 8,421,214 288,972,436 3,830,786
Alaska 12,168,162 31,646,356 19,671,298 - -
Arizona 1,565,498 206,027 56,205,118 1,431,418,497 -
Arkansas 84,465,101 43,604,265 53,900,984 4,359,975 5,488,182
California 1,461,040,635 477,040,219 577,661,831 2,867,713,795 6,976,144
Colorado 13,191,011 91,982,851 88,225,223 238,585,930 1,801,695
Connecticut 13,155,907 284,893,048 38,118,905 377,212,893 -
Delaware 23,982,676 30,242,559 12,234,800 122,048,974 -
District of Columbia 9,016,714 - 56,988,647 98,238,002 1,020,351
Florida 391,136,226 - 108,796,297 701,322,837 18,032,691
Georgia 101,836,605 146,234,294 27,214,508 57,871,451 23,190,993
Hawaii - - 10,384,058 213,612,580 -
Idaho 41,189,565 10,096,183 35,553,198 - 1,440,856
Illinois 37,604,578 418,523,830 222,113,084 241,278,075 710,585
Indiana 119,419,033 54,880,354 77,567,573 167,977,207 4,942,986
Iowa 16,554,369 74,697,885 69,039,766 107,189,198 1,002,062
Kansas 7,034,122 196,664,037 51,817,279 17,201,600 24,173,083
Kentucky 23,492,967 84,874,155 82,951,173 311,526,039 -
Louisiana 30,413,215 62,765,878 41,368,966 - -
Maine 27,570,385 85,600,648 167,202,572 4,237,958 -
Maryland 79,099,039 154,029,172 28,357,568 851,988,946 -
Massachusetts 28,926,115 363,334,110 316,130,351 477,932,296 9,288,830
Michigan 238,876,125 270,956,190 77,138,062 823,728,725 9,402,768
Minnesota 206,010,480 390,376,183 65,853,806 483,228,011 -
Mississippi 15,345,300 - 30,018,167 22,152,325 -
Missouri 360,789,849 679,049 67,554,180 277,652,554 -
Montana 32,546,074 - 10,049,415 53,600,495 1,468,077
Nebraska 4,836,944 50,040,956 21,637,799 72,980,602 415,790
Nevada 55,204,326 12,290,773 10,688,468 32,332,069 4,463,574
New Hampshire 18,486,793 111,506,824 25,034,883 12,128,535 -
New Jersey 243,903,851 249,988,289 101,339,785 617,591,322 -
New Mexico 5,320,387 (38) 88,194,680 372,647,285 760,878
New York 2,690,464,403 1,439,637,872 497,301,640 1,638,382,814 125,558
North Carolina 452,804,716 275,215,305 12,764,633 85,665,363 12,518,863
North Dakota 7,820,124 43,749,691 7,421,835 1,319,356 477,330
Ohio 64,907,670 262,590,804 580,256,144 494,845,239 -
Oklahoma - - - - -
Oregon 88,633,858 144,321,876 13,466,470 665,872,224 237,107
Pennsylvania 43,550,833 20,558,811 72,947,073 1,801,084,202 -
Rhode Island 57,280,255 10,108,166 55,859,821 114,870,881 -
South Carolina 73,310,778 123,052,297 102,108,042 17,172,147 -
South Dakota 14,637,149 43,004,042 6,250,599 3,797,234 889,464
Tennessee 128,077,009 - 141 1,859,127,110 -
Texas 425,887,768 203,678,629 53,173,072 - -
Utah 11,019,128 62,895,077 11,930,762 147,730,653 -
Vermont 5,761,603 58,670,584 46,416,750 53,890,106 -
Virgin Islands - - 392,013 - -
Virginia 117,734,230 95,785,869 54,680,560 186,255,441 1,697,486
Washington 7,262,046 - 103,678,034 529,020,076 -
West Virginia 125,929,361 100,995,995 35,751,670 26,573,906 -
Wisconsin 124,375,147 - 83,379,136 321,886,123 11,040
Wyoming 6,663,387 43,669,130 964,288 - -

Table 11. Medicaid Medical Vendor Payments for Recipients Who Receive Cash Payments
by State: FY 1998

State Name Payments And Older Disabled Children Adults Unknown
National Total $63,034,798,342 $9,175,983,172 $39,127,774,287 $8,426,821,440 $6,303,780,773 $438,668
Alabama 602,742,522 104,513,657 460,513,836 23,431,818 14,283,211 -
Alaska 213,828,341 28,824,334 104,037,418 40,331,657 40,634,932 -
Arizona 712,364,833 60,299,301 427,209,144 129,156,438 95,699,947 -
Arkansas 713,252,376 78,232,338 561,683,616 51,077,268 22,259,154 -
California 8,647,488,244 1,183,408,519 4,898,110,390 1,566,802,910 999,166,425 -
Colorado 304,817,936 95,573,584 117,920,331 49,219,528 42,104,493 -
Connecticut 563,107,925 61,520,290 303,954,741 118,266,090 79,366,804 -
Delaware 183,870,881 15,106,185 135,771,374 20,307,696 12,685,626 -
District of Columbia 361,750,299 30,859,174 240,493,617 55,783,946 34,613,562 -
Florida 2,950,414,878 380,519,516 1,889,065,482 395,519,106 285,310,774 -
Georgia 1,377,872,299 124,735,711 976,265,813 142,562,950 134,307,825 -
Hawaii 349,140,826 109,396,032 120,996,571 79,337,837 39,410,386 -
Idaho 77,400,112 7,069,411 62,698,923 3,049,437 4,582,341 -
Illinois 2,639,261,770 147,427,072 1,774,490,199 379,801,069 337,543,430 -
Indiana 954,525,663 161,282,234 627,460,798 80,491,333 85,291,298 -
Iowa 522,779,438 102,697,086 298,890,407 61,776,293 59,415,652 -
Kansas 374,101,538 33,019,252 285,871,129 28,883,787 26,327,370 -
Kentucky 1,376,672,479 110,247,544 1,002,698,813 151,768,704 111,957,418 -
Louisiana 1,227,251,177 215,325,121 810,905,188 112,404,628 88,616,240 -
Maine 289,878,332 17,692,847 212,676,163 33,849,947 25,659,375 -
Maryland 1,233,921,421 113,592,984 847,041,712 164,445,071 108,841,654 -
Massachusetts 2,143,677,179 283,296,710 1,441,171,460 252,210,899 166,998,110 -
Michigan 2,009,893,152 88,206,689 1,383,209,822 240,629,880 297,846,761 -
Minnesota 1,209,395,516 148,585,822 786,938,538 167,173,525 106,291,166 406,465
Mississippi 714,491,940 87,312,336 532,502,217 53,103,913 41,573,474 -
Missouri 340,186,310 32,253,899 93,216,860 126,878,239 87,837,312 -
Montana 141,690,577 8,823,262 89,382,721 26,473,390 17,011,204 -
Nebraska 430,209,028 87,384,446 250,552,885 37,251,060 55,020,637 -
Nevada 222,245,177 22,880,467 143,320,397 29,687,911 26,356,402 -
New Hampshire 170,615,173 14,723,622 119,048,938 22,536,517 14,306,096 -
New Jersey 1,963,153,334 240,196,251 1,319,415,872 198,115,568 205,425,643 -
New Mexico 437,218,245 26,126,120 275,434,457 78,809,778 56,847,890 -
New York 12,312,300,018 2,402,931,691 7,879,465,179 1,224,804,368 805,098,781 -
North Carolina 2,080,692,247 470,658,696 1,124,566,917 256,353,163 229,113,471 -
North Dakota 121,167,482 21,885,774 79,622,252 10,919,712 8,739,744 -
Ohio 824,053,633 6,171,893 91,779,316 409,565,263 316,537,161 -
Oregon 392,064,018 24,160,952 115,461,551 148,441,395 104,000,120 -
Pennsylvania 2,471,881,538 335,201,626 1,387,383,538 501,658,445 247,637,929 -
Rhode Island 430,262,938 35,312,486 297,800,358 55,240,146 41,909,948 -
South Carolina 751,927,407 142,977,503 511,725,270 54,700,129 42,524,505 -
South Dakota 156,736,607 8,344,318 120,166,195 16,370,593 11,855,501 -
Tennessee 988,402,868 72,855,779 747,284,126 97,873,612 70,357,148 32,203
Texas 3,164,249,057 707,491,516 1,850,133,604 317,008,004 289,615,933 -
Utah 150,439,909 14,138,243 89,019,591 23,313,210 23,968,865 -
Vermont 143,568,188 11,988,914 96,369,883 22,275,596 12,933,795 -
Virgin Islands 3,007,722 584,050 843,603 808,469 771,600 -
Virginia 1,013,741,200 187,012,654 657,646,370 83,879,652 85,202,524 -
Washington 845,368,582 85,138,908 447,814,652 127,587,258 184,827,764 -
West Virginia 830,135,721 347,814,749 364,958,698 61,493,372 55,868,902 -
Wisconsin 859,392,921 76,092,968 646,903,131 89,542,075 46,854,747 -
Wyoming 36,187,365 4,088,636 25,880,221 3,848,785 2,369,723 -

Table 12. Medicaid Medical Vendor Payments for Medically Needy Recipients by Basis of Eligibility

National Total $25,138,863,775 $12,361,168,832 $8,641,051,903 $2,331,098,475 $1,804,846,335 $698,230
Alabama - - - - - -
Alaska - - - - - -
Arizona - - - - - -
Arkansas 79,146,711 889,336 28,079,512 31,136,043 19,041,820 -
California 3,879,870,004 1,595,406,804 1,167,100,970 696,180,314 421,181,916 -
Connecticut 331,270,561 147,497,845 168,260,256 5,899,211 9,613,249 -
Florida 126,182,907 142,479 63,383,911 23,775,531 38,880,986 -
Georgia 3,794,773 274,620 3,294,913 218,759 6,481 -
Hawaii 58,350,850 47,795,992 7,346,400 1,936,738 1,271,720 -
Idaho - - - - - -
Illinois 2,449,228,109 922,432,463 1,224,045,905 134,088,989 168,660,752 -
Indiana - - - - - -
Iowa 43,959,500 12,328,729 20,664,061 2,622,330 8,344,380 -
Kansas 385,066,257 217,683,097 151,238,434 15,885,521 259,205 -
Kentucky 174,912,771 63,709,718 29,040,575 49,473,823 32,688,655 -
Louisiana 35,159,084 7,320,083 14,507,817 2,160,074 11,171,110 -
Maine 11,059,685 5,627,121 3,939,097 884,762 608,705 -
Maryland 798,379,206 478,833,202 258,830,120 46,878,973 13,836,911 -
Massachusetts 856,606,399 516,067,558 51,767,956 141,434,516 147,336,369 -
Michigan 1,613,885,806 846,891,239 548,453,540 83,731,109 134,809,918 -
Minnesota 138,072,538 47,477,188 86,927,932 2,099,126 1,382,476 185,816
Mississippi 29,257 9,007 20,250 - - -
Montana 104,383,328 79,096,557 25,259,060 4,406 23,305 -
Nebraska 2,974,236 454,382 1,992,544 39,387 487,923 -
Nevada - - - - - -
New Hampshire 121,049,747 82,549,114 32,542,469 2,603,896 3,352,838 1,430
New Jersey 57,860,478 48,038,072 8,474,784 1,341,987 5,635 -
New York 10,634,644,651 5,468,354,171 3,765,855,649 903,888,146 496,546,685 -
North Carolina 1,266,350,628 690,787,251 518,926,928 13,025,286 43,611,163 -
North Dakota 179,804,840 109,085,655 60,517,580 5,344,257 4,857,348 -
Ohio - - - - - -
Oregon 19,562,289 6,359,110 13,203,179 - - -
Pennsylvania 696,874,020 514,843,643 77,812,475 60,870,018 43,347,884 -
Rhode Island 140,267,792 107,253,067 30,407,052 47,936 2,559,737 -
Tennessee 162,210,873 37,060,800 17,988,219 31,768,343 74,882,527 510,984
Texas 125,836,860 - - 32,745,054 93,091,806 -
Utah 17,227,134 4,231,409 6,269,066 1,394,817 5,331,842 -
Vermont 21,108,255 2,542,982 9,408,181 4,929,981 4,227,111 -
Virgin Islands 6,056,113 1,906,171 923,492 1,995,822 1,230,628 -
Virginia 163,396,812 94,787,897 64,724,212 3,177,468 707,235 -
Washington 80,835,552 43,965,735 36,604,049 209,664 56,104 -
West Virginia 24,132,569 1,741,056 17,996,886 236,658 4,157,969 -
Wisconsin 95,661,451 45,035,036 30,757,688 14,110,667 5,758,060 -
Wyoming - - - - - -

Table 13. Medicaid Medical Vendor Payments for Poverty Related Medicaid Recipients by Basis of
Eligibility and by State: FY 1998

National Total $19,758,455,422 $4,565,969,420 $4,431,978,829 $6,296,469,645 $4,463,769,119 $268,406
Alabama 176,216,348 12,379,712 4,578,243 148,833,492 10,424,901 -
Alaska 43,610,989 2,984 3,141 26,956,105 16,648,759 -
Arizona 238,491,706 1,383,449 739,781 133,971,943 102,396,531 -
Arkansas 223,104,306 8,836,616 8,389,023 158,065,059 47,813,608 -
California 295,066,192 3,278,901 4,788,110 175,714,435 111,284,746 -
Colorado 129,898,201 855,228 1,384,318 71,584,652 56,074,003 -
Connecticut 90,114,928 587,386 287,908 80,331,280 8,908,354 -
Delaware 79,747,325 1,898,151 1,167,617 41,444,435 35,237,122 -
Florida 1,348,334,446 538,400,521 416,393,147 207,172,320 186,368,458 -
Georgia 689,569,489 24,402,577 17,226,614 373,943,804 273,996,494 -
Hawaii 81,498,940 64,510 - 34,025,915 47,408,515 -
Idaho 236,140,479 117,415,445 99,271,406 9,242,077 10,211,551 -
Illinois 415,474,024 18,585,853 100,582,572 189,301,093 107,004,506 -
Indiana 220,277,390 5,904,962 5,607,387 166,541,286 42,223,755 -
Iowa 80,855,385 5,750,901 4,912,988 44,468,194 25,723,302 -
Kansas 90,102,609 1,349,170 1,221,289 62,739,078 24,793,072 -
Kentucky 275,954,959 12,243,055 7,742,277 173,170,114 82,799,390 123
Louisiana 227,270,626 15,429,415 7,872,775 104,679,240 99,289,195 -
Maine 101,617,050 36,484,851 30,699,381 28,345,737 6,087,081 -
Maryland 231,634,487 11,300,440 9,036,644 133,240,135 78,057,268 -
Massachusetts 1,482,929,991 675,797,448 646,071,584 142,670,344 18,390,615 -
Michigan 272,152,987 4,231,452 12,000,170 176,674,586 79,246,779 -
Minnesota 64,387,956 3,841,613 2,541,512 50,624,013 7,115,062 265,756
Mississippi 306,914,267 41,728,923 46,127,432 162,687,404 56,370,508 -
Missouri 274,104,538 7,880,747 15,766,902 201,943,031 48,513,858 -
Montana 20,793,093 149,405 25,393 9,564,948 11,053,347 -
Nebraska 82,582,317 8,625,874 4,815,086 69,141,357 - -
Nevada 4,622,406 1,307,106 1,774,635 985,534 555,131 -
New Hampshire 52,614,350 248,498 111,491 45,002,089 7,249,745 2,527
New Jersey 458,183,790 122,437,688 127,461,536 134,127,028 74,157,538 -
New Mexico 241,810,168 409,905 2,933,380 190,611,655 47,855,228 -
New York 984,445,331 - - 195,317,258 789,128,073 -
North Carolina 558,638,298 - - 443,414,536 115,223,762 -
North Dakota 14,402,609 23,652 27,346 10,139,180 4,212,431 -
Ohio 5,180,692,237 2,239,035,797 2,453,077,208 270,502,570 218,076,662 -
Oregon 613,603,111 5,869,388 17,772,507 167,589,287 422,371,929 -
Pennsylvania 821,478,988 483,338,647 1,809,929 266,014,217 70,316,195 -
Rhode Island 27,623,971 7,630 12,152 17,331,267 10,272,922 -
South Carolina 448,329,281 70,953,823 103,443,171 192,671,226 81,261,061 -
South Dakota 31,265,704 477,516 316,454 19,967,569 10,504,165 -
Tennessee 693,524,367 1,924 97,708,390 198,841,784 396,972,269 -
Texas 1,024,387,837 28,285,148 20,500,823 627,565,322 348,036,544 -
Utah 67,272,642 6,507,397 26,072,325 6,849,931 27,842,989 -
Vermont 70,329,475 11,458,758 12,725,211 19,728,749 26,416,757 -
Virginia 276,531,633 17,338,208 12,330,125 156,019,733 90,843,567 -
Washington 155,230,925 1,780,234 2,067,486 96,667,404 54,715,801 -
West Virginia 121,766,318 8,086,718 90,559,071 436,882 22,683,647 -
Wisconsin 84,267,682 1,899,043 - 45,577,401 36,791,238 -
Wyoming 21,090,417 435,612 750,824 7,430,530 12,473,451 -

Table 14. Medicaid Medical Vendor Payment for Recipients of Other Coverage Groups by Basis of Eligibility
Total Age 65 Blind/

State Name Payments And Older Disabled Children
National Total $30,686,156,426 $14,498,995,409 $8,174,318,206 $3,404,751,399
Alabama 607,749,253 433,471,888 132,718,687 14,517,232
Alaska 71,856,764 28,293,986 11,095,814 18,677,708
Arizona 693,109,765 262,536,800 181,723,990 142,329,554
Arkansas 596,207,736 342,059,991 193,030,621 22,044,346
California 1,262,422,388 95,694,865 73,134,421 226,562,828
Colorado 960,589,934 341,275,440 462,611,249 28,764,143
Connecticut 1,436,298,060 838,539,167 417,829,975 84,621,730
Delaware 152,583,054 78,282,890 59,575,581 6,077,624
District of Columbia 21,665,816 2,955 - 1,050,170
Florida 1,236,568,867 636,131,051 290,408,477 219,791,672
Georgia 889,614,162 343,954,136 405,953,849 66,014,876
Hawaii 7,972,123 - - 1,790,257
Idaho 70,620,282 - 5,725,418 39,386,267
Illinois 668,901,358 16,332,286 163,271,980 83,259,143
Indiana 1,370,926,082 696,692,574 450,920,933 152,744,723
Iowa 637,601,466 343,062,385 164,932,213 70,450,786
Kansas 52,944,805 973,464 11,912,948 24,452,249
Kentucky 588,092,271 396,922,761 122,896,724 12,568,168
Louisiana 893,828,098 434,248,105 267,971,731 152,256,862
Maine 332,465,141 179,487,896 81,774,214 33,417,986
Maryland 189,104,492 207,864 68,729,190 42,134,228
Massachusetts 126,147,364 - 35,260,507 25,116,858
Michigan 70,708,537 927,670 861,536 14,587,834
Minnesota 1,494,649,325 793,508,385 346,985,092 235,201,490
Mississippi 417,485,900 286,274,251 86,748,250 10,129,164
Missouri 1,942,734,440 887,150,575 907,097,595 81,552,257
Montana 88,089,349 26,908,376 24,184,886 20,583,273
Nebraska 237,397,323 168,015,811 20,750,440 1,207,601
Nevada 211,394,224 67,463,660 29,034,907 48,328,090
New Hampshire 260,382,807 129,265,639 69,507,940 28,523,456
New Jersey 1,725,703,499 914,673,575 522,521,410 100,186,543
New Mexico 177,322,949 119,292,444 31,743,724 111,816
New York 367,220,635 - - -
North Carolina 108,315,569 31,845,642 19,571,705 3,392,423
North Dakota 22,843,885 366,918 - 7,273,174
Ohio 116,221,687 - - 24,972,591
Oklahoma - - - -
Oregon 335,137,219 76,591,433 121,427,044 50,477,129
Pennsylvania 2,087,655,250 1,176,619,603 521,006,672 196,236,131
Puerto Rico - - - -
Rhode Island 308,397,218 155,529,211 126,334,393 8,757,728
South Carolina 558,650,582 264,019,570 147,144,457 57,931,221
South Dakota 167,831,591 98,622,801 40,236,645 20,719,078
Tennessee 923,383,603 565,018,920 127,900,155 82,100,398
Texas 2,825,455,089 1,606,113,188 614,336,542 420,059,260
Utah 311,792,358 65,245,645 105,480,154 88,893,868
Vermont 115,229,024 71,210,786 17,250,565 7,976,060
Virgin Islands 664,533,221 339,362,377 198,632,778 93,245,058
Virginia 1,034,138 - - 320,729
Washington 830,670,996 441,687,590 136,411,805 116,391,755
West Virginia 144,277,023 1,625,940 - 91,415,201
Wisconsin 1,170,245,392 693,959,632 300,695,964 106,972,469
Wyoming 134,124,312 49,525,263 56,975,025 19,176,192

Table 14. Medicaid Medical Vendor Payment for Recipients of Other Coverage Groups by Basis of Eligibility
Foster Other/
National Total $2,260,701,158 $2,346,800,698 $589,554
Alabama 8,976,726 17,825,019 239,701
Alaska 4,135,573 9,653,683 -
Arizona 98,668,652 7,850,767 -
Arkansas 10,209,958 28,862,820 -
California 617,495,532 249,516,816 17,926
Colorado 26,722,462 101,216,640 -
Connecticut 78,090,916 17,216,272 -
Delaware 7,033,646 1,613,313 -
District of Columbia 4,808,252 15,804,439 -
Florida 38,781,531 51,456,136 -
Georgia 49,733,773 23,957,528 -
Hawaii 787,184 5,394,682 -
Idaho 23,016,016 2,492,581 -
Illinois 73,080,717 332,957,232 -
Indiana 47,832,963 22,734,889 -
Iowa 40,573,878 18,582,204 -
Kansas 8,208,810 7,397,334 -
Kentucky 12,471,147 43,231,020 2,451
Louisiana 39,196,967 154,433 -
Maine 11,384,580 26,400,465 -
Maryland 38,031,416 40,001,794 -
Massachusetts 64,788,051 981,948 -
Michigan 2,704,512 51,626,985 -
Minnesota 82,097,254 36,699,762 157,342
Mississippi 21,936,850 12,397,385 -
Missouri 20,325,741 46,608,272 -
Montana 10,396,814 6,016,000 -
Nebraska 11,199,594 36,223,877 -
Nevada 25,503,371 41,064,196 -
New Hampshire 8,958,776 24,126,996 -
New Jersey 90,867,227 97,454,744 -
New Mexico - 26,174,965 -
New York - 367,220,635 -
North Carolina 9,022,502 44,483,297 -
North Dakota 5,090,468 10,113,325 -
Ohio 19,854,482 71,394,614 -
Oklahoma - - -
Oregon 50,024,591 36,617,022 -
Pennsylvania 95,948,926 97,843,918 -
Puerto Rico - - -
Rhode Island 4,406,649 13,369,237 -
South Carolina 38,323,909 51,231,425 -
South Dakota 4,467,980 3,785,087 -
Tennessee 90,497,687 57,825,355 41,088
Texas 140,771,391 44,174,708 -
Utah 22,336,531 29,836,160 -
Vermont 3,199,564 15,461,003 131,046
Virgin Islands 23,904,434 9,388,574 -
Virginia 713,409 - -
Washington 114,273,156 21,906,690 -
West Virginia 18,953,153 32,282,729 -
Wisconsin 33,911,153 34,706,174 -
Wyoming 6,982,284 1,465,548 -

Table 15. Medicaid Eligibles by Full-Year, Partial Year and Months Covered and by State: FY 1998
Total Full-Year Partial Year Partial Year

State Name Eligibles Eligibles Eligibles Months
National Total 41,361,532 22,997,728 17,399,787 104,387,484
Alabama 628,220 352,365 275,855 1,749,290
Alaska 87,873 32,278 55,595 367,248
Arizona 649,302 272,640 376,662 2,218,598
Arkansas 426,080 206,010 220,070 1,385,264
California 6,191,269 3,809,289 2,381,980 13,906,720
Colorado 346,928 166,055 180,873 1,045,628
Connecticut 402,547 270,305 132,242 819,511
Delaware 105,153 54,703 50,450 316,264
Florida 2,040,541 923,737 1,116,804 6,501,745
Georgia 1,223,439 663,324 560,115 3,440,181
Hawaii 182,460 97,128 85,332 443,464
Idaho 116,718 43,432 73,286 446,038
Illinois 1,784,159 1,169,262 614,897 3,714,135
Indiana 610,146 286,792 323,354 1,892,603
Iowa 321,119 201,636 119,483 669,249
Kansas 246,598 113,754 132,844 754,482
Kentucky 653,553 388,599 264,954 1,650,057
Louisiana 723,864 403,647 320,217 1,962,179
Maine 195,839 111,951 83,888 494,830
Maryland 603,562 328,051 275,511 1,654,875
Massachusetts 953,469 750,084 203,385 1,282,741
Michigan 1,354,718 805,792 548,926 3,347,918
Minnesota 557,232 330,691 226,541 1,403,157
Mississippi 526,604 273,040 253,564 1,536,116
Missouri 772,622 453,274 319,348 1,935,404
Montana 93,298 40,760 52,538 304,464
Nebraska 210,261 110,520 99,741 560,457
Nevada 130,662 52,898 77,764 437,856
New Hampshire 98,340 53,810 44,530 270,721
New Jersey 857,898 504,335 353,563 2,155,234
New Mexico 339,527 172,211 167,316 1,008,741
New York 3,500,292 2,168,626 1,331,666 8,149,801
North Carolina 1,201,681 625,528 576,153 3,453,468
North Dakota 62,115 27,989 34,126 202,387
Ohio 1,402,364 740,166 662,198 3,921,544
Oklahoma 459,570 185,342 274,226 1,653,167
Oregon 537,465 215,517 321,948 1,894,454
Pennsylvania 1,720,000 1,104,850 615,150 3,650,919
Rhode Island 148,797 93,981 54,816 348,167
South Carolina 656,263 402,532 253,731 1,698,420
South Dakota 83,111 40,588 42,523 252,649
Tennessee 1,454,799 1,076,031 378,768 2,330,633
Texas 2,680,583 1,202,113 1,478,470 8,842,892
Utah 198,730 73,365 125,365 687,551
Vermont 131,639 80,720 50,919 333,252
Virgin Islands 19,914 14,093 5,821 -
Virginia 689,571 385,302 304,269 1,856,445
Washington 915,214 517,249 397,965 2,464,506
West Virginia 373,090 196,127 176,963 1,057,767
Wisconsin 538,229 292,355 245,874 1,442,518
Wyoming 51,367 18,744 32,623 187,070

Table 16. Medicaid Eligibles by Maintenance Assistance Status and by State: FY 1998

State Name Eligibles Cash Payments Needy Related Other Unknown
National Total 41,361,532 17,663,099 4,239,284 10,568,471 7,458,731 1,431,947
Alabama 628,220 260,614 - 263,587 104,019 -
Alaska 87,873 56,288 - 16,695 14,890 -
Arizona 649,302 263,593 - 206,776 178,933 -
Arkansas 426,080 74,087 108,750 195,128 47,801 314
California 6,191,269 3,202,001 1,361,944 369,005 1,258,319 -
Colorado 346,928 102,264 - 88,123 156,541 -
Connecticut 402,547 157,719 45,477 59,334 140,017 -
Delaware 105,153 34,034 - 53,788 17,331 -
Florida 2,040,541 1,181,859 56,251 569,091 233,339 1
Georgia 1,223,439 423,014 813 560,476 239,131 5
Hawaii 182,460 112,219 5,234 58,966 4,177 1,864
Idaho 116,718 12,725 - 37,162 66,831 -
Illinois 1,784,159 783,543 386,883 307,813 305,920 -
Indiana 610,146 238,360 - 205,636 166,150 -
Iowa 321,119 61,219 10,050 68,437 181,254 159
Kansas 246,598 84,965 36,572 87,505 37,556 -
Kentucky 653,553 333,376 53,842 197,815 68,520 -
Louisiana 723,864 389,032 8,030 186,270 137,265 3,267
Maine 195,839 74,747 2,019 50,959 68,114 -
Maryland 603,562 267,549 57,874 187,404 90,735 -
Massachusetts 953,469 451,577 244,709 199,301 57,882 -
Michigan 1,354,718 597,873 193,142 301,489 261,563 651
Minnesota 557,232 251,261 13,859 78,289 213,704 119
Mississippi 526,604 239,078 - 245,413 42,110 3
Missouri 772,622 190,147 - 296,853 285,622 -
Montana 93,298 43,590 7,275 16,618 25,749 66
Nebraska 210,261 93,822 27,657 74,285 14,497 -
Nevada 130,662 59,177 - 7,822 63,650 13
New Hampshire 98,340 28,041 9,811 36,535 23,945 8
New Jersey 857,898 410,748 6,302 196,530 244,318 -
New Mexico 339,527 141,399 - 163,968 34,160 -
New York 3,500,292 1,902,380 998,432 512,355 87,125 -
North Carolina 1,201,681 603,766 121,444 395,637 80,834 -
North Dakota 62,115 22,121 16,672 11,382 11,940 -
Ohio 1,402,364 535,575 - 807,506 59,283 -
Oklahoma 459,570 - - - - 459,570
Oregon 537,465 132,633 6,941 253,977 143,805 109
Pennsylvania 1,720,000 707,783 150,126 476,668 385,423 -
Puerto Rico 964,015 - - - - 964,015
Rhode Island 148,797 92,523 8,757 24,195 23,322 -
South Carolina 656,263 191,752 - 235,549 228,942 20
South Dakota 83,111 35,345 - 28,078 19,688 -
Tennessee 1,454,799 446,713 135,724 663,204 209,148 10
Texas 2,680,583 1,049,611 47,805 1,067,067 516,100 -
Utah 198,730 54,394 6,376 28,677 109,189 94
Vermont 131,639 34,988 10,057 64,994 21,598 2
Virgin Islands 19,914 6,345 12,092 - 1,477 -
Virginia 689,571 299,904 16,597 269,519 103,551 -
Washington 915,214 382,328 11,863 221,528 299,492 3
West Virginia 373,090 200,222 4,372 29,004 139,492 -
Wisconsin 538,229 236,456 33,736 64,972 203,062 3
Wyoming 51,367 9,447 - 17,018 24,899 3

Table 17. Medicaid Eligibles by Basis of Eligibility and by State: FY 1998
Total Age 65 Blind/

