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 HCFA2082, 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 HCFA2082 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:

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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.

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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.

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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.

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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

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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

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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

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Section 1: Expenditure Trends in Medicaid

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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%

$187.0

$200 16.0% $121.6 $108.2

$150 $100

$133.7

$144.1

$152.2

$159.8

$171.7

25 20 15

$93.2 12.4%

10 10.0%

$50

7.7%

7.5% 5.6%

8.9%

5

5.0%

$0

0 1991

1992

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1994

1995

1996

1997

1998

1999

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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 communitybased 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 $60

62^

1995

55 51 52

1996 1997

$50

1998

$40 26 25 23 22

$30 $20

21 21 20 18

14 10 11 12

$10 $0 LTC±

Hospital Inpatient‡

Physician†

Prescription Drugs

* 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 1-4

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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

$20.5

$14.8

18.3 M 10.6 M

7.9 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

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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 Hospitals

$60

Physicians and Clinical Services

$40

Nursing Homes

$20

Drugs

$0 Medicare

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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%

Growth

8%

8.9% 7.7%

6%

4%

5.4%

7.5% 5.6%

5.4%

5.2%

5.0%

5.6% 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.

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Figure 1-6a: National and Medicaid Nursing Home Expenditures1 $100 $80

$74.6

$90.0

$88.0

$85.1

$79.9

National

Billions

Medicaid $60 $40

$35.4

$37.8

$39.8

$40.7

$42.4

$20 $0 1995

1996

1997

1998

1999

Figure 1-6b: National versus Medicaid Nursing Home Expenditures, Growth Rates1 10%

9.1% 7.1%

8% 6%

National Medicaid

6.5%

6.6% 5.3%

4%

3.5%

4.1%

4.0% 2% 2.3%

2.3%

1998

1999

0% 1995

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1996

1997

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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 $400 $350

$343.6

$390.9

$377.1

$367.7

$355.9

Billions

$300

National

$250

Medicaid

$200 $150 $100

$54.3

$56.8

$58.0

$66.5

$60.8

$50 $0 1995

1996

1997

1998

1999

Figure 1-7b: National versus Medicaid* Hospital Expenditures, Growth Rates1 10% 9.4%

Billions

8% 6% 4.3%

3.3%

4% 2%

4.8%

4.5%

3.4%

3.7%

3.6% 2.2%

2.6%

National Medicaid

0% 1995

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1997

1998

1999

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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 $34.5

$33.6

$33.5

$33.1

$30.5

Billions

$30 National Medicaid

$20

$10 $4.2

$4.5

$4.9

$5.4

$5.6

$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% 10%

8.9%

11.7%

5%

10.3% 6.2%

2.8% 4.1%

0% -3.0%

-5% 1995

1-10

1996

1997

1998

-1.4% 1999

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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

Billions

$80

$75.1

$67.2

$60.8

National Medicaid

$60 $40 $20

$9.7

$10.9

$12.3

$14.4

$17.1

$0 1995

1996

1997

1998

1999

Figure 1-9b: National versus Medicaid Prescription Drug Expenditures, Growth Rate1 25% 18.7%

20%

Rate

15% 10%

16.7% 12.4%

11.2%

13.7%

16.9%

12.0%

10.5%

11.9%

13.4%

5%

National Rate Medicaid Rate

0% 1995

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1998

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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.

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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.

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Section 2: Medicaid Managed Care

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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

% of Enrollment

100% 80% 60%

85.6%

70.6%

76.8%

59.9%

52.2%

40% 20% 0%

14.4% 1993

23.2% 1994

29.4% 1995*

40.1%

1996

Managed Care

47.8%

1997

46.4%

53.6%

1998

44.4%

55.6%

1999

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.

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•

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

Plan Type Health Insuring Organization Comprehensive Managed Care Organization Comprehensive Medicaid-only Managed Care Organization Primary Care Case Management Prepaid Health Plan Other Total

Number of Plans 6 237 136 60 129 13 581

Number of Enrollees 365,738 8,488,107 3,524,049 4,274,456 8,104,413 20,192 24,776,955*

* Total number of enrollees includes 7,020,352 individuals enrolled in more than one managed care plan type. Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care.

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

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Medicaid Managed Care Enrollment, As of June 30, 1999 Rank Based on Percent in Medicaid Medicaid Managed Percent in Managed Care State Enrollment Care Enrollment 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. Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care.

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Pharmaceutical Benefits 2000

Pharmaceutical Benefits Under Managed Care Plans Special requirements Where do managed care recipients Medicaid for pharmacy benefits receive pharmacy benefits? Managed Care in managed care? (State, Managed Care Plan, Both) Enrollment State 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.

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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.

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Pharmaceutical Benefits 2000

Medicaid Managed Care Plan Type, As of June 30, 1999 Comprehensive Medicaid-only Comprehensive MCO PCCM PHP Other State HIO MCO 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. Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care.

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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. Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care.

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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. Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care.

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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. National Pharmaceutical Council

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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.

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1915(b) Waivers, As of June 30, 1999 State

Program(s) Approved Maternity Waiver Program

Alabama

Partnership Hospital Program Patient 1

st

1915b Statutes Utilized

Expiration

1

9/30/99

1, 4

3/29/01

1, 3, 4

6/29/01

Alaska

None

--

--

Arizona

None

--

--

Arkansas

Non-Emergency Transportation

1

2/29/00

1, 2, 4

5/06/00

1, 2, 3, 4

7/4/00

CALOPTIMA Health Plan of San Mateo Hudman

4

7/21/00

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

Managed Care Network

California

Partnership Health Plan of California

1, 2, 4

2/16/00

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

4

12/12/01

1, 2, 3, 4

12/16/00

1, 3, 4

3/8/00

Primary Care Case Management Program

Selective Provider Contracting Program Two-Plan Model Program Colorado

Mental Health Capitation Program 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

1

6/30/99

Prepaid Mental Health Plan

1, 4

6/30/01

Sub-Acute Inpatient Psychiatric Program

3, 4

3/22/00

MediPass Florida

Georgia

Georgia Better Health Care Mental Health/Mental Retardation Services

Hawaii

None

Idaho

Healthy Connections

Illinois

None

Indiana Iowa Kansas

Hoosier Healthwise Iowa Plan for Behavioral Health Iowa Medicaid Managed Health Care

7/01/00 2/19/00

--

--

1, 2

11/15/99

--

--

1

1/26/00

1, 3, 4

12/31/00

1, 2

5/9/01

KMMC: Prime Care Kansas

1, 2, 4

6/26/00

KMMC: Health Connect

1, 2, 4

6/26/00

4

10/30/00

Human Services Transportation Kentucky

1 1, 4

Kentucky Patient Access and Care System (KENPAC) Kentucky Access

National Pharmaceutical Council

1

4/13/00

1, 3, 4

11/24/99

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State

Program(s) Approved

Louisiana Maine Maryland Massachusetts

Community Care Program None None None Comprehensive Health Care Program Specialty Community Mental Health Services Consolidated Chemical Dependency Treatment Fund None Managed Care Plus (MC+) Mental Health Access Plan Passport to Health Medicaid Health Connection – MH/SA Nebraska Health Connection – Med/Surg None None None SALUD! Non-Emergency Transportation Southwest Brooklyn Managed Care Demonstration Project The Westchester County Managed Care Program ACCESS II Carolina Access Carolina Alternatives Health Care Connection Health Maintenance Organization (HMO) North Dakota Access and Care Program None None Tri-County Metro. Transportation District Family Care Network HealthChoices SE - Behavioral HealthChoices SE – Physical Health HealthChoices SW - Behavioral HealthChoices SW – Physical Health Lancaster Community Health Plan None High Risk Channeling Project (HRCP) Prime None Lonestar Select I Lonestar Select II HMO - STAR HMO - STAR Plus (+) PCCM - STAR Plus (+)

Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York

North Carolina

North Dakota Ohio Oklahoma Oregon

Pennsylvania

Rhode Island South Carolina South Dakota Tennessee

Texas

2-14

1915b Statutes Utilized

Expiration

1 ---1, 2, 4 1, 4 1, 4 -1, 2, 4 1 1 1 1, 2 ---1,4 4 1, 4 1, 4 1 1 1, 4 1 1 1 --4 1 1, 2, 3, 4 1, 2, 3, 4 1, 2, 3, 4 1, 2, 3, 4 1 -1, 3, 4 1, 3 -4 4 1, 2, 3, 4 1, 2, 3, 4 1, 2, 3, 4

6/28/00 ---12/27/99 9/30/00 3/24/01 -3/14/00 6/30/99 10/25/99 6/30/99 6/30/99 ---7/1/99 1/13/00 8/16/00 3/31/00 11/29/99 11/29/99 6/30/99 11/29/99 11/29/99 5/5/01 --1/25/01 7/26/01 1/26/00 1/26/00 12/31/99 12/31/99 7/21/00 -2/11/01 7/1/00 -9/3/00 8/19/99 8/31/010 1/31/00 1/31/00

National Pharmaceutical Council

Pharmaceutical Benefits 2000

State Utah Vermont Virginia

Washington

1915b Statutes Utilized

Expiration

1, 2, 4

2/16/01

Prepaid Mental Health Program

4

10/28/99

None

--

--

Program(s) Approved Choice of Health Care Delivery

Medallion

1

9/24/99

Medallion II

1, 4

9/27/00

Mental Health Services

1, 4

11/7/99

Healthy Options

1, 4

2/24/01

Hospital Selective Contracting West Virginia Wisconsin

4

12/31/00

1, 4

8/26/99

Physician Assured Access System (PAAS)

1

9/5/99

None

--

--

Mountain Health Care Trust

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.

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Section 1115 Research and Demonstration Waivers State

Program

Implemented

Expiration

Alabama

Bay Health Plan

5/1/97

10/1/99

Arizona

Arizona Health Care Cost Containment System (AHCCCS)

10/1/82

9/30/99

On Lock Senior Health Services

11/1/83

9/30/00

Senior Care Action Network

1/1/85

4/30/00

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

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

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

California

Minnesota

Oklahoma

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.

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Section 3: State Characteristics

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Age Demographics, 1999 State National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Total State Population 271,742,826 4,200,926 646,842 4,905,332 2,562,587 33,375,150 3,970,806 3,283,332 783,012 511,711 14,677,912 7,666,432 1,200,863 1,274,230 12,294,861 5,839,738 2,837,156 2,616,318 3,864,679 4,310,285 1,266,498 5,046,171 6,116,806 10,040,679 4,833,278 2,761,422 5,405,443 924,582 1,716,417 1,862,276 1,224,200 8,092,295 1,829,164 18,420,007 7,426,910 646,079 11,224,522 3,268,838 3,355,739 11,912,109 968,057 3,851,167 711,326 5,572,470 19,944,736 2,105,665 593,161 6,687,894 5,747,382 1,750,073 5,128,974 486,314

Percent Ages 20 and under 30.8% 27.7% 38.0% 33.2% 30.1% 32.2% 28.8% 29.2% 31.2% 23.2% 26.4% 31.1% 30.2% 34.7% 33.1% 30.8% 30.7% 31.4% 29.0% 31.7% 27.8% 27.2% 29.3% 33.3% 34.1% 32.6% 29.5% 33.7% 33.5% 33.2% 32.9% 29.7% 35.7% 30.5% 28.2% 33.7% 30.0% 29.2% 30.2% 28.6% 27.9% 29.6% 32.9% 31.5% 33.5% 37.7% 29.4% 29.5% 30.5% 24.8% 28.4% 31.3%

Percent Ages 21-44 35.9% 35.5% 38.7% 36.1% 35.0% 37.9% 42.1% 32.8% 35.5% 41.8% 34.1% 36.5% 35.7% 33.7% 36.4% 35.2% 33.8% 33.6% 33.9% 35.1% 33.9% 37.7% 36.5% 35.2% 35.8% 35.8% 36.9% 34.3% 35.2% 36.4% 33.7% 36.1% 31.6% 35.5% 36.1% 32.3% 35.3% 33.4% 35.2% 34.4% 34.9% 35.0% 33.1% 34.1% 36.7% 37.3% 37.1% 36.4% 37.5% 33.0% 36.7% 34.4%

Percent Ages 45-64 21.4% 24.0% 18.4% 19.7% 19.9% 19.6% 20.2% 24.8% 19.2% 20.1% 21.2% 22.8% 20.4% 21.2% 19.6% 22.6% 21.1% 19.7% 24.9% 21.5% 25.5% 21.8% 21.5% 19.9% 19.4% 19.0% 20.8% 21.3% 19.2% 19.9% 23.5% 23.3% 20.2% 21.1% 23.2% 20.2% 22.6% 23.7% 23.8% 23.4% 21.8% 22.8% 21.2% 23.9% 20.2% 17.4% 23.0% 22.2% 22.4% 24.7% 23.1% 23.4%

Percent Ages 65+ 11.9% 12.8% 4.9% 11.0% 15.0% 10.3% 8.9% 13.1% 14.0% 14.8% 18.3% 9.7% 13.6% 10.4% 10.8% 11.4% 14.4% 15.3% 12.1% 11.6% 12.9% 13.2% 12.7% 11.6% 10.7% 12.6% 12.7% 10.7% 12.0% 10.5% 9.9% 10.9% 12.4% 13.0% 12.5% 13.9% 12.1% 13.7% 10.7% 13.6% 15.4% 12.6% 12.9% 10.5% 9.5% 7.6% 10.5% 12.0% 9.6% 17.5% 11.8% 10.9%

Source: The Lewin Group analysis of the Current Population Survey, March 2000 Supplement.

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Pharmaceutical Benefits 2000

Race Demographics, 1999 State National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Total State Population 271,742,826 4,200,926 646,842 4,905,332 2,562,587 33,375,150 3,970,806 3,283,332 783,012 511,711 14,677,912 7,666,432 1,200,863 1,274,230 12,294,861 5,839,738 2,837,156 2,616,318 3,864,679 4,310,285 1,266,498 5,046,171 6,116,806 10,040,679 4,833,278 2,761,422 5,405,443 924,582 1,716,417 1,862,276 1,224,200 8,092,295 1,829,164 18,420,007 7,426,910 646,079 11,224,522 3,268,838 3,355,739 11,912,109 968,057 3,851,167 711,326 5,572,470 19,944,736 2,105,665 593,161 6,687,894 5,747,382 1,750,073 5,128,974 486,314

Percent White 71.1% 71.1% 73.0% 65.5% 79.4% 50.3% 79.8% 76.3% 69.6% 25.9% 65.4% 62.0% 21.7% 86.6% 71.0% 90.9% 92.5% 84.6% 89.0% 61.5% 97.9% 63.7% 84.1% 80.5% 89.4% 61.9% 85.8% 88.5% 88.7% 70.3% 96.6% 69.5% 47.6% 64.1% 69.5% 91.6% 86.4% 79.6% 85.9% 84.3% 84.8% 71.2% 92.0% 82.2% 51.1% 88.7% 97.7% 73.0% 88.8% 94.2% 88.5% 92.6%

Percent Black 12.5% 27.1% 4.1% 2.7% 17.5% 6.5% 3.0% 11.9% 25.4% 64.6% 15.1% 32.9% 2.9% 0.3% 16.0% 5.9% 1.9% 8.8% 8.9% 35.2% 0.1% 27.0% 5.8% 14.2% 2.5% 37.0% 11.0% 0.2% 4.5% 5.0% 1.0% 14.3% 1.2% 15.2% 24.1% 0.2% 11.3% 7.5% 2.2% 10.5% 5.3% 26.8% 1.6% 15.8% 12.5% 1.3% 0.3% 19.3% 1.8% 4.3% 6.7% 1.6%

Percent Hispanic 11.7% 0.8% 1.8% 28.7% 1.4% 30.3% 14.4% 9.9% 3.5% 6.3% 17.6% 3.3% 4.3% 10.9% 10.1% 2.5% 3.4% 4.1% 1.4% 1.6% 0.6% 3.3% 6.1% 2.8% 2.8% 0.8% 1.2% 1.8% 4.3% 18.5% 1.0% 12.1% 40.4% 15.2% 3.0% 0.6% 1.4% 2.6% 6.3% 3.0% 5.9% 0.8% 0.5% 0.8% 32.9% 5.8% 0.4% 2.5% 4.0% 0.4% 1.9% 4.4%

Percent Other 4.7% 0.9% 21.0% 3.0% 1.7% 12.9% 2.8% 1.9% 1.5% 3.2% 1.9% 1.8% 71.1% 2.3% 2.9% 0.8% 2.2% 2.4% 0.7% 1.8% 1.4% 5.9% 3.9% 2.5% 5.3% 0.4% 2.0% 9.5% 2.5% 6.3% 1.4% 4.2% 10.9% 5.5% 3.4% 7.6% 0.9% 10.3% 5.6% 2.2% 4.1% 1.2% 5.8% 1.1% 3.4% 4.2% 1.6% 5.2% 5.4% 1.1% 3.0% 1.4%

Source: The Lewin Group analysis of the Current Population Survey, March 2000 Supplement.

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National Pharmaceutical Council

Pharmaceutical Benefits 2000

Insurance Status, 1999 State National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Total State Population 271,742,826 4,200,926 646,842 4,905,332 2,562,587 33,375,150 3,970,806 3,283,332 783,012 511,711 14,677,912 7,666,432 1,200,863 1,274,230 12,294,861 5,839,738 2,837,156 2,616,318 3,864,679 4,310,285 1,266,498 5,046,171 6,116,806 10,040,679 4,833,278 2,761,422 5,405,443 924,582 1,716,417 1,862,276 1,224,200 8,092,295 1,829,164 18,420,007 7,426,910 646,079 11,224,522 3,268,838 3,355,739 11,912,109 968,057 3,851,167 711,326 5,572,470 19,944,736 2,105,665 593,161 6,687,894 5,747,382 1,750,073 5,128,974 486,314

Medicaid Population 28,485,614 399,999 117,183 438,939 264,677 4,277,170 172,031 232,809 72,312 107,897 1,243,033 960,075 124,588 117,487 1,068,655 321,825 204,886 205,572 408,724 584,223 126,610 222,431 795,817 1,138,541 441,987 309,529 506,629 130,020 168,997 93,607 103,841 499,489 326,668 2,792,226 730,203 67,742 1,068,729 384,492 480,716 1,227,356 89,947 355,727 75,786 1,083,307 1,895,039 151,444 93,991 355,615 684,140 273,880 457,212 31,811

Percent Covered by Medicaid 10.5% 9.5% 18.1% 8.9% 10.3% 12.8% 4.3% 7.1% 9.2% 21.1% 8.5% 12.5% 10.4% 9.2% 8.7% 5.5% 7.2% 7.9% 10.6% 13.6% 10.0% 4.4% 13.0% 11.3% 9.1% 11.2% 9.4% 14.1% 9.8% 5.0% 8.5% 6.2% 17.9% 15.2% 9.8% 10.5% 9.5% 11.8% 14.3% 10.3% 9.3% 9.2% 10.7% 19.4% 9.5% 7.2% 15.8% 5.3% 11.9% 15.6% 8.9% 6.5%

Medicare Population 35,886,603 634,905 33,271 598,907 429,046 3,782,175 402,074 495,807 115,330 80,852 2,901,579 863,436 161,514 147,135 1,451,317 758,451 426,795 426,411 549,788 592,659 194,020 695,125 849,412 1,271,138 535,510 419,869 768,233 113,110 220,248 213,939 128,917 932,604 262,578 2,596,260 1,073,054 95,936 1,564,115 530,082 411,036 1,761,765 160,201 582,075 99,149 644,347 2,070,144 179,783 69,493 928,879 593,766 349,774 657,393 63,196

Percent Covered by Medicare 13.2% 15.1% 5.1% 12.2% 16.7% 11.3% 10.1% 15.1% 14.7% 15.8% 19.8% 11.3% 13.4% 11.5% 11.8% 13.0% 15.0% 16.3% 14.2% 13.7% 15.3% 13.8% 13.9% 12.7% 11.1% 15.2% 14.2% 12.2% 12.8% 11.5% 10.5% 11.5% 14.4% 14.1% 14.4% 14.8% 13.9% 16.2% 12.2% 14.8% 16.5% 15.1% 13.9% 11.6% 10.4% 8.5% 11.7% 13.9% 10.3% 20.0% 12.8% 13.0%

Source: The Lewin Group analysis of the Current Population Survey, March 2000 Supplement.

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Pharmaceutical Benefits 2000

Income and Employment, 1999 State National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Total State Percent Below 100% Poverty Population Level 271,742,826 13.1% 4,200,926 15.1% 646,842 10.4% 4,905,332 16.8% 2,562,587 15.0% 33,375,150 15.6% 3,970,806 9.3% 3,283,332 10.1% 783,012 10.9% 511,711 23.0% 14,677,912 13.6% 7,666,432 14.7% 1,200,863 10.9% 1,274,230 13.2% 12,294,861 11.0% 5,839,738 9.8% 2,837,156 8.5% 2,616,318 9.9% 3,864,679 14.6% 4,310,285 20.1% 1,266,498 10.8% 5,046,171 7.7% 6,116,806 9.2% 10,040,679 11.4% 4,833,278 10.7% 2,761,422 17.4% 5,405,443 10.1% 924,582 17.3% 1,716,417 13.2% 1,862,276 11.2% 1,224,200 10.0% 8,092,295 9.1% 1,829,164 20.4% 18,420,007 17.0% 7,426,910 14.8% 646,079 15.2% 11,224,522 11.4% 3,268,838 14.8% 3,355,739 15.1% 11,912,109 11.6% 968,057 11.7% 3,851,167 13.0% 711,326 10.7% 5,572,470 12.8% 19,944,736 15.3% 2,105,665 9.4% 593,161 10.0% 6,687,894 8.9% 5,747,382 9.0% 1,750,073 18.0% 5,128,974 8.9% 486,314 11.7%

Percent Unemployed 2.0% 1.9% 3.7% 1.8% 1.7% 2.7% 1.1% 1.5% 1.4% 3.9% 1.5% 2.3% 2.6% 2.4% 1.5% 1.0% 1.4% 1.2% 2.3% 2.0% 2.2% 1.6% 1.7% 2.0% 1.3% 2.4% 1.8% 2.9% 1.0% 2.4% 1.6% 2.6% 2.2% 2.4% 1.4% 2.4% 1.7% 1.7% 3.0% 2.3% 1.6% 1.5% 1.3% 2.2% 1.8% 1.7% 2.5% 1.0% 1.8% 2.9% 1.9% 2.3%

Source: The Lewin Group analysis of the Current Population Survey, March 2000 Supplement.

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National Pharmaceutical Council

Pharmaceutical Benefits 2000

Medicaid/Medicare Certified Facilities State National Total* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Hospitals 6,052 123 24 85 96 468 83 47 11 16 239 182 27 48 219 151 120 149 118 175 41 67 119 174 151 104 141 62 96 42 30 107 51 268 135 51 205 151 63 252 17 76 63 148 479 50 16 118 97 66 142 27

Skilled Nursing Facilities 14,831 221 15 149 193 1,269 202 250 38 19 724 326 41 82 658 496 300 264 307 225 126 244 505 389 412 132 455 101 172 49 67 306 69 665 407 88 893 242 124 752 99 178 89 276 1,014 81 42 229 266 114 369 34

ICF-MR Facilities 6,731 8 0 11 40 1,041 3 122 2 131 108 13 22 67 318 574 127 42 12 473 28 5 7 2 272 13 18 2 4 20 1 9 43 750 333 66 461 54 1 206 5 158 4 83 915 14 2 19 17 62 41 2

Home Health Agencies 7,160 143 16 68 182 579 131 82 16 16 318 99 19 54 288 180 180 149 111 255 36 53 133 193 250 62 171 51 70 36 35 54 67 211 165 35 348 188 60 328 25 78 46 153 860 43 13 161 62 68 131 39

Rural Health Clinics 3,352 60 11 8 82 225 43 0 0 0 135 125 1 35 198 52 134 156 72 49 50 0 0 153 60 133 163 32 76 2 21 0 14 10 125 80 17 61 30 53 1 96 55 34 391 15 23 58 61 69 65 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.

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Pharmaceutical Benefits 2000

Licensed Pharmacies (As of June 30, 2000)* Hospital/ Institutional Independent Total Pharmacies Pharmacies State Pharmacies National Total 73,781 8,502 25,273 Alabama 1,779 178 816 Alaska 111 (g) 12 (h) Arizona 845 110 158 Arkansas 739 173 230 California 6,271 647 5,456 (a) Colorado 817 Connecticut 685 58 207 Delaware 154 13 19 District of Columbia 150 15 60 Florida 6,176 1,965 3,581 (a) Georgia 2,358 216 (p) Hawaii 407 Idaho 486 57 250 (a, e) Illinois 2,788 358 2,429 (a) Indiana 1,353 197 Iowa 1,188 131 (f) 825 (a, f) Kansas 787 178 609 (a) Kentucky 1,438 125 466 Louisiana 1,663 171 585 Maine 290 42 Maryland 1,243 (i) 61 274 Massachusetts 1,189 (j) 158 345 Michigan 2,329 Minnesota 1,338 181 516 Mississippi 962 130 Missouri 1,550 (k) 135 Montana 318 24 Nebraska 464 95 Nevada 575 43 187 New Hampshire 263 34 47 New Jersey 2,308 New Mexico 541 56 128 (a) New York 4,456 499 2,042 North Carolina 2,032 (f) 154 554 North Dakota 421 48 162 Ohio 2,833 (n) 228 574 Oklahoma 1,275 90 (d) 913 (a) Oregon 1,003 118 280 Pennsylvania 3,198 303 Rhode Island 206 22 48 South Carolina 1,079 136 285 South Dakota 421 41 146 Tennessee 1,710 370 493 Texas (a) 5,488 (b) 594 1,664 Utah 689 103 375 (a) Vermont 154 17 137 Virginia 1,513 Washington 1,440 216 (c) 412 West Virginia 797 Wisconsin 1,125 Wyoming 348 *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.

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Non-Independent Community Pharmacies (Four or More) 15,046 548 577 509 420 128 75 (a) (p) (a) (a) 671 520 600 669 31 461 345 169 152 (a) 1,902 967 20 1,574 (a) 427 138 566 75 727 2,153 (a) 628 0 -

Out-of-State or Non-Resident Pharmacies 7,714 237 122 0 117 168 205 175 216 0 272 167 159 198 145 216 230 176 223 187 175 0 200 220 254 111 181 (l) 172 0 182 N/A 189 191 234 257 172 210 215 159 120 188 157 0 307 184 217 0 206

National Pharmaceutical Council

Pharmaceutical Benefits 2000

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).

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Pharmaceutical Benefits 2000

Physicians, 1998 State National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Physicians 696,600 8,816 1,185 9,821 4,966 82,640 9,734 11,746 1,787 4,180 36,573 16,821 3,372 1,959 31,902 11,630 5,051 5,517 8,381 10,972 2,831 20,925 25,729 22,229 12,019 4,710 12,801 1,723 3,692 3,115 2,860 24,200 3,911 71,186 17,991 1,456 26,822 5,841 7,585 35,394 3,397 8,196 1,434 13,728 41,512 4,297 1,837 17,298 13,901 4,029 12,037 861

Physicians Per 1,000 2.6% 2.1% 1.8% 2.0% 1.9% 2.5% 2.5% 3.6% 2.3% 8.2% 2.5% 2.2% 2.8% 1.5% 2.6% 2.0% 1.8% 2.1% 2.2% 2.5% 2.2% 4.1% 4.2% 2.2% 2.5% 1.7% 2.4% 1.9% 2.2% 1.7% 2.3% 3.0% 2.1% 3.9% 2.4% 2.3% 2.4% 1.8% 2.3% 3.0% 3.5% 2.1% 2.0% 2.5% 2.1% 2.0% 3.1% 2.6% 2.4% 2.3% 2.3% 1.8%

Office Based Physicians 462,719 6,316 850 6,991 3,615 58,077 6,988 7,387 1,216 1,990 27,359 11,700 2,385 1,619 20,107 8,429 3,499 3,817 6,078 7,295 2,071 11,807 14,659 14,040 8,058 3,380 8,229 1,442 2,512 2,466 2,045 15,954 2,585 39,872 12,157 1,075 17,653 4,165 5,644 22,502 2,050 5,725 1,105 9,589 28,526 3,003 1,154 11,571 9,923 2,659 8,723 657

Percent Primary Care Percent Office Based Physicians Primary Care 66.4% 249,291 35.8% 71.6% 3,335 37.8% 71.7% 439 37.0% 71.2% 3,393 34.5% 72.8% 1,957 39.4% 70.3% 29,432 35.6% 71.8% 3,523 36.2% 62.9% 3,979 33.9% 68.0% 594 33.2% 47.6% 1,225 29.3% 74.8% 12,327 33.7% 69.6% 6,122 36.4% 70.7% 1,283 38.0% 82.6% 775 39.6% 63.0% 12,478 39.1% 72.5% 4,442 38.2% 69.3% 1,963 38.9% 69.2% 2,161 39.2% 72.5% 3,137 37.4% 66.5% 3,795 34.6% 73.2% 1,097 38.7% 56.4% 6,400 30.6% 57.0% 7,956 30.9% 63.2% 8,296 37.3% 67.0% 4,769 39.7% 71.8% 1,744 37.0% 64.3% 4,303 33.6% 83.7% 630 36.6% 68.0% 1,501 40.7% 79.2% 1,141 36.6% 71.5% 1,058 37.0% 65.9% 8,856 36.6% 66.1% 1,435 36.7% 56.0% 24,934 35.0% 67.6% 6,438 35.8% 73.8% 603 41.4% 65.8% 10,017 37.3% 71.3% 2,158 36.9% 74.4% 2,832 37.3% 63.6% 12,170 34.4% 60.3% 1,260 37.1% 69.9% 3,086 37.7% 77.1% 591 41.2% 69.8% 4,946 36.0% 68.7% 14,505 34.9% 69.9% 1,535 35.7% 62.8% 746 40.6% 66.9% 6,253 36.1% 71.4% 5,117 36.8% 66.0% 1,551 38.5% 72.5% 4,622 38.4% 76.3% 381 44.3%

Source: Area Resource File. Office of Research and Planning, Bureau of Health Professions. February 2000.

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National Pharmaceutical Council

Pharmaceutical Benefits 2000

Other Providers State National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Registered Nurses* 2,161,700 32,800 6,300 33,200 17,900 179,700 30,900 33,400 7,700 8,900 119,300 53,600 8,900 7,100 104,700 46,900 29,100 21,600 30,400 32,400 13,300 43,000 73,300 79,600 46,200 19,900 51,200 7,100 15,200 9,900 11,200 67,100 11,700 167,600 62,000 6,400 101,200 19,600 26,500 126,300 11,400 27,400 7,700 46,400 124,200 13,000 5,300 54,400 43,500 15,000 45,600 4,200

Registered Nurses* per 1,000 8.1 7.6 10.3 7.3 7.1 5.6 7.9 10.2 10.5 16.8 8.1 7.2 7.5 5.9 8.8 8.0 10.2 8.3 7.8 7.4 10.7 8.4 12.0 8.1 9.9 7.3 9.5 8.1 9.2 5.9 9.6 8.3 6.8 9.2 8.4 10.2 9.1 5.9 8.2 10.5 11.6 7.3 10.4 8.0 6.4 6.3 9.0 8.1 7.8 8.3 8.8 8.8

Pharmacists** (Licensed by State) 334,851 6,541 518 5,548 3,374 27,152 5,254 4,265 1,209 1,350 19,425 9,551 1,372 1,447 12,278 8,038 4,878 3,540 4,746 5,774 1,267 6,700 9,283 10,693 5,628 3,440 6,317 1,262 2,445 7,427 1,824 15,542 2,258 18,780 8,977 2,039 13,797 4,560 3,952 16,894 1,723 5,116 1,391 7,358 19,825 2,140 793 7,471 6,279 2,948 5,837 1,001

Pharmacists** per 1,000 1.2 1.6 0.8 1.1 1.3 0.8 1.3 1.3 1.5 2.6 1.3 1.2 1.1 1.1 1.0 1.4 1.7 1.4 1.2 1.3 1.0 1.3 1.5 1.1 1.2 1.2 1.2 1.4 1.4 4.0 1.5 1.9 1.2 1.0 1.2 3.2 1.2 1.4 1.2 1.4 1.8 1.3 2.0 1.3 1.0 1.0 1.3 1.1 1.1 1.7 1.1 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.

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Pharmaceutical Benefits 2000

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National Pharmaceutical Council

Pharmaceutical Benefits 2000

Section 4: Pharmacy Program Characteristics

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Pharmaceutical Benefits 2000

4-2

National Pharmaceutical Council

Pharmaceutical Benefits 2000

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;

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•

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 federallyqualified 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.

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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.

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•

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, 4-6

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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.

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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

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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.)).

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Total U.S. Medical Assistance Recipients* by Type of Service

Service

FY 1998

Percent Using Service

FY 1997

Percent Using Service

Percent 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%

126,490

0.3%

136,025

0.4%

-7.0%

ICF-Mentally Retarded 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.

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Total U.S. Medical Assistance Payments* by Type of Service

Service

FY 1998

Percent of Total

FY 1997

Percent of Total

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

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Federal Medical Assistance Percentage (FMAP), FY1999 and FY2000 State Alabama Alaska** Arizona Arkansas California Colorado Connecticut Delaware District of Columbia** Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

1999 FMAP 69.27% 59.80% 65.50% 72.96% 51.55% 50.59% 50.00% 50.00% 70.00% 55.82% 60.47% 50.00% 69.85% 50.00% 61.01% 63.32% 60.05% 70.53% 70.37% 66.40% 50.00% 50.00% 52.72% 51.50% 76.78% 60.24% 71.73% 61.46% 50.00% 50.00% 50.00% 72.98% 50.00% 63.07% 69.94% 58.26% 70.84% 60.55% 53.77% 54.05% 69.85% 68.16% 63.09% 62.45% 71.78% 61.97% 51.60% 52.50% 74.47% 58.85% 64.08%

2000 FMAP 69.57% 59.80% 65.92% 72.85% 51.67% 50.00% 50.00% 50.00% 70.00% 56.52% 59.88% 51.01% 70.15% 50.00% 61.74% 63.06% 60.03% 70.55% 70.32% 66.22% 50.00% 50.00% 55.11% 51.48% 76.80% 60.51% 72.30% 60.88% 50.00% 50.00% 50.00% 73.32% 50.00% 62.49% 70.42% 58.67% 71.09% 59.96% 53.82% 53.77% 69.95% 68.72% 63.10% 61.36% 71.55% 62.24% 51.67% 51.83% 74.78% 58.78% 64.04%

2000 Enhanced FMAP* 78.70% 71.86% 76.14% 80.99% 66.17% 65.00% 65.00% 65.00% 79.00% 69.57% 71.91% 65.71% 79.11% 65.00% 73.22% 74.14% 72.02% 79.38% 79.22% 76.36% 65.00% 65.00% 68.58% 66.04% 83.76% 72.36% 80.61% 72.62% 65.00% 65.00% 65.00% 81.32% 65.00% 73.74% 79.29% 71.07% 79.76% 71.97% 67.67% 67.64% 78.96% 78.11% 74.17% 72.95% 80.08% 73.57% 66.17% 66.28% 82.35% 71.15% 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.

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Medicaid Payments and Recipients, 1998 State

Total Vendor Payments

$142,317,903,795 National Total $1,902,300,047 Alabama $330,378,398 Alaska $1,643,966,305 Arizona $1,375,797,421 Arkansas $14,236,592,915 California $1,439,366,499 Colorado $2,420,791,474 Connecticut $419,732,143 Delaware $731,292,552 District of Columbia $5,686,844,862 Florida $3,012,346,312 Georgia $507,433,146 Hawaii $424,512,387 Idaho $6,172,865,261 Illinois $2,564,005,047 Indiana $1,288,770,390 Iowa $916,323,608 Kansas $2,425,288,141 Kentucky $2,383,508,985 Louisiana $747,027,618 Maine $2,489,280,148 Maryland $4,609,360,933 Massachusetts $4,345,007,824 Michigan $2,924,447,719 Minnesota $1,442,373,276 Mississippi $2,569,646,129 Missouri $361,238,668 Montana $753,162,904 Nebraska $462,087,777 Nevada $606,004,232 New Hampshire $4,218,822,993 New Jersey $862,144,872 New Mexico $24,298,610,635 New York $4,013,996,742 North Carolina $341,015,420 North Dakota $6,120,967,557 Ohio $1,177,853,941 Oklahoma $1,377,514,740 Oregon $6,080,191,710 Pennsylvania $250,000,000 Puerto Rico $919,353,410 Rhode Island $2,018,620,428 South Carolina $355,833,902 South Dakota $3,167,188,993 Tennessee $7,139,928,843 Texas $618,675,433 Utah $351,341,290 Vermont $10,097,973 Virgin Islands $2,118,202,866 Virginia $2,044,234,831 Washington $1,243,150,526 West Virginia $2,206,398,750 Wisconsin $192,004,819 Wyoming Source: HCFA, CMSO, HCFA-2082 Report, FY98.

National Pharmaceutical Council

Total Recipients 40,649,482 527,078 74,508 507,668 424,727 7,082,175 344,916 381,208 101,436 166,146 1,904,591 1,221,978 184,614 123,176 1,363,856 607,293 314,936 241,933 644,482 720,615 170,456 561,085 908,238 1,362,890 538,413 485,767 734,015 100,760 211,188 128,144 93,970 813,251 329,418 3,073,241 1,167,988 62,280 1,290,776 342,475 511,171 1,523,120 964,015 153,130 594,962 89,537 1,843,661 2,324,810 215,801 123,992 19,764 653,236 1,413,208 342,668 518,595 46,121

Payments Per Recipient $3,501 $3,609 $4,434 $3,238 $3,239 $2,010 $4,173 $6,350 $4,138 $4,402 $2,986 $2,465 $2,749 $3,446 $4,526 $4,222 $4,092 $3,788 $3,763 $3,308 $4,383 $4,437 $5,075 $3,188 $5,432 $2,969 $3,501 $3,585 $3,566 $3,606 $6,449 $5,188 $2,617 $7,907 $3,437 $5,476 $4,742 $3,439 $2,695 $3,992 $259 $6,004 $3,393 $3,974 $1,718 $3,071 $2,867 $2,834 $511 $3,243 $1,447 $3,628 $4,255 $4,163

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Pharmaceutical Benefits 2000

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.

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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.

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Drug Payments and Recipients, 1998 Total Drug Recipients‡

Drug Payments Per Recipient

$13,521,707,689 19,337,543 National Total* $236,674,147 395,290 Alabama $32,887,828 43,734 Alaska $1,442,917 56,796 Arizona $150,891,615 262,907 Arkansas $1,553,598,462 2,644,430 California $110,159,725 147,033 Colorado $186,593,992 108,331 Connecticut $41,350,537 69,027 Delaware $41,254,973 57,733 District of Columbia $933,782,041 1,014,372 Florida $370,562,935 805,923 Georgia $39,623,380 32,222 Hawaii $54,971,097 86,775 Idaho $583,239,675 959,472 Illinois $325,712,348 323,811 Indiana $147,115,884 215,173 Iowa $118,825,316 155,875 Kansas $319,983,951 429,102 Kentucky $352,784,785 552,481 Louisiana $121,771,298 137,816 Maine $148,532,940 176,403 Maryland $497,146,531 613,186 Massachusetts $374,145,567 589,818 Michigan $173,602,492 203,220 Minnesota $231,735,360 368,609 Mississippi $382,512,566 353,902 Missouri $42,368,399 58,641 Montana $92,558,539 145,408 Nebraska $34,518,901 50,903 Nevada $55,374,478 70,339 New Hampshire $426,075,488 309,849 New Jersey $41,507,229 96,637 New Mexico $1,368,451,273 1,803,428 New York $466,528,812 764,886 North Carolina $27,619,684 37,675 North Dakota $645,118,962 702,143 Ohio Oklahoma $87,805,350 148,258 Oregon $525,261,211 580,749 Pennsylvania $61,401,958 44,852 Rhode Island $224,962,203 401,611 South Carolina $31,106,511 46,588 South Dakota $36 1 Tennessee $817,591,112 1,894,447 Texas $68,827,853 126,953 Utah $43,445,887 58,037 Vermont $284,578,558 383,880 Virginia $244,478,658 274,463 Washington $148,962,081 267,398 West Virginia $232,326,359 221,508 Wisconsin $17,138,952 32,510 Wyoming *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. Source: HCFA, CMSO, HCFA-2082 Report, FY98.

$699 $599 $752 $25 $574 $587 $749 $1,722 $599 $715 $921 $460 $1,230 $633 $608 $1,006 $684 $762 $746 $639 $884 $842 $811 $634 $854 $629 $1,081 $723 $637 $678 $787 $1,375 $430 $759 $610 $733 $919 $592 $904 $1,369 $560 $668 $36 $432 $542 $749 $741 $891 $557 $1,049 $527

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State

Total Drug Payments

Pharmaceutical Benefits 2000

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

1994

1995

1996

1997

1998

$8,873,950,031 $163,021,321 $16,744,047 $1,165,786 $88,069,017 $1,122,754,027 $70,483,595 $120,470,177 $18,351,293 $25,227,269 $484,052,934 $260,307,087 $34,461,968 $29,378,146 $330,697,673 $232,645,959 $91,202,410 $71,285,408 $217,044,606 $269,035,462 $64,043,624 $125,216,705 $251,184,700 $290,264,217 $113,841,194 $140,045,378 $228,660,484 $26,211,646 $55,495,790 $17,653,922 $28,419,726 $308,046,437 $47,770,092 $727,303,151 $215,197,252 $17,639,044 $415,250,727 $89,253,227 $85,902,712 $489,131,313 $39,752,373 $110,845,482 $19,017,682 $76,314,794 $511,841,929 $39,728,466 $28,384,265 $195,777,613 $168,193,537 $106,852,366 $183,836,535 $10,475,463

$9,790,651,449 $178,667,753 $18,469,364 $2,027,734 $102,114,998 $1,145,514,700 $78,833,103 $145,366,245 $21,458,681 $26,231,966 $556,864,923 $288,511,672 $24,802,573 $33,153,237 $440,883,001 $187,674,037 $97,382,501 $81,455,408 $251,745,610 $292,293,619 $63,906,058 $139,205,331 $308,411,398 $312,003,749 $148,450,414 $162,743,883 $259,657,651 $28,335,142 $61,738,837 $21,320,507 $34,099,265 $344,176,481 $50,545,800 $819,359,316 $277,430,790 $19,711,865 $480,233,424 $100,909,395 $82,647,757 $543,774,387 $47,808,612 $124,500,348 $21,567,935 $190,467 $578,661,512 $44,397,971 $33,658,620 $213,182,924 $161,555,588 $130,451,359 $190,678,825 $11,884,713

$10,697,438,066 $203,811,076 $21,661,213 $2,460,613 $115,070,827 $1,223,444,736 $82,543,502 $146,856,083 $27,743,076 $32,765,197 $658,291,958 $319,230,386 $26,854,246 $41,028,033 $446,214,047 $269,001,714 $111,346,007 $90,754,656 $272,539,525 $297,433,210 $83,822,289 $154,908,882 $302,911,947 $352,620,438 $150,350,355 $176,758,960 $281,700,005 $32,742,122 $71,482,836 $24,384,747 $42,310,704 $374,015,636 $61,171,361 $907,083,895 $344,950,165 $20,904,298 $518,641,009 $98,292,786 $67,013,699 $536,797,657 $45,679,642 $143,804,519 $24,147,295 $15,337 $667,743,192 $48,149,414 $36,539,101 $221,421,619 $172,652,369 $124,984,023 $205,429,565 $13,635,463

$11,972,331,192 $226,105,163 $28,376,842 $1,855,672 $135,757,334 $1,335,065,753 $96,964,178 $166,667,301 $34,713,581 $37,512,355 $772,780,639 $339,257,021 $45,042,165 $523,561,885 $293,318,000 $123,861,339 $104,628,978 $316,464,180 $315,444,016 $102,537,196 $172,701,280 $398,076,057 $365,282,227 $155,830,086 $208,577,199 $320,660,206 $35,470,912 $79,727,194 $26,652,299 $45,361,780 $369,839,049 $63,345,896 $1,090,917,486 $403,811,339 $25,226,544 $580,572,988 $110,880,182 $73,216,753 $552,268,949 $52,165,739 $159,606,414 $27,591,466 $1,118 $750,056,208 $50,825,675 $44,291,004 $249,620,903 $204,980,369 $133,044,683 $205,503,614 $14,864,016

$13,521,707,689 $236,674,147 $32,887,828 $1,442,917 $150,891,615 $1,553,598,462 $110,159,725 $186,593,992 $41,350,537 $41,254,973 $933,782,041 $370,562,935 $39,623,380 $54,971,097 $583,239,675 $325,712,348 $147,115,884 $118,825,316 $319,983,951 $352,784,785 $121,771,298 $148,532,940 $497,146,531 $374,145,567 $173,602,492 $231,735,360 $382,512,566 $42,368,399 $92,558,539 $34,518,901 $55,374,478 $426,075,488 $41,507,229 $1,368,451,273 $466,528,812 $27,619,684 $645,118,962 $87,805,350 $525,261,211 $61,401,958 $224,962,203 $31,106,511 $36 $817,591,112 $68,827,853 $43,445,887 $284,578,558 $244,478,658 $148,962,081 $232,326,359 $17,138,952

*National figures include Puerto Rico and the Virgin Islands. **Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively. Source: HCFA, CMSO, HCFA-2082 Report, FY98.

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Drug Payment - Percent Change from 1997 to 1998 State National Total* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii** Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma** Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

1997

1998

Percent Change

$11,972,331,192 $226,105,163 $28,376,842 $1,855,672 $135,757,334 $1,335,065,753 $96,964,178 $166,667,301 $34,713,581 $37,512,355 $772,780,639 $339,257,021 $45,042,165 $523,561,885 $293,318,000 $123,861,339 $104,628,978 $316,464,180 $315,444,016 $102,537,196 $172,701,280 $398,076,057 $365,282,227 $155,830,086 $208,577,199 $320,660,206 $35,470,912 $79,727,194 $26,652,299 $45,361,780 $369,839,049 $63,345,896 $1,090,917,486 $403,811,339 $25,226,544 $580,572,988 $110,880,182 $73,216,753 $552,268,949 $52,165,739 $159,606,414 $27,591,466 $1,118 $750,056,208 $50,825,675 $44,291,004 $249,620,903 $204,980,369 $133,044,683 $205,503,614 $14,864,016

$13,521,707,689 $236,674,147 $32,887,828 $1,442,917 $150,891,615 $1,553,598,462 $110,159,725 $186,593,992 $41,350,537 $41,254,973 $933,782,041 $370,562,935 $39,623,380 $54,971,097 $583,239,675 $325,712,348 $147,115,884 $118,825,316 $319,983,951 $352,784,785 $121,771,298 $148,532,940 $497,146,531 $374,145,567 $173,602,492 $231,735,360 $382,512,566 $42,368,399 $92,558,539 $34,518,901 $55,374,478 $426,075,488 $41,507,229 $1,368,451,273 $466,528,812 $27,619,684 $645,118,962 $87,805,350 $525,261,211 $61,401,958 $224,962,203 $31,106,511 $36 $817,591,112 $68,827,853 $43,445,887 $284,578,558 $244,478,658 $148,962,081 $232,326,359 $17,138,952

13% 5% 16% -22% 11% 16% 14% 12% 19% 10% 21% 9% 22% 11% 11% 19% 14% 1% 12% 19% -14% 25% 2% 11% 11% 19% 19% 16% 30% 22% 15% -34% 25% 16% 9% 11% 20% -5% 18% 41% 13% -97% 9% 35% -2% 14% 19% 12% 13% 15%

*National figures include Puerto Rico and the Virgin Islands. **Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively. Source: HCFA, CMSO, HCFA-2082 Report, FY97, FY98.

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Pharmaceutical Benefits 2000

Ranking Based on Drug Payments

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

1998 Payments

1998 Ranking

% of 1998 Total Medicaid Drug Payments

1997 Payments

1997 Ranking

$1,553,598,462 $1,368,451,273 $933,782,041 $817,591,112 $645,118,962 $583,239,675 $525,261,211 $497,146,531 $466,528,812 $426,075,488 $382,512,566 $374,145,567 $370,562,935 $352,784,785 $325,712,348 $319,983,951 $284,578,558 $244,478,658 $236,674,147 $232,326,359 $231,735,360 $224,962,203 $186,593,992 $173,602,492 $150,891,615 $148,962,081 $148,532,940 $147,115,884 $121,771,298 $118,825,316 $110,159,725 $92,558,539 $87,805,350 $68,827,853 $61,401,958 $55,374,478 $54,971,097 $43,445,887 $42,368,399 $41,507,229 $41,350,537 $41,254,973 $39,623,380 $34,518,901 $32,887,828 $31,106,511 $27,619,684 $17,138,952 $1,442,917 $36 -

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 -

11.49% 10.12% 6.91% 6.05% 4.77% 4.31% 3.88% 3.68% 3.45% 3.15% 2.83% 2.77% 2.74% 2.61% 2.41% 2.37% 2.10% 1.81% 1.75% 1.72% 1.71% 1.66% 1.38% 1.28% 1.12% 1.10% 1.10% 1.09% 0.90% 0.88% 0.81% 0.68% 0.65% 0.51% 0.45% 0.41% 0.41% 0.32% 0.31% 0.31% 0.31% 0.31% 0.29% 0.26% 0.24% 0.23% 0.20% 0.13% 0.01% 0.00% -

$1,335,065,753 $1,090,917,486 $772,780,639 $750,056,208 $580,572,988 $523,561,885 $552,268,949 $398,076,057 $403,811,339 $369,839,049 $320,660,206 $365,282,227 $339,257,021 $315,444,016 $293,318,000 $316,464,180 $249,620,903 $204,980,369 $226,105,163 $205,503,614 $208,577,199 $159,606,414 $166,667,301 $155,830,086 $135,757,334 $133,044,683 $172,701,280 $123,861,339 $102,537,196 $104,628,978 $96,964,178 $79,727,194 $73,216,753 $50,825,675 $52,165,739 $45,361,780 $45,042,165 $44,291,004 $35,470,912 $63,345,896 $34,713,581 $37,512,355 $26,652,299 $28,376,842 $27,591,466 $25,226,544 $14,864,016 $1,855,672 $1,118 $110,880,182

1 2 3 4 5 7 6 9 8 10 13 11 12 15 16 14 17 21 18 20 19 24 23 25 26 27 22 28 31 30 32 33 34 37 36 38 39 40 42 35 43 41 46 44 45 47 48 49 50 29

*Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively. Source: HCFA, CMSO, HCFA-2082 Report, FY97, FY98.

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Pharmaceutical Benefits 2000

Drugs as a Percentage of Total Vendor Payments, 1998 State National Total* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma** Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Total Drug Payments

Total Vendor Payments

$13,521,707,689 $236,674,147 $32,887,828 $1,442,917 $150,891,615 $1,553,598,462 $110,159,725 $186,593,992 $41,350,537 $41,254,973 $933,782,041 $370,562,935 $39,623,380 $54,971,097 $583,239,675 $325,712,348 $147,115,884 $118,825,316 $319,983,951 $352,784,785 $121,771,298 $148,532,940 $497,146,531 $374,145,567 $173,602,492 $231,735,360 $382,512,566 $42,368,399 $92,558,539 $34,518,901 $55,374,478 $426,075,488 $41,507,229 $1,368,451,273 $466,528,812 $27,619,684 $645,118,962 $87,805,350 $525,261,211 $61,401,958 $224,962,203 $31,106,511 $36 $817,591,112 $68,827,853 $43,445,887 $284,578,558 $244,478,658 $148,962,081 $232,326,359 $17,138,952

$142,317,903,795 $1,902,300,047 $330,378,398 $1,643,966,305 $1,375,797,421 $14,236,592,915 $1,439,366,499 $2,420,791,474 $419,732,143 $731,292,552 $5,686,844,862 $3,012,346,312 $507,433,146 $424,512,387 $6,172,865,261 $2,564,005,047 $1,288,770,390 $916,323,608 $2,425,288,141 $2,383,508,985 $747,027,618 $2,489,280,148 $4,609,360,933 $4,345,007,824 $2,924,447,719 $1,442,373,276 $2,569,646,129 $361,238,668 $753,162,904 $462,087,777 $606,004,232 $4,218,822,993 $862,144,872 $24,298,610,635 $4,013,996,742 $341,015,420 $6,120,967,557 $1,177,853,941 $1,377,514,740 $6,080,191,710 $919,353,410 $2,018,620,428 $355,833,902 $3,167,188,993 $7,139,928,843 $618,675,433 $351,341,290 $2,118,202,866 $2,044,234,831 $1,243,150,526 $2,206,398,750 $192,004,819

% of Total Vendor Payments 9.5% 12.4% 10.0% 0.1% 11.0% 10.9% 7.7% 7.7% 9.9% 5.6% 16.4% 12.3% 7.8% 12.9% 9.4% 12.7% 11.4% 13.0% 13.2% 14.8% 16.3% 6.0% 10.8% 8.6% 5.9% 16.1% 14.9% 11.7% 12.3% 7.5% 9.1% 10.1% 4.8% 5.6% 11.6% 8.1% 10.5% 6.4% 8.6% 6.7% 11.1% 8.7% 0.0% 11.5% 11.1% 12.4% 13.4% 12.0% 12.0% 10.5% 8.9%

*National figures include Puerto Rico and the Virgin Islands. **Oklahoma did not submit detail drug information for 1998. Source: The Lewin Group analysis of HCFA, CMSO, HCFA-2082 Report, FY98

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Drugs as a Percentage of Total Vendor Payments, Trend State National* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii** Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma** Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

1994

1995

1996

1997

1998

8.2% 12.4% 6.9% 0.6% 7.0% 11.2% 7.4% 6.2% 6.6% 4.6% 11.4% 9.2% 10.2% 8.9% 6.9% 10.3% 9.3% 9.1% 12.2% 10.0% 7.9% 6.7% 8.2% 8.9% 5.7% 12.9% 12.6% 8.7% 9.4% 5.8% 7.3% 8.5% 7.5% 3.9% 8.0% 6.2% 8.3% 9.2% 8.3% 11.6% 5.8% 7.9% 6.7% 3.9% 8.3% 8.8% 10.9% 11.4% 10.7% 9.7% 10.1% 6.7%

8.1% 12.3% 7.3% 0.9% 7.4% 10.9% 7.4% 6.8% 6.6% 4.9% 11.6% 9.4% 9.6% 9.2% 7.9% 10.0% 9.4% 9.8% 12.9% 10.8% 8.4% 6.9% 7.8% 9.2% 5.8% 12.9% 12.7% 8.7% 10.2% 6.1% 7.2% 9.0% 7.1% 3.7% 8.7% 6.6% 8.6% 9.6% 6.2% 11.7% 7.1% 8.7% 7.1% 0.0% 8.8% 9.6% 10.5% 11.6% 11.1% 11.2% 10.1% 7.0%

8.8% 13.9% 7.8% 1.2% 9.4% 11.0% 8.0% 7.2% 9.0% 4.6% 14.1% 10.3% 10.1% 10.1% 8.3% 11.0% 10.2% 10.5% 14.1% 12.1% 11.6% 7.6% 8.0% 10.5% 6.2% 13.2% 14.0% 9.3% 10.5% 6.7% 7.7% 10.0% 7.0% 4.1% 9.4% 7.0% 9.4% 9.6% 5.1% 11.5% 6.7% 9.4% 7.6% 0.0% 9.7% 11.4% 12.1% 12.5% 12.4% 11.1% 10.8% 7.5%

9.7% 14.4% 8.8% 0.8% 10.4% 11.7% 8.6% 8.3% 12.6% 5.4% 15.8% 11.0% 10.4% 9.1% 12.3% 11.4% 11.4% 13.9% 13.5% 13.2% 7.8% 10.3% 10.2% 6.6% 14.6% 15.3% 11.2% 11.5% 7.1% 8.2% 10.4% 7.7% 5.1% 10.7% 7.7% 9.9% 10.7% 5.0% 11.8% 7.1% 9.9% 8.7% 0.0% 10.2% 12.0% 14.4% 13.4% 14.7% 10.6% 10.9% 8.1%

9.5% 12.4% 10.0% 0.1% 11.0% 10.9% 7.7% 7.7% 9.9% 5.6% 16.4% 12.3% 7.8% 12.9% 9.4% 12.7% 11.4% 13.0% 13.2% 14.8% 16.3% 6.0% 10.8% 8.6% 5.9% 16.1% 14.9% 11.7% 12.3% 7.5% 9.1% 10.1% 4.8% 5.6% 11.6% 8.1% 10.5% 6.4% 8.6% 6.7% 11.1% 8.7% 0.0% 11.5% 11.1% 12.4% 13.4% 12.0% 12.0% 10.5% 8.9%

*National figures include Puerto Rico and the Virgin Islands. **Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively. Source: The Lewin Group analysis of HCFA, CMSO, HCFA-2082 Report, FY94-FY98.

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Share of Drug Payments, Top 5 Therapeutic Categories, 1999 State

Analgesics and Antipyretics

Antibiotics

National Average 6.5% 5.4% 5.1% 9.2% Alabama 10.5% 5.8% Alaska Arizona* 6.0% 6.4% Arkansas 5.2% 3.6% California Colorado* 5.5% 3.5% Connecticut 7.0% 6.3% Delaware 3.3% 4.1% District of Columbia 6.1% 5.8% Florida 6.8% 8.6% Georgia 6.1% 3.7% Hawaii 7.7% 5.4% Idaho 5.3% 6.3% Illinois 7.2% 5.2% Indiana 5.6% 5.7% Iowa 7.2% 5.5% Kansas 5.7% 6.7% Kentucky 7.7% 7.9% Louisiana 8.0% 4.0% Maine 4.0% 2.7% Maryland 5.3% 3.9% Massachusetts 7.3% 4.3% Michigan 5.1% 3.9% Minnesota Mississippi* 7.1% 5.0% Missouri 7.1% 5.4% Montana 7.2% 7.3% Nebraska 8.1% 7.0% Nevada 6.9% 3.6% New Hampshire 6.1% 3.3% New Jersey 7.5% 3.8% New Mexico 5.0% 5.0% New York 6.4% 6.6% North Carolina 6.2% 5.4% North Dakota 7.1% 4.9% Ohio 7.6% 6.7% Oklahoma 5.2% 2.7% Oregon 5.9% 5.1% Pennsylvania 4.8% 3.8% Rhode Island 7.1% 6.5% South Carolina 6.0% 7.7% South Dakota Tennessee* Texas* 7.0% 7.4% Utah 7.4% 3.7% Vermont 6.5% 5.4% Virginia 8.0% 3.6% Washington 5.8% 8.0% West Virginia 6.9% 3.5% Wisconsin 6.9% 7.1% Wyoming *Data not reported for Arizona, Colorado, Mississippi, Tennessee, or Texas.

Cardiovascular Drugs

Miscellaneous GI Drugs

PsychoTherapeutics

6.1% 8.1% 4.3% 8.0% 7.7% 6.5% 5.1% 8.8% 5.4% 7.4% 7.6% 3.7% 6.4% 5.1% 5.3% 5.3% 6.6% 7.1% 5.2% 6.2% 5.5% 7.2% 4.2% 6.1% 4.5% 5.0% 5.8% 4.4% 6.1% 7.2% 6.6% 7.1% 5.8% 6.2% 6.8% 3.6% 6.7% 7.5% 8.3% 5.3% 3.4% 6.3% 6.5% 5.3% 6.5% 6.2% 4.2%

8.8% 9.3% 8.3% 9.0% 8.6% 7.4% 7.8% 3.6% 8.4% 8.1% 3.2% 11.2% 8.7% 9.9% 6.7% 10.1% 13.1% 8.4% 11.4% 7.0% 7.9% 8.4% 7.5% 10.4% 9.8% 9.7% 8.7% 8.9% 8.9% 12.3% 7.1% 10.6% 8.9% 10.3% 8.8% 3.7% 9.2% 10.1% 9.8% 9.1% 8.7% 12.0% 10.6% 9.6% 5.8% 7.4% 9.1%

20.1% 14.9% 19.5% 17.3% 17.2% 24.5% 15.0% 13.1% 13.2% 15.4% 19.5% 22.0% 18.6% 19.1% 22.6% 22.9% 18.0% 13.0% 20.5% 28.0% 25.6% 19.4% 28.7% 19.8% 21.0% 19.4% 18.5% 25.9% 15.6% 16.9% 16.7% 14.6% 22.9% 20.1% 17.5% 47.2% 19.3% 23.6% 14.5% 18.5% 24.3% 18.8% 15.8% 22.0% 18.3% 24.7% 20.7%

Source: The Lewin Group analysis of HCFA Drug Utilization data, FY99.

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Pharmaceutical Benefits 2000

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

1994

1995

1996

1997

24,473,189 409,406 40,812 63,944 257,861 3,796,517 209,290 255,218 54,384 68,211 1,197,915 825,875 95,805 81,394 1,054,436 480,648 237,667 184,400 493,689 604,163 136,623 299,875 531,851 863,391 294,307 411,813 543,833 68,661 128,501 55,336 67,200 611,638 172,752 1,920,814 653,792 42,442 1,023,733 283,428 227,825 996,129 57,942 355,545 47,614 454,323 1,989,651 120,093 74,224 470,048 495,379 273,714 342,705 35,964

23,723,349 404,581 40,076 66,860 253,181 3,656,783 196,737 273,511 56,710 53,992 1,111,466 875,647 28,971 81,755 1,134,214 428,116 231,256 186,362 491,370 598,579 120,029 291,626 558,233 823,485 305,363 416,065 561,167 67,244 131,974 59,170 73,938 612,074 178,087 1,880,506 737,558 41,128 1,007,970 285,654 181,553 941,013 93,639 365,571 47,969 1,395 2,020,864 119,776 78,694 480,405 405,558 295,210 329,711 35,505

22,585,295 412,511 40,839 63,103 255,211 3,565,667 173,707 209,557 61,380 66,349 1,079,467 891,335 29,657 84,553 1,028,753 401,042 230,749 179,653 497,251 593,415 138,360 268,440 527,114 763,232 294,589 404,263 469,821 66,465 138,322 60,274 75,701 518,833 197,565 1,737,372 764,482 40,062 902,211 245,075 154,801 857,818 52,239 365,409 49,056 18 2,058,903 114,321 78,376 417,580 305,791 299,967 309,582 35,415

20,954,163 412,739 42,174 80,450 254,079 3,158,386 156,631 120,522 68,672 64,494 1,024,555 846,963 79,961 1,008,740 352,814 221,061 170,167 494,293 563,864 139,524 256,423 559,215 688,882 227,027 391,328 395,478 62,092 151,973 55,876 71,692 347,105 184,502 1,667,927 779,229 39,654 786,322 207,441 149,461 763,255 46,817 359,910 47,845 3 1,986,178 105,676 83,057 396,719 292,733 280,550 265,987 33,426

1998 19,337,543 395,290 43,734 56,796 262,907 2,644,430 147,033 108,331 69,027 57,733 1,014,372 805,923 32,222 86,775 959,472 323,811 215,173 155,875 429,102 552,481 137,816 176,403 613,186 589,818 203,220 368,609 353,902 58,641 145,408 50,903 70,339 309,849 96,637 1,803,428 764,886 37,675 702,143 148,258 580,749 44,852 401,611 46,588 1 1,894,447 126,953 58,037 383,880 274,463 267,398 221,508 32,510

‡Recipients are defined as individuals who received drugs, not as everyone eligible to receive drugs. *National figures include Puerto Rico and the Virgin Islands. **Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively. Source: HCFA, CMSO, HCFA-2082 Report, FY94-FY98.

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Pharmaceutical Benefits 2000

Drug Payments Per Recipient‡ State

1994

1995

1996

1997

1998

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

$363 $398 $410 $18 $342 $296 $337 $472 $337 $370 $404 $315 $360 $361 $314 $484 $384 $387 $440 $445 $469 $418 $472 $336 $387 $340 $420 $382 $432 $319 $423 $504 $277 $379 $329 $416 $406 $315 $377 $491 $686 $312 $399 $168 $257 $331 $382 $417 $340 $390 $536 $291

$413 $442 $461 $30 $403 $313 $401 $531 $378 $486 $501 $329 $856 $406 $389 $438 $421 $437 $512 $488 $532 $477 $552 $379 $486 $391 $463 $421 $468 $360 $461 $562 $284 $436 $376 $479 $476 $353 $455 $578 $511 $341 $450 $137 $286 $371 $428 $444 $398 $442 $578 $335

$474 $494 $530 $39 $451 $343 $475 $701 $452 $494 $610 $358 $905 $485 $434 $671 $483 $505 $548 $501 $606 $577 $575 $462 $510 $437 $600 $493 $517 $405 $559 $721 $310 $522 $451 $522 $575 $401 $433 $626 $874 $394 $492 $852 $324 $421 $466 $530 $565 $417 $664 $385

$571 $548 $673 $23 $534 $423 $619 $1,383 $505 $582 $754 $401 $563 $519 $831 $560 $615 $640 $559 $735 $674 $712 $530 $686 $533 $811 $571 $525 $477 $633 $1,065 $343 $654 $518 $636 $738 $535 $490 $724 $1,114 $443 $577 $373 $378 $481 $533 $629 $700 $474 $773 $445

$699 $599 $752 $25 $574 $587 $749 $1,722 $599 $715 $921 $460 $1,230 $633 $608 $1,006 $684 $762 $746 $639 $884 $842 $811 $634 $854 $629 $1,081 $723 $637 $678 $787 $1,375 $430 $759 $610 $733 $919 $592 $904 $1,369 $560 $668 $36 $432 $542 $749 $741 $891 $557 $1,049 $527

‡Recipients are defined as individuals who received drugs, not as everyone eligible to receive drugs. *National figures include Puerto Rico and the Virgin Islands. **Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively. Source: The Lewin Group analysis of HCFA, CMSO, HCFA-2082 Report, FY94-FY98.

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Pharmaceutical Benefits 2000

Medicaid Drug Reimbursement Report, 1998 State Alabama Alaska Arizona* Arkansas California Colorado Connecticut* Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas* Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma** Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee* Texas* Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Drug Payments1

Drug Recipients1

Prescriptions Processed2

Average Prescription Cost2

$236,674,147 $32,887,828 $1,442,917 $150,891,615 $1,553,598,462 $110,159,725 $186,593,992 $41,350,537 $41,254,973 $933,782,041 $370,562,935 $39,623,380 $54,971,097 $583,239,675 $325,712,348 $147,115,884 $118,825,316 $319,983,951 $352,784,785 $121,771,298 $148,532,940 $497,146,531 $374,145,567 $173,602,492 $231,735,360 $382,512,566 $42,368,399 $92,558,539 $34,518,901 $55,374,478 $426,075,488 $41,507,229 $1,368,451,273 $466,528,812 $27,619,684 $645,118,962 $87,805,350 $525,261,211 $61,401,958 $224,962,203 $31,106,511 $36 $817,591,112 $68,827,853 $43,445,887 $284,578,558 $244,478,658 $148,962,081 $232,326,359 $17,138,952

395,290 43,734 56,796 262,907 2,644,430 147,033 108,331 69,027 57,733 1,014,372 805,923 32,222 86,775 959,472 323,811 215,173 155,875 429,102 552,481 137,816 176,403 613,186 589,818 203,220 368,609 353,902 58,641 145,408 50,903 70,339 309,849 96,637 1,803,428 764,886 37,675 702,143 148,258 580,749 44,852 401,611 46,588 1 1,894,447 126,953 58,037 383,880 274,463 267,398 221,508 32,510

7,852,261 662,575 3,142,993 40,646,534 1,431,595 830,829 1,858,364 18,681,483 9,284,700 1,119,545 630,770 17,981,685 4,379,620 4,457,957 9,630,473 20,664,690 2,868,068 2,336,929 12,598,550 10,357,765 4,612,393 5,368,429 9,860,308 1,179,484 2,991,257 814,185 1,572,638 8,400,194 1,176,851 35,512,292 11,633,909 585,260 19,983,451 3,449,399 2,374,283 14,219,369 1,570,662 3,555,427 762,406 2,063,349 799,552 8,098,755 6,552,127 5,370,453 6,358,445 453,071

$30.34 $51.73 $37.44 $40.56 $37.14 $38.68 $43.83 $47.86 $31.24 $34.40 $42.21 $34.01 $40.46 $19.70 $33.41 $34.35 $41.85 $42.54 $40.18 $34.23 $35.23 $40.27 $38.58 $34.74 $33.36 $43.14 $34.11 $47.83 $33.36 $44.45 $41.24 $35.44 $33.15 $41.07 $40.56 $38.75 $41.26 $49.21 $37.17 $34.25 $39.94 $35.70 $37.60 $30.13 $36.87 $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.

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Pharmaceutical Benefits 2000

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 multiplesource 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.

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Pharmaceutical Benefits 2000

Medicaid Drug Rebates State

Allocation of Drug Rebate Moneys1

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

Medicaid Drug Budget General Fund Medicaid General Medicaid Drug Budget Medicaid General General Fund Medicaid General Medicaid General Medicaid Drug Budget General Fund General Fund Medicaid General General Fund General Fund General Fund General Fund Medicaid General Medicaid Drug Budget General Fund Medicaid General General Fund Medicaid Drug Budget Medicaid General Medicaid Special Refund Medicaid Drug Budget General Fund General Fund and Medicaid General Medicaid Drug Budget General Fund Medicaid Drug Budget General Fund General Fund Medicaid General Medicaid General Medicaid General Medicaid General General Fund Medicaid Drug BudgetMedicaid General Medicaid Drug Budget Medicaid General Medicaid Drug Budget General Fund Medicaid General Medicaid Medical Budget General Fund Medicaid General Medicaid Drug Budget Medicaid Drug Budget

1999 Total Rebates2

1999 Federal Share2

$3,316,594,880 $49,785,076 $7,050,981 $37,931,853 $533,191,914 $25,150,259 $38,656,394 $9,787,444 $8,379,982 $195,512,719 $94,903,175 $8,378,292 $11,901,778 $121,540,781 $62,691,135 $32,369,409 $26,878,486 $72,676,810 $76,147,317 $30,032,364 $32,403,851 $140,102,747 $75,674,128 $37,389,033 $49,332,307 $84,620,799 $9,290,653 $21,609,490 $7,727,267 $12,956,727 $89,197,702 $7,972,600 $356,088,488 $111,326,116 $5,954,387 $148,477,399 $31,992,100 $21,360,688 $119,340,064 $14,440,971 $55,971,288 $5,971,015 $22,434,760 $185,695,267 $14,721,050 $10,579,999 $67,715,512 $54,331,249 $35,941,495 $38,644,764 $4,364,795

$1,899,896,508 $34,533,102 $4,216,486 $27,703,515 $278,960,679 $12,868,802 $19,328,198 $4,945,369 $5,866,114 $109,644,101 $57,612,243 $4,189,146 $8,313,393 $61,133,375 $38,247,862 $20,570,660 $16,184,126 $51,258,954 $53,686,416 $19,941,489 $16,274,193 $70,660,841 $39,969,595 $19,255,352 $37,964,206 $51,306,706 $6,688,938 $13,454,079 $3,882,559 $6,478,364 $44,750,228 $5,818,404 $178,044,244 $70,372,764 $4,171,965 $86,502,933 $22,786,690 $13,062,439 $64,407,705 $7,805,345 $39,382,765 $4,094,537 $14,154,090 $116,237,687 $10,566,770 $6,556,425 $35,066,017 $28,566,897 $26,765,632 $22,837,194 $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.

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Pharmaceutical Benefits 2000

Medicaid Drug Rebate Trends, 1995-1999 State

1995 Drug Rebate

1996 Drug Rebate

1997 Drug Rebate

1998 Drug Rebate

1999 Drug Rebate

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

$1,795,369,481 $26,713,236 $3,392,270 $15,838,282 $214,571,699 $16,164,945 $29,670,883 $39,108,649 $6,212,050 $99,995,743 $51,400,489 $5,451,328 $5,364,698 $68,635,826 $39,660,999 $17,082,336 $13,274,426 $42,282,025 $49,319,520 $13,111,934 $25,339,673 $53,656,921 $64,564,101 N/A $30,380,557 $45,080,603 $5,565,740 $10,418,227 $4,038,721 $5,046,055 $62,240,335 $9,071,911 $151,313,836 $43,275,244 $3,548,429 $97,259,136 $18,519,577 $18,887,522 $89,645,272 $8,904,676 $27,588,863 $3,248,482 $1,110,475 $106,027,639 $7,608,692 $7,363,796 $49,153,407 $33,803,617 $20,248,539 $32,786,506 $2,421,591

$1,961,842,019 $35,746,548 $3,631,600 $19,942,216 $259,522,046 $17,354,887 $30,787,226 $4,424,652 $5,669,258 $110,282,689 $56,905,277 $3,720,038 $6,534,816 $85,146,120 $45,845,822 $18,770,263 $16,682,962 $43,116,489 $55,702,577 $16,131,900 $28,493,983 $65,037,309 $67,989,816 $6,992,875 $32,191,139 $51,527,496 $6,031,657 $12,330,363 $4,400,121 $7,912,982 $65,377,388 $11,509,943 $150,547,790 $57,099,702 $3,734,060 $103,428,427 $19,696,492 $19,668,133 $99,204,380 $9,336,162 $30,483,825 $3,248,037 $247,255 $114,442,343 $9,145,247 $6,794,891 $41,059,487 $33,586,091 $27,287,834 $34,494,898 $2,624,507

$2,212,579,458 $47,135,670 $4,900,641 $24,514,373 $307,645,326 $16,950,071 $27,318,565 $5,851,285 $6,668,493 $128,466,755 $59,756,017 $4,654,126 $8,369,523 $85,128,380 $43,645,256 $21,755,142 $11,797,675 $59,890,925 $54,650,344 $18,246,061 $34,567,082 $73,047,452 $74,116,928 $31,873,349 $37,108,638 $54,614,194 $6,775,176 $14,931,313 $5,391,025 $8,788,296 $66,748,605 $13,367,028 $200,157,978 $68,332,867 $4,651,348 $84,238,194 $20,776,998 $13,852,833 $115,510,606 $10,121,820 $34,643,502 $4,940,121 $130,576,891 $8,374,299 $8,255,707 $45,240,474 $38,326,646 $26,079,819 $37,146,544 $2,679,097

$2,469,136,949 $36,537,095 $5,026,624 $22,518,230 $362,808,597 $20,424,896 $32,128,587 $7,096,836 $7,100,983 $150,733,077 $64,320,077 $5,992,722 $8,614,444 $100,811,862 $50,710,861 $25,265,390 $19,852,439 $57,082,387 $65,994,910 $19,650,719 $25,017,660 $89,011,664 $72,526,027 $31,058,740 $39,983,265 $66,460,159 $7,378,206 $16,545,572 $5,143,136 $9,676,461 $70,992,525 $10,670,766 $251,273,382 $81,211,796 $4,990,065 $110,484,575 $23,329,251 $14,433,179 $95,692,149 $11,041,552 $39,156,574 $5,070,643 $840 $145,635,499 $9,988,037 $8,868,263 $51,079,391 $39,191,376 $26,753,285 $40,776,543 $3,025,632

$3,316,594,880 $49,785,076 $7,050,981 $37,931,853 $533,191,914 $25,150,259 $38,656,394 $9,787,444 $8,379,982 $195,512,719 $94,903,175 $8,378,292 $11,901,778 $121,540,781 $62,691,135 $32,369,409 $26,878,486 $72,676,810 $76,147,317 $30,032,364 $32,403,851 $140,102,747 $75,674,128 $37,389,033 $49,332,307 $84,620,799 $9,290,653 $21,609,490 $7,727,267 $12,956,727 $89,197,702 $7,972,600 $356,088,488 $111,326,116 $5,954,387 $148,477,399 $31,992,100 $21,360,688 $119,340,064 $14,440,971 $55,971,288 $5,971,015 $22,434,760 $185,695,267 $14,721,050 $10,579,999 $67,715,512 $54,331,249 $35,941,495 $38,644,764 $4,364,795

*Does not apply for Arizona. Source: HCFA 64, Medicaid Financial Management Report, FY95-FY99.

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Pharmaceutical Benefits 2000

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National Pharmaceutical Council

Pharmaceutical Benefits 2000

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

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Pharmaceutical Benefits 2000

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 onethird pharmacists.

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Pharmacy Advisory Committees State

Pharmacy Advisory Committee

Meetings

Preferred Product Introduction Process

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

Pharmacy & Therapeutic Committee None N/A Contract Drug Advisory Committee DUR Board advises None DUR Board advises N/A DUR Board advises Yes DUR Board advises DUR Board advises No DUR Board advises Medicaid Pharmacy Advisory Committee DUR Board advises Drug Management Review Advisory Board Benefits Management Advisory Committee DUR Committee No DUR Committee No Drug Formulary Committee No Pharmacy Subcommittee DUR Board advises Medicaid Pharmacy Advisory Committee None None None N/A Pharmacy Advisory Committee None None Pharmacy & Therapeutic Committee Yes None Medical Assistance Advisory Committee N/A None None None DUR Committee DUR Committee Pharmacy Liaison Committee Drug Utilization and Education Council Medical Services Fund Advisory Council None None

Bi-Monthly Ad Hoc Quarterly Bi-Monthly Quarterly Quarterly Quarterly Bi-Monthly Quarterly Semiannually Bi-Monthly Quarterly Ad Hoc Bi-Monthly Quarterly Quarterly Quarterly Monthly Ad Hoc Quarterly Quarterly Monthly

Contact First Data Bank Introductory letter Inform health plans directly Introductory letter Introductory letter Introductory letter Introductory letter Introductory letter Introductory letter Introductory letter Introductory letter Introductory letter Introductory letter Contact First Data Bank Introductory letter Introductory letter Introductory letter, Formulary packet State form, Package insert Introductory letter Introductory letter Introductory letter Introductory letter State form Introductory letter Introductory letter Introductory letter Introductory letter Introductory letter Introductory letter Introductory letter, FDA updates Introductory letter Introductory letter Introductory letter Introductory letter, Package insert Introductory letter Introductory letter Introductory letter Contact First Data Bank Introductory letter Introductory letter Formulary packet Introductory letter Introductory letter, State form Introductory letter Introductory letter Introductory letter State form Introductory letter Introductory letter Introductory letter, Contact First Data Bank

Monthly Monthly Bi-Monthly Bi-Monthly Bi-Monthly Quarterly Bi-Monthly

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Pharmaceutical Benefits 2000

Pharmacy Benefit Design - Coverage State

Cosmetics

Fertility Drugs

Experiment Drugs

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

PA Required Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered N/A Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Covered Not Covered Not Covered Not Covered Not Covered Not Covered Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Covered Not Covered Not Covered Not Covered Not Covered PA Required Not Covered N/A Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Covered with Restrictions

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered N/A Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Covered Not Covered Not Covered Not Covered Not Covered Not Covered Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered N/A Covered Not Covered Not Covered Not Covered Not Covered Covered with Restrictions Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered N/A Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Covered Not Covered Not Covered Not Covered Not Covered Not Covered Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered N/A Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. PA = Prior Authorization, DME = Durable Medical Equipment Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Pharmaceutical Benefits 2000

Pharmacy Benefit Design – Coverage (Con’t) State

Prescribed Insulin

Disposable Needles for Syringe Combinations Blood Glucose Test Insulin Use for Insulin Use Strips

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

Covered Covered Covered with Restrictions Covered Covered Covered Covered N/A Covered Covered Covered Covered Covered Covered Covered Covered Not Covered Covered Covered Covered Covered Covered Not Covered Covered Covered Covered Covered with Restrictions Covered Covered Covered Covered Not Covered Covered Covered Covered as DME Covered as DME Covered Covered N/A Not Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered

Covered Covered Covered with Restrictions Covered Covered with Restrictions Covered Covered N/A Covered Covered Covered Covered Covered Covered Not Covered Covered Covered Covered Covered Covered Covered Covered Not Covered Not Covered Covered Not Covered Not Covered Not Covered Covered Covered Covered Not Covered Not Covered Covered Not Covered Covered as DME Not Covered Covered N/A Not Covered Covered Covered with Restrictions Covered Covered Covered Covered Covered as DME Covered as DME Covered

Covered Covered Covered Covered Covered with Restrictions Covered Covered N/A Covered Covered Covered Covered Covered Covered Not Covered Covered Not Covered Covered Covered Covered Covered Covered Not Covered Covered Covered Not Covered Not Covered Not Covered Covered Covered Covered Not Covered Not Covered Covered Not Covered Covered as DME Covered with Restrictions Covered N/A Not Covered Covered Covered Covered Covered Covered Covered Covered as DME Covered Covered

Covered Covered Not Covered Covered Covered with Restrictions Covered Covered N/A Covered Covered with Restrictions Covered Covered as DME Covered Covered Not Covered Covered Covered Covered Covered Not Covered Covered Covered Not Covered Covered as DME Covered as DME Not Covered Not Covered Not Covered Covered Covered Covered Not Covered Not Covered Covered Not Covered Covered as DME Not Covered Covered N/A Covered Covered Not Covered N/A Covered Covered Covered Covered as DME Covered as DME Covered

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. PA = Prior Authorization, DME = Durable Medical Equipment Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Pharmaceutical Benefits 2000

Pharmacy Benefit Design – Coverage (Con’t) State

Urine Ketone Test Strips

Total Parenteral Nutrition

Interdialytic Parenteral Nutrition

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

Covered Covered Not Covered Covered Covered with Restrictions Covered Covered N/A Covered with Restrictions Covered with Restrictions Covered Covered as DME Covered Covered Not Covered Covered Covered Covered Covered Not Covered Covered Covered Not Covered Covered as DME Covered as DME Not Covered Not Covered Not Covered Covered Covered Covered Not Covered Not Covered Covered Not Covered Covered as DME Not Covered Covered N/A Covered Covered Not Covered Covered Covered Covered Covered Covered as DME Covered as DME Covered

Covered Covered Not Covered PA Required PA Required Covered Covered N/A Covered Covered with Restrictions Covered Covered as DME Not Covered Covered Not Covered Covered Not Covered PA Required Covered Covered Covered Covered as DME Not Covered Covered as DME Covered as DME Not Covered Not Covered Covered Covered Covered Covered Not Covered Not Covered Covered Covered as DME Covered with Restrictions PA Required Covered N/A Covered Not Covered Not Covered Not Covered Covered Covered Covered Covered as DME Covered with Restrictions Covered as DME

Covered Covered Not Covered PA Required Not Covered Covered Not Covered N/A Not Covered Covered with Restrictions Covered Covered as DME Not Covered Covered Not Covered Covered as DME Not Covered PA Required Covered Not Covered Covered Covered as DME Covered with Restrictions Covered as DME Covered as DME Not Covered Not Covered Not Covered Covered Covered Covered Not Covered Not Covered Covered Covered as DME Covered with Restrictions PA Required Covered N/A Covered Not Covered Not Covered Not Covered Covered Covered as DME Covered Not Covered Covered with Restrictions Covered as DME

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. PA= Prior Authorization, DME = Durable Medical Equipment Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Pharmaceutical Benefits 2000

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

PDP PDP PDP Alabama PP PDP PDP Alaska Arizona* PP PDP PDP Arkansas PP PDP PDP California PP PDP PDP Colorado PP PDP PDP Connecticut PDP and PP PDP PDP Delaware N/A N/A N/A District of Columbia PP PDP PDP Florida PDP and PP PDP PDP Georgia PDP and PP PDP PDP Hawaii PDP and PP PDP PDP Idaho PDP PDP PDP Illinois PDP and PP PDP and PP PDP and PP Indiana PP PDP PDP Iowa PP PDP PDP Kansas PDP and PP PDP PDP Kentucky PDP and PP PDP PDP Louisiana PP PDP PDP Maine PP PDP PDP Maryland PP PDP PDP Massachusetts PP PDP PDP Michigan PP PDP and PP PDP Minnesota PP PDP PDP Mississippi PDP PDP PDP Missouri PP PDP PDP Montana PP PDP PDP Nebraska PP PDP PDP Nevada PP PDP PDP New Hampshire PP PDP PDP New Jersey PDP and PP PDP and PP PDP and PP New Mexico PP PDP PDP New York PP PDP PDP North Carolina PDP PDP PDP North Dakota PP PDP PDP Ohio PP PDP PDP Oklahoma PP PP PP Oregon PDP PDP PDP Pennsylvania N/A N/A N/A Rhode Island PP PDP PDP South Carolina PP PP PP South Dakota Tennessee* PP PDP PDP Texas PP PDP and PP PDP and PP Utah PP PP PP Vermont PP PDP PDP Virginia PP PDP PDP Washington PDP and PP PDP PDP and PP West Virginia PP PDP PDP Wisconsin PP PDP PDP Wyoming *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Pharmaceutical Benefits 2000

Coverage of Vaccines and Unit Dose State

Method for Vaccine Reimbursement ^

Reimbursement for Unit Dose

EPSDT, VCP Yes Alabama EPSDT, CHIP, VCP Yes Alaska Arizona* VCP Yes Arkansas VCP No California VCP No Colorado CHIP No Connecticut VCP No Delaware EPSDT No District of Columbia VCP Yes Florida EPSDT, CHIP, VCP Yes Georgia EPSDT, VCP Yes Hawaii EPSDT, CHIP, VCP Yes Idaho Special Program No Illinois EPSDT, CHIP, VCP No Indiana EPSDT, VCP Yes Iowa CHIP, VCP No Kansas EPSDT, CHIP, VCP, Pharmacy Services Yes Kentucky EPSDT, VCP No Louisiana EPSDT Yes Maine EPSDT Yes, LTC Maryland EPSDT No Massachusetts EPSDT, CHIP Yes Michigan EPSDT, CHIP, VCP Yes Minnesota EPSDT No Mississippi EPSDT, CHIP, VCP Yes Missouri EPSDT, CHIP, VCP Yes Montana EPSDT, CHIP, VCP No Nebraska EPSDT Yes Nevada EPSDT, CHIP, VCP Yes, LTC New Hampshire EPSDT, VCP Yes, LTC New Jersey VCP No New Mexico EPSDT, VCP No New York Health Check Yes North Carolina EPSDT No North Dakota VCP No Ohio ESPDT, VCP Yes Oklahoma VCP Yes Oregon EPSDT, CHIP, VCP, Pharmacy Services No Pennsylvania N/A No Rhode Island VCP Yes South Carolina VCP Yes South Dakota Tennessee* EPSDT Yes Texas EPSDT, CHIP, VCP, Medical Services Yes Utah EPSDT Yes Vermont VCP, Health Dept. Yes Virginia EPSDT Yes Washington EPSDT, VCP Yes West Virginia VCP Yes Wisconsin EPSDT, CHIP, VCP No Wyoming ^ Early and Periodic Screening, Diagnostic and Treatment (EPSDT), Children Health Insurance Program (CHIP), Vaccines for Children Program (VCP), or other. LTC = Long Term Care *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Pharmaceutical Benefits 2000

Coverage of Over-the-Counter Medications State

Allergy, Asthma, and Sinus

Analgesics

Cough and Cold

Smoking Deterrents

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

Covered with Rx Not Covered Limited Coverage PA Required Not Covered Not Covered Covered N/A Limited Coverage Not Covered Limited Coverage Not Covered Not Covered N/A Covered with Restrictions Not Covered Covered with Restrictions Not Covered Covered with Restrictions Not Covered Covered Limited Coverage Limited Coverage Not Covered Covered Not Covered Covered Covered with Restrictions Covered Limited Coverage Covered Limited Coverage Not Covered Not Covered Limited Coverage Not Covered Covered with Restrictions Covered with Restrictions N/A Covered with Restrictions Not Covered Covered Limited Coverage PA Required Covered with Restrictions Limited Coverage Limited Coverage Not Covered Limited Coverage

Covered with Rx Not Covered Limited Coverage PA Required Limited Coverage Limited Coverage Covered N/A Limited Coverage Limited Coverage Limited Coverage Not Covered PA Required N/A Covered with Restrictions Covered Covered with Restrictions Not Covered Covered with Restrictions Not Covered Covered Limited Coverage Limited Coverage Limited Coverage Covered Limited Coverage Covered Covered with Restrictions Covered Limited Coverage Covered Limited Coverage Not Covered Covered Limited Coverage Not Covered Covered with Restrictions Covered N/A Covered with Restrictions Not Covered Covered Covered PA Required Covered Limited Coverage Limited Coverage Covered Covered

Covered with Rx Not Covered Limited Coverage PA Required Not Covered Limited Coverage Covered N/A Limited Coverage Limited Coverage Limited Coverage Not Covered PA Required N/A Covered with Restrictions Limited Coverage Covered with Restrictions Not Covered Not Covered Not Covered Covered with Restrictions Not Covered Limited Coverage Limited Coverage Covered Not Covered Covered Covered with Restrictions Covered Limited Coverage Covered Limited Coverage Not Covered Not Covered Limited Coverage Not Covered Covered with Restrictions Covered with Restrictions N/A Covered with Restrictions Not Covered Covered Covered PA Required Covered with Restrictions Limited Coverage Limited Coverage Covered with Restrictions Covered

Not Covered Not Covered Not Covered PA Required Limited Coverage Not Covered Covered N/A Covered Not Covered Not Covered Not Covered Covered N/A Not Covered Limited Coverage Covered Not Covered Covered Not Covered Not Covered Limited Coverage Covered with Restrictions Not Covered Not Covered Not Covered Not Covered Covered with Restrictions Covered Not Covered Covered Covered Not Covered PA Required Limited Coverage Not Covered Covered with Restrictions Not Covered N/A Covered Not Covered Covered Not Covered PA Required Not Covered Covered PA Required Not Covered Not Covered

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. PA= Prior Authorization Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Pharmaceutical Benefits 2000

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

Digestive Products (no H2 antagonists)

H2 Antagonists

Feminine Products

Topical Products

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

Covered with Rx Not Covered Limited Coverage PA Required Not Covered Covered Covered N/A Not Covered Not Covered Covered with Restrictions Not Covered PA Required N/A Not Covered Not Covered Covered with Restrictions Not Covered Covered with Restrictions Not Covered Covered Limited Coverage Limited Coverage Not Covered Covered Covered Covered Covered with Restrictions Covered Not Covered Covered Limited Coverage Not Covered Not Covered Limited Coverage Not Covered Covered with Restrictions Covered with Restrictions N/A Covered with Restrictions Not Covered Covered Covered PA Required Covered Covered Limited Coverage Covered with Restrictions Not Covered

Covered with Rx Not Covered Covered PA Required Not Covered Not Covered Covered N/A Not Covered Not Covered Covered with Restrictions Not Covered Covered N/A Not Covered Covered Not Covered Not Covered Covered with Restrictions Not Covered Covered with Restrictions Limited Coverage Covered Not Covered Covered Covered Covered Covered with Restrictions Covered Not Covered Covered Covered Not Covered Covered Limited Coverage Not Covered Covered with Restrictions Covered with Restrictions N/A Covered with Restrictions Not Covered Covered Covered PA Required Covered Not Covered Not Covered Not Covered Covered

Not Covered Limited Coverage Limited Coverage PA Required Not Covered Covered Limited Coverage N/A Covered with Rx Not Covered Limited Coverage Not Covered Not Covered N/A Not Covered Not Covered Covered with Restrictions Not Covered Not Covered Not Covered Covered Limited Coverage Limited Coverage Not Covered Not Covered Not Covered Covered Covered with Restrictions Covered Not Covered Covered with Restrictions Limited Coverage Not Covered Not Covered Limited Coverage Not Covered Covered with Restrictions Covered N/A Covered with Restrictions Not Covered Covered N/A PA Required Covered Limited Coverage Covered Not Covered Covered

Covered with Rx Limited Coverage Limited Coverage PA Required Not Covered Not Covered Limited Coverage N/A Not Covered Not Covered Limited Coverage Not Covered PA Required N/A Covered with Restrictions Not Covered Covered with Restrictions Covered Covered with Restrictions Not Covered Covered with Restrictions Limited Coverage Limited Coverage Not Covered Limited Coverage Not Covered Covered Covered with Restrictions Covered Covered with Restrictions Covered Limited Coverage Not Covered Not Covered Limited Coverage Not Covered Covered with Restrictions Covered N/A Covered with Restrictions Not Covered Covered Limited Coverage PA Required Limited Coverage Limited Coverage Covered Covered with Restrictions Limited Coverage

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Pharmaceutical Benefits 2000

Prior Authorization Process and Procedures State

PA Procedure

Prior Authorization Committee

Members

Meetings

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

Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes No Yes No Yes Yes Yes No Yes Yes Yes Yes No Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No

N/A No DUR Board No Yes No N/A No Yes DUR Board Yes (Used only for Growth Hormones) Committee on Drugs and Therapeutics No No Prior Authorization Subcommittee No No No Drug Formulary Committee No Prior Authorization Committee No Utilization Review Committee No No No No No DUR Board No No No No No No No No Yes Drug Utilization and Education Council DUR Board No -

N/A N/A N/A N/A N/A 14 9 3 Varies 6 9 7

N/A N/A N/A N/A N/A Quarterly Quarterly Ad hoc Quarterly Quarterly Quarterly Quarterly

7 10 12 N/A 8 -

Ad hoc Monthly Quarterly Not Active Bimonthly -

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Pharmaceutical Benefits 2000

Prior Authorization Process and Procedures (Con’t) State

Initiated By:

Annual Requests

% Approved

M.D., R.Ph. N/A N/A Alabama R.Ph. 3,634 74% Alaska Arizona* M.D., R.Ph. 126,248 83% Arkansas M.D., R.Ph. 1,200,000 87% California M.D. 12,000 90% Colorado N/A N/A N/A Connecticut M.D., R.Ph. 50 N/A Delaware N/A N/A N/A District of Columbia M.D., R.Ph. N/A N/A Florida M.D., R.Ph. 50,000 85% Georgia M.D., R.Ph. N/A N/A Hawaii M.D. 1,200 97% Idaho M.D., R.Ph. 670,000 N/A Illinois N/A N/A N/A Indiana M.D., R.Ph. 30,000 80% Iowa M.D., R.Ph. 10,085 85% Kansas M.D., R.Ph., Social Worker 298,244 70% Kentucky N/A N/A N/A Louisiana M.D. 1,500 90% Maine M.D., R.Ph 8,640 95% Maryland M.D 14,000 95% Massachusetts M.D. 18,000 82% Michigan R.Ph. 6,000 96% Minnesota M.D. 40000 99% Mississippi M.D. 10,000 N/A Missouri M.D., R.Ph., Nurse 12,078 84% Montana M.D., R.Ph. 2,500 80% Nebraska M.D., R.Ph. 40,000 90% Nevada N/A N/A N/A New Hampshire R.Ph., DME Supplier 386,000 90% New Jersey M.D., R.Ph. 60 80% New Mexico Order Provider N/A N/A New York N/A 395 85 North Carolina R.Ph. 625 96% North Dakota M.D. 40,000 99% Ohio M.D., R.Ph. 6,000 75% Oklahoma M.D. 24974 70% Oregon M.D. N/A N/A Pennsylvania R.Ph. 200 N/A Rhode Island M.D., R.Ph. 4,200 90% South Carolina M.D., R.Ph. 50 95% South Dakota Tennessee* M.D., R.Ph. N/A N/A Texas R.Ph. N/A N/A Utah M.D. N/A 99% Vermont M.D. N/A N/A Virginia M.D., R.Ph. 82,480 80% Washington M.D., R.Ph. 153,235 73% West Virginia R.Ph. 58,321 99% Wisconsin N/A N/A N/A Wyoming *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Prior Authorization Process and Procedures (Con’t) State

Reviewer

Review Time

Response Vehicle

R.N., M.D., R.Ph. 24 hours Phone, fax, mail Alabama M.D., R.Ph., other Verbal-instant; paper-2 weeks Verbal, fax, mail Alaska Arizona* Voice Response 1-3 minutes Voice Response System Arkansas R.Ph. 24 hours Fax or telephone inquiry system California R.Ph., Fiscal Agent PA line Less than 1 working day Phone Colorado N/A N/A N/A Connecticut R.Ph. 1 working day Phone, fax Delaware N/A N/A District of Columbia N/A R.N., R.Ph., Other 10 minutes to 72 hours Verbal, fax, mail Florida R.Ph. 24 hours Phone, fax, mail Georgia R.N., M.D. 24 hours Phone Hawaii M.D., R.Ph. 24 hours or less Mail, fax Idaho M.D., R.Ph. 24 hours Automated phone Illinois N/A N/A N/A Indiana R.Ph. 24 hours or less Phone, fax Iowa R.N., M.D., R.Ph. 24 hours or less Phone Kansas R.N., M.D., R.Ph. Minutes to hours+ Phone, mail Kentucky N/A N/A N/A Louisiana M.D., R.Ph. 24 hours or less Phone, mail Maine M.D., R.Ph. 24 hours or less Phone Maryland R.Ph. 24 hours Phone, on-line Massachusetts Health Care Analysts 24 hours or less Phone Michigan R.N. Within 10 days Phone, mail Minnesota R.N., R.Ph., other 5-10 minutes Phone Mississippi R.N., Medicaid Tech. Within 24 hours Phone, fax Missouri R.Ph. 10-15 minutes Phone, fax Montana R.N., M.D., R.Ph. 1 hour Fax, mail Nebraska R.N., M.D., R.Ph. 24 hours Phone, fax, mail Nevada N/A N/A N/A New Hampshire R.N., R.Ph. Minutes Phone New Jersey R.Ph. 3 minutes Requestor notified if PA is denied New Mexico R.N., R.Ph., other Under 21 days PA sent to ordering provider New York R.Ph. 24 hours Fax North Carolina R.Ph., M.D., R.N. 2-3 days Mail North Dakota R.Ph. 24 hours Phone, fax Ohio R.Ph. 5-20 minutes Phone, fax Oklahoma R.Ph. 3-4 minutes Phone, fax Oregon R.N., M.D. Immediately to 24 hours Phone Pennsylvania R.Ph. Within 72 hours N/A Rhode Island R.Ph. Per OBRA '90 guidelines Phone, fax, mail South Carolina M.D. or R.Ph. 24 hours Phone, fax, mail South Dakota Tennessee* R.Ph. N/A Phone, fax, mail, e-mail Texas Nurse 24 hours Phone, fax, mail Utah R.N. 24 hours Phone, mail Vermont M.D., R.Ph. 24 hours Phone, fax, mail Virginia R.N., M.D., R.Ph.# 24 hours Phone, fax; denial through mail Washington R.Ph. 3 minutes to 2 hours Phone, fax West Virginia R.Ph. Immediate to a few days+ Phone, fax, mail Wisconsin N/A N/A N/A Wyoming *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. + Depends on urgency. # Reviewer also includes Medical Claims Examiner. Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Pharmaceutical Benefits 2000

Prior Authorization State

Anabolic Steroids

Analgesics, Antipyretics, NSAIDs

Anorectics

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

Covered, PA Required Covered Covered Covered, PA Required Covered, PA Required Covered Covered N/A Covered Covered, PA Required Covered, PA Required Covered N/A Covered Covered Covered Covered, PA Required Covered Covered, PA Required Covered Covered Not Covered Covered Covered Covered Covered Covered Covered Covered Partial Coverage Covered Covered Covered Not Covered Covered, PA Required Not Covered Covered Covered N/A Covered Covered Covered Partial Coverage, PA Required Covered Not Covered Partial Coverage, PA Required Covered Covered Not Covered

Covered, PA Required Covered Covered, PA Required Covered, Some PA Required Covered Covered Covered N/A Covered Partial Coverage, PA Required Partial Coverage Covered N/A N/A Covered, PA Required Covered Covered, Some PA Required Covered Covered Covered Covered Covered Covered Covered, PA Required Covered Covered, PA Required Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered, PA Required Covered Covered N/A Covered Covered Covered Covered Covered Partial Coverage Partial Coverage, PA Required Covered, PA Required Covered Covered

Not Covered Not Covered Not Covered Covered, PA Required Partial Coverage Not Covered Covered, PA Required N/A Not Covered Covered, PA Required Partial Coverage Not Covered N/A N/A Not Covered Covered, PA Required Not Covered Not Covered Covered, PA Required Not Covered Covered, PA Required Not Covered Not Covered Covered Not Covered Covered, PA Required Not Covered Not Covered Not Covered PA for ADD Diagnosis Covered Not Covered Covered Not Covered Not Covered Not Covered Covered Not Covered N/A Partial Coverage Not Covered Not Covered Covered Covered Partial Coverage, PA Required Partial Coverage, PA Required Not Covered Covered, PA Required Not Covered

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. PA = Prior Authorization Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Prior Authorization (Con’t) State

Antihistamines

Anxiolytics, Sedatives, and Hypnotics

Prescribed Cold Medications

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

Covered, PA Required Covered Covered, PA Required Covered, Some PA Required Covered Covered Covered N/A Covered Partial Coverage, PA Required Covered, PA Required Covered N/A N/A Covered, PA Required Covered Covered, PA Required Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered, PA Required Covered, PA Required Covered N/A Covered Covered N/A Covered Covered Covered Partial Coverage Covered, PA Required Covered Partial Coverage Covered

Covered Covered Partial Coverage Covered, Some PA Required Covered Covered Covered N/A Covered Partial Coverage, PA Required Covered, PA Required Covered N/A N/A Covered Partial Coverage, PA Required Covered, Some PA Required Covered Covered Covered Covered, PA for prolonged use Covered Covered Covered Partial Coverage, PA Required Covered, PA Required Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered, PA Required Covered Covered N/A Covered Covered N/A Covered Covered Covered Covered Covered, PA Required Partial Coverage Covered Covered

Covered Not Covered Partial Coverage Covered, Some PA Required Partial Coverage, Under 21 Covered Covered N/A Not Covered Partial Coverage Covered Covered N/A N/A Covered Covered Covered, Some PA Required Not Covered Not Covered Covered Covered, PA Required Not Covered Covered Not Covered Covered Covered Covered Covered, PA Required Covered Covered Covered Partial Coverage, PA Required Covered Partial Coverage Covered Not Covered Covered, PA Required Partial Coverage N/A Covered Covered N/A Covered Covered Covered Partial Coverage Covered, PA Required Partial Coverage Partial Coverage Covered

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. PA = Prior Authorization Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Prior Authorization (Con’t) State

Growth Hormones

Miscellaneous GI Products

Prescribed Smoking Deterrents

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

Covered, PA Required Covered, PA Required N/A Covered Covered, PA Required Covered, PA Required Covered Covered, PA Required N/A Covered, PA Required Covered, PA Required Covered, PA Required Covered, PA Required N/A N/A Covered, PA Required Covered, PA Required Covered Covered Covered, PA Required Covered, PA Required Covered Covered, PA Required Covered Covered, PA Required Not Covered Covered, PA Required Covered, PA Required Covered, PA Required Covered Partial Coverage Covered Covered Covered N/A Covered, PA Required Covered, PA Required Covered, PA Required Covered N/A Covered Covered PA Required N/A Covered Partial Coverage, PA Required Covered Covered Partial Coverage, PA Required Covered, PA Required Covered PA Required Covered

Covered Covered N/A Covered, PA Required Covered, Some PA Required Covered Covered Covered N/A Covered Covered Covered, PA Required Covered N/A N/A Covered, PA Required Covered Covered Covered Covered Covered Covered, PA for prolonged use Covered Covered, PA Required Covered Covered Partial Coverage, PA Required Covered Covered Covered Covered Covered Partial Coverage, PA Required Covered Covered Covered Covered, PA Required Covered, PA Required Covered N/A Covered Covered N/A Covered Covered Covered Covered Covered, PA Required Covered, PA Required Covered, PA Required Covered

Not Covered Not Covered N/A Covered, PA Required Covered, Some PA Required Covered, PA Required Not Covered Covered N/A Covered Not Covered Covered, PA Required Not Covered N/A N/A Not Covered Covered Not Covered Covered Covered Covered Not Covered Covered, PA Required Covered Not Covered Not Covered Covered, PA Required Not Covered Covered Covered Partial Coverage Covered Covered Covered Covered, PA Required Covered Partial Coverage, PA Required Covered Not Covered N/A Partial Coverage Not Covered N/A Covered Not Covered Covered, PA Required Covered Not Covered Covered, PA Required Covered, PA Required Not Covered

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. PA = Prior Authorization Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Drug Utilization Review State

State Contact

Telephone

In-House or Contracted

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

Louise Jones Dave Campana, R.Ph. Suzette Bridges, P.D. Vic Walker, R.Ph., B.C.P.P. Allen Chapman Elizabeth Geary, R.Ph. Cynthia Denemark Christopher Keeyes, Pharm.D. Marie Donnelly-Stephens Jean B. Cox, R.Ph. Kathleen Kang-Kaulupali Gary Duerr, R.Ph. N/A Karen Baer Cheryl Clarke, R.Ph. Glenn McNees, R.Ph., M.S. Debra Bahr Melwyn Wendt Timothy Clifford, M.D. Judy Geisler Anna Morin Mary Sandusky MaryBeth Reinke, Pharm.D. James G. "Jack" Lee, R.Ph. Jayne Zemmer Mark Eichler, R.Ph. Allison Jorgensen, Pharm.D., R.Ph. Laurie Squartsoff, R.Ph. Lisè Farrand Edward Vaccaro, R.Ph. Chuck Reynolds Michael Zegarelli Sharman Leinwand Pat Kramer Jan Lawson John Crumly, M.H.A., R.Ph. Mariellen Rich N/A Paula Avarista Caroline Sojourner Michael Jockheck Curtis Burch Duane Parke Gloria Jacobs Marianne Rollins, R.Ph. Siri Childs Peggy A. King, R.Ph. Dr. Michael Mergener Debra Devereuax, R.Ph.

334-242-5039 907-273-3224 501-324-9141 916-657-0785 303-866-3176 860-424-5150 302-453-8453 301-572-1616 850-487-4441 404-657-7241 808-692-8115 208-364-1829 N/A 317-232-4391 515-270-0713 785-864-3164 502-564-6511 504-219-4154 207-287-2674 410-767-1728 508-721-7104 517-335-5280 651-215-1239 601-359-6296 573-751-6963 406-443-4020 402-420-1500 702-687-4869 603-271-4419 609-588-2721 505-827-3174 518-474-0691 919-733-3590 701-328-4893 614-466-7936 405-522-7300 503-391-1980 401-464-2183 803-898-2876 605-773-6439 512-338-6922 801-538-6452 802-241-2763 804-225-4268 360-725-1564 304-588-1753 608-258-3348 307-766-6120

Contracted In-House and Contracted Contracted In-House Contracted Contracted Contracted In-House Contracted In-House In-House Contracted In-House Contracted Contracted Contracted Contracted Contracted Contracted Contracted Contracted Contracted In-House Contracted Contracted Contracted Contracted Contracted Contracted In-House Contracted In-House In-House In-House Contracted Contracted Contracted In-House Contracted In-House and Contracted In-House In-House In-House Contracted Contracted In-House Contracted Contracted Contracted

PRODUR Implemented Jul-96 Jun-95 Mar-97 Aug-95 Dec-98 Sep-96 Feb-94 No Jul-95 Planned for 2000 N/A Jan-98 Jan-93 Mar-96 Jul-97 Nov-96 Sep-94 Apr-96 Dec-95 Jan-93 Oct-95 Jul-00 Feb-96 Oct-95 Feb-93 Sep-94 Apr-95 Planned for 2001 Aug-95 Oct-96 Oct-93 Mar-95 Oct-96 Jul-96 Feb-00 Mar-93 Mar-94 Jun-93 Dec-94 No Planned for 2000 Feb-95 Jun-95 Nov-93 Jul-94 Mar-96 Mar-95 Planned for 2001 Oct-95

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. PRODUR = Prospective Drug Utilization Review System Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Prescribing/Dispensing Limits State

Limits on Prescriptions

Limits on Number, Quantity, and Refills of Prescriptions

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

Yes Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes No No Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes No No Yes Yes No Yes

5 refills per Rx 30 day supply per Rx 30 day supply per Rx; 3 Rx per month (extension to 6); 5 refills per Rx within 6 months 6 Rx per month without PA, other limitations specific to certain medications 100 day supply for maintenance medication 34 day supply or 100 unit doses per Rx (whichever is greater) 30 day supply per Rx, 3 refills per Rx within 4 mths. Max/min quantities for certain meds Variable 6/8/10/12 Rxs per month (with exceptions); Max/min quantities for certain meds 30 day supply per Rx; 5 (adult)/6 (child) Rx per month; Per Rx limit: $1000/Rx 30 day supply or 100 unit doses per Rx 34 day supply per Rx (with exceptions); 3 cycles of birth control Medically appropriate monthly quantity; 11 refills per Rx 34 day supply per Rx, other limitations specific to certain medications Maximum 5 refills in 6 months; one dispensing fee per month for maintenance medication 30 day supply or 100 unit doses (whichever is greater); 5 refills per Rx within 6 months 34 day supply per Rx; 2 refills per Rx 5 refills within 6 months per Rx No refills for Schedule II drugs; Schedule III & V, 5 refills per 180 days 30 day supply for maintenance drugs; max 3 month supply 34 day supply or 100 unit doses (whichever is greater); 5 Rx per month; 5 refills maximum 34 day supply or 100 unit doses; up to 90 day per Rx maximum 34 day supply or 100 unit doses per Rx (whichever is greater) 3 month supply maximum, 5 refills per Rx within 6 months for controlled substances 34 day supply per Rx; 3 Rx per month 34 day supply or 100 unit doses per Rx (whichever is greater) 34 day supply or 100 unit doses per Rx 6 months supply maximum 5 refills per Rx; annual limit on number of Rx and OTC drugs avail. (potential override) 100 day supply per Rx; 6 Rx per month 34 day supply per Rx Consistent with State/Federal requirements 3 Rx per month (21+; under 21 unlimited) 34 day supply per Rx 34 day supply or 100 unit doses per Rx (whichever is greater); 5 refills within 6 months 30 day supply per Rx (non-maintenance); 5 refills per Rx 100 day supply w/ unlimited Rx (children); 4 Rx per month 3 Rx per month with exceptions; unlimited Rxs for nursing home recipients or those < 21 Monthly quantity limit, maximum varies per person 34 day supply per Rx; usually 2 refills per month; 4 refills for antibiotics or scheduled drugs 10 Rx per month; 5 refills per Rx 34 day supply per Rx 90 day supply for maintenance drugs and birth control, 34 day supply for all others

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. Source: As reported by state drug program administrators in the 2000 NPC Survey.

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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” costsharing 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;

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•

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.