State Name Eligibles And Older Disabled Children
National Total 41,361,532 4,078,149 6,960,124 19,434,290
Alabama 628,220 76,756 165,972 326,400
Alaska 87,873 5,722 9,586 47,257
Arizona 649,302 32,752 89,642 359,687
Arkansas 426,080 50,770 102,277 185,051
California 6,191,269 557,436 892,277 3,093,098
Colorado 346,928 42,052 64,153 158,182
Connecticut 402,547 55,244 54,602 198,388
Delaware 105,153 7,565 14,958 51,057
Florida 2,040,541 202,885 412,175 1,002,737
Georgia 1,223,439 92,211 226,999 680,791
Hawaii 182,460 19,079 18,420 75,329
Idaho 116,718 12,848 18,468 65,776
Illinois 1,784,159 122,317 289,618 821,594
Indiana 610,146 70,806 93,879 337,737
Iowa 321,119 40,233 52,681 142,100
Kansas 246,598 29,238 46,314 124,514
Kentucky 653,553 69,450 187,148 282,190
Louisiana 723,864 93,353 164,758 350,492
Maine 195,839 24,463 40,114 86,689
Maryland 603,562 53,714 113,836 295,549
Massachusetts 953,469 101,133 198,747 463,804
Michigan 1,354,718 97,752 273,214 567,854
Minnesota 557,232 61,018 76,989 308,613
Mississippi 526,604 64,709 142,423 255,614
Missouri 772,622 92,655 119,232 421,830
Montana 93,298 9,204 16,262 44,416
Nebraska 210,261 21,508 27,483 120,392
Nevada 130,662 14,685 21,799 69,281
New Hampshire 98,340 11,690 11,980 56,064
New Jersey 857,898 108,805 165,497 394,443
New Mexico 339,527 21,105 46,502 221,490
New York 3,500,292 373,295 625,643 1,488,919
North Carolina 1,201,681 168,788 210,064 621,126
North Dakota 62,115 10,728 9,219 28,972
Ohio 1,402,364 147,520 231,324 652,630
Oklahoma 459,570 - - -
Oregon 537,465 41,337 112,407 141,508
Pennsylvania 1,720,000 246,811 299,438 799,439
Rhode Island 148,797 17,747 30,002 65,263
South Carolina 656,263 76,772 110,839 310,020
South Dakota 83,111 8,575 14,899 45,742
Tennessee 1,454,799 88,326 306,344 546,545
Texas 2,680,583 338,535 320,882 1,547,176
Utah 198,730 10,145 21,507 115,434
Vermont 131,639 15,610 16,350 57,405
Virgin Islands 19,914 1,526 1,240 11,489
Virginia 689,571 91,088 127,524 360,013
Washington 915,214 64,925 120,040 515,912
West Virginia 373,090 32,612 81,681 182,281
Wisconsin 538,229 66,223 126,166 242,255
Wyoming 51,367 4,408 7,660 28,045

Table 17. Medicaid Eligibles by Basis of Eligibility and by State: FY 1998 (Con’t)
Foster Other/
National Total 8,712,861 743,588 1,432,520
Alabama 54,419 4,673 -
Alaska 23,946 1,362 -
Arizona 160,345 6,876 -
Arkansas 82,815 4,853 314
California 1,511,094 137,334 30
Colorado 67,095 15,446 -
Delaware 30,964 609 -
Florida 400,324 22,419 1
Georgia 209,091 14,342 5
Hawaii 64,575 3,193 1,864
Idaho 17,936 1,690 -
Illinois 417,213 133,417 -
Indiana 101,308 6,416 -
Iowa 80,997 4,949 159
Kansas 41,714 4,818 -
Kentucky 107,045 7,717 3
Louisiana 111,937 57 3,267
Maine 42,014 2,559 -
Maryland 124,162 16,301 -
Michigan 413,701 1,546 651
Minnesota 102,477 7,925 210
Mississippi 60,329 3,526 3
Missouri 122,206 16,699 -
Montana 19,930 3,420 66
Nebraska 30,255 10,623 -
Nevada 21,207 3,677 13
New Hampshire 16,029 2,569 8
New Jersey 170,873 18,280 -
New Mexico 48,867 1,563 -
New York 925,310 87,125 -
North Dakota 11,649 1,547 -
Ohio 335,747 35,143 -
Oregon 229,567 12,537 109
Pennsylvania 347,440 26,872 -
Rhode Island 31,162 4,623 -
South Carolina 151,444 7,168 20
Tennessee 501,663 11,545 376
Texas 455,759 18,231 -
Utah 47,504 4,046 94
Vermont 40,026 2,163 85
Virginia 106,021 4,925 -
Washington 194,023 20,311 3
Wisconsin 87,424 16,158 3
Wyoming 10,636 615 3

Table 18. Medicaid Eligibles Who Receive Cash Payments by Basis of Eligibility and by State: FY 1998

State Name Eligibles And Older Disabled Children Adults Unknown
National Total 17,663,099 1,697,350 5,074,095 7,380,074 3,511,525 55
Alabama 260,614 34,599 146,339 58,099 21,577 -
Alaska 56,288 5,135 9,087 26,406 15,660 -
Arizona 263,593 14,136 71,501 125,158 52,798 -
Arkansas 74,087 18,961 5,738 35,349 14,039 -
California 3,202,001 354,618 770,362 1,460,553 616,468 -
Colorado 102,264 19,544 9,109 49,983 23,628 -
Connecticut 157,719 8,194 21,526 84,977 43,022 -
Delaware 34,034 2,339 11,068 14,951 5,676 -
Florida 1,181,859 107,990 321,282 501,407 251,180 -
Georgia 423,014 41,123 180,781 147,966 53,144 -
Hawaii 112,219 17,079 17,827 49,699 27,614 -
Idaho 12,725 1,636 7,501 2,462 1,126 -
Illinois 783,543 26,301 186,029 396,812 174,401 -
Indiana 238,360 17,408 60,345 101,145 59,462 -
Iowa 61,219 8,976 39,776 6,608 5,859 -
Kansas 84,965 5,293 33,270 28,443 17,959 -
Kentucky 333,376 25,974 167,550 94,384 45,468 -
Louisiana 389,032 52,649 147,904 137,157 51,322 -
Maine 74,747 4,017 27,026 28,750 14,954 -
Maryland 267,549 20,677 89,630 112,532 44,710 -
Massachusetts 451,577 41,702 148,876 178,824 82,175 -
Michigan 597,873 23,550 199,337 125,416 249,570 -
Minnesota 251,261 16,775 53,894 122,778 57,782 32
Mississippi 239,078 29,653 125,030 57,967 26,428 -
Missouri 190,147 4,280 9,317 125,418 51,132 -
Montana 43,590 1,981 13,036 19,022 9,551 -
Nebraska 93,822 8,242 23,874 41,879 19,827 -
Nevada 59,177 6,818 16,970 24,646 10,743 -
New Hampshire 28,041 1,629 5,953 13,975 6,484 -
New Jersey 410,748 35,717 128,411 161,921 84,699 -
New Mexico 141,399 10,204 41,826 59,091 30,278 -
New York 1,902,380 181,284 508,219 861,044 351,833 -
North Carolina 603,766 83,239 132,599 257,439 130,489 -
North Dakota 22,121 3,968 6,505 8,203 3,445 -
Ohio 535,575 1,209 7,801 383,866 142,699 -
Oregon 132,633 8,496 47,811 43,925 32,401 -
Pennsylvania 707,783 74,525 227,384 283,999 121,875 -
Rhode Island 92,523 5,133 23,474 41,930 21,986 -
South Carolina 191,752 37,766 85,148 47,284 21,554 -
South Dakota 35,345 2,565 13,275 13,421 6,084 -
Tennessee 446,713 40,534 242,903 114,145 49,108 23
Texas 1,049,611 177,775 275,960 409,182 186,694 -
Utah 54,394 3,238 12,728 24,982 13,446 -
Vermont 34,988 2,382 11,468 14,523 6,615 -
Virgin Islands 6,345 430 595 3,630 1,690 -
Virginia 299,904 38,864 100,317 112,615 48,108 -
Washington 382,328 22,416 93,848 169,471 96,593 -
West Virginia 200,222 24,570 65,892 63,063 46,697 -
Wisconsin 236,456 16,766 99,623 81,974 38,093 -
Wyoming 9,447 992 5,079 2,545 831 -

Table 19. Medically Needy Medicaid Eligibles by State: FY 1998

National Total 4,239,284 759,191 618,236 1,807,779 1,053,709 369
Alabama - - - - - -
Alaska - - - - - -
Arizona - - - - - -
Arkansas 108,750 299 79,925 17,867 10,659 -
California 1,361,944 170,805 98,679 787,798 304,662 -
Connecticut 45,477 14,868 19,776 6,007 4,826 -
Florida 56,251 16 11,387 16,020 28,828 -
Georgia 813 110 638 62 3 -
Hawaii 5,234 1,929 593 1,447 1,265 -
Idaho - - - - - -
Illinois 386,883 67,720 57,657 116,304 145,202 -
Indiana - - - - - -
Iowa 10,050 3,188 2,615 980 3,267 -
Kansas 36,572 22,601 10,949 2,766 256 -
Kentucky 53,842 4,044 3,085 28,767 17,946 -
Louisiana 8,030 1,312 1,907 1,848 2,963 -
Maine 2,019 702 531 494 292 -
Maryland 57,874 23,337 17,356 10,185 6,996 -
Massachusetts 244,709 29,480 7,538 132,622 75,069 -
Michigan 193,142 66,936 67,212 7,924 51,070 -
Minnesota 13,859 6,309 6,813 516 194 27
Mississippi - - - - - -
Montana 7,275 5,286 1,978 3 8 -
Nebraska 27,657 9,049 1,828 8,315 8,465 -
Nevada - - - - - -
New Hampshire 9,811 4,220 2,502 1,550 1,539 -
New Jersey 6,302 3,123 1,125 2,052 2 -
New York 998,432 192,011 117,424 501,513 187,484 -
North Carolina 121,444 43,491 55,713 8,238 14,002 -
North Dakota 16,672 6,613 2,710 4,591 2,758 -
Ohio - - - - - -
Oregon 6,941 1,935 5,006 - - -
Pennsylvania 150,126 28,438 5,172 57,730 58,786 -
Rhode Island 8,757 5,348 1,847 22 1,540 -
Tennessee 135,724 18,084 9,878 37,089 70,331 342
Texas 47,805 - - 11,327 36,478 -
Utah 6,376 648 1,091 2,309 2,328 -
Vermont 10,057 787 1,050 4,031 4,189 -
Virgin Islands 12,092 1,096 645 7,397 2,954 -
Virginia 16,597 8,866 6,030 1,423 278 -
Washington 11,863 5,754 5,852 114 143 -
West Virginia 4,372 342 2,719 143 1,168 -
Wisconsin 33,736 6,341 5,189 19,540 2,666 -
Wyoming - - - - - -

Table 20. Poverty Related Medicaid Eligibles by Basis of Eligibility and by State: FY 1998

National Total 10,568,471 704,722 670,007 6,940,283 2,253,438 21
Alabama 263,587 22,302 10,433 218,890 11,962 -
Alaska 16,695 19 16 12,611 4,049 -
Arizona 206,776 3,745 3,472 152,854 46,705 -
Arkansas 195,128 9,053 10,282 123,756 52,037 -
California 369,005 3,206 8,833 302,891 54,075 -
Colorado 88,123 2,170 3,135 59,866 22,952 -
Connecticut 59,334 2,247 925 49,822 6,340 -
Delaware 53,788 2,017 1,174 29,604 20,993 -
District of Columbia 10,068 1,918 1,783 5,629 738 -
Florida 569,091 58,571 62,472 363,123 84,925 -
Georgia 560,476 22,220 15,131 424,270 98,855 -
Hawaii 58,966 71 - 23,532 35,363 -
Idaho 37,162 11,212 10,336 10,398 5,216 -
Illinois 307,813 25,414 32,493 208,992 40,914 -
Indiana 205,636 4,966 6,420 180,069 14,181 -
Iowa 68,437 5,708 4,386 46,120 12,223 -
Kansas 87,505 1,224 939 73,598 11,744 -
Kentucky 197,815 16,458 11,124 140,600 29,632 1
Louisiana 186,270 13,503 5,593 136,655 30,519 -
Maine 50,959 9,806 6,887 30,485 3,781 -
Maryland 187,404 9,680 5,589 127,220 44,915 -
Massachusetts 199,301 29,951 39,813 121,318 8,219 -
Michigan 301,489 6,272 6,565 250,290 38,362 -
Minnesota 78,289 4,319 2,629 69,276 2,045 20
Mississippi 245,413 20,664 14,585 188,366 21,798 -
Missouri 296,853 9,887 6,918 245,522 34,526 -
Montana 16,618 437 146 12,378 3,657 -
Nebraska 74,285 3,784 1,565 68,936 - -
Nevada 7,822 4,115 3,558 143 6 -
New Hampshire 36,535 361 232 33,071 2,871 -
New Jersey 196,530 32,613 21,341 113,631 28,945 -
New Mexico 163,968 110 547 144,722 18,589 -
New York 512,355 - - 126,362 385,993 -
North Carolina 395,637 - - 354,150 41,487 -
North Dakota 11,382 142 4 9,740 1,496 -
Ohio 807,506 146,311 223,523 258,422 179,250 -
Oregon 253,977 727 9,014 75,462 168,774 -
Pennsylvania 476,668 99,249 13,772 303,037 60,610 -
Rhode Island 24,195 745 338 17,080 6,032 -
South Carolina 235,549 22,679 18,943 174,006 19,921 -
South Dakota 28,078 407 147 23,344 4,180 -
Tennessee 663,204 2 47,521 300,411 315,270 -
Texas 1,067,067 45,654 18,140 858,646 144,627 -
Utah 28,677 2,408 4,103 5,968 16,198 -
Vermont 64,994 9,054 2,912 27,364 25,664 -
Virginia 269,519 22,496 14,473 192,116 40,434 -
Washington 221,528 4,136 4,092 189,001 24,299 -
West Virginia 29,004 7,590 13,070 1,018 7,326 -
Wisconsin 64,972 4,336 1 43,703 16,932 -
Wyoming 17,018 763 632 11,815 3,808 -

Table 21. Medicaid Eligibles of Other Coverage Groups by Basis of Eligibility and by State: FY 1998
Total Age 65 Blind/

State Name Eligibles And Older Disabled Children
National Total 7,458,731 916,886 597,786 3,306,154
Alabama 104,019 19,855 9,200 49,411
Alaska 14,890 568 483 8,240
Arizona 178,933 14,871 14,669 81,675
Arkansas 47,801 22,457 6,332 8,079
California 1,258,319 28,807 14,403 541,856
Colorado 156,541 20,338 51,909 48,333
Connecticut 140,017 29,935 12,375 57,582
Delaware 17,331 3,209 2,716 6,502
District of Columbia 6,318 1 - 2,228
Florida 233,339 36,308 17,034 122,187
Georgia 239,131 28,758 30,449 108,493
Hawaii 4,177 - - 651
Idaho 66,831 - 631 52,916
Illinois 305,920 2,882 13,439 99,486
Indiana 166,150 48,432 27,114 56,523
Iowa 181,254 22,361 5,904 88,392
Kansas 37,556 120 1,156 19,707
Kentucky 68,520 22,974 5,389 18,439
Louisiana 137,265 25,889 9,354 74,832
Maine 68,114 9,938 5,670 26,960
Maryland 90,735 20 1,261 45,612
Massachusetts 57,882 - 2,520 31,040
Michigan 261,563 994 100 184,224
Minnesota 213,704 33,615 13,653 116,043
Mississippi 42,110 14,392 2,808 9,281
Missouri 285,622 78,488 102,997 50,890
Montana 25,749 1,500 1,102 13,013
Nebraska 14,497 433 216 1,262
Nevada 63,650 3,752 1,271 44,492
New Hampshire 23,945 5,480 3,293 7,468
New Jersey 244,318 37,352 14,620 116,839
New Mexico 34,160 10,791 4,129 17,677
New York 87,125 - - -
North Carolina 80,834 42,058 21,752 1,299
North Dakota 11,940 5 - 6,438
Ohio 59,283 - - 10,342
Oklahoma - - - -
Oregon 143,805 30,179 50,576 22,121
Pennsylvania 385,423 44,599 53,110 154,673
Puerto Rico - - - -
Rhode Island 23,322 6,521 4,343 6,231
South Carolina 228,942 16,327 6,748 88,730
South Dakota 19,688 5,603 1,477 8,977
Tennessee 209,148 29,706 6,042 94,900
Texas 516,100 115,106 26,782 268,021
Utah 109,189 3,851 3,585 82,175
Vermont 21,598 3,387 920 11,487
Virgin Islands 1,477 - - 462
Virginia 103,551 20,862 6,704 53,859
Washington 299,492 32,619 16,248 157,326
West Virginia 139,492 110 - 118,057
Wisconsin 203,062 38,780 21,353 97,038
Wyoming 24,899 2,653 1,949 13,685

Table 21. Medicaid Eligibles of Other Coverage Groups by Basis of Eligibility and by State: FY 1998 (Con’t)
Foster Other/
National Total 1,894,189 743,588 128
Alabama 20,880 4,673 -
Alaska 4,237 1,362 -
Arizona 60,842 6,876 -
Arkansas 6,080 4,853 -
California 535,889 137,334 30
Colorado 20,515 15,446 -
Delaware 4,295 609 -
District of Columbia 1,761 2,328 -
Florida 35,391 22,419 -
Georgia 57,089 14,342 -
Hawaii 333 3,193 -
Idaho 11,594 1,690 -
Illinois 56,696 133,417 -
Indiana 27,665 6,416 -
Iowa 59,648 4,949 -
Kansas 11,755 4,818 -
Kentucky 13,999 7,717 2
Louisiana 27,133 57 -
Maine 22,987 2,559 -
Maryland 27,541 16,301 -
Michigan 74,699 1,546 -
Minnesota 42,456 7,925 12
Mississippi 12,103 3,526 -
Missouri 36,548 16,699 -
Montana 6,714 3,420 -
Nebraska 1,963 10,623 -
Nevada 10,458 3,677 -
New Hampshire 5,135 2,569 -
New Jersey 57,227 18,280 -
New Mexico - 1,563 -
New York - 87,125 -
North Dakota 3,950 1,547 -
Ohio 13,798 35,143 -
Oklahoma - - -
Oregon 28,392 12,537 -
Pennsylvania 106,169 26,872 -
Puerto Rico - - -
Rhode Island 1,604 4,623 -
South Carolina 109,969 7,168 -
Tennessee 66,954 11,545 1
Texas 87,960 18,231 -
Utah 15,532 4,046 -
Vermont 3,558 2,163 83
Virginia 17,201 4,925 -
Washington 72,988 20,311 -
Wisconsin 29,733 16,158 -
Wyoming 5,997 615 -

Table 22. Medicaid Recipients of Medical Care by Age and by State: FY 1998
Total Ages From Ages From Ages From Ages From Ages
State Name Recipients Under 1 1 to 5 6 to 14 15 to 20 21 to 44
National Total 40,649,482 1,558,643 6,933,058 8,552,786 3,770,295 8,835,632
Alabama 527,078 27,969 111,576 111,380 43,098 93,433
Alaska 74,508 3,402 13,768 17,224 7,395 20,429
Arizona 507,668 46,561 110,446 119,360 43,213 122,185
Arkansas 424,727 16,248 77,228 93,906 48,658 88,600
California 7,082,175 138,898 1,206,917 1,534,178 753,019 1,694,033
Colorado 344,916 17,393 70,592 76,847 30,328 75,406
Connecticut 381,208 11,337 61,527 91,304 38,712 94,144
Delaware 101,436 3,611 18,017 24,015 10,825 28,552
Florida 1,904,591 72,385 360,477 457,266 175,370 424,619
Georgia 1,221,978 64,474 255,052 280,857 129,665 225,920
Hawaii 184,614 10,481 26,262 34,392 16,114 48,768
Idaho 123,176 5,313 26,308 26,804 10,351 25,513
Illinois 1,363,856 89,743 260,125 302,023 125,509 327,306
Indiana 607,293 27,842 125,480 137,858 55,705 126,370
Iowa 314,936 11,800 55,265 66,549 32,200 84,025
Kansas 241,933 10,427 47,237 54,610 26,317 51,939
Kentucky 644,482 22,487 108,103 136,877 56,460 153,490
Louisiana 720,615 57,639 144,132 158,730 64,869 139,767
Maine 170,456 4,257 22,420 36,703 18,827 42,537
Maryland 561,085 23,208 102,693 133,175 50,928 128,022
Massachusetts 908,238 36,321 126,727 178,469 79,006 245,415
Michigan 1,362,890 44,555 236,433 317,589 128,690 336,515
Minnesota 538,413 17,157 93,654 136,544 66,890 121,112
Mississippi 485,767 26,367 90,526 96,034 42,668 95,579
Missouri 734,015 27,330 142,186 181,373 81,044 147,058
Montana 100,760 3,530 17,888 22,870 9,490 25,881
Nebraska 211,188 17,290 39,175 49,790 22,657 43,831
Nevada 128,144 7,618 29,865 30,159 9,140 24,882
New Hampshire 93,970 2,499 16,657 24,433 9,903 20,093
New Jersey 813,251 26,256 149,651 181,330 73,879 195,093
New Mexico 329,418 12,877 70,445 97,061 42,995 58,552
New York 3,073,241 101,784 503,121 616,071 285,914 771,013
North Carolina 1,167,988 79,785 213,089 250,288 117,711 243,112
North Dakota 62,280 2,060 10,456 13,214 5,921 13,706
Ohio 1,290,776 91,067 220,394 276,683 123,728 307,773
Oklahoma 342,475 - - - - -
Oregon 511,171 14,102 80,111 94,824 47,731 164,643
Pennsylvania 1,523,120 43,654 248,534 360,366 160,445 374,254
Puerto Rico 964,015 - - - - -
Rhode Island 153,130 4,288 25,004 34,289 13,617 37,367
South Carolina 594,962 27,168 100,788 130,359 64,024 131,514
South Dakota 89,537 6,767 18,085 21,985 9,632 16,246
Tennessee 1,843,661 33,132 191,472 284,213 152,278 410,025
Texas 2,324,810 144,065 558,876 574,293 179,470 417,767
Utah 215,801 13,992 46,317 40,620 19,690 46,322
Vermont 123,992 2,410 15,757 26,550 12,569 35,932
Virgin Islands 19,764 840 4,553 4,168 2,103 5,059
Virginia 653,236 41,524 123,243 152,702 66,403 125,801
Washington 1,413,208 25,861 167,150 235,062 107,258 197,921
West Virginia 342,668 12,093 56,474 73,311 35,841 76,345
Wisconsin 518,595 20,872 98,851 114,714 46,662 112,151
Wyoming 46,121 2,740 10,221 10,522 4,416 10,675

Table 22. Medicaid Recipients of Medical Care by Age and by State: FY 1998 (Con’t)
From Ages From Ages From Ages From Ages

State Name 45 to 64 65 to 74 75 to 84 85 and Over Unknown
National Total 3,329,608 1,806,516 1,577,798 1,271,386 3,013,760
Alabama 51,573 31,817 30,249 25,309 674
Alaska 5,439 2,991 2,018 741 1,101
Arizona 30,740 14,001 11,580 9,582 -
Arkansas 34,820 21,708 22,996 19,644 919
California 573,977 357,113 261,022 141,650 421,368
Colorado 26,732 16,807 14,897 13,748 2,166
Connecticut 32,065 16,290 17,759 18,070 -
Delaware 8,598 2,934 2,607 2,127 150
Florida 150,693 100,119 85,574 65,924 12,164
Georgia 87,177 53,477 49,912 68,219 7,225
Hawaii 13,035 8,509 6,629 3,809 16,615
Idaho 9,084 4,212 4,077 3,873 7,641
Illinois 116,503 55,375 47,224 39,126 922
Indiana 45,457 26,414 26,052 25,780 10,335
Iowa 23,148 11,145 13,760 15,829 1,215
Kansas 19,175 8,927 9,813 11,298 2,190
Kentucky 75,170 35,195 30,128 22,252 4,320
Louisiana 59,953 36,578 33,406 25,404 137
Maine 18,530 9,387 8,784 7,287 1,724
Maryland 44,058 23,068 19,948 14,168 21,817
Massachusetts 104,051 42,822 44,504 50,923 -
Michigan 109,172 45,213 38,461 33,254 73,008
Minnesota 34,707 17,342 20,595 25,156 5,256
Mississippi 47,702 30,780 28,555 22,461 5,095
Missouri 58,750 32,984 32,949 29,374 967
Montana 8,332 3,582 3,659 3,594 1,934
Nebraska 13,038 7,140 8,327 9,940 -
Nevada 8,841 5,610 4,477 2,789 4,763
New Hampshire 6,988 3,490 4,253 5,151 503
New Jersey 60,994 43,824 41,617 36,436 4,171
New Mexico 19,573 11,319 8,569 6,708 1,319
New York 324,892 181,044 155,864 133,538 -
North Carolina 102,889 62,261 59,626 39,227 -
North Dakota 4,618 2,677 3,661 4,500 1,467
Ohio 114,741 54,935 54,832 46,623 -
Oklahoma - - - - 342,475
Oregon 62,059 14,678 12,961 9,942 10,120
Pennsylvania 155,593 66,800 60,712 51,748 1,014
Puerto Rico - - - - 964,015
Rhode Island 13,343 6,887 7,528 8,109 2,698
South Carolina 46,949 29,380 27,507 17,408 19,865
South Dakota 5,714 3,090 3,661 4,340 17
Tennessee 222,467 68,911 45,752 31,923 403,488
Texas 148,914 122,019 103,321 76,084 1
Utah 10,243 4,361 3,589 3,120 27,547
Vermont 13,359 5,897 5,905 3,954 1,659
Virgin Islands 1,381 839 619 202 -
Virginia 52,956 36,481 32,497 21,629 -
Washington 60,366 25,297 22,437 18,886 552,970
West Virginia 35,696 12,697 10,569 7,838 21,804
Wisconsin 41,219 21,719 26,802 28,800 6,805
Wyoming 2,811 1,332 1,496 1,501 407

Table 23. Medicaid Recipients of Medical Care by Sex and by State: FY 1998
Total
State Name Recipients Male Female Unknown
National Total 40,649,482 14,733,230 22,376,441 3,539,811
Alabama 527,078 196,812 322,644 7,622
Alaska 74,508 29,343 44,064 1,101
Arizona 507,668 - - 507,668
Arkansas 424,727 157,095 266,608 1,024
California 7,082,175 2,755,161 3,905,643 421,371
Colorado 344,916 134,691 208,059 2,166
Connecticut 381,208 147,258 233,950 -
Delaware 101,436 40,392 60,894 150
Florida 1,904,591 747,611 1,144,816 12,164
Georgia 1,221,978 466,356 748,398 7,224
Hawaii 184,614 74,800 93,280 16,534
Idaho 123,176 45,716 69,818 7,642
Illinois 1,363,856 531,086 831,848 922
Indiana 607,293 230,233 366,725 10,335
Iowa 314,936 124,286 189,435 1,215
Kansas 241,933 95,628 144,097 2,208
Kentucky 644,482 253,917 386,239 4,326
Louisiana 720,615 278,337 442,067 211
Maine 170,456 66,832 101,902 1,722
Maryland 561,085 209,354 329,915 21,816
Massachusetts 908,238 361,068 547,170 -
Michigan 1,362,890 514,653 775,234 73,003
Minnesota 538,413 219,165 313,992 5,256
Mississippi 485,767 176,349 304,322 5,096
Missouri 734,015 288,756 444,292 967
Montana 100,760 41,104 57,722 1,934
Nebraska 211,188 81,843 122,002 7,343
Nevada 128,144 48,510 74,729 4,905
New Hampshire 93,970 36,484 56,954 532
New Jersey 813,251 297,939 511,141 4,171
New Mexico 329,418 137,842 190,255 1,321
New York 3,073,241 1,201,561 1,871,645 35
North Carolina 1,167,988 443,966 724,022 -
North Dakota 62,280 23,579 37,224 1,477
Ohio 1,290,776 497,750 793,007 19
Oklahoma 342,475 - - 342,475
Oregon 511,171 219,412 281,633 10,126
Pennsylvania 1,523,120 602,675 919,434 1,011
Puerto Rico 964,015 - - 964,015
Rhode Island 153,130 57,293 93,137 2,700
South Carolina 594,962 205,046 369,944 19,972
South Dakota 89,537 35,541 51,522 2,474
Tennessee 1,843,661 603,827 836,338 403,496
Texas 2,324,810 910,233 1,414,555 22
Utah 215,801 75,205 112,713 27,883
Vermont 123,992 52,636 69,697 1,659
Virgin Islands 19,764 6,652 13,112 -
Virginia 653,236 253,854 399,382 -
Washington 1,413,208 355,421 504,765 553,022
West Virginia 342,668 132,574 187,552 22,542
Wisconsin 518,595 204,135 307,665 6,795
Wyoming 46,121 17,796 27,911 414

Table 24. Medicaid Recipients of Medical Care by Race/Ethnicity and by State: FY 1998
Total White Black Hispanic

State Name Recipients Not Hispanic Not Hispanic
National Total 40,649,482 16,771,976 9,847,580 6,353,196
Alabama 527,078 238,107 260,790 4,483
Alaska 74,508 34,485 4,797 2,671
Arizona 507,668 - - -
Arkansas 424,727 257,363 141,972 5,396
California 7,082,175 2,028,789 876,628 2,598,598
Colorado 344,916 176,003 27,613 110,326
Connecticut 381,208 170,175 95,626 109,224
Delaware 101,436 42,152 46,817 7,817
Florida 1,904,591 759,097 663,851 305,827
Georgia 1,221,978 443,904 647,000 40,754
Hawaii 184,614 24,871 1,817 6,427
Idaho 123,176 99,097 552 12,954
Illinois 1,363,856 554,463 567,071 208,620
Indiana 607,293 421,513 145,694 23,288
Iowa 314,936 271,369 25,612 11,179
Kansas 241,933 166,353 44,774 19,046
Kentucky 644,482 525,911 82,799 5,070
Louisiana 720,615 238,916 431,382 -
Maine 170,456 - - -
Maryland 561,085 184,348 307,223 19,120
Massachusetts 908,238 533,292 102,428 136,456
Michigan 1,362,890 682,290 488,168 49,697
Minnesota 538,413 343,748 80,703 28,932
Mississippi 485,767 151,798 298,883 1,319
Missouri 734,015 506,398 226,649 -
Montana 100,760 74,115 640 1,872
Nebraska 211,188 148,160 29,859 20,346
Nevada 128,144 71,199 23,871 22,083
New Hampshire 93,970 90,345 876 1,447
New Jersey 813,251 252,882 296,751 182,860
New Mexico 329,418 89,343 8,850 168,019
New York 3,073,241 859,517 688,544 649,517
North Carolina 1,167,988 511,841 515,303 43,585
North Dakota 62,280 44,676 1,008 1,508
Ohio 1,290,776 813,089 426,783 31,086
Oklahoma 342,475 - - -
Oregon 511,171 401,228 21,658 50,838
Pennsylvania 1,523,120 896,151 458,668 123,070
Rhode Island 153,130 87,594 15,172 26,785
South Carolina 594,962 220,674 326,308 4,108
South Dakota 89,537 52,126 185 130
Tennessee 1,843,661 952,473 414,173 12,588
Texas 2,324,810 645,978 458,055 1,119,760
Utah 215,801 140,036 3,966 26,951
Vermont 123,992 120,771 705 183
Virgin Islands 19,764 173 15,493 3,991
Virginia 653,236 300,535 311,541 24,123
Washington 1,413,208 629,997 57,659 102,737
West Virginia 342,668 296,447 14,776 497
Wisconsin 518,595 180,361 80,023 19,779
Wyoming 46,121 35,983 935 4,130

Table 24. Medicaid Recipients of Medical Care by Race/Ethnicity and by State: FY 1998 (Con’t)
Asian or American Indian/

State Name Pacific Islands Alaskan Native Unknown
National Total 1,022,077 335,582 6,319,071
Alabama 1,510 1,049 21,139
Alaska 3,888 25,929 2,738
Arizona - - 507,668
Arkansas 912 837 18,247
California 512,660 30,983 1,034,517
Colorado 3,744 2,301 24,929
Connecticut 5,525 582 76
Delaware 401 248 4,001
District of Columbia 779 16 52,583
Florida 8,633 926 166,257
Georgia 10,620 622 79,078
Hawaii 74,931 99 76,469
Idaho 332 2,600 7,641
Illinois 30,252 2,237 1,213
Indiana 1,455 398 14,945
Iowa 3,786 1,775 1,215
Kansas 6,490 3,080 2,190
Kentucky 1,286 208 29,208
Louisiana - - 50,317
Maine - - 170,456
Maryland 11,551 1,039 37,804
Massachusetts 30,441 2,469 103,152
Michigan 17,568 5,843 119,324
Minnesota 40,133 25,640 19,257
Mississippi 1,698 1,813 30,256
Missouri - 1 967
Montana 430 21,752 1,951
Nebraska 2,355 8,539 1,929
Nevada 2,912 2,577 5,502
New Hampshire 776 21 505
New Jersey 8,979 1,891 69,888
New Mexico 1,617 51,500 10,089
New York 57,224 7,092 811,347
North Carolina 10,659 20,124 66,476
North Dakota 321 13,278 1,489
Ohio 4,819 1,314 13,685
Oregon 14,412 9,425 13,610
Pennsylvania 26,676 1,285 17,270
Rhode Island 4,615 248 18,716
South Carolina 892 667 42,313
South Dakota 61 31,510 5,525
Tennessee 7,366 3,420 453,641
Texas 23,253 6,280 71,484
Utah 6,439 9,092 29,317
Vermont 434 240 1,659
Virgin Islands 78 11 18
Virginia 14,973 748 1,316
Washington 46,052 23,794 552,969
West Virginia 325 - 30,623
Wisconsin 17,679 6,233 214,520
Wyoming 135 3,846 1,092

Table 25. Medicaid Vendor Payments of Medical Care by Age and by State: FY 1998
State Name Payments Under 1 1 to 5 6 to 14 15 to 20 21 to 44
National Total $142,317,903,795 $4,181,702,420 $8,603,546,258 $11,154,216,158 $8,423,079,186 $35,470,454,641
Alabama 1,902,300,047 22,820,090 67,146,126 137,864,651 45,748,090 204,929,306
Alaska 330,378,398 18,512,179 26,147,375 46,203,751 32,941,090 98,122,887
Arizona 1,643,966,305 150,504,669 164,096,117 209,815,378 137,883,403 420,953,820
Arkansas 1,375,797,421 69,985,612 170,587,004 157,649,124 121,005,431 350,725,626
California 14,236,592,915 159,027,699 1,099,696,397 1,488,518,619 961,974,962 4,035,630,454
Colorado 1,439,366,499 37,548,894 91,164,647 122,067,919 114,342,985 347,447,472
Connecticut 2,420,791,474 37,449,638 105,518,904 119,339,122 81,403,500 585,828,450
Delaware 419,732,143 9,896,557 29,854,591 50,307,997 35,039,968 117,558,642
Florida 5,686,844,862 207,214,109 426,888,964 428,913,238 295,567,125 1,379,641,858
Georgia 3,012,346,312 130,274,039 256,674,945 228,998,832 229,873,552 737,273,945
Hawaii 507,433,146 13,215,325 37,860,256 42,742,017 21,814,656 101,708,497
Idaho 424,512,387 14,402,838 27,319,923 30,021,260 28,677,864 120,915,949
Illinois 6,172,865,261 369,710,789 297,236,608 394,413,854 529,742,708 1,861,505,117
Indiana 2,564,005,047 86,166,403 149,572,250 165,692,398 129,727,953 638,727,347
Iowa 1,288,770,390 31,010,044 73,834,267 115,849,468 108,926,139 347,901,735
Kansas 916,323,608 31,073,118 43,044,576 65,465,347 63,337,713 262,174,644
Kentucky 2,425,288,141 39,767,195 182,568,410 257,295,529 170,759,041 571,166,507
Louisiana 2,383,508,985 168,716,699 139,107,477 164,913,424 157,908,697 611,395,836
Maine 747,027,618 7,245,901 31,281,848 77,280,919 59,429,808 193,621,824
Maryland 2,489,280,148 59,865,791 176,722,191 242,862,808 154,004,636 641,599,245
Massachusetts 4,609,360,933 122,380,919 198,016,371 288,877,243 192,799,760 1,220,375,985
Michigan 4,345,007,824 103,768,590 242,082,971 287,871,822 210,654,465 1,177,273,480
Minnesota 2,924,447,719 61,200,048 208,440,363 232,135,456 170,201,289 746,278,109
Mississippi 1,442,373,276 55,834,210 96,211,119 111,359,490 104,913,877 310,382,434
Missouri 2,569,646,129 72,341,660 163,428,780 176,213,721 140,570,168 589,861,158
Montana 361,238,668 9,996,360 18,294,856 33,302,058 29,089,839 83,126,095
Nebraska 753,162,904 41,094,566 38,081,715 60,523,842 46,255,062 177,550,894
Nevada 462,087,777 20,897,202 44,967,398 56,851,800 42,129,982 112,883,176
New Hampshire 606,004,232 5,371,744 23,485,035 62,338,125 37,075,477 147,223,561
New Jersey 4,218,822,993 62,638,007 242,197,724 282,906,145 209,346,536 1,046,385,654
New Mexico 862,144,872 31,342,287 91,463,467 143,247,036 118,582,902 173,657,451
New York 24,298,610,635 465,752,704 1,098,859,279 1,573,592,359 1,031,876,055 6,368,540,586
North Carolina 4,013,996,742 219,104,317 233,057,550 335,643,471 294,081,459 991,888,410
North Dakota 341,015,420 5,421,612 13,258,687 20,678,612 19,985,618 86,326,115
Ohio 6,120,967,557 312,960,286 219,216,802 360,697,356 306,294,127 1,501,817,268
Oklahoma 1,177,853,941 - - - - -
Oregon 1,377,514,740 15,545,694 98,235,110 162,365,217 101,366,690 393,343,003
Pennsylvania 6,080,191,710 82,817,865 357,914,294 666,490,834 421,800,531 1,287,454,674
Puerto Rico 250,000,000 - - - - -
Rhode Island 919,353,410 12,399,211 48,529,981 59,308,455 38,847,474 224,855,093
South Carolina 2,018,620,428 79,118,760 117,683,342 163,537,315 146,855,007 426,843,487
South Dakota 355,833,902 22,685,147 19,035,793 29,797,699 27,517,415 85,332,923
Tennessee 3,167,188,993 30,739,369 139,001,982 237,099,354 253,428,307 763,980,092
Texas 7,139,928,843 428,826,197 681,906,816 523,617,923 410,885,398 1,602,967,227
Utah 618,675,433 32,591,866 53,961,059 52,186,345 56,276,177 183,641,866
Vermont 351,341,290 4,365,501 15,573,132 37,715,946 30,298,880 94,383,464
Virgin Islands 10,097,973 551,923 1,032,869 827,904 781,957 2,812,008
Virginia 2,118,202,866 114,024,927 126,666,594 147,224,727 122,588,008 552,938,255
Washington 2,044,234,831 35,769,579 154,415,362 166,326,790 124,864,608 521,145,517
West Virginia 1,243,150,526 17,099,015 59,891,308 92,021,543 87,059,121 279,277,299
Wisconsin 2,206,398,750 28,368,530 142,851,338 187,435,648 114,819,943 453,779,746
Wyoming 192,004,819 7,862,209 13,196,617 14,686,901 11,868,910 57,913,049

Table 25. Medicaid Vendor Payments of Medical Care by Age and by State: FY 1998 (Con’t)

National Total $25,428,205,744 $11,816,786,953 $15,787,654,578 $17,987,033,024 $3,465,224,822
Alabama 222,430,043 138,331,051 233,804,983 315,442,465 513,783,242
Alaska 48,111,274 21,079,241 22,794,123 16,180,644 285,834
Arizona 183,783,798 104,866,008 134,376,262 137,686,845 -
Arkansas 239,447,900 117,089,152 181,078,028 213,433,778 (245,204,234)
California 2,605,396,220 1,267,911,644 1,321,426,945 1,160,443,354 136,566,621
Colorado 235,123,077 101,694,946 153,088,046 194,124,581 42,763,932
Connecticut 439,438,023 211,019,689 351,701,578 489,092,570 -
Delaware 71,005,891 27,780,252 37,139,549 40,650,854 497,842
District of Columbia 161,332,148 58,421,889 66,322,438 59,170,120 66,994,173
Florida 948,473,963 492,763,811 672,651,882 814,255,757 20,474,155
Georgia 507,321,902 225,627,074 302,572,083 372,731,195 20,998,745
Hawaii 76,018,112 38,360,172 58,062,894 73,841,565 43,809,654
Idaho 71,893,153 26,739,298 40,002,588 51,931,442 12,608,072
Illinois 1,246,416,786 453,682,260 504,674,065 515,442,795 40,279
Indiana 501,374,204 226,730,761 305,021,585 352,618,604 8,373,542
Iowa 206,413,954 80,224,074 132,264,291 189,837,627 2,508,791
Kansas 175,770,453 66,162,248 87,292,819 117,594,529 4,408,161
Kentucky 492,554,678 183,342,077 250,195,634 271,845,644 5,793,426
Louisiana 465,816,270 195,457,195 240,901,709 239,184,115 107,564
Maine 134,278,978 57,972,838 81,036,079 101,971,621 2,907,802
Maryland 472,837,550 201,989,548 245,346,175 266,497,836 27,554,368
Massachusetts 909,101,419 361,200,739 564,592,348 752,016,149 -
Michigan 852,441,315 261,404,363 371,361,023 466,060,921 372,088,874
Minnesota 450,072,629 201,316,637 328,016,607 518,294,261 8,492,320
Mississippi 257,489,521 127,851,781 168,177,532 208,776,837 1,376,475
Missouri 465,882,450 228,326,459 325,826,357 406,569,598 625,778
Montana 61,098,168 23,253,794 42,424,696 59,096,081 1,556,721
Nebraska 122,546,774 56,085,965 85,095,618 125,928,469 -
Nevada 69,765,335 26,730,084 33,091,340 35,548,384 19,223,076
New Hampshire 97,365,677 44,633,623 75,165,683 112,644,970 700,337
New Jersey 719,076,240 396,093,554 566,277,295 686,390,687 7,511,151
New Mexico 116,690,103 48,756,597 60,110,922 72,980,615 5,313,492
New York 4,829,113,896 2,546,546,564 3,107,820,036 3,276,509,156 -
North Carolina 730,963,532 312,081,536 462,921,843 434,254,624 -
North Dakota 58,928,321 27,136,683 42,074,930 66,020,835 1,184,007
Ohio 1,212,619,311 551,295,117 815,224,323 840,842,962 -
Oklahoma - - - - 1,177,853,941
Oregon 252,153,490 92,448,859 127,029,299 128,852,296 6,175,082
Pennsylvania 963,973,632 497,082,758 796,964,252 1,004,040,138 1,652,732
Puerto Rico - - - - 250,000,000
Rhode Island 179,527,633 80,422,597 119,175,726 152,158,672 4,128,568
South Carolina 338,951,033 137,571,468 179,507,553 173,537,576 255,014,887
South Dakota 52,355,727 22,329,101 36,988,783 59,783,196 8,118
Tennessee 536,687,431 187,217,995 281,906,447 340,325,499 396,802,517
Texas 1,149,707,374 620,704,247 810,913,913 910,398,749 997
Utah 88,516,271 29,376,390 34,475,544 40,405,737 47,244,178
Vermont 63,400,831 25,835,031 35,828,585 43,230,554 709,366
Virgin Islands 1,357,835 1,158,325 1,072,172 502,980 -
Virginia 390,567,507 198,282,074 244,845,675 221,065,096 -
Washington 319,502,360 135,937,153 201,754,089 253,203,632 131,315,741
West Virginia 249,943,764 85,512,581 117,549,030 140,540,957 114,255,908
Wisconsin 352,207,086 180,113,687 311,428,280 439,100,543 (3,706,051)
Wyoming 30,960,702 12,835,963 18,280,921 23,974,909 424,638

Table 26. Medicaid Vendor Payments of Medical Care by Sex and by State: FY 1998
Total
State Name Payments Male Female Unknown
National Total $142,317,903,795 $54,505,135,169 $84,263,344,977 $3,549,423,630
Alabama 1,902,300,047 428,934,012 901,448,396 571,917,639
Alaska 330,378,398 143,251,512 186,841,052 285,834
Arizona 1,643,966,305 611,103,276 1,032,863,023 -
Arkansas 1,375,797,421 670,651,186 950,004,425 (244,858,190)
California 14,236,592,915 5,684,321,859 8,415,698,843 136,572,213
Colorado 1,439,366,499 568,161,269 828,441,298 42,763,932
Connecticut 2,420,791,474 909,770,244 1,511,021,230 -
Delaware 419,732,143 176,105,564 243,128,737 497,842
Florida 5,686,844,862 2,186,073,956 3,480,296,751 20,474,155
Georgia 3,012,346,312 1,024,630,832 1,966,718,337 20,997,143
Hawaii 507,433,146 205,541,343 258,176,979 43,714,824
Idaho 424,512,387 161,041,265 250,861,633 12,609,489
Illinois 6,172,865,261 2,683,512,469 3,489,312,513 40,279
Indiana 2,564,005,047 996,709,219 1,558,922,286 8,373,542
Iowa 1,288,770,390 524,987,594 761,274,005 2,508,791
Kansas 916,323,608 370,328,914 541,562,987 4,431,707
Kentucky 2,425,288,141 908,938,450 1,510,527,921 5,821,770
Louisiana 2,383,508,985 917,846,494 1,465,177,548 484,942
Maine 747,027,618 308,154,135 435,970,254 2,903,229
Maryland 2,489,280,148 1,003,696,022 1,458,030,690 27,553,436
Massachusetts 4,609,360,933 1,775,376,600 2,833,984,333 -
Michigan 4,345,007,824 1,536,838,141 2,436,083,617 372,086,066
Minnesota 2,924,447,719 1,199,637,751 1,716,317,648 8,492,320
Mississippi 1,442,373,276 495,820,726 945,154,295 1,398,255
Missouri 2,569,646,129 969,602,591 1,599,417,760 625,778
Montana 361,238,668 137,459,729 222,222,218 1,556,721
Nebraska 753,162,904 277,327,336 465,517,769 10,317,800
Nevada 462,087,777 187,811,985 254,846,778 19,429,014
New Hampshire 606,004,232 233,111,156 372,103,000 790,076
New Jersey 4,218,822,993 1,514,612,537 2,696,699,305 7,511,151
New Mexico 862,144,872 354,666,166 502,159,764 5,318,942
New York 24,298,610,635 10,246,955,529 14,050,848,812 806,292
North Carolina 4,013,996,742 1,537,982,121 2,476,014,620 -
North Dakota 341,015,420 138,869,223 200,950,010 1,196,187
Ohio 6,120,967,557 2,219,780,890 3,891,587,868 9,598,794
Oklahoma 1,177,853,941 - - 1,177,853,941
Oregon 1,377,514,740 560,534,420 810,785,923 6,194,397
Pennsylvania 6,080,191,710 2,244,847,299 3,833,695,224 1,649,187
Puerto Rico 250,000,000 - - 250,000,000
Rhode Island 919,353,410 367,807,751 547,415,973 4,129,686
South Carolina 2,018,620,428 691,382,912 1,072,190,466 255,047,050
South Dakota 355,833,902 144,940,742 209,534,188 1,358,972
Tennessee 3,167,188,993 1,050,449,413 1,719,918,660 396,820,920
Texas 7,139,928,843 2,628,419,621 4,511,436,002 73,218
Utah 618,675,433 248,855,565 322,010,723 47,809,145
Vermont 351,341,290 141,585,986 209,045,938 709,366
Virgin Islands 10,097,973 2,708,355 7,389,618 -
Virginia 2,118,202,866 802,007,954 1,316,194,909 -
Washington 2,044,234,831 662,728,122 1,250,021,549 131,485,160
West Virginia 1,243,150,526 431,380,707 695,486,096 116,283,723
Wisconsin 2,206,398,750 853,584,729 1,356,526,399 (3,712,378)
Wyoming 192,004,819 73,757,316 117,767,971 479,532

Table 27. Medicaid Vendor Payments of Medical Care by Race/Ethnicity and by State: FY 1998
Total White Black

State Name Payments Not Hispanic Not Hispanic Hispanic
National Total $142,317,903,795 $77,308,255,958 $27,924,916,921 $11,701,697,152
Alabama 1,902,300,047 827,952,829 438,900,267 3,315,366
Alaska 330,378,398 174,019,260 14,417,242 7,940,171
Arizona 1,643,966,305 807,626,871 94,508,661 471,119,023
Arkansas 1,375,797,421 1,073,552,240 425,077,863 9,412,021
California 14,236,592,915 6,166,204,632 1,876,614,170 2,889,656,926
Colorado 1,439,366,499 919,883,912 71,612,726 281,989,029
Connecticut 2,420,791,474 1,764,041,602 346,434,628 289,165,417
Delaware 419,732,143 222,835,727 146,959,824 19,433,350
Florida 5,686,844,862 2,882,195,485 1,489,923,156 486,938,537
Georgia 3,012,346,312 1,449,477,236 1,239,615,206 48,382,042
Hawaii 507,433,146 82,883,964 4,340,418 15,687,138
Idaho 424,512,387 383,043,599 1,286,656 19,683,988
Illinois 6,172,865,261 3,144,842,530 2,366,092,290 550,384,662
Indiana 2,564,005,047 2,092,496,250 396,194,656 47,183,688
Iowa 1,288,770,390 1,196,460,179 60,119,039 18,178,910
Kansas 916,323,608 749,842,750 108,914,987 32,226,321
Kentucky 2,425,288,141 1,993,823,547 266,183,359 12,665,231
Louisiana 2,383,508,985 1,099,777,803 1,065,218,687 -
Maine 747,027,618 - - -
Maryland 2,489,280,148 1,131,688,380 1,174,483,476 45,768,784
Massachusetts 4,609,360,933 3,532,575,981 328,298,442 252,985,739
Michigan 4,345,007,824 2,488,989,444 1,090,315,294 68,841,694
Minnesota 2,924,447,719 2,377,783,348 250,351,425 68,520,048
Mississippi 1,442,373,276 632,011,633 678,234,773 2,338,315
Missouri 2,569,646,129 1,996,030,667 572,989,632 -
Montana 361,238,668 300,075,153 1,673,278 4,103,634
Nebraska 753,162,904 620,174,553 69,028,503 33,978,627
Nevada 462,087,777 310,748,421 64,283,449 46,021,153
New Hampshire 606,004,232 597,538,126 2,998,753 3,358,173
New Jersey 4,218,822,993 2,306,563,061 1,081,590,761 351,049,969
New Mexico 862,144,872 334,362,382 24,062,597 328,367,182
New York 24,298,610,635 8,526,521,151 3,317,705,424 2,128,810,934
North Carolina 4,013,996,742 2,108,139,775 1,388,709,316 62,993,852
North Dakota 341,015,420 295,976,110 1,985,205 2,124,462
Ohio 6,120,967,557 4,523,992,068 1,444,982,894 77,540,662
Oklahoma 1,177,853,941 - - -
Oregon 1,377,514,740 1,174,610,986 57,050,374 66,963,540
Pennsylvania 6,080,191,710 4,168,714,616 1,435,448,567 312,794,476
Puerto Rico 250,000,000 - - -
Rhode Island 919,353,410 722,585,451 48,070,593 58,620,869
South Carolina 2,018,620,428 823,140,050 819,207,631 4,653,034
South Dakota 355,833,902 265,096,471 476,867 461,142
Tennessee 3,167,188,993 1,948,698,449 688,986,766 10,801,097
Texas 7,139,928,843 3,237,522,829 1,265,091,320 2,267,459,706
Utah 618,675,433 471,999,810 7,957,899 53,862,180
Vermont 351,341,290 347,145,661 1,481,137 498,532
Virgin Islands 10,097,973 158,015 8,196,959 1,686,823
Virginia 2,118,202,866 1,185,068,839 848,667,684 42,863,490
Washington 2,044,234,831 1,520,911,231 107,831,858 147,560,588
West Virginia 1,243,150,526 1,050,971,933 43,439,640 1,216,634
Wisconsin 2,206,398,750 1,072,860,297 139,997,459 28,153,946
Wyoming 192,004,819 164,148,931 2,787,697 9,694,849

Table 27. Medicaid Vendor Payments of Medical Care by Race/Ethnicity and by State: FY 1998 (Con’t)

National Total $1,966,402,451 $1,106,464,681 $22,310,166,621
Alabama 1,654,070 1,076,069 629,401,446
Alaska 12,240,077 114,087,825 7,673,823
Arizona 14,159,234 223,441,777 33,110,736
Arkansas 2,948,804 2,006,208 (137,199,715)
California 628,002,960 38,373,365 2,637,740,862
Colorado 9,908,033 5,693,343 150,279,456
Connecticut 17,312,049 3,385,027 452,751
Delaware 1,105,200 1,238,666 28,159,376
District of Columbia 2,680,052 120,284 127,641,885
Florida 11,254,474 1,353,164 815,180,046
Georgia 13,872,906 1,141,307 259,857,615
Hawaii 290,493,960 144,750 113,882,916
Idaho 751,185 7,138,887 12,608,072
Illinois 101,700,238 9,535,747 309,794
Indiana 4,841,617 1,036,794 22,252,042
Iowa 7,513,271 3,990,200 2,508,791
Kansas 14,513,033 6,418,356 4,408,161
Kentucky 2,464,396 395,633 149,755,975
Louisiana - - 218,512,495
Maine - - 747,027,618
Maryland 44,293,674 4,034,803 89,011,031
Massachusetts 48,043,679 14,419,906 433,037,186
Michigan 37,945,112 13,049,032 645,867,248
Minnesota 95,240,916 90,141,150 42,410,832
Mississippi 2,822,491 5,546,935 121,419,129
Missouri - 52 625,778
Montana 889,994 52,781,368 1,715,241
Nebraska 4,719,794 16,738,730 8,522,698
Nevada 8,741,149 8,923,139 23,370,466
New Hampshire 1,244,444 121,244 743,492
New Jersey 19,945,359 10,874,552 448,799,291
New Mexico 3,698,818 124,608,852 47,045,041
New York 209,885,774 23,977,462 10,091,709,891
North Carolina 16,512,917 49,156,977 388,483,905
North Dakota 892,876 38,824,907 1,211,860
Ohio 12,862,937 4,743,094 56,845,897
Oklahoma - - 1,177,853,941
Oregon 36,008,771 22,672,988 20,208,081
Pennsylvania 70,377,689 4,353,009 88,503,353
Puerto Rico - - 250,000,000
Rhode Island 10,763,133 566,136 78,747,228
South Carolina 1,161,374 1,154,481 369,303,858
South Dakota 215,280 83,251,611 6,332,531
Tennessee 7,597,700 3,973,350 507,131,631
Texas 41,302,705 16,224,173 312,328,108
Utah 11,642,604 19,437,596 53,775,344
Vermont 1,070,663 435,931 709,366
Virgin Islands 37,888 1,569 16,719
Virginia 36,992,590 1,703,034 2,907,226
Washington 82,984,768 53,631,256 131,315,130
West Virginia 791,928 - 146,730,391
Wisconsin 19,944,179 10,808,831 934,634,038
Wyoming 355,686 9,731,111 5,286,545

Table 28. Medicaid Eligibles of Medical Care by Age and by State: FY 1998
State Name Eligibles Under 1 1 to 5 6 to 14 15 to 20 21 to 44
National Total 41,361,532 2,014,962 7,205,401 9,131,328 3,979,331 9,305,563
Alabama 628,220 33,381 131,578 147,209 52,664 104,960
Alaska 87,873 3,974 16,913 22,459 9,082 23,394
Arizona 649,302 60,354 133,626 161,127 57,260 158,158
Arkansas 426,080 17,345 74,684 94,746 49,952 88,040
California 6,191,269 208,178 1,103,640 1,452,046 674,192 1,519,166
Colorado 346,928 20,123 70,573 79,258 30,454 76,396
Connecticut 402,547 13,284 63,646 95,206 41,559 99,390
Delaware 105,153 4,017 18,666 24,597 11,233 29,434
Florida 2,040,541 84,616 373,694 484,949 194,122 468,339
Georgia 1,223,439 70,643 254,844 288,518 132,840 224,595
Hawaii 182,460 10,481 26,262 34,392 16,114 48,768
Idaho 116,718 6,340 27,952 29,758 10,539 23,646
Illinois 1,784,159 122,734 354,562 402,627 165,950 446,101
Indiana 610,146 33,629 129,822 147,188 61,334 121,762
Iowa 321,119 13,467 56,116 69,327 33,328 84,648
Kansas 246,598 11,944 48,477 57,433 26,869 51,149
Kentucky 653,553 24,325 110,623 143,371 57,300 151,955
Louisiana 723,864 56,922 139,567 167,148 66,428 140,092
Maine 195,839 5,469 25,250 42,943 22,027 52,479
Maryland 603,562 27,373 109,740 143,818 57,635 151,227
Massachusetts 953,469 231,669 123,853 149,432 59,606 198,095
Michigan 1,354,718 55,629 246,010 340,091 139,279 338,950
Minnesota 557,232 19,738 98,267 144,380 70,801 125,605
Mississippi 526,604 29,728 100,482 120,046 48,018 94,316
Missouri 772,622 32,650 148,577 198,866 87,406 149,716
Montana 93,298 4,200 16,669 21,898 8,699 23,703
Nebraska 210,261 20,971 38,945 49,960 22,187 43,716
Nevada 130,662 9,005 29,982 32,428 9,332 24,927
New Hampshire 98,340 3,012 18,259 27,046 10,544 20,723
New Jersey 857,898 30,492 154,605 193,382 81,961 198,073
New Mexico 339,527 15,914 70,406 100,440 44,618 60,024
New York 3,500,292 124,586 524,368 656,138 316,777 940,604
North Carolina 1,201,681 88,252 211,122 255,365 119,267 248,009
North Dakota 62,115 2,174 10,539 13,859 6,085 13,805
Ohio 1,402,364 58,716 253,059 335,401 148,880 337,620
Oklahoma 459,570 - - - - -
Oregon 537,465 19,886 83,913 100,302 51,793 175,945
Pennsylvania 1,720,000 54,408 261,002 386,151 181,316 457,350
Puerto Rico 964,015 - - - - -
Rhode Island 148,797 4,717 24,666 34,432 13,936 36,881
South Carolina 656,263 30,163 112,674 152,085 75,061 158,586
South Dakota 83,111 6,417 17,077 20,752 8,679 14,791
Tennessee 1,454,799 35,630 192,922 286,070 154,441 416,376
Texas 2,680,583 162,406 627,209 680,891 219,455 485,901
Utah 198,730 15,377 46,724 43,188 21,001 47,592
Vermont 131,639 2,840 16,871 28,804 13,767 38,585
Virgin Islands 19,914 - - - - -
Virginia 689,571 46,016 128,645 168,243 69,331 126,533
Washington 915,214 33,407 175,278 249,653 114,589 211,109
West Virginia 373,090 15,738 64,968 85,709 42,926 90,418
Wisconsin 538,229 25,868 100,815 122,134 50,547 117,638
Wyoming 51,367 3,011 11,371 12,438 4,877 12,088

Table 28. Medicaid Eligibles of Medical Care by Age and by State: FY 1998 (Con’t)

National Total 3,489,125 1,934,986 1,597,608 1,172,148 1,531,080
Alabama 58,130 38,632 34,564 25,855 1,247
Alaska 6,028 3,285 2,040 698 -
Arizona 36,519 19,059 13,742 9,457 -
Arkansas 35,305 23,647 23,809 18,543 9
California 523,390 350,410 242,507 117,730 10
Colorado 27,455 16,972 14,185 11,511 1
Connecticut 33,795 17,914 19,039 18,714 -
Delaware 8,872 3,410 2,820 2,104 -
District of Columbia 13,962 6,354 4,856 2,836 4
Florida 159,809 117,026 93,111 64,875 -
Georgia 85,260 53,551 48,141 65,040 7
Hawaii 13,035 9,517 7,168 4,030 12,693
Idaho 7,943 3,781 3,466 3,290 3
Illinois 134,941 66,024 52,430 38,790 -
Indiana 45,305 25,595 24,149 21,362 -
Iowa 23,260 12,100 14,072 14,801 -
Kansas 19,192 10,174 10,467 10,893 -
Kentucky 76,449 37,918 30,904 20,662 46
Louisiana 60,726 37,753 32,477 22,749 2
Maine 21,263 10,218 9,018 7,111 61
Maryland 48,096 26,858 22,938 15,862 15
Massachusetts 84,509 41,166 36,769 28,370 -
Michigan 112,038 49,403 40,828 32,410 80
Minnesota 35,377 18,398 20,885 23,781 -
Mississippi 49,635 33,460 29,697 21,222 -
Missouri 59,689 34,298 33,194 28,224 2
Montana 7,935 3,449 3,476 3,269 -
Nebraska 12,931 6,996 7,241 7,279 35
Nevada 9,989 7,108 5,098 2,764 29
New Hampshire 6,860 3,445 4,001 4,450 -
New Jersey 64,994 51,802 47,118 35,454 17
New Mexico 20,310 12,480 8,833 6,329 173
New York 418,550 191,246 148,608 110,054 69,361
North Carolina 108,682 69,688 63,564 37,732 -
North Dakota 4,707 2,897 3,748 4,287 14
Ohio 118,880 54,092 51,225 44,491 -
Oklahoma - - - - 459,570
Oregon 65,374 16,040 13,845 10,359 8
Pennsylvania 183,119 76,914 66,694 53,037 9
Puerto Rico - - - - 964,015
Rhode Island 12,984 7,001 7,217 6,963 -
South Carolina 49,981 31,189 28,603 17,872 49
South Dakota 5,302 2,791 3,355 3,947 -
Tennessee 224,016 68,903 45,332 31,109 -
Texas 166,102 143,551 115,059 80,005 4
Utah 10,474 4,477 3,506 2,710 3,681
Vermont 13,931 6,525 6,319 3,997 -
Virgin Islands - - - - 19,914
Virginia 55,936 41,004 33,939 19,924 -
Washington 62,567 27,129 23,173 18,304 5
West Virginia 39,413 14,282 11,412 8,224 -
Wisconsin 42,962 23,516 27,463 27,271 15
Wyoming 3,143 1,538 1,503 1,397 1