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Pharmacy Payment and Patient Cost Sharing State

Dispensing Fee

Ingredient Reimbursement Basis

Copayment

$5.40 AWP- 10%; WAC+9.2% $0.50 - $3.00 Alabama $3.45 AWP-5% $2.00 Alaska Arizona* $5.51 AWP-10.5% $0.50 - $3.00 Arkansas $4.05 AWP-5% G: $1.00, B: $1.00 California $4.08 AWP-10% or WAC+18%, whichever is lowest G: $0.50, B: $2.00 Colorado $4.10 AWP-12% None Connecticut $3.65 AWP-12.9% None Delaware AWP-10% $1.00 District of Columbia $3.75 $4.23 AWP-13.25% None Florida $4.63 AWP-10% $0.50 Georgia $4.67 AWP-10.5% None Hawaii $4.94 ($5.54 for unit dose) AWP-11% None Idaho G: $3.75, B: $3.45 AWP-10%, AWP-12% for multi-source drugs None Illinois $4.00 AWP-10% $0.50 - $3.00 Indiana $4.13 - $6.42 AWP-10% $1.00 Iowa $4.50 AWP-10% $2.00 Kansas OP: $4.75, LTC: $5.75 AWP-10% None Kentucky $5.77 AWP-10.5% $0.50 - $3.00 Louisiana $3.35 (+ extra fees for compounding) AWP-10% $0.50 - $3.00 Maine $4.21 Lowest of :WAC + 10%, direct + 10%, AWP -10% $1.00 Maryland $3.00 WAC+10% $0.50 Massachusetts $3.72 AWP-13.5% (1 to 4 stores), AWP-15.1% (5+ stores) $1.00 Michigan $3.65 AWP-9% None Minnesota $4.91 AWP-10% $1.00 Mississippi Missouri $4.09 AWP-10.43% $0.50 - $2.00 $2.00 - $4.20 AWP-10% G: $1.00, B: $2.00 Montana $3.20 - $5.05 AWP-8.71% $1.00 Nebraska $4.76 AWP-10% None Nevada $2.50 AWP-12% G: $0.50, B: $1.00 New Hampshire $3.73 - $4.07 AWP-10% None New Jersey $4.00 AWP-12.5% None New Mexico B: $3.50 G: $4.50 AWP-10% G: $0.50, B: $2.00 New York $5.60 AWP-10% $1.00 North Carolina $4.60 AWP-10% None North Dakota $3.70 AWP-11% None Ohio $4.15 AWP-10.5% $1.00 - $2.00 Oklahoma $3.91-$4.28 (based on annual # of Rx) AWP-11% None Oregon $4.00 AWP-10% $1.00 - $2.00 Pennsylvania OP: $3.40, LTC: $2.85 WAC+5% None Rhode Island $4.05 AWP-10% $2.00 South Carolina $4.75 ($5.55 for unit dose) AWP-10.5% $2.00 South Dakota Tennessee* $5.27 + 2% of ingredient & dispensing fee AWP-15% or WAC+12%, whichever is lowest None Texas $3.90 - $4.40 (based on geographic area) AWP-12% $1.00 - $5.00 Utah $4.25 AWP-11.9% $1.00 - $2.00 Vermont $4.25 AWP-9% $1.00 Virginia $4.06 - $5.02 (based on annual # of Rx) AWP-11% None Washington $3.90 (+ extra fees for compounding) AWP-12% $0.50 - $2.00 West Virginia $4.88 AWP-10% $0.50 - $1.00 Wisconsin $4.70 AWP-4% $2.00 Wyoming WAC = Wholesalers Acquisition Cost; AWP = Average Wholesale Price; EAC = Estimated Acquisition Cost; G = Generic; B = Brand Name; OP = Outpatient; LTC = Long Term Care. *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Maximum Allowable Cost (MAC) Programs State

Federal Upper State-Specific Limits Upper Limits

MAC Override Provisions

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

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes No No

Brand medically necessary Brand medically necessary and reason for medical necessity Brand necessary Brand medically necessary Medically necessary and other products unavailable at MAC rate Prior authorization Brand medically necessary Brand medically necessary Brand medically necessary If drug is on Florida Negative Formulary Brand medically necessary Brand necessary, prior authorization Brand medically necessary, handwritten by M.D., prior authorization Prior authorization request by M.D. or R.Ph Brand medically necessary Brand medically necessary Brand medically necessary, prior authorization Brand necessary, brand medically necessary Brand necessary or brand medically necessary Dispense as written Brand medically necessary and reason for medical necessity Dispense as written, brand medically necessary Prior authorization Brand medically necessary Brand medically necessary Prior authorization Dispense as written, brand necessary Brand medically necessary and MC-6 form signed by M.D. Brand medically necessary Brand medically necessary Brand medically necessary Brand medically necessary Dispense as written and brand necessary, or brand medically necessary Brand medically necessary Dispense as written Prior authorization Brand medically necessary Brand necessary, medically necessary, or brand medically necessary Brand necessary or brand medically necessary, plus prior authorization Dispense as written, brand medically necessary Brand necessary or brand medically necessary Brand medically necessary Brand necessary or brand medically necessary Dispense as written, brand medically necessary, or medical necessary Dispense as written Brand necessary Brand medically necessary Brand medically necessary Brand medically necessary -

Yes No No Yes Yes Yes No Yes No Yes Yes No Yes Yes No No Yes No No No Yes No Yes Yes No Yes No Yes No No No No No No No Yes Yes No Yes No Yes No Yes No No Yes Yes No Yes No

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Mandatory Substitution State

Incentive Fee for Generic Substitution

Dispensing of Generic Multisource Required

Dispensing of Lowest Cost Multisource Required

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

No No No No No $0.50 No No No No No No No No No No No No No No No No No No No No No No No No No Yes No No No No No No No No No No No No No No No No No

No Yes Yes No Yes (if FUL or State MAC) No Yes No Yes Yes (brand PA required) Yes (if FUL) Yes No Yes Yes No Yes No Yes No (payment based on generic) Yes No Yes No No No No Yes Yes Yes Yes Yes (if M.D. allows substitution) Yes No No Yes Yes Yes Yes Yes (if M.D. authorizes) No Yes Yes Yes No No (except MAC drug, 3+ labelers) Yes No No

No No No Yes No No No Yes No Yes No No No No No No Yes No No No No No Yes No No No No Yes Yes No Yes No No No No No No No No Yes No No No No No No No No No

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Counseling Requirements and Payment for Cognitive Services State

Patient CounselingRequired1

Medicaid Payment for Cognitive Services2

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

All All All All All Medicaid Only Medicaid Only All Pending All All Medicaid Only All All All All All All All All Medicaid Only All All Medicaid Only All All All All All All All All All All All All All All All All Medicaid Only All All All All All All All All All All

No No No No No No No No No No No No No No No No No No Yes No No No No No No No No No No No No No No No No No No No No No No No No No No No No Yes 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.

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Prescription Price Updating State

Contact

Telephone

Updated

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

First DataBank Dave Campana First DataBank Electronic Data Systems Allen Chapman First DataBank Cynthia Denemark First DataBank First DataBank Etta Hawkins First DataBank Gary Duerr First DataBank First DataBank Sherry Swanson Karen Bramen Unisys Maggie Vick, Unisys Corp. Susan Curtis First DataBank Christopher Burke First DataBank First DataBank James G. Lee First DataBank First DataBank First DataBank First DataBank First DataBank First DataBank Chuck Reynolds Carl Cioppa, Pharm.D.. Benny Ridout First DataBank First DataBank Angela Thomasson Kathy Franklin, First DataBank First DataBank Paula Avarista First DataBank Mark Petersen Martha McNeill RaeDell Ashley Christine Dapkiewicz David Shepherd Marilyn Mueller Leslie Bratton First DataBank First DataBank

650-588-5454 907-273-3224 650-588-5454 916-636-1000 303-866-3176 650-588-5454 302-453-8453 650-588-5454 650-588-5454 404-657-7239 800-633-3453 208-334-5795 650-588-5454 317-469-5200 515-327-0950 785-296-6968 502-226-1140 504-237-3251 207-287-1818 650-588-5454 617-210-5592 650-588-5454 650-588-5454 601-359-6296 650-588-5454 650-588-5454 650-588-5454 650-588-5454 650-588-5454 650-588-5454 505-827-3174 518-486-3209 919-857-4034 800-633-3453 650-588-5454 405-522-7307 650-588-5454 800-633-3453 401-464-2183 650-588-5454 605-773-3498 512-338-6965 801-538-6495 802-879-4450 804-786-8057 360-725-1569 800-358-2381 800-633-3453 800-633-3453

Biweekly Weekly Weekly Monthly Weekly Weekly Bimonthly Monthly Weekly Monthly Monthly Bimonthly Weekly Monthly Weekly Weekly Bimonthly Weekly Bimonthly Weekly Weekly Weekly Bimonthly Weekly Weekly Weekly Weekly Monthly Biweekly Weekly Weekly Monthly Weekly Biweekly Monthly Weekly Bimonthly Monthly Biweekly Monthly Bimonthly Continuously Bimonthly Biweekly Monthly Weekly Weekly Bimonthly Weekly

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Section 5: State Pharmacy Assistance Programs

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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 California

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

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Law Enacted 1999 1985 1981 1999 2000 1985 2000 †‡ 2000† 1975 2000† 1979 2000 1996 1999 2000† 1988 1988 1997 1999 ‡ 1975 1987 1999 1999 1984 1996 1985 2000 1989 1996 2000 ‡ ‡ 1988

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Pharmaceutical Benefits 2000

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.

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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.

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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.

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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.

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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.

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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.

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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.

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Pharmaceutical Benefits 2000

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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 Medicarecovered 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.

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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.

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Pharmaceutical Benefits 2000

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): Eligible Income Level (Single): Other Eligibility Notes:

65+ Eligibility Age (Disabled): None Eligible Income Level (Married): Anyone who has a Medicare card is eligible

18+ None

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 00): Cost per Participant (FY 00): # of Rx’s Per Participant (FY 00): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

No funding, program offers state-negotiated discounts N/A N/A N/A Medicaid AWP – 5% None None None $0.15 per prescription All enrollees are eligible for discounts on prescriptions

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions: Notes:

Open Formulary All prescription drugs No formulary restrictions and no prior authorization 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 714 P Street, Room 1253 Sacramento, CA 95814

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Phone: 916/657-4213

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Pharmaceutical Benefits 2000

Connecticut ConnPACE Program Type: Direct Assistance Year Operational: 1986 Number of Recipients (FY 00): 31,666 (Elderly: 27,434; Disabled: 4,232) ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ $14,700 None

Eligibility Age (Disabled): Eligible Income Level (Married):

18+ $17,700

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 00): Cost per Participant (FY 00): # of Rx’s Per Participant (FY 00): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

General Revenue Fund $39.6 million $1,357.62 22.44 Medicaid AWP – 12% $25.00/annual None $12.00/Rx $4.10

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Prescription Drug Utilization: Notes:

Open Formulary All prescription drugs and insulin, 120 unit or 30 day supply limit, whichever is greater Restrictions on antihistamines, cough preparations, cosmetic, diet and fertility/contraceptive drugs. Also restricted are multivitamins, smoking cessation gum and DESI drugs. $39,417,855 program spending, 651,585 scripts ConnPACE pays the difference between the copayment paid by the enrollee and the cost of the drug.

PROGRAM CONTACT Elizabeth A. Geary, R.Ph. Department of Social Services 25 Siqourney Street Hartford, CT 06106

National Pharmaceutical Council

Phone: 860/424-5150 Fax: 860/951-9544 E-mail: [email protected]

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Pharmaceutical Benefits 2000

Delaware Nemours Pharmacy Assistance Program Type: Private Discount Program Year Operational: 1981 Number of Recipients (FY 00): 26,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ Eligibility Age (Disabled): $12,500 Eligible Income Level (Married): U.S. Citizen, Resident of Delaware

65+ $17,125

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

Nemours Foundation (Program receives no state or federal funds) N/A $622.63 19.69 None None None None 20% of drug cost None Maximum yearly benefit: $2,000 based on average retail cost

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions: Prescription Drug Utilization: Notes:

Open Formulary Prescription drugs, insulin syringes, and prescribed OTCs Injectables, except for insulin Program spending, volume of scripts unknown 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. Nemours Clinic Pharmacy Assistance 1801 Rockland Road Wilmington, DE 19803

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Phone: 302/651-4405 Fax: 302/651-4445 E-mail: [email protected]

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Pharmaceutical Benefits 2000

Delaware Prescription Assistance Program (DPAP) Program Type: Direct Assistance Year Operational: 2000 Number of Recipients (FY 00): 2,203 (Elderly: 986; Disabled: 1,217) ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ 21+ Eligibility Age (Disabled): $16,480 $22,120 Eligible Income Level (Married): 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 AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

Tobacco settlement (not subject to budget appropriation) $7.5 million N/A N/A Medicaid AWP – 12.9% None None Greater of $5 or 25% AAC $2.65

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions: Prescription Drug Utilization: Notes:

Open Formulary Similar to Medicaid but limited by state rebate participation Annual limit of $2,500 per person N/A None

PROGRAM CONTACT Cynthia Denemark Division of Social Services 248 Chapman Road Suite 200 Newark, DE 19702

National Pharmaceutical Council

Phone: 302/453-8453 ext. 211 Fax: 302/454-7603 E-mail: [email protected]

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Pharmaceutical Benefits 2000

Illinois Pharmaceutical Assistance Program (PAP) Program Type: Direct Assistance Year Operational: 1985 Number of Recipients (FY 00): 53,555 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ 16+ Eligibility Age (Disabled): $21,218 $28,480 Eligible Income Level (Married): Widow(er) who turned 63 or 64 before deceased claimant’s death is eligible

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount:

Dispensing Fee:

General Revenue Fund (subject to budget appropriations) $35 million $207.84 annually 24.58 Medicaid AWP – 10% or MAC if generic is available $5 if below FPL, $25 if above FPL None 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. None

DRUGS COVERAGE Formulary: Drugs Covered:

Open Formulary 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 Illinois Department of Revenue P.O. Box 19021 Springfield, IL 62794-9021

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Phone: 217/785-5905 Fax: 217/524-9213 E-mail: [email protected]

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Pharmaceutical Benefits 2000

Indiana Prescription Drug Fund “HoosierRx” Program Type: Refunds Year Operational: 2000 Estimated Eligibles (FY 00): 66,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ $11,280 None

Eligibility Age (Disabled): Eligible Income Level (Married):

N/A $15,192

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

National Tobacco Fund $20 million N/A N/A N/A N/A None None None None Refunds based on monthly income.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions: Notes:

Open Formulary FDA-approved prescription drugs and insulin Maximum benefit of $1,000 per year 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 HoosierRx P.O. Box 6224 Indianapolis, IN 46206-6224

National Pharmaceutical Council

Phone: 866/267-4679

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Pharmaceutical Benefits 2000

Maine Low Cost Drugs for the Elderly and Disabled Program Program Type: Direct Assistance Year Operational: 1975 Number of Recipients (FY 99): 24,900 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

62+ 55+ Eligibility Age (Disabled): $15,348 $20,461 Eligible Income Level (Married): If 40% of income goes to drugs the eligible incomes increase to $19,185 for Single and $25,575 for Married.

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

General Revenue Fund $7.6 million $154.55 N/A Medicaid AWP – 10% None None Greater of $2 or 20% of drug cost $3.35

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions: Notes:

Open Formulary All drugs from participating manufacturers used for the chronic treatment of diabetes, asthma, COPD, cardiac conditions, arthritis N/A

PROGRAM CONTACT Christine Gee Department of Human Services 11 State House Station August, ME 04333-0011

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Phone: 207/287-4018 Fax: 207/287-8601

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Pharmaceutical Benefits 2000

Maryland Pharmacy Assistance Program Program Type: Direct Assistance Year Operational: 1979 Number of Recipients (FY 00): 34,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

All ages Eligibility Age (Disabled): $9,650 Eligible Income Level (Married): No age restriction on eligibility

All ages $10,450

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

General Revenue Fund (subject to budget appropriations) $37.3 million $1,124 24.09 Medicaid WAC + 10% None None $5.00 $3.73 - $4.07

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions: Notes:

Open Formulary Specified categories of maintenance drugs used to treat chronic conditions, anti-infective drugs, and insulin syringes and needles 75% utilization required before prescription refill 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 Office of Operations & EligibilityDHMH 201 West Preston Street Baltimore, MD 21201

National Pharmaceutical Council

Phone: 410/767-5397 Fax: 410/333-7290 E-mail: [email protected]

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Pharmaceutical Benefits 2000

Maryland Short-Term Prescription Drug Subsidy Plan Program Type: Direct Assistance Enacted: 2000 Number of Recipients (FY 00): 1,004 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+* N/A Eligibility Age (Disabled): N/A N/A Eligible Income Level (Married): *And eligible for Medicare+Choice. Limited to residents of 17 underserved counties

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

N/A N/A N/A N/A N/A N/A $460/annually $50 $10 for generics, $20 for branded products N/A

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions: Notes:

N/A N/A Maximum benefit of $1,000 per year

PROGRAM CONTACT Secretary of Health and Mental Hygiene 201 West Preston Street Baltimore, MD 21201

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National Pharmaceutical Council

Pharmaceutical Benefits 2000

Massachusetts The Pharmacy Program (formerly Senior Pharmacy Assistance Program) Program Type: Direct Assistance Year Operational: 1997 Number of Recipients (FY 99): 24,934 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ N/A Eligibility Age (Disabled): $15,708 $21,576 Eligible Income Level (Married): 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 AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

Cigarette tax revenues and general revenue fund $30 million $735 N/A Medicaid WAC+10% or lowest and customary fee $15.00/annually None $3.00 (generic), $10.00 (brand) $3.00

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Open Formulary All therapeutic classes except those excluded from MassHealth. Some prior authorizations are required Annual limit of $1,250 per person Medicaid (MassHealth) recipients are ineligible for the program

Notes: PROGRAM CONTACT Sheila Martin Senior Pharmacy Program One Ashburton Place, Room 517 Boston, MA 02108

National Pharmaceutical Council

Phone: 617/727-7750 Fax: 617/727-9368

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Pharmaceutical Benefits 2000

Massachusetts Pharmacy Program Plus Program Type: Direct Assistance Year Operational: 2000 Number of Recipients (FY 00): 7,170 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ 18+ Eligibility Age (Disabled): $41,220 $55,320 Eligible Income Level (Married): 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 AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

Cigarette tax revenues and general revenue fund N/A N/A N/A Medicaid WAC+10% or lowest and customary fee None None $3 for generics, $10 for branded products N/A

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions: Notes:

Open Formulary All therapeutic classes except those excluded from MassHealth. Some prior authorizations are required N/A 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 Senior Pharmacy Program One Ashburton Place, Room 517 Boston, MA 02108

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Phone: 617/727-7750 Fax: 617/727-9368

National Pharmaceutical Council

Pharmaceutical Benefits 2000

Michigan Emergency Pharmaceutical Program for Seniors (MEPPS) Program Type: Direct Assistance Year Operational: 1990 Number of Recipients (FY 99): 12,968 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ Not eligible Eligibility Age (Disabled): $12,360 $16,596 Eligible Income Level (Married): Rx drug costs must be 10% (Single)/8% (Married) or more of the monthly income

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

Construction tax $6 million $33.00 6 Medicaid AWP – 13.5% None None Voluntary copay: $0.25/Rx $3.72

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Notes:

Open Formulary All prescriptions • Coverage limited to 3 months per year • Generics must be dispensed unless specified by the physician • No experimental or over-the-counter drugs 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 Office of Services to the Aging 611 West Ottawa, P.O. Box 30676 Lansing, Michigan 48909-8176

National Pharmaceutical Council

Phone: 517/373-7881 Fax: 517/373-4092

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Pharmaceutical Benefits 2000

Michigan State Medical Plan Program Type: Tax Credit Year Operational: 1990 Number of Recipients (FY 00): 20,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

None 150% of FPL

Eligibility Age (Disabled): Eligible Income Level (Married):

Not eligible 150% of FPL

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

Construction tax N/A None N/A N/A N/A N/A N/A N/A N/A

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions: Notes:

Open Formulary All prescriptions 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 Office of Services to the Aging 611 West Ottawa, P.O. Box 30676 Lansing, Michigan 48909-8176

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Phone: 517/373-7881 Fax: 517/373-4092

National Pharmaceutical Council

Pharmaceutical Benefits 2000

Minnesota Senior Citizen Drug Program Program Type: Direct Assistance Year Operational: 1999 Number of Recipients (00): 5,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ Not eligible Eligibility Age (Disabled): $10,260 $13,740 Eligible Income Level (Married): 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 AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

General Revenue Fund plus rebates (subject to budget appropriations) $19 million for FY 00 and FY 01 $725.30 (for the 2,167 elderly recipients in FY 99) 24.07 (for the 2,167 elderly recipients in FY 99) Same as Medicaid minus any CPI add-on AWP – 9% None $35/month None None

DRUGS COVERAGE Formulary: Drugs Covered:

Drug Coverage Restrictions: Notes:

Closed Formulary 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 Most other over-the-counter drugs are not covered

PROGRAM CONTACT Steven Hamilton Department of Human Services 444 Lafayette Road St. Paul, MN 55155-3853

National Pharmaceutical Council

Phone: 651/296-6627 Fax: 651/282-6744 E-mail: [email protected]

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Pharmaceutical Benefits 2000

Missouri State Income Tax Credit for Legend Drugs Program Type: Tax Credit Year Operational: 1999 Number of Recipients (FY 00): N/A ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ <$15,000

Eligibility Age (Disabled): Eligible Income Level (Married):

N/A N/A

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

N/A N/A N/A N/A N/A N/A None None None N/A 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: Drugs Covered: Drug Coverage Restrictions: Notes:

N/A Legend drugs only N/A

PROGRAM CONTACT Department of Revenue 301 West High Street Jefferson City, MO 65101

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Phone: 573/751-4081

National Pharmaceutical Council

Pharmaceutical Benefits 2000

New Hampshire Senior Prescription Drug Discount Program Program Type: State-Negotiated Discounts Year Operational: 2000 Estimated Number of Eligibles: 75,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ Eligibility Age (Disabled): None Eligible Income Level (Married): Must be a New Hampshire resident

Not eligible None

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Deductible Amount: Copayment Amount: Dispensing Fee:

Rebates and incentives from pharmaceutical manufacturers N/A N/A N/A N/A N/A None N/A N/A

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions: Notes:

No Formulary Most frequently prescribed medication for this population for multiple health problems N/A 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 Division Of Elderly And Adult Services 129 Pleasant Street Concord, NH 03301

National Pharmaceutical Council

Phone: 800/351-1888

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Pharmaceutical Benefits 2000

New Jersey Pharmaceutical Assistance to the Aged and Disabled (PAAD) Program Type: Direct Assistance Year Operational: 1975 Number of Recipients (FY 00): 187,358 (Elderly: 163,958; Disabled: 23,400) ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligible Groups:

65+ 18+ Eligibility Age (Disabled): $18,587 $22,791 Eligible Income Level (Married): Groups receiving Social Security Disability Benefits are eligible

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

State General Fund and Casino Revenue Fund $273 million Elderly: $1,313 (gross), $1,116 (net); Disabled: $2,654 (gross), $1,974 (net) 30 Elderly; 43 Disabled Medicaid without CPI component AWP – 10%, Federal MAC, or Usual & Customary None None $5.00 $3.73 - $4.07

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions: Prescription Drug Utilization:

No Formulary All legend drugs, syringes, needles, and diabetic testing materials DESI drugs, non-rebatable drugs, and over-the-counter drugs Branded: $273,946,609 (3,817,842 scripts) Generic: $37,180,099 (2,455,755 scripts)

PROGRAM CONTACT Kathleen Mason PAAD Program P.O. Box 715 Trenton, NJ 08625

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Phone: 609/588-7032 Fax: 609/588-7037 E-mail: [email protected]

National Pharmaceutical Council

Pharmaceutical Benefits 2000

New York Elderly Pharmaceutical Insurance Coverage (EPIC) Program Program Type: Direct Assistance Year Operational: 1987 Number of Recipients (FY 99): 118,431 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligible Groups:

65+ $35,000 None

Eligibility Age (Disabled): Eligible Income Level (Married):

Not eligible $50,000

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

State General Fund and tobacco tax and settlement funds $252.2 million $890 (net state cost) 32 Same as Medicaid, with modified additional (CPI) rebates AWP (less 5% for high volume pharmacies) Lower income seniors only (<$20,000 if single, <$26,000 if married ) $8-$300 depending on total income and marital status Upper income seniors only (over $20,000 single; over $26,000 married); $530-$1,715 depending on total income and marital status $3 to $20 based on cost of prescription $2.75 ($3.00 for full-service pharmacies) Based on level of income, seniors may enroll in the Fee Plan or the Deductible Plan.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions: Prescription Drug Utilization:

No Formulary All legend drugs, insulin, and insulin syringes and needles DESI drugs and non-participating manufacturers. Viagra limited to six tables per month 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 NYS Department of Health, EPIC Program 260 Washington Avenue Ext. One Corporate Plaza, Suite 101 Albany, NY 12203

National Pharmaceutical Council

Phone: 518/452-6828 Fax: 518/452-6882 E-mail: [email protected]

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Pharmaceutical Benefits 2000

North Carolina Prescription Drug Assistance Plan Program Type: Direct Assistance Year Operational: 2000 Number of Recipients (FY 00): 2,500 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ N/A Eligibility Age (Disabled): 150% FPL 150% FPL Eligible Income Level (Married): Individuals must have cardiovascular disease and/or diabetes

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

N/A $500,000 N/A N/A Medicaid AWP – 10% None N/A $6.00 N/A

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions: Notes:

N/A Only certain drugs used to treat cardiovascular disease and/or diabetes Program will not pay for other drugs Prescriptions may be issued for up to a 100-day supply

PROGRAM CONTACT Charles Reed Department of Health and Human Services 2001 Mail Service Center Raleigh, NC 27699

5-24

Phone: 919-715-3338

National Pharmaceutical Council

Pharmaceutical Benefits 2000

Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE) Type of Program: Direct Assistance Year Operational: 1984 Number of Recipients (FY 00): 208,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligible Groups:

65+ $14,000 None

Eligibility Age (Disabled): Eligible Income Level (Married):

Not eligible $17,200

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

State Lottery $290 million (subject to annual legislative appropriations) $1,350 40 Medicaid AWP - 10% None None $6.00 $3.50

DRUGS COVERAGE Formulary: Drugs Covered:

Drug Coverage Restrictions:

Prescription Drug Utilization

Open Formulary All federal legend drugs and insulin, insulin syringes and needles manufactured by companies who participate in the PACE rebate program 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. $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 PA Department of Aging 555 Walnut Street, 5th Floor Harrisburg, PA 17101-1919

National Pharmaceutical Council

Phone: 717/787-7313 Fax: 717/772-2730 E-mail: [email protected]

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Pharmaceutical Benefits 2000

Pennsylvania PACE Needs Enhancement Tier (PACENET) Program Type: Direct Assistance Year Operational: 1996 Number of Recipients (FY 00): 22,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligible Groups:

65+ $16,000 None

Eligibility Age (Disabled): Eligible Income Level (Married):

Not eligible $19,200

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

State Lottery $290 million (subject to annual legislative appropriations) $330 10 Mandatory 17% of AMP on all units reimbursed AWP – 10% None $500 per year $15.00 brand name, $8.00 generic $3.50

DRUGS COVERAGE Formulary: Drugs Covered:

Drug Coverage Restrictions:

Open Formulary All federal legend drugs and insulin, insulin syringes and needles manufactured by companies who participate in the PACE rebate program 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 PA Department of Aging 555 Walnut Street, 5th Floor Harrisburg, PA 17101-1919

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Phone: 717/787-7313 Fax: 717/772-2730 E-mail: [email protected]

National Pharmaceutical Council

Pharmaceutical Benefits 2000

Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE) Program Type: Direct Assistance Year Operational: 1985 Number of Recipients (FY 99): 31,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligible Groups:

65+ <$35,000 None

Eligibility Age (Disabled): Eligible Income Level (Married):

N/A <$40,000

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount:

Dispensing Fee:

State General Revenue Fund $8.5 million for FY 01 (subject to legislature and governor appropriation yearly) $123.99 19.5 Medicaid AWP – 13% None None 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% $2.75 per Rx

DRUGS COVERAGE Formulary: Drugs Covered:

Drug Coverage Restrictions: Notes:

Open Formulary 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. Limited by therapeutic class

PROGRAM CONTACT Denis Costa Rhode Island Dept. of Elderly Affairs 160 Pine St. Providence, RI 02903

National Pharmaceutical Council

Phone: 401/222-2858 x105 Fax: 401/222-3389 E-mail: [email protected]

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Pharmaceutical Benefits 2000

Vermont VSCRIPT Program Type: Direct Assistance Year Operational: 1989 Number of Recipients (FY 00): 2,125 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligible Groups:

65+ $18,540 None

Eligibility Age (Disabled): Eligible Income Level (Married):

Any age $24,885

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

Cigarette tax revenue and federal funding $1.1 million $232.00 4 Medicaid AWP – 11.9% None None $1.00 to $2.00 based on prescription cost $4.25

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions: Notes:

No Formulary Maintenance drugs only. No experimental or over-the-counter drugs. 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 Office of Vermont Health Access 103 South Main Street Waterbury, VT 05671-1201

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Phone: 802/241-3985 Fax: 802/241-2897 E-mail: [email protected]

National Pharmaceutical Council

Pharmaceutical Benefits 2000

Vermont Health Access Plan (VHAP) Program Type: Direct Assistance Year Operational: 1996 Number of Recipients (FY 00): 7,303 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligible Groups:

65+ $12,360 None

Eligibility Age (Disabled): Eligible Income Level (Married):

Any age $16,590

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

Cigarette tax revenue and federal funding $9.94 million $901.00 11 Medicaid AWP – 11.9% None None $1.00 to $2.00 based on prescription cost $4.25

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions: Notes:

No Formulary Approved prescription medications No experimental or over-the-counter drugs None

PROGRAM CONTACT Paul Wallace-Brodeur Office of Vermont Health Access 103 South Main Street Waterbury, VT 05671-1201

National Pharmaceutical Council

Phone: 802/241-3985 Fax: 802/241-2897 E-mail: [email protected]

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Pharmaceutical Benefits 2000

West Virginia Senior Prescription Assistance Network II (SPAN II) Program Type: State-Negotiated Discount Year Operational: 2000 Number of Recipients (FY 00): 2,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ <$25,050

Eligibility Age (Disabled): Eligible Income Level (Married):

N/A <$33,750

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

N/A N/A N/A N/A N/A N/A None None N/A N/A Enrollees will receive discounts on prescription drugs

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

No Formulary All FDA approved Federal legend pharmaceuticals Cannot be used in conjunction with other discount programs or prescription drug coverage plans

Notes: PROGRAM CONTACT WV Bureau of Senior Services 1900 Kanawha Boulevard, East Holly Grove, Building #10 Charleston, WV 25305-0160

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Phone: 877/987-4463

National Pharmaceutical Council

Pharmaceutical Benefits 2000

Wyoming Minimum Medical Program Program Type: Direct Assistance Year Operational: 1988 Number of Recipients (FY 00): 550 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligible Groups:

Any age $8,350 None

Eligibility Age (Disabled): Eligible Income Level (Married):

Any age 100% of FPL

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant (FY 99): # of Rx’s Per Participant (FY 99): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

State General Fund Approximately $600,000 $1,174 N/A N/A AWP – 4% None None $25.00/Rx (3 Rx/month cap) $4.70

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions: Notes:

Open Formulary Approved prescription medications No smoking cessation agents, hair growth products, anorexiant products, or fertility promotion agents. 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. Community and Family Health Division Hathaway Bldg, Rm 157 2300 Capitol Ave. Cheyenne, WY 82002

National Pharmaceutical Council

Phone: 307/777-6032 Fax: 307/777-6964 E-mail: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2000

Section 6: State Pharmacy Program Profiles

National Pharmaceutical Council

6-1

Pharmaceutical Benefits 2000

6-2

National Pharmaceutical Council

Pharmaceutical Benefits 2000

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. B. C. D.

Benefits Provided and Groups Eligible Expenditures for Drugs Administration 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

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6-3

Pharmaceutical Benefits 2000

ALABAMA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

OAA

AB

APTD MLIF

Prescribed Drugs









Inpatient Hospital Care









Outpatient Hospital Care









Laboratory & X-ray Service









Skilled Nursing Home Services









Physician Services









Dental Services

OAA

AB

APTD AFDC Children <21

Other SFO

*

*Dental Services EPSDT - under 21 years old. 1 See Appendix E, page E-29, for a list of acronyms.

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $236,674,147 395,290

1999* Expended Recipients

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 Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients MEDICALLY NEEDY TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients 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

Pharmaceutical Benefits 2000

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 syringe combinations for insulin; blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Prior authorization required for: cosmetics, Retin A, Accutane, Dipyridamole. Products not covered: fertility drugs and experimental drugs. Over-the-Counter Product Coverage: Products covered if prescribed by a physician: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products, topical products; antidiabetic products; prenatal vitamins; hemorrhoidal products. Products not covered: smoking deterrent products and feminine products. Therapeutic Category Coverage: Therapeutic categories covered: antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antilipemic agents; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); thyroid agents. Prior authorization required for: anabolic steroids; analgesics, antipyretics, NSAIDs; antihistamine drugs; anti-psychotics; ENT antiinflammatory agents; growth hormones; nutritional supplements. Therapeutic categories not covered: anorectics; prescribed smoking deterrents. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in physician offices, home health care, and extended care facilities. Vaccines: Vaccines reimbursable as part of the EPSDT service and the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization Formulary: Open formulary.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $5.40. Ingredient Reimbursement Basis: AWP-10%, WAC + 9.2%. Prescription Charge Formula: Medicaid pays for prescribed legend and non-legend drugs authorized under the program based upon and shall not exceed the lowest of: 1. 2. 3.

The Maximum Allowable Cost (MAC) of the drug plus a dispensing fee, The Estimated Acquisition Cost (EAC) of the drug plus a dispensing fee, or The provider’s usual and customary charge to the public for the drug.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. Override requires “Brand Medically Necessary.” Incentive Fee: None. Patient Cost Sharing: Variable copayment. Drug Ingredient Cost $0.00 to $10.00 $10.01 to $25.00 $25.01 to $50.00 $50.01 or more

Copayment $0.50 $1.00 $2.00 $3.00

Exemptions: No copayment amount is to be collected by the pharmacy or paid by the recipient for recipients under age 18, pregnant or living in nursing facilities. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Does not use MCOs to deliver services to Medicaid recipients.

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

Pharmaceutical Benefits 2000

F. STATE CONTACTS State Drug Program Administrator Louise F. Jones Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery, AL 36103-5624 T: 334/242-5039 F: 334/353-7014 E-mail: [email protected] Agency Internet Address: www.medicaid.state.al.us Prior Authorization Contact Larry Tatum, 334/242-5489 DUR Contact Louise Jones, 334/353-7014 Medicaid DUR Board Keith Campagna, Pharm.D. Auburn University Montgomery Family Medicine Residence Program 4371 Narrow Lane Rd. Suite 100 Montgomery, AL 36116 334/613-3687 Betty McCamy, R.Ph. Wal-Mart Pharmacy 102 Lanceleaf Court Dothan, AL 36303 334/792-5131 Terry Wingo Madison Drugs 7131 University Drive Huntsville, AL 35806 256/837-1747

Kelly S. Derbin, M.D. University of South Alabama Department of Family Practice 1504 Springhill Avenue Mobile, AL 36604 335/434-3489 Keith Fuller, D.O. 2125 Executive Park Drive Opelika, AL 36801 334/741-0075 William P. McCann, M.D. University of Alabama Birmingham School of Medicine 3875 South Cove Drive Birmingham, AL 35213 205/934-7047 John Searcy, M.D. Alabama Medicaid Agency Medical Director 501 Dexter Avenue Montgomery, AL 36130 334/242-5619 Sara Redden, R.Ph. 3654 Wiley Road Montgomery, AL 36106 334/286-3201 John E. Brandon, M.D. Intersection Highway 82 and 86 P.O. Box 390 Gordo, AL 35466 205/364-7135 Larry Tatum, R.Ph. Alabama Medicaid Agency Senior Pharmacist 334/242-5489

Tim Covington, Pharm.D., Chair Samford University 2024 Glen Eagle Road Birmingham, AL 35242 205/870-2988

Mike Mikell, R.Ph. Mike’s Pharmacy P.O. Box 1006 Millbrook, AL 36054 334/285-5154

Richard L. Bendinger, M.D. 217 Dothan Road Abbeville, AL 36310 334/585-6421

Richard Freeman, M.D. 411 B Opelika Road Auburn, AL 36830 334/821-4766

3-Alabama

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Pharmaceutical Benefits 2000

First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 650/588-5454

Larry A. Tatum, R.Ph., Associate Director Pharmaceutical Programs Alabama Medicaid Agency 501 Dexter Avenue; P.O. Box 5624 Montgomery, AL 36103 334/242-5489

Medicaid Drug Rebate Contacts

Title XIX Medical Care Advisory Committee

Technical: Jim Morrison, 334/242-2323 Policy: Larry Tatum, 334/242-5489 Audits: Jim Morrison 334/242-2323

Medical Association of State of Alabama Marsha D. Raulerson, M.D. 1205 Belleville Avenue Brewton, AL 36426-1304 334/867-3609

Prescription Price Updating

Claims Submission Contact Ricky Pope Account Manager, EDS 301 Technacenter Dr. Montgomery, AL 36117 334/215-0111 Medicaid Managed Care Contact Vicki Huff Director, Managed Care Alabama Medicaid Agency 501 Dexter Avenue Montgomery, AL 36103-5624 334/242-5011 Disease Management Program/Initiative Contact Mary G. McIntyre, M.D. Associate Medical Director Alabama Medicaid Agency 501 Dexter Avenue Montgomery, AL 36103-5624 334/242-5574 Physician-Administered Drug Program Contact Larry Tatum 334/242-5472 Alabama Medicaid Agency Officials W. Dale Walley Acting Commissioner Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery, AL 36103-5624 334/242-5600 John Searcy, M.D., Director Professional Services Alabama Medicaid Agency 501 Dexter Avenue; P.O. Box 5624 Montgomery, AL 36103 334/242-5619

National Pharmaceutical Council

Roy T. Hager, M.D. Institute for Total Eye Care 4255 Carmichael Ct. North Montgomery, AL 36106 334/277-9111 Alabama Nursing Home Association Frank R. Brown, Jr. P.O. Box 190 Cullman, AL 35056 334/784-5573 Montgomery Area Council on Aging Rose Posey 115 East Jefferson Street Montgomery, AL 36104 334/263-0532 Alabama State Medical Association Jefferson Underwood, III, M.D. 1031 Oak Street Montgomery, AL 36108 Recipient Representative Charles G. Spradling, Jr. P.O. Box 11765 Birmingham, AL 35202 334/328-3540 American Academy of Family Physicians Dr. John E. Brandon P.O. Box 390 Gordo, AL 35466 334/364-7135 S. T. Christian, Ph.D., Professor University of Alabama at Birmingham School of Medicine/Behavioral Neurobiology Birmingham, AL 35294

Alabama-4

Pharmaceutical Benefits 2000 Alabama Pharmaceutical Association Danny Cottrell 1335 McMillen, Box 259 Brewton, AL 36426 334/867-5454 Alabama State Nurses Association Elizabeth Morris 360 N. Hull Street Montgomery, AL 36130 334/262-8321 Alabama Institute for the Deaf and Blind Terry Graham, Ed.D. P. O. Drawer 698 Talladega, AL 35160 334/761-3274 Consumer Representative Ruth Smith 4001 Meadowood Drive Birmingham, AL 35242 334/290-5187 Mike Woodall Director, Recreation Department 450 Gilmer Tallassee, AL 36078 334/283-4726 Dr. A. Z. Holloway 2611 Woodley Park Drive Montgomery, AL 36116 334/288-0009 Alabama Chap. American Academy of Pediatrics Dr. John Searcy 1105 West Main Dothan, AL 36301 Medicaid Recipient Representative Gladys Stautner Rt. 4, Box 315 Greenville, AL 36037 334/382-6255 Sabrina Cooper 218 Lands End Avenue Selma, AL 36701 334/874-9001 West Alabama Health Services, Inc. Sandra Hullett, M.D., MPH Health Services Director P.O. Box 711 Eutaw, AL 35462 334/372-3281

5-Alabama

Pharmacy and Therapeutics Committee A.Z. Holloway, M.D., Chair 2611 Woodley Park Drive Montgomery, AL 36106 334/288-0009 Richard L. Bendinger, M.D. 217 Dothan Road Abbeville, AL 36310 334/585-6421 Richard Freeman, M.D. 411 B Opelika Road Auburn, AL 36830 334/821-4766 Michael Hogue, Pharm. D. 800 Lakeshore Drive Birmingham, AL 35229 205/726-2669 Jimmy Crane 413 19th Street West Ensley, AL 35218 205/787-4671 Edward Goldblatt 3517 S. Lake Parkway Birmingham, AL 35244 205/802-6650 Phil Jenkins, R.Ph. 12740 Country Lane Northport, AL 35476 205/391-3636 Roosevelt McCorvey, M.D. 3088 Rosa L. Parks Avenue Montgomery, AL 36105 334/262-0259 Ray Thweatt, M.D. 801 Princeton Avenue, SW Suite 506 Birmingham, AL 35211 205/783-7060 Executive Officers of State Medical and Pharmaceutical Societies Medical Association of the State of Alabama (MASA) Cary Kuhlmann 19 S. Jackson Street P.O. Box 1900 Montgomery, AL 36102-1900 334/263-6441

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Alabama State Medical Association Joel Powell, M.D. 1408 5th Avenue, SE Suite 1 Decatur, AL 35601 205/350-3405

Nursing Home Association Margie Sellers Executive Director 4156 Carmichael Road Montgomery, AL 36106 334/271-6214

Alabama Pharmacy Association (APA) William s. Eley, II 1211 Carmichael Way Montgomery, AL 36106 334/271-4222

Alabama Hospital Association Michael Horsley President, CEO 500 North East Blvd. Montgomery, AL 36117 334/272-8781

Alabama Optometric Association Amanda Jones Executive Director 400 South Union Street, Suite 435 Montgomery, AL 36104 State Board of Pharmacy Charles Thomas 1 Perimeter Park South, Suite 425 Birmingham, AL 35243 205/967-0130 Alabama Independent Drugstore Association (AIDA) Sharon Taylor 400 Interstate Park Drive Suite 401 Montgomery, AL 36109 334/213-2432 Alabama Primary Health Care Association Al Fox 6008 East Shirley Lane Suite A Montgomery, AL 36117 334/271-7068 Alabama Quality Assurance Foundation (AQAF) Dr. James DeLong Medicaid Pharmacy Admin. Service 1 Perimeter Park South, Suite 300 Birmingham, AL 35243 1-888-Medicaid

Alabama Pharmacy Coop, Inc. (APCI) Danny Johnson P.O. Box 170747 Birmingham, AL 35217-0747 205/870-3301 Electronic Data Systems (EDS) John Craft P.O. Box 7600 Montgomery, AL 36107 334/834-8330 Alabama Retail Association Charles McDonald President #2 North Jackson P.O. Box 1909 Montgomery, AL 36102 334/263-5757 Provider Notice Correspondence: Eckerd Corporation 813/395-6145 CVS/Revco 205/424-3421 x447

Department of Health Jim McVay, Director 343 Monroe Street Montgomery, AL 36130-3017 334/206-5226 Alabama State Nursing Association Ruth Harrell 360 North Hull Street Montgomery, AL 36104-3658

National Pharmaceutical Council

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Pharmaceutical Benefits 2000

ALASKA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

APTD AFDC OAA

AB

Other

OAA

AB

APTD AFDC Children <21

Prescribed Drugs









Inpatient Hospital Care











Outpatient Hospital Care











Laboratory & X-ray Service











Skilled Nursing Home Services











Physician Services











Dental Services











SFO

1

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

B. DRUG PAYMENTS AND RECIPIENTS

TOTAL CATEGORICALLY NEEDY CASH TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients CATEGORICALLY NEEDY NON-CASH TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients MEDICALLY NEEDY TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients

1998* Expended Recipients $32,887,828 43,734

1999 Expended Recipients $41,149,318 51,631 $35,948,104 $5,527,030 $23,025,340 $0 $2,038,831 $5,356,902 $0

34,829 3,993 7,586 0 13,499 9,751 0

$0 $0 $0 $0 $0 $0 $0

0 0 0 0 0 0 0

$1,431,244 $6,860 $0 $0 $1,152,027 $272,355 $0

11,128 6 0 0 9,076 2,046 0

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

Pharmaceutical Benefits 2000

Department of Health and Social Services, Division of Medical Assistance.

Prior Authorization: State currently has a formal prior authorization procedure. Request for fair hearing required for appealing coverage of an excluded product and PA 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 required.

C. ADMINISTRATION

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips; total parental nutrition; and interdialytic parenteral nutrition. Prior authorization required for: Clorazil; Lupron Depot; ADC infant vitamins; some DME; Synagis; Pauretin; and Actig Naltrexone. Products not covered: cosmetics; fertility drugs; and experimental drugs. Over-the Counter Product Coverage: Products covered: feminine products (vaginal yeast drugs, miconazole, ctotrimazole); topical products (bacitracin ointment); and calcium. Products not covered: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products; and smoking deterrent products. Therapeutic Category Coverage: Categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; miscellaneous GI drugs; and thyroid agents. Prior authorization required for: growth hormones. Categories not covered: anorectics; prescribed cold medications; amphetamines (except for narcolepsy and hyperactivity); prescribed smoking deterrents; sympathominetics (adrenergic); cough suppressants; DESI drugs; vitamins (except prenatal); and vitamins with fluoride. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities and through physician payment when used in physician offices. No injectable drug list. Vaccines: Vaccines reimbursable at cost as part of EPSDT service, Children Health Insurance Program and the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable when used in long-term care.

Drug Utilization Review PRODUR system implemented in June 1995. State currently has a DUR Board that meets nine times per year. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: No less than $3.45 and no more than the 90th percentile of all dispensing fees determined under the formula: 1) $23,192 added to the number resulting from multiplying total prescriptions filled by that pharmacy in the previous calendar year by 5.070; 2) to 1), add the result of multiplying total Medicaid prescriptions filled in the previous calendar year by 12.44; 3) from 2), subtract the result of multiplying the total floor space volume of the pharmacy in sq. ft. by 2.103; 4) divide 3) by total prescriptions filled by that pharmacy 5) add $0.73 to 4) Ingredient Reimbursement Basis: EAC = AWP - 5%. Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary” with the reason supplied. Incentive Fee: None. Cognitive Services: Does not pay for cognitive services. Patient Cost Sharing: $2.00 copayment for branded and generic products.

E. USE OF MANAGED CARE Does not use MCOs to deliver services to Medicaid recipients.

Formulary/Prior Authorization Formulary: No formulary. National Pharmaceutical Council

Alaska-2

Pharmaceutical Benefits 2000

F. STATE CONTACTS State Drug Program Administrator Dave Campana, R.Ph. Division of Medical Assistance 4501 Business Park Blvd., Suite 24 Anchorage, AK 99503 T: 907/273-3224 F: 907/561-1684 E-mail: [email protected] Health and Social Services Department Officials Karen Perdue Department of Health and Social Services Pouch H-01, Juneau, AK 99811-6040 907/465-3030 Bob Labbe, Director Division of Medical Assistance, DHSS Pouch H-07, Juneau, AK 99811 907/465-3355 Jack Nielson, Deputy Director Medical Assistance 4501 Business Park Blvd., Suite 24 Anchorage, AK 99503 907/561-2171 Prior Authorization Contact Dave Campana 907/273-3224 DUR Contact Dave Campana 907/273-3224 Prescription Price Updating Dave Campana 907/273-3224 Medicaid Drug Rebate Contacts Technical: Velma Drake, 907/561-2171 Policy: Dave Campana, 907/273-3224 Audit: Dave Campana, 907/273-3224

Claims Submission Contact Rose-Ellen Hope Pharmacist First Health 565 Union St. NE #205 Salem, OR 97301 T: 503/391-0184 F: 503/391-1979 Disease Management Program/Initiative Contact Bob Labbe Director, Division of Medical Assistance P.O. Box 110660 Juneau, AK 99811-0660 T: 907/465-3355 F: 907/465-2204 Physician-Administered Drug Program Contact Tom Porter, M.D. 907/561-2171 Alaska Medical Care Advisory Committee Dr. Patricia Connors Allen 2231 N. Jordan Avenue Juneau, AK 99801 Alaska DUR Committee Dave Campana, R.Ph. 4501 Business Park Blvd., Suite 24 Anchorage, AK 99503 Thomas Porter, M.D. 4501 Business Park Blvd., Suite 24 Anchorage, AK 99503 Richard Reem, M.D. 231 Iditarod Fairbanks, AK 99701-3639 Linda Shull, R.Ph. 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

Pharmaceutical Benefits 2000 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

Pharmaceutical Benefits 2000

ARIZONA ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AHCCCS - PRONOUNCED "ACCESS") AHCCCS FEATURES The Arizona Health Care Cost-Containment System (AHCCCS) is a Title XIX (Medicaid) demonstration project, jointly funded by the federal government and the State of Arizona. Begun in October 1982, it serves as a model for providing medical services to the indigent in a managed care system rather than through fee-for-service arrangements. Typically, Medicaid programs have incorporated the traditional hallmarks of the U.S. health care system: namely, independent providers and fee-forservice reimbursement. In contrast, organized health plans and capitation mark the AHCCCS model. In traditional Medicaid programs, the states assume responsibility for contracting with individual pharmacies and reimbursing them. In the AHCCCS model however, the state contracts instead with pre-paid health plans, HMOs and HMO-like entities. These plans are paid on a capitation basis and are responsible for providing all of the services covered by the program. Thus, the delivery of pharmacy services is the responsibility of each prepaid plan.

GENERAL INFORMATION The Arizona Health Care Cost Containment System (AHCCCS), developed in Senate Bill 1001, was passed by the Legislature and signed by the Governor in November 1981. It contained six major mechanisms for restraining health care costs at the same time ensuring that appropriate levels of quality health care services are provided to eligible persons in a dignified fashion. The goal of these 6 items was to contribute to the establishment of health care financing that is less expensive than conventional fee-for-service systems. The six mechanisms were: • • • • • •

Primary Care Physicians Acting as Gatekeepers Prepaid Capitated Financing Competitive Bidding Process Cost Sharing Limitations on Freedom-of-Choice Capitation of the State by the Federal Government

Primary Care Physicians as Gatekeepers 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

of primary care physicians was established to perform the gatekeeping function for the system. Because the primary care physicians must approve all care, the primary care network eliminated self-referrals to specialists and diminished excessive use of emergency rooms -- both of which have contributed substantially to high medical costs. Prepaid Capitated Financing It was the intent of the AHCCCS legislation that health plans and their providers offer all covered services to groups of members within a geographical area for a fixed price, for a definite period. The law allowed for the establishment of a statewide bidding process to accomplish this. Services are provided on a county-bycounty basis, by prepaid health plans. Providers may bid on a prepaid capitated basis for covered services to be provided within a particular county. The law allows for expansion and contraction of bids to achieve the best possible system. In the event there are insufficient bids for a given area, the legislation permits capped fee-forservice arrangements. It is intended, however, that capped fee-for-service will be authorized as a last resort only. In essence, AHCCCS prepaid health plans (PHPs), health maintenance organizations (HMOs), and other types of organized health delivery systems charge a fixed fee per individual enrolled (i.e., a capitation rate) and assume responsibility for providing a broad array of health care services to members. Competitive Bidding Process The statewide competitive aspect of the bid process for selecting providers and offering prepaid capitated services is the most unique feature of the AHCCCS model. A competition of this magnitude had never been attempted in any other state. The AHCCCS administration believes competitive bidding for health care service contracts, as opposed to conventional negotiation processes, provides accessible cost-effective delivery of health care without sacrificing quality performance. The AHCCCS administration issues an invitation to qualified health plans once every five years. Qualified health plans may bid to offer the full range of AHCCCS services in one or more counties.

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Cost Sharing

Provider Participation

The fourth major device for containing costs in the AHCCCS model is a provision for cost sharing by users. A statewide co-payment schedule was developed for this purpose, and the medically needy participate in coinsurance cost sharing. It is expected that the imposition of nominal co-payments will ensure optimal effectiveness in the area of service utilization. The copayment schedule accomplishes three objectives: curtailment of over-utilization; enhancement of patient dignity; and service utilization by members for truly needed health care. There is no co-payment for drugs and medication, prenatal care including all obstetrical visits, members in long care facilities and for visits scheduled by the primary care physician or practitioner, and not at the request of the member.

Providers may participate in AHCCCS in 2 different ways. First, they may contract with prepaid capitated plans as either full or partial benefit providers.

Limitations On Freedom-of-Choice

Contracting Health Plans

The fifth major item for containing costs is a restriction on provider/physician selection by AHCCCS members. Unlike conventional delivery models, Arizona does not rely on fee-for-service arrangements. The goal is to have the state completely blanketed with prepaid capitated arrangements. Members are linked to selected or assigned plans for definite durations of time. Freedom-of-choice is permitted to the extent practicable for members to select the particular group with which to enroll, as well as the primary care physician within the selected group. Capped fee-for-service health service arrangements are used as a last resort, and only in areas not covered by prepaid capitated plans.

Under the Contracting Health Plan arrangement, plans are defined in terms of explicit groups of providers organized as entities that are more formal. These consortia, or formal entities, are capable of providing the full range of AHCCCS benefits within a defined service area for all AHCCCS members who elect to join the plans, up to a predetermined capacity. This is the dominant mode of operation within AHCCCS -- with two or more competing plans wherever possible.

CAPITATION BY THE FEDERAL GOVERNMENT The State of Arizona will itself be capitated by the Federal Government and therefore will be at financial risk for containing health care costs. Capitation rates will be established according to sound actuarial principles, and will represent no more than 95 percent of the estimated cost of services delivered in Arizona under conventional fee-for-service arrangements. Capitation provides a key incentive for the state to monitor health care costs on a careful and continuous basis.

IMPLEMENTATION OF AHCCCS AHCCCS is based on plans that have been tested, in part, on smaller scales in different areas of the country. By combining a number of key mechanisms on a statewide basis, AHCCCS represents a novel health care model. The purpose of this section is to present a discussion of how the key concepts embodied in the AHCCCS legislation will be implemented and rendered operational.

National Pharmaceutical Council

The second mode of participation is on a capped fee-forservice basis. Here, providers agree to accept capped fee payments as payments in full for services provided on a FFS basis. Functions of the AHCCCS Administration The Arizona Health Care Containment System Administration (AHCCCSA) contracts with full benefit capitated health plans to serve AHCCCS members through a network of providers.

The Contracting Health Plans are delivery systems, not simply insurance plans, but they need not be Health Maintenance Organizations by any legal or conventional definition of the term. The AHCCCS legislation provides for the creation of provider consortia for the purpose of participation in the program. The Contracting Health Plan may be a loosely organized system, but it must be capable of providing the full range of AHCCCS benefits to a defined population at a capitation rate. The Organizational Role of AHCCCS Administration The AHCCCS Administration has been charged with the general implementation and monitoring of the AHCCCS program. The AHCCCS Administration develops the Rules and Regulations; manages the health plan bidding processes; awards the contracts; provides technical assistance to providers for the purpose of forming consortia to contract with AHCCCS; and monitors the overall operation of the program.

Arizona-2

Pharmaceutical Benefits 2000 The Operational Role of the AHCCCS Administration Organizationally, the AHCCCS Administration assumes responsibility for the oversight of every day operations. The AHCCCS Administration has overall responsibility for the following activity areas: • • • • • •

Promotion of AHCCCS Procurement of Health Plans Quality Management Provider Management Provider, Member, and Public Relations Program Operations

AHCCCS became effective December 1, 1981, and services commenced October 1, 1982. Services include: inpatient, outpatient, laboratory, x-ray, prescription drugs, medical supplies, prosthetic devices, emergency dental care including extractions and dentures, treatment of eye conditions and EPSDT. Though AHCCCS was a three-year experiment that was to end in October 1985, the federal government continues to extend funding for the program. In 1988, AHCCCS received a five-year extension from the federal government and in 1993, it received an additional oneyear extension. In 1994, AHCCCS received a three-year extension and in 1998, it is expected to receive a one-year extension.

MEDICAL PLANS AND ADMINISTRATORS AHCCCS Contracted Health Plans Access Blue Connection 602/864-4445 2444 W. Las Palmaritas Drive Phoenix, AZ 85021 Contract terminated, effective 10/1/97

Doctor’s Health Plan, P.C. 517 Main Street Stafford, AZ 85546

520/428-7801

Family Health Plan of NE Arizona P.O. Box 2069 Cottonwood, AZ 86326

520/921-8944

Health Choice Arizona Suite 260 1600 West Broadway Tempe, AZ 85282-1136

602/968-6866

Maricopa Managed Care Systems 2516 East University Drive Phoenix, AZ 85034

602/681-8700

Mercy Care Plan 2800 North Central, Suite 400 Phoenix, AZ 85004

602/230-9921

Phoenix Health Plan 2700 North 3rd Street Phoenix, AZ 85004

602/824-3700

Pima Health System Suite A-200 5055 East Broadway Tucson, AZ 85711

602/512-5500

Regional AHCCCS Health Plan 520/426-6648 1955 North Casa Grande Avenue, #116 Casa Grande, AZ 85222 Contract terminated, effective 5/1/97 University Family Care 575 East River Road Tucson, AZ 85704

520/321-7248

Phoenix Arizona Indian Health Services (IHS) Two Renaissance Square 602/640-2120 40 N. Central Avenue Phoenix, AZ 85004-5036

Arizona Health Concepts 7600 N. 16th Street, Suite 150 Phoenix, AZ 85020

602/331-5100

Arizona Physicians IPA, Inc. 3141 North 3rd Avenue Phoenix, AZ 85013

602/274-6102

Phoenix Indian Medical Center 4212 North 16th Street Phoenix, AZ 85016

602/263-1200

CIGNA Community Choice 11001 North Black Canyon Highway Phoenix, AZ 85029

602/942-4462

Indian Health Services (IHS) Southern Region 7900 J.J. Stock Road Tucson, AZ 85746

520/295-2550

DES/CMDP CMDP-942-C Century Plaza Building, 10th Floor 3225 North Central Avenue Phoenix, AZ 85012

602/351-2245

3-Arizona

Navajo Area Indian Health Services (IHS) P.O. Box 9020 520/871-5880 Window Rock, AZ 86515-9020

National Pharmaceutical Council

Pharmaceutical Benefits 2000 ALTCS Contractor List Arizona Physicians IPA (ALTCS) 242 West 28th Street, Suite A Yuma, AZ 85364 520/783-5691 Cochise Health Systems Cochise County Health & Social Services Cochise Health Systems 1415 West Melody Lane, Building A Bisbee, AZ 85603 520/432-9481 DES/DDD 1789 West Jefferson, 4th Floor Phoenix, AZ 85034 602/542-6866 Maricopa Managed Care Systems 2516 East University Drive Phoenix, AZ 85034 602/681-8700 Pima County LTC Pima Health System Suite A-200, 5055 East Broadway Tucson, AZ 85711 520/512-5500 Pinal County Health Plan - LTC P.O. Box 2140 574 South Central Avenue Florence, AZ 85232-2140 520/868-6775 Ventana Health Systems Apache, Gila, Graham, Greenlee, Mohave, Navajo, LaPaz & Santa Cruz Counties 7600 N. 16th St., Ste. 150 Phoenix, AZ 85020 602/331-5100 Yavapai County LTC Yavapai County Department of Medical Assistance 255 East Gurley Street, First Floor Prescott, AZ 86301 520/771-3560 AHCCCS FFS (ALTCS) Ventilator Dependent Central Office (Office of the Medical Director) 602/417-4283

National Pharmaceutical Council

STATE CONTACTS AHCCCS Officials John H. Kelly, Acting Director AHCCCS 801 E. Jefferson Phoenix, AZ 85034 602/417-4680 Leonard Jasinski, M.D. Medical Director Executive Officers of State Medical and Pharmaceutical Societies Arizona Medical Association, Inc. Chic Older Executive Vice President 810 West Bethany Home Road Phoenix, AZ 85013 602/246-8901 Arizona Pharmacy Association Kathy Boyle Executive Director 1845 E. Southern Ave. Tempe, AZ 852-82-5831 602/838-3385 Arizona Osteopathic Medical Association Amanda Weaver Executive Director 5150 N. 16th St., #A122 Phoenix, AZ 85016 602/266-6699 Arizona Board of Pharmacy L. A. Lloyd Executive Director 5060 North 19th Avenue, Ste. 101 Phoenix, AZ 85015 602/255-5125 Arizona Hospital and Healthcare Association John R. Rivers Pres., CEO 1501 West Fountainhead Parkway Suite 650 Tempe, AZ 85282 602/968-1083

Arizona-4

Pharmaceutical Benefits 2000

ARKANSAS A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

APTD AFDC OAA

AB

Other

OAA

AB

APTD AFDC Children <21

Prescribed Drugs



















Inpatient Hospital Care



















Outpatient Hospital Care



















Laboratory & X-ray Service



















Skilled Nursing Home Services



















Physician Services



















Dental Services



















SFO

1

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended $150,891,615

Recipients 262,907

1999 Expended Recipients $174,122,352 272,863

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

$21,923,101 $15,746,553 $979,341 $3,073,535 $2,123,161 $64 $445

43,898 15,658 919 20,352 6,967 1 1

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$90,570,658 $82,938 $86,427,655 $1,886,271 $2,173,792

20,598 4 12,882 7,512 200

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult

$15,416,172 $124,995 $890,988 $13,586,659 $813,529

63,625 4 4 63,573 44

$46,212,420

9,548

OTHER, TOTAL

$59,618,981

42,100

Source: HHS Report HCFA-2082, Sections A-4 and B-4. *1998 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

C. ADMINISTRATION Department of Human Services, Division of Medical Services, Pharmacy. 1-Arkansas

National Pharmaceutical Council

Pharmaceutical Benefits 2000

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin. Products not covered: blood glucose test strips; urine ketone test strips; total parenteral nutrition, interdialytic parenteral nutrition; cosmetics; fertility drugs; and experimental drugs. Prior authorization required for: nitroglycerin patches; agents for impotence; Synagis; and Respigam. Over-the-Counter Product Coverage: Products covered: digestive products (H2 antagonist). Limited coverage for: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products (non-H2 antagonist ) (under 21 years and long-term care limited needs); feminine products; and topical products. Product not covered: smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antilipemic agents; anti-psychotics; cardiac drugs; chemotherapy agents; contraceptives; ENT antiinflammatory agents; estrogens; growth hormones; hypotensive agents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: analgesics, antipyretics, NSAIDs; antihistamine drugs; misc. GI drugs; prescribed smoking deterrents. Therapeutic categories not covered: anorectics. Coverage of Injectables: Injectable medicines are reimbursable through the Prescription Drug Program when used in home health care, extended care facilities and through physician payment when used in physicians offices. No injectable drug list. Vaccines: Vaccines reimbursable as part of the Vaccines for Children Program.

Formulary/Prior Authorization Formulary: Closed formulary. General exclusions include: 1. 2. 3. 4. 5.

Agents used for hair growth. Vitamin products except prescription prenatal vitamins. Drugs determined by the FDA to be ineffective (DESI drugs). Sedatives and hypnotics in the benzodiazepine category (partial coverage). Compounded prescriptions (mixtures of two or more ingredients). States are not allowed to have state codes such as 99999-9999-99. All drugs reimbursed by the State must be traced by NDC code and appear on the utilization report.

Prior Authorization: State currently has a prior authorization procedure. Prescribing or Dispensing Limitations Prescription Refill Limit: 5 refills within 6 months are allowed. New Rx required every 6 months. Monthly Quantity Limit: 30-day supply. Monthly Prescription Limit: Three prescriptions per month per recipient, except unlimited in certified LTC recipients and recipients under 21 years old. Others can receive extension of three more per month. Drug Utilization Review PRODUR system implemented in March 1997. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $5.51 effective 7/1/99. Ingredient Reimbursement Basis: EAC = AWP – 10.5%.

Unit Dose: Unit dose packaging reimbursable. 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. Incentive Fee: None.

National Pharmaceutical Council

Arkansas-2

Pharmaceutical Benefits 2000 Patient Cost Sharing: Effective 9/1/92, for each prescription reimbursed, the Medicaid recipient is responsible for paying a copayment based on the following: State Payment $10.00 or less $10.01 to $25.00 $25.01 to $50.00 $50.01 or more ArKids

Copay $0.50 $1.00 $2.00 $3.00 $5.00

Services to individuals under 18, pregnant women, nursing home residents, emergency services, family planning services, and services provided by an HMO to its enrollees are excluded from the Medicaid copay policy. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE An estimated 230,000 Medicaid recipients were enrolled with managed care organizations PCP and ArKids. Pharmaceutical benefits are provided through the state.

F. STATE CONTACTS Medicaid Drug Program Administrator Suzette Bridges, P.D. Division of Medical Services Dept. of Human Services P.O. Box 1437, Slot 4105 Little Rock, AR 72203 T: 501/324-9141 F: 501/324-9140 E-mail: [email protected]

Scott Harris, P.D. 9601 I-630, Ext. 7 Little Rock, AR 72205-1749 501/202-1749 Benji Post, P.D. Physicians Thomas Lewellen, D.O. 105 West Waterman Dumas, AR 71639 870/382-1188 Michael N. Moody, M.D. P.O. Box 829 Salem, AR 72576 501/895-2541 Charles Rodgers, M.D. 4202 South University Little Rock, AR 72204 501/562-4838 Medicaid Pharmacist Suzette Bridges Prescription Price Updating First DataBank 1111 Bay Hill Drive San Bruno, CA 74066 415/588-5454 Medicaid Drug Rebate Contacts Audits: Suzette Bridges, P.D., 501/324-9141 PA: Mary Alice Easterling, EDS, 501/374-6608 Claims Submission Contact

Prior Authorization Contact Suzette Bridges 501/324-9141 Dr. Judith McGhee 501/682-6442DUR Contact Suzette Bridges 501/324-9141 DUR Board

John Herzog EDS Federal Corp. 500 East Markham, Ste 400 Little Rock, AR 72201 501/374-6608 Medicaid Managed Care Contact Bob Paladino P.O. Box 1437, Slot 1102 Little Rock, AR 772203

Pharmacists: Steve Bryant, P.D. Bryant’s Pharmacy 2000 Harrison Street Batesville, AR 72501 501/793-3999

3-Arkansas

National Pharmaceutical Council

Pharmaceutical Benefits 2000

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







Skilled Nursing Home Services



Note: Certain classifications of aliens in the above categories are eligible only for emergency and pregnancy-related benefits. 1 See Appendix E, page E-29, for a list of acronyms.

B. EXPENDITURES FOR DRUGS

TOTAL

1998 Expended $1,553,598,462

Recipients 2,644,430

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

$1,181,162,264 $254,611,395 $812,296,210 $35,413,433 $47,289,063 $10,991,408 $20,560,755

1,564,857 248,440 536,457 383,891 188,195 120,991 75,883

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

$281,093,222 $105,624,178 $125,615,464 $23,988,641 $24,884,939

566,080 111,101 60,154 283,220 111,605

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

$14,965,593 $732,955 $578,605 $12,486,033 $1,168,000

163,798 659 1,319 139,977 21,843

$1,695,126

301,095

OTHER, TOTAL

1999* Expended

Recipients

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

Pharmaceutical Benefits 2000

C. ADMINISTRATION

Unit Dose: Reimbursable at buck prices.

Under the Health and Human Services Agency with direct administration by the Department of Health Services.

Formulary/Prior Authorization

The Department of Health Services Pharmaceutical Unit of the Medi-Cal Policy Division monitors the full scope and quality of pharmaceutical benefits covered under the provisions of the California Medical Assistance Program.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; and urine ketone test strips. Products covered with prior authorization: total parenteral nutrition and interdialytic parenteral nutrition. Products not covered: cosmetics; fertility drugs; and experimental drugs. Over-the-Counter Product Coverage: Products covered with prior authorization: allergy, asthma and sinus products; analgesics; cough and cold preparations; nonH2 antagonist digestive products; digestive products, H2 antagonists; feminine products; topical products; and smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories covered: chemotherapy agents and contraceptives. Prior authorization required for: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; prescribed cold medications; ENT anti-inflammatory agents; estrogens; growth hormones; hypotensive agents; misc. GI drugs; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid agents. MediCal fee-for-service does not blanket exclude drug classes. Drugs for the treatment of cancer or AIDS are exempt from prior authorization. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities and through physician payment when used in physician offices. Vaccines: Vaccines reimbursable by schedule as part of the Vaccines for Children Program. Vaccines for adults covered through the prescription drug program.

2-California

Formulary: Closed formulary. Medi-Cal List of Contract Drugs: Over 600 drugs in differing strengths and dosage forms listed generically. A drug may be added to the list on contractual agreement by the manufacturer to provide the state a rebate based on the quantity reimbursed to pharmacies for Medi-Cal recipients. The patient’s physician or pharmacist may request prior authorization from the field office Medi-Cal consultant for approval of unlisted drugs or for listed drugs that are restricted to specific use(s). Examples of general limitations and exclusions (other uses require prior authorization): 1.

CNS stimulants, i.e., amphetamines and methylphenidate, are restricted to attention deficit disorder in individuals between 4 and 16 years of age.

2.

Diazepam is restricted to use in cerebral palsy, athetoid states, and spinal cord degeneration.

3.

Cimetidine, Famotidine are restricted to therapy lasting up to 90 days from the dispensing date of the first prescription.

4.

Most non-steroidal anti-inflammatory agents are restricted to use for arthritis.

5.

Many antibiotics have diagnostic and/or age restrictions.

6.

Acyclovir capsules are restricted to herpes genitalis, immunocompromised patients and herpes zoster (shingles).

7.

Codeine Combinations: payment to a pharmacy for ASA or APAP with codeine 30 mg is limited to a maximum dispensing quantity of 45 tablets or capsules and a maximum of 3 claims for the same beneficiary in any 75-day period.

8.

Excluded from coverage: multivitamins for persons over five years of age (except pre-natal vitaminmineral products for pregnant women); cosmetic drugs and fertility drugs; and most OTC household remedies.

9.

Enteral nutritional supplements or replacements are covered, subject to prior authorization, if used as a therapeutic regimen to prevent serious disability or death in patients with medically diagnosed conditions that preclude the full use of regular foodstuffs.

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 National Pharmaceutical Council

Pharmaceutical Benefits 2000 drugs rated less-than-effective by FDA are not covered. Prior Authorization: State currently has a formal prior authorization procedure. Medi-Cal frequently petitions to add drugs to the list of contract drugs. Denials of these petitions can be appealed to the director of the Department of Health and Human Services by the petitioner within 30 days after notice of the denial. Providers may appeal prior authorization decisions within 60 days of notification to the local field office and then to field services headquarters if necessary. Beneficiaries also have the ability to request a hearing to review the denial and must do so within 90 days of notification. Approval may be obtained from a Medi-Cal consultant for: covered items or services not included on the MediCal List of Contract Drugs (including special circumstance override of multiple source drug price ceilings or minimum quantity/ frequency of billing limitations); and for patients exceeding the 6 Rx per month limit. Statewide mail and fax requests are accepted in the Stockton and Los Angeles Medi-Cal Field Offices. Requests must include adequate information and justification. Authorization may only be given for the lowest cost item or service that meets the patient’s medical needs. Beneficiary or Prescriber Prior Authorization: On a case by case basis, the Dept. of Health Services restricts, through the requirements of prior authorization, the availability of designated prescription drugs to certain beneficiaries or prescribers found by the Department to abuse those benefits. Prescribing or Dispensing Limitations Prescription Refill Limit: A prescription refill can be dispensed as authorized by prescriber. Exception is allowed for refill of a reasonable quantity when prescriber is unavailable (pursuant to California law). Fee is prorated so that total fee (for partial quantity and balance of the prescription after prescriber is contacted) does not exceed fee for same prescription when refilled as routine service. Monthly Quantity Limit: This is flexible, but should be consistent with the medical needs of the patient. Limited to 100 tabs on some drugs, 100 days’ supply on others. Many maintenance drugs are subject to minimum quantity or maximum frequency of billing controls. Monthly Prescription Limit: Limited to 6 per month without prior authorization. The limit does not apply to family planning drugs, patients in nursing facilities or to AIDS or cancer drugs.

National Pharmaceutical Council

Hospital Discharge Medications: Quantities furnished as discharge medications are limited to no more than a 10day supply. Charges are incorporated in the hospital’s claims for inpatient services. Drug Utilization Review PRODUR system implemented in August 1995. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.05, effective 8/85. Ingredient Reimbursement Basis: EAC = AWP-5%, or direct price for 11 specified manufacturers. Prescription Charge Formula: Reimbursement is based on the lowest of: For Legend Drugs: 1. Estimated Acquisition Cost (EAC) + dispensing fee, less $0.25. 2. Federal Upper Limit (FUL) + dispensing fee, less $0.25. 3. State Maximum Allowable Ingredient Cost (MAIC) + dispensing fee, less $0.25. 4. Pharmacy’s usual price to general public, less $0.25. For Over-the-Counter Drugs: 1. Estimated acquisition cost (EAC) x 1.5, less $0.50. 2. Federal Upper Limit (FUL) x 1.5, less $0.50. 3. State Maximum Allowable Ingredient Cost (MAIC) x 1.5, less $0.50. 4. Pharmacy’s usual price to the general public, less $0.50. (Reimbursement is reduced by $0.25 per claim line as of January 1, 2000. Maximum Allowable Cost: State MACs are established for 51 multi-source items. Override requires “Medically Necessary” or unavailability of drug products at or below MAC. List is periodically revised and price limits changed to reflect current market conditions. Incentive Fee: None. Patient Cost Sharing: Copayment: $1.00 (optional). Cognitive Services: Does not pay for cognitive services, but this is under consideration.

California-3

Pharmaceutical Benefits 2000

E. USE OF MANAGED CARE Approximately 2,500,000 total unduplicated number of Medicaid recipients were enrolled in MCOs in FY 1999. Recipients receive pharmaceutical benefits through the state and managed care plans. Kaiser Foundation Health Plan, Inc. Northern California Region 1800 Harrison Street, 9th Floor P.O. Box 12916 Oakland, CA 94612-2998 Omni Health Care 2450 Ventura Oaks, Suite 300 Sacramento, CA 95833-3292 Denticare 125 Technology Street Irvine, CA 92618 Universal Care 1600 E. Signal Hill Street Signal Hill, CA 90806-3682 County of Contra Costa Contra Costa Health Plan 595 Center Avenue, Suite 100 Martinez, CA 94553 Western Health Advantage 1331 Garden Highway Suite 100 Sacramento, CA 95833-9754 CaliforniaCare Health Plans 2000 Corporate Center Dr., Bldg. 7 Newbury Park, CA 91320 Placer County Managed Care Network 11730 Enterprise Drive Auburn, CA 95603 Sonoma County Medi-Cal Managed care Network 1221 Farmers Lane, Suite 200 Santa Rosa, CA 95404-1705 Watts Health Foundation, Inc. United Health Plan 3405 West Imperial Highway, Suite 600 Inglewood, CA 90303

Orange County Organized Health System CalOptima 1120 West La Veta Ave, 5th Floor Orange, CA 92668 Santa Cruz County -Monterey Managed Care Commission Santa Cruz County Health Options 375 Encinal Street, Suite A Santa Cruz, CA 95060 Sutter Senior Care 1234 U Street Sacramento, CA 95816 Altamed Health Services Corp. 500 Citadel Drive, Suite 490 Los Angeles, CA 90040 CompCare Health Plan, Inc. 3200 Fourth Ave, Suite 200 San Diego, CA 92103 Blue Cross of California 5151-A Camino Ruiz Camarillo, CA 93012 Kern Health Systems Kern Family Health care 1600 Norris Road Bakersfield, CA 93308 LA Care Health Plan 3530 Wilshire Boulevard, Suite 704 Los Angeles, CA 90100 Inland Empire Health Plan 303 E. Vanderbilt Way, Suite 400 San Bernardino, CA 92408 San Francisco Health Authority San Francisco Health Plan 568 Howard Street, Fifth Floor San Francisco, CA 94105 Health Plan of San Joaquin 1550 W. Fremont Street Stockton, CA 95203-2643 Omni Healthcare Inc. 2450 Venture Oaks, Suite 300 Sacramento, CA 95833 Maxicare 1149 South Broadway, Suite 819 Los Angeles, CA 90015

4-California

National Pharmaceutical Council

Pharmaceutical Benefits 2000 UCSD Healthcare 200 West Arbor Dr. San Diego, CA 92103

Center for Elders Independence 1955 San Pablo Ave Oakland, CA 94612

Delta Dental Plan of CA 7687 Folsom Blvd Sacramento, CA 95826

HealthReach Family Care Center 7237 Lennane Drive, Suite 200 Sacramento, CA 95834

Western Dental Srvs., Inc. #424 300 Plaza Alicante, Ste. 810 Garden Grove, CA 92640 Health Net 3400 Data Drive, 1st Fl. W Rancho Cordova, CA 95670

AIDS Healthcare Foundation 6255 W. Sunset Blvd., 16th Floor Los Angeles, CA 90028-8073

Molina Medical Centers One Golden Shore Drive Long Beach, CA 90802 Orange County Organized Health System CalOptima 1120 West la Veta Ave., 5th Floor Orange, CA 92668 San Mateo Health Commission Health Plan of San Mateo 1500 Fashion Island Blvd., Suite 300 San Mateo, CA 94404 Santa Barbara County Special Healthcare Authority Santa Barbara Health Initiative 110 Castilian Dr. Goleta, CA 93117-3028 Solano County Medical Care Commission Solano Partnership Health Plan 421 Executive Court North, Suite A Suisun City, CA 94585 Solano-Napa County Commission on Medical Care Partnership HealthPlan of California 421 Executive Court North, Suite A Suisun City, CA 94585 Santa Cruz-Monterey Managed Medical Care Commission Central Coast Alliance for Health 375 Encinal Street, Suite A Santa Cruz, CA 95060 OnLok Senior Health Services 1441 Powell Street San Francisco, CA 94133-3879

National Pharmaceutical Council

Cohan Medical Corp Tower Health Services 200 Oceangate, Sixth Pl. Long Beach, CA 90802 Alameda Alliance for Health 1850 Fairway Drive San Leandro, CA 94557 San Francisco City & County Public Health Family Mosaic Project 1309 Evans Avenue San Francisco, CA 94124 Scan Health Plan Senior Care Action Network 3780 Kilroy Airport Way, Suite 600 Long Beach, CA 90806-2460 Santa Clara Family Health Plan 4050 Moopark Avenue San Jose, CA 95117 Access Dental Plan, Inc. 555 University Ave, Suite 182 Sacramento, CA 95825

F. STATE CONTACTS State Drug Program Administrator J. Kevin Gorospe, Pharm.D. Chief, Pharmaceutical Unit Medi-Cal Policy Division 714 P Street, Room 1540 Sacramento, CA 95814 T: 916/657-4213 F: 916/654-0513 E-mail: [email protected] Agency Internet Address: http://www.dhs.ca.gov

California-5

Pharmaceutical Benefits 2000 Prior Authorization Contact

Medicaid Drug Rebate Contacts

J. Kevin Gorospe, 916/657-4213

DUR: Vic Walker, R.Ph., B.C.P.P. 916/657-0785 PA: J. Kevin Gorospe, Pharm.D., 916/657-4213

DUR Contact Vic Walker, R.Ph. B.C.P.P Sr. Pharmaceutical Consultant Medi-Cal Policy Division 714 P Street, Room 1540 Sacramento, CA 95814 T: 916/654-0785 F: 916/654-0513 E-mail: [email protected] Medi-Cal Drug Utilization Review Board (DUR Board) Timothy E. Albertson, M.D., Ph.D. University of California-Davis Pulmonary/Critical Care Medicine 4301 X Street, Professional Bldg., Room 2120 Sacramento, CA 95817 Robert J. Matutat, Pharm.D. First Databank Attn: inpatient Pharmacy 1425 S. Main Walnut Creek, CA 94596 Janeen G. McBride, R.Ph. Rx America 1500 South Anaheim Blvd. Anaheim, CA 92815-0017 Gary M. McCart, Pharm.D. University of California, San Francisco 400 Parnassus Ave., Box 312 San Francisco, CA 94143 Anoush Miridjanian, M.D. Southern California Permanente Medical Group Department of Internal Medicine 4647 Zion Ave. San Diego, CA 92120 Stephen M. Stahl, M.D., Ph.D. Clinical Neuroscience Research Center 8899 University Center Lane, Ste. 130 San Diego, CA 92122 Prescription Price Updating EDS P. O. Box 13029 Sacramento, CA 95813-4029 916/636-1000

6-California

Claims Submission Contact Dennis Dworman Executive Program Director EDS-Medi-Cal Electronic Data Systems 3215 Prospect Park Drive Rancho Cordova, CA 95670 916/636-1000 Medicaid Managed Care Contact Susanne Hughes Acting Division Chief Medi-Cal Managed Care Division 714 P Street, Room 650 Sacramento, CA 95814 T: 916/654-8076 F: 916/657-2069 E-mail: [email protected] Disease Management Program/Initiative Contact J. Kevin Gorospe, 916/657-4213 Physician-Administered Drug Program Contact Fulton Lipscomb, M.D. 916/657-1460 Health and Welfare Agency Officials Grantland Johnson Secretary California Health and Human Services Agency 1600 9th Street, Suite 460 Sacramento, CA 95814 Diana Bonta, R.N., Director Department of Health Services 714 P Street, P. O. Box 942732 Sacramento, CA 95814 Gail L. Margolis, Acting Deputy Director Medical Care Services Medi-Cal Contract Drug Advisory Committee Michael B. Huff, M.D. 314 West Fourth St. Oxnard, CA 93030

National Pharmaceutical Council

Pharmaceutical Benefits 2000 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 San Francisco, CA 94143-0622 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. Sacramento, CA 95817 Shirley Ann Floyd 131 Chester Ave., Suite A Bakersfield, CA 93301 Executive Officers of State Medical and Pharmaceutical Associations/Boards California Medical Association Jack C. Lewin, M.D. P.O. Box 7690 San Francisco, CA 94120-7690 415/541-0900 Osteopathic Physicians & Surgeons of California Gary A. Gramm. D.O. Executive Director 1900 Point West Way, Suite 188 Sacramento, CA 95815-4703 916/561-0724 California Pharmacists’ Association Carlo Michelotti, R.Ph., M.P.H. Chief Executive Officer 1112 I Street, Suite 300 Sacramento, CA 95814-2865 T: 916/444-7811 F: 916/443-1915 State Board of Pharmacy Patricia F. Harris Executive Officer 400 R Street, #4070 Sacramento, CA 95814 916/445-5014

National Pharmaceutical Council

California-7

Pharmaceutical Benefits 2000

COLORADO A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

OAA

AB

APTD

AFDC

Prescribed Drugs









Inpatient Hospital Care









Outpatient Hospital Care









Laboratory & X-ray Service









Skilled Nursing Home Services









Physician Services









Dental Services









OAA

AB

APTD

AFDC

Other Children <21

SFO

1

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $110,159,725 147,033

1999* Expended Recipients

CATEGORICALLY NEEDY, RECEIVING 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 Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Colorado

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION Eligibility is determined by 63 County Departments of Social Services, and the Colorado Department of Health Care Policy and Financing administers the drug program.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin. Products covered with restriction: disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips, total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: cosmetics; DESI drugs; fertility drugs; prescribed vitamins (except prenatal); and experimental drugs. Over-the-Counter Product Coverage: Products covered with restriction: analgesics (ASA only); cough and cold preparations (except >21) and smoking deterrent products. Products not covered: allergy, asthma and sinus products; digestive products (non-H2 antagonist); digestive products (H2 antagonist); feminine products; and topical products. Therapeutic Category Coverage: Therapeutic categories covered: analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents (given in home); contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Therapeutic categories partially covered: anorectics. Prior authorization required for: anabolic steroids; prescribed cough and cold medication; growth hormones; vitamins; sexual dysfunction; Epogen; brand name and FUL drugs; and prescribed smoking deterrents. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities and through physician payment when used in physician offices. Vaccines: Vaccines reimbursable as part of the Vaccines for Children Program. Unit Dose: Unit dose packaging not reimbursable. Formulary/Prior Authorization Formulary: Closed formulary

National Pharmaceutical Council

Prior Authorization: State currently has a formal prior authorization procedure. There is an appeal process and re-review when appealing coverage of an excluded product and prior authorization decisions. Prescribing or Dispensing Limitations Monthly Quantity Limit: New prescriptions for chronic or acute conditions are prescribed at the discretion of the physician. However, reasonable amounts for more than a 30-day supply for chronic conditions are recommended. Maximum supply is 100 days for maintenance medication Drug Utilization Review PRODUR system implemented in December 1998. Lock-In Review Procedures: The Department receives computer processed printouts designed to discover overutilization of drugs prescribed by physicians, dispensed by vendors, and received by eligible recipients. Pharmacy Payment and Patient Cost Sharing Dispensing fee: $4.08 as of July 1, 1990. Institutional pharmacies will receive a dispensing fee equal to $1.89. Dispensing physicians shall not receive a dispensing fee unless their offices or sites of practice are located more than 25 miles from the nearest participating pharmacy. In the latter case, physicians receive a fee equal to $1.89. Ingredient Reimbursement Basis: EAC = AWP-10% or WAC (wholesaler acquisition cost) + 18%. Other: FUL, state Mac, usual and customary. Prescription Charge Formula: Benefit drugs shall be reimbursed at the lesser of the Medicaid allowable reimbursement charge, or the provider’s usual and customary charge or whatever is accepted from any third party, discounts, rebates, etc. The Medicaid allowable reimbursement charge is the sum of the ingredient cost of the drug dispensed and the provider’s dispensing fee. Ingredient cost for retail pharmacies (estimated acquisition cost) is the price of the drug actually dispensed as defined below or the MAC or the high volume EAC, whichever is less. The ingredient cost for institutional and government pharmacies is defined as the actual cost of acquisition for the drug dispensed or the MAC, or the high volume EAC, whichever is less. Maximum Allowable Cost: The state MAC is the maximum ingredient cost allowed by the Department for

Colorado-2

Pharmaceutical Benefits 2000 certain multiple-source drugs. The establishment of a MAC is subject, but not limited to, the following considerations: (1) Multiple manufacturers; (2) Broad wholesale price span; (3) Availability of drugs to retailers at the selected cost; (4) High volume of Medicaid recipient utilization; (5) Bioequivalence or interchangeability. When federal MAC limits for multiple source drugs are announced, they will be adopted if they are less than state MACs or if no state MACs exist. The ingredient cost of any drug subject to MAC shall be limited to MAC or wholesale price as determined by the Department, whichever is less. Exceptions that will allow reimbursement greater than MAC for a drug entity are obtained through a prior authorization mechanism. An exception will be granted if the patient’s response to the generic drug is not therapeutic, an allergic reaction is involved, or any similar situation exists. If a recipient requests a brand name for a prescription that is subject to MAC, then he/she may pay the ingredient cost difference between the MAC and brand name drug. The recipient must sign the prescription stating that he/she is willing to pay the difference in ingredient cost to the pharmacy. The pharmacy will be paid MAC plus a dispensing fee or reimbursement charges, whichever is lower. High volume Estimated Acquisition Cost (EAC): Reimbursement for single source drugs or certain multiple source drugs which are most frequently prescribed will be based upon average wholesale prices (AWP) minus 10%, or direct manufacturers’ prices for package sizes containing quantities greater than 100 dosage units or less if not available in 100’s. Basis for inclusion in the high volume estimated acquisition cost list includes but is not limited to: (1) Single source manufacturers; (2) High volume Medicaid recipient utilization; (3) Interchangeability problems with multiple source drugs; (4) Package sizes in excess of 100. Drug Pricing: The Department will maintain a drugpricing file that will be updated at least monthly. The 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. The Department will determine the average wholesale price that will be placed in the drug-pricing file as follows:

3-Colorado

(1) The average wholesale price as it appears in the Red Book, its supplements, and Medi-Span will be the first source. However, if there is a difference between the two published average wholesale prices, the Department will set the price as the published amount which is the closest to the lowest average price charged by two drug wholesalers doing business in Colorado. (2) If there is a price change which does not appear immediately in the Red Book, its supplements, or in MediSpan, then the Department will set the average wholesale price by averaging the wholesale prices of three drug wholesalers doing business in Colorado, until the price is published in the Red Book, its supplements, or in MediSpan. (3) If the prices or changes do not appear in the publications or the wholesalers’ records, then the distributors’ or manufacturers’ prices will be adjusted to the wholesale pricing level and used in the drug pricing file as the price of the drug. If the difference between the pharmacist’s invoice purchase price and the average wholesale price which appears in the Red Book, its supplements, or Medi-Span exceeds 18%, then the Department may adopt a lower price after a survey is conducted to determine the validity of the published prices. The price from the distributor or manufacturer will be adjusted the same as in 3 above. Special Note: The Maximum Allowable Cost shall be determined by the Division of Medical Assistance, based upon professional determination of a quality product available at the least expense possible. Exceptions to the above are: - Shelf package size oral liquid medications, in pint size only, or smaller package size when not packaged in pint size. - Shelf package size oral tablet and capsule medications in quantities of 100 only or smaller when not available in package size of 100. - Prescriptions for less than minimum amounts will be denied reimbursement of the professional fee unless the physician notified the Department in writing of the medical need for amounts less than a 30-day supply. Medical consultation determines the decision. Incentive Fee: None. Patient Cost Sharing: Copay is $2.00 for brand name products and $0.50 for generic. Cognitive Services: Does not pay for cognitive services.

National Pharmaceutical Council

Pharmaceutical Benefits 2000

E. USE OF MANAGED CARE Approximately 210,000 total unduplicated number of Medicaid recipients were enrolled in MCOs in FY 1999. Recipients receive pharmaceutical benefits through managed care plans.

DUR Contact Allen Chapman, 303/886-3176 Prescription Price Updating Allen Chapman, 303/886-3176

Managed Care Organizations

Medicaid Drug Rebate Contacts

Total Long-term Care 303 East 17th Avenue Suite 650 Denver, Colorado 80203 303/896-4664

Technical: Vince Sherry, 303/866-5408 DUR & PA: Allen Chapman, 303/866-3176

HMO Colorado 700 Broadway Denver, Colorado 80273 303/831-2374 Kaiser Permanente 10350 East Dakota Avenue Denver, Colorado 80905 303/344-7250 Rocky Mountain HMO 2775 Crossroads boulevard Grand Junction, Colorado 81506 800/843-0719 Colorado Access 600 South Cherry STREET Suite 800 Denver, Colorado 80222 303/-355-6707 Community Health Plan of the Rockies 400 South Colorado Boulevard Suite 300 Denver, Colorado 80222 303/355-3220 United Healthcare 6251 Greenwood Plaza Blvd, Suite 200 Englewood, Colorado 80111-4910 303/267/3594

Claims Submission Contact Consultec, Inc. 600 17th Street Suite 600 North Denver CO 80203 800/237-0757 Medicaid Managed Care Contact Gary Snider Director Managed Care Contractor Department of Health Care Policy and Financing 1575 Sherman Street, 5th Floor Denver, CO 80203 T: 303/886-3163 F: 303/866-2573 Physician-Administered Drug Program Contact Patti Campbell 303/866-5459 Health Care Policy & Financing Department Officials James T. Rizzato, Executive Director Richard Allen, Director Health Plan and Medical Services Office of Medical Assistance Colorado Department of Health Care Policy & Financing 1575 Sherman Street Denver, Colorado 80203

F. STATE CONTACTS Medicaid Drug Program Administrator Allen Chapman, R.Ph., M.S. Department of Health Care Policy and Financing 1575 Sherman Street, 5th Floor Denver, CO 80203 T: 303/886-3176 F: 303/866-2573

National Pharmaceutical Council

Medical Advisory Council Donald W. Schiff, M.D. 600 Front Range Road Littleton, CO 80120 303/837-2745 Molly A. Markert 11060 E. Wesley Pl. Aurora, CO 80014 303/756-7234

Colorado-4

Pharmaceutical Benefits 2000 Mary Jo Jacobs, M.D. 7425 E. Kenyon Ave. Denver, CO 80237 303/694-2878 Walter Daniels, D.D.S. 1633 Filmore Street Denver, CO 80206 303/388-0989 Rodney Fair, O.D. 105 Bridge Street Brighton, CO 80601 303/659-3036 Douglas Clinkscales Denver Health and Hospitals 777 Bannock Street Denver, CO 80204 303/426-7253 Cathy Corcoran 15920 W. 66th Place Golden, CO 80403 303/861-6256 Ernestine Kotthoff-Burrell 6098 S. Iola Ct. Englewood, CO 80111 303/270-8974 Carol Bartley Denver VNA 3801 E. Florida Ave., Suite 800 Denver, CO 80201 303/753-7312 Mary Ellen Kuhlman, MSW St. Mary’s Hospital & Medical Center P.O. Box 1628 Grand Junction, CO 81502 970/244-2273 Dan Stenerson Shalom Park 14800 E. Belleview Aurora, CO 80015 303/680-5000 Mark Kunart, D.O. 17200 E. Iliff Avenue Aurora, CO 80013 303/755-4111

5-Colorado

Robert Slay Jefferson Co. CCB 7456 W. 5th Avenue Lakewood, CO 80226 303/233-3363 x366 Department Contact Richard Allen, Director Health Plans and Medical Services 303/866-6092 Legislative Liaison Dean Woodward Department of Health Care Policy and Financing 303/866-2708 Executive Officers of State Medical and Pharmaceutical Societies Colorado Medical Society Sandra Mahoney Executive Vice President 7800 E. Dorado Pl. Englewood, CO 80111-2306 303/779-5455 Colorado Pharmaceutical Association Val Kalnins 5150 East Yale Circle, Suite 304 Englewood, CO 80112-1360 303/756-3069 Colorado Society of Osteopathic Medicine Kathleen Brennan Executive Director 50 S. Steele Street, Suite 770 Denver, CO 80209 303/322-1752 State Board of Pharmacy Kent Mount Program Administration 1560 Broadway, Suite 1310 Denver, CO 80202-5146 303/894-7750 Colorado Hospital Association Larry Wall President 2140 South Holly St. Denver, CO 80222-5607 303/758-1630

National Pharmaceutical Council

Pharmaceutical Benefits 2000

CONNECTICUT A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 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

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Recipients Expended $186,593,992 108,331

1999* Expended Recipients

CATEGORICALLY NEEDY, RECEIVING ASSISTANCE, TOTAL Aged Blind/Disabled Child Adult Unemployed Parent-Child Unemployed Parent-Adult MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult OTHER, TOTAL Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

National Pharmaceutical Council

Connecticut-1

Pharmaceutical Benefits 2000

C. ADMINISTRATION

Formulary/Prior Authorization

State of Connecticut Department of Social Services through five regional offices and nine sub-offices.

Formulary: Open formulary, however, the following products are excluded from Medicaid prescription coverage: experimental drugs, cosmetics, fertility drugs; smoking cessation products; DESI drugs, and drugs available free from the Department of Health Services.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin, disposable needles and syringe combinations for insulin; blood glucose test strips; urine ketone test strips; total parenteral nutrition (except in NH); and interdialytic parenteral nutrition (except in NH). Products not covered: cosmetics; fertility drugs; and experimental drugs. Over-the-Counter Product Coverage: Products covered: digestive products (non-H2 antagonists); feminine products; analgesics; and cough and cold preparations (children < 19 years). Products not covered: smoking deterrent products; allergy, asthma and sinus products; digestive products (H2 antagonists); topical products; iron; calcium; oral contraceptives; and some trace elements. For nursing home patients, the department will not pay for OTC drugs used in nursing facilities (such drugs are covered in the per diem rate). Some drugs require diagnosis for reimbursement such as CNS stimulants for ADD and narcolepsy. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); thyroid agents; and growth hormones. Therapeutic categories not covered: anorectics and prescribed smoking deterrents. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities, and through physician payment when used in physicians offices. No injectable drug list.

Prior Authorization: State currently has no prior authorization procedure. Prescribing or Dispensing Limitations Prescription Refill Limit: 6-month refill limit except for oral contraceptives, which have a 12-month limit. Controlled substances have a 5 refill or 6-month limit. Monthly Quantity Limit: Maximum 240 tablets or capsules. Oral contraceptives: 3 months supply may be dispensed at one time. Physicians are encouraged to prescribe drugs generically, when possible. Drug Utilization Review PRODUR system implemented September 1996. Retro DUR since September 1991; the state currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.10, effective 1/1/91. Ingredient Reimbursement Basis: EAC = AWP-12%. Prescription Charge Formula: Federal MAC or EAC plus dispensing fee; or usual and customary if lower. Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary.” Incentive Fee: The Department will pay an incentive professional dispensing fee of $0.50 per prescription, in addition to any other dispensing fee, for substituting a generically equivalent drug product. 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

Pharmaceutical Benefits 2000 Managed Care Organizations Blue Cross / Blue Shield of CT Blue Care Family Plan John Brangi, Director Medicaid Managed Care 370 Bassett Road North Haven, CT 06473-4201 203/985-6464 860/951-9544 Community Health Network of CT 290 Pratt - 2nd Floor Meriden, CT 06450 203/237-4000 PHS Healthy Options Janice Perkins, Assistant VP Government Relations and Programs One Far Mill Crossing, Box 904 Shelton, CT 06484-0944 203/239-7444 x664 HealthChoice of CT Preferred One Sylvia Kelley, VP, Executive Director 23 Maiden Lane North Haven, CT 06473 203/239-7444 x664 (withdrawing from program as of 4th quarter of 2000)

F. STATE CONTACTS Medicaid Drug Program Administrator Elizabeth A. Geary, R.Ph. Health Program Supervisor Dept. of Social Services 25 Sigourney Street Hartford, CT 06106 T: 860/424-5150 F: 860/951-9544 E-mail: [email protected] Department of Social Services Administrative Officials Patricia A. Wilson-Coker Commissioner Dept. of Social Services 25 Sigourney St. Hartford, CT 06016-5033

Michael Starkowski, Deputy Commissioner 860/424-5053 David Parrella, Director Medical Administration Policy 203/424-5116 Michelle Parsons, Manager Alternate Care Unit 203/424-5177 James Linnane, Manager Benefit Design Unit 203/424-5111 Marcia Mains, Manager Medical Operations 203/424-5219 DUR Contact Elizabeth A. Geary, R.Ph. 860/424-5150 Connecticut DUR Board Kenneth Fisher R.Ph. Brooks Pharmacy Arturo Morales M.D. St. Francis Hospital 860/714-2976 Lori Jane Duntz Lord R.Ph. Greenville Drug 860/889-9857 Jeffrey J. Messina R.Ph. Fort Hill Pharmacy 860/445-6431 Rick Carbray, R.Ph. 16 Beacon Street Newington, CT 06111 860/529-6305 Frederick N. Rowland, M.D. St. Francis Hospital and Medical Center 860/679-2281 Dennis Chapron, R.Ph., M.S. UConn Health Center 860/679-2281

Rita Pacheco, Deputy Commissioner 203/424-5055

National Pharmaceutical Council

Connecticut-3

Pharmaceutical Benefits 2000 Cynthia Huge, R.Ph. Lexicon Pharmacy Services 800/233-7873 800/342-4980 Prescription Price Updating First Data Bank Medicaid Drug Rebate Contacts Elizabeth Geary Medical Operations 860/424-5150 Ellen Arce, R.Ph., 860/832-5885 (Audits) Claims Submission Contact Twila Smith EDS Federal Corp. 100 Stanley Drive New Britain, CT 06053 860/832-5800 Medicaid Managed Care Contact James Gaito Department of Social Services 25 Signourney St. Hartford, CT 06106 860/424-5137 E-mail: [email protected]

Connecticut Pharmacists Association Margherita R. Guiliano, R.Ph. Executive V.P. 35 Cold Spring Road, Ste. 124 Rocky Hill, CT 06067-3100 203/563-4619 Osteopathic Medical Society Lynne Freiburger-Epstein, D.O. Secretary/Treasurer 225 Main Street Manchester, CT 06040 860/645-7014 State Board of Pharmacy Michelle Sylvestre, R.Ph. Board Administrator State Office Building, Room G-1A Hartford, CT 06106 203/566-3290 Connecticut Hospital Association, Inc. Dennis P. May President 110 Barnes Road P.O. Box 90 Wallingford, CT 06492-0090 203/294-7202 Prescription Price Adjustments and Updates First Data Bank-Blue Book

Elderly Drug Coverage Program Contact Elizabeth Geary 860/424-5150 Physician-Administered Drug Program Contact Zanita McKinney, Medical Policy 25 Sigourney Street Hartford, CT 06106 860/424-535 State Pharmacy Commission William Summa, P.D., Chairman Executive Officers of State Medical and Pharmaceutical Societies State Medical Society Timothy B. Norbeck, Executive Director 160 St. Ronan Street New Haven, CT 06511 203/865-0587

4-Connecticut

National Pharmaceutical Council

Pharmaceutical Benefits 2000

DELAWARE A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

OAA

AB

APTD

AFDC

Prescribed Drugs









Inpatient Hospital Care









Outpatient Hospital Care









Laboratory & X-ray Service









Skilled Nursing Home Services









Physician Services









Dental Services









OAA

AB

APTD

AFDC

Other Children <21

SFO

1

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $41,350,537 69,027

1999* Expended Recipients

RECEIVING CASH 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 Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

National Pharmaceutical Council

Delaware-1

Pharmaceutical Benefits 2000

C. ADMINISTRATION Division of Social Services, Department of Health and Social Services, through three county offices of the state agency.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips; and total parenteral nutrition. Products not covered: cosmetics; fertility drugs; experimental drugs; and interdialytic parenteral nutrition. Over-the-Counter Product Coverage: Products covered: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products (non-H2 antagonist); digestive products (H2 antagonists); and smoking deterrent products. Products covered with restriction: feminine products (antifungals) and topical products (antiinfectants). Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT antiinflammatory agents; estrogens; hypotensive agents; misc. GI drugs; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: anorectics and growth hormones. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program and physician payment when used in physician offices. Reimbursable only through the Prescription Drug Program when used in extended care facilities. Vaccines: Vaccines reimbursable under the Vaccines for Children program. Unit Dose: Unit dose packaging not reimbursable. No price based on AWP. Formulary/Prior Authorization Formulary: Open formulary.

Prescribing or Dispensing Limitations Prescription Refills: Prescription blank has space for physician to authorize renewals. Monthly Quantity Limit: Greater of 34-day supply or 100 dosing units. Monthly Dollar Limits: None. Drug Utilization Review PRODUR system implemented in August 1994. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.65. Ingredient Reimbursement Basis: EAC = AWP-12.9%. Prescription Charge Formula: Payment is based on AWP-12.9% or maximum allowable cost (MAC) plus a dispensing fee, or the usual and customary cost to the general public, whichever is lower. Maximum Allowable Cost: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. State-specific MAC list contains 90 drugs. Override requires “Brand Medically Necessary.” Incentive Fee: None. Patient Cost Sharing: None. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 68,000 total unduplicated number of Medicaid recipients were enrolled in MCOs in FY 1999. Recipients receive pharmaceutical benefits through the state. Managed Care Organizations DelawareCare 2751 Centerville Road, Suite 400 Wilmington, DE 19808 215/937-8285 First State Health Plan 1801 Rockland Road, Suite 300 Wilmington, DE 19803 302/576-7603

Prior Authorization: State currently has a formal prior authorization procedure.

2-Delaware

National Pharmaceutical Council

Pharmaceutical Benefits 2000

F. STATE CONTACTS State Drug Program Administrator

Carl Mulveny 1941 Limestone Rd. Wilmington, DE 19808

Phile Soulé Delaware Health and Social Services 1901 N. Dupont Highway New Castle, DE 19720 T: 302/577-4900 F: 302/577-4405 Agency Internet Address: http://www.state.de.us/govern/agencies/dhss

Michael Glacken 500 West 10th St. Wilmington, DE 19801

Prior Authorization Contact

Technical: Ralph Dominica, 302/454-7622 Policy: E. Beth Laucius, 302/577-4902 Dispute Resolution: Jessica Bullion, 302/454-7622

Cynthia Denemark Pharmacist Consultant EDS 248 Chapman Road, Suite 200 Newark, DE 197029720 T: 302/453-8453 F: 302/454-7603 E-mail: [email protected] DUR Contact Cynthia Denemark , 302/453-8453 DUR Board Calvin Freedman, R.Ph. 302 Lark Drive Newark, DE 19713-1216 Marvin H. Dorph, M.D. 614 Loveville Road Unit E4H Coffee Run Condo Hockessin, DE 19707 Daniel M. Hauser, Pharm.D. 325 W. Broadstair Dover, DE 19904 Victoria Paoletti 153 Owenwood Dr. Lincoln University, PA 19352 Richard Steele 2617 Epping Rd. Wilmington, DE 19810 Marcus Wilson, Pharm.D. 29 Peninsula Court Bear, DE 19701 Sharon Wisneski, R.N., M.S. 336 Pine Valley Road Dover, DE 19901

National Pharmaceutical Council

Prescription Price Updating Cynthia Denemark , 302/453-8453 Medicaid Drug Rebate Contacts

Claims Submission Contact Thomas Ignudo Account Manager EDS 248 Chapman Rd Newark, DE 19702 Physician-Administered Drug Program Contact Cynthia Denemark , 302/453-8453 Health and Social Services Department Officials Secretary Dept. of Health & Social Services Delaware State Hospital New Castle, DE 19720 302/577-4500 Philip P. Soulé, Sr. Deputy Director, Medicaid 302/577-4901 Dr. James B. Salva Medical Consultant 302/577-4900 Medical Advisory Committee Members Edward R. Sobel, D.O. 1100 S. Broom Street Wilmington, DE 19805 Anne Aldridge, M.D. 671 Clifton Dr. Bear, DE 19701 Sister Jeanne Cashman, O.S.U. Ursuline Academy Convent 1104 Pennsylvania Avenue Wilmington, DE 19806

Delaware-3

Pharmaceutical Benefits 2000 Neil McLaughlin Fernhook Community Mental Health 14 Central Avenue New Castle, DE 19720

George English Blue Cross Blue Shield of DE One Brandywine Plaza Wilmington, DE 19899

Richard Cherrin Visiting Nurses Association New Castle Corporate Commons One Reads Way New Castle, DE 19720

Micheal Glacken, M.D. Medical Director Connections, CSP 500 West 10th St. Wilmington, DE 19801

Steven A. Dowshen, M.D. A.I. duPont Institute P.O. Box 269 Wilmington, DE 19899

Daniese McMullin-Powell A.D.A.P.T 24 S. Old Baltimore Pike Newark, DE 19702

Bob Welch Bureau Health Planning & Resource Management Jesse Cooper Building, Suite 160 Dover, DE 19901

Leonard Nitowski, M.D. Doctors for Emergency Services PO Box 3048 Wilmington, DE 19804

John A. Forrest, Jr., M.D. 195 Lynnhaven Drive Dover, DE 19904

Julia M. Pillsbury, D.O. Center for Pediatric and Adolescent Medicine 125-1 Greentree Drive Dover, DE 19904

Mark Meister Medical Society of Delaware 1925 Lovering Avenue Wilmington, DE 19806 Olga Ramirez Community Legal Aid Society, Inc. 913 Washington Street Wilmington, DE 19801 Penny D. Chelucci De Counsel on Gambling Problems 100 W. 10th Street Community Service Bldg., Suite 303 Wilmington, DE 19801 Joseph Letnaunchyn Delaware Health Care Association 1280 S. Governor’s Avenue Dover, DE 19901 David Allen Vice President Ambulatory & Continuing Care Services Milford Memorial Hospital 21 W. Clark Ave. Milford, DE 19963

4-Delaware

Ulder Jane Tillman, M.D. Jesse Cooper Building 417 Federal and Water Streets Dover, DE 19901 Yrene E. Waldron Executive Director DE Health Care Facilities Association Two Mill Rd., Suite 200 Wilmington, DE 19806 Executive Officers of State Medical and Pharmaceutical Societies Medical Society of Delaware Mark Meister, Sr. Executive Director 1925 Lovering Avenue Wilmington, DE 19806 302/658-7596 Delaware Pharmaceutical Society Martin Golden Executive Director Tindell Square Professional Plaza 1601 Milltown Road, Suite 8 Wilmington, DE 19808 302/892-2880

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Osteopathic Medical Society Edward Sobel, D.O. Executive Secretary P. O. Box 845 Wilmington, DE 19899 302/475-6881 State Board of Pharmacy 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

National Pharmaceutical Council

Delaware-5

Pharmaceutical Benefits 2000

DISTRICT OF COLUMBIA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

Other

OAA

AB

APTD

AFDC

OAA

AB

APTD

AFDC

Children <21

Prescribed Drugs



















Inpatient Hospital Care



















Outpatient Hospital Care



















Laboratory & X-ray Service



















Skilled Nursing Home Services



















Physician Services





























Dental Services

SFO

1

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $41,254,973 57,733

1999* Expended Recipients

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 Children - Families w/Dep. Children Adults - Families w/Dep. Children Other Title XIX Recipients MEDICALLY NEEDY TOTAL Aged Blind Disabled Children - Families w/Dep. Children Adults - Families w/Dep. Children Other Title XIX Recipients Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-District of Columbia

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION

Pharmacy Payment and Patient Cost Sharing

The District of Columbia Department of Health (DOH), Medical Assistance Administration.

Dispensing Fee: $3.75.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; and ferrous sulfate. Prior authorization required for: injectable drugs administered on an outpatient basis; anorexic drugs for treatment of narcolepsy and minimal brain dysfunction in children; acute anti-ulcer drugs, and brand NSAIDS. Products not covered: all other non-legend items. Over-the-counter Product Coverage: Products covered: oral analgesics; oral antacids; contraceptive foams and jellies; prenatal vitamin formulations; geriatric vitamin formulations for recipients 65 and over; and multivitamin formulations for children 7 years of age and over. Coverage of Injectables: Injectable medicines reimbursable when used in physicians offices, home health care, and extended care facilities.

Ingredient Reimbursement Basis: AWP - 10%. Prescription Charge Formula: The lesser of: Upper limit established by HCFA or the AWP - 10% plus the dispensing fee or usual and customary to the public. Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary” with explanation. Incentive Fee: None. Patient Cost Sharing: $1.00 copay by recipient. Does not apply to recipients under 18, prescriptions for family planning, nursing home patients, or pregnancy related. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Recipients enrolled in managed care receive pharmaceutical benefits through managed care plans. Managed Care Organizations

Vaccines: Vaccines reimbursable at cost as part of the EPSDT service. Unit Dose: Unit dose packaging not reimbursable Formulary/Prior Authorization Formulary: Open formulary Prescribing or Dispensing Limitations

Advantage Health Plan, Inc. P.O. Box 9596 Washington, DC 20016 202/686-8555 American Preferred Provider Plan Mid-Atlantic, Inc. 1501 M Street, NW, Suite 500 Washington, DC 20002 202/408-0460

Monthly Quantity Limit: In general, amounts dispensed are to be limited to quantities sufficient to treat an episode of illness. Maintenance drugs such as thyroid, digitalis, etc. may be dispensed in amounts up to a 30-day supply with 3 refills that must be dispensed within 4 months. Antibiotic medications used in treatment of acute infections are not to be dispensed in excess of a 10-day supply. Birth control tablets may be dispensed in 3-cycle units with a maximum of 3 refills within one year.

D.C. Chartered Health Plan 820 First Street, NE, Ste. LL100 Washington, DC 20002 202/408-4710

Monthly Dollar Limits: $1,500 limit. Physicians are to request prior authorization for prescriptions that exceed this amount.

George Washington University Health Plan 4550 Montgomery Avenue Beheads, MD 20814 301/941-2044

Capitol Community Health Plan 750 First Street, NE, Ste. 1120 Washington, DC 20002 202/408-0460

Drug Utilization Review PRODUR system implemented in September 1996.

National Pharmaceutical Council

District of Columbia-2

Pharmaceutical Benefits 2000 Health Right, Inc. 3020 14th Street, NW Washington, DC 20009 202/518-2370 Prudential Health Care Plan 2800 N. Charles Street Baltimore, MD 21218 410/554-7224

F. STATE CONTACTS State Drug Program Administrator Donna Bowel Pharmacist Consultant Commission on Health Care Finance 2100 M.L. King Jr. Ave. SE Suite 302 Washington, DC 20020 202/727-0753 District of Columbia DUR Board Christopher Keeyes, Pharm.D. (Chair) President, Clinical Pharmacy Associates 11710 Beltsville Drive, Suite 510 Calberton, MD 20705 301/572-1616 Martin Dillard, M.D. (Vice Chair) Assistant Dean for Clinical Affairs Chief, Division of Nephrology Howard University Hospital 2041 Georgia Avenue, NW, Suite 5C02 Washington, DC 20060 202/865-1191 Howard Robinson, R.Ph. Manager, Central Pharmacy Greater Community Hospital 1310 Southern Avenue, SE Washington, DC 20032 Dr. Kim Bullock Providence Hospital Emergency Room 1150 Varuum St., NE Washington, DC 20017 202/269-7863 Medicaid Drug Rebate Contacts Technical: Ken Boni, 202/965-7400 Policy: Donna Bovell, 202/727-0753 DUR: Donna Bovell, 202/727-0753

3-District of Columbia

Physician-Administered Drug Program Contact Donna Bovell 202/727-0753 Department of Human Services Officials Geraldine Williams Director Department of Human Services 2700 MLK Avenue, SE (801 East Bldg.) Washington, DC 20023 Marlene Kelly, M.D. Acting Director Department of Health 1660 L Street, NW 12th Floor Washington, DC 20002 Paul Offner Deputy Director, DOH Medical Assistance Administration 2100 M.L. King Jr. Ave. SE Suite 302 Washington, DC 20020 Executive Officers of District Medical and Pharmaceutical Societies Medical Society of the District of Columbia K. Edward Shanbacker 2215 M St., NW Washington, DC 20037-2059 202/466-1800 Pharmaceutical Association Herbert Kwash, R.Ph., President 6406 Georgia Ave, NW Washington, DC 20012 202/829-1515 Osteopathic Association Roy Heaton, D.O., Secretary 4001 N. 9th Street, Suite 216 Arlington, VA 22203 703/522-8404 DC Board of Pharmacy Cheryl A. Robinson, Chair 614 H Street N.W., Rm. 904 Washington, DC 20001 202/727-7468

National Pharmaceutical Council

Pharmaceutical Benefits 2000 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. Washington, DC 20001 202/783-5610

National Pharmaceutical Council

District of Columbia-4

Pharmaceutical Benefits 2000

FLORIDA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

Other

OAA

AB

APTD

AFDC

OAA

AB

APTD

AFDC

Children <21

Prescribed Drugs



















Inpatient Hospital Care



















Outpatient Hospital Care



















Laboratory & X-ray Service



















Skilled Nursing Home Services







Physician Services



















Dental Services



SFO



1

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

B. EXPENDITURES FOR DRUGS

TOTAL RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult

1998* Expended Recipients $933,782,041 1,014,372

1999 Expended $1,089,866,582

Recipients 982,886

$710,423,515 $126,584,312 $509,397,909 $26,292,425 $36,189,923 $4,312,209 $7,646,737

555,823 76,097 212,404 151,467 69,409 25,383 21,063

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult

$46,363,601 $62,129 $38,021,526 $2,782,675 $5,497,271

19,024 20 8,395 3,521 7,088

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

$193,659,597 $71,343,167 $93,785,943 $22,471,261 $6,059,226

282,166 45,811 36,579 145,201 54,575

OTHER

$139,419,869

125,873

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1998 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

C. ADMINISTRATION Agency for Health Care Administration. Claims processing and payment by contract with fiscal agent. 1-Florida

National Pharmaceutical Council

Pharmaceutical Benefits 2000

D. PROVISIONS RELATING TO DRUGS

3.

Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; total parenteral nutrition; and urine ketone test strips for children under age 21. Prior authorization required for: Cytogam; Proleukin; Serostim; Albumin; Neutrexin; Provigil; Zoloft 50mg; Paxil 10mg; Panretin gel; Regranex (long term care); Botox; and nutritional supplements. Products not covered: cosmetics; fertility drugs; experimental drugs; and interdialytic parenteral nutrition. Over-the-Counter Product Coverage: Products covered: smoking deterrents; allergy, asthma and sinus medication (limited); analgesics (aspirin); cough and cold preparations (only children under 21 years); feminine products (prior Rx only); iron supplements; Guaifenesin; and vaginal antifungals. Products not covered: digestive products (H2 antagonists) and topical products. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antipsychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; ENT antiinflammatory agents; estrogens; hypotensive agents; misc. GI drugs; prescribed smoking deterrents (only children under 21 years); sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: growth hormones. Therapeutic categories not covered: anorectics. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facilities, and through physician payment when used in physician offices.

4. 5. 6. 7. 8. 9.

Non-legend drugs (except for prescribed insulin, pancreatic enzymes, buffered and enteric coated aspirin when prescribed as an anti-inflammatory agent only, and single entity hematinics). Anorexants unless the drug is prescribed for an indication other than obesity (i.e. narcolepsy, hyperkinesis). Drugs with questionable efficacy as rated by FDA (DESI). Investigational and experimental items. Oral vitamins with exception of fluorinated pediatric vitamins prescribed for pediatric patients, vitamins for dialysis patients, prenatal vitamins. Smoking cessation products only to EPSDT clients under age 21. Nursing home floor stock drugs.

Prior Authorization: State currently has a formal prior authorization procedure. An appeal hearing request is required to appeal prior authorization decisions. Prescribing or Dispensing Limitations Prescription Refill Limit: 1.

2. 3.

4. 5. 6.

Six (6) prescriptions monthly for community patients; 8 prescriptions per month for institutionalized patients. Increased grants are available based on need and diagnosis. Maintenance medication should be dispensed and billed for at least a one-month supply. Refills must be authorized by the prescriber and can be made for up to one year, except that controlled substances can be refilled only in accordance with federal and state regulations. Anti-ulcer, anti-anxiety, and sedative hypnotic drugs limited to 1 per therapeutic class per month, 1 refill per prescription. Nutritional supplements are covered with prior authorization when the patient is otherwise at risk of hospitalization. Other third parties, including Medicare, must be billed first

Vaccines: Vaccines reimbursable as part of the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization Formulary: Open formulary with the following limits and exclusions. 1. 2.

Vitamins and phosphate binders only for dialysis patients. Prostheses; appliances; devices; and personal care items.

National Pharmaceutical Council

Florida-2

Pharmaceutical Benefits 2000 Drug Utilization Review PRODUR system implemented in July 1994. State currently has a DUR board with a quarterly review. Retrospective Drug Utilization Review has been in place since 1982. The state Medicaid agency and the Florida Pharmacy Association, which performs the reviews, share the administration of the program. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.23, effective 3/11/86. Ingredient Reimbursement Basis: AWP-13.25 %. Prescription Charge Formula: Lower of: 1. 2. 3. 4.

FUL (Federal Upper Limits or State MAC) plus dispensing fee. EAC plus dispensing fee. Usual and customary charge. In-house unit dose diff. + 0.015/dose.

Maximum Allowable Cost: State imposes Federal Upper Limits and State Specific Limits on generic drugs. Provisions for MAC override by physicians only if listed on negative formulary. Incentive Fee: No incentive fee. Patient Cost Sharing: No copayment Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE All Medicaid recipients receive pharmaceutical benefits through managed care plans (inclusion of such benefits is mandated under state law). Managed Care Organizations Alpha Health Plan, Inc. Beacon Health Plans, Inc. Contact: Ana M. Berenguer 2511 Ponce de Leon Blvd., 5th Floor Coral Gables, FL 33134 305/774-2599 Discovery Plan Contact: Robert Wychulis 3520 Thomasville Road, Suite 200 Tallahassee, FL 32308 850/894-0100 ext. 801

3-Florida

Florida 1st Health Plans, Inc. Contact: Frank Willis 3425 Lake Alfred Road Winter Haven, FL 33881 941/293-0785 Foundation Health, A Florida Health Plan, Inc. Contact: Michael Comerford 1340 Concord Terrace Sunrise, FL 33323 800/422-7335 Healthease Contact: Christopher O’Connor 6800 N. Dale Mabry Hwy., Suite 168 Tampa, FL 33614-3988 813/290-6358 Healthy Palm Beaches, Inc. Humana Family Contact: Patricia L. Hubrig c/o Humana Medical Plan, Inc. 3400 Lakeside Drive, 5th Floor Miramar, FL 33027 305/626-5616 Jackson Memorial Health Plan Contact: Taryn Davis 1801 NW 9th Ave., Suite 700 Miami, FL 33136 305/575-3700 MedChoice Health Plan Contact: Jeffery G. Keiser 5300 West Atlantic Avenue Delray Beach, FL 33484-8190 561/496-0505 Neighborhood Health Partnership, Inc. Contact: Heidi Etzold 7600 Corporate Center Dr., Suite 300 Miami, Fl 33126-1216 305/715-4318 Personal Health Plan Contact: Debi L. Gavras Dr. Jeff Davis, D.O. (Interim) 324 Datura Street, Suite 401 West Palm Beach, FL 33401 561/659-1270 ext. 5885

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Physicians Healthcare Plans, Inc. Contact: Peter Jimenez 2333 Ponce de Leon Blvd. Ste 303 Coral Gables, FL 33134 305/441-9400 ext. 125 Preferred Medical Plan, Inc. Contact: Tamara Meyerson 4950 SW 8th Street Coral Gables, FL 33134 305/445-8373 St. Augustine Health Care, Inc. Contact: Mary Lynn Leach Mail: P.O. Box 23160 Location: 4300 NW 89th Blvd. Gainesville, FL 32606 352/337-8650 Stay Well Health Plan Contact: Nancy Gareau 6800 N. Dale Mabry Hwy., Ste. 209-211 Tampa, FL 33614 813/290-6283 United Healthcare of Florida, Inc. Contact: Linna Van Nette 800 North Magnolia Ave., Suite 600 Orlando, FL 32803 407/872-1000 United ElderCare Plan 800 N. Magnolia Ave., #600 Orlando, FL 32803 800/643-5337

F. STATE CONTACTS State Drug Program Administrator Jerry F. Wells Pharmacy Program Manager Agency for Health Care Administration 2727 Mahan Drive, MS 38 Tallahassee, FL 32308 T: 850/487-4441 F: 850/922-0685 E-mail: [email protected] Agency for Health Care Administration Officials Ruben J. King-Shaw, Jr., Director Agency for Health Care Administration Gary Crayton, Director for Medicaid 850/488-3560

National Pharmaceutical Council

Prior Authorization Contact Linda Anthony, R.Ph. Senior Pharmacist Agency for Health Care Administration 2727 Mahan Drive Tallahassee, FL 32308 T: 850/922-0679 F: 850/922-0685 DUR Contact Coordinator: Marie Donnelly-Stephens Senior Health Care Program Analyst Agency for Health Care Administration 2727 Mahan Drive Tallahassee, FL 32308 T: 850/487-4441 F: 850/922-0685 Medicaid DUR Board Matthew Cohen, M.D. Bryan A. Bognar, M.D. David B. Levine, D.P.M., D.O. Richard Roberts, Pharm.D. Michael Thompson, Pharm.D. Earlene E. Lipowski, Ph.D. Mechelle LaWarre, Pharm.D. Larry L. Mattingly, D.O. L. Leanne Lai, Ph.D. Lynn G. Massey, Pharm.D. Program Retro-DUR Gaylon Fruit, R.Ph. Director Retro DUR Program Prescribing Pattern Review Panel J. David Moore, M.D. Walter Flesner, D.O. Daryl D. Wier, M.D. Mary Stelnicki, R.Ph. Stephen Clark, M.D. Dennis Penzell, D.O. B.L. Stalnaker, M.D. Cynthia Griffin, Pharm.D. Prescription Price Updating First Data Bank

Florida-4

Pharmaceutical Benefits 2000 Medicaid Drug Rebate Contacts Technical: Ralph Quinn, 850/488-9190 Policy: Jerry Wells, 850/487-4441 Audits: Jerry Wells, 850/487-4441 Disputes: Greg Bracko, 850/488-9193 Claims Submission Contact

S. Shai Gold, Director, Business and Proposal Development Center The South Florida Community Care Network 1801 NW 9th Avenue, Ste 700 Miami, FL 33136 T: 305/585-5187 F: 305/585-3815 E-mail: [email protected]

Mark Steck PBM Director Consultec, Inc. 9040 Roswell Road, Suite 700 Atlanta, GA 30350 770/594-7799

Diabetes: Virginia M. Dollar Coordinated Care Solutions 210 N. University Drive, Ste 700 Coral Springs, FL 33071 T: 954/344-2444 F: 954/796-3688

Medicaid Managed Care Contact

Asthma: ITG (program sponsor)

Ralph Anderson, R.N. Agency for Health Care Administration 2727 Mahan Drive, BLD 1, Rm 323 Tallahassee, FL 32308 T: 850/487-0640 F: 850/414-5418 Disease Management Program/Initiative Contact Hemophilia: Michael L. Ansel Accordant Health Services 5509-A West Friendly Avenue, Ste 101 Greensboro, NC 27410 T: 336/855-5870 ext.134 F: 336/852-7413 E-mail: [email protected] George E. Hurrell, Jr. Director, Disease Management Caremark Inc. 1127 Bryn Mawr Avenue Redlands, CA 92374 T: 909/799-4160 F: 909/7998-4335 E-mail: [email protected] AIDS: Peter D. Reis Director of Business Development AIDS Healthcare Foundation 6255 West Sunset Blvd, 16th Fl. Los Angeles, CA 90028 T: 213/860-5200 F: 213/860-5235 E-mail: [email protected]

5-Florida

Plans exist for disease management programs for EndStage Renal Disease (ESRD) and congestive heart failure. Contact: Bob Sharpe Assistant Deputy Director for Medicaid Agency for Health Care Administration 2727 Mahan Drive Tallahassee, FL 32308 850/488-3560 Physician-Administered Drug Program Laura Rutledge 850/488-4481 Executive Officers of State Medical and Pharmaceutical Societies Florida Medical Association, Inc. Charles S. Amorosino, Jr. P.O. Box 10269 123 S. Adams St. Tallahassee, FL 32301 904/224-6496 Florida Pharmacy Association Michael Jackson, R.Ph. Executive Vice President 610 North Adams Street Tallahassee, FL 32301 850/222-2400 Florida Osteopathic Medical Association Larry Mattingly, D.O. 2007 Apalachee Parkway The Hull Building Tallahassee, FL 32301 850/878-7364

National Pharmaceutical Council

Pharmaceutical Benefits 2000 State Board of Pharmacy 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

National Pharmaceutical Council

Florida-6

Pharmaceutical Benefits 2000

GEORGIA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)* OAA

AB

APTD

Other

OAA

AB

APTD

AFDC

AFDC** Children <21

Prescribed Drugs













Inpatient Hospital Care













Outpatient Hospital Care













Laboratory & X-ray Service













Skilled Nursing Home Services













Physician Services













Dental Services













SFO

1

See Appendix E, page E-29, for a list of acronyms. *Aged, Blind & Disabled (all services) effective April, 1990 **Pregnant Women Only

B. EXPENDITURES FOR DRUGS

TOTAL

1998 Expended $370,562,935

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

$242,900,444 $36,834,592 $177,559,013 $14,661,159 $13,845,680

344,678 38,041 151,138 108,295 47,204

$41,423,040 $804,074 $787,847 $32,698,175 $7,132,944 $0

330,361 1,409 926 257,296 70,730 0

$740,135 $75,378 $657,789 $6,968 $0 $0

458 57 372 29 0 0

CATEGORICALLY NEEDY NON-CASH TOTAL Aged Blind/Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients MEDICALLY NEEDY TOTAL Aged Blind/Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients

Recipients 805,923

1999* Expended Recipients

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable .

1-Georgia

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION Department of Community Health, Division of Medicaid

D. PROVISIONS RELATING TO DRUGS Benefit Design

Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization Formulary: Closed formulary. Prior Authorization: State currently has a formal prior authorization procedure

Drug Benefit Product Coverage: Products covered: prescribed insulin; prescribed disposable needles; and syringe combinations for insulin. Products covered with restrictions: blood glucose test strips (100 per month); urine ketone test strips (100 per month); total parenteral nutrition (21 and younger); and interdialytic parenteral nutrition (21 and younger). Products requiring prior authorization: Marinol; Epoetin; interferons; lactulose; neupogen; acutretin; top.vit.A derivatives; blood factors; toradol; H2RA full dose > 2months; Regranex; Viagra; PPIs; Sucralfate full dose after 2 months; brand names and multi-source; and hemophilia clotting factors. Products not covered: cosmetics; fertility drugs; experimental drugs; prescription vitamins and minerals (except for prenatal and fluorides not in combination with other vitamins); barbituates (except Seconal); DESI drugs; and Miralax.

Prescribing or Dispensing Limitations:

Over-the-Counter Product Coverage: Products covered: analgesics (Ibuprofen suspension) covered with restriction for ages less than 21; cough and cold preparations; PINX; NIX; iron; and meclizine. Products not covered: digestive products; feminine products; topical products; and smoking deterrent products.

Dispensing Fee: $4.63, effective 7/1/98.

Therapeutic Category Coverage: Therapeutic Categories Covered: antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antilipemic agents; antipsychotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (andrenergic); and thyroid agents. Prior authorization required for: anabolic steroids; analgesics, antipyretics, NSAIDS for single source; anorectics; antihistamine drugs for non-sedating >21yo; anxiolytics, sedatives, and hypnotics; growth hormones; and immunoglobulins. Therapeutic categories not covered: prescribed smoking deterrents. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities, and through physician payment when used in physicians offices.

Prescription Refill Limit: Maximum of five refills for adults, six for children Monthly Quantity Limit: Physicians are encouraged to prescribe a 31-day supply. Monthly Dollar Limit: $1000, followed by manual review. Drug Utilization Review On-line PRODUR system implementation planned with a Sept.1, 2000 start date. State currently has a DUR Board under development. Pharmacy Payment and Patient Cost Sharing

Ingredient Reimbursement Basis: EAC = AWP - 10%. Prescription Charge Formula: Lower of average wholesale price (AWP) minus 10% plus dispensing fee, MAC plus fee, or usual and customary. Maximum Allowable Cost: State imposes Federal Upper Limits and State Specific Limits on generic drugs. Override requires “Brand Medically Necessary.” Approximately 55 drugs on the state-specific MAC list. Incentive Fee: None. Patient Cost Sharing: $0.50 per prescription copayment (branded or generic). Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Does not use MCOs to deliver services to Medicaid recipients. Program discontinued October 1999.

Vaccines: Vaccines reimbursable as part of the EPSDT service, Children Health Insurance Program, and as part of the Vaccines for Children Programs.

National Pharmaceutical Council

Georgia-2

Pharmaceutical Benefits 2000

F. STATE CONTACTS State Drug Program Administrator Etta L. Hawkins, R.Ph. Department of Community Health-Medical Division 2 Peachtree Street, 37th Floor Atlanta, GA 30303-3159 T: 404/657-7239 F: 404/656-8366 E-mail: [email protected] Agency Internet Address: http://www.state.ga.us/dch Department of Community Health

Catherine E. Burley, M.D., Chairperson 7365 Old National Hwy, Ste A Riverdale, GA 30296 Hal J. Henderson, R.Ph. Medical Arts Health Care 1483-B Milstead Ave. Conyers, GA 30012 Randall T. Maret, R.Ph. Vice Chairperson Maret’s Prescription Shop 222 N. Pentz Street Dalton, GA 30720

Russ Toal, Commissioner Department of Community Health 2 Peachtree Street Atlanta, GA 30303-3159 404/656-4479

J. Russell May, Pharm.D. Department of Pharmacy Medical College of Georgia Hospital and Clinics 1120 15th Street Augusta, GA 30912-5600

Herb Weldon, Deputy Commissioner Bill Connell, Interim Director Div. of Professional Services Dona Cole, Director Division of Acute Car 2 Peachtree Street Atlanta, GA 30303-3159

A. Thomas Taylor, Pharm.D. Medical College of Georgia College of Pharmacy Department of Family Medicine 4799 Hereford Farm Road Evans, GA 30809

Prior Authorization Contact Jean Cox, R.Ph. DUR/PA Coordinator DCH Medicaid 2 Peachtree Street, 37th floor Atlanta, GA 30303-3159 T: 404/657-7241 F: 404/656-8366 E-mail: [email protected] DUR Contact Jean Cox, 404/657-7241 Medicaid DUR Board John Stephen Antalis, M.D. Dalton Family Practice, P.C. 1114 Professional Blvd. Dalton, GA 30720 Term: 7/1/97-6/30/99 Edwin D. Bransome, Jr., M.D. Department of Medicine Room BIW-542 Medical College of Georgia Augusta, GA 30912-3185

3-Georgia

Earl S. Ward, Pharm.D. Mercer University School of Pharmacy 3001 Mercer University Drive Atlanta, GA 30341 Gary C. Richter, M.D, Consultative Gastroenterology 121 Linden Avenue, Suite 103 Atlanta, GA 30308 Norman C. Moore, M.D. Brain Research Center 655 First Street Macon, GA 31201 John Dorland Rowlett, M.D. Children’s Hospital at Memorial Medical Center PO Box 23089 Savannah, GA 31403 J.Grady Strom, Jr. Ph.D. Mercer University School of Pharmacy 3001 Mercer University Drive Atlanta, GA 30341-4155 Harry Strothers, M.D. 505 Fairburn Rd. S.W. Atlanta, GA 30331

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Reuben S. Roberts, Jr., M.D. Pulaski Professional Building P.O. Drawer 1237 Hawkinsville, GA 31036 Prescription Price Updating Etta L. Hawkins, 404/657-7239 Medicaid Drug Rebate Contacts Policy: Susan Oh, 404/657-9181 PA: First Health Services, 770/916-9269 Audits: Susan Oh, 404/657-9181 Claims Submission Contact Cheryl Collier Account Manager, EDS 736 Park North Blvd P.O. Box 736 Clarkston, GA 30021 T: 404/297-3700 F: 404/298-1031 Medicaid Managed Care Contact Kathy Driggers Director, Managed Care Department of Community Health 2 Peachtree Street, N.W. Atlanta, Georgia 30303 T: 404/657-7793 F: 404/656-8366 E-mail: [email protected] Disease Management Program/Initiative Contact Mark Trail Director of Program Policy Department of Community Health- Medicaid 2 Peachtree Street, N.W. Atlanta, Georgia 30303 T: 404/657-1502 F: 404/656-8366 E-mail: [email protected] Physician-Administered Drug Program Contact Shirley Benson 2 Peachtree Street, N.E. Atlanta, Georgia 30303 404/656-3961

National Pharmaceutical Council

Medical Assistance Advisory Committees Representatives from each of the following groups: Medical Association of Georgia Georgia Pharmaceutical Association Atlanta Medical Association Georgia Health Care Association Georgia Hospital Association Georgia Dental Association Georgia Osteopathic Medical Association National Pharmaceutical Association Executive Officers of State Medical and Pharmaceutical Societies Medical Association of Georgia Paul Shanor Executive Director 938 Peachtree Street, N. E. Atlanta, GA 30309 404/876-7535 Georgia Pharmaceutical Association Oren “Buddy” Harden Executive Vice President 20 Lenox Pointe, P.O. Box 95527 Atlanta, GA 30347 404/231-5074 Osteopathic Medical Association Jerome E. Mersberger, D.O. Secretary/Treasurer 2160 Idlewood Road Tucker, GA 30084 770/493-9278 State Board of Pharmacy Gregg W. Schuder Executive Director 166 Pryor Street, SW Atlanta, GA 30303 404/656-3912 Medical Georgia Association Katherine Daniels Executive Director Morehouse School of Medicine 720 Westview Drive, S.W. Atlanta, GA 30310-1495 404/752-1564 Georgia Hospital Association Joseph A. Parker President 1675 Terrell Mill Road Marietta, GA 30067 770/955-5801

Georgia-4

Pharmaceutical Benefits 2000

HAWAII A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 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

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $39,623,380 32,222

1999* Expended Recipients

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 Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients MEDICALLY NEEDY TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients 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. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Hawaii

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION

Prescribing or Dispensing Limitations

By the State Department of Human Services through its Med-Quest Division and four county branch offices.

Quantity of Medication: Physicians are encouraged to 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.

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations for insulin; blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Products requiring prior authorization: Clorazil; Procardia XL; Norvasc; brand products on FUL price list; and Betaseron. Products not covered: cosmetics; fertility drugs; and experimental drugs. Over-the-Counter Product Coverage: Products covered: some allergy, asthma and sinus products; some analgesics; some cough and cold preparations; digestive products; some feminine products; and some topical products. Products covered with restrictions: some non-H2 antagonist digestive products and H2 antagonist digestive products (requires diagnosis of H. Pylori, GERD, etc.). Products not covered: smoking deterrent products. Therapeutic Category Coverage: Prior authorization required for: anabolic steroids; anorectics; antihistamine drugs; anti-psychotics; anxiolytics, sedatives, and hypnotics; estrogens; misc. GI drugs; prescribed smoking deterrents; proton pump inhibitors; single source NSAIDs; chemotherapy agents; and growth hormones. Coverage of Injectables: Injectable medicines reimbursable through the prescription drug program when used in home health care, extended care facilities, and through physician payment when used in physicians offices. Vaccines: Vaccines reimbursable as part of EPSDT service if not covered by the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable Formulary/Prior Authorization Formulary: Open formulary. Prior Authorization: State currently has a formal prior authorization procedure. A fair hearing may be requested for appeal of prior authorization decisions.

National Pharmaceutical Council

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.67, effective May 9, 1990. Ingredient Reimbursement Basis: EAC = AWP - 10.5%. Prescription Charge Formula: Payment for prescription and OTC drugs listed in the formulary is limited to the federally established MAC price, or Estimated Acquisition Cost (EAC) plus dispensing fee, or billed amount, whichever is lowest. Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary” and “Dispense As Written” as well as prior authorization approval. Exclusions: anti-seizure medication and oral contraceptives. Incentive Fee: None. Patient Cost Sharing: No copayment. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 140,000 total unduplicated number of Medicaid recipients were enrolled in MCOs in FY 1999. Recipients receive pharmaceutical benefits through state/managed care plans or both. Managed Care Organizations DentiCare Wesley K.S. Mun 900 Fort Street Mall, Suite 930 Honolulu, HI 96813 808/528-4904 Hawaii Medical Service Association (HMSA) Ms. Carolyn J. Gire, Director QUEST Administration 818 Keeaumoku Street Honolulu, HI 96808 808/948-6588

Hawaii-2

Pharmaceutical Benefits 2000 Queen’s Hawaii Care Mr. Richard M. Jackson, General Manager Two Waterfront Plaza 500 Ala Moana Boulevard Honolulu, HI 96813 808/522-7522 Straub Clinic and Hospital, Inc. Deborah Stampfle, Executive Director 641 Kailua Road Kailua, HI 96734 Tube 63 808/266-6554 AlohaCare, Inc. Mr. John McComas 1357 Kapiolani Blvd., Suite 1250 Honolulu, HI 96814 808/973-1650 Kaiser Foundation Health Plan, Inc. Ms. Virginia Vierra 1441 Kapliolani Blvd, Suite 1600 Honolulu, HI 96814 808/944-0261 Kapliolani Health Hawaii Plan Administrator: Greg Oishi 55 Merchant Street, 27th Floor Honolulu, HI 96813-4306 808/535-7425 Behavioral Health Services Community Care Services (CCS) Sharon Yoshiura or Carolyn Gire 810 N. Vineyard Blvd. Honolulu, HI 96817 T: 808/ 948-5379 F: 808/948-6588

F. STATE CONTACTS Medicaid Drug Program Administrator Lynn Donovan, R.Ph. Medicaid Pharmacy Consultant Med-Quest Division P.O. Box 339 Honolulu, HI 96809-0339 T: 808/692-8116 F: 808/692-8131 Prior Authorization Contact Lynn S. Donovan 808/692-8116

3-Hawaii

DUR Contact Kathleen Kang-Kaulupali, 808/692-8115 Medicaid DUR Board Myron Shirasu, M.D. (Internal Medicine) 321 North Kuakini Street #200 Honolulu, HI 96817 808/523-8611 Gregory E.M. Yuen, M.D. (Psychiatry) Chair 1154 Fort Street Mall, Suite 200 Honolulu, HI 96813 808/599-5050 Linda Tom MD (Geriatric Medicine) 347 N. Kuakini Street, HPM-9 Honolulu, HI 96817 808/523-8461 James Lumeng, M.D. (Medicine/Pathology) 850 West Hind Drive, #114 Honolulu, HI 96821 808/377-5485 Brian Matsuura (Medical Services Rep.) 864 Kealahou St. Honolulu, HI 96825 808/396-3974 Joy Higa, R.Ph. (Long Term Care) 47-135 Heno Place Kaneohe, HI 96744 808/239-6353 Karen Huang, R.Ph. (Ambulatory Care) 1010 Pensacola Street Honolulu, HI 96814 F: 808/597-2549 Pager: 808/363-0838 Kerry Kitsu, R.Ph. (Community, chain) 98-629 Nohoalii Street Aiea, HI 96701 T: 808/536-5542 F: 808/536-0659 Carl Mudrick, R.Ph. (Community, independent) 2011 Coyne Street Honolulu. HI 96826 T: 808/739-1188 F: 808/735-6545

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Prescription Price Updating First Data Bank 111 Bayhill Dr. San Bruno, CA 94066 800/633-3453 Medicaid Drug Rebate Contacts Technical: Lynn Donovan, 808/692-8116 Policy: Lynn Donovan, 808/692-8116 Audits: Lynn Donovan, 808/692-8116 DUR: Kathleen Kang-Kaulupali, 808/692-8115

State Board of Pharmacy Ruth Gushiken Executive Secretary P. O. Box 3469 Honolulu, HI 96801 808/586-2698 Healthcare Association of Hawaii Richard E. Meiers Pres., CEO 932 Ward Avenue Suite 430 Honolulu, HI 96814-2126 808/521-8961

Claims Submission Contact HMSA - Medicaid Claims Service Attn: Luukia Abbley P.O. Box 860 Honolulu, HI 96808 808/948-5361 Department of Human Services Officials Susan M. Chandler, Director Department of Human Services 808/586-4997 Chuck Duarte Administrator, Med-Quest Division Executive Officers of State Medical and Pharmaceutical Societies 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

Pharmaceutical Benefits 2000

IDAHO A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

OAA

AB

APTD

AFDC

Prescribed Drugs









Inpatient Hospital Care









Outpatient Hospital Care









Laboratory & X-ray Service









Skilled Nursing Home Services









Physician Services









Dental Services

OAA

AB

APTD

AFDC

Other Children <21

SFO



1

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998 Expended $54,971,097

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult

$15,699,226 $2,228,943 $12,543,258 $254,663 $669,332 $501 $2,529

11,194 1,434 6,397 2,098 1,231 10 24

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult

$0 $0 $0 $0 $0

0 0 0 0 0

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

$26,669,496 $14,394,179 $12,703,668 $857,649 $1,714,000

26,219 8,038 8,035 6,575 3,571

$5,318,605

37,215

OTHER

Recipients 86,775

1999* Expended Recipients

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Idaho

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION Idaho Medicaid Agency By the State Department of Health and Welfare through seven regional offices, each serves five or more of the State’s 44 counties.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations for insulin; blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: cosmetics; fertility drugs; and experimental drugs. OTC Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; permethrin; and oral iron salts. Products not covered: allergy, asthma, and sinus; analgesics, cough and cold preparations; digestive products; feminine products; topical products; and smoking deterrent products. Therapeutic Category Coverage: Therapeutic Categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT antiinflammatory agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: growth hormones. Therapeutic categories not covered: anorectics and prescribed smoking deterrents. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities, and through physician payment when used in physicians offices. Vaccines: Vaccines reimbursable as part of the Children Health Insurance Program, and the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable when used in unit dose systems.

Prior Authorization: State currently has a formal prior authorization procedure and a Growth hormone prior authorization committee. Written “notice of appeal” required for fair hearing. Prescribing or Dispensing Limitations Monthly Quantity Limit: Prescription drugs are limited to a 34-day supply. The following drugs are limited to a 100day supply: Digoxin, thyroids, prenatal vitamins, nitroglycerin, fluoride, fluoride and vitamin combinations, non-legend oral iron salts and 3 cycles of birth control. Drug Utilization Review Contracted DUR through Idaho State University. PRODUR system implemented January 1998. State currently has a DUR board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.94 ($5.54 for unit dose), effective March 1999. Ingredient Reimbursement Basis: EAC = AWP-11% as determined by First DataBank Data File Service or manufacturer direct price for selected manufacturers. Prescription Charge Formula: Lower of FUL, SMAC or EAC plus a dispensing fee or provider’s usual and customary price to the general public. Maximum Allowable Cost: State imposes Federal Upper Limits and state-specific limits on generic drugs. Override requires prior authorization. Incentive Fee: None. Patient Cost Sharing: No copayment. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Does not use MCOs to deliver services to Medicaid recipients. Some Medicaid recipients are enrolled in primary care case management and receive their benefits from the state.

Formulary Authorization Formulary: Open formulary.

National Pharmaceutical Council

Idaho-2

Pharmaceutical Benefits 2000

F. STATE CONTACTS Medicaid Drug Program Administrator Gary Duerr, R.Ph. Medicaid Policy Americana Terrace, Suite 140 P.O. Box 83720 Boise, ID 83720-0036 T: 208/364-1829 F: 208/364-1846 E-mail: [email protected] Prior Authorization Contact Gary Duerr, 208/364-1829 DUR Contact Gary Duerr, 208/364-1829 Medicaid DUR Board Board Members: Bill Johns, R.Ph. Don Smith, R.Ph. Kent Jensen, R.Ph. Barbara Wells, R.Ph. John Lassere, M.D. E. Gregory Thompson, M.D. Robert Ting, M.D. Clayton Morgan, M.D., retired Staff: Gary Duerr, R.Ph., Dept. Contact Vaughn Culbertson, Pharm.D. Project Dir. Prescription Price Updating First Data Bank Medicaid Drug Rebate Contacts Technical: Gary Duerr, R.Ph. 208/364-1829 Policy: Gary Duerr, 208/364-1829 DUR: Gary Duerr, 208/ 364-1829 PA: Gary Duerr, 208/ 364-1829 Audits: David Mendoza, 208/ 364-1838 Claims Submission Contact EDS P.O. Box 1168 Boise, ID 83701 208/395-2000

3-Idaho

Medicaid Managed Care Contact Pam Mason Primary Physician Managed Care Program Healthy Connections Manager P.O. Box 83720 Boise, ID 83720 T: 208/364-1890 F: 208/364-1846 E-mail: [email protected] Physician-Administered Drug Program Contact Robbie Charlton Medicaid Policy PO Box 83720 Boise, ID 83720-0036 Health and Welfare Department Officials Karl Kurtz, Director Dept of Health & Welfare, Medicaid Division Towers Building, 10th Floor PO Box 83720 Boise, Idaho 83720-0036 208/334-5500 Bureau of Medicaid Policy and Reimbursement Dee Anne Moore, Bureau Chief Joe Brunson, Medicaid Administration Gary Duerr, R.Ph., Pharmacy Services Specialist Tom Young, M.D., Medical Consultant Title XIX Medical Care Advisory Committee Bob Beutler 1217 Kirk Drive Moscow, ID 83943 208/882-5536 Rep. Max C. Black 3731 Buckingham Drive Boise, ID 83704 208/327-3400 Marj Boren 1002 E. Bannock Boise, ID 83712 208/342-4368 Sen. Hal Bunderson 582 River Heights Drive Meridian, ID 83642 208/888-7156

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Loni Debbon, President Idaho Head Start Association 200 N. 4th Boise, ID 83702 208/345-1182

JoAn Silva, Director Region III Health & Welfare 111 Poplar, PO Box 1219 Caldwell, ID 83606 208/459-7456

Bonnie Haines, Senior Vice President Idaho Hospital Association PO Box 1278 Boise, ID 83701-1278 208/338-5100

Acting Executive Director Idaho State Council on Developmental Disabilities 280 N. 8th, Suite 208 Statehouse Boise, ID 83720 208/334-2178

Steven Hanson Human Service Connection 1380 Benton Idaho Falls, ID 83401 208/523-2490

Scott Spears Idaho Health Care Association PO Box 2623 Boise, ID 83701 208/343-9735

Cathy Hart Idaho Office on Aging Statehouse, Room 108 Boise, ID 83720-0007 208/334-3833 Sally Higginson Boise Alliance for the Mentally Ill 331 N. Allumbaugh Boise, ID 83704 208/376-4304 Shirley Osborn 5553 W. Lockport Boise, ID 83703 208/334-3110 Jim Peart Idaho Legal Aid, Caldwell Area Office 708 Main Street, PO Box 1116 Caldwell, ID 83606-1116 208/345-2193 Cathleen Pierson 3368 N. 34th Street Boise, ID 83703 208/385-7305 Rex Redden, President IACOR PO Box 50457 Idaho Falls, ID 83405 208/523-0053 Bob Seehusen, Executive Director Idaho Medical Association 305 W. Jefferson Boise, ID 83702 208/344-7888

National Pharmaceutical Council

Executive Officers of State Medical and Pharmaceutical Societies Idaho Medical Association Robert Seehusen Executive Director 305 West Jefferson, P.O. Box 2668 Boise, ID 83702 208/344-7888 Idaho State Pharmaceutical Association Jo An Condie Executive Director 305 W. Jefferson, P.O. Box 140117 Boise, ID 83714 208/424-1107 Idaho Osteopathic Medical Association Ron Higgenbotham, D.O. Secretary-Treasurer 522 West Main Street Grangeville, ID 83530 208/983-1133 State Board of Pharmacy Richard K. Markuson Executive Director 3380 Americana Terrace #320 Boise, ID 83706 208/334-2356 Idaho Hospital Association Steven A. Millard President 802 West Bannock St. Suite 500 Boise, ID 83702-5842 208/338-5100

Idaho-4

Pharmaceutical Benefits 2000

ILLINOIS A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 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

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $583,239,675 959,472

1999* Expended Recipients

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 Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients MEDICALLY NEEDY TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Illinois

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION

Drug Utilization Review

Illinois Department of Public Aid, Division of Medical Assistance.

PRODUR system implemented in January 1993. State currently has a DUR board with a review on an as needed basis.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; and urine ketone test strips. Products not covered: cosmetics; DESI-ineffectives; fertility drugs; experimental drugs; total parenteral nutrition; and interdialytic parenteral nutrition. OTC Coverage: Products covered: digestive products (H2 antagonists) and smoking deterrent products. Products requiring prior authorization: analgesics; digestive products (non-H2 antagonist); and topical products. Products not covered: allergy, asthma, and sinus; cough and cold preparations; and feminine products. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in physician offices, home health care, and extended care facilities.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.75/$3.45 for generic/branded drugs costing up to $37.50; 10.46% of the drug cost for drugs costing $37.51 and more; maximum of $15.70/$15.40 for generic/branded drugs. Effective 7/1/99. Ingredient Reimbursement Basis: EAC = AWP - 10%, AWP - 12% for multisource drugs. Prescription Charge Formula: Lowest of 1) usual and customary, 2) Department's MAC plus fee. Professional fee: $3.58 up to EAC of $35.80; above EAC of $35.80, fee is 10% of EAC. Maximum Allowable Cost: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. All drugs are interchangeable in Illinois but not for those with a Federal MAC. Other drugs appear on the Illinois MAC list where the Federal MAC was inappropriate. Override requires prior authorization. Incentive Fee: None.

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 pharmaceutical benefits through managed care plans.

Prior Authorization: State currently has a formal prior authorization procedure and a Committee on Drugs and Therapeutics. Recipient must file an appeal with their local office in order to appeal prior authorization decisions. To appeal the coverage of an excluded product, the recipient can request the opportunity to appear before the Committee on Drugs and Therapeutics. Prescribing or Dispensing Limitations Prescription Refill Limit: Maximum of eleven refills. Monthly Quantity Limit: As medically appropriate.

National Pharmaceutical Council

Managed Care Organizations Americaid Community Care 211 Wacker Drive Suite 1350 Chicago, IL 60606-3101 United Health Care of IL 233 N. Michigan Ave. 8th Fl-12th Fl. Chicago, IL 60601 Harmony Health Plan of Illinois 125 South Wacker Drive Suite 2900 Chicago, IL 60606-4402

Illinois-2

Pharmaceutical Benefits 2000 Humana Health Plan 30 South Wacker Drive Suite 3100 Chicago, IL 60606 Illinois Masonic Community Health Plan 836 West Wellington Chicago, IL 60657-5147 Family Health Network 910 West Van Buren 6th Floor Chicago, IL 60607-3523 Neighborly Care Plan 129 N. Eighth Street East St. Louis, IL 62201-2999

Medicaid Drug Rebate Contacts Technical: Marvin Hazelwood, 217/524-7112 Policy: Marvin Hazelwood, 217/524-7112 Audits: Alberta Levan, 217/782-5565 Dispute Resolutions: Alberta Levan, 217/524-7161 Medicaid Managed Care Contact Nelly Ryan Bureau Chief Illinois Department of Public Aid 201 S. Grand Avenue East Springfield, Illinois 62763 T: 217/524-7478 F: 217/524-7535 Elderly Expanded Drug Coverage Program

F. STATE CONTACTS State Drug Program Administrator Marvin L. Hazelwood Illinois Department of Public Aid Division of Medical Assistance 1001 N. Walnut St. Springfield, IL 62702 T: 217/524-7112 F: 217/524-7194 E-mail: [email protected] Agency E-mail Address: http://www.state.il.us/dpa/ Prior Authorization Contact Rick Mazzotti, R.Ph. 217/787-6252 DUR Contact Starlin Hayden Greatting, R.Ph. Pharmacy Consultant, DUR coordinator Illinois Department of Public Aid 1001 N. Walnut St. Springfield, Illinois 62702 T: 217/524-7112 F: 217/524-7194 Prescription Price Updating First Data Bank 111 Bayhill Dr. San Bruno, CA 94066

3-Illinois

Cheryl Payne Supervisor, Circuit Breaker Program Illinois Department of Revenue 101 W. Jefferson - Level 3- 250 Springfield, Illinois 62794 217/785-2097 Physician-Administered Drug Program Contact Cheryl Bechner 217/782-5565 Illinois Medicaid Agency Officials Ann Patla, DR.HL Illinois Department of Public Aid Division of Medical Assistance 201 South Grand Avenue, East Springfield, IL 62763-0001 217/782-1200 Mary Ann Langston, Administrator Division of Policy Norman L. Ryan, Administrator Division of General Services Kenneth J. Durst, Chief Bureau of Research & Analysis Matt Powers, Administrator Division of Medical Programs Steve Bradley, Chief Bureau of Comprehensive Health Services

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Patty Steward, R.Ph., Pharmacist Consultant Department of Public Aid P.O. Box 19117 Springfield, IL 62794-9117 217/782-5565 Title XIX Medical Care Advisory Committees State Medical Advisory Committee Arthur Traugott, M.D. 32207 Weisiger Way Urbana, IL 61801 Committee on Drugs and Therapeutics Marshall Blankenship, M.D., Chairman 1555 Astor Avenue Chicago, IL 60610 708/636-3757 Nicholas C. Bellios, M.D. 2504 Washington Waukegan, IL 60085 708/249-3660 Armand Littman, M.D. Medical Services Hines VA Hospital Hines, IL 60141 708/216-2006 Vincent A. Costanzo, Jr., M.D. 7501 South Stony Island Avenue Chicago, IL 60649 312/995-1075 Theodore M. Kanellakes, M.D. 229 N. Hammes Avenue Joliet, IL 60435 815/744-2300 Patrick R. Staunton, M.D. 156 N. Oak Park Avenue Oak Park, IL 60301 708/696-5887 Board of Trustees Phillip D. Boren, M.D. Doctor's Clinic S. Plum Street Carmi, IL 62821 618/382-4193

National Pharmaceutical Council

Joan E. Cummings, M.D. Extended Care 181 Hines VA Hospital Building 1, Room C-124D Hines, IL 60141 708/343-7200 ext. 5057 David B. Littman, M.D. 1030 Old Elm Road Highland Park, IL 60035 708/433-3900 Richard P. Snodgrass, M.D. 550 30th Avenue Moline, IL 61265 309/764-1910 IDPA Representative Marvin Hazelwood Illinois Department of Public Aid 1001 N. Walnut St. Springfield, IL 62702 217/524-7112 Illinois State Medical Society Kenneth E. Ryan Director, Department of Economics 20 N. Michigan Avenue, Suite 700 Chicago, IL 60602 312/782-1654 IDPH Representative: Ron Gottrich, R.Ph Illinois Department of Public Health 525 W. Jefferson Springfield, IL 62761 217/782-7532 Executive Officers of State Medical and Pharmaceutical Societies Illinois State Medical Society Alexander R. Lerner Executive Vice President 20 N. Michigan Avenue, Suite 700 Chicago, IL 60602 312/782-1654 Illinois Pharmacists Association Mark Pilkington, R.Ph. Executive Director 223 W. Jackson, Suite 1000 Chicago, IL 60606-6908 T: 312/939-7300 F: 312/939-7220

Illinois-4

Pharmaceutical Benefits 2000

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 State Board of Pharmacy John Rosa Pharmacy Coordinator Illinois Department of Professional Regulation Pharmacy Section 320 West Washington Street, 3rd Floor Springfield, IL 62786 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

5-Illinois

National Pharmaceutical Council

Pharmaceutical Benefits 2000

INDIANA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

OAA

AB

APTD

AFDC

Prescribed Drugs









Inpatient Hospital Care









Outpatient Hospital Care









Laboratory & X-ray Service









Skilled Nursing Home Services









Physician Services









Dental Services









OAA

AB

APTD

AFDC

Other Children <21

SFO

1

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

B. EXPENDITURES FOR DRUGS 1998* Expended Recipients TOTAL

$325,712,348

1999* Expended Recipients

323,811

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult POVERTY RELATED, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult OTHER Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

National Pharmaceutical Council

Indiana-1

Pharmaceutical Benefits 2000

C. ADMINISTRATION

Legend Drug Reimbursement Methodology:

Office of Medicaid Policy and Planning

Lower/Lowest of:

D. PROVISIONS RELATING TO DRUGS

1. 2. 3.

Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: cosmetics; fertility drugs; and experimental drugs. Over-the-Counter Product Coverage: Products covered if prescribed by a physician: Indiana has a Medicaid OTC drug formulary. Listed drugs are reimbursed based on State MAC. Therapeutic Category Coverage: All coverage in accordance with OBRA ’90 & ’93. Coverage of Injectables: Covered. Vaccines: Vaccines reimbursable as part of the EPSDT service, the Children Health Insurance Program, and the Vaccines for Children Program. Unit Dose: In accordance with OBRA 1990 Requirements. MCFA policy only. Formulary/Prior Authorization Formulary: No formulary for legend drugs. All coverage in accordance with OBRA ’90 & ’93. No PA for drugs. Prior Authorization: State currently does not have a formal prior authorization procedure. Prescribing or Dispensing Limitations Prescribing Refill Limit: None. Drug Utilization Review PRODUR system implemented in March 1996. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing

Federal MAC, if applicable, plus a dispensing fee. EAC plus a dispensing fee. Pharmacy’s usual and customary charge to the general public.

Maximum Allowable Cost: State imposes Federal Upper Limits. Override requires “Brand Medically Necessary.” Incentive Fee: None. Patient Cost Sharing: Copayment varies from $0.50 to $3.00 for branded drugs and is $0.50 for generic drugs. Cognitive Services: None.

E. USE OF MANAGED CARE Approximately 330,000 total unduplicated number of Medicaid recipients were enrolled in MCOs in FY 2000. Recipients receive pharmaceutical benefits through managed care plans.

F. STATE CONTACTS State Drug Program Administrator Marc Shirley, R.Ph. Pharmacy Program Director Office of Medicaid Policy and Planning Room W382 Indiana State Government Center South 402 W. Washington Street Indianapolis, IN 46204-2739 T: 317/232-4343 F: 317/232-7382 E-mail: [email protected] *DO NOT CONTACT STATE DRUG PROGRAM ADMINISTRATOR WITH SURVEYS. DIRECT ALL INDUSTRY/INDUCTRY CONTRACTOR INQUIRIES IN WRITING TO: EDS 950 N. Meridian St, 10th Floor 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

Pharmaceutical Benefits 2000 DUR Contact

Medicaid Managed Care Contact

Karen Baer DUR Board Secretary Office of Medicaid Policy & Planning Room W-382, Indiana Sate Government Center South, 402 West Washington St. Indianapolis, IN 46204 T: 317/232-4391 F: 317/232-7382 E-mail: [email protected]

Sharon Steadman Managed Care Director Office of Medicaid Policy and Planning 402 W. Washington St Room W382, MS07 Indianapolis, IN 46204 T: 317/233-4697 F: 317/232-7382

Medicaid DUR Board Physicians Thomas Bright, M.D. Neil Irick, M.D. Patricia Treadwell, M.D. John J. Wienert, M.D. Pharmacists Paula Ceh, R.Ph. Hamid Abbaspour, R.Ph. Thomas A. Smith, R.Ph. G. Thomas Wilson, R.Ph. Health Care Economist (Vacant) Pharmacologist Terry Lindstrom, Ph.D.

Physician-Administered Drug Program Contact EDS 950 N. Meridian Street, 10th Floor Indianapolis, IN 46204 Administration Officials Kathleen D. Gifford Assistant Secretary Medicaid Policy & Planning Indiana Family & Social Services Administration 402 W. Washington Street, Room W382 Indianapolis, IN 46204 317/233-4455 Sharon Steadman Managed Care Director 317/233-4697

Representative from Med Care Kirby Davis, R.Ph.

Pat Nolting, Director Medicaid Program Operations 317/232-4318

Prescription Pricing Updating

Medicaid Advisory Committee

First Data Bank Medicaid Drug Rebate Contacts Marcia Finn Myers and Stauffer/EDS 317/488-5000 Claims Submission Contact EDS 950 N. Meridian Street, 10th Floor Indianapolis, IN 46204

John B. DeLap 2365 Chestnut Street Columbus, IN 47201 Deborah A. Freund 1327 East First Street Bloomington, IN 47402 Eleanor DeArman Kinney 5140 Reed Road Indianapolis, IN 46254 Kayla Templin West 1014 N. Arsenal Avenue Indianapolis, IN 46201 Edward A. White, D.O. 410 North Main Street Princeton, IN 47670-1516

National Pharmaceutical Council

Indiana-3

Pharmaceutical Benefits 2000 Beverly Richards, D.N.S., R.N. Indiana St. Nurses Association 2915 North High School Road Indianapolis, IN 46224-2969

Vickie Trout Division of Mental Health 402 W. Washington - W 353 Indianapolis, IN 46204

David Giles, M.D. 6934 Hillsdale Court Indianapolis, IN 46250

David Harris 125 East 48th Street Indianapolis, IN 46205

L. Richard Gohman One American Sq. - Ste 1100 Indianapolis, IN 46204

Donald Mulligan, Sr. 6185 Broughton Portage, IN 46368

Polly E. Hendricks, O.D. 3222 Oceanline E. Drive Indianapolis, IN 46214

Barry Delks 21 Peregrine Court West Lafayette, IN 47906

James F. Jones, M.S. 101 W. Ohio Street - Ste 610 Indianapolis, IN 46204

Lula E. Baxter 9710 East 38th Street Indianapolis, IN 46236

Mike Weber Indiana Health Care Association One N. Capital, Ste 1115 Indianapolis, IN 46204

R. Stanley Wilson, M.D. 3 Hazelwood Drive Vinciennes, IN 47591

Anna Schenk, Pres., ILPNA 1501 W. 500 North Marion, IN 47952 Paul C. Johnson, D.D.S. 8240 Naab Road Indianapolis, IN 46260 Robin Taylor, R.Ph., President Healthcare Prescription Svs, Inc. 3830 E. Southport Road, Ste C Indianapolis, IN 46237 Greg Wilson, M.D. Developmental Pediatrics 702 Barnhill Dr., Room 1601 Indianapolis, IN 46202 Sen. Marvin Riegsecker 801 S. 6th Street Goshen, IN 46526 Rep. William Crawford PO Box 18446 Indianapolis, IN 46218-0446

Paul Schneider, Ph.D. 6320 Latona Court Indianapolis, IN 46278 Robert S. Mandresh, D.P.M. 3351 N. Meridian #101 Indianapolis, IN 46208 Chip Garver 101 West Ohio, Suite 560 Indianapolis, IN 46204 Michael Sullivan Ind. Assn. For Home Care, Inc. 8888 Keystone Crossing Suite 1000 Indianapolis, IN 46202 Louis Cantor, M.D. 702 Rotary Circle Indianapolis, IN 46202 Joe D. Hunt, Director Bureau of Policy Development State Department of Health 1330 W. Michigan Street Indianapolis, IN 46202

Rep. Jeffrey K. Espich 1250 W. Hancock Street, Box 158 Uniondale, IN 46791

4-Indiana

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Executive Officers of State Medical and Pharmaceutical Societies Indiana State Medical Association Richard R. King Executive Director 322 Canal Walk, Canal Level Indianapolis, IN 46202-3252 317/261-2060 Indiana Pharmacists Association Larry Sage Executive Vice President 156 E. Market Street, #900 Indianapolis, IN 46204 317/634-4968 Indiana Association of Osteopathic Physicians and Surgeons, Inc. Michael Claphan Executive Director 3520 Guion Road, #202 Indianapolis, IN 46222 317/926-3009 State Board of Pharmacy Kristen Burch Director Indiana Health Professions Bureau 402 West Washington Street, Room 041 Indianapolis, IN 46204-2739 317/232-1140 Indiana Hospital and Health Association Kenneth G. Stella President One American Square P.O. Box 82063 Indianapolis, IN 46282

National Pharmaceutical Council

Indiana-5

Pharmaceutical Benefits 2000

IOWA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN) APTD AFDC*

Other

OAA

AB

APTD

AFDC

OAA

AB

Children <21

Prescribed Drugs



















Inpatient Hospital Care



















Outpatient Hospital Care



















Laboratory & X-ray Service



















Skilled Nursing Home Services



















Physician Services



















Dental Services



















SFO

1

See Appendix E, page E-29, for a list of acronyms. *Pregnant women

B. EXPENDITURES FOR DRUGS

TOTAL

1998 Expended $147,115,884

Recipients 215,173

RECEIVING CASH ASSISTANCE TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult

$82,025,517 $11,582,919 $57,606,338 $5,286,110 $6,159,274 $492,801 $898,075

99,753 8,054 33,570 32,489 18,297 3,817 3,526

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult

$11,600,186 $4,661,291 $5,986,116 $197,038 $755,741

8,454 3,388 2,540 742 1,784

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

$6,054,769 $1,201,194 $1,355,437 $2,707,203 $790,935

34,692 1,478 1,060 24,765 7,389

$46,573,607

67,074

OTHER

1999* Expended Recipients

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Iowa

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION State Department of Human Services, Division of Medical Services.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin. Products covered requiring prior authorization: PPIs; dipyridamole; epoetin; filgrastim; vitamins; ergotamine derivatives; narcotic agonistantagonist nasal sprays; isotretinoin; oral antifungals; nonparenteral vasopressin derivatives; and Serotonin 5-HT1 receptor agonists. Products not covered: fertility drugs; experimental drugs; cosmetics; disposable needles and syringe combinations for insulin; blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Over-the-Counter Product Coverage: Products covered with restriction (selected products): allergy, asthma and sinus products; analgesics; cough and cold preparations; H2 antagonists; and topical products. Products not covered: digestive products; feminine products; and smoking deterrent products. The Iowa Department of Human Services adopted an administrative rule that permits coverage for these nonprescription drugs: − Aspirin: 325/650 mg Tabs; 81mg Chewable; Aspirin Enteric Coated: 325/650mg Tabs; 81mg Chewable; Aspirin Tablets Buffered, 325 mg − Acetaminophen: 325/500mg Tablets; 120mg/5ml and 160mg/5mL Elixir; 100 mg/ml Solution; 120mg Suppositories − Bacitracin Ointment 500 units/gm − Benzoyl Peroxide 5% and 10%, Cleanser, Lotion, Cream, Gel − Chlorpheniramine Maleate Tablets 4 mg − Diphenhydramine Hydrochloride: 25 mg Capsules; 6.25mg/5mL and 12.5mg/5ml Liquid − Ferrous Sulfate: 300/325mg Tablets; 220mg/5ml Elixir; 75 mg/0.6 ml Drops − Ferrous Gluconate: 300/325mg Tablets; 300mg/5ml Elixir − Ferrous Fumarate Tablets 300 mg, 325 mg − 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

− Permethrin Liquid 1% − Pseudoephedrine Hydrochloride: 30/60 mg Tablets; 30mg/5mg Liquid − Salicylic Acid Liquid 17% − Senokot: 326 mg/tsp Granules for children aged 20 and under; 187 mg Tablets for children aged 20 and under − Sodium Chloride Solution 0.9% for inhalation, with metered dispensing valve 90 ml, 240 ml − Tolnaftate 1% Cream, Solution, Powder − Nonprescription multiple vitamin and mineral products specifically formulated and recommended for use as a dietary supplement during pregnancy and lactation − With prior authorization, nonprescription multiple vitamins and minerals under the conditions specified in subparagraph 78.1(2) “a” (3) − Insulin − Oral solid forms of the above-covered items shall be prescribed and dispensed in a minimum quantity of 100 units per prescription or the currently available consumer package size except when dispensed via a unit dose system. When used for maintenance therapy, all of the above-listed items may be prescribed and dispensed in 90-day quantities Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT antiinflammatory agents; estrogens; hypotensive agents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: analgesics, antipyretics, NSAIDs; amphetamines; antihistamine drugs; growth hormones; and misc. GI drugs. Therapeutic categories not covered: anorectics and prescribed smoking deterrents. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities, and through physician payment when used in physicians offices. Vaccines: Vaccines reimbursable as part of the EPSDT service and the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable.

Iowa-2

Pharmaceutical Benefits 2000 Formulary/Prior Authorization Formulary: No formulary. Prior Authorization: State currently has a formal prior authorization procedure. State appeals and a fair hearing procedure required for appeal of prior authorization decisions and coverage of an excluded product. Prescribing and Dispensing Limitations: Prescribing or Dispensing Limitations: None. Drug Utilization Review PRODUR system implemented in July 1997. State currently has a DUR Board with a monthly review. Pharmacy Payment and Patient Cost Sharing

John Deere Healthplan Cynthia Greene Administrator / Government Programs Attn: Government Programs 1300 River Drive, Suite 200 Moline, IA 61265 309/765-7637 Coventry Health Care of Iowa Lou Garcia, Executive Director 4600 Westown Parkway, Ste. 301 Des Moines, IA 50392-0445 515/225-1234 Iowa Health Solutions Paul Carter, President 2550 Middle Road, Ste. 405 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

Prescription Charge Formula: Payment will be based on the pharmacist's usual, customary and reasonable charge, but payment may not exceed EAC plus a dispensing fee. Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary.” Incentive Fee: None. Patient Cost Sharing: Copayment of $1.00 branded and generic (federal exclusions). Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Iowa Medicaid recipients receive pharmaceutical benefits through the state. Managed Care Organizations United Health Care of the Midlands, Inc. /Share Kathy Ellithorpe 2717 North 118th Circle Omaha, NE 68164 402/445-5566

3-Iowa

Ronald Mahrenholz, R.Ph., M.S. Pharmacist Consultant Division of Medical Services Dept. of Human Services Hoover State Office Bldg. Des Moines, IA 50319 T: 515/281-6199 F: 515/281-6230 E-mail: [email protected] Prior Authorization Contact Randy Brentnall, R.Ph. Consultec, Inc. P.O. Box 14422 Des Moines, IA 50306-3422 T: 515/327-1322 F: 515/327-0945 DUR Contact Cheryl Clarke, R.Ph. DUR Coordinator Iowa Pharmacists Association 8515 Douglas Ave, Suite 16 Des Moines, IA 50322 T: 515/270-0713 F: 515/270-2979 E-mail: [email protected]

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Medicaid DUR Board Ronnie Martin, R.Ph., D.O. Rick Wilkens, M.D. Ilyenn Wiesley, R.Ph. Sharon Meyer, Pharm.D., M.S. Ronald Miller, M.D. Stephen Elliott, D.O., Ph.D. R. Joe Mahrenholz, R.Ph., M.S. James F. Scott, R.Ph. Paul Perry, Ph.D. Prescription Price Updating Sherry Swanson Deputy Account Manager Consultec, Inc. P. O. Box 14422 Des Moines, IA 50306-3422 T: 515/327-0950 ext. 1107 F: 515/327-0945 Medicaid Drug Rebate Contacts Technical: Rocco Russo, 515/327-0950 ext. 1114 Policy: Ron Mahrenholz, 515/281-6199 Audits: Rocco Russo, 515/327-0950 ext. 1114 DUR: Cheryl Clarke, 515/270-0713 PA: Randy Brentnall, 515/327-0950 ext. 1322 Claims Submission Contact Kristi Sheakley Account Manager Consultec, Inc. P. O. Box 14422 Des Moines, IA 50306-3422 T: 515/327-0950 ext. 1108 F: 515/327-0945 Medicaid Managed Care Contact Dann Stevens MHC Program Manager Medical Services- DHS Hoover Building, 5th Floor T: 515/281-7269 F: 515/281-6230 Physician-Administered Drug Program Contact Sherry Swanson Consultec, Inc. P. O. Box 14422 Des Moines, IA 50306-3422 T: 515/327-0950 ext. 1107 F: 515/327-0945

National Pharmaceutical Council

IPA Medicaid Advisory Committee Joe Cunningham 608 5th St. SW Waukon, IA 52172 319/568-4267 Robert Dean 2725 S. Paxton Sioux City, IA 51106 712/276-1307 Derek Duncan 4836 71st Street Urbandale, IA 50322 515/266-3174 Helen Eddy 209 S. 27th St. West Des Moines, IA 50265 515/267-2800 Hal Jackson 218 S. 4th Ave. Winterset, IA 50273 515/462-2479 Patty Kumbera 4704 80th Place Urbandale, IA 50322 515/276-0679 Beverly McMahon 625 Davis Ave. Corning, IA 50841 515/322-3324 Mark Richards 8119 Oakwood Dr. Urbandale, IA 50322 515/278/0778 Kenneth Hampson PO Box 271 Ames, IA 50010 515/232-7315 Alan Shepley 113 1st St. East Mount Vernon, IA 52314 319/895-6248 Wally Tschopp 861 1st St. SE Hartley, IA 51346 712/728-2563

Iowa-4

Pharmaceutical Benefits 2000 John Swegle 833 1st St. NW Mason City, IA 50401 515/422-0587 Iowa Human Services Department Officials Jessie K. Rasmussen, Director Dept. of Human Services Hoover State Office Bldg. Des Moines, IA 50319 515/281-8621 Denis Headlee, Administrator Division of Medical Services Title XIX Medical Assistance Council College of Medicine Stacey T. Cyphert University Hospitals Iowa City, IA 52242 House of Representatives Polly Bukta 604 S. 32nd St. Clinton, IA 52732 Brad Hansen 1015 Shoal Pointe Dr. Carter Lake, IA 51510 Iowa Nurses Association Linda Goeldner 1501 42nd Street, Suite 471 West Des Moines, IA 50266 Iowa Medical Society Sheryl Nuzum 1001 Grand Avenue West Des Moines, IA 50265

Iowa Senate Sen. Elaine Szymoniak 2116-44th Street Des Moines, IA 50310 Iowa State Dept. of Public Health Dr. Edward Schor Lucas State Office Bldg. Des Moines, IA 50319 Public Representatives Vacant Diana Walvoord 503 3rd Ave S.E. Spencer, IA 51301 Orvil Nelson 1534 Second Street Boone, IA 50036 Dr. Silvano Wueschner 1722 Lake Road Ottumwa, IA 52501 Iowa Speech, Language & Hearing Association Barbara Vogen 1401 50th Street, Suite 115 West Des Moines, IA 50266 Association of Iowa Hospitals and Health Systems Tracy Warner 100 E. Grand Avenue Des Moines, IA 50309 Iowa Health Care Association Steve Ackerson 950 12th Street Des Moines, IA 50309

Opticians Assn. of Iowa Vacant

Iowa Assn. for Home Care Larry Breeding 1540 High Street, Suite 203-B Des Moines, IA 50309

Iowa Assn. of Retarded Citizens Becky Godfrey 715 E. Locust Des Moines, IA 50309

Board of Chiropractic Examiners Dr. Terry Burk P.O. Box 370 Huxley, IA 50124

Iowa Senate Sen. Maggie Tinsman 3541 E. Kimberly Road Davenport, IA 52857

Iowa Pharmacy Association Cheryl Clarke, R.Ph. 8515 Douglas, Suite 16 Des Moines, IA 50322

5-Iowa

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Iowa Assn. of Homes for the Aging William Thayer 613 West North Street Madrid, IA 50156

Iowa State Association of Counties Virginia Bordwell P.O. Box 889 Washington, IA 52353

Community Mental Health Centers of IA Michelle Wray 520 11th Street, N.W. Cedar Rapids, IA 52405

Iowa Governor’s Planning Council for Developmental Disabilities Rick Shannon, DD Council 617 E. 2nd Street Des Moines, IA 50309

Iowa Dental Association Robert Harpster 333 Insurance Exchange Building Des Moines, IA 50309 Iowa Council of Health Care Centers George Appleby 400 Homestead Building, Ste. 300 Des Moines, IA 50309 Iowa Osteopathic Medical Association Norman Pawlewski 950 12th St. Des Moines, IA 50309 Iowa Optometric Association Gary Ellis 1454 30th Street, Suite 204 West Des Moines, IA 50266-1312 Iowa Pediatric Medical Society Rick DelPrado, D.P.M. 110 NW 9th, Suite 5 Ankeny, IA 50021 Iowa Psychological Association Mark Peltan North Iowa Mercy Health Center 84 Beaumont Drive Mason City, IA 50401-2921 Iowa Hearing Aid Society Bev Thomas 532 42nd St. DesMoines, IA 50312 Alliance for the Mentally Ill of Iowa Margaret Stout 5911 Meredith Drive Urbandale, IA 50322 Iowa Psych. Nurse Managers Network Vacant

National Pharmaceutical Council

Iowa Academy of Family Physicians Dr. Dave Carlyle 1215 Duff Avenue Ames, IA 50010 Iowa Physical Therapy Association Steven Clark 2386 Scenic View Dr. Adel, IA 50003 Iowa Physician Assistant Society Michael Farley 4524 Boulevard Pl. Des Moines, IA 50311 Iowa Association of Nurse Practitioners Wanda Marshall 2301 Beaver Avenue Des Moines, IA 50310 Iowa Association of Rural Health Clinics Ed Friedmann 1013 1st Street, Box C Redfield, IA 50233 Iowa Occupational Therapy Association Angela Hanson-Abbas 161 315th St. Perry, IA 50220 Executive Officers of State Medical and Pharmaceutical Societies Iowa Medical Society Michael Abrams Executive Vice-President 1001 Grand Avenue West Des Moines, IA 50265 515/223-1401 Iowa Pharmacy Association Thomas R. Temple, R.Ph., M.S. Executive Vice President 8515 Douglas, Suite 16 Des Moines, IA 50322

Iowa-6

Pharmaceutical Benefits 2000 Iowa Osteopathic Medical Association Norman Pawlewski Executive Director 950 12th St. Des Moines, IA 50309-1001 515/283-0002 State Board of Pharmacy Examiners Lloyd Jessen Executive Secretary/Director 400 SW 8th St., Suite E Des Moines, IA 50319-4688 515/281-5944 The Association of Iowa Hospitals and Health Systems Stephen F. Brenton President 100 East Grand Avenue Suite 100 Des Moines, IA 50309 515/288-1955

7-Iowa

National Pharmaceutical Council

Pharmaceutical Benefits 2000

KANSAS A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 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

.................................................KAN Be Healthy (EPSDT) .................................................

1

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $118,825,316 155,875

1999* Expended Recipients

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult POVERTY RELATED, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult OTHER

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

National Pharmaceutical Council

Kansas-1

Pharmaceutical Benefits 2000

C. ADMINISTRATION State Department of Social and Rehabilitation Services.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips; and total parenteral nutrition. Products covered with restriction: interdialytic parenteral nutrition. Products not covered: cosmetics; fertility drugs; experimental drugs; DESI drugs; and drugs not rebated by the manufacturer. Over-the-Counter Product Coverage: Products covered: analgesics (for adults); digestive products (H2 antagonist); and antifungals. Products covered with restrictions: cough and cold preparations and smoking deterrent products. Products not covered: allergy, asthma and sinus products; digestive products (non-H2 antagonists); feminine products; and topical products. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics (for children), antipyretics (for children), NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; anti-psychotics antilipemic agents; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT antiinflammatory agents; estrogens; hypotensive agents; misc. GI drugs; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: anxiolytics, sedatives, and hypnotics; anorectics; and growth hormones. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities, and through physician payment program when used in physician offices. Vaccines: Vaccines reimbursed as part of the Children Health Insurance Program and the Vaccines for Children Program. Unit Dose: Unit dose packaging not reimbursable. Formulary/Prior Authorization

Prior Authorization: State currently has a formal prior authorization procedure. The individual appealing may request an administrative hearing to appeal a prior authorization hearing by sending a request in writing to: Administrative Hearing Office 610 S. W. 10th Ave, 2nd Floor Topeka, KS 66612-1616 Prescribing or Dispensing Limitations Prescription Refill Limit: As authorized by the prescriber and allowed by statute up to a one-year period from the date of issuance of the prescription for non-controlled drugs. No early refills (<75% Rx utilized). Monthly Quantity Limit: 34-day supply. Other: Narcotics, Viagra, and Relenza have other specific limits. Drug Utilization Review PRODUR system implemented in November 1996. State currently has a DUR Board with review every two months. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $2.78-$6.71, average of $4.94, effective 1/95. Ingredient Reimbursement Basis: EAC = AWP - 10%. IV fluids, AWP - 50%. Blood fraction products, AWP - 30%. Prescription Charge Formula: Pharmacies are reimbursed the lesser of usual and customary, MAC, FUL, or acquisition cost (EAC) plus a dispensing fee. Maximum Allowable Cost: State imposes a combination of Federal Upper Limits and State Maximum Allowable Cost (MAC). Incentive Fee: None. Patient Cost Sharing: A recipient copay charge of $2.00 (effective 7/1/94) applies to each new and refill prescription not specifically exempted under federal regulations. Cognitive Services: Does not pay for cognitive services.

Formulary: Open formulary.

2-Kansas

National Pharmaceutical Council

Pharmaceutical Benefits 2000

E. USE OF MANAGED CARE Approximately 95,000 total unduplicated number of Medicaid Recipients were enrolled in MCOs in FY 1999. Recipients receive pharmaceutical benefits through managed care plans.

Medicaid Drug Rebate Contacts Technical: Karen Braman, 785/296-6968 Policy: Karen Braman DUR: Glenn McNees, 785/864-3264 PA: Karen Braman

Managed Care Organizations

Claims Submission Contact

First Guard 3801 Blue Pky Kansas City, MO 64130

Blue Cross Blue Shield of Kansas P.O. Box 3571 Topeka, KS 66611 800/933-6593

F. STATE CONTACTS State Drug Program Administrator Karen Braman, R.Ph., M.S. Department of Social and Rehabilitation Services 915 SW Harrison, Rm. 651-S DSOB Topeka, KS 66612-1570 T: 785/296-6968 F: 785/296-4813 E-mail: [email protected] Agency Internet Address: www.ink.org/public/srs/ Prior Authorization Contact Karen Braman, 785/296-6968 DUR Contact Glenn McNees, R.Ph., M.S., BCPS DUR Program Director KU School of Pharmacy 6052 Malott Hall Lawrence, KS 66045-2500 T: 785/864-3264 F: 785/864-5849

DUR Board Michael Burke, M.D., Ph.D. Lawrence Davidow, Ph.D., R.Ph. Stanley Edlavitch, Ph.D., M.A. John Lowdermilk, R.Ph. Linda McAnarney, R.N. Janette McMillan, R.Ph. Kathy Miller-Lemke, R.Ph. Brenda Shewe, M.D. John Whitehead, D.O.

Medicaid Managed Care Contact Bobbie Graff-Hendrixson Managed Care Team Leader Health Care Policy Division, Kansas Dept. of SRS Topeka, KS 66612-1570 T: 785/296-3981 F: 785/296-4813 Social and Rehabilitation Services Department Officials Janet Schalansky Secretary Department of Social and Rehabilitation Services Docking State Office Bldg. 915 SW Harrison Topeka, KS 66612-1570 785/296-3981 Medical Care Advisory Committee Contact Robert Day, Ph.D. Medicaid Policy/Medicaid Director Health Care Policy Division Kansas Dept of SRS 915 SW Harrison Topeka, KS 66612-1570 785/296-3981 Executive Officers of State Medical and Pharmaceutical Societies Kansas Medical Society Jerry Slaughter Executive Director 623 SW 10th Avenue Topeka, KS 66612 785/235-2383

Prescription Price Updating Karen Braman, 785/296-6968

National Pharmaceutical Council

Kansas-3

Pharmaceutical Benefits 2000 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 State Board of Pharmacy 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

Pharmaceutical Benefits 2000

KENTUCKY A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

Other

OAA

AB

APTD

AFDC

OAA

AB

APTD

AFDC

Children <21

Prescribed Drugs



















Inpatient Hospital Care



















Outpatient Hospital Care



















Laboratory & X-ray Service



















Skilled Nursing Home Services



















Physician Services



















Dental Services



















SFO

1

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $319,983,951 429,102

1999* Expended Recipients

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult POVERTY RELATED, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult OTHER Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

National Pharmaceutical Council

Kentucky-1

Pharmaceutical Benefits 2000

C. ADMINISTRATION

Formulary/Prior Authorization

Department for Medicaid Services, within the Cabinet for Health Services.

Formulary: Closed Formulary. The Kentucky Medicaid Program maintains a drug file of approximately 96,800 drugs and covers all rebated products, some of which require prior authorization.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: cosmetics; fertility drugs; experimental drugs; disposable needles used for insulin; blood glucose test strips; and urine ketone test strips. Products not covered: prescribed insulin; syringe combinations used for insulin; total parenteral nutrition; and interdialytic parenteral nutrition. Over-the-Counter Product Coverage: Products covered: smoking deterrent products. Products covered with restrictions: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products (non-H2 antagonist); feminine products; and topical products. Products not covered: digestive products (H2 antagonists). Therapeutic Category Coverage: Therapeutic categories covered: antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antilipemic agents; anti-psychotics; cardiac drugs; contraceptives; ENT antiinflammatory agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: anabolic steroids; analgesics, antipyretics, NSAIDs; antihistamine drugs; anxiolytics, sedatives, and hypnotics; chemotherapy agents; prescribed cold medications; and growth hormones. Therapeutic categories not covered: anorectics and prescribed smoking deterrents. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in physicians offices, home health care and extended care facilities and through physician payment when used in physician offices. Reimbursement is limited to antineoplastic drugs with “J” codes in physician offices.

Prior Authorization: State currently has a prior authorization procedure and a Drug List and Prior Authorization Sub-Committee. Review of written documentation by a peer review contractor is required for appeal of prior authorization decisions. A formal appeals process is available if a request is denied. Prescribing or Dispensing Limitations Prescription Refill Limit: (1) No prescriptions may be refilled more than 5 times or more than 6 months after the prescription is written. (2) After initial filling, one dispensing fee per 30-day period for designated maintenance drugs. Monthly Quantity Limit: For designated classes of maintenance drugs, refills of the original prescription and subsequent prescriptions for these drugs must be prescribed and dispensed in quantities of not less than a thirty-day supply unless the prescriber requests an exception to his policy. Drug Utilization Review PRODUR system implemented in September 1994. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.75 for outpatients and $5.75 for LTC facility patients, effective July 1, 1991. Ingredient Reimbursement Basis: EAC = AWP-10%. Prescription Charge Formula: Reimbursement consists of the lowest of: (1) the usual and customary charge; (2) the 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 Health Insurance Program, Vaccines for Children Program and through the pharmacy.

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary.”

Unit Dose: Unit dose packaging reimbursable.

Incentive Fee: None. Patient Cost Sharing: No copayment. Cognitive Services: Does not pay for cognitive services.

2-Kentucky

National Pharmaceutical Council

Pharmaceutical Benefits 2000

E. USE OF MANAGED CARE Approximately 300,000 total unduplicated number of Medicaid recipients were enrolled in MCOs in FY 1999. Recipients receive pharmaceutical benefits through the state and managed care plans. Region 3 Passport Health Plan, Fincastle Bldg. 305 W. Broadway, 4th Floor Louisville, KY 40202 502/585-7900

F. STATE CONTACTS Medicaid Drug Program Administrator Debra Bahr, R.Ph. Pharmacy Services Program Manager Department for Medicaid Services CHR Building, 6th Floor 275 East Main Street Frankfort, KY 40621 T: 502/564-6511 F: 502/564-3852 E-mail: [email protected] Prior Authorization Contact Debra Bahr, R.Ph., 502/564-6511 Prior Authorization Subcommittee Robert Hughes, M.D. (Chair) Marsha Adams, PAC James S. Davis, M.D. Nancy Stiles, M.D. DUR Contact Debra Bahr, R.Ph., 502/564-6511 DUR Committee George Rodgers Jr., M.D. Richard Arnold, M.D. Phillip Baier, O.D. Patricia Freeman, R.Ph., Ph.D. Tim Jenkins, R.Ph. Marilyn Osborne, M.S.N., A.R.N.P. Vaughn Payne, M.D. Janet Poe Wright, Pharm.D. Ms. Kathy Wheeler, MSN, ARNP**

Industry Representatives: J. Scott Moody, Glaxo Wellcome Kevin WeMett, Pharmacia & Upjohn Drugs Technical Advisory Committee Steve Adams, R.Ph. 217 Lexington Street Lancaster, KY 40444 R. N. Smith, R.Ph. P. O. Box 247 Burkesville, KY 42717 Clarence F. Sullivan III, R.Ph. 1095 Tatesbrook Drive Lexington, KY 40517 Paul Easley, R.Ph. 9804 Springbark Drive Louisville, KY 40241 Gary Wientjes, R.Ph. 496 Skaggs Road Morehead, KY 40351 Drug Management Review Advisory Board Robert C. Hughes, M.D., Chair 300 S. 8th Street, Suite 480W Murray, KY 42071 Tim Jenkins, R.Ph., Vice Chair 11502 Saratoga Ridge Drive Louisville, KY 40299-8316 Marsha Adams, P.A.-C 792 Mt. Carmel Road Kirksey, KY 42054 Richard W. Arnold, M.D. 300 East Pleasant Street Cynthiana, KY 41031 Phillip Baier, O.D. 121 Franklin Square Shopping Center Frankfort, KY 40601 James S. Davis, M.D. Department of Public Health 275 East Main Street-2GWB Frankfort, KY 40621 Patricia Freeman, R.Ph., Ph.D. American Pharmacy Services Corp. 975 Riverbend Road, Suite 1 Frankfort, KY 40601

National Pharmaceutical Council

Kentucky-3

Pharmaceutical Benefits 2000 Bill Howe Government Relations Manager Pfizer Inc. 209 North Walnut, Suite C Lansing, MI 48933 Ms. Marilyn Osborne, MSN, ARNP Perry County Health Center 239 Lovern Street Hazard, KY 41701 Vaughn Payne, M.D. 6420 Dutchman’s Pkwy. Louisville, KY 40205 George C. Rodgers, Jr., M.D.* 4250 Georgetown-Greenville Rd. Georgetown, KY 47122-8816 Nancy Stiles, M.D. K512 Kentucky Clinic Lexington, KY 40536-0284 Ms. Kathy Wheeler, MSN, ARNP** 201 Ashby Circle Versailles, KY 40383-1549 Janet Poe Wright, Pharm.D. RR #2, Box 6 Owenton, KY 40359-9601 Janet Poe Wright, Pharm.D. 430 Roland Avenue Owenton, KY 40359-9601 *Proxy: Janice Sullivan, M.D. 2908 Murray Hill Pike Louisville, KY 40242 **Proxy: Patricia Birchfield, ARNP, DSN 171 Louisiana Avenue Lexington, KY 40502 Association Contact: Robert L. Barnett, Jr., R.Ph. Executive Director Kentucky Pharmacists Association, Inc. 1228 Highway 127 South Frankfort, KY 40601 502/227-2303

4-Kentucky

Medicaid Drug Rebate Contact Marie Couch Program Coordinator CHR Building, 6th Floor 275 East Main Street Frankfort, KY 40621 502/564-3476 Claims Submission Contact Unisys Provider Services P.O. Box 2100 Frankfort, KY 40602 T: 502/226-1140 F: 502/226-1860 Medicaid Managed Care Contact Philip M. Kremer Director for Division of Physical Health Department of Medicaid Services 275 E. Main St Frankfort, KY 40621 T: 502/564-5969 F: 502/564-3852 Physician-Administered Drug Program Contact Barbara Utter 275 East Main Street Frankfort, KY 40621 502/564-2687 Department for Medicaid Services Officials Jimmy D. Helton, Secretary Cabinet for Human Resources CHR Building, 4th Floor 275 East Main Street Frankfort, KY 40621 502/564-7130 State Advisory Council on Medical Assistance Chester L. Parker, Pharm.D., R.Ph. 2086 Old Nassau Lexington, KY 40504 606/277-5723 Chester A. Nava, Jr., D.P.M. 110 North Hubbards Lane Louisville, KY 40207-3903 502/897-2047

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Carol J. Braun, D.D.S. 2816 Veach Road Owensboro, KY 42303 502/683-7114

Patricia Conner-Young 10409 Christina Court Louisville, KY 40223 502/5835034

James A. Burcham P.O. Box 20 Burlington, KY 41005 606/431-2244

Nancy Durham 8900 Hawley-Gibson Crestwood, KY 40014 502/241-9072

Leslie H. Rogers 109 Daniel Drive Hazard, KY 41701

Vicki Prichard 222 Ft. Mitchell Avenue Fr. Mitchell, KY 41011 606/344-0277

William T. Watkins, M.D. 125 Volunteer Drive Somerset, KY 42501 606/679-2169 Frank A. Butler, Hospital Director University of Kentucky Hospital 800 Rose Street Lexington, KY 40536-0084 606/323-5767 Faye Hensley, R.N. P.O. Box 85 Manchester, KY 40962 Bettie Speicher Weyler 3420 Grandview Avenue Louisville, KY 40207 502/893-4964 Bob Gray 2504 Duke Drive, Apt. 24 Owensboro, KY 42301 502/685-2976 Donnie Wilhite 106 Creekstone Court Frankfort, KY 40601 502/223-1052 Betty Rose Boyd Apt. #19, Highland Heights Prestonsburg, KY 41653 606/886-0343 Marianne Keller The Good Samaritan Center 106177 Watterson Terrace Jeffersontown, KY 40299 502/267-7403

National Pharmaceutical Council

Executive Officers of State Medical and Pharmaceutical Societies Kentucky Medical Association William T. Applegate 4965 U.S. Highway 42, Suite 2000 Louisville, KY 40222-6301 502/426-6200 Kentucky Pharmacists Association Robert Barnett, Jr., R.Ph. Executive Director 1228 U.S. Highway 127 South Frankfort, KY 40601 State Board of Pharmacy Michael Mone Executive Director 1024 Capital Center Drive, Suite 210 Frankfort, KY 40601-8204 502/573-1580 Kentucky Osteopathic Medical Association Tom Underwood Executive Director 1501 Twilight Trail Frankfort, KY 40601 502/223-5322 Kentucky Hospital Association Michael T. Rust President 1302 Clear Spring Trace P.O. Box 24163 Louisville, KY 40224 502/426-6220

Kentucky-5

Pharmaceutical Benefits 2000

LOUISIANA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 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

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998 Expended $352,784,785

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult

$248,254,802 $73,418,794 $147,147,115 $14,280,841 $13,311,365 $40,778 $55,909

305,635 48,320 121,962 95,024 39,945 235 149

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult

$3,727,172 $1,348,745 $1,275,027 $141,936 $961,464

5,606 1,031 1,246 705 2,624

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

$23,104,687 $630,135 $248,094 $19,625,711 $2,600,747

131,018 1,161 438 106,479 22,940

OTHER

$77,698,124

110,222

Recipients 552,481

1999* Expended

Recipients

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Louisiana

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION

Prescription Charge Formula: Medicaid reimbursement 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 maximum allowable cost limitations or when physician authorizes “Brand Medically Necessary” for a brand name product which has a state MAC or FUL.

2.

Louisiana Maximum Allowable Costs (LMAC) or the Federal Upper Limit plus the dispensing fee.

3.

AWP for multi-source drugs when lower than FUL or LMAC.

4.

The provider’s usual and customary charge to other payors.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products not covered: cosmetics; DESI drugs; and experimental drugs. Over-the-Counter Product Coverage: Products not covered: cough and cold preparations. Therapeutic Category Coverage: Therapeutic categories not covered: anorectics. Coverage of Injectables: Injectable medicines reimbursable when used in physician offices, home health care, and extended care facilities. Vaccines: Vaccines reimbursable at cost as part of EPSDT service and Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization Formulary: Open formulary Prior Authorization: State currently does not have a formal prior authorization procedure. Prescribing or Dispensing Limitations Prescription Refill Limit: Permitted as indicated by 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 after 6 months. Maximum quantity for prescriptions shall be either 30-day supply or 100 unit doses, whichever is greater. Other: Viagra and other drugs to treat impotence are limited to 6 prescriptions per month. Drug Utilization Review PRODUR system implemented in April 1996. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $5.77 maximum, effective 7/1/94. Ingredient Reimbursement Basis: EAC = AWP - 10.5%.

National Pharmaceutical Council

Maximum Allowable Cost: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. 414 drugs are listed on the state-specific MAC list. Override requires “Brand Necessary” or “Brand Medically Necessary.” Incentive Fee: None. 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

E. USE OF MANAGED CARE Does not use MCOs to deliver services to Medicaid recipients.

F. STATE CONTACTS State Drug Program Administrator M.J. Terrebonne, P.D. Pharmacy Program Director P.O. Box 91030 Baton Rouge, LA 70821 T: 504/342-9479 F: 504/342-3893 E-mail: [email protected] Department of Health and Hospital Administration Officials Thomas Collins, Director Bureau of Health Services Financing Department of Health and Hospitals 1201 Capitol Access Road Baton Rouge, LA 70821 504/342-3891

Louisiana-2

Pharmaceutical Benefits 2000 David Hood, Secretary Department of Health and Hospitals 504/342-9500 Melwyn Wendt Pharmaceutical Consultant 504/219-4154 DUR Committee Region I: Lisa Chetta, P.D. Donald Fellows, P.D. Edward J. Lang, P.D. Paul Staab, M.D. Region II: Leslie Day, P.D. Blake Pitre, P.D. Don Ramirez, P.D. Charles Raborn, M.D. Region III: John Baker, P.D. Shawn McGee, P.D. Matthew Peterson, P.D. Lori Vidrine-Parks, M.D. Region IV: Paul Chachere, P.D. W. Merwin McMahen, P.D. Donna White, P.D. Johnny Johnston, M.D.

Susan Hinton, Pharm.D. 7680 Dune Drive New Orleans, LA 70128 504/483-7570 Paul Staab, M.D. 5216 Lapalco Boulevard Marrero, LA 70072 504/348-4357 Nancy Toedter, Pharm.D. 1701 McKean Place, Apartment 58 Monroe, LA 71201 318/329-4554 Charmaine Venters, M.D. Earl K. Long Hospital 5825 Airline Highway Baton Rouge, LA 70805 225/358-1063 Medicaid Drug Rebate Contacts Technical: Susan Taskin, 504/342-3855 Policy: M.J. Terrebonne, 504/342-9479 Disputes: M.J. Terrebonne, 504/342-9479 DUR: Dan Scholl, 504/237-3208 Physician-Administered Drug Program Contact Kandis McDaniel 504/342-0127 Medicaid Drug Program Committee

Louisiana DUR Board Committee Members Ken Ardoin, Senior Manager State Government Relations Pfizer, Inc. 7 Village Circle, Suite 400 Westlake, TX 76262 817/491-8410 Brad Belding, P.D. Director of Pharmacy Thibodaux Hospital 402 Easy Street Thibodaux, LA 70301 504/493-4786 Sylvia Heidingsfelder, M.D. 5805 Highland Road Baton Rouge, LA 70808 225/358-1069

3-Louisiana

Cathi Fontenot, M.D. LSU Medical Center 1542 Tulane Avenue New Orleans, LA 70112 504/568-4791 Naurang Agrawal, M.D. Gastroenterologist Tulane University School of Medicine 1430 Tulane Avenue New Orleans, LA 70112 504/588-5838 Keith C. Ferdinand, M.D. 1201 Poland Avenue New Orleans, LA 70117 504/943-1177

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Elvin G. Tubre, M.D. Internal Medicine 3418 Medical Park Drive Suite 22 Monroe, LA 71201 318/361-0016 Milton C. Chapman, M.D. Pediatrician 921 Shreveport-Barksdale Hwy. Shreveport, LA 71105 318/865-5646 Merlin H. Allen, M.D. Family Practice Box A Ponchatoula, LA 70454 504/386-6198 Philip J. Medon, Ph.D. Northeast Louisiana University School of Pharmacy Monroe, LA 71201 318/342-4174 Charles Trahan, P.D. 721 East Academy Jennings, LA 70127 381/824-1648 Attn: Linda Foreman Leon Richard, P.D. Pharmacy Center LTD. 5310 Norgate Drive New Orleans, LA 70127 504/246-3620 Ken Ardoin Pfizer Pharmaceuticals 502 Fountain Parkway Grand Prairie, TX 75050-1499 214/647-0222 M. J. Terrebonne, P.D. Designee for the Secretary Dept. of Health & Hospitals P. O. Box 91030; BIN #24 Baton Rouge, LA 70821-9030 504/342-3956 Thomas Collins, Director P. O. Box 91030; BIN #24 Baton Rouge, LA 70821-9030 504/342-3956

National Pharmaceutical Council

Kathleen Kennedy, Pharm.D. Charity Hospital Pharmacy 1532 Tulane Avenue Dept. of Medicine New Orleans, LA 70112 Executive Officers of State Medical and Pharmaceutical Societies Louisiana State Medical Society Dave L. Tarver Executive Director 3501 North Causeway Boulevard, Suite 800 Metairie, LA 70002-3673 504/832-9815 Louisiana State Pharmacists Association Executive Director 4744 Jamestown, Suite 101 Building 7-B Baton Rouge, LA 70808 504/926-2666 Louisiana Association of Osteopathic Physicians George Cowan, D.O. Secretary-Treasurer 6018 Colbert Street New Orleans, LA 70124 504/488-6743 State Board of Pharmacy Malcolm Broussard Executive Director 5615 Corporate Boulevard, Suite 8E Baton Rouge, LA 70808-2537 504/925-6496 Louisiana Hospital Association Robert D. Merkel President 9521 Brookline Avenue Baton Rouge, LA 70898-0720 504/928-0026

MANAGEMENT WORK GROUP Ken Ardoin, Director State Government Relations Pfizer Inc. 7 Village Circle, Suite 400 Westlake, TX 76262 817/491-8410 Barney Barnhill 212 Forrest Lake Lane Natchitoches, LA 71457 318/352-7037

Louisiana-4

Pharmaceutical Benefits 2000 Belaire Bourg Eckerd Drugs 4530 S. Sherwood Forrest Baton Rouge, LA 70816 504/291-0596

Marty McKay Pearson’s Pharmacy 74 Foxfire Alexandria, LA 71302 318/443-8807

William Bourn, Dean or Designee Northeast Louisiana University School of Pharmacy Monroe, LA 71209-0470 318/342-1600

Angelo M. Rini, R.Ph. Louisiana Pharmacists Association 504 Fairfield Avenue Gretna, LA 70056 504/362-9812

Allan Brinkhaus P.O. Drawer F Sunset, LA 70584 318/662-5411

Andy Soileau Medicine Shoppe 401 ½ E. St. Peters Street New Iberia, LA 70560 318/365-6721

Bob Broadus, Manager State Government Relations Pharmacia and Upjohn 7147 Creekwood Drive Mandeville, LA 70471 504/674-0058

Kirt Soileau Soileau’s Vital Care Pharmacy 2647 Riverview Blvd. Suite 115 Gonzales, LA 70737 800/522-5706

Clovis Burch Medic Pharmacy 271 E. 70th Street Shreveport, LA 71106 318/865-0234

George Taylor Cecilia Pharmacy Hwy 355, Box 309 Cecilia, LA 70521 318/667-6271

Horace Bynum Bynum and Sons 3840 S. Bernard Ave. New Orleans, LA 70122 504/288-4829

Carl Aron, President LA Board of Pharmacy 1209 North 18th Street Monroe, LA 71201-5495

Marcellus Grace, Dean Or Designee Xavier University College of Pharmacy 7325 Palmetto Street New Orleans, LA 70125 504/483-7420

Fiscal Intermediary UNISYS P.O. Box 91030 Baton Rouge, LA 70821 504/924-7051 Claims Processing: Dan Scholl 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

5-Louisiana

National Pharmaceutical Council

Pharmaceutical Benefits 2000

MAINE A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 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

See Appendix E, page E-29, for a list of acronyms. *Routine dental services; other categories eligible for non-routine dental service only.

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $121,771,298 137,816

1999* Expended Recipients

CATEGORICALLY NEEDY CASH TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients CATEGORICALLY NEEDY NON-CASH TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients MEDICALLY NEEDY TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

National Pharmaceutical Council

Maine-1

Pharmaceutical Benefits 2000

C. ADMINISTRATION State Department of Human Services.

Prior Authorization: May be obtained in the case of necessary exceptions. State has no formal prior authorization committee.

D. PROVISIONS RELATING TO DRUGS

Prescribing or Dispensing Limitations

Benefit Design

Monthly Quantity Limit: 34 day for brand-name drugs and 90 days for generic drugs per month.

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin (not covered for nursing home patients); blood glucose test strips; urine ketone test strips; total parenteral nutrition; interdialytic parenteral nutrition; products not covered: vitamin and vitamin preparations (except pregnancy); and injectables when oral medication is available for equally effective treatment. Over-the-Counter Product Coverage: Products covered: allergy, asthma, and sinus products (limited coverage after 1/1/01); analgesics (limited coverage after 1/1/01); cough and cold preparations (limited coverage after 1/1/01); digestive products, H2 antagonists (limited coverage after 1/1/01); topical products; smoking deterrent products (by Rx only); products not covered: digestive products (not including H2 antagonists); feminine products.

Drug Utilization Review PRODUR system implemented in 1996. State currently has a DUR Board. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.35 for stock supply, or for solutions or lotions involving no weighing. $4.35 for compounding ointments and for solutions/lotions involving weighing one or more ingredients and making home IV solutions. $5.35 for compounding handmade supplies, pwd. papers, capsules and tablet priturates and for mixing home TPN hyperalimentation. Ingredient Reimbursement Basis: EAC = AWP - 10%.

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc. GI drugs; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: analgesics, antipyretics, NSAIDs; anorectics; antihistamine drugs; prescribed cold medications; growth hormones.

Prescription Charge Formula: Lowest of usual and customary, FUL, AWP-10%, or Maine MAC. Maine MAC includes approximately 50 drug products in addition to FUL products.

Coverage of Injectables: Injectable medicines reimbursable when used in physician offices, home health care, and extended care facilities.

Patient Cost Sharing: Sliding copay scale based on cost: $0.50 to $3.00 for branded, $0.50-$2.00 for generic drugs.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. Override requires “brand medically necessary” by the physician and prior authorization for some drugs. Incentive Fee: None.

Cognitive Services: State does not pay for cognitive services.

Vaccines: Vaccines reimbursable based on cost as part of 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.

Formulary/Prior Authorization Formulary: Open formulary

2-Maine

National Pharmaceutical Council

Pharmaceutical Benefits 2000

F. STATE CONTACTS State Drug Program Administrator Christine Gee Director of Pharmacy Programs Department of Human Services Bureau of Medical Services Pharmacy Programs Building 205, 3rd Fl. 11 State House Station Augusta, ME 04333-0011 T: 207/287-4018 F: 207/287-8601 E-mail: [email protected] Agency Internet Address: http://www.state.me.us/bms/bmshome.htm Prior Authorization Contact Christine Gee Bureau of Medical Services Pharmacy Programs Building 205, 3rd Fl. 11 State House Station Augusta, ME 04333-0011 207/287-4018 DUR Contact Christine Gee 207/287-4018 Maine DUR Board Timothy Clifford, M.D. Bureau of Medical Services 11 State House Station August, ME 04333 207/287-2674

Paula Knight, R.Ph. 31 Birch Circle Sidney, ME 04330 207/547-3881 Stephen McPike, R.Ph. 15 Wildwood Lane Gray, ME 04039 207822-7627 Michael Ouellette, R.Ph. RFD 3 Box 4235 Winslow, ME 04901 207/281-2727 Christine Gee 207/287-4018 Non-voting: Robert E. Carroll, Jr., R.Ph. Department of Professional and Financial Regulation Office of Licensing and Registration 35 State House Station Augusta, ME 04333-0035 207/624-8689 Joe Bruno (President) Goold Health Systems 24 Stone Street P.O. Box 708 Augusta, ME 04332 207/622-7153 Dennis G. Lyons, R.Ph. 255 Bear Hill Rd., 2nd Fl. Waltham, MA 02451 Prescription Price Updating

William Alto, M.D. Maine Dartmouth Family Practice 4 Sheridan Drive Fairfield, ME 04937 207/861-5000

Kathy Chadwick First DataBank 800/633-3453

John Grotton, R.Ph. Goold Health Systems 24 Stone Street P.O. Box 708 Augusta, ME 04332 207/622-7153

Technical: Rossi Rowe, 207/287-1838 Policy: Chris Zukas-Lessard, 207/624-5221 Rebates: Rossi Rowe, 207/287-1838 Audits: Vacant

National Pharmaceutical Council

Medicaid Drug Rebate Contacts

Maine-3

Pharmaceutical Benefits 2000 Claims Submission Contact Marcia Pykare Manager of Data Processing Gold Health Systems P.O. Box 1090 Augusta, ME 04332 207/622-7153 Elderly Expanded Drug Coverage Program Christine Gee Maine Drugs for the Elderly and Disabled Program 207/287-2674 http://www.state.me.us/sos/cec/rc/apa/10/chaps10.htm Disease Management Program/Initiative Contact Timothy Clifford, M.D. 207/287-2674 Human Services Department Officials Francis Finnegan, Director Bureau of Medical Services 207/287-2674 Susan Curtis Drug Program Coordinator Medical Claims Review 207/287-1818

Maine Pharmacy Association Gregory Jamison Executive Director P. O. Box 346 Brewer, ME 04412-0346 207/989-6190 Maine Osteopathic Association Kellie P. Miller Executive Director RR2, P.O. Box 1920 Manchester, ME 04351 207/623-1101 Maine Commission of Pharmacy Susan Greenlaw Board Clerk Department of Professional and Financial Regulation Division of Licensing and Enforcement State House Station No. 35 Augusta, ME 04333 207/624-8603 Maine Hospital Association Bruce J. Rueben President 150 Capitol Street Augusta, ME 04330 207/622-4794

Margaret Ross, Director Medicaid Surveillance/Utilization Review 207/624-5220 Medical Assistance Advisory Committee Robert Philbrook MAC c/o BMS 11 State House Station Augusta, ME 04333-0011 Executive Officers of State Medical and Pharmaceutical Societies Maine Medical Association Gordon Smith, Esq. Executive Vice President P. O. Box 190 Manchester, ME 04351-0190 207/622-3374

4-Maine

National Pharmaceutical Council

Pharmaceutical Benefits 2000

MARYLAND A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

Other

OAA

AB

APTD

AFDC

OAA

AB

APTD

AFDC

Children <21

Prescribed Drugs

















Inpatient Hospital Care



















Outpatient Hospital Care



















Laboratory & X-ray Service



















Skilled Nursing Home Services



















Physician Services



















Dental Services



















SFO*

1

See Appendix E, page E-29, for a list of acronyms. *Effective December 1, 1992, all State-Only services except subsidized adoptions were discontinued. Prescription services for these recipients were transferred to Pharmacy Assistance Program.

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $148,532,940 176,403

1999* Expended Recipients

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult POVERTY RELATED, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult OTHER Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

National Pharmaceutical Council

Maryland-1

Pharmaceutical Benefits 2000

C. ADMINISTRATION

Formulary/Prior Authorization

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 required for appeal of prior authorization decisions.

Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; and total parenteral nutrition. Products not covered: cosmetics; fertility drugs; experimental drugs; blood glucose test strips; urine ketone test strips; interdialytic parenteral nutrition; DESI drugs; prescriptions and injections for central nervous system; food supplements or infant formulas; products for which Federal Financial Participation is not allowed, i.e., "less than effective" drugs and products whose manufacturers have not signed rebate agreements; and (e) certain other items as specified in the state's Medicaid plan. Over-the-Counter Product Coverage: Products covered: contraceptives; oral ferrous sulfide; and aspirin for arthritis. Products not covered: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products (H2 and non-H2 antagonists); feminine products; topical products; and smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT antiinflammatory agents; estrogens; hypotensive agents; misc. GI drugs; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: growth hormones. Therapeutic categories not covered: anorectics. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities, and through physician payment when used in physician offices. Vaccines: Vaccines reimbursable as part of the EPSDT service. Unit Dose: Unit dose packaging reimbursable for nursing home patients only for commercially available products.

2-Maryland

Prior authorization required from the HealthChoice and Acute Care Administration when the usual and customary charge exceeds $100 and the prescribed amount is a 34day supply or more. Preauthorization is needed for any prescription with a usual and customary charge exceeding $400. Prior authorization is also needed for early refills, nutritional supplements, and excessive quantities. Prescribing or Dispensing Limitations Prescription Refill Limit: Maximum of two refills. The original prescription and its refills may not exceed a 100day supply except for birth control pills and oral sodium fluoride preparations. Refills may not be dispensed after 100 days of date of original prescription except for birth control pills and oral sodium fluoride preparations Monthly Quantity Limit: The amount of medication to be dispensed on a prescription at one time is limited to a less than 34-day supply except for specific maintenance drugs for chronic conditions, where up to a 100-day supply may be dispensed at one time. Drug Utilization Review PRODUR system implemented January 1993. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.21 as of July 1, 1996. Ingredient Reimbursement Basis: Estimated Acquisition Cost (EAC) equals/lowest of: 1. 2. 3. 4.

Wholesale Acquisition Cost (WAC) plus 10%. Direct cost plus 10%. Distributor's price plus 10%. Average Wholesale Price (AWP) minus 10%.

Prescription Charge Formula: Reimbursement will be the lower of: (1) the calculated ingredient cost plus a dispensing fee; (2) the usual and customary fee. Maximum Allowable Cost: State imposes Federal Upper 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.

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Incentive Fee: None.

F. STATE CONTACTS

Patient Cost Sharing: Copayment = $1.00. Does not apply to managed care, family planning, nursing home residents or recipients under 21 years old. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 375,000 total unduplicated number of Medicaid recipients were enrolled in MCOs in FY 1999. Recipients receive pharmaceutical benefits through the state and managed care plans. Managed Care Organizations Chesapeake FamilyFirst 6300 Security Boulevard Baltimore, MD 21207

68,785

FreeState Health Plan Blue Cross Blue Shield 10455 Mill Run Circle Owings Mills, MD 21117-5559

97,363

Helix Family Choice, Inc. 2330 W. Joppa Road Suite 301 Lutherville, MD 21093

18,039

Jai Medical Systems, Inc. 5010 York Road Baltimore, MD 21212

4,817

Maryland Physicians Care MCO 7106 Ambassador Road Suite 100 Baltimore, MD 21244

28,958

Prime Health Corporation 9602-C M.L.K., Jr. Hwy Lanham, MD 20706

15,405

Priority Partners MCO The Candler Building 111 Market Place Baltimore, MD 21202

55,349

Ameri Group 857 Elkridge Landing Road, #300 Linthicum, MD 21040

85,393

National Pharmaceutical Council

State Drug Program Administrator Mr. Frank Tetkoski Pharmacy Services Manager Division of Pharmacy and Clinic Services 201 West Preston Street Baltimore, MD 21201 T: 410/767-1455 F: 410/333-7049 E-mail: [email protected] Prior Authorization Contact Tuong Nguyen, P.D. Pharmacist Consultant DHMH-Office of Health Services Division of Pharmacy and Clinical Services 201 W. Preston St., Rm. 132 Baltimore, MD 21201 T: 410/787-1455 F: 410/333-7049 E-mail: [email protected] DUR Contact Judy Geisler, P.D. Pharmacist Consultant DHMH-Office of Health Services Division of Pharmacy and Clinical Services 201 W. Preston Street Baltimore, MD 212010 T: 410/767-1728 DUR Board Scott A. Spier, M.D., Chair Medical Director Outpatient Chemical Dependency Unit Mercy Medical Center Professional Building 301 St. Paul Place, Room 812 Baltimore, MD 21202 410/332-9230 Bonnie Rosiak, Pharm.D., Chair 8809 Heron’s Flight Laurel, MD 20723 Barbara A. Bartman, M.D., M.P.H. 3972 Ducks Foot Lane Ellicott City, MD 21042 410/955-1314

Maryland-3

Pharmaceutical Benefits 2000 Krishna Chary, R.Ph. 804 Bear Cabin Drive Forest Hill, MD 21050 800/380-9342 Babette S. Duncan, Pharm.D., BCPS Senior Director, Clinical Services Advance Paradigm, Inc. 11350 McCormick Road Suite 1000, Executive Plaza II Hunt Valley, MD 21031 410/785-2182 Michelle A. Forrest-Smith, Pharm.D. 1822 Chatfield Terrace Severn, MD 21144 410/748-6291 Myron Miller, M.D. 8201 Spring Bottom Way Baltimore, MD 21208 410/653-7952 Richard D. Moore, M.D. Johns Hopkins Hospital 1830 E. Monument Street, 8th floor Baltimore, MD 21205 410/955-2144 Jill RachBeisel, MD University of Maryland Medical System 22 South Greene Street S12A03 Baltimore, MD 21201

Claims Submission Contact First Health DataBank Division of Claims Processing Charlotte Krueger, Chief 201 W. Preston St. Baltimore, MD 21201 T: 410/767-5347 F: 410/333-7186 Medicare Managed Care Contact Rosalie Kosloff Chief, Division of Health Choice Management Office of Health Services 201 W. Preston St. Baltimore, MD 21201 410/767-5690 Elderly Expanded Drug Coverage Program Paul Roeger Manager, Pharmacy Assistance Program Medical Care Operations and Eligibility 201 W. Preston St Baltimore, MD 21201 T: 410/767-5394 F: 410/333-7290 Physician-Administered Drug Program Contact Edward Watters, M.D. 201 W. Preston Street Baltimore, MD 21201 410/767-1482

Prescription Price Updating

Health and Mental Hygiene Department Officials

First DataBank 1111 Bayhill Dr. San Bruno, CA 94066 T: 415/588-5454 F: 415/827-4578

Georges C. Benjamin, M.D. Secretary Department of Health and Mental Hygiene 201 W. Preston Street Baltimore, MD 21201

Medicaid Drug Rebate Contacts

Debbie I. Chang Deputy Secretary Health Care Financing 201 W. Preston Street Baltimore, MD 21201

Technical: Jeffrey Gruel, 410/767-1455 Policy: Jeffrey Gruel, 410/767-1455 P/A: Lynette Lane, 410/767-1728 Audits: Kenneth Smoot, 410/767-5186 Disputes: Katherine Novak, 410/582-9305

4-Maryland

Joseph M. Millstone Executive Director Office of Health Services 201 W. Preston Street Baltimore, MD 21201

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Shelby Boggs Director of Healthcare and Acute Care Office of Health Services 201 W. Preston Street Baltimore, MD 21201 Jeffrey Gruel Chief Division of Pharmacy and Clinic Services Office of Health Services 201 W. Preston Street Baltimore, MD 21201 410/767-1455 Joseph Fine, P.D. Chief Division of Recoveries Medical Care Operations and Eligibility 201 W. Preston Street Baltimore, MD 21201 410/767-5795 Paul Roeger Program Manager Pharmacy Assistance Program PO Box 386 Baltimore, MD 21203 410/767-5392

Howard Schiff Executive Director 650 West Lombard Street Baltimore, MD 21201-1572 State Board of Pharmacy LaVerne G. Naesea Executive Director 4201 Patterson Avenue Baltimore, MD 21215-2299 410/764-4755 Maryland Osteopathic Association, Inc. Francisco E. Ward, D.O. Secretary/Treasurer P.O. Box 6314 Annapolis, MD 21401 800/664-4274 The Maryland Hospital Association, Inc. Calvin M. Pierson, President 1301 York Road, Suite 800 Lutherville, MD 21093-6087 410/321-6200

Medical Assistance Staff Committee Members Judy Geisler, P.D. Division of Pharmacy and Clinic Services 201 W. Preston Street Baltimore, MD 21201 Mr. Frank Tetkoski, P.D., Manager, Pharmacy Services Division of Pharmacy and Clinic Services 201 W. Preston Street, Room 129 Baltimore, MD 21201 Tuong Nguyen, P.D. Division of Pharmacy and Clinic Services 201 W. Preston St., Rm. 132 Baltimore, MD 21201 Executive Officers of State Medical and Pharmaceutical Societies Medical/Chirurgical Faculty of Maryland T. Michael Preston Executive Director 1211 Cathedral Street Baltimore, MD 21201 410/539-0872 Maryland Pharmacists Association National Pharmaceutical Council

Maryland-5

Pharmaceutical Benefits 2000

MASSACHUSETTS A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 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

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $497,146,531 613,186

1999* Expended

Recipients

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 Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients MEDICALLY NEEDY TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Massachusetts

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION

Unit Dose: Unit dose packaging reimbursable; however, will not pay extra for the packaging.

Executive Offices of Health and Human Services, Division of Medical Assistance.

Formulary/Prior Authorization

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Products covered with restrictions: Ritalin and amphetamines are limited to treatment of hyperkinesis for children under age 17, except by prior authorization; and ADD by prior authorization (not covered for appetite control). Products not covered: cosmetics; fertility drugs; experimental drugs; DESI drugs; legend vitamins not on Drug List, non-legend drugs not on Drug List; propoxyphenecontaining products and products rated by the FDA as less-than-effective. Over-the-Counter Product Coverage: Products covered: allergy, asthma and sinus products; analgesics; digestive products (non-H2 antagonist); and feminine products. Products covered with restrictions: cough and cold preparations (except in LTC facilities or PA); digestive products (H2 antagonists) (90 days then PA required); and topical products (acne preps require PA). Products not covered: smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; cardiac drugs; chemotherapy agents; contraceptives; ENT antiinflammatory agents; estrogens; growth hormones; hypotensive agents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: anorectics; anxiolytics, sedatives, and hypnotics; prescribed cold medications and misc. GI drugs. Therapeutic categories not covered: prescribed smoking deterrents. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities and through physician payment when used in physician offices. Vaccines: Vaccines reimbursable as part of the EPSDT service if not provided by the Department of Public Health.

National Pharmaceutical Council

Formulary: Open formulary. Prior Authorization: State currently has a prior authorization procedure. A fair hearing process by the recipient on an individual basis is required for appealing a prior authorization decision. Prescribing or Dispensing Limitations Prescription Refill Limit: Prescription may be refilled, as authorized, with a limit of up to 5 refills within 6 months from the filling of the original prescription. Monthly Quantity Limit: Schedule II and III drugs are limited to a 30-day supply, except Ritalin and Dexedrine, which may be dispensed up to a 60-day supply. Monthly Dollar Limits: None. Drug Utilization Review PRODUR system implemented in October 1995. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.00. Ingredient Reimbursement Basis: EAC = WAC + 10%. Prescription Charge Formula: Payment shall be for the lowest of: 1. 2. 3.

EAC plus dispensing fee; The usual and customary charge defined as the lowest price charged or accepted by a provider for any payor; or FULP plus a dispensing fee.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. Override requires “Dispense as Written” and/or “Brand Medically Necessary.” Patient Cost Sharing: Copayment = $0.50 with the following exceptions: − − − − −

Institutionalized patients Children under age 19 Pregnant and postpartum women Hospice care Family planning items

Massachusetts-2

Pharmaceutical Benefits 2000 Incentive Fee: None. Cognitive Services: Does not pay for cognitive services.

Prescription Price Updating

Approximately 500,000 total unduplicated number of Medicaid recipients were enrolled in MCOs in FY 1999. Recipients receive pharmaceutical benefits through managed care plans.

Christopher Burke Pharmacy Program Analyst Dept of Medical Assistance 600 Washington Street Boston, MA 02111 T: 617/210-5592 F: 617/210-5597 E-mail: [email protected]

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 Audits: Policy: Paula McAree, R.Ph., 617/210-5594

E. USE OF MANAGED CARE

Gary Gilmore, R.Ph. Division of Medical Assistance 600 Washington Street Boston, MA 02111 T: 617/210-5593 F: 617/210-5597 E-mail: [email protected] Agency Internet Address: [email protected] Prior Authorization Contact Anna Morin, Pharm.D. DVR Program Director UMASS Medical School 11 Midstate Hwy Auburn, MA 01501-1863 T: 508/721-7104 F: 508/721-7138 E-mail: [email protected] DUR Contact Anna Morin, 508/721-7104 Medicaid DUR Board Spencer Wilking, MD (Chairman) C. Michael Bliss, MD Sarah Cheeseman, MD Thomas Hewitt, MD Anne Marie McCloskey, R.Ph. Leo McKenna, R.Ph. Dave Morgan, R.Ph. Robert Portney, MD James Scanlon, R.Ph. David Kosegarten, Ph.D. Gerry Longnecker, Pharm.D.

Claims Submission Contact Unisys Corp P.O. Box 9101 Somerville, MA 02145 617/576-4451 Medicaid Managed Care Contact Pricilla Portis Director, Primary and Specialty Services Division of Medical Assistance 600 Washington Street Boston, MA 02111 T: 617/210-5700 F: 617/210-5597 E-mail: [email protected] Disease Management Program/Initiative Contact Annette Hanson, MD Medical Director Division of Medical Assistance 600 Washington Street Boston, MA 02111 T: 617/210-5683 F: 617/210-5597 E-mail: [email protected] Elderly Expanded Drug Coverage Program Contact Pricilla Portis, 617/210-5700 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

Pharmaceutical Benefits 2000 Executive Officers of State Medical and Pharmaceutical Societies 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 State Board of Pharmacy 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

Pharmaceutical Benefits 2000

MICHIGAN A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 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

-----Limited for all eligibles-----

1

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

B. EXPENDITURES FOR DRUGS 1998* Expended Recipients TOTAL

$374,145,567

1999* Expended

Recipients

589,818

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult POVERTY RELATED, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult OTHER Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Michigan

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION Michigan Department of Community Health, Medical Services Administration.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; and urine ketone test strips. Products covered with restrictions: total parenteral nutrition (paid to medical suppliers) and interdialytic parenteral nutrition. Prior authorization required for: brand name products equivalent to MACs; Accutane & Retin-A; Dexedrine and Adderall; Persantine; Lactulose (Cephulac); Methylphenidate (selected ages); selected benzodiazepines; Epogen administered in the home setting; dietary formulas; and drugs not listed on the formulary. Products not covered: cosmetics; fertility drugs; and experimental drugs. Over-the-Counter Product Coverage: Products covered with restrictions (only selected products in each category): allergy, asthma and sinus products; analgesics; digestive products (non-H2 and H2 antagonists); feminine products; topical products; and smoking deterrent products (patches and gum). Products not covered: cough and cold preparations. Therapeutic Category Coverage: Therapeutic categories covered: analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; contraceptives; ENT antiinflammatory agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: chemotherapy agents; growth hormones; and prescribed smoking deterrents. Therapeutic categories not covered: anabolic steroids; anorectics; and prescribed cold medications. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities, and through physician payment when used in physicians offices. Vaccines: Vaccines reimbursable at cost plus a fee/or vaccine replacement as part of the EPSDT service and the Children Health Insurance Program.