Table 29. Medicaid Eligibles of Medical Care by Sex and by State: FY 1998
Total
State Name Eligibles Male Female Unknown
National Total 41,361,532 16,061,565 23,757,344 1,542,623
Alabama 628,220 246,111 373,496 8,613
Alaska 87,873 37,351 50,522 -
Arizona 649,302 254,985 394,317 -
Arkansas 426,080 158,087 267,867 126
California 6,191,269 2,549,535 3,641,730 4
Colorado 346,928 137,075 209,853 -
Connecticut 402,547 156,951 245,596 -
Delaware 105,153 42,157 62,996 -
District of Columbia 138,722 54,592 83,970 160
Florida 2,040,541 813,906 1,226,635 -
Georgia 1,223,439 472,711 750,722 6
Hawaii 182,460 75,609 94,239 12,612
Idaho 116,718 47,979 68,733 6
Illinois 1,784,159 734,788 1,049,370 1
Indiana 610,146 240,536 369,610 -
Iowa 321,119 128,417 192,702 -
Kansas 246,598 99,884 146,688 26
Kentucky 653,553 265,594 387,906 53
Louisiana 723,864 286,802 436,987 75
Maine 195,839 81,408 114,382 49
Maryland 603,562 230,580 372,969 13
Massachusetts 953,469 387,651 565,818 -
Michigan 1,354,718 553,462 801,256 -
Minnesota 557,232 231,848 325,384 -
Mississippi 526,604 204,935 321,668 1
Missouri 772,622 311,009 461,612 1
Montana 93,298 39,042 54,256 -
Nebraska 210,261 84,200 121,169 4,892
Nevada 130,662 52,910 77,583 169
New Hampshire 98,340 39,193 59,112 35
New Jersey 857,898 322,247 535,634 17
New Mexico 339,527 144,024 195,499 4
New York 3,500,292 1,405,012 2,025,906 69,374
North Carolina 1,201,681 462,274 739,407 -
North Dakota 62,115 24,403 37,687 25
Ohio 1,402,364 557,553 844,807 4
Oklahoma 459,570 - - 459,570
Oregon 537,465 236,268 301,187 10
Pennsylvania 1,720,000 688,234 1,031,766 -
Puerto Rico 964,015 - - 964,015
Rhode Island 148,797 57,441 91,354 2
South Carolina 656,263 233,707 422,372 184
South Dakota 83,111 34,135 48,961 15
Tennessee 1,454,799 610,842 843,949 8
Texas 2,680,583 1,075,529 1,605,019 35
Utah 198,730 79,772 117,584 1,374
Vermont 131,639 57,749 73,890 -
Virgin Islands 19,914 - - 19,914
Virginia 689,571 274,850 414,721 -
Washington 915,214 381,162 533,998 54
West Virginia 373,090 158,690 213,237 1,163
Wisconsin 538,229 217,485 320,744 -
Wyoming 51,367 20,880 30,474 13

Table 30. Medicaid Eligibles of Medical Care by Race/Ethnicity and by State: FY 1998
Total White Black

State Name Eligibles Not Hispanic Not Hispanic Hispanic
National Total 41,361,532 17,838,846 10,646,780 6,924,815
Alabama 628,220 273,245 322,829 5,575
Alaska 87,873 37,940 5,477 2,946
Arizona 649,302 250,559 42,748 246,508
Arkansas 426,080 258,183 143,381 5,349
California 6,191,269 1,806,631 804,451 2,515,612
Colorado 346,928 172,252 27,617 115,446
Connecticut 402,547 180,483 99,614 114,419
Delaware 105,153 43,908 48,219 8,202
Florida 2,040,541 824,278 704,220 336,323
Georgia 1,223,439 441,075 654,613 42,039
Hawaii 182,460 25,039 1,822 6,513
Idaho 116,718 99,797 550 13,680
Illinois 1,784,159 713,454 763,561 265,041
Indiana 610,146 426,177 151,049 25,813
Iowa 321,119 277,085 26,527 11,600
Kansas 246,598 170,132 46,234 20,212
Kentucky 653,553 537,100 84,798 5,097
Louisiana 723,864 231,218 441,877 -
Maine 195,839 - - -
Maryland 603,562 210,449 335,488 23,554
Massachusetts 953,469 532,005 105,065 136,792
Michigan 1,354,718 718,380 502,143 58,319
Minnesota 557,232 355,580 85,478 32,231
Mississippi 526,604 160,692 334,520 1,600
Missouri 772,622 537,215 235,406 -
Montana 93,298 69,648 604 1,712
Nebraska 210,261 146,079 30,199 21,085
Nevada 130,662 75,951 25,025 22,998
New Hampshire 98,340 94,836 969 1,629
New Jersey 857,898 259,995 307,264 189,885
New Mexico 339,527 92,276 9,236 173,187
New York 3,500,292 975,344 819,724 759,184
North Carolina 1,201,681 526,527 529,550 45,537
North Dakota 62,115 45,043 1,011 1,640
Ohio 1,402,364 883,444 460,334 1,407
Oklahoma 459,570 - - -
Oregon 537,465 428,563 23,122 55,968
Pennsylvania 1,720,000 1,036,265 496,909 136,041
Rhode Island 148,797 85,136 15,128 26,695
South Carolina 656,263 251,122 373,442 5,110
South Dakota 83,111 49,424 178 126
Tennessee 1,454,799 963,006 417,128 12,947
Texas 2,680,583 739,597 543,971 1,280,864
Utah 198,730 146,326 4,253 28,724
Vermont 131,639 129,962 761 206
Virgin Islands 19,914 - - -
Virginia 689,571 314,040 332,198 25,396
Washington 915,214 670,018 61,404 109,817
West Virginia 373,090 343,131 18,218 699
Wisconsin 538,229 187,321 83,707 21,540
Wyoming 51,367 40,249 1,083 4,782

Table 30. Medicaid Eligibles of Medical Care by Race/Ethnicity and by State: FY 1998 (Con’t)

National Total 1,028,316 482,594 4,440,181
Alabama 2,477 1,304 22,790
Alaska 4,640 34,922 1,948
Arizona 4,796 92,322 12,369
Arkansas 932 826 17,409
California 465,987 27,731 570,857
Colorado 3,793 2,268 25,552
Connecticut 6,030 642 1,359
Delaware 423 257 4,144
Florida 9,319 1,022 165,379
Georgia 10,774 625 74,313
Hawaii 76,438 101 72,547
Idaho 342 2,346 3
Illinois 38,551 2,968 584
Indiana 1,556 423 5,128
Iowa 4,061 1,846 -
Kansas 6,690 3,330 -
Kentucky 1,283 219 25,056
Louisiana - - 50,769
Maine - - 195,839
Maryland 13,757 1,139 19,175
Massachusetts 30,943 2,254 146,410
Michigan 18,724 6,304 50,848
Minnesota 42,220 27,012 14,711
Mississippi 1,981 1,825 25,986
Missouri - - 1
Montana 400 20,920 14
Nebraska 2,418 8,578 1,902
Nevada 3,101 2,818 769
New Hampshire 877 23 6
New Jersey 9,528 2,105 89,121
New Mexico 1,682 54,191 8,955
New York 71,262 8,351 866,427
North Carolina 11,269 20,514 68,284
North Dakota 321 14,061 39
Ohio 5,547 36,703 14,929
Oregon 15,287 10,537 3,988
Pennsylvania 29,882 1,521 19,382
Rhode Island 4,670 241 16,927
South Carolina 1,186 799 24,604
South Dakota 60 30,455 2,868
Tennessee 7,517 3,470 50,731
Texas 26,005 7,477 82,669
Utah 6,827 10,604 1,996
Vermont 464 246 -
Virgin Islands - - 19,914
Virginia 15,763 809 1,365
Washington 48,392 25,583 -
West Virginia 432 - 10,610
Wisconsin 18,593 6,608 220,460
Wyoming 162 4,273 818

Table 31. Medicaid Inpatient Hospital Recipients, Discharges, and Days of Care by State: FY 1998
Total Recipients Total Total

State Name Discharged Discharges Days of Care
National Total 2,792,656 3,970,901 19,091,219
Alabama 2,184 3,017 27,025
Alaska 8,699 10,898 51,128
Arizona 91,418 110,981 378,392
Arkansas 48,588 61,879 251,944
California 349,987 516,785 1,895,493
Colorado 23,568 30,787 147,863
Connecticut 10,151 16,123 96,982
Delaware 1,753 2,089 11,809
Florida 156,364 215,213 989,643
Georgia 110,240 138,776 657,879
Hawaii - - -
Idaho 13,518 16,891 56,223
Illinois 164,377 248,036 1,301,729
Indiana 19,787 84,102 442,636
Iowa 20,817 27,951 148,066
Kansas 22,537 28,945 120,568
Kentucky 53,780 81,507 300,124
Louisiana 82,645 114,480 570,417
Maine 5,197 10,155 25,177
Maryland 27,632 38,140 214,760
Massachusetts 37,350 54,197 720,322
Michigan 98,367 135,295 623,300
Minnesota 27,707 37,805 197,166
Mississippi 52,051 70,459 315,262
Missouri 53,387 77,868 381,867
Montana 9,587 13,669 47,170
Nebraska - - -
Nevada 17,933 23,758 139,834
New Hampshire 7,476 10,053 46,515
New Jersey 37,687 71,577 501,729
New Mexico 16,619 20,742 80,280
New York 290,616 412,783 2,744,476
North Carolina 102,240 137,791 692,093
North Dakota 6,071 7,993 34,456
Ohio 109,549 164,813 758,676
Oklahoma - - -
Oregon 2,710 24,786 8,969
Pennsylvania 82,768 113,654 658,135
Puerto Rico - - -
Rhode Island 5,451 10,267 98,741
South Carolina 75,007 99,277 438,550
South Dakota 9,221 12,562 89,503
Tennessee - - -
Texas 346,148 414,685 1,581,584
Utah 13,643 15,481 56,280
Vermont 3,352 4,786 22,098
Virgin Islands 997 1,138 5,281
Virginia 69,536 92,857 332,835
Washington 26,544 43,755 285,966
West Virginia 31,996 51,277 170,226
Wisconsin 25,346 59,522 184,578
Wyoming 7,132 9,065 31,272

Table 32. Medicaid Long-Term Care Recipients and Days of Care by State: FY 1998
Inpatient Mental Health Nursing Facility ICF/MR

Total Days of Total Days of Total Days of
State Name Recipients Care Recipients Care Recipients Care
National Total 125,632 6,514,273 1,555,329 384,548,919 123,658 50,635,779
Alabama 1,329 44,840 23,844 6,217,003 750 259,415
Alaska 627 41,468 887 203,831 8 526
Arizona 14 53 1,426 187,124 - -
Arkansas 3,146 166,910 21,486 6,464,116 1,867 1,273,503
California 463 15,224 123,270 25,166,839 9,885 3,234,774
Colorado 361 19,105 18,928 3,944,425 500 114,696
Connecticut 370 39,951 28,167 7,731,433 1,530 475,573
Delaware 531 23,033 3,256 1,083,374 342 120,187
District of Columbia 162 8,059 4,217 1,245,685 821 389,879
Florida 253 41,000 73,030 17,028,588 3,567 1,256,138
Georgia - - 40,390 14,236,601 1,728 643,772
Hawaii - - 4,420 1,065,390 146 44,281
Idaho 39 2,656 5,297 937 1,012 15,878
Illinois 3,768 73,442 79,751 21,499,940 12,081 5,464,459
Indiana 2,134 115,547 44,524 23,443,019 6,035 3,478,807
Iowa 958 137,683 25,115 5,878,668 2,338 780,929
Kansas 333 18,910 16,802 3,222,044 1,441 385,049
Kentucky 4,338 117,198 27,439 6,301,308 1,240 423,694
Louisiana 6,043 45,597 34,403 9,315,664 6,014 2,086,796
Maine 705 29,868 9,278 1,238,844 361 137,353
Maryland 1,827 214,908 27,834 5,950,791 627 218,311
Massachusetts 830 48,586 46,875 8,836,620 43 5,504
Michigan 2,334 107,850 44,678 10,964,698 1,322 280,090
Minnesota 249 27,079 37,580 9,863,220 4,273 1,241,279
Mississippi 2,334 39,556 19,552 4,725,887 2,490 837,052
Missouri 9 2,663 37,226 9,507,778 1,442 490,620
Montana 14 1,298 5,316 1,375,288 149 56,237
Nebraska - - - - - -
Nevada 686 36,007 3,747 943,285 293 115,832
New Hampshire 200 3,687 7,700 2,149,243 33 8,509
New Jersey 1,899 239,445 48,552 11,730,568 4,514 7,866,245
New Mexico 468 6,384 8,170 1,759,296 362 97,381
New York 36,713 2,246,241 135,450 33,887,907 11,928 4,017,960
North Carolina 2,377 101,370 41,218 9,872,937 4,853 1,670,529
North Dakota 145 165,060 5,506 1,291,824 637 147,873
Ohio 783 10,591 86,236 21,082,183 8,162 2,879,008
Oregon 761 146,234 11,960 2,683,606 373 128,121
Pennsylvania 8,512 229,355 76,592 19,505,418 5,757 1,886,153
Rhode Island 341 23,123 11,128 4,184,505 100 113,887
South Carolina 1,531 134,357 17,352 4,313,445 2,856 914,241
South Dakota 51 11,887 6,095 1,618,401 337 108,007
Tennessee - - 86,763 10,679,610 - -
Texas - - 88,522 23,558,778 13,935 4,757,721
Utah 2 8 5,433 1,347,951 867 295,499
Vermont 133 2,035 3,804 910,719 17 2,830
Virgin Islands - - 67 9,824 - -
Virginia 34,172 1,621,453 27,145 6,800,731 2,120 722,853
Washington 28 236 23,949 8,797,689 156 48,794
West Virginia 1,564 65,907 11,677 - 609 -
Wisconsin 2,087 88,239 40,715 10,113,439 3,600 1,092,081
Wyoming 8 170 2,557 608,445 137 47,453

Table 33. Medicaid Eligibles and Premium Payments for Capitation Plans and PCCM by State:
FY 1998
HMO/HIO Plans Prepaid Plans

State Name Eligibles Payments Eligibles Payments
National Total 14,722,177 $16,213,910,471 8,382,884 $1,790,303,756
Alabama 38,523 62,473,486 306,384 226,498,950
Alaska - - - -
Arizona 655,571 1,289,163,211 596,131 142,255,286
Arkansas - - 244,596 4,360,523
California 2,799,369 2,142,428,098 4,862,797 586,587,065
Colorado 112,705 131,714,033 297,604 101,006,921
Connecticut 271,411 377,212,893 - -
Delaware 85,147 121,932,232 - -
District of Columbia 60,710 45,298,685 1 21
Florida 722,113 684,011,686 88,872 16,860,657
Georgia 78,418 57,848,295 - -
Hawaii 144,744 213,612,580 - -
Idaho - - - -
Illinois 270,106 241,278,075 - -
Indiana 268,410 165,505,151 - -
Iowa 97,517 53,304,564 245,703 53,870,893
Kansas 43,887 17,149,248 - -
Kentucky 193,864 311,260,601 - -
Louisiana - - - -
Maine 9,268 4,098,201 - -
Maryland 447,701 803,474,501 47 779,269
Massachusetts 247,767 305,723,630 621,146 172,208,666
Michigan 631,599 707,677,964 147,765 102,308,349
Minnesota 317,914 482,903,353 - -
Mississippi 17,621 22,134,623 - -
Missouri 330,539 277,251,576 - -
Montana 3,574 3,189,285 88,837 49,392,200
Nebraska 19,506 - 110,606 -
Nevada 21,382 16,811,739 33,691 14,343,694
New Hampshire 11,097 12,100,995 - -
New Jersey 501,456 610,251,739 40,890 6,770,772
New Mexico 262,506 372,264,074 - -
New York 813,694 990,708,190 68,771 78,893,290
North Carolina 221,886 85,667,708 31 61,505
North Dakota 1,555 1,316,917 - -
Ohio 452,447 494,153,710 64 691,529
Oklahoma 82,973 - - -
Oregon 437,914 501,525,712 477,139 163,273,360
Pennsylvania 891,093 1,800,415,624 - -
Puerto Rico - - - -
Rhode Island 94,562 112,545,918 - -
South Carolina 8,202 4,345,686 9,027 12,827,431
South Dakota 13,734 6,420,420 - -
Tennessee 1,414,683 1,670,212,023 - -
Texas 284,226 - - -
Utah 92,951 73,991,642 141,226 33,112,909
Vermont 69,440 53,763,059 - -
Virgin Islands - - - -
Virginia 159,392 186,255,441 112 1,528,628
Washington 604,315 403,713,433 - -
West Virginia 131,349 - - -
Wisconsin 283,336 296,800,470 1,444 22,671,838
Wyoming - - - -

Table 33. Medicaid Eligibles and Premium Payments for Capitation Plans and PCCM by State:
FY 1998 (Con’t)
PCCM Unduplicated
State Name Eligibles Payments Enrolled Eligibles
National Total 4,569,691 $18,007,746 21,813,135
Alabama 151,910 3,830,786 362,272
Alaska - - -
Arizona - - 655,571
Arkansas 229,092 5,405,229 318,625
California 52,402 6,943,824 5,044,803
Colorado - - 308,035
Connecticut - - 271,411
Delaware - - 85,147
District of Columbia 8,403 1,003,654 66,873
Florida 835,207 17,980,527 1,411,107
Georgia 877,799 21,797,455 906,717
Hawaii - - 131,761
Idaho 45,745 1,389,468 45,745
Illinois 16,414 710,585 286,520
Indiana 241,557 4,936,728 477,480
Iowa 80,287 1,001,800 247,483
Kansas 118,281 1,618,536 152,288
Kentucky - - 194,314
Louisiana 40,729 - 40,729
Maine - - 9,345
Maryland - - 451,757
Massachusetts 621,146 9,288,830 720,576
Michigan - - 747,895
Minnesota - - 318,088
Mississippi - - 17,654
Missouri - - 333,096
Montana 57,957 1,460,907 88,872
Nebraska 17,466 - 110,606
Nevada 26,047 4,009,342 55,886
New Hampshire - - 11,097
New Jersey - - 542,826
New Mexico 101,119 754,694 272,499
New York 51,530 20,295,994 920,302
North Carolina 617,827 13,163,095 697,376
North Dakota 32,099 476,322 32,525
Ohio - - 452,511
Oklahoma 71,297 - 154,270
Oregon 11,112 231,444 481,050
Pennsylvania - - 897,853
Puerto Rico - - -
Rhode Island - - 94,563
South Carolina - - 17,186
South Dakota - - -
Tennessee - - 1,436,197
Texas 153,672 - 437,898
Utah - - 144,199
Vermont - - 69,440
Virgin Islands - - -
Virginia 110,559 1,697,486 259,808
Washington - - 613,060
West Virginia - - 131,349
Wisconsin 34 11,040 286,470
Wyoming - - -

Table 34. Prepaid Health Care Medicaid Recipients by Maintenance Assistance Status and by State:
FY 1998

National Total 20,202,887 9,662,017 2,401,288 3,514,045 2,894,690 2,045,872
Alabama 344,907 - - - - 344,907
Alaska - - - - - -
Arizona 368,344 - - - - 368,344
Arkansas 244,768 118,180 23,121 83,383 18,446 1,638
California 6,022,536 3,511,431 1,498,574 128,401 876,362 7,768
Colorado 316,060 115,659 - 77,144 121,401 316,881
Connecticut 271,411 122,049 7,488 48,312 93,562 -
Delaware 85,239 30,911 - 43,189 9,544 1,595
Florida 791,752 530,364 5,948 175,007 79,139 1,294
Georgia 78,463 45,792 - 18,770 13,694 207
Hawaii 144,744 77,313 2,712 58,895 3,960 1,864
Idaho - - - - - -
Illinois 142,429 107,279 8,436 13,065 13,649 -
Indiana 271,005 104,184 - 73,873 91,135 1,813
Iowa 246,582 114,478 3,992 50,841 77,015 256
Kansas 44,003 15,078 88 22,564 6,173 100
Kentucky 194,164 114,814 12,905 56,743 9,059 643
Louisiana - - - - - -
Maine 9,324 4,149 22 2,930 2,198 25
Maryland 449,825 240,158 22,856 117,274 65,366 4,171
Massachusetts 768,831 373,918 204,450 136,205 54,258 -
Michigan 758,185 469,222 141,355 123,737 21,719 2,152
Minnesota 318,854 144,319 1,497 65,421 106,102 1,515
Mississippi 17,628 8,939 - 7,681 980 28
Missouri 336,057 140,788 - 141,948 45,772 7,549
Montana 96,701 46,928 7,230 15,133 22,534 4,876
Nebraska 159,614 81,317 19 60,609 17,669 -
Nevada 55,923 25,874 - 258 27,944 1,847
New Hampshire 11,176 4,079 166 5,172 1,758 1
New Jersey 545,380 264,886 2,757 120,979 156,167 591
New Mexico 263,256 111,939 - 148,937 1,993 387
New York 884,443 575,752 228,890 76,179 3,622 -
North Carolina 220,700 102,128 2,311 111,834 4,427 -
North Dakota 1,549 467 202 460 416 4
Ohio 453,265 305,146 - 140,278 7,841 -
Oregon 481,498 133,858 6,564 213,327 116,095 11,654
Pennsylvania 902,896 509,692 51,371 170,453 171,186 194
Rhode Island 96,178 64,623 1,214 20,334 7,933 2,074
South Carolina 17,195 5,666 - 7,999 3,494 36
South Dakota 83,998 35,519 - 28,556 19,923 -
Tennessee 1,764,279 439,299 136,153 623,307 216,494 349,026
Texas - - - - - -
Utah 170,319 36,839 4,000 18,888 82,028 28,564
Vermont 69,682 21,104 4,602 34,184 9,547 245
Virginia 159,392 81,488 289 56,163 21,452 -
Washington 1,146,180 271,871 148 160,350 177,195 536,616
West Virginia 52 - - - - 52
Wisconsin 293,233 104,903 15,550 52,112 114,064 6,604
Wyoming - - - - - -

Table 35. Prepaid Health Care Medicaid Recipients by Basis of Eligibility and by State: FY 1998

National Total 20,202,887 997,266 2,351,991 10,356,858 4,493,559 2,003,213
Alabama 344,907 - - - - 344,907
Alaska - - - - - -
Arizona 368,344 - - - - 368,344
Arkansas 244,768 22,617 70,690 110,674 35,766 5,021
California 6,022,536 548,137 894,674 3,053,189 1,390,107 136,429
Colorado 316,060 37,302 58,614 148,339 56,531 15,274
Connecticut 271,411 13 919 185,624 77,905 6,950
Delaware 85,239 259 8,145 47,228 27,610 1,997
District of Columbia 100,867 - 1,896 43,292 15,317 40,362
Florida 791,752 17,332 110,154 507,475 149,399 7,392
Georgia 78,463 672 8,271 53,596 15,677 247
Hawaii 144,744 - - 75,329 64,575 4,840
Idaho - - - - - -
Illinois 142,429 86 1,338 101,088 38,686 1,231
Indiana 271,005 59,343 42,171 127,846 38,790 2,855
Iowa 246,582 817 41,618 130,634 68,540 4,973
Kansas 44,003 1 53 34,092 9,645 212
Kentucky 194,164 9,288 50,936 97,791 35,142 1,007
Maine 9,324 - 22 6,711 2,458 133
Maryland 449,825 6,261 75,205 258,313 91,156 18,890
Massachusetts 768,831 1,667 111,699 451,115 203,740 610
Michigan 758,185 8,715 130,478 422,747 180,954 15,291
Minnesota 318,854 27,611 2,607 222,262 64,298 2,076
Mississippi 17,628 795 4,666 9,709 2,413 45
Missouri 336,057 1 458 248,210 69,798 17,590
Montana 96,701 8,617 15,812 44,510 19,757 8,005
Nebraska 159,614 1,234 14,598 98,022 37,507 8,253
Nevada 55,923 646 65 40,708 12,594 1,910
New Hampshire 11,176 - 19 9,113 1,939 105
New Jersey 545,380 35,542 16,460 353,264 138,754 1,360
New Mexico 263,256 984 26,717 192,207 41,706 1,642
New York 884,443 6,220 51,023 565,619 257,959 3,622
North Carolina 220,700 - 12,346 194,263 9,761 4,330
North Dakota 1,549 - 1 1,125 414 9
Ohio 453,265 75 1,852 315,021 135,782 535
Oregon 481,498 37,705 93,759 123,793 201,456 24,785
Pennsylvania 902,896 63,018 144,515 505,598 178,596 11,169
Rhode Island 96,178 3 625 63,451 29,690 2,409
South Carolina 17,195 399 1,586 13,553 1,519 138
South Dakota 83,998 8,137 14,713 46,960 12,894 1,294
Tennessee 1,764,279 84,154 293,570 552,654 472,496 361,405
Texas - - - - - -
Utah 170,319 6,552 11,325 92,508 29,359 30,575
Vermont 69,682 33 1,082 36,706 31,477 384
Virginia 159,392 1,166 20,533 105,720 31,967 6
Washington 1,146,180 1,569 10,651 455,401 141,869 536,690
West Virginia 52 - - - - 52
Wisconsin 293,233 295 6,125 211,398 67,556 7,859
Wyoming - - - - - -

Table 36. PCCM Medicaid Recipients by Maintenance Assistance Status and by State: FY 1998

National Total 4,066,440 1,891,472 114,232 1,293,024 479,745 287,967
Alabama 151,910 - - - - 151,910
Alaska - - - - - -
Arizona - - - - - -
Arkansas 243,266 86,345 20,096 99,153 32,938 4,734
California 54,471 35,894 7,902 470 8,730 1,475
Colorado 48,907 - - - - 48,907
Connecticut - - - - - -
District of Columbia 8,623 7,325 547 250 233 268
Florida 841,304 520,029 5,340 190,927 119,245 5,763
Georgia 879,554 370,738 95 390,617 110,441 7,663
Hawaii - - - - - -
Idaho 50,665 6,018 - 11,983 26,587 6,077
Illinois 16,414 244 48 43 16,079 -
Indiana 242,844 92,311 - 101,825 47,301 1,407
Iowa 80,428 35,092 281 21,937 23,103 15
Kansas 123,902 53,718 1,202 48,543 17,387 3,052
Kentucky - - - - - -
Maine - - - - - -
Maryland - - - - - -
Massachusetts 264,035 157,495 51,179 43,461 11,900 -
Michigan 53,733 - - - - 53,733
Minnesota - - - - - -
Montana 59,578 30,807 18 12,528 14,748 1,477
Nebraska 27,577 15,431 - 9,799 2,347 -
Nevada 28,638 14,751 - 116 13,259 512
New Hampshire - - - - - -
New Jersey - - - - - -
New Mexico 103,867 56,583 - 47,230 46 8
New York 804 599 168 15 22 -
North Carolina 591,740 342,233 21,991 225,751 1,765 -
North Dakota 32,566 9,701 5,058 10,289 6,653 865
Ohio - - - - - -
Oregon 11,163 3,203 162 4,947 2,750 101
Pennsylvania - - - - - -
Rhode Island - - - - - -
South Dakota 39,858 13,963 - 19,322 6,573 -
Tennessee - - - - - -
Texas - - - - - -
Utah - - - - - -
Vermont - - - - - -
Virginia 110,559 38,962 144 53,818 17,635 -
Washington - - - - - -
West Virginia - - - - - -
Wisconsin 34 30 1 - 3 -
Wyoming - - - - - -

Table 37. PCCM Medicaid Recipients BY Basis OF Eligibility and by State: FY 1998

National Total 4,066,440 44,327 548,443 2,509,468 629,893 334,309
Alabama 151,910 - - - - 151,910
Alaska - - - - - -
Arizona - - - - - -
Arkansas 243,266 554 38,988 151,321 43,778 8,625
California 54,471 914 7,366 29,233 14,529 2,429
Colorado 48,907 - - - - 48,907
Connecticut - - - - -
District of Columbia 8,623 1 34 5,937 2,378 273
Florida 841,304 16,897 164,152 510,793 126,334 23,128
Georgia 879,554 11,665 136,798 623,313 98,975 8,803
Hawaii - - - - - -
Idaho 50,665 2,422 7,186 29,932 4,646 6,479
Illinois 16,414 - 13 310 34 16,057
Indiana 242,844 15 8,755 186,089 45,530 2,455
Iowa 80,428 1 180 54,447 25,593 207
Kansas 123,902 878 19,661 77,791 22,151 3,421
Maine - - - - - -
Massachusetts 264,035 15 50,706 153,613 59,549 152
Michigan 53,733 - - - - 53,733
Montana 59,578 60 7,485 36,330 12,310 3,393
Nebraska 27,577 193 1,434 17,862 7,223 865
Nevada 28,638 643 40 21,985 5,432 538
New Mexico 103,867 404 14,481 74,914 14,020 48
New York 804 - 96 685 1 22
North Carolina 591,740 7,937 72,988 409,100 100,288 1,427
North Dakota 32,566 2 98 22,956 8,489 1,021
Ohio - - - - - -
Oregon 11,163 959 2,178 2,948 4,668 410
South Dakota 39,858 2 4,615 27,754 7,486 1
Texas - - - - - -
Utah - - - - - -
Vermont - - - - - -
Virginia 110,559 765 11,156 72,154 26,479 5
Wisconsin 34 - 33 1 - -
Wyoming - - - - - -

Table 38. Prepaid Health Care Medicaid Recipients by Age and by State: FY 1998
National Total 20,202,887 586,976 3,726,967 4,846,633 2,005,878 4,409,601
Alabama 344,907 - - - - -
Alaska - - - - - -
Arizona 368,344 - - - - -
Arkansas 244,768 13,179 48,721 59,642 21,325 46,099
California 6,022,536 56,292 1,108,708 1,464,620 682,263 1,447,924
Colorado 316,060 17,262 67,679 74,094 26,941 66,164
Connecticut 271,411 10,871 60,801 89,814 36,608 67,780
Delaware 85,239 3,444 17,309 22,468 9,761 25,181
Florida 791,752 25,307 186,752 255,561 82,666 173,104
Georgia 78,463 2,229 19,706 26,211 7,937 17,074
Hawaii 144,744 - - - - -
Idaho - - - - - -
Illinois 142,429 10,484 40,833 43,205 14,486 31,492
Indiana 271,005 12,142 48,975 55,463 21,345 50,822
Iowa 246,582 11,271 51,530 63,471 28,943 72,874
Kansas 44,003 3,404 13,485 13,873 5,066 7,758
Kentucky 194,164 9,272 39,495 47,868 17,430 46,322
Maine 9,324 384 2,140 3,127 1,285 2,236
Maryland 449,825 22,652 99,718 130,238 46,561 106,271
Massachusetts 768,831 42,031 137,135 186,284 83,429 238,823
Michigan 758,185 27,295 157,771 223,507 78,367 198,428
Minnesota 318,854 12,140 66,172 98,887 46,762 60,530
Mississippi 17,628 1,137 3,869 4,417 1,681 3,684
Missouri 336,057 15,942 91,094 118,237 47,507 60,498
Montana 96,701 3,460 17,369 22,449 9,091 24,731
Nebraska 159,614 - - - - -
Nevada 55,923 5,115 16,955 17,228 4,340 10,263
New Hampshire 11,176 293 3,420 4,307 1,118 1,946
New Jersey 545,380 23,743 135,270 157,051 52,252 121,812
New Mexico 263,256 12,298 63,597 90,410 37,956 44,362
New York 884,443 25,673 208,860 255,227 91,352 243,955
North Carolina 220,700 27,921 72,570 84,209 24,303 10,149
North Dakota 1,549 60 433 515 159 363
Ohio 453,265 40,450 115,360 138,417 47,374 105,364
Oregon 481,498 13,741 78,629 91,859 45,563 158,953
Pennsylvania 902,896 26,835 167,058 245,379 98,823 236,745
Rhode Island 96,178 4,132 22,851 30,097 10,917 25,675
South Carolina 17,195 1,385 5,695 6,140 1,265 1,734
South Dakota 83,998 6,678 17,267 21,408 8,925 14,926
Tennessee 1,764,279 33,019 190,961 282,970 149,889 402,126
Texas - - - - - -
Utah 170,319 12,991 43,238 32,720 12,441 29,518
Vermont 69,682 1,451 10,400 17,383 7,553 25,745
Virginia 159,392 5,828 38,319 53,444 20,703 32,357
Washington 1,146,180 23,579 152,663 207,568 86,439 123,579
West Virginia 52 - - - - -
Wisconsin 293,233 18,945 84,738 88,584 29,059 59,145
Wyoming - - - - - -

Table 38. Prepaid Health Care Medicaid Recipients by Age and by State: FY 1998 (Con’t)

National Total 1,383,923 566,028 419,531 265,807 1,991,543
Alabama - - - - 344,907
Alaska - - - - -
Arizona - - - - 368,344
Arkansas 22,958 13,037 12,151 7,633 23
California 543,134 332,520 248,647 132,446 5,982
Colorado 24,520 15,269 12,901 10,560 670
Connecticut 5,504 32 1 - -
Delaware 6,437 467 131 34 7
District of Columbia 1,267 15 4 - 40,156
Florida 42,928 14,088 6,924 3,508 914
Georgia 3,699 903 320 360 24
Hawaii - - - - 144,744
Idaho - - - - -
Illinois 1,807 54 46 22 -
Indiana 20,724 20,901 20,976 19,075 582
Iowa 17,843 545 17 21 67
Kansas 379 2 - - 36
Kentucky 18,634 7,812 4,848 2,216 267
Louisiana - - - - -
Maine 148 1 - - 3
Maryland 32,166 6,872 2,608 732 2,007
Massachusetts 77,701 2,143 780 505 -
Michigan 54,646 11,785 3,885 1,210 1,291
Minnesota 4,958 8,882 9,317 10,736 470
Mississippi 1,668 670 369 129 4
Missouri 2,754 12 - - 13
Montana 7,957 3,305 3,415 3,375 1,549
Nebraska - - - - 159,614
Nevada 430 301 276 72 943
New Hampshire 92 - - - -
New Jersey 14,722 5,922 13,186 20,992 430
New Mexico 12,544 1,456 323 94 216
New York 50,578 5,235 2,468 1,095 -
North Carolina 1,544 3 - 1 -
North Dakota 19 - - - -
Ohio 6,224 30 26 20 -
Oklahoma - - - - -
Oregon 58,272 12,279 11,186 9,080 1,936
Pennsylvania 82,368 26,999 13,982 4,653 54
Rhode Island 2,108 13 2 1 382
South Carolina 548 115 161 142 10
South Dakota 5,204 2,636 3,108 3,840 6
Tennessee 218,221 66,293 43,792 30,025 346,983
Texas - - - - -
Utah 5,776 2,808 2,418 2,196 26,213
Vermont 6,765 146 8 1 230
Virgin Islands - - - - -
Virginia 7,133 1,209 343 56 -
Washington 14,058 632 508 683 536,471
West Virginia - - - - 52
Wisconsin 5,485 636 404 294 5,943
Wyoming - - - - -

Table 39. Prepaid Health Care Medicaid Recipients by Sex and by State: FY 1998
Total
National Total 20,202,887 7,517,298 10,692,036 1,993,553
Alabama 344,907 - - 344,907
Alaska - - - -
Arizona 368,344 - - 368,344
Arkansas 244,768 97,329 147,370 69
California 6,022,536 2,557,879 3,458,672 5,985
Colorado 316,060 126,797 188,593 670
Connecticut 271,411 106,677 164,734 -
Delaware 85,239 34,763 50,469 7
Florida 791,752 327,441 463,397 914
Georgia 78,463 29,947 48,492 24
Hawaii 144,744 - - 144,744
Idaho - - - -
Illinois 142,429 53,960 88,469 -
Indiana 271,005 101,216 169,207 582
Iowa 246,582 103,230 143,285 67
Kansas 44,003 18,121 25,844 38
Kentucky 194,164 77,712 116,183 269
Louisiana - - - -
Maine 9,324 3,703 5,618 3
Maryland 449,825 182,425 265,394 2,006
Massachusetts 768,831 318,398 450,433 -
Michigan 758,185 309,665 447,232 1,288
Minnesota 318,854 129,936 188,448 470
Mississippi 17,628 6,847 10,777 4
Missouri 336,057 136,846 199,198 13
Montana 96,701 39,763 55,389 1,549
Nebraska 159,614 - - 159,614
Nevada 55,923 21,770 33,168 985
New Hampshire 11,176 4,657 6,516 3
New Jersey 545,380 201,674 343,276 430
New Mexico 263,256 114,919 148,119 218
New York 884,443 332,669 551,774 -
North Carolina 220,700 105,782 114,918 -
North Dakota 1,549 604 945 -
Ohio 453,265 174,748 278,517 -
Oklahoma - - - -
Oregon 481,498 210,791 268,766 1,941
Pennsylvania 902,896 358,234 544,610 52
Puerto Rico - - - -
Rhode Island 96,178 36,784 59,012 382
South Carolina 17,195 7,733 9,452 10
South Dakota 83,998 33,826 48,327 1,845
Tennessee 1,764,279 596,030 821,259 346,990
Texas - - - -
Utah 170,319 61,485 82,572 26,262
Vermont 69,682 30,965 38,487 230
Virginia 159,392 62,955 96,437 -
Washington 1,146,180 260,243 349,451 536,486
West Virginia 52 - - 52
Wisconsin 293,233 114,613 172,685 5,935
Wyoming - - - -

Table 40. Prepaid Health Care Medicaid Recipients by Race/Ethnicity and by State: FY 1998
Total White Black

State Name Recipients Not Hispanic Not Hispanic Hispanic
National Total 20,202,887 7,683,322 4,888,675 3,645,975
Alabama 344,907 - - -
Alaska - - - -
Arizona 368,344 - - -
Arkansas 244,768 145,661 81,795 3,531
California 6,022,536 1,904,341 849,639 2,176,630
Colorado 316,060 162,596 25,982 100,816
Connecticut 271,411 96,431 79,049 91,794
Delaware 85,239 34,013 41,222 6,823
District of Columbia 100,867 211 57,416 2,397
Florida 791,752 248,119 362,279 133,084
Georgia 78,463 7,310 65,908 1,958
Hawaii 144,744 - - -
Idaho - - - -
Illinois 142,429 9,226 104,667 27,153
Indiana 271,005 178,634 80,562 8,581
Iowa 246,582 208,720 23,477 9,718
Kansas 44,003 27,176 11,496 3,607
Kentucky 194,164 130,145 52,200 2,377
Louisiana - - - -
Maine 9,324 - - -
Maryland 449,825 136,929 272,690 15,441
Massachusetts 768,831 392,392 101,038 147,030
Michigan 758,185 291,087 404,497 25,069
Minnesota 318,854 182,363 63,152 16,039
Mississippi 17,628 5,689 10,736 81
Missouri 336,057 168,003 168,041 -
Montana 96,701 71,008 615 1,789
Nebraska 159,614 - - -
Nevada 55,923 25,833 13,674 13,317
New Hampshire 11,176 10,402 228 466
New Jersey 545,380 144,448 224,543 153,390
New Mexico 263,256 63,342 7,369 145,092
New York 884,443 224,257 334,160 228,503
North Carolina 220,700 98,000 97,137 11,306
North Dakota 1,549 1,171 54 86
Ohio 453,265 168,223 261,557 14,515
Oklahoma - - - -
Oregon 481,498 384,633 21,039 48,341
Pennsylvania 902,896 371,692 400,482 97,753
Puerto Rico - - - -
Rhode Island 96,178 47,782 11,197 22,063
South Carolina 17,195 5,216 11,499 78
South Dakota 83,998 48,531 177 126
Tennessee 1,764,279 935,725 409,630 12,521
Texas - - - -
Utah 170,319 109,093 3,281 20,835
Vermont 69,682 68,419 457 124
Virginia 159,392 35,429 118,100 3,178
Washington 1,146,180 441,388 44,822 83,219
West Virginia 52 - - -
Wisconsin 293,233 99,684 72,808 17,144
Wyoming - - - -

Table 40. Prepaid Health Care Medicaid Recipients by Race/Ethnicity and by State: FY 1998 (Con’t)

National Total 720,118 182,202 3,082,595
Alabama - - 344,907
Alaska - - -
Arizona - - 368,344
Arkansas 582 522 12,677
California 481,230 28,708 581,988
Colorado 3,519 2,166 20,981
Connecticut 3,696 392 49
Delaware 338 184 2,659
Florida 3,285 380 44,605
Georgia 495 25 2,767
Hawaii - - 144,744
Idaho - - -
Illinois 1,183 195 5
Indiana 584 156 2,488
Iowa 2,993 1,607 67
Kansas 1,013 675 36
Kentucky 878 98 8,466
Louisiana - - -
Maine - - 9,324
Maryland 8,347 892 15,526
Massachusetts 30,562 2,154 95,655
Michigan 12,236 2,530 22,766
Minnesota 33,257 11,173 12,870
Mississippi 271 17 834
Missouri - - 13
Montana 420 21,304 1,565
Nebraska - - 159,614
Nevada 1,459 574 1,066
New Hampshire 80 - -
New Jersey 7,019 764 15,216
New Mexico 1,403 42,415 3,635
New York 14,955 2,603 79,965
North Carolina 3,195 1,841 9,221
North Dakota 8 230 -
Ohio 2,311 462 6,197
Oklahoma - - -
Oregon 14,145 8,078 5,262
Pennsylvania 22,620 677 9,672
Puerto Rico - - -
Rhode Island 3,637 162 11,337
South Carolina 10 4 388
South Dakota 60 30,412 4,692
Tennessee 7,313 3,400 395,690
Texas - - -
Utah 5,096 4,317 27,697
Vermont 311 141 230
Virginia 2,302 201 182
Washington 32,008 8,272 536,471
West Virginia - - 52
Wisconsin 16,954 4,465 82,178
Wyoming - - -

Table 41. PCCM Medicaid Recipients by Age and by State: FY 1998
National Total 4,066,440 208,733 990,902 1,133,983 395,065 710,818
Alabama 151,910 - - - - -
Alaska - - - - - -
Arizona - - - - - -
Arkansas 243,266 10,847 67,949 79,230 29,061 42,828
California 54,471 670 10,010 15,117 5,858 15,607
Colorado 48,907 - - - - -
Connecticut - - - - - -
District of Columbia 8,623 2 2,425 2,926 742 1,992
Florida 841,304 35,739 217,755 251,721 78,934 164,192
Georgia 879,554 56,272 237,384 259,590 95,548 125,516
Hawaii - - - - - -
Idaho 50,665 2,123 15,103 14,634 3,906 8,231
Illinois 16,414 250 4,741 8,802 2,581 40
Indiana 242,844 16,216 75,121 80,552 27,026 40,561
Iowa 80,428 3,173 21,332 25,611 8,366 20,645
Kansas 123,902 5,434 31,823 36,226 14,274 25,934
Maine - - - - - -
Massachusetts 264,035 10,836 57,169 67,929 22,604 72,465
Michigan 53,733 - - - - -
Montana 59,578 2,789 14,733 17,575 6,471 14,161
Nebraska 27,577 - - - - -
Nevada 28,638 401 10,149 10,258 2,103 4,636
New Mexico 103,867 630 29,335 39,046 9,883 16,651
New York 804 - 104 575 123 2
North Carolina 591,740 55,325 143,750 169,050 62,918 116,133
North Dakota 32,566 1,626 8,416 10,298 3,943 7,453
Ohio - - - - - -
Oregon 11,163 103 1,189 1,961 823 2,105
South Dakota 39,858 4,310 11,230 11,337 4,446 7,010
Texas - - - - - -
Utah - - - - - -
Vermont - - - - - -
Virginia 110,559 1,987 31,177 31,535 15,451 24,648
Wisconsin 34 - 7 10 4 8
Wyoming - - - - - -

Table 41. PCCM Medicaid Recipients by Age and by State: FY 1998 (Con’t)

National Total 238,041 41,889 18,300 36,817 291,892
Alabama - - - - 151,910
Alaska - - - - -
Arizona - - - - -
Arkansas 11,811 1,166 229 119 26
California 4,537 760 452 212 1,248
Colorado - - - - 48,907
Connecticut - - - - -
Delaware - - - - -
District of Columbia 313 3 - - 220
Florida 64,433 15,333 6,352 1,879 4,966
Georgia 53,776 13,829 5,833 31,504 302
Hawaii - - - - -
Idaho 3,445 1,240 883 431 669
Illinois - - - - -
Indiana 2,437 26 - - 905
Iowa 1,301 - - - -
Kansas 8,278 722 308 228 675
Kentucky - - - - -
Louisiana - - - - -
Maine - - - - -
Maryland - - - - -
Massachusetts 32,553 478 - 1 -
Michigan - - - - 53,733
Minnesota - - - - -
Mississippi - - - - -
Missouri - - - - -
Montana 3,512 129 22 4 182
Nebraska - - - - 27,577
Nevada 224 292 278 73 224
New Hampshire - - - - -
New Jersey - - - - -
New Mexico 7,242 933 121 25 1
New York - - - - -
North Carolina 36,085 5,297 2,318 864 -
North Dakota 515 4 - - 311
Ohio - - - - -
Oklahoma - - - - -
Oregon 1,507 715 1,297 1,427 36
Pennsylvania - - - - -
Rhode Island - - - - -
South Carolina - - - - -
South Dakota 1,462 56 6 1 -
Tennessee - - - - -
Texas - - - - -
Utah - - - - -
Vermont - - - - -
Virginia 4,605 906 201 49 -
Washington - - - - -
West Virginia - - - - -
Wisconsin 5 - - - -
Wyoming - - - - -

Table 42. PCCM Medicaid Recipients by Sex and by State: FY 1998
Total
National Total 4,066,440 1,608,714 2,165,338 292,388
Alabama 151,910 - - 151,910
Alaska - - - -
Arizona - - - -
Arkansas 243,266 102,544 140,652 70
California 54,471 22,083 31,140 1,248
Colorado 48,907 - 48,907
Connecticut - - - -
Delaware - - - -
District of Columbia 8,623 3,026 5,377 220
Florida 841,304 369,971 466,367 4,966
Georgia 879,554 385,892 493,361 301
Hawaii - - - -
Idaho 50,665 21,294 28,702 669
Illinois 16,414 8,198 8,216 -
Indiana 242,844 100,600 141,339 905
Iowa 80,428 32,228 48,200 -
Kansas 123,902 51,985 71,238 679
Kentucky - - - -
Louisiana - - - -
Maine - - - -
Maryland - - - -
Massachusetts 264,035 104,035 160,000 -
Michigan 53,733 - - 53,733
Minnesota - - - -
Mississippi - - - -
Missouri - - - -
Montana 59,578 25,894 33,502 182
Nebraska 27,577 - - 27,577
Nevada 28,638 11,597 16,805 236
New Hampshire - - - -
New Jersey - - - -
New Mexico 103,867 46,250 57,616 1
New York 804 394 410 -
North Carolina 591,740 244,990 346,750 -
North Dakota 32,566 12,534 19,717 315
Ohio - - - -
Oklahoma - - - -
Oregon 11,163 4,298 6,829 36
Pennsylvania - - - -
Puerto Rico - - - -
Rhode Island - - - -
South Carolina - - - -
South Dakota 39,858 16,338 23,087 433
Tennessee - - - -
Texas - - - -
Utah - - - -
Vermont - - - -
Virginia 110,559 44,545 66,014 -
Washington - - - -
West Virginia - - - -
Wisconsin 34 18 16 -
Wyoming - - - -

Table 43. PCCM Medicaid Recipients by Race/Ethnicity and by State: FY 1998
Total White Black

State Name Recipients Not Hispanic Not Hispanic Hispanic
National Total 4,066,440 1,715,126 1,379,717 382,938
Alabama 151,910 - - -
Alaska - - - -
Arizona - - - -
Arkansas 243,266 142,112 89,918 3,639
California 54,471 30,244 4,942 12,201
Colorado 48,907 - - -
Connecticut - - - -
Delaware - - - -
District of Columbia 8,623 24 8,054 252
Florida 841,304 320,189 289,775 153,504
Georgia 879,554 283,721 505,355 31,783
Hawaii - - - -
Idaho 50,665 42,432 248 6,045
Illinois 16,414 811 14,767 765
Indiana 242,844 168,806 58,866 11,832
Iowa 80,428 70,808 5,819 2,552
Kansas 123,902 79,178 27,391 11,084
Kentucky - - - -
Louisiana - - - -
Maine - - - -
Maryland - - - -
Massachusetts 264,035 141,491 29,800 55,751
Michigan 53,733 - - -
Minnesota - - - -
Mississippi - - - -
Missouri - - - -
Montana 59,578 44,690 449 1,263
Nebraska 27,577 - - -
Nevada 28,638 12,024 8,437 6,945
New Hampshire - - - -
New Jersey - - - -
New Mexico 103,867 22,610 2,674 54,959
New York 804 157 502 49
North Carolina 591,740 238,369 287,656 22,685
North Dakota 32,566 22,259 554 991
Ohio - - - -
Oklahoma - - - -
Oregon 11,163 10,379 122 326
Pennsylvania - - - -
Puerto Rico - - - -
Rhode Island - - - -
South Carolina - - - -
South Dakota 39,858 27,959 59 36
Tennessee - - - -
Texas - - - -
Utah - - - -
Vermont - - - -
Virginia 110,559 56,862 44,328 6,276
Washington - - - -
West Virginia - - - -
Wisconsin 34 1 1 -
Wyoming - - - -

Table 43. PCCM Medicaid Recipients by Race/Ethnicity and by State: FY 1998 (Con’t)

National Total 47,143 68,305 473,211
Alabama - - 151,910
Alaska - - -
Arizona - - -
Arkansas 546 529 6,522
California 2,491 932 3,661
Colorado - - 48,907
Connecticut - - -
Delaware - - -
District of Columbia 69 2 222
Florida 4,864 446 72,526
Georgia 8,058 454 50,183
Hawaii - - -
Idaho 145 1,126 669
Illinois 69 2 -
Indiana 422 161 2,757
Iowa 859 390 -
Kansas 3,920 1,654 675
Kentucky - - -
Louisiana - - -
Maine - - -
Maryland - - -
Massachusetts 15,703 692 20,598
Michigan - - 53,733
Minnesota - - -
Mississippi - - -
Missouri - - -
Montana 305 12,688 183
Nebraska - - 27,577
Nevada 726 222 284
New Hampshire - - -
New Jersey - - -
New Mexico 165 21,368 2,091
New York 6 10 80
North Carolina 5,826 9,566 27,638
North Dakota 171 8,263 328
Ohio - - -
Oklahoma - - -
Oregon 70 122 144
Pennsylvania - - -
Puerto Rico - - -
Rhode Island - - -
South Carolina - - -
South Dakota 19 9,540 2,245
Tennessee - - -
Texas - - -
Utah - - -
Vermont - - -
Virginia 2,709 138 246
Washington - - -
West Virginia - - -
Wisconsin - - 32
Wyoming - - -

Table 44 Medicaid Medical Vendor Payments for Prepaid Health Care Medicaid Recipients
by Maintenance Assistance Status and by State: FY 1998

State Name Payments Cash Payments Needy Related Other Unknown
National Total $19,296,223,487 $11,115,495,025 $1,367,726,879 $3,147,537,749 $2,897,425,088 $768,038,747
Alabama 288,972,436 - - - - 288,972,436
Alaska - - - - - -
Arizona 1,431,418,497 614,603,926 - 207,764,064 609,050,506 -
Arkansas 4,359,975 2,521,205 323,118 1,153,249 342,098 20,305
California 2,867,713,795 2,061,454,084 525,689,657 22,725,657 257,149,439 694,958
Colorado 238,585,930 65,864,936 - 35,788,921 130,183,665 6,748,408
Connecticut 377,212,893 175,591,675 7,832,085 59,283,808 134,505,325 -
Delaware 122,048,974 66,198,863 - 42,075,482 12,418,295 1,356,334
District of Columbia 98,238,002 39,248,549 3,729,742 1,608,362 584,193 53,067,156
Florida 701,322,837 566,149,381 2,316,992 83,078,417 49,258,606 519,441
Georgia 57,871,451 41,529,226 - 7,660,608 8,615,452 66,165
Hawaii 213,612,580 118,748,223 3,208,458 81,434,430 7,649,821 2,571,648
Idaho - - - - - -
Illinois 241,278,075 199,373,324 7,760,840 6,195,840 27,948,071 -
Indiana 167,977,207 68,108,993 - 37,036,720 62,255,871 575,623
Iowa 107,189,198 64,336,134 712,597 16,390,556 25,717,235 32,676
Kansas 17,201,600 4,815,387 18,507 10,247,585 2,080,091 40,030
Kentucky 311,526,039 218,623,439 13,597,872 69,595,167 9,018,745 690,816
Maine 4,237,958 2,052,490 4,697 1,317,463 846,918 16,390
Maryland 851,988,946 604,575,473 57,240,565 128,822,252 58,693,808 2,656,848
Massachusetts 477,932,296 297,071,252 83,364,337 74,100,646 23,396,061 -
Michigan 823,728,725 612,392,605 133,623,737 58,315,824 7,469,950 11,926,609
Minnesota 483,228,011 210,302,771 1,806,770 53,545,476 216,531,078 1,041,916
Mississippi 22,152,325 10,337,698 - 10,921,260 799,156 94,211
Missouri 277,652,554 125,014,933 - 103,237,881 48,121,506 1,278,234
Montana 53,600,495 33,796,563 3,533,417 3,767,984 11,584,313 918,218
Nebraska 72,980,602 39,927,033 3,390 11,124,260 21,925,919 -
Nevada 32,332,069 13,237,436 - 241,038 17,738,526 1,115,069
New Hampshire 12,128,535 4,824,765 112,995 5,348,430 1,842,210 135
New Jersey 617,591,322 331,952,834 403,857 143,310,698 141,522,476 401,457
New Mexico 372,647,285 221,083,291 - 143,723,448 7,546,939 293,607
New York 1,638,382,814 1,231,486,532 309,597,191 94,632,388 2,666,704 -
North Carolina 85,665,363 43,721,752 959,689 38,967,044 2,016,879 -
North Dakota 1,319,356 336,060 141,444 501,372 338,682 1,798
Ohio 494,845,239 342,793,287 - 145,671,328 6,380,624 -
Oregon 665,872,224 189,542,785 9,513,697 297,598,133 161,992,195 7,225,414
Pennsylvania 1,801,084,202 1,240,064,684 49,689,569 221,148,782 290,298,862 (117,695)
Rhode Island 114,870,881 76,874,255 1,278,891 21,317,460 10,210,320 5,189,955
South Carolina 17,172,147 6,807,312 - 4,788,444 5,567,623 8,768
South Dakota 3,797,234 1,666,614 - 1,310,044 820,576 -
Tennessee 1,859,127,110 649,322,117 129,917,182 686,664,190 204,999,975 188,223,646
Texas - - - - - -
Utah 147,730,653 42,275,707 3,090,652 15,338,023 45,224,158 41,802,113
Vermont 53,890,106 17,733,240 3,861,771 26,244,877 5,921,444 128,774
Virginia 186,255,441 124,695,551 277,865 36,783,725 24,498,300 -
Washington 529,020,076 200,698,542 70,098 82,034,437 124,357,212 121,859,787
West Virginia 26,573,906 - - - - 26,573,906
Wisconsin 321,886,123 133,740,098 14,045,197 54,721,976 117,335,261 2,043,591
Wyoming - - - - - -

Table 45. Medicaid Medical Vendor Payments for Prepaid Health Care by Basis of Eligibility and by State:
FY 1998

National Total $19,007,251,051 $1,281,654,876 $5,061,114,370 $7,258,178,184 $4,716,575,575 $689,728,040
Alabama 288,972,436 - - - - 288,972,436
Alaska - - - - - -
Arizona 1,431,418,497 305,894,109 538,339,506 348,626,397 230,958,895 7,599,583
Arkansas 4,359,975 381,256 1,770,581 1,664,699 448,043 95,396
California 2,867,713,795 243,415,639 502,135,327 1,461,163,668 626,989,806 34,009,355
Colorado 238,585,930 18,269,296 91,997,892 62,949,574 26,218,634 39,150,534
Connecticut 377,212,893 16,430 889,578 230,046,226 138,902,495 7,358,164
Delaware 122,048,974 1,717,732 50,022,867 31,807,937 36,919,623 1,580,815
District of Columbia 98,238,002 - 10,560,659 25,540,587 9,063,283 53,073,473
Florida 701,322,837 71,539,620 279,151,654 223,804,129 121,764,996 5,062,438
Georgia 57,871,451 760,211 18,236,400 22,359,579 16,442,094 73,167
Hawaii 213,612,580 - - 117,090,747 88,877,805 7,644,028
Idaho - - - - - -
Illinois 241,278,075 1,441,713 1,348,803 135,309,792 102,496,767 681,000
Indiana 167,977,207 33,281,397 22,104,213 75,113,583 36,352,314 1,125,700
Iowa 107,189,198 248,652 26,584,004 41,528,601 37,918,466 909,475
Kansas 17,201,600 188 7,484 11,334,679 5,798,449 60,800
Kentucky 311,526,039 9,948,951 140,944,026 122,137,361 37,474,425 1,021,276
Maine 4,237,958 - 2,964 2,925,767 1,259,800 49,427
Maryland 851,988,946 29,433,961 429,574,081 217,332,175 157,701,903 17,946,826
Massachusetts 477,932,296 17,799,618 168,863,527 191,656,653 99,465,302 147,196
Michigan 823,728,725 7,665,104 369,991,661 206,701,594 223,274,867 16,095,499
Minnesota 483,228,011 99,224,132 3,660,788 273,466,276 105,537,325 1,339,490
Mississippi 22,152,325 1,071,123 8,690,390 10,066,921 2,223,849 100,042
Missouri 277,652,554 349 216,687 207,000,926 60,088,789 10,345,803
Montana 53,600,495 4,081,792 21,674,024 18,234,121 5,883,408 3,727,150
Nebraska 72,980,602 1,827,740 17,877,950 20,941,089 12,862,703 19,471,120
Nevada 32,332,069 533,667 17,239 15,103,694 15,545,523 1,131,946
New Hampshire 12,128,535 - 12,690 10,046,700 1,953,315 115,830
New Jersey 617,591,322 8,007,536 37,308,372 338,914,552 232,546,221 814,641
New Mexico 372,647,285 1,788,025 134,622,609 163,844,455 66,324,600 6,067,596
New York 1,638,382,814 107,872,874 645,819,379 490,808,458 391,215,400 2,666,704
North Carolina 85,665,363 - 8,859,180 65,478,146 9,322,127 2,005,910
North Dakota 1,319,356 - 198 797,300 519,146 2,712
Ohio 494,845,239 663,103 3,350,900 282,677,169 207,768,926 385,141
Oregon 665,872,224 52,979,578 131,218,913 174,549,708 281,400,515 25,723,510
Pennsylvania 1,801,084,202 177,836,994 663,224,362 652,028,654 290,803,023 17,191,169
Rhode Island 114,870,881 1,982 302,363 58,118,090 51,092,650 5,355,796
South Carolina 17,172,147 10,258,041 2,606,790 3,160,340 1,119,935 27,041
South Dakota 3,797,234 321,796 703,936 2,316,950 379,036 75,516
Tennessee 1,859,127,110 61,216,442 571,127,838 396,513,777 630,339,991 199,929,062
Texas - - - - - -
Utah 147,730,653 4,469,049 35,856,760 45,468,041 19,196,670 42,740,133
Vermont 53,890,106 47,299 2,325,308 21,361,006 29,920,465 236,028
Virginia 186,255,441 1,975,407 68,820,208 73,769,467 41,689,275 1,084
Washington 529,020,076 858,720 6,971,922 211,108,633 188,203,019 121,877,782
West Virginia 26,573,906 - - - - 26,573,906
Wisconsin 321,886,123 4,805,350 43,320,337 193,309,963 72,311,697 8,138,776
Wyoming - - - - - -