National Pharmaceutical Council

Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization Formulary: Closed formulary. Prior Authorization: State currently has a formal prior authorization procedure. In order to appeal prior authorization decisions, a department appeals section in the Medicaid program sets up hearings for beneficiaries. The beneficiary is sent a letter with instructions on their appeal rights when appealing the coverage of an excluded product. Prescribing or Dispensing Limitations Prescription Refill Limit: Based on state law. Monthly Quantity Limit: Prescribed quantities should be limited to an amount necessary to keep the recipient supplied during the therapy regimen. In certain cases and conditions, more than a month’s supply will be appropriate. However, in no instance may more than 100 days supply be dispensed per prescription. Drug Utilization Review PRODUR system implemented in July 2000. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.72, effective 8/1/90. Ingredient Reimbursement Basis: 1-4 stores = AWP13.5%, 5 or more stores = AWP - 15.1%. Prescription Charge Formula: Reimbursement for legend drugs is limited to the lower of: 1. 2. 3.

AWP - 13.5% for 1 to 4 stores & AWP - 15.1% for 5 or more stores or LTC, plus dispensing fee minus selected $1.00 patient copay, or The MAC rate, plus dispensing fee, or The provider’s usual and customary charge to the general public.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. 800 drugs are listed on the state-specific MAC list. Override requires “Dispense as Written” and prior authorization. Incentive Fee: None.

Michigan-2

Pharmaceutical Benefits 2000 Patient Cost Sharing: Ambulatory recipients age 21 and older are required to pay a $1.00 copayment for most legend drugs. If the recipient is unable to pay a required copayment on the date of service, the pharmacy cannot refuse to render the service. However, the pharmacy may bill the recipient for the copayment amount, and he/she is responsible for paying it. If the recipient fails to pay a copayment, the pharmacy could, in the future, refuse to serve the recipient as a Medicaid recipient. Drugs not requiring a co-payment include pregnancyrelated and family planning products. Recipients are not required to make a copayment if: − −

−

They are under age 21, or They reside in a long-term care facility (nursing home, hospital long-term care facility, or medical care facility), or Health Maintenance Organization (HMO), or a capitated Clinic Plan.

Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 1,000,000 total unduplicated number of Medicaid recipients were enrolled in MCOs in FY 1999. Recipients receive pharmaceutical benefits through the state and managed care plans. Managed Care Organizations American Family Care 2000 S. Woodward, Ste. 200 Bloomfield Hills, MI 48302 248/454-1070 888/898-7969 Blue Care Network 25925 Telegraph Road Southfield, MI 48086 248/799-6674 800/414-3457 Botsford Health Plan 28050 Grand River Farmington Hills, MI 48336 248/473-6190 800/479-5122 Cape Health Plan 17421 Telegraph, Suite 209 Detroit, MI 48219 888/354-2273

3-Michigan

Care Choices HMO 34605 Twelve Mile Road Farmington Hills, MI 48331 248/489-6000 800/893-1113 Community Care Plan 1925 Breton Road, SE, #204 Grand Rapids, MI 49516 616/252-4792 800/807-5244 Community Choice Michigan 2369 Woodlake Drive Okemos, MI 48864 800/390-7102 DMC Clinic Plan Centrum Bldg., 7th Floor 20901 Northwestern Hwy. Southfield, MI 48075 Family Health Plan of Michigan 2200 Jefferson Avenue Toledo, OH 43624 800/231-8274 734/457-5370 (Monroe Office) Good Health Michigan 2000 S. Woodward, Ste. 200 Bloomfield Hills, MI 48302 248/454-1070 888/898-7969 Great Lakes Health Plan, Inc. 17117 W. Nine Mile, Ste. 1600 Southfield, MI 48075 248/559-5656 800/903-5253 Health Alliance Plan 2850 W. Grand Blvd. Detroit, MI 48202 313/664-8360 800-801-1769 Health Plan of Michigan 17515 W. Nine Mile, Ste. 650 Southfield, MI 48075 248/569-8640 888/437-0606

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Health Plus of Michigan 2050 S. Linden Road P.O. Box 1700 Flint, MI 48501-1700 810/230-2222 800/322-9161 M-Care 2301 Commonwealth Blvd. Ann Arbor, MI 48105-1573 800/527-5549 McLaren Health Plan 401 W. Greenlawn Lansing, MI 48910 517/346-4834 888/327-0671 Midwest Health Plan 5050 Schaefer Road Dearborn, MI 48126 313/581-3700 888/654-2200 North Med 109 E. Front, Ste. 204 Traverse City, MI 49684 616/935-0550 877/935-0599 Oakwood St. John Health Plan 19853 W. Outer Drive, Ste. 301 Dearborn, MI 48124 313/791-5229 888/493-4300 OmniCare Health Plan 1155 Brewery Park Blvd. Suite 250 Detroit, MI 48207 313/259-4000 800/955-4578 PHP of Mid-Michigan, Inc. P.O. Box 30377-7877 Lansing, MI 48909-7877 517/347-9425 800/661-8299

PHP of West Michigan, Inc. 250 Morris Ave., Ste 5500 Muskegon, MI 49440-1143 Priority Health 1231 E. Beltline, NE Grand Rapids, MI 49525-4501 616/942-0954 888/975-8102 Pro-Care Health Plan 3956 Mount Elliot Detroit, MI 48207 313/925-4607 888/861-0061 SelectCare HMO 2401 W. Big Beaver Road Suite 700 Troy, MI 48084 248/637-6777 800/332-2365 Total Health Care 3011 W. Grand Blvd., Ste. 1600 Detroit, MI 48202 313/871-2000 800/826-2862 Ultimed HMO of Michigan 2401 20th Street Detroit, MI 48216 313/961-1717 800/242-7955 Upper Peninsula 104 Coles Drive, Suite E Marquette, MI 49855 906/225-7500 888/904-7526 The Wellness Plan 2875 W. Grand Blvd. Detroit, MI 48202 313/875-4200 800/875-9355

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

National Pharmaceutical Council

Michigan-4

Pharmaceutical Benefits 2000

F. STATE CONTACTS State Drug Program Administrator James Kenyon, R.Ph. Pharmacist Consultant MDCH/Medical Services Administration 400 South Pine Street Lansing, MI 48933 T: 517/335-5265 F: 517/335-5294 E-mail: [email protected] Agency Internet Address: www.michigan.fhsc.com www.mdch.state.mi.us Prior Authorization Contact James Kenyon, 517/335-5265 DUR Contact Mary Sandusky, R.Ph. Pharmacist Consultant MDCH- Medical Services Administration 400 S. Pine St. Lansing, MI 48933 T: 517/335-5280 F: 517/241-7813 E-mail: [email protected] Medicaid DUR Board Richard Henderson, M.D. 34650 Versailles Court Farmington Hills, MI 48331 810/474-1397 Frank Check, M.D. St. Joseph Mercy Hospital 900 Woodward Avenue Pontiac, MI 48341 313/858-3233 Duane Kirking, Ph.D. College of Pharmacy University of Michigan Ann Arbor, MI 48109-1065 313/764-4483 313/764-7312 William Overkamp 2929 Walker, N.W. Grand Rapids, MI 49544

5-Michigan

Karen Jonas, R.Ph. 13121 Willow Grove Road Dewitt, MI 48820 517/315-1243 James Kenyon, R.Ph. Michigan Department of Community Health Medical Services Administration P.O. Box 30479 Lansing, MI 48909 Otto Graesser, DO 1421 W. Mt. Hope Lansing, MI 48910 Prescription Price Updating First DataBank 1111 Bayhill Drive San Bruno, CA 94066 415/588-5454 Medicaid Drug Rebate Contacts Technical: Randy Rothfuss, 517/335-5040 Audits: James Kenyon, 517/335-5265 PA: Barbara Jones, 517/335-5061 Claims Submission Contact First Health Services Corp 4300 Cox Rd. Glen Allen, VA 23060 Medicaid Managed Care Contact Rick Murdock, Director Comprehensive Health Plan Division MDCH- Medical Services Administration 400 S. Pine Street Lansing, MI 48933 T: 517/241-7933 F: 517/241-8231 Disease Management Program/Initiative Contact Mary Sandusky, 517/335-5280 Elderly Expanded Drug Coverage Contact Jean Friend MDCH- Aging, Community Services Division 517/373-4064 E-mail: [email protected]

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Physician-Administered Drug Program Contact Linda McCardel Medical Services Administration P.O. Box 30479 Lansing, MI 48909 517/335-5115 Michigan Dept. of Community Health (MDCH) James Haveman Director Michigan Department of Community Health 517/373-7720

State Board of Pharmacy Carol Johnson Licensing Administrator 611 W. Ottawa, P.O. Box 30018 Lansing, MI 48909 517/373-0620 Michigan Health and Hospital Association Spencer C. Johnson President 6215 West St. Joseph Highway Lansing, MI 48917 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 Executive Officers of State Medical and Pharmaceutical Societies 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)

National Pharmaceutical Council

Michigan-6

Pharmaceutical Benefits 2000

MINNESOTA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

Other

OAA

AB

APTD

AFDC

OAA

AB

APTD

AFDC

Children <21

Prescribed Drugs



















Inpatient Hospital Care



















Outpatient Hospital Care



















Laboratory & X-ray Service



















Skilled Nursing Home Services



















Physician Services



















Dental Services



















SFO

1

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998 Expended $173,602,492

Recipients 203,220

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult Other

$98,522,787 $7,783,421 $83,068,585 $2,941,090 $4,128,630 $173,682 $386,451 $40,928

95,678 7,013 45,306 23,913 15,857 2,006 1,487 96

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult Other

$18,229,273 $6,333,476 $11,739,504 $98,025 $32,350 $25,918

10,906 5,072 5,030 477 286 41

POVERTY RELATED, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult Other

$787,642 $184,259 $377,806 $175,561 $7,788 $42,228

2,390 414 360 1,509 54 53

$56,062,790

94,246

OTHER

1999* Expended

Recipients

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Minnesota

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION

Formulary/ Prior Authorization

Minnesota Department of Human Services, Health Care Management Division, Medical Assistance Program.

Formulary: Open formulary with general exclusions.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: cosmetics; fertility drugs; and experimental drugs. Products covered with restriction: interdialytic parenteral nutrition. Prior Authorization required for: Desmopressin; Epoetin Alpha; Filgrastim; Interferon Alfa; Interferon Gamma-IB; Ondansetron; Granisetron; and Sargramostim Products not covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips; and total parenteral nutrition. Over-the-Counter Product Coverage: Products covered if prescribed by a physician: digestive products (H2 antagonists). Products covered with restrictions: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products (non-H2 antagonist); feminine products (antifungals covered); topical products; and smoking deterrent products (within deterrent program). Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones; hypotensive agents; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: misc. GI drugs (proton pump inhibitor). Therapeutic categories not covered: anorectics and tretinoin products (covered only for acne). Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities, and through physician payment when used in physician offices. Vaccines: Vaccines reimbursable when billed as part of the EPSDT service, the Children’s Health Insurance Program, and the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable.

National Pharmaceutical Council

Prior Authorization: State currently has a prior authorization procedure and a Drug Formulary Committee. Recipient has the right to appeal Prior authorization decisions and coverage of an excluded product by appeals referee followed by an appeal in court. Prescribing or Dispensing Limitations Monthly Quantity Limit: 3 month supply. Minimum 30days for maintenance drugs. Contraceptives may be filled to provide a 3-month supply. Drug Utilization Review PRODUR system implemented in February 1996. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.65, effective 7/1/97. Ingredient Reimbursement Basis: EAC = AWP - 9%. Prescription Charge Formula: Reimbursement is based on the lesser of submitted AWP minus 9% plus a dispensing fee, MAC plus a dispensing fee, or usual and customary. Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “brand medically necessary.” Incentive Fee: None. Patient Cost Sharing: No copayment. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 280,000 total unduplicated number of Medicaid recipients were enrolled in MCOs in FY 1999. Recipients receive pharmaceutical benefits through managed care plans. Managed Care Organizations Itasca Medical Care Karen Campbell 123 1st Avenue SE Grand Rapids, MN 55744

Minnesota-2

Pharmaceutical Benefits 2000 Blue Plus/Blue Shield of MN Public Programs Cynthia MacDonald, Director 1200 Yankee Doodle Road, W4-43 Eagan, MN 55121-2202 First Plan of Minnesota 1601 London Road Duluth, MN 55812 HealthPartners Government Programs 8100 34th Avenue South P.O. Box 1309 Minneapolis, MN 55414-1309 Medica P.O. Box 9310 Mail Route 80280 Minneapolis, MN 55440-9310 Metropolitan Health Plan Mail Code 611 822 South 3rd Street, Suite 140 Minneapolis, MN 55415 UCare Minnesota 2550 University Avenue, West Suite 330N St. Paul, MN 55114 Altru Health Plan Minnesota 3065 Demers Avenue Grand Forks, ND 58201-4018

F. STATE CONTACTS State Drug Program Administrator Cody Wiberg, Pharm.D., R.Ph. Acting Pharmacy Program Manager Minnesota Department of Human Services 444 Lafayette Road St. Paul, MN 55155-3853 T: 651/296-8515 F: 651/282-6744 E-mail: [email protected] Agency E-mail Address: www.dhs.state.mn.us Prior Authorization Contact Cody Wiberg, 651/296-8515

3-Minnesota

DUR Contact Mary Beth Reinke, Pharm.D., R.Ph. DUR Coordinator 444 Lafayette Road St. Paul, MN 55155-3853 T: 651/215-1239 F: 651/282-6744 E-mail: [email protected] Medicaid DUR Board Physicians C. Dwight Townes, M.D. 16 Meadow Lane, South Minneapolis, MN 55416 612/377-8469 William P. Korchik, M.D. Veterans Affairs Medical Center One Veteran Drive (11L) Minneapolis, MN 55417 612/725-2035 Michael F. Koch, M.D. Director, Child Psychiatry Hennepin County Medical Center 701 Park Avenue South Minneapolis, MN 55402 612/347-2617 Health Care Professional Marilyn M. Ulseth, MS, RN, CNP 2909-33rd Ave South Minneapolis, MN 55406 Pharmacists Lynne M. Schneider, R.Ph. 12910 37th Avenue North Plymouth, MN 55441 612/571-2220 Ron Johnson, R.Ph. Lloyd’s Pharmacy 720 North Snelling St. Paul, MN 55104 651/645-8636 Micheal J. Barrett, PD-FASCP Director of Pharmacy Long Praire Memorial Hospital & Home 20 Southeast Ninth Street Long Prarie, MN 56347-1404

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Wendy L. St. Peter, Pharm.D. Hennepin County Medical Center Nephrology Analytical Services USRDS Coordinating Center 914 Eighth Avenue South Minneapolis, MN 55404 Consumers Representative Vacant DHS Staff Cody Wiberg, Pharm.D., R.Ph. Acting Pharmacy Program Manager Minnesota Department of Human Services 444 Lafayette Road, North St. Paul, MN 55155-3853 651/296-8515 Prescription Drug Updating First DataBank Medicaid Drug Rebate Contacts Audits: Jarvis Jackson, 651/282-5881 Policy: Cody Wiberg, 651/296-8515 Disease Management Program/Initiative Contact

Chris Reisdorf Supervisor Primary Care Benefits Policy 651/296-8822 Drug Formulary Committee Al Heaton, Pharm.D., R.Ph. Senior Director Prime Therapeutics 1020 Discovery Road No. 100 Eagan, MN 55164 Charlene Nusman Consumer Representative 2534 Lynn Avenue So. St. Louis Park, MN 55416 William P. Korchik, M.D. Veterans Affairs Medical Center One Veteran Drive (11L) Minneapolis, MN 55417 612/725-2035 Jack Alexander, M.D. Fairview Red Wing Clinic 2835 South Service Clinic Red Wing, MN 55066

Cody Wiberg, 651/296-8515 Elderly Expanded Drug Coverage Program Contact Cody Wiberg, 651/296-8515 Physician-Administered Drug Program Contact Chris Reisdorf Department of Human Services 444 Lafayette Road St. Paul, MN 55155 612/296-8822 Department of Human Services Officials

Executive Officers of State Medical and Pharmaceutical Societies Minnesota Medical Association John Van Etta, M.D., President 3433 Broadway Street NE, Suite 300 Minneapolis, MN 55413-1760 612/378-1875 Minnesota Pharmacists Association Keith Pearson Interim Executive Director 2550 University Avenue, West Minneapolis, MN 55114 612/644-3566

Michael O’Keefe Commissioner Department of Human Services 444 Lafayette Road St. Paul, MN 55155-3815 651/296-2701

Minnesota Osteopathic Medical Society Drenda G. Wendell, D.O. Executive Director 2912 80th Circle North Brooklyn Park, MN 55444-1644 612/560-3346

Mary Kennedy Medicaid Director 651/282-9921

State Board of Pharmacy David Holmstrom Executive Director 2829 University Avenue SE #530 Minneapolis, MN 55414-3251 612/617-2201

National Pharmaceutical Council

Minnesota-4

Pharmaceutical Benefits 2000 Minnesota Hospital and Healthcare Partnership Bruce Rueben President 2550 University Avenue, West Suite 350S St. Paul, MN 55114 651/641-1121

5-Minnesota

National Pharmaceutical Council

Pharmaceutical Benefits 2000

MISSISSIPPI A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

OAA

AB

APTD

AFDC

Prescribed Drugs









Inpatient Hospital Care









Outpatient Hospital Care









Laboratory & X-ray Service









Skilled Nursing Home Services









Physician Services









Dental Services









OAA

AB

APTD

AFDC

Other Children <21

SFO

1

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

B. EXPENDITURES FOR DRUGS

TOTAL 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 Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients

1998* Expended Recipients $231,735,360 368,609

1999 Expended $260,515,719

Recipients 374,942

$3,659,580 $774,913 $32,397 $2,505,079 $8,373 $338,818

178,594 26,072 1,239 102,843 988 47,452

$862,937 $0 $0 $0 $562,150 $300,787 $0

143,942 0 0 0 96,592 47,350 0

$0 $0 $0 $0 $0 $0 $0

0 0 0 0 0 0 0

MEDICALLY NEEDY TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1998 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

National Pharmaceutical Council

Mississippi-1

Pharmaceutical Benefits 2000

C. ADMINISTRATION

Formulary/Prior Authorization

Division of Medicaid, Office of the Governor.

Formulary: Open formulary, however, general exclusions include:

D. PROVISIONS RELATING TO DRUGS

1. 2.

Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin, syringe combinations used for insulin; total parenteral nutrition; and interdialytic parenteral insulin. Products not covered: cosmetics; fertility drugs; experimental drugs; disposable needles used for insulin; blood glucose test strips; and urine ketone test strips. Prior authorization required for: Sandimmune; Viagra; enteral feeding products; Clozaril (must be prescribed by Board Certified or Board Eligible Psychiatrist);* Protropin and Humatrope;* all Antihemophilic Factors including VIII and IX;* and all Home IV Drug Therapies. * These products are covered only for children ages 0-21 years through the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT). Over-the-Counter Product Coverage: Products covered: ASA, generic Tylenol; generic Robitussin, Benadryl; iron supplements; and calcium supplements. Products not covered: allergy, asthma, and sinus products; digestive products; feminine products; topical products; and smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; anorectics; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: analgesics, antipyretics, NSAIDS; and growth hormones. Therapeutic categories not covered: prescribed cold medications and prescribed smoking deterrents. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities, and through physician payment when used in physicians offices. Vaccines: Vaccines reimbursable as part of the EPSDT program. Unit Dose: Unit dose packaging not reimbursable.

2-Mississippi

3. 4.

5. 6. 7.

Drugs used for anorexia or weight gain. Drugs when used for the symptomatic relief of cough and colds (except quaifenesin syrup 100 mg/5 ml, iodinated glycerol tablets 30 mg, which are covered). Prescription vitamins and mineral products (except prenatal vitamins and fluoride preparations, which are covered). Covered outpatient drugs for which the manufacturer requires (as a condition of sale) that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee. Barbiturates (except amobarbital, butabarbital, mephobarbital, pentobarbital, phenobarbital, secobarbital, which are covered). Benzodiazepines (except Klonopin, Lorazapam, Diazepam and Temazepam which are covered). DESI drugs (those drugs that are designated less than effective by the FDA).

Prior Authorization: Administrative hearing require to appeal prior authorization decisions. Prescribing or Dispensing Limitations Prescription Refill Limit: Limited to five (5). Monthly Quantities Limit: 34-day supply or 100 units or doses, whichever is greater. Birth control pills may be supplied in 3-month quantities. Monthly Prescription Limit: Total prescriptions dispensed per month per recipient are limited to 5. With prior authorization recipients may get up to 10. Drug Utilization Review PRODUR system implemented in 1993. No state DUR Board exists. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.91. Ingredient Reimbursement Basis: EAC = AWP - 10%, effective July 1, 1990. 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%, or shelf price. OTC drugs are to be billed on pharmacy invoice at shelf price.

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary.” Incentive Fee: None.

Robert McMurry, M.D. University of MS Medical Center L525 Clinical Sciences Bldg. 2500 North State St. Jackson, MS 39216 601/362-4471 ext.1865

Patient Cost Sharing: Copayment $1.00. Cognitive Services: Pays for Disease Management Services for arthritis, diabetes, hyperlipidemia, asthma, and coagulatory disorders (effective 8/1/98). Pays $20 for average 30-minute encounter.

E. USE OF MANAGED CARE No Medicaid recipients receive health benefits through MCOs.

F. STATE CONTACTS State Drug Program Administrator James G. (Jack) Lee, R.Ph. Division of Medicaid, Office of the Governor 239 North Lamar St., Ste.. 801 Jackson, MS 39201-1399 T: 601/359-6296 F: 601/359-4185 E-mail: [email protected] http://www.dom.state.ms.us Division of Medicaid Official Rica Lewis-Payton Director, Division of Medicaid Suite 801, Robert E. Lee Building 239 North Lamar Street

Cindy Nobel, Pharm.D. University of MS Department of Family Medicine 2500 North State St. Jackson, MS 39216 601/984-5425 Richard Ogletree, Pharm.D. University of MS Department of Pharmacy 2500 North State St. Jackson, MS 39216 601/984-2055 Jerry Perry, R.Ph. 1700 Terry Road Jackson, MS 39204 601/355-2438 Dennis Read, R.Ph. 28 Wansley Rd. Laurel, MS 39440 601/428-8839 Mike Vinson, Pharm.D. University of MS P.O. Box 1274 University, MS 38677 601/232-1052 Prescription Price Updating

DUR Contact Jack Lee, R.Ph. T: 601/359-6296

Jack Lee, R.Ph. T: 601/359-6296 Medicaid Drug Rebate Contacts

Medicaid DUR Board R. Terry Jackson, M.D. University of MS 2500 North State St. Jackson, MS 39216 Robert Forbes, M.D. University of MS 2500 North State St. Jackson, MS 39216

National Pharmaceutical Council

Technical: Terry Childress, 601/359-6050 Rebate: Glenda Grant, 601/359-6050 PA: Jack Lee, 601/359-6296 Claims Submission Contact Terry Childress Director of Systems 239 North Lamar Street Jackson, MS 39201 T: 601/359-6050 F: 601/359-6048 E-mail: [email protected]

Mississippi-3

Pharmaceutical Benefits 2000

Medicaid Managed Care Contact

Fiscal Intermediary

Melzana Fuller Director of Provider and Beneficiary Relations Division of Medicaid, Office of the Governor 239 North Lamar Street, Ste. 801 Jackson, MS 39201 T: 601/359-6063 F: 601/359-4185 E-mail: [email protected]

EDS 111 Capitol St. Ste 390 Jackson, MS 39201 601/960-2800

Physician-Administered Drug Program Contact Patsy Crews, R.N. Director of Bureau of Policy Division of Medicaid 239 N. Lamar Street Jackson, MS 39201 601/359-5142 Executive Officers of State Medical and Pharmaceutical Societies Mississippi State Medical Association Charles L. Mathews Executive Director 735 Riverside Drive Jackson, MS 39202-6013 601/354-5433 Mississippi Pharmacists Association Bo Dalton, R.Ph. Executive Director 341 Edgewood Terrace Drive Jackson, MS 39206-6217 601/981-0416 William L. Stevens, R.Ph. Executive Director P.O. Box 24507 Jackson, MS 39225-4507 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

Pharmaceutical Benefits 2000

MISSOURI A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

OAA

AB

APTD

AFDC

Prescribed Drugs









Inpatient Hospital Care









Outpatient Hospital Care









Laboratory & X-ray Service









Skilled Nursing Home Services









Physician Services









Dental Services









OAA

AB

APTD

AFDC

Other Children <21

SFO

1

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

B. EXPENDITURES FOR DRUGS

TOTAL RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult

1998 Expended Recipients $382,512,566 353,902 $48,782,537 $9,278,584 $26,315,038 $5,053,612 $8,135,303 $0 $0

64,528 4,400 8,683 32,774 18,671 0 0

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult

$0 $0 $0 $0 $0

0 0 0 0 0

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

$21,033,758 $1,654,387 $5,035,842 $12,580,584 $1,762,945

100,458 1,770 2,080 77,140 19,468

$312,696,271

188,916

OTHER

1999* Expended Recipients

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

National Pharmaceutical Council

Missouri-1

Pharmaceutical Benefits 2000

C. ADMINISTRATION Division of Medical Services of the State Department of Social Services.

D. PROVISIONS RELATING TO DRUGS Benefit Design 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 quazepam. Products covered through the Durable Medical Equipment Program: blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Prior authorization required for: amphetamines; Isotretinoin; and Retinoic Acid. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in physician offices, home health care settings, and extended care facilities. Vaccines: Vaccines reimbursable as part of EPSDT program, Children Health Insurance Program, and Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization Formulary: Open formulary with exclusions. Prior Authorization: State currently has a prior authorization procedure, and 7 committee members who meet quarterly. Prescribing or Dispensing Limitations Prescription Refill Limit: Federal regulations must be observed for all drugs on the formulary that are listed in BNDD Schedules 2, 3, 4, and 5. All other prescriptions refilled should be in accordance with the directions given by the prescribing physician.

Dose Limit: Prescriptions for the following must be dispensed for at least 200 units per prescriptions: Aspirin 5 gr.; Aspirin buffered 5 gr.; Aspirin enteric-coated 5 gr.; Acetaminophen 5 gr. Prenatal vitamins must be dispensed in a quantity of at least 100. Drug Utilization Review PRODUR system implemented in 1993. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.09, effective 9/17/91. Ingredient Reimbursement Rate: EAC = AWP - 10.43%. Prescription Charge Formula: 1.

Method of reimbursement payment is based on acquisition cost plus a dispensing fee of $4.09 per prescription filled. Acquisition may vary depending whether it is based on AWP and Federal or Missouri MAC.

2.

Any drug that is not a federal or Missouri MAC drug will be based on the AWP less 10.43%. The majority of drugs listed are based on AWP. The method of pricing will be taken from the NDC number.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. 32 drugs are listed on the state-specific MAC list. Override requires prior authorization. Incentive Fee: None. Patient Cost Sharing: Variable copayment: Drug Ingredient Cost $0.00 to $10.00 $10.01 to $25.00 $25.01 or more

Copayment $0.50 $1.00 $2.00

Copayment retained by pharmacist. Cognitive Services: Payment for cognitive services is under consideration.

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

Pharmaceutical Benefits 2000

E. USE OF MANAGED CARE

F. STATE CONTACTS

Approximately 270,000 Medicaid recipients are enrolled in managed care organizations. All receive pharmacy services through managed care.

State Drug Program Administrator

Managed Care Organizations Healthcare USA 100 South 4th Street, Suite 1100 St. Louis, MO 63102 314/444-7239 Blue Advantage Plus Health Plan P.O. Box 419130 2301 Main St. Kansas City, MO 64141 816/395-3891 Mercy Health Plan 1508 S. Grand St. Louis, MO 63104 314/214-8000 Care Partners Health Plan The Clayton Center 120 S. Central, 8th Floor St. Louis, MO 63105 314/505-5400 Community Care Plus Health Plan 5615 Pershing Avenue, Suite 29 St. Louis, MO 63112 314/454-0055 ext. 234 HealthNet Health Plan 2300 Main Street, Suite 700 Kansas City, MO 64108 816/221-8400 FirstGuard Health Plan 3801 Blue Parkway Kansas City, MO 64130 816/922-7250 Family Health Partners Health Plan 215 W. Pershing Road, Suite 310 P.O. Box 411806 Kansas City, MO 64141 816/855-1871 Missouri Care Health Plan 2404 Forum Blvd. Columbia, MO 65203 573/441-2100

National Pharmaceutical Council

Susan McCann, R.Ph. Pharmaceutical Consultant Division of Medical Services P.O. Box 6500 Jefferson City, MO 65102-6500 T: 573/751-6963 F: 573/526-4650 E-mail: [email protected] Social Services Department Officials Gary J. Stangler, Director Department of Social Services Broadway State Office Building P.O. Box 1527 Jefferson City, MO 65102 Gregory Vadner, Director Division of Medical Services 615 Howerton Court, P.O. Box 6500 Jefferson City, MO 65102 Prior Authorization Contact Allison Lauf, R.N. Nurse Consultant Division of Medical Services P.O. Box 6500 Jefferson City, MO 65102 573/751-3762 DUR Contact Jayne Zimmer DUR Coordinator Division of Medical Services P.O. Box 6500 Jefferson City, MO 65102 573/751-6963 DUR Board John W. Newcomer, M.D. (Chair) Assistant Professor of Psychiatry Washington University, School of Medicine Campus Box 8134 660 S. Euclid St. Louis, MO 63110 Ronald Graham, Pharm.D. Government Relations Manager Novartis Corporation 1311 Granite Creek Drive Blue Springs, MO 64015

Missouri-3

Pharmaceutical Benefits 2000 Randall Huss, M.D. Rolla Family Practice 910 W. 10th Street Rolla, MO 65401

Gene Forrester, R.Ph. 2400 S. Blackthorne Columbia, MO 65201

Pamela C. Waggoner, MSN, R.N. 539 Wyatt Drive St. Peters, MO 63376

Henry Petry, D.O. Laurie Clinic P.O. Box 1277 Laurie, MO 65038

Joy S. Gronstedt, D.O. 30580 Summers Drive Sedalia, MO 65301

James E. Edwards, M.D. 1000 Executive Pkwy, Suite 103 St. Louis, MO 63141

Joseph M. Yasso, D.O. 3513 NW Primrose Lane Lee’s Summit, MO 64064

Lorraine C. Brown, D.O. Rt. 2, Box 247C Camdenton, MO 65020

Jacquelyn B. Dilworth, M.D. 1101 Courtwood Circle Ballwin, MO 63011

Conrad S. Balcer, D.O. 1241 W. Stadium Blvd. Jefferson City, MO 65109

Karla Dwyer, R.Ph. 901 Cherry Lane Kirksville, MO 63501

Prescription Price Updating

Susan Abdel-Rahman, Pharm.D. Division of Clinical Pharmacology Children’s Mercy Hospital 2401 Gillham Road, Ste 0411 Kansas City, MO 64108 Peggy Wanner-Barjenbrunch, M.D. Rt. 5, Box 82A Mexico, MO 65265 Sandra Bollinger, R.Ph. 112 E. Tywappity Benton, MO 63736 Drug Prior Authorization Committee Patrick J. Bryant, Pharm.D. Drug Information Center School of Pharmacy University of Missouri - Kansas City MG-200 Medical School Building 2411 Holmes Street Kansas City, MO 64108-2792 M. Dale Terrell, M.D. Washington University School of Medicine Division of Geriatric Medicine Room M238 1402 South Grand Blvd. St. Louis, MO 63104

4-Missouri

First DataBank 1111 Bayhill Dr. San Bruno, CA 94066 T: 650/588-5454 Medicaid Drug Rebate Contacts Technical: Julie Schulte, 573/751-7996 Policy: Susan McCann, 573/751-6963 Dispute Resolution: Lynn Hebenheimer, 573/751-2005 Audits: Lynn Hebenheimer, 573/751-2005 Claims Submission Contact Jim Judge GTE Data Services 905 Weathered Rock Road Jefferson City, MO 65101 573/635-2434 Medicaid Managed Care Contact Janice Gentile Regional Administrator Division of Medical Services P.O. Box 6500 Jefferson City, MO 65102 573/526-4274 Physician-Administered Drug Program Contact Pam Jarrett Division of Medical Services P.O. Box 6500 Jefferson City, MO 65102-6500 573/751-3277

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Pharmacy Subcommittee Roster Bill Fitzpatrick, R.Ph. Interlock Pharmacy Systems 2292 Weldon Parkway St. Louis, MO 63146

Missouri Hospital Association Charles L. Bowman President 4712 Country Club Drive Jefferson City, MO 65109-4544 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 Executive Officers of State Medical and Pharmaceutical Societies Missouri State Medical Association C. C. Swarens Executive Secretary 113 Madison Street, P.O. Box 1028 Jefferson City, MO 65102 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 Jefferson City, MO 65102 573/634-3415 State Board of Pharmacy Kevin E. Kinkade Executive Director P. O. Box 625 Jefferson City, MO 65102 573/751-0091

National Pharmaceutical Council

Missouri-5

Pharmaceutical Benefits 2000

MONTANA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

Other

OAA

AB

APTD

AFDC

OAA

AB

APTD

AFDC

Children <21

Prescribed Drugs



















Inpatient Hospital Care



















Outpatient Hospital Care



















Laboratory & X-ray Service



















Skilled Nursing Home Services



















Physician Services



















Dental Services



















SFO

1

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $42,368,399 58,641

1999* Expended Recipients $46,269,102 59,201

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult POVERTY RELATED, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult OTHER, TOTAL Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Montana

National Pharmaceutical Council

Pharmaceutical Benefits 2000

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 lessthan-effective (LTE) by the FDA are not covered. Drugs with no manufacturer rebate are not covered.

Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin. Products not covered: cosmetics; fertility drugs; experimental drugs; disposable needles used for insulin, syringe combinations for insulin use; blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Prior authorization required for Dipyridamole; Carafate; Ambien; Sonata; Cilostazol; Pentoxifylline; Isoproterenol; Isoetherine; Viagra; Thalidomide; DMARDs; Mobic, Celebrex, and Vioxx; anti-obesity drugs; Duract; Stadol; Tretinoin; and Zoloft (50mg); migraine headache drugs; single-source non-steroidal anti-inflammatory drugs; growth hormones; smoking cessation; oral Ketorolac; H2antagonists, proton pump inhibitors, single source benzodiazepines; hair growth products; and fertility agents. Over-the-Counter Product Coverage: Products covered: analgesics (Aspirin only); digestive products; head lice treatment products (permethrin and pyrethrin combination products); H-2 antagonists. Products not covered: allergy, asthma, and sinus products; cold and cough preparations; feminine products; topical products; and smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: anorectics; anxiolytics, sedatives, and hypnotics; analgesics, antipyretics, NSAIDs; misc. GI drugs; growth hormones; and prescribed smoking deterrents. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities, and through physician payment when used in physician offices.

Prior Authorization: State has a formal prior authorization procedure. Prescriber letter documenting evidence for use of prescribed medication in treatment of disease is reviewed by DUR Board for appeal of excluded product. An appeal procedure through the Department possible for PA decisions. Prescribing or Dispensing Limitations Prescription Refill Limit: 25% grace period over a 3month period is allowed. Monthly Quantity Limit: 100 doses or 34-day supply, whichever is greater. Drug Utilization Review PRODUR system implemented in September 1994. State DUR Board has 6 members and meets monthly. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $2.00-4.20; effective 7/1/98. Additional $0.75 is added to prescriptions unit dosed by the pharmacy. Ingredient Reimbursement Basis: EAC = AWP - 10%, or manufacturer’s direct price, if available. Prescription Charge Formula: The lower of EAC, the Federal MAC (plus a dispensing fee), or the provider usual and customary charge. Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Necessary.” Incentive Fee: None. Patient Cost Sharing: Copayment - $1.00 for all generic; $2.00 for all others; effective 5/1/94. Cognitive Services: Does not pay for cognitive services.

Vaccines: Vaccines reimbursable as part of the EPSDT service, the Children Health Insurance Program, and as part of the Vaccines for Children Program.

National Pharmaceutical Council

Montana-2

Pharmaceutical Benefits 2000

E. USE OF MANAGED CARE HMO availability began November 1995, to FAIM recipients. SSI and SSI-related clients were eligible to enroll October 1, 1997. HMO coverage ended June 30, 2000.

F. STATE CONTACTS State Drug Program Administrator Dorothy D. Poulsen Pharmacy Program Officer Department of Public Health and Human Services Medicaid Services Bureau P.O. Box 202951 1400 Broadway Helena, MT 59624 406/444-2738 Fax 406/444-1861 Public Health and Human Services Officials Laurie Ekanger Director Department of Public Health and Human Services P.O. Box 202951 1400 Broadway Helena, MT 59624 406/444-5622 Nancy Ellery, Administrator Health Policy and Services 406/444-4141 Mary Dalton, Bureau Chief Medicaid Services Bureau 406/444-4144 Jeff Buska, Supervisor Acute Services Section 406/444-4145 Mary Angela Collins, Supervisor Managed Care Section 406/444-4146 Prior Authorization Contact Mark Eichler, R.Ph. DUR Coordinator Mountain Pacific Quality Health Foundation 3404 Cooney Drive Helena, MT 59602 T: 406/443-4020 F: 406/443-4585 E-mail: [email protected]

3-Montana

DUR Contact Mark Eichler, R.Ph. 406/443-4020 Montana DUR Board Mark Eichler, R.Ph., FASCP DUR Coordinator Mountain Pacific Quality Health Foundation 3404 Cooney Drive Helena, MT 59602 406/443-4020 V. Lee Harrison, M.D. Richard Sargent, M.D. Nathan A. Munn, M.D. DeeDee Cress, Pharm.D. Marcella Barnhill, R.Ph. Ann Geidel, R.Ph. Prescription Price Updating First DataBank 1111 Bayhill Dr. San Bruno, CA 94066 T: 415/588-5454 Medicaid Drug Rebate Contacts Technical: Dan Forbes, 406/444-1794 P & A: Betty DeVaney, 406/444-3457 Claims Submission Contact Brett Jakovac Consultec, Inc. 34 N. Last Chance Gulch, Suite 200 Helena, MT 59601 T: 406/442-1837 F: 406/442-4402 E-mail: [email protected] Medicaid Managed Care Contact Mary Angela Collins Supervisor, Managed Care Section Dept. of Public Health and Human Services Medicaid Services Bureau P.O. Box 202951 Helena, MT 59620-2951 T: 406/444-4146 F: 406/444-1861 E-mail: [email protected]

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Disease Management Program/Initiative Contact Dorothy Poulsen Pharmacy Program Officer Dept. of Public Health and Human Services Medicaid Services Bureau P.O. Box 202951 Helena, MT 59620-2951 T: 406/444-2738 F: 406/444-1861 E-mail: [email protected] Physician-Administered Drug Program Contact Randy Bowsher P.O. Box 202951 1400 Broadway Helena, MT 59624 406/444-3995 Executive Officers of State Medical and Pharmaceutical Societies 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 State Board of Pharmacy 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

Pharmaceutical Benefits 2000

NEBRASKA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 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

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $92,558,539 145,408

1999* Expended Recipients $114,094,719 154,493

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 Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients MEDICALLY NEEDY TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Nebraska

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION

Formulary/Prior Authorization

State Department of Health and Human Services, Finance and Support, Medicaid Division.

Formulary: Open formulary. General exclusions include:

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin with prior approval on pre-filled syringes. Products not covered: disposable needles and syringe combinations for insulin; blood glucose test strips; urine ketone test strips; total parenteral nutrition; interdialytic parenteral nutrition; cosmetics; fertility drugs; and experimental drugs. Prior authorization required for: methadone; IV infusions; and protein replacement supplements. Over-the-Counter Product Coverage: Products covered: allergy, asthma, and sinus products; analgesics; topical products; cough and cold preparations; digestive products (H2 antagonists); and feminine products. Products not covered: smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT antiinflammatory agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: growth hormones; sunscreens; Erythropoetin (e.g., Epogen, Procrit); modified versions of FUL or SMAC drugs; convenience packaged drugs (e.g., Refresh Ophthalmic 0.3 ml and Novalin penfil insulin); drugs to prevent or treat Respiratory Syncytial Virus Immune Globulin (e.g., Palivizumab, RSV-IG); and drugs for sexual dysfunction (e.g., Sildenafil, Alprostadil). Therapeutic categories not covered: anorectics and prescribed smoking deterrents.

1.

More than a three-month supply of birth control tablets; 2. Experimental drugs or non-FDA approved drugs; 3. Drugs or items when the prescribed use is not for a medically accepted indication; 4. Liquors (any alcoholic beverages); 5. DESI drugs and all identical, related, or similar drugs; 6. Personal care items (e.g. non-medical mouthwashes, deodorants, talcum powders, bath powders, soaps, dentrifices, eye washes, and contact solutions); 7. Medical supplies and certain drugs for nursing facility and intermediate care facility for the mentally retarded (IDF/MR) patients; 8. Over-the-counter (OTC) drugs not listed on the Department’s Drug Name/License number Listing microfiche; 9. Baby foods or metabolic agents (Lofenalac, etc.,) normally supplied by the Nebraska Department of Health; 10. Drugs distributed or manufactured by certain drug manufacturers or labelers that have not agreed to participate in the drug rebate program. Drugs, items, or manufacturers that are identifiable as non-covered are so designated on the NE-POP system, and on the Department’s Drug Name/License Number Listing microfiche. Prior Authorization: The Department requires that authorization be granted prior to payment for certain products. Prior authorization can be verified through the NE-POP System, or by contacting the Department. (or its designated contractor) if authorization is not verified through the NE-POP System. Prescribing or Dispensing Limitations Prescription Refill Limit: As authorized by the prescribing physician. For controlled substances, maximum 5 refills every 6 months.

Coverage of Injectables: Injectables reimbursable through the Pharmacy program when used medicine used in home health care, extended care facilities and through physician payment when used in physician offices.

Monthly Quantity Limit: 90-day supply or 100 dosage units, whichever is greater.

Vaccines: Vaccines reimbursable by Medicaid for individuals under 21 years of age through the Vaccines for Children Program, the Children Health Insurance Program and as part of the EPSDT service.

PRODUR system implemented in April 1995. State currently has a DUR Board with a monthly review.

Drug Utilization Review

Unit Dose: Unit dose packaging not reimbursable.

National Pharmaceutical Council

Nebraska-2

Pharmaceutical Benefits 2000 Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.66. The Nebraska Department of Health and Human Services assigns a dispensing fee to each individual pharmacy. The fee is calculated from information obtained through the Department’s Prescription Survey. Ingredient Reimbursement Basis: EAC = AWP - 8.71%. Direct for some pharmaceutical companies. Prescription Charge Formula: Lower of: 1. 2.

Product cost (EAC, SMAC, or FUL) plus a dispensing fee, or The usual and customary price to the general public.

Listed OTCs are reimbursed at the lower of: 1. 2. 3.

Product cost (EAC, SMAC, or FUL) plus a dispensing fee, The usual and customary shelf price to the general public, or Product cost (EAC, SMAC, or FUL) plus a 50% mark-up.

Blue Cross/Blue Shield of Nebraska P.O. Box 241739 Omaha, NE 68124 Value Options Mental Health 10330 Regency Parkway Omaha, NE 68114

F. STATE OFFICIALS State Drug Program Administrator Gary J. Cheloha R.Ph. Pharmaceutical Consultant Health and Human Services, Finance and Support Medicaid Division, 5th Floor-NSOB P.O. Box 95026 Lincoln, NE 68509 T: 402/471-9379 F: 402/471-9092 E-mail: [email protected] Health and Human Services Department Officials

Maximum Allowable Cost: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. Approximately 450 drugs are listed on the state-specific MAC list. Override requires an MC-6 form signed by the physician.

Richard Raymond, M.D., Acting Director Department of Health and Human Services 301 Centennial Mall Lincoln, NE 68509 402/471-9105

Incentive Fee: None.

Robert J. Seiffert, Administrator Medicaid Division 402/471-3121

Patient Cost Sharing: Copayment = $1.00. Cognitive Services: State provides additional payment for cognitive services, effective January 2000.

E. USE OF MANAGED CARE Approximately 122,006 unduplicated Medicaid recipients were enrolled in managed care in 1999. None received pharmacy services through managed care. Managed Care Organizations Share Advantage United HealthPlans of the Midlands 2717 North 118th Circle Omaha, NE 68164

Ms. Kris Azimi Utilization Review Consultant 402/471-9365 Christine Wright, M.D., Medical Director Medicaid Division 402/471-9136 Prior Authorization Contact John Franklin, Pharm.D., R.Ph. Clinical Pharmacist HHSS-Medicaid Division P.O. Box 95026; NSOB 5th Fl. Lincoln, NE 68509-5026 402/471-9301

Wellness Option Exclusive Health Care, Inc. 10250 Regency Circle Suite 250 Omaha, NE 68114 Primary Care + 3-Nebraska

National Pharmaceutical Council

Pharmaceutical Benefits 2000 DUR Contact

Disease Management Initiative/Program Contact

Allison Jorgensen, Pharm.D., R.Ph. DUR Director Nebraska Pharmacists Association 6221 South 58th; Ste A Lincoln, NE 68516 402/420-1500

Gay Jeffries, R.N., B.A. QI Manager HHSS-Nebraska Medicaid 301 Centennial Mall South Lincoln, ME 68509 402/471-9415

Nebraska DUR Board

Physician-Administered Drug Program Contact

Pharmacist Members: Kevin Borcher, R.Ph. Janet Darnell, R.Ph. Patty Gollner, R.Ph. Duane Mines, R.Ph. John Guzallis, R.Ph. Kim Hamik, R.Ph. Shannon Nelson, R.Ph. Monty Scheele, R.Ph. Phillip Vuchetich, R.Ph.

Lorelee Novak, R.N. Department of Health and Human Services 301 Centennial Mall, 5th floor 402/471-9368

Physician Members: Warren Bosley, MD Kirk Muffly, MD Thomas B. Murray, MD Fred Ayers, MD Prescription Price Updating First DataBank 1111 Bayhill Dr. San Bruno, CA 94066 T: 415/588-5454

Health and Human Services Department Medical Care Advisory Committee Marlene Brondel League of Human Dignity 1701 P Street Lincoln, NE 68508 Tim Bruner Director of Fiscal Services Lincoln General Hospital 2300 South 16th Street Lincoln, NE 68502 Tom Dolan, R.Ph. Executive Director Nebraska Pharmacists Association 6221 South 58th Street, Suite A Lincoln, NE 68502

Medicaid Drug Rebate Contacts Technical: Arlene Ropers, 402/471-9159 Policy: Gary Cheloha, R.Ph., 402/471-9379 Claims Submission Contact Janice Jones, R.Ph. Clinical Pharmacy Manager 4300 Cox Road Glen Allen, VA 23060 804/965-7517 Medicaid Managed Care Contact David Cygan Managed Care Program Administrator HHSS-Finance & Support-Medicaid 301 Centennial Mall South Lincoln, ME 68509 402/471-9050

National Pharmaceutical Council

Karen Miller Health Insurance Specialist Room 227, Federal Building 601 East 12th Street Kansas City, MO 64106 Edmund A. Schneider, O.D. Lincoln Vision Clinic 810 North 48th Street Lincoln, NE 68504 Steven Lorenzen Director, Federal Programs Blue Cross/Blue Shield of NE Main P. O. Station Box 3248 Omaha, NE 68180

Nebraska-4

Pharmaceutical Benefits 2000 John Milligan Legal Services of Southeast Nebraska 825 Terminal Building Lincoln, NE 68508 Joan Penrod, Ph.D. Department of Preventive and Social Medicine UNMC Box 984350, 600 S. 42nd Street Omaha, NE 68198 Larry Rennecker NAHHS 1640 L Street, Suite D Lincoln, NE 68508 William Schellpepper Executive Secretary Nebraska Medical Association First Bank Bldg., Suite 1512 Lincoln, NE 68508 Pat Snyder Executive Director Nebraska Health Care Assoc. 421 South 9th Street, Suite 137 Lincoln, NE 68508

John Franklin, R.Ph. 4501 Elkridge Road Lincoln, NE 68516 Eric Hamik, R.Ph. 19 Kings Court Kearney, NE 68845 Roger Kaczmarek, R.Ph. 15763 Fountain Hills Drive Omaha, NE 68118 Duane Mines, R.Ph. 202 North Main Street Hooper, NE 68031 Gordon Ockinga, R.Ph. 1810 Stolley Park Circle Grand Island, NE 68803 Ran Varney, R.Ph. P.O. Box 70 Broken Now, NE 68822 Michael Wendt, R.Ph. 608 N 3rd Street Tecumseh, NE 68450

James Walker, D.D.S. 1640 South 70th, Suite 200 Lincoln, NE 68506

Beth Wilson, R.Ph. 5601 South 72nd Street Lincoln, NE 68516

Medicaid Pharmacy Advisory Committee

Executive Officers of State Medical and Pharmaceutical Societies

Ken Kunce, R.Ph., Chairman 1000 Reavis Street Falls City, NE 68355 Will Davis, R.Ph. 729 Walnut Drive Wayne, NE 68787 David Brehm, R.Ph. 1609 Custer Street St. Paul, NE 68873 Jacob Dering, R.Ph. P.O. Box 333 Crete, NE 68333 Leroy Dinslage, R.Ph. Pac N’ Save 1519 West Hwy 34 Seward, NE 68434

Nebraska Medical Association William Schellpeper Executive Secretary 233 S. 13th Street, Suite 1512 Lincoln, NE 68508-2091 402/474-4472 Nebraska Pharmacists Association Thomas R. Dolan, R.Ph. Executive Director 6221 South 58th, Suite A Lincoln, NE 68516 402/420-1500 Nebraska Assn. of Osteopathic Physicians & Surgeons Arthur Weaver, D.O. Secretary P.O. Box 24744 W. Omaha Station Omaha, NE 68124 402/333-2744 State Board of Pharmacy

5-Nebraska

National Pharmaceutical Council

Pharmaceutical Benefits 2000 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

National Pharmaceutical Council

Nebraska-6

Pharmaceutical Benefits 2000

NEVADA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

OAA

AB

APTD

AFDC

Prescribed Drugs









Inpatient Hospital Care









Outpatient Hospital Care









Laboratory & X-ray Service









Skilled Nursing Home Services









Physician Services









Dental Services









OAA

AB

APTD

AFDC

Other Children <21

SFO

1

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998 Expended $34,518,901

CATEGORICALLY NEEDY CASH TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients

$25,381,004 $5,265,564 $18,443,130 $698,439 $913,482 $0 $60,389

29,633 5,071 13,572 6,722 3,898 0 370

$156,978 $70,489 $70,820 $11,385 $4,284 $0

710 168 147 272 123 0

$0 $0 $0 $0 $0 $0 $8,721,337

0 0 0 0 0 0 19,345

CATEGORICALLY NEEDY NON-CASH TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients MEDICALLY NEEDY TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients

Recipients 50,903

1999* Expended Recipients

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Nevada

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION

4. 5.

State Welfare Division of the Department of Human Resources.

6.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin and total parenteral nutrition (prior payment authorization). Products not covered: cosmetics; fertility drugs; experimental drugs; disposable needles and syringe combinations for insulin; blood glucose test strips; and urine ketone test strips. Over-the-Counter Product Coverage: Products covered with restrictions: digestive products (H2 antagonists); smoking deterrent products; allergy, asthma and sinus products; analgesics; cough and cold preparations; and topical products. OTC Coverage: OTC drugs are reimbursed at EAC+$4.76 or the usual and customary amount, whichever is less, and require prior payment authorization. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; ENT antiinflammatory agents; estrogens; hypotensive agents; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: analgesics, antipyretics, NSAIDs; growth hormones; and prescribed cold medication. Therapeutic categories not covered: anorectics. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities, or through physician payment when used in physicians offices. Vaccines: Vaccines reimbursable at cost plus an administration fee ($3.83) as part of the EPSDT service. Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization

Radiographic adjuncts (e.g., Perchloracap). Pharmaceuticals designed “ineffective,” or “less than effective” (including identical, related, or similar drugs) by the FDA. Non-rebated medications.

Prior Authorization: Prior authorization procedure screening for individual drugs. Drugs requiring PA include: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Amphetamine (e.g., Dexedrine) Chorionic Gonadotropin (HCG) Dipyridamole (e.g., Persantine) Erythropoietin (e.g., Epogen, Procrit) Gonadotropin releasing hormone analog (e.g., Lupron, Zoladex) Growth hormone (e.g., Protropin, Nutropin) Interferon (all combinations manufactured by recombinant DNA technology) Intravenous antibiotic therapy Methylphenidate (e.g., Ritalin) Non-legend pharmaceuticals Nutritional supplements or replacements Pemoline (e.g., Cylert) Pulmozyme Vitamins, vitamin/mineral combinations or hematinics

Prescribing or Dispensing Limitations Monthly Prescription Limit: Eligible Medicaid recipients may receive three outpatient prescriptions per month plus those issued for EITHER prenatal OR family planning purposes. Monthly Quantity Limit: The maximum dispensable quantity is limited to a 34-day supply. Drug Utilization Review Plans to implement PRODUR system in February 2001. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.76, effective 10/1/98. Ingredient Reimbursement Basis: EAC = AWP - 10%. Prescription Charge Formula: The lowest of (1) specific upper limit (SUL) plus a dispensing fee, (2) estimated 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. 2. 3.

Agents used for cosmetic purposes or hair growth. Yohimbine (e.g., Yocon). Radiopaque agents (e.g., Telepaque, Hypaque, Barium Sulfate).

National Pharmaceutical Council

Nevada-2

Pharmaceutical Benefits 2000 Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary.” Incentive Fee: None.

Mary Loherry Deputy Administrator Nevada Medicaid Welfare Division 2527 N. Carson Street Carson City, NV 89710 702/687-4378

Patient Cost Sharing: None. Prior Authorization Contact Cognitive Services: Does not pay for cognitive services. Laurie Squartsoff, R.Ph. T: 702/687-4869

E. USE OF MANAGED CARE Approximately 38,614 Medicaid recipients are enrolled in MCOs; all receive pharmacy benefits through managed care. Managed Care Organizations Health Plan of Nevada P.O. Box 15645 Las Vegas, NV 89114 NevadaCare, Inc. 1701 W. Charleston Blvd. Suite 420 Las Vegas, NV 89102 United Healthcare 1160 Town Center Drive, Suite 390 Las Vegas, NV 89134

F. STATE CONTACTS State Drug Program Administrator Laurie Squartsoff, R.Ph. Pharmaceutical Consultant Nevada Medicaid Office 2527 N. Carson Street Capitol Complex Carson City, NV 89710 T: 702/687-4869 F: 702/687-8724 E-mail: [email protected] Human Resources Department Officials Charlotte Crawford, Director Department of Human Resources State Capital Complex 505 East King St. Room 600 Carson City, NV 89710

3-Nevada

9,894

25,164

3,556

DUR Contact Laurie Squartsoff, R.Ph. T: 702/687-4869 DUR Board Joseph W. Johnson, M.D. 110 E. Lake Mead Boulevard, #201 Henderson, NV 89015 702/565-8911 Steven W. Parker, M.D. 75 Pringle Way, #603 Reno, NV 89503 702/329-0333 David England, R.Ph. University Medical Center Pharmacy 1800 W. Charleston Boulevard Las Vegas, NV 89102 702/383-2601 Lori Winchell, R.N. 341 Pinnacle Court Henderson, NV 89014 702/895-3377 Prescription Price Updating First DataBank 1111 Bayhill Dr. San Bruno, CA 94066 T: 650/588-5454 Medicaid Drug Rebate Contacts Technical: Phil Boord, 702/687-7029 Policy: Laurie Squartsoff, 702/687-4869 Rebate: Laurie Squartsoff, 702/687-4869

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Claims Submission Contact Anthem Blue Cross/Blue Shield P.O. Box 12127 Reno, NV 89510-2127 775/448-4020 Medicaid Managed Care Contact Hilary Jones, R.N. Medicaid Services Specialist III 1100 E. Williams St., Ste 204 Carson City, NV 89701 775/687-4176 Physician-Administered Drug Program Contact

Linda Gellinger 1500 West Warm Springs Henderson, NV 89014 James Boscacci 3061 Conte Drive Carson City, NV 89701 Executive Officers of State Medical and Pharmaceutical Societies Nevada State Medical Association Larry Matheis Executive Director 3660 Baker Lane, Suite 101 Reno, NV 89509 702/825-6788

Laurie Squartsoff, R.Ph. Nevada Medicaid Office 2527 North Carson Street Carson City, NV 89710 702/687-4869

Nevada Pharmaceutical Association Mary Grear, R.Ph. Executive Director 3006 S. Amryland Parkway, #400 Las Vegas, NV 89109

Medical Care Advisory Group

Nevada Osteopathic Medical Association Patrick J. Boland, D.O. Secretary-Treasurer 2950 E. Flamingo Road, Suite E-4 Las Vegas, NV 89121 702/731-0304

Robert J. Burn 77 Pringle Way Reno, NV 89502 David England, Pharm.D. 4430 N. Cheiftain Las Vegas, NV 89129 Mary Guinan, M.D. Nevada State Health Officer 505 East King Street, Room 201 Carson City, NV 89701-4797 J. Gordon Kinard, D.D.S. 4121 West Sahara Avenue Las Vegas, NV 89102 Jon Sasser 650 Tahoe Reno, NV 89509

State Board of Pharmacy Keith W. MacDonald, R.Ph. Executive Secretary 1201 Terminal Way Suite 212 Reno, NV 89502 702/322-0691 Nevada Association of Hospitals and Health Systems Jeanette Belz President, CEO 4600 Kietzke Lane Suite A-108 Reno, NV 89502 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

Pharmaceutical Benefits 2000

NEW HAMPSHIRE A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 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

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $55,374,478 70,339

1999* Expended Recipients

CATEGORICALLY NEEDY, RECEIVING ASST Aged Blind/Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult MEDICALLY NEEDY, TOTAL Aged Blind/Disabled AFDC-Child AFDC-Adult POVERTY RELATED, TOTAL Aged Blind AFDC-Child AFDC-Adult OTHER, TOTAL Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-New Hampshire

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION Office of Medical Services, Department of Health and Human Services.

Prior Authorization: No prior authorization procedure. Prescribing or Dispensing Limitations Monthly Quantity Limit: Limited to 30-day supply or 100unit dosage, whichever is greater.

D. PROVISIONS RELATING TO DRUGS

Monthly Dollar Limits: None.

Benefit Design

Drug Utilization Review

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations for insulin; blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: cosmetics; fertility drugs; and experimental drugs.

PRODUR system implemented in July 1995. State currently has a DUR Board with a quarterly review.

Over-the-Counter Product Coverage: Products covered: allergy, asthma, and sinus products; analgesics; cough and cold preparations; digestive products (H2 antagonists), feminine products; smoking deterrents; and topical products.

Ingredient Reimbursement Basis: EAC = AWP - 12%.

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT antiinflammatory agents; estrogens; growth hormones; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); thyroid agents; and prescribed smoking deterrents. Therapeutic categories not covered: anorectics.

2.

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities and though physician payment when used in physician offices. Vaccines: Vaccines reimbursable as part of the EPSDT, CHIP, and VCP service. Childhood immunization vaccine is provided to all children through the Division of Public Health Services. The Medicaid program does not reimburse providers for routine vaccines, although an administration fee is allowed. Unit Dose: Unit dose packaging reimbursable for residents in long-term care facilities only. Formulary/Prior Authorization Formulary: Open formulary. General exclusions include anorectics, anorexiants (stimulants) except for treatment of narcolepsy and hyperkinetic children, cosmetic agents for hair growth, experimental and fertility drugs. National Pharmaceutical Council

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: AWP-12%+$2.50, effective 2/1/96.

Prescription Charge Formula: 1.

Lower of usual and customary charge or AWP - 12% or HCFA Upper Limit plus a dispensing fee. Maintenance medications are reimbursed by the above formula once every 34 days per recipient per provider: any refills of maintenance medications within the 34-day period are reimbursed at cost only.

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary.” Incentive Fee: None. Patient Cost Sharing: Copayment - $0.50 to $1.00. Copayments apply to all recipients except nursing home patients in SNF or ICF facilities; home and community based care waived recipients holding form 949; pregnant women; children under 18 years; and prescriptions for family planning drugs. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 5,000 Medicaid recipients are enrolled in MCOs. None receive pharmaceutical benefits through managed care. Managed Care Organizations Anthem Blue Cross/Blue Shield of New Hampshire Matthew Thornton Health Plan 3000 Goffs Falls Road Manchester, NH 03103-6020 Tufts Associated Healthplans of New England 333 Wyman Street Waltham, MA 02254-9112 New Hampshire-2

Pharmaceutical Benefits 2000 Medicaid Drug Rebate Contacts

F. STATE CONTACTS State Drug Program Administrator Lisè Farrand, R.Ph. Pharmaceutical Services Specialist Medicaid Administration Bureau 6 Hazen Drive Concord, NH 03301-6521 T: 603/271-4419 F: 603/271-4376 E-mail: [email protected] Department of Health and Human Services Officials Carol Early Director Medicaid Administration Bureau Office of Health Management 6 Hazen Drive Concord, NH 03301-6521 T: 603/271-8887

Technical: Julie Simpson, 603/224-1747 ext. 3016 Audits: Julie Simpson, 603/224-1747 ext. 3016 Claims Submission Contact Gary Patanaude EDS Federal Corp. 7 Eagle Sq. Concord, NH 03301 T: 603/224-1747 Medicaid Managed Care Contact Brenda Lovely Program Specialist NH DHHS, Medicaid Administration Bureau 6 Hazen Drive Concord, NH 03301 T: 603/271-4350 F: 603/271-4376 E-mail: [email protected] Disease Management Initiative/Program Contact

DUR Contact

Colin McHugh Administrator II Special Medical Services 6 Hazen Drive Concord, NH 03301 T: 603/271-0546

Lisè Farrand, R.Ph. T: 603/271-4419

Physician-Administered Drug Program Contact

Donald Shumway Commissioner Department of Health and Human Services

Medicaid DUR Board James P. Pilliod, M.D. Elaine M. Silverman, M.D. Steve Lawrence, M.D. Paul S. Collins, M.D. Mark Henschke, D.O. John Zinka, R.Ph. Elizabeth Gower, R.Ph. Helen Pervanas, R.Ph. Jody Goodrich, A.R.N.P. Michael Smith, R.Ph. Prescription Price Updating First DataBank

Vacant Executive Officers of State Medical and Pharmaceutical Services New Hampshire Medical Society Palmer P. Jones Executive Vice President 7 N. State Street Concord, NH 03301-6389 603/224-1909 New Hampshire Pharmaceutical Association 2 Eagle Square Concord, NH 03301-4956 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

Pharmaceutical Benefits 2000 State Board of Pharmacy Paul G. Boisseau Executive Secretary 57 Regional Drive Concord, NH 03301-8518 603/271-2350 New Hampshire Hospital Association Michael J. Hill President 125 Airport Road Concord, NH 03301-7300 603/225-0900

National Pharmaceutical Council

New Hampshire-4

Pharmaceutical Benefits 2000

NEW JERSEY A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

OAA

AB

APTD

AFDC

Prescribed Drugs









Inpatient Hospital Care









Outpatient Hospital Care









Laboratory & X-ray Service









Skilled Nursing Home Services









Physician Services









Dental Services









OAA

AB

APTD

AFDC

Other Children <21

SFO









1

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998 Expended $426,075,488

CATEGORICALLY NEEDY, RECEIVING ASST Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult

$270,025,213 $42,974,940 $219,896,088 $2,115,119 $5,039,066 $0 $0

167,661 30,587 100,921 20,294 15,859 0 0

MEDICALLY NEEDY Aged Blind / Disabled AFDC-Child AFDC-Adult

$4,504,987 $3,708,823 $527,195 $268,969 $0

3,906 2,543 171 1,192 0

POVERTY RELATED Aged Blind / Disabled AFDC-Child AFDC-Adult

$60,253,456 $21,199,966 $36,779,674 $1,591,982 $681,834

60,784 15,320 13,728 22,027 9,709

OTHER

$91,291,832

77,498

Recipients 309,849

1999* Expended

Recipients

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-New Jersey

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION Division of Medical Assistance and Health Services, Department of Health and Human Services.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations for insulin use; blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: cosmetics; fertility drugs; and experimental drugs. Prior authorization required for: methadone; IV infusions; and protein replacement supplements.

Prior Authorization: State currently has a formal prior authorization procedure. Periodic review for reconsideration possible for excluded product from formulary. Fair hearings possible for appealing prior authorization decisions. Prescribing or Dispensing Limitations Prescription Refill Limit: 5 times within a 6-month period. Monthly Quantity Limit: Originally, 34-day supply. Now, 34 days or 100 units, whichever is more. Drug Utilization Review PRODUR system implemented in October 1996. State currently has a DUR Board with a quarterly review.

Over-the-Counter Product Coverage: Products covered: allergy, asthma, and sinus products; analgesics; topical products; and cough and cold preparations for children under age 21. Products not covered: digestive products; feminine products; and smoking deterrent products.

Pharmacy Payment and Patient Cost Sharing

Therapeutic Category Coverage: Therapeutic categories covered: analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamine drugs; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: antilipemic agents. Partial coverage for: anabolic steroids; anorectics (for ADD); growth hormones; and prescribed smoking deterrents.

1.

24-hr Emergency Service: add $0.11

2.

Patient Consultation: add $0.08

3.

Impact Area Location: add $0.15 (provider shall have a combined Medicaid, NJ KidCare and PAAD prescription volume equal to or greater than 50% of total prescription volume.

Coverage of Injectables: Injectable medicines reimbursable when used in physician offices, home health care, and extended care facilities.

Dispensing Fee: $3.73 for legend drugs. Additional addons per/Rx shall be given to pharmacy providers who provide the following:

Ingredient Reimbursement Basis: EAC = AWP - 10%, WAC + 30%. AAC for injectables, effective 5/1/00. Prescription Charge Formula: “Maximum Allowable Cost,” or Average Wholesale Price – 10% (reduction from AWP is pharmacy specific) plus a dispensing fee or the provider’s usual and customary charge, whichever is lower.

Vaccines: Vaccines reimbursable at AWP as part of the EPSDT program and the Vaccines for Children Program.

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary”.

Unit Dose: Unit dose packaging reimbursable in longterm care facilities only, not in retail settings (unless u/d is only way item is packaged).

Incentive Fee: None.

Formulary/Prior Authorization

Patient Cost Sharing: None. 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

Pharmaceutical Benefits 2000

E. USE OF MANAGED CARE

DUR Contact

Approximately 400,000 Medicaid recipients received pharmacy benefits through managed care. All receive pharmaceutical benefits from MCOs.

Edward J. Vaccaro, R.Ph. Assistant Director, Office of Utilization Management Dept. of Human Services, Div. of Medical Assistance and Health Services P.O. Box 712, Bldg. 11-A Trenton, NJ 08625 T: 609/588-2721 F: 609/588-3839 E-mail: [email protected]

Managed Care Organizations Amerigroup of NJ 732/452-6002 Aetna/US HealthCare 610/251-6272 Physicians Health Services 1-800-963-6286 Americhoice of NJ 212/509-5999 Mercy Health Plan 1-800-682-9091 University Health Plan 1-800-564-6847

F. STATE CONTACTS State Drug Program Administrator Carl Tepper, R.Ph. Chief, Pharmaceutical Services Department of Human Services Division of Medical Assistance and Health Services P.O. Box 712, Bldg. 11-A Trenton, NJ 08625-0712 T: 609/588-2724 F: 609/588-3889 E-mail: [email protected] Department of Human Services Officials Michele Guhl Commissioner Department of Human Services Capitol Place 1 Trenton, NJ 08625 Margaret Murray Director Division of Medical Assistance and Health Services

Medicaid DUR Board Christopher A. Cella, R.Ph. Alfred F. Sorbelo, D.O. Edith Kessler-Feinstein, R.Ph. Joseph Nicholas Micale, M.D. Charles DeFeri, Jr., Pharm. D. Thomas A. Cavalieri, D.O. Linda Gooen, R.Ph. Mary E Petit, Pharm.D. David Ethan Swee, M.D. Prescription Price Updating First DataBank 1111 Bayhill Dr. San Bruno, CA 94066 T: 415/588-5454 Medicaid Drug Rebate Contacts Technical: Daniel Upright, 609/588-2792 Policy: Carl Tepper, 609/588-2724 PA: Carl Tepper, 609/588-2724 Claims Submission Contact P. Ringel Unisys Deputy Project Director 3705 Quakerbridge Rd. Suite 101 Trenton, NJ 08619 T:609/588-6000 F: 609/584-8270 E-mail: [email protected] Medicaid Managed Care Contact Edward Vaccaro T: 609/588-2721

3-New Jersey

National Pharmaceutical Council

Pharmaceutical Benefits 2000 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 Physician-Administered Drug Program Contact Edward Vaccaro 609/588-2721 Executive Officers of State Medical and Pharmaceutical Societies 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 State Board of Pharmacy 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

Pharmaceutical Benefits 2000

NEW MEXICO A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN) OAA

AB

APTD

AFDC

Other

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

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $41,507,229 96,637

1999* Expended Recipients

CATEGORICALLY NEEDY CASH TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients CATEGORICALLY NEEDY NON-CASH TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients MEDICALLY NEEDY TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-New Mexico

National Pharmaceutical Council

Pharmaceutical Benefits 2000

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 required for: amphetamines and stimulants for ADD. Products not covered: drugs for treatment of tuberculosis; cosmetics; experimental drugs; fertility drugs; drugs and immunizations available from any other source; medications supplied by the New Mexico State Hospital to clients on convalescent leave from hospital; legend multiple vitamins; tonic preparations and combinations with minerals, hormones, stimulants; hematinics (except non-sustained release forms of Ferrous Sulfate, Ferrous Gluconate, Ferrous Fumarate); drugs classified by FDA as “ineffective”; and hypnotic drugs (barbiturates).

Ingredient Reimbursement Basis: EAC = AWP - 12.5%, effective 7/1/97.

Over-the-Counter Product Coverage: insulin; antacids for active gastric and duodenal ulcers; infant vitamin drops for up to 1 year; Salicylates and acetaminophen; nonsustained release forms of Ferrous Sulfate, Ferrous Gluconate, Ferrous Fumarate; Scabicides and Pediculocides; Laxatives, stool softeners, calcium, nicotine replacement, ibuprofen, antihistamines, decongestants, expectorants, cough suppressants, anticandida, and antifungals. Coverage of Injectables: Injectable medicines reimbursable when used in physician offices, home health care, and extended care facilities. Vaccines: Vaccines reimbursable at acquisition cost plus 35% as part of the EPSDT program. Unit Dose: Does not reimburse for unit dose packaging. Formulary/Prior Authorization Formulary: Open formulary Prior Authorization: State currently has a formal prior authorization procedure screening for drug classes. Prescribing or Dispensing Limitations Prescription Refill Limit: Payment will be made to a particular pharmacy only three times for the same drug for the same client in a 90-day period. Monthly Quantity Limit: 6-month supply maximum, excluding birth control pills.

National Pharmaceutical Council

Prescription Charge Formula: Prescriptions reimbursed at the lesser of the following: 1. 2.

Cost (EAC or MAC) dispensed plus a dispensing fee or, The usual and customary charge by the pharmacy to the general public.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. Over 72 drugs are listed on the state-specific MAC list. Override requires “Brand Medically Necessary.” Incentive Fee: None. Patient Cost Sharing: No copayment. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Full-risk capitation managed care program implemented on July 1, 1997. Recipients receive pharmaceutical benefits through managed care plans.

F. STATE CONTACTS State Drug Program Administrator Neil Solomon Drug Program Administrator Medical Services Bureau P. O. Box 2348 Santa Fe, NM 87504-2398 T: 505/827-3174 F: 505/827-3185 Drug Education & Utilization Review Board John A. Heaton, R.Ph. Corner Drug Store, Inc. 201 W. Fox Carlsbad, NM 88220

New Mexico-2

Pharmaceutical Benefits 2000 Fredrica Smith, M.D. Los Alamos Medical Center 3917 West Road Los Alamos, NM 87544 Charles T. Spalding, M.D., Ph.D. Lovelace Medical Center 5400 Gibson, S.E. Albuquerque, NM 87108

Chris Isengard Executive Director Developmental Disabilities Planning Council 435 St. Michael’s Dr., Bldg. D Santa Fe, NM 87501 Michelle Lujan-Grisham New Mexico State Agency on Aging 228 East Palace Avenue Santa FE, NM 87501

William Troutman, Pharm. D. University of New Mexico Drug Information and Poison Control Center University of New Mexico Albuquerque, NM 87131-0176

Sam Cata, Commissioner Office of Indian Affairs 224 E. Palace Avenue Santa FE, NM 87501

Lionel Anaya R.Ph. 111 Coors Road N.W. Albuquerque, NM 87110

Loyola Burgess 1801 Dorothy Street, NE Albuquerque, NM 87112

Medicaid Drug Rebate Contacts Technical: Sal Montano, 505/827-3143 Policy: Sonya Miera, 505/827-7777 DUR & PA: Chuck Reynolds, 505/827-3174 Human Services Department Officials Robin O Dozier Secretary Designate P. O. Box 2348 Santa Fe, NM 87504-2398 T: 505/827-4072 Chuck Milligan Director Medical Assistance Division Ross Becker Deputy Director Medical Advisory Committee Members Linda Sechovec Executive Director NM Health Care 6400 Uptown Blvd., NE, Suite 520-W Albuquerque, NM 87110 Yvette Ramirez Ammerman Policy Analyst New Mexico Primary Care Association 2309 Renard, S.E., Suite 209 Albuquerque, NM 87106

3-New Mexico

Walace Begay, Co-Chairman Pueblo Health Council/All Indian Pueblo Council P.O. Box 56 New Laguna, NM 87038 Heather Wilson, Secretary CYFD, PERA Building 1120 Paseo de Peralta Santa Fe, NM 87501 Rosalyn Curtis Director of the Navajo Nation Division of Health P.O. Box 1390 Window Rock, AZ 86515 Lila Maples, R.N. 2769 Villa Venado Santa Fe, NM 87505 Clarice Pick, D.D.S 1405 Luisa Street Suite #2 Santa Fe, NM 87505 Richard L. Ragel, D.O. 1010 Bridge Blvd., SW Suite D Albuquerque, NM 87105-3734 Kathy Minoli, C.F.N.P. 1835 Solano, NE Albuquerque, NM 87110

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Mary Lou Edward 16 Applewood Lane, N.W. Albuquerque, NM 87107 505/898-5103 Richard Honsinger, M.S. Los Alamos Medical Center Los Alamos, NM 87544 Maureen Boshier New Mexico Hospital Association 2121 Osuna Road NE Albuquerque, NM 87113 Joie Glen Executive Director New Mexico Association for Home Care 3200 Carlisle N.E., Suite 115 Albuquerque, NM 87110 Dr. Norton Kalishman Chief Medical Officer Department of Health P.O. Box 26110 Santa Fe, NM 87502-6110

State Board of Pharmacy David Denoyer, Executive Director University Towers 1650 University Blvd., NE, Suite 400B Albuquerque, NM 87102 505/841-9102 New Mexico Hospitals and Health Systems Association Maureen L. Boshier President, CEO 2121 Osuna Road, NE Albuquerque, NM 87113 505/343-0010 Fiscal Intermediary Diane Gately Consultec 510 N. Guadelupe, Suite C Santa Fe, NM 87501 505/983-5555

Bert Umland, M.D. Division of Family Practice UNM Medical Center Albuquerque, NM 87131 505/277-2165 Executive Officers of State Medical and Pharmaceutical Societies New Mexico Medical Society G. R. “Randy” Marshall Executive Director 7770 Jefferson NE, Suite 400 Albuquerque, NM 87109 505/828-0237 New Mexico Pharmaceutical Association Dale Tinker Executive Director 4800 Zuni, S.E. Albuquerque, NM 87108-2898 505/265-8720 New Mexico Osteopathic Medical Association Floyd F. Smith Executive Director P. O. Box 90396 Albuquerque, NM 87199-0396 505/828-1905

National Pharmaceutical Council

New Mexico-4

Pharmaceutical Benefits 2000

NEW YORK A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 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

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

B. EXPENDITURES FOR DRUGS 1998 Expended $1,368,451,273

Recipients 1,803,428

1999 Expended 1,906,521,831

Recipients 2,122,000

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult

$973,744,961 $185,897,780 $688,950,800 $37,327,228 $61,569,154 $0 $0

1,073,631 145,227 390,585 358,928 178,891 0 0

1,292,083,557 220,345,467 893,845,203 58,757,046 119,135,841 0 0

1,202,687 147,162 421,594 430,163 203,768 0 0

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult

$326,652,214 $98,546,169 $174,038,100 $30,387,933 $23,680,012

515,780 80,929 81,238 254,244 99,369

425,045,080 117,455,198 219,616,402 46,307,214 41,666,266

657,663 85,432 88,679 346,029 137,523

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

$59,670,691 $0 $0 $6,050,198 $53,620,494

183,844 0 0 65,735 118,109

170,522,367 0 0 1,509,819 177,012,546

227,669 0 0 13,993 213,676

$8,383,406

32,173

10,870,828

33,981

TOTAL

OTHER Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.

1-New York

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION State Department of Health.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: cosmetics; fertility drugs; and experimental drugs. Products not covered: prescribed insulin; disposable needles and syringe combinations for insulin; blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition.

Prior Authorization: State currently does not have a formal prior authorization procedure. Prescribing or Dispensing Limitations Prescription Refill Limit: Cannot exceed 5, and the life of a prescription cannot exceed 6 months. Monthly Dollar Limits: None. Drug Utilization Review PRODUR system implemented in March 1995. State currently has a DUR Board with a review every other month.

Over-the-Counter Product Coverage: Products covered: digestive products (H2 antagonists) and smoking deterrent products. Products covered with restrictions: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products (non H2 antagonist); feminine products; and topical products.

Pharmacy Payment and Patient Cost Sharing

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones; hypotensive agents; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid agents. Therapeutic categories partially covered: prescribed cold medication and misc. GI drugs. Therapeutic categories requiring prior authorization; medical/surgical supplies; orthopedic shoes; compression stockings; and some DME items. Therapeutic categories not covered: anorectics and agents used for hair growth.

Prescription Charge Formula:

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities and through physician payment when used in physician offices. No special coverage policies exist for selfadministered injectable medicines. Vaccines: Vaccines are reimbursable under the EPSDT service and the Vaccines for Children program. Unit Dose: Unit dose packaging not reimbursable. Formulary/Prior Authorization Formulary: Open formulary. General Exclusions: New York State follows OBRA '90 guidelines in the reimbursement of prescription drugs.

National Pharmaceutical Council

Dispensing Fee: $3.50 for brand name drugs, $4.50 for generic drugs. Effective 8/1/98. Ingredient Reimbursement Basis: EAC = AWP - 10%.

1.

2. 3.

Payment for multiple source drugs must not exceed the aggregate of the specified upper limit set by the federal Health Care Financing Administration (HCFA), plus a dispensing fee, for a particular drug; and Payment for brand name drugs and other multiple source drugs not covered by clause (1) will be the lower of: EAC plus a dispensing fee; or The billing pharmacy's usual and customary price charged to the general public.

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Dispense as Written” and “Brand Necessary, ” or “Brand Medically Necessary.” Incentive Fee: None. Patient Cost Sharing: Copayment is $2.00 for brand name drugs, $0.50 for generic and OTC drugs. Exceptions include psychotropic drugs as well as drugs FDA approved for the treatment of tuberculosis and family planning drugs. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 670,000 total unduplicated number of Medicaid recipients were enrolled in MCOs in FY 1999. Recipients receive pharmaceutical benefits through the state.

New York-2

Pharmaceutical Benefits 2000 Health Maintenance Organizations

Formulary Contact

− − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − − −

Mark-Richard A. Butt, 518/486-3209

ABC Bluechoice HMO Options Broome MC Bronx HP Buffalo Com. Health Careplus, LLC CDPHP Center Care, Inc. Community Blue Community Choice HP Community Premier Plus Compre-Care, Inc. Capital Area CHP Empire BCBS Healthnet Fidelis Genesis HP, Inc. Health Choice HealthFirst Health Plus HIP/Nassau HIP/Westchester HMO of Greater NY HUM Healthcare Systems IHA/WNY Managed Healthcare Systems Metropolitan Plus Health Plan Neighborhood Health NY Hosp CHP Partners Preferred Care Suffolk Co PHSP Total Care United Healthcare Plan of NY, Inc. United Healthcare of Upstate Vytra Wellcare Westchester Prepaid Health Services Plan

F. STATE CONTACTS State Drug Program Administrator Mark-Richard A. Butt, M.S., R.Ph. Director, Pharmacy Policy and Operations Division of Provider Relations Office of Medicaid Management NYS Department of Health 99 Washington Ave., Suite 606 Albany, NY 12210 T: 518/486-3209 F: 518/473-5508 E-mail: [email protected] http://www.health.state.ny.us

3-New York

Prior Authorization Contact Mark-Richard A. Butt, 518/486-3209 DUR Contact Michael Zegarelli DUR Manager, Office of Medical Management NYS Department of Health 99 Washington Ave. Suite 601 Albany, NY 12237 T: 518/474-6866 F: 518/473-5332 E-mail: [email protected] DUR Committee Physicians Richard S. Blum, M.D. 25 Spruce Drive East Hills, NY 11576 Ronald J. Dougherty, M.D. 9429 Woodlawn Drive Brewerton, NY 13029-9724 Bernard Berkowitz, M.D. 63 Franklin Street Saratoga Springs, NY 12866 David F. Lehmann, M.D. Dept. of Medicine 750 East Adams Street Syracuse, NY 13210 Pharmacists Jill Braverman-Panza, M.D. 2 Executive Park Drive Albany, NY 12203 Sidney Falow, R.Ph. 12 Shore Park Road Great Neck, NY 11023-2033 Marilyn C. Fortin, R.Ph. NYS Department of Health Office of Continuing Care EPIC 260 Washington Avenue Albany, NY 12212 Marc L. Speert, R.Ph. 110 Russell Street Cornwall, NY 12518

National Pharmaceutical Council

Pharmaceutical Benefits 2000 James R. Suhrbier, R.Ph. 482 Mount Airy Road New Windsor, NY 12553 DUR Experts Mary Andritz, Pharm.D., R.Ph. Albany College of Pharmacy 106 New Scotland Ave. Albany, NY 12210 Robert A. Hamilton, Pharm.D., R.Ph. Albany College of Pharmacy 106 New Scotland Ave. Albany, NY 12210 Department Designee Lydia Kosinski, R.Ph. Division of Provider Relations Office of Medicaid Management NYS Department of Health 99 Washington Ave., Suite 601 Albany, NY 12210 518/474-6866 Prescription Price Updating Carl T. Cioppa Pharmacy Operations Manager Pharmacy Policy and Operations NYS Dept. of Health, Office of Medicaid Management 99 Washington Ave., Suite 606 Albany, NY 12210 T: 518/486-3209 F: 518/473-5508 E-mail: [email protected] Medicaid Drug Rebate Contacts Audit & Policy: Mark-Richard Butt, 518/486-3209 Disputes: Mark-Richard Butt, 518/486-3209 PRODUR: Dennis Pidgeon, 518/474-6866 Claims Submission Contact Computer Sciences Corporation (CSC) 800 North Pearl St. Albany, NY 12204 518/447-9200 Medicaid Managed Care Contact Elizabeth Macfarlane 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: [email protected]

National Pharmaceutical Council

Disease Management Program/Initiative Contact Karen A. Fuller, Ph.D. Director, Bureau of Program Guidance NYS Department of Health Office of Medicaid Management 99 Washington Ave, Suite 606 Albany, NY 12210-2806 T: 518/474-9219 F: 518/473-5508 E-mail: [email protected] Expanded Drug Program Contact Julie Naglieri Acting Director Elderly Prescription Insurance Coverage (EPIC) 1 Corporate Plaza, Suite 101 260 Washington Ave., Ext. Albany, NY 12203 T: 518/452-6828 F: 518-452-6882 E-mail: [email protected] Physician-Administered Drug Program Contact Karen A. Fuller, Ph.D., 518/474-9219 Department of Health Officials Antonia C. Novello, M.D, M.P.H., Dr. Ph. Commissioner NYS Department of Health Corning Tower The Governor Nelson A Rockefeller Empire State Plaza Albany, NY 12237 Kathryn Kuhmerker Deputy Commissioner Office of Medicaid Management NYS Department of Health Corning Tower The Governor Nelson A. Rockefeller Empire State Plaza Albany, NY 12237 Karen A. Fuller, Ph.D. Director, Bureau of Program Guidance Division of Provider Relations/Office of Medicaid Management 99 Washington Ave., Suite 606 Albany, NY 12210 618/474-9219

New York-4

Pharmaceutical Benefits 2000 Carl Cioppa, R.Ph. Pharmacy Operations Manager Division of Provider Relations Office of Medicaid Management NYS Department of Health 99 Washington Ave., Suite 606 Albany, NY 12210 Marlene Dickson, R.Ph. Pharmacy Program Specialist Division of Provider Relations Anita Murray, R.Ph. Pharmacy Program Specialist Division of Provider Relations Joseph Maiello, R.Ph. Pharmacy Program Specialist Division of Provider Relations Anne Budin, R.N. Pharmacy Program Specialist Division of Provider Relations Sally Nelsen, R.Ph. Pharmacy Program Specialist Division of Provider Relations Title XIX Medical Care Advisory Committee John Hollomon, M.D. 27-40 Ericsson Street E. Elmhurst, NY 11369 Roger W. Trifshauser, D.D.S., M.S. 63 Ellicott Avenue Batavia, NY 14020 Ellen M. Vossler, D.D.S. 57 High Park Blvd. Amherst, NY 14226 Charles Wisor, M.D. 70 Mason Street Geneva, NY 14456 Stoner E. Horey, M.D. 20 Elm Street, Suite 6 Hornell, NY 14823 Norman R. Loomis, M.D. 7736 Tamarak Lane Ontario, NY 14519

5-New York

William O'Dwyer, M.D. 14 Loudon Parkway Loudonville, NY 12211 Elena Padilla, Ph.D. 3 Washington Square Village Apt. 15-0 New York, NY 10012 Hugo Morales, M.D. P.C. Medical Director Bronx Mental Health Center Psychiatry & Neurology 1211 Gerard Avenue Bronx, NY 10452 Ruben Cowart, D.D.S., Chairman Executive Director Syracuse Community Health Center 819 South Salina Street Syracuse, NY 13202 Randall Bloomfield, M.D. NYS Medical Society 188 Lincoln Road Brooklyn, NY 11225 Ellen Chiang Prestige Care 150 W. 28th Street, Room 503 New York, NY 10001 Tanton Mustapha, M.D. 848 Columbia Street Hudson, NY 12534 Dennis P. Norfleet, M.D. 40 West Mohawk Street Oswego, NMY 13126 Louis Goldberg, DDS. University at Buffalo School of Dental Medicine 3435 Main St. Buffalo, NY 14214 Ann Wilkinson CHAP Office Jamaica Hospital 89th Avenue and Van Wyck Expressway Jamaica, NY 11418 John Angerosa, M.D. 11 Boyle Road Scotia, NY 12302

National Pharmaceutical Council

Pharmaceutical Benefits 2000 DSS Designee: Patricia Stevens, Deputy Commissioner NYS Office of Temporary and Disability Assistance Division of Temporary Assistance 40 N. Pearl St., 7th floor Albany, NY 12243

Charles Aswad, M.D. Executive Vice President 420 Lakeville Road P.O. Box 5404 Lake Success, NY 11042-5404 516/488-6100

Pharmacy Advisory Committee John P. Navarra, Chairman Town Total Nutrition 45 East 30th Street New York, NY 10016 212-213-5570

Pharmaceutical Society of the State of New York Craig Burridge, Executive Director Pine West Plaza IV Washington Avenue Extension Albany, NY 12205 518/869-6595

Patricia Donato Capital Consultants 251 New Karner Road Albany, NY 12205 518/456-3216

New York State Osteopathic Medical Society, Inc. Christian M. Hynes Executive Director 181 Weber Hill Road Carmel, NY 10512 800/841-4131

John Westerman, Jr. 14 Osprey Hill Drive Newburgh, New York 12550 914/561-4890 Kandyce J. Daley Eckerd Drug Co. Inc. 7245 Henry Clay Boulevard Liverpool, NY 13088 315/451-8000 x2292 Thomas F. Golden, Jr. Eckerd Drug Co. Inc. 1483 Route 9 Halfmoon, NY 12065 518/371-1513 Dilip Patel 7 Rubinstein Court New Hempstead, NY 10977 212-567-3384 Mohammed Saleh M & I Pharmacy 853 East New York Avenue Brooklyn, NY 11203 718/493-8118

New York State Board of Pharmacy Lawrence H. Mokhiber Executive Secretary Cultural Education Center Rm. 3035 Albany, NY 12230 518/474-3848 Healthcare Association of New York State Daniel Sisto President 74 North Pearl St. Albany, NY 12207 518/431-7600 Greater New York Hospital Association Subsidiaries and Affiliates Kenneth E. Raske President 555 W. 57th Street. 15th Floor New York, NY 10019 212/246-7100

Stephen L. Giroux Middleport Family Health Center 81 Rochester Road, Box 188 Middleport, NY 14105 716/735-7550 Executive Officers of State Medical and Pharmaceutical Societies Medical Society of the State of New York National Pharmaceutical Council

New York-6

Pharmaceutical Benefits 2000

NORTH CAROLINA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

Other

OAA

AB

APTD

AFDC

OAA

AB

APTD

AFDC

Children <21

Prescribed Drugs



















Inpatient Hospital Care



















Outpatient Hospital Care



















Laboratory & X-ray Service



















Skilled Nursing Home Services



















Physician Services



















Dental Services



















SFO

1

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998 Expended $466,528,812

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult

$290,607,349 $102,046,805 $137,208,166 $19,309,935 $30,503,271 $276,357 $1,262,815

419,155 75,511 103,517 147,596 86,761 2,188 3,582

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult

$137,663,846 $58,286,777 $74,389,528 $663,154 $4,324,387

95,003 38,339 45,957 2,975 7,732

POVERTY RELATED, TOTAL Aged Blind / Disabled AFDC-Child AFCC-Adult

$30,911,676 $0 $0 $27,787,899 $3,123,777

236,506 0 0 209,686 26,820

$7,345,941

14,222

OTHER

Recipients 764,886

1999* Expended Recipients

Source: HHS State HCFA-2082 Reports, Section A-4 and B-4. *1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-North Carolina

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION Division of Medical Assistance, Department of Human Resources.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin. Prior authorization required for: Viagra and Serostim. Products not covered: cosmetics; fertility drugs; experimental drugs; disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips, total parenteral nutrition; and interdialytic parenteral nutrition. Over-the-Counter Product Coverage: Products not covered: allergy, asthma and sinus products; analgesics; cough and cold preparations; non-H2 antagonist digestive products; digestive products, H2 antagonists; feminine products; topical products; and smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; anorectics; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones; hypotensive agents; misc. GI drugs; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid agents. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program 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. Unit Dose: Unit dose packaging reimbursable if packaged in unit dose only.

Prescribing or Dispensing Limitations Monthly Quantity Limit: 100-day supply maximum. Monthly Prescription Limit: Six prescriptions per month per recipient. Prescription Dollar Limits: None. Drug Utilization Review PRODUR system implemented in May 1996. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $5.60, effective January 1992. Ingredient Reimbursement Basis: EAC = AWP-10%. Prescription Charge Formula: The lowest price of AWP minus 10% or MAC, plus a dispensing fee for each different drug dispensed during a month, or AWP plus the lowest dispensing fee accepted from other third party payers. The pharmacist filling the original prescription will not be reimbursed for refills for the same drug within a calendar month. Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. 223 drugs are listed on the statespecific MAC list. Override requires “Brand Medically Necessary.” Incentive Fee: None. Patient Cost Sharing: $1.00 copayment/Rx (includes refills). Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 689,000 total unduplicated number of Medicaid recipients were enrolled in MCOs in FY 1999. Recipients receive pharmaceutical benefits through the state. Managed Care Organizations

Formulary/Prior Authorization Formulary: Closed formulary. Prior Authorization: State currently does not have a formal prior authorization procedure. A hearing officer is required to appeal prior authorization decisions.

National Pharmaceutical Council

The Wellness Plan of NC, Inc. Tim O’Brien 1409 East Blvd, Ste. 204 Charlotte, NC 28203-5476 704/370-0090

North Carolina-2

Pharmaceutical Benefits 2000 United HealthCare of NC Charren Nelson 2307 W. Cone Blvd. Greensboro, NC 28217 SouthCare/Coventry 2815 Coliseum Center Dr. Charlotte, NC 28217

Pharmacists: Joseph S. Moose, R.Ph., Pharm. D. Moose Professional Pharmacy 390 Copperfield Boulevard Concord, NC 28025 704/784-9613 Bruce R. Canaday, Pharm. D. Jennifer Burch, Pharm. D.

F. STATE CONTACTS State Drug Program Administrator C. Benny Ridout, R.Ph. Pharmacist Consultant NC Division of Medical Assistance 1985 Umstead Drive 2511 Mail Service Center Raleigh, NC 27699-2511 T: 919/733-4034 F: 919/733-2796 E-mail: [email protected]

Jeff Peterson, R.Ph. Glaxo 207 Glen Abbey Drive Cary, NC 27513 919/460-9375 Penny S. Shelton, Pharm.D. 113 Honeysuckle Lane Durham, NC 27703 919/733-5266 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 Rebate Disputes: Sharon Greeson, 919/233-6829 DUR: Sharman Leinwand, 919/733-3590

Sharman Leinwand DUR Coordinator N.C. Division of Medical Assistance 2515 Mail Service Center Raleigh, NC 27699-2515 T: 919/733-3590 F: 919/715-7706 Medicaid Drug Utilization Review Board Physicians: Patricia Burns, M.D. Douglas Pritchard, M.D. Carolina Anesthesia Associates P.O. Box 801 Statesville, NC 28677 Edward Treadwell, M.D. ECU School of Medicine Department of Medicine/Rheumatology Greenville, NC 27858

Claims Submission Contact Sharon Greeson, R.Ph. Pharmacist Consultant, EDS 4905 Waters Edge Drive Raleigh, NC 27606 T: 919/233-6829 F: 919/859-9703 E-mail: [email protected] Medicaid Managed Care Contact C. Benny Ridout, 919/733-4034 Disease Management Program/Initiative Contact C. Benny Ridout, 919/733-4034 Physician-Administered Drug Program Contact Geneva Fearrington Department of Health and Human Services Division of Medical Assistance 1985 Umstead Drive 2511 Mail Service Center Raleigh, NC 27699-2511

3-North Carolina

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Department of Human Resources Officials Paul R. Peruzzi, Director Department of Health and Human Services Division of Medical Assistance 1985 Umstead Drive 2517 Mail Service Center Raleigh, NC 27699-2517 Daphne O. Lyon Deputy Director H. David Bruton, M.D. Secretary Department of Health and Human Services 101 Blair Drive 2001 Mail Service Center Raleigh, NC 27699-2001 Department of Human Resources Advisory Committees Pharmaceutical Association, Third Party William Taylor 8208 Brownleigh Drive Raleigh, NC 27612 Paul Bisette PO Box 785 Wilson, NC 27893-0785 David T. Hix 235 Burke Street Gibsonville, NC 27249-2402 Jim LeCroy 5454 Eastwind Road Wilmington, NC 28403 Jim Hall 138 N. Churton Street Hillsboro, NC 27278 David S. Moody Jr. 4100 Grove Ridge Drive Durham, NC 27703 Mickey Watts, Liaison PO Box 39 Concord, NC 28026

Benny Ridout Box 88 Morrisville, NC 27560 William Holshouser 13 Dogwood Road Salisbury, NC 28144 George McLarty PO Box 1028 High Point, NC 27261-1028 Walton P. O’Neal III 302 Sunnyside Drive Washington, NC 27889 Health Care Access Committee II-3 Jack R. Page, M.D., Chairman 3 Hartley Place Durham, NC 27707 Donald T. Lucey, M.D. Vice-Chair 2800 Blue Ridge Blvd., Suite 403 Raleigh, NC 27607 H. David Burton, M.D. NC Department of Human Resources 101 Blair Drive PO Box 29526 Raleigh, NC 27626-0526 Lindsey E. deGuehery, M.D. 1812 Glendale Drive Wilson, NC 27893 Raphael J. DiNapoli, Jr., M.D. 1985 Umstead Drive, P. O. Box 29529 Raleigh, NC 27626-0529 E. Stephen Edwards, M.D. 2800 Blue Ridge Blvd. Ste. 501 Raleigh, NC 27607-6496 Brian R. Forrest 6016 Farmgate Road Raleigh, NC 27606

Vince Stevens 8408 Inverness Way Chapel Hill, NC 27516

Shelton P. Hager 2651 MacGregor Down Road Apt. K Greenville, NC 27858

John Zatti 5 Porchlight Court Durham, NC 27707

Ann Faris 2720 Bitting Road Winston-Salem, NC 27104

National Pharmaceutical Council

North Carolina-4

Pharmaceutical Benefits 2000

Donald T. Lucy, M.D. 2800 Blue Ridge Blvd., Ste. 403 Raleigh, NC 27607

Lee B. Hoffman Chief Certificate of Need Section Facility Services Division North Carolina Department of Human Resources P.O. Box 29530 Raleigh, NC 27626-0530

William O. McMillan, Jr., M.D. P.O. Box 9025 Wilmington, NC 28402-9025

Jeffrey A. Katz 18 Cherry Grove Road Hickory, NC 28602

Edwin W. Monroe, M.D. 104 W. Longmeadow Rd. Greenville, NC 27858-3714

Barbara D. Matula Director Medical Assistance Division NC Department of Human Resources P.O. Box 29579 Raleigh, NC 27626-0529

Johnson H. Kelly, M.D. 1001 N. Washington Street Shelby, NC 28150

William J. Murray, M.D. Duke University Medical Center Box 3094 Durham, NC 27710 Paul R. Peruzzi Deputy Director Medical Assistance Division NC Dept. of Human Resources PO Box 29529 Raleigh, NC 27626-0529 Kenneth G. Reeb, M.D. UNC School of Medicine, Family Practice Department Chapel Hill, NC 27599 C. Stewart Rogers, M.D. 1200 N. Elm Street Greensboro, NC 27401-1020 William J. Spencer, M.D. 851 Brookleigh Court Winston-Salem, NC 27104 Delford L. Stickel, M.D. Duke University, Box 3917 Durham, NC 27710 James D. Bernstein Rural Health and Resources Development Office Department of Human Resources 311 Ashe Avenue Raleigh, NC 27606 James A. Clarke, Ed.D. Associate State Director PO Box 37067 Raleigh, NC 27627

5-North Carolina

David E. Rice Sara Lee Corporation P.O. Box 2760 Winston-Salem, NC 27102-2760 Pam Silberman, JD 2108 Umstead Drive Raleigh, NC 27603 Executive Officers of State Medical and Pharmaceutical Societies North Carolina Medical Society Bob Seligson, M.B.A., CAE Executive Vice President 222 North Person St., P.O. Box 27167 Raleigh, NC 27611-7167 919/833-3836 North Carolina Pharmaceutical Association Dan Garrette Executive Director Box 151 Chapel Hill, NC 27514-0151 919/967-2237 North Carolina Osteopathic Association, Inc. Barbara Walker, D.O. President 207 Viking Drive Fayetteville, NC 28303 910/864-7515

National Pharmaceutical Council

Pharmaceutical Benefits 2000 State Board of Pharmacy 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 Raleigh, NC 27623-0428 919/677-2400

National Pharmaceutical Council

North Carolina-6

Pharmaceutical Benefits 2000

NORTH DAKOTA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

Other

OAA

AB

APTD

AFDC

OAA

AB

APTD

AFDC

Children <21

Prescribed Drugs



















Inpatient Hospital Care



















Outpatient Hospital Care



















Laboratory & X-ray Service



















Skilled Nursing Home Services



















Physician Services



















Dental Services



















SFO

1

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $27,619,684 37,675

1999 Expended Recipients $27,619,684 37,675

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult POVERTY RELATED, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult OTHER Source: HHS State HCFA-2082 Reports, Section A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-North Dakota

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION North Dakota Department of Human Services.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products not covered: cosmetics; drugs used for hair growth; prescription vitamins (except prenatal vitamins); and DESI drugs. Prior authorization required for: smoking cessation and nutritional supplements. Over-the-Counter Product Coverage: Products covered: antacids; analgesics; iron supplements; artificial tears; and anti-ulcer medications. Coverage of Injectables: Injectable medicines reimbursable when used in physician offices, home health care, and extended care facilities. Vaccines: Vaccines reimbursable as part of the EPSDT service. Unit Dose: Unit dose packaging not reimbursable. Formulary/Prior Authorization Formulary: Open formulary Prior Authorization:

Prescription Charge Formula: Acquisition Cost plus a dispensing fee per prescription or the usual and customary retail charge, whichever is lower. Acquisition Cost = EAC or MAC. Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Dispense As Written.” Incentive Fee: None.. Patient Cost Sharing: No copayment. Cognitive Services: Does not pay for cognitive services

E. USE OF MANAGED CARE !"#$%&&'(((%)#*+,-+*%$#,+.+#/01%2#$#%#/$344#*%+/ 5-/-6#*%,-$#%+/%7889:%%;3/#%$#,#+"#*%.<-$5-,=%1#$"+,#1 0<$3>6<%5-/-6#*%,-$#.

F. STATE CONTACTS State Drug Program Administrator Rick Detwiller, R.Ph. Administrator, Pharmacy Services Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismarck, ND 58505-0261 701/328-4023 Fax 701/328-1544

Monthly Quantity Limit: 34-day supply.

Pat Kramer, R.Ph. Director, Utilization Management Pharmacy Services, Medical Services Department of Human Services State Capital 600 East Boulevard Avenue Bismarck, ND 58505-0261 701/328-4893

Monthly Dollar Limits: None.

DUR Board

Prescribing or Dispensing Limitations Prescription Refill Limit: A prescription drug may be refilled for 12 months after the date of the original prescription, provided that such refills have been authorized by the physician.

Drug Utilization Review PRODUR system implemented in July 1996. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.60, effective 8/1/97. Ingredient Reimbursement Basis: EAC = AWP-10%.

National Pharmaceutical Council

Mark Biel, R.Ph. 517 W. Reno Ave. Bismarck, ND 58504 701/223-0936 Patricia M. Churchill, R.Ph. 103 West Ave. B Bismark, ND 58501 701/663-5188

North Dakota-2

Pharmaceutical Benefits 2000 Gregory L. Culver, M.D. Towner County MedCenter P.O. Box 579 Cando, ND 58324 701/968-3337 Community Practice Medical Resident (rotational contact: Susan Thompson) UND Family Practice Center 515 Broadway Avenue Bismarck, ND 58501 701/328-9950 Delbert J. Hlavinka, M.D. MeritCare Mayville Clinic 730 E Main Street Mayville, ND 58257 701/786-4503 James H. Irsfeld, R.Ph. 1042 West 4th Ave Dickinson, ND 58601 701/225-4858 Karen K. Iverson, R.Ph. Student Health Service Pharmacy North Dakota State University PO Box 5313 Fargo, ND 58105-5313 701/231-7332 Anthony T. Johnson, M.D. 102 Mandan Ave. Mandan, ND 58554 701/667-5005 Marty Meese, Pharm.D., R.Ph. St. Alexis Pharmacy 900 East Broadway Bismarck, ND 58501 701/224-7378 Pierre Rioux, MD 307 5th Ave Southeast Minot, ND 58701 701/852-0735 Ex-Officio Members Patricia A. Kramer, R.Ph. Director, Utilization Management Medical Services, DHS 600 East Boulevard Ave, Dept 325 Bismarck, ND 58505-0261 701/328-4893

3-North Dakota

Joseph Cleary, M.D. Medical Consultant ND Department of Human Services State Capitol - Judicial Wing Bismarck, ND 58505-0250 701/328-2321 Rick Detwiller R.Ph. Administrator, Pharmacy Services Medical Services, DHS 600 East Boulevard Ave, Dept 325 Bismarck, ND 58505-0261 701/328-4023 Medicaid Drug Rebate Contacts Technical: Rick Detwiller, 701/328-4023 Policy: Rick Detwiller, 701/328-4023 DUR: Pat Kramer, 701/328-4893 PA: Pat Kramer, 701/328-4893 Department of Human Services Officials Carol Olson Executive Director ND Dept. of Human Services Capitol Building Bismarck, ND 58505 LeRoy Bollinger Administrator Research and Statistics Dave Zentner Medicaid Director Department of Human Services Advisory Committees Medical Care Advisory Committee Jon Rice, M.D. State Health Officer State Health Department 600 East Boulevard Bismarck, ND 58505 701/328-2372 Joseph W. Cleary, M.D. 104 Seminole Avenue Bismarck, ND 58501 Robert A. Schindler, D.D.S. Northbrook Mall 1929 N. Washington Bismarck, ND 58501 701/223-3694

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Howard Anderson, R.Ph. PO Box 70 Turtle Lake, ND 58575 701/448-2542 Delores Farrell 401 North 14th Street Bismark, ND 58501 Patricia Carlson 172 Boise Avenue Bismarck, ND 58504 701/222-1822 Arne Springan, O.D. 1203 Oahe Bend Bismarck, ND 58504 Christine Becker HCO4 Box 12 Mandan, ND 58554 701/663-2659

Gregory A. Gapp, M.D. Grand Forks Clinic Ltd. Grand Forks, ND 58206 Stephen H. Goldberger, M.D. Grand Forks Clinic Ltd. Grand Forks, ND 58206 Genevieve M. Goven, M.D. Meritcare Clinic Valley City Valley City, ND 58072 Mark B. Hart, M.D. The Bone and Joint Center Bismack, ND 58504 George H. Hilts, M.D. Dakota Eye Institute Bismarck, ND 58504 Mark O. Jensen, M.D. 300 Main Avenue Fargo, ND 58103

Commission on Socio-Economic Affairs Robert F. Szczys, M.D., Chairman Grand Forks Clinic Ltd. Grand Forks, ND 58206

Donald R. Lamb, M.D. 100 4th Street, S., Ste. 504 Fargo, ND 58103

Russel J. Kuzel, M.D., Vice Chairman Dakota Clinic Ltd. Fargo, ND 58103

Gregory J. Post, M.D. Meritcare Medical Group Fargo, ND 58123

Bipin B. Amin, M.D. Mid Dakota Clinic Bismarck, ND 58502

David A. Rinn, M.D. Towner County Medcenter Cando, ND 58324

William W. Barnes, M.D. 307 5th Avenue, SE Minot, ND 58701

Pierre A. Rioux, M.D. 307 5th Avenue, SE Ste. 300 Minot, ND 58701

Norman E. Bystol, M.D. Dakota Clinic Ltd. Fargo, ND 58108

Thomas R. Templeton, M.D. Great Plains Clinic Dickinson, ND

James R. Carpenter, M.D. Meritcare Medical Group Fargo, ND 58123

Brian C. Willoughby, M.D. West River Health Clinics Hettinger, ND 58639

Stanley T. Diede, M.D. Heart and Lung Clinic Bismarck, ND 58502

Councilors Assigned David H. Lane, M.D. Anesthesia Associates Ltd. Grand Forks, ND 58208

Harold W. Evans, M.D. Grand Forks Clinic Ltd. Grand Forks, ND 58206

National Pharmaceutical Council

Larry E. Johnson, M.D. Dakota Clinic Ltd. P. O. Box 1980 Jamestown, ND 58402

North Dakota-4

Pharmaceutical Benefits 2000 Pharmacy Advisory Committee Robert L. Treitline, Chair 941 9th Avenue West Dickinson, ND 58601 Anton P. Welder, R.Ph. P.O. Box 835 Bismarck, ND 58502 Doreen M. Beiswanger, R.Ph 1140 SE 6 Street, Unit 10 Valley City, ND 58072 David L. Just, R.Ph. P.O. Box 99 Beulah, ND 58523 David J. Olig, R.Ph. 2400 32nd Avenue South Fargo, ND 58103 DuWayne Schlittenhard, R.Ph. 3408 Par Street Fargo, ND 58102

State Board of Pharmacy Howard Anderson Executive Director P. O. Box 1354 Bismarck, ND 58502-1354 701/328-9535 North Dakota Association of Osteopathic Physicians and Surgeons James Wolff Executive Director 736 Broadway Fargo, ND 58123 701/234-2400 North Dakota Hospital Association Arnold R. Thomas President 1120 College Drive P.O. Box 7340 Bismarck, ND 58507-7340 701/224-9732

Mary Beth Reinke, R.Ph. 3530 SW 28 #301 Fargo, ND 58104 Cindy Yeager, R.Ph. Box 9512 Fargo, ND 58108 Executive Officers of State Medical and Pharmaceutical Societies North Dakota Medical Association Cathy Rydell Executive Vice President 204 W. Thayer Avenue P.O. Box 1198 Bismarck, ND 58502-1198 701/223-9475 North Dakota Pharmaceutical Association Galen Jordre Executive Vice President P.O. Box 5008, 405 E. Broadway Bismarck, ND 58502-5008 701/258-9312

5-North Dakota

National Pharmaceutical Council

Pharmaceutical Benefits 2000

OHIO A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

OAA

AB

APTD

AFDC

Prescribed Drugs









Inpatient Hospital Care









Outpatient Hospital Care









Laboratory & X-ray Service









Skilled Nursing Home Services









Physician Services









Dental Services









OAA

AB

APTD

AFDC

Other Children <21

SFO

1

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

B. EXPENDITURES FOR DRUGS

TOTAL 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 Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients

1998* Expended Recipients $645,118,962 702,143

1999 Expended $758,909,302

Recipients 794,436

40,749,264 1,225,142 16,198 13,101,026 13,637,456 12,769,439

149,166 915 12 6,316 100,354 41,569

718,160,037 261,686,553 1,363,558 403,254,744 32,170,912 17,540,711 2,143,557

645,270 134,410 815 194,524 233,067 72,849 9,605

0 0 0 0 0 0 0

0 0 0 0 0 0 0

MEDICALLY NEEDY TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients Source: HHS State HCFA-2082 Reports, Section A-4 and B-4. *1998 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

National Pharmaceutical Council

Ohio-1

Pharmaceutical Benefits 2000

C. ADMINISTRATION

Formulary/Prior Authorization

Ohio Department of Job and Family Services.

Formulary: Closed formulary with approximately 38,000 NDC-specific trade and generic drugs. Products excluded include obesity, fertility, and experimental drugs.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered under DME/med supply program: prescribed insulin; total parenteral nutrition; interdialytic parenteral nutrition. Products not covered: cosmetics; fertility drugs; experimental drugs; disposable needles and syringe combinations used for insulin; urine ketone test strips; and blood glucose test strips. Prior authorization required for: Ceredase; Cerebyx; Cerezyme; Clorazepates; DepoProvera; Enbrel; immunoglobulins; Lioresal Intrathecal; Lodosyn; Methadone; Nascoral; Orgaran; Oxandrin Panretin; Periostat; Priftin; Prolastin; Proleukin; Provigil; Psoralens; Rebetin; Remicade; Piluter; Rituxan; Stimate; Synagis; and Targretin. OTC Coverage: Selected coverage for: allergy, asthma, and sinus products; analgesics; feminine products; smoking deterrent products; cough and cold preparations; non-H2 antagonist digestive products; digestive products, H2 antagonists; and topical products. Therapeutic Category Coverage: Therapeutic categories covered: analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic drugs; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; prescribed smoking deterrents; sympathominetics (andrenergic); and thyroid agents. PA required for: anabolic steroids and growth hormones. Therapeutic categories not covered: anorectics; innovator multi-source drugs; certain antibiotics (last-line therapies); selected high-risk drugs like (e.g., Accutane); and drugs used in special settings (e.g., outpatient hospital). Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities, and through physician payment when used in physicians offices. Vaccines: Vaccines reimbursable as part of the Vaccines for Children Program. Unit Dose: Unit dose packaging not reimbursable.