Table 46. Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Age
State Name Payments Under 1 1 to 5 6 to 14 15 to 20 21 to 44
National Total $19,296,223,487 $663,270,071 $2,571,271,634 $3,072,843,689 $1,713,753,844 $5,178,849,381
Alabama 288,972,436 - - - - -
Alaska - - - - - -
Arizona 1,431,418,497 - - - - -
Arkansas 4,359,975 165,478 956,290 884,160 305,391 957,597
California 2,867,713,795 13,209,454 515,347,850 766,649,821 298,185,030 680,351,715
Colorado 238,585,930 5,851,482 37,932,814 53,024,495 23,780,778 54,695,564
Connecticut 377,212,893 27,836,189 84,970,120 83,856,221 50,253,265 119,608,032
Delaware 122,048,974 7,444,938 14,473,261 18,190,902 12,883,886 45,342,960
Florida 701,322,837 20,416,040 97,246,070 104,294,029 57,717,411 221,554,555
Georgia 57,871,451 1,574,558 9,292,110 9,452,878 6,107,675 20,822,290
Hawaii 213,612,580 - - - - -
Idaho - - - - - -
Illinois 241,278,075 19,435,778 62,557,061 36,908,645 24,814,153 89,640,324
Indiana 167,977,207 11,690,185 31,209,886 25,648,505 14,574,725 40,060,244
Iowa 107,189,198 3,540,487 17,655,792 21,208,108 14,551,222 40,819,219
Kansas 17,201,600 3,358,384 4,260,169 1,694,930 3,159,391 4,504,848
Kentucky 311,526,039 10,065,260 53,935,311 74,499,203 27,021,626 80,383,927
Maine 4,237,958 452,074 1,004,906 966,790 622,067 1,058,095
Maryland 851,988,946 35,760,475 98,755,759 111,236,613 72,296,988 289,111,724
Massachusetts 477,932,296 11,606,162 68,653,269 99,211,663 40,656,305 153,404,081
Michigan 823,728,725 33,633,121 91,911,136 78,169,032 61,786,742 328,737,518
Minnesota 483,228,011 31,205,609 119,766,946 76,326,241 51,642,893 92,932,142
Mississippi 22,152,325 5,762,963 3,021,071 1,412,028 1,562,621 4,537,547
Missouri 277,652,554 28,275,079 85,689,665 73,232,376 35,930,476 50,514,480
Montana 53,600,495 123,307 1,051,688 17,091,288 14,450,375 12,081,374
Nebraska 72,980,602 - - - - -
Nevada 32,332,069 3,891,345 6,014,421 4,438,112 4,666,812 11,939,029
New Hampshire 12,128,535 155,925 3,796,335 4,988,385 1,151,685 1,949,400
New Jersey 617,591,322 47,468,930 149,390,573 107,664,770 65,997,142 206,213,047
New Mexico 372,647,285 14,531,960 49,072,446 89,770,157 68,706,455 93,634,772
New York 1,638,382,814 54,914,302 190,982,711 182,006,374 94,094,647 593,575,857
North Carolina 85,665,363 9,640,707 12,397,979 32,014,625 19,230,997 9,976,490
North Dakota 1,319,356 53,367 300,097 260,043 222,968 445,350
Ohio 494,845,239 116,389,364 62,355,148 76,664,074 62,884,487 161,461,589
Oregon 665,872,224 11,991,839 76,050,828 99,495,632 58,776,145 233,035,657
Pennsylvania 1,801,084,202 33,729,565 221,515,046 366,521,522 190,539,526 549,111,806
Rhode Island 114,870,881 9,353,107 26,101,164 16,604,258 15,284,178 42,375,112
South Carolina 17,172,147 569,572 1,495,569 1,188,910 509,547 1,359,628
South Dakota 3,797,234 276,666 897,180 1,126,800 404,718 488,728
Tennessee 1,859,127,110 30,658,983 132,596,542 204,177,921 193,056,223 587,144,169
Texas - - - - - -
Utah 147,730,653 10,553,967 18,670,383 16,976,877 7,198,759 34,292,229
Vermont 53,890,106 1,725,324 6,337,145 7,320,476 5,831,121 21,520,117
Virginia 186,255,441 9,030,622 33,615,628 30,826,600 24,253,318 57,608,532
Washington 529,020,076 22,773,492 84,295,694 75,975,889 48,454,641 162,010,235
West Virginia 26,573,906 - - - - -
Wisconsin 321,886,123 10,410,356 77,682,059 90,047,987 36,242,667 71,551,843
Wyoming - - - - - -

Table 46. Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Age

National Total $2,374,630,221 $615,929,994 $396,380,134 $247,911,989 $2,461,382,531
Alabama - - - - 288,972,436
Alaska - - - - -
Arizona - - - - 1,431,418,497
Arkansas 506,508 249,221 218,230 118,239 (1,139)
California 268,402,826 141,526,857 109,225,777 74,335,881 478,584
Colorado 36,903,487 9,149,216 6,190,210 4,568,995 6,488,889
Connecticut 10,638,402 50,441 223 - -
Delaware 20,868,858 1,909,646 750,768 181,267 2,488
District of Columbia 724,949 13,507 4,391 - 52,939,296
Florida 100,532,484 42,372,100 30,723,983 26,141,677 324,488
Georgia 8,890,305 1,187,070 360,359 171,785 12,421
Hawaii - - - - 213,612,580
Idaho - - - - -
Illinois 6,009,647 699,832 814,921 397,448 266
Indiana 10,692,692 11,708,270 12,470,176 9,833,271 89,253
Iowa 9,245,818 143,152 11,711 12,743 946
Kansas 208,948 1,061 - - 13,869
Kentucky 48,745,997 9,611,724 4,975,171 2,047,175 240,645
Louisiana - - - - -
Maine 132,090 585 - - 1,351
Maryland 192,222,579 35,774,016 12,503,907 3,240,544 1,086,341
Massachusetts 81,477,691 6,791,609 9,013,837 7,117,679 -
Michigan 197,402,303 15,906,082 3,784,086 1,094,952 11,303,753
Minnesota 8,198,704 38,022,997 35,119,240 29,804,940 208,299
Mississippi 4,194,860 975,335 506,104 162,517 17,279
Missouri 3,990,141 18,577 - - 1,760
Montana 3,922,798 1,523,252 1,605,578 1,597,184 153,651
Nebraska - - - - 72,980,602
Nevada 330,509 242,073 235,394 59,846 514,528
New Hampshire 86,805 - - - -
New Jersey 30,104,674 3,709,895 3,217,016 3,558,916 266,359
New Mexico 51,669,983 4,305,567 631,410 150,035 174,500
New York 349,214,118 94,422,624 55,137,837 24,034,343 -
North Carolina 2,403,413 995 - 158 -
North Dakota 37,531 - - - -
Ohio 14,442,636 292,370 259,985 95,586 -
Oklahoma - - - - -
Oregon 126,028,104 26,171,354 19,719,835 13,823,922 778,908
Pennsylvania 304,636,648 83,293,815 39,684,751 12,208,206 (156,683)
Rhode Island 3,344,627 17,865 2,112 492 1,787,966
South Carolina 1,637,531 2,536,145 4,091,505 3,781,995 1,745
South Dakota 215,384 113,116 125,624 148,922 96
Tennessee 396,748,525 69,289,240 35,633,293 22,288,636 187,533,578
Texas - - - - -
Utah 14,335,028 3,503,988 1,563,614 635,734 40,000,074
Vermont 10,850,404 164,873 14,885 1,776 123,985
Virginia 27,282,895 2,950,538 601,164 86,145 -
Washington 12,652,685 389,168 274,509 370,179 121,823,584
West Virginia - - - - 26,573,906
Wisconsin 14,696,634 6,891,818 6,908,528 5,840,801 1,613,430
Wyoming - - - - -

Table 47. Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Sex
Total
State Name Payments Male Female Unknown
National Total $19,296,223,487 $6,371,960,186 $10,460,328,903 $2,463,934,398
Alabama 288,972,436 - - 288,972,436
Alaska - - - -
Arizona 1,431,418,497 - - 1,431,418,497
Arkansas 4,359,975 1,848,704 2,511,984 (713)
California 2,867,713,795 1,188,412,224 1,678,818,709 482,862
Colorado 238,585,930 98,538,857 133,558,184 6,488,889
Connecticut 377,212,893 125,688,730 251,524,163 -
Delaware 122,048,974 46,701,836 75,344,650 2,488
Florida 701,322,837 256,733,902 444,264,447 324,488
Georgia 57,871,451 16,504,588 41,354,442 12,421
Hawaii 213,612,580 - - 213,612,580
Idaho - - - -
Illinois 241,278,075 71,473,133 169,804,676 266
Indiana 167,977,207 56,394,499 111,493,455 89,253
Iowa 107,189,198 38,730,632 68,457,620 946
Kansas 17,201,600 5,294,188 11,892,866 14,546
Kentucky 311,526,039 132,639,343 178,638,239 248,457
Louisiana - - - -
Maine 4,237,958 1,599,611 2,636,996 1,351
Maryland 851,988,946 328,225,186 522,678,351 1,085,409
Massachusetts 477,932,296 191,883,979 286,048,317 -
Michigan 823,728,725 286,073,576 526,353,707 11,301,442
Minnesota 483,228,011 177,115,708 305,904,004 208,299
Mississippi 22,152,325 8,252,448 13,882,598 17,279
Missouri 277,652,554 110,451,332 167,199,462 1,760
Montana 53,600,495 25,061,257 28,385,587 153,651
Nebraska 72,980,602 - - 72,980,602
Nevada 32,332,069 8,159,170 23,625,902 546,997
New Hampshire 12,128,535 5,147,550 6,978,285 2,700
New Jersey 617,591,322 186,936,733 430,388,230 266,359
New Mexico 372,647,285 154,292,150 218,178,420 176,715
New York 1,638,382,814 626,743,732 1,011,639,074 9
North Carolina 85,665,363 36,860,097 48,805,266 -
North Dakota 1,319,356 343,129 976,227 -
Ohio 494,845,239 145,797,261 346,632,905 2,415,072
Oklahoma - - - -
Oregon 665,872,224 270,264,196 394,817,726 790,302
Pennsylvania 1,801,084,202 700,297,042 1,100,947,308 (160,148)
Puerto Rico - - - -
Rhode Island 114,870,881 32,405,762 80,677,153 1,787,966
South Carolina 17,172,147 4,484,249 12,686,153 1,745
South Dakota 3,797,234 1,640,282 2,117,756 39,196
Tennessee 1,859,127,110 648,037,009 1,023,539,781 187,550,320
Texas - - - -
Utah 147,730,653 46,210,088 61,515,574 40,004,991
Vermont 53,890,106 21,314,625 32,451,496 123,985
Virginia 186,255,441 62,219,339 124,036,102 -
Washington 529,020,076 113,052,671 294,131,756 121,835,649
West Virginia 26,573,906 - - 26,573,906
Wisconsin 321,886,123 119,895,624 200,379,589 1,610,910
Wyoming - - - -

Table 48. Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Race/Ethnicity
Total White Black

State Name Payments Not Hispanic Not Hispanic Hispanic
National Total $19,296,223,487 $6,971,046,006 $5,424,759,152 $2,465,159,044
Alabama 288,972,436 - - -
Alaska - - - -
Arizona 1,431,418,497 - - -
Arkansas 4,359,975 2,384,384 1,614,896 48,468
California 2,867,713,795 820,555,222 487,617,383 967,106,015
Colorado 238,585,930 116,429,108 21,481,320 68,576,183
Connecticut 377,212,893 133,015,461 111,183,457 127,462,428
Delaware 122,048,974 51,811,375 55,384,205 9,308,431
District of Columbia 98,238,002 175,177 41,711,203 1,697,604
Florida 701,322,837 200,648,478 312,690,985 76,908,022
Georgia 57,871,451 6,211,574 46,212,136 778,345
Hawaii 213,612,580 - - -
Idaho - - - -
Illinois 241,278,075 17,977,074 190,654,668 30,831,653
Indiana 167,977,207 107,009,316 53,251,599 5,584,848
Iowa 107,189,198 88,529,917 13,074,920 3,499,999
Kansas 17,201,600 11,237,535 3,772,419 1,538,532
Kentucky 311,526,039 198,174,755 87,502,578 3,371,173
Louisiana - - - -
Maine 4,237,958 - - -
Maryland 851,988,946 289,337,600 494,247,122 20,220,791
Massachusetts 477,932,296 288,388,006 71,270,979 75,058,724
Michigan 823,728,725 291,325,697 448,956,331 18,650,003
Minnesota 483,228,011 284,480,133 89,825,022 25,909,085
Mississippi 22,152,325 8,071,914 11,913,383 129,995
Missouri 277,652,554 131,368,857 146,281,937 -
Montana 53,600,495 40,733,062 378,343 953,078
Nebraska 72,980,602 - - -
Nevada 32,332,069 16,029,764 6,870,965 7,415,636
New Hampshire 12,128,535 11,252,385 254,205 527,715
New Jersey 617,591,322 132,285,603 272,103,646 182,477,490
New Mexico 372,647,285 109,777,182 10,934,417 175,691,834
New York 1,638,382,814 491,797,939 450,530,344 261,095,778
North Carolina 85,665,363 33,406,093 43,866,121 3,263,231
North Dakota 1,319,356 1,056,698 48,005 48,234
Ohio 494,845,239 179,164,021 287,807,436 15,482,001
Oklahoma - - - -
Oregon 665,872,224 543,216,685 33,211,731 49,129,279
Pennsylvania 1,801,084,202 637,775,454 873,410,484 210,736,115
Puerto Rico - - - -
Rhode Island 114,870,881 54,749,866 12,986,826 25,379,168
South Carolina 17,172,147 4,236,183 11,916,431 16,070
South Dakota 3,797,234 2,135,624 8,146 5,642
Tennessee 1,859,127,110 1,098,535,007 475,376,234 9,936,111
Texas - - - -
Utah 147,730,653 82,460,377 2,741,398 14,009,607
Vermont 53,890,106 52,965,970 310,809 88,135
Virginia 186,255,441 42,397,973 138,049,280 2,674,894
Washington 529,020,076 294,984,443 31,790,969 52,830,212
West Virginia 26,573,906 - - -
Wisconsin 321,886,123 94,954,094 83,516,819 16,718,515
Wyoming - - - -

Table 48. Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Race/Ethnicity

National Total $584,061,196 $134,704,727 $2,461,382,531
Alabama - - 288,972,436
Alaska - - -
Arizona - - 1,431,418,497
Arkansas 10,176 7,377 (1,139)
California 294,236,703 8,640,240 478,584
Colorado 2,103,149 1,439,083 6,488,889
Connecticut 4,966,585 515,229 -
Delaware 542,146 440,451 2,488
District of Columbia 222,162 4,093 52,939,296
Florida 1,854,574 175,145 324,488
Georgia 346,375 12,683 12,421
Hawaii - - 213,612,580
Idaho - - -
Illinois 1,510,807 292,853 266
Indiana 665,533 75,529 89,253
Iowa 1,446,729 636,687 946
Kansas 375,410 263,835 13,869
Kentucky 1,211,148 108,466 240,645
Louisiana - - -
Maine - - 1,351
Maryland 22,909,496 2,040,903 1,086,341
Massachusetts 10,950,049 1,173,993 -
Michigan 12,516,835 1,994,247 11,303,753
Minnesota 55,641,385 14,708,695 208,299
Mississippi 377,365 26,934 17,279
Missouri - - 1,760
Montana 201,817 11,163,929 153,651
Nebraska - - 72,980,602
Nevada 1,053,602 365,238 514,528
New Hampshire 94,230 - -
New Jersey 8,524,702 944,911 266,359
New Mexico 2,430,041 58,314,252 174,500
New York 17,793,471 3,055,203 -
North Carolina 1,432,851 611,227 -
North Dakota 4,957 161,462 -
Ohio 2,658,216 525,561 -
Oklahoma - - -
Oregon 25,783,520 9,034,978 778,908
Pennsylvania 54,370,431 1,245,841 (156,683)
Puerto Rico - - -
Rhode Island 4,223,146 171,462 1,787,966
South Carolina 2,236 640 1,745
South Dakota 2,424 1,486,962 96
Tennessee 6,829,155 3,770,117 187,533,578
Texas - - -
Utah 5,029,685 2,244,147 40,000,074
Vermont 275,438 125,769 123,985
Virginia 2,640,478 238,376 -
Washington 22,213,553 5,377,315 121,823,584
West Virginia - - 26,573,906
Wisconsin 16,610,616 3,310,894 1,613,430
Wyoming - - -


Appendix C:
Medicaid Rebate Law
National Pharmaceutical Council C-1

C-2 National Pharmaceutical Council

42 USC Sec. 1396r-8 01/06/97
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 drugs
(a) Requirement for rebate agreement
(1) In general
In order for payment to be available under section 1396b(a) of this title 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 not be effective until the first day of the calendar quarter that begins
more than 60 days after the date 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

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 56b(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 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, and (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
(FOOTNOTE 1) for each of the manufacturer’s covered outpatient drugs.
(FOOTNOTE 1) So in original. Probably should be followed by a comma.
(B) Verification surveys of average manufacturer price

The Secretary may survey wholesalers and manufacturers that directly distribute their covered outpatient
drugs, when necessary, to verify manufacturer prices 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 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,
(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.
(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

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.

(c) 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 -
(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;
(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.
(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
(III) shall not take into account prices that are merely nominal in amount.

(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
(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), 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.
(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)) (FOOTNOTE 2) Establishment of upper payment limits

(FOOTNOTE 2) See 1993 Amendment note below.
HCFA 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
(1) Repealed. Pub. L. 103-66, title XIII, Sec. 13602(a)(1), Aug. 10, 1993, 107 Stat. 613
(2) Redesignated (e)((4))
(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) American Medical Association Drug Evaluations; and
(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:
(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 individuals (FOOTNOTE 3) drug therapy.
(FOOTNOTE 3) So in original. Probably should be “individual’s”.

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® 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 subsection (FOOTNOTE 4) (1)(B) as the
source of standards for such assessment) including but not limited to monitoring 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, 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.
(FOOTNOTE 4) So in original. Probably should be “paragraph”.
(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 * * * (FOOTNOTE 5) licensed and actively practicing
pharmacists.
(FOOTNOTE 5) So in original.
(C) Activities
The activities of the DUR Board shall include but not be limited to the following:
(i) Retrospective DUR as defined in section (FOOTNOTE 6) (2)(B).
(FOOTNOTE 6) So in original. Probably should be “paragraph”.
(ii) Application of standards as defined in section (FOOTNOTE 6) (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 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 (FOOTNOTE 7) operation of this section in the
preceding fiscal year.
(FOOTNOTE 7) So in original.
(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;

(C) how the size of such rebates compare with the size or (FOOTNOTE 8) rebates offered to other
purchasers of covered outpatient drugs;
(FOOTNOTE 8) So in original. Probably should be “of”.
(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 * * * (FOOTNOTE 7) Health Maintenance Organizations, including
those 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 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 (FOOTNOTE 9) 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.
(FOOTNOTE 9) So in original. Probably should be “biological product”.
(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
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 distributers (FOOTNOTE 01) operating under the new drug
application.
(FOOTNOTE 01) So in original. Probably should be “distributors”.
(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 -
(i) drug products are pharmaceuutically (FOOTNOTE 11) 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;
(FOOTNOTE 11) 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.
• SOURCE-
(Aug. 14, 1935, ch. 531, title XIX, Sec. 1927, as added Nov. 5, 1990, Pub. L. 101-508, title IV, Sec. 4401(a)(3),
104 Stat. 1388-143; amended Nov. 4, 1992, Pub. L. 102-585, title VI, Sec. 601(a)-(c), 106 Stat. 4962-4964; Apr.
12, 1993, Pub. L. 103-18, Sec. 2(a), 107 Stat. 54; Aug. 10, 1993, Pub. L. 103-66, title XIII, Sec. 13602(a), 107
Stat. 613.)

• REFTEXT-
REFERENCES IN TEXT
Section 107(C)(3) of the Drug Amendments of 1962, referred to in subsec. (k)(2)(A)(iii)(I), is section 107(c)(3) of
Pub. L. 87-781 which is set out in an Effective Date of 1962 Amendment note under section 321 of Title 21, Food
and Drugs. The Federal Food, Drug, and Cosmetic Act, referred to in subsecs. (d)(4)(C) and (k)(6), is act June
25, 1938, ch. 675, 52 Stat. 1040, as amended, which is classified generally to chapter 9 (Sec. 301 et seq.) of Title
21. For complete classification of this Act to the Code, see section 301 of Title 21 and Tables.
• MISC2-
PRIOR PROVISIONS
A prior section 1927 of act Aug. 14, 1935, was renumbered section 1928 and is classified to section 1396s of this
title.
AMENDMENTS
1993 - Subsec. (b)(1)(A). Pub. L. 103-66, Sec. 13602(a)(2)(A)(i)(II), which directed amendment of subpar. (A) by
substituting “dispensed after December 31, 1990, for which payment was made under the State plan for such
period” for “dispensed under the plan during the quarter (or other period as the Secretary may specify)”, was
executed by making the substitution for “dispensed under the plan during the quarter (or such other period as the
Secretary may specify)” to reflect the probable intent of Congress. Pub. L. 103-66, Sec. 13602(a)(2)(A)(i)(I),
substituted “for a rebate period” for “each calendar quarter (or periodically in accordance with a schedule
specified by the Secretary)”. Subsec. (b)(2)(A). Pub. L. 103-66, Sec. 13602(a)(2)(A)(ii), substituted “each rebate
period” for “each calendar quarter” and “units of each dosage form and strength and package size” for “dosage
units”, inserted “after December 31, 1990, for which payment was made” after “dispensed”, and substituted
“during the period” for “during the quarter”. Subsec. (b)(3)(A)(i). Pub. L. 103-66, Sec. 13602(a)(2)(A)(iii),
substituted “rebate period under the agreement” for “quarter” in two places. Subsec. (C). Pub. L. 103-66, Sec.
13602(a)(1), added subsec. (c) and struck out former subsec. (C) which related to determination of amount of
rebate for certain drugs. Pub. L. 103-18 substituted “such drug, except that for the calendar quarter beginning
after September 30, 1992, and before January 1, 1993, the amount of the rebate may not exceed 50 percent of
such average manufacturer price;” for “such drug;” in par. (1)(B)(ii)(II).
Subsecs. (d) to (f). Pub. L. 103-66, Sec. 13602(a)(1), added subsecs. (d) and (e), struck out former subsecs. (d)
consisting of pars. (1) to (8) relating to limitations on coverage of drugs, (e) relating to denial of Federal financial
participation in certain cases, and (f)(1) relating to reductions in pharmacy reimbursement limits, and struck out
par. designation for former par. (2) of subsec. (f) without supplying a new designation. The text of former subsec.
(f)(2) is now the last par. of subsec. (e). Subsec. (k)(1). Pub. L. 103-66, Sec. 13602(a)(2)(B)(i), substituted “rebate
period” for “calendar quarter” and inserted before period at end “, after deducting customary prompt pay
discounts”. Subsec. (k)(3). Pub. L. 103-66, Sec. 13602(a)(2)(B)(ii)(III), in concluding provisions, substituted “for
which a National Drug Code number is not required by the Food and Drug Administration or a drug or biological
used” for “which is used” and inserted at end “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.”
Subsec. (k)(3)(E). Pub. L. 103-66, Sec. 13602(a)(2)(B)(ii)(I), struck out “* * * *emergency room visits” after
“services”. Subsec. (k)(3)(F). Pub. L. 103-66, Sec. 13602(a)(2)(B)(ii)(II), which directed amendment of subpar. (F)
by substituting “services and services provided by an intermediate care facility for the mentally retarded” for
“services”, was executed by making the substitution for “sevices” to reflect the probable intent of Congress
because the word “services” did not appear. Subsec. (k)(6). Pub. L. 103-66, Sec. 13602(a)(2)(B)(iii), substituted
“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.” for “, which appears in peer-reviewed medical
literature or which is accepted by one or more of the following compendia: the American Hospital Formulary
Service-Drug Information, the American Medical Association Drug Evaluations, and the United States
Pharmacopeia-Drug Information.”
Subsec. (k)(7)(A)(i). Pub. L. 103-66, Sec. 13602(a)(2)(B)(iv), substituted “rebate period” for “calendar quarter” in
introductory provisions.
Subsec. (k)(8), (9). Pub. L. 103-66, Sec. 13602(a)(2)(B)(v), added par. (8) and redesignated former par. (8) as (9).
1992 - Subsec. (a)(1). Pub. L. 102-585, Sec. 601(b)(1), substituted “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)” for “manufacturer)”.

Subsec. (a)(5), (6). Pub. L. 102-585, Sec. 601(b)(2), added pars. (5) and (6).
Subsec. (b)(3)(D). Pub. L. 102-585, Sec. 601(b)(3), substituted “this paragraph or under an agreement with the
Secretary of Veterans Affairs described in subsection (a)(6)(A)(ii) of this section” for “this paragraph”, “Secretary
or the Secretary of Veterans Affairs” for “Secretary”, and “except - “ and cls. (i) to (iii) for “except as the Secretary
determines to be necessary to carry out this section and to permit the Comptroller General to review the
information provided.”
Subsec. (b)(4)(B)(ii). Pub. L. 102-585, Sec. 601(b)(4)(i), (ii), substituted “the calendar quarter beginning at least
60 days” for “such period” and “the manufacturer provides notice to the Secretary.” for “of the notice as the
Secretary may provide (but not beyond the term of the agreement).”
Subsec. (b)(4)(B)(iv), (v). Pub. L. 102-585, Sec. 601(b)(4)(iii), added cls. (iv) and (v).
Subsec. (C)(1)(B)(i). Pub. L. 102-585, Sec. 601(c)(1), which directed the substitution of “October 1, 1992,” for
“January 1, 1993,”, was executed by making the substitution in introductory provisions and in subcl. (II), to reflect
the probable intent of Congress.
Subsec. (C)(1)(B)(ii) to (v). Pub. L. 102-585, Sec. 601(c)(2), (3), added cls. (ii) to (v) and struck out former cl. (ii)
which read as follows: “for quarters (or other periods) beginning after December 31, 1992, the greater of -
“(I) the difference between the average manufacturer price for a drug and 85 percent of such price, or
“(II) the difference between the average manufacturer price for a drug and the best price (as defined in paragraph
(2)(B)) for such quarter (or period) for such drug.”
Subsec. (C)(1)(C). Pub. L. 102-585, Sec. 601(a), substituted “(excluding 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, any prices charged under the Federal Supply Schedule of the General
Services Administration, or any prices used under a State pharmaceutical assistance program, and excluding” for
“(excluding”.
• CHANGE-
CHANGE OF NAME
Committee on Energy and Commerce of House of Representatives treated as referring to Committee on
Commerce of House of Representatives by section 1(a) of Pub. L. 104-14, set out as a note preceding section 21
of Title 2, The Congress. Committees on Aging of the Senate and House of Representatives probably mean the
Special Committee on Aging of the Senate and the Select Committee on Aging of the House of Representatives
which was abolished on Jan. 5, 1993, by House Resolution No. 5, One Hundred Third Congress.
• MISC4-
EFFECTIVE DATE OF 1993 AMENDMENTS

Section 13602(d) of Pub. L. 103-66 provided that:
“(1) Except as provided in paragraph (2), the amendments made by this section (amending this section and
sections 1396a and 1396b of this title) shall take effect as if included in the enactment of OBRA-1990 (Pub. L.
101-508).
“(2) The amendment made by subsection (a)(1) (amending this section) (insofar as such subsection amends
section 1927(d) of the Social Security Act (subsec. (d) of this section)) and the amendment made by subsection
(C) (amending section 1396a of this title) shall apply to calendar quarters beginning on or after October 1, 1993,
without regard to whether or not regulations to carry out such amendments have been promulgated by such date.”
Section 2(b) of Pub. L. 103-18 provided that: “The amendment made by subsection (a) (amending this section)
shall take effect as if included in the enactment of section 601(C) of the Veterans Health Care Act of 1992 (Pub.
L. 102-585).”
EFFECTIVE DATE OF 1992 AMENDMENT
Section 601(e) of Pub. L. 102-585 provided that: “The amendments made by this section (amending this section)
shall apply with respect to payments to State plans under title XIX of the Social Security Act (this subchapter) for
calendar quarters (or periods) beginning on or after January 1, 1993 (without regard to whether or not regulations
to carry out such amendments have been promulgated by such date).”
REPORTS ON BEST PRICE CHANGES AND PAYMENT OF REBATES Section 601(d) of Pub. L. 102-585
provided that not later than 90 days after the expiration of each calendar quarter beginning on or after Oct. 1,
1992, and ending on or before Dec. 31, 1995, Secretary of Health and Human Services was to submit to
Congress a report containing information as to percentage of single source drugs whose best price either
increased, decreased, or stayed the same in comparison to best price during previous calendar quarter, median
and mean percentage increase or decrease of such price, and, with respect to drugs for which manufacturers

were required to pay rebates under subsec. (C) of this section, Secretary’s best estimate, on State-by-State and
national aggregate basis, of total amount of rebates paid under subsec. (C) of this section and percentages of
such total amounts attributable to rebates paid under pars. (1) to (3) of subsec. (C) of this section, limited
consideration to drugs which are considered significant expenditures under medicaid program, and contained
requirements for initial report.
DEMONSTRATION PROJECTS TO EVALUATE EFFICIENCY AND
COST-EFFECTIVENESS OF PROSPECTIVE DRUG UTILIZATION REVIEW
Section 4401(C) of title IV of Pub. L. 101-508 directed Secretary of Health and Human Services to establish
statewide demonstration projects to evaluate efficiency and cost-effectiveness of prospective drug utilization
review and to evaluate impact on quality of care and cost-effectiveness of paying pharmacists under this
subchapter whether or not drugs were dispensed for drug use review services, with two reports to be submitted to
Congress, the first not later than Jan. 1, 1994, and the second not later than Jan. 1, 1995.
STUDY OF DRUG PURCHASING AND BILLING PRACTICES IN HEALTH CARE INDUSTRY; REPORT
Section 4401(d) of title IV of Pub. L. 101-508, as amended by Pub. L. 104-316, title I, Sec. 122(i), Oct. 19, 1996,
110 Stat. 3837, provided that:
“(1) Study of drug purchasing and billing activities of various health care systems. -
“(A) The Comptroller General shall conduct a study of the drug purchasing and billing practices of hospitals, other
institutional facilities, and managed care plans which provide covered outpatient drugs in the medicaid program.
The study shall compare the ingredient costs of drugs for medicaid prescriptions to these facilities and plans and
the charges billed to medical assistance programs by these facilities and plans compared to retail pharmacies.
“(B) The study conducted under this subsection shall include an assessment of -
“(i) the prices paid by these institutions for covered outpatient drugs compared to prices that would be paid under
this section (enacting this section, amending sections 1396a, 1396b, and 1396s of this title, and enacting
provisions set out above and under section 1396b of this title),
“(ii) the quality of outpatient drug use review provided by these institutions as compared to drug use review
required under this section, and
“(iii) the efficiency of mechanisms used by these institutions for billing and receiving payment for covered
outpatient drugs dispensed under this title (see Tables for classification).
“(C) By not later than May 1, 1991, the Comptroller General shall report to the Secretary of Health and Human
Services (hereafter in this section referred to as the ‘Secretary’), 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 on the study conducted under subparagraph (A).
“(2) Report on drug pricing. - The Comptroller General shall submit to the Secretary, the Committee on Finance of
the Senate, the Committee on Energy and Commerce (now Committee on Commerce) of the House of
Representatives, and the Committees on Aging of the Senate and House of Representatives (see Change of
Name note above) a report on changes in prices charged by manufacturers for prescription drugs to the
Department of Veterans Affairs, other Federal programs, hospital pharmacies, and other purchasing groups and
managed care plans.
“(3) Study on prior approval procedures. -
“(A) The Secretary, acting in consultation with the Comptroller General, shall study prior approval procedures
utilized by State medical assistance programs conducted under title XIX of the Social Security Act (this
subchapter), including -
“(i) the appeals provisions under such programs; and
“(ii) the effects of such procedures on beneficiary and provider access to medications covered under such
programs.
“(B) By not later than December 31, 1991, the Secretary and the Comptroller General shall report 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 on the results of the study
conducted under subparagraph (A) and shall make recommendations with respect to which procedures are
appropriate or inappropriate to be utilized by State plans for medical assistance.
“(4) Study on reimbursement rates to pharmacists. -
“(A) The Secretary shall conduct a study on (i) the adequacy of current reimbursement rates to pharmacists under
each State medical assistance programs conducted under title XIX of the Social Security Act; and (ii) the extent to
which reimbursement rates under such programs have an effect on beneficiary access to medications covered
and pharmacy services under such programs.
“(B) By not later than December 31, 1991, the Secretary shall report 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 on the results of the study conducted under subparagraph (A).

“(5) Study of payments for vaccines. - The Secretary of Health and Human Services shall undertake a study of the
relationship between State medical assistance plans and Federal and State acquisition and reimbursement
policies for vaccines and the accessibility of vaccinations and immunization to children provided under this title.
The Secretary shall report to the Congress on the Study not later than one year after the date of the enactment of
this Act (Nov. 5, 1990).”
• SECREF-
SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 256b, 1396a, 1396b of this title; title 38 section 8126.

Appendix D:
HCFA Upper Limits for
Multiple Source Products
National Pharmaceutical Council D-1

D-2 National Pharmaceutical Council

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 HCFA 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. The listing is based on data current as of January 2000 from the First Data Bank (Blue Book), Medi-Span,
and the Red Book. 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.hcfa/gov/medicaid/drug10.htm.
In accordance with current policy, Federal financial participation will not be provided for any drug on the FUL
listing for which the 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 Food and Drug Administration or
reported by the drug manufacturer for purposes of the Medicaid drug rebate program.
The April 6, 2000 list has been amended with a new implementation date of no later than December 7, 2000.
Generic Name Upper Limit per Unit (Source)
Acebutolol Hydrochloride
Eq 200 mg base, Capsule, Oral 100 $0.4613 B
Eq 400 mg base, Capsule, Oral 100 0.6713 B
Acetaminophen; Codeine Phosphate

300 mg; 15 mg, Tablet, Oral 100 0.0980 B
Acetaminophen; Hydrocodone Bitartrate

500 mg; 5 mg, Capsule, Oral 100 0.1943 R
500 mg; 5 mg, Tablet, Oral 100 0.1060 R
500 mg; 7.5 mg, Tablet, Oral 100 0.2300 B
650 mg; 7.5 mg, Tablet, Oral 100 0.1850 B
750 mg; 7.5 mg, Tablet, Oral 100 0.1750 R
Acetaminophen; Oxycodone Hydrochloride

500 mg; 5 mg, Capsule, Oral 100 0.2250 B
Acetaminophen; Propoxyphene Hydrochloride

Acetaminophen; Propoxyphene Napsylate

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

Acetazolamide
125 mg, Tablet, Oral 100 0.0760 B
250 mg, Tablet, Oral 100 0.2565 B
Acetic Acid, Glacial

2%, Solution/Drops, Otic 15 ml 0.1380 R
Acetic Acid, Glacial; Hydrocortisone

2%; 1%, Solution/Drops, Otic 10 ml 0.4500 B
Acetylcysteine
10%, Solution, Inhalation 4 ml 0.8060 B
10%, Solution, Inhalation 10 ml 0.7640 R
20%, Solution, Inhalation 4 ml 0.9710 B
20%, Solution, Inhalation 10 ml 0.9290 R
Acyclovir
200 mg, Capsule, Oral 100 0.3530 B
400 mg, Tablet, Oral 100 0.7050 R
800 mg, Tablet, Oral 100 1.2160 B
Albuterol Sulfate
Eq 0.5% base, Solution, Inhalation 20 ml 0.3330 R
Eq 2 mg base/5 ml, Syrup, Oral 480 ml 0.0350 B
Eq 2 mg base, Tablet, Oral 100 0.0380 B
Allopurinol
100 mg, Tablet, Oral 100 0.0510 B
300 mg, Tablet, Oral 100 0.1198 B
Alprazolam
0.25 mg, Tablet, Oral 100 0.0560 B
0.5 mg, Tablet, Oral 100 0.0690 B
1 mg, Tablet, Oral 100 0.0920 B
Amantadine Hydrochloride
100 mg, Capsule, Oral 100 0.1572 R
50 mg/5 ml, Syrup, Oral 480 ml 0.0720 R
Amiloride Hydrochloride; Hydrochlorothiazide

Eq 5 mg Anhydrous; 50 mg, Tablet, Oral 100 0.0675 R
Aminophylline
100 mg, Tablet, Oral 100 0.0278 R
200 mg, Tablet, Oral 1000 0.0390 R

Amiodarone Hydrochloride
200 mg, Tablet, Oral 500 1.8912 R
Amitriptyline Hydrochloride
25 mg, Tablet, Oral 100 0.0330 R
100 mg, Tablet, Oral 100 0.0760 R
150 mg, Tablet, Oral 100 0.1800 B
Amitriptyline Hydrochloride; Perphenazine

Amoxapine
100 mg, Tablet, Oral 100 0.9300 B
Amoxicillin
125 mg/5 ml, Powder for reconstitution, Oral 100 0.0210 B
250 mg, Tablet, Chewable, Oral 100 0.1600 B
Ampicillin/Ampicillin Trihydrate
Aspirin; Carisoprodol
Aspirin; Oxycodone Hydrochloride; Oxycodone Terephthalate

325 mg; 4.5 mg; 0.38 mg, Tablet, Oral 100 0.1313 R
Atenolol
100 mg, Tablet, Oral 100 0.0672 B
Atenolol; Chlorthalidone

Atropine Sulfate; Diphenoxylate Hydrochloride

0.025 mg; 2.5 mg, Tablet, Oral 100 0.3743 R
Baclofen
Benzonatate
Benztropine Mesylate
0.5 mg, Tablet, Oral 100 0.0360 B
Betamethasone Dipropionate
Eq 0.05% base, Cream, Topical 15 gm 0.2130 B
Eq 0.05% base, Lotion, Topical 60 ml 0.1440 B
Eq 0.05% base, Ointment, Topical 15 gm 0.3350 B
Eq 0.05% base, Ointment, Topical 45 gm 0.2230 B
Betamethasone Valerate
Eq 0.1% base, Lotion, Topical 60 ml 0.1088 B
Brompheniramine Maleate; Codeine Phosphate; Phenylpropanolamine HCL

2mg/5 ml; 10 mg/5 ml; 12.5 mg/5 ml, Syrup, Oral 480 ml 0.0260 B
Brompheniramine Maleate; Dextromethorphan Hydrobromide; Pseudoephedrine HCL

2mg/5 ml; 10 mg/5 ml; 30 mg/5 ml, Syrup, Oral 480 ml 0.0160 B
Bumetanide
0.5 mg, Tablet, Oral 100 0.1613 R
Captopril
12.5 mg, Tablet, Oral 100 0.0480 B
100 mg, Tablet, Oral 100 0.2020 M

Captolpril; Hydrochlorothiazide
Carbamazepine
200 mg, Tablet, Oral 100 0.1500 R
Carbidopa; Levodopa
Carisoprodol
350 mg, Tablet, Oral 100 0.3743 B
Cefaclor
Eq 125 mg base/5 ml,
Powder for reconstitution, Oral 150 0.1320 R
Powder for reconstitution, Oral 100 0.2000 R
Powder for reconstitution, Oral 150 0.2440 B
Cephalexin
Chlordiazepoxide Hydrochloride
Chlorhexidine Gluconate
0.12%, Solution, Dental 480 ml 0.0150 B

Chlorpheniramine Maleate
4 mg, Tablet, Oral 100 0.0100 M
Chlorpropamide
100 mg, Tablet, Oral 100 0.1840 B
250 mg, Tablet, Oral 100 0.3885 R
Chlorthalidone
Cholestyramine
Eq 4 gm Resin/Packet, Powder, Oral 60 pk 0.9004 B
Cimetidine
200 mg, Tablet, Oral 100 0.1238 B
300 mg, Tablet, Oral 100 0.1080 R
400 mg, Tablet, Oral 100 0.1178 R
800 mg, Tablet, Oral 100 0.3261 B
Cimetidine Hydrochloride
Eq 1% Base, Solution, Topical 30 ml 0.1140 B
Clemastine Fumarate
2.68 mg, Tablet, Oral 100 0.3572 R
Clindamycin Hydrochloride
Eq 150 mg Base, Capsule, Oral 100 0.9230 B
Clindamycin Phosphate
Eq 1% base, Solution, Topical 30 ml 0.2095 B
Eq 1% base, Solution, Topical 60 ml 0.3150 R
Clomipramine Hydrochloride
Clonazepam
0.5 mg, Tablet, Oral 100 0.2760 B

Clonidine Hydrochloride
0.1 mg, Tablet, Oral 100 0.0900 B
0.2 mg, Tablet, Oral 100 0.1275 B
0.3 mg, Tablet, Oral 100 0.1650 B
Clorazepate Dipotassium
3.75 mg, Tablet, Oral 100 0.8351 R
7.5 mg, Tablet, Oral 100 1.0388 B
Codeine Phosphate; Phenylephrine Hydrochloride;Promethazine Hydrochloride

10 mg/5 ml; 5mg/5 ml; 6.25 mg/5 ml, Syrup, Oral 480 ml 0.0190 R
Codeine Phosphate; Promethazine Hydrochloride

10 mg/5 ml; 6.25 mg/5 ml, Syrup, Oral 480 ml 0.0128 B
Codeine Phosphate; Pseudoephedrine Hydrochloride; Triprolidine Hydrochloride

10 mg/5 ml; 30 mg/5 ml; 1.25 mg/5 ml, Syrup, Oral 480 ml 0.0190 B
Cyclobenzaprine Hydrochloride
Cyclopentolate Hydrochloride
1%, Solution/Drops, Ophthalmic 15 ml 0.4810 B
Desipramine Hydrochloride
100 mg, Tablet, Oral 100 0.4370 R
Desonide
0.05%, Ointment, Topical 15 gm 0.5840 B
Desoximetasone
0.25%, Cream, Topical 15 gm 0.8130 B
Dexamethasone
0.5 mg/5 ml, Elixir, Oral 240 ml 0.0400 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

Dextromethorphan Hydrobromide; Promethazine Hydrochloride

Diazepam
Diclofenac Potassiuim
Diclofenac Sodium
50 mg, Tablet, Delayed Release, Oral 100 0.4748 B
75 mg, Tablet, Delayed Release, Oral 100 0.6560 R
Dicyclomine Hydrochloride
20 mg, Tablet, Oral 100 0.1428 M
Diflunisal
Diltiazem Hydrochloride
120 mg, Tablet, Oral 100 0.3520 B
Diphenhydramine Hydrochloride
12.5 mg/5 ml, Elixir, Oral 480 ml 0.0080 B
Dipivefrin Hydrochloride
0.1%, Solution/Drops, Ophthalmic 5 ml 0.8700 B
Dipyridamole
Doxepin Hydrochloride
Eq 10 mg base/ml, Concentrate, Oral 120 ml 0.1144 B

Doxycycline Hyclate
Erythromycin
250 mg, Capsule, Delayed Released Pellets, Oral 100 0.1890 B
2%, Solution, Topical 60 ml 0.0650 B
Erythromycin Ethylsuccinate
Eq 200 mg base/5 ml, Suspension, Oral 480 ml 0.0340 B
Estazolam
Estradiol
0.5 mg, Tablet, Oral 100 0.1793 B
Estropipate
0.75 mg, Tablet, Oral 100 0.3453 R
1.5 mg, Tablet, Oral 100 0.3614 B
Etodolac
400 mg, Tablet, Oral 100 0.3450 B
500 mg, Tablet, Oral 100 1.0032 R
Fenoprofen Calcium
Fluocinolone Acetonide
0.01%, Solution, Topical 60 ml 0.1170 B
Fluocinonide
0.05%, Solution, Topical 60 ml 0.2640 B
Fluorometholone
0.1%, Suspension/Drops, Ophthalmic 5 ml 1.6590 R
0.1%, Suspension/Drops, Ophthalmic 10 ml 1.1835 R
0.1%, Suspension/Drops, Ophthalmic 15 ml 0.8950 B

Fluphenazine Hydrochloride
2.5 mg, Tablet, Oral 100 0.2775 B
Flurazepam Hydrochloride
Flurbiprofen
100 mg, Tablet, Oral 100 0.3680 B
Folic Acid
Furosemide
10 mg/ml, Solution, Oral 60 ml 0.1300 B
10 mg/ml, Solution, Oral 120 ml 0.0893 B
Gentamicin Sulfate
Eq 0.1% Base, Ointment, Topical 15 gm 0.1740 B
Eq 0.3% Base, Ointment, Ophthalmic 3.5 gm 2.6786 B
Eq 0.3% Base, Solution/Drops, Ophthalmic 5 ml 0.4890 B
Eq 0.3% Base, Solution/Drops, Ophthalmic 15 ml 0.2560 B
Glipizide
Glyburide
1.5 mg, Tablet, Oral 100 0.2550 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 1.6680 R
Griseofulvin, Ultramicrocrystalline
125 mg, Tablet, Oral 100 0.3743 B
250 mg, Tablet, Oral 100 0.5093 B
330 mg, Tablet, Oral 100 0.6690 B

Guanabenz Acetate
Eq 4 mg base, Tablet, Oral 100 0.3675 R
Guanfacine Hydrochloride
Haloperidol
0.5 mg, Tablet, Oral 100 0.0360 B
Haloperidol Lactate
Eq 2 mg Base/ml, Concentrate, Oral 120 ml 0.1500 B
Homatropine Methylbromide; Hydrocodone Bitartrate

1.5 mg/5 ml; 5mg/5 ml, Syrup, Oral 480 ml 0.0240 B
Hydralazine Hydrochloride
Hydrochlorothiazide; Propranolol Hydrochloride

Hydrochlorothiazide; Spironolactone
Hydrochlorothiazide; Triamterene
25 mg; 37.5 mg, Capsule, Oral 100 0.3181 B
25 mg; 50 mg, Capsule, Oral 100 0.1130 B
25 mg; 37.5 mg, Tablet, Oral 100 0.2438 R
Hydrocortisone
0.5%, Cream, Topical, 30 gm 0.0380 B
1%, Lotion, Topical 120 ml 0.0640 B
Hydroxychloroquine Sulfate
200 mg, Tablet, Oral 100 0.8540 B

Hydroxyurea
Hydroxyzine Hydrochloride
10 mg/5 ml, Syrup, Oral 480 ml 0.0370 B
Hydroxyzine Pamoate
Eq 25 mg HCL, Capsule, Oral 100 0.0794 B
Eq 50 mg HCL, Capsule, Oral 100 0.1013 R
Eq 100 mg HCL, Capsule, Oral 100 0.2710 B
Ibuprofen
400 mg, Tablet, Oral 100 0.0640 B
600 mg, Tablet, Oral 100 0.0740 R
800 mg, Tablet, Oral 100 0.1070 B
Imipramine Hydrochloride
Indapamide
1.25 mg, Tablet, Oral 100 0.1780 B
2.5 mg, Tablet, Oral 100 0.2080 B
Indomethacin
Isoniazid
300 mg, Tablet, Oral 100 0.0548 B
Isosorbide Dinitrate
5 mg, Tablet, Sublingual 100 0.0300 R
Isosorbide Mononitrate
Ketoconazole
200 mg, Tablet, Oral 100 2.7645 B

Ketoprofen
Ketorolac Tromethamine
Labetalol Hydrochloride
100 mg, Tablet, Oral 100 0.4670 B
200 mg, Tablet, Oral 100 0.6620 B
300 mg, Tablet, Oral 100 0.8810 B
Lactulose
10 gm/15 ml, Solution, Oral 480 ml 0.0219 B
Levobunolol Hydrochloride
0.5%, Solution/Drops, Ophthalmic 5 ml 1.3950 R
Lidocaine Hydrochloride
2%, Solution, Oral 100 ml 0.0278 M
Lindane
1%, Shampoo, Topical 480 ml 0.1660 B
Loperamide Hydrochloride
Lorazepam
0.5 mg, Tablet, Oral 100 0.4350 B
Meclizine Hydrochloride
12.5 mg, Tablet, Oral 100 0.0370 B
Medroxyprogesterone Acetate
Megestrol Acetate

Meprobamate
200 mg, Tablet, Oral 100 0.1080 B
400 mg, Tablet, Oral 100 0.1580 R
Methazolamide
Methocarbamol
500 mg, Tablet, Oral 100 0.1350 B
750 mg, Tablet, Oral 100 0.1710 B
Methyclothiazide
Methyldopa
250 mg, Tablet, Oral 100 0.1013 B
500 mg, Tablet, Oral 100 0.1800 B
Methylphenidate Hydrochloride
Methylprednisolone
Metoclopramide Hydrochloride
Eq 5 mg base/5 ml, Solution, Oral 480 ml 0.0155 B
Metoprolol Tartrate
100 mg, Tablet, Oral 100 0.1290 B
Metronidazole
250 mg, Tablet, Oral 100 0.0640 B
500 mg, Tablet, Oral 100 0.1350 B
Mexiletine Hydrochloride
Minocycline Hydrochloride

Minoxidil
2.5 mg, Tablet, Oral 100 0.3170 B
Nadolol
120 mg, Tablet, Oral 100 1.1220 B
160 mg, Tablet, Oral 100 1.1540 B
Naphazoline Hydrochloride
Naproxen
250 mg, Tablet, Oral 100 0.1035 B
375 mg, Tablet, Oral 100 0.1335 B
500 mg, Tablet, Oral 100 0.1628 B
Naproxen Sodium
Niacin
500 mg, Tablet, Oral 100 0.0390 R
Nicardipine Hydrochloride
Nifedipine
Nitrofurantoin, Macrocrystalline
Nortriptyline Hydrochloride
Eq 25 mg base, Capsule, Oral 100 0.1580 R

Nystatin
100,000 units/gm, Cream, Topical 15 gm 0.0900 R
100,000 units/gm, Cream, Topical 30 gm 0.0760 B
100,000 units/ml, Suspension, Oral 60 ml 0.0620 B
100,000 units/ml, Suspension, Oral 480 ml 0.0425 R
500,000 units, Tablet, Oral 100 0.3563 B
Nystatin; Triamcinolone Acetonide

100,000 units/gm; 0.1%, Cream, Topical 15 gm 0.0990 B
100,000 units/gm; 0.1%, Ointment, Topical 15 gm 0.0990 B
Oxazepam
Oxybutynin Chloride
Penicillin V Potassium
Eq 125 mg base/5 ml, Powder for reconstitution, Oral 200 ml 0.0120 B
Pentoxifylline
400 mg, Tablet, Extended Release, Oral 100 0.3150 B
Perphenazine
Phenylephrine Hydrochloride; Promethazine Hydrochloride

5mg/5 ml; 6.25 mg/5 ml, Syrup, Oral 480 ml 0.0092 B
Pindolol

Piroxicam
Polymyxin B Sulfate; Trimethoprim Sulfate

10,000 units/ml; Eq 1 mg base/ml, Solution/Drops, Opthalmic 10 ml 1.2360 B
Potassium Chloride
8 mEq, Tablet, Extended Release, Oral 100 0.0773 R
Prazosin Hydrochloride
Prednisolone
Prednisolone Acetate
1%, Suspension/Drops, Ophthalmic 5 ml 1.8900 B
1%, Suspension/Drops, Ophthalmic 10 ml 1.6200 B
Prednisolone Sodium Phosphate

Eq 0.9% Phosphate, Solution/Drops, Ophthalmic 5 ml 1.9200 B
Prednisone
Primidone
250 mg, Tablet, Oral 100 0.3610 B
Probenecid
500 mg, Tablet, Oral 100 0.7060 B
Procainamide Hydrochloride
Prochlorperazine Maleate
Promethazine Hydrochloride
6.25 mg/5 ml, Syrup, Oral 120 ml 0.0219 B
6.25 mg/5 ml, Syrup, Oral 480 ml 0.0079 B

Proparacaine Hydrochloride
Propoxyphene Hydrochloride
Propranolol Hydrochloride
Quinidine Gluconate
324 mg, Tablet, Extended Release, Oral 100 0.4200 R
Ranitidine Hydrochloride
Eq 150 mg base, Tablet, Oral, 100 0.3410 B
Selegiline Hydrochloride
Selenium Sulfide
2.5%, Lotion/Shampoo, Topical 120 ml 0.0350 B
Spironolactone
Sucralfate
1 gm, Tablet, Oral 100 0.3690 B
Sulfacetamide Sodium
10%, Ointment, Ophthalmic 3.5 gm 1.4530 M
10%, Solution/Drops, Opthalmic 15 ml 0.1240 B
Sulfamethoxazole; Trimethoprim
200 mg/5 ml; 40 mg/5 ml, Suspension, Oral 480 ml 0.0230 B
Sulfasalazine
500 mg, Tablet, Oral 100 0.1403 R
Sulindac
150 mg, Tablet, Oral 100 0.2138 R
200 mg, Tablet, Oral 100 0.3500 B

Temazepam
Tetracycline Hydrochloride
Theophylline
80 mg/15 ml, Elixir, Oral 480 ml 0.0070 B
300 mg, Tablet, Extended Release, Oral 100 0.1070 R
Thioridazine Hydrochloride
100 mg/ml, Concentrate, Oral 120 ml 0.2376 B
100 mg, Tablet, Oral 100 0.2324 R
Thiothixene
Timolol Maleate
Eq 0.25% base, Solution/Drops, Ophthalmic 5 ml 0.7500 B
Tobramycin
Tolazamide
250 mg, Tablet, Oral 100 0.1038 B
500 mg, Tablet, Oral 100 0.2480 B
Tolmetin Sodium

Trazodone Hydrochloride
100 mg, Tablet, Oral 100 0.0952 R
150 mg, Tablet, Oral 100 0.4280 B
Triamcinolone Acetonide
0.025%, Cream, Topical 15 gm 0.0950 R
0.1%, Cream, Topical 454 gm 0.0295 R
0.1%, Lotion, Topical 60 ml 0.1215 B
0.1%, Paste, Dental 5 gm 0.8250 B
Triazolam
0.125 mg, Tablet, Oral 100 0.4000 R
Trifluoperazine Hydrochloride
Trimethoprim
100 mg, Tablet, Oral 100 0.1553 B
Tropicamide
1%, Solution/Drops, Ophthalmic 15 ml 0.7000 B
Valproic Acid
Verapamil Hydrochloride
120 mg, Capsule, Extended Release, Oral 100 0.8250 B
120 mg, Tablet, Oral 100 0.0860 B

Warfarin Sodium
2.5 mg, Tablet, Oral 100 0.4692 B
7.5 mg, Tablet, Oral 100 0.6981 B


Appendix E:
Glossary
National Pharmaceutical Council E-1

E-2 National Pharmaceutical Council

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 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 (ASO) An insurance arrangement requiring the employer to be at risk for the cost 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.

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 eligibility
criteria (aged, blind, or disabled individuals) and Aid to Families with
Dependent Children 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 Health Care Policy and A federal agency under Health and Human Services (HHS) whose purpose is
Research (AHCPR) to enhance the quality and effectiveness of healthcare by funding healthcare
services research, conducting health technology assessments and outcomes
studies, and developing and disseminating clinical practice guidelines.
Aid to Families with Dependent A state-based federal cash assistance program for low-income families. In all
Children (AFDC) states, AFDC recipiency may be used to establish Medicaid eligibility. Now
known as Temporary Assistance to 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 Institute A nonprofit organization that coordinates the development of voluntary
(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.

Term Definition
Ancillary Services Hospital services other than room, board, and professional services. They
may include X-rays, lab tests, or anesthesia.
Antitrust A legal term encompassing a variety of efforts on the part of government to

assure that sellers do not conspire to restrain trade or fix prices for their goods
or services in the market.
Any Willing Provider A requirement that a health insurance plan or a health maintenance
organization (HMO) must sign a contract for the delivery of healthcare
services with any provider in the area that would like to provide such services
to the plan’s or HMO’s enrollees, and can meet the terms of a contract.
Assignee The person to whom the rights to a health insurance policy are assigned, either
in part or in whole, by the original policyholder.
Assignment of Benefits A method under which a claimant requests that his/her benefits under a claim
be paid to some designated person or institution, usually a physician or
hospital.
At-Risk Accepting prepayment as full coverage for a predetermined healthcare benefit

and assuming financial liability for any loss that occurs when premiums paid
are less than the cost of services provided.
Authorization As it applies to managed care, authorization is the approval of care, such as

hospitalization.
Average Cost Per Claim The average dollar amount of administrative and/or medical services rendered
for the unit of measure within each expenditure category. The calculation is
$amount / #of units.
Average Manufacturer Price (AMP) The average price paid by wholesalers for products distributed to the retail
class of trade.
Average Wholesale Price (AWP) The published suggested wholesale price of a drug. It is often used by
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.

Term Definition
Benefit Package Services an insurer, government agency, or health plan offers to a group or
individual under the terms of a contract.
Best Price For purposes of Medicaid rebate calculations, lowest price paid for a product
by any purchaser other than Federal agencies and state pharmaceutical
assistance programs.
Biological Equivalents Those chemical equivalents which, when administered in the same amounts,
will provide the same biological or physiological availability, as measured by
blood levels, urine levels, etc.
Blue Book (MDBT) The generic name for a widely used pricing guide entitled the American
Druggist First Databank Annual Directory of Pharmaceuticals. Brand name
and generic drugs are listed by product, manufacturer, National Drug or
Universal Price Codes, direct price and average wholesale price (AWP).
Other pricing guides are the Red Book and Medispan’s Pricing Guide.
Brand-Name Name identifying a drug as the product of a specific pharmaceutical company.

Also known as proprietary trademark name.
Cafeteria Plan An employee benefit plan under which all participants are permitted to choose
among two or more benefit options according to their needs and/or ability to
pay. Also called a flexible benefit plan of “flex plan.”
Capitation A method of payment in which a health plan, such as an HMO or a specific

health care provider, receives a fixed amount for each person eligible to
receive services ($ per member per month), which is made whether or not the
covered person becomes an active patient and without regard to the number
and mix of services used by that patient.
Capitation Fund A fund based on the number of members multiplied by the budgeted or
capitated amount each member pays. Some HMOs, in lieu of reimbursing
physicians on a direct capitation basis, may establish such a fund. Physicians
are then reimbursed on a fee-for-service basis from the capitation fund. The
HMO monitors patient visits for over-utilization; patients exceeding the norm
are notified.
Card Programs The use of a drug benefit identification card which, when presented to a
participating pharmacy by employees or their dependents, usually entitles
them to receive the medication for a copay.
Care Coordinator A primary health care practitioner: (1) who provides primary care services to
an enrollee, (2) who is generally responsible for coordinating the enrollee’s
healthcare, and (3) with whom, other than in an emergency, a patient must
consult to obtain a referral to a specialist provider in order to obtain the
highest level of benefits available under a health plan. Care coordinators are
sometimes called “gatekeepers.”
Carve Out A decision to purchase separately a service that is typically a part of an

indemnity or HMO plan. Example: an HMO may “carve out” the behavioral
health benefits and select a specialized vendor to supply these services on a
stand-alone basis.

Term Definition
Case Management (1) A process whereby covered persons with specific health care needs are
identified and a plan designed to efficiently utilize healthcare resources is
formulated and implemented to achieve the optimum patient outcome in the
most cost-effective manner. (2) A utilization management program that assists
the patient in determining the most appropriate and cost-effective treatment
plan. It is used for patients who have prolonged expensive or chronic
conditions, helps determine the treatment location (hospital, or other
institution, or home), and authorizes payment for such care if it is not covered
under the patient’s benefit agreement.
Case Manager An experienced professional (e.g., nurse, doctor or social worker) who works
with patients, providers and insurers to coordinate all services deemed
necessary to provide the patient with a plan of medically necessary and
appropriate health care.
Categorically Needy Under Medicaid, categorically needy causes are aged, blind, or disabled
individuals or families and children who meet financial eligibility
requirements for Aid to Families with Dependent Children, Supplemental
Security Income, or an optional state supplement.
Certificate of Need (CON) A certificate issued by a government body, where required, to an individual or
organization proposing to construct or modify a health facility, acquire major
new medical equipment, or offer a new or different health service. Such
issuance recognizes that a facility or services, when available, will meet the
needs of those for whom it is intended.
Chain Pharmacy One of a group of pharmacies, usually three or more, under the same
management or ownership.
Charity Care Pools The assets of several funds combined to cover health care costs to the poor
and uninsured. The pools are established by organizations such as hospitals
and insurance companies to offset a portion of the cost for providing health
care to the indigent.
Chemical Equivalents Those multiple-source drug products containing identical amounts of the same
active ingredients, in equivalent dosage forms, and meeting existing
physical/chemical standards.
Chronic Care Care and treatment rendered to individuals whose health problems are of a
long-term and continuing nature. Rehabilitation facilities, nursing homes, and
mental hospitals may be considered chronic care facilities.
Claim Information on medical services provided that is submitted by a provider or a

covered person from which processing for payment to the provider or covered
person is made. The term generally refers to the liability for health care
services received by covered persons.
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.

Term Definition
Claims Review The method by which an enrollee’s health care service claims are reviewed
before reimbursement is made. The purpose of this monitoring system is to
validate the medical appropriateness of the provided services and to be sure
the cost of the service is not excessive.
Clearinghouse Capability A company capable of submitting electronic and/or paper claims to several
third-party payers.
Clinical Indicator A tool or marker used to monitor and evaluate care to assure desirable
outcomes and to explain or prevent undesirable outcomes.
Clinical Outcome The status of the patient’s health, especially after receipt of medical care
services. Assessment of outcomes may be dependent upon targeted goals,
clinical markers, and the ability to provide objective measurements.
Clinical Practice Guidelines Guidelines that specify the appropriate course(s) of treatment for specified
health conditions.
Closed-Panel HMO Generally offers the services of a relatively limited number of healthcare
providers, e.g., physicians employed by the HMO. Staff- and group-model
HMOs are usually referred to as being in this category.
Coinsurance The portion of covered healthcare costs for which the covered person has a
financial responsibility, usually according to a fixed percentage. Often
coinsurance applies after first meeting a deductible requirement.
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 (CMP) A status granted by the federal government to an organization meeting
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 Reconciliation A federal law that, among other things, requires employers to offer continued
Act (COBRA) 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. Bureau of Labor using retail
prices of goods and services sold in large cities across the country.
Continuous Quality Improvement A formal process of constantly seeking better ways to achieve stated goals.
(CQI)

Term Definition
Continuum of Care A range of clinical services provided to an individual or group, which may
reflect treatment rendered during a single inpatient hospitalization, or care for
multiple conditions over a lifetime. The continuum provides a basis for
analyzing quality, cost and utilization over the long term.
Contract Pharmacy System Pharmaceutical benefit delivery arrangement in which an HMO contracts with
community pharmacies (chain or selected independents) to provide
medications to members. Reimbursement may be by fee-for-service,
capitation, or some other arrangement.
Contributory Program A method of payment for group coverage in which part of the premium is paid
by the employee and part is paid by the employer or union.
Copay/Copayment A cost-sharing arrangement in which a covered person pays a specified charge

for a specified service, such as $10 for an office visit. The covered person is
usually responsible for payment at the time the healthcare is rendered.
Typical copayments are fixed or variable flat amounts for physician office
visits, prescriptions or hospital services. Some copayments are referred to as
coinsurance, with the distinguishing characteristics that copayments are flat or
variable dollar amounts and coinsurance is a defined percentage of the
charges for services rendered.
Cosmetic Procedures Those procedures which involve physical appearance, but which do not
correct or materially improve a physiological function and are not deemed
medically necessary.
Cost Sharing Any provision of a health insurance policy that requires the insured to pay
some portion of medical expenses. The general term includes deductibles,
copayments, and coinsurance.
Cost Shifting The redistribution of payment sources. Typically, cost shifting occurs when
one payer obtains a discount on provider services, and the providers increase
costs to another payer to make up the difference.
Cost-Based Reimbursement Payment by third party insurers in which the amount is based on the cost to
the provider of delivering services.
Cost-Effectiveness Usually considered as a ratio, the cost-effectiveness of a drug or procedure,

for example, relates the cost of that drug or procedure to the health benefits
resulting from it. In health terms, it is often expressed as the cost per year per
life saved.
Cost-Sharing A general set of financing arrangements via deductibles, copays and/or

coinsurance in which a person covered by the health plan must pay some of
the costs to receive care. See also “Copayment”, “Coinsurance”, and
“Deductible”.
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.