Prior Authorization: Prior authorization is needed for certain individual drugs (listed above). Prescribing or Dispensing Limitations Prescription Refill Limit: 11 for non-controlled drugs up to one year. Thirteen for birth control drugs up to one year. Five for Scheduled III, IV, V drugs up to six months. None for Scheduled II drugs. Monthly Quantity Limit: Maximum of 34-day supply for acute and 102-dosage units for chronic maintenance medications. Amount designated in Ohio Medicaid drug formulary. Drug Utilization Review PRODUR system implemented in Feb 2000. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.70, effective 7/1/98. Ingredient Reimbursement Basis: EAC = WAC+11%. Prescription Reimbursement Formula: Reimbursement for legend drugs and selected OTC products based on the lowest of: 1. 2. 3.

Provider’s submitted charge, which should reflect usual and customary charge to the general public; WAC+11% plus a dispensing fee. Federal- or state-established Maximum Allowable Cost (MAC), for specifically designated generically equivalent drugs plus a dispensing fee.

Non-legend drugs - reimbursement is based on WAC+11% plus a dispensing fee, or MAC if applicable. Maximum Allowable Cost: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. Override requires prior authorization. Incentive Fee: None. Patient Cost Sharing: No copayment. Cognitive Services: Does not pay for cognitive services.

2-Ohio

National Pharmaceutical Council

Pharmaceutical Benefits 2000

E. USE OF MANAGED CARE !""#$%&'()*+,-.//0111-$2-3*4&5(&4-#*5&"&*6)7-8*#* *6#$++*4-&6-'(6(9*4-5(#*-&6-:;;;<--!++-#*5*&=*4-">(#'(5, 7*#=&5*7-)>#$?9>-'(6(9*4-5(#*-"+(67. Managed Care Organizations • • • • • • • • • • • • • • • • • • • •

Butler Health Plan ChoiceCare Community Health Plan DayMed Dayton Area Health Plan Emerald HMO, Inc. Family Health Plan Genesis Health Plan of Ohio Health Care USA Health Power HealthFirst HMO Health Ohio Paramount Care, Inc. Personal Physician Care QualChoice Health Plan, Inc. SummaCare, Inc. SuperBlue HMO SuperMed HMO Total Health Care Plan United Health Care

Sheila Fujii, Chief Bureau of Medical Assistance 65 E. State St., 4th Floor Columbus, OH 43215 614/466-2365 Prior Authorization Contact Robert P. Reid, R.Ph. 614/466-6420 DUR Contact Jan Lawson DUR Administrator SUR 65 E. State St. 4th Fl. Columbus, OH 43215 DUR Board Thomas E. Gretter, M.D. Stephen Baez, M.D. Jacob F. Palomaki, M.D. Beth T. Tranen, D.O. Rob Kubasak, R.Ph. Suzanne Eastman, R.Ph. Jill Orn, R.Ph. Donald Sullivan, Ph.D. Prescription Price Updating

F. STATE CONTACT

Robert P. Reid, R.Ph. 614/466-6420

State Drug Program Administrator

Medicaid Drug Rebate Contacts

Robert P. Reid, R.Ph. Administrator, Pharmacy Services Unit Ohio Department of Job and Family Services Bureau of Health Plan Policy 30 East Broad St., 27th Floor Columbus, OH 43266-0423 T: 614/466-6420 F: 614/466-2908 E-mail: [email protected]

Technical: JD Salvatore, 614/728-3955 Policy: Robyn Colby, 614/486-6420 Audits: Robert Reid, 614/486-6420

Medicaid Department Officials Jacqueline Romer-Sensky, Director Ohio Department of Job and Family Services 30 East Broad Street, 32nd Flr. Columbus, OH 43266-0423 Barbara C. Edwards, Deputy Director Office of Medicaid Robyn Colby, Chief Bureau of Health Plan Policy

National Pharmaceutical Council

Claims Submission Contact First Health Services 4300 Cox Road Glen Allen, VA 23060 Richmond, VA 800/884-2822 Medicaid Managed Care Contact Cynthia Burnell Bureau Chief Managed Health Care Ohio Department of Job and Family Services 65 E. State St., 3rd Fl. Columbus, OH 43266 614/466-4693

Ohio-3

Pharmaceutical Benefits 2000 Physician Administered Drug Program Contact Robert Reid, R.Ph. Bureau of Health Plan Policy 30 East Broad St., 27th Floor Columbus, OH 43266-0423 T: 614/466-6420 F: 614/466-2908 Pharmacy and Therapeutics Committee (2 vacancies pending) Robert P. Reid, R.Ph., Chairman Bureau of Health Plan Policy 30 East Broad Street, 27th Floor Columbus, OH 43266-0423 Suzanne Eastman, R.Ph., M.S. 3922 North Cliff Lane Cincinnati, OH 43220 Charles B. May, D.O. 2467 Plymouth Avenue Columbus, OH 43209 Ruth E. Purdy, D.O. 100 West Third Avenue Columbus, OH 43201 Susan Baker, APN 137 Otterbein Lexington, OH 44904 Mary Jo Walker, M.D. 2231 North High Street Columbus, OH 43210 Walter J. Wielkiewicz, M.D. 5190 Heritage Drive Nashport, OH 43830 James Visconti, Ph.D. 410 W. Tenth Avenue Columbus, OH 43210 Tammie J. Stroup, R.Ph. 30 E. Broad Street, 27th Fl. Columbus, OH 43266-0423

4-Ohio

Executive Officers of State Medical and Pharmaceutical Societies Ohio State Medical Association D. Brent Mulgrew 1500 Lakeshore Drive Columbus, OH 43204 614/486-2401 Ohio Pharmacists Association Ernest “Ernie” Boyd Executive Director 6037 Frantz Road, Ste. 106 Columbus, OH 43017 614/798-0037 Osteopathic Association Jon F. Wills Executive Director 53 W. 3rd Avenue P.O. Box 8130 Columbus, OH 43201 614/299-2107 State Board of Pharmacy William Winsley Executive Director 77 S. High Street, 17th Floor Columbus, OH 43266-0320 614/466-4143 Ohio Hospital Association James Castle President 155 E. Broad St. Columbus, OH 43215 614/221-7614 Formulary Contact Person Robert P. Reid, R.Ph. Bureau of Health Plan Policy 30 E. Broad Street, 27th Floor Columbus, OH 43266-0423 T: 614/466-6420 F: 614/466-2908 E-mail: [email protected]

National Pharmaceutical Council

Pharmaceutical Benefits 2000

OKLAHOMA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

Other

OAA

AB

APTD

AFDC

OAA

AB

APTD

AFDC

Children <21

Prescribed Drugs



















Inpatient Hospital Care



















Outpatient Hospital Care



















Laboratory & X-ray Service



















Skilled Nursing Home Services



















Physician Services



















Dental Services



















SFO

1

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998 Expended $135,622,036

Recipients 217,322

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

$74,745,255 $21,639,323 $385,479 $46,695,570 $3,587,811 $2,437,072

101,910 22,550 481 41,968 26,473 10,438

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

$56,590,131 $34,623,534 $53,640 $14,102,481 $6,317,934 $1,487,083 $5,459

78,701 21,563 34 7,749 42,627 6,671 57

$846,239 $169,914 $6,048 $383,769 $180,111 $102,784 $3,613

2,128 166 1 344 1,197 380 40

MEDICALLY NEEDY TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients

1999* Expended Recipients

Source: HHS State HCFA-2082 Reports, Section A-4 and B-4. *1999 expenditures broken down by maintenance assistance and basis of eligibility are unavailable.

National Pharmaceutical Council

Oklahoma-1

Pharmaceutical Benefits 2000

C. ADMINISTRATION

Prescription or Dispensing Limitations

Oklahoma Health Care Authority.

Prescription Refills: Shall be provided only if authorized by the prescriber, no more than 1 year.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered (DME benefit): prescribed insulin, disposable needles and syringe combinations for insulin; blood glucose test strips; and urine ketone test strips. Products covered with restrictions: total parenteral nutrition (reimburse single most costly ingredient). Products not covered: cosmetics; fertility drugs; and experimental drugs. Over-the-Counter Product Coverage: Products covered: birth control. Products not covered: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products, feminine products; topical products; and smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories covered: antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antilipemic agents; anti-psychotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: analgesics, antipyretics, NSAIDs; antihistamine drugs (partially covered); anxiolytics, sedatives, and hypnotics; growth hormones; misc. GI drugs; and prescribed smoking deterrents (partially covered). Therapeutic categories not covered: anabolic steroids; anorectics; prescribed cold medications; and OBRA ’90 Drugs identified as coverage optional. Coverage of Injectables: Injectable medicines reimbursable through the prescription drug program when used in home health care, extended care facilities and through physician payment when used in physician offices. Vaccines: Vaccines reimbursable as part of EPSDT service and the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization

Monthly Quantity Limits: Three prescriptions per month/recipient. ICF-MR, Medicaid children, and nursing home recipients are allowed unlimited orders. Quantity Limit per Prescription: 34-day supply or 100 units. Drug Utilization Review PRODUR system implemented in 1993 with a new system in 2000. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.15, effective 10/95. Ingredient Reimbursement Basis: EAC = AWP - 10.5%. Prescription Charge Formula: Estimated Acquisition Cost (EAC) plus dispensing fee, or usual and customary charge, whichever is lower. In no event shall charges to the Welfare Department exceed charges made to the general public for the same prescription or item. Maximum Allowable Cost: State imposes Federal Upper Limits. Override requires “Medically Necessary” or “Brand Medically Necessary.” Incentive Fee: None. Patient Cost Sharing: Copayment is $1.00 for prescriptions up to $29.99, $2.00 for prescriptions over $30.00. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE !""#$%&'()*+,-:;@0@@@-)$)(+-?64?"+&5()*4-6?'A*#-$2 3*4&5(&4-#*5&"&*6)7-8*#*-*6#$++*4-&6-3BC7-&6-DE-:;;;< F*5&"&*6)7-#*5*&=*-A*6*2&)7-)>#$?9>-'(6(9*4-5(#*-"+(67< Managed Care Organizations

Formulary: Closed formulary.

Community Care P.O. Box 3249 Tulsa, OK 74033

Prior Authorization: State currently has a formal prior authorization procedure and DUR Board. Agency Grievance process exists for appeal of prior authorization decisions or coverage of an excluded product.

Heartland 100 North Broadway, Ste. 1400 Oklahoma City, OK 73102-8601

2-Oklahoma

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Prime Advantage 1602 SW 82nd St. Lawton, OK 73505 Unicare P.O Box 268985 Oklahoma City, OK 73126

F. STATE CONTACTS State Drug Program Administrator John M. Crumley, R.Ph., MHA Pharmacy Programs Director Oklahoma Health Care Authority 4545 N. Lincoln, Ste. 124 Oklahoma City, OK 73105 T: 405/522-7325 F: 405/522-7378 E-mail: [email protected] Agency Internet Address: www.ohca.state.ok.us Prior Authorization Contact John M. Crumley, 405/522-7325 DUR Contact John M. Crumley, 405/522-7325

Medicaid Drug Rebate Contacts Technical: Judi Worsham, 405/530-3222 Policy: Jim Hancock 405/530-3268 Director: Tom Simonson 405-522-7327 Claims Submission Contact Laura Dickey-Hottel DP Analyst/Planning Specialist III Oklahoma Health Care Authority 4545 N. Lincoln, Ste. 124 Oklahoma City, OK 73105-7378 T: 405/522-7228 F: 405/522-7378 E-mail: [email protected] Medicare Managed Care Contact John M. Crumley, 405/522-7325 Disease Management Program/Initiative Contact Kathe Eastham, R.N Nurse Manager III Oklahoma Health Care Authority 4545 N. Lincoln, Ste. 124 Oklahoma City, OK 73105-9901 T: 405/522-7115 F: 405/522-7378 E-mail: [email protected]

Medicaid DUR Board Rick Crensaw, D.O. Dick Robinson, R.Ph. Dorothy Gourley, R.Ph. Cliff Meece, R.Ph. Gary Kirk, R.Ph. Cathy E. Hollen, R.Ph. Francois DuToit, M.D. Thomas Whitsett, M.D. (Chair) Dan McNeill, Ph.D., PA-C (Vacant position pending OSMA recommendation) Prescription Price Updating Angela Thomasson Pharmacy Claims Specialist Oklahoma Health Care Authority 4545N Lincoln Blvd, Ste. 124 Oklahoma City, OK 73105-9901 T: 405/522-7307 F: 405/522-7378 E-mail: [email protected]

National Pharmaceutical Council

Physician-Administered Drug Program Contact Lynn Mitchell, M.D. Medical Director 4545 N. Lincoln, Ste. 124 Oklahoma City, OK 73105 405/530-3365 Oklahoma Health Care Authority Officials Michael Fogarty, J.D. Chief Executive Officer Oklahoma Health Care Authority 4545 N. Lincoln, Ste. 124 Oklahoma City, OK 73105 Michael Fogarty, J.D. State Medicaid Director 4545 N. Lincoln, Ste. 124 Oklahoma City, OK 73105 Darcedia McCauley, Ph.D. Director of Quality Assurance 405/530-3355

Oklahoma-3

Pharmaceutical Benefits 2000 Advisory Committee on Medical Care for Public Assistance Recipients Frank Wilson, III, M.D., Chairman 4545 N. Lincoln, Ste. 124 Oklahoma City, OK 73105 Executive Officers of State Medical, Pharmaceutical, and Osteopathic Societies Oklahoma State Medical Association Kathy Musson 601 W. I-44 Service Road Oklahoma City, OK 73118 405/843-9571 Oklahoma Pharmaceutical Association John D. Donner, Executive Director Box 18731 Oklahoma City, OK 73154 405/528-3338 Oklahoma Osteopathic Association Bob E. Jones, CAE Executive Director 4848 N. Lincoln Boulevard Oklahoma City, OK 73105-3321 405/528-4848 State Board of Pharmacy Bryan H. Potter Executive Director 4545 N. Lincoln Boulevard, Ste. 112 Oklahoma City, OK 73105 405/521-3815 Oklahoma Hospital Association John C. Coffey President 4000 Lincoln Boulevard Oklahoma City, OK 73105 405/427-9537 Fiscal Agent UNISYS 405/841-3400

4-Oklahoma

National Pharmaceutical Council

Pharmaceutical Benefits 2000

OREGON A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 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

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $87,805,350 148,258

1999* Expended Recipients

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 Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients MEDICALLY NEEDY TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients Source: HHS State HCFA-2082 Reports, Section A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

National Pharmaceutical Council

Oregon-1

Pharmaceutical Benefits 2000

Office of Medical Assistance Programs (OMAP), Department of Human Services.

Prior Authorization: State currently has a formal prior authorization procedure. Client may request an administrative hearing to appeal a prior authorization decision or to appeal the coverage of excluded products.

D. PROVISIONS RELATING TO DRUGS

Prescribing or Dispensing Limitations

Benefit Design

Monthly Quantity Limit: 34-day supply per Rx.

Drug Benefit Product Coverage: Products covered: prescribed insulin and syringe combinations used for insulin (when insulin filled). Prior authorization required for: isotretionoin; acute anti-ulcer drugs; cosmetics; total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: fertility drugs; experimental drugs; disposable needles used for insulin; urine ketone test strips; and blood glucose test strips.

Drug Utilization Review

Over-the-Counter Product Coverage: Products covered: analgesics; feminine products; and smoking deterrent products. Products requiring prior authorization and physician prescription: allergy, asthma, and sinus; cough and cold preparations; digestive products (non-H2 antagonist); digestive products (H2 antagonists); and topical products.

1)

$4.05 for providers filling between 15,000 and 30,000 total prescriptions annually;

2)

$4.05 for providers filling 1-15,000 or providers filling between 15,000 and 30,000 with greater than 20% Medicaid prescription volume annually;

3)

$4.28 for providers filling 1-15,000 total prescriptions annually with greater than 20% Medicaid prescription volume annually or providers operating with a True or Modified Unit Dose Delivery System.

C. ADMINISTRATION

Therapeutic Category Coverage: Therapeutic categories covered: Anabolic steroids; analgesics, antipyretics, NSAIDs; anorectics; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic drugs; antilipemic agents; antipsychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; prescribed smoking deterrents; sympathominetics (andrenergic); and thyroid agents. Therapeutic categories requiring prior authorization: selected antihistamine drugs; prescribed cold medications (selected products); growth hormones; selected antifungals; legend laxatives; coal tar preparations; and misc. GI drugs (selected products). Coverage of Injectables: Injectable medicines reimbursable through physician payment when used in physician offices, home health care, and extended care facilities. Vaccines: Vaccines reimbursable by Medicaid as part of the Vaccines for Children Program.

PRODUR system implemented in March 1994. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.91 - $4.28, effective 10/01/00.

Ingredient Reimbursement Basis: EAC = AWP - 11%. Prescription Charge Formula: Estimated acquisition cost (EAC) defined as the lesser of: (1) AWP - 11% (2) HCFA upper limits for multiple source drugs or (3) the usual and customary charge plus a dispensing fee. Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary.” Incentive Fee: None. Patient Cost Sharing: No copayment. Cognitive Services: Does not pay for cognitive services.

Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization Formulary: Open formulary.

2-Oregon

National Pharmaceutical Council

Pharmaceutical Benefits 2000

E. USE OF MANAGED CARE Approximately 400,000 total unduplicated number of Medicaid Recipients were enrolled in MCOs in FY 1999. Recipients received pharmaceutical benefits through both state and managed care plans. Care Oregon, Inc 522 SW Fifth Ave, Ste. 200 Portland, OR 97204 (800) 224-4840 Cascade Comprehensive Care, Inc. 900 Main Street, Suit A PO Box 217 Klamath Falls, OR 97601-0368 (541) 883-2947 Central Oregon Independent Health Services, Inc. 2650 NE Courtney Drive P0 Box 5729 Bend, OR 97708-5729 (800) 431-4155 Deschutes County CDO Deschutes County Human Services Dept. Alcohol and Drug Treatment Program 409 NE Greenwood Ave Bend, OR 97701 Doctors of The Oregon Coast South (DOCS) 750 Central, Ste. 202 PO Box 1096 Coos Bay, OR 97420 (541) 269-7400 Douglas County IPA 500 SE Cass, Ste. 210 Roseburg, OR 97470 (541) 677-3453 Family Care, Inc 2121 SW Broadway, Ste. 300 Portland, OR 97201 (800) 335-3205 Intercommunity Health Network, Inc 3600 NW Samaritan Drive Corvallis, OR 97330 (800)757-5114

Lane Individual Practice Association, Inc. (LIPA) 1500 Valley Rive Drive, Ste. 370 Eugene, OR 97401 (541) 485-2155 Mid Rogue IPA Health Plan 820 NE 7th Street Grants Pass, OR 97526 (541) 471-4106 ODS Health Plans 601 SW 2nd Ave Portland, OR 97204 (800) 342-0526 Oregon Health Management Services 1051 NE 6th Street, Ste. 2C Grants Pass, OR 97526 (541) 471-4208 Providence Health Plan 1235 NE 47th, Ste. 220 Portland, OR 97213-2196 (800) 898-8174 Regence HMO Oregon 201 High Street SE PO Box 12625 Salem, OR 97309 (800) 541-8981 Tuality Health Alliance 335 SE 8th Avenue PO Box 925 Hillsboro, OR 97123-0925 (800) 681-1901

F. STATE CONTACTS State Drug Program Administrator Jesse Anderson Office of Medical Assistance Programs (OMAP) Department of Human Resources 500 Summer Street, NE Salem, OR 97310-1014 T: 503/945-6492 F: 503/373-7689 E-mail: [email protected] Agency Internet Address: www.omap.hr.state.or.us

Kaiser Permanente 500 NE Multnomah, Ste. 100 Portland, OR 97232-2099 (800) 813-2000

National Pharmaceutical Council

Oregon-3

Pharmaceutical Benefits 2000 Prior Authorization Contact Jesse Anderson, 503/945-6492 DUR Contact Mariellen Rich, R.Ph. Pharmacist Account Manager First Health Service Corporation 565 Union St., NE, Ste. 205 Salem, OR 97310 T: 503/391-1980 F: 503/391-1979 E-mail: [email protected]

James W. Winde, M.D. 1212 Aspen Drive La Grande, OR 97850 Dean Haxby, R.Ph., Ph.D. Oregon Health Sciences University 3181 SW Sam Jackson Park Rd., GH212 Portland, OR 97201-3098 Nancy Elder, MD Dept of Family Medicine 3181 SW Sam Jackson Park Rd. Portland, OR 97201

Medicaid DUR Board

Prescription Price Updating

Todd L. Anderson R.Ph., FASCP Budget Pharmacy 2829 Barclay Road Medford, OR 97504

Kathy Frankiln Customer Support Department First Databank, Inc. 1111 Bayhill Drive NE San Bruno, CA 94066 T: 650/588-5454 F: 650/588-4003 E-mail: [email protected]

Rickland G. Asai DMD 2375 SW Cedar Hills Blvd. Portland, OR 97225 Beverly Castor Office of Medical Assistance Programs 500 Summer Street NE Salem OR 97310-1014

Medicaid Drug Rebate Contacts

Marshall D. Bedder M.D., F.R.C.P. (C) Advanced Pain Management Group 2625 Lovejoy Portland, OR 97210

Claims Submission Contact

Charlene Charroll Clark M.D. Oregon State University MC: Student Health Center OSU Campus Shuttle Corvallis, OR 97330

(Vacant Position) Delivery Systems Manager Office of Medical Assistance Programs 500 Summer Street, NE Salem, OR 97310-1014 T: 503/945-6497 F: 503/947-5221

Mariellen Rich R.Ph. First Health 565 Union Street NE, Ste. 205 Salem OR 97301 2460 William H. Wilson M.D. Oregon Health Sciences University 3181 SW Sam Jackson Park Road MC: UHN –79 Portland, OR 97201-3098 John E. Launer R.Ph. South Salem Pharmacy 925 Commercial Street Se Ste. 100 Salem, OR 97302

4-Oregon

Audits: Jesse Anderson, 5033/945-6492 Disputes: Becky Smith, 503/391-1981

Mariellen Rich, R.Ph., 503/391-1980 Medicaid Managed Care Contact

Disease Management Program/Initiative Contact Jesse Anderson, 503/945-6492 Physician-Administered Drug Program Contact (Vacant Position) Office of Medical Assistance Programs Department of Human Resources 500 Summer Street, NE Salem, OR 97310 503/945-6490

National Pharmaceutical Council

Pharmaceutical Benefits 2000

Office of Medical Assistance Officials Gary Weeks Director Department of Human Services 500 Summer Street, NE Salem, OR 97310-1012 503/378-2263 Hersh Crawford Director Office of Medical Assistance Programs Title XIX Medical Care Advisory Committees Micheal Bierman, DMD Bruce Bliatout Rita Catapano Donna Crawford Maryann Curry James Davis Rosemari Fitts Michael Garland John Hogan David Strough Rick Wopat, MD Consultants to Health and Social Services Section Joseph Intile, M.D. Medical Director Office of Medical Assistance Programs Department of Human Resources 500 Summer Street, NE Salem, OR 97310 Pharmacy Advisory Task Force

Executive Officers of State Medical and Pharmaceutical Associations Oregon Medical Association Robert L. Dernedde, CAE Executive Director 5210 SW Corbett Street Portland, OR 97201 503/226-1555 Oregon State Pharmaceutical Association Tom Holt Executive Director 1460 State Street Salem, OR 97301-4296 503/585-4887 Osteopathic Physicians and Surgeons of Oregon Jeff Heatherington Executive Director 2121 SW Broadway, Ste. 300 Portland, OR 97201 800/533-6776 State Board of Pharmacy Gary Schnabel Executive Director State Office Bldg., Room 425 800 NE Oregon St., #9 Portland, OR 97232 503/731-4032 Oregon Association of Hospitals and Health Systems Kenneth M. Rutledge President 4000 Kruse Way Place Building 2, Ste. 100 Lake Oswego, OR 97035-2543 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.

National Pharmaceutical Council

Oregon-5

Pharmaceutical Benefits 2000

PENNSYLVANIA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN) OAA

AB

APTD

AFDC

Other

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

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998 Expended $525,261,211

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult

$256,910,619 $59,380,437 $176,079,255 $8,326,245 $12,352,307 $223,436 $548,939

228,067 41,206 105,477 52,459 24,557 2,450 1,918

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult

$37,074,413 $31,035,505 $2,050,862 $3,404,034 $584,012

41,741 19,173 970 18,857 2,741

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

$100,959,436 $88,149,940 $215,515 $11,368,722 $1,225,209

172,023 53,584 341 105,835 12,263

OTHER

$130,272,301

138,810

Recipients 580,749

1999* Expended Recipients

Source: HHS State HCFA-2082 Reports, Section A-4 and B-4. *1999 total and expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Pennsylvania

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION

Prescribing or Dispensing Limitations

Office of Medical Assistance, Department of Public Welfare.

Quantity Limit: Not to exceed a 34-day supply or 100 units, whichever is greater.

D. PROVISIONS RELATING TO DRUGS

Refill Limit: Up to 5 within 6 months.

Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips; interdialytic parenteral nutrition; and total parenteral nutrition. Products not covered: cosmetics; fertility drugs; and experimental drugs. Over-the-Counter Product Coverage: Products covered: analgesics; feminine products; topical products; laxatives; oral electrolytes; allergy, asthma, and sinus (indication or prescribed); cough and cold preparations (indication other than C+C on Rx); digestive products (not including H2 antagonists) (legend products only); and digestive products (H2 antagonists) (PA > 90 days at acute dose). Products not covered: smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Partially covered: prescribed cold medications. Therapeutic categories not covered: anorectics (unless for treatment of hyperkinesis or narcolepsy); and prescribed smoking deterrents. Coverage of Injectables: Injectable medicines reimbursable when used in physician offices, home health care, and extended care facilities. Vaccines: Vaccines reimbursable at AWP – 10% as part of the Medical Assistance, Children Health Insurance Program, and the Vaccines for Children Program.

Drug Utilization Review PRODUR system implemented in June 1993. DUR Board has 9 members (plus 1 vacancy) and meets quarterly. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.00, effective 10/1/95. Ingredient Reimbursement Basis: EAC = AWP-10%. Prescription Charge Formula: 1.

Payment for single source drugs and those multisource brand name drugs certified as medically necessary will be the lower of the EAC dispensing fee or the pharmacy's usual and customary charge.

2.

State MAC for the drug plus dispensing fee or the pharmacy's usual and customary charge.

3.

For compound prescriptions, an additional fee of $1.00 is allowed to a pharmacy, bringing the total dispensing fee to $5.00.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. 667 drugs are listed on the state-specific MAC list. Override requires “Brand Medically Necessary” or “Brand Necessary,” plus prior authorization. Incentive Fee: None. Patient Cost Sharing: Copayment is $1.00. The copayment will not apply to those recipients who are federally exempt, under 21 years of age, pregnancy cases and long-term care patients, plus patients receiving drugs in the following categories: − − − −

Unit Dose: Unit dose packaging not reimbursable.

− −

Formulary/Prior Authorization

− −

Formulary: Open formulary.

−

Anticonvulsants Antidiabetic agents Antiglaucoma agents Antihypertensive agents Antineoplastic agents Antiparkinson agents Cardiovascular preparations HIV/AIDS specific drugs Psychotherapeutic agents

Prior Authorization: State currently has a prior 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

Pharmaceutical Benefits 2000

Cognitive Services: Does not pay for cognitive services.

F. STATE CONTACTS State Drug Program Administrator

E. USE OF MANAGED CARE !""#$%&'()*+,[email protected]?64?"+&5()*4-3*4&5(&4-#*5&"&*6)7 8*#*-*6#$++*4-&6-'(6(9*4-5(#*-&6-:;;;<--!++-#*5*&=*4 ">(#'(5,-7*#=&5*70-4*"*64&69-$6-)>*&#-5()*9$#,-$2 (77&7)(65*0-)>#$?9>-'(6(9*4-5(#*!

Joseph E. Concino, R.Ph.. Office of Medical Assistance Programs P.O. Box 8046 Harrisburg, PA 17105 T: 717/772-6341 F: 717/772-6366

Managed Care Organizations AmeriHealth HMO/Mercy Health Plan 1901 Market Street, 45th Floor Philadelphia, PA 19103 Keystone Mercy Healthplan 200 Stevens Drive, Ste. 900 Philadelphia, PA 19113-1570

18,334

217,733

Oaktree/Oxford Health Plan The Curtis Center, Ste. 900 Independence Square West Philadelphia, PA 19106

57,501

Healthcare Management Alternatives The Wanamaker Building 100 Penn Square East, Ste. 900 Philadelphia, PA 19107

71,970

Welfare Department Officials Feather O. Houstoun Secretary Department of Public Welfare Health and Welfare Building Harrisburg, PA 17120 Peg J. Dierkers, Ph.D. Deputy Secretary for Medical Assistance Programs Christopher P. Gorton, M.D. Medical Director Robert Kelly Director Division of Data and Claims Management

Health Partners of Philadelphia/Partnership 841 Chestnut St. Ste. 900 Philadelphia, PA 19107

119,024

Jeffrey Bechtel Director Bureau of Program Integrity

Three Rivers Health Plans/MedPlus 300 Oxford Drive Monroeville, PA 15146

115,318

Suzanne Love Director Bureau of Policy, Budget, and Planning

UPMC Health Plan, Inc./Best Healthcare of Western PA One Chatam Center 112 Washington Place Pittsburgh, PA 15219 Gateway Health Plan Two Chatum Ctr, Ste. 500 Pittsburgh, PA 15219 PhilCare Health Systems, Inc./Pennsylvania HealthMATE 2005 Market Street, Ste. 500 Philadelphia, PA 19103

73,776

147,454

19,103

Guy L. Ridge, III Acting Director Bureau of Fee-for-Service Programs Christine M. Bowser Director Bureau of Managed Care Operations Andrew Major Director Bureau of Long Term Care Programs William M Peifer, R.Ph. Pharmacy Consultant Pharmacy Services Section John Ferrara, R.Ph. Director Division of Program Integrity

3-Pennsylvania

National Pharmaceutical Council

Pharmaceutical Benefits 2000 DUR Board

Claims Submission Contact

Richard D. Baltz, M.D. 3028 Market Street Camp Hill, PA 17011

EDS 275 Grandview Avenue Camp Hill, PA 17011 (Calls with contractor must be made through state agency.)

Richard T. Bell, M.D. Chairman 2016 Redwood Avenue Wyomissing, PA 19610 Richard W. Sloan, M.D. Thomas Hart Family Practice Center York Hospital 1001 South George Street York, PA 17405 Otto F. Wolke, R.Ph. Geisinger Health Plan Geisinger Office Building Danville, PA 17822 Patricia A. Keys, Pharm.D. 1514 Scenery Ridge Drive Pittsburgh, PA 15241 Marshall P. Burnside, R.Ph. 6000 Bell Road Harrisburg, PA 17111 Michael A. Zemaitis, Ph.D., R.Ph. 133 Shadowlawn Drive Pittsburgh, PA 15261 Bruce Pollock, M.D. 7032 Meade Place Pittsburgh, PA 15208 Robert J. Kordella, R.Ph. 145 Stilwell Court Mt. Lebanon, PA 15228 Prescription Price Updating First Data Bank 1111 Bayhill Drive San Bruno, CA 94066 800/633-3453 Medicaid Drug Rebate Contacts Technical: David Ehrhart, 717/772-6305 Policy: Suzanne Love, 717/772-6142 Disputes: Vacant, 717/772-6341

National Pharmaceutical Council

Medicaid Managed Care Contact Michael Jacobs Director, Division of MCO Monitoring and Compliance Office of Medical Assistance Programs Cherrywood Bldg, DPW Complex #2 Harrisburg, PA 17105 717/772-6977 Expanded Drug Coverage Program Contact Thomas Snedden PACE Program PA Dept. of Aging 555 Walnut St., 5th Fl. Harrisburg, PA 17101 717/787-7313 Medical Assistance Advisory Committee Peter D. Archey PA Association of Area Agencies on Aging 4701 Devonshire Rd Ste. 102 Harrisburg, PA 17109 Shirley Beer Armstrong County Low Income Rights Organization RD, #8, Box 134 Kittanning, PA 16201 724/543-5031 Kent D.W. Breams, M.D. Department of Family Practice University of Pennsylvania 2 Gates, HUP, 3400 Spruce Street Philadelphia, PA 19104 215/614-0523 Louise Brookins Philadelphia Welfare Rights 4358 N. Franklin Street Philadelphia, PA 19122 214/455-3497 Kevin Casey Pennsylvania Protection and Advocacy 1414 Cameron Street, 2nd Floor Harrisburg, PA 17103 717/236-8110

Pennsylvania-4

Pharmaceutical Benefits 2000 Michael D. Chambers County commissioners Association of Pennsylvania 17 North Front Street Harrisburg, PA 17101 717/232-7554 Cindy W. Christian, M.D. The Children’s Hospital of Philadelphia 34th Street and Civic Center Boulevard, Room 2416 Philadelphia, PA 19104 215/590-2058 Barbara Coffin Pennsylvania Association of Area Agencies on Again Berks County Office of Aging County Services Center 633 Court Street Reading, PA 19601-4303 610/478-6500 C. Lu Conser Pennsylvania Community Providers Association 2400 Park Drive Harrisburg, PA 17110 717/657-7078 Barbara J. Custer Clarion County Welfare Rights Organization 4096 Master Road Emlenton, PA 16373 814/797-0060 Peg Dierkers (Ex-Officio Co-Chair) Pennsylvania Department of Health Office of Policy, Health and Welfare Building, Room 515 Harrisburg, PA 17120 Shelley Eppley Pennsylvania Mental Health Consumers Association 4105 Derry Street Harrisburg, PA 17111 717/564-4930 Henry R. Fiumelli Executive Director Pennsylvania Forum for Primary Health Care 1017 Mumma Road, Ste. 209 Wormleysburg, PA 17043 717/761-6443 ext. 203 William L. Greene, R.Ph. Pennsylvania Pharmaceutical Association 2020 Union Boulevard Allentown, PA 18103 610/433-7577

5-Pennsylvania

Kathy Hubert Pennsylvania County Drug and Alcohol Program Administrators 17 North Front Street Harrisburg, PA 17107 717/232-7554 Christine Klejbuk PA Assn. Non-Profit Homes for the Aging Dir. of Public Policy 4720 Old Gettysburg Road, Ste. 409 Mechanicsburg, PA 17055 717/763-5724 Sefi Knoble, M.D. Pennsylvania Medical Directors Association Philadelphia, PA 19131 215/581-0705 Kimberly Kockler Vice-Chair Managed Care Association of Pennsylvania 240 North Third Street, Ste. 203 P.O. Box 12108 Harrisburg, PA 17108-2108 717/238-2600 Beverly Mackereth Healthy York County Coalition 1001 S. George Street York, PA 17405-7198 717/851-2333 Donald McCoy Pennsylvania Medical Society 777 East Park Drive P.O. Box 8820 Harrisburg, PA 17105-8820 717/558-7823 Kearline McKellar-Jones Health Partners 841 Chestnut Street, Ste. 900 Philadelphia, PA 19107 215/991-4063 Richard R. Orlandi Pennsylvania Medical Society 777 East Park Drive PO Box 8820 Harrisburg, PA 17105-8820 717/558-7750

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Kenneth J. Pierce Pennsylvania State Welfare Rights Organization 119 Camp Avenue Braddock, PA 15104 412/271-1426 Charles Pruitt, Jr. Seniorcare Solutions LLC 1215 Hulton Road Oakmont, PA 15139 412/826-6100 Mary Ellen Rehrman National Alliance for the Mentally Ill 2149 N. Second Street Harrisburg, PA 17110 717/268-1514 Virginia Schierscher HAP 4750 Lindle Road P.O. Box 8600 Harrisburg, PA 17105-8600 717/657-1222 David E. Shapter, D.D.S. Pennsylvania Dental Association 4934 Peach Street Erie, PA 16509 814/868-8673 Michael A. Yantis, Jr. Pennsylvania Department of Health Office of Policy Room 808, Health and Welfare Building Harrisburg, PA 17120 717/787-4525 Dawn Guzik Stocker Gateway Health Plan Two Chatham Center, Ste 500 Pittsburgh, PA 15219 412/255-4569 Jessie Rohner PA State Nurses Association 2578 Interstate Drive Harrisburg, PA 17106 717/657-1222

National Pharmaceutical Council

Executive Officers of State Medical and Pharmaceutical Associations Pennsylvania Medical Society Roger F. Mecum Executive Vice President 777 E. Park Drive Harrisburg, PA 17105-8820 717/558-7750 Pennsylvania Pharmaceutical Association Carmen A. DiCello, R.Ph. Executive Director 508 North Third Street Harrisburg, PA 17101-1199 717/234-6151 Pennsylvania Osteopathic Medical Association Mario E.J. Lanni Executive Director 1330 Eisenhower Boulevard Harrisburg, PA 17111 717/939-9318 Pennsylvania Podiatry Association Nancy Sullivan Assistant Executive Director 757 Poplar Church Road Camp Hill, PA 17011 717/763-7665 State Board of Pharmacy W. Richard Marshman Executive Secretary 124 Pine St. P.O. Box 2549 Harrisburg, PA 17105-2649 717/783-7157 Hospital Association of Pennsylvania Carolyn F. Scanlan President, CEO 4750 Lindle Road P.O. Box 8600 Harrisburg, PA 17105-8600 717/564-9200

Pennsylvania-6

Pharmaceutical Benefits 2000

RHODE ISLAND A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

Other

OAA

AB

APTD

AFDC

OAA

AB

APTD

AFDC

Children <21

Prescribed Drugs



















Inpatient Hospital Care



















Outpatient Hospital Care



















Laboratory & X-ray Service



















Skilled Nursing Home Services



















Physician Services



















Dental Services



















SFO

1

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $61,401,958 44,852

1999* Expended Recipients

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 Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients MEDICALLY NEEDY TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients Source: HHS State HCFA-2082 Reports, Section A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Rhode Island

National Pharmaceutical Council

Pharmaceutical Benefits 2000

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.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products not covered: DESI drugs; smoking cessation drugs; drugs for hair growth; and fertility drugs. Prior authorization required for: anorexants; central nervous system stimulants for recipients over 21 years of age; brand name vitamins; and hematinics and lipotropic preparations (selling for over $10 per 100 tablets/capsules or pint).

Ingredient Reimbursement Basis: EAC = WAC + 5%. Prescription Charge Formula: 1.

In accordance with federal regulation the upper limit for payment for prescribed drugs will be based upon the amount allowed by the Medical Assistance Program or the usual and customary charge to the general public, whichever is lower.

2.

Payment for over-the-counter drugs (non-legend drugs) will be based upon the lower of either the allowable cost of the drug plus 50 percent, the usual and customary charge to the general public, or the allowable cost plus the professional fee for service.

Over-the-Counter Product Coverage: analgesics; cough and cold preparations; and digestive products. Coverage of Injectables: Injectable medicines reimbursable when used in physician offices, home health care, and extended care facilities. Vaccines: Limited coverage. Unit Dose: Unit dose packaging not reimbursable. Formulary/Prior Authorization Formulary: Open formulary. Prescribing or Dispensing Limitations Prescription Refill Limit: Refills to a maximum of five are allowed for specified drugs: anti-hypertensives, diuretics, anti-convulsants, coronary vasodilators, tranquilizers, antidepressants, hormones, antibiotics, etc. Refills are not allowed for specified drugs, e.g., central nervous system stimulants, narcotics (Schedule II, III), and pentazocine.

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Dispense as Written” or “Brand Medically Necessary.” Documentation must be submitted with a medical reason why a generic cannot be used. Incentive Fee: None. Patient Cost Sharing: No copayment. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE 3(6(9*4-5(#*-#*5&"&*6)7-#*5*&=*-">(#'(5*?)&5(+-A*6*2&)7 )>#$?9>-'(6(9*4-5(#*-"+(67< Managed Care Organizations −

Monthly Quantity Limit: One month’s supply of drugs.

−

Maintenance Medication: The attending physician may prescribe certain maintenance drugs of 100 tablets, capsules or pint of liquid or a 30-day supply of these drugs - whichever is greater.

−

Monthly Dollar Limits: None Drug Utilization Review PRODUR system implemented in December 1994.

National Pharmaceutical Council

−

United Healthcare of New England Coordinated Health Partners, Inc. Neighborhood Health Plan of Rhode Island Harvard/Pilgrim Healthcare of New England

F. STATE CONTACTS State Drug Program Administrator Paula Avarista, R.Ph. Chief of Pharmacy Department of Human Services 600 New London Avenue Cranston, RI 02920 401/462-2183

Rhode Island-2

Pharmaceutical Benefits 2000 Rhode Island DUR Board Kimberly McDonough, Pharm.D. Chairperson Advanced Pharmacy Concepts, Inc. 52 Grinnell Street Jamestown, RI 02835 401/423-2542 Dr. James Burrill Co-Chairperson 135 Cass Avenue Woonsocket, RI 02895 401/765-3135 Paul Avarista, R.Ph. Chief of Pharmacy Rhode Island Department of Human Services 600 New London Avenue Cranston, RI 02920 401/464-2183 Craig Bowen, Pharm.D. 405 Lapham Farm Road Pascoag, RI 02859 401/568-2536 Anne Hume, Pharm.D. 233 Lepes Road Portsmouth, RI 02871 401/729-2760 Peter Jussila, RPH 10 Henry Brown Road West Greenwich, RI 02817-2469 401/397-6371 Peter Kogut, R.Ph. Harvard Pilgrim Health Plan 1 Hoppin Street Providence, RI 02903 401/331-3000 x.42150

Dr. Craig Winderman Harvard Pilgrim Health Plan 1 Hoppin Street Providence, RI 02903 401/331-4034 x.42276 David Yoburn, M.D. 1076 North Main Street Providence, RI 02904 401/861-7711 Medicaid Drug Rebate Contacts Technical: EDS Policy: Paula Avarista, 401/462-2183 DUR: Paula Avarista, 401/462-2813 PA: Paula Avarista, 401/462-2813 Physician-Administered Drug Program Contact Don Sullivan 600 New London Avenue Cranston, RI 02910 401/464-2176 Department of Human Services Officials Christine Ferguson Director Department of Human Services 600 New London Avenue Cranston, RI 02920 John Young Associate Director Medical Services Department of Human Services 600 New London Avenue Cranston, RI 02920 Executive Officers of State Medical and Pharmaceutical Societies

John Pagliarini, R.Ph. Regional Director/Government Programs Medco Containment Services, Inc. One Gateway Center, Ste. 804 Newton, MA 02158 617/969-5371

Rhode Island Medical Society Newell E. Warde, Ph.D. Executive Director 106 Francis Street Providence, RI 02903 401/331-3207

John Stoukides, M.D. Roger Williams Medical Center 825 Chalkstone Avenue Providence, RI 02903 401/456-2000

Rhode Island Pharmaceutical Association Donald Fowler Interim Executive Director 500 Prospect Street Independence Square Pawtucket, RI 02860 401/725-4141

3-Rhode Island

National Pharmaceutical Council

Pharmaceutical Benefits 2000

Society of Osteopathic Physicians and Surgeons Robert Salk, D.O. President P.O. Box 2344 Woonsocket, RI 02895 401/647-9150 State Board of Pharmacy 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 Providence, RI 02906 401/453-8400

National Pharmaceutical Council

Rhode Island-4

Pharmaceutical Benefits 2000

SOUTH CAROLINA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

OAA

AB

APTD

AFDC

Prescribed Drugs









Inpatient Hospital Care









Outpatient Hospital Care









Laboratory & X-ray Service









Skilled Nursing Home Services









Physician Services









Dental Services









OAA

AB

APTD

AFDC

Other Children <21

SFO

1

See Appendix E, page E-29, for a list of acronyms. Medically Needy Program was discontinued effective October 1, 1992.

B. EXPENDITURES FOR DRUGS

TOTAL

1998 Expended $224,962,203

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult

$120,899,672 $35,789,672 $74,950,233 $4,327,091 $5,833,129 $0 $0

156,910 33,696 68,329 36,715 18,170 0 0

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult

$0 $0 $0 $0 $0

0 0 0 0 0

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

$62,536,853 $22,045,692 $25,565,926 $12,703,177 $2,222,058

170,329 20,281 17,087 108,314 24,647

OTHER

$20,177,225

67,193

Recipients 404,611

1999* Expended Recipients

Source: HHS State HCFA-2082 Reports, Section A-4 and B-4. *1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-South Carolina

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION South Carolina Department of Health & Human Services.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: cosmetics; fertility drugs; experimental drugs; blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: prescribed insulin; disposable needles and syringe combinations used for insulin. Over-the-Counter Product Coverage: Products covered: smoking deterrent products. Products covered with restrictions: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products (non-H2 antagonist); digestive products (H2 antagonists); feminine products; and topical products. OTC Coverage: The following OTC medications and their generic equivalents are covered by the Medicaid program provided the manufacturer rebates the pharmaceutical dispensed. Federal or state upper limits of payment restrictions apply to several of these medications. − − − − − − − − − − − − − − − − − − − − − − − − −

Acetaminophen, all strengths and forms Actifed Tablets Alternagel Liquid Ascriptin, All Strengths and Forms Aspirin, All Strengths and Forms Axid AR Tablets Basaljel, All Strengths and Forms Cerose DM Syrup Contraceptive Condoms Contraceptive Products (i.e., foams, creams, films) Debrisan Beads Dimenhydrinate Tablets/Liquid Dimetane Extentabs Gaviscon Tablets/Suspension Gaviscon-2 Tablets Hydrocortisone 0.5% Cream/Ointment Insulin, all forms Insulin Syringes Iron Preparations Routinely covered for females of childbearing age and children Maalox Tablets/Suspension Maalox Extra Strength Suspension Maalox Plus Suspension Micatin 2% Cream Multivitamins

− − − − − − − − − − − − − −

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT antiinflammatory agents; estrogens; growth hormones; hypotensive agents; misc. GI drugs; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid agents. Therapeutic categories partially covered: anorectics. Coverage of Injectables: Injectables reimbursable through the Prescription Drug Program when used in home health care, extended care facilities and though physician payment when used in physician offices. Vaccines: Vaccines reimbursable based on CDC price as part of the Vaccines for Children Program (age under 21). Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization Formulary: Open formulary. With certain drug classifications excluded. General Exclusions: 1. 2. 3. 4. 5.

6. 7.

National Pharmaceutical Council

Routinely covered for females of childbearing age Mylanta Tablets/Liquid Mylanta Double Strength Tablets/Liquid Niacin 50 mg Tablets Niacin 100 mg Tablets Parepectolin Suspension Pepcid AC Tablets Riopan Plus Tablets/Suspension Robitussin AC Robitussin DAC Robitussin DM Tagamet HB Tablets Titralac Tablets Zantac 75 Tablets

Anorexants. Investigational pharmaceuticals or products. Immunizing agents. Pharmaceuticals determined by the FDA to be less than effective and identical, related, or similar drugs. Injectable pharmaceuticals administered by the practitioner in the office in a clinic, or in a mental health center (Synagis is reimbursable through the Physician Services Program and is non-covered through Pharmacy Services). Fertility Products. Smoking cessation products whether legend or OTC.

South Carolina-2

Pharmaceutical Benefits 2000 8. 9.

Pharmaceuticals which are not rebated. Nutritional supplements which are administered orally. 10. Pharmaceuticals used for cosmetic purposes or hair growth. Prior Authorization: State currently has a formal prior authorization procedure. To appeal a prior authorization decision, further documentation may be furnished to the pharmacy services program by the pharmacy provider. The pharmacist or physician may request coverage for the following medications, which require special authorization (SA) by completing the Special Authorization Request form and submitting it to the Department of Pharmacy Services: 1.

2.

Vitamins and vitamin combinations for the treatment of vitamin deficiencies for male patients as well as female patients of non-childbearing age. Oral dosage forms of iron preparations, multivitamins (whether legend or OTC) and folic acid are routinely covered for females of childbearing age. Oral iron preparations prescribed for children in the prevention and treatment of iron deficiency are routinely covered. The category of oral iron preparations includes: ferrous fumarate, ferrous gluconate, ferrous sulfate, and polysaccharide-iron complex. Special authorization is necessary in order for Medicaid to reimburse for vitamins and vitamin/mineral combination products dispensed to children. Fluoride vitamins for children are routinely covered. Compounded prescriptions when the primary or most expensive ingredient is NOT a routinely covered product. Special authorization requests should not be submitted for compounds that are commercially available in similar formulations.

3.

Non-routinely covered OTC medications.

4.

The following home-administered injectable products: Intravenous hydration therapies, injectable immune serums, injectable vitamins, and Serostim.Immunosuppressants such as CellCept, Imuran, Neoral, Prograf, Sandimmune, Zenapax, and Simulect.

5.

Prior Authorization: Medicare for a period of 36 months from the date of discharge following a hospital stay during which the Medicare covered organ or tissue transplant surgery was performed.

6.

Pharmaceutical products used to treat erectile dysfunction (ED) regardless of route of administration. This category of products currently includes pharmaceuticals such as alprostadil and sildenafil citrate. Special authorization will only be considered for males, age 21 and older, diagnosed with ED resulting from a defined organic cause, medical condition, and/or a specific disease. Special

3-South Carolina

authorization requests must be accompanied by a current, written statement from the prescriber detailing: 1) patient’s diagnosis and prognosis, 2) documentation regarding the defined organic cause, medical condition, or specific disease state resulting in the patient’s condition, including, but not limited to: age of the patient, date of onset of disease causing ED, date of ED diagnosis, statement verifying that the patient is not on nitrates, if requesting Medicaid reimbursement for sildenafil citrate. Prescribing or Dispensing Limitations Prescription Refill Limit: The prescriber authorizes the number of refills. Monthly Quantity Limit: Children (birth to age 21) are allowed unlimited prescriptions per month. Recipients over the age of 21 are limited to a maximum of four prescriptions per month. Quantity Limit per Prescription: 100-day supply maximum. In chronic conditions and for maintenance drugs, a minimum of a 30-day supply where appropriate. Monthly Dollar Limit: None. Drug Utilization Review Plans are under development for PRODUR system. State currently has a DUR Board with a monthly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.05, effective 7/1/89. Ingredient Reimbursement Basis: EAC = AWP - 10%. Prescription Charge Formula: Medicaid reimbursement for pharmacy services will be based on the lowest of: the Estimated Acquisition Cost (EAC); federal or state maximum allowable cost (MAC); or the provider's submitted usual and customary charge. Maximum Allowable Cost: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. Override requires “Brand Necessary” or “Brand Medically Necessary” handwritten certification by the prescriber. Incentive Fee: None. Patient Cost Sharing: $2.00 copayment per prescription. Cognitive Services: Does not pay for cognitive services.

National Pharmaceutical Council

Pharmaceutical Benefits 2000

E. USE OF MANAGED CARE !""#$%&'()*+,-.H0@@@-)$)(+-?64?"+&5()*4-6?'A*#-$2 3*4&5(&4-#*5&"&*6)7-8*#*-*6#$++*4-&6-3BC7-&6-DE-:;;;< F*5&"&*6)7-#*5*&=*-">(#'(5*?)&5(+-A*6*2&)7-)>#$?9> '(6(9*4-5(#*-"+(67< Managed Care Organizations Select Health of South Carolina, Inc. Patricia Marquis, Chief Operating Officer P.O. Box 40024 Charleston, SC 29403 843/569-1759

F. STATE CONTACTS State Drug Program Administrator

Prescription Price Updating First Data Bank, Inc. The Hearst Corporation 1111 Bayhill Dr. San Bruno, CA 94066 T: 650/588-5454 F: 650/588-4003 Medicaid Drug Rebate Contacts Technical: Rod Davis, 803/898-2610 Policy: James Assey, 803/898-2876 DUR & PA: Caroline Sojourner, 803/898-2876 Disputes: Kathy Bass, 803/898-2974 Claims Submission Contact

James M. Assey, R.Ph. Pharmacy Services, DME & Legislative Liaison S.C. Department of Health & Human Services P.O. Box 8206, Columbia, SC 29202-8206 T: 803/898-2876 F: 803/898-4517 E-mail: [email protected] Agency Internet Address: www.dhhc.state.sc.us

Rod Davis Bureau Chief, Bureau of Information Systems S.C. Department of Health and Human Services P.O. Box 8206 Columbia, SC 29202-8206 803/898-2610 E-mail: [email protected]

Prior Authorization Contact

Rosina Brown Department of Managed Care S.C. Department of Health and Human Services P.O. Box 8206 Columbia, SC 29202-8206 803/898-2650 E-mail: [email protected]

Caroline Y. Sojourner, R.Ph. Department Head Department of Pharmacy Services S.C. Department of Health and Human Services P.O. Box 8206 Columbia, SC 29202-8206 T: 803/898-2876 F: 803/898-4517 E-mail: [email protected] DUR Contact Caroline Y. Sojourner, 803/898-2876 DUR Committee Gwendolyn Cambron, M.D. F. Joseph Hodge, R.Ph. Henry Rose, R.Ph. Leslie M. Stuck, M.D. Caroline Sojourner, R.Ph. Michele Burnett, R.Ph. Ira Horton, M.D.

National Pharmaceutical Council

Medicare Managed Care Contact

Disease Management Program/Initiative Contact Sharon Parker S.C. Department of Health and Human Services P.O. Box 8206 Columbia, SC 29202-8206 803/898-3021 E-mail: [email protected] Physician-Administered Drug Program Contact Mary Barnett S.C. Department of Health & Human Services P.O. Box 8206 Columbia, SC 29202-8206 803/898-2645

South Carolina-4

Pharmaceutical Benefits 2000 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 Columbia, SC 29202-8206 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 Columbia, SC 29202-8206 803/898-2876 Executive Officers of State Medical and Pharmaceutical Societies South Carolina Medical Association William F. Mahon Executive Vice President 3210 Fernandina Rd. P. O. Box 11188 Columbia, SC 29211 803/798-6207 South Carolina Pharmacy Association James R. Bracewell Executive Vice President 1405 Calhoun Street, Ste. 200 Columbia, SC 29201-2509 803/254-1065 State Board of Pharmacy Cheryl A. Ruff Administrator, South Carolina Board of Pharmacy P. O. Box 11927 Columbia, SC 29211-1927 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

5-South Carolina

National Pharmaceutical Council

Pharmaceutical Benefits 2000

SOUTH DAKOTA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN) OAA

AB

APTD

AFDC

Other

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

See Appendix E, page E-29, for a list of acronyms. +Renal Disease

B. EXPENDITURES FOR DRUGS

TOTAL

1998 Expended $31,106,511

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult

$17,382,625 $2,111,867 $14,081,986 $614,756 $572,236 $489 $1,291

18,645 1,976 8,867 5,279 2,504 8 11

$20,094,115 $2,473,792 $15,974,007 $769,033 $874,164 $1,873 $1,246

19,620 1,930 8,857 5,747 3,043 22 21

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult

$0 $0 $0 $0 $0

0 0 0 0 0

$0 $0 $0 $0 $0

0 0 0 0 0

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

$1,677,158 $0 $0 $1,505,739 $171,419

14,610 0 0 12,477 2,133

$2,158,960 $0 $0 $1,964,103 $194,857

15,499 0 0 13,506 1,993

$12,046,728

13,333

$14,159,290

13,950

OTHER

Recipients 46,588

1999 Expended Recipients $36,412,365 49,069

Source: HHS State HCFA-2082 Reports, Section A-4 and B-4.

National Pharmaceutical Council

South Dakota-1

Pharmaceutical Benefits 2000

C. ADMINISTRATION Department of Social Services, Office of Medical Services.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; and urine ketone test strips. Products not covered: cosmetics; DESI drugs; fertility drugs; experimental drugs; total parental nutrition; drugs for impotence; and interdialytic parenteral nutrition. Over-the-Counter Product Coverage: Products not covered: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products; feminine products; topical products; and smoking deterrents. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: growth hormones. Therapeutic categories not covered: anorectics; nutritional supplements; and prescribed smoking deterrents. Coverage of Injectables: Injectable medicines reimbursable through physician payment when used in physicians offices, home health care, and extended care facilities. Vaccines: Vaccines reimbursable with HCPC code as part of the Vaccines for Children Program.

Drug Utilization Review PRODUR system implemented in 1998. State has a DUR Board with annual review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.75 to $5.55, effective 7/1/1991 Ingredient Reimbursement Basis: EAC = AWP-10.5%. Prescription Charge Formula: Payment is the lower of: 1. 2.

FUL, state MAC plus a dispensing fee, or EAC plus a dispensing fee, or usual and customary charge to the general public.

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary.” Incentive Fee: None. Patient Cost Sharing: Copayment is $2.00. Cognitive Services: Does not pay for cognitive services. E. USE OF MANAGED CARE Does not use MCOs to deliver pharmacy services to Medicaid recipients.

F. STATE CONTACTS State Drug Program Administrator Office of Medical Services Mark Petersen, R.Ph. Department of Social Services 700 Governors Drive Pierre, SD 57501 T: 605/773-3495 F: 605/773-5246 Prior Authorization Contact

Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization Formulary: Closed formulary. Prior Authorization: State currently has a formal prior authorization procedure. Prescribing or Dispensing Limitations Prescription Dollar Limit: None. Monthly Quantity Limit: None.

2-South Dakota

Mark Petersen, R.Ph., 605/773-3495 DUR Contact Mike Jockheck, R.Ph. Pharmacy Consultant SD Dept of Social Services 700 Governors Dr. Pierre, SD 57501 605/773-6439 E-mail: [email protected]

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Steering Committee (Medicaid DUR Board) Damian Prunty (Program Administrator) Tom Carlson, R.Ph. Richard Holm, M.D. Pam Jones, R.Ph. Bruce Lushbough, M.D. Prescription Price Updating Mark Petersen, R.Ph., 605/773-3495 Medicaid Drug Rebate Contacts Technical/Policy: Vacant Disputes/Audits: Helen Rokusek Rebate Coordinator Dept. of Social Services 700 Governors Dr Pierre, SD 57501 605/773-3653 Claims Submission Contact Meredith Heerman Dept. of Social Services 700 Governors Dr Pierre, SD 57501 T: 605/773-3495 F: (605) 773-5246 E-mail: [email protected] Disease Management Program/Initiative Contact Mark Petersen, R.Ph., 605/773-3495 South Dakota Medicaid Agency Officials James Ellenbecker Secretary Office of Medical Services Department of Social Services 700 Governors Drive Pierre, SD 57501 Damian Prunty Program Administrator Medical Services Medical Advisory Committee Paul Engbrecht, Chairman Tieszen Memorial Home 437 State Street Marion, SD 57043 605/648-3384

National Pharmaceutical Council

John Jones, Vice Chairman Division of Health, Medical & Laboratory Services Health Laboratory Building 615 E. 4th Street c/o 500 E. Capitol Avenue Pierre, SD 57501 605/773-3737 Jud Bergan, O.D. 103 South Eagan Madison, SD 57042 Sheryl Petersen 218 W. Third Street Pierre, SD 57501 James D. M. Russell Hospital Admin. St. Mary's Hospital 803 E. Dakota Pierre, SD 57501 605/224-3100 Herb McClellan, Jr., D.D.S. Box 189 Mobridge, SD 57601-0189 Lynn Greff Apothecary Shop at Medical Arts 719 St. Francis Street Rapid City, SD 57701 Stephen Schroeder, M.D. Hand Co. clinic P.O. Box 287 Miller, SD 57362 Michelle Miller McKennan Home Health 800 E. 21st Street Sioux Falls, SD 57105-1016 A.A. Lampert, M.D. 13075 Bogus Jim Road Rapid City, SD 57702-9720 Evaluation Committee V. R. Brandenburg, M.D. Dennis Hodge, Pharm.D. Helen Fiechtner, Pharm.D. Jane Mort, Pharm.D. James Clem, Pharm.D. Marc Aldrich (Physician)

South Dakota-3

Pharmaceutical Benefits 2000 Executive Officers of State Medical and Pharmaceutical Societies South Dakota State Medical Association Robert D. Johnson Chief Executive Officer 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 State Board of Pharmacy Dennis Jones Secretary 4305 S. Louise Ave., Ste. 104 Sioux Falls, SD 57106 605/362-2737 South Dakota Association of Healthcare Organizations Frank M. Drew President 3708 Brooks Place Ste. 1 Sioux Falls, SD 57106 605/361-2281

4-South Dakota

National Pharmaceutical Council

Pharmaceutical Benefits 2000

TENNESSEE -- TennCare In 1994, Tennessee made history by withdrawing from the Medicaid Program and implementing an innovative new health care reform plan called TennCare. TennCare replaced the existing Medicaid Program with a program of managed health care. TennCare required no new taxes and extended health coverage not only to the nearly 800,000 Tennesseans in the Medicaid population, but also to an approximately 400,000 uninsured or uninsurable persons using a system of managed care. Enrollment was open in 1994 to eligible persons in the uninsured, uninsurable, and Medicaid-eligible categories. On January 1, 1995, TennCare reached 90% of its target enrollment and closed enrollment in the uninsured category. However, on April 1, 1997, enrollment in the uninsured category re-opened to children under the age of 18 who do not have access to health insurance through a parent or guardian. On May 21, 1997, TennCare enrollment became available for eligible dislocated workers. Enrollment remains open to persons and their dependents who have lost access to a COBRA insurance plan and do not have access to other health insurance. In an effort to expand coverage to more of Tennessee's uninsured children, the Bureau of TennCare opened enrollment on January 1, 1998 to uninsured Tennesseans under the age of nineteen (19) with access to health insurance whose individual family incomes are below 200% of the poverty level. Effective January 1, 1998, uninsured children under age nineteen (19) who meet the TennCare criteria for uninsured are being allowed to enroll in TennCare indefinitely. The Bureau of TennCare eliminated deductibles and limited co-payments to 2% for these new eligibility populations and all uninsured children under eighteen (18) years of age who enrolled in TennCare during previous open enrollment periods. Enrollment remains open to persons who are Medicaideligible or who are uninsurable as determined by an insurance company's denial (for medical reasons) of health insurance to the individual. Current enrollment (5/30/00) is approximately 1,316,216, of which 795,968 are Medicaid eligibles and 520,248 are in the uninsured/uninsurable categories. 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 Security Act. State rules were promulgated to assist in administering the statewide program (TSOP). The initial five-year demonstration project ended December 31, 1998. HCFA approved a waiver extension for three years beginning January 1, 1999 through December 31, 2001.

National Pharmaceutical Council

TennCare services are offered through managed care organizations (MCOs) and behavioral health organizations (BHOs) under contract with the State. These MCOs, spread out over the twelve regions of Tennessee, are paid a fixed amount which averages $116 per enrollee per month for the MCO services. BHOs are paid $319.41 for priority participants and a variable rate for all other TennCare enrollees and state onlys. The MCOs and BHOs negotiate payment rates with individual providers. Enrollees have a choice of MCOs (and their corresponding BHO partner plan) from those available in their geographic area. Effective January 1, 1997, all services are delivered within a strict "gatekeeper" model system requiring primary care providers to manage enrollees' health care. TennCare services, as determined medically necessary by the MCO, cover inpatient and outpatient hospital care, physician services, prescription drugs, lab and x-ray services, medical supplies, home health care, hospice care, and ambulance transportation. Excluded from TennCare managed care services are long-term care services and Medicare cross-over payments which are continuing as they were under the former Medicaid system. TennCare is financed by pooling current federal, state and local expenditures for indigent health care, which include $2.4 billion for the TennCare/Medicaid Program in the 1998-99 fiscal year's budget. Pooled resources total $3.779 billion, including $226 million in local Certified Public Expenditures. Within this budget, $1.418 billion is identified as funding for long-term care programs, Home and Community Based Services Waiver programs, Medicare cross-overs through the Medicaid system, Medicare premiums, and administration for the total program. The remaining $2.361 billion has been identified to fund the current year of the TennCare Program. In the future, competition among managed care networks, combined with the enrollment cap, should enable TennCare to grow at a predictable rate not exceeding the annual rate of growth in state spending. Source: TennCare Home Page on the World Wide Web, last updated 08/09/00. http://www.state.tn.us/tenncare/

ELIGIBILITY FOR TENNCARE COVERAGE Currently, Medicaid eligible persons, children under age 19 with no access to health insurance, dislocated workers who previously had health insurance through employers 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 Tennessee-1

Pharmaceutical Benefits 2000 provide proof of uninsurability, one must have a letter of denial from an insurance company, on company letterhead stationary, that is licensed in the State of Tennessee. The TennCare applicant may then send in their application along with a copy of this letter to the address provided on the TennCare application. Someone is not uninsurable if they cannot afford health insurance. Someone is not a dislocated worker if they are laid-off or terminated at a plant that continues to operate. The Tennessee Department of Human Services makes decisions for most Medicaid eligibility categories. The Social Security Administration makes decisions regarding eligibility for Medicaid for disabled individuals. The Tennessee Department of Labor determines bona fide closures of businesses or plants. In some TennCare eligibility categories, persons may be eligible in cases where COBRA coverage is offered. In some TennCare eligibility categories, persons may not be eligible until their opportunity to purchase COBRA coverage has expired. Contact the TennCare Hotline with questions. A TennCare application can be received by calling the TennCare Hotline at 1-800-669-1851 or by visiting the local Tennessee Department of Health office. There is a local Health Department office in every Tennessee county. For the applicants' convenience, the Health Department will make a copy of the application, date stamp it, and keep it on file. If the applicant mails the application from their home, they should keep a copy for their personal files. Source: TennCare Home Page on the World Wide Web, last updated 08/07/00. http://www.state.tn.us/tenncare/

A. ADMINISTRATION Tennessee Department of Health, Bureau of TennCare

B. PROVISIONS RELATING TO DRUGS Benefit Design Pharmacy services are provided by the managed care organizations. Pharmacy services are to be covered as medically necessary, excluding DESI, less than effective and IRS drugs and some drugs for which TennCare does not mandate coverage (e.g., drugs for infertility, weight reduction, cosmetic purposes, hair growth products, products for symptomatic relief of cough and colds, smoking cessation products, and most OTCs). Growth hormone products and oral contraceptives require approval by the TennCare Prior Approval Unit. While the MCOs may participate in the drug rebate program, the State does not.

2-Tennessee

Formulary: Varying formularies used by the individual MCOs. Most are closed formularies. MCO formularies must conform to TennCare guidelines. TennCare must approve formulary additions/deletions. Prior Authorization: Prior authorization procedures are administered by the individual MCOs. Copayment: Deductibles and copayments apply to services other than preventive services (e.g., immunizations) based on a sliding scale according to income. Medicaid recipients and persons or families with income under 100% of the federal poverty level are not required to pay premiums, deductibles, or copayments in order to participate in the TennCare program.

C. USE OF MANAGED CARE Medicaid recipients and the uninsured/uninsurable are enrolled in MCOs through the TennCare program. All receive pharmacy benefits through managed care. Managed Care Organizations Heritage National Health Plan of Tennessee, Inc. (John Deere Health Care/ Heritage National Health Plan) Executive Tower I, Ste. 400 408 N. Cedar Bluff Road Knoxville, TN 37923 Memphis Managed Care Corporation (TLC Family Care Healthplan) P.O. Box 49 Memphis, TN 38101 OmniCare Health Plan, Inc. 1991 Corporate Ave. 5th Floor Memphis, TN 38132 Preferred Health Partnership of Tennessee, Inc. 1420 Centerpoint Blvd. Knoxville, TN 37932 Tennessee Managed Care Network (Access...MedPlus) 210 Athens Way Nashville, TN 37228 Xantus Health Plan of Tennessee, Inc. 3401 West End Ave., Ste. 470 Nashville, TN 37203 VUMC Care, Inc. (VHP Community Care) 210 Westwood Place, Ste 200 Brentwood, TN 37027 National Pharmaceutical Council

Pharmaceutical Benefits 2000 MCO/BHO "Partners" Premier Behavioral Systems of Tennessee (800-3257864) • Blue Care (except in East Tennessee and Knox County) • John Deere Health Plan • OmniCare Health Plan • Xantus Gold • VHP Community Care Tennessee Behavioral Health, Inc. (800-447-7242) • Access...Med Plus • Blue Care (in East Tennessee and Knox County) • Preferred Health Partnership (PHP) • Prudential Community Care • TLC Family Care Healthplan

Pharmacy and Therapeutics Committee – – – – – – – – –

Director of the Bureau of TennCare TennCare Medical Director TennCare Pharmacy Director TennCare Associate Medical Director Associated Medical Director of the TennCare Grievance Unit Medical Director of the TennCare Grievance Intervention Unit One Public Health Physician One Physician who is a TennCare participating provider One Pharmacist who is a TennCare participating provider

Each MCO is required to have its own Pharmacy and Therapeutics Committee.

D. STATE CONTACTS State Drug Program Administrator Leo Sullivan, D.Ph. Director of Pharmacy Services Bureau of TennCare 729 Church Street Nashville, TN 37243 T: 615/741-8155 F: 615/532-3479 TennCare Officials Karen Oldham, M.D., C.M.C.M. Chief Medical Officer, Bureau of TennCare 729 Church Street Nashville, TN 37243 T: 615/253-3262 F: 615/741-0064 Susie Baird Director of Programs Ken Okolo, FACHE Directory of Quality Oversight

Pharmaceutical Care Advisory Board A statewide TennCare Pharmaceutical Care Advisory Board is being created. Board members are to be appointed by the Commissioner of Health. Executive Officers of State Medical and Pharmaceutical Societies Tennessee Medical Association Donald H. Alexander 2301 21st Avenue, S. P.O. Box 120909 Nashville, TN 37212-0909 615/385-2100 State Board of Pharmacy Kendall M. Lynch, Director Volunteer Plaza, Second Floor 500 James Robertson Parkway Nashville, TN 37243-1149 615/741-2718

Keith Gaither Fiscal Director Office of Business, Finance & Research Joanna Damons Division of Long Term Care TennCare Information Line 800-669-1851 Claims Submission Contact Consultec, Inc. T: 877/296-1935 National Pharmaceutical Council

Tennessee-3

Pharmaceutical Benefits 2000 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

Pharmaceutical Benefits 2000

TEXAS A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

OAA

AB

APTD

AFDC

Prescribed Drugs







Inpatient Hospital Care





Outpatient Hospital Care



Laboratory & X-ray Service

OAA

AB

APTD

Other

AFDC

Children <21





































Skilled Nursing Home Services













Physician Services













Dental Services









SFO

1

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998 Expended $817,591,112

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult

$484,567,470 $148,567,470 $254,181,888 $41,448,918 $34,025,698 $3,946,327 $2,948,361

804,227 156,181 229,124 265,634 116,765 22,624 13,899

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult

$9,740,942 $0 $0 $3,806,777 $5,934,165

25,564 0 0 6,185 19,379

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

$103,719,857 $497,968 $416,683 $92,122,948 $10,682,258

708,576 865 625 597,641 109,445

OTHER

$219,562,843

356,080

Recipients 1,894,447

1999* Expended Recipients

Source: HHS State HCFA-2082 Reports, Section A-4 and B-4. *1999 recipient data broken down by maintenance assistance status and basis of eligibility are unavailable.

National Pharmaceutical Council

Texas-1

Pharmaceutical Benefits 2000

C. ADMINISTRATION

Formulary/Prior Authorization

Texas Department of Health. Vendor drug program was implemented September 1, 1971.

Formulary: Open formulary; however, products must be listed in the Texas Drug Code Index. General exclusions (diseases, drug categories, etc.) include: amphetamines, appliances, durable medical equipment (bedpans, etc. either rental or purchase), elastic stockings, first aid supplies, medical supplies, oxygen, supports and suspensories, and trusses.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles (pen needles only) and syringe combinations used for insulin. Products not covered: cosmetics; fertility drugs; experimental drugs; total parenteral nutrition; and interdialytic parenteral nutrition; blood glucose test strips; urine ketone test strips. Prior authorization required for: human growth hormones and dextramphetamines. Over-the-Counter Product Coverage: Products covered: feminine products; topical products; allergy, asthma, and sinus products; analgesics; cough and cold preparations; digestive products (non-H2 antagonist); smoking deterrent products; digestive products (H2 antagonists). Certain OTC drugs are covered on a prescription basis except as otherwise provided in the reimbursement formula and vendor payment to hospitals, nursing homes and institutions. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; authorization: analgesics, antipyretics, NSAIDs; anticoagulants; anticonvulsants; anti-depressants; antidiabetic drugs; antihistamine drugs; antilipemic agents; antipsychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; prescribed cold mediation; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc. GI drugs; thyroid agents; prescribed smoking deterrents; and sympathominetics (adrenergic). Prior authorization required for: growth hormones. Therapeutic categories not covered: anorectics. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities and through physician payment when used in physicians offices. Vaccines: Vaccines reimbursable as part of EPSDT service, not under the Vendor Drug program. Unit Dose: Unit dose packaging reimbursable only when there is not an added expense for the packaging.

Prior Authorization: Prior authorization procedure screening for drug classes and individual drugs. Prescribing or Dispensing Limitations Prescription Refill Limit: Five refills, but total amount may not exceed 6-month supply. Monthly Quantity Limit: Prescribed quantity cannot exceed 6-month supply. Monthly Prescription Limit: Limited to 3 per month except for recipients under age 21 and nursing home recipients. Other Limit: Recipients in managed care pilots receive unlimited prescription coverage. Drug Utilization Review PRODUR system implemented in February 1995. State currently has a DUR board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $5.27 +2%. The dispensing fee, including all costs of filling a prescription, was established by cost accounting and service evaluation of the expenses involved in dispensing a prescription. Therefore, fees paid to providers who experience different cost and service factors considered in arriving at the fee may receive more or less than actual costs incurred in dispensing. Ingredient Reimbursement Basis: EAC = AWP-15% or WAC + 12%, whichever is lower, AAC for hospitals and public health providers. Prescription Charge Formula: Average dispensing expense (ADE) formula for payment: 1. 2.

(EAC + 5.27) divided by 0.980 = amount paid + $0.15 delivery service. 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

Pharmaceutical Benefits 2000 plus 50% of cost, whichever is lower; 50% of cost not to exceed assigned variable dispensing fee.

Debbie Blount Deputy Commissioner for Health Care Financing

Maximum Allowable Cost: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. 465 drugs are listed on the state-specific MAC list. Override requires “Brand Necessary” or “Brand Medically Necessary.”

Prior Authorization Contact

Incentive Fee: None. Cognitive Services: Does not pay for cognitive services. Patient Cost Sharing: No copayment.

E. USE OF MANAGED CARE An undisclosed number of Medicaid recipients are enrolled in MCOs (all of whom are AFDC/AFDC related). Managed Care Organizations Physician Corporation of America 8303 Mopac, Ste. 450 Austin, TX 78759-8370 Vista, Inc. 9310 North Lomar Austin, TX 78753 Primary Care Case Management

F. STATE CONTACTS State Drug Program Administrator

Barbara Dean, R.Ph. Pharmacist III Texas Department of Health 1100 W. 49th Street Austin, TX 78756-3174 512/338-6920 E-mail: [email protected] Vendor Drug Program Martha McNeill, R.Ph. Director, Product Enrollment Division Texas Department of Health 1100 W. 49th Street Austin, TX 78756-3174 512/338-6965 E-mail: [email protected] Patsy Napier, R.Ph. Pharmacy Field Coordinator 512/338-6992 DUR Contact Curtis Burch, R.Ph. Director, Drug Utilization Review Division Texas Department of Health 1100 W. 49th Street Austin, TX 78756-3174 T: 512/338-6922 F: 512/338-6910 E-mail: [email protected]

Robert Harriss, Director Texas Department of Health 1100 W. 49th Street Austin, TX 78756 T: 512/338-6961 F: 512/338-6910

DUR Board

Department of Health Officials

Leroy Knodel, Pharm.D., Vice Chairman Drug Information Service Department of Pharmacology The University of Texas Health Science Center 7703 Floyd Curl Drive San Antonio, TX 78284-7766

Reyn Archer, M.D. Commissioner Texas Department of Health 1100 W. 49th Street Austin, TX 78756 Linda Wertz Medicaid Director Texas Health & Human Services Commission P. O. Box 13247 Austin, TX 78711 512/502-3200

National Pharmaceutical Council

Robert Barr, M.D., R.Ph. Chairman 2414 Florence Avenue Pasadena, TX 77502

Thomas Lee Kurt, M.D., M.P.H. 3645 Stratford Avenue Dallas, TX 75205

Texas-3

Pharmaceutical Benefits 2000 Mark S. Gittings, D.O., R.Ph. 4327 Grants Glen Wichita Falls, TX 76309 Robert L. Hogue, M.D. 101 A South Park Drive Brownwood, TX 75801 Daniel Saylak, D.O. 4607 Locksford Bryan, TX 77802

Medicaid Managed Care Contact Susan P. Milam, Ph.D. Chief, Bureau of Managed Care Texas Department of Health 1100 W. 49th Street Austin, TX 78756 T: 512/794-6836 www.tdh.state.tx.us/hcf/mcstart.htm Physician-Administered Drug Program Contact

Mary Spies Maxwell, M.D. 4526 Burnet Road Austin, TX 78731

Rodger Love, Director 1100 W. 49th Street Austin, TX 78756-3168 512/338-6505

Adelina Barbosa, R.Ph. #10 Casa De Palmas Brownsville, TX 78521

Executive Officers of State Medical and Pharmaceutical Societies

Anita Martinez, R.Ph. 2819 Burning Hill San Antonia, TX 78247 James B. Hills, R.Ph. Lava Rock Apothecary 1907 E. Southmore Street Pasadena, TX 77502 Robert T. Reilly, Pharm.D. Thomason Hospital Department of Pharmacy 4815 Alameda Avenue, P. O. Box 2009 El Paso, TX 79998 W. Perry Flowers 6607 Sandie Dr. Amarillo, RX 79109 Prescription Price Updating Martha McNeill, R.Ph. 512/338-6965 Medicaid Program Contacts Technical: Matt Sneed, 512/231-5604 (claims) Policy: Patricia Gladden, 512/338-6967 Rebate: Heather Murphy, 512/338-6963 Claims: Patsy McElroy, 512/338-6909

Texas Medical Association J. James Rohack, M.D. President 401 W. 15th Street Austin, TX 78701-1680 512/370-1300 Texas Pharmaceutical Association Lonnie Hollingsworth, R.Ph. Interim Executive Director P. O. Box 14709- 1624 E. Anderson Lane Austin, TX 78761-4709 512/836-8350 Texas Osteopathic Medical Association Terry Boucher Executive Director, Secretary/Treasurer 1415 Lavaca Austin, TX 78701-1634 (512) 708-8662 State Board of Pharmacy Gay Dodson Executive Director/Secretary William P. Hobby Building Ste. 3-600 333 Guadalupe St. Box 21 Austin, TX 78701-3942 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

Pharmaceutical Benefits 2000

UTAH A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 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

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $68,827,853 126,953

1999* Expended Recipients

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 Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients MEDICALLY NEEDY TOTAL Aged Blind/Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients Source: HHS State HCFA-2082 Reports, Section A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

National Pharmaceutical Council

Utah-1

Pharmaceutical Benefits 2000

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 antiulcer drugs. Products not covered: hair growth products.

Prescribing or Dispensing Limitations

Over-the-Counter Product Coverage: Products covered: − − − − − − − − − − − − − − − − − − − − −

Acetaminophen, All dosage forms Acetone tests (e.g., Acetest, Chemstrip-K, Ketostix) Antacid liquid and tablets Aspirin, All dosage forms Contraceptive creams, foams, tablets and sponges DSS caps liquid and syrup DSS concentrate drops 5% Ferrous fumerate, All dosage forms Ferrous gluconate, All dosage forms Ferrous sulfate, All dosage forms Glucose blood tests (e.g., Chemstrip, BG, Dextrostix, Visidex) Glucose urine tests (e.g., Clinitest, Clinistix, Diatrix, Tes Tape, Chemstrip G) Insulin Insulin syringes/needles/disposable Kaolin w/pectin suspension (e.g., Kaopectate) Lactobacillus acidophilus (e.g., Bacid, Lactinex) Nutrients (all nutrients require prior approval) Pedialyte liquid Prophylactics male Psyllium muciloid powder Quinine, 5 gr.

Products not covered: vitamins (except for expectant mothers and children to age 5); smoking deterrent products; and Therapeutic Category Coverage: Products not covered: anorectics (except for amphetamines and derivatives only for specific indications of narcolepsy and hyperkinesis).

Prescription Refill Limit: Limited to five. Monthly Quantity Limit: In general, the quantity of medication shall be limited to a supply not to exceed 30 days. Drug Utilization Review PRODUR system implemented in June 1995. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.90 for urban, $4.40 for rural, effective 1993. Ingredient Reimbursement Basis: EAC = AWP - 12%. Prescription Charge Formula: Lowest of: 1. 2.

EAC/MAC plus a dispensing fee, or Usual and customary charges to the private sector for legend and generic legend drugs.

Formula for OTCs is AWP minus 12% plus $1.00 dispensing fee. Maximum Allowable Cost: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. Override requires “Brand Medically Necessary.” Incentive Fee: None. Patient Cost Sharing: Copayment = $1.00, maximum is $5.00 per month.

Coverage of Injectables: Injectable medicines reimbursable when used in home health care, and extended care facilities, and through physician payment.

Cognitive Services: Does not pay for cognitive services.

Vaccines: Vaccines reimbursable at AWP minus 12% plus a fee as part of the EPSDT service, Children Health Insurance Program, and the Vaccines for Children Program.

An unavailable number of Medicaid recipients are enrolled in managed care; however the number of enrollees is listed for some of the following MCOs. The pharmacy benefits are through the state.

2-Utah

E. USE OF MANAGED CARE

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Managed Care Organizations Altius 10421 S. Jordan Gateway South Jordan, UT 84095 American Family Care 2120 South 13th East #303 Salt Lake City, UT 84106 IHC Access P.O. Box 116670 Salt Lake City, UT 84147 Med Utah Healthwise P.O. Box 30804 Salt Lake City, UT 84130-0804 PHS 35 West Broadway Salt Lake City, UT 84101 United Medchoice 7910 South 3500 East Salt Lake City, UT 84121 U of U Health Network 35 W. Broadway Salt Lake City, VT 84101

F. STATE CONTACTS State Drug Program Administrator RaeDell Ashley Pharmacy Director Division of Health Care Financing Department of Health 288 N. 1460 West Salt Lake City, UT 84114-2906 T: 801/538-6495 F: 801/538-6099 DUR Board Dennis Beasley, R.Ph. 76 North 1100 East American Fork, UT 84003 801/756-5866 Lowry Bushnell, M.D. University of Utah Neuropsychiatric Institute 501 Chipeta Way Salt Lake City, UT 84108 801/584-2034

National Pharmaceutical Council

Carter Burke Hoechst Marion Roussel 1912 Lawrence Circle South Jordan, UT 84065 801/254-9026 Jeff Coursey 774 5th Avenue Salt Lake City, UT 84103 801/537-7219 Larry Dent, Pharm.D. 11756 S. Briarglen Drive Sandy, UT 84092 801/571-4155 Terry Frank, R.Ph. Apothecary Shoppe 1002 East South Temple Salt Lake City, UT 84102 Bradford D. Hare, M.D. Department of Anesthesiology 50 North Medical Drive Salt Lake City, UT 84132 801/585-7246 Jeff Jones, R.Ph. Riverton Drug 1741 West 12600 South Riverton, UT 84065 801/254-3911 Richard Martinez, D.D.S. 2936 Highland Drive Salt Lake City, UT 84106 801/467-6555 J. Brent Muhlestein, M.D. Department of Cardiology Eighth Avenue and C Street Salt Lake City, UT 84143 801/321-5013 Lynda Oderda, Pharm.D. Assistant Professor (Clinical) Department of Pharmacy Practice University of Utah College of Pharmacy Salt Lake City, UT 84112 801/581-6304 Rodney A. Pollary, M.D. Nighttime Pediatrics Attention: Lynda Stuart 7001 S. 900 E. Ste. 400 Midvale, UT 84047-1761 801/256-6483

Utah-3

Pharmaceutical Benefits 2000 John M. Tudor, Jr., M.D. Cigna Healthcare of Utah 5295 South 320 West Ste. 280 Salt Lake City, UT 84107 801/261-7502 Medicaid Drug Rebate Contacts Technical: RaeDell Ashley, 801/538-6495 Policy: RaeDell Ashley, 801/538-6495 PA: RaeDell Ashley, 801/538-6495 DUR: Duane Parke, 801/538-6495 Physician-Administered Drug Program Contact

State Board of Pharmacy Theresa Whitney 160 E. 300 South P.O. Box 45802 Salt Lake City, UT 84145 801/530-6740 Utah Association of Healthcare Providers Richard B. Kinnersley President 127 South 500 East Ste. 625 Salt Lake City, UT 84102 801/364-1515

RaeDell Ashley Division of Health Care Financing Department of Health 288 N. 1460 West Salt Lake City, UT 84114-2906 801/538-6495 Department of Health Officials Rod Betit, MD Executive Director Department of Health 288 N. 1460 West Salt Lake City, UT 84116 801/538-6151 Executive Officers of State Medical and Pharmaceutical Societies Utah State Medical Association J. Leon Sorenson Executive Director 540 East 500 South Salt Lake City, UT 84102 801/355-7477 Utah Pharmaceutical Association C. Neil Jensen Executive Director 1062 East 21st St. S., Ste. 212 Salt Lake City, UT 84106 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

Pharmaceutical Benefits 2000

VERMONT A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 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

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998 Expended $43,445,887

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult

$19,492,508 $2,902,730 $15,354,411 $450,223 $723,299 $20,536 $21,409

19,702 2,146 9,295 5,058 2,754 315 138

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult

$4,238,401 $1,155,290 $2,504,106 $207,975 $371,029

4,630 504 1,174 1,378 1,274

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

$13,092,099 $7,569,978 $4,295,028 $875,242 $351,851

24,197 7,308 2,357 9,514 5,018

$5,053,540

8,019

OTHER

Recipients 58,307

1999* Expended Recipients

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

Vermont-1

Pharmaceutical Benefits 2000

D. PROVISIONS RELATING TO DRUGS

Monthly Quantity Limit: Initial prescription should be sufficient to allow for the determination of the patient’s tolerance of the medication without creating unnecessary waste (expense) to the program. This quantity could be up to a 60-day supply on all maintenance medication prescriptions.

Benefit Design

Drug Utilization Review

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: cosmetics and experimental drugs.

PRODUR system implemented in November 1993. State currently has a DUR board with a bimonthly review.

Over-the-Counter Product Coverage: Products covered with prior authorization: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products (H2 antagonists); feminine products; topical products; and smoking deterrent products.

Ingredient Reimbursement Basis: EAC = AWP – 11.9%.

C. ADMINISTRATION Agency of Human Services.

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; anorectics; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: prescribed smoking deterrents. Coverage of Injectables: Injectable medicines reimbursable when used in physician offices, home health care, and extended care facilities. Vaccines: Reimbursable at AWP minus 10% as part of EPSDT service.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.25, effective 7/1/96.

Prescription Charge Formula: Pharmacies bill their usual and customary charge. Medicaid pays the lower of: 1. 2. 3.

Usual and customary charge; EAC plus a dispensing fee; or Maximum allowable cost plus a dispensing fee.

Maximum Allowable Cost: State imposes Federal Upper Limits and State-specific limits on generic drugs. Override requires “Dispense as Written.” Incentive Fee: None. Patient Cost Sharing: Copayment of $1.00 per dispensation required (excluding standard federal exemptions). Copayment of $2.00 when ingredient cost exceeds $29.99. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE

Unit Dose: Unit dose packaging reimbursable.

!""#$%&'()*+,-JI0J;.-)$)(+-3*4&5(&4-#*5&"&*6)7-(#* *6#$++*4-&6-3BC7<--K$6*-#*5*&=*4-">(#'(5,-7*#=&5*7 )>#$?9>-'(6(9*4-5(#*<-

Formulary/Prior Authorization

F. STATE CONTACTS

Formulary: Open formulary. General exclusions include cosmetics and experimental drugs.

State Drug Program Administrator

Prior Authorization: Prior authorization procedure screening for drug classes. PA is required for nonpregnancy multi-vitamins, smoking deterrents, amphetamines, food supplements, and OTC drugs. Prescribing or Dispensing Limitations

Pat House Operations Manager Office of Vermont Health Access 103 South Main Street Waterbury, VT 05671 T: 802/241-2765 F: 802/241-2974 E-mail: [email protected]

Prescription Refill Limit: Up to 5 may be authorized by a physician.

2-Vermont

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Agency of Human Services Officials Jane M. Kitchel Secretary Agency of Human Services 103 South Main Street Waterbury, VT 05650-1201 802/241-2880 Eileen Elliott Commissioner Department of Social Welfare John Dick Policy & Procedures 802/241-2880 Prior Authorization Contact Pat House 802/241-2765 DUR Contact Gloria Jacobs Operations Administrator Office of VT Health Access 103 S. Main St. Waterbury, VT 05671 T: 802/241-2763 F: 802/241-2974 E-mail: [email protected]

Dr. Virginia Hood UVM, Nephrology Unit FAHC, Burgess 318 111 Colchester Ave Burlington, VT 05156 Prescription Price Updating Christine Dapkiewicz Drug Rebate Coordinator 312 Hurricane Lane Williston, VT 05495 T: 802/879-4450 F: 802/878-3440 Medicaid Drug Rebate Contacts Technical: Christine Dapkiewicz, 802/979-4450 Policy: Vacant Disputes: Shona M. Lothrop, 802/879-4450 Claims Submission Contact EDS Fiscal Agent 312 Hurricane Lane, Ste 101 Williston, VT 05495 T: 802/879-4450 F: 802/878-3440 Medicaid Managed Care Contact Pat House 802/241-2765

DUR Board John Low, R.Ph. Chairman 10 Greenbriar Dr. Essex Junction, VT 05452 Richard Harvie, R.Ph. Brooks Pharmacy 60 Main Street Montpelier, VT 05602 Norman Ward, M.D. P.O. Box 1150 Burlington, VT 05402 Dr. James Gray 253 Stratton Road Rutland, VT 05701 Dennis Fortier, R.Ph. Pharmacy Department Springfield Hospital 25 Ridgewood Road Springfield, VT 05156

National Pharmaceutical Council

Disease Management Initiative/Program Contact Shona Mossey-Lothrop Pharmacy Consultant EDS 312 Hurricane Lane, Ste 101 Williston, VT 05495 T: 802/879-4450 F: 802/878-3440 E-mail: [email protected] Expanded Drug Coverage Program Contact Pat House 802/241-2765 Physician-Administered Drug Program Contact Dr. Joseph Jacobs Medical Director Office of Vermont Health Access Department of Social Welfare 103 South Main Street Waterbury, VT 05650-1201 802/241-2745

Vermont-3

Pharmaceutical Benefits 2000 Executive Officers of State Medical and Pharmaceutical Societies 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 Montpelier, VT 05602 802/229-9418 State Board of Pharmacy 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 Montpelier, VT 05602 802/223-3461

4-Vermont

National Pharmaceutical Council

Pharmaceutical Benefits 2000

VIRGINIA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

Other

OAA

AB

APTD

AFDC

OAA

AB

APTD

AFDC

Children <21

Prescribed Drugs



















Inpatient Hospital Care



















Outpatient Hospital Care



















Laboratory & X-ray Service



















Skilled Nursing Home Services



















Physician Services



















Dental Services

SFO

All eligible recipients under age 21

1

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998* Expended Recipients $284,578,558 383,880

1999* Expended Recipients

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 Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients MEDICALLY NEEDY TOTAL Aged Blind Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients Source: HHS State HCFA-2082 Reports, Section A-4 and B-4. *1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

National Pharmaceutical Council

Virginia-1

Pharmaceutical Benefits 2000

C. ADMINISTRATION

Ingredient Reimbursement Basis: EAC = AWP - 9%.

Department of Medical Assistance Services. Eligibility determination by the Department of Social Services.

Prescription Charge Formula: Based upon the lower of MAC or EAC plus a fee if legend, or the usual and customary charge minus an applicable copayment.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products not covered: fertility drugs; hair growth products; designated DESI drugs; experimental drugs; non-legend drugs; and expired drugs. Over-the-Counter Drug Coverage: A majority of OTC drugs reimbursable when used in nursing homes and certain classes in outpatient populations. Therapeutic Category Coverage: Prior authorization required for: amphetamines and growth hormones. Coverage of Injectables: Injectable medicines reimbursable through physician payment when used in physician offices (through physician payment), home health care, and extended care facilities. Vaccines: Vaccines reimbursable based on HCPCS code as part of the Health Department and Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable in nursing homes. Formulary/Prior Authorization Formulary: Open formulary. Prior Authorization: Prior authorization procedure screening for individual drugs. Prescribing or Dispensing Limitations 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 supply, or 100 units or doses. Drug Utilization Review PRODUR system implemented in July 1994. Pharmacy Payment and Patient Cost Sharing

Maximum Allowable Cost: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. Override requires “Brand Necessary.” Incentive Fee: None. Patient Cost Sharing: Copayment is $1.00/Rx for all qualifying prescriptions. Exclusions include less than 21 years old, pregnancy related, family planning, and nursing home patients. Cognitive Services: Does not pay for cognitive services at present.

E. USE OF MANAGED CARE F*5&"&*6)7-#*5*&=*-">(#'(5*?)&5(+-A*6*2&)7-)>#$?9> '(6(9*4-5(#*-"+(67< 1) Medallion - primary care physicians, 2) Options - optional enrollment for recipients into HMOs, and 3) Medallion II - mandatory HMOs in the Tidewater region and the Richmond area.

F. STATE CONTACTS State Drug Program Administrator David B. Shepherd, R.Ph. Pharmacy Supervisor Division of Program Operations Department of Medical Assistance Services 600 East Broad Street, Ste. 1300 Richmond, VA 23219 T: 804/225-2773 F: 804/786-0414 Medicaid Drug Rebate Contacts Policy: David Shepherd, 804/225-2773 DUR: Marianne Rollings, 804/225-4268 Disputes: Mike Beahm, 804/225-3359 Physician-Administered Drug Program Contact Sally Rice 804/786-9490

Dispensing Fee: $4.25, effective 7/1/95.

2-Virginia

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Department of Medical Assistance Services Officials Dennis Smith Director Department of Medical Assistance Services 600 East Broad Street, Ste. 1300 Richmond, VA 23219 804/786-8099 Sally Rice Manager Provider Relations Division of Program Operations 804/786-9490 Executive Officers of State Medical and Pharmaceutical Societies Medical Society of Virginia Paul Kitchen Executive Vice-President 4205 Dover Road Richmond, VA 23221-3267 804/353-2721 Virginia Pharmaceutical Association Rebecca Smead Executive Director 5501 Patterson Ave., Ste. 200 Richmond, VA 23226

Fiscal Intermediary First Health Services P.O. Box 6987 Richmond, VA 23230 Virginia Medicaid Pharmacy Liaison Committee (PLC) Bill Hancock, R.Ph. Pharmacist Long Term Care Pharmacy Coalition Cindy Warriner, R.Ph. Pharmacist Community Pharmacy Coalition David Kozera, R.Ph. Pharmacist Virginia Association of Chain Drug Stores Rebecca Snead, R.Ph. Pharmacist Virginia Pharmacists Association Ellen Frank Government Relations Mtg. Pharmaceutical Research and Manufacturers of America

State Board of Pharmacy 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

Pharmaceutical Benefits 2000

WASHINGTON A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 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

See Appendix E, page E-29, for a list of acronyms. *Limited to children in foster care, subsidized adoption, SNH, IFC, ICMR or inpatient psychiatric facility.

B. EXPENDITURES FOR DRUGS

TOTAL

1998 Expended $244,478,658

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult

$150,637,488 $24,421,684 $120,847,808 $1,203,115 $3,447,197 $193,028 $524,656

149.823 20,484 77,084 21,981 21,817 3,580 4,877

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult

$21,855,285 $7,032,474 $14,817,475 $4,148 $1,188

10,368 5,164 5,167 25 12

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

$2,687,631 $435,200 $705,545 $1,052,246 $494,640

27,700 631 702 17,157 9,210

$69,224,013

86,103

OTHER

Recipients 274,463

1999* Expended Recipients

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Washington

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION

Formulary/Prior Authorization

Medical Assistance Administration, Department of Social and Health Services.

Formulary: Open formulary

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations for insulin; blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Products requiring prior authorization: Alzheimer drugs; MS drugs (betaseron); AIDS wasting drugs; non sedating histamines; and laxatives. Products not covered: cosmetics; fertility drugs; DESI drugs; and experimental drugs. Over-the-Counter Product Coverage: Products covered: digestive products (non-H2 antagonists) and smoking deterrent products. Products covered with restrictions: allergy, asthma and sinus products (selected items); analgesics (ASA and Acetaminophen); cough and cold preparations (selected items); feminine products (selected items); and topical products. Products not covered: digestive products (H2 antagonists). Therapeutic Category Coverage: Therapeutic categories covered: antibiotics; anticoagulants; anticonvulsants; antidiabetic agents; antilipemic agents; cardiac drugs; chemotherapy agents; contraceptives; ENT antiinflammatory agents; estrogens; hypotensive agents; sympathominetics (adrenergic); and thyroid agents. Therapeutic categories covered requiring prior authorization: anti-depressants; antihistamine drugs; antipsychotics; anxiolytics, sedatives, and hypnotics; prescribed cold medications; and misc. GI drugs. Therapeutic categories partially covered: anorectics. Therapeutic categories partially covered requiring prior authorization: anabolic steroids; analgesics, antipyretics, NSAIDs; and growth hormones. Therapeutic categories not covered: prescribed smoking deterrents and weight loss drugs. Coverage of Injectables: Injectable medicines reimbursable through the Physician Drug Program when used in home health care, extended care facilities and through physician payment when used in physician offices. Vaccines: Vaccines reimbursable at EAC as part of EPSDT service.

Prior Authorization: State currently has a prior authorization procedure and a Drug Utilization and Education Review Council. Recipients can request a fair hearing and exception to policy to appeal an excluded product or prior authorization decision. Prescribing or Dispensing Limitations Prescription Refill Limit: Two (2) refills in 30-day period except for antibiotics, anti-asthmatics, Schedule II and III drugs, anti-neoplastic, topicals, and any propoxyphene, which may have 4 refills. Monthly Quantity Limit: No maximums, minimum of 34day supply for maintenance medications. Drug Utilization Review PRODUR system implemented in March 1996. State currently has a DUR Board with a bi-monthly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.98 to $4.92, effective 7/1/99. − − − −

$3.98 - Retail pharmacies, filling over 35,000 Rxs annually. $4.26 - Retail pharmacies, filling 15,000-35,000 Rxs annually. $4.92 - Retail pharmacies, filling 15,000 or less Rxs annually. $4.92 - Unit dose systems (nursing home Rxs).

Ingredient Reimbursement Basis: EAC = AWP - 11%. Prescription Charge Formula: The amount shall not exceed the usual and customary charge to the public or EAC plus a dispensing fee. Any drug with more than 3 labelers will be reimbursed according to the Maximum Allowable Cost. Maximum Allowable Cost: State imposes State-specific limits on generic drugs. Override requires “Brand Medically Necessary.” Incentive Fee: None. Patient Cost Sharing: No copayment. Cognitive Services: Does not pay for cognitive services.

Unit Dose: Unit dose packaging is reimbursable.

National Pharmaceutical Council

Washington-2

Pharmaceutical Benefits 2000

E. USE OF MANAGED CARE Approximately 700,000 total unduplicated number of Medicaid recipients were enrolled in MCOs in FY 1999. Recipients receive pharmaceutical benefits through the state and managed care plans.

Regence Blue Shield 1800 Ninth Avenue PO Box 21267 Seattle, WA 98111-3267 206/464-3600

F. STATE CONTACTS

Managed Care Organizations Aetna US Healthcare of Washington 1400 One Union Square Seattle, WA 98101 Clark United Providers/SWMD 505 NE 87th Avenue, LL-46 Vancouver, WA 98664 800/325-7862 Community Health Plan of Washington 401 Second Avenue, Ste. 400 Seattle, WA 98104-2891 800/444-1561 Group Health Cooperative 12400 East Marginal Way South Seattle, WA 98111-3267 206/901-4424 Kaiser Foundation Health Plan of the Northwest 500 NE Multnomah, Ste. 100 Portland, OR 97232-2099 800/813-2000 Kitsap Physician Service P.O. Box 339 Bremerton, WA 98337 800/552-7114 Northwest Washington Medical Bureau 110 South 2nd PO Box 699 Mount Vernon, WA 98273-0699 Premera Blue Cross PO Box 327 Seattle, WA 98111-0327 Qual-Med Health Plan P.O. Box 3387 Bellevue, WA 98009-3387 (2331 130th Ave. NE, Ste. 200 Bellevue, Washington 98005) T: 800/423-9899 F: 800/869-7175

3-Washington

State Drug Program Administrator Siri Childs, Pharm D. Pharmacy Research Specialist Medical Assistance Administration, DSHS 805 Plum Street, SE P.O. Box 45506 Olympia, WA 98504-5506 T: 360/725-1564 F: 360/664-3884 E-mail: [email protected] Internet Agency Address: http://maa.dshs.wa.gov Prior Authorization Contact Siri Childs, 360/725-1564 DUR Contact Siri Childs, 360/725-1564 Department of Social and Health Services Drug Utilization and Education Council Council Members Marc Avery, M.D. 2704 “I” Street, NE Auburn, WA 98002 253/833-7444 Louis Saeger, M.D. 2500 Cherry Street, Ste. 103 Bremerton, WA 98310 360/373-9026 Gerald N. Yorioka, M.D. Co-Chair 805 164th SE, Ste. 100 Mill Creek, WA 98012 425/742-4242 Cara Marks, ARNP 2025 1st Avenue, Ste. 790 Seattle, WA 98121 206/663-1808

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Chris Wilkinson, PA-C 833 NW 54th Street Seattle, WA 98107 206/783-2061 Teri L. Ferreira, R.Ph. 13514 Lost Lake Road Snohomish, WA 98296 425/820-7600 Dana Hadfield, R.Ph. 507 6th Avenue South Edmonds, WA 98020 425/744-1793 Coordinating Staff Tom K. Hazlet, Pharm.D., Ph.D. School of Pharmacy University of Washington P.O. Box 357630 Seattle, WA 98195 206/616-2732 Siri Childs, Pharm D DUR Program Coordinator 805 Plum Street SE Olympia, WA 98504-5506 360/725-1564 Joan Baumgartner Medical Consultant MAA, P.O. Box 45540 Olympia, WA 98504-5540 360/586-5274 Tim Fuller, R.Ph. Board of Pharmacy 1948 Boyer Ave. East Seattle, WA 98112 360/753-6834 Support Staff Johnna Dodge 206/586-5269 Drug Utilization and Education Council Marc Avery, M.D. 2704 “I” Street NE Auburn, WA 98002 253/833-7444 Cara Marks, ARNP 2025 First Ave., Ste. 790 Seattle, WA 98121 206/663-1808 E-mail: [email protected]

National Pharmaceutical Council

Teri L. Ferreira, R.Ph. 13514 Lost Lake Road Snohomish, WA 98296 425/820-7600 E-mail: [email protected] Louis Saeger, M.D. 2500 Cherry, Ste. 103 Bremerton, WA 98310 360/373-9026 E-mail: [email protected] Chris Wilkinson, PA-C 833 NW 54th Street Seattle, WA 98107 206/783-2061 E-mail: [email protected] Gerald N. Yorioka, M.D. 805 – 164th SE, Ste. 100 Mill Creek, WA 98012 425/742-4242 E-mail: [email protected] Dana Hadfield, R.Ph. 507 – 6th Avenue South Edmonds, WA 98020 425/744-1793 Prescription Price Updating Marilyn Mueller Pharmacy Program Manager Medical Assistance Administrator-DSHS P.O. Box 45506 Olympia, WA 98504-5506 360/725-1569 E-mail: [email protected] Medicaid Drug Rebate Contacts Manager: Sue Hilton, 360/586-7179 Technical: Rich Boyesen, 360/586-2593 Policy: Geo Sego, 360/753-4259 Audits/Disputes: George Sego, 360/753-4259 PA: Gini Egan 360/664-8140 Claims Submission Contact Chris Johnson Claims Processing Manager Medical Assistance Administrator-DSHS P.O. Box 45506 Olympia, WA 98504-5506 T: 360/725-1067 F: 360/586-4994 E-mail: [email protected]

Washington-4

Pharmaceutical Benefits 2000 Medicaid Managed Care Contact Diane Weeden Director Division of Program Support- MAA/DSHS 805 Plum St. S.E. Olympia, WA 98504-5506 T: 360/725-1786 F: 360/753-7315 E-mail: [email protected] Disease Management Program/Initiative Contact Siri Childs, 360/725-1564 Social and Health Services Department Officials Lyle Quasim Secretary Department of Social and Health Services PO Box 44 Olympia, WA 98504 Tom Bedell Assistant Secretary Medical Assistance Administration P.O. Box 5500 Olympia, WA 98504-5500 (Vacant) DRI Medical Director Office of the Medical Director P.O. Box 5506 Olympia, WA 98504-5506 Social and Health Services Department Medical Consultants Full-time: Joan Baumgartner, MD Sam Salama, M.D. Nancy Anderson, M.D. Eric Houghton, M.D. Part-time: James B. Hutchinson, DDS (Dental) Kevin Moss (Orthodontia) Jerrol R. Neupert, MD (Ophthalmology) Department of Social and Health Services Title XIX Advisory Committee Janet Varon, Co-chair 3303 E. Howell Seattle, WA 98122

5-Washington

Robert Wardell, Co-chair 3815 N. Pearl Apt. K-1 Tacoma, WA 98407 Elise Chayet Harborview Medical Center 325 Ninth Avenue Seattle, WA 98104-2499 Ted Rudd, M.D. 307 S. 12th Avenue #12 Yakima, WA 98902 Andy Anderson Family Health Center P.O. Box 1340 Okanogan, WA 98840 509/422-1925 Errol Fife, DDS 3999 Englewood Yakima, WA 98902 509/577-8277 Tom Price P.O. Box 339 Bremerton, WA 98337 360/478-2608 Janene Jones-Heino 12856 NE Central Valley Road Poulsbo, WA 98370 360/377-3753 Maxine Hayes, M.D. Department of Health MS: 7880 Olympia, WA 98504 206/753-7021 Jane Beyer Assistant Secretary Medical Assistance Administration P.O. box 45080 Olympia, WA 98504-5080 Linda Casten PO Box 5200 Tacoma, WA 98415-0200 Bonnie Kostelecky 2000 Fort Vancouver Way Vancouver, WA 98663

National Pharmaceutical Council

Pharmaceutical Benefits 2000 DSHS Staff Members Debbie Meyer Secretary Medical Assistance Administration 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 Executive Officers of State Medical and Pharmaceutical Societies 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 Seattle, WA 98116-0486 206/937-5358 State Board of Pharmacy Donald H. Williams Executive Director Department of Health 1300 Quince Street, SE P. O. Box 47863 Olympia, WA 98504-7863 360/753-6834 Washington State Hospital Association Leo F. Greenawalt President, CEO 300 Elliott Avenue W., Ste. 300 Seattle, WA 98119-4118 206/281-7211

National Pharmaceutical Council

Washington-6

Pharmaceutical Benefits 2000

WEST VIRGINIA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

OAA

AB

APTD

AFDC

OAA

AB

APTD

AFDC

Prescribed Drugs















Inpatient Hospital Care















Outpatient Hospital Care















Laboratory & X-ray Service















Skilled Nursing Home Services

















Physician Services

















Dental Services















Other Children <21

SFO



1

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998 Expended $148,962,081

CATEGORICALLY NEEDY CASH TOTAL Aged Blind/Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children AFDC Unemployed – Children (98) AFDC Unemployed – Adult (98) Other Title XIX Recipients

$115,591,878 $30,914,085 $67,956,619 $5,737,746 $8,792,794 690,594 $1,500,040 $0

152,428 21,877 53,764 41,057 24,769 5,584 5,377 0

$158,223,906 $39,137,625 $98,120,814 $7,672,107 $11,610,190 $502,409 $1,180,758 0

161,897 22,736 59,192 42,241 29,937 3,574 4,217 0

-

-

$14,674,077 $399,304 $12,610,179 $842,940 $821,653 0

22,719 321 8,880 6,088 7,430 0

$3,652,798 $306,383 $2,640,270 $21,311 $684,834 $0

3,544 312 2,230 77 925 0

$4,859,746 $385,039 $3,781,126 $18,428 $675,152 0

4,610 420 3,027 81 1,082 0

CATEGORICALLY NEEDY NON-CASH TOTAL Aged Blind/Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients MEDICALLY NEEDY TOTAL Aged Blind/Disabled Children-Families w/Dep. Children Adults-Families w/Dep. Children Other Title XIX Recipients

Recipients 267,398

1999 Expended $195,202,609

Recipients 274,214

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.

1-West Virginia

National Pharmaceutical Council

Pharmaceutical Benefits 2000

C. ADMINISTRATION Bureau for Medical Services, Department of Health & Human Resources.

D. PROVISIONS RELATING TO DRUGS Benefit Design

Prior Authorization: Prior authorization procedure screening for drug classes and home health care. Prescribing or Dispensing Limitations Prescriptions are limited to 10 per recipient per month. All covered outpatient drugs are reimbursed up to a 34day supply and five refills.

Drug Benefit Product Coverage: Products covered: prescribed insulin. Covered under DME program: disposable needles and syringe combinations used for insulin; total parenteral nutrition; interdialytic parenteral nutrition; blood glucose test strips; and urine ketone test strips. Products not covered: cosmetics; fertility drugs; and experimental drugs. Prior authorization required for: acute dosing of anti-ulcer medications, branded NSAIDS, Retin-A for adults, Ultram; ED drugs; and most injectable medications.

Exceptions include:

Over-the-Counter Product Coverage: Products covered: feminine products and topical products. Selected coverage: allergy, asthma, and sinus products; analgesics; cough and cold preparations; digestive products (non-H2 antagonist). Prior authorization for: smoking deterrent products. Products not covered: digestive products (H2 antagonists).

PRODUR system implemented in March 1995. State currently has a DUR Board with a quarterly review.

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic drugs; antilipemic agents; antihistamine drugs; antipsychotics; anxiolytics, sedatives, and hypnotics (partial coverage); cardiac drugs; chemotherapy agents; contraceptives; prescribed cold mediation (partial coverage); ENT antiinflammatory agents; estrogens; hypotensive agents; and thyroid agents. Therapeutic categories requiring prior authorization: analgesics, antipyretics, NSAIDs; growth hormones; prescribed smoking deterrents; and sympathominetics (adrenergic). Therapeutic categories not covered: anorectics; and hair growth products. Coverage of Injectables: Injectable medicines reimbursable when used in physician offices, home health care, and extended care facilities; most require prior approval.

1. 2. 3.

Antibiotics are covered for a 14-day supply and one refill. Opiate agonists (excluding Schedule II drugs), analgesics and miscellaneous antipyretics are covered for 30 days and one refill. Sedatives and hypnotics are covered for a 30-day supply and one refill.

Drug Utilization Review

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.90, effective 1/1/96. For a compounded prescription, an additional $1.00 will be added to the dispensing fee. A compound prescription is defined as any legend medication requiring a combination of any two or more substances to exclude normal reconstitution operations. Ingredient Reimbursement Basis: EAC = AWP - 12%. Prescription Charge Formula: Reimbursement based on the lowest of: 1. 2. 3.

4.

The estimated acquisition cost (EAC) plus a dispensing fee. The maximum allowable cost (MAC) plus a dispensing fee. The usual and customary price charged by the pharmacy to the general public including any sale price that may be in effect on the date of service. Children under age of 18 years.

Vaccines: Vaccines reimbursable as part of the EPSDT service and the Vaccines for Children Program.

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override will require physician certification of “Brand Medically Necessary.”

Unit Dose: Unit dose packaging reimbursable.

Incentive Fee: None.

Formulary/Prior Authorization Formulary: Open formulary. General exclusions include: legend agents used for cosmetic purposes; DESI drugs.

National Pharmaceutical Council

West Virginia-2

Pharmaceutical Benefits 2000 Patient Cost Sharing: Copayment varies - $0.50 to $2.00. Exclusions include: 1. 2.

Family planning services and supplies. Prescriptions originating with the Early and Periodic Screening, Diagnosis and Treatment Program.

3.

Nursing home residents.

Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE !""#$%&'()*+,-::@0@@@-?64?"+&5()*4-3*4&5(&4-#*5&"&*6)7 8*#*-*6#$++*4-&6-3BC7-&6-:;;;<--K$6*-#*5*&=*4 ">(#'(5,-7*#=&5*7-)>#$?9>-'(6(9*4-5(#*< Managed Care Organizations Carelink Health Plans 141 Summers Square Charleston, WV 25301 304/348-2041 The Health Plan of the Upper Ohio Valley 52160 National Road, East St. Clairsville, OH 43950 740/695-3585 Optimum Choice Physician Assured Access System (PAAS)

F. STATE CONTACTS State Drug Program Administrator Peggy A. King, R.Ph. Pharmaceutical Coordinator WV Department of Human Services 350 Capitol Street, Rm 251 Charleston, WV 25301-3707 T: 304/926-1753 F: 304/926-1993 E-mail: [email protected] Department of Health & Human Resources Officials Greg Clarke, M.D. Medical Director Division of Medical Care West Virginia Department of Human Services 350 Capitol St., Rm 251 Charleston, WV 25301-3707

3-West Virginia

Prior Authorization Contact Steve Small, R.Ph., M.S. Director, Rational Drug Therapy Program Robert C. Byrd Health Sciences Center P.O. Box 9511 Morgantown, WV 26506-9511 800/847-3859 E-mail: [email protected] DUR Contact Peggy A. King, R.Ph. T: 304/926-1753 Medicaid DUR Board Steven C. Judy, R.Ph. (Chairman) Tom Robinette, R.Ph., M.S., Director, Pharm. Ser. Kevin W. Yingling, M.D. David P. Elliott, Pharm.D. Wallace Johnson, M.D. Bernard Lee Smith, R.Ph., MBA, MHA Patrick M. Regan, R.Ph. Karen Reed, R.Ph. Mary Nemeth-Pyles, M.S.N., R.N., C.S. Mitch Shaver, M.D. Myra Chiang, M.D. Matthew Watkins, D.O. John R. Vanin, M.D. Lester Labus, M.D. Ernest Miller, D.O. Carl Malanga, Ph.D. James M. Bennett, M.D. Kent Van Devender, PA-C Lisa Hedrick, R.Ph. Daniel Dickman, M.D. Prescription Price Updating Leslie Bratton Account Manager Consultec, Inc. 9040 Roswell Road, Ste 700 Atlanta, GA 30350 800/358-2381 E-mail: [email protected] Medicaid Drug Rebate Contacts Technical: Pharmacy Management Consultants, Inc., 304/558-1700 Policy: Peggy A. King, 304/558-1753 Rebate: Gail Goodnight, R.Ph., 304/558-1700

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Claims Submission Contact Leslie Bratton 800/358-2381 Medicaid Managed Care Contact Randy Myers Director, Office of Medicaid Managed Care Bureau for Medical Services 350 Capitol Street, Rm 251 Charleston, WV 25301-3708 304/558-5974 E-mail: [email protected] Disease Management Initiative/Program Contact Peggy A. King, R.Ph. T: 304/926-1753 Physician-Administered Drug Program Contact Barbara White West Virginia Department of Human Services 350 Capitol St., Rm 251 Charleston, WV 25301-3707 304/558-1700 Medical Services Fund Advisory Council William A. Neal, M.D., Chairperson Mark B. Ayoubi, M.D. Nursing Home Representative John Elliot Ex Officio Public Health Member Henry Taylor, M.D. Commissioner, Bureau of Public Health Consumer Representative Sheryl Kiser MH/BH Health Representative John Russell West Virginia Behavioral Health Care Providers Association Aging Program Representative Earl Jarvis Chair Kanawha Valley Senior Services Home Health Representative Violet Burdette Executive Director Extended Care, Inc.

National Pharmaceutical Council

Hospice Representative Charlene Farrell Executive Director Hospice of Huntington, Inc. Pharmacist Representative William McFarland, R.Ph. Loop Plaza Pharmacy Consumer/Dental Representative Charles Smith, D.D.S. Hospital Representative Dan Hogan Assistant Executive Director/CFO St. Mary’s Hospital Ex-Officio Bureau for Children and Families Representative Jack Frazier Commissioner Bureau for Children and Families Executive Officers of State Medical and Pharmaceutical Societies West Virginia State Medical Association George Rider, Executive Director 4307 MacCorkle Avenue SE Box 4106 Charleston, WV 25364 West Virginia Pharmacists Association Richard D. Stevens, Executive Director 2003 Quarrier St. Charleston, WV 25311 West Virginia Society of Osteopathic Medicine Charlotte Ann Cales Pulliam Executive Director P.O. Box 5266 Charleston, WV 25361-0266 State Board of Pharmacy William T. Douglass, Jr. Executive Director 236 Capitol Street Charleston, WV 25301 West Virginia Hospital Association Steven J. Summer President 100 Association Drive Charleston, WV 25311

West Virginia-4

Pharmaceutical Benefits 2000

WISCONSIN A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 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

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

B. EXPENDITURES FOR DRUGS

TOTAL

1998 Expended $232,328,359

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Child AFDC-Unemployed-Adult

$131,188,380 $15,629,581 $113,162,140 $688,895 $1,411,683 $66,343 $229,718

112,031 14,671 78,454 9,304 7,364 881 1,357

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult

$15,994,923 $6,454,692 $9,336,436 $144,518 $59,277

14,228 5,408 4,489 3,210 1,123

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

$1,230,818 $466,539 $0 $392,495 $371,784

16,261 727 0 8,455 7,079

$83,881,774

78,454

OTHER

Recipients 221,508

1999* Expended Recipients

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1999 expenditures are broken down by maintenance assistance status and basis if eligibility are unavailable.

1-Wisconsin

National Pharmaceutical Council

Pharmaceutical Benefits 2000

State Department of Health and Family Services.

Vaccines: Vaccines provided plus reimbursement for administrative fee as part of the Vaccines for Children Program.

D. PROVISIONS RELATING TO DRUGS

Unit Dose: Unit dose packaging reimbursable.

Benefit Design

Formulary/Prior Authorization

Drug Benefit Product Coverage: Products covered: prescribed insulin and syringe combinations for insulin. Products covered with restrictions: disposable needles used for insulin (over 100/mo requires PA); blood glucose test strips (over 100/mo requires PA); enteral nutrition (requires PA); alpha one proteinase inhibitors (requires PA); urine ketone test strips (over 200/mo requires PA); total parenteral nutrition (must be billed as a compound drug); and interdialytic parenteral nutrition (must be billed as a compound drug). Products not covered: cosmetics; fertility drugs; impotence treatment drugs; and experimental drugs.

Formulary: Open formulary.

C. ADMINISTRATION

Over-the-Counter Product Coverage: Products covered with restriction: analgesics (not buffered); digestive products (non-H2 antagonists) (general antacids); topical products (generic antifungals, antibiotics, trocortisone ointment); insulin; ophthlubran; anti-lice; contraceptives; diphenhydramine; cough preps with/out DM; codeine; meclizine; psedoephed; and oral electrolyte replacement therapy. Products not covered: allergy, asthma and sinus products; cough and cold preparations (psedoephedrine covered); digestive products (H2 antagonists); feminine products; and smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamine drugs (legend only); antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications (legend only); contraceptives; ENT antiinflammatory agents; estrogens; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid agents. Therapeutic categories covered requiring prior authorization: analgesics, antipyretics, NSAIDs (cox2 inhibitor and brands for which no generic exists); anorectics; growth hormones; hypotensive agents (some ACE inhibitors for which no generic exists); and misc. GI drugs (Axid, Pepcid). Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities, and through physician payment when used in physician offices.

Prior Authorization: State currently has a formal prior authorization procedure. When appealing coverage of an excluded product or prior authorization procedure, the recipient is notified of the denial and given instructions on how to request a hearing. Prescribing or Dispensing Limitations Prescription Refill Limit: Maximum of 11 refills during a 12-month period for non-scheduled medications. Monthly Quantity Limit: Pharmacists may not dispense more than 34-day supply of a legend drug. Certain exceptions for maintenance drugs (100-day supply). Monthly Dollar Limits: None. Drug Utilization Review Implementation of PRODUR system planned for 2001. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.88 to a maximum of $40.11, effective 7/1/98. Maximum of two dispensing fees per month, per drug. Ingredient Reimbursement Basis: EAC = AWP - 10%. Prescription Charge Formula: Reimbursement at the lowest of: 1.

AWP-10% plus dispensing fee; Maximum Allowable Cost (MAC) plus dispensing fee; or providers usual and customary.

2.

State MAC or direct price for selected manufacturers: Wyeth-Ayerst, Merck & Co., and Pharmacia & Upjohn.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. Override requires “Brand Medically Necessary.” Incentive Fee: None.

National Pharmaceutical Council

Wisconsin-2

Pharmaceutical Benefits 2000 Patient Cost Sharing: All legend drugs are subject to a $1.00 copay, limited to $5.00 per month maximum. OTCs and disposable medical supplies are subject to a $0.50 copay. Residents of Skilled Nursing Facilities (SNF) or Intermediate Care Facilities (ICF), subsidized adoption recipients, children under age 18 and HMO enrollees are exempt from the copayment. Cognitive Services: Provides payment for cognitive services.

E. USE OF MANAGED CARE !""#$%&'()*+,-:;@0@@@-)$)(+-?64?"+&5()*4-6?'A*#-$2 3*4&5(&4-#*5&"&*6)7-8*#*-*6#$++*4-&6-3BC7-&6-DE-:;;;(#'(5*?)&5(+-A*6*2&)7-)>#$?9>'(6(9*4-5(#*-"+(67< Managed Care Organizations Atrium Health Plan, Inc. c/o Group Health Cooperative of Eau Claire P.O. Box 3217 Eau Claire, WI 54702-3217 Children Comefirst Dane County Department of Human Services Human services 1202 Northpost Drive Madison, WI 53704

Eldercare of Dane County 2802 International Lane Madison, WI 53704 Family Health Plan Cooperative 11524 W. Theodore Trecker Way Milwaukee, WI 53214 Greater La Crosse Health Plans, Inc. P.O. Box 188 La Crosse, WI 54602-0118 Group Health Cooperative of Eau Claire P.O. Box 3217 Eau Claire, WI 54702 Group Health Cooperative of South Central Wisconsin P.O. Box 44971 Madison, WI 53744-4971 Humana Wisconsin Health Organizations Ins. Corp. 111 W. Pleasant Street P.O. Box 12359 Milwaukee, WI 53212-0359 Independent Care 1555 N. Rivercenter Dr. Ste. 202 A Milwaukee, WI 53212-3958

Compcare Health Services Insurance Corporation 401 W. Michigan Street Milwaukee, WI 53202

Managed Health Services Insurance Corp. 2040 W. Wisconsin Ave., Ste. 452 Milwaukee, WI 53233

Community Care for the Elderly 1555 South Layton Blvd. Milwaukee, WI 53215

MercyCare Insurance Company P.O. Box 2770 Janesville, WI 53547-2770

Community Health Partnership 2240 Fastridge Center Eau Claire, WI 54701

Network Health Services c/o Managed Health Services 2040 W. Wisconsin Ave., Ste. 452 Milwaukee, WI 53233

Community Living Alliance 22 N 2nd St. Madison, WI 53704

Physicians Plus Insurance Corporation P.O. Box 2078 Madison, WI 53701-2078

Coordinated Care Health Plan of Wisconsin c/o Managed Health Services 2040 W. Wisconsin Ave., Ste. 452 Milwaukee, WI 53233

PrimeCare Health Plan, Inc. 10701 W. Research Drive Milwaukee, WI 53226

Dean Health Plan, Inc. P.O. Box 56099 Madison, WI 53705

Security Health Plan of Wisconsin, Inc. P.O. Box 8000 Marshfield, WI 54449

3-Wisconsin

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Touchpoint Health Plan 5 Innovation Court P.O. Box 507 Appleton, WI 54912-0507

Mark E. Buhler, R.Ph. 3905 Vista Drive, Racine, WI 53405

Unity Health Plans Insurance Corporation 840 Carolina Street Sauk City, WI 53583-1374

Daniel R. Erickson, M.D. 146 Larabee Street P.O. Box 127 Horicon, WI 53032

Valley Health Plan 2270 EastRidge Center P.O. Box 3128 Eau Claire, WI 54702-3128

Barry Hess, R.Ph. 3209 Latham Drive Madison, WI 53713 608/277-1110

Wraparound of Milwaukee 9501 Watertown Plank Rd. Milwaukee, WI 53226

Nancy E. Ness MD 100 W. Monroe St, Mauston, WI 53948

F. STATE CONTACTS State Drug Program Administrator Roma Rowlands, R.Ph. Pharmacy Practices Consultant Division of Health Care Financing Department of Health and Family Services One West Wilson Street P.O. Box 309 Madison, WI 53701-0309 T: 608/266-3753 F: 608/266-1096 E-mail: [email protected] Agency Internet Address: www.dhfs.state.wi.us/medicaid Prior Authorization Contact Roma Rowlands, 608/266-3753 DUR Contact Michael A. Mergener, R.Ph., Ph.D. Chief Pharmacist Meridian Resource Corporation 10 East Duty St., Ste. 210 Madison, WI 53703 T: 608/258-3348 F: 608/258-3359 Wisconsin Drug Utilization Review Committee Robert M. Breslow, R.Ph. 1926 N. Kollath Road Verona, WI 53593

Pamela Ploetz, R.Ph. Lee C. Vermeulen, Jr., R.Ph., M.S. 21 Lancaster Court Madison, WI 53719 Mary Jo Willis, MS, NP 2653 Stardust Trail, Verona, WI 53948 Prescription Price Updating First Databank 1111 Bayhill Dr. San Bruno, CA 94066 T: 800/633-3453 F: 415/588-6867 Medicaid Drug Rebate Contacts Audits: Roma Rowlands, 608/266-3753 Disputes: Ellen Orsburne, 608/267-7939 Technical: Randy Zirk, 608/266-8532 Policy: Rita Hallett, 608/267-0938 Claims Submission Contact Mark Gajewski Account Director EDS 6406 Bridge Rd. Madison, WI 53713 608/221-9326

Ward Brown, M.D. 1836 South Avenue LaCrosse, WI 54601 608/782-7300, X2076

National Pharmaceutical Council

Wisconsin-4

Pharmaceutical Benefits 2000 Medicaid Managed Care Contact Jodie Mender, Chief Department of Health and Family Services Division of Health and Family Services Bureau of Managed Health Care Programs 1 W. Wilson Madison, WI 53701 T: 608/261-6763 F: 608/261-7792 E-mail: [email protected] Physician-Administered Drug Program Contact Richard Carr, M.D. 608/266-0957

State Board of Pharmacy Patrick Braatz Director Bureau of Health Professions P.O. Box 8935 1400 E. Washington Ave. Madison, WI 53708 608/266-2812 Wisconsin Hospital Association Robert C. Taylor President, CEO 5721 Odana Road Madison, WI 53719-1289 608/274-1820

Health and Family Services Department Officials Joe Leann Secretary Department of Health and Family Services 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 Executive Officers of State Medical and Pharmaceutical Societies State Medical Society of Wisconsin John Patchett, J.D. Executive Vice President 330 East Lakeside, Box 1109 Madison, WI 53701-1109 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

5-Wisconsin

National Pharmaceutical Council

Pharmaceutical Benefits 2000

WYOMING A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1 Type of Benefit

Categorically Needy

Medically Needy (MN)

OAA

AB

APTD

AFDC

Prescribed Drugs









Inpatient Hospital Care









Outpatient Hospital Care









Laboratory & X-ray Service









Skilled Nursing Home Services









Physician Services









Dental Services









OAA

AB

APTD

AFDC

Other Children <21

SFO

1

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

B. EXPENDITURES FOR DRUGS

TOTAL RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult AFDC-Unemployed-Children AFDC-Unemployed-Adult

1998 Expended $17,138,952

Recipients 32,510

$6,318,738 $857,467 $4,943,472 $290,311 $227,486 $0 $0

8,945 762 3,760 1,836 587 0 0

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled AFDC-Child AFDC-Adult

$0 $0 $0 $0 $0

0 0 0 0 0

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

$1,304,484 $29,388 $191,789 $803,303 $280,024

9,570 43 148 6,569 2,810

OTHER, TOTAL

$9,496,162

15,946

1999* Expended Recipients

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4. *1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

C. ADMINISTRATION Department of Health, Division of Health Care Financing. National Pharmaceutical Council

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D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin, syringe combinations, disposable needles for insulin; cosmetics (Retin A not covered over age 21); blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition (covered under DME programs). Products not covered: fertility drugs; and experimental drugs. Over-the-Counter Product Coverage: Products covered: allergy, asthma, and sinus products (some); analgesics; cough and cold preparations; digestive products (H2 antagonists); feminine products; some topical products; antidiarrheals; antitussives; hyperglycemics; laxatives; pediatric and prenatal vitamins; sodium chloride for nebulizer; topical antifungals; vaginal antifungals. Covered OTC drugs are reimbursed at 150% of AWP. Products not covered: digestive products (non-H2 antagonists); and smoking deterrent products. Upon approval, additional OTC drugs may be covered if they are alternatives to more expensive therapy or they are unavailable by prescription order. Therapeutic Category Coverage: Therapeutic categories covered: analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones (covered under CHS program); hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Therapeutic categories not covered: anabolic steroids; anorectics; and prescribed smoking deterrents. Coverage of Injectables: Injectable medicines reimbursable when used in physician offices, home health care, and extended care facilities. Vaccines: Vaccines reimbursable at AWP plus a $7.00 injection fee as part of the EPSDT service. Unit Dose: Unit dose packaging not reimbursable.

Formulary/Prior Authorization Formulary: Open formulary. General exclusions include anorexants, except amphetamines and derivatives which are used for narcolepsy and hyperkinetic states; products to stimulate hair growth. Prior Authorization: No prior authorization procedure. Prescribing or Dispensing Limitations Quantity Limit: No more than a maximum quantity of a 90-day supply may be dispensed for a maintenance drug or any drug used in a chronic manner as defined. Oral contraceptives -- a 3-month supply may be dispensed at one time. A maximum quantity to be dispensed for a prescription drug for all other conditions shall be a onemonth supply. Drug Utilization Review PRODUR system implemented in October 1995. State currently has a DUR Board with 13 members. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.70, effective 3/91. Ingredient Reimbursement Basis: EAC = AWP - 4%. Prescription Charge Formula: Payments shall be the lowest of: 1. 2. 3.

The Estimated Acquisition Cost (AWP - 4%) of the ingredient, plus a dispensing fee. Usual and customary charge. The upper limit established by the Health Care Financing Administration (HCFA) for multiple source drugs.

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary” or “Brand Necessary.” Incentive Fee: None. 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

Cognitive Services: Does not pay for cognitive services.

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E. USE OF MANAGED CARE Does not use MCOs to deliver services to Medicaid recipients.

F. STATE CONTACTS State Drug Program Administrator Roxanne Homar, R.Ph. Deputy Administrator Community and Family Health Division Primary Case Services 2300 Capital Ave. Hathaway Building, 1st Fl. Cheyenne, WY 82002 T: 307/777-6032 F: 307/777-6964 Internet Agency Address: http://www.state.wy.us Shannon Whalen, R.Ph. Pharmacy Program Manager 2300 Capital Ave. Hathaway Building, 1st Fl. Cheyenne, WY 82002 T: 307/777-6016 F: 307/777-6964 E-mail: [email protected] Department of Health Officials Garry McKee, Ph.D., M.P.H. Director Department of Health 117 Hathaway Building Cheyenne, WY 82002-0710 T: 307/777-7656 Roxanne Homar, R.Ph. Deputy Administrator Community and Family Health Division Primary Case Services 2300 Capital Ave. Hathaway Building, 1st Fl. Cheyenne, WY 82002 T: 307/777-6032 F: 307/777-6964 DUR Contact Debra Devereaux, R.Ph. DUR Coordinator University of Wyoming School of Pharmacy P.O. Box 3375 Laramie, WY 82071-3375 T: 307/766-6750

National Pharmaceutical Council

DUR Board Debra Devereaux, R.Ph. DUR Coordinator University of Wyoming School of Pharmacy P.O. Box 3375 Laramie, WY 82071-3375 307/766-6750 E-mail: [email protected] Ed Baker, R.Ph. Smith’s Pharmacy 2531 Foothill Blvd. Rock Springs, WY 82901 307/362-1841 Dawn Ford, R.Ph. 2022 Reagan Avenue Rock Springs, WY 82901 307/382-5437 Roxanne Homar, R.Ph. Deputy Administrator Community and Family Health Director Primary Care Services 2300 Capital Ave. Hathaway Building, 1st Fl. Cheyenne, WY 82002 307/777-6032 Kathryn Kohler, M.D. 204 McCollum Drive Laramie, WY 82070 307/745-8991 Leonard Kosirog, R.Ph. 3095 Galloway Riverton, WY 82501 307/856-6993 Jay Swedberg, M.D. 1020 S. Conwell Casper, WY 82609 307/577-5100 George Zaharas, R.Ph. Town and Country Pharmacy 514 S. Greeley Cheyenne, WY 82009 307/634-6662 Stephen Brown, M.D. 2521 E. 15th St. Casper, WY 82609 307/234-3638

Wyoming-3

Pharmaceutical Benefits 2000 Michael Carpenter, PA-C 1121 Washington Blvd. Newcastle, WY 82701 307/746-3582 William Harrison, M.D. MedPed Primary Care Clinic 903-A South Greeley Highway, Ste A Cheyenne, WY 82007 307/634-8800 Linda G. Martin, R.Ph. University of Wyoming School of Pharmacy P.O. Box 3375 Laramie, WY 82071-3375 307/766-6128 Shannon Whalen, R.Ph. Community & Family Health Div. 2300 Capital Avenue 154 Hathaway Building Cheyenne, WY 82002 307/777-6016 Prescription Price Updating First Data Bank T: 800/633-3453 F: 650/872-4510 Medicaid Drug Rebate Contacts Technical: Renee Greenmeyer, 307/777-5500 Policy: Shannon Whalen, R.Ph., 307/777-6016 Audits: Shannon Whalen, R.Ph., 307/777-6016 Claims Submission Contact Jennifer Dillinger Account Manager Consultec, Inc. P.O. Box 667 Cheyenne, WY 82003 307/777-5500 E-mail: [email protected]

Physician-Administered Drug Program Contact Shannon Whalen, R.Ph. 307/777-6016 Executive Officers of State Medical and Pharmaceutical Societies Wyoming State Medical Society Wendy Curran Executive Director 1920 Evans P.O. Box 4009 Cheyenne, WY 82003-4009 307/635-2424 Wyoming Pharmacists Association Robert E. Smith, R.Ph. Executive Director Glenrock, WY 82432 307/436-8001 Wyoming Association of Osteopathic Physicians & Surgeons Shirley Carpenter Executive Director 625 Albany Avenue Torrington, WY 82240 307/532-2107 State Board of Pharmacy Jim Carder Executive Director 1720 S. Poplar Street, Ste. 5 Casper, WY 82601 307/234-0294 Wyoming Hospital Association Dan Perdue President 2005 Warren Avenue Cheyenne, WY 82001 307/632-9344

Disease Management Program/Initiative Contact Shannon Whalen, R.Ph. 307/777-6016 Expanded Drug Coverage Program Contact Shannon Whalen, R.Ph. 307/777-6016

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Appendix A: State and Federal Medicaid Contacts

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A-2

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STATE MEDICAID DRUG PROGRAM ADMINISTRATORS, 2000 ALABAMA

CALIFORNIA

Louise F. Jones Pharmacy Program Manager Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery, AL 36103-5624 P: 334/242-5039 F: 334/353-7014 E-mail: [email protected] Agency Internet Address: www.medicaid.state.al.us

J. Kevin Gorospe, Pharm.D. Chief, Pharmaceutical Unit Medi-Cal Policy Division 714 P Street, Room 1540 Sacramento, CA 95814 P: 916/657-4213 F: 916/654-0513 E-mail: [email protected] Agency Internet Address: http://www.dhs.ca.gov

ALASKA Dave Campana, R.Ph. Pharmacy Program Manager Division of Medical Assistance 4501 Business Park Blvd., Suite 24 Anchorage, AK 99503 P: 907/273-3224 F: 907/561-1684 E-mail: [email protected] ARIZONA Juman Abujbara, M.D. Director Arizona Health Care Containment System 801 E. Jefferson Street Phoenix, AZ 85034 P: 602/417-4241 F: 602/254-1769 ARKANSAS Suzette Bridges, P.D. Department of Human Services Division of Medical Services Pharmacy Program P.O. Box 1437, Slot 4105 Little Rock, AR 72203 P: 501/324-9141 F: 501/324-9140 E-mail: [email protected]

National Pharmaceutical Council

COLORADO Allen Chapman Department of Health Care Policy & Financing 1575 Sherman Street, 5th Floor Denver, CO 80203 P: 303/866-3176 F: 303/866-2573 CONNECTICUT Elizabeth A. Geary Health Program Supervisor Department of Social Services 25 Sigourney Street Hartford, CT 06106 P: 860/424-5150 F: 860/951-9544 E-mail: [email protected] Agency Internet Address: http://www.dss.state.ct.us DELAWARE Phile Soulé Medicaid Pharmacy Director Delaware Health and Social Services 1901 N. Dupont Highway New Castle, DE 19720 P: 302/577-4900 F: 302/577-4405

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DISTRICT OF COLUMBIA

IDAHO

Donna Bovell, R.Ph. Pharmacist Consultant Commission on Health Care Finance 2100 M.L. King Jr. Ave. SE, Suite 302 Washington, DC 20023 P: 202/698-2043 F: 202/610-3209 E-mail: [email protected]

Gary Duerr, R.Ph. Medicaid Policy Americana Terrace, Suite 140 P.O. Box 83720 Boise, ID 83720-0036 P: 208/364-1829 F: 208/364-1846 E-mail: [email protected]

FLORIDA

ILLINOIS

Jerry Wells Agency for Healthcare Administration Services 2727 Mahan Drive, Building 1, Room 170 Tallahassee, FL 32308 P: 850/922-0681 F: 850/922-0685 E-mail: [email protected] Agency Internet Address: www.fdhc.state.fl.us

Marvin L. Hazelwood Illinois Department of Public Aid Division of Medical Assistance 1001 N. Walnut St. Springfield, IL 62702 P: 217/524-7112 F: 217/524-7194 E-mail: [email protected] Agency Internet Address: www.state.il.us/dpa/

GEORGIA Etta L. Hawkins, R.Ph. Department of Community Health-Medical Division 2 Peachtree Street, 37th Floor Atlanta, GA 30303-3159 P: 404/657-7239 F: 404/656-8366 E-mail: [email protected] Agency Internet Address: www.state.ga.us/dch HAWAII Lynn Donovan, R.Ph. Medicaid Pharmacy Consultant Med-Quest Division P.O. Box 339 Honolulu, HI 96809-0339 P: 808/692-8116 F: 808/692-8131

A-4

INDIANA Marc Shirley, R.Ph. Pharmacy Program Director-Indiana Medicaid Office of Medicaid Policy and Planning Indiana State Government Center South-Rm. W382 402 W. Washington Street Indianapolis, IN 46204-2739 P: 317/232-4343 F: 317/232-7382 E-mail: [email protected] IOWA Ronald J. Mahrenholz, R.Ph. Pharmacist Consultant Division of Medical Services Department of Human Services Hoover State Office Bldg. Des Moines, IA 50319 P: 515/281-6199 F: 515/281-6230 E-mail: [email protected]

National Pharmaceutical Council

Pharmaceutical Benefits 2000

KANSAS

MARYLAND

Karen Braman, R.Ph., M.S. Health Care Policy Division Kansas Department of Social and Rehabilitation Services 915 SW Harrison, Room 651-South DSOB Topeka, KS 66612-1570 P: 785/296-6968 F: 785/296-4813 E-mail: [email protected] Agency Internet Address: www.ink.org/public/srs

Frank Tetkoski Pharmacy Services Manager Division of Pharmacy and Clinic Services 201 West Preston Street Baltimore, MD 21201 P: 410/767-1455 F: 410/333-7049 E-mail: [email protected] Agency Internet Address: www.dhmh.state.md.us MASSACHUSETTS

KENTUCKY Debra Bahr, R.Ph. Pharmacy Services Program Manger Department for Medicaid Services CHR Building, 6th Floor 275 East Main Street Frankfort, KY 40621 P: 502/564-6511 F: 502/564-3852 E-mail: [email protected] LOUISIANA M.J. Terrebonne, P.D. Pharmacy Program Director Department of Health and Hospitals P.O. Box 91030 Baton Rouge, LA 70821 P: 225/342-9479 F: 225/342-3893 E-mail: [email protected] MAINE Christine Gee Director of Pharmacy Programs Department of Health Services Bureau of Medical Services Pharmacy Programs Building 205, 3rd Fl. 11 State House Station Augusta, ME 04333 P: 207/287-4018 F: 207/287-8601 E-mail: [email protected]

National Pharmaceutical Council

Gary P. Gilmore, R.Ph. Division of Medical Assistance 600 Washington Street Boston, MA 02111 P: 617/210-5593 F: 617/210/5597 E-mail: [email protected] MICHIGAN James Kenyon, R.Ph. Pharmacist Consultant MDCH/ Medical Services Administration 400 South Pine Street Lansing, MI 48933 P: 517/335-5265 F: 517/335-5294 E-mail: [email protected] Agency Internet Address: www.mdch.state.mi.us MINNESOTA Cody Wiberg, Pharm.D., R.Ph. Acting Pharmacy Program Manager Minnesota Department of Human Services 444 Lafayette Road St. Paul, MN 55155-3853 P: 651/296-8515 F: 651/282-6744 E-mail: [email protected]

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MISSISSIPPI

NEVADA

James G. (Jack) Lee, R.Ph. Division of Medicaid, Office of the Governor Robert E. Lee Building 239 North Lamar Street, Suite 801 Jackson, MS 39201-1399 P: 601/359-6296 F: 601/359-4185 E-mail: [email protected]

Laurie Squartsoff, R.Ph. Pharmaceutical Consultant Nevada Medicaid Office 2527 N. Carson Street, Capitol Complex Carson City, NV 89710 P: 702/687-4869 F: 702/687-8724 E-mail: [email protected]

MISSOURI

NEW HAMPSHIRE

Susan McCann, R.Ph. Pharmaceutical Consultant Division of Medical Services 615 Howerton Court P.O. Box 6500 Jefferson City, MO 65102-6500 P: 573/751-6963 F: 573/526-4650 E-mail: [email protected]

Lisè Farrand, R.Ph. Pharmaceutical Services Specialist Medicaid Administration Bureau 6 Hazen Drive Concord, NH 03301-6521 T: 603/271-4419 F: 603/271-4376 E-mail: [email protected]

MONTANA Dorothy D. Poulsen Pharmacy Program Officer Department of Public Health and Human Services Medicaid Services Bureau P.O. Box 202951 1400 Broadway Helena, MT 59620-2951 P: 406/444-2738 F: 406/444-1861 E-mail: [email protected] NEBRASKA Gary J. Cheloha M.B.A., R.Ph. Department of Health and Human Services Finance and Support, Medicaid Division P.O. Box 95026 301 Centennial Mall S., 5th Fl. Lincoln, NE 68509 P: 402/471-9379 F: 402/471-9092 E-mail: [email protected] Agency Internet Address: www.hhs.state.ne.us

A-6

NEW JERSEY Carl D. Tepper, R.Ph. Department of Human Services Division of Medical Assistance and Health Services P.O. Box 712, Room 202 Trenton, NJ 08625-0712 P: 609/588-2724 F: 609/588-3889 E-mail: [email protected] NEW MEXICO Neil Solomon Medicaid Assistance Division P. O. Box 2348 Santa Fe, NM 87504 P: 505/827-3174 F: 505/827-3185

National Pharmaceutical Council

Pharmaceutical Benefits 2000

NEW YORK

OKLAHOMA

Mark-Richard Butt, M.S., R.Ph. NYS Department of Health Pharmacy Policy and Operations Office of Medicaid Management 99 Washington Ave., Room 606 Albany, NY 12210 P: 518/486-3209 F: 518/473-5508 E-mail: [email protected] Agency Internet Address: www.health.state.ny.us

John Crumly, MHA., R.Ph. Oklahoma Health Care Authority 4545 N. Lincoln Boulevard, Suite 124 Oklahoma City, OK 73105-9901 P: 405/522-7300 F: 405/522-7378 E-mail: [email protected]

NORTH CAROLINA C. Benny Ridout, R.Ph. NC Division of Medical Assistance 1985 Umstead Drive 2511 Mail Service Center Raleigh, NC 27699-2511 P: 919/733-4034 F: 919/733-2796 E-mail: [email protected] NORTH DAKOTA Cindy Frolick Department of Human Services State Capital, 600 East Boulevard Department 325 Bismarck, ND 58505-0250 P: 701/328-4023 F: 701/328-1544 E-mail: [email protected] OHIO Robert P. Reid, R.Ph. Administrator, Pharmacy Services Unit Department of Human Services 30 East Broad St., 31st Floor Columbus, OH 43266-0423 P: 614/466-6420 F: 614/466-2908 E-mail: [email protected]

National Pharmaceutical Council

OREGON Jesse Anderson Department of Human Resources Office of Medical Assistance Programs 500 Summer Street, NE Salem, OR 97310-1014 P: 503/945-6492 F: 503/373-7689 E-mail: [email protected] PENNSYLVANIA Joseph E. Concino, R.Ph. Chief, Pharmacy Services Office of Medical Assistance Programs P.O. Box 8046 Harrisburg, PA 17105 P: 717/772-6341 F: 717/772-6366 RHODE ISLAND Paula J. Avarista, R.Ph. Chief of Pharmacy Department of Human Services 600 New London Avenue Cranston, RI 02920 P: 401/462-2183 F: 401/462-2185 SOUTH CAROLINA James M. Assey, R.Ph. Division Director S.C. Department of Health & Human Services P.O. Box 8206 Columbia, SC 29202-8206 P: 803/898-2876 F: 803/898-4517 E-mail: [email protected]

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SOUTH DAKOTA

VERMONT

Mark Petersen, R.Ph. Department of Social Services 700 Governors Drive Pierre, SD 57501 P: 605/773-3498 F: 605/773-5246 E-mail: [email protected]

Paul Wallace-Brodeur Office of Vermont Health Access 103 South Main Street Waterbury, VT 05671-1201 P: 802/241-2156 F: 802/241-2974 E-mail: [email protected]

TENNESSEE

VIRGINIA

Jeff Stockard, D.Ph. Director of Pharmacy Bureau of TennCare 729 Church Street, 1st Floor Nashville, TN 37247-6501 P: 615/532-3107 F: 615/741-0882 Agency Internet Address: www.state.tn.us/health/tenncare/

David B. Shepherd, R.Ph. Department of Medical Assistance Services 600 East Broad Street, Ste 1300 Richmond, VA 23219 P: 804/225-2773 F: 804/786-0414 E-mail: [email protected]

TEXAS Robert P. Harriss Director, TX Department of Health Vendor Drug Program 1100 W. 49th Street Austin, TX 78756-3174 P: 512/338-6961 F: 512/338-6910 E-mail: [email protected] UTAH RaeDell Ashley, R.Ph. Pharmacy Director Division of Health Care Financing Utah Department of Health 288 N. 1460 West, P.O. Box 143102 Salt Lake City, UT 84114-2905 P: 801/538-6495 F: 801/538-6099 E-mail: [email protected]

A-8

WASHINGTON Siri A. Childs, Pharm D. Pharmacy Research Specialist Medical Assistance Administration, DSHS 805 Plum Street, SE P.O. Box 45506 Olympia, WA 98504-5506 P: 360/725-1564 F: 360/664-3884 E-mail: [email protected] WEST VIRGINIA Peggy A. King, R.Ph. Pharmaceutical Coordinator WV Department of Human Services 350 Capitol St., Room 251 Charleston, WV 25301-3707 P: 304/558-1753 F: 304/558-1542 E-mail: [email protected]

National Pharmaceutical Council

Pharmaceutical Benefits 2000

WISCONSIN Roma Rowlands, R.Ph. Division of Health Care Financing Department of Health and Family Services One West Wilson Street P.O. Box 309 Madison, WI 53701-0309 P: 608/266-3753 F: 608/266-1096 E-mail: [email protected] Agency Internet Address: www.dhfs.state.wi.us/medicaid WYOMING Roxanne Homar, R.Ph. Deputy Administrator 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: [email protected]

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DUR CONTACT INFORMATION, 2000

ALABAMA Contracted DUR

ALASKA In-House and contracted DUR

ARIZONA DUR is conducted at the plan level.

State Contact Louise F. Jones Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery, AL 36103-5624 P: 334/242-5039 F: 334/353-7014 E-mail: [email protected]

Contractor Alabama Quality Assurance Foundation 1 Perimeter Park South, Suite 200N Birmingham, AL 35243 P: 205/970-1600

State Contact Dave Campana, R.Ph Pharmacy Program Manager Division of Medical Assistance 4501 Business Park Blvd., Ste. 24 Anchorage, AK 99503 P: 907/273-3224 F: 907/561-1684 E-mail: [email protected]

Contractor Not Available

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

ARKANSAS Contracted DUR

State Contact Suzette Bridges, P.D. Administrator Arkansas Department of Human Services Division of Medical Services P.O. Box 1437, Slot 4105 Little Rock, AR 72203 P: 501/324-9141 F: 501/324-9140 E-mail: [email protected]

CALIFORNIA In-House DUR

State Contact Vic Walker, R.Ph. B.C.P.P. Sr. Pharmaceutical Consultant Medi-Cal Policy Division 714 P Street, Rm. 1540 Sacramento, CA 95814 P: 916/657-0785 F: 916/654-0513 E-mail: [email protected]

National Pharmaceutical Council

Contractor Craig Atkins, Pharm D. Director, Retro Spective DUR Health Information Design 1550 Pumphrey Avenue Auburn, AL 36832 P: 205/402-9530 F: 205/402-9531

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Contractor Not Available

COLORADO Contracted DUR

State Contact Allen Chapman Pharmacist Deptartment of Health Care Policy and Financing 1575 Sherman St., 5th Floor Denver, CO 80203 P: 303/866-3176 F: 303/866-2573

CONNECTICUT Contracted DUR

State Contact Elizabeth Geary, R.Ph. Health Program Supervisor Department of Social Services 25 Sigourney Street Hartford, CT 06106 P: 860/424-5150 F: 860/951-9544 E-mail: [email protected]

Contractor Michelle Lester-Bradley Account Manager Health Information Designs 1550 Pumphrey Ave. Auburn, AL 35832 P: 334/502-3262 x21 F: 334/821-6589 E-mail: [email protected]

DELAWARE Contracted DUR

State Contact Cynthia Denemark Pharmacist Consultant EDS 248 Chapman Road, Suite 200 Newark, DE 197029720 P: 302/453-8453 F: 302/454-7603 E-mail: [email protected]

Contractor Cynthia Denemark Pharmacist Consultant EDS

DISTRICT OF COLUMBIA In-House DUR

State Contact Chrisopher Keeyes, Pharm.D. President Clinical Pharmacy Administration 11710 Beltsville Drive, Ste. 510 Calberton, MD 20705 P: 301/572-1616

FLORIDA In-house and Contracted DUR

State Contact Marie Donnelly-Stephens Senior Healthcare Program Analyst AHCA 2727 Mahan Drive, mail stop 38 Tallahassee, FL 32308 P: 850/487-4441 F: 850/922-0685

A-12

Contractor Gaylen Fruit, R.Ph. DUR Coordinator Florida Pharmacy Association 610 N. Adams St. Tallahassee, FL 32301 P: 850/222-2400

National Pharmaceutical Council

Pharmaceutical Benefits 2000

GEORGIA In-house DUR

State Contact Jean B. Cox, R.Ph. DUR Coordinator GA Dept. of Community Health 2 Peachtree St. NW Atlanta, GA 30303 P: 404/657-7241 F: 404/656-8366 E-mail: [email protected]

HAWAII In-House DUR

State Contact Kathleen Kang-Kaulupali Pharmacy Consultant Med-Quest Division PO Bopx 339 Honolulu, HI 96809-0339 P: 808/692-8115 F: 808/692-8131

IDAHO Contracted DUR

State Contact Gary Duerr, R.Ph. Medicaid Policy Americana Terrace, Suite 140 PO Box 83720 Boise, ID 83720-0036 P: 208/364-1829 F: 203/364-1846 E-mail: [email protected]

ILLINOIS In-House DUR

State Contact Starlin Haydon Greatting, R.Ph. Pharmacist Consultant DUR Coordinator Illinois Department of Public Aid 1001 N. Walnut St. Springfield, IL 62702 P: 217/524-7112 F: 217/524-7194

INDIANA Contracted DUR

State Contact Ms. Karen Baer DUR Board Secretary Office of Medicaid Policy and Planning P: 317/232-4391 F: 317/232-7382 E-mail: [email protected]

National Pharmaceutical Council

Contractor Vaughn Culbertson, Pharm.D. DUR Coordinator Idaho State U. - College of Pharmacy Campus Box 8356 Pocatello, ID 83209-8356 P: 208/236-4385 F: 208/236-4482 E-mail: [email protected]

Contractor Pharmacy Services EDS 950 N. Meridian St., 11th Floor Indianapolis, IN 46204 P: 317/488-5000

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Pharmaceutical Benefits 2000

IOWA Contracted DUR

State Contact Cheryl Clarke, R.Ph. DUR Coordinator Iowa Pharmacy Association 8515 Douglas, Ste. 16 Des Moines, IA 50322 P: 515/270-0713 F: 515/270-2979 E-mail: [email protected]

Contractor Cheryl Clarke, R.Ph. DUR Coordinator Iowa Pharmacy Association

KANSAS Contracted DUR

State Contact Glenn McNeese, R.Ph., M.S., BCPS DUR Program Director Kansas University School of Pharmacy 6052 Malott Hall Lawrence, KS 66045-2500 P: 785/864-3264 F: 785/864-5849 E-mail: [email protected]

Contractor Glenn McNeese, R.Ph., M.S., BCPS DUR Program Director Kansas University School of Pharmacy

KENTUCKY Contracted DUR

State Contact Debra Bahr, R.Ph. Pharmacy Services Program Manger Department for Medicaid Services CHR Building, 6th Floor 275 East Main Street Frankfort, KY 40621 P: 502/564-6511 F: 502/564-3852 E-mail: [email protected]

Contractor Kim Moore, R.Ph. Unisys PO Box 2100 Frankfort, KY 40602 P: 502/226-1867 F: 502/266-1860

LOUISIANA Contracted DUR

State Contact Melwyn Wendt Pharmaceutical Consultan Department of Health and Hospitals PO Box 91030 Baton Rouge, LA 70821 P: 225/219-4154 F: 225/342-3893 E-mail: [email protected]

Contractor Dan Scholl Pharmacy Director Unisys PO Box 3396 Baton Rouge, LA 70809 P: 225/237-3208 F: 225/924-6179 E-mail: [email protected]

MAINE Contracted DUR

State Contact Christine Gee Director of Pharmacy Programs DHS – Bureau of Medical Servies Bldg 205, 3rd Fl. 11 State House Station Augusta, ME 04333-0011 P: 207/287-2674 F: 207/287-8601

Contractor Dennis G. Lyons, R.Ph. Retrospective DUR Director Pharmaceutical Strategies Inc. 255 Bennhill Rd. Waltham, MA 02451 P: 781/830-3435

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National Pharmaceutical Council

Pharmaceutical Benefits 2000

Contractor Contact Judy Geisler Pharmacist Consultant

MARYLAND Contracted DUR

State Contact Judy Geisler Pharmacist Consultant DHMH-Office of Health Services Division of Pharmacy and Clinical Services 201 W. Preston St., Rm. 208A Baltimore, MD 21201 P: 410/787-1728 F: 410/333-7049 E-mail: [email protected]

MASSACHUSETTS Contracted DUR

State Contact Anna Morin, Pharm.D. DUR Program Director UMASS Medical school 11 Midstate Hwy Auburn, MA 01501-1863 P: 508/721-7104 F: 508/721-7138 E-mail: [email protected]

Contractor Anna Morin, Pharm.D. DUR Program Director UMASS Medical school mailto:[email protected]

MICHIGAN Contracted DUR

State Contact Mary Sandusky, R.Ph. Pharmacist Consultant MDCH/Medical Services Administration 400 S. Pine Street Lansing, MI 48933 P: 517/335-5280 F: 517/335-7813 E-mail: [email protected]

Contractor First Health Services Corp. 4300 Cox Rd. Glen Allen, VA 23060

MINNESOTA In-House DUR

State Contact Mary Beth Reinke, Pharm.D. DUR Coordinator Minnesota Dept. of Human Services 444 Lafayette Rd. St. Paul, MN 55155-3853 P: 651/215-1239 F: 651/282-6744 E-mail: [email protected]

MISSISSIPPI Contracted DUR

State Contact Jack Lee, R.Ph. Pharmacy Program Administrator Div. Of Medicaid, Office of the Governor 239 North Lamar St., Ste. 801 Jackson, MS 39201-1399 P: 601/359-6296 F: 601/369-4185 E-mail: [email protected]

National Pharmaceutical Council

Contractor Cliff Oshon Heritage Information System, Inc. 2618 A. Southerland Dr. Jackson, MS 39216 P: 601/362-3388 F: 601/982-0143

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Pharmaceutical Benefits 2000

MISSOURI Contracted DUR

State Contact Jayne Zemmer DUR Coordinator Div. Of Medical Services PO Box 6500 Jefferson City, MO 65102-6500 P: 573/751-6963 F: 573526-4650 E-mail: [email protected]

Contractor ProVantage retro DUR) 1300 N. 17th St., Ste. 1350 Arlington, VA 22209 P: 703/243-9571 F: 703/528-5869

MONTANA Contracted DUR

State Contact Mark Eichler, R.Ph. DUR Coordinator Mountain-Pacific Quality Health Foundation 3404 Cooney Drive Helena, MT 59602 P: 406/443-4020 F: 406/443-4585 E-mail: [email protected]

Contractor Mark Eichler, R.Ph. Mountain-Pacific Quality Health Foundation

NEBRASKA Contracted DUR

State Contact Allison Jorgensen, Pharm.D., R.Ph. DUR Director Nebraska Pharmacists Association 6221 South 58th, Ste. A Lincoln, NE 68516 P: 402/420-1500 F: 402/420-1406 E-mail: [email protected]

Contractor Allison Jorgensen, Pharm.D., R.Ph. DUR Director Nebraska Pharmacists Association 6221 South 58th, Ste. A Lincoln, NE 68516 P: 402/420-1500 F: 402/420-1406 E-mail: [email protected]

NEVADA In-House DUR

State Contact Laurie Squartsoff, R.Ph. Pharmacy Services Consultant Nevada Medicaid 2527 N. Carson St., Capitol Complex Carson City, NV 89710 P: 702/687-4869 F: 702/687-8724

NEW HAMPSHIRE Contracted DUR

State Contact Lisè Ferrand, R.Ph. Pharmaceutical Services Specialist Medicaid Administration Bureau 6 Hazen Drive Concord, NH 03301 P: 603/271-4359 F: 603/271-4376 E-mail: [email protected]

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Contractor Julie Simpson, R.Ph. Pharmacy Consultant EDS Federal Corp. 7 Eagle Square Concord, NH 03301 P: 603/225-4899

National Pharmaceutical Council

Pharmaceutical Benefits 2000

NEW JERSEY In-House DUR

State Contact Edward Vaccaro, R.Ph. Assistant Director, OHSA Division of Medical Assistance and Health Services Office of Health Service Administration, P.O. Box 712 Trenton, NJ 08625-0712 P: 609/588-2721 F: 609/588-3889 E-mail: [email protected]

NEW MEXICO Contracted DUR

State Contact Neil Solomon P: 505/827-3174

NEW YORK In-House DUR

State Contact Michael Zegarelli DUR Manager, Office of Medicaid Management NYS Dept. of Health 99 Washington Ave, Suite 601 Albany, NY 12210 P: 518/474-6866 F: 518/473-5332 E-mail: [email protected]

NORTH CAROLINA In-House DUR

State Contact Sharman Leinwand DUR Coordinator N.C. Division of Medical Assistance 2515 Mail Service Center Raleigh, NC 27699-2515 P: 919/733-3590 F: 919/715-7706

NORTH DAKOTA In-House DUR

State Contact Pat Kramer Director, Utilization Management Human Services 600 E. Blvd., Dept. 325 Bismarck, ND 58505-0250 P: 701/328-4893 F: 701/328-1544 E-mail: [email protected]

National Pharmaceutical Council

Contractor UNM College of Pharmacy

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Pharmaceutical Benefits 2000

OHIO Contracted DUR

State Contact Jan Lawson DUR Coordinator DUR 6S E. State, 4th Floor Columbus, OH 43215 P: 614/466-7936

Contractor Theresa Shireman University of Cincinnati Medical Center 3223 Eden Avenue Cincinnati, Ohio 45267-0004 P: 614/466-7936

OKLAHOMA Contracted DUR

State Contact John Crumly, MHA, R.Ph. Medicaid Pharmacy Director Oklahoma Health Care Authority 4545 N. Lincoln Blvd. Ste 124 Oklahoma City, OK 73105-9901 P: 405/522-7300 F: 405/522-7378 E-mail: [email protected]

Contractor Ron Graham Pharmacy Consultant Manager College of Pharmacy P.O.Box 26901 Oklahoma City, OK 73190 P: 405/271-9039 F: 405/271-2615 E-mail: [email protected] Contractor Same as state contact.

OREGON Contracted DUR

State Contact Mariellen Rich, R.Ph. Pharmacist Account Manager First Health Service Corporation 565 Union St., NE, Suite 205 Salem, OR 97310 P:503/391-1980 F: 503/391-1979 E-mail: [email protected]

PENNSYLVANIA In-House DUR

State Contact PRODUR – EDS/ RETRODUR – University of Maryland P.O. Box 8046 Harrisburg, PA 17105

RHODE ISLAND Contracted DUR

State Contact Paula Avarista P: 401/462-2183

Contractor EDS -- Merck/Medco

SOUTH CAROLINA In-House and Contracted DUR

State Contact Caroline Y. Sojourner, R.Ph. Deptartment Head, Pharmacy Services S.C. Department of Health & Human Services P.O. Box 8206 Columbia, SC 29202-8206 P: 803/898-2876 F: 803/898-4517 E-mail: [email protected]

Contractor First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 P: 800/884-2822 F: 804/273-6961

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National Pharmaceutical Council

Pharmaceutical Benefits 2000

SOUTH DAKOTA In-House DUR

TENNESSEE DUR is conducted at the plan level.

State Contact Michael Jockheck, R.Ph. Pharmacy Consultant SD Department of Social Services 700 Governors Drive Pierre, SD 57501 P: 605/773-6439 E-mail: [email protected]

Contractor Michael Jockheck, R.Ph. Pharmacy Consultant SD Department of Social Services

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

TEXAS In-House DUR

State Contact Curtis Burch Director Drug Utilization Review Division Texas Department of Health 1100 West 49th Street Austin, TX 78756-3174 P: 512/338-6922 F: 512/338-6910 E-mail: [email protected]

UTAH In-House DUR

State Contact Duane Parke DUR Coordinator Health Care Financing 288 N. 1460 West, P.O. Box 143102 Salt Lake City, UT 84114-2905 P: 801/538-6452 F: 801/538-6099

VERMONT Contracted DUR

State Contact Gloria Jacobs Operations Administrator Office of VT Health Access 103 S. Main St. Waterbury, VT 05671 P: 802/241-2763 F: 802/241-2974 E-mail: [email protected]

Contractor EDS Fiscal Agent 312 Hurrican Lane, Ste 101 Williston, VT 05495 P: 802/879-4450 F: 802/878-3440

VIRGINIA Contracted DUR

State Contact Marianne Rollins, R.Ph. DUR Coordinator Deparment of Medical Asisstance Services 600 East Broad Street, Suite 1300 Richmond, VA 23112 P: 804/225-4268

Contractor First Health Services Glen Allen, VA

National Pharmaceutical Council

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Pharmaceutical Benefits 2000

WASHINGTON In-House DUR

State Contact Siri A. Childs, Pharm D. Pharmacy Research Specialist Medical Assistance Administration, DSHS 805 Plum Street, SE P.O. Box 45506 Olympia, WA 98504-5506 P: 360/725-1564 F: 360/664-3884 E-mail: [email protected]

WEST VIRGINIA Contracted DUR

State Contact Peggy A. King Pharmacy CoordinatoBureau for Medical Services 7012 MacCorkle Ave., SE Charleston, WV 25304 P: 304/926-1753 F: 304/926-1993 E-mail: [email protected]

Contractor Martha Kophazi Health Information Design 11200 Waples Mill Road, Suite 360 Fairfax, VA 22032 P: 703/218-5800 F: 703/218-5810 E-mail: [email protected]

State Contact Michael Mergener, R.Ph., Ph.D. Chief Pharmacist Meridian Resource Corporation 10 East Duty St., Suite 210 Madison, WI 53703 P: 608/258-3348 F: 608/258-3359

Contractor Same as state contact

State Contact Debra Devereaux, M.B.A., R.Ph. DUR Coordinator, WY-DUR University of Wyoming-School of Pharmacy P.O. Box 3375 Laramie, WY 82071-3375 P: 307/766-6120

Contractor Shannon Whalen Pharmacy Program Manager Office of Primary Care-CAFHD 2300 Capital Ave, 154 Hathaway Bldg. Chyenne, WY 82002 P: 307/777-3016 F: 307/777-6964 E-mail: [email protected]

WISCONSIN Contracted DUR

WYOMING Contracted DUR

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National Pharmaceutical Council

Pharmaceutical Benefits 2000

CLAIMS SUBMISSION, 2000 ALABAMA

COLORADO

Ricky Pope Account Manager, EDS 301 Technacenter Dr. Montgomery, AL 36117 P: 334/215-0111

Consultec, Inc. 600 17th Street Suite 600 North Denver CO 80203 P: 800/237-0757 F: 303/534-0435

ALASKA Rose-Ellen Hope Pharmacist First Health 565 Union St. NE #205 Salem, OR 97301 P: 503/391-0184

CONNECTICUT Twila Smith Account Manager EDS 100 Stanley Drive New Britain, CT 06053 P: 860/832-5800

ARIZONA AHCCCS/DBF/CLMS Lori Petre, Claims Administrator 701 E. Jefferson Phoenix, AZ 85034 P: 602/417-4547

DELAWARE Thomas Ignudo Account Manager EDS 248 Chapman Rd Newark, DE 19702

ARKANSAS John Herzog Account Manager EDS Federal Corp 500 East Markham, Suite 400 Little Rock, AR 72201 P: 501/374-6608 F: 501/372-2971 E-mail: [email protected] CALIFORNIA Dennis Dworman Executive Program Director EDS-Medi-Cal Electronic Data Systems 3215 Prospect Park Drive Rancho Cordova, CA 95670 P: 916/636-1000 F: 916/636-1000

National Pharmaceutical Council

DISTRICT OF COLUMBIA Contact not provided FLORIDA Mark Steck PBM Director Consultec, Inc. 9040 Roswell Rd. Suite 700 Atlanta, GA 30350 P: 770/594-7799 GEORGIA Cheryl Collier Account Manager, EDS 736 Park North Blvd P.O. Box 736 Clarkston, GA 30021 P: 404/297-3700 F: 404/298-1031

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Pharmaceutical Benefits 2000

HAWAII

LOUISIANA

Luukia Abbley Supervisor, Medicaid HMSA - Medicaid Claims Service P.O. Box 860 Honolulu, HI 96808 P: 808/948-5361

Department of Health and Hospitals Susan Taskin, Chief, MMIS P.O. Box 91030 Baton Rouge, LA 70821 P: 225/342-9494 MAINE

IDAHO EDS P.O. Box 1168 Boise, ID 83701 P: 208/395-2000

Marcia Pykare Goold Health Systems 12 Stone Street Augusta, ME 04332 P: 207/622-7153

ILLINOIS

MARYLAND

Self-administered

Charlotte Krueger, Chief First Health Services Corporation Division of Claims Processing 201 W. Preston St. Baltimore, MD 21201 P: 401/767-5347 F: 410/333-7186

INDIANA EDS 950 North Meridan Street, 11th Floor Indianapolis, IN 46204 P: 317/488-5000 IOWA Kristi Sheakley Account Manager Consultec, Inc. P.O. Box 14422 Des Moines, IA 50306-3422 P: 515/327-0950 x1108 F: 515/327-0945 KANSAS Blue Cross Blue Shield of Kansas P.O. Box 3571 Topeka, KS 66611 P: 800/933-6593

MASSACHUSETTS Unisys P.O. Box 9101 Somerville, MA 02145 P: 617/576-4451 MICHIGAN First Health Services Corp. 4300 Cox Rd. Glen Allen, VA 23060 MINNESOTA Minnesota Dept. of Human Services P: 415/588-5454

KENTUCKY

MISSISSIPPI

Unisys-Provider Services P.O. Box 2100 Frankfort, KY 40602 P: 502/226-1140 F: 502/226-1860

Terry Childress Director of Systems 239 North Lamar St. Jackson, MS 39201-1399 P: 601/359-6050 E-mail: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2000

MISSOURI

NEW MEXICO

GTE Data Services Jim Judge 905 Weathered Rock Rd. Jefferson City, MO 65101 P: 573/635-2434

Neil Solomon P: 505/827-3174

MONTANA Consultec, Inc. Brett Jakovac, Account Manager 34 N. Last Chance Gulch, Ste. 200 Helena, MT 59601 P: 406/442-1837 NEBRASKA First Health Services Corp. Janice Jones, R.Ph., Clinical Pharmacy Manager 4300 Cox Rd. Glen Allen, VA 23060 P: 804/965-7517 F: 804/273-6961 E-mail: [email protected]

NEW YORK Computer Sciences Corporation 800 North Pearl Street Albany, NY 12204 P: 518/447-9200 NORTH CAROLINA EDS Sharon Greeson, R.Ph., Pharmacist Consultant 4905 Waters Edge Dr. Raleigh, NC 27606 P: 919/233-6829 F: 919/859-9703 E-mail: [email protected] NORTH DAKOTA

Anthem/ Blue Cross Blue Shield P.O. Box 12127 Reno, NV 89510-2127 P: 775/448-4020

Cindy Froler Department of Human Services State Capital, 600 East Boulevard Department 325 Bismarck, ND 58505-0250 P: 701/328-4023 F: 701/328-1544 E-mail: [email protected]

NEW HAMPHSHIRE

OHIO

EDS Gary Patenaude, Account Manager 7 Eagle Square Concord, NJ 03301 P: 603/225-4899 E-mail: [email protected]

First Health Services Corp. 4300 Cox Rd. Glen Allen, VA 23060 P: 800/884-2822 F: 800/884-7682

NEVADA

OKLAHOMA NEW JERSEY Unisys P.Ringel, Chief Architect 3705 Quakerbridge Rd., Suite 101 Trenton, NJ 08619 P: 609/588-6000 F: 609/584-8270 E-mail: [email protected]

National Pharmaceutical Council

Laura Dickey-Hottel DP Analyst/Planning Specialist III Oklahoma Health Care Authority 4545 N. Lincoln Blvd, Suite 124 Oklahoma City, OK 73105-9901 P: 405/522-7228 F: 405/522-7378 E-mail: [email protected]

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Pharmaceutical Benefits 2000

OREGON

UTAH

Mariellen Rich, R.Ph. Director, Pharmacist Account Manager First Health Service, Corporation 565 Union St., NE, Suite 205 Salem, OR 97310 P: 503/391-1980 F: 503/391-1979 E-mail: [email protected]

Brenda Bryant (In-House) Health Care Financing 288 North 1460 West Salt Lake City, UT 84114

PENNSYLVANIA EDS

VERMONT EDS 312 Hurricane Lane, Ste 101 Williston, VT 05495 P: 802/879-4450 F: 802/878-3440 E-mail: [email protected]

RHODE ISLAND Contact not provided. SOUTH CAROLINA Rod Davis Bureau Chief, Bureau of Information Systems S.C. Department of Health & Human Services P.O. Box 8206 Columbia, SC 29202-8206 P: 803/898-2610 E-mail: [email protected] SOUTH DAKOTA Meredith Heerman SD Dept. of Social Services Claims Processing Supervisor 700 Governors Dr. Pierre, SD 57501 P: 605/773-3495 E-mail: [email protected] TENNESSEE Contact not provided TEXAS Texas Dept. of Health Patsy McElroy, Director, Electronic Claims Management 1100 West 49th Street Austin, TX 78756 P: 512/338-6909 E-mail: [email protected] A-24

VIRGINIA First Health Services Glen Allen, VA WASHINGTON Chris Johnson Claims Processing Manager Medical Assistance Administrator P.O. Box 45560 Olympia, WA 98504-5506 P: 360/725-1067 F: 360/586-4994 E-mail: [email protected] WEST VIRGINIA Consultec, Inc. Leslie Bratton, Account Manager 9040 Roswell Road, Suite 700 Atlanta, GA 30350 P: 800/358-2381 F: 800/793-2305 E-mail: [email protected] WISCONSIN Mark Gajewski Account Director EDS 6406 Bridge Road Madison, WI 53713 P: 608/221-9326

National Pharmaceutical Council

Pharmaceutical Benefits 2000

WYOMING Consultec, Inc. Jennifer Dillinger, Account Manager P.O. Box 667 Cheyenne, WY 82003 P: 307/777-5500

National Pharmaceutical Council

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Pharmaceutical Benefits 2000

National Pharmaceutical Council

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Pharmaceutical Benefits 2000

PRESCRIPTION PRICE UPDATING CONTACTS, 2000 ALABAMA

CONNECTICUT

First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 P: 650/588-5454

First DataBank 1111 Bayhill Drive San Bruno, CA 94066 P: 650/588-5454

ALASKA

DELAWARE

Dave Campana, R.Ph Pharmacy Program Manager Division of Medical Assistance 4501 Business Park Blvd., Ste. 24 Anchorage, AK 99503 P: 907/273-3224 F: 907/561-1684 E-mail: [email protected]

Cynthia Denemark Pharmacist Consultant EDS 248 Chapman Road, Suite 200 Newark, DE 197029720 P: 302/453-8453 F: 302/454-7603 E-mail: [email protected]

ARIZONA

DISTRICT OF COLUMBIA

Joan Terry DBF/CLMS/AHCCCS 701 E. Jefferson Phoenix, AZ 85034 P: 602/417-7927

First DataBank 1111 Bayhill Drive San Bruno, CA 94066 P: 650/588-5454 FLORIDA

ARKANSAS First DataBank 1111 Bayhill Drive San Bruno, CA 94066 P: 650/588-5454

First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 P: 650/588-5454 GEORGIA

CALIFORNIA EDS PO Box 13029 Sacramento, CA 95813-4029 P: 916/636-1000 COLORADO Allen Chapman Department of Health Care Policy and Financing 1575 Sherman St., 5th Floor Denver, CO 00008-0203 P: 303/866-3176 F: 303/866-2573

National Pharmaceutical Council

Etta L. Hawkins, R.Ph. Department of Community Health-Medical Division 2 Peachtree Street, 37th Floor Atlanta, GA 30303-3159 P: 404/657-7239 F: 404/656-8366 E-mail: [email protected] HAWAII First DataBank 111 Bayhill Dr. San Bruno, CA 94066 P: 800/633-3453

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Pharmaceutical Benefits 2000

IDAHO

LOUISIANA

Gary Duerr, R.Ph. Pharmacy Services Specialist Idaho Medicaid Policy Americana Terrace, Suite 140 PO Box 83720 Boise, ID 83720-0036 P: 208/364-1829 F: 203/364-1846

Maggie Vick Unisys PO Box 3396 Baton Rouge, LA 70809 P: 225/219-3251 F: 225/219-4164 E-mail: [email protected] MAINE

ILLINOIS First Data Bank 1111 Bay Hill Drive San Bruno, CA 94066 P: 650/588-5454

Kathy Chadwick First DataBank 1111 Bay Hill Drive San Bruno, CA 94066 P: 800/633-3453 E-mail: [email protected]

INDIANA First DataBank 1111 Bay Hill Drive San Bruno, CA 94066 P: 650/588-5454

MARYLAND First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 P: 650/588-5454

IOWA Sherey Swanson Deputy Account Manager Consultec, Inc. P.O. Box 14422 Des Moines, IA 50306-3422 P: 515/327-0950 x1107 F: 515/327-0945

MASSACHUSETTS Christopher Burke Pharmacy Program Analyst Division of Medical Assistance 600 Washington Street Boston, MA 02111 P: 617/210-5592 F: 617-210-5597

KANSAS Karen Braman, R.Ph., M.S. Health Care Policy Division Kansas Department of Social and Rehabilitation Services 915 SW Harrison, Room 651-South DSOB Topeka, KS 66612-1570 P: 785/296-3981

MICHIGAN First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 P: 650/588-5454 F: 650/827-4578

KENTUCKY Unisys-Provider Services P.O. Box 2100 Frankfort, KY 40602 P: 502/226-1140

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National Pharmaceutical Council

Pharmaceutical Benefits 2000

MINNESOTA

NEW HAMPSHIRE

First DataBank 1111 Bay Hill Drive San Bruno, CA 94066 P: 650/588-5454 F: 650/827-4578

First DataBank 1111 Bay Hill Drive San Bruno, CA 94066 P: 650/588-5454 F: 650/827-4578

MISSISSIPPI

NEW JERSEY

Jack Lee, R.Ph. Pharmacy Program Administrator Div. Of Medicaid, Office of the Governor 239 North Lamar St., Ste. 801 Jackson, MS 39201-1399 P: 601/359-6296 F: 601/369-4185

First DataBank, Inc. 1111 Bayhill Drive San Bruno, CA 94066 P: 650/588-5454 F: 650/827-4578

MISSOURI First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 P: 650/588-5454 F: 650/827-4578 MONTANA First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 P: 650/588-5454 F: 650/827-4578 NEBRASKA First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 P: 650/588-5454 F: 650/827-4578 NEVADA First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 P: 650/588-5454 F: 650/827-4578

National Pharmaceutical Council

NEW MEXICO Neil Solomon Medicaid Assistance Division P. O. Box 2348 Santa Fe, NM 87504 P: 505/827-3174 NEW YORK Carl Cioppa Pharmacy Program Specialist Pharmacy Policy and Operations Office of Medicaid Management NYS Dept. of Health 99 Washington Ave., Suite 606 Albany, NY 12210 P: 518/486-3209 F: 518/473-55008 E-mail: [email protected] NORTH CAROLINA C. Benny Ridout, R.Ph. Pharmacist Director NC Division of Medical Assistance 1985 Umstead Drive 2511 Mail Service Center Raleigh, NC 27699-2511 P: 919/857-4034 F: 919/733-2796 E-mail: [email protected]

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Pharmaceutical Benefits 2000

NORTH DAKOTA

SOUTH CAROLINA

First DataBank, Inc. 1111 Bayhill Drive San Bruno, CA 94066 P: 800/633-3453

First DataBank, Inc. 1111 Bayhill Drive San Bruno, CA 94066 P: 650/588-5454 F: 650/588-4003

OHIO First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 P: 650/588-5454 F: 650/827-4578 OKLAHOMA Angela Thomasson Pharmacy Claims Specialist Oklahoma Health Care Authority 4545 N. Lincoln Blvd., Suite 124 Oklahoma City, OK 73105-9901 P: 405/522-7307 F: 405/522-7378 E-mail: [email protected] OREGON Kathy Frankiln Customer Support Department First DataBank, Inc. 1111 Bayhill Drive San Bruno, CA 94066 P: 650/588-5454 F: 650/588-4003 PENNSYLVANIA First DataBank, Inc. 1111 Bayhill Drive San Bruno, CA 94066 P: 800/633-3453

SOUTH DAKOTA Mark Petersen, R.Ph. Department of Social Services 700 Governors Drive Pierre, SD 57501 P: 605/773-3498 F: 605/773-5246 E-mail: [email protected] TENNESSEE Contact Not Provided TEXAS Martha McNeill Director, Product Enrollment Division Texas Department of Health 1100 West 49th Street Austin, TX 78756-3174 P: 512/338-6965 F: 512/338-6462 UTAH RaeDell Ashley Pharmacy Director Health Care Financing 288 N. 1460 West, P.O. Box 143102 Salt Lake City, UT 84114-2905 P: 801/538-6495 F: 801/538-6099 VERMONT

RHODE ISLAND Paula J. Avarista, R.Ph. Department of Human Services 600 New London Avenue Cranston, RI 02920 P: 401/462-2183 F: 401/462-2185

A-30

Christine Dapkiewicz Drug Rebate Coordinator EDS 312 Hurricane Lane Williston, VT 05495 P: 802/879-4450 F: 802/878-3440

National Pharmaceutical Council

Pharmaceutical Benefits 2000

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 Pharmacy Program Manager Medical Assistance Administration--DSHS P.O. Box 45506 Olympia, WA 98504-5506 P: 360/725-1569 E-mail: [email protected] 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: [email protected] 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

National Pharmaceutical Council

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Pharmaceutical Benefits 2000

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National Pharmaceutical Council

Pharmaceutical Benefits 2000

MEDICAID DRUG REBATE, 2000 ALABAMA

COLORADO

Jim Morrison Alabama Medicaid Agency 501 Dexter Avenue Montgomery, AL 36103-5624 334/242-2323 E-mail: [email protected]

Vince Sherry Department of Health Care Policy and Financing 1575 Sherman St., 5th Floor Denver, CO 00008-0203 P: 303/866-5408 F: 303/866-2573

ALASKA

CONNECTICUT

Dave Campana, R.Ph Pharmacy Program Manager Division of Medical Assistance 4501 Business Park Blvd., Ste. 24 Anchorage, AK 99503 P: 907/273-3224 F: 907/561-1684

Ellen Arce, R.Ph. Pharmacy Team Lead EDS 100 Stanley Drive New Britain, CT 06053 P: 860/832-5885 F: 860/832-5832

ARIZONA

DELAWARE

AHCCCS/DBF/CLMS Lori Petre, Claims Administrator 701 E. Jefferson Phoenix, AZ 85034 P: 602/417-4547

Christine Whitlock Rebate Analyst EDS 248 Chapman Road Newark, DE 19702 P: 302/454-7622 F: 302/454-7603 E-mail: [email protected]

ARKANSAS Suzette Bridges, P.D. Department of Human Services Division of Medical Services Pharmacy Program P.O. Box 1437, Slot 4105 Little Rock, AR 72203 P: 501/324-9141 CALIFORNIA Craig Miller Chief, Contracting Unit Medi-Cal Policy Division 714 P Street, Room 1540 Sacramento, CA 95814 P: 916/654-0532 F: 916/654-0513 E-mail: [email protected]

National Pharmaceutical Council

DISTRICT OF COLUMBIA Contact not provided FLORIDA Greg Bracko Rebate Coordinator AHCA 2727 Mahan Dr. Tallahassee, FL 32308 P: 850/488-9193 E-mail: [email protected]

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Pharmaceutical Benefits 2000

GEORGIA

IOWA

Susan Oh Drug Rebate Coordinator Department of Community Health 2 Peachtree St. 37th Floor Atlanta, GA 30303 P: 404/657-9181 F: 404/656-8366 E-mail: [email protected]

Rocco Russo Third Party Liability Manager Consultec, Inc. P.O. Box 14422 Des Moines, IA 50306-3422 P: 515/327-0950 x1114

HAWAII Brian Pang Finance Officer Department of Human Services Med QUEST Division P.O. Box 339 Honolulu, HI 96809-0339 P: 808/692-7956 F: 808/692-7989 IDAHO David Mendoza Medicaid Programs P.O.Box 83720 Boise, ID 83720-0036 P: 208/364-1838 F: 208/364-1846 E-mail: [email protected] ILLINOIS Alberta Levan Supervisor Illinois Department of Public Aid 110 West Lawrence Springfield, IL 62763 P: 217/524-7161 F: 217/524-5176 INDIANA EDS 950 North Meridan Street, 11th Floor Indianapolis, IN 46204 P: 317/488-5000

A-34

KANSAS Karen Braman, R.Ph., M.S. Health Care Policy Division KS Dept of Social and Rehabilitation Services 915 SW Harrison, Room 651-South DSOB Topeka, KS 66612-1570 P: 785/296-3981 KENTUCKY Marie Couch Department for Medicaid Services 275 E. Main St. Frankfort, KY 40621 P: 502/564-3476 F: 502/564-3852 LOUISIANA Susan Taskin, Chief, MMIS Department of Health and Hospitals P.O. Box 91030 Baton Rouge, LA 70821 P: 225/342-9494 MAINE Rossi Rowe TPL Manager DHS/BMS Building 205, 2nd Fl. Augusta, ME 04333-0011 P: 207/287-1838 F: 207/287-1788 E-mail: [email protected]

National Pharmaceutical Council

Pharmaceutical Benefits 2000

MARYLAND

MISSOURI

Kenneth Smoot Deputy Director Office of Management and Finance 201 W. Preston St. Baltimore, MD 21201 P: 401/767-5186 F: 410/333-5409

Lynn Hebenheimer Pharmacy Rebate Manager Division of Medical Services P.O. Box 6500 Jefferson City, MO 65102 P: 573/751-2005 F: 573/526-2045 E:mail: [email protected]

MASSACHUSETTS Paula McAree Drug Rebate Specialist Division of Medical Assistance 600 Washington St. Boston, MA 02111 P: 617/210-5594 F: 617/210-5597 E-mail: [email protected] MICHIGAN Dawn Parsons, R.Ph. MDCH/Medical Services Administration 400 S. Pine St. Lansing, MI 48933 P: 517/335-5078 E-mail: [email protected] MINNESOTA Jarvis Jackson, R.Ph. Drug Rebate Coordinator Dept. of Human Services 444 Lafayette Rd. St. Paul, MN 55155-3849 P: 651/282-5881 F: 651/282-6744 E-mail: [email protected] MISSISSIPPI Glenda Grant Rebate Coordinator 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: [email protected]

National Pharmaceutical Council

MONTANA Betty DeVaney Drug Rebate Coordinator Dept. of Public Health and Human Services P.O. Box 202951 Helena, MT 59620-2951 P: 406/444-3457 F: 406/444-1861 [email protected] NEBRASKA Arlene Rogers Fiscal Project Analyst HHSS-Finance and Support NSOB, 5th Floor Lincoln, NE 68509 P: 402/471-9159 F: 7402/471-7783 E-mail: [email protected] NEVADA Laurie Squartsoff, R.Ph. Pharmacy Services Consultant Nevada Medicaid 2527 N. Carson St. Capitol Complex Carson City, NV 89710 P: 775/687-4869 F: 775/687-8724 [email protected]

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NEW HAMPHSHIRE

NORTH DAKOTA

Julie Simpson, R.Ph. EDS Federal Corp. 7 Eagle Square Concord, NH 03301 P: 603/224-1747 ext. 3016 E-mail: [email protected]

Cindy Frolick Department of Human Services State Capital, 600 East Boulevard Department 325 Bismarck, ND 58505-0250 P: 701/328-4023 F: 701/328-1544 E-mail: [email protected]

NEW JERSEY Carl Tepper, R.Ph. Chief, Pharmaceutical Services Department of Human Services Division of Medical Assistance and Health Services P.O. Box 712, Bldg 11-A Trenton, NJ 08625 P: 609/588-2724 F: 609/588-3889 E-mail: [email protected]

OHIO Program Administrator OKLAHOMA

Neil Solomon P: 505/827-3174

Tom Simonson Drug Rebate Manager Oklahoma Health Care Authority 4545 N. Lincoln Blvd, Suite 124 Oklahoma City, OK 73105-9901 P: 405/522-7327 F: 405/522-7472 E-mail: [email protected]

NEW YORK

OREGON

Mark-Richard Butt, M.S., R.Ph. Director, Pharmacy Policy and Operations NYS Department of Health Office of Medicaid Management 99 Washington Ave., Room 606 Albany, NY 12210 P: 518/486-3209 F: 518/473-5508

Becky Smith Rebate Analyst First Health Services Corporation 565 Union St. NE, Suite 205 Salem, OR 97301 P: 503/391-1981 F: 503/391-1979 E-mail: [email protected]

NORTH CAROLINA

PENNSYLVANIA

Sharon Greeson, R.Ph. Pharmacist Consultant EDS 4905 Waters Edge Dr. Raleigh, NC 27606 P: 919/233-6829 F: 919/859-9703 E-mail: [email protected]

EDS

NEW MEXICO

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RHODE ISLAND Contact not provided.

National Pharmaceutical Council

Pharmaceutical Benefits 2000

SOUTH CAROLINA

VIRGINIA

Kathy Bass Department Head S.C. Department of Health & Human Services P.O. Box 8206 Columbia, SC 29202-8206 P: 803/898-2974 E-mail: [email protected]

First Health Services Glen Allen, VA

SOUTH DAKOTA Helen Rokusek Rebate Coordinator SD Dept. of Social Services 700 Governors Dr. Pierre, SD 57501 P: 605/773-3653 TENNESSEE Contact not provided TEXAS Texas Dept. of Health Patsy McElroy, Director, Electronic Claims Management 1100 West 49th Street Austin, TX 78756 P: 512/338-6909 E-mail: [email protected] UTAH Brenda Bryant (In-House) Health Care Financing 288 North 1460 West Salt Lake City, UT 84114 VERMONT Christine Dapkiewicz Drug Rebate Coordinator EDS 312 Hurricane Lane Williston, VT 05495 P: 802/879-4450 F: 802/878-3440

National Pharmaceutical Council

WASHINGTON Sue Hilton Drug Rebate Manager Medical Assistance Administration P.O. Box 45503 Olympia, WA 98504-5503 P: 360/725-1251 F: 360/586-2373 E-mail: [email protected] WEST VIRGINIA Gail Goodnight, R.Ph. Rebate Coordinator DHHR, Bureau for Medical Services 350 Capitol Street, Room 251 Charleston, WV 25301-3707 P: 304/558-1700 F: 304/558-1542 [email protected] WISCONSIN Ellen Orsborne Division of Health Care Financing Department of Health and Family Services One West Wilson Street, Rm 472 P.O. Box 309 Madison, WI 53701-0309 P: 608/267-7939 F: 608/266-1096 WYOMING Shannon Whalen Pharmacy Program Manager Office of Primary Care-CAFHD 2300 Capital Ave, 154 Hathaway Bldg. Cheyenne, WY 82002 P: 307/777-6016 F: 307/777-6964 [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2000

STATE OFFICIALS, 2000 ALABAMA

ARIZONA

Governor Honorable Don Siegelman State Capitol 600 Dexter Avenue Montgomery, AL 36103 334/242-7100 Single State Agency Director Mr. W. Dale Walley Acting Commissioner, Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery, AL 36103-5624 334/242-5010 Medicaid Director Mr. W. Dale Walley Acting Commissioner, Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery, AL 36103-5624 334/242-5600 F: 334/242-5097 E-mail – [email protected]

Governor Honorable Jane Dee Hull State Capitol 1700 W. Washington Phoenix, AZ 85007 602/542-4331 Single State Agency Director Ms. Phyllis Beidess, Director Arizona Health Care Cost Containment System 80l East Jefferson Street Phoenix, AZ 85034 602/417-4680 F: 602/252-6536 E-mail – [email protected] Medicaid Director Ms. Phyllis Beidess, Director Arizona Health Care Cost Containment System 801 East Jefferson Street Phoenix, AZ 85034 602/417-4680 F: 602/252-6536 E-mail – [email protected]

ALASKA

ARKANSAS

Governor Honorable Tony Knowles P.O. Box 110001 Juneau, AK 99811-0001 907/465-3500 Single State Agency Director Ms. Karen Perdue Commissioner Department of Health and Social Services P.O. Box 110601 Juneau, AK 99811-0601 907/465-3030 Medicaid Director Mr. Bob Labbe Director Division of Medical Assistance Department of Health and Social Services P.O. Box 110660 Juneau, AK 99811-0660 907/465-3355 F: 907/465-2204 E-mail – [email protected]

Governor Honorable Mike Huckabee State Capitol Building Little Rock, AR 72201 501/682-2345 Single State Agency Director Mr. Kurt Knickrehm, Director Department of Human Services P.O. Box 1437, Slot 329 Little Rock, AR 72203-1437 501/682-8650 Fax 501/682-6836 E-mail – [email protected] Medicaid Director Mr. Ray Hanley, Director Division of Medical Services Dept. of Human Services P.O. Box 1437, Slot 1100 Little Rock, AR 72203-1437 50l/682-8292 F: 501/682-1197 E-mail – [email protected]

National Pharmaceutical Council

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Pharmaceutical Benefits 2000

CALIFORNIA

CONNECTICUT

Governor Honorable Gray Davis State Capitol, First Floor Sacramento, CA 958l4 916/445-2841 F: 916/445-4633 Single State Agency Director Ms. Diana M. Bonta, Director 714 P Street, Room 1253 Sacramento, CA 95814 916/657-1425 Medicaid Director Ms. Gail M. Margolis, Deputy Director Medical Care Services Department of Health Services 714 P Street, Room 1253 Sacramento, CA 95814 916/654-0391 F: 916/657-1156 E-mail – [email protected]

Governor Honorable John G. Rowland State Capitol, Room 202 Hartford, CT 06l06 860/566-4840 Single State Agency Director Ms. Patricia Wilson-Coker, Commissioner Department of Social Services 25 Sigourney Street Hartford, CT 06106-5033 860/424-5008 Medicaid Director Mr. David Parella, Deputy Commissioner Department of Social Services 25 Sigourney Street Hartford, CT 06106-5116 860/424-5116 F: 860/424-5114 E-mail – [email protected]

COLORADO Governor Honorable Bill Owens State Capitol Room 136 Denver, CO 80203 303/866-2471 F: 303/866-2003 Single State Agency Director Mr. James T. Rizzuto Executive Director Department of Human Services l575 Sherman Street Denver, CO 80203-1714 303/866-5096 F: 303/866-4740 E-mail – [email protected] Medicaid Director Mr. Richard Allen Executive Director Department of Health Care Policy and Financing l575 Sherman Street Denver, CO 80203-1714 303/866-5401 F: 303/866-2803 TDD 303/866-3883 E-mail – [email protected]

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DELAWARE Governor Honorable Thomas R. Carper Tatnall Building William Penn Street Dover, DE 19901 302/739-4101 Single State Agency Director Mr. Greg Sylvester Secretary Department of Health and Social Services 1901 North DuPont Highway New Castle, DE l9720 302/421-6705 Medicaid Director Mr. Philip Soulé, Sr. Director Medical Assistance Program Department of Health and Social Services P.O. Box 906, Lewis Building 1901 North DuPont Highway New Castle, DE 19720 302/577-4901 F: 302/577-4577 E-mail – [email protected]

National Pharmaceutical Council

Pharmaceutical Benefits 2000

DISTRICT OF COLUMBIA

GEORGIA

Mayor Honorable Anthony A. Williams District of Columbia 441 4th Street, NW Suite 1100 Washington, DC 20001 202/727-2980 Single State Agency Director Ivan C. A. Walks, MD, Director Department of Health 825 North Capitol S., NE Fourth Floor Washington, DC 20002 202/442-5999 F: 202/442-4788 Medicaid Director Mr. Herbert H. Weldon, Jr., Deputy Director Medical Assistance Administration Department of Health 825 North Capitol S., NE Fifth Floor Washington, DC 20002 202/442-9090

Governor Honorable Roy Barnes 203 State Capitol Atlanta, GA 30334 404/656-l776 Single State Agency Director Russ Toal, Commissioner Department of Community of Health 2 Peachtree Street, NW Suite 4043 Atlanta, GA 30303-3159 404/656-4479 Medicaid Director Gary B. Redding, Director Department of Community Health 2 Peachtree Street, NW Suite 4043 Atlanta, GA 30303-3159 404/656-4479 F: 404/651-6880 E-mail – [email protected]

FLORIDA

Governor Honorable Carl T. C. Gutierrez Adelup Complex P.O. Box 2950 Agana, GU 96932 671/472-8931 F: 671/472-4926 Single State Agency Director Dennis Rodriguez, Director Dept. of Public Health and Social Services P.O. Box 2816 Agana, GU 96910 671/734-7123 F: 671/734-5910 Medicaid Director Ms. Ma Theresa Arcangel, Acting Administrator Bureau of Health Care Financing Department of Public Health and Social Services P.O. Box 28l6 Agana, GU 96910 671/735-7269 F: 671/734-5910

Governor Honorable Jeb Bush State Capitol Plaza 05 Tallahassee, FL 32399-0001 904/488-2272 Single State Agency Director Mr. Ruben King-Shaw, Director Agency for Health Care Administration 325 John Knox Road Suite 301 Atrium Tallahassee, FL 32303 904/922-5527 Medicaid Director Mr. Gary Crayton, Director of Medicaid Agency for Health Care Administration 2727 Mahan Drive, Bldg. 3 Tallahassee, FL 32308 850/922-6463 F: 850/488-3560 E-mail – [email protected]

National Pharmaceutical Council

GUAM

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Pharmaceutical Benefits 2000

HAWAII

ILLINOIS

Governor Honorable Carl Benjamin J. Cayetano State Capitol Honolulu, HI 968l3 808/586-0034 Single State Agency Director Ms. Susan M. Chandler, Director Department of Human Services P.O. Box 339 Honolulu, HI 96809-0339 808/586-4997 Medicaid Director Mr. Chuck C. Duarte, Administrator Med-Quest Division Department of Human Services P.O. Box 399 Honolulu, HI 96809-0339 808/692-8056 F: 808/692-8173 E-mail – [email protected]

Governor Honorable George H. Ryan 207 Capitol Building State Capitol Springfield, IL 62706 2l7/782-6830 Single State Agency Director Ms. Ann Patla, Dr.HL, Director Department of Public Aid 201 South Grand Avenue, East, Third Floor Springfield, IL 62763-0001 2l7/782-6717 F: 217/524-7979 Medicaid Director Mr. Matt Powers, Administrator Department of Public Aid 20l South Grand Avenue, East, Third Floor Springfield, IL 62763-0001 2l7/782-2570 F: 217/524-7979 E-mail – [email protected]

IDAHO Governor Honorable Dirk Kempthorne P.O. Box 83720 Boise, ID 83720-0034 208/334-2100 Single State Agency Director Mr. Karl Kurtz, Director Department of Health and Welfare 450 West State Street Boise, ID 83720-0036 208/334-5500 F: 208/334-6558 Medicaid Director Mr. Joe Brunson, Administrator Division of Medicaid Department of Health and Welfare Americana Building P.O. Box 83720 Boise, ID 83720-0036 208/364-1802 F: 208/334-1811 E-mail: [email protected]

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INDIANA Governor Honorable Frank O’Bannon State House, Room 206 Indianapolis, IN 46204 3l7/232-4567 Single State Agency Director Mr. Peter Sybinsky, Secretary Family and Social Services Administration Room 461, Mail Stop 25 P.O. Box 7083 402 W. Washington Street Indianapolis, IN 46207-7083 317/233-4452 E-Mail: [email protected] Medicaid Director Ms. Kathleen D. Gifford, Assistant Secretary Medicaid Policy and Planning Family and Social Services Administration 402 W. Washington Street, Room W382 Indianapolis, IN 46204-2739 317/233-4455 F: 317/232-7382 E-Mail: [email protected]

National Pharmaceutical Council

Pharmaceutical Benefits 2000

IOWA

KENTUCKY

Governor Honorable Thomas J. Vilsack State Capitol Building Des Moines, IA 503l9 5l5/28l-5211 F: 515/281-6611 Single State Agency Director Jessie K. Rasmussen, Director Department of Human Services Hoover State Office Building Fifth Floor Des Moines, IA 503l9-0114 5l5/28l-5452 F: 515/281-4597 Medicaid Director Dennis Headlee, Administrator Division of Medical Services Department of Human Services Hoover State Office Building Fifth Floor Des Moines, IA 503l9-0114 5l5/281-8621 F: 515/281-7791

Governor Honorable Paul E. Patton State Capitol Building 700 Capitol Avenue Frankfort, KY 4060l 502/564-2611 Single State Agency Director Mr. Jimmy D. Helton, Commissioner Department for Medicaid Services Third Floor 275 East Main Street Frankfort, KY 40621 502/564-4321 Medicaid Director Mr. Dennis Boyd, Commissioner Department for Medicaid Services Third Floor 275 East Main Street Frankfort, KY 40621 502/564-4321 F: 502/564-0509 E-mail- [email protected]

KANSAS Governor Honorable Bill Graves 2nd Floor State Capitol Building Topeka, KS 66612-1590 785/296-3232 F: 785/296-7973 Single State Agency Director Ms. Janet Schalansky, Secretary Kansas Department of Social and Rehabilitation Services State Office Building Topeka, KS 66612 785/296-3271 F: 785/296-4685 E-mail – [email protected] Medicaid Director Mr. Robert Day, Commissioner Adult and Medical Services Department of Social and Rehabilitation Services Docking State Office Building 915 Harrison Street Topeka, KS 66612 785/296-8904 F: 785/296-4813 E-mail – [email protected]

National Pharmaceutical Council

LOUISIANA Governor Honorable M. J. “Mike” Foster State Capitol P.O. Box 94004 Baton Rouge, LA 70804 504/342-7015 F: 504/342-7099 Single State Agency Director Mr. David W. Hood, Secretary Department of Health and Hospitals P.O. Box 629, Bin #2 Baton Rouge, LA 70821-0629 504/342-9500 F: 504/342-5568 Medicaid Director Mr. Thomas D. Collins, Director Bureau of Health Services Financing Department of Health and Hospitals P.O. Box 91030 Baton Rouge, LA 70821-9030 504/342-3891 F: 504/342-9508 E-mail – [email protected]

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Pharmaceutical Benefits 2000

MAINE

MASSACHUSETTS

Governor Honorable Angus S. King, Jr. 1 State House Station Augusta, Maine 04333-0001 207/287-3531 Single State Agency Director Mr. Kevin Concannon, Commissioner Department of Human Services State House Station 11 Augusta, ME 04333-0011 207/287-2736 Medicaid Director Mr. Francis T. Finnegan, Jr., Director Bureau of Medical Services Department of Human Services State House Station 11 Augusta, ME 04333-0011 207/287-2093 F: 207/287-2675 E-mail: [email protected]

Governor Honorable Argeo Paul Cellucci Executive Office, State House Room 360 Boston, MA 02133 617/727-9173 Single State Agency Director Mr. Bruce Bullen, Commissioner Division of Medical Assistance Medicaid Division 600 Washington Street Boston, MA 02111 617/210-5690 Medicaid Director Mr. Bruce Bullen, Commissioner Division of Medical Assistance 600 Washington Street Boston, MA 02111 617/210-5690 F: 617/210-5697 E-mail: [email protected]

MARYLAND Governor Honorable Parris N. Glendening State House Annapolis, MD 21401 410/974-3901 Single State Agency Director Georges Benjamin, M.D. Secretary Department of Health & Mental Hygiene Herbert R. O'Connor Building 201 West Preston Street Fifth Floor Baltimore, MD 21201 410/225-6535 Medicaid Director Debbie Chang Deputy Secretary for Health Care Financing Department of Health & Mental Hygiene 201 West Preston Street Baltimore, MD 21201 410/767-4664 F: 410/333-7687 E-mail – [email protected]

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MICHIGAN Governor Honorable John Engler P.O. Box 30013 Lansing, MI 48909 5l7/373-3400 Single State Agency Director Mr. James K. Haveman, Jr., Director Michigan Department of Community Health Lewis Cass Building 320 South Walnut Street Lansing, MI 48913 517/335-0267 Medicaid Director Mr. Robert M. Smedes, Chief Executive Officer Medical Services Administration Michigan Department of Community Health 400 S. Pine Street Lansing, MI 48909 517/335-5001 F: 517/335-5007 E-mail – [email protected]

National Pharmaceutical Council

Pharmaceutical Benefits 2000

MINNESOTA

MISSOURI

Governor Honorable Jesse Ventura 130 State Capitol St. Paul, MN 55155-1099 651/296-3391 Single State Agency Director Mr. Michael O’Keefe, Commissioner Minnesota Department of Human Services 444 Lafayette Road North St. Paul, MN 55155-3815 651/296-2701 F: 651/297-3230 E-mail – [email protected] Medicaid Director Ms. Mary B. Kennedy, Medicaid Director Assistant Commissioner Health Care Minnesota Department of Human Services 444 Lafayette Road St. Paul, MN 55l55-3852 651/282-9921 F: 651/297-3230 E-mail – [email protected]

Governor Honorable Mel Carnahan State Capitol Building P.O. Box 720 Jefferson City, MO 65101 573/751-3222 F: 573/751-1495 Single State Agency Director Mr. Gary J. Stangler, Director Department of Social Services P.O. Box 1527 Jefferson City, MO 65102 573/751-4815 F: 573/751-3203 Medicaid Director Mr. Gregory A. Vadner Division of Medical Services Department of Social Services 615 Howerton Court P.O. Box 6500 Jefferson City, MO 65102-6500 573/751-6922 F: 573/751-6564 E-mail – [email protected]

MISSISSIPPI Governor Honorable Kirk Fordice State Capitol P.O. Box 139 Jackson, MS 39205 60l/359-3150 Single State Agency Director Ms. Helen Wetherbee, Executive Director Division of Medicaid Office of the Governor Suite 801, Robert E. Lee Building 239 North Lamar Street Jackson, MS 39201-1399 601/359-6050 Medicaid Director Ms. Helen Wetherbee, Executive Director Division of Medicaid Office of the Governor Suite 801, Robert E. Lee Building 239 North Lamar Street Jackson, MS 39201-1399 601/359-6050 F: 601/359-6048 E-mail – [email protected]

National Pharmaceutical Council

MONTANA Governor Honorable Marc Racicot Capitol Station Helena, MT 59620-0801 406/444-3111 Single State Agency Director Ms. Laurie Ekanger, Director Department of Public Health and Human Services P.O. Box 4210 111 N. Sanders Helena, MT 59604-4210 406/444-5622 Medicaid Director Ms. Nancy Ellery, Administrator Division of Health Policy and Services Department of Public Health and Human Services 1400 Broadway Helena, MT 59601 406/444-4141 F: 406/444-1861 E-mail – [email protected]

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Pharmaceutical Benefits 2000

NEBRASKA

NEW HAMPSHIRE

Governor Honorable Mike Johanns P.O. Box 94848 Lincoln, NE 68509-4848 402/471-2244 F: 402/471-6031 Single State Agency Director Jeff Elliot, Director Nebraska Department of Health and Human Services Finance and Support P.O. Box 95026 Lincoln, NE 68509-5026 402/471-8533 F: 402/471-9449 Medicaid Director Bob Seiffert, Administrator Medicaid Division Nebraska Department of HHS Finance and Support P.O. Box 95026 Lincoln, NE 68509-5026 402/471-9506 F: 402/471-9092

Governor Honorable Jeanne Shaheen Room 208 Concord, NH 03301-4990 603/271-2121 Single State Agency Director Mr. Donald L. Shumway, Commissioner Department of Health and Human Services 129 Pleasant Street Concord, NH 03301-3857 603/271-4331 F: 603/271-4912 Medicaid Director Carol Early Medicaid Director Medicaid Administration Bureau Department of Health and Human Services 6 Hazen Drive Concord, NH 03301-6521 603/271-8887 F: 603/271-4376

NEVADA Governor Honorable Kenny C. Guinn State Capitol Carson City, NV 89710 702/687-5670 Single State Agency Director Ms. Charlotte Crawford, Director Department of Human Resources 505 East King Street, Room 600 Carson City, NV 89710 775/684-4000 F: 775/684-4010 Medicaid Director Mr. Mike Willden, Administrator Nevada State Welfare Division 2527 North Carson Street Carson City, NV 89706 775/687-4128 F: 775/687-5080 Mr. Chuck Duarte, Administrator Division of Health Care Financing and Policy 1100 East William Street, Suite 116 Carson City, NV 89701 775/687-4176 ext. 251 F: 775/684-8792 E-mail – [email protected]

A-46

NEW JERSEY Governor Honorable Christine Todd Whitman 125 West State Street State House CN-001 Trenton, NJ 08625 609/292-6000 Single State Agency Director Ms. Michele Guhl, Commissioner Department of Human Services Capitol Place One CN-700, Fifth Floor 222 South Warren Street Trenton, NJ 08625 609/292-3717 Medicaid Director Ms. Margaret A. Murray, Director Division of Medical Assistance and Health Services Department of Human Services P.O. Box 712 Trenton, NJ 08625-0712 609/588-2600 F: 609/588-3583

National Pharmaceutical Council

Pharmaceutical Benefits 2000

NEW MEXICO

NORTH CAROLINA

Governor Honorable Gary E. Johnson State Capitol Suite 400 Santa Fe, NM 87503 505/827-3000 Single State Agency Director Mr. William H. Johnson Jr., Secretary New Mexico Human Services Department P.O. Box 2348 Santa Fe, NM 87504-2348 505/827-7750 800/432-6217 F: 505/827-6286 Medicaid Director Mr. Charles J. Milligan, Director Medical Assistance Division New Mexico Human Services Department P.O. Box 2348 Santa Fe, NM 87504-2348 505/827-3106 888/997-2583 Toll free client info F: 505/827-3185 E-mail: [email protected]

Governor Honorable James B. Hunt, Jr. 116 West Jones Street Raleigh, NC 27603-8001 919/733-4240 Single State Agency Director David Bruton, M.D., Secretary Department of Human and Human Services P.O. Box 29526 101 Blair Drive, Adams Building Raleigh, NC 27626-0526 919/733-4534 Medicaid Director Mr. Paul R. Perruzzi, Director Division of Medical Assistance Department of Health and Human Services 1985 Umstead Drive P.O. Box 29529 Raleigh, NC 27626-0529 919/857-4011 F: 919/733-6608 E-mail – [email protected]

NEW YORK

Governor Honorable Edward T. Schafer 600 East Boulevard Avenue Bismarck, ND 58505-0001 701/328-2200 Single State Agency Director Ms. Carol Olson, Executive Director Department of Human Services 600 East Boulevard Avenue Bismarck, ND 58505-0250 701/328-2310 Medicaid Director Mr. David J. Zentner, Director Division of Medical Assistance Department of Human Services 600 East Boulevard Avenue Bismarck, ND 58505-0261 701/328-3194 F: 701/328-1544 E-mail – [email protected]

Governor Honorable George E. Pataki Executive Chamber State Capitol Albany, NY 12224 5l8/474-1041 Single State Agency Director Antonio C. Novello, M.D., M.P.H., Commissioner NYS Department of Health ESP, Corning Tower Building Albany, NY 12237 518/474-2011 Medicaid Director Kathryn Kuhmerker, Deputy Commissioner NYS Department of Health Office of Medicaid Management Empire State Plaza Room 1466, Corning Tower Building Albany, NY 12237 518/474-3018 F: 518/486-6652 E-mail – [email protected]

National Pharmaceutical Council

NORTH DAKOTA

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Pharmaceutical Benefits 2000

NORTHERN MARIANA ISLANDS

OKLAHOMA

Governor Honorable Froilan C. Tenorio Commonwealth of the Northern Mariana Islands Capitol Hill Saipan, MP 96950 670/322-5091 Single State Agency Director Mr. Joseph K.P. Villagomez Secretary for Health Services Department of Public Health and Environmental Services Commonwealth of the Northern Mariana Islands P.O. Box 409 CK Saipan, MP 96950 670/234-6225 Medicaid Director Ms. Maria A.V. Leon Guerrero, Medical Administrator Department of Public Health and Environmental Services Commonwealth of the Northern Mariana Islands P.O. Box 409 CK Saipan, MP 96950 670/234-8931

Governor Honorable Frank Keating 212 State Capitol Oklahoma City, OK 73105 405/521-2342 Single State Agency Director Garth L. Splinter, M.D. Chief Executive Officer Oklahoma Health Care Authority 4545 North Lincoln Boulevard Suite 124 Oklahoma City, OK 73105 405/522-7439 F: 405/530-3471 Medicaid Director Mr. Michael Fogarty, State Medicaid Director Oklahoma Health Care Authority 4545 North Lincoln Boulevard Suite 124 Oklahoma City, OK 73105 405/522-7373 F: 405/530-3478 E-mail – [email protected]

OHIO Governor Honorable Bob Taft 77 South High Street, 30th Floor Columbus, OH 43266-0601 614/466-3555 Single State Agency Director Ms. Jacqueline Romer-Sensky, Director Department of Human Services 30 East Broad Street, 32nd Floor Columbus, OH 43266-0423 614/466-6282 Medicaid Director Ms. Barbara Edwards, Deputy Director Office of Medicaid Department of Human Services 30 East Broad Street, 31st Floor Columbus, OH 43266-0423 614/644-0140 F: 614/752-3986 E-mail – [email protected]

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OREGON Governor Honorable John A. Kitzhaber State Capitol Salem, OR 97310 503/378-3111 Single State Agency Director Ms. Gary Weeks, Director Department of Human Resources 500 Summer Street, NE Human Resources Building Salem, OR 97310-1012 503/945-5944 Medicaid Director Mr. Hersh Crawford, Director Senior and Disabled Services Division Department of Human Resources 500 Summer Street, NE 2nd Floor Human Resources Building, Third Floor Salem, OR 97310-1015 503/945-5767 F: 503/373-7689 E-mail – [email protected]

National Pharmaceutical Council

Pharmaceutical Benefits 2000

PENNSYLVANIA

RHODE ISLAND

Governor Honorable Thomas J. Ridge 25 Main Capitol Building Harrisburg, PA 17120 717/787-2500 Single State Agency Director Ms. Feather O. Houstoun, Secretary Department of Public Welfare Health and Welfare Building P.O. Box 2675 Harrisburg, PA 17120 717/787-2600 Medicaid Director Margaret J. Dierkers, Ph.D. Deputy Secretary Medical Assistance Programs Department of Public Welfare Health and Welfare Building, Room 515 Harrisburg, PA 17120 717/787-1870 F: 717/787-4639 E-mail – [email protected]

Governor Honorable Lincoln C. Almond State House Room 143 Providence, RI 02903 401/222-2080 Single State Agency Director Ms. Christine C. Ferguson, Director Department of Human Services 600 New London Avenue Cranston, RI 02920 401/462-2121 Medicaid Director Mr. John Young, C.P.M. Associate Director Division of Medical Services Department of Human Services 600 New London Avenue Cranston, RI 02920 401/462-3113 F: 401/462-6338 E-mail – [email protected]

PUERTO RICO

SOUTH CAROLINA

Governor Honorable Pedro Rossello La Fortaleza P.O. Box 82 San Juan, PR 00901 809/721-7000 Single State Agency Director Carmen Feliciano-DeMelecio, M.D. Secretary Department of Health G.P.O. Box 70184 San Juan, PR 00936 809/765-1230 Medicaid Director Ms. Margarita Latorre, Medicaid Director Office of Economic Assistance to the Medically Indigent Department of Health G.P.O. Box 70184 San Juan, PR 00936 809/765-1230 F: 809/250-0990

Governor Honorable Jim Hodges P.O. Box 11369 Columbia, SC 29211 803/734-9818 Single State Agency Director Dr. J. Samuel Griswold, Director Department of Health and Human Services P.O. Box 8206 Columbia, SC 29202-8206 803/253-6100 Medicaid Director Dr. J. Samuel Griswold, Director Department of Health and Human Services P.O. Box 8206 Columbia, SC 29202-8206 803/898-2504 F: 803/898-4515 E-mail – [email protected]

National Pharmaceutical Council

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Pharmaceutical Benefits 2000

SOUTH DAKOTA

TEXAS

Governor Honorable William J. Janklow 500 East Capitol Pierre, SD 57501 605/773-3212 Single State Agency Director Mr. James W. Ellenbecker, Secretary Department of Social Services Richard F. Kneip Building 700 Governors Drive Pierre, SD 57501-2291 605/773-3165 Medicaid Director Mr. David M. Christensen Program Administrator Medical Services Department of Social Services Richard F. Kneip Building 700 Governors Drive Pierre, SD 57501-2291 605/773-3495 F: 605/773-5246 E-mail – [email protected]

Governor Honorable George W. Bush State Capitol P.O. Box 12428 Austin, TX 78711 5l2/463-2000 Single State Agency Director Don Gilbert, Commissioner Health and Human Services Commission P.O. Box 13247 Austin, TX 78711 5l2/424-6502 F: 512/424-6586 E-mail [email protected] Medicaid Director Ms. Linda K. Wertz State Medicaid Director Health and Human Services Commission P.O. Box 13247 Austin, TX 78711 512/424-6549 F: 512/424-6547 E-mail – [email protected]

TENNESSEE Governor Honorable Don Sundquist State Capitol First Floor Nashville, TN 37243-0001 615/741-2001 Single State Agency Director Mr. John Ferguson, Commissioner Department of Finance and Administration 1st Floor, State Capitol Nashville, TN 37219 615/741-2401 Medicaid Director Mr. John Tighe Deputy Commissioner Department of Finance and Administration 729 Church Street Nashville, TN 37247-6501 615/741-0213 F: 615/741-0882 E-mail – [email protected]

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UTAH Governor Honorable Michael O. Leavitt 210 State Capitol Salt Lake City, UT 84114 801/538-1000 Single State Agency Director Mr. Rod Betit, Executive Director Department of Health P.O. Box 141000 Salt Lake City, UT 84114-1000 801/538-6111 Medicaid Director Mr. Rod Betit, Executive Director Department of Health Division of Health Care Financing P.O. Box 14100 Salt Lake City, UT 84114-1000 801/538-6111 F: 801/538-6306

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VERMONT

VIRGIN ISLANDS

Governor Honorable Howard Dean, M.D. 109 State Street Montpelier, VT 05609 802/828-3333 Single State Agency Director Mr. Cornelius D. Hogan, Secretary Agency of Human Services 103 South Main Street Waterbury, VT 05671-0201 802/241-2220 Medicaid Director Mr. Paul Wallace-Brodeur, Director Office of Health Access Department of Social Welfare 103 South Main Street Waterbury, VT 05676 802/241-3985 F: 802/241-2974 E-mail – [email protected]

Governor Honorable Roy L. Schneider Government House 21-22 Kongens Gada Charlotte Amalie St. Thomas, VI 00802 809/774-0001 Single State Agency Director Jose F. Poblete, M.D. Commissioner of Health Virgin Island Department of Health Charles Harwood Hospital 3500 Richmond Christenstead, St. Croix, VI 00820-4370 809/774-0117 Medicaid Director Ms. Priscilla Berry-Quetel, Director Bureau of Health Insurance and Medical Assistance Department of Health 210-3A Altona, Suite 302 Frostco Center Charlotte Amalie, VI 00802 809/774-4624 F: 809/774-4918

VIRGINIA Governor Honorable James S. Gilmore III State Capitol Building, Third Floor Richmond, VA 232l9 804/786-2211 Single State Agency Director Mr. Dennis G. Smith, Director Department of Medical Assistance Services 600 East Broad Street Suite 1300 Richmond, VA 23219 804/786-7933 Medicaid Director Mr. Dennis G. Smith, Director Department of Medical Assistance Services 600 East Broad Street Suite 1300 Richmond, VA 23219 804/786-8099 F: 804/371-4981 E-mail – [email protected]

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WASHINGTON Governor Honorable Gary Locke Legislative Building Olympia, WA 98504-0002 360/753-6780 Single State Agency Director Mr. Lyle Quasim, Secretary Department of Social and Health Services P.O. Box 45010 Olympia, WA 98504-5010 360/902-7800 F: 360/902-7848 Medicaid Director Mr. Tom Bedell, Acting Assistant Secretary Medical Assistance Administration P.O. Box 45080 Olympia, WA 98504-5080 360/902-7807 F: 360/902-7855 E-mail – [email protected]

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WEST VIRGINIA

WYOMING

Governor Honorable Cecil Underwood State Capitol Charleston, WV 25305-0370 304/558-2000 Single State Agency Director Ms. Joan Ohl, Secretary Department of Health and Human Resources Building 3, State Capitol Complex Room 206 Charleston, WV 25305 304/348-0627 Medicaid Director Ms. Elizabeth Lawton, Commissioner Bureau for Medical Services Department of Health and Human Resources 7012 MacCorkle Avenue, SE Charleston, WV 25304 304/926-1703 ask for Ms. Lawton’s Secty) F: 304/926-1833 E-mail: [email protected]

Governor Honorable Jim Geringer State Capitol, Room 124 Cheyenne, WY 82002 307/777-7434 Single State Agency Director Mr. Garry KcKee, Director Department of Health 2300 Capital Avenue Hathaway Building, Room 117 Cheyenne, WY 82002 307/777-7656 Medicaid Director Mr. Daniel G. Stackis, Administrator Health Care Access and Resource Division Department of Health Hathaway Building, Suite 154 2300 Capitol Avenue Cheyenne, WY 82002 307/777-7531 F: 307/777-6964 E-mail – [email protected]

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 One West Wilson Street Madison, WI 53701 608/266-9622 Medicaid Director Ms. Peggy Bartels, Administrator Division of Health Care Financing Department of Health and Social Services One West Wilson Street, Room 350 Madison, WI 53701 608/266-8922 F: 608/266-1096 E-mail – [email protected]

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Pharmaceutical Benefits 2000

REGIONAL ADMINISTRATIVE OFFICES HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION Region I Boston Regional Office

John F. Kennedy Federal Bldg. Government Center, Room 2325 Boston, MA 02203-0003 617/565-1223

Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont

Region II New York Regional Office

26 Federal Plaza Room 3811 New York, NY 10278-0063 212/264-2058

New Jersey, New York, Puerto Rico, Virgin Islands

Region III Philadelphia Regional Office

Suite 216, The Public Ledger Building 150 South Independence Mall West Philadelphia, PA 19106 215/861-4263

Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia

Region IV Atlanta Regional Office

Atlanta Federal Center 61 Forsyth Street, S.W., Suite 4T20 Atlanta, GA 30303-8909 404/562-7400

Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee

Region V Chicago Regional Office

233 North Michigan Avenue Suite 600 Chicago, IL 60601-5519 312/353-9805

Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin

Region VI Dallas Regional Office

1301 Young Street, Room 714 Dallas, TX 75202 214/767-6301

Arkansas, Louisiana, New Mexico, Oklahoma, Texas

Region VII Kansas City Regional Office

Richard Bolling Federal Building 601 East 12th Street, Room 235 Kansas City, MO 64106-2808 816/426-5925

Iowa, Kansas, Missouri, Nebraska

Region VIII Denver Regional Office

Colorado State Bank Building 1600 Broadway, Suite 700 Denver, CO 80202-4367 303/844-1977

Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming

Region IX San Francisco Regional Office

75 Hawthorne Street, 4th & 5th Floors San Francisco, CA 94105-3901 415/744-3568

Arizona, California, Hawaii, Guam Nevada, and Pacific Islands

Region X Seattle Regional Office

2201 6th Avenue Mail Stop RX-40 Seattle, WA 98121-2500 206/615-2313

Alaska, Idaho, Oregon, Washington

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Pharmaceutical Benefits 2000

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

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Appeals and Grievances Nicole Martin 410/786-1068

Drug Rebate Agreement/Data Judy Allison 410/786-3330

Assignment of Rights to Benefits Bob Nakielny 410/786-4466

Drug Utilization Review Christina Lyon 410/786-3332

Beneficiary Services Lindsey Cometa 410/786-8201

Eligibility Marty Svolos 410/786-4582

Budget Information for State Agencies Miles McDermott 410/786-3722

Investigational/Experimental Drugs Tami Bruce 410/786-1519

Child Health Insurance Cindy Shirk 410/786-6614

HCFA 2082 Statistical Report Roger Buchanan 410/786-0780

Coordination of Benefits Dave Witt 410/786-5600

Managed Care Enrollment Report Carolyn Lawson 410/786-0704

Data Inquiries Marilyn McMillan 410/786-4623

Program Reviews Mary Jean Duckett 410/786-3294

Department Appeals Board Decisions Ed Davis 410/786-3280

Pharmacy Issues/Pharmacy Reimbursement Sue Gaston 410/786-6918

Drugs (Coverage, Payment & Rebate Program Issues) Larry Reed 410/786-3325

Statistical Information System Roger Buchanan 410/786-0780

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Pharmaceutical Benefits 2000

Appendix B: Medicaid Program Statistics -HCFA-2082 Report

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B-2

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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 CAVEATS AND DATA LIMITATIONS*

The Federal Fiscal Year 1998 (October 1997-September 1998) HCFA-2082 data tables are based on information reported to HCFA on an annual basis by the 50 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

National Pharmaceutical Council

•

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. B-3

Pharmaceutical Benefits 2000

•

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.

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National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 1.