Term Definition
Covered Expenses Medical and related costs, experienced by those covered under the policy, that
qualify for reimbursement under terms of the insurance contract.
Covered Services The specific services and supplies for which Medicaid will provide
reimbursement. Covered services under Medicaid consist of a combination of
mandatory and optional services within each state.
Credentialing A process of review to approve a provider who applies to participate in a

health plan. Specific criteria and prerequisites are applied in determining
initial and ongoing participation in the health plan.
Customary Charge The charge a physician or supplier usually bills his patients for furnishing a
particular service or supply is called the customary charge.
Customary, Prevailing, and Reasonable Method of reimbursement which limits payment to the lowest of the
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.
Diagnostic Center Freestanding or hospital-based facility that specializes in diagnosing illnesses

and injuries.
Diagnostic Related Group (DRG) A system of classification for inpatient hospital services based on principal
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.

Term Definition
Disease Management An effort to improve patient outcomes and lower costs by organizing managed
care initiatives around patients with a particular disease or condition.
Dismemberment Loss of body parts stemming from accidental physical injury.
Dispense As Written (DAW) A prescribing directive issued by physicians to indicate that the pharmacy
should not in any way alter a prescription. Such alterations are usually done
in order to substitute a generic drug for the brand-name drug ordered.
Dispensing, Fill or Professional Fee The amount paid to a pharmacy for each prescription, in addition to the
negotiated formula for reimbursing ingredient cost.
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.
Early and Periodic Screening, The EPSDT program covers screening and diagnostic services to determine
Diagnosis, and Treatment (EPSDT) physical or mental defects in recipients under age 21, as well as health care
and other measures to correct or ameliorate any defects and chronic
conditions discovered.
Electronic Data Interchange (EDI) The computer-to-computer exchange of business or other information. The
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 Security A Federal act passed in 1974, that established new standards and
Act of 1974, Public Law 93-406 reporting/disclosure requirements for employer-funded pension and health
(ERISA) benefit programs. To date, self-funded health benefit plans operating under
ERISA have been held to be exempt from state insurance laws.

Term Definition
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 (EAC) An estimate of the price generally, and currently, paid by providers for a 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 or Medical, surgical, psychiatric, substance abuse or other healthcare services,
Unproven Procedures supplies, treatments, procedures, drug therapies or devices that are determined
by the health plan (at the time it makes a determination regarding coverage in
a particular case) to be either: not generally accepted by informed healthcare
professionals in the U.S. as effective in treating the condition, illness or
diagnosis for which their use is proposed; or not proven by scientific evidence
to be effective in treating the condition, illness or diagnosis for which their
use is proposed.
Extended Care Long-term care, ranging from routine assistance for daily activities to
sophisticated medical and nursing care for those needing it. The care, covered
under certain insurance policies, can be provided in homes, day-care centers
or other facilities.
Family Planning Services Any medically approved means, including diagnosis, treatment, drugs,
supplies and devices, and related counseling which are furnished or prescribed
by or under the supervision of a physician for individuals of childbearing age
for purposes of enabling such individuals freely to determine the number or
spacing of their children.
Favorable Selection A tendency for utilization of health services in a population group to be lower
than expected or estimated.
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
the Health Care Financing Administration (HCFA) administers the process.
Fee Maximum The maximum amount a participating provider may be paid for a specific
healthcare service provided to a covered person under a specific contract.
Sometimes called “fee max.”

Term Definition
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 Reimbursement The traditional healthcare payment system, under which physicians and 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.
Generic Equivalent See “Generic Drug.”
Generic Substitution Dispensing a generic drug in place of a brand-name medication.
Global Target A financing method identical to a global budget except that no enforcement
mechanism is used to keep providers and hospitals within budget (i.e.,
providers and hospitals will receive additional funding if their costs exceed
their budgeted payments).
HCFA 1500 A universal form developed by the government agency known as Health Care
Financing Administration (HCFA), for providers of services to bill
professional fees to health carriers.

Term Definition
HCFA Common Procedural Coding A listing of services, procedures and supplies offered by physicians and other
System (HCPCS) providers. HCPCS includes current procedural terminology (CPT) codes,
national alphanumeric codes and local alphanumeric codes. The national
codes are developed by HCFA 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 Administration The government agency within the Department of Health and Human Services
(HCFA) which directs the Medicare and Medicaid programs (Titles XVIII and XIX of
the Social Security Act) and conducts research to support those programs.
Health Care Prepayment Plan (HCPP) A cost contract with the HCFA that prepays a health plan a flat amount per
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 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.
Health Maintenance Organizations (1) An entity that provides, offers or arranges for coverage of designated
(HMO’s) health services needed by plan members for a fixed, prepaid premium. There
are four basic models of HMOs: staff model, group model, network model
and individual practice association; (2) Under the federal HMO Act, an entity
must have three characteristics to call itself an HMO: (a) An organized system
for providing healthcare or otherwise assuring healthcare delivery in a
geographic area, (b) An agreed upon set of basic and supplemental health
maintenance and treatment services, and (c) A voluntary enrolled group of
people.
Health Plan An organization that provides a defined set of benefits; this term usually refers
to an HMO-like entity, as opposed to an indemnity insurer.
Health Plan Employer Data and A core set of performance measures to assist employers and other health
Information Set (HEDIS) purchasers in understanding the value of healthcare purchases and evaluating
health plan performance. HEDIS 3.0 is currently used and distributed by
NCQA (National Committee for Quality Assurance).
HMO - Group Model A healthcare model involving contracts with physicians organized as a
partnership, professional corporation, or other association. The health plan
compensates the medical group for contracted services at a negotiated rate,
and that group is responsible for compensating its physicians and contracting
with hospitals for care of their patients.

Term Definition
HMO - Individual Practice Association A healthcare model that contracts with physicians and other community
(IPA) healthcare providers, to provide services in return for a negotiated fee.
Physicians continue in their existing individual or group practices and are
compensated on a per capita, fee schedule, or fee-for-service basis.
HMO - Network Model An HMO type in which the HMO contracts with more than one physician
group, and may contract with single- and multi-specialty groups. The
physician works out of his/her own office. The physician may share in
utilization savings, but does not necessarily provide care exclusively for HMO
members.
HMO - Staff Model A healthcare model that employs physicians to provide healthcare to its
members. All premiums and other revenues accrue to the HMO, which
compensates physicians by salary and incentive programs.
Home Health Agency (HHA) A facility or program licensed, certified or otherwise authorized pursuant to
state and federal laws to provide healthcare services in the home.
Home Health Services Services and items furnished to an individual who is under the care of a
physician by a home health agency or by others under arrangements made by
such agency. Services are furnished under a plan established and periodically
reviewed by a physician. They are provided on a visiting basis in an
individual’s home and include: nursing, physical therapy, dietary, counseling,
and social services; part-time or intermittent skilled nursing care; physical,
occupational, or speech therapy; medical social services, medical supplies and
appliances (other than drugs and biologicals); home health aide services; and
services of interns and residents.
Hospice A program that provides palliative and supportive care for terminally ill
patients and their families, either directly or on a consulting basis with the
patient's physician or another community agency. Originally a medieval name
for a way station for crusaders where they could be replenished, refreshed,
and cared for, hospice is used here for an organized program of care for
people going through life's "last station." The whole family is considered the
unit of care, and care extends through their period of mourning.
Indemnity Insurance An insurance program in which the insured person is reimbursed or the
provider is paid for covered expenses after services are rendered.
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.

Term Definition
Intensive Care Skilled nursing services, usually in a hospital, prescribed by a physician for
individuals with serious medical conditions and delivered with the guidance of
a registered nurse.
Intermediate Care Facility (ICF) An institution that is licensed under state law to provide on a regular basis,
health-related care and services to individuals who do not require the degree
of care or treatment which a hospital or skilled nursing facility is designed to
provide. Public institutions for care of the mentally retarded or people with
related conditions are also included in the definition. The distinction between
"health-related care and services" and "room and board" has often proven
difficult to make but is important because ICFs are subject to quite different
regulations and coverage requirements than institutions which do not provide
health-related care and services.
International Classification of Diseases, A listing of diagnoses and identifying codes used by physicians for reporting
9th Edition (Clinical Modification) diagnoses of health plan enrollees. The coding and terminology provide a
(ICD-9-CM) uniform language that can accurately designate primary and secondary
diagnoses and provide for reliable, consistent communications on claim
forms.
Investigational Treatments Medical treatments, including drugs waiting for FDA approval, that are
considered experimental and, therefore, may not be covered by insurance
plans. The definition of experimental currently varies from plan to plan.
Laboratory and Radiological Services Professional and technical laboratory and radiological services ordered by a
licensed practitioner, provided in an office or similar facility (other than a
hospital outpatient department or clinic) or by a qualified lab.
Legend Drug A drug that, by law, can be obtained only by prescription and bears the label,
“Caution: federal law prohibits dispensing without a prescription.” See
“Prescription Medication.”
Lifetime Maximum Benefit A limitation on financial coverage for healthcare for an individual stated by an
insurer. This amount serves as a cap on contractual liability and can be
exceeded only in rare and unusual circumstances.
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 fields to produce
comprehensive pictures of the anatomy.
Managed Care (1) A system of healthcare delivery that influences utilization and cost of
services and measures performance. The goal is a system that delivers value
by giving people access to high quality, cost-effective healthcare; (2) A
systemized approach which seeks to ensure the provision of the right
healthcare at the right time, place and cost.

Term Definition
Managed Care Organization (MCO) Broad term that encompasses various types of health plans, including Health
Maintenance Organizations (HMOs), Preferred Provider Organizations
(PPOs), Point-of-Service plans (POSs) and Provider-Sponsored Organizations
(PSOs). Often used to refer to a health plan that is similar to an HMO but
which does not have an HMO license and serves only Medicaid beneficiaries.
Mandated Benefits Those benefits which health plans are required by state or federal law to
provide to policyholders and eligible dependents.
Maximum Allowable Cost, or A maximum cost is fixed for which the pharmacist can be reimbursed for
“Reasonable Cost Range” selected products, as identified in a “formulary.”
Maximum Out-of-Pocket Costs The limit on total member copayments, deductibles and coinsurance under a
benefit contract.
Medicaid A Federally aided State-operated and administered program that provides

medical benefits for certain indigent or low-income persons in need of health
and medical care. The program, authorized by Title XIX of the Social
Security Act, is basically for the poor. It does not cover all of the poor,
however, but only persons who meet specified eligibility criteria. Subject to
broad Federal guidelines, states determine the benefits covered, program
eligibility, rates of payment for providers, and methods of administering the
program.
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 Information Federally developed guidelines for a computer system designed to achieve
System (MMIS) national standardization of Medicaid claims processing, payment, review and
reporting for all health care claims.
Medical Necessity The evaluation of healthcare services to determine if they are: medically
appropriate and required to meet basic health needs; consistent with the
diagnosis or condition and rendered in a cost-effective manner; and consistent
with national medical practice guidelines regarding type, frequency and
duration of treatment.
Medical Savings Account (MSA) A non-taxable savings account used to cover medical expenses. Based
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 (AFDC or SSI) but are within limits set under the
Medicaid state plan.

Term Definition
Medicare (Part A/Part B) A U.S. health insurance program for people aged 65 and over, for persons
eligible for social security disability payments for two years or longer, and for
certain workers and their dependents who need kidney transplantation or
dialysis. Monies from payroll taxes and premiums from beneficiaries are
deposited in special trust funds for use in meeting the expenses incurred by
the insured. It consists of two separate but coordinated programs: hospital
insurance (Part A) and supplementary medical insurance (Part B).
Medicare Beneficiary A person designated by the Social Security Administration as entitled to

receive Medicare benefits.
Medicare Payment Advisory A federal commission established under the Balanced Budget Act of 1997 to
Commission (MedPAC) advise and assist Congress and the Department of Health and Human Services
in maintaining and updating the Medicare prospective payment system.
MedPAC replaces and assumes the responsibilities of the Physician Payment
Review Commission (PPRC) and the Prospective Payment Assessment
Commission (ProPAC).
Medicare Supplemental 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 Supplemental See “Medicare Supplemental Insurance.”

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.
Most Favored Nations Discount or A contractual agreement that stipulates that a vendor must provide to a
Clause particular payor the lowest prices that would be available to any purchaser.
The federal government often invokes most favored nation clauses for
healthcare contracts.
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.”

Term Definition
Other Practitioners’ Services Health care services of licensed practitioners other than physicians and
dentists.
Out-of-Pocket Costs/Expenses (OOPs) The portion of payments for health services required to be paid by the
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.
Outcome Measures Assessments which gauge the effect or results of treatment for a particular
disease or condition. Outcome measures include such parameters as: the
patient’s perception of restoration of function, quality of life and functional
status, as well as objective measures of mortality, morbidity and health status.
Outcomes Management Systematically improving healthcare results, typically by modifying practices

in response to data gleaned through outcomes measurement, then remeasuring
and remodifying - often in a formal program of continuous quality
improvement.
Outcomes Research Studies aimed at measuring the effect of a given product, procedure, or
medical technology on health or costs.
Outlier An observation in a distribution that is outside a certain range, often defined

as two or three standard deviations from the mean or exceeding a specific
percentile. Frequently refers to a case or hospital stay that is unusually long or
expensive for its type, or to a physician practice that uses an abnormally high
or low volume of resources.
Outpatient Services Outpatient services are medical and other services provided on a non-resident
basis (patients are not admitted to the facility) by a hospital or other qualified
facility, such as a mental health clinic, rural health clinic, mobile X-ray unit,
or freestanding dialysis unit. Such services include outpatient physical therapy
services, diagnostic X-ray and laboratory tests, and X-ray and other radiation
therapy.
Over-the-Counter (OTC) A drug product that does not require a prescription under federal or state law.
Participating Provider A provider who has contracted with the health plan to provide medical
services to covered persons. The provider may be a hospital, pharmacy, other
facility or a physician who has contractually accepted the terms and
conditions as set forth by the health plan.
Patient Health Status Survey Questionnaire used to solicit patient perceptions regarding the state of their
health. Questions may be general and address overall health status with regard
to a specific condition (e.g., an arthritic patient’s ability to make a fist or an
asthmatic patient’s ability to climb a flight of stairs).
Patient Satisfaction Survey Questionnaire used to solicit the perceptions the plan enrollees or patients
have regarding how a health plan meets their medical needs and how the
delivery of care is handled, (e.g., waiting time, access to treatments).

Term Definition
Payer A general term indicating the responsible party for the payment of medical
care service expenses. Payers may be patients, insurance companies,
government agencies, or a combination of these.
Peer Review The evaluation of quality of total healthcare provided, by medical staff with
equivalent training.
Peer Review Organization (PRO) An entity established by the Tax Equity and Fiscal Responsibility Act of 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.”
Pharmacy And Therapeutics (P&T) An organized panel of physicians and pharmacists from varying practice
Committee specialties, who function as an advisory panel to the plan regarding the safe
and effective use of prescription medications. Often compromises the official
organizational line of communication between the medical and pharmacy
components of the health plan. A major function of such a committee is to
develop, manage and administer a drug formulary.
Physician Any doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who is duly
licensed and qualified under the law of jurisdiction in which treatment is
received.
Physician-Hospital Organization A legal entity formed by a hospital and a group of physicians to further mutual
(PHO) interests and to achieve market objectives. A PHO generally combines
physicians and a hospital into a single organization for the purpose of
obtaining payer contracts. Doctors maintain ownership of their practices and
agree to accept managed care patients according to the terms of a professional
service agreement with the PHO. The PHO serves as a collective negotiating
and contracting unit. It is typically owned and governed jointly by a hospital
and shareholder physicians.
Point-Of-Service (POS) Plan A health plan allowing the covered person to choose to receive a service from
a participating or non-participating provider, with different benefit levels
associated with the use of participating providers. POS can be provided in
several ways: an HMO may allow members to obtain limited services from
non-participating providers; an HMO may provide non-participating benefits
through a supplemental major medical policy; a PPO may be used to provide
both participating and non-participating levels of coverage and access; or
various combinations of the above may be used.
Portability Requirement that health plans guarantee continuous coverage without waiting
periods for persons moving between plans.
Practice Guideline Systematically developed statements on medical practice that assist a

practitioner and a patient in making decisions about appropriate healthcare for
specific medical conditions. Managed care organizations frequently use these
guidelines to evaluate appropriateness and medical necessity of care. Terms
used synonymously include practice parameters, standard treatment protocols
and clinical practice guidelines.
Practice Parameters See “Practice Guidelines.”

Term Definition
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 Organization A program in which contracts are established with providers of medical care.
(PPO) Providers under such contracts are referred to as preferred providers. Usually,
the benefit contract provides significantly better benefits (fewer copayments)
for services received from preferred providers, thus encouraging covered
persons to use these providers. Covered persons are generally allowed
benefits for non-participating providers’ services, usually on an indemnity
basis with significantly higher copayments. A PPO arrangement can be
insured or self-funded. Providers may be, but are not necessarily, paid on a
discounted fee-for-service basis.
Prepaid Group Practice Plans Organized medical groups of essentially full-time physicians in appropriate
specialties, as well as other professional and subprofessional personnel, who,
for regular compensation, undertake to provide comprehensive care to an
enrolled population for premium payments that are made in advance by the
consumer and/or their employers.
Prepaid Health Plan (PHP) An entity that provides a non-comprehensive set of services on either
capitated risk or non-risk basis or the entity provides comprehensive services
on a non-risk basis.
Prescribed Drugs Prescribed drugs are drugs dispensed by a licensed pharmacist on the
prescription of a practitioner licensed by law to administer such drugs, and
drugs dispensed by a licensed practitioner to his own patients. This item does
not include a practitioner’s drug charges that are not separable from his other
charges, or drugs covered by a hospital bill.
Prescription Medication A drug which has been approved by the Food and Drug Administration and
which can, under federal and state law, be dispensed only pursuant to a
prescription order from a duly licensed prescriber, usually a physician.
Preventive Care Comprehensive care emphasizing priorities for prevention, early detection and
early treatment of conditions, generally including routine physical
examinations, immunization and well person care.
Primary Care Basic or general healthcare traditionally provided by family practice,

pediatrics and internal medicine. See also “Secondary Care.”
Primary Care Case Management Managed care arrangements where primary care providers receive a per capita
(PCCM) management fee to coordinate a patient's care in addition to reimbursement
(fee-for-service or capitation) for the medical services they provide.

Term Definition
Primary Care Physician (PCP) The primary care practitioner (e.g., internist, family/general practitioner,
pediatrician, and in some cases, OB/Gyn) in managed care organizations who
determines whether the presenting patient needs to see a specialist or requires
other non-routine services. See Care Coordinator.
Prior Authorization The process of obtaining prior approval as to the appropriateness of a service
or medication. Prior authorization does not guarantee coverage.
Prospective Financing Financing for health care services based on prices or budgets determined prior
to the delivery of service. Payments can be per unit of service, per member, or
per time period. In all its forms prospective financing differs from cost-based
reimbursement, under which a provider is paid for costs incurred.
Protocol See “Practice Guidelines.”
Provider Network See “Network Plan.”
Providers A physician, hospital, group practice, nurse, nursing home, pharmacy or any
individual or group of individuals that provides a healthcare service.
Quality assurance (QA) or quality A formal set of activities to review and affect the quality of services provided.
improvement (QI) Quality assurance includes assessment and corrective actions to remedy any
deficiencies identified in the quality of direct patient, administrative and
support services.
Rate Setting A form of financing under which hospitals or nursing homes are paid prices
that are prospectively determined, generally by a state agency. Prospectively
determined prices may be paid by all payers for all covered services, as in all
payer systems, or by only some payers. The unit of payment can be service,
patient, or time period. See “Prospective Financing.”
Rational Drug Therapy Prescribing the right drug for the right patient, at the right time, in the right
amount, and with due consideration of relative cost.
Reasonable Charge In processing claims for Supplementary Medical Insurance benefits, carriers
use HCFA 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 HCFA
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.

Term Definition
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 HCFA and an HMO or competitive medical plan
requiring the HMO to furnish at a minimum all Medicare covered services to
Medicare eligible enrollees for an annually determined, fixed monthly
payment rate from the government and a monthly premium paid by the
enrollee. The HMO is then liable for services regardless of their extent,
expense or degree. (2) An agreement between a provider and payer, or
intermediary, on behalf of a payer, that requires the provider to furnish all
specified services for a specified enrollee for a set fee, usually prepaid, and
for a set period of time (usually one year). The provider is then liable for
services regardless of their extent, expense or degree. Such stated limitations
for such liability are stated in advance and may be subject to reinsurance.
Rural Health Clinic A rural health clinic is an outpatient facility which is primarily engaged in
furnishing physicians’ 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.

Term Definition
Section 1915(b) Waivers Prior to the passage of the Balanced Budget Act (BBA) of 1997, Section
1915(b) freedom-of-choice waivers allowed states to require Medicaid
recipients to enroll in HMOs or other managed care plans in an effort to
control costs. The waivers allowed states to: implement a primary care case-
management system; require Medicaid recipients to choose from a number of
competing health plans; provide additional benefits in exchange for savings
resulting from recipients’ use of cost-effective providers; and limit the
providers from which beneficiaries can receive non-emergency treatment.
Under the BBA, states can enroll recipients into managed care without
applying for 1915(b) 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.
Skilled Nursing Facility (SNF) A facility, 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.
Skilled Nursing Facility Services All services furnished to inpatients of, and billed for by, a formally certified
skilled nursing facility that meets standards set by Secretary of DHHS.
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 Mandated Benefits Laws State laws requiring insurance contracts to provide coverage for certain health
services (e.g., in vitro fertilization) or services provided by certain health care
providers (e.g., audiologists). Self-insureds are exempt from these
requirements. There are over 800 mandates nationwide.
State Plan The Medicaid State Plan is a comprehensive written commitment by a

Medicaid agency to administer or supervise the administration of a Medicaid
program in accordance with Federal requirements.
Stop Loss That point at which a third party has reinsurance to protect against the overly
large single claim or the excessively high aggregate claim during a given
period of time. Large employers, who are self-insured, may also purchase
“reinsurance” for stop-loss purposes.
Supplemental Security Income (SSI) A federal cash assistance program for low-income aged, blind and disabled
individuals established by Title XVI of the Social Security Act. States may
use SSI income limits to establish Medicaid eligibility.

Term Definition
Tax Equity and Fiscal Responsibility The federal law which created the current risk and cost contract provisions
Act of 1982 (TEFRA) under which health plans contract with HCFA and which defined the primary
and secondary coverage responsibilities of the Medicare program.
Temporary Assistance to Needy Federal-state welfare program which replaces Aid to Families with Dependent
Families (TANF) 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 (TPA) An independent person or corporate entity (third party) that administers 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 (TQM) See “Continuous Quality Improvement.”
Universal Access The availability of affordable public or private insurance coverage for every
United States citizen or legal resident. There is no guarantee, however, that all
individuals will actually choose to purchase or have the funds to purchase
coverage. See “Universal Coverage.”
Universal Coverage The guaranteed provision of at least basic health care services to every United
States citizen or legal resident. See “Universal Access.”
Usual, Customary and Reasonable A term used to refer to the commonly charged or prevailing fees for health
Charges services within a geographic area. A fee is considered to be reasonable if it
falls within the parameters of the average or commonly charged fee for the
particular service within that specific community.
Utilization The extent to which the members of a covered group use a program or obtain
a particular service, or category of procedures, over a given period of time.
Usually expressed as the number of services used per year or per 100 or 1,000
persons eligible for the service.
Utilization Management (UM) A process of integrating review and case management of services in a
cooperative effort with other parties, including patients, providers, and payers.
Utilization Review A formal assessment of the medical necessity, efficiency, and/or

appropriateness of healthcare services and treatment plans on a prospective,
concurrent or retrospective basis.

Term Definition
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 HCFA waiver or plan modification.
Withhold “At-risk” portion of a claim deducted and withheld by the health plan before
payment is made to a participating physician as an incentive for appropriate
utilization and quality of care. This amount – for example, 20% of the claim
– remains within the plan and is credited to the doctor’s account. Can be used
where the plan needs additional funds to pay for claims. The withhold may be
returned to the physician in varying levels which are determined based on
analysis of his/her performance or productivity compared against his/her
peers. Also called “physician contingency reserve (PCR).”


ACRONYMS
AABD Aid to Aged, Blind, and Disabled

AB Aid to the Blind
AFDC Aid to Families with Dependent Children
AHCPR Agency for Health Care Policy and Research
AIDS Acquired Immune Deficiency Syndrome
AMP Average Manufacturer Price
ANSI American National Standards Institute
APTD Aid to the Permanently and Totally Disabled
ARF Area Resource File
ASO Administrative Services Only
AWP Any Willing Provider OR Average Wholesale Price
BBA Balanced Budget Act of 1997
CFR Code of Federal Regulations
CMP Competitive Medical Plan
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
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
DHHS Department of Health and Human Services
DRGs Diagnostic Related Groupings
DUE Drug Use Evaluation
DUR Drug Utilization Review
EAC Estimated Acquisition Cost
EDI Electronic Data Interchange
EPSDT Early and Periodic Screening, Diagnostic and Treatment
ERISA Employee Retirement Income Security Act
ESRD End Stage Renal Disease
FFP Federal Financial Participation
FFS Fee-for-Service
FMAP Federal Medical Assistance Percentage

FOC Freedom of Choice

FPL Federal Poverty Level
FY Fiscal Year
HCFA Health Care Financing Administration
HCPCS HCFA Common Procedural Coding System
HCPP Health Care Prepayment Plan
HEDIS Health Plan Employer Data and Information Set
HH Home Health
HIO Health Insuring Organizations
HIPAA Health Insurance Portability and Accountability Act
HMO Health Maintenance Organization
ICF Intermediate Care Facility
ICF-MR Intermediate Care Facility for the Mentally Retard
IPA Individual Practice Association
MAC Maximum Allowable Cost
MAIC Maximum Allowable Ingredient Cost
MCO Managed Care Organization
MMIS Medicaid Management Information System
MNAB Medically Needy Aid to the Blind
MNAFDC Medically Needy Aid to Families with Dependent Children
MNAPTD Medically Needy Aid to the Permanently and Totally Disabled
MNOAA Medically Needy Old Age Assistance
MQC Medicaid Quality Control
MSA Medical Savings Account
NDC National Drug Code
NMCUES National Medicare Care Utilization and Expenditure
NP Nurse Practitioner
OAA Old Age Assistance
OACT Office of the Actuary
OASDI Old Age, Survivors, and Disability Insurance
OBRA Omnibus Budget Reconciliation Act
OHS Outpatient Hospital Services
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
PCCM Primary Care Case Management
PCF Program Characteristics File
PCP Primary Care Physician
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
RHC Rural Health Clinic
RPH Registered Pharmacist
Rx Pharmaceutical
SFO State Funds Only
SNF Skilled Nursing Facility
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
TPA Third-Party Administrator
TQM Total Quality Management
UCR Usual, Customary and Reasonable
UM Utilization Management
UR Utilization Review
WAC Weighted Average Cost OR Wholesale Acquisition Cost


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Pharmaceutical Benefits Under State Medical Assistance Programs, 2000

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Pharmaceutical Benefits

under State Medical Assistance

©2000 by the National Pharmaceutical Council

The year 2000 edition of Pharmaceutical Benefits under State Medical

The “Medicaid Compilation” incorporates information on each State pharmacy

Historically, states summarized and reported data processed through their

In order to give a better understanding of the content of the “Medicaid

• Section 1: Reports on the trends in of Medicaid expenditures over the last

• Section 2: Contains details about Medicaid Managed Care enrollment as of

National Pharmaceutical Council iii

• Section 3: Consists of sociodemographic statistics, by age, race, insurance,

• Section 4: Provides Medicaid pharmacy program characteristics, drawn

• Section 5: Profiles the 20 states that are providing pharmaceutical coverage

• Section 6: Contains detailed profiles of the States’ Medicaid pharmacy

The book also contains a series of appendixes. Appendix A features a list of

We hope you continue to find the information contained in this compilation

iv National Pharmaceutical Council

SECTION 1: EXPENDITURE TRENDS IN MEDICAID.................................................................1-1

SECTION 2: MEDICAID MANAGED CARE ...................................................................................2-1

Medicaid Managed Care Enrollment.......................................................................................2-3

Medicaid Managed Care Waivers ..........................................................................................2-11

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

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

The Medicaid Program..............................................................................................................4-3

Medicaid Drug Program..........................................................................................................4-15

National Pharmaceutical Council i

− Medicaid Drug Reimbursement Report ...................................................................4-26

Medicaid Drug Rebates ...........................................................................................................4-27

Medicaid Drug Coverage.........................................................................................................4-31

Pharmacy Payment and Patient Cost Sharing ......................................................................4-49

SECTION 5: EXPANDED DRUG COVERAGE FOR THE ELDERLY ........................................5-1

SECTION 6: STATE PROFILES ........................................................................................................6-1

ii National Pharmaceutical Council

National Pharmaceutical Council 1-1

1-2 National Pharmaceutical Council

EXPENDITURE TRENDS IN MEDICAID

Figure 1-1: Medicaid Expenditures and Growth Rates1

National Pharmaceutical Council 1-3

Figure 1-2: Distribution of Medicaid Spending* by Type of Service3

* Excludes managed care payments

POPULATION SIZE, DEMOGRAPHICS, AND GROWTH RATE

1-4 National Pharmaceutical Council

Figure 1-3: Medicaid Expenditures & Enrollment by Group, 19985

MANAGED CARE TRENDS

National Pharmaceutical Council 1-5

PROVIDER PARTICIPATION IN MEDICAID

MEDICARE AND MEDICAID COMPARISON

Figure 1-4: Medicare versus Medicaid Spending, 19991

1-6 National Pharmaceutical Council

MEDICAID COMPARED TO NATIONAL HEALTH SPENDING

Figure 1-5: National versus Medicaid Average Growth Rates1

National Pharmaceutical Council 1-7

Figure 1-6a: National and Medicaid Nursing Home Expenditures1

$39.8 $40.7 $42.4

1-8 National Pharmaceutical Council

Figure 1-7a: National and Medicaid Hospital Expenditures1

Figure 1-7b: National versus Medicaid* Hospital Expenditures, Growth Rates1

3.4% 3.6% 3.7%

National Pharmaceutical Council 1-9

Figure 1-8a: National versus Medicaid Home Health Care Expenditures1

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Figure 1-9a: National versus Medicaid Prescription Drug Expenditures1

National Pharmaceutical Council 1-11

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