Medicaid Recipients by Maintenance Assistance Status and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 40,649,482 527,078 74,508 507,668 424,727 7,082,175 344,916 381,208 101,436 166,146 1,904,591 1,221,978 184,614 123,176 1,363,856 607,293 314,936 241,933 644,482 720,615 170,456 561,085 908,238 1,362,890 538,413 485,767 734,015 100,760 211,188 128,144 93,970 813,251 329,418 3,073,241 1,167,988 62,280 1,290,776 342,475 511,171 1,523,120 964,015 153,130 594,962 89,537 1,843,661 2,324,810 215,801 123,992 19,764 653,236 1,413,208 342,668 518,595 46,121

Receiving Cash Payments 17,556,201 231,997 48,821 171,977 157,450 3,595,292 120,745 151,939 36,876 87,261 1,100,787 473,537 109,151 13,767 608,119 231,768 129,836 90,083 346,507 372,578 73,907 274,117 445,998 660,669 239,835 235,016 206,175 47,965 104,483 61,123 28,219 418,784 144,046 1,679,561 594,269 22,462 515,191 139,766 718,234 92,176 190,767 36,920 449,326 917,603 54,561 38,507 6,316 285,976 397,055 172,278 216,998 9,407

Medically Needy 4,368,961 33,542 1,647,992 41,568 17,242 41,070 841 4,751 286,438 12,299 32,802 50,532 8,629 2,396 49,892 224,414 323,778 15,263 231 7,586 436 9,734 6,296 1,009,659 122,027 15,711 6,843 119,253 9,437 139,188 38,247 5,080 9,057 11,991 17,884 12,333 3,895 30,624 -

Poverty Related 9,202,219 219,029 14,556 175,730 162,638 287,622 84,801 52,394 46,928 7,753 498,267 536,420 58,953 34,793 248,864 181,086 63,159 79,787 184,829 190,227 47,447 142,031 191,690 252,770 69,756 200,645 259,920 15,922 71,025 5,534 33,005 167,133 167,569 302,265 389,458 12,196 730,667 222,907 361,594 21,172 225,889 31,169 628,086 903,813 27,564 56,418 245,429 183,766 29,197 63,944 14,402

Other 6,347,817 74,385 9,315 159,961 63,045 1,113,380 135,255 135,307 15,291 4,108 249,348 179,778 4,006 56,599 220,435 172,542 107,262 33,327 53,190 149,181 42,843 69,419 46,136 46,477 204,665 38,716 251,738 23,572 35,244 54,947 21,900 213,615 15,579 81,756 62,234 9,618 44,918 121,234 322,065 22,610 155,498 21,448 221,416 465,147 97,612 18,082 1,457 103,947 265,814 111,592 199,063 21,740

MAS Unknown 3,174,284 1,667 1,816 8,052 437,889 4,115 2,341 49,782 15,119 31,402 7,753 18,017 21,897 2,380 5,934 9,424 3,863 25,626 79,196 8,894 11,159 16,182 5,715 6,540 1,112 7,423 2,224 2,293 342,475 20,421 1,974 964,015 7,735 22,808 405,645 30,984 1,928 554,240 25,706 7,966 572

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

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Pharmaceutical Benefits 2000 Table 2.

Medicaid Recipients by Basis of Eligibility and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 40,649,482 527,078 74,508 507,668 424,727 7,082,175 344,916 381,208 101,436 166,146 1,904,591 1,221,978 184,614 123,176 1,363,856 607,293 314,936 241,933 644,482 720,615 170,456 561,085 908,238 1,362,890 538,413 485,767 734,015 100,760 211,188 128,144 93,970 813,251 329,418 3,073,241 1,167,988 62,280 1,290,776 342,475 511,171 1,523,120 964,015 153,130 594,962 89,537 1,843,661 2,324,810 215,801 123,992 19,764 653,236 1,413,208 342,668 518,595 46,121

Age 65 And Older 3,964,223 64,651 5,306 27,473 50,746 587,326 43,264 51,741 6,652 7,979 186,566 89,197 17,022 12,210 108,132 72,880 39,847 27,388 65,739 93,838 22,669 44,502 113,876 91,663 58,701 60,567 88,776 9,130 25,162 12,320 12,291 94,244 19,601 393,567 158,676 10,376 168,246 39,401 222,458 17,540 72,074 9,496 88,948 301,368 9,716 14,101 1,516 86,550 61,996 29,157 63,432 4,146

Blind/ Disabled 6,637,980 145,892 8,912 78,121 96,507 926,252 62,492 51,586 13,726 22,551 383,978 226,263 16,913 17,395 262,773 91,514 51,219 43,388 178,672 160,544 37,064 104,461 197,426 259,243 73,913 131,439 113,652 16,378 27,724 19,320 12,124 151,050 44,824 592,598 198,254 8,953 232,986 97,889 272,083 28,524 102,904 15,767 302,470 288,293 20,093 15,258 1,208 121,112 112,306 73,037 120,136 6,793

Children 18,309,145 262,547 37,429 282,256 179,405 3,345,491 154,206 189,083 49,425 58,488 944,280 666,385 75,329 57,056 620,251 313,972 138,633 120,383 273,114 345,723 74,213 264,965 409,962 616,825 293,632 218,491 384,773 45,686 106,023 65,349 51,166 372,807 209,014 1,315,777 609,190 27,779 586,546 129,409 745,977 64,882 269,751 48,794 554,235 1,327,276 106,259 53,842 11,424 333,370 489,005 153,021 231,607 24,639

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

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National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 2.

Medicaid Recipients by Basis of Eligibility and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Adults 7,907,935 48,049 19,990 114,360 85,023 1,646,576 66,485 81,613 28,831 25,682 354,337 202,223 64,575 17,147 293,879 101,228 78,021 40,811 111,161 120,369 30,487 106,312 186,362 287,617 96,443 61,217 115,773 20,665 42,199 21,460 14,838 172,122 52,197 689,543 189,692 11,398 278,603 210,350 257,602 30,866 121,013 14,154 479,727 391,786 44,966 36,814 5,616 107,944 181,319 56,682 82,360 9,448

Foster Care Children 654,684 4,038 1,055 5,458 4,994 138,609 14,354 7,185 461 1,664 20,311 6,508 3,022 1,351 78,821 5,802 4,836 4,029 6,369 141 2,160 15,219 612 28,346 6,476 2,894 14,859 3,186 10,080 3,155 2,434 15,605 1,558 81,756 12,176 1,481 24,395 13,701 23,026 3,583 6,412 1,326 12,130 16,087 3,783 1,952 4,260 14,342 5,065 13,094 523

Other/ Unknown 3,175,515 1,901 1,816 8,052 437,921 4,115 2,341 49,782 15,119 31,402 7,753 18,017 21,897 2,380 5,934 9,427 3,863 25,626 79,196 9,248 11,159 16,182 5,715 6,540 1,117 7,423 2,224 2,293 342,475 20,421 1,974 964,015 7,735 22,808 406,151 30,984 2,025 554,240 25,706 7,966 572

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

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Pharmaceutical Benefits 2000 Table 3.

Medicaid Recipients by Type of Service and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 40,649,482 527,078 74,508 507,668 424,727 7,082,175 344,916 381,208 101,436 166,146 1,904,591 1,221,978 184,614 123,176 1,363,856 607,293 314,936 241,933 644,482 720,615 170,456 561,085 908,238 1,362,890 538,413 485,767 734,015 100,760 211,188 128,144 93,970 813,251 329,418 3,073,241 1,167,988 62,280 1,290,776 342,475 511,171 1,523,120 964,015 153,130 594,962 89,537 1,843,661 2,324,810 215,801 123,992 19,764 653,236 1,413,208 342,668 518,595 46,121

Inpatient General Hospital 4,272,878 28,911 11,084 94,153 72,883 495,143 24,250 26,198 3,781 17,487 241,668 161,694 3,221 17,056 176,928 91,414 32,182 27,435 93,875 153,081 18,009 43,196 91,546 128,694 42,969 111,615 72,848 12,315 24,577 19,926 10,832 70,725 54,968 462,705 171,477 8,480 165,016 3,014 116,765 11,993 137,289 15,126 58 444,750 16,934 6,235 1,056 98,015 42,082 43,213 45,591 8,415

Inpatient Mental Hospital 135,284 1,329 627 710 3,146 463 361 398 531 162 253 39 3,768 2,134 958 333 4,338 2,847 705 1,827 952 2,334 249 2,334 9 14 418 686 200 1,899 468 45,770 2,387 145 783 761 8,512 341 1,531 51 2 133 36,689 28 1,564 2,087 8

Nursing Facility Services 1,645,728 23,844 887 14,670 21,486 123,270 18,928 28,791 3,256 4,217 73,030 40,390 37,583 5,297 79,751 44,524 25,115 16,802 27,439 34,403 9,278 27,834 72,342 44,678 37,580 19,552 37,226 5,316 16,528 3,747 7,700 48,552 8,170 135,450 41,683 5,506 86,236 11,960 76,592 11,128 17,352 6,095 86,763 88,522 5,433 3,804 67 28,053 23,949 11,677 40,715 2,557

ICF Mentally Retarded 126,490 750 8 209 1,867 9,885 500 1,556 342 821 3,567 1,728 146 1,012 12,081 6,035 2,338 1,441 1,240 6,014 361 627 1,949 1,322 4,273 2,490 1,442 149 685 293 33 4,514 362 11,928 4,853 637 8,162 373 5,757 100 2,856 337 13,935 867 17 2,126 156 609 3,600 137

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

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Pharmaceutical Benefits 2000 Table 3.

Medicaid Recipients by Type of Service and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Physician Services 18,554,746 393,194 50,070 237,544 271,538 2,621,178 150,497 103,264 16,453 42,789 754,818 872,557 34,412 88,192 902,308 345,017 197,337 142,424 438,403 598,546 92,879 203,528 497,694 544,576 215,960 365,280 259,688 61,621 133,342 60,344 61,209 275,224 125,982 1,486,182 805,816 37,865 729,550 71,294 522,594 34,577 418,331 51,049 220,657 1,783,470 67,664 46,583 79 438,974 286,442 242,889 115,612 37,250

Outpatient EPSDT Hospital Screening Services 12,157,729 6,174,628 221,538 121,122 37,166 1,074 192,365 360,994 160,321 100,589 1,466,203 680,220 84,807 37,337 79,692 5,176 9,203 1,495 50,346 848 644,876 256,591 540,218 287,928 16,154 341 45,261 22,688 647,402 482,495 218,100 125,592 120,492 60,276 79,508 75,475 292,864 38,422 355,568 279,309 38,361 50,661 105,346 45,814 411,868 33,551 372,791 155,631 133,447 16,844 177,966 143,184 246,492 71,161 32,775 10,866 77,751 32,513 46,068 27,822 42,768 16,155 220,552 12,317 77,898 17,983 1,302,949 503,968 459,214 387,904 25,740 42 548,785 124,921 48,058 386,011 163,797 36,740 3,953 233,585 108,591 39,419 13,837 1,011,359 1,046,345 40,234 5,142 30,432 19,735 2,070 347 267,436 85,641 147,633 36,564 166,885 61,956 146,281 31,200 18,731 8,211

Prescribed Drugs 19,337,543 395,290 43,734 56,796 262,907 2,644,430 147,033 108,331 69,027 57,733 1,014,372 805,923 32,222 86,775 959,472 323,811 215,173 155,875 429,102 552,481 137,816 176,403 613,186 589,818 203,220 368,609 353,902 58,641 145,408 50,903 70,339 309,849 96,637 1,803,428 764,886 37,675 702,143 148,258 580,749 44,852 401,611 46,588 1 1,894,447 126,953 58,037 12,938 383,880 274,463 267,398 221,508 32,510

Dental Services 4,965,202 68,485 20,498 91,734 37,433 76,020 52,131 42,588 8,065 12,682 374,202 229,794 3,475 31,969 2,086 105,402 95,466 34,083 131,560 128,341 28,593 8,725 288,682 331,316 86,274 24,282 85,188 20,635 63,484 22,372 25,024 93,991 19,263 847,717 212,697 16,598 238,685 3,018 174,702 51,266 130,360 45 7,026 48,521 44,187 1,788 76,341 275,281 81,557 102,194 9,376

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

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Pharmaceutical Benefits 2000 Table 3.

Medicaid Recipients by Type of Service and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Other Practitioner 4,341,915 72,649 10,699 25,836 77,588 693,399 19,792 63,038 22,641 8,837 121,191 132,412 6,974 22,693 73,268 141,790 71,169 30,572 95,907 71,230 33,625 19,151 115,654 110,247 83,294 9,598 84,827 10,391 51,858 11,224 20,508 93,388 25,720 433,693 159,902 11,748 237,356 24,468 137,692 10,880 87,212 10,826 1 478,837 14,449 16,716 70,449 91,089 62,112 57,506 5,809

Clinic Services 5,285,415 111,804 15,352 59,496 80,534 801,776 70,266 24,389 3,050 7,339 169,145 60,632 2,592 16,147 200,455 94,541 41,158 72,021 144,896 69,912 29,225 39,897 120,551 298,371 45,304 134,967 293,062 7,420 6,698 7,463 29,049 88,631 60,811 616,595 182,633 17,361 108,729 25,546 122,534 11,113 224,554 17,975 31 267,969 16,087 18,629 10,912 95,786 56,459 98,672 182,191 4,685

Lab & X-Ray 9,380,689 157,551 31,121 156,286 120,126 1,692,841 64,421 29,134 5,549 19,585 463,748 167,860 21,327 38,057 581,922 211,802 29,810 71,632 238,713 432,781 62,810 50,211 114,014 328,030 138,016 74,063 118,223 26,931 52,194 17,716 12,930 192,194 16,603 933,858 594,307 25,018 110,324 38,933 282,362 23,188 150,252 23,615 815,014 37,823 22,021 91 180,726 152,580 78,244 151,585 22,547

Family Planning 2,011,124 35,953 1,710 30,092 50,089 248,680 9,321 4,183 4,821 4,316 137 107,417 233 6,188 92,355 20,754 22,447 15,530 34,698 60,975 8,570 19,141 80,262 65,390 18,684 23,557 3,695 13,268 2,632 7,861 40,837 5,401 262,810 73,849 3,757 16,802 8,442 45,743 1,926 112,341 4,579 181,434 7,554 9,919 1,496 23,655 166,048 25,549 22,174 3,849

Home Health 1,224,714 43,277 583 15,650 9,966 60,918 19,626 18,372 2,113 2,914 33,507 84,820 698 1,869 17,259 10,243 14,628 6,395 67,405 41,705 6,825 8,114 39,534 10,823 71,770 10,879 24,954 3,512 1,445 2,359 17,611 2,026 230,195 62,187 678 29,654 7,298 14,398 11,794 10,331 530 13 116,552 922 2,600 7,470 3,997 21,797 48,247 4,251

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-10

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 3.

Medicaid Recipients by Type of Service and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Personal Care Home/Community Support Services Based Services 3,108,432 467,451 52,098 4,112 9,482 1,741 18,635 3,567 30,524 9,369 497,531 36,286 3,335 9,267 20,376 12,262 4,353 1,442 6,641 199,651 194,528 15,251 17,888 787 39,760 88,727 70,735 4,523 13,974 7,751 8,579 15,406 27,589 13,125 67,602 2,751 24,933 3,245 63,467 3,820 4,661 13,452 141,167 12,147 61,532 18,048 4,430 75,373 104 18,270 1,056 1,781 16,328 1,647 5,973 3,828 41,062 12,995 8,636 349,647 31,868 356,450 14,421 5,096 4,265 29,241 28,640 78,965 26,753 51,201 1,888 13,129 1,627 61,734 14,675 13,841 2,024 4,337 209,980 25,762 15,280 3,247 6,333 2,734 31,984 4,589 16,623 60,409 5,437 45,441 8,572 2,087

Other Care 6,975,027 75,170 24,510 152,121 100,502 1,722,936 51,060 52,881 14,266 23,241 275,172 137,889 11,940 29,513 312,616 129,439 70,781 47,549 208,539 142,350 57,423 44,395 309,835 175,146 93,767 63,361 92,017 19,901 31,651 15,756 16,940 109,463 41,592 681,519 165,210 17,115 335,039 39,196 177,888 27,042 113,086 15,852 2 186,423 16,230 34,118 2,268 100,122 234,814 36,243 135,974 3,164

Prepaid Healthcare 20,202,887 344,907 368,344 244,768 6,022,536 316,060 271,411 85,239 100,867 791,752 78,463 144,744 142,429 271,005 246,582 44,003 194,164 9,324 449,825 768,831 758,185 318,854 17,628 336,057 96,701 159,614 55,923 11,176 545,380 263,256 884,443 220,700 1,549 453,265 481,498 902,896 96,178 17,195 83,998 1,764,279 170,319 69,682 159,392 1,146,180 52 293,233 -

PCCM Services 4,066,440 151,910 243,266 54,471 48,907 8,623 841,304 879,554 50,665 16,414 242,844 80,428 123,902 264,035 53,733 59,578 27,577 28,638 103,867 804 591,740 32,566 11,163 39,858 110,559 34 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-11

Pharmaceutical Benefits 2000 Table 4.

Medicaid Recipients Who Receive Cash Payments by Basis of Eligibility and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 17,556,201 231,997 48,821 171,977 157,450 3,595,292 120,745 151,939 36,876 87,261 1,100,787 473,537 109,151 13,767 608,119 231,768 129,836 90,083 346,507 372,578 73,907 274,117 445,998 660,669 239,835 235,016 206,175 47,965 104,483 61,123 28,219 418,784 144,046 1,679,561 594,269 22,462 515,191 139,766 718,234 92,176 190,767 36,920 449,326 917,603 54,561 38,507 6,316 285,976 397,055 172,278 216,998 9,407

Age 65 And Older 1,663,402 33,782 4,707 11,050 19,810 366,023 19,733 7,743 2,208 2,889 94,402 42,268 15,367 1,597 24,430 21,814 9,088 5,115 26,791 51,275 3,862 17,585 44,593 22,413 16,395 29,516 4,697 1,995 9,475 6,409 1,619 33,922 9,522 179,121 83,182 3,820 1,218 8,805 69,084 4,867 35,808 2,658 40,467 164,663 3,039 2,339 429 38,986 22,597 22,828 16,484 912

Blind/ Disabled 4,938,095 133,568 8,439 62,484 79,422 791,034 10,839 20,673 10,415 17,408 305,121 181,366 16,471 7,174 173,098 59,055 40,438 32,803 162,095 143,060 24,631 83,990 148,246 191,253 51,453 116,291 9,476 13,072 25,281 16,060 6,119 120,029 40,594 469,035 126,773 6,365 10,443 42,068 208,952 22,199 78,065 13,886 241,337 251,266 12,257 10,635 583 97,404 88,491 57,955 94,396 4,527

Children 7,518,095 47,498 22,130 62,968 40,822 1,690,580 61,544 82,351 17,496 46,490 486,777 182,592 49,699 3,225 283,637 97,242 50,912 34,049 105,190 128,630 29,368 124,733 173,428 290,969 117,548 62,653 132,426 21,795 38,101 26,717 13,912 175,742 61,327 726,236 254,658 8,470 352,125 51,743 316,699 42,872 55,126 13,865 117,476 350,262 24,936 17,305 3,627 103,548 183,623 57,225 72,808 2,940

Adults 3,436,434 17,149 13,545 35,475 17,396 747,655 28,629 41,172 6,757 20,474 214,487 67,311 27,614 1,771 126,954 53,657 29,398 18,116 52,431 49,613 16,046 47,809 79,731 156,034 54,288 26,556 59,576 11,103 31,626 11,937 6,569 89,091 32,603 305,169 129,656 3,807 151,405 37,150 123,499 22,238 21,768 6,511 50,022 151,412 14,329 8,228 1,677 46,038 102,344 34,270 33,310 1,028

Other/ Unknown 175 151 24 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-12

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 5.

Medically Needy Medicaid Recipients by Basis of Eligibility and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 4,368,961 33,542 1,647,992 41,568 17,242 41,070 841 4,751 286,438 12,299 32,802 50,532 8,629 2,396 49,892 224,414 323,778 15,263 231 7,586 436 9,734 6,296 1,009,659 122,027 15,711 6,843 119,253 9,437 139,188 38,247 5,080 9,057 11,991 17,884 12,333 3,895 30,624 -

Age 65 And Older 791,880 356 193,514 14,001 3,554 23 99 1,597 63,711 3,898 21,739 5,363 1,315 816 20,476 31,375 66,766 6,644 211 5,461 135 4,565 3,340 214,446 46,527 6,520 2,317 23,357 5,811 18,667 550 881 1,087 9,792 6,092 355 6,519 -

Blind/ Disabled 553,524 6,210 116,129 18,741 3,674 11,243 682 442 51,144 3,304 9,265 3,754 1,989 538 15,532 6,593 65,436 6,728 20 2,112 211 2,604 1,117 123,563 55,200 2,559 4,526 4,068 2,085 10,989 806 1,363 625 6,504 6,127 2,401 5,240 -

Children 1,980,201 16,132 977,396 4,822 6,503 12,031 58 1,447 88,849 1,468 1,631 25,574 1,199 652 8,832 109,840 104,792 1,243 3 23 1,297 1,837 474,192 6,974 3,632 50,761 68 39,504 9,164 1,890 3,583 7,345 1,308 76 106 15,969 -

Adults 1,042,805 10,844 360,953 4,004 3,511 17,773 2 1,265 82,734 3,629 167 15,841 4,126 390 5,052 76,606 86,784 577 10 67 1,267 2 197,458 13,326 3,000 41,067 1,473 69,549 29,083 1,834 3,230 2,934 280 38 1,033 2,896 -

Other/ Unknown 551 71 1 479 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-13

Pharmaceutical Benefits 2000 Table 6.

Poverty Related Medicaid Recipients by Basis of Eligibility and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 9,202,219 219,029 14,556 175,730 162,638 287,622 84,801 52,394 46,928 7,753 498,267 536,420 58,953 34,793 248,864 181,086 63,159 79,787 184,829 190,227 47,447 142,031 191,690 252,770 69,756 200,645 259,920 15,922 71,025 5,534 33,005 167,133 167,569 302,265 389,458 12,196 730,667 222,907 361,594 21,172 225,889 31,169 628,086 903,813 27,564 56,418 245,429 183,766 29,197 63,944 14,402

Age 65 And Older 600,117 11,413 4 142 7,398 2,544 1,477 1,025 1,267 1,535 54,232 20,439 58 10,613 17,300 4,666 3,920 407 11,124 12,317 8,539 6,423 37,908 2,225 2,190 16,531 6,146 186 3,646 2,060 286 17,386 115 29 167,028 614 84,483 20 21,738 682 4 26,121 2,281 7,502 14,215 1,947 5,883 1,579 469

Blind/ Disabled 571,132 5,906 4 653 4,881 5,076 2,275 508 692 1,469 51,193 12,492 9,610 25,510 6,153 2,677 354 7,692 5,102 6,213 3,644 40,053 2,478 1,538 12,352 4,950 60 996 2,121 151 15,700 546 29 222,543 7,768 1,379 17 18,248 316 44,431 11,642 3,713 2,530 10,117 2,206 12,681 463

Children 6,116,866 184,459 10,231 147,738 103,574 234,783 56,902 45,200 26,499 4,127 303,233 407,203 23,532 9,864 167,005 151,004 43,854 66,183 131,909 134,775 28,633 96,672 105,030 206,938 64,120 147,744 211,830 11,492 66,383 903 29,507 107,203 147,314 115,349 346,302 10,405 224,508 60,676 248,475 15,856 155,544 25,094 290,466 729,443 5,965 23,797 176,514 157,526 774 45,021 9,307

Adults 1,914,007 17,251 4,317 27,197 46,785 45,219 24,147 5,661 18,470 622 89,609 96,286 35,363 4,706 39,049 19,263 12,708 12,843 34,103 38,033 4,062 35,292 8,699 41,129 1,816 24,018 36,994 4,184 450 3,057 26,844 19,594 186,916 43,156 1,733 116,588 153,849 27,257 5,279 30,359 5,077 293,185 136,607 15,605 22,589 44,583 22,087 9,859 17,344 4,163

Other/ Unknown 97 1 92 4 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-14

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 7.

Medicaid Recipients of Other Coverage Groups by Basis of Eligibility and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 6,347,817 74,385 9,315 159,961 63,045 1,113,380 135,255 135,307 15,291 4,108 249,348 179,778 4,006 56,599 220,435 172,542 107,262 33,327 53,190 149,181 42,843 69,419 46,136 46,477 204,665 38,716 251,738 23,572 35,244 54,947 21,900 213,615 15,579 81,756 62,234 9,618 44,918 121,234 322,065 22,610 155,498 21,448 221,416 465,147 97,612 18,082 1,457 103,947 265,814 111,592 199,063 21,740

Age 65 And Older 908,824 19,456 595 16,281 23,182 25,245 22,054 28,972 3,177 1 37,909 26,391 2,691 46,400 22,941 127 22,461 28,931 9,452 18 259 33,472 14,309 77,933 1,488 11,906 3,851 5,821 39,596 9,964 28,967 7 27,665 45,534 6,842 14,528 6,156 29,810 110,584 3,846 3,379 23,557 31,360 91 38,850 2,765

Blind/ Disabled 575,229 6,418 469 14,984 5,994 14,013 49,378 11,664 2,619 16,421 31,723 611 13,021 26,306 4,800 966 5,131 10,393 5,682 1,295 2,534 76 14,194 2,776 99,226 1,134 1,236 1,139 3,250 14,204 3,684 16,281 43,527 57,684 4,223 6,591 1,565 5,713 25,385 3,317 730 7,087 15,482 20,500 1,803

Children 2,693,983 30,590 5,068 71,550 18,877 442,732 35,760 56,710 5,430 1,368 142,239 76,532 651 43,967 80,760 65,726 42,399 18,520 10,441 81,119 15,560 34,728 21,664 14,126 110,721 8,094 40,517 12,396 1,516 37,729 6,450 88,025 373 1,256 5,272 9,913 16,990 130,042 6,086 59,081 9,835 106,789 238,407 73,468 9,157 452 52,000 147,780 94,916 97,809 12,392

Adults 1,514,689 13,649 2,128 51,688 9,998 492,749 13,709 30,776 3,604 1,075 32,468 38,624 333 10,670 45,142 28,308 32,286 9,685 8,786 28,597 9,989 18,159 21,326 3,670 39,762 10,643 19,203 5,368 10,506 9,073 3,945 56,185 3,554 2,858 10,610 19,351 65,779 1,876 68,886 2,566 66,971 74,684 13,198 2,767 1,005 17,043 56,850 11,520 28,810 4,257

Foster Children 654,684 4,038 1,055 5,458 4,994 138,609 14,354 7,185 461 1,664 20,311 6,508 3,022 1,351 78,821 5,802 4,836 4,029 6,369 141 2,160 15,219 612 28,346 6,476 2,894 14,859 3,186 10,080 3,155 2,434 15,605 1,558 81,756 12,176 1,481 24,395 13,701 23,026 3,583 6,412 1,326 12,130 16,087 3,783 1,952 4,260 14,342 5,065 13,094 523

Other/ Unknown 408 234 32 2 40 3 97 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-15

Pharmaceutical Benefits 2000 Table 8.

Medicaid Medical Vendor Payments by Maintenance Assistance Status of Recipient and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Receiving Medically Poverty Payments Cash Payments Needy Related Other $142,317,903,795 $63,034,798,342 $25,138,863,775 $19,758,455,422 $30,686,156,426 1,902,300,047 602,742,522 176,216,348 607,749,253 330,378,398 213,828,341 43,610,989 71,856,764 1,643,966,305 712,364,833 238,491,706 693,109,765 1,375,797,421 713,252,376 79,146,711 223,104,306 596,207,736 14,236,592,915 8,647,488,244 3,879,870,004 295,066,192 1,262,422,388 1,439,366,499 304,817,936 129,898,201 960,589,934 2,420,791,474 563,107,925 331,270,561 90,114,928 1,436,298,060 419,732,143 183,870,881 79,747,325 152,583,054 731,292,552 361,750,299 233,651,729 27,498,854 21,665,816 5,686,844,862 2,950,414,878 126,182,907 1,348,334,446 1,236,568,867 3,012,346,312 1,377,872,299 3,794,773 689,569,489 889,614,162 507,433,146 349,140,826 58,350,850 81,498,940 7,972,123 424,512,387 77,400,112 236,140,479 70,620,282 6,172,865,261 2,639,261,770 2,449,228,109 415,474,024 668,901,358 2,564,005,047 954,525,663 220,277,390 1,370,926,082 1,288,770,390 522,779,438 43,959,500 80,855,385 637,601,466 916,323,608 374,101,538 385,066,257 90,102,609 52,944,805 2,425,288,141 1,376,672,479 174,912,771 275,954,959 588,092,271 2,383,508,985 1,227,251,177 35,159,084 227,270,626 893,828,098 747,027,618 289,878,332 11,059,685 101,617,050 332,465,141 2,489,280,148 1,233,921,421 798,379,206 231,634,487 189,104,492 4,609,360,933 2,143,677,179 856,606,399 1,482,929,991 126,147,364 4,345,007,824 2,009,893,152 1,613,885,806 272,152,987 70,708,537 2,924,447,719 1,209,395,516 138,072,538 64,387,956 1,494,649,325 1,442,373,276 714,491,940 29,257 306,914,267 417,485,900 2,569,646,129 340,186,310 274,104,538 1,942,734,440 361,238,668 141,690,577 104,383,328 20,793,093 88,089,349 753,162,904 430,209,028 2,974,236 82,582,317 237,397,323 462,087,777 222,245,177 4,622,406 211,394,224 606,004,232 170,615,173 121,049,747 52,614,350 260,382,807 4,218,822,993 1,963,153,334 57,860,478 458,183,790 1,725,703,499 862,144,872 437,218,245 241,810,168 177,322,949 24,298,610,635 12,312,300,018 10,634,644,651 984,445,331 367,220,635 4,013,996,742 2,080,692,247 1,266,350,628 558,638,298 108,315,569 341,015,420 121,167,482 179,804,840 14,402,609 22,843,885 6,120,967,557 824,053,633 5,180,692,237 116,221,687 1,177,853,941 1,377,514,740 392,064,018 19,562,289 613,603,111 335,137,219 6,080,191,710 2,471,881,538 696,874,020 821,478,988 2,087,655,250 250,000,000 919,353,410 430,262,938 140,267,792 27,623,971 308,397,218 2,018,620,428 751,927,407 448,329,281 558,650,582 355,833,902 156,736,607 31,265,704 167,831,591 3,167,188,993 988,402,868 162,210,873 693,524,367 923,383,603 7,139,928,843 3,164,249,057 125,836,860 1,024,387,837 2,825,455,089 618,675,433 150,439,909 17,227,134 67,272,642 311,792,358 351,341,290 143,568,188 21,108,255 70,329,475 115,229,024 10,097,973 3,007,722 6,056,113 1,034,138 2,118,202,866 1,013,741,200 163,396,812 276,531,633 664,533,221 2,044,234,831 845,368,582 80,835,552 155,230,925 830,670,996 1,243,150,526 830,135,721 24,132,569 121,766,318 144,277,023 2,206,398,750 859,392,921 95,661,451 84,267,682 1,170,245,392 192,004,819 36,187,365 21,090,417 134,124,312

MAS Unknown $3,699,629,829 515,591,924 1,082,304 (235,913,708) 151,746,087 44,060,428 3,530,883 86,725,854 25,343,764 51,495,589 10,470,407 40,351,514 18,275,912 3,574,601 14,108,399 9,655,661 12,007,410 36,240,542 378,367,342 17,942,384 3,451,912 12,620,841 6,282,321 23,825,970 1,342,155 13,921,892 5,793,510 2,796,604 1,177,853,941 17,148,103 2,301,914 250,000,000 12,801,491 259,713,158 399,667,282 71,943,390 1,106,348 132,128,776 122,838,895 (3,168,696) 602,725

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-16

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 9.

Medicaid Medical Vendor Payments by Basis of Eligibility of Recipient and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Payments $142,317,903,795 1,902,300,047 330,378,398 1,643,966,305 1,375,797,421 14,236,592,915 1,439,366,499 2,420,791,474 419,732,143 731,292,552 5,686,844,862 3,012,346,312 507,433,146 424,512,387 6,172,865,261 2,564,005,047 1,288,770,390 916,323,608 2,425,288,141 2,383,508,985 747,027,618 2,489,280,148 4,609,360,933 4,345,007,824 2,924,447,719 1,442,373,276 2,569,646,129 361,238,668 753,162,904 462,087,777 606,004,232 4,218,822,993 862,144,872 24,298,610,635 4,013,996,742 341,015,420 6,120,967,557 1,177,853,941 1,377,514,740 6,080,191,710 250,000,000 919,353,410 2,018,620,428 355,833,902 3,167,188,993 7,139,928,843 618,675,433 351,341,290 10,097,973 2,118,202,866 2,044,234,831 1,243,150,526 2,206,398,750 192,004,819

Age 65 And Older $40,602,116,833 550,365,257 57,121,304 324,219,550 430,018,281 2,877,789,089 437,704,252 1,048,144,688 95,287,226 150,809,511 1,555,193,567 493,367,044 157,256,534 124,484,856 1,104,777,674 863,879,770 463,839,101 253,024,983 583,123,078 672,322,724 239,292,715 603,934,490 1,475,161,716 940,257,050 993,413,008 415,324,517 927,285,221 114,977,600 264,480,513 91,651,233 226,786,873 1,325,345,586 145,828,469 7,871,285,862 1,193,291,589 131,361,999 2,245,207,690 112,980,883 2,510,003,519 298,102,394 477,950,896 107,444,635 674,937,423 2,341,889,852 90,122,694 97,201,440 2,490,221 638,501,136 572,572,467 359,268,463 816,986,679 54,049,511

Blind/ Disabled $60,375,123,225 597,810,766 115,136,373 609,672,915 791,182,772 6,143,133,891 581,915,898 890,332,880 196,514,572 346,252,423 2,659,251,017 1,402,741,189 128,342,971 167,695,747 3,262,390,656 1,083,989,118 489,399,669 450,243,800 1,162,378,389 1,101,257,511 329,088,855 1,183,637,666 2,174,271,507 1,944,525,068 1,223,393,074 665,398,149 1,016,081,357 138,852,060 278,110,955 174,129,939 221,210,838 1,977,873,602 310,111,561 11,645,320,828 1,663,065,550 140,167,178 2,544,856,524 267,864,281 1,988,012,614 454,553,955 762,312,898 160,719,294 990,880,890 2,484,970,969 226,841,136 135,753,840 1,767,095 933,333,485 622,897,992 473,514,655 978,356,783 83,606,070

Children $20,459,140,959 186,782,542 85,965,470 405,457,935 262,322,716 2,665,260,487 149,568,323 289,118,311 67,829,755 78,395,395 846,258,629 582,740,389 117,090,747 51,677,781 786,450,294 399,777,342 179,317,603 131,960,635 386,980,809 371,500,804 96,498,432 386,698,407 561,432,617 515,623,409 455,098,154 225,920,481 410,373,527 56,626,017 107,639,405 79,001,535 98,665,958 433,771,126 269,533,249 2,324,009,772 716,185,408 33,676,323 705,040,424 366,507,811 1,024,778,811 81,377,077 305,302,576 57,057,240 410,584,137 1,397,377,640 120,451,826 54,910,386 3,125,020 336,321,911 340,856,081 153,582,113 256,202,612 30,455,507

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-17

Pharmaceutical Benefits 2000 Table 9.

Medicaid Medical Vendor Payments by Basis of Eligibility of Recipient and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Adults $14,833,097,385 33,684,838 61,419,264 296,765,130 99,324,540 2,149,128,619 124,900,958 175,979,323 54,956,394 53,304,930 549,341,749 458,044,573 88,877,805 37,809,908 686,289,405 175,348,016 134,057,212 59,588,457 239,916,610 238,273,512 43,739,741 238,767,249 397,513,145 514,607,970 196,885,958 119,880,832 156,676,911 38,484,670 66,708,154 52,414,904 33,867,455 370,456,043 104,703,118 2,090,773,539 396,970,898 22,899,991 554,468,305 576,396,640 457,250,934 59,149,256 162,109,475 26,827,646 632,709,631 871,515,674 79,480,227 46,777,227 2,715,637 200,657,760 353,872,825 101,663,671 123,315,198 21,825,458

Foster Children $2,346,800,698 17,825,019 9,653,683 7,850,767 28,862,820 249,516,816 101,216,640 17,216,272 1,613,313 15,804,439 51,456,136 23,957,528 5,394,682 2,492,581 332,957,232 22,734,889 18,582,204 7,397,334 43,231,020 154,433 26,400,465 40,001,794 981,948 51,626,985 36,699,762 12,397,385 46,608,272 6,016,000 36,223,877 41,064,196 24,126,996 97,454,744 26,174,965 367,220,635 44,483,297 10,113,325 71,394,614 36,617,022 97,843,918 13,369,237 51,231,425 3,785,087 57,825,355 44,174,708 29,836,160 15,461,003 9,388,574 21,906,690 32,282,729 34,706,174 1,465,548

Other/ Unknown $3,701,624,687 515,831,625 1,082,304 (235,913,708) 151,764,013 44,060,428 3,530,883 86,725,854 25,343,764 51,495,589 10,470,407 40,351,514 18,275,912 3,574,601 14,108,399 9,658,235 12,007,410 36,240,542 378,367,342 18,957,763 3,451,912 12,620,841 6,282,321 23,825,970 1,346,112 13,921,892 5,793,510 2,796,604 1,177,853,941 17,148,103 2,301,914 250,000,000 12,801,491 259,713,158 400,251,557 71,943,390 1,237,394 132,128,776 122,838,895 (3,168,696) 602,725

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-18

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 10.

Medicaid Medical Vendor Payments by Type of Service and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Payments $142,317,903,795 1,902,300,047 330,378,398 1,643,966,305 1,375,797,421 14,236,592,915 1,439,366,499 2,420,791,474 419,732,143 731,292,552 5,686,844,862 3,012,346,312 507,433,146 424,512,387 6,172,865,261 2,564,005,047 1,288,770,390 916,323,608 2,425,288,141 2,383,508,985 747,027,618 2,489,280,148 4,609,360,933 4,345,007,824 2,924,447,719 1,442,373,276 2,569,646,129 361,238,668 753,162,904 462,087,777 606,004,232 4,218,822,993 862,144,872 24,298,610,635 4,013,996,742 341,015,420 6,120,967,557 1,177,853,941 1,377,514,740 6,080,191,710 250,000,000 919,353,410 2,018,620,428 355,833,902 3,167,188,993 7,139,928,843 618,675,433 351,341,290 10,097,973 2,118,202,866 2,044,234,831 1,243,150,526 2,206,398,750 192,004,819

Inpatient General Hospital $21,498,719,619 42,908,107 55,725,816 75,903,069 178,532,888 2,539,212,053 186,830,191 166,380,038 15,358,566 198,380,143 1,038,563,277 668,075,530 36,301,298 68,827,832 1,690,971,723 411,039,286 144,960,334 115,383,465 277,720,828 527,916,078 47,116,426 324,719,290 546,768,099 792,887,794 252,541,378 324,944,298 313,541,971 48,271,464 97,977,946 106,004,413 34,844,009 402,674,879 90,148,335 3,972,442,080 692,184,068 30,884,006 870,502,764 12,124,512 539,676,985 178,178,042 522,891,024 67,004,925 76,296 1,643,167,234 90,973,076 19,306,558 3,739,587 334,376,705 265,579,863 194,479,017 210,485,418 29,216,635

Inpatient Mental Hospital $2,800,541,598 26,475,030 13,764,917 20,966 54,470,602 7,648,556 5,955,144 23,576,663 10,648,377 2,498,290 14,638,423 770,647 355,291,866 19,825,621 18,447,053 5,935,917 42,689,470 15,963,066 19,950,621 56,546,963 30,800,067 39,700,896 16,286,663 15,483,002 248,998 308,414 5,651,820 11,508,517 1,904,281 72,438,654 2,077,546 1,525,566,813 26,557,229 3,918,724 4,452,888 35,339,858 85,078,979 12,260,928 47,960,982 2,818,786 218 1,219,044 101,470,932 101,471 24,905,723 37,293,417 68,556

Nursing Facility Services $31,892,064,551 522,825,844 45,782,809 16,458,558 300,012,732 2,158,053,360 333,591,591 858,713,862 83,062,656 155,399,067 1,340,608,163 603,835,584 144,973,700 90,878,627 1,268,060,053 699,667,232 318,547,045 189,319,221 491,196,404 490,677,315 169,130,251 546,941,004 1,276,236,770 898,994,947 843,536,749 313,037,056 677,899,462 95,255,260 234,516,077 72,595,501 195,434,499 1,154,707,872 138,825,024 5,032,111,363 760,826,548 111,162,630 1,911,111,609 188,522,343 1,961,739,776 234,578,181 302,667,749 101,120,652 1,066,992,955 1,384,415,773 90,411,547 74,038,926 1,194,261 394,719,042 496,372,294 256,580,323 748,856,930 45,867,354

ICF Mentally Retarded $9,481,723,907 55,663,840 293,827 108,852,817 559,948,974 26,124,204 203,094,688 32,687,748 71,613,329 255,636,949 107,450,025 10,066,595 44,777,200 661,728,014 314,681,105 179,085,736 73,011,007 79,305,645 322,468,549 27,011,643 55,095,149 250,951,685 92,056,064 234,768,692 125,503,877 101,104,939 16,269,810 42,963,860 28,894,383 1,519,278 347,217,754 16,317,149 2,196,796,587 361,838,061 44,567,046 537,681,556 77,395,292 442,232,151 4,930,618 167,959,347 19,582,925 728,574,336 43,954,818 1,031,673 143,102,604 8,999,877 47,738,110 198,693,920 10,480,451

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-19

Pharmaceutical Benefits 2000 Table 10.

Medicaid Medical Vendor Payments by Type of Service and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Physician Services $6,070,022,680 115,683,384 36,742,125 24,742,477 120,802,774 744,150,459 55,434,596 43,027,135 5,689,663 15,832,207 201,410,207 367,096,683 32,883,850 30,240,179 242,774,121 116,841,929 67,672,741 37,813,417 164,972,078 196,895,190 21,137,156 46,541,325 197,750,106 130,599,586 84,806,776 177,155,371 51,276,977 27,356,355 49,001,395 39,449,916 18,962,156 72,855,718 35,207,392 327,039,971 335,106,875 14,780,039 271,665,208 15,646,781 115,538,851 7,051,133 150,905,913 20,495,792 112,908,373 661,475,584 20,149,326 9,490,861 195,307 187,632,422 91,489,892 111,149,189 26,755,558 17,740,161

Outpatient Hospital $5,758,982,745 55,232,113 22,710,772 8,377,604 37,099,507 332,585,224 48,863,284 63,273,506 3,309,098 40,597,949 322,884,138 266,142,731 12,656,332 16,952,114 202,113,879 83,721,391 59,171,793 12,667,886 211,965,422 146,755,783 17,436,520 53,105,201 231,764,549 149,872,689 50,953,215 68,541,350 154,379,218 16,184,168 31,187,108 25,062,559 26,598,507 282,697,673 34,276,483 1,145,218,581 209,392,736 20,795,249 244,422,218 17,909,248 112,286,027 19,380,312 52,518,262 27,514,589 446,493,015 19,162,944 11,029,031 303,353 120,861,960 89,625,083 61,622,445 65,575,950 5,731,976

EPSDT Screening $1,334,828,107 14,722,820 125,107 4,361,822 55,748,372 46,051,880 3,011,047 400,479 99,029 238,707 28,486,368 25,513,441 38,941 4,114,029 64,468,090 7,082,193 5,485,072 8,874,886 61,282,505 43,497,715 3,421,839 73,840,753 2,388,137 13,622,196 2,935,735 21,663,630 40,121,136 1,610,004 3,281,729 3,914,920 983,291 735,125 1,921,546 109,536,163 30,846,296 211,991 13,012,653 182,678,258 211,727 7,942,631 5,817,668 416,748,794 307,155 1,819,403 28,550 8,139,341 2,388,569 7,642,253 2,482,161 971,950

Prescribed Drugs $13,521,707,689 236,674,147 32,887,828 1,442,917 150,891,615 1,553,598,462 110,159,725 186,593,992 41,350,537 41,254,973 933,782,041 370,562,935 39,623,380 54,971,097 583,239,675 325,712,348 147,115,884 118,825,316 319,983,951 352,784,785 121,771,298 148,532,940 497,146,531 374,145,567 173,602,492 231,735,360 382,512,566 42,368,399 92,558,539 34,518,901 55,374,478 426,075,488 41,507,229 1,368,451,273 466,528,812 27,619,684 645,118,962 87,805,350 525,261,211 61,401,958 224,962,203 31,106,511 36 817,591,112 68,827,853 43,445,887 2,796,833 284,578,558 244,478,658 148,962,081 232,326,359 17,138,952

Dental Services $901,385,043 9,698,164 8,420,013 2,518,958 7,789,946 17,764,417 9,477,271 7,461,733 1,752,407 1,367,185 79,571,073 32,076,080 342,042 9,262,516 215,457 25,616,874 17,727,507 8,611,769 23,876,778 18,204,824 4,500,980 354,031 53,661,108 33,412,598 13,553,739 2,746,014 9,726,354 5,062,200 9,742,058 12,458,638 4,589,120 13,016,134 3,947,881 182,756,864 42,821,503 4,451,231 33,705,390 424,893 20,591,630 9,372,139 18,640,048 17,126 2,165,089 10,531,291 7,965,583 88,095 10,991,454 75,222,685 18,553,850 12,373,895 2,186,408

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-20

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 10.

Medicaid Medical Vendor Payments by Type of Service and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Other Practitioner $587,137,593 4,502,485 1,122,830 154,063 7,022,549 84,350,296 4,054,732 27,819,279 8,839,087 8,567,475 37,239,783 18,735,368 1,164,072 2,193,545 24,532,236 44,540,516 6,178,733 2,871,248 8,865,468 4,492,336 3,660,348 1,016,724 7,732,818 5,349,653 22,306,688 522,487 4,862,991 2,795,476 8,861,275 2,506,707 3,277,888 7,891,739 3,792,233 28,371,373 10,405,963 1,033,246 22,152,879 13,049,696 16,378,048 1,188,997 6,023,393 1,749,501 18 70,751,154 1,571,558 4,557,773 7,747,728 5,664,924 10,060,720 13,966,929 640,565

Clinic Services $3,921,167,731 62,372,094 41,247,912 17,310,281 128,802,658 427,958,908 34,940,819 19,702,620 20,037,258 12,113,259 103,185,250 114,306,637 766,029 4,467,987 68,143,140 21,354,616 9,897,420 35,264,649 98,656,658 33,718,060 7,483,979 6,643,345 110,221,454 331,384,716 12,456,913 72,866,687 68,809,727 1,469,660 3,127,968 2,307,097 88,397,728 117,799,809 20,484,797 1,220,723,903 47,713,966 15,462,744 44,383,797 7,404,707 68,910,361 3,386,680 138,424,592 6,329,164 1,196 52,613,251 31,508,963 5,429,887 1,191,919 44,638,403 34,712,064 46,008,114 51,528,358 3,095,527

Lab & X-Ray $938,700,266 9,563,557 5,947,523 1,379,779 11,348,972 259,080,646 6,240,321 4,409,946 294,317 2,128,643 36,231,750 12,445,037 2,826,800 3,391,858 46,360,141 19,574,422 1,441,968 3,843,169 26,978,851 42,386,889 4,583,536 3,137,857 9,377,844 24,631,759 15,517,890 5,643,549 6,568,226 5,460,753 5,773,091 1,231,397 873,180 18,202,916 1,204,963 49,239,115 69,535,830 2,552,182 9,581,841 2,644,788 20,529,415 1,800,816 12,185,658 2,100,717 94,105,855 2,011,687 1,523,301 47,288 12,882,270 34,356,590 5,844,856 17,001,830 2,674,677

Family Planning $449,136,397 6,639,031 1,022,171 884,686 8,389,414 32,791,127 2,893,789 976,553 656,579 821,195 81,663 27,091,933 25,718 836,858 17,568,951 2,486,445 5,191,063 3,733,061 8,543,697 11,599,544 1,509,167 4,613,117 20,222,721 9,163,934 3,713,564 5,124,562 1,162,644 3,250,360 1,096,613 2,043,842 5,446,420 999,819 68,785,044 22,561,251 954,964 13,237,826 1,154,298 14,783,309 479,444 34,421,428 783,923 40,544,183 700,045 1,729,559 120,767 2,750,996 49,005,157 2,458,392 3,357,816 727,754

Home Health $2,701,512,000 22,844,852 1,098,932 1,015,977 13,985,570 82,965,929 168,003,075 101,980,227 7,437,812 15,216,416 75,237,726 42,656,324 1,767,751 3,013,366 27,167,763 47,073,916 39,364,761 13,271,790 96,406,052 41,600,791 13,702,291 48,456,286 178,727,342 30,029,536 51,998,745 11,727,240 46,793,370 15,357,587 4,806,532 4,044,940 84,239,565 3,621,004 805,659,216 98,708,726 1,671,089 97,338,109 5,451,650 36,365,790 147,013,312 15,473,934 813,135 4,524 98,543,994 2,586,721 3,726,368 8,156,865 6,274,767 17,894,521 56,048,763 4,167,048

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-21

Pharmaceutical Benefits 2000 Table 10.

Medicaid Medical Vendor Payments by Type of Service and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Personal Care Home/Community Support Services Based Services $8,221,956,899 $6,708,703,006 71,655,382 83,614,761 12,168,162 31,646,356 1,565,498 206,027 84,465,101 43,604,265 1,461,040,635 477,040,219 13,191,011 91,982,851 13,155,907 284,893,048 23,982,676 30,242,559 9,016,714 391,136,226 101,836,605 146,234,294 41,189,565 10,096,183 37,604,578 418,523,830 119,419,033 54,880,354 16,554,369 74,697,885 7,034,122 196,664,037 23,492,967 84,874,155 30,413,215 62,765,878 27,570,385 85,600,648 79,099,039 154,029,172 28,926,115 363,334,110 238,876,125 270,956,190 206,010,480 390,376,183 15,345,300 360,789,849 679,049 32,546,074 4,836,944 50,040,956 55,204,326 12,290,773 18,486,793 111,506,824 243,903,851 249,988,289 5,320,387 (38) 2,690,464,403 1,439,637,872 452,804,716 275,215,305 7,820,124 43,749,691 64,907,670 262,590,804 88,633,858 144,321,876 43,550,833 20,558,811 57,280,255 10,108,166 73,310,778 123,052,297 14,637,149 43,004,042 128,077,009 425,887,768 203,678,629 11,019,128 62,895,077 5,761,603 58,670,584 117,734,230 95,785,869 7,262,046 125,929,361 100,995,995 124,375,147 6,663,387 43,669,130

Other Care $4,386,176,341 8,421,214 19,671,298 56,205,118 53,900,984 577,661,831 88,225,223 38,118,905 12,234,800 56,988,647 108,796,297 27,214,508 10,384,058 35,553,198 222,113,084 77,567,573 69,039,766 51,817,279 82,951,173 41,368,966 167,202,572 28,357,568 316,130,351 77,138,062 65,853,806 30,018,167 67,554,180 10,049,415 21,637,799 10,688,468 25,034,883 101,339,785 88,194,680 497,301,640 12,764,633 7,421,835 580,256,144 13,466,470 72,947,073 55,859,821 102,108,042 6,250,599 141 53,173,072 11,930,762 46,416,750 392,013 54,680,560 103,678,034 35,751,670 83,379,136 964,288

Prepaid Healthcare $19,296,223,487 288,972,436 1,431,418,497 4,359,975 2,867,713,795 238,585,930 377,212,893 122,048,974 98,238,002 701,322,837 57,871,451 213,612,580 241,278,075 167,977,207 107,189,198 17,201,600 311,526,039 4,237,958 851,988,946 477,932,296 823,728,725 483,228,011 22,152,325 277,652,554 53,600,495 72,980,602 32,332,069 12,128,535 617,591,322 372,647,285 1,638,382,814 85,665,363 1,319,356 494,845,239 665,872,224 1,801,084,202 114,870,881 17,172,147 3,797,234 1,859,127,110 147,730,653 53,890,106 186,255,441 529,020,076 26,573,906 321,886,123 -

PCCM Services $134,367,179 3,830,786 5,488,182 6,976,144 1,801,695 1,020,351 18,032,691 23,190,993 1,440,856 710,585 4,942,986 1,002,062 24,173,083 9,288,830 9,402,768 1,468,077 415,790 4,463,574 760,878 125,558 12,518,863 477,330 237,107 889,464 1,697,486 11,040 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-22

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 11.

Medicaid Medical Vendor Payments for Recipients Who Receive Cash Payments by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Payments $63,034,798,342 602,742,522 213,828,341 712,364,833 713,252,376 8,647,488,244 304,817,936 563,107,925 183,870,881 361,750,299 2,950,414,878 1,377,872,299 349,140,826 77,400,112 2,639,261,770 954,525,663 522,779,438 374,101,538 1,376,672,479 1,227,251,177 289,878,332 1,233,921,421 2,143,677,179 2,009,893,152 1,209,395,516 714,491,940 340,186,310 141,690,577 430,209,028 222,245,177 170,615,173 1,963,153,334 437,218,245 12,312,300,018 2,080,692,247 121,167,482 824,053,633 392,064,018 2,471,881,538 430,262,938 751,927,407 156,736,607 988,402,868 3,164,249,057 150,439,909 143,568,188 3,007,722 1,013,741,200 845,368,582 830,135,721 859,392,921 36,187,365

Age 65 Blind/ And Older Disabled $9,175,983,172 $39,127,774,287 104,513,657 460,513,836 28,824,334 104,037,418 60,299,301 427,209,144 78,232,338 561,683,616 1,183,408,519 4,898,110,390 95,573,584 117,920,331 61,520,290 303,954,741 15,106,185 135,771,374 30,859,174 240,493,617 380,519,516 1,889,065,482 124,735,711 976,265,813 109,396,032 120,996,571 7,069,411 62,698,923 147,427,072 1,774,490,199 161,282,234 627,460,798 102,697,086 298,890,407 33,019,252 285,871,129 110,247,544 1,002,698,813 215,325,121 810,905,188 17,692,847 212,676,163 113,592,984 847,041,712 283,296,710 1,441,171,460 88,206,689 1,383,209,822 148,585,822 786,938,538 87,312,336 532,502,217 32,253,899 93,216,860 8,823,262 89,382,721 87,384,446 250,552,885 22,880,467 143,320,397 14,723,622 119,048,938 240,196,251 1,319,415,872 26,126,120 275,434,457 2,402,931,691 7,879,465,179 470,658,696 1,124,566,917 21,885,774 79,622,252 6,171,893 91,779,316 24,160,952 115,461,551 335,201,626 1,387,383,538 35,312,486 297,800,358 142,977,503 511,725,270 8,344,318 120,166,195 72,855,779 747,284,126 707,491,516 1,850,133,604 14,138,243 89,019,591 11,988,914 96,369,883 584,050 843,603 187,012,654 657,646,370 85,138,908 447,814,652 347,814,749 364,958,698 76,092,968 646,903,131 4,088,636 25,880,221

Children $8,426,821,440 23,431,818 40,331,657 129,156,438 51,077,268 1,566,802,910 49,219,528 118,266,090 20,307,696 55,783,946 395,519,106 142,562,950 79,337,837 3,049,437 379,801,069 80,491,333 61,776,293 28,883,787 151,768,704 112,404,628 33,849,947 164,445,071 252,210,899 240,629,880 167,173,525 53,103,913 126,878,239 26,473,390 37,251,060 29,687,911 22,536,517 198,115,568 78,809,778 1,224,804,368 256,353,163 10,919,712 409,565,263 148,441,395 501,658,445 55,240,146 54,700,129 16,370,593 97,873,612 317,008,004 23,313,210 22,275,596 808,469 83,879,652 127,587,258 61,493,372 89,542,075 3,848,785

Adults $6,303,780,773 14,283,211 40,634,932 95,699,947 22,259,154 999,166,425 42,104,493 79,366,804 12,685,626 34,613,562 285,310,774 134,307,825 39,410,386 4,582,341 337,543,430 85,291,298 59,415,652 26,327,370 111,957,418 88,616,240 25,659,375 108,841,654 166,998,110 297,846,761 106,291,166 41,573,474 87,837,312 17,011,204 55,020,637 26,356,402 14,306,096 205,425,643 56,847,890 805,098,781 229,113,471 8,739,744 316,537,161 104,000,120 247,637,929 41,909,948 42,524,505 11,855,501 70,357,148 289,615,933 23,968,865 12,933,795 771,600 85,202,524 184,827,764 55,868,902 46,854,747 2,369,723

Other/ Unknown $438,668 406,465 32,203 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-23

Pharmaceutical Benefits 2000 Table 12.

Medicaid Medical Vendor Payments for Medically Needy Recipients by Basis of Eligibility and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Age 65 Payments And Older $25,138,863,775 $12,361,168,832 79,146,711 889,336 3,879,870,004 1,595,406,804 331,270,561 147,497,845 233,651,729 112,690,243 126,182,907 142,479 3,794,773 274,620 58,350,850 47,795,992 2,449,228,109 922,432,463 43,959,500 12,328,729 385,066,257 217,683,097 174,912,771 63,709,718 35,159,084 7,320,083 11,059,685 5,627,121 798,379,206 478,833,202 856,606,399 516,067,558 1,613,885,806 846,891,239 138,072,538 47,477,188 29,257 9,007 104,383,328 79,096,557 2,974,236 454,382 121,049,747 82,549,114 57,860,478 48,038,072 10,634,644,651 5,468,354,171 1,266,350,628 690,787,251 179,804,840 109,085,655 19,562,289 6,359,110 696,874,020 514,843,643 140,267,792 107,253,067 162,210,873 37,060,800 125,836,860 17,227,134 4,231,409 21,108,255 2,542,982 6,056,113 1,906,171 163,396,812 94,787,897 80,835,552 43,965,735 24,132,569 1,741,056 95,661,451 45,035,036 -

Blind/ Disabled $8,641,051,903 28,079,512 1,167,100,970 168,260,256 94,486,741 63,383,911 3,294,913 7,346,400 1,224,045,905 20,664,061 151,238,434 29,040,575 14,507,817 3,939,097 258,830,120 51,767,956 548,453,540 86,927,932 20,250 25,259,060 1,992,544 32,542,469 8,474,784 3,765,855,649 518,926,928 60,517,580 13,203,179 77,812,475 30,407,052 17,988,219 6,269,066 9,408,181 923,492 64,724,212 36,604,049 17,996,886 30,757,688 -

Children $2,331,098,475 31,136,043 696,180,314 5,899,211 14,958,863 23,775,531 218,759 1,936,738 134,088,989 2,622,330 15,885,521 49,473,823 2,160,074 884,762 46,878,973 141,434,516 83,731,109 2,099,126 4,406 39,387 2,603,896 1,341,987 903,888,146 13,025,286 5,344,257 60,870,018 47,936 31,768,343 32,745,054 1,394,817 4,929,981 1,995,822 3,177,468 209,664 236,658 14,110,667 -

Adults $1,804,846,335 19,041,820 421,181,916 9,613,249 11,515,882 38,880,986 6,481 1,271,720 168,660,752 8,344,380 259,205 32,688,655 11,171,110 608,705 13,836,911 147,336,369 134,809,918 1,382,476 23,305 487,923 3,352,838 5,635 496,546,685 43,611,163 4,857,348 43,347,884 2,559,737 74,882,527 93,091,806 5,331,842 4,227,111 1,230,628 707,235 56,104 4,157,969 5,758,060 -

Other/ Unknown $698,230 185,816 1,430 510,984 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-24

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 13.

Medicaid Medical Vendor Payments for Poverty Related Medicaid Recipients by Basis of Eligibility and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Payments $19,758,455,422 176,216,348 43,610,989 238,491,706 223,104,306 295,066,192 129,898,201 90,114,928 79,747,325 27,498,854 1,348,334,446 689,569,489 81,498,940 236,140,479 415,474,024 220,277,390 80,855,385 90,102,609 275,954,959 227,270,626 101,617,050 231,634,487 1,482,929,991 272,152,987 64,387,956 306,914,267 274,104,538 20,793,093 82,582,317 4,622,406 52,614,350 458,183,790 241,810,168 984,445,331 558,638,298 14,402,609 5,180,692,237 613,603,111 821,478,988 27,623,971 448,329,281 31,265,704 693,524,367 1,024,387,837 67,272,642 70,329,475 276,531,633 155,230,925 121,766,318 84,267,682 21,090,417

Age 65 And Older $4,565,969,420 12,379,712 2,984 1,383,449 8,836,616 3,278,901 855,228 587,386 1,898,151 7,257,139 538,400,521 24,402,577 64,510 117,415,445 18,585,853 5,904,962 5,750,901 1,349,170 12,243,055 15,429,415 36,484,851 11,300,440 675,797,448 4,231,452 3,841,613 41,728,923 7,880,747 149,405 8,625,874 1,307,106 248,498 122,437,688 409,905 23,652 2,239,035,797 5,869,388 483,338,647 7,630 70,953,823 477,516 1,924 28,285,148 6,507,397 11,458,758 17,338,208 1,780,234 8,086,718 1,899,043 435,612

Blind/ Disabled $4,431,978,829 4,578,243 3,141 739,781 8,389,023 4,788,110 1,384,318 287,908 1,167,617 11,272,065 416,393,147 17,226,614 99,271,406 100,582,572 5,607,387 4,912,988 1,221,289 7,742,277 7,872,775 30,699,381 9,036,644 646,071,584 12,000,170 2,541,512 46,127,432 15,766,902 25,393 4,815,086 1,774,635 111,491 127,461,536 2,933,380 27,346 2,453,077,208 17,772,507 1,809,929 12,152 103,443,171 316,454 97,708,390 20,500,823 26,072,325 12,725,211 12,330,125 2,067,486 90,559,071 750,824

Children $6,296,469,645 148,833,492 26,956,105 133,971,943 158,065,059 175,714,435 71,584,652 80,331,280 41,444,435 6,602,416 207,172,320 373,943,804 34,025,915 9,242,077 189,301,093 166,541,286 44,468,194 62,739,078 173,170,114 104,679,240 28,345,737 133,240,135 142,670,344 176,674,586 50,624,013 162,687,404 201,943,031 9,564,948 69,141,357 985,534 45,002,089 134,127,028 190,611,655 195,317,258 443,414,536 10,139,180 270,502,570 167,589,287 266,014,217 17,331,267 192,671,226 19,967,569 198,841,784 627,565,322 6,849,931 19,728,749 156,019,733 96,667,404 436,882 45,577,401 7,430,530

Adults $4,463,769,119 10,424,901 16,648,759 102,396,531 47,813,608 111,284,746 56,074,003 8,908,354 35,237,122 2,367,234 186,368,458 273,996,494 47,408,515 10,211,551 107,004,506 42,223,755 25,723,302 24,793,072 82,799,390 99,289,195 6,087,081 78,057,268 18,390,615 79,246,779 7,115,062 56,370,508 48,513,858 11,053,347 555,131 7,249,745 74,157,538 47,855,228 789,128,073 115,223,762 4,212,431 218,076,662 422,371,929 70,316,195 10,272,922 81,261,061 10,504,165 396,972,269 348,036,544 27,842,989 26,416,757 90,843,567 54,715,801 22,683,647 36,791,238 12,473,451

Other/ Unknown $268,406 123 265,756 2,527 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-25

Pharmaceutical Benefits 2000 Table 14.

Medicaid Medical Vendor Payment for Recipients of Other Coverage Groups by Basis of Eligibility and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Payments $30,686,156,426 607,749,253 71,856,764 693,109,765 596,207,736 1,262,422,388 960,589,934 1,436,298,060 152,583,054 21,665,816 1,236,568,867 889,614,162 7,972,123 70,620,282 668,901,358 1,370,926,082 637,601,466 52,944,805 588,092,271 893,828,098 332,465,141 189,104,492 126,147,364 70,708,537 1,494,649,325 417,485,900 1,942,734,440 88,089,349 237,397,323 211,394,224 260,382,807 1,725,703,499 177,322,949 367,220,635 108,315,569 22,843,885 116,221,687 335,137,219 2,087,655,250 308,397,218 558,650,582 167,831,591 923,383,603 2,825,455,089 311,792,358 115,229,024 664,533,221 1,034,138 830,670,996 144,277,023 1,170,245,392 134,124,312

Age 65 And Older $14,498,995,409 433,471,888 28,293,986 262,536,800 342,059,991 95,694,865 341,275,440 838,539,167 78,282,890 2,955 636,131,051 343,954,136 16,332,286 696,692,574 343,062,385 973,464 396,922,761 434,248,105 179,487,896 207,864 927,670 793,508,385 286,274,251 887,150,575 26,908,376 168,015,811 67,463,660 129,265,639 914,673,575 119,292,444 31,845,642 366,918 76,591,433 1,176,619,603 155,529,211 264,019,570 98,622,801 565,018,920 1,606,113,188 65,245,645 71,210,786 339,362,377 441,687,590 1,625,940 693,959,632 49,525,263

Blind/ Disabled $8,174,318,206 132,718,687 11,095,814 181,723,990 193,030,621 73,134,421 462,611,249 417,829,975 59,575,581 290,408,477 405,953,849 5,725,418 163,271,980 450,920,933 164,932,213 11,912,948 122,896,724 267,971,731 81,774,214 68,729,190 35,260,507 861,536 346,985,092 86,748,250 907,097,595 24,184,886 20,750,440 29,034,907 69,507,940 522,521,410 31,743,724 19,571,705 121,427,044 521,006,672 126,334,393 147,144,457 40,236,645 127,900,155 614,336,542 105,480,154 17,250,565 198,632,778 136,411,805 300,695,964 56,975,025

Children $3,404,751,399 14,517,232 18,677,708 142,329,554 22,044,346 226,562,828 28,764,143 84,621,730 6,077,624 1,050,170 219,791,672 66,014,876 1,790,257 39,386,267 83,259,143 152,744,723 70,450,786 24,452,249 12,568,168 152,256,862 33,417,986 42,134,228 25,116,858 14,587,834 235,201,490 10,129,164 81,552,257 20,583,273 1,207,601 48,328,090 28,523,456 100,186,543 111,816 3,392,423 7,273,174 24,972,591 50,477,129 196,236,131 8,757,728 57,931,221 20,719,078 82,100,398 420,059,260 88,893,868 7,976,060 93,245,058 320,729 116,391,755 91,415,201 106,972,469 19,176,192

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-26

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 14.

Medicaid Medical Vendor Payment for Recipients of Other Coverage Groups by Basis of Eligibility and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Adults $2,260,701,158 8,976,726 4,135,573 98,668,652 10,209,958 617,495,532 26,722,462 78,090,916 7,033,646 4,808,252 38,781,531 49,733,773 787,184 23,016,016 73,080,717 47,832,963 40,573,878 8,208,810 12,471,147 39,196,967 11,384,580 38,031,416 64,788,051 2,704,512 82,097,254 21,936,850 20,325,741 10,396,814 11,199,594 25,503,371 8,958,776 90,867,227 9,022,502 5,090,468 19,854,482 50,024,591 95,948,926 4,406,649 38,323,909 4,467,980 90,497,687 140,771,391 22,336,531 3,199,564 23,904,434 713,409 114,273,156 18,953,153 33,911,153 6,982,284

Foster Children $2,346,800,698 17,825,019 9,653,683 7,850,767 28,862,820 249,516,816 101,216,640 17,216,272 1,613,313 15,804,439 51,456,136 23,957,528 5,394,682 2,492,581 332,957,232 22,734,889 18,582,204 7,397,334 43,231,020 154,433 26,400,465 40,001,794 981,948 51,626,985 36,699,762 12,397,385 46,608,272 6,016,000 36,223,877 41,064,196 24,126,996 97,454,744 26,174,965 367,220,635 44,483,297 10,113,325 71,394,614 36,617,022 97,843,918 13,369,237 51,231,425 3,785,087 57,825,355 44,174,708 29,836,160 15,461,003 9,388,574 21,906,690 32,282,729 34,706,174 1,465,548

Other/ Unknown $589,554 239,701 17,926 2,451 157,342 41,088 131,046 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-27

Pharmaceutical Benefits 2000 Table 15.

Medicaid Eligibles by Full-Year, Partial Year and Months Covered and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Eligibles 41,361,532 628,220 87,873 649,302 426,080 6,191,269 346,928 402,547 105,153 138,722 2,040,541 1,223,439 182,460 116,718 1,784,159 610,146 321,119 246,598 653,553 723,864 195,839 603,562 953,469 1,354,718 557,232 526,604 772,622 93,298 210,261 130,662 98,340 857,898 339,527 3,500,292 1,201,681 62,115 1,402,364 459,570 537,465 1,720,000 964,015 148,797 656,263 83,111 1,454,799 2,680,583 198,730 131,639 19,914 689,571 915,214 373,090 538,229 51,367

Full-Year Eligibles 22,997,728 352,365 32,278 272,640 206,010 3,809,289 166,055 270,305 54,703 94,137 923,737 663,324 97,128 43,432 1,169,262 286,792 201,636 113,754 388,599 403,647 111,951 328,051 750,084 805,792 330,691 273,040 453,274 40,760 110,520 52,898 53,810 504,335 172,211 2,168,626 625,528 27,989 740,166 185,342 215,517 1,104,850 93,981 402,532 40,588 1,076,031 1,202,113 73,365 80,720 14,093 385,302 517,249 196,127 292,355 18,744

Partial Year Eligibles 17,399,787 275,855 55,595 376,662 220,070 2,381,980 180,873 132,242 50,450 44,585 1,116,804 560,115 85,332 73,286 614,897 323,354 119,483 132,844 264,954 320,217 83,888 275,511 203,385 548,926 226,541 253,564 319,348 52,538 99,741 77,764 44,530 353,563 167,316 1,331,666 576,153 34,126 662,198 274,226 321,948 615,150 54,816 253,731 42,523 378,768 1,478,470 125,365 50,919 5,821 304,269 397,965 176,963 245,874 32,623

Partial Year Months 104,387,484 1,749,290 367,248 2,218,598 1,385,264 13,906,720 1,045,628 819,511 316,264 284,704 6,501,745 3,440,181 443,464 446,038 3,714,135 1,892,603 669,249 754,482 1,650,057 1,962,179 494,830 1,654,875 1,282,741 3,347,918 1,403,157 1,536,116 1,935,404 304,464 560,457 437,856 270,721 2,155,234 1,008,741 8,149,801 3,453,468 202,387 3,921,544 1,653,167 1,894,454 3,650,919 348,167 1,698,420 252,649 2,330,633 8,842,892 687,551 333,252 1,856,445 2,464,506 1,057,767 1,442,518 187,070

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-28

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 16.

Medicaid Eligibles by Maintenance Assistance Status and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Eligibles 41,361,532 628,220 87,873 649,302 426,080 6,191,269 346,928 402,547 105,153 138,722 2,040,541 1,223,439 182,460 116,718 1,784,159 610,146 321,119 246,598 653,553 723,864 195,839 603,562 953,469 1,354,718 557,232 526,604 772,622 93,298 210,261 130,662 98,340 857,898 339,527 3,500,292 1,201,681 62,115 1,402,364 459,570 537,465 1,720,000 964,015 148,797 656,263 83,111 1,454,799 2,680,583 198,730 131,639 19,914 689,571 915,214 373,090 538,229 51,367

Receiving Cash Payments 17,663,099 260,614 56,288 263,593 74,087 3,202,001 102,264 157,719 34,034 98,892 1,181,859 423,014 112,219 12,725 783,543 238,360 61,219 84,965 333,376 389,032 74,747 267,549 451,577 597,873 251,261 239,078 190,147 43,590 93,822 59,177 28,041 410,748 141,399 1,902,380 603,766 22,121 535,575 132,633 707,783 92,523 191,752 35,345 446,713 1,049,611 54,394 34,988 6,345 299,904 382,328 200,222 236,456 9,447

Medically Needy 4,239,284 108,750 1,361,944 45,477 21,796 56,251 813 5,234 386,883 10,050 36,572 53,842 8,030 2,019 57,874 244,709 193,142 13,859 7,275 27,657 9,811 6,302 998,432 121,444 16,672 6,941 150,126 8,757 135,724 47,805 6,376 10,057 12,092 16,597 11,863 4,372 33,736 -

Poverty Related 10,568,471 263,587 16,695 206,776 195,128 369,005 88,123 59,334 53,788 10,068 569,091 560,476 58,966 37,162 307,813 205,636 68,437 87,505 197,815 186,270 50,959 187,404 199,301 301,489 78,289 245,413 296,853 16,618 74,285 7,822 36,535 196,530 163,968 512,355 395,637 11,382 807,506 253,977 476,668 24,195 235,549 28,078 663,204 1,067,067 28,677 64,994 269,519 221,528 29,004 64,972 17,018

Other 7,458,731 104,019 14,890 178,933 47,801 1,258,319 156,541 140,017 17,331 6,318 233,339 239,131 4,177 66,831 305,920 166,150 181,254 37,556 68,520 137,265 68,114 90,735 57,882 261,563 213,704 42,110 285,622 25,749 14,497 63,650 23,945 244,318 34,160 87,125 80,834 11,940 59,283 143,805 385,423 23,322 228,942 19,688 209,148 516,100 109,189 21,598 1,477 103,551 299,492 139,492 203,062 24,899

MAS Unknown 1,431,947 314 1,648 1 5 1,864 159 3,267 651 119 3 66 13 8 459,570 109 964,015 20 10 94 2 3 3 3

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-29

Pharmaceutical Benefits 2000 Table 17.

Medicaid Eligibles by Basis of Eligibility and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Eligibles 41,361,532 628,220 87,873 649,302 426,080 6,191,269 346,928 402,547 105,153 138,722 2,040,541 1,223,439 182,460 116,718 1,784,159 610,146 321,119 246,598 653,553 723,864 195,839 603,562 953,469 1,354,718 557,232 526,604 772,622 93,298 210,261 130,662 98,340 857,898 339,527 3,500,292 1,201,681 62,115 1,402,364 459,570 537,465 1,720,000 964,015 148,797 656,263 83,111 1,454,799 2,680,583 198,730 131,639 19,914 689,571 915,214 373,090 538,229 51,367

Age 65 And Older 4,078,149 76,756 5,722 32,752 50,770 557,436 42,052 55,244 7,565 10,020 202,885 92,211 19,079 12,848 122,317 70,806 40,233 29,238 69,450 93,353 24,463 53,714 101,133 97,752 61,018 64,709 92,655 9,204 21,508 14,685 11,690 108,805 21,105 373,295 168,788 10,728 147,520 41,337 246,811 17,747 76,772 8,575 88,326 338,535 10,145 15,610 1,526 91,088 64,925 32,612 66,223 4,408

Blind/ Disabled 6,960,124 165,972 9,586 89,642 102,277 892,277 64,153 54,602 14,958 28,890 412,175 226,999 18,420 18,468 289,618 93,879 52,681 46,314 187,148 164,758 40,114 113,836 198,747 273,214 76,989 142,423 119,232 16,262 27,483 21,799 11,980 165,497 46,502 625,643 210,064 9,219 231,324 112,407 299,438 30,002 110,839 14,899 306,344 320,882 21,507 16,350 1,240 127,524 120,040 81,681 126,166 7,660

Children 19,434,290 326,400 47,257 359,687 185,051 3,093,098 158,182 198,388 51,057 65,697 1,002,737 680,791 75,329 65,776 821,594 337,737 142,100 124,514 282,190 350,492 86,689 295,549 463,804 567,854 308,613 255,614 421,830 44,416 120,392 69,281 56,064 394,443 221,490 1,488,919 621,126 28,972 652,630 141,508 799,439 65,263 310,020 45,742 546,545 1,547,176 115,434 57,405 11,489 360,013 515,912 182,281 242,255 28,045

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-30

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 17.

Medicaid Eligibles by Basis of Eligibility and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Adults 8,712,861 54,419 23,946 160,345 82,815 1,511,094 67,095 85,395 30,964 30,139 400,324 209,091 64,575 17,936 417,213 101,308 80,997 41,714 107,045 111,937 42,014 124,162 189,180 413,701 102,477 60,329 122,206 19,930 30,255 21,207 16,029 170,873 48,867 925,310 189,333 11,649 335,747 229,567 347,440 31,162 151,444 12,618 501,663 455,759 47,504 40,026 5,659 106,021 194,023 70,294 87,424 10,636

Foster Children 743,588 4,673 1,362 6,876 4,853 137,334 15,446 8,918 609 2,328 22,419 14,342 3,193 1,690 133,417 6,416 4,949 4,818 7,717 57 2,559 16,301 605 1,546 7,925 3,526 16,699 3,420 10,623 3,677 2,569 18,280 1,563 87,125 12,370 1,547 35,143 12,537 26,872 4,623 7,168 1,277 11,545 18,231 4,046 2,163 4,925 20,311 6,222 16,158 615

Other/ Unknown 1,432,520 314 30 1,648 1 5 1,864 159 3 3,267 651 210 3 66 13 8 459,570 109 964,015 20 376 94 85 3 3 3

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-31

Pharmaceutical Benefits 2000 Table 18.

Medicaid Eligibles Who Receive Cash Payments by Basis of Eligibility and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Eligibles 17,663,099 260,614 56,288 263,593 74,087 3,202,001 102,264 157,719 34,034 98,892 1,181,859 423,014 112,219 12,725 783,543 238,360 61,219 84,965 333,376 389,032 74,747 267,549 451,577 597,873 251,261 239,078 190,147 43,590 93,822 59,177 28,041 410,748 141,399 1,902,380 603,766 22,121 535,575 132,633 707,783 92,523 191,752 35,345 446,713 1,049,611 54,394 34,988 6,345 299,904 382,328 200,222 236,456 9,447

Age 65 And Older 1,697,350 34,599 5,135 14,136 18,961 354,618 19,544 8,194 2,339 3,998 107,990 41,123 17,079 1,636 26,301 17,408 8,976 5,293 25,974 52,649 4,017 20,677 41,702 23,550 16,775 29,653 4,280 1,981 8,242 6,818 1,629 35,717 10,204 181,284 83,239 3,968 1,209 8,496 74,525 5,133 37,766 2,565 40,534 177,775 3,238 2,382 430 38,864 22,416 24,570 16,766 992

Blind/ Disabled 5,074,095 146,339 9,087 71,501 5,738 770,362 9,109 21,526 11,068 23,291 321,282 180,781 17,827 7,501 186,029 60,345 39,776 33,270 167,550 147,904 27,026 89,630 148,876 199,337 53,894 125,030 9,317 13,036 23,874 16,970 5,953 128,411 41,826 508,219 132,599 6,505 7,801 47,811 227,384 23,474 85,148 13,275 242,903 275,960 12,728 11,468 595 100,317 93,848 65,892 99,623 5,079

Children 7,380,074 58,099 26,406 125,158 35,349 1,460,553 49,983 84,977 14,951 49,055 501,407 147,966 49,699 2,462 396,812 101,145 6,608 28,443 94,384 137,157 28,750 112,532 178,824 125,416 122,778 57,967 125,418 19,022 41,879 24,646 13,975 161,921 59,091 861,044 257,439 8,203 383,866 43,925 283,999 41,930 47,284 13,421 114,145 409,182 24,982 14,523 3,630 112,615 169,471 63,063 81,974 2,545

Adults 3,511,525 21,577 15,660 52,798 14,039 616,468 23,628 43,022 5,676 22,548 251,180 53,144 27,614 1,126 174,401 59,462 5,859 17,959 45,468 51,322 14,954 44,710 82,175 249,570 57,782 26,428 51,132 9,551 19,827 10,743 6,484 84,699 30,278 351,833 130,489 3,445 142,699 32,401 121,875 21,986 21,554 6,084 49,108 186,694 13,446 6,615 1,690 48,108 96,593 46,697 38,093 831

Other/ Unknown 55 32 23 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-32

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 19.

Medically Needy Medicaid Eligibles by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Eligibles 4,239,284 108,750 1,361,944 45,477 21,796 56,251 813 5,234 386,883 10,050 36,572 53,842 8,030 2,019 57,874 244,709 193,142 13,859 7,275 27,657 9,811 6,302 998,432 121,444 16,672 6,941 150,126 8,757 135,724 47,805 6,376 10,057 12,092 16,597 11,863 4,372 33,736 -

Age 65 And Older 759,191 299 170,805 14,868 4,103 16 110 1,929 67,720 3,188 22,601 4,044 1,312 702 23,337 29,480 66,936 6,309 5,286 9,049 4,220 3,123 192,011 43,491 6,613 1,935 28,438 5,348 18,084 648 787 1,096 8,866 5,754 342 6,341 -

Blind/ Disabled 618,236 79,925 98,679 19,776 3,816 11,387 638 593 57,657 2,615 10,949 3,085 1,907 531 17,356 7,538 67,212 6,813 1,978 1,828 2,502 1,125 117,424 55,713 2,710 5,006 5,172 1,847 9,878 1,091 1,050 645 6,030 5,852 2,719 5,189 -

Children 1,807,779 17,867 787,798 6,007 8,785 16,020 62 1,447 116,304 980 2,766 28,767 1,848 494 10,185 132,622 7,924 516 3 8,315 1,550 2,052 501,513 8,238 4,591 57,730 22 37,089 11,327 2,309 4,031 7,397 1,423 114 143 19,540 -

Adults 1,053,709 10,659 304,662 4,826 5,092 28,828 3 1,265 145,202 3,267 256 17,946 2,963 292 6,996 75,069 51,070 194 8 8,465 1,539 2 187,484 14,002 2,758 58,786 1,540 70,331 36,478 2,328 4,189 2,954 278 143 1,168 2,666 -

Other/ Unknown 369 27 342 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-33

Pharmaceutical Benefits 2000 Table 20.

Poverty Related Medicaid Eligibles by Basis of Eligibility and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Eligibles 10,568,471 263,587 16,695 206,776 195,128 369,005 88,123 59,334 53,788 10,068 569,091 560,476 58,966 37,162 307,813 205,636 68,437 87,505 197,815 186,270 50,959 187,404 199,301 301,489 78,289 245,413 296,853 16,618 74,285 7,822 36,535 196,530 163,968 512,355 395,637 11,382 807,506 253,977 476,668 24,195 235,549 28,078 663,204 1,067,067 28,677 64,994 269,519 221,528 29,004 64,972 17,018

Age 65 And Older 704,722 22,302 19 3,745 9,053 3,206 2,170 2,247 2,017 1,918 58,571 22,220 71 11,212 25,414 4,966 5,708 1,224 16,458 13,503 9,806 9,680 29,951 6,272 4,319 20,664 9,887 437 3,784 4,115 361 32,613 110 142 146,311 727 99,249 745 22,679 407 2 45,654 2,408 9,054 22,496 4,136 7,590 4,336 763

Blind/ Disabled 670,007 10,433 16 3,472 10,282 8,833 3,135 925 1,174 1,783 62,472 15,131 10,336 32,493 6,420 4,386 939 11,124 5,593 6,887 5,589 39,813 6,565 2,629 14,585 6,918 146 1,565 3,558 232 21,341 547 4 223,523 9,014 13,772 338 18,943 147 47,521 18,140 4,103 2,912 14,473 4,092 13,070 1 632

Children 6,940,283 218,890 12,611 152,854 123,756 302,891 59,866 49,822 29,604 5,629 363,123 424,270 23,532 10,398 208,992 180,069 46,120 73,598 140,600 136,655 30,485 127,220 121,318 250,290 69,276 188,366 245,522 12,378 68,936 143 33,071 113,631 144,722 126,362 354,150 9,740 258,422 75,462 303,037 17,080 174,006 23,344 300,411 858,646 5,968 27,364 192,116 189,001 1,018 43,703 11,815

Adults 2,253,438 11,962 4,049 46,705 52,037 54,075 22,952 6,340 20,993 738 84,925 98,855 35,363 5,216 40,914 14,181 12,223 11,744 29,632 30,519 3,781 44,915 8,219 38,362 2,045 21,798 34,526 3,657 6 2,871 28,945 18,589 385,993 41,487 1,496 179,250 168,774 60,610 6,032 19,921 4,180 315,270 144,627 16,198 25,664 40,434 24,299 7,326 16,932 3,808

Other/ Unknown 21 1 20 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-34

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 21.

Medicaid Eligibles of Other Coverage Groups by Basis of Eligibility and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Eligibles 7,458,731 104,019 14,890 178,933 47,801 1,258,319 156,541 140,017 17,331 6,318 233,339 239,131 4,177 66,831 305,920 166,150 181,254 37,556 68,520 137,265 68,114 90,735 57,882 261,563 213,704 42,110 285,622 25,749 14,497 63,650 23,945 244,318 34,160 87,125 80,834 11,940 59,283 143,805 385,423 23,322 228,942 19,688 209,148 516,100 109,189 21,598 1,477 103,551 299,492 139,492 203,062 24,899

Age 65 And Older 916,886 19,855 568 14,871 22,457 28,807 20,338 29,935 3,209 1 36,308 28,758 2,882 48,432 22,361 120 22,974 25,889 9,938 20 994 33,615 14,392 78,488 1,500 433 3,752 5,480 37,352 10,791 42,058 5 30,179 44,599 6,521 16,327 5,603 29,706 115,106 3,851 3,387 20,862 32,619 110 38,780 2,653

Blind/ Disabled 597,786 9,200 483 14,669 6,332 14,403 51,909 12,375 2,716 17,034 30,449 631 13,439 27,114 5,904 1,156 5,389 9,354 5,670 1,261 2,520 100 13,653 2,808 102,997 1,102 216 1,271 3,293 14,620 4,129 21,752 50,576 53,110 4,343 6,748 1,477 6,042 26,782 3,585 920 6,704 16,248 21,353 1,949

Children 3,306,154 49,411 8,240 81,675 8,079 541,856 48,333 57,582 6,502 2,228 122,187 108,493 651 52,916 99,486 56,523 88,392 19,707 18,439 74,832 26,960 45,612 31,040 184,224 116,043 9,281 50,890 13,013 1,262 44,492 7,468 116,839 17,677 1,299 6,438 10,342 22,121 154,673 6,231 88,730 8,977 94,900 268,021 82,175 11,487 462 53,859 157,326 118,057 97,038 13,685

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-35

Pharmaceutical Benefits 2000 Table 21.

Medicaid Eligibles of Other Coverage Groups by Basis of Eligibility and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Adults 1,894,189 20,880 4,237 60,842 6,080 535,889 20,515 31,207 4,295 1,761 35,391 57,089 333 11,594 56,696 27,665 59,648 11,755 13,999 27,133 22,987 27,541 23,717 74,699 42,456 12,103 36,548 6,714 1,963 10,458 5,135 57,227 3,355 3,950 13,798 28,392 106,169 1,604 109,969 2,354 66,954 87,960 15,532 3,558 1,015 17,201 72,988 15,103 29,733 5,997

Foster Children 743,588 4,673 1,362 6,876 4,853 137,334 15,446 8,918 609 2,328 22,419 14,342 3,193 1,690 133,417 6,416 4,949 4,818 7,717 57 2,559 16,301 605 1,546 7,925 3,526 16,699 3,420 10,623 3,677 2,569 18,280 1,563 87,125 12,370 1,547 35,143 12,537 26,872 4,623 7,168 1,277 11,545 18,231 4,046 2,163 4,925 20,311 6,222 16,158 615

Other/ Unknown 128 30 2 12 1 83 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-36

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 22.

Medicaid Recipients of Medical Care by Age and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 40,649,482 527,078 74,508 507,668 424,727 7,082,175 344,916 381,208 101,436 166,146 1,904,591 1,221,978 184,614 123,176 1,363,856 607,293 314,936 241,933 644,482 720,615 170,456 561,085 908,238 1,362,890 538,413 485,767 734,015 100,760 211,188 128,144 93,970 813,251 329,418 3,073,241 1,167,988 62,280 1,290,776 342,475 511,171 1,523,120 964,015 153,130 594,962 89,537 1,843,661 2,324,810 215,801 123,992 19,764 653,236 1,413,208 342,668 518,595 46,121

Ages Under 1 1,558,643 27,969 3,402 46,561 16,248 138,898 17,393 11,337 3,611 3,164 72,385 64,474 10,481 5,313 89,743 27,842 11,800 10,427 22,487 57,639 4,257 23,208 36,321 44,555 17,157 26,367 27,330 3,530 17,290 7,618 2,499 26,256 12,877 101,784 79,785 2,060 91,067 14,102 43,654 4,288 27,168 6,767 33,132 144,065 13,992 2,410 840 41,524 25,861 12,093 20,872 2,740

From Ages 1 to 5 6,933,058 111,576 13,768 110,446 77,228 1,206,917 70,592 61,527 18,017 23,730 360,477 255,052 26,262 26,308 260,125 125,480 55,265 47,237 108,103 144,132 22,420 102,693 126,727 236,433 93,654 90,526 142,186 17,888 39,175 29,865 16,657 149,651 70,445 503,121 213,089 10,456 220,394 80,111 248,534 25,004 100,788 18,085 191,472 558,876 46,317 15,757 4,553 123,243 167,150 56,474 98,851 10,221

From Ages 6 to 14 8,552,786 111,380 17,224 119,360 93,906 1,534,178 76,847 91,304 24,015 28,842 457,266 280,857 34,392 26,804 302,023 137,858 66,549 54,610 136,877 158,730 36,703 133,175 178,469 317,589 136,544 96,034 181,373 22,870 49,790 30,159 24,433 181,330 97,061 616,071 250,288 13,214 276,683 94,824 360,366 34,289 130,359 21,985 284,213 574,293 40,620 26,550 4,168 152,702 235,062 73,311 114,714 10,522

From Ages 15 to 20 3,770,295 43,098 7,395 43,213 48,658 753,019 30,328 38,712 10,825 10,957 175,370 129,665 16,114 10,351 125,509 55,705 32,200 26,317 56,460 64,869 18,827 50,928 79,006 128,690 66,890 42,668 81,044 9,490 22,657 9,140 9,903 73,879 42,995 285,914 117,711 5,921 123,728 47,731 160,445 13,617 64,024 9,632 152,278 179,470 19,690 12,569 2,103 66,403 107,258 35,841 46,662 4,416

From Ages 21 to 44 8,835,632 93,433 20,429 122,185 88,600 1,694,033 75,406 94,144 28,552 28,937 424,619 225,920 48,768 25,513 327,306 126,370 84,025 51,939 153,490 139,767 42,537 128,022 245,415 336,515 121,112 95,579 147,058 25,881 43,831 24,882 20,093 195,093 58,552 771,013 243,112 13,706 307,773 164,643 374,254 37,367 131,514 16,246 410,025 417,767 46,322 35,932 5,059 125,801 197,921 76,345 112,151 10,675

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-37

Pharmaceutical Benefits 2000 Table 22.

Medicaid Recipients of Medical Care by Age and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

From Ages 45 to 64 3,329,608 51,573 5,439 30,740 34,820 573,977 26,732 32,065 8,598 11,323 150,693 87,177 13,035 9,084 116,503 45,457 23,148 19,175 75,170 59,953 18,530 44,058 104,051 109,172 34,707 47,702 58,750 8,332 13,038 8,841 6,988 60,994 19,573 324,892 102,889 4,618 114,741 62,059 155,593 13,343 46,949 5,714 222,467 148,914 10,243 13,359 1,381 52,956 60,366 35,696 41,219 2,811

From Ages 65 to 74 1,806,516 31,817 2,991 14,001 21,708 357,113 16,807 16,290 2,934 5,038 100,119 53,477 8,509 4,212 55,375 26,414 11,145 8,927 35,195 36,578 9,387 23,068 42,822 45,213 17,342 30,780 32,984 3,582 7,140 5,610 3,490 43,824 11,319 181,044 62,261 2,677 54,935 14,678 66,800 6,887 29,380 3,090 68,911 122,019 4,361 5,897 839 36,481 25,297 12,697 21,719 1,332

From Ages 75 to 84 1,577,798 30,249 2,018 11,580 22,996 261,022 14,897 17,759 2,607 4,058 85,574 49,912 6,629 4,077 47,224 26,052 13,760 9,813 30,128 33,406 8,784 19,948 44,504 38,461 20,595 28,555 32,949 3,659 8,327 4,477 4,253 41,617 8,569 155,864 59,626 3,661 54,832 12,961 60,712 7,528 27,507 3,661 45,752 103,321 3,589 5,905 619 32,497 22,437 10,569 26,802 1,496

From Ages 85 and Over 1,271,386 25,309 741 9,582 19,644 141,650 13,748 18,070 2,127 2,388 65,924 68,219 3,809 3,873 39,126 25,780 15,829 11,298 22,252 25,404 7,287 14,168 50,923 33,254 25,156 22,461 29,374 3,594 9,940 2,789 5,151 36,436 6,708 133,538 39,227 4,500 46,623 9,942 51,748 8,109 17,408 4,340 31,923 76,084 3,120 3,954 202 21,629 18,886 7,838 28,800 1,501

Unknown 3,013,760 674 1,101 919 421,368 2,166 150 47,709 12,164 7,225 16,615 7,641 922 10,335 1,215 2,190 4,320 137 1,724 21,817 73,008 5,256 5,095 967 1,934 4,763 503 4,171 1,319 1,467 342,475 10,120 1,014 964,015 2,698 19,865 17 403,488 1 27,547 1,659 552,970 21,804 6,805 407

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-38

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 23.

Medicaid Recipients of Medical Care by Sex and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 40,649,482 527,078 74,508 507,668 424,727 7,082,175 344,916 381,208 101,436 166,146 1,904,591 1,221,978 184,614 123,176 1,363,856 607,293 314,936 241,933 644,482 720,615 170,456 561,085 908,238 1,362,890 538,413 485,767 734,015 100,760 211,188 128,144 93,970 813,251 329,418 3,073,241 1,167,988 62,280 1,290,776 342,475 511,171 1,523,120 964,015 153,130 594,962 89,537 1,843,661 2,324,810 215,801 123,992 19,764 653,236 1,413,208 342,668 518,595 46,121

Male 14,733,230 196,812 29,343 157,095 2,755,161 134,691 147,258 40,392 45,453 747,611 466,356 74,800 45,716 531,086 230,233 124,286 95,628 253,917 278,337 66,832 209,354 361,068 514,653 219,165 176,349 288,756 41,104 81,843 48,510 36,484 297,939 137,842 1,201,561 443,966 23,579 497,750 219,412 602,675 57,293 205,046 35,541 603,827 910,233 75,205 52,636 6,652 253,854 355,421 132,574 204,135 17,796

Female 22,376,441 322,644 44,064 266,608 3,905,643 208,059 233,950 60,894 72,968 1,144,816 748,398 93,280 69,818 831,848 366,725 189,435 144,097 386,239 442,067 101,902 329,915 547,170 775,234 313,992 304,322 444,292 57,722 122,002 74,729 56,954 511,141 190,255 1,871,645 724,022 37,224 793,007 281,633 919,434 93,137 369,944 51,522 836,338 1,414,555 112,713 69,697 13,112 399,382 504,765 187,552 307,665 27,911

Unknown 3,539,811 7,622 1,101 507,668 1,024 421,371 2,166 150 47,725 12,164 7,224 16,534 7,642 922 10,335 1,215 2,208 4,326 211 1,722 21,816 73,003 5,256 5,096 967 1,934 7,343 4,905 532 4,171 1,321 35 1,477 19 342,475 10,126 1,011 964,015 2,700 19,972 2,474 403,496 22 27,883 1,659 553,022 22,542 6,795 414

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-39

Pharmaceutical Benefits 2000 Table 24.

Medicaid Recipients of Medical Care by Race/Ethnicity and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 40,649,482 527,078 74,508 507,668 424,727 7,082,175 344,916 381,208 101,436 166,146 1,904,591 1,221,978 184,614 123,176 1,363,856 607,293 314,936 241,933 644,482 720,615 170,456 561,085 908,238 1,362,890 538,413 485,767 734,015 100,760 211,188 128,144 93,970 813,251 329,418 3,073,241 1,167,988 62,280 1,290,776 342,475 511,171 1,523,120 964,015 153,130 594,962 89,537 1,843,661 2,324,810 215,801 123,992 19,764 653,236 1,413,208 342,668 518,595 46,121

White Not Hispanic 16,771,976 238,107 34,485 257,363 2,028,789 176,003 170,175 42,152 1,840 759,097 443,904 24,871 99,097 554,463 421,513 271,369 166,353 525,911 238,916 184,348 533,292 682,290 343,748 151,798 506,398 74,115 148,160 71,199 90,345 252,882 89,343 859,517 511,841 44,676 813,089 401,228 896,151 87,594 220,674 52,126 952,473 645,978 140,036 120,771 173 300,535 629,997 296,447 180,361 35,983

Black Not Hispanic 9,847,580 260,790 4,797 141,972 876,628 27,613 95,626 46,817 106,929 663,851 647,000 1,817 552 567,071 145,694 25,612 44,774 82,799 431,382 307,223 102,428 488,168 80,703 298,883 226,649 640 29,859 23,871 876 296,751 8,850 688,544 515,303 1,008 426,783 21,658 458,668 15,172 326,308 185 414,173 458,055 3,966 705 15,493 311,541 57,659 14,776 80,023 935

Hispanic 6,353,196 4,483 2,671 5,396 2,598,598 110,326 109,224 7,817 3,999 305,827 40,754 6,427 12,954 208,620 23,288 11,179 19,046 5,070 19,120 136,456 49,697 28,932 1,319 1,872 20,346 22,083 1,447 182,860 168,019 649,517 43,585 1,508 31,086 50,838 123,070 26,785 4,108 130 12,588 1,119,760 26,951 183 3,991 24,123 102,737 497 19,779 4,130

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-40

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 24.

Medicaid Recipients of Medical Care by Race/Ethnicity and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Asian or Pacific Islands 1,022,077 1,510 3,888 912 512,660 3,744 5,525 401 779 8,633 10,620 74,931 332 30,252 1,455 3,786 6,490 1,286 11,551 30,441 17,568 40,133 1,698 430 2,355 2,912 776 8,979 1,617 57,224 10,659 321 4,819 14,412 26,676 4,615 892 61 7,366 23,253 6,439 434 78 14,973 46,052 325 17,679 135

American Indian/ Alaskan Native 335,582 1,049 25,929 837 30,983 2,301 582 248 16 926 622 99 2,600 2,237 398 1,775 3,080 208 1,039 2,469 5,843 25,640 1,813 1 21,752 8,539 2,577 21 1,891 51,500 7,092 20,124 13,278 1,314 9,425 1,285 248 667 31,510 3,420 6,280 9,092 240 11 748 23,794 6,233 3,846

Unknown 6,319,071 21,139 2,738 507,668 18,247 1,034,517 24,929 76 4,001 52,583 166,257 79,078 76,469 7,641 1,213 14,945 1,215 2,190 29,208 50,317 170,456 37,804 103,152 119,324 19,257 30,256 967 1,951 1,929 5,502 505 69,888 10,089 811,347 66,476 1,489 13,685 342,475 13,610 17,270 964,015 18,716 42,313 5,525 453,641 71,484 29,317 1,659 18 1,316 552,969 30,623 214,520 1,092

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-41

Pharmaceutical Benefits 2000 Table 25.

Medicaid Vendor Payments of Medical Care by Age and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Payments $142,317,903,795 1,902,300,047 330,378,398 1,643,966,305 1,375,797,421 14,236,592,915 1,439,366,499 2,420,791,474 419,732,143 731,292,552 5,686,844,862 3,012,346,312 507,433,146 424,512,387 6,172,865,261 2,564,005,047 1,288,770,390 916,323,608 2,425,288,141 2,383,508,985 747,027,618 2,489,280,148 4,609,360,933 4,345,007,824 2,924,447,719 1,442,373,276 2,569,646,129 361,238,668 753,162,904 462,087,777 606,004,232 4,218,822,993 862,144,872 24,298,610,635 4,013,996,742 341,015,420 6,120,967,557 1,177,853,941 1,377,514,740 6,080,191,710 250,000,000 919,353,410 2,018,620,428 355,833,902 3,167,188,993 7,139,928,843 618,675,433 351,341,290 10,097,973 2,118,202,866 2,044,234,831 1,243,150,526 2,206,398,750 192,004,819

Ages Under 1 $4,181,702,420 22,820,090 18,512,179 150,504,669 69,985,612 159,027,699 37,548,894 37,449,638 9,896,557 14,424,526 207,214,109 130,274,039 13,215,325 14,402,838 369,710,789 86,166,403 31,010,044 31,073,118 39,767,195 168,716,699 7,245,901 59,865,791 122,380,919 103,768,590 61,200,048 55,834,210 72,341,660 9,996,360 41,094,566 20,897,202 5,371,744 62,638,007 31,342,287 465,752,704 219,104,317 5,421,612 312,960,286 15,545,694 82,817,865 12,399,211 79,118,760 22,685,147 30,739,369 428,826,197 32,591,866 4,365,501 551,923 114,024,927 35,769,579 17,099,015 28,368,530 7,862,209

From Ages From Ages 1 to 5 6 to 14 $8,603,546,258 $11,154,216,158 67,146,126 137,864,651 26,147,375 46,203,751 164,096,117 209,815,378 170,587,004 157,649,124 1,099,696,397 1,488,518,619 91,164,647 122,067,919 105,518,904 119,339,122 29,854,591 50,307,997 46,265,668 41,119,366 426,888,964 428,913,238 256,674,945 228,998,832 37,860,256 42,742,017 27,319,923 30,021,260 297,236,608 394,413,854 149,572,250 165,692,398 73,834,267 115,849,468 43,044,576 65,465,347 182,568,410 257,295,529 139,107,477 164,913,424 31,281,848 77,280,919 176,722,191 242,862,808 198,016,371 288,877,243 242,082,971 287,871,822 208,440,363 232,135,456 96,211,119 111,359,490 163,428,780 176,213,721 18,294,856 33,302,058 38,081,715 60,523,842 44,967,398 56,851,800 23,485,035 62,338,125 242,197,724 282,906,145 91,463,467 143,247,036 1,098,859,279 1,573,592,359 233,057,550 335,643,471 13,258,687 20,678,612 219,216,802 360,697,356 98,235,110 162,365,217 357,914,294 666,490,834 48,529,981 59,308,455 117,683,342 163,537,315 19,035,793 29,797,699 139,001,982 237,099,354 681,906,816 523,617,923 53,961,059 52,186,345 15,573,132 37,715,946 1,032,869 827,904 126,666,594 147,224,727 154,415,362 166,326,790 59,891,308 92,021,543 142,851,338 187,435,648 13,196,617 14,686,901

From Ages From Ages 15 to 20 21 to 44 $8,423,079,186 $35,470,454,641 45,748,090 204,929,306 32,941,090 98,122,887 137,883,403 420,953,820 121,005,431 350,725,626 961,974,962 4,035,630,454 114,342,985 347,447,472 81,403,500 585,828,450 35,039,968 117,558,642 39,854,823 177,387,401 295,567,125 1,379,641,858 229,873,552 737,273,945 21,814,656 101,708,497 28,677,864 120,915,949 529,742,708 1,861,505,117 129,727,953 638,727,347 108,926,139 347,901,735 63,337,713 262,174,644 170,759,041 571,166,507 157,908,697 611,395,836 59,429,808 193,621,824 154,004,636 641,599,245 192,799,760 1,220,375,985 210,654,465 1,177,273,480 170,201,289 746,278,109 104,913,877 310,382,434 140,570,168 589,861,158 29,089,839 83,126,095 46,255,062 177,550,894 42,129,982 112,883,176 37,075,477 147,223,561 209,346,536 1,046,385,654 118,582,902 173,657,451 1,031,876,055 6,368,540,586 294,081,459 991,888,410 19,985,618 86,326,115 306,294,127 1,501,817,268 101,366,690 393,343,003 421,800,531 1,287,454,674 38,847,474 224,855,093 146,855,007 426,843,487 27,517,415 85,332,923 253,428,307 763,980,092 410,885,398 1,602,967,227 56,276,177 183,641,866 30,298,880 94,383,464 781,957 2,812,008 122,588,008 552,938,255 124,864,608 521,145,517 87,059,121 279,277,299 114,819,943 453,779,746 11,868,910 57,913,049

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-42

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 25.

Medicaid Vendor Payments of Medical Care by Age and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

From Ages From Ages From Ages From Ages 45 to 64 65 to 74 75 to 84 85 and Over $25,428,205,744 $11,816,786,953 $15,787,654,578 $17,987,033,024 222,430,043 138,331,051 233,804,983 315,442,465 48,111,274 21,079,241 22,794,123 16,180,644 183,783,798 104,866,008 134,376,262 137,686,845 239,447,900 117,089,152 181,078,028 213,433,778 2,605,396,220 1,267,911,644 1,321,426,945 1,160,443,354 235,123,077 101,694,946 153,088,046 194,124,581 439,438,023 211,019,689 351,701,578 489,092,570 71,005,891 27,780,252 37,139,549 40,650,854 161,332,148 58,421,889 66,322,438 59,170,120 948,473,963 492,763,811 672,651,882 814,255,757 507,321,902 225,627,074 302,572,083 372,731,195 76,018,112 38,360,172 58,062,894 73,841,565 71,893,153 26,739,298 40,002,588 51,931,442 1,246,416,786 453,682,260 504,674,065 515,442,795 501,374,204 226,730,761 305,021,585 352,618,604 206,413,954 80,224,074 132,264,291 189,837,627 175,770,453 66,162,248 87,292,819 117,594,529 492,554,678 183,342,077 250,195,634 271,845,644 465,816,270 195,457,195 240,901,709 239,184,115 134,278,978 57,972,838 81,036,079 101,971,621 472,837,550 201,989,548 245,346,175 266,497,836 909,101,419 361,200,739 564,592,348 752,016,149 852,441,315 261,404,363 371,361,023 466,060,921 450,072,629 201,316,637 328,016,607 518,294,261 257,489,521 127,851,781 168,177,532 208,776,837 465,882,450 228,326,459 325,826,357 406,569,598 61,098,168 23,253,794 42,424,696 59,096,081 122,546,774 56,085,965 85,095,618 125,928,469 69,765,335 26,730,084 33,091,340 35,548,384 97,365,677 44,633,623 75,165,683 112,644,970 719,076,240 396,093,554 566,277,295 686,390,687 116,690,103 48,756,597 60,110,922 72,980,615 4,829,113,896 2,546,546,564 3,107,820,036 3,276,509,156 730,963,532 312,081,536 462,921,843 434,254,624 58,928,321 27,136,683 42,074,930 66,020,835 1,212,619,311 551,295,117 815,224,323 840,842,962 252,153,490 92,448,859 127,029,299 128,852,296 963,973,632 497,082,758 796,964,252 1,004,040,138 179,527,633 80,422,597 119,175,726 152,158,672 338,951,033 137,571,468 179,507,553 173,537,576 52,355,727 22,329,101 36,988,783 59,783,196 536,687,431 187,217,995 281,906,447 340,325,499 1,149,707,374 620,704,247 810,913,913 910,398,749 88,516,271 29,376,390 34,475,544 40,405,737 63,400,831 25,835,031 35,828,585 43,230,554 1,357,835 1,158,325 1,072,172 502,980 390,567,507 198,282,074 244,845,675 221,065,096 319,502,360 135,937,153 201,754,089 253,203,632 249,943,764 85,512,581 117,549,030 140,540,957 352,207,086 180,113,687 311,428,280 439,100,543 30,960,702 12,835,963 18,280,921 23,974,909

Unknown $3,465,224,822 513,783,242 285,834 (245,204,234) 136,566,621 42,763,932 497,842 66,994,173 20,474,155 20,998,745 43,809,654 12,608,072 40,279 8,373,542 2,508,791 4,408,161 5,793,426 107,564 2,907,802 27,554,368 372,088,874 8,492,320 1,376,475 625,778 1,556,721 19,223,076 700,337 7,511,151 5,313,492 1,184,007 1,177,853,941 6,175,082 1,652,732 250,000,000 4,128,568 255,014,887 8,118 396,802,517 997 47,244,178 709,366 131,315,741 114,255,908 (3,706,051) 424,638

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-43

Pharmaceutical Benefits 2000 Table 26.

Medicaid Vendor Payments of Medical Care by Sex and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Payments $142,317,903,795 1,902,300,047 330,378,398 1,643,966,305 1,375,797,421 14,236,592,915 1,439,366,499 2,420,791,474 419,732,143 731,292,552 5,686,844,862 3,012,346,312 507,433,146 424,512,387 6,172,865,261 2,564,005,047 1,288,770,390 916,323,608 2,425,288,141 2,383,508,985 747,027,618 2,489,280,148 4,609,360,933 4,345,007,824 2,924,447,719 1,442,373,276 2,569,646,129 361,238,668 753,162,904 462,087,777 606,004,232 4,218,822,993 862,144,872 24,298,610,635 4,013,996,742 341,015,420 6,120,967,557 1,177,853,941 1,377,514,740 6,080,191,710 250,000,000 919,353,410 2,018,620,428 355,833,902 3,167,188,993 7,139,928,843 618,675,433 351,341,290 10,097,973 2,118,202,866 2,044,234,831 1,243,150,526 2,206,398,750 192,004,819

Male $54,505,135,169 428,934,012 143,251,512 611,103,276 670,651,186 5,684,321,859 568,161,269 909,770,244 176,105,564 290,532,181 2,186,073,956 1,024,630,832 205,541,343 161,041,265 2,683,512,469 996,709,219 524,987,594 370,328,914 908,938,450 917,846,494 308,154,135 1,003,696,022 1,775,376,600 1,536,838,141 1,199,637,751 495,820,726 969,602,591 137,459,729 277,327,336 187,811,985 233,111,156 1,514,612,537 354,666,166 10,246,955,529 1,537,982,121 138,869,223 2,219,780,890 560,534,420 2,244,847,299 367,807,751 691,382,912 144,940,742 1,050,449,413 2,628,419,621 248,855,565 141,585,986 2,708,355 802,007,954 662,728,122 431,380,707 853,584,729 73,757,316

Female $84,263,344,977 901,448,396 186,841,052 1,032,863,023 950,004,425 8,415,698,843 828,441,298 1,511,021,230 243,128,737 373,738,633 3,480,296,751 1,966,718,337 258,176,979 250,861,633 3,489,312,513 1,558,922,286 761,274,005 541,562,987 1,510,527,921 1,465,177,548 435,970,254 1,458,030,690 2,833,984,333 2,436,083,617 1,716,317,648 945,154,295 1,599,417,760 222,222,218 465,517,769 254,846,778 372,103,000 2,696,699,305 502,159,764 14,050,848,812 2,476,014,620 200,950,010 3,891,587,868 810,785,923 3,833,695,224 547,415,973 1,072,190,466 209,534,188 1,719,918,660 4,511,436,002 322,010,723 209,045,938 7,389,618 1,316,194,909 1,250,021,549 695,486,096 1,356,526,399 117,767,971

Unknown $3,549,423,630 571,917,639 285,834 (244,858,190) 136,572,213 42,763,932 497,842 67,021,738 20,474,155 20,997,143 43,714,824 12,609,489 40,279 8,373,542 2,508,791 4,431,707 5,821,770 484,942 2,903,229 27,553,436 372,086,066 8,492,320 1,398,255 625,778 1,556,721 10,317,800 19,429,014 790,076 7,511,151 5,318,942 806,292 1,196,187 9,598,794 1,177,853,941 6,194,397 1,649,187 250,000,000 4,129,686 255,047,050 1,358,972 396,820,920 73,218 47,809,145 709,366 131,485,160 116,283,723 (3,712,378) 479,532

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-44

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 27.

Medicaid Vendor Payments of Medical Care by Race/Ethnicity and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Payments $142,317,903,795 1,902,300,047 330,378,398 1,643,966,305 1,375,797,421 14,236,592,915 1,439,366,499 2,420,791,474 419,732,143 731,292,552 5,686,844,862 3,012,346,312 507,433,146 424,512,387 6,172,865,261 2,564,005,047 1,288,770,390 916,323,608 2,425,288,141 2,383,508,985 747,027,618 2,489,280,148 4,609,360,933 4,345,007,824 2,924,447,719 1,442,373,276 2,569,646,129 361,238,668 753,162,904 462,087,777 606,004,232 4,218,822,993 862,144,872 24,298,610,635 4,013,996,742 341,015,420 6,120,967,557 1,177,853,941 1,377,514,740 6,080,191,710 250,000,000 919,353,410 2,018,620,428 355,833,902 3,167,188,993 7,139,928,843 618,675,433 351,341,290 10,097,973 2,118,202,866 2,044,234,831 1,243,150,526 2,206,398,750 192,004,819

White Not Hispanic $77,308,255,958 827,952,829 174,019,260 807,626,871 1,073,552,240 6,166,204,632 919,883,912 1,764,041,602 222,835,727 40,491,720 2,882,195,485 1,449,477,236 82,883,964 383,043,599 3,144,842,530 2,092,496,250 1,196,460,179 749,842,750 1,993,823,547 1,099,777,803 1,131,688,380 3,532,575,981 2,488,989,444 2,377,783,348 632,011,633 1,996,030,667 300,075,153 620,174,553 310,748,421 597,538,126 2,306,563,061 334,362,382 8,526,521,151 2,108,139,775 295,976,110 4,523,992,068 1,174,610,986 4,168,714,616 722,585,451 823,140,050 265,096,471 1,948,698,449 3,237,522,829 471,999,810 347,145,661 158,015 1,185,068,839 1,520,911,231 1,050,971,933 1,072,860,297 164,148,931

Black Not Hispanic $27,924,916,921 438,900,267 14,417,242 94,508,661 425,077,863 1,876,614,170 71,612,726 346,434,628 146,959,824 546,117,413 1,489,923,156 1,239,615,206 4,340,418 1,286,656 2,366,092,290 396,194,656 60,119,039 108,914,987 266,183,359 1,065,218,687 1,174,483,476 328,298,442 1,090,315,294 250,351,425 678,234,773 572,989,632 1,673,278 69,028,503 64,283,449 2,998,753 1,081,590,761 24,062,597 3,317,705,424 1,388,709,316 1,985,205 1,444,982,894 57,050,374 1,435,448,567 48,070,593 819,207,631 476,867 688,986,766 1,265,091,320 7,957,899 1,481,137 8,196,959 848,667,684 107,831,858 43,439,640 139,997,459 2,787,697

Hispanic $11,701,697,152 3,315,366 7,940,171 471,119,023 9,412,021 2,889,656,926 281,989,029 289,165,417 19,433,350 14,241,198 486,938,537 48,382,042 15,687,138 19,683,988 550,384,662 47,183,688 18,178,910 32,226,321 12,665,231 45,768,784 252,985,739 68,841,694 68,520,048 2,338,315 4,103,634 33,978,627 46,021,153 3,358,173 351,049,969 328,367,182 2,128,810,934 62,993,852 2,124,462 77,540,662 66,963,540 312,794,476 58,620,869 4,653,034 461,142 10,801,097 2,267,459,706 53,862,180 498,532 1,686,823 42,863,490 147,560,588 1,216,634 28,153,946 9,694,849

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-45

Pharmaceutical Benefits 2000 Table 27.

Medicaid Vendor Payments of Medical Care by Race/Ethnicity and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Asian or Pacific Islands $1,966,402,451 1,654,070 12,240,077 14,159,234 2,948,804 628,002,960 9,908,033 17,312,049 1,105,200 2,680,052 11,254,474 13,872,906 290,493,960 751,185 101,700,238 4,841,617 7,513,271 14,513,033 2,464,396 44,293,674 48,043,679 37,945,112 95,240,916 2,822,491 889,994 4,719,794 8,741,149 1,244,444 19,945,359 3,698,818 209,885,774 16,512,917 892,876 12,862,937 36,008,771 70,377,689 10,763,133 1,161,374 215,280 7,597,700 41,302,705 11,642,604 1,070,663 37,888 36,992,590 82,984,768 791,928 19,944,179 355,686

American Indian/ Alaskan Native $1,106,464,681 1,076,069 114,087,825 223,441,777 2,006,208 38,373,365 5,693,343 3,385,027 1,238,666 120,284 1,353,164 1,141,307 144,750 7,138,887 9,535,747 1,036,794 3,990,200 6,418,356 395,633 4,034,803 14,419,906 13,049,032 90,141,150 5,546,935 52 52,781,368 16,738,730 8,923,139 121,244 10,874,552 124,608,852 23,977,462 49,156,977 38,824,907 4,743,094 22,672,988 4,353,009 566,136 1,154,481 83,251,611 3,973,350 16,224,173 19,437,596 435,931 1,569 1,703,034 53,631,256 10,808,831 9,731,111

Unknown $22,310,166,621 629,401,446 7,673,823 33,110,736 (137,199,715) 2,637,740,862 150,279,456 452,751 28,159,376 127,641,885 815,180,046 259,857,615 113,882,916 12,608,072 309,794 22,252,042 2,508,791 4,408,161 149,755,975 218,512,495 747,027,618 89,011,031 433,037,186 645,867,248 42,410,832 121,419,129 625,778 1,715,241 8,522,698 23,370,466 743,492 448,799,291 47,045,041 10,091,709,891 388,483,905 1,211,860 56,845,897 1,177,853,941 20,208,081 88,503,353 250,000,000 78,747,228 369,303,858 6,332,531 507,131,631 312,328,108 53,775,344 709,366 16,719 2,907,226 131,315,130 146,730,391 934,634,038 5,286,545

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-46

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 28.

Medicaid Eligibles of Medical Care by Age and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Eligibles 41,361,532 628,220 87,873 649,302 426,080 6,191,269 346,928 402,547 105,153 138,722 2,040,541 1,223,439 182,460 116,718 1,784,159 610,146 321,119 246,598 653,553 723,864 195,839 603,562 953,469 1,354,718 557,232 526,604 772,622 93,298 210,261 130,662 98,340 857,898 339,527 3,500,292 1,201,681 62,115 1,402,364 459,570 537,465 1,720,000 964,015 148,797 656,263 83,111 1,454,799 2,680,583 198,730 131,639 19,914 689,571 915,214 373,090 538,229 51,367

Ages Under 1 2,014,962 33,381 3,974 60,354 17,345 208,178 20,123 13,284 4,017 3,743 84,616 70,643 10,481 6,340 122,734 33,629 13,467 11,944 24,325 56,922 5,469 27,373 231,669 55,629 19,738 29,728 32,650 4,200 20,971 9,005 3,012 30,492 15,914 124,586 88,252 2,174 58,716 19,886 54,408 4,717 30,163 6,417 35,630 162,406 15,377 2,840 46,016 33,407 15,738 25,868 3,011

From Ages 1 to 5 7,205,401 131,578 16,913 133,626 74,684 1,103,640 70,573 63,646 18,666 25,888 373,694 254,844 26,262 27,952 354,562 129,822 56,116 48,477 110,623 139,567 25,250 109,740 123,853 246,010 98,267 100,482 148,577 16,669 38,945 29,982 18,259 154,605 70,406 524,368 211,122 10,539 253,059 83,913 261,002 24,666 112,674 17,077 192,922 627,209 46,724 16,871 128,645 175,278 64,968 100,815 11,371

From Ages 6 to 14 9,131,328 147,209 22,459 161,127 94,746 1,452,046 79,258 95,206 24,597 33,624 484,949 288,518 34,392 29,758 402,627 147,188 69,327 57,433 143,371 167,148 42,943 143,818 149,432 340,091 144,380 120,046 198,866 21,898 49,960 32,428 27,046 193,382 100,440 656,138 255,365 13,859 335,401 100,302 386,151 34,432 152,085 20,752 286,070 680,891 43,188 28,804 168,243 249,653 85,709 122,134 12,438

From Ages 15 to 20 3,979,331 52,664 9,082 57,260 49,952 674,192 30,454 41,559 11,233 13,270 194,122 132,840 16,114 10,539 165,950 61,334 33,328 26,869 57,300 66,428 22,027 57,635 59,606 139,279 70,801 48,018 87,406 8,699 22,187 9,332 10,544 81,961 44,618 316,777 119,267 6,085 148,880 51,793 181,316 13,936 75,061 8,679 154,441 219,455 21,001 13,767 69,331 114,589 42,926 50,547 4,877

From Ages 21 to 44 9,305,563 104,960 23,394 158,158 88,040 1,519,166 76,396 99,390 29,434 34,185 468,339 224,595 48,768 23,646 446,101 121,762 84,648 51,149 151,955 140,092 52,479 151,227 198,095 338,950 125,605 94,316 149,716 23,703 43,716 24,927 20,723 198,073 60,024 940,604 248,009 13,805 337,620 175,945 457,350 36,881 158,586 14,791 416,376 485,901 47,592 38,585 126,533 211,109 90,418 117,638 12,088

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-47

Pharmaceutical Benefits 2000 Table 28.

Medicaid Eligibles of Medical Care by Age and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

From Ages 45 to 64 3,489,125 58,130 6,028 36,519 35,305 523,390 27,455 33,795 8,872 13,962 159,809 85,260 13,035 7,943 134,941 45,305 23,260 19,192 76,449 60,726 21,263 48,096 84,509 112,038 35,377 49,635 59,689 7,935 12,931 9,989 6,860 64,994 20,310 418,550 108,682 4,707 118,880 65,374 183,119 12,984 49,981 5,302 224,016 166,102 10,474 13,931 55,936 62,567 39,413 42,962 3,143

From Ages 65 to 74 1,934,986 38,632 3,285 19,059 23,647 350,410 16,972 17,914 3,410 6,354 117,026 53,551 9,517 3,781 66,024 25,595 12,100 10,174 37,918 37,753 10,218 26,858 41,166 49,403 18,398 33,460 34,298 3,449 6,996 7,108 3,445 51,802 12,480 191,246 69,688 2,897 54,092 16,040 76,914 7,001 31,189 2,791 68,903 143,551 4,477 6,525 41,004 27,129 14,282 23,516 1,538

From Ages 75 to 84 1,597,608 34,564 2,040 13,742 23,809 242,507 14,185 19,039 2,820 4,856 93,111 48,141 7,168 3,466 52,430 24,149 14,072 10,467 30,904 32,477 9,018 22,938 36,769 40,828 20,885 29,697 33,194 3,476 7,241 5,098 4,001 47,118 8,833 148,608 63,564 3,748 51,225 13,845 66,694 7,217 28,603 3,355 45,332 115,059 3,506 6,319 33,939 23,173 11,412 27,463 1,503

From Ages 85 and Over 1,172,148 25,855 698 9,457 18,543 117,730 11,511 18,714 2,104 2,836 64,875 65,040 4,030 3,290 38,790 21,362 14,801 10,893 20,662 22,749 7,111 15,862 28,370 32,410 23,781 21,222 28,224 3,269 7,279 2,764 4,450 35,454 6,329 110,054 37,732 4,287 44,491 10,359 53,037 6,963 17,872 3,947 31,109 80,005 2,710 3,997 19,924 18,304 8,224 27,271 1,397

Unknown 1,531,080 1,247 9 10 1 4 7 12,693 3 46 2 61 15 80 2 35 29 17 173 69,361 14 459,570 8 9 964,015 49 4 3,681 19,914 5 15 1

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-48

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 29.

Medicaid Eligibles of Medical Care by Sex and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Eligibles 41,361,532 628,220 87,873 649,302 426,080 6,191,269 346,928 402,547 105,153 138,722 2,040,541 1,223,439 182,460 116,718 1,784,159 610,146 321,119 246,598 653,553 723,864 195,839 603,562 953,469 1,354,718 557,232 526,604 772,622 93,298 210,261 130,662 98,340 857,898 339,527 3,500,292 1,201,681 62,115 1,402,364 459,570 537,465 1,720,000 964,015 148,797 656,263 83,111 1,454,799 2,680,583 198,730 131,639 19,914 689,571 915,214 373,090 538,229 51,367

Male 16,061,565 246,111 37,351 254,985 158,087 2,549,535 137,075 156,951 42,157 54,592 813,906 472,711 75,609 47,979 734,788 240,536 128,417 99,884 265,594 286,802 81,408 230,580 387,651 553,462 231,848 204,935 311,009 39,042 84,200 52,910 39,193 322,247 144,024 1,405,012 462,274 24,403 557,553 236,268 688,234 57,441 233,707 34,135 610,842 1,075,529 79,772 57,749 274,850 381,162 158,690 217,485 20,880

Female 23,757,344 373,496 50,522 394,317 267,867 3,641,730 209,853 245,596 62,996 83,970 1,226,635 750,722 94,239 68,733 1,049,370 369,610 192,702 146,688 387,906 436,987 114,382 372,969 565,818 801,256 325,384 321,668 461,612 54,256 121,169 77,583 59,112 535,634 195,499 2,025,906 739,407 37,687 844,807 301,187 1,031,766 91,354 422,372 48,961 843,949 1,605,019 117,584 73,890 414,721 533,998 213,237 320,744 30,474

Unknown 1,542,623 8,613 126 4 160 6 12,612 6 1 26 53 75 49 13 1 1 4,892 169 35 17 4 69,374 25 4 459,570 10 964,015 2 184 15 8 35 1,374 19,914 54 1,163 13

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-49

Pharmaceutical Benefits 2000 Table 30.

Medicaid Eligibles of Medical Care by Race/Ethnicity and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Eligibles 41,361,532 628,220 87,873 649,302 426,080 6,191,269 346,928 402,547 105,153 138,722 2,040,541 1,223,439 182,460 116,718 1,784,159 610,146 321,119 246,598 653,553 723,864 195,839 603,562 953,469 1,354,718 557,232 526,604 772,622 93,298 210,261 130,662 98,340 857,898 339,527 3,500,292 1,201,681 62,115 1,402,364 459,570 537,465 1,720,000 964,015 148,797 656,263 83,111 1,454,799 2,680,583 198,730 131,639 19,914 689,571 915,214 373,090 538,229 51,367

White Not Hispanic 17,838,846 273,245 37,940 250,559 258,183 1,806,631 172,252 180,483 43,908 2,666 824,278 441,075 25,039 99,797 713,454 426,177 277,085 170,132 537,100 231,218 210,449 532,005 718,380 355,580 160,692 537,215 69,648 146,079 75,951 94,836 259,995 92,276 975,344 526,527 45,043 883,444 428,563 1,036,265 85,136 251,122 49,424 963,006 739,597 146,326 129,962 314,040 670,018 343,131 187,321 40,249

Black Not Hispanic 10,646,780 322,829 5,477 42,748 143,381 804,451 27,617 99,614 48,219 123,675 704,220 654,613 1,822 550 763,561 151,049 26,527 46,234 84,798 441,877 335,488 105,065 502,143 85,478 334,520 235,406 604 30,199 25,025 969 307,264 9,236 819,724 529,550 1,011 460,334 23,122 496,909 15,128 373,442 178 417,128 543,971 4,253 761 332,198 61,404 18,218 83,707 1,083

Hispanic 6,924,815 5,575 2,946 246,508 5,349 2,515,612 115,446 114,419 8,202 4,765 336,323 42,039 6,513 13,680 265,041 25,813 11,600 20,212 5,097 23,554 136,792 58,319 32,231 1,600 1,712 21,085 22,998 1,629 189,885 173,187 759,184 45,537 1,640 1,407 55,968 136,041 26,695 5,110 126 12,947 1,280,864 28,724 206 25,396 109,817 699 21,540 4,782

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-50

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 30.

Medicaid Eligibles of Medical Care by Race/Ethnicity and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Asian or Pacific Islands 1,028,316 2,477 4,640 4,796 932 465,987 3,793 6,030 423 954 9,319 10,774 76,438 342 38,551 1,556 4,061 6,690 1,283 13,757 30,943 18,724 42,220 1,981 400 2,418 3,101 877 9,528 1,682 71,262 11,269 321 5,547 15,287 29,882 4,670 1,186 60 7,517 26,005 6,827 464 15,763 48,392 432 18,593 162

American Indian/ Alaskan Native 482,594 1,304 34,922 92,322 826 27,731 2,268 642 257 21 1,022 625 101 2,346 2,968 423 1,846 3,330 219 1,139 2,254 6,304 27,012 1,825 20,920 8,578 2,818 23 2,105 54,191 8,351 20,514 14,061 36,703 10,537 1,521 241 799 30,455 3,470 7,477 10,604 246 809 25,583 6,608 4,273

Unknown 4,440,181 22,790 1,948 12,369 17,409 570,857 25,552 1,359 4,144 6,641 165,379 74,313 72,547 3 584 5,128 25,056 50,769 195,839 19,175 146,410 50,848 14,711 25,986 1 14 1,902 769 6 89,121 8,955 866,427 68,284 39 14,929 459,570 3,988 19,382 964,015 16,927 24,604 2,868 50,731 82,669 1,996 19,914 1,365 10,610 220,460 818

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-51

Pharmaceutical Benefits 2000 Table 31.

Medicaid Inpatient Hospital Recipients, Discharges, and Days of Care by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients Discharged 2,792,656 2,184 8,699 91,418 48,588 349,987 23,568 10,151 1,753 12,923 156,364 110,240 13,518 164,377 19,787 20,817 22,537 53,780 82,645 5,197 27,632 37,350 98,367 27,707 52,051 53,387 9,587 17,933 7,476 37,687 16,619 290,616 102,240 6,071 109,549 2,710 82,768 5,451 75,007 9,221 346,148 13,643 3,352 997 69,536 26,544 31,996 25,346 7,132

Total Discharges 3,970,901 3,017 10,898 110,981 61,879 516,785 30,787 16,123 2,089 22,231 215,213 138,776 16,891 248,036 84,102 27,951 28,945 81,507 114,480 10,155 38,140 54,197 135,295 37,805 70,459 77,868 13,669 23,758 10,053 71,577 20,742 412,783 137,791 7,993 164,813 24,786 113,654 10,267 99,277 12,562 414,685 15,481 4,786 1,138 92,857 43,755 51,277 59,522 9,065

Total Days of Care 19,091,219 27,025 51,128 378,392 251,944 1,895,493 147,863 96,982 11,809 156,197 989,643 657,879 56,223 1,301,729 442,636 148,066 120,568 300,124 570,417 25,177 214,760 720,322 623,300 197,166 315,262 381,867 47,170 139,834 46,515 501,729 80,280 2,744,476 692,093 34,456 758,676 8,969 658,135 98,741 438,550 89,503 1,581,584 56,280 22,098 5,281 332,835 285,966 170,226 184,578 31,272

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-52

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 32.

Medicaid Long-Term Care Recipients and Days of Care by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Inpatient Mental Health Total Days of Recipients Care 125,632 6,514,273 1,329 44,840 627 41,468 14 53 3,146 166,910 463 15,224 361 19,105 370 39,951 531 23,033 162 8,059 253 41,000 39 2,656 3,768 73,442 2,134 115,547 958 137,683 333 18,910 4,338 117,198 6,043 45,597 705 29,868 1,827 214,908 830 48,586 2,334 107,850 249 27,079 2,334 39,556 9 2,663 14 1,298 686 36,007 200 3,687 1,899 239,445 468 6,384 36,713 2,246,241 2,377 101,370 145 165,060 783 10,591 761 146,234 8,512 229,355 341 23,123 1,531 134,357 51 11,887 2 8 133 2,035 34,172 1,621,453 28 236 1,564 65,907 2,087 88,239 8 170

Total Recipients 1,555,329 23,844 887 1,426 21,486 123,270 18,928 28,167 3,256 4,217 73,030 40,390 4,420 5,297 79,751 44,524 25,115 16,802 27,439 34,403 9,278 27,834 46,875 44,678 37,580 19,552 37,226 5,316 3,747 7,700 48,552 8,170 135,450 41,218 5,506 86,236 11,960 76,592 11,128 17,352 6,095 86,763 88,522 5,433 3,804 67 27,145 23,949 11,677 40,715 2,557

Nursing Facility Days of Care 384,548,919 6,217,003 203,831 187,124 6,464,116 25,166,839 3,944,425 7,731,433 1,083,374 1,245,685 17,028,588 14,236,601 1,065,390 937 21,499,940 23,443,019 5,878,668 3,222,044 6,301,308 9,315,664 1,238,844 5,950,791 8,836,620 10,964,698 9,863,220 4,725,887 9,507,778 1,375,288 943,285 2,149,243 11,730,568 1,759,296 33,887,907 9,872,937 1,291,824 21,082,183 2,683,606 19,505,418 4,184,505 4,313,445 1,618,401 10,679,610 23,558,778 1,347,951 910,719 9,824 6,800,731 8,797,689 10,113,439 608,445

Total Recipients 123,658 750 8 1,867 9,885 500 1,530 342 821 3,567 1,728 146 1,012 12,081 6,035 2,338 1,441 1,240 6,014 361 627 43 1,322 4,273 2,490 1,442 149 293 33 4,514 362 11,928 4,853 637 8,162 373 5,757 100 2,856 337 13,935 867 17 2,120 156 609 3,600 137

ICF/MR Days of Care 50,635,779 259,415 526 1,273,503 3,234,774 114,696 475,573 120,187 389,879 1,256,138 643,772 44,281 15,878 5,464,459 3,478,807 780,929 385,049 423,694 2,086,796 137,353 218,311 5,504 280,090 1,241,279 837,052 490,620 56,237 115,832 8,509 7,866,245 97,381 4,017,960 1,670,529 147,873 2,879,008 128,121 1,886,153 113,887 914,241 108,007 4,757,721 295,499 2,830 722,853 48,794 1,092,081 47,453

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-53

Pharmaceutical Benefits 2000 Table 33.

Medicaid Eligibles and Premium Payments for Capitation Plans and PCCM by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Eligibles 14,722,177 38,523 655,571 2,799,369 112,705 271,411 85,147 60,710 722,113 78,418 144,744 270,106 268,410 97,517 43,887 193,864 9,268 447,701 247,767 631,599 317,914 17,621 330,539 3,574 19,506 21,382 11,097 501,456 262,506 813,694 221,886 1,555 452,447 82,973 437,914 891,093 94,562 8,202 13,734 1,414,683 284,226 92,951 69,440 159,392 604,315 131,349 283,336 -

HMO/HIO Plans Payments $16,213,910,471 62,473,486 1,289,163,211 2,142,428,098 131,714,033 377,212,893 121,932,232 45,298,685 684,011,686 57,848,295 213,612,580 241,278,075 165,505,151 53,304,564 17,149,248 311,260,601 4,098,201 803,474,501 305,723,630 707,677,964 482,903,353 22,134,623 277,251,576 3,189,285 16,811,739 12,100,995 610,251,739 372,264,074 990,708,190 85,667,708 1,316,917 494,153,710 501,525,712 1,800,415,624 112,545,918 4,345,686 6,420,420 1,670,212,023 73,991,642 53,763,059 186,255,441 403,713,433 296,800,470 -

Eligibles 8,382,884 306,384 596,131 244,596 4,862,797 297,604 1 88,872 245,703 47 621,146 147,765 88,837 110,606 33,691 40,890 68,771 31 64 477,139 9,027 141,226 112 1,444 -

Prepaid Plans Payments $1,790,303,756 226,498,950 142,255,286 4,360,523 586,587,065 101,006,921 21 16,860,657 53,870,893 779,269 172,208,666 102,308,349 49,392,200 14,343,694 6,770,772 78,893,290 61,505 691,529 163,273,360 12,827,431 33,112,909 1,528,628 22,671,838 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-54

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 33.

Medicaid Eligibles and Premium Payments for Capitation Plans and PCCM by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Eligibles 4,569,691 151,910 229,092 52,402 8,403 835,207 877,799 45,745 16,414 241,557 80,287 118,281 40,729 621,146 57,957 17,466 26,047 101,119 51,530 617,827 32,099 71,297 11,112 153,672 110,559 34 -

PCCM Payments $18,007,746 3,830,786 5,405,229 6,943,824 1,003,654 17,980,527 21,797,455 1,389,468 710,585 4,936,728 1,001,800 1,618,536 9,288,830 1,460,907 4,009,342 754,694 20,295,994 13,163,095 476,322 231,444 1,697,486 11,040 -

Unduplicated Enrolled Eligibles 21,813,135 362,272 655,571 318,625 5,044,803 308,035 271,411 85,147 66,873 1,411,107 906,717 131,761 45,745 286,520 477,480 247,483 152,288 194,314 40,729 9,345 451,757 720,576 747,895 318,088 17,654 333,096 88,872 110,606 55,886 11,097 542,826 272,499 920,302 697,376 32,525 452,511 154,270 481,050 897,853 94,563 17,186 1,436,197 437,898 144,199 69,440 259,808 613,060 131,349 286,470 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-55

Pharmaceutical Benefits 2000 Table 34.

Prepaid Health Care Medicaid Recipients by Maintenance Assistance Status and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 20,202,887 344,907 368,344 244,768 6,022,536 316,060 271,411 85,239 100,867 791,752 78,463 144,744 142,429 271,005 246,582 44,003 194,164 9,324 449,825 768,831 758,185 318,854 17,628 336,057 96,701 159,614 55,923 11,176 545,380 263,256 884,443 220,700 1,549 453,265 481,498 902,896 96,178 17,195 83,998 1,764,279 170,319 69,682 159,392 1,146,180 52 293,233 -

Receiving Cash Payments 9,662,017 118,180 3,511,431 115,659 122,049 30,911 49,614 530,364 45,792 77,313 107,279 104,184 114,478 15,078 114,814 4,149 240,158 373,918 469,222 144,319 8,939 140,788 46,928 81,317 25,874 4,079 264,886 111,939 575,752 102,128 467 305,146 133,858 509,692 64,623 5,666 35,519 439,299 36,839 21,104 81,488 271,871 104,903 -

Medically Needy 2,401,288 23,121 1,498,574 7,488 6,378 5,948 2,712 8,436 3,992 88 12,905 22 22,856 204,450 141,355 1,497 7,230 19 166 2,757 228,890 2,311 202 6,564 51,371 1,214 136,153 4,000 4,602 289 148 15,550 -

Poverty Related 3,514,045 83,383 128,401 77,144 48,312 43,189 3,150 175,007 18,770 58,895 13,065 73,873 50,841 22,564 56,743 2,930 117,274 136,205 123,737 65,421 7,681 141,948 15,133 60,609 258 5,172 120,979 148,937 76,179 111,834 460 140,278 213,327 170,453 20,334 7,999 28,556 623,307 18,888 34,184 56,163 160,350 52,112 -

Other 2,894,690 18,446 876,362 121,401 93,562 9,544 1,374 79,139 13,694 3,960 13,649 91,135 77,015 6,173 9,059 2,198 65,366 54,258 21,719 106,102 980 45,772 22,534 17,669 27,944 1,758 156,167 1,993 3,622 4,427 416 7,841 116,095 171,186 7,933 3,494 19,923 216,494 82,028 9,547 21,452 177,195 114,064 -

MAS Unknown 2,045,872 344,907 368,344 1,638 7,768 316,881 1,595 40,351 1,294 207 1,864 1,813 256 100 643 25 4,171 2,152 1,515 28 7,549 4,876 1,847 1 591 387 4 11,654 194 2,074 36 349,026 28,564 245 536,616 52 6,604 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-56

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 35.

Prepaid Health Care Medicaid Recipients by Basis of Eligibility and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 20,202,887 344,907 368,344 244,768 6,022,536 316,060 271,411 85,239 100,867 791,752 78,463 144,744 142,429 271,005 246,582 44,003 194,164 9,324 449,825 768,831 758,185 318,854 17,628 336,057 96,701 159,614 55,923 11,176 545,380 263,256 884,443 220,700 1,549 453,265 481,498 902,896 96,178 17,195 83,998 1,764,279 170,319 69,682 159,392 1,146,180 52 293,233 -

Age 65 And Older 997,266 22,617 548,137 37,302 13 259 17,332 672 86 59,343 817 1 9,288 6,261 1,667 8,715 27,611 795 1 8,617 1,234 646 35,542 984 6,220 75 37,705 63,018 3 399 8,137 84,154 6,552 33 1,166 1,569 295 -

Blind/ Disabled 2,351,991 70,690 894,674 58,614 919 8,145 1,896 110,154 8,271 1,338 42,171 41,618 53 50,936 22 75,205 111,699 130,478 2,607 4,666 458 15,812 14,598 65 19 16,460 26,717 51,023 12,346 1 1,852 93,759 144,515 625 1,586 14,713 293,570 11,325 1,082 20,533 10,651 6,125 -

Children 10,356,858 110,674 3,053,189 148,339 185,624 47,228 43,292 507,475 53,596 75,329 101,088 127,846 130,634 34,092 97,791 6,711 258,313 451,115 422,747 222,262 9,709 248,210 44,510 98,022 40,708 9,113 353,264 192,207 565,619 194,263 1,125 315,021 123,793 505,598 63,451 13,553 46,960 552,654 92,508 36,706 105,720 455,401 211,398 -

Adults 4,493,559 35,766 1,390,107 56,531 77,905 27,610 15,317 149,399 15,677 64,575 38,686 38,790 68,540 9,645 35,142 2,458 91,156 203,740 180,954 64,298 2,413 69,798 19,757 37,507 12,594 1,939 138,754 41,706 257,959 9,761 414 135,782 201,456 178,596 29,690 1,519 12,894 472,496 29,359 31,477 31,967 141,869 67,556 -

Other/ Unknown 2,003,213 344,907 368,344 5,021 136,429 15,274 6,950 1,997 40,362 7,392 247 4,840 1,231 2,855 4,973 212 1,007 133 18,890 610 15,291 2,076 45 17,590 8,005 8,253 1,910 105 1,360 1,642 3,622 4,330 9 535 24,785 11,169 2,409 138 1,294 361,405 30,575 384 6 536,690 52 7,859 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-57

Pharmaceutical Benefits 2000 Table 36.

PCCM Medicaid Recipients by Maintenance Assistance Status and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 4,066,440 151,910 243,266 54,471 48,907 8,623 841,304 879,554 50,665 16,414 242,844 80,428 123,902 264,035 53,733 59,578 27,577 28,638 103,867 804 591,740 32,566 11,163 39,858 110,559 34 -

Receiving Cash Payments 1,891,472 86,345 35,894 7,325 520,029 370,738 6,018 244 92,311 35,092 53,718 157,495 30,807 15,431 14,751 56,583 599 342,233 9,701 3,203 13,963 38,962 30 -

Medically Needy 114,232 20,096 7,902 547 5,340 95 48 281 1,202 51,179 18 168 21,991 5,058 162 144 1 -

Poverty Related 1,293,024 99,153 470 250 190,927 390,617 11,983 43 101,825 21,937 48,543 43,461 12,528 9,799 116 47,230 15 225,751 10,289 4,947 19,322 53,818 -

Other 479,745 32,938 8,730 233 119,245 110,441 26,587 16,079 47,301 23,103 17,387 11,900 14,748 2,347 13,259 46 22 1,765 6,653 2,750 6,573 17,635 3 -

MAS Unknown 287,967 151,910 4,734 1,475 48,907 268 5,763 7,663 6,077 1,407 15 3,052 53,733 1,477 512 8 865 101 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-58

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 37.

PCCM Medicaid Recipients BY Basis OF Eligibility and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 4,066,440 151,910 243,266 54,471 48,907 8,623 841,304 879,554 50,665 16,414 242,844 80,428 123,902 264,035 53,733 59,578 27,577 28,638 103,867 804 591,740 32,566 11,163 39,858 110,559 34 -

Age 65 And Older 44,327 554 914 1 16,897 11,665 2,422 15 1 878 15 60 193 643 404 7,937 2 959 2 765 -

Blind/ Disabled 548,443 38,988 7,366 34 164,152 136,798 7,186 13 8,755 180 19,661 50,706 7,485 1,434 40 14,481 96 72,988 98 2,178 4,615 11,156 33 -

Children 2,509,468 151,321 29,233 5,937 510,793 623,313 29,932 310 186,089 54,447 77,791 153,613 36,330 17,862 21,985 74,914 685 409,100 22,956 2,948 27,754 72,154 1 -

Adults 629,893 43,778 14,529 2,378 126,334 98,975 4,646 34 45,530 25,593 22,151 59,549 12,310 7,223 5,432 14,020 1 100,288 8,489 4,668 7,486 26,479 -

Other/ Unknown 334,309 151,910 8,625 2,429 48,907 273 23,128 8,803 6,479 16,057 2,455 207 3,421 152 53,733 3,393 865 538 48 22 1,427 1,021 410 1 5 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-59

Pharmaceutical Benefits 2000 Table 38.

Prepaid Health Care Medicaid Recipients by Age and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 20,202,887 344,907 368,344 244,768 6,022,536 316,060 271,411 85,239 100,867 791,752 78,463 144,744 142,429 271,005 246,582 44,003 194,164 9,324 449,825 768,831 758,185 318,854 17,628 336,057 96,701 159,614 55,923 11,176 545,380 263,256 884,443 220,700 1,549 453,265 481,498 902,896 96,178 17,195 83,998 1,764,279 170,319 69,682 159,392 1,146,180 52 293,233 -

Ages Under 1 586,976 13,179 56,292 17,262 10,871 3,444 2,641 25,307 2,229 10,484 12,142 11,271 3,404 9,272 384 22,652 42,031 27,295 12,140 1,137 15,942 3,460 5,115 293 23,743 12,298 25,673 27,921 60 40,450 13,741 26,835 4,132 1,385 6,678 33,019 12,991 1,451 5,828 23,579 18,945 -

From Ages 1 to 5 3,726,967 48,721 1,108,708 67,679 60,801 17,309 19,421 186,752 19,706 40,833 48,975 51,530 13,485 39,495 2,140 99,718 137,135 157,771 66,172 3,869 91,094 17,369 16,955 3,420 135,270 63,597 208,860 72,570 433 115,360 78,629 167,058 22,851 5,695 17,267 190,961 43,238 10,400 38,319 152,663 84,738 -

From Ages 6 to 14 4,846,633 59,642 1,464,620 74,094 89,814 22,468 18,281 255,561 26,211 43,205 55,463 63,471 13,873 47,868 3,127 130,238 186,284 223,507 98,887 4,417 118,237 22,449 17,228 4,307 157,051 90,410 255,227 84,209 515 138,417 91,859 245,379 30,097 6,140 21,408 282,970 32,720 17,383 53,444 207,568 88,584 -

From Ages 15 to 20 2,005,878 21,325 682,263 26,941 36,608 9,761 5,993 82,666 7,937 14,486 21,345 28,943 5,066 17,430 1,285 46,561 83,429 78,367 46,762 1,681 47,507 9,091 4,340 1,118 52,252 37,956 91,352 24,303 159 47,374 45,563 98,823 10,917 1,265 8,925 149,889 12,441 7,553 20,703 86,439 29,059 -

From Ages 21 to 44 4,409,601 46,099 1,447,924 66,164 67,780 25,181 13,089 173,104 17,074 31,492 50,822 72,874 7,758 46,322 2,236 106,271 238,823 198,428 60,530 3,684 60,498 24,731 10,263 1,946 121,812 44,362 243,955 10,149 363 105,364 158,953 236,745 25,675 1,734 14,926 402,126 29,518 25,745 32,357 123,579 59,145 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-60

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 38.

Prepaid Health Care Medicaid Recipients by Age and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

From Ages 45 to 64 1,383,923 22,958 543,134 24,520 5,504 6,437 1,267 42,928 3,699 1,807 20,724 17,843 379 18,634 148 32,166 77,701 54,646 4,958 1,668 2,754 7,957 430 92 14,722 12,544 50,578 1,544 19 6,224 58,272 82,368 2,108 548 5,204 218,221 5,776 6,765 7,133 14,058 5,485 -

From Ages 65 to 74 566,028 13,037 332,520 15,269 32 467 15 14,088 903 54 20,901 545 2 7,812 1 6,872 2,143 11,785 8,882 670 12 3,305 301 5,922 1,456 5,235 3 30 12,279 26,999 13 115 2,636 66,293 2,808 146 1,209 632 636 -

From Ages 75 to 84 419,531 12,151 248,647 12,901 1 131 4 6,924 320 46 20,976 17 4,848 2,608 780 3,885 9,317 369 3,415 276 13,186 323 2,468 26 11,186 13,982 2 161 3,108 43,792 2,418 8 343 508 404 -

From Ages 85 and Over 265,807 7,633 132,446 10,560 34 3,508 360 22 19,075 21 2,216 732 505 1,210 10,736 129 3,375 72 20,992 94 1,095 1 20 9,080 4,653 1 142 3,840 30,025 2,196 1 56 683 294 -

Unknown 1,991,543 344,907 368,344 23 5,982 670 7 40,156 914 24 144,744 582 67 36 267 3 2,007 1,291 470 4 13 1,549 159,614 943 430 216 1,936 54 382 10 6 346,983 26,213 230 536,471 52 5,943 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-61

Pharmaceutical Benefits 2000 Table 39.

Prepaid Health Care Medicaid Recipients by Sex and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 20,202,887 344,907 368,344 244,768 6,022,536 316,060 271,411 85,239 100,867 791,752 78,463 144,744 142,429 271,005 246,582 44,003 194,164 9,324 449,825 768,831 758,185 318,854 17,628 336,057 96,701 159,614 55,923 11,176 545,380 263,256 884,443 220,700 1,549 453,265 481,498 902,896 96,178 17,195 83,998 1,764,279 170,319 69,682 159,392 1,146,180 52 293,233 -

Male 7,517,298 97,329 2,557,879 126,797 106,677 34,763 24,161 327,441 29,947 53,960 101,216 103,230 18,121 77,712 3,703 182,425 318,398 309,665 129,936 6,847 136,846 39,763 21,770 4,657 201,674 114,919 332,669 105,782 604 174,748 210,791 358,234 36,784 7,733 33,826 596,030 61,485 30,965 62,955 260,243 114,613 -

Female 10,692,036 147,370 3,458,672 188,593 164,734 50,469 36,541 463,397 48,492 88,469 169,207 143,285 25,844 116,183 5,618 265,394 450,433 447,232 188,448 10,777 199,198 55,389 33,168 6,516 343,276 148,119 551,774 114,918 945 278,517 268,766 544,610 59,012 9,452 48,327 821,259 82,572 38,487 96,437 349,451 172,685 -

Unknown 1,993,553 344,907 368,344 69 5,985 670 7 40,165 914 24 144,744 582 67 38 269 3 2,006 1,288 470 4 13 1,549 159,614 985 3 430 218 1,941 52 382 10 1,845 346,990 26,262 230 536,486 52 5,935 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-62

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 40.

Prepaid Health Care Medicaid Recipients by Race/Ethnicity and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 20,202,887 344,907 368,344 244,768 6,022,536 316,060 271,411 85,239 100,867 791,752 78,463 144,744 142,429 271,005 246,582 44,003 194,164 9,324 449,825 768,831 758,185 318,854 17,628 336,057 96,701 159,614 55,923 11,176 545,380 263,256 884,443 220,700 1,549 453,265 481,498 902,896 96,178 17,195 83,998 1,764,279 170,319 69,682 159,392 1,146,180 52 293,233 -

White Not Hispanic 7,683,322 145,661 1,904,341 162,596 96,431 34,013 211 248,119 7,310 9,226 178,634 208,720 27,176 130,145 136,929 392,392 291,087 182,363 5,689 168,003 71,008 25,833 10,402 144,448 63,342 224,257 98,000 1,171 168,223 384,633 371,692 47,782 5,216 48,531 935,725 109,093 68,419 35,429 441,388 99,684 -

Black Not Hispanic 4,888,675 81,795 849,639 25,982 79,049 41,222 57,416 362,279 65,908 104,667 80,562 23,477 11,496 52,200 272,690 101,038 404,497 63,152 10,736 168,041 615 13,674 228 224,543 7,369 334,160 97,137 54 261,557 21,039 400,482 11,197 11,499 177 409,630 3,281 457 118,100 44,822 72,808 -

Hispanic 3,645,975 3,531 2,176,630 100,816 91,794 6,823 2,397 133,084 1,958 27,153 8,581 9,718 3,607 2,377 15,441 147,030 25,069 16,039 81 1,789 13,317 466 153,390 145,092 228,503 11,306 86 14,515 48,341 97,753 22,063 78 126 12,521 20,835 124 3,178 83,219 17,144 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-63

Pharmaceutical Benefits 2000 Table 40.

Prepaid Health Care Medicaid Recipients by Race/Ethnicity and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Asian or Pacific Islands 720,118 582 481,230 3,519 3,696 338 343 3,285 495 1,183 584 2,993 1,013 878 8,347 30,562 12,236 33,257 271 420 1,459 80 7,019 1,403 14,955 3,195 8 2,311 14,145 22,620 3,637 10 60 7,313 5,096 311 2,302 32,008 16,954 -

American Indian/ Alaskan Native 182,202 522 28,708 2,166 392 184 6 380 25 195 156 1,607 675 98 892 2,154 2,530 11,173 17 21,304 574 764 42,415 2,603 1,841 230 462 8,078 677 162 4 30,412 3,400 4,317 141 201 8,272 4,465 -

Unknown 3,082,595 344,907 368,344 12,677 581,988 20,981 49 2,659 40,494 44,605 2,767 144,744 5 2,488 67 36 8,466 9,324 15,526 95,655 22,766 12,870 834 13 1,565 159,614 1,066 15,216 3,635 79,965 9,221 6,197 5,262 9,672 11,337 388 4,692 395,690 27,697 230 182 536,471 52 82,178 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-64

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 41.

PCCM Medicaid Recipients by Age and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 4,066,440 151,910 243,266 54,471 48,907 8,623 841,304 879,554 50,665 16,414 242,844 80,428 123,902 264,035 53,733 59,578 27,577 28,638 103,867 804 591,740 32,566 11,163 39,858 110,559 34 -

Ages Under 1 208,733 10,847 670 2 35,739 56,272 2,123 250 16,216 3,173 5,434 10,836 2,789 401 630 55,325 1,626 103 4,310 1,987 -

From Ages 1 to 5 990,902 67,949 10,010 2,425 217,755 237,384 15,103 4,741 75,121 21,332 31,823 57,169 14,733 10,149 29,335 104 143,750 8,416 1,189 11,230 31,177 7 -

From Ages 6 to 14 1,133,983 79,230 15,117 2,926 251,721 259,590 14,634 8,802 80,552 25,611 36,226 67,929 17,575 10,258 39,046 575 169,050 10,298 1,961 11,337 31,535 10 -

From Ages 15 to 20 395,065 29,061 5,858 742 78,934 95,548 3,906 2,581 27,026 8,366 14,274 22,604 6,471 2,103 9,883 123 62,918 3,943 823 4,446 15,451 4 -

From Ages 21 to 44 710,818 42,828 15,607 1,992 164,192 125,516 8,231 40 40,561 20,645 25,934 72,465 14,161 4,636 16,651 2 116,133 7,453 2,105 7,010 24,648 8 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-65

Pharmaceutical Benefits 2000 Table 41.

PCCM Medicaid Recipients by Age and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

From Ages 45 to 64 238,041 11,811 4,537 313 64,433 53,776 3,445 2,437 1,301 8,278 32,553 3,512 224 7,242 36,085 515 1,507 1,462 4,605 5 -

From Ages 65 to 74 41,889 1,166 760 3 15,333 13,829 1,240 26 722 478 129 292 933 5,297 4 715 56 906 -

From Ages 75 to 84 18,300 229 452 6,352 5,833 883 308 22 278 121 2,318 1,297 6 201 -

From Ages 85 and Over 36,817 119 212 1,879 31,504 431 228 1 4 73 25 864 1,427 1 49 -

Unknown 291,892 151,910 26 1,248 48,907 220 4,966 302 669 905 675 53,733 182 27,577 224 1 311 36 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-66

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 42.

PCCM Medicaid Recipients by Sex and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 4,066,440 151,910 243,266 54,471 48,907 8,623 841,304 879,554 50,665 16,414 242,844 80,428 123,902 264,035 53,733 59,578 27,577 28,638 103,867 804 591,740 32,566 11,163 39,858 110,559 34 -

Male 1,608,714 102,544 22,083 3,026 369,971 385,892 21,294 8,198 100,600 32,228 51,985 104,035 25,894 11,597 46,250 394 244,990 12,534 4,298 16,338 44,545 18 -

Female 2,165,338 140,652 31,140 5,377 466,367 493,361 28,702 8,216 141,339 48,200 71,238 160,000 33,502 16,805 57,616 410 346,750 19,717 6,829 23,087 66,014 16 -

Unknown 292,388 151,910 70 1,248 48,907 220 4,966 301 669 905 679 53,733 182 27,577 236 1 315 36 433 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-67

Pharmaceutical Benefits 2000 Table 43.

PCCM Medicaid Recipients by Race/Ethnicity and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Recipients 4,066,440 151,910 243,266 54,471 48,907 8,623 841,304 879,554 50,665 16,414 242,844 80,428 123,902 264,035 53,733 59,578 27,577 28,638 103,867 804 591,740 32,566 11,163 39,858 110,559 34 -

White Not Hispanic 1,715,126 142,112 30,244 24 320,189 283,721 42,432 811 168,806 70,808 79,178 141,491 44,690 12,024 22,610 157 238,369 22,259 10,379 27,959 56,862 1 -

Black Not Hispanic 1,379,717 89,918 4,942 8,054 289,775 505,355 248 14,767 58,866 5,819 27,391 29,800 449 8,437 2,674 502 287,656 554 122 59 44,328 1 -

Hispanic 382,938 3,639 12,201 252 153,504 31,783 6,045 765 11,832 2,552 11,084 55,751 1,263 6,945 54,959 49 22,685 991 326 36 6,276 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-68

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 43.

PCCM Medicaid Recipients by Race/Ethnicity and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Asian or Pacific Islands 47,143 546 2,491 69 4,864 8,058 145 69 422 859 3,920 15,703 305 726 165 6 5,826 171 70 19 2,709 -

American Indian/ Alaskan Native 68,305 529 932 2 446 454 1,126 2 161 390 1,654 692 12,688 222 21,368 10 9,566 8,263 122 9,540 138 -

Unknown 473,211 151,910 6,522 3,661 48,907 222 72,526 50,183 669 2,757 675 20,598 53,733 183 27,577 284 2,091 80 27,638 328 144 2,245 246 32 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-69

Pharmaceutical Benefits 2000 Table 44

Medicaid Medical Vendor Payments for Prepaid Health Care Medicaid Recipients by Maintenance Assistance Status and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Receiving Payments Cash Payments $19,296,223,487 $11,115,495,025 288,972,436 1,431,418,497 614,603,926 4,359,975 2,521,205 2,867,713,795 2,061,454,084 238,585,930 65,864,936 377,212,893 175,591,675 122,048,974 66,198,863 98,238,002 39,248,549 701,322,837 566,149,381 57,871,451 41,529,226 213,612,580 118,748,223 241,278,075 199,373,324 167,977,207 68,108,993 107,189,198 64,336,134 17,201,600 4,815,387 311,526,039 218,623,439 4,237,958 2,052,490 851,988,946 604,575,473 477,932,296 297,071,252 823,728,725 612,392,605 483,228,011 210,302,771 22,152,325 10,337,698 277,652,554 125,014,933 53,600,495 33,796,563 72,980,602 39,927,033 32,332,069 13,237,436 12,128,535 4,824,765 617,591,322 331,952,834 372,647,285 221,083,291 1,638,382,814 1,231,486,532 85,665,363 43,721,752 1,319,356 336,060 494,845,239 342,793,287 665,872,224 189,542,785 1,801,084,202 1,240,064,684 114,870,881 76,874,255 17,172,147 6,807,312 3,797,234 1,666,614 1,859,127,110 649,322,117 147,730,653 42,275,707 53,890,106 17,733,240 186,255,441 124,695,551 529,020,076 200,698,542 26,573,906 321,886,123 133,740,098 -

Medically Needy $1,367,726,879 323,118 525,689,657 7,832,085 3,729,742 2,316,992 3,208,458 7,760,840 712,597 18,507 13,597,872 4,697 57,240,565 83,364,337 133,623,737 1,806,770 3,533,417 3,390 112,995 403,857 309,597,191 959,689 141,444 9,513,697 49,689,569 1,278,891 129,917,182 3,090,652 3,861,771 277,865 70,098 14,045,197 -

Poverty Related $3,147,537,749 207,764,064 1,153,249 22,725,657 35,788,921 59,283,808 42,075,482 1,608,362 83,078,417 7,660,608 81,434,430 6,195,840 37,036,720 16,390,556 10,247,585 69,595,167 1,317,463 128,822,252 74,100,646 58,315,824 53,545,476 10,921,260 103,237,881 3,767,984 11,124,260 241,038 5,348,430 143,310,698 143,723,448 94,632,388 38,967,044 501,372 145,671,328 297,598,133 221,148,782 21,317,460 4,788,444 1,310,044 686,664,190 15,338,023 26,244,877 36,783,725 82,034,437 54,721,976 -

Other $2,897,425,088 609,050,506 342,098 257,149,439 130,183,665 134,505,325 12,418,295 584,193 49,258,606 8,615,452 7,649,821 27,948,071 62,255,871 25,717,235 2,080,091 9,018,745 846,918 58,693,808 23,396,061 7,469,950 216,531,078 799,156 48,121,506 11,584,313 21,925,919 17,738,526 1,842,210 141,522,476 7,546,939 2,666,704 2,016,879 338,682 6,380,624 161,992,195 290,298,862 10,210,320 5,567,623 820,576 204,999,975 45,224,158 5,921,444 24,498,300 124,357,212 117,335,261 -

MAS Unknown $768,038,747 288,972,436 20,305 694,958 6,748,408 1,356,334 53,067,156 519,441 66,165 2,571,648 575,623 32,676 40,030 690,816 16,390 2,656,848 11,926,609 1,041,916 94,211 1,278,234 918,218 1,115,069 135 401,457 293,607 1,798 7,225,414 (117,695) 5,189,955 8,768 188,223,646 41,802,113 128,774 121,859,787 26,573,906 2,043,591 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-70

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 45.

Medicaid Medical Vendor Payments for Prepaid Health Care by Basis of Eligibility and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Payments $19,007,251,051 288,972,436 1,431,418,497 4,359,975 2,867,713,795 238,585,930 377,212,893 122,048,974 98,238,002 701,322,837 57,871,451 213,612,580 241,278,075 167,977,207 107,189,198 17,201,600 311,526,039 4,237,958 851,988,946 477,932,296 823,728,725 483,228,011 22,152,325 277,652,554 53,600,495 72,980,602 32,332,069 12,128,535 617,591,322 372,647,285 1,638,382,814 85,665,363 1,319,356 494,845,239 665,872,224 1,801,084,202 114,870,881 17,172,147 3,797,234 1,859,127,110 147,730,653 53,890,106 186,255,441 529,020,076 26,573,906 321,886,123 -

Age 65 And Older $1,281,654,876 305,894,109 381,256 243,415,639 18,269,296 16,430 1,717,732 71,539,620 760,211 1,441,713 33,281,397 248,652 188 9,948,951 29,433,961 17,799,618 7,665,104 99,224,132 1,071,123 349 4,081,792 1,827,740 533,667 8,007,536 1,788,025 107,872,874 663,103 52,979,578 177,836,994 1,982 10,258,041 321,796 61,216,442 4,469,049 47,299 1,975,407 858,720 4,805,350 -

Blind/ Disabled $5,061,114,370 538,339,506 1,770,581 502,135,327 91,997,892 889,578 50,022,867 10,560,659 279,151,654 18,236,400 1,348,803 22,104,213 26,584,004 7,484 140,944,026 2,964 429,574,081 168,863,527 369,991,661 3,660,788 8,690,390 216,687 21,674,024 17,877,950 17,239 12,690 37,308,372 134,622,609 645,819,379 8,859,180 198 3,350,900 131,218,913 663,224,362 302,363 2,606,790 703,936 571,127,838 35,856,760 2,325,308 68,820,208 6,971,922 43,320,337 -

Children $7,258,178,184 348,626,397 1,664,699 1,461,163,668 62,949,574 230,046,226 31,807,937 25,540,587 223,804,129 22,359,579 117,090,747 135,309,792 75,113,583 41,528,601 11,334,679 122,137,361 2,925,767 217,332,175 191,656,653 206,701,594 273,466,276 10,066,921 207,000,926 18,234,121 20,941,089 15,103,694 10,046,700 338,914,552 163,844,455 490,808,458 65,478,146 797,300 282,677,169 174,549,708 652,028,654 58,118,090 3,160,340 2,316,950 396,513,777 45,468,041 21,361,006 73,769,467 211,108,633 193,309,963 -

Adults $4,716,575,575 230,958,895 448,043 626,989,806 26,218,634 138,902,495 36,919,623 9,063,283 121,764,996 16,442,094 88,877,805 102,496,767 36,352,314 37,918,466 5,798,449 37,474,425 1,259,800 157,701,903 99,465,302 223,274,867 105,537,325 2,223,849 60,088,789 5,883,408 12,862,703 15,545,523 1,953,315 232,546,221 66,324,600 391,215,400 9,322,127 519,146 207,768,926 281,400,515 290,803,023 51,092,650 1,119,935 379,036 630,339,991 19,196,670 29,920,465 41,689,275 188,203,019 72,311,697 -

Other/ Unknown $689,728,040 288,972,436 7,599,583 95,396 34,009,355 39,150,534 7,358,164 1,580,815 53,073,473 5,062,438 73,167 7,644,028 681,000 1,125,700 909,475 60,800 1,021,276 49,427 17,946,826 147,196 16,095,499 1,339,490 100,042 10,345,803 3,727,150 19,471,120 1,131,946 115,830 814,641 6,067,596 2,666,704 2,005,910 2,712 385,141 25,723,510 17,191,169 5,355,796 27,041 75,516 199,929,062 42,740,133 236,028 1,084 121,877,782 26,573,906 8,138,776 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-71

Pharmaceutical Benefits 2000 Table 46.

Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Age and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Payments $19,296,223,487 288,972,436 1,431,418,497 4,359,975 2,867,713,795 238,585,930 377,212,893 122,048,974 98,238,002 701,322,837 57,871,451 213,612,580 241,278,075 167,977,207 107,189,198 17,201,600 311,526,039 4,237,958 851,988,946 477,932,296 823,728,725 483,228,011 22,152,325 277,652,554 53,600,495 72,980,602 32,332,069 12,128,535 617,591,322 372,647,285 1,638,382,814 85,665,363 1,319,356 494,845,239 665,872,224 1,801,084,202 114,870,881 17,172,147 3,797,234 1,859,127,110 147,730,653 53,890,106 186,255,441 529,020,076 26,573,906 321,886,123 -

Ages Under 1 $663,270,071 165,478 13,209,454 5,851,482 27,836,189 7,444,938 3,743,655 20,416,040 1,574,558 19,435,778 11,690,185 3,540,487 3,358,384 10,065,260 452,074 35,760,475 11,606,162 33,633,121 31,205,609 5,762,963 28,275,079 123,307 3,891,345 155,925 47,468,930 14,531,960 54,914,302 9,640,707 53,367 116,389,364 11,991,839 33,729,565 9,353,107 569,572 276,666 30,658,983 10,553,967 1,725,324 9,030,622 22,773,492 10,410,356 -

From Ages 1 to 5 $2,571,271,634 956,290 515,347,850 37,932,814 84,970,120 14,473,261 18,013,512 97,246,070 9,292,110 62,557,061 31,209,886 17,655,792 4,260,169 53,935,311 1,004,906 98,755,759 68,653,269 91,911,136 119,766,946 3,021,071 85,689,665 1,051,688 6,014,421 3,796,335 149,390,573 49,072,446 190,982,711 12,397,979 300,097 62,355,148 76,050,828 221,515,046 26,101,164 1,495,569 897,180 132,596,542 18,670,383 6,337,145 33,615,628 84,295,694 77,682,059 -

From Ages 6 to 14 $3,072,843,689 884,160 766,649,821 53,024,495 83,856,221 18,190,902 10,816,349 104,294,029 9,452,878 36,908,645 25,648,505 21,208,108 1,694,930 74,499,203 966,790 111,236,613 99,211,663 78,169,032 76,326,241 1,412,028 73,232,376 17,091,288 4,438,112 4,988,385 107,664,770 89,770,157 182,006,374 32,014,625 260,043 76,664,074 99,495,632 366,521,522 16,604,258 1,188,910 1,126,800 204,177,921 16,976,877 7,320,476 30,826,600 75,975,889 90,047,987 -

From Ages 15 to 20 $1,713,753,844 305,391 298,185,030 23,780,778 50,253,265 12,883,886 3,944,788 57,717,411 6,107,675 24,814,153 14,574,725 14,551,222 3,159,391 27,021,626 622,067 72,296,988 40,656,305 61,786,742 51,642,893 1,562,621 35,930,476 14,450,375 4,666,812 1,151,685 65,997,142 68,706,455 94,094,647 19,230,997 222,968 62,884,487 58,776,145 190,539,526 15,284,178 509,547 404,718 193,056,223 7,198,759 5,831,121 24,253,318 48,454,641 36,242,667 -

From Ages 21 to 44 $5,178,849,381 957,597 680,351,715 54,695,564 119,608,032 45,342,960 8,037,555 221,554,555 20,822,290 89,640,324 40,060,244 40,819,219 4,504,848 80,383,927 1,058,095 289,111,724 153,404,081 328,737,518 92,932,142 4,537,547 50,514,480 12,081,374 11,939,029 1,949,400 206,213,047 93,634,772 593,575,857 9,976,490 445,350 161,461,589 233,035,657 549,111,806 42,375,112 1,359,628 488,728 587,144,169 34,292,229 21,520,117 57,608,532 162,010,235 71,551,843 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

B-72

National Pharmaceutical Council

Pharmaceutical Benefits 2000 Table 46.

Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Age and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

From Ages 45 to 64 $2,374,630,221 506,508 268,402,826 36,903,487 10,638,402 20,868,858 724,949 100,532,484 8,890,305 6,009,647 10,692,692 9,245,818 208,948 48,745,997 132,090 192,222,579 81,477,691 197,402,303 8,198,704 4,194,860 3,990,141 3,922,798 330,509 86,805 30,104,674 51,669,983 349,214,118 2,403,413 37,531 14,442,636 126,028,104 304,636,648 3,344,627 1,637,531 215,384 396,748,525 14,335,028 10,850,404 27,282,895 12,652,685 14,696,634 -

From Ages 65 to 74 $615,929,994 249,221 141,526,857 9,149,216 50,441 1,909,646 13,507 42,372,100 1,187,070 699,832 11,708,270 143,152 1,061 9,611,724 585 35,774,016 6,791,609 15,906,082 38,022,997 975,335 18,577 1,523,252 242,073 3,709,895 4,305,567 94,422,624 995 292,370 26,171,354 83,293,815 17,865 2,536,145 113,116 69,289,240 3,503,988 164,873 2,950,538 389,168 6,891,818 -

From Ages 75 to 84 $396,380,134 218,230 109,225,777 6,190,210 223 750,768 4,391 30,723,983 360,359 814,921 12,470,176 11,711 4,975,171 12,503,907 9,013,837 3,784,086 35,119,240 506,104 1,605,578 235,394 3,217,016 631,410 55,137,837 259,985 19,719,835 39,684,751 2,112 4,091,505 125,624 35,633,293 1,563,614 14,885 601,164 274,509 6,908,528 -

From Ages 85 and Over $247,911,989 118,239 74,335,881 4,568,995 181,267 26,141,677 171,785 397,448 9,833,271 12,743 2,047,175 3,240,544 7,117,679 1,094,952 29,804,940 162,517 1,597,184 59,846 3,558,916 150,035 24,034,343 158 95,586 13,823,922 12,208,206 492 3,781,995 148,922 22,288,636 635,734 1,776 86,145 370,179 5,840,801 -

Unknown $2,461,382,531 288,972,436 1,431,418,497 (1,139) 478,584 6,488,889 2,488 52,939,296 324,488 12,421 213,612,580 266 89,253 946 13,869 240,645 1,351 1,086,341 11,303,753 208,299 17,279 1,760 153,651 72,980,602 514,528 266,359 174,500 778,908 (156,683) 1,787,966 1,745 96 187,533,578 40,000,074 123,985 121,823,584 26,573,906 1,613,430 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

National Pharmaceutical Council

B-73

Pharmaceutical Benefits 2000 Table 47.

Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Sex and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Payments $19,296,223,487 288,972,436 1,431,418,497 4,359,975 2,867,713,795 238,585,930 377,212,893 122,048,974 98,238,002 701,322,837 57,871,451 213,612,580 241,278,075 167,977,207 107,189,198 17,201,600 311,526,039 4,237,958 851,988,946 477,932,296 823,728,725 483,228,011 22,152,325 277,652,554 53,600,495 72,980,602 32,332,069 12,128,535 617,591,322 372,647,285 1,638,382,814 85,665,363 1,319,356 494,845,239 665,872,224 1,801,084,202 114,870,881 17,172,147 3,797,234 1,859,127,110 147,730,653 53,890,106 186,255,441 529,020,076 26,573,906 321,886,123 -

Male $6,371,960,186 1,848,704 1,188,412,224 98,538,857 125,688,730 46,701,836 20,235,744 256,733,902 16,504,588 71,473,133 56,394,499 38,730,632 5,294,188 132,639,343 1,599,611 328,225,186 191,883,979 286,073,576 177,115,708 8,252,448 110,451,332 25,061,257 8,159,170 5,147,550 186,936,733 154,292,150 626,743,732 36,860,097 343,129 145,797,261 270,264,196 700,297,042 32,405,762 4,484,249 1,640,282 648,037,009 46,210,088 21,314,625 62,219,339 113,052,671 119,895,624 -

Female $10,460,328,903 2,511,984 1,678,818,709 133,558,184 251,524,163 75,344,650 25,051,743 444,264,447 41,354,442 169,804,676 111,493,455 68,457,620 11,892,866 178,638,239 2,636,996 522,678,351 286,048,317 526,353,707 305,904,004 13,882,598 167,199,462 28,385,587 23,625,902 6,978,285 430,388,230 218,178,420 1,011,639,074 48,805,266 976,227 346,632,905 394,817,726 1,100,947,308 80,677,153 12,686,153 2,117,756 1,023,539,781 61,515,574 32,451,496 124,036,102 294,131,756 200,379,589 -

Unknown $2,463,934,398 288,972,436 1,431,418,497 (713) 482,862 6,488,889 2,488 52,950,515 324,488 12,421 213,612,580 266 89,253 946 14,546 248,457 1,351 1,085,409 11,301,442 208,299 17,279 1,760 153,651 72,980,602 546,997 2,700 266,359 176,715 9 2,415,072 790,302 (160,148) 1,787,966 1,745 39,196 187,550,320 40,004,991 123,985 121,835,649 26,573,906 1,610,910 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

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Pharmaceutical Benefits 2000 Table 48.

Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Race/Ethnicity and by State: FY 1998

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Total Payments $19,296,223,487 288,972,436 1,431,418,497 4,359,975 2,867,713,795 238,585,930 377,212,893 122,048,974 98,238,002 701,322,837 57,871,451 213,612,580 241,278,075 167,977,207 107,189,198 17,201,600 311,526,039 4,237,958 851,988,946 477,932,296 823,728,725 483,228,011 22,152,325 277,652,554 53,600,495 72,980,602 32,332,069 12,128,535 617,591,322 372,647,285 1,638,382,814 85,665,363 1,319,356 494,845,239 665,872,224 1,801,084,202 114,870,881 17,172,147 3,797,234 1,859,127,110 147,730,653 53,890,106 186,255,441 529,020,076 26,573,906 321,886,123 -

White Not Hispanic $6,971,046,006 2,384,384 820,555,222 116,429,108 133,015,461 51,811,375 175,177 200,648,478 6,211,574 17,977,074 107,009,316 88,529,917 11,237,535 198,174,755 289,337,600 288,388,006 291,325,697 284,480,133 8,071,914 131,368,857 40,733,062 16,029,764 11,252,385 132,285,603 109,777,182 491,797,939 33,406,093 1,056,698 179,164,021 543,216,685 637,775,454 54,749,866 4,236,183 2,135,624 1,098,535,007 82,460,377 52,965,970 42,397,973 294,984,443 94,954,094 -

Black Not Hispanic $5,424,759,152 1,614,896 487,617,383 21,481,320 111,183,457 55,384,205 41,711,203 312,690,985 46,212,136 190,654,668 53,251,599 13,074,920 3,772,419 87,502,578 494,247,122 71,270,979 448,956,331 89,825,022 11,913,383 146,281,937 378,343 6,870,965 254,205 272,103,646 10,934,417 450,530,344 43,866,121 48,005 287,807,436 33,211,731 873,410,484 12,986,826 11,916,431 8,146 475,376,234 2,741,398 310,809 138,049,280 31,790,969 83,516,819 -

Hispanic $2,465,159,044 48,468 967,106,015 68,576,183 127,462,428 9,308,431 1,697,604 76,908,022 778,345 30,831,653 5,584,848 3,499,999 1,538,532 3,371,173 20,220,791 75,058,724 18,650,003 25,909,085 129,995 953,078 7,415,636 527,715 182,477,490 175,691,834 261,095,778 3,263,231 48,234 15,482,001 49,129,279 210,736,115 25,379,168 16,070 5,642 9,936,111 14,009,607 88,135 2,674,894 52,830,212 16,718,515 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

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Pharmaceutical Benefits 2000 Table 48.

Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Race/Ethnicity and by State: FY 1998 (Con’t)

State Name National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Asian or Pacific Islands $584,061,196 10,176 294,236,703 2,103,149 4,966,585 542,146 222,162 1,854,574 346,375 1,510,807 665,533 1,446,729 375,410 1,211,148 22,909,496 10,950,049 12,516,835 55,641,385 377,365 201,817 1,053,602 94,230 8,524,702 2,430,041 17,793,471 1,432,851 4,957 2,658,216 25,783,520 54,370,431 4,223,146 2,236 2,424 6,829,155 5,029,685 275,438 2,640,478 22,213,553 16,610,616 -

American Indian/ Alaskan Native $134,704,727 7,377 8,640,240 1,439,083 515,229 440,451 4,093 175,145 12,683 292,853 75,529 636,687 263,835 108,466 2,040,903 1,173,993 1,994,247 14,708,695 26,934 11,163,929 365,238 944,911 58,314,252 3,055,203 611,227 161,462 525,561 9,034,978 1,245,841 171,462 640 1,486,962 3,770,117 2,244,147 125,769 238,376 5,377,315 3,310,894 -

Unknown $2,461,382,531 288,972,436 1,431,418,497 (1,139) 478,584 6,488,889 2,488 52,939,296 324,488 12,421 213,612,580 266 89,253 946 13,869 240,645 1,351 1,086,341 11,303,753 208,299 17,279 1,760 153,651 72,980,602 514,528 266,359 174,500 778,908 (156,683) 1,787,966 1,745 96 187,533,578 40,000,074 123,985 121,823,584 26,573,906 1,613,430 -

Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

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Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.

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Appendix C: Medicaid Rebate Law

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Pharmaceutical Benefits 2000

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.

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Pharmaceutical Benefits 2000 (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 C-4

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Pharmaceutical Benefits 2000 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).

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Pharmaceutical Benefits 2000 (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.

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Pharmaceutical Benefits 2000 (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.

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Pharmaceutical Benefits 2000 (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).

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Pharmaceutical Benefits 2000 (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 National Pharmaceutical Council

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(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, C-10

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Pharmaceutical Benefits 2000 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, drugallergy 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”.

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Pharmaceutical Benefits 2000 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;

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Pharmaceutical Benefits 2000 (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;

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Pharmaceutical Benefits 2000 (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

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Pharmaceutical Benefits 2000 (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

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(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.

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Pharmaceutical Benefits 2000 (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. •

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(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.)

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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. •

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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)”. National Pharmaceutical Council

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Pharmaceutical Benefits 2000 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”. •

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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. •

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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 C-18

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Pharmaceutical Benefits 2000 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).

National Pharmaceutical Council

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Pharmaceutical Benefits 2000 “(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.

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Appendix D: HCFA Upper Limits for Multiple Source Products

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The following list of multiple source drugs meets the criteria set forth in 42 CFR 447.332 and §1927(e) of the Social Security Act, as amended by OBRA 1993. The development of the current Federal Upper Limit (FUL) listing has been accomplished by computer. Payments for multiple source drugs identified and listed in the accompanying addendum must not exceed, in the aggregate, payment levels determined by applying to each drug entity a reasonable dispensing fee (established by the State and specified in the State plan), plus an amount based on the limit per unit which 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 Acebutolol Hydrochloride Eq 200 mg base, Capsule, Oral 100 Eq 400 mg base, Capsule, Oral 100

Upper Limit per Unit (Source) $0.4613 B 0.6713 B

Acetaminophen; Codeine Phosphate 300 mg; 15 mg, Tablet, Oral 100 300 mg; 30 mg, Tablet, Oral 100 300 mg; 60 mg, Tablet, Oral 100

0.0980 B 0.1200 B 0.2280 B

Acetaminophen; Hydrocodone Bitartrate 500 mg; 5 mg, Capsule, Oral 100 500 mg; 5 mg, Tablet, Oral 100 500 mg; 7.5 mg, Tablet, Oral 100 650 mg; 7.5 mg, Tablet, Oral 100 650 mg; 10 mg, Tablet, Oral 100 750 mg; 7.5 mg, Tablet, Oral 100

0.1943 R 0.1060 R 0.2300 B 0.1850 B 0.1850 R 0.1750 R

Acetaminophen; Oxycodone Hydrochloride 500 mg; 5 mg, Capsule, Oral 100 325 mg; 5 mg, Tablet, Oral 100

0.2250 B 0.1190 B

Acetaminophen; Propoxyphene Hydrochloride 650 mg; 65 mg, Tablet, Oral 100

0.1688 B

Acetaminophen; Propoxyphene Napsylate 650 mg; 100 mg, Tablet, Oral 100

0.2510 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book National Pharmaceutical Council

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Generic Name

Upper Limit per Unit (Source)

Acetazolamide 125 mg, Tablet, Oral 100 250 mg, Tablet, Oral 100

0.0760 B 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 10%, Solution, Inhalation 10 ml 20%, Solution, Inhalation 4 ml 20%, Solution, Inhalation 10 ml

0.8060 B 0.7640 R 0.9710 B 0.9290 R

Acyclovir 200 mg, Capsule, Oral 100 400 mg, Tablet, Oral 100 800 mg, Tablet, Oral 100

0.3530 B 0.7050 R 1.2160 B

Albuterol Sulfate Eq 0.5% base, Solution, Inhalation 20 ml Eq 2 mg base/5 ml, Syrup, Oral 480 ml Eq 2 mg base, Tablet, Oral 100 Eq 4 mg base, Tablet, Oral 100

0.3330 R 0.0350 B 0.0380 B 0.0550 B

Allopurinol 100 mg, Tablet, Oral 100 300 mg, Tablet, Oral 100

0.0510 B 0.1198 B

Alprazolam 0.25 mg, Tablet, Oral 100 0.5 mg, Tablet, Oral 100 1 mg, Tablet, Oral 100

0.0560 B 0.0690 B 0.0920 B

Amantadine Hydrochloride 100 mg, Capsule, Oral 100 50 mg/5 ml, Syrup, Oral 480 ml

0.1572 R 0.0720 R

Amiloride Hydrochloride; Hydrochlorothiazide Eq 5 mg Anhydrous; 50 mg, Tablet, Oral 100

0.0675 R

Aminophylline 100 mg, Tablet, Oral 100 200 mg, Tablet, Oral 1000

0.0278 R 0.0390 R

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-4

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Generic Name

Upper Limit per Unit (Source)

Amiodarone Hydrochloride 200 mg, Tablet, Oral 500

1.8912 R

Amitriptyline Hydrochloride 10 mg, Tablet, Oral 100 25 mg, Tablet, Oral 100 50 mg, Tablet, Oral 100 75 mg, Tablet, Oral 100 100 mg, Tablet, Oral 100 150 mg, Tablet, Oral 100

0.0315 B 0.0330 R 0.0400 B 0.0592 B 0.0760 R 0.1800 B

Amitriptyline Hydrochloride; Perphenazine 10 mg; 2 mg, Tablet, Oral 100 25 mg; 2 mg, Tablet, Oral 100 25 mg; 4 mg, Tablet, Oral 100

0.0652 B 0.0870 B 0.0983 B

Amoxapine 25 mg, Tablet, Oral 100 50 mg, Tablet, Oral 100 100 mg, Tablet, Oral 100 150 mg, Tablet, Oral 30

0.3524 B 0.5426 B 0.9300 B 1.5475 B

Amoxicillin 250 mg, Capsule, Oral 100 500 mg, Capsule, Oral 100 125 mg/5 ml, Powder for reconstitution, Oral 100 125 mg/5 ml, Powder for reconstitution, Oral 150 250 mg/5 ml, Powder for reconstitution, Oral 100 250 mg/5 ml, Powder for reconstitution, Oral 150 250 mg, Tablet, Chewable, Oral 100

0.0636 R 0.1270 B 0.0210 B 0.0119 B 0.0218 B 0.0210 B 0.1600 B

Ampicillin/Ampicillin Trihydrate 250 mg, Capsule, Oral 100 500 mg, Capsule, Oral 100

0.0850 B 0.1115 B

Aspirin; Carisoprodol 325 mg; 200 mg, Tablet, Oral 100

0.5960 R

Aspirin; Oxycodone Hydrochloride; Oxycodone Terephthalate 325 mg; 4.5 mg; 0.38 mg, Tablet, Oral 100

0.1313 R

Atenolol 25 mg, Tablet, Oral 100 100 mg, Tablet, Oral 100

0.0460 B 0.0672 B

Atenolol; Chlorthalidone 50 mg; 25 mg, Tablet, Oral 100 100 mg; 25 mg, Tablet, Oral 100

0.2550 B 0.3730 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book National Pharmaceutical Council

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Generic Name

Upper Limit per Unit (Source)

Atropine Sulfate; Diphenoxylate Hydrochloride 0.025 mg; 2.5 mg, Tablet, Oral 100

0.3743 R

Baclofen 10 mg, Tablet, Oral 100 20 mg, Tablet, Oral 100

0.0899 B 0.1688 R

Benzonatate 100 mg, Capsule, Oral 100

0.3899 B

Benztropine Mesylate 0.5 mg, Tablet, Oral 100 1 mg, Tablet, Oral 100 2 mg, Tablet, Oral 100

0.0360 B 0.0380 B 0.0430 B

Betamethasone Dipropionate Eq 0.05% base, Cream, Topical 15 gm Eq 0.05% base, Cream, Topical 45 gm Eq 0.05% base, Lotion, Topical 60 ml Eq 0.05% base, Ointment, Topical 15 gm Eq 0.05% base, Ointment, Topical 45 gm

0.2130 B 0.1313 B 0.1440 B 0.3350 B 0.2230 B

Betamethasone Valerate Eq 0.1% base, Cream, Topical 15 gm Eq 0.1% base, Cream, Topical 45 gm Eq 0.1% base, Lotion, Topical 60 ml

0.1130 B 0.0750 B 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 1 mg, Tablet, Oral 100 2 mg, Tablet, Oral 100

0.1613 R 0.2810 B 0.3675 R

Captopril 12.5 mg, Tablet, Oral 100 25 mg, Tablet, Oral 100 50 mg, Tablet, Oral 100 100 mg, Tablet, Oral 100

0.0480 B 0.0560 B 0.1180 B 0.2020 M

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-6

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Pharmaceutical Benefits 2000

Generic Name

Upper Limit per Unit (Source)

Captolpril; Hydrochlorothiazide 25 mg; 15 mg, Tablet, Oral 100 25 mg; 25 mg, Tablet, Oral 100 50 mg; 15 mg, Tablet, Oral 100 50 mg; 25 mg, Tablet, Oral 100

0.2313 R 0.2313 R 0.3629 R 0.3629 R

Carbamazepine 200 mg, Tablet, Oral 100

0.1500 R

Carbidopa; Levodopa 10 mg; 100 mg, Tablet, Oral 100 25 mg; 100 mg, Tablet, Oral 100 25 mg; 250 mg, Tablet, Oral 100

0.1971 B 0.2127 B 0.2513 B

Carisoprodol 350 mg, Tablet, Oral 100

0.3743 B

Cefaclor Eq 250 mg base, Capsule, Oral 100 Eq 500 mg base, Capsule, Oral 100 Eq 125 mg base/5 ml, Powder for reconstitution, Oral 150 Eq 187 mg base/5 ml, Powder for reconstitution, Oral 100 Eq 250 mg base/5 ml, Powder for reconstitution, Oral 150 Eq 375 mg base/5 ml, Powder for reconstitution, Oral 100 Cephalexin Eq 250 mg base, Capsule, Oral 100 Eq 500 mg base, Capsule, Oral 100 Eq 125 mg base/5 ml, Powder for reconstitution, Oral 200 Eq 250 mg base/5 ml, Powder for reconstitution, Oral 100 Eq 250 mg base/5 ml, Powder for reconstitution, Oral 200

0.9290 B 1.7990 B 0.1320 R 0.2000 R 0.2440 B 0.3660 B 0.1700 B 0.2150 B 0.0310 B 0.0510 B 0.0450 B

Chlordiazepoxide Hydrochloride 10 mg, Capsule, Oral 100 25 mg, Capsule, Oral 100

0.0950 B 0.1090 B

Chlorhexidine Gluconate 0.12%, Solution, Dental 480 ml

0.0150 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book National Pharmaceutical Council

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Generic Name

Upper Limit per Unit (Source)

Chlorpheniramine Maleate 4 mg, Tablet, Oral 100

0.0100 M

Chlorpropamide 100 mg, Tablet, Oral 100 250 mg, Tablet, Oral 100

0.1840 B 0.3885 R

Chlorthalidone 25 mg, Tablet, Oral 100 50 mg, Tablet, Oral 100

0.0510 B 0.0560 B

Cholestyramine Eq 4 gm Resin/Packet, Powder, Oral 60 pk

0.9004 B

Cimetidine 200 mg, Tablet, Oral 100 300 mg, Tablet, Oral 100 400 mg, Tablet, Oral 100 800 mg, Tablet, Oral 100

0.1238 B 0.1080 R 0.1178 R 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 Eq 1% base, Solution, Topical 60 ml

0.2095 B 0.3150 R

Clomipramine Hydrochloride 25 mg, Capsule, Oral 100 50 mg, Capsule, Oral 100 75 mg, Capsule, Oral 100

0.3750 B 0.4985 B 0.6464 R

Clonazepam 0.5 mg, Tablet, Oral 100 1 mg, Tablet, Oral 100 2 mg, Tablet, Oral 100

0.2760 B 0.3210 B 0.4390 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-8

National Pharmaceutical Council

Pharmaceutical Benefits 2000

Generic Name

Upper Limit per Unit (Source)

Clonidine Hydrochloride 0.1 mg, Tablet, Oral 100 0.2 mg, Tablet, Oral 100 0.3 mg, Tablet, Oral 100

0.0900 B 0.1275 B 0.1650 B

Clorazepate Dipotassium 3.75 mg, Tablet, Oral 100 7.5 mg, Tablet, Oral 100 15 mg, Tablet, Oral 100

0.8351 R 1.0388 B 1.4094 R

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 10 mg, Tablet, Oral 100

0.0910 B

Cyclopentolate Hydrochloride 1%, Solution/Drops, Ophthalmic 15 ml

0.4810 B

Desipramine Hydrochloride 25 mg, Tablet, Oral 100 50 mg, Tablet, Oral 100 75 mg, Tablet, Oral 100 100 mg, Tablet, Oral 100

0.0675 R 0.0825 B 0.0900 R 0.4370 R

Desonide 0.05%, Ointment, Topical 15 gm 0.05%, Ointment, Topical 50 gm

0.5840 B 0.4077 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

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book National Pharmaceutical Council

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Generic Name

Upper Limit per Unit (Source)

Dextromethorphan Hydrobromide; Promethazine Hydrochloride 15 mg/5 ml; 6.25 mg/5 ml, Syrup, Oral 120 ml 15 mg/5 ml; 6.25 mg/5 ml, Syrup, Oral 480 ml

0.0199 B 0.0111 B

Diazepam 2 mg, Tablet, Oral 100 5 mg, Tablet, Oral 100 10 mg, Tablet, Oral 100

0.0300 B 0.0320 B 0.0420 B

Diclofenac Potassiuim 50 mg, Tablet, Oral 100

0.8630 B

Diclofenac Sodium 50 mg, Tablet, Delayed Release, Oral 100 75 mg, Tablet, Delayed Release, Oral 100

0.4748 B 0.6560 R

Dicyclomine Hydrochloride 10 mg, Capsule, Oral 100 20 mg, Tablet, Oral 100

0.1223 B 0.1428 M

Diflunisal 500 mg, Tablet, Oral 60

0.4750 B

Diltiazem Hydrochloride 30 mg, Tablet, Oral 100 60 mg, Tablet, Oral 100 90 mg, Tablet, Oral 100 120 mg, Tablet, Oral 100

0.1160 B 0.1810 B 0.2180 B 0.3520 B

Diphenhydramine Hydrochloride 25 mg, Capsule, Oral 100 12.5 mg/5 ml, Elixir, Oral 480 ml

0.0250 B 0.0080 B

Dipivefrin Hydrochloride 0.1%, Solution/Drops, Ophthalmic 5 ml 0.1%, Solution/Drops, Ophthalmic 10 ml 0.1%, Solution/Drops, Ophthalmic 15 ml

0.8700 B 0.6360 B 0.7280 B

Dipyridamole 75 mg, Tablet, Oral 100

0.0770 B

Doxepin Hydrochloride Eq 10 mg base, Capsule, Oral 100 Eq 25 mg base, Capsule, Oral 100 Eq 75 mg base, Capsule, Oral 100 Eq 100 mg base, Capsule, Oral 100 Eq 10 mg base/ml, Concentrate, Oral 120 ml

0.1720 B 0.1820 B 0.1290 B 0.3830 B 0.1144 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-10

National Pharmaceutical Council

Pharmaceutical Benefits 2000

Generic Name

Upper Limit per Unit (Source)

Doxycycline Hyclate Eq 50 mg base, Capsule, Oral 50 Eq 100 mg base, Capsule, Oral 50 Eq 100 mg base, Tablet, Oral 50

0.0819 B 0.1050 B 0.0953 B

Erythromycin 250 mg, Capsule, Delayed Released Pellets, Oral 100 2%, Solution, Topical 60 ml

0.1890 B 0.0650 B

Erythromycin Ethylsuccinate Eq 200 mg base/5 ml, Suspension, Oral 480 ml

0.0340 B

Estazolam 1 mg, Tablet, Oral 100 2 mg, Tablet, Oral 100

0.5954 B 0.6563 B

Estradiol 0.5 mg, Tablet, Oral 100 1 mg, Tablet, Oral 100 2 mg, Tablet, Oral 100

0.1793 B 0.2205 B 0.3060 B

Estropipate 0.75 mg, Tablet, Oral 100 1.5 mg, Tablet, Oral 100

0.3453 R 0.3614 B

Etodolac 200 mg, Capsule, Oral 100 300 mg, Capsule, Oral 100 400 mg, Tablet, Oral 100 500 mg, Tablet, Oral 100

0.4800 B 0.5100 B 0.3450 B 1.0032 R

Fenoprofen Calcium Eq 600 mg base, Tablet, Oral 100

0.2990 B

Fluocinolone Acetonide 0.01%, Solution, Topical 60 ml

0.1170 B

Fluocinonide 0.05%, Cream, Topical 15 gm 0.05%, Cream, Topical 30 gm 0.05%, Cream, Topical 60 gm 0.05%, Solution, Topical 60 ml

0.1880 B 0.1439 B 0.1187 B 0.2640 B

Fluorometholone 0.1%, Suspension/Drops, Ophthalmic 5 ml 0.1%, Suspension/Drops, Ophthalmic 10 ml 0.1%, Suspension/Drops, Ophthalmic 15 ml

1.6590 R 1.1835 R 0.8950 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book National Pharmaceutical Council

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Generic Name

Upper Limit per Unit (Source)

Fluphenazine Hydrochloride 1 mg, Tablet, Oral 100 2.5 mg, Tablet, Oral 100 5 mg, Tablet, Oral 100 10 mg, Tablet, Oral 100

0.2120 R 0.2775 B 0.3675 B 0.4760 R

Flurazepam Hydrochloride 15 mg, Capsule, Oral 100 30 mg, Capsule, Oral 100

0.0656 B 0.0830 R

Flurbiprofen 100 mg, Tablet, Oral 100

0.3680 B

Folic Acid 1 mg, Tablet, Oral 100

0.0460 B

Furosemide 10 mg/ml, Solution, Oral 60 ml 10 mg/ml, Solution, Oral 120 ml 20 mg, Tablet, Oral 100 40 mg, Tablet, Oral 100 80 mg, Tablet, Oral 100

0.1300 B 0.0893 B 0.0420 B 0.0440 R 0.0710 B

Gentamicin Sulfate Eq 0.1% Base, Ointment, Topical 15 gm Eq 0.3% Base, Ointment, Ophthalmic 3.5 gm Eq 0.3% Base, Solution/Drops, Ophthalmic 5 ml Eq 0.3% Base, Solution/Drops, Ophthalmic 15 ml

0.1740 B 2.6786 B 0.4890 B 0.2560 B

Glipizide 5 mg, Tablet, Oral 100 10 mg, Tablet, Oral 100

0.0650 R 0.0937 B

Glyburide 1.5 mg, Tablet, Oral 100 3 mg, Tablet, Oral 100 6 mg, Tablet, Oral 100

0.2550 R 0.3204 R 0.8471 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 100 250 mg, Tablet, Oral 100 330 mg, Tablet, Oral 100

0.3743 B 0.5093 B 0.6690 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-12

National Pharmaceutical Council

Pharmaceutical Benefits 2000

Generic Name

Upper Limit per Unit (Source)

Guanabenz Acetate Eq 4 mg base, Tablet, Oral 100 Eq 8 mg base, Tablet, Oral 100

0.3675 R 0.5625 R

Guanfacine Hydrochloride Eq 1 mg base, Tablet, Oral 100 Eq 2 mg base, Tablet, Oral 100

0.5250 B 0.7200 B

Haloperidol 0.5 mg, Tablet, Oral 100 1 mg, Tablet, Oral 100 2 mg, Tablet, Oral 100 5 mg, Tablet, Oral 100 10 mg, Tablet, Oral 100

0.0360 B 0.0400 R 0.0440 B 0.0570 R 0.0770 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 10 mg, Tablet, Oral 100 25 mg, Tablet, Oral 100

0.0350 B 0.0450 B

Hydrochlorothiazide; Propranolol Hydrochloride 25 mg; 40 mg, Tablet, Oral 100 25 mg; 80 mg, Tablet, Oral 100

0.0771 B 0.1044 B

Hydrochlorothiazide; Spironolactone 25 mg; 25 mg, Tablet, Oral 100

0.3225 B

Hydrochlorothiazide; Triamterene 25 mg; 37.5 mg, Capsule, Oral 100 25 mg; 50 mg, Capsule, Oral 100 25 mg; 37.5 mg, Tablet, Oral 100 50 mg; 75 mg, Tablet, Oral 100

0.3181 B 0.1130 B 0.2438 R 0.0530 B

Hydrocortisone 0.5%, Cream, Topical, 30 gm 2.5%, Cream, Topical 20 gm 2.5%, Cream, Topical 30 gm 1%, Lotion, Topical 120 ml

0.0380 B 0.1814 B 0.1820 B 0.0640 B

Hydroxychloroquine Sulfate 200 mg, Tablet, Oral 100

0.8540 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book National Pharmaceutical Council

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Generic Name

Upper Limit per Unit (Source)

Hydroxyurea 500 mg, Capsule, Oral 100

1.1666 B

Hydroxyzine Hydrochloride 10 mg/5 ml, Syrup, Oral 480 ml 10 mg, Tablet, Oral 100 25 mg, Tablet, Oral 100 50 mg, Tablet, Oral 100

0.0370 B 0.0248 B 0.0347 B 0.0450 R

Hydroxyzine Pamoate Eq 25 mg HCL, Capsule, Oral 100 Eq 50 mg HCL, Capsule, Oral 100 Eq 100 mg HCL, Capsule, Oral 100

0.0794 B 0.1013 R 0.2710 B

Ibuprofen 400 mg, Tablet, Oral 100 600 mg, Tablet, Oral 100 800 mg, Tablet, Oral 100

0.0640 B 0.0740 R 0.1070 B

Imipramine Hydrochloride 10 mg, Tablet, Oral 100 25 mg, Tablet, Oral 100 50 mg, Tablet, Oral 100

0.1557 R 0.1880 R 0.2290 R

Indapamide 1.25 mg, Tablet, Oral 100 2.5 mg, Tablet, Oral 100

0.1780 B 0.2080 B

Indomethacin 25 mg, Capsule, Oral 100 50 mg, Capsule, Oral 100

0.0440 B 0.0501 B

Isoniazid 300 mg, Tablet, Oral 100

0.0548 B

Isosorbide Dinitrate 5 mg, Tablet, Oral 100 10 mg, Tablet, Oral 100 20 mg, Tablet, Oral 100 5 mg, Tablet, Sublingual 100

0.0242 B 0.0280 B 0.0248 B 0.0300 R

Isosorbide Mononitrate 10 mg, Tablet, Oral 100 20 mg, Tablet, Oral 100

0.6110 R 0.4950 B

Ketoconazole 200 mg, Tablet, Oral 100

2.7645 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-14

National Pharmaceutical Council

Pharmaceutical Benefits 2000

Generic Name

Upper Limit per Unit (Source)

Ketoprofen 50 mg, Capsule, Oral 100

0.4750 B

Ketorolac Tromethamine 10 mg, Tablet, Oral 100

0.6374 B

Labetalol Hydrochloride 100 mg, Tablet, Oral 100 200 mg, Tablet, Oral 100 300 mg, Tablet, Oral 100

0.4670 B 0.6620 B 0.8810 B

Lactulose 10 gm/15 ml, Solution, Oral 480 ml

0.0219 B

Levobunolol Hydrochloride 0.25%, Solution/Drops, Ophthalmic 10 ml 0.5%, Solution/Drops, Ophthalmic 5 ml 0.5%, Solution/Drops, Ophthalmic 10 ml 0.5%, Solution/Drops, Ophthalmic 15 ml

1.2749 B 1.3950 R 1.4930 B 1.4190 R

Lidocaine Hydrochloride 2%, Solution, Oral 100 ml

0.0278 M

Lindane 1%, Shampoo, Topical 480 ml

0.1660 B

Loperamide Hydrochloride 2 mg, Capsule, Oral 100

0.1500 B

Lorazepam 0.5 mg, Tablet, Oral 100 1 mg, Tablet, Oral 100 2 mg, Tablet, Oral 100

0.4350 B 0.5718 B 0.8480 B

Meclizine Hydrochloride 12.5 mg, Tablet, Oral 100 25 mg, Tablet, Oral 100

0.0370 B 0.0390 B

Medroxyprogesterone Acetate 5 mg, Tablet, Oral 100

0.2250 B

Megestrol Acetate 20 mg, Tablet, Oral 100 40 mg, Tablet, Oral 100

0.5000 R 0.8000 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book National Pharmaceutical Council

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Pharmaceutical Benefits 2000

Generic Name

Upper Limit per Unit (Source)

Meprobamate 200 mg, Tablet, Oral 100 400 mg, Tablet, Oral 100

0.1080 B 0.1580 R

Methazolamide 25 mg, Tablet, Oral 100 50 mg, Tablet, Oral 100

0.3260 B 0.5000 B

Methocarbamol 500 mg, Tablet, Oral 100 750 mg, Tablet, Oral 100

0.1350 B 0.1710 B

Methyclothiazide 5 mg, Tablet, Oral 100

0.3689 B

Methyldopa 250 mg, Tablet, Oral 100 500 mg, Tablet, Oral 100

0.1013 B 0.1800 B

Methylphenidate Hydrochloride 5 mg, Tablet, Oral 100 10 mg, Tablet, Oral 100 20 mg, Tablet, Oral 100

0.3020 B 0.4224 B 0.6180 B

Methylprednisolone 4 mg, Tablet, Oral 100

0.4658 R

Metoclopramide Hydrochloride Eq 5 mg base/5 ml, Solution, Oral 480 ml Eq 5 mg base, Tablet, Oral 100 Eq 10 mg base, Tablet, Oral 100

0.0155 B 0.1200 B 0.0195 R

Metoprolol Tartrate 50 mg, Tablet, Oral 100 100 mg, Tablet, Oral 100

0.1060 B 0.1290 B

Metronidazole 250 mg, Tablet, Oral 100 500 mg, Tablet, Oral 100

0.0640 B 0.1350 B

Mexiletine Hydrochloride 150 mg, Capsule, Oral 100 200 mg, Capsule, Oral 100 250 mg, Capsule, Oral 100

0.6452 B 0.7784 R 0.8568 R

Minocycline Hydrochloride Eq 50 mg base, Capsule, Oral 100 Eq 100 mg base, Capsule, Oral 50

0.5020 B 0.7875 B SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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Generic Name

Upper Limit per Unit (Source)

Minoxidil 2.5 mg, Tablet, Oral 100 10 mg, Tablet, Oral 100

0.3170 B 0.6970 B

Nadolol 20 mg, Tablet, Oral 100 40 mg, Tablet, Oral 100 120 mg, Tablet, Oral 100 160 mg, Tablet, Oral 100

0.4650 B 0.5780 B 1.1220 B 1.1540 B

Naphazoline Hydrochloride 0.1%, Solution/Drops, Ophthalmic 15 ml

0.3140 R

Naproxen 250 mg, Tablet, Oral 100 375 mg, Tablet, Oral 100 500 mg, Tablet, Oral 100 375 mg, Tablet, Delayed Release, Oral 100 500 mg, Tablet, Delayed Release, Oral 100

0.1035 B 0.1335 B 0.1628 B 0.6450 B 0.9750 B

Naproxen Sodium Eq 250 mg base, Tablet, Oral 100 Eq 500 mg base, Tablet, Oral 100

0.1670 R 0.2070 B

Niacin 500 mg, Tablet, Oral 100

0.0390 R

Nicardipine Hydrochloride 20 mg, Capsule, Oral 100 30 mg, Capsule, Oral 100

0.3380 B 0.4050 B

Nifedipine 20 mg, Capsule, Oral 100

0.2470 B

Nitrofurantoin, Macrocrystalline 50 mg, Capsule, Oral 100 100 mg, Capsule, Oral 100

0.5040 R 0.7425 B

Nortriptyline Hydrochloride Eq 10 mg base, Capsule, Oral 100 Eq 25 mg base, Capsule, Oral 100 Eq 50 mg base, Capsule, Oral 100 Eq 75 mg base, Capsule, Oral 100

0.1020 B 0.1580 R 0.1720 B 0.2204 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book National Pharmaceutical Council

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Pharmaceutical Benefits 2000

Generic Name Nystatin 100,000 100,000 100,000 100,000 500,000

Upper Limit per Unit (Source) units/gm, Cream, Topical 15 gm units/gm, Cream, Topical 30 gm units/ml, Suspension, Oral 60 ml units/ml, Suspension, Oral 480 ml units, Tablet, Oral 100

0.0900 R 0.0760 B 0.0620 B 0.0425 R 0.3563 B

Nystatin; Triamcinolone Acetonide 100,000 units/gm; 0.1%, Cream, Topical 15 gm 100,000 units/gm; 0.1%, Cream, Topical 30 gm 100,000 units/gm; 0.1%, Cream, Topical 60 gm 100,000 units/gm; 0.1%, Ointment, Topical 15 gm 100,000 units/gm; 0.1%, Ointment, Topical 30 gm 100,000 units/gm; 0.1%, Ointment, Topical 60 gm

0.0990 B 0.0940 B 0.0747 B 0.0990 B 0.0975 B 0.0747 B

Oxazepam 10 mg, Capsule, Oral 100 15 mg, Capsule, Oral 100 30 mg, Capsule, Oral 100

0.3100 R 0.5160 B 1.1200 B

Oxybutynin Chloride 5 mg, Tablet, Oral 100

0.1650 B

Penicillin V Potassium Eq 125 mg base/5 ml, Powder for reconstitution, Oral 200 ml Eq 250 mg base/5 ml, Powder for reconstitution, Oral 100 ml Eq 250 mg base/5 ml, Powder for reconstitution, Oral 200 ml Eq 250 mg base, Tablet, Oral 100 Eq 500 mg base, Tablet, Oral 100

0.0120 B 0.0220 B 0.0170 B 0.0491 B 0.0800 B

Pentoxifylline 400 mg, Tablet, Extended Release, Oral 100

0.3150 B

Perphenazine 2 mg, Tablet, Oral 100 4 mg, Tablet, Oral 100 8 mg, Tablet, Oral 100 16 mg, Tablet, Oral 100

0.2550 B 0.3150 B 0.4290 R 0.6000 B

Phenylephrine Hydrochloride; Promethazine Hydrochloride 5mg/5 ml; 6.25 mg/5 ml, Syrup, Oral 480 ml

0.0092 B

Pindolol 5 mg, Tablet, Oral 100 10 mg, Tablet, Oral 100

0.1540 B 0.1970 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-18

National Pharmaceutical Council

Pharmaceutical Benefits 2000

Generic Name

Upper Limit per Unit (Source)

Piroxicam 10 mg, Capsule, Oral 100 20 mg, Capsule, Oral 100

0.1090 B 0.1480 B

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 Eq 1 mg base, Capsule, Oral 100 Eq 2 mg base, Capsule, Oral 100 Eq 5 mg base, Capsule, Oral 100

0.0580 B 0.0790 R 0.1380 R

Prednisolone 15 mg/5 ml, Syrup, Oral 240 ml 15 mg/5 ml, Syrup, Oral 480 ml

0.2580 B 0.2090 B

Prednisolone Acetate 1%, Suspension/Drops, Ophthalmic 5 ml 1%, Suspension/Drops, Ophthalmic 10 ml

1.8900 B 1.6200 B

Prednisolone Sodium Phosphate Eq 0.9% Phosphate, Solution/Drops, Ophthalmic 5 ml

1.9200 B

Prednisone 5 mg, Tablet, Oral 100 10 mg, Tablet, Oral 100 20 mg, Tablet, Oral 100

0.0332 B 0.0550 B 0.0760 B

Primidone 250 mg, Tablet, Oral 100

0.3610 B

Probenecid 500 mg, Tablet, Oral 100

0.7060 B

Procainamide Hydrochloride 500 mg, Tablet, Extended Release, Oral 100

0.2460 B

Prochlorperazine Maleate Eq 5 mg base, Tablet, Oral 100 Eq 10 mg base, Tablet, Oral 100

0.3986 R 0.5766 B

Promethazine Hydrochloride 6.25 mg/5 ml, Syrup, Oral 120 ml 6.25 mg/5 ml, Syrup, Oral 480 ml

0.0219 B 0.0079 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book National Pharmaceutical Council

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Pharmaceutical Benefits 2000

Generic Name

Upper Limit per Unit (Source)

Proparacaine Hydrochloride 0.5%, Solution/Drops, Ophthalmic 15 ml

0.4990 B

Propoxyphene Hydrochloride 65 mg, Capsule, Oral 100

0.1350 B

Propranolol Hydrochloride 10 mg, Tablet, Oral 100 20 mg, Tablet, Oral 100 40 mg, Tablet, Oral 100 80 mg, Tablet, Oral 100

0.0500 B 0.0410 B 0.0490 B 0.0530 B

Quinidine Gluconate 324 mg, Tablet, Extended Release, Oral 100

0.4200 R

Ranitidine Hydrochloride Eq 150 mg base, Tablet, Oral, 100 Eq 300 mg base, Tablet, Oral 100

0.3410 B 0.6830 B

Selegiline Hydrochloride 5 mg, Tablet, Oral 60

0.8230 R

Selenium Sulfide 2.5%, Lotion/Shampoo, Topical 120 ml

0.0350 B

Spironolactone 25 mg, Tablet, Oral 100

0.3000 B

Sucralfate 1 gm, Tablet, Oral 100

0.3690 B

Sulfacetamide Sodium 10%, Ointment, Ophthalmic 3.5 gm 10%, Solution/Drops, Opthalmic 15 ml

1.4530 M 0.1240 B

Sulfamethoxazole; Trimethoprim 200 mg/5 ml; 40 mg/5 ml, Suspension, Oral 480 ml 400 mg; 80 mg, Tablet, Oral 100 800 mg; 160 mg, Tablet, Oral 100

0.0230 B 0.1325 B 0.2070 B

Sulfasalazine 500 mg, Tablet, Oral 100

0.1403 R

Sulindac 150 mg, Tablet, Oral 100 200 mg, Tablet, Oral 100

0.2138 R 0.3500 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-20

National Pharmaceutical Council

Pharmaceutical Benefits 2000

Generic Name

Upper Limit per Unit (Source)

Temazepam 15 mg, Capsule, Oral 100 30 mg, Capsule, Oral 100

0.1300 B 0.1560 B

Tetracycline Hydrochloride 500 mg, Capsule, Oral 100

0.0650 B

Theophylline 80 mg/15 ml, Elixir, Oral 480 ml 100 mg, Tablet, Extended Release, Oral 100 200 mg, Tablet, Extended Release, Oral 100 300 mg, Tablet, Extended Release, Oral 100 450 mg, Tablet, Extended Release, Oral 100

0.0070 B 0.0710 B 0.0940 B 0.1070 R 0.2700 B

Thioridazine Hydrochloride 100 mg/ml, Concentrate, Oral 120 ml 10 mg, Tablet, Oral 100 25 mg, Tablet, Oral 100 50 mg, Tablet, Oral 100 100 mg, Tablet, Oral 100

0.2376 B 0.0939 R 0.1103 R 0.1760 B 0.2324 R

Thiothixene 1 mg, Capsule, Oral 100 2 mg, Capsule, Oral 100 5 mg, Capsule, Oral 100 10 mg, Capsule, Oral 100

0.0890 B 0.1190 B 0.1690 B 0.2289 B

Timolol Maleate Eq 0.25% base, Solution/Drops, Ophthalmic 5 ml Eq 0.25% base, Solution/Drops, Ophthalmic 10 ml Eq 0.25% base, Solution/Drops, Ophthalmic 15 ml Eq 0.5% base, Solution/Drops, Ophthalmic 5 ml Eq 0.5% base, Solution/Drops, Ophthalmic 10 ml Eq 0.5% base, Solution/Drops, Ophthalmic 15 ml 5 mg, Tablet, Oral 100 10 mg, Tablet, Oral 100

0.7500 B 0.7970 B 0.7500 B 1.4070 B 1.0310 B 1.0000 B 0.1538 B 0.2138 B

Tobramycin 0.3%, Solution/Drops, Ophthalmic 5 ml

0.7680 B

Tolazamide 250 mg, Tablet, Oral 100 500 mg, Tablet, Oral 100

0.1038 B 0.2480 B

Tolmetin Sodium Eq 400 mg base, Capsule, Oral 100 Eq 600 mg base, Tablet, Oral 100

0.7280 B 0.9098 R

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book National Pharmaceutical Council

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Pharmaceutical Benefits 2000

Generic Name

Upper Limit per Unit (Source)

Trazodone Hydrochloride 50 mg, Tablet, Oral 100 100 mg, Tablet, Oral 100 150 mg, Tablet, Oral 100

0.0640 B 0.0952 R 0.4280 B

Triamcinolone Acetonide 0.025%, Cream, Topical 15 gm 0.025%, Cream, Topical 454 gm 0.1%, Cream, Topical 15 gm 0.1%, Cream, Topical 80 gm 0.1%, Cream, Topical 454 gm 0.5%, Cream, Topical 15 gm 0.1%, Lotion, Topical 60 ml 0.1%, Ointment, Topical 15 gm 0.1%, Ointment, Topical 80 gm 0.1%, Ointment, Topical 454 gm 0.1%, Paste, Dental 5 gm

0.0950 R 0.0132 B 0.0810 B 0.0420 B 0.0295 R 0.1889 B 0.1215 B 0.0810 B 0.0502 B 0.0381 B 0.8250 B

Triazolam 0.125 mg, Tablet, Oral 100

0.4000 R

Trifluoperazine Hydrochloride Eq 1 mg base, Tablet, Oral 100 Eq 2 mg base, Tablet, Oral 100 Eq 5 mg base, Tablet, Oral 100 Eq 10 mg base, Tablet, Oral 100

0.2433 B 0.3552 B 0.4271 B 0.5400 B

Trimethoprim 100 mg, Tablet, Oral 100

0.1553 B

Tropicamide 0.5%, Solution/Drops, Ophthalmic 15 ml 1%, Solution/Drops, Ophthalmic 15 ml

0.6550 B 0.7000 B

Valproic Acid 250 mg, Capsule, Oral 100 250 mg/5 ml, Syrup, Oral 480 ml

0.2100 B 0.0670 B

Verapamil Hydrochloride 120 mg, Capsule, Extended Release, Oral 100 180 mg, Capsule, Extended Release, Oral 100 240 mg, Capsule, Extended Release, Oral 100 40 mg, Tablet, Oral 100 80 mg, Tablet, Oral 100 120 mg, Tablet, Oral 100 180 mg, Tablet, Extended Release, Oral 100 240 mg, Tablet, Extended Release, Oral 100

0.8250 B 0.8700 B 0.9900 B 0.1840 R 0.0620 B 0.0860 B 0.2352 B 0.2175 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-22

National Pharmaceutical Council

Pharmaceutical Benefits 2000

Generic Name Warfarin Sodium 1 mg, Tablet, Oral 100 2 mg, Tablet, Oral 100 2.5 mg, Tablet, Oral 100 3 mg, Tablet, Oral 100 4 mg, Tablet, Oral 100 5 mg, Tablet, Oral 100 6 mg, Tablet, Oral 100 7.5 mg, Tablet, Oral 100 10 mg, Tablet, Oral 100

Upper Limit per Unit (Source) 0.4361 B 0.4553 B 0.4692 B 0.4718 R 0.4724 B 0.4761 B 0.6752 R 0.6981 B 0.7244 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book National Pharmaceutical Council

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Pharmaceutical Benefits 2000

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-24

National Pharmaceutical Council

Pharmaceutical Benefits 2000

Appendix E: Glossary

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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.

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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 Research (AHCPR)

A federal agency under Health and Human Services (HHS) whose purpose is to enhance the quality and effectiveness of healthcare by funding healthcare services research, conducting health technology assessments and outcomes studies, and developing and disseminating clinical practice guidelines.

Aid to Families with Dependent Children (AFDC)

A state-based federal cash assistance program for low-income families. In all 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 (ANSI)

A nonprofit organization that coordinates the development of voluntary national standards in both the public and private sectors.

Ancillary Charge

(1) The fee associated with additional service performed prior to and/or secondary to a significant procedure. (2) Also referred to as hospital “extras” or miscellaneous hospital charges. They are supplementary to a hospital’s daily room and board charge. They include such items as charges for drugs, medicines and dressings, lab services, x-ray examinations, and use of the operating room.

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Pharmaceutical Benefits 2000

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.

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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.

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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.

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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 Act (COBRA)

A federal law that, among other things, requires employers to offer continued health insurance coverage to certain employees and their beneficiaries whose group health insurance coverage has been terminated.

Consumer Price Index (CPI)

A price index constructed monthly by the U.S. Bureau of Labor using retail prices of goods and services sold in large cities across the country.

Continuous Quality Improvement (CQI)

A formal process of constantly seeking better ways to achieve stated goals.

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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.

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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 Charges

Method of reimbursement which limits payment to the lowest of the 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.

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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, Diagnosis, and Treatment (EPSDT)

The EPSDT program covers screening and diagnostic services to determine 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 Act of 1974, Public Law 93-406 (ERISA)

A Federal act passed in 1974, that established new standards and reporting/disclosure requirements for employer-funded pension and health benefit programs. To date, self-funded health benefit plans operating under ERISA have been held to be exempt from state insurance laws.

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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 Unproven Procedures

Medical, surgical, psychiatric, substance abuse or other healthcare services, 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.”

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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.

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Term

Definition

HCFA Common Procedural Coding System (HCPCS)

A listing of services, procedures and supplies offered by physicians and other 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 (HCFA)

The government agency within the Department of Health and Human Services 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 (HMO’s)

(1) An entity that provides, offers or arranges for coverage of designated 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 Information Set (HEDIS)

A core set of performance measures to assist employers and other health 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.

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Term

Definition

HMO - Individual Practice Association (IPA)

A healthcare model that contracts with physicians and other community 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.

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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, 9th Edition (Clinical Modification) (ICD-9-CM)

A listing of diagnoses and identifying codes used by physicians for reporting diagnoses of health plan enrollees. The coding and terminology provide a uniform language that can accurately designate primary and secondary diagnoses and provide for reliable, consistent communications on claim forms.

Investigational Treatments

Medical treatments, including drugs waiting for FDA approval, that are considered experimental and, therefore, may not be covered by insurance plans. The definition of experimental currently varies from plan to plan.

Laboratory and Radiological 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 longterm 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.

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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 “Reasonable Cost Range”

A maximum cost is fixed for which the pharmacist can be reimbursed for 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 System (MMIS)

Federally developed guidelines for a computer system designed to achieve 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. 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.

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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 Commission (MedPAC)

A federal commission established under the Balanced Budget Act of 1997 to advise and assist Congress and the Department of Health and Human Services in maintaining and updating the Medicare prospective payment system. MedPAC replaces and assumes the responsibilities of the Physician Payment Review Commission (PPRC) and the Prospective Payment Assessment Commission (ProPAC).

Medicare Supplemental Insurance

A policy guaranteeing that a health plan will pay a policyholder’s coinsurance, deductible and copayments and will provide additional health plan or nonMedicare 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 Insurance)

See “Medicare Supplemental Insurance.”

Members

A participant in a health plan (member or eligible dependent). Also used to describe an individual specified within a subscriber contract that may receive health care services according to the terms of the subscriber policy. Also known as "beneficiary," "enrollee," "subscriber," or "insured."

Modified Fee-for-Service

A system in which providers are paid on a fee-for-service basis, with certain fee maximums for each procedure.

Most Favored Nations Discount or Clause

A contractual agreement that stipulates that a vendor must provide to a 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 Assurance (NCQA)

A national organization founded in 1979 composed of 14 directors 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.”

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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).

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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) Committee

An organized panel of physicians and pharmacists from varying practice 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 (PHO)

A legal entity formed by a hospital and a group of physicians to further mutual interests and to achieve market objectives. A PHO generally combines physicians and a hospital into a single organization for the purpose of obtaining payer contracts. Doctors maintain ownership of their practices and agree to accept managed care patients according to the terms of a professional service agreement with the PHO. The PHO serves as a collective negotiating and contracting unit. It is typically owned and governed jointly by a hospital and shareholder physicians.

Point-Of-Service (POS) Plan

A health plan allowing the covered person to choose to receive a service from a participating or non-participating provider, with different benefit levels associated with the use of participating providers. POS can be provided in several ways: an HMO may allow members to obtain limited services from non-participating providers; an HMO may provide non-participating benefits through a supplemental major medical policy; a PPO may be used to provide both participating and non-participating levels of coverage and access; or various combinations of the above may be used.

Portability

Requirement that health plans guarantee continuous coverage without waiting periods for persons moving between plans.

Practice Guideline

Systematically developed statements on medical practice that assist a practitioner and a patient in making decisions about appropriate healthcare for specific medical conditions. Managed care organizations frequently use these guidelines to evaluate appropriateness and medical necessity of care. Terms used synonymously include practice parameters, standard treatment protocols and clinical practice guidelines.

Practice Parameters

See “Practice Guidelines.”

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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 (PPO)

A program in which contracts are established with providers of medical care. Providers under such contracts are referred to as preferred providers. Usually, the benefit contract provides significantly better benefits (fewer copayments) for services received from preferred providers, thus encouraging covered persons to use these providers. Covered persons are generally allowed benefits for non-participating providers’ services, usually on an indemnity basis with significantly higher copayments. A PPO arrangement can be insured or self-funded. Providers may be, but are not necessarily, paid on a discounted fee-for-service basis.

Prepaid Group Practice Plans

Organized medical groups of essentially full-time physicians in appropriate specialties, as well as other professional and subprofessional personnel, who, for regular compensation, undertake to provide comprehensive care to an enrolled population for premium payments that are made in advance by the consumer and/or their employers.

Prepaid Health Plan (PHP)

An entity that provides a non-comprehensive set of services on either capitated risk or non-risk basis or the entity provides comprehensive services on a non-risk basis.

Prescribed Drugs

Prescribed drugs are drugs dispensed by a licensed pharmacist on the prescription of a practitioner licensed by law to administer such drugs, and drugs dispensed by a licensed practitioner to his own patients. This item does not include a practitioner’s drug charges that are not separable from his other charges, or drugs covered by a hospital bill.

Prescription Medication

A drug which has been approved by the Food and Drug Administration and which can, under federal and state law, be dispensed only pursuant to a prescription order from a duly licensed prescriber, usually a physician.

Preventive Care

Comprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, generally including routine physical examinations, immunization and well person care.

Primary Care

Basic or general healthcare traditionally provided by family practice, pediatrics and internal medicine. See also “Secondary Care.”

Primary Care Case Management (PCCM)

Managed care arrangements where primary care providers receive a per capita management fee to coordinate a patient's care in addition to reimbursement (fee-for-service or capitation) for the medical services they provide.

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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 improvement (QI)

A formal set of activities to review and affect the quality of services provided. Quality assurance includes assessment and corrective actions to remedy any deficiencies identified in the quality of direct patient, administrative and support services.

Rate Setting

A form of financing under which hospitals or nursing homes are paid prices that are prospectively determined, generally by a state agency. Prospectively determined prices may be paid by all payers for all covered services, as in all payer systems, or by only some payers. The unit of payment can be service, patient, or time period. See “Prospective Financing.”

Rational Drug Therapy

Prescribing the right drug for the right patient, at the right time, in the right amount, and with due consideration of relative cost.

Reasonable Charge

In processing claims for Supplementary Medical Insurance benefits, carriers use 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.

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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.

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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 casemanagement 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.

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Term

Definition

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)

The federal law which created the current risk and cost contract provisions under which health plans contract with HCFA and which defined the primary and secondary coverage responsibilities of the Medicare program.

Temporary Assistance to Needy Families (TANF)

Federal-state welfare program which replaces Aid to Families with Dependent Children. Authorized by the 1996 Welfare Reform Act. States may use TANF to establish Medicaid eligibility.

Therapeutic Alternatives

Drug products containing different chemical entities but which should provide similar treatment effects, the same pharmacological action or chemical effect when administered to patients in therapeutically equivalent doses.

Therapeutic Substitution

Dispensing by a pharmacist of a product different from that which was prescribed, but which is deemed to be therapeutically equivalent. In most states such a practice requires the prescribing physician’s authorization before the substitution may occur. A pharmacy and therapeutics committee (P&T) most often approves the rationale for therapeutic equivalency prior to such practice.

Third-Party Administrator (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 Charges

A term used to refer to the commonly charged or prevailing fees for health 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.

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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).”

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ACRONYMS

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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

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Pharmaceutical Benefits 2000

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

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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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